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Step 1 > MSK, Skin and Connective Tissue > Flashcards

MSK, Skin and Connective Tissue Flashcards

1
Q

Unhappy triad

A
  • Common injury in contact sport due to lateral force applied to a planted leg
  • Classically consists of damage to ACL, MCL and medial meniscus (attached to MCL)
  • However lateral meniscus injury is more common
  • Presents with acute knee pain and signs of joint injury and instability
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2
Q

Prepatellar bursitis

A
  • Inflammation of knee’s largest sac of synovial fluid

- Can be caused by repeated trauma or pressure from excessive kneeling

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3
Q

Baker cyst

A

Popliteal fluid collection in gastrocnemius-semimembranous bursa commonly communicating with synovial space and related to chronic joint disease

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4
Q

Shoulder muscles that form the rotator cuff

A

Supraspinatus:

  • Innervated by supraspinatus nerve
  • Abducts arm initially (before the action of the deltoid)
  • Most common rotator cuff injury (trauma or degeneration and impingement → tendinopathy or tear)
  • Assessed by “empty/full can” test

Infraspinatus:

  • Innervated by supraspinatus nerve
  • Laterally rotates arm
  • Pitching injury

teres minor:

  • Innervated by axillary nerve
  • Adducts and laterally rotates arm

Subscapularis:

  • Upper and lower subscapular nerves
  • Medially roates and adducts arm

“SItS”

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5
Q

Medial epicondylitis

A
  • Golfer’s elbow

- Repetitive flexion (forehand shots) or idiopathic → pain near medial epicondyle

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6
Q

Lateral epicondylitis

A
  • Tennis elbow

- Repetitive extension (backhand shots) or idiopathic → pain near lateral epicondyle

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7
Q

Most commonly fractured carpal bone

A
  • Scaphoid (palpated in anatomic snuff box)
  • Typically from a fall on an outstretched hand
  • Prone to avascular necrosis owing to retrograde blood supply
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8
Q

Dislocation may cause acute carpal tunnel syndrome

A

Lunate

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9
Q

Fall on outstretched hand that causes ulnar nerve injury

A

Hook of the hamate

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10
Q

Carpal tunnel syndrome is associated with

A
  • Pregnancy
  • Rheumatoid arthritis
  • Hypothyroidism
  • Diabetes
  • Dialysis-related amyloidosis
  • Repetitive use
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11
Q

Guyon canal syndrome

A
  • Compression of ulnar nerve at wrist or hand

- Classically seen in cyclists due to pressure from handlebars

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12
Q

Muscle conduction to contraction structure in skeletal and cardiac muscle

A

Skeletal muscle → 1 T-tubule + 2 terminal cisternae = triad

Cardiac muscle → 1 T-tubule + 1 terminal cisterna = dyad

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13
Q

What is mechanically coupled to the ryanodine receptor on the sarcoplasmic reticulum

A

Depolarization of the voltage-sensitive dihydropyridine receptor, mechanically coupled to the ryanodine receptor on the SR induces a conformational change in both receptors, causing Ca2+ release from SR

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14
Q

Contraction changes length of which bands

A

Contraction results in shortening of H and I bands and between the Z lines (HIZ shrinkage) but the A band remains the same length (A band is Always the same length)

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15
Q

Endochondral ossification

A
  • Bones of axial skeleton, appendicular skeleton and base of skull
  • Cartilaginous model of bone is first made by chondrocytes
  • Osteoclasts and osteoblasts later replace with woven bone and then remodel to lamellar bone
  • In adults, woven bone occurs after fractures and in Paget disease
  • Defective in achondroplasia
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16
Q

Membranous ossification

A
  • Bones of calvarium and facial bones
  • Woven bone formed directly without cartilage
  • Later remodeled to lamellar bone
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17
Q

Osteoblast

A
  • Builds bone by secreting collage and catalyzing mineralization in alkaline environment via ALP
  • Differentiates from mesenchymal stem cells in periosteum
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18
Q

