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RRPA Clinical Med II > Topics In MSK Jaynstein (Exam 2) > Flashcards

Topics In MSK Jaynstein (Exam 2) Flashcards

1
Q

Avascular Necrosis (AVN)/Osteonecrosis is what?

A

Necrosis of bone secondary to an interruption of blood supply

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2
Q

AVN risk factors?

A

Trauma Obstruction of blood supply: coag disorders, alcoholism (fat emboli), sickle cell disease, pregnancy Long-term steroid use Auto-immune dz and immunosuppression, chemo and radiation therapy

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3
Q

Most common bone for AVN?

A

Head of femur or humerus Scaphoid (bone of wrist) Neck of talus (tibia sits on this in foot)

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4
Q

What do you look for on XR that would indicate AVN of femoral head?

A

Crescent sign at head of femur

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5
Q

AVN sxs?

A

Progressive pain over weeks/months Early dz process: pain w/ activity/wt bearing, decreased ROM Late dz process: pain at rest with sig decreased ROM

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6
Q

AVN/osteonecrosis Dx?

A

Early xrays may be normal: unfortunately dx is usually late Eventually xrays will show bone destruction/collapse CT, MRI, and bone scan can all reveal AVN

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7
Q

AVN/osteonecrosis Tx?

A

Ortho referral for ALL! Tx directed at bone involved Hip/shoulder: almost all require replacement Scaphoid: depends on degree, may attempt to surgically restore blood supply (debride and re-align) or bone graft

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8
Q

Osteomyelitis is?

A

Inflammation and infection of bone

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9
Q

What can cause osteomyelitis?

A

Viruses, parasites, bacteria, fungi

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10
Q

What bug is most responsible for osteomyelitis?

A

S aureus is 80-90% Sickle cell pts “sickle cellmonella”

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11
Q

Osteomyelitis bugs from GU tract infections or IV drug users?

A

E coli Pseudomonas Klebsiella

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12
Q

Osteomyelitis risk factors?

A

Children IVDU DM Sickle cell Open wounds H/o hardware

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13
Q

Bones most often effected by osteomyelitis?

A

Long bones and vertebral bodies most commonly involved Toes/feet affected in DM

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14
Q

How does Osteomyelitis present clinically?

A

Acute systemic illness with malaise, fever, chills, leukocytosis and throbbing pain over affected site, pain with active and passive ROM

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15
Q

Osteomyelitis work up?

A

Labs: CBC, ESR, CRP, LDH, BCx, wound Cx, Bone Bx (Ca, phos, alk phos usually normal) Xray: STS, periosteal elevation, cortical erosion/lysis> necrotic bone (bone changes lag infection by 10-14 days; 30-50% of bone demineralization before it’s seen on xray) Bone scan, CT, and MRI are useful (MRI first if possible)

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16
Q

Osteomyelitis Tx?

A

Combination of abx and surgical drainage is usually curative Empiric Abx: Vanco+Ceftriaxone or Cirpo or Cefepime

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17
Q

Osteomyelitis complications?

A

Pathologic fx, endocarditis, sepsis, amputation

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18
Q

Chronic osteomyelitis can develop, but in which pt population?

A

Immunocompromised and DM Eventually a sinus tract breaks through skin and drains externally Tx with abx and open debridement Osteomyelitis top dxd for pt with DM with open would you can probe bone

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19
Q

Osteoma definition?

A

Benign lesions of bone that in many cases represent developmental or reactive growths rather than true neoplasms

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20
Q

Osteoma locations most common?

A

Facial bones (nose, ears) and skull

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21
Q

Osteoma age group?

A

40-50

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22
Q

Osteomyelitis age group?

A

Bimodal peaks 20yoa and 65yoa

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23
Q

Do osteomas undergo malignant change?

A

No

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24
Q

Osteosarcoma definition?

