CM

Question 1

polymyalgia rheumatica (PMR)

who is it common in? what are the lab tests like? what is commonly associated with this disease? what do you use to treat this disease? how soon can people come off it?

Answer 1

>50, northern european ancestry 2:1 females

abrupt onset of intense morning stiffness of neck, shoulders and hip girdle but muscle strength is normal, fatigure and anorexia also common

elevated ESR >50 mm/hr and CRP

15% can get great cell arteritis/temporal arteritis

low dose steroids 10-20 mg only drug that works, looks to normalize the CRP and ESR

usually self limiting 65% taper of steroids 1 year, 85% in 2 years

Question 2

what can people develop from Polymyalgia rheumatica (PMR) and what percent of people does this happen in?

Answer 2

giant cell arthritis/temporal areritis

15%

Question 3

what should you do if the ESR and the CRP values for polymyalgia rheumatica (PMR) don’t normalize with steroid use?

Answer 3

rethink the diagnosis

Question 4

Giant cell arteritis (GCA)

what age group is this common in and what other disease does this commonly present with? the release of which things cause this? 6 presentations? what can this damage? tests? treatments?

[giant head]

Answer 4

>50, often seen with PMR

involves the medium/large blood vessels of the head and neck including those that supply the optic nerve, involves release of IL1 and IL6

inflammatory cells get into the adventia of the temporal and other arteries and plug the flow

1. scalp tenderness

2. temporal headaches

3. jaw claudication

4. sudden loss of vision

5. bounding or absent temporal pulses

6. rare subclavian bruits

higher ESR and CRP than PMR, anemia

high dose steroids 60mg, slowly tabler off 1-2 years, some require low dose chronically <10 mg

Question 5

what are the four complications that can come from giant cell arteritis?

Answer 5

blindness

scalp necrosis

lingual infarction

aortic dissection/aneurysm

Question 6

what are the four major complications seen with long term use of high dose steroids?

Answer 6

osteoporosis

cataracts

increased BS

weight gain

Question 7

Granulomatosis with polyangitis (GWP)

what causes it? what are the 6 presentations? what do you worry about the most? what tests are important for this? what is the treatment and the new drug? where are these patients? what 3 systems do you worry about the most?

Answer 7

potentially fatal, involves small vessels, forms necrotizing granulomas in the upper airways, lungs, and kidneys, multisystem is key, very sick so in the hospital

the antineutrophil cytoplasmic antibodies C-ANCA attack the neutrophil and cause vascular injury and necrosis,

1. eyes
2. 5. skin (palpable purpura)
3. Upper airway ( ottis media, sinusitis, epitaxis, subglottic stenosis)
4. kidney (nephrotic syndrome/failure)
5. lung (hemmorage, lung failure)
6. cardiac (pericarditis)
   labs: elevated CRP, ESR, thrombocytosis, creatine, hematuria, casts, and proteinuria (all elevated)

treatment:

1. High-dose steroids with cyclophosphamide
2. methotrexate (chemo) or azathioprine (transplant drug)
3. rituximab=anti CD20 drug targets B cells

Question 8

what is the survival rate for giant cell arteritis after the invention of immunosuppressants?

Answer 8

90%

Question 9

polyarteritis nodosa (PAN)

what causes this and what illness is it typically associated with? what are 6 possible presentations on the body? what are four complications we worry about? what is the treatment? what is the special test we do to diagnose this?

[no do web, need a plan B]

Answer 9

50s-60s, medium blood vessels, high adominal involvement, associated with HEP B

abdominal pain due to mesenteric ischemia, pain associated with meal consumption

myalgia

hypertension

skin: livdeo reticularis (lace like rash), palpable purpura, fingertip ulcerations, subcutantous nodules on palms

testicular pain

labs: increased ESR, CRP, increased transaminadases, decreased albumin, HEP B, proteinuria/hematuria without casts

mesenteric/renal angiography where you see beading instead of smooth tubes

treatment:

1. high dose steroids with cyclophosphamide
2. mexotrexate or azathioprine
3. treat Hep B with antiviral acyclovir
4. plasma exchange to remove immune complexes

see bowel perforation, renal failure, stroke to HTN, foot/wrist drop since complexes wipe out nerve

Question 10

ESR inflammation test

what two things effect it? what other 3 factors will it increase in? How long does it take to see result?

Answer 10

sedimentation rate, rate at which RBC fall in a standarized tube in 1 hour

influenced by fibrinogen and immunoglobulins

increases with : age, women, adipose tissue

can take days to increase or decrease

high sed rate means falls faster

Question 11

CRP inflammation test

Answer 11

synthesized by the liver in response to inflammation or infectious state, rises and falls quickly

Question 12

what does it mean if the ESR and CRP are both elevated?

Answer 12

infection, inflammation, trauma, cancer

Question 13

ESR is ELEVATED, CRP is NORMAL

what does this mean? 4 examples?

Answer 13

conditions with elevated immunoglobulins

SLE

myoloma

liver disease

sjogrens

Question 14

rheumatoid factor test

what is this most commonly seen in? what 4 other diseases can produce a postivite test? what is important to keep in mind when doing this test?

Answer 14

IgM that is directed against IgG that is present in 80% of patients with RA

also seen in: Hep C, Sjogrens, TB, cryoclobulinemia

***may have a low positive result***so must use in relation to clinical picture

Question 15

anti-CCP antibody

Answer 15

antibody against citrulline-containing peptides

more specific for RA than rheumatoid factor? (95%)

Question 16

Antinuclear antibody (ANA)

who is it likely to produce a false positive in? percentage? Name 6 patterns

Answer 16

IgG against nuclear antigens

produces titer and pattern with immunofluoresence

higher the titer more clinical significance

false positives in 10-20% of females

diffuse/homogenous

periphreal

speckled

nucleolar

centromere

SCL-70

Question 17

diffuse homogenous ANA pattern seen in…..

1

Answer 17

SLE

Question 18

periphreal ANA pattern seen in …..

1

Answer 18

SLE

Question 19

Speckled ANA patter seen in….

2

Answer 19

SLE, Sjogrens

Question 20

nucleolar ANA pattern seen in…

1

Answer 20

scheloderma systemic disease

Question 21

Centromere ANA pattern seen in…

1

Answer 21

CREST syndrome

Question 22

SCL-70 ANA pattern seen in….

1

Answer 22

schleroderma systemic disease

Question 23

Antineutrophil cytoplasmic antibody (ANCA)

what are the two types and what do they test for?

Answer 23

autoantibodies that recognize proteins in the neutrophil, associated with vasculitis

P-ANCA- myeloperoxidases (MPO), microscoptic polyangitis

C-ANCA- proteinase 3 (PR3), granulomatosis

Question 24

fibromyalgia

what is it? how long do you need to have it? what are the requirements? what are the 4 presentations? what are the 4 important things you need to rule out? what testing is ok? which arent? what should you NOT treat with? what are 4 potential medical treatments?

Answer 24

central pain syndrome, pain threshold disorder >3 months 6:1 females

increased activity in somatosensory cortex, posterior insula, and thalamus

allodynia (percieved pain when non, hugging), hyperplasia (aplified pain perception)

aggrevated by stress, lack of sleep, activity

1. widespread muskulo pain
2. sleep disturbance
3. no objective physical findings
4. 11/18 trigger points
   * important to test deep tendon reflexes and sensation*

testing proceed with caution: NEED TO RULE OUT CELIAC DISEASE, IBS, VIT D DEF, HYPOTHYROIDISM

DO NOT ORDER RA/ANA

can order thyroid, electrolytes, vit D, ESR/CRP, Hep C, CPK

Don’t treat with: NSAIDS, narcotics

Treat with: Tricylic antipressants (help sleep), selective serotonin reuptake inhibitors (SSRIs), dual acting, lyrica neurontin but SO many side effects

Question 25

what are other therapies important for treating fibromyalgia that aren't medications? 5 things

Answer 25

1. lifestyle modifications 2. **low impact aerobic exercise** 3. sleep hygiene/check for sleep apnea 4. **address depression/stressors** 5. encourage patients to take control

Question 26

fibromyalgia what percent of females have this by age 20? what percent by age 70?

Answer 26

2% have by age 20 8% by age 70

Question 27

fibromyalgia and depression 1. what percent have depression at time of diagnosis? 2. what percent have lifttime incidence of depression? 3. what percent have lifetime incidence of anxiety?

Answer 27

depression at diagnosis: 30% lifetime depression incidence: 74% lifetime anxiety incidence: 60%

Question 28

chronic fatigue syndrome ## Footnote what ususally comes before this? what type of people are usually effected? what percentage of people have despression before? how many of the symptoms do you need to have? list some of the 8 possible symptoms? what should you NOT treat with? what should you treat with??

Answer 28

affects previously active people, often preceeded by flu like symptoms **25-45 years old**, can happen in clusters, maybe "immune system temper tantrum" **2/3 of people are depressed** **need to have 4/6 of the following for 6 months** 1. short term memory impairment 2. sore throat 3. tender cervical/axillary nodes 4. muscle pain 5. multijoint pain 6. headaches 7. unrefreshing sleep 8. postexertional malaise lasting longer than 24 hrs **DONT USE ANTIVIRALS, CORTICOSTEROIDS, IV Ig** **USE: NSAIDS, antihistamines, antidepressants, EDUCATE**

Question 29

what is a strang symptom associated with chronic fatigue syndrome?

