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Medicine 2 > Musculoskeletal and Trauma > Flashcards

Musculoskeletal and Trauma Flashcards

1
Q

Sedentary behaviour and immobilisation result in (apart from DVT)

A

Muscle atrophy and insulin resistance (muscle less able to increase glucose uptake in response to elevated blood glucose)

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2
Q

State the two changes in protein balance during immobilisation (e.g. due to immobilisation)

A

Muscle protein synthesis declines
Muscle protein breakdown increases but not as much as the decrease in synthesis
Anabolic resistance - even if you eat more protein = protein synthesis still declines = atrophy

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3
Q

Describe the 3 cellular factors that induce muscle proteolysis

A

Increased Ca2+ = increased protein breakdown

Ubiquitin proteasome-dependent - breakdown of defective and old proteins

Lysosomal

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4
Q

Describe the pathway involved in increased muscle protein synthesis in response to exercise

A

increased phosphorylation of the Akt/mTOR pathway. Increased ATP demand = increased AMP = increased activation of glucose transporters = increased glucose uptake and Ca2+ release
Muscle protein breakdown is also inhibited

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5
Q

Post immobilisation , lean muscle and strength can be recovered by …

A

Isometric high load exercise

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6
Q

Trauma and inflammation

A

Inflammation induces muscle atrophy via elevation of muscle cytokines = increased muscle breakdown and inhibition of muscle protein synthesis

Muscle becomes resistant to the insulin and impairs carbohydrate oxidation

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7
Q

Roles of the different bone cells

A

Osteoclast - resorb bone; responds to calcitonin
Osteoblast - lay down bone; responsd to all hormones (PTH, Vit D)
Osteocyte - trapped osteoblast that has become a regulatory cell after it has laid down bone

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8
Q

Describe cortical bone

A

Compact
Found in mature bone
80% of the adult skeleton
Lamellae in concentric rings with lines of force (from exercise/activity)
Canals present (haversian canals) for blood vessels/lymph vessel/nerves

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9
Q

Primary bone healing

A

Requires stability - reduced motion and gap between the cells
Doesn’t occur naturally - operation induced

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10
Q

Secondary bone healing

A

Haematoma - pool of mostly clotted up
Nears blood vessels and spongy bone trabeculae form within the haematoma = fibrocartilaginous callus
Fibrocartilaginous callus becomes a bony callus
Bone remodelling

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11
Q

What is a fracture

A

Soft tissue damage along with bone break

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12
Q

Describing fractures

A

Bone
Location within a bone - proximal/middle/third ; intraarticular(inside joint or outside joint)
Fracture type - oblique/transverse/spiral

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13
Q

Complications of fractures

A

dislocation; ligament tear; rupture of tendon; internal bleeding (higher risk in patients taking anticoagulants); nerve damage; pulmonary embolism; fat embolism (fat released from interior of long bones); compartment syndrome - compression of blood vessels due to excessive swelling of muscles; scar tissue in cartilage can lead to osteoarthritis

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14
Q

What is traction ?

A

Pulling on the limb to reposition the bones and putting pins in to hold them in position

Traction allows control of haemorrhage

Complication - clots, pressure sores, atrophy of muscle, skin tears, pin site infection

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15
Q

External fixation and nails result in what type of healing

A

Secondary

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16
Q

Intermedullary nails

A

Running along the centre of the bone (medullary cavity)
Provide stability to whole bone
Minimal soft tissue dissection

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16
Q

Intermedullary nails

A

Running along the centre of the bone (medullary cavity)
Provide stability to whole bone
Minimal soft tissue dissection

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17
Q

Intervention techniques for fractures *

A

PRICE (protect by immoblising with splint or cast, rest, ice, elevate)

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18
Q

Hip fracture

A

Particularly dangerous because blood supply is compromised (no anastomosis) = femoral head dies if fracture occurs intracapsularly

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19
Q

The 4Ps of compartment syndrome

A

Pain on passive flexion and extension
Pallour
Paresthesia
Pulselessness

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20
Q

Fasciotomy

A

a surgery to relieve swelling and pressure in a compartment of the body. Tissue that surrounds the area is cut open to relieve pressure.
Skin graft may be given to replace the skin
Life long scarring

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21
Q

Define neuropraxia
Axonotmesis
Neurotmesis

A

Neuropraxia - loss of motor function without nerve degeneration
Axnotmesis - axon is damaged but the surrounding connecting tissue remains intact
Neurotmesis - both the axon and connective tissue are damaged is called neurotmesis.

