Term
Which feature is FALSE about degenerative arthritis?
1) Bouchard nodes may be found at the PIP joints.
2) “Gelling” is prominent.
3) Most often affects weight-bearing joints with increased motion.
4) Pain is worse with activity and better with rest.
5) Synovial fluid WBC is typically 5,000 – 15,000 per cubic mm. |
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Definition
5
The statement “Synovial fluid WBC is typically 5,000 – 15,000 per cubic mm” is false about degenerative arthritis. The following are all true statements: In degenerative arthritis, the typical WBC count is < 2000 per cubic mm with <50% polymorphonuclear cells. Bouchard nodes (PIP) and Heberden nodes (DIP) are due to bony overgrowth in degenerative arthritis. Gelling is characteristic of degenerative arthritis; morning stiffness typical of inflammatory arthritis; and constant pain found in gout, pseudogout and infection. Weight-bearing joints with increased motion are the most frequently affected joints in degenerative disease; they include the cervical spine, lumbar spine, hips and knees. In degenerative arthritis, pain is worse with activity and better with rest. Consequently, overuse of joints results in pain in degenerative arthritis. |
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Term
Which combination of arthritis subtype and synovial fluid finding is CORRECT?
1) Gout and high viscosity
2) Osteoarthritis and WBC 10,000 per cubic mm
3) Pseudogout and positive Gram stain
4) Rheumatoid arthritis and WBC 18,000
5) Staphylococcal arthritis and 25% PMNs |
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Definition
| In RA, the synovial fluid WBC is 5,000-25,000 with a predominance of PMNs. In gout, inflammatory synovial fluids have low viscosity because mucopolysaccharide polymers are degraded to monomers by WBC enzymes. Pseudogout synovial fluid contains CPPD crystals and not bacteria (so the Gram stain would be negative). Bacterial arthritis most often has synovial fluid WBC >50,000 per cubic mm and 90+% PMNs. |
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Term
Which of the following statements is TRUE?
1) A high synovial fluid WBC is associated with reduced synovial fluid viscosity.
2) Ankylosing spondylitis occurs most commonly in older women.
3) Bacterial infection typically affects multiple small joints of the upper extremities.
4) Laboratory test results are more important than history and physical examination in classifying patients with joint diseases.
5) Synovial fluid is produced by articular cartilage. |
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Definition
| There is a reciprocal relationship because synovial fluid WBC enzymes degrade large polysaccharide polymers into small monomers. Ankylosing spondylitis is a disease of younger men, not older women. Bacterial infection typically affects one larger joint only, occasionally two joints, and rarely three or more joints. In making a joint disease diagnosis, the history and physical examination are more important than laboratory tests. The synovium produces synovial fluid. |
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Term
Which feature is False about inflammatory arthritis?
1. RA, CTDs and AS all primarily affect the joint synovium
2. CTDs tend to occur in young-middle age women
3. AS primarily affects peripheral small, symmetrical joints
4. AS tends to affect the LE of young males |
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Definition
3. AS is a systemic, non-crystal induced inflammatory arthritis that affects the joint synovium of young males, particularly in the spinal and LARGE LE (asymmetrically) joints.
1. All these inflammatory arthritis forms affect the synovium
2)
- RA and CTDs symmetrically affect young-middle aged women in their small, peripheral joints (UE>LE)
- AS asymmetrically affects young men in spinal and large joints (LE>UE)
4. AS does effect this population, usually asymmetrically) |
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Term
Which statement is FALSE regarding inflammatory arthritis?
1. Systemic forms of inflammatory arthritis typically manifest with severe episodes of morning stiffness
2. Gout and Pseudogout tend to affect the synovium and/or cartilage few, large joints in elderly patients (LE>UE)
3. AS affects spinal, large joints asymmetrically in young males.
4. RA primarily affects weight-bearing joints of young-middle aged women |
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Definition
4. RA does affect young-midle aged women, but affects small, peripheral joints of the UE>LE (symmetrically)
1. Systemic inflammatory arthritis (RA, CTD, AS) due tend to present with morning stiffness
2. Localized, crystal-induced forms do affect synovium/cartilage of few, large joints in elderly patients (vs. infectious that hits babies and elderly)
3. AS does affectpinal, large joints asymmetrically in young males (vs. symmetrical, small peripheral joints in young women for CTD and RA) |
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Term
Which characteristic does NOT fit crystal/infectious forms of inflammatory arthritis?
1. Constant pain with or without fever/chills
2. Bony overgrowth with significant "gelling"
3. Moderate-markedly increased ESR, CRP and WBC count
4. Red, hot, synovial effusions. |
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Definition
2. Bony overgrowth (without synovial thickening or effusions) is typical of osteoarthritis
Patients with local, crystal-induced or infective inflammatory arthritis typically have constant pain with fever/chills, red, hot effusions (low viscosity), elevated labs and WBC.
Patients with osteoarthritis typically have
- pain that gets worse with activity, or stiffness following stasis (Gelling)
- bony overgrowth with no synovial thickening/effusion
- normal labs.
Patients with Systemic inflammatory arthritis typically have
- morning stiffness (pain in morning and evening)
- synovial thickening, effusion
- increased labs and WBC count |
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Term
| When is examination of synovial fluid absolutely critical? |
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Definition
In monoarticular arthritis (crystal-induced) or if bacterial infection is in the differential diagnosis, examining synovial fluid is imperative
Help you distinguish between forms of arthritis
1. Normal will have viscous, clear/transparent fluid with <200 WBC/mm3, <25% polys and >2/3 glucose
2. Osteoarthritis will also have viscous, clear fluid (may have yellow tinge) with > 2/3 glucose, but WBC will be 200-2000, with <50% Polys
3. Inflammatory (both crystal and non-crystal) arthritis will have a cloudy, non-visious fluid with 5-25k WBC, >75% polys and >2/3 glucose
4. Infectious arthritis will have thick, opaque, non-viscious fluid with >50K WBCs and >90% Polys and <2/3 glucose |
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Term
Which of the following is FALSE regarding synovial fluid testing?
1. Normal fluid is viscous and clear/transparent, with <200 WBC/mm3, <25% polys and >2/3 glucose
2. Osteoarthritis will fluid is viscous and clear/yellow, with WBC 200-2000 and <50% Polys
3. Inflammatory (both crystal and non-crystal) arthritis will have a cloudy, viscous fluid with 5-25k WBC, >75% polys and >2/3 glucose
4. Infectious arthritis fluid wil be thick, opaque and non-viscious ,with >50K WBCs and >90% Polys and <2/3 glucose |
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Definition
3. Inflammatory and infectious synovial fluids will be NON-visous, because of the increased WBC enzyme levels. Infectious fluid may be thick, but it is not viscious.
- Glucose is lowered in infectious arthritis because of the bacterial and immune-related consumption of glucose
- If WBC <2000, you are either normal or degenerative |
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Term
Which of the following statements is TRUE concerning the symptom of muscle weakness?
1. Asthenia is synonymous with this symptom.
2. Both proximal and distal muscle weakness are invariably found together in the patient with a complaint of muscle weakness.
3. Hypothyroidism is a potential cause for which a muscle biopsy may not be necessary to make the diagnosis.
4. It is uniformly associated with proximal muscle weakness and the inability to raise one’s arms above their head.
5. The serum creatine kinase (CK) is often elevated to 10x (or greater) the normal level in patients with all causes of muscle weakness. |
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Definition
3
Hypothyroidism can cause generalized muscle weakness. Asthenia implies overall exhaustion without pinpointing muscle tissue as the target, and so is not a synonym. The combination of both proximal and distal patterns of muscle weakness are NOT commonly found together in the same patient. The symptom of muscle weakness is not always associated with objective findings on physical examination (such as the findings of weakness or inability to raise the arms when the patient is examined). The CK can be normal in patients with myopathy. |
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Term
Which of the following is FALSE regarding the diagnostic work-up of patients with muscle weakness?
1. A normal EMG is frequently found in patients with an underlying myopathy associated with muscle weakness.
2. Elevation of the serum creatine kinase (CK) is often associated with pathologic involvement of muscle tissue.
3. Muscle tissue from biopsy material may show inflammatory cells, ragged red fibers or myopathic changes that provide diagnostic clues.
