Test 3 Flashcards
Low back Pain with cauda equina signs and symptoms immediate ____ to r/o __________
Immediate MRI to r/o cauda equina syndrome
Low back pain with infection risk factors, symptoms/signs order a _____ to look for ____ or ________
MRI
abscess or
vertebral osteomyelitis
Low back pain with cancer risk factors, symptoms/signs? order ____ or _____ to look for
spine film or MRI to look for vertebral metastasis
low back pain with compression fracture risk factors, symptoms/signs order _____ to look for _____
spine film
osteoporotic compression fracture
low back pain with spinal stenosis symptoms/signs? with leg pain and vascular risk factors. What is your first step?
utilize conservative therapy for presumed spinal stenosis
low back pain with spinal stenosis symptoms/signs? with leg pain and vascular risk factors with no response to conservative therapy. What is your next step?
MRI perform ABIs (Ankle Brachial Index) to look for PAD (Peripheral Artery Disease)
low back pain with spinal stenosis symptoms/signs? with no leg pain or vascular risk factors What is your next step?
utilize conservative therapy for presumed spinal stenosis
low back pain with spinal stenosis symptoms/signs? with no leg pain and vascular risk factors with no response to conservative therapy. What is your next step?
MRI
low back pain with sciatica or abnormal neuro exam
treat conservatively for herniated disk or osteophytic lumbar radiculopathy
positive yeargason test suggests
bicipital tendonitis
positive yeargason test produces pain in the
bicipital groove
patient supinate forearm against resistance
Yeargason test
Ask patient to externally rotate and abduct shoulder
what are you looking for?
Rotator cuff tear
Ask patient to externally rotate and abduct shoulder
pt can raise arm but cannot maintain position against resistance
Partial rotator cuff tear
Ask patient to externally rotate and abduct shoulder
attempt to abduct arm will produce a shoulder shrug
complete rotator cuff tear
Contact sports, repetitive motion, rubbing or placing pressure on the elbow or overuse.
Pain over bursae
ROM normal
Joint may be warm or red
Think Olecranon Bursitis
Penetrating injury may cause _____ ______
septic bursitis
Aseptic inflammation of the bone to tendon junction
From repetitive concentric contractions that transmit force via the muscles to the origin on the lateral epicondyle
Gradual onset of pain and tenderness over the lateral epicondyle that worsens
No limited range of motion
Resisted forearm supination with the elbow flexed at 90 degrees will intensify symptoms (hook-t test)
Lateral humeral Epicondylitis (Tenis Elbow)
Upward pulling of a child’s hand or wrist causes
subluxation of the radial head.
subluxation of the radial head.
Pulled out of the ____ ligament
(children)
annular
subluxation of the radial head causes the elbow to be ______ and the forearm to be _____
(children)
child will hold affected arm close to body with the elbow slightly flexed and forearm pronated
Subluxation of the radial head
causes pain in the ______ and can cause partial dislocation of the
(children)
elbow
radial head
(the annular ligament that holds the radial bone in place at the elbow has slipped over the top of the bone
Have seated patient place heel of affected leg on knee of other leg
Iliopsoas
what are you looking for on the Iliopsoas knee maneuver
Pain with movement indicates muscle iliopsoas tendonitis
what is the nickname for subluxation of the radial head
Nurse maids elbow
what are you looking for in the foucher sign
Look for change in consistency of a mass in popliteal fossa that hardens with extension and softens with flexion
Positive foucher sign
with knee flexion - the cyst is soft
with knee extension - the cyst becomes hard -
(the valvular opening occurs during knee flexion, during which the fluid can flow. It is compressed and closed during knee extension due to tension in the semimembranosus and the medial head of gastrocnemius)
indicates Baker’s Cyst
negative foucher sign indicates
tumor or popliteal aneurysm
how do you look for bulge sign
Apply pressure to area adjacent to patella
what does a positive bulge sign look like
Medial bulge will appear if fluid is in knee joint
Pt supine, flex knee 90 degrees and hip 45 degrees with foot on table; apply slow, steady anterior pull, and in same position, gently push tibia back
Drawer sign
Positive
Drawer sign indicates
Positive sign movement of tibia on femur indicates ligamentous instability.
(ACL or PCL)
Maximally flex knee and hip; externally and internally rotate tibia, palpate joint
McMurray maneuver
Positive McMurray maneuver indicates a
Indicate a meniscus injury
Apply medial or lateral pressure when knee is flexed 30 degrees and when it is extended
Collateral ligament test
Medial or lateral collateral ligament sprain will show
laxity in movement and no solid end points, depending on degree of sprain on the Collateral ligament test
Knee flexed 30 degrees, pull tibia forward with one hand while other hand stabilizes femur
Lachman test (cruciate ligaments)
Positive Lachman test (cruciate ligaments)
result is a mushy or soft end feel when tibia is moved forward, indicating damage to anterior cruciate ligament (ACL)
Present with any condition that causes venous thrombosis
Homans sign - passively dorsiflex clients ankle which causes pain to the deep calf
what do the Gluteal muscles do
Upper gluteal fibers abduct the thighs
lower gluteal fibers adduct the thighs
what does the Iliopsoas do
Flexes the thigh
Hip flexion
important for standing, walking running
what does the Medial compartment do (medial side of knee)
adduct the thigh
what does the quadriceps femoris do
straightens the leg at the knee
keep your kneecap stable
helps you walk, run, jump and squat
What do the hamstrings do
flex the leg at the knee (bringing heel to buttocks)
hip extension (moving leg to the rear)
what does the Tibialis anterior do
dorsiflexes the foot
also inverter of foot in combo with the tibialis posterior
what does the Gastrocnemius and soleus muscles
do
plantar flex the foot
low back pain with sciatica or abnormal neuro exam that does not respond to conservative treatment
MRI to confirm diagnosis
consider epidural injection
low back pain without GI/GU/gynecologic symptoms; abdominal burit, AAA risk factors
mechanical back pain, treat conservatively
low back pain without GI/GU/gynecologic symptoms; abdominal burit, AAA risk factors with no response to conservative treament
Consider MRI
consider inflammatory arthritis
How do you calculate ABI (Ankle Brachial Index)
take BP on ankle and arm on same side
divide Ankle SBP/Brachial SBP
< ____ on an ABI = PAD
<0.9
back pain with no definite relationship between anatomic abnormalities seen on imaging and symptoms
Nonspecific (mechanical) back pain
back pain clear relationship between anatomic abnormalities and symptoms
Specific MSK back pain:
infection differentials for back pain
Osteomyelitis
Septic disk
Paraspinal abscess
Epidural abscess
The classic presentation is nonradiating pain and stiffness in the lower back, sometimes precipitated by heavy lifting or another muscular stress.
