Ortho E1- Conditions/syndromes

What age group is commonly affected by acute osteomyelitis?

Children (<5)

What is the MC site of acute osteomyelitis?

Metaphyseal end of long bone near joints (knee common)

What is the tx for acute osteomyelitis?

IV abx 4-6 weeks

(Cefazolin, Clindamycin, Vanc, FQ -if Pseudomonas)

What are sx of acute osteomyelitis?

+ hx trauma, RA, immunocompromised, DM, sickle cell, IV drug use; limp, fever, swelling/heat/erythema to soft tissue

What is the gold standard for diagnosis of acute osteomyelitis?

Open biopsy & bone aspiration

When treating acute osteomyelitis, what should be done before giving abx?

Joint aspiration

What is the MC pathogen for acute osteomyelitis?

Staph aureus

Why do children develop acute osteomyelitis?

systemic illness

What is the MC cause of chronic osteomyelitis?

Open fx or wound of extremities

What are sx of chronic osteomyelitis?

s/p open fx, fever, pain, soft tissue swelling/inflammation, cellulitis

What would you see on an Xray showing Chronic osteomyelitis?

irregular sclerotic bone destruction w/ areas of radiolucency & involcrum (dead bone)

What is the tx for chronic osteomyelitis?

Ortho & ID consults, I&D, IV abx

What is the MC location of septic arthritis?

young, monoarticular, large peripheral joint such as knee or hip

What is the most common pathogen associated with septic arthritis in adults?

Staph aureus

What is the most common pathogen associated with septic arthritis in sexually active YA?

Neisseria Gonorrhea

What is the most common pathogen associated with septic arthritis in children?

H. influenza

What is the most common pathogen associated with septic arthritis in IV drug users?

Pseudomonas (G- rods)

What is the tx for septic arthritis?

IV abx, EMERGENT arthrotomy/I&D, serial needle aspiration & lavage, Monitor CRP levels

What is the confirmatory test for septic arthritis?

Joint aspiration (cloudy, purulent, WBC >50,000)

What is the MC soft tissue mass of the hand?

Ganglion cysts

What are ganglion cysts?

soft tissue lesions in extremities -adjacent to joint or tendon sheath

*MC to dorsum of hand

What is the tx for Ganglion cysts?

50% resolve spontaneously, needle aspiration, excision

What are the characteristics of benign bone tumors?

well-defined, nonagressive, w/o cortical destruction, periosteal rxn

What are the characteristics of malignant bone tumors?

lytic, destructive, permeative, ill-defined, aggressive, moth-eaten, cortical destruction, periosteal rxn

How do benign bone tumors typically present?

may or may not be aggressive; present in 3 stages - latent, active, aggressive

How do malignant bone tumors typically present?

dull aching pain that progresses over time

What are the 5 MC primary cancers that metastasize?

Breast, Lung, Kidney, Thyroid, Prostate

What is the most valuable imaging when assessing bone tumors?

Xrays

What medication can you give to slow benign bone tumors?

Biphosphonates

What non-surgical tx can you use for malignant tumors?

radiation & chemo

What is a simple bone cyst?

simple fluid filled cyst on the bone; common ages < 20

What is an Osteochondroma?

cartilage-capped bony spur arising on the external surface of a bone; usually long bone near knee or proximal humerus

What is an Osteochondroma look like on an XR?

bone arising from stalk or "bump" on bone

What is the MC location of a Giant Cell Tumor?

distal femur

Giant Cell Tumors are common for what age range?

20-40 yo

What age range most commonly presents with enchondromas?

15-40 yo

Where are enchondromas commonly found?

Hands/fingers, Metaphysis of long bones

What does an Enchondroma show on an XR?

lucency of hands/fingers or matrix calcification of long bones on XR, usually an incidental finding

What does Fibrous Dysplasis show on an XR?

ground-glass appearance; lytic lesions

What age range most commonly presents with osteoid osteomas?

10-35 yo

Where are osteoid osteomas commonly found?

Long bones, Posterior spine segments

How does an Osteoid osteoma present on an XR?

Sclerotic lesions with small lucent nidus

What bone tumor may present with typical night pain that is responsive to NSAIDs or ASA?

Osteoid osteoma

What is the most common primary bone tumor?

Osteosarcoma

When is Multiple Myeloma MC?

*2nd MC blood cancer that affects bone

50-70 yo

What is the tx for an osteosarcoma?

Pre-op chemo, Limb salvage

Where does Osteosarcoma most commonly METS?

lungs

How does an Osteosarcoma present on XR?

"Hair-on-end" appearance; sunray burst mixed sclerotic lesions, Codman’s triangle periosteal rxn

What are the MC locations of Ewing's sarcoma?

Femur, Pelvis, Upper arm, Ribs in diaphysis

What population most commonly presents with Ewing's sarcoma?

