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MSK: Part 5 Flashcards

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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
How does Vit D cause osteomalacia
1. Vit D is fat soluble so GI disease can result in malabsorption 2. Poor diet 3. Lack of sunlight
26
How does renal failure cause osteomalacia
1. Inadequate conversion of 25-hydroxy vit D to 1,24-hydroxy vit D
27
How do drugs cause osteomalacia
Anticonvulsants induce liver enzymes leading to increased breakdown of 25-hydroxy Vit D Rifampicin
28
How do liver diseases cause osteomalacia
Reduce hydroxylation of Vit D to 25-hydroxy Vit D (cirrhosis)
29
Clinical presentation of osteomalacia
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
30
Clinical presentation of rickets
1. Growth retardation 2. Knock knees, bowed legs 3. Widened epiphyses at the wrists 4. Hypocalcaemic tetany may occur (intermittent muscular spasms)
31
Diagnosis of rickets and osteomalacia
1. FBC 2. Biopsy 3. X-ray
32
FBC test in osteomalacia
1. Low ca and phosphate 2. Raised serum alkaline phosphatase 3. Elevated parathyroid hormone 4. Low 25=hydroxy vit D
33
Biopsy in osteomalacia
Shows incomplete mineralisation
34
X-ray test in osteomalacia
1. Shows defective mineralisation | 2. Looser's pseudo fractures (low density bands extending from cortex inwards in the shafts of the long bones)
35
Treatment of osteomalacia
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)
36
What diseases are associated with Vit D insufficiency
Typ 2 diabetes, several cancers, CVD
37
What is Acute disc disease
Prolapse of intervertebral disc results in ACUTE BACK PAIN (LUMBARGO)
38
What aged people are effected by acute disc disease
Younger people as disc degenerates with age and in the elderly it is no LONGER ABLE TO PROLAPSE
39
What causes SCIATICA (Acute disc disease in elderly)
Compression (as opposed to prolapse) of the nerve root by osteophytes in the lateral recess of the spinal canal
40
Clinical presentation of acute disc disease
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
41
Where is root lesson in S1 felt
Buttock down back of thigh to ankle
42
What reflex is lost in S1 root lesion
Ankle Jerk
43
What other sign is found in S1 root lesions
Diminished straight leg raising
44
Pain felt in L5 root lesion
1. Buttock to lateral aspect of leg and top of foot
45
What reflex is lost in L5 root lesion
None
46
Other signs of L5 root lesions
DIMINISHED STRAIGHT LEG RAISING
47
Pain in the L4 root lesions
1. LATERAL ASPECT OF THIGH TO MEDIAL SIDE OF CALF
48
What reflex is lost in L4 root lesions
Knee Jerk
49
Other signs of L4 root lesions
1. Positive femoral stretch test
50
Diagnosis of Acute Disc Disease
1. X-rays NORMAL | 2. MRI
51
How is Acute Disc Disease treated
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)
52
What is Chronic Disc Disease
Associated with degenerative changes in the lower lumbar discs and facet joints
53
What causes pain in chronic disc damage
Aggravated by movement
54
Describe distribution of pain in CDD
1. Sciatic radiation in the buttocks radiating into posterior thigh
55
Is there a cure to chronic disc disease
Long-standing with no cure
56
Surgical intervention for CDD
Fusion at single identifiable level if possible and decompression of affect nerve root
57
Treatment for CCD
1. NSAIDs 2. Physiotherapy 3. Weight reduction
58
Describe pain in Primary and secondary bone tumours
1. Unremitting and worst at night
59
When are primary tumours of the bone seen
1. YOUNG Osteosarcomas Fibrosarcomas Chrondromas Ewing's tumour
60
Where can bone tumours metastasise to
1. Lungs 2. Breast 3. Prostate (often osteosclerotic) 4. Thyroid 5. Kidney
61
What do bone tumour symptoms rely on
Anatomical position of the tumour with local bone pain
62
What are systemic symptoms
Malaise, pyrexia as well as aches and pains occur and occasionally related to hypercalcaemia
63
Diagnostics of Primary and Secondary tumours