Can have pain and stiffness in the butt and hips
Improves with patient supine; usually occurs hours to days after a new or unusual exertion
Resolution within 4-6 weeks
What is mechanical back pain?
inflammatory arthritis with or Without sacroiliitis on x-ray (with sacroiliitis on MRI or HLA-B27 positive plus clinical criteria)
Axial spondyloarthritis
Inflammatory arthritis
With psoriasis
With inflammatory bowel disease
With preceding infection
Without associated condition
Peripheral spondyloarthritis
Urinary retention
Saddle anesthesia
Bilateral leg weakness
Bilateral sciatica
Cauda equina syndrome
Fever
Recent skin or urinary tract infection
Immunosuppression
Injection drug use
Spine procedure
Infection
Cancer history, especially active cancer
Unexplained weight loss
Age over 50
Duration > 1 month
Nocturnal pain
Malignancy
Age over 70
Female sex
Corticosteroid use
Aromatase inhibitor use
History of osteoporosis
Trauma
Compression fracture
Sciatica
Abnormal neurologic exam
Lumbar radiculopathy
Younger than 45 years at onset
Duration > 3 months
Insidious onset
Morning stiffness > 30 minutes
Improvement with exercise
No improvement with rest
Awakening with pain, especially during second half of night, with improvement on arising
Alternating buttock pain
Inflammatory back pain
Sciatica
Neurologic signs and symptoms, especially in L5–S1 distribution
Positive straight leg raise
Herniated lumbar disk
Test for Herniated lumbar disk
CT or MRI
radicular pain in the L5–S1 distribution
sciatica
aromatase inhibitors such as letrozole _____ bone loss and are associated with an _____risk of fractures
aromatase inhibitors such as letrozole increase bone loss and are associated with an increased risk of fractures
Duration of pain > 1 month
Age > 50
Previous cancer history
Unexplained weight loss (> 10 lbs over 6 months)
Nocturnal pain
Metastatic breast cancer
important tests for
Metastatic breast cancer
Spine radiograph
MRI
Age > 70
Female sex
Significant trauma
History of osteoporosis
Corticosteroid use
Prior fracture
Aromatase inhibitor use
Osteoporotic compression fracture
Osteoporotic compression fracture
important tests
Spine radiograph
MRI
Wide-based gait
Neurogenic claudication
Age > 65
Improvement with sitting/bending forward
Spinal stenosis
test for spinal stenosis
MRI
Duration of pain > 1 month
Age > 50
Previous cancer history
Unexplained weight loss (> 10 lbs over 6 months)
Nocturnal pain
Metastatic cancer
tests for Metastatic cancer
Spine radiograph
MRI
Vascular risk factors; leg pain with walking
Peripheral arterial disease
Peripheral arterial disease test
ABIs
Bilateral radicular pain
Central disk herniation
Test for Central disk herniation
MRI
The classic presentation is the development of constant, dull back pain that is not relieved by rest and is worse at night in a patient with a known malignancy
Back pain due to Metastatic Cancer
can be limited to the vertebral body or extend into the epidural space, causing cord compression.
Bone metastases
_____can precede cord compression by weeks or even months, but compression progresses ____ once it starts.
Pain can precede cord compression by weeks or even months, but compression progresses rapidly once it starts.
Cancer + back pain + neurologic abnormalities =
an emergency.
Most common sources that metastasize to the bone causing back pain are ___, ___, or ___ cancer.
Most common sources are breast, lung, or prostate cancer.
______lesions are seen with prostate cancer, small cell lung cancer, Hodgkin lymphoma
Blastic lesions are seen with prostate cancer, small cell lung cancer, Hodgkin lymphoma
_____ lesions are seen with renal cell, myeloma, non-Hodgkin lymphoma, melanoma, non–small cell lung cancer, thyroid cancer.
Lytic lesions are seen with renal cell, myeloma, non-Hodgkin lymphoma, melanoma, non–small cell lung cancer, thyroid cancer.
Mixed blastic and lytic lesions are seen with ______ cancer and____cancers
Mixed blastic and lytic lesions are seen with breast cancer and GI cancers
_________is the best test for diagnosing or ruling out cancer as a cause of back pain and for determining whether there is cord compression.
MRI scan is the best test for diagnosing or ruling out cancer as a cause of back pain and for determining whether there is cord compression.
What lab test is sometimes helpful for diagnosing or ruling out cancer as a cause for back pain
ESR
moderate to severe pain radiating from the back down the buttock and leg, usually to the foot or ankle, with associated numbness or paresthesias. This type of pain is called sciatica, and it is classically precipitated by a sudden increase in pressure on the disk, such as after coughing or lifting.
Lumbar Radiculopathy due to a Herniated Disk
frequently asymptomatic; pain occurs when direct contact of the disk with a nerve root provokes inflammation.
Disk disease
95% of clinically important disk herniations occur at __–__ and __–__, so pain and paresthesias are most often seen in the distributions of these nerves
95% of clinically important disk herniations occur at L4–L5 and L5–S1, so pain and paresthesias are most often seen in the distributions of these nerves
____ pain is often described as sharp, shooting or burning but can also be described as throbbing, tingling, or dull.
Radicular pain is often described as sharp, shooting or burning but can also be described as throbbing, tingling, or dull.
Neurologic abnormalities such as _____and _____ are found variably and can occur in the absence of pain
Neurologic abnormalities such as paresthesias/sensory loss and motor weakness are found variably and can occur in the absence of pain
Myofascial pain syndromes and hip and knee pathology can be difficult to distinguish from _____
Myofascial pain syndromes and hip and knee pathology can be difficult to distinguish from radiculopathy; many patients have both radiculopathy and other musculoskeletal conditions.
What can can aggravate radicular pain from a herniated disk?
Coughing, sneezing, or prolonged sitting
nonspinal causes of sciatica.
Traumatic injury of the nerve in pelvic fracture or hamstring injury
Gynecologic and peripartum causes such as compression from ovarian cysts or the fetal head
Compression of the nerve by the overlying piriformis muscle (piriformis syndrome), characterized by focal mid-buttock pain, tenderness over the sciatic notch, increased pain with sitting, and increased pain with external hip rotation.
There are no ____ or ____ symptoms with unilateral disk herniations.
There are no bowel or bladder symptoms with unilateral disk herniations.
Large midline herniations can cause
cauda equina syndrome.
rare condition caused by tumor or massive midline disk herniations.
Cauda equina syndrome
Characteristics of Cauda Equina syndrome
combo of measured urinary retention >500mL and at least 2 of 3 typical symptoms
1) bilateral sciatica
2) subjective urinary retention
3) rectal incontinence
other symptoms urinary incontinence decreased anal sphincter tone sensory loss in a saddle distribution leg weakness
what test to determine cauda equina syndrome
MRI
Suspected cauda equina syndrome is a medical emergency that requires immediate _____ and _____.
Suspected cauda equina syndrome is a medical emergency that requires immediate imaging and decompression.
Pain in the Anteromedial thigh
is associated with what nerve root?
L4
pain the Lateral thigh, lateral lower leg, dorsum of foot is associated with what nerve root
L5
Pain in the Posterior thigh, calf, heel is associated with what nerve root
S1
Paresthesias/Sensory changes in the medial lower leg
is associated with what nerve root
L4
Paresthesias/Sensory changes in the Lateral thigh, lateral lower leg, dorsum of foot
is associated with what nerve root
L5
Paresthesias/Sensory changes in the Sole, lateral foot + ankle, fourth + fifth toes
is associated with what nerve root
S1
Motor weakness in the Knee extension, hip adduction
is associated with what nerve root
L4
Motor weakness in the Foot dorsiflexion, foot eversion + inversion, hip abduction
is associated with what nerve root
L5
Motor weakness in the Foot plantar flexion, knee flexion, hip extension
is associated with what nerve root
S1
Absent reflexes in the knee are associated with what nerve root
L4
Absent reflexes in the ankle are associated with what nerve root
S1
is performed by holding the heel in 1 hand and slowly raising the leg, keeping the knee extended.
Straight leg test
A positive Straight leg test
reproduces the patient’s sciatica when the leg is elevated between 30 and 60 degrees.
(The patient should describe the pain induced by the maneuver as shooting down the leg not just a pulling sensation in the hamstring muscle.)
Increased pain on a straight leg test
on dorsiflexion of the foot or large toe increases sensitivity.
performed by lifting the contralateral leg; a positive test reproduces the sciatica in the affected leg.
Crossed straight leg test
A straight leg raise test that elicits just back pain is positive or negative
negative
Plain radiographs are ___for diagnosing herniations.
