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Musculoskeletal and Connective Tissue 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
Where is the anterior interosseous nerve injured?
Compressed in deep forearm
26
What is the cause of injury to recurrent branch of the median nerve?
Lesioned by superficial laceration
27
Bones of arm
Humerus Ulna (pinky side) Radius (thumb side)
28
Attachments of Flexor Retinaculum
Scaphoid and Trapezium to Pisiform and Hook of hamate
29
``` Abductor Pollicis Brevis Origin Insertion Innervation Action ```
Flexor Retinaculum, Scaphoid, Trapezius Lateral side of proximal phalanx of the thumb Recurrent branch of median nerve Abducts the thumb
30
How does the ulnar nerve enter the hand? Possible pathology?
Through Guyon's Canal | Guyon's Canal Syndrome
31
``` Abductor digiti minimi Origin Insertion Innervation Action ```
Pisiform and tendon of flexor carpi ulnaris Medial side of base of proximal phalanx of little finger Ulnar nerve Abducts little finger
32
hypothenar
Pinky side
33
Thenar
Thumb side
34
``` Flexor Pollicis Brevis Origin Insertion Innervation Action ```
FR and Trapezius Base of proximal phalanx of thumb Median nerve Flexes thumb
35
``` Opponens Pollicis Origin Insertion Innervation Action ```
FR and Trapezius 1st metacarpal Median Opposes thumb to other digits
36
``` Adductor Pollicis Origin Insertion Innervation Action ```
``` Oblique head: Capitate and base of 2nd and 3rd metacarpals Transverse head: 3rd metacarpal Proximal phalanx of thumb Ulnar nerve Adducts thumb ```
37
``` Palmaris Brevis Origin Insertion Innervation Action ```
FR, Palmar aponeurosis Skin of medial palm Ulnar Wrinkles skin
38
``` Flexor Digiti Minimi Brevis Origin Insertion Innervation Action ```
FR and hook of hamate Proximal Phalanx of pinky Ulnar Flexes
39
``` Opponens Digiti Minimi Origin Insertion Innervation Action ```
FR and hook of hamate 5th metacarpal Ulnar Opposes pinky
40
``` Lumbriclas # Origin Insertion Innervation Action ```
``` 4 Tendons of Flexor Digitorum Profundus Lateral sides of extensor expansions Lateral 2: Median Medial 2: Unlar Flexes metacarpophalangeal joints and extends interphalangeal joints ```
41
``` Dorsal interossei # Description Origin Insertion Innervation Action ```
``` "DAB" 4 Bipennate Adjacent sides of metacarpal bones Lateral sides of proximal phalanges Ulnar Abducts fingers, flexes metacarpophalangeal joints and extends interphalangeal joints ```
42
``` Palmar Interossei # Description Origin Insertion Innervation Action ```
``` "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 ```
43
Divisions of the Brachial Plexus
``` "Real Texans Drink Cold Bear" Roots Trunks Divisions Cords Branches ```
44
Upper trunk of the Brachial Plexus Roots? Injury?
C5-C6 | "Waiter's Tip" - Erb's Palsy
45
Lower Trunk of Brachial Plexus Roots? Injury?
C8, T1 | Claw hand - Klumpke's Palsy
46
Posterior Cord of Brachial Plexus Roots? Injury?
C5-T1 | Wrist Drop
47
Long Thoracic Nerve Roots? Muscles innervated w/ function? Context and consequences of Injury?
C5-C7 Serratus Anterior anchors scapula to thoracic cage. Used for abduction above horizontal position Injured in mastectomy --> Winged Scapula and ipsilateral lymphedema
48
``` Musculocutaneous nerve Roots? Cause of injury? Motor deficit? Sensor deficit? Manifestation of injury? ```
C5-C7 Upper Trunk Compression Biceps, Brachialis, Coracobrachialis, Flexion of arm at elbow Lateral forearm Difficulty flexing the elbow. Variable sensory loss
49
``` Median nerve Causes of injury? Roots Motor deficit Sensory deficit Manifestation of injury? ```
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)
50
``` Ulnar Nerve Causes of injury? Roots? Motor deficit Sensory deficit? Sign ```
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
51
What protects the brachial plexus when the clavicle is fractured?