4. Neuroimaging may be necessary to elucidate the cause of muscle weakness.
5. The ANA (antinuclear antibody) test is frequently positive in patients with an autoimmune etiology of muscle weakness (i.e. myositis) |
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Definition
1. EMG findings are very sensitive, and are almost never normal if myopathy is present.
2. CK is a sensitive, non-specific marker if muscle damage
3. These are real clues- inflammatory (autoimmune), ragged red fibers (mitochondrial),
4. Neuroimaging is often helpful
5. ANA is frequently positive in autoimmune myopathies like SLE |
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Term
Which of the following is TRUE about proximal muscle weakness?
1. Associated with difficulty rising from a chair secondary to weakness of the hip flexor muscles.
2. Associated with inflammation in the muscle tissue of the gastrocnemius muscle.
3. Is always insidious in onset.
4. Not a feature of genetic or drug-induced myopathies.
5. Results in reduced hand grip strength. |
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Definition
1. These are proximal
The hip girdle muscles are proximal muscles, and so weakness would result in difficulty rising from a chair. The gastrocnemius is a DISTAL muscle. Of muscle weakness can be either insidious or rapid. Genetic and drug-induced myopathies can cause either proximal or distal muscle weakness. The intrinsic muscles of the hands are DISTAL muscles. |
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Term
| Distinguish between fatigue, asthenia and muscle weakness. |
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Definition
- Fatigue is exhaustion after repetition
- Asthenia is diffuse, general weakness/exhaustion with depression
- Muscle weakness is inability to use muscle on first try, and may indicate underlying myopathy. |
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Term
| What is the major worry for patients taking Fibric acid derivative and statins to lower cholesterol? |
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Definition
Drug-induced myopathy.
Biopsy will show atrophic, degenerative fibers |
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Term
A patient presents with difficulty combing their hair and you discover an elevated CK level in their labs.
What is the next step in the workup of this patient? |
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Definition
Pattern of weakness...CK...EMG...Biopsy
Get an EMG, since proximal muscle weakness and elevated CK suggest myopathy, but you MUST distinguish it from a neuropathy.
Very sensitive, but rarely specific
If EMG is STILL inconclusive, get a biopsy from proximal (deltoid) and distal muscles (gastrocnemius) |
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Term
Which of the following is FALSE regarding common causes of myopathy.
1. Hypothyroidism produces a generalized pattern of muscle weakness with a myopathic EMG and a normal biopsy
2. Autoimmune myopathy presents with proximal weakness, rash/dysphagia, lung involvement and a myopathic EMG
3. Drug-induced myopathy affects both proximal and distal muscles with an elevated CK, but a normal biopsy
4. Genetic myopathies tend to manifest with developmental delays. |
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Definition
3.
Drug-induced forms CAN affect proximal or distal muscles with elevated CK levels, but muscle biopsy will be atrophic/degenerating (EMG MAY BE NORMAL). |
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Term
| When might an ESR not be an accurate indicator of an underlying inflammatory process? |
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Definition
Pregnancy, stress, or RBC/plasma issue such as anemia or clotting disorder.
CRP is MORE sensitive and MORE $$, but will also have issues with pregnancy, stress and trauma |
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Term
Which of the following conditions would not likely produce an ESR >100 mm/h
1. Metastatic colon cancer
2. Acute pyelonephritis
3. SLE
4. Giant cell arteritis |
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Definition
SLE
This is a systemic inflammatory disorder, but it would likely not produce an ESR >100 |
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Term
Which of the following is FALSE regarding acute phase reactants in clinical practice?
1. CRP can be used to stage the activity of RA
2. ESR and CRP should always be ordered together
3. CRP is always the best marker of longitudinal inflammatory processes
4. ESR>100 may be seen in giant cell arteritis. |
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Definition
| 3. ESR or CRP may be the best depending upon the situation (they measure different things). Always order both! |
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Term
Which is TRUE about the erythrocyte sedimentation rate?
ESR > 100 mm/hr is associated with osteoarthritis.
1. ESR correlates most closely with serum gamma globulin.
2. ESR is due to different plasma protein factors than CRP.
3. The ESR is lower in women than in men.
4. The ESR is higher in younger than in older individuals. |
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Definition
| The results of ESR and CRP do not always parallel one another in the same patient. Osteoarthritis is a local inflammatory condition in joints which does not produce a systemic response, and so does not cause an increased ESR. The ESR correlates most closely with plasma fibrinogen, not gamma globulin. The ESR is higher in women than in men. The ESR increases with age in normal healthy adults. |
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Term
Which of the following 5 scenarios would be expected to have an intermediate ESR result (3rd highest of 5)?
1. Acute gouty arthritis
2. 80 year old woman with osteoarthritis
3. Healthy 30 year old man
4. Moderately active rheumatoid arthritis
5. Untreated acute bacterial pneumonia |
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Definition
| Gout is typically more inflammatory than rheumatoid arthritis; it can cause fever and red, hot swollen joints. The ESR in osteoarthritis is normal but would be expected to be elevated slightly in this older woman. The ESR in a healthy 30 year old is normal. An untreated bacterial infection often causes a very high ESR. |
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Term
Which of the following is FALSE regarding the mechanism of anti-inflamatory action of corticosteroid drugs?
1. Generate release of lipocortin, which activates phospholipase A2 and reduces production of LTCs and PGEs
2. Inhibition of interleukins (1,2) and IFN-y, inhibiting lymphocyte proliferation and migration
3. Decrease neutrophil and monocyte activation and migration
4. Inhibit COX-2 production
4. |
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Definition
| 1. These drugs DO generate lipocortin, but this compound INHIBITS PLA2 (as well as COX2, TNF-a, IFN-y and IL production), in order to decrease production of PGE/LTC |
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Term
Which of the following is not a typical NSAID agent.
1. Acetaminophin.
2. ASA
3. Ibuprofin
4. Indomethacin |
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Definition
| 1. Tylenol IS listed, because it has minor anti-inflammatory capabilities, but it is really an ANALGESIC, not an anti-inflammatory |
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Term
Which of the following is FALSE regarding the anti-inflammatory mechanism of action of ASA?
1. Diminish pain predominately by inhibition of prostangandin production at the sites of inflammation
2. Inhibit PGI2 production via inhibition of inducible COX (COX2) production
3. Prevent platelet aggregation through inhibition of Txa
4. Likely produce vasodilatory states by inhibiting PLA2 |
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Definition
4. ASA-mediated inhibition of COX2 (inducible) and PLA2 will decrease production of PGI2 (prostacyclin), which will lead to unrestricted vasoconstriction.
NSAIDs do prevent pain by local inhibition of PGE, inhibit PGI2 production by COX-2 inhibition and inhibit platelet aggregation by inhibiting Txa (through COX-1) |
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Term
Which of the following is not a noted side effect of NSAID use?
1. Gastritis
2. DVT risk
3. Acute renal failure
4. Cerebral edema
5. bleeding risk |
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Definition
4. Not noted
1. Gastritis, GERD and small bowel ulcers occur because of COX-1 inhibition (prevention of PGE protection)
2. COX-2/PGI2 inhibition (often balanced by COX-1 inhibition)
3. Renal blood flow is regulated by PGEs, so you can get HTN, AFR and fluid retention
5. Inhibition of COX-1 prevents Txa from causing coagulation |
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Term
Corticosteroids have ubiquitous physiological effects when utilized in pharmacological doses. These include all of the following EXCEPT:
1. Inhibit activation and proliferation of lymphocytes.
2. Inhibit migration and activation of neutrophils and monocytes.
3. Modulate pain perception via the opioid receptor.
4. Suppress production of inflammatory mediators such as interferon-gamma and IL-1. |
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Definition
| 3. Corticosteroids do not function as analgesics, and do not directly modulate pain perception. The remaining three answers are true. Steroids do: Inhibit activation and proliferation of lymphocytes; Inhibit migration and activation of neutrophils and monocytes; and Suppress production of inflammatory mediators such as interferon-gamma and IL-1. |
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Term
Non-steroidal anti-inflammatory drugs decrease pain and inflammation by inhibiting prostaglandin synthesis. Which of the following statements is FALSE?
