week 6- musculoskeletal Flashcards
• Musculoskeletal disorders (MSDs) can affect the body’s:
o muscles, joints, tendons, ligaments and nerves.
• Musculoskeletal dos Etiology is very broad and can be due to:
o injury, inflammatory disease, mechanical degeneration, infection, metabolic disorders, crystal accumulation, cancer or environmental exposure.
• Joint Classifications:
o Synarthroses- ‘suture lines’ found in skull
o Amphiarthroses- adjacent bones bound by flexible fibrocartilage (ex: pubic symphysis, SI jt upper 2/3rds, intervertebral discs)
o Diarthroses-articular design, contain synovial membrane and synovial fluid (lower 1/3rd SI joint, crico arytenoid, TMJ, facets, knee, etc.)
• Synovial Fluid roles:
o Reduction of friction - lubricates the articulating joints
o Shock absorption - becomes more viscous under applied pressure.
o Nutrient and waste transportation
• Tenosynovium:
o Protective lining of tendons
• Articular Cartilage:
o Reduce friction and absorb shock
o 70% water
o Type II collagen
o Large proteoglycan
• Terms for # of joints involved:
o Monoarticular- involving one joint
o Pauciarticular- involving 2-4 joints
o Polyarticular- involving 5 or greater joints
• Types of inflammation of the synovium:
o Synovitis- Inflammation of the synovial membrane
o Tenosynovitis- Inflammation of a tendon and its enveloping sheath.
o Stenosing- swelling of a tendon sheath causing “triggering”
o Serous synovitis- synovitis with a large effusion of nonpurulent fluid
• General hx for M/S dos:
o Onset and progression o location of pain o Regional vs generalized o Symmetrical vs asymmetrical o Peripheral vs central o Acute vs chronic o Progressive vs static
• Specific hx for M/S do:
o Morning stiffness? (>1hr → inflam dz)
o quality of pain? Pain scale
o pain at rest? Time of day. How long does it last?
o ADLs impacted? Work, school, cooking, etc
o Modalities
o Travel?
o Swelling? ROM?
o Diet, Exercise, Hobbies, Sex hx, Toxic exposure, Hx trauma
o family members w similar problems?
• patterns of joint involvement in M/S dos:
o Symmetrical: RA, polymyalgia rheumatica, SLE, viral arthritis and drug/serum sickness reactions.
o Asymmetrical: gout, PsA, ReA
o Monoarthritis: infx, crystals, trauma, tumor
• Assoc sxs to ask about w M/S do:
o fever, weight loss, fatigue, weakness
o scalp tenderness, vaginal burning, penile discharge,
o deformity, locking, giving way, snapping?
o Assoc eye, bowel, skin rash, oral ulcers, pleurisy?
• General PE for M/S do?
o Temp o Eyes: inflammation o Skin: rashes, vasculitis o extensor aspects of forearms: nodules o Shins: erythema nodosum o Nail changes: PsA o suspect rheumatic fever, listen to heart o LA o Other systems if indicated
• Categories of abnormality in a jt exam:
o Deformity o Swelling (hard or soft?) o Color Change o Muscle atrophy o Changes in ROM o Changes in Gait
• Upper Extremity- ROM
o Observe dorsal and palmer surfaces for atrophy
o Spread all fingers (extension)
o Make a fist (flexion)
o Pronate and supinate with fist
o Flex/ext wrist, then elbow
o AROM of shoulder is all directions, place hands behind head of ext rotation assessment
• Lower Extremity- ROM
o Inspect (standing and lying)
o Hip flexion by lifting knee, then open for external rotation
o Return leg to neutral and internally rotate ankle for hip internal rotation
o Flex/extend knee
o Feel up the shin for cool knees
o Ballottement of the patella? Not the most sensitive test!