Subclavius muscle
52
Muscles innervated by Dorsal Scapular Nerve
Rhomboids and Levator Scapulae
53
Suprascapular nerve What muscles does it innervate? Roots
Supra and Infra spinatus | C5, C6
54
Lateral Pectoral Nerve Roots? Muscles innervated?
C5-C7 | Pectoralis Major
55
Thoracodorsal Nerve Roots Muscles innervated
C7, C8 | Latissimus Dorsi
56
``` Erb-Duchenne Palsy Nickname Site of lesion Context of injury Findings ```
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)
57
``` Klumpke's Palsy Site of lesion Context of injury Complication Findings ```
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
58
Clawing
Loss of lumbricals which flexes the MCP joints and extends the DIP and PIP joints
59
Ulnar Claw Cause of lesion PathoPhys
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
60
Medial Claw Caused by PathoPhys
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
61
Pope's Blessing PathoPhys Findings
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
62
Ape Hand
Proximal median nerve lesion --> loss of opponens pollicis muscle function --> unopposable thumb (cannot abduct the thumb)
63
Klumpke's Total Claw Site of lesion PathoPhys
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
64
Thenar eminence muscles
Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis
65
Hypothenar eminence mucles
Opponens digiti minimi, Abductor digiti minimi, Flexor digiti minimi
66
``` Obturator Nerve Roots Cause of injury Motor deficit Sensory deficit ```
L2-L4 Anterior hip dislocation Thigh Adduction Medial Thigh
67
``` Femoral Nerve Roots Cause of injury Motor deficit Sensory deficit ```
L2-L4 Pelvic fracture Thigh flexion and leg extension Anterior thigh and medial leg
68
``` Common Peroneal nerve Roots Cause of injury Motor deficit Sensory deficit ```
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
``` Tibial Nerve Roots Cause of injury Motor deficit Sensory deficit ```
``` L4-S3 Knee trauma "TIP" Foot inversion and plantarflexion (cannot stand on TIPtoes), toe flexion Sole of foot ```
70
Superior Gluteal Nerve Roots Cause of injury Motor deficit
L4-S1 Posterior hip dislocation or polio Thigh abduction (positive trendelenburg sign)
71
Trendelenberg Sign What is it? What does it mean?
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
Inferior Gluteal Nerve Roots Cause of injury Motor deficit
L5-S2 Posterior hip dislocation Cant jump, climb stairs, rise from seated position, push inferiorly
73
Sciatic nerve Roots Sensory area Branches
L4-S3 Posterior thigh Splits into common peroneal and tibial nerve
74
Steps of Ca entrance into skeletal muscles
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
How does Ca activate muscles
1. Ca --> troponin C | 2. Troponin C moves tropomyosin out of myosin binding groove on actin filaments
76
Steps of skeletal and cardiac muscle contraction
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
During contraction, what happens to the bands in the skeletal muscle
Shortening H and I bands and between Z line (HIZ shrinkage) | A band remains the same length (A always the same)
78
``` Type 1 Muscle Speed Length of contraction Color Primary Reaction ```
"1 Slow Red Ox" Slow twitch, Sustained contraction Red fibers (from ↑ mito and myoglobin) Oxidative phosphorylation
79
``` Type 2 Muscle Speed Color Primary Reaction What kind of training affects them? ```
Fast twitch White fibers (↓ mito and myoglobin) Anaerobic glycolysis Weight training --> hypertrophy
80
Z line
Where actin attaches to backbone
81
I band
Just Actin
82
H band
Just Myosin
83
A band
Myosin + Where Myosin overlaps with Actin
84
M line
Center of myosin
85
Endochondral Ossification Which bones form this way? Process
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
In adults, when does woven bone occur?