Answer 29

unusual sensitivity to sustained upright tilting resulting in hyptension and syncope

Question 30

Systemic Lupus Erythematosis (SLE) ## Footnote who is this common in? what happens? what are the four main body systems you worry about? what are the 11 presentations and how many do they need to have?

Answer 30

**womens disease, 16-55, african american 15:1** debris from abnormal cell apoptosis promotes polyclonal B cels and autoantibodies, complexes deposit everywhere causing the symptoms **1. renal** (nepthritis, nephrotic syndrome, tubulointerstitial disease) **2. neuro** (seizures, psychosis) **3. hematologic** (hemolytic anemia, leukopenia, lymphopenia ALL GO DOWN) **4. Immunological (vascular thrombosis)** (antiophospholipid syndrome) **_malar rash_, _arthritis without erosion just deformity, alopecia, raynauds, photosensitivity, positive ANA_** _arthritis_ must have 4/11 symptoms ANA is the only one that MUST be there

Question 31

what are 8 lab tests seen in SLE?

Answer 31

1. CBC (anemia/cytopenias) 2. BUN/Cr (kidney involvment) 3. UA (proteinuria/ casts) 4. C3/C4 (decreased) **4. ESR ELEVATED, CRP NORMAL** **5. positive ANA** with all patterns EXCEPT centromere and SCL70 6. **dsDNA** that is more specific than ANA, *speckled or nucleolar*

Question 32

SLE treatment 1. skin 2. renal 3. other

Answer 32

**Skin/fatigue: hydroxychloroquine** **renal: high dose corticosteroids and cyclophosphamadine (immunosuppressant)** other immuno: azathioprine mycophenalate methotrexate

Question 33

the drugs used to treat SLE puts the patients at increased risk for two things? you should treat the side effects of these when treating SLE patients

Answer 33

atherosclerosis osteoporosis

Question 34

what is an important thing you want to discuss with women who have SLE?

Answer 34

birthcontrol and family planning, Pregnancy is VERY risky!!!

Question 35

what interesting false positive test resulte can SLE create?

Answer 35

false positive syphilis

Question 36

drug induced SLE ## Footnote what is it? what are 3 drugs that commonly cause it? what pattern does it have?

Answer 36

acts and looks like SLE but is reversible when the drug is discontinued **minocycline**: most common derm drug for acne **hydralazine:** for BP procainamide histone pattern ANA

Question 37

discoid lupus ## Footnote what is it and where is it located? how do you confirm it?

Answer 37

limited to the skin "limited SLE" confirmed by biopsy scarring rash don't need to have 4/11 since subset

Question 38

what do most SLE patients die from?

Answer 38

thromboembolitic disease from long term steroid use

Question 39

systemic scleroderma ## Footnote who is it common in? what is it? what are the 6 unique physical findings? what do you worry most about? what do you see on the test restults? what is the treatment? [scler scler..eating]

Answer 39

**hardening and thickening of the collagen in the skin, females 4:1 30-50** **1. raynauds** **2. thickening of the skin and vascular changes in the nailbeds** **3. lung disease and fibrosis** **4. GI dysmotility "watermelon stomach"** **5. renal failure with HTN** **6. cardiac complications** **7. arthalgias puffy hands** think they have carpal tunnel but when it leaves left with thickened skin, same thing with fixed face _most worried about thickening of the lungs!!_ positive ANA with nuceolar/SCL-70 pattern treatment aimed at the organs it involves or affects renal=ace inhibitors raynauds=calcium channel blockers GI=promotility agents lung=**cyclophosphamide**

Question 40

what do you never want to use in a patient with systemic scleroderma?

Answer 40

high dose steroids...can lead to renal crisis

Question 41

CREST scleroderma ## Footnote What does the acronym stand for? what do you worry about in these patients? what should you reccomend them to do and how often?

Answer 41

"limited scleroderma" **C-**calcinosis of joints and fingers, bone growths off it **R-**raynauds **E-**esophageal dysmotility **S-** sclerodactyly of fingers and MCPs **T-**telangiectasia (dilation of blood vessels) **worry about pulmonary hypertension so encourage these patients to get ANNUAL PFT/DLCO** (diffusing capability of lungs for CO), pulmonary function tests

Question 42

polymyositis/dermatomyositis ## Footnote what is this? what is it strongly associated with? what are 6 presentations? what will you find for tests and what imaging can be done? what do you treat with?

Answer 42

**autoimmune myopathy of striated muscles of _proximal_ limbs** **pts have hard time getting out of chairs, climbing stairs, curling hair** **_usually associated with underlying malignancy_** PAINLESS MUSCLE WEAKNESS 1. **heliotrope** (lavander around eyes) 2. **gottren's papules** (rashes over joints) 3. **shawl sign** **4. mechanic's hands** 5. periungal erythema 6. calcinosis cutis +/- ANA, **elevated CPK (creatine phosphokinase) aldoase** EMG, MRI, muscle biopsy treat: **high dose corticosteroids** **methotrexate or azathiorine** **IV Ig for severe cases** if there is a maligancy, DM will resolve once malignancy is cleared

Question 43

sjogren's syndrome ## Footnote what is it? what are 3 main things you see? what are two things it can transition into? what is 1 important tests and what are the other 4 tests you want to do? what do you do to treat it?

Answer 43

**extremely female dominant 20:1, 30-40** often seen with SLE and RA **autoimmune effecting exocrine glands** **xerostomia** (dry mouth) and **xeropthalmia** (dry eyes), **parotid swelling** **B cells produce autoantibodies, over time transitions to malignant expansion or lymphoma** **POSITIVE RHEUMATOID (70) AND ANA (60), elevated ESR _normal_** **_CRP_** **shirmer's test** treatment: hydration, artificial tears, lacriminal duct plugs, restasis eye drops

Question 44

Shirmer's test what disease do you use it for and what is the test?

Answer 44

use for sjogren's tests exocrine glands in eye, put a strip of paper in the eye \<5mm is positive for decreased production \>10 mm is normal

Question 45

what is important to reccomend to patients with sjogrens for good health precautions?

Answer 45

3-4 dental visits per year since they have decreased salivary secretions the enzymes to fight bacteria aren't there

Question 46

what are 5 complications you should worry about from sjogrens?

Answer 46

1. lymphoma 2. primary biliary cirrohosis 3. accelerated dental caries 4. cornreal atrophy/ulcerations 5. oral candidiasis

Question 47

inpingement/bursitis/tendonitis ## Footnote what happens in this? what three things ilicit pain? what degrees do you catch at? what are the movement limitations? what two movement tests should the patient do? what tests do you want to order? what are the five treatment considerations?

Answer 47

**repetitive overhead work**, gradual progression impingement: subacromial bursa, rotator cuff compressed between humeral head and acromion inflammation: subacromial bursa, rotator cuff tendons (as it gets more inflammed the space gets smaller and pinches the tendons more) **pain: lifting or reaching****, night** _catch at 80-120\*_ DECREASED AROM BUT FULL PROM **tests: Neers inpingment sign, hawkins manuver** (elbow bent out in front and push down) xray: A/P/axillary/lateral, MRI rarely indicated REST, NSAIDS, **naprosen**, PT, corisone injection, surgery

Question 48

what two exam tests are important for impingement/bursitis/tendonitis of the shoulder?

Answer 48

hawkins Neers (impingement sign)

Question 49

what type of surgery do you do for impingment, bursitis, or tendonitis of the shoulder?

Answer 49

arthroscopic subacromial decompression | (scrapping off the bursa)

Question 50

rotator cuff tear ## Footnote what four muscles are included as part of the rotator cuff? which is the most common culpriate? what types of pain will you find? what 5 tests do you want to do? what are the three types of images you can use and why are they helpful?

Answer 50

can be **complete** or **partial** tear of musculotendonous complex, +/- muscle atrophy/tendernous/crepitus includes: **1. supraspinatus (most common)** **2. infraspinatous** **3. teres minor** **4. subscapularis** pain/_weakness_ with **elevation and rotation**, **@ night, radiates to mid humerous AROM\>\>PROM PAIN** testing: **1. drop arm test** **2. empty can test (supraspinatus)** **3. lift off test (subscapularis)** 4. hawkins (think it looks like a bird wing) 5. Neer impingement sign imaging: 1. xrays (subacromial spur, calcified tendonosis, **head of humerus may migrate forward** 2. MRI-helpful but expensive 3. arthrogram

Question 51

when is a arthrogram used for a patient with a rotator cuff tear?

Answer 51

when pt has an implant and can't have MRI, dye is injected into the joint and you wait to see if the dye leaves the joint

Question 52

what does a "global" tear mean for a rotator cuff tear?

Answer 52

all the four muscle tendons are torn can be acute (trauma) or gradual (fraying over time)

Question 53

what are the conservative vs aggressive treatment options for someone with a rotator cuff tear? what is important fun fact to know here?

Answer 53

conservative: 1. PT 2. Cortisone Injections (good for elderly) 3. NSAIDS Surgical: 1. arthroscoptic repair Fun fact: want to have it repaired in healthy individual because it can lead to **rotator cuff arthritis and arthropathy which leads to total shoulder replacement**

Question 54

should seperation ## Footnote what happens? what does the patient report? what are the 3 important tests to do? what do you want for imaging? how are they classified?

Answer 54

AC joint stress or disruption, fall on the point of shoulder, obvious deformity **sudden onset of pain (trauma), patient reports "pop", "arm went dead", depressed affected shoulder** **pain with or WITHOUT motion** tests: 1. cross arm test 2. pain with restricted horizontal abduction 3. spring test (push down on clavicle) xray: A/P, no need for weighted views **6 grads of shoulder seperation**

Question 55

what are the 6 grades of shoulder seperation?

