Scenario 14: Wilma's Woeful Wrist Flashcards
1
Q
Which muscles are abductors of the wrist joint?
A
Flexor carpi radialis and extensor carpi radialis longus and brevis
2
Q
Which pro-inflammatory cytokines modulate inflammation in arthritis?
A
TNF-a, IL-1, IL-6, IL-17
3
Q
How does rheumatoid arthritis usually begin?
A
Insidious onset of joint pain, stiffness, swelling over months. Can be over weeks or acute onset
4
Q
What is the cutaneous nerve supply of the skin in the medial arm and arm pit?
A
T2
5
Q
What are some of the corticoids or glucocorticoids used to treat rheumatoid arthritis?
A
Hydrocortisone, dexamethasone, prednisodone
6
Q
Describe the fasica of the palm
A
No superficial fascia, fascia is thin over the thenar and hypothenar eminences and thick where it forms the palmar aponeurosis
7
Q
What are some negatives of the assessments of social barriers model when looking at disability?
A
Takes attention away from effects of pain and other symptoms in causing disability/handicap and role of medical treatments/rehabilitation
8
Q
Which is the most commonly fractured carpal bone?
A
The scaphoid
9
Q
What are some features of rheumatoid arthritis?
A
Symmetrical polyarthritis, stiffness, rheumatoid factor/anti-CCP antibodies (not necessary for diagnosis), nodules indicate seropositive disease, systemic disease, joint destruction, doesn’t involve DIP joints
10
Q
What are Gilula’s arcs?
A
Arcs of the normal position of the carpal bones, disruption of which indicate ligament tear or fracture of the carpal bones
11
Q
Which muscles are adductors of the wrist joint?
A
Flexor carpi ulnaris and extensor carpi ulnaris
12
Q
What is Erb-Duchenne’s palsy?
A
Lesion of C5/6 spinal roots caused by a fall onto the shoulder or stretch of a baby’s shoulder during birth causing the patient to present with a adducted, pronated and medially rotated limb with extended elbow
13
Q
Where is the radial nerve prone to injury?
A
In the spiral groove of the humerus or by fracture of the lateral epicondyle
14
Q
What lessens the side effects of corticoids or glucocorticoids to treat rheumatoid arthritis?
A
Local treatment (intra-articular)
15
Q
What is the function of abductor pollicis brevis?
A
Abducts the thumb
16
Q
What is carpal tunnel syndrome?
A
Compression of the median nerve and other structures in the carpal tunnel caused by swelling or oedema such as in pregnancy or arthritis
17
Q
What are some non-pharmacological treatments for arthritis?
A
All drugs may be given alongside diet, exercise and surgical approaches
18
Q
What is the function of opponens digiti minimi?
A
It rotates the metacarpal of the little finger towards the palm, producing opposition.
19
Q
What is the contents of the carpal tunnel?
A
The 8 flexor tendons of the fingers (4 flexor digitorum superficialis and 4 flexor digitorum profundus) and 1 flexor tendon of the thumb (flexor pollicus longus) as well as flexor carpi radialis. The median nerve.
20
Q
What are some positives of the assessments of social barriers model when looking at disability?
A
Shifted focus from individual to society, identified importance of political action and social change to ensure opportunities for full participation
21
Q
Where does the median nerve give motor supply?
A
Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, radial 2 lumbricals, oppenons pollicis, abductor pollicis, flexor pollicis brevis. The anterior interosseous nerve supplies flexor pollicus longus, lateral half of flexor digitorum profundus and pronator quadratus
22
Q
Where is the plane of adduction and abduction of the fingers?
A
Around the 3rd digit
23
Q
What are some major and minor activities of daily living used in the Barthel index?
A
Major: get to and use toilet, eat and drink, do up buttons and zips
Minor: get in and out of bed, have bath, wash hands/face
24
Q
What are the toxicities of the DMARD paraentral gold?
A
Myleo-suppression, proteinuria - moderate risk
25
Describe palmar grip
Thumb acts as buttress to object placed in the palmar gutter, most powerful
26
Which anti-inflammatory cytokines modulate inflammation in arthritis?
