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MS4 - MDEMO > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

3 parts of the bone

A

diaphysis (shaft)

metaphysis (neck)

epiphysis (end)

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2
Q

abnormal gaits?

A
  1. trenedelenburg : compensating bending on the opposite side
  2. antalgic
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3
Q

Antalgic gait?

A

stance phase shorter than the swing phase.

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4
Q

hip replacement, small vs bigger heads?

A

Small: wears off more slowly

Big: wears off more quickly, gives better range of movement

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5
Q

Complications of a hip replacement?

A

fracture

damage to the neurovasculature

change in length of the leg

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6
Q

Why fractures in metaphysis heal more quickly?

A

Bigger cross-sectional area

Better blood supply

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7
Q

Why being intra-articular matters for a fracture?

A

Most likely cartilage is also damaged

Limits movement at the joint

Needs to be immobilised to try to achieve 1^ bone formation and not secondary

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8
Q

Descriptions of a fracture:

  1. Side
  2. Location
  3. Pattern
  4. No of fragments
  5. relation to joint
  6. relation to skin
  7. Displacement of the bone
A
  1. Proximal, middle, distal 1/3 // shaft, head neck
  2. transverse, oblique (>30 degrees), spiral (when oblique on 2 plains)
  3. Multi or simple or segmental
  4. intra or extra articular
  5. open or close
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9
Q

Types of displacement

A

Translation

Shortened

Angulated

Rotated

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10
Q

Management of fracture/dislocation?

A
  1. Reduce ( open or close)
  2. Immobilise
  3. Rehabilitate
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11
Q

Non-surgical immobilsation methods

A

Cast:

first backslab to avoid compartment syndrome by build up of pressure (inflam),

then plaster cast for chronic use

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12
Q

Surgical methods of immobilisation

A

Intramedullary

Extramedullary

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13
Q

Intramedullary fixation methods

A

Intramedullary nail

K wires

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14
Q

Extramedullary fixation methods

A

screws and plate

external fixation (allows treatment of the wound at the same time)

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15
Q

Difference between subluxed and dislocated

A

sublux: partial
dis: complete loss of contact

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16
Q

Non-union risk factors

A

Patient: Old, smoker, alcoholic

Fracture: Open, multi-fragmented

Treatment: poor reduction

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17
Q

Valgus vs varus

A

vaLgus: distal bone points Laterally, apex medially

varus: distal bone points medially

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18
Q

Primary bone healing?

A

absolute stability (rigid fixation)

tunneling resorption

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19
Q

Secondary bone healing

A

Callus formation

Relative stability

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20
Q

3 important compartments of the knee joint?

A

Medial femorohumeral joint

Lateral femorohumeral joint

Femoropatellar joint

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21
Q

Femoropatellar joint arthrtitis pain

A

pain on walking down the stairs

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22
Q

Femoropatellar joint arthritis mx

A

Knee skyline view

1/3 narrowing partial replacement

2/3 narrowing complete replacement

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23
Q

Why infection is important during knee replacement?

A

if infected, abx cant reach, so has to be taken out

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24
Q

virchow’s triad for blood clots?

A
  1. hyper coagulity
  2. immobility
  3. injury to vessels
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25
Q

Sesamoid bone in knee?

A

fabella, within lateral head of gastrocnemius acts as a lever to increase the power

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26
Q

Treatment of injury to menisci within knee?

A

made of fibrocartilage, not much blood supply

the middle 2/3 gets no blood, so damage –> disected out

Outside 1/3 small blood supply, fixed with sutures

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27
Q

pseudogout x-ray differences?

A

calcified meniscus on knee

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28
Q

Gout x-ray changes

A

tophus on x ray, (most common on big toe)

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29
Q

Why ask for a rosenberg radiograph of knee?

A

On supine or standing ones cartilage loss/narrowing of joint may not be visible and are only visible when knee is at 45 degress

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30
Q

Avulsion fracture?

A

bone fragment pulled away by muscle

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31
Q

Normal soft tissue width anterior to cervical vertebrae on a lateral radiograph?

A

C1 to c3 : 1/3 of vertebral body

C4 to c7: width of vertebral body

bigger than that may be due to bleeding

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32
Q

Difference in growth plate of thumb and and other digits metacarpals?

A

thumb: proximal plate
others: distal

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33
Q

What features would make an intra-articular fracture require surgical attention? Why?

