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Medicine year 2 semester 2 > Case 25- anatomy > Flashcards

Case 25- anatomy Flashcards

1
Q

The location of the lesser trochanter

A

Medial aspect of the proximal femur

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2
Q

The location of the intertrochanteric crest

A

Running between the greater and lesser trochanters on the posterior aspect of the proximal thigh

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3
Q

The location of the gluteal tuberosity

A

Inferior to the intertrochanteric crest on the posterior aspect of the proximal femur, attachment of the gluteus maximus

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4
Q

The location of the quadrate tuberosity

A

Approximately half-way along the intertrochanteric crest on the posterior aspect of the proximal femur. Attachment of the quadratus femoris

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5
Q

The location of the Pectineal line

A

Running inferiorly from the lesser trochanter on the postero-medoal aspect of the proximal femur, attachment of the pectineis

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6
Q

The location of the intertrochanteric line

A

Running between the greater and lesser trochanters on the anterior aspect of the proximal femur

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7
Q

Intracapsular ligaments of the hip

A
  • Transverse acetabular ligament: Completes the labrum and forms acetabular foramen.
  • Ligamentum teres: (ligament of the head of femur): Connects the fovea to the acetabulum. Provides passage for acetabular branch of obturator artery (artery of ligament of head of femur) into the head of the femur.
  • The intrinsic hip ligaments restrict extension
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8
Q

Intrinsic (Extracapsular) ligaments of the hip

A
  • Ischiofemoral ligament: Supports the posterior aspect of the hip joint. Limits extension and medial rotation. Holds the femoral head in the acetabulum
  • Iliofemoral ligament: Supports anterior/superior aspect of hip joint. Limits extension and lateral rotation of the hip. Main role is to prevent extension
  • Pubofemoral ligament: Supports anterior/inferior aspect of the hip joint. Limits extension and lateral rotation of the hip. Limits medial rotation
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9
Q

What type of joint is the hip joint

A

The hip joint is a multi-axial ball and socket synovial joint. The shape of the acetabulum and support of ligaments and muscles around the joint increase the stability of the joint but reduce the range of movement (when compared to the shoulder joint).

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10
Q

Head of femur

A

Covered in articular hyaline cartilage except the fovea. Only 50% of the head articulates with the acetabulum at any one time

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11
Q

Acetabulum

A

1) Meaning ‘vinegar cup’. The articular (lunate) surface is covered in hyaline cartilage.
2) Non-articulating acetabular fossa contains a fat pad for joint cushioning.
3) Deepened by a fibrocartilaginous acetabular labrum in an incomplete ring.
4) Remaining inferior portion of the ring is completed by the transverse acetabular ligament.
5) Vessels and nerves to the hip joint enter through the acetabular foramen beneath the transverse acetabular ligament.

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12
Q

Ligament of the Head of the Femus

A

Meaning ‘vinegar cup’. The articular (lunate) surface is covered in hyaline cartilage. Non-articulating acetabular fossa contains a fat pad for joint cushioning. Deepened by a fibrocartilaginous acetabular labrum in incomplete ring. Remaining inferior portion of the ring is completed by the transverse acetabular ligament. Vessels and nerves to the hip joint enter through the acetabular foramen beneath the transverse acetabular ligament.

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13
Q

Joint capsule- hip bone

A

Strong fibrocartilaginous capsule. Non-articular surfaces are lined with synovial membrane. IIiopsoas bursa protects the tendon of iliopsoas from the anterior aspect of the hip joint. Ring of circular fibres of capsule forms orbicular zone. Intrinsic ligaments provide joint stability.

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14
Q

Angles of movement- Hip

A
  • Lateral rotation (60 degrees) Limited by iliofemoral and pubofemoral ligaments, and the medial rotators
  • Flexion (120 degrees). Limited by soft tissue and tension in hip extensors
  • Extension (25 degrees). Limited by the extracapsular ligaments
  • Abduction (45 degrees). Limited by the adductor muscles, and pubofemoral and iliofemoral ligament
  • Adduction (20-30 degrees). Limited by the abductors, and also soft tissue apposition (the other lower limb).
  • Medial rotation (30 degrees) Limited by the ischiofemoral ligament, and lateral rotators
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15
Q

External (lateral rotation) of the hip joint

A
  • Piriformis (sacrum to greater trochanter, nerve to piriformis)
  • Superior gemellus (ischium to greater trochanter, nerve to obturator internus)
  • Obturator internus (obturator membrane to greater trochanter, nerve to obturator internus)
  • Gemellus inferior (ischium to greater trochanter, nerve to quadratus femoris)
  • Quadratus femoris (ischium to quadrate tubercle, nerve to quadratus femoris)
  • Obturator externus (obturator membrane to greater trochanter, obturator nerve)
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16
Q

Internal (medial rotation)

A
  • Gluteus medius (ilium to greater trochanter, superior gluteal nerve)
  • Gluteus minimus (ilium to greater trochanter, superior gluteal nerve)
  • Tensor fasciae latae (ilium to iliotibial tract, superior gluteal nerve)
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17
Q

Hip abductors

A
  • Gluteus medius (ilium to greater trochanter, superior gluteal nerve)
  • Gluteus minimus (ilium to greater trochanter, superior gluteal nerve)
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18
Q

Abductor weakness

A

Trendelenburg’s sign can indicate abductor muscle weakness or superior gluteal nerve damage. This sign is characterised by a pelvis drop on the non weight bearing side during locomotion.

