MSK/Rheumatology

Gonna skip slides for poly and dermatomyositis and rheumatoid, pulling from book for those

Slides were not specific, book reading was short and had better info

Most common autoimmune disease

Sjögren's syndrome

sjorgens syndrome symptoms

dry eyes, dry mouth, bilateral parotid enlargement

Serologic hallmark of sjorgens

Antibodies against Ro/SS-A and La/SS-B

Gold standard for diagnosing sjogrens

Minor salivary gland lip biopsy with a chronic lymphocytic infiltrate

Is Sjogrens more common in men or women?

women 9-1

Sjogrens treatment

Hydroxychloroquine

Methotrexate

What is one complication of sjogrens

Lymphoma

End of slideshow 1

This guy was kinda bad

Juvenile idiopathic arthritis is classified as

Younger than 16

Lasts more than 6 weeks

Unknown cause

Systemic JIA

Most serious short/long term morbidity

Equal male and female

Involves wrist, knee, ankles, cervical spine, hands

Systemic JIA other symptoms

Daily fever in a pattern, salmon colored rash, lymphadenopathy, hepatosplenomegaly

Oligoarticular arthritis is and when does it present

Less than 5 joints total, most present before 5 years old, more females

Presentation?

Limp but not pain, knees most common, no systemic symptoms

Labs and what to watch for

Positive ANA, associated with chronic anterior uveitis, may be asymptomatic so needs regular eye exams

JIA: Polyarthritis, RF-

Presents throughout childhood, low grade fever, symmetric joint involvement

Knees, wrists, ankles, hands, cervical

JIA: Polyarthritis, RF+

12-16, mostly female, symmetrical small joint involvement, small lower jaw

Psoriatic arthritis presentation

Psoriasis

Nail pitting

Sausage digits from tendon inflammation

DIP joints involved

Inflammatory back disease

Enthesitis-related arthritis presentation

Females, between 9 and 11

HLA-B27 positive

Lower extremity arthritis that occurs when tendons or ligaments attach to bone

JIA treatment

NSAIDs

DMARDs

-methotrexate

--monitor liver functions

--no alcohol

--birth control!!! to prevent birth defects

-etanercept

--TB skin test required before and yearly

--SC injections once to twice a week

Corticosteroids

-systemic or intraarticular

--weight gain possible

--growth delays possible

--avoid infectious agents--immunocompromised possible

Physical therapy, occupational therapy, patient/family education

End of slideshow 2

Need a nap but it's too early

Who does lupus most commonly affect

Women, African American, 15-45

90% of lupus patients present with

Malaise, fatigue, arthalgia, myalgia

Photosensitivity in 70%

Lupus physical manifestations

Butterfly rash

Pleural effusion

Heart problems

Arthritis

Lupus nephritis

Raynaud's phenomenon

Discoid rash

Hair loss

Lupus diagnosis criteria

>4 criteria, 1 clinical and 1 lab

If a patient has a positive ANA, no other symptoms and no other antibodies do they have lupus?

Nah

Most specific antibody for SLE

Anti SM

What drugs are associated with lupus

Procainamide

Hydralazine

DIL antibody

Anti-histone antibody

Neonatal lupus is increased risk in those who have

SSA/AAB antibodies

Lupus treatment

Avoidance of sun, use of spf > 35

Healthy diet

Good sleep hygiene

Lupus meds

Oral and IV steroids have the quickest onset of action

Poor prognostic factors of lupus

Male, black, age extreme, HTN, renal disease

Causes of death in lupus

Infection

CVD accelerated atherosclerosis

Malignancy

Lupus prognosis

10 yr 85-90%

End of slideshow 3

It needs to be Halloween already

The hip joint is

Ball and socket joint

Highly mobile, highly stable

If hip ligaments are damaged the hip is

Dislocated, ligaments extremely difficult to injure

Patient will be unable to walk

What directions is the hip able to rotate

Abduction

Adduction

Internal rotation

External rotation

Extension

Flexion

Hip special tests

Not super accurate in practice but probably high yield for the test

What does the Obers/Nobles test for

IT band tightness

What to stinchfeild maneuvers help to distinguish?

Intra-articular pathology- OA, FAI(femoroacetabular displacement), labral tears versus iliopsoas/hip flexor pain

Thomas test is used for

Iliopsoas/flexor strains/tightness

FABER tests for

Flexion, abduction, external rotation

External posterior structures- SI, lumbar, piriformis, FAI

FADIR tests for

Flexion, abduction, internal rotation

Internal and anterior structures (FAI, labrum, iliopsoas)

Trendelenburg tests for

Glute med/abductor weakness

Logroll exam tests for

Hip fracture

Ortolani/Bartlow tests for

Infantile/congenital hip dysplasia

Femoroacetabular Impingement (FAI) presents with

Groin pain increased with flexion activities, pain with prolonged sitting, mechanical symptoms

FAI is most common in

Runners, congenital malformations (hip dysplasia)

