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• Knowing the imaging ABCS is important
• Ankylosing spondylitis, gout, spondylolisthesis, and rheumatoid arthritis all require knowledge about symptoms/presentation for each
• Treating gout can be achieved through lifestyle factors such as weight loss, hydration, and reducing alcohol intake

Imaging

• It's important to differentiate CT vs. Xray images
• Identifying ultrasound pictures is a key part of diagnosis
• MRI is used for post-traumatic knee injuries, specifically ligament or meniscal tears, and soft tissue damage
• Bisphosphonates can have side effects which require that the patient be placed in a supine position
• Red flags/yellow flags/ and constitutional symptoms should be known
• DVT (Deep Vein Thrombosis) diagnosis often involves case scenarios where scoring is used like the Wells score

Pathophysiologic Responses

• Increased workloads elicit pathophysiologic responses
• Smoking induces responses centered around endothelial dysfunction, inflammation, oxidative stress, and platelet activation
• Smoking leads to atherosclerosis, cardiovascular diseases, lung damage, and cancer through mechanisms like impaired vascular function, blood clotting, and direct cellular damage from toxic chemicals in tobacco smoke
• There are three phases of something which should be known

Types/Causes of Cell/Tissue Injury

• This can be divided into reversible vs irreversible causes
• Ischemia is caused by insufficient or absent blood flow (hypoxia or anoxia)
• Infection can be bacterial, where the inflammatory response leads to cell injury/death
• Viral infections have a direct cytopathic effect (RNA) or indirect cytopathic effect (DNA)
• Immune reactions include hypersensitivities or autoimmune disorders
• Chemical factors include carbon monoxide, ammonia, heavy metals, alkylating agents in pharmaceutical drugs, and free radicals
• Physical/Mechanical factors include physical or blunt trauma, temperature (hypo/hyperthermia) radiation, and electricity
• Mechanical factors are a subset of physical factors that include tissue tolerance, age, utilization, and load factors like compression, friction, torsion, or shear forces based on tissue properties and load magnitude Nutritional deficiencies such as:
• Vitamin B12 (neuropathy)
• Calcium (decreased bone quality)
• Protein malnutrition (edema, weight loss, diminished functional capacity)
• Psychological factors include fear, tension, anxiety, depression, isolation
• Aging involves a progressive decline in homeostasis balance, leading to pathology
• Irreversible cell injury:
  • Cell death
  • Necrosis (coagulation, liquefactive, gaseous, fatty, fibrinoid) which is the endpoint of a pathological process
  • Apoptosis, or programmed cell death

Types of Bone, Tendinous, & Ligamentous Injuries

• Know the associated phases of healing
• Tendons Intrinsic healing involves vascular internal vascular response resulting in fibroblast proliferation from intrinsic blood supply
• Fibroblasts are a type of cell found in connective tissue. Proliferation is a rapid increase of these cell types when repairing tissues
• Tendons Extrinsic healing is through vascular-inflammatory-cellular response from adjacent tissue cells
• The Degree of healing depends on injury severity, the need for surgical repair, and the amount of mobilization or immobilization after injury
• Three stages of tendon healing:
  • Acute: Hemostasis, inflammatory phase
  • Subacute: Repair and healing
  • Chronic: maturation and remodeling
• Tendon healing is detrimental:
  • When the tendon is unloaded completely by temporary paralysis
    • OR when it is overloaded by active mobility or exercise
• Tendon healing by cast Immobilization:
  • Benefits tendon to bone healing
  • Detrimental for flexor tendon healing
• Tendon healing by passive motion:
  • Beneficial for flexor tendon healing
  • Detrimental for tendon to bone healing
• Tendons need controlled stress to develop tensile strength for recovery
• A tendon can heal without surgery in usually incomplete injuries, A suture repair can help minimize scar formation by closing the gap between tendon ends

Tendon Repair Strength

• Weakest at 7-10 days
• Regaining strength at 21-28 days
• Near full strength at 6 months
• Ligamentous healing requires 3 conditions for remodeling:

1. Torn ligament ends in contact
2. Progressive controlled stress to orient scar tissue
3. Protection against excessive forces during remodeling

• Not all ligaments heal at the same rate or degree
• Intra Articular ligaments DO NOT heal spontaneously
• Extra Articular ligaments heal in a specific order:

1. Inflammatory phase (inflammation and Hemostasis)
2. Repair (fibroplasia and cell proliferation)
3. Remodeling (maturation)

• Intraarticular ligaments stabilize joints and are within the joint capsule like the ACL, PCL
• Extraarticular ligaments are outside the joint capsule, examples: the MCL and LCL

