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Family Medicine EOR > Orthopedics and Rheumatology > Flashcards

Orthopedics and Rheumatology Flashcards

1
Q

What is a herniated disc (lumbar disc)?

A

sudden movement causes the weakened and frayed nucleus pulposus to prolapse and protrudes through the annulus where they impinge on one or more nerve roots and cause sciatica or radicular pain

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2
Q

What are the characteristics of a herniated disc?

A
  • L5-S1, L4-L5, L3-L4, L2-L3, L1-L2
  • pain referral (sciatica)
  • mid-gluteal sciatica; posterior thigh; posterolateral leg; lateral foot, heel, or toes
  • mild to aching discomfort to a severe knife-like stabbing, radiating down the leg, superimposed on intense ache
  • weakness plantar flexion and hamstring weakness, absent or diminished ankle jerk, paresthesias
  • pain with straight leg raise and tenderness over the lumbosacral joint and sciatic notch
  • discomfort walking on heels
  • drop foot (L5) and weakness with plantar flexion (S1)
  • straight leg raise with the healthy leg (Laseque maneuver): flexion at the hip, extension at the knee - produces sciatic pain on the contralateral side
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3
Q

How is a herniated disc dx?

A
  • noncontrast MRI of the lumbar spine (not needed unless persistent pain for weeks)
  • CT with myelography
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4
Q

What is the tx of a herniated disc dx?

A

most comfortable lying supine with legs flexed at knees and hips, shoulders raised on pillows

  • analgesics - NSAIDs or opioids for a few days
  • repeated epidural injections of steroids with unconfirmed efficacy
  • surgical decompression - emergency if a bilateral sensorimotor loss, sphincteric paralysis
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5
Q

What is a back strain?

A
  • the most common cause of back pain - commonly due to lifting or strenuous activity
  • characterized by stiffness and difficulty bending
  • the patient will present with axial back pain and no radicular symptoms
  • the patient should resume activity as tolerated
  • patients who have no improved in 4 weeks should be reevaluated
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6
Q

What is the tx of a back strain?

A

in the absence of ‘red-flag’ symptoms, treat conservatively with NSAIDs, heat or ice, PT, and home-based exercises (avoid bed-rest)
-may include a muscle relaxant such as cyclobenzaprine or short-term use of a benzodiazepine

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7
Q

What is spinal stenosis?

A

lumbar spinal stenosis (LSS) is narrowing of the central or lateral lumbar spinal canal caused by degenerative joint disease which puts pressure on the cord or sciatic nerve roots before their exit from the foramina

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8
Q

What are the characteristics of spinal stenosis?

A
  • there are several types of spinal stenosis, with lumbar stenosis and cervical stenosis being the most frequent
  • neurogenic claudication - positional back pain and referred buttock pain, symptoms of nerve root compression, and lower-extremity pain during walking or weight-bearing
  • pain in elderly that increases with extension (walking downhill and standing upright) and is relieved with flexion at the hips and by leaning forward (sitting, leaning over a shopping cart)
  • bladder disturbances: recurrent UTI present in up to 10% due to autonomic sphincter dysfunction
  • Kemp sign - unilateral radicular pain from foramina stenosis made worse by extension of the back
  • straight leg raise (nerve root tension sign) is usually negative
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9
Q

How is spinal stenosis dx?

A

x-ray, CT myelogram, MRI

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10
Q

What is the tx of spinal stenosis?

A
  • (abdominal muscle strengthening), weight loss and bracing
  • steroid injections (epidural and transforaminal) for advanced symptoms
  • surgical decompression laminectomy and/or fusion when neural compression and poor quality of life
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11
Q

What is a vertebral compression fracture?

A
  • most common in the elderly (>60) with osteoporosis
  • thoracic spine: wedge compression fracture
  • lumbar: compression or burst fracture
  • axial pain localized to fractured level
  • Dowager hump: loss of height, patient’s “back becomes rounded”
  • no neurologic dysfunction and no radiation of pain
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12
Q

What is the dx of vertebral compression fractures?

A

x-ray, CT scan, DEXA (dual-energy X-ray absorptiometry)

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13
Q

What is the tx of vertebral compression fractures?

A
  • prevention of osteoporosis
  • HRT if there no history of breast cancer, VTE, or endometrial disease
  • calcitonin therapy if HRT contraindicated
  • bisphosphonates (alendronate) prevent osteoclastic resorption of bone
  • surgery (anterior decompression and fusion) for neurologic deficits or significant compression
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14
Q

What is spondylosis?

