MSK

Vocabulary practice flashcards covering clinical definitions, physical findings, staging, and diagnostic criteria for acute musculoskeletal injuries, sprains, carpal tunnel syndrome, osteoarthritis, rheumatoid arthritis, gout, low back pain, and systemic lupus erythematosus.

Acute Musculoskeletal (MSK) Injury

Conditions characterized by acute pain lasting less than 6wks involving damage to muscles, tendons, ligaments, nerves, or bursae.

Grade I Sprain

A ligament injury characterized by a partial tear without instability or opening of the joint during stress maneuvers

• Managed with symptomatic treatment only.

Grade II Sprain

A ligament injury featuring a partial tear with some joint instability, demonstrated by partial joint opening on stress maneuvers;

• Managed by protective immobilization with full healing expected.

Grade III Sprain

A complete ligament tear presenting with complete opening of the joint upon stress testing, requiring joint immobilization and possible surgical repair.

Ottawa Ankle Rules

Get an X-ray for ankle injury if:

• Ankle pain is present

• Tenderness along the posterior $6\,\text{cm}$ or tip of the posterior/lateral malleolus

• Inability to bear weight for four steps, both immediately and in the emergency department.

Ottawa Foot Rules

Get an X-ray for foot injury if:

• Midfoot pain present

• Tenderness at the navicular or the base of the fifth metatarsal

• An inability to take four steps both immediately and in the emergency facility.

POLICE Protocol

An acute soft-tissue management framework standing for

• Protect

• Optimally Loaded

• Ice

• Compression

• Elevate

early fracture management

__ management

• control hemorrhage

• pain relief

• prevent ischemia-reperfusion injury

• remove potential sources of contamination

• refer for stabilization of fracture (ortho urgent care or ER)

fracture complications

__ complications

• R/T casting - pressure ulcer, thermal burns, thrombophlebitis

• R/T surgery - Neurovascular injury, compartment syndrome, infection, thromboembolic events, avascular necrosis, post-trauma arthritis

Carpal Tunnel Syndrome (CTS)

A compression neuropathy of the median nerve within the wrist, causing pain, tingling, and sensory changes in the median nerve distribution, commonly waking patients from sleep.

Etiology:

• Repetitive wrist flexion or extension - occupational

• Hormone imbalance

• Hx of wrist trauma

carpal tunnel presentation

__ presentation

• Aching sensation that radiates into thenar area, forearm, and/or shoulder

• Nighttime awakening w/ pain and numbness

• Paresthesia in median distribution

• Frequently drops things, can’t open jars/lids

• atrophied/flattened thenar eminence

• Phalen’s/tinel’s +

carpal tunnel diagnostics

__ dianostics

• + Phalen’s/Tinel’s

• X-ray for limited ROM

• Median nerve conduction velocity study

carpal tunnel differentials

__ differentials

• Arthritis of carpometacarpal joint of thumb

• Cervical radiculopathy of C6

• Diabetes with paresthesia

• Medial nerve compression at elbow

• Wrist arthritis

carpal tunnel management

__ management

• Splint -prevent flexion and extension

• NSAIDs

• Corticosteroid injections

• Vitamin B6 (Pyridoxine)

• Ergonomic modification

• Avoid carrying heavy bags w/ hands; use shoulder bags or wheels

Thenar Wasting

Atrophy and flattening of the thenar eminence musculature at the base of the thumb resulting from chronic median nerve compression in carpal tunnel syndrome.

Median Nerve Conduction Velocity Study

An electrodiagnostic study utilized to evaluate median nerve conduction delay across the carpal tunnel; negative in $5\text{--}10\%$ of affected individuals.

Osteoarthritis (OA)

A progressive, non-inflammatory degenerative joint disease marked by the loss of articular cartilage and secondary bone formation, leading to asymmetrical joint pain and deformity.

