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Flashcards in Week 4 Deck (44):
1

Development dysplasia of the hip
-description
-dx
-tx

1. Femoral head doesn't sit completely inside acetabulum
-2ndary to capsular laxity and mechanical factors

2a) Ortolani's test
-elevate hip and abduct of femur
-hip is reducible

b) Barlow's test
-adduct and depress femur
-hip is dislocatable out the back

c) Ultrasound

3. Achieve and maintain early, concentric reduction
-pavlik harness
-closed and open reduction
-osteotomies

2

Slipped capital femoral fracture
-description
-epidemiology
-clinical presentation
-tx

1. Slip through the growth plate
-The femoral head remains in the acetabulum, the neck is displaced anteriorly and externally rotates

2. Seen most commonly in
-Adolescent, obese, African American boys

3. Presentation
• Limp
• Externally rotated gait
• Obligatory external rotation with hip flexion • Decreased hip internal rotation
• Hip, thigh
• Knee pain - referred from obturator nerve

4. Stick a pin going through head and neck until growth plate heals and solidifies

3

Femoral shaft fracture tx

• Restore limb length
• Restore alignment
• Restore rotation

-use intramedullary nail
-early stabilization important to reduce blood loss and fat emboli

4

Which vessels provide blood to head of femur

Circumflex femoral vessels and obturator artery

5

AVN
-what happens
-most common non-traumatic causes
-imaging
-tx

-occlusion of vessels leading to bone necrosis and cartilage collapse

-alcoholism and steroid use

-X-ray + MRI (for earlier stages)

TREATMENT
i. Early stages
1. Bisphosphonates
2. Anticoagulants
ii. Core decompression
1. Unpredictable outcome
iii. Rotational osteotomy
1. Cut and rotate proximal femur towards a better weight bearing area of bone
iv. Vascularized fibular strut grafting
v. Hip arthroplasty
1. Do this if there is an area of collapse

6

Greater trochanteric bursitis
-presentation
-tx

-pain right over the greater trochanter
-bursitis b/w greater trochanter and IT band

TX
-activity mods
-anti-inflammatories
-physical tx -> stretches to give bursa more room
-cortisone injection -> to help w/ PT

7

Wear and tear arthritis =
-what increases risk
-presentation in the hip
-physical exam
-imaging
-tx

osteoarthritis

-obesity, age, FH

• Stiffness in the hip
• Pain “flares”
• Groin pain - always check hip w/ groin pain
• Limp

PHYSICAL EXAM
• Decreased range of motion
• Internal rotation most often restricted
• Obligatory external rotation of the hip when flexed
• Limp
• Reproducible groin pain

XRAYS
• Joint height narrowing
• Sclerosis
• Cystic formation
• Osteophytes

Tx
1. Start w/ activity mods and ice
2. Anti-inflammatory
3. Cortisone injection
4. Only “cure” is total hip replacements

8

Hip fracture
-younger vs older patients

i. In younger patients -> preserve bone and cartilage as much as possible

ii. Older -> harder to heal so reduction and fixation on some and total hip replacements on others
iii. In older individuals -> very high (30-50%) 3 month mortality rate

9

Unique aspect of seronegative spondyloarthropathies

Enthesitis -> inflammation of insertion of ligament or tendon into the bone

10

Key feature to separate mechanic back pain from inflammatory

inflammatory gets better w/ exercise

11

Progression of anklylosing spondylitis

Bilat SI inflammation w/ pain in gluteal area -> ossification of spinal ligaments (bamboo spine)

12

Reactive arthritis presentation

asymmetric inflammatory oligoarthritis that develops 1-4 weeks after a nongonococcal urethritis or an infectious diarrhea; usually involves joints in the lower extremities

13

Triad for Reiter's syndrome

1. Nongonococcal urethritis
2. Uveitis/Conjunctivitis
3. Arthritis of large joints (inflammatory)

14

Organisms associated with Reactive arthritis

U CCSSY

Ureaplasma

Campylobacter
Chlamydia
Salmonella
Shigella
Yersinia

15

Other key manifestation unique to reactive arthritis

1. Oral ulcers

2. Keratoderma blenorrhagica—erythematous scaly hyperkeratotic skin lesions on palms and soles

3. Circinate balanitis—red scaly area on the glans penis with a gray, serpiginous annular edge that spreads outwards in phases

IMAGING
-asymmetric non-marginal jug handle syndesmophytes

16

Unlike in RA, which phalangeal joints can be involved with psoriatic arthritis?