A

Step off >2mm

Split >2mm

One part of cartilage gets more loaded: increased weight on one side is not tolerable by the cartilage: risk of arthritis

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34
Q

What are the white lines on the surface of the bone?

A

Trabeculae: shows the direction of spread of the weight

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35
Q

Which articular surface of calcaneous gets the most pressure?

A

posterior articular facet

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36
Q

Classifications of the ankle fractures?

A

Webbers A: Distal to syndesmoses (tibia and fibula touching distally)

Webbers B: At the syndesmoses

Webbers C: Above syndesmoses

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37
Q

Mx of ankle fracture

A

A no fix

B fix if unstable

C always fix Bimaleolar, trimaleolar (posteriro side)

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38
Q

2 types of bone?

A
  1. Woven: laid down in disorganised manner
  2. Lamellar a. cortical b. cancellous
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39
Q

Cortical bone

A

dense, concentric rings

mostly around diaphysis, little around metaphysis

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40
Q

Cancellous bone

A

laid along the stress linse (tabeculae)

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41
Q

Bone cell types

A

Oosteocyte (90%, Ca hoemostasis)

Oesteoblast

Oesteoclast

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42
Q

Matrix types

A

Inorganic (60%) aka calcium ; resists compressive load

Organic (40%) aka type 1 collagen: resists extensile force

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43
Q

Bone blood supply in children

A

Metaphyseoepipheal system and diaphyseal system separated by growth plate

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44
Q

Adult bone blood supply

A

Nutrient artery
Periosteal artery

Volkmanns canal (transverse)

Haversian canal (within a concentric ring)

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45
Q

Nutrient artery fx

A
  • Ascending and descending limbs
  • high pressure, flow from inside to outside
  • supplies the inner 2/3
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46
Q

Periosteal artery fx

A

low pressure, from muscle blood supply

supplies the outer third

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47
Q

Pereosteum 2 layers?

A

Outer fibrous

Inner vascular (Oesteoblastic activity, helps with bone healing)

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48
Q

Shenton line

A

is an imaginary line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur.

This line should be continuous and smooth

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49
Q

Lipohaemarthrosis?

A
  • Intra-articular fracture
  • with escape of fat and blood from the bone marrow into the joint
  • seen on horizontal beam radiograph, lateral view of knee, fat superior to blood
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50
Q

Difference between gout and pseudogout crystals UNDER THE MICROSCOPE?

A

Gout: needle-shaped

Pseudo: cuboid crystals

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51
Q

Ewing’s sarcoma?

A
  • cancer cells are found in the bone or in soft tissue
  • most common areas in which it occurs are the pelvis, the femur, the humerus, the ribs and clavicle (collar bone)
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52
Q

Most common sites of fractures on an extended arm?

A

Triquetrum

Scaphoid

medial/lateral epicondyl

suprachondylar fossa

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53
Q

3 stages of walking?

A

Foot strike

Flat foot

Toe off

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54
Q

Greenstick fracture

A

a fracture of the bone, occurring typically in children, in which one side of the bone is broken and the other only bent.

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55
Q

5 common shoulder problems?Age?

A

Dislocation 20-40 yo

Impingement 40-60

Rotator cuff tear 45-65

OA >60

Frozen shoulder 40-80

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56
Q

Structures posterior to medial malleolus

A

Tom dick and very naughty harry

Tibialis posterior

Flexor Digitorum longus

Tibial artery

Tibial vein

Tibial nerve

Flexor hallucis longus

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57
Q

Structures anterior to medial malleolus

A

Extensor hallucis longus

Extensor digitorum longus

Dorsalis pedis

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58
Q

Foot and ankle exam?

A

a. Look
1. Look at nail beds for psoriatic arthritis
2. sunshine sign (sausage like toes)
3. scars between toes
4. flat foot. 5. Look at sole for calluses
6. Achilles tendon (plantar flex: varus toes, landing :valgus toes)
7. gait
b. Feel Go from medial to lateral to feel joints

Dorsalis pedis and post. tibialis

c. Move: both passive and active
1. Extend,flex big toe
2. Invert-exvert
3. dorsiflex, plantar flex
4. Thomas test: squeezing gastrocnemious to see achilles tendon moving normally (rupture otherwise)
5. Squeez MTP joints to check for pain/ sign of OA

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59
Q

Things to consider on a fracture x-ray?

A

Name, date, side

The most obvious abnormality is… JOAST

Joint

Outline : break along outline?

