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Flashcards in MSK Deck 1 Deck (464):
1

What are these hands representative of?

Dermatomyositis: inflammation of the skin and muscle over the joints

2

What is this picture representative of?

Vasculitis: inflammation of the muscles of arteries

3

What is this picture representative of?

Gout: deposition of uric acid crystals in the joints

4

What is this picture representative of:

Scleroderma: tightening of the skin over the joints

5

Do all, some, or zero synovial joints have a meniscus?

Some, e.g. the knee

6

What is this?

A meniscus, a fibrocartilagenous washer in certain joints

7

Which three major joints have a meniscus?

The knee, the radiocarpal, and the sternoclavicular

8

Which layer of the joint capsule is more fibrous?  Which is highly vascular?

The outer is more fibrous; the inner is highly vascular

9

What is the color of the synovium in real life?

Pinkish (it is highly vascular)

10

What type of cell coats the surface of the synovium?

Synoviocytes

11

What are the two major types of synoviocytes?  What is the function of each?

Type A and Type B; Type A is phagocytic, while Type B synthesizes hyaluronate

12

What does normal synovial fluid look and feel like?

Egg whites

13

Does synovial fluid normally clot?

No

14

What substance makes synovial fluid viscous?

Hyaluronate

15

The three types of joint lubrication processes are:
- [...] lubrication
- weeping lubrication
- boosted lubrication

The three types of joint lubrication processes are:
- boundary lubrication
- weeping lubrication
- boosted lubrication


16

The three types of joint lubrication processes are:
- boundary lubrication
- [...] lubrication
- boosted lubrication

The three types of joint lubrication processes are:
- boundary lubrication
- weeping lubrication
- boosted lubrication


17

The three types of joint lubrication processes are:
- boundary lubrication
- weeping lubrication
- [...] lubrication

The three types of joint lubrication processes are:
- boundary lubrication
- weeping lubrication
- boosted lubrication


18

What does weeping lubrication refer to?

The permeability of the cartilage in the joint allows it to be soaked with fluid, and applying pressure causes the fluid to weep out and lubricate the surfaces. Increasing the load increases the weeping.

19

Where is the fluid involved in boosted lubrication stored?

In the peaks and valleys of the cartilaginous surface, so when the joint becomes active, it is dislodged

20

What properties of synovial fluid might be used to diagnose gout or pseudogout? What about trauma?

Presence of crystals; presence of blood or inflammatory markers

21

What is inflammation of bone and marrow (mostly as a result of infection) called?

Osteomyelitis

22

What class of organisms causes the majority of bone infections?

Pyogenic bacteria or mycobacteria

23

What are the main types of osteomyelitis?
[...] Osteomyelitis
• Tuberculous Osteomyelitis
• Syphilitic Osteomyelitis

What are the main types of osteomyelitis?
Pyogenic Osteomyelitis
• Tuberculous Osteomyelitis
• Syphilitic Osteomyelitis


24

What are the main types of osteomyelitis?
• Pyogenic Osteomyelitis
[...] Osteomyelitis
• Syphilitic Osteomyelitis

What are the main types of osteomyelitis?
• Pyogenic Osteomyelitis
Tuberculous Osteomyelitis
• Syphilitic Osteomyelitis


25

What are the main types of osteomyelitis?
• Pyogenic Osteomyelitis
• Tuberculous Osteomyelitis
[...] Osteomyelitis

What are the main types of osteomyelitis?
• Pyogenic Osteomyelitis
• Tuberculous Osteomyelitis
Syphilitic Osteomyelitis


26

What is the most common organism responsible for adult pyogenic osteomyelitis?

S. aureus

27

What vascular change causes septic arthritis to be more common in adults than in growing children?

Closure of the growth plates allows metaphyseal vessels to reunite with the epiphyseal vessels and permits spread of bacteria into the subchondral region

28

What two organisms should be suspected (besides S. aureus) for neonatal pyogenic osteomyelitis?

H. influenzae and group B streptococci

29

The three sources of long bone infection are:
- [...]
- Vascular
- Direct impact/fracture

The three sources of long bone infection are:
- Soft tissue
- Vascular
- Direct impact/fracture


30

The three sources of long bone infection are:
- Soft tissue
- [...]
- Direct impact/fracture

The three sources of long bone infection are:
- Soft tissue
- Vascular
- Direct impact/fracture


31

The three sources of long bone infection are:
- Soft tissue
- Vascular
- [...]

The three sources of long bone infection are:
- Soft tissue
- Vascular
- Direct impact/fracture


32

Is hematogenous osteomyelitis common in healthy adults?  What does it associate with?

No; it is mostly in patients with chronic diseases (e.g., diabetes) or drug addictions

33

Why are metaphyseal vessel particularly supporting of proliferation of bacteria and abscess formation?

They have relatively slow circulation in long sinusoidal vessels

34

How fast does bone necrosis occur after the acute inflammatory reaction to bacterial proliferation in osteomyelitis?

48 hours

35

How might infection in osteomyelitis spread from a metaphyseal abscess to the periosteum?

The Haversian system

36

What is the dead piece of bone in osteomyelitis called?  What about the sleeve of reactive bone around it?

Sequestrum; the involucrum

37

What disease is this?  Label the two areas of damaged bone.

Osteomyelitis; left: sequestrum (necrotic bone), right: involucrum (reactive bone)

38

What are these abnormalities on this bone scan called, indicative of either osteomyelitis or round cell tumor?

Hot spots

39

How does osteomyelitis appear on an MRI?

Increased signal intensity in the medullary space

40

What are these called, indicative of osteomyelitis?
 

Brodie abscesses

41

What pathological changes are seen in this preparation of long bone?  What does this indicate clinically?

Neutrophils in the Haversian system; acute inflammation and necrosis of the bone, suggesting osteomyelitis

42

What infiltrating cell types signify the changeover from acute inflammation to chronic inflammation in osteomyelitis?

Lymphocytes

43

What is happening in the reactive bone sleeve (involucrum) seen in osteomyelitis?

Resorption of the necrotic bone, fibrosis of marrow, and formation of new bone

44

What critical step is necessary for adequate diagnosis and specific treatment of osteomyelitis?

Bone biopsy and cultures

45

What is the usual treatment for pyogenic osteomyelitis?

Antibiotics and surgical drainage

46

What is the probability of progression from acute to chronic osteomyelitis?

5-25%

47

Describe the difference between chronic recurrent multifocal osteomyelitis and "typical" osteomyelitis.

Chronic recurrent multifocal osteomyelitis is idiopathic, commonly seen in children/young adults, and manifests as multifocal non-pyogenic inflammatory bone lesions that recur over time.  Cultures of biopsies will be negative.

48

What dermatologic disorders associate with chronic recurrent multifocal osteomyelitis?
- [...]
- Psoriasis
- Acne fulminans

What dermatologic disorders associate with chronic recurrent multifocal osteomyelitis?
- Palmoplantar pustulosis
- Psoriasis
- Acne fulminans


49

What dermatologic disorders associate with chronic recurrent multifocal osteomyelitis?
- Palmoplantar pustulosis
- [...]
- Acne fulminans

What dermatologic disorders associate with chronic recurrent multifocal osteomyelitis?
- Palmoplantar pustulosis
- Psoriasis
- Acne fulminans


50

What dermatologic disorders associate with chronic recurrent multifocal osteomyelitis?
- Palmoplantar pustulosis
- Psoriasis
- [...]

What dermatologic disorders associate with chronic recurrent multifocal osteomyelitis?
- Palmoplantar pustulosis
- Psoriasis
- Acne fulminans


51

What do we see in this MRI of a young adult?  He presents with psoriasis and acne fulminans, and complains of pain, tenderness and swelling in his lower extremities over a course of months.

Chronic recurrent multifocal osteomyelitis

52

How is chronic recurrent multifocal osteomyelitis treated?

NSAIDs, steroids, and anti-TNFα

53

How many TB patients develop musculoskeletal involvement?

1-3%

54

In an AIDS patient, what is different about the way tuberculous osteomyelitis usually presents?

Multifocal as opposed to one site

55

What is the gross and microscopic pathologic appearance of tuberculous osteomyelitis?

Necrotic tissue with a white "cheesy" appearance, and microscopically, central necrosis is surrounded by granuloma-like cell collections (epithelioid histiocytes, multinucleated giant cells, lymphocytes)

56

When do bone lesions appear in congenital syphilis?

5th month of gestation, and they are fully developed at birth

57

Which stage of adult syphilis (and at what timepoint) can show development of bone infection?

Tertiary, 2 to 5 years after initial infection

58

How can syphilis infection of the bone be demonstrated on a histological study?

Silver stain (Warthin-Starry)

59

What is this deformity, indicative of skeletal congenital syphilis, called?

"boomerang deformity" or "saber shin"

60

If bacterial osteomyelitis spreads hematogenously into the surrounding joints, what is it now called?

Infectious (septic) arthritis

61

Where do most cases of septic arthritis occur?

The knee joint

62

What are the typical sites of tuberculous arthritis?  What is visible in the synovium?

Hip, knee, and ankle; caseous granulomas

63

In young immunocompromised patients, what nonbacterial infection of the joints can occur?  How do they manifest?

Fungal (blastomycosis, cryptococcosis, aspergillosis, candidiasis); similar to TB, with granulomatous inflammation

64

This parasitic bone infection, caused by ingestion of substances contaminated with dog feces, is caused by what organism?  What is the cyst below called?

Echinococcus granulosus; hydatid cyst

65

What is the etiology of rheumatoid arthritis?

Unknown: could be bacterial, viral...

66

What is the best evidence that rhematoid arthritis actually has an unknown infectious cause?

Skeletal remains in Alabama where peripheral erosive arthritis was discovered without axial damage (reminiscent of rheumatoid). This suggests that the agent is endemic to America, and spread to Europe via colonial travels at the end of the 18th century, where it was first described in 1800.

67

How thick is normal synovium?  What has happened here?

