OSTOEARTHRITIS
OA
ETIOLOGY
PRIMARY-IDIOPATHIC
SECONDARY- 2/2 TRAUMA INFECTION, METABOLIC DISORDER
OA INCIDIENCE
> 40 YO
W>M > 50
COMMON 30 MILL
50-70 WORST
OA RISK FACTORS
OBESITY
AGE
TRAUMA
OVERUSE OF JOINTS
FAMILY HISTORY
HIP DYSPLASIA AS CHILD
PAGETS
HEMOPHILIA
OA ASST FINDINGS LOCATION
knees, hips, CERVICAL SPINE, lUMBAR SPINE
COMMON SITES
DIP( DISTAL INTERPHALANGEAL JOINT) HERBERDENS
PIP BOUCHARD
FIRST CMC- JOINT
FIRST MTP JOINT SEE PIC
OA ASST FINDINGS
UNILATERAL OA-REMEMBER ONE IS OA
JOINT REMODELLING OSTEOPHYTE OVERGROWTH-BONY SPURS-BUNIONS, HEBERDENS BOUCHARDS
MORNING STIFFNESS< 60 MINS, STIFF END OF DAY OR AFTER ACTIIVITY
JOINT INSTABILITY ESP KNEES
OA DIFF DX
GOUT
PSEUDOGOUT
INFLAMMATORY ARTHRITIS:
RA
PSORIATIC, ANKYLOSING SPONDYLITIS, JUVENILE IDIOPATHIC, SLE
GIANT CELL ARTERITIS
BURSITIS
TENDINITIS
NEUROPATHY
HEMOCHROMATOSIS ( IRON OVERLOAD) CAN CAUSE FINGER JOINT PAIN)
DIAGNOSITCS
NO LAB TESTS
H&p AND XRAY DIAGNOSTICS
XRAYS_ OSTEOPHYTES, JOINT SPACE NARROWING, SUBCHONDRAL SCLEROSIS
LABS TO R/O :
ESR, OR CRP -NON SPECIFIC
RF
ANA
CCP- ANTI CYCLIC CITRULINATED PEPTIDE-DIAGNOSTIC Of RA
YOUNGER PT IRON SAT FERRITIN LEVELS TO R/O HEMACHROMATOSIS ( IRON OVERLOAD DISORDER)
USS -SYNOVIAL FLUID INFLAMMATION
SYNOVIAL FLUID ANALYSIS-USU NONINFLAMMATORY
OA PHARM
SYMPTOM RX ONLY NOT PREVENTIVE
CONSIDER COMORBIDITIES FIRSTDM, HTN, CAD,PUD, CKD , ELDERLY
SHORT ACTING NSAIDS-NON SELECTIVE NAPROXEN
COX 2 INHIBITORS NSAIDS< GIB SELECTIVE; CELEBREX.RELATIVELY SELECTIVE COX MOBIC/MELOXICAM(>BLEEDING RISK)
USE WITH MISOPROSTOL TO < GI EFFECTS
CYMBALTA
TOPICALS VOLTAREN CAPSAICIN
TRAMADOL REC BY AMRICAN COLLEGE OF RHEUMATOLOGY ( ACR) AS 2ND LINE
NARCOTICS NOT RECOMMENDED XCEPT BRIEF SEVERE EXC
S/E
NSAIDS/COX 2 > RISK OF STROKE- MI- HEMOLYTIC ANEMIA-KIDNEY SPECIFIC INTERSTITIAL NEPHRITIS- RENAL NECROSIS
NEPHROSIS : CLASSIC TRIAD OF FEVER RASH EOSINOPHILIA
OA PHARM NOT TO TAKE
ACR GUIDELINES:
VITAMIN D
FOSAMAX OR BIPHOSPHANATES,
FISH OIL
NON TRAMADOL OPIOIDS
METHOTREXATE
GLUCOSAMINE AND CHONDROITIN
HYDROXYCHLOROQUINE
OA NON PHARM
EXERCISE -WEIGHT BEARING, STRENGTHENING, WALKING TAI CHI, BIKING, YOGA AQUATIC
WEIGHT LOSS
INTRAARTICULAR GLUCOCORTICOID INJECTIONS 4 X YEAR
OA REFERRAL
ORHTOPEDIST
PT
NUTRITIONIST ( iF OBESE)
CBT
ACUPUNCTURE
OA F/U
SCHEDULE REGULAR
NSAIDS/COX LABS :
PERIODIC STOOL OB
RENAL FUNCTION STUDIES
CBC-? ANEMIA
OA COURSE
PROGRESSIVE
JOINT EFFUSIONS
BONY ENLARGEMENT
RHEUMATOID
RA DEFINITION
AUTOIMMUNE DISEASE
PROGRESSIVE REMITTING/RELAPSING
SYNOVIAL INFLAMMATION
BONE AND CARTILARGE DESTRUCTION
HYPERPLASIA
SYSTEMIC CHANGES
UNKNOWN
? GENETIC + ENVIRONMENTAL
ANTIGEN-ANTIBODY
INCIDENCE
1%WORLD POP
FEMALE SEX
AGE 40+
CIGARETTES
DIET: >PROCESSED FOODS REFINED CARBOHYDRATES
VIT D DEFICIENCY
ASST FINDINGS
