MUSCULOSKELETAL PA RT I QUESTION #1 A 63yo fe ma le pre se nts - - PowerPoint PPT Presentation

PA RT I

MUSCULOSKELETAL

QUESTION #1

a . Ba c te ria l infe c tio n b . Crysta l de po sitio n c . We a r a nd te a r

• d. Vira l infe c tio n

e . Auto a ntib o die s A 63yo fe ma le pre se nts with b o ny swe lling in he r dista l inte rpha la ng e a l jo ints witho ut e rythe ma . He r pro xima l inte rpha la ng e a l jo ints, ha nds, a nd wrists a re no rma l. Wha t is the unde rlying c a use o f he r c o nditio n?

QUESTION #1

a . Ba c te ria l infe c tio n- se ptic arthritis b . Crysta l de po sitio n- go ut and pse udo go ut c . We a r a nd te a r- o ste o arthritis

• d. Vira l infe c tio n- transie nt arthralgia/

arthritis

e . Auto a ntib o die s- rhe umato id arthritis A 63yo fe ma le pre se nts with b o ny swe lling in he r dista l inte rpha la ng e a l jo ints witho ut e rythe ma . He r pro xima l inte rpha la ng e a l jo ints, ha nds, a nd wrists a re no rma l. Wha t is the unde rlying c a use o f he r c o nditio n?

WHY CAN WE RULE OUT GOUT/ PSEUDOGOUT?

• T

he jo ints a re usua lly swo lle n, pa inful, a nd re d in the se c o nditio ns

HOW DO WE DIFFERENTIATE BETWEEN RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS?

• T

he re is usua lly no re dne ss o r te nde rne ss o f jo ints in

• ste o a rthritis
• Rhe uma to id a rthritis c a n pre se nt with swe lling o f jo ints,

b ut re dne ss is no t a lwa ys se e n

OSTEOARTHRITIS

• Who : E

lde r ly (usua lly >60yo ),

• b e se , tho se with tra uma to

a jo int, wo me n

• Wha t: No n-infla mma to ry

b o ne dise a se invo lving

de ge ne r ation of ar tic ular c ar tilage

• Whe re : Hip, kne e , c e rvic a l

a nd lumb a r ve rte b ra e , DIP

and PIP

• Why: Ne xt slide
• Ho w (to dia g no se ): I

ma g ing

Othe r fa c ts

• Mo st c o mmo n type o f

a rthritis

• E

nla rg e me nt o f DI Ps= He rb e de n’ s no de s

• E

nla rg e me nt o f PI Ps= Bo uc ha rd’ s no de s

• Pa in in jo ints a fte r use
• Ca rtila g e lo ss usua lly

b e g ins o n the me dia l side

THE “WHY” OF OSTEOARTHRITIS

• T

he me c ha nic a l tra uma le a ds to de g ra da tio n o f a rtic ula r c a rtila g e *

• Co mpo ne nts o f c a rtila g e :

pro te o g lyc a ns a nd type I I c o lla g e n

F inding s

• F

ra ying o f c a rtila g e (“jo int mic e ”)

• E

bur nation (e ro sio n o f

• ve rlying c a rtila g e à

po lishe d a ppe a ra nc e o f b o ne )

• Oste ophyte fo rma tio n

(re a c tive b o ne fo rma tio n)

• Sub c ho ndra l c ysts
• NO ANKYL

OSIS (fusio n)

1) E b urna tio n 2) Sub c ho ndra l c yst 3) No rma l a rtic ula r c a rtila g e

OSTEOARTHRITIS

Bo uc ha rd no de (PI P) He b e rde n no de (DI P)

RHEUMATOID ARTHRITIS

• Who : Wome n 20-50yo
• Wha t: Chro nic , autoimmune

syste mic dise a se (T ype I I I )

