Musculoskeletal

TABLE OF CONTENTS
1. Skeletal Muscle
Musculoskeletal 2. Non-Rheumatologic Diseases
3. Rheumatologic Diseases
4. Seronegative Spondyloarthritis
5. Bone Tumors
6. Vasculitides
7. Brachial Plexus Nerves & Lesions
8. Shoulder & Elbow
9. Childhood Musculoskeletal Pathology
OUTLINE
1. Skeletal Muscle Overview
A. General Principles
Musculoskeletal B. Structures
C. Skeletal Muscle Histology
D. Myofilaments
System:
E. Proteins
2. Skeletal Muscle Contraction
A. Neuromuscular Junction
Skeletal Muscle
B. Muscle Cell Depolarization
C. Muscle Contraction
D. Muscle Relaxation
E. Malignant Hyperthermia
3. Metabolic Exercise Physiology
A. ATP Sources by Time
B. Type I (Red) Muscle Fibers
C. Type II (White) Muscle Fibers
4. Sarcomere
A. Thick Filaments
B. Thin Filaments
C. M Band
D. H Zone
E. I Band
F. A Band
5. Muscle Proprioception
A. Muscle Spindles
B. Golgi Tendon Organ
Musculoskeletal System: Skeletal Muscle Bootcamp.com
General Principles:
• Function: Muscle contraction or tension to resist load
• Calcium required for muscle cell contraction
• Striated fibers: Skeletal muscle
• Nonstriated fibers: Smooth muscle
• Embryologic origin: Mesoderm
Structures:
• Sarcolemma: Muscle cell membrane, T-tubules à Dihydropyridine receptor
• Sarcoplasmic Reticulum: Muscle cell endoplasmic reticulum, stores calcium, ryanodine receptor
• Sarcoplasm: Muscle cell cytoplasm
Skeletal Muscle Histology:
• Multinucleated, striated, nuclei located in periphery
Myofilaments:
• Actin: Thin filament
• Myosin: Thick filament, binding site for actin and ATP (ATPase activity)
• Slide along actin filament via ATP hydrolysis
Proteins:
• Tropomyosin: Blocks myosin binding on actin
• Troponin C: Activated by Ca2+ à Conformational change in tropomyosin
Neuromuscular Junction:
• Depolarization transmission down axon à ↑ Voltage-gated Ca2+ channel opening à ↑ Ca2+ into axon
• Calcium-induced ACh vesicle exocytosis à ACh binds to AChR on motor end-plate à Ligand-gated Na+ channel opening
Muscle Cell Depolarization:
• ↑ Na+ into sarcoplasm à Depolarization of muscle cell à Travels down T-tubule
• Depolarization of DHPRà Mechanical coupling to RYR
• Opening of ryanodine receptor à ↑ Ca2+ into sarcoplasm
Muscle Contraction:
• Ca2+ binds troponin C à Exposes binding site on actin for myosin to bind
• Myosin performs ‘power stroke’ releasing Pi and ADP
• Myosin binds ATP à Myosin detaches from actin à ATP is hydrolyzed to ADP (process repeats if Ca2+ present)
Muscle Relaxation:
• SERCA pumps calcium into sarcoplasmic reticulum via ATP à ↓ Ca2+ in sarcoplasm
• Troponin C blocks myosin binding site due to ↓ Ca2+
Malignant Hyperthermia:
• AD (usually) ryanodine receptor mutations (RYR-1)
• Volatile anesthetics, succinylcholine are classic causes
• Continuous opening of ryanodine receptor à ↑↑↑ Ca2+ into sarcoplasm
• ↑ ATP requirements à O2 consumption, ↑ CO2 production à Myonecrosis
• Lactic acidosis, hyperkalemia, hyperthermia, hypercatabolic state, rhabdomyolysis
• Caffeine-Halothane contracture test
• Management with dantrolene and cooling measures
ATP Sources by Time:

• Initial seconds: Cellular stored ATP + creatine phosphate
• 10 seconds: Anaerobic glycolysis
• 1 minute: Aerobic metabolism à Glycogen oxidation
• Minutes to hours: Aerobic metabolism à Glycogen and free fatty acid β-oxidation
Type I (Red) Muscle Fibers:
• ↑ Mitochondria, ↑ Myoglobin à Aerobic metabolism à Oxidative phosphorylation
• Slow twitch contractions à ↓ Myosin ATPase activity
• Essential for endurance training and postural maintenance
• Classic Examples: Paraspinals, soleus
Type II (White) Muscle Fibers:
• ↓ Mitochondria, ↓ Myoglobin à Anaerobic metabolism à Substrate level phosphorylation
• Fast twitch contractions à ↑ Myosin ATPase activity
• Essential for high intensity training
• Classic Example: Triceps
Thick Filaments:
• Myosin
Thin Filaments:
• Actin
M Line:
• Located in center of H zone
H Zone:
• Located on both sides of the M line
• Pale appearing zone
• Contains only myosin filaments
• ↓ w/ contraction
I Band:
• Pale appearing zone outside of the A band
• Contains only actin filaments
• ↓ w/ contraction
A Band:
• AI Zone: Dark appearing zone between I band and H zone
• Contains H Zone + AI Zone
• H zone à Only myosin filaments
• AI Zone à Overlapping myosin and actin filaments
• AI Zone also contains myosin heads
• Remains the same length w/ contraction
Muscle Spindles:
• Stretch receptor containing intrafusal fibers
• Run parallel to extrafusal muscle fibers
• Provide information about muscle length
• Afferent innervation à Type Ia and II sensory neurons
• Efferent innervation à Ɣ-motor neurons, ⍺-motor neurons
• Myotatic Reflex: ↑ Muscle stretch at spindle à Action potential firing Ia afferent fibers à
• Agonist ⍺-motor neurons activated à Extrafusal agonist muscle activation
• Antagonist ⍺-motor neurons inhibited à Extrafusal antagonist muscle relaxation
• Sensitivity of reflex regulated by Ɣ-motor neurons
• Example: L4 reflex arc
Golgi Tendon Organ:
• Contains nerve fibers and collagen
• Located between muscle fibers and tendon
• Provide information about muscle tension
• Afferent innervation à Type Ib sensory neurons
• Golgi Tendon Reflex: ↑↑↑ Muscle tension/stretch à Action potential firing Ib afferent fibers à
• Antagonist ⍺-motor neurons activated à Extrafusal antagonist muscle activation
• Agonist ⍺-motor neurons inhibited à Extrafusal agonist muscle relaxation
• Prevents overstretching by causing muscle relaxation
• Example: Lifting heavy weight
≣ Item 1 of 1 Test Your Knowledge
Difficulty Rating: ✪✪ Bootcamp.com
Question ID: 0071
A 51-year-old male with no significant past medical history was admitted for reconstructive septoplasty. The patient was given midazolam,
propofol, and a short acting opioid agonist for pain just prior to the procedure. Rocuronium and succinylcholine were given for
neuromuscular relaxation as well. There were no complications during the surgery and the patient’s vital signs were stable throughout.
Within minutes after the procedure, the patient was noted to become tachycardic up to 150 beats/min. A temperature taken in the post-
operative suite was 42.2 ℃ (108℉). The patient was immediately transferred to the intensive care unit and given an initial dose of
dantrolene. Initial laboratory testing revealing a significantly elevated lactate, arterial pH of 7.05, and a potassium of 5.7 mEq/L.
Which of the following best explains the role of dantrolene in the setting of this patient’s presentation?
⚪ A. Increases frequency of chloride channel opening
⚪ B. Persistent depolarization of motor end-plate
⚪ C. Increases calcium levels within the sarcoplasmic reticulum
⚪ D. Direct inhibition of sarcoendoplasmic reticulum calcium transport ATPase
⚪ E. Increases binding of calcium to troponin C

≣ Item 1 of 1 Test Your Knowledge
Difficulty Rating: ✪✪ Bootcamp.com
Question ID: 0071
A 51-year-old male with no significant past medical history was admitted for reconstructive septoplasty. The patient was given midazolam,
propofol, and a short acting opioid agonist for pain just prior to the procedure. Rocuronium and succinylcholine were given for
neuromuscular relaxation as well. There were no complications during the surgery and the patient’s vital signs were stable throughout.
Within minutes after the procedure, the patient was noted to become tachycardic up to 150 beats/min. A temperature taken in the post-
operative suite was 42.2 ℃ (108℉). The patient was immediately transferred to the intensive care unit and given an initial dose of
dantrolene. Initial laboratory testing revealing a significantly elevated lactate, arterial pH of 7.05, and a potassium of 5.7 mEq/L.
Which of the following best explains the role of dantrolene in the setting of this patient’s presentation?
⚪ A. Increases frequency of chloride channel opening
⚪ B. Persistent depolarization of motor end-plate
" C. Increases calcium levels within the sarcoplasmic reticulum
⚪ D. Direct inhibition of sarcoendoplasmic reticulum calcium transport ATPase
⚪ E. Increases binding of calcium to troponin C

OUTLINE
1. Osteoarthritis 6. Osteoporosis
Musculoskeletal A. Pathophysiology A. Pathophysiology

B. Presentation B. Presentation
C. Diagnostics C. Diagnostics
System: 2.
D. Management
Gout 7.
D. Management
Osteopetrosis
A. Pathophysiology
A. Pathophysiology
Non-rheumatologic B. Presentation
C. Diagnostics
B. Presentation
C. Diagnostics
Diseases D. Management D. Management

3. CPPD 8. Osteomalacia/Rickets
A. Pathophysiology A. Pathophysiology
D. Management D. Management
4. Septic Arthritis 9. Osteitis Deformans
5. Achondroplasia 10. Osteitis Fibrosa Cystica
Musculoskeletal System: Non-Rheumatologic Diseases Bootcamp.com
Osteoarthritis
● Pathophysiology:
○ Chronic mechanical stress on joint +/- ↓ Proteoglycans → ↓ Cartilage elasticity + inflammation/degeneration → ↓ Joint space, subchondral sclerosis
○ Most common joint disorder, ↑ Incidence with age
○ Modifiable risk factors: Obesity, overuse
○ Non-modifiable: Age, hx of trauma, family hx, anatomy, sex (♀>♂)
○ Incidence: Knee > Hip > Hand
● Presentation:
○ ↑ Pain with activity, relieved with rest (commonly hands, hips, & knees)
○ Asymmetric involvement, morning stiffness (~<30 min)
○ Crepitus, ↓ ROM
○ Heberden nodes (DIP joint)
○ Bouchard nodes (PIP joint)
● Diagnostics:
○ Mostly clinical diagnosis
○ X-ray (1st line): Irregular joint space narrowing, subchondral sclerosis
■ Osteophyte formation, subchondral cysts
○ Arthrocentesis: Non Inflammatory synovial joint fluid (WBC <2000/mm3)
● Management:
○ Non-pharmacologic: Weight loss, diet/exercise, physical therapy, activity modification
○ Pharmacologic: Topical or oral NSAIDs, acetaminophen, opioids (use sparingly)
○ Interventional: Intra-articular glucocorticoid injection
○ Surgical: Total knee arthroplasty (TKA)
Gout
○ Precipitation of monosodium urate crystals → Deposition into tissues → Inflammatory crystalline arthropathy
■ Precipitation occurs by ↑ Uric acid production or ↓ Excretion
○ Risk factors: ♂ > ♀, diet (↑ Purine intake), tumor lysis syndrome, CKD, genetic predisposition (e.g, Lesch-Nyhan, Von Gierke disease)
○ Additional risk factors: Medications (e.g., thiazide & loop diuretics, aspirin, niacin)
● Presentation:
○ Acute pain, typically mono-articular
■ Classically 1st MTP joint (podagra)
○ ↓ ROM, swelling, warmth, erythema, tenderness to palpation
○ Often precipitating trigger: ↑ Uric acid levels, trauma, dehydration
○ Symptoms may wake the patient at night
○ Chronic gout can present with tophi (commonly olecranon, ear, or Achilles tendon)
● Diagnostics:
○ Gold standard: Arthrocentesis/synovial fluid analysis
■ Classic finding: Needle-shaped crystals, (-) birefringence under polarized light
■ Yellow under parallel light, blue under perpendicular light
○ Serum uric acid: Elevated (Hyperuricemia)
■ Level may be normal during an acute attack
● Management:
○ Acute: NSAIDs (e.g., indomethacin, naproxen), colchicine, steroids
○ Chronic (prevention): Xanthine oxidase inhibitors (e.g., allopurinol, febuxostat), uricosuric agents (e.g, probenecid)
Calcium Pyrophosphate Deposition Disease (CPPD)

○ Precipitation of calcium pyrophosphate dihydrate crystals → Deposition into tissues → Inflammatory crystalline arthropathy
○ Also known as pseudogout
○ More common in older patients, often idiopathic
○ Associations: Hemochromatosis, hyperparathyroidism, joint trauma
● Presentation:
○ Acute pain, typically mono-articular (most commonly affecting the knee)
○ Can be asymptomatic
● Diagnostics:
■ Classic finding: Rhomboid-shaped crystals, weakly (+) birefringence under polarized light
■ Blue under parallel light, yellow under perpendicular light
○ X-ray: Chondrocalcinosis
○ Serum uric acid: Typically normal
● Management:
○ Acute: NSAIDs, glucocorticoids, colchicine
■ Often self-limiting
○ Chronic: NSAIDs, colchicine
Septic Arthritis
○ Exposure to infection (hematogenous vs. direct contamination) → Inflammation of the joint
○ Risk factors: Underlying joint disease (e.g., RA), IVDU, prosthetic implants, immunosuppression, diabetes mellitus, advance age
○ Common organisms: Staphylococcus aureus (most common), Streptococcus, Neisseria gonorrhoeae, Pseudomonas aeruginosa
○ Disseminated gonococcal infection: Systemic disease following STI with gonorrhea
● Presentation:
○ Typically monoarticular (most commonly affect the knee)
○ Fever due to infection
○ Disseminated gonococcal infection triad: Polyarthralgias, tenosynovitis, dermatitis
■ Migratory/asymmetric polyarthralgias
● Diagnostics:
■ Purulent synovial fluid with ↑ WBC count >50,000/mm3 (neutrophil dominant)
■ Contraindicated if overlying signs of infection
○ Blood cultures, gram stain
○ X-ray: Soft tissue swelling, potentially unremarkable (particularly important with prostheses)
● Management:
○ Antibiotics coverage based on culture and sensitivity
○ Consider aspiration, drainage for native joint
○ Consult orthopedic surgery for prosthetic joint infection (PJI)
Achondroplasia
○ Defect in FGFR3 gene → ↑ FGF receptor stimulation → ↓ Chondrocyte proliferation/endochondral ossification → ↓ Longitudinal bone growth
■ FGFR3 (fibroblast growth factor receptor 3) gene located on chromosome 4
■ Gain-of-function mutation
■ Most commonly a sporadic mutation, can be autosomal dominant (homozygosity potentially lethal)
■ Most common cause of short-limbed dwarfism
■ ↑ Risk with paternal age
● Presentation:
○ Disproportionately short stature/size (normal torso, short extremities)
○ Craniofacial abnormalities: Macrocephaly, frontal bossing, flattened nose, prominent brow
○ Can experience recurrent otitis media (due to middle ear deformity)
○ Normal life span/intelligence
● Diagnostics:
○ X-ray: Shortened extremities, forehead prominence, scoliosis/spinal canal stenosis
● Management:
○ Mostly supportive (e.g., physical therapy)
○ Early growth hormone therapy
○ Consider surgery for significant musculoskeletal deformities (e.g., scoliosis, spinal stenosis, genu varum)
Osteoporosis
○ ↑ Activity osteoclasts > osteoblasts → ↑ Bone resorption → Loss of cortical and trabecular bone mass
■ Type 1 (Postmenopausal osteoporosis): ↓ Estrogen → ↑ Bone resorption → ↑ Weakness/susceptibility to fractures
■ Type 2 (Senile osteoporosis): ↓ Osteoblast activity → ↑ Bone resorption → ↑ Weakness/susceptibility to fractures
○ Risk factors: Age, sex (♀>♂), smoking, alcohol, inactivity, poor nutrition/malabsorbtion (Vitamin D, calcium)
○ Secondary causes: Corticosteroids, hyperparathyroidism, renal disease, proton pump inhibitors
● Presentation:
○ Often asymptomatic
○ Fragility fractures: Pathologic fractures occurring with regular daily activities (e.g., sitting down, sneezing, bending over)
■ Most commonly: Vertebral fractures, femoral neck, distal radius
○ Pain at site of fracture, possible loss of height (vertebral fx)
● Diagnostics:
○ Dual-energy x-ray absorptiometry (DEXA)
■ T-score ≤ -2.5 standard deviations (SDs) and/or a known fragility fracture
■ T-score -1 to -2.4 SDs = osteopenia
■ T-score ≥ -1 = normal
○ X-ray: Fracture, cortical thinning, radiolucency
○ Serum labs: Normal serum Ca2+, PO43-, ALP, PTH
● Management:
○ Prevention 1st: ↑ Physical activity, ↑ vitamin D/calcium intake (if deficient), avoid alcohol, smoking, and glucocorticoids
○ Pharmacologic: 1st line - Bisphosphonates (e.g., alendronate, risedronate, zoledronic acid)
■ Adverse effects: Jaw osteonecrosis, esophagitis, hypocalcemia
○ Alternatives: Denosumab (MAB against RANKL), teriparatide (PTH analogue), raloxifene (SERM), rarely calcitonin
Osteopetrosis
○ Genetic mutation → Defective osteoclasts → ↓ Bone resorption → Thick, poorly formed bone → ↑ Risk of fracture
■ Multiple genetic variations
■ Carbonic anhydrase II mutations impairs osteoclasts ability to create acidic environment
○ Also known as marble bone disease
● Presentation:
○ Recurrent pathologic fractures
○ Cranial nerve palsies (due to hyperostosis of foramina)
○ Pancytopenia (due to overgrowth of cortical bone crowding bone marrow space)
■ Can lead to extramedullary hematopoiesis
○ Can be asymptomatic
● Diagnostics:
○ X-ray: Symmetric dense osteosclerosis, bone-in-bone appearance (“stone bone”)
○ Serum labs: Normal/↓ Serum Ca2+, normal PO43-, ALP, PTH
● Management:
○ Bone marrow transplant (some forms)
○ High dose calcitriol (Vitamin D) may stimulate dormant osteoclasts
Osteomalacia/Rickets
○ ↓ Vitamin D → ↓ Ca2+ → Defective osteoid mineralization
○ Impaired growth plate mineralization (children)
■ Breastfed infants, ↓ UV exposure, malabsorption of fat soluble vitamins
● Presentation:
○ Bone pain, pathologic fractures, myopathy
○ Bony deformity (children) → Genu varum, kyphosis
○ Symptoms of ↓ Ca2+
● Diagnostics:
○ X-ray (Osteomalacia): Pseudofractures (looser zones), osteopenia
○ X-ray (Rickets): Metaphyseal cupping/fraying, widened epiphysis, rachitic rosary, craniotabes
○ Serum labs: ↓ Ca2+, ↓ PO43-, ↑ ALP, ↑ PTH
● Management:
○ Vitamin D supplementation (especially breastfed infants), ↑ Ca2+ intake
Osteitis Deformans (Paget disease of bone)

