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Year 2 > MSK: Part 5 > Flashcards

MSK: Part 5 Flashcards

1
Q

What is Paget’s disease of Bone

A

It is a condition involving disorder of bone remodelling and deformities

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2
Q

What age does Paget’s effect

A

Under 40

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3
Q

Where is Paget’s most prevalent

A

Europe and North England

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4
Q

What gender is Paget’s most common

A

Females

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5
Q

Risk factors in Paget’s

A
  1. Aetiology known
  2. Measles
  3. Family history

results from latent viral infection (canine distemper virus, measles or respiratory syncytial virus) in osteoclasts in generally susceptible individuals

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6
Q

Pathophysiology of Paget’s

A
  1. Increased osteoclastic bone resorption followed by formation of WEAKER NEW BONE, increased local bone blood flow and fibrous tissue
  2. Formation exceeds resorption but new woven bone is WEAKER than normal bone - leads to deformity and increased fracture risk
  3. Diseases doesn’t spread but can become symptomatic at previously silent sites
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7
Q

Clinical presentation of Paget’s

A
  1. Pelvis, lumbar spine, femur, thoracic spine, skull and tibia
  2. Bone pain
  3. Most are asymptomatic
  4. Joint pain - when an involved bone is close to a joint (leading to cartilage damage and osteoarthritis)
  5. Deformities, in particular bowed tibia and skull changes
  6. High-output cardiac failure and myocardial hypertrophy due to increased bone blood flow (RARE)
  7. Osteosarcoma
  8. Deafness from 8th cranial nerve involvement
  9. Paraparesis - partial paralysis of lower limbs
  10. Hydrocephalus due to blockage of aqueduct of Sylvius
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8
Q

Diagnostics of Paget’s

A
  1. FBC
  2. X-ray
  3. Isotope bone scans
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9
Q

FBC result of Paget’s

A
  1. Increased serum alkaline phosphatase with normal calcium and phosphate (reflects increased bone turnover)
  2. Urinary hydroxyproline excretion is raised
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10
Q

What does X-ray show in Paget’s

A
  1. Localised boney enlargement and distortion
  2. Sclerotic changes (increased density)
  3. Osteolytic areas (loss of bone and reduced density)
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11
Q

What does isotope bone scans show in Paget’s

A
  1. Determines extent of skeletal involvement but unable to distinguish between page’s and sclerotic metastatic carcinoma
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12
Q

How is Paget’s treated

A
  1. BISPHOSPHONATES (ORAL ZOLENDRONATE or ALENDRONATE)
  2. NSAIDs (IBUPROFEN)
  3. Disease activity monitored by symptoms and measurement of serum alkaline phosphatase or urinary hydroxyproline
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13
Q

What is osteomalacia

A
  1. Normal amount of bone but its mineral content is LOW (there is excess uncalcified osteoid and cartilage) - DEFECTIVE MINERALISATION
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14
Q

How does osteomalacia compare to osteoporosis

A
  1. Mineralisation is unchanged, overall there is bone loss
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15
Q

What is rickets

A

Defective mineralisation during bone growth at epiphyseal growth plates

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16
Q

Osteomalacia vs rickets

A

Osteomalacia is defective mineralisation after fusion of epiphyses

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17
Q

What can cause osteomalacia and rickets

A

Vit D deficiency

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18
Q

Why is Vit D important

A

Required for calcium and phosphate absorption and incorporation into bone

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19
Q

Where is Vit D produced

A

Skin

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20
Q

How is Vit D produced

A
  1. UV B sunlight on 7-dehydrocholesterol
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21
Q

Where is Vit D found in food

A

Oily fish
Egg yolks
Margarine

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22
Q

What happens to Vit D produced in the skin

A

Converted to 25-hydroxy Vit D in the LIVER

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23
Q

What happens to 25-hydroxy Vit D

A

Converted to 1,25-hydroxy Vit D (calcitriol) in the KIDNEY

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24
Q

What is the most common cause os osteomalacia

A
  1. Hypophopsphataemia (excess release of parathyroid hormone causes decreased absorption of phosphate in the kidneys - HYPERPARATHYROIDISM)
  2. Vit D deficiency
  3. Renal failure
  4. Drug induced
  5. Liver disease
  6. Tumour-induced osteomalacia
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25
Q

How does Vit D cause osteomalacia

A
  1. Vit D is fat soluble so GI disease can result in malabsorption
  2. Poor diet
  3. Lack of sunlight
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26
Q