1 or 2 cells; Inflammation, causing thousands of cells to appear

68

How many joints need to experience soft-tissue swelling in order to diagnose rheumatoid arthritis?

≥3

69

How often is rheumatoid factor present in cases of rheumatoid arthritis?  What is it?

75%; it is an antibody that can be found in the blood

70

Is a test for anti-CCP (Cyclic Citrullinated Peptide) antibodies more specific than sensitive for rheumatoid arthritis or vice versa?  What about sensitivity?

Yes, more specific, less sensitive

71

What is the appearance of synovial fluid in rheumatoid arthritis?  What is the glucose level?  Are cultures or crystals positive?

Slightly turbid; glucose low; negative cultures and crystals

72

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative [...]
– Other connective tissue diseases
– Gout/pseudogout
– SLE (Lupus)
– Infectious arthritis
– Osteoarthritis

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other connective tissue diseases
– Gout/pseudogout
– SLE (Lupus)
– Infectious arthritis
– Osteoarthritis


73

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other [...] diseases
– Gout/pseudogout
– SLE (Lupus)
– Infectious arthritis
– Osteoarthritis

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other connective tissue diseases
– Gout/pseudogout
– SLE (Lupus)
– Infectious arthritis
– Osteoarthritis


74

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other connective tissue diseases
– Gout/[...]
– SLE (Lupus)
– Infectious arthritis
– Osteoarthritis

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other connective tissue diseases
– Gout/pseudogout
– SLE (Lupus)
– Infectious arthritis
– Osteoarthritis


75

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other connective tissue diseases
– Gout/pseudogout
– [...]
– Infectious arthritis
– Osteoarthritis

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other connective tissue diseases
– Gout/pseudogout
– SLE (Lupus)
– Infectious arthritis
– Osteoarthritis


76

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other connective tissue diseases
– Gout/pseudogout
– SLE (Lupus)
– [...] arthritis
– Osteoarthritis

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other connective tissue diseases
– Gout/pseudogout
– SLE (Lupus)
– Infectious arthritis
– Osteoarthritis


77

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other connective tissue diseases
– Gout/pseudogout
– SLE (Lupus)
– Infectious arthritis
– [...]

A differential diagnosis for probable rheumatoid arthritis should include:
– Seronegative spondyloarthropathies
– Other connective tissue diseases
– Gout/pseudogout
– SLE (Lupus)
– Infectious arthritis
– Osteoarthritis


78

What is the difference in early symptoms between rheumatoid and osteoarthritis?

Rheumatoid: morning stiffness, osteoarthritis: pain increases throughout the day and with use

79

What is the difference in age of onset between rheumatoid and osteoarthritis?

Rheumatoid: childhood and adults, peak incidence in 50's, osteoarthritis gets more common with higher age

80

Would arthritis in the MCP, wrists, or PIPs be more suggestive of rheumatoid or osteoarthritis?

Rheumatoid

81

Would pain and swelling in the distal interphalangeal joints, hips, and knees be more suggestive of osteoarthritis or rheumatoid arthritis?

Osteoarthritis

82

Is this presentation more typical for rheumatoid or osteoarthritis?

Rheumatoid arthritis, because the PIPs are swollen and not the DIPs

83

What is seen in this radiographic study that suggests rheumatoid arthritis?

Periarticular osteopenia and marginal erosions at the PIP joints

84

What are these characteristic hand deformities called?  What are they significant for?

Top: swan neck, bottom: boutonnieres (think button stitchers); Rheumatoid arthritis

85

What has happened here?  Is it painful?  What type of arthritis is it typical of?

Proliferative synovitis; not really, but function of the fingers is lost; rheumatoid arthritis

86

What are osteophytes?  Are they more typically seen in rheumatoid or osteoarthritis?

They are bony projections that form along joint margins; osteoarthritis

87

If radiographic findings (e.g., in these hip joints) are perfectly symmetrical, is it more suggestive of rheumatoid or osteoarthritis?

Rheumatoid arthritis, as osteoarthritis is a disease of wear and tear and rarely presents perfectly symmetrically

88

What symptom secondary to knee arthritis has happened here?  What does it need to be differentiated from?

Baker's cyst, a benign swelling of the bursa behind the knee joint that communicates with the synovial sac of the knee; it needs to be distinguished from DVT by MRI, ultrasound, or Doppler

89

Is this radiographic study more suggestive of osteoarthritis or rheumatoid arthritis? Why?

Rheumatoid arthritis; the MTPs are osteopenic but the more distal joints are well preserved

90

What distance here in a fixed flexion radiographic study of the neck is concerning?  What are implications for general anesthesia?

The C1-C2 distance between spinous processes is >3mm; this can cause risk for transecting the spinal cord during the hyperextension applied during intubation

91

What are the two main strategies of treatment for rheumatoid arthritis?

Palliative and remittive

92

Do palliative treatments for rheumatoid arthritis prevent disease progression (joint destruction)?

No

93

Poor prognostic signs for rheumatoid arthritis include:
– Rapid development of erosions
– High titer of rheumatoid factor
– Rheumatoid nodules
[...]

Poor prognostic signs for rheumatoid arthritis include:
– Rapid development of erosions
– High titer of rheumatoid factor
– Rheumatoid nodules
Extra-articular disease


94

Poor prognostic signs for rheumatoid arthritis include:
– Rapid development of erosions
– High titer of rheumatoid factor
– Rheumatoid [...]
– Extra-articular disease

Poor prognostic signs for rheumatoid arthritis include:
– Rapid development of erosions
– High titer of rheumatoid factor
– Rheumatoid nodules
– Extra-articular disease


95

Poor prognostic signs for rheumatoid arthritis include:
– Rapid development of erosions
– High titer of [...]
– Rheumatoid nodules
– Extra-articular disease

Poor prognostic signs for rheumatoid arthritis include:
– Rapid development of erosions
– High titer of rheumatoid factor
– Rheumatoid nodules
– Extra-articular disease


96

Poor prognostic signs for rheumatoid arthritis include:
– Rapid development of [...]
– High titer of rheumatoid factor
– Rheumatoid nodules
– Extra-articular disease

Poor prognostic signs for rheumatoid arthritis include:
– Rapid development of erosions
– High titer of rheumatoid factor
– Rheumatoid nodules
– Extra-articular disease


97

Palliative rheumatoid arthritis treatments include:
[...]
– NSAIDs
– Steroids
– TNFα inhibitors

Palliative rheumatoid arthritis treatments include:
Salicylates
– NSAIDs
– Steroids
– TNFα inhibitors


98

Palliative rheumatoid arthritis treatments include:
– Salicylates
[...]
– Steroids
– TNFα inhibitors

Palliative rheumatoid arthritis treatments include:
– Salicylates
NSAIDs
– Steroids
– TNFα inhibitors


99

Palliative rheumatoid arthritis treatments include:
– Salicylates
– NSAIDs
[...]
– TNFα inhibitors

Palliative rheumatoid arthritis treatments include:
– Salicylates
– NSAIDs
Steroids
– TNFα inhibitors


100

Palliative rheumatoid arthritis treatments include:
– Salicylates
– NSAIDs
– Steroids
[...] inhibitors

Palliative rheumatoid arthritis treatments include:
– Salicylates
– NSAIDs
– Steroids
TNFα inhibitors


101

What B-cell-targeted therapy has recently shown promise against rheumatoid arthritis?

Rituximab

102

What is the difference between concentric and eccentric excercise of the upper and lower extremities?

Eccentric movements are where you relax a muscle while resisting gravity or a loading force, while concentric movements are when you contract a muscle while resisting gravity or a loading force

103

What is an isocentric movement of an extremity?

When you hold a muscle at the same length while resisting a force: e.g. hanging with arms flexed from a bar

104

What is the normal cadence for walking?

100-115 steps/minute

105

What is a typical comfortable walking speed?

~3mph or about a Manhattan block per minute

106

When walking (as opposed to running), there is a phase called "double support", referring to what?

Both feet are touching the ground

107

Where is the position of the center of gravity in an average human?  How must it move during walking to use the least energy?

A few cm in front of S2; in a straight line

108

What is the average lateral displacement of the body's center of gravity during walking?  What is the shape of this curve when viewed from above?

5cm; smooth sinusoidal curve

109

During normal walking, does the pelvis drop toward the leg on the ground or the swinging leg?  By how much?

Toward the swinging leg; 5°

110

What is the point of the knee flexion in the middle of the stance phase of walking?

It shortens the leg, reducing the height of the apex of the curve of CG (and tangentially, makes us about 1 inch shorter while walking)

111

Forces during walking that are the most influential are due to:
1) [...]
2) muscle contraction
3) inertia
4) floor reaction

Forces during walking that are the most influential are due to:
1) gravity
2) muscle contraction
3) inertia
4) floor reaction


112

Forces during walking that are the most influential are due to:
1) gravity
2) muscle [...]
3) inertia
4) floor reaction

Forces during walking that are the most influential are due to:
1) gravity
2) muscle contraction
3) inertia
4) floor reaction


113

Forces during walking that are the most influential are due to:
1) gravity
2) muscle contraction
3) [...]
4) floor reaction

Forces during walking that are the most influential are due to:
1) gravity
2) muscle contraction
3) inertia
4) floor reaction


114

Forces during walking that are the most influential are due to:
1) gravity
2) muscle contraction
3) inertia
4) [...] reaction

Forces during walking that are the most influential are due to:
1) gravity
2) muscle contraction
3) inertia
4) floor reaction


115

What is an antalgic gait?  What are common causes of it?

A lopsided gait (more time spent on one foot); osteoarthritis, fracture, tendonitis, sprain

116

What is the Trendelenberg gait?  What are its common causes?

Side to side bending of the trunk (kind of like swagger); painful hip, hip abductor weakness (gluteus medius), leg-length discrepancy, abnormal hip joint

117

When somebody has forward-backward sway while walking, what muscle weakness should be suspect?

