Msk Flashcards
Bones shoulder
Scapula humerus clavicle
Acromion
Protrusion scapula
Muscles shoulder greater tubercle of humerus
Supraspiantus, infraspinatus, teres minor
Subscapularis
Attach to lesser tubercle
Deltoid
Abdutor
Supraspinatus
Abduction 15 degrees first
Subscapularis
Internal rotate
Infraspinatus
External rotate
Teres minor
External toration
Suprascapular
Supraspinatus
Infraspinatus
Axillary
Teres minor deltoid
Upper and lower subscapularis nerves
Subscapularis muscle
Shoulder impingement syndrome
Pain with overhead activity
Athletes in overhead sports-swimming, volleyball, job painting stocking shelves,
Impingement syndrome path
When arm abducted over 90 degrees the greater tuberosity of humerus compresses the rotator cuff against the acromion causing pain and decreased motion in the shoulder
Diagnose
Clinical
- cross over test…cross arm pain in shoulder
- never test passively raise arm forward
- Hawkins Kennedy test floes shoulder 90 degrees and internally rotate
No radiograph, US can evaluate impingement bursitis ,MRI f no work could be tear
Treat
Rice, PT, corticosteroid injections into subacromial space
Thoracic outlet syndrome
OT-above 1st rib behind clavicle
Arteries nerves pass though
Cause
Muscular abnormalities
Brachial plexus and subclavian pass between what
Anterior and middle scalene in thoracic outlet…scalene muscles can have attachments that narrow space OR fusion of anterior and middle scalene or numerous
Cervical rib
1% women cervical rb can complex brachial plexus or subclavian
Higher risk of getting TOS after hyperextensive injury
Injury TOS
1st rub fractures, clavicle, whip lash, repetitive overhead movement, pitching, swimming
Symptoms thoracici outlet syndrome
What is compressed
Types of TOS
Neurogenic
arterial
Venous
Neurogenic
Most common
Arm. Hand pain, numbness weakness
Aggravated by elevation or sustained use
Muscle atrophy
Venous TOS
Swelling pain
Bluish color
Venous thrombosis ay develop
Arterial TOS
Least common
Associated with cervical rb
Spontaneous symptoms hand ischemia
Thromboembolization in subclavian artery
Diagnosis
Reproduce symptoms on exam with arm movements
Imaging
US initial duplex first test done
CT, MRI more anatomical
Treat TOS neurogenic
PT, surgical decompression
Treat venous
Anticoagulation
Surgical decompression
Treat arterial
Surgical embolectomy
Surgical decompression
Developmental dysplasia of hip
In utero displacement from acetabulum
At birth not formed completely ..interactions ith femoral head forms it
If dont get femoral headin disrupt hip joint
Risk factors
First born
Breech presentation
Female
Presentation
Hip clicks or clunk from Barlow or ortolani maneuver
Barlow test
Flex hip 90 degrees internal rotate and press down or back
If feel or hear clunk or click +
Then external rotate and punch femoral head anterior to relocate doesn’t take a lot of force and clunk
Ortolani
Then external rotate and punch femoral head anterior to relocate doesn’t take a lot of force and clunk
Clunk positive
Appearance
Asymmetric skin folds and unequal leg length knees unequal height when flexedGALEAZi sign
If diagnosis not made
Delayed walking abnormal gait
Gait
Trendelenberg—opposite hip sag when weight on hip
Diagnose
PE
Hip US
X rays not helpful not enough bone mineralization
Screening-if from breech, female, female neonates with family history
Treat before 6 moths
Pavlik harness positions femoral head in proper place so it can develop correctly before 6 month
Treat after 6 months
Closed or open reduction and spica casting for 6 months to 2 years
Diagnose after 8 years
Not attempted bc reduced benefit
