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monoarticular joint patterns

gout, septic arthritis, Lyme

CCP is 96% sensitive for

rheumatoid arthritis

nonspecific marker of inflammation

ESR

if ANA is negative, assume

pt does not have SLE

<25% PMNs typically is

non-inflammatory

the initial joint manifestation involved in ~50% of gout

podagra (1st Meta-Tarso-Phalangeal joint)

collections of uric acid crystals in the soft tissues, frequently occurs after 10 yrs of untreated gout

tophi

calcium pyrophosphate, prism-shaped crystals, positive birefringence in synovial fluid indicates

pseudogout

needle shaped crystals, negative birefringence, uric acid crystals

gout

mainstay (tx of choice) for acute gouty attacks

NSAIDs (indomethacin)

tx for pt who cannot take NSAIDs for gout

corticosteroids

tx for pt who cannot take NSAIDs or corticosteroids for gout

colchicine

side effects of colcichine

cramping, nausea, vomiting, diarrhea

gout pts should

- avoid high urine foods (red meats, alcohol, yeasts, beans, lentils)
- manage obesity
- decrease ETOH (cruise)
- stop offending meds

drugs that exacerbate gout are

- thiazide, loop diuretics
- aspirin (may give low dose)
- niacin (use fish oil instead)

tx for chronic gout or recurrent attacks

uricosuric drugs (probenecid or allopurinol)

mechanism of allopurinol

blocks xanthine oxidase and thus decreases uric acid production. Thus, it should be used in overproducers

epidemiology of rheumatoid arthritis

female, 20 - 40 yo

30yo female with insidious symmetric swelling with redness, warmth, tenderness and pain with movement. morning stiffness >30 mins.

rheumatoid arthritis

flexion of the PIP joint and extension of the DIP joint of the affected finger

boutonniere deformity

extension of the PIP joint and flexion of the distal interphalangeal (DIP) joint

swan neck deformity

xray findings of rheumatoid arthritis

- juxta-articular demineralization/osteoporosis
- erosions of joint
- space narrowing

rheumatoid arthritis may be associated with

Sjogren's syndrome

tx of rheumatoid arthritis

- pt education, PT/OT, exercise to preserve joint motion (swimming), assistive devices

- NSAIDS

- DMARDs (disease modifying antirheumatic)

name some DMARDs (disease modifying antirheumatic)

- methotrexate (anti-folate)
- tumor necrosis factor inhibitors
- corticosteroids (do not help in suppression of dz)
- azthioprine (Imuran)

1st line med in rheumatoid arthritis

NSAIDs

2nd line med in rheumatoid arthritis

methotrexate (tx of choice after NSAIDs)
- it is the initial tx of choice for suppressing the progress of RA

side effects of methotrexate

- gastritis/stomatitis
- it is an anti-folate drug

- rare but severe life-threatening interstitial pneumonitis (tx by discontinuing drug)

3rd line med in rheumatoid arthritis
- examples
- side effects

tumor necrosis factor inhibitors (after fail methotrexate)

- etanercept, infliximab

- side effecs: leukopenia (rare), reactivation of latent TB

side effects of corticosteroids

- avascular necrosis
- gastritis/ulcers
- cataracts
- immunosuppression
- cushing syndrome
- osteoporosis

features of SLE

1. joint pain & swelling (95%)
2. renal disease
3. malar rash/photosensitivity
4. pleuritis
5. pericarditis
6. neurologic disease
7. spontaneous abortions
8. oral ulcers
9. seroritis
10. anemia of chronic dz (~100%)/thrombocytopenia

most helpful screening tool for SLE. very sensitive but not specific

ANA

the antibodies in SLE causes difficulty to maintain pregnancy

antiphospholipid antibodies

Tx of SLE

- antimalarials (hydroxychloroquine)
- prednisone (mainstay of therapy)
- if proteinuria for biopsy, refer to nephro

side effect of hydroxychloroquine

- pigmentary retinitis (opth exam q 6 - 12 months); it is rare

20% of SLE pts have false positive

VDRL

drugs that induce ANA

- procainamide (mc)
- hydralazine
- isoniazid

50yo female c/o dry eyes, burning & dry mouth. she has RA or SLE

Sjogren's syndrome

Sjogren's syndrome is usually associated with

rheumatoid arthritis, SLE, or other connective tissue disease (+RF)

condition characterizes as lymphocytic invasion of lacrimal and salivary glands. it increases incidence of lymphoma