1. COX-1 is constitutively expressed in diverse tissues.
2. Cycloxygenase -2 (COX-2) is induced at the sites of inflammation.
3. Non-selective COX inhibition decreases platelet aggregation.
4. Selectively blocking COX-2 may increase thrombosis risk. |
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Definition
| 3. Non-selective COX inhibition decreases platelet aggregation via thromboxane. The remaining three answers are true. COX-2 inhibition is induced and selectively blocking it may increase thrombotic risk. COX-1 is constitutively expressed in a wide variety of tissues. |
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Term
Which of the following pairs of drug class and corresponding toxicity is INCORRECT?
1. Corticosteroids and Hyperglycemia
2. Corticosteroids and Infection
3. NSAIDs and Fluid retention
4. NSAIDs and Osteoporosis |
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Definition
| 4. Osteoporosis can be caused by corticosteroids but not NSAIDs. The remaining three answers are true – they are correct pairings. |
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Term
| Describe the 2 basic muscle groups that control hand movement and their innervation patterns |
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Definition
1) Intrinsic (ULNAR) – located within the hand and perform finger ab/adduction and thumb and little finger opposition
2) Extrinsic (MEDIAN AND RADIAL) – located outside the hand with tendinous attachment to phalanges. These muscles perform finger flexion and extension as well as wrist movements.
- Median controls finger flexion and thumb/little finger opposition
- Radial controls wrist and finger extension. |
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Term
What of the following is FALSE concerning the nervous innervation of the the hand?
1. The ulnar nerve passes through Guyon's canal and supplies sensation to the little finger and ventral ½ of the ring finger
2. The radial nerve controls wrist and finger extension
3. The median nerve controls finger ab/adduction and thumb and little finger opposition
4. The median nerve runs through the carpal tunnel and supplies sensation to the volar hand and thumb, index, and middle finger
5. The radial nerve supplies sensation to the dorsal hand and portions of the dorsal thumb, index and middle finger |
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Definition
| 3. These motions are intrinsic muscle-mediated, and are innervated by the ULNAR NERVE |
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Term
Which of the following is true regarding the arterial blood supply of the hand?
1. Only the radial artery separates into deep and superficial branches
2. The digital arteries originate from the superficial palmar arch
3. The median artery is the major supplier of the distal digits.
4. The radial artery only supplies the proximal digits. |
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Definition
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Term
Which of the following is TRUE regarding the nervous system innervation of the hand?
1. The median nerve controls wrist and finger extension
2. The radial nerve controls finger flexion and thumb/little finger opposition
3. The intrinsic muscles of the hand are supplied by the Radial nerve
4. The radial nerve supplies sensation to the dorsal hand and portions of the dorsal thumb, index and middle finger
5. Extrinsic muscles that control finger flexion and thumb/little finger opposition are primarily supplied by the ulnar nerve. |
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Definition
4. Radial nerve supplies sensation to dorsal hand and controls wrist and finger extension (extrinsic muscles)
- Median nerve runs through the carpal tunnel and supplies sensation to the volar hand and thumb, index, and middle finger, as well as controlling finger flexion and thumb/little finger opposition (Extrinsic)
- The ulnar nerve passes through Guyon’s canal and supplies sensation to the little finger and ulnar ½ of the ring finger, as well as supplying the intrinsic muscles of the hand. |
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Term
Which of the following is true about the intrinsic muscles of the hand?
1. Their muscle bellies lie outside the hand
2. They are primarily supplied by the median nerve
3. They perform finger abduction
4. They perform finger flexion |
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Definition
3. The intrinsic muscles of the hand are primarily responsible for finger ab/adduction and thumb/little finger opposition. They are supplied by the ulnar nerve and their muscle bellies are within the hand – hence intrinsic.
The median nerve handles finger flexion. |
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Term
Which of the following is true about the extrinsic muscle of the hand?
1. They are attached to the carpal bones through long tendons
2. They are supplied by the ulnar nerve
3. They are the primary muscles of wrist movement
4. They perform finger adduction |
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Definition
| 3. The extrinsic muscles of the hand are the primary muscle of wrist movement as well as finger flexion and extension. They are supplied by the median and radial nerves. They attach to the phalanges through long tendinous insertions. |
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Term
Which nerve supplies sensation to the volar portion of the hand and the volar thumb, index and middle finger?
1. Axillary nerve
2. Median nerve
3. Radial nerve
4. Ulnar nerve |
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Definition
| The median nerve supplies sensation to the volar hand and thumb, index, middle finger. The ulnar nerve supplies the ulnar portion of the hand and the little and ulnar portion of ring finger. The radial nerve provides sensation to the dorsal hand and the axillary nerve provides sensation to the lateral upper arm. |
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Term
What best describes the origin of the digital arteries?
1. The deep palmar arch
2. The radial artery
3. The superficial palmar arch
4. The ulnar artery |
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Definition
| 3. The digital arteries arise from the superficial palmar arch of the hand. That arch is created by communicating branches of the radial and ulnar arteries. |
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Term
Which of the following groups is not known to get carpel tunnel syndrome?
1. Women > Men
2. Typists
3. Bikers.
4. Runners
5. Pregant women |
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Definition
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Term
Which of the following is NOT a common cause of carpel tunnel syndrome?
1. Fracture healing
2. Osteoarthritis
3. Tenosynovitis (RA)
4. Hypothyroidism
5. Gout |
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Definition
5. Gout is a crystal-induced local inflammatory arthritis that generally affects few, large joints and does not hit the wrist very often.
Remember, this is ischemia of axons due to compression of perineural vascular plexi
- 1 and 2 are causes of bony impingement
- Tenosynovitis has enlarged soft tissue sheath, which causes compression.
- Mucin deposition in hypothyroidism causes soft tissue enlargement/compression |
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Term
A patient presents because he has been having difficulty buttoning his shirt with some pain in his thumb and forearm.
On PE, you note weak "pinching" and reduced two-point discrimination. You also note (+) Tinel and Phelan maneuvers.
Which of the following should not be on your differential?
1) Cervical spine arthritis or disc disease with C6 or C7 radiculopathy
2) Pregnancy
3) Ulnar nerve compression at the wrist (Guyon’s canal) or at the elbow (cubital tunnel syndrome)
4. Radial nerve compression at the wrist.
5) Thoracic outlet syndrome (brachial plexus and vascular compression in the neck); ulnar distribution of symptoms; cervical rib |
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Definition
4.
1- Median exit
2- would produce pronator syndrome
3- would compress median nerve next to it
5- would produce ulnar distribution of symptoms; cervical rib
Classic findings of carpel tunnel syndrome (median nerve compression)
Tinel: percussion over median nerve on volar surface of wrist
Phelan: forced wrist flexion for one minute |
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Term
| What are the surgical and non-surgical treatment options for carpel tunnel syndrome? |
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Definition
1) Non-surgical: within 1 year after symptom onset
- night splints
- depot corticosteroid injection
2) Surgical: before 2 years after symptom onset
- release or decompression: transection of transverse carpal ligament |
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Term
| What are the anatomic structures that define the carpel tunnel? |
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Definition
| The carpal bones (3 sides) and the transverse carpal ligament (volar surface). |
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Term
Which of the following are FALSE regarding carpel tunnel syndrome?
1. The symptoms are numbness and “pins-and-needles” sensations (paresthesias) occurring nocturnally and with excessive wrist flexion or extension.
2. The distribution of paresthesias is the thumb, index and long finger and the radial side of the ring finger.
3. Nerve conduction tests can show reduced sensory and nerve conduction velocities in the segments proximal to the carpal tunnel
4. The differential diagnosis includes cervical radiculopathy, thoracic outlet syndrome and ulnar nerve compression syndromes.
5. Late in disease (after several years), muscles supplied by the median nerve (thenar muscle) become atrophied. In this stage, surgery is often unsuccessful in relieving symptoms. |
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Definition
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Term
Which of the following statements is FALSE about carpal tunnel syndrome?
1) Affects sensory nerve fibers first and later motor nerve fibers
2) Can be provoked by forced wrist flexion
3) Increased frequency in association with hypothyroidism
4) Leads to reduced median nerve conduction velocity distal to the wrist
5) Results from immunologic injury to the median nerve |
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Definition
5
The nerve injury is not due to an immunologic mechanism. The nerve injury is due to direct external compression and resulting ischemia. Hypothyroidism, pregnancy and amyloidosis are recognized associations. Sensory nerves are more sensitive to injury, and motor nerve involvement with atrophy of the opponens muscles is a late finding. The Phelan test, which utilizes sustained forced wrist flexion, is one of the provocative tests for carpal tunnel syndrome. Ischemic damage leads to slowed conduction in the nerve segment distal to the site of compression. |
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Term
Treatment for carpal tunnel syndrome due to rheumatoid arthritis DOES NOT include which of the following modalities?
