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Medicine YEAR 1 > Phase 1 - Week 5 (Bones, Cartilage, Osteoarthritis), Phase 2 - Week 4 + 6 (Synovial Joints, Rheumatoid Arthritis, Wrist + Hand, Hip + Knee, Fractures) > Flashcards

Phase 1 - Week 5 (Bones, Cartilage, Osteoarthritis), Phase 2 - Week 4 + 6 (Synovial Joints, Rheumatoid Arthritis, Wrist + Hand, Hip + Knee, Fractures) Flashcards

1
Q

Where is the diaphysis of a long bone?

A

The central shaft

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2
Q

Where is the epiphysis of a long bone?

A

The regions at either end of the bone

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3
Q

Epiphyseal plate of a long bone

A

Present in growing bones, between the diaphysis and epiphyses. Also called growth plate. Growth in length of the bone is the result of deposition of new cartilage at the epiphyseal plate and subsequent mineralisation.

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4
Q

Where is the metaphysis of a long bone?

A

Adjacent to the epiphyseal plate, at the growing end of the diaphysis

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5
Q

What is the epiphyseal line?

A

After puberty the epiphyseal plate becomes fully calcified and remains as the epiphyseal line

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6
Q

Periosteum

A

Covers the surface of bones, consists of an outer layer of tough fibrous connective tissue and an inner layer of osteogenic tissue

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7
Q

Medullary cavity

A

Space running through the centre of bone, lined with osteogenic tissue (endosteum). Contains fatty yellow marrow - not involved in haematopoiesis

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8
Q

Where is red bone marrow located and what is its function?

A

Found in small, flat and irregular bones and the epiphysis of long bones. Contains haematopoietic tissue which produces blood cells

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9
Q

Describe the blood supply to long bones

A
  • Nutrient artery - splits into ascending/descending medullary artery
  • Periosteal arteries - outside of bone
  • Metaphyseal arteries + epiphyseal arteries supplied by the nutrient artery
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10
Q

List the types of bone tissue

A
  1. Compact (dense/cortical)

2. Spongey (trabecular/cancellous)

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11
Q

Where is cortical bone located?

A
  • Outer region of all bones
  • Diaphysis of long bones
  • Outer and inner regions of flat bones
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12
Q

What is the function of cortical bone?

A

Few spaces, provides protection + support especially to long bones - reduce the stress of weight bearing

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13
Q

What are the functional units of cortical bone?

A

Osteons

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14
Q

Describe the structure of osteons

A
  • Central canal containing blood vessels, lymphatics + nerves
  • Surrounded by rings of intercellular substance (lamellae) with spaces (lacunae) between containing osteocytes (mature bone cells)
  • Tiny canals (canaliculi) radiate from lacunae forming a branching network by which nutrients/waste products are transported to and from the osteocytes
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15
Q

Describe the structure of trabecular bone

A
  • Irregular lattice of thin plates of bone called trabeculae between which there are large spaces filled with bone marrow
  • Lacunae containing osteocytes within the trabeculae
  • Osteocytes are nourished directly by blood circulation through marrow cavities from blood vessels penetrating spongey bone from the periosteum
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16
Q

Where is trabecular bone located?

A

Epiphysis of long bones, most of short, flat and irregular bones

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17
Q

List the types of bone cells

A
  1. Osteoblasts
  2. Osteocytes
  3. Osteoclasts
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18
Q

Give the progenitor cells for osteoblasts, osteocytes and osteoclasts

A

Osteoblasts - osteoprogenitor cells
Osteocytes - osteoblasts
Osteoclasts - mononuclear phagocytic cells

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19
Q

Where are osteoblasts found?

A

Surface of all bones, line the internal marrow cavities

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20
Q

How is the structure of osteoblasts specialised for their function?

A

Contain numerous mitochondria and golgi apparatus for rapid protein synthesis

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21
Q

What is the function of osteoblasts?

A

Secrete the constituents of osteoid - the organic matrix of the bone - collagen, proteoglycans + glycoproteins. Important in the process of mineralisation of the matrix

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22
Q

Which hormones regulate the activity of osteoblasts

A

Parathyroid hormone and calcitriol

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23
Q

Where are osteocytes located?

A

Trapped in lacunae within the matrix

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24
Q

Describe the function of osteoclasts

A
  • Giant multinucleated cells
  • Highly mobile
  • Responsible for resorption of bone during growth and skeletal remodelling
  • Bone resorption through the action of collagenase, lysosomal enzymes and acid phosphatase
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25
Q

Where are osteoclasts located?

A

Abundant at surfaces of bone undergoing erosion. At site of contact with bone, highly folded ‘ruffled border’ of microvilli that infiltrates the disintegrating bone surface.

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26
Q

What are the products of bone dissolution and where are they released?

A

Calcium, phosphate and bone matrix constituents are released into the extracellular fluid

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27
Q

Which hormones control the activity of osteoclasts?

A

Parathyroid hormone, calcitonin, thyroxine, oestrogen + metabolites of vitamin D

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28
Q

Describe the main functions of bone

A
  1. Protection and structural support
  2. Attachment for muscles, tendons + ligaments allowing movement by means of articulation (joints)
  3. Homeostasis of minerals (calcium + phosphate)
  4. Forming blood cells - haematopoietic tissue in red bone marrow in short, flat and irregular bones
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29
Q

Where does the nutrient artery enter the bone?

