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Clinical Presentation

Anterior Shoulder Dislocation
pts hold arm in slight abduction and external rotation
(opposite posterior dislocations)
Which nerve is at risk in Anterior Shoulder Dislocation?
axillary nerve
Clinical Presentation

Posterior Shoulder Dislocation
rare

associated with sz and electrocutions

pts hold arm in adduction and internal rotation
(opposite anterior dislocations)
Tx

Shoulder Dislocations
reduction followed by a sling and swath

recurrent dislocations may need surgical tx
Which nerve is at risk in an anterior hip dislocation?
obturator nerve
Which nerve is at risk in an posterior hip dislocation?
sciatic nerve
Whats the mechanism and complication of Posterior Hip Dislocation?
most common > 90%

MECHANISM
posteriorly directed force on an internally rotated, flexed, adducted hip
"dashboard injury"

COMPLICATION
avascular necrosis
Tx

Hip Dislocation
closed reduction followed by abduction pillow/bracing

evaluate with CT after reduction
closed reduction is re-alignment of bone without opening the skin

x-rays before and after manually manipulating the bones to put it back together
Mechanism and appearance of a Colles' fracture.
involves distal radius bone

MECHANISM
fall onto an outstretched hand

APPEARANCE
dorsally displaced, dorsally angulated fracture
What patient population is more prone to Colles' fractures?
elderly (osteoporosis)

children
Tx

Colles' Fracture
closed reduction followed by application of a long-arm cast

open reduction if the fracture is intra-articular
Clinical Presentation

Scaphoid Fracture
may take 2 weeks for radiographs to show the fracture

assume a fracture if there is tenderness in the anatomical snuff box
Tx

Scaphoid Fracture
thumb spica cast

if displacement or scaphoid nonunion is present, tx with open reduction
Complication

Scaphoid Fracture
with proximal-third scaphoid fractures, AVN may result from disruption of blood flow
What is Boxer's fracture?
fracture of the 5th metacarpal neck

due to forward trauma of a closed fist

(eg punching a wall)
Tx

Boxer's Fracture
closed reduction and ulnar gutter splint

percutaneous pinning if the fracture is excessively angulated

if skin is broken, assume infection by human oral pathogens, tx with surgical irrigation, debridement, IV abx
(cover Eikenella)
What nerve is at risk of injury in a humerus fracture?
radial nerve
Clinical Presentation

Humerus Fracture
MECHANISM
direct trauma

NERVE INJURY
radial nerve palsy:
wrist drop and loss of thumb extension
Tx

Humerus Fracture
hanging-arm cast vs coaptation splint and sling

functional bracing
What is a "nightstick fracture"?
ulnar shaft fracture resulting from self-defense with the arm against a blunt object
Tx

"nightstick fracture"
open reduction and internal fixation
ORIF

if significantly displaced
What is a Monteggia's fracture?
diaphyseal fracture of the proximal ulna with subluxation of the radial head

DIAPHYSIS
middle part of long bone
Tx

Monteggia's Fracture
open reduction and internal fixation of the shaft fracture

closed reduction of the radial head
What is a Galeazzi's Fracture?
diaphyseal fracture of the radius with dislocation of the distal radioulnar joint

MECHANISM
results from a direct blow to the radius
Tx

Galeazzi's Fracture
open reduction and internal fixation of the radius

casting of the fractured forearm in supination to reduce the distal radioulnar joint
Risk Factors

Hip Fracture
osteoporosis
Clinical Presentation

Hip Fracture
shortened and externally rotated leg
Diagnosis

Hip Fracture
hip fractures can sometimes be radiographically occult

so a good clinical hx with negative radiographs should warrant a CT or MRI
Complications

Hip Fracture
displaced femoral neck fractures

increases the risk of AVN and nonunion
Other Conditions Associated With

Hip Fracture
DVTs
Tx

Hip Fracture
open reduction and internal fixation

displaced femoral neck fractures in elderly pts may require a hip hemiarthroplasty

anticoagulate to decrease likelihood of DVTs
Tx

Femoral Fractures
intramedullary nailing of the femur

irrigate and debride open fractures
Complications and Its Presentation

Femoral Fractures
FAT EMBOLI
F
AMS
dyspnea
hypoxia
petechiae
decreased platelets
Complications

Tibial Fractures
compartment syndrome
Tx

Tibial Fractures
casting vs intramedullary nailing vs ORIF
Tx

Open Fractures
ORTHOPEDIC EMERGENCY
must get to OR within 8-24 hrs in light of risk of infection

irrigation/debridement
repair fracture

abx
tetanus ppx
Clinical Presentation

Achilles Tendon Rupture
sudden "pop" like a rifle shot

more likely with decreased physical conditioning
Physical Exam

Achilles Tendon Rupture
limited plantar flexion

+Thompson's test
pressure on gastrocnemius leading to absent foot plantar flexion
Tx

Achilles Tendon Rupture
surgical repair

long-leg cast x 6 weeks
Mechanism

ACL Injury
noncontact twisting

forced hyperextension

impact to an extended knee
Physical Exam

ACL Injury
+ anterior drawer and Lachman tests

MCL INJURY = +valgus stress test

LCL INJURY = +varus stress test
Classic unhappy triad of knee injury involves which structures?
ACL
MCL
medial meniscus

however, lateral meniscal tears are more common in ACUTE ACL injuries
Mechanism

PCL Injury
posteriorly directed force on a flexed knee

(eg dashboard injury)
Physical Exam

PCL Injury
+ posterior drawer test
Mechanism

Meniscal Tears
acute twisting
or
degenerative tear in elderly pts
Clinical Presentation

