Rheumatology for Studs

RHEUMATOLOGY

 Newborn ® Uneven gluteal folds ® easy posterior dislocation of hip with “click” and returned to normal position with “snapping” ® positive family
history ® Developmental dysplasia of Hip ® sonogram of the Hip (not X-ray)
˗ Tx : Abduction splinting with Pavlik harness
 Legg calve Parthes disease ®Avascular necrosis of the capital femoral epiphysis
® around 6 yrs of age ® Tx: keep femoral head in acetabulum by casting and
crutches
 Slipped capital femoral epiphysis ® obese, around 13 yrs of age ® sits with the
sole of the foot on the affected side pointing toward the other foot ® Tx : Pin
the femoral head in place
 Osgood – Schlatter Disease ® Osteochondrosis of the tibial tubercle
® Persistent pain over tibial tubercle, aggravated by contraction of quadriceps ®
Teenagers ® Tx: immobilization of the knee in an extension (or) Cylinder cast
for 4 – 6 weeks.
 Spondylolisthesis ® development disorder characterized by a forward slip of
vertebrae – palpable “step off” on examination if the disease is severe
 Flexible Kyphosis – postural round back which is correct on voluntary
hyperextension, no angular deformity and no neurological problem – it is a
common finding in adolescent and usually has no long term deformity
 Scoliosis – angularity in the thorax region on forward bending – Tx: Milwaukee
brace and spinal muscle exercises
Joint aspiration
¯ ¯
Cell count Gram stain Microscopic
¯ ¯ Polarization
 < 2,000 – OA,
Traumatic
(+) organism (-) organism Needle-shaped / (-)
birefringent – Monosodium
Urate (Gout)
 Up to 50,000 –
Inflammatory
(RA, Gout,
Pseudogout)
 >75,000 (without
crystal) – Septic
Staph
Aureus
N. Gonorrhea Rhomboid / (+) birefringent –
Calcium Pyrophosphate
(Pseudogout)

· Rheumatoid Arthritis (RA) · Osteo Arthritis (OA)
- Polyarticular Symmetric - Monoarticular Asymmetric
- Inflammatory synovitis - Non-inflammatory
- bone erosions - Non-erossive
- MCP & PIP involvement - PIP& DIP involvement
- Swan-neck deformity - Osteophytes & unequal joint space
- Boutonniere deformity - Bouchard’s node (PIP)
- radial deviation of the wrist with ulnar - Heberden’s node (DIP)
deviation of the digits - Tx: Acetoaminophen (NSAID)
- Tx: NSAID, Glucocorticoids, methotraxate, Capsaicin cream,joint Arthroplasty
Gold, Sulfasalazine, Infliximab, Hydroxychloroquine
· Best initial drug for Rheumatoid Arthritis (AR) – NSAID
· Best initial DMARDs – Methotraxate
· Patient on hydroxychloroquin – require frequent eye exam
■ Ankylosing Spondylitis : Positive HLA B-27, M>W, 2nd - 3rd decade
- chronic lower back pain, morning stiffness >1 hrs improve with exercise
- Anterior uveitis, Aortic insufficiency, 3rd degree heart block, Apical Pulmonary
fibrosis, Restrictive lung disease and Ig A nephropathy
- Best initial test : X-ray of lumbar spine ® sacroilitis and eventual fusing of the
sacroiliac joint, bamboo spine – Repeat X-ray after 3-months & ESR (used to
monitor disease activity)
- Tx : NSAID, Physical therapy, exercise
· Next step in management of patient with low back pain who do NOT respond to
6-wks of conservative therapy – ESR; If increase in ESR, next step? – Imaging
studies (MRI / CT scan)
■ Reactive Arthritis : infectious diarrhea (C.Jejunii) + Arthritis
- Urethritis (Chlamydia) / conjunctivitis + Arthritis ® Reiter Syndrome [Strong
association with HLA-B27 (80%); No HLA-B27 = no Reiter syndrome; negative
rheumatoid factor]
- Early Antibiotic use in urethritis decrease the chances of Reiter Syndrome
■ Psoriatic Arthritis : DIP joint + pitting of nail + skin lesions
■ Enteropathic Arthritis (Ulcerative colitis/ Crohn’s disease):
- Inflammatory Bowel disease + Arthritis + Pyoderma gangrenosum + erythema
nodosum
■ Gout : deposit of uric acid crystals in joints – most common site first toe
(podagra) – precipitating factors are alcohol, steroid withdrawal, diuretics,
Pyrazinamide, Ethambutol, following anti-cancer treatment

