Soft tissue disorders Flashcards
Describe the type of structure of tendon tissue [1]
Dense regular collagenous CT
Avsacular [1]
Which region of the muscle tissue connects the muscle fibre to the tendon?
Endomysium is around each muscle fibre & blends into tendon
Whats the difference between tendinitis and tendinosis? [2]
Tendinitis: acute inflammation of tendon, does not have microscopic tendon damage
Tendinosis: chronic inflammation of tendon; characterised by disorganised fibres and a hard, thickened, scared and rubbery appearance
What is difference in structure between normal tendon and tendon with tendinosis? [2] Why is this clinically significant [1]
Normal structure: tendon allows contraction of muscle to cause movement of skeletal system
Tendinosis: disorganiesd collagen means that stresses are not transmitted efficiently: can lead to full thickness tear
Note the disorganise collagen
Tendinitis & tendinosis
Name three causes of tendinitis & tendinosis [3]
Name three common site of tendinitis & tendinosis [3]
Causes:
* Overuse
* Collagen disorders
* Renal dialysis
Locations:
* Lateral epicondylitis
* Achilles tendonitis
* Supraspinatus tendinitis
Which of the following is rotator cuff most likely to suffer from tendinitis & / or tendinosis?
Supraspinatous
Teres major
Infraspinatous
Subscapularis
Which of the following is rotator cuff most likely to suffer from tendinitis & / or tendinosis?
Supraspinatous
Teres major
Infraspinatous
Subscapularis
tendinitis & / or tendinosis
Name 4 ways can treat tendinitis & / or tendinosis? [4]
- RICE
- Analgesia and NSAIDs
- Stretching
- Surgery
Achilles tendinitis
Which physiological process may occur during the healing process? [1]
Form heterotopic calcified regions (formation of extraskeletal bone in muscle and soft tissues)
Where in the tendon does tendonitis usually occur? [1]
Tendonitis usually occur in the middle of the tendon as this is the weakest spot [1]
Explain the pathophysiology of heterotopic bone [3]
Fibroblasts, osteoblasts and chondroblasts come from same precursors
Tendon fibroblast differentiate into chondrocytes / hypertrophic chondrocyte and osteoblasts via COX-2
Pro-inflammtory cytokines like prostaglandin E2 induces osteoblasts to differentiate
How can you treat heteropoic bone formation? [1]
NSAIDs
Why is it heterotrophic tendon at increase risk of bone fracture? [1]
Previously damaged tendon that calcifies becomes more brittle and may rupture
Explain how tendons enclosed by tendon sheats heal differently compared to open tendons [2]
Tendons enclosed by tendon sheaths:
* Local environment for tendon healing; problematic for healing as can only repair from fibroblasts within the the tendon sheath
Open Tendons
* Can recruit fibroblasts from other areas
* Heal quicker
Describe how healing compares when undergo unloading by temporary paralysis versus overloading by active mobility or exercise for:
- tendon-bone healing
- flexor tendon healing
Complete unloading by temporary paralysis:
* Beneficial for tendon-bone healing
* Detrimental for flexor-tendon healing
Overloading by active mobility or exercise:
* Detrimental for tendon-bone healing
* Beneficial for flexor-tendon healing
State which is more beneficial for shorter [1] or longer [1] tendons
Unloading by temporary paralysis
Overloading by active mobility or exercise
Short: Unloading by temporary paralysis / cast immobilisation
Long:loading by active mobility or exercise
State the location of intrinsic tendons (covered by tendon sheath) [1]
Hand flexors
Describe the different phases of tendon repair [3]
Describe the different types of enthesis in body [2]
Fibrous
* tendon extends all way up to bone: collagen bundles extend all the way to periosteum & become calcified
* Both are made from type 1 collagen
Fibrocartilaginous: when want to dissapate the stress
* Small section of fibrocartilage at attachment site
* Fibrocartilage calcififies at insertion
* Helps stiffen the tendon / ligament and creates a gradual change in mechanical properties
Name two locations of fibrous enthesis ligaments [2]
Name three locations of fibrocartilage enthesis ligaments [2]
Fibrous enthesis
* spring ligament
* periodontal ligament
Fibrocartilage enthesis
* rotator cuff muscles
* achilles tendon
* plantar fascia
What type of enthesis is depicted? [1]
Fibrous enthesis
Define sharpey fibres [1]
Sharpey’s fibres: are a matrix of connective tissue consisting of bundles of strong predominantly type I collagen fibres connecting periosteum to bone.