IL-10, TGFB
27
Which muscles are extensors of the wrist joint?
Extensors carpi radialis longus and brevis, extensor carpi ulnaris
28
What is the cutaneous nerve supply of the skin of mid palm and middle fingers?
C7
29
Where does the thoracodorsal nerve supply?
Latissimus dorsi
30
What is the innervation of the interossei muscles?
Ulnar nerve
31
What is the cutaneous nerve supply of the skin of the hypothenar eminence and medial wrist?
C8
32
Why are DIPJs not involved in RA?
The DIPJS contain very little synovium, so do not cause clinically significant synovitis. Although it is possible to get inflammation it is less clinically apparent
33
Which cytokines are angiogenic/growth factors?
TNFa
34
Which cytokines induce apoptosis?
IL-2, IFNy
35
How is rituximab administered?
Given IV 1-2 weeks apart and retreated as required
36
What does the loss of radial nerve function cause?
Wrist drop and paraesthesia over the lateral dorsum of the hand
37
What are the inflammatory mediators involved in rheumatoid arthritis?
Histamine, bradykinin, nitric oxide, eicosanoids (prostaglandins, leukotrienes) neuropeptides (substance P), cytokines (TNFa) complement, PAF
38
Name digit 2
Digiti indicus or index finer
39
Why do patients with RA develop ulnar deviation?
Persistent inflammatory activity weakens the ligaments and tendons. This leads to instability in the joints. As resistance to displacing forces is lost, extensor tendons are displaced in an ulnar and palmar direction which leads to the characteristic subluxation of the joints and ulnar deviation.
40
Name digit 1
Pollex or thumb
41
Describe the superficial venous drainage of the hand.
Via a dorsal venous plexus, which drains either medially via the basilic vein or laterally via the cephalic vein
42
What are the cons of using corticoids or glucocorticoids to treat rheumatoid arthritis?
Side effects: osteoporosis, increased risk of infection, adrenal atrophy
43
How do most NSAIDs work?
Inhibit enzyme PGH synthase
44
What is the function of the lumbricals?
Flex MCP and extend IP joints of each digit
45
What does rituximab do?
CD20, reduces B cells and the antibodies the produce The B cells that produce harmful autoantibodies such as rheumatoid factor are therefore reduced.
46
How does arachidonic acid form prostaglandins and thromboxanes?
Via cyclo-oxygenase
47
Describe the course of the ulnar nerve
No branches in the arm, lies in a deep groove behind the medial epicondyle. In the forearm it courses between the two heads of flexor carpi ulnaris lying anterior to flexor digitorum profundus. In the wrist it lies between flexor digitorum superficialis and flexor carpi ulnaris. It passes though the canal of Guyon and it's motor branch winds round the hook of the hamate.
48
Which NSAIDs have reversible competitive inhibition?
Ibuprofen and meloxicam
49
What are the range of movement's possible at the wrist joint?
Large flexion/extension range and shorter abduction/adduction range
50
How are the common digital arteries formed?
From the superfical palmar arch formed of the ulnar artery.
51
Where does the median nerve give sensory supply?
Palmar cutaneous branch to thenar skin, lateral 3.5 digits on the palm and nail beds dorsally
52
What are the toxicities of the DMARD sulfasalazine?
Myleo-suppression- low risk
53
How does arachidonic acid get liberated from phospholipids?
Cleavage of phospholipase A2
54
Where does the dorsal scapula nerve supply?
The rhomboids and levator scapulae
55
How long does the DMARD leflunomide take to benefit the patient?
4-12 weeks
56
Where does the ulnar nerve give motor supply?
Flexor carpi ulnaris, medial half of flexor digitorum profundus, all small muscles of hand except thenar eminence
57
Describe median nerve palsy
Loss of opposition of the thumb and abduction. Muscle wasting causes flat (Simian) hand
58
Describe the route of the radial nerve.
