MSK wk4 Flashcards
What does an osteoblast do?
Builds bone
What does an osteoclast do?
Deconstructs bone
What is pagets bone disease?
A localised disorder of bone turnover
Increased bone resorption followed by increased by increased bone formation
However, disorganised placement
Bigger, less compact, more vascular and more susceptible to deformity and fracture
Deep pulsating pain
What is the genetic component of Paget’s disease?
SQSTMI gene
15-30% cases are familial
What is the suspected environmental trigger of pagets disease?
Possible chronic viral ingection within osteoclast
What are the symptoms of paget’s disease?
Over 40 Bone pain Bone deformity Excessive hear over pagetic bone Neurological problems such as nerve deafness
What is the presentation of paget’s disease?
Isolated elevation of serum alkaline phospjatase Bone pain + local heat Bone deformity/fracture Hearing loss Rarely osteosarcoma in bone
How do you treat Paget’s disease?
Nothing if asymptomatic
Do not treat on raised alkaline phosphatase alone
IV bisphosphonate therapy
One off therapy of zoledronic acid
What is rickets/osteomalacia?
Severe nutritional Vit D/calcium deficiency results in insuficient mineralisation
Rikets in children; osteomalacia in adults
What are the symptoms of rickets?
Stunted growth Fontanelles in skull don't fuse so enlarged head Enlarged abdomen Bent legs Growth plates enlarged - abnormal joints More common in darker skin Failure to thrive
What are the symptoms of osteomalacia?
Microfractures
Never get through cortex
Bone pain
Muscle weakness
Increased fall risk
What is osteogeneis imperfecta?
Connective dissue genetic disorder
Characterised by fragile bones - fracture in acts of daily life
Other non-bone features as defect in type 1 collagen
Large clinical range (even within families)
How many types of osteogensis imperfecta?
8, although only 4 common
Type 1 - milder form - when child starts to walk
Type 2 - lethal by age 1
Type 3 - progressive deforming with severe bone dysplasia and poor growth
Type 4 - similar to type 1 but more severe
What are the other features of osteogensis imperfecta?
Growth deficincy Defective bone formation Hearing loss Blue sclera (eyes etc very obvious) Scoliosis/barrel chest Ligamentous laxity Easy bruising
How do you manage osteogenesis imperfecta?
Treat all fractures
Medical - IV bisphosophates
Social - educational and social adations
Genetic counselling
What is osteoporosis?
Metabolic bone characterised by low bone mass and micro architectural deterioation of bone tissue leading to enhanced fragility + fracture risk
What is Q fracture?
Program with variables to predict risk of fracture within age 30-85 in men and women
What is a DXA scan?
Scan that calculates bone density
Along with a T score - standard deviations against the norm
What are the endocrine causes of osteoporosis? (secondary osteoporosis)
Thyrotoxicosis Hyper/hypo parathyroidism Cushings Hyperprolactinaemia Hypopituitarism Low sex hormone levels
What are the rheumatic causes of secondary osteoporosis?
Rheumatoid arthritis
Ankylosing spondylitis
Polymyalgia rhuematica
What are the gastroenterologycauses of secondary osteoporosis?
Inflammatory diseaes (UC/crohns)
Liver diseaes - PBC, CAH, alcoholic/viral cirrhosis
Malabsorption
What medications cause osteoporosis?
Steroirds PPI Enzyme inducting antiepipleptic medications Aromatase inhibitrs GnRH inhibitors Warfarin
How do you prevent osteoporotic fractures?
Minimise risk factors
Ensure good calcium and vitamin D
Fall prevention strategies
Medications
What medications are used for osteoporosis?
HRT (best before early 60s/late 50s)
Selective oestrogen modulator (raloxifene)
Bisphosponates! Normal first line
Denosumab
What are the side effects of HRT?
Increased risk of blood clots
Increased risk of breast cancer of breast cancer with extended use into late 50s/early 60s
Increased heart disease risk/stroke if used after large gap from menopause
What are the side effects of selective osestrogen receptor modulator (raloxifene)?
Endometrium cancer. Therefore limited to 5 yr use
What are the negative effects of SERMs?
Hot flushes if taken close to menopause
Increased clotting
Lack of protection at hip site
What are the limitations of bisphosponates?