Osteoclast

A
  • Dissolves bone by secreting H+ and collagenases

- Differentiates from a fusion of monocyte/macrophage lineage precursors

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19
Q

PTH

A
  • Low, intermittent levels → anabolic effects (building bone) on osteoblasts and osteoclasts (indirect)
  • Chronically ↑ PTH levels (primary hyperparathyroidism) → catabolic effects (osteitis fibrosa cystica)
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20
Q

Estrogen induces and inhibits apoptosis in which cells

A

Inhibits apoptosis in osteoblasts and induces apoptosis in osteoclasts

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21
Q

What inhibits chondrocyte proliferation in achondroplasia

A

Constitutive activation of fibroblast growth factor receptor (FGFR3) inhibits chondrocyte proliferation, therefore interfering with endochondral ossification

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22
Q

Causes of osteoporosis

A
  • Most commonly due to ↑ resorption related to ↓ estrogen levels and old age
  • Can be secondary to drugs (eg steroids, alcohol, anticonvulsants, anticoagulants, thyroid replacement therapy) or other medical conditions (hyperparathyroidism, hyperthyroidism, multiple myeloma, malabsorption syndromes)
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23
Q

What causes osteopetrosis

A

Failure of normal bone resorption due to defective osteoclasts. Mutations (eg carbonic anhydrase II) impair ability of osteoclast to generate acidic environment necessary.

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24
Q

How does osteopetrosis cause pancytopenia and extramedullary hematopoiesis

A

Bone fills marrow space

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25
Q

What is potentially curative of osteopetrosis

A

Bone marrow transplant is potentially curative as osteoclasts are derived from monocytes

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26
Q

Presentation of osteomalacia/rickets

A

X rays show osteopenia and “looser zones” (pseudofractures) in osteomalacia, epiphyseal widening and metaphyseal cupping/fraying in rickets. Children with rickets have bow legs bead-like costochondral junctions (rachitic rosary), craniotabes (soft skull)

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27
Q

Stages of Paget disease

A
  • Lytic → osteoclasts
  • Mixed → osteoclasts + osteoblasts
  • Sclerotic → osteoblasts
  • Quiescent → minimal osteoclast/osteoblast activity
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28
Q

What type of fractures are seen with Paget disease

A

Long bone chalk-stick fractures

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29
Q

What causes heart failure in Paget disease

A

↑ blood flow from ↑ arteriovenous shunts may cause high-output heart failure

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30
Q

Causes of osteonecrosis

A
  • Corticosteroids
  • Alcoholism
  • Sickle cell disease
  • Trauma
  • “the Bends” (caisson/decompression disease)
  • LEgg-Calve-Perthes disease (idiopathic)
  • Gaucher disease
  • Slipped capital femoral epiphysis

“CAST Bent LEGS”

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31
Q

Lab values of osteoporosis

A
  • Normal Ca2+, PO43-, ALP, PTH

- ↓ bone mass

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32
Q

Lab values of osteopetrosis

A
  • Normal or ↓ Ca2+

- Normal PO43-, ALP, PTH

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33
Q

Lab values of Paget disease of bone

A
  • Normal Ca2+, PO43-, PTH
  • ↑ ALP
  • Abnormal “mosaic” bone architecture
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34
Q

Osteitis fibrosa cystica - Primary hyperparathyroidism

A
  • ↑ Ca2+
  • ↓ PO43-
  • ↑ ALP
  • ↑ PTH
  • “Brown tumors” due to fibrous replacement of bone, subperiosteal thinning
  • Idiopathic or parathyroid hyperplasia, adenoma, carcinoma
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35
Q

Osteitis fibrosa cystica - Seondary hyperparathyroidism

A
  • ↓ Ca2+
  • ↑ PO43-
  • ↑ ALP
  • ↑ PTH
  • Often as compensation for CKD
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36
Q

Osteomalacia/rickets

A
  • ↓ Ca2+
  • ↓ PO43-
  • ↑ ALP
  • ↑ PTH
  • Soft bones
  • Vitamin D deficiency also causes secondary hyperparathyroidism
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37
Q

