Rheumatology/Orthopaedics Flashcards
what is probenecid? caution?
what has a similar effect?
preventes reabsorption of uric acid in PCT
also inhibits secretion/clearance penicillin
caution: can precipitate uric acid crystals
Similar effect is acheived by salicylates at high-dose
what biological is useful in the treatment of GCA?
tocilizumab - anti IL-6 antibody as this is mediator of CD4+ T lymphocyte/macrophage inflammatory response
weakness of dorsiflexion and difficulty heel walking suggest disc heriation at what level?
L4-5
boney tumour that has bone pain resolving with aspirin
osteoid osteoma
name the nerve and artery that run by this bone/region:
surgical neck of humerus
axillary
posterior circumflex humeral artery
what are the distinguishing features of osteoblastoma from osteoid osteoma?
larger (>2cm)
found in vertebrae
unresponsive to aspirin
what bone cancer occurs on the surface of facial bones?
osteoma
associated with Gardner syndrome
nerve damage with # surgical neck of humerus
axillary nerve (C5-6)
nerve damage with medial condylar #
signs?
ulnar nerve
loss of wrist flexion and all other muscles in hand; sensation over hypothenar eminence and medial 1.5 fingers
osteonecrosis of the femoral head is caused by what, other than fracture? (4)
- sickle cell disease
- vasculitis (SLE)
- alcoholism
- high-dose corticosteroids
where does a Baker’s cyst form?
popliteal fluid collection in gasctrocnemius-semimembranosus bursa
back pain
focal tenderness with recent infection, IVDU or immunocompromise
vertebral osteomyelitis
nerve damage with midshaft # humerus
signs?
radial nerve
loss of extensors at elbow, wrist and fingers
considerations of scaphoid #
AVN and non-union due to retrograde blood supply
what are the side effects of colchicine?
mainly diarrhoea but also N&V, abdo pain sometimes - come on shortly after beginning therapy
anti-smooth muscle antibodies are associated with which condition?
autoimmune hepatitis
arm hanging by side, held in extension and internal rotation
indicates damage where in the brachial plexus? what is this called?
upper trunk - Erb palsy
what are the two growth factor essential for osteoclastic differentiation?
RANK-L and M-CSF
what is this and who gets it?
Greenstick fracture
incomplete fracture extending partway through width of bone following bending stress
children
growth of the lateral sestion of the growth plate outward leading to boney tumour with overlying cartilage
diagnosis?
what is the dangerous progression from this?
osteochrondroma
overlying cartilage growth plate can transform to costochondroma (malignant)
pathogenesis of McCune Albright Syndrome?
mutation of GNAS gene
constituative activation of G(s)/AC/cAMP cAMP activates melanocytes (cafe au lait spots), osteoclasts (lytic bone lesions), precocious puberty etc..
what is golfers elbow and what action predisposes to it?
medial epicondylitis
repetitive flexion (forehand)
what ligament separates the lesser and greater sciatic foramen?
sacrospinous ligament
pathogenesis of reactive arthritis?
immune complex deposition involving bacterial antigens from the precipitating GI/GU infection
campylobacter, clostridium, shigella, salmonella, yersinia, chlamydia
flaccid lower limbs and absent ankle reflexes
poorly developed sacrum
diagnosis and association?
caudal regression syndrome
poorly controlled diabetes, but not always
4 changes associated with degenerative arthritis of the spine
- bulging intraverterbral disc
- thickened ligamentus flavum
- hypertrophied/osteophitic facet joint
- foraminal stenosis
what is the difference between tamoxifen and raloxifene?
both selective estrogen receptor modulators
- *tamoxifen** - strong breast antagonist, endometrial agonist, medium bone agonist
- significant endometrial effects means only used in breast CA treatment*
- *raloxifene** - bone agonist, antagonist on breast, antagonist on endometrium
- perfect for breat CA and osteoporosis prevention*
which vessel is at risk of damage with a femoral neck #?
medial femoral circumflex artery
back pain
pain with spinal extension (standing), walk around with hunched back
spinal stenosis
type 1 muscle also known as?
