Rheum at Ology

LUMBAR SPINAL STENOSIS
Saturday, May 17, 2014
4:11 PM
A common cause of combined low back pain and leg pain.

Lumbar spinal stenosis is a degenerative condition where the spinal canal is narrowed, resulting in compression of one or more of the spinal
roots.
It most commonly results from a combination of two factors:
Enlarging osteophytes at the facet joints
Hypertrophy of the ligamentum flavum
Patients experience back pain that radiates to the buttocks and thighs.
Numbness and paresthesia may occur.
Lumbar spinal stenosis occurs from any condition that narrows the spinal canal and compresses nerve roots.
Vertebral degenerative disk disease(DJD) is the most common cause of spinal stenosis, disk herniation and facet osteophytes impinge upon the
spinal cord.
This is most commonly seen in middle-aged and elderly patients.
The symptoms of spinal stenosis are posture-dependent.
Flexion of the spine causes widening of the spinal canal, while extension causes narrowing of the canal.
Therefore, the leg pain of lumbar spinal stenosis is exacerbated by extension of the spine(standing, downhill walking) and improved by
flexion(sitting, lying down, and uphill walking).
This phenomenon is referred to as "neurogenic claudication".
Neurogenic claudication is most easily distinguished from the claudication of peripheral vascular disease(PVD) by the presence of normal
arterial pulses.
The neurological examination in these patients is most often normal and the straight leg test is negative, only 10% have a positive SLRT.
On exam, normal ankle-brachial index and arterial pulses are seen.
Diagnosis is confirmed radiologically with MRI, and treatment may be conservative or surgical(laminectomy).
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D/D
PVD
Atherosclerosis is responsible for PVD.
Like, lumbar stenosis, PVD presents with claudication.
However, the leg pain of vascular claudication is exertional rather than position-dependent.
Furthermore, PVD does not cause associated low back pain.
Pain worsens with sitting.
Patients present with low back pain and sciatica.
A positive straight leg test is sensitive for a herniated disc.
Vertebral metastasis
Should be suspected in patients with low back pain in conjunction with H/O malignancy, weight loss, failure to improve with conservative
therapy and constant dull pain worse at night and changes little with activity. Pain is non-radiating.
Spinal cord compression
Presents with back pain, paralysis, hyperreflexia, urinary and fecal incontinence or urinary retention.
Autoimmune arthritis
Broad spectrum of conditions
Of these, ankylosing spondylitis(AS) has the most prominent spine involvement.
AS presents in young males as low back pain and limited spine mobility.
Leg pain is not a prominent complaint.
Symptoms of autoimmune arthritis improve with exercise, whereas this patient's symptoms worsen with walking.
Iliac artery atherosclerosis
Causes claudication in the buttocks and thighs.
This pain typically occurs during activity as is relieved by rest.
The key clinical differences between iliac artery atherosclerosis and lumbar stenosis are that the former is not affected by lumbar extension or
flexion and does not cause back pain.
Lumbar disk herniation
Typically presents with the acute onset of back pain with or without radiation down one leg.
Patients usually recall an inciting event.
As with LSS, the pain may be radiating and be associated with neurologic symptoms.
However, in disc herniation, lumbar flexion and sitting will make the pain worse.
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CHARCOT'S JOINT
Monday, May 19, 2014
11:59 AM
Also known as Neurogenic arthropathy

The process of developing neurogenic arthropathy starts with decreased pain, proprioception and temperature perception.
Can occur due to
Diabetes
Peripheral nerve damage
Syringomyelia
Spinal cord injury
B12 deficiency
Tabes dorsalis
As normal neurologic input is lost, patients unknowingly traumatize their weight bearing joints.
This causes secondary degenerative joint disease, joint deformation and functional limitation.
X-rays will reveal loss of cartilage, osteophyte development and loose bodies.
Associated pain is typically mild.
Management of a Charcot's joint involves treating the underlying disease and providing mechanical devices(e.g. special shoes) to assist in weight
bearing and to decrease further trauma.
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RA
Common cause of polyarticular inflammatory arthritis.
It typically affects the hands, wrist, feet and ankles.
X-rays of patients with long-standing, poorly controlled disease will reveal periarticular osteoporosis, joint erosions and joint space narrowing.
Osteoporosis
Bone demineralization is the hallmark.
This disease predisposes patients to pathologic fractures, particularly of the hip and vertebrae, but does not itself cause joint destruction.
Bacterial infection
An important cause of acute monoarticular arthritis.
It is exquisitely painful and rapidly destructive.
An X-ray will reveal joint destruction but not osteophytes or loose bodies.
A septic joint is diagnosed by joint fluid aspiration.
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OSTEOARTHRITIS(OA)
4:35 PM
Studies have shown a particularly strong link between obesity and knee OA.
Patients with OA typically present with brief morning stiffness(< 30 minutes) and exertional joint pain.
Systemic symptoms such as fever and weight loss are generally absent.
Plain films of an osteoarthritic knee reveal a narrowed joint space, osteophytes and subchondral sclerosis or cysts.
Osteophytes are bony growths that develop in the joints of patients with OA.
Cartilage degradation is the pathogenesis of OA.
OA patients may develop muscle atrophy from limitations of joint movement.
In the setting of a painful knee, there are six classic criteria used to establish the diagnosis of OA. These include:
Age > 50
Minimal or no morning stiffness
Bony tenderness
Bony enlargement
Crepitus on active motion
No warmth of the joint
In the case of a painful knee which meets at least 3 of these criteria, the sensitivity and specificity for OA are 95 and 69 percent,
respectively.
Nodular protrusions at the DIP and PIP in OA result from bony enlargement and are known as Herben and Bouchard nodes, respectively.
They are hard, bony nodules.
Obesity
Obesity is the most readily modifiable risk factor for OA.
Weight loss has been shown to slow progression of the OA and improve joint pain and function.
Hence, weight loss is the most effective measure in slowing progression of OA>
Muscle strengthening physical therapy
Integral part, but does not slow the progression of OA.
NSAIDs, acetaminophen and chondroitin sulfate
Pharmacotherapy of OA
Provide effective, temporary pain relief but do not slow the progression of OA.
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A diagnosis of OA should be considered in patients greater than 40 years of age presenting with knee pain.
In addition to age, pain that is aggravated by activity and relieved with rest is consistent with OA.
Morning stiffness of >30 minutes suggests inflammatory arthritis; 10 minutes of morning stiffness is consistent with OA, a non-inflammatory
arthritis.
Crepitus is a popping sound and feeling that occurs in OA as a result of cartilage erosion and incongruous joint surfaces.
Effusions may occur in OA but the joint will remain cool to touch.
Bony crepitus, bony enlargement and painful or decreased ROM are also common on exam.
Synovial fluid analysis will reveal a WBC count of 200-2000/ml.
As opposed to
Normal joint 0-200/ml
Inflammatory condition 2,000-50,000/ml
Septic arthritis > 50,000/ml
Hip arthritis
Degenerative joint disease/OA/"wear and tear" arthritis typically presents indolently in patients over 40 years of age with progressive
anterior hip pain exacerbated by walking and relieved by rest.
Morning stiffness or stiffness after prolonged resting is a consistent feature, but in contrast to RA, the morning stiffness of OA lasts less than
30 to 60 minutes.
Pain localized deep within the joint that may be referred to the inguinal area or rarely to the knee.
Classically, internal rotation of the hip worsens this pain.
Active and passive internal and external rotation of the hip is limited on exam.
Tenderness to palpation and systemic symptoms are characteristically absent in OA, and pain at rest or overnight occurs only in advanced
disease.
The etiology is progressive mechanical destruction of the articular cartilage leading to bone-on-bone friction and the formation of
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The etiology is progressive mechanical destruction of the articular cartilage leading to bone-on-bone friction and the formation of
osteophytes.
OA is the most common joint disease, predisposing factors are advanced age and obesity, particularly for hip and knee arthritis.
Treatment
The initial drug of choice for pain relief in mild to moderate OA is acetaminophen.
It has proven efficacy and a favorable side effect profile.
NSAIDs like ketorolac have proven efficacy but GI and renal side effects with long-term use make them second-line agents.
Short-term use minimizes the risk of side effects and is helpful for treating OA exacerbations.
Colchicine is used to treat OA refractory to NSAIDs and intra-articular steroids.
Its efficacy may be due to the presence of CPPD crystal in affected joints.
Opioids such as oxycodone are sometimes used to treat acute exacerbations of OA.
But not first-line agent because of risk of confusion, sedation, constipation and abuse.
Prednisone is an oral steroid used to treat RA, SLE and gout.
Oral steroids have no role in treating OA but intra-articular corticosteroid injections can be useful in flare-ups.
Hemochromatosis-associated arthropathy
Include squared-off bone ends and hook-like osteophytes in the 2nd and 3rd MCP joints.
Meralgia paresthetica
A condition where compression of the lateral femoral cutaneous nerve causes lateral hip paresthesia unaffected by motion or palpation.
Cutaneous nerve compression may cause hip pain.
Trochanteric bursitis
Inflammation of trochanteric bursa is caused by friction between the tendons of the gluteus medius and tensor fascia lata over the greater
trochanter of the femur.
Pain is localized over the lateral hip and is worsened by palpation.
Pain caused by pressure on the lateral hip may interfere with sleeping in patients with this condition.
Excessive frictional forces secondary to overuse, trauma, joint crystals, or infection are responsible.
Patients with this condition complain of hip pain when pressure is applied(as when sleeping) and with external rotation or resisted
abduction.
Osteonecrosis
Disruption of bone vasculature may cause osteonecrosis.
Osteonecrosis of the femoral head is typically associated with chronic corticosteroid use.
Referred pain from the lumbosacral area
Can cause posterior hip or gluteal pain and when impingement of the lumbar nerve roots occurs pain may radiate laterally down the thigh.
Such patients typically have no limitation of hip mobility but will exhibit positive findings on a SLRT.
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RHEUMATOID ARTHRITIS(RA)
4:47 PM
Subluxation of the cervical vertebrae and tendon damage in the hands may occur in RA .
Subcutaneous nodules appear at sites of repetitive trauma, such as the extensor surfaces of the forearm.
Rheumatoid nodules are firm, flesh-colored and nontender.
They typically occur over pressure points such as the elbow and extensor surface of the proximal ulna.
X-ray may show joint space erosions, juxta-articular demineralization and soft tissue swelling.
Clinical features of rheumatoid arthritis
Clinical presentation/symptoms Insidious onset, multiple joint pain, stiffness & swelling
Morning stiffness lasting hours, improves with activity
Small joints(e.g. PIP, MCP, MTP)commonly involved
Monoarthritis(e.g. knees, elbows)can also occur later
Spares the DIP joint, unlike OA
Examination
Affected joints are tender to the touch, swollen, with limited ROM
Tenosynovitis of the palms "trigger finger"
Rheumatoid nodules(especially on elbows)
Cervical joint involvement can lead to spine subluxation spinal cord compression
Laboratory/imaging studies
Positive anti-CCP antibodies(diagnostic testing)

High IgM rheumatoid factor
High CRP & ESR correlate with disease activity
X-ray: soft tissue swelling, joint space narrowing & bony erosions
RA affects women more often than men and has a typical onset at age 30-50.
Arthritis must be present for at least 6 weeks in order to diagnose RA.
Symmetric joint swelling is characteristic.
Due to autoimmune nature of the disease, systemic symptoms such as fatigue, fever and anemia often occur.
Patients are started on treatment(including DMARDs)based on the severity of their symptoms.
Increased levels of proinflammatory cytokines, corticosteroid therapy and lack of physical activity may contribute to local(around inflamed
joints) or generalized loss of bone mass in RA patients.
RA most commonly affects the cervical spine joints in the axial Skelton and can lead to cervical spine subluxation, which can also cause spinal
cord compression.
Patients with cervical spine involvement often complain of neck pain, stiffness and radicular pain in the upper extremity.
Subluxation with spinal cord compression can present with hyperreflexia or upgoing toes on Babinski testing.
There is an increased risk of osteopenia, osteoporosis and bone fractures, especially if other risk factors are present such as
Low body weight
Female sex
Family H/O osteoporosis
Cigarette smoking
Postmenopausal state
Excessive alcohol use
Other comorbidities
The degree of bone loss generally correlates with disease activity.
Strategies to prevent bone loss should be implemented
Adequate physical activity
Optimization of vitamin D and calcium intake
Minimization of glucocorticoid dose
Most experts suggest a low threshold for starting bisphosphonate therapy in RA patients.
Treatment
All patients diagnosed with RA should be started on DMARDs as soon as possible as joint damage begins early in its course.
NSAIDs and COX-2 inhibitors(e.g. celecoxib) are adjunctive therapies for symptomatic relief but do not reduce disease progression.
Glucocorticoids can also relieve symptoms and short-term radiographic progression but are also not effective in preventing eventual joint
destruction.
In fact, they can result in generalized bone loss(i.e. osteoporosis)
Disease-modifying anti-rheumatic drugs(DMARDs)
Include
Nonbiologic agents i.e. small-molecule drugs produced by conventional chemical synthesis which target inflammatory pathways like MTX,
hydroxychloroquine, sulfasalazine, leflunomide, azathioprine
Biologic agents i.e. large-molecule agents produced by biological means, primarily recombinant DNA technology, which target cytokines and
cell-surface proteins like etanercept, infliximab, adalimumab, toclizumab, rituximab.
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Agent
Mechanism
Adverse effects
Methotrexate
Purine antimetabolite
Hepatotoxicity
Stomatitis
Cytopenias
Leflunamide
Pyrimidine synthesis inhibitor Hepatotoxicity

