MSK Flashcards
(351 cards)
1
Q
Name 4 morbid outcomes of cauda equina syndrome
A
sensory deficits motor deficits perianal paraesthesia urinary dysfunction sexual dysfunction
2
Q
An angiosarcoma is a malignant tumour of vascular tissue - True or false?
A
True
3
Q
what is the name given to benign tumours of the vascular tissue?
A
haemangioma, aneurysmal bone cyst
4
Q
what is the name given for
a. benign
b. malignant
tumours of ADIPOSE tissue?
A
a. lipoma
b. liposarcoma
5
Q
all sarcomas are malignant - True or false?
A
True
6
Q
an osteoblastoma is a malignant tumour of bone. true or false?
A
false.
An osteoblastoma and osteoma are both benign tumours. the malignant bone-forming tumour is known as an osteosarcoma.
7
Q
what are the names given to cartilage-forming tissues?
A
benign - enchondroma, osteochondroma
malignant - chondrosarcoma
8
Q
what is the name given to fibrous tissue tumours?
A
benign - fibroma
malignant - fibrosarcoma, malignant fibrous histiocytoma (MFH)
9
Q
osteosarcomas are more prevalent in younger populations whereas myelomas are more common in elderly patients - true or false?
A
true
10
Q
Name 5 clinical features of an osteosarcoma
A
- swelling
- joint effusion
- pathological fracture
- deformity
- loss of function
- systemic effects of neoplasia
- neurovascular effects
11
Q
Osteosarcoma bone pain often worsens at night - true or false?
A
true
the pain is also unlinked to exercise and is deep and boring
12
Q
what are the main functions of synovium
name 3
A
- maintenance of intact tissue surface
- lubrication of cartilage
- control of synovial fluid volume and composition (hyaluronan, lubricin)
- nutrition of chondrocytes within joints
13
Q
what joints in the body are most commonly affected by rheumatoid arthritis?
A
small joints of the hands and the feet
it is a chronic symmetric condition.
14
Q
which type of cells are found in the synovial fluid in the joint cavity during an acute flare up of RA?
A
neutrophils
the rheumatoid synovitis (pannus) is characterised by inflammatory cell infiltration, synoviocyte proliferation and neoangiogenesis
15
Q
Name 2 commonly associated autoantibodies associated with rheumatoid arthritis
A
- rheumatoid factor - this is an autoantibody to self IgG Fc
- anti-citrullinated protein
these autoantibodies will recognise either joint antigens such as type II collagen or systemic antigens such as glucose phosphate isomerase
these autoantibodies can sometimes activate the complement system
16
Q
In seropositive rheumatoid arthritis, patients with anti-citrullinated protein antibody have a less favourable prognosis - true or false?
A
true
diagnostic anti -CCP assays will recognise citrullinated self-proteins
17
Q
What percentage of concordance occurs in twins with rheumatoid arthritis?
A
monozygotic twins - 15%
dizygotic twins - 5%
18
Q
What is the most common locus in rheumatoid arthritis?
A
HLA-DRB1
- there is a role in promoting autoimmunity and molecular mimicry
however remember that genetic associations in RA are complex and involve many genes
19
Q
describe the main environmental factors that influence rheumatoid arthritis
A
- smoking
- bronchial stress (exposure to silica)
- infectious agents
3a. viruses - EBV and CMV
3b. E.coli
3c. mycoplasma
repeated insults in genetically susceptible patient may lead to
- formation of immune complexes and rheumatoid factor (high affinity autoantibodies against the Fc portion of Ig)
- altered citrullination of proteins and breakdown of tolerance, with resulting ACPA response
20
Q
which amino acids does citrullination involve?
A
citrullination basically means deamination
conversion of arginine in proteins into citrulline via PAD enzymes
21
Q
what are some of the features of synovitis?
A
- increased vascularity
- villous hyperplasia
- infiltration of T cells and B cells , macrophages and plasma cells
- intimal cell proliferation (fibroblasts)
- production of cytokines and proteases
22
Q
suggest 2 drugs that may used in the treatment of rheumatoid arthritis?
A
- rituximab
2. abatacept - fusion protein that blocks T-cell co-stimulation
23
Q
In rheumatoid arthritis, B cells are responsible for the production of IL-6 and TNF-alpha as well as the production of autoantibodies and autoantigen presentation.
what mediatory effects does IL-6 have? name 3 things
A
- anaemia
- acute phase response
- cognitive dysfunction
- lipid metabolism dysregulation
24
Q
suggest 4 systemic factors that arise as a consequence of rheumatoid arthritis
A
- vasculitis/nodules/scleritis/amyloidosis
- fatigue and reduced cognitive function
- liver - elevated acute phase response, anaemia of chronic disease
- lungs - interstitial lung disease
- muscles - sarcopenia
- bone - osteoporosis
25
Females are affected more by rheumatoid arthritis - true or false?
false. RA affects males more and usually presents between the 4th and 5th decade.
26
What are the main presentations of patients with rheumatoid arthritis?
1. pain
2. stiffness
3. immobility
4. poor function
5. systemic function
27
what are the main clinical signs of rheumatoid arthritis?
1. swelling
2. tenderness
3. decreased RoM
4. redness/heat
28
what scoring system is mainly used in RA?
disease activity score - DAS
A DAS score of <2.4 represents clinical remission whereas a DAS of >5.1 represents eligibility for biologic therapy
29
what are the 4 main categories of drugs used to treat RA?
1. NSAIDs
2. disease modifying anti-rheumatic drugs DMARD - slower effect on disease activity - methotrexate, sulfasalazine and hydroxychloroquine
3. biologics
4. corticosteroids
30
methotrexate is the cornerstone of combination treatment for RA - with DMARD and biologics.
true or false?
true.
biologics actually have an enhanced response when co-prescribed with methotrexate
31
where does the subclavian artery become the axillary artery?
at the lateral border of the 1st rib
32
where does the axillary artery become the brachial artery?
the inferior border of the teres major
33
what artery is the main contributor to the superficial palmar arch?
the ulnar artery
34
where do superficial veins of the upper limb originate?
the deep dorsal venous arch on the back of the hand
35
the cephalic vein will travel up the limb on the lateral side of the arm and drain into the axillary vein below the clavicle - true or false?
true
36
the basilic vein will travel up the limb on the medial side and become continuous with the brachial veins - true or false?
true
37
what is the name of the vein connecting the cephalic and basilic veins?
median cubital vein
38
grossly describe the lymphatic drainage of the upper limbs
the right lymphatic duct will drain the right upper quadrant of the body and the thoracic duct will drain the rest.
39
what nerve innervates the brachioradialis muscle?
the radial nerve
40
Name the 4 muscles of the superficial layer of the anterior forearm
1. flexor carpi radialis (FCR)
2. palmaris longus
3. pronator teres
4. flexor carpi ulnaris (FCU)
all of these muscles are innervated by the median nerve
41
the flexor digitorum superficialis is the only muscle in the intermediate layer of the anterior compartment of the forearm.
It has dual innervation - true or false?
false
the FDS has single innervation - median nerve
the FDP has dual innervation
medial side - ulnar nerve
lateral side - median nerve
42
besides the flexor digitorum profundus, what other muscle (s) are found in the deep layer of the anterior forearm?
the pronator quadratus
43
which epicondyle do the pronators of the hand arise from?
the medial epicondyle
the anterior compartment of the forearm muscles are generally wrist pronators
44
Which muscle(s) in the anterior forearm are responsible for adduction of the wrist - give its innervation also
flexor carpi ulnaris
ulnar nerve
45
which anterior forearm muscle is capable of flexing the distal IPJ?
the flexor digitorum profundus
46
which digits does the flexor digitorum superficialis attach to?
digits 2-5
acts at the proximal IPJ
47
which muscle lies more laterally:
a. extensor carpi radialis longus
b. extensor carpi radialis brevis?
ECRL lies more laterally and also more superiorly
48
what nerve is found in the anatomical snuff box?
the radial nerve
49
does the median nerve travel inside or outside of the flexor retinaculum?
inside.
50
what digits are affected by carpal tunnel syndrome
1, 2, 3 and lateral aspect of 4th finger.
51
there are 4 lumbricals, 4 dorsal interossei and 3 palmar interossei muscles - true or false?
true
52
name the 4 thenar muscles
1. flexor pollicis brevis
2. abductor pollicis brevis
3. adductor pollicis
4. Opponens pollicis
53
2 out 3 hypothenar muscles are named below,
1. flexor digiti minimi
2. abductor digiti minimi
what is the name of the 3rd:
opponens digiti minimi
54
which of the hypothenar muscles lies the most medial?
abductor - technically makes sense if you think about it.
55
how does the function of the palmar interossei differ from that of the dorsal interossei?
PAD palmar - adduct
| DAB - dorsal -abduct
56
what is the function of the lumbricals?
1. flex the MCP (knuckles)
| 2. extend the PIPJ
57
why is the thumb unlike the other digits (in terms of bones)
it has no middle phalanx and therefore only an interphalangeal joint.
58
what are the boundaries of the anatomical snuff box?
1. extensor pollicis longus
2. extensor pollicis brevis
3. abductor pollicis longus
59
which bones are palpable in the anatomical snuff box?
the scaphoid and trapezium
60
Arrange the following muscles in terms from most lateral to most medial
Pronator teres
Palmaris longus
Flexor carpi ulnaris
Flexor carpi radialis
1. pronator teres
2. flexor carpi radialis (FCR)
3. palmaris longus
4. flexor carpi ulnaris (FCU)
61
which artery supplies the deep arch of the hand?
radial artery
62
osteoblasts are responsible for bone formation - true or false?
true.
