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230 Cards in this Set
- Front
- Back
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What is the primary medical reason for loss of time at work?
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back pain
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What are 7 epidemiologies of back pain?
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-Degeneration: herniated disc, degenerative disc
-Trauma: sprain, strain, herniated disc, fracture -Tumor:primary, metastatic -Infection: disc space, bone, retroperitoneal -Congenital or Developmental: scoliosis, kyphosis -Psychological: depression, narcissism, etc. -Malingering: secondary gain |
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What should be included in the history taking for back pain?
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Severity – Mild, Moderate, Severe
Nature – Sharp, Burning, Gnawing, Aching, Constant, Intermittent Onset – Sudden, Gradual Cause – Known, Unknown Location – Midline, Paraspinal, Buttock, Leg Aggravation – Flexion, Extension, Walking Relief – Flexion, Extension, Rest, Change in Position Duration – Days, Weeks, Months, Years |
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What are the "mechanisms" of back pain?
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Constant ache - inflammation, venous hypertension
Pain with motion – mechanical (strain, sprain, crush) Pain increase with activity – recurrent mechanical, inflammatory, degenerative disc Pain with sustained postures – fatigue Latent nerve root pain – acute and temporary neuropraxia |
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What are 7 predicitors of chronic back pain?
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Nerve root pain or specific spinal pathology
Severe pain during acute phase Belief pain is work-related Psychological stress Psychosocial aspects of work Compensation Duration of time of work |
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What diagnostic tests are used for back pain?
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Physical examination
Radiographs MRI Computerized Tomography Bone Scan/Dexa Scan Electromyography/Nerve Conduction Studies Laboratory testing |
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What should be done during the PE for back pain?
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Observation – gait, heel-toe, posture
Palpation – masses, lesions, tenderness ROM – flexion, extension, lateral bending, rotation Muscle Strength Neurological – dermatones, reflexes Special tests – Patrick, leg length discrepancy, Trendelenberg, straight leg raising, Valsalva, Thomas, Ober |
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Why are radiographs beneficial for back pain?
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bone detail (however, findings frequently not conclusive)
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What type of radiograph views are done for back pain?
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AP and Lateral
2 obliques, spot L5-S1 as needed Flexion and extension |
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Why is a MRI beneficial for back pain?
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bone/soft tissue detail
able to look at slices |
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What are the disadvantages of MRI? (3)
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expensive
lengthy process resources remain limited |
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Why is a CT beneficial for back pain? (3)
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bone detail
contrast good for space occuyping lesions good for 3D reconstructions |
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What is a bone/dexa scan beneficial for with back pain?
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Infections
Tumors Occult fractures Osteoporosis (Dexa Scan) |
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What is an EMG/NCS good for with back pain?
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localizing lesion
evaluate severity of damage to nerve can be done in office setting |
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When is an EMG/NCS valid?
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after first 3 weeks of symptoms
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What labs may be taken for back pain?
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CBC – systemic infection
ESR - inflammation CRP – inflammation, infection RA – rheumatoid disease ANA – SLE, RA, etc. HLA-B27 – Ankylosing spondylitis |
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What are the patterns of back dominant-mechanical pain caused by a disc, sprain, or strain?
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Back or buttocks
Dermatones not affected Myotomes seldom affected Flexion/Stiff in AM Onset – hours or days Duration – Days to months |
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What are the patterns of back dominant-mechanical pain caused by facet syndrome or strain?
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Back or buttocks
Dermatomes not affected Myotomes not affected Extension or rotation Onset – Minutes to hours Duration – Days to weeks |
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What are the patterns of back leg dominantnon-mechanical pain caused by nerve root irritation or herniated nucleus pulposis?
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Leg – usually below knee
Dermatomes painful Myotomes commonly affected Flexion Onset – Hours to Days Duration – Weeks to months |
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What are the patterns of back leg dominant non-mechanical pain caused by neurogenic intermittent claudication or spinal stenosis?