Ankle sprain
Lateral most common frame xcessive inversion of plantarflexed foot
Medial from excessive eversion
Syndesmosis high ankle sprain from dorsiflexion/eversion and leads to chronic ankle instability
Lateral ankle sprain ligaments
Anterior talofibrular ligament(anterior aspect of lateral malleolus to talus)
Calcaneofibular ligament(lateral malleolus to calcaneous)
Posterior talofinrular ligament (posterior side of lateral malleolus to posterior surface to talus
Medial ankle sprain
Deltoid ligament-strongest hard to hurt it
Syndesmosis sprain
Anterior tbiofibular ligament and posterioinferior tibiofibular ligament and transverse ligament or interosseous membrane
Grade 1
Mild stretching of ligament, microscopic tears, no joint instability, bear weight, ambulated Manila pain
Grade II
Incomplete tear of ligament
More pain/swelling
Ecchymosis
Mild/moderate joint instability
Decreased range of motion
Walking is painful
Grade III
Complete tear of ligament
Severe pain/swelling
Ecchymosis
Unstable joint
Can’t walk
Diagnosis
Clincial Tenderness, swelling Ecchymosis Inversion eversion test Anterior drawer test
When get x ray
Ottawa Raul
Ottawa rule who gets
Bone tenderness at the posterior edge of lateral or medial malleolus
Unable to bear weight
(Can’t walk 4 steps)
Anyone with bone tenderness at fifth metatarsal or navicular
Treatment
Rice, range of motion exercises, bracing/splints, surgery if severe instability
Plantar fasciitis
First steps of day pain as walk improves sit down for breakfast but get up better then better with walking
Didn’t injure foot but walks a lot at work
Pain worse with dorsiflexion
Radiograph normal
What is plantar fasciitis
Thick pearly white originate at calcaneous insert at base of toe is the plantar aponeurosis inflamed and leadto plane
40-60 peak
Diagnose
Clincial
Heel pain worse with initiation of walking
First steps of the day, limp out of bed
Sit more pain with steps
Worsening throughout day
Point tenderness heel with dorsiflexion
Imaging
Not necessary
X ray
May see plantar fascia thickening
Fat abnormalities
US plantar
Plantar fascia thickening
Hypoechogenecity
Treat plantar fasciitis
Weight loss, stretching, avoid flat shoes or walking barefoot, have padded arch support, even immediately after waking up , prefab silicone inserts, decrease physical activities, NSAIDS, inject glucocorticoids
Myasthenia gravis and lambert Eaton
Look similar
Myasthenia gravis
Most common NMJ disorder
Thymus pathology
-50% have thymic hyperplas, 20% have atrophy, 15% thymoma
Lambert Eaton syndrome
Uncommon
Associated with small cell lung cancer -may be immune response to SSC
Clincial presentation myasthenia
Fluctuating uncle weakness
-ptosis
-diplopia bc extraocular muscle weakness
-Bilbao msucle weakness (chewing swallowing prob or slurred speech)
Neck muscle weak
-proximal arm shoulder
-respiratory weakness and maybe need for mechanical ventilation
Clincial lambert Eaton’s
Proximal limb weakness Har walkinga -hard raising arm -autonomic dysfunction —dry mouth, ED
Myasthenia gravis cause
Antibodies post synaptic ach receptors in NMJ
Worse with muscle use**
Give edrophonium which give transient improvement with weakness (doesn’t work with lambert eaton)
Cause lambert eaton syndrome
Antibodies against presynaptic ca channels
Usually open , if prevent get decrease ach and muscle weakness
Weakness improves with muscle use***
Treat
Long acting cholinesterase inhbiitors, plasmapheresis for myasthenia
Lambert eaton-treat lung cancer
Asprin
Permanently inhibit cyclooxygenase
Cox1 and 2
What do COX do
Convert arachidonic acid to endoperoxides