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22
Q

Complications of plasters

A

Pressure sores
Respiratory complications
Clots
Muscle wasting

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23
Q

What are soft tissue injuries

A

Most common kind of injury
Soft tissue includes muscles, tendons, ligaments, fascia, nerves, fibrous tissue, bursa and fat pads , blood vessels, synovial membrane

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24
Q

Describe overuse injuries

A

If exercise is applied in a way that adaptation of the muscle and tendons cannot occur, microscopic injuries can occur leading to inflammation

Causes - training errors, improper form, excessive training, inadequate, rests muscle weakness

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25
Q

Overuse injuries associated with bone

A

Stress fracture
Osteitis - bone inflammation
Periostitis
Apophysitis

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26
Q

Overuse injuries associated with articular cartilage

A

Chondropathy

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27
Q

Overuse injuries associated with joints

A

Synovitis - inflammation of connective tissue lining the inside of a joint capsule
Osteoarthritis

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28
Q

Overuse injuries associated with muscles

A

Chronic compartment syndrome
DOMS
Focal tissue fibrosis

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29
Q

Describe the different types of mechanism of injury

A 
Blunt or penetrating 
Direct or indirect trauma
Torsion 
Shearing
Hyperextension or hyperflexion
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30
Q

Describe the initial treatment of soft tissue injuries

Use acronyms PRICE and HARM

A 
Protect - support or splint
Rest
Ice - 15-20 mins every 2-3 hours 
Compressed 
Elevate
Also avoid 
Heat
Alcohol 
Running 
Massage
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31
Q

Later treatment for soft tissue injuries

A

Stretching, mobilisation, isometric and resistance exercise

Stretching, weighted exercise

Strengthening and proprioception training (injury cause nerve pathway damage that affects your ability to control joint position)

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32
Q

What are bursa

A

Tendons, ligaments, muscles, and skin must glide over bones during joint movement. Tiny, slippery sacs of synovial fluid called bursae facilitate this gliding motion

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33
Q

Energy deficiency syndrome

A

Disordered eating (or low energy availability), amenorrhoea/oligomenorrhoea (in women), and decreased bone mineral density (osteoporosis and osteopenia) are present.

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34
Q

Most common basketball and football injuries

A

Basketball - inversion

Football - ACL tear

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35
Q

Describe the features of sub-maximal exercise

A

Can be sustained between 30-180 minutes before fatigue

Rate of muscle ATP resynthesis is low, metabolic fuel integration occurs (carbs + fat both used)

Glycogen availability is an important determinant of fatigue

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36
Q

How can liver and muscle glycogen recovery be maximised? Why is this important?

A

By ingesting carbs immediately after glycogen-depleting exercise when insulin sensitivity is at its highest

Improves capacity for repeated exercise; useful for athletes

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37
Q

Describe chronic pain

A 
>3 months
Tissues have healed 
Pain is unhelpful 
Caused by changes to nerve network 
Medication has limited effectiveness
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38
Q

Pain is produced by

A

Receptors that detect damage produce threat signals

The brain has to decide , do i need to protect the threat with pain

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39
Q

Risk factors for DVT

A

> 60 , obesity, smoke, contraceptive pill/ HRT, cancer, CHF, varicose veins, dehydration, being bed-bound, long journeys, pregnancy

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40
Q

Describe cellulitis

What is it ?
Symptoms
Treatment

A

Bacterial deep infection of skin
usually affects arms and legs, sometimes eyes/mouth/anus/belly ;

can happen spontaneously but usually after skin break due to trauma or surgery

Makes affected areas red, painful and swollen ; swollen and painful glands

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41
Q

What does erythematous mean?

A

Superficial reddening of skin

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42
Q

Describe the diagnosis/symptoms and treatment for DVT

How does DVT treatment differ during pregnancy ?

