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Flashcards in Bone Phys/path Deck (98):
0

Vascular response in fracture repair

- Bloodflow increased substantially peaks at two weeks
- Angiogenesis and vasodilation increases

1

Inter-medullary callus

- forms new bone from endochonral ossification following hematoma formation
- soft callus -> hard callus

2

Concave/convex remodeling

- convex: electropositive->osteoclast
- concave: electronegative->osteoblast

3

Contact vs. gap healing

- contact: allows for direct healing with lamellar bone
- gap: 200-500 nm: fill with woven bone, remodeled to lamellar

4

TGF in bone repair

- induces the synthesis of cartilage specific proteoglycans and type II collagen
- stimulates osteoblasts

5

BMP in bone repair

- 1,2 and 3
- 1: cleaves carboxy terminus of procallagen I,II and III
- 2: induces endochonral ossification
- 3: potent inducer of mesenchymal -> bone tissue

6

FGF in bone repair

- acidic (FGF-1), basic (FGF-2)
- proliferation of chondrocytes and osteoblasts
- FGF2 stims angiogenesis

7

PDGF in bone repair

- I and II
- IGF-I induced by GH in liver
- bone and collagen synthesis, osteoblasts proliferation and inhibits bone collagen degradation

8

Cytokines in bone repair: IL-1,4,6 and 11, CSF, TNF

- Stimulates bone resorption: IL-1 most potent
- IL-1 and 6 inhibited by estrogen

9

Prostaglandins in bone healing

- PGEs inhibit osteoclasts and stimulate bone formation
- leukotriens do the opposite

10

Hormones in bone repair: estrogen, thyroid, glucocorticoids

- estrogen: stimulates fracture healing through IL I inhibitor
- T3/4: stimulat osteoclast resorption
- glucocorticoids: inhibits Ca absorption from gut -> increased PTH -> increases osteoclast activity indirectly

11

PEMF

- Signals in 20 to 30 Hz range
- Shows efficacy in bone healing

12

- Bluegray skin and yellow brown microscopic pigment
- Presents with black urine
- Associated with severe early-onset arthritis and spine and lower extremity joints

- Alcaptonuria
- Results from homogentistate 1,2 deoxygenase deficiency -> Buildup of homogentisic acid

13

Anatomic sequelae of osteoarthritis

- Joint space narrowed
- sclerosis of subchondral
- cystic degeneration of bone
- osteophyte lipping
- chronic pain and debilitation

14

- Insidious onset of malaise fatigue and generalized musculoskeletal pain
- This is followed by polyarticular joint pain in the hands and then the fee

- RA
- Sequela a: destruction of ligaments tendons joint capsules-> deformities

15

RA immunopathenogenesis

- HLA-DRB1 assoc
- Activated CD4 stimulates macrophages and B cells
- b cells contribute autoantibodies
- TNF/IL1: Stimulates synoviocytes to make inflammatory mediators/mellatoproteases

16

Synovium and stroma consisting of inflammatory cells granulation tissue and fibroblasts which grow over articular cartilage

- pannus
- sq: fiberous ankylosis, -> bony ankylosis

17

Fibrinoid necrosis surrounded by palisading rim of macrophages with no microbial infiltrates

- Rheumatoid nodule

18

- onset under age 16
- arthritis present for 6 weeks, spiking fevers, malaise
- rheumatoid nodules skin usually absent
- rheumatoid factor usually negative

Juvenile idiopathic Rheumatoid arthritis

19

- HLA-B27 assoc
- oligoarthritis and tendinitis
- immune-mediated disease

- ankylosing spondylitis
- reactive arthritis
- psoriatic arthritis
- arthritis assoc with chronic inflammatory conditions

20

- Negatively biferingient crystals
- hyperuricemia
- tophi

- gout/gouty arthritis

21

Mechanism for hyperuricemia

- 90% due to decreased excretion of uric acid (upregulation of URAT1->increased resorption

22

HGPRTase deficiency

- overproduction of uric acid due to lacking purine salvage pathway
- Lesch-Nyhan syndrome

23

Mechanism for acute gouty arthritis

- hyperuricemic conditions addressed by neutrophils which phag the crystals. They aren't broken down and destroy the neutrophils releasing inflammatory cytokines.