Hip extensor (gluteus maximus)

118

What are common natural compensations for a leg length discrepancy that can be observed in a patient?

Vaulting gait, high-knee gait, hip circumduction, foot drop

119

What volume of the body is composed of bone (on average)?

9%

120

What minerals does bone participate in homeostasis of?

Ca++, P+++, Na+, Mg++

121

What is the main constituent of the inorganic mineralized matrix of bone?

Calcium phosphate-hydroxyapatite

122

Identify the cell type in each half.

Left—osteoblasts, right—osteoclasts

123

What are these little pyknotic cells embedded in bone (bottom left)?

Osteocytes

124

What cell type is hanging out in these lacunae, and depicted in yellow in the bottom diagram?

Osteocytes

125

How does assembled triple helix collagen move from the ER to the extracellular space of osteoblasts?

Golgi apparatus and secretory vesicles

126

Are osteoblasts controlled by polypeptide hormones only, steroid hormones only, or both?

Both

127

Label the cell types in this diagram.  What process is this?

Bone remodeling

128

What receptor on osteoclast precursors responds to direct cell-to-cell contact to cause differentiation into an osteoclast?

RANK (receptor activator for Nuclear Factor κB)

129

What does the osteoclast pump into the Howship's lacuna that causes resorption of hydroxyapatite?

Protons

130

Bone remodeling is performed by BMU's—what does that stand for?

Basic multicellular units

131

Compact bone has canals running parallel to the axis of the long bone, and some perpendicular.  What are the parallel ones called?  The perpendicular ones?

Parallel: Haversian canals; perpendicular: Volksmann's canals

132

What attaches the periosteum to the bone?

The Sharpey's fibers

133

What are the little tunnels through which osteocytes extend their dendritic processes to communicate with one another?

Canaliculi

134

What kind of bone is defined by its layering into flat, parallel bundles, with straight cement lines?  What disease involves disruption of these layers?

Lamellar; Paget's disease (below)

135

Almost all bones are primarily formed via endochondral ossification starting in the 6th embryonic week, but not all.  What bones are the exceptions?

The flat bones of the calvaria (skull cavity)

136

Is the center of ossification seen in the middle of this long bone the primary or secondary ossification center?  What about the two ones on either end seen starting from the second panel?

Middle – Primary; Ends – Secondary

137

What is the structure seen here, which is the primary area where bones grow in length?

The epiphyseal growth plate

138

Can osteclasts resorb material (e.g. cartilage) that is not calcified?

No

139

In intramembranous ossification, does cartilage form before bone calcification occurs?  What is it called when bone forms directly on pre-existing bone?

No; appositional growth

140

What types of bone are being contrasted here?

Top: compact, and bottom: cancellous or trabecular

141

What transition in morphology occurs as bone remodeling occurs over the years?

Woven to lamellar

142

What is the color of articular cartilage on a young person?  What about an elderly person?

Young - left; elderly - right

143

When you compress hyaline cartilage, what extrudes out of the extracellular matrix giving it its spongy quality?

Water and mobile ions

144

What are the three main types of cartilage, seen here?

From left to right: hyaline, fibrous, and elastic

145

The synovial membrane has two or three layers of cells.  What do type B synovicytes do?  What about type A?

Type B: resorb debris from synovial cavity; Type A: secrete synovial fluid, rich in hyaluronic acid

146

How much of the skeleton is renewed every year?

~10%

147

What is the most common joint disorder in the world, and which costs the US $60B/yr?

Osteoarthritis

148

How much more likely are obese females to develop knee osteoarthritis?

5x

149

Name two developmental deformities that are risk factors for osteoarthritis.

Congenital hip dysplasia, Slipped femoral capital epiphysis (SCFE)

150

Does osteoarthritis incidence increase with more use of the joint?

Yes (for example, as seen in a study with chopstick and non-chopstick hands in Beijing)

151

What vitamin deficiency increases risk for osteoarthritis?

Vitamin D

152

Secondary causes for osteoarthritis include:
– [...] and Metabolic
– Connective Tissue
– Dysplasia (abnormal development)
– Post-trauma
– Skeletal failure
– Post-inflammation

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
– Connective Tissue
– Dysplasia (abnormal development)
– Post-trauma
– Skeletal failure
– Post-inflammation


153

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
[...] Tissue
– Dysplasia (abnormal development)
– Post-trauma
– Skeletal failure
– Post-inflammation

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
Connective Tissue
– Dysplasia (abnormal development)
– Post-trauma
– Skeletal failure
– Post-inflammation


154

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
– Connective Tissue
[...] (abnormal development)
– Post-trauma
– Skeletal failure
– Post-inflammation

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
– Connective Tissue
Dysplasia (abnormal development)
– Post-trauma
– Skeletal failure
– Post-inflammation


155

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
– Connective Tissue
– Dysplasia (abnormal development)
– Post-[...]
– Skeletal failure
– Post-inflammation

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
– Connective Tissue
– Dysplasia (abnormal development)
– Post-trauma
– Skeletal failure
– Post-inflammation


156

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
– Connective Tissue
– Dysplasia (abnormal development)
– Post-trauma
– Skeletal failure
– Post-[cellular process]

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
– Connective Tissue
– Dysplasia (abnormal development)
– Post-trauma
– Skeletal failure
– Post-inflammation


157

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
– Connective Tissue
– Dysplasia (abnormal development)
– Post-trauma
[...] failure
– Post-inflammation

Secondary causes for osteoarthritis include:
– Endocrine and Metabolic
– Connective Tissue
– Dysplasia (abnormal development)
– Post-trauma
Skeletal failure
– Post-inflammation


158

What tissue is gradually lost in osteoarthritis?  What tissue thickens?

Articular cartilage; Subchondral bone

159

What are the bony outgrowths that result from the thickening of subchondral bone in osteoarthritis called?

Osteophytes

160

With age, does synthesis of proteinases in the ECM of cartilage increase or decrease?  What about tissue inhibitors of metalloproteinases (TIMPs)?

Proteinases increase; TIMPs decrease

161

What does this patient have (this is an MCP joint)? What is sticking out to the left?

Osteoarthritis; osteophyte

162

What is it called to look inside a joint?

Arthroscopy

163

What type of osteoarthritis is seen here?

Inflammatory, note the redness and swelling

164

What is seen on the DIP of this patient?  What is it a sign for?

A synovial cyst; osteoarthritis

165

The DIPs of this patient are palpated and the bulges seen here are bony, not spongy.  Is osteoarthritis or rheumatoid arthritis more likely and why?

Osteoarthritis, firstly beause it affects the DIPs and PIPs preferentially, and secondly because the bony outgrowths are osteophytes

166

What kind of deformity is this?

Valgus deformity, where the abductors of the hip are very weak and great pressure is put on the lateral epicondyle of the femur into the knee joint

167

What is this characteristic appearance of the DIPs and PIPs that suggests osteoarthritis? 

Seagull appearance—overgrowth of the bone surrounding them

168

What two conditions of a joint increase its likely involvement in osteoarthritis?

Overused and weight-bearing

169

For osteoarthritis, is pain worse in the early morning, or toward the end of the day?  Is there morning stiffness?

Toward the end of the day after using the joints; typically no A.M. stiffness

170

What is crepitus of a joint?

When it is moved and air bubbles are heard crackling or popping, a sign that bony edges are protruding

171

Is there a blood test for osteoarthritis?

No

172

What lifestyle changes can be recommended for an osteoarthritis patient?

Avoid traumatic occupational or sports usage of the affected joints, lose weight, avoid fall risks (e.g. walking aids), increase endurance and strength via exercise programs or physical therapy

173

What is notable about the osteoarthritic cervical spine (right) as compared to the normal?

Greater intervertebral disc height, and hypertrophic bone spurs on them

174

Which is normal, left or right? What is the abnormality? (This is a lumbar vertebral body)

Right is normal; Left shows bony outgrowths (spinal stenosis) into the spinal canal, which is the nice trangular center area seen in the right

175

What is seen in this cross section of intervertebral bodies?

Herniation of the discs into the vertebrae, called Schmorl's nodes

176

Which hip here is normal?  What is wrong with the other?

The left (patient's left) hip shows no space to cushion the joint, revealing end stage osteoarthritis and likely a need to replace the joint

177

What risk must be carefully managed in older patients with osteoarthritis, both in the hospital and the home setting?

Fall risk

178

What kind of drugs are prescribed to help osteoarthritis patients?

Nonopioid analgesics, NSAIDs, topical agents (capsaicin or lidocaine), glucosamine/chondroitin, intra-articular agents, and in the worst cases opioid analgesics

179

What is the proposed mechanism of glucosamine or chondroitin in treating osteoarthritis?  Is there strong evidence for this?

Anti-inflammatory activity and "rebuilding" of the cartilage; no, the evidence for this is weak

180

What is an intra-articular agent?  Which might be used for osteoarthritis?

It is a drug injected into the joint; steroids or hyaluronic acid

181

Is this medicine recommended by the FDA for treatment of osteoarthritis?

No

182

Are primary tumors of the spine more common than tumors metastasizing to the spine?

