Lecture 2- Rheum Flashcards

Question

OA: * What type of patients?

Answer 1

* Older patients * F>M * Asymmetric

Answer 2

* Weight reduction, moderate physical activity, NSAIDs, intra-articular steroids, bracing, canes, and muscle-strengthening exercises * Acetaminophen vs NSAIDs (depends on risk factors, but NSAIDs are preferred) * Intraarticular glucocorticoid injections provide symptomatic relief but do infrequently as cartilage breakdown may be accelerated if performed too often * Systemic glucocorticoids have no place in Rx of OA (RA might get this) * Surgery last resort ## Footnote NSAIDs: kideney clearance so be careful with diabetes, HTN, and kidney disease

Answer 3

* OA – assymetrical, weight bearing, NO redness or heat, Pain gets worse as day goes on and is alleviated by rest. * RA – symmetrical (PIP/MCP), worse in AM and gets better as day goes on.

Answer 4

* The worldwide prevalence of RA has been estimated as 0.24 percent based upon the Global Burden of Disease 2010 Study. * Estimates of RA prevalence in the United States and northern European countries are typically higher, usually between 0.5 to 1 percent dt auntoimmune, diet * The annual incidence of RA in the United States and northern European countries is estimated to be approximately 40 per 100,000 persons (also undiagnosised)

Answer 5

* Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by an inflammatory polyarthritis that preferentially affects the small joints. * RA is a "multicausal" disease that most likely results from a combination of genetic predisposition and various environmental and lifestyle factors. Articular and systemic manifestations in RA can lead to poor long-term outcomes such as disability and death

Answer 6

* MCP joints are involved, others are spared. * Joint pain and deformity * Muscle weakness, myositis, osteopenia, and osteoporosis * Extra-articular manifestations include changes in skin, lungs, kidneys, eyes, liver, blood system, and heart-> pul hem, chronic kidney disease, rash, eye issue

Answer 7

Symmetric polyarthritis involving small joints, may start as simple inflammation or synovitis, will progress to bone/cartilage erosions

Answer 8

* General: Fatigue, fever, weight loss * Derm: Nodules * Heme: Anemia (**Felty’s Syndrome**) * Pulmonary: pleuritis/pneumonitis * Cardiac: Peri or myocarditis and higher chance of having DVT (has autoimmune then need high awareness) * Renal: Interstitial nephritis * Ophthalmic: Episcleritis * GI: Xerostomia * MS: myositis

Answer 9

* Common at C1-C2, but remainder of spine is usually spared * Instability of C spine is a life threatening complication of RA. * Instability results from a cervical ligament synovitis in region of C1-C2. * Occurs in 30-40% of pts who develop RA * 5% of these eventually develop a myelopathy or cord injury | Issue since breathing is C4 so anything above-> DEAD

Answer 10

A score ≥ 6 is needed for classification of a patient as having definite RA

Answer 11

Consult with rheumatology * PT/OT * Pharm tx early and aggressive to reduce pain, preserve function, and prevent deformity * NSAIDs with DMARDs (usually started together) * DMARDs-initially methotrexate

Answer 12

* Others DMARDs are steroids, sulfasalazine, antimalarials (hydroxychloroquine), and leflunomide. * Newer biologic DMARDs are etanercept, abatacept, rituximab, infliximab, and adalimumab

Answer 13

Felty’s syndrome which usually occurs late in the disease process is manifested by splenomegaly, neutropenia, & + RA factor.

Answer 14

Pulmonary-nodules, interstitial disease, pleural disease, Caplan’s syndrome [sero(+) RA associated with pneumoconiosis] * Sero (+) that of CRP or RF

Answer 15

* Affects all races and geographical locations * Incidence: 6-20 cases per 100,000 children * Prevalence: 16-150 per 100,000 * Females to Males ratio: 2>1

Answer 16

* Exact Causes of JIA – UNKNOWN * Is Autoimmune disease – body attacks itself * In JIA, the synovial membrane is recognized by own immune system as a “foreign” invader, which causes immunologic attack in attempt to kill the tissue, hence the inflammatory process. * Infection (septic arthritis), cancer, bone disease, Lyme disease and lupus must be ruled out before making a JIA/JRA diagnosis

Answer 17

* Age of Onset <16yo * Duration of Disease >6 weeks * Arthritis (swelling or effusion, limited ROM, tn or pain, increased warmth) in one or more joints * Exclusion of other forms of arthritis

Answer 18

Type of disease defined in the first 6 months: * Polyarticular: 5 or more inflamed joints * Oligoarticular: less than 5 inflamed joints * Systemic arthritis with presence of fever

Answer 19

* DMARDs preferred over NSAIDs (2019 ACR guideline) * Methotrexate preferred, Alt: Leflunomide or sulfasalazine * MTX requires CBC (pancytopenia) and LFT monitoring (cirrhosis and hepatitis) * PT/OT * Anakinra, TNFs, or abatcept for intractable cases * Monitor for growth abnormalities, nutritional deficiencies and school/social impairment.

Answer 20

Children with systemic JIA who fail to respond adequately to therapy have a significantly poorer prognosis than do children who achieve disease control.

Answer 21

* Fibromyalgia (FM) is a common cause of chronic pain and the most common cause of generalized, musculoskeletal pain in women between ages of 20 and 55 years * Prevalence is 2-3 percent and increases with age. * Initially termed fibrositis, FM is more common in women than men and occurs in both children and adults. It is six times more common in women ## Footnote The diagnosis may be under-recognized in clinical practice according to some sources, others indicate that those that are diagnosed, only half meet the actual criteria.