Arthritis : displaced?

Soft tissue : open/close?

Texture of the bone : trabeculae?

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60
Q

Primary ossification centres?

A

develops first

starts at diaphysis

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61
Q

Secondary ossification centre

A

ends of long bone

these 2 separated by epiphyseal plates

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62
Q

2 types of ossification?

A
  1. Endochondral - bone laid on cartilage- eg long bones
  2. Intramembranous- bone laid on bone eg skull and clavicle
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63
Q

2 types of bone healing?

A
  1. primary Cutting cone model
  2. secondary
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64
Q

Primary bone healing

A

Oclasts cut bone, Oblasts lay bone, followed by vascularisation

  • no cartilage formation
  • Aim of surgical fixation by plate and screw ( needs to have very little strain on the fractured part of the bone to achieve this)
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65
Q

Secondary bone healing

A

4 stages:

  1. inflammation (fibroblasts form granulation tissue)
  2. Soft callus formation (granulation tissue -> fibrocartilage (chondrocytes) (3rd week)
  3. hard callus (fibrocartilage –>woven bone) ( 6th week, appears on x-ray)
  4. Remodelling (Woven –> lamellar bone , several yrs)
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66
Q

2 types of non-union

A

Either stability or blood supply is impaired:

  1. hypertrophic non-union:new bone forms, but no bridges at fracture site, shows blood supply intact, but lack of stability
  2. atrophic non-union: soft edges of bone shows lack of blood supply
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67
Q

Plastering of tibial fracture?

A

above knee for 6 weeks, followed by sarmiento (patellar tendon bearing plaster) which allows movement of the knee

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68
Q

Which fractures are intra-articular on femur? How treated?

A

capsule is between greater and lesser trochantar, anything proximal is intra.

Either screws or hemiarthroplasty

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69
Q

Which joint(s) need(s) to be involved in a plaster of extra articular fracture?

A

above and below

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70
Q

Colle’s fracturewhat?/where?4 features?

A
  • extra-articular fractures of distal radius-

dorsal angulation

  • radial displacement
  • dorsal displacement
  • shortening
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71
Q

Action of interossei muscles?

A

DAB PAD

Dorsal interpssei abduction

Palmar interossei adduction

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72
Q

Nerve supply of various muscles in hand?

A

Median (LOAF) :

  • Lumbricals
  • Opponens pollicis,
  • Abductor pollicis brevis
  • Flexor pollicis brevis

Radial: - Extensors of digits, thumb and wrist

Ulnar:- everything else

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73
Q

Dupuytren’s contracture def

A

DEF: flexion contracture of MCP or PIP,

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74
Q

Dupuytrens cause

A

caused by palmar fascia thickening

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75
Q

Dupuytrens sx

A

little finger and ring finger slightly flexed

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76
Q

Dupuytrens mx

A

if interfering with function, excised

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77
Q

Ganglion def

A

non-painful lump in hand

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78
Q

ganglion contracture cause

A

myxoid degeneration of fibrous tissue

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79
Q

Ganglion site

A

most common on the back of the hand (medial to snuffbox),

A1 pulley

DIP digits

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80
Q

Ganglion mx

A

aspirate (refills) or excision if affecting function

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81
Q

Trigger finger def

A

thickening of flexor tendon of a finger (most commonly ring finger)

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82
Q

Trigger finger mx

A

trigger finger release surgery (cutting the A1 pulley, to allow extension of the digits)

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83
Q

Positive Carpal tunnel test?

A

Hyperextend wrist, press on carpal tunnel. Painful is a positive test

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84
Q

Tendonopathy vs tendonitis

A

pathy: - more chronic- wear and tear
itis: - acute inflammation

85
Q

Funtional elbow range of movement?

A

30 (wipe back passage) to 140 (feed)

50 % of Supination (put clothes on)/ pronation (operate computer)

Sup/pron less important as shoulder can compensate

86
Q

Tennis elbow

A

affects lateral epicondyle

87
Q

Tennis elbow examination

A

tender lateral epicondyle at 90 degrees

  • Mills test: passively extend elbow, flex wrist, radial deviate wrist. pain on lateral epicondyle
  • limited extension of elbow
88
Q

Tinnel sign

A

tapping lateral to medial epicondyle, on the nerve, brings on symptoms

89
Q

Tennis elbow mx

A

clasp below elbow, rests the long extensors

90
Q

Ulnar nerve neuropathy examination

A

Muscle wasting : hypothenar muscle, interossei wasting (guttering of hand)

