Download ORTHO CASES - Bone & Joint Center

Jim Messerly DO
Case #1
78-year-old female seen on 8/31/12 with complaint of
neck pain for 4 months. She had been seen at the
Urgent Care on 5/6/12 complaining of neck and
shoulder pain and stiffness for 3 days after her recent
car ride from Florida. She was diagnosed with
Torticollis and was given Flexeril for the stiffness and
noted some improvement of her neck pain but the
Flexeril caused fatigue.
Follow- up neck pain 1 month
later on 6/8/12 with PCP
The patient had noted some
improvement of her neck
pain, but now complained of
interscapular pain, low back
pain and fatigue. The patient's
past medical history of
hypertension, hyperlipidemia
and hypothyroidism was
reviewed. There was concern
that her symptoms might be
related to her
antihypertensive medications.
Lab work was ordered.
Lab Results 6/8/12:
 CBC H/H- 12.4/37.1,
WBC-7.1 with normal
diff.
 COMP- Normal
 TSH and Free T4Normal
 UA- + for Urate
Crystals and Hyaline
Casts. Trace Bacteria
PCP Follow- up 7/6/12
2 months post onset of symptoms
The patient was now complaining of low-grade fevers to 101° with some
associated headaches, muscle aches, stiff neck and somnolence. Lyme
titer was obtained and was negative.
PCP Follow-up 8/6/12
3 months post onset of symptoms
The patient complained of ongoing fatigue, neck pain, headaches, new
tremor, loss of appetite and abdominal pain.
Lab work was obtained:
CBC- Hgb had decreased to 11.7
CMP- K+ 3.4. Glucose was elevated at 184, non-fasting
B12- Normal
Folate- Normal
Erhlichiosis AB + which was treated with Doxycycline
Ortho Office visit 8/31/12
Chief complaint:
Neck pain without upper extremity radicular symptoms. The neck
pain radiated into the bilateral posterior shoulders. She denied any
other joint complaints. She was still complaining of significant
fatigue.
Physical Exam:

Cervical spine was examined. There was generalized decreased range
of motion of the cervical spine with only 20° of cervical flexion, 20° of
extension and 30° of rotation bilaterally with the patient complaining of
diffuse posterior neck pain. Upper and lower neuro exam was normal.
Hoffman's testing was negative bilaterally.
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Bilateral shoulder exam showed flexion and abduction limited to 140°
bilaterally with associated shoulder pain. There was mild weakness with
rotator cuff testing bilaterally.
Cervical Spine X-rays
Lab work 8/31/12
CBC- H/H decreased to 10.8/32.1, WBC 5.6
ESR- 58 (0-20)
CRP- 8.46 (<0.5)
RA Titer- <11.0 (<15)
ANA Titer- <80 (<80)
Differential Diagnoses
1.
2.
3.
4.
Degenerative Disc Disease and
Facet Arthropathy cervical spine
(Spondylosis)
Polymyalgia Rheumatica
Fibromyalgia
Depression
Treatment
The patient was started on Prednisone 30
mg daily and in 3 days her neck and
shoulder pain decreased from 10/10 to
1/10.
Polymyalgia Rheumatica
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The most common chronic inflammatory condition in
older adults
Primarily affects the muscles and joints of the
shoulders, neck and hip girdles with prominent
bilateral pain and morning stiffness lasting more than
45 minutes
May develop rapidly or over several weeks
Age: >50
Cause: Unknown
Approximately 20% of PMR also involves Giant Cell
(Temporal) Arteritis
Up to 50% of patients may have distal transient,
asymmetric arthritis in knee or wrist
PMR Testing
No definitive test for PMR
 ESR- mean ESR for PMR is 65 mm/hour. 91%
of patients with PMR have ESR > 40. ESR
>100 raises concern for Giant Cell Arteritis.
Normal ESR found in about 10% of PMR
cases.
