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USMLE > Musculoskeletal and Connective Tissue > Flashcards

Musculoskeletal and Connective Tissue Flashcards

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USMLE® Step 1 flashcards
1
Q 
Unhappy Triad
Context of injury?
What happens?
Tears?
Treatment
A

Common injury in contact sports
Lateral force applied to planted leg
Tear of ACL, MCL (medial or tibial collateral ligament) and Meniscus (classically medial but lateral more common)
Surgical ACL reconstruction

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2
Q

Positive anterior drawer sign

A

ACL tear

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3
Q

Abnormal passive abduction of the leg

A

MCL tear

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4
Q

ACL attachments and function

A

Lateral condyle of the femur to the anterior intercondylar area of the tibia
Prevents femur from shifting backwards

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5
Q

PCL attachments and function

A

Medial condyle of the femur to the posterior intercondylar area of the tibia
Prevents femur from shifting forward

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6
Q

Pudendal nerve block
Function
Location

A

Relieve pain of delivery

Ischial Spine

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7
Q

Location of lumbar puncture in adults

A

Iliac Crest (L3-4 or L4-5)

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8
Q

Rotator Cuff Muscles
Function
Attachement
Innervation

A

“Superman Subsumes his Inferior Minors”
Supraspinatus - Abducts before deltoid. Most common injury. Attaches superiorly
Infraspinatus - Lateral rotation. Pinching injury. Attaches posteriorly
Teres Minor - Adducts and lateral rotation. Attaches posteriorly
Subscapularis - medial rotates and adducts. Attaches anteriorly
C5-C6

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9
Q

Writs Bones (Carpals)

A 
"So Long To Pinky, Here Comes The Thumb"
Closest to arm, Thumb to Pinky
Scaphoid, Lunate, Triquetrum 
Closest to fingers, Pinky to Thumb
Pisiform, Hamate, Capitate, Trapezoid
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10
Q

Most commonly fractured carpal? Other risks to this bone?

A

Scaphoid. Prone to avascular necrosis owing to retrograde blood supply

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11
Q

Cause of acute carpal tunnel syndrome

A

Dislocation of the lunate

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12
Q

Carpal Tunnel Syndrome
PathoPhys
Presentation

A

Entrapment of median nerve in carpal tunnel

Paresthesia, pain and numbness in median nerve area.

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13
Q

Median Nerve Sensation

A

Anterior: thumb side of hand, 1st, 2nd, and half of 3rd fingers
Posterior: 1st, 2nd, and half of 3rd fingers

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14
Q

Innervation of Palm of Hand

A

Thumb side - median nerve

Pinky side - Ulnar nerve

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15
Q

Innervation of Back of Hand

A

Thumb side - Radial nerve (superficial branch)
Pinky side - Ulnar nerve
1st, 2nd, and 3rd fingers - Median nerve

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16
Q

Innervation of top of shoulder?

A

C4

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17
Q

Innervation of lateral side of upper arm?

A

C5

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18
Q

Innervation of lateral side of lower arm?

A

C6

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19
Q

Innervation of medial side of lower and most of upper arm?

A

T1

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20
Q

Innervation of Axilla

A

T2

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21
Q

Injury to lower trunk of brachial plexus
What can cause it?
What does it produce?

A

Compressed by cervical rib or Pancoast tumor of lung

Produces Klumpke’s Palsy

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22
Q 
How and where is Radial nerve injured 
Roots of radial nerve?
Motor manifestation of injury?
Sensory manifestation of injury?
Manifestation of injury?
A

Compressed in axilla by incorrect use of a crutch
Lesioned by midshaft fracture of humerus in spiral groove
Deep branch stretched by subluxation of radius
Posterior cord (C5-T1)
“BEST extensors”
Brachioradialis, Extensor of wrist and fingers, Supinator, Triceps
Posterior arm and dorsal hand and thumb
Saturday night palsy (wrist drop)

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23
Q

How is upper trunk of brachial plexus injured?

A

Trauma

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24
Q 
Axillary nerve?
How is it injured?
Roots?
Motor manifestation of injury? 
Sensory manifestation of injury? 
Sign of injury?
A 
Lesioned by fracture of surgical neck of humerus, dislocation of humeral head, or intramuscular injections 
Posterior cord (C5, C6)
Deltoid paralysis (problem with abduction at shoulder). 
Sensory loss of deltoid muscle.
Deltoid atrophy
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25
Q

Where is the anterior interosseous nerve injured?

A

Compressed in deep forearm

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26
Q

What is the cause of injury to recurrent branch of the median nerve?

A

Lesioned by superficial laceration

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27
Q

Bones of arm

A

Humerus
Ulna (pinky side)
Radius (thumb side)

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28
Q

Attachments of Flexor Retinaculum

A

Scaphoid and Trapezium to Pisiform and Hook of hamate

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29
Q 
Abductor Pollicis Brevis 
Origin
Insertion 
Innervation 
Action
A

Flexor Retinaculum, Scaphoid, Trapezius
Lateral side of proximal phalanx of the thumb
Recurrent branch of median nerve
Abducts the thumb

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30
Q

How does the ulnar nerve enter the hand? Possible pathology?