Cytopenias
Hydroxychloroquine
TNF and IL-1 suppressor
Retinopathy
Sulfasalazine
TNF and IL-1 suppressor
Hepatotoxicity
Stomatitis
Hemolytic anemia
Tumor necrosis factor inhibitors

Adalimumab
Certolizumab
Etanercept
Golimumab
Infliximab
Infection
Demyelination
Congestive heart failure
malignancy
Methotrexate
Works by inhibiting dihydrofolate reductase.
Hematologic toxicity with macrocytic RBCs may occur with its usage and one of the more serious abnormalities is development of
pancytopenia.
In an attempt to prevent these complications, the American College of Rheumatology recommends routine peripheral blood counts every
three months.
Other side effects of methotrexate include
Nausea
Stomatitis
Rash
Hepatotoxicity-acute rise in serum transaminases
Pulmonary toxicity-Interstitial lung disease
Alopecia
Fever
Oral ulcers
Bone marrow suppression- macrocytic anemia, leukopenia, thrombocytopenia
Methotrexate(MTX) acts by interfering with the cellular utilization of folic acid and folate depletion is considered to be the cause of most of
these complaints.
Some of these reactions can be alleviated or prevented by the addition of supplemental folic acid, without changing the efficacy of MTX.
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Some of these reactions can be alleviated or prevented by the addition of supplemental folic acid, without changing the efficacy of MTX.
MTX is the preferred initial DMARD in patients with moderately to severely active RA due to its efficacy and long-term safety profile.
Patients should be tested for hepatitis B and C and tuberculosis before starting therapy.
MTX should not be used in patients who are pregnant or are planning to become pregnant in the near future and those with severe renal
insufficiency, liver disease or excessive alcohol intake.
Patients who do not respond after 6 months may require biologic DMARDs such as TNF-alpha inhibitors(e.g. etanercept, infliximab) as stepup therapy.
Most adverse affects of MTX are reversible if the medication is discontinued, but patients should be observed closely as withdrawal may
precipitate a flare of RA symptoms.
Hydroxychloroquine
Common adverse effects are
GI distress
Visual disturbances-retinopathy, corneal damage
Hemolysis in G6PD deficiency
Therefore, eye examinations at 6 month intervals are indicated in all patients taking hydroxychloroquine.
Azathioprine
An immunosuppressive agent used in RA
However, it is not as efficacious as other DMARDs and is associated with significant hematologic and GI toxicity.
Prednisone
A glucocorticoid that is often used in RA.
Many side effects such as
Iatrogenic Cushing's syndrome
Osteoporosis
Adrenocortical atrophy
Poor wound healing
Drug
Adverse effect
Anti-TNF
Reactivation of TB
Hydroxychloroquine Ocular
Sulfasalazine
Rash, hemolysis
Rituximab
Infection
Gold salts
Nephrotic syndrome
Methotrexate
Liver, lung, marrow
Felty syndrome
A clinical disorder seen in patients with severe, long-standing(>10years)RA that is characterized by neutropenia and splenomegaly.
Splenomegaly without neutropenia can also occur in patients with RA, but the diagnosis of Felty syndrome should be made in the absence of
neutropenia.
Septic arthritis
RA predisposes development of septic arthritis.
Synovial fluid analysis, gram stain and culture are critical for distinguishing septic from crystal-induced arthritis.
Treatment of septic arthritis requires prompt administration of IV antibiotics and adequate joint drainage to lessen the likelihood of joint
destruction.
PSORIATIC ARTHRITIS
12:18 PM
Occurs in 5-30% of patients who suffer from psoriasis.

Psoriatic arthritis can present with many different patterns, but the classic presentation involves the distal interphalangea l joints.
Morning stiffness, deformity of involved joints, dactylitis("sausage digit"- a diffusely swollen finger) and nail involvement are common.
The image above shows all of these classic signs.

The left index finger demonstrates dactylitis, many of the nails shoe pitting and onycholysis(separation of nail bed) and the DIP joints are
prominently involved.
Furthermore, well-demarcated red plaques with silvery scaling- the classic lesions of psoriasis- are seen on the dorsum of each hand.
Enteropathic arthritis
Occurs in 10-20% of patients with Crohn's disease and ulcerative colitis.
It most often affects the lower extremities and sacroiliac joints and tends to wax and wane with the symptoms of bowel diseas e.
These patients present with prominent GI symptoms and other extra-intestinal manifestations of IBD.
P-ANCA is positive in UC.
IBD typically presents in patients during their 2nd or 3rd decade and the presenting symptoms of UC often include bloody diar rhea, lower
abdominal pain and tenesmus.
Extracolonic manifestation include skin findings, such as erythema nodosum and Pyoderma gangrenosum, episcleritis, arthritis and
cholangitis.
Presentation of arthritis is similar to AS.
Whipple disease
A multisystem disorder with a varied presentation caused by infection with gram-positive bacillus Tropheryma whippelii.
Chronic malabsorptive diarrhea, weight loss, migratory non-deforming arthritis, lymphadenopathy and a low-grade fever are the most
common presenting symptoms.
GOUT
3:56 PM
Results from either overproduction or underexcretion of uric acid.

Gout begins with asymptomatic hyperuricemia and subsequently progresses to monoarticular arthritis.
Accumulation of urate crystals in the synovial fluid causes inflammation of the synovial lining and precipitates an acute attack of gout.
The attacks often occur at night.
The most common joint affected is the first MTP joint, the great toe.
A gouty flare, in a patient with H/O gouty arthritis common.
In fact, greater than 60% patients with a first episode of gouty arthritis suffer from a recurrence within one year.
Severe swelling and pain in the great toe due to the deposition of monosodium urate crystals is referred as podagra.
Uric acid crystals form in the renal tubules and collecting system resulting in nephrolithiasis.
Synovial fluid analysis shows yellow needle like crystals when parallel to the polarizing axis and blue needlelike crystals when perpendicular to
the polarizing axis.
This is consistent with negatively birefringent crystals, which are typically seen with urate crystals in gouty arthritis.
Predisposing factors for gout include
High meat and/or sea food consumption
Volume depletion
Excessive alcohol intake
Drugs(e.g. diuretics)
1.
2.
Alcoholism
Chronic alcoholism is a risk factor for the development of gout.
Ethanol is metabolized to lactate, which competes with urate for renal excretion, leading to accumulation of urate in the body.
Cessation of alcohol plays an important role in prevention of future attacks, especially in chronic alcoholics.
Other measures that should be observed by patients with gout are
Staying low on a purine diet
Avoiding drugs such as diuretics and pyrazinamide.
Treatment of an acute attack is with NSAIDs(drug of choice), colchicine or steroids.
Induction chemotherapy
Causes rapid tumor destruction or lysis.
This process releases uric acid, a byproduct of DNA, into the circulation and results in an elevated serum uric acid level that can predispose to
gout attacks.
Acute, monoarticular arthritis affecting the first metatarsophalangeal joint(podagra) is the most common presentation of a gout attack.
Definitive diagnosis is achieved by joint aspiration with demonstration of needle-shaped, negatively birefringent urate crystals and a WBC
count of 2,000-50,000/mm3.
Allopurinol, a xanthine oxidase inhibitor, is often used to prevent gout attacks.
It works by decreasing uric acid production.
Uricosuric drugs(e.g. probenecid) are used to prevent gout attacks and work by increasing urinary excretion of uric acid.
There is risk of inducing uric acid renal stones with probenecid.
Adequate hydration is recommended during probenecid therapy to prevent the formation of uric acid kidney stones.
Chronic tophaceous gout
In chronic disease, urate crystals may deposit in the soft tissues forming tumors known as tophi .
Tophi can ulcerate and drain a chalky material.
The differential diagnosis of tophi includes rheumatoid nodules and calcinosis cutis.
Diuretics in general have a hyperuricemic effect resulting from hypovolemia-associated enhancement of uric acid reabsorption in the proximal
tubule.
Treatment
Patients generally respond to NSAIDs (preferred) such as indomethacin, colchicine or corticosteroids(systemic or intra-articular).
Long-term prophylactic medications(e.g. allopurinol) are initiated after recurrent gouty attacks.
Colchicine is an anti-inflammatory drug used for the treatment of acute gout.
It acts by decreasing leukocyte activity primarily by inhibiting tubulin polymerization.
Polycythemia Vera-related gout
The myeloproliferative disorders are common causes of uric acid overproduction because there is increased catabolism and turnover of
purines.
The resultant increases in serum uric acid levels can precipitate attacks of gouty arthritis.
Polycythemia Vera commonly causes splenomegaly and characteristic pruritus with hot baths due to histamine release from an increased
number of circulating basophils.
Up to 40% of patients with Polycythemia Vera suffer from gout.
Lesch-Nyhan syndrome
Caused by a genetic deficiency of the enzyme hypoxanthine-guanine phosphoribosyl transferase(HPRT).
The disease is characterized by overproduction of uric acid, behavioral problems(especially self-injurious actions) and neurologic disability and
is generally diagnosed in childhood.
KNEE PAIN
12:52 PM
Differential diagnosis of anterior knee pain in the young patient

Patellofemoral syndrome
Patellar tendonitis
Osgood-Schlatter disease
Typical patient
Young/middle-aged
Women > men
Primarily athletes
("jumper's knee")
Preadolescent/adolescent
Recent growth spurt
Natural course
Subacute to chronic
Episodic
Episodic
Examination findings Pain with squatting

Pain & tenderness at inferior patella Tenderness at tibial tubercle
Patellofemoral compression test
Patellofemoral syndrome(PFS)
A young patient with chronic anterior knee pain that is worse with climbing stairs.
Women are affected much more frequently than men.
Risk factors include
Overuse
Malalignment
Trauma
Although overuse during training is probably most common.
The diagnosis is often challenging to confirm and is based primarily on history and examination findings.
The Patellofemoral compression test -pain elicited by extending the knee while compressing the patella, and reproduction of pain with squatting
are highly suggestive.
Tests such as X-ray of knee and MRI are usually normal and are generally needed only if the diagnosis is in doubt or the patient fails to improve as
expected.
Management
Primarily mechanical-exercises to stretch and strengthen the thigh muscles and avoiding activities that aggravate pain.
NSAIDs are often prescribed but frequently not helpful.
Persistence is required on the part of the patient as resolution of symptoms may often take weeks to months.
Osgood-Schlatter disease
Caused by chronic/repetitive strain at the insertion of the patellar tendon on the tibial tubercle and is seen in pre-adolescent and adolescent
patients undergoing rapid growth spurts.
Ruptured baker's cyst

Causes pseudothrombophlebitis syndrome.
Swelling is seen in the posterior calf, just below the knee.
The fluid from the cyst may also leak down the inner leg, resulting in a hematoma over the medial malleolus known as the "crescent sign".
Baker cyst
The tender mass located in the popliteal fossa.
Baker cysts develop as a result of excessive fluid production by inflamed synovium, as occurs in cases of RA, OA and cartilage tears.
As the synovial fluid volume expands, excess fluid accumulates in the popliteal bursa.
The popliteal bursa bulges beyond its usual size and fills the popliteal fossa producing the tender synovial fluid-filled mass known as a baker cyst.
Clinical features of popliteal(Baker's) cyst
Risk factors
Trauma(e.g. meniscal tear)

Underlying knee joint disease(e.g. OA,RA)
Clinical presentation Can be asymptomatic

Posterior knee pain, swelling or stiffness
Posterior knee swelling increased with patient standing and knee extended
Swelling usually decreases with knee flexion to 45 0(Foucher's sign)
Complications
Cyst enlargement with dissection into calf

Can present with erythema, distal edema, positive Homan's sign
Cyst enlargement into popliteal space
Can compress adjacent vein and cause leg/ankle swelling
Cyst rupture with severe calf pain, warmth, tenderness, erythema
Cyst rupture with severe calf pain, warmth, tenderness, erythema

Can also have ecchymoses from posterior calf to ankle
Meniscal injury
Most commonly caused by a twisting injury with foot in a fixed position.
Patients typically have swelling and pain(usually gradually occurs within 24 hours after the injury) in the knee made worse with twisting
movements and occasionally causing a popping sensation.
Untreated patients can develop symptoms weeks later consisting of popping, catching, the knee giving out and locking(i.e. inability to extend the
knee).
Physical examination findings that indicate possible meniscal injury are summarized below.
Knee function
Joint line tenderness

