MSK Flashcards

Question

medial epicondyle fracture puts what nerve at risk?

Answer 1

ulnar nerve

Answer 2

axillary nerve

Answer 3

distal radius +/- distal ulna associated with osteoporosis Treatment: long cast to immobilize the wrist and elbow (immobilize the joint above and below the fracture)

Answer 4

fracture of distal radius with anterior displacement MOI: fall and land on flexed wrist less common than Colles

Answer 5

fall on radially deviated outstretched hand tenderness in snuffbox indicates scaphoid fracture until proven otherwise Treatment: immobilization of wrist with spica cast poor union rate even when treated correctly, with risk of avascular necrosis

Answer 6

MOI: punching a wall force transferred to 5th metacarpal Treat: closed reduction surgical pinning open wounds from teeth require surgical exploration to rule out tendon involvement Copious irrigation

Answer 7

dislocation of radial head and ulnar diaphyseal fracture defense injuries falls on outstretched hand with forearm in excessive pronation Treatment: surgery

Answer 8

isolated ulnar shaft fracture Treatment: does not require surgery

Answer 9

distal radial ulnar joint dislocation and radial diaphyseal fracture Treatment: this will require surgery

Answer 10

intratrochanteric subtrochanteric increased risk for avascular necrosis with femoral neck fractures H and P: injured leg is shortened and externally rotated

Answer 11

Caused by severe trauma Treatment: surgery Increased risk for fat embolizatin - hypoxemia - petechiae serial H/H compartment syndrome exams secondary survey as indicated by MOI XRay, CT, spinal immobilization

Answer 12

increased risk for compartment syndrome

Answer 13

if unstable, then requires operative stabilization

Answer 14

high risk of major blood loss decreased pelvic volume If hypotensive and can't find blood in pelvis, consider retroperitoneal hemorrhage (angiogram to diagnose, then embolize if you find retroperitoneal)

Answer 15

injury to ligaments and soft tissues surrounding a joint Partial or complete tear at the ligament- bone interface Grade 1: overstretching of muscles with microscopic tears Grade 2:incomplete tear Grade 3: complete tear pain with weightbearing and movement ankle and knee are most common Rest Ice Compression Elevation

Answer 16

ACL, PCL Anterior drawer Lachman MRI for soft tissue CT for bone

Answer 17

medially- directed blow to lateral side of knee Structures injured: ACL tear MCL tear Lateral meniscus tear

Answer 18

H and P: vague pain inside knee clicking or locking joint line pain near knee Radiology: MRI Treatment: NSAIDS PT Arthroscopic repair for debridement Complications: Debridement puts the patient at risk for osteoarthritis

Answer 19

Meniscus tear

Answer 20

``` Late manifestations: Pain Pallor Poikilothermia Pulselessness Paralysis Paresthesias ``` Sensitive screening test: Compartment pain with passive stretching, pain in excess of what is expected Diagnosis: Manometry needle placed into the muscle, greater than 30mmHg makes the diagnosis also treat if within 20mmHg of diastolic BP Most common compartments involved: volar compartment of forearm, anterior compartment of leg Most commonly due to fractures (supracondylar humerus, both- bones of forearm, proximal tibia) Treatment: emergency fasciotomy of ALL the compartments involved and not just the one compartment exertional compartment syndrome can happen in young athletes, and resolves with rest, minimal risk of ischemia

Answer 21

PUD, GERD, gastritis

Answer 22

pancreatitis

Answer 23

renal stones

Answer 24

pyelonephritis

Answer 25

muscle strain (don't want patient to be completely inactive)

Answer 26

compression fracture

Answer 27

anterior slip of disk (spondylolisthesis)

Answer 28

meningitis discitis osteomyelitis

Answer 29

disc herniation

Answer 30

spinal stenosis

Answer 31

ankylosing spondylitis | young male, 20's, 30's

Answer 32

cauda equina syndrome

Answer 33

radiculopathy H and P: - pain extends along path of compressed nerve - sensory and motor deficits - pain worsens with straight leg raises or Valsalva MRI will allow you to diagnose ``` Treatment: NSAIDs Activity modification epidural steroid injection surgical decompression ``` Neuropathic pain: Gabapentin Pregabalin Depression + neuropathic pain Duloxetine

Answer 34

generalized narrowing of the bony spaces in the spine 2.2 arthritic changes older adults H and P: radiating pain worse with walking/standing Radiology: CT, Xray, MRI to rule out herniation and look for nerves ``` Treatment: Analgesics physical therapy epidural injections surgical decompression ```

Answer 35

trauma to the nerves running in the dural sac ``` H and P: urinary retention change in bowel habits saddle anesthesia due to impairment of the pudendal nerve decreased rectal tone bulbocavernosus reflex impairment ``` Treatment: surgical decompression, and IV steroids to reduce risk of permanent injury Radiation in cases of neoplasm

Answer 36

Superior trunk | MOI: hyperadduction of the arm causing widening of the humoral- glenoid gap

Answer 37

Ulnar nerve injury Injury to medial epicondyle of the humerus weak finger adduction poor 4th and 5th finger flexion (extended at MCP, flexed at interphalangeal finger joints)

Answer 38

Site of injury: radial nerve inability to extend upper fingers

Answer 39

axillary nerve injury associated with anterior shoulder dislocation

Answer 40