A

Through Guyon’s Canal

Guyon’s Canal Syndrome

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31
Q 
Abductor digiti minimi 
Origin
Insertion 
Innervation 
Action
A

Pisiform and tendon of flexor carpi ulnaris
Medial side of base of proximal phalanx of little finger
Ulnar nerve
Abducts little finger

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32
Q

hypothenar

A

Pinky side

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33
Q

Thenar

A

Thumb side

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34
Q 
Flexor Pollicis Brevis
Origin
Insertion 
Innervation 
Action
A

FR and Trapezius
Base of proximal phalanx of thumb
Median nerve
Flexes thumb

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35
Q 
Opponens Pollicis
Origin
Insertion 
Innervation 
Action
A

FR and Trapezius
1st metacarpal
Median
Opposes thumb to other digits

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36
Q 
Adductor Pollicis 
Origin
Insertion 
Innervation 
Action
A 
Oblique head: Capitate and base of 2nd and 3rd metacarpals 
Transverse head: 3rd metacarpal 
Proximal phalanx of thumb
Ulnar nerve 
Adducts thumb
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37
Q 
Palmaris Brevis
Origin
Insertion 
Innervation 
Action
A

FR, Palmar aponeurosis
Skin of medial palm
Ulnar
Wrinkles skin

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38
Q 
Flexor Digiti Minimi Brevis 
Origin
Insertion 
Innervation 
Action
A

FR and hook of hamate
Proximal Phalanx of pinky
Ulnar
Flexes

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39
Q 
Opponens Digiti Minimi
Origin
Insertion 
Innervation 
Action
A

FR and hook of hamate
5th metacarpal
Ulnar
Opposes pinky

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40
Q 
Lumbriclas 
#
Origin
Insertion 
Innervation 
Action
A 
4
Tendons of Flexor Digitorum Profundus 
Lateral sides of extensor expansions 
Lateral 2: Median
Medial 2: Unlar
Flexes metacarpophalangeal joints and extends interphalangeal joints
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41
Q 
Dorsal interossei 
#
Description 
Origin
Insertion 
Innervation 
Action
A 
"DAB"
4
Bipennate
Adjacent sides of metacarpal bones
Lateral sides of proximal phalanges 
Ulnar
Abducts fingers, flexes metacarpophalangeal joints and extends interphalangeal joints
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42
Q 
Palmar Interossei
#
Description 
Origin
Insertion 
Innervation 
Action
A 
"PAD"
3
Unipennate
Medial side of 2nd metacarpal
Lateral sides of 4th and 5th metacarpals 
Proximal phalanges 
Ulnar
Adducts fingers, flexes metacarpophalangeal joints and extends interphalangeal joints
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43
Q

Divisions of the Brachial Plexus

A 
"Real Texans Drink Cold Bear"
Roots
Trunks
Divisions
Cords
Branches
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44
Q

Upper trunk of the Brachial Plexus
Roots?
Injury?

A

C5-C6

“Waiter’s Tip” - Erb’s Palsy

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45
Q

Lower Trunk of Brachial Plexus
Roots?
Injury?

A

C8, T1

Claw hand - Klumpke’s Palsy

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46
Q

Posterior Cord of Brachial Plexus
Roots?
Injury?

A

C5-T1

Wrist Drop

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47
Q

Long Thoracic Nerve
Roots?
Muscles innervated w/ function?
Context and consequences of Injury?

A

C5-C7
Serratus Anterior anchors scapula to thoracic cage. Used for abduction above horizontal position
Injured in mastectomy –> Winged Scapula and ipsilateral lymphedema

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48
Q 
Musculocutaneous nerve 
Roots?
Cause of injury?
Motor deficit?
Sensor deficit?
Manifestation of injury?
A

C5-C7
Upper Trunk Compression
Biceps, Brachialis, Coracobrachialis, Flexion of arm at elbow
Lateral forearm
Difficulty flexing the elbow. Variable sensory loss

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49
Q 
Median nerve
Causes of injury?
Roots
Motor deficit 
Sensory deficit 
Manifestation of injury?
A

Compressed in supracondylar fracture of humerus producing pronator teres syndrome
Compressed in carpal tunnel syndrome and by dislocation of lunate
C5-T1
Opposition of thumb, Lateral finger flexion, Wrist flexion
Lateral hand
Decreased Thumb Function (pope’s blessing)

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50
Q 
Ulnar Nerve
Causes of injury?
Roots?
Motor deficit
Sensory deficit?
Sign
A

Lesioned by repeat minor traumas, Fracture of medial epicondyle of humerus, Trauma to heel of the hand, Fracture to hook of hamate
C8, T1
Medial finger flexion, Wrist flexion
Pinky side of hand
Radial deviation of wrist upon wrist flexion, Ulnar Claw

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51
Q

What protects the brachial plexus when the clavicle is fractured?