Answer 55

1. AC lig injury 2. AC lig torn 3. AC and CC lig torn 4. AC and CC lig torn, avulsion (pulling away), displacement through skin or muscle 5. AC and CC lig torn with deltoid and trapezius fascia stripped off acromion and clavicle 6. AC and CC lig torn with inferior dislocation with many other injuries **AC-acromioclavicular lig CC-coracoclavicular lig**

Question 56

what is the treatment plan for shoulder seperation? what is it dependent on?

Answer 56

depends on the grade _**Grade 1-3: conservative approach** (only ligs are torn)_ 1. immobolization for pain, get out quickly to avoid pain for **1-3 weeks** 2. NSAIDS 3. PT **_Grade 3-6 surgical aggressive treatment_** _(any displacement or fascia stripping)_ needed if unstable or cosmetic

Question 57

AC DJD ## Footnote \*denegenerative joint disease\* who is it common in? when/where is the pain? presentation? what motion tests and imaging should you do? what might you see on these images? what is conservative vs aggresive treatment?

Answer 57

**middle aged men,** esp in manual laborers, weighlifters, and athletes with a lot of **horizontal adduction** **pain with pushing, horizontal adduction, resisted abduction** may see AC hypertrophy, so larger on one side +/- crepitus tests: cross arm test Imaging: A/P, axillary, lateral xray, this will show the degenerative changes **changes possibly seen: hypertrophy, spurring, joint space narrowing** conservative treatment: rest, NSAIDS, cortisone injection but is hard to get it in surgical: excision of distal clavicle **mumford procedure** \*\*\*no cure for arthritis, can only cut it out\*\*\* conservative treatment: rest, NSAIDS, cortisone injection but difficult to get it in

Question 58

what is the most common fracture in children and adolescents?

Answer 58

clavicular fracture

Question 59

what can sometimes occure as a result of live birth trauma?

Answer 59

clavicular fracture

Question 60

clavicular fracture ## Footnote what part of the clavicle does this usually happen on? how does it present? what causes pain? what is it always nessacary to check???? what imaging do you need to do

Answer 60

**fall on outstretched arm, sometimes in live births** **breaks between middle and lateral 1/3 of clavicle,** always "looks bad", feel crepitus and pain at fraction site **obvious visual deformity,** pain with AROM, PROM, and rest "I broke my collar bone" Xray: A/P only, **bone fragments usually overlap** _always want to check for reflexes, sensory, and weakness of extremity since right next to major blood vessels and brachial plexus_, need to know if these are damaged

Question 61

what imaging shouldn't you do for a clavicle fracture?

Answer 61

MRI and CT

Question 62

what are the conservative and aggressive treatments for clavicle fracture?

Answer 62

_conservative_ 1. sling for 3-4 weeks 2. reassurance!! almost always heal w/o surgery, may still have deformity but 100% functional 3. gradual return **\*\*\*\*even though it looks bad on a xray, the body can heal it!! a callus will form and the body can reabsorb the bone!\*\*\*\*** _surgical_ 1. used for unstable fractures (aka bone is puncture skin or injurying something below) 2. tricky and dangerous since next to Brachial plexus and subclavian a 3. sometimes can still fail because of tension on the clavicle

Question 63

adhesive capsulitis ## Footnote what are 4 risk factors? what causes this? what imaging do you want to do? what is the reccomended treatment and how long can this take to be effective? what is last resort treatment? how do you make the diagnosis?

Answer 63

**sedentary people**, **decreaed volume of the joint capsule and capsular contraction** **"frozen shoulder",** *insidious onset, gradual progression, pain at night* **increased risk with: age, obesity, diabetic, middle aged women** there is a physical "block" preventing motion xray: rule out other bony deformities **diagnosis is based on history and PE** treatment: NSAIDS and stretching, GH cortisone injection, takes patience since it can take up to a year to heal, _manipulation under anesthesia as last chance_

Question 64

should instability/dislocation ## Footnote who is this common in? what falling position is most common? what are the two types? what type is the most common? if dislocated what will it look like? what interesting thing should you look for on a xray?

Answer 64

**overhead, younger athletes** 95% are **anterior dislocations,** 90% will reoccur *most common cause is falling on abducted extended arm* **dislocation**: full disarticulation of GH joint **subluxation**: partial disarticulation, pops out and then back in **"dead arm", can relocate spontaneously,** sense of instability, may sense **clicking in GH joint**, patient usually holding affected arm with the other _if dislocated_: **flattened deltoid (not held up by head of humerus), prominent acromion, arm held in splitting position, dramatically reduced ROM** ON XRAY LOOK FOR HILLS SACHS, DENT IN HEAD OF THE HUMERUS

Question 65

what imaging should you do for something with shoulder insability/dislocation?

Answer 65

_X-ray_ 1. A/P, **Y view** **2. always get xray with first time dislocators** **3. MUST ALWAYS GET A POST REDUCTION XRAY, 2 FILMS!!!!** _MRI_ 1. helpful to access for **Bankart** lesion tear of the **anterior glenoid labrum (lining)** during shoulder location

Question 66

what is a interesting thing you should look for on a xray of someone who has dislocated their shoulder?

Answer 66

Hill-Sach lesion -labrum catches on the head of humerus during dislocation and puts a dent in the head of the humerus

Question 67

what is the treatment conservative vs aggresive treatment for dislocation?

Answer 67

_conservative_ NSAIDS, sling PT after **3 weeks for \<40 yr olds** PT after **1 week for \>40 yr olds** \*\*don't want them to stiffen\*\* _surgical_ 1. Bankhard (labral) repair for labrum tear 2. capsulorrhaphy: tightens the capsule

Question 68

what does a capsulorraphy do? what do you use it in/

Answer 68

surgical intervention to tighten the capsule and prevent against future dislocations

Question 69

elbow dislocation ## Footnote who is it common in? how does it happen? what must you access for? what do you treat with? what is important to do after reduction?

Answer 69

most common in children, 50% happen from sports **fall on outstrectched hand, 98% are posterior** arm held at side in splinted position, unwillingness to move elbow **obvious deformity, olecranon swelling** **MUST access neurovascular structures**, MUST perform POST reduction xray!!! two films! treatment: 1. reduction 2. spint/cast 1-3 weeks **elbow gets very stiff very fast esp in kids, so want to initiate early ROM exercises to prevent _flexion contracture_** NSAIDS

Question 70

lateral epicondylitis ## Footnote what is a nickname for this condition? what muscles specifically does it effect? what does this person have a difficult time doing? what happens with pain and ROM? what are 5 treatment options? what is the last resort treatment and why?

Answer 70

**"****TENNIS ELBOW", dengeneration/inflammation of the *wrist extensor mechanism*** ***LATERAL EPICONDYLE, DIFFICULTY LIFTING THINGS WHEN HAND IS PRONATED*** **involves the tendonous insertion of _extensor carpi radialis brevis_** tennis, golf, weight lifting pain with repetitive extension and flexion pain: 1. radiate down the arm 2. **passive wrist flexion** **3. active and resisted wrist extension** Treatment: 1. _eliminate aggrevating factors_ 2. NSAIDS, ICE, HEAT 3. tennis elbow strap 4. cortisone injection, DONT INJECT TENDON 5. surgical release/faciotomy if all else fails. only successful in 50% of people and longer than 6 months

Question 71

olecranon bursitis ## Footnote what are the two different causes? what is the difference in treatment between the two? what is the most common organism to cause it? what should you test? and for what two things?

Answer 71

inflammation of olecranon bursitis, can be from resting on the elbows a lot usually quick onset can be from infection: septic bursa **suspect infection if erythema and intense pain on palpation** send joint fluid for analysis: culture and crystal analysis treatment for non infectious: 1. padding/compression wrap, NSAIDS, heat, ice 2. cortisone injection **\*\*\*need to make sure 100% not infected if so\*\*\*** treatment for infectious: 1. treat cultured pathogens 2. incision and drainage **most common organism is S. aureus**

Question 72

carpal tunnel syndrome ## Footnote what happens? what causes the symptoms? what 4 special tests can you when diagnosing? what is the gold standard of care? what should you do first and for how long? describe the numbness pattern

Answer 72

**most common nerve entrapement syndrome, _median nerve under transverse carpal lig_** pain and numbness in media distribution (pic), **pain at night**, **weakness in thumb grip strength** tendernous and tingling at wrist and palmar area Special tests: Phalens test w/tingling after 1 min (I think of "flailing hands) Tinel's sign-taping over transverse lig produces tingling (I think tinel=tingle) decreased 2 point sensation electromyography/nerve conduction **gold standard: surgery**, releases transverse lig, but first try **night splint, NSAIDS for 4-6 weeks before surgery consult**

Question 73

DeQuervain's disease ## Footnote what is this caused by? who is it more common in? where do you see the localized pain, between what two things? what is 1 special test you want to do? what are the two treatment options?

Answer 73

**extensor pollicus brevis and abductor pollicus longus act to abduct the thumb away from the hand in the radial plane, more common in women and diabetics** **synovial/tendon sheath** becomes inflammed from OVERUSE **pain over the CMP joint of first digit, trapezium and metacarpal of thumb** special test**: finkelstein's test** (place thumbs inside of fist and ulnar deviate which causes pain!!) tests: xray to rule out other things, labs for gout treatment: 1. NSAIDS, splint, cortisone injection, symptoms resolve in about a year 2. fasciotomy of 1st dorsal compartment (not as common) but releases overlying lig

Question 74

scaphoid fracture ## Footnote why are scaphoid fractures important not to miss? what is unique about this bone? where does pain present? what two images do you do? what is really interesting about the treatment plan for this? what happens at the second xray?