No

183

There are six broad categories of spinal disorders.
[...] (wear and tear)
– Inflammatory (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
– Tumors (metastatic and primary)
– Infection (i.e. osteomyelitis)
– Deformity (scoliosis/kyphosis)

There are six broad categories of spinal disorders.
Degenerative (wear and tear)
– Inflammatory (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
– Tumors (metastatic and primary)
– Infection (i.e. osteomyelitis)
– Deformity (scoliosis/kyphosis)


184

There are six broad categories of spinal disorders.
– Degenerative (wear and tear)
[...] (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
– Tumors (metastatic and primary)
– Infection (i.e. osteomyelitis)
– Deformity (scoliosis/kyphosis)

There are six broad categories of spinal disorders.
– Degenerative (wear and tear)
Inflammatory (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
– Tumors (metastatic and primary)
– Infection (i.e. osteomyelitis)
– Deformity (scoliosis/kyphosis)


185

There are six broad categories of spinal disorders.
– Degenerative (wear and tear)
– Inflammatory (i.e. rheumatoid arthritis)
– [...] (fractures/dislocations)
– Tumors (metastatic and primary)
– Infection (i.e. osteomyelitis)
– Deformity (scoliosis/kyphosis)

There are six broad categories of spinal disorders.
– Degenerative (wear and tear)
– Inflammatory (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
– Tumors (metastatic and primary)
– Infection (i.e. osteomyelitis)
– Deformity (scoliosis/kyphosis)


186

There are six broad categories of spinal disorders.
– Degenerative (wear and tear)
– Inflammatory (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
[...] (metastatic and primary)
– Infection (i.e. osteomyelitis)
– Deformity (scoliosis/kyphosis)

There are six broad categories of spinal disorders.
– Degenerative (wear and tear)
– Inflammatory (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
Tumors (metastatic and primary)
– Infection (i.e. osteomyelitis)
– Deformity (scoliosis/kyphosis)


187

There are six broad categories of spinal disorders.
– Degenerative (wear and tear)
– Inflammatory (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
– Tumors (metastatic and primary)
[...] (i.e. osteomyelitis)
– Deformity (scoliosis/kyphosis)

There are six broad categories of spinal disorders.
– Degenerative (wear and tear)
– Inflammatory (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
– Tumors (metastatic and primary)
Infection (i.e. osteomyelitis)
– Deformity (scoliosis/kyphosis)


188

There are six broad categories of spinal disorders.
– Degenerative (wear and tear)
– Inflammatory (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
– Tumors (metastatic and primary)
– Infection (i.e. osteomyelitis)
[...] (scoliosis/kyphosis)

There are six broad categories of spinal disorders.
– Degenerative (wear and tear)
– Inflammatory (i.e. rheumatoid arthritis)
– Traumatic (fractures/dislocations)
– Tumors (metastatic and primary)
– Infection (i.e. osteomyelitis)
Deformity (scoliosis/kyphosis)


189

What pedicle does the L5 nerve root exit underneath? What about C4?

L5; C3 (recall that C1 exits over C1, and it switches at C8 where there is no vertebra)

190

Which spinal root is this exam for?

C5

191

Which spinal root is this exam for?

C6

192

Which spinal root is this exam for?

C7

193

What spinal root is this exam for?

C8

194

What is Hoffman's sign?

Flicking the DIP of one finger into hyperextension causes the others to contract

195

Of these dermatomes, which landmarks are best to know?

T4: nipple line, T10: belly button, L1: groin, L2: thighs, L5: lateral calf, L4: medial calf; C5: upper side of upper arm, C6: upper side of lower arm, T1: lower side of lower arm, T2: lower side of upper arm

196

Which spinal root controls the patellar tendon reflex?

L4

197

Is there a reflex controlled by L5?  What motion?

There is no reflex; extending (dorsiflexing) the toes

198

What reflex is controlled by the S1 spinal root?

Achilles tendon

199

What do superficial tenderness, pain on simulation rotation, and pain on axial loading indicate about a CC of lower back pain?

It may not be physiological (instead, psychological)

200

What proportion of spinal column trauma is due to MVAs?  At what level of the column are the most serious injuries?

45%; 93% of fatal MVAs with spinal trauma occur between occiput and C3

201

When neurologic injury occurs with motor deficits (e.g., contusion or compression of the spinal cord), how likely is complete recovery?

Very unlikely

202

What kind of injury is this?  Is it survivable?

Dislocation of the occiput from the atlas; no

203

The following are X-rays of what kind of injury?  Which involves bilateral facets?

Distractive flexion (or dislocation of cervical vertebrae); the rightmost is bilateral facet dislocation

204

What is the treatment for injuries like the following?

For cervical dislocations, the team stabilizes the neck, evaluates neurological function, uses imaging studies, and then reduces the dislocation and decompresses surgically with rigid stabilization
 

205

At the level of spinal stenosis, does radiculopathy (nerve dysfunction) only, myelopathy (spinal dysfunction) only, or both occur?  What about below this level?

At the level both; below, myelopathy only

206

What kind of disk herniation is more likely to result in radiculopathy?  Which is more likely to result in myelopathy?  What about both?

1. intraforaminal, radiculopathy;
2. central, myelopathy
3. a mixture of both, e.g. posterolateral, will result in both symptoms

207

What is a laminoplasty?

A reshaping of the spinal canal in the case of spinal stenosis that decompresses the spinal cord

208

What is a spondylolithesis?

A slipped disc

209

What type of cartilage is in the nucleus pulposus?  What about the annulus?  What disease is shown here?

Type II (hyaline); Type I (fibrous); degenerative disk disease

210

When a patient says "sciatica" what do they mean?

A pain, numbness and/or weakness in their leg(s)

211

What are the most common sites for a lumbar herniated disc?

Between L4-5 and L5-S1

212

What is the surgical technique for relieving pressure from a herniated disc?

Discectomy or microdiscectomy, where the disc is shaved via a small incision

213

What condition is present in 30% of the population over 60, where narrowing of one or more levels of the lumbar spinal canal causes compression of nerve roots?

Lumbar spinal stenosis

214

What is the "shopping cart" sign for lumbar spinal stenosis?

The patient likes leaning on a shopping cart like a walker in the supermarket, because it allows them to flex their back, which opens the spinal canal

215

What is claudication?

Limping

216

When a patient comes in with claudication (limping), how can vascular causes be differentiated from a neurogenic etiology?

If patient is relieved while sitting, it is neurogenic; if they are relieved while standing, it is vascular.  Lower back pain and spinal motion also point to neurogenic.  With neurogenic claudication, one can ride a bicycle—with vascular this is too painful.

217

What is the success rate for laminectomy in treating spinal stenosis?

80-90%

218

What is this procedure?  What is it used to treat?

Laminectomy; spinal stenosis

219

What condition is seen in this patient, which keeps him in this hunched pose?

Ankylosing spondylitis

220

What is this procedure used to correct?

Ankylosing spondylitis, where the vertebra fuse in a permanently arched position

221

Four seronegative spondylarthropathies are:
– Ankylosing spondylitis
– Psoriatic arthritis
– Reiter's (reactive) arthritis
– Arthropathy of [other disease name]

Four seronegative spondylarthropathies are:
– Ankylosing spondylitis
– Psoriatic arthritis
– Reiter's (reactive) arthritis
– Arthropathy of Inflammatory Bowel Disease


222

Four seronegative spondylarthropathies are:
– Ankylosing spondylitis
– Psoriatic arthritis
[...] arthritis
– Arthropathy of Inflammatory Bowel Disease

Four seronegative spondylarthropathies are:
– Ankylosing spondylitis
– Psoriatic arthritis
Reiter's (reactive) arthritis
– Arthropathy of Inflammatory Bowel Disease


223

Four seronegative spondylarthropathies are:
– Ankylosing spondylitis
[...] arthritis
– Reiter's (reactive) arthritis
– Arthropathy of Inflammatory Bowel Disease

Four seronegative spondylarthropathies are:
– Ankylosing spondylitis
Psoriatic arthritis
– Reiter's (reactive) arthritis
– Arthropathy of Inflammatory Bowel Disease


224

Four seronegative spondylarthropathies are:
[...]
– Psoriatic arthritis
– Reiter's (reactive) arthritis
– Arthropathy of Inflammatory Bowel Disease

Four seronegative spondylarthropathies are:
Ankylosing spondylitis
– Psoriatic arthritis
– Reiter's (reactive) arthritis
– Arthropathy of Inflammatory Bowel Disease


225

What are the unifying features of seronegative spondylarthropathies?
1) [Symmetric or assymetric] presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent


226

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal [cellular process]
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent


227

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) [which joint] involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent


228

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony [...] (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent


229

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) [gender] predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent


230

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: [...]
9) Role of bacterial infection
10) Rhematoid factor is absent

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent


231

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of [...] infection
10) Rhematoid factor is absent

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent


232

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is [absent or present]

What are the unifying features of seronegative spondylarthropathies?
1) Assymetric presentation
2) Axial/skeletal inflammation
3) DIP involvement
4) Enthesopathy
5) Distinctive mucocutaneous and opthalmologic lesions
6) Bony ankylosis (joint stiffness)
7) Male predominance
8) Unique genotype: HLA-B27
9) Role of bacterial infection
10) Rhematoid factor is absent


233

This man with ankylosing spondylitis has which symptom?  How do we differentiate between this and an inflammatory osteoarthritis of the vertebrae?

Kyphosis; it doesn't matter if the person overuses the joints

234

What is notable about this hip X-ray?  What late-stage disease is represented here?

The sacroiliac joints have disappeared; ankylosing spondylitis

235

What is the finding of this spinal X-ray?  What disease is this indicative of?

"Bamboo spine": the ligaments are calcifying; ankylosing spondylitis 

236

We see squaring of the vertebral bodies in this radiograph, indicating progression of what disease?

Ankylosing spondylitis

237

The small, lateral calcifications that originate from ligament attachments into the bone during ankylosing spondylitis are formed from which cell type?

Syndesmocytes

238

What is significant on this X-ray, and what disease of the vertebral column does it point to?

Inflammation of the periosteum; ankylosing spondylitis

239

Which sensory organ is affected by ankylosing spondylitis?

Eyes: acute inflammation

240

What is the treatment regimen for ankylosing spondylitis?
1) [...]
2) NSAIDs
3) SSZ, MTX
4) TNF inhibitors

What is the treatment regimen for ankylosing spondylitis?
1) Physical therapy
2) NSAIDs
3) SSZ, MTX
4) TNF inhibitors


241

What is the treatment regimen for ankylosing spondylitis?
1) Physical therapy
2) [...]
3) SSZ, MTX
4) TNF inhibitors

What is the treatment regimen for ankylosing spondylitis?
1) Physical therapy
2) NSAIDs
3) SSZ, MTX
4) TNF inhibitors


242

What is the treatment regimen for ankylosing spondylitis?
1) Physical therapy
2) NSAIDs
3) [...]
4) TNF inhibitors

What is the treatment regimen for ankylosing spondylitis?
1) Physical therapy
2) NSAIDs
3) SSZ, MTX
4) TNF inhibitors


243

What is the treatment regimen for ankylosing spondylitis?
1) Physical therapy
2) NSAIDs
3) SSZ, MTX
4) [...]

