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Rheumatology 2


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Rheumatology 2

  1. 1. Rheumatology Archer’s Online USMLE Reviews All Rights Reserved
  2. 2. Osteoarthritis
  3. 3. OA Involvement of first carpo-metacarpal joint. DIP Joints Hip joint Stiffness lasting less than 30 minutes Presence of Heberden’s nodes and Bouchard’s nodes ( these are bony enlargements – Heberdens are the ones at distal PIP joints and very important clue to diagnosing OA) Some times there is joint swelling and arthrocentesis will reveal  non –inflammatory wbc count < 2000/microliter X-Ray findings – joint space narrowing, osteophytes and subchondral sclerosis.
  4. 4. This patient has knee pain bilaterally. Likely cause? – OA Clue: Heberden nodes
  5. 5. Rx General therapy : Quadriceps strengthening exercises Glucosamine and chondroitin sulfate role is controversial – but if patient is already taking them, do not contradict as noa dverse effects and there might be subjective relief with these. Weight loss for Hip and Knee OA Joint arthroplasty for Hip and Knee OA if the pain is unresponsive to medical therapy
  6. 6. Rx Tylenol – drug of choice for OA NSAIDS – if patients do not respond to OA or if the pain is very severe. Tramadol – if NSAIDS are contraindicated ( CAD, renal disease, very elderly) or if they are of no benefit Topical capsaicin, lidocaine patches are effective for hand and Knee OA especially if your patient cannot tolerate tylenol or NSAIDs. Acute exacerbation of Knee OA  intraarticular corticosteroids – do not use more often than every 4 months
  7. 7. OA - Prevention Maintain adequate BMI ( Body weight) Continued moderate joint activity is very important – Normal joint use facilitates cartilage remodeling ( cartilage repair will be decreased if joint use is decreased – do not advise complete rest etc for early OA patients)
  8. 8. Septic Arthritis
  9. 9. Septic Arthritis C/F : Fever, jointpain, warmth, joint swelling and limited movements Hematogeous spread is the most common way of infection If a patient with rheumatoid arthritis has a flare in just “one” joint – think septic arthritis – always do arthrocentesis rather than just dismissing it as RA flare
  10. 10. Septic arthritis MCC – S.aureus Can occur with disseminated gonococcal infection ( clues – young adult, presence of skin pustule, migratory arthralgia, tenosynovitis of wrist or ankle) Diagnosis : Do arthrocentesis – wbc count is 50,000 to 100,000 usually. Get Gram stain and bacterial cultures
  11. 11. Septic Arthritis – Prosthetic joint Difficult to treat Surgical removal of prosthesis needed Antibiotic therapy Suspect prosthetic joint infection if a previously painless prosthetic joint now becomes painful – examine the joint for local signs like infection, erythema and warmth.
  12. 12. Septic Arthritis - Therapy Emperic therapy with ceftazidime If MRSA is a concern in high risk patients  add Vancomycin In IV Drug users  use ceftazidime + gentamicin.
  13. 13. Rheumatoid Arthritis
  14. 14. Diagnosis - RA Diagnostic Criteria of RA: (4 or more) – 1) Morning stiffness>45 minutes for 6 weeks – 2) Swelling of wrists, MCP, PIP’s for 6 weeks – 3) Swelling of 3 joints for 6 weeks – 4) Symmetric joint swelling for 6 weeks – 5) Rheumatoid nodules – 6) Erosive synovitis X-Ray changes in hands – 7) Positive Rheumatoid Factor RF is adjunctive test. If it is –ve it does not rule out diagnosis Anti-cyclic citrullinated Peptide ( CCP) has a better sensitivity to detect RA in early disease when RF is –ve.