A

An aggressive malignant mesenchymal tumor in which the cancerous cells produce bone matrix

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25
Osteosarcoma is the most common bone cancer in?
Kids
26
Osteosarcoma common sites?
Long bones (proximal humerus, proximal and distal femur, proximal tibia) and mandible
27
Osteomyelitis: how long will pts be on IV abx?
6 weeks
28
Osteosarcoma presentation?
Painful and progressively enlarging masses; occasionally pathologic fx is first symptom
29
Osteosarcoma work up?
CBC, ESR, CRP, xrays, CT/MRI/PET scan
30
Approx. 20% of osteosarcoma patients have what kind of mets at time of dx?
Pulmonary mets
31
Osteosarcoma tx?
Excision, radiation (Paulson Onc 2 ppt says radio resistant), chemo
32
Osteosarcoma prognosis?
5yr survival 60%
33
OsteoStarcoma on imaging?
Sunburst appearance on bone scan Also Codman’s triangle
34
What is osteochondroma?
A benign cartilage growth that is attached to the underlying skeleton by a stalk
35
Osteochondroma more commonly involve the metaphysis of what bones in the 10-30yr age group?
Long tubular bones (like distal femur)
36
When do osteochondromas stop growing?
At the time of growth plate closure
37
Ewing Sarcoma definition?
Malignant neoplasm of bone that occurs predominantly in children-second most common malignancy after osteosarcoma Highly aggressive M:F 1.6:1 Peaks at 10-20yrs
38
Common sites of Ewing Sarcoma?
Pelvis and proximal ends of long bones (femur, tibia, humerus)
39
Presentation of Ewing Sarcoma?
Clinically presents with pain often accompanied by local inflammation, swelling/mass; fever is fairly common along with elevated ESR, anemia, and leukocytosis
40
Ewing sarcoma imaging and dx?
X-ray shows a destructive lytic tumor- onion peel appearance (Onions are Ewwy) CT/MRI/Bone scan Bx is definitive
41
Ewing sarcoma Tx?
Chemo Surgery w/ or w/o radiation This treatment increased the 5 year survival to 75%
42
Osteoarthritis (OA) definition?
Degenerative joint disease Most common type of joint disease and arthritis Characterized by progressive erosion of articular cartilage
43
OA prevalence in age groups?
\>40 yrs 70% affected \>65 yrs 80% affected
44
OA most commonly affects what joints?
Weight bearing joints and spine
45
OA risks?
Obesity, h/o trauma, overuse, female
46
OA characteristics?
Deep achy pain Better with rest Worse with use Morning stiffness \<30 mins (RA is over 30) Crepitus Limitation of ROM
47
OA PIP node? OA DIP node?
Bouchard’s node Heberden’s node B comes before H (proximal\>distal)
48
OA work-up?
Clinical dx or xray Xray shows non-uniform joint space narrowing, osteophytes
49
OA tx?
RICE (rest, ice, compression, elevation) APAP (acetaminophen) NSAIDs Wt loss PT w/ exercise program Surgery-joint replacement No means of prevention or halting progression
50
Osteogenesis imperfecta definition?
“Brittle bone disease” is a group of hereditary conditions characterized by abnormal development of type I collagen
51
Osteogenesis imperfecta is characterized by multiple bone fractures which may occur in utero in the severe forms. 1:20,000 live births. Other findings include?
Blue sclerae Hearing loss Dental imperfections Profound debilitation
52
how to dx osteogenesis imperfecta?
DNA analysis
53
Osteogenesis imperfecta Tx?
No cure Bisphosphanates Surgery w/ rods Treat pain
54
Osteoporosis definition?
Denotes increased porosity of the skeleton resulting from a reduction in bone mass and increasing the risk of fx May be localized or generalized as a manifestation of metabolic bone dz
55
Contributors to osteoporosis?