 CRP-more sensitive than ESR
 CBC-may show mild to moderate anemia
 Other testing should include- COMP, Thyroid
studies, Rheumatoid Factor, ANA, Lyme titer,
Serum Protein Electrophoresis and Urinalysis
Differential Diagnosis of PMR
Shoulder/Cervical spine pain
 Degenerative disc disease cervical spine/Cervical
spondylosis
 Rotator cuff pathology/adhesive capsulitis of shoulder
 Osteoarthritis of the shoulder
Muscle stiffness or pain
 Myofascial pain syndrome
 Polymyositis
 Thyroid disease
 Parkinson's disease
 Inflammatory myopathy from statin use
 Multiple Myeloma or other Paraneoplastic Syndromes
PMR Treatment
Standard initial treatment: Oral prednisone
 15 mg/day for 3 weeks, then
 12.5 mg/day for 3 weeks, then
 10 mg/day for 4-6 weeks, then
 Decrease by 1 mg every 4-8 weeks
Note:
 Symptoms of PMR usually respond quickly to prednisone
therapy in 1-2 days
 About 15% of patients require higher initial dose of
prednisone
 Average length of treatment is 1.8 years with concerns for
Osteoporosis/Diabetes with chronic prednisone use
 Consider early Rheumatology consultation
Giant Cell (Temporal) Arteritis
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New onset headache
Fatigue
Anorexia and weight loss in patient older than
50
Jaw claudication
Visual disturbance
Scalp tenderness
Polymyalgia Rheumatica
Very high ESR and CRP
High-dose prednisone 60 mg or greater
Temporal Artery biopsy
“PMR-like” Syndrome
Fairly sudden onset bilateral shoulder
pain and stiffness
 Normal to mildly elevated ESR and CRP
 Significant improvement with short
course of oral steroids
 Concern for chronic steroid therapy
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Case #2
11 y/o female presented to the emergency department on
12/11/13 with 1-2 day history of fever and left knee pain
and swelling. The fever at home was apparently to 104°.
There was no history of trauma to the left knee. No
abdominal pain or rash. The patient did complain of mild
URI symptoms including cough prior to the onset of her left
knee pain and swelling.
Physical Exam
Temperature 101.1
degrees. Throat was
clear. Lungs were clear.
Neck was supple. Left
knee exam showed
moderate joint effusion.
No erythema. "She does
have a lot of pain with
range of motion of leg".
Differential Diagnosis
1.
2.
3.
4.
Septic Arthritis
Reactive Arthritis
JRA/JIA
Lyme Arthritis
Lab Results- Blood
CBC: H/H- 11.0/33.5,
WBC-12.3; 65%
Neutrophils, 27%
Lymphs
 ESR: 107 (nl <15)
 CRP: 4.81 (nl <0.80)
 COMP: Mild elevated
glucose (120) and
mild increased
globulin
 UA: 8 RBCs/hpf (nl 02), bacteria neg.
 Influenza A/B neg.
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Knee Aspiration- Synovial Fluid
Analysis
Joint Fluid RBCs:
4400/cmm
 Joint Fluid Nucleated
Cells: 101,800; 95%
Neutrophils
 Gram Stain: Many
PMNs, No organisms
seen. No crystals
seen
 Joint Fluid Glucose:
87
 Lyme PCR: Pending
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Disposition
(Knee x-rays were read as normal)
The case was discussed with the orthopedic
surgeon on call by phone. Since there were
no signs of toxicity, negative Gram stain, mild
elevated cell count, no redness, the patient's
knee pain and swelling were felt to be related
to Reactive Arthritis. The patient was
discharged on Advil with close Orthopedic
follow-up recommended in 24-48 hours.
Follow-up Ortho visit 12/16/13,
5 days post ED visit
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CC: Left knee pain was
much improved. The
patient was ambulating
with a slight limp. No
further fevers.
Left knee exam showed
trace effusion. No
tenderness of the joint
capsule. There was full
flexion and extension of
the left knee with only
mild discomfort.
 12/11/13 Culture results
were reviewed: Synovial
fluid and blood cultures
were negative at 5 days.
Lyme PCR: Not
detected
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Differential Diagnosis
1.
2.
3.
4.