What is the treatment regimen for ankylosing spondylitis?
1) Physical therapy
2) NSAIDs
3) SSZ, MTX
4) TNF inhibitors


244

Why is physical therapy so important for ankylosing spondylitis sufferers?

There is no pharamacological agent to prevent fusion of the joints, so the patient should rather fuse with the vertebral joints in an extended position

245

Why are SSZ and MTX prescribed to ankylosing spondylitis patients?

They are antibiotic therapies that may combat some chronic infections thought to associate with the disease, e.g., Klebsiella

246

What arthritis are these hands characteristic of?

Psoriasis: note the sausage finger, onycholytic nails, DIPs inflamed

247

What arthritis is associated with these nail abnormalities?

Psoriatic

248

Why isn't this hand likely to be affected by rheumatoid arthritis?  What arthritis is it?

There is no involvement of the radiocarpal joint; Psoriatic, because of the DIP involvement and the sparing of the wrist

249

These toes are likely to be affected by what kind of arthritis?

DIP involvement (soft tissue swelling) points to psoriatic arthritis

250

What presentation of arthritis is this?  What type of arthritis is it a progression from?

Arthritis mutilans; a late stage of psoriatic arthritis

251

How is psoriatic arthritis treated?
1) [...] or steroids
2) DMARDs (SSZ, MTX, gold, etc.)
3) TNF inhibitors

How is psoriatic arthritis treated?
1) NSAIDs or steroids
2) DMARDs (SSZ, MTX, gold, etc.)
3) TNF inhibitors


252

How is psoriatic arthritis treated?
1) NSAIDs or [...]
2) DMARDs (SSZ, MTX, gold, etc.)
3) TNF inhibitors

How is psoriatic arthritis treated?
1) NSAIDs or steroids
2) DMARDs (SSZ, MTX, gold, etc.)
3) TNF inhibitors


253

How is psoriatic arthritis treated?
1) NSAIDs or steroids
2) [...] (SSZ, MTX, gold, etc.)
3) TNF inhibitors

How is psoriatic arthritis treated?
1) NSAIDs or steroids
2) DMARDs (SSZ, MTX, gold, etc.)
3) TNF inhibitors


254

How is psoriatic arthritis treated?
1) NSAIDs or steroids
2) DMARDs (SSZ, MTX, gold, etc.)
3) [...]

How is psoriatic arthritis treated?
1) NSAIDs or steroids
2) DMARDs (SSZ, MTX, gold, etc.)
3) TNF inhibitors


255

What does DMARD stand for?

Disease-modifying anti-rheumatic drug

256

Would you provide plaquenil to a patient with psoriatic arthritis?  Why or why not?

No, it is contraindicated; it can cause an exfoliative erythroderma

257

What type of arthritis do these features point toward?

Reiter's (reactive) arthritis

258

Is reactive arthritis caused by infection or autoinflammation?

Infection

259

How is Reiter's (reactive) arthritis treated?

1) Eradicate the infection (antibiotics)
2) NSAIDs or steroids
3) DMARDs (SSZ, MTX, gold)

260

Does arthropathy of IBD occur with greater prevalence in ulcerative colitis or Crohn's colitis?

Crohn's colitis

261

How is arthropathy of IBD treated?

1) Treat the underlying bowel disease (steroids, antibiotics, etc.)
2) Physical therapy

262

What are the muscles of the rotator cuff?

Teres minor, infraspinatus, supraspinatus, subscapularis

263

Which is anterior: the acromion, or the coracoid process?

Coracoid process

264

Label the following rotator cuff muscles.

265

Rotator cuff disease presents with a spectrum of pathology from [...] to partial or full tears.

Rotator cuff disease presents with a spectrum of pathology from inflammation to partial or full tears.

266

Rotator cuff disease presents with a spectrum of pathology from inflammation to partial or full [...].

Rotator cuff disease presents with a spectrum of pathology from inflammation to partial or full tears.

267

How long does a tear of the rotator cuff muscles take to heal?

>6 months

268

What is the most common cause of shoulder pain?

Impingement (bursitis)

269

What type of shoulder problem is seen here?  The patient reports shoulder pain, is of younger age, and had good strength in the arm before falling off his skateboard onto it.

It is a distal fracture in the clavicle that has caused bursitis and impingement.

270

What is notable about this glenohumoral joint?

Calcification in the bursa above the head of the humerus

271

How is a diagnosis of calcific tendonitis made?  What is the treatment?

X-ray; cortisone injection

272

What is the incidence of rotator cuff tears in patients over 70 years?

30%

273

Is fatty atrophy or infiltration of a rotator cuff tear a reversible or irreversible change?

Irreversible

274

What priorities are factored in the decision to surgically fix a rotator cuff tear?

Acuteness of and trauma causing the tear, age of the patient

275

What is the layman term for "adhesive capsulitis"?

Frozen shoulder

276

What is the hallmark of adhesive capsulitis?

Limited and passive range of motion of the arm

277

What is the top two differential for a CC of frozen shoulder (adhesive capsulitis)?  What can be performed to differentiate between the two?

Adhesive capsulitis vs. arthritis; X-ray of shoulder will be normal for adhesive capsulitis

278

What two preconditions cause a 4x increase in incidence of frozen shoulder?

Diabetes and thyroid disease

279

What are the two treatments for frozen shoulder?  What is the prognosis with therapy?

Physical therapy (aggressive stretching) and cortisone injection; 90% of patients regain 90% of function over 3 years

280

Is osteoarthritis or rheumatoid arthritis more common in the shoulder?  What type of athlete is most likely to develop shoulder arthritis?

Osteoarthritis; weight lifters

281

Which shoulder has osteoarthritis? Which has rheumatoid arthritis?

Right: osteoarthritis, with irregular degradation of the bony edges at the joint; Left: rheumatoid (inflammation and hyperdensity at the joint margin)

282

What is the surgery procedure for osteoarthritis of the shoulder that does not improve with treatment?  Following this procedure, what can patients NOT do?

Shoulder replacement; lift weights or do manual labor (but gentle sports are OK)

283

What is this surgical treatment for the shoulder?

Reverse shoulder replacement: the ball and socket is reversed!

284

Do you typically operate on fractures of the humerus that affect the glenohumeral joint? What indicates surgery?

No; displacement indicates surgery

285

In which direction is the shoulder joint more unstable following trauma?

Anterioinferiorally

286

Are CTs blurred by overlying tissues?

No

287

In a CT, the final pixel value for a point is produced by the difference of [...] vs. transmission of x-rays through that given point.

In a CT, the final pixel value for a point is produced by the difference of absorption vs. transmission of x-rays through that given point.

288

In a CT, the final pixel value for a point is produced by the difference of absorption vs. [...] of x-rays through that given point.

In a CT, the final pixel value for a point is produced by the difference of absorption vs. transmission of x-rays through that given point.

289

What is the standardized unit of the attenuation values in a CT?

Hounsfield units

290

Can a CT detect fractures that conventional radiography cannot?

Yes, particularly complex fractures in large bones surrounded by a lot of tissue e.g. hips

291

In NMR, the relaxation toward equilibrium is described by two parameters. T1 is the time constant for relaxation of the [...] component of magnetization and T2 is the time constant of transverse component.

In NMR, the relaxation toward equilibrium is described by two parameters. T1 is the time constant for relaxation of the longitudinal component of magnetization and T2 is the time constant of transverse component.

292

In NMR, the relaxation toward equilibrium is described by two parameters. T1 is the time constant for relaxation of the longitudinal component of magnetization and T2 is the time constant of [...] component.

In NMR, the relaxation toward equilibrium is described by two parameters. T1 is the time constant for relaxation of the longitudinal component of magnetization and T2 is the time constant of transverse component.

293

Can MRI distinguish beween yellow and red marrow?  Fat and muscle?

Yes to both

294

Does MRI require contrast agents to visualize blood vessels? 

No

295

What has MRI demonstrated in these proximal femurs that the X-ray could not?

Ischemic necrosis (note the black cavities in the heads of the femurs)

296

Bone destruction may not be detected on an X-ray until what percentage of the bone has been destroyed?

50%

297

What is the use of radionuclides such as Strontium 85 and Technetium99m (99mTc) labeled phosphate compounds to detect osseous abnormalities?  Is this technique more sensitive than specific, or vice versa?

They will show increased uptake at those areas; yes, more sensitive than specific

298

The amount of radiopharmaceutical agent accumulated in any region of bone (in a radionuclide study) depends on the [...] and integrity of blood supply.

The amount of radiopharmaceutical agent accumulated in any region of bone (in a radionuclide study) depends on the rate of bone turnover and integrity of blood supply.

299

The amount of radiopharmaceutical agent accumulated in any region of bone (in a radionuclide study) depends on the rate of bone turnover and integrity of [...].

The amount of radiopharmaceutical agent accumulated in any region of bone (in a radionuclide study) depends on the rate of bone turnover and integrity of blood supply.

300

What is the most widely used radioisotope in clinical nuclear medicine?

Technetium99m

301

What kind of radiographic study is this?

Radionuclide study of osseous abnormalities (darker means more bone turnover)

302

In a PET/CT scan, what tracer can detect bone metastases and directly incorporates into the tumor cells?

FDG

303

What type of radiographic study detects pairs of gamma rays emitted by a positron-emitting radionuclide?

PET

304

Are PET scans 3-dimensional?