Hereditary (allele for Vit D receptor) Lack of physical activity Lack of muscle strength Poor diet Hormones (post menopausal women) Menopause accelerates loss to 3-4% annually
56
The following are related to the development of Osteoporosis?
Age related changes: in older people, bone-forming cells have diminished capacity to make bone Reduced physical acticity: mechanical forces important stimuli for normal bone remodeling Genetic factors: importance of vit D receptors Body’s calcium nutritional state: adolescent girls with insufficient Ca intake puts them at a later risk of developing osteoporosis Hormonal influence: postemenopausal osteoporosis is characterized by a hormone-dependent acceleration of bone loss; estrogen replacement protects against bone loss
57
Secondary osteoporosis causes?
Multiple myeloma Paget’s disease (elev. alk phos) Hyperparathyroidism (increased osteoclasts) Grave’s disease or hyperthyroidism Nutritional deficiency- Vit D, alcoholism, anorexia, malnutrition Chronic disease: CRF, RA, SLE, chronic liver failure, HIV/AIDS Multiple meds: steroids, anticonvulsants, PPI, loop diuretics
58
Osteoporosis manifestations ?
Vertebral fxs Lumbar lordosis Kyphoscoliosis
59
Osteoporosis screening?
All women over 65 Postmenopausal women 60-65 years with 1 risk: Fx after age 45, hip fx, tobacco use, BMI \<22, extended steroid use \>3 months No formal indications in men, consider in men over 70 with: Nontraumatic fx (esp hip, vertebrae, wrist) Glucocorticoid use (prednisone \>3mo) Hypogonadism Hyperparathyroidism
60
Osteoporosis work-up?
Labs: CBC, CMP, Ca, Phos, TSH, vit D X rays: pathologic fxs, loss of density (osteopenia)
61
DEXA scan (bone mineral density) scores? +1 to -1? -1 to -2.5? -2.5 or lower?
Normal Osteopenia Osteoporosis
62
Benefit of Tx at 3 years for hip fx and vertebral fx? Vit D? Bisphosphanates? HRT? Hormone replacement therapy
Vit D NNT 45 to prevent hip fx Bisphosphonates NNT 80 to prevent hip fx and NNT 15 to prevent vertebral fx HRT? NNT 385 to prevent hip fx (also risk of clotting CVA, DVT, PE)
63
Osteoporosis tx?
Vit D and Ca most cost effective approach Vit D 2000 IU QD (increases bone density) Ca 1200-1500mg QD (decreases bone loss) Bisphosphonates - increase bone density and prevent loss (Boniva, Actonel, Fosamax, Reclast) Calcitonin- inhibits osteoclastic bone resorption Estrogen therapy (HRT): not an initial option, contraindicated in pts w/ risk of breast or endomentrial CA
64
Osteoporosis follow-up?
Repeat DEXA Mild: 15 years Moderate: 5 years Severe: 2 years
65
Paget disease (osteitis deformans) definition?
Chronic disorder caused by the excessive breakdown and formation of bone, followed by disorganized bone remodeling that can result in enlarged, misshapen, and weak bones
66
When does Paget disease usually begin?
During middle adulthood and becomes progressively more common thereafter
67
Common sites for Paget disease?
Skull, spine, pelvis, long bones
68
What is the most common problem in Paget disease?
Pain, headache, hearing and visual disturbances, enlargement of the head, bowing and chalkstick-type fxs of legs
69
Paget disease tx?
Bisphosphonates Calcitonin
70
Rhabdomyolysis definition?
Skeletal muscle cell break down and necrosis that leads to the release of intra-cellular debris into the blood stream Electrolytes: Ca, K Proteins: myoglobin
71
Rhabdomyolysis etiology?
Exertional Crush injury, compartment syndrome Sz Hyperthermia Statins Infection Genetics “Found down”
72
Rhabdomyolysis SxS?
None Muscle pain Weakness/fatigue Swelling-legs Low-grade fever N/V Confusion/AMS Cardiac dysfunction “Tea” colored urine w/ decreased output