• Whe re : symme tric MCP and

PIP jo ints, wrists, e lb o ws,

a nkle s, kne e s

• Why: Ne xt slide
• Ho w (to dia g no se ): b a se d
• n c linic a l pre se nta tio n a nd

la b finding s

• Ca n inc lude r

he umatoid fac tor,

a nti-CCP , a ntinuc le a r a ntib o dy

Othe r fa c ts

• Asso c ia tio n with HL

A- DR4

• E

xtr a-ar tic ular manife stations

• Ple ura l/ pe ric a rdia l e ffusio ns
• Pulmo na ry fib ro sis
• Ane mia o f c hro nic dise a se
• Rhe umatoid nodule s
• E

xte nso r surfa c e o f the fo re a rm, lung s

• Ce ntra l ne c ro sis surro unde d b y

histio c yte s

• F

e ve r , ma la ise , we ig ht lo ss

• Ba ke r’ s c yst
• Swe lling o f b ursa b e hind kne e

THE “WHY” OF RHEUMATOID ARTHRITIS

• I

nitia l inc iting a g e nt (virus? )

à B c e ll a c tiva tio nà

a uto a ntib o die sà immune c o mple x de po sitio nà c hro nic syno vitis a nd pa nnus fo rma tio nà a nkylo sis

Jo int F inding s

• Ulna r de via tio n o f fing e rs
• Usua lly po lya rtic ula r
• Mor

ning stiffne ss (usua lly

>30 minute s tha t impro ve s with use )

• Swa n ne c k de fo rmity
• PI

P hype re xte nds while DI P fle xe s no rma lly

X-Ra y: Jo int-spa c e na rro wing ,

• ste o pe nia , ulna r

de via tio n o f fing e rs

RHEUMATOID ARTHRITIS

Swa n-ne c k de fo rmity (fle xio n o f DI P , hype re xte nsio n

• f PI

P)

COMPARISON

Oste oar thr itis Rhe umatoid ar thr itis Inc ide nc e

E lde rly, wo me n>me n Wo me n o f c hildb e a ring a g e

F r e que nt site s

We ig ht-b e a ring jo ints; DI P a nd PI P Symme tric invo lve me nt; PI P a nd MCP

E tiology

Me c ha nic a l injury Auto immune (type I I I )

1° site of de str uc tion Artic ula r c a rtila g e

Syno via l fluid

Notable fe atur e s

Oste o phyte s; jo int mic e ; e b urna tio n RF ; syste mic sympto ms; HL A-DR4

T r e atme nt

NSAI Ds, T yle no l, he a t, visc o supple me nta tio n (hya luro nic a c id inje c tio ns), intra -a rtic ula r g luc o c o rtic o ids, jo int re pla c e me nt NSAI Ds, c o rtic o ste ro ids, dise a se -mo difying a g e nts (e .g . me tho tre xa te ), b io lo g ic a l a g e nts (e .g . T NF

• a lpha inhib ito rs)

QUESTION #2

A 45yo wo ma n pre se nts with swe lling , stiffne ss, a nd pa in invo lving multiple jo ints, e spe c ia lly in he r ha nds. Sympto ms b e g a n 6-7 mo nths prio r a nd ha ve le d to sig nific a nt re stric tio n o f he r da ily a c tivitie s. She e xpe rie nc e s pro lo ng e d mo rning stiffne ss a nd g e ne ra lize d fa tig ue . T yle no l a nd ib upro fe n ha ve pro vide d o nly minima l re lie f. Whic h o f the fo llo wing drug s wo uld pro vide mo st ra pid a nd c o mple te re lie f o f he r sympto ms?

• F

irst, is this o ste o arthritis o r rhe umato id arthritis?

QUESTION #2

A 45yo wo ma n pre se nts with swe lling , stiffne ss, a nd pa in invo lving multiple jo ints, e spe c ia lly in he r ha nds. Sympto ms b e g a n 6-7 mo nths prio r a nd ha ve le d to sig nific a nt re stric tio n o f he r da ily a c tivitie s. She e xpe rie nc e s pro lo ng e d mo rning stiffne ss a nd g e ne ra lize d fa tig ue . T yle no l a nd ib upro fe n ha ve pro vide d o nly minima l re lie f. Whic h o f the fo llo wing drug s wo uld pro vide mo st ra pid a nd c o mple te re lie f o f he r sympto ms? a . Co lc hic ine b . Me tho tre xa te c . Pre dniso ne

