Orthopedics and Rheumatology

Question 1

What are the most common causes of low back pain?

Answer 1

Low back strain and prolapsed intervertebral disc

Question 2

Differentiate the features of low back pain associated with a musculoskeletal cause, sciatica, SI joint problems, and spinal stenosis.

Answer 2

MSK: Point tenderness and localized to one region
Scia: Pain in buttock, posterior thigh, posterolateral aspect of leg to lateral malleolus.
SI: Unilateral low back and butt pain that worsens with standing
Sten: Pain in elderly worsened by walking and better when leaning forward.

Question 3

T/F: X-ray is the best test to use on initial exam of a patient with complaint of low back pain.

Answer 3

False: X-ray typically not required if neuro exam is normal

Question 4

What are the red flag S/S of low back pain?

Answer 4

fever, weight loss, morning stiffness, IVDU or steroid use Hx, trauma, CA, saddle anesthesia, loss of anal sphincter tone, motor weakness (req emergent x-ray)

Question 5

What are the best uses of CT and MRI in the patient with low back pain?

Answer 5

CT: identifying bony stenosis and lateral nerve root entrapment
MRI: cord pathology, neural tumors, stenosis, herniated discs, and infections

Question 6

What is the recommended treatment for uncomplicated low back pain?

Answer 6

Rest for 2 days with support under knees and neck
NSAIDs
Progressive walking to normal activities
Postural exercises/PT
Imaging if no improvement in 6 weeks
Surgery if conservative therapy fails (about 5%)

Question 7

Define bursitis.

Answer 7

Inflammation of the thin walled sac lined with synovial tissue located in larger moveable joints.

Question 8

Describe the common S/S and treatment for bursitis.

Answer 8

S/S: pain and swelling that may persist for weeks

Tx: Rest, brace/support, stretching, NSAIDs, steroid injection

Question 9

Define and state common S/S associated with tendonitis.

Answer 9

Tendon inflammation most commonly s/p overuse and arthritis. S/S = pain with movement, swelling, impaired function, commonly recurrs.

Question 10

What is the treatment for tendonitis?

Answer 10

Rest, ice, stretching, NSAIDs, steroid injection, surgery if conservative therapy fails.

Question 11

Define and state common S/S associated with costochondritis.

Answer 11

Inflammation of rib cage cartilage. S/S: tender, radiating pain down limbs, C/P - often with inspiration

Question 12

What are the risk factors for costochondritis?

Answer 12

Age > 40, high impact sports, manual labor, allergies, RA, ankylyosing spondylitis, reactive arthritis

Question 13

What is used in diagnosis and treatment of costochondritis?

Answer 13

Dx: clinical –> imaging, ECG, serum labs to r/o other conditions
Tx: NSAIDs, lifestyle changes, rest, ice

Question 14

Define and state the S/S of fibromyalgia.

Answer 14

Central pain disorder. S/S: non-articular MSK pain, fatigue, sleep disturbance, mood changes, cognitive disturbance, multiple trigger points, dysmenorrhea, IBS

Question 15

How is fibromyalgia diagnosed and what other conditions should be ruled out?

Answer 15

Dx of exclusion –> r/o hypothyroid, Hep C, vitamin D deficiency

Question 16

Describe the treatment of fibromyalgia.

Answer 16

SSRIs, SNRIs, TCAs may be helpful
Gabapentin to reduce pain and improve sleep
Exercise without overtraining
Treat associated psych disorders –> CBT, sleep assistance, stress reduction, mindfulness

Question 17

T/F: NSAIDs are an essential part of treatment for pain associated with fibromyalgia.

Answer 17

False: NSAIDs have no benefit

Question 18

What is the most common soft tissue tumor of the hand and what are they caused by?

Answer 18

Ganglion cyst –> arise from torn or degenerated joint capsule or tendon

Question 19

What are the most common locations for a ganglion cyst and what is the most common cause?

Answer 19

Location: wrist and fingers
Cause: repetitive activity

Question 20

What are the most common S/S associated with ganglion cyst?