Loss of smooth flexion or extension
Inability to move forward and backward while squatting
Effusion
Provocative
tests
Thessaly test: pain or locking with internal and external rotation of the knee while standing on one leg with the knee flexed to
200
McMurray test: painful click with passive flexion and extension of the knee with the examiner's thumb and index finger placed
on the medial and lateral joint lines
Apley test: pain with pressing the heel toward the floor while internally and externally rotating the foot with knee flexed to 900
Patients are clinically diagnosed and need further evaluation if the knee is locked, there is pain with minimal knee flexion, recurrent effusions are
present, or symptoms persist for weeks despite initial conservative treatment.
In these patients, MRI is the preferred test over arthroscopy.
Surgery(arthroscopy or open) is usually necessary to correct the problem.
Intraarticular steroid injections can be used in patients with secondary meniscal injury due to degenerative joint disease.
Medial meniscus injury
Injury to a number of different structures within the knee, including ligaments and cartilaginous menisci, can cause a popping or snapping
sensation.
Damage to the medial meniscus is a common knee injury.
Meniscal injuries occur most common in patients in their thirties and forties while performing activities requiring axial loading and rotation.
Classically the patient will report feeling a "pop" that is followed by severe pain at the time of injury.
Meniscal injuries typically cause joint swelling over the following 12 to 24 hours, in contrast to ligamentous injuries, which cause rapid joint
swelling due to hemarthrosis.(ligaments have much greater vascular supply than menisci, which rely on diffusion for nourishment).
Physical exam may show joint line tenderness, decreased range of motion and a positive McMurray's test.
McMurray's sign, refers to a palpable or audible snap occurring while slowly extending the leg at the knee from full flexion while simultaneously
applying tibial torsion.
Locking of the knee joint on extension is generally seen in "bucket handle" tears, while ROM at the knee is limited by pain in all meniscal tears.
MRI provides the definitive diagnosis.
ACL tear
An anterior cruciate ligament tear would cause immediate swelling due to rapid development of hemarthrosis.
Moreover, patients typically experience immediate inability to weight-bear and then lasting knee instability following such an injury.
Features of anterior cruciate ligament injury
Injury mechanisms
Rapid deceleration or direction changes

Pivoting on lower extremity with foot planted
Symptoms
Pain: rapid onset, may be severe

A "popping" sensation at the time of injury
Significant swelling(effusion/hemarthrosis)
Joint instability
Examination findings Anterior laxity of tibia relative to femur

(anterior drawer test, Lachman test)
Diagnosis
MRI
Treatment
RICE(rest, ice, compression, elevation) measures

+/- surgery

Injuries to the ACL are common in young athletes, especially in women participating in noncontact sports requiring rapid direction changes or
pivots on the lower extremity(e.g. soccer, basketball, tennis).
ACL tears can also occur in high-contact sports or injuries involving a blow to the knee or significant twisting force.
Patients with partial- or full-thickness ACL tears typically complain of a "popping" sensation in their knee during the injury followed by rapid onset
of hemarthrosis and a feeling of instability when bearing weight on the affected side.
Patients with an ACL tear will show laxity at the knee with the tibia able to be pulled forward relative to the femur.
Two such maneuvers-the Lachman test and the anterior drawer sign- are highly sensitive and specific for ACL injuries.
In addition, there is usually significant knee effusion due to hemarthrosis.
Medial collateral ligament(MCL) tear
May also occur in pivoting/twisting injuries or if the knee is struck from the lateral side with the foot planted.
Examination usually shows tenderness at the medial knee along the joint line and there may be laxity when the foot is gently forced into
abduction with knee stationary(valgus stress test).
However, MCL injuries are not usually associated with significant hemarthrosis unless there is a concurrent ACL injury.
Special tests for knee examination

Medial/lateral collateral ligament injury Valgus stress test for medial instability
Place 1 hand above knee along lateral thigh & other along medial
gastrocnemius muscle
Apply outward pressure with hand on medial aspect along calf
Pain in the knee with movement usually indicates sprain but false
positive possible with wearing of medial articular cartilage
positive possible with wearing of medial articular cartilage

Valgus stress test for lateral instability
Place 1 hand above knee along medial thigh & other along lateral
gastrocnemius muscle
Apply inward pressure with hand on lateral aspect along calf
Pain in the knee with movement usually indicates sprain but false
positive possible with wearing of lateral articular cartilage
Anterior cruciate ligament injury
Anterior drawer test

Have patient lie down supine with knee flexed at 90 degrees
Grip proximal tibia with both hands & pull anteriorly
Intact ACL prevents significant anterior knee displacement
Lachman test
Place knee at 30 degrees flexion
Stabilize distal femur with 1 hand & pull proximal tibia anteriorly
with the other
Intact ACL prevents significant anterior movement
Posterior cruciate ligament injury
Posterior drawer test

Flex knee to 90 degrees and stabilize foot
Grasp tibia with both hands and push posteriorly
Intact PCL prevents significant posterior movement
Posterior sag test
Place patient supine with hips flexed to 45 degrees, knees flexed to
90 degrees & feet flat on table
PCL injury causes affected leg to sag backward relative to unaffected
leg
Meniscal tear
Thessaly test
While holding the examiner's hand, patient stands on 1 leg with knee
flexed 20 degrees
Positive test is pain or locking with internal &/or external knee
rotation, suggesting meniscal tear
Apley test
With patient prone & knee flexed to 90 degrees, stabilize patient's
thigh with examiner's knee or hand
Press patient's heel directly toward floor while internally & externally
rotating foot to compress meniscus between tibial plateau and
femoral condyles
Focal pain with compression suggests meniscal tear
McMurray test
Passive flexion & extension while placing examiner's thumb & index
finger on medial and lateral joint lines
Clicking with passive movements or medial/lateral rotation suggests
meniscal tear
Posterior cruciate ligament injury

Classically seen in the "dashboard injury", which refers to forceful posterior-directed force on the tibia with the knee flexed at 90 degress.
The posterior drawer test, reverse pivot shift and posterior sag tests will help in clinical diagnosis.
Lateral collateral ligament injury
Very rare and would be seen in adduction injury to the knee.
The varus stress test will help in clinical diagnosis.
PSEUDOGOUT
10:19 PM
A acute form of calcium pyrophosphate dihydrate(CPPD) crystal disease.

Attacks of pseudogout often occur in the setting of trauma, surgery or medical illness.
Patients present with
acute pain
Swelling
Redness
Limited motion of involved joint(s), with knee being most commonly affected(>50% of
cases).
Fever
Leukocytosis with a left shift
Chondrocalcinosis(calcified articular cartilage)
Diagnosis cannot be made based on history and examination alone.
Synovial fluid analysis is critical for distinguishing between gout, pseudogout and septic arthritis.
The identification of rhomboid, positively birefringent crystals on synovial fluid analysis is
diagnostic of pseudogout.
Patients with hyperparathyroidism are at increased risk of developing pseudogout, a

monoarthropathy caused by CPPD deposition.
MORTON NEUROMA
5:20 PM
Commonly occurs in runners and is not a true neuroma.

The disorder is a mechanically induced neuropathic degeneration with symptoms including numbness and burning of the toes, aching and
burning in the distal forefoot that radiates forward from the metatarsal heads to the third and fourth toes.
The symptoms are worsened by walking on hard surfaces and wearing tight or high-heeled shoes.
Physical examination typically shows pain between the third and fourth toes on the plantar surface and a clicking sensation(Mulder sign) when
simultaneously palpating this space and squeezing the metatarsal joints.
The diagnosis is made clinically, and treatment involves using metatarsal support with a bar or padded shoes to ensure that the patient walks
evenly.
If conservative treatment fails, then the patient usually requires surgical treatment.
Plantar fasciitis
Causes burning pain in the plantar area of the foot that is made worse with walking.
It is common in runners with repeated micro trauma who develop local point tenderness on the plantar aspect of the foot.
Stress fractures
Occur due to a sudden increase in repeated tension or compression without adequate rest that eventually breaks the bone.
Patients typically present with a sharp and localized pain over a bony surface that is worse with palpation.
They are insidiously secondary to repeated stress.
Athletes, especially long-distance runners, are most commonly affected.
The tibia and fibula are most vulnerable.
Patient in the vignette is an avid runner who presents with 5 weeks of right foot pain worsening over 1 week consistent with a likely stress
fracture, which most commonly occurs in athletes(up to 15% incidence in runners) and nonathletes who suddenly increase their activity.
Stress fractures occur due to a sudden increase in repeated tension or compression without adequate rest that eventually breaks the bone.
Female runners who have the "female athlete triad"(i.e. amenorrhea, poor eating habits and osteoporosis) such as this patient are more likely to
Female runners who have the "female athlete triad"(i.e. amenorrhea, poor eating habits and osteoporosis) such as this patient are more likely to
develop a stress fracture.
Are also common in ballet dancers, basketball and soccer players and military recruits.
The causes of stress fractures are categorized as
Activity related- excessive training and improper footwear
Biomechanical-weak calf muscles, high arched feet
Metabolic-demineralized bone from hormonal or nutritional diseases
The tibia is a major weight-bearing bone in the leg, and patients usually develop medial tibial stress syndrome(i.e. "shin splints" with no tibial
tenderness on palpation).
This can progress with further activity to a complete or incomplete fracture, resulting in pain to palpation of the tibia.
The diagnosis of a stress fracture is clinically made on examination with pain at a specific area that increases with jumping or running and is
associated with local swelling and point tenderness to palpation.
X-rays are frequently normal but can reveal periosteal reaction in the site of the fracture.
The injury is best defined radiographically using MRI or bone scan.
Treatment involves rest and healing of the stress fracture.
D/D: Pain in the forefoot involving the tarsal bone is usually due to a stress fracture, arthritis, bursitis or Morton neuroma.
A stress fracture usually causes a sharp and localized pain over a bony surface that is worse with palpation of the area.
Arthritis typically occurs in the metatarsal joints and is not localized to a single bony surface.
Bursitis is usually caused by wearing poor-fitting shoes for an extended period, leading to inflammation between the metatarsal heads.
Morton neuroma is not a neuroma but is associated with pain between the third and fourth toes on the plantar surface and a clicking
sensation(Mulder sign)when simultaneously palpating this space and squeezing the metatarsal joints.
This patient has point tenderness over the foot consistent with a stress fracture and should be managed with rest from running.
Metatarsal stress fractures
Typically occur in athletes and military recruits, particularly due to the sudden and drastic increase in activity by the latter.
The second metatarsal, which is subjected to significant extremes of loading during gait is the most commonly involved metatarsal.
Patient present complaining of slow onset foot pain that initially only occurs with activity but later is present during rest as well.
Point tenderness over the affected metatarsal is present on examination.
Fractures of the 2nd,3rd and 4th metatarsals are managed conservatively because the surrounding metatarsals act as splints and nonunion is
uncommon.
Rest and pain control are the most appropriate treatments in this case.
Patients may additionally be managed with a hard-sole shoe and light activity may be resumed immediately.
Bone scan and MRI of the foot may be used to make the diagnosis of a metatarsal stress fracture if plain radiographs are unable to demonstrate
the fracture.
Plaster casting is used for patients with persistent pain following more conservative treatment.
Surgical intervention is reserved for fractures of the 5th metatarsal such as jones fractures or for displaced fractures not amenable to closed
reduction.
Tarsal tunnel syndrome
Involves compression of the tibial nerve as it passes through the ankle and is usually caused by a fracture of the bones around the ankle.
Patients typically present with burning, numbness and aching of the distal plantar surface of the foot or toes that sometimes radiate up to the
calf.
Tenosynovitis
An inflammation of the tendon and its synovial sheath.
It is usually seen in hands and wrist joints following a bite or puncture wounds.
Patients have pain and tenderness along the tendon sheath, particularly with flexion and extension movements.
ANKYLOSING SPONDYLITIS(AS)
5:45 PM
More common in young males, it is the most likely diagnosis in a patient with low back pain and sacroiliitis.
The male-to-female ratio of AS is 2-3:1.
The highest incidence of AS occurs between ages 20-30 years and there is a strong association with HLA-B27.
AS is primarily a disease of the axial Skelton, causing progressive back pain and spinal stiffness.
Morning stiffness and improvement with exercise are typical.
Although there are no pathognomic signs of AS on exam, reduced ROM in the lower back and sacroiliac tenderness support the diagnosis.
AS may be definitely diagnosed in a patient with symptoms of AS and bilateral sacroiliitis on plain film.
Usually occurs at age < 40 and presents with gradual onset of LBP.
The pain improves with exercise(rather than rest) and can be associated with hip or buttock pain.
Other possible findings include anterior uveitis and enthesitis(inflammation of tendon insertion site at bone)
Anterior uveitis is the most common extra-articular manifestation of AS and occurs in 25-40% of patients.
It presents with monocular pain, blurring and photophobia.
AS is an inflammatory disorder that involves primarily the apophyseal(facet)joints of the axial Skelton.
Patients with suspected AS require
Measurement of inflammatory markers(e.g. ESR, CRP)
HLA-B27 typing
Imaging of the spine-fusion of the sacroiliac joints and/or bamboo spine is diagnostic
Enthesitis
Refers to inflammation and pain at sites where tendons and ligaments attach to bone.
Enthesitis is most commonly seen in cases of recurrent tendon or ligament stress and the HLA-B27- associated arthropathies- AS, psoriatic
arthritis and reactive arthritis.
It is particularly prominent in AS and classically manifests with heel pain due to tenderness at the insertion of the Achilles tendon.
The tibial tuberosities and iliac crests are also common sites of symptomatic enthesitis.
Shoulder and hip pain, stiffness, low back pain and limited spinal mobility, are other common manifestations of AS.
Other less common manifestations

