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Family Medicine Clerkship- Case files > Musculoskeletal Pain > Flashcards

Musculoskeletal Pain Flashcards

1
Q

What is the next diagnostic step for joint paint (monoarticular) that is not preceded by a history of joint pain, sudden onset, and non traumatic, but is edematous, erythematous, and warm?

A
  • Joint aspiration for examination of joint fluid to identify crystals and exclude infection
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2
Q

What is the treatment of acute gout?

A
  • NSAID
  • Colchicine
  • Glucocorticoids
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3
Q

Why must an infected joint be ruled out quickly (i.e. 24hrs?)

A

Exclusion of infectious etiology is paramount because cartilage can be destroyed within the first 24hrs of infection

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4
Q

What age groups are most affected by gout?

A
  • Men => 30-50

- Women => 50-70

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5
Q

List some exacerbating factors of gout.

A
  • Alcohol consumption
  • Trauma
  • Surgery
  • Large meals (often protein) or thiazides that induce hyperuricemia
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6
Q

What type of crystals are seen in crystal induced arthritis?

A
  • Upon microscopy, monosodium urate (MSU) crystals (look like needles) are seen; these have a strong negative birefringence.
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7
Q

Describe the appearance of calcium pyrophosphate dehydrate crystals under microscopy.

A

Calcium pyrophosphate dehydrate => rod shaped, rhomboid, weakly positive birefringence

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8
Q

Describe the appearance of calcium hydroxyapatite crystals under microscopy.

A

Calcium hydroxyapatite => cytoplasmic inclusions that are NOT birefringent

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9
Q

Describe the appearance of calcium oxalate crystals under microscopy.

A

Calcium oxalate => bipyramidal appearance, strongly positive birefringence; seen mostly in end stage renal disease patients

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10
Q

How does the CBC of a crystal induced arthritis differ from a septic joint?

A
  • Crystal induced arthritis => white cells 2,000-60,000

- Septic joint => ~100,000 white cells and >90% PMNs

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11
Q

What is the difference between gout and pseudo gout?

A
  • Gout => due to uric acid deposition in the joints

- Pseudogout => due to calcium pyrophosphate dehydrate crystals (rhomboid, weakly positive birefringent)

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12
Q

What is the DDX for non traumatic swollen joint/joint pain?

A
  • Gout/Pseudogout
  • Infectious arthritis
  • Osteoarthritis
  • Rheumatoid arthritis
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13
Q

What is the pattern of articular involvement in bacterial arthritis?

A

Monoarticular => often knee, hip, shoulder

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14
Q

What organisms may be responsible for chronic monoarticular pain?

A
  • Mycobacterium

- Fungi

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15
Q

Acute, polyarticular arthritis may be due to what kinds of infections?

A
  • Endocarditis

- Disseminated gonococcal infection

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16
Q

Patients with rheumatoid arthritis are susceptible to joint infections from which organisms?

A
  • Staph. aureus
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17
Q

Patients with HIV are susceptible to joint infections from which organisms?

A
  • Pneumococcal, salmonella, H. influenzae
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18
Q

Patients who are IV drug users are susceptible to joint infections from which organisms?

A
  • Streptococcal, staphylococcal, gram negative, or psuedomonas
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19
Q

How does a septic joint differ from cellulitis, bursitis, or osteomyelitis?

A
  • Septic joints have very limited ROM in comparison to cellulitis, bursitis, or osteomyelitis
20
Q

What are the main features of osteoarthritis?

A
  • > 65yo
  • Associated with trauma, history of repetitive joint use, and obesity (especially knee)
  • Primarily affects cartilage, but can damage bone surface, synovium, meniscus, and ligaments
  • Dull, deep, and achey pain
  • Worse with activity
  • Crepitus with passive ROM
  • X rays may reveal => bone sclerosis, subchondral cysts and osteophytes
21
Q

What are the main features of rheumatoid arthritis?

A
  • Onset at 30-55yo
  • Women more than men
  • Morning stiffness
  • Involvement of 3+ joints
  • Symmetric arthritis
  • Positive rheumatoid factor, ESR, CRP, anemia, thrombocytosis, or low albumin
  • Rheumatoid nodules
  • Xray => decalicifications or erosions
22
Q

What is the maintenance therapy for gout?

A
  • Probenecid => increases urinary excretion of uric acid

- Allopurinol => reduces the production of uric acid

23
Q

What is the therapy for a septic joint?

A
  • A septic joint requires surgical debridement/ drainage and antibiotics
24
Q

What is the therapy for DJD?