Meniscal Tears
clicking or locking may be present
Physical Exam

Meniscal Tears
joint line tenderness

+ McMurray's test
palpate the joint line and move the leg around flex/extend/rotate tibia
pop or pain at the joint line is evidence of menisceal injury
Diagnosis

ACL/PCL/Meniscal Injuries
MRI
Tx

MCL/LCL and Meniscal Tears
can be conservative

especially if they are not athletes or not physically active or competing
Tx

ACL Injuries
surgical grafting from the patellar or hamstring tendons
Tx

PCL Injuries
PCL reconstruction

this is reserved for highly competitive athletes with high-grade injuries
Radial Nerve Injury

What is the motor deficit?
wrist extension
Radial Nerve Injury

What is the sensory deficit?
dorsal forearm and hand
(the first 3 fingers)
Radial Nerve Injury

What are common causes?
humeral fracture
Radial Nerve Injury

Clinical Finding
wrist drop
Median Nerve Injury

What is the motor deficit?
pronation

thumb opposition
Median Nerve Injury

What is the sensory deficit?
palmar surface
(the first 3 fingers)
Median Nerve Injury

Common Causes
carpal tunnel
Median Nerve Injury

Clinical Findings
weak wrist flexion

and

flat thenar eminence
Ulnar Nerve Injury

What is the motor deficit?
finger abduction
Ulnar Nerve Injury

What is the sensory deficit?
palmar and dorsal surface
(the last 2 fingers)
Ulnar Nerve Injury

What is the common cause?
elbow dislocation
Ulnar Nerve Injury

Clinical Finding
claw hand

(ring and pinky curl towards palm)
Axillary Nerve Injury

What is the motor deficit?
abduction
Axillary Nerve Injury

What is the sensory deficit?
lateral shoulder
Axillary Nerve Injury

What is the common cause?
*anterior* humeral dislocation
Peroneal Nerve Injury

What is the motor deficit?
dorsiflexion
eversion
Peroneal Nerve Injury

What is the sensory deficit?
dorsal foot

lateral leg
Peroneal Nerve Injury

What is the common cause?
knee dislocation
Peroneal Nerve Injury

Clinical Finding
foot drop
What is compartment syndrome?
increased pressure within a confined space that compromises nerve, muscle and soft tissue perfusion
Where does compartment syndrome normally occur?
anterior compartment oft he lower leg

forearm
Clinical Presentation

Compartment Syndrome
pain out of proportion to physical findings

pain with passive motion of fingers and toes
What are the 6 P's of compartment syndrome (and peripheral vascular disease)?
pain out of proportion
paresthesias
pallor
poikilothermia
pulselessness
paralysis
Diagnosis

Compartment Syndrome
measure compartment pressure
positive if > 30 mmHg

measure delta pressures
diastolic - compartment pressure
positive if > 30 mmHg
Tx

Compartment Syndrome
immediate fasciotomy

to decrease pressures and increase tissue perfusion
What is carpal tunnel syndrome?
entrapment of the median nerve at the wrist

caused by decreased size or space of the carpal tunnel
What can precipitate carpal tunnel syndrome?
overuse of wrist flexors
What is carpal tunnel syndrome associated with?
DM

thyroid dysfunction
Patient population mostly affected by carpal tunnel syndrome.
pregnant

middle-aged women
Clinical Presentation

Carpal Tunnel Syndrome
aching over the thenar area of the hand and proximal forearm
Physical Exam

Carpal Tunnel Syndrome
paresthesias or numbness in a media nerve distribution
(first 3 fingers, palm side)

thenar atrophy
(if long-standing)
When does carpal tunnel syndrome pain worsen?
at night
or
when wrists are flexed
What are two physical tests for carpal tunnel?

Describe each.
Phalen's maneuver
flexing the wrist produces pain

Tinel's sign
lightly tap over the nerve elicits tingling
Diagnosis

Carpal Tunnel Syndrome
clinical impression

EMG can confirm
Tx

Carpal Tunnel Syndrome
splint the wrist in a neutral position at night and during day

NSAIDs

CONSERVATIVE TX
steroid injection into carpal canal
Surgical Tx

Carpal Tunnel Syndrome
surgical release of the carpal tunnel
(widely accepted form of tx)

particularly helpful for fixed sensory loss, thenar weakness, or intolerable sx
What is the purpose of the bursa?
it's a flattened sac filled with a small amount of synovial fluid

serves as a protective buffer btw bones and overlapping muscles
Common sites of bursitis.
subacromial
olecranon
trochanteric
prepatellar
infrapatellar
What causes bursitis?
repetitive use
trauma
infection
systemic inflammatory dis
Clinical Presentation

Bursitis
hx of trauma or inflammatory dis
Physical Exam

Bursitis
localized tenderness

decreased ROM

edema

erythema
Diagnosis

Bursitis
needle aspiration if septic bursitis is suspected

no labs or imaging needed
Tx

Bursitis
CONSERVATIVE
rest
heat
ice
elevation
NSAIDs
Tx

Septic Bursitis
do not inject steroid!

abx 7-10 days
What medication is associated with an increased risk of tendon rupture and tendinitis?
PO FQ
Describe tendinitis.
pain at tendinous insertions into bone

inflammation
swelling
impaired function
Common sites of tendinitis.
supraspinatus
biceps
wrist extensor
patellar
iliotibial band
posterior tibial
achilles tendon
Physical Exam

Tendinitis
pain at tendinous insertion

pain worsens with repetitive stress or if the pt resists strength testing
(pull or push to assess muscle strength)
Diagnosis

