MSK disorders Flashcards
(54 cards)
1
Q
Bursitis treatment
A
Prepatellar bursitis → US guided aspiration
Others → eliminate offending activity, apply ice for 15 minutes x4/day, elevate, take NSAIDs
- If does not work after 4-8 weeks, intrabursal corticosteroid injection
Septic bursitis → antibiotics while waiting for culture results
2
Q
Tendinitis treatment
A
- Limit or discontinue contributing activity
- Apply ice
- NSAIDs
- Splinting for hands/wrist/achilles
- For biceps tendonitis, limit overhead movement and intrabursal corticosteroid injections to prevent bursitis
3
Q
Tendonosis (chronic state of tendonitis) treatment
A
- PT
- Extracorporeal shock wave therapy (ESWT)
4
Q
Lateral vs medial epicondylitis
A
Lateral → tennis elbow
Medial → golfer’s elbow
5
Q
Tennis elbow (lateral epicondylitis) clinical presentation
A
- Can be due to other repetitive activities that are not tennis
- Pain increases with resisted wrist extension (especially when lifting object in front of patient) and elbow extension
- Tender to palpation
- Without warmth or redness
6
Q
Golfer’s elbow (medial epicondylitis) clinical presentation
A
- Associated with racquet sports, bowling, archery, weight lifting
- Local tenderness and pain
- Wrist and forearm weakness
- Pain aggravated by wrist flexion and pronation
- Decreased grip strength
7
Q
Epicondylitis treatment
A
- Rest, applying ice, avoidance of precipitating activity
- Topical or oral NSAIDs and/or corticosteroids for short term relief
- PT
- Counterforce bracing
8
Q
Gout risk factors
A
- Obesity
- DM
- Family history
- Medications → thiazides, niacin, ASA, cyclosporine
- Chronic alcohol use
9
Q
Gout clinical presentation
A
- Sudden pain
- Most commonly affect MCP joint of great toe
- Unable to walk, move joint, tolerate weight of bed sheet on affected joint
- Red and enlarged
- Chronic gout → tophi
10
Q
Gout diagnostic testing
A
- First episode → uric acid level
- Diagnostic → joint aspiration
- X-ray
After acute flare subsides → 24 hour urine collection for uric acid
11
Q
Gout treatment
A
Inflammation prevention/management
- Loading dose of NSAID followed by lower doses
- Short course of systemic corticosteroid (replaced colchicine)
Reduction of uric acid
- Complete at least 6 months of anti inflammatory therapy first
- Xanthine oxidase inhibitors → allopurinol or febuxostat
- Probenecid
Chronic gout refectory to other meds → pegloticase (krystexxa)
12
Q
Gout diagnostic testing
A
Serum uric acid should be maintained below 6 mg/dL
- Levels monitored at 6 month intervals
13
Q
Dietary modifications to prevent gout
A
Avoid high purine foods
- Seafood (scallops, mussels)
- Organ and game meat
- Beans
- Spinach
- Asparagus
- Oatmeal
- Baker’s and brewer’s yeast
14
Q
Osteoarthritis clinical presentation
A
- Insidious/gradual onset
- Joint pain relieved with rest
- Joint stiffness worse at rest but resolves with <15 minutes of activity
- Reduced ROM
- Discomfort increases as day progresses
- Heberden’s nodes on DIP joints of hands
15
Q
Osteoarthritis treatment
A
- Weight loss with minimal weight bearing (water based activities)
- Application of heat before activity and ice after activity
- Acetaminophen (if using NSAIDs for long term, also add PPI)
- Duloxetine (cymbalta) as alternative for chronic MSK pain
- Topical analgesics
- Intra articular corticosteroid joint injection
- Knee or hip joint replacement
16
Q
Rheumatoid arthritis clinical presentation
A
- Initial presentation → acute polyarticular inflammation
- Slowly progressive malaise, weight loss, stiffness
- Morning stiffness (lasts about 1 hour)
- Symmetric
- Involves at least three joint groups
- Smaller joints (hands, toes, etc.)
