Week 9 MSK rheum falls Flashcards
Patho of osteoporosis
function of osteoblasts and osteoclasts
resorption of old bone (osteoclasts)
formation of new bone (osteoblasts)
Physical exam findings in osteoporosis:
- height
- rib-pelvis distance
- inability to….
- height loss >4 cm
- rib-pelvis distance <2 finger-breadths
- inability to touch occiput to wall when standing with heels to wall
decreased rib-pelvis distance is suggestive of….
occult vertebral fracture
what is the risk of prolonged bisphosphonate use?
osteonecrosis of jaw
atypical femoral fracture (subtrochanter, diaphysis of femur)
what is the max duration of treatment with bisphosphonates?
po: 5 years
IV: 3 years
LIFESTYLE risk factors for osteoporosis?
Smoking (current or former) Daily ETOH > 3 units Caffeine > 4 cups/day Inadequate calcium and vitamin D intake Lack of sunlight exposure Prolonged immobility and lack of weight-bearing exercise
MEDICAL risk factors for osteoporosis?
specific
for women?
for men?
Advanced age Frailty Hyperthyroidism (including iatrogenic) or hyperparathyroidism Celiac and other malabsorption syndromes BMI < 20 kg/m2 or weight loss Medication history, particularly chronic glucocorticoid use** Rheumatoid arthritis Chronic liver or kidney disease
For men: Androgen deficiency (primary or secondary)
For women:
Estrogen deficiency (primary or secondary)
Early menopause (< 45 years)
Cessation of menstruation for 6-12 consecutive months (excluding pregnancy, menopause or hysterectomy)
what is a fragility fracture?
common locations?
Fractures sustained in falls from standing height or less, in which bone damage is disproportional to the degree of trauma. Includes vertebral compression fractures not attributable to previous major trauma, which may be suggested by height loss.
Fractures of the hip, vertebra, humerus, and wrist are most closely associated with OP and increased future fracture risk whereas those of the skull, fingers, toes, and patella fractures are not.
when is BMD indicated? (BC Guidelines)
men and women age > 65 years
at moderate risk of fracture (10 - 20% 10-year risk),
and results are likely to alter patient care
T-score cut off
normal:
osteopenia:
osteoporosis:
severe osteoporosis:
Normal: T is -1 and above
Osteopenia: T is -1.1 to -2.4
Osteoporosis: T -2.5 and below
Established or severe OP: T is -2.5 or below and one or more prevalent low-trauma fractures
what is first line treatment for OP for those at high risk of falling?
Falls in the past year
Time taken to stand from sitting
Muscle strength, balance, and gait by watching the patient walk and move
Check and correct postural hypotension and cardiac arrhythmias
Evaluate any neurological problems
Review prescription meds that may affect balance
Provide a checklist for improving safety at home
what individuals are automatically considered high risk of OP without doing FRAX
-hip and fragility fracture
follow up of osteoporosis: when to repeat BMD?
- if not on OP meds?
- if on OP meds?
BC Guidelines: if not on OP meds, may retest in 3-10 years based on risk profile
If on OP meds, repeat BMD not justified (hard to detect changes on BMD prior to 3 years) unless specific high risk (eg on prednisone dose >7.5 mg daily for 3 consecutive months etc)
If repeat BMD is done: do on same DXA machine at same time of year
bisphosphonates:
- patient teaching
- contraindications
- side effects
Administration: swallow whole with full glass of water 30 min before first food of day; patients must not lie down for at least 30 min after dose
To enhance absorption and decrease gastrointestinal side effects emphasize proper administration
-po: available as 10 mg once daily or 70 mg once weekly
Contraindications: renal impairment [i.e., CrCl < 30 mL/min], hypocalcemia
Precautions: upper gastrointestinal problems
Adverse effects: abdominal pain, dyspepsia, nausea, esophagitis, esophageal ulcers, joint/muscle pain [may
need to discontinue if persists], ocular inflammation, osteonecrosis of the jaw (ONJ) atypical femoral fractures [although rare, seems to be more common with long term bisphosphonate use and can present as thigh or groin
pain], esophageal cancer, afib
Denosumab (prolia)
- route
- contraindications
- side effects
Administration: subcutaneous injection into the upper arm, upper thigh, or abdomen q6 months
Contraindications: hypocalcemia
Adverse effects: cellulitis, dermatitis, eczema, rashes, pancreatitis, osteonecrosis of the jaw (rare)
Osteoarthritis
risk factors
- Increasing age (55+)
- F more commonly affected, greater severity
- Genetics
- Trauma: previous #, ligamentous injury
- Obesity
- inflammation from infection, inflammatory arthropathies, metabolic disorders
Rheumatoid arthritis
risk factors
- Bimodal age distribution (30s, 70s)
- F
- Genetics: family hx
- Smoking
- Periodontal disease
- systemic illness/trauma
Onset of OA vs RA
OA: worse as day goes on, worse with activity
RA: morning stiffness
OA vs RA
affected joints and associated deformities
OA: hands, knees, hips, neck, back.
