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msk - cortex notes Flashcards

1
Q

What is an echondroma

A

Benign bone tumour that is intramedullary adn usually a metaphyseal cartilaginous tumour caused by failure of normal echondral ossification at the growth plate

Can weaken the bone leading to pathological fractures

Can occur in the femur, humerus, tibia and small bones of hand and feet

Can be scraped out

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2
Q

What is a simple bone cyst

A

A single cavity of benign fluid filled cyst in bone

Usually a growth defect from the physis

Can cause weakness > pathological fracture

Treatment = curettage and grafting

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3
Q

What is an aneurysmal bone cyst

A

Contains lots of chambers filled with blood or serum
- the different chambers may be seen on x-ray

Due to small arteriovenous malformation

Occur in the metaphyses of long bones , flat bones, and vertebral bodies

This lesion is LOCALLY AGGRESSIVE causing cortical expansion and destruction and so is painful

Treatment = curettage

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4
Q

What is a giant cell bone tumour ?

A

Can be LOCALLY AGRESSIVE AS WELL AS ANEURYSMAL BONE CYST

Most commonly occur in the knee, distal radius, spine and pelvis

5% can met. To the lung

Treatment = intralesional excision with use of phenol, bone cement or liquid nitrogen

May need joint replacement with very aggressive lesions

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5
Q

*soap bubble appearance on x-ray

A

Giant cell bone tumour

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6
Q

Which benign bone tumours are locally invasive

A

Giant cell
Aneurysmal cyst

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7
Q

What is fibrous dysplasia

A

Benign bone tumour which occurs in adolescence where a genetic mutation results in fibrous tissue lesions and immature bone

Can get defective mineralisation

Treatment = Biphosphonates (reduce pain and risk of pathological fractures)

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8
Q

What is an osteoid osteoma

A

Benign bone tumours of immature bone surrounded by intense sclerotic halo

Commonly in adolescence and most common site is the proximal femur (long bones)

Intense and constant pain, worse at night

Treatment = NSAIDs, CT guided radio frequency ablation (if doesn’t resolve spontaneously)

Investigation = CT + bone scan to confirm diagnosis

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9
Q

Investigation for osteoid osteoma

A

CT + bone scan are both needed to confirm diagnosis despite them being seen on x-ray

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10
Q

*brodie’s abscess

A

Subacute osteomyelitis

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11
Q

*brown tumours

A

Indicate hyperparathyroidism

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12
Q

Are malignant primary bone tumours common ?

A

No ! Very rare

But other cancers metastasising to bone is very common

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13
Q

Most common malignant primary bone tumour

A

Osteosarcoma - seen in younger age groups

60% involving knee bones

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14
Q

Treatment of osteosarcoma

A

Since they are not radiosensitive

Adjuvant chemotherapy can prolong survival

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15
Q

What is a chondrosarcoma

A

Malignant cartilage producing primary bone tumour

Less common

Not as aggressive as osteosarcoma

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16
Q

What are fibrosarcoma and malignant fibrous histiocytoma

A

Fibrous malignant primary bone tumours which tend to occur in abnormal bone ie bone infarct, fibrous dysplasia

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17
Q

What is Ewing’s sarcoma

A

A malignant tumour of primitive cells in the marrow

2nd most prevalent primary bone tumour

Has the poorest prognosis

Most cases are between the ages of 10-20 years

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18
Q

Staging investigation for primary bone tumours

A

Bone scan and CT chest

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19
Q

what investigation are helpful to determine local extent of tumours and involvement of muscle, nerve adn vessels

A

MRI and CT

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20
Q

Treatment of primary bone tumours

A

Normally surgery to remove the tumour and any surrounding tissue

> limb salvage surgery is better than amputation

Also chemotherapy and radiotherapy

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21
Q

Diagnosis of myeloma

A

Plasma protein electrophoresis

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22
Q

What are the top5 cancers that metastasise to bone (In order of frequency)

A
  1. Breast
  2. Prostate
  3. Lung
  4. Renal cell
  5. Thyroid adenocarcinoma
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23
Q

Suspected bone cancer investigation

A

X-ray

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24
Q

What investigation tells you the extent of bony mets. ?