A

Nutrient foramen

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30
Q

Volkmann’s canals

A

Transfer blood from periosteum to central canals of osteons

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31
Q

List the types of joints by structural classification

A
  1. Fibrous joints
  2. Cartilaginous joints
  3. Synovial joints
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32
Q

Describe the structure of fibrous joints

A
  • Predominantly synarthroses
  • Held together by fibrous connective tissue
  • No space between bones - immovable
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33
Q

List the types of fibrous joints

A
  1. Sutures
  2. Syndesmoses
  3. Gomphoses
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34
Q

Suture joints

A
  • In skull

- Short fibres of connective tissue hold bones tightly in place

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35
Q

Syndesmosis joints

A
  • Bones connected by band of connective tissue
  • Small amount of movement depending on length of fibres
  • E.g. joint of tibia and fibula in ankle
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36
Q

Gomphosis joints

A
  • Between teeth and sockets

- Connected into socket by connective tissue called periodontal ligament

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37
Q

Describe the structure of cartilaginous joints

A
  • Predominantly amphiarthroses
  • Bones connected by cartilage
  • Slight movement
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38
Q

List the types of cartilaginous joints

A
  1. Synchondroses

2. Symphyses

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39
Q

Synchondrosis joints

A
  • Bones joined by hyaline cartilage

- In epiphyseal plates of growing children

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40
Q

Symphysis joints

A
  • Hyaline cartilage covers end of bone but connection between bones is fibrocartilage
  • Joints between vertebrae, pubic symphysis
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41
Q

Describe the structure of synovial joints

A
  • Predominantly diarthroses
  • Have space between bones - synovial cavity, filled with synovial fluid
  • Synovial fluid lubricates joints, reduces friction between the bones and allows greater movement
  • Ends of bones covered with articular cartilage (hyaline cartilage)
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42
Q

List the types of movement possible at synovial joints

A
  1. Gliding (flat bone surfaces) e.g. carpal and tarsal
  2. Angular - flexion, extension, abduction, adduction, circumduction
  3. Rotational - medial or lateral
  4. Special - inversion, eversion, protraction, retraction, elevation, depression etc.
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43
Q

Describe the structure of the articular capsule of synovial joints

A
  • Articular capsule is fibrous and continuous with periosteum of articulating bones
  • Articular capsule consists of two layers - outer fibrous membrane, may contain ligaments and inner synovial membrane that secretes the synovial fluid
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44
Q

What is the function of synovial fluid?

A

Lubricating, shock-absorbing, joint nourishing

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45
Q

List the components of synovial fluid

A
  • Blood monocytes
  • Hyaluronic acid
  • Lubricin
  • Proteinases
  • Collagenases
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46
Q

What is the synovial membrane?

A

Soft tissue between articular capsule and joint cavity of synovial joints

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47
Q

Describe the structure of the synovial membrane

A

2 layers

  1. Outer layer or subintima - fibrous, fatty or loosely areolar
  2. Inner layer or intime - thin sheet of cells
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48
Q

How are synovial joints stabilised?

A

Ligaments around the joint allow less movement making the joint stronger and less susceptible to injury

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49
Q

List the types of synovial joint

A
  1. Pivot - between C1/C2 vertebrae
  2. Hinge joint - elbow
  3. Saddle joint - trapezium carpal bone-1st metacarpal bone
  4. Plane joint - between tarsal bones
  5. Ball + socket - hip joint
  6. Codyloid joint - radius-carpal bones of wrist
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50
Q

List the structural classifications of types of cartilage

A
  1. Hyaline cartilage
  2. Fibrocartilage
  3. Elastic cartilage
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51
Q

Describe the production of cartilage

A
  • Mesenchymal cells differentiate into chondroblasts which produce cartilage
  • Chondroblasts grow and begin synthesis of proteoglycan ground substance and fibrous extracellular matrix
  • Chondroblasts develop into chondrocytes (mature cartilage cells)
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52
Q

Perichondrium

A
  • A layer surrounding mature cartilage masses
  • Composed of collagen fibres and spindle shaped cells resembling fibroblasts
  • Also contains capillaries from which nutrients diffuse into the cartilage matrix
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53
Q

Which types of cartilage have/do not have a perichondrium

A

Hyaline and elastic cartilage has a perichondrium, articular hyaline and fibrocartilage do not have a perichonidrium

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54
Q

What is consequence of cartilage not possessing a perichondrium?

A

Cannot regenerate after damage - poor blood supply

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55
Q

How are metabolites transferred between chondrocytes and the surrounding tissues?

A
  • Through diffusion through the water of the ground substance
  • This limits the thickness of cartilage - thick areas need cartilage canals to allow small vessels into centre of cartilage of cartilage mass
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56
Q

Where is hyaline cartilage found?

A
  • On articular surfaces of joints - over surface of bone ends
  • Nasal septum
  • Tracheal rings
  • Sternal ends of ribs
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57
Q

Describe the macrostructure of hyaline cartilage

A

Characterised by small aggregates of chondrocytes embedded in amorphous matrix of ground substance, reinforced by collagen fibres

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58
Q

Where is fibrocartilage found?

A

In intervertebral discs, pubic symphysis, ligaments, connections of tendons to bones

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59
Q

Describe the macrostructure of fibrocartilage

A
  • Resembles dense connective tissue, very abundant collagen fibres with intervening bands of ECM
  • Alternating layers of hyaline cartilage matrix with thick layers of dense collagen fibres, orientated in direction of the functional stress
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60
Q

Where is elastic cartilage found?

