MSK CORTEXT Flashcards
You are the orthopaedic registrar in the fracture clinic. An 8 year old girl has been referred from A + E with a fracture to her right clavicle. She did this when she fell from a swing onto her outstretched hand. She’s comfortable in the broad arm sling she has been given and she’s neurovasularly intact in the right arm. She had no preceding symptoms, such as pain, in the shoulder or collar bone prior to the accident. She is fit and well. On examination, there is a mild deformity in the middle 1/3 of the clavicle at the site of the fracture but the skin is intact. So far, there is nothing atypical about this girl’s story or injury. However, when you look at the x-ray, you notice that the bone at the fracture site isn’t completely normal. There is a lucent lesion in the middle 1/3 of the clavicle with a smooth edge where it meets the more normal looking bone. There is mild expansion of the cortex. What do you suspect has caused this pathological fracture?
A simple bone cyst
A simple bone cyst (aka unicameral bone cyst) is a single cavity benign fluid filled cyst in a bone. They are probably a growth defect from the physis and are therefore metaphyseal in long bones (usually in the proximal humerus and femur) although they can occur in the talus or calcaneus. They may be asymptomatic and an incidental finding on xray (usually a child or young adult), however, they can cause weakness leading to pathological fracture. Treatment with curettage and bone grafting with or without stabilization may be required. Pathological fractures caused by a weakness due to a simple bone cyst usually heal with normal treatment for that fracture, so this patient would be treated conservatively as is usual for a clavicle fracture. However, the patient should be seen in clinic until the fracture has definitely healed. After the fracture has healed, the bone will be stronger than before as the bone cyst will have filled with normal bone!
You are the orthopaedic reigistrar in the out-patient clinic. You are referred an 11 year old boy by his GP because he is concerned about a lump which has appeared on the outside of his thigh, just above his knee. The boy and his father tell you it has grown in size and they’re quite concerned. The lump itself is painless although it sometimes catches on the ilio-tibial band on the lateral aspect of his thigh. The boy is well, he doesn’t complain of any other symptoms and doesn’t have any significant past medical history. There is no family history of similar problems. On examination, the boy is slim and you can feel a firm, bony lump on the lateral aspect of the distal femoral metaphysis. The skin and soft tissues overlying the lump are healthy. You do an x-ray and it shows a bony spur originating from the distal femoral metaphysis. The cortex is otherwise normal. What is the diagnosis?
Osteochondroma The commonest benign bone tumour is an osteochondroma which produces a bony outgrowth on the external surface with a cartilaginous cap (which isn’t visible on the x-ray). These do not usually cause any problems but can produce local pain. There is a very small (1%) risk of malignant transformation and any lesion growing in size or producing pain may require excisional biopsy. Multiple osteochondromata can occur as an autosomal dominant hereditary disorder.
A malignant primary bone tumour which tends to occur in abnormal bone (bone infarct, fibrous dysplasia, post irradiation, Paget’s disease), most commonly in adolescents or young adults
Fibrosarcoma
A malignant tumour of endothelial cells in the marrow. Most cases occur between the ages of 10 and 20. It may be associated with fever, raised inflammatory markers and a warm swelling and may be misdiagnosed as osteomyelitis
Ewing’s sarcoma
The most common form of primary bone tumour, producing abnormal bone. Most cases are seen in younger age groups (adolescence and early adulthood) with 60% involving the bones around the knee
Osteosarcoma
What is the name given to the space chondrocytes occupy?
Lacuna
The cell found in cartilage are called chondrocytes (chondroblasts when immature)
Condition X is a qualitative defect of bone with abnormal softening of the bone due to deficient mineralization of osteoid (immature bone) secondary to inadequate amounts of calcium and phosphorus
Osteomalacia (Ricketts is the same disease occurring in children)
A - Haversian canal
B - Cement line
Malignant soft tissue tumours of muscles? Fat? Blood vessels?