Leaves the posterior cord and passes posteriorly through a triangular interval (long head of triceps, teres major and humeral shaft) with the profunda brachii artery before reaching the spiral groove on the posterior aspect of the humerus over the medial head of triceps before passing between brachialis and brachioradalis. It supplies them and extensor carpi radialis and then passes between the heads of supinator before dividing into superficial and deep branches.
59
What kind of joints are the proximal and distal interphalangeal (or just interphalangeal for the thumb) joints?
Synovial hinge joints
60
What separates distal radioulnar and radiocarpal joints?
An articular disc lying between the radius and styloid process of the ulna
61
What are the carpal bones in the distal row?
Hamate, capitate, trapezoid and trapezium
62
What are the attachments of the palmar aponeurosis?
Covers the soft tissues and long flexor tendons, the proximal end is continuous with the flexor retinaculum and palmaris longus tendon. Distally it forms 4 longitudinal bands attaching to the bases of the proximal phalanges becoming continuous with the fibrous digital sheaths
63
What is the purpose of using activities of daily living (ADLs)?
Reduces different diagnostic groups to a common disability currency, estimates overall prevalence/severity, enables comparisons between diseases men/women, age groups, areas of country
64
Which cytokine is the central mediator of arthritis?
TNFa
65
Which joints make up the wrist joint?
Radiocarpal, (ulnocarpal), midcarpal, intercarpal, carpometacarpal and distal radioulnar joints
66
What are the functions of the palmar interossei muscles?
Adduct fingers at MCP joint
67
What are the structural differences between COX-1 and COX-2?
COX-1 has a bulky isoleucine at 523 and no hydrophobic side pocket so that COX-2 inhibitors don't fit into the space. COX-2 has a valine at 523.
68
Where does the princeps pollicis artery originate from?
From the radial artery as it leaves the dorsum of the hand
69
Give the proximal attachments of the 5 metacarpal bones
1st metacarpal: trapezium. The other four contact the trapezoid, capitate, hamate and lateral medial surface of other metacarpals
70
What is seronegative spondyloarthropathy?
An umbrella term for inflammatory diseases that involve both the joints and the entheses
71
Where can the C5 dermatome be tested?
Lateral edge of upper arm
72
Which bone of the wrist is technically not a true carpal bone?
The pistiform, a sesamoid bone
73
What are some of the pathophysiological signs of rheumatoid arthritis?
Increased size of synovium, infiltration with lymphocytes and macrophages, increased vascularisation (angiogenesis) multiple cytokines, chemokines and other inflammatory mediators
74
Where can the C6 dermatome be tested?
The thumb
75
What is the function of flexor pollicis brevis?
Flexes MCP of the thumb
76
Describe the route of the axillary nerve.
Leaves posterior cord of brachial plexus to wind around the surgical neck of the humerus then passes through the quadrangular space (formed of long head of triceps, shaft of humerus, teres minor and major). It supplies teres minor and deltoid and the regimental patch of skin on the arm.
77
What are the functions of the dorsal interossei muscles?
Abduct fingers at MCP joint
78
Name digit 3
Digiti medius or middle finger
79
What are the clinical symptoms of an ulnar nerve lesion?
Claw hand, reduction of flexion of proximal phalanges and MCP and weakness of extension at IP joint due to loss of lumbrical muscle action
80
What is anakinra?
An IL-1 receptor antagonist
81
Where is the thenar eminence and hypothenar eminence?
The thenar eminence is on the lateral side of the palm of the hand at the base of the thumb, the hypothenar eminence is on the medial side at the base of the little finger
82
What is SOCRATES in regards to patients describing pain?
Site, Onset, Character, Radiation, Alleviating, Triggers, Exacerbating, Severity
83
What are some signs and symptoms of Systemic Lupus Erythematosus?
Arthritis, rash, mouth ulcers, alopecia, renal disease, CNS, anaemia, auto-antibody production
84
What is methotrexate?
A folate antagonist, the most widely used DMARD
85
How is disability a threat to self identity?
