00 Musculoskeletal Disorders Chp 09. Usmle Step 2 Step Up

Front 1

(H/P) =
Wrist pain that radiates up arm and worsens with hand flexion and grasping, decreased hand strength, numbness in thumb, and in index and middle fingers; decreased palmar two-point discrimination, except on the radial side of the palm
Positive Tinel's sign (i.e., tapping over carpal tunnel elicits wrist tingling and pain) and Phalen's sign (i.e., placing dorsal side of hands together and flexing wrists 90° causes the onset of symptoms within a minute)
Thenar muscle atrophy is seen in long-term cases

Back 1

Carpal tunnel syndrome
Syndrome resulting from median compression at the wrist (see Figure 9-1)
Risk factors =
Pregnancy, rheumatoid arthritis (RA), diabetes mellitus (DM), acromegaly, hypothyroidism, obesity, overuse (activities requiring significant wrist motion, including typing, piano playing, writing, etc.)
Most common in persons 30–55 yr of age; female > male

Hint 1

(EMG) = can be used in addition to nerve conduction studies to evaluate nerve compromise (will show impaired conduction)
Treatment = wrist splints, activity modification, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, surgical release of the transverse carpal ligament

Front 2

Shoulder Dislocations

Back 2

Most commonly anterior (posteriorly directed force on distal humerus or forearm during abduction causes cantilever effect that drives humeral head forward and tears anterior shoulder capsule)
Posterior dislocations most frequently occur following Seizures and Electrical shocK (strong contraction in internally rotated, adducted arm causes humeral head dislocation)
Complications = axillary artery and nerve injury, increased risk of future dislocations

Hint 2

Treatment = urgent closed reduction, sling; chronic dislocations may require surgery to improve joint stability
Suspect axillary nerve injury in cases of deltoid malfunction (inability to extend arm) or shoulder numbness following shoulder dislocation.

Front 3

Hip Dislocations

Back 3

Most commonly posterior via a posteriorly directed force on an internally rotated, flexed, and adducted hip (e.g., dashboard injury)

Hint 3

Treatment = closed reduction, bracing, abduction pillow

Front 4

H/P = pain in involved joint with weight bearing or movement
Most common in the ankle and knee

Back 4

Sprains
Injuries to ligaments and surrounding soft tissues in a joint; structures are partially or completely torn at ligament–bone interface or within ligament substance

Hint 4

Treatment = RICE: Rest, Icing, and Compression of swelling, Elevation of joint; analgesics

Front 5

H/P = pain and swelling that worsens with joint stress, decreased joint range of motion; ligamentous InstabilitY on joint stress testing

Back 5

Ligament tears
Occur from excessive stress across joints

Hint 5

Radiology = magnetic resonance imaging (MRI) may confirm tear
Treatment = initially, as for sprains; may require surgical repair

Front 6

H/P = vague pain inside knee joint, clicking or locking of joint; pain along joint line near tear

Back 6

Meniscus tears (knee)
Result from repetitive microtrauma and degeneration or forceful twisting of a planted knee
Frequently associated with anterior cruciate ligament (ACL) injury (especially from blunt trauma or sports injuries)
Complications = meniscal débridement predisposes knee to developing osteoarthritis at an earlier age

Hint 6

Radiology = MRI may detect tear
Treatment = NSAIDs, physical therapy, arthroscopic repair or débridement

Front 7

medially directed blow to the lateral side of the knee (i.e., a valgus stress)

Back 7

unfortunate triad: medial meniscus tear, medial collateral ligament (MCL) tear, and ACL tear

Front 8

H/P = 6 Ps are signs of progression (Pain, Pallor, Poikilothermia, Pulselessness, Paresthesia, Paralysis); compartment pain with passive stretching is best screening test

Back 8

Compartment syndrome
Trauma (surgical or accidental) in extremities leads to reperfusion injury and swelling of fascial compartments; intracompartmental swelling can cause compression of neurovascular structures leading to ischemia of soft tissues within compartment and distal to site of compression
Most common in lower leg (e.g., tibial fracture) and forearm
Young athletes may get an exertional compartment syndrome during athletic activity with mild elevation of compartment pressures that resolves following activity cessation and carries a minimal risk of significant tissue ischemia.

Hint 8

Labs = elevated compartment pressures (needle inserted into compartment and attached to manometer to determine pressures)
Treatment = emergent fasciotomy for pressures >30 mm Hg or for pressures within 20 mm Hg of diastolic blood pressure

Front 9

H/P=Fall on outstretched hand, forearm dorsally displaced and angulated (forearm profile looks like a dinner fork)

Back 9

Colles Fractures
Distal radius ± distal ulna
Most common wrist fracture; particularly common in osteoporotic bone

Hint 9

Treatment=Closed reduction Long arm cast Possible surgery

Front 10

H/P=“Snuffbox” tenderness, fall on radially deviated outstretched hand

Back 10

Scaphoid Fractures
Increased risk of AVN; not seen on x-ray for 1–2 wk after injury; most common carpal fracture

Hint 10

Treatment=Thumb spica cast Possible surgery

Front 11

H/P=Punching hard object or surface with a strong force applied to fifth metacarpal

Back 11

Boxer's Fractures
Fifth-metacarpal neck
Beware the “fight bite”—open wounds from teeth will need surgical exploration to rule out tendon involvement

Hint 11

Treatment=Closed reduction Ulnar gutter splint Surgical pinning

Front 12

H/P=Trauma (motor vehicle accident, blunt trauma, etc.)
With wrist drop or weakened thumb abduction, think radial nerve injury

Back 12

Humerus Fractures

Hint 12

Treatment=Closed reduction Splint Possible surgery

Front 13

H/P=Defense against blunt trauma (e.g., nightstick injury)
Dislocation of radial head and ulnar diaphyseal fracture

Back 13

Monteggia Fractures

Hint 13

Treatment=Closed reduction of radial head
Surgical repair of ulna

Front 14

H/P=Trauma (direct blow or fall)
DRUJ dislocation and radial diaphyseal fracture

Back 14

Galeazzi Fractures

Hint 14

Treatment=Surgical repair Cast forearm in supination to maintain reduction of DRUJ

Front 15

H/P=Fall, motor vehicle accident, trauma
Injured leg is shortened and externally rotated
Frequently occurs from strong axial force (e.g., fall or knee hitting a car dashboard)