how dose it work?
where in the body is it found?
slow twitch fibres
red from increased myoglobin and mitrochondria, more oxidative phosphorylation; high endurance
postural maintenance - paraspinal muscles, rectus abdominis etc
association with myositis(es)
visceral organ solid tumour e.g. gastric adenocarcinoma
what is the effect of anti-epileptics on bone?
increase vitamin D catabolism = osteoporosis
specifically phenobarbital, phenytoin, carbamazepine
what is tennis elbow and what action predisposes to it?
lateral epicodylitis
repetitive extension (backhands)
what is the Ewing Sarcoma translocation?
t(11;22)
serum marker of osteoblast activity?
how can you tell this from liver or placenta released ALP?
alk phos
bone ALP denatures in heat (bone - boil), electrophoresis and specific monoclonal antibodies
woven bone is found where in genetically normal individuals?
following # and Paget’s disease
what does an osteoclast secrete to break down bone?
H+ and collagenases
bisphosphonates are structurally similar to what compound? how does this make it work?
pyrophosphate
competitively binds hydroxyapatite in bone, stopping osteoclasts’ ability to break it down
what is Charcot-Marie-Tooth disease? mutation symptoms classic finding
genes affecting proper myelin sheath
hammer toe, foot drop, polyneuropathy champagne-bottle legs (distal muscle wasting)
what structures pass through the greater sciatic foramen?
piriformis, originating from the anterior aspect of sacrum
gluteal (sup and inf) and sciatic nerves
gluteal vessels (sup and inf)
piriformis syndrome - muscle injury and hypertrophy, sciatica-like symptoms; muscle tender with deep palpation and stretching
tingling of the hand when held at 90deg flexion suggests?
carpel tunnel syndrome
(Phalen maneuver)
what are the cancers associated with familial retinoblastoma?
bilateral retinoblastoma
osteosarcoma in teenage years
onion skin appearance on x-ray…
pathoG?
Ewing Sarcoma
anti-desmoglein 1 and 3 antibodies are associated with which condition?
pemphigus vulgaris
myositis antibodies
ANA
Anti-Jo-1 (a.k.a. anti-histidyl-tRNA synthetase)
name the nerve and artery that run by this bone/region:
distal humerus/cubital fossa
median
brachial
inability to anchor scapula to the thoracic cage resulting in inability to ABduct arm over 90deg
where is the injury, how do you get it and what is the sign called?
long thoracic nerve supplying serratus anterior
axillary node clearance/stab wound
winged scapula
diagnosis?
osteoid osteoma
what primaries give osteolytic boney mets?
multiple myeloma
NSCLC, NHL, RCC, melanoma
anteriomedial supracondylar # risks which nerve?
median
what three diseases are caused by parvovirus B19?
- erythema infectiosum
- acute arthropathy
- aplastic crisis
nerve damage with lateral traction on neck during delivery
upper trunk, C5-7, musckulocutaneous nerve damage
Erb’s palsy
what is leflunomide? indications?
inhibits dihydroorotate dehydrogenase, blocks pyrimidine synthesis. inhibits T cell proliferation
RA and psoriatic arthritis
describe the injury resulting from significant axial traction of the radius in children
strategy for reduction?
subluxation of radial head
annular ligament displaces over the head of the radius and slips into the radiohumeral joint, where it becomes trapped causing pain
complete supination of forearm then complete flexion of elbow
what is teriparatide? How is it given? indications?
contraindications
recominant PTH analog, increases osteoblast activity to lay down more bone
daily SC injection
osteoporosis, c/o bisphosphonates. this stimulates bone growth versus inhibiting resorption
do not use: Paget’s disease of bone or unexplained alk phos elevation; increases risk of osteosarcoma
consideration of lunate dislocation
impingement on the carpal tunnel leading to carpal tunnel syndrome
in the sarcomere, what bands contact and what band stays equal length?
