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424 Cards in this Set
- Front
- Back
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6 benign primary bone tumors
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osteoma
osteoid osteoma osteoblastoma osteoclastoma (giant cell) osteochondroma enchondroma |
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tumor: new piece of bone grows on another piece of bone
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osteoma
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osteoma common location
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skull
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tumor associated with Gardners syndrome (FAP)
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osteoma
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osteoma
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benign tumor
new piece of bone grows on another piece of bone |
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osteoid osteoma
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benign tumor
interlacing trabeculae of woven bone surrounded by osteoblasts |
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interlacing trabeculae of woven bone surrounded by osteoblasts
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osteoid osteoma
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tumor less than 2 cm
found in proximal tibia and femur |
osteoid osteoma
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osteoid osteoma location and size
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tumor less than 2 cm
found in proximal tibia and femur |
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osteoid osteoma epidemiology
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men less than 25
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benign tumors common in men less than 25
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osteoid osteoma
osteochondroma |
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osteoblastoma
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same as osteoid osteoma but larger and found in vertebral column
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same as osteoid osteoma but larger and found in vertebral column
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osteoblastoma
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osteoblastoma location
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vertebral column
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osteochondroma
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most common benign bone tumor
mature bone with cartilaginous cap men less than 25 originates from long metaphysis |
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most common benign bone tumor
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osteochondroma
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mature bone with cartilaginous cap
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osteochondroma
(exostosis) |
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osteochondroma epi
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men less than 25
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osteochondroma location
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originates from long metaphysis
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enchondroma
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benign cartilaginous tumor of intramedullary bone
distal extremities |
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benign cartilaginous tumor of intramedullary bone
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enchondroma
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enchondroma location
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distal extremities
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osteosarcoma
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second most common malignant bone tumor
men 10-20 metaphysis of long bones distal femur, prox tibial (knee) |
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second most common malignant tumor of bone
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osteosarcoma
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location of osteosarcoma
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metaphysis of long bones
distal femur proximal tibial region (knee) |
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predisposing factors of osteosarcoma
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pagets
bone infarcts radiation familial retinoblastoma |
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codman's triangle or sunburst pattern on xray
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osteosarcoma
from elevation of periosteum |
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ewings sarcoma
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anaplastic small blue cell malignant tumor
aggressive, early mets |
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ewings sarcoma epi
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boys less than 15
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malignant bone tumor that is responsive to chemo
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ewings sarcoma
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onion skin appearance of bone
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ewings sarcoma
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ewings sarcoma location
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diaphysis of long bones
pelvis scapula ribs |
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ewings chromosome abnormality
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11;22 translocation
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11;22 translocation tumor
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ewings
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chondrosarcoma
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malig cartilaginous tumor
men 30-60 primary or from osteochondroma |
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expansile glistening mass within medullary cavity
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chondrosarcoma
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epiphysis tumor
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giant cell tumor/osteoclastoma
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metaphysis tumor:
benign malignant |
osteochondroma
osteosarcoma |
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diaphysis tumor:
benign malignant |
osteoid osteoma
ewings |
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intramedullary tumor
benign malignant |
enchondroma
chondrosarcoma |
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soap bubble appearance
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giant cell tumor
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tumor of hands/feet
inside bone |
enchondroma
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giant cell tumor/osteoclastoma
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eiphyseal long bones
20-40 yrs locally aggressive, benign distal femur, prox tibial |
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double bubble on xray
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giant cell/osteoclastoma
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osteoclastoma/giant cell location
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epiphyseal long bones
distal femur prox tibial |
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spindle shaped cells
multinucleated giant cells bone tumor |
osteoclastoma
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OA
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mechanical
wear and tear of joints leads to destruction of articular cartilage |
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subchondral cysts
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OA
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sclerosis
osteophytes (bone spurs) eburnation (polished appearance) |
OA
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Heberden's nodes
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OA
DIP |
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bouchards nodes
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OA
PIP |
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predisposing factors for OA
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age
obesity joint deformity |
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pain in weight bearing joints after use/end of day
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OA
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pain in joints that improves with rest
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OA
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OA in knees location
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medial aspect
bowlegged- vargus |
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noninflammatory joint pain
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OA
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pain in only a few joints
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OA
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rheumatoid arthritis
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inflammatory
