Locomotor Flashcards
(247 cards)
1
Q
If abducting the shoulder 180 degrees how much of the movement is from which joint?
A
120 degrees is from glenohumeral joint and 60 from the scapulothoracic joint
2
Q
What nerve is affected if there is injury to the lattimus dorsi?
A
Thoracodorsal
3
Q
What nerve is most at risk in fractures of the medial epicondyle?
A
Ulna
4
Q
What sign do you get in ulna injuries?
A
Claw hand (clawing and flexion of 4th and 5th fingers)
5
Q
In what nerve injury would you get loss of thenar muscles
A
median
6
Q
What is the name of the test for collateral circulation in hand
A
Allan test
7
Q
What does a disruption to Shenton’s line show?
A
NOF
8
Q
What is the strongest ligament in the hip joint?
A
The ilio-femoral ligament (anterior)
9
Q
What does a positive Tredelenburg test show?
A
Damage to superior gluteal nerve
10
Q
What are the borders of the femoral triangle?
A
Inguinal ligament, sartorius, adductor longus
11
Q
What is the unhappy triad?
A
PCL, ACL and medial meniscus
12
Q
What nerve wraps around neck of fibula?
A
common peroneal
13
Q
What does the common peroneal innervate and what do you get if its damaged?
A
Muscles of anterior and lateral compartment of the leg = foot drop.
And sensory to the dorsum of the foot
14
Q
What nerve passes through the tarsal tunnel?
A
Tibial nerve
15
Q
What type of collagen is bone?
A
Type 1
16
Q
What is a romosozumab?osteoporosis
A
A monoclonal antibody inhibiting sclerostin (treats osteoporosis)
17
Q
How do osteoclasts absorb bone?
A
They acidify a matrix area and the hydroxyapatite dissolves setting free Calcium
18
Q
What do osteoblasts fill lacuna with?
A
Osteoid
19
Q
How does calcitonin regulate calcium?
A
It lowers plasma ca2+ by directly inhibiting osteoclast activity, increasing excretion from kideny and inhibiting absorption from intestines
20
Q
how does Cinacalcet work for secondary hyperparathyroidism?
A
It binds to allosteric site of calcium sensing receptor of parathyroid which increases the sensitivity of the receptor to calcium. Therefore reduces PTH
21
Q
What does calcitrol do?
A
It is the active form of vit D and binds to Vit D receptor and induces genes necessary to maintain calcium reserves. It mainly increases uptake of calcium from intestines
22
Q
What hormone counters PTH affect on vit D?
A
Fibroblast growth factor 23
23
Q
When and where is FGF23 secreted?
A
By osteocytes and osteoblasts in response to increased calcitrol and dietary phopshate
24
Q
A mutation in what gene causes x linked hypophosphatemia?
A
PHEX gene (causes rickets/osteomalacia)
25
What hormone does Growth Hormone stimulate release of?
IGF-1
26
What does IGF1 do to chondrocytes
Stimulates chondrocytes in epiphyseal plate to divide
27
What effect does oestrogen have on bone?
It directly stimulates bone formation and reduces the number and activity of osteoclasts
28
What is tendinosis?
Chronic injury of a tendon
29
For tendon healing, when is passive motion beneficial as opposed to cast immobilisation?
Beneficial for flexor tendon healing, detrimental for tendon to bone healing
30
What connecting fibres do you find in fibrous enthesis?
Sharpey fibers
31
When are fibrocartilage enthesis better than that fibrous enthesis?
In joints where theres going to be angle changes
32
What HLA is enthesitis associated with?
HLA B27
33
What co-morbid conditions are associated with enthesitis?
inflammatory bowel disease, psoriatic arthritis, ankylosing spondylitis
34
What's the difference between enthesophytes and osteophytes?
Enthesophytes originate from insertion of ligament and tendons
Osteophytes originate from border of articular cartilage
35
What could be used for severe autoimmune enthesitis?
Anti TNF therapy
36
What is a treatment for De Quervian's?
Shave down the radial styloid as it is caused by tendon sheath rubbing over styloid
37
What is an undifferentiated connective tissue disease?
Systematic Lupus Erythematosus
38
What type of hypersensitivity is lupus?
Type 3 - anti nuclear antigens against intra-nuclear proteins
39
What treatment inhibits B cell activating factor and is a treatment for SLE?