How does renal failure cause osteomalacia

A
  1. Inadequate conversion of 25-hydroxy vit D to 1,24-hydroxy vit D
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27
Q

How do drugs cause osteomalacia

A

Anticonvulsants induce liver enzymes leading to increased breakdown of 25-hydroxy Vit D

Rifampicin

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28
Q

How do liver diseases cause osteomalacia

A

Reduce hydroxylation of Vit D to 25-hydroxy Vit D (cirrhosis)

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29
Q

Clinical presentation of osteomalacia

A
  1. Muscle weakness - leading to waddling gait, difficulty climbing stairs and getting out of a chair
  2. Widespread bone pain - dull ache that is worse on weight-bearing and walking
  3. Bone pain and tenderness
  4. Fractures of the femoral neck
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30
Q

Clinical presentation of rickets

A
  1. Growth retardation
  2. Knock knees, bowed legs
  3. Widened epiphyses at the wrists
  4. Hypocalcaemic tetany may occur (intermittent muscular spasms)
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31
Q

Diagnosis of rickets and osteomalacia

A
  1. FBC
  2. Biopsy
  3. X-ray
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32
Q

FBC test in osteomalacia

A
  1. Low ca and phosphate
  2. Raised serum alkaline phosphatase
  3. Elevated parathyroid hormone
  4. Low 25=hydroxy vit D
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33
Q

Biopsy in osteomalacia

A

Shows incomplete mineralisation

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34
Q

X-ray test in osteomalacia

A
  1. Shows defective mineralisation

2. Looser’s pseudo fractures (low density bands extending from cortex inwards in the shafts of the long bones)

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35
Q

Treatment of osteomalacia

A
  1. Vit D replacement:
    Calcium D3 FORTE (dietary cure)
  2. Oral ERGOCALCIFEROL or IM CALCITRIOL (hepatic disease and malabsorption)
  3. ALFACIDOL or CALCITRIOL (in renal disease)
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36
Q

What diseases are associated with Vit D insufficiency

A

Typ 2 diabetes, several cancers, CVD

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37
Q

What is Acute disc disease

A

Prolapse of intervertebral disc results in ACUTE BACK PAIN (LUMBARGO)

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38
Q

What aged people are effected by acute disc disease

A

Younger people as disc degenerates with age and in the elderly it is no LONGER ABLE TO PROLAPSE

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39
Q

What causes SCIATICA (Acute disc disease in elderly)

A

Compression (as opposed to prolapse) of the nerve root by osteophytes in the lateral recess of the spinal canal

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40
Q

Clinical presentation of acute disc disease

A
  1. Sudden onset of severe back pain
  2. Pain is often clearly related to position and aggravated by movement
  3. Muscle spasm leads to sideways tilt when standing
  4. Radiation of pain and clinical findings depend on the disc affected - LOWER THREE DISCS being most commonly affected
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41
Q

Where is root lesson in S1 felt

A

Buttock down back of thigh to ankle

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42
Q

What reflex is lost in S1 root lesion

A

Ankle Jerk

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43
Q

What other sign is found in S1 root lesions

A

Diminished straight leg raising

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44
Q

Pain felt in L5 root lesion

A
  1. Buttock to lateral aspect of leg and top of foot
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45
Q

What reflex is lost in L5 root lesion

A

None

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46
Q

Other signs of L5 root lesions

A

DIMINISHED STRAIGHT LEG RAISING

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47
Q

Pain in the L4 root lesions

A
  1. LATERAL ASPECT OF THIGH TO MEDIAL SIDE OF CALF
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48
Q

What reflex is lost in L4 root lesions

A

Knee Jerk

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49
Q

Other signs of L4 root lesions

A
  1. Positive femoral stretch test
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50
Q

Diagnosis of Acute Disc Disease

A
  1. X-rays NORMAL

2. MRI

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51
Q

How is Acute Disc Disease treated

A
  1. Acute Stage - bed rest on a firm mattress, analgesia and epidural corticosteroid injections
  2. Surgery for severe near impairment (foot drop or bladder symptoms)
  3. Physio in recovery phase (helping correct posture and restore movement)
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52
Q

What is Chronic Disc Disease

A

Associated with degenerative changes in the lower lumbar discs and facet joints

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53
Q

What causes pain in chronic disc damage

A

Aggravated by movement

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54
Q

Describe distribution of pain in CDD

A
  1. Sciatic radiation in the buttocks radiating into posterior thigh
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55
Q