``` inferior trunk (C8 and T1) claw hand and dropped wrist ```

Answer 41

``` low dietary calcium smoking alcohol sedentary lifestyle post- menopause decreased testosterone steroids (>3 months, add ppx bisphosphonates) ``` hyperparathyroidism hyperthyroidism Classic presentation: thin, white or Asian, post-menopausal woman Less likely to occur in obese people who bear more weight Complications: vertebral fracture colles fracture Diagnosis: DEXA scan of hip and lumbar spine Dual Energy x-ray Absorptiometry labs normal Treatment: weight-bearing exercise calcium vitamin D bisphosphonates (alendronate, etidronate, pamidronate) Raloxifene (SERM) Teriparatide (pulsatile PTH analog) daily injection for 2 years that stimulates osteoblasts to lay down new bone denosumab (RANK-L inhibitor that inhibits osteoclast activity)

Answer 42

``` rock-like bone impaired osteoclastic activity increased risk of fractures boney compression of nerves (hearing loss, vision loss) thickening of bones in skull and spine ``` Labs: anemia increased acid phosphatase increased creatine kinase normal calcium normal phosphate normal alk phos

Answer 43

overactive osteoclasts and osteoblasts new bone is disorganized focal discrete lesions axial spine and long bones of legs are affected usually asymptomatic ``` May have symptoms: bone pain increased fractures bowing of tibia kyphosis narrowing of auditory foramen increased cranial diameter overgrowth of bone in skull ``` Labs: increased Alk Phos normal calcium and phosphate Treatment: bisphosphonates calcitonin- injectable SQ most cases do not require treatment

