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Conditions + definitions > MSK - week 1 > Flashcards

MSK - week 1 Flashcards

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1
Q

What are the three joint types?

A

Fibrous
Cartilainous
Synovial

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2
Q

What are the examples of fibrous joints

A

Cranial sutures
Interossous membranes
Peridontal ligaments (teeth)

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3
Q

What are the types of cartiliganous joints?

Give an example of both

A

Primary - only hyaline
– Synchondrosis (growth plates)
Secondary - hyaline and fibrocartilage
–Symphysis - intervertebral discs

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4
Q

What are the common features of a synovial joint?

A

Synovial cavity
Fibrous capsule
Synovial membrane
Articular cartilage

May contain:
Articular discs
Ligaments
Bursea (fluid filled sacs)

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5
Q

What are the types of synovial joints?

A 
Plane
Hinge
Pivot
Condylar
Saddle
Ball and socket
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6
Q

What contributes to joint stability?

A

Shape of articulating surfaces
Capsule + ligaments
Muscles

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7
Q

What is the arrangement of articular cartilage?

A

Made of two levels, superficial and transitional.
Superficial - made up of flattened chondrocytes that produce collagen and glycoproteins
Transitional - round glycoproteins producing protoglycans
Made up of at least 75% water so uncompressible

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8
Q

What are glycoproteins?

A

proteins to which oligosaccharide chains are attached, i.e. more a protein than a carbohydrate!
IE lubricin

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9
Q

What are proteoglycans?

A

proteins that are heavily glycosylated (= a protein core to which one or more GAGs attach), i.e. tend to be more carb than protein!
IE aggrecan

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10
Q

What are Glycosaminoglycans (GAGs)?

A

long unbranched polysaccharides, which are highly polar and thus attract water
IE hyaluronic acid

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11
Q

How does cartilage get its nutrients?

A

Gets it from the synovial fluid (in the synovial membrane)

Not from blood supply as it’s avascular

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12
Q

Describe the synovium.

A

Contains synoviocytes which produce the synovial fluid
Has no epithelial lining and a rich capillary network
This facilitates direct exchange of oxygen + other nutrients

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13
Q

What are the differences between the types of synoviocytes?

A

Type A - look similar to macrophages
Remove debris
Contribute to synovial fluid production

Type B - fibroblast like
Main producer of synovial fluid

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14
Q

What is synovial fluid + functions?

A

A viscous fluid present in small volumes with rapid turnover

Lubricates joints + exchanges nutrients for cartilage

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15
Q

What are bursae?

A

Sacks around joints filled with liquid to reduce friction

Can lead to bursitis if inflammed

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16
Q

How does aging affect joints?

A

Viscosity of the synovial fluid increases
Leads to slower joint movements and reduced lubrication

Water content of cartilage decreases, reducing shock absorption

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17
Q

How does osteoarthritis affect the bones?

A

Narrowing vertebral disks

Bone spurs

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18
Q

What is sarcoma?

A

A malignant tissue from connective tissues
Spreads along fascial planes
Haematogenous spread to lungs

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19
Q

Describe bone tumours

A

Benign tumours common, although malignant is rare

Tend to be more secondary tumours

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20
Q

What are the bone forming tumours? (malignant and benign)

A

Benign - osteoid osteoma
Osteoblastoma

Malignant - osteosarcoma

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21
Q

What are the cartilage forming tumours?

A

Benign - enchondroma
Osteochondroma

Malignant - chondrosarcoma

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22
Q

What are fibrous tissue tumours?

A

Benign - firoma
Malignant - fibrosarcoma
Malignant fibrous histiocytoma (MFH)

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23
Q

What are the vascular tissue tumours?