1) Corticosteroid injection
2) Surgical decompression
3) Systemic anti-inflammatory or immunosuppressive drugs
4) Wrist splints
5) Vascular surgical reconstruction |
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Definition
3
Surgical decompression, NOT vascular surgery, is effective. Although ischemia plays a role in pathogenesis, the blood vessels involved are very small and not amenable to surgical revascularization. Corticosteroid injection and systemic anti-inflammatory approaches are reasonable since the problem causing median nerve compression is likely to be inflammatory (tenosynovitis). Wrist splints prevent nocturnal wrist flexion. Surgery to decompress the median nerve is always an option and often the most effective and long-lasting. |
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Term
You are evaluating a patient with numbness and tingling in the right hand which has been present for 6 weeks. Which finding is CONSISTENT with carpal tunnel syndrome?
1) Atrophy of the thenar muscles
2) History of a fall on the outstretched right hand 3 years ago; x-rays showed no fracture
3) History of osteoarthritis of the right elbow
4) Recent laboratory tests showing a T4 of 2.6 (low) and TSH of 24.3 units (high)
5) Reduced sensation in the right fourth and fifth fingers |
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Definition
| The patient has laboratory evidence of hypothyroidism, a recognized association of carpal tunnel syndrome. Though atrophy of the thenar muscles does appear late in CTS, this would be after years, not weeks. A case of post traumatic carpal tunnel would be more likely to be associated with a fracture, and occur in proximity to the time of the injury. Osteoarthritis can be associated with cubital tunnel compression of the ulnar nerve, but not carpal tunnel syndrome. The 4th and 5th fingers are innervated by the ulnar nerve, not the median nerve. |
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Term
Which of the following muscles is NOT part of the rotator cuff?
1. Supraspinatus
2. Infraspinatus
3. Teres minor
4. Teres major
5. Subscapularis |
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Definition
4. Teres major
SItS
Subscapularis: internal rotation
Supraspinatus: forward elevation
Infraspinatus/teres minor: external rotation |
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Term
| What is the basic nervous system innervation and functions of the rotator cuff muscles? |
|
Definition
SItS
1) Innervation
- Subscapularis: upper and lower subscapular nerves
- Supraspinatus/infraspinatus: suprascapular nerve
- Teres minor: axillary nerve
2) Function
- Subscapularis: internal rotation
- Supraspinatus: forward elevation
- Infraspinatus/teres minor: external rotation |
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Term
Why might a patient have impaired active motion in their shoulder, but normal passive motion?
When you passively move their right arm in forward flexion or adduction/internal rotation they cringe in pain.
What is going on? |
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Definition
Right rotator cuff tair.
Passive FF (Neer's sign) and Adduction and internal rotation (Hawkin's) |
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Term
| How might you test the strength of each of the rotator cuff muscles on PE? |
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Definition
SItS COMPARE SIDES
1) Subscapular (superior and inferior subscapular nerves)
- internal rotation (Hawkin's), lift off test, belly-press test
2) Infraspinata (suprascpular nerve)
- External rotation
3) Supraspinata (surprascapular nerve)
- Forward elevation (Neer's sign)
4) Teres minor (axillary nerve)
- External rotation |
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Term
| When and how should imaging studies be carried out for a suspected shoulder injury? |
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Definition
Indicated with shoulder pain and weakness after trauma or worsening over time
1) Xrays to assess for fracture, arthritis
2) MRI to assess for rotator cuff tear |
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Term
Patient presents to you complaining of shoulder pain after falling from a ladder.
On inspection, there is diffuse swelling and ecchymosis of shoulder and arm. The Patient cannot actively elevate the arm more than 60° and belly press test is positive.
Forward elevation and external rotation strength are 3/5.
What should be done? |
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Definition
Order X-rays for fracture/arthritis, but NEED MRI to look for SItS tear.
For massive rotator cuff tare, perform rotator cuff repair (GET IT EARLY).
Arthroscopically or through a small incision are similarly effective. |
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Term
Rotator cuff tears can appear very similar clinically to which one of the following:
1) Glenohumeral dislocation
2) Proximal humerus fracture
3) Subacromial impingement
4) Total biceps muscle rupture |
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Definition
3
Subacromial impingement is caused by calcific deposits in the subacromial space or in the rotator cuff tendons themselves. This causes pain and weakness with stress on the cuff tendons. Glenohumeral dislocations and proximal humerus fractures are acute injuries that usually have obvious visual deformity and patient have very limited if any passive range of motion intact. Biceps muscle rupture causes a ball-shaped deformity in the biceps area and loss of elbow flexion. |
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Term
75 year old patient presents complaining of aching pain along the lateral aspect of the thigh while laying on their side.
What is going on? |
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Definition
Greater trochanteric bursopathy
Fluid-filled sac over greater trochanter (Apophysis-lever arm) becomes inflamed.
Remember, greater torchanter bursopathy |
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Term
| What is "Wolf's law"? How does it relate to osteoporosis? |
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Definition
Wolff’s law refers to the capacity of bone to remodel in response to the stress placed on it (In osteoporosis, osteoclast activity exceeds osteoblast activity, so you get thinning of bone)
The process of bone remodeling (trabecular remodeling) to accommodate changes in stress on bone is an important process in maintaining healthy bone |
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Term
Which of the following is INCORRECT regarding avascular necrosis of the hip?
1) The femoral head is prone to avascular necrosis because of its vascular supply.
2) The most common causes of avascular necrosis are corticosteroid use and alcoholism.
3) Can be caused by lupus, sickle-cell anemia, and trauma.
4) Is commonly caused by RA and osteoarthritis |
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Definition
4- does cause hip injury, but not typically from avascular necrosis.
CASTLe
Corticosteroids and Alcoholism are most common
Sickel cell disease, Truama and Lupus erethematosis are also common causes.
Remember, in kids this is called "Legg-Calve-Perthes" syndrome with infection |
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Term
| Describe the basic anatomy of the hip and how it relates to the concept of "true hip pain". |
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Definition
"True hip pain" arises at the ball-and-socket joint of the femoral head and the acetabulum (where ischeum, pubus and illeum meet)
Femur (Head, neck, greater trochanter and lesser trochanter)
Greater trochanter, Lesser trochancer and Ischeal tuberosity= Apophysis- lever arm, not in joint)
Femoral head= Epiphysis (within joint). |
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Term
| What is the arterial supply of the femoral head and how does it relate surgery for fractures of the femoral neck. |
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Definition
One of the major reasons why femoral head is subject to avascular necrosis.
1) Small direct branch of obturator artery (travel through round ligament of femur
2) Collateral supply from Medial and Lateral circumflex femoral arterial branches (Most important for femoral head)
This vulnerability means that the fracture must be corrected QUICKLY. |
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Term
| What is the differential diagnosis for avascular necrosis of the hip? |
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Definition
PLASTIC RAGS
1) Pancreatitis
2) Lupus
3) Alcohol
4) Steroids
5) Trauma
6) Infection (Legg-Calve-Perthes syndrome in kids)
7) Collagen vascular disease
8) Radiation
9) Amyloid
10) Gouchet's disease (Lysosomal storage disease with abnormal tissue deposition in hip bone)
11) Sickle cell |
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Term
| What type of hip injury are obese patient's particular prone to? |
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Definition
Slipped capital femoral epiphyses are most commonly seen in overweight adolescent boys, and usually requires surgical pinning or fixation.
Legg-Calve-Perthes (avascular necrosis), infection and Slippled capital femoral epiphysis are common in pediatric patients.D |
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Term
Which of the following is the most likely cause for hip pain in a 74 year old man?