H and I bands contract, bringing Z lines closer together
A band is always equal length
back pain
radiates to leg, neuro findings, positive straight leg raise
radiculopathy (disc herniation)
what primaries give osteoblastic lesions?
prostate
small cell lung CA, hodgkin’s lymphoma
modern name for Churg-Strauss?
eosinophilic granulomatosis with polyangiitis
RA affects what part of the spine?
cervical spine
back pain
positional that is relieved by rest
degenerative, OA
multinucleated giant cell with over 100 nuclei from bone biopsy
suggestive of what disease?
Paget’s disease of the bone
absent motor component of cremasteric reflex
nerve and nerve roots?
genitofemoral nerve, L1-2
what is keratoderma blenorrhagicum?
blistering of the sole of feet in reactive (Reiter’s) arthritis
name the nerve and artery that run by this bone/region:
pop fossa
tibial
popliteal
risk factors for elderly onset osteosarcoma?
Paget’s disease of bone (also leads to high output cardiac failure)
radiation exposure
what is the mechanism for urinary/faecal incontinence following childbirth?
stretch damage to the pudendal nerve (S2-4)
normally controls external urethral and anal sphincters
what medication is implicated in drug-induced lupus?
heart: procainamide, hydralazine
bugs: isoniazid, minocycline, quinidine
a lateral ankle sprain most common tears which ligament only?
anterior talofibular ligament
worse injuries can also tear the calcaneofibular ligament or posterior talofibular ligament
osteoma benigin or malignant?
benign
back pain
young man, relieved by exercise
spondyloarthropathy
3 main antibodies for systemic sclerosis
anti-topoisomerase I (anti-Scl70)
anti-centromere
anti-RNA Pol III
polyarteritis nodosa is associated with what infection?
hepatitis B
weakness of plantar flexion and toe-walking, decreases achilles reflex suggests disc heriation at what level?
L5-S1
what are the two factors responsible for the differentiation of osteoclast precursors?
- M-CSF
- RANK:RANK-L binding
OPG binds RANK-L, inhibiting RANK activation. low OPG:RANK-L ratio needed for osteoclast precursor differentiation
pleimorphic cells producing osteoid on biopsy
radiograph shown below
what are the classic radiological findings shown?
osteosarcoma
destructive lesion, sunburst pattern, Codman’s triangle (periosteum lifts off bone)
carpal tunnel syndrome is associated with what systemic conditions?
- pregnancy
- endocrinopathy - diabetes, hypothyroidism, acromegaly
- dialysis-related amyloidosis
- Rh arthritis
endomyseal mononuclear infiltrate with patchy muscle fibrosis is suggestive of which disease?
polymyositis
where do cartilage tumours arise?
medulla
tumour in young adults with multinucleated giant cells and stromal cells
where is it found?
giant cell tumour
only tumour found in epiphysis
who gets Ewing Sarcoma?
where does it occur?
male children
diaphysis of long boneinside the medullary cavity
where do you find chondrosarcoma versus chondroma?
CSoma - malignant in pelvis or central skeleton
Coma - benign in small bones of hand and feet
what is the effect of PPI on bone?
inhibit Ca++ absorption = osteoporosis
name the nerve and artery that run by this bone/region:
posterior to medial malleolus
tibial
posterior tibialis
what test should be done before starting anyone on etanercept?
etanercept = TNF-alpha blocker.
can lead to activation of latent TB
test with Tuberculin skin test before starting
what is a specific marker of bone osteoclast activity?
urine deoxypyridinoline
symptoms of polyarteritis nodosa? (classify in 4)
- GI - ischaemia/infarction, bleeding
- Msk - myositis, arthritis
- Nervous - mononeuritis multiplex, peripheral neuropathy
- Kidney - glomerulonephritis, hypertension
what is the diagnosis and what is the radiological sign?
giant cell tumour
soap-bubble appearance
3 extraskeletal manifestations of ank spond
- respiratory - chest wall becomes stiff giving type 2 respiratory failure
- cardiovascular - ascending aortitis, aortic root dilatation and aortic insufficiency
- opthalmic - uveitis
vasculitis with eosinophilia suggests?
