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MSK Flashcards

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1
Q

clincial signs of fractures?

A 
pain 
swelling
crepitus
deformity
adjacent structural injury - vessels, nerves, ligaments, tendons
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2
Q

how to describe a fracture radiograph?

A 
location - epi/dia/metaphysis
fragments 
pattern - transverse, oblique, spiral
displacement?
angulated? valgus(distal away from midline)/varus?
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3
Q

general steps to fracture healing?

A

bleeding
inflammation - neutrophils/macrophages
new tissue - fibro/osteo/chondroblasts
remodelling - macrophages, osteoblasts and clasts

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4
Q

what happens in the inflammation step of fracture healing?

A

haematoma forms
cytokines released
granulation tissue and blood vessel formation

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5
Q

what happens in the repair step of fracture healing?

A

soft callous formation w type II collagen - cartilaginous

hard callous formation w type I collagen - bone

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6
Q

what happens in the remodelling step of fracture healing?

A

callus responds to activity, external forces, functional demands etc (Wolff’s law)
excess bone removed

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7
Q

two types of bone healing?

A

primary : intramembranous ossification - mesenchymal stem cells → osteoblasts (absolute stability)
secondary : endochondral ossification - MSC → chondral precursor → osteoblasts (relative stability) more callous

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8
Q

principles of fracture management?

A

reduce
hold
rehabilitate

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9
Q

reduction options?

A

closed - manipulation / traction

open - mini incision / full exposure

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10
Q

hold options?

A

closed - plaster / traction

fixation - intramedullary pins/nails | extra medullary plate/pins/screws | monoplanar/multiplanar

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11
Q

rehabilitation principles?

A

use - retrain & pain relief
move
strengthen
weight bear

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12
Q

general fracture complications?

A

fat embolus
DVT
infection
prolonged immobility - UTIs, sores

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13
Q

specific fracture complications?

A 
neurovascular/tendon/ligament injury
non/mal union
local infection
degenerative change
reflexive sympathetic dystrophy (excess pain)
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14
Q

what can affect fracture healing?

A 
movement
blood supply
infection
immune function
nutrition
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15
Q

causes of fracture NoF?

A

osteoporosis (old)

trauma (young)

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16
Q

bony landmark division of intra and extra capsular NoF fractures?

A

intratrochanteric line

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17
Q

in which NoF fracture is blood supply more likely to compromised?

A

intracapsular

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18
Q

management for an extracaspualr fracture?

A

fix with plate and dynamic hip screw

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19
Q

management for an intracaspualr fracture? replacement options?

A 
undisplaced = less risk to blood supply → fix with screws
displaced = risk of AVN → replace in older pts(≥55), fix in young

total hip replacement in independent pts
hemiarthroplasty if lower mobility/multiple comorbs

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20
Q

what nerve should be tested in shoulder dislocation?

A

axillary nerve

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21
Q

first line Ix for shoulder dislocation?

A

x ray prior to manipulation

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22
Q

shoulder dislocation management?

A

traction counter traction with gentle internal rotation

adequate pt relaxation - benzodiazepines

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23
Q

what is a hill-sachs defect?

A

deformity of humeral head secondary to shoulder dislocation when it collides with glenoid

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24
Q

management options for distal radius fracture?

A

minimal displacement - cast/splint

instability/child - MUA & K wire

displaced/intraatricular - open reduction internal fixation with plate and screws