Answer 74

**most common fracture carpal bone, most common in men 20-40** **caution: poor blood supply to this bone so can be easily comprimised by fractures and lead to necrosis** blood enters through distal 1/3 of bone high rate of non-unions **fall on outstretched hand**, **PAIN IN ANATOMICAL SNUFF BOX** xray: scaphoid views _must repeat xrays 2 weeks after injury_ to look for healing or signs of injury, sometimes fractures don't show up immediately or seen easily can do a *bone scan* which will show metabolic activity interesitng plan of action: **CAST with or without fracture after first xray**, then reacess at second xray **at second xray if** **healing-recast 4 weeks** **no fracture-splint two weeks** **displaced fracture-surgical intervention**

Question 75

what is one interesting thing about a scaphoid fracture that you don't see with other breaks?

Answer 75

if you suspect a scaphoid fracture and the xray is negative YOU STILL CAST IT!!! breaks are hard to see here so you need to be really cautious since the bone has poor blood supply it can become necrotic easily so cast!! reacess at 2nd xray in two weeks and if still no evidence YOU STILL SPLINT FOR 2 WEEKS!! how strange.

Question 76

mallet finger ## Footnote what happens here? what can't this person do? How do you treat?

Answer 76

most common extensor injury **rupture of the extensor tendon at distal phalynx** **hyper-flexion injury, if you flex too far forward it pops off** **_cant extend finger tip_** swelling and ecchymosis at DIP, DIP held in slight flexion since nothing counterbalancing it xray: A/P and lateral, look for avulsion (bony fracture from tendon ripping off) treatment: splint DIP in FULL EXTENSION, 4 weeks

Question 77

jersey finger ## Footnote what tendon is effected? what can't this person do? how do you treat this?

Answer 77

**rupture of the flexor digitorum profundus** **inability to flex fingertip** swelling and ecchymosis of DIP xray: A/P, lateral, may show avulsion treat: split initially but refer ASAP to surgery **_\*\*\*all flexor tendon injuries require surigcal repair\*\*\*_**

Question 78

All flexor tendon injuries require....

Answer 78

SURGICAL REPAIR!!!

Question 79

boutinere deformity ## Footnote what happens here? what is the presentation? what can't this pt do? how do you treat?

Answer 79

**tear of the central slip (median band) of the extensor tendon at PIP level** **fingers are slightly flexed** since nothing is opposing it **_DIP joints extend_** due to pull of intact **lateral** bands Classic boutinere look seen in pic Xray: A/P abd lateral, rule out fracture treatment: splint PIP in complete EXTENSION, can leave DIP free for movement, splint 6 WEEKS

Question 80

Explain the grading for muscles

Answer 80

5/5: complete ROM, maximal resistance 4/5: complete ROM, moderate resistance 3/5: complete ROM, against gravity 2/5: complete ROM, gravity eliminated 1/5: no ROM, isometric muscle contraction 0/5: no muscle contraction

Question 81

osteoarthritis ## Footnote what is this? where is it most common? what are the two types? what would you expect to see on a xray?

Answer 81

joint disease with **protective cartilage on the ends of your bones wears down over time** and subchondral bone wears down over time **\>40 yrs olds** THINK ELDERLY, slow developing joint pain early onset and late onset OA, erosive **hands, hips and knees most common** primary or secondary causes **joint enlargement, red swollen PIP, DIP, weakness and wasting of muscles around joint, deformities** **xray: see narrowed asymetric joint space, with osteophyte formation, bony sclerosis**

Question 82

what is a osteophyte? what disease is this commonly seen in?

Answer 82

a bony outgrowth associated with the degeneration of cartilage at joints. osteoarthritis

Question 83

what are the characteristics associated with early osteoarthrits? (4 things)

Answer 83

1-2 years morning stiffness **lasting \<1 hour** they're ok, they say they just keep going **red, prominent PIP, DIP joints with normal radiographs**

Question 84

what are the characteristics associated with late osteoarthritis?

Answer 84

**AM stiffness lasting \<30 mins** mechanical stiffness that gets **worse** with **movement**, more pain the more they do claim not to have the same strength they used to (opening jars/doors etc) little evidence of inflammation ABNORMAL RADIOGRAPHS get **_less_ symptomatic in non-weight bearing joints AKA many patients have extreme hand deformities but are asymptomatic (once they are deformed they don't hurt anymore)**

Question 85

what is the treatment options for osteoarthritis? (7 things)

Answer 85

joint conservation exercise weight loss NSAIDs (caution with ulcers) COX-2 inhibitor (safer for people with history of ulcers, but still need to watch for cardiac complications) cartilage replacement (15-55) total joint replacement

Question 86

why are patients who take COX-2 inhibitors for osteoarthritis at increased risk for heart complications?

Answer 86

use these instead of tNSAIDs beacuse they reduce the risk for stomache ulcers but they also increase **thromboxane** levels **making platelets stickier** cause **vascular remodeling** after 18 months which causes **hypertension** these patients are 2.5 more likely to get a MI or CVA

Question 87

what are the genes associated with osteoporosis?

Answer 87

weight trauma **genetics FR2B, GDF-5, DIO2** -**endochondryl ossification, skeletal malformations, chondrocyte self destruction**

Question 88

primary osteoarthritis is.....

Answer 88

idiopathic, arises spontaneously

Question 89

secondary osteoarthritis can come from....

Answer 89

1. posttraumatic 2. congentiral deformation 3. endocrinopathy 4. neuropathic arthropathy 5. padgets disease 6. avascular necrosis 7. skeletal hyperostosis DISH

Question 90

characteristics of erosive osteoarthritis

Answer 90

more agressive destruction persistent symptoms inflammatory findings

Question 91

what puts a person for increased risk for stomach ulcers when using NSAIDS?

Answer 91

\>60 years old coumadin past ulcers prednisone long term NAID use

Question 92

what is the most common joint disorder in the US?

Answer 92

osteoarthritis

Question 93

Osteoarthritis of the hip ## Footnote what is this? what will you see on the xray? what is the "definitive cure"? what other surgical interventions can you do in younger patients?

Answer 93

degredation of articular cartilage, thickening of the subcondral bone **progressive hip pain that often complain of groin pain**, "crunching" noises aka crepitus **xray osteophyte formation, decreased joint space, sunchondryl sclerosis and cysts** conservative: same as always _definitive cure:_ total hip arthroplasty THA (replace joint) surgical: arthroscopic debridement, femoral head resurfacing in younger patients

Question 94

avascular necrosis ## Footnote what causes the necrosis? how long can the cells survive? what is a unique sign that you will see? where does the pain present and what happens when the person rests? what are four surgical interventions you can do?

Answer 94

bone death from disruption of blood supply osteocytes, blasts and clasts, die withing 24-48 hours of oxygen deprivation reprofusion may regenerate bone growth _cresent sign: collapse of sunchondral bone_ **often seen pain in groin, thigh, buttock** **pain typically decreases with rest** Treatment: NSAIDS, anticoagulants (heparin, coumadin etc) since can thin blood and help it get to the site if there is a clot!! Surgical intervention: hip resurfacing, core depression, **fibular bone graft**, total hip arthroplasty

Question 95

greater trochanteric bursitis what does the bursa do? what 5 potential causes? when do you get pain (KEY!)? what do you do for treatment and what won't help you with diagnosis?

Answer 95

inflammation of the greater trochanteric bursa bursa function: acts as a pad for the greater trochanter causes: **overuse, trauma, weak abductors, prior sugery, unequal leg length** pain with: repetitive motions (running, cycling, etc) **_pain with RESISTED ABDUCTION, PASSIVE ADDUCTION KEY!!_** POINT TENDER OVER GT xrays will be normal. NSAIDS, ice/heat, PT, activity modification or surgical removal

Question 96

what is the difference between a strain and a sprain?

Answer 96

**strain**: injury to the **bone-tendon unit at the myotendinous junction or the muscle itself** _sprain_: involves _collagenous tissue, such as tendons or ligaments_

Question 97

quadriceps/hamstring strain ## Footnote what motions can cause a strain in both the quads and hamstrings? what do you use to classify the amount of damage done? what do you NEED to make a diagnosis? when do you do a MRI? what might you feel or see? what is the treatment?

Answer 97

quadriceps strain: cause forced hip extension or knee flexion hamstring strain: forced hip flexion, knee extension **excessive force causing excessive muscular contraction, causes musculotendous unit stretch or tear** grading system for type, _palpable hematoma in muscle belly_, possible defect in muscle or tendon HX and PE all that are needed to make DX mri may be helpful if complete tear is suspected TX: conservative usuals surigcal: hematoma evacuation, repair COMPLETE TEAR tendom/muscle , fasciotomy

Question 98

what are 4 predisposing factors for a strain?

Answer 98

inflexibility overtraining poor body mechanics muscle imbalance

Question 99

Extensor Mechanism Rupture ## Footnote what are the four structures included in this mechanism? what trauma causes this (1) or atraumatic events (3)? what might this patient say? what can't they do? what do you always want to do with this patient unless they don't qualify? what are the two sites this can occur at and what are their funny names?