Tendinitis
clinical diagnosis

radiograph if trauma
Tx

Tendinitis
rest and NSAID's

ice for first 24-48 hrs

CONSIDER
splinting
bracing
immobilization

CONDITION
strength exercise after pain is gone
Is injection of the achilles tendon a good idea to tx tendinitis?
NEVER

risk of rupture
If the patient fails conservative tx of tendinitis, what can you do next?
surgical debridement
Nerve Root L4

What is the motor deficit?
foot dorsiflexion
(tibialis anterior)
Nerve Root L4

What is the sensory deficity?
medial aspect of the lower leg
Nerve Root L4

What is the reflex deficit?
patellar
Nerve Root L5

What is the motor deficit?
big toe dorsiflexion
(extensor hallucis longus)

foot eversion
(peroneus muscle)
Nerve Root L5

What is the sensory deficit?
dorsum of the foot

lateral aspect of the lower leg
Nerve Root L5

What is the reflex deficit?
none
Nerve Root S1

What is the motor deficit?
plantar flexion
(gastroc/soleus)

hip extension
(glut max)
Nerve Root S1

What is the sensory deficit?
plantar and lateral aspects of the foot
Nerve Root S1

What is the reflex deficit?
achilles
Most herniated disks occur in which region?
MOST COMMON SITE L5-S1

2ND MOST COMMON SITE L4-L5
Clinical Presentation

Herniated Disk
sudden onset, severe, electricity like low back pain

preceded by months of aching, "discogenic" pain

numbness, tingling, muscular weakness, paralysis, paresthesia, and affection of reflexes
What worsens low back pain from herniated disk?
increased intra-abdominal pressure or valsalva (coughing)
What sx are associated with herniated disk?
sciatica
paresthesias
muscle weakness
atrophy
contractions
spasms
Physical Exam

Herniated Disk
passive straight-leg raise increases pain
(sensitive but not specific)

crossed straight-leg raise increases pain
(specific but not sensitive)
Large midline herniations can cause what syndrome?
cauda equina syndrome
What are the sx of cauda equina syndrome?
bowel or bladder dysfunction
(urinary overflow incontinence)
impotence
saddle-area anesthesia

CAUDIA-EQUINA SYNDROME IS A SURGICAL EMERGENCY
Diagnosis Herniated Disk
ESR
BACK X-RAY
shows herniation

MRI
for caudia equina or severe, rapidly progressive or refractory to conservative mgmt
Tx Herniated Disk
NSAIDs
physical therapy
local heat

all x 4 weeks
What is advised and not advised in the conservative tx of herniated disks?
DO NOT ADVISE BED REST
most lower back pain is mechanical
so bed rest is contraindicated

CONTINUE REGULAR ACTIVITIES
What are red flags for lower back pain?
age > 50
> 6 weeks of pain
previous cancer history
severe pain
constitutional sx
neurologic deficits
loss of anal sphincter tone
What is spinal stenosis?
narrowing of the lumbar or cervical spinal canal

leads to compression of the nerve roots and spinal cord
Most common cause of spinal stenosis.
DJD

PATIENT POPULATION
middle-aged or elderly pts
Clinical Presentation

Spinal Stenosis
neck pain radiates to arms
back pain radiates buttocks or legs
leg numbness/weakness
Clinical Presentation

Lumbar Stenosis
leg cramping is worse with standing and with walking
What improves sx of lumbar stenosis?
sx improve with flexion at the hips and bending forward

relieves pressure on the nerves
Diagnosis

Spinal Stenosis
X-RAYS
shows degenerative changes that include:
disk space narrowing
facet hypertrophy
sometimes spondylolisthesis

MRI/CT
shows spinal stenosis
Tx

Spinal Stenosis
MILD TO MODERATE
NSAIDs and abdominal muscle strengthening

ADVANCED
epidural steroid injections
Refractory to Conservative Treatment

Spinal Stenosis
surgical laminectomy for short-term relief ... recurrence is a problem
Most common benign bone tumor.
osteochondroma
What is the second most common primary malignant bone tumor?
osteosarcoma second to multiple myeloma
Where does osteosarcoma normally occur in the bone?
distal femur
proximal tibial
proximal humerus
Where does osteosarcoma usually metastasize to?
lungs
Clinical Presentation

Osteosarcoma
progressive and eventually intractable pain that worsens at night

CONSTITUTIONAL SX
F
wt loss
night sweats

erythema/enlargement over tumor site
X-RAY FINDINGS

Osteosarcoma
CODMAN'S TRIANGLE

periosteal new-bone formation at the diaphyseal end of the lesion

SUNBURST PATTERN
CT / MRI

Osteosarcoma
MRI/CT of chest for staging and surgical planning
Tx

Osteosarcoma
limb-sparing surgical procedures

pre and postop chemo
(methotrexate, doxorubicin, cisplatin, ifosfamide)

amputation may be necessary
Classic Finding

Ewing's Sarcoma
child 10-20 yo

X-RAY
multilayered "onion-skinning" in the diaphyseal regions of femur
Classic Findings

Giant Cell Tumor of Bone
female 20-40 yo

knee pain and a mass

X-RAY
"soap bubble" in the epiphyseal/metaphyseal region of long bones
What are the risk factors for septic arthritis?
GREATLY INCREASED RISK
prosthetic joints

