Lecture 3: Misc MSK Injuries Flashcards
1
Q
Essentials of diagnosis of Osteomyelitis (4)
A
- Fever with bone pain and tenderness
- (+) blood cultures
- Elevated ESR/CRP
- Early radiographs are typically negative, esp within 2 weeks
Trending ESR and CRP is much better than WBC due to chronicity
2
Q
What are the etiologies of osteomyelitis? (3)
A
- Hematogenous spread
- Contiguous spread
- Secondary infection d/t vascular insufficiency or neuropathy
3
Q
Who is hematogenous osteomyelitis MC in? Where exactly?
A
Children, esp males, in the metaphysis of their long bones
4
Q
MC primary sites of hematogenous osteomyelitis? (5)
A
- Urinary tract
- Skin/soft tissue
- IV sites
- Endocardium
- Dentition
Staph
5
Q
Biggest RFs for hematogenous osteomyelitis (3)
A
- IVDU
- Diabetes
- IVs
Also similar for spinal epidural abscesses
6
Q
Who is contiguous spread osteomyelitis MC in and how?
A
Adults, usually post fracture/open wound (diabetic ulcers)
Most commonly polymicrobial
7
Q
How does osteomyelitis present? (4)
A
- Gradual onset of S/S
- Dull pain at site, fever and rigors
- Tenderness, warmth, erythema, swelling on exam
- Probing for bone is recommended if ulcer is present
8
Q
How does vertebral involvement of osteomyelitis present?
A
- Much slower onset
- Localized pain/tenderness
- Pain with percussion over affected area
- Neurologic symptoms in 1/3 of pts
9
Q
Dx of osteomyelitis
A
- Early XR: maybe swelling, loss of tissue planes, periarticular demineralization of bones
- Later XR: Periosteal thickening or elevation, bone cortex irregularity
- Ideal: CT or MRI, which is highly sensitive
Children: 5-7d for changes
Adults: 10-14d for changes
10
Q
When is CT/MRI indicated for osteomyelitis evaluation?
A
- Onset < 2 weeks at presentation
- XR neg but clinical presentation is sus
- (+) neuro findings on exam
MRI is especially good for feet
Nuclear is alternative.
11
Q
Who is bone biopsy indicated in for osteomyelitis?
A
Any patient with radiologic evidence without (+) blood cultures.
Do not delay biopsy due to abx use.
12
Q
What would histology show for a positive bone biopsy for osteomyelitis?
A
Necrotic bone with extensive resorption adjacent to an inflammatory exudate
Must collect through an uninfected site if percutaneous.
13
Q
Empiric ABX for osteomyelitis
A
MRSA and G- coverage: Vanco + 3rd/4th gen cephalosporin
Typically only used in long-bone infections
14
Q
How long is staph osteomyelitis?
A
4 weeks
15
Q
If you want to transition a pt to PO abx for osteomyelitis, what is the combo?
A
After 2 weeks of IV agents at minimum, you can use Levofloxacin/ciprofloxacin + rifampin
16
Q
When is debridement indicated for osteomyelitis? (4)
A
- Infection related to open fx or surgical hardware
- Extensive disease
- Concomitant joint infection
- Recurrent/persistent infection
17
Q
Persistent elevation of what labs over 2 weeks with appropriate ABX is suggestive of a persistent osteomyelitis infection?
A
ESR/CRP
18
Q
What are the complications of osteomyelitis? (3)
A
- Pathological fx
- Chronic
- Impaired bone growth
19
Q
What is chronic osteomyelitis?
A
Bone infection over months-years resulting in the development of a sequestrum +/- sinus tract
bone sequestrated/trapped
20
Q
What is an involucrum?
A
Bone formation in areas where the periosteum was damaged
21
Q
Where is chronic osteomyelitis MC in? (3)
A
- Sternal
- Mandibular
- Feet
22
Q
How does chronic osteomyelitis present? (4)
A
- Pain, erythema, swelling
- +/- draining sinus tract
- fever usually not present
- bone palpation is positive
23
Q
How do labs differ between chronic vs acute osteomyelitis?
A
Leukocytosis and ESR/CRP are rarely elevated in chronic.
24
Q
What is a marjolin ulcer?
