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MSK Domain > Skeletal Diseases > Flashcards

Skeletal Diseases Flashcards

1
Q

Osgood-Schlatter

A

Inflammation of the patellar tendon corresponding small subacute avulsion fractures of the tibial tuberosity due to repetitive use of the quads and knee
Onset: Late childhood or adolescence; more common in males
Pain last into evening after activity subsides
Diagnosis: clinical or X-ray
Treatment: self limiting and resolves with maturity, use rest, less activity, knee imobilizer, isometric and flexibility exercises, Rarely surgery

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2
Q

Osteoarthritis

A

Etiology: mechanical-joint wear and tear destroys articular cartilage (asymetric joint narrowing)
pathogenesis: progressive breakdown of articular cartilage with remodeling of subchondral bone

Joint Findings: Subchondral cysts, sclerosis, osteophytes (bone spurs)
Eburnation (polished, ivory appearance of bone), Heberden nodes (DIP), and bouchard nodes (PIP). NO MCP involvement

Predisposing factors: age, obesity, joint deformity, trauma

Clinical features:
Boney hypertrophy, crepitance, reduced range of motion, hammertoe

Classic Presentation: slow onset, Pain in weight bearing joints after use, improving with rest, knee cartilage loss beings medially (bowlegged), short morning stiffness, limb and axial distribution
Noninflammatory
No systemic symptoms

Treatment: NSAIDS, intraarticular glucocorticoids, heat, short acting narcotics, SSRI, GABA inhibitor, Tricyclic anitdepressant, long acting narcotics
Activity modification and weight loss
Joint stabilization (strengthening, orthoticcs, bracing, heel wedge), increase flexibility supportive muscles-ligaments
Surgery-total joint arthroplasty>arthroscopy

NO cartilage stabilizing disease modifying agent

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3
Q

Rheumatoid arthritis

A

Etiology: Autoimmune-inflammatory destruction of synovial joints. Mediated by IgM against Fc portion of own IgG (rheumatoid factor)-activates complement
Type III and IV hypersensitivity reactions

Joint findings: pannus formation in joins (MCP, PIP)
Subcutaneous rheumatoid nodules (fibrinoid necrosis), ulnar deviation of fingers, subluxation
Baker cyst in poplitieal fossa
No DIP involvement
Pencil-in-cup deformity

Predisposing factors: females>males
80% are positive for rheumatoid factor
Anti-cyclic citrullinated peptide Ab is more specific
Strong association with HLA-DR4
Ethinicity: greatest in Northern European ancestry
Age of onset 20-60 can follow giving birth
More common in smokers

Classic presentation: Morning stiffness lasting > 30 mins
and improving with use, symmetric joint narrowing, systemic symptoms (fever, fatigue, pleuritis, pericarditis), soft tissue swelling (periarticular), osteopersosis (decreased bone density periarticular)
Develop secondary osteoarthritis

Treatment: NSAIDS, glucocorticoids, disease modifying agents (methotrexate, sulfasalazine, TNF-alpha inhibitors
Adaptive shoes and othotics, splints bracing and heel wedge
pacing, prioritizatin, positioning, incremental goal setting

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4
Q

Avascular necrosis injuries

A

Scaphoid, Talus, Femoral neck (most common-medial circumflex), Navicular
ischemic necrosis of bone and bone marrow
Infarcts can be subchondral or intramedullary

Causes include: trauma or fracture, steroids, sickle cell anemia, caisson disease (gas emboli), lupus, high dose corticosteroids, alcoholism

Osteoarthritis and fracture are major complications
usually very painful

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5
Q

Gout

A

Uric acid buildup
Diagnosis: arthrocentesis of single painful swollen joint
Needle shaped, negatively birefringent monsodium urate crystals (yellow under polarized light)

Due to:
Underexcretion of Uric acid (90%): idiopathic or thiazide diuretics
Overproduction of uric acid (10%): Lesch-Nyhan syndrome, PRPP excess, increased cell turnover (tumor lysis syndrome), Von Gierkes disease

Triggered by dehydration, diuretics, joint trauma, large meal, alcohol intake (alcohol metabolites share same excretion site in kidney as uric acid)

Presents with single acutely swollen joint (great toe)
max inflammation in 1 day (neutrophil response)
Redness over joint-MTP and tarsus most common
tophi (ear, olecranon bursa, or Achilles’ tendon)
Serum uric acid>7
Synovial fluid culture=negative

