Lecture 3: Misc MSK Injuries Flashcards
(72 cards)
1
Q
Essentials of diagnosis of Osteomyelitis
A
- Fever with bone pain and tenderness
- positive 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 causes of osteomyelitis?
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 their metaphysis in long bones
4
Q
MC primary site of hematogenous osteomyelitis?
A
Urinary tract, skin/soft tissue, IV sites, endocardium, dentition
Staph
5
Q
where is hematogenous spread MC in adults
A
vertebral column LS>TS>CS
6
Q
Biggest RFs for hematogenous osteomyelitis in adults
A
- IVDU
- Diabetes
- IVs
in children - sickle cell, comp delivery, maternal infections, premature
7
Q
Who is contiguous spread osteomyelitis MC in and how?
A
Adults, usually post fracture/open wound (diabetic ulcers)
Most commonly polymicrobial
8
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
9
Q
How does vertebral involvement of osteomyelitis present?(4)
A
- Much slower onset
- Localized pain/tenderness
- Pain with percussion over affected area
- Neurologic symptoms in 1/3 of pts
10
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
11
Q
When is CT/MRI indicated for osteomyelitis evaluation?
A
- Onset < 2 weeks at presentation
- XR neg but clinical presentation is suspicious
- positive neuro findings on exam
MRI is especially good for feet
Nuclear is alternative.
12
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.
13
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.
14
Q
Empiric ABX for osteomyelitis
A
MRSA and G- coverage: Vanco +3/4th gen cephalosporin
Typically only used in long-bone infections
ceftriaxone, ceftaz, cefepime
15
Q
How long is staph osteomyelitis? what is the abx regimen used for this strain?
A
4 weeks
- IV cefazolin, nafcillin or oxacillin
- MRSA = vanc
16
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
can also use bactrim, doxy, or clinda
17
Q
When is debridement indicated for osteomyelitis?
A
- Infection related to open fx or surgical hardware
- Extensive diseas involving multiple bony/ soft tissue layers
- Concomitant joint infection
- Recurrent/persistent infection
18
Q
Persistent elevation of what labs over 2 weeks with appropriate ABX is suggestive of a persistent osteomyelitis infection?
A
ESR/CRP
19
Q
What are the complications of osteomyelitis?
A
- Pathological fx
- Chronic
- Impaired bone growth
20
Q
What is chronic osteomyelitis?
A
Bone infection over months-years resulting in the development of a sequestrum +/- sinus tract
21
Q
what bone changes occur in chronic osteomyelitis
A
- increased intramedullary pressure causes rupture of periosteum and formation of cloaca (sinus tract)
- periosteal blood supply interruptions lead to necrosis
- necrotic bone leads to sequestrum
- new bone forms in areas where periosteum was damaged (involucrum)
22
Q
What is involucrum?
A
Bone formation in areas where the periosteum was damaged
23
Q
Where is chronic osteomyelitis MC in?
A
- Sternal
- Mandibular
- Feet
24
Q
How does chronic osteomyelitis present?
A
- Pain, erythema, swelling
- +/- draining sinus tract
- fever usually not present
- bone palpation is positive
25
How do labs differ between chronic vs acute osteomyelitis?
Leukocytosis and ESR/CRP are rarely elevated in chronic.
26
What is a marjolin ulcer?
Epithelium of the sinus tract develops squamous cell carcinoma
27
Management of chronic osteomyelitis
* Debridement
* Obliteration of dead space
* Long-term ABX therapy
28
What is compartment syndrome?
Increased pressure within a limited space compromises the circulation and function of the muscles and nerves within that space
29
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
30
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
31
Clinical presentation of compartment syndrome?
* 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
32
How do you measure compartment pressure?
* **Two separate measurements** within 5 cm of the site
* **Pressures must be > 45 mm/Hg**
* 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
33
Management of compartment syndrome?
1. Remove casts/dressings
2. Elevate affected limb
3. Surgical fasciotomy if patient has had it within 24h-48h
34
Essentials of rhabdomyolysis
* Crush injuries
* Serum elevations in CK and lyte abnormalities
* Release of myoglobin leads to **renal toxicity**
35
What is rhabdomyolysis?
* Acute skeletal muscle cell death leading to release of intracellular contents
* ATN will occur, leading to AKI
36
What causes ATN due to rhabdo?
Hypovolemia + myoglobin + uric acid crystals + decreased GFR + nephrotoxic ferrihemate (metabolite of myoglobin)
37
Clinical presentation of rhabdomyolysis
* **Dark tea colored urine**
* Myalgias and weakness
* Malaise, low-grade fever
* N/V, abd pain, and tachy if severe
| Similar to a flu patient
## Footnote
swelling/tender of involved muscles. AMS d/t severe renal failure and urea-induced encephalopathy if severe!
38
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, K+. low calcium.
* **CBC to monitor potential DIC**
| A UA cant differentiate blood and myoglobin
## Footnote
can see cardiac dysrhythmias on EKG d/t hyperkalemia or hypocalcemia
39
Management of Rhabdo
* IVF aggressively for first 72h early
* Monitor I&O to get goal of 200-300 urine output
* Urine alkalization via bicarb only if CK levels are higher than 5000, acidemia, dehydration or underlying renal disease
40
When would you treat hypocalcemia in rhabo?