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25
management options for tibial plateau fracture?
non operative - true undisplaced w good joint line congruancy operative - restore articular surface using plate and screws , ±bone graft/cement
26
management options for ankle fracture?
non-operative - below knee cast then physio (Weber A/stable B) operative - ORIF ± syndemsosis repair (Weber unstable B/C)
27
how can ankle fractures be classified?
weber A - below syndesmosis, more stable weber B - at level of syndesmosis weber C - fibular fracture above syndesmosis
28
2 types of low back pain?
non-speciifc - no underlying cause found | mechanical - pain after abnormal stress/strain
29
causes of lower back pain?
``` mechanical - disc herniation/degenrartion, annular tear, oA tumours infection spondyloarthropy pars interarticularis injury visceral ```
30
what symptoms indicate sciatica?
``` unilateral leg pain ≥ back pain pain radiating to feet/toes paraesthesia straight leg raising test = more pain localised neurology ```
31
when is imaging indicated for back pain?
only if it's likely to change the management (specialist care)
32
conservative treatment for back pain?
``` analgesia NSAIDs manipulation acupuncture massage ```
33
red flags for low back pain?
``` weight loss fever ≤19 yrs night pain = imaging ```
34
red flags for leg pain?
bowel/bladder dysfunction saddle anasethisa neurological deficit =imaging
35
what back pain diseases require early diagnosis for effective treatment?
myeloma metastases inflammatory arthropathy tuberculosis of spine
36
imaging for low back pain?
MRI - primary | radiographs, CT
37
different pain therapies?
``` waiitng physical therapy analgesia facet injections root blocks epidural injection - interlaminar, caudal, transforaminal neurostimulation ```
38
surgical options for back pain?
decomprreesison of nerve roots/spinal stenosis disc replacement fusion
39
what is the female athlete triad?
disordered etaing amenhorrhea osteoporosis → stress fractures
40
how does a stress fracture occur?
overuse → stress exerted on bone is greater than its capacity to remodel → bone weakens → stress fracture → ±complete fracture
41
causes of pathological fractures?
``` osteoporosis malognancy vit d deficiency → osteomalacia/rickets osteomyeltiis pages disease osteogensis imperfecta ```
42
causes of secondary osteoporosis?
hypogonadism excess glucocorticoids alcoholism
43
pathophysiology of OI?
decreased type 1 collagen (abnormal or decreased secretion) → insufficient osteoid production → brittle bones
44
stages of pages disease?
osteoclastic activity mixed osteoclastic-blastic activity osteoblastic activity malignant denegernation
45
what malignancy is blastic?
prostate
46
what malignancies are lytic?
kidney thyroid lung
47
what malignancy is lytic and blastic?
breast
48
primary bone cancers?
osteosarcoma chondrosarcoma Ewing sarcoma lymphoma
49
different types of tendinopathies?
tendinosis - abnormal thickening tendinitis rupture
50
how are ligament injuries classified?
grade I - slight incomplete tera grade II - moderate/severe incompleet tear - some joint instability garde III - complete tearing , obvious instability
51
treatment options for tendon/ligament tears?
immobilise - plaster/boot/brace or surgery - suture
52
disadvantages of immobilisation for injured ligaments?
less overall strength of repair protein degradation ≥ synthesis → ↓ collagen inferior tissue production by blast cells resorption of bone at ligament insertion ↓ tissue tensile strength
53
benefits of mobilisation on injured ligaments?
scars are wider stronger and more elastic | better alignment and quality of collagen
54
outline intramembranous ossification?
eg cranial boens and clavicle mesnchycmal cells condense → differentiate into osteoblasts → ossification centre forms → secreted osteoid traps osteoblasts → osteocytes → trabecular matrix and periosteum form → com[act bones develops → blood vessels condense into red bone marrow
55
different between primary and secondary ossification centres?
primary - site of pre-natal bone growth through endochondral ossifatcion at central part of bone secondary - post natal bone growth at the physics
56
outline endochondral primary ossification?
mesenchymal differetiaiotn at primary centre → cartilage model of skeleton forms → capillaries penetrate , calcifatcion at primary centre (spongy bone), perichondrium into periosteum → cartilage and chondrocytes continue to grow at ends of bone → secondary centres form
57
outline endochindral secondary ossification?
long bone lengthening happens at physis where theres cartilage epiphyseal side → hyaline cartilage divides to form HC matrix diaphysial side → cartilage calcifies and dies → replaced by bone
58
why are children bones more elastic than adults? what can this lead to?
↑ density of Haversian canals plastic deformity - bends before breaking buckle fractures - column like greenstick fracture
59
4 differences between child and adult bones?
more elastic physis present ↑ speed of heeling & remodelling