24

Positive biferingient rhomboid crystals and assoc mutation

- pseudo gout: Calcium pyrophosphate accumulation
- associated with AD mutation of ANKH gene

25

Infectious arthritis: epidemiology

- H. flu: under age 2
- S. aureus: older kids and adults
- N. gonorrhea: late adolescence and younger adults
- salmonella: sickle cell

26

-Insidious onset of worsening pain resulting from caseating granulomatous inflammation often times within the spinal column

- osteomyelitis from infectious TB
- Potts disease
- hips>knees>ankles

27

Arthritis associated with cross reactive Borrelia antigens

- infectious arthritis
- silver stain positive in only 25%

28

Ganglion cyst

- 1-2 centimeter translucent cyst not communicating with the joint space and has no cellular lining
- excision is curative

29

Lipoma/liposarcoma
Fibromatoses/fibrosarcoma
Rhabdomyoma/rhabdomyosarcoma
Leiomyoma/leiomyosarcoma
Hemangioma/angiosarcoma

- Benign/malignant adipose tumor
- Benign/malignant fibrous tissue tumor
- Benign/malignant skeletal muscle tumor
- Benign/malignant smooth muscle tumor
- Benign/malignant vessel tumor

30

Lipoma versus angiolipoma

Lipoma: more common, painless, Subcubitus extremities and trunk
- Well differentiated circumscribed adipocytes
Angiolipoma: Male predominance subcutaneous often painful
- Well differentiated adipocytes and capillary sized vessels with thrombi

31

MDM2 amplification, lack of p53 inhibition
TLS-CHOP
Pleomorphic
- lipoblasts (lipid vacuoles, scalloping nucleus) with atypical lymphocytes

- MDM2: Well differentiated, best prognosis for liposarcoma
- myxoid morphology
- pleomorphic: Liposarcoma with poorest prognosis

32

- Rapidly expanding subcubitus mass muscle of forearm or trunk
- Immature tissue culture would fibroblasts and myofibroblasts high cellularity

- Nodular fasciitis

33

Aggravating deforming fibrous lesion in 3 superficial location
- Fascicles of mature myofibroblasts with dense collagen

- Palmer (dupuytrens contracture),
- plantar (ledderhose disease),
- penile (peyronie disease)

34

Locally aggressive infiltrating disfiguring mass
Associated with deep proximal structures
Long fascicles of bland fibroblasts infiltrating surrounding tissue
Associated with the B-catenin/APC gene

- Desmoid tumor (deep fibromatosis)
- abdominal (anterior wall) extra abdominal, intra abdominal

35

Infiltrated fleshy masses with hemorrhaging and necrosis
Herringbone pattern of fascicles of malignant spindle cells

- Fibrosarcoma

36

The most common sarcoma in kids
- Cluster of grapes
- t2;13, PAX3-FOXO1A
- Atypical bizarre tumor cells

Rhabdomyosarcoma
- botryoid and embryonal (best prognosis) bladder, vagina, nasopharynx
- alveolar in extremities, adolescents (worst prognosis)
- pleomorphic

37

HOXD-13 mutation

- sympolydactyly

38

FGFR 3 mutation

- achondroplasia
- thanatotropic dwarfism

39

COL1A1 mutation

Osteogenesis Imperfecta

40

Synpolydactyly

- HOXD-13 mutation
- Extra third digit and fuse third and fourth
- homeobox genes associated with absent/extra bones and acrodactyly

41

Decrease of normal chondrocyte proliferation at growth plate

Achondroplastic dwarfism

42

Osteogenesis Imperfecta types

Defective synthesis of type I collagen: too little bone density
- type I mild: normal lifespan
- type II: non-survivable
- type III/IV: moderate severity, deforming

43

Osteogenesis imperfecta morphology

- commonly shin deformations and scoliosis

44

Deficiency of lysosomal acid hydrolase enzymes that degrade mucopolysaccharides
- progressive accumulation in cells