Skeletal Muscle = rhabdomyosarcoma
Fat = liposarcoma
Blood vessels = angiosarcoma
Inflammation of the usually present, small fluid filled sac lined by synovium around joints which prevents friction between tendons, bones, muscle and skin. This inflammation commonly occurs after repeatedpressure or trauma and, therefore, may present as a soft tissue swelling.
Bursitis
A cystic swelling which occurs around a synovial joint or tendon sheath, as a result of herniation or out‐pouching of a weak portion of joint capsule or tendon sheath.
Ganglion
A collection of pus which can be formed secondary to a penetrating wound
Abscess
What is the name of the layer of thin connective tissue that surrounds individual muscle fibres, such as shown at ‘B’?
B = endomysium
The sacromere is defined as the region from one [blank] to the next
z-line
Skeletal muscle
(top left = transverse section, peripheral nuclei)
(top right = long fibres + striations)
The radiographic features of which biochemical bone disorder include: bone enlargement, thickened cortices, thickened trabeculae with mixed areas of lysis and sclerosis?
Paget’s disease
“The chief form of bone found at the epiphyses of long bones is ____ bone.”
Trabecular bone
Chrondrocytes (chondroblasts when immature)
A mostly lucent lesion, with a patchy sclerosis, found within the metaphyseal region of long bones
Enchondroma
A bony spur, originating the in metaphyseal regions of long bones, growing away from the epiphysis.
Osteochondroma
A lucent, multi-loculated cyst found within the medulla of many different bones, often with associated cortical expansion.
Aneurysmal bone cyst
Avascular necrosis is a cause of??
Secondary osteoarthritis
Osteochrondromas are always benign?
NO
The commonest benign bone tumour is an osteochondroma which produces a bony outgrowth on the external surface with a cartilaginous cap. These do not usually case any problems but can produce local pain. However, there is a very small (1%) risk of malignant transformation and any lesion growing in size orproducing pain may require excisional biopsy. Multiple osteochondromata can occur as an autosomal dominant hereditary disorder!!!
Multiple osteochondromata can occur as?
autosomal dominant hereditary disorder.
Which of the following is NOT a recognised feature of anti-phospholipid syndrome
Select one:
a. livedo reticularis
b. recurrent pregnancy loss
c. migraine
d. thrombocytosis
e. venous thrombosis
Thrombocytosis
* Thrombocytopenia (as well as neutropenia and lymphopenia) are features of most connective tissue diseases (with the exception of rheumatoid arthritis)
* In rheumatoid arthritis thrombocytosis and a moderate neutrophilia can occur as markers of inflammation)
Which of the following tests may help in the diagnosis of Sjogren’s syndrome?
Select one:
a. Schrodinger’s test
b. Schober test
c. Schirmer test
d. Schilling test
e. Schubert’s test
Schirmer test
* Schirmer test involves placing a strip of filter paper under the lower eye lid to assess tear production.
* Schober test is a measure of spinal flexion in ankylosing spondylitis.
* Schilling test is a test to measure Vit B12 absorption
Which of the following best describes the therapeutic approach to connective tissue diseases?
Select one:
a. Discharge to general practitioner with a request for rereferral if major organ involvement occurs
b. Start high dose steroids on diagnosis
c. Immunosuppression with an aim to normalise antibody levels
d. Physiotherapy and if necessary surgery to stabilise the joints
e. Treat symptomatically and monitor closely for major complications
Treat symptomatically and monitor closely for major complications
* Treatment should be tailored to the individual patient (although generally in SLE hydroxychloroquine would be started routinely).
Which would be the most appropriate first test to do in a patient with suspected SLE?
Select one:
a. Urinalysis
b. Anti-mitochondrial antibody
c. MRI brain
d. Nerve conduction studies
e. Renal biopsy
Urinalysis
It is essential to screen for renal disease in SLE and urinalysis is a simple bedside test. If there is evidence of blood or protein in the urine then further investigations such as renal biopsy may be indicated.
Anti-mitochondrial antibody is associated with Primary Biliary Cirrhosis.
MRI brain and nerve conduction studies may be performed in a patient with SLE displaying neurological symptoms.
Which of the following is true of primary Sjogren’s syndrome?