Patients with AS are at risk of aortic regurgitation secondary to scarring of the aortic valve cusps.
Thoracic aortic aneurysm is associated with Marfan syndrome, Ehlers-Danlos syndrome and syphilis.
It also has an association with many inflammatory arthritides, including AS.
There is some risk of developing a thoracic aortic aneurysm.
Patients with AS may develop secondary amyloidosis and IgA nephropathy and only occasionally lead to renal failure.
Multiple studies have concluded that patients suffering from AS for two decades or longer are at an increased risk of vertebral fracture due to
decreased bone mineral density.
The annual incidence of vertebral fracture in this population may reach 0.5-1% and often these vertebral fractures result from minimal trauma.
The clinical suspicion for vertebral fracture in these patients must be high.
Low back pain associated with AS typically begins as insidious, unilateral, intermittent pain that may become bilateral and persistent with flares.
The pain is not typically sudden and severe.
Patients with AS are at increased risk for muscle spasms.
Back spasms present with sudden severe back pain that resolves within seconds to minutes and may recur.
Restrictive lung disease
May result due to AS, FEV1/FVC ratio > 80%.
Clinically, patients with AS experience slowly progressive back pain of insidious onset, spinal fusion, sacroiliitis and enthesopathy.
Inflammation also leads to fusion of the costovertebral joints, resulting in restriction of chest wall motion.
While most restrictive lung diseases present with a decreased FRC, AS presents with a normal or increased FRC due to fixation of the chest wall
in an inspiratory position.
Other restrictive lung diseases:
Interstitial lung diseases
Neuromuscular disease
Alveolar edema
Pleural fibrosis
Chest wall abnormalities
Reactive arthritis
Reactive arthritis
May follow an infectious diarrhea caused by Shigella, salmonella, Yersinia, campylobacter or C.difficile.
Reactive arthritis is characterized by urethritis, conjunctivitis/uveitis, arthritis, malaise and characteristic cutaneous skin findings( keratoderma
blennorhagica and balnitis circinata)
A type of seronegative spondyloarthropathy.
Classic reactive arthritis consists of a triad of nongonococcal urethritis, asymmetric oligoarthritis and conjunctivitis.
The arthritis often involves the knee and sacroiliac spine.
In addition to the classic triad, mucocutaneous lesions and enthesitis(Achilles tendon pain) are common findings in reactive arthritis.
NSAIDs are the first line therapy during the acute phase of this condition.
LOW BACK PAIN

6:01 PM
Common causes of low back pain

Condition
Musculoskel Mechanical
etal
(muscle strain, spasm,
Degenerative arthritis)
Clinical clues
Normal neurologic examination
Negative straight leg raise
Possible paraspinal tenderness
Herniated nucleus
Pulposus/disk disease
Radiculopathy(usually L4-L5)
Possible positive SLR
Possible neurologic deficits
Spinal stenosis
Pseudoclaudication
Better with spine flexion
Worse with extension
Older age
Compression fracture
Older age
Compression fracture
Older age
More common in women
Trauma/fall(may be minor)
Osteomalacia
Osteoporosis
(bone demineralization)
Inflammator Ankylosing spondylitis,

y
reactive arthritis, IBD
Better with activity or exercise

No improvement with rest
Gradual onset
HLA-B27 present
Malignancy
Metastatic cancer to bone
H/O malignancy
Age>50
Worse at night
Unintentional weight loss
Cauda equina syndrome(weakness, urine
retention/incontinence, saddle anesthesia)
Infectious
Osteomyelitis, discitis, abscess Recent infection

IV drug abuse
Diabetes
Fever, exquisite point tenderness
Low back pain(LBP) is most commonly due to mechanical causes(e.g. muscle spasm, sprain, arthritis).
Mechanical LBP usually improves with rest, worsens with exercise and is not worse at night during sleep.
Most patients also improve over a period of 2-4 weeks with symptomatic treatment.
Red flags indicating more serious cases of LBP include
Age > 50
Neurologic findings- weakness, urine retention/incontinence, Saddle anesthesia
H/O malignancy
Unintentional weight loss
Worsening pain at night
Systemic symptoms-fever
If a patient has gradual onset of LBP that is worse at night but improves with physical activity rather than rest.
If younger age and normal neurologic examination make back pain due to fractures, spinal stenosis or malignancy less likely.
Absence of systemic symptoms or recent infection is less consistent with infectious causes of LBP(e.g. osteomyelitis)
Absence of systemic symptoms or recent infection is less consistent with infectious causes of LBP(e.g. osteomyelitis)
As a result, his presentation suggests an inflammatory spondyloarthritis such as
Ankylosing spondylitis(AS)
Psoriatic arthritis
Reactive arthritis
Arthritis associated with IBD
Osteomalacia
Abnormal bone mineralization can lead to pathologic bone fracture, with back pain that is worse with activity or positional changes.
Inadequate serum vitamin D, calcium or phosphorus results in demineralized osteoid.
Ligamentous strains
A common cause of back pain and can often be traced to a specific event or action
Patients typically experience more pain with movement and improvement with rest.
Pain is typically perispinal.
Lumbar osteoarthritis
Often develops in the setting of advanced age, disk degeneration and a more sagittal orientation of the facet joints.
It frequently presents as LBP in the elderly.
OA pain typically worsens with activity and is relieved with rest.
Nerve root demyelination
Can be due to immune mediated(e.g. Guillain-Barre), toxin- or medication-induces, metabolic, hereditary or infectious processes.
Nerve root demyelination will cause neurologic deficits specific to the affected nerve roots but is unlikely to cause LBP without additional
neurologic findings.
The majority of LBP is due to musculoskeletal causes, but the following red flags suggest a systemic disorder, herniated disk or bony
abnormalities such as lytic lesion and compression fractures
Age over 50
H/O previous cancer
Unexplained weight loss
Pain greater than one month duration
Nighttime pain causing difficulty with sleep
No response to previous therapy
Neurologic symptoms
Pain to palpation of the vertebra on exam is suggestive of a spinal infection or possibly lytic lesions in the spine.
A positive SLRT suggests a herniated disc.
If patient is over 50 years and has concerning symptoms of nighttime pain for greater than a month and should be evaluated further.
The initial test of choice is plain films of the back to look for lytic lesions and compression fractures.
If this test is nondiagnostic and there is still a high clinical suspicion, then a MRI of the back or CT scan should be done to evaluate for
possible disc disease, cancer and spinal infections.
The most common cancers that metastasize to the bone are lung, breast, prostrate, renal, multiple myeloma, melanoma and thyroid.
Disc herniation
Acute onset of back pain and positive SLRT suggest disc herniation.
At the same time, no neurologic deficit is present and the perianal area is intact(it is always important to rule out Cauda equina syndrome).
These patients managed conservatively.
In randomized clinical trials, patients did better without bed rest than with it; so, bed rest is no longer advised for this type of low back pain.
Patients should be advised to return to daily activities as soon as possible.
Pain and stiffness is better managed with NSAIDs and muscle relaxants.
An exercise program has also not been shown to be beneficial for this type of pain.
If the pain persists after 4-6 weeks of conservative treatment or progressive neurologic deficit evolves, high-resolution diagnostic modalities
are usually employed: MRI and CT with or without contrast myelography.
Vertebral osteomyelitis
High risk patient's are
Injection drug users
Those with sickle cell anemia
Immunosuppressed patients
Spine is a frequent site of osteomyelitic infection in injection drug users.
In this group, Staphylococcus aureus is the most common pathogen, but infections with Gram-negative organisms also occur frequently.
Tenderness to gentle percussion over the spinous process of the involved vertebra is the most important clue.
Pain is often not relieved with rest, and ever is an inconsistent finding.
WBC count may be normal or elevated.
Platelet count is often high as a marker of inflammation/stress.
The ESR is often significantly elevated>100mm/h.
MRI is the most sensitive diagnostic study.
The treatment is long-term IV antibiotics with or without surgery.
Metastatic disease of the vertebrae
The most common tumors to metastasize to bone include lung, breast, prostate, thyroid and kidney.
The bone pain caused by bone metastases is typically constant and worse at night.
By comparison, the pain caused by degenerative disease is typically exacerbated by exercise and relieved by rest.
By comparison, the pain caused by degenerative disease is typically exacerbated by exercise and relieved by rest.
The characteristic of the pain and H/O known malignancy is crucial.
Iliac artery thrombosis

May cause LBP associated with claudication of the hip muscles and possibly impotence.
Lumbar strain
Lumbosacral strain is the most common cause of acute back pain.
The typical scenario includes acute onset of back pain after physical exertion, absence of radiation, presence of paravertebral tenderness,
negative straight-leg raising test, and normal neurologic examination.
Treatment includes NSAIDs and early mobilization.
Caused in relation to lifting a heavy object, no radicular signs and good response to conservative therapy.
Proper patient education is very helpful in protecting the back from recurrent injury.
The education should emphasize the importance of strengthening the supporting muscles(including abdominal muscles)by regular exercise,
choosing an appropriate sleeping posture(e.g. avoiding sleeping on the stomach) and learning proper techniques for bending and lifting
objects.
Exercises with repetitive twisting and bending should be avoided.
It is important to bend at the knees, not at the waist.
While lifting an object, one should also bend the knees, keeping the back straight; this technique is very useful in preventing strains and back
injuries.
Warm-up exercises should be done before any sporting activities.
ERYTHEMA NODOSUM(EN)
5:03 PM
A condition in which painful, subcutaneous nodules develop on the anterior surface of the lower legs.
It is most common in women aged 15-40 years.
EN tends to be a relatively benign condition which heals on its own within a few weeks.
However, it can be early symptom of more serious disease processes and rapid identification of the underlying cause may prevent
disease-specific morbidity.
Recent streptococcal infection is believed to be the most common cause of EN, while other clinically important causes include
sarcoidosis, TB, histoplasmosis and inflammatory bowel disease.
Sarcoidosis is most common in African-American women.
Therefore, the most appropriate next step in her management would be a chest X-ray.
Bilateral hilar adenopathy or interstitial lung disease would be consistent with the diagnosis.
Typically, EN occurs around the time of IBD exacerbation, may need CT of abdomen, colonoscopy or stool cultures.
The cause of EN is most often diagnosed by history, physical exam and symptom-guided work-up.
However, skin biopsy is performed in atypical cases.
The initial work-up of EN is symptom-guided and includes chest X-ray, PPD skin testing and Antistreptolysin-O(ASO)titer.
SYSTEMIC LUPUS ERYTHEMATOUS(SLE)

6:49 PM
Women in their 20's and 30's are the highest risk for developing this multisystem autoimmune disease.
Young women and individuals with a family H/O autoimmune disease are at most commonly affected by SLE.
Common signs and symptoms of SLE include
malar"butterfly" rash, annular, discoid
Low grade fever
Weakness
Weight loss
arthritis,/ arthralgias
serositis
painless oral ulcers and
renal disease , proteinuria
Hematological abnormalities-anemia, thrombocytopenia and leukopenia
Positive anti-DS DNA is highly specific(75-100%) for SLE.
Renal disease
One of the leading causes of morbidity and mortality in SLE is renal disease, occurring in 40-75% of patients.
Main mechanism of kidney damage in SLE patients is immune complex-mediated.
Immune complexes circulate in the blood and are deposited in renal glomeruli causing their damage via several mechanisms.
One of these mechanisms includes complement activation.
That's why serum C3 level is decreased in immune complex-mediated kidney diseases such as SLE and PSGN
The spectrum of lupus-induced renal disease is broad, ranging from mild elevations in serum creatinine to rapidly progressive renal failure.
Similarly, the pathologic type of lupus nephritis ranges from class I(minimal mesangial) to class VI(advanced sclerosis).
Renal biopsy is essential in patients with lupus nephritis because different forms of nephritis have different treatments.
Furthermore, an initial biopsy provides a baseline histology against which future biopsies may be compared to monitor disease
progression.
Delay in renal biopsy may adversely affect outcome.
Arthritis
Affects 90% of patients with SLE, and most commonly occurs in the hand or knee.
It is a migratory arthritis with pain that is often disproportionate to objective physical findings.
Lupus arthritis, like RA, most commonly affects the MCP and PIP joints.
The arthritis of SLE has a lower incidence of erosion, synovial abnormality and permanent joint deformity than that of RA; therefore, SLE is
considered a non-deforming arthritis.
Cyclophosphamide
An alkylating agent frequently used as an immunosuppressant in SLE, vasculitis and certain cancers.
Regarding SLE, cyclophosphamide is reserved for patients with significant renal or CNS problems.
Unfortunately, cyclophosphamide has many side effects.
Serious side effects include
Acute hemorrhagic cystitis
Bladder carcinoma
Sterility
Myelosuppression
Hemorrhagic cystitis and bladder cancer are caused by acrolein, a bladder-toxic metabolite of cyclophosphamide.
Drinking plenty of fluids, voiding frequently and taking MESNA are all helpful in preventing these complications.
SARCOIDOSIS
11:06 PM
A systemic illness that most commonly afflicts African-American woman in the 3rd and 4rth
decades of life.
Half of cases are diagnosed based on incidental findings on chest x-rays.
In those patients who present symptomatically, the most common complaints are cough, dyspnea,
fever and weight loss.
While the lungs are the most frequently involved organ system, the skin(erythema nodosum), eyes
(anterior uveitis), joints (arthritis) and many other organ systems may be affected.
Classic findings on chest X-ray include bilateral hilar adenopathy and reticular opacities.
The description of red eye with leukocytes in the anterior chamber is consistent with anterior
uveitis.