Plain radiographs do not image the disks and are useless for diagnosing herniations.
what tests are good for diagnosing herniated disks
CT or MRI
similar in sensitivity and specificity
Primarily used to confirm lumbosacral radiculopathy and exclude other peripheral nerve abnormalities, particularly when physical exam abnormalities do not correlate with imaging abnormalities
Electromyography (EMG)
Also used to determine the severity and chronicity of a radiculopathy, and the functional significance of an imaging abnormality
Electromyography (EMG)
Most useful for subacute neuromuscular abnormalities (3 weeks to 3 months after the onset of symptoms)
Electromyography (EMG)
The physical exam findings for the diagnosis of __________
sciatica positive crossed straight leg raise positive ipsilateral straight leg raise great toe extensor weakness impaired ankle reflex foot dorsiflexion weakness foot plantar flexion weakness
disk herniation
for Lumbar Radiculopathy due to a Herniated Disk
In the absence of cauda equina syndrome or progressive neurologic dysfunction, conservative therapy should be tried for ___weeks. There is little evidence to guide clinicians.
6
conservative therapy for Lumbar Radiculopathy due to a Herniated Disk
NSAIDs are the first choice.
Gabapentin is often used but has not been well studied; pregabalin was ineffective in a recent study.
Tramadol and other opioids should be used only in patients with severe pain and for short periods of time.
Short courses of oral corticosteroids modestly improve acute pain; epidural corticosteroid injections may provide temporary pain relief.
Supervised exercise modestly reduces pain, and bed rest should be avoided.
Chiropractic manipulation has been shown to reduce pain in the short term
indications for surgery for Lumbar Radiculopathy due to a Herniated Disk
Impairment of bowel and bladder function (cauda equina syndrome)
Gross motor weakness
Progressive neurologic symptoms or signs
No response after 6 weeks of conservative therapy.
Surgery should/should not be done for painless herniations or when the herniation is at a different level than the symptoms.
should not
In the absence of progressive neurologic symptoms, surgery is ______
In the absence of progressive neurologic symptoms, surgery is elective; patients with disk herniations and radicular pain generally recover with or without surgery.
Lumbar Radiculopathy due to a Herniated Disk
The median time to recovery was __weeks for the surgery group and __ weeks for the conservative therapy group.
The median time to recovery was 4 weeks for the surgery group and 12 weeks for the conservative therapy group.
classic presentation is nonradiating pain and stiffness in the lower back, sometimes precipitated by heavy lifting or another muscular stress.
Mechanical Low Back Pain
risk factors for persistent low back pain
Maladaptive pain coping behaviors
High level of baseline functional impairment
Low general health status
Presence of psychiatric comorbidities
Presence of “nonorganic signs” (signs suggesting a strong psychological component to pain, such as superficial or nonanatomic tenderness, overreaction, non-reproducibility with distraction, nonanatomic weakness or sensory changes)
are effective for acute low back pain
nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants
acetaminophen is not effective in clinical trials.
have been shown to reduce acute low back pain
Heat and spinal manipulation
acupuncture and massage may also help.
Best approach for acute low back pain
is NSAIDs and heat during the acute phase with activity as tolerated until the pain resolves, followed by specific daily back exercises.
Bed rest may prolong the duration of pain
There is moderate quality evidence that exercise, yoga, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction are effective for
chronic low back pain.
There is low-quality evidence that cognitive-behavioral therapy, spinal manipulation, tai chi, progressive relaxation, and electromyography biofeedback, are effective for
chronic low back pain.
first line pharm therapy for subacute or chronic low back pain
NSAIDS
second line pharm therapy for subacute or chronic low back pain
Tramadol or duloxetine
are an option for patients who have not responded to all other therapies after a discussion of risks and benefits for subacute or chronic low back pain
Opioids
The classic presentation is acute, severe pain that develops in an older woman and radiates around the flank to the abdomen, occurring either spontaneously or brought on by trivial activity such as minor lifting, bending, or jarring.
Osteoporotic Compression Fracture
Osteoporotic Compression Fracture
Fractures are usually in the
mid to lower thoracic or lumbar region.
Fractures at T4 or higher are more often due to
malignancy than osteoporosis
Pain is often increased by slight movements, such as turning over in bed
and can also be asymptomatic
Osteoporotic Compression Fracture
Pain usually improves within 1 week and resolves by 4–6 weeks, but some patients have more chronic pain.
Osteoporotic Compression Fracture
Osteoporosis is usually related to
menopause and aging.
Most common diseases associated with osteoporosis include
hyperthyroidism, primary hyperparathyroidism, vitamin D deficiency, hypogonadism, and malabsorption.
Medications that can lead to osteoporosis include
corticosteroids (most common), anticonvulsants, aromatase inhibitors, and long-term heparin therapy.
Risk factors for osteoporosis include
Age (Strongest risk factor)
Relative risk of almost 10 for women aged 70–74 (compared with women m under 65), increasing to a relative risk of 22.5 for women over 80
Personal history of rib, spine, wrist, or hip fracture
Current smoking or use of ≥ 3 units of alcohol daily
White, Hispanic, or Asian ethnicity
Weight < 132 lbs
Parental history of hip fracture
T score is given with what test
Bone density testing
T score >= -1.0
normal
T score < -1.0 and > -2.5
osteopenia
<= -2.5
osteoporosis
used to estimate the 10-year probability of a hip fracture or a major osteoporotic fracture
The FRAX score,
most compression fractures are diagnosed with _______, unless there is a concern for malignancy.
most compression fractures are diagnosed with radiographs, unless there is a concern for malignancy.
Bone scan can be useful for determining ____ in Osteoporotic Compression Fracture
acuity
Total calcium intake (dietary plus supplementation, if necessary) should be ____mg daily for women over 50 years of age
Total calcium intake (dietary plus supplementation, if necessary) should be 1200 mg daily for women over 50 years of age
total vitamin D intake should be __ international units daily for women up to age 70
total vitamin D intake should be 600 international units daily for women up to age 70
total vitamin D intake should be __ international units daily for women over age 70.
800
Bisphosphonates both ____ bone density and ____fracture risk.
Bisphosphonates both increase bone density and reduce fracture risk.
___ and ___ (oral, once per week) reduce vertebral, nonvertebral, and hip fractures.
Alendronate and risedronate
_______(oral, once per month) reduces vertebral fractures
Ibandronate
________ (intravenous, once per year) reduces vertebral, nonvertebral, and hip fractures.
Zoledronic acid
______ reduces risk of spine fractures but not hip fractures.
Raloxifene
Raloxifene _____ the risk of estrogen receptor–positive breast cancer and _____the risk of venous thromboembolism
Raloxifene reduces the risk of estrogen receptor–positive breast cancer and increases the risk of venous thromboembolism
_________(teriparatide; subcutaneous, daily) increases bone density and reduces vertebral and nonvertebral fractures.
Parathyroid hormone (teriparatide; subcutaneous, daily) increases bone density and reduces vertebral and nonvertebral fractures.
_________, a monoclonal antibody RANKL inhibitor that blocks osteoclast function, (subcutaneous, every 6 months) reduces vertebral, nonvertebral, and hip fractures.
Denosumab, a monoclonal antibody RANKL inhibitor that blocks osteoclast function, (subcutaneous, every 6 months) reduces vertebral, nonvertebral, and hip fractures.
______ prevents fractures but is no longer recommended for long-term therapy due to such adverse events such as venous thromboembolism, breast cancer and MI and cerebrovascular accidents
Estrogen prevents fractures but is no longer recommended for long-term therapy due to such adverse events such as venous thromboembolism, breast cancer and MI and cerebrovascular accidents
Calcitonin does or does not significantly increase bone density or prevent fractures
Calcitonin does not significantly increase bone density or prevent fractures
Calcitonin sometimes reduces the ____from an acute vertebral compression fracture.
pain
percutaneous injection of bone cement under fluoroscopic guidance into a collapsed vertebra
Vertebroplasty
(introduction of bone cement and inflatable bone tamps into the fractured vertebral body
kyphoplasty
as reproducible, exercise-induced calf pain that requires stopping and is relieved with < 10 minutes of rest
Peripheral Arterial Disease (PAD)
classically presents with pain in the feet at rest that may be relieved by placing the feet in a dependent position.