deformities: Bouchard’s (PIP), Heberden’s (DIP)
RA: peripheral joints (late onset proximal joints)
fingers, elbows, shoulders, ankles, knees, toes
PIP: boutonniere deformities, swan-neck contractures, ulnar deviation
OA vs RA
pain characteristics
OA:
Sharp/aching unilateral joint pain
Morning stiffness <30 min
Worse with activity
RA:Symmetrical
Morning stiffness >30 min
Accompanied by swelling and warmth in 3+ joints
Rheumatoid arthritis
extra-articular manifestations
Systemic symptoms: fatigue, malaise, low grade fever, weight loss, depression
Anemia, pleuropericarditis, neuropathy, myopathy, splenomegaly, Sjogren’s, scleritis, vasculitis, renal disease, carpel tunnel syndrome
Increased risk of OP #
Labwork. OA vs RA
OA: neg CRP, RF, ANA
RA: reactive CRP, RF and anti-CCP may be positive
Management of OA
Exercise and strengthening Weight loss Pain relief: • Acetaminophen up to 1 g QID first line • NSAIDs if tylenol ineffective ○ Naproxen 220-385 mg OD-BID PRN ○ Limit to 2-4 weeks max effect ○ Celebrex 200 mg OD-BID PRN • H2RA for gastritis and PUD protection • Topical voltaren ○ Preferred over po NSAIDs for those >75+ • Capsaicin Intra-articular injections: Avoid >3-4x/year
Management of RA
EARLY DETECTION to start DMARDs by rheum Exercise and joint mobility Smoking cessation DMARDS first line, start ASAP • MTX weekly first line • Sulfasalazine 500-1000 mg daily • Hydroxychloroquine 200-400 mg daily Pain relief: • NSAIDs ○ Ibuprofen 600-800 mg q6-8h PRN ○ Naproxen 500 mg q12h PRN • Prednisone for active joint inflammation ○ Short course recommended Intra-articular injections to reduce synovitis
OA
Hallmark pathology:
Xray findings
Hallmark: cartilage loss
Xray:
Joint space narrowing
osteophytes
subchondral sclerosis
RA
Hallmark pathology
Xray findings:
Hallmark: synovial inflammation extending to cartilage
Xray: Osteopenia joint space narrowing bone erosions Loss of articular space ulnar deviation
why is folate supplementation needed with methotrexate?
Folic acid supplementation during methotrexate therapy can reduce the risks of adverse effects including nausea, vomiting, abdominal pain, mouth ulcers, raised liver enzymes and bone marrow toxicity
what are two major ADE associated with hydroxychloroquine (Plaquenil)?
- retinopathy–> needs annual ophtho (q6-12 months)
- rash (rare but SJS and TENs can occur)
biologics for RA
before starting, important to check for which infections?
Screen for TB, hep B, hep C
**biologics can reactivate
**also ensure immunizations up to date
what is the most important risk factor for pseudogout (CPPD)?
other risk factors?
advanced age
-phosphate, Mg, parathyroid and thyroid disorders, hemochromatosis
All patients with PMR should be screened for….?
Giant cell arteritis
PMR
symptoms? timing?
joints affected?
acute onset ache and MORNING STIFFNESS
timing: worse in AM, lasts >1 hour
IMPROVES with activity, WORSEN with inactivity
duration: >2 weeks
joints: shoulders and/or hip girdle BILATERAL
may have fever, malaise, fatigue, decreased ADLs
also ask re: symptoms of GCA
GCA symptoms
headache
jaw claudication
***visual disturbances
fever, weight loss, and fatigue
PMR
labwork
CRP elevated
CK normal
RF and anti-CCP negative
PMR
imaging
ultrasound: bursitis, tenosynovitis, synovitis
PMR treatment
prednisone 12.5-25 mg daily
-depends on comorbidities eg brittle diabetic, frail
reassess in 1-2 weeks
recheck CRP in 4-6 weeks
often on steroids for long term before attempting taper consider OP protection
what are two main risk factors that predispose geriatric patients to foot problems?