autoimmune synovial joints subcutaneous nodules |
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pannus (hanging flap of tissue) formation in MCP, PIP
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RA
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ulnar deviation
subluxation (partial dislocation) |
RA
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baker's cyst behind knee
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RA
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RA epi
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females > males
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diagnose RA
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positive rheumatoid factor in 80%
strong assoc with HLA DR4 |
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HLA DR4
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RA
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morning stiffness improving with use
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RA
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Boutonnieres deformity
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RA
PIP is flexed |
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swan neck deformity
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RA
PIP is extended and DIP is flexed |
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Z thumb deformity
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RA
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sjogrens syndrome triad
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1. xerophthalmia (dry eyes, sandlike)
2. xerostomia (dry mouth, dysphagia) 3. arthritis |
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1. xerophthalmia (dry eyes, sandlike)
2. xerostomia (dry mouth, dysphagia) 3. arthritis |
sjogrens
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parotid enlargement
dental caries |
sjogrens
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risk of what cancer with sjogrens
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B cell lymphoma
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sjogrens autoantibodies
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ribonucleoprotein antigens
SS-A (Ro) SS-B (La) |
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ribonucleoprotein antigens
SS-A (Ro) SS-B (La) |
sjogrens
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sjogrens epi
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females 40-60
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sjogrens is associated with
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RA
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sicca syndrome
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sjogrens:
dry eyes dry mouth nasal and vaginal dryness chronic bronchitis reflux esophagitis NO arthritis |
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gout
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asymmetric joint distribution
joint is red,swollen, painful usually MTP (big toe) |
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gout acute attack occurs when
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after large meal or alcohol
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alcohol and gout mechanism
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alcohol metabolites compete for same excretion sites in kidney as uric acid, causing dec uric acid excretion and subsequent buildup in blood
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tophus formation
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external ear or achilles tendon
gout |
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what is precipitating in joints with gout
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monosodium urate crystals due to hyperuricemia
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causes of hyperuricemia
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Lesch-Nyhan syndrome
PRPP excess thiazides (dec uric acid excretion) von Gierkes inc cell turnover |
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needle shaped crystals
negatively birefringent yellow under parallel light |
monosodium urate crystals
gout |
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treat gout
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colchicine
NSAIDS- indomethicin probenecid allopurinol |
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pseudogout
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caused by deposition of calcium pyrophosphate crystals within joint space
affects large joints |
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basophilic rhomboid crystals
weakly positively birefringent |
pseudogout
calcium pyrophosphate crystals |
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pseudogout epi
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greater than 50
both sexes equally |
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gout crystal findings with light
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yellow when parallel to light
blue perpendicular to light |
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pseudogoat crystal findings with light
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yellow when perpendicular to light
blue when parallel to light |
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septic arthritis
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swollen, red, painful joint due to bacterial infection
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septic arthritis bugs
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Staph
strep N gon-- migratory, asymmet., 1 joint |
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chronic infectious arthritis cause
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TB
Lyme disease |
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seronegative spondyloarthropathies epi
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more common in men
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HLA B27
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seronegative spondyloarthropathies
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bamboo spine
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ankylosing spondylitis
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ankylosing spondylitis
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chronic inflamm of spine and sacroiliac joints-> ankylosis (stiff pain due to fusion of joints)
uveitis aortic regurg |
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stiff spine
uveitis aortic regurg |
ankylosing spondylitis
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chronic inflamm of spine and sacroiliac joints
stiff, fused spine |
ankylosing spondylitis
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Reiters syndrome
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triad:
conjunctivitis and anterior uveitis urethritis arthritis |
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conjunctivitis and anterior uveitis
urethritis arthritis |
reiters/reactive
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cant see
cant pee cant climb a tree |
reiters
(eye stuff, urethritis, arthritis) |
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associated with post GI or chlamydia infections
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reiters
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psoriatic arthritis
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joint pain and stiffness
psoriasis asymmetric and patchy involvement |
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dactylitis (sausage fingers)
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psoriatic arthritis
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pencil in cup deformity on xray
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psoriatic arthritis
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how many patients with psoriasis have arthritis?
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less than 1/3
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SLE epi
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90% female
14-45 african american |
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fever
fatigue wt loss nonbacterial verrucous endocarditis hilar adenopathy raynauds |
SLE
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wire loop lesions in kidney with immune complex deposition
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SLE
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SLE death from
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renal failure
infections |
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false positive on syphilis test (RPR/VDRL) can be seen with
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SLE
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SLE has false pos on syphilis test due to
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antiphospholipid antibodies which cross react with cardiolipin used in test
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SLE lab tests
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ANA- sensitive
anti-dsDNA- specific, poor prog anti-Smith antibodies- specific antihistone antibodies- drug induced SLE |
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anti-ANA
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SLE
sensitive |
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anti dsDNA
