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Heberden's nodes affect what joints in what disease?
DIPs in OA
Bouchard's nodes affect what joint in what disease?
What is found on OA xrays?
Asymmetric narrowing, subchondral sclerosis, cysts, and marginal osteophytes
Pathophysiology of RA
Hyperplastic synovial tissue may erode cartilage, subchondral bone, articular capsule, tendons, and ligaments
Dx criteria for RA
- Morning stiffness > 1 hour
- Radiologic changes suggestive of jt erosion or bony decalcification
- Symmetric arthritis, present for at least 6 weeks
- Hand arthritis
- Arthritis in > 3 joints
- RF > 95%
- Nodules on bony prominences, extensor surfaces, or juxta-articular regions
Extra-articular manifestations of RA
Kidneys, blood, eyes, liver, lungs
RA lab findings
- elevated RF and anti-CCP in 70-80% of pts (but levels low in early disease)
- Elevated ESR and CRP
RA radiography findings
soft-tissue swelling and juxta-articular demineralization
RA initial tx
NSAIDs + DMARD (methotrexate) initially
Other DMARDS than methotrexate
corticosteroids, sulfasalazine, antimalarials, leflunomide
New biologic tx for RA
etanercept, abatacept, rituximab, infliximab, and adalimumab
Still's Disease presentation
Spiking fevers, myalgias, polyarthralgias, and salmon-pink maculopapular rash appearing in the evening with fever
A process in Still's disease where the rash can be elicited by scratching skin in susceptible areas
Extra-articular manifestations of Still's disease
HSM, lymphadenopathy, leukocytosis, pericarditis, or myocarditis
WBC count in septic arthritis
PMN % in septic arthritis
When are Still's disease pts at risk for uveitis?
When they have a postive ANA
lab findings in Stills
- 10-15% have positive RF
- ESR and CRP increased or nl
Treatment of JRA
- First line: NSAIDS, PT/OT
- Second line: methotrexate or leflunomide
Prognosis of JRA
- 75-80% remit without serious disability
- Pts who are RF positive are at a greater risk of progressing to disabling arthritis as adults
m/c pathogen in septic arthitis
Diff b/w osteomyelitis and septic arthritis
osteomyelitis has systemic sx
What % of septic arthritis pts have pos blood culture?
distribution of psoriatic arthritis
few joints, may involve hands and feet
sausage finger appearance
Lab findings in psoriatic arthritis
- Elevated ESR
- normochromic, normocytic anemia
- RF is nl
Psoriatic arthritis tx
- NSAIDs for mild cases
- Methotrexate for skin inflammation and arthritis
- Avoid corticosteroids and antimalarials
What is the tetrad of Reiter's
urethritis, conjunctivitis, oligoarthritis, and mucosal ulcers
Reiter's is a common sequalae to what conditions?
STDs and gasteroenteritis
Clinical features of Reiter's arthritis
asymmetric arthritis that involves large joints below the waist; mucocutaneous lesions, urethritis, and conjunctivitis
Leading cause of nontraumatic monoarthritis
Lab findings in Reiter's
- Positive HLA-B27 in 50-80% of pts
- Negative synovial fluid
Treatment of Reiter's
- PT and NSAIDs are the mainstay
- ABX given at tiem of infection will reduce the chance of developing the disorder, but do not alleviate the sx of the reactive arthritis
initial gout attack of the great toe
Joint fluid analysis in gout
rod-shaped, negatively birefringent urate crystals
Uric acid level in gout
- Indomethacin 25-50mg TID until sx resolve
- Corticosteroid injections for accessible jts, PO prednisone if other medicines are not tolerated and septic arthritis has been ruled out
Management of gout between attacks
allopurinol, colchicine, probenacid, sulfapyrazone, or febuxostat
Pseudogout m/c joints
knee, wrist, and elbow
Joint aspiration results in CPPD
positively birefringent rhomboid shaped crystals
women of child-bearing age; AA>C
Dx criteria for SLE
- MS. PARANOID
- Malar rash
- Renal dz (proteinuria, cellular casts)
- Neurologic disorders (seizures or psychosis in absence of any other cause)
- Oral ulcers
- Immunologic disorders (LE cell, anti-DNA, anti-Sm, false-positive RPR)
- Discoid rash
What labs should be ordered in SLE?
CBC, BUN/Cr, UA, ESR, and serum complement (C3 or C4)
- Regular exercise and sun protection
- NSAIDs for MS complaints
- Anatimalarials for MS and cutaneous manifestations)
- Corticosteroids for skin and disease flares
- Methotrexate (low dose) for arthritis, rashes, serositis, and constitutional sx
What is polymyositis?
inflammatory dz of striated muscle affecting the proximal limbs, neck, and pharynx
Other organ involvement in polymyositis
joints, lungs, heart, and GI tract
disease with a strong association with occult malignancy
Clinical features of polymyositis
insious, painless, proximal muscle weakness; dysphagia, skin rash (malar or heliotrope), polyarthralgias, and muscle atrophy
Lab findings in polymyositis
elevated CPK and aldolase
high dose steroids, methtrexate, or azathioprine until sx resolve
Pain and stiffness in the neck, shoulder, and pelvic girdles; accompanied by constitutional sx
women twice as much as men, usually in pts > 50
What % of PMR pts develop GCA?
clinical features of PMR
- Stiffness, primarily after rest and in the morning
- MS sx are B/L, proximal, and symmetrical
Lab results in PMR
ESR > 50 mm/hr
Tx of PMR
low dose cortocosteroids, unless GCA is present, then it's high dose
What is polyarteritis nodosa?