PAD
neuropathy
what is a major foot deformity associated with diabetes?
what is an early sign?
Charcot foot
- bone disintegration and trauma (neurotrophic arthropathy) –> bone disintegration –> severe deformity
- causes altered gait, higher risk of ulceration and limb loss
EARLY SIGN: swelling, redness
will not necessarily have pain due to neuropathy
Onychia
signs and symptoms?
treatment?
complications?
-inflammation of posterior nail wall and nail bed
Sx: redness, swelling, pain
Treatment: tepid saline compress x 15 min TID (do not soak feet)
modification to shoes to relieve pressure to toe and nail
complication: paronychia, osteomyelitis (esp in presence of DM and vascular insufficiency)
what is the most common non-bacterial infection of toenails?
symptom?
treatment?
onychomycosis
-chronic and communicable
Sx: entire thickness of nail hypertophic and deformed
pain not significant due to age-related changes
Treatment: often systemic contraindicated in older adults (medication interaction, hepatotoxicity)
-debridement with 35-50% urea, topical fungicide
What are 3 questions to ask when assessing for falls risk?
Have you fallen in the last year?
Do you worry about falling?
Do you feel unsteady when standing or walking?
what are 3 main systems responsible for maintaining balance?
proprioception (dorsal column –> thalamus –> posterior spinocerebellar tract –> cerebellum)
vestibular (CN VIII)
vision
what is the role of the cerebellum in maintaining balance?
processing and responding to priorioception and vestibular input, correcting errors
SPLATT for assessing falls?
symptoms immediately prior to fall? previous falls? location? activity? time of fall? time down? trauma from fall?
risk factors that impair balance and increase risk of falls
HISTORY of previous falls medications lower body weakness, pain and stiffness from arthritis depression environmental clutter continence - rushing to use bathroom vision impairment small pets
4 S’s of a gait assessment
Sit to stand
Speed
Stance
Step patterns
what is the triad of symptoms that would raise suspicion for normal pressure hydrocephalus?
- gait disturbance
- urinary incontinence
- cognitive impairment
what is the single most effective fall prevention intervention?
participation in safe exercise program to promote strength and balance
balance training 3 or more days/week
**TAI CHI
physical exam for patient with frequent falls?
what systems to assess
- visual acuity
- CV: orthostatic vitals, arrhythmia, murmurs, bruits
- neuro: sensory, cerebellar, neuropathy, spinal stenosis, radiculopathy
- sensory exam
- MSK: strength, kyphosis, leg length measurement
- cognitive screen
- depression screen
how to measure orthostatic vitals?
what is abnormal finding?
lie down x 5 min –> measure BP and HR
stand x 1 min –> measure BP and HR
repeat at 3 min
abnormal:
SBP drop >20 mm Hg
DBP drop >10 mm Hg
what is the cause of PMR?
unknown cause
?environmental trigger (eg viruses)
?genetics
risk factors for PMR?
age >50
F>M (2-3x)
Ethnicity (northern european»_space;> African american and latino)
what is the most common joint affected in pseudogout?
knee (50%)
other joints: shoulder, wrists, ankles, feet, elbows
larger joints
psoriatic arthritis
symptoms?
joint pain, swelling and AM stiffness around insertion points of tendons and ligaments
-common to Achilles, plantar fascia, tibial tuberosity
psoriatic arthritis
history?
personal or family hx psoriasis skin rashes nail lesions (onycholysis, pitting) dactylitis (sausage digits) photosensitivity *have any treatments for psoriasis improved joint pain?
patients with rheumatoid arthritis are at increased risk of developing what comorbidities?
- carpal tunnel syndrome
- stroke
- osteoporotic fracture
- renal disease secondary to drug toxicity
- CV disease
rheumatoid arthritis
stiffness present for how long?
how many joints?
AM stiffness for at least 30-60 min
- at least 6 weeks of symptoms
- 3 joints or more
Giant cell arteritis
pharm treatment?
high dose prednisone 40-60 mg daily
- do not wait for biopsy results
- start immed to reduce risk of permanent vision loss
ASA 81-325 mg daily
NIFTI red flags for MSK assessment
neurological infection fracture tumour inflammatory
History questions to ask with arthritis?
location
stiffness
activity - improves or worsens?
impact on function
avoiding ALL activities due to pain/stiffness/weakness?
joint instability - locking, giving way, clicking
MSK assessment for hip and knee arthritis?