Loss of previous identity and plans for future, low feelings of self worth, changes in roles and relationships, social stigma and feelings of shame and exclusion
86
What kind of joints are the metacarpophalangeal joints?
The MCP joints are synovial ellipsoidal joints although the first one behaves more like a hinge joint
87
What are some signs and symptoms of Psoriatic Arthritis?
Can mimic RA with DIP joint involvement, spinal involvement, dactylitis, enthesitis, severe destruction, psoriasis
88
What are the two types of power grip?
Palmar and hook grip
89
How does arachidonic acid form leukotrienes?
Via lipoxygenase
90
Where is the axillary nerve prone to injury?
Dislocation of the glenohumeral joint following fracture of the surgical neck of the humerus
91
Which ligaments prevent excessive abduction, adduction and hyperextension of the thumb?
Radial and ulnar collateral ligaments, and the volar plate
92
Where can the T2 dermatome be tested?
Where the arm meets axilla
93
What is the cutaneous nerve supply of the skin of the upper arm?
C5
94
Which cytokines cause bone and cartilage destruction?
IL-1, TNFa
95
What are the features of the distal radius?
Styloid process laterally and tubercle posteriorly as well as scaphoid and lunate fossa for articulation with scaphoid and lunate bones respectively
96
What are the pros of using corticoids or glucocorticoids to treat rheumatoid arthritis?
Several anti-inflammatory properties, cytokine inhibition, down regulation of adhesion molecules, inhibition of enzyme induction, inhibition of T cell production, induces apoptosis
97
What are the symptoms of oestoarthritis?
Joint pain on movement, little morning stiffness, commonly involved joints are DIPJ, 1st CMCJ, knees, hips, primary pathology is due to cartilage destruction not synovial inflammation
98
Which COX inhibitors are non-specific and what is the issue with these?
Ibuprofen, aspirin, indomethacin. Cause side effects in gut and kidney
99
Describe the course of the musculocutaneous nerve
Follows on from the lateral branch of the brachial plexus and supplies biceps brachii, coracobrachialis and brachialis
100
What upregulates COX-2?
Cytokines: IL-1, TNF, growth factors
101
What are the symptoms of a Colle's fracture?
Dinner fork deformity of the forearm caused by a fall onto the palm with an outstretched arm
102
What is the innervation of the muscles of the thenar eminence?
Median nerve (thenar branch)
103
What are some treatments for oestoarthritis?
Weight loss, excercise, education programme, orthoses, pain relief (oral/topical), surgery (realignment vs replacement)
104
Name digit 4
Digiti anularis or ring finger
105
What is the range of movements of the fingers?
Flexion, extension, abduction and adduction
106
When will a patient receive biologics?
When they have failed to respond to at least 2 standard 2nd line drugs (DMARDs) of which one must be methotrexate. Their arthritis must score highly in severity on more than one occasion.
107
What are the attachments of the flexor retinaculum?
The pistiform bone and hook of hamate medially, tubercle of the scaphoid and trapezium bones laterally
108
Give two connective tissue diseases.
Systemic Lupus Erythematosus (SLE) and Systemic Sclerosis (SS)
109
Which muscles and movements are needed in a precision grip of the hand?
Rotation at the carpometacarpal joint of thumb and MCP joints of fingers and thumb. Involves intrinsic muscles together with flexor digitorum superficialis and profundus and flexor pollicus longus. Opposition is key.
110
What are some monoclonal antibodies (anti TNFa drugs)?
Infliximab and adalinumab
111
What type of joints are the 2-5 carpometacarpal joint?
Synovial ellipsoidal joints
112
What is the function of abductor digiti minimi?
Abducts the little finger
113
What are some risk factors for Ankylosing Spondylitis?
Male sex, gene test for HLA B27
114
Where does the ulnar nerve give sensory supply?
Ulnar 1.5 digits on palmar and dorsal surfaces
115
What investigations can we do for oestoarthritis?
X-rays- see joint space narrowing, subchondral sclerosis, cyst formation, marginal osteophytes
116
What is the root of the median nerve?