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Leg – usually below knee (may be bilateral)
Dermatomes painful Myotomes commonly affected (esp. in chronic cases) Walking Onset – with walking Duration (gradually more persistent) |
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On a scale of 0-5 for muscle strength, what number is normal?
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5
(0 is absent/flaccid) |
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24 year old male walks into your office requesting to be seen. He complains of low back pain for 12 hours. You have a time slot open and agree to see him. He states he was working on his pickup truck last PM when he twisted his back while changing his oversized tires. He has tried Goody’s powders and beer but his pain came back. What's going on?
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lumbar strain or sprain
-Muscular or ligamentous injury -Improper technique in lifting or twisting -Attempting higher weights than usual -Tx: NSAID, rest |
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43 year old competitive weightlifter arrives in your clinic in acute distress complaining of Rt posterior leg pain that initially started in his back, but now is primarily in his leg. It started last week while lifting weights. He has had no treatment as he does not like medicine.
What do you think is going on? |
herniated nucleus pulpsosis
-“slipped disc” -Protrusion of central disc material into spinal canal -May or may not impinge on nerve roots -Symptoms may vary as fragment shifts -May be simple bulge up to large free fragment |
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60 year old female RN with a history of intermittent low back pain for several months. She arrives at work stating that she suddenly has loss of bowel and bladder function. Her back pain is not present at this time. She has had previous PT and NSAIDs. What is her problem?
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cauda equina syndrome
-Loss of bowel, bladder function -May have initial back dominant pain, then leg dominant pain -Surgical emergency -Consult spine surgeon quickly |
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26 year old male barber complains of back pain, hip pain and stiffness. It is difficult for him to work a full day. He has tried OTC med with only temporary relief.
PE reveals decreased ROM of bilateral hips and the lumbar spine. Neurologically, he is intact. Why is he hurting? |
arthropathies
-may be from standing in one place for a long time -Marie-Strumpel Arthritis (anklosing spondylitis “bamboo spine”) -Degenerative disc disease (Exostoses “spurs” or “Dry disc”) -Spinal stenosis -Facet hypertrophy (spondylosis) |
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54 year old female presents with complaint of upper back pain that has gradually gotten worse in the last few days. There is no history of trauma. PMH is significant for breast CA about 5 years ago. No recurrence on last mammogram. Dexascan 1 year ago WNL. What do you think is going on?
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tumor
-Benign or malignant -Primary – original lesion (Myeloma, osteoid osteoma) -Secondary – metastatic disease (Breast, prostate, lung, thyroid, lymphoma) -Bone, meningeal, spinal cord |
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12 year old female with increasing back pain brought in because mother worried about posture. No history of trauma.
PE reveals gibbus deformity with local tenderness. Mild erythema over apex of gibbus deformity. What do you think could be going on? |
Infection
Bone Disc space Meningeal May be primary or from remote source -Surgical complication superficial to deep -Retroperitoneal infection -Other source (need to find) -may be TB? |
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16 year old male, brought in to ER via ambulance s/p MVA. He was passenger in VW beetle that spun on wet pavement.
PE reveals handle of tennis racquet in RLQ. Also has back pain and is paresthesthic in bilateral lower legs. What do you think is going on? |
fracture
-location? (body, lamina, spinous process) -type? (compression, burst, chance) |
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18 year old male Marine recruit in 3rd week of training complains of LBP when doing PT. Denies trauma. No leg pain. He had been previously seen by Hospital Corpsman and prescribed ibuprofen x 3 days, which helped, but the pain has not completely resolved. What do you think?
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pars defect
-Spondylolysis (inadequate development or stress fracture of pars interarticularis) -Spondylolithesis (slipping of vertebrae) -how much is it subluxed? (grading?) |
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What are 3 characteristics of osteoarthritis?
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Degeneration of articular cartilage
Pain Stiffness |
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What joints are the most affected by osteoarthritis?
