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Rheum Lectures > MSK Dz in the ER > Flashcards

MSK Dz in the ER Flashcards

1
Q

What are the 2 most common MSK symptoms in the ER?

A
  1. Pain

2. Swelling

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2
Q

In descending order, what are the most common joints presenting to the ER?

A
  1. Ankle
  2. Wrist
  3. Knee
  4. Hip
  5. Shoulder
  6. Elbow
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3
Q

What is the most common type of ankle injury?

A

Lateral sprain due to inversion while walking or running.

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4
Q

What is the tx of an ankle sprain?

A

PRICE: protection, rest, ice, compression, elevation

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5
Q

Epidemiology of ankle fractures?

A

Young men and late middle-aged women

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6
Q

The vast majority of ankle fractures are where?

A

Malleolar fractures (majority of these are unimalleolar)

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7
Q

What are the complications of ankle fractures?

A

Joint space disruption, dislocation, soft tissue/skin necrosis, nerve injury, arterial disruption

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8
Q

Loss of arterial blood supply after a fracture is what type of emergency?

A

Surgical emergency. Dislocation pressuring skin needs reduction ASAP to avoid necrosis of overlying skin.

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9
Q

What is the most common type of wrist injury?

A

Fracture of radius, ulna, or carpal bones due to fall on outstretched hand

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10
Q

Which injury more commonly causes fracture: wrist or ankle?

A

Wrist

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11
Q

What is the most common type of wrist fracture?

A

Colles Fracture: occurs at distal radial metaphysis with proximal and dorsal displacement creating a “dinner fork” deformity.

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12
Q

What are the clues to an ACL injury?

A

Immediate pain and audible “pop” at time of injury.

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13
Q

Most ligamentous injuries (i.e. ACL tear) of the knee present with what?

A

Hemarthroses

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14
Q

What is mandatory for any knee injury associated with an effusion or hemarthroses?

A

X ray is mandatory to exclude fractures and ligamentous avulsion fractures. MRI rarely changes clinical decisions and is not a substitute for a careful H&P.

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15
Q

Epidemiology for hip fractures?

A

Old white ladies

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16
Q

Pathophysiology of hip fractures?

A

Occurs due to weakening of bone with aging. Elderly ppl fall b/c femoral neck breaks.

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17
Q

Symptoms of hip fracture?

A

Sudden onset of hip pain before or after fall and inability to bear weight.

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18
Q

Signs of hip fracture?

A

Leg shortened and externally rotated if the fracture is displaced.

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19
Q

Risk of hip fracture?

A

DVT in leg

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20
Q

The majority of back pain is idiopathic. What are the non-idiopathic causes of lower back pain?

A

IV disc herniation, spinal metastases, spinal infection, epidural abscess, hemorrhage, spinal fracture, and ankylosing spondylitis.

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21
Q

Epidemiology of lumbar IV disc herniation?

A

Middle-aged adult 30-50 yo typically with recurring episodes of lower back pain

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22
Q

T or F. 1% of patients with back pain have sciatica, but 95% of patients with back pain due to a herniated disc have sciatica.

A

T

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23
Q

Signs and symptoms of sciatica?

A

Syndrome of pain +/- sensorimotor symptoms in the distribution of a sciatic nerve. Pain in the lower back, buttock, and leg. Typically sharp and commonly in a single dermatome +/- leg weakness +/- numbness/tingling. Typically unilateral.

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24
Q

90% of sciatica is due to what?

A

Herniation of lower lumbosacral IV disc

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25
Q

What is the test for lower lumbar IV disc herniation?

A

Straight leg raise test: raise the pt’s straight leg b/t 30-70 degrees. If pain in distribution of sciatic nerve, the test is positive. 90% sensitive, 25% specific.

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26
Q

Features of cauda equina syndrome?

A

Combination of lower back pain, sciatica, leg weakness, bladder dysfunction, saddle hypo- or anesthesia, fecal incontinence, and/or sexual dysfunction.

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27
Q

What is the key feature of cauda equina syndrome?

A

Bladder dysfunction

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28
Q

What is the bladder dysfunction in incomplete cauda equina syndrome?

A

Altered urinary sensation, loss of desire to void, poor urinary stream, and the need to strain to be able to pee.

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29
Q

What is the bladder dysfunction of complete cauda equina syndrome?

A

Painless urinary retention, overflow incontinence, and inability to pass urine spontaneously.

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30
Q

What are the signs of cauda equina syndrome?

A

Bladder distension, decreased anal tone, absent ankle, knee, or bulbocavernosus reflexes, saddle anesthesia, and bilateral sciatica.