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19
Q

Hip adductors

A
  • Adductor magnus (pubis and ischium to linea aspera and adductor tubercle, obturator nerve)
  • Adductor longus (pubis to linea aspera, obturator nerve)
  • Adductor brevis (pubis to linea aspera, obturator nerve)
  • Gracilis (pubis to pes anserinus of tibia, obturator nerve)
  • Pectineus (pectineal line of pubis to pectineal line of femur, femoral and obturator nerve)
  • Obturator externus (obturator membrane to greater trochanter, obturator nerve)
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20
Q

Hip flexors

A
  • Iliopsoas (ilium and vertebral column to lesser trochanter, femoral nerve)
  • Sartorius (anterior superior iliac spine to pes anserinus of the tibia, femoral nerve)
  • Rectus femoris (anterior inferior iliac spine to patella tendon, femoral nerve)*
  • Tensor fasciae latae, pectineus, adductor longus, adductor brevis and gracilis also contribute to hip flexion.
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21
Q

Hip extensors

A
  • Gluteus maximus (ilium to gluteal tuberosity, inferior gluteal nerve)
  • Semitendinosus (ischium to pes anserinus of tibia, tibial division of sciatic nerve)
  • Semimembranosus (ischium to medial tibia, tibial division of sciatic nerve)
  • Biceps femoris (long head ischium and short head linea aspera to fibula, tibial division of sciatic nerve)
  • Hamstring part of adductor magnus (ischium to adductor tubercle, tibial division of sciatic nerve)
22
Q

Shenton’s line

A

An imaginary curved line from the inferomedial aspect of the femoral shaft and femoral neck and the superior border of the obturator foramen, this line should be smooth and continuous. Disruption in this line could be a fractured neck of the femus or developmental dysphasia of the hip.

23
Q

Common hip fractures

A

Hip fractures include an intertrochanteric fracture, femoral shaft (sub-trochanteric) fracture and a femoral neck fracture.

24
Q

Traumatic hip dislocation

A

Typically occurs in cases of major trauma. Most commonly its posterior dislocation (i.e. in a road traffic accident). Fractures of the acetabular rim and damage to the posterior thigh structures (including the sciatic nerve) can occur in posterior dislocation. Anterior dislocation can also occur.

25
Q

Development dysphasia of the hip

A

Congenital hip displacement can occur in neonates when the head of the femur does not articulate with the malformed, shallow acetabulum.

26
Q

Osteoporosis

A

Reduced bone density and mass
Equal loss of mineral and organic matrix
Increased risk of fractures

27
Q

Osteoporosis- Pathogenesis

A

1) Uncoupling of normal balance between bone formation and resorption
2) Bone resorption exceeds bone formation-too much resorption (high turnover), too little formation (low turnover)
3) Bone present is biochemically normal

28
Q

Risk factors for osteoporosis (women)

A

USA: 1:2 female > 50 years will suffer an osteoporosis-related fracture (male = 1 in 8)
Why- females have a lower bone mass and oestrogen is involved
Most frequent in postmenopausal women- natural loss with ageing exacerbated. Lack of oestrogen promotes bone resorption (high turnover). Most bone loss in the first ten years after the menopause or oophorectomy

29
Q

Other risk factors for osteoporosis

A

1) Genetics
2) Ethnicity- northern european and Asian
3) Smoking and alcohol
4) Immobilisation- low physical activity, astronauts
5) Drug induces= corticosteroids inhibit bone formation (low turnover)
6) Testosterone deficiency (males)- hypogonadism

30
Q

Major risk factors for osteoporosis

A

History of fracture as an adult
Fragility fracture in first degree relative
Low body weight (< 127 lb)

31
Q

Additional risk factors for osteoporosis

A 
Impaired vision
Oestrogen deficiency at early age (< 45)
Dementia
Poor health/frailty
Recent falls
Low calcium intake (lifelong)
32
Q

What conditions increase the risk of osteoporosis

A 
COPD
Cushing’s syndrome
Eating disorders
Hyperparathyroidism
Hypophosphatasia
IBS
RA - autoimmune connective tissue disorders
Insulin dependent diabetes
Multiple sclerosis
Multiple myeloma
Stroke (CVA)
Thyrotoxicosis
Vitamin D deficiency
Liver diseases
33
Q

Postmenopausal osteoporosis- therapy for prevention and treatment (Oral bisphosphonates)

A

1) First-line choices - alendronic acid, risedronate sodium
2) Anti-fracture efficacy
3) Reduce occurrence of vertebral, non-vertebral and hip fractures
4) Adsorbed onto hydroxyapatite
5) Induce apoptosis of osteoclasts
6) Reduces rate of bone turnover

34
Q

Intravenous bisphosphonates

A

Ibandronic acid, zoledronic acid, denosumab, raloxifene hydrochloride alternative if intolerant of oral bisphosphonates or contra-indicated.