Answer 99

middle aged men most common includes: **quadriceps, quadriceps tendon, patella, patella tendon (ligament actually)** caused by hyperflexion of the knee (traumatic) or inflammation, degredation, cortisone injections around patella, tendon weakening **_inability to bear weigh_**, "I tore my knee, I felt a pop" always want to do surgery unless they don't qualify otherwise they will most likely loose extensor function, tendon repaired with sutures, otherwise they will be in a boot 6-8 weeks. after surgery can WBAT in immobalizer _patella alta:_ patella tendon rupture _patella baja:_ quad tend rupture

Question 100

osteoarthritis of the knee ## Footnote what is this? what are four presentations you see with this? what is a possible muscle presentation? what is the gold standard for diagnosis? what are the conservative vs surgical treatment options?

Answer 100

degredation of the hyaline cartilage of the knee pain is **worse in AM, _giving away or locking_** **_joint hypertrophy, and tendernous at the joint line_**, possivle quadricept atrophy gold standard: xray...see osteophyte formation, decreased joint space so bone on bone, sunchondral sclerosis treatment: conservative normals plus cortisone injections and *hyaluronic acid injections* surgical: knee arthroscopy, tibial/femoral osteotomy, total knee arthroplasty

Question 101

patellofemoral pain syndrome/anterior knee pain syndrome ## Footnote who is it common in? what are the four main categories of causes? what do these pts have pain doing? what are 5 things specific to the knee area you might find? what might you see on a xray (2)? what is the difference between the conservative (2) and surgical (3) options?

Answer 101

**one of most frequence complaint in teens!** can be caused by 4 things: biomechanical, muscular, trauma, overuse anterior knee pain with difficulty **squatting, kneeling, down stairs, sitting for long periods of time (car, movie theater****)** _quadriceps weakness, peripatellar pain, patella apprehension, "J" sign, pain with resisted knee extension_ shows **shallow femoral sulcus, tilted patella** conservative: normal, quad strengthening, **patellar support brace, foot orthotics** surgical: **medial patellofemoral ligament reconstruction, lateral release, tibial tubercle osteotomy**

Question 102

patellofemoral pain syndrome biomechanical cause explaination (6)

Answer 102

**increased Q angle (normal is 10-22\*)** **pronation** **tibial internal rotation** **patell instability** **shape of patella or femoral sulcus** **angle of flexed knee**

Question 103

patelloafemoral pain syndrome muscular explaination aka, where is their weakness and tightness?

Answer 103

weakness in: quadriceps, hip flexors tightness in: hamstrings, iliotibial band, gastrocs

Question 104

what is the function of the patella? (5) specifically as part of the extensor mechanism

Answer 104

1. thickest hyaline cartilage 2. protects tibiofemoral joint 3. provides mechanical advantage for extension mechanism 4. decreases friction in extension mechanism 5. acts to guide/direct forces in extension mechanism

Question 105

Medial collateral ligament (MCL) ## Footnote what is this the most common of? what else is often injured if this is injured? what stress does this prevent against? where is the stability? where do you specifically find tenderness? what is the degree range of extension with valgus force?

Answer 105

**most commonly injured lig in the knee** *prone to injury because of long lever arms of tibia and femur* **provides medial stability against lateral force, prevents against _valgus_** **_force_** variable laxity with valgus force (0-30\* extension) _medial meniscus tear association, medial femoral condyle tenderness_ loose knee, giving way

Question 106

lateral collateral ligament (LCL) ## Footnote where is the stability? what force can cause it? it is associated with what other 2 injuries? where are the two point tender locations?

Answer 106

provides lateral stability, varus deformity **associated with fibular head fracture and posterolateral corner injuries** "loose knee" sense of instability **point tender over LCL/fibular head** laxity with varus force

Question 107

posterior cruciate ligament (PCL) ## Footnote where is the stability? what is it assocaited with? what does it feel like and where is the pain? what two tests should you do?

Answer 107

provides posterior and rotational stability dashboard injury/total knee dislocation **associated with multiple ligament injuries** so always check for others "knee is un-hinged", posterior/popliteal pain **posterior drawer sign, sag sign** (lay on back with hips and knees 90\*)

Question 108

anterior cruciate ligament (ACL) ## Footnote what other two things are commonly injured with this and what is this called when they're all injured? what type of stability does this provide? who and how does this typically happen? what do patients hear? what develops quickly? what test is diagnostic?

Answer 108

**_terrible triad! UH OH:_** **included MCL and medial meniscus tears** provides anterior and rotational stability MOI**: medial tibial rotation and anterior tibial translation** very common in younger athletes, from **cutting, pivoting, sudden stop while running** 1/3 of patients hear "pop", large effusion women\>men **hemarthrosis** develops quickly within 3 to 4 hours **Lachman's test** is sensitive for diagnostic

Question 109

what imaging should you do for knee ligament tears?

Answer 109

Xrays: 1. associated fractures 2. medial femoral condyle avulsion 3. lateral tibial fracture MRI: definitive test for ligament damage/meniscus

Question 110

what are the treatment options for knee ligament tears? ## Footnote what are the two big branches? who are they appropriate for? what options must be considered for surigcal repair? who do you always repair in?

Answer 110

**_conservative:_ bracing, ice,** appropriate in patients who do not do competitive activities or do not report instability with desired activities **-all grade I and II sprains, some III** -can be MCL if isolated injury **_surgical:_** **those who report instability, compete in competitive activities,** **-MCL/PCL reconstruction if associated with multiple lig injury** **-LCL reconstruction if posterolateral corner injury** **-ACL reconstruction _always repair in young people_**, age, activity, demands, allograph vs. auto (\<40)

Question 111

Meniscal tear ## Footnote what two common pt populations does this happen in? how do injuries in these two groups occur? which one is more commonly injured? when does the patient have pain? what are 3 things they may report as feelings? what are the two tests that are important? what are the two next steps after conservative treatment fails? what must be considered?

Answer 111

**older patients:** associated with OA, degenerative tear, chronic complaints **younger patients:** associated with rotational injury from femur on tibia or trauma W\>M, **medial more commonly torn** **pain with rotation/squatting**, fullness behind knee, and _giving way or locking (can't extend knee)_ _joint-line tenderness biggests key_ **mcMurray's test is the gold standard** **appleys compression tests** *tears rarely heal on their own, symptoms may get better but they will return* **repair vs.** **menisectomy** (dependent on type of tear, zone red vs white, activity demands)

Question 112

what is the difference between the white and red zones on the meniscus?

Answer 112

white: inner **avascular** portion of meniscus red: outter **vascularized** portion of the meniscus

Question 113

what are the functions of the meniscus? 5 things

Answer 113

lubrication of the joint nuitrition diffuses forces from femor onto the tibia decreases hyaline cartilage wear shock absorption

Question 114

what does the medial meniscus look like? how much motion is allowed? what does it attach to?

Answer 114

**Medial Meniscus** "C" shaped attaches to tibia and MCL 2mm of motion

Question 115

what is the shape of the lateral meniscus? how is it attached? how many mm of motion does it have?

Answer 115

**Lateral meniscus** "o" shaped loosely attached, decreasing risk for for injury 10 mm of motion as knee flexes

Question 116

Pre-patella bursitis ## Footnote what else is this known as? what do patients get it from? what is the organism that can cause it if infection? what do you want to do for imaging/testing? what do you do for treatment?

Answer 116

roofers, floorers, people who are kneeling down all the time, feels like water on the knee "housemaids knee" inflammation of prepatellar bursa, between patella and skin trauma or repetitive kneeling *can become infected by micropenetrating trauma **S. aureus*** xray to rule out bony injury, or foreign body in bursa *joint aspiration* if question of infection, analyze for organism conservative approach plus *knee pad or cortisone if 100% no infection*

Question 117

shin splints/tibial stress fractures ## Footnote who is this more common in? where does the pain present for shin splints? what makes it worse? what do stress fractures disrupt? what causes them? where will this patient be tender? what two movements will illicit pain in these patients? what might you see on a xray? what is conservative treatment? what are the two surgical options?

Answer 117

women\>\>men **3x** 15% of runners biggest complaint, *dull ache in middle 1/3 of tibia, gets worse with longer activity* tibial stress fracture disrupts **tibial cortex from repetitive stress, point tender at posteromedial border of tibia, pain with _dorsiflexion and toe extension_** xray: may be able to see periosteal thickening **bone scan:** show early stages of stress reaction, _compartment pressure measurement_ _conservative+footwear/orthotics_, crutches for stress fracture **surgical: release deep posterior fascia for exercise induced compartment syndrome, prophylatic intramedullary rodding** for stress fx

Question 118

how many more times is a achilles tendon rupture common in men than women?

Answer 118

**20x more common in men than women** **WHAT?!**

Question 119

achillnes tendon rupture ## Footnote what two ways can this happen? what do you see? what exam test can you do? what imaging? what are the two treatment options and which is preferred? what does the achilles connect?

Answer 119

complete or partial tear of achillnes tendon strongest, thickest tendon in body connects gastrocnemius and soleus to calcaneous, can't walk if completely torn, feel a big hole if torn **plantar flexion at ankle, _pain posterior calf 2-6 cm above insertion_** **causes: acute dorsiflexion, chronic degredation** _thompson test, squeezing calves_ those who refuse or don't qualify for surgery: **cast up to 12 weeks, change cast every 2 weeks, progressively increase dorsiflexion to neutral, 3 months no WB** surgical is best: decreases risk for retears, **cast 8 weeks, progressively increase dorsiflexion to neutral by recasting, 6 months full recovery**

Question 120

what are 2 medical risk factors for achilles tendon tear?