OTHERS
rheumatoid arthritis
osteoarthritis
Clinical Presentation

Septic Arthritis
warm, red, immobile joint

palpable effusions

F/chills if bacteremic
Diagnosis

Septic Arthritis
joint aspiration

WBC > 80,000 + gram stain + fluid culture
Most common organisms

Septic Arthritis
Staph
Stretp
GNRs
Tx

Septic Arthritis
EMPIRIC
CTX and Vanco

SEPTIC JOINTS
surgical debridement or serial aspirations
What kind of joints do osteoarthritis involve?
synovial joints
What are the characteristics of osteoarthritis?
deterioration of the articular cartilage

osteophyte bone formation at joint surfaces
Risk factors for osteoarthritis.
+ fam hx
obesity
hx of joint trauma
Clinical Presentation

Osteoarthritis
crepitus
decreased ROM
pain worse with activity and wt bearing
improves with rest
morning stiffness lasts < 30 min
stiffness after periods of rest ("gelling")
Diagnosis

Osteoarthritis
X-RAYS
joint space narrowing
osteophytes
subchondral sclerosis
subchondral bone cysts
SYNOVIAL FLUID RESULTS

Osteoarthritis
straw-colored fluid
normal viscosity
WBC < 2,000
Tx

Osteoarthritis
physical therapy
weight reduction
NSAIDs
intra-articular steroid injections

joint replacement in advanced cases
COMPARE/CONTRAST

The clinical history of osteoarthritis vs RA.
OSTEOARTHRITIS
affects elderly
slow onset
pain worsens with use

RA
affects the young
morning stiffness
improves with use
COMPARE/CONTRAST

The joint involvement of osteoarthritis vs RA.
OSTEOARTHRITIS
affects DIP, PIP, hips, knees

RA
affects wrists, MCPs
ankles, knees, shoulders, hips and elbows
symmetrical joint distribution
COMPARE/CONTRAST

The synovial fluid analysis and imaging of osteoarthritis vs RA.
OSTEOARTHRITIS
WBC < 2000
osteophytes
joint space narrowing on x-ray

RA
anti-cyclic citrullinated peptide (anti-CCP) antibodies
What kind of crystals do you see in gout?
monosodium urate crystals
What are the risk factors of gout?
male gender
obesity
postmenopausal status in females
binge drinking
What would you consider in a child who has gout and inexplicable injuries?
Lesch-Nyhan syndrome
hypoxanthine-guanine phosphoribosyltransferase deficiency --> uric acid build up

self-mutilation
Clinical Presentation

Gout
excruciating joint pain of sudden onset
most commonly affects first MTP joint (podagra)

midfoot, knees, ankles, wrists hips/shoulders are spared
Physical Exam

Gout
joints are erythematous, swollen, and exquisitely tender

Tophi
(urate crystal deposits in soft tissue)
seen in chronic disease
What are kidney manifestations in gout?
uric acid kidney stones
What color are gout crystals?
yellow
Diagnosis

Gout
JOINT ASPIRATION
needle-shaped negatively birefringent
elevated WBC
serum uric acid > 7.5
What signs do you see in advanced gout?
punched-out erosions with overhanging cortical bone

"rate-bite" erosions
Tx

Acute Attacks of Gout
HIGH DOSE NSAIDs
eg indomethacin

COLCHICINE
may be used but is inferior to NSAIDs

STEROIDS
use when NSAIDs are ineffective or contraindicated, as in renal disease
Maintenance Tx

Gout
allopurinol
for overproducers

probenecid
for undersecreters

wt loss
avoid triggers
avoid alcohol consumption
What kind of crystals are seen in pseudogout?
calcium pyrophosphate
rhomboid shape
weakly positive birefringence
Causes of hyperuricemia.
INCREASED CELL TURNOVER
hemolysis
blast crisis
tumor lysis
myelodysplasia
psoriasis

DRUGS
cyclosporine
diuretics
lead poisoning
salicylates (low dose)

OTHER
dehydation
DI
diet (eg red meat, alcohol)
Lesch-Nyhan syndrome
starvation
Mechanism of colchicine.
inhibits neutrophil chemotaxis
When is colchicine use most effective?
early in a gout flare
Side Effects

Colchicine
diarrhea
BM suppression (neutropenia)
GOUT VS PSEUDOGOUT

Contrast the clinical history.
GOUT
male
binge drinking
acute onset afterward

PSEUDOGOUT
hemochromatosis
hyperparathyroidism
GOUT VS PSEUDOGOUT

Contrast the physical findings.
GOUT
first big toe

PSEUDOGOUT
wrists and knees
GOUT VS PSEUDOGOUT

Contrast the crystal shape.
GOUT
needle-shaped

PSEUDOGOUT
rhomboid
GOUT VS PSEUDOGOUT

Contrast the crystal birefringence.
GOUT
negatively birefringence

PSEUDOGOUT
weakly positive
What is ankylosing spondylitis?
chronic inflammatory disease of spine and pelvis

leads to fusion of joints
What immunologic marker is associated with ankylosing spondylitis?
HLA-B27
Clinical Presentation

Ankylosing Spondylitis
ONSET
late teens early 20s
fatigue
intermittent hip pain
LBP that worsens with inactivity and in the mornings
Physical Exam

Ankylosing Spondylitis
POSITIVE SCHOEBER TEST
decreased spine flexion
loss of lumbar lordosis
hip pain and stiffness
decreased chest expansion
What are uncommon findings would you see in ankylosing spondylitis?
anterior uveitis
heart block
Diagnosis

Ankylosing Spondylitis
+ HLA-B27
85-95% of cases

X-RAYS
fused sacroiliac joints
squaring of the lumbar vertebrae
vertical syndesmophytes
bamboo spine

LABS
negative RF
negative ANA
increased ESR/CRP
Tx

Ankylosing Spondylitis
NSAIDs for pain (eg indomethacin)