  15. 15. Extra-Articular Manifestations of RA Heart: Pericarditis Renal: Drug related, amyloid Lung: Pleurisy with effusion, diffuse interstitial fibrosis Blood: Anemia Vasculitis: Nail fold infarct Nerve: Mononeuritis multiplex Rheumatoid Nodules Most common cause of death in RA – coronary artery disease
  16. 16. Rx NSAIDS Low dose oral and intra-articular corticosteroids for quick relief of symptoms in case of flares For mild joint disease – use sulfasalazine or Hydroxychloroquine For Erosive arthritis or extra-articular manifestations or nodules use Methotrexate. If Methotrexate not effective  use Anti TNF inhibitors ( infliximab, adalimunab and etanercept )  prior to using these place a PPD and check HEP-C serology
  17. 17. Long Steroid Use Many patients with Rheumatological disease are often placed on long term steroids Know the side effects – steroid acne ( no comedones), cushings, HTN, peptic ulcer disease, Immunosuppression and Osteoporosis Screen for osteoporosis if your patient may require more than 2 month steroids eg: DEXA scan Start calcium + vitamin D in all patients. If DEXA shows osteopenia or osteoporosis, start bisphosphanates also
  18. 18. Adult Still’s High spiking fevers Arthralgias, arthritis Maculopapular rash Lymphadenopathy Serositis Sore throat (90%), cultures negative Negative RF and ANA Leukocytosis Hepatosplenomegaly
  19. 19. Felty’s Syndrome Rheumatoid arthritis + Splenomegaly + Hematological manifestations : leucopenia, thrombocytopenia and anemia
  20. 20. Crystal Deposition Diseases Gout Pseudogout
  21. 21. Gout Presence of at least 6 of the following 12 American College of Rheumatology criteria confirms the diagnosis of gout: Maximum joint inflammation within 1 day More than one attack over time Monoarticular arthritis (although gout can be polyarticular) Redness of joint Great metatarsophalangeal pain or swelling Unilateral great metatarsophalangeal involvement Unilateral tarsal involvement Suspected tophus Hyperuricemia Asymmetrical swelling within the joint on x-ray Subcortical cysts without erosion on x-ray Joint fluid culture negative for organisms during attack
  22. 22. Gout Screening asymptomatic patients for hyperuricemia – not recommended/ No treatment unless uric acid urine secretion > 1000mg/day Consider gouty arthritis as a d/d in septic arthritis ( fever, pseudoparalysis) – do arthrocentesis, intracellular monosodium urate crystals Acute Gout Rx Do not start allopurinol Give NSAIDS if no renal issues May consider Colchicine ( GI side effects common, remember myopathy) No colchicine if Renal or Hepatic insufficiency In renal insufficiency and conditions where both NSAIDs and Colchicine are contraindicated, USE INTRA –ARTICULAR STEROIDS if Monoarthritis. If many joints are affected by gout  Use oral steroids ( R/O Septic arthritis first) Prevention  In patients with recurrent acute attacks or more than 1 or 2 acute attacks in 1 year , use uric acid lowering therapy to prevent gout  classify undersecretors or overproducers ( check 24 hr urinary uric acid excretion)  Undersecretors( excretion < 600mg per day)  Use uricosuric drug such as probenecid or sulfinpyrazone ( do not use if renal insufficiency or nephrolithiasis  Over producers or in case of Renal insufficiency/ Nephrolithiasis/ urate nephropathy, use ALLOPURNOL ( Target to reduce serum uric acid to less than 5 mg%) While using uric acid lowering therapy, use colchicine to prevent gouty attacks!