- hurlers: type I MPS, deficiency of a-L induronidase
- hunters: type II MPS, deficiency of iduronate-2-sulfatase;
XL recessive

45

Long bones lacking normal medullary cavity filled with persistent primary spongiosa
- Fractures pancytopenia and cranial nerve deficits

- osteopetrosis "marble bone" disease
- very heaped but very brittle bones
- type II Carbonic anhydrase deficiency
- May also have renal tubular acidosis

46

Mosaic pattern of lamellar bone in axial skeleton/femur
Increased ALPase
Increased osteoblast/osteoclast
Predominantly whites

- Paget's disease
- sqstm1 mutation in 50%
- abnormal bone architecture

47

Osteoclast signaling

- RANK binds and MCSF is released with osteoprotegrin from stromal cell/osteoblasts
- causes release of NFKB in monocyte osteoclast precursor
- OPG binds and inhibits RANK

48

A specific and sensitive marker for osteoblast activity

- osteocalcin

49

Osteogenesis imperfecta

- AD (primarily)
- type I collagen defect (COL1A)
- type I (mild) type II (lethal) type III/IV (moderate to severe, deforming)

50

- Short stature, chest wall abnormalities, bone malformations
- a-L induronidase
- indurate-a-sulfatase

- hunters and hurlers
- mucopolysaccharide accumulation

51

- dense, brittle bones
- concurrent renal tubular acidosis
- pancytopenia -> Extra medullary hematopoiesis

- carbonic anhydrase II deficiency -> osteopetrosis (marble bone disease)
- decreased osteoclast activity

52

Genetic factors and developing osteoporosis

Estrogen receptor, vitamin D receptor and LRP 5

53

Severe complications of Paget's disease

- Giant cell tumors, sarcoma (osteosarcoma/Fibrosarcoma)
- 5-10% in people with polyostoic disease

54

Vitamin D deficiency in kids
Deformed bones

Ricketts,
In adults it's osteomalacia

55

Severe cortical bone defect: increased bone resorption
Dissecting trabeculae on X-ray
Brown tumor

- hyperparathyroidism
- can result in osteitis Fibrosis cystica if untreated
- brown tumor not actually tumor: microinfarcts and 2nd hemorrhages

56

- Increased bone resorption
- delayed matrix mineralization
- growth retardation
- osteoporosis
- metabolic acidosis

Renal osteodystrophy
- Phosphate retention due to renal failure results and secondary hyperparathyroidism (phosphate is a secondary regulator of PTH: PTH blocks resorption of phosphate in tubules normally leading to excretion, so with increased phosphate more PTH is needed to induce -> too much resorb)
- decreased vitamin D conversion

57

Wedge shaped infarcts in medullary bone

- subchondral infarcts
- cortical bone not usually affected by infarcts due to the periosteal collateral circulation

58

Pyogenic osteomyelitis

- H. Fu: kids under 2
- S. aureus: kids and adults
- N. gonnoreae: adolescents and young adults
- salmonella: HbS
Typically hematogenous spread: ots. Tuberculosis increasing

59

Osteomyelitis clinical course

- a necrotic center known as a sequestrum forms inside of the involucrum
- may form a communicating nidus to drain through the soft tissue

60

Osteomyelitis localized to the jaw

- sclerosing osteomyelitis of Garre

61

- HLA B27 to susceptibility
- Destruction of sacroiliac and apophysial joints
- ANA seronegative

Ankylosing spondylitis

62

- B 27 Cw6 susceptibility
- Psoriatic condition associated with axial joints and enthesis

Psoriatic arthritis

63

Finkelstine test

- adduction of wrist with thumb adducted causes pain over radial styloid process
- DeQuervains tenosynovitis

64

Yergasons sign

Bicipital tendinitis: Anterior shoulder pain

65

Shoulder pain with full range of motion

- Olecranon bursitis not involving the joint itself

66

Capsulitis arthrogram

- Reduced uptake of die on MRI

67

Pain in shoulder with abduction of arm from 60-120°

- Rotator cuff tendinitis: Most commonly weakness of the supraspinatus tendon -> Impingement of supraspinatus between humeral head and acromion process