Belimumab
40
How does rituximab work for SLE?
It is a CD20 blocker (suppresses B cells)
41
Difference between a T score and a Z score?
T score = number of standard dev of the mean health 30 year old of same age
Z score = number of standard devs from someone of same age, gender and ethnicity
42
What type of bone is most affected by osteoporosis?
Trabecular bone eg vertebral bodies and femoral neck
43
How can teriparatide treat osteoporosis?
It is a portion of PTH. Intermittent PTH activates osteoblasts more than osteoclasts (once daily injections)
44
45
What are some complications of bisphosphonates?
Osteonecrosis of the jaw, atypical fractures eg subtrochanteric and femoral shaft fractures
46
How does romosozumab work for osteoporosis?
It is an antibody against sclerostin which leads to increased osteoblast activity
47
What would you find in lab results for osteomalacia (rickets)?
Low serum calcium and phosphate
High alkaline phosphotase
48
What is a characteristic finding of osteomalacia on xray?
Looser zones - pseudo fractures (areas of unmineralised bone)
49
What can you label bone with to check for mineralisation?
Tetracycline
50
What type of cartilage is the meniscus?
Fibrocartilage
51
What is the tide mark?
The line in which the cartilage changes from calcified to uncalcified
52
Articular cartilage is mainly type II collagen, but what is the other main type of collagen present particularly in the deep layers?
Collagen type X
53
A loss of expression of what can cause osteoarthritis?
HMGB2 = high mobility group protein 2 which is normally prominent in superficial zone and supports chondrocyte survival
54
Loss of what causes water to move in an out of the joint faster and leads to osteoarthritis
Proteoglycans
55
What are type A and type B synoviocytes?
Type A = bone mArrow derived macrophages
Type B = fibroBlast like connective tissue
56
How long would a normal string of synovial fluid be?
4-6cm
57
What is a key interleukin in RA that induces more osteoclasts, sensitises noiceptors and attracts neutrophils?
IL8
58
What CD4+ cells infiltrate in RA and what do they secrete?
Th17 and they secrete IL-17
59
What are the most numerous cells in synovial effusion in RA
neutrophils
60
What does seropostive RA mean?
They are ACPA positive
61
What are the strongest risk alleles for seropositive RA?
HLA-DRB1
PTPN22
62
What interleukins and cytokines are produced by macrophages and leak into blood stream in RA?
IL-1 and IL-6 and TNF alpha. TNF alpha important to remember
63
What type of anemia does RA usually cause?
Normochromic, normocytic anemia but can progress to hypochromic
64
What does citrullination mean?
It is when arginine is converted into citrulline and then the immune system might not recognise them as self antigens
65
What type of Ig is rheumatoid factor?
IgM antibody that targets the Fc domain of altered IgG
66
What does anti-CCP target?
Citrullinated proteins
67
What protein can cause scelrostin to be released which inhibits osteoblast differentiation?
DKK-1
68
What antibodies are associated with severe, erosive RA despite treatment with TNF inhibitors?
PAD4
69
What is carbamylation?
Conversion of lysine into homocitrullines by chemical reaction with cyanate
70
How can smoking lead to RA?
It increases the levels of cyanate and so increases amount of carbamylation
71
What does a histological section of a classic infantile myopathic hypotonia look like?
The type 1 slow fibres (paler) are a lot smaller
(the other way around for non classic)
72
What might you see on biopsy for the myositis?
Variation in fibre size, central nuclei, necrosis and regeneration and infiltrate of lymphocytes (CD8 cytotoxic T cells)
73
What is the most common ANA in myositis that gives a worse outcome?
Anti-Jo1
74
What muscles are affected more in inclusion body myositis?
Finger and wrist flexors
Knee extensors (loss of quadricep reflex)
75
What is inheritance pattern of Duchenne and Becker muscular dystrophy?
X-linked recessive
76
How many points on the ACR/EULAR score do you need for an RA diagnosis?
6 or more out of 10
77
What are the standard treatment concepts for mild, moderate and severe RA?
Mild - methotrexate + second line DMARD
Moderate -methotrexate and TNF alpha inhibitor
Severe - methotrexate + rituximab
78
How does methotrexate work?