Sjogren's syndrome

most common type of scleroderma

CREST (limited)

CREST syndrome stands for

- C alcinosis
- R aynaud phenomenon
- E sophageal
- S clerydactyly (skin thickening limited to face & hands)
- Telangiectasias

if ANA and RF are both negative, next step is to get

HLA-B27 (seronegative sphondyloarthropathies)

4 seronegative sphondyloarthropathies (- ANA & RF, but +HLAB27)

- ankylosing spondylitis
- reiter's syndrome
- psoriatic arthritis
- colitis arthritis

Tx of seronegative sphondyloarthropathies

tumor necrosis factors (TNF)

<40 man, stiff painful back, fusion of spine.
ESR is elevated.
ANA & RF are negative.
HLA-B27 is specific.
Xray shows bamboo spine.

ankylosing spondylitis

young man with urethritis + conjunctivitis/uveitis + asymmetric arthritis of knee or ankle + then GI infection or Chlamydia

Reiter's (Reactive) arthritis

can't pee, can't see, can't climb tree, can't sleep with me

Reiter's (Reactive) arthritis

psoriasis precedes arthritis. asymmetric sausage fingers and toes. sacroilitis (sarcoiliac joint disease) is common.

psoriatic arthritis

Tx of psoriatic arthritis

- short-term: aspirin or NSAIDs
- severe or chronic dz: DMARDS (ex: sulfasalazine)

nondeforming arthritis, IBD (20% of pts), anemia

colitic arthritis

Tx of colitic arthritis

tx intestinal inflammation

temporal arteritis (giant cell) is concurrent with _________ in 50% of pts

polymyalgia rheumatica

>50yo female with fever, malaise, anorexia, headache, jaw claudication, scalp tender. sudden monocular blindness (optic neuropathy). think

temporal arteritis

palpable tender inflamed cord in temporal region + headache in >50yo. think

temporal arteritis

most helpful initial test to order for temporal arteritis

ESR (always >70)

labs for temporal arteritis

- ESR elevated >70
- normal WBC (despite fever)
- biopsy

diagnostic test for temporal arteritis

temporal artery biopsy

*do not delay giving prednisone pending biopsy

tx of temporal arteritis

- prednisone 60 - 120 mgm PO QD immediately
then perform biopsy

complications of temporal arteritis

- can cause irreversible blindness without appropriate therapy
- thoracic aneurysm is 17x more common in pts with hx of TA

young 30yo Asian woman with fever, malaise, weight loss, arthralgias, erythema multiforme, pulseless disease, and involvement of aortic arch and abdominal aorta (including renal arteries)

takyasu's arteritis

polyarteritis nodosa is associated with ______

Hep B

meds that can cause polyarteritis nodosa are

sufa, gold, (penicillamine used for Wilson's dz)

middle-aged man with disease involving all organ systems but lungs. fever, malaise, weight loss, arthralgias, myalgias, coronary, mesenteric, acute MI, HTN, abdominal pain, GI hemorrhage/infarct. elevated ESR. normochromic normocytic anemia.

polyarteritis nodosa

Diagnostic for polyarteritis nodosa

biopsy

small vessel, necrotizing, granulomatous arteritis with c-ANCA positive. think

wegener's granulomatosis

triad
- upper respiratory symptoms
- lower respiratory symptoms
- focal segmental glomerulonephritis

wegener's granulomatosis

40yo caucasian with epistaxis, recurrent sinusitis, rhinorrhea (despite tx), crusting ulcers or nasal mucosa.
CXR shows granuloma
Think

wegener's granulomatosis

saddle nose deformity

wegener's granulomatosis

male with oral and genital uclers. iritis. polyarthralgias. dementia. parkinsonism. erythema nodosum. associate with HLA

Behcet disease

>50yo with pain and stiffness of shoulder, pelvic girdle, & neck that is worse with rest and better with activity. NO WEAKNESS. +fever (of unknown origin), malaise, weight loss, muscle pain & tender points, limited ROM. High ESR. think

polymyalgia rheumatica

50% polymyalgia rheumatica is associated with

temporal arteritis (tx with high dose steroids)

proximal muscle WEAKNESS + heliotrope rash. elevated CK

polymyositis/dermatomyositis

polymyositis/dermatomyositis has increased risk of

malignancy

Tx of polymyositis/dermatomyositis

steroids

30yo with widespread muscular pain (upper and lower extremities). multiple tender points (pinpoints; 11 of 18).
No signs of inflammation (nl ESR/labs).