1. Skeletal isotope scan 2. X-rays 3. MRI 4. FBC
64
What would skeletal isotope scan show
Bony metastases as 'hot' areas BEFORE radiological changes occur
65
What would X-rays show in tumours
1. Metastasis as osteolytic areas with bony destruction | 2. Osteosclerotic (increased bone density) metastases
66
What defines osteolytic areas
Lost greater than 60% bone density
67
What do MRIs show in tumours
1. Vertebral lesions
68
FBC results in primary and secondary tumours
1. SEURM ALKALINE PHOSPHATASE raised 2. HYPERCALACAEMIA 3. PSA raised in prostatic metastases
69
How are bone tumours treated
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 5. Bisphosphanates (ALDENRONATE)
70
Name some primary bone tumours
Osteosarcoma Ewing's sarcoma Chrondrosarcoma
71
Peak onset of osteosarcoma
15-19 yrs
72
What disease is osteosarcoma associated with
Paget's
73
Where does osteosarcoma occur
Metaphases of long bones
74
Common sites of osteosarcomas
Knees or humerus
75
Clinical presentation of osteosarcomas
Painless tumour
76
Metastases of osteosarcomas
Destroys bone and spreads into surrounding tissues and rapidly metastasises to the LUNG
77
Diagnostics of osteosarcomas
X-ray: 1. Bone destruction and formation 2. Soft tissue calcification produces sunburst appearance
78
What cells cause Eqing's sarcoma
Mesenchymal stem cells
79
Onset of Ewing's sarcoma
15 years
80
Clinical presentation of Ewing's sarcoma
``` 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
What is chrondrosarcoma
Cancer of the cartilage
82
Clinical presentation of chrondrosarcoma
1. Dull, deep pain | 2. Affected area is swollen and tender
83
Common sites effected in chondrosarcoma
1. Pelvis 2. Femur 3. Humerus 4. Scapula 5. Ribs
84
Define fibromyalgia
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
Clinical presentation of Fibromyalgia
1. CENTRAL (non-nociceptive)chronic pain 2. Depression 3. Chronic headache 4. Irritable bowel syndrome 5. Chronic fatigue syndrome 6. Myofascial pain syndrome
86
What gender does fibromyalgia effect
Females
87
Risk factors for fibromyalgia
1. Female 2. Middle age 3. Low household income 4. Divorced 5. Low educational status
88
Where is pain found in fibromyalgia
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
How is pain in fibromyalgia aggravated
Stress Cold Activity
90
CNS effect in fibromyalgia
Paraesthesiae of hands and feet
91
Fibromyalgia clinical presentations
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
Differential diagnosis in fibromyalgia
1. Hypothyroidism 2. SLE 3. Polymyalgia rheumatic 4. High calcium 5. Low Vit D 6. Inflammatory arthritis
93
Diagnostics in fibromyalgia
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
Treatment in fibromyalgia
``` 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
How long does it take for ORAL AMIARYPTILINE and ORAL PREGABALIN to function
1 month
96
Do NSAIDs and steroids work in fibromyalgia
No
97
Red flag signs for cancer
1. Rest pain 2. Night Pain 3. Lump present 4. Loss of function 5. Neuro symptoms 6. Unwell and weight loss
98
Why is a CT done for cancer
1. Bone quality and staging
99
MRI scan for cancer
Soft tissue reactive changes
100
Bone scan for cancer
Skeletal metastases
101
X-Ray for cancer
1. Bone density changes 2. Zone of transition 3. Periosteal reaction Osteoblastoma vs osteosarcoma
102
X-ray in what conditions show Codman's triangle
``` Osteosarcoma Equine's GCT Osteomyelitis Metastases ```
103
X-Ray in what conditions show sunburst appearance
Osteosarcoma and Ewing's
104
X-ray in what condition shows onion-skin appearance of the bone
Ewing's
105
What type of MRI is used to look at bone pathology
T2
106
Three phases of a bone scan
1. Arterial (1 minute) 2. Blood pooling (capillary dilation) 3. Delayed (uptake within the bone) Uses Gamma Camera
107
Ways we can scan for cancer
1. PET-CT 2. Whole body MRI 3. T2 MRI 4. Ultrasound 5. X-Ray
108
Define a histologically beingn gradient, Low grade malignant and high grade malignant tumour
