LOCO Revision5 Flashcards by patrick ellis

Which would commonly present with a fracture from a low force injury?

RA
OA
OP
Gout

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Osteoporosis patients are likely to present with

lordosis
kyphosis
scoliosis

kyphosis: called

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Osteonecrosis is associated with the treatment of

RA
OA
OP
Gout

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Recombinant PTH used to treat OP is called? [1]

Teriparatide

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Name drug A used to treat osteoporosis [1]

Denosumab

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Name drug A used to treat osteoporosis [1]

Teriparatide

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alkaline phosphatase (ALP) is produced by which cell type? [1]

Osteoblast

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Which disease is shown in this CT [1]

Describe the pattern shown in the skull [1]

Pagets disease; cotton wool skull

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Osteoporosis

What is T and Z score on a DEXA scan? [2]

Which is more commonly used? [1]

T-score = number of standard deviations from the mean young (30 yr) same gender and ethnicity. More commonly used

Z-score = number of standard deviations from same age, gender and ethnicity. Used for younger populations

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Which 3 locations do you measure a T score from in the body? [3]

Why do you measure these areas? [1]

Neck of femur, lumbar vert or distal radius

Have high areaa trabecular bone here [1]

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What T score is a clinical cut off that suggests osteoporosis? [1]

What T score is a clinical cut off that suggests osteopenia?

Osteoporosis: T-score lower than -2.5. [1]

Osteopenia: T-score between –1.0 and –2.5 standard deviations below normal.

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How would a patient present with osteoporosis? [1]

Have a fracture due to low force injury

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Name two bones that are more likely to suffer from osteoporosis [2]

Vertebral bodies
Femoral neck

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Describe pathophysiology of osteoporosis [3]

Bone formation is normal
Just relative increase in bone resorption not matched by formation
Trabecular bone more at risk

Trabecular bone almost dissapeared on R (L is normal)

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Describe the clinical presentation of osteoporosis [3]

Fracture is the only cause of symptoms in osteoporosis
Sudden onset of severe pain in the spine, often radiating to the front
Thoracic vertebral fractures may lead to kyphosis - ‘widows stoop’

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What is first line treatment for osteoporosis? [1]
Describe MoA [3]

Bisphosphonates:

inhibits osteoclast activity
promotes osteoclast apoptosis
Decreases RANKL expression (so osteoblasts don’t turn into osteoclasts [?])

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Describe complications of bisphosphonates

Kills off osteoclasts: don’t remove old bone: thickened bone

Get giant osteoclasts: poisoned osteoclasts

Osteonecrosis occurs

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Osteoporosis treatment

Describe the MoA of Teriparatide [2]

Teriparatide is a recombinant PTH:

PTH upregulates RANKL - signals osteoblast to differentiate when have low Ca2+: work indirectly on osteoclasts to boost bone making potential
Intermittent exposure to PTH activates osteoblasts more than osteoclasts

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Osteoporosis treatment

Describe the MoA of Denosumab [2]

PTH normally inhibits OPG.

Denosumab is a an osteoprotegrin artificial antibody & acts as a monoclonal antibody to RANK:

Denosumab: human monoclonal antibody that inhibits RANKL and helps regulate turnover in healthy bone. Denosumab binds with high specificity and affinity to the cytokine RANKL, inhibiting its action; as a result, osteoclast recruitment, maturation and action are inhibited, and bone resorption slows

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Descibe pathophysiology of Pagets disease [2]

Describe the three phases of Pagets disease [3]

(Theory) osteoclasts: may be infected with a virus that alters them AND genetics

Phases:
1. increased rate of bone resorption:
* large number of giant osteoclasts

2. Compensatory phase / proliferative:
* increased bone formation & accelerated depostion in disorganised manner

3. Burnt out phase: sclerotic:
* Hyper-vascular bone marrow; Bone hypercellularity may diminish leaving dense “Pagetic bone”

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How do serum results for Ca, PO4, ALP, PTH and 1,25(OH)D2 present for osteoporosis? [1]

Normal

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How do serum results for Ca, PO4, ALP, PTH and 1,25(OH)D2 present for osteomalacia? [1]