A

Subclavius muscle

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52
Q

Muscles innervated by Dorsal Scapular Nerve

A

Rhomboids and Levator Scapulae

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53
Q

Suprascapular nerve
What muscles does it innervate?
Roots

A

Supra and Infra spinatus

C5, C6

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54
Q

Lateral Pectoral Nerve
Roots?
Muscles innervated?

A

C5-C7

Pectoralis Major

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55
Q

Thoracodorsal Nerve
Roots
Muscles innervated

A

C7, C8

Latissimus Dorsi

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56
Q 
Erb-Duchenne Palsy
Nickname
Site of lesion
Context of injury 
Findings
A

Waiters Tip
Upper Trunk of Brachial Plexus (C5, C6)
Seen in infants following trauma during delivery
Limb hangs by side (paralysis of abductors - suprascapular and deltoid), Medially rotated (paralysis of lateral rotators), Forearm pronated (loss of biceps)

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57
Q 
Klumpke's Palsy 
Site of lesion 
Context of injury
Complication 
Findings
A

Lower trunk of brachial plexus (C8, T1)
Embryological or childbirth defect
Cervical rib can compress subclavian artery and Lower Trunk resulting in Thoracic Outlet Syndrome
Atrophy of thenar and hypothenar eminences, Atrophy of interosseous muscles, Sensory deficits on medial side of forearm and hand, Loss of radial pulse when head moved to ipsilateral side

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58
Q

Clawing

A

Loss of lumbricals which flexes the MCP joints and extends the DIP and PIP joints

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59
Q

Ulnar Claw
Cause of lesion
PathoPhys

A

Long standing injury to ulnar nerve at hook of hamate (falling)
Distal Ulnar lesion –> Loss of medial lumbricals –> inability to extend 4th and 5th digits

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60
Q

Medial Claw
Caused by
PathoPhys

A

Carpal Tunnel Syndrome or Dislocated Lunate
Distal median nerve injury (after branch containing C5-C7 branches off to feed forearm flexors) –> Loss of lateral lumbricals –> Clawing of 2nd and 3rd fingers

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61
Q

Pope’s Blessing
PathoPhys
Findings

A

Proximal median nerve lesion causes loss of lateral finger flexion and thumb opposition.
When asked to make a fist, 2nd and 3rd fingers remain extended and thumb remains unopposed

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62
Q

Ape Hand

A

Proximal median nerve lesion –> loss of opponens pollicis muscle function –> unopposable thumb (cannot abduct the thumb)

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63
Q

Klumpke’s Total Claw
Site of lesion
PathoPhys

A

Lesion to lower trunk (C8, T1) of Brachial plexus
Loss of function of all lumbricals –> Forearm finger flexors (fed by median nerve with C5-C7) and finger extensors (fed by Radial nerve) are unopposed –> clawing of all digits

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64
Q

Thenar eminence muscles

A

Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis

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65
Q

Hypothenar eminence mucles

A

Opponens digiti minimi, Abductor digiti minimi, Flexor digiti minimi

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66
Q 
Obturator Nerve
Roots
Cause of injury
Motor deficit 
Sensory deficit
A

L2-L4
Anterior hip dislocation
Thigh Adduction
Medial Thigh

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67
Q 
Femoral Nerve
Roots
Cause of injury
Motor deficit 
Sensory deficit
A

L2-L4
Pelvic fracture
Thigh flexion and leg extension
Anterior thigh and medial leg

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68
Q 
Common Peroneal nerve
Roots
Cause of injury
Motor deficit 
Sensory deficit
A

L4-S2
Trauma or compression of lateral aspect of leg or fibula neck fracture
“PED”
Foot eversion and dorsiflexion, toe extension, foot dropPED, foot slap, steppage gait (Peroneus longus and brevis)
Anterolateral leg and dorsal aspect of food

69
Q 
Tibial Nerve
Roots
Cause of injury
Motor deficit 
Sensory deficit
A 
L4-S3
Knee trauma
"TIP"
Foot inversion and plantarflexion (cannot stand on TIPtoes), toe flexion 
Sole of foot
70
Q

Superior Gluteal Nerve
Roots
Cause of injury
Motor deficit

A

L4-S1
Posterior hip dislocation or polio
Thigh abduction (positive trendelenburg sign)

71
Q

Trendelenberg Sign
What is it?
What does it mean?

