Bones Flashcards
What happens to bone mass and bone mineralisation in osteoporosis?
Bone mass decreases
Bone mineralisation stays the same
What is osteoporosis characterised by?
Low trauma fragility fractures
Family history is important for what kind of fracture?
Hip fracture
Risk factors for osteoporosis?
Woman Menopause Early menopause Low calcium diet especially teenage years Lack of mobility FH of hip fracture
2 causes of primary osteoporosis?
Post-menopausal lack of oestrogen
Lack of mobility
Pneumonic RACISM for secondary causes of osteoporosis?
Rheumatoid arthritis Alcohol Corticosteroids Immobility Smoking Multiple myeloma
% of fractures in women over the age of 45 that are caused by osteoporosis?
70%
4 most common sites for fractures?
Proximal humerus
Proximal femur
Colle’s fracture
Vertebral fracture
What types of things can result from multiple vertebral fractures?
Chronic back pain Reflux oesphagitis Kyphosis Loss of height Abdominal distension Neck pain Depression
What is the 1 year mortality after a hip fracture?
25%
In osteoporosis how will a bone profile be affected?
Calcium normal
Phosphate normal
ALP normal
How are vertebral fractures identified on xray
with more than a 20% loss in vertebral height
What percentage loss in height of the vertebrae is classified as a crush fracture?
50%
Very advanced vertebral fractures are known as what?
Vertebra plana
What scan do you perform to assess osteoporosis?
DEXA scan
What is a T score on a DEXA scan and what does it symbolise?
T score is a measure of the bone mineral density as standard deviations relative to the peak bone mass
What is the T score of normal bone density?
1
What is the t score of osteopenia?
-1 to -1.5
What is the T score of osteoporosis?
-2.5 or more
What is the difference between osteoporosis and established osteoporosis?
They will both have a T score below -2.5 but the established osteoporosis will also have fractures
How can you prevent osteoporosis?
1g of Calcium per day in diet
Weight baring exercises in adolescence
3 supplements given to elderly patients with a fracture?
1g Calcium
800 IU of Vitamin D3
Oral bisphosphonates
What do you have to tell a patient about taking bisphosphonates and the side effect?
Need to be taken fasting
Side effect of reflux oesophagitis if not taking standing with a glass of water
Name 2 commonly used bisphosphonates
Alendronic acid
Risedronate
What is the only drug that actually increases the bone mass density?
Teriparatide
How is Teriparatide administerd?
daily SC injection for 18 months
What is osteomalacia?
Failure of the matrix to calcify leading to low bone mineralisation
What causes osteomalacia?
Vitamin D deficiency
Compare bone mineralisation and bone density in both osteoporosis and osteomalacia?
Bone mineralisation is normal in osteoporosis but abnormal in osteomalacia
Bone density is normal in osteomalacia but abnormal in osteoporosis
What is the active form of Vitamin D
1,25 - dihydroxycholecalciferol
What is the childhood form of osteomalacia?
Rickets
What causes Vitamin D deficiency in elderly?
Lack of sunlight Immobility Isolation Dietary deficiency due to gastrectomy Chronic renal failure Drugs - barbituates
Classical symptoms of osteomalacia?
Bone pain
Weakness of proximal muscles - waddling gait
What 4 investigations would you perform in suspected osteomalacia?
Bone profile U&E X-rays Bone biopsy LFT - albumin
What would a bone profile and urinalysis find in osteomalacia?
Calcium slightly low Phosphate is slightly low ALP slightly raised Urinary calcium is low CKD sees raised phosphate on urinalysis
3 things you would find on an xray of osteomalacia?
Looser zones
Transverse lucencies
Pseudofractures at point of stress
(diagnostic when present)
Diagnostic investigation into osteomalacia?
Bone biopsy
What do you treat osteomalacia with?
Vitamin D
Calcium supplements
What calcium supplement do you treat osteomalacia with?
Ergocalciferol
If there is poor compliance to ergocalciferol what is used instead?
IM calciferol 600k IU
How many units of vitamin D is in ergocalciferol?
10000-20000 IU
Prophylaxis of osteomalacia what 2 things are given?
Vit D3 800 IU OD
Calcium 1g
What is Paget’s Disease? 7 bones most likely effected in Pagets?
localised and patchy with new born being soft and spongy, prone to deformity and fractures Pelvis Lumbar spine Humerus Femur Tibia Clavicle Skull
4 key features seen in the bone of someone with Paget’s disease?
Increase in multinucleated osteoclasts
Increase in osteoblasts
Increased fibrosis
Bone matrix becomes disorganised
What 2 investigations would you do for someone with suspected Paget’s disease? What abnormalities would you see on both?
Bone profile - normal phosphate and calcium but abnormally high ALP
X-ray - Cortical thickening and thickened trabecular pattern
Pagets disease is the only disease that does what to the bone?
Causes bony expansion
What is used as treatment for Pagets disease?
bisphosphonates - Oral risedronate 30mg OD for 2 months or IV zoledronic acid 5mg one dose
What are the main 2 ways in which effectiveness of Pagets disease treatment is assessed?