A
  • spondylosis is degenerative osteoarthritis of the joints between the center of the spinal vertebrae or neural foramina
  • if severe, it may cause pressure on nerve roots with subsequent sensory or motor disturbances, such as pain, paresthesia, and muscle weakness in the limbs
  • pain is worse with extension, twisting, and improved with flexion
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15
Q

How is spondylosis dx?

A

X-ray: formation of osteocytes and disc narrowing = facet joints, MRI

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16
Q

What is the tx of spondylosis?

A

NSAIDs, PT, lumbar epidural injections, facet injections (selective nerve blocks), ACDF in advanced disease

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17
Q

What is bursitis?

A

inflammation of the bursa (thin-walled sac lined with synovial tissue); caused by trauma/overuse
-pain, swelling, tenderness - may persist weeks

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18
Q

What is the tx of bursitis?

A

prevention of precipitating factors, rest, brace/support, NSAIDs, steroid injection

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19
Q

What is prepatellar bursitis (housemaid’s knee)?

A
  • pain with direct pressure on the knee (kneeling)
  • swelling over the patella
  • common in wrestlers: concern for septic bursitis in wrestlers - aspiration with gram stain and culture
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20
Q

What is the tx of prepatellar bursitis?

A

-compressive wrap, NSAIDs, +/- aspiration and immobilization

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21
Q

What is subacrominal bursitis?

A
  • a condition caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon from the overlying coracoacromial ligament, acromion, and coracoid (the acromial arch) and from the deep surface of the deltoid muscle
  • pain often not associated with trauma
  • pain on motion and at rest can cause fluid to accumulate
  • the presentation is very similar to what you would see with subacromial impingement
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22
Q

What is the tx of a subacromial bursitis?

A
  • aspirate if fever, diabetic or immunocompromised
  • prevention of precipitating factors, rest, and NSAIDs
  • cortisone injections can be helpful
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23
Q

What is tendonitis?

A
  • inflammation of the tendon commonly due to overuse injuries and systemic disease (arthritis)
  • features: pain with movement, swelling, impaired function; resolves over several weeks but recurrence common
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24
Q

What is the tx for tendonitis?

A

ice, rest, stretching for inflammation

  • NSAIDs help but don’t penetrate tendon circulation; steroid injection + anesthesia may be beneficial
  • surgery for excision of scar tissue/necrotic debris if conservative measures fail
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25
Q

What is patellar tendinitis?

A
  • activity-related anterior knee pain associated with focal patellar tendon tenderness
  • also known as “jumper’s knee” (up to 20% of jumping athletes)
  • may present with swelling over tendon and tenderness at the inferior border of the patella
  • Basset’s sign: tenderness to palpation at the distal pole of patella in full extension and no tenderness to palpation at the distal pole of the patella in full flexion
  • radiographs - AP, lateral, skyline views of the knee - usually normal - may show inferior traction spur (enthesophyte) in chronic cases
  • ultrasound - thickening of the tendon and hypo echoic areas
  • MRI in chronic cases - demonstrates tendon thickening
  • ice, rest, activity modification, followed by physical therapy, surgical excision and suture repair as needed
  • cortisone injections are contraindicated due to the risk of patellar tendon rupture
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26
Q

What is biceps tendonitis?

A
  • patient will present with = pain at the biceps groove
  • anterior shoulder pain - may have pain radiating down the region of the biceps, symptoms may be similar in nature and location to the rotator cuff or subacromial impingement pain
  • pain with resisted supination of the elbow
  • X-ray to r/o fracture, ultrasound: can show thickened tendon within the bicipital groove
  • MRI: can show thickening and tenosynovitis of proximal biceps tendon - increased T2 signal around the biceps tendon
  • “Popeye” deformity - indicates a rupture
  • treat with NSAIDs, PT strengthening, and steroid injections
  • surgical release reserved for refractory cases for bicep pathology seen during arthroscopy
  • speed test: pain elicited in the bicipital groove when the patient attempts to forward elevate shoulder against examiner resistance while the elbow extended and forearm supinated, positive if the pain is reproduced, may also be positive in patients with SLAP lesions
  • Yergason’s test: elbow flexed 90 degrees, wrist supination against resistance, positive if the pain is reproduced
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27
Q

What is Costochondritis?

A

inflammation of the cartilage that connects a rib to the breastbone

  • costochondritis causes pain and tenderness on the breatbone, pain in more than one rib, or pain that gets worse with deep breaths and coughing
  • risk factors: age >40, high-impact spots, manual labor, allergies, rheumatoid arthritis, ankylosing spondylitis, reactive arthritis
  • pain is reproduced with palpation
28
Q

How is Costochondritis dx?