60
when does physis closure complete?
girls 15-16 | boys 18-19
61
what is developmental dysplasia of the hip?
in neonates where head of femur is unstable or incongruous in relation to the acetabulum dysplasia → sublaxation → dislocation
62
risk factors for developmental dysplasia of the hip?
``` female first born breech FH oligohydraminos swaddling of hip ```
63
how is developmental dysplasia of the hip usually picked up?
baby check | RoM check - limited hip abduction
64
investigations for developmental dysplasia of the hip?
US from birth to 4 months | post 4 months - xray
65
treatment options for developmental dysplasia of the hip/
reducible hip and <6months : Pavlik harness failed harness or 6-18months : manipulation under anaesthesia + closed reduction and spica
66
clubfoot alt name?
congeniital talipes equinovarus
67
risk factors for clubfoot?
hawaiin M2:1F genetic PITX1 gene
68
what is the CAVE deformity in clubfoot?
``` due to muscle contraction Cavus - high arch, tight FHL, FDL Adductus of foot - tight tibialis post and ant Varus - tight tendoachilles and TP, TA Equinous - tight tendoachilles ```
69
treatment for clubfoot?
``` ponsetti method is gold standard series of casts to correct deformity operative treatment foot orthosis brace ± further Sx ```
70
what is achondroplasia?
autosomal dominant in FGFR3 | inhibition of chondrocyte proliferation in proliferative zone of physis → defect in endochondral bone formation
71
what is thizomelic dwarfism?
humerus shorter than forearm femur shorter than tibia normal trunk
72
signs/symptoms of OI?
``` fragility fractures short stature scoliosis blue sclera soft brown teeth worming skull hypermetabolism ```
73
what is an avulsion fracture?
occurs where ligament/tendon attaches
74
how are phsyeal injuries classified?
Salter-Harris classification 1 - physical Separation 2 - fracture transverses physis and exits metaphysis (Above) 3 - fracture transverses physis and exits epiphysis (Lowe) 4 - fracture passes Through epiphysis, physis and metaphysic 5 - crush injury to physis
75
what can physis injuries lead to?
growth arrest whole physis = limb length discrepancy partial = angulation as unaffected side keeps growing
76
treatment for growth arrest?
limb length correction - shorten or lenghtne | angulation - stop growth of unaffected side or reform bone (osteotomy)
77
what's most often used to restrict fractures in children?
splints and plaster
78
first thought for a limping child?
septic arthritis - emergency!
79
what can be used to score probability of septic arthritis?
``` Kocher's classification non-weight bearing ESR ≥ 40 WBC ≥ 12000 Temp ≤36 or ≥ 38 ```
80
what is perthes disease?
idiopathic necrosis of the proximal femoral epiphysis 4-8 years old M4 : 1F
81
4 cause of the limping child?
septic arthritis transient synovitis perthes disease SUFE
82
what is transient synovitis?
inflamed joint in response to systemic illness | supportive treatment with abx
83
what is SUFE?
slipped upper femoral epiphysis - proximal epiphysis slips in relation to metaphysis
84
risk factors of SUFE?
obese adolescent males 12 -13 yrs with rapid growth hypothyroidism/pituitarism
85
treatment for SUFE?
screw to prevent further slipping
86
outline the structure of a synocvila joint?
synovium - lining containing synoviocytes (A- phagocytic type , B - hyaluronic acid producing) and type I collagen synovial fluid - hyaluronic acid rich articular cartilage - type II collagen and preoteoglycan
87
what changes occur during inflammation?
↑ blood flow leukocytes migrate into tissues and are activated/differentiate cytokines produced - TNFa, IL6,1,17
88
pathogenesis of gout?
deposition of uric acid (monosodium urate) crystals in joints → inflammation rf = hyperuricaemia (genetics, ↑ purine intake,, renal disease)
89
pathogenesis of pseudogout?
deposition of calcium pyrophosphate dihydrate → inflammation rfs = background OA, elderly, intercurrent infections
90
symptoms of gout?
gouty arthiritis tophi - subcutaneous crystals podagra - MTP joint of big toe affected, ↑ pain, resolves spontaneously
91
how is gout seen on X-rays?
rate bite erosions on big toe MTPJ
92
investigations for gout?
joint aspiration for synovial fluid analysis
93
gout management?
acute - colchicine , nsaids, steroids | chronic - allopurinol
94
how do gout and pseudogout differ in synovial fluid analysis?
shape - needle vs brick | birefringence - negative vs positive
95
pathogenesis of RA?
abnormal synovial membrane synovium → proliferated mass of tissue → pannus due to neovascularisation , lymohangiogenesis , inflammatory cells cytokine imbalance esp TNFa
96
role of TNFa in RA?
dominant pro-inflmamtory cytokine causes pannus & synovitis activates osetcolasts → bony erosions destroys synoviovytes → jt inflammation → pain and swelling activates chondrocytes → cartilage degradation → jt space narrowing
97
functions of TNFa?
``` releases proniflmmatory cytokines hepciidn induction PGE2 production chemokine release endocethelial cell activation → leukocyte accumulation angiogenesis chondrocyte activation → ↑ MMP, ↓ cartilage osteoclast activation ```