Clawing : lumbricals vs long flexors

Tinnel sign

91
Q

Ulnar nerve neuropathy ix

A

nerve conduction study
60 m/s normal nerve conduction
40 m/s in neuropathy

92
Q

Ulnar nerve neuropathy mx

A

surgical decompression

93
Q

Olecranon bursitis examination

A

ROM unaffected
Swelling in the normally loose skin on the posterior side of elbow

94
Q

Olecranon bursitis mx

A
  • rest
  • ice
  • compression
  • cut out
95
Q

Keinbocks disease

A
  • avascular necrosis of lunate bone,
  • pain and discomfort in wrist, reduced ROM
96
Q

Keinbocks rx

A
  • surgical fusion of the wrist
97
Q

Developmental dysplasia of the hip (DDH) Def

A

failure of normal development of the acetabulum leading to excessive joint laxity

98
Q

DDH sx

A

loss of abduction

leg length discrepancy

asymmetrical posterior skin crease

99
Q

DDH Dx

A

screened at 24hrs/6mo post birth

Barlow test:- attempts to dislocate a reduced hip, by pulling down and adduction of a hip at 90 degrees

Ortolani’s test:- attempts to reduce a dislocated hip, by abducting a 90 flexed hip4. ultrasound younger babies, x-ray older children

100
Q

DDH mx

A

Conservative: Palvik harness

Surgery: close/open reduction

101
Q

Perthe’s disease def

A

segmental avascular necrosis of femoral head of unknown aetiology

102
Q

Perthe’s X-ray results

A

X-ray:

  • fragmentation
  • subluxation
  • loss of epiphyseal height
103
Q

Perthe’s sx

A

gradual hip/knee pain with impaired abduction

104
Q

Perthes mx

A

75% require no treatment (initially collapses & fragments, then repairs and remodels over years)

  • rest treated by surgical osteotomy
105
Q

Slipped upper femoral epiphysis (SUFE) def

A

displacement of epiphysis due to failure of growth plate, associated with endochondral abnormalities and obesity

106
Q

RFs for SUFE

A

Obesity

Endochondrial abnormalities

107
Q

SUFE x ray

A

epiphysis looks inferior and posterior to femoral neck

108
Q

SUFE mx

A

slip fixed in situ immediately to avoid further displacement

cant be reduced due to risk of avascular necrosis

109
Q

Congenital talipes equinovarus (club foot) presentation

A

calf wasting and inward pointing of the feet

110
Q

Club foot signs

A

fixed varusfixed equinous (plantar flexed)

111
Q

Club foot mx

A

Ponseti casting:

  • slowly corrects the varus deformity
  • weekly changes in cast (external rotation)
  • treatment can last up to 4 years (3mo norm)
112
Q

Development of spinal curves

A

–when born–> thoracic kyphosis–> cervical lordosis —when they walk–> lumbar lordosis

113
Q

movements of different spinal regions

A
  • flexion/extension in lumbar spine
  • rotation in thoracic
  • lateral flexion(abduction) in cervical
114
Q

what level cauda equina comes out?

A

L1/L2

115
Q

4 important bony parts of vertebra

A

spinous and transverse processes, facets, pedicle (aka, foot) and body

116
Q

4 lines to look at on a c-spine x-ray?

A
  • anterior vertebral line
  • posterior vertebral line
  • spinolamilar line
  • posterior spinous line
117
Q

2 parts of vertebral disc

A

annulus fibrosis and nucleus pulposis

118
Q

Spondylolisthesis1. def2. Ix3. Mx

A

slipping of one vertebra onto another

119
Q

SPONDYLOLYSIS

A

defect in pars interarticularis

Intervertebral disc degeneration

OA of facet joints

Commonly cervical and lumbar spine

Support, NSAIDs, surgery (spinal fusion or decompression)

120
Q

Spondylolithiasis X ray

A

Scottie dog appearance

121
Q

Spondylolithiasis mx

A

conservative: - reduction in activity may allow it to heal
surgical: - fusion if pain is really bad

122
Q

Gibbus?

A

A Gibbus deformity is a form of structural kyphosis, where one or more adjacent vertebrae become wedged.

123
Q

Cauda equina syndrome def

A

the cauda equina, located below the level of L2, becomes compressed

  • This condition is a surgical emergency, requiring immediate referral
124
Q

Metastasis to spine

A

Breast

Bronchus

Prostate

Kidney

Thyroid

125
Q

Abductor attachment?