Answer 44

``` pediatric disease type I collagen disorder brittle bones frequent fractures from minimal trauma (may resemble child abuse) blue sclerae pliable skin joint hypermobility teeth deformities deafness or hearing loss ``` Tx:bisphosphonates restrict activity surgical correction of bony misalignment

Answer 45

arthritis: sodium urate crystals that precipitate out of blood and get deposited in the joints usually, the small peripheral joints, like first MTP joint inflammatory response to these crystals causes arthritis and pain ``` Risk factors: renal disease (hyperuricemia) male sex obesity purine-rich foods- organ meat, seafood, alcohol urate underexcretion diuretics cyclosporine cancer ``` red hot painful joint, without systemic symptoms serum uric acid either normal or increased joint aspiration will show needle-shaped negatively birefringent crystals, yellow when parallel to light, an inflammatory cells blue needles perpendicular to polarized light ``` Acute Treatment: NSAIDs -indomethacin -ketorolac -ibuprofen -naproxen -celecoxib Steroids (prednisone) work safer and faster ``` Colchicine inhibits microtubules, 3rd line, use 2 low doses) SE- GI upset ``` Longterm management: decrease alcohol use decrease diuretic use avoid purine-rich foods Probenecid, inhibits uric acid resorption in the kidney ``` Allopurinol, inhibits xanthine oxidase Complications: chronic tophaceous gout

Answer 46

calcium pyrophosphate dihydrate deposited in the joints affects different joints knee or wrist MC postively birefringent rhomboid crystals yellow when perpendicular chondrocalcinosis on xray especially visible in the menisci treatment: NSAIDs, colchicine to address inflammation

Answer 47

NSAIDs steroids colchicine NOT probenecid or steroids

Answer 48

NSAIDs | Colchicine

Answer 49

osteopetrosis

Answer 50

Colles, osteoporosis

Answer 51

bisphosphonates

Answer 52

Radionuclide bone scan to look for metabolic hot spots

Answer 53

wrist drop | lost thumb abduction

Answer 54

MCC: staph a Sexually active? also consider n. gonorrhea DM, cancer, other underlying illess: gram- negative rods

Answer 55

sudden onset joint pain pain with any motion children: vague signs of pain, refusal to walk Labs: increased WBC count, increased ESR, increased CRP ``` Joint aspiration shows numerous WBCs with >50,000/mm^3 high % PMN decreased glucose positive cultures ``` Treatment: surgical irrigation drainage Vancomycin if staph aureus (assume MRSA with any staph infection) Ceftriaxone if n. gonorrhoeae Aminoglycosides if gram- negative bacteria

Answer 56

OA 50,000/mm^3

Answer 57

MCC staph aureua Coagulase- negative staph Pseudomonas Salmonella MCC in SCD ``` H and P: Bone pain tenderness fever chills possible skin involvement with a draining sinus ``` Labs: increased WBC, ESR, CRP, culture, biopsy Radiology: Xrays not helpful until >10 days bone edema on MRI on bone scan, increased uptake after 72 hours tagged WBC scan Treatment: IV abx for 4-6 weeks (vancomycin assumin MRSA then alter according to culture results) I and D for abscess inside bone or surrounding tissue Complications: chronic osteomyelitis amputation

Answer 58

Early localized disease (80% of patients, usually within 1 month -erythema chronicum migrans- bull's eye rash with central clearing that expands over days to weeks +/- constitutional symptoms (fatigue, HA, myalgias, arthralgias) Early disseminated disease- weeks to months after the tick bite, may include the following: - Meningitis (lymphocytic) - Unilateral or bilateral cranial nerve palsies (esp facial nerve with b/l Bell's palsy) - Radiculopathy - Peripheral neuropathy - Carditis (AV heart block, myopericarditis) Late Lyme disease- months to years after infection onset - arthritis (esp knee) - subacute encephalitis Labs: ELISA and Western Joint aspiration if NOT helpful

Answer 59

Early Lyme disease treatment options (14-21 days) - Doxycycline (preferred agent, can be dosed over only 14 days, avoid in pregnancy) - Amoxicillin - Cefuroxime Late Lyme disease (carditis, encephalitis, arthritis), usually ceftriaxone for 14-28 days

Answer 60

Doxycycline for about 7 days | Chloramphenicol in pregnant patients

Answer 61

Affects articular cartilage -hips, knees, ankles, wrists, shoulders Can cause spinal stenosis and vertebral bodies ``` RF: advancing age family history obesity previous joint trauma ``` H and P: - joint crepitus - joint stiffness/pain that worsens with activity and weight-bearing, and is relieved by rest - no systemic symptoms - decreased range of motion - Heberden nodes (distal) - Bouchard nodes (proximal) - Typically asymmetric Labs: normal ESR

Answer 62

Bony metastases BLT with a Kosher Pickle ``` Breast Lung (lytic, breaks down bone) Thyroid Kidney Prostate (blastic, builds up bone) ``` H and P: palpable bony mass fractures following minor trauma Labs: biopsy -increased alkaline, phosphatase Radiology: - xray - bone scan - MRI Treatment: - chemotherapy - bisphosphonates can help slow bone loss - radiation therapy - prophylactic fixation can be performed for an impending fracture

Answer 63

Distal femur Proximal tibia Proximal humerus ``` Risk factors: Paget disease p53 mutation Familial retinoblastoma Radiation exposure Bone infarcts ``` History and physical: deep bone pain palpable bony mass ``` Labs increased alkaline phosphatase increased ESR increased LDH biopsy provides definitive diagnosis ``` ``` Radiology: sunburst pattern Codman triangle (periosteum pushed up by tumor) MRI and PET to determine extent Chest CT for determining metastasis ``` 90% 5yr survival rate for low grade

Answer 64

highly malignant diaphyseal long bone cancer seen in children ``` Bone pain tissue swelling fever, fatigue, weightloss fractures with minor trauma palpable mass ``` ``` Labs: increased WBCs decreased hemoglobin increased ESR biopsy important for making this diagnosis ``` Xray: large lesions with significant periosteal reaction (this is onion- skinning) Codmann triangle MRI to determine extent of cancer Treatment: radiation adjuvant chemotherapy radical excision Complications: 20% 5-year survival rate if metastesized

Answer 65

lower femur, upper tibia H and P: irritated soft tissue overlying mass nontender hard on palpation Xray: bony spur pointing away from the joint Surgical excision may be indicated Complications rare

Answer 66

``` 1. Pauci-immune glomerulonephritis 2, Microscopic polyangiitis 3, Eosinophilic granulomatosis with polyangiitis (Churg- Strauss syndrome) 4. Ulcerative colitis 5. Primary sclerosing cholangitis ```