5-20 yo; MC- males

What type of bone tumor may mimic symptoms of osteomyelitis? (fever, pain, weight loss)

Ewing's sarcoma

What does Ewing's sarcoma show on an XR?

lytic lesions w/ "onion peel" appearance

What is the tx for Ewing's sarcoma?

Chemo, surgery, radiation

Chondrosarcoma is a cancer of cartilage that is most commonly seen in what population?

adults: 40-70 yo

Which joints does Osteoarthritis MC affect?

weight bearing joints (LEs & spine)

How does Osteoarthritis present?

stiffness, dec ROM, pain worsening w/ movement and relieved w/ rest, tender to palpation, deformity

What is the MC location of Osteoarthritis?

knee joints

What is the MC type of arthritis?

Osteoarthritis

What is the tx for Osteoarthritis?

NSAIDs, steroid injections, PT/OT, lifestyle changes, surgery

Which type of arthritis is symmetric?

RA

What demographic does RA affect more?

W > M (3:1); inc w/ age

Which joints are spared in RA?

DIP

What extraarticular manifestations can RA cause?

nodules, vasculitis, pericarditis, tenosynovitis, scleritis

How does Rheumatoid Arthritis present?

morning stiffness, symmetric swelling, nodules, +RF, radiologic changes, claw deformity of foot, ulnar drifting

What is the first line tx for RA?

NSAIDs

What else can you use to tx RA?

opioids, glucocorticoids, DMARDS, splints, surgery

What is the most common genetic factor associated with seronegative spondyloarthropathies?

+HLA-B27 antigen

What system is most commonly involved in spondyloarthropathies?

Axial skeleton

Which disease has the strongest association to HLA-B27?

*stronger association in white pts

Ankylosing Spondylitis

Ankylosing spondylitis MC affects what demographic?

M > F (3:1); begins 20-30s

What are findings of early Ankylosing spondylitis on an XR?

squaring of superior and anterior margins of vertebral bodies

What are the findings of late Ankylosing spondylitis on an XR?

ossification of the longitudinal ligaments, autofusion of fact joints → poker spine (bamboo spine)

What does Sacroiliitis show on an XR?

narrowing of SI joints

Who is MC affected by Reactive Arthritis?

young men

What causes reactive arthritis?

inflammation triggered by GI or GU infxn (STDs and dysenteric)

*Chlamydia, Gonorrhea, Shigella, Salmonella, Campylobacter

What is the triad of sx associated with reactive arthritis?

Conjunctivitis, Urethritis, Oligoarticular arthritis

(can't see, can't pee, can't climb a tree)

What antigen might be present in some pts (63%) w/ Reactive Arthritis?

HLA-B27

What does Psoriatic arthritis show on an XR?

Pencil-in-cup deformity = joint destruction; resorption of terminal phalanges

*aggressive and destructive

What demographic is most affected by Psoriatic arthritis?

M=F 1:1; onset in 30s

What is the tx for psoriatic arthritis?

DMARD- methotrexate

What differentiates Psoriatic arthritis from RA?

DIP joint involvement and absence of nodules

Gout or Pseudogout:
Bony erosions & spurs on XR

Gout

Gout or Pseudogout:
Punctate or linear calcifications of cartilage (chondrocalcinosis)

Pseudogout

Gout or Pseudogout:

Negatively birefringent urate crystals

Gout

Gout or Pseudogout:

Weakly positive birefringent rhomboid-shaped crystals

Pseudogout

Gout or Pseudogout:

Serum uric acid (+)

Gout

What is the tx for gout?

Indomethacin -1st line, Colchicine -2nd line, NSAIDs, steroids

Long term: Allopurinol or Probenecid (inc urine excretion)

What is the tx for pseudogout?

Joint aspiration, Intra-articular steroids, NSAIDs

Acute: Colchicine

What causes Osteopenia?

dec bone density, poor nutrition, low estrogen, lack of exercise, smoking, excess ETOH intake

What is a precursor to Osteoporosis?

Osteopenia

Which type of Osteoporosis is found in Post-menopausal women?

Type 1

What type of Osteoporosis is found in older (senile) pts?

Type 2

Which form of Osteoporosis is due to an agent or disease process that is causing bone loss?

Secondary

Who is more likely to get Primary Osteoporosis? Seconday?

primary: W>M

secondary: M>F

What is the GOLD standard for diagnosing osteoporosis?

DEXA

What is the FRAX too used for?

evaluate 10-yr fracture risk of pts

Normal bone density T score

+1.0 to -1.0

T scores less than ____ indicate osteoporosis

-2.5

T scores between ____ and ____ indicate osteopenia

-1.0 to -2.5

T score of -1.0 has ___x risk of fractures

2x