Septic Arthritis
Reactive Arthritis
JRA/JIA
Lyme Disease
Repeat Lab Results 12/16/13
CBC: WBC-7.6 with normal differential,
Platelet count 485 (nl- 130-425)
 ESR: 102 (nl <15), Previous 107
 CRP: 1.10 (nl <0.80), Previous 4.81
 RA titer: < 11.0
 ANA titer: < 80
 Lyme ELISA screen: Positive
 Western blot: IgG- Positive, IgM–
Positive
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Lyme Arthritis History
In 1977, Steere et al described a mysterious arthritis
epidemic that affected 39 children and 12 adults in 3
contiguous communities in Connecticut. The illness
was characterized by recurrent attacks of asymmetric
swelling and pain in large joints. The knee was the
most common site of involvement. Early cases in
children were misdiagnosed as juvenile rheumatoid
arthritis; however, the geographic clustering of cases
indicated an infectious etiology. This previously
unrecognized entity was dubbed Lyme arthritis after
the town of Lyme, Connecticut, where most of the first
known patients lived.
Lyme, Not Limes, Disease
Lyme Disease Geographic Distribution
Lyme Arthritis–Presentation
Classic Arthritis: episodic synovitis with
involvement of 1-4 joints lasting less than
one week. Knee involvement up to 90% of
patients. The elbow, ankle, hip and wrist
may be affected
2. Acute Pauciarticular form "Pseudo-septic":
Similar to acute bacterial septic arthritis
3. Other less common forms:
1.
 Chronic pauciarticular
 Migratory
 Polyarticular
Lyme Arthritis Diagnosis
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3.
Recognition of
characteristic clinical
findings (effusion)
History of exposure in
an area in which the
disease is endemic
(Wisconsin)
Confirmatory
serologic testing
(Lyme ELISA screen
followed by Western
Blot confirmatory
testing)
Lyme Arthritis-Diagnostic
Dilemma
The classic presentation of Lyme
arthritis characterized by episodic
synovitis is frequently confused with
inflammatory arthritis
 The pauciarticular form may be
confused with acute bacterial septic
arthritis
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Differentiating Lyme Arthritis
vs Septic Arthritis
Lyme Arthritis:
 Frequently involves the knee
 History of tick exposure
 Less likely to have temp > 100.5°
 Usually lower to normal ESR/CRP
 Less likely to refuse to weight bear on
affected extremity
 Less intense pain with passive range of
motion testing
Lyme Disease Antibiotic Treatment
Lyme Arthritis Prognosis
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Up to 95% of Lyme arthritis patients remain
asymptomatic after a single course of oral
antibiotics.
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Persistent arthritis post Lyme arthritis
treatment is a challenging problem defined
as synovitis that persists for more than 2
months after completion of two 4 week
courses of oral antibiotics or a course of IV
antibiotics and is probably an autoimmune
mediated synovitis. Arthroscopic
synovectomy may be indicated.
Case #3
58 y/o Male with complaint of low back
pain worse over the past 2-3 months.
He describes occasional radiation of
pain into the anterior lateral right thigh.
His pain is worse with prolonged
standing especially at the end of his
workday. He denies increased pain
with coughing or sneezing. There has
been no bowel or bladder dysfunction.
He denies any significant night pain.
Previous Diagnostics and Treatments
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MRI scan of the lumbar spine had been obtained 2 years prior
and showed multilevel disc bulging with mild central canal
narrowing at L3-4 and L4-5 and some neuroforaminal
narrowing at L4-5 on the right. There was moderate facet
arthropathy in the lower lumbar spine.
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Previous chiropractic care and physical therapy brought only
temporary improvement of the patient's low back pain. He
did undergo left L4-5 facet injection and subsequent
radiofrequency ablation therapy 2 years prior with
improvement of his low back pain at that time.
Visual defects (ophthalmoplegia, optic disc
pallor, reduced visual acuity)
Lumbar Spine Examination
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There was a moderate decreased lumbar
lordosis. Slight lateral shift with shoulders
to the right. Standing flexion was 60°
without pain. Standing extension
reproduced low back pain at 20°. Heel/toe
walking was normal. Deep tendon reflexes
lower extremities showed patellar reflexes
2.5+/4 bilaterally. Achilles reflexes were
2+/4 bilaterally. There was 1-2 beats of
ankle clonus with forced dorsiflexion of the
ankles. Babinski sign was downgoing
bilaterally. No obvious lower extremity
muscle weakness was detected with
manual muscle testing. Sensation of the
lower extremities was normal. Sitting and
supine straight leg raises were negative to
60° bilaterally. Hips showed full range of
motion without pain. Patrick's testing was
negative bilaterally.
New x-rays of the lumbar spine were
obtained which showed normal alignment
with degenerative disc changes at L5-S1.