A

External ear, larynx, epiglottis, walls of Eustachian tubes

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61
Q

Describe the macrostructure of elastic cartilage

A
  • Firm but flexible due to elastin fibres within ECM similar to hyaline cartilage
  • Elasticity from bundles of branching elastin fibres in cartilage matrix
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62
Q

Describe the microstructure of hyaline cartilage

A

Matrix of chondroitin sulphate into which many fine collagen fibrils are embedded, contains numerous chondrocytes

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63
Q

Explain the function of hyaline cartilage

A
  • Provides smooth surfaces enabling movement/sliding of tissues over each other e.g. at joints
  • Provides flexibility and support
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64
Q

Describe the microstructure of fibrocartilage

A
  • Tough cartilage - chondrocytes scattered among visible dense bundles of collagen fibres within the matrix
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65
Q

Explain the function of fibrocartilage

A
  • Provides support and rigidity to attached/surrounding structures
  • Strongest type of cartilage
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66
Q

Describe the microstructure of elastic cartilage

A

Chondrocytes located in a threadlike network of elastic fibres within the matrix

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67
Q

Explain the function of elastic cartilage

A

Provides support to surrounding structures, helps define + maintain the shape of the area, e.g. external ear

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68
Q

Define osteoarthritis

A

Progressive disorder of the joints caused by gradual loss of cartilage and resulting in the development of bony spurs and cysts at the margins of the joints

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69
Q

Describe the features of an osteoarthritic joint

A
  • Thickened capsule - synovial hypertrophy
  • Cyst formation and sclerosis
  • ‘Shelving’ - fibrillated cartilage
  • Osteophytic lipping
  • Altered contour of bone
  • Cartilage erosion down to subchondral bone
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70
Q

Describe the pathogenesis of osteoarthritis

A
  • Decrease in water content
  • Decrease in proteoglycan synthesis
  • Increase in collagen x-linking
  • Traumatic damage
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71
Q

Which joints are most commonly affected by osteoarthritis?

A

Weight bearing joints e.g. knees/hips and hands

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72
Q

List and describe the types of osteoarthritis

A
  1. Primary - degenerative disorder

2. Secondary - due to trauma, hip dysplasia, infection or diabetes

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73
Q

List the risk factors associated with development of osteoarthritis

A
  • Age - <45
  • Genetics
  • Gender - <50 men at higher risk, >50 women at higher risk
  • Nutritional - low Vitamin C/D intake
  • Joint trauma
  • Obesity
  • Occupation
  • Abnormal joint biomechanics e.g. hip dysplasia
  • Knee extensor weakness
  • Sports w/ joint risk
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74
Q

List the symptoms associated with osteoarthritis

A
  • Pain, especially when doing load-bearing activities e.g. walking
  • Short lived stiffness in the morning - improves in 30 mins or less
  • Difficulty moving affected joints
  • Swelling
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75
Q

Describe the features found when taking a clinical history which would indicate osteoarthritis

A
  • Pain
  • Decreased walking distance
  • Sleep disturbance
  • Limp - Trendelenburg sign
  • Stiffness
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76
Q

Describe the typical features seen on X-Rays of osteoarthritic joints which are used in diagnosis of the disease

A
  • Joint space narrowing
  • Osteophytes - ossifying cartilaginous protrusions lead to irregular outgrowth of new bone
  • Fragmentation of osteophytesor articular cartilage results in presence of intra-articular loss bodies (joint mice)
  • Subchondral sclerosis
  • Cyst formation
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77
Q

Explain the general aims of management of osteoarthritis

A
  • Symptoms of osteoarthritis progress slowly over many years
  • There is no cure for osteoarthritis
  • Treatment is directed at symptom management/slowing progress of condition
  • Goals include reducing pain, increasing range of motion and increasing muscle strength
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78
Q

List the non-operative treatments used to manage osteoarthritis

A
  1. Medications
  2. Physiotherapy
  3. Walking aids
  4. Joint injections
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79
Q

Describe how medication can be used to manage osteoarthritis

A
  • Pain management - paracetamol, NSAIDs

- Alternative medication - glucosamine/chondroitin sulfate

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80
Q

Describe how physiotherapy can be used to manage osteoarthritis

A
  • Exercises to improve range of motion
  • Muscle strengthening
  • Aerobic condition
  • Weight loss
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81
Q

Describe how walking aids can be used to manage osteoarthritis

A
  • Particularly used for osteoarthritic hips
  • Transfer load to unaffected side
  • Reduces load on hip by 40%
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82
Q

Describe how joint injections can be used to manage osteoarthritis

A
  • Cortisone/corticosteroid
  • Reduce inflammation response around joint
  • More rapid effect than NSAIDS
  • Viscous supplement - replace midified synovial fluid in joints
  • Increase viscosity + elasticity of fluid
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83
Q

List the surgical treatments used to manage osteoarthritis

A
  1. Arthroscopy
  2. Cartilage transplantation
  3. Joint transplantation
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84
Q

Describe how arthroscopy is used to manage osteoarthritis

A
  • Keyhole

- Debridement of articular cartilage

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85
Q

Describe how cartilage/joint transplantation is used to manage osteoarthritis

A
  • Remove worn cartilage and replace with cartilage from other joints/synthetic material
  • Remove whole of joint + replace with synthetic material
  • Pain relief and increase in range of motion
  • Improve activities of daily living
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86
Q

What is the extracellular matrix (ECM)

A
  • The acellular component of supporting/connective tissue
  • Complex network of proteins and ploysaccharides
  • Secreted locally by cells and remain closely associated with them
  • Provides structural, adhesive and biochemical signalling support
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87
Q

Where is ECM found?