A

Bone scan

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25
Q

What bone area is considered an ‘at risk’ area for cortical thinning

A

Subtrochanteric area of the femur

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26
Q

Treatment of fractures / impending fractures ?

A

Stabilisation via long rods (inrtamedullary nails)

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27
Q

Treatment of joint destruction

A

Joint replacement

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28
Q

What is the most common benign sot tissue tumour ?

A

Lipoma

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29
Q

what is a ganglion cyst

A

Occurs around a synovial joint or tendon sheath

May results as herniation/ out-pouching of weak portion of joint capsule etc

Excision may be required

Can be quite firm and they transilluminate

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30
Q

what is bursitis

A

A nurse is a small fluid filled sac lined by synovium around a joint which prevents friction (for everything)

Inflamed bursae will usually occur after repeated pressure or trauma which may present as a soft tissue swelling

Excision may be required - there are issues with scarring

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31
Q

Do sebaceous cysts require any treatment ?

A

Yes - excision and/or biopsy

They are implantation of dermoids

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32
Q

Treatment of abscesses ?

A

Antibiotics alone is not enough

Need incision + drainage

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33
Q

Risk factors of AVN

A

Trauma
Idiopathic
Alcoholism (coagulability)
Steroid use - as in long term use of prednisolone (coagulability)
Primary lipidaemia (coagulability)

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34
Q

Weird causes of AVN

A

Caisson’s disease Aka decompression sickness

Due to nitrogen bubbles forming in the circulation

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35
Q

What happens after AVN

A

Get osteoarthritis of the area affected

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36
Q

How to treat AVN if the articular surface hasn’t collapsed yet and is in an amenable site ?

A

‘ Drilling’ with fluoroscopy to decompress the bone - prevent further necrosis and aid healing

Otherwise joint replacement is needed

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37
Q

Disease which put you more at risk of AVN

A

Thrombophlebitis
Sickle cell disease
Antiphospholipid disease
Primary hyperlipidaemia

(All to do with coagulability)

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38
Q
A

Osteochondroma

  • produces a bony outgrowth on surface of cartilaginous cap
  • is the most common
  • 1% chance of malignant transformation
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39
Q

what type of bone us this ? (It’s either cancellous or cortical)

A

It cancellous .

Why ? Cos its at the epiphysis of the bone and it looks like a fine meshwork

Cortical bone makes up the shaft if the bone (diaphysis)

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40
Q

What are A and B

A

A = epimysium

B = endomysium

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41
Q

A group of muscle fibres are called what ?

A

Fascicles

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42
Q

What are these lines

A

Cement lines

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43
Q

What are all these?

A
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44
Q

what are the cells the arrows are pointing at - and what is the space these cell are located in and also maintain (as they secrete)

A

Chondrocytes = the cells

Matrix = lacuna (the ECM)

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45
Q

Features that are suggestive of a potential malignant soft tissue neoplasm

A

Large lesions >5cm
Rapid growth in size
Solid lesion
Illdefined border
Irregular surface
Lymphadenopathy
Systemic upset

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46
Q

What type of muscle is shown here

A

Skeletal muscle

Peripheral nuclei + striations

47
Q

Treatment for pathological fracture Of clavicle causing weakness due to simple bone cyst

A

Should be managed conservatively

48
Q

*shepherd crook deformity

A

Fiberous dysplasia

49
Q

What investigation tells of bone mineral density

A

DEXA scan

Osteoporosis by DEXA = a score of <2.5

50
Q

Tool to help evaluate fracture risk

A

FRAX

51
Q

5 risk factors for the development of osteoporosis

A

Lack of sunlight
Female
Increased alcohol intake
Inactivity
Smoking

52
Q

*bone enlargement, thickened cortices, thickened trabeculae, mixed areas of lyses and sclerosis