  23. 23. CPPD Short stubby crystal Weakly positively birefringent under polarized compensated light 4 “H”s  associated conditions  Hyperparathyroidism, Hemochromatosis, Hypothyroidism, Hypomagnesemia and Hypophosphatasia Rx Colchicine Q2h ( not in Liver/ Renal disease) No NSAIDs with renal insufficiency Allopurinol will not work here Intra-articular steroid best Rx in renal or GI disease
  24. 24. Raynaud’s Phenomenon Defined as Hypersensitivity to cold temperatures associated with color changes of digits during cold or stress exposure – Mottling with acrocyanosis are common changes and are benign where as "White attacks“( pallor) indicate severe ischemia  may lead to digital ulcers After exposure to cold, remember the course of events here  blanching, cyanosis first and then erythema and pain on rewarming. Numbness or "pins and needles" sensation Rx : smoking cessation, Avoid cold exposure, CCBs like Nifedepine and Topical Nitroglycerineointment for attacks If digital ulcers  use IV prostaglandins eg: Epoprostenol
  25. 25. Raynaud Phenomenon Primary or Idiopathic Secondary Raynaud's Phenomenon Connective tissue disease – – – – Scleroderma (95% have Raynaud's) Systemic Lupus Erythematosus Sjogren's Syndrome Dermatomyositis Trauma – use of occupational tools (vibratory tool – driller etc) – Carpal Tunnel Syndrome Occlusive vascular disease – Atherosclerosis , Systemic Vasculitis , Thromboembolism Medications – Cocaine, pseudoephedrine, amphetamine, non selective beta blockers, Topbacco Hyperviscosity state like Polycythemia vera Cryoglobulinemia
  26. 26. Scleroderma Diffuse Scleroderma CREST Syndrome ( Remember Distal RTA, Pulmonary Hypertension, GERD like symptoms, Dysphagia and Renal Crises for HIGH YIELD Questions)
  27. 27. Scleroderma Some key features in history Raynaud's phenomenon Skin thickening Digital ulcers Gastroesophageal reflux Shortness of breath Some Key Features on Physical : Taut skin Digital ulcers Skin pigmentary changes Basilar crackles on lung exam ( Get HRCT to check for ILD) Accentuated P2 on cardiac exam ( Get an echo to evaluate pulm HTN) Diagnostic tests : ANA, Anti-scl70
  28. 28. Scleroderma ACR classification : One major or two minor criteria must be met to make the diagnosis of scleroderma. Major criterion: – Scleroderma skin changes proximal to the metacarpophalangeal joints Minor criteria: – Sclerodactyly – Pits in the fingertips – Chest x-ray evidence of basilar fibrosis
  29. 29. Rx - Scleroderma Raynauds phenomenon CCBs ( nifedepine) and antiplatelet agents (ASA) Digital ulcers  use topical nitrates Arthritis  NSAIDS GERD  PPIs Severe myositis, arthralgias  prednisone Pulmonary HTN  high dose CCBs, prostacyclin, bosentan
  30. 30. Scleroderma Renal Crisis Scleroderma + ↑ BP + ↑ Creatinine =Renal Crisis Rx : ACE Inhibitors, Control BP aggressively. Continue ACEI despite rise in creatinine Captopril, usually, the choice as it’s short acting – so, can be titrated
  31. 31. Sjogren’s Syndrome Eye/mouth dryness, ocular complications Parotid gland swelliing Nasal congestion Associated with Fibromylagias High risk of lympomas Autoantibodies : anti-Ro/SSA and/or anti-La/SSB, ANA Rx : supportive – artificial tears and saliva. Cholinesterase inhibitor – Pilocarpine DMARDS : Cyclophosphamide
  32. 32. SLE
  33. 33. LUPUS word lupus, which The means "wolf" in Latin, was first used in the Middle Ages to describe a chronic rash on the skin. The name may have been chosen because the rash on the skin resembled the effects of a bite from one of these wild animals. Or, some believe the name arises from the fact that the rash was common about the cheeks, giving lupus victims a werewolflike appearance. Whichever the case, the disease is not the bite of a Canis lupus, but the bite of a person's own immune system.
