Misc MSK injury trigger

Question 1

MC in Children, esp males, in their metaphysis in long bones

Answer 1

hematogenous osteomyelitis

Question 1

fever with bone pain and tenderness. Associated elevations in ESR, CRP and negative radiographs

Answer 1

osteomyelitis

may also see positive blood cultures!!

Question 2

Urinary tract, skin/soft tissue, IV sites, endocardium, dentition are MC originations for what?

Answer 2

hematogenous osteomyelitis

Question 3

MC in vertebral column LS>TS>CS in adults

Answer 3

hematogenous osetomyelitis

Question 4

can be caused by prosthetic devices, neurosurgery, septic arthritis or open fractures/trauma

Answer 4

contiguous osteoarthritis

Question 5

pt presenting with gradual onset of dull plantar foot pain and fever/chills 1 week ago. Ankle shows tenderness, warmth, erythema and swelling. what labs/imaging would you order in this patient? if imaging/labs are positive what would you see and what would be your next step?

Answer 5

suspected dx: osteomyelitis
labs: blood cultures (+), CBC (^WBC), ESR (^), CRP (^), BMP (just to assess renal/liver prior to meds)
Imaging: jump straight to MRI/CT d/t onset being <2 weeks and it being in the foot.

next step: consult ID/Ortho.

if + for staph start cefazolin, nafcillin or oxacillin (vanc for MRSA or PCN allergy) for 2 weeks followed by 4-6 wks of levo/cipro + rifampin

(slides say typically only use abx in long bone infections but i guess you could give abx)

Question 6

Pt presents with 6 wk hx of localized pain over her lumbar area. pain is increased with percussion to the area. she has also been complaining of headaches and suffered a seizure en route to the hospital. what is your suspected dx? what imaging would you get in this patient?

Answer 6

osteomyelitis w vertebral involvement

remember neuro s/s can be seen in 1/3 of pts!

if you see neuro s/s you can jump straight to MRI/CT!

Question 7

Xray shows loss of tissue planes and periarticular demineralization of bones

Answer 7

early osteomyelitis

Question 8

Xray shows periosteal thickening or elevation and bone cortex irregularity

Answer 8

later osteomyelitis

Question 9

if a pt has suspected osteomyelitis with radiologic evidence but their blood cultures are negative what is the protocol

Answer 9

bone biopsy

Question 10

histology shows necrotic bone with extensive resorption adjacent to inflammatory exudate

Answer 10

osteomyelitis

Question 11

(ceftaz/ceftriaxone/cefepime) + vanc is for what

Answer 11

empiric ABX for osteomyelitis (typically only used in long bone infections)

Question 12

cefazolin/nafcillin/oxacillin is used when? when would vanc be used instead?

Answer 12

abx regimen for staph osteomyelitis

use vanc for MRSA or PCN allerg

Question 13

levo/cipro + rifampin is used when? what are alternatives to this

Answer 13

PO abx that can be used for osteomyelitis after 2 weeks of IV abx.

alternatives are bactrim, doxy or clinda.

Question 14

what suggests a persistent osteomyelitis infection

Answer 14

persistent elevation of ESR/CRP over 2 weeks of appropriate ABX

Question 15

can lead to chronicity, pathological fracture, and impaired bone growth

Answer 15

complications of osteomyelitis

Question 16

formation of cloaca, necrosis, sequestrum and involucrum are all associated with what condition

Answer 16

chronic osteomyelitis

Question 17

MC in sternum, mandible and feet

Answer 17

chronic osteomyelitis

Question 18

what physical exam and lab findings may differentiate chronic and acute osteomyelitis

Answer 18

fever is NOT usually present in chronic.
chronic may have a draining sinus tract.
chronic - ESR/CRP and WBC are not elevated usually

chronic is developed over months to years!!

Question 19

when the epithelium of an osteomyelitis sinus tract develops squamous cell carcinoma it is known as what

Answer 19

marjolin ulcer

Question 20

in compartment syndrome, how long before myocytes die and we develope contractures

Answer 20

12 hours

develope neuropathy after 8 hours

Question 21

after a suspected fracture of her tibia, a patient begins having increased pain out of proportion to her pain 20 minutes ago. on exam her skin is tense to palpation over the injury and she reports she is starting to experience deceased sensation and paresthesias. what is the diagnostic of choice in this pt and, if positive, what is the tx

Answer 21

dx: compartment syndrome
diagnostic: two separate pressure readings withiin 5cm of the site. if over 45 mmHg its positive
tx: elevate limb. remove restrictive dressings. consult if sugrical fasciotomy is needed. admit!