• d. Sulfa sa la zine

e . Mino c yc line

QUESTION #2

A 45yo wo ma n pre se nts with swe lling , stiffne ss, a nd pa in invo lving multiple jo ints, e spe c ia lly in he r ha nds. Sympto ms b e g a n 6-7 mo nths prio r a nd ha ve le d to sig nific a nt re stric tio n o f he r da ily a c tivitie s. She e xpe rie nc e s pro lo ng e d mo rning stiffne ss a nd g e ne ra lize d fa tig ue . T yle no l a nd ib upro fe n ha ve pro vide d o nly minima l re lie f. Whic h o f the fo llo wing drug s wo uld pro vide most r

apid a nd c o mple te

re lie f o f he r sympto ms? a . Co lc hic ine - fo r ac ute go ut b . Me tho tre xa te - pre fe rre d in mo de rate o r se ve re RA but

take s we e ks

c . Pre dniso ne - c o rtic o ste ro id

• d. Sulfa sa la zine - fo r mild, e arly se ro ne gative RA

e . Mino c yc line - fo r mild, e arly se ro ne gative RA

QUICK REVIEW: METHOTREXATE

• I

nhib its dihydro fo la te re duc ta se

• Side e ffe c ts to

kno w:

mye losuppr e ssion,

fa tty live r (AL T / AST e le va tio ns),

muc ositis (pa inful

mo uth ulc e rs), te ra to g e nic

Me tho tre xa te

QUESTION #3

A 35 yo ma n c o me s in c o mpla ining o f se ve re le ft hip pa in tha t is te rrib le whe n he a wa ke ns b ut impro ve s thro ug ho ut the da y. He a lso ha s o c c a sio na l swe lling o f his ha nds a nd fing e rs. On physic a l e xa m, yo u no tic e a g ra y, dry sc a ly ra sh o n his knuc kle s a nd e lb o ws. X-ra ys o f his lumb a r spine a nd hips sho w sa c ro iliitis o n the le ft side . Ha nd X-ra ys sho w se ve re e ro sio ns o f the DI P jo ints o n the rig ht. He is HL A-B27 po sitive . Wha t is the mo st stro ng ly a sso c ia te d c o nditio n?

a . Re ite r’ s syndro me b . Budd-c hia ri syndro me c . Sjo g re n syndro me

• d. Re ye ’ s syndro me

e . Go o dpa sture ’ s dise a se

QUESTION #3

A 35 yo ma n c o me s in c o mpla ining o f se ve re le ft hip pa in tha t is te rrib le whe n he a wa ke ns b ut impro ve s thro ug ho ut the da y. He a lso ha s o c c a sio na l swe lling o f his ha nds a nd fing e rs. On physic a l e xa m, yo u no tic e a g ra y, dry sc a ly ra sh o n his knuc kle s a nd e lb o ws. X-ra ys o f his lumb a r spine a nd hips sho w sa c ro iliitis o n the le ft side . Ha nd X-ra ys sho w se ve re e ro sio ns o f the DI P jo ints o n the rig ht. He is HL A-B27 po sitive . Wha t is the mo st stro ng ly a sso c ia te d c o nditio n?

a . Re ite r’ s syndro me b . Budd-c hia ri syndro me c . Sjo g re n syndro me

• d. Re ye ’ s syndro me

e . Go o dpa sture ’ s dise a se

SERONEGATIVE SPONDYLOARTHROPATHIES [“PAIR”]

What the y all have in c ommon: no RF

, a sso c ia tio n with HL A-B27, M>F , a xia l ske le to n invo lve me nt

• Psor

iatic ar thr itis

• Sa usa g e -sha pe d DI

P jo ints

• “pe nc il-in-c up” x-ra y
• Asymme tric , pa tc hy invo lve me nt
• Ankylosing spondylitis
• Sa c ro ilia c jo ints/ spine infla mma tio n
• Ankylo sis (“b a mb o o spine ”)
• Ca n’ t b e nd fo rwa rd
• Re stric tive lung dise a se
• Also uve itis, a o rtic re g urg ita tio n
• IBD + ar

thr itis/ spondylitis

• Re ite r

’s syndr

• me (r

e ac tive ar thr itis)

• Po st GI

(S

hige lla, S almo ne lla, Ye rsinia, Campylo bac te r) o r po st-c hla mydia infe c tio n