Explain each result

Low Ca
Low PO4
ALP high
PTH high
Vit D low

Main cause of osteomalacia: low vitamin d
Low PO4 and Ca due to phosphate being excreted in order to keep any calcium possible via renal regulation).
ALP high because produced in osteoblasts
PTH high due to low Ca2+

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How do serum results for Ca, PO4, ALP, PTH and 1,25(OH)D2 present for Pagets disease? [5]

Explain your answer [1]

Ca: normal
PO4: normal
ALP: raised
PTH normal
Vit D: normal

ALP raised due to characterised by high burn turnover

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How do serum results for Ca, PO4, ALP, PTH and 1,25(OH)D2 present for renal failure [5]

Explain your answer [1]

failure leads to vitamin D deficiency, as 1,25(OH)2 D3 is made in the kidney.

This results in high PO4, low calcium and normal/high alkaline phosphatase

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Name a rare complication of Paget’s disease that occurs in 1% of cases [1]

**Osteosarcoma**

What would lab results of a patient with osteomalacia show: - Ca2+ levels [1] - PO4- levels [1] - ALP levels [1] - Vitamin D levels [1]

* **Reduced** serum **calcium** and **phosphorous** * **High alkaline phosphatase** (as this is a product of osteoblasts, so there is increase compensatory osteoblastic activity) * **Low vitamin D levels**

Describe the pathophysiology of osteomalacia [2]

Osteomalacia is a condition that is the result of i**nsufficient calcium and phosphate** to **mineralise** **new** bone **osteoid**. This results in bones becoming **softer** and **more liable to bend or fracture** . It is usually result of **vitamin D deficiency** either in diet or production, and has different clinical presentation in adults and kids:

How would you diagnose osteomalacia from a bone biopsy? [1]

Normal bone: - approx. 20% unmineralized bone osteoid Osteomalacia: - wide seams of **unmineralized osteoid**. In severe cases, up to **100% of the bone** is covered by **unmineralised osteoid.**

Which drug would allow you to determine the level of bone mineralisation [1]

**Tetracycline** chelates: less labelling would be seen

What phase of Pagets Disease is depicted? [1] Explain your answer [1]

Burnt-out sclerotic phase of Paget disease (**Phase 3**): Woven bone appears as **bony shelves** divided by **cement lines into irregular regions.**

What are the arrows pointng to in this slide from a Pagets disease patient? [1]

Cement lines

Which pathology is depicted in this X-ray Osteoporosis Osteomalacia Pagets Disease Osteoarthiritis Osteosarcoma

Which pathology is depicted in this X-ray Osteoporosis Osteomalacia **Pagets Disease** Osteoarthiritis Osteosarcoma

How would you confirm Osteosarcoma from a biopsy? [1

Giant cells confirm the diagnosis of an osteosarcoma arising out of Paget’s disease.

Osteosarcoma arises as a complication from: Osteoporosis Osteomalacia Pagets Disease Osteoarthiritis

Osteosarcoma arises as a complication from: Osteoporosis Osteomalacia **Pagets Disease** Osteoarthiritis

How do you treat Pagets disease? [5]

* **Bisphosphonates** work directly on osteoclasts to slow bone resorption. Can be given orally for 2-6 months, or IV single infusion-3 infusions. Bisphosphonates can almost cure Paget’s disease if you catch it early, and **stop the osteoclast hyperactivity**, as this will prevent sclerotic bone from forming. * **Calcium and vitamin D supplements** * **Pain** management * **Surgery** * **Calcitonin** used to be used more often, but now less than bisphosphonates

What is sclerostosis caused by? [1] How do patients with sclerotosis present? [2] Explain your answer [1]

**Absence, abnormal or reduced produced of sclerostin** Sclerostin produced by healthy osteocytes and inhibtis osteoblasts to prevent **XS bone formation** Condition results in **resistance to fractures** and **XS height**

Which nerve is at risk here? [1]

median

Ptx has normal serum calcium, phosphate, ALP & PTH. Which condition are they most likely to have? Paget's disease Chronic kidney disease Primary hyperparathyroidism Osteoporosis Osteomalacia

**Osteoporosis**

Damage occurs from twisting injuries: Posterior cruciate ligament injury Menisical injury Medial collateral ligament injury Lateral collateral ligament injury