UTDATE *MORNING STIFFNESS>60 MIINUTES
BILATERAL AND SYMMETRICAL
WEKNESS MALAISE FATIGUE WT LOSS DEPRESSION ANOREXIA
ONSET ACUTE OR GRADUAL
LYMPHADENOPATHY, LOW GRADE FEVER
EYE INFLAMMATION
VASCULITIS
PERICARDITIS
PLEURISY
JOINT PAIN
POLY ARTICULAR PIP MCP WRIST ELBOWKNEE ANKLE
SUBCUTANEOUS NODES ON BODY-SEE . NODES ON HEART VALVES,PLEURA ,LUNG PARENCHYMA, SPLEEN ( CANT SEE)
SWAN NECK DEFORMITY
DIFF DX
SEPTIC ARTHRITIS
SLE- + ANA ALSO
TENDINITIS OR TENDINOPATHY
SYNOVITIS
PMR IF UPPER JOINTS -SHOULDER HIPS
DIAGNOSTIC CRITERIA
ACR
A-D
American College of Rheumatology RA Classification Criteria
Target population is patients who:
Have at least one joint with clinical synovitis
The synovitis is not better explained by another disease
Classification criteria for RA use a score-based algorithm in which categories A-D are added together. Score of ≥6 classifies the patient as having RA:
A. Joint Involvement (tender or swollen):
1 large joint = 0
2-10 large joints = 1
1-3 small joints (with or without involvement of large joints) = 2
4-10 small joints (with or without involvement of large joints) = 3
>10 joints with at least 1 small joint = 5
B. Serology (at least one needed for classification):
Negative RF and anti-citrullinated protein antibodies (ACPA) = 0
Low-positive rheumatoid factor (RF) or low-positive ACPA = 2
High-positive RF or high-positive ACPA = 3
C. Acute phase reactants (at least 1):
Normal CRP & ESR = 0
Abnormal C-reactive protein (CRP) or Erythrocyte sedimentation rate (ESR) = 1
D. Duration of symptoms (patient reported):
<6 weeks = 0
>6 weeks = 1
note now we have ccp
DIAGNOSTIC TESTING
LABS-STILLWANT TO R/O OTHER DIFFS??
CONFIRMATORY TESTING: TWO TESTS
RF (69 percent SENSITIVITY,NOT VERY SPECIFIC FOR INFLAMMATORY CAUSE)
CCP- = ANTICYCLIC CITRULLINATED PEPTIDE ( ANTI CCP) ANTIBODIES
SPECIFICITY FOR ra 90% SPECIFIC, 67 PERCENT SENSITIVITY
ACPA =anti-citrullinated protein antibodies W HIGH ACPA-MATY EVEN BE PRESENT BEFORE SYMPTOMS APPEAR
ACPA ANTICYCLIN PEPTIDE ANTIBODIES
ESR AND CRP SHOW INFLAMMATORY STATE-THESE ARE ACUTE PHASE REACTANTS
ESR VARIES WITH SEVERITY OF RA
URIC ACID -R/O GOUT
NEW EVIDENCE
RADIOGRAPHY NOT MUCH EFFICACY, USUALLY JOINT SPACE NARROWING ETC ARE LATE PHASES
GOOD TO XRAY FAT PEOPLE, JOINTS HARDER TO SEE
JOIINT ASPIRATION -R/O SEPTIC ARTHRITIS GOUT
MRI AND USS MAY IDENTIFY SYNOVITIS
PHARM
disease-modifying antirheumatic drugs DMARDs- as soon as ra dx
IMMUNOSUPPRESSANTS
METHOTREXATE 7.5 mg po q weekly
or 2.5 mg q12 for 3 days a week
F/U cbc+platelets?lfts baseline,then q 4-8 weeks onward
SULFASALAZINE
f/u CBC+LFT BASELINE, THEN Q 2 WEEKLY X 3 MONTHS.Q MONTHLY X 3 MONTHS
AZATHIPRONE/IMURAN
1-2.5 MG DAILY
f/u cr baseline, weekly cbc x 4 weeks , q2 wk x 4 then monthly on