What inhibits cyclooxygenase from converting aa to endoperoxidase
NASIDS< celecoxib, apap, asa
How make arachidonic acid
Phospholipase a2 makes it from cell membrane phospholipids
How stop phospholipase 2 from making aa
Glucocorticoids
How does arachidonic acid become hydroperoxides
5-lipoxygenase
How stop 5 lipoxygenase from making hydroperoxides
Zileuton
What do endoeroxides become
PGI2, prostagladina, thromboxane a2
Pgi2
Decrease platelet aggregation
Decrease vascular tone
Decrease uterine tone
Prostagladin
Increase uterine tone (PGE2,2a)
Decrease vascular tone PGE1
Thromboxane a2
Increase platelet aggregation and increase vascular tone
What does hydroperoxides become
Leukotrienes
What do leukotrienes do
Neutrophil chemotaxis (LBT4)
Increase bronchial tone (LTC4, LTD4, LTE4)
How stop leukotriene
Zafirlukast, montelukast
NSAID effect
Decrease platelet aggregation, decrease fever, analgesia, decrease inflammation
Most ocommon use
Antiplatelet drug to prevent mi stroke
Acute mi
Take an asprin
Side effects asprin
Increase risk of bleeding
Increase risk of peptic ulcers
Hyperventilation (stimulate respiratory centers of brain)
High anion gap metabolic acidosis
Tinnitus
Interstitial nephritis
AKI
Reye syndrome -hepatoencephalopathy ..and hypoglycemia from impaired gluconeogenesis
What pediatric disease give asprin
Kawasaki disease
Kawasaki disease
Vasculitis in kids high fever, inflammation lips tongue and coronary artery aneurysm
NSAIDS
Ibuprofen, naproxen, indometacin, diclofenac, asprin, ketorolac
NSAID
Inhibit cyclooxygenase 1 and 2
Asprin permanent
NASIDS reversible
Effect of nsaids
Decrease fever, decrease pain, decrease inflammation, decrease platelet aggregation
Endomethacin
Can close PDA in new born
Inhibit prostagladins increase vascular tone in newborn increase vascular tone in PDA and close
Side effects nsaids
AKI from increase vascular tone and reduced RBF
Acute interstitial nephritis
Gastric ulcers
Aplastic anemia
Cox 2 inhibitors selective
Celecoxib
Meloxicam
Nabumetone
Cox 2 enzyme
In inflammatory and endothelial cells
Cox 1
Everywhere
Cox 2 inhibitor benefit and bad
Decrease peptic ulcer disease
Increase risk fo thrombosis though so careful with heart disease
Sulfa drug allergies
Rem and derm
Ok
Epiphysis plate
End of long bone to allow bone to lengthen-signs of endochondral ossification
Limbs achondroplasia
Proximal shorter than distal
Bowing tibia
Life expectancy achondroplasia
Fine life span and fertility
Pass on AD
One parent achondroplasia what chance pass, both have what is likely hood have
1/2
3/4. 1/5 hetero, 1/4 die bc homozygous
Bone healing phase
Inflammatory-hematoma forms. Then osteoclasts resorb 1-2 mm of bone along the fracture edges (takes a few days why fracture lines show up better a week after fracture then right after) then fill in with granulation tissue. Then multipotent periosteal cells become osteoprogenitor cells
Reparative-new blood vessels form outside the bone. Cartilage forms across the fracture site from fibroblasts chondroblasts. Callus formation (endochondral ossification of cartilage)
Remodeling-callus becomes completely ossified. New bone is structurally remodeled by osteoclasts and osteoblasts
Osteochondroma
Hamartoma of hte bone
Where is osteoclastoma
Distal femur or proximal tibia
Most tumors in the bone
Metastatic
What cancers metasticize to the bone
Permanently relocated tumors that like bones
-prostate, renal cell cancer, testes, thyroid, lung, breast
Lytic lesion
Renal cell carcinoma
Thyroid
Blastic lesion
Prostate cancer
Lytic of blastic
Breast cancer , lung cancer
Clincial manifestation bone mass
Bone pain