Moderate facet arthropathy of the lumbar
spine.
Assessment
Low Back Pain which seemed facet
mediated
2. Facet Arthritis Lumbar spine
3. Degenerative Disc Disease Lumbar spine
mainly at L5-S1
4. Mild Hyperreflexia lower extremities
1.
Treatment Plan
Physical Therapy
2. Celebrex samples
3. Tramadol for pain
4. Monitor lower extremity neurologic
status, consider further spinal imaging if
there is more significant evidence of
upper motor neuron lesion
1.
Phone call from PT
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Phone call from physical therapist one week after
office visit. The patient had evidence of gait
disturbance with apparent lower extremity
weakness. Follow-up was recommended.
Follow-up Office Visit
Physical Exam
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Gait: Stiff legged and with some
spasticity
Deep tendon reflexes: Patella
2.5+/4 on the right, 3+/4 on the left
with 1-2 beats of clonus Achilles
reflexes 2.5+/4 bilaterally with 2-3
beats of ankle clonus
Babinski sign: Neutral to extensor.
Sensation: Mild decreased
sensation in a stocking distribution
Strength: Mild generalized lower
extremity weakness
Follow-up visit continued
Diagnosis
Abnormality of gait
probably related to upper
motor neuron lesion
Plan
MRI scans of the cervical
and thoracic spine
Lab work
Symptoms and Signs of Multiple
Sclerosis
Symptoms
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Depressed mood
Dizziness or vertigo
Fatigue
Hearing loss or tinnitus
Heat sensitivity
Incoordination and gait
disturbance
Pain
Sensory disturbances
(dysesthesias, numbness,
paresthesias)
Urinary symptoms
Visual disturbance-diplopia
Weakness
Signs
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Ataxia
Decreased sensation (pain,
vibration, position)
Hyperreflexia, spasticity
Nystagmus
Visual defects
(ophthalmoplegia, optic disc
pallor, reduced visual acuity)
Types of Multiple Sclerosis
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Relapsing remitting (90% of cases): Discrete attacks
that evolve over days to weeks, followed by some degree
of recovery over weeks to months; the patient has no
worsening of neurologic function between attacks
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Secondary progressive (50% of relapsing remitting
cases): Initial relapsing remitting disease, followed by
gradual neurologic deterioration not associated with acute
attacks
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Primary progressive and progressive relapsing (10%
of cases): Characterized by steady functional decline from
disease onset; these types cannot be distinguished during
early stages until attacks occur or fail to occur
Differential Diagnosis of Multiple Sclerosis
Disease
Central and peripheral nervous system disease
Examples
Degenerative disease
Amyotrophic lateral sclerosis, Huntington's disease
Demyelinating disease
Chronic inflammatory demyelinating polyneuropathy, progressive multifocal leukoencephalopathy
Infection
Human immunodeficiency virus infection, Lyme disease, mycoplasma, syphilis
Inflammatory disease
Behcet syndrome, sarcoidosis, Sojourn syndrome, systemic lupus erythematosus
Structural disease
AV malformation, herniated disc, neoplasm
Vascular disease
Cerebrovascular accident, diabetes mellitus, migraine, vasculitis
Differential Diagnosis of Multiple Sclerosis
Continued
Disease
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Genetic disorder
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Medication and illicit drug
effects
Nutritional deficiency
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Psychiatric disease
Examples
Leukodystrophy,
mitochondrial disease
 Alcohol, cocaine, lithium,
penicillin, phenytoin
 Folate deficiency, vitamin
B12 deficiency, vitamin E
deficiency
 Anxiety, conversion
disorder, somatization
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References
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2.
3.
Caylor TL, Perkins A. Recognition and
Management of Polymyalgia Rheumatica and
Giant Cell Arteritis. Am Fam Physician. November
15, 2013; 88 (10): 676–684.
Smith BG, Cruz AL Jr., Milewski MD, Shapiro ED.
Lyme disease and the Orthopaedic Implications of
Lyme Arthritis. J Am Acad Orthop Surg. Feb 2011;
19(2):91-100.
Sagul A, Kane S, Farnell E. Multiple sclerosis: A
Primary Care Perspective. Am Fam Physician.
November 1, 2014. 90(9):644-652