PLAQUENIL/HYDROXYCHLOROQUINE
f/u cbc ecg (prolonged qti) q 3 months
extra card
LFTS-SIGNIFICANCE
AST
ALT
BILIRUBIN -MEASURES HEPATOCELLS ABILITY TO DETOXIFY METABOLITES, AND TRANSPORT ORGANIC ANIONS INTO BILE
ALK PHOS - LIVER INJURY
AST ALT NOT ALWAYS RELATED TO LIVER AND BILE DUCTS, MAY BE ELVATED AST CAN BE > 2/2 CARDIAC MUSCLE, SKELETAL MUSCLE, KIDNEY AND BRAIN
ALTS CORRELATE WITH ABDOMINAL ADIPOSITY
ALK PHOS BONES AND LIVER, > PREGNANT WOMEN 3RD TRIMESTER( FROM PLACENTA), TYPE O AND TYPE B BLOOD > ALK PHOS
> ALK PHOS CAN BE FRACTIONATED TO DETECT SOURCE
GAMMA GLUTAMYL TRANSPEPTIDASE-GGT- LIVER BILE DUCT, ALSO INTESTINE, BRAIN, HEART PANCREAS BLOOD VESSELS-ONLY RELEASED INTO BLOODSTREAM BY HEPATOBILIARY TISSUE SO SPECIFIC TO THESE
LDH -LACTATE DEHYDROGENASE-CYTOPLASMIC ENZYME IN TISSUES THROUGHOUT BODY-BETTER AS MARKER FOR HEMOLYSIS
HEPATIC SYNTHETIC PRODUCTION TESTS:
SERUM ALBUMIN
PROTHROMBIN TIME/INR
ra pharm
TNF-TUMOR NECROSING GACTOR ALPHA INHIBITORS
MABS
ADALIMUMAB/HUMIRA
40 MG SQ WEEKLY
f/u do not start if >65 and comorbidity with > infection risk , can get TB
CERTOLIZUMAB/CEMZIA
ETANERCEPT/ENBREL
GOLIMUMAB/SIMPONI
REMICADE/INFLIXIMAB
OTHER MABS
B CELL INHIBITORS
RITUXIMAB/RITUXAN
TCELL INH
ORENCIA
PLAIN OLD
PREDNSIONE , DEXAMETHASONE, USED AS BRIDGING AGNE
RA NON PHARM
EXERCISE PROGRAM
EXCLUDE INFLAMED JOINTS
ORHTOTICS-PREVENT DEFORMITIES
THERAPEUTIC FOOTWEAR
COLD AND HEAT THERAPY
AVOID SUGARY FOODS
MEDITERRANEAN DIET
DCONTROL BMI
SURGERY SYNOVECTOMY
ARTHROPLASTY
F/U REFERRAL ra
RHEUMATOLOGIST
OT
PODIATRIST
COMPS
DEPRESSION
DRUG TOXICITY
JOINT SESTRUCTION
SJOGRENS
DISABILITY
COMMON SYMPTOMS
Soft tissue swelling
●Warmth over a joint
●Joint line tenderness to palpation
●Joint effusion
●Loss of motion
gout
ETIOLOGY CAUSE
CAUSED BY TISSUE DEPOSITION OF MONOSODIUM URATE ( MSU) AS A RESULT OF PROLONGED HYPERURICEMIA
GOUT CAUSES
SYSTEMIC METABOLIC DX
CAUSED BY
EXCESS URIC ACID PRODUCTION 10%
DECREASE IN RENAL EXCRETION 90%
OR BOTH
PRMARY -ABOVE
SECONDARY
2/2 LEUKEMIA (2/2 HIGHH CELL TURNOVER)OFR A DRUG
GOUT STAGES
4
ASYMPTOMATIC HYPERURICEMIA
ACUTE GOUTY FLARES
INTERCRITICAL STAGE9INTERVALS BETWEEN FLARES)
CHRONIC TOPHACEOUS GOUT
EPIDEMIOLOGY
MEN > WOMEN 4/1
V.RARE PREMENOPAUSAL WOMEN
4% ADULTS IN US
DEVELOPED COUNTRIES AND WHITE POEPLE
30-50 MEN
>60 WOMEN
GOUT CAUSING DRUGS
ASPIRIN
CYCLOSPORINE
TACROLIMUS
PYRAZINIMIDE( FOR tb)
DIURETICS
GOUT RISK FACTORS
DRUGS
BLOOD CANCERS
SEAFOOD
MEAT
ALCOHOL ESP BEER
METABOLIC SYNDROME/INSULIN RESISTANCE
HYPERTENSION
PRESENTATION
MONOARTICULAR
MAX PAIN 4-12 HOURS
NIGHT FLARE
RED
WARM
TENDER
SAUSAGE TOE
FIRST MTP JOINT (PODAGRA)
GOUT PRESENTATION
EARS HELIX + ANTIHELIX
DIP HANDS
DIP FEET
OLECRANON BURSA
GOUT PATHO
HUMANS DONT EXPRESS GENE FOR URICASE ENZYME WHICH DEGRADES URIC ACID BETTER