1) Femoro-acetabular osteoarthritis
2) Legg-Calve-Perthes syndrome
3) Slipped capital femoral epiphysis
4) Systemic lupus erythematosus |
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Definition
| 1) Femoro-acetabular osteoarthritis is the most common source of hip pain in older adults. Legg-Calve-Perthes syndrome and slipped capital femoral epiphysis are both common sources of hip pain in the pediatric population, but not common in adults. While systemic lupus erythematosus can cause hip pain in an older man, it is far less common than osteoarthritis, and would more frequently be seen a younger adult female. Additionally, lupus would tend to have accompanying systemic symptoms as well. |
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Term
| Describe the basic anatomy of the knee (Bony, ligamentous and Meniscal) |
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Definition
ACL and medial meniscus most commonly injured structures
1) Bony
- Femoral and tibial condyles and patella
2) Ligamentous
- ACL (forward motion and rotation of tibia)
- PCL (backward motion of tibia)
- MCL (resist valgus forces that push knee in)
- LCL (resist varus) that push knee out)
3) Meniscal (cartilage shock absorbers)
- Medial, Lateral |
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Term
| What are the most commonly injured structures of the knee and how do they present clinically? |
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Definition
Effusions are commonly seen and diagnosed by MRI
ACL (most common) + MCL + Medial meniscus= unhappy triad due to "lateral blow to knee"
1) ACL (resist forward motion of tibia) "POP with swelling"
- h/x of deceleration, hyperextension, or internal rotation
- Positive anterior drawer sign and Positive Lachman test
2) Medial meniscus
- history of knee “locking up” in either flexion OR extension, limiting mobility, with "popping sensation" while walking |
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Term
| How should most ligamentous knee injuries be treated? |
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Definition
Remember, most common are ACL and Medial meniscus, diagnosed by MRI in young athletes
Treatment is generally conservative
1) Ice initially to reduce inflammation
2) NSAID medications with narcotics as needed for breakthrough pain
3) MRI as outpatient
4) Many clinicians will use knee immobilizers, but must caution patients to perform daily ROM exercises to reduce chance of contracture and mobility restrictions |
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Term
| What diagnostic maneuvers can be used to narrow down a soft tissue knee injury diagnosis? |
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Definition
Diagnostic tests tend to be insensitive, but still widely used
1) Anterior and posterior drawer tests (ACL, PCL)
2) Varus and valgus stress maneuvers (LCL, MCL)
3) Lachman’s test (similar to anterior drawer test)
4) McMurray’s test for meniscal injuries |
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Term
Which of the following is the most sensitive method of diagnosing ligamentous injury?
1) CT scan
2) MRI
3) Physical exam
4) X-ray |
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Definition
| MRI has a close to 90% accuracy rate in detecting both ligamentous and meniscal injury. While a CT scan will show occult fractures of the joint, the sensitivity of MRI for soft tissue injury is still higher than CT scan. Performing a history and physical will provide clues to the diagnosis, but all exam maneuvers are too insensitive to relay on just them to diagnose. Plain x-ray films will be normal or show only a small effusion in more than 75% of cases of ligamentous injury. |
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Term
Which of these is not part of proper initial treatment of knee injuries?
1) Ice
2) NSAIDs
3) Rest
4) Vigorous physical therapy |
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Definition
4
Vigorous physical therapy is NOT part of initial treatment. Until the patient has been evaluated by a musculoskeletal specialist (orthopedist, etc.) the patient should limit activity using the leg, until a definitive plan of care is established. The 3 remaining answers ARE part of proper initial treatment: Ice to the site of injury immediately after will help to slow the rate of inflammation and limit the pain. NSAIDs such as ibuprofen or naproxsyn effectively and safely aid in reducing both pain and inflammation and should be considered first line therapy. Non- or partial weight bearing of the affected extremity is routinely recommended to prevent further injury. |
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Term
| Describe the anatomical organization of the ankle joint. |
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Definition
Primary hinge joint with articulation between distal tibia and fibula with talus
Three sets of ankle ligaments
1) Lateral ligament complex (WEAKEST subject to inversion injury)
- Anterior talofibular
- Calcaneofibular
- Posterior talofibular
2) Medial ligament (“deltoid”)- eversion injury
3) Syndesmosis- Dorsiflexion injury
- Complex connecting distal tibia and fibula |
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Term
| Which portions of the ankle joint are most commonly injured in joint sprains and fractures? |
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Definition
1) Sprains are commonly inversion injuries of the lateral ligament complex (anterior and posterior talofibular and calcanofibular)
***MOST common is anterior talofibular***
2) Fractures
- Most commonly eversion injuries
- Example is Maisoneuve fracture
(Medial ankle injury + proximal fibula fracture)
- |
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Term
| How do you know whether to order imaging for an apparent ankle injury? How do you treat based upon the results? |
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Definition
Ottawa Ankle Rules
1) Age < 18 years or > 55
2) Inability to take 4 steps following injury and in ED
3) Tender to palpation over distal 6cm of medial or lateral malleolus
For sprains or very minor (<3cm) fracture
- Rest / Ice / Compression / Elevation
- Ankle brace or “aircast”
- Posterior splint if unstable or severe
For Fractures
- Open reduction / internal fixation (Excluding stable unimalleolar fractures)
- Posterior splinting
- Non-weight bearing
- Orthopaedic consultation
**Emergent for open fractures or fracture dislocations** |
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Term
Which is the most common mechanism of ankle injury?
1) Eversion
2) Inversion
3) Plantar flexion
4) Dorsiflexion |
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Definition
| 2: Inversion injuries are most common and usually will result in injury to the lateral ankle ligaments. Eversion is less likely to produce an acute injury, partially because the medial or deltoid ligament is so thick and strong. Hyperdorsiflexon can produce injury to the syndemosis but is less common |
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Term
According to the Ottawa Ankle rules, all of the following are reasons to obtain x-rays in patients with acute ankle injuries except:
1. Age less than 18 years or greater than 55 years
2. Inability to walk 4 steps in the emergency department
3. Tenderness to palpation over the anterior talofibular ligament
4. Tenderness to palpation over the distal medial malleolus |
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Definition
| 3: The Ottawa Ankle Rules have been developed to assist in clinical decision making in obtaining imaging of patients with acute ankle injuries. These rules were developed only for patients over the age of 18 and under the age of 55. In general, tenderness over the distal 6 cm of the lateral or medial malleolus, or inability to walk 4 steps immediately after the injury and in the emergency department are indications for obtaining imaging |
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Term
| What is the difference between spondylosis, spondylolysis and spondyloisthesis? |
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Definition
1) Spondylosis- degeneration of the spine
- often due to osteoarthritis
2) Spondylolysis
- Absense or fracture of pars interarticularis (part between articular processes)
3) Spondylolisthesis
- Slippage of one vertebral body over another |
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Term
| Describe how pain with flexion or extension in the lower back can help you distinguish the anatomical location of a lower back injury. |
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Definition
1) Anything anterior to the PLL will cause worse pain with Flexion (i.e. herniated disc or damage to body itself)
2) Anything posterior to the PLLwill cause pain with
Extension (i.e. Damage to Articular processes of the zygapophysial joint or "facet joint", or Neuroforaminal stenosis)
Vertebral body
- Spinous process
- Transverse process
- Centrum
- Pedicle
- Lamina
Vertebral disc
- Anulus
- Nucleus pulposis |
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Term
| Why might a patient feel pain in a slightly different location for a posterior disc herniation at L4-L5 of the lumbar spine, than for a far lateral herniation? |
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Definition
80-90% of disk herniations are either posterior or posterolateral.
A posteriorly herniated disk will most commonly affect the descending nerve root- e.g., an L4-L5 posterior or postero-lateral herniation will most commonly affect the descending L5 nerve root.
A laterally herniated disk will most commonly affect the exiting nerve root- e.g., an L4-L5 lateral herniation will most commonly affect the exiting L4 nerve root. |
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Term
| How can the location of a spinal chord radiculopathy be determined on PE? |
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Definition
Myotome testing
- 3/5 is against gravity
1) L2- Hip flexion
2) L3- Knee extension
3) L4- Ankle dorsiflexion
4) L5- Long toe extension- check medial hamstring
5) S1- Ankle plantar flexion- check angle jer reflex |
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Term
Patient presents with pain along the postero-lateral thigh, lateral leg, and the dorsum of the foot, difficulty with long toe extension, and decreased medial hamstring reflex.
What is the most effective treatment? |
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Definition
L5 radiculopathy
- the most effective approach for an epidural injection is using the transforaminal approach (steroid)
- Can supplement with Anti-inflammatory, Analgesic or Neuromembrane stabalizers |
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Term
Patient presents with pain along the anterior thigh, anterior leg, and medial foot, weakness with leg extension and single-leg squats, and decreased knee jerk reflex.They also have difficulty with ankle dorsiflexion.