Answer 120

2. medications **fluoroquinolones** 3. corticosteroid injections also prolonged immoalization, causes it to be weak

Question 121

ankle sprain ## Footnote what are the three types that can cause this and which ligaments are included in which types? what are the presents? what exam tests are important to do? what rule do you use to determine if a xray is needed? what is the treatment and what is one exception and how long do these patients need to be immobalized?

Answer 121

inversion injuries (90%), **_anterior talofibular_ (#1), calcaneofibular, posterior talofibular** eversion (10%), **deltoid lig** lateral rotation (**high ankle sprain**): **syndesmotic ligs**, anterior tibiofibular joint, high ligs connect the tibia and fibula, pain with _external rotation_, pain just above the ankle _squeeze test of tibia/fibula_ point tender over lig, hypermobility with stress testing anterior drawer tests ottowa ankle rule to determine if xray is needed Tx: conservative even if grade III, surgical repairs but is reserved for chronic instability, crutches 48-72 hours and brace, with *syndesmotic sprain* longer immobalization for 4-6 weeks

Question 122

what is the grading for ligament sprain?

Answer 122

1. stretch 2. partial tear 3. complete disruption

Question 123

what are 5 risk factors for ankle sprains?

Answer 123

- joint instability - muscle weakness - poor shoe selection - decreased flexibility - prior sprains/injuries

Question 124

plantar fascititis ## Footnote what are 3 risk factors for this? where does this attach and insert? what happens here? what arch does this support? where might there be palpable pain and how does the pt describe the pain? what isn't present that you would think would be? what might you see on a xray? what are some unique conservative treatment options? what is the last resort?

Answer 124

RF: overweight, poor footwear, weight-bearing activities inflammation of plantar fascia, calcaneous to metatarsal head supports **transverse longitudal arches** pain in AM, **"stepping on knife", first steps very painful and heel pain at _night_**, **pain over medial calcaneus, tight fascia on palpation and inflexible achilles w/o swelling** Xray: *can show heel spur at fascia origin* conservative: stretching, arch support, orthotics, **night splints, reccomended for 6-12 months** surgical: release fascia, ABSOLUTE last resort, not that effective in relieving pain

Question 125

Metatarsalgia/stress fracture ## Footnote what are 3 risk factors? where is the most common site for pain? where is the most common site for fracture? what MUST you differentiate this from? what is the pain like? what is a better choice than a xray? why? what are the conservative choices for treatment? what about a stress fracture?

Answer 125

RF: running, ballet, pes cavus foot, excessive arch **mid-foot pain from metatarsals, _head of 1st metatarsal or 1st cuneiform/metarsal joint_** *need to differentiate from **seamoiditis*** (fracture of semoids that rest under big toe) *_stress fractures common at 2nd/3rds metatarsal shafts_* "dull ache", relieved with rest bone scan better than xray since fracture can take 2-4 weeks to appear Tx: conservative, metatarsal pad, **stiff soled shoes** stress factor: cast or brace for **4weeks**

Question 126

how long may a metatarsal fracture take to show up on xray? therefor what should you do instead?

Answer 126

2-4 weeks, therefore, do a bone scan

Question 127

gout ## Footnote what happens here? what do the crystal depositions look like? what is effected commonly as a strange presentation in most cases? what are the two ways these crystals accumulate and what are the percentages? what hardened structure can be found within joints of chronic gout? what labs do you do? what is diagnostic? what is the difference between the treatment for acute and chronic treatment?

Answer 127

most common form of inflammatory arthritis in m/w over 40 **acute arthritis (usually at night) by sudden increase and deposition of uric acid crystals in the joint** **great toe effected in 50% of cases**, but can effect any joint in the body: ankles, knee, hands, wrists cause: **hyperuricemia, too much in circulation and in 90% of cases there isn't enough secreted from the kidneys** instead of overproduction (10%) joints contain _tophi, hardened nodules_ (chronic) Labs: **uric acid levels, may have elevated WBC, _uric acid crystals in joints are diagnostic_,** xray to access joint damage Acute TX: NSAIDS, colchicine Chronic: Xanthine oxidase inhibitor, **allopurinol (blocks production) or probenecid (increases uric acid excretion)**

Question 128

what do the crystals in gout look like?

Answer 128

needle like WITHOUT birefringence

Question 129

when does the ratio of men\>women, switch to women\>men who are effected by gout?

Answer 129

after menopause, then it is more common in women

Question 130

what is the name when the big toe is effected by gout?

Answer 130

podogra

Question 131

what is the most common cause of gout in people?

Answer 131

metabolic syndrome 75%

Question 132

what are three interesting things that increase risk of gout?

Answer 132

alcohol, meat, seafoods metabolic conditions

Question 133

charcots foot ## Footnote what two joints are most commonly effected with this? what are the 3 characteristics associated with this? what are the two man theories about what this happens? what can the foot look like? what are 3 presentations you would see with this? who is this really common in? what will you see on the xray for this think Candy? what will you ALWAYs do for treatment forthis and what do you try to avoid with this?

Answer 133

degeneration of the **WB joints, tarsal-metatarsal (TMT) 60%, and metatarsal-phalange joints (MTP) 30%** **joint dislocations, fractures, anatomic deformities** diabetics pretty common 50% relate to traumatic mode of injury _foot may look like it is flattening out (deformed), increased skin temp, possible skin ulcers, decreased sensation depending on neuropathy_ Two theories: neurotraumatic and neurovascular total contact cast doesnt allow any motion, prevents further destruction 6-9 months for stability surgery rarely indicated, causes lots of problems Xray: **atrophic changes, distal metatarsal thinning "Licking candy stick", hypertrophic changes "the 6 d's"**

Question 134

what are the 6 "D's" hypertrophic changes associated with charcots foot?

Answer 134

1. distended joint 2. increased density 3. debris production 4. dislocation 5. disorganization 6. destruction

Question 135

what is the neurotraumatic theory of charcots foot?

Answer 135

decreased periphreal sensation leads to repeated micro trauma of joints micro trauma tiggers inflammation causes bone reabsorption and decreased density less bone density makes them more likely to continue to get injured

Question 136

what is the neurovasculature theory associated with charcots foot?

Answer 136

neuropathy causes densensitized joint to have increased blood flow blood stimulates increases osteoclast activity more than osteoblast decreases density, creating more chance for injury

Question 137

what is a major population that is effected by charcots foot?

Answer 137

diabetics, esp with neuropathy

Question 138

pseudogout ## Footnote what is this caused by? what joint is the most commonly effected? what isn't present that is seen in regular gout? where do you see the deposits? what do the crystals look like under the microscope?

Answer 138

acute inflammatory disease caused by **calcium pyrophospate crystals** calcium pyrophosphate dihydrate disease **knees most commonly effected** \*\*\*\*\*no tophi present that differentiates from gout\*\*\*\* **see calium deposits in the cartilage** aspiration see _rod shapped crystals with blunt ends and befringement unlike gout_ conservative and excision of chondrocalcinosis

Question 139

osteomyelitis ## Footnote what is this and how does it present? what is the most common organism in this and what are the different potential organisms from adults to children? what can a xray show you? MRI? Labs? How long does this person need to be on antibiotics? what is commonly needed? what needs to be removed?

Answer 139

infection of the bone, bacterial, fungal symtoms come from inflammatory response, pus inhibits blood flow, causing necrosis, if bacteria gets into the bone itself it can be difficult to eradicate **S. aureus most common in children and adult** Adults: S. pyogenes, Pseudomonas, E. coli Children: Group B strep, E. coli, Streptococcus pyogenes, haemophilis influenzae **fever, chills, malaise, may have ulcer over effected area** xray:done destruction/hetertrophic bone formation Labs: soft tissue involvement _6 weeks of antibiotic therapy required, can do hyperbaric chamber if not healing, debridement required in most cases and hardware removal, also amputation_

Question 140

where are the 3 most common locations for osteomyelitis in children?

Answer 140

femur, tibia, and humerus aka the long bones

Question 141

where are the three most common locations for osteomyelitis in adults?

Answer 141

vertebrae, maxilla, pelvis

Question 142

what are two things you can see on a xray in osteomyleitis?

Answer 142

**late sequestra:** dead bone surround granulation tissue **involucrum:** (periseal new bone) make take several weeks to months to appeare but careful when looking at xray.....visible changes on cray lag behind symptoms by **10 days**

Question 143

when it comes to osteomyelitis, sickel cell patients are at risk for...

Answer 143

salmonella osteomyelitis

Question 144

infectious (septic) arthritis ## Footnote how many joints does this involve? what joint is the most common? what is the most common agent? what are the four agents in children? what active people does this often effect and percent? what should you treat with until the cultures come back?

Answer 144

**involves a _single_ joint, most commonly the knee 90%** then hip, shoulder, anklet **Adults: S. aureus, streptococcus** **children: Haemophilis influenzae, E. coli, pseudomonas, borrelia burgdoferi** * sexually activite individuals have increased risk from **Neisseria gonnoreah 50%*** xray: may see gas in the joint space, arthrotomy and culture * treat until culture comes back: ceftrixaone, followed by **4 weeks** of antibiotic after organism identified*

Question 145

in infectious (septic) arthritis....what must you always do if the hip is involved?

Answer 145

arthrotomy....test it and see what it is!!

Question 146

what is a exciting new drug that is being used for Giant Cell Arteritis? What does it do?