Sarcoidosis is a chronic multi-system disease due to noncaseating granulomatous inflammation
deposited into various organs, that most frequently involves the lungs.
It typically affects young adults, is 3-4 times more common in African Americans, and affects more
women than men.
Sarcoidosis is frequently detected incidentally on chest x-ray but can also present with symptoms
such as cough, dyspnea, fever, malaise and weight loss.
Cough, dyspnea are suggestive of lung involvement.
Other manifestations include erythema nodosum, anterior uveitis and acute polyarthritis.
Paratracheal adenopathy and reticulonodular infiltrates on chest x-ray are highly suggestive of
sarcoidosis.
Pathologically, the disease is characterized by noncaseating granulomas.
Elevated calcium and Angiotensin converting enzyme(ACE) levels are often seen but are not specific
for diagnosis.
Definitive diagnosis can be established with mediastinoscopy/bronchoscopy for tissue biopsy.
Definitive diagnosis can be established with mediastinoscopy/bronchoscopy for tissue biopsy.

Since there is no definitive diagnostic test for sarcoidosis, the diagnosis is made in the setting of a
compatible clinical presentation, classic findings on chest X-ray, and biopsy of noncaseating
granulomas.
Asymptomatic sarcoidosis is often followed without treatment due to high rate of spontaneous
remission.
However, patients with symptomatic disease generally receive systemic glucocorticoids.
Manifestations of sarcoidosis
Pulmonary
Bilateral hilar adenopathy

Interstitial infiltrates
Ophthalmologic
Anterior uveitis(iridocyclitis or iritis)

Posterior uveitis
Reticuloendothelial Peripheral lymphadenopathy

Hepatomegaly
Splenomegaly
Musculoskeletal
Acute polyarthritis(especially the ankle joints)

Chronic arthritis with periosteal bone resorption
Central venous
system/endocrine
Central diabetes insipidus

Hypercalcemia
Lofgren's syndrome Erythema nodosum

Hilar adenopathy
Migratory polyarthralgias
Fever
CARPAL TUNNEL SYNDROME(CTS)

9:48 PM
If patient has nocturnal symptoms of pain and paresthesia in the right median nerve
distribution that are worse with flexion of the wrist(positive phalen test).
This is consistent with a diagnosis of carpal tunnel syndrome(CTS)with compression of
the median nerve within the carpal tunnel in the wrist.
CTS symptoms are worsened by manual activity and often wake the patient from sleep.
Repetitive wrist flexion and extension is the usual cause of CTS.
When associated with hypothyroidism, has symptoms of fatigue, constipation,
menorrhagia and dry skin.
CTS occurs frequently in those with hypothyroidism, in up to 30% of patients compared
to 3%-5% in the general population.
The pathogenesis of CTS is thought to be deposition of mucopolysaccharide protein
complexes within the perineum and endoneurium of the median nerve and in the
tendons and synovial sheath that causes direct pressure on the median nerve within
the carpal tunnel.
CTS in hypothyroidism patients is commonly bilateral and presents with more severe
symptoms compared to other etiologies.
The pathologic findings and symptoms of CTS often improve with thyroid hormone
replacement therapy.
All patients with CTS, especially bilateral, should be screened with a detailed history,
physical examination and serum TSH levels for the presence of hypothyroidism.
Accumulation of fluid in the carpal tunnel can cause CTS in pregnancy, particularly in
the third trimester.
The incidence is increased in pregnancy secondary to an estrogen-mediated
depolymerization of ground substance, which causes interstitial edema in the
hands(and face) and thus increased pressure within the carpal tunnel.
Amyloid fibril deposition within the carpal tunnel causes CTS in patients with primary
systemic amyloidosis as well as those with secondary forms.
The most common CTS due to amyloid deposition occurs in the setting of end-stage
renal disease or chronic hemodialysis from deposition of beta 2 microglobulin.
Patients with acromegaly frequently have an associated bilateral median nerve
compression and CTS due to soft-tissue enlargement caused by synovial edema and
tendon hyperplasia. Patients with RA have inflammation of the tendons and synovial
sheath.
This in turn causes increased compartmental pressure in the carpal tunnel and can lead
to CTS.
to CTS.
Tinel's sign
Treatment
Prolonged or repetitive wrist flexion and extension also increase pressure within carpal
tunnel pressure.
Therefore, the initial treatment is a neutral position wrist splint.
While NSAIDs may decrease the pain associated with CTS, their use during pregnancy is
associated with an increased risk of miscarriage and may promote premature closure of
the fetal ductus arteriosus.
When splinting and analgesics fail to relieve CTS symptoms, direct injection of
corticosteroids into the carpal tunnel may help.
For CTS symptoms resistant to conservative interventions, or if hand weakness and
thenar muscle atrophy progresses, then open or endoscopic surgical decompression of
the carpal tunnel is indicated.
ATHEROEMBOLISM
10:48 PM
If patient has blue toes, elevated creatinine and abdominal tenderness are most likely the result of atheromatous emboli dislodged from the
aorta during cardiac catheterization.
Cardiac catheterization can cause a variety of complications, although the risk-to-benefit ratio of the procedure is generally highly favorable.
One of the more common complications is atheroembolism, occurring in 0.6-1.4% of patients.
Dislodged plaques may embolize to cerebral, GI, renal and cutaneous circulation and cause local ischemia and organ dysfunction.
Blue toe syndrome
Results from emboli to small pedal vessels and is characterized by intact pulses and cyanotic and painful toes.
It may be accompanied by livedo reticularis(the result of ischemic lesions in the lower legs).
"blue toe syndrome" and elevation of creatinine, resulting from atheroembolism of the pedal and renal circulations, respectively, were the two
most common atheroembolic sequelae seen in one major study.
CERVICAL SPONDYLOSIS
9:54 AM
It is estimated that cervical spondylosis affects 10% of people older than 50 years of age.
The history of chronic neck pain is typical.
Limited neck rotation and lateral bending is due to osteoarthritis and secondary muscle spam.
Sensory deficit is due to osteophyte-induced radiculopathy and isolated sensory abnormalities are associated with good prognosis.
Typical radiographic findings include bony spurs and sclerotic facet joints.
Interestingly, such "osteoarthritic' changes are common in asymptomatic patients older than 50 years of age; therefore, specificity of these
findings are low.
Other findings during cervical spondylosis may include narrowing of the disk spaces and hypertrophic vertebral bodies.
Reversed lordotic curve is characteristic for severe cervical strain.
SUBACROMIAL BURSITIS
10:16 AM
The subacromial bursa lies between the acromion and the tendon of the supraspinatus muscle.
Inflammation of the subacromial bursa typically occurs in the setting of chronic microtrauma to the supraspinatus tendon caused by overhead
work and repeated overhead movements of the arm during work or sporting activities.
The tendon is traumatized by compression between the acromion and the humeral head, and its vascular supply may be temporarily
compromised during such episodes of compression.
The physical examination in subacromial bursitis reveals pain with active range of motion of the shoulder, tenderness in the shoulder when the
arm is internally rotated and forward flexed at the shoulder(Neer impingement sign) and no signs of deltoid atrophy.
Rotator cuff injury

A tear of the proximal end of the long head of biceps tendon is associated with rotator cuff injury and typically occurs during forceful flexion of
the arm.
Patients present with a prominent bulge in the midportion of the upperarm.
Axillary nerve injury may occur as a result of anterior dislocation of the humerus out of the glenoid fossa.
Axillary nerve palsy
The axillary nerve supplies the deltoid and the teres minor with motor innervation.
Palsy of this nerve would result in paralysis and ultimately denervation atrophy of these muscles.
Rotator cuff tear
The rotator cuff is formed by the tendons of the supraspinatus, infraspinatus, teres minor and subscapsularis muscles.
The supraspinatus is most commonly injured, due to repeated bouts of ischemia near its insertion on the humerus induced by compression
between the humerus and the acromion.
Patients usually have severe shoulder pain and edema following the traumatic event and are unable to abduct the arm past 90 degrees.
Patients usually have severe shoulder pain and edema following the traumatic event and are unable to abduct the arm past 90 degrees.
This condition presents with shoulder pain and weakness.
The pain is aggravated by pushing, pulling, lifting the arm above the head and lying on the affected shoulder.
Rotator cuff tears may occur as the end result of chronic rotator cuff tendonitis or as a result of trauma.
The classic presentation of trauma-induced rotator cuff tear involves a fall on an outstretched hand.
Limitation of mid arc abduction and external rotation are common findings on exam.
The drop arm test is a maneuver that can help to diagnose a rotator cuff tear.
Here, the patient's arm is abducted passively to greater than 90 degrees, and the patient is then asked to lower the arm slowly.
With a complete rotator cuff tear, the patient will be unable to lower the arm smoothly and it will appear to drop rapidly from near the 90
degree position.
That a patient's limitation of movement remains after lidocaine injection provides strong support for a diagnosis of rotator cuff tear.
While rotator cuff tendinitis may present with similar pain and limitation of movement, the symptoms of rotator cuff tendinitis resolve with
lidocaine injection.
An MRI of the shoulder is the test of choice for diagnosing a rotator cuff tear.
Rotator cuff tendonitis

Patients complain of shoulder pain aggravated by activities such as reaching or lifting the arm over the head.
The condition results from repetitive activity above shoulder height and is most common in middle-aged and older individuals.
For this reason, painters are particularly prone to developing rotator cuff tendonitis.
Impingement is present in all patients with rotator cuff tendonitis.
It is confirmed on physical exam by performing the Neer test(passive motion of the arm above the head).
Pain and guarding during the Neer test confirms impingement.
To distinguish rotator cuff tendinitis from other forms of rotator cuff pathology, lidocaine is injected into the joint.
Improved ROM and pain relief after the injection corroborates the diagnosis of rotator cuff tendonitis.
MRI is used for definitive diagnosis.
Tennis elbow
Causes chronic nagging pain over the lateral epicondyle(lateral epicondylitis)
Lateral epicondylitis can result from a variety of activities that involve repeated forceful wrist extension and supination(backhand in tennis, use
of a screwdriver).
Patients presents with pain near the lateral epicondyle that is worsened by use.
Examination reveals point tenderness just distal to the lateral epicondyle and production of pain during active extension of the wrist.
The underlying pathophysiology is degeneration of the extensor carpi radialis brevis tendon near the lateral epicondyle.
Radial tunnel syndrome
Signs and symptoms similar to lateral epicondylitis and may occur in conjunction with that condition.
The tenderness in radial tunnel syndrome tends to overlie the extensor muscle wad and pain in this syndrome is elicited on examination by
flexing the patient's long finger while the patient actively extends the fingers and wrists.
Posterior interosseous nerve entrapment
Results in weakness of the extrinsic extensors of the hand and fingers.
Rupture of long head of biceps tendon
Rupture of long head of biceps tendon

Causes pain in the upper arm and shoulder and a prominent bulge in the midportion of the upper arm.
Produces a positive "Popeye sign" where the biceps muscle belly becomes prominent in the mid upper arm.
Weakness with supination is prominent and forearm flexion is typically preserved.
Adhesive capsulitis or frozen shoulder
An idiopathic condition characterized by pain and contracture.
This condition presents with an inability to lift the arm above the head.
Even after injection of lidocaine, the arm still cannot be lifted above the head due to fibrosis of the shoulder capsule.
Cervical radiculopathy
Typically presents with pain of the neck and arm.
Paresthesias of the arm are present in 80% of patients.
Weakness may affect the shoulder, elbow or wrist depending on the cervical root(s) involved.
Movement at the neck exacerbates symptoms.
Vascular compression
May occur in thoracic outlet syndrome.
This most commonly presents with a combination of numbness, weakness and swelling due to compression of the subclavian vessels and lower
trunk of the brachial plexus.
A weakened radial pulse and reproduction of symptoms with specific arm movements supports the diagnosis.
Injury to long thoracic nerve
Causes a winged scapula due to paralysis of he serratus anterior muscle.
The most common cause is iatrogenic injury during the axillary lymphadectomy.
Klumpke's palsy
Injury to lower(inferior)trunk of the brachial plexus which originates from the C8 and T1 cervical roots.
This palsy primarily affects muscles innervated by the ulnar nerve, which supplies most of the intrinsic muscles of the hand.
Weakness and atrophy of the hypothenar and interosseous muscles characterized this palsy and a "claw hand" deformity may also result.
Humeral neck fracture
More likely to present with swelling, ecchymosis and crepitus over the fracture.
Axillary nerve injury may be present.
GIANT CELL ARTERITIS