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SLE
specific poor prognosis |
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antismith antibodies (anti Sm)
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SLE
very specific |
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antihistone antibodies
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drug induced lupus
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SLE:
IM DAMN SHARP |
immunoglobulins
malar rash discoid rash antinuc ab mucositis neurologic serositis hematologic arthritis renal photosensitivity |
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malar rash
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SLE
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discoid rash
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SLE
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mucositis
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oropharyngeal ulcer
SLE |
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serositis (pleuritis, pericarditis)
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SLE
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positive antinuclear antibodies
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SLE
sjogrens scleroderma polymyositis dermatomyositis RA JA mixed CT disease |
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sjogrens auto ab
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antinuclear ab
anti Ro and anti La |
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scleroderma auto ab
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antinuclear ab
anti-scl70 anti-centromere (CREST) |
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sarcoidosis
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immune mediated
widespread non cas granulomas elevated serum ACE african american females |
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elevated serum ACE
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sarcoid
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sarcoid is associated with
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restrictive lung disease
bilateral hilar lymphadenopathy erythema nodosum bells palsy uveoparotidis hypercalcemia |
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restrictive lung disease
bilateral hilar lymphadenopathy erythema nodosum bells palsy uveoparotidis hypercalcemia |
sarcoid
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epithelial granulomas with schaumann and asteroid bodies
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sarcoid
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sarcoid and vitamin D
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elevated conversion of vit D to active form in epitheloid macs due to 1 alpha hydroxylase activity
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sarcoid tx
|
steroids
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sarcoid: GRAIN
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granulomas
RA ACE increase Interstitial fibrosis Noncaseating granulomas |
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granulomas
RA ACE increase Interstitial fibrosis Noncaseating granulomas |
sarcoid
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polymyalgia rheumatica
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pain and stiffness
shoulders, hips, fever, malaise, wt loss |
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pain and stiffness
shoulders, hips, fever, malaise, wt loss |
polymyalgia rheumatica
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polymyalgia rheumatica epi
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over 50
|
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polymyalgia rheumatica is associated with
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giant cell temporal arteritis
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polymyalgia rheumatica tx
|
prednisone
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polymyositis
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progressive symmetric proximal muscle weakness caused by CD8 Ts injuring myofibers
shoulders need muscle biopsy |
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progressive symmetric proximal muscle weakness caused by CD8 Ts injuring myofibers
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polymyositis
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polymyositis location
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shoulders
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dermatomyositis
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like polymyositis but with malar rash like SLE
heliotrope rash shawl and face rash gottrons papules |
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gottrons papules
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dermatomyositis
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shawl and face rash
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dermatomyositis
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heliotrope rash (around eyes)
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dermatomyositis
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dermatomyositis- inc risk of what?
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malignancy
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poly/dermatomyositis lab findings
|
inc CK
inc aldolase pos ANA anti Jo 1 |
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poly/dermatomyositis tx
|
steroids
|
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inc CK
inc aldolase pos ANA anti Jo 1 |
poly/dermatomyositis
|
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Neuromuscular junction diseases: 2
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MG
Lambert Eaton |
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autoantibodies to postsynaptic AChR
|
MG
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associated with thymoma
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MG
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autoabs to presynaptic ca channels
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Lambert eaton
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NMJ disease associated with paraneoplastic diseases
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lambert eaton
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NMJ disease- symptoms worsen with use
|
MG
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NMJ disease- symptoms improve with use
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Lambert eaton
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mixed connective tissue diseases
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Raynauds
arthralgias myalgias fatigue esophageal hypomotility |
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antibodies to U1RNP
|
mixed CT disease
|
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mixed CT disease tx
|
steroids
|
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scleroderma
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excessive fibrosis and collagen deposition throughout body
common in skin- puffy and taut w/o wrinkles |
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puffy tout wrinkle free skin
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scleroderma
|
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systems affected with scleroderma
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skin
GI renal cardio resp |
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scleroderma epi
|
75% female
|
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2 types of scleroderma
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diffuse
CREST |
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diffuse scleroderma
|
widespread skin involvement
rapid early visceral involvement anti-Scl-70 |
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anti Scl 70
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diffuse scleroderma
|
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CREST
|
calcinosis
raynauds esophageal dysmotility sclerodactyly telangiectasia |
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calcinosis
raynauds esophageal dysmotility sclerodactyly telangiectasia |
CREST
|
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location of CREST
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limited skin involvement
mostly fingers and face more benign than diffuse scleroderma |
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anti centromere antibody
|
CREST
|
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CREST auto ab
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anti centromere
|
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liposarcoma
|
malignant large fat tumor
will recur |
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rhabdomyosarcoma
|
most common soft tissue tumor in kids
malignant skeletal muscle |
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location of rhabdomyosarcoma
|
head/neck
|
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OA risk factors
|
age
genetics obesity mechanical malalignment repetitive injury/overuse |
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knee OA- what part?
|
medial compartment
patellofemoral joint (anterior and medial pain- leads to vargus deformity) |
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OA of hands- what parts?