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-Weight bearing surfaces
-also shoulder, elbow, wrist and metacarpal and distal inter-phalangeal joints |
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What is going on with osteoarthritis (pathophysiology)?
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-Non-inflammatory
-non-systemic -Gradual onset -All races -All ages but more prominent > 40 years of age -90% of all people have radiologic findings by age 40 -May be primary or secondary -May cause joint effusion |
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What are some of the non-pharmacologic treatment options for osteoarthritis (3)?
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cane
brace accupuncture |
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What are some of the pharmacologic treatment options for osteoarthritis (5)?
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Acetaminophen
NSAIDs Cox – 2 inhibitors Steroid Injections Hyaluronic Acid Injections |
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What are 3 surgical options for osteoarthritis?
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Debridement
Prosthesis Salvage Procedures |
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What type of crystals does gout have?
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urate
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What type of crystals does pseudogout have?
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calcium pyrophosphate
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What are 3 risk factors for an acute gout attack?
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alcohol ingestion
changes in diet rapid fluctuations in serum urate levels |
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What is the origin of primary hyperuricemia?
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idopathic; inc. production or decreased excretion of uric acid
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What are the origins of secondary hyperuricemia?
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myeloproliferative disorders
lymphoproliferative disorders carcinoma/sarcoma chronic hemolytic anemias cytotoxic drugs psoriasis intrinsic kidney disease impairment of tubular transport |
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What can cause functional impairment of tubular transport?
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thiazides
hyperlacticacidemia (EtOH, lactic acidosis) hyperketoacidemia (DKA, starvation) diabetes insipidus |
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What is tophus?
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nodular deposit of monosodium urate monohydrate crystals w/ associated foreign body rxn
-cartilage, subcutaneous, periarticular, tendon, bone, kidneys |
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Why is the relationship b/t hyperuricemia and gouty arthritis unclear?
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b/c some people can have one w/out the other
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What is podagra?
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gout in MTP joint of great toe (most common)
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What type of onset does gout have?
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acute, usually nocturnal and monoarticular
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Is fever common with gout?
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yes
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When is tophi usually seen and where does it generally occur?
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after several acute attacks
-may be on ears, hands, feet, olecranon, and prepatellar bursas |
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What can gout evolve into?
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chronic, deforming polyarthritis
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What do the labs for gout show?
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serum uric acid level elevated
sed rate/WBCs elevated |
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What do the sodium urate crystals look like under polarized light for gout?
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needle-like and negatively birefringent (blue in perpendicular light and yellow in parallel light)
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What type of lesions may develop adjacent to a soft-tissue tophus and are diagnostic of gout (seen on x-ray)?
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"rat bite" lesions
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What is a "rat bite" lesion?
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punched out lesion with an overhanging rim of cortical bone (gout)
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What is the treatment of choice for an acute gout attack?
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NSAIDs
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How is an acute attack of gout treated?
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NSAIDS (Indomethacin)
corticosteroids analgesics (not ASA) bed rest |
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What is the treatment between gout attacks focused on?
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minimizing urate deposition in the tissues
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How is gout treated b/t attacks?
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dietary changes (low purine diet, weight loss, reduction of EtOH, increased fluids)
avoidance of hyperuricemic meds (thiazides, loop diuretics, low doses of ASA, niacin) colchicine |
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What 2 drugs can be used if gout cannot be controlled by colchicine prophylaxis?
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uricosuric agents (undersecretors)
allopurinol (overproducers) |
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What do uricosuric drugs do?
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block tubular reabsorption of filtered urate
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Can uricosuric drugs be given with colchicine?
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yes
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What uricosuric drugs are used for gout?
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Probenecid (gradually inc.)
Sulfinpyrazone (gradually inc.) ASA (>3g) |
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What does Allopurinol do for gout patients?
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lowes plasma urate levels and facilitates tophus mobilization
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What is the most frequent adverse event with allopurinol?
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acute gout attack
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What drugs does Allopurinol have an interaction with?