Answer 146

tocilizumab: promising anti-IL6 drug

Question 147

what are 3 characteristics of general spondyloarthroapies? (3)

Answer 147

1. synovitis 2. enthesitis: inflammation of the tendon and lig insertions to bone **don't have in RA** 3. spinal AND periphreal involvement

Question 148

what is the gene associated with general arthrospondloarthropathies?

Answer 148

HLA-B27

Question 149

what are two things that can increase someones risk for general spondyarthapies?

Answer 149

genetics predisposition infectious influence

Question 150

are there any diagnositc tests for general spondyarthropathies?

Answer 150

no

Question 151

where do you typically see the periphreal arthritis for general spondyloarthropathies?

Answer 151

_assymetric lower limb and random_ _EXCEPT **psoriatic arthritis which is upper limbs**_

Question 152

Ankylosing spondylitis ## Footnote what age group does this happen in? what joint does it often effect first and then where does it go? what does the spine classically look like? Fast or slow? what else can it effect which you wouldn't normally think of? what are 4 other things this can commoly present with? what test do you want to do? what do you see?

Answer 152

leads to fusion of the vertebrae in **20s-30s** effects the sacroiliac joint symmetricaly and then the rest of the spine in **ascending matter _bamboo spine, plantar fascia, achilles tendon, patellar tendon involvement_** **commonly also see: uveitis, aortic valve, cauda equine sundrome, interstitial lung disease** *strong association with HLA-B27* *_gradual onset, morning stiffness that improves with activity for \>3 months_* *schober test: lumbar flexion is abnormal* can't do anything about it except NSAIDS then try DMARDS, try to restore function

Question 153

Reactive Arthritis (Reiter Syndrome) ## Footnote what is this join infection caused by? what are the two most common routes a person can contract this? what are the 4 symtoms that are included as a part of this tetrad? what do you want to make sure you do? and what test will be negative? what do you treat with?

Answer 153

joint inflammation that presents after PREVIOUS INFECTIONs commonly from **sexually transmitted or gastroenteritis** _chlamydia urethritis most common pathogen_ **Tetrad presentation:** 1. **urethritis** (difficulty urinating, **2. conjunctivitis** (eye inflammation) **3. olioarthritis (1-4 joints)** **4. mucosal ulcers** (oral, balantitis\*peeling of skin on penis\*, stomatitis \*inflammation of the mouth) **5. *keratoderma blennhoragicum rash/ulcers on bottom of feet*** want to do a culture, will be RF NEGATIVE! Treatment: NSAIDS, DMARDS antibiotics not really helpfuly even though infection!

Question 154

what are te two bacteria seen in _reactive arthritis_ in the sexually transmitted pathway?

Answer 154

chlamydia urethritis ureaplasma 9:1 Men

Question 155

what are the 4 bacteria you should worry about in _reactive arthritis_ that you should worry about in the gastroenteritis pathway?

Answer 155

Yersina Salmonella Shigella Campylobacter

Question 156

psoriatic arthritis ## Footnote what is this associated with? what is a classic sign of this? what are 2 other things you commonly see? which 2 joints are most commonly effected? what will you never have with this? what is the worst case presentation of this called? what is the treatment?

Answer 156

inflammatory arthritis with skin involvement of **psoriasis** usually preceeding joint disease **spinal and DIP joints** **1. spondyloarthritis** **2. DIP arthritis "PENCIL IN CUP" (pic, see psoriasis in joints)** **3. NO OSTEOPENIA** **4. EROSION NEXT TO ANKYLOSIS** (FORMATION OF NEW BONE)...interesting see both **3. in extreme cases can be in arthritis mutilans where all joints fuse!! can't move** (see in pics, here all tendons are gone, could stretch out finger and move it all around) fingers collapse down **sausage digits (dactylitisi) , nail pitting or onycolysis, tendon swelling** treatment: NSAIDS, DMARDS

Question 157

what condition is this called and what is it a classic sign of?

Answer 157

PENCIL IN A CUP, seen with psoratic arthritis Seen in this picture is spine involvement, with the weird little outcrops, doesn't look like ankylosing spondylitits spine!

Question 158

Explain the ranking of DMARDS for spondyarthropathyies...when do you use each of these? sulfasalazine Methotrexate Anti-TNF etanercept

Answer 158

sulfasalazine: mild **not for skin** methotrexate: moderate to severe disease Anti-TNF Etanercept: used in Methotrexate non responders!

Question 159

Cool table about the differences between RA and spondyloarthropathys

Question 160

cauda equina syndrome

Answer 160

large midline disk herniation that compresses the nerves at **L4-L5** **#1 SPINE EMERGENCY--BY WALL** concerning triad: saddle anastesia, loss of bowel and urinary function, bilateral weakness requires surgical emergency!!! diagnose with CT/MRI

Question 161

Burning prodrome of pain into dermatome followed by a vesicular rash...what is this bacteria?

Answer 161

Herpes Zoster...SHINGLES

Question 162

what plane are the abnormalites in scoliosis found?

Answer 162

coronal

Question 163

scoliosis ## Footnote what are the two general shapes of the spine you can see? what age group is this in and what gender? what are two **unique** indicators you can see? what do you see with the shoulder, iliac, scapula and flank? how do you describe the curve? what vertebrae is this most common in? what type of curvature is really rare?

Answer 163

lateral curvature of the spine in **C or S shape, 3-18 years old!** **cafe au lait spots and tufts of hair present=indicators** **asymmetric in shoulder and iliac height, asymmetric scapula, flank decrease flexion** more common in girls during puberty growth spurt and cessation of spinal growth rate at are the greatest risk! to measure the curvatue you look at the vertebrare at the apex of the curve and then describe relative to that _most common at T7-T8, left curvatures is rare!_

Question 164

what is the most common spinal deformity evaluated by a clinician?

Answer 164

idiopathic adolescent scoliosis

Question 165

explain the 2 divisions of patients for _scoliosis_ and what the treatment reccomendations are?

Answer 165

**\>20\* curvatures: back brace and surgery consult**

Question 166

in scoliosis patients, when are increased xrays indicated? what is considered clinically significant for a curvature change using scolimeter?

Answer 166

\>5\* curvature change: increased xray ## Footnote curve changes: \>15% is signficant!!

Question 167

herniated nucleus pulposus ## Footnote what happens in a herniation? where does this most commonly occur in the vertebrae and in the spinal cord? what will the 3 main symptoms be and what are 3 things a patient will get pain with that are normal things? what do you do for treatment?

Answer 167

this is when the **nucleus pulposus**, the soft gelatinous center is herniated **posteriorally** since this is where the **annulus fibrosis** is the **weakest!!!** usually occurs in **lumbar spine since takes the most load** see motor and sensory manifestation - tingling, numbness, or burning pain (seen in sagital and axial MRI images) - **pain with coughing, sneezing, and laughing** RICE, NSAIDs, surgery

Question 168

what test should you do for herniated disk pulposa?

Answer 168

straight leg test ## Footnote **pain at \<60\* is positive test**

Question 169

spinal stenosis ## Footnote what is this caused by? what two conditions for the risk of stenosis increase with? what **unique** thing makes this better, and what makes this worse? what can you see the in the lumbar region? what will you see on the MRI? what can you do for treatments for this?

Answer 169

compression of nerves of spinal cord caused by **narrowing of the spinal cord and foramen** commonly seen in **spondylosis and degenerative arthritis** pain increases with walking or axial loading (leaning back), and decreases with _leaning forward, flexion!_ back and leg pain, **soft tissue and thecal narrowing, can see loss of lumbar lordosis** TX: acetaminophen, weight reduction, pelvic tilt, abdominal exercises....last choice decompressive surgery

Question 170

MRI with gadalidium allows you to see...

Answer 170

see the nerves better!

Question 171

if you suspect ankylosing spondylitis what should you test for? what is the ratio of males to females?

Answer 171

CHECK FOR HLA-B27 3:1 male to female

Question 172

what would you commonly see sacroilliacitis with?

Answer 172

ankylosing spondylitis and bamboo spine

Question 173

kyphosis ## Footnote what vertebrae do you see this in? what other curvature typically accompanies this in the spine? what is the difference in treatments based on the degress of curvature in the spine?

Answer 173

increased curvature of **_thoracic_ vertebrae, commonly associated with scoliosis** _rounded back appearance, usually accompanied by excessive lordosis_ **if 45-60\* of curvature: PT and bending** **if \>60\*: _milwakee brace_** **surgery as last resort**

Question 174

what is one interesting illness that can subsequently cause kyphosis??

Answer 174

tuberculosis!! weird! POTT DISEASE

Question 175

what is the name of kyphosis seen in children?

Answer 175

scheurermanns idiopathic osteochondrosis

Question 176

what are four things that can cause kyphosos?

Answer 176

- dengeneration - osteoporosis - trauma - spondylolisthe

Question 177

what are the two most common causes of low back pain?

Answer 177

prolapsed intervertebral disk low back strain

Question 178

what percent of americans have low back pain?

Answer 178

90%

Question 179

what are 7 red flags you should look for when someone presents with low back pain?

Answer 179

**\>50 or \<20** **histroy of cancer** **night sweats/weight loss** **urinary or bowel incontinence** **recent bacterial infection** **pain worse when supine** **Hx of trauma**

Question 180

what are the three general rule of thumb for treatment of someone with lower back pain? (3 options) WITHOUT RED FLAGS

Answer 180

1. 2 days with pillow under legs and NSAIDS 2. Mckenzie exercises for disk herniations 3. if not better in 6 weeks move on to imaging unless indicated by red flags 4. if nothing, continue with conservative SURGERY IS NOT COMMON WITH BACK PAIN!!