• Pattern of joint involvement for dos: Hands
o OA - DIPS, PIPS. rare MCP, wrist
o RA - PIPS, MCP’s, wrist. very rare DIPS
o Psoriatic - nails, asymmetric. DIP; PIP, MCP, sausage fingers
o SLE-similar to RA, interarticular dermatitis, periungual erythema
o Scleroderma - skin thickened, flexion contractures, Raynaud’s
o Crystal arthropathies, Sarcoidosis – DIP, PIP, MCP
• Jt patterns in elbow:
o loss of 180° of extension is early change in arthritis
o tennis elbow- pain w pressure over lat. Epicondyle
• jt patterns in shoulder:
o raise hands over head- assess ROM, weakness, pai
o RA- occ. Swellin
o bursitis- common are
o tendonitis- common
• jt patterns in feet and ankle:
o RA- rubbery below, front of, behind malleoli; MTP’s or whole midfoot swollen, tender
o ReA, PsA: IP synovitis
o Gout- IP synovitis, 1st MTP of great toe
• Jt patterns in spine:
o OA - ↓ cervical flexion, facet joints often affected
o Ankylosing spondylitis- ↓lumbar flexion, chest expansion
o Osteomyelitis, leukemia, CA, compression fxs, herniated disk- localized bone pain
o Fibromyalgia- trigger points
• Jt patterns in knee:
o look for meniscus tear, collateral ligament injuries, cruciate via M/S exam
o Assess for edema
• Jt patterns in hip:
o OA - large weight-bearing joints
o Arthritis- limp
o bursitis- tenderness over greater trochanter
• general labs for M/S dos:
o ESR- non-specific o CRP- more sensitive o Serum uric acid (gout) o CBC: infx, anemia (of chronic dz) o Urinalysis: any renal involvement (esp SLE)
• Antibodies in M/S dos:
o RF: not specific for RA. (-) in osteoarthritis, gout, rheumatic fever, reactive arthritis, infection arthritis, ulcerative colitis
o Anti-CCP (anti-cyclic citrullinated peptide antibody)- more specific than RF. RA. Also (+): SLE, Sjögren’s, TB
o ANA: SLE 95%, scleroderma 60 -70%, Sjorgen’s 50 - 60%, RA 20 - 50%, dermatomyositis 10-50%, polyarteritis 10%
o Anti-DNA, anti-Sm, anti-ribonucleoprotein- SLE
• Other assoc w M/S do:
o HLA-B27: spondyloarthropathies (AS), ReA, PsA
o Vit D def: many M/S dos
• X-rays for M/S dos:
o tumors, calcifications, cysts, jt space narrowing, Periarticular osteopenia
o useful first line investigation.
o Other imaging modalities may be needed
• Synovial fluid as a dx tool:
o Assess inflam, infx, hemorrhagic, crystals
o suspicion of septic arthritis (acute monoarthritis) → immediate aspiration of synovial fluid
o dx: crystal arthropathies and inflam conditions
• Types of causes of polyarthritis:
o Infx: viral, direct bacterial, reactive to bacterial, other infx o Crystal arthropathy/metabolic disease o Systemic rheumatological disease o Systemic vasculitic disease o Spondyloarthropathies o Endocrine disease o Malignancy o Degenerative/structural o Miscellaneous
• Viral infx causng polyarthritis:
o EBV, CMV, HBV, Mumps, HIV
• Direct bacterial infx →polyarthritis:
o Gonococcal, staph aureus, strep, g(-)
• Polyarthritis dt reactive bacterial infx:
o Gonococcal, Campylobacter, chlamydia, salmonella, shigella, rheumatic fever (GAS)
• Polyarthritis dt other infx:
o Lyme, TB, fungal, Whipple’s dz
• Crystal arthropathy/metabolic disease → polyarthritis:
o Gout (urate, pseudogout (Ca pyrophosphate), Wilson’s dz, hemochromatosis, amyloidosis, hyperlipidemia
• Systemic rheumatological disease → polyarthritis:
o RA, SLE, polymyositis/dermatomyositis, JIA, scleroderma, sjogrens
• Systemic vasculitic disease → polyarthritis:
o HSP, polyarteritis nodosa, Wegener’s, giant cell arteritis
• Splondyloarthropathies→ polyarthritis:
o AS, PsA, EA (IBD)
• Endocrine dz → polyarthritis:
o Hyper-PTH, hyper/hypo-thyroid, acromegaly
• Malignancy → polyarthritis:
o Mets, multiple myeloma
• Degenerative structural dos → polyarthritis:
o Osteoarthritis, neuropathic jts
• Miscellaneous causes → polyarthritis:
o Sarcoidosis, fibromyalgia, Marfan’s, osteomalacia
• RA etio:
o Multifactorial and complex: TLRs, Genetic, Epigenetics, Infx (P. gingivalis).