C6-T1
117
What are some key signs of oestoarthritis?
Tender spots around joint margins, firm swellings (Heberden's/Bouchard's nodes), coarse crepitus/locking, restricted painful movements, instability
118
What are the toxicities of the DMARD oral gold?
Myleo-suppression, proteinuria - low risk
119
Where do the median and lateral pectoral nerves supply?
The pectoral muscles
120
Describe the ligaments of the radiocarpal joint.
Weak anterior and posterior ligaments but strong collateral ligaments
121
How long does the DMARD sulfasalazine take to benefit the patient?
1-3 months
122
What are the boundaries of the carpal tunnel?
Formed of two layers: the deep carpal arch floor and superficial flexor retinaculum roof
123
What are osteophytes?
Osteophytes form as a part of OA or any process that causes cartilage degeneration. Consider it is as a wear, tear and repair process. They are bony spurs
124
Where can the C8 dermatome be tested?
Little finger
125
What kind of joint is the wrist joint?
Biaxial synovial joint
126
What is the origin of the axillary nerve?
C5/6 of brachial plexus
127
What are the toxicities of the DMARD azathioprine?
Myleo-suppression, hepatotoxicity, lymphproliferative disorders- moderate risk
128
What is the innervation of the lumbricals?
The medial two lumbricals (of the little and ring fingers) are innervated by the ulnar nerve. The lateral two lumbricals (of the index and middle fingers) are innervated by the median nerve.
129
What is the position of rest of the wrist?
The midprone position with the thumb uppermost as if holding a book
130
What are the dorsal expansions?
Formed on the distal end of the metacarpals and digits as extensor tendons become flattened
131
What is the root of the ulnar nerve?
C8 and T1
132
Which NSAIDs have time dependant irreversible inactivation?
Aspirin and indomethacin
133
What is the supply of the hypothenar muscles?
Ulnar nerve
134
How long does the DMARD paraentral gold take to benefit the patient?
3-6 months
135
What is the function of opponens pollicis?
Opposes the thumb, by medially rotating and flexing the metacarpal on the trapezium
136
What are DMARDs?
Disease modifying anti-rheumatic drugs. Slow acting anti-rheumatic drugs used as second line therapies. A large range of chemical entities, slow acting with a serious array of side effects.
137
What causes septic arthritis?
Bacterial infection
138
Where can the C7 dermatome be tested?
Middle finger
139
How long does the DMARD hydroxychloroquine take to benefit the patient?
2-6 months
140
What are some risk factors for oestoarthritis?
Age, obesity, FHx (nodal OA), past trauma (fractures, infections, inflammation, RA)
141
What is Klumpke's palsy?
Injury to the lower spinal roots by overstretch of the arm or repetitive strain. The elbow is flexed and the forearm supinated, sometimes a claw like deformity of the hand. Weakness in the muscles of the hand, adduction of the wrist and flexion of digits 4-5 and paraesthesia over the medial arm and forearm as well as Horner's syndrome (constriction of pupil, flushed face and loss of sweating on affected side)
142
Where is the musculocutaeous nerve prone to injury?
By compression as it passes through the coracobrachialis muscle
143
What are the 4 stages of the pathology of oestoarthritis?
1) Breakdown of cartilage matrix (production of enzymes e.g. metalloproteinases MMPs)
2) Fibrillation and erosion of cartilage surface (proteoglycan/collagen fragments released into synovial fluid)
3) Cartilage breakdown products within synovium lead to direct destruction of tissue, stimulation MMP production by chondrocytes
4) Disturbed joint architecture (compensatory bone overgrowth by oestophytes)
144
What is the cutaneous nerve supply of the skin of the medial forearm?
T1
145
What are the side effects of biologics?
Minor reaction at site of injection, increased risk of infections e.g. TB
146
What are the toxicities of the DMARD hydroxychloroquine?
Rarely, macular damage
147
How common is oestoarthritis?
In over 50% of over 65s
148
Name digit 5
Digiti minimae or little finger
149
What is the cutaneous nerve supply of the skin of the lateral forearm and thenar eminence?