A

Benign - haemangioma
Aneursmal bone cyst

Malignant - angiosarcoma

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24
Q

Examples of adipose tissue tumours

A

Benign- lipoma

Malignant - liposarcoma

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25
Examples of marrow tissue tumours
Malignant Ewings sarcoma Lymphoma Myeloma
26
What invesitgations are pertinent with suspected bone lesions?
Plain X-rays
27
What are the differences in x-rays for aggressive and non-aggresive bone tumours?
Aggressive have less well defined transition zones Cortical destruction is a sign of malignancy
28
What are isotop bone scans?
Used for staging of skeletal mets Frequently negative in myeloma Not great at distinguishing malignant from benign as benign also demonstrate increased uptake
29
What are the cardinal features of a primary bone tumour?
Pain either unexplained, at night or increasing in severity With a deep seated boring nature Difficulty weight bearing Deep swelling
30
Name 3 examples of primary bone tumours
Osteosarcoma Ewings sarcoma Chondrosarcoma
31
What are the clinical features of osteosarcoma?
Pain Loss of function ``` Swelling Pathological fracture Joint effusion Deformity Neurovascular effects Systemic effects of neoplasia ```
32
What is the pain like in osteosarcoma?
Pain increasing in nature, not related to exercise Deep boring character worse at night Analgesics eventually inneffective
33
What characterises loss of function in osteosarcoma?
Limp Reduced joint movement Stiff back - especially in a child
34
What are the clinical features of swelling in osteosarcoma?
Generally difuse in malignancy Near end of long bone Enlargement can be rapid Warmth over swelling + venous congestion = active
35
Why is MRI the investigtion of choice for suspected osteosarcoma?
``` Very sensitive Very good for showing: Intraosseous AND extraosseous (soft tissue) extent of tumour Can show joint involvement Skip metastesis Epiphyseal extension ``` Good for determining resection margins
36
Treatment for osteosarcoma?
Chemo Surgery Radiotherapy Goal is to make free of disease
37
What are the suspicous signs of a soft tissue tumour?
Deep (deeper than deep fascia) Subcutaneous tumours greater than 5cm Rapid growth, hard, craggy or non-tender If any of these refer to specialist tumour centre
38
What are the common sites causing bone metastases?
``` Breast Melanoma Lung Prostate Kidney Thyroid GI tract ``` Most common site after lung and liver for secondary tumours
39
What are the common bones to develop a secondary tumour?
``` Order: Vertebrae Proximal femur Pelvis Ribs Sternum Skull ```
40
How can you prevent pathological fractures?
Early chemotherpay | Prophylactic internal fixation based on Mirel's scoring system. 8+ indicates fixation
41
What is Mirel's scoring system?
Picture needed
42
What is osteoarthritis?
``` Most common form of joint problem Consists of "Tear, flare and repair" -Trauma and mechanical imbalance -Causes inflammation and pain -Repair processes around joint ```
43
What are the biomechanical factors of osteoarthritis?
``` Abnormal anatomy Intra-articular fracture Ligament rupture Meniscal injury Occupation (farmers/football players Persistent heavy physical activity Elite running Obesity ```
44
What events happen due to inflammation in the joints?
Synovial hypertophy Subocondral changes Joint effusion
45
What is the pathogensis of primary OA?
Wear + tear - joint use over the years causes degeneration in cartilage
46
What is the pathogensis of secondary OA?
Due to increased load that causes joint microtrauma Increased load can be due to weight gain (obesity) or instability / misalignment of joint This can arise from either muscle weakness, ligament injury or abnormal anatomy
47
How do you diagnose OA?
A patient who is 45+ with activity related joint pain | With morning joint related stiffness being absent or lasting less than 30 minutes
48
What are the differentials of OA?
Gout Other inflammatory arthritides Septic arthritis Malignancy
49
What are the non-pharmacological treatments for OA?
Thermotheraphy Electrotherarpy Aids/devices Manual therapy
50
What are the pharmological treatments of OA?
Oral analgesia - paracetamol, NSAIDs | Topical - NSAIDs, capsaicin