Back 15

Hip Fractures
Femoral head or neck
Increased risk for AVN and DVT (should anticoagulate patient); particularly common in osteoporotic bone

Hint 15

Treatment=Surgical repair
May require joint replacement

Front 16

H/P=Trauma
Increased risk of fat embolization

Back 16

Femur Fractures
Femoral diaphysis

Hint 16

Treatment=Surgical repair

Front 17

H/P= Trauma
+ risk for compartment syndrome

Back 17

Tibial Fractures

Hint 17

Treatment=Cast Surgical repair

Front 18

H/P=Trauma, excessive twist of ankle (most commonly supination and external rotation)

Back 18

Ankle Fractures
Medial, lateral, and/or posterior malleoli

Hint 18

Treatment=Cast
Possible surgical repair

Front 19

H/P=Trauma, pain worse during deep breathing

Back 19

Rib Fracture
Nonfloating ribs

Hint 19

Treatment=Pain control
Possible splinting

Front 20

H/P=Major trauma
High risk of major blood loss

Back 20

Pelvic Fracture

Hint 20

Treatment=Pain control Surgical repair, if in weight-bearing portion

Front 21

Back pain Differential

Back 21

MAD BRACING: Muscular strain, AAA, Degeneration (disc herniation, stenosis), Bone (fracture, scoliosis, spondylolisthesis), Renal stones, Ankylosing spondylitis, Cauda equina, Infection, Neoplasm, Gastrointestinal (GI) (peptic ulcer disease [PUD], pancreatitis).

Hint 21

Treatment = NSAIDs, physical therapy, or rest for muscular injuries
90% of back pain caused by muscular injury resolves within 6 wk, regardless of treatment.

Front 22

Back Pain
Along spine only
Paraspinal pain only

Back 22

Muscular strain

Hint 22

90% of back pain caused by muscular injury resolves within 6 wk, regardless of treatment.

Front 23

Back Pain
Along spine only
Osteoporotic patient

Back 23

Compression fracture

Front 24

Back Pain
Along spine only
Back Asymmetry

Back 24

Scoliosis

Front 25

Back Pain
Along spine only
Abnormal gait

Back 25

Spondylolisthesis

Front 26

Back Pain
Along spine only
Systemic symptoms

Back 26

meningitis, discitis, or osteomyelitis

Front 27

Back Pain
Radiation to epigastrum
related to eating

Back 27

Peptic Ulcer Disease

Front 28

Back Pain
Radiation to epigastrum
High amylase, lipase

Back 28

Pancreatitis

Front 29

Back Pain
Radiation to epigastrum
Pulsative mass

Back 29

Abdominal Aortic Aneurysm

Front 30

Back Pain
Radiation to pelvis
Pain on urination

Back 30

Renal stones

Front 31

Back pain
radiates down legs or new neurological symptoms
worse w/ exertion

Back 31

disc herniation

Front 32

Back pain
radiates down legs or new neurological symptoms
pain w/ walking, standing

Back 32

spinal stenosis

Front 33

Back pain
radiates down legs or new neurological symptoms
pain worse at rest, better w/ activity

Back 33

ankylosing spondylitis
(activity soothing)

Front 34

Back pain
radiates down legs or new neurological symptoms
night pain or rest pain

Back 34

R/O cancer

Front 35

Back pain
radiates down legs or new neurological symptoms
bowel or bladder dysfunctino or saddle area anesthesia

Back 35

suspect cauda equina

Front 36

H/P = pain extending from the nerve root along path of compressed nerve; characteristic sensory and motor deficits, depending on nerve root involved; pain worsens with straight leg raises or Valsalva maneuver (see Table 9-2)

Back 36

Degenerative disc disease
Vertebral disc is composed of a dense annulus fibrosus and a gelatinous nucleus pulposus
Degenerative changes in disc lead to herniation (most frequently, posterior or posterior lateral) of nucleus pulposus and subsequent nerve impingement
Herniation is most common in the lumbosacral region (L4–L5, L5–S1 discs), but can also be cervical (see Figure 9-3)

Hint 36

Radiology = MRI confirms diagnosis; CT is helpful for analysis of bone structure
Treatment = disease may be self-limited; NSAIDs, activity modification, epidural injection of anti-inflammatory agents, or surgical decompression can be used, depending on symptom duration and severity

Front 37

Nerve Roots Compression
Motor Deficit=Deltoid, biceps
Sensory Deficit=Anterior shoulder
Reflex=Biceps

Back 37

Nerve Roots Compression
C5

Front 38

Nerve Roots Compression
Motor Deficit=Biceps, wrist extensors
Sensory Deficit=Lateral forearm
Reflex=Brachioradialis

Back 38

Nerve Roots Compression
C6

Front 39

Nerve Roots Compression
Motor Deficit=Triceps, wrist flexors, finger extensors
Sensory Deficit=Posterior forearm
Reflex=Triceps

Back 39

Nerve Roots Compression
C7

Front 40

Nerve Roots Compression
Motor Deficit=Finger flexors
Sensory Deficit=4th&5th fingers, medial forearm
Reflex=None

Back 40

Nerve Roots Compression
C8

Front 41

Nerve Roots Compression
Motor Deficit=Finger interossei
Sensory Deficit=Axilla
Reflex=None

Back 41

Nerve Roots Compression
T1

Front 42

Nerve Roots Compression
Motor Deficit=Tibialis anterior (foot dorsiflexion)
Sensory Deficit=Medial leg
Reflex=Patellar

Back 42

Nerve Roots Compression
L4

Front 43

Nerve Roots Compression
Motor Deficit=Extensor hallucis longus (first-toe dorsiflexion)
Sensory Deficit=Lateral lower leg, first web space
Reflex=None

Back 43

Nerve Roots Compression
L5

Front 44

Nerve Roots Compression
Motor Deficit=Peroneus longus and brevis (foot eversion), gastrocnemius (foot plantarflexion)
Sensory Deficit=Lateral foot
Reflex=Achilles

Back 44

Nerve Roots Compression
S1

Front 45

H/P = radiating pain that is worse with walking and standing

Back 45

Spinal stenosis
Generalized narrowing of bony spaces in the spine secondary to arthritic changes causing nerve compression
Most common in middle-aged and older adults