10:10 PM
Symptoms include
headache
Jaw claudication
Muscle fatigue
Visual disturbance
On examination, patients have scalp tenderness and a decreased temporal artery pulse.
The ESR is generally more than 50 mm/hr.
As giant cell arteritis can involve the branches of aorta, an aortic aneurysm is a well known complication and patients should be followed with
serial chest X-rays.
Clinical manifestations-giant cell arthritis

Systemic
symptoms
Fever, fatigue, malaise, weight loss
Localized
symptoms
Headaches: Located in temporal areas

Jaw claudication: Most specific symptom of GCA
Polymyalgia rheumatica
Arm claudication: Associated bruits in subclavian or axillary areas
Aortic wall thickening or aneurysms
Central nervous system: Transient ischemic attacks or stroke, vertigo, hearing loss
Visual symptoms Amaurosis fugax: Transient vision field defect progressing to monocular blindness
Anterior ischemic optic neuropathy: Most common ocular manifestation
Laboratory
results
Normochromic anemia
Elevated ESR and CRP
Temporal artery biopsy
Treatment
Polymyalgia rheumatica only: Low-dose oral glucocorticoids(e.g. prednisone 10-20 mg daily)

GCA: intermediate-to high-dose oral glucocorticoids(e.g. prednisone 40-60 mg daily)
GCA with vision loss: Pulse high-dose IV glucocorticoids(e.g. methylprednisolone 1000mg daily) for 3 days followed by
intermediate- to high-dose oral glucocorticoids
GCA also referred to as temporal arteritis is a chronic vasculitis affecting the medium and large vessels and is characterized by a variety of
GCA also referred to as temporal arteritis is a chronic vasculitis affecting the medium and large vessels and is characterized by a variety of
localized, systemic, ocular manifestations.
Physical examination may show diminished pulses and/or bruits on auscultation of the axillary, brachial or femoral arteries and over the
supraclavicular and/or carotid areas.
Anterior ischemic optic neuropathy is the most common ocular manifestation and is detected on Fundoscopy by the presence of a swollen and
pale disc with blurred margins.
Visual syndromes with vision loss are the most dreaded complication of GCA and blindness can develop in up to 25-50% of untreated patients.
In patients with suspected GCA and visual loss, the most appropriate next step is to initiate therapy with high-dose IV corticosteroids, followed
by oral therapy with a slow taper over several months.
Immediate therapy with systemic corticosteroids reduces the progression of visual complications in the affected and unaffected eyes; it should
be started promptly while awaiting confirmation of the diagnosis.
Methotrexate is used primarily as a steroid-sparing agent for patients who develop significant adverse effects with systemic glucocorticoids.
MRI with contrast enhancement can identify vessel wall edema and provide a noninvasive method of diagnosis in patients with suspected GCA.
INFLAMMATORY MYOPATHIES
10:48 AM
Condition
Distinguishing clinical features
Laboratory/diagnosis
Fibromyalgia
Usually young-to-middle-aged women

Widespread musculoskeletal pain in both sides of
body, above & below waist
Fatigue when arising from sleep & mid-afternoon
Cognitive difficulties(e.g. attention/tasks requiring
rapid thought changes)
Nonspecific GI symptoms(e.g. diarrhea, constipation)
No abnormal laboratory studies

Possible tender points on physical examination(e.g. mid trapezius,
lateral epicondyle, costochondral junction)
Symptoms > 3 months with increased widespread pain index or
symptom severity score
Polymyositis
Symmetrical proximal muscle weakness

Increasing difficulty climbing stairs, getting up from a
chair, carrying heavy groceries
Less prominent hip/shoulder involvement
Elevated muscle enzymes(e.g. creatine kinase, aldolase, lactate

dehydrogenase, aspartate aminotransferase)
Possible autoantibodies
Electromyography abnormal
Polymyalgia
rheumatica
Age usually > 50

Aching & morning stiffness > pain in shoulders, hips,
neck, torso
Synovitis, bursitis, decreased range of motion
No significant muscle tenderness
Possible systemic symptoms
Clinical diagnosis
Significantly elevated erythrocyte sedimentation rate
Symptoms improve with corticosteroids
Fibromyalgia(FM)
Presents Most commonly in young-to-middle-aged women with widespread pain, fatigue and cognitive/mood disturbances.
Patients tend to have a fairly normal physical examination except for point muscle tenderness in areas such as mid trapezius, lateral
epicondyle, costochondral junction in the chest and greater trochanter.
Patients perceive that their pain and fatigue worsen acutely after exercise.
However, studies show that gradual and incremental low-impact exercises(e.g. fast walking, swimming, water aerobics) can improve pain and
fatigue and provide long-term benefit.
FM has no specific diagnostic laboratory findings and the diagnosis is primarily based on history and exam findings.
Symptoms frequently overlap with those of other disorders(e.g. chronic fatigue syndrome, irritable bowel syndrome).
Revised 2010 American College of Rheumatology criteria suggest using the widespread pain index and symptom severity score rat her than
trigger points for FM diagnosis.
The index and score better emphasize cognitive problems, fatigue and severity of somatic symptoms.
Widespread pain index

(score 0-19)
Symptom severity scale

0 = No problem, 1 = 1 slight,
2 = 2 moderate, 3 = severe
Neck
Jaw(left and right)
shoulder(left and right)
Upper arm(left and right)
Lower arm(left and right)
Chest
Abdomen
Upper back
Lower back
Hip(left and right)
Upper leg(left and right)
Lower leg(left and right)
Fatigue(0-3)
Waking unrefreshed(0-3)
Cognitive symptoms(0-3)
Somatic symptoms
0 = none
1 = few
3 = many
Final score between 0-12
Initial FM treatment involves a multidisciplinary approach including patient education, regular aerobic exercise, and good sleep hygiene.
Patients who do not respond to conservative measures may require medications.
Amitriptyline is a TCA used to decrease the pain of FM. Muscle pain, not objective weakness, is present in FM.
Pregabalin, duloxetine and milnacipran are alternate therapies approved for patients not responding to TCAs.
Selection of the therapeutic agent should be tailored to patients based on their symptoms and the drug's side effect profile.
Patients with persistent symptoms may require combination drug therapy, referral for supervised rehabilitation, pain manageme nt referral or
cognitive behavioral therapy.
Polymyositis and dermatomyositis
Most common inflammatory myopathy.
Peak incidence occurs between 40-50 years of age and women are more commonly afflicted than men.
Both conditions manifest with gradual onset of proximal muscle weakness.
Polymyositis(PM) presents initially with slowly progressive proximal weakness of the lower extremities characterized by diffi culty ascending
Polymyositis(PM) presents initially with slowly progressive proximal weakness of the lower extremities characterized by diffi culty ascending
and descending stairs or rising from a seated position.
The weakness usually progresses over the course of years; an acute presentation is not typical.
Proximal arm weakness usually follows leading to complaints of difficulty with combing hair or working with the hands overhea d.
In PM, the muscles of mastication and facial expression are classically spared; however, patients with PM may develop dysphagia due to
involvement of the striated muscles of the upper pharynx.
A muscle biopsy is the best diagnostic study for PM.
MRI of the affected muscles can assist in identifying the best location for a muscle biopsy.
Biopsy in PM shows a mononuclear infiltrate surrounding necrotic and regenerating muscle fibers.
In more advanced disease, an inflammatory infiltrate may be absent and replacement of muscle with fibrotic tissue may be evid ent.
Dermatomyositis presents with proximal muscle weakness, rash of the shoulders and back and scales on the hands.
Other symptoms with similar symptoms
Drug-induced myopathy(e.g. statins, antipsychotics and alcohol)
Hypothyroid myopathy
Muscular dystrophy
Myasthenia gravis
Paraneoplastic syndromes affecting the peripheral nerve and/or muscle(e.g. MG, LES, dermatomyositis) most commonly present wi th muscle
weakness.
Dermatomyositis patients typically present with symmetrical proximal muscle weakness and erythematous rash on the dorsum of the
fingers(Gottron's sign) and/or upper eyelids(heliotrope eruption)
These cutaneous findings include a violaceous poikiloderma over various regions of the body.
On the face, the eruption is most often accompanied by periorbital edema and is known as the heliotrope sign.
On the chest and lateral neck it is called the shawl sign.
On the knuckles, elbows and knees it is referred to a Gottron's sign.
Lichenoid papules overlying the joints are known as Gottron's papules; these are pathognomic for DM.
DM is 6 times more common in females and the classic autoantibody associated with DM is anti-Mi-2(against helicase).
Internal malignancies have been shown to be more common in patients with DM compared to the general population.
Over 10% of patients with DM will have such a malignancy.
The most common malignancies are ovarian, but breast, lung and other female urogenital cancers may occur in an increased freq uency as well.
Diagnosis is usually confirmed by muscle biopsy.
Polyarteritis nodosa
Typically presents with systemic symptoms, skin findings(e.g. livedo reticularis, purpura), kidney disease, abdominal pain an d muscle aches or
weakness.
ESR is usually significantly elevated.
DE QUERVAIN TENOSYNOVITIS
11:29 AM
A condition that classically affects new mothers who hold their infants with the thumb outstretched(abducted/extended).
This condition is caused by inflammation of the abductor pollicis longus and extensor policis brevis tendons as they pass through a fibrous
sheath at the radial styloid process.
Tenderness can typically be elicited with direct palpation of the radial side of wrist at the base of the hand.
Additionally, the Finkelstein test, which is conducted by passively stretching the affected tendons by grasping the flexed thumb into the palm
with the fingers, elicits pain.
Trigger thumb
Results in pain over the palmar aspect of the 1st metacarpophalangeal joint and locking of the thumb in flexion.
Scaphoid fractures
Typically occur during forceful hyperextension of the wrist as may occur in a fall on an outstretched hand.
Pain typically localizes to the anatomic snuffbox.
Flexor carpi radialis tenosynovitis
Results in pain with radial flexion of the wrist and point tenderness over the trapezium.
SJOGREN SYNDROME
1:14 PM
An autoimmune condition that most commonly affects women in their 5th or 6th decade of life.
Clinical findings include keratoconjunctivitis sicca(xerophthalmia, dry eyes) and xerostomia(dry mouth).
Due to the antimicrobial and lubricating properties of normal saliva, patients with Sjogren syndrome, who lack normal amounts of saliva, will
have an increased incidence of dental caries and will complain of difficulty swallowing.
Lymphocytic infiltration of the salivary glands in Sjogren syndrome will cause enlargement and firmness to palpation of these glands.
The diagnosis is made when there is subjective and objective evidence of dry mouth and eyes in the presence of either histologic evidence of
lymphocytic infiltration of the salivary glands or serum autoantibodies directed against SSA(Ro) and/or SSB(La).
SECONDARY AMYLOIDOSIS
1:33 PM
Clinical features of secondary amyloidosis

Epidemiology
Extracellular deposit of insoluble polymeric protein fibrils in tissues & organs, elevated amyloid A
Can be secondary to chronic inflammatory conditions
Inflammatory arthritis(e.g. RA)
Chronic infections(e.g. bronchiectasis, TB, osteomyelitis)
Inflammatory bowel disease(e.g. Crohn's disease)
Malignancy(e.g. lymphoma)
Vasculitis
Clinical presentation Asymptomatic proteinuria or nephrotic syndrome

Cardiomyopathy with heart failure
Hepatomegaly
Mixed sensory & motor peripheral neuropathy &/or autonomic neuropathy
Visible organ enlargement(e.g. macroglossia)
Bleeding diathesis
Waxy thickening, easy bruising of skin
Diagnosis
Abdominal fat pad aspiration biopsy
Treatment
Treatment of underlying condition

Colchicine for prevention & treatment
Patient in the vignette clinical presentation of facial swelling, bilateral lower-extremity edema and massive proteinuria are consistent with
nephrotic syndrome.
The presence of nephrotic syndrome with palpable kidneys, hepatomegaly and ventricular hypertrophy(suggested by 4th heart sound) in the
setting of chronic inflammatory disease(recurrent pulmonary infections, bronchiectasis) is suggestive of secondary amyloidosis(AA) as a
common unifying diagnosis.
Colchicine is approved for both the treatment and prophylaxis of AA.
D/D
Hepatorenal syndrome
Refers to acute renal failure in patients with acute or chronic liver disease and portal HTN.
It usually presents in patients with severe liver disease with progressively rising serum creatinine with minimal proteinuria(< 500mg/day)
Hypertensive nephrosclerosis
Seen in patients with chronic HTN and is associated with retinopathy, LVH, progressive renal failure and mild proteinuria(generally <1g/day).
Kidneys are usually small and hepatomegaly is not present.
IgA nephropathy
A type of nephritis that typically presents with hematuria on urinalysis.
Usually restricted to kidneys.
Polycystic kidney disease
Typically present with flank pain, hematuria, renal failure, HTN and large palpable kidneys.
Hepatomegaly can also be present due to co-occurrence of hepatic cysts in some patients.
However, they usually do not have proteinuria or generalized edema.
VIRAL ARTHRITIS
1.
2.
3.
4.
4:11 PM
In evaluating a case of arthritis, it is critical to address the following questions.