A

Abductors attach at greater trochanter

126
Q

Hip capsule attachment

A

Inter-trochanteric line on the anterior side

Mid-neck of femur on the posterior side

127
Q

Blood supply to neck of femur

A

Medial and lateral trochanteric arteries which form the trochanteric anastemosis

128
Q

Different classification of intracapsular fracture

A
  • Subcapital
  • Midcervical
  • Basicervical
    ( + sub trochanteric)
129
Q

NOF X ray?

A

X-ray:

  • CXR
  • AP pelvis
  • horizontal beam of the affected hip

7.

130
Q

Sx of NOF?

A
  • Shortened leg: gluteus maximus and abductors pull up the femur
  • Externally rotated
  • Groin/hip pain
  • neurovascular impairment
131
Q

3 different surgical procedures for NOF

A

hemiarthroplasty

full hip replacement

In-situ fixation: with dynamic hip screws or intermedullary nail

132
Q

Back pain causes?

A

I. Mechanical

a. non-specific: Muscle or ligamentous strains
b. trauma: Vertebral fractures, intervertebral disc prolapse (PID)
c. degenerative: Spondylosis, intervertebral disc prolapse, spinal stenosis, spondylolisthesis, scoliosis, kyphosis, spina bifidaII.

Non-mechanical

a. Inflammatory: Spondyloarthropathy, rheumatoid arthritis, polymyalgia rheumatica
b. Metabolic: Osteoporosis (vertebral collapse), Paget’s disease, Osteomalacia
c. neoplasm
d. Infection: Osteomyelitis, paravertebral abscess, discitis, TB

III. Referred

a. GI/GU: biliary colic, renal colic, pancreatitis
b. Visceral organs: endometriosis and prostatitis, atopic pregnancy

133
Q

Knee examination

A

LOOK (anterior , lateral, posterior)GaitSkin: redness, scars Soft tissue: swelling (Baker’s cyst), muscle wasting (disc prolapse)Bone: Valgus (7 degrees of valgus normal)/ varus - hyperextensionSIT UP on bed (legs hanging) Extend leg: normal patellar traction laterally? Feel for creptationsFEEL (always keep an eye on the patient to look for pain)1. Temperature2. From tibial tuborisity->go proximal -> and medial to patella to feel the medial joint line -> after reaching the joint space go away from midline medially to feel the medial joint line3. From tibial tuborisity->go proximal and lateral to patella to feel the medial joint line -> after reaching the joint space go away from midline laterally to feel the lateral joint line4. Go proximal from tibial tuborisity, feeling patellar tendon, patella and quadriceps5. Feel the medial collateral ligament by pressing on the medial epicondyle 6. Feel the lateral collateral ligament by pressing on the lateral epicondyle (move proximal from head of fibula)7. Popliteal fossa8. Sweep test: put a hand on suprapatellar pouch, other hand go up on the medial side, then start distally moving proximally on the lateral side, If positive parapatellar fossa fills with fluid.MOVE (passuve and active)1. Flex and extend 2. At 20 degrees, check the collaterals3. At 90, sit on toes and perform the draw test for ACL and PCL (thumps on the fossa, rest of the hand wraps around the back) 4. Loss of tibial step off at 90 degrees means PCL injuryNVS examJoint above and below

134
Q

Examination of elbow

A

LOOK-wasting-scar-asymmetry FEEL4 bony prominences: - olecranon - medial epicondyl- lateral epicondyl- radial head (felt on supination/pronation) Feel for tenderness, heat, rheumatoid nodulesMOVEFlex 140 degreesExtend 0 degreesSupinate 90 degreesPronate 80 degrees (radial head doesnt go all the way next to ulna)

135
Q

Shoulder examination?