Hint 45

Radiology = CT or x-ray confirms diagnosis; MRI may also be helpful to rule out herniation
Treatment = analgesics (e.g., NSAIDs), physical therapy, epidural injections, surgical decompression

Front 46

H/P = urinary retention following trauma, change in bowel habits; anesthesia in perineal region (i.e., saddle anesthesia), - rectal tone or bulbocavernosus reflex

Back 46

Cauda equina syndrome
Cauda equina is the extension of the dural-arachnoid sac beyond the inferior tip of the spinal cord and the complex of terminal nerve roots contained within it
Trauma can damage nerves running in the sac; neoplasms can cause nerve compression

Hint 46

Treatment = emergency surgical decompression of cauda equina; intravenous (IV) corticosteroids commonly given to decrease spinal cord inflammation; radiation used in cases of neoplasm

Front 47

Waiter's tip (arm extended and adducted with pronated forearm)

Back 47

Erb-Duchenne palsy
Injury= Hyperadduction of arm causing widening of the humeral-glenoid gap (e.g., birth, shoulder dystocia)

Hint 47

site of injury=Superior trunk

Front 48

Weak finger adduction, poor 4th or 5th finger flexion, clawed fourth or fifth fingers from lumbrical weakness

Back 48

Claw hand
Injury=Epiphyseal separation of medial epicondyle of humerus

Hint 48

site of injury=Ulnar nerve

Front 49

Inability to extend wrist or fingers; loss of sensation from dorsal hand

Back 49

Wrist drop
Injury=Mid-humerus fracture causes nerve impingement or tear

Hint 49

site of injury=Posterior cord or radial nerve

Front 50

Impaired shoulder abduction or elevation

Back 50

Deltoid paralysis
Injury=Anterior shoulder dislocation causes axillary nerve impingement or stretching

Hint 50

site of injury=Axillary nerve

Front 51

Claw hand, poor wrist and hand function, association with Horner's syndrome

Back 51

Klumpke's palsy
Injury=Hyperabduction of arm places excess tension on lower cords and nearby sympathetic chain

Hint 51

site of injury=Posterior or medial cords

Front 52

H/P = usually asymptomatic until fractures (e.g., Colles, femoral neck, and vertebral) and neurovascular impingement occur
Risk factors = inadequate dietary calcium during young adulthood, smoking, excessive alcohol consumption, sedentary lifestyle, decreased estrogen (e.g., postmenopausal), long-term steroid use, hyperparathyroidism, hyperthyroidism; typical patients are thin, white, postmenopausal women

Back 52

Osteoporosis
Substantial osteopenia (i.e., decreased bone density), but normal mineralization in existing bone stock
Results from decreased bone formation or increased resorption of bone
Peak bone mass occurs at 20–25 yr of age
Osteoporosis is less likely to occur in obese people, because the increased load placed on bones helps to prevent osteopenia.
Hormone and electrolyte levels will be normal for age in osteoporosis unless an underlying endocrine disorder exists.

Hint 52

Radiology = decreased bone density evident on dual x-ray absorptiometry (DXA), x-ray, and CT
X-rays will only show changes in osteoporotic bone after significant bone loss.
Treatment =
Prevention is key, with exercise and sufficient calcium and vitamin D in diet (especially before the peak bone density age of 35 yr) important for maintaining bone stock
Bisphosphonates decrease osteoclast activity (less bone resorption), increase bone density, and decrease fracture risk
Selective estrogen receptor modulators (e.g., raloxifene) help increase bone density with fewer adverse effects than classic hormone replacement therapy

Front 53

H/P =
Sudden severe pain and swelling in one joint that frequently starts at night
First metatarsophalangeal joint most commonly affected (i.e., podagra); ankle, knee, and foot joints also common sites
Possible concurrent fever, chills, or malaise

Back 53

Gout
Peripheral monoarthritis caused by deposition of sodium urate crystals in joints
Risk factors = renal disease, male gender, urate underexcretion, diuretic use, cyclosporine use, cancer, hemoglobinopathies, excessive alcohol consumption
Complications = long-standing disease leads to chronic tophaceous gout with formation of nodular tophi (large deposits of crystals in soft tissues), leading to permanent deformity

Hint 53

Labs = serum uric acid can be normal or increased; joint aspiration shows needle-shaped, negatively birefringent crystals and several white blood cells (WBCs) (see Color Figure 9-1)
Radiology = x-ray may show punched-out bone lesions in chronic cases
Treatment =
NSAIDs (especially indomethacin), colchicine, corticosteroids
Decreasing alcohol and diuretic use and avoiding foods high in purines (e.g., red meats, fish) help prevent exacerbations
Probenecid (inhibits kidney uric acid resorption) or allopurinol (inhibits uric acid formation) used in cases of chronic gout to prevent flare-ups
Allopurinol should not be administered in acute attacks of gout.

Front 54

H/P = similar presentation to gout, but less severe symptoms; knee and wrist most commonly initially affected joints
Labs = joint aspiration shows positively birefringent, rhomboid crystals

Back 54

Pseudogout (calcium pyrophosphate dihydrate deposition disease, or CPPD)
Calcium pyrophosphate dehydrate crystal deposition in joints
Familial condition associated with other endocrine diseases (e.g., DM, hyperparathyroidism)
Podagra r/o CPPD and suggests a diagnosis of gout.

Hint 54

Radiology = x-ray may show chondrocalcinosis (i.e., calcification of articular cartilage in joints)
Treatment = NSAIDs, colchicine

Front 55

H/P = possibly, asymptomatic or deep bone pain, increased incidence of fractures; Tibial bowinG, kyphosis, + cranial diameteR, deafness (from changes in auditory ossicles)
Labs = + alkaline phosphatase; + urine hydroxyproline; normal calcium and phosphorus

Back 55

Paget's disease of bone
Overactive osteoclasts and osteoblasts leading to excessive bone turnover and disorganized bony architecture
“my hats no longer fit"=consider a workup for Paget's disease or osteopetrosis.