• “Ca n’ t se e , c a n’ t pe e , c a n’ t c limb a

tre e ” (c o njunc tivitis/ uve itis, ure thritis, a rthritis)

QUESTION #4

A 64 yo Ca uc a sia n ma le with re pe a te d e piso de s o f a nkle a rthritis no tic e s a no dule ne a r his rig ht kne e jo int. Bio psy re ve a ls ma ny infla mma to ry c e lls tha t a re ne g a tive ly b ire fring e nt unde r po la rize d lig ht. T he c rysta ls mo st like ly re pre se nt: a . Uric a c id b . Ca lc ium o xa la te c . Ca lc ium pyro pho spha te

• d. Mo no so dium ura te

e . Ca lc ium hydro xya pa tite

+ b ire fring e nc e = ___________whe n pa ra lle l

• b ire fring e nc e =___________ whe n pa ra lle l

GOUT

Ne e dle -sha pe d mo no so dium ura te c rysta ls Rho mb o id-sha pe d c a lc ium pyro pho spha te de hydra te (CPPD) Ne g a tive b ire fring e nc e Po sitive b ire fring e nc e Jo int is pa inful, swo lle n, a nd re d Asso c ia te d with he mo c hro ma to sis, he mo side ro sis,1° hype rpa ra thyro idism Asso c ia te d with L e sc h- Nyha n, le uke mia , re na l insuffic ie nc y, Vo n Gie rke ’ s dise a se Crysta l upta ke b y ne utro philsà fre e ra dic a l re le a se , c yto kine pro duc tio n, a nd infla mma to ry re spo nse Ca n b e ra dio pa q ue Ra dio luc e nt Rx fo r a c ute : NSAI Ds, ste ro ids, c o lc hic ine

PSEUDGOUT

QUESTION #5

A 35yo ma le with a histo ry o f pe ptic ulc e rs de ve lo ps sudde n

• nse t pa in, swe lling , a nd re dne ss o f his 1st rig ht

me ta ta rso pha la ng e a l jo int. Ne e dle a spira tio n sho ws ne e dle - sha pe d, ne g a tive ly b ire fring e nt c rysta ls. (Sto p he re …g o ut o r pse udo g o ut? ) He is pre sc rib e d a me dic a tio n, b ut c a lls yo u b a c k in o ne da y sa ying he de ve lo pe d na use a , vo miting , a nd dia rrhe a . Wha t is the me c ha nism o f a c tio n o f the drug pre sc rib e d? a . I nhib it mic ro tub ule fo rma tio n b . I nhib it xa nthine o xida se c . I nhib it re a b so rptio n o f uric a c id in pro xima l c o nvo lute d tub ule

• d. I

nhib it c yc lo o xyg e na se e . I nhib it T NF

• a lpha

QUESTION #5

A 35yo ma le with a histo ry o f pe ptic ulc e rs de ve lo ps sudde n

• nse t pa in, swe lling , a nd re dne ss o f his 1st rig ht

me ta ta rso pha la ng e a l jo int. Ne e dle a spira tio n sho ws ne e dle - sha pe d, ne g a tive ly b ire fring e nt c rysta ls. He is pre sc rib e d a me dic a tio n, b ut c a lls yo u b a c k in o ne da y sa ying he de ve lo pe d na use a , vo miting , a nd dia rrhe a . Wha t is the me c ha nism o f a c tio n o f the drug pre sc rib e d? a . I nhib it mic ro tub ule fo rma tio n- c o lc hic ine b . I nhib it xa nthine o xida se - allo purino l c . I nhib it re a b so rptio n o f uric a c id in pro xima l c o nvo lute d tub ule - pro be ne c id

• d. I

nhib it c yc lo o xyg e na se - NS

AI Ds

e . I nhib it T NF

• a lpha - e tane rc e pt, infliximab

TREATMENT OF GOUT

• Ac ute g o ut a tta c ks
• NSAIDs ar

e 1st line

• Colc hic ine is 2nd line (due to GI

side e ffe c ts)