Hypervitaminosis D

A
  • ↑ Ca2+
  • ↑ PO43-
  • Normal ALP
  • ↓ PTH
  • Caused by oversupplementation or ganulomatous disease (eg sarcoidosis)
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38
Q

Osteochondroma

A
  • Most common benign bone tumor

- Males

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39
Q

Giant cell tumor/ osteoclastoma

A
  • 20-40 yo
  • Epiphyseal end of long bones
  • Often around knee
  • Locally aggressive benign tumor
  • “Soap bubble” appearance on x-ray
  • Multinucleated giant cells
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40
Q

Osteosarcoma/ osteogenic sarcoma

A
  • 2nd most common primary malignant bone tumor (after multiple myeloma)
  • Bimodal distribution: 10-20 yo (primary), > 65 yo (secondary)
  • Predisposing factor → Paget disease, bone infarcts, radiation, familial retinoblastoma, Li-fraumeni syndrome (germline p53 mutation)
  • Metaphysis of long bones, often around knee
  • Codman triangle (from elevation of periosteum)
  • Sunburst pattern
  • Aggressive
  • Treat with surgical en bloc resection (with limb salvage) and chemotherapy
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41
Q

Ewing sarcoma

A
  • Boys
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42
Q

Osteoid osteoma

A
  • Diaphysis
  • Nighttime pain
  • Central nidus
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43
Q

Juvenile idiopathic arthritis

A
  • Most common arthritis seen in pediatric patients
  • Often presents as recurrent and relapsing fevers accompanied by polyarticular joint pain, an evanescent macular, salmon-pink rash (anywhere on body)
  • Rheumatoid factor not usually present
  • Also associated with chronic anterior uveitis and decreased growth rates
  • 30-50% develop hemophagocytic syndrome
  • In adults, JIA is known as “Still disease”
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44
Q

Which glycogen storage disease is associated with Gout

A

Overproduction of uric acid is seen in von Gierke disease

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45
Q

Calcium pyrophosphate deposition disease is associated with

A
  • Idiopathic (most often)
  • Hemochromatosis
  • Hyperparathyroidism
  • Joint trauma
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46
Q

In which disease where crystals are found in joints is distribution of disease between the sexes equal

A

Both sexes are affected equally in calcium pyrophosphate deposition disease where as gout is more common in males

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47
Q

Is underexcretion or overproduction of uric acid a more common cause of gout

A

Underexcretion of uric acid

48
Q

Prophylactic treatment of gout vs calcium pyrophosphate deposition disease

A

Gout → xanthine oxidase inhibitors (eg allopurinol, febuxistat)

Calcium pyrophosphate deposition disease → colchicine (can be used for acute and chronic treatment)

49
Q

Chondrocalcinosis is seen in

A

Chondrocalcinosis, cartilage calcification, is seen on x-ray in calcium pyrophosphate deposition disease

50
Q

Findings in Sjogren syndrome

A
  • Inflammatory joint pain
  • Keratoconjunctivits sicca (↓ tear production and subsequent corneal damage)
  • Xerostomia (↓ saliva production)
  • Presence of antinuclear antibodies: SS-A (anti-Ro) and/or SS-B (anti-La)
  • Bilateral parotid enlargement
51
Q

Complications of Sjogren syndrome

A
  • Dental caries

- Mucosa associated lymphoid tissue (MALT) lymphoma → may present as parotid enlargement

52
Q

Gonococcal arthritis

A

STI that presents as either purulent arthritis (eg knee) or triad of polyarthralgias, tenosynovitis (eg hand), dermatitis (eg pustules)