Answer 22

* Alterations in CNS pain processing patterns * Sleep, mood, stress and cognitive disturbances. * Genetics and environment

Answer 23

* Rule out Differential diagnosis (Hypothyroidism, Hep C, Vitamin D deficiency, inflammatory processes) * No specific tests, previously was diagnosed using tender point counting, no longer validated * Generalized pain and tenderness, especially if disproportionate to physical findings * Negative laboratory results despite widespread symptoms * Fatigue as a predominant symptom * Clinical diagnosis-> rule out everything before FM

Answer 24

* Chronic issue * Waves often-> pain up and down

Answer 25

* Inflammatory CTD of WBC’s attacking healthy striated muscle affecting the proximal limbs, neck, pharynx. * Skin can be affected = dermatomyositis * Other organs - heart, joints, lungs, and GI tract

Answer 26

* Association of malignancy with dermatomyositis suggests that a tumor may incite myositis as result of an autoimmune reaction directed against a common antigen in muscle & tumor * Symmetrical weakness & pain cause classic complaint of **difficulty rising from a chair**. Patients may eventually have difficulty breathing or swallowing | Tissue is replaced by scar tissue= decrease fxn

Answer 27

* Dermatomyositis (DM) and polymyositis (PM) are relatively uncommon disorders. In a population-based study of the residents of Olmsted County in Minnesota that incorporated data from 1976 to 2007, the estimated annual incidence of all subtypes of DM was approximately 1 per 100,000 persons. * The incidence of DM is higher in females compared with males. In the population-based study from Olmsted County, 22 of the 29 patients (76 percent) with DM were female. Individuals of any age can be affected. * The annual incidence of PM has been reported to be 0.41 to 0.75 per 100,000 persons

Answer 28

* The cardinal manifestation of dermatomyositis (DM) and polymyositis (PM) is gradual skeletal muscle weakness (usually painless), specifically symmetric proximal>distal muscle weakness. * Muscle weakness may start suddenly & progress over weeks to months * Difficulty raising their arms above shoulders, climbing steps or arising from a sitting position * Flexors of neck may be severely affected, causing an inability to raise head from pillow * Dysphagia * Malar skin rash * Polyarthralgias (less pronounced than weakness) * Muscle atrophy

Answer 29

* Heliotrope rash (be careful-> similar to lupus) * Reddish-violaceous eruption on upper eyelids, often accompanied by swelling of eyelid * Symmetric, erythematous to purplish, scaly, flat papules on extensor surfaces of metacarpophalangeal & interphalangeal joints)

Answer 30

* ESR, CPK and aldolase levels are elevated * ANA may be positive * Autoantibodies---anti-Jo-1 seen in 50% of pts with PM/15% with DM * Muscle biopsy should be performed and will show inflammatory changes

Answer 31

* Step 1-Glucocorticosteroids-Prednisone 1mg/kg/d for 3-4 weeks, then tapered very gradually * Step 2- Azathioprine or methotrexate * Step 3 IV immunoglobulin over 2-5 days * Step 4- Cyclosporine, chlorambucil, cyclophosphamide, or mycophenolate

Answer 32

* 5-year Survival is >80% * Mortality is often associated with increased chance of malignancy and CV complications * Residual weakness is present in 30% of patients following resolution * Those with DM, 5% of them will have fulminant progression leading to death-> No treatment works

Answer 33

* Polymyalgia rheumatica (PMR) is almost exclusively a disease of adults over the age of 50, with a prevalence that increases progressively with advancing age. The peak incidence of PMR occurs between ages 70 and 80. * PMR is relatively common. The lifetime risk of developing PMR has been estimated at 2.43 percent for women and 1.66 percent for men and is second only to rheumatoid arthritis (RA) as a systemic rheumatic disease in adults. * Women are affected two to three times more often than men. Cases of familial aggregation are recognized

Answer 34

* Big association with patients having Giant Cell Arteritis (GCA)

Answer 35

* Clinical syndrome characterized by aching & morning stiffness in the shoulder girdle, hip girdle, or neck for > 1 month * Elevated ESR, & rapid response to low-dose prednisone (15mg qd) * Rarely occurs before age 50 * Can occur in association with giant cell arteritis, which requires treatment with higher doses of prednisone

Answer 36

ESR levels are markedly elevated. Temporal artery biopsy if suspected GCA. * Labs to R/O other disorders (RF, ANA,CBC, CPK, SPEP) * Renal, hepatic, & thyroid function tests

Answer 37

* Primarily Low vs high-dose corticosteroids. Usually up to 2 years and slowly tapered. * Average length of disease is 3 years * Can recur if steroids are tapered too quickly

Answer 38

* Estimates of the incidence and prevalence of Sjögren's syndrome (SS) vary widely, depending upon the specific classification criteria, study design, and the population examined. * Only a small minority (approximately 10 percent) of patients with clinically significant dry eye have SS.

Answer 39

* Constituional- fatigue * Sicca symptoms- keratoconjunctivits sicca (KCS) & xerostomia * Dryness of other surfaces-nose, vagina, trachea, skin * Extraglandular features- arthralgia/arthritis, Raynaud’s, lymphadenopathy, interstitial pneumonitis, vasculitis (usually cutaneous), nephritis, lymphoma

Answer 40

* Criteria: keratoconjunctivits sicca (KCS) xerostomia, (+) serologic features of autoimmunity * Postive ANA, Anti SSA/Ro, anti SSB/La * Positive lip biopsy considered necessary in some series-should be performed in setting of objective KCS/xerostomia with negative serologies

Answer 41

* RF is present in over 70% * ANA in 60% * Anti-Ro (SS-A) antibodies in 60% * Anti-La (SS-B) antibodies in 40% * Biopsy of lower lip mucosa confirms gland fibrosis and lymphocytic infiltrate (if negative above) * Schirmer test (tear production) * Labial salivary gland biopsy-demonstrates lymphocytic infiltration and destruction of glandular tissue

Answer 42

* Small strip of paper applied in conjunctival sac (lower eyelid) and eyes closed for 5 minutes. * Moisture is measured after 5 minutes * <5mm in 5 minutes is diagnostic for Sjogren’s syndrome

Answer 43

* Primary Sjogren: Usually good, unless severe extraglandular manifestations develop * Pediatric patients often do not develop sicca symptoms, therefore often do not seek care until more severe symptoms develop (eye irritation, dental caries, dyspareunia) * Secondary Sjogren: depends on primary autoimmune disorder

Answer 44

* Female to male 4:1 * Peak age is between 30-50 years * 2.5 million people-worldwide

Answer 45

* Unknown cause and characterized by deposition of collagen in the skin and less commonly heart, kidney, lungs and stomach. * Chronic and rare autoimmune systemic vascular and connective tissue disease * Involves immunologic mechanisms leading to vascular endothelial damage & activation of fibroblasts * Antibodies are produced to deoxyribonucleoprotein, nucleolar, centromere, & topoisomerase 1 antigens

Answer 46

Shiny, taut skin seen here in a middle-aged woman who has no facial wrinkles at all is typical of scleroderma.