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Ampicillin (rash)
Probenecid (increases half-life of probenecid, but probenecid increases excretion of allopurinol) Azathiprine (need to reduce dose before starting allopurinol) |
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What can a hypersensitivity rash progress to in patients taking Allopurinol?
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toxic epidermal necrolysis (2%)
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How can tophaceous deposits associated with chronic tophaceous gout be shrunk?
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with allopurinol therapy
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With chronic tophaceous gout, what do you need to maintain the serum uric acid level under?
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5mg/dL
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How can chronic tophaceous gout be treated?
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-may require use of Allopurinol and an uricosuric agent
-surgical excision of large tophi |
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Without treatment, how long can an acute gout attack last?
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a few days to several weeks
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When does chronic gout occur?
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after several inadequately treated attacks
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Where are the most common locations for pseudogout?
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knees and wrists
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What is chondrocalcinosis?
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presence of calcium-containing salts in articular cartilage
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What is the clinical correlate of chondrocalcinosis?
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pseudogout
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What is the age of patients who generally get pseudogout?
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>60 years
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What is pseudogout?
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acute, recurrent arthritis of large joints
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Is pseudogout familial?
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it can be
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What are the metabolic disorders that pseudogout is commonly associated with?
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hemochromatosis, hyper-parathyroidism, ochronosis, DM, hypothyroidism, Wilson’s disease, and gout
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How many hours after surgery does pseudogout often develop?
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24-48 hours (like gout)
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How is pseudogout diagnosed?
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by identification of calcium pyrophosphate crystals in joint aspirate
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How do the crystals appear under polarized light for pseudogout?
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rhomboid shaped with positive birefringence (blue when parallel and yellow when perpendicular)
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What do the x-rays for pseudogout show?
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calcification of cartilaginous structures and signs of DJD
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Does pseudogout improve with colchicine?
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no
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How is pseudogout treated?
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NSAIDS (acute episodes)
Colchicine (prophylaxis) steroid injections (resistant cases) |
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How is the examination of periarticular disorders accomplished?
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done by direct palpation, passive and active ROM, and isometric loading against resistance
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Was does palpation cause with synovitis?
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generalized tenderness over entire synovial surface
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Where is bursitits tenderness localized to?
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the bursa :)
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What can the pain of periarticular disorders be confused with?
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arthritis
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Does tendinitis cause swelling?
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only a little
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What is the best type of exam to elicit pain with tendinitis?
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active ROM or isometric loading
-Rarely tender with passive ROM unless it stretches the inflamed tendon |
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What are the 3 most common causes of shoulder pain?
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Subacromial bursitis
Rotator cuff problems Biceps tendinitis |
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What is the most common cause of shoulder pain?
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rotator cuff problems
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What is rotator cuff problems usually caused by?
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overuse of the arm in an overhead position
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What may acute impingement be caused by?
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a fall on the arm or shoulder
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When is there pain with rotator cuff problems?
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on active abduction of the shoulder
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When is pain usually worse with rotator cuff problems?
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at night
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Where is rotator cuff pain focused?
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over the lateral aspect of the shoulder, but can be tough to localize
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What is the ROM for rotator cuff problems?
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full passive ROM; Passive forward flexion to 90 degrees impinges the inflamed rotator cuff and confirms the diagnosis
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Are rotator cuff problems chronic?
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can be --> leading to a tear
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What anatomy does bicipital tendinitis involve?
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Involves the long head of the biceps as it traverses the bicipital groove
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Where is the pain for bicipital tendinitis located?
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anterior shoulder
-worse w/ active use of biceps |
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Where is bicipital tendinitis tender?
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to direct palpation of the tendon
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What can chronic tendinits lead to?
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rupture of the tendon
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What is the largest and most frequently inflamed shoulder bursa?
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subacromial bursa
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Where is the pain with subacromial bursitis?
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lateral aspect of the shoulder
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How does subacromial bursitis differ from rotator cuff tendinitis?