+
HIGH RATE OF REABSORPTION OF URATE IN KIDNEYS
= > URICEMIA + GOUT
URIC ACID EXISTS AS URATE AT A NORMAL PH
TOO MUCH LEADS TO CRYSTAL FORMATION
GOUT FORMS IN COLD JOINTS FIRST PODOGRA AND IN OA NODES
PODOGRA COOL , SOLUBILTY OF URATE CRYSTALS DEPEND ON TEMP
URATE CRYSTALS + HAGOCYTES + INFLAMMATION
TNF AND IL8 + NEUTROPHIL ADHESION OT ENDOTHELIUM AND NEUTROPHILIC SYNOVITIS
GOUT DIAGNOSIS
URIC ACID -MAY BE LOW OR NORMAL
CBC MILD LEUCOCYTOSIS
ESR
CRP
DEF DIAGNOSIS NEEDLE ASPIRATION
MSK USS
HYPERCHOIC BAND ( DOUBLE CONTOUR SIGN ) SPEC 90% SENS 65%
DECT IS VALID AND RELIABLE
DUAL ENERGY CT- SEE CRYSTALS , NOT SENSITIVE LOWER EARLY ONSET
XRAY NOT MUCH COP
gout flare prevention
AVOID
ORGAN MEATS
HI FRUCTOSE CORN SYRUP
ALCOHOL OVERUSE >2 SERVINGS/DAY MALE , 1 SERVING /DAY FEMALE
LIMIT:
BEEF,LAMB PORK SHELLFISH SARDINES
ALCOHOL BEER RED WINE
ENCOURAGE
CHERRIES-not true
-NOT EBP EPOCRATES SAYS NO CHERRIES OR JUICE AS PER GUIDELINES
VEGETABLES
GOUT PHARM
ACUTE START RX ASAP
FIRST
NSAIDS
INDOMETHACIN 50 MG TID
ALL NSAIDS WORK , GIVE AT MAX DOSAGE
SECOND
COLCHICINE ( HIGH SAME AS LOW FOR EFFECT, START LOW)
AVOID IN RENAL FIALURE***LIVER FAILURE
COLCHICINE 1.2 MG THEN 0.6 MG THEN 0.6MG TO 1.2 MG DAILY
THIRD NOT TRUE CAN USE ANY OF 3
OCS
CAN USE ORAL OR IM DEPOMEDROL
MUST TAPER STEROIDS TO REDUCE RISK OF FLARES***
PREVENTATIVE OR CHRONIC GOUT PREVENTION
ULT
URATE LOWERING RX
ALLOPURINOL 100 MG /DAY- XANTHINE OXIDASE INHIBITORS
PROBENECID- NOT FOR RENAL FAILURE
interesting fact:Sexually transmitted infections, as a pharmacokinetic enhancer to prolong beta-lactam serum levels (adjunctive agent): as agent with cefoxitin in gonorrhea syphillis, pid
FEBUXOSTAT-uloric > risk cv death black box
DEFINIITION OF CHRONIC GOUT
2 OR MORE FLARES IN ONE YEAR
1 FLARE A YEAR IF CKD
HISTORY OF KDNEY STONES
START ALLOPURINAL 6-8 WEEKS AFTER FLARE RESOLVED, START LOW
INCREASE Q 4-6 WEEKLY
AIM: URATE LEVEL <6MG/DL
GERI
NO LOOP AND THIAZIDE > URIC ACID
USE LOSARTAN AND CCB- REDUCE GOUT
NOT OTHER ARBS ONLY LOSARTAN
INDOMETHACIN TOO STRONG FOR ELDERLY
USE GCS FOR THEM PO OR IM FIRST LINE
NSAIDS GI RENAL, HEART FAILURE
COLCHICINE RENAL/ LIVER
GOUT REFER
RHUEMATOLOGIST
TO DO THE JOINT ASP
DRUG TOXICITY OR INTOLERANCE
TOO MANY FLARES
DX NOT CONFIRMED
GOUT F/U
ACUTE
1 WEEK
CHRONIC
2 MONTHS
LOWER BACK PAIN
SPINAL SLIPPAGE
deifinition
spondylolisthesis (spinal slippage)
If the pain is only located at the low back, it is considered axial back pain
AXIAL ISthe part of the skeleton that consists of the bones of the head and trunk of a vertebrate. In the human skeleton, it consists of 80 bones and is composed of six parts; the skull (22 bones), also the ossicles of the middle ear, the hyoid bone, the rib cage, sternum and the vertebral column.