A

Diagnosis via venogram (x-ray) or ultrasound

Anticoagulants; if they are not available - filter put into a large vein ; breaking up and suck out the clot through a small tube in the vein + anticoagulant after

Treatment during pregnancy is different - treated with anticoagulants injection for the rest of the pregnancy and until the baby is 6 weeks

43
Q

Describe superfacial vein thrombosis (thrombophlebitis)

Symptoms
Risk factors
Treatment

A

Results in vein inflammation due to blood clotting inside damaged vein walls ; usually occurs at varicose veins

Symptoms - painful hard lumps under skin ; redness of skin on lower leg ; can also occur in arms, penis or breast

Not usually serious - typically clears by itself in a few weeks

risk factor - same as for DVT + thrombophilia (increased blood clotting), polycythaemia

Treatment - elevation of leg, compression stockings, keeping active, cold flannel, NSAIDs

44
Q

Interpreting ultrasound imaging - main features of arteries and veins

A

-Veins generally have thinner walls and larger lumens when compared to the adjacent arteries
– Veins are compressible structures unlike arteries and should collapse when pressure is applied by the operator during the examination
- Vessels can be imaged in a transverse or longitudinal plane

45
Q

Colour Doppler imaging techniques for ultrasound scans

A

The enables assessment of flow velocity and direction within a vessel. Absence of colour means there is lack of flow and could suggest an occlusion

46
Q

Which blood tests should be ordered after commencing treatment for DVT?

A

D-dimer test (determines if there is a blood clot or a condition causing inappropriate blood clots)
INR

47
Q

Causes of leg pain

A

Vascular - limb ischaemia , DVT
Infection - cellulitis
Trauma - fracture, intramuscular haematoma
Autoimmune - myositis
Metabolic - myopathy
Iatrogenic - complex regional pain syndrome
Neoplastic - sarcoma
Degenerative - osteoarthritis, tendinopathy

48
Q

which conditions can cause problems with bone healing

A

diabetes and peripheral vascular disease

49
Q

nerve damage often results in

A

tingling, numbness and pins and needles in the affected areas; can lead to amputation if left untreated

50
Q

damage to nerve often caused by

A

compression from misalignment of bones and joints post trauma

51
Q

what is wallerian degeneration

A

loss of peripheral nerve function (peripheral nerve disease) through degeneration of neuron axons; can occur due to trauma or alzheimers or motor neurone disease (ALS) ; can occur 24-36 hours post injury ; regeneration occurs if lesion is outside cell body

52
Q

treatments for nerve injuries

A

nerve grafts, nerve conduits (artificial grafts) to join the ends of nerves after the damage part has been removed

53
Q

Define sarcopenia

What is the main cause

A

Loss of muscle mass and quality

Muscle less able to increase muscle protein synthesis in response to eating more protein = anabolic resistance (deficits in mTOR signalling pathway)

54
Q

Changes in muscle mass/strength/fibre composition/oxygen utilisation with age

A

Decreased muscle mass/strength/oxygen consumption

Decreased oxygen consumption due to decreased CO of heart and decreased mitochondrial mass and function

Loss of fast-twitch fibres ; slow-twitch stays the same. This is due to loss of spinal motor neurones from 60+

Sarcopenia is due to anabolic resistance - can be overcome by high protein ingestion

55
Q

Explain how exercise can reverse sarcopenia

A

Restores muscle insulin sensitivity
Increases muscle capillarisation/mitochondrial mass
Reduces muscle fat mass

56
Q

Confounding variables that may explain age related muscle mass and quality

A

Muscle mass from degree of exercise
Change of liver size
Delay of carb absorption
Chewing problems - foods high in fibre are avoided
Salivary gland atrophy - difficulty eating
Decreased digestive enzyme conc and gastric acid - worsened absorption

57
Q

Define glucose tolerance

A

Determined by balance of insulin secretion and insulin action
Deteriorates with age

58
Q

Falls and older patients

A

All older patients should be asked how many times they have fallen in the last year