Answer 20

Obvious swelling or joint pain with no obvious cause

Question 21

Describe the treatment of ganglion cyst?

Answer 21

Observation, needle aspiration, surgery.

Question 22

T/F: Ganglion cysts typically recur regardless of the treatment modality.

Answer 22

True

Question 23

Define gout.

Answer 23

Altered purine metabolism and sodium urate crystal precipitate into synovial fluid.

Question 24

T/F: Men are at much higher risk of gout than women.

Answer 24

True until menopause, then risk is equal.

Question 25

What S/S are most commonly associated with gout?

Answer 25

podagra (attack at MTP of great toe), pain, swelling, redness, exquisite tenderness, tophi in chronic gout.

Question 26

What are tophi?

Answer 26

Swollen, outgrowths at the joints under the skin

Question 27

State diagnostic findings in gout.

Answer 27

Joint fluid: negatively birefringent rods Serum uric acid > 8 --> common but not diagnostic X-ray: small, punched out lesions

Question 28

Describe treatment options for gout.

Answer 28

Lifestyle: elevation, rest, decrease purines in diet (meat, seafood, ETOH), weight loss, inc protein NSAIDs --> indomethicin = drug of choice Colchicine --> effective between attacks but bad GI AEs Allopurinol --> DOC between attacks

Question 29

What medications should be avoided by patients with gout?

Answer 29

ASA, thiazide diuretics

Question 30

T/F: Allopurinol is used to reduce attacks of gout but is best to start when an attack is active.

Answer 30

False: never start allopurinol during acute attack

Question 31

What is CPPD and what is the classic presentation?

Answer 31

Pseudogout --> usually older than 60 yoa, occurs in large joints in the lower extremities, S/S similar to gout but no tophi present.

Question 32

State diagnostic findings in pseudogout.

Answer 32

Joint fluid: positive birefringent --> rhomboid shaped Ca pyrophosphad crystals X-ray: fine, linear calcifications in cartilage

Question 33

Describe treatment options for pseudogout.

Answer 33

NSAIDs for acute attacks (steroid injections an option) | Colchicine for prophylaxis (benefit controversial)

Question 34

Define osteoarthritis.

Answer 34

Progressive loss of articular cartilage with reactive changes in bone.

Question 35

T/F: Osteoarthritis is a clinical diagnosis in which imaging has no benefit.

Answer 35

False: 90% of osteoarthritis patients have evidence of disease on X-ray

Question 36

Describe the S/S of osteoarthritis.

Answer 36

Dec ROM, joint crepitus, morning stiffness with pain that worsens throughout the day

Question 37

What x-ray findings are indicative of osteoarthritis?

Answer 37

asymmetric joint narrowing, subcondral sclerosis, bony cysts, marginal osteophytes.

Question 38

What are the treatment options for osteoarthritis?

Answer 38

DOC = APAP | Weight reduction, moderate exercise, NSAIDs, intra-articular steroids, braces, canes, joint replacement

Question 39

Define osteoporosis.

Answer 39

Decrease in bone density s/p abnormal bone remodeling leading to increased risk of fracture.

Question 40

Differentiate between type 1 and type 2 primary osteoporosis.

Answer 40

1: Post-menopausal (most prevalent) --> loss of estrogen or testosterone in men 2: senile --> occurs equally in men and women.

Question 41

What bones are most commonly affected/fractured in primary osteoporosis?

Answer 41

1: Trabecular bone --> vertebrae, hip, distal radius 2: trabecular and cortical bone --> hip and pelvis

Question 42

What conditions most commonly cause secondary osteoporosis?

Answer 42

Malignancy, steroid use, GI disease, hormone issues

Question 43

What is the most beneficial method to evaluate patients for osteoporosis and when should it be used for screening?

Answer 43

DEXA scan --> Postmenopausal women < 65 yoa with one or more risk factor, Any woman > 65, women on HRT, osteopenia on x-ray, Fx with minimal trauma, patients with Hx of RA

Question 44

Describe the normal and abnormal findings of a DEXA scan.

Answer 44

T-score > -1 = normal T-score between -1 and -2.5 = osteopenia T-score < -2.5 = osteoporosis

Question 45

What are the management options for osteoporosis?