After fractures or in Paget's disease
87
Membranous ossification Which bones form this way? Process
Calavarium and facial bones | Woven bone forms directly w/o cartilage. Later remodeled to lamellar bone
88
Osteoblasts Function Derived from?
Build Bone by secreting collagen and catalyzing mineralization Differentiate from mesenchymal stem cells in periosteum
89
Osteoclasts Histo Function Derived from?
Multinucleated cells Dissolve bone by secreting acid and collagenases Differentiate from monocytes/macrophages
90
Affects of PTH on Bone
At low, intermittent levels, exert anabolic affects (building bone) on osteoblasts and (indirectly) osteoclasts. Primary hyperparathyroidism --> catabolic affects (osteitis fibrosa cystica)
91
Affects of Estrogen on Bone
Estrogen --/ apoptosis in bone forming osteoblasts and induces apoptosis in bone-resorbing osteoclasts
92
``` Achondroplasia What is it? PathoPhys Genetics Presentation ```
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
Osteoporosis What is it? Lab Values What can in lead to?
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
Osteoporosis Type 1 Context PathoPhys Areas affected
Postmenopausal ↑ bone resorption due to ↓ estrogen Femoral neck fracture, distal radius (Colles' fracture)
95
``` Osteoporosis Type 2 Context Prophylaxis Treatment Contraindications ```
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
``` Osteopetrosis AKA PathoPhys Description of bones Consequences of bone pathology? ```
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
Osteopetrosis XR Complications Treatment
Bone-in-bone appearance Cranial nerve impingement and palsies b/c of narrow foramina Bone marrow transplant because osteoclasts derived from monocytes
98
Osteomalacia/Rickets Population affected PathoPhys Findings
Adults: Osteomalacia, Children: Rickets Defective mineralization/calcification of osteoid. ↓ VitD --> ↓ serum Ca --> ↑ PTH --> ↓ serum Phosphate Hyperactive osteoblasts --> ↑ AlkPhos (osteoblasts require alkaline environment)
99
``` Paget's Disease of Bone AKA Frequency PathoPhys Findings Description of bone Fractures? Complications Presentation ```
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
``` Osteoporosis Serum Ca Serum PO4 ALP PTH Bone description ```
``` - - - - ↓ Bone Mass ```
101
``` Osteopetrosis Serum Ca Serum PO4 ALP PTH Bone description ```
``` ↓Ca No change in PO4 ↑ ALP No change in PTH Thickened, dense bones ```
102
``` Osteomalacia/Rickets Serum Ca Serum PO4 ALP PTH Bone description ```
``` ↓ Ca ↓ PO4 ↑ ALP ↑ PTH Soft Bones ```
103
``` Osteitis Fibrosa Cystica Serum Ca Serum PO4 ALP PTH Bone description ```
``` ↑ Ca ↓ PO4 ↑ ALP ↑ PTH "Bone tumors" of hyperparathyroidism ```
104
``` Paget's Disease Serum Ca Serum PO4 ALP PTH Bone description ```
``` No change in Ca No change in PO4 ↑ ALP No change in PTH Abnormal bone architecture ```
105
Polyostotic Fibrous Dysplasia PathoPhys Name of a form of it?