17
Q
Rheumatoid arthritis diagnostic testing
A
- Labs: ANA, ESR, CRP, ACPA, RF
- X-rays at early stages of disease can determine progression
18
Q
Rheumatoid arthritis treatment and management
A
- Referral to rheumatology
- Anti inflammatory → NSAIDs, cox-2 inhibitors (celecoxib), corticosteroids
- Analgesic → NSAIDs, cox-2 inhibitors, acetaminophen, opioids, topicals
- DMARDs (methotrexate)
- Monitored every 3-6 months
- Non biologic and biologic DMARD (TNF inhibitor) indicated for moderate to high disease
- PT, water exercises
19
Q
SLE clinical presentation
A
- Malar rash (covering cheeks and nasal bridge, spares nasolabial folds)
- Fever without identifiable cause
- Unexplained fatigue
- Headaches
- Involuntary weight loss
- Joint pain, stiffness, swelling
20
Q
SLE diagnostic testing
A
- Labs: anemia, elevates ESR, proteinuria, positive ANA
- Chest x-ray → inflammation in lungs
- Echocardiogram → changes in heart
21
Q
SLE treatment and management
A
- Pregnancy should be delayed until SLE under control for at least 6 months
- NSAIDs
- Hydroxychloroquine for long term treatment
- Systemic corticosteroids for inflammation
- Immune suppressants for those who do not respond to initial therapy
22
Q
What is sjogren syndrome?
A
Autoimmune disease that occurs in conjunction with another chronic inflammatory condition (RA or SLE)
- Affects the eyes, mouth, parotid gland, lungs, kidneys, skin, nervous system
- Symptoms: oral and ocular secretions, underlying disease with RA and SLE, dry eyes (xerophthalmia), dry mouth (xerostomia), bilateral parotid swelling
- Diagnosis: salivary gland biopsy, schirmer’s test
23
Q
Sjogren syndrome treatment and management
A
- NSAIDs or medications that suppress immune system
- Methotrexate, hydroxychloroquine
- Eye lubricants
- Sips of water, artificial saliva, sugar free mouth drops
- Routine dental care and fluoride treatment
24
Q
Meniscal tear clinical presentation
A
Can be due to injury or degenerative changes
- Knee locking
- Popping sound or “gives out”
25
Diagnostic tests and maneuvers for meniscal tears
* McMurray test → palpable popping of joint
* Apley grinding test
* Squatting for kneeling impossible for large tears
* MRI if symptoms do not resolve within 2-4 weeks
26
Carpal tunnel syndrome clinical presentation
* Burning, aching, tingling pain radiating to forearm along median nerve
* Can radiate to shoulder, neck, chest
* Worse at night (acroparesthesia): waking up at night with numbness and burning pain in fingers
* Positive Tinel and Phalen test
* Muscle weakness later on
27
Carpal tunnel syndrome diagnostic testing
* EMG
* Nerve conduction studies
* MRI and high resolution US to rule out other causes of wrist pain
28
Carpal tunnel syndrome treatment and management
* Limit activity that cause CTS
* Elevate affected extremity
* Nighttime use of solar splints
* NSAIDs and acetaminophen
* Corticosteroid injections at 6 week intervals
* PT
* Surgery
29
What is sarcoidosis?
Inflammatory condition that results in production of noncaseating granulomas in various sites of the body
* Predominantly in the lungs, lymph nodes, eyes, skin
* Likely due to exaggerated immune response to unidentified antigen
30
Sarcoidosis clinical presentation
* Derm → rash, lesions, color change, nodule formation under skin
* Ocular → blurred vision, eye pain, severe redness, sensitivity to light
* Resp → DOE, cough, chest pain
* Systemic → fever, fatigue, anorexia, arthralgia
31
Sarcoidosis diagnostic testing
* Serological markers: serum amyloid A, soluble interleukin-2 receptor, ACE, glycoprotein KL-6
* Hypercalcemia
* Hypercalciuria
* Chest x-ray → lung damage, enlarged lymph nodes
* CT → alveolitis, fibrosis
* *Biopsy to check for noncaseating granulomas*
32
Sarcoidosis treatment and management
Often self limiting
* NSAIDs for arthralgia
* *Corticosteroids*
* Hydroxychloroquine and immune suppressing medications used to treat RA
33
What is cauda equina syndrome?
When associated with lumbar radiculopathy, will have:
* Rectal or perineal pain
* Disturbance in bowel and bladder function (neurologic deficits in Les)
* Medical emergency
34
Lower back pain conservative management
* Cold packs for 20 minutes 3-4 times/day
* Heat application before gentle stretching exercises
* NSAIDs or acetaminophen
* Muscle relaxants for short periods of time
* Anticonvulsants (gabapentin) for neuropathic pain
35
What is reactive arthritis?
Acute non purulent arthritis complicating an infection elsewhere in the body
* Occurs after exposure to certain GI and GU infections
* Develops about 2-4 weeks after infection
36
Reactive arthritis clinical presentation
* Acute onset malaise, fatigue, fever
* Unilateral LE arthritis (especially knees)
* Lower back pain
37
Reactive arthritis diagnostic testing
* Bacterial urethral or urine testing
* Stool cultures
* Elevated ESR
38
Reactive arthritis treatment and management
* Symptomatic and supportive care
* NSAIDs or systemic corticosteroids
* Can consider corticosteroid injections
* DMARDs for chronic states
* If associated with urethritis, doxycycline x7 days or single dose azithromycin
39
Osteoporosis treatment and management
* Calcium and vitamin D supplementation
* Bisphosphonates
* Taken in the AM with full glass of water, wait 30 minutes before food or drinks, remain upright for at least one hour
* Selective estrogen receptor modulators (SERMs)
* Raloxifene, calcitonin, estrogen
* Bone forming medications (teriparatide)
* For women with low bone density or prior fracture
40
Are drug holidays necessary when considering treatment with bisphosphonates?