Asymptomatic hyperurecmia to acute intermittent gout to chronic tophaceous gout

WBC=20,000 to 50,000

Treatment: NSAIDs (acute), glucocorticoids (elderly), Colichine, febuxostat (peptic ulcer disease or other CI)

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6
Q

Pseudo-gout

A

Calcium pyrophosphate buildup
Intra-PMN (neutrophils), romboidal shaped, postiviely bi-refringent

Clinical features:
Acute joint swelling especially in knees>wrists>shoulder>elbow
Triggered by joint trauma, acute medical illness or surgery
Occasionally associated with hyperparathryoidism (increase of calcium), hypoparathyroidism and hemochromatosis

Calcification of cartilage on X-ray
Intracellular CPPD in joint fluid during attack
Synovial fluid culture=negative
\+ bifrngent
Crystals are blue when parallel to light

Treatment: NSAIDS (acute), steroids and colcichine

WBC= 20,000 to 50,000

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7
Q

Systemic Lupus Erythematosis

A

Acute onset, chronic, remitting and relapsing Injury to skin, joints kidney and serosal membranes

Affects childbearing-age African American and Hispanic women most (sex hormones associated)

Failure of mechanisms that maintain self tolerance

Antinuclear antibodies DNA (sensitive), anti-histones (drug induced), nonhistone proteins bound to RNA, nucleolar Ags Abs to dsDNA (specific) and smith Ag (snRNPs), anti cardiolipin (syphilis FP) are diagnostic

May have false positive for syphillis due to cardiolipin Ag produced

Have hypercoagulability state despite slow PTT test

HLA-DQ gene linked to production of anti-dsDNA, anti smith antigen and anti phospholipid Abs

Inherited defienciencies of C1q, C2, or C4 associated with lupus-defective clearance of apoptotic cells
SLE also has hypocomplimentemia of C3, C4 and CH50

Exposure to Uv light exacerbates the disease-induces apoptosis, changes DNA to be immunogenic, or stimulating keratinocytes to produce Il-1
Hydralazine, isoniazid and procainamide associated with drug induced lupus (antihistone Ab)

Failure of self tolerance of B cells

Clinical: fever, weight loss, fatigue, raynaud phenomenon, Butterfly rash upon sunlight exposure, anemia (type II hypersensitivity)
Painless oral or nasopharyngeal ulcers Arthritis (>2 joints) Serotitis (pleuritis and pericarditis) Psychosis and seizures Renal damage (glomerulonephritis) Anemia, thrombocytopenia, or leukopenia (type II hypersensitivy)

Sterile deposits on both sides of mitral valve (lib man sacks valvular endocarditis)-can lead to MI or thrombus

Death: renal failure or accelerated coronary atherosclerosis

Treatment: NSAIDs, immunosuppressants, hydroxychloroquine

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8
Q

Spondyloarthropathritis

A

Age of onset: teens to 40
Ethinicity: Northern European
Associated with HLA B27-HLA MHC class I
mucosal infection can predispose you to spondyloarthritis

Pathogenesis: Immune response to unknown Ag which cross reacts with native Ag in the synovium or enthesis (tendon or ligament insertion)
IL-23/IL-17 are central to pathogensis

Clinical features (P.E.A.R.)
Psoriatic arthritis
Enteric arthritis/Irritable bowel syndrome-Crohn's disease
Ankylosing Spondylitis
Reactive Arthritis

Common features: asymmetric oligoarthritis, enthesitis, dactylitis, sacroiliitis (sclerosis, erosion, narrowin-fusion) spondylitis (vetebral squaring, marginal eroion, vertical bridging osteophytes) and iritis

Treatment: NSAIDS
Oral injectable steroids
Topical: steroids and retinoids, tar based creams phototherapy (Psoriasis)
Sulfasalazine, methotrexate, leflunomide
TNF blockers
IL-12/23 blocker
IL-17 blocker
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9
Q

Psoriatic arthritis

A 
Part of spondyloarthropathies
Joint pain and stiffness associated with psoriasis
Assymetric and patchy involvment
Dactylitis (sausage fingers) 
Pencil-in-Cup deformity

Psoriasis: Salmon colored plaques with silvery scale
on elbows, knees, gluteal cleft, lumbrosacral area, glans penis, and scalp
Nails have yellow brown discoloration with pitting, thickening or crumbling