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presence of pain on direct palpation beneath the acromion process (subacromial bursitis)
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Does subacromial burstitis have full passive ROM?
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yes
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What increases the pain for subacromial bursitis?
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active resisted abduction
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What is adhesive capsulitis?
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"frozen shoulder"
-initially painful -Loss of passive and active ROM in all directions |
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What conditions is adhesive capsulitis associated with?
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DM, TB, cervical spine disease, upper extremity injuries, CAD, and chronic pulmonary disease
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What are the 2 most common causes of elbow pain?
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epicondylitis
olecranon bursitis |
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Is golfer's elbow medial or lateral epicondylitis?
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medial
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Is tennis elbow medial or lateral epicondylitis?
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lateral
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How is tenderness elicited with epicondylitis?
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direct palpation or strectching the involved muscle group
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Epicondylitis is an ___ syndrome.
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overuse
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Is swelling common with epicondylitis?
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no
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Where is tenderness and swelling localized with olecranon bursitis?
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to the bursa by palpation
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With olecranon bursitis, what 2 things should be excluded by examination/cultures of aspirate?
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infection
gout |
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What anatomy is involved with DeQuervain's tenosynovitis?
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First dorsal extensor compartment
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Who does DeQuervain's tenosynovitis typically affect?
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middle-aged women
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Where is the pain with DeQuervain's tenosynovitits located?
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along the radial aspect of the wrist
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What worsens DeQuervain's tenosynovitis?
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active use of the hand
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How is the diagnosis confirmed for DeQuervain's tenosynovitis?
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Finkelstein's test (ulnar deviation)--> exquisite tenderness
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What happens with trigger finger?
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-Painful clicking in the affected finger during active use
-Locking sensation when extending the flexed finger |
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What is trigger finger caused by?
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thickening of the A1 retinacular pulley in the palm, causing entrapment of the tendon within the tendon sheath
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How many main bursae are in the hip?
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3
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What is the most clinically significant bursa in the hip?
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trochanteric bursa
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What are 3 S/S of trochanteric bursitis?
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Hip pain
Tender to direct palpation Full passive ROM |
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What is prepatellar bursitis?
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Swelling and tenderness limited to prepatellar area
-Palpation along medial and lateral knee is unremarkable |
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Where is the pain for pes anserine bursitis located?
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medial aspect of the knee below the medial tibial plateau
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Is swelling common with pes anserine bursitis?
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no
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Where is tenderness with pes anserine bursitis?
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tenderness to palpation of the bursa
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How does patellar tendinits occur?
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overuse of the patellar tendon
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How is patellar tendinits exacerbated?
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Anterior knee pain exacerbated by use of the quadriceps muscles (jumping)
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Where is tenderness with patellar tendinits?
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tenderness to palpation localized to the patellar tendon
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Where is pain located with iliotibial band bursitis?
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over lateral aspect of the knee
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Where is tenderness with iliotibial band bursitis?
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confined to lateral aspect of the knee without effusion
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What is Achilles tendinitis?
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Posterior ankle pain reproduced by active loading of the Achilles tendon
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Where is pain localized with Achilles tendinits?
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to the tendon
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What is the risk of Achilles tendinitis?
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Achilles tendon rupture
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What is plantar fasciitis?
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Pain along the plantar surface of the medial heel is most common complaint
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How is the diagnosis of plantar fasciitis confirmed?
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by reproducing the pain with deep palpation of the plantar surface of the heel
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What physical therapy is generally helpful with periarticular disorders?
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ice and heat, strengthening exercises
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What can be used for analgesia for periarticular disorders?
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NSAIDs
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How are periarticular disorders treated?
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conservative (bed rest)
physical therapy NSAIDs intralesional steroid injections U/S therapy surgery |
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When may surgery be required for periarticular disorders?
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refractory cases
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What is a risk with intralesional steroid injections?
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tendon rupture
especially for Achilles and bicipital tendinitis |
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What are the essentials of diagnosis for septic (nongonoccal) arthritis?