○ ↑ Activity between RANKL & RANK → ↑ Activity NF-κB ligand → ↑ Disorganized osteoclast & osteoblast activity → “Woven” bone formation
○ Bone remodeling phases
■ Lytic phase: ↑ Activity osteoclasts > osteoblasts → ↑ Bone resorption
■ Mixed lytic & blastic phase: ↑ Activity osteoclasts ≅ osteoblasts → ↑ Rate of bone formation
■ Sclerotic phase: ↑ Activity osteoclasts < osteoblasts → ↑ Bone formation
■ Quiescent stage: ↓ Activity osteoclasts & osteoblasts activity
● Presentation:
○ Typically adults >55 years old, often asymptomatic
○ Most commonly affects: Skull, vertebral column, pelvis, long bones
○ Bone pain, enlarging skull (↑ Hat size), hearing impairments (compression of nerve), pathologic fx
● Diagnostics:
○ X-ray: Poorly formed bone, areas of osteolytic lesions and sclerosis
○ Normal serum Ca2+, PO43-, PTH; ↑↑ ALP
● Management:
○ Pharmacologic: 1st line - Bisphosphonates (e.g., alendronate, risedronate, zoledronic acid)
■ Adverse effects: Jaw osteonecrosis, esophagitis, hypocalcemia
○ Alternatives: Calcitonin, vitamin D/calcium, NSAIDs for pain control
● Complications:
○ High-output cardiac failure, osteosarcoma
Osteitis Fibrosa Cystica

○ ↑ PTH → ↑ RANKL activation → ↑ Activity osteoclasts → Formation of cystic bone spaces/brown fibrous tissue (“brown tumor”)
○ 1° hyperparathyroidism: Idiopathic, parathyroid adenoma, malignancy/carcinoma
○ 2° hyperparathyroidism: CKD
● Presentation:
○ Bone pain
○ Signs of hyperparathyroidism
■ 1° hyperparathyroidism: Weakness, constipation, abdominal pain, psychiatric changes
● Diagnostics:
○ X-ray: ↓ Bone mineral density, subperiosteal thinning, cystic lesions, salt-and-pepper skull
○ Serum labs 1° hyperparathyroidism: ↑ Ca2+, ↓ PO43-, ↑ ALP, ↑ PTH
○ Serum labs 2° hyperparathyroidism: ↓ Ca2+, ↑ PO43-, ↑ ALP, ↑ PTH
● Management:
○ Vitamin D
○ Treat underlying causes (e.g., parathyroidectomy for malignancy)
Diagnostics of Bone Disorders
Etiology Serum Ca2+ Serum PO43- PTH ALP
Osteoporosis — — — —
Osteopetrosis —/↓ — — —
Osteomalacia ↓ ↓ ↑ ↑
Rickets
Osteitis Deformans — — — ↑↑
(Paget disease)
Osteitis Fibrosa Cystica
1° Hyperparathyroidism ↑ ↓ ↑ ↑
2° Hyperparathyroidism ↓ ↑ ↑ ↑
Hypervitaminosis D ↑ ↑ ↓ —
REVIEW OUTLINE
1. Rheumatoid Arthritis 7. Polymyositis/dermatomyositis

Musculoskeletal B. Associated Conditions

C. Presentation
D. Diagnostics
E. Management
B. Associated Conditions
B. Presentation
C. Diagnostics
D. Management
System: 2. Systemic Lupus Erythematosus

A. Pathophysiology
B. Presentation
8. Myositis Ossificans
A. Pathophysiology
B. Presentation
Rheumatologic
E. Drug-Induced Lupus 9. Systemic JIA
3. Sjӧgren Syndrome
Diseases
A. Pathophysiology
A. Pathophysiology B. Presentation
B. Associated Conditions C. Diagnostics
C. Presentation D. Management
D. Diagnostics 10. Raynaud Phenomenon
E. Management
A. Pathophysiology
F. Complications
4. Antiphospholipid syndrome C. Presentation
A. Pathophysiology D. Diagnostics
B. Presentation E. Management
C. Diagnostics 11. Scleroderma & MCTD
D. Management
A. Pathophysiology
5. Polymyalgia Rheumatica B. Presentation
A. Pathophysiology C. Diagnostics
B. Associated Conditions D. Management
C. Presentation 12. Sarcoidosis
D. Diagnostics
A. Pathophysiology
E. Management
6. Fibromyalgia C. Presentation
A. Pathophysiology D. Diagnostics
B. Associated Conditions E. Management
C. Presentation
D. Diagnostics
Musculoskeletal System: Rheumatologic Diseases Bootcamp.com
Rheumatoid Arthritis
Pathophysiology:
○ ↑ Inflammation → Proliferative angiogenesis → ↑ Granulation tissue/pannus formation → Hypertrophy of synovium + bone/cartilage destruction
■ IgM antibodies (Rheumatoid factor) against Fc portion of IgG
○ Risk factors: Genetic predisposition (HLA-DR1, HLA-DR4), smoking
Associated conditions:
○ Felty syndrome (arthritis, neutropenia, splenomegaly)
○ Caplan syndrome (pneumoconiosis)
Presentation:
○ ♀>♂, ↑ Age, constitutional symptoms (fever, fatigue, myalgias, weight loss)
○ Symmetric involvement typically of MCP & PIP joints, wrist, knees; morning stiffness (~>30 min)
■ DIP & CMC typically spared (contrast to OA)
○ Joint deformity: Atlantoaxial subluxation, boutonniere deformity (PIP flexion, DIP hyperextension), swan neck deformity (PIP hyperextension, DIP flexion)
○ Extra-articular manifestations: RA nodules, ILD, pleural effusions, carpal tunnel syndrome, anemia of chronic disease
Diagnostics:
○ Often a clinical diagnosis
○ X-ray: Soft tissue swelling, osteopenia, marginal erosions of the bone & cartilage, joint space narrowing
○ Autoantibody: Anti-cyclic citrullinated peptide (anti-CCP)
○ Nonspecific serology: Rheumatoid factor (RF), antinuclear antibody (ANA)
○ Arthrocentesis: Mild inflammatory synovial joint fluid (WBC 5000-50,000/mm3)
Management:
○ Acute: NSAIDs, selective COX-2 inhibitors (e.g., celecoxib), glucocorticoids
○ Disease-modifying antirheumatic drugs (DMARDs): Methotrexate (first-line), hydroxychloroquine, sulfasalazine, leflunomide
○ Biologic DMARDS for persistent disease: TNF-ɑ inhibitors (e.g., etanercept, infliximab)
Systemic Lupus Erythematosus

Pathophysiology:
○ Type II & III HSR → Autoantibody development/autoimmune reaction → ↑ Complement activation & inflammation → Multisystem tissue damage
○ Risk factors: Genetics (HLA-DR2, HLA-DR3), ↓ Classical complement proteins, ↑ Estrogen, smoking, UV light, medication (e.g., hydralazine, procainamide)
Presentation:
○ ♀>♂, ~15-45, constitutional symptoms (fever, fatigue, myalgias, weight loss)
○ Cutaneous involvement: Malar (butterfly rash), discoid rash, photosensitivity (maculopapular rash)
○ Musculoskeletal: Symmetrical polyarthritis, inflammation MCP & PIP joints without deformity (contrast RA)
○ Additional manifestations: Lupus nephritis, pericarditis/pleuritis, painless oral ulcers, cytopenia, lupus cerebritis, ↑ risk of thrombosis
■ Libman-Sacks Endocarditis
○ Fatal complications: Renal disease, infections, cardiovascular disease (“Redness In Cheeks”)
○ Pregnancy: ↑ Risk for neonatal lupus in an Anti-Ro/SSA or Anti-La/SSB (+) mother
■ Neonatal lupus: Congenital AV heart block, periorbital/diffuse rash, cytopenia, transaminitis
Diagnostics:
○ Autoantibody: Anti-double stranded DNA (anti-dsDNA) antibodies, Anti-Smith (anti-Sm) antibodies
○ Non-specific serology: Antinuclear antibodies (ANA), ↓ Complement proteins (C3, C4), ↑ ESR/CRP
■ ANA is sensitive but not specific (Negative ANA = low likelihood of disease)
■ Risk for false-positive RPR/VDRL (Syphilis diagnostic)
Management:
○ Hydroxychloroquine, glucocorticoids, immunosuppressants, NSAIDs
■ Routine eye exams for patients taking hydroxychloroquine
○ Avoid triggers (UV light, smoking)
Drug-Induced Lupus:
○ Lupus-like presentation triggered by certain medications (Classically: ɑ-methyldopa, hydralazine, isoniazid, procainamide, sulfa)
○ Anti-histone antibody (+)
Sjögren Syndrome
Pathophysiology:
○ ↑ Activation of immune system → Lymphocytic infiltration and destruction of lacrimal/salivary gland
○ RA, SLE, Raynaud phenomenon, viral infections, primary biliary cirrhosis (PBC)
Presentation:
○ ♀>♂, ~40 years of age
○ Keratoconjunctivitis sicca (dry eyes): Patient may feel “dirt/sand” in eyes
○ Xerostomia (dry mouth): Patient may have difficulty chewing/swallowing; ↑ Risk of cavities, halitosis
○ Xerosis (dry skin), joint pain
○ Often confused with age-related sicca syndrome
■ Differentiate by: 1) Age of onset, 2) normal antibody test, 3) normal biopsy
Diagnostics:
○ Autoantibody: Anti-Ro/SSA, anti-La/SSB
○ Non-specific serology: Rheumatoid factor (RF), antinuclear antibody (ANA), ↑ ESR/CRP
○ Salivary Gland Histopathology: Dense lymphocytic infiltration
○ Schirmer test: ↓ Production of tears measured by filter paper near lower eyelid
Management:
○ Symptom management: Artificial tears/saliva, muscarinic agonists (e.g., cevimeline, pilocarpine), hydration, oral hygiene
○ Severe case: Immunosuppression, glucocorticoids
Complications:
○ ↑ Risk B-cell non-hodgkin lymphoma (e.g., MALT lymphoma), corneal damage, neonatal lupus
Antiphospholipid Syndrome (APS)

Pathophysiology:
○ ↑ Antiphospholipid antibody production → ↑ Activation of platelets, ↓ Anticoagulant proteins → ↑ Hypercoagulability/risk of thrombosis
○ 1° idiopathic
○ 2° to underlying condition: SLE (most commonly), RA, HIV and/or hepatitis, bacterial infections, neoplasms
Presentation:
○ ♀>♂, ↑ Risk with age
○ Pregnancy: Recurrent miscarriages
○ Vascular abnormalities: DVT, PE, MI, stroke, livedo reticularis
Diagnostics:
○ Coagulation panel: ↑ Partial thromboplastin time (aPTT)
○ CBC: Thrombocytopenia, leukocytopenia, +/- hemolytic anemia
○ Autoantibody: Lupus anticoagulant, anti-cardiolipin, anti-β2-glycoprotein
■ Anti-cardiolipin → False-positive RPR/VDRL (Syphilis diagnostic)
○ Mixing study: Mix patient’s plasma with normal plasma/clotting factors
■ 1) aPTT normalizes → Lack of lupus anticoagulant
■ 2) aPTT remains prolonged → Presence of lupus anticoagulant Measure PTT
Management:
○ Thrombophylaxis: Aspirin, warfarin, LMWH/HMWH
○ Pregnancy: Combination of aspirin & heparin
○ Avoid medications containing estrogen (↑ Risk of thrombosis)
Polymyalgia Rheumatica (PMR)

Pathophysiology:
○ Poorly understood, overactive immune related response → ↑ Inflammation
○ Giant cell temporal arteritis (GCA)
■ ↑ Risk of blindness due to ophthalmic artery occlusion
Presentation:
○ ♀>♂, ↑ Risk with age (~60-70 years old)
○ Systemic: Fevers, fatigue, night sweats, weight loss
○ Musculoskeletal: Stiffness and pain of the neck, shoulders, trapezius, and pelvis/hips (Worse in morning)
■ Does not typically present with weakness
Diagnostics:
○ Serum labs: ↑ ESR & CRP, normal creatine kinase (CK)
○ Serology: No specific autoantibodies, (-) Rheumatoid factor (RF)
Management:
○ Low-dose glucocorticoids
Fibromyalgia
Pathophysiology:
○ Poorly understood, non-inflammatory musculoskeletal symptoms
○ Somatic conditions (e.g., IBS, migraines, chronic fatigue syndrome)
○ Psychiatric conditions (e.g., GAD, depression)
Presentation:
○ ♀>♂, ~20-50 years old
○ Systemic: Headache, fatigue, poor sleep, cognitive changes (“Fibro fog”)
○ Musculoskeletal: Diffuse pain with “tender points,” paresthesias
Diagnostics:
■ 3 months duration, pain affects all quadrants of the body, profuse “tender points” on exam
○ Serum labs: Normal ESR, no specific autoantibodies
○ Imaging: No significant changes
Management:
○ Exercise
○ Antidepressants (e.g., Duloxetine, amitriptyline)
○ Neuropathic pain medications (e.g., Gabapentin, pregabalin)
■ Avoid opioid medications for pain control
Polymyositis/Dermatomyositis
Pathophysiology:
○ Autoimmune inflammatory myopathy → Progressive muscle weakness +/- cutaneous involvement (dermatomyositis)
■ Polymyositis: cell-mediated cellular damage
■ Dermatomyositis: antibody mediated cellular damage (paraneoplastic or idiopathic)
Associated Conditions:
○ Malignancy
○ Esophageal weakness
○ Myocarditis
○ Respiratory failure, interstitial lung disease
Presentation:
○ Polymyositis: Symmetric proximal muscle weakness/myalgias (typically shoulders)
○ Dermatomyositis: Symmetric proximal muscle weakness/myalgias (typically shoulders)
■ Cutaneous involvement: Heliotrope edema, Gottron papules, mechanic’s hands, “shawl and V” sign
Diagnostics:
○ Autoantibody: Anti-Jo-1 (histidyl-tRNA synthetase), anti-SRP (signal recognition particle), anti-Mi-2 (helicase)
○ Non-specific serology: Rheumatoid factor (RF), antinuclear antibody (ANA)
○ Serum labs: Normal/↑ ESR/CRP, ↑ CK, ↑ aldolase, ↑ myoglobin, ↑ LDH
○ Muscle biopsy: Polymyositis: Endomysial inflammation with CD8+ T-cells; Dermatomyositis: Perimysial inflammation with CD4+ T-cells
○ Patients diagnosed with PM or DM should be tested for underlying malignancy
Management:
○ Glucocorticoids +/- steroid-sparing medications (e.g., methotrexate, azathioprine)
Myositis Ossificans
Pathophysiology:
○ Repeated or blunt trauma/damage → Heterotopic ossification of skeletal muscle
■ Can be seen overuse injuries
Presentation:
○ Painful soft tissue mass
○ Local swelling, tenderness, ↓ ROM
Diagnostics:
○ Serum: ↑ ESR, alkaline phosphatase
○ Imaging: Peripheral bone formation/soft tissue calcifications
Management:
○ Symptom management (e.g., rest, activity modification, physical therapy)
○ Often self-limiting
○ Consider surgery if refractory to conservative management
Systemic Juvenile Idiopathic Arthritis (Still’s Disease)

Pathophysiology:
○ Poorly understood
Presentation:
○ ♀=♂, typically <16 years old (Peak incidence ~2-4 y/o)
○ Systemic: Intermittent spiking fevers
○ Musculoskeletal: Arthritis typically involving ≥ 2 joints (typically knee, ankle or wrist)
■ Symptoms lasting > 6 weeks
○ Additional findings: Uveitis, salmon-colored macular rash, hepatosplenomegaly, serositis
Diagnostics:
○ Serum labs: ↑ ESR & CRP, can present with ↓ RBCs/↑ WBCs
○ Non-specific serology: (+) ANA, (-) RF
Management:
○ NSAIDs (e.g., Indomethacin)
○ DMARDS (e.g., Methotrexate)
○ Steroids
○ TNF inhibitors (e.g., Etanercept)
Raynaud Phenomenon
Pathophysiology:
○ Reversible vasoconstriction of arteries & arterioles → ↓ Blood flow to extremities → Ischemia
○ 1° idiopathic
○ 2° to underlying disease, medications, hyperviscosity
○ Scleroderma (CREST syndrome), SLE, MCD
○ Cryoglobulinemia, Waldenstrom macroglobulinemia
Presentation:
○ Typically affect distal digits for 10-20 minutes (e.g., fingers & toes)
■ Prolonged constriction can lead to necrosis
○ Triphasic presentation: Ischemic, hypoxic, hyperemic
■ Possible livedo reticularis
Diagnostics:
○ Consider further work-up for underlying disease
Management:
○ Avoid triggers (e.g., cold exposure, triggering medications, smoking, stress)
○ Calcium channel blockers (e.g., nifedipine)
Scleroderma & Mixed Connective Tissue Disease (MCTD)