MECHANICAL - RADIATES INTO BUTTOCKS AND POSTERIOR THIGHS-IF FOLLOWS DERMATOME IT IS RADICULOPATHY-CONSIDER SPINAL NERVE COMPRESSION
LBP CAUSES
STRETCH/TEAR OF NERVE MUSCLE LIGAMENT, DISCS OR FASCIA OF BACK FROM TRAUMA OR CHRONIC STRESS
SX OF DEGERNATIVE DISC DX OR HERNIATION
USU L4-L5, L5-S1
ARTICLE ON PE AND DX TESTS
Observe the patient walking into the office or examining room
Observe the patient's sitting posture and look for any signs of discomfort, during the history-gathering portion of the visit
Observe how the patient removes his/her shoes
Observe the patient's standing posture
Measure blood pressure, pulse, respirations, temperature, height, and weight
Inspect the back for signs of asymmetry, lesions, scars, trauma, or previous surgery
Note chest expansion: If < 2.5 cm, this finding can be specific, but not sensitive, for ankylosing spondylitis
Take measurements of the calf circumferences (at midcalf). Differences of less than 2 cm are considered normal variation
Measure lumbar range of motion (ROM) in forward bending while standing (Schober test)
Neurologic examination should test 2 muscles and 1 reflex representing each lumbar root to distinguish between focal neuropathy and root problems
Measure leg lengths (anterior superior iliac spine to medial malleolus) if side-to-side discrepancy is suspected-CAN LEAD TO LBP
Use the inclinometer to measure forward, backward, and lateral bending. With the goniometer positioned over the head, measure trunk rotation
Palpate the entire spine to identify vertebral tenderness that may be a nonspecific finding of fracture or other cause of low back pain
Test for manual muscle strength in both lower extremities.
Test for sensation and reflexes
Imaging studies: Persistent pain may require computed tomography (CT) scanning, diskography, and 3-phase bone scanning
Electrodiagnostic studies: Electromyography (EMG) and nerve conduction studies (NCS) can aid in evaluating neurologic symptoms and/or deficits detected on examination
ARTICLE ON DX TESTS
If the history elicits reports of fever, night sweats, and chills that might suggest other causes for the low back pain, then, at a minimum, obtain a CBC count, erythrocyte sedimentation rate, and urinalysis to rule out cancer or infection. Serum and urine electrophoresis studies may help to rule out multiple myeloma at an early stage when radiographic imaging studies appear negative or inconclusive.
ARTICLE ON MGT GOALS
Management of mechanical low back pain can be outlined in the following 6 steps:
Control of pain and the inflammatory process
Restoration of joint ROM and soft tissue extensibility
Improvement of muscular strength and endurance
Coordination retraining
Improvement of general cardiovascular condition
Maintenance exercise programs
Surgical interventions for mechanical low back pain (LBP) are the last choice for treatment.
Pharmacological interventions for the relief of low back pain include acetaminophen, nonsteroidal anti-inflammatory drugs, topical analgesics, muscle relaxants, opioids, corticosteroids, antidepressants, and anticonvulsants.
LBP
ACUTENESS CLASSIFIER
<6 WEEKS
SUBACUTE 6/52 TO 3 MONTHS
CHRONIC >3 MONTHS
LBP MOST COMMON AREAS
L4
L5
S1
RED FLAGS
CAUDA EQUINA:
COMPRESSION OF MULTIPLE LUMBOSACRAL NERVE ROOTS
BLADDER DYSFUNCTION
PERINEAL SENSORY LOSS
NEUROLOGIC DEFICIT
LE WEAKNESS