Critical limb ischemia
Risk factors PAD
smoking
diabetes
HTN
hyperlipidemia
other vascular disease (ischemic heart disease, stroke)
skin being cooler to the touch and the presence of a foot ulcer in the affected leg
atrophic or cool skin, blue/purple skin, absence of lower limb hair
skin changes associated with PAD
presence of an iliac, femoral, or popliteal bruit associated with
PAD
Risk factor modification for PAD
smoking cessation, control of hypertension and diabetes, treatment with a high-intensity statin
Antiplatelet therapy with ___or ____ reduces myocardial infarction, stroke, and death from vascular causes; there is no additional benefit with combination therapy.
Antiplatelet therapy with aspirin or clopidogrel reduces myocardial infarction, stroke, and death from vascular causes; there is no additional benefit with combination therapy.
first-line therapy. PAD
Exercise, especially a supervised exercise program, can increase walking by up to 150% over 3–12 months
Revascularization, either surgical or percutaneous transluminal angioplasty, is indicated for the following:
Limb salvage in critical limb ischemia
Claudication unresponsive to exercise and pharmacologic therapy that limits patients’ lifestyle or ability to work
The classic presentation is a patient with a history of diabetes or injection drug use who has fever and back pain, followed by neurologic symptoms (eg, motor weakness, sensory changes, and bowel or bladder dysfunction).
Spinal Epidural Abscess
predisposing conditions of Spinal Epidural Abscess
underlying disease such as DM, injection drug use, ESRD, immunosuppressant therapy, cancer, HIV
invasive spine intervention (surgery, percutaneous spine procedure, trauma)
potential local or systemic source of infection (skin or soft tissue infection, endocarditis, osteomyelitis, UTI, injection drug use, epidural anesthesia, indwelling vascular access)
Spinal Epidural Abscess causative organism in 66% of the cases
Staphylococcus aureus
other organisms for Spinal Epidural Abscess
Staphylococcus epidermidis, Escherichia coli, Pseudomonas aeruginosa
Anaerobes, mycobacteria, fungi, and parasites are occasionally found
Classic triad of fever, spine pain, and neurologic deficits
Spinal Epidural Abscess
Spinal Epidural Abscess Occur more commonly in _____ than ____epidural space and more commonly in the ______than _____areas.
Occur more commonly in posterior than anterior epidural space and more commonly in the thoracolumbar than cervical areas.
Spinal Epidural Abscess Generally extend over – vertebrae.
3-5
back pain at the level of the affected spine
Spinal Epidural Abscess stage
Spinal Epidural Abscess
Stage 1
nerve root pain radiating from the involved spinal area
Spinal Epidural Abscess stage
Spinal Epidural Abscess
Stage 2
motor weakness, sensory deficit, bladder/bowel dysfunction
Spinal Epidural Abscess stage
Spinal Epidural Abscess
Stage 3
paralysis
Spinal Epidural Abscess stage
Spinal Epidural Abscess
Stage 4
Labs elevated/present in Spinal Epidural Abscess
ESR and CRP usually elevated
Leukocytosis
Bacteremia
Best imaging study for spinal epidural abscess
MRI with gadolinium
Alternative imaging if they cannot have an MRI for spinal epidural abscess
CT myelogram
if you have a normal WBC and negative blood cultures does this rule out spinal epidural abscess?
no
treatment for spinal epidural abscess
CT-guided or open biopsy, followed by percutaneous or surgical decompression and drainage
Antibiotics
The classic presentation is somewhat vague, but persistent back and leg discomfort brought on by walking or standing that is relieved by sitting or bending forward is typically seen.
Spinal Stenosis
radiographic abnormalities such as spondylolisthesis, disk-space narrowing, facet-joint hypertrophy, neural foramina osteophytes
Spinal Stenosis
Neurogenic claudication, a variable pain or discomfort with walking or prolonged standing that radiates into the buttocks, thighs, or lower legs, is the most common symptom.
Spinal Stenosis
Radicular or polyradicular pain can occur and is not as related to position as neurogenic claudication.
Spinal Stenosis
medical term usually referring to impairment in walking, or pain, discomfort, numbness or tiredness in the legs that occurs during walking or standing and is relieved by rest
claudication
vascular or neurogenic claudication
fixed walking distance before onset of symptoms
vascular
vascular or neurogenic claudication
Variable walking distance before onset of symptoms
neurogenic
vascular or neurogenic claudication
Improved by standing still
vascular
vascular or neurogenic claudication
Worsened by walking
vascular
vascular or neurogenic claudication
Painful to walk uphill
vascular
vascular or neurogenic claudication
Improved by sitting or bending forward
neurogenic
vascular or neurogenic claudication
Worsened by walking or standing
neurogenic
vascular or neurogenic claudication
Can be painless to walk uphill due to tendency to bend forward
neurogenic
vascular or neurogenic claudication
Absent pulses
vascular
vascular or neurogenic claudication
Skin shiny with loss of hair
vascular
vascular or neurogenic claudication
Present pulses
neurogenic
vascular or neurogenic claudication
Skin appears normal
neurogenic
a variable pain or discomfort with walking or prolonged standing that radiates into the buttocks, thighs, or lower legs, is the most common symptom.
Neurogenic claudication
can occur and is not as related to position as neurogenic claudication.
Radicular or polyradicular pain
Stenosis is seen most often in the ____ spine
Stenosis is seen most often in the lumbar spine, sometimes in the cervical spine, and rarely in the thoracic spine.
Stenosis is rarely seen in the _____ spine
thoracic
due to hypertrophic degenerative processes and degenerative spondylolisthesis compressing the spinal cord, cauda equina, individual nerve roots, and the arterioles and capillaries supplying the cauda equina and nerve roots
Spinal stenosis
in spinal stenosis pain is ____ by extension and ____ by flexion.
worsened by extension
relieved by flexion
generally have bilateral, non-dermatomal pain involving the buttocks and posterior thighs.
Patients with central stenosis
Patients with___ stenosis generally have pain in a dermatomal distribution.
Patients with lateral stenosis generally have pain in a dermatomal distribution.
Repeating the physical exam after ____ might demonstrate subtle abnormalities in spinal stenosis
rapid walking
Lumbar spinal stenosis does/does not progress to paralysis and should be managed based on severity of symptoms.
does not
what spinal stenoses can cause myelopathy and paralysis and requires surgery more often than lumbar spinal stenosis.
Progression of cervical and thoracic stenoses
______ are not necessary: they do not change management, or provide the degree of anatomic detail necessary to guide interventional treatment (such as epidural injection or surgery). (in spinal stenosis)
plain radiographs
what imaging for spinal stenosis
CT and MRI
CT and MRI scans can rule out spinal stenosis but cannot necessarily determine whether visualized stenosis is causing the patient’s symptoms.
Medications used for pain relief include in spinal stenosis
NSAIDs, tricyclic antidepressants, gabapentin, pregabalin, tramadol, and sometimes opioids.
In spinal stenosis physical therapy improves
stamina and muscle strength in the legs and trunk;exercises performed with lumbar flexion, such as cycling, may be better tolerated than walking.
spinal stenosis
epidural injections of
epidural injection of corticosteroids and lidocaine, vs. lidocaine alone, found that adding corticosteroids did not reduce pain at 6 weeks.
primary indication of surgery to treat spinal stenosis
increasing pain that is not responsive to conservative measures.
surgery in spinal stenosis is more effective in reducing ___ pain than ___ pain
More effective in reducing leg pain than back pain.
Predictors of a positive response to surgery in spinal stenosis
male sex, younger age, better walking ability, better self-rated health, less comorbidity, and more pronounced canal stenosis.
The classic presentation is unremitting back pain with fever.