A

Contralateral hip drop when standing on leg ipsilateral to site of lesion
Sign of injury to Gluteus minimus or medius (abductors of the hip)

72
Q

Inferior Gluteal Nerve
Roots
Cause of injury
Motor deficit

A

L5-S2
Posterior hip dislocation
Cant jump, climb stairs, rise from seated position, push inferiorly

73
Q

Sciatic nerve
Roots
Sensory area
Branches

A

L4-S3
Posterior thigh
Splits into common peroneal and tibial nerve

74
Q

Steps of Ca entrance into skeletal muscles

A
  1. ACh binding –> muscle depolarization at motor end plate
  2. Depolarization travels along T tubule
  3. V gated Dihydrophyridine receptors mechanically coupled to Ryanodine receptors in SR
  4. Ca from SR enters cell
75
Q

How does Ca activate muscles

A
  1. Ca –> troponin C

2. Troponin C moves tropomyosin out of myosin binding groove on actin filaments

76
Q

Steps of skeletal and cardiac muscle contraction

A
  1. ATP hydrolysis cocks myosin head
  2. Tropomyosin displaced and myosin binds actin
  3. P released –> power stroke
  4. ADP released and ATP binds allowing separation of myosin and actin
77
Q

During contraction, what happens to the bands in the skeletal muscle

A

Shortening H and I bands and between Z line (HIZ shrinkage)

A band remains the same length (A always the same)

78
Q 
Type 1 Muscle 
Speed
Length of contraction 
Color
Primary Reaction
A

“1 Slow Red Ox”
Slow twitch, Sustained contraction
Red fibers (from ↑ mito and myoglobin)
Oxidative phosphorylation

79
Q 
Type 2 Muscle 
Speed
Color
Primary Reaction 
What kind of training affects them?
A

Fast twitch
White fibers (↓ mito and myoglobin)
Anaerobic glycolysis
Weight training –> hypertrophy

80
Q

Z line

A

Where actin attaches to backbone

81
Q

I band

A

Just Actin

82
Q

H band

A

Just Myosin

83
Q

A band

A

Myosin + Where Myosin overlaps with Actin

84
Q

M line

A

Center of myosin

85
Q

Endochondral Ossification
Which bones form this way?
Process

A

Axial and appendicular skeleton and base of skull
Cartilaginous model of bone is made by chondrocytes. Osteoclasts and Osteoblasts later replace with woven bone and then remodel to lamellar bone

86
Q

In adults, when does woven bone occur?

A

After fractures or in Paget’s disease

87
Q

Membranous ossification
Which bones form this way?
Process

A

Calavarium and facial bones

Woven bone forms directly w/o cartilage. Later remodeled to lamellar bone

88
Q

Osteoblasts
Function
Derived from?

A

Build Bone by secreting collagen and catalyzing mineralization
Differentiate from mesenchymal stem cells in periosteum

89
Q

Osteoclasts
Histo
Function
Derived from?

A

Multinucleated cells
Dissolve bone by secreting acid and collagenases
Differentiate from monocytes/macrophages

90
Q

Affects of PTH on Bone

A

At low, intermittent levels, exert anabolic affects (building bone) on osteoblasts and (indirectly) osteoclasts.
Primary hyperparathyroidism –> catabolic affects (osteitis fibrosa cystica)

91
Q

Affects of Estrogen on Bone

A

Estrogen –/ apoptosis in bone forming osteoblasts and induces apoptosis in bone-resorbing osteoclasts

92
Q 
Achondroplasia 
What is it?
PathoPhys
Genetics 
Presentation
A

Failure of longitudinal bone growth (endochondral ossification) –> short limbs. Membranous ossification not affected –> Large head relative to limbs.
Constitutive activation of Fibroblast Growth Factor Receptor 3 (FGFR3) inhibits chondrocyte proliferation
More than 85% of mutations are sporadic and associated with advanced paternal age. Condition also shows Autosomal Dominant inheritance
Dwarfism. Normal lifespan and fertility

93
Q

Osteoporosis
What is it?
Lab Values
What can in lead to?

A

Trabecular (spongy) bone loses mass and interconnections despite normal bone mineralization
Normal lab values (serum Ca and PO4)
Vertebral Crush Fractures (Acute back pain, Loss of height, Kyphosis)

94
Q

Osteoporosis Type 1
Context
PathoPhys
Areas affected

A

Postmenopausal
↑ bone resorption due to ↓ estrogen
Femoral neck fracture, distal radius (Colles’ fracture)

95
Q 
Osteoporosis Type 2
Context
Prophylaxis 
Treatment
Contraindications
A

Men and Women > 70 years old
Regular weight bearing exercise, Ca and Vit D intake
SERMs (estrogen) +/or Calcitonin, Bisphosphonates or pulsatile PTH for severe cases
Glucocorticoids are contraindicated

96
Q 
Osteopetrosis 
AKA
PathoPhys
Description of bones 
Consequences of bone pathology?
A

Marble Bone Disease
Failure of normal bone resorption due to defective osteoclasts. Mutations (Carbonic Anhydrase II) impairs ability of osteoclasts to generate acidic environment necessary for bone resorption
Thickened, dense bones that are prone to fracture.
Bone fills marrow space causing pancytopenia, extramedullary hematopoiesis

97
Q

Osteopetrosis
XR
Complications
Treatment

A

Bone-in-bone appearance
Cranial nerve impingement and palsies b/c of narrow foramina
Bone marrow transplant because osteoclasts derived from monocytes