It is a folic acid antagonist- limiting RNA and DNA synthesis and it is an anti-cytokine inhibiting production of IL1 and NF-kB
79
What is sulfasalazine a combination of?
Sulfapyridine and 5-amino salicyclic acid. (5-ASA stays in the gut)
80
What RA drug also treats ulcerative collitis?
Sulfasalazine
81
How does hydroxychloroquine work?
It increases the lysosomal pH in antigen presenting cells and blocks TLR9
82
What pro drug efficacy is similar to methotrexate?
Leflunomide
83
How does leflunomide work?
Inhibits pyrimidine biosynthesis
84
Name some TNFalpha blockers
Infliximab - monoclonal antibody against TNFalpha
Etanercept- binds to TNFalpha and stops signal transduction
Adalimub -monoclonal antibody
85
How do you measure the Q angle?
Draw a line from ASIS to centre of patella
Draw a line from tibial tuberosity to patella.
Normal Q angle = 15-20 degrees
86
What are the nodes that grow on the distal interphalangeal joint in OA?
Herberden's node
87
What are the nodes that grow on the proximal interphalangeal joint in OA?
Bouchard's node
88
What spinal joint is most often damaged in RA?
Atlanto-axial (misalignment of 1st and 2nd vertebrae). You get subluxation
89
What infections can go on to result in reactive arthritis?
Urethritis / cervicitis /infectious diarrhea
90
What can sausage toe be a sign of?
Reactive arthritis
91
What prostaglandin inhibits gastric secretion?
PGE2
92
What kind of drug is diclofenac?
Preferential COX-2 inhibitor
93
What is an example of an irreversible non selective NSAID?
Aspirin
94
What is basement membrane composed of?
Laminin 332, collage IV, collagen VII
95
What type of collagen is papillary dermis?
Type III collagen
96
What type of collagen is reticular dermis?
Type I
97
What are the two types of hair follicles?
Vellus - body hair, Terminal - scalp and secondary sexual hair
98
What are the three main phases of hair cycle?
Anagen -active
Catagen - regressive
Telogen -resting
99
What hip replacement material has least wear and tear?
Ceramic on ceramic
100
What muscles are often used for free muscle transfer?
Gracilis muscle and rectus femoris
101
What does a Colles fracture refer to?
Dorsal displacement of distal fragment of radius - dinner fork look. Think fallen with wrist extended
102
What is a torus fracture?
A buckle fracture, happens in kids, axial loading causes trabecular compression on one side
103
In bone healing, how long does fibrocartilaginous callus last?
About 3 weeks
104
What are the cells involved in fibrocartilaginous callus formation?
Fibroblasts and osteogenic cells invade procallus and make collagen
Chondroblasts begin to produce fibrocartilage
105
How long does the bony callus last?
from week 3 to about 3-4 months (woven bone)
106
What is neurotmesis?
Complete transection of a peripheral nerve
107
What is a common bacteria that can cause septic arthritis in children?
Haemophilus influenza
108
What is talipes equinovarus?
Club foot - fixed varus and equinus deformity
109
What are associated with club foot?
Breech, connective tissue disorders eg Ehlers Danlos, oligohydramnios, genetic syndromes
110
What is the Ponseti method?
Use of multiple manipulative casts to correct club foot
111
What is Perthes disease?
Avascular necrosis of femoral head (normally self limiting)
112
What does SUFE stand for?
Slipped upper femoral epiphysis
(more common in boys and in the left hip)
113
What type of fracture is a SUFE?
Salter Harris type 1
114
How do you detect SUFE on XRAY?
No femoral head above Klein's line
115
What is Blount's disease?
A growth problem of medial part of proximal tibia, causes tibial varus (knees bow outwards)
116
What risk factors are associated with Blount's disease?
Obesity and walking early
117
What is sever's disease
Calcaneal apophysis
118
What causes Kohler's disease?
Avascular necrosis to navicular bone often associated with infection
119
What causes Kienbock disease?
Interruption of blood supply to the lunate, cause not known.
maybe think KienBOCK like BOX, think Boxing to remember its in the hand
120
What crystals get deposited in gout?
Monosodium urate crystals
121
What is podagra?
Inflammation of 1st MTP joint (big toe)
122
Eating a diet high in what substance can lead to gout?
Purine
123
What cells would you see in the synovial fluid in gout?
