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Grandma’s aching knees and snapping fingers

Grandma’s aching knees and snapping fingers. C1. Chief Complaint. 79 y/o F. Pain and stiffness of thumb and middle finger of R hand. History of Present Illness. Past Medical History. Physical Examination. Normal vital signs; BMI 28 Musculoskeletal Exam

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Grandma’s aching knees and snapping fingers

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  1. Grandma’s aching knees and snapping fingers C1

  2. Chief Complaint 79 y/o F Pain and stiffness of thumb and middle finger of R hand

  3. History of Present Illness

  4. Past Medical History

  5. Physical Examination • Normal vital signs; BMI 28 Musculoskeletal Exam • Crepitus on both knees without effusion • 1st and 3rd fingers of R hand would snap on flexion and required assistance due to pain on attempted extension

  6. Physical Examination Stooped posture Bilateral genu varum deformity Non-tender bony nodes on PIP and DIP

  7. Salient Features • 79 y/o female • Years of painful knees, pronounced when walking • Crepitus on both knees without effusion • Bilateral genu varum • Pain and stiffness of thumb and middle finger of R hand • would snap on flexion and require assistance on extension • Non-tender bony nodules on PIP and DIP • Diagnosed with osteoporosis, received 2 yearly infusion of zoledronic acid • Stooped posture • Hypertension controlled on daily amlodipine

  8. Musculoskeletal signs and symptoms in the Patient • Painful knees, more pronounced on walking; Non-tender bony nodules on PIP and DIP; Crepitus on both knees without effusion; bilateral genu varum • Pain and stiffness of thumb and middle finger of R hand; would snap on flexion and require assistance on extension • Stooped posture; previous diagnosis of osteoporosis with prescribed medication

  9. Musculoskeletal conditions in the Patient Osteoarthritis Painful knees, more pronounced on walking; Non-tender bony nodules on PIP and DIP; Crepitus on both knees without effusion; bilateral genu varum “Trigger Finger/ Digit” Pain and stiffness of thumb and middle finger of R hand; would snap on flexion and require assistance on extension Osteoporosis Stooped posture

  10. Osteoarthritis

  11. Management for OA Non-pharmacologic Management (1) avoiding activities that overload the joint, as evidenced by their causing pain (2) improving the strength and conditioning of muscles that bridge the joint, so as to optimize their function (3) unloading the joint, either by redistributing load within the joint with a brace or a splint or by unloading the joint during weight bearing with a cane or a crutch. Exercise lessens pain and improves physical function consist of aerobic and/or resistance training (strengthens muscles across the joints) Correction of Malalignment

  12. Management for OA

  13. “Trigger-finger/digit”

  14. Management for “Trigger-finger/digit” • Local steroid injection • Cortisone, prednisolone, dexamethasone, and triamcinolone. • A mixture of steroid, 1% lidocaine, and 0.5% bupivacaine is used, in a ratio of 2:1:1, respectively • After injection, the patient is encouraged to move the digit. • A follow-up appointment is made for 3-4 weeks after the treatment

  15. Management for “Trigger-finger/digit” • Splinting • For those patients who decline injection • MCP joint is splinted in approximately 15° of flexion.

  16. Osteoporosis

  17. Management for Osteoporosis To maintain bone health: • Make sure there is enough calcium in your diet • Get adequate vitamin D intake, which is important for calcium absorption and to maintain muscle strength • Get regular exercise, especially weight-bearing exercise.

  18. Management for Osteoporosis • Bisphophonates • alendronate, residronate, etidronate • Patient was given zoledronic acid • Calcitonin • Calcitonin works by directly inhibiting osteoclast activity via the calcitonin receptor. • Calcitonin directly induces inhibition of osteoclastic bone resorption by affecting actin cytoskeleton which is needed for the osteoclastic activity.

  19. Management for Osteoporosis • Selective Estrogen Receptor Modulators (SERMs) • are a class of medications that act on the estrogen receptors throughout the body in a selective manner • Raloxifene (60 mg/d) - act on the bone by slowing bone resorption by the osteoclasts

  20. What is the mechanism of action of NSAIDs?

  21. Most NSAIDs act as nonselective inhibitors of the enzyme cyclooxygenase(COX), inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes. • COX catalyzes the formation of prostaglandins and thromboxane from arachidonicacid • Prostaglandins act as messenger molecules in the process of inflammation.

  22. Many aspects of the mechanism of action of NSAIDs remain unexplained, for this reason further COX pathways were hypothesized. The COX pathway was believed to fill some of this gap but recent findings make it appear unlikely that it plays any significant role in humans and alternative explanation models are proposed. The FASEB journal : official publication of the Federation of American Societies for Experimental Biology22 (2): 383–390

  23. MOA of NSAIDS

  24. Selective and Non-Selective NSAID

  25. Bisphosphonate preparations

  26. Thank You!

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