63
what kind of cells do osteoblasts originate from?
mesenchymal progenitor cells
64
what type of cells are responsible for bone resorption and what kind of cells do they originate from?
myeloid progenitor cells
65
where is calcidiol produced in the body?
calcidiol is produced in the liver
66
calcitriol is produced by the kidneys - true or false?
true
67
name 4 sites in the body where calcium levels are regulated
1. intestines
2. bone
3. parathyroid glands
4. liver
5. kidney
68
what is the effect of severe nutritional vitamin D/calcium deficiency in:
a. growing children
b. adults
a. rickets
b. osteomalacia
Vitamin D will stimulate the absorption of calcium and phosphate from the gut; these then become available for bone mineralisation.
muscle function is also impaired in low vitamin D states
69
describe paget's disease
localised disorder of bone turnover. there is increased bone resorption followed by increased bone formation. this leads to disorganised bone - bigger, less compact and more vascular and more susceptible to deformity and fracture.
70
describe 3 presentations of paget's disease
1. isolated elevation of serum alkaline phosphatase
2. bone pain and local heat
3. prone to fractures and may experience hearing loss
4. patient is in 4th decade
5. bone deformity
71
suggest 2 treatments for Paget's disease
IV bisphosphonate
IV zoledronic acid
but don't treat based on an increased serum alkaline phosphatase alone.
72
describe 5 consequences of osteogenesis imperfecta
1. growth deficiency
2. defective tooth formation
3. hearing loss
4. blue sclera
5. scoliosis
6. barrel chest
7. ligament laxity
8. easy bruising
treatment of osteogenesis imperfecta medically will be with IV bisphosphonate
73
what is osteogenesis imperfecta?
genetic disorder of connective tissue characterised by fragile bones from mild trauma and even acts of daily life
there is a broad clinical range from those who are prenatally fatal to those only presenting in 40s with early osteoporosis
74
osteoporosis is a metabolic bone disease - true or false?
true
patients have a low bone mass and micro-architectural deterioration of bone tissue leading to enhanced bone fragility and an increase in fracture risk.
75
suggest 4 things that contribute to risk of fracture in osteoporosis
1. age
2. BMD - bone mineral density
- DXA (bone densitometry) hip and spine
3. falls
4. bone turnover
76
Bone mineral density (BMD) can sometimes be calculated to check to risk of fracture in a patient with osteoporosis. what T score is indicative of osteopenia?
a T score of between -1 and -2.5 is indicative of osteopenia.
give the patient treatment if there has been a previous fracture.
osteoporosis is a T score that is less than 2.5
77
suggest 2 drugs that can be given to patients for the primary prevention of osteoporotic fragility in post menopausal women
1. alendronate
2. etidronate
3. risedronate
4. teriparatide
5. denosumab - monoclonal antibody against RANKL (safer in patients with renal impairment than bisphosphonates)
78
suggest 2 risk assessment tools used for osteoporosis
1. FRAX - fracture risk assessment tool
2. Qfracture
if the patient has a >10% risk at any site in the next 10 years then they should be referred for a DXA scan
79
what independent factors does the FRAX tool take into account?
1. prior fractures
2. family history
3. smoking
4. history of corticosteroid use
5. alcohol (>3 units)
6. rheumatic arthritis
80
what variables does the Qfracture screening tool take into account?
1. CV risk
2. falls
3. TCA
81
suggest 3 endocrine causes of secondary osteoporosis
1. hyperthyroid
2. hyperparathyroid
3. GH deficiency
4. hyperprolactinemia
5. Cushing's
82
suggest 3 medical treatment options for osteoporosis
1. HRT - these have a good effect on osteoporosis
2. Selective Estrogen Receptor Modulator (SERM) - no effect on vertebral fractures unfortunately
3. Bisphosphonates - this is first line treatment. ensure the patient has adequate renal function as wella s an adequate calcium and vitamin D status.
83
what are some side effects of bisphosphonates?
1. oesophagitis
2. iritis/uveitis
3. atypical femoral shifts
for this reason patients should be encouraged to take a drug holiday for 1-2 years after 10 years exposure to bisphosphonates
84
what are the side effects of
a. teriparatide
b. denosumab
in the treatment of osteoporosis
a. teriparatide can cause hypercalcaemia and allergy
| b. denosumab can cause allergy/rash, symptomatic hypocalcemia
85
Juvenile idiopathic arthritis affects people up to the age of 16. true or false?
true
JIA is an important cause of disability and blindness.
86
what is the typical presentation of juvenile idiopathic arthritis?
1. painful/limited joint motion
2. tenderness
3. warmth
4. joint swelling
87
what is the diagnostic test for systemic onset JIA?
there is no diagnostic test for systemic onset JIA.
ESR will be elevated and very high in systemic JIA but doesnt correlate with disease activity.
88
what are the 3 major subtypes of JIA - juvenile idiopathic arthritis?
1. pauciarticular (<4 joints)
2. polyarticular (5>)
3. systemic (aka Still's disease - extra-articular features define the disease)
89
Pauciarticular JIA can be split into 3 types.
| give a brief description of each.
type 1 - patient presents with a limp rather than pain. Girls and those under the age of 5 are affected. positive ANA gene is up to 75% and the lower limb is mostly affected. chronic uveitis.
Type 2 - iridocyclitis. Presence of back involvement and HLA-B27 gene classifies as juvenile ankylosing spondylitis. lower limb involvement.
- those lacking back involvement are termed seronegative enthesopathy arthropathy (SEA). boys are mainly affected at about age 8-9. may require THR early in life.
type 3 - chronic iridocyclitis. destructive arthritis with 40% having history of psoriasis. Naill pitting
90
Describe polyarticular JIA
RF negative - iridocyclitis is rare. small and large joints are affected equally. constitutional manifestations - low grade fever and malaise. hepato and splenomegally with mild anaemia.
RF positive - similar to RA but in a child. erosions can be seen in an XR. symptoms such as malaise, weight loss, anaemia and nodules. ANA is present in 40-60% of patients.
91
describe some of the common systemic onset symptoms of JIA
1. abdominal - hepatosplenomegaly, abdominal pain
2. arthritis - wrists, knees, spine, ankles, cervical
3. serositis - pericarditis, polyserositis
4. rash - most cases present with a rash
5. fever
6. lymph nodes - non-tender lymphadenopathy
7. pulmonary - pulmonary fibrosis or a pleural effusion
remember there is no diagnostic test for systemic JIA
92
what is the first line therapy for JIA
simple pain killers and NSAIDS
NSAIDs can control (pain and fever) disease but doses should be considered.
NSAIDs can also be used as a bridge to DMARDs and also are useful in children who are undergoing surgery.
93
Assuming there is no response to NSAIDs/steroid injection, what is second line therapy for JIA?
1. methotrexate
2. anti-TNF therapy - if methotrexate fails
3. IL1 R-antagonist in refractory systemic arthritis - anakinra
4. IL^ antagonist - tocilizumab for refractory systemic disease
94
what are some risks of using systemic steroids in children?
1. osteoporosis
2. infections
3. growth abnormalities
95
Name 3 common clinical presentations of spondyloarthritis
1. lower back pain that worsens at night.
2. spinal morning stiffness relieved by exercise
3. psoriatic arthritis
4. bowel related arthritis
5. ankylosing spondylitis
96
Name a few clinical presentations of ankylosing spondylitis
1. inflammatory back pain
2. limitation of movements in anteroposterior as well as lateral planes at lumbar spine
3. there may be a limitation of chest expansion
4. bilateral sacroiliitis on XR
97
what is the management of ankylosing spondylitis?
1. exercise/physiotherapy
2. TNF alpha blockers - etanercept, adalimumab (use only if NSAIDs fail)
3. NSAIDS - ibuprofen, diclofenac
4. DMARDs - sulfasalazine
98
suggest a common finding on examination of a patient with psoriatic arthritis
1. nail pitting
2. dactylitis
3. enthesitis
the severity of the joint disease does not correlate to extent of the disease.
99
what is the suggested treatment for psoriatic arthritis?
1. sulfasalazine
2. methotrexate
3. cyclosporine
4. Anti-TNF
5. steroids
6. physiotherapy and occupational therapy
100
what are the common organisms associated with reactive arthritis?
1. salmonella
2. shigella
3. yersinia
4. campylobacter
reactive arthritis is a sterile arthritis typically affecting the lower limb following dysentery, urethritis (chlamydia) etc.
101
what is Reiter's syndrome?
1. urethritis
2. arthritis
3. conjunctivitis
102
what are some common presentations of reactive arthritis
1. keratoderma blennorrhagica (brown, raised plaques on soles and palms)
2. circinate balanitis (painless serpiginous penile ulceration secondary to chlamydia)
3. enthesitis - plantar fasciitis, achilles tendonitis
4. mouth ulcers
5. conjunctivitis
6. iritis
103
what investigations would you like to do to confirm a diagnosis of Reactive arthritis
1. increased CRP and ESR
2. culture stool for diarrhoea
3. infectious serology
4. sexual health review
5. XR/US for enthesitis
104
what are the prognostic signs for chronicity in reactive arthritis?
1. hip/heel pain
2. high ESR
3. family history with HLA-B27
105
what is the treatment for reactive arthritis?