98
Q

Osteomalacia/Rickets
Population affected
PathoPhys
Findings

A

Adults: Osteomalacia, Children: Rickets
Defective mineralization/calcification of osteoid. ↓ VitD –> ↓ serum Ca –> ↑ PTH –> ↓ serum Phosphate
Hyperactive osteoblasts –> ↑ AlkPhos (osteoblasts require alkaline environment)

99
Q 
Paget's Disease of Bone
AKA
Frequency 
PathoPhys
Findings 
Description of bone 
Fractures?
Complications
Presentation
A

Osteitis Deformans
Common
Localized bone remodeling disorder causes by ↑ in osteoblasts and osteoclasts
Serum Ca, PO4, and PTH normal. ↑ ALP
Mosaic (woven) bone pattern
Long bone chalk-stick fractures
↑ blood flow from ↑ arteriovenous shunts –> high output heart failure
↑ risk of osteogenic sarcoma
Hat size ↑, hearing loss (auditory foramen narrowing)

100
Q 
Osteoporosis 
Serum Ca
Serum PO4
ALP
PTH
Bone description
A 
-
-
-
-
↓ Bone Mass
101
Q 
Osteopetrosis 
Serum Ca
Serum PO4
ALP
PTH
Bone description
A 
↓Ca 
No change in PO4
↑ ALP
No change in PTH
Thickened, dense bones
102
Q 
Osteomalacia/Rickets 
Serum Ca
Serum PO4
ALP
PTH
Bone description
A 
↓ Ca
↓ PO4
↑ ALP
↑ PTH
Soft Bones
103
Q 
Osteitis Fibrosa Cystica 
Serum Ca
Serum PO4
ALP
PTH
Bone description
A 
↑ Ca
↓ PO4
↑ ALP
↑ PTH
"Bone tumors" of hyperparathyroidism
104
Q 
Paget's Disease 
Serum Ca
Serum PO4
ALP
PTH
Bone description
A 
No change in Ca
No change in PO4
↑ ALP
No change in PTH
Abnormal bone architecture
105
Q

Polyostotic Fibrous Dysplasia
PathoPhys
Name of a form of it?

A

Bone replaced by fibroblasts, collagen, and irregular bony trabeculae
McCune-Albright Syndrome characterized by multiple unilateral bone lesions associated with endocrine abnormalities (precocious puberty) and cafe-au-lait spots

106
Q 
Giant Cell Tumor of Bone
Name
Epidemiology 
Location 
Malignant? 
XR
Histo
A

Osteoclastoma
20-40 year olds
Epiphyseal end of long bones: distal femur, proximal tibial region (knee)
Locally aggressive benign tumor
Double bubble or soap bubble appearance
Spindle-shaped cells with multinucleated giant cells

107
Q 
Osteochondroma 
Name
Frequency
Epidemiology
Location 
Description 
Malignant?
A 
Exostosis
Most common benign tumor
Males < 25 
Originates from long Metaphysis 
Mature bone w/ cartilaginous cap 
Malignant transformation into chondrosacroma is rare
108
Q 
Osteosarcoma 
Name 
Frequency 
Epidemiology 
Prognosis
Treatment
A

Osteogenic sarcoma
2nd most common primary malignant bone tumor (after multiple myeloma)
Male > female, 10-20 years old
Aggressive
Surgical en bloc resection (with limb salvage) and chemotherapy

109
Q

Metaphysis

A

Wider portin of long bone adjacent to epiphyseal plate

110
Q

Osteosarcoma
Predisposing factors
Location
XR

A

Paget’s disease of bone, Bone infarcts, Radiation, Familial Retinoblastoma
Metaphysis of long bone often around distal femur and proximal tibial region (knee)
Codman’s Triangle (from elevation of periosteum) or sunburnt pattern

111
Q 
Ewing's Sarcoma 
Epidemiology 
Location 
Histo
Malignant?
A

Boys < 15 years old
Diaphysis of long bones, pelvis, scapula, and ribs
Anaplastic small blue cell tumor
Malignant

112
Q 
Ewing's Sarcoma 
XR
Genetics 
Prognosis
Treatment
A

Onion skin appearance in bone
t(11;22) translocation
Extremely aggressive with early mets
Responsive to chemotherapy

113
Q 
Chondrosarcoma 
Epidemiology 
Location 
Malignant
Type of tissue?
Origin?
Gross
A

Men 30 - 60
Diaphysis. Pelvis, Spine, Scapula, Humerus, Tibia, Femur
Malignant
Cartilaginous
Primary or from osteochondroma
Expansive glistening mass within medullary cavity

114
Q

Osteoarthritis
Etiology
Predisposing factors
Treatment

A

Mechanical (wear and tear) destruction of articular cartilage
Age, Obesity, Joint deformity
NSAIDs, Intra-articular glucocorticoids

115
Q

Osteoarthritis
Presentation
XR
Gross

A

Pain in weight-bearing joints after use (at end of day), Improves with rest, Knee cartilage loss begins medially (bowlegged), No systemic symptoms, Not inflammatory
Subchondral cysts, Sclerosis, Joint narrowing, Osteophytes (bone spurs)
Eburnation (polished, ivory like appearance of bone), Ulcerated cartilage, Thickened capsule, Synovial hypertrophy, Bouchard’s nodes (PIP), No MCP involvement

