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msk - cortex notes Flashcards

1
Q

What is an echondroma

A

Benign bone tumour that is intramedullary adn usually a metaphyseal cartilaginous tumour caused by failure of normal echondral ossification at the growth plate

Can weaken the bone leading to pathological fractures

Can occur in the femur, humerus, tibia and small bones of hand and feet

Can be scraped out

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2
Q

What is a simple bone cyst

A

A single cavity of benign fluid filled cyst in bone

Usually a growth defect from the physis

Can cause weakness > pathological fracture

Treatment = curettage and grafting

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3
Q

What is an aneurysmal bone cyst

A

Contains lots of chambers filled with blood or serum
- the different chambers may be seen on x-ray

Due to small arteriovenous malformation

Occur in the metaphyses of long bones , flat bones, and vertebral bodies

This lesion is LOCALLY AGGRESSIVE causing cortical expansion and destruction and so is painful

Treatment = curettage

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4
Q

What is a giant cell bone tumour ?

A

Can be LOCALLY AGRESSIVE AS WELL AS ANEURYSMAL BONE CYST

Most commonly occur in the knee, distal radius, spine and pelvis

5% can met. To the lung

Treatment = intralesional excision with use of phenol, bone cement or liquid nitrogen

May need joint replacement with very aggressive lesions

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5
Q

*soap bubble appearance on x-ray

A

Giant cell bone tumour

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6
Q

Which benign bone tumours are locally invasive

A

Giant cell
Aneurysmal cyst

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7
Q

What is fibrous dysplasia

A

Benign bone tumour which occurs in adolescence where a genetic mutation results in fibrous tissue lesions and immature bone

Can get defective mineralisation

Treatment = Biphosphonates (reduce pain and risk of pathological fractures)

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8
Q

What is an osteoid osteoma

A

Benign bone tumours of immature bone surrounded by intense sclerotic halo

Commonly in adolescence and most common site is the proximal femur (long bones)

Intense and constant pain, worse at night

Treatment = NSAIDs, CT guided radio frequency ablation (if doesn’t resolve spontaneously)

Investigation = CT + bone scan to confirm diagnosis

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9
Q

Investigation for osteoid osteoma

A

CT + bone scan are both needed to confirm diagnosis despite them being seen on x-ray

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10
Q

*brodie’s abscess

A

Subacute osteomyelitis

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11
Q

*brown tumours

A

Indicate hyperparathyroidism

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12
Q

Are malignant primary bone tumours common ?

A

No ! Very rare

But other cancers metastasising to bone is very common

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13
Q

Most common malignant primary bone tumour

A

Osteosarcoma - seen in younger age groups

60% involving knee bones

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14
Q

Treatment of osteosarcoma

A

Since they are not radiosensitive

Adjuvant chemotherapy can prolong survival

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15
Q

What is a chondrosarcoma

A

Malignant cartilage producing primary bone tumour

Less common

Not as aggressive as osteosarcoma

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16
Q

What are fibrosarcoma and malignant fibrous histiocytoma

A

Fibrous malignant primary bone tumours which tend to occur in abnormal bone ie bone infarct, fibrous dysplasia

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17
Q

What is Ewing’s sarcoma

A

A malignant tumour of primitive cells in the marrow

2nd most prevalent primary bone tumour

Has the poorest prognosis

Most cases are between the ages of 10-20 years

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18
Q

Staging investigation for primary bone tumours

A

Bone scan and CT chest

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19
Q

what investigation are helpful to determine local extent of tumours and involvement of muscle, nerve adn vessels

A

MRI and CT

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20
Q

Treatment of primary bone tumours

A

Normally surgery to remove the tumour and any surrounding tissue

> limb salvage surgery is better than amputation

Also chemotherapy and radiotherapy

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21
Q

Diagnosis of myeloma

A

Plasma protein electrophoresis

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22
Q

What are the top5 cancers that metastasise to bone (In order of frequency)

A
  1. Breast
  2. Prostate
  3. Lung
  4. Renal cell
  5. Thyroid adenocarcinoma
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23
Q

Suspected bone cancer investigation

A

X-ray

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24
Q

What investigation tells you the extent of bony mets. ?