A
  • Mobility exercises
  • Weight loss
  • Intra-articular corticosteroid injections every 4-6mo
  • Joint replacement in severe disease
25
Q

What is the therapy for rheumatoid arthritis?

A
  • Exercises to protect mobility and muscle strength (PT and OT)
  • NSAIDs
  • Glucocorticoids
  • DMARDS (disease modifying anti-rheumatic drugs) => Sulfasalazine and methotrexate
  • Anticytokines => infliximab and etanercept
  • Topical analgesics
26
Q

What should be monitored especially when administrating rheumatoid medications?

A
  • Monitor liver function
27
Q

What action is the most common cause of ankle sprains?

A
  • Ankle sprains are the results of inversion of an ankle that is plantar flexed
28
Q

Which structures protect the medial ankle from injury?

A
  • Tibulotalar joint and the deltoid ligament protect the medial ankle from injury
29
Q

What is the most commonly injured ligament of the lateral ankle?

A
  • Anterior talofibular ligament (followed by the calcaneofibular ligament)
30
Q

When should ankle X-rays be performed?

A
  • If there is bony tenderness over the posterior edge or tip of the distal 6cm of either the medial or lateral malleolus
  • If the patient is unable to bear weight immediately or when examined
31
Q

When should foot X-rays be performed?

A
  • If there is bony tenderness over the navicular bone, the base of the fifth metatarsal or if the patient is unable to bear weight
32
Q

What is the management of ankle sprains?

A
  • Protection (splinting or casting)
  • Rest
  • Ice
  • Compression
  • Elevation
  • Acetaminophen or NSAIDs can be used for pain relief
33
Q

What is the difference between a sprain and a strain?

A
  • Sprain => a stretching a tearing injury of a ligament

- Strain => stretching or tearing injury of a muscle or tendon

34
Q

In a possible rotator cuff injury or tear, how would we test supraspinatus?

A
  • Empty can test=> with arm abducted, elbow extend and thumb pointing down, patient elevates arm against resistance
35
Q

In a possible rotator cuff injury or tear, how would we test infraspinatus and teres minor?

A
  • External rotation => with elbows at sides and flexed at 90, patient externally rotates against resistance
36
Q

In a possible rotator cuff injury or tear, how would we test subscapularis?

A
  • Lift off test => patient places dorsum of hand on lumbar back and attempts to lift hand of of back
37
Q

In a possible rotator cuff injury or tear, how would we test subacromial impingement?

A
  • Hawkin’s impingement => pain with internal rotation when the arm is flexed to 90 degrees with the elbow bent to 90 degrees
38
Q

How would we test for a large rotator cuff tear?

A
  • Drop arm rotator cuff => patient is unable to lower his arm slowly form a raised position
39
Q

How would we test for an anterior talofibular ligament tear?

A
  • Anterior drawer => examiner pulls forward on patient’s heel while stabilizing lower leg with other hand
    • Excessive translation of joint suggests ATFL tear
40
Q

How would we test for a calcaneofibular ligament tear?

A
  • Inversion stress test => examiner inverts ankle with one hand while stabilizing lower leg with other hand
    • Excessive translation or palpable “clunk” of talus on tibia suggests ligament tear
41
Q

What is syndesmosis?

A

A syndesmosis is a slightly movable fibrous joint in which bones such as the tibia and fibula are joined together by connective tissue.

42
Q

How would we test for syndesmosis?

A
  • Squeeze test => examiner compresses tibia/fibula at midcalf
    • Pain at anterior ankle joint would be positive for syndesmosis
43
Q

How would we test for ACL injury/tear?

A
  • Lachman test => knee in 20 flexion, examiner pulls forward on upper tibia while stabilizing upper leg
    • ACL tear => excessive translation with no solid end point suggests tear
44
Q

How would we test for MCL tear?

A
  • Valgus stress => in full extension and at 30 degree flexion, medial directed force on knee with lateral directed force on ankle
    • Excessive translation suggests tear
45
Q

How would we test for a lateral collateral ligament tear?

A
  • Varus stress=> in full extension and at 30 degree flexion, lateral directed force on knee and medial directed force on ankle
    • Excessive translation suggests tear
46
Q

When should a knee X-ray be performed?

A
  • patient is >55yo
  • isolated patella tenderness
  • tenderness of the head of the fibula
  • inability to flex the knee to 90 degrees
  • inability to bear weight for 4 steps immediately and in the exam room

Family Medicine Clerkship- Case files (13 decks)

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