Adequate renal function needed
Adequate calcium/vit D levels
Good dental health advised
ONLY work in osteoporosis
What is the MOA of bisphosponates?
Bind to calcium
Inert until osteoclast comes up
Poisons osteoclast - and dies
What are the side effects of bisphosponates?
Oesophagitis Iritis/uveitis Not same in eGFR less than 30 Atypical demorla shaft fractures Osteonecrosis Jaw
What is denosumab?
Monoclonal antibodiy against RANKL
Reduces osteclatic bone resoprtion
What are teh side effects of denosumab?
Allergy/rash
Symptomatic hypogylcaemia if given when vit D deplete
What is teriparatide?
An analogue of parathyroid hormone
Only anabolic treatment for bone
What are the side effects of teriparatide?
Injection site irritation
Rarely - hypercalcaemia
Allergy
Only one treatment course otherwise osteosarcoma
What are the different connective tissue diseases?
Systemic Lupus Erythematous (SLE) Scleroderma Sjogren's Syndrome Auto-Immune Myositis Mixed Connective Tissue Disease
What are the types of systemic vasculitis?
Giant Cell Arteritis
ANCA associated vasculitis:
Granulomatosis Polyangiitis (Wegner’s Granulomatosis)
Microscopic Polyangiitis
Eosinophilic Granulomatosis Polyangiitis (Churg-Strauss Granulomatosis)
What are the types of multi-system autoimmune conditions?
Connetive tissue diseases
Systemic vasculitis
What is the process for diagnosing multi-system autoimmune conditions?
Cardinal features in history/exam Immunology Imaging Tissue Exclusion of differentials
What are the mimics of multi-system autoimmune conditions (something that presents with multiple systems at once)?
Drugs (cocaine, minocycline
Infection (HIV, Endocarditis, Hep, TB)
Malignancy (lymphoma)
Cardiac myxoma
Cholesterol emboli
Scurvey
What are the common patterns of SLE (lupus)?
4+ of: Malar rash (butterfly rash) Discoid rash Photosensitivty Oral ulcers Arthritis Serositis Renal Neurological Haematological Immunological ANA
Who is affected by SLE (Lupus)?
Young females
Women 9:1 compared to men
Young (20% before 16, 65% before 16-55)
Afro-caribbeans >asian > caucasian
What is the difference on X-ray between lupus arthritis and rheumatoid arthritis?
In rheumatoid arthritis damage seen on x-ray
Lupus - only ligaments softened (reversible)
What are the kidney involvement signs of lupus ?
Blood + protein in urine dipstick
What is scleroderma?
Thickening of skin - top layer of skin 5x thicker than it should be
Who is affected by scleroderma?
Girls 3:1 Middle aged (30-50)
What are the groups of scleroderma?
Morphea
Limited
Diffuse
What is the morpea group of scleroderma?
No complications beyond cosmetic
What s the limited group of scleroderma?
Skin thickening limited to hands and forearms (does not travel above elbow)
AKA crest syndrome
What does crest stand for?
C - calsidosis
R- Ranodes (poor circulation in fingers)
E - Oesphageal dismobility (heartburn, GORD)
S - scleradactialy (sausage fingers)
T - Teljectasia (small blood vessel visible on face/chest)
Don’t need all to diagnose
What is diffuse scleroderma?
Thickening of skin can be across whole body
What are the complciations ofl imited scleroderma?
Pulmonary hypertension
What are the complications of diffuse scleroderma?
Pulmonary fibrosis
Renal crisis
Small bowel bacterial overgrowth
Who gets sjorgens syndrome?
Women (9:1)
Onset 40-50 yrs
More common than others, less severe
What is sjogren’s syndrome?
Syndrome that affects salivary glands + tear glands
Dryness in eyes + mouth
Parotid enlargement
What are the complications of sjogren’s syndrome?
Lymphoma Neuropathy Pupura Intestitial lung disease Renal tubular acidosis
What is autoimmune myositis?
Immune system affects muscles, often proximal (upper limb, thigh)
Weakness not pain
What are the types of auto-immune myositis?
Polymyositis - younger patietns
Dermatomyositis - elderly people (skin lesiojns
Gottron’s papules
Helitrope rash
What is a heliotrope rash?