A

Bone scan

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25
What bone area is considered an ‘at risk’ area for cortical thinning
Subtrochanteric area of the femur
26
Treatment of fractures / impending fractures ?
Stabilisation via long rods (inrtamedullary nails)
27
Treatment of joint destruction
Joint replacement
28
What is the most common benign sot tissue tumour ?
Lipoma
29
what is a ganglion cyst
Occurs around a synovial joint or tendon sheath May results as herniation/ out-pouching of weak portion of joint capsule etc Excision may be required Can be quite firm and they transilluminate
30
what is bursitis
A nurse is a small fluid filled sac lined by synovium around a joint which prevents friction (for everything) Inflamed bursae will usually occur after repeated pressure or trauma which may present as a soft tissue swelling Excision may be required - there are issues with scarring
31
Do sebaceous cysts require any treatment ?
Yes - excision and/or biopsy They are implantation of dermoids
32
Treatment of abscesses ?
Antibiotics alone is not enough Need incision + drainage
33
Risk factors of AVN
Trauma Idiopathic Alcoholism (coagulability) Steroid use - as in long term use of prednisolone (coagulability) Primary lipidaemia (coagulability)
34
Weird causes of AVN
Caisson’s disease Aka decompression sickness Due to nitrogen bubbles forming in the circulation
35
What happens after AVN
Get osteoarthritis of the area affected
36
How to treat AVN if the articular surface hasn’t collapsed yet and is in an amenable site ?
‘ Drilling’ with fluoroscopy to decompress the bone - prevent further necrosis and aid healing Otherwise joint replacement is needed
37
Disease which put you more at risk of AVN
Thrombophlebitis Sickle cell disease Antiphospholipid disease Primary hyperlipidaemia (All to do with coagulability)
38
Osteochondroma - produces a bony outgrowth on surface of cartilaginous cap - is the most common - 1% chance of malignant transformation
39
what type of bone us this ? (It’s either cancellous or cortical)
It cancellous . Why ? Cos its at the epiphysis of the bone and it looks like a fine meshwork Cortical bone makes up the shaft if the bone (diaphysis)
40
What are A and B
A = epimysium B = endomysium
41
A group of muscle fibres are called what ?
Fascicles
42
What are these lines
Cement lines
43
What are all these?
44
what are the cells the arrows are pointing at - and what is the space these cell are located in and also maintain (as they secrete)
Chondrocytes = the cells Matrix = lacuna (the ECM)
45
Features that are suggestive of a potential malignant soft tissue neoplasm
Large lesions >5cm Rapid growth in size Solid lesion Illdefined border Irregular surface Lymphadenopathy Systemic upset
46
What type of muscle is shown here
Skeletal muscle Peripheral nuclei + striations
47
Treatment for pathological fracture Of clavicle causing weakness due to simple bone cyst
Should be managed conservatively
48
*shepherd crook deformity
Fiberous dysplasia
49
What investigation tells of bone mineral density
DEXA scan Osteoporosis by DEXA = a score of <2.5
50
Tool to help evaluate fracture risk
FRAX
51
5 risk factors for the development of osteoporosis
Lack of sunlight Female Increased alcohol intake Inactivity Smoking
52
*bone enlargement, thickened cortices, thickened trabeculae, mixed areas of lyses and sclerosis
Paget’s disease
53
What are the smallest contractile elements in striated muscle cells
Sarcomere ‘The unit of contraction’ of muscle cell
54
‘The sarcomere is defined as the region from one Z-disk to the next’
55
Which cell lays down new lamellar bone
Osteoblasts
56
Which cells congregate and drill into the bone to form a tunnel
Osteoclasts
57
DEXA of osteopenia
<1.0 - 2.5 (Whether DEXA of osteoporosis is <2.5, osteopenia is like an intermediate stage)
58
When do we start losing bone mineral density
Around 30
59
Why does menopause drive osteoporotic pathway ?
Due to an increase in osteoclastic bone reabsorption With the loss of protective effects of oestrogen
60
What are the 2 types of osteoporosis
Type 1 = menopausal Type 2 = of old age
61
What fractures are more commonly seen in type 1 osteoporosis
Colles and vertebral insufficiency fractures
62
What fractures are more commonly seen in type 2 osteoporosis
Femoral neck fractures, vertebral fractures
63
Investigation of osteoporosis
DEXA
64
What are 2 things that can increase bone mineral density
A cat purring on top of you Exercise
65
Are there any treatments to increase bone mineral density
Nope Management of osteoporosis = prevent further deterioration ie calcium, vit D supplements, Biphosphonates, desunomab, strontium and zolendronic acid
66
Treatment of osteoporosis
Vitamin D and calcium supplementation Biphosphonate Desonumab Strontium Zolendronic acid - once yearly
67
Can you use intranasal calcitonin for osteoporosis ?
No extra benefit over other treatments and has a an association with increase in cancer SO NO DO NOT USE
68
Just for interest
69
MoA of Biphosphonates
Reduces osteoclastic resorption
70
MoA desunomab
