Complex Regional Pain Disorder

1. What are the clinical features of CRPS?
2. What are the clinical stages of CRPS?
3. What are the radiographic findings of CRPS?
4. What is the treatment of CRPS?
*5. What are four tests used to determine if the pain is sympathetically mediated?

Answers:
1. Pain, deep burning exacerbated by movement, allodynia, hyperalgesia. local edema and vasomotor changes (initially warm and red, then becomes cool and cyanotic), muscle weakness, dystrophic changes.
2. Acute (pain, hypersensitivity, swelling, vasomotor changes), dystrophic (atrophic skin changes, decreased temp, hyperhidrosis), atrophic (atrophy, contractures, skin glossy, cool, and dry).
3. Sudeck's atrophy shows up on plain radiographs as patchy osteopenia. Three-phase bone scan is non-specific in first two phases, in third phase is abnormal with enhanced uptake in peri-articular structures.
4. Immediate mobilization, pain control. Corticosteroids for two weeks then gradual taper. Sympathetic ganglion block.
5. Sympathetic block with local anesthetic, guanethidine test (inject distal to suprasystolic cuff --> positive if pain reproduced after injection and relieved after cuff released), pentolamine test (reprod pain with IV pentolamine), ischemia test (inflation of suprasystolic cuff decreases pain).

Fibromyalgia

1. What are the clinical features of fibromyalgia?
2. What are the ARA criteria for diagnosis of fibromyalgia?
3. What is the treatment of fibromyalgia?

Answers:
1. Diffuse aching stiffness, tender points, headaches, neck/upper trap discomfort, UE paresthesias, fatigue. May be associated with IBS, RA, Lyme, hyperthyroidism.
2. Widespread pain in left and right side of body above and below waist with axial involvement. Also must have at least 11/18 tender points (occiput, lower cervical, traps, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter, knee).
3. Nortriptyline, NSAIDs, steroids, combination therapy, biofeedback, tender point injection, acupuncture, aerobic exercise.

Avascular necrosis

What are the causes of avascular necrosis?

Pancreatitis
Lupus
Alcohol
Steroids
Trauma
Idiopathic, Infection
Collagen vascular disease

Radiation
Amyloid
Gaucher's disease
Sickle cell

Neuropathic arthropathy (Charcot's joint)

1. What are the causes of Charcot's joint?
2. What are the clinical symptoms of Charcot's jt?
3. What are the radiologic findings of Charcot's jt?
4. What is the treatment of Charcot's jt?

Answers:
1. Syringomyelia (shoulder), tabes dorsalis from syphilis (knee), and diabetic neuropathy (ankle).
2. Early there are painless swelling, effusion, and joint destruction. Late there is crepitation and destruction of cartilage and bones.
3. Joint destruction with hypertrophic osteophytes, loose bodies, subluxxation, and periarticular debris.
4. Immobilization and restriction of wt bearing.

Deposition and storage disease

1. What are the symptoms of hemochromatosis?
2. What are the symptoms of alkaptonuria?
*3. What is ochronosis?
4. What are the symptoms of Wilson's disease?
5. What are the symptoms of Gaucher's disease?

Answers:
1. Hepatic cirrhosis, cardiomyopathy, DM, pituitary dysfunction, skin pigmentation, arthritis in the hands and hips.
2. Autosomal recessive. Darkening of skin and urine, progressive degenerative arthropathy involving the spinal column and large joints.
3. Ochronosis is the darkening of tissue parts in alkaptonuria, resulting in bluish urine, cartilage, skin, and sclera.
4. Deposition of copper leading to liver cirrhosis, brain and kidney dysfunction, and Kayser-Fleisher rings in the eyes, OA in wrists, MCP, knees, spine.
5. Autosomal recessive, glucocerebroside accumulates in cells of spleen, liver, bone marrow, also resulting in hip and knee degeneration.

Other infectious causes of arthritis

1. What are viral causes of arthritis?
*2. What joints are involved in TB arthritis?
*3. What sort of arthritis is seen with Lyme disease?

Answers:
1. Rubella, infectious hepatitis.
2. Thoracic spine (Pott's disease), hips, knees.
3. Intermittent migratory episodes of polyarthritis.