Only if hyperkalemia is present
41
Discharge criteria for rhabdo
* Normal renal
* Normal lytes
* Alkaline urine
* Isolated cause of injury
* No uncontrolled comorbidities
42
Main complications of rhabdo
* AKI
* Compartment syndrome
* DIC
43
What is fibromyalgia?
Chronic condition characterized by multiple MSK pain with multiple tender points but **no objective findings**
44
MC demographic for fibromyalgia
20-55
45
Presentation of Fibromyalgia
* Chronic fatigue and generalized aching pain
* Depression
* Widespread soft tissue tenderness
* No joint involvement
46
How is fibromyalgia diagnosed?
ACR criteria:
1. Widespread pain index (WPI) > 7 + symptom severity (SS) > 5 or WPI 3-6 with SS > 9
2. 3months
3. No other disorder
| Dx of exclusion
47
Management of fibromyalgia
* Patient education
* CBT
* Exercise
* Wt loss if overweight
* Muscle relaxant: flexeril
* Antidepressants
* Neurontin/pregabalin
* Tramadol
| Careful of tramadol addiction
48
Treatment protocol for fibromyalgia
**On average: start with cyclobenazeprine and amitriptyline QHS
49
What is neurogenic arthropathy/charcot joint?
Condition characterized by progressive destruction of bone and soft issues at **weight bearing joints**
50
What is the hallmark sign of neurogenic arthropathy?
Mid-foot collapse, described as a **rocker-bottom foot**
51
MC etiologies for neurogenic arthropathy
* DM (MC)
* Cerebral palsy
* Alcoholic neuropathy
* Spinal cord injury
* Syphilis
52
Where does neurogenic arthropathy occur most commonly?
* Foot
* Ankle
* Tarsometatarsal joint
* Ankle articulations
## Footnote
articulations are cuneonavicular, talonavicular and calcaneocuboid articulations
53
Presentation of neurogenic arthropathy
* Unilateral warmth, redness, and edema oer joint
* Hx of minor trauma
* Pain is present but **low severity**
* Loss of arch, bony protrusions
* **40% have concomitant ulcers**
54
Dx imaging of neurogenic arthropathy
* XR with weight-bearing
* MRI if XR negative OR **osteomyelitis is in DDx**
55
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)
56
Staging of neurogenic arthropathy
1. Stage 0: early/inflammatory - localized swelling, erythema, warmth. little/no xray findings
2. Stage 1: cont localized inflamm. Xray - fx, subluxation/dislocation, bony debris.
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.
57
Tx for stage 0-2 neurogenic arthropathy
* Avoid weight-bearing via casting of foot
* CROW (charcot restraint orthotic walker) use
58
Tx for stage 3 or failed therapy neurogenic arthropathy
Discuss risk/benefit of surgery
59
What is Raynaud's phenomenon?
* Syndrome of paroxysmal digital ischemia in cold or emotional stress.
* Vasoconstriction and then rapid vasodilation
| MC in the fingers
60
What is primary Raynaud's?
* NO vascular structural abnormalities
* MC in healthy females 15-30
* FMHx
| MC type
61
What is secondary Raynaud's?
* Underyling systemic condition leads to Raynaud's
* MC in males > 40
* MC with rheumatologic conditions
* Frostbite, jackhammers
* **More severe and higher risk of ulceration/gangrene**
62
What are raynaud attacks?
* 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**
63
What do nailfold capillaries look like in raynaud's?
64
Management of primary raynaud's
| Normal PE and nailfold capillaries
* Pt Ed
* Regular f/u
65
Management of secondary raynaud's
Tx underlying
66
What is the patient education for Raynaud's?
* Mittens and stockings
* Avoid vasoconstrictors
* Smoking cessation
67
First-line pharmacologic therapy for Raynaud's
1. CCBs (amlodipine)
2. NTG or PDE5 inhibitors
| Indicated if failure to control symptoms
## Footnote
If all fails, refer to vascular
68
What is Marfan's syndrome?
**Genetic disorder** of CT tissue characterized by **skeletal, ocular, and CV abnormalities**
| 1 in 5000
69
Presentation of Marfan's
* Tall, long arms, and digits (arachnodactylyl)
* Scoliosis
* Pectus Carinatum/excavatum
* Ecotopia lentis (eye lens displacement)
* Myopia (Near sighted)
* Retinal detachment
* MVP
* Aortic root dilation => aortic regurg or dissection
70
How is marfan's confirmed?
Genetic testing showing a mutation in the fibrillin gene (FBN1) on chromosome 15
71
What criteria is used to score marfan syndrome?
Ghent criteria
| No need to memorize criteria components
72
How do we manage Marfans?
* Annual Ophthalmology
* Annual Orthopedic
* Annual Echo/cardio
* **Long term BBs (atenolol/metoprolol)**
* Restriction from vigorous physical exertion