Pathophysiology:
○ Autoimmune non-inflammatory vasculopathy → ↑ Fibroblast activation → ↑ Collagen synthesis & deposition → ↑ Organ fibrosis
Presentation:
○ ♀>♂, ~30-50 years old
○ Cutaneous manifestations: Thickened skin/fibrosis, pruritus, loss of wrinkles, telangiectasias
○ Non-cutaneous manifestations: Raynaud phenomenon, ↓ renal function, oliguria, MAHA, pulmonary HTN, ILD, GERD, constipation
○ Limited (CREST): Calcinosis cutis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia
■ More benign course, less skin involvement, slower onset
○ Diffuse: Widespread skin thickening multiorgan involvement, life-threatening complications
○ MCTD: Overlapping characteristics of 3 syndromes (systemic sclerosis, SLE, polymyositis)
Diagnostics:
○ Autoantibody: Anticentromere (limited), anti-Scl-70 (both), anti-RNA polymerase III (diffuse)
○ Non-specific serology: ANA
○ MCTD: Anti-U1 RNP antibody
Management:
○ Symptom management
■ CCBs for Raynaud phenomenon
■ PPIs for GERD
■ Methotrexate for cutaneous fibrosis
■ PDE-5 inhibitor or endothelin receptor antagonist for pulmonary HTN
■ ACEis for scleroderma renal crisis
Sarcoidosis
Pathophysiology:
○ Antigen trigger → ↑ Inflammation/immune response → Noncaseating granuloma formation
■ Macrophages activate Th1 cells → ↑ IFN-ɣ release → ↑ Formation epithelioid cell (↑ ACE + cytokines)
○ Calcium dysfunction: ↑ Activity of macrophages → ↑ 1 ɑ-hydroxylase → ↑ Calcitriol → Hypervitaminosis D
○ ↑ Risk for malignancy
○ CV/Pulm: Aspergilloma, bronchiectasis, pulmonary fibrosis/HTN, myocarditis
○ Facial nerve palsy
Presentation:
○ ♀>♂, ~30-55 years old; ↑ Prevalence in African Americans
○ Can be asymptomatic early in course
○ Systemic: Fever, fatigue, myalgias, weight loss
○ CV/Pulm: Chest pain, cough, dyspnea
○ Additional manifestations: Anterior uveitis, arthritis, butterfly rash, erythema nodosum, lupus pernio
○ Lofgren syndrome: Fever + 1) Bilateral hilar lymphadenopathy, 2) Erythema nodosum, 3) Migratory polyarthritis
Diagnostics:
○ CXR: Bilateral hilar lymphadenopathy
○ Serum: ↑ ACE, ↑ ESR/CRP, ↑ Ca2+
○ Biopsy: Noncaseating granulomas with giant cells
○ Bronchoalveolar lavage (BAL): ↑ CD4:CD8 ratio
○ PFTs consistent with restrictive lung disease
Management:
○ Glucocorticoids for systemic or extrapulmonary symptoms
○ Isolated pulmonary sarcoidosis does not require treatment
Video Vignettes
Video 3.1 Rheumatoid Arthritis:
○ A 38 year-old woman presents to the clinic with a chief complaint of bilateral hand pain and stiffness. The patient reports some increased fatigue over the
last several months with not obvious fluctuations in her weight. Vital signs are within normal limits. On physical exam the patient has tenderness over the
wrist and 4 out of 5 strength with hand grip secondary to pain. There is hyperextension of the PIP and flexion of the DIP joints. Labs show elevated CRP
but negative rheumatoid factor. Which of the following is the most likely diagnosis?
Video 3.2 Systemic Lupus Erythematosus:
○ A 33 year-old patient presents to the clinic with a chief complaint of fevers, fatigue, and weight loss over the last 3 weeks. The patient reports
experiencing multiple sunburns on her face this year with minimal sun exposure. On physical exam you notice a mildly erythematous face on the face
that spares the nasolabial folds. Which of the following antibody test would help confirm the diagnosis?
Video 3.3 Sjӧgren Syndrome:
○ A 42 year-old woman presents to the office with a chief complaint of a dry eyes and a new lump on near her neck. The patient reports noticing the lump
about one week ago but she has also had severely dry/burning eyes for several months. Upon further questioning the patient reports having five new
dental caries at her recent dental visit. Vital signs are normal. On physical exam the patient has an approximately 1.5 cm submandibular palpable lump.
Which of the following labs could help confirm this patients underlying diagnosis?
Video 3.4 Antiphospholipid Syndrome:
○ A 32 year-old patient presents to clinic after her third miscarraige. The patient reports overall good health, but does have history of two deep venous
thrombosis in the past. Vital signs are normal. On physical exam you notice a reddish-blue netlike skin discoloration on the lower extremities. Which of
the following is the most likely cause for the patients recurrent miscarriages?
Video Vignettes
Video 3.5 Polymyalgia Rheumatica:
○ A 55 year-old patient presents to clinic with a chief complaint of fatigue and pain in her hips and shoulders. The patient reports intermittent night sweats
and 10 pounds of unintentional weight loss over the last month. Vital signs are normal. On physical exam the patient has 5/5 strength in bilateral upper
and lower extremities with generalized tenderness over both deltoid muscles. Notable labs include elevated ESR with a normal CK. Which of the
following is the most likely diagnosis?
Video 3.6 Fibromyalgia:
○ A 44 year-old woman presents to clinic with a chief complaint of headache and neck pain. The patient reports symptoms have been worsening for years
and she has been to many doctors without improvements. Vital signs are within normal ranges. On physical exam the patient has point tenderness over
the upper trapezius muscles and greater trochanters bilaterally. Labs reveal normal ESR, CRP, CK and electrolytes. Which of the following is the best
treatment option for this patient?
Video 3.7 Polymyositis/Dermatomyositis:
○ A 50 year-old patient presents to the clinic with a chief complaint of weakness climbing stairs and brushing her hair. The patient also reports new onset
redness around both of her eyelids. Vital signs are normal. Which of the following would you expect to see on muscle biopsy.?
Video 3.8 Myositis Ossificans:
○ A 76 year-old patient presents to clinic with a chief complaint of pain and stiffness in the right hip. The patient underwent a total hip arthroplasty 6 months
ago and although the pain and stiffness was better in the weeks after surgery it has been getting worse. Vital signs are normal. On physical exam the
patient has 5/5 strength in right leg with restricted motion on hip internal and external rotation. On x-ray the hip is not dislocated, but there is increased
ossification around the hip joint that was not present on the initial postoperative x-ray. Which of the following is the most likely diagnosis for this patient?
Video Vignettes
Video 3.9 Systemic Juvenile Idiopathic Arthritis (Still’s Disease):
○ An 8 year-old patient presents to clinic with a chief complaint of bilateral knee and ankle pain for 2 months. The patient reports the pain is worse after
recess. Vital signs are normal in the office, but his mother reports intermittent fevers taken at home over the last several weeks. On physical exam there
is moderate right knee swelling and mild left knee swelling. Notable labs include elevated ESR/CRP. Which of the following might you also expect to see
on this patient’s exam?
Video 3.10 Raynaud Phenomenon:
○ A 29 year-old patient who recently moved to Colorado from Nevada comes to the clinic with a chief complaint of white finger discoloration that is worse
with walking outside. The fingers tend to turn blue-ish and then return to their normal color upon returning from the walk. Vital signs are within normal
ranges. Which of the following is a possible pharmacologic treatment option for this patient?
Video 3.11 Scleroderma & MTCD:
○ A 42 year-old patient with a medical history of interstitial lung disease (ILD) presents to the clinic with a chief complaint of increasing acid reflux. The
patient reports she feels well overall but has previously been told she had a thyroid disorder. On physical exam you notice several small blood vessels
around the left ear. Which of the following antibodies is most closely associated with this patients condition?
Video 3.12 Sarcoidosis:
○ A 31 year-old patient presents to clinic with new onset dyspnea, malaise, and redness in her eyes. The patient also reports noticing a nodular purple
lesions on both of her cheeks right next to the nose. On physical exam the patient has hepatosplenomegaly. Chest X-ray shows bilateral hilar
lymphadenopathy. Which of the following conditions might also be seen in this patient?
REVIEW OUTLINE
1. Seronegative Spondyloarthritis Overview
Musculoskeletal A. Pathophysiology
B. Common Presentations
C. Key Types
System: 2. Psoriatic Arthritis

A. Pathophysiology
Seronegative
B. Presentation
C. Diagnostics
D. Management
Spondyloarthritis 3. Ankylosing Spondylitis

A. Pathophysiology
B. Presentation
C. Diagnostics
D. Management
4. IBD-Associated Spondyloarthritis
A. Pathophysiology
B. Presentation
C. Diagnostics
D. Management
5. Reactive Arthritis
A. Pathophysiology
B. Presentation
C. Diagnostics
D. Management
Musculoskeletal System: Seronegative Spondyloarthritis Bootcamp.com
Seronegative Spondyloarthritis Overview

Pathophysiology:
○ Chronic inflammatory arthritis that is negative for rheumatoid factor (anti-IgG antibody)
○ Risk factors: Genetics (HLA-B27)
Common presentations:
○ ♂>♀, typically <45 years old
○ Constitutional symptoms (fever, fatigue, weight loss)
○ Arthritis
■ Asymmetric oligoarthritis
■ Pain & stiffness (worse in the morning)
○ Dactylitis
○ Enthesitis
○ Ocular manifestations (e.g., uveitis)
Key Types:
○ Psoriatic arthritis
○ Ankylosing spondylitis (strongest association with HLA-B27)
○ IBD-associated spondyloarthritis
○ Reactive arthritis
Psoriatic Arthritis
Pathophysiology:
○ Seronegative spondyloarthritis
○ ↑ IFN-⍺, IL-6, TNF-⍺ → ↑ T-cell recruitment to skin & joints → ↑ Osteoclast activation → Osteolysis
Presentation:
○ ~30-50 years old
○ Asymmetric oligoarthritis → Symmetric polyarthritis (later stages)
○ Skin psoriasis, pitting nail beds, enthesitis, dactylitis (“sausage digits”)
■ Occasionally uveitis
Diagnostics:
○ X-ray: “Pencil-in-cup” deformity of DIP joint, paravertebral ossification
○ Serum labs: ↑ CRP, ESR, uric acid
○ Associated with HLA-B27; Typically rheumatoid factor (RF) negative
○ Classification criteria for psoriatic arthritis (CASPAR)
■ ↑ Score = ↑ Likelihood of PsA
Management:
○ NSAIDs
○ Disease-modifying antirheumatic drugs (DMARDs)
■ TNF-ɑ inhibitors
○ Intra-articular glucocorticoids
Ankylosing Spondylitis
Pathophysiology:
○ ↑ TGF-β, TNF-⍺, IL-17, and IL-23 → ↑ T-cell and macrophage recruitment → Joint erosion/bone spur formation
Presentation:
○ ♂>♀; typically ~15-35 years old
○ Symmetric bilateral low back pain (sacroiliac joint)
■ Classically improves with activity, but does not improve with rest
■ ↓ Spine mobility
○ Peripheral arthritis, anterior uveitis, restrictive lung disease, aortitis/aortic regurgitation, enthesitis (inflammation of tendon/ligaments)
■ RLD due to costovertebral and costosternal ankylosis
Diagnostics:
○ X-ray: Vertebral fusion (“Bamboo spine”), erosion and sclerosis of SI joints classically on iliac side of SI joint
■ MRI is most sensitive for early disease
○ Strong association with HLA-B27
○ ↑ Inflammatory markers (ESR & CRP)
Management:
○ Physical therapy
○ Non-steroidal anti-inflammatories (NSAIDs)
○ TNF-alpha inhibitors (e.g., infliximab, etanercept)
○ Surgery rarely indicated
IBD-Associated Spondyloarthritis
Pathophysiology:
○ Unclear pathophysiology
○ Associated with patients who have Crohn's disease or ulcerative colitis
Presentation:
○ IBD symptoms: diarrhea (possibly bloody), abdominal pain, weight loss
○ Typically asymmetric oligoarthritis
○ Patients can also have other symptoms associated with spondyloarthritis: uveitis, enthesitis, dactylitis
Diagnostics:
○ Associated with HLA-B27
○ Serum labs: ↑ CRP, ESR
Management:
○ Symptom management: NSAIDs, glucocorticoids
○ Treat underlying IBD: DMARDs, TNF-ɑ inhibitors, mesalazine
Reactive Arthritis
Pathophysiology:
○ ↑ Immune response following infection → ↑ T-cell and macrophage recruitment → Damage to joint synovium, conjunctiva, urethra, cutaneous infiltration
Presentation:
○ Asymmetric migratory oligoarthritis (typically lower extremities)
○ Classic triad: conjunctivitis, urethritis, arthritis
■ “Can’t see, can’t pee, can’t bend my knee”
○ Cutaneous manifestations: Keratoderma blenorrhagicum
Diagnostics:
○ Clinical diagnosis
○ Classic triggering infections: Campylobacter, Chlamydia, C. diff, E. Coli, Shigella, Salmonella, Ureaplasma urealyticum, Yersinia
○ Associated with HLA-B27
○ Serum labs: ↑ CRP, ESR
○ Typically negative for RF & anti-CCP antibodies
Management:
○ Self limited, can take months to resolve
○ Symptom management: NSAIDs, glucocorticoids, DMARDs (chronic/severe disease)
○ Antibiotics for underlying infection
○ High rate of recurrence
Video Vignettes
Video 4.1:
○ Overview video - no vignette
Video 4.2 (Psoriatic Arthritis):
○ A 28 year-old patient presents to the emergency department with a chief complaint of new onset hand pain. The patient reports morning stiffness in the
fingers which interferes with the patients job as a secretary. The patient has a known history of psoriasis which is appropriately treated and under control.
Which of the following additional physical exam findings might you see on this patient?
Video 4.3 (Ankylosing Spondylitis):
○ A 29 year-old patient presents to the clinic with a chief complaint of low back pain for two months. The patient reports a gradual onset of the symptoms
and that they tend to be worse with prolonged sitting and improved with walking. Vital signs are stable. The patient is found to have elevated
inflammatory markers on his lab work. Which of the following would most likely confirm the patient's diagnosis?
Video 4.4 (IBD-associated Spondyloarthritis):
○ A 33 year-old patient presents to the clinic with a chief complaint of bloody stools and intermittent knee and ankle pain. The patient reports no recent
trauma and is unsure if activity worsens the joint pain. The bloody stools have been present for about two weeks and the patient has also had a 10
pound weight loss during that time. Which of the following is another associated finding that this patient could present with?
Video 4.5 (Reactive Arthritis):
○ A 23 year-old female presents to the clinic with a chief complaint of left knee pain for the last week. The patient denies other symptoms at this time, but is
sexually active with multiple partners. On physical exam the left knee is mildly swollen without erythema or warmth. On labs the patient has an elevated
ESR and a nucleic acid amplification test positive for chlamydia trachomatis. Which of the following is the best treatment option at this time?
REVIEW OUTLINE
1. Osteochondroma & Enchondroma 6. Chondrosarcoma
Musculoskeletal A. Epidemiology
B. Presentation
C. Diagnostics
A. Epidemiology
B. Presentation
C. Diagnostics
System: 2.
D. Management
Osteoma & Osteoid Osteoma 7.
D. Management
Ewing Sarcoma
Primary Bone
A. Epidemiology A. Epidemiology
Tumors 3.
D. Management
Osteoblastoma 8.
D. Management
Bone Tumors Summary
A. Epidemiology
B. Presentation
C. Diagnostics
D. Management
4. Giant Cell Tumor
A. Epidemiology
B. Presentation
C. Diagnostics
D. Management
5. Osteosarcoma
A. Epidemiology
B. Presentation
C. Diagnostics
D. Management
Musculoskeletal System: Primary Bone Tumors Bootcamp.com
Osteochondroma & Enchondroma

● Epidemiology:
○ Osteochondroma: Most common benign bone tumor; typically ~10-30 years old
○ Enchondroma: Most common tumor of the hand; typically ~20-50 years old
● Presentation:
○ Osteochondroma: Typically metaphysis of long bones
■ Typically asymptomatic, but can be painful to palpation
○ Enchondroma: Medulla of hand (most common), feet, or distal femur
■ Typically painless, but can present as pathologic fracture
■ Often located in medulla of bone
● Diagnostics:
○ Osteochondroma: X-ray: Sessile, pedunculated lesion near metaphysis (exostosis with cartilaginous cap)
○ Enchondroma: X-ray: Well-defined lucent medullary lesion (arises from hyaline cartilage)
● Management:
○ Osteochondroma: If symptomatic → Consider surgical excision
■ ~1% rate of transformation into chondrosarcoma (malignant)
○ Enchondroma: If symptomatic, consider surgical excision Osteochondroma Enchondroma
Osteoma & Osteoid Osteoma

● Epidemiology:
○ Benign bone tumors
○ Osteoma: Typically middle age
○ Osteoid osteoma: ~5-25 years old
● Presentation:
○ Osteoma: Surface of facial & cranial bones
■ Typically asymptomatic
■ Associated with Gardner syndrome (variant of FAP w/ bone/soft tissue tumors)
○ Osteoid osteoma: Metaphysis & diaphysis of long bones
■ Pain that is worse at night Osteoma Osteoid osteoma
■ Typically relieved by NSAIDs
● Diagnostics:
○ Osteoma: CT scan: Hyperdense, well demarcated smooth bony mass
○ Osteoid osteoma: CT scan: Radiolucent osteoid core with surrounding perifocal sclerosis
■ Typically smaller than osteoblastoma (<2 cm)
● Management:
○ Osteoma: Surgical removal if extensive
○ Osteoid osteoma: NSAIDs or surgical removal, if needed
Osteoblastoma
● Epidemiology:
○ Benign bone tumor
○ ♂>♀; typically ~10-20 years old
● Presentation:
○ Localized pain +/- swelling
○ May cause neurological symptoms if nerve compression occurs
● Diagnostics:
○ X-ray: Tumor in cortical bone
■ Vertebrae (most common), long bone diaphysis
■ Typically larger than osteoid osteoma (>2 cm)
● Management:
○ Does NOT respond to NSAIDs
○ Surgical removal may be necessary
Giant Cell Tumor (Osteoclastoma)

● Epidemiology:
○ Typically ~20-40 years old
● Presentation:
○ Localized pain +/- swelling
○ Pathologic fractures
○ ↓ Range of motion
○ Typically the epiphysis or metaphysis of long bones
■ Commonly in the knee region/distal femur
● Diagnostics:
○ X-ray: Osteolytic multicystic lesion (“soap-bubble” appearance)
○ Histopathology: Multinucleated giant cells, ↑ Macrophages, ↑ Stromal cells
■ RANK-L expressing neoplastic mononuclear cells
● Management:
○ Surgical intervention
■ ↑ Age = ↑ Risk of malignancy
Osteosarcoma
● Epidemiology:
○ Malignant bone tumor
○ Bimodal age distribution: ~10-30 & >60 years old
○ Primary osteosarcoma: Unknown
○ Secondary osteosarcoma: Paget disease, radiation, bony infarcts, retinoblastoma, Li-Fraumeni syndrome, ↑ Age
● Presentation:
○ Typically in the metaphysis of long bones (near knee region)
○ Localized pain (worse at night) & swelling, ↓ ROM
○ +/- B-symptoms (fever, night sweats, unintentional weight loss)
● Diagnostics:
○ X-ray: Sunburst pattern, Codman triangle (due to periosteal elevation), osteolysis (“Moth-eaten appearance”)
○ Histopathology: Pleomorphic osteoid producing cells (malignant osteoblasts)
○ Serum labs: ↑ ESR, ↑ LDH, ↑ Alkaline phosphatase
● Management:
○ Primary causes respond to surgery & chemotherapy
■ Often resistant to radiation therapy
○ Secondary causes often have poor prognosis
Chondrosarcoma
● Epidemiology:
○ ♂>♀; Typically >50 years old
○ Primary chondrosarcoma has unknown etiology
○ Secondary chondrosarcoma: Paget disease, radiation, osteochondroma
● Presentation:
○ Typically in medullary portion of femur, humerus, pelvis, ribs
○ Localized pain & swelling
■ Pain is worse at night
● Diagnostics:
○ X-ray: Osteolysis (“Moth-eaten appearance”); Intralesional calcification (“popcorn appearance”)
○ Histopathology: Peripheral calcification with hyaline cartilage nodules, malignant chondrocytes
● Management:
○ Surgical excision +/- chemotherapy and/or radiation therapy
■ Overall low metastatic potential
Ewing Sarcoma
● Epidemiology:
○ Typically young white males ~10-20 years old
○ Aggressive with early metastasis
● Presentation:
○ Diaphysis of long bones (femur) or flat bones (pelvis)
○ Localized pain & swelling
○ B-symptoms (fever, night sweats, unintentional weight loss)
● Diagnostics:
○ X-ray: “Onion skin” appearance, lytic bone lesions (“Moth-eaten appearance”)
○ Histopathology: Anaplastic small blue cells of neuroectodermal (mesenchymal) origin
■ Must differentiate from similar cell morphology such as lymphocytes seen in lymphoma or chronic osteomyelitis
○ Chromosomal translocation: t(11;22) → EWS-FLI1 fusion protein → ↑ Cellular proliferation
○ Serum labs: ↑ ESR, ↑ LDH, ↑ Leukocytosis
● Management:
○ Surgical resection +/- chemotherapy
■ Radiation therapy in some cases
Summary - Benign Bone Tumors