A

x-ray, bone scan, vitamin D level, biopsy, ECG (rule out other things)

29
Q

What is the tx of Costochondritis?

A

analgesics (NSAIDs), physical therapy, local steroid injections

30
Q

What is fibromyalgia?

A

a common condition characterized by widespread pain in joints, muscles, tendons, and other soft tissue

  • the cause of the disorder is unknown, physical or emotional trauma may play a role
  • three months of widespread pain at 11 of 18 tender sites
  • DX is clinical
31
Q

What is the tx of fibromyalgia?

A

with tricyclics (TCAs) - cmyblata, SSRIs, Neurontin, and exercise, prcegablin (Lyrica) is the only drug FDA approved to treat fibromyalgia

32
Q

What is the American College of Rheumatology criteria for classification of fibromyalgia?

A
  • widespread pain for at least 3 months, defined as the presence of all of the following:
  • pain on the right and left sides of the body
  • pain above and below the waist (including shoulder and buttock pain)
  • pain in the axial skeleton (cervical, thoracic, or lumbar spine; anterior chest)
  • pain on palpation with a 4-kg force in 11 of the following 18 sites (9 bilateral sites, for a total of 18 sites)
  • occiput: at the insertions of one or more of the following muscles; trapezius, sternocleidomastoids, selenium wapitis, semispinalis chapati s
  • low cervical: at the anterior aspect of the interspaces between the transverse processes of C5 to C7
  • Trapezius: at the midpoint of the upper border
  • Supraspinatus: above the scapular spine near the medial border
  • second rib: just lateral to the second costochondral junctions
  • lateral epicondyle: 2 cm distal to the lateral epicondyle
  • gluteal: at the upper outer quadrant of the buttocks at the anterior edge of the gluteus Maximus muscle
  • greater trochanter: posterior to the greater trochanteric prominence
  • Knee: at the medial fat pad proximal to the joint line
33
Q

What is a ganglion?

A

noncancerous mucin-filled synovial cyst caused either by trauma, mucoid degeneration or synovial herniation

  • usually on the hands, especially on the dorsal aspect of the wrists
  • median or ulnar nerve compression and hand ischemia due to vascular occlusion may be caused by solar ganglion
  • firm and well-circumscribed often fixed to deep tissue but no the the overlying skin, transilluminates
  • allen’s test to ensure radial and ulnar artery flow
34
Q

What is the tx of a ganglion?

A

usually, observation, aspiration second line, and excision

35
Q

What is gout?

A

involves the accumulation of uric acid in the soft tissue of joints and bone

  • altered purine metabolism and sodium urate crystal precipitation into the synovial fluid, M>W (9:1) until menopause (1:1)
  • usually young, > 30 yo, asymmetric; great toe; tophy
36
Q

What are the MC signs and symptoms of gout?

A

podagra (attack of MTP of the great toe) (70% of cases); pain swelling, redness, exquisite tenderness, in chronic gout = tophi

37
Q

How is gout dx?

A

by arthrocentesis - rod-shaped negatively birefringent, serum uric acid level > 8 (not diagnostic)
-imaging: small, punched out lesions on XR = high likelihood diagnosis

38
Q

What is the tx of gout?

A

lifestyle: elevation, rest, decreases purines (meats, beer, seafood, alcohol), weight loss, increase protein, limit alcohol
- pharm: NSAIDs = drug of choice (indomethacin tid); colchicine = effective but bad GI s/e; steroid injections for those who can’t take NSAIDSs, oral pred if other meds not tolerated
- thiazide diuretics and aspirin should be avoided
- the management between acute attacks: colchicine, allopurinol
- don’t start someone on allopurinol in an acute attack

39
Q

What is pseudo gout?

A

usually > 60 yo, large joints, lower extremity, no top

-similar gout sympomts

40
Q

How is pseudo gout dx?

A

rhomboid-shaped calcium pyrophosphate crystals - positively birefringent
-XR shows fine, linear calcifications in cartilage

41
Q

What is the tx of pseudo gout?

A

NSAIDs, colchicine, intra-articular steroid injections

-colchicine = prophylaxis, NSAIDs = acute attacks

42
Q

What is osteoarthritis?

A

defined by morning stiffness lasting < 30 minutes, evening joint stiffness worsens with use and improves with rest

  • worsened by use and relieve by rest
  • crepitus or grating sensations may develop
  • commonly involves the hands, hips, and knees
  • Heberden nodes: swelling of the distal interphalangeal joints
  • Bouchard nodes: swelling of the proximal interphalangeal joints
  • DOES NOT affect MCP joints
43
Q

What are the x-ray findings of osteoarthritis?