1. splintage and rest the joints affected
2. injection of steroids locally with NSAIDs
3. consider sulfasalazine or methotrexate
106
what are the common presentations of spondyloarthritis?
1. episodic inflammation of the sacroiliac joints
2. pain in one or both buttocks
3. low back pain and stiffness (worse in the morning but imporve with exercise)
patients will often be underdiagnosed because they are asymptomatic between episodes and radiological abnormalities are absent.
107
what are the back pain criteria for diagnosing ankylosing spondylitis?
1. age of onset < 50
2. insidious onset
3. improvement of back pain with exercise
4. no improvement with rest
5. pain at night with improvement on getting up
108
name a test that is useful for diagnosing spinal stiffness
Schober's test
109
Suggest some non-articular problems in spondyloarthritis
1. uveitis in all types
2. cutaneous lesions in reactive arthritis (keratoderma blennorrhagica)
3. nail dystrophy in psoriasis and reactive arthritis
4. aortitis occasionally in AS and reactive arthritis.
110
Severe eye pain, photophobia and blurred vision are an emergency in ankylosing spondylitis. true or false?
True
Acute anterior uveitis is strongly associated with HLA-B27 in AS and related diseases – occasionally the presenting complaint
111
what are the investigations for ankylosing spondylitis?
blood - check ESR and CRP (they will be high)
HLA testing - not very useful but may give supporting evidence
MRI may show sacroiliitis before XR and also persistent enthesitis
XR - medial and lateral cortical margins of both sacroiliac joints lose definition owing to erosions and eventually becoming sclerotic.
earliest radiological appearances in the spine are blurring of the upper and lower vertebral rims at the thoracolumbar junction caused by an enthesitis caused at the insertion of the intervertebral ligaments
syndesmophytes cause bony ankylosis and permanent stiffening.
112
what is the treatment of enteropathic arthritis?
NSAIDs
intra-rticular corticosteroids
sulfasalazine/mesalazine
TNF-alpha block - infliximab
113
do patients with lupus tend to present when they are young or old?
patients with SLE tend to present when they are young.
114
Name 9 of the presentations of SLE - systemic lupus erythematosus
1. malar rash
2. discoid rash
- raised scarring
permanent marks
alopecia
3. photosensitivity
4. oral ulcers
5. arthritis
- affecting at least 2 joints (XR may be useful)
6. serositis
- pleurisy or pericarditis
7. haematological
- low WCC, platelets, lymphocytes, haemolytic anaemia
8. neurological
- unexplained seizures or psychosis
9. renal
- significant proteinuria or cellular casts in urine (do dipstick test)
10. immunological
- anti dsDNA, SM, cardiolipin, lupus anticoagulant, low complement
11. ANA - antinuclear antibodies (easiest one to remember)
115
what is the name of the skin lesions that patients with scleroderma tend to present with?
morphea
females tend to be affected by scleroderma the most between their 30s and 40s. it may lead to complications such as pulmonary hypertension and pulmonary fibrosis or renal crisis or small bowel bacterial overgrowth)
for control of renal crisis and pulmonary hypertension offer the patient ACEI and ATII receptor blockers.
116
In Sjogren's syndrome, patients are usually female. what is the typical presentation of this condition - name 3 symptoms and 6 signs of the condition
SYMPTOMS
1. dry eyes and mouth
2. enlarged parotid
3. a dry cough and dysphagia
SIGNS (systemic)
1. fatigue
2. fever
3. myalgia
4. arthralgia
5. lymphadenopathy
6. vasculitis
7. myositis
8. lung, liver and kidney involvement
9. Raynauds
10. peripheral neuropathy
117
suggest some systemic signs of Sjorgens syndrome (name 5)
1. fatigue
2. fever
3. myalgia
4. arthralgia
5. lymphadenopathy
6. vasculitis
7. myositis
8. lung, liver and kidney involvement
9. Raynauds
10. peripheral neuropathy
118
name 3 associated conditions with Sjogren's syndrome
1. autoimmune hepatitis
2. PBC
3. thyroid disease
119
what possible investigations can you do for Sjorgens syndrome?
1. rheumatoid factor is usually positive
2. positive ANA test
3. conjunctival dryness - Schirmer's test
4. hypergammaglobulinaemia
5. gland biopsy - lymphocytic aggregation
120
what is the treatment for Sjorgens syndrome?
1. hydroxychloroquine
2. eye drops
3. NSAIDS
4. in severe disease give immunosuppresants
121
what are some of the complications of Sjogren's syndrome?
1. lymphoma
2. neuropathy
3. purpura
4. interstitial lung disease
5. renal tubular acidosis
122
autoimmune myositis is typically muscle weakness that is asymmetrical, localised and distal. true or false?
false
autoimmune myositis is symmetrical, diffuse and proximal.
complications include cancer and interstitial lung disease
123
what are the two main large vessel vasculitis conditions?
1. Takayasu's arteritis
2. giant cell arteritis (GCA)
in these conditions, a histological diagnosis will demonstrate inflammation of the arterial wall with fragmentation and disruption of the internal elastic lamina.
124
what are the classification criteria for GCA?
1. age>50
2. new headache
3. temporal artery tenderness/reduced pulsation
4. ESR>50
5. abnormal temperature
125
giant cell arteritis is associated with polymyalgia rheumatica in 50% of cases - true or false?
true
126
what are the symptoms of giant cell arteritis?
1. a headache
2. temporal artery and scalp tenderness
3. jaw claudication
4. amaurosis fugax - loss of vision in 1 eye
5. morning stiffness
6. dyspnoea
7. unequal or weak pulses
127
what should you do if you suspect a patient has giant cell arteritis (GCA)
1. do an ESR and start prednisolone immediately
the risk is the irreversible bilateral loss of vision which can occur suddenly if not treated
128
what investigations should you carry out for GCA? suggest 6
1. ESR and raised CRP
2. raised platelets
3. raised alkaline phosphatase
4. low haemoglobin
5. temporal artery biopsy
6. MRA
7. CT angiography
8. USS - look for the halo sign
skip lesions may occur so don't be out off by a negative biopsy
129
what are the criteria for diagnosing SLE (systemic lupus....)
1. malar rash (butterfly rash) - fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds.
2. discoid rash erythematous patches with adherent keratotic scales and affecting ears, cheeks, scalp etc-
3. immunological - anti dsDNA antibody and anti-SM and antiphospholipid
4. renal - persistent proteinuria and cellular casts (maybe red cell granular or mixed)
5. haematological - haemolytic anaemia, leukopaenia, thrombocytopenia
6. non-erosive arthritis - involving more than 2 joints. tenderness, swelling
7. serositis - pleuritis (dyspnoea and pleuritic chest pain) or pericarditis (chest pain, ECG, pericardial rub etc)
8. CNS disorder - seizures in the absence of causative drugs or metabolic imbalance (uraemia or ketoacidosis) and psychosis
9. ANA - positive in 95%
10. oral ulcers - usually painless nasopharyngeal and oral ulcers
11. photosensitivity - may cause flare
one of the most important questions so always hit '1' and repeat as many times as you can.
130
suggest the name of two medium vessel diseases
1. polyarteritis nodosa
| 2. Kawasaki disease
131
what are the common complications of granulomatosis?
1. hearing loss
2. nerve damage
3. end-stage renal disease
4. lung damage
5. malignancy
132
describe Takayasu's arteritis
there is an early inflammatory stage with myalgia and anorexia. the symptoms are often non-specific
PET scanning has use in picking up early disease prior to stenosis etc which are picked up by angiogrpahy
133
suggest the name of a drug that is used for the treatment of multisystem autoimmune disease in the following severity:
a. mild
b. moderate
c. severe
a. mild give the patient hydroxychloroquine
b. moderate give the patient azathioprine, methotrexate and mycophenolate
c. in severe give the patient cyclophosphamide and rituximab
134
where does Takayasu's arteritis usually affect the body?
it mainly affects the aorta and its major branches causing stenosis and thrombosis
it is actually also called aortic arch syndrome
135
what are the clinical manifestations of Takayasu's arteritis?
also, give the diagnostic steps for the condition
acute inflammation will cause dilatation and aneurysms. it mainly affects women and can present with some ophthalmological and upper limb symptoms such as visual changes, weak arm pulses and dizziness.
SYSTEMIC
- fever
- weight loss
- malaise
- high BP (renovascular involvement)
DIAGNOSIS
- increased ESR and CRP
- angiography of the aorta
TREATMENT
- prednisolone
- methotrexate
- cyclophosphamide
BP control is essential to minimise the risk of stroke
136
what investigation would you want to carry out for a small vessel disease called microscopic polyangiitis?
pANCA
microscopic polyangiitis is a necrotizing vasculitis that affects the small and medium-sized vessels. there is rapidly progressing glomerulonephritis and usual features are pulmonary haemorrhage
137
suggest 4 general laboratory tests you may wish to consider for immunological conditions
1. ANA (antinuclear antibodies)
2. antineutrophil cytoplasmic antibodies (ANCA)
3. antiphospholipid antibodies
4. complement
5. cryoglobulins
138
what are the main immunoglobulins that are associated with SLE?
polyclonal IgG, IgA and IgM
139
what type of immune reaction (I-IV) is SLE?
it is a type III hypersensitivity reaction
they contain autoantigens and autoantibodies throughout the body - with a predilection for the skin and joints and kidney. autoantibodies are characteristically produced against a range of nuclear autoantigens - dsDNA, ssDNA, histones and other nuclear antigens
ANA is found in 95% of SLE cases
140
ANA has a high specificity or sensitivity for SLE?