Small and medium artery inflammation involving the skin, kidney, peripheral nerves, muscle, and gut
polyarteritis nodosa epidemiology
male > female 3:1, onset between 40-60 yrs, although it can occur in any age group
Rheum dz with strong association with Hep B
Clinical characteristics of polyarteritis nodosa
fever, anorexia, weightloss, abdominal pain, peripheral neuropathy, arthralgias, arthritsi
Skin manifestations of polyarteritis nodosa
palpable purpura and livedo reticularis
Kidney involvement of polyarteritis nodosa
htn, edema, oliguria, uremia
Lab findings in polyarteritis nodosa
- Dx with vessel bx or angiography
- Elevated ESR and CRP and proteinuria, as well as positive Hep B surface antigen
- presence of ANCA is suggestive but not dx
Tx of polyarteritis nodosa
- high dose corticosteroids
- cytotoxic drugs and immunotherapy may be used
female > male 4:1; onset b/w 30-50yo
Difference between body involvement of diffuse and limited scleroderma
- diffuse: skin, heart, lungs, GI tract, and kidneys
- limited: mostly affects the skin of the face, neck, and distal elbows and knees; can cause pulm HTN
calcinosis, raynaud's phenomenon, esophageal dysfunction, sclerodactily, telangiectasias in association with LIMITED scleroderma
Lab findings in scleroderma
- ANA positive in 90% of pts
- anicentromere Ab in limited scleroderma
Tx of scleroderma
- no cure
- tx the organ-specific disease processes (PPIs for reflux, ACE-Is for renal dz, avoidance of triggers and tx with CCBs for Raynaud's, immunosuppressive drugs for pulm HTN
autoimmune disorder that destroys the salivary and lacrimal glands
What can Sjogren's be a secondary complication to?
RA, SLE, polymyositis, or scleroderma
most common in middle-aged females
Enlarged parotid glands
Lab findings in Sjogrens
- RF positive in 70%
- ANA positive in 60%
- Anti-Ro Abs in 60%
- Anti-La Abs in 40%
How can you make the dx?
Bx of lower lip mucosa, to confirm lymphocytic infiltrate and gland fibrosis
Tx of Sjogrens
- artifical tears and saliva
- increase oral fluid intake
- ocular and vaginal lubricants
- pilocarbine for saliva flow
What can fibromyalgia be concurrent with?
RA, SLE, and Sjogrens
Tx of fibromyalgia
- SSRIs, SSNRIS, and TCAs
- Pre-gabalin (Lyrica) only drug that is FDA approved specifically for tx of fibromyaglia
- Aerobic exercise
- pt education, stress reduction, sleep assistance, and tx of psychological problems
what bones are m/c affected in osteomyelitis?
Who is at risk for salmonella osteomyelitis?
Use of radiography for dx osteomyelitis
xray evidence lags behind sx by 7-10 days, therefore use ultrasound
What are sequestra of osteomyelitis?
- dead bone surrounding granulation tissue
- involucrum (periosteal new bone)
- Abx x 3 weeks (1 week IV, 2 weeks PO)
- immobilization and surgical drainage
- surgical tx to remove sequestra, sinus tract, infected bone, and scar tissue
What Ca mets to the bone?
- BLT with a Kosher Pickle
- Breast, Liver, Thyroid, Kidney, Prostate
What is the m/c site of bony metastases?
M/C primary benign bone neoplasm of the hand
m/c types of primary sarcomas of the bone
chondrosarcoma, Ewing's sarcoma, and osteosarcoma
m/c primary malignant bone tumor
Epidemiology of Ewing's Sarcoma
5 and 25 yo
Where are Ewing's sarcomas found?
diaphyses of long bones, ribs, and flat bones
Epidemiology of osteosarcomas
where are osteosarcomas generally found?
metaphyseal area of long bones
M/C source of bone lesions in adults > 60 yo
soft tissue sarcoma tx
radiation therapy followed by local resection
When do xrays show decreased bone density?