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10
Q

Ankylosing spondylitis

A

Chronic inflammatory disease of spine and sacroiliac joints leading to ankylosis (stiff spine due to fusion of joints)
uveitis and aortic regurgitation
Bamboo spine
3 months

Improves with exercise
Peripheral enthesitsi (tendon inflammation)
Limits chest wall expansion

Morning stiffness and lower back pain

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11
Q

Inflammatory bowel disease

A

Crohn disease and ulcerative colitis accompanies by ankylosing spondylitis or peripheral arthritis

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12
Q

Reactive arthritis

A

Classic triad: conjuctivitis, urethritis, Arthritis
Can’t pee, can’t see, can’t climb a tree
Post GI (Shigella, Salmonella, Yersinia, Campylobacter) or Chlamydia infections

Also hyperkeratotic vesicles on palms and soles
Annular dermatitis of glans penis

Sterile joints-large joints affected

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13
Q

Cauda Equina syndrome

A

Acute loss of function of the nerve roots in the Cauda equina usually due to tumor, trauma, herniated lumbar disk
Patients present with lower extremity weakness and bowel and bladder incontinence
Best assessed by MRI
Neurosurgical or radiation therapy emergency

Red flags: bladder/bowel dysfunction-urinary overflow incontinence
Saddle anesthesia: numb where you sit
Bilateral sciatica
Leg muscle weakness
Surgical emergency
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14
Q

Piriformis syndrome

A

Piriformis compresses or irritates sciatic nerve
Buttock pain radiating down the posterior leg
Overlaps in symptoms with sciatica

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15
Q

Herniated Disk

A

Red flags:
Pain in back down the leg in the sciatic distribution frequently to the foot and ankle (worse than back pain)
Not compression of sciatic nerve but pressure on L5 or S1 nerve roots
Tingling or weakness in ankle dorsifleors, toe extension
Can increase with coughing, sneezing, valasalva
L1-L3: nerve roots radiates to hip and/or anterior thigh
L4-S1 below the knee

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16
Q

Osteoporosis

A

Decrease in trabecular bone mass resulting in porous bone with an increased risk for fracture (decreased interconnections)
Peak bone mass is achieved during young adulthood determined by genetics, physical activity, diet and hormonal state
Aging causes decreased replicative activity of progenitor cells, decreased activity of osteoblasts, and decreased physical activity
Menopause causes estrogen deficiency leading to increased IL-1, IL-6, TNF, RANK, RANK-L and osteoclast acitivity
Risk factors: family history, thin body, poor nutrition, Caucasian or Asian, decreased physical activity, aging, estrogen deficiency, smoking, alcohol, corticosteroisd

Clinical: early is asymptomatic
Skeletal integrity declines, fractures with minimal trauma, vetebral compression fractures are most common-hip and wrist fractures major problem, femoral neck fracturse
End stage-marked dorsal kyphosis and bone pain

Diagnosis: plain films provide a very poor assessment
Bone densitometry measurements (DEXA scan)
T score=2.5 SDs below the mean for young normal or fragility fracture regardless of T-score
Osteopenia=-1 to -2.5 SD
Calcium, phosphate, PTH, and alkaline phosphate will be normal-helps distinguish between osteoporosis and osteomalacia

Prevention: adequate calcium and vitamin D in susceptible individuals
avoid hypogonadism, add weight bearing exercise

Treatment: bisphosphonates, PTH, SERMS, calcitonin, denosumab

17
Q

Osteomalacia and rickets

A

Inadequate mineralization of osteoid (rickets is prior to closure of growth plates)-increased unmineralized osteoid and widening between osteoid seams

Vitamin D deficiency or resistance is due to inadequate intake, inadequate sunlight exposure, malabsorption, severe liver disease, renal failure or hereditary syndromes
Phosphate deficiency occurs as a result of renal tubular disorders tumor associated osteomalaxia, X-linked hypophosphatemia, or phosphate binders

Vitamin D deficiency leads to decreased absorption of calcium and phosphate by the GI tract-leads to secondary hyperparathyrodism
Elevated PTH levels maintain the serum calcium but the cost is phosphaturia, hypophosphatemia and increased bone reabsorption-low serum phosphate results in inadequate bone mineralization and a decrease in bone density

Clinical: bone pain and pathologic fractures, decreased bone density, increased PTH, increased alkaline phosphatase and hypophosphatemia