DIP
dactylitis w/ pitting for finger nails

17

Which type of arthritis with PA?

-most commonly asymmetric oligoarthritis
-can also be poly like RA

18

Arthritis mutilans

-associated with PA or poorly managed RA
-complete joint erosion

19

Imaging finding with PA

Pencil in a cup sign -> central erosion

Followed by ankylosis

Spondyloarthropathy -> comma shaped

20

Key points about paget's disease
-most common location
-number of bones involved
-uni or bi lateral

-pelvis
-polyostotic
-unilateral

21

T1 vs T2 MR imaging

T1 -> bone, vessels, nerve (any soft tissue)

T2 -> fat suppression (appears dark)
-so fluid can show up bright
-good for looking at edema

22

3 general fractures

1. Traumatic

2. Stress
A) Fatigue - abnormal stress across normal bone
B) Insufficiency - normal stress across abnormal bone

23

#1 cause of AVN

-trauma

-most occur at head of femur

24

Radiology signs of quadriceps tendon rupture

fat pad displaced anteriorly
->edema in suprapatellar bursa

25

Key radiology signs of ACL tear

Acute injury with joint effusion on X-ray
-fat pad displaced anteriorly

26

Anakinra
-generic
-MoA
-side effects

o IL-1Ra
o Endogenous antagonist of IL-1
o Binds to receptor but no signaling ensures
o IL-1 is produced by RA synovium
o Drug didn’t work too well
o Receptor antagonist was only occupying receptor for a brief period of time
o Also increased incidence of bacterial infections
o Additional IL-1 antagonists are being studies
• Canakinumab and rilonacept

27

TNF inhibitors
-categories + drugs
-side effects
-contraindications

1. Soluble TNF receptor
-Etancercept

2. mAb
-Adalimumab - fully humanized -> high affinity
-infliximab - chimeric

SIDE EFFECTS
-increased risk of infection
-reactivation of TB

CONTRAINDICATIONS
-pregnant/nursing women
-recent live virus vaccine (e.g. HSV for shingles)
-allergy to mouse/hamster proteins

28

Abatecept (Orencia)

-CTLA4 w/ IgG1
-blocks activation of T-cell

29

Tocilizumab (Actemra)

IL-6 inhibitor
• Blocking this will push naïve T-cell towards the T-reg pathway which tones down the immune response

ADVERSE EFFECTS
• Serious infectious adverse events are a concern
o Risk increases w/ time
• Cause neutropenia as well but not progressive but improves over time
• Elevates LFT but not a major issue
• Can raise LDL
• Diverticuli
• Can increase metabolism of some drugs by enhancing CYP450

30

Rituximab (Rituxan)

• Targeting B-cells
• Anti-CD20
o Not present on the progenitor cells
• Rituximab targets this marker
o Induces apoptosis of B-cells

Adverse effects
• Inc risk for infections
• Allergic rxns

31

BAFF (BLys)

• Target B-lymphocyte stimulating hormones
• BAFF promotes B cell maturation and survival
• BAFF also synergizes w/ IL-6 in TH17 creation
• Anti-BAFF agents are in trial – Benlysta
-Human mAb
-Tested in lupus patients
-Significant improvement over conventional tx

32

Classify the primary lesions

1. Flat
-macule/patch

2. Raised
-papule/plaque
-nodule
-tumor

3. fluid filled
-vesicles/bulla
-pustules -> fulled w/ neutrophils/eosinophils

33

Translucent lesions on skin - think?

-BCC
-eccrine neoplasms -> very translucent

34

Distribution of Herpes Zoster lesion

Dermatomal

35

Arrangement/pattern of HSV

grouped vesicles on an erythematous base

36

linear pattern of lesion due to?

external sources such as poison ivy

37

Annular morphology
-def
-example

-ring with central clearing

Tinea corporis (ringworm)

38

Pityriasis rosea presents with what type of lesion?

Oval

39

Round or nummular lesions
-description
-cause

-coin shaped lesions

-discoid lupus or nummular dermatitis

40

Hemorrhagic crust
-which layer of skin
-risk for

-past the epidermis
-risk for scarring

41

Lab to look at scabies

Mineral oil prep of scraping

42

Lab to look at fungal infection

KOH prep - margin scaling of lesion

43

Fissure on the lower leg think

Eczema craquele

44

Umbilicated lesion
-description
-example

-central depression or dell
-Molluscum