Hallmark Signs

• Know the Hallmark signs of OA vs RA on radiograph, risk factors, management, and presentation of these conditions
• Osteoarthritis (OA) Hallmark Signs:
  • Joint Space Narrowing is asymmetrical, typically affecting weight-bearing surfaces
  • Osteophytes (bone spurs)
  • Subchondral Sclerosis (increased bone density beneath cartilage)
  • Subchondral Cysts
  • Malalignment & Joint Deformity (late-stage)
• Rheumatoid Arthritis (RA) Hallmark Signs:
  • Symmetrical Joint Space Narrowing
  • Periarticular Osteopenia (loss of bone density)
  • Erosions (especially at the margins of joints, “bare area")
  • Soft Tissue Swelling
  • Joint Subluxation & Deformities
• Risk Factors for Osteoarthritis (OA) include Age, Obesity, Joint Trauma, Repetitive Stress, Genetics, and Female Sex
• Rheumatoid Arthritis (RA) risk factors; Genetic Predisposition, Female Sex Smoking, Infections, and Hormonal Factors
• Osteoarthritic presentations include Morning Stiffness worsening with use, and Asymmetrical Joint Involvement
• Rheumatoid Arthritis (RA) presentations; Morning Stiffness >1 Hour, Worse with Rest, Better with Use, and Symmetrical Polyarthritis
• Systemic Symptoms of RA are Fatigue, weight loss, fever and Extra-Articular Involvement, like Rheumatoid nodules and interstitial lung disease
• Management of Osteoarthritis includes Non-Pharmacologic interventions like weight loss and exercise and Pharmacologic treatments, such as acetaminophen or NSAIDs
• RA Management; Non-pharmacologic interventions, such as PT & OT and Smoking Cessation and Pharmacologic DMARDs

Radiographical Assessment

ABC'S of radiographical assessment:

• Alignment - General issues, Contour of bone, Bones relative to other bones
• Bone Density
• Cartilage
• Soft Tissue
• Important to be able to differentiate which one is which on T2 vs T1 MRI vs CT vs Ultrasound vs Radiograph
• MRI:
  • T1 (left) (marrow is bright/fluid is dark)
  • T2 (right)(marrow is dark/fluid is bright) MRI uses different sequences (protocols) that target different tissues
• Sequences often referred to as T1- or T2-weighted
• T1 weighted: greater anatomical detail, emphasize fat, bone marrow
• T2 weighted: less anatomical detail, emphasize fluid/ edema/inflammation

Imaging Modalities

• CT Scans reveal true presentation of tissue density
• Radiographs reveal scoliosis curve of more than 10 degrees as well as Monteggia fracture
• You can see "scottie dog faces" in the pars inter articularis

Pathology

• Increased molecular weight increases radiodensity increase radiopaque
• Radiodense: high-density structures appear bright
• Radiolucency: low density structures appear dark
• • stuctures that are not dense appear bright if they are thick enough or superimposed on other structures
• Fracture healing has 3 overlapping phases:inflammation reparative and remodeling
• Types of MSK Injuries; Strain vs sprain
  1. Strain: stretching or tearing of the musculotendinous unit
  2. Sprain: Injury of the ligamentous structure around a joint
  • The 4 different classifications

Pain Signs

• Signs/symptoms of emotional overlay
• General signs of pain can be physical behaviours
• Constitutional signs and symptoms include fever, vomiting diarrhea fatigue and weight loss
• Common sites for referred visceral pain should be noted, particularly Kehr's sign related to referred shoulder pain from splenic rupture
• Presenting symptoms of; stroke, osteomyelitis, TB, staphylococcus, and pancreatitis need to be considered

Red Flags

• Important to know risk factors, pain patterns, clinical presentation
• Two Main Routes for Drug Dministration; Enteral and Parenteral
  1. Enteral through the alimentary canal
     • Has subcategories of drug uptake

Pharmacokinetics

• Understand pharmacokinetics and have a general understanding for pharmacodynamics (general understanding/definitions) a. Pharmacokinetics The movement of the drug through the body
  • Absorption
  • Distribution
  • Metabolism
  • Excretion b. Bioavailability
  • Expressed as a percent of the drug administered that reaches the bloodstream c. First Pass Effect
  • Only orally administered drugs undergo first-pass effect d. Drug Elimination Rate Drug safety should be understood
• US Department of Justice updates Drug Schedules regularly
  • Have a look at each Schedule

Analgesics

• NSAIDs, and Tylenol: risks/benefits of each
  • Treats of mild to moderate pain & information
  • Treats of fever
  • Prevents excessive blood clotting
  • Prevents colorectal cancer
  • Side effects
• Pharmacological management of MSK infections and adverse side effects of the drugs should be understood
• Osteoporosis • Signs/Symptoms • Non-modifiable Risk Factors • Modifiable Risk Factors • Management • Osteomalacia Signs/Symptoms and its Risk Factors

Screening

• Screening for intermittent claudication, DVT, and arterial disease
• Intermittent Claudication; Key Signs & Symptoms and Screening Tests
  • screening using ABI

Pathologies

• Deep Vein Thrombosis (DVT); Signs & Symptoms ( >3cm is the key indicator)
• Important tests and criteria to follow guidelines
• Arterial Disease (PAD)

Aging

• Major physiologic changes seen with aging include sarcopenia, increased stiffness, and bone quality changes