What is going on? |
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Definition
L4 radiculpathy
Treated with multimodal therapy (corticosteroid injection, analgesics and neuromembrane modulators) |
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Term
Patient presents with lack of sensation during sexual intercourse and wiping after defecation.
What is going on? |
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Definition
Cauda Equina syndrome (Compression of S2-S4, which will become pudendal nerve for genitals and rectum).
Must be dealt with emergently! |
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Term
What is slippage of one vertebral body over an adjacent vertebral body called?
1) Lumbar disk extrusion
2) Spondylolisthesis
3) Spondylolysis
4) Spondylosis |
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Definition
| 2: Spondylolisthesis. This term is easily confused with two other terms with similar spellings and pronunciations. Spondylosis is a generic term referring to degeneration of the spine. Spondylolysis refers to a defect in the pars interarticularis, which is the portion of bone between the superior and inferior articular processes of a vertrebra, and may make a patient predisposed to spondylolisthesis. A lumbar disk extrusion is a sub-type of lumbar disk herniation. |
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Term
An 83 year old woman complains of aching low back pain that is worse with standing and walking, and is improved with leaning on a counter, walking with a shopping cart, or sitting down. Which is the most likely cause of her aching low back pain?
1) Lumbar disk hernation
2) Lumbar spinal stenosis
3) Vascular claudication
4) Zygapophysial joint arthropathy |
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Definition
| 4: Zygapophysial joint arthropathy, also called facet joint pain. Lumbar disk herniation is not a correct answer because disk hernations tend to occur in a younger population, are typically worse with flexion rather than extension, and typically cause symptoms down the lower limb. Both spinal stenosis and zygapophysial joint arthropathy are classically painful with extension in older patients. However, spinal stenosis does not cause aching low back pain. It more typically is associated with neuropathic pain down the lower limbs. For older patients with tingling pain in their lower limbs, the main differential is between lumbar spinal stenosis and vascular claudication. One useful indicator is that walking uphill or with a shopping cart tends to be helpful for lumbar spinal stenosis, since it places the spine in a flexed position, whereas it has no effect or makes the symptoms worse with vascular claudication. |
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Term
A 37 year old runner complains of vague aching low back pain and burning pain that radiates down her lateral thigh, lateral leg, and the dorsum of her foot. Her pain is worst early in the morning, especially when putting on her shoes. She has difficulty extending her long toe, and she has noticed that she tends to catch her foot on the ground and scuff the top of her shoes. Which reflex is most likely to be abnormal in this patient?
1) A decreased ankle jerk reflex
2) An increased ankle jerk reflex
3) A decreased knee jerk reflex
4) A decreased medial hamstring reflex |
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Definition
| 4: A decreased medial hamstring reflex. Her symptoms are most characteristic of an L5 radiculopathy, based on her classic radiation of pain along the L5 dermatome, and decreased strength in L5 innervated muscles (the extensor hallicus longus, which extends the long toe, is innervated by L5-S1, and the tibialis anterior, which dorsiflexes the ankle, is innervated by L4-L5). Therefore the medial hamstring reflex, which is the L5 reflex, is likely to be decreased. The ankle jerk is the S1 reflex and the knee is the L4 reflex. Additionally, reflexes will tend to be reduced in radiculopathy, rather than increased. |
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Term
Which of the following is FALSE concerning RA?
1) RA is the most common immune-mediated autoimmune disease.
2) The etiology of RA is largely unknown and tends to be mistaken for systemic lupus erythematosus, viral arthritis and psoriatic arthritis.
3) Patients with RA tend to present with nodules in the skin, lung disease, anemia and fatigue
4) RA diagnosis is made primarily by evidence of RF anto-antibodies in the serum. |
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Definition
4:RF if seen in many diseases and normal people- CCP is MUCH MORE SPECIFIC
- The diagnosis of RA is clinical (history & physical examination) with supportive evidence from measuring autoantibodies (rheumatoid factor [RF] and anti-cyclic citrullinated peptide [anti-CCP]) and obtaining radiographs of hands and feet |
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Term
Which of the following is NOT a useful treatment option for RA patients?
1. NSAIDS
2. Ribavirin
3. Methotrexate
4. Etanercept
5. Infliximab
6. Rituximab |
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Definition
Most common immune-mediated autoimmune disorder where many patients die from CVD (symmetrical, additive, polyarthritis).
Treatment of RA includes NSAIDs, steroids, disease modifying drugs (e.g., methotrexate, sulfasalazine, hydroxychloroquine, leflunomide), and targeted biological therapies such as anti-tumor necrosis factor agents (adalimumab, etanercept, and infliximab), interleukin-1 receptor blocker (anikinra), B-cell inhibitor (rituximab) and a T-cell co-stimulatory blocker (abatacept). Other targeted biological therapies are in various stages of development for the treatment of RA. |
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Term
| What environmental and genetic factors are known to be involved in RA |
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Definition
Thickening of synovium and resulting secretion of TNF (infliximab, etanercept), IL-1, IL-6, T cells (abatacept) and B cells (rituximab) leads to inflammation and destruction of overlying cartilage and bone.
Produces symetrical synovitis of small joints and patients die from early CVD
1) Cigarette smoke
2) HLA DRB1 alleles (class II MHC complex) and others
**Also more common in Pima indians** |
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Term
Which of the following laboratory tests is most specific for a diagnosis of rheumatoid arthritis?
1) Anti-cyclic citrullinated peptide (CCP)
2) Antinuclear antibody (ANA)
3) C-reactive protein (CRP)
4) Parvoviral antibodies (IgM) |
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Definition
3:
Anti-CCP has a very high specificity for diagnosis of RA. It is seldom seen in the other autoimmune diseases. ANA is a screening test with high sensitivity (90+%) for some autoimmune diseases such as systemic lupus erythematosus and systemic sclerosis (scleroderma) and occurs in up to half of patients with Sjögren syndrome and Hashimoto thyroiditis. ANA can also be seen in many patients with RA. CRP is an acute phase reactant which is the result of inflammation or tissue injury, regardless of the cause. Anti-parvovirus antibodies are specific to paroviral infections. Parvoviral infection can cause fever, rash and polyarthritis which is self-limited, lasting only a few weeks. |
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Term
The biological therapies adalimumab, etanercept and infliximab are used to treat patients with rheumatoid arthritis. What is the target in the immune system for which these agents block?
1) Interleukin-1
2) Interleukin-6
3) Transforming growth factor (TGF) - Beta
4) Tumor necrosis factor (TNF) - alpha |
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Definition
| 4: These 3 agents are designed to inhibit TNF-alpha. IL-1 receptor is targeted by anakinra. IL-6 is targeted by tocilizumab. TGF-beta does not play an important role in the synovitis of RA. |
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Term
Which of the following is FALSE regarding crystalline arthropathy?
1. Gout and Pseudogout often present with redness, swelling, warmth, and pain of peripheral joints.
2. Crystals seen in the peripheral joints of patients with Pseudogout are composed of calcium pyrophosphate dyhadrate
3. Gout and Pseudogout are distinguished based primarily upon PE findings.
4. Treatment options for acute gouty arthritis include intra-articular corticosteroids, NSAIDs, and/or oral corticosteroids |
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Definition
3: Although the distribution of involved joints may be different in gout and pseudogout (gout hits joints, soft tissue and kidney, while pseudogout hits articular and peri-artiuclar structures, sufficient overlap exists between these forms of crystalline arthropathy that they cannot be reliably distinguished on clinical grounds alone.
Diagnosis rests on examination of synovial fluid under polarized microscopy.
1) Monosodium urate crystals (gout) are spindle-shaped and Negatively birefringent (yellow) when aligned in the axis of polarization.
2) CPPD crystals (pseudogout) are rhomboid-shaped and Positively birefringent (blue) when aligned in the axis of polarization.
**Additional laboratory studies including synovial fluid gram stain/culture and blood cultures MUST be run to rule out septic arthritis; synovial fluid cell count/differential is also important, but does not reliably distinguish septic arthritis from different forms of crystalline arthropathy. |
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Term
| Describe the basic treatment options for gouty arthritis. |
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Definition
Monosodium urate crystals in joints, soft tissue (typhi) and kidneys.