59
Q

Causes of falls

A 
Inactivity 
Lack of foot care
Poor vision or hearing
Medication adherence or taking drugs incorrectly 
Poor diet
60
Q

Risk factors for falls

A 
Vestibular 
Vitamin D insufficiency 
Polypharmacy - check interactions and especially psychotropic medication
Orthostatic hypotension
Vision loss
Foot or ankle disorder 
Alcohol/drug misuse
Parkinson’s 
Stroke 
Dementia 
Diabetes 
Arthritis 
Syncope 
Continence 
Low mood
Extrinsic - poor lighting/difficulty reaching items
61
Q

Medical and social history for a fall in an elderly patient

A

What was person doing before the fall
Direction of fall - fwd, bwd, sideways, vertical

Injuries caused - FOOSH, facial, head, LOC

Recovery?

62
Q

Causes of dizziness in elderly patients

A

BPPV(benign paroxysmal positional vertigo) - dislodged calcium carbonate crystals in otoliths - causes ear to be sensitive to head position changes when it normally would not

Progressive spine degeneration causing peripheral sensitisation from inflammation

Orthostatic hypotension (also called postural hypotension) - sudden drop in BP when sitting up or down

Mental disorder - anxiety in particular

Polypharmacy - ACEIs, beta-blockers, Ca-blockers, psychotropics

63
Q

Causes of syncope (temporary loss in consciousness)

A

Due to transient global cerebral hypo-perfusion

ID is more important
Can occur after standing up (postural syncope)
Or after meals (post prandial syncope)
Or the classic random faint (reflex syncope)

64
Q

Describe the features of synovial joints

A

Consists of two bone ends separated by synovial fluid and enclosed in fibrocollagenous capsule with synovium secreting cells

Hyaline cartilage covers bone ends not perichondrium in order to reduce friction and absorb shock

Fibroelastic ligaments and tendon attachments prevent excessive movement

65
Q

Describe hyaline cartilage

A

Resist compression: elasticity and stiffness of proteoglycans (hydrogel)
Tensile strength: collagen
Maintained and turned over by chondrocytes
Limited repair and regeneration capacity.
Most is avascular: nutrition is by diffusion-limits thickness

66
Q

Bursitis

A

Swollen bursa cause pain by increasing the friction between bones/tendons/muscles
Typically occurs at shoulder, elbow and knee

67
Q

Osteoarthritis - clinical presentation

A

Monoarticular - only one or a few
No morning stiffness

Crepitations - audible grinding when the joints are moved

Aching/enlarged/rigid/deviated joints; typically occurs at lumbar/cervical spine, proximal and distal hand joints, feet (metatarsophalangeal joint)

Joint effusion/warmth/tenderness

Functional impairement - poor hand grip/dexterity/walking/driving etc

X-ray - narrowing of joint space/osteophytes ; only order x-ray is referral for surgery is an option

No abnormalities in biochemistry/blood tests

68
Q

Rheumatoid arthritis
What is it?
Causes/pathogenesis
Risk factor

A

Chronic systemic inflammation involving synovial joints

Autoimmune cause ; rheumatoid factor present in most

Inflammation due to macrophages and neutrophils ; phagocytosis of IgG and release of lysosomal enzymes = destruction of joint cartilage and recruitment of inflammatory cells ; vasodilation, hyperplasia of synovium and angiogenesis = pannus ; ankylosis as well (stiffening and fusion)

Women far more prone

69
Q

Symptoms of rheumatoid arthritis

A

Morning stiffness for at least 1 hour and present for at least 6 weeks
Simultaneous swelling of three or more joints for at least 6 weeks
Symmetric joint swelling for 6 or more weeks
Rheumatoid nodules anywhere on skin
Serum rheumatoid factor positive

70
Q

Compare rheumatoid arthritis and osteoarthritis

A

RA is inflammatory always, osteoarthritis more due to normal wear and tear

Osteoarthritis often occurs in single joints; rheumatoid arthritis occurs in several joints and is symmetrical

fever, anemia, fatigue, loss of appetite also accompany the symptoms of RA

RA is two to three times more common in women; OA is more common in men before age 45. More common in women after age 45.