Tumor Type Osteochondroma Enchondroma Osteoma Osteoid Osteoma Osteoblastoma Giant Cell Tumor
Epidemiology Most common bone Most common bone Middle age ~5-25 y/o ~10-20 y/o ~20-40 y/o
tumor, ~10-30 y/o tumor of the hand,
~20-50 y/o
Location Metaphysis Medulla of hand, Surface of facial & Metaphysis & Vertebrae, diaphysis Metaphysis and/or
foot, femur cranial bones diaphysis epiphysis
Diagnostics Sessile, pedunculated Well-defined Hyperdense, Radiolucent Well-demarcated Osteolytic multicystic

lesion lucency smooth osteoid core cortical tumor lesions (“soap-bubble”)
Pathology: Giant cells
Management Surgery if Surgery if Surgery if Surgery if Surgery if Surgical excision

symptomatic; symptomatic symptomatic symptomatic; symptomatic; does
~1% transform into NSAIDs not respond to
chondrosarcoma NSAIDs
Summary - Malignant Bone Tumors

Tumor Type Osteosarcoma Chondrosarcoma Ewing Sarcoma
Epidemiology ~10-30 & >60 years old >50 years old ~10-20 years old; early metastasis
Location Metaphysis (near knee region) Medulla of femur, humerus, pelvis, ribs Diaphysis of long bones (femur),
flat bones (pelvis)
Diagnostics
Radiographs Sunburst pattern, codman triangle, Intralesional calcification (“popcorn”), Osteolysis (“Moth-eaten”),
osteolysis (“Moth-eaten”) osteolysis (“Moth-eaten”) “Onion skin” appearance
Histopathology Pleomorphic osteoid producing cells Peripheral calcification, Anaplastic small blue cells
hyaline cartilage nodules
Management 1° causes surgery & chemotherapy, Surgical excision +/- chemotherapy, Surgical resection +/- chemotherapy
2° causes = poor prognosis consider radiation therapy
Video Vignettes
Video 5.1 (Osteochondroma & Enchondroma):
○ A 13-year-old boy presents to the pediatrician with a chief complaint of a “bump” on his right thigh just above the knee. The patient denies any symptoms
of illness or known trauma to the area. On physical exam there is a palpable painless mass above the lateral joint line. Which of the following imaging
modalities would be most appropriate for further evaluation at this time?
Video 5.2 (Osteoma & Osteoid Osteoma):
○ A 21 year-old patient presents to the clinic with a chief complaint of left knee pain that is worse at night. The patient denies any symptoms of illness or
known trauma to the area. On physical exam there is a palpable painless mass above the lateral joint line. Radiographic imaging shows a 2cm
radiolucent core with surrounding hyperintensity. Which of the following treatment options could help improve this patient's nighttime pain?
Video 5.3 (Osteoblastoma):
○ A 15-year-old patient presents to the pediatrician with new onset upper back & neck pain. The patient feels well overall and denies any known trauma to
the area. He reports occasional numbness and tingling down his right arm as well. The patient's mother reports they have been trying conservative
measures such as stretching, ice, and anti-inflammatories but these do not seem to improve the symptoms. Which of the following is the most likely
bone tumor this patient has?
Video 5.4 (Giant Cell Tumor):
○ A 33 year-old patient presents to clinic with a chief complaint of new onset right thigh pain. The patient reports he was helping his friend move to a new
apartment and when lifting up a heavy box he heard a crack in his leg. On imaging studies the patient is found to have a right distal femur spiral fracture
that is located next to multiple osteolytic lesions. Which of the following cell types is most likely overactive in this patient?
Video Vignettes
Video 5.5 (Osteosarcoma):
○ An 18 year-old patient presents to the ED with distal thigh pain for the last several weeks. The pain is progressively worsening and affecting his ability to
sleep comfortably at night. On physical exam there is tenderness and swelling around the affected area. Which of the following imaging modalities would
be the most appropriate to further work up this patient's chief complaint?
Video 5.6 (Chondrosarcoma):
○ A 68 year-old patient presents to clinic with 2 months of right leg pain that is worse at night. The pain is most notable in the distal thigh and there is a
mild effusion on physical exam. Vital signs are within normal limits. An x-ray is taken of the leg and knee which shows multiple small lytic lesions in the
distal femur. Which of the following would be most useful to treat this patient's condition?
Video 5.7 (Ewing Sarcoma):
○ A 13 year-old boy presents to the pediatric clinic with 1 week of worsening pain and swelling below his left knee. He denies any recent trauma to the
area or falls. The patient reports he feels well overall but has had intermittent night sweats over the past couple of weeks. Vital signs are within normal
limits for this patient. The physician orders a radiograph which shows slight elevation of the proximal tibial periosteum. Which of the following
chromosomal translocations is most likely in this patient?
REVIEW OUTLINE
1. Giant Cell Arteritis (GCA) 7. Cutaneous Small-Vessel Vasculitis
B. Pathophysiology B. Pathophysiology
Musculoskeletal C. Presentation
D. Diagnostics
E. Management
C. Presentation
D. Diagnostics
E. Management
2. Takayasu Arteritis
System:
8. Eosinophilic Granulomatosis with Polyangiitis
C. Presentation C. Presentation
Vasculitides
D. Diagnostics D. Diagnostics
E. Management E. Management
3. Thromboangiitis Obliterans (Buerger Disease) 9. Granulomatosis with Polyangiitis (GPA)
4. Kawasaki Disease 10. IgA Vasculitis (Henoch-Schonlein Purpura)
5. Polyarteritis Nodosa 11. Microscopic Polyangiitis
6. Behcet Disease 12. Mixed Cryoglobulinemia
Musculoskeletal System: Vasculitides Bootcamp.com
Giant Cell Arteritis (GCA)

Epidemiology:
○ ♀>♂; typically >70 years old
○ Associated with polymyalgia rheumatica (PMR) & HLA-DR4
Pathophysiology:
○ Dendritic cell activation → ↑ Th1 response → Monocyte recruitment/Macrophage differentiation → Giant Cells
○ Giant cell cytokine production → Acute phase reactants (e.g., IL-6, TNF-ɑ)
○ ↑ Production of metalloproteinases → ↑ Vascular damage to surrounding tissue
○ ↑ Production of growth factors (e.g., PDGF, VEGF) → ↑ Intimal hyperplasia → ↓ Vascular blood flow
Presentation:
○ Systemic symptoms: Fatigue, fevers, night sweats, weight loss
○ Cranial symptoms: New-onset headache over the temple (typically unilateral), jaw claudication, vision loss (e.g., Amaurosis fugax, diplopia)
○ Additional symptoms: Abdominal pain, chest pain, limb claudication, asymmetric pulses
○ Symptoms of PMR
Diagnostics:
○ Serum labs: ↑ ESR, CRP
○ Histopathology (Gold Standard): Temporal artery biopsy showing panarteritis, mononuclear infiltration with formation of giant cells
■ Should be considered in all patients who have suspected GCA
Management:
○ High-dose glucocorticoid therapy
■ Initiate immediately if clinical suspicion for GCA is high to ↓ risk of complications
○ Untimely administration of treatment can lead to aortic aneurysms, brain ischemia, and/or permanent loss of vision
Takayasu Arteritis
Epidemiology:
○ ♀>♂; typically 15-45 years old
○ Most common in Asian individuals
Pathophysiology:
○ Not well understood
○ ↑ Local inflammation & immune cell recruitment → Damage to vascular smooth muscle
○ ↑ Transmural fibrosis and thickening of arterial walls → Vessel occlusion → ↓ Vascular blood flow
Presentation:
○ Systemic symptoms: Fatigue, fevers, myalgias, night sweats
○ Vascular symptoms: ↓ Brachial and/or radial pulses bilaterally (“Pulseless disease”), angina, carotid bruits, syncope, ocular changes
Diagnostics:
○ Serum labs: ↑ ESR, CRP
○ Imaging: MR angiography (MRA) showing stenosis or occlusion of vascular lumen
○ Histopathology: Transmural fibrosis with granulomatous thickening of the aortic arch
Management:
○ Glucocorticoids + glucocorticoid-sparing agent (e.g., cyclophosphamide, methotrexate)
○ Surgery indicated in emergency situations (e.g., vascular bypass for severe stenosis)
Thromboangiitis obliterans (Buerger Disease)

Epidemiology:
○ ♂>♀; typically 30-50 years old
○ Smoking (MCC)
Pathophysiology:
○ ↑ Local inflammation & immune cell recruitment → Damage to vascular wall (specifically small & medium-sized vessels)
○ ↑ Local microthrombi formation → Vessel occlusion → ↓ Vascular blood flow
Presentation:
○ Intermittent claudication typically in the hands, feet, or calves
○ Migratory superficial thrombophlebitis
○ Raynaud phenomenon
○ Progressive symptoms similar to peripheral artery disease (PAD)
■ Cool extremities, skin ulcers, gangrene, pain at rest or with mild exertion
Diagnostics:
○ Serum labs: ESR, CRP within normal limits
○ Imaging: Arteriography showing nonathroslcerotic segmental lesions and vessel occlusion
■ Can initially use doppler ultrasound imaging, but arteriography is preferred
○ Ankle-brachial index: ↓ typically, but can be normal
Management:
○ Smoking cessation
○ Medical therapy for symptom management (e.g., CCBs, Iloprost, hyperbaric oxygen)
○ Surgical intervention may be needed for debridement or amputation
Kawasaki Disease (Mucocutaneous Lymph Node Syndrome)

Epidemiology:
○ ♂>♀; typically <5 years old
○ ↑ Prevalence in Asian & Pacific Islander descent
Pathophysiology:
○ Not well understood, likely multifactorial
○ Suspected to be infection → ↑ Immune response in genetically predisposed individuals
Presentation:
○ Conjunctivitis: Painless, bilateral, no exudate
○ Rash: Desquamating, polymorphous
○ Adenopathy: Typically unilateral cervical lymphadenopathy
○ Strawberry tongue (oropharyngeal mucositis): Redness, cracked lips
○ Hand/feet erythema & edema
○ Fever for 5+ days
■ CRASH & BURN
Diagnostics:
○ Serum: ↑ ESR, ↑ CRP, ↑ AST/ALT, ↑ WBCs/Platelets
○ Imaging: Echocardiogram to assess for coronary artery aneurysms
Management:
○ Intravenous immunoglobulin (IVIG)
■ Start with single high-dose to ↓ risk of coronary artery aneurysm, MI, etc.
○ Aspirin
■ Typically avoided in children due to risk of Reye syndrome
Polyarteritis Nodosa
Epidemiology:
○ 1° can be idiopathic
○ 2° causes include:
■ Autoimmune disease (e.g., Sarcoidosis, SLE, Sjogren syndrome)
■ Infections (e.g., HBV, HCV, HIV, syphilis, tuberculosis)
Pathophysiology:
○ Systemic vascular inflammation (medium-size vessels) → Tissue ischemia
Presentation:
○ Systemic: Fever, headache, malaise, myalgia, weight loss
○ Organ specific involvement:
■ Cardiovascular: ↑ Risk of myocardial infarction
■ Renal: Dysfunction, hypertension
■ Cutaneous: Skin nodules, rashes, ulcers
■ Gastrointestinal: Abdominal pain, nausea, vomiting
■ Neurological: Polyneuropathy (mononeuritis multiplex)
■ Typically spares the lungs
Diagnostics:
○ Serology: ANCA (-)
○ Imaging: Visceral angiography with multiple microaneurysms (“String of pearls”)
○ Histopathology: Transmural inflammation, leukocytic infiltration, fibrinoid necrosis
Management:
○ Glucocorticoids + cyclophosphamide
○ Antiviral therapy for HBV-associated
Behçet Disease
Epidemiology:
○ ↑ Prevalence in Eastern Asia & Mediterranean regions
○ Associated with HLA-B51, family history, infections (e.g., HSV, parvovirus)
Pathophysiology:
○ ↑ Autoimmune activation → ↑ Immune complex formation & deposition → ↑ CD4+ T-cells, cytokines, neutrophil activity
Presentation:
○ Cutaneous ulcers: Aphthous ulcers, genital ulcers
○ Erythema nodosum, uveitis
○ Non-specific: Arthritis, GI symptoms, vascular pathology
■ Neuro-Behcet syndrome - cognitive changes, paresis, hearing loss
Diagnostics:
○ Mainly a clinical diagnosis
○ Serum: ↑ ESR/CRP, (-) ANA/ANCA/RF
○ (+) Pathergy skin test
Management:
○ Symptom specific management
■ Topical steroids for ulcers
■ Colchicine for arthritis
■ Immunosuppressants
○ High-dose glucocorticoids & immunosuppressants are needed severe disease
Cutaneous Small-Vessel Vasculitis (CSVV)

Epidemiology:
○ Primarily idiopathic
○ Associated with autoimmune conditions (e.g., SLE), infections (e.g., HIV, HCV) medications (e.g., allopurinol, cephalosporins, penicillin, sulfonamides)
■ Drug induced reactions can occur ~7-10 days after some medications
Pathophysiology:
○ ↑ Immune complex formation & deposition → ↑ Complement system activation → ↑ Neutrophil activity → Vascular inflammation/damage
Presentation:
○ Painful palpable purpura
○ No significant visceral involvement
○ May present with various cutaneous manifestations (e.g., ulcer, urticaria, vesicles)
Diagnostics:
○ Cutaneous biopsy: Leukocytoclastic vasculitis
Management:
○ Treat underlying condition
■ Discontinue provoking medication, if suspected
○ Symptoms management
○ Severe disease may warrant glucocorticoids and/or glucocorticoid-sparing medication (e.g., methotrexate, rituximab)
Eosinophilic Granulomatosis with Polyangiitis (EGPA)

Epidemiology:
Pathophysiology:
○ ↑ T-cell differentiation to Th2 cells → ↑ Cytokine release, inhibition of eosinophil apoptosis → ↑ Tissue damage
Presentation:
○ Systemic symptoms: Fevers, chills, weight loss, night sweats, ↓ Appetite
○ Prodromal phase: Allergen related stimulation (e.g., asthma attack, rhinosinusitis)
○ Eosinophilic phase: GI complications (e.g., bleeding, ischemia, perforation), pericarditis
○ Vasculitis phase: Cutaneous involvement (e.g., palpable purpura, skin nodules), mononeuritis multiplex, pauci-immune glomerulonephritis
Diagnostics:
○ Serum: ↑ ESR/CRP, ↑ IgE & IgG4, eosinophilia, (+) MPO-ANCA/p-ANCA
■ (-) ANCA does not exclude EGPA
○ Imaging: High-resolution chest CT, echocardiogram
○ Histopathology: Eosinophilic infiltration with surrounding fibrinoid necrosis (necrotizing vasculitis)
Management:
○ Glucocorticoids + glucocorticoid-sparing medication (e.g., methotrexate, mepolizumab, rituximab)
■ Dosage depends on disease severity
Granulomatosis with Polyangiitis (GPA)

Epidemiology:
○ ♂=♀; typically 40-60 years old
○ Primarily idiopathic, some association with URI
Pathophysiology:
○ ↑ Neutrophilic expression of proteinase-3 → Anti-proteinase-3 antibody formation → ↑ Excessive neutrophil activation → ↑ Tissue damage
■ Typically affects small-medium sized vessels
Presentation:
○ Systemic symptoms: Fevers, chills, weight loss, night sweats
○ HEENT: Chronic sinusitis, mastoiditis; otitis media
■ Nasopharyngeal ulcers → ↑ Risk for septum perforation → Saddle nose deformity
○ Pulmonary: Cough, dyspnea, hemoptysis
○ Renal: Pauci-immune rapidly progressive glomerulonephritis, hematuria/RBC casts
Diagnostics:
○ Serum: (+) c-ANCA/PR3-ANCA (anti-proteinase-3)
○ Urinalysis: Nephritic sediment, microscopic hematuria
○ Imaging: Chest imaging showing cavitating nodules
○ Histopathology: Vasculitis, necrotizing granulomas
Management:
○ Glucocorticoids + glucocorticoid-sparing medication (e.g., cyclophosphamide, rituximab)
IgA Vasculitis (Henoch-Schonlein Purpura)