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
``` Where do the following bone tumours present: Osteosarcoma Parosteal osteosarcoma Chondrosarcoma Giant cel tumours Chordoma Adamantinoma ```
1. Knee 2. Distal femur 3. Plevis 4. Knee 5. Sacrum 6. Tibia
110
Clinical presentation of osteoid osteoma
1. Localised pain and self-limiting Produces Prostaglandin E2
111
What is seen on an X-ray for osteoid osteoma
Active reactive bone and nidus
112
Diagnostics for osteoblastoma
PAIN X-ray: Bone destruction surrounded by reactive new bone Histology: Interlacing trabecular + loose fibrovascular stroma
113
How is osteoblastoma treated
Excision with at least a marginal line of excision
114
What is an osteochondroma
Metaphysical lesion covered by cartilage cap that grows away from growth plate and stops growing after puberty
115
Clinical presentation of osteochondroma
Painless lumps
116
How is osteochondroma treated
Excision
117
What are osteosarcomas
Spindle cell neoplasms that produce asteroids
118
Name four types of osteosarcomas
1. Intramedullary osteosarcoma 2. Parosteal osteosarcoma 3. Periosteal sarcoma 4. Telangiectatic osteosarcoma
119
What is osteosarcoma associated with
p53 mutation | Chondrosarcoma
120
What are intramedullary osteosarcomas
These penetrate the cortex forming soft tissue mass
121
How is intramedullary sarcoma diagnosed
1. X-ray: bone formation and destruction seen | 2. MRI
122
Where do intramedullary osteosarcomas metastases to
LUNGS
123
What causes secondary osteosarcoma
1. Paget's 2. Irradiation (radiotherapy) 3. Fibrous dysplasia
124
Management of osteosarcoma
1. Limb Salvage surgery 2. Adjuvant Chemotherapy 3. Chemotherapy pre-op (8-12 weeks)
125
What osteosarcoma has the best prognosis
Parosteal
126
Where are endchondromas seen
Small bones of hand and feel
127
What are enchondromas
Benign lesions that DO NOT destroy cells
128
Diagnostics for echondromas
1. X-ray: Metaphysical popcorn 2. Bone scan: HOT 3. Histology: Island of cartilage
129
What is chondroblastoma similar to
Giant cell tumour - both metastasise to lungs GCT has NOT SCLEROTIC RIM on imaging while chondroblastoma does
130
What is fibrous dysplasia
Failure to produce lamellar bone
131
What cause fibrous dysplasia
1. Mutation of the GS-alpha protein
132
Diagnostics and treatment for fibrous dysplasia
1. X-ray: Ground glass lesion with sclerotic margin | 2. Histology: Chinese alphabet
133
Treatment of fibrous dysplasia
1. Bisphosphonates | 2. Curettage and cortical autograft - surgery
134
What is non-ossifying fibroma
1. Diaphysial variant of normal growth - benign
135
Radiographic features of non-ossifying fibroma
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
What are unicameral bone cysts
1. Metaphysical 2. Purely lytic 3. Epand the bone symmetrically and border the growth plate 2. Fallen leaf sign - trabeculations after they fracture
137
Characteristics of Aneurysmal Bone cyst
Metaphysical and eccentric
138
Diagnostics of ABC
1. X-ray: Eccentric, lytic and expansile lesion | 2. MRI - fluid levels
139
How is ABC treated
Simple curettage
140
What are GCTs
1. Locally destructive neoplasms with poorly defined cells
141
Diagnostics for GCT
1. Xrays: Destructive lesion + no sclerotic rim | 2. Histology: Multinucleate cells
142
How is GCT treated
1. Curettage, bisphosphonates
143
What are adamantinoma
1. Rare tumour of long bones with pain
144
Diagnostics of adamantinoma
1. Xray: Radiolucent zones interlaced with sclerosis and cortical destruction 2. Histology: Epithelial cells in fibrous storm
145
How is Adamantinoma treated
Wide surgical excision plus reconstruction
146
What four features of a soft tissue could indicate sarcoma
1. Size > 5cm 2. Deep to the fascia 3. Enlarging 4. Painful
147
``` Define the following surgical margins: INtralegional Marginal Wide Radical ```
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

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