Risk Factors:

• genetics

• joint injury/trauma

• aging

• obesity

• mechanical stress

• occupational overload of joints

OA presentation

__ presentation

• asymmetrical joint pain

• morning stiffness lasting <30min

• joint locking or instability “buckling”

• cool joints, effusions possiple

• crepitus

• limited active/passive ROM

• osteophyte overgrowth causing bony enlargement

Gel Phenomenon

Transient joint stiffness occurring after periods of rest or upon waking that lasts less than $30\,\text{minutes}$, characteristic of osteoarthritis.

Heberden's Nodes

Bony enlargements or osteophytes located at the distal interphalangeal (DIP) joints of the hands in patients with osteoarthritis.

Bouchard's Nodes

Bony osteophytic enlargements formed at the proximal interphalangeal (PIP) joints in individuals with osteoarthritis.

oa differential

__ differential

• RA

• Gout/pseudogout

• Bursitis

• Tendonitis

• Avascular necrosis of femoral head

• Lyme disease

• Neuropathy

• Psoriatic arthritis

• Ankylosing spondylitis

• Fibromyalgia

• SLE

• Osteopenia/porosis

• Bone malignancy

oa diagnostics

__ diagnostics

• Xrays/CT/MRI - osteophytes, asymmetrical joint space narrowing

• Inflammatory markers - ESR, CRP, RF, and ANA all negative

oa management

__ management

• Wt loss (BMI <25)

• PT/OT

• Exercise as tolerated, can recommend water exercise

• Acupunction, nutritional therapy

• NSAIDS - preferrably topical

• Topical capsaicin (works on subtance P), do not use for hands

• Gabapentin, SSRI, and tricyclics for chronic pain

• Intra-articular corticosteroids or viscosupplementation

Rheumatoid Arthritis (RA)

A chronic autoimmune systemic disease characterized by persistent, symmetric, and erosive polyarthritis of synovial joints.

Causes:

• Familial/genetics - HLA-DRB1 risk alleles

• Infection

• Autoimmunity

• Hormonal influence

• Environmental triggers

RA presentation

__ presentation

• Early - wt loss, fever, fatigue, malaise, depression, neuropathic pain

• Joint pain/stiffness at rest and with movement

• Peripheral symmetric polyarthritis - swelling and morning stiffness lasting >1hr

• Affected joints - painful/tender to pressure and partially immobile

  • Hands and feet are usually first

• MC joints - proximal interphalangeal and metacarpophalangeal, knees, toes, ankles

• Deformities in advanced disease - Boutonnière’s and Swan neck deformity

Fever >38.3 concerning for systemic vasculitis or infection

Extra-articular manifestations

• Neuro - Cervical myelopathy

• Heme - AOCD, Neutropenia, Splenomegaly, Felty’s syndrome, Large granular lymphocytes leukemia, Lymphoma

• HEENT - Keratoconjunctivitis sicca, Xerostomia, Peridontitis

• Pulm - Pleural effusions, Pulmonary nodules, ILD

• Cardiac - Pericarditis, Ischemic heart dx, Myocarditis, Cardiomyopathy, Arrhythmia, Mitral regurg

• Renal - Membranous nephropathy, Secondary amyloidosis

• Endo - Hypoandrogenism

• Derm - Rheumatoid nodules, Purpura, Pyoderma gangrenosum

RA differentials

__ differentials

• Gout

• SLE

• OA

• Chronic Lyme disease

• Polymalgia Rheumatics (PMR)

• Sjogren’s syndrome

RA diagnosis

__ diagnosis

Joint involvement:

• 1 large joint (shoulder, elbow, hip, knee, ankle) - 0

• 2-10 large joints 1

• 1-3 small joints (MCP, PIP, thumb, IP, MTP, wrists) - 2

• 4-10 small joints - 3

• > joints (w/ at least 1 small) - 5

Serology:

• Negative RF and negative ACPA - 0

• Low positive RF or low-positive anti-CCP (cyclic citrullinated peptides) antibodies (<3x ULN) - 2

• High positive RF or high positive anti-CCP antibodies (>x ULN) - 3

Acute phase reactants:

• Normal CRP and normal ESR - 0

• Abnormal CRP or abnormal ESR - 1

Duration of sx:

• <6wks - 0

• >/= 6 weeks - 1

Need a score of >/= 6 w/ newly presenting clinical synovitis w/o another explanation

HERE

HERE

Morning Stiffness in Rheumatoid Arthritis

Prolonged morning joint stiffness lasting greater than $1\,\text{hour}$ that reflects severe synovial inflammation and improves with physical activity.