1) Treatment options for acute gouty arthritis include intra-articular corticosteroids, NSAIDs, and/or oral corticosteroids
2) Colchicine plays a role in maintenance therapy/prophylactic management of gout, BUT uric acid lowering agents may be needed for long term management of tophaceous or refractory gout.
- Xanthine oxidase inhibitors (allopurinol, febuxostat)
- Uricosurics (probenecid). |
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Term
All of the following are TRUE regarding pseudogout EXCEPT:
1) Managed with aspiration +/- corticosteroid injection as well as NSAIDs.
2) Chronic pyrophosphate arthropathy may respond to colchicine and long-term NSAIDs
3) Often treated chronically with Probenecid
4) CPPD crystals (pseudogout) are rhomboid-shaped and positively birefringent (blue) when aligned in the axis of polarization. |
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Definition
3) Uricosurics like Probencid and Xanthine oxidase inhibitors like Allopurinol are used for chronic management of GOUT.
Pseudogout will look similar clinically, but will have blue, romboid crystals under the polarizing microscope when examining synovial fluid. |
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Term
True or False:
Pseudogout is most common in elderly women. |
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Definition
True!
Gout is more common in men >35
Remember, warmth and redness is from PMNs phagocytosing crystalline particles (e.g. its the IMMUNE response) |
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Term
Which of the following factors favor a diagnosis of acute gout rather than pseudogout?
1) 1st MTP joint involvement (podagra)
2) Hypercalcemia
3) Negatively birefringent crystals in synovial fluid
4) Negative gram stain
5) Synovial fluid WBC count > 30,000/ml
All of the above |
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Definition
| 3: Spindle-shaped, negatively birefringent crystals (yellow in the axis of polarization) reflect monosodium urate composition=gout. 1st MTP joint involvement, a high synovial fluid WBC count, and a negative Gram stain could apply to gout or pseudogout. Hypercalcemia may be associated with CPPD/pseudogout, but not gout. |
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Term
Which of the following is true regarding management of crystalline arthropathy?
1) Allopurinol should be used in all patients in whom the diagnosis of gout is made
2) Colchicine may be useful in management of both gout and chronic pyrophosphate arthropathy
3) Demonstrating crystals in synovial fluid effectively rules out septic arthritis and the need for antibiotics
4) Intra-articular corticosteroids are only effective in gouty arthritis
5) None of the above |
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Definition
| 2) Colchicine inhibits neutrophil function, effectively combating inflammation in both gout and chronic pyrophosphate arthropathy where neutrophils play a prominent role in generating inflammation. Not all patients diagnosed with gout require uric acid lowering therapy such as allopurinol. Furthermore, uricosurics such as probenecid may be the drug of choice for uric acid under-excretors who require long term therapy for management of chronic gout. Because crystalline arthritis and septic arthritis may co-exist, answer c is incorrect. Finally, intra-articular corticosteroids may be effective for management of both acute gouty arthritis and pseudogout once infection has been ruled out, making answer d incorrect. |
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Term
Which of the following is FALSE?
1) Acute gouty arthritis may result in edema and peri-articular erythema
2) B cell production of antibodies plays a key role in the pathogenesis of gouty arthritis
3) Binding of immunoglobulin to monosodium urate crystals enhances neutrophil phagocytosis
4) Calcium pyrophosphate crystals are blue, or positively birefringent, when viewed in the axis of polarization (via polarized microscopy)
5) Monosodium urate crystals and gram + cocci may be found together in the same joint |
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Definition
| 2) “B cell production of antibodies plays a key role in the pathogenesis of gouty arthritis” is a false statement. This is incorrect because neutrophils and other cells of the innate immune system play a predominant role; B and T cells (adaptive immune system) have little or no role in mediating the inflammatory responses of gouty arthritis. The remaining statements are true: Immunoglobulin-coating of monosodium urate crystals attracts neutrophils, serving as a pro-inflammatory stimulus. When acute inflammation occurs due to gout, both joints and peri-articular structures (including skin and soft tissue) are affected, resulting in edema and erythema (answer a). CPPD crystals are positively birefringent (answer d). Because gout and septic arthritis may co-exist, answer e is also true. |
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Term
Which of the following is FALSE regarding Polymyalgia Rheumatica?
1. Symptoms include neck, shoulder and hip girdle pain with pronounced stiffness, and morning stiffness lasting over 1 hour
2. Elevated ESR and/or CRP are characteristic
3. Initial treatment for PMR involves aspirin
4. Inflammatory condition found primarily in patients over the age of 50.
5. Giant cell arteritis frequently occurs in patients with PMR, and may be associated with significant morbidity |
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Definition
3. Corticosteroids are used to treat PMR, with initial therapy being prednisone 10-15 mg/day, tapered slowly over a period of months
If there is relapse, chronic therapy is required. |
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Term
70 year old caucasian woman presents with symmetric, subacute pain of the neck, shoulders and pelvic gurdle that is worst in the morning (lasting for hours).
What is known about the disease pathophysiology of this condition and what complications are common. |
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Definition
1) Unknown
- HLA-DR4 association
- Parvovirus P19
- M. and C. pneumonia
2) Occurs in 40% of patients with Giant Cell Arteritis, which affects aorta and primary branches (look for tender temporal artery, jaw claudication, headache and visual disturbances)
- Unlike PMR, GCA can lead to serious complications such as complete visual loss (15%), aortic aneurysm/dissection, large artery stenosis and treatment-related morbidity
Treat PMR and GCA with corticosteroids (10-15 mg/day and then tapered slowly, 10% every 2-4 weeks, after 4 weeks maintanence), but look out for osteoporosis, infection and other side effects. |
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Term
| How is polymyalgia rheumatica diagnosed? |
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Definition
CLINICALLY
- Bilateral shoulder, hip girdle, neck pain and stiffness
- Morning stiffness (>1h)
- Synovitis
- Fatigue, anorexia, low-grade fever, weight loss
- NORMAL proximal muscle strength on PE
Labs may show elevated ESR, CRP, anemia, arthritis (non-erosive), normal CK/EMG/biopsy |
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Term
Which of the following statements regarding PMR is FALSE?
1) PMR is found primarily in patients over the age of 50.
2) PMR is typically associated with the presence of autoantibodies on serologic testing.
3) Patients with PMR often have morning stiffness lasting more than one hour.
4) Patients with PMR often suffer disease relapse and require chronic corticosteroid therapy.
5) All of the above are true |
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Definition
| 2: The false statement is” PMR is typically associated with the presence of autoantibodies on serologic testing”. All of the following statements are true. PMR is a disease of patients over the age of 50 who have prominent morning stiffness lasting over one hour after arising, particularly affecting the neck, shoulder and hip girdles. PMR often relapses, requiring chronic corticosteroid therapy. |
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Term
Other conditions that may present similarly to PMR include:
1) Hypothyroidism
2) Malignancy
3) Medication side effects
4) Rheumatoid arthritis
5) Systemic infection
6) All of the above except systemic infection
7) All of the above |
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Definition
| 7: All of the above. All of the diseases mentioned can mimic PMR. Statin associated myopathy is one example of a medication side effect associated with myalgias that could mimic PMR. |
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Term
Which of the following is TRUE about PMR?
1) After treatment with corticosteroid therapy, PMR rarely recurs.
2) Patients with PMR generally do not suffer adverse effects of corticosteroid therapy.
3) PMR is often seen in patients with GCA and may occur prior to or following this diagnosis.
4) The signs and symptoms of PMR are specific and readily establish this diagnosis.
5) X-ray findings can help establish the diagnosis of PMR. |
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Definition
| 3: PMR is often seen in patients with GCA and may occur prior to or following this diagnosis. Recurrence of PMR is common. PMR patients are often elderly, increasing the risks of some corticosteroid side effects. PMR can be mimicked by the conditions listed in question 2. PMR does not result in x-ray changes like joint space narrowing or bony erosions (seen in other forms of arthritis that can mimic PMR). |
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Term
Which of the following is NOT a common manifestation of PMR?