A
  • osteophyes: bony projections that form along joints
  • narrowed joint spaces
  • joint sclerosis: area just below the cartilage layer fills with collagen and becomes denser than healthy bones
44
Q

What is the tx of osteoarthritis?

A

with stretching, acetaminophen, NSAIDs (oral and topical), joint replacement surgery

45
Q

What is osteoporosis?

A
  • typically, DEXA is done in all women > 65 year
  • women between menopause and 65 who have risk factors, including a family history of osteoporosis, a low body mass index (eg, previously defined as body weight < 127 lb), and use of tobacco and/or drugs with a high risk of bone loss (eg, glucocorticoids)
  • DEXA is also recommended for both men and women of any age who have had fragility fractures, older adults with unexplained sudden onset of back pain, patients with decreased bone density or asymptomatic vertebral compression fractures incidentally noted on imaging studies and patients at risk of secondary osteoporosis
46
Q

What are the guidelines for pharmacologic intervention in postmenopausal women and men >50 years of age?

A
  • history of a hip or vertebral fracture
  • T-score <2.5 (DXA) at the femoral neck or spine, after appropriate evaluation to exclude secondary causes
  • T-score between -1 and -2.5 at the femoral neck or spine, and a 10-year probability of hip fracture >3 percent or a 10-year probability of any major osteoporosis-related fracture >20 percent based upon the United States-adapted WHO algorithm
47
Q

What is the follow up DEXA based on T score?

A

the current recommendations for frequency of DEXA scars for postmenopausal women based on their T scores are

  • T score of -1.0 to -1.5 every 5 years
  • T score of -1.5 to -2.0 every 3-5 years
  • T score of greater than -2.0 every 1 to 2 years
48
Q

What is the tx for osteoporosis?

A
  • calcium: an intake of 1200 to 1500 mg/day (including dietary consumption)
  • vitamin D supplementation is recommended with 800 to 1000 IU/day
  • bisphosphnates are first-line drug therapy, by inhibiting bone resorption, bisphosphonates preserve bone mass and can decrease vertebral and hip fractures by 50%, they can be given orally or IV
  • oral bisphosphonates (aldendronate, risedronate) are preferred in most patients
  • osteonecrosis of the jaw has been associated with use of bisphosphnates; however, this condition is rare and patients taking oral bisphosphonates
  • risk factors include invasive dental procedures, IV bisphosponate use, and cancer
  • stay upright for at least 30-60 minutes after ingesting
  • if patient cannot tolerate oral bisphosphonates, IV bisphosphonates (IV zoledronic acid)
49
Q

What is overuse syndrome?

A

the results of repetitive stresses and micro trauma outpacing the body’s ability to heal

  • also called repetitive strain injury
  • there types of injuries can be caused by improper technique or overuse
  • the elderly are most commonly affected
  • symptoms include tenderness, stiffness, or tingling in the affected area
50
Q

What is the tx of overuse syndrome?

A

may include anti-inflammatory drugs, physical therapy, ergonomic evaluation, and rarely surgery

51
Q

What is plantar fasciitis?

A
  • pain on the plantar surface, usually at the calcanea insertion of plantar fascia upon weight bearing, especially in the morning or on the initiation of walking after prolonged rest
  • dancers, runners, court sport athletes
52
Q

What is the tx of plantar fasciitis?

A

stretching, ice, calf strengthening, shoe inserts, and NSAIDs, rarely surgery

53
Q

What is reactive arthritis (Reiter syndrome)?

A

autoimmune response to infection in another part of the body (Chlamydia +/- gonorrhea MC)

  • asymmetric inflammatory arthritis
  • conjunctivitis, uveitis, urethritis, and arthritis (can’t see, can’t pee, can’t climb a tree)
  • most commonly seen in Chlamydia (+/- gonhorrhea and GI infections such as salmonella, shigella, campylobacter, yersinia)
54
Q

How is reactive arthritis dx?

A

a history of infection, clinical exam, positive HLA-B27 (80%)

55
Q

What is the tx of reactive arthritis?

A

NSAIDs are the mainstay of therapy, antibiotics to treat the infection that triggered the disease (Chlamydia)

56
Q

What is rheumatoid arthritis?