Epidemiology:
○ ♂>♀; typically <10 years-old
○ Often precipitated by upper respiratory infection (URI)
Pathophysiology:
○ Not well understood, likely multifactorial
○ Allergen/infection exposure → ↑ Production of IgA → IgA tissue deposition → ↑ Complement system → ↑ Vascular wall inflammation & damage
Presentation:
○ Systemic symptoms: Fevers, fatigue, malaise
○ Classic triad: Arthralgias, colicky abdominal pain, palpable purpura typically in lower extremities/buttocks
○ Variable symptoms: Intussusception, melena/hematochezia, hematuria
Diagnostics:
○ Serum: Normal platelet count, ↑ BUN/Cr, ↑ ESR/CRP, ↓ Hgb if bleeding
■ If thrombocytopenic, consider alternative causes of symptoms
○ Cutaneous histopathology: Leukocytoclastic vasculitis with IgA & C3 complex deposition
○ Renal histopathology: Mesangial IgA deposition, C3, fibrin
Management:
○ Supportive care, often self-limited
○ Systemic glucocorticoids if severe
Microscopic Polyangiitis
Epidemiology:
○ ♂>♀; typically ~ 50 years-old
Pathophysiology:
○ Not well understood, typically affects small vessels
○ Suspected genetic predisposition + trigger (e.g., infection, medication) → ↑ Neutrophil binding to p-ANCA → ↑ Inflammatory cytokine release
Presentation:
○ Systemic symptoms: Fevers, malaise
○ Cutaneous: Palpable purpura, livedo reticularis, urticaria, ulcers
○ Gastrointestinal: Abdominal pain
○ Neurologic: Peripheral neuropathy, mononeuritis multiplex
○ Pulmonary: Hemoptysis from alveolar hemorrhage, dyspnea
○ Renal: Pauci-immune glomerulonephritis, hypertension
Diagnostics:
○ Serum: ↑ ESR/CRP, ↑ WBCs/RBCs/Platelets
○ (+) MPO-ANCA/p-ANCA; (+) PR3-ANCA
■ (-) Values do not rule out MPA
○ Histopathology: Confirmatory test - No granulomas, neutrophilic infiltration with fibrinoid necrosis
Management:
○ Glucocorticoids + Cyclophosphamide
■ Severe disease may require plasmapheresis
Mixed Cryoglobulinemia
Epidemiology:
○ Most commonly associated with viral infections (e.g., HCV)
○ Additional associations include autoimmune diseases & lymphoproliferative disorders
Pathophysiology:
○ ↑ Immune system activation → Mixed IgG & IgM immune complex deposition
■ Pathophysiology differs slightly based on the type of cryoglobulinemia
Presentation:
○ Systemic symptoms: Fatigue, malaise
○ Classic triad: Arthralgias, palpable purpura, weakness
○ Renal disease (e.g., glomerulonephritis)
○ Polyneuropathy
○ Raynaud phenomenon
Diagnostics:
○ Serum: Cryoglobulinemia, ↓ C4, may have (+) RF
■ Test for hepatitis C
○ Urine: RBC casts, hematuria, proteinuria
○ Histopathology: Cryoglobulin deposition, leukocytoclastic vasculitis, membranoproliferative glomerulonephritis type I
Management:
○ Treat the underlying condition
■ Anti-virals (e.g., interferon, ribavirin), chemotherapy
○ Symptomatic therapy +/- immunosuppression
■ Severe disease may require plasmapheresis
Video Vignettes
Video 6.1 (Giant Cell Arteritis):
○ A 68 year-old woman presents to the emergency department with new onset left sided headache that awoke her from sleep early in the morning. The
patient reports she is in fairly good health but often experiences joint stiffness in the mornings for which she is currently seeing a rheumatologist. The
patient reports feeling well the night prior but she did notice a bit of jaw pain while chewing her food which is unusual for her. On physical exam the
patient has mildly decreased vision and tenderness to palpation over her left temple. Which of the following is the next best step for the ED physician?
Video 6.2 (Takayasu Arteritis):
○ A 41 y/o woman presents to her primary care physician with 3 weeks of malaise, night sweats, and intermittent chest pain. Vital signs are within normal
limits. On physical exam the physician notes soft radial pulses bilaterally and auscultates a bruit on the left carotid artery. Laboratory results come back
with elevated ESR and CRP. Which of the following would be the preferred imaging study to work up this patients condition?
Video 6.3 (Thromboangiitis Obliterans):
○ A 40 year-old male with a 20 year smoking history presents to his primary care provider with approximately one month of intermittent pain and color
changes in his toes. Symptoms have been progressively worsening. Vitals are within normal limits except for mildly elevated blood pressure which is
control with medication. Labs are drawn and the patients cholesterol panel, ESR, and CRP are within the normal ranges. Which of the following is the
biggest risk factor for this patient's presentation?
Video 6.4 (Kawasaki Disease):
○ A 5 year-old patient presents to pediatric emergency department with a new onset stomach rash. The parents report the patient has not been feeling
very well for almost a week and they are concerned that the patients younger sibling will begin to feel ill soon. They do not have a home thermometer,
but report the patient has felt very warm the entire week. On physical exam you notice conjunctival injection, and small red bumps all over the patient's
torso. Temperature is found to be 38.2 degrees celsius on arrival. Which of the following should this child be treated with at this time?
Video Vignettes
Video 6.5 (Polyarteritis Nodosa):
○ A 48 year-old patient presents to the emergency department with abdominal pain, fever, and myalgias. The patient denies any known medical history
and states they work as a sharps collector at a local hospital. Vital signs are notable for a blood pressure of 157/99 mmHg. On physical exam the patient
has abdominal tenderness and several small skin ulcers in the lower extremities. The patient is also noted to have decreased sensation in the left hand
and foot. Which of the following is most likely to help confirm the patient's diagnosis?
Video 6.6 (Behcet Disease):
○ A 41 year-old woman who recently moved from Greece presents to the primary care clinic to establish care. The patient feels well overall, but reports a
painful oral ulcer for about the past week. On physical exam you note conjunctival injection in addition to painful pretibial subcutaneous nodules. Vital
signs are within normal ranges. Laboratory results come back with elevated ESR, CRP, and a negative ANA. Which of the following genes is closely
associated with this patients mostly likely condition?
Video 6.7 (Cutaneous Small-Vessel Vasculitis):
○ A 54 year-old patient presents to the emergency department with new onset painful redness on the lower extremities. The patients reports they are in
fairly good health and they have never had this rash before. The patient does report having some recent lower extremity swelling and states they were
prescribed a “water pill” by their primary care provider one week ago. Vital signs are within normal ranges. On physical exam the physician notes non
blanching purple areas that are tender to palpation. Which of the following should first be considered in the treatment of this patient’s condition?
Video 6.8 (Eosinophilic Granulomatosis with Polyangiitis (EGPA)):
○ A 28 year old patient presents to the ED with complaints of fevers, night sweats, and a new onset purple rash in the bilateral lower extremities. The
patient reports they have a history of asthma which is managed with albuterol, but they are in otherwise good health. Vital signs are normal. On physical
exam you notice bilateral raised purpleish rash on the lower extremities and that the patient has ⅘ strength in the left lower extremity and right upper
extremity. ESR and CRP are elevated. Which of the following additional labs is most likely associated with this patients condition?
Video Vignettes
Video 6.9 (Granulomatosis with Polyangiitis (GPA)):
○ A 58 year-old patient to the emergency department due to an episode of coughing up blood last night. The patient reports feeling a little “under the
weather” for the last week and an unintentional 10 pound weight-loss over the last 2 weeks. On physical exam you notice some dried blood around the
mouth and nares. A chest xray is taken showing cavitating nodules. Which of the following is the patient most likely to need to help treat his underlying
condition?
Video 6.10 (IgA Vasculitis (Henoch-Schonlein Purpura)):
○ A 6 year-old boy presents to the pediatrician with one week of intermittent abdominal pain that has forced him to miss several days of school. The father
reports the patient has also had a rash on both of his legs. The patient feels well overall aside from a runny nose that began after his brother was sick
last week. The parents deny any known blood in the stools. On exam the patient is mildly tender in all abdominal quadrants. Lab values return without
any significant abnormalities. Which of the following is the best treatment option to offer the patient at this time?
Video 6.11 (Microscopic Polyangiitis):
○ A 53 year-old patient presents to the clinic with 5 days of fever and malaise. The patient reports a raised purplish rash in the lower extremities in addition
to intermittent abdominal pain. He reports last night he also coughed up a bit of blood tinged sputum. The patient denies any nasal congestion or a runny
nose. The blood pressure was 151/99 mmHg when the patient checked in for the visit. Serum labs show elevated inflammatory markers. Which of the
following would be the most helpful to confirm this patient's diagnosis of microscopic polyangiitis?
Video 6.12 (Mixed Cryoglobulinemia):
○ A 37 year-old patient with a history of hypertension and IVDU presents to the clinic with generalised fatigue, joint pain and a new onset rash on the
buttocks. The patient reports some decrease sensation in their right hand as well. Physical exam notes a raised, non-blanchable rash on the patients
buttocks, but is otherwise unremarkable. Which of the following test should be ordered with this patients labs to help make the diagnosis?
REVIEW OUTLINE
1. Brachial Plexus Overview 6. Ulnar Nerve
A. Roots A. Nerve Roots
Musculoskeletal B. Trunks
C. Divisions
B. Motor Innervation
C. Sensory Innervation
D. Cords
System:
D. Causes of Injury
E. Branches 7. Erb Palsy
2. Musculocutaneous Nerve A. Pathophysiology
Brachial Plexus A. Nerve Roots

B. Causes
C. Presentation
D. Treatment
Nerves & Lesions 3.
D. Causes of Injury
Axillary Nerve
8. Klumpke Palsy
A. Pathophysiology
A. Nerve Roots B. Causes
B. Motor Innervation C. Presentation
C. Sensory Innervation D. Treatment
D. Causes of Injury
9. Thoracic Outlet Syndrome
4. Radial Nerve A. Pathophysiology
A. Nerve Roots B. Causes
B. Motor Innervation C. Presentation
C. Sensory Innervation D. Treatment
D. Causes of Injury
10. Winged Scapula
5. Median Nerve
A. Pathophysiology
A. Nerve Roots
B. Causes
C. Presentation
D. Treatment
D. Causes of Injury
Musculoskeletal System: Brachial Plexus Nerves & Lesions Bootcamp.com
Brachial Plexus Overview

Roots:
○ Comprised of ventral rami of spinal cord (C5-T1)
■ C5 → Dorsal scapular nerve → Innervates periscapular stabilizers
■ C5 → Phrenic nerve → Innervates diaphragm
■ C5-C7 → Long thoracic nerve → Innervates serratus anterior
○ Superior and posterior to subclavian artery
Trunks:
○ Comprised of 3 trunks
■ Superior (C5-C6)
■ Middle (C7)
■ Inferior (C8-T1)
Divisions:
○ 6 Divisions from trunks to cords
■ 3 Anterior + 3 Posterior
Cords:
○ Comprised of 3 cords; Named relative to axillary artery
■ Lateral → Lateral pectoral nerve → Pectoralis. major
■ Posterior
● Thoracodorsal nerve → Latissimus dorsi
● Lower subscapular nerve → Subscapularis + Teres major; Upper subscapular nerve → Subscapularis
■ Medial → Medial pectoral nerve → Pectoralis major + Pectoralis minor
Branches
○ Comprised of 5 terminal branches
■ Musculocutaneous, Axillary, Radial, Median and Ulnar Nerves
Musculocutaneous Nerve
Nerve Roots:
○ C5-C7 (Includes C5-C6 biceps tendon reflex)
Motor Innervation:
○ Coracobrachialis → Flexes arm at shoulder joint
○ Biceps brachii → Flexes elbow and supinates wrist
○ Brachialis → Flexes elbow
Sensory Innervation:
○ Lateral antebrachial cutaneous nerve → Lateral Forearm
Causes of Injury:
○ Damage/compression of upper trunk (Erb palsy) or lateral cord
■ Trauma (e.g., accidents, dislocation)
■ Lateral flexion of neck (e.g., excessive traction)
■ Tumor
Axillary Nerve
Nerve Roots:
○ C5-C6 (Does NOT include C5-C6 biceps tendon reflex)
Motor Innervation:
○ Teres minor → External rotation of the arm
○ Deltoid → Abducts arm at the shoulder (>15°)
■ Injury leads to “flattened deltoid”
○ Superior lateral cutaneous nerve → Lower shoulder + lateral arm
Causes of Injury:
○ Anterior dislocation of humerus
○ Fracture at surgical neck of humerus
○ Compression from tumor
○ Iatrogenic (eg., shoulder surgery)
Radial Nerve
Nerve Roots:
○ C5-T1 (All nerve roots of brachial plexus)
Motor Innervation:
○ Triceps brachii → Elbow extension, shoulder extension & adduction
○ Anconeus → Elbow extension
○ Brachialis (lateral aspect) → Flexion of the elbow
○ Posterior compartment of the forearm (extensors)
■ Injury of radial nerve can lead to wrist drop
○ Dorsal aspect of arm & forearm
○ Dorsal aspect of radial hand & 3 ½ fingers
Causes of Injury:
○ Fracture at midshaft of humerus
○ Compression of the axilla (e.g., crutches, sleeping position)
■ “Saturday night palsy”
○ Excessive supination/pronation of the wrist
Median Nerve
Nerve Roots:
○ C5-T1 (All nerve roots of brachial plexus)
Motor Innervation:
○ Most flexors of forearm → Wrist and finger flexion
○ 1st and 2nd lumbricals → Flexion at MCP, Extension at PIP & DIP
■ Injury can lead to “hand of benediction”
○ Thenar muscles of the hand → Abduction, Flexion, Opposition of thumb
■ Injury can lead to “ape hand”
○ Palmar cutaneous branch → Lateral aspect of palm
○ Digital cutaneous branches → Palmar side of lateral 3 ½ digits + fingertips
Causes of Injury:
○ Fracture of humerus (typically supracondylar)
○ Trauma (e.g., laceration, penetrating injury)
○ Compression
■ Carpal tunnel syndrome
■ Tumor
Ulnar Nerve
Nerve Roots:
○ C8-T1
Motor Innervation:
○ FCU → Wrist adduction + flexion
○ FDP (medial) → Flexion of 4th and 5th digits
○ Intrinsic muscles of hand (Excluding ½ LOAF)
■ Injury can lead to “ulnar claw”
○ Medial hand + medial 1½ digits (palmar and dorsal aspect)
Causes of Injury:
○ Fracture hook of hamate (e.g., FOOSH)
○ Fracture at medial epicondyle of humerus
○ Compression of nerve
■ Guyon canal syndrome (e.g., bikers)
■ Cubital tunnel syndrome
■ Ganglion cyst
Erb Palsy
Pathophysiology:
○ Injury to the upper trunk (C5-C6)
■ Affects musculocutaneous, axillary, radial, and suprascapular nerves
Causes:
○ Infants: Birth injury
■ Excessive lateral traction from delivery
■ Shoulder dystocia
○ Adults: Traumatic injury
■ Falling on head and shoulder from motor vehicle accident
■ Dislocation of humerus, fracture of humerus or clavicle
Presentation:
○ Adduction of the arm
■ Impaired abduction by deltoid (axillary nerve)
○ Flexion of the wrist
■ Impaired extension by posterior forearm (radial nerve)
○ Pronation of the forearm + extension at the elbow
■ Impaired supination and elbow flexion by biceps brachii (musculocutaneous nerve)
○ Medial (internal) rotation of the arm
■ Impaired external rotation by infraspinatus + supraspinatus (suprascapular nerve)
○ ↓ Moro reflex in infants
○ ↓ Sensation in C5 & C6 dermatomes (anterior forearm and thumb)
Treatment:
○ Immobilization in flexion and external rotation
○ Physical therapy or surgery if severe
Klumpke Palsy
Pathophysiology:
○ Injury to the lower trunk (C8-T1)
■ Affects ulnar nerve and median nerve
Causes:
○ Infants: Birth injury
■ Excessive upward traction from delivery
■ Shoulder dystocia (more likely to cause Erb palsy)
○ Adults: Traumatic injury or chronic compression
■ Falling out of tree and catching a branch to break fall
■ Pancoast tumor or cervical rib
Presentation:
○ Flexion of PIP & DIP joints + extension at MCP → Total claw hand
■ Impaired intrinsic muscles of the hand (ulnar and median nerve)
○ ↓ Grasp reflex in infants
○ ↓ Sensation in C8 & T1 dermatomes (medial forearm and medial two fingers)
○ May include Horner Syndrome (miosis, ptosis, anhidrosis)
Treatment:
○ Splinting the affected hand for proper alignment
○ Physical therapy or surgery if severe
Thoracic Outlet Syndrome

Pathophysiology:
○ Compression of the lower trunk (C8-T1)
○ Compression of subclavian arteries (arterial) or veins (venous)
Causes:
○ Compression/damage of vessels or nerves
■ Cervical rib or fibrous band
■ Pancoast tumor
■ Hypertrophy of neck muscles
■ Poor posture/obesity
Presentation:
○ Compression of nerves (neurogenic)
■ Pain or weakness (especially gripping)
■ Paresthesia (classically ulnar distribution)
■ Atrophy of intrinsic hand muscles
■ ↓ Sensation in C8 & T1 dermatomes
○ Compression of the subclavian artery (arterial)
■ Fatigue, pain, pallor, ↓ pulse strength, ↓ blood pressure
○ Compression of subclavian vein (venous)
■ Edema, pain, distension of veins, ↑ risk of venous thrombosis
Treatment:
○ Physical therapy, weight loss
○ NSAIDs
○ Thrombolytics
○ Surgery in case of cervical rib or fibrous band
Winged Scapula
Pathophysiology:
○ Injury to the long thoracic nerve (C5 -C7)
○ Serratus anterior → Pulls scapula anterolaterally and stabilizes to ribs at rest
Causes:
○ Axillary node surgery
■ Lymph node dissection with mastectomy
○ Stab wound
○ Using excessively heavy backpack (especially in children)
Presentation:
○ Medial protrusion of scapula on affected side
■ Emphasized with patient pressing against a wall
○ Impaired protraction of scapula
○ Impaired abduction of shoulder >90°
○ Pain in the affected shoulder and arm
Treatment:
○ Physical therapy to strengthen muscles
○ Surgery in severe cases
All Abductor pollicis
THENAR For Flexor pollicis brevis
One Opponens pollicis brevis
ADDUCTOR And Adductor pollicis brevis
One Opponens digiti minimi
HYPOTHENAR For Flexor digiti minimi
All Abductor digiti minimi