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31
Q

All pts with cauda equina syndrome have what?

A

> 500 mL urinary retention

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32
Q

Cauda equina syndrome is what type of emergency?

A

Neurosurgical emergency

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33
Q

Spinal epidural abscesses are rare. What are the most important risk factors?

A

Spinal surgery, recent trauma, immunosuppression, distal site of infection, IV drug use, DM, and alcoholism.

34
Q

What are 2 commonly missed manifestations of spinal epidural abscesses?

A
  1. Back pain

2. Fever

35
Q

What is the 2nd leading cause of accidental death in the US?

A

Drug overdose. Opioid pain relievers account for more of these than cocaine and heroine combined.

36
Q

What are the 4 predictors for drug-seeking behavior?

A
  1. Pt requests opioid medication by name
  2. Multiple visits for same complaint
  3. Suspicious Hx
  4. Symptoms out of proportion to exam
37
Q

What is necrotizing fasciitis?

A

Rare acute progressive destructive infection of muscle fascia and overlying subq fat.

38
Q

What are some features of necrotizing fasciitis?

A
  1. Infxn spreads along muscle fascia due to its poor blood supply
  2. Overlying tissue can seem initially unaffected
  3. Poorly demarcated area of erythema, swelling, warmth, shiny, exquisitely tender
  4. Pain out of proportion to physical findings
39
Q

What causes type 1 necrotizing fasciitis?

A

Polymicrobial so aerobes + anaerobes

40
Q

What causes type 2 necrotizing fasciitis?

A

Group A Strep or MRSA (or both)

41
Q

What are the risk factors for necrotizing fasciitis?

A

Diabetes, vascular dz, immunosuppression, trauma, surgery, etc.

42
Q

What is the microscopic pathology of necrotizing fasciitis?

A

Coagulative necrosis with acute inflammation (neutrophils + fibrin exudate) starting at edge. +/- aggregates of bacteria not where neutrophils are present. +/- nuclear dust (which is debris from neutrophil breakdown). +/- hemorrhage.

43
Q

How long does it take necrotizing fasciitis to progress?

A

3-7 days

44
Q

What is the progression of necrotizing fasciitis?

A
  1. Skin color changes from red to purple to blue-gray patches
  2. W/in first 3-5 days, skin breaks down with bullae containing thick pink or purple fluid
  3. Finally frank cutaneous gangrene…involved areas have become anesthetic due to thrombosis of small blood vessels and destruction of superficial nerves
    Note: anesthesia may precede skin necrosis
45
Q

What are the 2 most common sites of necrotizing fasciitis?

A
  1. Legs

2. Perineum

46
Q

What is often present in type 1 necrotizing fasciitis?

A

Subq gas

47
Q

How is the dx of necrotizing fasciitis made?

A

H&P

48
Q

What is the treatment of necrotizing fasciitis?

A

Surgical debridement of necrotic tissue, broad spectrum empirical antibiotics, and hemodynamic support.

49
Q

What type of emergency is necrotizing fasciitis?

A

Surgical emergency

50
Q

What is compartment syndrome?

A

Increased pressure within a muscle compartment compromises the circulation w/in that space.

51
Q

Epidemiology of compartment syndrome?

A

Athletes presenting with insidious pain.

52
Q

Pathophysiology of compartment syndrome?

A

Fascia prevents adequate expansion of tissue volume to compensate for an increase in fluid. As compartment pressure rises, venous outflow is reduced thus raising venous pressure which decreases the AV pressure gradient. Arterioles collapse when tissue pressure exceeds end-arteriolar pressure. Ultimately, arteriolar pressure is insufficient to overcome compartment pressure and blood is shunted away from compartmental tissues.

53
Q

Compartment syndrome is most common after what?

A

Significant trauma. Especially with leg or forearm long bone fractures or after fractures of tibial diaphysis or distal radius.

54
Q

What are the non-traumatic causes of compartment syndrome?

A

Bleeding, thrombosis, vascular dz, nephrotic syndrome, extravasation of IV fluids, injection of recreational drugs, and prolonged limb compression (i.e. after severe drug or alcohol intoxication).

55
Q

Symptoms of compartment syndrome?

A
  1. Pain out of proportion to apparent injury
  2. Persistent deep ache or burning pain
  3. Paresthesias (0.5-2 hour onset)
56
Q

Signs of compartment syndrome?

A
  1. Pain w/ passive stretch of muscles in the affected compartment
  2. Tense compartment w/ a firm “wood-like” feeling
  3. Diminished sensation
  4. Muscle weakness (2-4 hour onset)
57
Q

How do you dx acute compartment syndrome?