  34. 34. SLE – Diagnostic criteria Malar rash - red rash over cheeks & bridge of nose Discoid rash – red scaly rash on face, scalp, ears, arms/ chest Photosensitivity Oral ulcers Arthritis Serositis: (a) pleuritis, or (b) pericarditis Renal disorder: (a) proteinuria > 0.5g/24 h or 3+, persistently, or (b) cellular casts Neurological disorder: (a) seizures or (b) psychosis (having excluded other causes, eg drugs) Haematologic disorder: (a) haemolytic anaemia or (b) leucopenia of < 4000/mm3 on two or more occasions (c) lymphopenia of < 1500/mm3 on two or more occasions (d) thrombocytopenia < 100k/mm3 Immunologic disorders: (a) positive anti-ds DNA antibody or (b) positive anti-Sm antigen or (c) positive test for lupus anticoagulant or (d) +ve antiphospholipid antibodies or (e) false positive serologic test for syphilis, present for at least 6 months. Antinuclear antibody in raised titers ( in the absence of drugs associated with drug induced SLE ) - Presence of four or more of the 11 criteria, serially or simultaneously, during any interval of observation…
  35. 35. Systemic Lupus Erythematosus Clinical Features on Presentation in SLE – Arthritis or Arthralgia 55% – Skin Involvement – Nephritis – Fever 5% – Other 20% 5%
  36. 36. Systemic Lupus Erythematosus Organ Involvement in the Course of SLE •Joints •SkinRashes •Discoid Lesions •Alopecia •Pleuropericardium •Kidney •Raynaud’s •Mucous Membranes •CNS (Seizures/Psychosis) 90% 70% 30% 40% 60% 50% 20% 15% 15%
  37. 37. Mortality/ Morbidity Risk in SLE The Most Risk Comes From : – Early: Organ (esp Renal) Disease – Overt Lupus nephritis is the most serious manifestation of SLE. Differs in clinical pattern, severity, prognosis and treatment. Aggressive treatment is warranted. – Throughout the Course: Infection – Late: Atherosclerosis and Coronary events
  38. 38. Lupus Nephritis Clinical features : – Hypertension – new onset – Peripheral edema, Weight gain, Ascites – Renal insufficiency or failure ( elevated creatinine ) – Asymptomatic/ symptomatic urinary findings: Proteinuria - RBCs, less commonly WBCs - Casts : RBC casts are ominous
  39. 39. Dermatomyositis Heliotropic erythema, Gottron’s papules Polymyositis
  40. 40. Polymyalgia Rheumatica Temporal Arteritis
  41. 41. Polymyalgia Rheumatica • Profound hip and shoulder girdle stiffness • Anemia • Elevated ESR usually greater than 100 • Very responsive to prednisone trial – 15mg/d Vascular symptoms may indicate concomitant temporal arteritis: • Headache • Jaw claudication • Visual changes (amaurosis/ blurring) • Scalp tenderness • Cough
  42. 42. Reiter’s Syndrome
  43. 43. Reactive Arthritis ( Reiter’s) Pre-infection with These bugs are assocaited  chlamydia, yersinia, shigella and campylopbacter and HIV Arthritis onset 1-4 weeks after GI or GU infection Classic Clinical Triad (Rarely present) Arthritis Conjunctivitis Non-Gonococcal Urethritis Clues for Reactive Arthritis ( Reiter’s): hx of diarrhea OR non-gonococcal Urethritis asymmetric polyarthritis, predominantly affecting lower extremities, with enthesopathy and skin lesions on bottom of feet. In anyone with new onset Reactive Arthritis (Reiter’s) - get an HIV test. ( Reactive arthritis may be initial presentation of HIV) Sausage shaped fingers and toes seen ( d/d – psoriatic arthritis – dactylitis seen there too) CVS abnormalities like Heartblock and AR may be present
  44. 44. Gonococcal arthritis DGI For full details on DGI – Refer ID slides
  45. 45. Migratory polyarthritis. Skin pustules. Joint effusions are often inflammatory but usually sterile. Culture all portals of entry that are exposed during sex(pharynx, anus, urethra). Culture pustule if present. Even if a sexual history is negative, suspect it!