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Sudden onset of acute arthritis, usually monarticular, most often in large weight-bearing joints and wrists
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What are 2 common risk factors for septic (nongonococcal) arthritis?
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previous joint damage
injection drug use (persistent bacteremia) |
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With septic (nongonococcal) arthritis, ___ with causative organism is commonly found elsewhere in the body.
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infection
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Are joint effusions usually small or large with septic (nongonoccal) arthritis?
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large
-with white blood cell counts commonly > 50,000/L |
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What is the most common cause of nongonoccal septic arthritis?
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Staphylococcus aureus
-followed by group A and group B streptococci |
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What type of arthritis is seen in injection drug users and in other immunocompromised patients?
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gram-negative septic arthritis (septic nongonococcal arthritis)
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What is the most usual organism in prosthetic joint arthritis?
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Staphylococcus epidermidis
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What is the onset for septic (nongonococcal) arthritis?
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sudden with pain swelling, and heat of one joint
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Where is the onset of septic (nongonococcal) arthritis most frequently located at onset?
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the knee
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What are the unusual sites for septic (nongonococcal) arthritis that can be involved in injection drug users?
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sternoclavicular or sacroiliac joint
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What 2 symptoms with septic (nongonoccal) arthritis are common but absent in 20% of patients?
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chills and fever
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What generally occurs with infection of the hip with septic (nongonococcal) arthritis?
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usually does not produce apparent swelling but results in groin pain greatly aggravated by walking (commonly children)
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What is included in the differential diagnosis of septic (nongonococcal) arthritis?
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Gonococcal arthritis
Gout pseudogout Acute rheumatic fever rheumatoid arthritis Still's disease |
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What differentiates septic (nongonoccal) arthritis from gout/pseudogout?
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Gout and pseudogout are excluded by the failure to find crystals on synovial fluid analysis
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What differentiates septic (nongonoccal) arthritis from acute rheumatic fever and rheumatoid arthritis?
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Acute rheumatic fever and rheumatoid arthritis commonly involve many joints
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What differentiates septic (nongonoccal) arthritis from Still's disease?
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Still's disease may mimic septic arthritis, but laboratory evidence of infection is absent
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What diagnostic procedure is required for septic (nongonoccal) arthritis?
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joint aspiration (to differentiate from gout)
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What do the labs show for septic (nongonoccal) arthritis?
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-Blood cultures are positive in approximately 50% of patients
-The leukocyte count of the synovial fluid exceeds 50,000/L and often 100,000/L, with 90% or more polymorphonuclear cells -Gram stain of the synovial fluid is positive in 75% of staphylococcal infections and in 50% of gram-negative infections |
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What do x-rays show with septic (nongonoccal) arthritis?
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-usually normal early in the disease
-Bony erosions and narrowing of the joint space followed by osteomyelitis and periostitis may be seen within 2 weeks |
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How is septic (nongonoccal) arthritis treated medically?
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prompt antibiotics
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If the organism for septic (nongonococal) arthritis cannot be determined clinically, what type of antibiotics should be given?
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bactericidal antibiotics effective against staphylococci, pneumococci, and gram-negative organisms
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How is septic (nongonococal) arthritis treated surgically?
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Immediate surgical drainage septic arthritis of the hip, because it is inaccessible to repeated aspiration
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How is septic (nongonococal) arthritis treated therapeutically?
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-Rest, immobilization, and elevation at the onset of treatment
-Early active motion exercises within the limits of tolerance will hasten recovery -Frequent (even daily) local aspiration is indicated to complement antibiotic therapy when synovial fluid rapidly reaccumulates and causes symptoms |
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What are the complications for septic (nongonococal) arthritis if treatment is delayed or inadequate?
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Bony ankylosis and articular destruction
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What is the mortality rate for patients with polyarticular sepsis with septic (nongonococcal) arthritis?
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30%
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What is the prodrome for gonococcal arthritis?
|
migratory polyarthralgias
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What is the most common sign of gonococcal arthritis?