o Environment: E mimickers.
o Hormonal: E metabolism, PRL, adrenal hormones
o Nutritional Def: Vit D, Omega 3
o Sugar
• RA epidem:
o F > M 3:1.
o Any age, peak onset 50-75
o 1% pop (~6.5M in US)
• RA ssx:
o Variable: Insidious, sudden, migratory, intermittent, unrelenting, hand and foot swelling
o Pain, stiffness, swelling of >5 or ↓5 jts. Morning stiffness (usu >1 hr).
o usu symmetric (MCP, PIP, wrist, MTP, elbow, knee, midfoot)
o Palindromic onset: episodic attacks resolve as they have come on
o often → full blown RA
o 1/3 systemic onset w myalgia, fatigue, ↓fever, ↓wt, depression
o Uncommon: extra-articular dz w/o synovitis
• RA labs:
o anemia 80%, normochromic/ normocytic or slightly hypochromic, Hb usu >10
o ↑CRP, ESR.
o RF+50-95%, ↑ titer helps confirm dx, worse px
o a-CCP 95%
o synovial fluid: cloudy, sterile, ↓viscosity, 3-50,000 WBCs (usu PMNs)
• RA imaging:
o Periarticular osteopenia o Jt space narrowing o Bare area erosions o Subluxation o Ulnar deviation of fingers o Carpal collapse o Ankylosis
• RA ddx:
o Acute viral polyarthritis
o SLE. ReA. Arthritis of IBD. Lyme arthritis. PsA.
o Crystalline arthritis. Osteoarthritis.
o Paraneoplastic dz.
o Sarcoid.
o Polymyalgia rheumatica
• JIA, systemic onset:
o MC chronic dzs in kids. Dx of exclusion! No lab to definitively dx
o 10-15% of children (aka Still’s Dz). F=M, onset ↓17
o Affects all joints, may destroy
o Ssx: ↑fever, rashes (pale pink blanching), generalized LA, HSM, serositis.
o Often mistaken for infx or malignancy.
o Complications: cardiac tamponade, vasculitis, M0 activation syndrome (MAS).
o Labs: RF/ANA (-), ↑WBCs (20,000+), ↑Ns, anemia, ↑CRP (all may precede arthritis)
• Polyarthritis type JIA:
o 30-40% of kids, F > M 3:1, bimodal peak age 2-5, then 10-14
o Ssx: Affects any jt (small and large). >5 jts in 1st 6 mos. Rare systemic dz but mb fatigue, anorexia, poor growth. Can destroy jts
o Labs: mild anemia, mild ↑ESR, ↓ ANA in young, +RF in 10-20% older
• Pauciarthritis (aka Oligoarthritis) type JIA:
o 50% of children, F > M 3:1, peak 2-3
o Ssx: ↓5 jts in 1st 6 mos. No systemic dz. Rare destroy jts. Usu larger jts (knee, shoulders, elbows) but not hips. Jts are warm, swollen, tender, not erythematous. Chronic uveitis (often asx)
o Lab: CBC, ESR, CRP, RF (-). ↓ ANA common esp w/ uveitis
• Psoriatic JIA
o Bimodal age onset. preschool girls like oligoarthritis. Later like adult PsA
o Ssx: Variable. Mild enthesitis to polyarticular involvement of multiple axial (spine and SIJ) and peripheral jts, dactylitis, DIP rare. Mb skin, psoriatic plaques, guttate nail pitting
o Labs: can have +ANA, CRP, ESR, thromocythemia but not always. RF, CCP(-)
• Entheses JIA/ Spondyloarthritis
o Common mis-dx initially w recurrent sprains or strains
o Ssx: Pauciarticular, asymmetric, usu leg jts. Enthesitis mc legs. Knees, ankles, heel pain, hip pain. Uveitis (pnful or pnless)
o Lab: HLA-B27 mb +. Mb ↑ESR, CRP in severe dz.