1) Anorexia and weight loss
2) Fatigue
3) Morning stiffness lasting more than one hour
4) New onset of daily headaches not relieved with analgesic therapy
5) Pain and stiffness of the neck, shoulder, and hip areas |
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Definition
| 4: "New onset of daily headaches not relieved with analgesic therapy” is NOT a common manifestation of PMR. The new onset of daily headaches refractory to therapy can be associated with Giant Cell Arteritis (GCA), which is a condition that is frequently seen in patients with PMR (but is not a part of PMR itself). PMR is a systemic disease often associated with fatigue, anorexia, and weight loss. Pain and stiffness of the neck, shoulder, and hip areas with morning stiffness lasting longer than one hour are common manifestations of PMR. |
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Term
| Describe the 3 phases of fracture healing |
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Definition
Osteoblasts are bone-forming, Osteoclasts are bone resorbing and Osteocytes maintain bone homeostasis
1) Inflammatory phase
- Macrophages and degranulating platelets recruitment to fracture site, where inflammatory factors recruit stem cells and angiogenic factors
2) Reparative phase
- Neovascularization and mesenchymal stem cell differentiation into osteoblasts.
3) Remodeling phase.
- Endochondral (formation of cartilage template, up which osteoblasts deposit minerals and collagen producing a fracture "callus")
- Intramembranous (formation of bone spiccules without cartilage template)
- Apositional (cutting cones of osteoclasts are followed by osteoblasts that produce smooth, healed bone with optimized biomechanics). |
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Term
| How are bone fractures diagnosed? |
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Definition
| Clinical and radiographic examination, including orthogonal X-rays (2 X-ray views taken in perpendicular planes) of the fracture itself, as well as the joints immediately proximal and distal to the fracture. |
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Term
| How should most acute bone fractures be managed? |
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Definition
Most heal with combination of endochondrial and intramembranous ossification.
Acute fractures should almost never be treated acutely in cylindrical casts, but should be reduced and placed into a splint (elastic) that will accommodate soft-tissue swelling. |
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Term
| How do most fractures heal? |
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Definition
Most fractures heal through a combination of endochondral and intramembranous ossification.
1) Endochondral ossification is manifested clinically by the formation of fracture callus, which is abundant at the fracture site.
**Appositional ossification is the process of remodeling which will occur later in the fracture healing process once the fracture callus matures and mechanical stability has been re-established. Osmosis is an irrelevant process. |
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Term
Which of the following is NOT considered a musculoskeletal emergency?
1) Ankle fracture/dislocation with medial skin tenting
2) Compartment syndrome
3) Open fractures
4) Native hip dislocation with acute onset 1Cfoot drop 1D
5) Torus fractures |
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Definition
5.
Torus fractures are generally low-energy unicortical fractures with plastic deformation of the opposite cortex that occur largely in children due to the more cartilaginous and malleability of their bones. Compartment syndrome is a musculoskeletal emergency that must be treated surgically with fasciotomy to prevent massive tissue necrosis, renal failure, and loss of distal extremity function. Open fractures must be treated operatively with irrigation, debridement, and fracture stabilization as quickly as possible, ideally within 6 hours of injury, to minimize the risk of infection. An ankle fracture/dislocation with medial skin tenting requires emergent reduction because this represents 1Cskin at risk 1D, which if allowed to necrose due to continuous pressure of the underlying bone will form a large eschar or even rupture. creating an open fracture dislocation. A native hip dislocation with acute onset 1Cfoot drop 1D is due to direct pressure of the femoral head on the sciatic nerve, most commonly manifested early by an acute 1Cfoot drop 1D and loss of function in the peroneal division. Femoral head reduction is the first-line treatment for this condition to relieve the sciatic nerve, as well as to optimize femoral head vascularity and hopefully avoid avascular necrosis. |
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Term
The primary bone-forming cell in humans is the:
1) Chondroblast
2) Endothelial cell
3) Osteoblast
4) Osteoclast
5) Osteocyte |
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Definition
| C) Osteoblasts are the primary bone-forming cells in humans. Osteoclasts are largely responsible for bone resorption and regulation of osteoblast activity. Osteocytes maintain homeostasis within the bone through intercellular communication and regulation of local ion gradients. Endothelial cells line blood vessels and do not play a direct role in bone formation. Chondroblasts are the primary cartilage-forming cells in humans and do not directly synthesize bone matrix. |
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Term
Which of the following is NOT a cardinal size of compartment syndrome?
1) Pain
2) Paresthesias
3) Pupura
4) Paresis
5) Pallor
6) Pulselessness. |
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Definition
5 P's! but not purpura
Pain
Parasthesia (2-point discrimination and touch)
Paresis
Pulseless/Pallor (TOO LATE)
Anyone with pain out of proportion to the injury and pain with passive range of motion must be further evaluated for CS. |
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Term
| What are the primary indications to measure compartment pressure with a Stryker Manometer? What do you do if pressures are > 30 mmHg? |
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Definition
Anyone with pain out of proportion to an injury and pain with passive range of motion must be further evaluated for CS.
If > 30mm Hg, early decompression (6h) is essential to relieve function.
- Fasciotomy is definitive, but elevate limb and treat hypotension while you are waiting.
REMOVE any casts or splints. |
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Term
In compartment syndrome, which of these is the latest sign to appear?
1) Pain
2) Paralysis
3) Paresthesia
4) Purple hue
5) Reduction of distal pulses |
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Definition
5
By the time pulses are reduced, tissue necrosis has begun. The earliest sign is pain out of proportion to apparent injury, especially pain with passive motion. Nerves are more sensitive than muscle to ischemia, so nerve-related symptoms occur before pulses are lost |
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Term
The most definitive test for diagnosis compartment syndrome is...
1) CPK
2) Elevated compartment pressure
3) Extremity dopplers
4) MRI
5) Pain with passive range of motion |
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Definition
| 2: Measuring compartment pressures with manometry is the only way to definitively diagnose acute compartment syndrome. Radiologic imaging has no use except to look for associated bony injury. While CPK can be elevated with muscle injury, there is no reliable value to diagnose compartment syndrome versus simple muscle injury. Extremity dopplers could detect pulse deficits but this finding is late in the disease and is an indirect finding. |
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Term
The most common sites of acute compartment sydrome are...
1) Foot and hand
2) Forearm and lower leg
3) Thigh and upper arm |
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Definition
| 2) The forearm and lower leg are the most common sites of acute complartment syndrome. While this disease can happen in any closed space in the body, the forearm and lower leg are commonly injured areas and have thick fascial sheaths which don't allow for expansion under increased pressure. This results in elevated pressure and tissue anoxia. |
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Term
Causes of acute compartment syndrome include all of the following EXCEPT:
1) Bleeding
2) External compression
3) First degree burn
4) Fracture
5) Severe overuse |
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Definition
| 3: Dirst degree burns WILL NOT cause compartment syndrome since they aren't associated with deep structure injury or loss of skin elasticity. Deep, full thickness burns, however, can cause compartment syndrome. Fractures, bleeding, overuse, and external compression are all potential causes of increased intracompartment pressure and subsequent compartment syndrome. |
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Term
| Describe the 4 basic compartments of the lower leg. |
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Definition
1) Lateral Compartment
- Superfiscial Peroneal Nerve
- Motor – Foot Eversion
- Sensory – Lateral dorsum of foot
2) Anterior Compartment
- Anterior Tibial Artery
- Deep Peroneal Nerve
- Motor – Toe dorsiflexion
- Sensory – Dorsal I – II web space
3) Deep Posterior Compartment
- Posterior Tibial Artery
- Tibial Nerve
- Motor – Toe Plantar flexion
- Sensory – Sole of foot
4) Superficial Posterior Compartment
- Sural Nerve
- Motor – Ankle Plantar flexion
- Sensory – Lateral heel |
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Term
| Describe the 3 basic compartments of the forearm. |
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Definition
1) Volar Compartment
- Finger and wrist flexors
- Brachial & Ulnar Artery
- Ulnar & Median Nerves
- Thumb opposition
- Finger Abduction/Adduction
2) Dorsal Compartment
- Finger extensor muscles
3) Mobile Wad
- Wrist extensor muscles |
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Term
| What is the basic pathophysiology of compartment syndrome? |
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Definition
Most often in forearm and lower leg, where compartments cannot accommodate increases in pressure (>30 mmHg for CS)
1) Anoxia causes myocyte necrosis and release of osmotically active proteins
2) This causes influx of water and increasing edema
Increasing edema further limits arterial blood flow and causes more ischemia |
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