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
``` Giant Cell Tumor of Bone Name Epidemiology Location Malignant? XR Histo ```
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
``` Osteochondroma Name Frequency Epidemiology Location Description Malignant? ```
``` Exostosis Most common benign tumor Males < 25 Originates from long Metaphysis Mature bone w/ cartilaginous cap Malignant transformation into chondrosacroma is rare ```
108
``` Osteosarcoma Name Frequency Epidemiology Prognosis Treatment ```
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
Metaphysis
Wider portin of long bone adjacent to epiphyseal plate
110
Osteosarcoma Predisposing factors Location XR
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
``` Ewing's Sarcoma Epidemiology Location Histo Malignant? ```
Boys < 15 years old Diaphysis of long bones, pelvis, scapula, and ribs Anaplastic small blue cell tumor Malignant
112
``` Ewing's Sarcoma XR Genetics Prognosis Treatment ```
Onion skin appearance in bone t(11;22) translocation Extremely aggressive with early mets Responsive to chemotherapy
113
``` Chondrosarcoma Epidemiology Location Malignant Type of tissue? Origin? Gross ```
Men 30 - 60 Diaphysis. Pelvis, Spine, Scapula, Humerus, Tibia, Femur Malignant Cartilaginous Primary or from osteochondroma Expansive glistening mass within medullary cavity
114
Osteoarthritis Etiology Predisposing factors Treatment
Mechanical (wear and tear) destruction of articular cartilage Age, Obesity, Joint deformity NSAIDs, Intra-articular glucocorticoids
115
Osteoarthritis Presentation XR Gross
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
``` Rheumatoid Arthritis Etiology Histo Gross Regions involved ```
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
``` Rheumatoid Arthritis Epidemiology Labs HLA Presentation Treatment ```
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
``` Sjogren's Syndrome PathoPhys Locations Classic Presentation Risks Labs Epidemiology Associated with what other disease? ```
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
``` Gout PathoPhys Causes Epidemiology Crystals ```
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
``` Gout Distribution Description of joints Classic manifestation Gross signs When does it present? ```
``` 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
Why does EtOH aggravate Gout
EtOH metabolites compete for same excretion sites in kidney as uric acid causing ↓ uric acid secretion
122
``` Pseudogout What causes it? Histo Which joints affected? Epidemiology Treatment ```
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
Crystals in Gout vs Pseudogout
Gout: yellow when parallel to light Pseudogout: blue when parallel to light
124
Infectious Arthritis Causative agents Presentation
S. aureus, Streptococcus, Neisseria gonorrhoeae Joints are swollen, painful, and red "STD" Synovitis (knee), Tenosynovitis (hand), Dermatitis (pustules)
125
Gonoccal Arthritis
STD that presents as a migratory arthritis with an asymmetric pattern
126
``` Osteonecrosis Name What happens? Presentation What causes it? Most common site? ```
``` Avascular necrosis Infarction of bone and marrow Pain associated with activity Trauma, high-dose corticosteroids, alcoholism, sickle cell Femoral head ```
127
``` Seronegative Spondyloarthropathies What are they? HLA Epidemiology Names ```
``` Arthritis w/o RF HLAB27 Males "PAIR" Psoriatic arthritis, Ankylosing spondylitis, IBD, Reactive arthritis ```
128
``` Psoriatic Arthritis What is it? Distribution Gross XR % of pts with psoriasis that get it? ```
``` 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
Ankylosing Spondylitis What is it? Where is it? Presentation XR
``` Chronic inflammatory disease of spine and sacroiliac joints Ankylosis (stiff spine due to fusion of joints), Uveitis, Aortic Regurgitation Bamboo spine (vertebral fusion) ```
130
Reactive Arthritis Name Presentation Causes
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
``` Polymyalgia Rheumatica Symptoms Epidemiology Associated with what other diseases? Labs Treatment ```
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
Fibromyalgia Epidemiology Presentation Secondary symptoms
Women 20-50 Chronic, widespread musculoskeletal pain Associated with stiffness, paresthesia, poor sleep, and fatigue
133
``` Polymyositis Presentation Histo Common location Findings Treatment ```
Progressive symmetric proximal muscle weakness Endomysial inflammation with CD8+ T cells Shoulders ↑ CK, ANA+, +anti Jo1 Abs Steroids
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``` Dermatomyositis Presentation Histo Risks Findings Treatment ```
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
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Names of Neuromuscular Junction Diseases
Myasthenia gravis | Lambert-Eaton Myasthenic Syndrome
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``` Myasthenia gravis Frequency Pathophysiology Presentation Associated w/ Treatment ```
``` Most common NMJ disorder AutoAbs to postsynaptic ACh receptors Ptosis, Diplopia, Weakness, Worsens with muscle use Thymoma, Thymic hyperplasia AChE inhibitors ```
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``` Lambert-Eaton Myasthenic Syndrome Frequency Pathophysiology Presentation Associated w/ Treatment ```
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
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Myositis Ossificans What is it? Location Presentation
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
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Lipoxygenase pathway yields...