Exercise to improve posture and breathing
Tx for refractory Ankylosing Spondylitis
tumor necrosis factor (TNF) inhibitors or sulfasalazine
DISEASES SIMILAR TO ANKYLOSING SPONDYLITIS

What are the characteristics of reactive arthritis?
AKA REITER'S SYNDROME
can't see, can't pee, can't climb a tree

PATIENT POPULATION
young men

FINDINGS
arthritis
uveitis / conjunctivitis
urinary sx
What organisms causes reactive arthritis?
Campylobacter
Shigella
Salmonella
Chlamydia
Ureaplasma
DISEASES SIMILAR TO ANKYLOSING SPONDYLITIS

Describe psoriatic arthritis.
DIP joints affected

SKIN CHANGES
sausage-shaped digits
(dactylitis - inflammation of the entire digit)

X-RAY
shows a classic "pencil in cup" deformity
DISEASES SIMILAR TO ANKYLOSING SPONDYLITIS

Describe enteropathic spondylitis.
sacroilitis
usually asymmetric
associated with IBD
What is polymyositis?
immune-mediated inflammation of striated muscle

connective tissue disease
What is dermatomyositis?
sx of polymyositis + cutaneous involvement
Clinical Presentation

Polymyositis
symmetric, progressive, proximal muscle weakness

pain and difficulty breathing or swallowing
Clinical Presentation

Dermatomyositis
Heliotrope rash
a violaceous periorbital rash

"shawl sign"
rash involving shoulders, upper chest, back

Gottron's papules
a papular rash with scales located dorsa of hands, over bony prominences
What are systemic sx of polymyositis and dermatomyositis?
myocarditis
cardiac conduction deficits
Diagnosis

Polymyositis and Dermatomyositis
SEROLOGIES
increased serum CK and anti-Jo-1 antibodies

MUSCLE BX
muscle inflammation
muscle fibers in various stages of necrosis and regeneration
Tx

Polymyositis and Dermatomyositis
high-dose corticosteroids with taper after 4-6 weeks

azathioprine and/or methotrexate can be used as steroid-sparing agents
What disease is associated with the following antinbody?

ANA
SLE
What disease is associated with the following antinbody?

Anti-CCP
RA
What disease is associated with the following antinbody?

Anticentromere
CREST syndrome
Scleroderma
What disease is associated with the following antinbody?

Anti-dsDNA
SLE
What disease is associated with the following antinbody?

Antihistone Ab
Drug-induced SLE
What disease is associated with the following antinbody?

Anti-Jo-1
Polymyositis
Dermatomyositis
What disease is associated with the following antibody?

Antimitochondrial
primary biliary cirrhosis
What disease is associated with the following antibody?

Anticentromere
scleroderma
What disease is associated with the following antibody?

Anti-Scl-70
Scleroderma
What disease is associated with the following antibody?

Anti-Sm
SLE
What disease is associated with the following antibody?

Anti-smooth muscle
Autoimmune hepatitis
What disease is associated with the following antibody?

Antitopoisomerase I
Scleroderma
What disease is associated with the following antibody?

Anti-TSHR
Graves' disease
What disease is associated with the following antibody?

c-ANCA
Vasculitis
especially Wegener's
What disease is associated with the following antibody?

p-ANCA
Vasculitis
especially microscopic polyangiitis
(Hematuria, Proteinuria)
What disease is associated with the following antibody?

Rheumatoid factor
RA
What disease is associated with the following antibody?

U1RNP Antibody
mixed connective tissue disease
Describe Rheumatoid arthritis.
autoimmune
symmetric joint involvement
synovial hypertrophy
pannus formation

EROSION OF
cartilage
bone
tendons
Risk factors for Rheumatoid arthritis.
female
age 35-50
What immunologic factor is associated with Rheumatoid arthritis?
HLA-DR4
Clinical Presentation

Rheumatoid arthritis
insidious onset of morning stiffness for > 1 hr

painful, warm, swelling of multiple symmetric joints
(wrists, MCP joints, ankles, knees, shoulders, hips, elbows)
for > 6 weeks
Constitutional Sx

Rheumatoid arthritis
F
fatigue
malaise
anorexia
wt loss
What do the joints look like in late stage rheumatoid arthritis?
ulnar deviation of the fingers

seen with MCP joint hypertrophy
What ligament and tendon deformations do you see in Rheumatoid arthritis?
swan-neck
boutonniere deformities
What features does Rheumatoid arthritis share with Sjogren's syndrome?
Keratoconjunctivitis
sicca
dry eyes
(dryness and/or inflammation of the cornea and conjunctivitis)
LABS

Rheumatoid arthritis
increased RF
(IgM ab against Fc IgG)

anti-CCP is more specific than RF
SYNOVIAL FLUID ASPIRATE FINDINGS

Rheumatoid arthritis
turbid fluid
decreased viscosity
elevated WBC (3,000 - 50,000)
IMAGING

Rheumatoid arthritis
EARLY
soft tissue swelling
juxta-articular demineralization

LATE
symmetrical joint space narrowing
erosions
Tx

Rheumatoid arthritis
NSAIDs
decrease or dc following DMARDs

DMARDs
(disease-modifying antirheumatic drugs)
start this early, includes:
**methotrexate**
hydroxychloroquine
sulfasalazine

2ND LINE AGENTS
TNF inhibitors
rituximab (anti-CD20)
leflunomide
Side effect of hydroxychloroquine.
retinal toxicity
How do you distinguish RA from OA by looking at the finger joints involved?
RA does not involve DIP joint

OA does
What are the 3 findings of Felty's syndrome?
RA
splenomegaly
neutropenia
CREST syndrome
Calcinosis
Raynaud's phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasias
What is scleroderma?
inflammation that leads to progressive tissue fibrosis and excess deposition of Type I and II collagen
What's the most common manifestation of scleroderma?
CREST syndrome
Clinical Presentation