53
Q

Enthesitis

A
  • Inflamed insertion sites of tendons

- Associated with seronegative spondyloarthritis

54
Q

Dactylitis and “pencil-in-cup” deformity of DIP on x-ray are associated with

A

Psoriatic arthritis

55
Q

Ankylosis (joint fusion), uveitis and aortic regurgitation are associated with

A

Ankylosing spondylitis

56
Q

Causes of reactive arthritis/ Reiter syndrome

A
  • Post-GI → Shigella, Salmonella, Yersinia, Campylobacter

- Chlamydia

57
Q

Common causes of death in SLE

A
  • Cardiovascular disease
  • Infections
  • Renal disease
58
Q

What does “RASH OR PAIN” stand for with regards to SLE

A
  • Rash (malar or discoid)
  • Arthritis (nonerosive)
  • Serositis
  • Hematologic disorders (eg cytopenias)
  • Oral/nasopharyngeal ulcers
  • Renal disease
  • Photosensitivity
  • Antinuclear antibodies
  • Immunologic disorder (anti-DNA, anti-Sm, antiphospholipid)
  • Neurologic disorders (eg seizures, psychosis)
59
Q

Antihistone antibodies are sensitive for

A

Drug-induced lupus (eg hydralazine, procainamide)

60
Q

Antinuclear antibodies and SLE

A

Sensitive but not specific

61
Q

Anti-dsDNA antibodies

A

Specific and indicates poor prognosis (renal disease)

62
Q

Anti-Smith antibodies

A
  • Directed against snRNPs

- Specific but not prognostic

63
Q

Which complement components are decreased in serum in SLE

A

↓ C3, C4, and CH50 due to immune complex formation

64
Q

Treatment of SLE

A
  • NSAIDs
  • Steroids
  • Immunosuppressants
  • Hydroxychloroquine (traditionally, anti-malarial)
65
Q

Antiphospholipid syndrome

A
  • Primary or secondary autoimmune disorder (most commonly SLE)
  • Diagnose based on clinical criteria including history of thrombosis (arterial or venous) or spontaneous abortion along with laboratory findings of lupus anticoagulant, anticardiolipin, anti-β2 glycoprotein antibodies
  • Anticardiolipin and lupus anticoagulant can cause false positive VDRL/RPR and PROLONGED PTT
  • Not corrected with 1:1 fresh frozen plasma
  • Treat with systemic anticoagulation
66
Q

Mixed connective tissue disease

A
  • Features of SLE, systemic sclerosis, and/or polymyositis
  • Associated with anti-U1 RNP antibodies (speckled ANA)
  • U1 RNP = U1 snRNP → also associated with splicesome
67
Q

Sarcoidosis is associated with

A
  • Restrictive lung disease (interstitial fibrosis)
  • Erythema nodosum
  • Lupus pernio (skin lesions on face resembling lupus)
  • Bell palsy
  • Epithelioid granulomas containing microscopic Schaumann and asteroid bodies
  • Uveitis
  • Hypercalcemia
68
Q

Polymyalgia rheumatica

A
  • Pain and stiffness in shoulders and hips, often with fever, malaise, and weight loss
  • Does NOT cause muscular weakness
  • More common in women > 50 years old
  • Associated with giant cell (temporal) arteritis
  • ↑ ESR, ↑ CRP, normal CK
  • Rapid response to low-dose corticosteroids
69
Q

Fibromyalgia

A
  • Most commonly seen in females 20-50 years old
  • Chronic, widespread musculoskeletal pain associated with stiffness, paresthesias, poor sleep, fatigue, cognitive disturbance (“fibro fog”)
  • Treatment: regular exercise, antidepressants (TCAs, SNRIs), anticonvulsants
70
Q

Antibodies seen in polymyositis and dermatomyositis

A
  • ↑ CK
  • ANA +
  • Anti-Jo-1 + → histidyl tRNA synthase
  • Anti-SRP + → signal recognition particle, universally conserved ribonucleoprotein that recognizes and targets specific proteins to the endoplasmic reticulum in eukaryotes and plasma membrane in prokaryotes
  • Anti-Mi-2 +
71
Q

Compare polymyositis and dermatomyositis

A

Polymyositis:

  • Progressive symmetric proximal muscle weakness, characterized by endomysial inflammation with CD8+ T cells
  • Most often involves the shoulders

Dermatomyositis:

  • Similar to polymyositis
  • Malar rash (similar to SLE)
  • Grotton papules
  • Heliotrope (erythematous periorbital) rash
  • “Shawl and face” rash
  • “Mechanic’s hands”
  • ↑ risk of occult malignancy
  • Perimysial inflammation and atrophy with CD4+ T cells
72
Q