Vertebral Osteomyelitis
Vertebral Osteomyelitis is Most commonly from
hematogenous spread
most common sources of infections that lead to Vertebral Osteomyelitis
Urinary tract, skin, soft tissue, vascular access site, endocarditis, septic arthritis
Vertebral Osteomyelitis patients usually have _____ or history of _____
Patients usually have underlying chronic illnesses or injection drug use.
Can also occur due to contiguous spread from an adjacent soft tissue infection or direct infection from trauma or surgery.
Vertebral Osteomyelitis
Generally causes bony destruction of 2 adjacent vertebral bodies and collapse of the intervertebral space.
Vertebral Osteomyelitis
Vertebral Osteomyelitis is most often found in ____, followed by _____ and _____. complicated by ______
lumbar spine
thoracic spine
cervical spine
epidural, paravertebral and disk space abscess
causative agent for Vertebral Osteomyelitis in over 50% of patients
S aureus
what causative agents for vertebral osteomyelitis are esp seen in diabetic patients
Group B and G hemolyic strep
what causative agents for vertebral osteomyelitis are seen esp after UT instrumentation
Enteric gram neg bacilli
what other agent sometimes causes vertebral osteomyelitis
Coagulase-negative staphylococci
lab tests for vertebral osteomyelitis
leukocytosis (normal WBC does not rule out)
ESR - nearly all report elevated
CRP - nearly all elevated
Blood cultures positive in 58%
image guided spinal biopsy
imaging for vertebral osteomyelitis
from highest sensitivity/specificity to lowest
MRI with gadolinium
Bone scan
Radiographs
treatment for vertebral osteomyelitis
ABX for 4-6 weeks at least
Surgery is necessary only if neurologic symptoms suggest onset of vertebral collapse causing cord compression or development of spinal epidural abscess; surgery is always necessary for osteomyelitis associated with a spinal implant.
surgery is always necessary for osteomyelitis associated with a spinal implant
______ should be considered in patients with either vertebral osteomyelitis or a spinal epidural abscess.
Endocarditis
surgery is always necessary for osteomyelitis associated with a
spinal implant
polyarticular joint pain with acute onset consider what kind of causes
infectious
postinfectious
causes
polyarticular joint pain
chronic onset
history and physical exam consistent with an inflammatory process
what should be considered
rheumatologic disease
polyarticular joint pain
chronic onset
history and physical exam consistent with an inflammatory process
anti-ds DNA present
SLE is likely
polyarticular joint pain
chronic onset
history and physical exam consistent with an inflammatory process
nodules are present or ACPA positive
RA is likely
polyarticular joint pain
chronic onset
history and physical exam not consistent with an inflammatory process
consider
OA
CPPD
monoarticular joint pain consistent with periarticular disease, consider
joint-specific periarticular syndromes
monoarticular joint pain with history and physical exam not consistent with an inflammatory process
Consider OA
CPPD
monoarticular joint pain with history and physical exam consistent with an inflammatory process
at least 6 findings associated with gout
treat for gout
monoarticular joint pain with history and physical exam consistent with an inflammatory process
does not have at least 6 findings associated with gout
Aspirate joint to differentiate crystalline arthropathy from a septic arthritis
what does a positive crossed straight leg sign is associated with a
herniated lumbar disk in 97% of patients
what are some causes of infectious inflammatory for monoarticular arthritis
Nongonococcal septic arthritis
Gonococcal arthritis
Lyme disease
what are some causes of crystalline inflammatory for monoarticular arthritis
Monosodium urate (gout)
Calcium pyrophosphate dihydrate deposition disease (CPPD or pseudogout)
what are some non-inflammatory causes of monoarticular arthritis
Osteoarthritis (OA)
Traumatic
Avascular necrosis
what are some inflammatory causes of polyarticular arthritis that fall under rheumatologic causes
Rheumatoid arthritis (RA)
Systemic lupus erythematosus (SLE)
Psoriatic arthritis
Other rheumatic diseases
what are some infectious causes of polyarticular arthritis - Bacterial
Bacterial endocarditis
Lyme disease
Gonococcal arthritis
what are some infectious causes of polyarticular arthritis - Viral
Rubella
Hepatitis B
HIV
Parvovirus
what are some post-infectious causes of polyarticular arthritis
Enteric
Urogenital
Rheumatic fever
Men > women
Previous episodes
Rapid onset
Involvement of first
MTP joint
Gout
sodium urate crystals in synovial fluid
Gout
May present as chronic or acute arthritis
Demonstration of calcium pyrophosphate crystals in synovial fluid or classic radiographic findings
CPPD (pseudogout)
Fever with monoarticular or polyarticular arthritis
Positive synovial (or other body) fluid cultures
Bacterial arthritis (gonococcal or nongonococcal)
Exposure to endemic area
History of tick bite
Rash
Lyme disease
Morning stiffness
Symmetric polyarthritis
Commonly involves the MCP joints
Rheumatoid arthritis
important tests for RA
Rheumatoid factor
Anti-citrullinated protein antibody
Psoriasis
Dactylitis
Spinal arthritis
Often asymmetric
Often involves the DIP joints
Psoriatic arthritis
Multisystem disease
More common in women than in men
In the United States, more common in Asians, African Americans, African Caribbeans, and Hispanic Americans
Systemic lupus erythematosus
Chronic arthritis in weight-bearing joints
In the hands, DIP and PIP involvement more common than MCP involvement
Osteoarthritis
important imaging in osteoarthritis
Radiograph of affected joints
Parvovirus infection often includes viral symptoms, joint pain and rash
Viral arthritis, parvovirus most common
what labs are important in viral arthritis
antibody titers and serology
Migratory polyarthritis
Carditis
Erythema marginatum
Rheumatic fever
Jones criteria is used in what
Rheumatic fever
Fever with monoarticular or polyarticular arthritis
Bacterial arthritis (gonococcal or nongonococcal)
important tests in Bacterial arthritis
Positive synovial (or other body) fluid cultures
History of recent colonic or urogenital infection
Presence of arthritis, urethritis, and iritis
Reactive arthritis
Chronic pain in weight-bearing joints
Osteoarthritis
Pain worse with straining
Inguinal hernia
Lateral hip pain
Tenderness over the bursa
Trochanteric bursitis
Positive straight leg raise
Lumbar nerve root compression
imaging for
Lumbar nerve root compression
MRI
Most common in young women involved in weight-bearing exercise
Femoral stress fractures
imaging for Femoral stress fractures
MRI
Bone scan
generally presents in older patients. It may present with an acute flare or, more commonly, as a degenerative arthritis with suspicious radiographic findings that distinguish it from OA. Patients often have other diseases associated such as hyperparathyroidism.
Calcium Pyrophosphate Deposition Disease (CPPD)
Acute flare of CPPD is called
pseudogout
crystal-induced arthropathy
Calcium Pyrophosphate Deposition Disease (CPPD)
when CPPD is diagnosed as an incidental finding in an asymptomatic patient. What was found on what test?
incidental radiographic finding of chondocalcinosis, the linear calcifications of articular cartilage
An acute, inflammatory, usually monoarticular arthritis
Pseudogout
presentation of Calcium Pyrophosphate Deposition Disease (CPPD)
chronic arthritis that is clinically similar to OA
May affect joints less commonly affected by OA like the wrists, MCPs, and shoulders
CPPD arthropathy aka (pseudo OA)
A chronic, inflammatory polyarthritis resembling RA
pseudo RA
presentation of Calcium Pyrophosphate Deposition Disease (CPPD)
Resembles a Charcot joint
Destructive monoarthropathy is seen in this presentation.
Pseudoneuropathic arthropathy (rarely)
presentation of Calcium Pyrophosphate Deposition Disease (CPPD)
similarities between pseudogout and gout.
oth are caused by the inflammatory response to crystals in the synovial space.
Both cause acute painful monoarticular attacks.