A
Epithelium of the sinus tract develops squamous cell carcinoma
25
Management of chronic osteomyelitis (3)
* Debridement
* Obliteration of dead space
* Long-term ABX therapy
26
What is compartment syndrome?
Increased pressure within a limited space compromises the circulation and function of the muscles and nerves within that space
27
What are the 4 compartments of the lower leg?
1. Anterior
2. Lateral
3. Superficial posterior
4. Deep posterior
| MC location for compartment is lower leg
28
What is normal compartment pressure and how long can we tolerate increased pressure?
* **10mm is normal, but we can tolerate up to 20** without damage.
* After around **8h, we start developing neuropathy.**
* After around **12h, myocytes die** and we develop contractures.
29
Clinical presentation of compartment syndrome? (6)
* **Pain out of proportion**
* **Pain that worsens with passive stretching**
* Paresthesias within 30min onset
* **Tense to palpation**
* Decreased sensation (**use 2 point**)
* Weak pulse in severe
| Paralysis is late and pallor is rare
30
How do you measure compartment pressure and what is an elevated pressure? (3)
* **Two separate measurements** within 5 cm of the site
* **Pressures must be > 45 mmHg**
* Must **account for hypotensive patients, aka if DBP is within 30** of their compartment pressure. (DBP of 52 with pressure of 28 = compartment syndrome)
| DO NOT USE in hands or feet
31
Management of compartment syndrome? (3)
1. Remove casts/dressings
2. Elevate affected limb
3. Surgical fasciotomy if patient has had it within 24h-48h
32
Essentials of rhabdomyolysis (3)
* MCC: Crush injuries
* Serum elevations in **CK and lyte abnormalities**
* Release of myoglobin leads to **renal toxicity**
33
What is rhabdomyolysis? (2)
* Acute skeletal muscle cell death leading to release of intracellular contents
* ATN will occur, leading to AKI
34
What causes ATN due to rhabdo? (5)
Hypovolemia + myoglobin + uric acid crystals + decreased GFR + ferrihemate (metabolite of myoglobin)
35
Clinical presentation of rhabdomyolysis (4)
* **Dark tea colored urine**
* Myalgias and weakness
* Malaise, low-grade fever
* N/V, abd pain, and tachy if severe
| Similar to a flu patient
36
Dx of rhabdo
* **Elevated CK 5x ULN (Most sensitive)**
* UA showing tea color when urine myoglobin is > 100
* A (+) blood on UA with negative RBC on microscopy = myoglobinuria
* CMP: Elevated phosphorus, uric acid, BUN/Cr, AST/ALT
* **CBC to monitor potential DIC**
| A UA cant differentiate blood and myoglobin
37
Management of Rhabdo
* **IVF aggressively for first 72h** early
* Monitor I&O to get goal of 200-300
* Urine alkalization via **bicarb**
| fluids & bicarb
38
When would you treat hypocalcemia in rhabo?
Only if hyperkalemia is present
39
Discharge criteria for rhabdo (5)
* Normal renal
* Normal lytes
* Alkaline urine
* Isolated cause of injury
* No uncontrolled comorbidities
40
Main complications of rhabdo (3)
* AKI
* Compartment syndrome
* DIC
41
What is fibromyalgia?
Chronic condition characterized by multiple MSK pain with multiple tender points but **no objective findings**
42
MC demographic for fibromyalgia
Women 20-55
43
Presentation of Fibromyalgia (4)
* Chronic fatigue and generalized aching pain
* Depression
* Widespread soft tissue tenderness
* **No joint involvement**
44
How is fibromyalgia diagnosed? (3)
ACR criteria:
1. Widespread pain index (WPI) > 7 + symptom severity (SS) > 5 or WPI 3-6 with SS > 9
2. 3 months
3. No other disorder
| Dx of exclusion
45
Management of fibromyalgia
* Patient education
* CBT
* Exercise
* Wt loss if overweight
* **Muscle relaxant: flexeril**
* Antidepressants
* Neurontin/pregabalin
* **Tramadol**
| Careful of tramadol addiction
46
Treatment protocol for fibromyalgia
**On average: start with cyclobenzeprine or amitriptyline QHS**
47
What is neurogenic arthropathy/charcot joint?
Condition characterized by progressive destruction of bone and soft issues at **weight bearing joints**
48
What is the hallmark sign of neurogenic arthropathy?