A

Paget’s disease

53
Q

What are the smallest contractile elements in striated muscle cells

A

Sarcomere

‘The unit of contraction’ of muscle cell

54
Q

‘The sarcomere is defined as the region from one Z-disk to the next’

A
55
Q

Which cell lays down new lamellar bone

A

Osteoblasts

56
Q

Which cells congregate and drill into the bone to form a tunnel

A

Osteoclasts

57
Q

DEXA of osteopenia

A

<1.0 - 2.5

(Whether DEXA of osteoporosis is <2.5, osteopenia is like an intermediate stage)

58
Q

When do we start losing bone mineral density

A

Around 30

59
Q

Why does menopause drive osteoporotic pathway ?

A

Due to an increase in osteoclastic bone reabsorption
With the loss of protective effects of oestrogen

60
Q

What are the 2 types of osteoporosis

A

Type 1 = menopausal
Type 2 = of old age

61
Q

What fractures are more commonly seen in type 1 osteoporosis

A

Colles and vertebral insufficiency fractures

62
Q

What fractures are more commonly seen in type 2 osteoporosis

A

Femoral neck fractures, vertebral fractures

63
Q

Investigation of osteoporosis

A

DEXA

64
Q

What are 2 things that can increase bone mineral density

A

A cat purring on top of you
Exercise

65
Q

Are there any treatments to increase bone mineral density

A

Nope

Management of osteoporosis = prevent further deterioration ie calcium, vit D supplements, Biphosphonates, desunomab, strontium and zolendronic acid

66
Q

Treatment of osteoporosis

A

Vitamin D and calcium supplementation

Biphosphonate

Desonumab

Strontium

Zolendronic acid - once yearly

67
Q

Can you use intranasal calcitonin for osteoporosis ?

A

No extra benefit over other treatments and has a an association with increase in cancer

SO NO DO NOT USE

68
Q
A

Just for interest

69
Q

MoA of Biphosphonates

A

Reduces osteoclastic resorption

70
Q

MoA desunomab

A

It’s a monoclonal antibody which reduces osteoclastic activity

71
Q

MoA strontium

A

Increases osteoblastic replication and reduces resorption

72
Q

Difference between osteoporosis and osteomalacia

A

Osteoporosis = quantitive defect (not enough of)
Osteomalacia = qualitative defect (bone is shit quality bruv)

73
Q

What is osteomalacia

A

Abnormal softening of the bone due to deficient mineralisation of osteoid (immature bone) secondary to inadequate amounts of calcium and phosphorus

74
Q

Is rickets osteomalacia ?

A

Yes but just in children so has subsequent effects on growing skeleton

75
Q

Causes of osteomalacia

A

Malnutrition
Malabsorption
No sunlight exposure (no activation of Vit D)
Hypophosphataemia (re-feeding syndrome/ alcohol abuse)
CKD
Long term anticonvulsant use

76
Q

*pseudofracture on x-ray

A

Osteomalacia

77
Q

Treatment of osteomalacia

A

Vitamin D therapy with calcium and phosphate supplementation ›

78
Q

What to remember with hyperPARAthyroidism

A

Painful moans, renal stones, abdominal groans and psychic overtones

(Overproduction of PTH = hypercalcaemia, = fatigue, depression, myalgia , nausea, thirst, polyuria, renal stones, osteoporosis)

79
Q

Bone biochemistry for hyperparathyroidism

A

Serum PTH = ++
Calcium = ++
Phosphate = normal/low

80
Q

*brown tumours

A

Hyperparathyroidism fragility fracture

81
Q

How to treat hypercalcaemia

A

Emergency
IV fluids
Biphosphonates
Calcitonin

82
Q

What is renal dystrophy

A

Describes bone change due to CKD

Reduced phosphate excretion and inactive Vit D results in secondary hyperparathyroidism

