E1: conditions & syndromes part 1

infection of bone or bone marrow most commonly in metaphyseal end of long bone near knee joint, common in children (after URI or weak immune system), IVDU, immunocompromised, DM and after trauma

acute osteomyelitis

what is the treatment for acute osteomyelitis?

IV ABX → Cefazolin, clinda, vanco, FQ

what is the gold standard diagnostic test for acute osteomyelitis?

open biopsy & bone aspiration

what is the most common pathogen that causes acute osteomyelitis?

S. aureus

what is the first symptoms that adults experience with acute osteomyelitis?

limitation of joint movement

spinal tuberculosis is also called?

Pott's disease

what populations is chronic osteomyelitis common in?

elderly or malnourished

chronic osteomyelitis is most commonly caused by?

open fx or wound of extremities

what are S&S of chronic osteomyelitis?

s/p open fx

fever

pain

soft tissue swelling/inflammation

cellulitis

what is seen on an x-ray of chronic osteomyelitis?

irregular sclerotic bone destruction w several areas of radiolucency

involucrum

what is the treatment for chronic osteomyelitis?

I&D intra-operaticely

IV ABX 4-6 wks

consult ortho and ID

why is septic arthritis considered to be a medical emergency?

because it can rapidly destroy a joint

what population is septic arthritis more common in?

young

where does septic arthritis most commonly occur?

monoarticular large peripheral joints (knee or hip)

what is the most common pathogen causing septic arthritis?

adults → S. aureus

children → H. flu

IVDU → pseudo

what are the S&S of septic arthritis?

pain in joint → most common early symptom

warm/hot, swollen tender joint

limited ROM

limp when weight bearing

what is the confirmatory test for septic arthritis?

joint aspiration → will show cloudy fluid, purulent, WBC > 50,000

what is the treatment for septic arthritis?

IV ABX

emergent arthrotomy, I&D of joint

what occurs in the stages of Lyme disease?

early localized → erythema migrans, viral S&S

early disseminated → pericarditis, AV block, Bell's palsy, meningitis

late stage → conjunctivitis, joint pain & swelling (knee MC)

what are the diagnostic tests for Lyme disease?

IgM & IgG Borrelia antibodies

Western blot/ELISA to confirm dx

what is the treatment for Lyme disease?

doxy

children < 8 = amox

soft tissue lesion found in the extremities adjacent to joint or tendon sheath, most commonly on the dorm of the hand

ganglion cyst → MC soft tissue mass of hand

what is the treatment for ganglion cyst?

aspirate

inject steroid

excision

what are characteristics of benign bone tumors?

well defined

nonagressive

w/o cortical destruction or periosteal reaction

what are characteristics of malignant bone tumors?

lytic/moth-eaten

destructive

permeative

ill-defined

aggressive

cortical destruction

periosteal reaction

what are the 3 stages of benign bone tumors?

stage 1 → latent

stage 2 → active

stage 3 → aggressive

what is a sign of a malignant bone tumor?

dull aching pain that progresses over time

what is the most valuable imaging for diagnosing bone tumors?

x-ray

what is the most valuable imaging for evaluation of bone tumors?

CT

what are the 2 types of biopsies for bone tumors?

closed-needle

open-bone

what are the most important factors when diagnosing a bone tumor?

the morphology of the bone lesion on plain radiograph

age of the pt

what is the treatment for benign bone tumors?

observation

meds → biphosphonates (decrease activity of cells that dissolve bone)

excision

what are the treatment options for malignant bone tumors?

radiation

chemo

surgery

limb salvage

amputation

when do you refer a pt with a bone tumor?

suspicious bone or soft-tissue mass

unusual pain or night pain

constitutional symps w bone pain

lytic or plastic changes of bone

soft-tissue calcification

periosteal rxn

what population is a simple bone cyst more common in?

< 20 y/o

where are simple bone cysts most commonly seen?