Septic arthritis

1. What is the clinical picture of septic arthritis?
*2. What are the most common bacterial causes of septic arthritis in different age groups?
3. How is septic arthritis diagnosed?
4. What is the treatment of septic arthritis?
5. What are risk factors for septic arthritis?

Answers:
1. Rapid onset of monoarticular joint pain, erythema, decreased ROM. Most common in the knee.
2. Neonates: S aureus and GBS. Infants: H flu. Children: S aureus. Adults: gonorrhea.
3. Synovial fluid analysis with pos culture, >100,000 WBC, >85% PMN. Plain films with show soft tissue swelling early with later joint space narrowing, erosions, and gas formation.
4. Antibiotics, frequent needle aspirations with arthroscopic lavage.
5. Risk factors include age, prosthetic joints, anemia, chronic disease, hemophilia.

Sjogren's syndrome

*1. What is the clinical presentation of Sjogren's?
2. What do labs show in Sjogren's?
3. What are extraglandular manifestations of Sjogren's?

Answers:
1. Dry eyes, dry mouth, skin lesions, parotid involvement.
2. Primary form shows ANA+, RF+. Secondary form involves Sjogren's plus SLE, RA, PSS, or polymyositis.
3. Arthralgias, Raynaud's.

Vasculitis

1. What is polyarteritis nodosa?
2. What is temporal arteritis?
*3. What is polymyalgia rheumatica?
4. What is Wegener's granulomatosis?
5. What organs does Goodpasture's disease involve?

Answers:
1. Systemic necrotizing vasculitis with palpable purpura and arthritis, in which glomerulonephritis is the leading cause of death.
2. Involves tenderness of scalp, abrupt vision loss, and is treated with high dose steroids.
3. Possibly a form of giant cell arteritis, involving fever, wt loss, malaise. It affects proximal muscles, myalgias, arthralgia. Diagnosis by elev ESR, treated with steroids.
4. Small artery involvement, "saddle-nose" deformity. Necrotizing granulomatous vasculitis involves respiratory tract and glomerulonephritis.
5. Pulmonary and kidney involvement.

Polymyositis/dermatomyositis

1. What muscles are affected?
*2. What are the five subtypes?
*3. What are the clinical features?
*4. What does muscle biopsy and EMG show?
5. What is the treatment?
*6. What are the features of juvenile dermatomyositis?

Answers:
1. Symmetrical weakness of proximal muscles, including shoulder and hip girdle, anterior neck flexors, pharyngeal involvement.
2. I: Primary idiopathic polymyositis (insidious). II: primary idiopathic dermatomyositis (acute). III: Polymyositis/dermatomyositis associated with malignancy. IV: Childhood dermatomyositis/polymyositis --> severe joint contractures. V: Associated with collagen vascular disease.
3. Symmetric proximal weakness which may involve respiratory muscles and cause dysphagia. Skin features include lilac heliotrope rash with periorbital edema and Gotton's papules.
4. Muscle biopsy shows perifascicular atrophy with necrosis of type I and II fibers. EMG shows myopathic cahnges (PSW, fibs, CRD), small short MUAPs with early recruitment.
5. Steroids, azathioprine, methotrexate. ROM, isometric exercises. Follow strength and serum enzymes.
6. Heliotrope rash is predominant, clumsiness, transient arthritis. Responds well to steroids.

Scleroderma

1. What are the characteristics of scleroderma?
2. What is CREST syndrome?
3. What are the symptoms of scleroderma?
*4. What is Raynaud's phenomena? What are other causes of Raynaud's?
5. What is the treatment of scleroderma?
*6. What is eosinophilic fasciitis?

Answers:
1. Skin thickening with fibrosis-like changes in the skin and epithelial tissues of affected organs.
2. CREST (variant of scleroderma) = Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly, Telangiectasia.
3. Skin thickening, symmetric arthritis, Raynaud's.
4. Raynaud's involves vasospasm of digital arteries causing ischemia and ulceration of fingertips, triggered by cold or stress. Other causes include SLE, RA, dermatomyositis, arterial occlusive disease, pulmonary HTN, SCI, CVA, blood dyscrasia, medications.
5. Maintain ROM BID, strengthening. For Raynaud's, educate against triggers, rewarming, Ca channel blockers, biofeedback.
6. Eosinophilic fasciitis is a variant of scleroderma precipitated by strenuous exercise, resulting in pain and swelling. It is treated with steroids.