Genetic predisposition for OA; less of a genetic component for RA

OA often gets better after waking up, RA stays the same throughout the day

71
Q

Gout
Pathogenesis
Symptoms
Treatment

A

Urate crystals in joints

Due to hyperuricaemia as a result of underexcretion of uric acid (primary gout) from breakdown of purines ; caused by excess consumption of red meat, shellfish

Leads to acute inflammation/arthritis at the joint often MP of big toe and soft tissues ; sudden severe joint pain lasting up to a week

Intermittent attacks destroy joint cartilage and soft tissue —> chronic gouty arthritis

Treatment - NSAIDs, steroid injection, avoiding kidney/liver/seafood/fatty foods/alcohol, uric acid lowering medications to prevent (uric acids crystal deposits under skin0 and kidney stones

72
Q

Pseudogout

Causes and mechanism

Treatment

A

Aging cartilage degeneration

Age related type of osteoarthritis

calcium pyrophosphate crystals depositing in joint cavity

Called pseudogout as symptoms are similar - sudden onset of joint pain typically in knee

Treatment - NSAIDs, corticosteroids for long term symptoms, some gout medication also works

73
Q

Inflammatory diseases of the joints has 4 main causes - identify them

A

Degeneration
Autoimmunity
Crystal deposition
Infection

74
Q

Causes of osteoarthritis

A

Primary - wear, flare and repair

Secondary - trauma, inflammatory disease, joint defects

75
Q

Pathogenesis of osteoarthritis

A

Damage leads to chondrocyte inflammatory response = release of cytokines

This results in the alteration in cartilage composition:

reduced proteoglycans and collagen; increased water, chondrocyte hypertrophy. Cartilage spilts and erodes

Surface cracks, and bone is exposed. Eburnation occurs - bone rubs against bone

Sclerosis(bone becomes more dense) and subchondral osteoporosis

Muscle weakness

bone shock absorbing properties reduced

Osteophytes: abnormal bony
outgrowths form in response to subchondral bone damage

Synovitis/inflammation of joint capsule with hyperplasia and oedema

76
Q

What is the synovium?

A

Specialised connective tissue that lines the inside of synovial joints

77
Q

Risk factors for gout

A 
Being male
Being obese
CHF
Hypertension
Insulin resistance
Metabolic syndrome
Diabetes
Poor kidney function
Using diuretics (water pills).
Drinking excess alcohol.
High fructose consumption
Having a diet high in purines - red meat/organ meat/seafood
78
Q

Ankylosing spondylitis

A

Erosion of sites where ligaments and tendons attach to bone in lumbar spine and sacroiliac joints

Eventual fusion of lower spine and sometimes upper spine/large joints

HLA-B27 antigen

79
Q

Reactive arthropathies

A

Inflammatory joint disorders with an infective primary cause
Inflammation occurs long time after initial infection and distal from site of infection

80
Q

Infectious arthritis

A

Infection of a single joint by Phoenician bacteria due to hameatigenous spread or trauma

Rapid joint destruction and deformity

81
Q

Intervention for sarcopenia in elderly patients

A

Resistance exercise
Balance training
However contraindicated in patient with uncontrolled arrhythmia/tachycardia/hypotension/heart failure/unstable diabetes as you may cause them to have a traumatic injury

82
Q

Normal bp readings

A

Systolic - 90-120

Diastolic - 60-80

83
Q

Bisphosphotanes

A

Reduce bone turnover
Reduce risk of fracture
Used to treat postmenopausal women and elderly men

84
Q

Cancer and osteoporosis

A

Chemotherapy can cause long term effects such as osteoporosis

85
Q

Zoplicone

Uses
Side effects

A

Used to treat insomnia short-term

Side effects (in elderly patients even worse); dry mouth, bitter mouth, dizziness, anxiety, sleep disorders

Interacts with alcohol

86
Q

What is a hemiarthroplasty

A

a procedure used to artificially replace the femur part of your hip joint. It is primarily used when a femur fracture occurs intra-capsularly and patient already had reduced mobility beforehand