Yes, they can be

305

What kind of fractures do tumors and metabolic bone disease collectively cause?

Pathologic fractures (which are typically transverse)

306

In medicine and orthopedics, is the term "fracture" always equivalent to "broken bone"?

Yes

307

What is the immediate treatment for an open fracture?

It is a surgical emergency: antibiotics, tetanus injection, NPO, wound debridement in the ER or OR

308

Under the Gustilo & Anderson classification for open fractures, what would a fracture that is 1-10cm, with moderate soft tissue damage, be classified as?  Is a Type I fracture most serious or least serious?

Type II; least serious

309

When are wounds from open fractures closed?

Not until 3-7 days after the initial surgery, when the soft tissues have been thoroughly cleaned and assessed

310

What is the Gustilo & Anderson classification for this open fracture?

Type IIIA: >10cm, high energy

311

What is the difference between IIIA and IIIB open fractures?

IIIB has periosteal stripping

312

What does a "comminuted" fracture mean?

There are more than two pieces

313

Which type of fracture line is most likely to be pathological?

Transverse

314

What is the shape of this fracture line?  What kind of force produced the fracture?

Spiral (see the top ridge of the tibia come around the back of the film); twisting

315

What is the difference betwen an intra-articular and an extra-articular fracture?

Intra-articular goes into a joint

316

What assessment must be done before and after reduction of a fracture to ensure best possible recovery of function?

Assessment of neurovascular status

317

Why might a bone be woven instead of lamellar, even if it is a mature bone?

Pathological overactivity of osteoblasts/clasts

318

What is osteocalcin used as a serum or urine marker for?

Bone formation

319

Long bones have three blood supplies:
1.  [...] artery (intramedullary and inner 2/3 cortex)
2.  Periosteal vessels (outer 1/3 cortex)
3.  Metaphyseal vessels

Long bones have three blood supplies:
1.  Nutrient artery (intramedullary and inner 2/3 cortex)
2.  Periosteal vessels (outer 1/3 cortex)
3.  Metaphyseal vessels


320

Long bones have three blood supplies:
1.  Nutrient artery (intramedullary and inner 2/3 cortex)
2.  [...] vessels (outer 1/3 cortex)
3.  Metaphyseal vessels

Long bones have three blood supplies:
1.  Nutrient artery (intramedullary and inner 2/3 cortex)
2.  Periosteal vessels (outer 1/3 cortex)
3.  Metaphyseal vessels


321

Long bones have three blood supplies:
1.  Nutrient artery (intramedullary and inner 2/3 cortex)
2.  Periosteal vessels (outer 1/3 cortex)
3.  [...] vessels

Long bones have three blood supplies:
1.  Nutrient artery (intramedullary and inner 2/3 cortex)
2.  Periosteal vessels (outer 1/3 cortex)
3.  Metaphyseal vessels


322

How much of cardiac output do bones collectively receive?

5-10%

323

Which growth factors for bone formation are found in fracture hematomas?

Platelet-derived growth factors

324

Does estrogen stimulate or inhibit fracture healing?

Stimulate healing

325

Do thyroid hormones and glucocorticoids increase or decrease osteoclastic activity?

Increase

326

What are "cutting cones"?

A mechanism to remodel bone: osteoclasts at the front of the cone, remove bone, trailing osteoblasts lay down new bone

327

Do long bones grow in length via endochondral or intramembranous ossification?

Endochondral (because it uses a cartilage precursor, endo + chondral)

328

What are the three stages of fracture healing?

Inflammation, repair, remodeling

329

What has appeared at this fracture site during the inflammation stage of healing?

A hematoma

330

What is the extracellular matrix formed in this reparative phase of fracture healing called?

Soft callus

331

With absolute rigid stability of a fracture, do you see a callus form during healing? What bone remodeling structures traverse the fracture site to join the bone?

No; cutting cones

332

How long does a femur fracture take to heal (on average), and so therefore how long is the cast on?  What about a finger?  Why wouldn't you immobilize the finger for more than this time?

Femur: 12 weeks; Finger: 3 weeks; beyond this point, the capsule might calcify and mobility of the finger may not be regained

333

[...] Law states that bone responds dynamically to stress by altering its internal architecture.

Wolff's Law states that bone responds dynamically to stress by altering its internal architecture.

334

What is the maximum size of a gap in a fracture after which it cannot be filled with woven bone, and must be filled instead with fibrous tissue that ossifies?

500 microns

335

What cavity must be reconstituted to say that fracture healing is complete?

The medullary cavity

336

Is direct or indirect bone healing preferred (typically)?

Direct, hence stabilization of many open fractures

337

What are some drawbacks of casting?

Joint stiffness, disuse osteopenia, and muscle atrophy, difficult to maintain the alignment of bones

338

Smoking increases the time needed for fracture healing.  Is this mitigated by a patient using nicotine patches?

No, the nicotine is directly responsible for decreasing bloodflow to bone

339

In the case of non-union of a fracture that was internally fixed, what are three surgical options?

Incision & draining, revision of the fixation, or bone grafting

340

What disease ties together the pictured symptoms?

Systemic Lupus Erythematosus

341

What are the auto-antibodies in lupus selective for?

The cell nucleus (anti-nuclear antibodies or ANA)

342

Is SLE (Lupus) more common in females or males?  Blacks or whites?

Females; blacks

343

Out of 1000 black women, age 15-64, how many will develop SLE?

~4

344

What is the 5 year survival rate for SLE (Lupus)?

93%

345

What is the usual cause of death in late SLE?

Atherosclerosis and/or infection

346

Is SLE (Lupus) inheritable?

Partially, it clearly has heritable factors, but heritability is not close to 100%

347

Why is SLE (Lupus) a disease that mostly affects women?

Estrogen probably plays a role in the etiology, along with decreased levels of androgens

348

Which two immune cell types are defective in SLE (Lupus)?

B and T cells

349

The top 6 of 11 clinical criteria for lupus are (SLE):
1. [...] rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Non-erosive arthritis
6. Pleuritis or pericarditis

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Non-erosive arthritis
6. Pleuritis or pericarditis


350

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. [...] rash
3. Photosensitivity
4. Oral ulcers
5. Non-erosive arthritis
6. Pleuritis or pericarditis

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Non-erosive arthritis
6. Pleuritis or pericarditis


351

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. Discoid rash
3. [...]
4. Oral ulcers
5. Non-erosive arthritis
6. Pleuritis or pericarditis

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Non-erosive arthritis
6. Pleuritis or pericarditis


352

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral [...]
5. Non-erosive arthritis
6. Pleuritis or pericarditis

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Non-erosive arthritis
6. Pleuritis or pericarditis


353

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. [...]
6. Pleuritis or pericarditis

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Non-erosive arthritis
6. Pleuritis or pericarditis


354

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Non-erosive arthritis
6. Pleuritis or [...]

The top 6 of 11 clinical criteria for lupus are (SLE):
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Non-erosive arthritis
6. Pleuritis or pericarditis


355

The last 5 of 11 classification criteria for SLE (Lupus) are:
7. [...] disorder (> 0.5 gm proteinuria or cellular casts)
8. Neurologic disorder (seizures or
psychosis)
9. Hematologic disorder (anemia, leukopenia, lymphopenia,
thrombocytopenia)
10. Immunologic disorder (anti-db str. DNA, anti-Sm, APLA)
11. Positive ANA

The last 5 of 11 classification criteria for SLE (Lupus) are:
7. Renal disorder (> 0.5 gm proteinuria or cellular casts)
8. Neurologic disorder (seizures or
psychosis)
9. Hematologic disorder (anemia, leukopenia, lymphopenia,
thrombocytopenia)
10. Immunologic disorder (anti-db str. DNA, anti-Sm, APLA)
11. Positive ANA


356

The last 5 of 11 classification criteria for SLE (Lupus) are:
7. Renal disorder (> 0.5 gm proteinuria or cellular casts)
8. [...] disorder (seizures or
psychosis)
9. Hematologic disorder (anemia, leukopenia, lymphopenia,
thrombocytopenia)
10. Immunologic disorder (anti-db str. DNA, anti-Sm, APLA)
11. Positive ANA

The last 5 of 11 classification criteria for SLE (Lupus) are:
7. Renal disorder (> 0.5 gm proteinuria or cellular casts)
8. Neurologic disorder (seizures or
psychosis)
9. Hematologic disorder (anemia, leukopenia, lymphopenia,
thrombocytopenia)
10. Immunologic disorder (anti-db str. DNA, anti-Sm, APLA)
11. Positive ANA


357

The last 5 of 11 classification criteria for SLE (Lupus) are:
7. Renal disorder (> 0.5 gm proteinuria or cellular casts)
8. Neurologic disorder (seizures or
psychosis)
9. [...] disorder (anemia, leukopenia, lymphopenia,
thrombocytopenia)
10. Immunologic disorder (anti-db str. DNA, anti-Sm, APLA)
11. Positive ANA

The last 5 of 11 classification criteria for SLE (Lupus) are:
7. Renal disorder (> 0.5 gm proteinuria or cellular casts)
8. Neurologic disorder (seizures or
psychosis)
9. Hematologic disorder (anemia, leukopenia, lymphopenia,
thrombocytopenia)
10. Immunologic disorder (anti-db str. DNA, anti-Sm, APLA)
11. Positive ANA


358

The last 5 of 11 classification criteria for SLE (Lupus) are:
7. Renal disorder (> 0.5 gm proteinuria or cellular casts)
8. Neurologic disorder (seizures or
psychosis)
9. Hematologic disorder (anemia, leukopenia, lymphopenia,
thrombocytopenia)
10. [...] disorder (anti-db str. DNA, anti-Sm, APLA)
11. Positive ANA

The last 5 of 11 classification criteria for SLE (Lupus) are:
7. Renal disorder (> 0.5 gm proteinuria or cellular casts)
8. Neurologic disorder (seizures or
psychosis)
9. Hematologic disorder (anemia, leukopenia, lymphopenia,
thrombocytopenia)
10. Immunologic disorder (anti-db str. DNA, anti-Sm, APLA)
11. Positive ANA


359

The last 5 of 11 classification criteria for SLE (Lupus) are:
7. Renal disorder (> 0.5 gm proteinuria or cellular casts)
8. Neurologic disorder (seizures or
psychosis)
9. Hematologic disorder (anemia, leukopenia, lymphopenia,
thrombocytopenia)
10. Immunologic disorder (anti-db str. DNA, anti-Sm, APLA)
11. Positive [serum test]

The last 5 of 11 classification criteria for SLE (Lupus) are:
7. Renal disorder (> 0.5 gm proteinuria or cellular casts)
8. Neurologic disorder (seizures or
psychosis)
9. Hematologic disorder (anemia, leukopenia, lymphopenia,
thrombocytopenia)
10. Immunologic disorder (anti-db str. DNA, anti-Sm, APLA)
11. Positive ANA


360

What is the blood test that is one of the criteria for diagnosing SLE (Lupus)?