• Binds tub ulin, inhib iting po lyme riza tio n whic h impa irs le uko c yte

mig ra tio n a nd pha g o c yto sis

• Re c o mme nde d fo r tho se who c a n’ t ta ke NSAI

Ds

• Gluc oc or

tic oids if NSAI

Ds a nd c o lc hic ine c o ntra indic a te d (e .g . re na l fa ilure )

• Chro nic - c o ntra indic a te d in in a c ute g o ut
• Allopur

inol

• inhib its xa nthine o xida se , de c re a sing c o nve rsio n o f xa nthine to uric

a c id

• F

e b uxo sta t

• inhib its xa nthine o xida se
• Pr
• be ne c id
• inhib its re a b so rptio n o f uric a c id in PCT

QUESTION #6

A mo the r b ring s he r 3yo so n to the physic ia n fo r a n a nnua l c he c k-up. T he do c to r no te s tha t the c hild ha s ha d 5 b o ne fra c ture s, 3 o f whic h re sulte d fro m minima l tra uma . He r pre g na nc y wa s no rma l. T he c hild ha s b e e n in the 50th pe rc e ntile fo r b o th he ig ht a nd we ig ht sinc e b irth. On e xa m, this is a ple a sa nt c hild with no rma l sta ture , sma ll te e th, a nd no b ruising . His e ye s a ppe a r a s b e lo w. Wha t is the prima ry impa irme nt? a . E ndo c ho ndra l o ssific a tio n b . Bo ne ma trix fo rma tio n c . E piphyse a l va sc ula r supply

• d. I

ntra me mb ra no us o ssific a tio n e . No thing b e c a use this is c hild a b use

OSTEOGENESIS IMPERFECTA

• “Brittle b o ne dise a se ”
• Mo st c o mmo n: Auto so ma l do mina nt, de fic ie nc y/

abnor mality with type 1 c ollage nà b o ne ma trix

fo rma tio n impa irme nt

• T

ype 1 c o lla g e n in b o ne s, te e th, lig a me nts, skin, a nd sc le ra

• Usua lly g ive s fle xib ility to b o ne
• Clinic a l finding s
• Pa tho lo g ic fr

ac tur e s (Mimic s c hild a b use , b ut no b ruising )

• Blue sc le r

a (a c tua lly se e ing unde rlying c ho ro ida l ve ins due to

thinning o f c o lla g e n)

• He ar

ing loss (middle e a r b o ne s a re a b no rma l/ fra c ture e a sily)

• De nta l pro b le ms (la c k o f de ntin)
• T

re a tme nt: b ispho spho na te s to inc re a se mine ra liza tio n

QUESTION #7

A 24 ye a r o ld Afric a n Ame ric a n fe ma le pre se nts with c o nsta nt le ft hip pa in e xa c e rb a te d b y we ig ht-b e a ring b ut a lso pre se nt a t re st. She ha s a histo ry o f a c ute c he st syndro me a nd pne umo c o c c a l pne umo nia . He r vita l sig ns a re liste d b e lo w. T he re is re stric tio n o f mo ve me nt a t the le ft fe mo ra l jo int, witho ut re dne ss o r wa rmth. Wha t is the mo st like ly c a use o f pa in?

a . Oste o mye litis b . Oste o po ro sis c . Pa g e t’ s dise a se

• d. Ava sc ula r ne c ro sis

e . Oste o c ho ndritis disse c a ns

T e mpe ra ture : 99 F BP: 110/ 65 Pulse : 110 Re spira tio ns: 15

AVASCULAR (ASEPTIC) NECROSIS

• Mo st c o mmo n lo c a tio n:

fe mor al he ad

• I

nfa rc tio n o f b o ne a nd ma rro w due to impa ire d b lo o d supply

• Mo st c o mmo n c a use :

tra uma o r fra c ture

• Also a sso c ia te d with
• Sic kle c e ll dise a se
• Alc oholism
• L
• ng -te rm c or

tic oste r

• id use
• De c o mpre ssio n sic kne ss

(Ca isso n dise a se )

• Dia g no sis: MRI

mo st se nsitive

Pre se nta tio n: Gro in pa in wo rse ne d b y we ig ht b e a ring ; pa inful, re stric te d pa ssive a nd a c tive mo ve me nt, no swe lling o r e rythe ma