Systemic Lupus Erythematosis

1. What are the criteria for diagnosis of SLE?
2. What are the arthritic symptoms of SLE?
3. What is Jaccoud's arthritis?
4. What labs are positive in SLE?
5. What is the treatment of SLE?

Answers:
1. 4/11 of the following: malar butterfly rash, discoid rash, photosensitivity, oral painless ulcers, arthritis (nonerosive), serositis, renal d/o, neurologic d/o, hematologic d/o, immunologic test positive (LE cell, anti-DNA, anti-SM, or false pos syphilis), ANA positive.
2. Involves small jts of hands, wrist, knees; symmetric; nonerosive; subQ nodules; Jaccoud's arthritis.
3. Nonerosive deforming arthritis, resulting in ulnar deviations of fingers and subluxation that is reversible early.
4. Depressed complement C3 and C4, Ds-DNA, anti-SM.
5. NSAIDs, steroids, antimalarials, methotrexate, cyclophosphamide, azathioprine, cyclosporine A.

Enteropathic arthropathy

1. What is enteropathic arthropathy and what is its frequency?
*2. What are the clinical joint manifestations of enteropathic arthropathy?
3. What are the extra-articular manifestations?
4. What are the lab findings of enteropathic arthropathy?

Answers:
1. Arthritis 2/2 inflammatory bowel disease (Crohn's, UC), occuring in 10-20% of those with IBD.
2. Asymmetric, involving large joints (knees, ankles, feet), sacroiliitis.
3. Erythema nodosa (Crohn's), pyoderma gangraenosa (UC), deep oral ulcers, uveitis, fever, wt loss.
4. Anemia, elev ESR/CRP, RF-, ANA-, pos anti-neutrophil cytoplasmic ab, incr HLA-B27.

Psoriatic arthritis

*1. What are the manifestations of HIV-associated psoriatic arthritis? What is the treatment?
2. What are the clinical manifestations of psoriatic arthritis?
3. What are the clinical manifestations of psoriasis?
4. What are the radiographic findings in psoriatic arthritis?
*5. What is the treatment of psoriatic arthritis?

Answers:
1. Foot and ankle involvement is most common. Treatment is the same as for psoriatic arthritis, including NSAIDs, with no oral steroids or methotrexate.
2. Morning stiffness in spine ~ 30 min, asymmetric, oligoarticular, arthritis mutilans (telescoping of finger), enthesopathy, spondylitis, sacroiliitis.
3. Erythematous silvery scales on extensor surfaces, Auspitz sign (scraping of lesions -> pinpoint bleeding), nail pitting, conjunctivitis, aortic insufficiency.
4. Pencil in cup appearance of DIP, asymmetric sacroiliitis, "fluffy periostitis", syndesmophytes, and bone erosions.
5. ROM, similar meds to RA, PUVA, steroid injections.

Reiter's syndrome

1. What is the triad seen in Reiter's syndrome?
2. What infections are associated with Reiter's syndrome? What % progress to AS?
*3. What are the joint-associated manifestations of Reiter's syndrome?
4. What are other manifestations of Reiter's?
*5. What are the radiographic findings of Reiter's syndrome?

Answers:
1. Conjunctivitis, arthritis, nongonococcal urethritis.
2. Chlamydia, campylobacter, yersinia, shigella, salmonella, HIV. 3-10% progress to AS.
3. Asymmetric arthritis starting 2-4 weeks after infection, avg of 4 joints affected (distal LE>UE), sausage digits, enthesopathies, sacroiliitis.
4. Ocular, urethritis, balanitis circinata (painless ulcers on penis), keratoderma blennorrhagia, Reiter's nails, cardiac conduction defects, weight loss, fever, amyloidosis.
5. Lover's heel (erosion and periosteal changes at insertion of plantar fascia and Achilles), asymmetric SI joint involvement, syndesmophytes, pencil in cup deformities.

Diagnosis and treatment of ankylosing spondylitis

1. What are the lab findings in AS?
2. What are the radiographic findings in AS?
3. What physical exam test is used in AS?
4. What is the non-drug treatment for AS?
5. What medications are used to treat AS?