Answer 45

Prevention: weight bearing exercise, dec ETOH, ensure adequate Ca, Vitamin D, Phosphorus, smoke cessation Bisphosphonate = DOC HRT = risk for MI, breast cancer, blood clots

Question 46

Describe plantar fasciitis and state which patients are most susceptible.

Answer 46

Micro-tears in the plantar fascia and the calcaneal origin. Most common in runners and overweight patients.

Question 47

What S/S are most commonly associated with plantar fasciitis?

Answer 47

Pain with first few steps in the morning, heel pain at night, pain at calcaneal origin, inflexible achilles

Question 48

What findings on imaging are most common in plantar fasciitis?

Answer 48

X-ray: normal | MRI: calcifications of plantar fascia

Question 49

What treatment options are available for plantar fasciitis?

Answer 49

Conservative for first 6-12 months --> PT, stretching, heel pads, arch supports, massage with tennis ball Steroid injections Surgery only for extreme cases

Question 50

What is the risk of steroid injections to treat plantar fasciitis?

Answer 50

Rupture of plantar fascia --> use with caution

Question 51

What is another name for reactive arthritis and what is the classic triad of symptoms?

Answer 51

Reiter's Syndrome --> "can't see, can't pee, can't climb a tree" --> urethritis, oligoarthritis of large joints, uveitis.

Question 52

Other than the classic triad, what are other clinical features of reactive arthritis?

Answer 52

Usually preceded by an STI, asymmetric arthritis usually involving large joints below the waist, mucocutaneous lesions.

Question 53

What diagnostic findings are commonly present in reactive arthritis?

Answer 53

Most are HLA-B27 positive, synovial fluid culture is negative, evidence of permanent and progressive joint disease on x-ray.

Question 54

What is the best management for reactive arthritis?

Answer 54

NSAIDs = mainstay of treatment, PT, Abx at time of infection can lower risk but do not alleviate symptoms after development.

Question 55

Define rheumatoid arthritis.

Answer 55

Chronic inflammatory disease with synovitis affecting multiple joints and extra-articular manifestations.

Question 56

T/F: Women are more likely than men to have rheumatoid arthritis.

Answer 56

True: women are three times more likely

Question 57

What are the S/S of rheumatoid arthritis?

Answer 57

joint pain and deformity, muscle weakness, osteopenia, extra-articular changes in skin, lungs, kidneys, eyes, blood system, and heart.

Question 58

What lab and imaging findings are used to diagnose rheumatoid arthritis?

Answer 58

``` ESR and CRP elevated (non-specific) RF positive in 80% of patients ACPA and anti-CCP positive in 95% of patients --> most specific test for RA Absence of ANA used to exclude SLE X-ray = juxta-articular demineralization ```

Question 59

How is rheumatoid arthritis treated?

Answer 59

Refer to rheumatology PT and OT Pharmacology early --> NSAIDs and DMARDs, combo therapy with steroids and biologics (newer DMARDs) Reconstructive surgery in severe cases

Question 60

Define DMARDs and give some examples.

Answer 60

Disease Modifying Antirheumatic Drugs | Methotrexate (first line), sulfasalazine, hydroxychloriquine, leflunomide, azathioprine.

Question 61

What is the most commonly affected ligament in an ankle sprain?

Answer 61

Anterior Talofibular

Question 62

What is required to diagnose systemic lupus erythematosus?

Answer 62

At least four of the following: maloid rash, discoid rash, photosensitivity, oral ulcers, arthritis, serositis, renal disease, ANA, hematologic disorders, immunologic disorders (LE cell, anti-DNA, anti-SM), neuro disorders (seizures/psychosis) with no other cause

Question 63

What medications may induce SLE?

Answer 63

Procainamide, hydralazine, isoniazid, methyldopa, quinidine, chlorpromazine

Question 64

What serum labs are used to diagnose SLE?

Answer 64

ANA present 99% of the time but not specific to lupus Presence of Anti-dsDNA is specific for lupus Anti-Smith antibodies used to monitor disease progression.