ANA (anti-nuclear antibody)

361

How many of the 11 criteria for SLE (Lupus) must be present to include a patient in a clinical study on Lupus?

4

362

If you have a positive ANA and an anti-double stranded DNA antibody test, what is the likelihood that you do not have SLE (Lupus)?  Which of these tests is more specific?

Very low; the double-stranded DNA antibody is more specific but less sensitive

363

What disease does this histological finding prove?  How specific is it?  Why is it not typically done?

This is the LE cell showing SLE (Lupus) with a PMN containing expanded, coagulated nuclear matter; extremely specific; it is labor intensive and not very sensitive

364

What kind of rash is this?  What autoimmune disorder does it form one of the 11 criteria for?

Discoid rash; SLE (Lupus)

365

What is this test, used when ANA is negative but SLE (Lupus) is still suspected?

Skin biopsy for autoimmune complex deposition at the epidermal basement membrane

366

What kind of rash is this?  What is it highly suggestive of?  What notable part of the face is spared?

Malar rash; SLE (lupus); nasolabial fold

367

What scalp related symptom is common for SLE (Lupus) patients?

Allopecia

368

What variant of SLE is this?  Is it more or less concerning than other variants?

Bullous Lupus; more concerning

369

What kind of rash is this?  What autoimmune disorder does it associate with?

Interarticular; SLE (Lupus)

370

What kind of arthritis accompanies SLE (Lupus)?

Non-erosive, soft tissue inflammation

371

How can this nonerosive arthritis be distinguished from rheumatoid?  What is the name of this particular arthropathy?  What autoimmune condition is it significant for?

It can be reduced into normal position with no pain, because it is due to soft tissue inflammation without bony erosion; Jaccoud's; SLE (Lupus)

372

What is Jaccoud's arthropathy?

An ulnar deviation of fingers 2-5 that is a sign of SLE (Lupus)

373

Is synovial fluid from an SLE (Lupus) patient inflammatory?

No

374

What renal symptoms associate with SLE (Lupus)?

Hematuria, proteinuria, cellular casts, possibly nephrotic syndrome

375

What immunofluorescence study that suggests SLE (Lupus) is shown here?

IgG in the glomerulus

376

Are the neuropsychiatric manifestations for SLE (Lupus) specific or broad?

Very broad, many different manifestions are known

377

Hematologic findings for an SLE (Lupus) patient may show:
[...]
– Thrombocytopenia
– Leukopenia

Hematologic findings for an SLE (Lupus) patient may show:
Anemia
– Thrombocytopenia
– Leukopenia


378

Hematologic findings for an SLE (Lupus) patient may show:
– Anemia
[...]
– Leukopenia

Hematologic findings for an SLE (Lupus) patient may show:
– Anemia
Thrombocytopenia
– Leukopenia


379

Hematologic findings for an SLE (Lupus) patient may show:
– Anemia
– Thrombocytopenia
[...]

Hematologic findings for an SLE (Lupus) patient may show:
– Anemia
– Thrombocytopenia
Leukopenia


380

Cardiac findings for an SLE (Lupus) patient may include:
[...]
– Endocarditis
– Myocarditis

Cardiac findings for an SLE (Lupus) patient may include:
Pericarditis
– Endocarditis
– Myocarditis


381

Cardiac findings for an SLE (Lupus) patient may include:
– Pericarditis
[...]
– Myocarditis

Cardiac findings for an SLE (Lupus) patient may include:
– Pericarditis
Endocarditis
– Myocarditis


382

Cardiac findings for an SLE (Lupus) patient may include:
– Pericarditis
– Endocarditis
[...]

Cardiac findings for an SLE (Lupus) patient may include:
– Pericarditis
– Endocarditis
Myocarditis


383

Are embolisms and thrombosis commonly associated with SLE (Lupus)?

Yes, and they are often a cause of death

384

What are the 4 separate diseases that are used as principles of management for SLE (Lupus)?
1. [...]
2. Renal disease
3. Organ or life threatening
4. Anti-phospholipid syndrome (APLS)

What are the 4 separate diseases that are used as principles of management for SLE (Lupus)?
1. Non-renal, non-organ, non-life threatening
2. Renal disease
3. Organ or life threatening
4. Anti-phospholipid syndrome (APLS)


385

What are the 4 separate diseases that are used as principles of management for SLE (Lupus)?
1. Non-renal, non-organ, non-life threatening
2. [...] disease
3. Organ or life threatening
4. Anti-phospholipid syndrome (APLS)

What are the 4 separate diseases that are used as principles of management for SLE (Lupus)?
1. Non-renal, non-organ, non-life threatening
2. Renal disease
3. Organ or life threatening
4. Anti-phospholipid syndrome (APLS)


386

What are the 4 separate diseases that are used as principles of management for SLE (Lupus)?
1. Non-renal, non-organ, non-life threatening
2. Renal disease
3. [...]
4. Anti-phospholipid syndrome (APLS)

What are the 4 separate diseases that are used as principles of management for SLE (Lupus)?
1. Non-renal, non-organ, non-life threatening
2. Renal disease
3. Organ or life threatening
4. Anti-phospholipid syndrome (APLS)


387

What are the 4 separate diseases that are used as principles of management for SLE (Lupus)?
1. Non-renal, non-organ, non-life threatening
2. Renal disease
3. Organ or life threatening
4. [...]

What are the 4 separate diseases that are used as principles of management for SLE (Lupus)?
1. Non-renal, non-organ, non-life threatening
2. Renal disease
3. Organ or life threatening
4. Anti-phospholipid syndrome (APLS)


388

When SLE (Lupus) does not immediately threaten renal function, organ function, or life, how is it treated?

Low dose steroids, antimalarials, NSAIDs, methotrexate

389

When SLE (Lupus) threatens the kidneys, how is it treated?

High dose steroids with rapid taper, immunosuppressive therapy, and BP control (diuretics, etc.)

390

When SLE (Lupus) is organ or life-threatening, how is it treated?

High dose steroids, immunosuppressants, rituximab (experimental)

391

When SLE (Lupus) manifests primarily as an anti-phospholipid syndrome, how is it treated?

High intensity anticoagulants, because there is a significant risk of thrombosis or embolism and sudden death

392

What syndrome does SLE (Lupus) sometimes manifest as, causing a combination of thrombosis, recurrent fetal loss, thrombocytopenia, and livedo reticularis?

Anti-phospholipid syndrome

393

What is livedo reticularis?

A mottled, reticulated purplish vascular pattern on the skin

394

What is this skin finding?  In a patient that presents with this skin, thrombocytopenia, and a positive ANA test, what would you suspect? How would you initiate treatment?

Livedo reticularis; SLE (Lupus) manifesting as anti-phospholipid syndrome; high intensity anticoagulation

395

What is the average age of onset of systemic sclerosis?  Is it as skewed towards women as SLE (Lupus)?

30-50; no, slightly less (4:1)

396

What is the key clinical feature of scleroderma?

Skin tightening

397

What is the key histologic findings here that are consistent with scleroderma?  Are these pictures unique to scleroderma?

Collagen deposition throughout the skin without inflammation; no, this could be found in fibrous scars on normal people, so clinical features are needed

398

Is scleroderma independent of environmental agents?

No, there is an unknown external trigger despite some inheritable susceptibility

399

Scleroderma is associated with this vasospastic disorder, which can cause discoloration of fingers and toes or brittle nails.  This is a microscopy image of the nail bed.  What is it called?

Raynaud's

400

Vinyl chloride, epoxy resins, pentazocine, bleomycin and silicone are all associated with what connective tissue disease?

Scleroderma (systemic sclerosis)

401

What connective tissue disorder is graft vs. host (GVH) disease or persistent fetal cells (microchimerism) associated with?

Scleroderma (systemic sclerosis)

402

A patient presenting with Raynaud's, arthralgias, and skin thickening on the distal fingers should be evaluated for what?

Scleroderma

403

What is this phenomenon?  What connective tissue disorder is it highly suggestive of, assuming the patient doesn't smoke?  What if the patient smokes a lot?

Raynaud's; scleroderma; if the patient is a smoker, consider Buerger's disease (a medium vessel vasculitis)

404

What kind of environment should somebody with Raynaud's avoid?

Cold weather, since it can cause microinfarcts of bones, renal vessels, etc.

405

What disorder of the joints is seen in these hands?

Scleroderma

406

What other underlying condition could help perpetuate this ulcer in a patient with scleroderma?

Diabetes

407

Are patients with scleroderma ANA positive?  What about dsDNA antibody?