A

1- Look:scars, inflammation, muscle wasting

  1. Feel:Acromioclavicular, sternoclavicular, acromion
  2. Move:

I. non-specific tests:abduction, rotation, flexioncombined touch c7 and t6

II. specific

a. Dislocation Apprehension test (flexed elbow 90, flex shoulder, abduction) : Sulcus sign (pulling down arm, prone to dislocation)
b. Impingement test Neer’s test: thumb down, put fingers posterior superior to AC joint, flex shoulder –> pain at low elevation
c. rotator cuff tear supra: thumbs down, resist elevationinfra: elbow 90 flexed, external rotationsubcapsularis: put your hands behind you, dont let me push them towards your belt, internal rotation,
d. AC joint pain/arthritis: SCARFpain at high elevation

136
Q

Hand examination

A

LOOK

  1. Deformities: - 4 signs of RA
  2. Scars: - carpal tunnel? trigger finger release?
  3. Lumps: - Dupuytren’s contracture? ganglions?
  4. Muscle wasting

FEEL

  1. Painful swellings
  2. Characteristics of lump (6 Ss and P: - Site (and underlying structures), - Size, - Shape, - Surface and edges, - Structure (soft or hard), - Sensation (tenderness, temperature),- Pulsatile
  3. Pulses (ALANS TEST: hold both ulnar and radial arteries, pump their fist, relax hand, let go of ulnar, should slowly go pink)

Motor

  1. Grips:- Power: lift a heavy object- Tripod: hold a pen- Key: thumb and index, unlocking motion
  2. Nerve function- motor and sensory
    - Radial: S: 1st interweb space, M: flex their wrist, ask to extend finger
    - Median: S: tip of index finger, M: ask to point upwards with thumb, dont let you push it down
    - Ulnar: S: tip of little finger, M: piece of paper between fingers dont let me pull it out
137
Q

Hip examination

A

STANDING UP::

LOOK- Gait (trendelenburg/antalgic)

  • Trendelenburg test
  • Spinal screening test (lumbar flexion for AS, crossing arms and twisting both ways, sliding palms down to knees)

Anterior, lateral and posterior sides:- skin ( scars, erythamatous) + - soft tissue (swelling, muscle wasting)

  • bone (pelvic obliquity)
  • coronal view abnormalities such as fixed flexion, sagittal: scoliosis

LYING SUPINE:: LEG LENGTH:

  • apparant : umbilicus to med malleolus
  • true leg length

– ASIS to the tip of medial malleolus

FEEL

  • Skin (temp, erythema, distal sensation)
  • Bone (ASIS, greater trochantar, hip joint halfway between ASIS and trochantar)

MOVE:

  • Thomas test (also tests active flex/extend)
  • abduct/adduct (hand and elbow and ASIS)
  • internal/external rotation, knee at 45
  • FABER and FADIR for acetabular impingement

LYING PRONE- test extension

TO COMPLETE:

  • x-ray of hip
  • examine joints above and below
  • full neurovascular test
138
Q

Spine examination

A

I. LookAnt: symmetry in head, neck and shouldersSide: kyphosis or lordosis Back: scoliosis II. Feel- spinous processes - paravertebral muscles III. MoveA. Cervical- Lateral flexion - Flexion/extension - rotationB. Thoracic - RotationC. Lumbar - lateral flexion- extension/flexionSpecial test:A. Schober test:- Lumbar flexionB. Sciatic stretch test (straight leg raise) - tests sciatica ( sciatic root impingement) - Supine position, flex hip to max possible, Dorisflex - remarkable: posterior thigh/ buttock

139
Q

Albrights Hereditary Osteodystrophy

A

Brachydactyly

Short stature

Mental retardation

140
Q

Arthrodesis

A

Surgical fusion of joint

Cartilage removes and exposed surfaces compressed

Pain relief - but LOM

141
Q

Arthroplasty bearing surfaces

A

Metal on polyethylene (UHMWP)

Ceramic on polyethylene

Metal on metal - fluid film lubrication

Ceramic on ceramic

142
Q

Bisphosphonates mech of action

A

Analogues of normal bone pyrophosphate

Adhere to hydroxyapatite and inhibit osteoclasts

Suppress bone resorption

Exclusively act on calcified tissue

143
Q

When to take bisphosphonate

A

Poor oral bioavailability - take on empty stomach

Remain upright 30 mins after taking

144
Q

Bisphosphonate eg

A

Alendronate, risedronate, pamidronate, zoledronate, ibandronate

145
Q

Blood test for osteoprosis

A

normal

146
Q

Systemic Bone homeostasis regulatory hormones

A
  • PTH
  • Vit D
  • Oestrogen
  • GH
147
Q

Local Bone homeostasis regulatory hormones

A

OSF (osteoclast regulation)

Wnt signalling (osteoblast regulation)

