MSS/Rheum

DIPs in OA

PIP, OA

Asymmetric narrowing, subchondral sclerosis, cysts, and marginal osteophytes

40-60 yo

Hyperplastic synovial tissue may erode cartilage, subchondral bone, articular capsule, tendons, and ligaments

• Morning stiffness > 1 hour
• Radiologic changes suggestive of jt erosion or bony decalcification
• Symmetric arthritis, present for at least 6 weeks
• Hand arthritis
• Arthritis in > 3 joints
• RF > 95%
• Nodules on bony prominences, extensor surfaces, or juxta-articular regions

Kidneys, blood, eyes, liver, lungs

• elevated RF and anti-CCP in 70-80% of pts (but levels low in early disease)
• Elevated ESR and CRP

soft-tissue swelling and juxta-articular demineralization

NSAIDs + DMARD (methotrexate) initially

corticosteroids, sulfasalazine, antimalarials, leflunomide

etanercept, abatacept, rituximab, infliximab, and adalimumab

Spiking fevers, myalgias, polyarthralgias, and salmon-pink maculopapular rash appearing in the evening with fever

A process in Still's disease where the rash can be elicited by scratching skin in susceptible areas

HSM, lymphadenopathy, leukocytosis, pericarditis, or myocarditis

>50k

75%

25-50

3-50k

When they have a postive ANA

• 10-15% have positive RF
• ESR and CRP increased or nl

• First line: NSAIDS, PT/OT
• Second line: methotrexate or leflunomide

• 75-80% remit without serious disability
• Pts who are RF positive are at a greater risk of progressing to disabling arthritis as adults

staph

osteomyelitis has systemic sx

40%

few joints, may involve hands and feet

psoriatic arthritis

• Elevated ESR
• normochromic, normocytic anemia
• RF is nl

• NSAIDs for mild cases
• Methotrexate for skin inflammation and arthritis
• Avoid corticosteroids and antimalarials

urethritis, conjunctivitis, oligoarthritis, and mucosal ulcers

STDs and gasteroenteritis

asymmetric arthritis that involves large joints below the waist; mucocutaneous lesions, urethritis, and conjunctivitis

Reiter's

• Positive HLA-B27 in 50-80% of pts
• Negative synovial fluid

• PT and NSAIDs are the mainstay
• ABX given at tiem of infection will reduce the chance of developing the disorder, but do not alleviate the sx of the reactive arthritis

initial gout attack of the great toe

rod-shaped, negatively birefringent urate crystals

>7.5 (CMDT)

• Indomethacin 25-50mg TID until sx resolve
• Corticosteroid injections for accessible jts, PO prednisone if other medicines are not tolerated and septic arthritis has been ruled out

allopurinol, colchicine, probenacid, sulfapyrazone, or febuxostat

knee, wrist, and elbow

positively birefringent rhomboid shaped crystals

women of child-bearing age; AA>C

• MS. PARANOID
• Malar rash
• Serositis

• Photosensitivity
• ANA
• Renal dz (proteinuria, cellular casts)
• Arthritis
• Neurologic disorders (seizures or psychosis in absence of any other cause)
• Oral ulcers
• Immunologic disorders (LE cell, anti-DNA, anti-Sm, false-positive RPR)
• Discoid rash

CBC, BUN/Cr, UA, ESR, and serum complement (C3 or C4)

• Regular exercise and sun protection
• NSAIDs for MS complaints
• Anatimalarials for MS and cutaneous manifestations)
• Corticosteroids for skin and disease flares
• Methotrexate (low dose) for arthritis, rashes, serositis, and constitutional sx

inflammatory dz of striated muscle affecting the proximal limbs, neck, and pharynx

joints, lungs, heart, and GI tract

polymyositis

insious, painless, proximal muscle weakness; dysphagia, skin rash (malar or heliotrope), polyarthralgias, and muscle atrophy

elevated CPK and aldolase

high dose steroids, methtrexate, or azathioprine until sx resolve

PMR

women twice as much as men, usually in pts > 50

~30%

• Stiffness, primarily after rest and in the morning
• MS sx are B/L, proximal, and symmetrical

ESR > 50 mm/hr

low dose cortocosteroids, unless GCA is present, then it's high dose

Small and medium artery inflammation involving the skin, kidney, peripheral nerves, muscle, and gut

male > female 3:1, onset between 40-60 yrs, although it can occur in any age group

polyarteritis nodosa

fever, anorexia, weightloss, abdominal pain, peripheral neuropathy, arthralgias, arthritsi

palpable purpura and livedo reticularis

htn, edema, oliguria, uremia

• Dx with vessel bx or angiography
• Elevated ESR and CRP and proteinuria, as well as positive Hep B surface antigen
• presence of ANCA is suggestive but not dx

• high dose corticosteroids
• cytotoxic drugs and immunotherapy may be used

female > male 4:1; onset b/w 30-50yo

• diffuse: skin, heart, lungs, GI tract, and kidneys
• limited: mostly affects the skin of the face, neck, and distal elbows and knees; can cause pulm HTN

calcinosis, raynaud's phenomenon, esophageal dysfunction, sclerodactily, telangiectasias in association with LIMITED scleroderma