Both can cause polyarticular flares.
Flares can be induced by trauma or illness.
Both can potentially cause destructive arthropathy.
Incidence increases with age.
how is pseudogout different from gout
Episodic “gout-like” flares only occur in a small percentage of patients.
As above, CPPD commonly manifests as a degenerative arthritis (in about 50% of patients).
It has highly specific radiologic features.
It most commonly affects the knee.
pseudogout is most commonly associated with what diseases
Hyperparathyroidism
Hemochromatosis
Hypomagnesemia
Hypophosphatasia
Acute arthritis of a large joint, especially the knee, in the absence of hyperuricemia.
Chronic arthritis with acute flares.
Chronic arthritis involving joints that would be atypical for OA such as the wrists, metacarpophalangeal (MCP) joints, and shoulders.
CPPD
Evaluation of a patient with pseudogout should include testing for related diseases. The evaluation generally includes measuring the levels of the following:
Calcium
Magnesium
Phosphorus
Iron, ferritin, and total iron-binding capacity (TIBC)
In the right setting, markers of other rheumatologic diseases (uric acid, rheumatoid factor [RF], anti-cyclic citrullinated peptide [anti-CCP])
Acute Calcium Pyrophosphate Deposition Disease (CPPD) attacks are managed with
NSAIDs
Joint aspiration with corticosteroid injection
Colchicine
Chronic degenerative arthritis is difficult to treat. what is usually used
NSAIDS
classically seen in young, sexually active women who have fever and joint pain. The most common presentation is severe pain of the wrists, hands, and knees with warmth and erythema diffusely over the backs of the hands. A rash may sometimes be present.
Disseminated Gonorrhea
what gender is more likely to have Disseminated Gonorrhea
Women 3 times more likely then men
Disseminated gonorrhea usually occurs in patients without a history of
recent sexually transmitted infection.
Disseminated gonorrhea presents in 1 of 2 ways (with a good deal of overlap):
a classic septic arthritis or a triad of tenosynovitis, dermatitis, and arthralgia. (reflects a high-grade bacteremia with reactive features)
tenosynovitis presents predominantly as
polyarthralgia of the hands and wrists
rash associated with disseminated gonorrhea
scattered, papular, or vesicular rash.
what labs should be sent for suspicion of disseminated gonorrhea
Besides synovial fluid cultures, blood cultures, pharyngeal cultures, and PCR testing of urine or genital swabs should be sent.
Negative cultures do or do not necessarily exclude the diagnosis of disseminated gonorrhea
Negative cultures do not necessarily exclude the diagnosis of disseminated gonorrhea
If all cultures are negative, the disease can still be diagnosed if there is a high clinical suspicion and a rapid response to appropriate antibiotics.
Treatment for disseminated gonorrhea
Ceftriaxone 1 g IV or IM every 24 hours or cefotaxime 1 g IV every 8 hours.
IV therapy is generally recommended for 24–48 hours after improvement.
most commonly seen in young female athletes. Symptoms begin acutely with groin pain that persists and worsens as the day progresses. On physical exam, there is often mild tenderness over the proximal one-third of the femur. Range of motion of the hip is normal. Radiographs are usually normal.
Femoral Stress Fractures
femoral stress fractures are most common in
Athletes who have recently increased their level of training
Women
Persons with decreased bone density
The most common stress fractures are
tibial and metatarsal.
diagnostic of choice for femoral stress fractures
MRI and bone scans
Many stress fractures heal with
reduced physical activity and short-term immobilization.
Femoral stress fractures may resolve with
decreased weight bearing (crutches) or may require casting or internal fixation.
most commonly presents in older patients with severe, acute pain of the first metatarsophalangeal (MTP) joint. The pain generally begins acutely and becomes unbearable within hours of onset. Classically, patients say that they are not even able to place a bed sheet over the toe. On physical exam, the first MTP joint is warm, swollen, and red.
Gout
most common inflammatory arthritis and most common crystal-induced arthropathy.
Gout
attacks occur when sodium urate crystallizes in synovial fluid inducing an inflammatory response.
Gouty attacks
The primary risk factor for gout is
hyperuricemia
The prevalence of gout increases with ___ and is more common in ___ than ___.
The prevalence of gout increases with age and is more common in men than women.
The classic location for gout is the
first MTP joint (podagra).
other sites for gout that are less common though usually seen after and initial attack of podagra
The joints of the lower extremities and the elbows
common causes of Gouty attacks that cause a abrupt change in uric acid levels
Large protein meals
Alcohol binges
Initiation of thiazide or loop diuretics
Initiation of urate-lowering therapy
Worsening kidney disease
can also be induced by trauma, illness or surgery
The initial gouty attack nearly always involves ___ joint, while later attacks may be ___
The initial attack nearly always involves a single joint, while later attacks may be polyarticular
Tophaceous gout occurs when there is
macroscopic deposition of sodium urate crystals in and around joints.
what organ can be affected by gout
Sodium urate stones or a urate nephropathy can develop in patients. (kidney)
most common type of gout.
Acute gouty arthritis
what form of gout can develop in patients who have untreated hyperuricemia.
Chronic arthritis
Patients with a new diagnosis of gout should be evaluated for
alcoholism, chronic kidney disease, myeloproliferative disorders, and hypertension.
Patients in whom gout develops before the age of thirty should be evaluated for
disorders of purine metabolism.
Acute, inflammatory, monoarticular arthritis is an absolute indication for
arthrocentesis.
what can be done to rule out potentially joint destroying septic arthritis and usually make a diagnosis.
sampling synovial fluid
Every acute, inflammatory joint effusion should be
aspirated
Joint fluid should be sent for
cell count, Gram stain, culture, and crystal analysis.
Yellow and clear synovial fluid
normal or OA
yellow green and cloudy synovial fluid
RA or similar arthritides
yellow green and opaque
synovial fluid
Acute crystal or septic arthritis
what are the classifications of treatment in gout
abortive (treat acute flare)
prophylactic (to prevent flares and the destructive effects on the joints and kidneys).
abortive treatment for gout and potential adverse effects
NSAIDS -
Nephrotoxicity
GI toxicity
Colchicine - GI toxicity (diarrhea)
Oral corticosteroids-
GI toxicity
Hyperglycemia
Intra-articular corticosteroids
Complications of joint -injection
Hyperglycemia
5 basic indications for prophylactic therapy for gout
Frequent attacks
Disabling attacks
Urate nephrolithiasis
Urate nephropathy
Tophaceous gout
nonpharmacologic interventions to decrease uric acid levels.
Decrease intake of high purine foods (red meat, shellfish, yeast rich foods)
Weight loss
Discontinuation of medications that impair urate excretion (eg, aspirin, thiazide diuretics).
Potential prophylactic treatments for GOUT
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Antigout agent-
Colchicine
Xanthine oxidase inhibitors-
1)Allopurinol - contraindicated in pt with chronic kidney or liver disease
2)Febuxostat - avoid with high cardiovascular risk
Uricosuric agent
1) Probenecid (must have GFR > 30)
2)Sulfinpyrazone
Uricase agents (eg, pegloticase) - tophaceous and actively symptomatic disease
Urate-lowering therapy does not reduce the risk of gout attacks for at least
6 months
If xanthine oxidase inhibitor therapy is ineffective, uric acid excretion should be measured. Patients with low uric acid excretion (present in 80% of patients with gout) should be given a
uricosuric agent
presents in different ways at different stages of the disease. A classic presentation of the joint symptoms is a patient with acute, inflammatory knee pain who has been in an area where the disease is endemic. There may be a history of a previous tick bite, rash, or nonspecific febrile illness.
lyme disease
Lyme disease is caused by
the spirochete Borrelia burgdorferi, transmitted by a number of species of Ixodes ticks.