Scleroderma
CUTANEOUS FORM
symmetric thickening of skin of face and/or distal extremities
CREST syndrome

DIFFUSE FORM
**pulmonary fibrosis**
cor pulmonale
acute renal failure
malignant HTN
LABS

Scleroderma
RF and ANA may be +

Anticentromere ab
specific for CREST

Anti-Scl-70 (antitopoisomerase 1) antibody
associated with diffuse
poor prognosis
Tx

Scleroderma
steroids for acute flares

penicillamine for skin changes

CCBs for Raynaud's

ACEIs
for renal disease and prevention of a scleroderma renal crisis
Complications

Scleroderma
PULMONARY FIBROSIS LEADS TO

pulmonary HTN
complications of pulm HTN
Criteria for SLE

DOPAMINE RASH
HAVE SLE IF HAVE 4 OF THESE:
Discoid rash
Oral ulcers
Photosensitivity
Arthritis
Malar rash
Immunologic criteria
Neurologic sx (lupus cerebritis, sz)
Elevated ESR

Renal disease
ANA+
Serositis (pleural or pericardial effusion)
Hematologic abnorm
Which patient population are at greatest risk for SLE?
African American women mostly

women of childbearing age some
Clinical Presentation

SLE
CONSTITUTIONAL SX
F
anorexia
wt loss
symmetric joint pain
LABS

SLE
+ ANA
sensitive but not specific

+ Anti-dsDNA and anti-SM
specific but not sensitive
LABS

Drug-Induced SLE
+ antihistone antibodies

100% of cases, but not specific
LABS

Neonatal SLE
+anti-Ro ab
transmitted from mother to neonate
Tx

SLE
NSAID's
for mild joint sx

ACUTE EXACERBATIONS
steroids
Tx

Progressive or Refractory SLE
HYDROXYCHLOROQUINE
for isolated skin and joint involvement
(side effect --> retinal toxicity)

CYCLOPHOSPHAMIDE
severe cases of lupus nephritis
(get a renal bx)
What is Libman-Sacks endocarditis?
noninfectious vegetations seen on mitral valve

associated with SLE and antiphospholipid syndrome
SLE can cause a false positive in what test?
VDRL and RPR
Compare and contrast SLE and RA.
SLE and RA both affect MCP and PIP

SLE is non-deforming though!
What kind of inflammation is temporal arteritis?
granulomatous inflammation
What vessels are affected in temporal arteritis?
large vessels:
aorta
external carotid (esp temporal branch)
vertebral arteries
Most feared manifestation of temporal arteritis.
blindness secondary to occlusion of central retinal artery
(a branch of the internal carotid)
Risk factors for temporal arteritis.
polymyalgia rheumatica
age > 50
female
Clinical Presentation

Temporal Arteritis
new HA
(unilateral or bilateral)

scalp pain

temporal tenderness

jaw claudication
Physical Exam Temporal Arteritis
F permanent monocular blindness wt loss myalgias/arthralgias (esp of shoulders and hips)
Diagnosis

Temporal Arteritis
ESR > 50
opthalmologic consult

Temporal Artery Biopsy
look for thrombosis
necrosis of media
lymphocytes
plasma cells
giant cells
Tx Temporal Arteritis
immediate high-dose prednisone to prevent ocular involvement
What is complex regional pain syndrome?
a pain syndrome accompanied by loss of function and autonomic dysfunction usually occurs after trauma
Name the 3 phases of complex regional pain syndrome.
acute/traumatic --> dystrophic phase --> atrophic phase
Clinical Presentation

complex regional pain syndrome
diffuse pain occurs out of proportion to the initial injury

in a non-anatomic distribution

loss of function of the affected limb

sympathetic dysfunction occurs and may be documented by skin, soft tissue or blood flow changes
Diagnosis

complex regional pain syndrome
clinical impression

objective changes in skin temperature, hair growth, or nail growth
Tx

complex regional pain syndrome
NSAIDs
steroids
low-dose TCAs
gabapentin
pregabalin
calcitonin
chemical sympathetic blockade

REFER TO CHRONIC PAIN SPECIALIST
What is fibromyalgia?
chronic pain disorder
soft tissue and axial skeletal pain
*absence of joint pain*
inflammation is notably absent

HURT EVERYWHERE
EXCEPT JOINTS
Patient Population

Fibromyalgia
women
30-50 yo
What conditions are associated with Fibromyalgia?
depression
anxiety
sleep disorders
IBS
cognitive disorders ("fibro fog")
Diagnosis

Fibromyalgia
multiple tender points

over all 4 body quadrants and axial skeleton

(> 11 of 18)
What is it called if you have < 11 of 18 tender points?
myofascial pain syndrome
Tx

Fibromyalgia
ANTI-DEPRESSANTS
SSRI/TCA combo
2 SNRIs combo

OTHERS
gabapentin
pregabalin
muscle relaxants
physical therapy
(stretching, heat application, hydrotherapy)

AVOID NARCOTICS
Risk factors for polymyalgia rheumatica.
female age > 50
Clinical Presentation

polymyalgia rheumatica
pain and stiffness of shoulder and pelvic girdle musculature

difficulty getting out of chair or lifting arms above head

F
wt loss

*weakness is NOT a sx*

50% OF PPL WITH PMR HAVE TEMPORAL ARTERITIS
Dx

polymyalgia rheumatica
markedly increased ESR

often anemia
Tx polymyalgia rheumatica
low-dose prednisone 10-20 mg/day
PEDIATRIC ORTHOPAEDIC INJURIES