A
  • Bone
  • Tendon
  • Cartilage
  • BV walls
  • Subcutaneous fat
  • Vitreous body of the eye
  • Cornea
  • Dermal layer of skin
  • Basement membrane
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88
Q

Describe the components of the ECM

A
  1. Fibres - collagen + elastin

2. Ground substance - proteoglycans, glycosaminoglycans (e.g. hyaluronan), glycoproteins

89
Q

List some morphologically and functionally distinct ECM types

A
  1. Submucosa - loose networks to allow movement
  2. Skin - tightly ‘woven’ 3D gives resilient properties
  3. Tendon - unidirectionally aligned for tensile strength
  4. Bone - calcified for mechanical strength
  5. Basal lamina - ultrathin tough sheets for separation/filtration
90
Q

Describe the function of ECM

A
  • Mechanical and structural support
  • Tensile strength
  • Determines cellular microenvironment
91
Q

Describe how ECM determines the cellular microenvironment

A
  • Anchors cells
  • Strongly influences embryonic development
  • Provides pathways for cellular migration (e.g. wound repair)
  • Sequesters growth factors
  • Provides a residence for roaming phagocytic cells
  • Establishes and maintains stem cell niches
92
Q

Explain collagen’s role in ECM

A
  • Major insoluble fibrous protein of ECM
  • Fibrillar collagen in skin, tendons, bones for strength
  • Sheet/network-forming in basement membrane for support/filtration
93
Q

List the types of collagen and where they are found

A
  1. Type I - dermis, tendons, ligaments, bones
  2. Type II - hyaline cartilage
  3. Type III - liver, bone marrow, lymphoid organs, granulation tissue
  4. Type IV - basement membranes
  5. Type V - linker to basement membrane, cornea
94
Q

Explain the role of elastin in ECM

A
  • Structural protein arranged as fibres
  • In skin, lungs + BVs - stretch and elastic recoil
  • Assembly into functional fibres requires the presence of a structural glycoprotein - Fibrillin
95
Q

Ground substance

A
  • Amorphous, colourless, gelatinous material
  • Fills the spaces between fibres and cells
  • Consists of large molecules - glycosaminoglycans (GAGs) which link together to form proteoglycans
  • V good at absorbing water so resistant to compressive forces
96
Q

Glycosaminoglycans

A
  • Also called mucopolysaccharides
  • Chains of repeating disaccharide units
  • Carbohydrate component of proteoglycans
  • E.g. hyaluronic acid in synovial fluid
  • Attracts water - gel/cushioning + hydrating properties
97
Q

List some proteoglycans of ECM and where they are found

A
  • Aggrecan - cartilage
  • Perlecan - basement membrane
  • Syndecan - cartilage
  • Decorin - widespread in connective tissues
98
Q

List some glycoproteins and their functions

A
  • Fibrillin - controls deposition and orientation of elastin
  • Fibronectin - linker role in BM
  • Laminin - primary organiser of BM
  • Entactin - linker role in BM
  • Tenascin - linker role in connective tissue
99
Q

Describe the synthesis of collagen

A
  • Synthesised as pro-collagen
  • Undergoes post-translational modifications - glycosylation + hydroxylation
  • Assembled into a triple helix
100
Q

Describe the synthesis of elastin

A
  • Synthesised as tropoelastin
  • Undergoes post-translational modification - hydroxylation
  • Assembled as a fibrillin scaffold with cross-linked fibres
101
Q

Describe the synthesis of proteoglycans

A
  • Core protein synthesises on rER
  • Addition of polysaccharide as disaccharide repeats in Golgi
  • Delivered to extracellular compartment by exocytosis
  • Assembly with other ECM components
102
Q

Describe the steps involved in ECM remodelling

A
  1. Degradation
  2. Deposition
  3. Modification
103
Q

List the proteins involved in ECM remodelling and describe the changes they bring about

A

Proteases, matrix-metalloproteinases (MMPs) and elastase

Involved in wound repair, embryogenesis and angiogenesis

104
Q

Describe the structure of the basement membrane/basal lamina

A
  • Thin, tough sheet of ECM

- 3 layers - lamina lucida, lumina densa, lamina fibroreticularis

105
Q

List the components of the basement membrane/basal lamina

A
  • Collagen IV
  • Laminin (glycoprotein)
  • Perlecan (heparan sulphate proteoglycan)
  • Entactin + fibronectin (glycoprotein)
106
Q

List the functions of the basement membrane

A
  • Support
  • Binding to underlying connective tissue
  • Mediates signals between cells and connective tissue
  • Determines cell polarity
  • Permits flow of nutrients (permeability)
  • Path for cell migration
  • Barrier to downward growth
107
Q

List some disorders of the basement membrane

A
  1. Cancer - epithelial tumours regarded as malignant once BM is breached
  2. Diabetes mellitus - thickening of BM in glomerulus changes permeability
  3. Epidermolysis bullosa - attachment of epidermis to BM
  4. Goodpastures syndrome - autoantibodies to collagen IV destroy BM in glomerulus and lung
108
Q

What is the main mineral component of osteoid?

A

Calcium hydroxyapatite

109
Q

What type of collagen is found in cartilage?

A

Type II

110
Q

What is the effect of dysfunction of elastin in ECM?

A

Supravalvular aortic stenosis (SVAS) - arterial defects

111
Q

What is the effect of dysfunction of Fibrillin-1 in ECM?