80% proximal humerus or femur

what is seen on x-ray of a simple bone cyst?

central medullary lytic lesion

fluid-filled lesion

"fallen-leaf" sign → pathognomonic

a cartilage-capped bony spur arising on the external surface of a bone, most commonly the metaphysis of a long bone around knee or proximal humerus; common in childhood & YA

osteochondroma

what does osteochondroma look like on an x-ray?

bone arising from stalk or "bump" on bone

normal appearing bone growing from surface of bone

what is the treatment for osteochondroma?

Observation with radiographs yearly

where are giant cell tumors commonly located?

distal femur (knee = MC)

proximal tibia

distal radius

proximal humerus (Codman's tumor)

pelvis and sacrum

what is the synonymous tumor to a giant cell tumor in children?

chondroblastoma

what is seen on an x-ray of a giant cell tumor?

eccentric, lytic epiphyseal/metaphyseal long bones

lytic lesion may erode beyond cortex

where are enchondromas located?

hands and fingers

metaphysis of long bones

what does an enchondroma look like on an x-ray?

Lucent in hands and fingers

matrix calcification of long bones

what does an x-ray of fibrous dysplasia (which can occur in any bone) look like?

lytic, may expand the bone with thinning of the cortex

ground-glass appearance

Where is osteoid osteoma located?

long bones and posterior segments of the spine

what does an x-ray of osteoid osteomyelitis look like?

sclerotic with small Lucent nidus

distinct nidus

what is the treatment for an osteoid osteomyelitis?

night pain is responsive to NSAIDs or ASA

what are the 3 most common primary bone tumors?

osteosarcoma

Ewing's sarcoma

Chondrosarcoma

malignant tumor of the bone marrow

Multiple myeloma

what is the most common primary bone tumor, commonly occurs in teenagers

osteosarcoma

Where is osteosarcoma most commonly seen?

knee = MC

hip

shoulder

where does osteosarcoma originate from?

metaphysis in the femur, tibia and humerus

what is the most common met location of osteosarcoma?

lungs

what are S&S of osteosarcoma?

pain

swelling

+/- Paget's disease

what is the treatment for osteosarcoma?

chemo

limb salvage

what does an x-ray of osteosarcoma look like?

hair on end or sunray burst appearance (mixed sclerotic lesions)

Codman's triangle

what type of Ewing's sarcoma is most common in children?

giant cell tumor

what are the most common locations of Ewing's sarcoma?

diaphysis of bone:

femur

pelvis

upper arm

ribs

what are the S&S of Ewing's sarcoma?

painful soft tissue mass

weight loss

fever

what disease can Ewing's sarcoma mimic?

Osteomyelitis

what does an x-ray of Ewing's sarcoma look like?

lytic lesion with periosteal reaction

"onion peel" appearance

what is the treatment for Ewing's sarcoma?

chemo, surgery and radiation

what are the periosteal reactions from least malignant to most malignant?

solid → onion-peel → sunburst → Codman's triangle

cancer of cartilage most commonly seen in adults 40-70

chondrosarcoma

what are the MC locations of chondrosarcoma?

hip/pelvis and shoulder

progressive, irreversible condition involving the loss of articular cartilage that leads to pain and deformity specifically in the weight bearing joints (LEs and spine) and is associated with obesity, age, trauma and genetics

Osteoarthritis (OA)

- knee is MC joint then hips

what is the most common type of arthritis?

Osteoarthritis (OA)

which condition has diffuse wear and tear of articular cartilage, disorganized collagen and proteoglycan breakdown?

OA

which condition has S&S of stiffness, pain, decreased ROM, deep, poorly localized pain that is only relieved with rest and creptus?

OA

what will you see on physical exam of OA?

joint tenderness to palpation, decreased ROM and crepitus

- varus or valgus deformity

- Baker's cyst

- pain & limitation w internal rotation of hip

what does OA look like on an x-ray?

loss of joint space

sclerosis

subchondral cysts

osteophytes

what are adverse outcomes of OA?

pain

deformity

loss of limb function

joint instability

what is the treatment for OA?

lifestyle modifications

PT or OT

surgery

meds → NSAIDs, Tylenol, COX2 inhibitor, tramadol, steroids, opioids

viscosupplementation

when do you refer a pt with OA?

pain at rest

pain at night

pain is disabling

pain unrelieved w meds

loss of function