• ANA positive in 90% of pts
• anicentromere Ab in limited scleroderma

• no cure
• tx the organ-specific disease processes (PPIs for reflux, ACE-Is for renal dz, avoidance of triggers and tx with CCBs for Raynaud's, immunosuppressive drugs for pulm HTN

sjogrens

RA, SLE, polymyositis, or scleroderma

most common in middle-aged females

Sjogrens

• RF positive in 70%
• ANA positive in 60%
• Anti-Ro Abs in 60%
• Anti-La Abs in 40%

Bx of lower lip mucosa, to confirm lymphocytic infiltrate and gland fibrosis

• artifical tears and saliva
• increase oral fluid intake
• ocular and vaginal lubricants
• pilocarbine for saliva flow

RA, SLE, and Sjogrens

• SSRIs, SSNRIS, and TCAs
• Pre-gabalin (Lyrica) only drug that is FDA approved specifically for tx of fibromyaglia
• Aerobic exercise
• pt education, stress reduction, sleep assistance, and tx of psychological problems

long bones

SCA

xray evidence lags behind sx by 7-10 days, therefore use ultrasound

• dead bone surrounding granulation tissue
• involucrum (periosteal new bone)

• Abx x 3 weeks (1 week IV, 2 weeks PO)
• immobilization and surgical drainage
• surgical tx to remove sequestra, sinus tract, infected bone, and scar tissue

• BLT with a Kosher Pickle
• Breast, Liver, Thyroid, Kidney, Prostate

spine``

endochondroma

chondrosarcoma, Ewing's sarcoma, and osteosarcoma

multiple myeloma

5 and 25 yo

diaphyses of long bones, ribs, and flat bones

10-20 yo

metaphyseal area of long bones

metastatic carcinoma

radiation therapy followed by local resection

When 30% of bone loss is present

MRI

• debrided and irrigated within 4-8 hours of injury
• IV abx (1-2G cephs, and aminoglycosides) for 48 hours after the fx and for 48 hours after surgical procedures

If angulation <15%, may long cast; if >15%, refer to ortho

TMJ

spondylosis

a condition where degenerative changes occur in the disk, m/c C5-C6, with the formation of osteophytes and disk narrowing; later on in the dz, facet joints and the joints of Luschka are affected

long-tract signs (clonus, Babinskis sign) and gait disturbance

humeral head deformities d/t recurrent dislocations

tear of glenoid labrum in shoulder dislocation

• immobilization by sling and swath
• therapy, begin after 1 week if >40 yo; at 3 weeks if < 40 yo

pain and restricted glenohumeral movement; arthrography may show decreased volume of the joint capsule

NSAIDs, passive ROM, and occasionally, manipulation under anesthesia

• children: figure of eight slin for 4-6 weeks
• adults: sling for 6 weeks is generally enough to tx the tx

classification of humeral head fx

caused by injury to brachial artery, possible with supracondylar humerus fx

osteonecrosis of the lunate

palmar aponeurosis, ring, little and middle fingers, causing painful nodules, pitting, and contractures

Carpal tunnel

Eikenella corrodens

colles fx (distral radius fx with dorsal angulation)

colles' fx

sprain or tear of the UCL of the thumb

lateral epicondylitis

extensor carpi radialis brevis

staph aureus

holding affected arm just above the wrist and just below the elbow, place thumb of proximal hand over the radial head while fully supinating and felxing the forearm and applying posteriorly directed pressure (screws the radial head back within annular ligament)

child will present with extremity fully pronated, with slight flexion and held tightly to side

scaphoid

radial artery by way of lateral and distal branches

stenosis tenosynovitis involving the abductor pollicus longus and extensor pollicis brevis

diabetics, females > 30

radiation of pain up in the forearm, pain and tenderness occur at the wrist and base of the humb

right thoracic curves at the T7 or T8 level

• 10-15 degree curves: 6-12 month f/u with clinical evaluation and possibly xrays
• 15-20 degree surves: serial AP radoigraphs q3-4mo for larger curves and q6-8months for smaller curves
• 20+ degree curves: refer to ortho

Juvenile kyphosis

TB of the spine (Pott's disease)

nerve compression caused by narrowing of the spinal canal or neural foramina

compression of the thecal sac

impingement of the nerve root lateral to the thecal sac

neural claudication and exacerbation of pain with walking, pain relieved by leaning forward, variable back and leg pain

a seronegative spondyloarthropathy that progresses to fusion of the vertebrae

• restricted lumbar motion
• limited motion int hes houlders and hips, synovitis of the knees, plantar fascitis, and achilles tendinitis, hip contractures and fixed cervical, thoracic, and lumbar kyphosis

uveitis, cardiac abnormalities, and interstitial lung dz

• elevated ESR and CRP
• HLA-B27 positive in 90% of whites, 50% of blacks

rare condition involving a large midline risk herniation that compresses several nerve roots, usually at L4-L5

• bowel and bladder function is severely impaired
• leg pain, numbness, saddle anesthesia and/or paralysis

results from loss of blood supply to the trabecular bone which causes a collapse of the femoral head

Legg Calves Perthes

4-8 years old

MRI

weakening of the epiphyseal plate of the femur, resulting in a displacement of the femoral head

anterior talofibular ligmanet

Bunions

lateral deviation of the proximal phalanx

an angle of greater than 15 degrees

a results of traction of the interdigital nerve against the transverse metatarsal ligament causing degeneration of the nerve and chronic inflammation

third web space

pain and localized numbness when walking and standing, which is relieved with rest; pain localized to web space commonly with a palpable mass; squeezing forefoot will often reproduce sx