C6
150
Where can the T1 dermatome be tested?
Medial edge of cubital fossa
151
What are the carpal bones in the proximal row?
Scaphoid, lunate and triquetrum
152
What is the position of function of the wrist?
The neutral position of the hand where flexor and extensor tendons have equilibrium
153
Where is the median nerve prone to injury?
By a supracondylar fracture of the humerus or by compression in the carpal tunnel
154
What are the signs and symptoms of Ankylosing Spondylitis?
It is a peripheral large joint arthritis with tendinopathy, sacroilitis, spine pain and stiffness with extra-articular features (uveitis, ILD)
155
What are the attachements of interossei muscles?
Each interossei originates from the lateral and medial surfaces of the metacarpals. They attach into the extensor hood and proximal phalanx of each finger.
156
Where does the radial nerve give sensory supply?
Radial 3.5 digits on the dorsum of the hand
157
What is the cutaneous nerve supply of the skin over the shoulder?
C4
158
Where does the median nerve supply in the hand?
Motor to the thenar muscles and radial lumbrical muscles as well as sensory to the 3.5 lateral digits on the palmar surface and the tips of the 3.5 lateral digits on the dorsal surface
159
Which nerves innervate the wrist joint?
Anterior and posterior interosseous nerves
160
What extra-articular conditions can arise in rheumatoid arthritis?
Local problems with nodules, pleurisy and pericarditis, systemic vasculitis, neuropathy, Sjogren's syndrome, Felty's syndrome, amyloidosis
161
Describe the course of the median nerve
Travels lateral to brachial artery in arm then medial to it in the cubital fossa. Courses between two heads of pronator teres in forearm then between flexor digitorum profundus and flexor digitorum superficialis. It enters the carpal tunnel between flexor carpi radialis and palmaris longus
162
Where does the suprascapular nerve supply?
Supraspinatus and infraspinatus
163
What is the tenodesis effect?
When you extend the wrist, the fingers flex and when you flex the wrist, the fingers extend
164
What is tenosynovitis?
Infection of the synovial tendon sheaths of the long tendons of the fingers. They can be painful, swell, and limit finger movement
165
What 5 major drug therapies are available to patients with rheumatoid arthritis?
DMARDS, Biologic treatments, NSAIDs, steroids and analgesics
166
What downregulates COX-2?
Glucocorticoid, cytokines: IL-4
167
What are the features of the distal ulna?
Head and styloid process
168
What are the hypothenar muscles?
Opponens digiti minimi, abductor digiti minimi, flexor digiti minimi brevis
169
Which COX inhibitors are COX-2 specific and why are they rarely used?
Celecoxib, rofecoxib, meloxicam. Media hyped up fears over doubled heart attack risk although are actually thought to have the same risk as non-specific inhibitors
170
What level of the spinal cord does a triceps jerk test?
C7/8
171
What are the toxicities of the DMARD leflunomide?
Low risk of diarrhoea, alopecia, rash, headache
172
Where does the radial nerve supply in the hand?
Sensory to the 3.5 lateral digits on the dorsal surface of the hand (except the tips of fingers) and an area over the thenar eminence
173
What are the morbidities of rheumatoid arthritis?
Persisting pain, joint destruction, functional decline, social isolation, impaired function, mortality increased by 30-300% over 10-20 years, CV mortality, infection
174
Describe hook grip
Grip only secure in one direction, object held between palm and flexed fingers
175
Which cytokines modify Th2 lymphocytes?
IL-4, IL-13, IL-10, chemokines
176
Where does the long thoracic nerve supply?
Serratus anterior muscle
177
What are some risk factors for rheumatoid arthritis?
Genes, gender (more in females), hormones, smoking, infection, autoimmunity
178
What are some local causes of inflammatory musculoskeletal pain?
Gout (urate crystals), pseudogout (calcium pyrophosphate) infection, tenosynovitis
179
Gives 4 types of seronegative spondyloarthropathy.