  46. 46. Low Backache Lumbar Muscle Strain Lumbar disc herniation Lumbar Disc Prolapse Lumbar Canal Stenosis Lumbar Radiculopathy Ankylosisng Spondylitis Medical Causes – Renal colic, Pancreatitis, AAA rupture, aortic Dissection
  47. 47. Mechanical Back Pain Mechanical back pain Sudden onset (only 50% patients remember an inciting incident) Minimal stiffness Hurts more with exercise Gets better lying down Pain may accentuate with cough or straining Motion may be limited but Schober test usually is negative Causes : Lumbar Strain, Lumbar disc prolapse, Disc Herniation, Lumbar
  48. 48. Ankylosing Spondylitis Five factors differentiate inflammatory back pain from mechanical back pain: Onset before age 40 years Insidious onset Persistence for at least 3 months Associated morning stiffness Improvement with exercise Only 10-20% of male first-degree relatives who inherit B-27 actually develop AS. Rx for pain – NSAIDS ( use antinflammatory agents)
  49. 49. Lumbar Stenosis
  50. 50. Clues- Lumbar stenosis Maneuvers which extend the L/S spine narrow the canal (and compress the nerve roots), while spine flexion opens the canal). Increases symptoms: Walking (pseudoclaudication*) Walking down hill Leaning backwards Lying prone in bed * Pulses are intact and ankle-brachial index ≥ 1.0  but don’t let this fool you because a man have cluadication pain – may have both PAD and Lumbar stenosis – your job is to find out what’s the cause of his claudication pain! So, go by other differences  like Lumbar stenosis pain first appears on standing and decreases on bending forward. Also, go by Releif time differences with rest ( 5 mins of rest in PAD, 30 mins after changing position or sitting in LCS) Decreases symptoms: Sitting still Bending forward while walking (shopping cart) Walking with cane Walking uphill Lying supine in bed
  51. 51. Fibromyalgia Fibromyalgia is a diagnosis of exclusion Criteria : Widespread musculoskeletal pain ("I hurt all over") Each of the body quadrant is involved - Pain on left and right side of body and Pain above and below waist Skeletal pain present : Cervical, Thoracic, lumbar spine and anterior chest Pain worse in the morning and at the end of the day Symptoms present more than 3 months Presence of 11 of 18 tender points
  52. 52. Fibromyalgia Patient quotes: “I hurt all over.” “I feel like a truck hit me.” “This fatigue is the worst.” “I don’t sleep worth a damn.”
  53. 53. Management Reassurance Exercise Program Sleep hygiene Drug Rx : Amitryptiline SSRIs Anticolnvulsants – pregabalin Tylenol
  54. 54. Behcet’s Syndrome
  55. 55. Behcet’s Syndrome Recurrent oral ulcers (at least 3 per year) And 2 of the following: – Recurrent genital ulcers – Eye lesions ( anterior, posterior uveitis) – Skin lesions: E. nodosum Pseudofolliculitis Papular pustular lesions Acneiform lesions – Pathergy  The pathergy test is a simple test in which the forearm is pricked with a small, sterile needle. Occurrence of a small red bump or pustule at the site of needle insertion constitutes a positive test. Although a positive pathergy test is helpful in the diagnosis of Behcet’s, only a minority of Behcet’s patients demonstrate the pathergy phenomenon (i.e., have positive tests).
  56. 56. Behcets - Rx Disease confined to mucocutaneous regions (mouth, genitals, and skin)  topical steroids and non– immunosuppressive medications such as colchicine Moderate doses of systemic corticosteroids are also frequently required for disease exacerbations In the event of serious end–organ involvement such as eye or central nervous system disease  both high doses of prednisone and immunosuppressive treatment are usually necessary. Immunosuppressive agents : azathioprine, cyclosporine, cyclophosphamide, and chlorambucil. With organ- or life-threatening disease, the combination of prednisone and either cyclophosphamide or chlorambucil (both of which are from the same class of drug — “alkylating agents”) is the preferred therapy.
  57. 57. Orthopedics/ Sports Medicine Very High-yield Topics Only!