Polymorphonuclear neutrophils (PMNS), would have a high WBC too
124
How does colchicine work for gout?
It stops microtubule polymerisation hence stopping neutrophils
125
What's the MAO of Allopurinal?
It inhibits xanthine oxidase hence reducing generation of uric acid
126
What is pseudogout?
It is the deposition of calcium pyrophosphate, you often get it in OA
127
What are the spinal changes in osteoporosis kyphosis?
Increased thoracic curvature (kyphosis) and then a compensatory increase in cervical lordosis
128
What is Sheuermann's disease?
A disease of adolescence (epiphyseal growth plates of vertebral bodies) that causes hyper kyphosis
129
What muscle dysfunction is associated with excessive lumbar lordosis
Shortened Psoas muscle
130
How great a curve in scoliosis before you do surgery?
50 degrees
131
What are the most common levels for herniated disc?
L4/L5, L5/S1
132
What does DISH stand for?
Diffuse idiopathic skeletal hyperostosis (ossification of anterior longitudinal ligament, looks like candle wax dripping)
133
What radiographic signs do you get on MRI of ankylosing spondylitis?
Dagger sign and bamboo shoot spine
134
If impetigo is just in one place how should you treat it?
1% hydrogen peroxide cream
135
What is the pathophysiology behind scalded skin syndrome?
Exotoxins to staph aureus are produced which destroy the desmosomes holding together keratinocytes so you get detachment of epidermal cells
136
What does molluscum contagiosum cause?
water warts
137
What is pityriasis versicolour an example of?
Yeast infection
138
What are permethrin, ivermectin and crotamiton examples of?
Anti parasite medications, used to treat scabies
139
What bacteria is spread by ticks causing Lyme disease?
Borrelia
140
What causes lupus vulgaris?
TB infection
141
What causes Leishmaniasis?
Sandflies
142
What does type 1 hypersensitivity refer to?
IgE mediated hypersensitvity. IgE bound to mast cells, when allergen binds causes degranulation
143
What is type 2 hypersensitivity?
IgG mediated cytotoxic hypersenstivity eg blood transfusion RBCs destroyed
144
What is type 3 hypersensitivity?
Immune complex mediated, eg antigen-antibody complexes desposited in tissues causing activation of complement
eg RA, systemic lupus erythematosus
145
What is type 4 hypersensitivity?
Cell mediated hypersensitivity. Th1 cells secreting cytokines etc eg contact dermatitis, tuberculin reaction, MS
146
What type of hypersensitivity is uticaria (hives)?
Type 1
147
What common allergens do dust mites release?
Der P1
148
What is a new biological treatment for urticaria and asthma (IgE mediated)?
Omalizumab (binds to IgE decreasing cell bound IgE)
149
What antibodies cause pemphigus vulgaris? (blisters on mucus membranes)
antibodies to desmoglein 3 (an epidermal desmosomal adhesion protein)
150
What are new treatments for alopecia and vitiligo?
JAK inhibitors - Ruxolitinib
151
What cell is the link between adaptive and innate immunity?
APCs
152
What do hybrid hip replacements involve?
The use of a cemented femoral stem with an uncemented acetabular cup
153
In what injury do you get loss of rounded profile?
anterior dislocation
(normally from deltoid muscle)
154
What nerve is damaged in winging of the scapula?
long thoracic
154
What are the signs of deltoid paralysis?
loss of roundness of shoulder, numbness over regimental badge and weakness in abduction
155
What palsy do you see shoulder falling?
trapezius palsy (spinal accessory)
156
What do radius and ulna articulate with in the hand?
radius articulates with scaphoid and lunate
ulna doesnt articulate with any carpals (fibrocartilage fills the gap)
157
What nerve passes through the carpal tunnel?
median nerve
158
What artery runs through ligamentum teres?
obturator
159
What nerve palsy would result in paralysis of plantar flexors and sensory loss back of leg and sole of foot?
tibial nerve palsy
159
Nerve roots of femoral nerve?
L2, L3, L4
160
What nerve provides sensation to the skin between big and second toe?
deep peroneal nerve
161
What is the inorganic part of bone?
Calcium hydroxyapatite
162
Where is preferred for bone marrow transplantation?
iliac crest
163
What cells sense mechanical strain on the bone?
osteocytes
164
What is sclerostin secreted by and what inhibits its secretion?
produced by osteocytes
inhibited by PTH, and mechanical strain
165
What regulates elimination of phosphate via kidneys?