|
DIPs
PIPs 1st CMC |
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commonly affected joints in OA
|
knee
1st MTP hand- DIP, PIP, 1st CMC spine |
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causes of OA in young person
|
meniscal injury
avascular necrosis coagulopathy with recurrent hemarthrosis |
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OA in lupus can be caused by
|
avascular necrosis due to long term corticosteroid use
|
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tx of OA
|
education/lifestyle
symptomatic analgesics physical therapy/exercise surgery last resort |
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crystal formation mechanism
|
low pH
low temperature leads to supersaturated solute->crystals-> activate mast cells/endothelial cells/neutrophils -> inflammation/synovitis |
|
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acute gout
|
classical podagra 1st toe
severe pain/swelling 7-10 days frequent onset over night |
|
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uric acid
|
end product of purine metabolism
higher uric acid levels due to lack of uricase in humans excreted renally |
|
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hyperuricemia mechanism
|
abnormality of urate transport mechanism
insulin resistance- insulin causes urate reabsorption renal disease, cyclosporin, diuretics |
|
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lesch nyhan syndrome
|
hypoxanthine guanine phosphoribosyl transferase deficiency (purine enzyme) causing hyperuricemia
|
|
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acquired increased production of uric acid causes
|
tumor lysis syndrome
fructose consumption alcohol- beer |
|
|
chronic gout tx
|
lower uric acid level to 6.0 mg% or lower
allopurinol- xanthine oxidase inhibitor probenecid- uricosuric drug |
|
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calcium pyrophosphate dihydrate diseases
|
acute pseudogout
chronic atypical OA chondrocalcinosis in the elderly |
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|
Calcium pyrophosphate dihydrate disease causes
|
changes in pyrophosphate metabolism due to:
hyper PTH hemochromatosis hypomag hypophosphate |
|
|
hyper PTH
hemochromatosis hypomag hypophosphate all cause calcium pyrophosphate dihydrate disease how? |
due to decreased pyrophosphatase activity -> increased extracellular pyrophosphate -> inc crystals
|
|
|
patellofemoral knee pain
|
common in adolescent girls
pain with knee flexion, walking downstairs |
|
|
common in adolescent girls
pain with knee flexion, walking downstairs |
patellofemoral knee pain
|
|
|
in child with joint hypermobility think about
|
downs
ehlers danlos marfans |
|
|
marfans genetics
|
AD
fibrillin 1 gene defect- elastin problem chromosome 15 |
|
|
marfans msk findings
|
dolichostenomelia- long thin arms
increased lower segment scoliosis chest wall deformity arachnodactyly- long thin fingers steinberg sign- thumb adducted across palm wrist sign- thumb and pinky overlap around wrist |
|
|
marfans non msk findings
|
lens dislocation
high arched palate dental malocclusion cardiac- MVP early, aortic dissection late |
|
|
synovial joints are made up of
|
joint capsule
synovial membrane cavity with fluid |
|
|
2 types of synoviocytes
|
a- macs
b- fibroblasts |
|
|
rheumatoid synovium
|
hyperplasia of synovial intimal layer
infiltrate of T lymphs, b cells, macs |
|
|
rheumatoid pannus
|
granulation tissue
new blood vessel formation activated osteoclasts macs -> bone/cart destruction |
|
|
flexed DIP joint
hyperextended PIP |
swan neck
(opposite is boutenniere) |
|
|
wrist extensor tenosynovitis
|
RA
risk of extensor tendon rupture at the wrist |
|
|
cock up toes
|
seen in RA
advanced walking on ends of MTs risk of ulcers, infections |
|
|
rheumatoid nodule:
what is it location |
subcutaneous
areas of overlying pressure, friction sites: olecranon achilles |
|
|
rheumatoid nodule features
|
central zone of fibrinoid necrosis
palisading phagocytes surrounding gran tissue |
|
|
central zone of fibrinoid necrosis
palisading phagocytes surrounding gran tissue |
rheumatoid nodule
|
|
|
polyarticular- how many joints
|
> 6
like RA |
|
|
oligoarticular- how many joints
|
1-5
spondylarthropathies |
|
|
4 spondylarthropathies
|
psoriatic arth
ank spond arth related to IBD reactive arth 4 to 5 weeks after chlamydia and bacterial infections |
|
|
asymmetric
involves entire digit (ray) more common in lower extremities |
spondylarthropathies
|
|
|
new bone formation
periostitis joint fusion |
spondylarthropathies
|
|
|
HLA B27
|
spondylarthropathies
|
|
|
preg and RA
|
goes into remission
|
|
|
RA genetics
|
HLA DR4
chrom 6 shared epitope on other DR alleles |
|
|
cigarettes and shared epitope with HLA DR4
|
inc risk of RA
|
|
|
people with shared epitope produce what antibodies
|
citrulinated peptides (activated by tobacco in lung--> RA)
|
|
|
What drives RA? mechanism
|
activation of helper T cells is the first event.