o X-ray usu normal, MRI mb sacroilitis
• Epidem/etio of Sjogrens:
o 2-3 million+ in US.
o 90% are F
o 1st: Specific AI
o 2nd: mc RA, SLE, scleroderma, pulmonary fibrosis
• Sjogren’s ssx:
o Xerophthalmia (dry eyes): Keratoconjunctivitis sicca (Burning, itching, Foreign Body sensation, Corneal ulcers, Conjunctival injection) o Xerostomia (dry mouth): difficulty chewing, swallowing, tooth decay, if severe difficulty speaking o Other exocrine: Vasculitis, Vag dryness, Pleuritis, Obstructive lung dz (no smoking), Peripheral neuropathies, Pancreatitis, RTA in 20%, Chronic interstitial nephritis, Cryoglobulinemia →glomerular lesions, Dry skin, Chronic bronchitis
• Sjogren’s PE:
o dryness: Oral cavity, eyes, skin
o 2nd: red, hot, swollen jts. hair loss, rash, mouth/oral sores, easy bruising, thyroid, tender abd, tight skin, weak muscle, tender temporal artery
• Sjogren’s labs:
o ANA+ (Ro/ SSA, La/SSB, Sm, RNP) o RF+ o a-cardiolipin and lupus anticoag o ACA B or topoisomerase, w nucleolar pattern; ANCA w vasculitis o a-dsDNA w proteinuria o TFT w Abs o Serum C3 and C4 o Serum cryoglobulins o CBC: mb leukopenia, anemia o CMP: mb ↑transaminases o Serum, urine protein & immune electrophoresis o Quantitative Ig (IgG, M, A)
• Dx tests for Sjogren’s:
o Schirmer’s tear test: ↓5mm is abn
o Rose Bengal test: corneal epithelium damage
o Slit Lamp Exam of Cornea: Punctate erosive keratopathy
o Tear break-up time: tear osmolarity
• Sjogren’s Dx Criteria:
o +ANA (≥1:320) or +RF.
o Ocular staining score ≥3 (w/o eye drops).
o Lip & Salivary gland bx & US: focal lymphocytic sialadenitis, ≥1 focus/4 mm2 in labial salivary gland bx
• Ssx of discoid lupus erythematous:
o 1st lesion: erythematous papule, plaque, scaling →may thicken, adhere, pigment changes (hypo in central/inactive area, hyper at active border). Centrifugal spread, may merge.
o As lesions age: dilation of follicular openings, w keratinous plug (follicular plugging or patulous follicles). → atrophy and scarring. Photosensitive.
• 3 types of DLE:
o Localized: mc, usu neck, esp scalp, bridge of nose, cheeks, lower lip, ears.
o Generalized: lc, any degree of severity; usu thorax, arms, head, neck.
o Childhood: M=F. usu no photosensitivity, ↑ progression to SLE, mostly similar to adults
• DLE labs:
o 20% ANA(+).
o Anti-Ro (SS-A) in 1-3%.
o ↓ 5% Anti ds-DNA or anti-Sm (usu in SLE)
• DLE ddx:
o Actinic Keratosis, Dermatomyositis, Granuloma Annulare, Granuloma Faciale,
o Keratoacanthoma, Lichen Planus,
o SLE, Subacute Cutaneous, Psoriasis, Plaque, Rosacea, Sarcoidosis, SCC, Syphilis