51
When do you refer a patient with OA for surgery?
Substantial impact on QOL
52
What are the differentials for a knee injury?
``` Fracture Acute/chornic degnerative joint disease Meniscal injury Ligament injury Tendon injury ```
53
What are the important questions in a knee history?
Sport/recreation? Or whilst resting/at work? Activity at the time - jumping? Sports tackle Energy at time of impact - how fast/heavy? Chronology - was it quick or slow onset For swelling, quick onset means blood Any previous injuries in same spot? Pop/crack heard?
54
What are the characteristics of a meniscal injury?
Often caused by a twisting movement on a loaded fixed knee Results in painful squelch Slow to swell (quicker in young though) Painful to bear weight Can result in locked knee - unable for even physician to move
55
What are the characteristics of an ACL tear?
Caused by forward momentum against a fixed leg with or without rotation Loud pop heard at time Quick to swell Able to bear weight
56
What are the characteristics of collateral tears?
Lateralised pain Feel of crack with sharp pain No or minimal effusion Bruising localised to one side
57
What are the important things to look for in a knee examination?
scars, brusing, swelling | Joint line irregularities
58
What are the important things to feel for in a knee examination
``` Effusion Crepitus Heat Tenderness Tissue lumps/defects ```
59
What are the important movements in a knee examination?
Passive/active Straight leg raise Range of movement Ligament + dyanmic testing
60
What are the indications for knee surgery?
``` Failure of conservative treatment Demands of work/sport Problems with daily activities Prevention of further joint injury Prevention of falls ```
61
What are the non-surgical managements for acute knee injuries?
Restoration of function Physio Analgesia Swelling reduction
62
What are the surgeries available for a meniscal tear?
Meniscal repair Partial menisectomy Meniscal transplant
63
What are the zones in a meniscus, what is their significance?
Red to white, with red/white inbetween Indicates the vascularity of the meniscus (more vascular on lateral side) Indicates how well it will heal And thus how successful surgery would be
64
Who is eligible for meniscal surgery?
Young or sporty Fresh tears - less than 3 months Health meniscus with damage in red or red/white zone, NOT in white zone
65
What is the treatment for anterior cruciate ligament issues?
Rehab or reconstruction
66
When is reconstruction indicated?
Prevention of further injury Helping to get back to work/sport To prevent osteoarthritis
67
What is osteomyelitis?
Infection in the bone
68
What is septic arthritis?
Infection in the joint
69
Who is most likely to get acute osteomyelitis?
Children, boys more than girls Often with history of minor trauma Associated with diabetes, immunocompromised/steroids, rheumatic arthritis, sickle cell
70
What are the types of osteomyelitis?
Acute Chronic Can be specific or non-specific causation
71
Who is affected by acute osteomyelitis?
Mostly children, favouring boys with history of trauma (minor trauma) Assocaited with diabetes, Rheumatic arthritis, steroid/immune compromised, sickle cell
72
How is acute osteomyelitis spread?
Haematogenous spread in children/elderly Local spread from contiguous site of infection (open fracture, joint replacement etc) Secondary to vascular insufficiency
73
What are the sources of infection in acute osteomyeltits?
Infants - infected umbilical cord Children - boils, tonsilitis, skin abraisons Adults - UTI, arterial line
74
What are the most likely organisms in an infant for acute osteomyelitis?
Staph A Group B streptococci E coli
75
What are the most likely organisms to cause acute osteomyelitis in older children?
Staph A Strep pyogenes Haemophilus influenzae
76
What are the most likely organisms to cause acute osteomyelitis in adults?
Staph A Coagulase-negative staphylococci (prostheses) Propionibacterium (prostheses) Streptococcus pyogenes (infective arthritis) Mycobacterium tuberculosis Pseudomonas aerginosa (especially in penetrating foot injury)
77
What other organisms can sometimes cause acute osteomyeltits?