QUESTION #8

An 80yo ma le pre se nts with b o ne pa in a nd c ha ng e s in fa c ia l fe a ture s. He ha s ha d pro g re ssive de fo rmitie s o f his le g s a nd a rms with c hro nic , diffuse b o ny pa in. L a b studie s sho w e le va te d a lka line pho spha ta se a nd urine hydro xypro line . X-ra ys sug g e st Pa g e t dise a se . Wha t is the po ssib le unde rlying me c ha nism?

a . Ge ne ra lize d re duc tio n in b o ne ma ss b . Ge ne tic de fic ie nc y o f c a rb o nic a nhydra se I I c . Pa ra myxo virus infe c tio n o f o ste o c la sts

• d. Mo no c lo na l pro life ra tio n o f pla sma c e lls

e . Ove rpro duc tio n o f g ro wth ho rmo ne

QUESTION #9

An 80yo ma le pre se nts with b o ne pa in a nd c ha ng e s in fa c ia l fe a ture s. He ha s ha d pro g re ssive de fo rmitie s o f his le g s a nd a rms with c hro nic , diffuse b o ny pa in. L a b studie s sho w e le va te d a lka line pho spha ta se a nd urine hydro xypro line . X-ra ys sug g e st Pa g e t dise a se . Wha t is the po ssib le unde rlying me c ha nism?

a . Ge ne ra lize d re duc tio n in b o ne ma ss- o ste o po ro sis b . Ge ne tic de fic ie nc y o f c a rb o nic a nhydra se I I

• ste o pe tro sis

c . Pa ra myxo virus infe c tio n o f o ste o c la sts

• d. Mo no c lo na l pro life ra tio n o f pla sma c e lls- multiple

mye lo ma

e . Ove rpro duc tio n o f g ro wth ho rmo ne - ac ro me galy

PAGET DISEASE

AKA OSTEITIS DEFORMANS

• Who : Prima rily middle -

a g e d to e lde rly ma le s

• Wha t: Inc r

e ase d

• ste oc last and
• ste oblast ac tivityà

diso rg a nize d b o ne re mo de ling à mosaic

bone patte r n tha t

fra c ture s e a sily

• Whe re : spine , pe lvis,

skull, fe mur , tib ia

• Why: re c e nt te c hniq ue

sho ws par

amyxovir us in

• ste oc lasts o f a ffe c te d

b o ne s, b ut still unkno wn

• Ho w (to dia g no se ):

ra dio lo g y

Boar d F avor ite

PAGET DISEASE

• Clinic a l fe a ture s
• Bo ne pa in
• Inc r

e asing hat/ shoe size

• He a ring lo ss
• E

le vate d alk phosp (no rma l Ca , PT

H, pho spho rus)

• L

io n-like fa c ie s

• Co mplic a tio ns
• Hig h-o utput c a rdia c fa ilure
• AV shunts within va sc ula r le sio ns
• Oste osar

c oma

A QUICK NOTE ON SOME THE OTHER ANSWERS…

• Oste ope tr
• sis: “ma rb le b o ne dise a se ”
• po o r o ste o c la st func tio nà thic k, de nse

b o ne s

• Ofte n muta tio n in c a rb o nic a nhydra se I

I

• X-ra y: b o ne -in-b o ne a ppe a ra nc e , ve ry

de nse (b rig ht white )

• Sx: b o ne fra c ture s, pa nc yto pe nia , b lindne ss,

de a fne ss, hydro c e pha lus

• Rx: b o ne ma rro w tra nspla nt
• Ac r
• me galy
• Ove rpro duc tio n o f g ro wth ho rmo ne
• Big he a d, ha nds, fe e t
• Hype rte nsio n, 2° dia b e te s, c a rdio me g a ly,
• ste o po ro sis

OSTEOPOROSIS

• De c re a se d tra b e c ula r b o ne ma ss a nd de nsity
• Due to lo ss o f o rg a nic b o ne ma trix a nd mine ra ls
• Wo me n > me n
• re la te d to pe a k b o ne ma ss
• Nor

mal lab value s (c a lc ium, pho spha te , PT

H, a lk pho spha ta se )