148
Q

PTH produced where

A

parathyroid glands following fall in plasma ionised calcium

149
Q

PTH effect

A

Increases plasma calcium

Reduces plasma phosphate

Increases calcium reabsorption in kidneys

Bone resorption

150
Q

Calcitonin produced where

A

c cells of thyroid

151
Q

Calcitonin action

A

inhibits osteoclast

152
Q

Calcium distribution

A

Bound to protein (mainly albumin)

Complexed with citrate and phosphate (<10%)

Free ions (>50%)

153
Q

Calcium normal ranges

A

2.25 - 2.60 mmol/L

154
Q

Corrected calcium level

A

Takes into account albumin level

155
Q

Recommended daily calcium intake

A

1000 mg

1500 mg post menopause

156
Q

Common causes of hypercalcaemia

A

hyperparathyroid

malignancies

157
Q

Presentation of hypercalcaemia

A

“Bones, stones, abdo groans and psychic moans”

Bone pain/fracture

Renal stones

Constipation

Abdo pain/duodenal ulcer/pancreatitis

Confusion and depression

Thirst

158
Q

Investigations for hypercalcaemia

A

Check PTH

If high due to hyperparathyroidism - scintogram (identify site of parathyroid adenoma)

If malignancy - bone isotope (identify bone metastases)

159
Q

Skeletal complications of hypercalcaemia

A

Osteoporosis

Fractures

Osteolytic lesions (Brown tumours)

Pepper pot skull

160
Q

Management of hypercalcaemia

A

Treat underlying cause

Rehydrate with IV fluids

IV pamidronate (bisphosphonate) - if malignant cause

161
Q

Causes of hypocalcaemia

A

Vit D deficiency

Hypoparathyroidism - Di George syndrome, autoimmune, surgery

Pseudohypoparathyroidism - resistance to PTH

162
Q

Clinical features of hypocalcaemia

A

Tetany

Carpo-pedal spasm

Perioral paraesthesiae

Arrhythmias

Convulsions

163
Q

Causes of osteomalacia and rickets

A

Vit D deficiency

Impaired vit D hydroxylation

Vit D resistance

164
Q

Vitamin D action

A

Increases gut absorption of calcium and phosphate

Increases kidney reabsorption of calcium and phosphate

Bone resorption

165
Q

Impaired vit D hydroxylation causes

A

chronic renal/liver failure

166
Q

Vit D resistance

A
  • Hypophosphataemic
  • Renal tubular disorders
  • Sex linked (X chromosome)
  • Oncogenic osteomalacia
  • Drugs (eg. epiliptics)
167
Q

Clinical features of Osteomalacia

A

Bone pain

Proximal muscle weakness

Waddling gait

Skeletal deformity

Increased fractures

168
Q

Common joint arthrodesed

A

1st MTP joint

Ankle

Wrist

Spine

169
Q

Common Osteomyelitis causing organisms in UK

A

Staph aureus

E. coli

Pseudomonas

Proteus

170
Q

Common sites of osteoporotic fractures

A

Vertebrae

NOF

Distal radius

171
Q

Dowager’s hump

A

Kyphotic deformity following osteoporotic fracture of vertebra

172
Q

DEXA scan

A

Bone mineral density measured at femur and lumbar spine

Given T and Z scores

Investigation for diagnosis of osteoporosis

T score < -2.5 = osteoporosis

-2.5 < T score < -1 = osteopenia

T score > -1 = normal

173
Q

Indications to request DEXA scan

A

Low trauma fracture

Oral glucocorticoids > 3 months

Osteopenia on radiograph

Predisposing condition - eg. malabsorption, thyroid disease

FH osteoporosis

Low lifetime oestrogen exposure

174
Q

Management of osteoporosis

A

Improve diet

Stop smoking

Reduce alcohol

Encourage regular weight bearing exercise

Increase calcium and vit D

Start medications to decrease bone resorption:

  • Bisphosphonates
175
Q

Raloxifene

A

SERM

Exert oestrogen like skeletal effects

Protect against breast cancer

Reduce risk of vertebral fractures

Used for osteoporosis

176
Q

Strontium ranelate

A

Mechanism unclear

Stimulates osteoblasts and inhibits osteoclasts

Reduces fracture risks

Used for osteoporosis

177
Q

Teriparatide

A

Recombinant PTH

Treats refactory osteoporosis

178
Q

Define Osteoarthritis

A

Chronic irreversible degenerative disease to articular cartilage.