CAUSES
VERTEBRAL FX
LONG TERM CCS, > 70, OP CANCER
INFECTION
FEVER >100.4
IV DRUG USER
SEVERE PAIN
LAMINECTOMY WIITHIN A YEAR
IMMUNOCOMPROMISED
CANCER RELATED
HAVE CANCER SX, WT LOOS, RECENT DX
FEMORAL NERVE STRETCH
L2 - L4
take pt leg bend it , put your hand under the knee and lift it off the bed
STRAIGHT LEG TEST
L5-S1
no higher than 60 degrees or false positive, then dorsiflex foot to confirm
CROSS STRAIGHT LEG-LUMBAR DISC PROTRUSION- LIFT UNAFFECTED LEG, WILL CAUSE SHOOTING PAIN IN AFFECTED LEG
SEATED SLUMP TEST
HERE IS STRAIGHT LEG TEST PASSIVE-DO NOT TENSE LEG
EXPERIENCE PAIN IN BUTTOCK,BACK OF THIGH, BACK AND LATERAL CALF AND CAN BE LATERAL FOOT -POSITIVE =SCIATICA
IF PAIN IS IN BACK ONLY, OR AT > 70 DEGREES THIS IS NEGATIVE TEST- JUST HAMSTRING MUSCLE
IF SCIATICA-DISC HERNIATION IS MOST COMMON CAUSE OF SCIATICA
TRIPOD TEST l5-s1
neuro exam LBP
L4 IS THIGH/KICK OUT BENT KNEE
L5 IS FOOT /HEEL TESTWALK/DORSI
S1 IS LATERAL FOOT/TOE TEST WALK/PLANTAR
MOTOR
BEND KNEE AND KICK OUT-TENSES QUADRICPS L4
COMPARE TO OPP SIDE
DORSIFLEX TOES AGAINST PRESSURE
PLANTAR FLEX AGINST PRESSUR
WALK ON HEELS,ONE FOOT DROPS
WALK ON TOES, ONE HEEL DROPS
SENSORY
MONOFILAMENT
L4- ANTERIOR LATERAL THIGH
L5- SPACE BETWEEN 1ST AND 2ND TOE
S1-LATERAL ASPECT OF FOOT. NUMBNESS
REFLEXES
L4 PATELLAR REFLEX
L5 HAMSTRING RELFEX INSIDE KNEE
S1 ACHILLES
FOOT ACROSS OTHER LEG
< DTR= MYOPATHIES, <MUSCLE MASS, NERVE ROOT IMPAIRMENT
> DTR = > THYROID, PYRAMIDAL TRACT DISEASE-UMN
LOW BACK STRAIN
HERNIATED DISC
MULTIPLE MYELOMA
OM
PROSTATITIS /PYELONEPHRITIS
CARCINOMA-BONY MET
MALINGERING
COMPRESSION FRACTURE
ANKYLOSING SPONDYLITIS
CAUDA EQUINA SYNDROME
LBP DIAGNOSTICS
NO XRAY
> 4-6 WEEKS:
LS ANTERIOR POSTERIOR AND LATERAL VIEWS
MRI ONLY FOR SEVERE PROGRESSIVE RADICULOPATHY AND NEURO DEFICITS
DO CT SCAN MRI
LABS CBC ESR SERUM CA++ ,ALK PHOS ( BONE) SERUM IMMUNOELCTROPHERESIS ? MULTIPLE MYELOMA
LBP NON PHARM
ICE -ACUTE
HEAT
REFER TO Physical therapyT EARLY 0-2 WEEKS low evidence
takes 6-8 weeks
TENS
CHIRO
ACUP-
lumbar support all low evidence
LIFESTYLE CHANGE ( WT LOSS)
BODY MECHANICS
AVOID BEDREST
shoe lifts insoles for leg length discrepancy
cbt
LBP PHARM
IBUPROFEN 600-800 Q 8 ( 3200 MG)
MELOXICAM 7.5-15 MG DAILY
CELECOXIB 200-400 DAILY
TYLENOL
MUSCLE RELAXANT -ONLY IN ACUTE PHASE
USE W NSAIDS
CYCLOBENZAPRINE/FLEXERIL 5-10 MG TID
?? TORADOL dcd in us ketorolac
SPRAINSTRAIN
DEFINITION AND RISK FACTORS
STRETCHING OR PARTIALTEAR OF LIGAMENTS-SPRAIN
MUSCLE INJURY-STRAIN
distinguishing between SPRAIN STRAIN IS DIFFICULT SO OFTEN CALLED SPRAIN/STRAIN
OFTEN ANKLE KNEE WRIST-SPRAIN
MOST COMMON HAMSTRING AND BACK -STRAIN
HAND IS FOOSH 0 FALL ON OUTSTRETCHED HAND
MOST SPORTS RELATED
MEN>FEM
85% ANKLE INJURY ARE SPRAINS
SPRAIN
ASST
PAIN
SWELLING
BRUISED
POP
DISCOMFORT W WEIGHT BEARING
DECREASED ROM =GR 1 OR 2
NO FOCAL POINT OF EXQUISITE PAIN
SPRAIN GRADE
knee anatomy pic
GR1 STRETCHING /MINIMAL TEAR STABLE JOINT
G2MORE SEVERE TEAR STABLE JOINT
G3 COMPLETE TEAR UNSTABLE JOINT
FRACTURE
DISLOCATION
TENINITIS OR TENDINOSIS
CARTILAGE INJURY ( NOT MUSCLE OR LIGAMENT)
Ligaments and tendons are body tissues that are essential to our movement. Ligaments are fibrous connective tissue that connect bones to bones and serve to hold structures together, while tendons are fibrous connective tissue that attach muscles to bone or other body structures.