Label A
sharpey fibres
State the 4 zones of the fibrocartilage enthesis [4]
- Tendon proper
- Fibrocartilage
- Mineralised fibrocartilage
- Bone
Label which type of enthesis A & B are [2]
A: fibrous
B: fibrocartilage
What is name for inflammed enthesis? [1]
Enthesitis
Name an autoimmune diseases that can cause / associated with enthesitis [1]
ankylosing spondylitis
Ankylosing spondylitis is associated with which HLA? [1]
HLA B27
Describe enthesitis pathogenesis:
Normal enthesitis insertion occurs at a location with lots of which structure? [1]
How does this influence enthesitis pathogenesis? [3]
Normal enthesis inserts into porous bone at a location with lots of small transcortical vessels (TCV)
Mechanical trauma; TCVs become inflammed:
* Vasodilation
* Efflux of immune cells (neutrophils)
* Osteoblasts form bone at enthesis - causes bone to be formed
Which IL is specifically associated with enthesitis? [1]
IL-23
Enthesitis is associated with which three conditions? [3]
Ankylosing spondylitis
Psoriatic arthritis
IBD
Where does enthesitis bone formation occur? [1]
At the insertion point
How do you differentiate between enthesophytes and osteophytes? [2]
Enthesophytes: originate from insertion of the joint capsule, ligament or tendons: no articular border involvement
Osteophytes: orginate from border of articular cartilage
How do you treat enthesitis:
- If mechanical? [2]
- If Inflammatory [5]
Mechanical:
* RICE
* NDSAIDs
Inflammatory:
* Sulfasalazine
* Methotrexate
* Anti-TNF therapy (restricted use for severe autoimmune enthetitis)
* Local radiotherapy
* Corticosteroid injection
* Hyperosmolar dextrose (initiates proliferation of intrinsic fibroblasts - race to repair damage c.f. osteoblasts)
Which drug class is used for ankylosing spondylitis enthesitis? [1]
Anti-TNF treatment
What are the names for arteries that supply tendons (of the hands)? [1]
Vincular arteries
Name two tenosynovitis conditions [2]
De Quervain’s tenosynovitis
Trigger finger
Explain pathophysiology of De Quervien tenosynovitis [3]
Fibrosis and narrowing of tendon sheath: extensor retinaculum
Around anatomical snuffbox
Causes tendons and sheath rubbing over radial styloid process
Thickening and narrowing of tendon sheath
Lymphocyte inflammation
State and describe the name for test of De Querviens tensynovitis [1]
Finkelstein test:
- Patient resting their forearm on a surface in a neutral position with the wrist hanging off and unsupported
- The examiner holds the patient’s thumb and passively flexes the thumb into the palm, causing the wrist to adduct (ulnar deviation), putting **strain on the APL and EPB tendons. **
- If this causes pain at the radial aspect of the wrist, the test is positive, indicating De Quervain’s tenosynovitis.
Describe pathophysiology of trigger finger
Enlargement of tendon within sheath
Treatment for tenosynovitis?
Treatments [4]
Surgery - for trigger finger [1] and De Quervains [1]
Treatment:
* RICE
* Splinting
* Anti-inflam
* Corticosteroids
Surgery:
* TF: cut annular ligament
* DQ: shave styloid processs or cut sheath
Describe pathophysioloy of SLE [1]
Antibodies agaisnt a wide range of self antigens:
* Anti-nuclear antibodies (ANA): intranuclear and cytoplasmic proteins (95% are positive)
* Anti-Histone
* Anti-Ro
* Anti-La
* (loads of antibodies due to B cell hyperactivity)
Describe lesions seen in SLE [1]
Discoid lesions
Describe the arthritis seen in SLE patients [1]
Jaccoud arthropathy: due to tendinitis
Can move back into the correct position.
DMARD treatments for SLE? [4]
Cylcophosphamide
Mycophenolate mofetil
Methotrexate
Tacrolimus
Describe two biological DMARDs for SLE? [2]
Belimubab: inhibits BAFF (B cell activating factor)
Rituximab: CD20 blocker