87
Q

Total hip replacement indications

A

Very active people

Patients with arthritis

88
Q

Label the types of femur fracture

A
89
Q

Counselling for alendronate and calcium supplements

A

Alendronate should be taken first thing in the morning on an empty stomach (if taken with food, irritation can occur to oesophagus - contraindicated for Barrett’s oesophagus)

Calcium supplements can interact with many different prescription medications, including blood pressure medications, synthetic thyroid hormones, bisphosphonates, antibiotics and calcium channel blockers. To avoid this, take calcium supplements hours before or after the interacting medication

90
Q

Autoimmunity vs hypersensitivity

A

Hypersensitivity occurs where foreign material is recognised but self is damaged

Autoimmunity occurs when self material is recognised as foreign and self is damaged

91
Q

What is the antigen of rheumatoid arthritis

A

IgG

92
Q

Describe central tolerance

A

Occurs in the primary lymphoid organs ; bone marrow for B cells; thymus for T cells

Strong interaction with antigen in immature lymphocytes induces apoptosis

Clonal deletion of immature auto reactive lymphocytes that interact with autoantigens

93
Q

Peripheral tolerance

A

Central tolerance is not totally effective so autoreactive mature B and T cells are still present ; peripheral tolerance inhibits autoreactive T cells via the action of Treg cells

94
Q

Describe how genetic factors and environmental factors are associated with autoimmune diseases.

A

Much more common in women

HLA type

95
Q

Fucntion of Cox 1 and Cox 2 enzymes

A

Cox 1 = protect stomach, kidney and blood vessels and produce prostaglandins; also involved in activating platelets and kidney function
Cox 2 = produce prostaglandins that promote inflammation, pain and fever

96
Q

Adverse effects of NSAIDs

A

Stomach ulcers
Liver failure - Jaundice
Severe stomach pain
Constipations/diarrhoea
Vomiting
Kidney failure - inability to pass urine, bloody/cloudy urine,
CNS - blurred vision, severe headache, ear ringing, photosensitivity

97
Q

Treatment for RA

A

Corticosteroids to reduce inflammation

Kinase/TNF-alpha inhibitors to control immune system activity

98
Q

Diabetics and RA both have an increased risk of

A

Cardiovascular events

99
Q

How do corticosteroids reduce inflammation?

A

Analogues of cortisol - hormone made by adrenal glands in response to metabolism, immune response, stress

Glucorticoids and corticosteroids are interchangeable

They work by suppressing multiple inflammatory genes and the immune system

100
Q

Risk factors for osteoarthritis

A

Age
Women>men
Obesity
Previous damage to bone/cartilage/ligaments
Muscle strength
Virus/valgus knee deformities/hip dysplasia
Genetic
Occupation - prolonged lifting and standing

101
Q

Non-pharmacological management for OA

A

Weight reduction for obese patients
Muscle strengthening - in particular quad exercises for knee OA
Heat or cold packs
Supports/braces/splints
Appropriate footwear with thick soles to provide support for arches of foot
Psychological support for stress, anxiety and depression

102
Q

Pharmacological management of OA

A

Simple analgesia - paracetamol and topical NSAIDs; however risk of side effects with prolonged use

Glucocorticoid injection - however pain relief is often short lived And possible side effects can be dangerous (fat necrosis/tendon rupture, infection, increase in blood sugar levels/BP) also diminishing efficacy

103
Q

Injection site for knee glucocorticoid injection

Contradictions for steroid injections

A

Superomedial - between patella and medial femoral condyle

6 weeks between injections
Contraindications - anticoagulant/awaiting joint replacement surgery/had their joints replaced

104
Q

Pros and cons of knee replacement surgery

A

Pros - for most freedom from pain/ improved mobility and quality of life
Cons - restriction of movement/numbness/stiffness/only lasts 20 years; risk of infection/may need revision surgery/DVT post op/ long recovery period/ effectiveness relies on patient adherence to physiotherapy

105
Q

Radiographic changes typical of rheumatoid arthritis on hand or wrist radiographs

A

erosion; reduced joint space in all joints
soft tissue swelling
osteoporosis: initially juxta-articular, and later generalised
PIP and MCP joints affected

Medicine 2 (14 decks)

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