fibromyalgia

tx of fibromyalgia

- exercise
- amitriptyline (elavil) is tx of choice/most appropriate med
- pregabalin (lyrica)
- duloxetine hcl (cymbalta)

bone to bone is

ligament

muscle to bone is

tendon

sTrain is _______; sPrain is ______

TR = muscle
PR = tendon

unilateral contraction of sternocleidomastoid muscle

torticollis (wry neck) = twisted neck

infant or child prefers to holdhead toward the shortened SCM and chin rotates to opposite side. there is a mass palpable in the inferior 1/3 of affect SCM.

torticollis (wry neck)

tx of torticollis (wry neck)

- usually resolves spontaneously in 2 - 4 weeks
- Xrays to r/o congenital bone abnormalities
- passive stretching
- follow-up in 2 - 4 week intervals
- refer if no improvement in 2 - 3 mths

cervical strain/sprain (whiplash)

...

cervical radiculopathy
C5 is for
C6 is for
C7 is for
C8 is for

C5 (deltoid) - abduction of arm

C6 (biceps) - sensation for thumb & index; elbow/arm flexion, wrist extension; brachioradialis reflex

C7 (triceps) - sensation for middle; elbow/arm extension, wrist flexion; triceps radii

C8 - sensation for 4th & 5th fingers

test specific and sensitive for dx cervical spondylosis or cervical (neck) radiculopathy aka cervical nerve root impingement

** Spurling test

which test?
provider extends the neck, rotating the head, and then applies downward pressure on the head

** spurling test

contraindications of MRI

pacemaker (no MRI)

Tx of cervical radiculopathy

- most pts have spontaneous resolution of all or most symptoms within first 6 - 12 weeks

Jefferson fracture (C1)
- dx
- mechanism

- seen best on odontoid view

- caused by diving accident

avulsion of C6, C7, or T1 is which fracture?

clay shoveler's fracture

bilateral C2 pedicle fracture secondary to hyperextension

Hangman's fracture

compression of brachial plexus, subclavian arteries & veins as they exit the shoulder girdle and the first rib

thoracic outlet syndrome

woman with triad: numbness + weakness + sensation of upper extremity swelling

thoracic outlet syndrome

adson's test

...

roos test

...

tx of thoracic outlet syndrome

- tx with PT and irritant avoidance
- surgical rib resection

woman with LATERAL curvature of the spine

scoliosis

asymmetry, paraspinal humping
- One shoulder higher than another
- Uneven waistline
- One shoulder blade sticking out further than the other one
- Rib hump deformity

scoliosis

- screening for scoliosis with _______

- most accurate using AP & lateral xray of entire spine

- scoliometer

- Cobb angle

scoliosis + pain, need to get

MRI

Tx of scoliosis

- less than 20 degrees: conservative (watch/follow)

- 20 - 40: brace

- 40 degrees or more: surgery

adolescence with increased kyphotic curvature and anterior thoracic spine wedging

scheuermann's disease

shmorl's nodes on xray

scheuermann's disease

Tx of scheuermann's disease

- hyperEXTension exercise
- proper posture
- bracing
- surgery

most common site of compression fractures

T10 - L2

spinal pain upon movement and better with rest

compression fracture

most common cause of compression fractures

osteoporosis

elder with 2 inch height loss,
suspect?
next step?

compression fractures
X-ray PA and lateral and check PA for pedicle widening

Tx of compression fracture

- NSAIDs & analgesia. Brace. Walk.
- work up for osteoporosis
- consider bisphosphonate
- miacalcin for pain
- kyphoplasty/vertebroplasty

low back pain, impairing function for days to weeks, precipitated by repetitive twisting or lifting. difficult standing erect. worse with activity but better with rest

acute low back pain (strain)