Is there a cure to chronic disc disease

A

Long-standing with no cure

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56
Q

Surgical intervention for CDD

A

Fusion at single identifiable level if possible and decompression of affect nerve root

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57
Q

Treatment for CCD

A
  1. NSAIDs
  2. Physiotherapy
  3. Weight reduction
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58
Q

Describe pain in Primary and secondary bone tumours

A
  1. Unremitting and worst at night
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59
Q

When are primary tumours of the bone seen

A
  1. YOUNG

Osteosarcomas
Fibrosarcomas
Chrondromas
Ewing’s tumour

60
Q

Where can bone tumours metastasise to

A
  1. Lungs
  2. Breast
  3. Prostate (often osteosclerotic)
  4. Thyroid
  5. Kidney
61
Q

What do bone tumour symptoms rely on

A

Anatomical position of the tumour with local bone pain

62
Q

What are systemic symptoms

A

Malaise, pyrexia as well as aches and pains occur and occasionally related to hypercalcaemia

63
Q

Diagnostics of Primary and Secondary tumours

A
  1. Skeletal isotope scan
  2. X-rays
  3. MRI
  4. FBC
64
Q

What would skeletal isotope scan show

A

Bony metastases as ‘hot’ areas BEFORE radiological changes occur

65
Q

What would X-rays show in tumours

A
  1. Metastasis as osteolytic areas with bony destruction

2. Osteosclerotic (increased bone density) metastases

66
Q

What defines osteolytic areas

A

Lost greater than 60% bone density

67
Q

What do MRIs show in tumours

A
  1. Vertebral lesions
68
Q

FBC results in primary and secondary tumours

A
  1. SEURM ALKALINE PHOSPHATASE raised
  2. HYPERCALACAEMIA
  3. PSA raised in prostatic metastases
69
Q

How are bone tumours treated

A
  1. Analgesics and Anti-inflammatory drugs
  2. Local radiotherapy to relive pain and reduce fractures
  3. Chemotherapy for SOME
    4 .Hormonal therapy for tumours hormone dependant
  4. Bisphosphanates (ALDENRONATE)
70
Q

Name some primary bone tumours

A

Osteosarcoma
Ewing’s sarcoma
Chrondrosarcoma

71
Q

Peak onset of osteosarcoma

A

15-19 yrs

72
Q

What disease is osteosarcoma associated with

A

Paget’s

73
Q

Where does osteosarcoma occur

A

Metaphases of long bones

74
Q

Common sites of osteosarcomas

A

Knees or humerus

75
Q

Clinical presentation of osteosarcomas

A

Painless tumour

76
Q

Metastases of osteosarcomas

A

Destroys bone and spreads into surrounding tissues and rapidly metastasises to the LUNG

77
Q

Diagnostics of osteosarcomas

A

X-ray:

  1. Bone destruction and formation
  2. Soft tissue calcification produces sunburst appearance
78
Q

What cells cause Eqing’s sarcoma

A

Mesenchymal stem cells

79
Q

Onset of Ewing’s sarcoma

A

15 years

80
Q

Clinical presentation of Ewing’s sarcoma

A 
1. Mass/swelling in long bones of the:
arms
legs
pelvis
chest 
skull and flat bones of trunk

Painful swelling, redness in area surrounding tumour, malaise, anorexia, weight loss, fever and paralysis

81
Q

What is chrondrosarcoma

A

Cancer of the cartilage

82
Q

Clinical presentation of chrondrosarcoma

A
  1. Dull, deep pain

2. Affected area is swollen and tender

83
Q

Common sites effected in chondrosarcoma

A
  1. Pelvis
  2. Femur
  3. Humerus
  4. Scapula
  5. Ribs
84
Q

Define fibromyalgia

A
  1. Widespread musculoskeletal pain AFTER other diseases are excluded
  2. Symptoms present for at least 3 months and other causes have been excluded
  3. Pain at 11/18 tender point sites on digital palpation (with enough pressure so that thumb blanches)
85
Q

Clinical presentation of Fibromyalgia

A
  1. CENTRAL (non-nociceptive)chronic pain
  2. Depression
  3. Chronic headache
  4. Irritable bowel syndrome
  5. Chronic fatigue syndrome
  6. Myofascial pain syndrome
86
Q

What gender does fibromyalgia effect

A

Females

87
Q

Risk factors for fibromyalgia

A
  1. Female
  2. Middle age
  3. Low household income
  4. Divorced
  5. Low educational status
88
Q

