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Flashcards in General MSK Deck (87):
1

Red flags of back pain?

• Use of IV drugs --> epidural abscesses
• Hx of cancer
• Steroid use
• Age over 50 years
• Night time pain
• Unresponsive to therapy
• Hx of AAA
• Saddle anaesthesia
• Bladder/bowel incontinence or retention
• Paraplegia
• Duration of pain greater than 1 month
• Unexplained weight loss, night sweats and fever
• Mid back pain

2

differential diagnosis for acute mono arthritis?

1. bacterial septic arthritis
2. Crystal arthritis- like gout or pseudo gout
3. subchondral bone lesion due to fracture, osteonecrosis, osteomyelitis
4. haemarthrosis (trauma)

3

risk factors for joint sepsis?

-Very young or advanced age
- recent joint aspirate, penetrating injury
- portals for bacteramia
- previous joint damage
- DM, chronic renal or liver disease
-corticosteroid therapy
-immunodeficiency
-prosthetic joints

4

what do you think if there are multiple joints affected with septic arthritis?

immune complex response to a systemic infection. OR neisseria meningitis dissemination

5

what bacteria is most commonly associated with septic arthritis?

staph aureus

6

what is the acute management of septic arthritis?

arthroscopic wash out
Antibiotics

7

what Ix do we order for osteoporosis?

1.XRAY
2.Blood tests- calcium, phosphate, magnesium, Vit d, TFT, 3 3.LFT
4.ALP, albumin
5.need a bone DEXA scan to monitor osteoporosis

8

what is torticollis?

wry neck

9

how do OB interact with OC? and how is the balance affected in post menopausal women?

OB express RANKL which binds to OC RANKL receptor. OB produces OPG to inhibit RANKL receptor on OC. Post menopausal women have E2 deficiency and this leads to overexpression of RANKL as compared to OPG, further activating OC and leading to bone resorption.

10

risk factors for osteoporosis?

Risk factors include an older age, female gender, white ancestry, low BMI, FHx of maternal hip fracture, postmenopause, glucocorticoid use, prior fracture, hypogonadism, loss of height, secondary amenorrhoea, smoking, excessive alcohol use, prolonged immobilisation, vitamin D deficiency, hyperthyroidism, weight loss of >10% of body weight, androgen deprivation treatment (in men), aromatase inhibitor treatment (in women), tobacco use, heparin use, anticonvulsant use, or kidney stone disease.

11

What T score from DEXA test will indicate osteoporosis?

T-score of ≤-2.5 indicates osteoporosis; T-score ≤-2.5 with fragility fracture(s) indicates severe (or established) osteoporosis

12

what does DEXA test screen for?

risk of fracture and osteoporosis

13

whats the difference between a T score and a Z score for the Dexa test?

T score- compared to a healthy 30 year old adult male
Z score- compared to another healthy individual of the same age group

14

Describe the Ottawa ankle rules for suspected ankle fracture thus requiring X-ray

Ottawa ankle rules:
1. Tenderness posterior borders lower 6 cm of malleoli
2. Tenderness base 5th metatarsal
3. Tenderness navicular
4. Unable to fully bear weight for 4 steps
If all four present- then must XRAY

15

what does enthesitis mean?

Inflammatory process affecting the sites of insertion of ligaments and tendons into bone. The lower limbs with the heel, knee, and ischial tuberosities are most commonly affected.

16

what are the 3 phases of paget's disease of the bone?

1. An initial, short-lived burst of multinucleate osteoclastic activity causing bone resorption

2. A mixed phase of both osteoclastic and osteoblastic activity, with increased levels of bone turnover leading to deposition of structurally abnormal bone

3. A final chronic sclerotic phase, during which bone formation outweighs bone resorption.

17

some features of paget's disease?

- skull, femur, pelvis involvement
- hearing loss and facial pain
- pathological fractures
-bone deformities
-back pain

18

complications of paget's disease

• Osteosarcoma
• Malignant fibrosarcoma
• Pathological fractures
• Spinal stenosis
High output cardiac failure

19

difference between osteoporosis and osteomalacia?