ANA has a high sensitivity for SLE but a low specificity because it is also present in other conditions
If ANA is negative then SLE is probably not the diagnosis.
SLE is relatively rare and other conditions such as old age, cancer and even infection, which are all causes of a positive ANA are much more common
141
Generally, what are the 4 main types of antinuclear antibody present?
1. homogenous - autoantibodies against double stranded or single stranded DNA/histone proteins
2. speckled - non-chromosomal nuclear proteins. found in Ro and La patients who have SLE and Sjogren's
3. nucleolar - against nucleolar RNA, scleroderma, systemic sclerosis and overlap syndromes
4. peripheral (AKA membranous ANA) - confined to the membrane, seen when antibodies are produced against dsDNA (combination of homogenous)
a positive ANA test should act as a stimulus to undertake more specific relevant tests.
142
what is the main autoantigen associated with C-ANCA?
anti-proteinase 3.
the major autoantigen associated with P-ANCA is anti-MPO or myeloperoxidase
143
ANCA is not disease specific (as with most autoantibodies), what other conditions can cause it to be elevated?
1. infection
2. inflammation
3. drugs
4. connective tissue disorder
5. inflammatory bowel disease
144
is complement part of the innate immune system?
yes
145
what are the two main immunoglobulins present in the classical pathway of the complement system?
1. IgM and IgG
146
what are the features of antiphospholipid syndrome?
antiphospholipid syndrome is commonly associated with SLE but can occur as a primary disease.
C - coagulation defect
L- livedo reticularis
O- obstetric
T- thrombocytopaenia
treatment is with low dose aspirin or warfarin if there are recurrent thromboses (aim INR is 2-3). seek advice if pregnant
147
what is the name of the crystal found in gout?
monosodium urate
tophi/tophus are massive accumulations of uric acid
148
what is the name of the crystal found in pseudogout?
calcium pyrophosphate dihydrate (CCPD)
149
what are the body's sources of urate?
uric acid will come from degradation of purines and the other 1/3 of production is from the diet.
most uric acid produced is removed by the kidney, the remained is eliminated into the biliary tract and subsequently converted by colonic bacterial uricase to allontoin.
150
what is the biggest pathological cause of gout?
hyperuricaemia from reduced efficiency of renal urate clearance.
hyperuricaemiacan come from overproduction or from under excretion
151
give some examples (2) of overproduction of uric acid and 2 examples of under excretion
overproduction
1. malignancy
2. drugs (ethanol)
3. severe exfoliative psoriasis
underexcretion
1. renal impairment
2. hypertension
3. hypothyroidism
4. drugs - alcohol, low dose aspirin, diuretic
5. exercise
152
why may alcohol increase the risk of gout?
Some alcoholic drinks such as beer are rich in purines (guanosine) eventually causing the formation of adenosine monophosphate - a precursor for uric acid. alcohol also increases the lactic acid level in the blood which inhibits uric acid excretion
153
what are the characteristics of a patient with Lesch Nyan syndrome?
1. HGPRT deficiency and X-linked.
2. patients have an intellectual disability, aggressive and impulsive behaviour with gout
3. renal disease
it is caused by an enzymatic defect of HPRT which is involved in recycling of purines. without HPRT purine bases are wasted and excreted as uric acid. the body notices this and then accelerates the formation of purines
154
what is the effect of oestrogen on uric acid?
uricosuric effect making gout very rare in younger women. however, after menopause, urate levels rise and gout becomes increasingly prevalent.
Age may also play an important role for other reasons:
- decreased renal function
- increased use of diuretics and other drugs that raise sUA
- age-elevated changes in connective tissues which may encourage crystal formation and an increase in the prevalence of OA
155
what is the protocol to manage an acute flare of gout?
1. gout
2. NSAIDs
3. colchicine and steroids (IA or IM/oral doesn't matter)
hyperuricaemia may not be needed to be treated unless the first attack of gout is :
- a single attack of polyarticular gout
- tophaceous gout
- urate calculi
- renal insufficiency
DONT TREAT ASYMPTOMATIC HYPERURICAEMIA
156
what are some treatment methods available for lowering the uric acid content
1. xanthine oxidase inhibitor
2. febuxostat
3. uricosuric agents
4. canakinumab
wait until the acute attack has settled before attempting to reduce the urate level. use prophylactic NSAIDs or low dose colchicine/steroids until the urate level is normal
157
where in the body does pseudogout usually occur?
knee
there is the presence of pyrophosphate crystals and is managed with NSAIDs and IA steroids. there are no prophylactic therapies.
158
polymyalgia rheumatica tends to mainly affect the young, true or false?
false- it typically affects older people and there is a close relationship with GCA.
GCA --> high ESR --> polymyalgia rheumatica
159
what is the typical presentation of PMR? (polymyalgia rheumatica)
also give 5 symptoms
1. sudden onset of shoulder +/- pelvic girdle stiffness.
2. rare in those under 50 and mainly affects females
3. ESR is high
SYMPTOMS
1. anaemia
2. malaise
3. weight loss
4. fever
5. depression
6. arthralgia
7. synovitis
there is, unfortunately, no specific diagnostic test
treat with prednisolone and sometimes in some cases bone prophylaxis is given
160
suggest a few risk factors for calcium pyrophosphate dehydrate arthropathy
this is also known as pseudogout
1. old age
2. diabetes
3. hypothyroidism
5. hyperparathyroidism
radiographs show soft tissue swelling
161
describe the diagnosis of gout
1. polarised light microscopy of synovial fluid - shows negatively bi-fringent urate crystals
2. serum urate may be raised but may be normal
3. radiographs - soft tissue swelling
162
name a common site for a femoral hernia
the femoral ring - a weak area in the lower abdominal wall
163
where can the femoral pulse be felt?
the inguinal point - midway between the anterior superior iliac spine and the pubic symphysis. it is inferior to the midpoint of the inguinal ligament
164
where is the sciatic nerve point?
the midpoint between the greater trochanter and the ischial tuberosity.
a safe injection site is in the upper lateral quadrant
165
damage to which nerve in the popliteal fossa will result in foot drop?
damage to the fibular nerve around the neck of the fibula will result in foot drop
don't forget that the tibial nerve is more medial and travels deeper than the common fibular nerve
166
which tendon lies more superior in regard to the lateral malleolus of the fibula bone:
- the fibularis brevis
- the fibularis longus
the fibularis brevis lies more superior to the fibularis longus.
remember that the extensor digitorum brevis lies deep to the extensor digitorum longus.
167
the other name for the Achilles tendon is what?
the calcaneal tendon
168
does the tibialis anterior tendon pass anterior or posterior to the medial malleolus?
anterior
169
the deep muscles of the posterior compartment of the leg can be memorised with a pneumonic tom Dick AN Harry. what is the order in which the structures pass the medial malleolus?
T - tibialis anterior
D - flexor digitorum longus
AN - artery nerve
H - flexor hallicus longus
170
the lateral plantar artery will go on to form the plantar arch which will then be a connection with the dorsalis pedis artery - true or false?
true
171
what are the symptoms of polymyalgia rheumatica?
1. subacute onset (<2weeks)
2. symmetrical aching
3. tenderness
4. morning stiffness
5. in shoulders and proximal limbs
SYSTEMIC
1. fatigue
2. weight loss
3. fever
4. anorexia and depression
172
what investigations would you carry out for PMR?
1. CRP
3. plasma viscosity
3. raised ESR
4. high alkaline phosphatase
management is with prednisolone
173
suggest 5 pre-disposing biomechanical factors of osteoarthritis
1. abnormal anatomy (DDH)
2. intra-articular fracture
3. ligament rupture
4. meniscal injury
5. occupation - farmers or football player
6. persistent heavy physical activity
7. elite running
8. obesity
174
Morning stiffness is a common presentation in osteoarthritis - true or false?
false.
```
pay attention to the following signs, however:
trauma
prolonged morning stiffness
the rapid deterioration of symptoms
hot, swollen joint
```
175
what are warning signs to look out for in osteoarthritis?
1. trauma
2. prolonged morning-related stiffness
3. rapid deterioration
4. hot, swollen joint
176
what is the differential diagnosis of OA (osteoarthritis)?
1. gout
2. other inflammatory arthritides
3. septic arthritis
4. malignancy
177
what are the treatment options available for OA?
generally, the best treatment methods are holistic and self-management
core treatments include information, exercise and weight loss
NON-PHARMACOLOGICAL
1. thermotherapy
2. electrotherapy
3. aids and devices
4. manual therapy
PHARMACOLOGICAL
- oral analgesia - paracetamol and NSAIDs
- topical treatments - NSAIDS, capsiacin (knee and hand)
178
what are the most appropriate investigations to be done to confirm osteoarthritis?
a plain radiograph will show
1. loss of joint space
2. subchondral sclerosis
3. marginal osteophytes
CRP may also be slightly elevated
179
what is the management of OA?
1. do exercises to improve muscle strength and joint stability.
2. regular paracetamol and codeine for pain
3. consider NSAIDs only if paracetamol is ineffective
4. If BMI>28 then advise weight loss
5. the best way to deal with severe OS is to give a joint replacement.