Hint 55

Radiology = x-rays may demonstrate osteolytic lesions and expanded hyperdense bone; bone scan will detect diffuse “hot spots” in areas of active disease
Treatment = bisphosphonates, calcitonin

Front 56

H/P = Frequent fractures from minimal traumA, Blue sclerA, skin and teeth deformities, possible deafness, joint hypermobility (may resemble child abuse)

Back 56

Osteogenesis imperfecta
Defective production of collagen from a genetic disorder
Diagnosis primarily made during childhood
Osteogenesis imperfecta can be inadvertently diagnosed during a workup for suspected child abuse.

Hint 56

Treatment = activity restriction, surgical correction of bony misalignment, bisphosphonates decrease fracture risk

Front 57

H/P = increased incidence of fractures, possible blindness or deafness, variable neurologic symptoms (from bony compression of nerves), impaired fracture healing
Labs = - hemoglobin (Hgb)& hematocrit (Hct) (via narrowing of marrow cavities), + acid phosphatase, + creatine kinase (CK)

Back 57

Osteopetrosis
Increased bone density caused by impaired osteoclast activity

Hint 57

Radiology = general increased bone density seen on x-ray, including thickening of cranium and vertebrae
Treatment = transfusion of marrow components necessary for osteoclast production, activity restriction

Front 58

H/P = sudden onset of joint pain or several days of migratory polyarthralgias; warm, red, tender, swollen joint, pain with Any motioN (i.e., micromotion tenderness), possible overlying skin lesions; children may show vague signs of pain and refusal to walk

Back 58

Septic joint and septic arthritis
Most commonly occurs through hematogenous spread of bacteria, extension of local infection, or direct inoculation (e.g., open fracture)
Most commonly caused by Staphylococcus aureus; consider Neisseria gonorrhoeae in sexually active patients
Consider gram-negative rods in patients with DM, cancer, or other underlying illnesses
Preexisting arthritis increases risk of progressive damage to cartilage
N. gonorrhoeae is the most common cause of septic arthritis in young adults.

Hint 58

Labs = increased WBC, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP); joint aspiration shows numerous WBCs (lower for N. gonorrhoeae than S. aureus) with a high percentage of neutrophils and decreased glucose; positive cultures (frequent false–negative findings for N. gonorrhoeae)
Treatment = surgical irrigation and drainage (I + D) required for any infection other than N. gonorrhoeae; for N. gonorrhoeae, use IV ceftriaxone and doxycycline for possible Chlamydia coinfection; for S. aureus, use penicillinase-resistant penicillin; for gram-negative bacteria, use aminoglycosides

Front 59

H/P = bone pain, tenderness, fever, chills; possible skin involvement with a draining sinus

Back 59

Osteomyelitis
Bone infection via hematogenous spread or local extension
S. aureus and Pseudomonas most common causes; consider Salmonella in patients with sickle cell disease
Complications = inadequately treated infection can lead to chronic osteomyelitis that is difficult to cure or may require amputation
Salmonella should be considered in patients with sickle cell disease and Pseudomonas should be considered in intravenous drug abusers, S. aureus is still the most common cause of osteomyelitis in these patients

Hint 59

Labs = increased WBC, ESR, and CRP; cultures needed to define appropriate antibiotic therapy
Radiology = x-rays are not helpful initially and only show signs of infection after 10 days; MRI demonstrates bone edema early in disease; bone scan will show increased uptake after 72 hr; tagged-WBC scan is more sensitive than standard bone scan
Treatment = IV antibiotics for 4–6 wk (empiric initially, pathogen-specific following culture); I + D must be performed for an abscess inside the bone (i.e., sequestrum) or in surrounding tissue

Front 60

H/P =
Early localized stage: chills, fatigue, arthralgias, headache; erythema chronicum migrans (i.e., bulls-eye rash), fever (see Color Figure 9-3)
Early disseminated stage: MyocarditiS weeks to months after infection, cardiac arrhythmias, heart block, Bell's palsY, sensory-motor neuropathies, aseptic meningitis, or meningoencephalitis
Late disseminated stage: a few months to years later, chronic synovitis, monoarthritis or oligoarthritis, subacute encephalopathy, or polyneuropathy may develop

Back 60

Lyme disease
Caused by Borrelia burgdorferi; the organism is delivered through the bite of the Ixodes tick

Hint 60

Labs = + enzyme-linked immunosorbent assay (ELISA) and western blot tests for antibodies; joint aspiration is not helpful
Treatment = doxycycline, amoxicillin, or cefuroxime (oral form can be used in early disease, but IV forms required in disseminated disease)

Front 61

Joint Aspiration Leukocytes <2,000/mm3

Back 61

Osteoarthritis, trauma

Hint 61

Histology
May see signs of hemarthrosis (bleeding into joint) for trauma; otherwise negative

Front 62

Joint Aspiration Leukocytes 5,000–50,000/mm3

Back 62

Inflammatory arthropathies (e.g., rheumatoid arthritis, gout, pseudogout)

Hint 62

Histology
Needle-shaped, negatively birefringent crystals for gout
Positively birefringent rhomboid crystals for pseudogout

Front 63

Joint Aspiration Leukocytes >50,000/mm3

Back 63

Septic joint

Hint 63

Histology
Many WBCs; infrequently bacteria seen

Front 64

H/P = joint crepitus, insidious onset of joint stiffness and pain that Worsens with activity and weight-bearinG and is relieved by rest, no systemic symptoms; patients have decreased range of motion, bony protuberances in the distal interphalangeal (DIP) (i.e., Heberden nodes) and proximal interphalangeal (PIP) (i.e., Bouchard nodes) joints
Labs = normal ESR; <2,000 leukocytes on joint aspiration

Back 64

Osteoarthritis (OA) / Degenerative joint disease
Chronic, noninflammatory joint degeneration involving articular cartilage deterioration
Most commonly affects hips, knees, ankles, hands, wrists, and shoulders; can cause spinal stenosis in vertebral bodies
Risk factors = advanced age, family history, obesity, previous joint trauma, repetitive joint stress (heavy labor occupations)

Hint 64

Radiology = x-ray demonstrates osteophyte formation, joint space narrowing, subchondral bone sclerosis, and subchondral bone cyst formation (see Figure 9-5)
Treatment = activity modification, heat, analgesics (e.g., NSAIDs), weight loss, physical therapy, corticosteroid or hyaluronan injections, joint replacement in advanced cases

