Intro LD/CT

order of msk physical exam

1. inspection

2. ROM

3. palpation

4. neurovascular

5. special testing

xray basics rule of two

two views - a/p and lat

two joints - joint above and below

two occasions - repeat scans

two limbs - compare

xray interpretation ABCS

a - adequacy, alignment

b - bones

c - cartilage

s - soft tissues

alignment

anatomic relationship between bones on xray

bones

examine bones for fracture lines or distortions

cartilage

examine the joint spaces on xrays for increased or decreased joint space

soft tissue

swelling and joint effusions

foreign bodies

air (break in integrity)

interpreting fx: direction

transverse - straight across

oblique - angled

spiral - curves around bone

comminuted - 3+ pieces

interpreting fx: description

pattern

displacement

interpreting fx: patterns

segmental - two fx in same bone creating floating segment

impacted - one fragment is driven into another

compression - bone is crushed, often in vertebrae

depression - portion of bone is pushed inward (often in skull fx)

interpreting fx: displacement

nondisplaced

displaced

angulated

rotated

shortened

nondisplaced

bone fragments maintain alignment

displaced

bone fragments are out of alignment - based off most distal segment

angulated

fragments are at an angle to each other

rotated

one fragmented is twisted relative to the other

shortened

overlapping fragments reduce the bone's length

DEXA z-scores

normal -1.0+

penia -1.0-(-2.5)

porosis -2.5+

bisphosphonate examples

alendronate

risedronate

ibandronate

zoledronic (IV)

bisphosphonate moa

bind to hydroxyapatite on bone surfaces -> inhibit osteoclast-mediated bone resorption -> reducing bone turnover

bisphosphonate indications

tx and prev of postmenopausal osteoporosis

tx of osteoporosis in men

tx of glucocorticoid-induced osteoporosis

tx of paget's disease of bone

bisphosphonate z-score improvement

alen, rise, zole all have data that z score is improved in vertebrae and hip/femoral neck

bisphosphonate se

GI - nausea, abd pain, dyspepsia

msk pain

HA

flu-like symp (IV formula)

bisphosphonate adr

osteonecrosis of jaw

atypical femur fx

esophageal ulceration

bisphosphonate labs

serum calcium and vit d

renal fxn

BMD

oral exam at baseline

bisphosphonate drug

calcium supplements and antacids

NSAIDs

PPI

bisphosphonate contraindications

known esophageal stricture

hx of known malabsorption

bisphosphonate special pops

peds - specific conditions only

geri - careful monitoring

preg/lac - nope

renal - dose adjust on crcl

hepatic - ok

bisphosphonate pearls

oral taken on empty stomach with water

remain upright 30 mins after taking

dental exams

drug holiday after 3-5 years of taking

adequate calcium and vit d intake

anti-RANKL antibody example and dose

denosumab (prolia)

60mg SQ q6m

anti-RANKL antibody moa

monoclonal antibody that binds to and inactivated receptor activator of nuclear factor kappa-B ligand -> inhibiting osteoclast formation, maintenance, and survival -> reducing bone resorption and turnover

anti-RANKL antibody indications

postmenopausal osteoporosis

male osteoporosis

steroid induced osteoporosis

cancer tx induced bone loss

bone metastases

hyper ca of malignancy

anti-RANKL antibody se

msk pain

diarrhea

hypertension

hypocalcemia, hyperphosphatemia

URI symptoms

dizziness, vertigo

peripheral edema

dermatitis/eczema/rash

anti-RANKL antibody adr

severe hypocalcemia

anaphylaxis

vasculitis

serious infection

ONJ

atypical femur fractures

vertebral fracture

pancreatitis

anti-RANKL antibody BBW

severe hypocalcemia in advanced CKD (GFR < 30)