Epidural spinal cord compression -pain, sensory and motor deficits and bladder and bowel dysfunction
Hypercalcemia(lytic)
Where does new born formation take place in long bone
Epiphyseal plate
Osteosarcoma or osteomyeloma more common
Osteomyeloma
Tb mutation
Osteosarcoma
Hamartoma
Osteochondroma
Anticholinesterase
Keep acetylcholine around
Neostigmine
Myasthenia gravis
Reverse neuromuscular blockade
Post op urinary retention
Pyrostigmine
Anticholinesterase
For Anticholinergic poisoning (atropine)
Pyridostigmine
Reverse neuromuscular blockade
Myasthenia gravis
Rivastigmine
Alzheimer’s disease
Anticholinesterase
How increase heart contractility
Catecholamines-exercise stress
Increase intracellular ca
Decrease extracellular na
Digoxin-increase intracellular ca and decrease intracellular ca
Osteoblast to osteocytes
Osteocyte live in lacune and contact and communicate with each other by canaliculi
-osteoblast get suck and become osteocyte
Osteoblast look like
Multinucleated giant cell
Why get osteoporosis
More bone loss than bone gain
DEXA
How much x ray absorbed when pass-absorb more
Colles
Hand goes dorsally
Treat osteoporosis
Stop smoking, stop steroids, increase weight bearing
Calcium and vit D
Bisphosphonates -inhibit osteoc
Bisphosphonates
-dronate
Inhibit osteoclast allow osteoblast to catch up
What use bisphosphonates for
Osteoporosis
Paget
Humoral hypercalcemia of malignancy-tumor make pthrp
Long term steroid use
AE bisphosphonates
Erosive esophagitis
Osteopetrosis of the jaw -wont do jaw surgery unless of for a few months
Conjugated estrogen for osteoporosis
WHI trial->hip fracture reduction
USPSTF recommends not using estrogen for the sole purpose for fracture reduction risk due to risk of other side effects (MI CVA)
SERM (raloxifene)
Decreases vertebral fracture by 40% in women with osteoporosis, no effect on risk of non vertebral fracture risk, reduces risk of breast cancer
Teriparatide (recombinant TPH analog that stimulates osteoblasts)
Decreases hip fracture rate by 53%. During of therapy not to exceed two years. Must use bisphosphate after stopping teriparatide to maintain bone mineral density.
Denosumab
Rank-L inhibitor
Paget disease symptoms
None
Big ass skull
Fractures
Increase osteosarcoma
Renal tubules not absorbing phosphate
Type 1A pseudohypoparathyroidism (Albright hereditary osteodystrophy)
PTHn resistance at renal tubules and low serum a and high phosphate
Reversible when VD replaced
Osteomalacia, rickets
Joints
-3 to -5 mmHg negative pressure
It is a potential space like pleural and pericardial cavity that brings fluid into it
Rupture biceps tendon /popeye lesion
Can tear at elbow or shoulder from lifting something heavy
See bruising and muscle bulge in middle part
Looks bad
If older and can function just rest
Youngster-surgery if effecting function
Antibiotics increase tendon rupture
Fluoroquinolones -Achilles
Empty can test
Abduct to 90 and flex thumb straight down try to push down as they resist if pain and weakness or both it is that injury
Dislocated vs separated shoulder
Dislocated-head of humerous rotates out of glenoid cavity
Separation-clavicle separate from acromion and coracoid process of scapula
Anterior shoulder dislocation
Axillary nerve and posterior circumflex artery
Supraspinatus tendon
Anterior glenohumoral ligaments separation glenoid labrum from articular surface of anterior glenoid neck-Bankart lesion
Posterolateral humeral head from forceful impact against anterior in of glenoid-hill sachs lesion
-see hill sacks lesion
Squared off shoulder
Resist abduction and internal rotation
Humeral head palpable anteriorly
Must texst axillary