What are the features of clavicular fractures?
birth related
brachial nerve palsies

involves middle third of clavicle

proximal fracture end displaced superiorly owing to pull of SCM
PEDIATRIC ORTHOPAEDIC INJURIES

What is the treatment of clavicular fractures?
figure-of eight sling vs arm sling
PEDIATRIC ORTHOPAEDIC INJURIES

What are the features of greenstick fractures?
incomplete fracture involving the cortex of only 1 side (tension side) of bone
PEDIATRIC ORTHOPAEDIC INJURIES

What is the treatment of greenstick fractures?
reduction with casting

order films at 10-14 days
PEDIATRIC ORTHOPAEDIC INJURIES

What are the features of nursemaid's elbow?
radial head subluxation that typically occurs as a result of being pulled or lifted by the hand

presents with pain and refusal to bend the elbow
PEDIATRIC ORTHOPAEDIC INJURIES

What is the treatment of nursemaid's elbow?
manual reduction by gentle supination of the elbow at 90 degrees of flexion

no immobilization needed
PEDIATRIC ORTHOPAEDIC INJURIES

What are the features of the Torus fracture?
buckling of the compression side of the cortex of a long bone 2nd to trauma

usually occurs in the distal radius or ulna
PEDIATRIC ORTHOPAEDIC INJURIES

What is the treatment for a Torus fracture?
cast immobilization for 3-5 weeks
PEDIATRIC ORTHOPAEDIC INJURIES

What are the features of supracondylar humerus fractures?
tends to occur at 5-8 yo

proximity to brachial artery increases risk of Volkmann's contracture
(results from compartment syndrome of forearm)

beware of brachial artery entrapment
(remember to do radial artery pulse test)
PEDIATRIC ORTHOPAEDIC INJURIES

What is the treatment for a supracondylar humerus fracture?
cast immobilization

closed reduction with percutaneous pinning if significantly displaced
What is Volkmann's contracture?
permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers

Passive extension of fingers is restricted and painful

fingers are white or blue and cold and the radial pulse is absent

COMPARTMENT SYNDROME OF THE FOREARM
humerus fracture results in acute ischemia/necrosis of the muscle fibres of the flexor group of muscles of the forearm
PEDIATRIC ORTHOPAEDIC INJURIES

What are the features of Osgood-Schlatter Disease?
overuse apophysitis of the tibial tubercle

causes localized pain, esp with quadriceps contraction, in active young boys
PEDIATRIC ORTHOPAEDIC INJURIES

What is the treatment for Osgood-Schlatter Disease?
decrease activity for 2-3 months or until asymptomatic

neoprene brace for symptomatic relief
PEDIATRIC ORTHOPAEDIC INJURIES

What are the features of Salter-Harris fractures?
fracture of the growth plate

FRACTURE PATTERN CLASSIFICATION
I - physis (growth plate)
II - metaphysis and physis
III - epiphysis and physis
IV - epiphysis, metaphysis and physis
V - crush injury of the physis
PEDIATRIC ORTHOPAEDIC INJURIES

What is the treatment for Salter-Harris fractures?
closed vs open reduction to obtain appropriate alignment

followed by immobilization
Inheritance Pattern

Duchenne Muscular Dystrophy
X-linked recessive
Pathogenesis

Duchenne Muscular Dystrophy
deficiency of dystrophin
(a cytoskeletal protein)

ONSET
3-5 yo
Clinical Presentation

Duchenne Muscular Dystrophy
MUSCLE INVOLVEMENT
axial and proximal muscles more than distal muscles

CLINICAL PRESNTATION
clumsiness
fatigability
difficulty standing/walking
Why do children with Duchenne muscular dystrophy have a hard time walking on toes?
gastrocnemius shortening
What maneuvers do Duchenne Muscular Dystrophy patients do?
Gower's maneuver
use hands to push off thighs when rising from the floor

Waddling gait
Describe the appearance of the gastrocnemius.
pseudohypertrophy
LABS

Duchenne Muscular Dystrophy
negative dystrophin immunostain

increased CK
EMG

Duchenne Muscular Dystrophy
polyphasic potentials
increased recruitment
MUSCLE BIOPSY FINDINGS

Duchenne Muscular Dystrophy
necrotic muscle fibers from degeneration

variation in fiber size with fibrosis from regeneration
Tx

Duchenne Muscular Dystrophy
physical therapy to maintain ambulation and prevent contractures

liberal use of tendon release surgery may prolong ambulation
Complications

Duchenne Muscular Dystrophy
mortality due to pulmonary congestion caused by high-output cardiac failure

(stemming from cardiac fibrosis)
DMD vs Becker Muscular Dystrophy

Age at Onset
DMD
3-5 yo

Becker's
5-15 and beyond
DMD vs Becker Muscular Dystrophy

Life expectancy
DMD
teens

Becker's
30-40s
DMD vs Becker Muscular Dystrophy

Presence of MR
DMD
MR is present

Becker's
uncommon
DMD vs Becker Muscular Dystrophy

Western Blot Result
DMD
dystrophin is markedly decreased or absent

Becker's
dystrophin levels normal, but the protein is abnormal
Another name for developmental dysplasia of the hip.
congenital hip dislocation
What causes developmental dysplasia of the hip?
dislocation of the hip joint due to poor development of the hip due to lax musculature and from excessive uterine packing in the flexed and adducted position (eg breech position)

leads to excessive stretching of the posterior hip capsule and contractures
What happens to the femoral head in developmental dysplasia of the hip?
subluxed or dislocated femoral head leads to early DJD
Patient Population

developmental dysplasia of the hip
first-born females in the breech position
What is Allis' (Galeazzi's) sign?
knees are at unequal heights when the hips and knees are flexed