Front 65

H/P =
Malaise, weight loss, insidious onset of morning stiffness with pain, decreased mobility
Warm joints, joint swelling, fevers, ulnar deviation of fingers; MCP hypertrophy, swan neck deformities (i.e., flexed DIP plus hyperextended PIP), boutonniere deformities (i.e., flexed PIP), subcutaneous nodules, pleuritis, pericarditis, scleritis, chorea
Labs =
Rheumatoid factor (RF) positive in 75% of patients, but not specific for the disease
Positive antinuclear antibodies (ANA) in 40% of patients (see Table 9-5)
Increased ESR, increased anticitrulline-containing protein IgM antibodies
Joint aspiration shows 5,000–50,000 leukocytes

Back 65

Rheumatoid arthritis (RA)
Chronic inflammatory disorder, with infiltration of synovial joints by inflammatory cells and progressive erosion of cartilage and bone
Synovial hypertrophy, with granulation tissue formation on articular cartilage (i.e., pannus formation) caused by joint inflammation
Most commonly seen in middle-aged women; increased frequency in people with HLA-DR4 serotype
PIP and metacarpophalangeal (MCP) joints usually first involved; symmetric polyarthropathy develops, involving ankles, knees, shoulders, hips, elbows, and spine

Hint 65

Radiology = x-rays may demonstrate soft tissue swellings, joint space narrowing, marginal bony erosions, or subluxation; MRI is more sensitive than x-ray for detecting similar findings
Treatment =
Initially, NSAIDs and physical therapy, as needed
Patients still mildly symptomatic following NSAID use may be started on sulfasalazine or hydroxychloroquine and analgesics, as needed
Moderate disease can be treated with methotrexate; anti-tumor necrosis factor (TNF) drugs (e.g., infliximab) or corticosteroids may be considered
Anti-TNF drugs and corticosteroids combined with other regimens in severe disease

Front 66

H/P =
Common findings include malar and discoid rashes, serositis, oral ulcers, arthritis, photosensitivity, CNS symptoms, cardiac symptoms, and renal symptoms (see Figure 9-6)
criteria=MD SOAP BRAIN' or 'DOPAMIN(E) RASH
Can also experience fevers, malaise, weight loss, abdominal pain, vomiting, conjunctivitis, blindness
Any combination of symptoms is possible and can change during the course of the disease
Labs =
Positive ANA in 95% of patients (see Table 9-5)
Anti-double-stranded DNA (dsDNA) antibodies in 60% of patients, but not found in other rheumatologic disorders
Presence of anti-Sm antibodies is very specific for disease
Anti-histone antibodies may be seen for drug-induced, lupus-like symptoms
Patients frequently have a false–positive test for syphilis

Back 66

Systemic lupus erythematosus (SLE)
Multisystem autoimmune disorder involving a variety of autoantibodies affecting several body systems
Antibody-mediated cellular attack occurs with deposition of antigen-antibody complexes in affected tissues
Risk factors = young women, blacks, Asians, Hispanics
Hydralazine, procainamide, isoniazid, methyldopa, quinidine, and chlorpromazine can cause similar symptoms that resolve when the drug is discontinued
Complications = lupus anticoagulant and anticardiolipin antibodies increase the risks of miscarriage and fetal death; disease follows variable course, with some cases remaining benign and others progressing rapidly; patient death results from progressive impairment of lung, heart, brain, and kidney function

Hint 66

Treatment = avoidance of sun, NSAIDs given for pain, hydroxychloroquine improves skin and renal symptoms, corticosteroids given for immunosuppression and to decrease exacerbations, other immunosuppressant drugs given in cases resistant to corticosteroids, anticoagulation required if patient considered hypercoagulable

Front 67

H/P =
Symmetric progressive proximal muscle weakness (occurs in legs first) and myalgias, muscle atrophy in later stages of disease
Cutaneous manifestations of dermatomyositis are a red heliotropic rash on the face, upper extremities, chest, or back; violet discoloration of eyelids or scaly patches over hand joints
Patients with lung involvement have dyspnea and poor oxygenation saturation
Labs =
Increased creatinine, aldolase, CK, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH)
ANA frequently positive
Anti-Jo-1 antibodies in patients with interstitial lung disease (see Table 9-5)
Muscle biopsy shows inflammatory cells and muscle degeneration, inflammatory cells within muscle fascicles in polymyositis and surrounding muscle fascicles in dermatomyositis

Back 67

Polymyositis and dermatomyositis
Progressive systemic diseases with skeletal muscle inflammation; one third of patients with polymyositis also have dermatomyositis (i.e., polymyositis with skin manifestations)
Risk factors = more common in women, blacks, elderly
Complications = possible interstitial lung disease, increased risk of several malignancies

Hint 67

EMG = spontaneous fibrillations
Treatment = high-dose corticosteroids, methotrexate, or azathioprine for 4–6 wk followed by tapered dosing; IV immune globulin or other immunosuppressants can be added to regimen in resistant cases

Front 68

H/P = pain and stiffness in shoulder and pelvic girdle, difficulty raising arms and getting out of bed because of pain, malaise, unexplained weight loss; fever, minimal joint swelling, muscle strength maintained, although movement limited by pain
Labs = - Hct, markedly + ESR, -RF

Back 68

Polymyalgia rheumatica (PMR)
Rheumatic disease with multiple sites of muscle pain and frequently associated with temporal arteritis; most common in elderly women

Hint 68

Radiology = MRI demonstrates increased signal at tendon sheaths and synovial tissue outside of joints; positron emission tomographic (PET) scan shows increased uptake in large vessels
Treatment = low-dose corticosteroids, followed by tapered dosing
Patients with PMR will frequently experience significant symptomatic improvement after just 1 day of corticosteroid administration

Front 69

H/P = myalgias and weakness without inflammation; “trigger points” on examination (i.e., specific locations that when stimulated reproduce pain symptoms), fatigue; possible depression, sleep disturbances, dizziness, headaches, and mood disturbances

Back 69

Fibromyalgia
Disease causing chronic pain in muscles and tendons in absence of apparent inflammation
Unknown etiology, but frequently associated with depression, anxiety, and irritable bowel disease
Possible predisposition with hypothyroidism, RA, sleep apnea; more common in women, 20–50 yr of age

Hint 69

Treatment = stretching, antidepressants (e.g., tricyclic antidepressants [TCAs], selective serotonin reuptake inhibitors [SSRIs]), patient education, physical therapy modalities