■ Pseudogout : deposit of calcium pyrophosphate in joints – most common site
knee joints – pre-existing joint damage is a precipitating factor – causes:
Hyperparathyroidism, Hemochromatosis, Hypophosphatemia, Hypomagnesemia
■ Septic arthritis : Gonococcal: migratory polyarthropathy, Tenosynovitis
(inflammation of tendon sheath) Staphylococci: pre-existing joint damage (eg. RA patient) – First step in Mx of septic arthritis – immediate surgical drainage followed by IV antibiotics

 Inflammatory myopathies (polymyositis, Dermatomyositis, Inclusion body myositis)

● Difficulty with task involving proximal muscles (lifting, combing hair, etc)

● Creatinine Kinase & Aldolase (most sensitive test)
● EMG®short duration, low amplitude myopathic potentials
● Muscle Biopsy (most specific test)
● Tx : Steroids® polymyopathies & Dermatomyositis
● Inclusion body myositis® Resistant to immunosuppressive therapy

· Fibromyalgia : chronic widespread pain (multiple tender points), fatigue, women (20-50 yrs) – Tx: TCA or Cyclobenzaprine

· Polymyalgia rheumatica : pain & stiffness (at least 30 min) of the shoulder and pelvic girdle, >50 yrs of age

· Polymyositis : c/o proximal muscles weakness (combing hair, difficulty raising
from chair)
■ SLE : anti-nuclear Ab, Anti-smith & Anti-ds-DNA Ab (most specific)
- non-erosive arthritis, malar rash, photosensitivity, Renal, CVS (Libman-Sack
endocarditis – sterile vegetation on MV), CNS involvement (psychosis)
- Anti-phospholipids antibody – anticoagulant, recurrent abortion
- Anti-cardiolipin antibody – give false VDRL & RPR test
- Absent of SLE symptoms, mildly high titer of ANA – No further work up require
- All SLE patients with renal involvement (Hematuria, Proteinuria) should have
renal biopsy to guide the treatment
- Tx of arthritis in SLE – NSAID
- Tx of SLE rash – cortisone cream
- Tx of Lupus Nephritis – pulse Cyclophosphamide
 Rosacea : facial rash same distribution as SLE, but rosacea has pustules &
papules & flushing of this rash by hot drinks – Tx: Metronidazole
■ Scleroderma : excessive collagen deposition – Raynaud’s phenomenon (blue
discoloration of fingers on exposure to cold), skin thickening, dysphagia – Antiscl-
70 Ab; Tx of Scleroderma induce HTN – ACE inhibitors

■ CREST Syndrome : Anti-centromere antibody
˗ C alcinosis, Raynaud’s phenomena, Esophagus (dysphagia), Scleroductly (clawlike finger), Telangiectasia (dilated blood vessels) [Calcinosis is a feature of
CREST syndrome, not Scleroderma]
■ Raynaud’s Disease – Raynaud’s phenomena occurs independently without
connective tissue involvement – Tx: Nifedepine / Amlodepine
■ Sjogren syndrome : anti-Ro (SS-A) & Anti-La (SS-B) Antibodies, Dry eye
(constant sensation of foreign body in eye), dental caries, parotid enlargement
(lymphatic infiltration of glands – lip biopsy - most specific) – also gives
positive RA factor – Malignancy associated with Sjogren Syndrome – Hodgkin’s
Lymphoma (B-cell lymphoma)
 Juvenile Rheumatoid Arthritis : salmon pink evascent rash ® Tx : NSAIDs
with monitoring of liver enzymes
 Adult Still’s disease – evanescent, salmon colored maculopapular rash that
involves the trunk & extremities typically develops with fever; Arthralgia /
Arthritis, significant leucocytosis – Tx: NSAID with monitoring liver panel
 Osteoporosis : hypogonadism, h/o taking steroids for long time – normal ALP
[Osteomalacia, Paget’s disease of bone – increase ALP] – Dx: Bone densitometry
[T-score: > -2.5 – osteoporosis; -1.5 to -2.5 – osteopenia] – Tx: Ca & Vit D (best
initial drugs), Bisphosphonates, Calcitonin, Estrogen [only when perimanopausal
(c/o hot flashes) + osteopenia] Only Bisphosphonates has shown to
reduce incidence of hip fracture.
· Breast feeding increase bone resorption in women during post-partum period.
Breast feeding increase the level of PTHrP which is important for transferring
calcium in breast milk.
· Osteochondroma ® most common benign tumor ® Metaphysis
· Osteoma ® Facial bones ® associated with Gardner’s Polyposis Syndrome
· Giant cell tumor ® Epiphysis ® Females
· Osteogenic Sarcoma ® Metaphysis of distal femur , Proximal tibia “sunburst”
appearance on X-ray ® Male ( 10-25 yrs ) ® Familial retinoblastoma
· Ewing’s Sarcoma ® Diaphysis & metaphysis of proximal femur, ribs, pelvic
bones ® “onion skin” appearance on X-ray
· Erb’s Palsy – upper trunk (C5, C6) → Axillary N. & Musculocutaneous N. →
muscles of shoulder & arm → Arm: medially rotated & adducted → Forearm:

extended & pronated (“waiter’s tip”) → Prognosis of obstetrical Erb’s palsy is
good, with 80% chance of full or near-full recovery
· Klumpke’s Palsy – lower trunk (C8, T11) → loss of muscles of Hand
· Open fracture – stabilization (eg. cast) + delayed primary closure (dressing of
wound for few days to prevent risk of osteomyelitis)
· Green stick fracture: one cortex break & another is intact Torus fracture :
impaction injury leads to buckling of cortex of long bones but on breach in
continuity
Plastic deformation: bones simply bend without any break in cortex
Physeal Injury: fracture across the growth plate of bone.
 Supracondylar Fracture ® require appropriate casting / traction ® tense &
tender forearm after casting ® Volkmann contracture (complication)
® immediate fasciotomy
 Fracture Clavicle ® junction of middle and distal thirds ® Tx: figure of 8
device for 4 –6 weeks.
 Anterior dislocation of shoulder – held arm close to the body – risk of Axillary
nerve damage ®AP & Lateral view ® Tx: reduction
 Posterior dislocation of shoulder ® high-voltage electric burns, severe muscle
contraction (generalized seizure) ® Axillary (or) Scapular view
 Frozen shoulder  joint stiffness & restriction of movement in all direction
(both active and passive)
 Rotator cuff tear or tendinitis  severe pain during mid arc abduction (passive
movement is normal); lidocaine injection  if movement improve  tendinitis; if
movement doesn’t improve  tear; diagnostic test?  MRI of shoulder
 Humeral shaft fracture ®Radial nerve injury ® Tx: reduction (If S&S of radial
nerve injury persist after reduction of the fracture ® open reduction & remove
entrapped nerve)
 Colles Fracture ® Osteoporosis, fall on outstretched hand ® “ dinner fork
deformity ® Tx: close reduction and long arm cast
 Monteggia fracture ® direct blow to the ulna (eg. Someone hits you by stick) ®
diaphyseal fracture of the proximal ulna , with anterior dislocation of the radial
head ® Tx: close reduction of the radial head & open reduction and internal
fixation of the ulnar fracture

 Galeazzi fracture ® fracture of the distal radius and dorsal dislocation of the
radioulnar joint ® Tx: open reduction and fixation of the radius & casting of the
forearm in supination to reduce dislocated joint.
 Carpel tunnel Syndrome : chronic use of hands (typist), DM, Hypothyroidism,
Acromegaly – eliciting pain by compressing median nerve at wrist / ask patient to
do forced and prolong flexion of the wrist [best initial test] – electromyography
[most accurate test] – Hand splinting at night [best initial treatment] – PO
prednisone has shown to improve symptoms
 Trigger finger ® Acutely flexed finger ® Tx: steroid injection / surgery
 de Quervain Tenosynovitis ® young mother, holding baby’s head with hand ®
pain occur when asking her to hold her thumb in her closed fist & forcing the
wrist into ulnar deviation ® Tx: splint & NSAIDs / steroid injection
 Dupuytren contracture ® contracture of the palm of the hand & palmar fascial
nodule on palpation (hand can not placed on a flat table) ® Tx: surgery
 Felon ® abscess in the pulp of a fingertip ® throbbing pain ®Tx: urgent
surgical drainage is require
 Scaphoid fracture ® fall on outstretched hand ® tenderness over anatomic
snuff – box ® Tx: Thumb spica cast, with follow-up X-ray 3 weeks later (high
rate of nonunion). If displaced and angulated fracture of the scaphoid ® open
reduction & internal fixation
 Gamekeeper Thumb ® ulnar collateral ligament injury by forced hyper
extension of the thumb ® collateral laxity at the thumb metacarpophalangeal
joint ® Tx: cast
 Jersey finger ® flex finger is forcefully extended – injury to flexor tendon ®
Tx: splint
 Mallet finger ® Extended finger is forcefully flexed ® injury to extensor tendon
® Tx: splint
 Compartment Syndrome ® intense & persistent pain few hours after casting ®
excruciating pain with passive movement of muscles ® Tx: fasciotomy
 Achilles tendon rupture ® loud “pop” sound (like a gunshot) ® palpation of
Achilles tendon reveals an obvious defect right beneath the skin ® Tx : casting in
equines position for several months / open surgical repair