anti-RANKL antibody labs

oral exam at baseline

pregnancy test at baseline

serum calcium

vit D levels

consider mag + phosphate levels

DEXA ever 1-2 years

anti-RANKL antibody special pops

peds - specialist

geri - caution

preg/lac - nope

renal - caution in crcl <30

hepatic - ok

anti-RANKL antibody drug

avoid bisphosphonates, anabolics, synthetic PTH agents, calcimimetics

anti-RANKL antibody pearls

do not incorporate into bone matrix

effect is rapidly reversible when d/c

preferred in renal impairment

anabolic osteoporosis examples

teriparatide

abaloparatide

romosozumab

anabolic osteoporosis moa teri and abalo

PTH analogs that stimulate bone formation

anabolic osteoporosis moa romo

sclerostin inhibitor that increases bone formation and decreases bone resorption

anabolic osteoporosis indications

postmenopausal osteoporosis at high risk for fx

increase bone mass in men with osteoporosis at high risk for fx

treatment of glucocorticoid related osteoporosis

anabolic osteoporosis se

injection site reaction

nausea, dizziness, HA

leg cramps

hypercalcemia

arthralgia

anabolic osteoporosis adr

osteosarcoma

hypercalcemia

ortho hypo

anabolic osteoporosis bbw

teri and abalo - risk of osteosarcoma

romo - increased risk of CV death, stroke, and MI

anabolic osteoporosis drug

caution with digoxin

anabolic osteoporosis special pops

peds - nope

geri - ok

preg/lac - nope

hepatic - caution

anabolic osteoporosis renal

teri and abal - caution in severe

romo - no go in severe

anabolic osteoporosis pearls

reserved for pts at very high risk of fx

ensure adequate calcium and vit d intake

no long term data

NSAID examples

ibuprofen

naproxen

celecoxib

diclofenac

meloxicam

NSAID moa

inhibit cox 1 and 2 enzymes reducing prostaglandin synthesis

melox and cele are cox 2 selective

NSAID indications

mild - mod pain management

inflammation

fever reduction

OA

RA

dysmenorrhea

NSAID se

GI upset (dyspepsia, nausea, abd p!)

HA

dizziness

edema

NSAID adr

gi bleed or ulceration

cv events

renal impairment

hepatotoxicity

anaphylaxis

NSAID BBW

increased risk of severe cv thrombotic events (MI/stroke)

increased risk of serious GI events

NSAID labs

CBC

CMP

LFT

BP

PPI

NSAID drug

anticoags

antihypertensives

lithium

methotrexate

ace/arb

low-dose aspirin

NSAID special pops

peds - ibu and naproxen ok

geri - caution

preg - avoid if possible

lac - ok

renal - caution, no <30

hepatic - caution

NSAID pearls

lowest dose shortest time

take with food

glucocorticoid uses in msk/rheum

oral and injectable

if systemic - go oral

if one joint - go inj

oral glucocorticoids

multiple joints

systemic sx present

6-24hr onset

days to weeks duration depending on taper

higher risk of systemic effects

inj glucocorticoids

single or few joints

no systemic sx

takes 24-48 hours

duration weeks to months

minimal systemic effects

tramadol drug class

atypical opioid analgesic

schedule IV controlled

tramadol moa

weak mu-opioid receptor agonist

inhibits reuptake of serotonin and norepi

tramadol indications

mod - mod/severe acute pain

mod - mod/severe chronic pain

mainly short term use due to dependency risk

tramadol se

N/V

constipation

dizziness and vertigo

drowsiness

HA

dry mouth

tramadol adr

seizures

serotonin syndrome

respiratory depression

addiction/dependence

anaphylaxis and hypersensitivity

tramadol BBW

risk of addiction, abuse, misuse

life-threatening resp depression

accidental ingestion, esp in children

neonatal withdrawal syndrome

risk of concomitant use with benzos

cyp interactions

tramadol labs

LFTs

renal fxn

drug screening in chronic pain management

tramadol drug

CYP2D6

CYP3A4

serotonins

benzos

warfarin

tramadol special pops

peds - nope

geri - caution

preg/lac - nope

renal - dose adjust

hepatic - dose adjust

opioid examples

morphine

oxycodone

hydrocodone

oxymorphone

hydromorphone

fentanyl

opioid moa

bind to mu receptors in CNS -> inhibit ascending pain pathways -> alter pain perception and emotional response to pain

morphine miligram equivalents

a standardized unit used to compare the potency of different opioid medications

converts dose of any opioid to an equivalent dose of morphine

higher doses of MME associated with

increased risk of:

overdose

respiratory depression

death

CDC MME prescribing guidelines

>50 caution

>90 avoid or carefully justified

opioid indications

moderate to severe acute pain

cancer-related pain

palliative care

chronic pain

opioid se

constipation

N/V

sedation and drowsiness

dizziness

pruritus

opioid induced hyperalgesia

paradoxical state where chronic opioid exposure increases pain sensitivity rather than reducing it

opioid adr

respiratory depression

addiction and physical dependence

overdose

serotonin syndrome

adrenal insufficiency

opioid BBW

risk of addiction, abuse, and misuse

respiratory depression and death

opioid labs

LFTs

renal function

UDS in chronic management

opioid drug

benzos

CNS depressants

MAOIs

serotonins

opioid special pops

peds - nope

geri - start low titrate slow

preg - nope

lac - low dose short duration ok

opioid renal

morphine - avoid

fentanyl and methadone - preferred in renal impairment

opioid hepatic

dose adjust

start low titrate slow

avoid in severe hepatic impairment

fentanyl preferred