Front 70

H/P =
Hip and low back pain that is worse in the morning and following inactivity; pain improves over course of day
Possible limited range of motion in spine, hip, or chest
Painful kyphosis that is relieved by bending forward
Possible self-limited anterior uveitis
Labs = + HLA-B27 in 90% of patients, + or normal ESR, -RF, -ANA

Back 70

Ankylosing spondylitis
Chronic inflammatory disease of the spine and pelvis that results in eventual bone fusion
Risk factors = 20–40 yr of age, male > female, white > black

Hint 70

Radiology = x-ray shows Bamboo spinE (multiple vertebral fusions); MRI shows increased signal in sacroiliac joints and vertebrae
Treatment = physical therapy, NSAIDs; exercise helps to prevent or delay permanent deformities; sulfasalazine, methotrexate, or anti-TNF drugs may be beneficial in more significant disease; joint replacement may be needed in extremities

Front 71

H/P = asymmetric joint pain and stiffness, symptoms worse in morning and improve with activity, symptoms usually less severe than RA, possible anterior uveitis; joint line pain, pain with stress on joints, pitting of nails
Labs = -RF&ANA, possible positive HLA-B27

Back 71

Psoriatic arthritis
Arthritis that develops in approximately 1% of patients with psoriasis; DIP joints and spine most commonly affected

Hint 71

Radiology = x-rays show findings similar to RA and highly destructive lesions of DIP and PIP joints (i.e., “pencil in cup” deformities); MRI is more sensitive in finding marrow edema
Treatment = NSAIDs, methotrexate, sulfasalazine, or anti-TNF drugs, depending on severity

Front 72

H/P = arthralgias, myalgias, hand swelling, Raynaud's phenomenon (i.e., blue distal extremities caused by arteriolar spasm), Skin thickeninG, Esophageal dysmotilitY, intestinal hypomotility, dyspnea, possible arrhythmias or heart failure
Labs = + anti-scl-70 ANA

Back 72

Scleroderma
Chronic multisystem sclerosis with accumulation of connective tissue, skin thickening, and visceral involvement
Complications = pulmonary fibrosis, heart failure, acute renal failure caused by malignant renal hypertension

CREST syndrome is a variant, with Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasias
Skin thickening limited to distal extremities and face
Labs show anticentromere antibodies (see Table 9-5)
Better prognosis than scleroderma

Hint 72

Treatment = supportive care; angiotensin-converting inhibitors (ACE-I) for malignant renal hypertension; calcium channel blockers and avoidance of caffeine, nicotine, and decongestants to relieve Raynaud symptoms; methotrexate or corticosteroids may improve skin thickening and pulmonary symptoms

Front 73

H/P = Raynaud's phenomenon, polyarthralgias, arthritis, swollen hands, proximal muscle weakness, esophageal hypomotility, pulmonary symptoms; absence of renal and neurologic symptoms
Labs = + anti-ribonucleoprotein (RNP) ANA

Back 73

Mixed connective tissue disease (MCTD)
Overlapping features of SLE, scleroderma, and polymyositis
Can progress to a single diagnosis

Hint 73

Treatment = NSAIDs, corticosteroids, ACE-I, supportive measures

Front 74

H/P = dry eyes, dry mouth, enlarged parotid glands, purpura on legs, peripheral neuropathy, possible symmetric arthritis associated with other autoimmune conditions
Labs = +anti-Ro (anti-SSA) and anti-La (anti-SSB) antibodies

Back 74

Sjögren's syndrome
Autoimmune disorder, with lymphocytic infiltration of exocrine glands
Can be seen in association with RA, SLE, or primary biliary cirrhosis
Sicca syndrome is Sjögren's syndrome without a secondary autoimmune association.

Hint 74

Treatment = supportive care, corticosteroids for significant symptoms

Front 75

ANA (95% of patients)
Anti-dsDNA antibodies (60% of patients)
Anti-Sm antibodies
False–positive RPR (syphilis test)

Back 75

Systemic lupus erythematosus (SLE)
Immunologic Markers

Front 76

Anti-histone antibodies

Back 76

Drug-induced lupus
Immunologic Markers

Front 77

RF (75% of patients)
ANA (<50% of patients)
HLA-DR4 common

Back 77

Rheumatoid arthritis (RA)

Front 78

ANA
Anti-Jo-1 antibodies

Back 78

Polymyositis or dermatomyositis

Front 79

HLA-B27 (90% of patients)

Back 79

Ankylosing spondylitis

Front 80

Possible HLA-B27

Back 80

Psoriatic arthritis

Front 81

Anti-scl-70 ANA

Back 81

Scleroderma

Front 82

Anti-centromere antibodies

Back 82

CREST syndrome

Front 83

Anti-RNP ANA

Back 83

Mixed connective tissue disease (MCTD)

Front 84

Anti-Ro (anti-SSA) ANA
Anti-LA (anti-SSB) ANA

Back 84

Sjögren's syndrome

Front 85

H/P = deep bony pain, later development of palpable bony mass
Labs = + alkaline phosphatase, + ESR, + LDH; biopsy provides definitive diagnosis

Back 85

Osteosarcoma
Most common primary malignant bone tumor; more common in adolescents, male > female
Most frequently involves distal femur, proximal tibia, or proximal humerus
Risk factors = Paget's disease of bone, p53 genetic mutations, familial retinoblastoma, radiation exposure, bone infarcts
Complications = 90% 5-yr survival rate for low grade disease, 50% 5-yr survival for higher grade lesions

Hint 85

Radiology = x-ray shows bone lesion with a sunburst pattern and Codman's triangle (i.e., periosteal new bone formation at the diaphyseal end of the lesion) (see Figure 9-7); MRI or PET scan useful for determining extent of lesion; chest CT routinely performed to look for metastases
Treatment = radical surgical excision, chemotherapy

Front 86

H/P = presence of primary form of cancer; deep bone pain, possible palpable bone mass, Fractures following minor traumA

Back 86

Bone metastases
Most common bone tumors in adults
Can result from nearly any primary tumor (Really Large Lesions Pulverize Troubled Bones: Renal cell, Lung, Lymphoma, Prostate, Thyroid, Breast.)