The tick most commonly transmits the disease during its
nymphal stage
lyme disease season
Peak incidence is in June and July, with disease occurring from March through October
Transmission from a tick that has been discovered and removed is
very low.
when does transmission from infected nymphal ticks generally occur
only after 36–48 hours of attachment (longer for adult ticks).
what finding is most common in the early localized lyme disease
skin findings
usually a large area of localized erythema.
about 50% of the time the acute rash in early lyme disease occurs where
below the waist
The mean diameter of the rash for lyme disease
10cm
what can the rash look like with lyme disease
60% homogenous erythema
30% classic target lesion
10% have multiple lesions
symptoms for early localized lyme disease stage
rash
Myalgias and arthralgias (59%)
Fever (31%)
Headache (28%)
Early disseminated disease (weeks to a couple of months after the bite) usually involves the ____ and the ____
CNS
Heart
CNS symptoms lyme disease
headache
facial nerve palsy
lymphocytic meningitis
radiculopathy
Cardiac disease r/t lyme disease generally involves
conduction abnormalities (heart block).
Joint symptoms predominate ___ in the lyme disease.
late
type of arthritis is the most common joint related finding with lyme disease
Monoarticular knee arthritis
Definitive diagnosis of Lyme disease is based on
clinical characteristics, exposure history, and antibody titers.
_____are insensitive early in the disease and are thus not helpful in the setting of acute infection.
Antibodies
Treatment of arthritis caused by Lyme disease consists of
4 weeks of oral antibiotics.
Chronic symptoms that develop after appropriate treatment of Lyme disease do not respond to
intensive antibiotic therapy.
most commonly presents in older patients as chronic joint pain and stiffness. Pain is usually worse with activity and improves with rest. Knees, hips, and hands are most commonly affected. On examination of the joints, there is bony enlargement without significant effusions. Mild tenderness may be present along the joint lines. There is limited range of motion. Radiographs are diagnostic.
Osteoarthritis (OA)
disease of aging, with peak prevalence in the eighth decade. However, as obesity is a risk factor, it may be seen in much younger people with severe obesity.
OA
OA is More common in ____ than ___
More common in women than men
often referred to as “wear and tear” arthritis
OA
Joint destruction manifests as a loss of cartilage with change to the underlying bone seen as bony sclerosis and osteophyte formation.
OA
OA is most common in the
knees, hips, hands, and spine.
arthritis
Pain with activity
Relief with rest
OA
Gelling: Joint stiffness brought on by rest and rapidly resolving with activity
OA
Late in the disease, constant pain with joint deformation and severe disability is common.
OA
Pain with activity
Relief with rest
Periarticular tenderness
Occasional mildly inflammatory flares
Gelling: Joint stiffness brought on by rest and rapidly resolving with activity.
Late in the disease, constant pain with joint deformation and severe disability is common.
OA
there is bony enlargement, crepitus, and decreased range of motion without signs of inflammation or synovial thickening.
OA
Knee
Crepitus
Tenderness on joint line
Varus or valgus displacement of the lower leg related to asymmetric loss of the articular cartilage.
OA
Marked decrease first in internal and then external rotation in hip
Groin pain with rotation of the hip
OA
Tenderness and bony enlargement of the first carpometacarpal joint
Joint involvement in decreasing order of prevalence is DIP, PIP, MCP.
Heberden nodes (prominent osteophytes of the DIP joints)
Bouchard nodes (prominent osteophytes of the PIP joints)
OA
Spine
Pain and limited range of motion are common.
Radicular symptoms resulting from osteophyte impingement on nerve roots is seen.
Spinal stenosis with associated symptoms (radiculopathy and pseudoclaudication) can result from bony hypertrophy .
OA
diagnosis of OA
compatible history, physical exam, and radiologic findings.
decreases the symptoms of lower extremity OA.
Weight loss
nonpharmacologic have been shown to improve pain and improve the efficacy of pharmacologic interventions in OA
Patient education and improved social support
can help patients with functional impairment due to OA.
Physical and occupational therapy
Frequently used as initial therapy given its low side-effect profile.
Recent data has questioned its efficacy.
for OA
Tylenol
____ are probably more effective than ____ for severe OA.
NSAIDs are probably more effective than acetaminophen for severe OA.
Oral combinations of ____and _____ ____ probably are modestly effective in some patients and have a very favorable side-effect profile.
Oral combinations of glucosamine and chondroitan sulfate probably are modestly effective in some patients and have a very favorable side-effect profile.
intra-articular med that is very effective for pain relief in acute flares of OA
Intra-articular corticosteroids
given by intra-articular injection may provide a small benefit to some patients for OA
Hyaluronic acid
pain meds for severe symptoms of OA
Tramadol and opioid analgesics
surgical options for OA
Arthroscopic surgery for OA is probably ineffective.
Hip and knee replacement can have remarkable effects on decreasing pain and improving function in patients in whom conservative therapy has failed.
commonly seen in young people who are in contact with children (mothers, teachers, daycare workers, and pediatricians).
may present with a flu-like illness, macular rash, arthralgias/arthritis, or any combination of these symptoms. Joint symptoms generally improve over the course of weeks.
Parvovirus
5 major manifestations of parvovirus infection in humans.
Erythema infectiosum (fifth disease) in children
Acute arthropathy in adults
Transient aplastic crises in patients with chronic hemolytic diseases
Chronic anemia in immunocompromised persons
Fetal death complicating maternal infection prior to 20 weeks gestation.
In adults, parvovirus infection usually includes some combination of
viral symptoms, arthritis, and rash.
Nonspecific viral symptoms for parvovirus
fever, malaise, headache, myalgia, diarrhea, and pruritus.
The arthritis is a symmetric polyarthritis.
Commonly involved joints are elbows, wrists, knees, ankles, feet.
parvovirus
rash seen in parvovirus
usually a peripheral macular rash that occasionally spreads to the trunk.
incidence of parvovirus infection peaks between
January and June.
Viral causes of arthritis
Parvovirus
Rubella
Hepatitis B
HIV
ANA can be transiently elevated in patients with
parvovirus
Common cause of “stiff neck” in patient who is otherwise well
Often noticed upon wakening
Spasm of the cervical and upper back muscles
Neck pain often worst with lateral flexion
Head tilt often present
Cervical strain
Pain and stiffness of cervical spine, usually with radiation to upper back and arm
Occasionally manifests solely as pain between spine and scapula
Spurling test: sensitivity, 30%; specificity, 93%
MRI diagnostic
Cervical radiculopathy
Shoulder pain, often subacute onset, often worse at night
Positive painful arc test
Subacromial or rotator cuff disorder
Shoulder pain, often subacute onset, often worse at night
Occurs after injury in younger patients
Often spontaneous in older patients
Rotator cuff tear
Pain over tendon insertion on medial and lateral epicondyle
Tenderness at site of pain
Exacerbated with wrist flexion (medial) or extension (lateral)
Lateral and medial epicondylitis
Pain over olecranon bursa
Tenderness and swelling over the olecranon bursa
Olecranon bursitis
Pain at the lateral base of the thumb
Worse with pincer grasp
Positive Finkelstein maneuver (ulnar deviation of wrist with fingers curled over thumb)
DeQuervain tenosynovitis
Pain over bursa
Patient often notes pain when lying on area at night
Tenderness over bursa
Sometimes visualized on radiograph
Trochanteric bursitis
Pain or numbness over lateral thigh
Often after weight gain or loss
Neuropathic-type pain
Abnormal sensation over lateral femoral cutaneous nerve distribution
Meralgia paresthetica
Anterior knee pain, often worse climbing or descending stairs
Crepitus beneath patella
Patellofemoral syndrome
Ligament injuries tend to be traumatic
Classically associated with the knee giving way
Meniscal injuries may be traumatic or degenerative
Knee locking is classic
Ligament injuries will manifest as laxity on exam
Meniscal injuries as a click
MRI is diagnostic
Meniscal and ligamentous injuries
Pain over distal tendon
Pain and stiffness worse after inactivity
Tenderness over insertion of tendon
Achilles tendinitis
Pain anterior to heel
Worse with first standing
History usually diagnostic
Radiograph may show heel spur
Plantar fasciitis
Pain between the second and third or third and fourth metatarsal heads
Tenderness between the second and third or third and fourth metatarsal heads
Morton neuroma
Diffuse pain syndrome
Often nonrestorative sleep
Fibromyalgia
Pain and disability of large muscles of shoulder and hips
Disease is often associated with findings consistent with inflammatory disease (anemia, elevated CRP and ESR)
Polymyalgia rheumatica
most commonly presents as joint pain in middle-aged patients with a history of psoriasis. There are signs and symptoms of an inflammatory arthritis often involving the wrists, MCP, PIP, and DIP joints. Exam of the skin reveals psoriasis and psoriatic nail changes.