Ankylosing Spondylitis (AS) Psoriatic Arthritis (PsA) Enteropathic Arthritis, Reactive Arthritis
180
How long does the DMARD oral gold take to benefit the patient?
4-6 months
181
What are the attachments of the lumbricals?
Each lumbrical originates from a tendon of the flexor digitorum profundus. They pass dorsally and laterally around each finger, and inserts into the extensor hood.
182
What is the function of flexor digiti minimi?
Flexes the MCP joint of the little finger
183
What are the tendon sheaths surrounding the tendons of the carpal tunnel?
One for the flexor carpi radialis, one for the tendon of flexor pollicus longus (radial bursa), one for the flexor tendons of the digits (ulnar bursa)
184
Where are the thenar and midpalmar spaces?
Between the flexor tendons and fascia covering the deep palmar muscles lie these spaces separated by a fascial layer
185
How long does the DMARD methotrexate take to benefit the patient?
3-12 weeks
186
How long does the DMARD azathioprine take to benefit the patient?
2-3 months
187
What kind of joint is the distal radioulnar joint?
A pivot joint formed of the head of the ulna and the ulnar notch of the ulna
188
Where do the upper and lower subscapular nerves supply?
Subscapularis and teres major
189
What supports the DIP, PIP and IP joints?
The collateral ligaments and volar plate
190
What is the difference between an impairment, disability and handicap?
Impairment: abnormality in structure or function of body
Disability: functional limitation and activity restriction
Handicap: inability to fulfil normal social role
191
Where does the ulnar nerve supply in the hand?
Motor to hypothenar muscles, ulnar lumbrical muscles and palmar interosseous muscles. Sensory to 1.5 medial digits on the palmar surface and the 2 medial digits on the dorsal surface (except half of the tip of digit 4)
192
Which cytokines modify Th1 lymphocytes?
IL-12, IL-18, IFNy
193
Which digits have tendon sheaths that are continuous with the carpal tunnel?
The ulna bursa is continuous with the sheath around the flexor tendon of the 1st digit, the radial bursa is continuous with the flexor tendon of the 5th digit
194
What are the muscles of the thenar eminence?
Opponens pollicis, abductor pollicis brevis, flexor pollicis brevis
195
What is the purpose of the strong interosseous membrane between radius and ulna?
Prevents parallel displacement of the radius and ulna and allows forces to be transmitted from one bone to the another
196
Name 5 biologics.
Etanercept, infliximab, adalinumab, anakinra and rituximab
197
Where does the subclavian nerve supply?
Subclavius
198
What type of joint is the 1st carpometacarpal joint? What movements are possible?
Synoval saddle joint, bi-axial joint which allows flexion/extension and abduction/adduction so the thumb can do opposition
199
Which digits have isolated tendon sheaths which do not extend to the carpal tunnel?
2-4
200
Which muscles are flexors of the wrist joint?
Flexor carpi radialis and flexor carpi ulnaris and palmaris longus if present
201
Why is it important clinically to block COX-2 not COX-1?
COX-2 is induced in inflammatory cells by inflammatory stimuli, releasing high levels of prostaglandins at inflammatory sites which is bad. COX-1 however is important in forming a thrombus, maintaining blood flow in the GI tract to prevent ulcers and other homeostatic reactions
202
What level of the spinal cord does a biceps jerk test?
C5/6
203
What investigations can we do into patients with suspected rheumatoid arthritis?
RhF or anti-CCP antibodies positive (only in 70-80% cases), acute phase response markers on bloods for inflammation, X-ray hands/feet, MRI and ultrasound for joint damage
204
What are the toxicities of the DMARD cyclosporin?
Affects kidneys and blood pressure, cytotoxic
205
Where is the ulnar nerve prone to injury?
By fracture of the medial epicondyle or pistiform bone and by compression in Guyon's canal of the wrist
206
What is etanercept?
A souble TNF receptor fusion protein (sTNFR construct)
207
What are the toxicities of the DMARD methotrexate?
Myleo-suppression, hepatic fibrosis, cirrhosis, pulmonary infiltrates