mac type A synoviocytes drive the inflammatory process, releasing cytokines TNF a, IL1, IL6 |
|
|
cytokines of RA
|
TNF a
IL 1 IL 6 |
|
|
viral syndromes connected with RA
|
parvo B19
hep B rubella |
|
|
joint symptoms more than 6 wks
morning stiffness > 30 min multiple joints MC and MT joints involved |
RA
|
|
|
physical exam test for RA
|
squeeze tenderness
|
|
|
asymmetric, larger joints affected
lower extremities individual digit involvement |
spondyloarthropathies
|
|
|
RA spine involvement
|
C1-2 only
|
|
|
spondyloarthropathy epi
|
M > F
|
|
|
spondyloarth eye symptoms
|
iritis
|
|
|
spondyloarthropathy skin symptoms
|
psoriasis
keratoderma |
|
|
cardio stuff with spondyloarthropathies
|
heart block
aortic valvulitis |
|
|
RA lung disease
|
pleural- exudate, transudate
interstitial |
|
|
RA cardiac probs
|
coronary artery disease due to systemic inflammation
restrictive cardiomyopathy due to amyloid after chronic RA |
|
|
RA:
on methotrexate, get lung prob- what is it? |
acute interstitial pneumonitis due to hypersensitivity reaction
can lead to hypoxic resp failure |
|
|
tx RA
|
methotrexate
|
|
|
sulfazalazine
|
tx RA
|
|
|
hydroxychloroquine
|
tx RA
|
|
|
leflunomide
|
tx RA
|
|
|
TNF inhibitors
|
tx RA
|
|
|
IL-6 inhibitors
|
tx RA
|
|
|
Abatacept
|
tx RA
T cell inhib |
|
|
tx RA if methotrexate fails
|
sulfasalazine
hydroxychloroquine leflunomide TNF inhib, IL 6 inhib abatacept rituximab |
|
|
tx spondyloarthropathy
|
NSAID
TNF inhibitor |
|
|
concerns with infliximab (TNF inhibitor)
|
reactivate latent TB
histoplasma |
|
|
polymyalgia rheumatica
|
elderly caucasian women
severe symmetric morning stiffness pain in shoulder and hip malaise, wt loss |
|
|
Polymyalgia rheumatica, 10% of ppl also have
|
giant cell temporal arteritis
|
|
|
tx polymyalgia rheumatica
|
prednisone
|
|
|
single joint
swollen painful red hot diff dx? |
1.crystals- gout, pseudo
2.infection 3.reactive- GI/GU infection? erythema nodosum- sarcoid, histo, valley fever 4. trauma 5. cellulitis |
|
|
erythema nodosum and swollen joint
diff dx |
sarcoid
histo valley fever --reactive process |
|
|
septic arthritis risk factors
|
immunosup
alcohol diabetes |
|
|
swollen painful joint and restricted ROM
|
joint inflammation
(vs cellulitis, ROM ok) |
|
|
synovial fluid
clear viscous < 200 cells |
normal
|
|
|
immediate diagnostic step with acute monoarthritis
|
joint aspiration
|
|
|
acute monoarthritis
synovial fluid tests include |
bact gram stain
aerobic culture crystal cell count |
|
|
synovial fluid
clear, yellow viscous 200-2000 cells |
OA
|
|
|
synovial fluid
yellow cloudy watery 2000-100,000 cells |
inflammatory (RA) or
crystalline |
|
|
synovial fluid
purulent watery pus 20,000-100,000 cells >80 PMN |
septic arthritis
|
|
|
age risk factors for bacterial arthritis
|
very young
very old |
|
|
most common route of joint infection
|
hematogenous
|
|
|
most commonly infected joint
|
knee
|
|
|
most common bugs to infect joints
|
staph
strep N gonhorrhea |
|
|
hyperuricemia leads to what
|
high blood pressure
salt insensitivity |
|
|
most patients with hyperuricemia- mechanism
|
underexcretors
due to abnormality of renal urate transport |
|
|
things that impair urate excretion
|
renal insufficiency
diuretics cyclosporin |
|
|
less common mech for hyperuricemia
|
overproduction
|
|
|
urate anion exchanger
|
URAT1
located in prox renal tubule |
|
|
uricosuric drugs
|
probenecid
losartan inhibit URAT1 urate transporter in prox renal tubule |
|
|
probenecid
losartan |
inhibit URAT1 urate transporter in prox renal tubule
|
|
|
things that affect uric acid precipitation
|
low ph
low temp |
|
|
gout risk factors
|
men
age family HTN renal insufficiency metabolic syndrome/obesity alcohol |
|
|
joint pain, 1 swollen joint,
awaken in middle of night, early morning with pain usually 1st MTP joint |
acute gout
|
|
|
gout:
crystals are phagocytosed and stimulate what pathway? |
Toll like receptor pathway and NALP3 inflammosome-> IL 1 production-> neutrophils
|
|
|
needle shaped crystals
neg birefringement yellow parallel |
gout
|
|
|
rhomboid crystals
positive birefringement yellow perpendicular |
pseudogout
|
|
|
overhanging edge, subchondral punched out erosions on xray
|
gout
|
|
|
allopurinol mech
|
inhibits xanthine oxidase
lowers serum uric acid |
|
|
allopurinol hypersensitivity
|
steven johnsons syndrome rash
hepatitis inhibits azathioprine metabolism |
|
|
allopurinol inhibits metabolism of what drug
|
azothioprine
leads to leukopenia |
|
|
risk of taking probenecid for gout
|
nephrolithiasis
|
|
|
problem when first treating chronic gout with allopurinol
|
gout episodes increase at first
give NSAIDS/steroids in meantime |
|
|
medications that worsen hyperuricemia
|
diuretics- thiazides
(switch to ARB losartan) low dose aspirin |
|
|
if gout, replace patients diuretic with
|
losartan (ARB)
|
|
|
elderly
joints affected are knee/elbow/wrist |
pseudogout
|
|
|
young person with pseudogout
|
hyperPTH
hemochromatosis |
|
|
triggers for pseudogout
|
hospital
surgery trauma age |
|
|
Lyme disease rash
|
erythema migrana
|
|
|
Lyme cardio probs
|
carditis manifested as heart block
|
|
|
Lyme arthritis stuff
|
60%
usually the knee |
|
|
tx Lyme arthritis
|
doxycycline
|
|
|
what is erythema nodosum?