Menisical injury

A female immigrant from the Indian subcontinent presents with 'bone pain', muscle weakness and anorexia. Bloods show a decreased calcium and phosphate level is a stereotypical history of ? [1]

**Osteomalacia**

A patient is found to have the following results: low serum calcium, low serum phosphate, raised ALP and raised PTH. Which condition are these findings most consistent with? Paget's disease Chronic kidney disease Primary hyperparathyroidism Osteoporosis Osteomalacia

**Osteomalacia**

Which of the following commonly affects the DIP and PIP joints? Paget's disease Osteoathritis Osteoporosis Osteomalacia Rheumatoid arthritis

**Osteoathritis**

Which of the following commonly affects the MCP and PIP joints? Paget's disease Osteoathritis Osteoporosis Osteomalacia Rheumatoid arthritis

Rheumatoid arthritis

X-ray findings include osteophytes forming at joint margins Paget's disease Osteoathritis Osteoporosis Osteomalacia Rheumatoid arthritis

Osteoathritis

Which of the following antibodies is most associated with RA? P-ANCA Anti-dsDNA Anti-Ro Anti ACPA Anti La

Anti ACPA

**SLE**

An elderly man is investigated for 'bone pains'. He is known to be deaf. Bloods show a raised ALP and a skull x-ray shows a thickened vault is a stereotypical history of? [1]

**Paget's disease**

Colchicine - inhibits microtubule polymerization by binding to tubulin, interfering with mitosis. Also inhibits neutrophil motility and activity

STI --> arthritis, urethritis, conjunctivitis in a question is most likely to indicate ? [1]

**Reactive arthritis**

State three categories of inflammatory joint disease [3]

1. **Infection**: septic arthiritis or generalised arthralgia 2. **crystal arthropathy**: gout and pseudogout 3. **Autoimmune disorders**: RA, spondarthritis, connective tissue disease

Many joints / polyarthralgia would be suggestive of what type of disease? [1] Single joint / monarthralgia would be suggestive of what type of disease? [1]

polyarthralgia: autoimmune disorders monarthralgia: inflammatory disorder

Draw a flow chart for diagnosis of joint pain

Describe the features of RA [3]

**Symmetrical** Hands and feet in 80% of cases Early morning stiffness Valgus deformity Bakers cyst: synovial fluid at popliteal area

What is this sign of RA [1]

**Bakers cyst**: synovial fluid at popliteal area

State three eye complications of RA [3] Why is the eye commonly a problem? [1]

RA effects type 2 collagen; get lots of type 2 collagen in they eye Keratoconjunctivitis sicca Scleritis & episcleritis Scleromalacia perforans: intraocular contents prolaspes out of the sclera

Describe three neuromuscular complications of RA [3]

**Muscle wasting** **Carpal tunnel syndrome** **Atlanto-axial subluxation**: odointal peg impinges on the spinal cord

What causes cervical myelopathy in RA patients? [1] What are signs of cervical myelopathy? [5]

Compression of the spinal cord and brain stem is typically caused by atlantoaxial instability (AAI) or atlantoaxial subluxation (AAS) **spasticity** (sustained muscle contractions) **hyperreflexia** **pathologic reflexes** **digit/hand clumsiness** **gait disturbance**

State a cardiac [1] and bone [1] complication of RA

ischaemic heart disease osteoporosis

State three connective tissue diseases

**Systemic lupus erythematosus:** **Scleroderma / Systemic sclerosis:** progressive atrophy of soft tissue **Dermatomyositis**: high level of creatine kinase; muscle weakness - get lots of rashes. proximal weakness

Describe pathophysiology of Systemic lupus erythematosus

Characterised by **anti nuclear antibodies** (antibodies to proteins within the persons own nucleus): causes immune system to target these proteins and generates **inflammatory response** / **loss of tolerance** Inflammation leads to the symptoms

Describe the symptoms of SLE

**90% of patients have arthritis**: * symmetrical small joint polyarticular arthiritis (most common) * jaccoud arthropathy (rare) * avascular necrosis Fatigue Weight loss arthralgia myalgia fever **butterfly rash**: gets worse with sunlight shortness of breath hair loss