180
suggest 6 factors predisposing to osteoarthritis
1. obesity
2. hereditary
3. gender - polyarticular OA is more common in women, higher prevalence after menopause suggesting a role for sex hormones.
4. hypermobility
5. osteoporosis
6. disease
7. trauma
8. congenital joint dysplasia
9. joint congruity
10. occupation
11. sport
181
suggest 5 causes of secondary osteoarthritis
```
PRE-EXISTING JOINT DAMAGE
1. rheumatoid arthritis
2. gout
3. spondyloarthritis
4. septic arthritis
5. Paget's disease
METABOLIC DISEASE
1. chondrocalcinosis
2. hereditary haemochromatosis
3. acromegaly
SYSTEMIC DISEASES
1.haemophilia
2. haemoglobinopathies
3. neuropathies
```
182
what are 3 clinical SIGNS and SYMPTOMS of osteoarthritis?
SIGNS
1. joint pain
2. short-lived morning joint stiffness
3. functional limitation
SIGNS
1. crepitus
2. restricted movement
3. bony enlargement
4. joint effusion
183
investigations in OA? name 4
1, blood tests - no specific test but ESR is normal although high sensitivity CRP may be slightly raised. RhF and ANA are negative
2. XR are abnormal when the damage is advanced
3. MRI for meniscal tears early cartilage injury and subchondral bone marrow changes
4. arthroscopy - early fissuring
5. aspiration of synovial fluid - if there is a painful effusion shows a viscous fluid with few leucocytes
184
what are the general principles of management for OA? comment on the treatment in terms of
a. physical measures
b. medication
c. surgery
PHYSICAL MEASURES
1. weight loss and exercise for strength and stability
2. hydrotherapy
3. local heat/ice packs/massage or local NSAIDs gels
4. insoles for flat feet
MEDICATION
1. paracetamol (should always be prescribed before NSAIDs)
2opioids should be used cautiously in elderly patients
3. IA CS give short-term improvement when there is a painful joint effusion.
SURGERY
1. arthroscopy is not beneficial
2. replacement arthroplasty
185
what are Heberden nodes?
Heberden's nodes are hard or bony swellings that can develop in the distal interphalangeal joints (DIP)
186
what are Bouchard nodes?
Bouchard's nodes are hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints. They are seen in osteoarthritis, where they are caused by formation of calcific spurs of the articular (joint) cartilage
187
what is the normal angle of the neck shaft of the femur?
140 degrees
the hip is a diarthrodial joint - ball and socket. there is femoral anteversion of around 20 degrees.
188
name 2 static stabilisers of the hip
1. labrum
| 2. negative intra-articular pressure
189
name the 4 hip flexor muscles
1. ilio-psoas
2. rectus femoris
3. sartorius
4. pectineus
these muscles are all innervated by the femoral nerve
190
what nerve innervates the hip extensors?
the sciatic nerve, excluding the gluteus maximum - innervated by the inferior gluteal nerve
191
name 4 hip extensor muscles
1. gluteus maximus
2. semitendinosus
3. semi-membranosus
4. biceps femoris
192
which of the gluteal muscles is not involved with hip abduction?
the gluteus maximum
the hip abductors are:
- gluteus medius
- gluteus minimus
- tensor fascia latae
they are all supplied by the superior gluteal nerve
193
what are the main adductors of the hip?
1. adductor longus
2. adductor brevis
3. adductor magnus7
4. gracilis
all of these muscles are innervated by the obturator nerve
194
which muscle lies most superior in the adductor group of the thigh?
1. the pectineus
2. adductor brevis
3. adductor longus
4. adductor Magnus
195
what are the main internal hip rotator muscles?
1. anterior fibres of the gluteus medius
| 2. tensor fascia latae
196
what nerve innervates the internal hip rotators?
the superior gluteal nerve
197
what are the external hip rotator muscles?
1. gluteus maximus (inf. gluteal n.)
2. piriformis (n. to piriformis)
3. superior and inferior gemellus (obturator nerve)
4. obturator internus
5. obturator externus
6. quadratus femoris
198
what muscle separates the superior and inferior gemellus?
the obturator internus muscle
199
what type of bone is the patella?
it is a sesamoid bone
- don't forget that the centre of the femoral shaft is 6 degrees off the mechanical axis. the centre of the tibia is parallel to the mechanical axis of the foot and leg. therefore the 'knee angle' is 6 degrees of valgus relative to the mechanical axis.
200
menisci of the knee joint are attached to the femur bone - true or false?
false they are attached to the tibia. if you got this wrong go home and stop studying
because you aren't concentrating
201
what are the 4 muscles responsible for knee extension?
1. rectus femoris 7
2. vastus edialis
3. vastus lateralis
4. vastus intermedialis
all of these muscles are innervated by the femoral nerve
202
what are the 4 muscles responsible for knee flexion
1. biceps femoris
2. semimembranous
3. semitendinosus
4. gastrocnemius
all of these muscles are innervated by the sciatic nerve except the gastrocnemius (what innervates the gastrocnemius muscle?)
203
Are all spondyloarthropathies all seronegative - true or false?
true
examples include
Ankylosing spondylitis (AS)
Psoriatic arthritis
Reactive arthritis (sexually acquired, Reiter’s disease) Post-dysenteric reactive arthritis
Enteropathic arthritis (ulcerative colitis/Crohn’s disease)
204
what is a dermatome?
a dermatome is a sensory area of skin that is supplied by one one spinal nerve
adjacent dermatomes overap considerably
205
what is a myotome?
a group of muscles supplied by one segment of the spinal cord.
206
in the brachial plexus, roots will combine to form divisions. divisions will divide to form trunks and trunks will divide to form the cords - true or false?
false
RTDCB
roots>trunks>divisions>cords>branches
207
from which cord does the axillary nerve arise from?
the axillary nerve arises from the posterior cord.
208
what is the main branch(es) of the lateral cord in the brachial plexus?
the lateral cord will give off the musculocutaneous nerve and then join with the medial cord to give off the median nerve
209
the median nerve and the medial cutaneous nerve of the forearm will arise from which cord from the brachial plexus?
they arise from the medial cord.
210
what is the nerve root(s) of the middle trunk?
C7 = middle trunk
upper trunk = C5,6
lower trunk = C8T1
211
the lateral cord is formed from which divisions of the brachial plexus
the lateral cord is formed from the anterior divisions from the upper and middle trunks
212
how is the medial cord of the brachial plexus formed?
it is a continuation of the anterior division of the lower trunk (C8, T1)
213
in Erb's palsy, where is the site of injury?
the region of the upper trunk of the brachial plexus
the main nerves involved are C5 and C6. it is also known as Porter's tip hand with the arm hanging, adducted and medially rotated and forearm extended and pronated
it results in the following muscles being paralysed:
1. biceps (mainly)
2. deltoid
3. brachialis
4. brachioradialis
5. supraspinatus
6. infraspinatus
7. supinator
214
what muscles are affected by Klumpke's paralysis?
the site of injury is the lower trunk of the brachial plexus and mainly involves T1 and partly C8.
the muscles paralysed are:
1. intrinsic muscles of the hand (T1)
2. ulnar flexors of the wrist and fingers (C8)
it will present as claw hand due to the unopposed action of the long flexors and extensors of the fingers. in a claw hand, there is a hyperextension at the MCP joints and flexion at the IP joints.
215
in Klumpke syndrome the disability includes:
1. claw hand
2. cutaneous anaesthesia and analgesia (along ulnar border of forearm and hand)
3. Horner's syndrome
4. Vasomotor changes (drier and warmer due to arteriolar dilation and absence of sweating)
5. tropic changes (dry and scaly skin)
why may there be Horner's syndrome in Klumpke's syndrome?
. This is because of injury to sympathetic fibres to the head and neck that leave the spinal cord through nerve T1.
```
ptosis
miosis
anhydrosis
enophthalmos
loss of ciliospinal reflex
```
216
what nerve and subsequent muscle would be affected by damage to the lateral cord of the brachial plexus?
the musculocutaneous nerve would be most affected and the lateral root of the median nerve.
the muscles that will be paralysed are the biceps and coracobrachialis as well as all of the muscles supplied by the median nerve except those that are affected by the hand
217
what anatomical position in the humerus would need to be fractured to result in injury to the medial cord of the brachial plexus?
subcoracoid dislocation of the humerus.
damage to the medial cord would result in the damage the ulnar and medial root of the median nerve
muscles supplied by the ulnar nerve and the five muscles of the hand supplied by the median nerve would be most affected
patients present with a claw hand
sensory loss on the ulnar side of the forearm and hand
vasomotor and tropic changes as a bone
218
what is the typical presentation of a patient with Erb's palsy?
shoulder adduction
elbow extension
forearm pronation
wrist flexion
219
from which cord does the axillary nerve arise from?
the posterior cord will give rise to the ulnar nerve
the ulnar nerve wraps around the surgical neck of the humerus and supplies the deltoid and teres minor
it supplies the skin over the lateral arm - the regimental badge area
don't forget that the axillary nerve is most at risk at the surgical neck of the humerus.
220
what are the spinal roots of the radial nerve?
the radial nerve arises from the posterior cord and will have the spinal roots C5-T1.
the radial nerve supplies the triceps muscle and passes from medial to lateral epicondyle running in the radial groove of the arm.