Select one:
a. It is commoner in males
b. It has the worst prognosis of all the connective tissue diseases
c. There is an increased incidence of lymphoma in patients with primary Sjogren’s syndrome
d. The best treatment for dry mouth is total dental clearance
e. There are no antibody tests to aid diagnosis
There is an increased incidence of lymphoma in patients with primary Sjogren’s syndrome
Compared to other connective tissue diseases overall, life threatening or major organ complications are relatively rare and there is a massive ‘iceberg effect’ – most cases go undiagnosed.
Anti-Ro and anti-La antibodies frequently occur in primary Sjogren’s syndrome, ANA and Rheumatoid Factor may also occur.
The best approach to dry mouth is artificial saliva and meticulous attention to dental hygiene.
A 69 year old woman complains of pain at the base of her thumbs. On examination she has bony swelling of her thumb carpometacarpal (CMC) joints and finger distal interphalangeal (DIP) joints. Blood tests show a positive anti-nuclear antibody and a positive anti-RNP antibody. Hand radiographs show loss of joint space, subchondral sclerosis, subchodral cysts and osteophytes at thumb CMC and finger DIP joints. What is the most likely cause of her joint pain.
Select one:
a. Primary Sjogren’s syndrome
b. Systemic lupus erythematosus
c. Osteoarthritis
d. Mixed connective tissue disease
e. Limited systemic sclerosis
Osteoarthritis
The clinical and radiological features are classic for osteoarthritis.
False positive immunological tests are common and immunology should only be checked if there is reason to suspect a connective tissue disease. If the immunology was relevant then the immunology would be most consistent with SLE or MCTD
In SLE, patients will likely be on oral steroids long term
Select one:
True
False
Steroids should only be used when required and for short periods to suppress disease activity whilst other agents are introduced. Long term use of steroids is associated with an increased risk of cardiovascular disease, T2 diabetes and osteoporosis amongst others
Which of the following is NOT a recognised feature of limited systemic sclerosis?
Select one:
a. Anti-centromere antibody
b. Butterfly rash
c. Raynaud’s phenomenon
d. Calcinosis
e. Pulmonary hypertension
Butterfly rash
Butterfly rash is classically a feature of systemic lupus erythematosus.
Although not included in the previous acronym ‘CREST’ pulmonary hypertension is the most serious complication of limited systemic hypertension.
Anti-centromere antibodies, Raynaud’s phenomenon and calcinosis are all characteristics of limited systemic sclerosis
Which of these autoantibodies is most specific for SLE?
Select one:
a. Anti-Scl-70
b. Anti-smooth muscle antibody
c. Anti-nuclear antibody
d. Anti-DNA binding antibody
e. Anti-Ro antibody
Anti-DNA binding antibody
* ANA and Anti-Ro antibody are seen in SLE but can be seen in other conditions and are less specific.
* Anti Scl-70 is associated with systemic sclerosis and anti smooth muscle antibody with autoimmune hepatitis
Which of the following would be most likely to make you suspect antiphospholipid syndrome?
Select one:
a. Pregnancy loss at 32 weeks with evidence of placental insufficiency
b. Deep venous thrombosis in a 80 year old man with pancreatic cancer
c. A single pregnancy loss at 8 weeks
d. Ectopic pregnancy
e. Myocardial infarction in a 64 year old man who smokes 20 cigarettes per day
Pregnancy loss at 32 weeks with evidence of placental insufficiency
* Criteria for antiphospholipid syndrome include preganacy loss prior to 34 weeks due to eclampsia, pre-eclampsia or with evidence of placental insufficiency.
* Other criteria are 3 pregnancy losses before 10 weeks or one between 10 and 34 weeks with no other explanation.
* Thrombosis is a feature but both of these patients have other much more likely explanations.
Which of the following tests is not useful in a patient who presents with symmetrical, small joint swelling. On examination there is a nodule on his elbow but there are no other skin changes. Systemic examination reveals features of pulmonary fibrosis.