Where is pain found in fibromyalgia

A
  1. Neck and back
  2. Lower neck in front
  3. Base of skull
  4. Upper edge of breast
  5. Neck and shoulder
  6. Below side bone at elbow
  7. Upper outer buttock
  8. Hip Bone
  9. Just above the knee on inside
89
Q

How is pain in fibromyalgia aggravated

A

Stress
Cold
Activity

90
Q

CNS effect in fibromyalgia

A

Paraesthesiae of hands and feet

91
Q

Fibromyalgia clinical presentations

A
  1. fatigue is extreme after minimal exertion
  2. Non-restorative sleep:
    - Frequent waking during the night
    - Waking unrefreshed
    - Poor concentration and forgetfulness
    - Low mood, irritable and weepy
    - Lack of non-REM sleep causes functional pain
    - Patient is anxious and angry for no reason
92
Q

Differential diagnosis in fibromyalgia

A
  1. Hypothyroidism
  2. SLE
  3. Polymyalgia rheumatic
  4. High calcium
  5. Low Vit D
  6. Inflammatory arthritis
93
Q

Diagnostics in fibromyalgia

A
  1. Pain at 11/18 tender point sites on digital palpation
  2. Thyroid function test (excludes hypothyroidism)
  3. ANA and SaSNA
  4. ESR and CRP raised
  5. Ca and electrolytes (exclude high ca)
  6. VIt D (exclude low Vit D)
  7. Examine patient and CRP (exclude inflammatory arthritis)
94
Q

Treatment in fibromyalgia

A 
1, Educat patient and family: Explain that they have real symptoms but pain doesn't always mean damage (migraine of joints)
2. Avoid unnecessary investigations 
3. Rest pain thermostat:
- correct non-restorative sleep 
- Improve aerobic fitness (tires them)
4. ORAL AMITRYPTILINE - cure depression 
ORAL PREGABALIN (anticonvulsants)
95
Q

How long does it take for ORAL AMIARYPTILINE and ORAL PREGABALIN to function

A

1 month

96
Q

Do NSAIDs and steroids work in fibromyalgia

A

No

97
Q

Red flag signs for cancer

A
  1. Rest pain
  2. Night Pain
  3. Lump present
  4. Loss of function
  5. Neuro symptoms
  6. Unwell and weight loss
98
Q

Why is a CT done for cancer

A
  1. Bone quality and staging
99
Q

MRI scan for cancer

A

Soft tissue reactive changes

100
Q

Bone scan for cancer

A

Skeletal metastases

101
Q

X-Ray for cancer

A
  1. Bone density changes
  2. Zone of transition
  3. Periosteal reaction

Osteoblastoma vs osteosarcoma

102
Q

X-ray in what conditions show Codman’s triangle

A 
Osteosarcoma
Equine's
GCT
Osteomyelitis
Metastases
103
Q

X-Ray in what conditions show sunburst appearance

A

Osteosarcoma and Ewing’s

104
Q

X-ray in what condition shows onion-skin appearance of the bone

A

Ewing’s

105
Q

What type of MRI is used to look at bone pathology

A

T2

106
Q

Three phases of a bone scan

A
  1. Arterial (1 minute)
  2. Blood pooling (capillary dilation)
  3. Delayed (uptake within the bone)

Uses Gamma Camera

107
Q

Ways we can scan for cancer

A
  1. PET-CT
  2. Whole body MRI
  3. T2 MRI
  4. Ultrasound
  5. X-Ray
108
Q

Define a histologically beingn gradient, Low grade malignant and high grade malignant tumour

A
  1. Well defined margins
  2. Progressive growth limited by natural barriers and well defined margin with thin cortical bone
  3. Growth not limited by natural barriers
109
Q 
Where do the following bone tumours present:
Osteosarcoma
Parosteal osteosarcoma
Chondrosarcoma
Giant cel tumours
Chordoma
Adamantinoma
A
  1. Knee
  2. Distal femur
  3. Plevis
  4. Knee
  5. Sacrum
  6. Tibia
110
Q

Clinical presentation of osteoid osteoma

A
  1. Localised pain and self-limiting

Produces Prostaglandin E2

111
Q

What is seen on an X-ray for osteoid osteoma

A

Active reactive bone and nidus

112
Q

Diagnostics for osteoblastoma

A

PAIN
X-ray: Bone destruction surrounded by reactive new bone
Histology: Interlacing trabecular + loose fibrovascular stroma