116
Q 
Rheumatoid Arthritis 
Etiology 
Histo
Gross
Regions involved
A

Autoimmune - inflammatory destruction of synovial joints. Type III hypersensitivity reaction
Pannus formation in joints (MCP and PIP), Increased synovial fluid, Bone and Cartilage erosion
Subcutaneous rheumatoid nodules (fibrinoid necrosis), Ulnar deviation in fingers, Subluxation, Baker’s Cyst (in popliteal fossa)
MCP and PIP, No DIP

117
Q 
Rheumatoid Arthritis 
Epidemiology 
Labs
HLA
Presentation 
Treatment
A

Females > Males
80% have RF+ (anti IgG Ab), Anti-cyclic citrullinated peptide Ab (specific)
HLA-DR4
Morning stiffness lasting >30 minutes and improving with use. Systemic joint involvement and systemic symptoms (fever, fatigue, pleuritis, pericarditis)
NSAIDs, Glucocorticoids, Disease modifying agents (Methotrexate, Sulfasalazine, TNFα inhibitors)

118
Q 
Sjogren's Syndrome 
PathoPhys
Locations
Classic Presentation 
Risks 
Labs 
Epidemiology 
Associated with what other disease?
A

Lymphocytic infiltration of exocrine glands
Especially lacrimal and salivary glands
Xerophthalmia (dry eyes, conjunctivitis, “sand in my eyes”), Xerostomia (dry mouth, dysphagia), Arthritis, Parotid enlargement
Risk of B cell lymphoma, dental caries
Auto Abs to ribonucleoprotein antigens: SS-A (Ro), SS-B (La)
Females between 40 and 60
Rheumatoid Arthritis

119
Q 
Gout 
PathoPhys
Causes 
Epidemiology 
Crystals
A

Precipitation of monosodium Urate Crystals into joints due to hyperuricemia
Lesch-Nyhan syndrome, PRPP excess, ↓ excretion of uric acid (thiazide diuretics), ↑ cell turnover, von Gierke’s disease. 90% due to underexcretion, 10% due to overproduction.
More common in men
Crystals are needle shaped and negatively birefringent (yellow crystals under parallel light)

120
Q 
Gout
Distribution 
Description of joints
Classic manifestation 
Gross signs 
When does it present?
A 
Asymmetric joint distribution 
Joints are swollen, red, and painful 
Painful MTP (metatarsophalangeal) joint of the big toe (podagra)
Tophus formation (external ear, olecranon bursa, achilles tendon)
Acute attacks tend to occur after a large meal  or EtOH consumption
121
Q

Why does EtOH aggravate Gout

A

EtOH metabolites compete for same excretion sites in kidney as uric acid causing ↓ uric acid secretion

122
Q 
Pseudogout
What causes it?
Histo
Which joints affected?
Epidemiology 
Treatment
A

Deposition of Ca pyrophosphate crystals w/in joint space
Basophilic rhomboid crystals that are weakly positively birefringent
Large joints (knee)
Older than 50, male and female equal
NSAIDs (sudden severe attacks), Steroids, Colchicine

123
Q

Crystals in Gout vs Pseudogout

A

Gout: yellow when parallel to light
Pseudogout: blue when parallel to light

124
Q

Infectious Arthritis
Causative agents
Presentation

A

S. aureus, Streptococcus, Neisseria gonorrhoeae
Joints are swollen, painful, and red
“STD”
Synovitis (knee), Tenosynovitis (hand), Dermatitis (pustules)

125
Q

Gonoccal Arthritis

A

STD that presents as a migratory arthritis with an asymmetric pattern

126
Q 
Osteonecrosis 
Name
What happens?
Presentation 
What causes it?
Most common site?
A 
Avascular necrosis
Infarction of bone and marrow
Pain associated with activity 
Trauma, high-dose corticosteroids, alcoholism, sickle cell 
Femoral head
127
Q 
Seronegative Spondyloarthropathies 
What are they?
HLA
Epidemiology 
Names
A 
Arthritis w/o RF
HLAB27
Males
"PAIR"
Psoriatic arthritis, Ankylosing spondylitis, IBD, Reactive arthritis
128
Q 
Psoriatic Arthritis 
What is it?
Distribution 
Gross
XR
% of pts with psoriasis that get it?
A 
Joint pain and stiffness associated with psoriasis 
Asymmetric and patchy involvement 
Dactylitis (sausage fingers)
Pencil in cup deformity on XR
1/3 of pts with psoriasis get it
129
Q

Ankylosing Spondylitis
What is it? Where is it?
Presentation
XR

A 
Chronic inflammatory disease of spine and sacroiliac joints 
Ankylosis (stiff spine due to fusion of joints), Uveitis, Aortic Regurgitation
Bamboo spine (vertebral fusion)
130
Q