98
symptoms of RA?
``` polyarthrits - common in hands and wrists , MCP , PIP< MTP symmetricla early morning stiffness extensor tenosynovitis bursitis ```
99
extra articular manifestations of RA?
rheumatoid nodules, fever, weight loss vasculititis episcleritis amyloidosis, lung daisies, felty's syndrome
100
what can be detected in blood in RA patients?
rheumatoid factotr - IgM autoantibody against Fc portion of IgG antibodies to citrullinated protein antigens
101
what is felty's syndrome?
splenomegaly, leukopenia and RA
102
what are rheumatoid nodules?
central area of fibrinoid necrosis surrounded by histiocytes and connective tissue
103
what enzymes mediate citrullination of peptides?
peptidyl arginine deaminases
104
management of RA?
early recognition of symptoms and aggressive treatment DMARDs 1st - methotrexate with hydroxychloroquine/sulfasalazine 2nd - biologics, janus kinase inhibitors prednisolone but not long term MDT approach
105
biologic options for RA?
anti-TNFa - infliximab, etanercept anti-B cells - rituximab abatacept IL-6 inhibitors - tocilizumab
106
what is ankylosing spondylitis?
``` seronegative spondyloarthropy chronic sacroilitis spinal fusion young males HLA B27 ```
107
symptoms of ankylosing spondylitis?
``` lower back pain/stifness in early morning, improves w exercise ↓ spinal movements peripheral; arthritis achilles tendonitis fatigue ```
108
what will blood tests show in ankylosing spondylitis?
normocytic anaemia HLA B27 ↑CRP,ESR
109
management for ankylosing spondylitis?
phhysio nsaids exercise DMARDs
110
how does psoriatic arthritis present?
``` assymetrical , IPJs ±symmetrical involvement of small joints spinal and sacroiliac jt inflammation oligoarthritis of large jts arthritis mutilans - pencil in cup deformity ```
111
investigations for psoriatic arthritis?
xray MRI - sacroilitis, enthesitis bloods - seronegative
112
management of psoriatic arhtiritis?
DMARDs - methotrexate
113
what is reactive arthritis?
sterile inflammation of jts following infetcion , 1-4 weeks (esp urogenital and GI)
114
extra-articular manifestations of reactive arthritis?
enthesitis skin inflammation eye inflammation
115
what can reactive arthritis often be the first manifestation of?
HIV or Hep C
116
what autoantibodies are commonly involved with SLE?
antinuclear antibodies - high sensitivity but not specific (quite common in gen pop , needs to be in combo with clinical features) anti-dsDNA antibodies - high specificity anti-phospholipid antibodies
117
risk factors for SLE?
F9 : 1M 15-40yrs african/asian ancestry
118
what are the seronegative spondyloarthopathies?
ankylosing spondilytis reactive arthritis psoriatic arthritis entreropathic synovitis
119
what is commonly seen in connective tissue disorders?
arthralgia and arthritis autoantibodies Raynaud's phenomenon
120
what is reynauds phenomenon?
intermittent vasopsams of digits on cold exposure → blanching → cyanosis → rectaove hyperaemia whites → blue → red
121
clinical manifestations of SLE?
``` malar rash - spares nasolabial fold photosensitive rash mouth ulcers hair loss Raynaud's arthralgia ± arthritis serositis glomerulonephritis cerebral disease ```
122
what do anti-phospholipid antibodies increase the risk of?
arterial and venous thromboses
123
what will bloods show for SLE?
``` ↑ ESR but normal CRP unless infection, arthritis or serositis haemolytic anameia, thrombocytopenia ANAs, anti-dsDNA, antiphospholipid low C3 & C4 ↓albumin ↑protein:creatine ratio ```
124
management of SLE?
hydroxychloroquine ±maintenance glucocorticoid methotrexate/azathioprine biologics
125
what is Sjorgen's. syndrome?
autoimmune exocrinopathy dry eyes, dry mouth and enlarged parotid gland non-erosive arthritis and Raynaud's phenomenon
126
rheumatology diagnostics?
bloods synovial fluid analysis x rays, US. CT , MRI
127
rheumatology blood tests?
``` FBC U&E LFT bone profile ESR CRP ```
128
what's usually raised in FBC of septic arthritis?
WCC
129
what can be low in a FBC for inflammatory arthritis?
↓Hb
130
why are U&E done in rheumatology?
renal impairment eg in SLE, vasculitis, chronic inflammation and with NSAIDs
131
why are LFTs done in rheumatology?
DMARDs → liver damage | ↓ albumin → ↓ synthesis in liver or leakage form kidneys
132
what will be raised in bone profile for Paget's disease?
↑↑ALP
133
what is synocvial fluid analysis used to diagnose?
septic arthritis - gold standard , send for MC&S | crystal arthritis
134
3 differences between septic and reactive arthritis?
postive culture, give abx and joint lavage
135
4 X-ray features of OA?
loss of joint space osteophytes subchondral cysts subchondral bony sclerosis
136
3 xray features of RA?
soft tissue swellling peri-articular osteopenia bony erosions
137
US changes in RA?
synovial hypertrphy ↑ blood flow erosions
138
RA vs OA xray?
both jt space narrowing OA : sclerosis and osetophytes RA : osteopenia, bony erosions

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