Dermatomyositis - endomysial or perimysial inflammation

A

Perimysial inflammation and atrophy with CD4+ T cells

73
Q

Polymyositis - endomysial or perimysial inflammation

A

Endomysial inflammation with CD8+ T cells

74
Q

Compare the presentation of myasthenia gravis and Lambert-Eaton myasthenic syndrome

A

Myasthenia gravis → ptosis, diplopia, weakness; worsens with muscle use

Lambert-Eaton → proximal muscle weakness, autonomic symptoms (dry mouth, impotence); improves with muscle use

75
Q

Myositis ossificans

A
  • Heterotropic ossification of skeletal muscle following muscular trauma
  • Most often seen in upper or lower extremity
  • May present as suspicious mass at site of known trauma or as incidental finding on radiography
76
Q

Scleroderma/ systemic sclerosis

A
  • Triad → autoimmunity, noninflammatory vasculopathy and collagen deposition with fibrosis
  • Commonly sclerosis of skin, manifesting as puffy, taut skin without wrinkles, fingertip pitting
  • Also sclerosis of renal, pulmonary (most common cause of death), cardiovascular, GI systems
  • 2 major types → diffuse and limited
77
Q

Most common cause of death in scleroderma

A

Sclerosis of pulmonary system

78
Q

Diffuse scleroderma

A
  • Widespread skin involvement
  • Rapid progression
  • Early visceral involvement
  • Associated with anti-Scl-70 antibody (anti-DNA topoisomerase I antibody)
79
Q

Limited scleroderma

A
  • Limited skin involvement confined to fingers and face
  • Also with CREST syndrome
  • Calcinosis
  • Raynaud phenomenon
  • Esophageal dysmotility
  • Sclerodactyly
  • Telangiectasia
  • More benign clinical course than diffuse scleroderma
  • Associated with anti-Centromere antibody
80
Q

Tight junction

A
  • Zonula occludens
  • Prevents paracellular movement of solutes
  • Composed of claudins and occludins
81
Q

Adherens junction

A
  • Belt desmosome, zonula adherens
  • Below tight junction, forms “belt” connecting actin cytoskeletons of adjacent cells with CADhereins (Ca+ dependent adhesions proteins)
  • Loss of E-cadherin promotes metastasis
82
Q

Desmosomes

A
  • Spot desmosome, macula adherens
  • Structural support via intermediate filament interactions
  • Autoantibodies → pemphigus vulgaris
83
Q

Gap junctions

A

Channel proteins called connexons permit electrical and chemical communication between cells

84
Q

Integrins

A

Membrane proteins that maintain the integrity of basolateral membrane by binding to collagen and laminin in basement membrane

85
Q

Hemidesmosome

A
  • Connects keratin in basal cells to underlying basement membrane
  • Autoantibodies → bullous pemphigoid
86
Q

Compare the presentation of intradermal and junctional nevi

A

Intradermal nevi → papular

Junctional nevi → macule

87
Q

What layers of the epidermis are increased and decreased in psoriasis

A
  • ↑ stratum spinosum (a part of acanthosis)
  • ↓ stratum granulosum

Also seen is acanthosis with parakeratotic scaling (nuclei still in stratum corneum)

88
Q

What changes are seen in the epidermis of verrucae

A

Epidermal hyperplasia, hyperkeratosis (↑ thickness of stratum corneum), koilocytosis

89
Q

What are characteristic findings of utricaria

A

Superficial dermal edema and lymphatic channel dilation

90
Q

Hyperkeratosis

A
  • ↑ thickness of stratum corneum

- Psoriasis, calluses

91
Q

Parakeratosis

A
  • Hyperkeratosis with retention of nuclei in stratum corneum

- Psoriasis

92
Q

Hypergranulosis

A
  • ↑ thickness of stratum granulosum

- Lichen planus

93
Q

Spongiosis

A
  • Epidermal accumulation of edematous fluid in intercellular spaces
  • Eczematous dermatitis (utricaria)
94
Q