Reactive Arthritis
Name
Presentation
Causes

A

Reiter’s Syndrome
“Can’t see, Can’t Pee, Can’t Climb a Tree”
Conjunctivitis and anterior uveitis, Urethritis, Arthritis, Palm and Sole Rash
Post GI or Chlamydia infection

131
Q 
Polymyalgia Rheumatica 
Symptoms 
Epidemiology 
Associated with what other diseases?
Labs
Treatment
A

Pain and stiffness in shoulders and hips often with fever, malaise, and wt loss. Does not cause muscular weakness
More common in women > 50
Associated with Temporal Giant Cell Arteritis
↑ ESR. Normal CK
Rapid response to low-dose corticosteroids

132
Q

Fibromyalgia
Epidemiology
Presentation
Secondary symptoms

A

Women 20-50
Chronic, widespread musculoskeletal pain
Associated with stiffness, paresthesia, poor sleep, and fatigue

133
Q 
Polymyositis
Presentation 
Histo
Common location 
Findings 
Treatment
A

Progressive symmetric proximal muscle weakness
Endomysial inflammation with CD8+ T cells
Shoulders
↑ CK, ANA+, +anti Jo1 Abs
Steroids

134
Q 
Dermatomyositis 
Presentation 
Histo
Risks 
Findings 
Treatment
A

Progressive symmetric proximal muscle weakness with malar rash, Gottron’s papules, Heliotrope rash, Shawl and Face rash, Mechanic hands
Perimysial inflammation and atrophy with CD4+ T cells
↑ risk of occult malignancy
↑ CK, ANA+, +anti Jo1 Abs
Steroids

135
Q

Names of Neuromuscular Junction Diseases

A

Myasthenia gravis

Lambert-Eaton Myasthenic Syndrome

136
Q 
Myasthenia gravis 
Frequency 
Pathophysiology 
Presentation 
Associated w/
Treatment
A 
Most common NMJ disorder 
AutoAbs to postsynaptic ACh receptors 
Ptosis, Diplopia, Weakness, Worsens with muscle use
Thymoma, Thymic hyperplasia 
AChE inhibitors
137
Q 
Lambert-Eaton Myasthenic Syndrome 
Frequency 
Pathophysiology 
Presentation 
Associated w/
Treatment
A

Uncommon
AutoAbs to presynaptic Ca channels –> ACh release
Proximal muscle weakness that improves with muscle use
Small cell lung cancer
No effect with AChE inhibitors

138
Q

Myositis Ossificans
What is it?
Location
Presentation

A

Metaplasia of skeletal muscle to bone following muscular trauma
Most often seen in upper and lower extremity
May present as suspicious mass at site of known trauma or as incidental finding on radiography

139
Q

Lipoxygenase pathway yields…

A

Leukotrienes

140
Q

LTB4

A

“Neutrophils Arrive Before Others”

Neutrophil chemotactic

141
Q

LTC4, D4, and E4

A

Bronchoconstriction, Vasoconstriction, Contraction of Smooth Muscle, ↑ Vascular permeability

142
Q

PGI2
Name
Function
Synthesis

A

Prostacyclin
“Platelet Gathering Inhibitor”
Inhibits platelet aggregation and promotes vasodilation. ↓ Bronchial tone, ↓ Uterine tone
Membrane lipids (eg phosphatidylinositol) –> [PLA2] –> Arachidonic Acid –> [COX] –> Endoperoxides (PGG2, PGH2) –> Prostacyclin (PGI2)

143
Q

Leukotriene Synthesis

A

Membrane lipids (eg phosphatidylinositol) –> [PLA2] –> Arachidonic Acid –> [Lipoxygenase] –> Hydroperoxides (HPETEs) –> Leukotrienes

144
Q

Prostaglandins
Names
Function
Synthesis

A

PGE2, PGF2α
↑ Uterine tone, ↓ Vascular tone, ↓ Bronchial tone
Membrane lipids (eg phosphatidylinositol) –> [PLA2] –> Arachidonic Acid –> [COX] –> Endoperoxides (PGG2, PGH2) –> Prostaglandins

145
Q

Thromboxane
Names
Function
Synthesis

A

TXA2
↑ Platelet aggregation, ↑ Vascular tone, ↑ Bronchial tone
Membrane lipids (eg phosphatidylinositol) –> [PLA2] –> Arachidonic Acid –> [COX] –> Endoperoxides (PGG2, PGH2) –> Thromboxane

146
Q

Aspirin
Mechanism
Net result
Class

A

Irreversibly inhibits COX1 and COX2 by acetylation
↓ synthesis of both TXA2 and Prostaglandins, ↑ bleeding time, No effect on PT of PTT
NSAID

147
Q

Aspirin
Uses
Tox

A 
Low dose (less than 300mg):  ↓ platelet aggregation. 
Intermediate dose (300-2400): antipyretic and analgesic.
High dose (2400-4000): anti-inflammatory 
Gastric ulcers, Tinnitus (CNVIII), Chronci use can lead to acute renal failure, interstitial nephritis, upper GI bleed. Reyes syndrome in children. Stimulates respiratory centers leading to hyperventilation and respiratory alkalosis
148
Q 
NSAIDs
Names 
Mechanism 
Use
Tox
A

Ibuprofen, Naproxen, Indomethacin, Ketorolac, Diclofenac
Reversibly inhibits COX1 and COX2. Blocks Prostaglandin synthesis
Antipyretic, analgesic, anti-inflammatory. Indomethacin used to close PDA
Interstitial nephritis, Gastric ulcer, Renal ischemia

149
Q

COX2 Inhibitors
Name
MoA
What does it Spare?