Tx of back strain

- rest for 1 - 2 days. ice vs heat. NSAIDs. education. MUST follow-up

spinous stenosis vs herniated disc

spinous stenosis - pain worse with stand & walk; better with sitting

herniated disc - oppposite

Laseque's sign

ankle dorsiflexoin worsens pain from lumbar radiculopathy

straight leg test

lumbar radiculopathy

Lumbar myotomes & deep tendon reflexes

L4
L5
S1

L4 (quadriceps) = knee extension; patellar reflex
L5 (anterior tibialis) = heel walking; extensor hallucis longus strength
S2 (gastrocnemius) = toe walking; achilles reflex

narrowing of the spinal canal

spinal stenosis

anterior slippage of vertebral body on inferior counterpart; degenerative slip.

spondylolisthesis

spondylolisthesis occurs most commonly at

L4/L5 or L5/S1

pars interarticularits defect or stress fracture. usually pt is asymptomatic, except for pain with exertion. Pt is fine when bending over to tie shoes, but hurts when stands back up.

spondylolysis

spondylolysis is common in

* gymnasts & football lineman *

scotty dog on xray

spondylolysis

Xray views for spondylolysis

oblique and lateral

normal xray and pain with extension, consider

consider bone scan
spondylolysis

tx of consider bone scan and spondylolisthesis

- rest, conservative tx with <50%
- PT & bracing

25yo with back pain and progressive stiffness of spine. originates in lumbar/sacral spine and progresses cephalad. uveitis.

ankylosing spondylitis

MOST COMMON EXTRAARTICULAR COMPLICATION OF ANKYLOSING SPONDYLITIS

UVEITIS (know for the board!)

Xray findings in anylosing spondylitis

bamboo spine

failure of posterior vertebral arches to close

spina bifida

pain over acromioclavicular joint resulting fro a fall on lateral (tip of the shoulder). pain is worse with lifting arm, but is not possible.
Dx?
Next step?

acromioclavicular sprain
X-rays

grades of acromioclavicular sprain
1
2
3

1 - strain of AC ligament
2 - tear of AC ligament & sprain of coracoclavicular ligament
3 - tear of both ligaments

Tx of acromioclavicular sprain

- 1st & 2nd grade: immobilize
- 3rd grade: surgery

most common pediatric fracture

clavicle (middle 1/3)

child struck on clavicle and not able to lift arm secondary to pain

clavicle fracture

Tx of clavicle fracture

- figure 8 strap or cradle sling
- surgery is rare & if very severe
- follow up for up to 8 weeks

most humerus fracture are _______ displaced and treated with _____ and _____ movement

minimally
sling
early

elder female with hx of osteoporosis FOOSH. severe pain and ecchymosis following the fall.

humerus fracture

most common joint dislocation

shoulder (anterior)

squared off appearance of shoulder, pt typically hold arm in abduction

...

by holding your arm in abduction (away from your body), you test which muscle

supraspinatus

management of shoulder dislocation

- Xray with Y-view before & after reduction (look for Hill-Sachs deformity)
- immobilize and check axillary nerve
- follow up 2-3 wks and begin PT

squared off humeral head

Hill-Sachs deformity for shoulder dislocation

a compression fracture at the posterolateral head of the humerus due to impingement against anterior rim of glenoid fossa when the humeral head dislocates

Hill-Sachs deformity for shoulder dislocation

fall onto abducted/externally rotated arm

anterior shoulder dislocation

direct blow to anterior shoulder, *seizures*, or electrocution

posterior should dislocation

Rotator cuff is the group of tendons in the shoulder joint.

SITS

- S upraspinatus
- I nfraspinatus
- T eres minor
- S ucscapularis

pt >40yo with recurrent pain for months.
- Pain, weakness, and loss of shoulder motion.
- Pain or ache is felt over the FRONT and OUTER shoulder.
- It is worse leaning on the elbow and pushing upwards on the shoulder (such as leaning on the armrest of a reclining chair), with OVERHEAD activities, when reaching forward (ex: unable to lift a galloon of milk from the refrigerator), and at NIGHT when lying on the affected shoulder.

rotator cuff tear

Abduct the patient's shoulder to 90° and ask the patient to lower the arm slowly to the side in the same arc of movement. Pain or inability to do this is

+drop-arm test indicates rotator cuff tear

The shoulder is forcibly forward flexed and internally rotated, causing the greater tuberosity to jam against the anterior inferior surface of the acromion. Pain is

+Neer impingement test, indicates rotator cuff tear (impingement) and overuse injury to the supraspinatus muscle

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