A

Marfan syndrome - skeletal, ocular + cardiovascular abnormalities

112
Q

What is the effect of dysfunction of collagen in ECM?

A

Ehlers-Danlos syndrome - joint + skin abnormalities

113
Q

What is the effect of dysfunction of keratan sulphate in ECM?

A

Macular corneal dystrophy - corneal transparency

114
Q

What is the effect of dysfunction of perlecan in ECM?

A

Silverman-Handmaker type of dyssegmental dysplasia (DDSH) - neonatal lethal dwarfism

115
Q

List the articulations of the hip bones

A
  1. Sacroiliac joint - articulation with the sacrum
  2. Pubis symphysis - articulation between left and right pelvis
  3. Hip joint - articulation with the head of the femur
116
Q

List the parts of the hip bone

A
  1. Ilium
  2. Ischium
  3. Pubis
117
Q

Describe the hip joint articulation

A

Cup-shaped socket called the acetabulum articulates with the head of the femur. Ball + socket joint.

118
Q

Describe the structure of the ilium

A
  • Located superiorly
  • Expands superiorly to form wing (ala)
  • 2 surfaces of the wing - internal and external
  • Internal = concave, produces iliac fossa - site of origin of iliacus muscle
  • External = convex, attachment of gluteal muscles
  • Superior margin = iliac crest - from anterior superior iliac spine to posterior superior iliac spine
  • Posterior aspect has greater sciatic notch
119
Q

Describe the structure of the pubis bone

A
  • Anterior portion of hip bone
  • Made of body, superior ramus and inferior ramus
  • Pubic body = medial, articulates w/ opposite pubic body at pubic symphysis
  • Superior pubic ramus = extends laterally from body to form part of acetabulum
  • Inferior pubic ramus - projects towards ischium
  • Obturator foramen = through which obturator nerve, artery and vein pass through to reach lower limb
120
Q

Describe the structure of the ischium

A
  • Posteroinferior
  • Made of body, inferior ramus and superior ramus
  • Inferior ischial ramus + inferior pubis ramus forms ischiopubic ramus which encloses part of obturator foramen
  • Posteroinferior aspect forms ischial tuberosity
  • Ischial spine = near junction of the superior ramus and body is posteromedial projection of bone
121
Q

Explain which important ligaments attach to the ischium

A
  1. Sacrospinous ligament - runs from ischial spine to sacrum, creating the greater sciatic foramen through which lower limb neurovasculature (including sciatic nerve) transcends
  2. Sacrotuberous ligament - runs from sacrum ischial tuberosity, forming the lesser sciatic foramen
122
Q

Describe the function of the hip joint

A
  • Designed for stability + weight bearing

- Smaller range of movement than shoulder - more stable

123
Q

Describe the structure of the acetabulum

A
  • Deepened by fibrocartilaginous collar - acetabular labrum
124
Q

Describe the intracapsular ligaments which stabilise the hip joint

A

Ligament of head of femur (from acetabular fossa to fovea of femur). Encloses a branch of the obturator artery (artery to head of femur), a minor source of arterial supply to the hip joint.

125
Q

Describe the extracapsular ligaments which stabilise the hip joint

A
  1. Iliofemoral ligament - prevents hyperextension
  2. Pubofemoral ligament - prevents excessive abduction and extension
  3. Ischiofemoral - prevents excessive extension
126
Q

Describe the vascular supply to the hip joint

A
  • Arterial supply from medial and lateral circumflex femoral arteries - branches of profunda femoris artery
  • They anastomose at base of femoral neck to form a ring - small arteries arise from ring to supply hip
  • Medial circumflex artery - majority of arterial supply
127
Q

Explain the effect of damage to the medial circumflex femoral artery

A

Can cause avascular necrosis of femoral head

128
Q

List the additional arterial supply to the head of the femur

A
  • Artery to head of femur

- Superior/inferior gluteal arteries

129
Q

Describe the innervation of the hip joint

A
  • Femoral nerve
  • Obturator nerve
  • Superior gluteal nerve
  • Nerve to quadratus femoris
130
Q

List the movements of the hip joint

A
  1. Flexion
  2. Extension
  3. Abduction
  4. Adduction
  5. Lateral rotation
  6. Medial rotation
131
Q

How is flexion at the hip joint increased?

A

When knee is flexed - relaxes the hamstring muscles

132
Q

How is extension at the hip joint limited?

A

Joint capsule and iliofemoral ligament

133
Q

Describe the structure of the head of the femur

A

Smooth surface w/ a depression on the medial aspect, for the attachment of the ligament of the head of the femur

134
Q

List the significant structural parts of the proximal femur

A
  • Head
  • Neck
  • Greater trochanter
  • Lesser trochanter
  • Lesser trochanteric line
  • Intertrochanteric crest
135
Q

Describe the structure of the neck of the femur

A
  • Connects head of femur to shaft
  • Cylindrical, projecting in superior + medial direction - angle of projection allows for increased range of movement at hip joint
136
Q

Greater trochanter of the femur

A
  • Projection of bone
  • Originates from anterior aspect, lateral to neck
  • Angled superiorly + posteriorly
  • Site of attachment for many muscles in gluteal region, e.g. gluteus medius, gluteus minimus and piriformis
137
Q

Lesser trochanter of the femur

A

A tuberosity from the medial aspect of the neck of the femur

138
Q

Intertrochanteric line

A

Thin, roughed line that joins the trochanters anteriorly

139
Q

Intertrochanteric crest

A

Thick, rounded ridge that joins trochanters posteriorly

140
Q

List the articulations of the knee joint

A
  1. Femoropatellar joint - between patella and from of femur

2. Femorotibial joint - between femur and tibia

141
Q

List the bones involved in the knee joint

A
  1. Femur - lateral + medial condyle
  2. Tibia - lateral + medial condyle
  3. Patella - articular facets
142
Q