Churg-Strauss
rotator cuff muscles
SItS
supraspinatus, infraspinatus, teres minor, supscapularis
weakness of knee extension and decreased patellar reflex suggests what level disc herniation?
L3-4
what primaries give mixed boney mets?
GI and breast CA
a benign tumour of osteoblasts surrounded by rim of sclerotic/reactive bone
diagnosis?
osteoid osteoma
excessive MMP at the site of a joint injury leads to what?
contracture
what medication dose is affected by allopurinol?
increases azathioprine and 6mercaptopurine conc
both are normally metabolised by xanthine oxidase
what is the cell lineage of Ewing Sarcoma?
neuroectoderm
anti-neutrophil myeloperoxidase means…
it’s a pANCA
Churg-Strauss (eGPA)
anchondroplasia is associated with what gene mutation?
FGFR3 leads to premature ossification and fusion of the growth plates, normal torso but short limbs, especially proximally
type 2 muscle also known as?
how does it work?
fast twitch
white fibres from less mitochondria and myoglobin, more anaerobic glygolysis
foot drop is a lesion of what nerve and nerve roots?
common peroneal
L4-S2
how does calcium induce smooth muscle contraction?
calcium bind calmodulin
activates myosin light chain kinase, phosphorylates MLC
MLC-P = contraction
which bones undergo membranous ossification?
clavicle, calvarium (frontal, parietal and occipital), facial bones
what is pegloticase?
recombinant uricase
catalyzes uric acid to allantoin, water-soluble produce with renal clearance
prophylactic/long term treatment for gout
hand held in MCP extension and DIP/PIP flexion
where is the lesion and what is this called?
traction/tear of the lower trunk -
Klumpke palsy
also seen in thoracic outlet syndrome (+vascular compression)
what is the cell signalling pathway implicated in the pathogenesis of Paget’s disease of the bone? 3 phases of history of the disease?
RANK and NF-kappaB activation
osteoclastic - breakdown of bone.
Mixed - new bone formation
osteosclerotic - osetoblasts lay down dense, hypoplastic, mosaic pattern, weak bone and eventually overgrows. prominent cement lines
who gets osteoid osteoma?
where in the body is it found?
young adults <25 y/o
cortex of diaphysis of long bone
what is the triad of McCune Albright syndrome?
- fibrous dysplasia
- café au lait spots
- endocrinopathy
antiphospholipid antibody syndrome is associated with which antibodies?
anti-cardiolipin
circulating antibodies against collagen IV means what?
anti-GBM antibodies
Goodpasture’s disease
back pain
worse at night, constant, no response to positional change
boney met in spine
how does nitric oxide induce smooth muscle relaxation?
NO stimulates conversion of GTP to cGMP
cGMP activates MLC-phosphatase
dephosphorylated MLC relaxes muscle
nerve damage with supracondylar #
signs?
median nerve
loss of wrist flexion and LLOAF, sensation over thenar eminence and lateral 3.5 fingers
pathologic # or bone pain
lesion in metaphysis of long bone
diagnosis?
osteosarcoma
what drugs directly inhibit bone formation leading to osteoporosis?
glucocorticoids, TZDs, unfractionated heparin
name the nerve and artery that run by this bone/region:
axilla/lateral thorax
long thoracic
lateral thoracic
knee trauma, Baker cyst or tarsal tunnel syndrome
what nerve can these damage? what nerve roots?
presentation?
tibial
L4 - S3
loss of sensation to sole of foot, cannot stand on tip toes, cannot flex toes
achondroplasia is a defect in what process?
endochondral ossification
inheritance pattern of achondroplasia?
AD
bones of the hand
scaphoid, lunate, triquetrum, pisiform
hamate, capitiate, trapezoid, trapezium
so long to pinky, here come the thumb
what is Tinel sign?
tingling of median nerve distribution on repetitive tapping of the wrist
anteriolateral supracondylar # risks which nerve?
radial nerve
name the nerve and artery that run by this bone/region:
midshaft of humerus
radial
deep brachial