``` Brucella in butchers Mycobacterium marinum in fishermen/filliters Proteus mirabilis Candida in immunocompromised Diabettic foot - mixed anaerobes Vertebral osteomyelitis - S. Aureus, TB Sickle cell - salmonella STD - gonococcus ```
78
What bones are likely to be affected?
``` Distal femur Proximal tibia Proximal humerus Hip Elbow (radial head) ```
79
What are the clinical features in an infant with acute osteomyeltits?
``` Minimal signs or may be very ill Fail to thrive Possible drowsiness /irritation Metaphyseal tenderness/swelling Positional change Decreased range of movement ``` Most common around knee
80
What is the pathology of acute osteomyelitis?
Trauma causes acute inflammation and vascular stasis Pus forms and bone reformation occurs If infection gets into bone whilst reforming granulation tissue walls off diseased bone tissue Bacterial proliferation resultsin further destruction + potential abscess formation
81
What are the clinical features of acute osteomyeltis in a child?
``` Severe pain Reluctant to move (non weight bearing, neighboring joints flexed) May be tender fever + tachycardia Malaise Toxaemia ```
82
What are the clinical features of osteomyelitis in an adult? (primary)
``` Backache (most primary OM seen in thoracolumbar spine) History of UTI/urological procedure Elderly Diabetic Immunocompromised ```
83
What are the clinical features of osteomyelitis in an adult (secondary)?
More common Often after open fracture Mixed organisms
84
How do you blood tests are used to diagnose acute osteomeylitis?
``` History + clinical exam (pulse+temp) FBC + diffuse WBC ESR +CRP (inflamm markers) 3 blood cultures U&Es ```
85
What are the differentials for acute osteomyelitis?
``` Acute septic arthritis Trauma (fracture, dislocation etc) Acute inflammatory arthritis Transient synovitis Soft tissue infection (cellulitis, necrotising fasciitis, gas gangrene, txic shock syndrome) ```
86
What are the rare differentials for acute osteomyelitis?
Sickle cell crisis Gaunchers disease Rheumatic fever Haemophillia
87
What investigations are used to diagnose acute osteomyelitis?
``` X-Ray US Aspiration Isotope bone scan Labelled white cell scan MRI ```
88
What is shown on an x-ray in acute osteomyelitis?
Normal for first 10-14 days Then shows late metaphysial destruction Latermedullay changes Later, osteoneceosis and ner periosteal bone
89
What is the process for microbial identification in acute osteomyleitis?
Blood cultures in haemataogenous OM and septic arthritis Bone biopsy Tissue/swabs from 5 sites around implant in prosthetic infection
90
How do you treat acute osteomyelitis?
``` Rest + splintage Supportive for pain + dehydration Antibiotics IV for first week, oral thereafter 4-6wks - treat before results empirically ```
91
What are the indications for surgery in acute osteomyeltis ?
Aspiration of pus Abscess drainage Debridement of dead/infected tissue Infected joint replacements
92
What are the complications of acute osteomyelitis?
Sepitcemia Death ``` Metastatic infection Pathological fracture Septic arthritis Altered boine growth Chronic osteomyelitis ```
93
What is subacute osteomyelitis?
osteomyelitis where the host has resistance Bacteria has lower virulance Or use of antibiotics Prolonged by lessened symptoms
94
What are the clinical features of subacute osteomyelitis?
``` long history (weeks-months) Variable symptoms Pain, limp Local swelling/warmth Tenderness ```
95
What are the differentials of subacute osteomyelitis?
Ewings sarcoma Osteoid oseoma TB
96
What is brodie's abscess?
An abcess that forms in Subacute osteomyelitis Painful limb with no systemic features Older children
97
What is seen in X-ray of brodie's abcess?
Luency in long bone metaphysis
98
What are the differntials of brodie's abscess?
Ewings sarcoma
99
What is the treatment of brodie's abcess?
Curettage surgery
100
What are the investigations in subacute osteomyelitis?
X-ray Bone scan Biopsy
101
How do you treat subacute osteomyelitis?
Prolonged course of antibiotics | Surgery - curettage
102
What leads to chornic osteomyelitis
May follow acute osteomyelitis May start de novo Either after operation or open fracture Or in immunocomprmised patients - immunosuppressed, diabetics, elderly, drug abusers Repeated breakdown of healed wounds can contribute