Children: bowing of legs, pigeon breast deformity, frontal bossing and rachitic rosary with osteoid deposition, sofetining of skull, indentations of ribs

Diagnosis: Low levels of 25-hydroxyvitamin D or 1, 25 (OH) D

18
Q

Paget disease of bone

A

Increased bone turnover
May be preceded by childhood infection of paramyxovirus
Over the age of 55
Localized does not involve the entire skeleton
3 phases
1) osteoclastic (increased RANK and NFkB) 2) mixed osteoblastic/clastic 3) osteoblastic (hypovascular separated by cement lines)
End result is thick, sclerotic bone that fractures easily
Biopsy reveals mosaic pattern of lamellar bone
Axial skelton or proximal femur is involved

Clinical: Many asymptomatic
Causes bone pain and deformity (bowing)
fractures, increased hat size, hearing loss, lion like faces arthritis, excessive bleeding with orthopedic surgery

Complications: osteosarcoma, high output cardiac failure due to formation of AV shunts in bone

Diagnosis: isolated increased alkaline phosphatase, characteristic radologic apperance: mixed lytic/sclerotic lesions, cotton wool appearance, pseudofractures) bone scan to determine extent
Serum Ca2+, phosphorus and PTH are normal

Treatment: bisphosphonates (very effective) calcitonin (less effective)

19
Q

Osteomyelitis

A

Infection of marrow and bone that usually occurs in children
Bacteria arises via hematogenous spread
Bacteremia seeds metaphysis in children and open wound bactermia seeds epiphysis in adults
Clinical: bone pain with systemic signs of infection, lytic focus (abscess), surrounded by sclerosis of bone on X-ray
Diagnosis: blood culture

20
Q

Fracture healing

A

Need skeletal progenitor cells, ECM matrix scaffolding, Vasculature
Step 1: hematoma (1-7 days): matrix factors are released and inflammation is initiated
Immune cells infiltrate releasing cytokines
FGFs and BMPs increase stem cell, fibroblast, chondrocyte, and osteoblast proliferation and differentiation. FGFs are also angiogenic

Step 2: Callus (soft, 2-5 weeks) stem celsl differentiate into chondrocytes which form cartilage to stabilize the joint (endochondrial bone fomration) moderately stable

Step 3: Callus (hard, 6-12 weeks): osteoclasts absorb the cartialge callus which is converted to woven bone. TGFs, BMPs and IGFs promote osteogenesis
Both intramembranous (bone periphery/periosteum) and endochondrial bone formation are involved

Step 4: remodeling (18 wks-years): woven bone becomes lamellar with time and the mature bone is indistinguishable from the surrounding bone

Failure to heal: soft callus breaks down due to too much movement, too much stress on woven bone, inadequate or over stabilization (excessive or too little cartilage formation), interruption of blood supply, bone cell death, malnutrition, smoking (decreased formation, vasoconstriction), diabetes (collagen defects, decreased formation), anti inflmmatories

21
Q

Knee injury

A

Presents with acute knee pain and signs of joint instability/injury

Anterior drawer sign (pull forward)-ACL injury
Posterior drawer sign (push in)-PCL injury
Abnormal passive abduction (of leg/foot-varus stretch)-LCL injury
Pain on external rotation-medial meniscus
Pain on internal rotation-lateral meniscus

ACL/PCL refer to tibial attachment
ACL inferior attachment is away from fibula
PCL inferior attachment is same side as fibula

ACL connects lateral femoral condyle to antermodeal tibial head
Prevents anterior motion of tibia with respect to femur

22
Q

Unhappy triad

A

common injury in contact sports due to lateral force applied to a planted leg

Damage to ACL, MCL and medial meniscus
HOWEVER lateral meniscus is more commonly injured

23
Q

Rotator Cuff Muscles/Injury

A

Primarily innervated by C5-C6

Supraspinatus (Suprascapular nerve)-Abducts arm initially (before the action of deltoid)
Most common rotator cuff injury-impingement trauma between humeral head and acromion
Simulataneous abduction and flexion of the arm at the shoulder can cause inflammation leading to fibrosis
Empty Can test: abduct arm 90 and flex thaem at 30 with thumbs down-90% specific for supraspinatus

Infraspinatus (suprascapular nerve)-laterally rotates arm 
Pitching injury (pitch an INning)