In osteoporosis, there is decreased bone mass with a normal ratio of mineral to matrix
In osteomalacia, the ratio of mineral to matrix is decreased (ie there is too much matrix relative to the amount of bone)

20

what is the difference between osteopenia and osteoporosis?

osteopenia also refers to reduced bone density but not to the extent as osteoporosis

21

how do we treat psoriatic arthritis?

Treatment:
• NSAIDs first line- naproxen, ibuprofen, diclofenac
• DMARDs- methotrexate, sulfasalazine, cyclosporin
• Adjunct physiotherapy, intra-articular corticosteroids

In severe cases upgrade to biological agents like inflixamab

22

what are some radiological findings of psoriatic arthritis?

The hallmark of PsA is the combination of erosive change with bone proliferation, in a predominantly distal distribution (i.e. interphalangeal more than MCP joints). The disease most commonly involves the hands, followed by feet. It can also affect sacroiliac joints and spine.

23

what are the key differences between psoriatic arthritis and RA?

how are they similar?

PA is usually seronegative -ve RF -Anti CCP
PA affects distal joints whereas RA predominantly affects proximal joints
RA is symmetrical whereas PA may or may not be symmetrical

Both inflammatory pain conditions
Both have erosions on plain film

24

what is the mutation associated with Paget's disease of bone?

SQSMT1 gene

25

what is the main driver of osteoclastic activity in Paget's disease of bone

NFKB induces OC activity

26

treatment for Paget's disease of bone?

• Bisphosphonate
• Calcitonin
• Calcium supplementation
Vitamin D supplementation

27

what is another name for avascular necrosis?

osteonecrosis

28

2 key causes of avascular necrosis?

trauma and corticosteroid use

29

what part of the bone does avascular necrosis usually affect?

medullary part of the bone usually has infarcts bc the cortex area has collateral blood supply and the medulla doesn't

30

what are the most common bacteria associated with osteomyelitis?

pyogenic bacteria (staph aureus)

31

what do we mean by osteosarcoma

a malignant mesenchymal tumour in which the tumour cells produce bone

32

where does osteosarcoma commonly metastasise to?

lung

33

what conditions predispose pathological fractures?

paget's
malignancy (bony mets)
osteoporosis
Osteogenesis imperfecta

34

what are the mutations associated with osteosarcoma

RB and p53 mutations

35

what are the main types of soft tissue tumours?

fatty tumours
fibrous tumours
skeletal muscle tumours
smooth muscle tumours

36

what is a ganglion?

cysts around joints and arising from tendon sheaths

37

2 descriptions of fractures in femurs?

intracapsular or extracapsular

38

what levels are most affected for lumbar spondylosis?

L4-L5, L5- S1

39

what does a positive tredenlenberg test indicate

weakness of the gluteal medius muscle

40

what is another name for vertebral osteomyelitis?

diskitis or discitis

41

what might cause genu varum and genu valgus?

osteoarthritis- varus
rheumatoid arthritis- valgus

fracture
congenital deformity
rickets

42

the most common site for hip pain?

laterally around the hip

43

What pain refers to the buttock?

lumbosacral spine, hip joint

44

what pain refers to the groin?

hip joint, lumbosacral spine, SI joint

45

what sort of things do we think when a patient presents with lateral hip pain?

trochanteric bursitis
gluteal pathology

46

what nerves innervate the hip joint?

femoral, obturator, gluteal nerves

47

what does GALS stand for?

gait
arms
legs
spine

48

is there any need for a blood test to dx OA?

no

49

management of OA?

exercise, reduce body weight
analgesia--> paracetamol used regularly--> opiates

eventually- surgery

50

indications for total hip replacement?

disabling pain with failed non operative treatment
- impaired ADLS
-reduced ROM and fn
-pain at night
- deformity

51

will you do a THR on a patient with UTI

no bc risk of bacteremia. So always need to do a UTI screen (MSU) preoperatively

52

complications of THR?