Leukotrienes
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LTB4
"Neutrophils Arrive Before Others" | Neutrophil chemotactic
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LTC4, D4, and E4
Bronchoconstriction, Vasoconstriction, Contraction of Smooth Muscle, ↑ Vascular permeability
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PGI2 Name Function Synthesis
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)
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Leukotriene Synthesis
Membrane lipids (eg phosphatidylinositol) --> [PLA2] --> Arachidonic Acid --> [Lipoxygenase] --> Hydroperoxides (HPETEs) --> Leukotrienes
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Prostaglandins Names Function Synthesis
PGE2, PGF2α ↑ Uterine tone, ↓ Vascular tone, ↓ Bronchial tone Membrane lipids (eg phosphatidylinositol) --> [PLA2] --> Arachidonic Acid --> [COX] --> Endoperoxides (PGG2, PGH2) --> Prostaglandins
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Thromboxane Names Function Synthesis
TXA2 ↑ Platelet aggregation, ↑ Vascular tone, ↑ Bronchial tone Membrane lipids (eg phosphatidylinositol) --> [PLA2] --> Arachidonic Acid --> [COX] --> Endoperoxides (PGG2, PGH2) --> Thromboxane
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Aspirin Mechanism Net result Class
Irreversibly inhibits COX1 and COX2 by acetylation ↓ synthesis of both TXA2 and Prostaglandins, ↑ bleeding time, No effect on PT of PTT NSAID
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Aspirin Uses Tox
``` 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 ```
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``` NSAIDs Names Mechanism Use Tox ```
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
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COX2 Inhibitors Name MoA What does it Spare?
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
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COX2 Inhibitors Use Tox
RA and Osteoarthritis in pts with gastritis or ulcers | ↑ risk of thrombosis. Sulfa allergy
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Acetaminophen MoA Use Tox
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
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Cure for Acetaminophen OD
N-acetylcysteine regenerates Glutathione
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``` Bisphosphonates Names Kind of drug MoA Use Tox ```
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
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Names of Gout Drugs
Allopurinol, Febuxostat, Probenecid, Colchicine
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``` Allopurinol MoA Use Findings w/ use What drugs cannot go with it? Affect on uric acid clearance? ```
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
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Febuxostat MoA Use
Inhibits xanthine oxidase | Gout
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Probenecid MoA Use Tox
Inhibits reabsorption of uric acid in PCT Gout inhibits secretion of penicillin
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Colchicine MoA Use Tox
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
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Acute drugs for gout
NSAIDs (Naproxen and Indomethacin) | Oral or Intramuscular Glucocorticoids
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Risks of TNFα inhibitors
Predispose to infection including TB since TNF blockade prevents activation of macrophages and destruction of phagocytosed microbes
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``` Etanercept Class of drug Description of drug MoA Use ```
"etanerCEPT is a TNF decoy reCEPTor" TNFα inhibitors Fusion protein: receptor for TNFα and IgG1 Fc produced by recombinant DNA RA, Psoriasis, Ankylosing Spondylitis
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Infliximab, Adalimumab Class of drug MoA Use
TNFα inhibitors Anti TNFα monoclonal Ab RA, Psoriasis, Ankylosing Spondylitis, Crohn's Disease
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Periosteum
A membrane that lines the outer surface of all bones, except at the joints of long bones.
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Osteoid
Unmineralized bone
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Bones of lateral foot
Posterior to anterior: Calcaneus and Cuboid
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Bones of medial foot
Posterior to anterior: Talus and Navicular bones | Medial, Intermediate, and Lateral Cuneiforms
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Sensory innervation of anterior leg
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
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Sensory innervation of posterior leg
``` 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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