221
a sensory deficit in the 1st dorsal web space is caused by damage to which nerve?
the radial nerve
damage to the radial nerve will also cause a wrist drop - inability to extend the wrist (posterior forearm compartment)
222
what are the nerve roots of the median nerve?
the spinal roots are C7-T1
it arises from the medial and lateral cords. it will supply the flexors of the forearm (bar the FCU and the medial half of the FDP)
223
the floor of the carpal tunnel is composed of the carpal bones and the roof is composed of the flexor retinaculum, what is contained inside the tunnel?
1. FDS tendons
2. FDP tendons
3. PL
4. palmaris longus
9 tendons and a nerve facebook
224
damage to the carpal tunnel will result in nocturnal pain, paraesthesia and muscle wasting on the hypothenar muscles - true or false?
false - there will be wasting of the thenar muscles
the motor deficit caused by the median nerve would bee mostly the volar aspect of the hand.
225
the ulnar nerve arises from which spinal roots?
the ulnar nerve arises from C7-T1 from the medial cord of the brachial plexus
it will supply the medial half of the FDP and the FCU as well as the intrinsic muscles of the hand.
it also supplies complete sensation to the medial 1.5 fingers (including the hypothenar muscles)
226
at what site in the arm is the ulnar nerve most at risk to damage?
behind the medial epicondyle of the humerus
the motor deficit seen is claw hand, hypothenar and 1st dorsal interosseous wasting
Ulnar claw hand is caused by hyperextension at the MCPJ, flexion at the IPJ’s. a distal lesion has worse clawing than a proximal lesion, due to intact long flexors with a distal lesion.
227
what are the boundaries of the anatomical snuff-box?
1. extensor pollicus longus
2. extensor pollicus brevis
3. abductor pollicus longus
228
describe the feature of cubital tunnel syndrome
this is the second most common nerve entrapment. it affects the cubital tunnel between the medial epicondyle and the olecranon, with the fascial bands from the FCU as the roof.. the patient has numbness on the ulnar side of their hand and difficulty with fine tasks.
229
what are the nerve roots of the Musculocutaneous nerve?
the nerve roots are C5-7 and it arises from the lateral cord.
it will pierce the coracobrachialis muscle. it will also supply the elbow joint and terminate as the lateral cutaneous nerve to the forearm.
230
which nerve plexus gives rise to the sciatic nerve?
the sacral plexus gives rise to the sciatic nerve
231
which nerve plexus will give rise to the femoral nerve?
the lumbar plexus
232
what are the nerve roots of the sacral plexus?
L4-S4
233
what is the difference in nerve supply to the gluteal muscles?
the inferior gluteal nerve will supply the gluteus maximus
the superior gluteal nerve will go on to supply the gluteus minimus and the medius as well as the TFL (tensor fascia latae)
234
what are the nerve roots of the femoral nerve?
L2-L4 it will exit the pelvis under the inguinal ligament, lateral to the femoral artery, vein and lymphatic channels.
235
what are the nerve roots of the lateral femoral cutaneous nerve?
L2 and 3
compression of this nerve will cause meralgia paraesthesia - altered sensation and pain in the lateral thigh
236
what are the two main tributaries of the sciatic nerve?
1. tibial nerve
2. common peroneal nerve
3. nerve roots are L4-S3
it supplies the hamstring muscles in the posterior compartment of the thigh
it will leave the pelvis via the sciatic foramen below the piriformis muscle
237
what are the nerve roots of the common fibular nerve?
L4-S2
this is the smaller and more lateral branch of the sciatic nerve
a deficit in this nerve will cause a foot drop and a slapping gait.
238
which nerve supplies the anterior compartment of the leg?
the deep fibular nerve
the lateral compartment is supplied by the superficial fibular nerve
posterior compartment is supplied by the tibial nerve
239
what is a callus?
an intermediary stabilising structure formed after a fracture, which has cartilaginous growth plate characteristics and results in eventual endochondral ossification
240
what are the 3 main phases of bone healing?
1. inflammatory (formation of haematoma and release of vasoconstrictor mediators)
2. reparative (fibrin deposition and osteoid formation and callus formation)
3. remodelling (remodelling of woven bone)
241
bone sheal without scarring - true or false?
true
242
what does the term malunion mean?
malunion means when the fracture has healed but not in an anatomically correct position
243
what is the clasficiation system used for open fractures?
GUSTILO
Type 1 is of low energy, wound<1cm, clean and often bone piercing skin from inside.
Type II has moderate soft tissue damage, wound <10cm, no soft tissue flap or avulsions.
Type III has high energy and extensive tissue damage. There may be a severe fracture (communication and displacement) with a wound that is >10cm. any gunshot, farm accident or segment fracture, bone loss, severe crush injury and marine injuries:
IIIA – soft tissue damage +++ but not grossly contaminated
IIIB – periosteal stripping, extensive muscle damage, heavy contamination
IIIC – associated neurovascular complication
- About 70% of type IIIB tibial shaft fractures require flap cover.
244
what are the structured guidelines to direct initial trauma care?
Advanced Trauma Life Support (ATLS)
245
damage to which nerve will result in foot drop?
damage to the fibular nerve around the neck of the fibula
246
what type of joint is the ankle joint?
the ankle joint is a hinge type synovial joint. it is uniaxial. it will connect the distal part of the tibia, fibula and upper part of the talus bone. the talus bone is the most proximal bone of the foot.
247
in which position is the malleolar grip of the foot most strong?
it is strongest during dorsiflexion and weakest during plantar flexion.
248
the medial malleolus of the foot has 3 ligaments that connect to 3 bones - name them
- talus, calcaneus and navicular
249
the most anterior muscle of the leg is the tibialis anterior. name the main muscles responsible for dorsiflexion of the foot
1. tibialis anterior
2. extensor digitorum longus
3. extensor hallicus longus
4. peroneus (fibular terrtius)
250
Plantar flexion (toes to the ground) is controlled by the posterior aspect of muscles of the leg. name these muscles responsible for plantar flexion
1. gastrocnemius
2. soleus
3. fibialis posterior
4. flexor digitorum longus
5. plantaris
251
NAme the bones of the tarsus
1. talus (main bone of the ankle joint)
2. calcaneous (heel bone)
3. cuboid (most lateral)
4. navicular (medial bone - involved with deltoid joint)
252
at which joints do inversion and eversion take place?
these movements will take place at the subtalar and transverse tarsal joints
253
the achilles tendon is formed from which two muscles in the leg?
1. soleus
| 2. gastrocnemius
254
name the 3 tests used to test the function of the achille's tendon
1. thompsons
2. simmonds
3. meatle's - patient is unable to plantar flex to foot
255
what is equinus?
a condition in which the upward bending motion of the ankle joint is limited. Someone with equinus lacks the flexibility to bring the top of the foot toward the front of the leg.
256
what is the axis of movement for cervical vertebrae?
1. flexion
2. extension
3. rotation
257
which spinal segments have a lordosis?
the cervical and lumbar spine have a physiological lordosis
the thoracic spine has a kyphosis
258
what are the 3 groups of the erector spinae muscles?
1. spinalis (medial)
2. longissimus
3. iliocostalis (most lateral)
These deep group of muscles overlap and run approximately parallel to one another
259
what muscle lies postero-lateral to the psoas muscle?
the quadratus lumborum muscle
260
at which vertebral level does the spinal cord end?
it will end at L1 - below the conus medullaris
261
which myotome supplies the iliopsoas muscle?
L2
262
knee extension is controlled by which myotomes?
L3/4 (quadriceps)
263
which myotome is responsible for dorsiflexion of the foot?
L4 - tibialis anterior
264
foot plantarflexion is controlled by which myotome?
S1 - gastrocnemius
265
spinal cord injuries are classified using which system?
ASIA
266
what is tetraplegia/quadriplegia?
this involves the total or partial loss of use of all four limbs and the trunk
There is sensory and motor function loss in cervical segments of the spinal cord. Tetraplegia is caused by a cervical fracture. There is the risk of respiratory failure due to the loss of innervation of the diaphragm.
267
what are the roots of the phrenic nerves?
C3-5
268
what is paraplegia?
partial/total loss of use of the lower limbs. it is accompanied by a loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord. arm function is spared but there is a possibility of impairment in the function of the trunk
269
CErebral palsy gets worse with age - true or false?
false. CP is a permanent, non-progressive condition due to brain damage either before birth or up until 2 years of age.
270
suggest 6 causes of cerebral palsy under the following headings (2 each)
PRENATAL
PERINATAL
POSTNATAL
prenatal
- placental insufficiency
- TORCH
- smoking
- alcohol
perinatal
- prematurity
- infections
- kernicterus (bilirubin-induced brain damage)
Postnatal
- infection
- head trauma
271
what part of the brain is affected by spastic cerebral palsy?
the pyramidal system and motor cortex
272
what part of the brain is affected in athetoid cerebral palsy?
extrapyramidal system is affected - basal ganglia
in ataxic cerebral palsy the cerebellum and brainstem are affected.
273
describe the diagnosis of cerebral palsy
1. spasticity
2. lack of voluntary control
3. weakness
4. poor co-ordination
5. sensory impairment
--> dynamic contractures
increased muscle tone and hyperreflexia
no fixed deformity of joints
deformity can be overcome
--> fixed muscle contractures
persistent spasticity and contracture
shortened muscle-tendon units
deformity cannot be overcome
--> fixed contractures with joint subluxation/dislocation and secondary bone changes
274
what is the difference between kinematics and kinetics?
kinematics is how the body moves through space but kinetics is the force exerted on a body/by a body. the unit of kinetics is in newtons.