  58. 58. Tendon Injuries Injury to a a muscle tendon Important topics Rotator Cuff Tendinitis Patellar Tendinitis ( Jumper’s Knee) Achilles Tendon Rupture Tendinopathy at Elbow Medial Epicondylitis ( Golfer’s Elbow) Lateral epicondylitis ( Tennis Elbow)
  59. 59. Rotator Cuff Tendinitis Synonyms : Impingement Syndrome Pain worse at nights Inability to lie on the affected shoulder due to pain Painful overhead activities ( combing hair etc) Locking sensation with abduction Tenderness maximum at supraspinatus insertion Pain is worse between 60 to 120 degrees of abduction. ( painful arc) Presence of ecchymoses and shoulder atrophy may point towards rotator cuff rupture. ( not just tendinitis) Management : Do not recommend complete rest of shoulder as it can lead to Frozen shoulder Avoid overhead work NSAIDS for pain If no improvement in 6 weeks, consider steroid injection in to sub-acromial space Improvement will typically occur in 3 to 5 weeks. If the improvement in pain much delayed, suspect rotator cuff rupture ( Do MRI to rule out this)
  60. 60. Adhesive Capsulitis Synonyms : Frozen Shoulder Conditions that predispose to adhesive capsulitis – – Diabetes Mellitus Thyroid Disease Insiduous onset of increasing shoulder stiffness Onset of pain is typically after significant Shoulder ROM is lost Pain with shoulder activity  accompanied by progressively decreasing passive and active shoulder movements ( passive movements are possible in simple rotator cuff tendinitis) Loss of shoulder motion evident in all planes ( Shoulder ROM is extremely limited. If the Q says severe pain but normal shoulder ROM, that rules out adhesive capsulitis) Management : Conservative measures : Heat, physical therapy, Home exercises Analgesics If symptoms do not improve after 6 weeks on conservative management and physical therapy  Steroid inj in to subacromial space If symptoms refractory to 6 months of conservative management  surgery
  61. 61. Patellar Tendinitis/ Patellar Tendon Rupture Most common age is 25 to 40 years Recurrent corticosteroid injections in to knee joint can also lead to patellar tendon rupture. Can occur in teen boys – associated with jumping sports if done during growth spurt Signs include : large Knee Effusion and palpable defect between tibial tubercle and inferior patella, Active knee extension will be difficult Rx : Physical therapy, Surgery within 10 days and plaster cast immobilization for 6 weeks post surgery
  62. 62. Achilles tendonitis Poor running techniques and poor fitting shoes can predispose to achilles tendinitis. Rheumatoid arthritis and spondylarthropathies are some predisposing conditions. Symptoms include stiffness and heel apin at achilles tendon that are worse with exercise. Signs : Rx : Pain and tenderness at the insertion of achilles tendon Do Thompson test to differentiate from rupture ( with the patient lying prone, squeeze the calf muscle. Normally, there should be a plantar flexion as a reflex response. However, in Achilles tendon rupture Plantar flexion is absent) Ice Therapy, NSAIDS, Stretching exercises Never use cortocosteroid injection  can lead to achilles tendon rupture
  63. 63. Achilles Tendon Rupture Can be associated with Quinolones ( due to tendon degeneration) Sports associated with it : foot ball and basket ball ( due to excess force) C/F: Hx of sudden stress on the tendon such as jumping followed by a “pop” sound at the heel. Usually, there is severe pain. Sometimes, pain is mild initially. Patient walks with a flatfoot and there is loss of plantar flexion. There might be ecchymoses at the tendon site Thompson's Test is abnormal Rx : Ortho consult – Surgical repair – Non weight bearing ( use crutches) for 3 weeks.
  64. 64. Golfer’s Elbow Also called as medial epicondylitis – is an inflammation of common flexor origin C/F Dull pain at medial epicondyle Tenderness on medial epicondyle Pronation of forearm and wrist flexion against resistance will elicit pain ( provacative maneuvers) Rx : NSAIDS, Conservative rx – Rest and ice therapy. Steroid injection in refractory cases