DIAGNOSTICD
XRAY
SPRAIN MGT
CONTROL PAIN
MINIMIZE SWELLING
MAINTAIN /REGAIN ROM:
PRICE**
PREVENT FURTHER INJURY
REST 48-72 HOURS NWB-CRUTCHES
ICE-20 MINUTES PER HOUR FIRST 24-48 HOURS
COMPRESSION OF AFFECTED AREA WRAP WITH ACE
ELEVATION-INJURED JOINT ABOVE HEART LEVEL
IMMOBILIZE- SLING OR SPLINT. AIR CAST
HEAT > 48 HOURS 20 MIN/HOUR 4 X DAY
SUPPORTIVE DEVICE , CRUTCHES WHILE NWB- AIR CASTS WHEN WB
REFER TO ORTHO FOR GRADE 3
OR NO IMPROVEMENT FOR 3 WEEKS
RECOVERY DEPENDS ON INJURY SEVERITY
SPRAIN F/U
ACUTE PHSE 1-3 DAYS
RECOVERY 2-6 WEEKS
F/U* 2 WEEKS
EVAL FOR PAN SWELLING AND WB ABILITY
EDUCATE ON PREVENTION
SPRAIN STRAIN RED FLAG
TOO MUCH ROM SEVERE TEAR OR RUPTURE OF LIGAMENT
SPRAIN PREVENTION
PRPER SHOE FIT
WARM UP EXERCISES
SUPPORTIVE DEVICE/ORHTOTIC BRACE/TAPE
fractures
SPIRAL -FRACTURE SPIRALS AROUND BONE
COMMINUTED -BONE SHATTERS INTO 3 OR MORE PIECES
OPEN -THROUGH SKIN
FRACTURES ;
CLINICAL PRESENTATION
PAIN PREVENTS MOVEMENT
PAIN STOPS WEIGHT BEARING
-POINT TENDERNESS
BRUISING
DEFORMITY
TAKE A GOOD HISTORY
FRACTURES
TREATMENT IN PRIMARY CARE
IMMOBILIZE
ORTHO
osteoporosis
DEFINITION
INCREASED BONE FRAGILITY LEADING TO HIGHER FRACTURE RISK
OP
RISK FACTORS
AGEING
50 % WOMEN +
20 % MEN 50 YO AND ABOVE WILL GET OP FRACTURE???? whats the other 30%???
ESTROGEN 80% WOMEN ESP 65 +>
RX FOR RA -GLUCOCORTICOIDS
WHITE PEOPLE /ASIANS
LESS COMMON BLACK /HISPANIC
SMALL BODY FRAME
CAL/VIT D DEFICIENCY
SEDENTARY LIFESTYLE
CAUSATIVE DRUGS
CCS
THYROID SUPPLEMENTS
ANTICONVULSANTS
AROMATASE INHIBITORS: BREAST CANCERS RX- ANASTRAZOLE
EXEMESTANE
FEMARA /LETROZOLE
PATHO
bone remodelling- AWAYS HAPPENING
BONE REMODELLING RELIES ON USING CALCIUM STORES IN THE BONE WITHOUT COMPROMISING BONE INTEGRITY
OSTEOBLASTS FORM BONE
OSTEOCLASTS BREAK BONE DOWN
SMOKING
ALCOHOL ABUSE
CCS BREAK DOWN BONE
BONE MINERAL DENSITY LOSS
OP DIAGNOSIS
DIAGNOSIS
DXA SCAN GOLD STANDARD
WHO CRITERIA 2003
T SCORE
REFERENCE IS SD DIFFERENCE BETWEEN PT BMD AND A YOUNG ADULT
FRAX IS FRACTURE RISK ASSESSMENT TOOL USES BONE MINERAL DENSITY (BMD) OF FEMORAL NECK MEASURED BY DXA
OP CLINICAL PRESENTATION
PAINLESS DOWAGER HUMP-DORSAL KYPHOSIS
HEIGHT LOSS
STOOPED POSTURE
BACK PAIN
FRACTURES COMMON IN VERTEBRAE HIP OR WRIST
OP DIFF DX
YOUNGER AGE GROUP - PRE MENOPUSAL AND MEN<50
RULE OUT:
CANCERS : BLOOD,LEUKEMIA, MYELOMAS, MELANOMAS, METS
METABOLIC/GENETIC;HOMOCYSTINURIA ( GENETIC)
SICkLE,PAGETS , HYPERPARA THYROID
SCURVY
VIT D- REVERSIBLE
AVASCULAR HIP NECROSIS
DIAG TESTING
MEASURE HEIGHT
LABS R/O:
TSH
SERUM CALCIUM
25-HYDROXYVITAMIN D
PARATHYROID HORMONE??