Describe the types of movement possible at the knee joint

A
  • Flexion
  • Extension
  • Medial rotation
  • Lateral rotation
143
Q

Describe the synovial membrane and joint capsule of the knee joint

A
  • Joint is lined by synovial membrane from upper border of the patella, between the femur and the quadriceps tendon to form the suprapatella bursa
  • The capsule and synovial membrane surround the entire joint to create a single synovial cavity
144
Q

List the intracapsular ligaments which stabilise the knee joint

A
  1. Anterior cruciate ligament

2. Posterior cruciate ligament

145
Q

List the extracapsular ligaments which stabilise the knee joint

A
  1. Tibial collateral

2. Fibular collateral

146
Q

Describe the epidemiology of hip fractures

A
  • Typically occur in elderly female patients
  • Also common in high impact trauma
  • Mean age = 75 y/o
  • 20-35% mortality in first year
147
Q

List the types of hip fracture

A
  1. Extracapsular

2. Intracapsular

148
Q

Extracapsular hip fractures

A
  • Fracture occurs outside joint capsule
  • Blood supply to femoral head not affected
  • Complications of bone union are rare
  • Described as stable or unstable
  • Unstable = detached fragment of lesser trochanter
149
Q

Intracapsular hip fractures

A
  • Fracture occurs inside joint capsule
  • Can affect blood supply to femoral head, especially if fracture is displaced (ends of bone are not aligned)
  • Complications common - avascular necrosis of femoral head
150
Q

Describe the typical clinical presentation of hip fractures

A
  • History of fall/trauma
  • Leg may be shortened/externally rotated in displaced trauma
  • 10% have other fracture
  • Avascular necrosis is common - treated with total hip replacement
  • Sciatic nerve damage risk in dislocation fractures + dislocation
151
Q

Describe the treatment of undisplaced intracapsular hip fractures

A

Can often displace without treatment so are treated with internal fixation using a dynamic hip screw. 5% have avascular necrosis - will need hip replacement

152
Q

Describe the treatment of displaced intracapsular hip fractures

A

Reduction and fixation - high risk of non-union and fixation failure. 15% have avascular necrosis. Hemiarthroscopy often first line - femoral head is replaced but not acetabular cup. Total hip replacement often only for osteoarthritis. Reduction and fixation more likely in younger patients (without underlying pathology)

153
Q

Describe treatment of extracapsular hip fractures

A

Internal fixation

154
Q

Describe methods of fall prevention in the home

A
  • Removing wires and frayed carpets
  • Using non-slip mats/rugs
  • Wearing well fitting shoes that support the ankle
  • Railing around home
  • Bars in bathroom
  • Personal alarm system
155
Q

List other methods of fall prevention for the elderly

A
  1. Strength and balance training e.g. Tai Chi
  2. Medication review - some medications’ side effects may increase risks of fall
  3. Sight tests - poor vision increases chance of falls
  4. Avoiding alcohol/reducing consumption
156
Q

List the components of a synovial joint

A
  1. Articular cartilage
  2. Synovial cavity
  3. Articular capsule
  4. Synovial fluid
  5. Accessory ligaments
  6. Articular fat pad
  7. Bursae and tendon sheaths
157
Q

Synovial cavity

A
  • Space between two articulating bones

- Contains a small amount of synovial fluid

158
Q

Articular capsule

A
  • Surrounds any surface within interior joint not covered by hyaline cartilage
  • Two layers - external fibrous membrane and internal synovial membrane
159
Q

Accessory ligaments of synovial joints

A
  • Intracapsular and extracapsular
  • Stabilise the joint
  • Intracapulsar - within articular capsule, outside synovial cavity, e.g. cruciate ligaments
  • Extracapsular - outside joint capsule, e.g. tibial collateral ligament
160
Q

Articular fat pads

A
  • Accumulation of adipose tissue
  • Between fibrous capsule and synovial membrane
  • Found in most synovial joints
  • E.g. infrapatellar fat pad of knee
  • Some also have cartilaginous disc between bones for additional cushioning
161
Q

Bursae

A
  • Found in close proximity to synovial joints
  • Fibrous, slightly flattened sacs, lined with synovial membrane, containing a thin film of synovial fluid
  • Between bone and other tissues e.g. skin, tendons, muscles + ligaments
  • Function to cushion movement between structures as they rub together
162
Q

Tendon sheaths

A
  • Reduce joint friction
  • Elongated bursae that wrap around tendons subjected to stress
  • Found primarily at joints undertaking a high degree of movement
163
Q

Define rheumatoid arthritis

A

A chronic inflammatory autoimmune disease causing pain, swelling and stiffness in the joints

164
Q

Which joints are most commonly affected by rheumatoid arthritis

A

Small joints of the hands, feet and wrists

165
Q

Define autoimmunity

A

Loss of immunological tolerance to self

166
Q

What are the causes of autoimmunity?