Teres minor-(axillary nerve)-adducts and laterally rotates arm

Subscapularis (subscapular nerve)-medially rotates and adducts arm

24
Q

Radial head subluxation

A

Most common injury in children 1-4
Sharp pull of hand when forearm is pronated and elbow extended
Annular ligament tears from periosteal attachement at radial neck and slides into radiohumeral joint

Children present with arm held close to body with elbow extended and forearm pronated
No distress until attempt to move arm

reduction accomplished by supinating forearm followed by fully flexing the elbow

25
Q

FOOSH and wrist bones

A

Scaphoid-palpated in anatomical snuff box
Most commonly fractured wrist bone
Prone to avascular necrosis (dorsal scaphoid branch of radial artery) owing to retrograde blood supply

Dislocation of lunate leads to acute carpal tunnel syndrome

hook of hamate leads to ulnar nerve injury

26
Q

Carpal Tunnel Sydnrome

A

entrapment of median nerve in carpal tunnel

Nerve compression leads to parasthesia, pain and numbness worse at night in thumb, middle finger and index finger
Weakness of thumb and atrophy in advanced cases

Due to: chronic repetitive stress, fluid retention (hypothyroidism, renal failure, pregnant), diabets, rheumatoid arthritis and acromegaly

Tinel’s sign: tap on flexors to induce parathesia
Phalens sign: flex wrists to induce symptoms

27
Q

Guyon Canal syndrome

A

Compression of the ulnar nerve at wrist or hand

See in cyclists

28
Q

Duputryen’s Contracture

A

Slowly progressive fibroproliferative disease of palmar faschia

Scarring progresses leading to nodules on palmar faschia and fingers lose flexibility

Contractions cause flexion

29
Q

Clavicle Fracture

A

Middle 1/3 most likely fractured

Sternocleidomastoid responsible for medal traction of bone causing it to raise upward

30
Q

Prepatellar Bursitis

A

Located between patella and overlying skin and prepatellar tendon
Contains very little fluid
Function: to diminish friction and ensure max range of motion at the knee
Repeated kneeling leads to bursitis

symptoms: knee pain, swelling, redness, inability to flex knee on affected side (relieved by rest)
Physical exam: tenderness to palpitation, erythema, crepitance, and fluctuant edema

31
Q

Anserine Bursitis

A

Pain along medial side of knee
Overuse in athletes or chronic trauma with heavy body habitus
Tenderness to palpitation 4 cm distal to anteromedial joint margin of knee

32
Q

Sciatica

A

Irritation of sciatic nerve or its roots
Causes: vertebral disc herniations, spinal canal stenosis, irritation by bone spurs, irritated by piriformis

Weakness of posterior thigh muscles and muscles below the knee
Ankle reflex diminished (patellar reflex normal)

33
Q

Achondroplasia

A

Failure of longitudinal bone growth (endochondral ossification) leading to short limbs
Membranous ossification is not affected leading to large head relative to limbs

Constitutive activation of fibroblast growth factor receptor (only 1 copy needed, 2 cause death) inhibits chondrocyte proliferation

Associated with advanced paternal age or AD

Normal life span and fertility

Epiphyseal cartilage responisible for linear growth regulated by GH, IGF-1, insulin, thyroid hormone, sex steroids and fibroblast growth factor

34
Q

Osteopetrosis

A

Failure of normal bone resorption due to defective osteoclasts
Thickened bones that are prone to fracture

Bone fills marrow space leading to pancytopenia and extramedullary hematopoiesis

Mutations (carbonic anyhydrase II) impair ability of osteoclasts to generate acidic environment necessary for bone resorption

X-Rays show bone-in-bone appearance

Can result in nerve impingement and palsies as a result of narrowed foramina (hearing loss)

Bone marrow transplant could be curative because osteoclasts are derived from monocytes

35
Q

Digital Clubbing

A

Thickening of distal phalanges associated with chronic diseases that cause hypoxia

Etiology: failure of platelets to fragment completely leading to finger and toes to release PDGF and VEGF leading to fibromuscular proliferation and clubbing (also increased PGE2)

Fingers with drumstick appearance, flattening of nail folds and shininess of nail
Pressing on nail produces spongy sensation

Caused by:
Lung diseases: lung cancer, Tb, Cystic fibrosis, bronchiectasis, pulmonary hypertesion, emphysema
Heart diseases: Cyanotic congenital heart disease, bacterial endocarditis
Other: inflammatory bowel disease, hyperthyroidism, malabsorption

MSK Domain (3 decks)

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