Mid-foot collapse, described as a **rocker-bottom foot**
49
MC etiologies for neurogenic arthropathy (5)
* **DM (MC)**
* Cerebral palsy
* Alcoholic neuropathy
* Spinal cord injury
* Syphilis
| peripheral neuropathy related things
50
Where does neurogenic arthropathy occur most commonly?
* Foot
* Ankle
* Tarsometatarsal joint
* Ankle articulations
51
Presentation of neurogenic arthropathy (5)
* **Unilateral warmth, redness, and edema over joint**
* Hx of minor trauma
* Pain is present but **low severity**
* **Loss of arch**, bony protrusions
* **40% have concomitant ulcers**
52
Dx imaging of neurogenic arthropathy
* XR with **weight-bearing**
* MRI if XR negative OR **osteomyelitis is in DDx**
53
What 3 things are key to look at for an XR for neurogenic arthropathy?
* Progressive decline of the yellow angle (**calcaneal inclination**)
* **Equinus deformity** (can't dorsiflex)
* Destruction of **TMT joint** (red line)
54
Staging of neurogenic arthropathy (4)
1. Stage 0: early/inflammatory with **no radiographic evidence**
2. Stage 1: development with swelling and XR findings
3. Stage 2: coalescence with **decreasing inflammation** and healing of XR findings
4. Stage 3: Remodeling with no inflammation, bony deformities, and mature fracture callus.
55
Tx for stage 0-2 neurogenic arthropathy
* Avoid weight-bearing via casting of foot
* CROW (charcot restraint orthotic walker) use
| before foot remodeling has occurred mostly
56
Tx for stage 3 or failed therapy neurogenic arthropathy
Discuss risk/benefit of surgery
57
What is Raynaud's phenomenon? (2)
* Syndrome of paroxysmal digital ischemia in **cold or emotional stress.**
* Vasoconstriction and then rapid vasodilation
| MC in the fingers
58
What is primary Raynaud's & who is it MC in? (3)
* **NO vascular structural abnormalities**
* MC in healthy females 15-30
* FMHx
| MC type
59
What is secondary Raynaud's & who is it MC in? (5)
* Underlying systemic condition leads to Raynaud's
* MC in **males > 40**
* MC with **rheumatologic conditions**
* Frostbite, jackhammers
* **More severe and higher risk of ulceration/gangrene**
60
What are raynaud attacks & where do they MC occur? (3)
* Sudden onset of cold digits with demaracation of skin pallor (white attack) or cyanosis (blue attack)
* Massive erythema when rewarming
* MC in the **index, middle, and ring fingers**
61
What do nailfold capillaries look like in raynaud's?
62
Management of primary Raynaud's (2)
| Normal PE and nailfold capillaries
* Pt Ed
* Regular f/u
63
Management of secondary Raynaud's (1)
Tx the underlying condition
64
What is the patient education for Raynaud's? (3)
* Wear mittens and stockings
* Avoid vasoconstrictors
* Smoking cessation
65
First-line pharmacologic therapy for Raynaud's (2)
1. CCBs (amlodipine)
2. NTG or PDE5 inhibitors
| **Indicated if failure to control symptoms**, vasodilators
## Footnote
If all fails, refer to vascular
66
What is Marfan's syndrome?
**Genetic disorder** of CT tissue characterized by **skeletal, ocular, and CV abnormalities**
| 1 in 5000, bones, eyes, heart
67
Presentation of Marfan's
* Tall, long arms, and digits (arachnodactylyl)
* Scoliosis
* Pectus Carinatum/excavatum
* Ectopia lentis (eye lens displacement)
* Myopia (Near sighted)
* Retinal detachment
* MVP
* Aortic root dilation => aortic regurg or dissection
68
How is marfan's confirmed?
Genetic testing showing a mutation in the **fibrillin gene (FBN1) on chromosome 15**
69
What criteria is used to score marfan syndrome?
Ghent criteria
| No need to memorize criteria components
70
How do we manage Marfans? (5)
* Annual Ophthalmology
* Annual Orthopedic
* Annual Echo/cardio
* **Long term BBs (atenolol/metoprolol)**
* Restriction from vigorous physical exertion
| Eye, Bones, Heart