Hint 86

Labs = biopsy is important to identifying source of metastasis
Radiology = x-ray identifies lesion in a bone; bone scan suggests extent of metastases in body; MRI useful to determine extent of a lesion
Treatment = chemotherapy as for primary tumor; bisphosphonates help slow bone loss; radiation therapy helps to decrease metastasis size; fixation of fractures required; prophylactic fixation may be performed for impending fractures

Front 87

H/P = bony pain, tissue swelling, fever, fatigue, weight loss, fractures with minor trauma; possible palpable mass
Labs = + WBCs, - Hgb, + ESR; biopsy important for making diagnosis
Complications = 60% 5-yr survival rate when both radiation and chemotherapy are used in nonmetastatic disease, 20% 5-yr survival with metastases

Back 87

Ewing sarcoma
Highly malignant cartilage tumor occurring in diaphysis of long bones; most common in children, 5–15 yr of age

Hint 87

Radiology = x-ray may detect large destructive lesions with significant periosteal reaction; MRI determines extent of lesion
Treatment = radiation, adjuvant chemotherapy, radical excision

Front 88

H/P = irritated soft tissues overlying mass, mass itself frequently nontender; palpable hard mass
Typically occurs in lower femur or upper tibia

Back 88

Osteochondroma
Most common benign bone tumor in metaphysis of long bones; more common in patients <25 yr of age, male > female
Complications = rare (1%) transformation into chondrosarcoma

Hint 88

Radiology = x-ray shows bony growth off metaphysis of long bone; CT or MRI shows cancellous portion of long bone to be continuous with interior of lesion
Treatment = none necessary unless causing soft tissue irritation or neurovascular compromise or if continued growth occurs (surgical excision indicated)
A bony growth on a long bone that sits on top of cortical bone and is not continuous with the normal cancellous bone is concerning for a malignant lesion.

Front 89

H/P =
Children have delayed walking or abnormal gait if diagnosis not made early
Positive Barlow's and Ortolani's maneuvers (provocation of hip dislocation or reduction)
Knees at unequal heights when hips and knees flexed (i.e., Galeazzi's sign)
Positive Trendelenburg sign (i.e., sagging of opposite hip)
Asymmetric skin folds

Back 89

Developmental dysplasia of the hip (DDH)
Perinatal displacement of the femoral head from acetabulum disrupting normal development of the hip joint
Occurs because of poor development of acetabulum in utero
Risk factors = female > male, first-born children, babies delivered in breech presentation, oligohydramnios
Complications = permanent hip dysplasia results from inadequately treated cases; likelihood of successful treatment and normal hip development improves with earlier treatment

Hint 89

Radiology = ultrasound is the most commonly used method of imaging hip congruity; x-rays are not helpful in making a diagnosis until after 4 months of age
Treatment = Pavlik harness used in children <6 months of age; closed or open reduction and spica casting performed in children 6 months to 2 yr of age; open reduction performed after age 2 yr; correction may not be performed after age 8 yr because of reduced benefit

Front 90

H/P = thigh and knee pain; limp, limited internal rotation and abduction of the hip, hip flexion produces obligatory external hip rotation

Back 90

Slipped capital femoral epiphysis (SCFE)
Separation through growth plate of femoral epiphysis from metaphysis
Risk factors = adolescent, obese, black race, hypothyroidism
Complications = increased risk of avascular necrosis (AVN) and premature osteoarthritis if treatment is not performed early

Hint 90

Radiology = x-rays indicate posterior and medial displacement of the femoral head from the femoral metaphysis
Treatment = surgical pinning, weight-bearing restrictions following repair if unstable (unable to bear-weight on presentation), prophylactic pinning of normal contralateral side performed in cases of hypothyroidism

Front 91

H/P = bone pain, delayed walking; bowed legs, kyphoscoliosis, proximal limb weakness, decreased height, softened skull bones; fractures that result from minimal trauma in adults
Labs = + alkaline phosphatase (all types), - phosphorus (all types), - calcium (hypocalcemic), - (hypocalcemic) or +(hypophosphatemic) 25-hydroxyvitamin D3 and 1, 25-dihydroxycholecalciferol, + parathyroid hormone (hypocalcemic)

Back 91

Rickets
Impaired calcification of bone in children caused by deficient vitamin D intake, absorption, or metabolism (i.e., hypocalcemic types) or impaired phosphate absorption (i.e., hypophosphatemic type)
Called osteomalacia in adults
Results from lack of sunlight and/or poor diet in absence of renal or metabolic defects
Epiphyseal cartilage becomes hypertrophic without calcification

Hint 91

Radiology = x-rays will demonstrate widening of physes, bowing of long bones, translucent lines in bones, flattening of skull, and enlarged costal cartilages
Treatment = phosphorus supplementation for all types, vitamin D supplementation for poor intake, 1,25-dihydroxycholecalciferol for impaired vitamin absorption or metabolism

Front 92

H/P = arthralgias of joints involved, morning stiffness; fever; additional findings depend on subtype

Back 92

Juvenile rheumatoid arthritis (JRA)
Nonmigratory arthropathy affecting one or more joints for >3 months
Classified as pauciarticular, polyarticular, or systemic, depending on the constellation of symptoms

Hint 92

Labs = vary with subtype
Radiology = x-rays may demonstrate osteopenia and subchondral sclerosis around involved joints
Treatment = varies with subtype, but usually consists of NSAIDs, methotrexate, or corticosteroids

Front 93

Joint symptoms=Insidious swelling and decreased range of motion
2–3 yr
30% cases have uveitis or iridocyclitis
Lab=Weakly positive ANA

Back 93

Juvenile Rheumatoid Arthritis
Pauciarticular
Fewer than four joints; large joints except hips
Complication=Blindness from iridocyclitis, leg length discrepancy, rare chronic disease with progressive arthritis

Hint 93

Treatment=NSAIDs; methotrexate for chronic cases
Most cases resolve in <6 months; uncommon chronic arthritis

Front 94

Joint symptoms=Symmetric joint involvement, spine involvement, hand deformities
2–5, 10–14 yr
Growth retardation, fever, rare iridocyclitis
Lab=Mildly increased ESR, mildly decreased Hgb, weakly positive ANA in younger ages, positive RF in older ages

Back 94

Juvenile Rheumatoid Arthritis
Polyarticular
Five or more joints; hips less common
Complication=Chronic arthritis, leg length discrepancy