Video Vignettes
Video 8.1 (Brachial Plexus Overview):
○ A 24 year old male presents to you two weeks after an accident while mountain biking. He said that while he normally recovers well from his accidents,
this time he has noticed that breathing has become more difficult and that his pitching during baseball practice is noticeably slower since the accident.
His lungs are clear to auscultation and heart sounds are unremarkable. On physical exam you notice slight muscle wasting of the patients right arm
despite being right-hand dominant. What terminal branch of this patient was most likely spared in the injury of this patient?
Video 8.2 (Musculocutaneous Nerve):
○ A 33-year-old male presents to the emergency department with right-sided arm weakness after an injury while surfing. The patient reports his surfboard
hit him after falling off. In the ED, vital signs show a BP of 129/88, a temperature of 36.8° C (98.6° F), and a HR of 78 bpm. On physical exam, you
notice a diminished right-sided biceps reflex and 3 out of 5 strength with elbow flexion. Which area of his affected arm might have reduced sensation
based on the most likely nerve affected?
Video 8.3 (Axillary Nerve):
○ A 75 year-old female presents to the ED with intense shoulder pain after a fall. Vital signs include a BP of 139/99 mmHg, temperature of 37° C (98.6°F),
heart rate of 98 beats per minute. On physical exam the patient has a shoulder that is externally rotated and abducted. X-ray shows anterior dislocation
of the shoulder. What are the nerve roots of the nerve that is most likely injured in this patient?
Video 8.4 (Radial Nerve)
○ A 55 year-old male presents to ED after a motor vehicle accident. The patient reports a decrease in sensation in the back of the hands and wrist in
addition to difficulty extending his fingers . Vital signs include a BP of 135/91 mmHg, temperature of 38° C, heart rate of 99 beats per minute. On
physical exam the patient has reduced sensation on the radial dorsum of the left hand and 1 out of 5 strength with wrist extension. Imaging shows a
transverse fracture of the patients left humerus. Assuming the nerve damage is from the fracture, what is the most likely location of the fracture on the
humerus?
Video Vignettes
Video 8.5 (Median Nerve):
○ A 6 year-old male presents to the emergency department with left-sided arm pain after falling off a trampoline. The patient’s mother reports seeing her
son try to catch his fall with his arms and thinks he may have broken his arm . Vital signs include a BP of 134/85, temperature of 36.8° C (98.2° F) and a
HR of 98 bpm. On physical exam you notice the patient has reduced sensation on the radial palmar aspect of the hand and fingers and 2 out of 5
strength with wrist flexion. If left untreated, what area of the hand would be most likely to show muscle wasting?
Video 8.6 (Ulnar Nerve):
○ A 34-year-old male presents to the primary care clinic with one week of new-onset left-hand weakness. The patient denies any trauma to the extremity
but reports that symptoms worsen when holding his cell phone up to his ear during long meetings and when resting his elbow on his office chair for
extended periods of time. The patient's vital signs are within normal limits, and he reports he is in good health overall. On physical exam, the patient has
decreased sensation over the 4th & 5th digits and 4/5 grip strength of the left hand. Which anatomical structure is most likely compressing this patient's
nerve and leading to this presentation?
Video 8.7 (Erb Palsy):
○ A G2P2 woman gives birth to a boy at 42 weeks gestational age via vaginal delivery. The birthing process was complicated by shoulder dystocia. Which
eventually required a forceps delivery. The child's APGAR scores were 7 and 9 at 1 and 5 minutes, respectively. And the child's birth weight is 9 pounds,
6 ounces, with vital signs within normal limits. On physical exam, you notice elbow extension and forearm pronation. In addition to a reduced Moro
reflex. What additional motor deficits are also likely to be found in the patient's affected arm?
Video 8.8: (Klumpke Palsy)

○ A 14 year old male presents to your clinic with shooting right arm pain after an incident in the bouncy house. The patient reports that his hand was
caught on the side netting with his arms raised when attempting a flip. Vital signs are within normal limits. On physical exam, you notice that the patient's
proximal and distal interphalangeal joints are flexed, but there is extension at the metacarpophalangeal joint. What area of the affected arm are we most
likely to see reduced sensation? Is this patient at an increased risk for having Horner Syndrome?
Video Vignettes
Video 8.9 (Thoracic Outlet Syndrome):
○ A 52 year old female presents to your clinic after noticing difficulty gripping her golf club in her left hand. In addition to the weakness, the patient reports a
tingling, painful sensation going down the medial portion of her arm when she braids her hair. Vital signs are within normal limits, and on physical exam,
you notice 2 out of 5 strength with finger adduction and abduction on the affected hand. An x ray of the patient reveals an overdevelopment of the
transverse process of the 7th cervical rib. In addition to the brachial plexus, what other vessels are most likely compressed in this patient?
Video 8.10 (Winged Scapula):
○ A 59-year-old female presents to the clinic with complaints of left shoulder weakness five weeks after her mastectomy. The patient reports that she has
been unable to reach any of the high shelves in her home. Vital signs are within normal limits. On physical exam the patient has normal sensation on the
shoulder and arm but cannot raise the left arm above her shoulder. On physical exam there is mild medial protrusion of the left scapula that is worsened
when the patient pushes on a wall. What are the nerve roots of the most likely affected nerve?
REVIEW OUTLINE
1. Shoulder Anatomy 4. Humerus Fractures

A. Bones A. Etiology
Musculoskeletal B. Muscles
C. Ligaments
B. Presentation
C. Diagnostics
System: 2.
D. Articulations
Rotator Cuff Tears 4.
D. Management
Elbow Anatomy
Shoulder & Elbow

A. Etiology A. Bones
B. Presentation B. Muscles
C. Diagnostics C. Ligaments
D. Management D. Articulations
3. Clavicle Fractures 6. Epicondylitis
A. Etiology A. Etiology
Musculoskeletal System: Shoulder & Elbow Bootcamp.com
Shoulder Anatomy
Bones:
○ Scapula: Flat, triangular bone connecting clavicle and humerus
○ Clavicle: S-shaped bone connecting sternum and scapula
○ Humerus: Long bone of arm that articulates with scapula to form shoulder girdle
Muscles:
○ Rotator cuff comprised of 4 muscles
■ Supraspinatus → Shoulder abduction (0-15°)
■ Infraspinatus → External rotation of humerus
■ Teres minor → External rotation of humerus + Adduction
■ Subscapularis → Internal rotation of humerus + Adduction
○ Deltoid → Shoulder Abduction (15°+)
○ Teres major → Internal rotation + Adduction
Ligaments:
○ Glenohumeral ligaments
○ Acromioclavicular ligament
○ Coracoclavicular ligaments
○ Transverse humeral ligament
Articulations:
○ Glenohumeral joint: Glenoid fossa of scapula & head of humerus
○ Sternoclavicular joint: Medial end of clavicle & manubrium of sternum
○ Acromioclavicular joint: Lateral end of clavicle & acromion of scapula
○ Scapulothoracic joint: Scapula & thoracic wall (not a true anatomical joint)
Rotator Cuff Tear

Etiology:
○ Chronic tendon degeneration = ↑ Risk of tear
■ ↑ Incidence with age (>60 yo)
■ Can result from repetitive overhead motions
○ Acute traumatic injury
■ More common in athletes
Presentation:
○ Supraspinatus is most commonly injured tendon
○ Limited mobility or pain with shoulder movement
■ “Empty can test” → Supraspinatus
Diagnostics:
○ Often diagnosed clinically
○ Imaging: X-ray showing high-riding humeral head
○ Consider ultrasound and/or MRI
Management:
○ Supportive care, physical therapy, pain management (e.g., NSAIDS, injection therapy)
○ Consider surgery for traumatic cuff injuries
Clavicle Fractures
Etiology:
○ Direct trauma to the shoulder (MCC: Fall)
○ Indirect trauma to the shoulder (e.g., FOOSH)
○ Birth injury (most common fracture during delivery)
Presentation:
○ Pain, swelling, limited mobility, crepitus with movement
○ Palpable step-off
○ Shoulder drop
○ Shortening of the clavicle
○ Tenting of the skin due to protruding clavicle
○ +/- Neurovascular damage
Diagnostics:
○ Imaging: X-ray (best initial test); Ultrasound in children
Management:
○ Immobilization in a sling
○ Pain management: Acetaminophen, NSAIDS, opioids
○ Consider surgical intervention
Humerus Fractures
Etiology:
○ Indirect trauma to the arm (MCC: FOOSH)
○ Direct trauma to the arm (e.g., motor vehicle accident)
○ Pathological fracture (e.g., osteitis deformans)
Presentation:
○ Pain, swelling, limited mobility
○ Shortening of the arm
○ May have radial nerve palsy (especially with midshaft fracture)
■ Numbness along dorsum of forearm and radial hand
■ Wrist drop
■ ↓ Grip strength
○ Axillary or median nerve palsy (less commonly)
Diagnostics:
○ Imaging: X-ray for showing signs of fracture, displacement, dislocation or angulation
Management:
○ Pain management: Acetaminophen, NSAIDS, opioids
○ Immobilization of the arm using a sling or coaptation splint
○ Physical therapy
○ Consider surgical intervention
Elbow Anatomy
Bones:
○ Radius: Lateral bone of forearm
○ Ulna: Medial bone of forearm
○ Humerus: Long bone of arm that articulates distally with radius and ulna
Muscles:
○ Flexors of the elbow → Biceps brachii, brachialis, brachioradialis
○ Extensors of the elbow → Triceps brachii, anconeus
○ Supinators of forearm → Biceps brachii, supinator, brachioradialis
○ Pronators of forearm → Pronator teres, pronator quadratus, brachioradialis
Ligaments:
○ Ulnar collateral ligament
○ Radial collateral ligament
○ Annular ligament
Articulations:
○ Humeroradial joint: Head of radius & capitulum of humerus
■ Allows for supination of the forearm
■ Subluxation of this joint → “Nursemaid's elbow”
○ Humeroulnar joint: Trochlea of humerus & trochlear notch of ulna
○ Radioulnar joint: Head of radius & proximal ulna
Epicondylitis
Etiology:
○ Lateral epicondylitis
■ Repetitive wrist extension, supination
■ “Tennis elbow”
○ Medial epicondylitis
■ Repetitive wrist flexion, pronation
■ “Golfer’s elbow”
○ Most common in patients ages 40-60
Presentation:
○ Lateral epicondylitis → Lateral elbow pain worsened with palpation & wrist extension
○ Medial epicondylitis → Medial elbow pain worsened with palpation & wrist flexion
Diagnostics:
○ Imaging: X-ray (normal), US (↑ Tendon thickness), MRI (↑ Tendon activity)
Management:
○ Pain management: Rest, ice, NSAIDS
○ Physical therapy, bracing
○ Consider surgical intervention if symptoms do not resolve
Video Vignettes
Video 9.1 (Shoulder Anatomy):
○ A 37 year old male comes to your clinic with complaints of left-sided shoulder weakness. In addition to thewekaness the patient reports a painful
sensation with activity which he first noticed when pitching during baseball practice. Vital signs are within normal limits. On physical exam you notice that
initiation of abduction on the affected side is painful and difficult for the patient. When abduction in initiated at 30 degrees, the patient reports reduced
pain. Based on the presentation what is the most likely injured muscle in this patient?
Video 9.2 (Rotator Cuff tear):
○ A 72-year-old male presents to the with complaints of right sided shoulder pain that worsens with activity. The patient reports he first noticed the pain
about 3 months ago and has had decreasing mobility and increasing pain since. Vital signs are within normal limits. On physical examination the empty
can test elicits pains on the affected side. X-ray shows a mild elevation of the humeral head. What is the nerve that innervates the most likely affected
muscle in this patient?
Video 8.3 (Clavicle Fracture):
○ AA four year old male presents to your emergency department with complaints of right sided shoulder pain. The patient's father reports that he was
learning to ride his bicycle when he fell off and landed on his shoulder on the sidewalk. The patient has a heart rate of 104 beats per minute, and other
vital signs are within normal limits. The patient reports pain with movement of the affected side, and on physical exam, you note a palpable step off in the
middle of the clavicle. You suspect a clavicle fracture. What imaging test would you most likely order for this patient?
Video 8.4 (Humerus Fracture)
○ A 73 year-old female presents to the ED with intense right sided arm pain after a fall. The patient reports tripping on an uneven sidewalk and trying to
catch her fall with her hands. On physical exam, you notice there is redness and swelling on the affected side, as well as wrist drop and ⅖ grip strength.
Which area of skin on this patient’s affected side is most likely to have reduced sensation?
Video Vignettes
Video 9.5 (Elbow Anatomy):
○ A 4 year old female comes to your clinic with complaints of left-sided arm pain. The patients father reports letting her hold the leash while walking the
dog when the dog took a sudden dart at a squirrel and pulled on the patient's arm. Vital signs show a HR of 106 bpm, a blood pressure of 125/95 and an
internal temp of 38° C. On physical exam you notice the patient is holding her injured elbow at slight flexion and pronation. The patient refuses to move
her affected arm but there are no changes in sensation along the arm. Imaging on ultrasound shows a subluxation of the radial head at the humeroradial
joint. What ligament of this patient is most directly involved in the injury of this patient?
Video 9.6 (Epicondylitis):
○ A 57 year old male comes in to your clinic with complaints of right sided elbow pain. He has recently retired and began to pick up tennis as a hobby
which he plays 4 times a week, but noticed his elbow began to hurt during his last few sessions. Her vital signs are within normal limits. On physical
exam there is no visible swelling or deformities, but the lateral epicondyle of the humerus is tender to palpation. Additionally, her grip strength on the
affected side is normal but elicits pain, as does wrist extension. There are no changes to sensation along the arm, and an X-ray shows no abnormalities.
What action of the biceps brachii is most likely to elicit pain on the patients affected side?
REVIEW OUTLINE
1. Wrist & Hand Anatomy 5. Hand Distortions

A. Bones A. Etiology
Musculoskeletal B. Muscles
C. Soft Tissue
B. Presentation
C. Diagnostics
System: 2.
D. Articulations
Carpal Tunnel Syndrome 6.
D. Management
De Quervain Tenosynovitis
Wrist & Hand

3. Guyon Canal Syndrome 7. Dupuytren Contracture
4. Fractures & Dislocations 8. Ganglion Cyst
Musculoskeletal System: Wrist & Hand Bootcamp.com
Wrist & Hand Anatomy

Bones:
○ Radius: Lateral bone of the forearm, larger distally
○ Ulna: Medial bone of forearm, thinner distally
○ Carpals: Small, irregular bones at the base of the hand
■ Scaphoid fracture → Most common carpal fracture
■ Hook of Hamate fracture/dislocation → Guyon canal syndrome
○ Metacarpals: Long bones at the middle of the hand
○ Phalanges: Long bones that constitute the fingers
Muscles:
○ Median Nerve
■ 1st and 2nd lumbricals → Flexion at MCP, Extension at PIP & DIP
■ Thenar muscles of the hand → Abduction, Flexion, Opposition of thumb
○ Ulnar Nerve
■ 3rd and 4th lumbricals → Flexion at MCP, Extension at PIP & DIP
■ Hypothenar muscles of the hand → Opposition, Flexion, Adduction of pinky
■ Dorsal & palmar interossei muscles
Soft tissue:
○ Palmar aponeurosis, carpal tunnel, Guyon canal
Articulations:
○ Radiocarpal joint: Radius & proximal carpal joint (other than pisiform)
○ Ulnocarpal joint: Ulna & lunate + triquetrum
○ Metacarpal phalangeal joint: Metacarpals & phalanges
○ Interphalangeal joint: Between phalanges (DIP & PIP)
Carpal Tunnel Syndrome

Etiology:
○ Compression of the median nerve between the carpal bones and carpal transverse ligament
○ Increased risk from swelling: Pregnancy, hypothyroidism, rheumatoid arthritis
○ Other associated risks: Acromegaly, diabetes mellitus, amyloidosis and overuse
Presentation:
○ Paresthesia and pain in median nerve area innervation
■ May radiate up the forearm
■ Palmar cutaneous branch is spared by branching before carpal tunnel
○ Thenar eminence atrophy
Diagnostics:
○ Positive Tinel sign (percussion of anterior wrist elicits tingling)
○ Positive Phalen's test (90° Wrist flexion elicits tingling)
Management:
○ Pain management: Splinting, rest, corticosteroid injection
○ Consider surgical decompression surgery for severe damage
Guyon Canal Syndrome

Etiology:
○
Presentation:
○
Diagnostics:
○
Management:
○
REVIEW OUTLINE
5. Legg-Calvé-Perthes Disease
Musculoskeletal 1. Radial Head Subluxation
A. Etiology
B. Pathophysiology
A. Etiology
B. Pathophysiology
System: C. Presentation
D. Diagnostics
E. Management
C. Presentation
D. Diagnostics
E. Management
Childhood 2. Pediatric Fractures

A. Bowing Fracture
6. Patellofemoral Syndrome
A. Etiology
Musculoskeletal B. Greenstick Fracture B. Pathophysiology

C. Torus Fracture C. Presentation
D. Salter-Harris Fracture D. Diagnostics
Pathology 3.
E. Supracondylar Humerus Fracture
Developmental Dysplasia of the Hip 7.
E. Management
Osgood-Schlatter Disease
4. Slipped Capital Femoral Epiphysis
A. Etiology
B. Pathophysiology
C. Presentation
D. Diagnostics
E. Management
Musculoskeletal System: Childhood Musculoskeletal Pathology Bootcamp.com
Radial Head Subluxation (Nursemaid’s Elbow)

Etiology:
○ MCC: Trauma (e.g., adult quickly pulling a child's extended arm)
■ Classically seen in young child <5 years-old due to immature cartilage and ligamentous structures
○ ↑ Risk from congenital conditions (e.g., abnormal collagen development)
Pathophysiology:
○ Forceful or sudden traction on pronated/extended arm → Annular ligament slips over radial head
Presentation:
○ Elbow flexed, pronated, and held near body
○ Pain & tenderness around the elbow
○ Normal neurovascular exam
○ ↓ ROM
○ Lack of significant swelling
Diagnostics:
○ Imaging often unnecessary
■ Consider if failed reduction or to rule out fracture
Management:
○ Closed manual reduction
■ Hyperpronation maneuver
■ Supination-flexion maneuver
Pediatric Fractures
Bowing Fracture Greenstick Fracture Torus Fracture
Bowing Fracture:
○ Bending stress to bone → No disruption of bony cortex → Incomplete fracture
○ Commonly at the diaphysis of ulna or fibula
○ Manage with splinting and/or casting
Greenstick Fracture:
○ Bending stress to bone → Bone failure on tension side → Incomplete fracture
○ Convex side disrupted
○ Commonly at the diaphysis of fibula, radius, or ulna
Torus (Buckle) Fracture:
○ Axial force to bone → Disruption of bony cortex → Incomplete fracture
○ Convex side remains intact, minimal bony angulation
○ Commonly at the distal radius/ulna
Salter-Harris Fracture: Salter-Harris Fracture SCH
○ Fracture involving the epiphyseal/growth plate (classified as type I-V)
○ Commonly at the distal humerus/radius
○ Complications: Limb-length discrepancy
Supracondylar Humerus Fracture:
○ Transverse fracture at distal humerus
○ Most common pediatric elbow fracture
○ Complications: Brachial a. or median n. injury
Developmental Dysplasia of the Hip (DDH)

Etiology:
○ ↑ Risk with breech presentation, family history, oligohydramnios in utero
Pathophysiology:
○ Abnormal development of acetabulum and proximal femur → ↑ Joint instability → Joint dislocation and/or subluxation
Presentation:
○ Varies by age
○ Asymptomatic, lack of hip abduction, asymmetric gluteal folds
○ Hip and/or knee pain, leg-length discrepancy, Trendelenburg gait
○ (+) Barlow and Ortolani maneuver (typically <6 months)
Diagnostics:
○ Newborn screening, well-baby visits
○ Imaging: Hip ultrasound (<4 months); X-ray (>4 months) showing dysplasia and/or dislocation
■ Radiographs before 4 months are less useful because cartilage has not ossified
Management:
○ <6 months: Pavlik harness
○ >6 months: May need hip casting and/or surgical intervention
○ Complications: Leg-length discrepancy
Slipped Capital Femoral Epiphysis (SCFE)