Answer 47

* Toxic-oil syndrome * Vinyl chloride-induced disease * Bleomycin-induced fibrosis * Pentazocine-induced fibrosis * Epoxy & aromatic hydrocarbons-induced fibrosis * Eosinophilia- myalgia syndrome

Answer 48

* ANA is present in 90% with diffuse scleroderma. * Anticentromere antibody is associated with CREST Syndrome * Anti-SCL-70 antibody is associated with diffuse scleroderma and has poor prognosis * Watch for HTN and kidney function decline * Renal failure, pulmonary fibrosis and/or pulmonary HTN are leading causes of death

Answer 49

* No cure * Treatment is aimed at organ-specific disease processes * D-penicillamine-controversial benefit to reduce skin thickening & prevent organ involvement * Glucocorticoids-indicated for inflammatory myositis or pericarditis * Cyclophosphamide-improves lung function & survival in patients with alveolitis * Epoprostenol-may improve cardiopulmonary hemodynamics in pts with PHTN

Answer 50

* PPIs for GI, ACEI for kidneys, avoidance of triggers * CCBs for Raynaud’s phenomenon * Immunosuppressive drugs for pulmonary HTN.

Answer 51

* Quite variable; males have a worse prognosis * Patients with limited cutaneous scleroderma, better prognosis * Malabsorption syndrome & primary biliary cirrhosis (PBC) causes of death & morbidity in some patients with limited cutaneous disease * Prognosis worse in patients with diffuse cutaneous disease * Death occurs most often from pulmonary, cardiac, & renal involvement (CKD) * In patients with diffuse cutaneous disease, 5-year cumulative survival rate is ~70% & 10-year is ~55%. * In limited cutaneous disease 5-year is ~90% & 10-year is ~75%.

Answer 52

Autoimmune disorder characterized by inflammation, positive ANA level and involvement of multiple organs

Answer 53

* The reported prevalence of systemic lupus erythematosus (SLE) in the United States is 20 to 150 cases per 100,000. * 90% women, usually of child-bearing age & more common in African Americans * Due to improved detection of mild disease, the incidence nearly tripled in the last 40 years of the 20th century. * Estimated incidence rates are 1 to 25 per 100,000 in North America, South America, Europe, and Asia

Answer 54

* Production of autoantibodies with specificity for nuclear antigenic determinants leads to immune complex formation. * Immune complexes deposited in glomeruli, skin, lungs, synovium, mesothelium, & other places. * Deposition leads to manifestations of disease

Answer 55

* Genetics may play a role * Environmental/diet/ chemical agents/drugs, UV radiation and infections all play a role

Answer 56

* INH * Hydralazine * Minocycline * Methyldopa * Chlorpromazine * Quinidine * Procainamide

Answer 57

* Clinical features predominantly constitutional, joint, & pleuropericardial * Rare CNS & renal disease * All patients have antinuclear antibodies(ANA) * Improvement following withdrawal of offending drug

Answer 58

* Constitutional-fatigue, fever, malaise, weight loss * Arthritis-inflammatory, symmetric, nonerosive * Cardiopulmonary- Pericardial effusions & serous pericarditis, myocarditis, Libman- Sacks endocarditis * Nephritis * GI-peritonitis, vasculitis * Cutaneous-rashes-malar “butterfly” rash, photosensitivity, vasculitis, alopecia, oral ulcers

Answer 59

* CBC, CMP, Urinalysis, ESR, and Serum complement C3 or C4 * Antibodies of Smith antigen (anti-Smith antibody) * Anti-Double-stranded DNA (Anti-dsDNA) * ANA is present in 99% * But ANA is not specific for SLE * Anti-histone antibodies (present in most JRA/JIA/RA/SLE or even drug induced lupus) * 50% have + Anticardiolipin Antibody

Answer 60

* Approximately 50% have an anticardiolipin antibody, which is associated with a prolonged PTT & false-positive serologic tests for syphilis. * This so-called lupus anticoagulant may be manifested by thrombocytopenia, venous or arterial clotting, & recurrent fetal loss * Although thrombotic problems are most common, if antibody is associated with hypoprothrombinemia, severe thrombocytopenia, or antibodies to clotting factors (usually VIII or IX), bleeding may result. * Confirmation that PTT is prolonged on basis of a lupus anticoagulant may be proved by failure of normal plasma to correct defect | Clotting ot bleeding issue

Answer 61

Behçet's syndrome, a recurrent disease of unknown cause, is characterized by painful oral and genital ulcers, eye inflammation, arthritis, central nervous system symptoms, thrombophlebitis/vasculitis, fever, and abdominal symptoms. * HLA-B51 is a major risk facto ## Footnote HLA-B27 for AS

Answer 62

* (1)Requires the presence of recurrent oral ulcers + 2 of following * Recurrent genital ulcerations * Eye lesions * Skin lesions or a positive pathergy test (inflammatory reactivity to scratches or intradermal saline). * Neutrophil infiltration is detected in biopsy specimens from oral aphthous ulcers and erythema nodosum and **pathergy lesions**

Answer 63

Anti-TNF drugs and/or colchicine, dapsone, azathioprine, apremilast, thalidomide, MTX, cyclosporine, biologics like infliximab

Answer 64

* Syndrome characterized by a combination of clinical features seen in SLE, SSC, Polymyositis & RA * High titers of ANA’s to nuclear ribonucleoprotein (RNP) * Overlap syndromes are diseases that fulfill diagnostic criteria for two rheumatic diseases.