Answers:
1. 90% have +HLA B27, incr ESR/CRP, anemia (normocytic, normochromic), RF-, ANA-.
2. SI joint narrowing, pseudowidening of joint space due to subchondral bone resorption and erosion sclerosis, bamboo spine, syndesmophyte formation (squaring of lumbar vertebrae's anterior concavity), osteopenia, straightening of C-spine.
3. Schober test: place landmark midline at a pt 5cm below iliac crest and 10cm above. On forward flexion, the line should increase to greater than 20cm. Any less is a restriction.
4. Good posture, firm mattress, prevent flexion contractures, PT (extension exercises), deep breathing exercises, no smoking.
5. NSAIDs (indocin), steroid (taper, PO, injections, eye drops), sulfasalazine, methotrexate.

Ankylosing spondylitis

1. What are the major seronegative spondyloarthropathies?
2. What is the hallmark of ankylosing spondylitis?
3. What genetic marker is associated with AS?
4. What skeletal symptoms are associated with AS? What is the frequency of different sites of involvement?
5. What are the extraskeletal manifestations of AS?
*6. What are the HLA B27 pos diseases?

Answers:
1. Ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, and arthritis of inflammatory bowel disease. Most are RF- and HLA B27+.
2. Bilateral sacroiliitis.
3. HLA-B27 pos in 90%.
4. Sites of involvement: (1) SI jt, (2) Lumbar vertebrae, (3) Thoracic vertebrae, (4) Cervical vertebrae. Initially may be assymetric, lumbar morning stiffness, decreased lumbar lordosis and incr thoracic kyphosis, enthesitis, respiratory restriction.
5. Fatigue, weight loss, low grade fever, acute iritis (pain, photophobia, blurred vision), aortitis, apical pulmonary fibrosis, amyloidosis, cauda equina syndrome, C1-C2 subluxation.
*6. AS, Reiter's syndrome, psoriatic arthritis, enteropathic arthropathy, pauciarticular JRA.

Pseudogout

1. What sort of crystals are seen in pseudogout?
*2. What disorders are associated with pseudogout?
3. What is the clinical presentation of pseudogout?
4. What are the radiologic findings in pseudogout?
5. What is the treatment of pseudogout?

Answers:
1. Calcium pyrophosphate dihydrate crystals with positive birefringence.
2. Hypothyroidism, hyperparathyroidism, hemochromatosis, amyloidosis, hypomagnesemia, hypophosphatemia.
3. Inflammation in one or more large joints (most commonly in the knee), symmetric, flexion contractures, less painful than gout, lasts ~2wks.
4. Punctate fine line of crystals in articular hyaline or fibrocartilage tissues.
5. NSAIDs, corticosteroids, and colchicine.

Gout

*1. What sort of crystals are seen in gout?
2. What is the epidemiology of gout?
3. What is the clinical presentation of gout?
4. What are provocative factors for gout?
5. What are the lab and radiographic findings in gout?
6. What is the treatment for gout?

Answers:
1. Monosodium or sodium urate crystals with negative birefringence.
2. Male >> female, 30-50 years.
3. Exquisite pain in first MTP (podagra), monoarticular, may also be seen in midfoot, ankles, heels, knees. May last days to wks. Tophi form after years of attacks.
4. Trauma, alcohol, drugs (thiazides).
5. Hyperuricemia. Radiograph shows soft tissue swelling around joint, asymmetric, with joint space preserved, no osteopenia.
6. For acute attacks: colchicine inhibits phagocytosis of urate crystals, indocin, corticosteroids. For chronic: allopurinal (decr urate synthesis), probenecid (incr renal excretion of urate).

Treatment of osteoarthritis

1. What is the standard non-pharm treatment of OA?
2. What medications are used to treat OA?
3. When are steroids used in OA?

Answers:
1. Weight loss, ROM, strengthening, assistive devices, joint protection.
2. NSAIDs, Tylenol, rarely narcotics.
3. Intra-articular steroids for acute flares, oral steroids contraindicated.

Radiographic findings in osteoarthritis

1. What are the major radiographic findings in OA?
2. Are erosive changes seen on X-ray in OA?
3. Is osteopenia seen on X-ray in OA?
4. Where is joint space narrowing seen in knee and hip OA?

Answers:
1. Asymmetric narrowing of the joint space, new bone formation, osteophytes, osseous cysts, loose bodies.
2. No, this is seen in RA.
3. No, this is seen in RA.
4. Knee: medial joint space narrowing. Hip: superior lateral joint space narrowing.