Hint 94

Treatment=NSAIDs, methotrexate, sulfasalazine, or etanercept
60% patients enter remission within 15 yr; higher rate of severe chronic arthritis than pauciarticular; worse prognosis with older onset

Front 95

Joint symptoms=Acute significant pain, pain severity may follow fevers, neck stiffness common, occasional jaw involvement
Any age <17 yr
Spiking fevers, maculopapular rash, organomegaly, lymphadenopathy, pericarditis, growth retardation
Lab=Increased WBC, decreased Hgb, increased ESR, negative ANA, rarely positive RF

Back 95

Juvenile Rheumatoid Arthritis
Systemic
Any number
Complication=Leg length discrepancy, chronic arthritis, jaw arthritis, amyloidosis

Hint 95

Treatment=NSAIDs, methotrexate, corticosteroids, cytotoxic drugs
Highly variable course; 50% patients will achieve eventual remission, significant minority have chronic disease

Front 96

H/P = pain at involved site that worsens with activity
Most common in young boys during pubertal growth spurt

Back 96

Osgood-Schlatter disease
Inflammation of the bone–cartilage interface of the tibial tubercle (i.e., osteochondritis)

Hint 96

Treatment = stretching exercises, NSAIDs

Front 97

H/P = pain overlying midshaft clavicle, most common fracture sustained during birth

Back 97

Clavicular fracture
Most common fracture in children (e.g., birth trauma, falls)

Hint 97

Treatment = figure-of-eight sling

Front 98

H/P = pain at site of injury; possible gross deformity, swelling, warmth at fracture site; growth disturbance with limb inequality seen in cases of permanent physeal damage

Back 98

Physeal fractures
Fractures involving the growth plate of growing bones; described by Salter-Harris classification system (see Table 9-7)
Most heal uneventfully, but some will result in impairment of bone growth at site of injury

Hint 98

Radiology = x-ray demonstrates fracture at site of injury; premature closure of physis seen in cases of growth disturbance
Treatment = adequate reduction and immobilization, fixation for unstable fractures; growth disturbance may require limb-lengthening procedures, excision of closed portion of physis, or epiphysiodesis of contralateral physis (i.e., surgical disturbance of physis) to achieve equal limb size

Front 99

Salter-Harris Classification of Physeal Fractures
Physeal separation without extension into adjacent bone

Back 99

Type I

Hint 99

Prognosis=Good with adequate reduction, quick healing

Front 100

Salter-Harris Classification of Physeal Fractures
Partial physeal separation with proximal extension into metaphysis

Back 100

Type II

Hint 100

Prognosis=Good; rare growth disturbance

Front 101

Salter-Harris Classification of Physeal Fractures
Partial physeal separation with distal extension into epiphysis

Back 101

Type III

Hint 101

Prognosis=Poor unless accurate reduction; fixation usually required to maintain stability

Front 102

Salter-Harris Classification of Physeal Fractures
Fracture extends through metaphysic, physis, and epiphysis

Back 102

Type IV

Hint 102

Prognosis=Perfect reduction must be achieved; guarded prognosis even with good reduction

Front 103

Salter-Harris Classification of Physeal Fractures
Crush injury of physis

Back 103

Type V

Hint 103

Prognosis=High likelihood of partial growth arrest

Front 104

H/P = child with painful arm who will not bend elbow

Back 104

Nursemaid's elbow
Radial head subluxation that occurs via pulling and lifting on the hand (e.g., yanking the child out of danger by his or her arm)

Hint 104

Treatment = manual reduction via supination of the arm with flexion of the elbow from 0° to 90° of flexion

Front 105

H/P = gradual progressive limp, insidious onset of pain, decreased range of motion
Radiology = x-ray shows asymmetric hips, affected femoral head appears small with sclerotic bone and widened joint space

Back 105

Legg-Calvé-Perthes disease
AVN of capital femoral epiphysis most common between 3 and 8 yr of age

Hint 105

Treatment = containment of hip within acetabulum via bracing or surgical means; acetabular reconstruction performed in cases of permanent hip dysplasia
Complications = 50% untreated cases recover fully; increased risk of hip complications in adulthood, including osteoarthritis, progressive AVN, and need for early arthroplasty in cases of permanent dysplasia

Front 106

H/P = child who is slow to walk, limp; obvious defect on examination

Back 106

Club foot
Inversion of foot, plantar flexion of ankle, and adduction of forefoot

Hint 106

Treatment = serial casting of foot in correct position; surgery required in long-standing cases to release contractures and modify bone alignment

Front 107

H/P = asymmetry of back musculature and palpable curve of the spine that are augmented when patient bends at the waist; possible pulmonary compromise in severe cases

Back 107

Scoliosis
Resting lateral curvature of the spine, with associated rotatory deformity
Curve is at risk of progressing during periods of rapid growth; risk of curve progression increases with size of curve
Initially, mainly a cosmetic issue; progressive curvature interferes with activities
Severe cases result in decreased pulmonary function
Complications = severe curves can cause restrictive respiratory disease by limiting lung expansion

Hint 107

Treatment = observation for small curves; bracing for moderate curves in young patients; surgery for more severe curves or curves in older patients

Front 108

H/P = progressive clumsiness, easy fatigability, Difficulty standing up and walkinG, waddling gait, positive Gower's maneuveR (i.e., must push on thighs with hands to stand up); weakness occurs in proximal muscles before distal muscles; pseudohypertrophy occurs in calf muscles from fatty infiltration
Onset at 2–6 yr of age
Labs = increased CK; muscle biopsy shows muscle fiber degeneration and fibrosis and basophilic fibers; immunostaining for dystrophin (absent in disease) is diagnostic

Back 108

Duchenne muscular dystrophy
X-linked disorder resulting from deficiency of dystrophin (subsarcolemmal cytoskeletal protein)
Most common lethal muscular dystrophy
Complications = progressive cardiac issues, scoliosis, and flexion contractures; death commonly occurs by 20 yr of age because of respiratory issues
Becker muscular dystrophy is similar to Duchenne muscular dystrophy, except symptoms are less severe and progression occurs more slowly.

Hint 108

EMG = polyphasic potentials and increased fiber recruitment
Treatment = physical therapy, corticosteroids, pulmonary support, ACE-I decrease cardiac afterload