Yes - bisphosphonates provide a degree of anti fracture reduction when treatment is discontinued; recommend a drug holiday after 5-10 years of therapy
* If low risk for fracture, consider stopping after 5 years and remain off treatment until bone mineral density is stable
* If high risk, can be treated for 10 years and have drug holiday of no more than 1-2 years with consideration of a non bisphosphonate treatment
41
Grade I ligamentous sprain (pathology and presentation, intervention)
Pathology: slight stretching or microscopic tear
Presentation: no instability
Intervention:
* RICE
* Immobilizer
* Limit weight bearing
* Analgesia
* Length of disability usually limited to a few days
42
Grade II ligamentous sprain (pathology and presentation, intervention)
Pathology: partial ligamentous tear
Presentation: moderate joint instability, moderate swelling, mild to moderate ecchymosis
Intervention:
* RICE
* Immobilizer
* Limit weight bearing
* Analgesia
* Length of disability usually several weeks to a few months
* Ortho referral
43
Grade III ligamentous sprain (pathology and presentation, intervention)
Pathology: complete ligamentous tear
Presentation: complete ankle instability, significant swelling, moderate to severe ecchymosis
Intervention:
* RICE
* Immobilizer
* Limit weight bearing
* Analgesia
* Length of disability may be many months
44
Ottawa Ankle Rules criteria
* Is imaging necessary for an ankle sprain?
Only if the patient experiences malleolar pain and any of the following:
* Bone tenderness at posterior edge or tip of lateral malleolus
* Bone tenderness at posterior edge or tip of medial malleolus
* Inability to bear weight immediately after injury and in ED
45
What is fibromyalgia?
Chronic pain syndrome diagnosed by widespread presence of body pain
* Sometimes begins after physical trauma, surgery, infection, or significant psychological stress
46
Fibromyalgia clinical presentation
* Burning, aching, sore pain
* Point tenderness
* Lasted for at least 3 months
* Persistent fatigue, non refreshing sleep
* Tension headaches
* TMJ
* IBS
* Anxiety and/or depression
47
Is diagnostic testing required for fibromyalgia?
No imaging or labs are diagnostic but can be used to rule out other causes
* Labs: CBC w/ diff, metabolic panel, UA
* TSH, vitamin D, vitamin b12 for fatigue and muscle pain
* IDA normal
48
Fibromyalgia conservative management
* Physical activity → flexibility exercises, progressive stretching, low impact activities (aquatics)
* Stress management
* Maintain healthy lifestyle
* Eat healthy foods
* Limite caffeine
* Get sufficient sleep
49
Fibromyalgia pharmacotherapy
* Acetaminophen and NSAIDs for pain
* Trazadone for sleep
* Antidepressants
* TCAs
* SNRIs (duloxetine)
* Anti epileptics (gabapentin, pregabalin)
50
Causes of vitamin D deficiency
* Sun avoidance and use of sun protection
* Increased skin pigmentation
* Inadequate dietary and vitamin D supplemental intake
* Breastmilk only without vitamin D supplementation
* Malabsorptive syndromes (gastric bypass, hepatic and renal disease)
* Obesity
* Medications (phenytoin, phenobarbital)
51
Vitamin D deficiency clinical presentation
Often mistaken for fibromyalgia
* Muscle weakness and muscles aches
* Osteomalacia → pain to palpation
* Dull, aching pain
* Difficulty arising from a chair or walking
* Pseudofractures
52
Vitamin D deficiency diagnostic testing
* Serum 25-hydroxyvitamin D
* Increased PTH levels with vitamin D levels of at least 20
* Normal vitamin D range is 20-100
53
Vitamin D deficiency treatment and management
* Vitamin D intake recommendations
* Infants (400 IU/day)
* Ages 1-70 years, pregnant and lactating women (600 IU/day)
* Older than 70 years (800 IU)
* Vitamin D3 supplementation
* 50,000 IU PO once/week for at least 8 weeks
54
Foods high in vitamin D
* Fortified milk, OJ, infant formulas, yogurts, breakfast cereals
* Salmon
* Tuna
* Mackerel
* Cod liver oil
* Shitake mushrooms
* Egg yolk