It’s a monoclonal antibody which reduces osteoclastic activity
71
MoA strontium
Increases osteoblastic replication and reduces resorption
72
Difference between osteoporosis and osteomalacia
Osteoporosis = quantitive defect (not enough of) Osteomalacia = qualitative defect (bone is shit quality bruv)
73
What is osteomalacia
Abnormal softening of the bone due to deficient mineralisation of osteoid (immature bone) secondary to inadequate amounts of calcium and phosphorus
74
Is rickets osteomalacia ?
Yes but just in children so has subsequent effects on growing skeleton
75
Causes of osteomalacia
Malnutrition Malabsorption No sunlight exposure (no activation of Vit D) Hypophosphataemia (re-feeding syndrome/ alcohol abuse) CKD Long term anticonvulsant use
76
*pseudofracture on x-ray
Osteomalacia
77
Treatment of osteomalacia
Vitamin D therapy with calcium and phosphate supplementation ›
78
What to remember with hyperPARAthyroidism
Painful moans, renal stones, abdominal groans and psychic overtones (Overproduction of PTH = hypercalcaemia, = fatigue, depression, myalgia , nausea, thirst, polyuria, renal stones, osteoporosis)
79
Bone biochemistry for hyperparathyroidism
Serum PTH = ++ Calcium = ++ Phosphate = normal/low
80
*brown tumours
Hyperparathyroidism fragility fracture
81
How to treat hypercalcaemia
Emergency IV fluids Biphosphonates Calcitonin
82
What is renal dystrophy
Describes bone change due to CKD Reduced phosphate excretion and inactive Vit D results in secondary hyperparathyroidism
83
What is Pagets
Chronic disorder which results in thickened, brittle misshapen bones Aka brittle bone disease
84
Pathophysiogoy of pagets
Increased osteoclastic activity (due to an exaggerated response to vitamin D) leads to osteoblasts trying to catch up and correct excessive bone resorption. The new bone formed fails to remodel sufficiently and so even tho the bone is thick and denser it is brittle and fractures easily
85
Bones commonly affected in pagets
Pelvis Femur Skull Tibia Ear ossicles
86
Hearing problem associated with pagets ?
Conductive deafness due to misshapen ear ossicles
87
Virus associated with pagets
Paramyxovirus
88
Bone biochemistry of pagets
Serum alkaline phosphatase is raised Calcium and phosphorus are usually normal
89
Treatment of pagets
Biphosphonates or calcitonin if lots of breakdown of bone Also joint replacement may be necessary
90
Management of intracapsular displaced hip fractures
Garden III or IV Either tota hip replacement or hemiarthroplasty ( due to Avascular necrosis of the femoral head )
91
Management of intracapsular non-displaced hip fracture
This means the blood supply to the femoral head is intact still so can preserve the femoral head Can be treated therefore with internal fixation (screws) to hold femoral head in place while the bone heals over
92
Management of extra-capsular intertrochanteric fractures (hip)
Dynamic hip screw
93
Management of extra-capsular subtrochanteric fracture (hip)
Intramedullary nail
94
Treatment of mechanical back pain
Analgesia and physio
95
*pain worse on coughing
Acute disc tear (coughing increases pressure)
96
Acute disc tear management
Analgesia and physio Symptoms can take 2-3 months to settle
97
Commonest nerve roots that can herniate on an acute disc tear
L4 L5 S1 (sciatic nerves)
98
Damage to what nerve roots cause cauda equina
L1-L5 typically
99
A laterally placed prolapse between L4-L5 would compress which root ?
L4 A more central prolapse would compress L5 A completely central prolapse would cause cauda equina (C) D - shows osteophyte formation causing compression
100
What is spinal stenosis
When multiple nerve roots can be compressed/irritated Due to combination of spondylosis/bulging discs etc
101
Features of spinal stenosis
Pain is better walking up hill Pain is burning Pedal pulses are preserved 60+ ages and characteristically have pain in the legs when walking (claudication)
102
Affected sacral nerve roots in cauda equina
S4 and S5 These control defaecation and urination
103
*saddle anaesthesia
Cauda equina
104
What investigation is mandatory in cauda equina
PR
105
Investigation for cauda equina
URGENT MRI PR exam
106
Red flags for back pain
- back pain in young <20 years - new back pain in old people - constant, severe, worse at night back pain - systemic upset
107
Treatment of osteoporotic crush fracture on the vertebral body
Conservation - this fracture is stable Can sometimes do a balloon vertebroplasty
108
*slow onset stiffness and pain in the neck which can radiate locally to shoulders and occiput
Cervical spondylosis
109
*subluxation of Atlanto-axial instability Is suggestive of what conditions
Downs RA This is due to cervical spine instability
110
Which nerve passes through the carpal tunnel
Median
111
What is Tinel’s test
Percussion over the radial nerve Can reproduce carpal tunnel symptoms
112
Nerve responsible for hip pain referring to groin radiating to knee
Obturator nerve
113
Muscles responsible for trendelenburg gait
Muscle weakness of gluteus minimus and mediu

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