275
`describe how to calculate cadence and stride length in analysis of a patient's gait with cerebral palsy
cadence
- these are the steps per minute
stride length is right initial contact to right initial contact
276
the rectus femoris muscle is concentric at hip flexion (shortening, power generation and acceleration) but is eccentric at knee limiting knee flexion (control lengthening, power absorption and deceleration)
true or false?
true
277
what is the classification system used in cerebral palsy?
GMFCS - gross motor function classication system
it will have 5 levels - level I being the [patietn walking without limitations and level V the patient having to be transported in a wheelchair.
the higher the GMFCS, the higher the risk of dislocation
278
give some mechanisms for the management of spasticity
GENERAL
- baclofen
- diazepam
SPECIFIC
- botulinum toxin
- surgery
279
suggest 6 professions involved with the MDT management of cerebral palsy
1. social workers
2. OT
3. orthotics
4. ophthalmology/audiology
5. orthopaedics
6. community paediatrics
7. education support
280
spina bifida is caused by the failure of the neural tube to close. folic acid can be given to women as a protective measure.(400 mcg per day).
suggest the 3 most common presentations of spina bifida and the complications that can arise from the condition
SB Occulta
SB meningocele
SB meningomyelocele
COMPLICATIONS
1. hydrocephaly
2. Chiari II malformation
3. tethered cord
4. urinary tract problems
5. locomotor limitations
6. latex allergy
281
describe the diagnosis of muscular dystrophy
1. muscle biopsy
| 2. DNA and blood enzymes
282
the main two types of muscular dystrophy are Duchenne's and Becker's. describe the differences between the two
Duchenne
- sex-linked recessive condition and failure to produce dystrophin. patients will be in a wheelchair by age 12 and probably develop scoliosis
Becker
- same gene affected by DMD - poor dystrophin expression. it is a milder condition and has typically later adolescent onset. most are in a wheelchair by age 30.
283
suggest 3 risk factors for paediatric trauma
1. Age - increased physeal injury with age
2. Boys
3. previous fractures
4. metabolic bone disease
284
what is the difference between Geleazzi and Monteggia fractures?
Geleazzi fractures tend to mostly affect the shaft of the radius
Monteggia fractures affect only the shaft of the ulna
if there is failed reduction then ORIF may be the treatment option considered.
285
describe a Salter-Harris type 1 fracture
the fracture line is entirely within the physis
286
describe the difference between a Salter-Harris Type 2 and 3 fracture
in a type 2 fracture the fracture line will extend from the physis into the metaphysis (these are very common -80%)
in type 3, the fracture enters the epiphysis from the physis
287
how do type 5 Salter-Harris fractures differ from Type 4 fractures?
Type 4 - the fracture extends across the physis from the articular surface and epiphyses to end in the margin of the metaphysis
Type 5 are crush injuries of the physes
288
what is the classification system used for supracondylar fractures?
Modified Gartland Classification
I - undisplaced
II - hinged posteriorly
III - displaced
IV - displaces into extension and flexion
289
fractures involving the physes can result in progressive deformity - true or false?
true
290
what are some complications of using nails to fix fractures?
1. compartment syndrome
2. non-union
3. re-fracture
4. PIN injury
5. superficial radial nerve injury
291
suggest some Rx for knee physeal injury
1. cast immobilisation
2. per-cutaneous fix
3. ORIF articular displacement
the ROM will be early (around 6 weeks)
292
suggest 4 situations in which you would need to supplement a cast with fixation
1. severe swelling is likely
2. need to re-inspect the wound (open fractures)
3. multiple injuries
4. segmental limb injuries
5. fracture is very unstable
6. approaching skeletal maturity
293
what is the name of the classification used to predict fracture injuries that affect growth?
Salter-Harris
SH 2 injuries are the most common and SH£ will need anatomical reduction and fixation if displaced. SH4 is rare and the management is with ORIF if displaced and monitor the patient for growth arrest.
294
what are 5 risk/predisposing factors of developing DDH - developmental hip dysplasia
1. first born
2. oligohydramnios
3. breech presentation
4. family history
5. other lower limb deformities
6. increased weight
if the baby has any of these risks then they should have an US at 2-4 weeks with treatment given at 6 weeks if not spontaneously resolved.
The older the child is at diagnosis, the poorer the result, the worst results are associated with AVN of the head
295
Clinical features of DDH will only be able to pick up 40% of diagnosis. which other 4 tests are useful for diagnosis of the condition?
1. ortolani's sign - relocates subluxed or
partially dislocated hip.
2. Barlow's sign - this test aims to sublux or dislocate an unstable hip.
3. Geleazzi test - looks for apparent shortening of the femur caused by dislocation of the femoral head.
4. Piston Motion sign
5. The hamstring
US and pelvic XR can be used for imaging.
296
what are the main management options for DDH?
1. maintaining hip motion
2. analgesia
3. restriction of painful activities
4. spints
5. physio
6. NWB - weight bearing)
7. an osteotomy can be considered in selected groups of older children
297
What is the typical presentation of slipped upper Femoral Epiphysis (SUFE)?
young and left groin mainly affected. short femur that is externally rotated and painful when trying to weight bear. boys are more affected than girls. around 1/5 cases will be bilateral and many of the patients are overweight and some have endocrine abnormalities.
298
what are some bad prognostic characteristics of slipped upper femoral epiphyses?
1. magnitude of slip
2. unstable (unable to weight bear) or stable (able to weight bear)
3 acute or chronic (3 weeks)
detected first by pain in the hip or knee with an externally rotated posture or gait.
plain XR can be used for diagnosis . there is a displacement through the hypertrophic zone and the metaphysis moves anterior and proximal .
operative treatment is available but in severe unstable SUFE then maybe consider open reduction but AVN is a high risk.
299
what are some common complications or outcomes of slipper upper femoral epiphyses? name 5.
1. AVN
2. chondrolysis
3. deformity
4. early osteoarthritis
5. possibility of slip on the other side
6. limb length discrepancy
7. impingement
300
try and think of 8 questions you would ask a patient when trying to take a paediatric limp history from them
think about what questions you would ask in a diagnosis of DDH and SUFE
1. duration and progression of a limp
2. recent trauma and mechanism
3. associated pain and its characteristics
4. accompanying weakness
5. time of day when the limp is worse
6. can the child walk or bear weight
7. has the limp interfered with normal activities
8. presence of systemic symptoms like fever and weight loss
9. medical history - birth history, immunisation history, nutritional history and developmental history
10. drugs and allergies
11. family history
301
suggest 3 other conditions that may be related to Congenital Talipes Equinovarus club feet - CTEV
1. DDH
2. Down's and Larsen's syndrome
3. Arthrogryposis
4. other neuromuscular conditions
This is a multifactorial condition.
60% of cases may be identified by US and 50% may have defects in other systems. There is no relation to the stiffness of feet
302
what si the treatment of CTEV - congenital talipes equinovarus (club feet)
1. strapping
2. serial casting
3. Dennis Browne boots
4. surgery
a. postero-medial release
b. lizarov frame
303
at what points in the cervical spine are there lordosis?
1. cervical and lumbar regions
but there is a kyphosis present in the sacral and thoracic regions
304
what is the classification system used in Scoliosis?
```
CINTO
Congenital
Idiopathic
Neuromuscular
Trauma
Infection
Other - neurofibromatosis or neoplasms
```
305
how would you examine a patient with scoliosis - go thhrough the steps
- Inspect the posterior torso. Structural scoliosis will look worse when bent forward into flexion.
- Any abnormal neurology or pain should be noted
- Investigate spinal contour and flexibility
- Hips – ROM
- Neurology (including abdominal reflexes)
- Functional limitation
306
what are the main risks of progression in scoliosis?
i. Female, premenarchal
ii. <12 yoa at presentation (ie time remaining ill skeletal maturity is longer)
iii. Size of curve at presentation
307
what are the main causes of back pain?
- Mechanical
- Developmental
- Neoplastic
- Inflammatory
Scoliosis however NEVER presents with pain.
An MRI and bone scan should be used for investigations. MRI will be able to pick up things such as
- Cerebellar tonsils
- Syrinx
- Tethering
- Vertebral anomalies
308
An MRI, USS and bone scan should be used for investigations for scoliosis. True or False?
what are the things that an MRI may pick up when investigating a patient with suspected scoliosis?
a. False, a USS will not be used for the detection of scoliosis - focus!!
b. - Cerebellar tonsils
- Syrinx
- Tethering
- Vertebral anomalies
309
what are the main complications of scoliosis?
1. Nerve root damage
2. Cord traction injury
3. Vascular injury
Outcomes are less favourable from severe curves therefore the earlier the diagnosis the better. It may cause cardiorespiratory compromise, pain from rib/pelvic abutment or seating issues
310
aside from the cervix, where is the other site of cancer resulting from HPV infection?
Anus
311
what iare the meanings of
1. squamous intraepithelial lesion and
2. cervical intraepithelial neoplasia?
1. squamous intraepithelial lesion is an abnormal growth of squamous cells detectable on smear. they can be low grade (LSIL) or high (HSIL) grades, depending on how much of the cervical epithelium is affected.
2. cervical intraepithelial neoplasia is when abnormal cells are in the cervix. they are detected by cervical cytology, biopsy and histological examination. it is graded 1 to 3 depending on the proportion of the cervix affected, Cervical intraepithelial neoplasia is the abnormal proliferation of cells in squamous epithelium. THE CHANGE IS INVISIBLE TO THE NAKED EYE
312
what is the main cause for cervical cancer?