A

morning joint stiffness > 30 minutes after initiating movement and improves later in the day (vs OA which gets worse throughout the day and if morning stiffness is present will be < 30 minutes)

  • prodrome of constitutional symptoms including fevers, fatigue, weight loss, and anorexia
  • small joint stiffness (MCP, wrist, PIP, knee, MTP, shoulder ankle) worse with rest
  • symmetric arthritis: swollen, tender, and boggy joints
  • Boutonneire deformity: flexion at PIP, hyperextension of DIP
  • swan neck deformity: flexion at DIP with joint hyperextension at PIP
  • ulnar derivation at MCP joint
  • rheumatoid nodules
57
Q

What are the diagnostic studies for rheumatoid arthritis?

A
  • (+) rheumatoid factor (sensitive but not specific); increase CRP and ESR
  • (+) anti-citrullinated peptide antibodies (most specific for RA)
58
Q

What is the tx of rheumatoid arthritis?

A

prompt initiation of DMARDs

  • methotrexate - methotrexate (MTX) is the cornerstone of therapy for RA and is effective as mono therapy for many patients
  • hydroxychloroquine (Plaquenil) - hydroxychloroquine (HCQ) may be added to a number of traditional DMARDs, including MTX, to improve response, HCQ is less effective as mono therapy
  • Sulfasalazine - sulfasalazine (SSZ) is often used in combination with HCQ and MTX as part of the so-called “triple therapy” regimen, when used in this combination, response rates may rival those seen with biologic DMARDs
  • Leflunomide - LEF is effective as mono therapy for both RA and spondyloarthritis, and therefore may be a good choice when the clinical diagnosis is less clear, diarrhea is a common side effect, however, and may limit its use
  • other - other drugs with a much more limited role, due to the more effective and/or safer agents that are available, including azathioprine, gold, and cyclosporine
  • NSAIDs for pain control and low dose corticosteroids
  • Biologic agents - the development of biologic agents represented an advance in the treatment of RA comparable to the introduction of glucocorticoids
  • the cytokines interleukin (IL)-1 and tumor necrosis factor (TNF)- alpha both mediate inflammation and bone resorption in RA, agents that inhibits B-cell function, T-cell function, and the actions of pro inflammatory cytokines (eg, the human recombinant IL-1 receptor antagonist, anakinra, and anti-TNF-alpha agents including entanjrcept, infliximab, and adalimumab) are all used for the treatment of RA
59
Q

What is a sprain?

A

a sprain involves ligaments and a strain involves muscles and tendons
-the symptoms of a sprain and a strain are very similar, that’s because the injuries themselves are very similar

60
Q

What is a joint sprain?

A

a joint sprain is the overstitching or tearing of ligaments

  • ligaments connect two bones together
  • the most common location for a sprain is the ankle joint
  • symptoms include pain, bruising, swelling, limited flexibility, decrease ROM
61
Q

What is a joint strain?

A

a joint strain is the overstitching or tearing of muscles or tendons

  • tendons connect bones to muscles
  • the most common locations for a muscle strain are the hamstring muscle and the lower back
  • symptoms include pain, muscle spasms, swelling, limited flexibility, decrease ROM
62
Q

How are strain/sprains dx?

A

diagnosis is often clinical = x-ray or MRI

63
Q

How are strain/sprains treatment?

A

RICE, NSAIDs

-more severe strains and sprains may require surgery to repair damaged or torn ligaments, tendons, or muscles

64
Q

What is systemic lupus erythematsous?

A

triad of joint pain + fever + Malar (butterfly rash) - fixed erythematous rash on cheeks and bridge of nose sparing nasolabial folds

  • (+) anti-nuclear Ab (ANA): ANA best initial test (not specific)
  • (+) anti-double-stranded DNA and anti-smith Ab: 100% specific for SLE (not sensitive)
65
Q

How is the dx of systemic lupus erythematous made?

A

4 or more of the following 11 criteria met

  • malar rash (butterfly rash)
  • discoid rash (chronic, can scar)
  • photosensitivity (other rashes from sun exposure)
  • mucosal involvement (ulcers, mouth, and nose)
  • serositis (pleurites, pericarditis)
  • joint arthritis (2 or more)
  • renal disorders (abnormal urine protein, diffuse glomerulnoephritits)
  • neurologic disorders (seizures, psychosis)
  • hematologic disorders (anemia, thrombocytopenia, leukopenia
  • ANA
  • other antibodies: Anti smith, anti-dsDNA, Anti-phospholipid, (Anticardiolipin, lupus anticoagulant, anti-B2 glycoprotein)
66
Q

What is the tx of systemic lupus erythematous?

A

manage with sun protection, hydroxychlorquine (for skin lesions), NSAIDs or acetaminophen for arthritis
-pulse dose steroids; cytotoxic drugs (methotrexate, cyclophosphamide)

Family Medicine EOR (14 decks)

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