Question 181

what percent of people with lower back pain actually recieve surgical intervention?

Answer 181

ONLY 5% so it is not very comon at all!!!

Question 182

osteoarthris...explain what happens in this...

Answer 182

normal bone programming "cartilage scenescence"--we outlive our chondrocytes around **25-30 years old**, it frays and falls apart and the chondrocytes become **hypertrophic** and grow larger, however they produce enzymes MMP and aggrecanases that break down the cartilage and act like growth plate cells where THEY MAKE MORE collagen 1 and 9, BONE THAN BREAK IT DOWN...CARTILAGE CAN'T REGROW SO YOU JUST GET INCREASED BONE GROWTH!! "progressive loss of articular cartilage and reactive changes at the joint margins from bone rubbing on sunchondral bone rubbing on bone "behaves like a fracture" and stimulates chondrocyte hypertrophy and increased bone growth

Question 183

what are the Early osteoarthritis presentations? (4)

Answer 183

**1-2 years** ## Footnote **morning stiffness lasting _\<1 hour!!!_ "they're ok, they just keep going!"** **red, prominent _DIP_ and PIP joint involvement** **normal radiographs**

Question 184

what are the common presentations of late osteoarthritis? (5)

Answer 184

**morning stiffness lasting** **\<30 mins/1 hour** **mechnical stiffness,** **gets worse with movement****, more pain the more they do** **not the same strength they used to** **(opening jars, turning handles)** **abnormal radiographs!** **deformities obviously present, bone hypertrophies** **get** **LESS** **symtomatic in non weight bearing joints, asymatic once they are deformed because they aren't able to move them**

Question 185

what is neuropathic arthropathy nicknamed? what are 3 risk factors for this?

Answer 185

CHARCOT foot!! this is a type of osteoarthritis diabetes, alcoholism, tabes dorsalis!

Question 186

what is an osteophyte?

Answer 186

bone outgrowth seen in osteoarthritis, increase in bone production

Question 187

what joints are most commonly effected by osteoarthritis?

Answer 187

PIP, DIP, hips, knees

Question 188

what are the treatment options for someone with osteoporosis?

Answer 188

Not much...its a natural bone programming Its "supposed" to happen - joint conservation - exercise low impact - weight loss to relieve load on joints NSAIDS and COX-2, **total joint replacement, autologous cartilage implantation (not many people qualify)**

Question 189

what are the genes associated with osteoarthritis? (3) what do they do?

Answer 189

FR2B, GDF-5, DIO2 endochondral ossification, skeletal malformations, and hypertrophic chondrocyte activity

Question 190

secondary cause of osteoporosis: Padget's disease

Answer 190

ribbed or holey bones which throws the angles off and causes you to get bone on bone running

Question 191

osteoporosis ## Footnote what is this? who is it most common in? what is the nickname for this disease? what imaging type do you want to preform? what 3 presentations might you find on physical exam?

Answer 191

abnormal bone remodeling, decrease in the total volume of bone making it less dense, since less strong it leads to increased fractures! **imbalance between bone formation and reabsorption** **_most common in menopausal women_** **_"silent disease"_** presentation: _height loss, kyphosis, severe cervical lordosis **dowagers hump**_ Dexxa scan of spine and hip

Question 192

what is an abnormal DEXA scan result that can indicate osteoporosis?

Answer 192

-2.5 and below

Question 193

what are the treatment options for osteoporosis? (3)

Answer 193

1. bisphosphonates: inhibits osteoclasts (jaw necrosis) 2. HRT, estrogen, or progesterone (stroke, breast cancer) 3. selective estrogen receptor modulator (serms)

Question 194

rheumatoid arthritis what are the four criteria for diagnosis?

Answer 194

**1. morning stiffness \>1 hour, usually don't feel better till 10-11 am** **2. arthritis of \>3 joints and soft tissue, immune system is activated!** **3. symmetrical!!** **4. \>6 weeks!**

Question 195

explain what happens in rheumatoid arthritis?

Answer 195

affects the lining of multiple joints synovitis, causing a painful swelling that can eventually result in bone erosion and joint deformity, **autoimmune** (not wear and tear like osteoarthritis) hyperplastic synovial tissue called pannus erodes the cartilage, subchondral bone, tendons, and ligs "like a line of soldier marching to battle and destroying everything in their pathway. joint erosion

Question 196

what two tests do you want to run for someone with rheumatoid arthritis? which is more specific?

Answer 196

RF: 65-70% positive A-CCP: POSITIVE 70, more specific

Question 197

what is the a specific indicator for Rheumatoid arthritis that isn't seen in ANY OTHER DISEASE!!!!!!

Answer 197

cyclic citrullinated protein

Question 198

when is the most critical point to catch Rheumatoid arthritis? what is the difference in the timeframe for progression? when are you likely to see radiologic changes?

Answer 198

ASAP will see radiographic changes \<2 years **rapid during first year compared to second and thurs** "at first its a fire and an entire war so need to get treatment asap, the second wave is just the reserve and the damage and action has already taken place"

Question 199

explain the 3 phases of rheumatoid arthritis?

Answer 199

1. TNF and IL cause catabolic effect on chondrocytes, attracts macrophages, weakens it 2. introduction of metalloproteinases, stromolysin, and collagenase 3. phagocytosis of cartilage and bone by pannus

Question 200

why is it important to always look at the feet of a rheumatoid arthritis pt? if suspicious they have it what is important to do?

Answer 200

see it on the feet before the hands so really important to get xrays of both the hands and feet!! ALWAYS DO BOTH!! if suspicious on physical exam, must feel joints because you will feel the difference between individual joints!

Question 201

what three joints does RA commonly effect?

Answer 201

MCP, PIP, wrist also feet fyi

Question 202

what is rheumatoid arthritis an independent predictor of?

Answer 202

cardiovascular disease 2.5

Question 203

what are the 3 stages to accepting a chronic illness?

Answer 203

1. denial 2. anger/sadness 3. acceptance but people still worry about it regardless

Question 204

what two inflammatory contributors will you find remarkedly elevated in RA?

Answer 204

TNF, IL-1

Question 205

if you add a biologic agent to methotrexate, how much do you increase remission by?

Answer 205

20%

Question 206

why don't you prescribe two biologic agents?

Answer 206

increase infection rates by 30%

Question 207

NEW RA DRUG xeljanz does what?

Answer 207

blocks phosphorylation of janus kinase inhibitor only had for 1.5 years

Question 208

if a RA patient isn't responding to the biologic agent what should you do?

Answer 208

try a different one!! 70% will respond to a medication switch with biologic meds!

Question 209

explain the medication treatment rational for rheumatoid arthritis!! 3 conditions

Answer 209

1. methotrexate 2. in partial or non responders frm 4-8 weeks, get them on biologic DMARD **ETANERCEPT combined with Methotrexate!!** 3. if erosions at time of xray, then go straight to **Etanercept or biologic dmards!**

Question 210

how many of the characteristics do you need to have to qualify for rheumatoid arthritis?

Answer 210

6/10

Question 211

juvenile rheumatoid arthritis ## Footnote what common general age is this found in? what age range is most common for females? what age range is most common for males? what are 3 types that you can see and what are associated with each?

Answer 211

chronic synovitis **in** females: **1-3 years old** males: **8-12** see spiking fever, pink macropapular rash, warm, red joints _Systemic_: fevers, rash, hepatosplenomegaly, leukocytosis, myocarditis _pauciarticular_: _poly articular_: like adult RA, five or mor small joints, nodules

Question 212

Bilateral LBP- Diffuse, Non-Radiating, worse with sitting, stationary positions pain associated with?

Answer 212

degenerative disc disease

Question 213

Unilateral Right LBP, posterior buttock, radiating into right leg typical for

Answer 213

lumbar disk herniation

Question 214

LBP at night, persistent, unrelieved by rest or laying supine common in...

Answer 214

malignancy

Question 215

when would you see cafe au lait spots and missing tufts of hair and edema?

Answer 215

neurofibromatosis, scoliosis

Question 216

most lower back pain/strain will result in...

Answer 216

1-4 weeks with conservative treatment guidelines reccomend conservative treatment for 4-7 weeks

Question 217

30% of **asymptomatic individuals** may display **abnormal** MRI changes c**onsistent with disc degeneration in the absence of clinical symptoms.**

Answer 217

fun fact!

Question 218

what type of imaging is the gold standard for tumors, disk herniation, nerve impingement? when would you use the next step down?

Answer 218

Magnetic Resonance Imaging MRI if they have a pacemaker or internal metal and can't get one

Question 219

what can you see with a CT (computed tomography)? what about when you add contrast? what type of patient would have to use this if they couldn't use MRI?

Answer 219

3D image, bone, facet joints with contrast look at nerves or intradural lesions use with a patient if they have a placemake and can't use MRI

Question 220

Bone scan (scintigraphy) what do you use this for?

Answer 220

vertebral body osteomyelitis or osteoblastic lesion

Question 221

what is always important to test for someone who presents with back pain?

Answer 221

LYME TITERS

Question 222

if adams forward bending test is positive...what is it likely the patient has?

Answer 222

scoliosis

Question 223

where is a common site for stress fractures? what makes these fractures worse?

Answer 223

pars interarticularis region, **spondylolysis** full extension and rotation to the effected side if postivie, need to brace for at least **3 months**