83
Q

What is Pagets

A

Chronic disorder which results in thickened, brittle misshapen bones

Aka brittle bone disease

84
Q

Pathophysiogoy of pagets

A

Increased osteoclastic activity (due to an exaggerated response to vitamin D) leads to osteoblasts trying to catch up and correct excessive bone resorption. The new bone formed fails to remodel sufficiently and so even tho the bone is thick and denser it is brittle and fractures easily

85
Q

Bones commonly affected in pagets

A

Pelvis
Femur
Skull
Tibia
Ear ossicles

86
Q

Hearing problem associated with pagets ?

A

Conductive deafness due to misshapen ear ossicles

87
Q

Virus associated with pagets

A

Paramyxovirus

88
Q

Bone biochemistry of pagets

A

Serum alkaline phosphatase is raised
Calcium and phosphorus are usually normal

89
Q

Treatment of pagets

A

Biphosphonates or calcitonin if lots of breakdown of bone

Also joint replacement may be necessary

90
Q

Management of intracapsular displaced hip fractures

A

Garden III or IV

Either tota hip replacement or hemiarthroplasty ( due to Avascular necrosis of the femoral head )

91
Q

Management of intracapsular non-displaced hip fracture

A

This means the blood supply to the femoral head is intact still so can preserve the femoral head

Can be treated therefore with internal fixation (screws) to hold femoral head in place while the bone heals over

92
Q

Management of extra-capsular intertrochanteric fractures (hip)

A

Dynamic hip screw

93
Q

Management of extra-capsular subtrochanteric fracture (hip)

A

Intramedullary nail

94
Q

Treatment of mechanical back pain

A

Analgesia and physio

95
Q

*pain worse on coughing

A

Acute disc tear (coughing increases pressure)

96
Q

Acute disc tear management

A

Analgesia and physio

Symptoms can take 2-3 months to settle

97
Q

Commonest nerve roots that can herniate on an acute disc tear

A

L4 L5 S1 (sciatic nerves)

98
Q

Damage to what nerve roots cause cauda equina

A

L1-L5 typically

99
Q

A laterally placed prolapse between L4-L5 would compress which root ?

A

L4

A more central prolapse would compress L5

A completely central prolapse would cause cauda equina (C)

D - shows osteophyte formation causing compression

100
Q

What is spinal stenosis

A

When multiple nerve roots can be compressed/irritated

Due to combination of spondylosis/bulging discs etc

101
Q

Features of spinal stenosis

A

Pain is better walking up hill
Pain is burning
Pedal pulses are preserved
60+ ages and characteristically have pain in the legs when walking (claudication)

102
Q

Affected sacral nerve roots in cauda equina

A

S4 and S5

These control defaecation and urination

103
Q

*saddle anaesthesia

A

Cauda equina

104
Q

What investigation is mandatory in cauda equina

A

PR

105
Q

Investigation for cauda equina

A

URGENT MRI
PR exam

106
Q

Red flags for back pain

A
  • back pain in young <20 years
  • new back pain in old people
  • constant, severe, worse at night back pain
  • systemic upset
107
Q

Treatment of osteoporotic crush fracture on the vertebral body

A

Conservation - this fracture is stable

Can sometimes do a balloon vertebroplasty

108
Q

*slow onset stiffness and pain in the neck which can radiate locally to shoulders and occiput

A

Cervical spondylosis

109
Q

*subluxation of Atlanto-axial instability

Is suggestive of what conditions

A

Downs
RA

This is due to cervical spine instability

110
Q

Which nerve passes through the carpal tunnel

A

Median

111
Q

What is Tinel’s test

A

Percussion over the radial nerve

Can reproduce carpal tunnel symptoms

112
Q

Nerve responsible for hip pain referring to groin radiating to knee

A

Obturator nerve

113
Q

Muscles responsible for trendelenburg gait

A

Muscle weakness of gluteus minimus and mediu

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