68

Typically healthy young person with inability to abduct the arm at all

- Supraspinatus tendon tear

69

Morphological changes in osteoarthritis

- thickened joint capsule, synovial hypertrophy
- sclerosed subchondral bone
- cyst formation

70

Bouchards and heberdens nodes

- B before H in osteoarthritis
- B=proxymal
- H= distal

71

Gullwing deformity on X-ray

- Indicative of osteoarthritis

72

RA vs OA in hand

- OA spares MCP joints, RA does not
- RA is disfiguring, not just inflammatory

73

Boutonnière and swan neck deformities

- Both due to contracture of muscle groups in the hands in rheumatoid arthritis

74

Extra-articular features of rheumatoid arthritis

- pleuritis
- pulmonary nodules
- interstitial lung disease
- Caplans syndrome
~ lung nodules
~ pneumoconiosis
~ RA

75

RA, splenomegaly, granulocytopenia

Feltys syndrome

76

Scleromalacia perforans

- complication from RA
- thinning of sclera result in extrusion of intra occular contents

77

Caplans syndrome

~ lung nodules
~ pneumoconiosis
~ RA

78

Jaccouds vs. SLE arthropathy

Both are symmetrical and nonerosive but SLE is nondeforming unlike jaccouds

79

SLE trt

- avoidance of the sun
- hydroxychloroquine
- steroids
- cyclophosphamide/mycophenolate mofetil

80

SSA Ro/La

ANA sp to sjorgens syndrome

81

Calcinosis, Raynaud's phenomenon p, esophageal dysmotility, sclerodactyly, telangiectasia

- crest syndrome assoc with scleroderma (limited cutaneous)

82

Can't see, can't pee, can't tree

- conjunctivitis, urethritis, arthritis
- triad of reactive arthritis
- typically oligoarthritis

83

Treatment for reactive arthritis

Abx if infection is still present
NSAIDs
Corticosteroids
DMARDs: sulfalazine, methotrexate, anti-TNFa

84

Keratoderma blenorrhagica

- identical to pustular psoriasis
- variable prognosis

85

Enteropathic arthropathy trt

- NSAIDs are a problem
- sulfasalazine
- TNFa inhibitors

86

Hyperuricemia levels

- M: 7.1mg/dl
- F: 6.0 Mg/dl

87

Precipitants of gout and gouty arthritis

- drugs: Diuretics, heparin, cyclosporine
- trauma
- EtOH

88

Disease states associated with CPPD crystals

- Hypothyroidism, Hyperparathyroidism,hypophosphatasia, hemochromatosis, hypomagnesemia

89

Vasculitis affecting large and medium blood vessels

- giant cell arteritis
- takayasu's arteritis
- angiitis of CNS

90

Vasculitis affecting predominantly medium and small blood vessels

- polyarteritis nodosa
- microscopic angiitis
- Wegeners syndrome
- Churg-straus syndrome

91

Vasculitis affecting predominantly small blood vessels

- Henoch-schonlein purpura
- HSN vasculitis
- mixed cryoglobinemia

92

- medium/small vessels
- Identified by recent history of severe asthma, eosinophilia, sinusitis, pulmonary infiltrates, G.I. ischemia

Churg straus vasculitis

93

- Small/medium vessels
- ischemia involving
~ renal, GI mesentery, peripheral nerves, CNS
- livedo reticularis (doily rash)

Polyarthritis nodosa

94

Angiogram demonstrating aneurysmal dilation tapering a blood vessel

Diagnostic for polyarteritis nodosa

95

- Headache, scalp tenderness, fever, weight loss, night sweats, visual disturbance, blindness
- Vasculitis involving cranial arteries and large branches aorta

- Giant cell arteritis (temporal arteritis)
- trt with high dose steroids

96

Wegeners syndrome

- Radiographically identical to metastatic carcinoma of the lung
- get a biopsy
- saddle nose deformity

97

Henoch schonlein purpura

- classic triad:
~ lower extremity rash
~ abdominal pain
~ hematuria