Level of ALP
Level of bone pain
What scan is performed to assess Paget’s disease?
bone scintigraphy
Assesses level of technetium uptake
Technetium isotope bone scintigraphy
6 most common sites for a pathological fracture to occur?
Thoracic vertebrae Lumbar vertebrae Skull Femur Ribs Pelvis
7 big cancers that are known to spread to the bone?
3 pairs - lungs, breast, kidney
2 midline glands - thyroid, prostate
2 Ms - myeloma, melanoma
What 4 investigations can be done for a pathological fracture?
X-ray
Bone profile
MRI
Techetium isotope scintography
What is raised in a bone profile of a pathological fracture?
Calcium and ALP
How are metastases seen on an x-ray?
Sclerotic, lytic mixed lesions
3 treatments of bone metastases?
Bisphosphonates
Radiotherapy
Orthopaedic surgery
What is polymyalgia rheumatica and what are 4 locations where it usually occurs?
Pain or stiffness caused by blood vessel inflammation that usually occurs in the shoulders, neck, upper arms and hips
3 main features of temporal arteritis? what is the concern if it is left untreated?
Headache
temple tenderness
jaw claudication
4 risk factors for polymyalgia rheumatica?
Viral or bacterial infection
Genetics
over 65
female twice as likely
Presenting complaints in polymyalgia rheumatica?
vague symptoms of weight loss, pain, mild fever
Stiffness in neck, arms and shoulders
What 3 things will blood tests show in polymyalgia rheumatica?
Abnormal LFTs
Mild anaemia
Raised ESR and CRP
What is the full steroid treatment course in polymyalgia rheumatica?
40mg Prednisolone for 1 week then a reducing dose over 12-18 months
What happens to Calcium, Phosphate, ALP, Urea and Urine Ca in osteoporosis?
Dont change
What happens to Calcium, Phosphate, ALP, Urea and Urine Ca in Osteomalacia?
Calcium decreases Phosphate decreases ALP increases Urea stays the same Urine Ca decreases
What happens to Calcium, Phosphate, ALP, Urea and Urine Ca in Renal bone disease?
Calcium decreases Phosphate increases ALP increases Urea increass Urine Ca decreases
What happens to Calcium, Phosphate, ALP, Urea and Urine Ca in Paget’s Disease?
Calcium is the same Phosphate is the same ALP increases loads Urea is the same Urine Ca increases
What happens to Calcium, Phosphate, ALP, Urea and Urine Ca in Hyperparathyroidism?
Calcium increases Phosphate decreases ALP increases Urea is normal Urine Ca increases
What is osteoarthritis?
Disintegration of articular cartilage usually accompanied by osteophyte formation
What are some predisposing factors to the development of osteoarthritis?
Previous damage Avascular necrosis of the joint Disease of the joint - rheumatoid, gout Hypermobility Endocrine diseases - acromegaly, diabetes, hyperparathyroidism Obesity Occupation Hereditory
Which joints are most effected in osteoarthritis?
Knees
Hips
Sometimes elbows and shoulders
Women = DIP joints
How is the pain characterised in osteoarthritis?
Worse late in evenings after use
Morning stiffness less than an hour
Can impair mobility
What can be felt on examination of joints with osteoarthritis?
Crepitus
Bony swelling - herbedens (DIJ) and bouchards (PIJ)
4 signs of osteoarthritis on xray?
Sclerotic changes
Subchondral cysts
Loss of joint space
Osteophytes
What can be put into joints of osteoarthritis to reduce pain?
Intra-articular injection of steroids such as methylprednisolone
Surgical treatment of osteoarthritis?
Arthroplasty
What form of Rheumatoid arthritis is most likely to lead to old, frail individuals with fragile skin and peripheral neuropathy/vasculitis?
Seropositive RA
What medication can be used in RA if there is evidence of active disease?
DMARDs
What is the predominant pathophysiology thought to be developing in RA?
Autoimmune response that effects the synovial membranes and causes joint destruction
Is inflammation present in OA/RA?
Only in RA really
What generalised symptoms may be present in RA that arent present in OA?
Feelings of fatigue, weakness, anaemia
What can be found in the blood that is specific to rheumatoid arthritis?
Rheumatoid factor
What is the antibody present in the blood of those with RA?
Anti-CCP
4 blood tests in RA?
CRP
ESR
Anti-CCP
Rheumatoid factor
How does drug metabolism change over time?
decreases as liver enzymes become less active
How does drug excretion change as we age?
Glomerular filtration and renal plasma flow decrease
What is the difference between a stroke and a TIA?
They are both disturbances of cerebral function due to a presumed vascular origin but TIA lasts less than 24 hours and stroke last longer
Risk factors for atherosclerosis?
High blood pressure Smoking Diabetes elevated blood lipids OCP Obesity
3 reasons why a CT scan used in stroke?