|
a septal panniculitis (inflam of subq adipose)
appears as tender red nodules over anterior shins synovitis over ankles may go with it |
|
|
cartilage is made of what type of collagen
|
2
|
|
|
largest glycoprotein in cartilage
|
aggrecan:
glycosaminoglycan chains, mostly chondroitin and keratin sulfate |
|
|
OA cause- increased bone density disease
|
pagets
|
|
|
OA cause- abnormal collagen disease
|
inherited CT diseases
(marfans, ehlers danlos) |
|
|
OA genetics
|
nodular OA is usually inherited from mother's side
|
|
|
leading risk factor for OA of knee
|
obesity
|
|
|
nodal OA
|
base of thumb- 1st CMC
knees 1st MTP facet joints of cervical and lumbar |
|
|
bursae
|
synovium lined sacs in areas where there are planes of tissue movement
|
|
|
sites of bursae
|
olecranon
greater trochanter first MTP bunion joint |
|
|
subscapularis
|
internal rotation
adduction |
|
|
pec major
|
internal rotation
adduction |
|
|
latissimus dorsi
|
internal rotation
adduction |
|
|
3 structures to think of with shoulder pain that are not muscles
|
coracoacromial ligament
subacromial bursa tendon of long head biceps |
|
|
shoulder impingement syndrome
|
repetitive overhead activity
encroachment of coracoacromial arch of rotator cuff |
|
|
three stages of shoulder impingement
|
1. edema and hemorrhage (<25 yrs)
2. fibrosis and thickening of cuff ( 3. cuff/biceps tendon tear (>40 yrs) |
|
|
mechanism of tendinopathy
|
1. microinjuries due to repetitive use
2. abnormal collagen repair- increased MMPs |
|
|
what causes pain with tendinopathy
|
swelling
fibrosis calcium deposits stimulation of mast cells neuropeptides- sub p, cgrp, glutamate |
|
|
extrinsic sources of shoulder pain
|
cervical referred pain
diaphragm irritation apical lung lesion-pancoast cardiac herpes zoster |
|
|
well localized shoulder pain
postive impingement sign anterolateral pain normal passive ROM |
rotator cuff injury
|
|
|
shoulder stiffness
restricted active and passive ROM |
adhesive capsulitis or genohumeral arthritis
|
|
|
signs of rotator cuff tear
|
weakness of supraspinatous
impaired abduction |
|
|
ROM tests for rotator cuff impingement
|
AB
ER IR |
|
|
overhead activity triggers pain
|
rotator cuff impingement
|
|
|
tx rotator cuff tendinopathy
|
PT
corticosteroid injection acromioplasty |
|
|
night pain
shoulder impingement signs pain and weakness drop arm test lidocaine injection test- weakness |
rotator cuff tear
|
|
|
rotator cuff tear
|
night pain
shoulder impingement signs pain and weakness drop arm test lidocaine injection test- weakness |
|
|
adhesive capsulitis
|
inflammatory
frozen shoulder 40-70 yrs old |
|
|
stiff shoulder
not always painful restricted AB and ER on both passive and active ROM |
adhesive capsulitis
|
|
|
tx adhesive capsulitis
|
PT
corticosteroid injection 1 year recovery |
|
|
who is at risk for adhesive capsulitis
|
patients with diabetes
|
|
|
hips
shoulders older |
polymyalgia rheumatica
|
|
|
2 kinds of RA
|
seropositive
seronegative |
|
|
young men (20s) with back pain
|
spondyloarthropathies
|
|
|
lateral epicondylitis mechanisms
|
extensor tendinopathy
microtear with collagen disarray |
|
|
dull ache about elbow
pain by grasping or twisting symptoms radiate into the forearm hand or arm weakness |
symptoms of lateral epicondylits
|
|
|
lateral epicondylitis clinical findings
|
tenderness over lateral epic
also distal and anterior to epicondyle resisted wrist extension provokes pain normal ROM |
|
|
areas most prone to bursitis infection
|
olecranon
prepatellar |
|
|
how does bursitis occur
|
dry cracked skin subjected to friction-> infection of bursa
|
|
|
median nerve in carpal tunnel can be trapped by
|
transverse carpal lig
|
|
|
conditions associated with carpal tunnel syndrome
|
most are idiopathic
pregnancy- edema inflam arthritis hypothyroid- edema wrist fracture diabetes- neuropathy amyloidoisis- infiltrate |
|
|
numbness or tingling over wrist
shake hand to relieve symptoms positive tinel or phalen test EMG shows slow nerve conduction |
carpal tunnel syndrome
|
|
|
most common systemic autoimmune disease
|
lupus
|
|
|
major connective tissue diseases:
5 |
lupus
mixed CT disease inflammatory myositis scleroderma sjogrens |
|
|
2 types of inflammatory myositis
|
dermatomyositis
polymyositis |
|
|
where do autoantigens appear?