Answer 65

Laboratory Evaluation * High-titer ANA’s * Very high titers of antibody to RNP * +RF in 50% of pts Treatment * Little published data * Treat based upon manifestations with similar approach to that used if feature occurred in other CTD’s

Answer 66

* Necrotizing vasculitis of medium or small arteries * Excludes glomerulonephritis or vasculitis in arterioles, capillaries or venules * Unusual findings, such as infarcts in odd places such as liver or testes, should heighten suspicion

Answer 67

* Incidence of 0.7/100,000 * Decreased concomitantly with HBV vaccination * Prevalence 50/100,000 * Etiology – HBC/HCV, rarely HIV, parvovirus B19, EBV, deficiency of ADA2 (adenosine deaminase)

Answer 68

* If untreated, prognosis is poor: 10-20% survival rate at 5 years * Death usually results from gastrointestinal issues (infarcts or perforation) or CV issues (Intractable HTN causing damage across the body)

Answer 69

Gout (monosodium urate [MSU] crystal deposition disease or Podagra) is a systemic disease characterized biochemically by extracellular fluid urate saturation, which is reflected in the blood by hyperuricemia, with serum or plasma urate concentrations exceeding 6.8 mg/dL (approximately 400 micromol/L); this level of urate is the approximate limit of urate solubility. * Altered purine metabolism and subsequent sodium urate crystal precipitation into Synovial fluid. * Seen with patient consuming lots of meat/beer/seafood | 1ST MTP JOINT

Answer 70

* Gout tends to occur earlier in life in men than women and is rare in childhood. * Both the incidence and prevalence of the disease appear to be increasing since at least the late 1970s in the United States, where the prevalence is likely to exceed 3 percent of adults, and worldwide

Answer 71

* Lifestyle changes and Diet changes * Elevation and rest * No Thiazide (>25mg) diuretics or ASA (both compete with uric acid excretion) * Pharm: * NSAIDs for pain * How I remember it: A for C and C for A

Answer 72

AKA: Calcium pyrophosphate crystal deposition disease (CPPD)

Answer 73

* Calcium pyrophosphate crystal deposition (CPPD) has been estimated to affect 4 to 7 percent of the adult populations, especially among persons of advanced age. * However, an estimate of the prevalence of clinically significant CPPD disease has been more difficult to attain, because the available prevalence estimates have relied primarily upon radiographically detected cartilage calcification rather than clinical evaluation, and also because prevalence data concerning patients less than about 60 years of age are not available. * The average age at diagnosis of CPPD disease in one study was 72 years

Answer 74

Etiology * Unknown, but thought to be secondary to elevated levels of calcium or inorganic pyrophosphate Pathology * CPPD crystals are found in the joint capsule and fibrocartilaginous structures associated with neutrophil infiltration and erosion

Answer 75

* Large peripheral joints more affected than Gout; Knee, wrist and elbow and lower extremity * Painful, red, swollen but **no tophi**

Answer 76

* Rhomboid-shaped crystals that are positively birefringent * X-rays show fine, linear calcification in cartilage

Answer 77

* NSAIDs, colchicine, steroid injections * HCTZ: Can increase Calcium concentration * Prognosis is good, but tends to relapse

Answer 78

* Inflammation of synovial membrane (very common in kids) * Should be considered as a cause of joint pain, has many etiologies * Inflammatory from OA/RA/overuse/infection etc. * Treatment is directed towards the cause, so work them up for RA/infection etc. * NSAIDs, DMARDs, steroids, PT * Surgical synovectomy in rare cases

Answer 79

* Tendinitis is inflammation of a tendon. Tenosynovitis is tendinitis accompanied by inflammation of the protective covering around the tendon (tendon sheath). * Tendinopathy (weakening of the tendon) leading to rupture

Answer 80

* Is an inflammation of synovial membrane with purulent effusion into the joint capsule, due to infection * Expect a nontraumatic joint pain with systemic symptoms * Exactly why General ROS is important to ask everyone

Answer 81

* ~ 75% of non-GC pyroarthroses due to gram + cocci with S. aureus most common pathogen * Hemophilus influenzae * PEAK AGE INCIDENCE -Children * Salmonella * PEAK AGE INCIDENCE -Children & young adults with sickle cell anemia * Neisseria gonorrhea * PEAK AGE INCIDENCE -Young adults * Most common cause of an acute septic arthritis in young adults * GC infection common cause of septic arthritis in young adults(<35)

Answer 82

* Bacteremia * Intravenous drug abuse (IVDA) * Skin Infection * Diabetes * RA * HIV * Age>80yo * Recent joint procedure or surgery * Presence of prosthetic device * Or any other state causing immunocompromised status

Answer 83

Systemic * Fevers * Chills * Malaise Localized * Joint pain and tn * Edema * Erythema * Inflammation/warmth * Decreased ROM

Answer 84

If gram stain is positive, vancomycin should be initiated IV. If gram stain is negative, a third generation cephalosporin should be used. * 2 weeks of IV antibiotics (vancomycin and ceftriaxone) * Oral antibiotics covering pathogen based on culture and sensitivity for another month afterwards Arthrotomy or joint drainage by arthrocentesis * Post-surgical artificial joints have to be removed

Answer 85

* Osteoarthritis sometimes follows * DDx includes reactive arthritis, rheumatoid arthritis, Lyme disease, gout and psuedogout

Answer 86

* Accounts for 70% of episodes of infectious arthritis in persons < 40 * Results from bacteremia arising from GC infection or, from asymptomatic gonococcal mucosal colonization of urethra, cervix, or pharynx * 2/3 of patients women & symptoms of bacteremia often begin during menses * Most women or men with DGI do not have symptoms of urogenital, anorectal, or pharyngeal GC * Women greatest risk during menses or during pregnancy & overall are 2-3 x more likely than men to develop DGI & arthritis

Answer 87

* Syndrome of fever, chills, rash, & articular symptoms * Small numbers of papules that progress to hemorrhagic pustules develop on trunk & extensor surfaces of distal extremities * Migratory arthritis & tenosynovitis of knees, hands, wrists, feet, & ankles * Cutaneous lesions and articular findings believed to be consequence of an immune reaction to circulating gonococci and immune complex deposition in tissues

Answer 88

* Synovial fluid may be difficult to obtain from inflamed joints & usually contains only 10,000 to 20,000 leukocytes/ L. * C/S synovial fluid are consistently negative, & blood cultures + in < 45% of patients.