Select one:
a. PV and /or CRP
b. Chest X-ray
c. Hand and feet X rays
d. Anti-ds DNA antibody
e. Anti-CCP antibody
Anti dsDNA antibodies
* PV and CRP are not specific for any condition but may suggest inflammation.
*A chest x-ray may reveal pulmonary fibrosis.
* Anti CCP antibodies are specific for rheumatoid arthritis which is what seems likely from the clinical picture.
* X-rays may give prognostic information in rheumatoid arthritis.
* Anti dsDNA antibodies are useful for diagnosis of SLE
The following medications are appropriate treatments for acute gout (under 4 weeks duration)
Select one or more:
a. Flucloxacillin
b. Allopurinol
c. Colchicine
d. Prednisolone
e. Non-steroidal anti-inflammatory drugs (eg. Naproxen)
c. Colchicine
d. Prednisolone
e. Non-steroidal anti-inflammatory drugs (eg. Naproxen)
Classical radiological findings associated with rheumatoid arthritis include which of the following features? There may be more than one correct answer.
Select one or more:
“Bamboo spine”
Subchondral sclerosis
Periarticular erosions
Loss of joint space
Osteophye formation
Subchondral cysts
Periartiular erosions + loss of joint space
Which of the following statements about changes on X-ray is correct?
Select one:
a. Peri-articular osteopenia and erosions are seen in rheumatoid arthritis
b. Chondro-calcification is a typical feature in gout
c. Punched out lesions are seen often in osteoarthritis
d. Pencil-in cup change is characteristic of pseudogout
e. Subchondral sclerosis is seen in psoriatic arthritis
a. Peri-articular osteopenia and erosions are seen in rheumatoid arthritis
HLA B27 positivity is a definite diagnostic test for Ankylosing Spondylitis
Select one:
True
False
False
Which of the following is the description of uric acid crystals as seen under polarised light microscopy?
Select one:
a. Hexagonal crystal structure without birefringence
b. Positively birefringent, needle shaped crystals
c. Positively birefringent, rhomboid shaped crystals
d. Negatively birefringent, rhomboid crystals
e. Negatively birefringent, needle shaped crystals
Negatively birefringent, needle shaped crystals
Which of the following clinical features would be most suggestive of rheumatoid arthritis?
Select one:
a. Early morning stiffness
b. Symmetrical small joint swelling
c. Pulmonary fibrosis
d. Peripheral neuropathy
e. Fever and weight loss
Symmetrical small joint swelling
A 45 year old non-smoking woman has been referred to you with very painful joints since 12 weeks. She has significant early morning stiffness and swelling in the small joints of her hands. On enquiry, she has lost 2 stones in weight during that time and has been feeling tired and ill. She also complains of numbness in her feet . She has also developed a cough lately and has had a couple of episodes of haemoptysis. Her medical history includes bilateral hearing loss and blocked sinuses for which she has been seeing an ENT consultant since a year.
On examination, you notice that her nasal bridge looks flat. She also has a left sided foot drop, absent reflexes and reduced sensation in a stocking distribution bilaterally. Her blood results are as follows:
Hb: 9.9 g/dl (12-16).
CRP 87(normal less than 5).
Plasma Viscosity 2.00(normal less than 1.72)
Eosinophil count 0.0
Her urine shows: Blood +
Protein +++
A CXR requested by her GP was reported as showing a cavity. She has had a CT scan and which has excluded a lung malignancy and infection.
What is the test that you would like to do next?
Select one:
a. Anti-nuclear antibody
b. Anti-mitochondrial antibody
c. Anti-CCP antibody
d. ANCA
e. Anti-centromere antibody
ANCA
The diagnosis here is most likely to be granulomatosis with polyangiitis (Wegener`s) and therefore ANCA is the most appropriate screening test. This patient is likely to have c-ANCA with anti PR3 positivity
Fibromyalgia syndrome can be treated successfully with a reducing course of prednisolone
Select one:
True
False
False
Treatment of fibromyalgia is complex and combines medical therapies such as atypical analgesics (amitriptyline, gabapentin) with graded exercise and psychological approaches such as cognitive behavioural therapy. There is no indication for steroids
You are asked to see a gentleman with weight loss, night sweats, anorexia and persistent nasal crusting and epistaxis.He has also been bothered with cough with haemoptysis .A CT scan of the chest, abdomen and pelvis organised by the admitting team has excluded a malignancy.Clinically, you are suspicious that this gentleman has a small vessel vasculitis.What is the most appropriate immunological test to request in this scenario?