73
Rhabdomyolysis work-up?
* **_CPK (creatine phospokinase) elevated 5x normal_** (\>1000) * Electrolyte abnormalities: hyperkalemia, hyperphosphatemia, hypocalcemia (early) then hypercalcemia (late) * **_UA dip will be positive for blood without RBC’s_** * LFT’s may be elevated * AKI labs (acute kidney injury) * Urine myoglobin is rarely ordered * EKG * Muscle bx is definitive but not used often
74
Rhabdomyolysis Tx?
* Goals to treat shock and preserve kidney function * **_IVF (6-12 liters over 24 hrs)_** * Goal is 200-300cc’s of urine /hr * Furosemide (lasix) used but no evidence it prevents AKI (acute kidney injury) * Manage electrolyte imbalance (bring potassium levels down by giving insulin and Ca-unless hypercalcemic) * Kidney mgmt may include hemodialysis
75
Complications of Rhabdomyolysis?
Renal failure Compartment syndrome (tx w/ fasciotomy) Volume depletion shock DIC Cardiac dysrhythmias
76
Prognosis in Rhabdomyolysis?
Mortality w/ trauma 20% W/ icu admission w/o renal impairment 20% W/ icu admission w/ renal impairment 60% If survives, renal impairment improves w/ near full recovery of renal function in most patients always keep rhabdo in your ddx for all pts “found down”
77
Where can soft tissue sarcomas arise?
Muscle Fat Tendon Blood vessels Fibrous tissue Or any other type of soft tissue
78
What is the most common type of soft tissue sarcoma?
Fibrosarcoma (connective tissue)
79
Name 3 Other types of soft tissue sarcomas.
Leiomyosarcoma (leio- uterine myo- muscle) Liposarcoma (fat) Kaposi sarcoma
80
What soft tissue sarcoma do you often see with HIV+ patients?
Kaposi sarcoma
81
Are soft tissue sarcomas more common in kids or adults?
Kids, 7% of all childhood cancers
82
What are the signs and symptoms of a soft tissue sarcoma?
A soft tissue mass Only 1/3 are painful Get a good hx: fever?weight loss?night sweats?fatigue? All point to cancer
83
What is the best imaging for soft tissue sarcomas, and what is definitive?
MRI Bx
84
Tx for soft tissue sarcoma is type directed
That’s it
85
Where is a Baker cyst found, and what is it?
Behind the knee in the popliteal space. It is a synovial fluid out-pouching that is usually benign but occurs after trauma
86
What imaging modality would you use to dx a Baker’s cyst?
US
87
What is the appropriate tx for a Baker’s cyst?
RICE May aspirate large collections Corticosteroid injections Surgical excision
88
What anatomical location on the body would you find a Ganglion cyst or Bible bump?
Posterior side of the wrist (think anatomical position)
89
What is a ganglion cyst?
Benign synovial fluid collection
90
What is the tx for a ganglion cyst?
Nothing Or surgical if \>5cm Or smash that bastard with a Jesus Journal
91
How would you define compartment syndrome?
Insufficient blood supply to muscles and nerves due to increased pressure within one of the body’s compartments (arms/legs, etc) usually occurring after trauma (car crash, crush injury, burns, electrocution, s/p cast placement)
92
What are the 6 P’s of compartment syndrome, a medical emergency?
Pain out of proportion Paresthesia (pins and needles) Pallor (loss of color, pale, white) Poikilothermia (“dapple or painted,” cold, blue) Paralysis (late finding) Pulselessness (late finding...oh shit, better do a fasciotomy)
93
What are the ranges for compartment syndrome? NL? Concerning? Emergent?
\<10 10-20 \>30 mmHg
94
Tx for compartment syndrome?
Splint, never cast Elevate Fasciotomy \<6hrs from onset NO ICE! Will reduce already reduced blood flow

RRPA Clinical Med II (45 decks)

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