Answer 89

* Less common than DGI & always follows disseminated infection, which is unrecognized in 1/3 of patients * **A single joint, such as hip, knee, ankle, or wrist, usually involved** * Synovial fluid, which contains >50,000 leukocytes/ L, can be obtained; gonococcus is only occasionally evident in gram-stained smears, & C/S of synovial fluid + in <40% * C/S & gram-stained smears of skin lesions occasionally are positive * Because it is difficult to isolate gonococci from synovial fluid & blood, specimens for culture should be obtained from potentially infected mucosal sites

Answer 90

* Ceftriaxone (1 g IV or IM every 24 h) to cover possible penicillin-resistant organisms * Once local & systemic signs are resolving, 7-day course of therapy can be completed with PO cefixime (400 mg bid) or ciprofloxacin (500 mg bid) * Suppurative arthritis usually responds to needle aspiration of involved joints & 7 to 14 days of AB treatment

Answer 91

Classic Triad * Conjunctivitis (cant see) * Urethritis (cant pee) * Arthritis (cant climb a tree) Incidence ranges from 0.6 to 3.1 cases per 100,000, depending upon the organism Immune response associated to GU or GI organisms * Chlamydia is the most common causative agent * Campylobacter, Salmonella, and Shigella are common pathogens

Answer 92

* Up to 80% are HLA-B27 positive. What was the other condition we discussed recently? * X-ray show evidence of permanent and progressive joint disease. * Synovial fluid culture is negative because chlamydia will not grow

Answer 93

* No specific treatment other than ABX for confirmed infection * NSAIDs, topical or systemic steroid based on symptom severity * DMARDs if NSAIDs contraindicated or ineffective * 30% develop chronic symptoms

Answer 94

* Typically is self-limited, unless its caused by an infection * Typical resolution is 3-12 months with high recurrence * Even higher in those with + HLA-B27

Answer 95

* Complicates 1 to 4% total joint replacements * Majority acquired intraoperatively or immediately postoperatively as a result of wound breakdown or infection * Less commonly, develop later after joint replacement from hematogenous spread or direct inoculation * Presentation may be acute, with fever, pain, & local signs of inflammation, especially in infections due to S. aureus, pyogenic streptococci, & enteric bacilli

Answer 96

* Needle aspiration of joint * Synovial fluid pleocytosis with a predominance of PMN’s * C/S & Gram's stain usually yield responsible pathogen * Use of special media for unusual pathogens such as fungi, atypical mycobacteria, & Mycoplasma may be necessary if routine & anaerobic cultures are negative

Answer 97

* Surgery & high doses parenteral antibiotics, x 4 to 6 weeks because bone usually involved * In most cases, prosthesis must be replaced to cure infection. * Implantation of a new prosthesis best delayed for several weeks or months because relapses of infection occur most commonly within this time frame. ; In some cases, reimplantation not possible

Answer 98

* Exact cause is unknown * 30% of psoriasis patients will develop psoriatic arthritis * Prevalence increased with AIDS or Immunodeficiency * Strong familial association (mom to daughter and dad to son) * HLA-B27 presence increases risk of PA development (among other autoimmune diseases)

Answer 99

Among the skin lesions, DIP joints are more commonly affected * Skin lesions may develop after the arthritis * May lead to sausage-shaped deformities, which are not present in patients with RA * Once can have arthritis mutilans (destruction of multiple hand joints with telescoping of the digits

Answer 100

* Asymmetric involvement of large and small joints, including the sacroiliacs and spine, is common * Enthesopathy (inflammation at tendinous insertion into bone—eg, Achilles tendinitis, patellar tendinitis, elbow epicondyles, spinous processes of the vertebrae) can develop and cause pain

Answer 101

* Diagnosis is Clinical with exclusion of other causes of arthritis elbow * RF is necessary to r/o PA * In some cases RF is positive, but the anticyclic citrullinated peptide antibodies (anti-CCP) are negative (which are highly positive in RA)

Answer 102

* Aside the topical therapy for dermatological psoriasis, PA is treated with DMARDs (MTX) and/or TNF-alpha antagonists biological agents * Very similar to RA management * Hydroxychloroquine may cause exfoliative dermatitis and worsen the derm presentation, thus worsening the PA

Answer 103

* Peripheral & axial arthritis associated with Ulcerative Colitis or Crohn’s disease * Arthritis can occur after or before onset of intestinal symptoms * Peripheral arthritis episodic, asymmetric, & most frequently affects knee & ankle * Attacks usually subside within several weeks & characteristically resolve completely without residual joint damage

Answer 104

Clinical Findings * Enthesitis * Achilles tendonitis & plantar fasciitis * Axial involvement as spondylitis &/ or sacroiliitis (often symmetric) Lab * RF negative * X-Rays peripheral joints usually normal * Axial involvement often indistinguishable from AS

Answer 105

* Directed as underlying IBD * NSAIDs may alleviate joint symptoms * Sulfasalazine may benefit peripheral arthritis

Answer 106

* Some develop arthritis-dermatitis following intestinal bypass surgery * Possibly related to bacterial overgrowth * Symptoms may be relieved by NSAID’s, suppression of bacterial overgrowth with tetracycline or other antibiotics, or surgical reanastomosis of bypassed segment

Answer 107

* Characterized by arthritis in up to 90% of pts that usually precedes appearance of intestinal symptoms * Polyarticular, symmetric, transient but may become chronic * GI & joint manifestations respond to antibiotic therapy

Answer 108

* AKA Charcot’s Joint * Severe destructive arthropathy in joints deprived of pain & position sense * Usually begins in single joint but may spread to involve other joints * Joint effusions are usually noninflammatory but can be hemorrhagic * Radiographs can reveal either bone resorption or new bone formation with bone discoloration & fragmentation

Answer 109

Etiologies * Diabetic neuropathy * Tabes dorsalis -> untreatedsyphilis * Syringomyela * Amyloidosis * Spinal cord or peripheral nerve injury Treatment * Stabilization of joint * Surgical fusion may improve function

Answer 110

* Syndrome consisting of periosteal new bone formation, digital clubbing, & arthritis * Most commonly seen in association with CA lung but occurs with chronic lung or or none liver disease, CHD, lung, or liver disease in children * Idiopathic & familial forms * Symptoms include burning & aching pain most severe in distal extremities * X-rays show periosteal thickening with new bone formation of distal ends of long bones