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tenosynovitis
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What type of monoarthritis is seen in 50% of patients with gonococcal arthritis?
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purulent
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Who is gonoccal arthritis most common in?
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-young women during menses or pregnancy
-male homosexuals |
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Does gonococcal arthritis generally have a skin rash?
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yes
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Does gonococcal arthritis frequently have symptoms of urethritis?
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no
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Does gonococcal arthritis respond to antibiotics?
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yes dramatically :)
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What is the most common cause of infectious arthritis in large urban areas?
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gonococcal arthritis
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Is gonococcal arthritis generally in healthy individuals?
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yes
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When does recurrent disseminated gonococcal infection occur?
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when there is a congenital deficiency of terminal complement components, especially C7 and C8
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Is gonococcal arthritis more common in men or women?
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women
-2-3 x more common in women than in men |
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After what age is gonoccal arthritis rare?
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after age 40
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What are the S/S of gonococcal arthritis?
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-1-4 days of migratory polyarthralgias involving the wrist, knee, ankle, or elbow
-60% will have tenosynovitis -40% will have purulent monarthritis, most frequently involving the knee -Less than half of patients have fever -Less than one-fourth have genitourinary symptoms -Most patients will have characteristic skin lesions: two to ten small necrotic pustules distributed over the extremities, especially the palms and soles |
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What is included in the differential diagnosis for gonococcal arthritis?
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Reactive arthritis (Reiter's syndrome)
Lyme disease involving the knee Infective endocarditis with septic arthritis Nongonococcal septic arthritis Gout or pseudogout Meningococcemia |
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What may the synovial fluid with gonococcal arthritis show?
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WBC > 50,000 cells/L
gram stain positive |
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Are positive blood cultures typically seen in gonococcal arthritis patients with tenosynovitis?
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in 40% of patients
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Are positive blood cultures typically seen in gonococcal patients with suppurative arthritis?
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virtually never
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What 3 types of cultures should be done in all gonococcal arthritis patients?
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urethral
throat rectal |
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What is the serum WBC count average in gonococcal arthritis patients?
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10,000 cells/L and is elevated in less than one-third of patients
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How is gonococcal arthritis treated?
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IV Ceftriaxone (Rocephin) or Spectinomycin
oral Cefixime, Levofloxacin, or Ciprofloxacin (once improvement from parenteral antibiotics has been achieved for 24–48h, patients can be switched to an oral regimen to complete a 7-to-10-day course ) |
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What are the key features of viral arthritis?
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-Arthritis may be a manifestation of many viral infections
-Generally MILD and of short duration, terminating WITHOUT lasting ill effects |
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What are the 5 clinical findings with viral arthritis?
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mumps arthritis
rubella arthritis human parvovirus B19 Hepatitis B Hepatitis C |
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Does mumps arthritis have to occur with parotitis?
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no, it may occur in the absence of parotitis
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Does rubella arthritis occur more commonly in adults or children?
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adults
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Does rubella arthritis occur immediately before, during, or soon after the disappearance of the rash?
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May appear immediately before, during, or soon after the disappearance of the rash
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How does rubella arthritis mimic rheumatoid arthritis?
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usually polyarticular and symmetric distrubution
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In adults, what may follow infection with human parvovirus B19?
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polyarthritis
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Is monoarticular or polyarticular arthritis generally associated with hepatitis B?
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polyarthritis
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Does viral arthritis typically occur before, during, or after the onset of jaundice?
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before
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In relation to the musculoskeletal system, what may hepatitis C be associated with?
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polyarthralgia or polyarthritis that mimics rheumatoid arthritis
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How is viral arthritis diagnosed?
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viral serologies
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How is viral arthritis treated?
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NSAIDs
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How may symptoms secondary to hepatitis C (viral arthritis) respond medically?
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Interferon and Riboviran
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What are the essentials of diagnosis for osteomyelitis?