  65. 65. Tennis Elbow Lateral epicondylitis Inflammation of common extensor origin Sports involved : Throwing sports, hammering, use of computer mouse C/F : Dull ache and tendernessat lateral epicondyle Wrist extension and Supination against resistance elicit pain Rx : Similar to Medial epicondylitis
  66. 66. Nursemaid Elbow This refers to Pediatric condition – Very Highyield Synonyms : Radial head subluxation, Pulled elbow Common between 1 to 3 years. Rare after 6 years of age Occurs due to injury from longitudinal traction on hand – Elbow extended and forearm pronated ( this happens when child lifted by wrist or hand) C/F A snapping sound may be heard with radial head subluxation . Radial head is tender Child holds arm without any motion at side ( arm is kept in Slight flexed, Pronated and Adducted position) X-rays of elbow are normal Rx : includes manual reduction ( while applying pressure over the radial head, supinate ( palm up) and flex the forearm to 90 degrees). Once reduced child can use the forearm in 10 minutes
  67. 67. Knee Pain  Bursitis : Pre-patellar bursitis, Anserine bursitis Ligament injuries : medial collateral ligament injury, lateral collateral ligament Injury, Anterior cruciate ligament injury Patellar tendinitis Meniscal Injuries : medial meniscal tear and lateral meniscal tear Osteoarthritis Inflammatory arthritis : RA, SLE, Septic, Gout Iliotibial band syndrome ( focal aching or burning pain at lateral femoral epicondyle. Rx : conservative  RICE-M, NSAIDS) Patellofemoral syndrome
  68. 68. Bursitis at Knee Pes-anserine bursitis Associated with direct trauma or over use Seen in middle aged, obese women Presents with “medial” knee pain – 3 to 5 cm below the joint line Repeated flexion and extension of knee will cause pain ( “provocative” test) Pain occurs both at motion and at rest ( esply at nights) Rx  ICE, NSAIDS, Steroid injs if refractory Pre-patellar bursitis Housemaids knee Assocaiated with direct trauma to anterior patella such as chronic kneeling C/F  Anterior knee pain + swelling  Tenderness over pre-patellar bursa i.e; on the anterior knee overlying the patella NSAIDS, Ice, Steroid injection if refractory
  69. 69. Medial Collateral Ligament Injury Associated with tenderness and pain along the medial joint line. Most common of all knee ligament injuries caused by an injury involving valgus (abductor) stress to the partially flexed knee with the foot fixed Eg: skiing or during contact sports ( football), when another person falls across the knee from the lateral to medial direction. Signs : Valgus stress maneuver  keep knee in 30 degree position and apply valgus stress. Presence of laxity (excess movement) and pain on valgus stress confirms instability and hence, MCL injury Do a Knee MRI if the pain is persistent in the joint line even after 4 to 6 weeks of injury. Rx : Rest, ICE, Compression(Elastic) bandage, Elevation of extremity, Motion restriction and weight bearing as tolerated until healed ( Mnemonic - “RICE-M” for all sprains) Remember “ LORI” ( Valgus – outward, Varus – inward)
  70. 70. Lateral Collateral Ligament Injury Associated with tenderness and pain along the lateral joint line. Caused by an injury involving dramatic varus (adductor) stress – Force against the medial knee LCL injury usually occurs concurrent with ACL or PCL injury Rx : RICE-M LCL tears heal much slowly than MCL tears.
  71. 71. Anterior Cruciate Ligament Injury Knee Hyper-extension injury – occurs after non-contact deceleration, a cutting movement, or hyperextension. ( sudden stopping after running can cause tibial displacement anteriorly and ther by, causing ACL rupture) May be accompanied by pain and a "popping" sound at the time of injury Swelling (bleeding in to knee, Hemarthrosis) occurs within 12 hours of injury "Giving way" or buckling sensation of knee Most sensitive test “Lachman test” ( with the femur fixed, pull the proximal tibia anteriorly and posteriorly +ve Test is associated with pain and laxity on anterior movement) Other test – “Anterior Drawer’s” test ( with the pt’s feet flat on the table, hold the lower leg above calf and suddenly pull forward  excess laxity at the end indicates ACL rupture) Rx : Quadriceps strengthening exercises, Knee braces. - Surgical reconstruction after conservative therapy in adults. Knee Bracing not needed after surgical reconstruction.