Answer 67

chronic inflammatory arthritis with a lot of systemic effects type 3 hypersensitivity, more common in middle- aged and elderly women Frequently associated with HLA_DR4 Which joints are involved? PIPs and MCPs This is a symmetric polyarthropathy (DIP involvement is more consistent with OA) - hypertrophy of the synovium - granulation tissue on the articular cartilage- pannus formation - active inflammation; squishy, warm, swollen, boggy, when you push on the cartilage - ulnar deviation - hypertrophy at MCPs and PIPs - sawn neck deformities - Boutonniere deformities morning stiffness improves with use (Gel phenomenon), unlike OA which gets worse with use ``` Also: Rheumatoid nodules Pleuritis Pericarditis Scleritis ```

Answer 68

Synovitis in at least 1 joint, not better explained by another disease, plus a total score of >6/10 (Add score of categories A-D below) A. Joint involvement swelling in 2-10 large joints= 1 point 1-3 small joints (with or without large joints)= 2 points 4-10 small joints= 3 points >10 joints (at least 1 small joint)= 5 points ``` B. Serology RF (an IgG positive in 75% of RA patients) Anti-citrullinated antibody low positive RF or ACPA= 2 points high positive RF or ACPA= 3 points ``` C. Abnormal CRP or ESR= 1 point D. Duration of symptoms >6 weeks= 1 point

Answer 69

Make the diagnosis early Refer to a rheumatologist Early use of DMARDs (start using them early) DMARDs; Hydroxychloroquine Sulfasalazine Methotrexate ``` TNFalpha inhibitors Etanercept Adalimumab Golimumab Certolizumab Infliximab (check PPD first 2/2 immunosuppression) ``` Leflunomide (inhibits immune system by inhibiting proliferation of lymphocytes) Anakinra (IL1 receptor antagonist, which is anti-inflammatory) Steroids or NSAIDs are used only as adjuncts

Answer 70

``` autoimmune, systemic women age 14-45 blacks asians latinas ``` Anti-histone antibodies ``` Diagnostic criteria (4/11) Skin disorders -malar rash -discoid rash -photosensitivity -oral ulcers Inflammatory disorders -arthritis -serositis -significantly positive ANA (non-specific), very high Organ system disorders -renal disease -neurologic disorders -hematologic disoders -immunologic disorders ``` ``` Labs: positive ANA Anti-dsDNA antibodies Anti- smoth abs anti-histone abs False positive RPR and VDRL Antiphospholipid antibodies decreased serum C3 and C4 ``` ``` Treatment: avoid sun NSAIDs hydroxychloroquine steroids anticoagulation ``` Complications: Hypercoagulability increased risk of miscarriage progressive impairment of lung, heart, brain, kidney function Infections

Answer 71

``` sulfonamides hydralazine INH Procainamide Phenytoin ``` reversible with drug cessation look for antihistone antibodies

Answer 72

positive ANA anti-dsDNA abs anti-Smith abs false pos RPR

Answer 73

Rheumatoid factor ANA HLA-DR4 Anti-citrullinated protein antibody (ACPA)