A
  • Dysfunction in tolerance
  • Presentation of self
  • Molecular mimicry
  • Loss of regulatory mechanisms
167
Q

Describe the impact and long-term consequences of rheumatoid arthritis

A

Can be a major cause of work loss, decreased quality of life and ultimately mortality

168
Q

List the pathways which dysfunction to cause rheumatoid arthritis

A

T-cell/B-cell/Cytokine signalling pathway abnormalities

169
Q

List the risk factors associated with rheumatoid arthritis

A
  1. Genetic predisposition
  2. Environmental factors - e.g. smoking, infection
  3. Imbalance of intestinal microbes - natural or as a result of an infection or other event
  4. Sex - females at higher risk
170
Q

Explain how genetic predisposition can increase risk of rheumatoid arthritis

A
  • Gene associated with RA = HLA-DR4, found in 60-70% of caucasians wth RA, 20% of general population
  • Increases liklihood of develoing RA - not an accurate diagnostic tool
171
Q

Explain how environmental factors can increase risk of rheumatoid arthritis

A
  • Smoking and nicotine exposure - not fully understood, believed that prolonged smoking increases rheumatoid factor (antibody, presence of which in the blood is a sign of autoimmunity)
  • Diet - regularly drinking sugary drinks increases risk. People who are overweight or obese have a greater risk of developing rheumatoid arthritis, symptoms are worse
172
Q

Explain how sex can increase risk of rheumatoid arthritis

A
  • Disruption in hormone balance
  • Women more likely to have RA than men, suggests hormones are a factor
  • Possibly due to oral contraceptives - containing progesterone/oestrogen
173
Q

List the diagnostic tools used to diagnose rheumatoid arthritis

A
  1. Symptoms/clinical examination
  2. Blood tests
  3. Imaging tests
174
Q

Describe the symptoms which indicate rheumatoid arthritis

A

Active synovitis lasting 6+ weeks:

  • Inflammation of joint’s synovial tissue
  • Symptoms = swelling, redness, warmth, pain + stiffness
175
Q

Describe how blood tests can be used to diagnose rheumatoid arthritis

A

Test for rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) and inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)

176
Q

List the imaging techniques used to diagnose rheumatoid arthritis

A
  • Can show evidence of joint damage/inflammation
  • Ultrasound
  • X-Ray
  • MRI
177
Q

Explain how ultrasound can be used to diagnose rheumatoid arthritis

A
  • Detect inflammation of synovial tissue that encapsulates joints + tendons - synovitis
  • Can also detect tenosynovitis in finger, early sign of RA
  • Can be used to measure patient’s response to drugs
178
Q

What is the goal of treatment of rheumatoid arthritis

A

No cure - management to allow high quality of life

179
Q

List the methods used to treat rheumatoid arthritis

A
  1. Physiotherapy
  2. Occupational therapy
  3. Psychological interventions
  4. Pharmacological treatment
180
Q

Describe the role of physiotherapy in treating rheumatoid arthritis

A
  • Improve general fitness and encourage exercise
  • Learn exercises for enhancing joint flexibility, muscle strength and managing other functional impairments
  • Short-term pain relief provided by methods such as transcutaneous electrical nerve stimulators (TENS) and wax baths
181
Q

Describe the role of occupational therapy in treating rheumatoid arthritis

A
  • Help with difficulties with any everyday activities

- Help with problems with hand function

182
Q

Describe the psychological interventions used as part of treatment of rheumatoid arthritis

A

Relaxation, stress management + cognitive coping skills to help people with RA adjust to living with their condition

183
Q

List the types of pharmacological management used in the treatment of rheumatoid arthritis

A
  1. DMARDs

2. Glucocorticoids

184
Q

DMARDs

A
  • Disease modifying anti-rheumatic drugs
  • Reduce pain, swelling and stiffness over a period of weeks/months by slowing down the disease and its effects on the joints
185
Q

Compare DMARDs to NSAIDs and steroids

A

DMARDs treat the disease, in contrasts to NSAIDs - which treat inflammation but not the underlying cause -and steroids - which blunt the immune response but are insufficient to slow down the progression of the disease

186
Q

List the types of DMARDs

A
  1. Conventional DMARDs

2. Biological therapies

187
Q

Describe the mechanism of action of conventional DMARDs

A
  • Slow-acting, can take several weeks to work
  • Mechanism of action e.g. Methotrexate = inhibition of T-Cell activation + inhibition of IL-1 binding, selective down-regulation of B cells
188
Q

List some examples of conventional DMARDs

A

Ciclosporin, cyclophosphamide, hydroxycholoquine, methotrexate

189
Q

Give an example of a biological therapy used to treat rheumatoid arthritis and describe its mechanism of action

A
  • Work more quickly that conventional DMARDs
  • E.g. anti-TNF drugs - target proteins called tumour necrosis factor which increases inflammation when excess amounts are present in the blood/joints e.g. infliximab, monoclonal antibodies
  • Only given to those who have already had other treatments and not responded well
  • Often given in combination with conventional DMARDs
190
Q

Describe the use of glucocorticoids to treat rheumatoid arthritis

A
  • Bind to the glucocorticoid receptor - reduces inflammation
  • Up-regulate the expression of anti-inflammatory proteins, down-regulate the expression of proinflammatory proteins
  • Also play role in development and homeostasis of T lymphocytes
  • Lots of adverse side effects - immunodeficiency, withdrawal problems
191
Q

Describe the generic processes of musculoskeletal ageing

A
  • Decreasing amount of tissue
  • Altered molecular disposition of the matrix
  • Accumulation of degraded molecules
  • Reduced efficiency of functional tissue elements
  • Reduced synthetic capacity of differentiated cells
  • Altered levels of trophic hormones, GFs and cytokines or altered ability of cells to respond
  • Alterations in loading patterns of tissues or tissues response to loading
192
Q

Describe the effect of ageing on bone

A

Reduced bone tissue, relative decline in trophic factors favouring osteoclastic over osteoblasts activity, diminished differentiation potential of bone marrow stem cells

193
Q

Describe the effect of ageing on chondroid tissues

A

Reduced ability to form large hydrophilic complexes leading to decreased swelling pressure, predisposing to OA and IVD degeneration

194
Q

Describe the effect of ageing on ligaments

A

Altered collagen synthesis leading to reduced elasticity

195
Q

Describe the effect of ageing on skeletal muscle

A

Loss of muscle mass and decreased power due to loss of fibre number and fibre atrophy

196
Q

Primary immunodeficiency

A

Congenital, resulting from genetic defects. Inherited. Deficiency causes disease.