|
surface blebs of apoptotic cells
enters MHCII, activates B and T inherited defects in clearing apoptotic debris-> autoimmune dis. (ex: complement deficiencies, recetpor tyrosine kinase deficiencies) |
|
|
Lupus HLA types
|
HLA DR2
HLA DR3 |
|
|
HLA DR2
HLA DR3 |
lupus
|
|
|
SLE patients overexpress what
|
type 1 interferon-> inc release of cytokines, activation of APCs, etc
|
|
|
Lupus pathology
|
multiple autoantibodies
circulating immune complexes tissue damage in multiple organs |
|
|
what can trigger lupus flares
|
UV light/sun
(increases apoptosis of keratinocytes and inc expression of autoantigens such as SSA) |
|
|
virus associated with lupus
|
epstein barr
|
|
|
lupus epi
|
women
asian african american |
|
|
lupus msk probs
|
polyarthralgia
small joint polyarthritis damage to joint capsule-> jacquards arthropathy/chronic lupus arthritis |
|
|
Jacquards arthropathy
|
chronic lupus arthritis
damage to the joint capsule |
|
|
difference between RA and lupus
|
Lupus: no cartilage damage, no bone erosions
|
|
|
butterfly rash
|
lupus
less than 50% of patients involves malar cheeks spares nasolabial folds |
|
|
discoid lupus
|
skin disease in lupus
raised plaques on face, scalp, hands |
|
|
subacute cutaneous lupus
|
associated with SSA/SSB autoabs
photosensitive papulosquamous eruption non scarring |
|
|
cardiopulmonary lupus
|
serositis
pleurisy pericarditis pulmonary hemorrhage interstitial lung disease libman sachs endocarditis |
|
|
lupus valve lesions- what valves
|
aortic
mitral seen frequently with patients with anti-phospholipid antibodies |
|
|
renal lupus
|
50% of patients
immune complex dep: low serum C3 high anti-dsDNA ab |
|
|
CNS lupus
|
headaches
organic brain syndrome seizures strokes movement disorders |
|
|
general symptoms of lupus
|
fever
fatigue anemia leukopenia thrombocytopenia lymphadenopathy |
|
|
lupus antiphospholipid and anticoagulant antibodies cause what
|
miscarriage
venous thrombosis |
|
|
highly sensitive, low specificity test for lupus
|
ANA
|
|
|
positive ANA and asymptomatic patient
|
thyroid disease
drug induced lupus |
|
|
malignancy causing positive ANA
|
lymphoma
|
|
|
inflammatory arthritis
rash fever fatigue |
lupus
most common presentation |
|
|
lupus ab:
nephritis hypocomplementemia |
anti-DNA
|
|
|
lupus ab:
cutaneous photosensitivity neonatal also sjogrens |
anti SSA/SSB
|
|
|
ab:
lupus raynauds mixed CT |
anti RNP
|
|
|
highly specific ab for lupus
|
anti Sm
more common in blacks |
|
|
lupus ab:
thrombosis fetal loss |
anti phospholipid
anticoagulant |
|
|
tx neonatal lupus
|
dexamethasone
otherwise baby has heart block and needs a pacemaker |
|
|
tx:cutaneous lupus
arthritis serositis drug? |
antimalarials- hydroxychloroquine
|
|
|
risk of antimalarials used to tx lupus
|
retinal toxicity
|
|
|
renal and cns lupus tx
|
immunosuppressants-
azothioprine mycophenolate mofetil cyclophosphamide |
|
|
progressive proximal muscle weakness
painless interstitial pneumonia dysphagia, dyspnea |
inflammatory myositis
|
|
|
inflammatory myositis;
parenchymal lung disease ab? |
anti Jo-1 ab
anti synthetase syndrome |
|
|
heliotrope rash
gottrons lesion |
dermatomyositis
|
|
|
perifasicular and perivascular lymphocytic infiltrate
immune complex deposition |
dermatomyositis
|
|
|
endomysial infiltrate of CD8 lymphocytes
|
polymyositis
|
|
|
heliotrope rash
|
violet colored eyelids
|
|
|
gottrons papules
|
over knuckles
|
|
|
two forms of scleroderma
|
CREST (limited)
progressive system scleroderma |
|
|
scleroderma epi
|
more common in women
|
|
|
vascular component of scleroderma
|
raynauds phenomenon
|
|
|
CREST/limited scleroderma skin involvement
|
hands
feet face |
|
|
progressive systemic sclerosis organ systems
|
skin- extensive
cardiopulm renal GI |
|
|
CREST organ systems
|
skin
cardiopulm GI (no renal, as in progressive systemic scleroderma) |
|
|
slow progression over years, first manifestation is raynauds
|
CREST
|
|
|
positive ANA
anti-Scl 70 ab |
progressive systemic sclerosis
|
|
|