Is it an inflammatory process?
Is it monoarticular or polyarticular?
Is it symmetric or asymmetric?
What is the duration of symptoms?
Joint fluid
Normal Non-inflammatory Inflammatory
characteristics
(E.g. OA)
(e.g. crystals, RA)
Septic joint
Fluid clarity
Clear
Clear
Translucent or opaque Opaque
WBCs/mm3
< 200
200-2,000
2,000-100,000
50,000-150,000
PMNs
<25%
25%
Often > 50%
Often > 80-90%
Patient in the vignette presents with an episode of polyarticular and symmetric arthritis of acute onset and short duration.
Joint swelling and low-grade fever suggest an inflammatory process.
Furthermore, this patient's symptoms resolve in less than 2 months.
Inflammatory symmetric arthritis that resolves within 2 months is due to viral infection with causative agents including parvovirus, hepatitis,
HIV, mumps and rubella among many others.
Positive rheumatoid factor and a weakly positive ANA are not surprising findings in viral arthritis.
Positive RF may occur in
RA
Viral or bacterial infection
Malignancy
Normal individuals
ANA is sensitive for SLE, but many other inflammatory conditions including RA, hepatitis and HIV may present with this finding.
Additionally, a weakly positive ANA can be found in approximately 5% of normal individuals.
RA and SLE present as symmetric inflammatory arthritides, while this patient has a symmetric inflammatory arthritis.
Fungal arthritis
Usually due to candida species but is uncommon in non-immunocompromised patients.
The majority of patients have had a recent or concurrent invasive candida infection.
However, the onset is less acute and dramatic than gout.
Definitive diagnosis is made by fungal culture of synovial fluid.
Sarcoid arthritis
More commonly presents with gradual onset of symptoms.
Sarcoid arthritis can present as monoarthritis usually affecting the ankles(sometimes other joints) or a polyarthritis.
The diagnosis is confirmed by synovial membrane biopsy showing noncaseating granulomas.
Avascular necrosis of bone
Most commonly seen in patients with
systemic corticosteroid therapy
Heavy alcohol use
SLE
Sickle cell disease
ANSERINE BURSITIS
5:32 PM
The anserine bursa is located anteromedially over the tibial plateau just below the joint line of the knee.
Inflammation of the anserine bursa can be result of an abnormal gait, overuse or trauma.
Patients typically present complaining of localized pain over the anteromedial tibia; the pain is often present overnight as pressure from the
knees making contact with one another while the patient lies on their side can exacerbate the pain.
Examination reveals a well-defined area of tenderness over the medial tibial plateau just below the joint line.
A valgus stress test does not aggravate the pain indicating that disease of the medial collateral ligament is absent.
X-ray of the tibia is normal in this condition.
Treatment is with rest, ice and maneuvers to reduce pressure on the bursa.
Corticosteroid injections into the bursa are also helpful.
Prepatellar bursitis
Presents with pain and swelling directly over the patella.
Examination shows cystic swelling over the patella with variable signs of inflammation.
The most common cause is trauma.
Medial collateral ligament injury
Presents with pain along the medial joint line and is aggravated by walking.
It is caused by valgus stress applied on the lateral aspect of the knee when it is partially flexed.
The knee pain in this condition is aggravated by valgus tress testing.
Medial compartment osteoarthritis

Presents with pain of medial joint line typically in patients older than 40.
Other clinical features include morning stiffness of less than 30 minutes, crepitus and bony tenderness on examination.
X-ray of the knee shows narrowing of the joint space and osteophyte formation.
Anserine bursitis may accompany medial compartment OA due to chronic gait abnormality caused by the arthritic pain.
OSTEOPOROSIS
6:28 PM
Compression fracture of the vertebrae

Acute onset of pain without an obvious trauma is typical.
A compression fracture of the vertebrae is a common complication of advanced osteoporosis.
Predisposing factors
Age
Glucocorticoid therapy
Local tenderness on physical examination is usually present.
Bilateral decreased ankle reflex has little clinical significance, because it is usually the result of the normal aging process.
Knee reflex is normal, muscle power is 5/5 suggesting no nerve root compression.
Absent Babinski sign suggests no UMN-type lesion.
Lumbago
Usually elated to physical strain and has less dramatic onset.
Usually paravertebral muscle tenderness rather than spinal tenderness is the feature.
Herniated disk
Manifests with sciatica-type pain that radiates along the thigh and typically below the knee.
SLRT will be positive because of nerve root compression.
SLRT will be positive because of nerve root compression.
Osteoporosis risk factors

Advanced age
Medical history of fracture with minimal trauma(fragility fracture)
Low body weight{<127 pounds[58 Kg]}
Family history of hip fracture
Current smoking
Excessive alcohol intake
Medications(e.g. steroids, anticonvulsants)
Secondary causes of osteoporosis
Premature menopause
Hypogonadism
Malabsorption(celiac disease)
Inflammatory disorders(e.g. IBD, RA)
Hyperthyroidism and hyperparathyroidism
Cushing's syndrome
Vitamin D deficiency
Chronic liver or renal disease
Patients at risk for developing osteoporosis should be screened with dual-energy x-ray absorptiometry(DEXA) of the spine and hips.
By convention, osteoporosis is defined as a bone density>2.5 standard deviations below the mean for a young adult at peak bone density(i.e.
T-score < -2.5)and is associated with significant bone fragility and risk of fracture.
A bone density of 1-2.5 standard deviations below the mean young adult reference(i.e. T-score -1 to -2.5) is considered osteopenia.
The most important risk factor for osteoporosis in the US is post-menopausal state, with other significant risk factors including poor calcium/
vitamin D intake, smoking, corticosteroid use, lack of weight-bearing exercise, low body mass index and heavy alcohol use.
USPSTF recommend initial DEXA screening for osteoporosis in all women age> 65 years and screening can be considered for younger patirnts
who have other risk factors.
GONOCOCCEMIA
6:52 PM
Classic triad of polyarthralgia, tenosynovitis and painless vesiculopustular skin lesions present in disseminated gonococcal infection.
DG results from gonococcal bacteremia in patients with untreated mucosal N.gonorrhoeae infections.
Dissemination is most likely to occur during the menstrual periods.
Patients experience high fever, chills, tenosynovitis and migratory polyarthralgias early in their illness.
Characteristically, the skin lesions number from 5 to 40 and are most commonly seen on the extremities.
These lesions are discrete purpuric or pustular lesions with a hemorrhagic component and occasionally central necrosis.
This condition may progress to cause suppurative infectious arthritis, but it is important to note that the early arthralgias experienced in
this condition are not the result of suppurative arthritis.
Blood cultures and cultures from the cutaneous pustules in this condition are often negative due to the specific growth requirements of the
strain of N.gonorrhoeae that causes this disseminated form of infection.
Patient may complain of wrist, elbow and ankle pain consistent with gonococcal polyarthralgias and pain is elicited along the tendon
sheaths suggesting tenosynovitis.
The lesions shown in the photograph are typical vesiculopustular lesions of disseminated gonococcal infection; they tend to number from 2
to 10 and may be disseminated as furuncles or pimples.
Fevers and chills may be present.
A history of recent unprotected sex with a new partner is frequently associated with disseminated gonococcal infection, while symptoms of
symptomatic venereal diseases are most often absent.
Gonococcal septic arthritis
Septic arthritis in a young, sexually active individual is most often caused by Neisseria gonorrhea.
Gonococcal septic arthritis may present in one of two ways:
As an asymmetric polyarthritis(often associated with tenosynovitis and skin rash) or
As an isolated purulent arthritis affecting one or a few joints.
In some patients, asymmetric polyarthritis may preced purulent monoarthritis.
For this patient in the vignette, asymmetric polyarthritis of the right wrist and left ankle preceded purulent monoarthritis of the left knee.
Purulent arthritis in a sexually active individual is gonococcal arthritis until proven otherwise.
Gram stain of the synovial fluid, blood cultures and urethral cultures are used to confirm the diagnosis.
Lyme disease
Arthritis and rash are associated.
The rash(erythema migrans) of Lyme disease occurs early on in illness, while arthritis, typically monoarticular knee pain, does not occur
until months later.
Erythema migrans occurs at the site of a tick bite and has a "bulls eye "appearance.
Tenosynovitis is not typical of Lyme disease.
Syphilis
Skin findings include a painless ulcer of the genitalia that occurs in the primary stage of infection and a maculopapular rash of the palms
and soles in the secondary stage.
Meningococcemia
Presents with a petechial rash, high fever, headache, N & V, stiff neck and photophobia.
Acute HIV
Fever, arthralgias, sore throat, lymphadenopathy, mucocutaneous lesions, diarrhea and weight loss.
Acute rheumatic fever
An episode of pharyngitis typically precedes the onset of acute rheumatic fever by 2-4 weeks.
Symptoms of ARF include migratory arthritis of the large joints, erythema marginatum(raised ring-shaped lesions over the trunk and
Symptoms of ARF include migratory arthritis of the large joints, erythema marginatum(raised ring-shaped lesions over the trunk and
extremities), subcutaneous nodules, carditis and Sydenham chorea.
PARANEOPLASTIC SYNDROMES
8:52 PM
Paraneoplastic syndrome
Involved site
Clinical features
Myasthenia gravis
Acetylcholine receptor in post synaptic

membrane
Fluctuating muscle weakness

Ocular(ptosis, diplopia)
Bulbar(dysphagia, dysarthria)
Facial, neck & limb muscles
Lambert-Eaton syndrome
Presynaptic membrane voltage-gated calcium

channels
Proximal muscle weakness

Autonomic dysfunction(e.g. dry mouth)
Cranial nerve involvement(e.g. ptosis)
Diminished or absent deep-tendon reflexes
Dermatomyositis/polymyos Muscle fiber injury

itis
Symmetrical & more proximal muscle weakness

Interstitial lung disease, esophageal dysmotility, Raynaud's
phenomenon
Polyarthritis
Skin findings(e.g. Gottron's papules, heliotrope rash) in
dermatomyositis
Patients with suspected malignancy can develop a Paraneoplastic syndrome due to the tumor producing hormones and/or cytokines .
PNS are not directly related to the cancer's invasion.
They are most commonly seen in cancers of the lung, breast and ovaries and lymphomas.
Symptoms typically resemble those of primary endocrine, metabolic, hematologic or neuromuscular disorders.
Paraneoplastic myelopathy of the spinal cord
Typically presents with flaccid or spastic paraplegia or quadriplegia, sensory deficits and/or urinary or fecal retention/inc ontinence.
CREST SYNDROME
Tuesday, May 20, 2014
8:25 AM
Refers to a constellation of findings including

Calcinosis cutis
Raynaud phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasias
CREST syndrome is a limited from of systemic sclerosis.
Calcinosis cutis refers to localized dystrophic deposition of calcium in the skin and manifests as subcutaneous pink-to-white nodules typically
on the upper extremities.
These may ulcerate and drain a chalky material.
Raynaud phenomenon refers to acute bouts of digital ischemia in response to cold and may lead to digital necrosis.
The fingers typically progress through white, blue and hyperemic stages.
Esophageal dysmotility classically results in complaints of food being "stuck" in the esophagus and GERD.
Sclerodactyly describes fibrosis of the skin of the fingers distal to the MCP joints resulting in a shiny appearance of the skin and flexion
contractures and joint pain
Finally, telangiectasia in CREST manifest as "mat-like " patches most commonly on the face and palms.
SYSTEMIC SCLEROSIS
11:34 AM
A clinically heterogeneous condition that can affect every organ system in the body.
Thickening of the skin begins in the acral sites(hands and feet)with edema that transitions to dermal sclerosis with obliteration of skin
appendages(hair follicles and sweat glands) and flexion contractures.
Raynaud phenomenon and calcinosis cutis are also commonly observed.
The face may take on a "mask-like" appearance due to dermal thickening.
Connective tissue thickening, the product of myofibroblast proliferation and increased collagen and ground substance production, is the
underlying pathogenesis of many of the features of systemic sclerosis.
Involvement of the kidneys produces HTN, and before the advent of ACEI scleroderma renal crisis was the most common cause of death in
these patients.
Pulmonary arterial HTN ultimately results in right heart failure in patients with scleroderma.
Esophageal and gastric dysmotility cause these patients to suffer GERD.
Antinuclear autoantibodies are present in all patients with scleroderma; anti-topoisomerase-I-antibodies would most likely be present .
BEHCET'S SYNDROME
11:05 AM
Recurrent oral ulcers, recurrent genital ulcers, anterior uveitis and a skin lesion which most probably is erythema nodosum(painful and nodular
with areas of hyperpigmentation suggested by the old, healed nodules).
This picture fits the diagnosis of Behcet's syndrome, a multi-systemic inflammatory disease.
This syndrome is more common in the Turkish, Asian and Middle Eastern population.
The international criteria for diagnosis includes:
Recurrent oral ulcers plus two of the following features Recurrent genital ulcers
Eye lesions including anterior uveitis and posterior uveitis; retinal vascularization
Skin lesions including erythema nodosum, acneiform nodules and papulopustular lesions
A positive pathergy test
Some patients have involvement of the GIT, skeletal and vascular systems.
Combined environmental and hereditary factors are assumed to play a role in the pathophysiology of this condition.
Corticosteroids offer relief from most of the symptoms but do not protect from progression to dementia or blindness.
AVASCULAR NECROSIS
4:12 PM
Avascular necrosis/aseptic necrosis/osteonecrosis/ischemic necrosis/osteochondritis dessicans