113
Q

How is osteoblastoma treated

A

Excision with at least a marginal line of excision

114
Q

What is an osteochondroma

A

Metaphysical lesion covered by cartilage cap that grows away from growth plate and stops growing after puberty

115
Q

Clinical presentation of osteochondroma

A

Painless lumps

116
Q

How is osteochondroma treated

A

Excision

117
Q

What are osteosarcomas

A

Spindle cell neoplasms that produce asteroids

118
Q

Name four types of osteosarcomas

A
  1. Intramedullary osteosarcoma
  2. Parosteal osteosarcoma
  3. Periosteal sarcoma
  4. Telangiectatic osteosarcoma
119
Q

What is osteosarcoma associated with

A

p53 mutation

Chondrosarcoma

120
Q

What are intramedullary osteosarcomas

A

These penetrate the cortex forming soft tissue mass

121
Q

How is intramedullary sarcoma diagnosed

A
  1. X-ray: bone formation and destruction seen

2. MRI

122
Q

Where do intramedullary osteosarcomas metastases to

A

LUNGS

123
Q

What causes secondary osteosarcoma

A
  1. Paget’s
  2. Irradiation (radiotherapy)
  3. Fibrous dysplasia
124
Q

Management of osteosarcoma

A
  1. Limb Salvage surgery
  2. Adjuvant Chemotherapy
  3. Chemotherapy pre-op (8-12 weeks)
125
Q

What osteosarcoma has the best prognosis

A

Parosteal

126
Q

Where are endchondromas seen

A

Small bones of hand and feel

127
Q

What are enchondromas

A

Benign lesions that DO NOT destroy cells

128
Q

Diagnostics for echondromas

A
  1. X-ray: Metaphysical popcorn
  2. Bone scan: HOT
  3. Histology: Island of cartilage
129
Q

What is chondroblastoma similar to

A

Giant cell tumour - both metastasise to lungs

GCT has NOT SCLEROTIC RIM on imaging while chondroblastoma does

130
Q

What is fibrous dysplasia

A

Failure to produce lamellar bone

131
Q

What cause fibrous dysplasia

A
  1. Mutation of the GS-alpha protein
132
Q

Diagnostics and treatment for fibrous dysplasia

A
  1. X-ray: Ground glass lesion with sclerotic margin

2. Histology: Chinese alphabet

133
Q

Treatment of fibrous dysplasia

A
  1. Bisphosphonates

2. Curettage and cortical autograft - surgery

134
Q

What is non-ossifying fibroma

A
  1. Diaphysial variant of normal growth - benign
135
Q

Radiographic features of non-ossifying fibroma

A
  1. TO one side of the bone (eccentric)
  2. Metaphysical
  3. Sclerotic rim
  4. Overlying cortex thinned
  5. Lesion based on cortex
  6. CLEAR ZONE OF TRANSITION
136
Q

What are unicameral bone cysts

A
  1. Metaphysical
  2. Purely lytic
  3. Epand the bone symmetrically and border the growth plate
  4. Fallen leaf sign - trabeculations after they fracture
137
Q

Characteristics of Aneurysmal Bone cyst

A

Metaphysical and eccentric

138
Q

Diagnostics of ABC

A
  1. X-ray: Eccentric, lytic and expansile lesion

2. MRI - fluid levels

139
Q

How is ABC treated

A

Simple curettage

140
Q

What are GCTs

A
  1. Locally destructive neoplasms with poorly defined cells
141
Q

Diagnostics for GCT

A
  1. Xrays: Destructive lesion + no sclerotic rim

2. Histology: Multinucleate cells

142
Q

How is GCT treated

A
  1. Curettage, bisphosphonates
143
Q

What are adamantinoma

A
  1. Rare tumour of long bones with pain
144
Q

Diagnostics of adamantinoma

A
  1. Xray: Radiolucent zones interlaced with sclerosis and cortical destruction
  2. Histology: Epithelial cells in fibrous storm
145
Q

How is Adamantinoma treated

A

Wide surgical excision plus reconstruction

146
Q

What four features of a soft tissue could indicate sarcoma

A
  1. Size > 5cm
  2. Deep to the fascia
  3. Enlarging
  4. Painful
147
Q 
Define the following surgical margins:
INtralegional
Marginal
Wide
Radical
A

Intraleisonal: Plane of surgery goes through the tumour
Marginal: Plane of surgery goes through reactive zone of the lesion
Wide: Plane of dissection through normal tissue
Radical: Entire anatomic compartment of the lesion is removed

Year 2 (155 decks)

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