- sit to stand x 30 min
- hip flexion
- hip internal rotation
- knee flexion (shallow knee bend from standing if patellar joint pain)
- meniscal testing
what is dysdiadochokinesia?
the inability to perform rapid alternating muscle movements.
what kind of gait is seen in Parkinson’s?
shuffling, festination, bradykinesia, wide based
what kind of conditions can cause Trendelenburg gait?
contralateral hip abductor weakness (nerve entrapment)
radiculopathy
CNS lesion
what kind of conditions can cause steppage gait?
foot drop from peripheral neuropathy
radiculopathy
stroke
what is a normal T score?
-1 or above
what T score range is osteopenia?
osteopenia:
-1.1 to -2.4
what T score range is osteoporosis?
-2.5 and below
monoclonal antibody for osteoporosis (eg Prolia)
side effects?
myalgia/arthralgia
rashes (eczema, cellulitis)
UTI
pancreatitis
bisphosphonate (eg alendronate) patient teaching?
take with full glass of water, do not lie down for 30 min
-
labwork for diagnosis of osteoporosis
not indicated to make dx of OP or determine risk
- only helpful to r/o secondary causes of OP
- vit D testing not required to dx or recommended before/after starting supplementation
what is the role of PTH on serum calcium concentration?
- action on bone?
- action on kidney?
increase serum Ca, decrease serum PO4
PTH acts on bone to RELEASE calcium by stimulating osteoclasts
PTH acts on kidney to INCREASE calcium reabsorption
what is role of vit D3 on bone mineralization?
-works as co-factor with PTH –> promotes calcium and PO4 absorption in gut
what is a T-score?
what is a Z-score?
T score compares your bone density to that of a healthy 30 year old white woman
*T score used for adults 50+
Z-score compares your bone density to the average bone density of people your own age and gender. For example, if you are a 60-year-old female,
Z-score compares your bone density to the average bone density of 60-year-old females.
*Z score used for adults <50
what symptoms would make someone suspect inflammatory arthritis?
- pain increased with rest
- persistent joint swelling/tenderness
- frequent warmth/erythema
- 3+ joints affected
- AM stiffness > 30 min
- unexplained weight loss
RA increases risk of _______ mortality (2x general population)
cardiovascular
if RA is suspected, NP can order ______ until dx of RA is confirmed by rheum
hydroxychloroquine
side effects associated with hydroxychloroquine?
GI: nausea, diarrhea, anorexia
Rash: TENS
Serious: retinopathy, myopathy
eye exam q6-12 months
side effects associated with methotrexate?
GI: nausea, vomiting, oral ulcers
myalgia
Serious: bone marrow toxicity (NO septra), hepatitis, infection, pneumonitis
side effects associated with sulfasalazine?
nausea, headache, rash
serious: bone marrow toxicity
monitoring bloodwork MTX?
CBC, Cr, LFT, hep B and C at baseline
CBC, LFT, albumin, Cr monthly
monitoring bloodwork for sulfasalazine?
CBC with diff, LFT monthly
what spinal level has highest incidence of spinal stenosis?
L4-L5
L5-S1
larger diameter of lower lumbar and sacral roots
early symptoms of spinal stenosis
Neurogenic claudication, low back pain, unilateral leg pain (sciatica-type), numbness, weakness, sensory disturbances
nature of back pain with spinal stenosis
type: location: radiation: exacerbation: Relief:
lower back pain: type: cramping, aching, burning in lower extremities
location: back, buttock, lower extremities
radiation: proximal –> distal
worse: with standing, less with walking, rare with biking
relief: sitting, flexion, squatting
straight leg raise test is (positive/negative) in spinal stenosis
usually negative
deep tendon reflexes in spinal stenosis?
loss or decrease in Achilles DTR
toe and heel gait (normal/abnormal) in spinal stenosis?
abnormal
skin changes to lower extremity in spinal stenosis?
no skin changes
DDx for lower back pain
-lumbar spinal stenosis
-vascular claudication
-mass lesions
-spinal mets
-central disc hernation
-spondylolisthesis
-vertebral #
epidural abscess