Non-inflammatory

Synovial joints

Attempted repair and new bone formation

179
Q

OA history

A

Gradual increasing asymetrical joint pain over several years

Worsened by activity

Relieved by rest

Night pain at later disease stage

One or multiple joint involvement

180
Q

Classification of OA

A

Primary OA (no underlying cause found)

Secondary OA (secondary to a cause):

1) Congenital
2) Acquired

181
Q

Common OA affected joints

A

Knee

Hip

Hands (thumb CMC)

Fingers (DIP)

Spine

Shoulder

Elbow

Wrists

182
Q

Congenital secondary OA

A

Developmental dysplasia of the hip

Perthes disease

Slipped upper femoral epiphysis

183
Q

RFs for OA

A

Age

F

Low Oestrogen stuff

Low Ca/vit D

Smoking

184
Q

OA radiological changes

A

Loss of joint space

Osteophytes

Sclerosis

Subchondral cysts

185
Q

OA conservative mx

A

wt loss

walking aids

physio

186
Q

medical mx of OA

A

analgesia

steroid injection

187
Q

Surgical options for OA

A

Debridement (open/arthroscopic)

Synovectomy

Cheilectomy

Osteotomy

Arthrodesis (fusion)

Arthroplasty

188
Q

Cheilectomy

A

Surgical excision of osteophytes

Reduces painful impingement

Used in 1st MTP joint and ankle

189
Q

Dermatome of lower limb

A
190
Q

Paget’s disease pathophysiology

A

Increased bone turnover - leads to bone remodelling, enlargement, deformity and weakness

191
Q

Pagets affects where

A

skull, pelvis, vertevrae and long bones

192
Q

Clinical features of Paget’s disease

A

Bone pain

Bone swelling and deformity

Increased head circumference

193
Q

Investigations for Paget’s disease

A

Calcium and phosphate normal

Alkaline phosphatase high

Isotope bone scan - extent of disease

194
Q

Pagets X ray

A
  • Bone enlargement
  • Patchy cortical thickening
  • Sclerosis
  • Osteolysis
  • Deformity
195
Q

Complications of Paget’s disease

A

Long bone fractures

Osteosarcomas

Nerve compression - can cause deafness

OA

196
Q

Management of Paget’s disease

A

Bisphosphonates:

  • Oral (eg. risedronate 30 mg daily)
  • IV (eg. pamidronate)

Monitor response by clinical response and ALP

197
Q

Clinical features of Rickets

A

Bone pain

Skeletal deformity

Muscle weakness

Widened and irregular epiphyses

Bowing of long bones

Rib deformities - diaphragm pull produces groove in rib cage

198
Q

X ray for rickets

A
  • Looser’s zones
  • Bowed long bones
  • Widened epiphyses (larger gap)
199
Q

Bloods for rickets

A
  • Corrected calcium low or borderline
  • Secondary hyperparathyroidism (low PO4, high PTH, high ALP)
200
Q

Rickets vs Osteomalacia

A

Rickets - childhood vitamin D inadequacy

Osteomalacia - adult vit D inadequacy

201
Q

Management of osteomalacia and rickets

A

Depends on cause

Dietary deficiency - oral cholecalciferol (vit D)

Malabsorption - parenteral cholecalciferol

Renal failure - alfacalcidol (1 alpha hydroxy vitamin D)

202
Q

RA pathology

A

Synovitis

Synovium infiltrated with inflammatory cells

Chronically inflammed tissue (Pannus) extends from joint margins - erosion of articular cartilage and bone

203
Q

Joints commonly affected in RA

A

PIPs

MCPs

Wrists

Elbow

Shoulder

Knees

Ankles

MTPs

204
Q

RA x ray

A

Loss of joint space

Juxta-articular osteopenia

Bone erosions

Deformity

205
Q

Pannus

A

Granulation tissue

Stimulates release of IL-1 and PDGF

Cartilage destruction and bone erosion

206
Q

Modes of Arthroplasty fixation

A

Cemented - PMMA bone cement supports prosthesis

Uncemented - prosthesis larger than hole and coated so bone bonds to prosthesis

207
Q

Osteogenesis imperfecta

A

Hx of multiple fracturs from early childhood

Blue sclerae

208
Q

Polyethylene

A

Low friction and cheap

209
Q

Radiograph changes in vertebral osteomyelitis

A

No changes first few weeks

Intervertebral disc space narrowing

Localised osteopenia

Sclerosis

Soft tissue swelling

Later development of vertebral collapse and kyphosis

MS4 - MDEMO (4 decks)

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