Boutonnière Deformity

An advanced rheumatoid arthritis structural change marked by fixed flexion of the proximal interphalangeal (PIP) joint paired with hyperextension of the distal interphalangeal (DIP) joint.

Swan Neck Deformity

A rheumatoid finger deformity characterized by hyperextension at the proximal interphalangeal (PIP) joint with flexion at the distal interphalangeal (DIP) joint.

Rheumatoid Factor (RF)

An autoantibody (typically IgM directed against human IgG) present in approximately $75\%$ of individuals diagnosed with rheumatoid arthritis.

Anti-Citrullinated Protein Antibodies (ACPA)

Highly specific serologic autoantibodies used in diagnosing rheumatoid arthritis that appear early in the course of the disease.

Methotrexate

A non-biologic disease-modifying antirheumatic drug (DMARD) recognized as the primary first-line therapeutic agent for chronic rheumatoid arthritis management.

Gout

A metabolic inflammatory arthropathy resulting from hyperuricemia and tissue deposition of monosodium urate crystals, most commonly mediated by renal under-excretion of uric acid.

Podagra

Acute, excruciating monoarticular gouty arthritis localized specifically to the first metatarsophalangeal joint.

Tophi

Firm, movable, nodular subcutaneous aggregates of monosodium urate crystals deposited within articular or periarticular tissues during stage IV chronic gout.

Monosodium Urate Crystals

Needlelike crystals demonstrating negative birefringence aspirated from synovial fluid to establish a definitive diagnosis of gouty arthritis.

Intercritical Gout

The asymptomatic period (Stage III) occurring between acute attacks of gout, during which serum urate concentrations should ideally be suppressed below $6\,\text{mg/dL}$.

Allopurinol

A xanthine oxidase inhibitor serving as the first-line pharmacologic agent for chronic urate-lowering therapy, aiming for a serum uric acid level below $5\text{--}6\,\text{mg/dL}$.

Straight-Leg Raise Test

A provocative physical examination maneuver placing the $L5$ and $S1$ nerve roots and sciatic nerve under tension to detect nerve root irritation or disc herniation.

Reverse Straight-Leg Raise Test

A neural tension maneuver performed to stress the upper lumbar nerve roots, specifically $L1\text{--}L4$.

Cauda Equina Syndrome

A medical emergency caused by acute compression of the lumbosacral nerve roots, presenting with saddle anesthesia, urinary or fecal incontinence, decreased rectal tone, and progressive motor deficits.

Spinal Stenosis

A degenerative narrowing of the spinal canal seen primarily in patients over $60\,\text{years}$ of age, causing bilateral leg pain that worsens with standing and relieves with sitting or forward lumbar flexion.

Herniated Nucleus Pulposus

Extrusion of intervertebral disc content compressing adjacent nerve roots, typically causing acute unilateral radiating back and leg pain exacerbated by sitting and bending.

Systemic Lupus Erythematosus (SLE)

A chronic multisystem autoimmune disease involving overactivation of innate and adaptive immune pathways, resulting in pathogenic autoantibodies and immune complex deposition.

Malar Rash

A fixed erythematous butterfly-shaped cutaneous eruption presenting over the cheeks and nasal bridge while sparing the nasolabial folds, characteristic of systemic lupus erythematosus.

Anti-Smith (Anti-Sm) Antibodies

Specific antinuclear autoantibodies directed against core ribonucleoproteins that constitute a highly specific serologic diagnostic criterion for systemic lupus erythematosus.

Lupus Nephritis

Immune complex-mediated kidney disease occurring in systemic lupus erythematosus, characterized by greater than $0.5\,\text{g/day}$ proteinuria or cellular casts and evaluated via renal biopsy.