A

Celecoxib
Reversibly inhibits COX2 which is found in inflammatory cells and vascular endothelium and mediates inflammation and pain.
Spares COX1 and thus doesn’t affect gastric mucosa. Also spares TXA2 and spares platelet function

150
Q

COX2 Inhibitors
Use
Tox

A

RA and Osteoarthritis in pts with gastritis or ulcers

↑ risk of thrombosis. Sulfa allergy

151
Q

Acetaminophen
MoA
Use
Tox

A

Reversibly inhibits COX, mostly in CNS. Inactivated peripherally
Antipyretic, analgesic, not anti-inflammatory. Used instead of aspirin to avoid Reyes Syndrome in children w/ viral infection
OD produces hepatic necrosis. Metabolite depletes glutathione and forms toxic tissue adducts in liver

152
Q

Cure for Acetaminophen OD

A

N-acetylcysteine regenerates Glutathione

153
Q 
Bisphosphonates 
Names 
Kind of drug
MoA
Use
Tox
A

Alendronate, other -dronates
Pyrophosphate analog
Bind hydroxyapatite in bone and inhibits osteoclast activity
Osteoporosis, hyperCa, Paget’s disease of bone
Corrosive esophagitis, Osteonecrosis of the jaw

154
Q

Names of Gout Drugs

A

Allopurinol, Febuxostat, Probenecid, Colchicine

155
Q 
Allopurinol 
MoA
Use
Findings w/ use
What drugs cannot go with it?
Affect on uric acid clearance?
A

Inhibits xanthine oxidase thus ↓ conversion of xanthine to uric acid
Gout, Lymphoma and Leukemia (to prevent tumor lysis and associated urate nephropathy).
↑ concentrations of azathioprine and 6MP (both normally metabolized by xanthine oxidase)
Do not give salicylates
All but highest doses depress uric acid clearance. Even high doses have only minor uricosuric activity

156
Q

Febuxostat
MoA
Use

A

Inhibits xanthine oxidase

Gout

157
Q

Probenecid
MoA
Use
Tox

A

Inhibits reabsorption of uric acid in PCT
Gout
inhibits secretion of penicillin

158
Q

Colchicine
MoA
Use
Tox

A

Binds and stabilizes tubulin to inhibit polymerization thus impairing leukocyte chemotaxis and degranulation (decreases LTB4)
Gout
GI side effects, especially if given orally: diarrhea, abdominal pain, nausea
Myelosuppression

159
Q

Acute drugs for gout

A

NSAIDs (Naproxen and Indomethacin)

Oral or Intramuscular Glucocorticoids

160
Q

Risks of TNFα inhibitors

A

Predispose to infection including TB since TNF blockade prevents activation of macrophages and destruction of phagocytosed microbes

161
Q 
Etanercept 
Class of drug
Description of drug 
MoA
Use
A

“etanerCEPT is a TNF decoy reCEPTor”
TNFα inhibitors
Fusion protein: receptor for TNFα and IgG1 Fc produced by recombinant DNA
RA, Psoriasis, Ankylosing Spondylitis

162
Q

Infliximab, Adalimumab
Class of drug
MoA
Use

A

TNFα inhibitors
Anti TNFα monoclonal Ab
RA, Psoriasis, Ankylosing Spondylitis, Crohn’s Disease

163
Q

Periosteum

A

A membrane that lines the outer surface of all bones, except at the joints of long bones.

164
Q

Osteoid

A

Unmineralized bone

165
Q

Bones of lateral foot

A

Posterior to anterior: Calcaneus and Cuboid

166
Q

Bones of medial foot

A

Posterior to anterior: Talus and Navicular bones

Medial, Intermediate, and Lateral Cuneiforms

167
Q

Sensory innervation of anterior leg

A

Deep Peroneal nerve: In between big toe and 2nd toe
Superficial Peroneal nerve: Top of foot and Lateral Leg
Sural Nerve: Lateral foot
Saphenous nerve (L3-L4): Medial leg and medial knee
Femoral nerve: Anterior and lateral thigh
Obturator nerve: Medial thigh

168
Q

Sensory innervation of posterior leg

A 
Tibial nerve: plantar surface of foot
Sural nerve: lateral leg
Saphenous nerve: Medial leg
Femoral nerve: Lateral thigh
Sciatic nerve: Posterior thigh

USMLE (25 decks)

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