• X-ra y: diffuse ra dio luc e nc y o f b o ne
• Pro ne to ve r

te br al c r ush fr ac tur e s

• Ac ute pa in, sho rte ne d sta ture , kypho sis
• Ma y b e prima ry o r se c o nda ry
• Se c o nda ry c a use s: hype rc o rtiso lism, hype rthyro idism, a no re xia

ne rvo sa

PRIMARY OSTEOPOROSIS

Postme nopausal

• De c re a se d e stro g e n le a ds

to inc re a se d b o ne re so rptio n

• Asso c ia tio ns: fe mo ra l ne c k

fra c ture , Co lle s’ fra c ture s Se nile

• De c re a se d a b ility o f
• ste o b la sts to divide /

pro duc e o ste o id

• Usua lly se e n in >70 yo

Pr e ve ntion

We ig ht-b e a ring e xe rc ise , a de q ua te Vit D a nd Ca lc ium, smo king c e ssa tio n

T r e atme nt

Bispho spho na te s E stro g e n re pla c e me nt is de b a ta b le

RISK FACTORS FOR OSTEOPOROSIS

Menopause SUCKS

Ca uc a sia n fe ma le Smo king Physic a l ina c tivity Co rtic o ste ro id the ra py Alc o ho l Me no pa use

CHART COMPARING BLOOD CHEMISTRIES IN BONE DISEASE

Calc ium Phosphate PT H Alk Phosph

Oste o po ro sis no rma l no rma l no rma l No rma l Pa g e t dise a se No rma l No rma l No rma l

é

Oste o pe tro sis

ê

no rma l no rma l

é

Oste o ma la c ia / Ric ke ts*

ê ê é é

Vo n Re c kling ha use n dise a se **

é ê é é

*Vit D de fic ie nc yà de c re a se d c a lc iumà inc re a se d PT H à de c re a se d pho spha te ; hype ra c tivity o f o ste o b la stsà inc re a se d a lka line pho sph **a lso kno wn a s o ste itis fib ro sa c ystic a : wide spre a d o ste o lytic le sio ns due to hype rpa ra thyro idism, c a n ma nife st a s b ro wn tumo rs a nd diffuse ra dio luc e nc y o f b o ne

QUESTION #9

A 16 ye a r o ld b o y pre se nts with le ft kne e pa in a nd swe lling tha t ha s b e e n pre se nt fo r a mo nth. He tho ug ht the pa in wa s fro m a n o ld b a ske tb a ll injury, b ut it ha s pe rsiste d a nd c a use d him to

• limp. X-ra ys o f the kne e sho w a sunb urst pa tte rn ne xt to lifting o f

the pe rio ste um. Wha t is the mo st like ly dia g no sis?

a . ACL te a r with a vulsio n b . E wing sa rc o ma c . Gia nt c e ll tumo r

• d. Oste o sa rc o ma

e . Cho ndro sa rc o ma

MALIGNANT BONE TUMORS

• Multiple mye lo ma - Mo st c o mmo n 1° ma lig na nt
• Pro life ra tio n o f pla sma c e lls in b o ne ma rro w
• Mo no c lo na l M pro te in spike , o the r syste mic sx
• Punc he d-o ut lytic b o ne le sio ns
• Oste o sa rc o ma - 2nd c o mmo n 1° ma lig na nt
• Ma le s 10-20yo
• Risk fa c to rs: re tino b la sto ma , Pa g e t’ s dise a se ,

ra dia tio n

• X-ra y: sunb urst a ppe a ra nc e , lifting o f pe rio ste um

(Co dma n tria ng le )

• Me ta physis, usua lly a ro und kne e
• Ag g re ssive , re q uire s c he mo a nd surg ic a l

re se c tio n

MALIGNANT BONE TUMORS

• E

wing sa rc o ma

• Ana pla stic “sma ll b lue c e ll” tumo r usua lly in

dia physis

• Bo ys <15 yo (c a n mimic a c ute o ste o mye litis in

this a g e g ro up)