When 30% of bone loss is present
Study of choice to dx occult hip fx
Open fx tx
- debrided and irrigated within 4-8 hours of injury
- IV abx (1-2G cephs, and aminoglycosides) for 48 hours after the fx and for 48 hours after surgical procedures
Tx of greenstick fx
If angulation <15%, may long cast; if >15%, refer to ortho
M/C cause of facial pain
M/C condition affecting cervical spine
What is spondylosis?
a condition where degenerative changes occur in the disk, m/c C5-C6, with the formation of osteophytes and disk narrowing; later on in the dz, facet joints and the joints of Luschka are affected
What happens with compression caused by central disk protrusion or osteophytes in spondylosis?
long-tract signs (clonus, Babinskis sign) and gait disturbance
humeral head deformities d/t recurrent dislocations
tear of glenoid labrum in shoulder dislocation
Tx of dislocations
- immobilization by sling and swath
- therapy, begin after 1 week if >40 yo; at 3 weeks if < 40 yo
Features of adhesive capsulitis
pain and restricted glenohumeral movement; arthrography may show decreased volume of the joint capsule
Tx of adhesive capsulitis
NSAIDs, passive ROM, and occasionally, manipulation under anesthesia
Tx of clavicle fx
- children: figure of eight slin for 4-6 weeks
- adults: sling for 6 weeks is generally enough to tx the tx
classification of humeral head fx
Volkmann's ischemic contractures
caused by injury to brachial artery, possible with supracondylar humerus fx
osteonecrosis of the lunate
Dupuytren's Disease affects what parts of the hand?
palmar aponeurosis, ring, little and middle fingers, causing painful nodules, pitting, and contractures
Organism specific to human mouth
silver fork deformity
colles fx (distral radius fx with dorsal angulation)
m/c injury of wrist
What is gamekeeper's thumb?
sprain or tear of the UCL of the thumb
m/c common overuse injury of the elbow
What muscle is involved in lateral epicondylitis?
extensor carpi radialis brevis
m/c organism causing olecranon bursitis
tx of nursemaid's elbow
holding affected arm just above the wrist and just below the elbow, place thumb of proximal hand over the radial head while fully supinating and felxing the forearm and applying posteriorly directed pressure (screws the radial head back within annular ligament)
Presentation of nursemaid's elbow
child will present with extremity fully pronated, with slight flexion and held tightly to side
m/c fx carpal bone
what supplies blood to scaphoid?
radial artery by way of lateral and distal branches
What is DeQuervain's Disease?
stenosis tenosynovitis involving the abductor pollicus longus and extensor pollicis brevis
epidemiology in de quervains
diabetics, females > 30
sx of de quervains
radiation of pain up in the forearm, pain and tenderness occur at the wrist and base of the humb
m/c types of scoliosis
right thoracic curves at the T7 or T8 level
How do you manage scoliosis?
- 10-15 degree curves: 6-12 month f/u with clinical evaluation and possibly xrays
- 15-20 degree surves: serial AP radoigraphs q3-4mo for larger curves and q6-8months for smaller curves
- 20+ degree curves: refer to ortho
M/C extrapulmonary location of TB after the LN
TB of the spine (Pott's disease)
What is spinal stenosis?
nerve compression caused by narrowing of the spinal canal or neural foramina
what is central stenosis?
compression of the thecal sac
What is lateral spinal stenosis?
impingement of the nerve root lateral to the thecal sac
Clinical features of spinal stenosis
neural claudication and exacerbation of pain with walking, pain relieved by leaning forward, variable back and leg pain
What is ankylosing spondylitis?
a seronegative spondyloarthropathy that progresses to fusion of the vertebrae
What are sx of ankylosing spondylitis?
- restricted lumbar motion
- limited motion int hes houlders and hips, synovitis of the knees, plantar fascitis, and achilles tendinitis, hip contractures and fixed cervical, thoracic, and lumbar kyphosis
extra-articular manifestations of ankylosing spondylitis
uveitis, cardiac abnormalities, and interstitial lung dz
lab findings in ankylosing spondylitis
- elevated ESR and CRP
- HLA-B27 positive in 90% of whites, 50% of blacks
What is cauda equina syndrome?
rare condition involving a large midline risk herniation that compresses several nerve roots, usually at L4-L5
what are clinical features of cauda equina syndrome?
- bowel and bladder function is severely impaired
- leg pain, numbness, saddle anesthesia and/or paralysis
What is aseptic necrosis?
results from loss of blood supply to the trabecular bone which causes a collapse of the femoral head
What is aseptic necrosis called in children?
Legg Calves Perthes
When is the peak age for LEgg Calve Perthes
4-8 years old
Imaging of choice for aseptic necrosis of the hip
What is SCFE?
weakening of the epiphyseal plate of the femur, resulting in a displacement of the femoral head
What ligament is m/c involved in an ankle sprain?
anterior talofibular ligmanet
What is hallux valgus?
What causes hallux valgus?
lateral deviation of the proximal phalanx
What is considered abnl with an xray of a bunion?
an angle of greater than 15 degrees
What is a morton's neuroma?
a results of traction of the interdigital nerve against the transverse metatarsal ligament causing degeneration of the nerve and chronic inflammation
Where does a morton's neuroma m/c affect?
third web space
what are sx of morton's neuroma?
pain and localized numbness when walking and standing, which is relieved with rest; pain localized to web space commonly with a palpable mass; squeezing forefoot will often reproduce sx
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