ANA positive; dsDNA negative

408

Musculoskeletal features of scleroderma include:
[...] and weight loss
– Arthralgia and arthritis
– Tendon friction rubs
– Myopathy and myositis

Musculoskeletal features of scleroderma include:
Fatigue and weight loss
– Arthralgia and arthritis
– Tendon friction rubs
– Myopathy and myositis


409

Musculoskeletal features of scleroderma include:
– Fatigue and weight loss
[...] and arthritis
– Tendon friction rubs
– Myopathy and myositis

Musculoskeletal features of scleroderma include:
– Fatigue and weight loss
Arthralgia and arthritis
– Tendon friction rubs
– Myopathy and myositis


410

Musculoskeletal features of scleroderma include:
– Fatigue and weight loss
– Arthralgia and arthritis
– Tendon [...]
– Myopathy and myositis

Musculoskeletal features of scleroderma include:
– Fatigue and weight loss
– Arthralgia and arthritis
– Tendon friction rubs
– Myopathy and myositis


411

Musculoskeletal features of scleroderma include:
– Fatigue and weight loss
– Arthralgia and arthritis
– Tendon friction rubs
– Myopathy and [...]

Musculoskeletal features of scleroderma include:
– Fatigue and weight loss
– Arthralgia and arthritis
– Tendon friction rubs
– Myopathy and myositis


412

What upper GI symptoms are associated with scleroderma?

Esophageal dysmotility causing reflux and dysphasia

413

Do patients with scleroderma have small bowel symptoms?

Yes, including bloating, cramps, dysmotility and diarrhea

414

What are these strange abdominal X-ray features (barium contrast was used)?  What systemic connective tissue disorder is implicated by them?

Wide-mouth diverticula; scleroderma

415

What cardiac abnormality is found in 81% of systemic sclerosis patients?

Patchy myocardial fibrosis due to intermittent microvascular ischemia

416

What causes a huge surge in the renin-angiotensin system in scleroderma leading to acute renal failure?

Microangiopathy in the renal vessels, similar to Raynaud's

417

This scleroderma patient died of what renal condition?

Cortical infarcts due to renal microangiopathy, causing scleroderma renal crisis

418

If a patient has considerable symptoms of CNS dysfunction like chorea, headache, and seizures, are they more likely to have SLE (Lupus) or scleroderma?

SLE (scleroderma does not affect the CNS)

419

What is this variant of scleroderma called?  What is the symptom demonstrated on this woman's face?

The CREST variant (Calcinosis, Raynaud's, Esophageal dismotility, Sclerodactyly, Telangectasia) also called limited scleroderma; telangectasia

420

Scleroderma is treated with:
[...]
– ACE inhibitors
– Ca++ channel blockers
– Immunosuppression
– H2 blockers (omeprazole)

Scleroderma is treated with:
D-penicillamine
– ACE inhibitors
– Ca++ channel blockers
– Immunosuppression
– H2 blockers (omeprazole)


421

Scleroderma is treated with:
– D-penicillamine
[...]
– Ca++ channel blockers
– Immunosuppression
– H2 blockers (omeprazole)

Scleroderma is treated with:
– D-penicillamine
ACE inhibitors
– Ca++ channel blockers
– Immunosuppression
– H2 blockers (omeprazole)


422

Scleroderma is treated with:
– D-penicillamine
– ACE inhibitors
– [...] blockers
– Immunosuppression
– H2 blockers (omeprazole)

Scleroderma is treated with:
– D-penicillamine
– ACE inhibitors
– Ca++ channel blockers
– Immunosuppression
– H2 blockers (omeprazole)


423

Scleroderma is treated with:
– D-penicillamine
– ACE inhibitors
– Ca++ channel blockers
[...]
– H2 blockers (omeprazole)

Scleroderma is treated with:
– D-penicillamine
– ACE inhibitors
– Ca++ channel blockers
Immunosuppression
– H2 blockers (omeprazole)


424

Scleroderma is treated with:
– D-penicillamine
– ACE inhibitors
– Ca++ channel blockers
– Immunosuppression
– [...]

Scleroderma is treated with:
– D-penicillamine
– ACE inhibitors
– Ca++ channel blockers
– Immunosuppression
– H2 blockers (omeprazole)


425

Is a SBP over 140 in a scleroderma patient concerning, and if so what do you do?

Yes, it requires prompt treatment with ACE inhibitors

426

There are 5 inflammatory complications of scleroderma.  They are:
[...]
– interstitial pneumonitis
– pericarditis
– myocarditis
– myositis

There are 5 inflammatory complications of scleroderma.  They are:
synovitis
– interstitial pneumonitis
– pericarditis
– myocarditis
– myositis


427

There are 5 inflammatory complications of scleroderma.  They are:
– synovitis
– interstitial [...]
– pericarditis
– myocarditis
– myositis

There are 5 inflammatory complications of scleroderma.  They are:
– synovitis
– interstitial pneumonitis
– pericarditis
– myocarditis
– myositis


428

There are 5 inflammatory complications of scleroderma.  They are:
– synovitis
– interstitial pneumonitis
[...]
– myocarditis
– myositis

There are 5 inflammatory complications of scleroderma.  They are:
– synovitis
– interstitial pneumonitis
pericarditis
– myocarditis
– myositis


429

There are 5 inflammatory complications of scleroderma.  They are:
– synovitis
– interstitial pneumonitis
– pericarditis
[...]
– myositis

There are 5 inflammatory complications of scleroderma.  They are:
– synovitis
– interstitial pneumonitis
– pericarditis
myocarditis
– myositis


430

There are 5 inflammatory complications of scleroderma.  They are:
– synovitis
– interstitial pneumonitis
– pericarditis
– myocarditis
[...]

There are 5 inflammatory complications of scleroderma.  They are:
– synovitis
– interstitial pneumonitis
– pericarditis
– myocarditis
myositis


431

What variant of scleroderma is this?

Morphea

432

What disease is this?  What is it a rare variant of?  What chemical was it associated with in a 1989 epidemic?

Eosinophilic fasciitis; systemic sclerosis; L-tryptophan contaminated with 1,1'-ethylidenebis

433

What poison causes this chloracne, which disfigured a Ukrainian president?

TCDD or dioxin

434

Where are the greater and lesser trochanter of the femur?

435

What nerves do the sciatic split into above the knee?

Tibial and common peroneal

436

What nerve innervates the anterior compartment of the thigh?

Femoral nerve

437

Is range of motion of the hip governed by the bony socket, or the muscles and ligaments surrounding it?

The muscles and ligaments, since the ball and socket provide for a far greater range of motion without such constraints

438

Label the following bursae of the hip:

Top–trochanteric, bottom–ischial

439

Diseases of the hip can be classified using four main criteria:
[...]
– Traumatic?
– Vascular?
– Degenerative?

Diseases of the hip can be classified using four main criteria:
Pediatric vs. adult
– Traumatic?
– Vascular?
– Degenerative?


440

Diseases of the hip can be classified using four main criteria:
– Pediatric vs. adult
[...]?
– Vascular?
– Degenerative?

Diseases of the hip can be classified using four main criteria:
– Pediatric vs. adult
Traumatic?
– Vascular?
– Degenerative?


441

Diseases of the hip can be classified using four main criteria:
– Pediatric vs. adult
– Traumatic?
[...]?
– Degenerative?

Diseases of the hip can be classified using four main criteria:
– Pediatric vs. adult
– Traumatic?
Vascular?
– Degenerative?


442

Diseases of the hip can be classified using four main criteria:
– Pediatric vs. adult
– Traumatic?
– Vascular?
[...]?

Diseases of the hip can be classified using four main criteria:
– Pediatric vs. adult
– Traumatic?
– Vascular?
Degenerative?


443

What are some non-orthopedic causes of hip pain?

Hernia, testicular, referred from the spine, gynecological

444

Are all leg length discrepancies due to one leg being anatomically longer than the other?

No, functional discrepancies result from lateral pelvic tilt, flexion, etc.

445

Is this a child or adult?

Child, notice open growth plates

446

In general, is a CT or an MRI more useful for hip problems?

MRI, since the soft tissue detail is good for picking out common diagnoses like osteonecrosis

447

What muscle attaches to the lesser trochanter of the femur?

The iliopsoas, the major flexor of the hip

448

What is this cavity in this hip?

It is gas in the colon

449

What hip abnormality is seen in this child?

Perthes, where there is avascular necrosis of the femoral head

450

A tall boy, age 12, comes in with pain in the groin and hip and knee pain during motion.  The following X-ray is taken.  What condition is this?

Slipped capital femoral epiphyses or SCFE

451

A child comes in with problems walking; his family has not has access to medical care since before he was born.  The X-ray reveals the following.  What is this called?

Developmental dysplasia: a congenital issue where the femur heads grow outside of the sockets

452

What is the typical patient that has a femur neck or intertrochanteric fracture?

Elderly patients with osteoporosis that fell

453

How is a intertrochanteric fracture treated in an elderly patient that fell?

Surgery is necessary

454

What is the top priority for surgical treatment of a intratrochanteric fracture?

Get the patient walking as soon as possible, since it aids in the healing process

455

What kind of fracture to the femur happened in this patient?

Intertrochanteric

456

What is the major differentiator between femoral neck fractures that will heal and those that likely will not without hip replacement?

Whether the femoral neck was displaced, in which case hip replacement is recommended

457

What kind of fracture was fixed here?

Femoral neck

458

What is the etiology of osteonecrosis of the hip?

Temporary or permanent loss of blood supply to the femoral head

459

What are the signs and symptoms of osteonecrosis (also called avascular necrosis) of the hip?

Joint pain with weight bearing, limited range of motion, osteoarthritis

460

How is avascular necrosis treated surgically?

Channels are drilled into the bone to promote vascular regrowth

461

What is the gold standard for diagnosis of avascular necrosis of the hip?

MRI

462

When the pain in a hip is related to arthritis of the join as opposed to the sciatic nerve, is it most likely to be described as radiating down the posterior or anterior thigh?

Anterior

463

What kind of arthritis of the hip is this?

Osteoarthritis, because the joint space is narrow.  Subchondral sclerosis produces higher density at the margin, with cysts where the synovial fluid has invaded the head of the femur

464

What is the recommended treatment for arthritis of the hip when lifestyle modification is impossible and pain is significant?

Hip replacement