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Fever and chills associated with pain and tenderness of involved bone
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What is essential for precise diagnosis of osteomyelitis?
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culture of blood or bone
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Are radiographs early in the course of osteomyelitis typically negative or positive?
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negative
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How does osteomyelitis occur?
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consequence of hematogenous dissemination of bacteria, invasion from a contiguous focus of infection, or skin breakdown
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In sickle cell anemia, what is the most common pathogen for osteomyelitis?
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*Salmonella
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In injection drug users, what is the most common pathogen for osteomyelitis?
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Staphylococcus aureus
or gram-negative infections (Pseudomonas aeruginosa and Serratia) |
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What are contiguous focus infections usually due to with osteomyelitis? (2)
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S. aureus or Staph. epidermidis
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What are the S/S of hematogenous ostemyelitis?
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-Associated with sickle cell disease, injection drug users, or the elderly
-High fever, chills, and pain and tenderness of the involved bone |
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What are the S/S of osteomyelitis from a contiguous focus of infection?
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Localized signs of inflammation are usually evident, but high fever and other signs of toxicity are usually absent
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What are the common sources of infection with osteomyelitis from a contiguous focus of infection? (4)
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Prosthetic joint replacement, decubitus ulcer, neurosurgery, and trauma
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What are the S/S of osteomyelitis associated with vascular insufficiency?
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-Infection originates from an ulcer or other break in the skin may appear disarmingly unimpressive
-Bone pain is often absent or muted by the associated neuropathy -Fever is also commonly absent |
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Does an arterial or venous lesion have shiny skin, hairless, dependent rubor (red when dangling, white when elevated), and is painful and well circumscribed?
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arterial
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What is included in the differential diagnosis for osteomyelitis?
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-Acute hematogenous osteomyelitis should be distinguished from suppurative arthritis, rheumatic fever, and cellulitis
-More subacute forms must be differentiated from tuberculosis or mycotic infections of bone or tumors -Cellulitis -Septic arthritis -Diabetic or arterial insufficiency ulcer -TB or mycotic bone infection |
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What labs are used for osteomyelitis?
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blood cultures
anemia of chronic disease elevated ESR |
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Are cultures from overlying ulcers, wounds, or fistulas reliable for osteomyelitis?
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*NO*
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What may early x-ray findings show with osteomyelitis?
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soft tissue swelling, loss of tissue planes, and periarticular demineralization of bone
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What may show up on x-ray about 2 weeks after onset of symptoms of osteomyelitis?
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erosion and alterations of bone appear, followed by periostitis
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What 3 types of imaging are more sensitive than conventional radiography for osteomyelitis?
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MRI
CT nuclear medicine bone scanning |
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What is one of the best bedside clues to osteomyelitis (clinical pearl)?
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*ability to easily advance a sterile probe through a skin ulcer to bone
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___ biopsy for osteomyelitis is essential except in those with hematogenous osteomyelitis with ___ blood cultures.
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bone
positive |
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What 2 methods are used for treatment of osteomyelitis?
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debridement of necrotic bone
prolonged admin. of antibiotics |
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What meds. are used to treat osteomyelitis?
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IV antibiotics for 4-6 wks OR oral quinolones (Cipro) for 6-8 wks
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When treating S. aureus associated with osteomyelitis, what are quinolones typically combined with?
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Rifampin
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When is revascularization of the extremity required with osteomyelitis?
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when osteomyelitis of a foot is accompanied by decreased perfusion due to large artery disease
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What does inadequate Tx of bone infections with osteomyelitis result in?
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chronic infection
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What are 2 complications of osteomyelitis?
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-inadequate treatment of bone infections results in chronic infection
-squamous cell transformation within the chronic fistula tract |
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What is the prognosis for osteomyelitis?
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-a good result can be expected in most cases if there is no compromise of the patient's immune system
-progression of the disease to a chronic form may occur, especially in the lower extremities and in patients in whom circulation is impaired (diabetics) |