 Fourth & fifth metacarpal neck fracture ® hitting the wall with closed fist ®
Tx: closed reduction & ulnar gutter splint (if mild) (or) K-wire / plate fixation (if
severe)
 Elderly patient walking “like drunken sailor”, c/o backache, claudication, pain improves when lean forward and gets worse by extension, most likely diagnosis?
– Lumbar spinal stenosis; best test? – MRI of spine
 Spinal Nerve root irritation (radiculopathy) – pain increased by bending forward and straining; decrease by lying down – SLR test is positive at 60o or less
 Externally rotated short leg ® Hip fracture, femoral neck fracture, intertrochanteric fracture ® Tx: femoral head replacement with prosthesis in
femoral neck fracture & open reduction and pinning in intertrochanteric fracture
 Internally rotated short leg ® Posterior dislocation of the Hip ® typically in
car accident where knee hit the dashboard ® Tx: emergency reduction (to avoid
avascular necrosis of femoral head)
 Medial collateral ligament injury : pain on direct palpation over the medial
aspect of the knee ® Affected leg abducted more than normal leg (valgus stress
test) ® MRI ® Tx: Hinged cast / repair
 Avascular necrosis of femoral head : progressive hip pain with normal range of
movements – Causes: chronic steroid therapy, alcoholism, hemoglobinopathies –
diagnostic test? MRI of hip – Tx: Core decompression (stage 1 or 2 – positive
radiograph without femoral head collapse) / Total hip replacement (stage 4 –
flattening of femoral head with joint space narrowing)
 Lateral collateral ligament Injury : pain on direct palpation over the lateral
aspect of the knee ® Affected leg Adducted more than normal leg (varus stress
test) ® MRI ® Tx: Hinged cast / repair
 Anterior Cruciate ligament Injury : leg can be pulled anteriorly (positive
drawer sign) ® MRI ® Tx: immobilization / repair
 Meniscal Tears ® catching & locking that limit knee motion and a “ click ”
when the knee is forcefully extended ® Tx: repair (complete meniscectomy ®
degenerative arthritis)
 Ankle fracture ® falling on an inverted / everted foot ® both malleoli break ®
AP, lateral & mortise X-ray ® Tx: open reduction and internal fixation
 Posterior dislocation of knee ® popliteal artery injury ® Tx: reduction

 Metatarsal Stress Fracture ® H/O rigorous walking, marching
 Traumatically Amputed Digits ® cleaned with sterile saline , wrapped in a
saline – moistened gauze , placed in a sealed bag (plastic) and then bag placed on
ice ® surgically reattached
 Marjolin ulcer ® squamous cell CA of developing in a chronic leg ulcer ®
heaped up tissue growth around the edges ® Tx: wide local excision & skin
grafting
 Herniated Lumbar disk ® L4 –L5 / L5 – S1 ® Severe back pain (h/o heavy
weigh lift recently) without neurologic deficit & intact perianal area; positive
straight leg raising test, diagnosis?  Herniated disc; Treatment?  NASIDs
& early mobilization
 Cauda Equina Syndrome ® Loss of bowel & bladder control & loss of sensation in perianal area ® Emergency decompression
 Motor Neuroma ® inflammation of the common digital nerve at the 3rd interspace between 3rd & 4th toes ® pointed , high heel shoes ® Tx: NSAIDS /surgical excision

Rheumatology for Studs

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Wednesday, February 3, 2010

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