• (11;22) tra nslo c a tio n
• X-ra y: “o nio n skin”
• Ofte n me ta sta size s, re spo nds to c he mo the ra py
• Cho ndro sa rc o ma
• Me n 30-60 yo
• Gliste ning ma ss within me dulla ry c a vity
• Me ta sta tic
• Mo re c o mmo n tha n prima ry tumo rs
• Punc he d-o ut le sio ns

“ O NIO N SKIN” = D UE TO PERIO STEA L REA C TIO N

EWING SARCOMA

BENIGN BONE TUMORS

• Oste o c ho ndro ma
• Mo st c o mmo n b e nig n
• T

umo r o f b o ne with o ve rlying c a rtila g e c a p

• Usua lly g ro ws la te ra lly fro m me ta physis
• Ma le s <25 yo
• Gia nt c e ll tumo r (o ste o c la sto ma )
• 20-40yo , fe ma le s slig htly mo re tha n ma le s
• “so a p b ub b le ”/ ”do ub le b ub b le ” o n X-ra y
• E

piphyse a l e nd, o fte n a ro und kne e

• Multinuc le a te d g ia nt c e lls a nd o va l/

spindle -sha pe d c e lls

OTHER BENIGN BONE TUMORS

• Oste o ma
• usua lly o n fa c ia l b o ne s
• Oste o id o ste o ma
• o ste o b la st tumo r usua lly in fe mur
• Cho ndro ma
• usua lly in sma ll b o ne s o f ha nds/ fe e t

SKELETAL MUSCLE INFLAMMATORY DISORDERS

Po lymyo sitis

• Pro g re ssive symme tric

pro xima l musc le we a kne ss

• Mo st o fte n sho ulde rs
• T

c e ll-me dia te d da ma g e

• E

ndomysial inflammation with

CD8+ T c e lls

De rma to myo sitis

• Po lymyo sitis + skin

involve me nt

• he lio tro pe ra sh, Go ttro n

pa pule s, ma la r ra sh

• Antib o dy-me dia te d da ma g e
• Pe r

imysial inflammation with

CD4+ T c e lls

• I

nfla mma to ry diso rde rs o f ske le ta l musc le +/ - skin

• I

nc re a se d CK , po sitive ANA, po sitive a nti-Jo -1 a ntib o die s*

• Wo me n 40-60 ye a rs o ld
• Rx: ste ro ids

POST-TEST

A 48yo ma n pre se nts with wo rse ning kne e pa in. X- ra ys sho w fine , ra dio g ra phic a lly de nse c rysta ls in the tissue s o f the kne e jo int. Wha t is the mo st like ly dia g no sis?

• A. Go no c o c c a l a rthritis
• B. Oste o a rthritis
• C. Go ut
• D. Rhe uma to id a rthritis

E . Pse udo g o ut

POST-TEST

A wo ma n pre se nts with lo we r b a c k pa in. Physic a l e xa m sho ws c o a rse fa c ia l fe a ture s a nd kypho sis. L a b re sults a re sig nific a nt fo r inc re a se d a lka line pho spha ta se . A b o ne b io psy sho ws a mo sa ic pa tte rn

• f b o ne spic ule s with pro mine nt o ste o id se a ms. Wha t

kind o f c a nc e r is she a t a n inc re a se d risk o f de ve lo ping ?

• A. Ho dg kin lympho ma
• B. Oste o c ho ndro ma
• C. E

wing sa rc o ma

• D. Oste o sa rc o ma

E . No n-Ho dg kin lympho ma

POST-TEST

A 34 yo Ca uc a sia n ma le ha s mild ure thritis tha t re so lve s. Swa b s a re ne g a tive fo r g o no c o c c a l infe c tio n. T wo we e ks la te r , he e xpe rie nc e s c o njunc tivitis, rig ht kne e pa in, a nd a ve sic ula r ra sh o n his pa lms a nd so le s. Wha t e lse is this a sso c ia te d with?

• A. pe rio stitis
• B. hype ruric e mia
• C. sa c ro iliitis
• D. infe c tio us a rthritis

E . pa nc re a titis

POST-TEST

Wha t fa c to r is mo st c o nsiste nt with c urve A?

Ag e Bo ne Ma ss

• A. Me no pa use
• B. Physic a l ina c tivity
• C. Bla c k ra c e
• D. Smo king

E . Ste ro id use

A B