197
Q

Secondary immunodeficiency

A

Acquired - result of other diseases or conditions.

198
Q

List the immune cells involved with primary immunodeficiencies

A
  • Humoral defect (B cells and antibodies)
  • Combines humoral and cellular immunodeficiencies (B and T cells)
  • Defect of cell-mediated immunity (T cells)
  • Phagocytic dysfunction (PMNs)
  • Complement deficiency
199
Q

How do humoral defects present?

A
  • Recurrent sepsis an bacterial infections often in airways
  • Chronic gastroenteritis
  • Autoimmune disease = arthritis, lupus
  • Hyper IgM syndrome, IgA deficiency
200
Q

Describe treatments of primary deficiencies

A
  • Mild - no treatment
  • Antibody deficiencies -antibiotics, antibody replacements
  • Granulocyte deficiencies - antibiotics, stem cell transplantation
  • Severe combines immunodeficiency - stem cell transplantation, gene therapy
201
Q

List some examples of secondary immunodeficiency

A
  1. HIV
  2. Irradiation and chemotherapy treatments
  3. Removal of spleen
202
Q

List the articulations of the wrist joint

A
  • Distally - the proximal row of the carpal bones

- Proximally - the distal end of the radius and the articular disc

203
Q

Why is the ulna not part of the wrist joint?

A

It articulates with the radius just proximal to the wrist joint, at the distal radioulnar joint. It is prevented from articulating with the carpal bones by a fibrocartilaginous ligament, called the articular disk, which lies over the superior surface of the ulna

204
Q

List the carpal joints of the wrist

A

Anticlockwise from scaphoid:

  • Scaphoid
  • Lunate
  • Triquetrum
  • Pisiform
  • Hamate
  • Capitate
  • Trapezoid
205
Q

Describe the structure of the joint capsule of the wrist joint

A
  • Dual layered
  • Fibrous outer layer which attaches to the radius, ulna and the proximal row of the carpal bones
  • Internal layer = synovial membrane, secretes synovial fluid which lubricates the joint
206
Q

List the important ligaments of the wrist joint

A
  1. Palmar radiocarpal ligament
  2. Dorsal radiocarpal ligament
  3. Ulnar collateral ligament
  4. Radial collateral ligament
207
Q

Describe the blood supply to the wrist joint

A

Recieves blood from branches of the dorsal and palmar carpal arches, which are derived from the ulnar and radial arteries

208
Q

Describe the innervation to the wrist joint

A

Supplied by branches of 3 nerves:

  1. Median nerve - anterior interosseous branch
  2. Radial nerve - posterior interosseous branch
  3. Ulnar nerve - deep and dorsal branches
209
Q

List the types of movements possible at the wrist joint

A
  • Flexion
  • Extension
  • Adduction
  • Abduction
210
Q

List the joints of the hand

A
  1. Carpometacarpal joints
  2. Metacarpophalangeal joint
  3. Interphalangeal joints:
    - Proximal interphalangeal joints
    - Distal interphalangeal joints
211
Q

Metacarpals

A

5 miniature long bones, support the palm of the hand

212
Q

Phalanges

A
  • 14 miniature long bones of the digits, 3 in each finger, 2 in the thumb
  • Proximal, middle and distal
213
Q

List the movements possible in the hand

A
  • Flexion of digits
  • Extension of digits
  • Abduction of digits
  • Adduction of digits
  • Opposition of thumb + little finger
  • Reposition of thumb and little finger
214
Q

Describe the structure of the palmar fascia

A

Fibrous connective tissue which thickens in the centre of the hand forming the palmar aponeurosis which is continuous with the palmaris longus tendon and flexor retinaculum

215
Q

Palmar aponeurosis

A
  • Protects the underlying muscle compartments

- Fans out distally into four digital rays which then become the fibrous digital sheaths

216
Q

Fibrous digital sheaths

A

Cover the synovial sheaths (containing the flexor tendons) in the digits and keep them in place.

217
Q

List the important ligaments of the hands

A
  1. Flexor retinaculum
  2. Extensor retinaculum
  3. Palmar (volar) plates
  4. Collateral ligaments
218
Q

List the important tendons of the hands

A
  1. Flexor tendons of the digits - flexor digitorum profundus and flexor digitorum superficialis
  2. Extensor tendons of the digits - extensor digitorum
219
Q

Describe the blood supply of the hands

A
  • Supplied by branches of the ulnar and radial arteries
  • Anastomose near the wrist via 4 arches, branches supply the digits
  • Deep palmar arch
  • Palmar metacarpal arteries
  • Superficial palmar arch
  • Dorsal carpal arch
  • Dorsal metacarpal arteries
  • Digital arteries

Venous drainage:
- Dorsal venous arch

Medicine YEAR 1 (18 decks)

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