positive ANA
anti-centromere ab |
CREST
|
|
|
symptom of early sclerodactyly
|
puffy diffuse swelling of fingers
|
|
|
cardiopulmonary scleroderma
|
pulmonary interstitial fibrosis
(leading cause of death) pulmonary htn pericardial effusions |
|
|
renal scleroderma
|
hypertensive crisis
microangiopathy hemolytic uremic syndrome seen within first 5 years of the disease |
|
|
GI scleroderma
|
fibrosis of LES
hypomotility dysphagia reflux diarrhea, constipation |
|
|
CREST stands for
|
calcinosis
raynauds sclerodactyly telangiectasia |
|
|
raynauds disease
|
benign vasospastic disorder
young adolescent women |
|
|
raynauds phenomenon
|
later in life = more likely a secondary cause
capillary pattern abnormalities in nail beds |
|
|
telangiectasia
|
dilated capillaries on palmar aspects of hands and in face
vasospasm small vessel occlusion gangrene |
|
|
tx scleroderma
|
symptoms only:
raynauds- ca channel blocker renal- ace inhib IPF- immunosuppressive |
|
|
sjogrens
|
exocrine tissue
lacrimal and salivary glands |
|
|
primary sjogrens
|
females
severe sicca parotid swelling extraglandular disease risk of lymphoma |
|
|
secondary sjogrens
|
females
mild sicca parotid swelling rare no nonexocrine symptoms no risk of lymphoma |
|
|
keratoconjunctivitis sicca
|
dry eyes
seen in sjogrens |
|
|
xerostomia
|
dry mouth
seen in sjogrens |
|
|
sicca syndrome
|
dry eyes
dry mouth sjogrens |
|
|
secondary is most commonly seen along with what
|
seropositive RA
|
|
|
extraglandular symptoms in primary sjogrens
|
arthralgia
raynauds cutaneous vasculitis interstitial lung disease interstitial nephritis peripheral neuropathy |
|
|
arthralgia
raynauds cutaneous vasculitis interstitial lung disease interstitial nephritis peripheral neuropathy |
primary sjogrens
|
|
|
pos ANA, SSA, SSB
|
primary sjogrens
|
|
|
pos RF, nonspecific ANA in some cases
|
secondary sjogrens
|
|
|
schimer test
|
dx sjogrens
measures timed wetting of litmus paper |
|
|
rose bengal staining
|
dx sjogrens
highlights dry areas of conjunctiva |
|
|
cells involved in sjogrens periductal inflammation
|
CD4 lymphocytes
|
|
|
tx sjogrens
|
symptoms only
immunosuppression for lung disease/vasculitis |
|
|
methotrexate mech
|
inhibits dihydrofolate reductase
anti inflamm release of adenosine t cell inhib |
|
|
methotrexate toxicity
|
teratogen
bm suppression cirrhosis hypersensitivity pneumonitis |
|
|
hydroxychloroquine use and mech
|
RA
SLE interferes with mac antigen presentation to T cells |
|
|
infliximab use and mech
|
RA, spondys, crohns
monoclonal ab to TNF that blocks binding |
|
|
rituximab mech
|
binds CD20+ cells and lysis them (B cells)
|
|
|
back pain
improves with activity does NOT improve with rest pain at night age < 40 |
ank spondy
|
|
|
heel pain
plantar fasciitis chest wall pain iritis |
ank spondy
|
|
|
sausage digit
pencil in cup spine, sacroiliac, and hip involvement |
psoriatic arthritis
|
|
|
reactive arthritis most common bug
|
chlamydia
followed by enterics |
|
|
psoriasis like rash
penile rash conjunctivitis lower extremity oligoarthritis fever |
reactive arthritis
1-2 weeks after an infection |
|
|
lower extremity oligoarthritis and IBD
|
reflects active flares
|
|
|
axial arthritis and IBD
|
not related to bowel activity
|
|
|
erythema nodosum + ankle synovitis
|
sarcoid
fungal infections tx NSAIDS (reccurrent think IBD) |
|
|
benign
painful- asprin helps!! males young long bones nidus- radioluscent core surrounded by dense bone |
osteoid osteoma- prostaglandin mediated
osteoblasts, immature woven bone |
|
|
causes of cauda equina syndrome
|
L4-5 disc herniation
b cell lymphoma |
|
|
female over 70
hx trauma or corticosteroid use back pain at thoracic or thoracolumbar junction cause? |
vertebral fracture- acute compression
|
|
|
acute back pain
constant progressive non mechanical- hurts with any movement cause? |
infection
|
|
|
root or leg symptoms with walk/stand
pain relief with stopping/sitting "shopping cart" leg pain> back pain |
neurogenic claudication
|