Answer 111

* Autosomal dominant CTD characterized by varying degrees of joint hypermobility, skin extensibility, and tissue fragility. * Mild trauma causes gaping wounds, hard to place sutures as they rip the skin, dehiscence later is very common as well * Dx: Clinical * Genetic testing reveals Type 5 collagen mutation * Gorlin's sign (tongue to nose) and Metenier's sign (upper eyelide eversion) * Tx: Supportive

Answer 112

* Hereditary Collagen disease leading to bone fragility, hearing loss, blue sclera and joint hypermobility * Diagnosis is clinical supported by genetic testing * COL1A1 and COL1A2 genes * Tx: hGH, bisphosphonates, and cochlear implants ## Footnote Life expectancy according to Cleveland clinic is 72yo for a male

Answer 113

* The incidence of osteomyelitis ranged from approximately 1 in 5000 to 7700 children in developed countries and 1 in 500 to 2300 children in developing countries. * Some countries have noted a decrease in the incidence over time, whereas others, including the United States, have noted an increase, particularly with the emergence of community-associated methicillin- resistant Staphylococcus aureus. * Metaphyses of long bones(tibia, femur, humerus) & vertebrae most frequently involved sites

Answer 114

* Staph. aureus is the most common cause in ALL age groups * Strep. pneumoniae is most common in kids 1m-24mo old * Salmonella and Staph. aureus are the most common causes in children with sickle cell anemia * Group B strep and E.coli are most common in neonates * Pseudomonas aeruginosa and MRSA are most common in drug abusers and foot injuries

Answer 115

* Osteomyelitis may be classified based on the duration of illness (acute versus chronic) and the mechanism of infection (hematogenous versus nonhematogenous). * Acute osteomyelitis typically presents with a symptom duration of a few days or weeks. Sequestra (pieces of necrotic bone that separate from viable bone) are absent. * Chronic osteomyelitis is characterized by long-standing infection over months or years. Sequestra are usually present; they form as a result of bone ischemia and necrosis in the context of blood vessel compression due to elevated medullary pressure associated with bone marrow inflammation. Sequestra can be seen radiographically. The presence of a sinus tract is pathognomonic of chronic osteomyelitis. * Nonhematogenous osteomyelitis can occur as a result of contiguous spread of infection to bone from adjacent soft tissues and joints or via direct inoculation of infection into the bone (as a result of trauma or surgery). * Hematogenous osteomyelitis is caused by microorganisms that seed the bone in the setting of bacteremia.

Answer 116

* X-ray will usually show bone resorption (osteolytic patchy lesions) * Takes approximately 2 weeks from onset of infection to start destroying the bone and appear on plain radiography * Bone scans are sensitive but not specific

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* CBC (Increased WBC’s), CRP, ESR * Blood culture * Bone biopsy * Late sequestra take several weeks to months to appear on X-ray * MRI is best

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* Acute: 6-8 weeks for antibiotics (IV) via PICC line * Chronic: 1-24 months of IV and oral antibiotics * Immobilization and surgical drainage may be indicated * Wound attention * Surgical debridement

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Acute * Responds to treatment after several weeks (typically 6) Chronic * May persist for years with exacerbations and remissions

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* The most common malignant bone tumor in children and adolescents * Incidence of 4.4 per million * Peak age 10-20 y/o – highest during growth spurts * Distal femur most common site, followed by proximal tibia and then proximal humerus.

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* Most will have pain before tumor is noticeable (might come in for knee pain but PE is normal) -> dull pain but worst at night) * You may observe dilated veins in overlying skin (dt tumor blood supply) * Start with plain radiographs * Stage with MRI

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Osteosarcoma

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* Before advent of multidrug chemotherapy – radical amputation lead to 80% dying from disseminated pulmonary disease * Currently, with a combo of chemotherapy and surgical treatment, 5 year survival approaches 70% * Amputation is reserved for the exceptional or recurrent tumors * Endo-prosthetics are emerging as limb saving options

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* Central lytic tumor of the diaphyseal-metaphyseal bone * Extensive permeative destruction on the cortical bone * As it breaks through the periosteum, it has an “onionskin”, or multi –layered appearance. * “Hair on end” appearance * may be mistaken for osteomyelitis

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* If locally resectable and treated with chemotherapy, 5 year survival rate is 70% * If at presentation, the patient has nonlocalized disease/advanced metastatic disease, the survival rate is 30%

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* Dependent on location * Orbital RMS may present with pain in eye, orbital swelling, bulging of eye. * Tumors of the sinus, nose, pharynx may be mistreated as URI’s for weeks or months

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* Depends on location * Typically surgical, resection * Prognosis dependent on location and extent of insult

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* Most common primary tumor of bone * Accounts for 45% of all malignant bone tumors * 90% occur in patients over 40 years old * Triad of osteolytic ”punched-out” lesions “multifocal”, neoplastic proliferation of atypical plasma cells and and a monoclonal gammopathy * Considered a hematologic malignancy

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Punched out lesions of multiple myeloma

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* Bone pain with lytic lesions on plain radiograph * Increased serum protein * Unexplained anemia chronic bone * Hypercalcemia * Acute renal failure may occur

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* Bone scan or plain xray is sufficient to Dx * ALP may be elevated but Calcium and Phosphate is normal * Tx: Biphosphonates, calcitonin is secondary * If osteosarcoma noted, surgical removal and palliative care is advised.

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* Frequently asymptomatic * Usually detected incidentally * Easily diagnosed with plain radiography * Well circumscribed with evidence of host bone response * Sclerotic margins or dense osteoblastic reactive zone

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Pseudotumor-cystic bone lesions

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* Upper extremity – conservative * Lower extremity – aspiration and injection with bone marrow or corticosteroid * Series of 3-5 Injections occur every 2-3 months | Can add cement to fill in

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## Footnote Cystic bone lesions is common in prox humerus and femur

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Giant Cell Tumors appear lytic and involve the epiphyseal- metaphyseal end of long bones, may contact cartilage, but rarely enters joints

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* Aggressive curettage, followed by high speed burring, followed by phenol, hydrogen peroxide and bone cement * If tumor involves expendable bone (fibula) – gross resection

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* Sprain – involves stretched or torn ligament * Strain – Musculotendinous unit injury * Contusions – bruise * Laceration – skin integrity disruption

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1.Split-Spitting of skin and underlying tissues occur when there is compression/crushing, of the affected tissues between 2 hard objects (usually over scalp, chin, eye brow and cheek. 2.Stretch-Caused by overstretching of the skin to produce by blunt tangential impact 3.Avulsion (Shearing)-Caused by shearing force delivered at an acute angle to detach a portion of traumatized surface. 4.Tears-Caused by impact by or against the irregular or semi-sharp objects such as the handle of the car. Typically seen in open fractures. 5.Cut-caused by heavy and sharp-edged instruments.

