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Flashcards in MSK Deck (125):
1

Risk factors for carpal tunnel syndrome

pregnancy
RA
DM
Acromegaly
hypothyroidism
obesity
overuse

age 30-55
more common in females

2

Carpal tunnel syndrome H and P

H and P
hand numbness and tingling
wrist pain that radiates up the arm
dropped objects
decreased hand strength
decreased palmar 2-point discrimination

thenal muscle atrophy

Tinel sign
Phalen sign (hold for about a minute)

EMG and nerve- conduction studies for definitive diagnosis

3

Carpal tunnel syndrome treatment

wrist spiints
activity modification
NSAIDs
steroid injections
surgical release of transverse carpal ligament

4

Shoulder dislocation

anterior is most common
humeral head comes forward and tears the anterior labrum of the shoulder

5

Treatment for anterior shoulder dislocation

pain control, then closed reduction, then immobilize with a sling and have the patient follow up with an orthopedic surgeon

Pain control: lidocaine, narcotics, conscious sedation

6

Bankart lesion

anterior labrum is torn 2/2 anterior dislocation

90% of anterior dislocations
Repair may prevent future dislocation

7

Posterior hip dislocation

posteriorly directed force on internally rotated, flexed, adducted hip

Treatment:
closed reduction
bracing
abduction pillow
confirm normal alignment with xray, without chips of bone in the socket

8

nerve damage implicated in claw hand

ulnar nerve

9

ape hand

median nerve

10

wrist drop

radial nerve

11

scapular winging

Long thoracic nerve

12

unable to wipe bottom

thoracodorsal nerve

13

loss of forearm pronation

median nerve

14

cannot abduct or adduct fingers

ulnar nerve

15

loss of shoulder abduction

axillary nerve

16

weak external rotation of arm

suprascapular nerve, axillary nerve

17

loss of elbow flexion and forearm supination

musculocutaneous nerve

18

loss of wrist extension

radial nerve

19

trouble initiating shoulder abduction

suprascapular nerve

20

unable to abduct arm beyond 10 degrees

axillary nerve

21

unable to raise arm above horizontal

long thoracic nerve
spinal accessory nerve

22

fracture of humoral shaft puts what nerve at risk?

radial nerve

23

fracture of surgical neck of humerus puts what nerve at risk?

axillary nerve

24

supracondylar fracture puts what nerve at risk?

median nerve

25

medial epicondyle fracture puts what nerve at risk?

ulnar nerve

26

anterior shoulder dislocation puts what nerve at risk?

axillary nerve

27

Colles fracture

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

28

Smith fracture

fracture of distal radius with anterior displacement

MOI: fall and land on flexed wrist
less common than Colles

29

Scaphoid fracture

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

30

Boxer's fracture

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

31

Monteggia fracture

dislocation of radial head and ulnar diaphyseal fracture

defense injuries

falls on outstretched hand with forearm in excessive pronation

Treatment: surgery

32

Nightstick injury

isolated ulnar shaft fracture

Treatment:
does not require surgery

33

Galeazzi fracture (DRUJ)

distal radial ulnar joint dislocation and radial diaphyseal fracture

Treatment: this will require surgery

34

Hip fracture

intratrochanteric
subtrochanteric

increased risk for avascular necrosis with femoral neck fractures

H and P:
injured leg is shortened and externally rotated

35

Femur fractures

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

36

Tibial fracture

increased risk for compartment syndrome

37

Ankle fracture

if unstable, then requires operative stabilization

38

Pelvic fracture

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)

39

Sprain

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

40

Ligament tear

ACL, PCL
Anterior drawer
Lachman

MRI for soft tissue
CT for bone

41

Unhappy triad

medially- directed blow to lateral side of knee

Structures injured:
ACL tear
MCL tear
Lateral meniscus tear

42

Meniscus tears

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

43

most commonly injured knee ligament

MCL

44

positive Lachman test

ACL

45

Positive McMurray test aids in diagnosis

Meniscus tear

46

common dashboard injury in an MVA

PCL

47

Compartment syndrome

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

48

Back pain radiating to epigastrium while eating

PUD, GERD, gastritis

49

Back pain radiating to epigastrium with elevated amylase/lipase

pancreatitis

50

Back pain radiating to epigastrium with pulsatile mass

triple A

51

Back pain radiating to pelvis and hematuria

renal stones

52

Back pain radiating to pelvis and CVA tenderness

pyelonephritis

53

Back pain only along spine along paraspinals

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

54

Back pain only along spine with osteoporosis

compression fracture

55

Back pain only along spine with back asymmetry

scoliosis

56

Back pain only along spine with abnormal gait (knees/hips flexed)

anterior slip of disk (spondylolisthesis)