103
What are teh causative organisms of chronic osteomyelitis?
``` Often mixed Normally same organism for each flareup Staph A E coli Strep pyogenes Proteus ```
104
What is chronic osteomyelitis?
Chrnoically discharging sinus attached to underlying bone Contains dead bone tissue due to infection (sequestrum) Surrounded by granulation tissue and layer of new bone growth
105
What is the pathology of chronic osteomyelitis?
Due to insult cavity occurs which becomes infected Dead bone leads to abcess + forming of new bone Picture of chornic inflammation
106
How do you treat chronic osteomyelitis?
``` Long term antibiotics Erradicate bone infection (multiple surgeries) Treat soft tissue problems Correct deformity if present Reconstruction? Amputation? ```
107
What are the complications of chronic osteomyelitis?
``` Chronically discharging sinus + flare ups Ongoing infection Patolgical fractures Growth distubrance Squamous cell carcinoma (0/07%) ```
108
What is the route of infection in acute septic arthritis?
Direct invasion (pentrating wound, intra-articular injury) Eruption of bone abscess Haematogenous
109
What are the common caustative agents of acute septic arthritis?
Staph A H. influenzae Strep pyogenes Ecoli
110
What is the pathology of acute septic arthritis?
Acute synovitis with purulent joint effusion Articular cartilage attacked by bacterial toxin/cellular enzyme Complete destruction of articular cartilage
111
What are the possible outcomes (sqeulae) of acute septic arthritis?
Complete recover Partial loss of articular cartilage --> OA Fibrous or bony ankylosis
112
What is the clinical picture in a neonate with acute septic arthritis?
Irritability Resitant to movement Ill
113
What is the clinical picture in a child with acute septic arthritis?
Acute pain in single large joint Reluctant to move joint (any movment) Increased temp + pulse Increased tenderness
114
What is the clinical picture of an adult with acute septic arthritis?
Often superficial joint Rare in healthy adult Most common after joint replacement
115
How do you investigate acute septic arthritis?
FBC, WBC, ESR, CRP, blood culture X-ray US Aspiration
116
How rare is an infected joint replacement?
``` 1.1-5% However deadly (staph A) ```
117
What are the differential diagnoses of acute septic arthritis?
``` Acute osteomyelitis Trauma Irritabile joint Haemophilia Rheumatic fever Gout Gauchers disease ```
118
How do you treat acute septic arthritis?
General supportive measures Antibiotics for 3-4 weeks Surgical drainage in ermgency (ie pus)
119
What are the three types of TB joint infections?
Extra-articular (epipihyseal/haemodynamic marrow) Intra-articular (large joints) Vertebral body
120
How many patients have multiple TB bone infection lesions?
1/3
121
What are the clinical features of TB bone/joint infections?
``` Insidious onset History of TB contact Pain (night!) swelling, weight loss Joint swelling Decreased range of movenet Ankylosis Deformity ```
122
What is the pathology of TB bone/joint infections?
Primarily in lung This spreads, sometimes to bones Forms tuberculos granuloma - early (vascular ) and chronic (avascular) Chronic develops obliterative endarteritis so difficult to treat with antibiotics
123
How do you diagnose TB joint/bone infection?
Long history with single joint involvement Marked thickening of synovium Marked muscle wastage Periarticular osteoporosis
124
How do you investigate TB joint/bone infection?
``` FBC, ESR Mantoux test Sputum/urine culture Xray Joint aspiration and biopsy ```
125
What does the bone x-ray show in joint/bone TB infection?
Soft tissue swelling Periarticular ostepaenia Articular space narrowing
126
What tests are done on aspirated fluid in a TB joint/bone infection?
AAFB (10-20% ID rate) | Culture (50% positive)
127
What are the differentials of TB joint infection?
Transient synovitis Monoarticular RA Haemorrhagic arthritis Pyogenic arthritis
128
What is the treatment regime in TB joint/bone infection? (note, differs from usual)
8 weeks Rifampicin Isoniazid Ethambutol Then 6-12 months Rifampicin Isoniazid Rest + splintage

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