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* In any fracture, dislocation or traumatic injury, you MUST ensure that there is a distal intact neurovascular supply * EVERY known or suspected fracture/dislocation MUST be immobilized until cleared or appropriately treated

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* Reduction – the action of re-aligning fractured pieces of bone or placing a dislocated joint back into correct anatomical position * Non-union – failure of the fractured ends to bond, heal back together * Malunion – healing occurs but not in correct anatomical position * External fixation – the use of an external brace to maintain alignment during healing * Open Reduction Internal Fixation (ORIF) – surgical procedure with use of plates, rods, screws, pins, staples. * Fracture/Dislocation – a fracture associated with dislocation

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* Factors influencing non-union – smoking, venous stasis disease, atherosclerosis, malnutrition * Factors contributing to malunion – poor skill of clinician, inadequate blood flow, loss of reduction

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Malunion ## Footnote most common: clavicle

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* Pain control, return of MSK function * May splint, cast, apply traction, surgically fixate or replace (joints) * Deformed bone transmits abnormal forces to the joints below and above * Primary goals – correction of deformity and return to function

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External fixation ## Footnote Used for open fractures

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* One of the oldest forms of treatment * Used with long-bone fractures * Historically, using traction to heal long-bone fractures had many potential risks and complications – DVT, infection, decubiti, PE, pneumonia * Remember – long bone fractures carry highest risk of fat embolus development

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## Footnote ORIF: Open reduction and internal fixation (ORIF)

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* Knee dislocation – vascular compromise (NOT patella dislocation) * Traumatic amputation * Spinal fracture * Any open fracture

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* ALWAYS Conduct a thorough neurological and peripheral vascular exam of injured limb * Repeat this exam as you wait on radiography, consult, casting * Repeat after immobilization * Repeat post op * Repeat on daily rounds

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*alleviates pain * relieve tension on nerves and vessels * eliminating risk of conversion to open * restores circulation to pulseless ext

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* Elevate injured limb – above the level of the heart. This is only effective in a recumbent or semi-recumbent position * Instruct patients to wiggle toes, fingers if not covered with cast or splint * Monitor fingers and toes for loss of sensation, excessive swelling or cyanosis * Report any significant increase in pain * If any of the signs/symptoms above appear – instruct them to go to ED or seek immediate follow up with physician

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* Hemorrhage – rich vascular supply, potential for large blood loss, shock, death * Pelvic Fractures can cause large vascular compromise and DIC (disseminated intravascular coagulation) * Neurologic injury – from traction or pressure on a peripheral nerve or nerve plexus – may be temporary or perm. * “**Neurapraxia**” – contusion to nerve * Vascular Injury – this an orthopedic emergency and requires a vascular surgeon in the OR with Ortho.

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* ACS occurs when the pressure in a muscle compartment rises sufficiently to cause tissue ischemia leading to muscle or nerve damage. Impending ACS occurs when tissue pressure has begun to increase and tissue perfusion is reduced but is not sufficient to cause muscle or nerve damage. * Increased pressure within the limb compromises circulation * If untreated – necrosis of muscle and neurologic injury * Most common site – anterior compartment of lower leg ## Footnote * This is an emergent condition requiring early recognition * Always consider Compartment Syndrome when pain increases or seems out of proportion to known injury

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Long bone fractures carry an increased risk of fat embolus originating from marrow (especially large bones) * Typically will occur in first 3 days after injury * Tachypnea * Pulmonary edema * Confusion * Petechial Rash-> does not blench so when press on, it does not go away

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* DVT * Infection * PE * Muscle atrophy * Psychiatric disorders | * Geriatric age increases risk of these complications

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* Occur on overlying skin due to swelling * Try to keep intact, clean, antibiotic ointment or silver sulfadiazine dressing * Appear as early as 6 hours post injury * Usually clear fluid – if hemorrhagic, worse prognoses, indicating detachment between the epidermal and dermal layers

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* Spondylolysis – fracture of the pars interarticularis * Spondylolisthesis – a vertebra shifts due to instability

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* Traumatic * Pathologic * Degenerative

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CT but ideally an MRI

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Traumatic Spondylolisthesis ”vertebral vertebrae slip”

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Burst fracture

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compression fracture

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Degenerative Spondylolisthesis

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a NORMAL appearance of the lumbar spine when seen on oblique view

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A “collar” on the Scotty Dog = Pars defect or fracture *Remember, a “Scotty” shows up on the oblique view

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* PARS defects are small stress fractures resulting from over-use, typically in a young athlete, results from repetitive hyperextension. * Occurs in up to 30% * Sports with highest risk – football (offensive line), gymnastics, diving, weight lifting, wrestling, dancing, volleyball * Treatment – rest, good nutrition, strengthening and stretching, prevent overextension

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Dowager’s Hump with Compression FX

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* Diagnosis - radiography * Prevention of Osteoporosis is Key * Initial treatment is analgesic therapy and bracing – this should last for up to twelve months, especially if effective in reducing pain * Surgical – If neurologic deficits or significant spinal cord compression evident – anterior decompression and fusion, posterior segmental instrumentation and fusion * Red Flags – neurological compromise – watch for bladder dysfunction

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* Stabilization of fracture via percutaneous application of cement into the fracture. * Two most popular procedures – kyphoplasty (minor) and vertebroplasty (burst/major) * Safe and effective * Difference between the two procedures – a balloon is used to create more space within the compressed vertebra, allowing for some remodeling and increased injection of cement

Answer 170

* Fractured ribs (also known as cracked ribs), usually occur as a result of blunt chest wall trauma or lifestyle injuries that range from cycling to football. * Fractured ribs may heal on their own without treatment. * However, some patients have rib fractures in which bone fragments can damage major blood vessels, or structures like the lung, liver, kidneys or spleen. * In these cases, rib fractures usually require treatment.