57

Back pain only along spine along with systemic signs of infection

meningitis
discitis
osteomyelitis

58

Back pain (radiating) or new neuro symptoms worse with exertion

disc herniation

59

Back pain (radiating) or new neuro symptoms and pain with walking or standing

spinal stenosis

60

Back pain (radiating) or new neuro symptoms worse with rest, better with activity

ankylosing spondylitis

(young male, 20's, 30's)

61

Back pain (radiating) or new neuro symptoms all day

cancer

62

Back pain (radiating) or new neuro symptoms with bowel/bladder dysfunction, saddle area anesthesia

cauda equina syndrome

63

degenerative disc disease

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

64

Spinal stenosis

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

65

Cauda equina syndrome

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

66

Erb-Duchenne palsy: Waiter's tip

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

67

Claw hand

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)

68

wrist drop

Site of injury:
radial nerve
inability to extend upper fingers

69

Deltoid paralysis

axillary nerve injury

associated with anterior shoulder dislocation

70

Klumke palsy

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

71

Risk factors for osteoporosis

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)

72

Osteopetrosis

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

73

Pagent disease of bone

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

74

Osteogenesis imperfecta

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

75

Gout

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

76

Pseudogout
CPPD

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

77

Acute gout treatment

NSAIDs
steroids
colchicine

NOT probenecid or steroids

78

Pseudogout treatment

NSAIDs
Colchicine

79

narrowing of the marrow cavity results in low H and H

osteopetrosis

80

55yo female who trips and sustains distal radius fracture

Colles, osteoporosis

81

How do we treat osteogenesis imperfecta in children

bisphosphonates

82

What test do we use to test for Paget disease?

Radionuclide bone scan to look for metabolic hot spots

83

Physcial exam- sIgns of radial nerve damage

wrist drop
lost thumb abduction

84

Causes of septic joint

MCC: staph a

Sexually active? also consider n. gonorrhea

DM, cancer, other underlying illess: gram- negative rods

85

Presentation of septic joint

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

86

Joint aspirate leukocytes in
OA vs. inflammatory arthropathy vs septic joint

OA 50,000/mm^3

87

Osteomyelitis

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

88

Lyme disease- classic presentation and clinical course

Early localized disease
Early disseminated disease

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

89

What is the treatment for Lyme disease?

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

90

Treatment for RMSF

Doxycycline for about 7 days
Chloramphenicol in pregnant patients

91

Osteoarthritis, aka degenerative joint disease

Chronic non-inflammatory

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

92

Neoplasms

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

93

Osteosarcoma

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

94

Ewing sarcoma

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

95

Osteochondroma

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

96

diseases associated with pANCA

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

97

Rheumatoid arthritis

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

98

Diagnostic criteria for RA

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

99

Treatment of RA

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

100

SLE

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

101

Drugs associated with drug- induced lupus

sulfonamides
hydralazine
INH
Procainamide
Phenytoin

reversible with drug cessation

look for antihistone antibodies

102

Lupus immunologic markers

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

103

RA immunologic markers

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

104

Polymyositis and dermatomyositis immunologic markers

ANA
Anti-Jo-1 antibodies

105

ankylosing spondylitis immunologic markers

HLA-B27

106

Scleroderma immunologic markers

Anti-Scl-70

107

CREST syndrome immunologic markers

anti-centromere abs

108

Mixed connective tissue disease immunologic markers

Anti-RNP

109

Sjogren syndrome immunologic markers

Anti-Ro
Anti-La

110

Anti-histone antibodies

Drug- induced lupus

111

HLA-DR4

RA

112

Anti-Sm antibodies

SLE

113

Anti-dsDNA antibodies

SLE

114

Lupus skin findings (n=4)

malar rash
discoid rash
photosensitivity
painless oral ulcers

115

Anti-Jo-1 antibodies

polymyositis

116

Anti-topoisomerase antibodies

scleroderma

117

Polymyositis and dermatomyositis

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

118

Polymyalgia rheumatica

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

119

Fibromyalgia

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

120

Ankylosing spondylitis

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

121

Psoriatic arthritis

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)

122

Limited Cutaneous systemic sclerosis: CREST Scleroderma

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

123

Mixed connective tissue disease

A mix of symptoms and feature
can progress

+ anti-ribonucleoprotein (RNP)

124

Sjogren syndrome

-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

125

What labs do you order when you suspect dermatomyositis?

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