Etiology:
○ Typically ~8-16 years-old
○ ↑ Risk with endocrine disorder (e.g., hypothyroidism), family history, obesity, trauma
Pathophysiology:
○ Poor growth plate development → ↑ Epiphyseal width → ↑ Risk for slippage with inciting factor
Presentation:
○ Antalgic gait, pain in hip/groin/knee
○ ↓ ROM (mostly abduction & internal rotation)
○ Bilateral in 20-40% of patients
Diagnostics:
○ Imaging: X-ray showing widening of the joint space and posteroinferior displacement of femoral head relative to epiphysis
Management:
○ Surgical intervention (i.e., pinning of femoral head)
■ ↓ Weight-bearing activities before surgery
■ Consideration may be given for contralateral hip fixation
○ Complications: Avascular necrosis of the femoral head, chondrolysis, early-onset osteoarthritis
Legg-Calvé-Perthes Disease
Etiology:
○ ↑ Risk with bleeding disorders, genetic mutation, repetitive trauma
Pathophysiology:
○ Inadequate blood supply to femoral head → Avascular necrosis → Bony collapse
Presentation:
○ Antalgic gait, hip and/or knee pain
○ ↓ ROM (mostly abduction & internal rotation)
○ Leg-length discrepancy
Diagnostics:
○ Imaging: ↑ Femoral head lucency with flattened epiphysis
■ Initial radiograph often normal
■ Consider MRI if x-ray unremarkable
Management:
○ Conservative: ↓ Weight bearing activities, casting, physical therapy
○ Surgery: Femoral osteotomy, total hip arthroplasty in adults
Patellofemoral Syndrome
Etiology:
○ Common cause of anterior knee pain
○ ↑ Risk with knee malalignment, muscular imbalance & repetitive activities (e.g., running, basketball, etc.)
Pathophysiology:
○ Poor knee alignment/imbalance → Biomechanical overload → ↑ Patellofemoral joint trauma → ↑ Knee pain
Presentation:
○ Classically a dull pain over front of knee
○ Tenderness over medial & lateral patella
○ Crepitus with ROM testing
○ ↑ Pain with weightbearing, knee flexion, and extended periods of sitting
○ Knee buckling due to pain
Diagnostics:
○ Imaging: Not routinely indicated
■ X-ray can help rule out other causes of knee pain (e.g., fracture, arthritis, etc.)
Management:
○ Conservative: RICE, NSAIDs, physical therapy, quadriceps strengthening (e.g., VMO), orthotics, weight loss
○ Surgical: Rarely indicated
Osgood-Schlatter Disease
Etiology:
○ ↑ Risk during growth spurts and with repetitive movements (sports participation)
Pathophysiology:
○ Repetitive force to tibial tuberosity from patellar tendon traction → ↑ Microtrauma → Micro-avulsion
Presentation:
○ Anterior knee pain, swelling, tenderness, enlarged/palpable tibial tubercle
○ Pain worsens with activity and resisted knee extension
Diagnostics:
○ Imaging: X-ray showing elevated tibial tuberosity, soft tissue swelling, possible fragmentation
Management:
○ Conservative: RICE, NSAIDs, stretching/strengthening
○ Surgical: Rare, for severe cases
Video Vignettes
Video 14.1 (Radial Head Subluxation):
○ A 4 year-old child presents to the pediatric emergency department for evaluation of left elbow and knee pain. The father reports the patient tripped and
fell forward while they were out for a walk landing on the left hand and knee. The father reports he helped his son from the ground by pulling him up by
his left arm. On physical examination you notice a small, non-bloody scrape on the left knee as well as good skin perfusion and distal pulses. The child is
holding the left arm near his body with 90 degrees of flexion at the elbow. The arm is neurovascularly intact with no appreciable swelling us bited. Which
of the following does the patient most likely need at this time?
Video 14.2 (Pediatric Fractures):
○ An 8 year-old patient presents to the ED after a fall during recess. The patient reports he was running after his friend when he tripped and fell forward on
his outstretched hands. He immediately felt pain in the right upper arm. On examination the patient has decreased sensation in the anterior forearm and
the palm. Radial pulse is faint on the right extremity. Injury to which of the following vascular structures is the most likely reason for the faint distal pulse?
Video 14.3 (DDH):
○ A 2 month-old female returns to the clinic for examination. The parents report they have no concerns at this time, however the child was recently sick
one-week ago. The baby appears well and to be obtaining appropriate age-related milestones. On physical examination the physician notes asymmetric
gluteal skin folds and a positive barlow and ortolani maneuver. Which of the following imaging studies should be performed at this time?
Video 14.4 (SCFE):
○ A 12 year-old boy presents to the to the pediatrician with complaints of left knee and groin pain. On his way into the exam room you notice an antalgic
gait. The patient has no significant health history, but does report staying home from school 1-week ago due to an upper respiratory infection. Vitals
show slightly elevated blood pressure for his age, normal HR, and a BMI in the 90th percentile. Radiographs show a displaced femoral head relative to
the epiphysis. Which of the following treatment options would be recommended for this patients most likely pathology?
Video Vignettes
Video 14.5 (Legg-Calvé-Perthes):
○ An 8 year-old patient presents to the pediatrician with a limping gait after football practice. The patient's parents report he is pretty healthy, but there has
been a viral infection going around school which he had last week. On physical exam the patient has a bruise on the left knee along with pain around the
knee and upper thigh. The patient has limited and painful internal rotation of the left hip relative to the right hip. Radiograph of the left knee shows mild
soft tissue swelling but no fractures or dislocation. A radiograph of the left hip shows widening of the joint space and increased femoral head lucency.
You send a referral to orthopedic surgery and should advise the patient to do which of the following in the meantime?
Video 14.6 (Patellofemoral Syndrome):
○ A 22 year-old woman presents to the primary care office with new onset knee pain. The patient reports she recently began training for a marathon with
her best friend. She reports her mother has rheumatoid arthritis and her father has osteoarthritis. On physical examination the patient has pain in the
anterior knee, but no significant joint line tenderness. There is mild crepitus when passively flexing the knee. Which of the following is the most likely
reason for this patient's knee pain?
Video 14.7 (Osgood-Schlatter Disease):
○ An 11 year-old boy presents to the pediatrician with left knee pain for 3 weeks. The child has no remarkable health history to report. He recently joined
the school's basketball team and says he wants to go pro. On physical exam there is full range of motion, no ligamentous laxity, along with tenderness to
palpation over the tibial tubercle. The patient has 5/5 strength with resisted knee flexion and extension, but reports it is painful during knee extension.
Which of the following is the patient most likely to be experiencing?
References:
● Skeletal striated muscle.jpg
○ https://commons.wikimedia.org/wiki/File:Skeletal_striated_muscle.jpg Gabriel Caponetti, CC BY-SA 3.0
○ Nephron, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons
● Smooth muscle tissue.jpg

○ https://commons.wikimedia.org/wiki/File:Smooth_muscle_tissue.jpg
○ Juan Carlos Fonseca Mata, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
● Skeletal Muscle Cross-section and Longitudinal section

○ Created with Biorender.com
● Skeletal Muscle Contraction

● Sarcomere resting
● Sarcomere contracted
● Sarcomere.gif
○ https://commons.wikimedia.org/wiki/File:Sarcomere.gif
○ User:Sameerb, Copyrighted free use, via Wikimedia Commons
● Stretch reflex
● Inverse Stretch Reflex