35
Q

Postmenopausal osteoporosis- therapy for prevention and treatment (HRT)

A

Younger postmenopausal females with menopausal symptoms who are at a high risk of fractures. Risk of adverse effects- cardiovascular, cancer in older postmenopausal females and long term HRT therapy

36
Q

Postmenopausal osteoporosis- therapy for prevention and treatment (Teriparatide)

A

Treatment is limited to 24 months
Reserved for postmenopausal females- severe osteoporosis
High risk of vertebral fractures

37
Q

Glucocorticoid induced osteoporosis

A

Glucocorticoid therapy associated with bone loss and increased risk of fractures

Bone-protection treatment should be started at the onset of therapy if risk fractures

Oral bisphosphonates - First-line treatment

38
Q

Osteoporosis in men

A

Long-term androgen deprivation therapy for prostate cancer - increased fracture risk

Oral bisphosphonates - First-line treatment

39
Q

Useful investigations in diagnosing bone disease

A 
X-ray 
BMD ( DEXA calcaneum)  Screening
DEXA ( Dual Energy X–Ray Absorptiometry)
FRAX 
Hormone levels
Quantitative CT Scan
Body Composition Analysis to detect bone loss
MRI
40
Q

Dual energy x-ray absorptiometry (DEXA)

A

Diagnose of assess risk of osteoporosis
Measure BMD before starting treatment that may have an adverse effect on bone density- se hormone deprivation for treatment for breast or prostate cancer

41
Q

When may they be recommended to measure BMD

A

1) Have had a broken bone after a minor fall or injury
2) Have arthritis
3) Take oral glucorticoids for three months
4) Early menopause
5) Postmenopausal women- smoke or drink excessively, family history or hip fractures, BMI <21
6) Large gaps between periods (>years)

42
Q

Osteomalacia (Rickets in children)

A

Inadequate mineralisation of new bone matrix or osteoid

Rickets is defective mineralisation at the epiphyseal growth plates

43
Q

Causes of rickets/osteomalacia- deficient intake or absorption of vitamin D

A

Inadequate sun exposure
Low dietary intake
Malabsorption: Coeliac disease, Crohn’s disease, Primary biliary cirrhosis, Gastrectomy

44
Q

Causes of rickets/osteomalacia- Dietary 1-alpha hydroxylation

A

Chronic kidney disease

Vit D dependent Rickets type I (Lack of 1α-Hydroxylase)

45
Q

Causes of rickets/osteomalacia- Primary renal PO4 wasting

A

Renal tubular acidosis
Fanconi syndrome
X-Linked hypophosphatemia

46
Q

Other causes of rickets/osteomalacis

A

Inhibitors of mineralisation- Fluoride, Aluminium. Metabolic acidosis
Defective vitamin D receptors- Vit D dependent Rickets type II

47
Q

Clinical features of rickets- at birth

A

craniotabes, softened occipital bones, flattened parietal bones can be buckled

48
Q

Clinical features of rickets- Early years

A

Widened epiphyses (wrists), frontal bossing, squared appearance to the head
Presence of Rickety rosary - Beading at costo-chondral joints
Groove in the rib cage (Harrison’s sulcus)
Pigeon chest

49
Q

Clinical features of rickets in older children

A 
Lower limb deformities
Myopathy
Lumbar lordosis and bowing of the legs
Hypocalcemic tetany (severe cases)
50
Q

Clinical features of osteomalacis

A

Usually asymptomatic- identified incidentally in routine investigation

Symptomatic=
Proximal Muscle weakness
Widespread bone pain – tenderness, hydration of the demineralized matrix
Dull pain, worse on weight bearing
Insufficiency fracture= stress upon weakened bone - bone elastic resistance decreased
Abnormal gait

51
Q

Laboratory tests for osteomalacia

A 
Serum Calcium (normal in Osteoporosis)
Plasma Phosphate
Vitamin D status
T4, TSH 
PTH
FSH 
Testosterone
Bone Specific Alkaline Phosphatase (Bone ALP / BALP)
Type 1 Collagen propeptides
Bone resorption and Bone Formation Markers

Medicine year 2 semester 2 (47 decks)

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