Confirm the diagnosis
Identify if there is any haemorrhage
Determine underlying pathology
Benefits of an early CT scan vs a late CT scan on type of stroke identifiable?
Early - haemorrhagic
2-4 days - ischaemic
Symptoms of a haemorrhagic stroke vs an ischaemic?
Haemorrhagic usually accompanied by headache and more sudden onset
Haemorrhagic nearly always a hypertensive patient whereas ischaemic isnt
Usually vomiting with haemorrhagic not often with ischaemic
Consciousness usually lost with haemorrhagic but not with ischaemic
If a stroke presents with an isolated motor impairment, where is it likely to have occured?
In the internal capsule
Which side of the brain is the speech centre in?
Usually the opposite to your dominant hand except half of left handed people where it is still on the left side
Difference between aphasia and dysphasia?
Aphasia is when speech is absent and dysphasia is when speech is impaired
2 types of dysphasia?
Expressive and receptive
How should you talk to someone with receptive dysphasia?
Speak slower in smaller sentences
Stand in front of the patient so they can see facial movements
what is the difference between dysarthria and dysphasia?
Dysarthria is a disorder of the muscles of articulation
What is dysphonia?
disease of the vocal cords, larynx or respiratory system
What is neglect?
When the patient becomes inattentive to the affected side
What area of the brain is usually effected which causes the patient to present with neglect?
Non-dominant parietal lobe
How can you see neglect present in body language? following an object? 2 tests?
Shift body away from stimulus, posture of head, eyes and body turned away
Difficulty following an object past the effected side
Alberts test or star cancellation test
3 motor disorders that can develop in stroke?
Hemiplegia
Spasticity
Apraxia
What is the usual presentation of spasticity in the upper and lower limbs following a stroke?
Flexion in the upper limbs and extension in the lower limbs
Name 2 thrombolytic drugs that can be used in the treatment of acute ischaemic stroke? time limit
Alteplase
Streptokinase
4.5 hours
3 phases of stroke care?
Acute phase - 1-2 weeks
rehabilitation phase - 2-12 weeks
Up to 2 years - to regain full function
How long after someone has had a stroke do you then assess the severity and make a management plan?
2 weeks
What aspects of the patient need to be examined post stroke?
General medical and exercise tolerance Speech impairment Sensory impairment - sight, hearing, sensation Muscle tone - spasticity, tone Mental capacity Motivation Swallowing
What is the most common cause of death in stroke survivors?
IHD
3 factors that are associated with poor prognosis of survival in stroke that indicate extensive damage to cerebral hemisphere or brain stem invovlement?
Impaired consiousness
Paralysis of conjugate deviation of the eye
Dense paralysis
How does alteplase effect rates of mortality and morbidity in relation to ischaemic stroke?
decreases rate of morbidity but has little effect on mortality
How do you manage and assess dysphagia in the early days post stroke?
Assess by SLT before feeding
Food through NG tube/PEG
Gag reflex does not indicate in tact swallow
If a patient does not appear to improve 48 hours after stroke symptoms, what do you need think about as alternative diagnosis?
Acute infection - respiratory, urinary tract Subdural haematoma Subarachnoid haemorrhage Metabolic disorders - DKA Cardiac impairment Renal or hepatic failure Hypothermia Drugs
3 aspects of the stroke rehabilitation?
Physical rehabilitation
Mental rehabilitation
Social rehabilitation
What dose of aspirin in used in acute phase of stroke and in long term prophylactic prevention post stroke?
Acute phase = 150mg
Long term = 75mg OD
Before prescribing aspirin what needs to be excluded?
Cerebral haemorrhage
5 situations where long term anticoagulant therapy beneficial?
AF Completed ischaemic stroke TIA Valvular heart disease Prosthetic heart valves
List some complications of stroke?
Depression Epilepsy Venous thrombosis Painful stiff shoulder Persistent pain Fracture of long bones Peripheral nerve palsies Oedema of affected limb Bullae Contractures Foot drop
How does painful stiff shoulder develop after a stroke and what is its management?
Due to poor positioning and hemiplegia
Results in painful capsulitis
Treat with analgesia, heat packs and passive movements
Main prevention and treatment of stroke related physical complications?
Individually designed orthoses
Foot rest when seated
Surgery
What is the ABCD2 criteria for having another stroke at 7 days and 90 days?
Age - over 65 Blood pressure - over 140/90 Clinical features - unilateral weakness D - diabetic D - Duration over 60 mins or less than 60 mins
What are the points allocated for each criteria in the ABCD2 criteria?
Age over 65 is 1 point Blood pressure is 1 point Unilateral weakness is 2 points dibetic is 1 points duration over 60 mins is 2 points and under 60 mins is 1 point
If someone scores 6 or 7 on the ABCD2 criteria what is the chance of them suffering another stroke in 7 days and 90 days?
12%
18%
If someone scores 0-3 on the ABCD2 criteria what is the chance of them suffering another stroke in 7 days or 90 days?
1%
3%