Acantholysis

A
  • Separation of epidermal cells

- Pemphigus vulgaris

95
Q

Acanthosis

A
  • Epidermal hyperplasia (↑ spinosum)

- Acanthosis nigricans

96
Q

Angiosarcoma

A
  • Rare blood vessel malignancy typically occuring in the head, neck and breast areas
  • Usually in elderly, on sun-exposed areas
  • Associated with radiation therapy and chronic postmastectomy lymphedema
  • Hepatic angiosarcoma → associated with vinyl chloride and arsenic exposures
  • Very aggressive and difficult to resect due to delay in diagnosis
97
Q

Cystic hygroma

A

Cavernous lymphangioma of the neck. Associated with Turner syndrome.

98
Q

Glomus tumor

A

Benign, painful, red-blue tumor, commonly under fingernails. Arises from modified smooth muscle cells of the thermoregulatory glomus body.

99
Q

Pyogenic granuloma

A

Polyploid lobulated capillary hemangioma that can ulcerate and bleed. Associated with trauma and pregnancy.

100
Q

Differentiate bacillary angiomatosis and Kaposi sarcoma

A

Bacillary angiomatosis → benign capillary skin papules found in AIDS patients; caused by Bartonella henselae infections; has neutrophilic infiltrate

Kaposi sarcoma → endothelial malignancy most commonly of the skin, but also mouth, GI tract, and respiratory tract; associated with HHV-8 and HIV; has lymphocytic infiltrate

101
Q

Compare Staphylococcal scalded skin syndrome and TEN

A

Exotoxin of S aureus destroys keratinocyte attachments in stratum granulosum only, vs TEN which destroys dermal-epidermal junction

102
Q

Staphylococcal scalded skin syndrome is seen in

A

Newborns, children and adults with renal insufficiency

103
Q

Acantholysis is characteristic of

A
  • Pemphigus vulgaris

- Acantholysis = keratinocytes in stratum spinosum are connected by desmosomes

104
Q

Tense blisters of bullous pemphigoid contain

A

Eosinophils

105
Q

Pemphigus vulgaris and bullous pemphigoid - which involves oral mucosa

A

Pemphigus vulgaris involves oral mucosa

106
Q

Dermatitis herpetiforms

A
  • Pruritic papules, vesicles, and bullae (often found on elbows)
  • Deposits of IgA at tips of dermal papillae
  • Associated with celiac disease
  • Treatment → dapsone, gluten free diet
107
Q

Erythema multiforme is associated with

A
  • Infections (eg Mycoplasma pneumoniae, HSV)
  • Drugs (eg sulfa drugs, beta lactams, phenytoin)
  • Cancers
  • Autoimmune disease
108
Q

How many mucous membranes are usually involved with Stevens-Johnson syndrome

A

2

109
Q

When is erythema multiforme/ Stevens-Johnson syndrome categorized as toxic epidermal necrolysis

A

> 30% of body surface involved

110
Q

With actinic keratosis, the risk of SCC is proportional to

A

Degree of epithelial dysplasia

111
Q

Erythema nodosum is associated with

A
  • Sarcoidosis
  • Coccidiomycosis
  • Histoplasmosis
  • TB
  • Streptococcal infections
  • Leprosy
  • Inflammatory bowel disease
112
Q

Lichen planus is associated with

A

Hepatitis C

113
Q

Describe microscopic findings of lichen planus

A

Sawtooth infiltrate of lymphocytes at dermal-epidermal junction

114
Q

Which skin cancer is associated with palisading nuclei

A

BCC

115
Q

Which skin cancer is associated with chronic draining sinuses

A

SCC

116
Q

Name 4 types of melanoma

A
  • Superficial spreading
  • Nodular
  • Lentigo maligna
  • Acral lentiginous
117
Q

Vemurafenib benefits which patients

A

Patients with BRAF V600E mutations and metastatic or unresectable melanoma. Vemurafenib is a BRAF kinase inhibitor.

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