Answer 74

ANA | Anti-Jo-1 antibodies

Answer 75

Anti-Scl-70

Answer 76

anti-centromere abs

Answer 77

Anti-Ro | Anti-La

Answer 78

Drug- induced lupus

Answer 79

malar rash discoid rash photosensitivity painless oral ulcers

Answer 80

polymyositis

Answer 81

scleroderma

Answer 82

``` H and P symmetric, progressive, proximal muscle weakness occurs in legs first myalgias muscle atrophy (later stages) ``` Rash features: heliotropic (periorbital) red-purple rash "shawl sign" rash involving the shoulders, upper chest, back, worsened by UV light exposure Gottron's papuls Erythrodema in the malar region Mechanic's hands- roughened, cracking skin on the tips and lateral aspects of the fingers Polymyositis features: symmetric proximal muscle weakness myalgias and muscle tenderness in 25-50% of patients ``` Labs: elevated CK and LDH elevated ALT and AST ANA is positive in 80% Anti-Jo antibodies elevated serum myoglobin elevated urine myoglobin ``` DIagnose by muscle biopsy EMG shows spontaneous fibrillation ``` Treatment: high- dose corticosteroids methotrexate or azathioprine IVIG interstitial lung disease, increased risk for several malignancies ```

Answer 83

multiple sites of muscle pain associated with temporal arteritis ``` H and P: temporal arteritis jaw claudication HA blindness or vision problems shoulder and pelvic girdle ``` PMR: pain, stiffness, different from myositis b/c it is without weakness difficulty raising arms and getting out of bed because of pain malaise unexplained weight loss fever joint swelling Labs: temporal arteritis temporal artery biopsy ESR Labs: PMR decreasd HCT increased ESR negative rheumatoid factor Radiology: - increased signal at tendon sheaths and synovial tissue outside of joints on MRI - positive emission or PET scans can show increased uptake in large vessels Treatment: low-dose corticosteroids, followed by tapered dose or corticosteroids Patient should experience significant improvement almost immediately Any patient diagnosed with PMR should immediately be worked up for temporal arteritis most commonly seen in elderly women

Answer 84

associated with depression, anxiety, and IBS non-inflammatory, unknown etiology possible link to sleep apnea, RA, hypothyroid women age 20-50 ``` myalgias weakness without inflammation trigger points fatigue depression, sleep disturbances, dizziness, HA, mood disturbances ``` Treatment: reassurance that it's a real illness that is benign, not life- threatening, not deforming Walking, strength training, stretching daily relaxation techniques stress reduction encourage journaling and emotional writing of past traumatic experiences Appropriate sleep: address any sleep hygiene issues Address any other psychiatric disorders: depression, anxiety, PTSD Pharmacological treatment options: Amitriptyline or nortriptyline at bedtime- improvement in 25-45% of patients Acetaminophen + tramadol- 50% pain reduction Pregabalin Duloxetine (SNRI) Fluoxetine (+/- amitriptyline at bedtime) Milnacipran

Answer 85

RF: 20-40yo, M>F, Caucasians > blacks H and P: hip and lower back pain worse in morning and following inactivity pain improves over course of day limited ROM of spine Painful kyphosis relieved by bending forward +/- anterior uveitis ``` Labs: Positive HLA-B27 Increased or normal ESR Negative rheumatoid factor Negative ANA ``` Radiology: Bamboo spine on xray (encased intervertebral discs) MRI shows increased signal in the sacroiliac joints ``` Treatment: physical therapy NSAIDs Sulfasalazine Methotrexate Anti-TNF drugs ```

Answer 86

develops in 10-20% of patients who have psoriasis DIP joints and spine are more commonly affected ``` H and P: asymmetric joint pain and stiffness symptoms worse in the morning, improved with activity +/- anterior uveitis joint line pain pain with stress on joints pitting of nails ``` Labs: negative rheumatoid factor negative ANA positive HLA-B27 Radiology: destructive lesions of DIP and PIP on xray "pencil in cup deformity" marrow edema on MRI ``` Treatment: NSAIDs Methotrexate Sulfasalazine Anti-TNF drugs ``` ``` PEAR Psoriatic arthritis Enteropathic arthritis (IBD) Ankylosing spondylitis Reactive arthritis (Reiter syndrome) ```

Answer 87

chronic multisystem sclerosis ``` H and P: Arthralgias, myalgias, hand swelling Raynaud phenomenon Esophageal dysmotility skin thickening ``` no wrinkles intestinal hypomotility dyspnea arrythmias or heart failure Labs: Positive Anti-SCL-70 ANA Primarily, CREST is a clinical diagnosis, but lab studies can provide support. CREST= Calcinosis cutis: subQ calcifications often in the fingers, not always present Raynaud phenomenon: cyanotic vasoconstriction, especially in the fingers Esophageal dysmotility: due to lower esophageal sphincter sclerosis leading to reflux, dysphagia Sclerodactyly: skin fibrosis, especially in the fingers, hands, and face Telangiectasias: on the lip, hand, or face; not always present Labs: anti-Scl-70 anti-RNA anti-U1-RNP anti-centromere (lab work can support the diagnosis but cannot rule out scleroderma) ``` Treatment: supportive care ACE inhibitors Dihydropyridine CCBs Avoid caffeine, nicotine, decongestants Methotrexate Corticosteroids ``` Complications: Pulmonary fibrosis Heart failure Acute renal failure caused by malignant hypertension

Answer 88

A mix of symptoms and feature can progress + anti-ribonucleoprotein (RNP)

Answer 89

-dry eyes, dry mouth (sicca syndrome) -enlarged parotid glands purpura of the legs -peripheral neuropathy -possible symmetric arthritis with other autoimmune conditions Positive anti-Ro antibodies Positive anti-La antibodies lymphocytic infiltration of exocrine glands Treatment: supportive care corticosteroids

Answer 90

``` CK aldolase AST, ALT LDH ANA Anti-Jo 1 BMP CBC ```

MSK Flashcards

(125 cards)