A

Clinically via H&P. Compartment pressure measurements are an important adjunct in the dx.

58
Q

Normal compartment pressure is 0-8 mmHg. Pain may develop when pressures reach what levels? Capillary blood flow becomes compromised? Ischemia?

A
  1. Pain: 20-30 mmHg
  2. Capillary blood flow: increases to w/in 25 mmHg of MAP
  3. Ischemia: when pressures approach diastolic pressure
    Note: Perfusion pressure (diff b/t diastolic and compartment) <30 mmHg is advocated for an actionable dx.
59
Q

Acute compartment syndrome is what type of emergency?

A

Surgical

60
Q

What is the treatment for compartment syndrome?

A

Fasciotomy

61
Q

How is compartment syndrome defined?

A

Ischemic necrosis caused by elevated pressure w/in fascial compartments

62
Q

What is Clostridial myonecrosis aka gas gangrene?

A

Life-threatening necrotizing muscle infection from either contiguous area of trauma or hematogenous muscle seeding from GI tract.

63
Q

What are the 2 major forms of Clostridial myonecrosis and what is the most common causative organism for each?

A
  1. Traumatic: C. perfringens

2. Spontaneous: C. septicum

64
Q

What are C. perfringens 2 virulence factors and what do they do?

A
  1. Alpha toxin: causes platelet aggregation, adherence of neutrophils to endothelium, and negative inotrope
  2. Theta toxin: lyses cells
65
Q

Pathophysiology of Clostridial myonecrosis?

A

Trauma introduces Clostridia bacteria or spores into deep tissue. If the trauma impairs blood supply, it provides an anaerobic environment which Clostridia loves.

66
Q

With Clostridial myonecrosis, how long does it take for necrosis to ensue after the trauma?

A

24-36 hours

67
Q

In Clostridial myonecrosis, are neutrophils present in the infected tissues?

A

No b/c the alpha toxin causes them to stick to the endothelium so they never get to the site of infection.

68
Q

Histology of Clostridial myonecrosis shows what?

A

Necrotic muscle with gas bubbles in it and an absence of neutrophils. Clostridia appear as large boxcar-shaped Gram + rods (but can be Gram - in tissue).

69
Q

So alpha toxin of Clostridia causes intravascular occlusions b/c of aggregates of activated platelets, leukocytes, and fibrin. This process is dependent upon alpha toxin activation of what?

A

Platelet fibrinogen receptor glycoprotein IIb/IIIa therefore, inhibitors (such as eptifibatide or abciximab) may be therapeutic for maintaining blood flow.

70
Q

Pain in Clostridial myonecrosis is due to what?

A

Toxin-mediated ischemia

71
Q

Describe the skin changes of Clostridial myonecrosis.

A
  1. Skin over infected area initially appears pale, then rapidly develops a bronze color, then purple or red discoloration
  2. Becomes tense and exquisitely tender
  3. Clear, red, blue, or purple bullae form
  4. Blood vessels filled with hemolyzed blood form an arborizing pattern
  5. Gas in soft tissue may be palpated at the bedside
72
Q

What are the signs of systemic toxicity in Clostridial myonecrosis? Do they develop rapidly or slowly?

A

Rapidly. Tachycardia and fever followed by shock and multiple organ failure.

73
Q

Dx of Clostridial myonecrosis?

A

Requires demonstration of large Gram stain-variable rods at site of injury and absence of acute inflammatory cells.

74
Q

Tx of Clostridial myonecrosis?

A

Surgical debridement + clindamycin + penicillin

75
Q

What is rhabdomyolysis?

A

Condition of muscle necrosis and release of intracellular muscle constituents into the circulation.

76
Q

Symptoms of rhabdomyolysis?

A

Classic Triad=muscle pain, weakness, and dark urine

77
Q

Signs of rhabdomyolysis?

A

Reddish-brown urine, muscle swelling w/ rehydration, muscle tenderness, muscle weakness. Note: many pts have no signs or symptoms.

78
Q

What are the 3 categories of causes of rhabdomyolysis?

A
  1. Trauma
  2. Exertion
  3. Miscellaneous
79
Q

What is the hallmark of rhabdomyolysis?

A

Elevation in serum muscle enzymes. CK is usually 5x normal upon presentation.

80
Q

Describe the myoglobinuria seen with rhabdomyolysis.

A

Results in a positive test for blood on urine dipstick but without RBCs on microscopic exam. Myoglobin can clog the renal tubules causing acute renal failure.

Rheum Lectures (7 decks)

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