Select one:
a.
Anti-nuclear antibody
b.
Anti-neutrophil cytoplasmic antibody
c.
Anti-Jo-1 antibody
d.
Anti-cyclic citrullinated peptide antibody
e.
Anti-centromere antibody
b.
Anti-neutrophil cytoplasmic antibody
ANCA
ANCA is the appropriate screening test for medium-small vessel vasculitis
Tenderness over the medial epicondyle?
Tenderness over the greater trochanter?
Tenderness in the heel on walking?
Tenderness over the lateral epicondyle of the elbow?
Restricted rotation of the shoulder?
* Golfer’s elbow
* Trochanteric bursitis
* Planter fasciitis
* Tennis elbow
* Adhesive capsulitis
In Polymyositis which of the following is most likely to be positive?
Select one:
a. Anti-DNA binding antibody
b. Anti-mitochondrial antibody
c. Anti-centromere antibody
d. Anti-Jo-1
e. Anti-La
Anti-Jo-1 antibody.
Anti-DNA binding antibody is associated with SLE, Anti-centromere with systemic sclerosis and Anti-La with Sjogrens syndrome
Which of the following is true?
Select one:
a. All of the above.
b. The starting dose of prednisolone in PMR is 15 mg/day.
c. The proximal limb girdle muscles are the predominant site of symptoms in PMR.
d. Polymylagia rheumatic (PMR) is seen in 50% of patients with giant cell arteritis (GCA).
e. GCA is seen in 15% of patients with PMR
All of the above
Polymyalgia rheumatica principally affects patients over the age of 50 years
Select one:
True
False
true
Which of the following statements are false?
Select one:
a. Biological agents are generally more expensive than synthetic DMARDs.
b. Anti-TNF agents are more effective in combination with standard DMARDs.
c. Anti-Tumour Necrosis Factor (TNF) agents are 1.5 times more effective than standard synthetic DMARDs
d. Biological agents are associated with a higher risk of infections than synthetic DMARDs.
e. All patients with inflammatory arthritis should be given biological agents.
All patients with inflamamtory arthritis should be given biological agents
Febuxostat is a uricosuric agent.
Select one:
True
False
False
Febuxostat, like allopurinol is a xanthine oxidase inhibitor, which reduces the production of uric acid
s/s Marfans? (7)
* disproportionately long limbs
* limb laxity
* high arched palate
* scoiliosis
* flattening of the chest (pectus excavatum)
* eye problems (lens dislocation, retinal detachment)
* aortic aneurysm and cardiac valve incompetence
Slipped Upper Femoral Epiphysis?
S/s?
Dx?
Tx?
condition mainly affecting overweight pre‐pubertal adolescent boys where the femoral head epiphysis slips inferiorly in relation to the femoral neck
s/s
* patients can present purely with pain in the knee!!!
* Loss of internal rotation of the hip is the predominant clinical sign
* antalgic limp
* groin pain
Dx = x-ray (ice cream falling off cone)
Tx = URGENT surgery to pin the hip
+ pin other side as prophylaxis
Ax claw and hammer toes?
Features of claw toes?
Hammer toes?
acquired imbalance between the flexor and extensor tendons
* Claw toes = hyperextension at the MTPJ + hyperflexion at the PIPJ and DIP
* Hammer toes = same thing but hyperextension at DIP
Fracture patterns
Patterns of pelvic injury? (3)
* Lateral compression fracture - side impact (one half of pelvis displaced medially)
* Vertical shear fracture - axial force (fall from height) - hemipelvis displaced superiorly
* Anteroposterior compression injury - open book pelvic fracture
limited features systemic sclerosis?