Test nerve damage in anterior shoulder dislocation-check before reduction and after
Sensationof deltiod region
Reduction closed
Put back into place
Open reduction
Put back into shoulder with surgery
Most common type of hip dislocation
Posterior
Acetabulum slips out posteriorly
MVA where knee strikes dashboard with hip abducted
Medial and lateral circumflex femoral artery-from deep femoral artery give blood to femoral neck
Femoral vein
Sciatic nerve
Head of femur
Posterior shoulder
Arm held addicted in internal rotation inability to actively or passively externally rotate or abduct arm, palpable posterior fullness, prominent coracoid process
From fall onoutstretched hand
Anterior flatness, unable to externally rotate or abduct the affectedarm
Humeral head medially rotated
Empty glenoid sign
Imaging to diagnose ACL injury
mri
Lose clear line and hazy from hemarage and edema
Ligemtns ankle
- ATF most common always tear first
- Calcaneofibular ligament
3 posterior talo fibular ligament
Media ligaments
Deltoid ligament -hard to do it
How treat ankle sprain
RICE
Rest, ice, compression, elevation
Most common arthritis
Osteoarthritis
Wear and tear of articular cartilage
Eburnation of bone
Bone hard and dense like ivory in osteoarthritis
See nobby hands
Joints effects in osteoarthritis
Hands
Knee fingers
Spine hip
Treat osteoarthritis
Acetaminophen
NSAIDS
COX2 inhibitor
Topical capsaicin cream
Intraarticular glucocorticoid injections .comopioids
Tramadol
Joint replacement-obese and cant walk, then
Acetaminophen
Max 4 grams a day
Fewer side effects than NSAIDS
Acetaminophen
NAPQ! Depletes glutathione
Floats around and reacts with hepatocytes ALT AST rise get liver failure and die
N acetylcysteine retreated glutathione
N acetylcysteine
Acetaminophen overdose
Mucolytic in CF or incubated inhaled
Prevent contrast nephropathy -chronic kidney disease where need IV contrast and worry worsen renal failure give oral n acetylcysteine
Nephropathy
NSAIDS for osteoarthritis
Asprin Diclofenac Ibuprofen Naproxen Nabumetone Meloxicam Indomethacin
COX2 inhibitors
Celecoxib
Meloxicam-inhibtis more cox2 than cox1
Where is cox2
Inflammatory cells in vascular endothelium
Less peptic ulcer disease
Can still cause some PUD and gastritis
COX1
Helps gastric mucosa
If have PUD
Stop NSAID
COX2
Osteoarthritis and rheumatoid arthritis
Gout
COX2 AE
Increase thrombosis
Sulfa
Asprin
Antiplatelet at low
Analgesic and anti inflammatory at higher levels
Asprin side effects
Gastric ulcer GI bleed
Tinnitus
Hyperventilation
Acute renal failure
Joint hand RA
Swan neck
Boutonnière deformity
Wrist RA
Radial deviation at the wrist with ulnar deviation of the digits
Deformity resulting in median nerve entrapment (carpal tunnel syndrome)
Elbow RA
Flexion contracture
Knee RA
Synovial hypertrophy with chronic effusion and ligamentous laxity
Posterior knee RA
Synovial hypertrophy with chronic effusion and ligamentous laxity
Ankle, forefoot, subtalar
Deformities,pain with ambulatory
Upper cervical spine
Atlantoaxial subluxation
Treat RA
Acute-NSAIDS, COX2 inhibtiors, steroids
Long-DMARDS, methotrexate, hydroxychloroquine, sulfasalazine, TNF a inhibitors
TNF a inhibitors
Etanercept Infliximab Adalimumab Golimumab Certolizumab
Swollen, hard, painful finger
Osteoarthritis
Swollen boggy painful finger joints
RA
Cartilage erosion with polished bone beneath
Osteoarthritis
Ankylosis arthritis
Run in morning. Bc reduce stiffness
Conduction abnormalities-CVD in general
Treat seronegative spondylitis
TNF a inhibits
TNF
Cytokine that induces the immune system
TNFa inhibitors
Bind to TNFa
Prevent activation of the immune system