  72. 72. Posterior Cruciate Ligament Injury Uncommon Injury Mechanism : the dashboard being struck by the anterior of the flexed knee in a motor vehicle accident ( when a flexed knee decelerates rapidly) or from hyperextension. Pain is minimal/ does not restrict much movement Posterior Drawers test is positive Get a lateral knee x-ray to rule out tibial avulsion fracture Rx : Knee braces, immobilization, quadriceps strengthening exercises. Surgery indicated only if associated with avulsion fractures
  73. 73. Meniscal Injury Most common knee injury – medial meniscal injury is the most common. Lateral is very rare Mechanism of injury : Twisting injury of the knee or fixed rotation of tibia with knee flexion or extension Associated with Anterior Cruciate Ligament Tear in 33% of cases C/F : Twisting injury to knee followed initial tearing, painful sensation. Pain localized to affected meniscus Locking or buckling sensation Gradual effusion following injury – may be seen on x-ray Stair climbing or descent and Squatting can provoke pain Medial joint line tenderness McMurray's Test positive ( 97% specific) If in doubt, MRI is the best study to evaluate menisci – not x-rays Management: Conservative : RICE-M, NSAIDs , Quadriceps strengthening Exercises for 2 weeks Management: Surgery ( Diagnostic arthroscopy and repair) indicated only in Irreducible locking Refractory meniscus symptoms despite above management Complications of meiniscal injury include Osteoarthritis of knee
  74. 74. McMurray’s Test Patient lies supine, Knee is flexed to 45 degrees and Hip flexed to 45 degrees Examiner braces lower legs holds ankle with one hand and knee with other Medial meniscus assessment : apply valgus stress and externally rotate leg and then slowly extend the knee while still in “valgus”  Assess for "click" suggesting meniscus relocation. Lateral meniscus  above is repeated with varus stress and internal rotation Interpretation: Test is positive for Meniscal Injury  If "Click" heard or palpated with above maneuvers
  75. 75. Patello-femoral syndrome Most common cause of knee pain in patients younger than 45 years of age common in women. The patello-femoral joint is affected by the disease; the histologic abnormalities observed in these patients are typically described as "chondromalacia patellae". The syndrome is classified as "overuse" injury, and is common in athletes. C/F Anterior knee pain provoked by climbing the stairs or prolonged sitting. IMP SIGN - Retropatellar crepitation and Pain on compressing the - patella. Another imp test “ PATELLAR APPREHENSION TEST” – a provocative test where when the examiner applies pressure on medial side of patella and presses it laterally – produces pain. Patient will tighten the quadriceps and refuses the test in anticipation of pain!! NO “LOCKING” or “CATCHING” sensation unlike in meniscal injury Rx : NSAIDS, patellofemoral knee exercises, quadricepsstrengthening exercises Indications for surgery Persistent symptoms >6-12 months Refractory to rehab program - Surgery involves - First ruling out other causes of knee pain – do a diagnostic arthroscopy and then smooth the patellar undersurface.
  76. 76. Osgood – Schattler’s disease Common cause of knee pain in young boys near puberty ( 13 to 14 yrs) Tibial apophysitis – cartilage detaches from tibial tuberosity Pathophysiology involves recent increase in athletic activity at the same time as recent growth spurt. Anterior knee pain increased by running, kneeling, climbing stairs etc Sign : localized tenderness and swelling at tibial tuberosity. D/D – SCFE (though involves hip area, pain refers to knee) Rx : – – – Reduce Physical Activity, Quadriceps strengthening, Splint the knee if required Surgical excision of ossicle may be needed eventually Never give local Steroid Injections as they can cause patellar tendon rupture.
  77. 77. Limping Child Transient Hip Tenosynovitis SCFE Legg-Calve-Perthe’s disease Tibial apophysitis Refer To PEDIATRICS SLIDES
  78. 78. Foot Pains Plantar Fascitis Metatarsalgia Morton’s Neuroma Bunions
  79. 79. Plantar Fascitis Presents with heel pain – worse in the morning i.e; worst with first few steps after resting and improves on walking. Signs : focal tenderness along the plantar fascia or at the calcaneal origin Rx : Calf stretching exercises Silicone heel inserts/ heel pads Padded athletic shoes with good arch support Steroid injections at tender points if refractory to conservative rx. Surgery in refractory cases
  80. 80. Metatarsalgia Presents with anterior foot pain Pain under metatarsal heads – increases on walking or standing Tenderness present on palpation of plantar aspect of affected metatarsal head Rx : well padded shoes, taping technique to keep affected toes in plantar position
  81. 81. Morton’s Neuroma Pain in the ball of the foot – radiates to the third and fourth toes Maximum tenderness in the 3rd intermetarsal space Rx : – Silicon pads/ orthotics – Steroid injection in to 3rd space – Surgical excision
  82. 82. Hallux Valgus Also called bunion Pain and redness on medial aspect of 1st MTP joint. Lateral deviation of great toe, callosity of the skin on medial aspect of 1st MTP joint Rx : Wide – toed shoes Foam pad to protect bunion Surgical correction of hallux valgus