CBC
CHEM
DXA SCORE-WHO
NORMAL BMD VALUE WITHIN 1.0 SD OF YOUNG ADULT MEAN YAM
T SCORE > OR =TO -1.0 SD
OSTEOPENIA -LO BONE MASS
BMD VALUE >1.0 BUT LESS THAN 2.5 BELOW SD OF YAM
T SCORE <-1.0 OR >-2.5 SD
OSTEOPOROSIS
BMD VALUE 2.5 OR > SD BELOW YAM
T SCORE <OR= -2.5 SD
SEVERE OSTEOPOROSIS
SAME T SCORE BUT WITH 1 OR MORE FRACTURES
LOOK AT
SPINE
TOTALHIP
FEMORAL NECK
DXA Z SCORE
BMD TO AGE MATCHED POP
Z SCORE -2 OR LOWER ( i think this means > -2 eg -4. BAD
IF Z SCORE -2 OR LOWER IS IT CCS OR ALCOHOL
ISCD INTERNATIONAL SOCIETY FOR CLINICAL DENSITOMETRY
POST MENOPAUSAL WOMEN AND MEN
FRAX SCORE
FRAX SCORE CALCULATES 10 YEAR PROBABILITY OF MAJOR OP FRACTURE
IF PT DX WITH OP -DECISION TO TREAT
PREVENTION
ADEQUATE CALCIUM BETTER THAN SUPPLEMENTS
CA 100-2000MG(1200 UTD) DAY( ONLY ABSORB 500 MG CALCIUM SO SPLIT IT UP)
VITAMIN D 1000-1200 MG( 600-800 IU ) DAILY (4000 IU -UTD)
HYPOGONADISM MEN - TESTOSTERONE TO CORRECT DEFICIENT HORMONE LEVELS
REGULAR WIEGHT BEARING EXERCISE
DAIRY
DARK LEAFY AND GREEN VEG
OP NON PHARM
SAME AS PREVENTION
ADD
PHYSICAL THERAPY
KYPHOPLASTY
VERTEBROPLASTY
ANYONE WITH HIP FRAGILITY FRACTURE
BIOPHOSPHONATES 3-5 YEARS- MOA INHIBIT OSTEOCLASTIC BONE RESORPTION
FOSAMAX/ALENDRONATE 10 MG QD OR 70 MG WEEKLY
PREVENTION: 5 MG DAILY OR 35 MG WEEKLY
DONT USE FOR GERD PTS
IBANDRONATE ( OLD BONIVA -PULLED BY ROCHE) 2.5 MG QD OR 50 MG Q MONTHLY
PREVENTION SAME DAILY OR 30 MONTHLY
CALCIUM PHOSPHATE /POSTURE D 1-2 TABS QD -BETTER FOR GI TRACT ISSUES
TAKE ON EMPTY STOMACH, UPRIGHT FOR 30 MINS
OP PHARM CONTD
BIOPHSOPHANATES
RISENDRONATE /ACTONEL 5 MG PT Q D OR 75 MG MONTH .PREVENTION DOSE SAME
RECLAST ZOLEDRONIC ACID IV YEARLY-
SUPPLEMENT WITH CA 500 MG 3 X DAYY AND VITAMIN D 1000IU
WELLHYDRATED
OP CALCIUM
TUMS ULTRA 400 MG TID
CA CITRATE 315 MG CALCIUM + 200 IU D
POSTURE D
OP PHARM
SERMS
BIND TO ESTROGEN RECEPTORS
PREVENT VERTEBRAL FRACTURES IN POST MENOPAUSE
UNSAFE IN PREGNANCY
RALOXIFENE/VERTEBRA
POLYPEPTIDE LAST RESORT
CALCITONIN -SALMON MIACALCIN NASAL SPRAY -CAN REDUCE CANCER RISK -NOT FOR PRE MENOPAUSAL
MAB
POST MENOPAUSE HGIH RISK
INHIBITS BONE RESORPTION
PROLIA /DENOSUMAB- 6 MONTHLY INJECTIONS OF 60 MG SQ
5 YEARS-UGI PAIN AND MS PAIN
F/U OP
ONE MONTH AFTER BIOPHOSPHONATE
CHECK VIT D AND CA LEVELS
SERUM OSTEOCALCIN AND ALK PHOS ONLY IF SUSPECT ANOTHER DX
NO REAL REFERRAL UNLESS SECONDARY- TREAT UNDERLYING
OP GERI
YEAR 1 AFTER HIP FX >10-20 % MORTALITY. MEN HIGHTER
CARPAL TUNNEL
ENTRAPMENT NEUROPATHY OF MEDIAN NERVE
CTS CAUSES
REPETITVE MOVMENT
PREGNANCY
ARTHRITIS
DM
HTN
LOW THYROID
CTS PRESENTATION
THUMB 1 2 AND MEDIAL HALF 3 PINKKY SPARED
CTS
PHYSICAL EXAM
FLICKS SIGN
HYPOALGESIA 2 POINT DISCRMINATION TEST
SQUARE WRIST SIGN
THUMB ABDUCTION WEAKNESS
PHALENS TEST
TINELS SIGN
CERVICAL RADICULOPATHY- FINGERS
C6 THUMB AND INDEX
C 7 INDEX+ MIDDLE FINGER
C8 ( NERVE ROOT -NO C 8 DISC) 4 + 5 FINGERS
CTS DIAGNOSITC
H&P
X RAY CARPAL TUNNELL SERIES
LABS
ELECTROMYOGRAPHY AND NERVE CONDUCTION STUDIES
CTS NON PHARM
SPLINTWRIST - CAN BUY ONLINE
PHYSICAL THERAPY USS RX
REST
WORK HOME MODIFICATION
ICE
CTS PHARM
STEROIDS
ORAL
INJECTION- HAND SPECIALIST
SURGERY
CARPAL TUNNEL RELEASE
CTS F/U
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