• Intra op- injury to NV structures
• Early post op- haematoma, infection
• Late post op- dislocation, fracture, loosening, heterotropic ossification

53

when do we use a dynamic hip screw?

when there is a hip fracture (NOF)

54

what do we mean by gluteus medius tendinopathy syndrome

degeneration of muscle fibres in the gluteus medius--> tearing and oedema of the gluteus medius tendon

can be associated with greater trochanteric bursitis

55

define impingement syndrome

Impingement may be defined as the encroachment of the acromion, coracoacromial ligament, coracoid process, or AC joint on the rotator cuff as it passes beneath them during glenohumeral motion.

56

define baker's cyst

a synovial fluid-filled mass located in the popliteal fossa. The most common synovial popliteal cyst is considered to be a distention of the bursa located beneath the medial head of the gastrocnemius muscle.

57

OA typically affects which compartment in the knee?

medial

58

which is stronger in the knee- ACL or PCL

PCL

59

what is mechanism of injury of ACL injury

knee extended, impact, internal rotation of tibia on fibula

60

what is mechanism of injury of PCL injury?

falling on knee whilst bent, hitting knee on dashboard
-high impact injuries

61

what is tennis elbow?

inflammation of the lateral epicondyle

62

what is meralgia parasthetica?

compression of lateral cutaneous nerve of thigh--> sensory loss in lateral area

63

risk factors for carpal tunnel syndrome?

• Radial fractures
• Strenuous overwork
• RA, acromegaly
• Diabetes, CCF sometimes
Menopause and pregnancy

64

first line ix for carpal tunnel syndrome?

nerve conduction tests

or MRI and U/s wrist

65

risk factors for osteoporosis

low exercise levels
smoking
co-morbidities
poor nutrition/calcium intake
vitamin D insufficiency
prolonged amenorrhoea in younger years
post menopausal at age 42-53
never reached peak bone density

66

what does the DEXA scan use as its reference

normal BMD in a 30 year old healthy woman

67

what bones does the DEXA scan analyse?

measures BMD of spine and proximal femur and total hip

68

if you have vitamin d deficiency, what do you expect the PTH levels to be?

secondary hyperparathyroidism

69

What are the bone turnover markers?

Serum B-CTX indicates bone resorption (cleared by the kidneys)

P1NP indicates bone formation (cleared by the liver)

70

What are the SECONDARY causes of osteoporosis?

Cushing's syndrome
Exogenous corticosteroids!!
Excessive alcohol use
Smoking
Malabsorption (coeliac, IBD)
Primary or secondary hypogonadism

71

how do we calculate absolute fracture risk?

using calculation tools like the Garvan absolute fracture risk

72

do we use HRT for osteoporosis? why?

NO. Increases risk of breast and endometrial ca and increases risk of CVD

73

what are some therapies for osteoporosis

Bisphosphonates (alendronate, risedronate, zoledronate)
Teriparatide
Denosumab
Strontium

Raloxifine (women only)- SERM not often used anymore

74

tell me about raloxifine and why we do not use it much anymore

main action is- reducing vertebral fractures

strongly predisposes the patient to DVT and clots

75

why might teriparatide be used in osteoporosis?

intermittent PTH therapy can actually reduce bone resorption

76

SE of strontium

negative cardiovascular effects

77

which bisphosphonate is given intravenously once a yr?

zoledronate

78

how do we administer denosumab?

SC injections at the GP every 6 months

79

SE of denosumab

Osteonecrosis of the jaw
atypical fractures
allergy

slight increased risk of infection

80

what are the main side effects of bisphosphonates (oral)?

GIT upset!!!!!

Osteonecrosis of the jaw
atypical fractures

81

do we prescribe bisphosphonates in patients with CKD?

no, because the drug are renally cleared

82

what is adynamic bone disease?

condition where there is static bone- not forming bone or not resorbing bone

83

should we use denosumab post renal transplant?

no. bc it increases the risk of infection in immunosuppressed patients

84

what actually is osteonecrosis of the jaw?

exposed necrotic bone of more than 8 weeks

85

how might we assess a patient's risk of atypical bone fractures due to bisphosphonate use?

ask the patient if they have experienced mid thigh pain. If they say yes, then cease bisphosphonates immediately.

86

causes for vitamin D deficiency

malabsorption
inadequate sunlight exposure
dark skin
renal failure
inadequate diet

87

mechanism of denosomab?

binds rank ligand