Fibroblast growth factor 23
166
What essentially has the opposite effect to PTH?
Calcitonin
167
Where does the final step of hydroxylation of vit D to active form take place?
Proximal tubule via 1-alpha hydroxylase
168
What is the central target organ of calcitrol/ activated vit d?
Duodenum
169
How can chronic kidney disease have affect on bones?
Increased FGF23 and decreased calcitrol, leads to increased PTH and therefore bone disorder
170
What is FSH effect on bone?
stimulates osteoclast activity but is compensated by actions of oestrogen
171
What are centrally located nuclei a sign of?
muscle repair
172
What can be given prophylactically to prevent heterotopic ossification?
NSAIDs (inhibit COX2)
173
How would you control loading for ruptured achilles?
Cast immobilisation, as it is tendon to bone
174
When does intrinsic tendon healing occur?
In any tendon that is covered by a tendon sheath
175
What essentially is ankylosing spondylitis?
Enthesitis of IV disc and anterior longitudinal ligament
176
What is a surgical treatment for trigger finger?
cut the annular ligament
177
What are more than 95% patients with SLE positive for?
ANA - anti-nuclear antigens
178
What is raloxifene? (used for osteoporosis)
it is a selective oestrogen receptor modulator (estrogenic effects on bone)
179
During which part of ovulatory cycle does bone resorption decrease?
Decreases during luteal phase bc of high progesterone
180
How does denosumab work for osteoporosis?
It is a monoclonal antibody to RANK L
(RANKL is what binds to RANK receptor on osteoclasts)
181
What do you see on osteomalacia bone biopsies?
wide seams of unmineralised osteoid
182
What type of collagen is the ECM of cartilage?
II, IX, X and XI
183
How do collagen fibre orientations change as you move down the articular layers?
superficial - parallel, highest tensile strength
intermediate - criss-crossed oblique allows compression
deep zone - perpendicular
184
What is presence in cartilage and can hold up to 50x their dry weight in water?
proteogylacans
185
What is synovial fluid?
The ultrafiltrate of blood with added hyaluronic acid
186
What is added to synovial fluid in mucin clot test?
2-5% acetic acid
187
What is produced by osteoclasts that leads to more osteoclasts, attracts neutrophils and sensitises nociceptors increasing pain?
IL8
188
Which autoantibodies do not seem to play a major pathogenic role in RA?
Rheumatoid factor autoantibodies
189
What is polymyositis and dermatomyositis?
They are inflammatory myopathies, autoimmune and associated with microbial infection
190
When in dermatomyositis or polymyositis would you need long term immunosuppression?
If there are anti Jo-1 antibodies
191
What do you see on a biopsy for inclusion body myositis?
fibres contain empty vacuoles and clumps of cellular material that contain amyloid like material ( congo red)
192
What is Duchenne's a problem of?
Dystrophin (responsible for connecting cytoskeleton of muscle fibre to basal lamina)
193
Which muscle fibres get more affected by corticosteroids and statins?
type 2
194
Foods rich in this could help improve osteoarthritis symptoms?
Omega-3 (oily fish)
195
What is used in mosaicplasty?
undamaged cartilage from less weight bearing regions
196
What are future options for biological treatments for OA?
IL-1 blockage, TNF inhibition
197
What do you need to check at least every three months in methotrexate patients?
complete blood count and liver function tests
198
What drugs aren't really used much anymore for RA?
D-pencillamine and gold salts
199
Anakinra, canakinumab and rilonacept all work on what?
IL-1 (for gout)
200
What is the first oral biological option?
JAK inhibitors (tofacitinib, barcitinib and upadacitinb)
201
When might you see gull-wing or saw-tooth appearance?
In erosive OA, post-menopausal women more affected
202
What effects can NSAIDs have on kidney?
They can leads to Na and water retention = hypertension and kidney injury
203
Where is the only place that both COX1 and COX2 are found under resting conditions?
CNS
204
What links keratin cytoskeleton to basement membrane?
Hemidesmosomes
205
What is the most abundant cell in the dermis?
fibroblast
206
Which layer of skin contains many blood vessels?
Papillary layer (directly below epidermis and BM)
207
What antibody activates osteoclast in RA?