Refers to bone destruction due to poor vascular supply.
It is a complication of corticosteroid use, trauma, lupus, sickle cell disease and a number of other processes.
It most commonly affects the proximal and distal femur.
Pain is the main symptom.
Typical clinical scenario progressive hip pain without restriction of motion range and normal radiograph on early stages.
A high index of suspicion is required, because early diagnosis is desirable whether nonoperative or operative treatment is considered;
therefore, knowing the predisposing factors is important.
MRI and scintigraphy are used to confirm the diagnosis.
In all cases, the vasculature to the affected bone is disrupted causing bone and bone marrow infarction.
Subsequently, the bone is unable to remodel and trabecular thinning occurs ultimately leading to collapse of the affected bone.
This process may take months to years, on occasion, to occur.
Clinically, the patient experiences progressive pain during this time.
In the case of osteonecrosis of the femoral head, patients experience anterior hip pain worsened by activity and relieved by rest with
progressive limitation of ROM.
Progression of disease will ultimately cause joint instability and pain at rest.
Precipitating factors include chronic steroid use, chronic alcohol use, trauma and the antiphospholipid syndrome.
Legg-Calve-Perthes disease
Or idiopathic osteonecrosis(avascular necrosis)of the femoral capital epiphysis.
This condition most commonly affects boys between ages 4 and 10, with a peak incidence between 5 and 7.
The classic presentation is hip, groin or knee pain plus an antalgic gait.
In general, these patients are managed conservatively with observation and bracing, though surgery may be indicated in cases where
femoral head is not well contained within the acetabulum.
X-ray of this patient's pelvis shows a flattened and fragmented left femoral head.
The altering regions of lucency and density reflect replacement of necrotic bone by new bone.
Compare the circled regions below:
Slipped capital femoral epiphysis(SCFE)

Characterized by displacement of the femoral head on the femoral neck due to disruption of the proximal femoral growth plate.
It is commonly seen in obese adolescent boys.
The physis(i.e. physical junction between the femoral head and neck) weakens during early adolescence because it is rapidly expanding and
primarily composed of cartilage, which does not possess the strength of bone.
When exposed to excessive shear stress, which is magnified by obesity, the physis fractures and the femoral head slips posteriorly and
medially relative to the femoral neck.
Patients typically present with hip or knee pain of insidious onset that causes limping.
Acute presentations can occur.
Diagnosis requires a high degree of clinical suspicion because knee pain(referred pain), not hip pain, is a common presenting complaint with
this condition.
Physical examination shows loss of abduction and internal rotation of the hip as well as external rotation of the thigh while the hip is being
flexed.
A frog-leg, lateral view X-ray of the hip is the diagnostic imaging technique of choice.
Patients with SCFE should promptly treated with surgical pinning of the slipped epiphysis where it lies(i.e. in situ) in order to lessen the risks
of avascular necrosis of the femoral head and chondrolysis.
The metaphysis and proximal femur slip relative to the epiphysis at the epiphyseal plate.
The capital femoral epiphysis remains structurally intact within the acetabulum.
The classic presentation is an obese adolescent male with complaints of pain.
Transient Synovitis of the hip

A common cause of limp in otherwise healthy children.
There are no associated radiographic abnormalities.
BONE TUMORS
Thursday, May 29, 2014
8:03 PM
Osteosarcoma
The most common primary bone tumor affecting children and young adults.
Boys between ages 13 and 16 years are at higher risk.
In children, the tumor occurs most frequently at the metaphyses of long bones such as the distal femur, proximal tibia and proximal
humerus.
Constitutional symptoms such as fever, weight loss and malaise are usually absent.
On physical examination, the most important finding is a tender soft-tissue mass.
Characteristic X-ray findings include a spiculated "sunburst" pattern(yellow arrow) and periosteal elevation known as the Codman
triangle(red arrow).
Alkaline phosphatase and lactate dehydrogenase are elevated from turnover of damaged osteocytes; high levels may correlate with
adverse prognosis.
Increased ESR is a non-specific marker of inflammation.
Treatment includes tumor excision and chemotherapy.
Ewing sarcoma
Although overall rare, Ewing sarcoma is the second most common primary bone malignancy.
The incidence is also highest in adolescent males and up to 20% of patients may have systemic symptoms.
X-ray shows an osteolytic lesion with a periosteal reaction that produces layers of reactive bone, giving the classic "onion skin"
appearance.
This diagnosis is less likely due to its lower prevalence and the lack of characteristic X-ray findings.
Osteoid Osteoma
Appears as a sclerotic, cortical lesion on imaging with a central nidus of lucency.
It typically causes pain that is worse at night and unrelated to activity.
However, the pain is quickly relieved by NSAIDs.
POLYMYALGIA RHEUMATICA(PMR)
Thursday, May 8, 2014
10:41 AM
The features required to make diagnosis include

Age over 50 years
Aching pain in the neck, shoulders and pelvic girdle lasting at least one month
Morning stiffness lasting over one hour
Elevated ESR>40mm/hr.
In the absence of other diseases that may account for these symptoms
In PMR, the physical examination is frequently unremarkable with patients denying tenderness
with active or passive range of motion.
Signs of inflammation in the joints are absent.
When asked to identify the location of their pain, patients typically indicate that it is in the soft
tissues and not the joints.
The treatment of choice is low-dose prednisone.
SHOULDER DISLOCATIONS
Friday, May 30, 2014
11:06 AM
Anterior dislocation
Most common form of shoulder dislocations and usually caused by a direct blow or fall on an outstretched arm.
In anterior dislocations, the patient holds the arm slightly abducted and externally rotated.
Posterior dislocation
Commonly caused by violent muscle contractions during a tonic-clonic seizure.
Examination will shoe flattening of the anterior shoulder, prominent coracoid process, and the patient holding the arm adducted and
internally rotated with an inability of external rotation.
Radiographs can show internal rotation of the humeral head with circular appearance(light bulb sign), widened joint space > 6 mm(rim sign),
or two parallel cortical bone lines on the medial aspect of the humeral head(trough line sign).
Management involves closed reduction, usually in the operating room but sometimes in the emergency room.
COMPARTMENT SYNDROME
Friday, May 30, 2014
7:47 PM
May be caused by
Direct trauma(hemorrhage)
Prolonged compression of an extremity or
After revascularization of an acutely ischemic limb.
Muscles of the extremity are encased in fascial compartments that do not allow for expansion of tissue.
Blood flow at the capillary level relies on the pressure difference between the arterial and venous systems.
Hemorrhage or edema within muscle causes increased pressure within the non-distensible fascial compartment.
This increased pressure interferes with perfusion by disallowing passage of blood from the arterial system into the capillary beds of the
affected muscles.
This eventually leads to muscle necrosis.
Patients with compartment syndrome classically complain of severe pain that is worsened on passive range of motion, paresthesias, pallor
and paresis of the affected limb.
Pressure in the compartments can be measured directly using a needle and pressure transducing catheter system.
Pressures over 30 mm Hg may result in cessation of blood flow through the capillaries and should be treated emergently by fasciotomy.
Ischemia-reperfusion syndrome
A form of compartment syndrome.
Following more than 4 to 6 hours of ischemia, tissues can suffer both intracellular and interstitial edema upon reperfusion.
When the extremities are involved, this creates a risk for compartment syndrome.
Compartment syndrome is defined as increased pressure within an enclosed fascial space causing ischemia of muscles and nerves.
Compartment pressures in excess of 30 mm Hg indicate the presence of compartment syndrome and the need for emergent fasciotomy.
Compartment syndrome most commonly affects the distal leg and forearm, and classically follows fracture or crush injuries.
The most reliable indicators of early compartment syndrome include severe pain in the affected extremity that is out of proportion to the
physical examination findings and pain that is exacerbated by passive stretch of the muscles in the affected compartment.
The clinical findings in compartment syndrome can be remembered as the five "P's":
Pain is the earliest symptom. It is classically increased by passive stretch of the muscles in the affected compartment.
Paresthesias(burning or tingling sensations) occur in the distribution of the affected peripheral nerve.
Pallor of the overlying skin is the result of tense swelling and compromised perfusion.
Pulselessness is a late finding. The presence of a pulse on exam does not rule out compartment syndrome.
Paresis/paralysis is a late finding resulting from nerve and muscle ischemia and necrosis.
TRANSIENT SYNOVITIS
Friday, July 11, 2014
12:15 PM
The most common cause of hip pain in children typically occurring in boys age 3-10 years.
The cause is unknown but usually follows a viral infection or mild trauma.
Synovial inflammation leads to pain, decreased range of motion, and limping.
On examination, the affected hip is typically flexed, slightly abducted and externally rotated.
This position maximizes the joint space, thereby providing some pain relief.
Because characteristics of transient synovitis overlap with septic arthritis, laboratory studies
should be sent to assess for severity of inflammation.
In contrast to septic arthritis, children with transient synovitis rarely have fever or significant
laboratory abnormalities.
Features of septic arthritis of the hip
Fever >38.50C(101 0F)
Inability to bear weight
White blood cell count > 12,000/mm3
Erythrocyte sedimentation rate > 40 mm/h
C-reactive protein > 2.0 mg/dL(20 mg/L)
Patients who are ill-appearing, febrile or have > 3 or 4 findings shown in the table should undergo
immediate arthrocentesis and intravenous antibiotics.
Plain radiographs should be done to exclude bony lesions, fractures and Legg-Calv-Perthes
disease(LCP).
Anteroposterior and frog-leg lateral vies of both hips should be obtained to compare affected and
normal sides for subtle changes.
Additional workup is unnecessary unless symptoms persist or worsen.
Treatment consists of rest and NSAIDs medications.
NSAIDs(e.g. ibuprofen) have both analgesic and anti-inflammatory properties and are
recommended over other pain relievers(e.g. acetaminophen, opioids).
The exception is aspirin, which should be avoided due to the risk of Reye syndrome.
Children usually recover within 1-4 weeks and have no complications.

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LUMBAR SPINAL STENOSIS

Saturday, May 17, 2014

A common cause of combined low back pain and leg pain.

Also known as Neurogenic arthropathy

Positive anti-CCP antibodies(diagnostic testing)

Pyrimidine synthesis inhibitor Hepatotoxicity

TNF and IL-1 suppressor

TNF and IL-1 suppressor

Tumor necrosis factor inhibitors

Liver, lung, marrow

Occurs in 5-30% of patients who suffer from psoriasis.

The image above shows all of these classic signs.

Results from either overproduction or underexcretion of uric acid.

Differential diagnosis of anterior knee pain in the young patient

Examination findings Pain with squatting

Ruptured baker's cyst

Trauma(e.g. meniscal tear)

Clinical presentation Can be asymptomatic

Cyst enlargement with dissection into calf

Cyst rupture with severe calf pain, warmth, tenderness, erythema

Joint line tenderness

Rapid deceleration or direction changes

Pain: rapid onset, may be severe

Examination findings Anterior laxity of tibia relative to femur

RICE(rest, ice, compression, elevation) measures

Special tests for knee examination

positive possible with wearing of medial articular cartilage

Anterior cruciate ligament injury

Anterior drawer test

Posterior cruciate ligament injury

Posterior drawer test

Posterior cruciate ligament injury

A acute form of calcium pyrophosphate dihydrate(CPPD) crystal disease.

Patients with hyperparathyroidism are at increased risk of developing pseudogout, a

Commonly occurs in runners and is not a true neuroma.

Other less common manifestations

LOW BACK PAIN

Common causes of low back pain

Inflammator Ankylosing spondylitis,

Better with activity or exercise

Metastatic cancer to bone

Osteomyelitis, discitis, abscess Recent infection

Iliac artery thrombosis

SYSTEMIC LUPUS ERYTHEMATOUS(SLE)

Definitive diagnosis can be established with mediastinoscopy/bronchoscopy for tissue biopsy.

Bilateral hilar adenopathy

Anterior uveitis(iridocyclitis or iritis)

Reticuloendothelial Peripheral lymphadenopathy

Acute polyarthritis(especially the ankle joints)

Central diabetes insipidus

Lofgren's syndrome Erythema nodosum

CARPAL TUNNEL SYNDROME(CTS)

Reversed lordotic curve is characteristic for severe cervical strain.

Rotator cuff injury

Rotator cuff tendonitis

Rupture of long head of biceps tendon

GIANT CELL ARTERITIS

Clinical manifestations-giant cell arthritis

Fever, fatigue, malaise, weight loss

Headaches: Located in temporal areas

Polymyalgia rheumatica only: Low-dose oral glucocorticoids(e.g. prednisone 10-20 mg daily)

Distinguishing clinical features

Usually young-to-middle-aged women

No abnormal laboratory studies