PD2 Systemic Issues MSK

single joint is assoc with

injury

extra-articular issues

multiple joints + symmetric, migrating one to another =

rheumatic fever

gonococcal arthritis

multiple joints + asymetric

psoriatic

reactive arthritis

multiple joints + similar joints on both sides of body =

rheumatoid arthritis

acute

<6 weeks

chronic

> 12 weeks

sudden onset condition

acute septic arthritis

gout

osteomyelitis

how urgent is tx septic arthritis

significant morbidity/mortality assoc. w/ delay in diagnosis + tx

septic arthritis definition

Invasion of synovium and synovial fluid by microorganism (bacteria most common)

septic arthritis is spread by

hematogenous

direct inoculation to joint

contiguous spread from adjacent skin

bone infection

most common joint effected by septic arthritis

knee

small joints with septic arthritis assoc with?

percutaneous trauma

bites

septic arthritis RF

Pre-existing joint dz (OA, RA, crystalline arthritis)

Age

Immunocompromised conditions

Co-morbidity: DM, ETOH, liver dz, malignancy, ESRD

IV drug use

septic arthritis s/sx

Pain: days to 1-2 weeks

Pain worse with movement

fever/chills/night sweats

septic arthritis PE

Inspection: swelling, erythema

Warmth, effusion

Guarding of joint with ROM

Tachycardiac

Possibly elevated BP or low BP

Fever

septic arthritis dx

CBC: elevated WBC, elevated neuts

Inflammatory markers: ESR, C-reactive protein

Arthrocentesis!!

Blood cultures (takes a long time to get back)

imaging (not super specific)

degree of suspicion

if pt has septic arthritis + is immunocompromised, tx?

glucocorticoids

antitumor necrosis factors

ostemomyelitis definition

infection of bone

ostemomyelitis 3 modes of transmission

Hematogenous

Underlying dz (vascular insuff, neuropathy)

Compromised skin/tissue barrier (trauma/post-surg) (laying down for long period)

osteomyelitis location in child

long bones

osteomyelitis location in adults

vertebral body (spine)

(she usually sees them in DM on the foot)

osteomyelitis s/sx

Localized pain, increasing

fever/malaise

osteomyelitis PE

warmth/swelling/erythema/tenderness to area

Possible wound drainage

osteomyelitis dx

X-ray, and THEN MRI or nuclear med bone scan

Deep soft tissue swelling!

hallmark of osteomyelitis

Deep soft tissue swelling

reactive arthritis definition

Inflammation of joint following dysentery (GI) and GU infection

reactive arthritis RF

Post GI infection

M when post GU infection

Large-weight bearing bones (knees, ankles, sacroilitis)

(history is pretty important to differentiate, look for infection)

reactive arthritis sx

Joint pain: asymmetric

Conjunctivitis

Urethritis

Mouth ulcers

Rash

Fever

Weight loss

Sx begin 1-4 weeks after predisposing illness

rheumatoid arthritis affects what size joitns

small joints

reactive arthritis PE

Asymmetric oligo-arthritis: lower extremities more common, esp knees

Inflammation/pain/swelling/tenderness around insertion points of tendons/ligaments

Dactylitis (swelling of digits) - multiple fingers

Axial pain (esp lower back)

Extra-articular sx: conjunctivitis, GU sx, GI sx, oral lesions, rash

reactive arthritis work-up

Labs: stool cultures, acute phase reactants, HLA-B27, synovial aspiration, STI testing

Imaging: non-specific findings

Stool cultures: only if past GI illness

HLA-B27: rules out ankylosing spondylitis

Synovial aspiration: expects septic arthritis

muscles affected by polymyalgia rheumatica

Proximal muscles affected (shoulders, hips, knees)

NOT usually hands/grip

RF for polymyalgia rheumatica

>50 yo (peak 70-80)

F

s/sx of polymyalgia rheumatica

Malaise (sensation of weakness)

Symmetric: aching and morning stiffness of shoulders/hips/neck

Bilateral shoulders sx most common complaint

Weight loss

Depression

Acute onset, significant change inability to do normal activities

Achiness, limitation of shoulder abduction

Constitutional sx: anorexia, weight loss, low-grade fever

If high fever -> giant cell arteritis

limitations for polymyalgia rheumatica

proximal stiffness can impede ADLs

work-up for polymyalgia rheumatica

Acute phase reactants elevated (CRP or sed rate)

CBC: unremarkable

Rheumatoid factors, autoantibodies, anticyclic citrullinated peptide (anti-CCP) is negative

Imaging: not helpful

polymyalgia rheuamtica tx

high-dose corticosteroids

Ankylosing Spondylitis definition

Inflammatory arthritis/fusion of spine

often has conjunctivitis, uveitis, costochondritis

Ankylosing Spondylitis is assoc w/?

hla-b27

Ankylosing Spondylitis RF

M

Fam hx

<40 yo

ankylosing spondylitis PE

Lack of normal contour (lordosis/kyphosis) of spine

Affects SI joints, possible tenderness around hip

LROM

Extra-articular findings: dactylitis, conjunctivitis, enthesitis (tender at plantar insertion of heel or sternum where cartilage comes together)

Possible sacroiliitis

ankylosing spondylitis dx

Bamboo spine on x-ray 2n1s

HLA-b27

Acute phase reactants

bamboo spine on x-ray = ?

ankylosing spondylitis

late complication of lyme dz

arthritis

lyme dz is assoc w

rash

mental status changes

facial weakness

lyme dz s/sx

Early localized dz: erythema migrans (erythema w/ central clearing) -> bull’s eye appearance

Occurs at site of bite: axilla, inguinal region, popliteal fossa, belt line (crease areas)

Fatigue, fever/chills, HA, myalgia, arthralgia

lyme dz dx

Lyme titers (enzyme immunoassay or immunofluorescence assay) (sometimes the titers don’t show up immediately and tx regardless of what the titer says)

Labs: acute phase reactants elevated

Elevated aminotransferases

tx of lyme dz

doxycycline 100 mg BID 10 days

compartment syndrome cause if acute

following injury (long bone fracture), EMERGENCY

compartment syndrome pop if chronic

athletes

compartment syndrome sx

Pain out of proportion to injury

Persistent deep ache/burning pain

Paresthesia (begins 30-120 mins of ACS -> ischemic nerve dysfunction)

copmratment syndrome dx

Clinical suspicion

Confirmed w/ measuring compartment pressures

compartment syndrome PE

Pain w/ passive stretch of muscles in affected compartment

Tense compartment = firm “wood-like” feeling

Pallor

Diminished sensation

Muscle weakness/paralysis

copmartment syndrome if left untrated can lead to?

muscle necrosis, sensory deficits, paralysis, infection, limb amputation