Question 22

pt presents with myalgias, weakness, and a low grade fever. she reports swelling and tenderness of her left lower extremity. she also has dark colored urine.
what lab findings would you see in this patient?

Answer 22

rhabdomyolysis
labs:

Question 23

treat with aggressive IVF for 72 hours with a goal of 200-300 mL/hr of urine output.

when would you use bicarb in this patient? when would you be concerned about hypocalcemia?

Answer 23

this is rhabdomyolysis.

use bicarb to alkalize urine only if:
CK levels are higher than 5,000
acidemia
dehydration
underlying renal disease

only treat hypocalcemia if hyperkalemia is present!

Question 24

complications can include compartment syndrome, DIC and AKI

Answer 24

rhabdomyolysis

Question 25

widespread soft tissue tenderness with chronic fatigue and generalized aching pain. often with associated depression. no joint involvement

Answer 25

fibromyalgia

Question 26

when do you treat with neurontin or lyrica

Answer 26

fibromyalgia with severe sleep disturbance

Question 27

when do you treat with cymbalta/savella

Answer 27

fibromyalgia patients with severe fatigue

Question 28

initial tx for this dz is cyclobenzaprine or amitriptyline at bedtime

Answer 28

fibromyalgia

Question 29

Condition characterized by progressive destruction of bone and soft issues at weight bearing joints

Answer 29

neurogenic arthropathy/ charcots joint

Question 30

MC in pts with DM, cerebral palsy, syphilis, spinal cord injury and alcoholic neuropathy

Answer 30

neurogenic arthropathy

Question 31

pt presents and reports pain that is a 2/10 of her right foot onset 2 weeks ago after stumbling and stepping on a rock. on exam you see unilateral warmth, redness and edema over the dorsal and plantar aspects of the foot. she reports the pain is low severeity but constant. she has a hx of DM, alcoholism and syphilis. what could the diagnosis be and how would it present if it is not treated.

Answer 31

neurogenic arthropathy. could see bony protrusions of the plantar foot and loss of arch leading to charcots foot.

Question 32

when would you want to use a weight bearing xray

Answer 32

neurogenic arthropathy ( probs to assess the arch of the foot)

Question 33

what stage of neurogenic arthropathy includes bony changes such as fx, subluxation/dislocation and bony debris

Answer 33

stage 1 developement swelling/redness/warmth from stage 0 will persist throughout stage 1 as well

Question 34

what stage of neurogenic arthropathy do clinical inflammatory signs begin to decrease and fractures and bony debris begin to heal with new bone formation

Answer 34

stage 2 coalescence

Question 35

what stage of neurogenic arthropathy do you see stable or unstable bony deformity but no signs of inflammation. xray may show fracture callus and decreased sclerosis

Answer 35

stage 3 remodeling

Question 36

when do you use a charcot restraint orthotic walker?

Answer 36

stage 0-2 neurogenic arthropathy treatment in addition to avoiding weight bearing. for stage 3 discuss surgery

Question 37

MC in males > 40 and in those with rheumatologic conditions. can also be seen d/t frostbite or jackhammer use

Answer 37

secondary raynauds (Increased risk of gangrene and ulceration compared to primary)

Question 38

when do you use amlodipine as first line and nitro or PDE5 inhibitors as second line? what do you do if all of these fail

Answer 38

raynauds phenomenon refer to vascular surgery if they dont work

Question 39

what heart conditions are assocaited with marfans

Answer 39

MVP aortic root dilation leading to aortic regurgitiation or dissection

Question 40

what visual problems are associated with marfans sydnrome

Answer 40

myopia (near sighted) ecotopia lentis (eye lens displacement) retinal detatchement

Question 41

what is the gene for marfans

Answer 41

fibrillin gene FBN1 on chromosome 15

Question 42

what is the ghent criteria used for

Answer 42

marfans syndrome

Question 43

Long term BB is used in management for what disease. What other management guidlines are there

Answer 43

marfans annual ophthalmology, orthopedic, cardio checkups. restrict from physical exertion