(the dislocated side is lower)
What is Barlow's maneuver?
posterior pressure is placed on the inner aspect of the abducted thigh, and the hip is then adducted

leads to an audible "clunk" as the femoral head dislocates posteriorly
What is Ortolani's maneuver?
the thighs are gently abducted from teh midline with anterior pressure on the greater trochanter

a soft click signifies reduction of the femoral head into the acetabulum
Diagnosis

developmental dysplasia of the hip
EARLY DETECTION IS CRITICAL
to allow for proper hip development

US
helpful esp after 10 weeks of age

RADIOGRAPHS
are unreliable until pts > 4 mo bc of lack of ossification of the femoral head
Tx

developmental dysplasia of the hip
< 6 MONTHS
splint with a Pavlik harness
(maintains the hip flexed and abducted)

to prevent AVN, do not flex the hips > 60 degrees

6-15 MONTHS
spica cast

15-24 MONTHS
open reduction followed by spica cast
Complications

developmental dysplasia of the hip
joint contractures

AVN of femoral head

WITHOUT TREATMENT
significant defect by 2 yo
What is Legg-Calve-Perthes Disease?
idiopathic AVN of the femoral head

PATIENT POPULATION
4-10 yo
self-limited, lasts < 18 mo
Clinical History

Legg-Calve-Perthes Disease
painless limp

IF PAIN IS PRESENT
can be referred to knee
or pain in groin or anterior thigh
Physical Exam

Legg-Calve-Perthes Disease
limited abduction and internal rotation

atrophy of the affected leg
Tx

Legg-Calve-Perthes Disease
OBSERVATION
if there is limited femoral head involvement or if full ROM is present

IF EXTENSIVE OR DECREASED ROM
brace
hip abduction with a Petrie cast
osteotomy
What is Slipped Capital Femoral Epiphysis (SCFE)?
separation of the proximal femoral epiphysis through the growth plate

leads to inferior and posterior displacement of the femoral head relative to the femoral neck
Why is Slipped Capital Femoral Epiphysis misleading?
the epiphysis remains within the acetabulum while the metaphysis moves anteriorly and superiorly
Risk Factors

Slipped Capital Femoral Epiphysis
obesity
age 11-13
male
African American
Clinical History

Slipped Capital Femoral Epiphysis
acute or insidious groin or knee pain

painful limp

inability to bear weight

restricted ROM
(limited IR and abduction of hip)
What happens when you flex the hip in Slipped Capital Femoral Epiphysis?
flexion of the hip results in an obligatory external rotation

secondary to physical displacement
Diagnosis

Slipped Capital Femoral Epiphysis
X-RAYS OF BOTH HIPS IN AP AND FROG-LEG LATERAL VIEWS
reveals posterior and inferior displacement of the femoral head
What endocrinopathy is Slipped Capital Femoral Epiphysis associated with?
hypothyroidism

get a thyroid panel if the height is < 10th percentile
Tx

Slipped Capital Femoral Epiphysis
tx promptly since the disease is progressive

NO WEIGHT BEARING
until surgically stabilized

percutaneous single-screw fixation
Complications

Slipped Capital Femoral Epiphysis
chondrolysis

AVN of the femoral head

premature hip osteoarthritis leading to hip arthroplasty
What is scoliosis?
lateral curvature of the spine > 10 degrees

sometimes associated with kyphosis or lordosis
Patient Population

Scoliosis
M:F is 1:7
Clinical History

Scoliosis
idiopathic disease

identified during school physical screenings
Physical Exam

Scoliosis
ADAMS FORWARD BENDING TEST
vertebral and rib rotation deformities accentuated with bending forward
Diagnosis

Scoliosis
spinal x-rays
posterior, anterior, full-length views
Tx

Scoliosis
< 20 DEGREES
close observation

20-49 DEGREES
spinal bracing
(if patient has remaining growth)
curvature may progress even with bracing

> 50 DEGREES
surgery
Complications

Scoliosis
restrictive lung disease
What is Juvenile Idiopathic Arthritis (JIA)?

AKA Juvenile Rheumatoid Arthritis
non-migratory, nonsuppurative mono- and polyarthritis

with bony destruction
Patient Population

Juvenile Idiopathic Arthritis
< 16 yo
Clinical Presentation

Juvenile Idiopathic Arthritis
lasts > 6 weeks
95% resolve by puberty

F
nodules
erythematous rashes
pericarditis
fatigue
Juvenile Idiopathic Arthritis Subtype: Pauciarticular

Describe this subtype.
asymmetric arthritis
involves < 4 joints

increased risk of iridocyclitis
(leads to blindness if untreated)
Juvenile Idiopathic Arthritis Subtype: Polyarticular

Describe this subtype.
resembles RA
symmetric involvement of small joints

decreased risk of iridocyclitis
Juvenile Idiopathic Arthritis Subtype: Acute Febrile (Still's disease, systemic)

Describe this subtype.
the least common subtype

daily high, spiking fevers

maculopapular, evanescent, salmon-colored rash

HSM
no iridocyclitis
LABS

Juvenile Idiopathic Arthritis
no diagnostic test for JIA

+ RF in 15% of cases
ANA may be +

increased ESR, WBC, platelets
IMAGING

Juvenile Idiopathic Arthritis
soft tissue swelling and osteoporosis
Tx

Juvenile Idiopathic Arthritis
FIRST-LINE
NSAIDs
steroids

SECOND LINE
methotrexate