FAI tests

FABER/FADIR, stinchfeild

FAI gold standard imaging

MRI

FAI treatment

Start with NSAIDs, PT, ergonomics, strength abductors

If failed- osteotomy, labral repair

Most hamstring injuries occurs in the

Myotendinous junction

Hamstring injury presentation

Intense pain, limping, posterior palpable pain, limited motion, bruising common

Often will have history of athletic event

Hamstring injury treatment

Clinical diagnosis, virtually all resolve with PT, surgical repair not recommended in almost all cases

Greater trochanteric bursitis presentation

Occurs from falling on affected hip or too much pressure, more in women

Pain localized to direct point tenderness over lateral hip (greater trochanter)

Greater trochanteric bursitis treatment

Exclusively conservative- avoid aggrevation, PT, NSAIDs, great option for cortisone injections

IT Band Friction Syndrome presents with

Almost always a overuse injury- running or cycling

Pain at lateral knee, better with rest

IT band tests

Obers

Noble

Trendelenburg

ITBFS diagnosis and treatment

Diagnosis is clinical

Treatment PT, NSAIDs, activity modification

Hip Osteoarthritis (OA) signs

Deep pain in groin when weight bearing

Stiffness or crepitation felt

Limp in end stages

Hip OA exam

Positive stinchfield maneuvers

Obvious gait deformities

Hip OA imaging

X-ray, always weight bearing

Is age a requirement for hip OA surgery

Never

Eventually most hip OA patients will need

Total hip arthroplasty

Complication of total hip arthroplasty and treatment

Sepsis, immediate washout, IV antibiotics (PICC) and holiday

Contraindications to cortisone injection

Diabetes (A1C under 8)

Immunosuppression/cancer

Infection

Allergy

Severe bone loss/necrosis

Avascular necrosis is

Vascular insufficiency issue

Progressive, irreversible

MRI finds 99%

Most common indirect cause of avascular necrosis

Alcohol is most common

SLE

Long term oral corticosteroid use

AVN treatment if caught early

Prevention is best

Bisphosphonates if caught early

Eventually most AVN patients need

Total hip arthroplasty

What is the most common hernia in the groin

Inguinal

Athletic pubalgia

Sports hernia, strain/tear of soft tissue

Athletes in planting sports

Clinical diagnosis

Treatment is conservative treatment

Most common orthopedic hip fracture

Femur fractures (proximal)- intertrochanteric fractures

Unstable pelvic fractures are

Anterior-posterior compression

Lateral compression

Vertical shear

Developmental hip dysplasia is caused by

Shallow acetabulum leads to poor femoral head coverage

What is the top cause of developmental hip dysplasia

Breech

Most common adolescent hip disorder

Slipped Capital Femoral Epiphysis (SCFE)

SCFE is caused by and more common in

Cause- metaphysis slippage on epiphysis

More common- males and obese

SCFE treatment

Precutaneous pin placement

SCFE presentation and mode of imaging

Limping obese adolescent 10-12 years old with externally rotated foot with chronic pain

X-ray for imaging

Legg-Calve-Perthes Disease

Disrupted blood supply causes deformation of femoral head

LCPD risk factors and treatment

Positive family history

Low birth weight

Second hand smoke

After age 8 required osteotomy, monitor before then

Meralgia Paresthetica

-compression of the *lateral femoral cutaneous nerve

Burning/hypersensitivity of the lateral thigh region

More in men

Classically from tight belt/pants

Best test for meniscus

Thesalys- single led squat with rotation

Other meniscus tests

Mcmurray- flexion with valgus/varus stress

Apleys compression- prone, 90 degrees, axial compression with rotation applied

Circumduction maneuvers- flexion with rotation

Best test for ACL

Lachman's- knee flexed 90 degrees, clinician pulls towards themselves

PCL tests

Posterior drawer- examiner pushes back on tibia, looking for tibia to sag posteriorly

Sag sign

LCL/MCL stress tests

Valgus/Varus

Petellar Apprehension tests for

Patellar instability, MPFL tear/incompetency, patellar subluxation/dislocations

Patellar Grind Test (Clarke's Sign)

chondromalacia patella, patellar femoral OA

Patellar glide tests for

Patellar mobility/chondromalacia

Bulge sign tests for

Effusion

Effusion vs swelling

Effusion- fluid or intraarticular damage present

Feels like water balloon

Easiest to identify in suprapatellar region

Present with all ACL tears

Swelling- response to trauma, subcutaneous tissue and extraarticular structures

Rigid swelling would pose a concern for

Compartment syndrome

ACL tear mechanism

Rits final most common, hyper extension, direct trauma to posterior tibia

ACL management

Timely MRI, time to surgery matters

Start PT same day if possible

ACL history

Traumatic, feel pop, twisted or rotated knee, adolescent

ACL physical exam

Inability to extend or raise leg straight (extensor lag)

Limp, weight bearing trouble

Large effusion

Positive lachman is key