Psoriatic arthritis
Patients with these diseases classically have a negative ANA and RF, giving the group the “seronegative” moniker.
Psoriatic arthritis
Oligoarthritis often involving large joints and the hands. Dactylitis, a swelling of the entire finger causing a “sausage digit” secondary to both arthritis and tenosynovitis, is a classic finding.
Psoriatic arthritis
Common involvement of DIP joints
Spine involvement that is uncommon in RA
Arthritis mutilans, a syndrome in which there is marked boney destruction around joints causing “telescoping digits.”
Psoriatic arthritis
most diagnostic feature of psoriatic arthritis is the
presence of psoriasis.
(pitted, “oil stained” nails).
Psoriasis
The treatment of psoriatic arthritis is similar to the treatment of
RA
most commonly seen in middle-aged patients with a symmetric polyarthritis manifesting itself with painful, stiff, and swollen hands. Morning stiffness is often a predominant symptom. Swollen and tender wrists, MCP, and proximal interphalangeal (PIP) joints are usually seen on exam. Laboratory evaluation may reveal an anemia of inflammation and positive RF and anti-citrullinated protein antibody (ACPA, sometimes called anti-CCP).
Rheumatoid arthritis (RA)
Laboratory evaluation may reveal an anemia of inflammation and positive RF and anti-citrullinated protein antibody (ACPA, sometimes called anti-CCP).
Rheumatoid arthritis (RA)
Symmetric arthritis of the hands
Presence of serum RF and ACPA
Presence of radiographic changes on hand and wrist radiographs.
Prolonged morning stiffness (> 30–60 minutes) is a classic finding in those with inflammatory arthritis.
RA
Prolonged morning stiffness is a clue to an
inflammatory arthritis
Joints commonly involved in RA
hand (wrists, MCP, PIP joints) Elbow knee ankle cervical spine
arthritis that when seen in cervical spine presents as neck pain and stiffness
RA
what causes joint destruction in RA
chronic synovitis causes erosions of bone and cartilage
Rheumatoid nodules, when present, are usually over extensor surfaces.
Dry eyes are common.
Pulmonary nodules or interstitial lung disease
Pericardial disease
Asymptomatic pericardial effusion is most common.
Restrictive pericarditis can occur.
Anemia of inflammation
RA
A positive ACPA is very predictive of a diagnosis of
RA
ACR criteria
score of >= ____ fulfills the criteria
A score of ≥ 6/10 fulfills the criteria of RA
what drugs are used to treat RA
NSAIDS
Corticosteroids
DMARDS (hydroxychloroquine, methotrexate, leflunomide, sulfasalazine)
Biologic DMARDS (Etanercept, Infliximab, Abatacept, Rituximab)
A common course of therapy for RA
begin with low-dose prednisone and methotrexate. In patients not adequately controlled, the next step is would be the addition of hydroxychloroquine or biologic, such as etanercept.
classically presents as a subacute, oligoarticular arthritis, often involving the knees, ankles, and back. Physical exam reveals arthritis. There may be a history of an antecedent infection and symptoms of urethritis and conjunctivitis.
Reactive Arthritis
extra-articular manifestations of Reactive Arthritis
enthesitis, tendinitis, bursitis, urethritis, or conjunctivitis.
nail changes, and oral ulcers.
Bacteria commonly implicated in reactive arthritis are
Shigella
Salmonella
Yersinia
Campylobacter
Chlamydia
history of diarrhea urethritis conjunctivitis fever arthritis in knees, ankles, feet
Reactive arthritis
In most patients, symptoms of reactive arthritis resolve within
1 year
in Reactive arthritispatients with a chronic arthritis, negative traditional cultures, but evidence of persistent chlamydial infection (positive synovial fluid or blood polymerase chain reaction [PCR]) be treated with
antibiotics.
classically presents in a child in the weeks following streptococcal pharyngitis. The 5 cardinal manifestations are arthritis, carditis, rash, subcutaneous nodules, and chorea. The arthritis is typically migratory, involving the knees, ankles, and hands.
Rheumatic fever
Rheumatic fever is an inflammatory disease that follows streptococcal pharyngitis by - weeks.
2-4
in rheumatic fever clinical documentation of a previous streptococcal infection is ___in adults and the most pronounced symptoms are joint pain and stiffness.
rare
Rheumatic fever may involve what organ in what way
any, or all, parts of the heart—pericarditis, myocarditis, endocarditis, or pancarditis.
diagnosis of rheumatic fever is based on the
Jones Criteria.
what is the mainstay of therapy for Rheumatic fever
ASA
What meds are used in Rheumatic fever
ASA
corticosteroids for severe carditis
PCN for strep
lifelong prophylactic therapy with PCN recommended after initial therapy
presents as subacute joint pain associated with low-grade fever and progressive pain and disability. Because the infection is usually caused by hematogenous spread, a risk factor for bacteremia (such as injection drug use) is sometimes present.
Septic arthritis
what joint is the most commonly affected in septic arthritis
knee
2 most common organisms in order for septic arthritis
Staphylococcus aureus
Streptococcus
Fever can /cannot distinguish septic arthritis from other forms of monoarticular arthritis.
cannot
Patients with gout may be febrile while those with septic joints may not be.
Definitive diagnosis for septic arthritis is
made by Gram stain and culture of synovial fluid
Empiric therapy for septic arthritis should cover
S aureus
Affected joints in septic arthritis should be
drained
presents in a young woman with fatigue and arthritis, commonly of the hands. There are often suspicious findings in the history such as an episode of pleuritis or undiagnosed anemia.
Systemic Lupus Erythematosus (SLE)
a systemic autoimmune disease primarily affecting women of childbearing age.
Systemic Lupus Erythematosus (SLE)
Almost every organ can be involved, although the joints, skin, serosa, and kidneys are most commonly affected.
Systemic Lupus Erythematosus (SLE)
Arthralgia Rashes kidney involvement arthritis Raynaud phenomenon CNS involvement (Headaches) GI (Abd pain) Lymphadenopathy Pleurisy Pericarditis
SLE
4 or more criteria to standardize diagnosis of ____
malar rash discoid rash photosensitivity oral ulcers nonerosive arthritis Serositis (pleuritis or pericarditis) Kidney disorder (proteinuria, cellular casts) headache, seizures, psychosis hemolytic anemia immunologic disorder positive ANA
SLE
the most sensitive test for SLE. It is nonspecific.
ANA
Anti-ds-DNA and anti-Sm are highly specific
SLE
Lupus nephritis
A negative___essentially rules out SLE
A negative ANA essentially rules out SLE
A positive____ or ____essentially rules in SLE.
A positive anti-ds-DNA or anti-Sm essentially rules in SLE.
Anti-ds-DNA
Nephritis in SLE
Anti–Smith
SLE
Anti-RNP
Raynaud phenomenon and myositis in SLE
SLE treatment
NSAIDs, corticosteroids, and immunosuppressants are the mainstays of therapy