References:
Slide 2:
● Knee x-ray, https://www.nature.com/articles/s41598-021-95419-3, CC by 4.0 https://creativecommons.org/licenses/by/4.0/
● https://commons.wikimedia.org/wiki/File:Heberden-Arthrose.JPG, <a href="https://commons.wikimedia.org/wiki/File:Heberden-Arthrose.JPG">Drahreg01</a>, <a
href="http://creativecommons.org/licenses/by-sa/3.0/">CC BY-SA 3.0</a>, via Wikimedia Commons
Slide 3:
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href="https://commons.wikimedia.org/wiki/File:Birefringence_microscopy_of_gout,_original.jpg">Mikael Häggström, M.D. - Author info - Reusing images- Conflicts of interest: NoneMikael
Häggström, M.D.Consent note: Consent from the patient or patient's relatives is regarded as redundant, because of absence of identifiable features (List of HIPAA identifiers) in the
media and case information (See also HIPAA case reports guidance).</a>, CC0, via Wikimedia Commons
● https://commons.wikimedia.org/wiki/File:GoutTophiKnee.JPG, <a href="https://commons.wikimedia.org/wiki/File:GoutTophiKnee.JPG">NickGorton</a>, <a
● https://commons.wikimedia.org/wiki/File:Podagra.jpg, <a href="https://commons.wikimedia.org/wiki/File:Podagra.jpg">Gonzosft</a>, <a
href="https://creativecommons.org/licenses/by/3.0/de/deed.en">CC BY 3.0 DE</a>, via Wikimedia Commons
Slide 4:
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profile)Annotated by Mikael Häggström</a>, CC0, via Wikimedia Commons
● https://commons.wikimedia.org/wiki/File:Birefringence_microscopy_of_pseudogout.jpg, <a
href="https://commons.wikimedia.org/wiki/File:Birefringence_microscopy_of_pseudogout.jpg">Mikael Häggström, M.D. - Author info - Reusing images- Conflicts of interest: NoneMikael
Häggström, M.D.Consent note: Consent from the patient or patient's relatives is regarded as redundant, because of absence of identifiable features (List of HIPAA identifiers) in the
media and case information (See also HIPAA case reports guidance).</a>, CC0, via Wikimedia Commons
Slide 5:
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Slide 7:
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● https://commons.wikimedia.org/wiki/File:Osteoporosis_Locations.png, <a href="https://commons.wikimedia.org/wiki/File:Osteoporosis_Locations.png">BruceBlaus</a>, <a
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email, Alexandros H Payatakes2,3 email, Vasilios T Chouliaras2 email, Georgios C Mandellos2 email, Nikolaos E Pyrovolou1 email, Fani M Pliarchopoulou4 email and Panayotis N
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Ngyuen</a>, Public Domain, via Wikimedia Commons
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● ***
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Slide 9:
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Slide 11:
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Slide 12:
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● RF IgM, Created with Biorender.com (2022).
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Commons
Slide 6:
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Slide 7:
● Chondrosarcoma radiograph; https://emedicine.medscape.com/article/388869-overview
● https://commons.wikimedia.org/wiki/File:Chondrosarcoma_(1).jpg, <a href="https://commons.wikimedia.org/wiki/File:Chondrosarcoma_(1).jpg">No machine-readable author provided. KGH assumed (based on copyright
claims).</a>, <a href="http://creativecommons.org/licenses/by-sa/3.0/">CC BY-SA 3.0</a>, via Wikimedia Commons
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Slide 8:
● https://commons.wikimedia.org/wiki/File:Ewing_sarcoma_tibia_child.jpg, <a href="https://commons.wikimedia.org/wiki/File:Ewing_sarcoma_tibia_child.jpg">Michael Richardson, M.D. on Oct 25th, 2004; Upload by Christaras
A</a>, <a href="http://creativecommons.org/licenses/by-sa/3.0/">CC BY-SA 3.0</a>, via Wikimedia Commons
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References
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● GCA histopathology. https://commons.wikimedia.org/wiki/File:Giant_cell_arteritis_--_low_mag.jpg, <a href="https://commons.wikimedia.org/wiki/File:Giant_cell_arteritis_--_low_mag.jpg">Nephron</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0</a>, via Wikimedia Commons
Slide 3:
● Vessel stenosis. https://commons.wikimedia.org/wiki/File:Takayasu_Arteritis.jpg, <a href="https://commons.wikimedia.org/wiki/File:Takayasu_Arteritis.jpg">Justin Ly</a>, Public domain, via Wikimedia Commons
● Active vasculitis with giant cells. https://www.pathologyoutlines.com/topic/kidneynontumortakayasuarteritis.html, Davis D, Andeen NK. Takayasu arteritis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/kidneynontumortakayasuarteritis.html. Accessed April 26th, 2023.
Slide 4:
● Angiography. https://commons.wikimedia.org/wiki/File:Buerger%27s_disease,HBO.jpg, <a href="https://commons.wikimedia.org/wiki/File:Buerger%27s_disease,HBO.jpg">Intermedichbo - Milorad Dimic M.D.</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0">CC BY-SA 4.0</a>, via
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58.12 (2015): 501. https://creativecommons.org/licenses/by/3.0/ Modifications: Cropped to half image size.
Slide 6:
● PAN histopathology:. https://commons.wikimedia.org/wiki/File:Periarteritis_nodosa_renis.jpg, <a href="https://commons.wikimedia.org/wiki/File:Periarteritis_nodosa_renis.jpg">dr n. med. Krystyna Bielnik, lek. med. Dariusz Młoczkowski, dr n. med. Tadeusz Modrzewski, lek. med. Dorota Snopkowska,
prof. dr hab. med. Krzysztof W. Zieliński</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0</a>, via Wikimedia Commons
● Renal angiography: https://www.hindawi.com/journals/crim/2015/428074/, Figure 2: Choi, Hyung-Il, et al. "Bilateral spontaneous perirenal hemorrhage due to initial presentation of polyarteritis nodosa." Case Reports in Medicine 2015 (2015). https://creativecommons.org/licenses/by/3.0/ Modifications:
Cropped to half image size.
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Slide 8:
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Commons
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Slide 9:
● https://commons.wikimedia.org/wiki/File:Churg-Strauss_syndrome_-_high_mag.jpg, <a href="https://commons.wikimedia.org/wiki/File:Churg-Strauss_syndrome_-_high_mag.jpg">Nephron</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0</a>, via Wikimedia Commons
Slide 10:
● https://commons.wikimedia.org/wiki/File:C_anca.jpg, <a href="https://commons.wikimedia.org/wiki/File:C_anca.jpg">Malittle at English Wikipedia</a>, Public domain, via Wikimedia Commons
● https://commons.wikimedia.org/wiki/File:Wegeners_Granulomatosis_CXR.jpg, <a href="https://commons.wikimedia.org/wiki/File:Wegeners_Granulomatosis_CXR.jpg">Tom Buur</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0">CC BY-SA 4.0</a>, via Wikimedia Commons
● https://commons.wikimedia.org/wiki/File:Wegeners_granulomatosis_-_Core_biopsy_Case_241_(7603841482).jpg, <a href="https://commons.wikimedia.org/wiki/File:Wegeners_granulomatosis_-_Core_biopsy_Case_241_(7603841482).jpg">Yale Rosen from USA</a>, <a
Slide 11:
● https://commons.wikimedia.org/wiki/File:Plamica_w_zespole_Henocha-Schonleina.JPG, <a href="https://commons.wikimedia.org/wiki/File:Plamica_w_zespole_Henocha-Schonleina.JPG">Ajd52</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0</a>, via Wikimedia Commons
● https://commons.wikimedia.org/wiki/File:Purpura2.JPG, <a href="https://commons.wikimedia.org/wiki/File:Purpura2.JPG">The original uploader was Okwikikim at English Wikipedia.</a>, Public domain, via Wikimedia Commons
Commons
Slide 12:
● https://commons.wikimedia.org/wiki/File:P_anca.jpg, <a href="https://commons.wikimedia.org/wiki/File:P_anca.jpg">Malittle at English Wikipedia</a>, Public domain, via Wikimedia Commons
Slide 13:
● https://commons.wikimedia.org/wiki/File:Cryoglobulinemia2.jpg, <a href="https://commons.wikimedia.org/wiki/File:Cryoglobulinemia2.jpg">Madhero88</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0</a>, via Wikimedia Commons
Commons
References
Slide 2:
● Brachial Plexus anterior view https://commons.wikimedia.org/wiki/File:Brachial_plexus_anterior_view_nerves.JPG, <ahref="https://commons.wikimedia.org/wiki/File:Brachial_plexus_anterior_view_nerves.JPG">Kinstudent</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0</a>, via Wikimedia
Commons
● Brachial Plexus - Created with BioRender.com
Slide 3:
● Biceps brachii https://commons.wikimedia.org/wiki/File:Biceps_brachii_muscle01.png, <a href="https://commons.wikimedia.org/wiki/File:Biceps_brachii_muscle01.png">Anatomography</a>, <a href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en">CC BY-SA 2.1 JP</a>, via Wikimedia Commons
● Coracobrachialis https://commons.wikimedia.org/wiki/File:Coracobrachialis_muscle01.png, <a href="https://commons.wikimedia.org/wiki/File:Coracobrachialis_muscle01.png">Anatomography</a>, <a href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en">CC BY-SA 2.1 JP</a>, via Wikimedia Commons
● Brachialis https://commons.wikimedia.org/wiki/File:Brachialis_muscle01.png, <a href="https://commons.wikimedia.org/wiki/File:Brachialis_muscle01.png">Anatomography</a>, <a href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en">CC BY-SA 2.1 JP</a>, via Wikimedia Commons
● Brachial Plexus and Cutaneous Innervation - Created with BioRender.com
Slide 4:
● Teres minor https://commons.wikimedia.org/wiki/File:Teres_minor_muscle_back2.png, <a href="https://commons.wikimedia.org/wiki/File:Teres_minor_muscle_back2.png">Anatomography</a>, <a href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en">CC BY-SA 2.1 JP</a>, via Wikimedia Commons
● Deltoid https://commons.wikimedia.org/wiki/File:Deltoid_muscle_top11.png, <a href="https://commons.wikimedia.org/wiki/File:Deltoid_muscle_top11.png">Anatomography</a>, <a href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en">CC BY-SA 2.1 JP</a>, via Wikimedia Commons
Slide 5:
● Triceps brachii https://commons.wikimedia.org/wiki/File:Triceps_brachii_muscle06.png, <a href="https://commons.wikimedia.org/wiki/File:Triceps_brachii_muscle06.png">Anatomography</a>, <a href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en">CC BY-SA 2.1 JP</a>, via Wikimedia Commons
● Brachialis https://commons.wikimedia.org/wiki/File:Brachialis_muscle01.png, <a href="https://commons.wikimedia.org/wiki/File:Brachialis_muscle01.png">Anatomography</a>, <a href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en">CC BY-SA 2.1 JP</a>, via Wikimedia Commons
● Posterior Forearm https://picryl.com/media/extensor-carpi-ulnaris-muscle-3c0f7d, Henry Gray adjusted by picryl user: Helgo13 Public Domain via Picryl.com
● Bones of arm https://commons.wikimedia.org/wiki/File:Human_arm_bones_diagram-ca.svg, <a href="https://commons.wikimedia.org/wiki/File:Human_arm_bones_diagram-ca.svg">LadyofHats Mariana Ruiz Villarreal. Translated by Jmarchn</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0</a>, via
Wikimedia Commons
● Brachial Plexus and Cutaneous Innervation - Created with BioRender.com.
Slide 6:
● Anterior Forearm https://picryl.com/media/gray-musculus-flexor-carpi-ulnaris-f533f1?action=upgrade, Henry Gray adjusted by picryl user: Helgo13 Public Domain via Picryl.com
● Intrinsic muscles of the hand https://commons.wikimedia.org/wiki/File:1121_Intrinsic_Muscles_of_the_Hand_Superficial_sin.png , <a href="https://commons.wikimedia.org/wiki/File:1121_Intrinsic_Muscles_of_the_Hand_Superficial_sin.png">CFCF</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0">CC BY-SA
● Brachial Plexus and Cutaneous Innervation - Created with BioRender.com.
Slide 7:
● Anterior Forearm https://picryl.com/media/gray-musculus-flexor-carpi-ulnaris-f533f1?action=upgrade, Henry Gray adjusted by picryl user: Helgo13 Public Domain via Picryl.com
● Intrinsic muscles of the hand https://commons.wikimedia.org/wiki/File:1121_Intrinsic_Muscles_of_the_Hand_Superficial_sin.png , <a href="https://commons.wikimedia.org/wiki/File:1121_Intrinsic_Muscles_of_the_Hand_Superficial_sin.png">CFCF</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0">CC BY-SA
Slide 8:
● Erb Palsy https://commons.wikimedia.org/wiki/File:Erb%27s_Palsy_2.jpg, <a href="https://commons.wikimedia.org/wiki/File:Erb%27s_Palsy_2.jpg">r</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0">CC BY-SA 4.0</a>, via Wikimedia Commons
● Dermatome of the arm https://commons.wikimedia.org/wiki/File:1611_Dermatomes-02.jpg, <a href="https://commons.wikimedia.org/wiki/File:1611_Dermatomes-02.jpg">OpenStax Anatomy and PhysiologyOpenStax</a>, <a href="https://creativecommons.org/licenses/by/4.0">CC BY 4.0</a>, via Wikimedia Commons - Cropped
to fit
● Brachial Plexus - Created by BioRender.com
Slide 9:
● Claw Hand https://commons.wikimedia.org/wiki/File:Tiger_KungFu.jpg, <a href="https://commons.wikimedia.org/wiki/File:Tiger_KungFu.jpg">Emilie Morvant</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0">CC BY-SA 4.0</a>, via Wikimedia Commons
to fit
● Brachial Plexus - Created with BioRender.com
Slide 10:
● Cervical rib x-ray https://commons.wikimedia.org/wiki/File:C7ribMark.png, <a href="https://commons.wikimedia.org/wiki/File:C7ribMark.png">James Heilman, MD</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0">CC BY-SA 4.0</a>, via Wikimedia Commons
● Thoracic Outlet Anatiomy https://commons.wikimedia.org/wiki/File:Wikipedia_medical_illustration_thoracic_outlet_syndrome_brachial_plexus_anatomy_with_labels.jpg, <a href="https://commons.wikimedia.org/wiki/File:Wikipedia_medical_illustration_thoracic_outlet_syndrome_brachial_plexus_anatomy_with_labels.jpg">English:
Nicholas Zaorsky, M.D.</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0</a>, via Wikimedia Commons
to fit
Slide 11:
● Scapula https://commons.wikimedia.org/wiki/File:Scapula_-_posterior_view2.png, <a href="https://commons.wikimedia.org/wiki/File:Scapula_-_posterior_view2.png">Anatomography</a>, <a href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en">CC BY-SA 2.1 JP</a>, via Wikimedia Commons
● Serratus anterior https://commons.wikimedia.org/wiki/File:Serratus_anterior_muscles_lateral.png, <a href="https://commons.wikimedia.org/wiki/File:Serratus_anterior_muscles_lateral.png">Anatomography</a>, <a href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en">CC BY-SA 2.1 JP</a>, via Wikimedia Commons
● Winged Scaoula “Fig 4, in: Isolated long thoracic nerve paralysis - a rare complication of anterior spinal surgery: a case report” by Ameri E, Behtash H, Omidi-Kashani F, Journal of Medical Case Reports, licensed under CC BY 2.0.
References
Slide 2:
● Shoulder joint https://commons.wikimedia.org/wiki/File:Blausen_0797_ShoulderJoint.png, <a href="https://commons.wikimedia.org/wiki/File:Blausen_0797_ShoulderJoint.png">BruceBlaus. When using this image in external sources it can be cited
as:Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.</a>, <a href="https://creativecommons.org/licenses/by/3.0">CC BY 3.0</a>, via
Wikimedia Commons
● Clavicle https://commons.wikimedia.org/wiki/File:Clavicle_-_lateral_view2.png, <a href="https://commons.wikimedia.org/wiki/File:Clavicle_-_lateral_view2.png">Anatomography</a>, <a
href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en">CC BY-SA 2.1 JP</a>, via Wikimedia Commons
● Shoulder cuff muscles https://commons.wikimedia.org/wiki/File:Shoulder_joint_bf.svg, <a href="https://commons.wikimedia.org/wiki/File:Shoulder_joint_bf.svg">Jmarchn</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA
● Ligaments of Shoulder https://commons.wikimedia.org/wiki/File:202107_Ligament_of_the_shoulder_joint.svg, <a href="https://commons.wikimedia.org/wiki/File:202107_Ligament_of_the_shoulder_joint.svg">DataBase Center for Life Science
(DBCLS)</a>, <a href="https://creativecommons.org/licenses/by/4.0">CC BY 4.0</a>, via Wikimedia Commons
● Scapula bone https://commons.wikimedia.org/wiki/File:Right_scapula_-_close-up_-_anterior_view.png, <a href="https://commons.wikimedia.org/wiki/File:Right_scapula_-_close-up_-_anterior_view.png">Anatomography</a>, <a
Slide 3:
● X-ray of supraspinatus tear https://commons.wikimedia.org/wiki/File:Supraspinatustear.PNG. <a href="https://commons.wikimedia.org/wiki/File:Supraspinatustear.PNG">James Heilman, MD</a>, <a
Slide 4:
● X-ray of fracture https://commons.wikimedia.org/wiki/File:Clavicle_Fracture_Left.jpg, <a href="https://commons.wikimedia.org/wiki/File:Clavicle_Fracture_Left.jpg">Majorkev at English Wikipedia</a>, <a
● Clavicle fracture image https://commons.wikimedia.org/wiki/File:Collarbone_fracture_-_Clavicle_fracture_--_Smart-Servier.jpg, <a
href="https://commons.wikimedia.org/wiki/File:Collarbone_fracture_-_Clavicle_fracture_--_Smart-Servier.jpg">Laboratoires Servier</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0</a>, via Wikimedia Commons
● Clavicle https://commons.wikimedia.org/wiki/File:Left_clavicle_-_close-up_-_inferior_view.png, <a href="https://commons.wikimedia.org/wiki/File:Left_clavicle_-_close-up_-_inferior_view.png">Anatomography</a>, <a
Slide 5:
● X-ray of humerus fracture https://commons.wikimedia.org/wiki/File:2016-Humerus_fracture.jpg, <a href="https://commons.wikimedia.org/wiki/File:2016-Humerus_fracture.jpg">Ivtorov</a>, <a
● Communicated fracture https://commons.wikimedia.org/wiki/File:Communitive_midshaft_humeral_fracture_callus.jpg, <a href="https://commons.wikimedia.org/wiki/File:Communitive_midshaft_humeral_fracture_callus.jpg">Bill Rhodes from
Asheville</a>, <a href="https://creativecommons.org/licenses/by/2.0">CC BY 2.0</a>, via Wikimedia Commons
● Humerus with drawn fractures https://commons.wikimedia.org/wiki/File:820_Humerus_Radius_Fractures_(cropped).jpg, <a href="https://commons.wikimedia.org/wiki/File:820_Humerus_Radius_Fractures_(cropped).jpg">OpenStax College</a>,
<a href="https://creativecommons.org/licenses/by/3.0">CC BY 3.0</a>, via Wikimedia Commons
● Sensory Innervations, Created with BioRender.com
Slide 6:
● Elbow joint https://commons.wikimedia.org/wiki/File:202107_Anterior_view_of_the_elbow_joint.svg, <a href="https://commons.wikimedia.org/wiki/File:202107_Anterior_view_of_the_elbow_joint.svg">DataBase Center for Life Science
(DBCLS)</a>, <a href="https://creativecommons.org/licenses/by/4.0">CC BY 4.0</a>, via Wikimedia Commons
● Ligaments of Elbow https://commons.wikimedia.org/wiki/File:915_Elbow_Joint.jpg, <a href="https://commons.wikimedia.org/wiki/File:915_Elbow_Joint.jpg">OpenStax College</a>, <a href="https://creativecommons.org/licenses/by/3.0">CC BY
● Pronator teres https://commons.wikimedia.org/wiki/File:Pronator_teres.svg, <a href="https://commons.wikimedia.org/wiki/File:Pronator_teres.svg">Egmason</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0</a>, via
Wikimedia Commons
● Forearm bones https://commons.wikimedia.org/wiki/File:Forearm_anterior.svg, <a href="https://commons.wikimedia.org/wiki/File:Forearm_anterior.svg">Athikhun.suw</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0">CC BY-SA
Slide 7:
● Tennis Elbow https://commons.wikimedia.org/wiki/File:Tennis_Elbow.png, <a href="https://commons.wikimedia.org/wiki/File:Tennis_Elbow.png">BruceBlaus</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0">CC BY-SA 4.0</a>, via
Wikimedia Commons
● Golfers elbow https://commons.wikimedia.org/wiki/File:Golfers-Elbow_SAG.jpg, <a href="https://commons.wikimedia.org/wiki/File:Golfers-Elbow_SAG.jpg">www.scientificanimations.com</a>, <a
References
Slide 2:
● Bones of the Hand
https://commons.wikimedia.org/wiki/File:Human_left_hand_bones_with_metacarpal_numbers_and_carpal_letters.svg, <a
href="https://commons.wikimedia.org/wiki/File:Human_left_hand_bones_with_metacarpal_numbers_and_carpal_letters.svg">Mariana
Ruiz Villarreal (LadyofHats)NyksBibi Saint-PolBloubériWhidou</a>, CC0, via Wikimedia Commons
Slide 3:
● Carpal Tunnel Syndrome https://commons.wikimedia.org/wiki/File:Carpal_Tunnel_Syndrome.png, <a
href="https://commons.wikimedia.org/wiki/File:Carpal_Tunnel_Syndrome.png">BruceBlaus. When using this image in external
sources it can be cited as:Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1
(2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.</a>, <a href="https://creativecommons.org/licenses/by/3.0">CC BY 3.0</a>, via
Wikimedia Commons
References
Slide 2 (Radial Head Subluxation):
● https://commons.wikimedia.org/wiki/File:En-elbow_joint.svg, <a href="https://commons.wikimedia.org/wiki/File:En-elbow_joint.svg">Henry Vandyke Carter</a>, Public domain, via Wikimedia Commons
● https://commons.wikimedia.org/wiki/File:Elbow_subluxation.svg, <a href="https://commons.wikimedia.org/wiki/File:Elbow_subluxation.svg">InjuryMap</a>, <a
Slide 3 (Pediatric Fractures):
● https://radiopaedia.org/articles/bowing-fracture?lang=us, Ranchod Ashesh Ishwarlal. “Bowing fracture: Radiology reference article.” Radiopaedia Blog RSS. Radiopaedia.org. <a
href="https://radiopaedia.org/articles/bowing-fracture?lang=us" target="_blank">[Link]</a>.
● https://commons.wikimedia.org/wiki/File:Gruenholzfraktur_-_Unterarmfraktur.jpg, <a href="https://commons.wikimedia.org/wiki/File:Gruenholzfraktur_-_Unterarmfraktur.jpg">Hellerhoff</a>, <a
● https://commons.wikimedia.org/wiki/File:Buckle_Fracture.jpg, <a href="https://commons.wikimedia.org/wiki/File:Buckle_Fracture.jpg">Apaul291003</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0">CC
● https://commons.wikimedia.org/wiki/File:SalterHarris2010.JPG, <a href="https://commons.wikimedia.org/wiki/File:SalterHarris2010.JPG">James Heilman, MD</a>, <a
● https://commons.wikimedia.org/wiki/File:Supracondylar09.JPG, <a href="https://commons.wikimedia.org/wiki/File:Supracondylar09.JPG">James Heilman, MD</a>, <a
Slide 4 (DDH):
● https://commons.wikimedia.org/wiki/File:Congenitaldislocation10.JPG, <a href="https://commons.wikimedia.org/wiki/File:Congenitaldislocation10.JPG">James Heilman, MD</a>, <a
● https://commons.wikimedia.org/wiki/File:Pavlik.jpg, <a href="https://commons.wikimedia.org/wiki/File:Pavlik.jpg">Londenp</a>, <a href="http://creativecommons.org/licenses/by-sa/3.0/">CC BY-SA 3.0</a>, via
Wikimedia Commons
Slide 5 (SCFE):
● https://commons.wikimedia.org/wiki/File:Slipped_capital_femoral_epiphysis.jpg, <a href="https://commons.wikimedia.org/wiki/File:Slipped_capital_femoral_epiphysis.jpg">Dr. Jochen Lengerke</a>, CC0, via Wikimedia
Commons
Slide 6 (LCP):
● https://commons.wikimedia.org/wiki/File:LeggCalvePerthes1.jpg, <a href="https://commons.wikimedia.org/wiki/File:LeggCalvePerthes1.jpg">Jfrolick</a>, <a href="https://creativecommons.org/licenses/by/3.0">CC BY
● https://commons.wikimedia.org/wiki/File:LeggCalvePerthes2.jpg, <a href="https://commons.wikimedia.org/wiki/File:LeggCalvePerthes2.jpg">Jfrolick</a>, <a href="https://creativecommons.org/licenses/by/3.0">CC BY
Slide 7 (Patellofemoral Syndrome):
● https://commons.wikimedia.org/wiki/File:PFPS.png, <a href="https://commons.wikimedia.org/wiki/File:PFPS.png">BodyParts3D/Anatomography</a>, <a
● https://commons.wikimedia.org/wiki/File:X-ray_of_a_normal_patella.jpg, <a href="https://commons.wikimedia.org/wiki/File:X-ray_of_a_normal_patella.jpg">Mikael Häggström, M.D. Author info - Reusing images-
Conflicts of interest: NoneMikael Häggström, M.D.</a>, CC0, via Wikimedia Commons
Slide 8 (Osgood-Schlatter Disease):
● https://commons.wikimedia.org/wiki/File:Radiograph_of_human_knee_with_Osgood%E2%80%93Schlatter_disease.png, <a
href="https://commons.wikimedia.org/wiki/File:Radiograph_of_human_knee_with_Osgood%E2%80%93Schlatter_disease.png">James Heilman, MD</a>, <a href="https://creativecommons.org/licenses/by-sa/3.0">CC
● https://commons.wikimedia.org/wiki/File:MaleWithOsgoodSchlatter.jpg, <a href="https://commons.wikimedia.org/wiki/File:MaleWithOsgoodSchlatter.jpg">D3aj86</a>, <a

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TABLE OF CONTENTS

ATP Sources by Time:

⚪ A. Increases frequency of chloride channel opening

⚪ B. Persistent depolarization of motor end-plate

⚪ C. Increases calcium levels within the sarcoplasmic reticulum

⚪ D. Direct inhibition of sarcoendoplasmic reticulum calcium transport ATPase

⚪ E. Increases binding of calcium to troponin C

⚪ A. Increases frequency of chloride channel opening

⚪ B. Persistent depolarization of motor end-plate

" C. Increases calcium levels within the sarcoplasmic reticulum

⚪ D. Direct inhibition of sarcoendoplasmic reticulum calcium transport ATPase

⚪ E. Increases binding of calcium to troponin C

Musculoskeletal A. Pathophysiology A. Pathophysiology

Diseases D. Management D. Management

Calcium Pyrophosphate Deposition Disease (CPPD)

Osteitis Deformans (Paget disease of bone)

Osteitis Fibrosa Cystica

Etiology Serum Ca2+ Serum PO43- PTH ALP

Osteitis Fibrosa Cystica

1. Rheumatoid Arthritis 7. Polymyositis/dermatomyositis

Musculoskeletal B. Associated Conditions

System: 2. Systemic Lupus Erythematosus

Systemic Lupus Erythematosus

Antiphospholipid Syndrome (APS)

Polymyalgia Rheumatica (PMR)

Systemic Juvenile Idiopathic Arthritis (Still’s Disease)

Scleroderma & Mixed Connective Tissue Disease (MCTD)

1. Seronegative Spondyloarthritis Overview

System: 2. Psoriatic Arthritis

Spondyloarthritis 3. Ankylosing Spondylitis

Seronegative Spondyloarthritis Overview

1. Osteochondroma & Enchondroma 6. Chondrosarcoma

Osteochondroma & Enchondroma

Osteoma & Osteoid Osteoma

Giant Cell Tumor (Osteoclastoma)

Summary - Benign Bone Tumors

Diagnostics Sessile, pedunculated Well-defined Hyperdense, Radiolucent Well-demarcated Osteolytic multicystic

Pathology: Giant cells

Management Surgery if Surgery if Surgery if Surgery if Surgery if Surgical excision

Summary - Malignant Bone Tumors

Giant Cell Arteritis (GCA)

Thromboangiitis obliterans (Buerger Disease)

Kawasaki Disease (Mucocutaneous Lymph Node Syndrome)

Cutaneous Small-Vessel Vasculitis (CSVV)

Eosinophilic Granulomatosis with Polyangiitis (EGPA)

Granulomatosis with Polyangiitis (GPA)

IgA Vasculitis (Henoch-Schonlein Purpura)

Brachial Plexus A. Nerve Roots

Brachial Plexus Overview

Thoracic Outlet Syndrome

All Abductor pollicis

THENAR For Flexor pollicis brevis

One Opponens pollicis brevis

ADDUCTOR And Adductor pollicis brevis

One Opponens digiti minimi

HYPOTHENAR For Flexor digiti minimi

All Abductor digiti minimi

Video 8.8: (Klumpke Palsy)

1. Shoulder Anatomy 4. Humerus Fractures

Shoulder & Elbow

Rotator Cuff Tear

1. Wrist & Hand Anatomy 5. Hand Distortions

Wrist & Hand