Scaly lesion on knucles
What is a gottron’s papule?
Violet discoleration around eyes
What are the complciations of auto-immune myosistis?
Elderly - cancer
Younger - interstitial lung disease
What is giant cell arteritis?
Medical emergency
Elderly age
Can often become blind if not immediately treated
Templar artery often affected
What are the main classification criteria for giant cell artertiis?
3 or more of following Over 50 New headache Temporal artery tenderness Raised ESR (above 50) Abnomrla temporal biopsy
What is ANCA?
Anti-neutraphil cytoplasmic antibody
Targets neutrophils + burst innapropriately - destroys blood vesse
What are the main ANCA associated vasculitises?
Granulomatosis with Polyangiitis (Wegner’s Granulomatosis)
Microscopic Polyangiitis
Eosinophilic Granulomatosis Polyangiitis (Churg-Strauss Granulomatosis)
What is granulomatosis with polyangitis?
NEcrotising granulomatous inflammation
Usually invovled URT/LRT esp sinuses
Glomerulonephritis common
Normally affect small-medium vessels
What is Microscoptic polynagintis?
Necrotising vasculitis with few/no immune deposits Normally affects small blood vessels Necrotising arteritis may be present Necrotising glomerulonephritis common Pulmonary capillaritis often occurs Granulotomatous infiltration absent
What is esionpjilic granulomatosis with polyangitis?
Eosinophil rich + necrotising granulotomatomous inflammation
Often affects respiratory tract
Necrotising vascultiis often small-medium vessels
Associated with astham + eosinophillia
ANCA more common when glomerulonephritis present
What conditions are likely to have anti-nuclear antibodies?
SLE (lupus) Systemic sclerosis MCTD Drug induced lupus Sjorgens syndrome Poly/dermatomyositis
What is the downside to ANA tests?
Very sensitive but not specific
What are the specific ANA tests for lupus?
dsDNA
Ro
Sm
What are teh specific ANA for scleroderma?
Scl-70
Centromere
What are the specific ANA tests for polymyositis?
Jo-1
What are the specific ANA tests for sjorgens?
Ro
La
What lab/radiological investigations are used in auto-immune (multi system) diseases?
MRI
Pet-scan
Biopsy!
What information abuot a patient should be conveyed when the paramedics hand over a patient?
Time of injury Mechanism of injury Suspected serious injuries Vital signs If any interventions have been carried out
What is catastrophic haemorrhage control?
Treating catastrophic haemorrhage first
If not derteriation can occur
What do you assess in airway?
Noises (speech, gurgling, stridor?)
Visual (swelling, vomit/blood debris)
When should you assume a spine injury?
Dangerous mechanism
Reduced conscious level
Injury above clavicles
Neruolgical signs
What is assessed in breathing?
Look for visible injuries, resp rate, effort/expansion
Palpate/percuss
Ascultate
Oxygen, analgesia + frain if required
What is the clinical assessment of circulation? (ABC)
Heart rate Palpable radial pulse? CRT BP Urine output Confusion? Pulse pressure?
What are the blood tests taken in circulation assesment?
Haemoglobin levels
lactate
What imaging is done during circulation assessment?
Ultrasound
CT
What are the five most common sites for blodd loss?
Chest Abdomen Pelvis Long bones Floor
What should be considered when thinking about volume replacement?
IV access vs IO (intraosseous) access
Tye of fluid
Amount of fluid
Follow transfusion protocols - no need to get BP up to normal, only enough to perfuse organs
When volume replacement is being performed, what should you monitor?
Vital signs
Urine output
Lactate
What is the lethal triad during blood loss?
Coagulopathy (execssive bleeding)
Lactate
Hypothermia (clotting factors don’t work well if cold)
What should be assessed in the disability stage?
AVPU GCS Pupils Tone + reflexes Log roll
What is the expose stage?
Exposure to allow for full examination in case of hidden injuries
Recover to keep warm
What does DEFG stand for?
Don’t ever forget Glucose!
What are the bed side tests?
ECG
Arterial blood gas
Urine dipstick
What does the secodnary survery entail?
A detailed head-toe examination
Although now with minimal handling
Also includes radiology
Plan management of injuries
What are the options for further managment?
Teahter (operative)
Interventional radiology (control bleeding)
ITU