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1.Taking a deep breath 2.Pressing on the injured area 3.Bending or twisting your body

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1.Osteoporosis – this disease decreases the density of your bones, making your rib more sensitive to fractures. 2.Playing sports 3.Having an area of cancer in your rib – cancer may weaken the bone, making your rib more sensitive to fractures.

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* X-Ray: Rib fractures are typically diagnosed on chest x-ray with **rib series** and the severity of the fracture is easily seen. * CT Scan: CT scans may show rib fractures that were not visible on an X-ray. Injuries to blood vessels and soft tissues are easier to see on a CT scan than an X-ray. * MRI: An MRI can also look at the organs and soft tissues around the ribs to detect damage to these areas.

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* Most nondisplaced fractured ribs heal without surgery in one to two months and are treated with non-surgical care that ranges from aggressive pain management to proper ventilation (i.e. incentive spirometer) * For patients with displaced fractures, flail segments, or high narcotic requirement surgical treatment with rib plating may be required along with aggressive pain management and proper ventilation. * Always watch out for risk of pneumothorax!

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* Mechanism: Fall on shoulder or direct blow to shoulder (football injuries common), middle shaft is common lesion * Signs and Symptoms: Tenderness, swelling, and deformity * Tests: AP X-ray * Treatment: Ice, analgesics, sling, surgery * Watch for multiple fractures

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* Mechanism of injury: * Elderly (osteopenia)—fall on outstretched hand * Young—high energy trauma (e.g. MVA or fall) * Signs and Symptoms: Tenderness, swelling, and decreased ROM * Tests: X-ray is sufficient * Treatment: Ice, analgesics, sling and swath

Answer 177

humeral head fracture

Answer 178

Unlike the radial head fracture, most other elbow fractures are treated with posterior long arm splint or double sugar tongue splint

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Mostly due to OA and RA

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* MOI typically a FOOSH * Common in falls in post-menopausal women * High impact motor or bike sports * “Silver Fork” Deformity – dorsal angulation * TX – reduction with splint vs SX based on degree of displacement and/or age of pt. rem * Volar or Sugar tongue splint

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Boxer’s Fracture – distal 3rd of the 5th metacarpal * Tx with Ulnar Gutter splint, RICE, analgesia Colles Fracture – distal end of radius with dorsal angulation * Tx Sugar Tongue Splint, RICE, analgesia

Answer 182

* Common but can be occult on x-ray in the 1st week * Poor blood supply-can lead to avascular necrosis or nonunion of the scaphoid * Pain over anatomic snuffbox-common complaint, swelling with bruising * AP, lateral, scaphoid views may not see anything. Bone scan or MRI possibly * If suspected, appropriate to immobilize with thumb spica cast or splint for 7-10 days, re-eval post

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* Easier to see on x-ray at 7-10 day post injury , so re-xray if negative study initially * High risk of non-union, necrotizing bone, early onset arthritis * Once confirmed and not displaced – cast for 6-8 weeks * Surgery indicated if displaced

Answer 184

* Thinnest, most fragile part of the femur * Very common fracture * Surgical – hip replacement * If acetabulum intact – only the head portion is replaced, this is called a “**hemiarthroplasty**” * A non-displace femur neck fracture may be “pinned”

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* Area between the greater and lesser trochanters * Surgical - plates, screws, rods for fixation

Answer 186

* “Hip” fracture * Poor blood supply * Left untreated, the femoral head usually necroses – therefore, nearly always surgical * Big push on surgery within 24 hours, so you will hear “Hip Alerts” * In elderly patients – risk of avascular necrosis very high – hip replacements is the TX of Choice * In patients younger than 40, these can be treated with immediate reduction and surgical fixation

Answer 187

A displaced femoral neck fracture

Answer 188

* Avascular necrosis of femoral head * Unable to ambulate * Rarely chosen and if non-surgical treatment is chosen, typically relates to pre-fx debility and quality of life issues

Answer 189

* Blood supply is intact to the femur head * Not as common as femoral neck fracture, but still common * Surgical fixation (i.e. hip alert)

Answer 190

* Superior and inferior rami – non-weight-bearing areas * Typically occur in geriatric patients, trauma or demineralizing conditions * Obturator nerve injury can be present * Do not require surgery, can not be immobilized * Admission generally required in intractable pain only * Curtail weight-bearing only for pain management * Get patient up and mobilizing as soon as pain is tolerable * Refer to Physical Therapy

Answer 191

* Probably the injury that is the worst of all of the possible knee injuries but that is also not uncommon. * Surgery and prolonged immobilization is often required * Use posterior long leg splint * Recall Salter Harris classification if physis is still present

Answer 192

* Proximal end of the tibia, typically intra-articular * Will require hospitalization * Provide analgesia, ice, splint (knee immobilizer) and call ortho

Answer 193

* Notorious for having a poor blood supply, particularly at the junction of the middle and distal thirds * Very prone to nonunion * Good reduction, immobilization and non-weight-bearing improve odds of union. * In short-term, immobilize via posterior long leg splint

Answer 194

* Inability to bear weight * Pain and swelling * Point tenderness * Obvious deformity

Answer 195

Fractures are commonly either medial or lateral, but may be complex: * Bimalleolar fracture—Pott’s fx or Dupuytren fx * Trimalleolar fracture—Henderson fx (involves medial, lateral, and posterior malleoli of tibia) * ALWAYS Evaluate Mortise

Answer 196

junction of the metaphysis and diaphysis of the proximal end of the 5th metatarsal

Answer 197

* The first step of Jones fracture treatment is rest and to prevent movement in the foot. * **Posterior short leg/boot or post-op** shoe non-weightbearing (crutches/walker) * Apply ice to the break as well. * Jones fracture surgery may be needed to align the bone and help with healing. * These fractures will sometimes heal on their own but may take months to heal without surgery. * Can be occult like Scaphoid fractures, so re-xray them if negative initially

Lecture 2- Rheum Flashcards

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