HPV infection -mainly types 16 and 18
Persistent infection with oncogenic papillomavirus types is required for the development of cervical cancer
313
- Cervical cancer rates are directly linked to the quality of the prevention programmes - true or false?
true.
Women must be aged 25-64 and they will take 3 yearly smears up to age 50 and 5 yearly smears from age 50.
314
suggest an investigation that can be carried out in women who have CIN (cervical intraepithelial neoplasia) to differentiate between those who have no abnormality and those who require further investigation
CERVICAL CYTOLOGY
In the normal cervix, there are squamous epithelial cells. there are also other cells - glandular cells and inflammatory cells
315
in a normal cervical cytology what may be found in dyskariosis (abnormal cells) of a woman with cervical intraepithelial neoplasia?
1. abnormal cells and few in number
2. nucleus increased in size and nuclear:cytoplasmic ratio
3. variation in size, shape and outline
4. coarse irregular chromatin
5. nucleoli
Depending on the degree of underlying CIN on cytology we will grade as low or high dyskaryosis. Koilocytes – reflect productive HPV infection. Koilocytes are cells that have a wrinkled nucleus and perinuclear halo. They have multiple nuclei
316
if under cervical cytology there appears to be high grade dyskariosis, suggest what further steps should be taken for a woman who we now fear has cervical cancer
colposcopy.
for low grade dyskariosis then repeat the test in 6 months.
317
where is the main site of HPV infection and the most likely site for precancerous change in the cervix?
the transformation zone.
HPV infection infects the basal layer of cells and utilises host for replication
Glandular lining cells of exposed endocervical epithelium transformed into squamous cells – squamous metaplasia
318
what are other risk factors for developing CIN and cervical cancer? name 5
1. early age first intercourse
2. multiple sexua partners
3. prolonged oral contraceptive use
4. smoking
5. STDs
6. immunodeficiency
7. persistent infection
319
how many different grades of severity are there in cervical intraepithelial neoplasia?
CIN 1
CIN 2
CIN 3
Cervical intraepithelial neoplasia is a precursor of invasive cancer. There is disarray in the arrangement of the cells within the epithelium, variation in cellular size and shape, nuclear enlargement and irregularity and hyperchromatism
CIN may regress or persist. A minority of CIN3 will progress to invasive cancer over 10-20 years if untreated
320
what is the histological appearance of cells in the cervix?
squamous carcinoma.
Squamous carcinoma is the malignant change in squamous cells of the transformation zone of the cervix. In invasive cell carcinoma there are abnormal cells invading into the underlying tissues.
321
what is the treatment for CIN - cervical intraep...)
1. LLETZ
2. cold coagulation
3. laser ablation
FOLLOW UP AFTER TREATMENT OF CIN
1. confirm that the treatment was effective
a. residual disease within 2 years
2. 2. To prevent invasive cancer
a. Recurrent disease 5% after 3-5 years
b. Detect occasional cancer
3. To reassure the woman
After the treatment of CIN there is an increased risk of cervical cancer compared with the normal population. There is a follow up LBC at 6 months for cytology and high-risk HPV. If both are negative then return to recall. If either are positive then return to colposcopy
322
what are the aims of cervical screening?
1. detect cervical dyskaryosis
2. reduce the risk of cervical cancer
3. detect CIN
4. prevent cervical cancer
323
what are the symptoms of cervical cancer? name 4
```
Abnormal vaginal bleeding
Post-coital bleeding
Intermenstrual bleeding (PMB)
Discharge
Pain
```
324
how is cervical cancer diagnosed?
1. clinical presentation
2. screen detected
3. biopsy
- Remember screening aims to detect pre-cancerous disease not cancer
325
how is cervical cancer staged?
learn this question well as will probably come up in exam
1. EUA (especially rectal) - examination under anaesthetic
2. PET-CT
3. MRI
326
how is cervical cancer treated?
1. Radiotherapy – external beam x20 fraction
2. Chemotherapy – 5 cycles of cisplatin
3. Caesium insertion (24 hours
327
what is a radical hysterectomy?
exploration of pelvic and para-aortic space. It involves the removal of:
- Uterus, cervix, upper vagina
- Parametria
- Pelvic nodes
the ovaries are conserved
328
name 5 short terrm health impacts of fema;le genital mutilation
1. severe pain and shock
2. infection
3. injury ot adjacent tissues
4. sprains, dislocations, broken bones or internal injuries from being restrained.
5. immediate fetal haemorrhage
6. infection by blood borne virus
329
name 5 long-term health impacts of female genital mutilation
urine retention and difficulties in menstruation
uterine, vaginal and pelvic infections
cysts and neuromas
complications in pregnancy and childbirth
increased risk of fistula
on-going impact of trauma / PTSD
sexual dysfunction
330
what is the common presentation of vulvar cancer? - name 4.
Presentation:
1. Pain
2. Itch
3. Bleeding
4. Lump/ulcer
Vulvar cancer is squamous cell carcinoma.
Staging is surgico-pathological
The main treatment for VIN is surgery and there is a generally good prognosis
331
what are the screening methods for Down's syndrome?
- Maternal age
- Biochemical and US screening
- Selection for amniocentesis
- Free-fetal DNA
i. HIGH RISK
Recent recommendation in England
ii. LOW RISK
Private market at present
332
are breasts a primary or secondary sexual feature?
secondary
333
what are the surface landmarks of the breasts?
from the 2nd rib to the 6th rib. from the sternal edge to the midaxillary line. they lie on the deep pectoral fascia covering the pectoralis major.
334
there are 4 quadrants of each breast. which quadrant does the axillary tail of the breast extend into?
the superolateral quadrant.
335
what is gynaecomastia?
it is the postnatal development of rudimentary lactiferous ducts in males.
i. Polymastia is the development of an extra breast
ii. polythelia is the development of an extra nipple
iii. Athelia or Amastia is the absence of a nipple or breast.
336
what 3 arteries supply the breasts?
- Thoraco acromial artery
- Lateral thoracic artery
- Internal mammary (thoracic) artery
Anterior and lateral cutaneous branches of the 4th to 6th intercostal nerves will provide innervation to the breasts
337
why are the lymphatics of the breasts of great importance?
their ability to disseminate metastases
Most lymph (more than 75%) is from the lateral quadrants – axillary lymph nodes. Some lymph may drain directly to supraclavicular or inferior cervical lymph nodes. Lymph from medial quadrants – parasternal or to opposite breast
338
why is the sentinel node of clinical importance?
The sentinel lymph node is the first draining node. The sentinel node allows for lymphatic mapping and staging of patients
339
how is breast cancer diagnosed?
1. mammography and USS
2. fine needle aspiration cytology (FNAC)
3. core biopsy
A core biopsy should be done in all cases with clinical or radiological or cytological suspicion. Breast screening should be done especially in architectural distortion and microcalcification
340
what is cytology?
thi sis the microscopic examination of a thin layer of cells on a slide obtained by:
- FNAC
1. direct smear from nipple discharge
2. scrape of nipple with scalpel
cytology is often used in a symptomatic clinic
341
With breast cysts, aspiration is curative true or false?
true.
. This is mostly a simply procedure and can be done at most clinics. It is well tolerated by patients. It is inexpensive and there are immediate results.
342
what are the complications of FNA?
1. pain
2. haematoma
3. fainting
4. infection
5. pneumothorax
there arent any real contraindications
A core biopsy should be done in all cases with clinical or radiological or cytological suspicion. Breast screening should be done especially in architectural distortion and microcalcification
343
Ultrasound can be used to differentiate a solid from cystic mass and a solid benign from malignant mass. true or false?
true.
344
what are some indications to take an MRI of breast tissue?
1. Recurrent disease
2. Implants
3. Indeterminate lesion following triple assessment
4. Screening high risk women
other imaging techniques include:
- PET
Sentinel node samploing
- nuclear medicine
345
in breast disease, what is meant by triple assessment?
1. clinical examination
2. imaging
3. FNAC
346
what is the most common type of breast tumour in adolescent and young women?
fibroadenoma
- well circumscribed
- freely mobile
- non-painful masses
- may regress with age if left untreated
347
name 8 risk factors for developing breast cancer
1. gender
2. age
3.menstrual history
4. age at first pregnancy
5. radiation
6. family history
7. personal history 8. hormonal history
9. genetic factors
10. other factors
obesity
alcohol
348
breast cancer can be histologically classified, name 3 histological types.
1. tubular carcinoma
2. mucous carcinoma
3. medullary carcinoma
most breast cancers are ductal.
349
Screening for breast cancer results in a 30% reduction in mortality - true or false?
true.
Ladies are offered a scan every 3 years between the ages of 50 and 70.
350
where is breast cancer most likely to metastasize?
1. local - skin and pectoral muscles
2. lymphatic - axillary and internal mammary
3. blood - nodes, lungs and brain/liver
351
suggest 7 factors that will influence the prognosis of a woman with breast cancer
1. node status (best prognostic indicator)
2. tumour size (<2cm)
3. type
4. grade (1, 2 and 3)
5. age
6. lymphovascular space invasion
7. oestrogen receptors (ER)
8. progesterone receptors (PR)
9. HER-2
10. Nottingham Prognostic Index (NPI) based on tumour size, grade and nodal status.
11. overall 64% five year survival