ACPA causes monocytes to differentiate
208
What does reverse hybrid hip replacement mean?
That the cemented version is the bit in the acetabulum and not in femur
209
What tendons are often used for ACL?
semitendinosous or gracilis tendon
210
Neck of fibula fractures what nerve is at risk?
common peroneal
211
What are you looking for on xrays of stress fractures and why?
Periosteal lifting as they are fractures of the trabeculae network within the bone
212
What are the stages of bone healing?
1) fracture haematoma
2) fibrocartilaginous callus
3) soft callus
4) bony callus lasts about 3-4 months
5) bone remodelling
213
In pelvic fractures where is the majority of the haemorrhage coming from?
posterior venous plexus
214
What is a complication of fractures that can lead to deterioration in consciousness and petchiae rash?
Fat embolism - fat getting into blood stream
215
What is normal compartment pressure and at what pressure would it be an emergency?
normal = 0-10
emergency = 30 plus
216
What is the most common organism causing septic arthritis?
staphylococcus aureus
217
What is a common lab finding in septic arthritis particularly in children?
neutrophilia
218
What is i can't see, can't pee, can't climb a tree about?
reactive arthritis bc it affects eye, urinary system and hands and feet
219
What is the name for necrotic bone?
sequestrum
220
What can be used to treat gram pos osteomyelitis?
flucloxacilin
221
How do you test for congenital hip dysplasia?
Barlow test - adduct and push downwards
Ortolani - abduct and push forwards with fingers
Galeazzi sign - leg length discrepency
222
complications of congenital hip dysplasia?
Avascular necrosis and femoral nerve palsies
223
What are the four stages of Perthes?
1) necrosis - up to one year
2) fragmentation - dead cells absorbed and replaced, variable femoral head shapes
3) reossification - femoral head continues to grow
4) remodelling - continues
224
What age does Perthes frequently occur?
between 4-8 years
225
What are the steps to a gout attack?
proteins lower Ph making more crystals form
white blood cells attack
crystals pop the cell
cell releases proteins
proteins call in more white blood cells
226
What is inside the tophi in gout?
urate crystals surrounded by lymphocytes, macrophages and foreign body cells
227
How high does serum uric acid need to be before it should definitely be treated?
11mg/dL
228
What biologicals can be used for gout?
IL1 biologicals - rilonacept, canakinumba, anakinra
229
How does probenecid work for gout?
It increases uric acid excretion
230
How does rasburicase work for gout?
it catalyses the conversion of uric acid to allantoin
231
What can acute pseudogout be triggered by?
trauma, rapid reduction of serum calcium
232
What direction would gout and pseudogout crystals face?
gout - yellow diagonally up, blue diagnonally down
pseudo-gout - other way around
233
What crystals might you find in a rare case of RA?
cholestrol crystals / lipid spherules
234
What is a treatment for osteoporosis kyphosis?
kyphoplasty - inserting and inflating balloon into bone to make it less wedge shaped
235
What are Schmorl's nodes?
They are herniated discs bulging upwards or downwards - common in Sheuermann's disease
236
How do you treat Sheuermann's disease?
physio - increase strength of paraspinals
bracing - if less than 65 degree angle
surgical if greater than 65 degrees
237
What type of collagen is annulus fibrosus?
type 1
238
What bacteria tend to cause folliculitis (carbuncles, boils)
stayphyloccous aureus
239
Difference between cellulitis and erysipelas?
cellulitis - infection in subcut tissuess
erysipelas - superficial cellulitis (infection just in dermis and not the sub cut fat)
240
what is Scrofuloderma?
tuberculous involvement of skin from TB infection in underlying lymph nodes
241
What causes leprosy?
mycobacterium leprae or mycobacterium leptomatosis
242
What is the treatment for leprosy?
rifampicin, dapsone and clofazimine
243
How do you treat pemphigus vulgaris?
immunosuppression with c mycophenolate motefil or azathioprine
rituximab - targeting CD20 on b cells
244
What are five types of salter harris fracture
S - straight across type 1
A - Above type 2
L - lower type 3
T - two or through type 4
ER - erasure type 4
245
What kind of injury will lead to hand of benediction when asked to make a fist?
a high median injury (common in supracondylar fractures of humerus). results from paralysis of flexor digitorum superficialis, and pollicis longus
