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Flashcards in MSK Deck 2 Deck (390):
1

In metabolic bone disease, will only some bones in the body be affected?

No, all will be affected, but to varying degrees of severity

2

What are the four most common molecular etioligies for metabolic bone disease?

Calcium metabolism, phosphate metabolism, vitamin D, and PTH 

3

What is this condition, characterized by the deposition of unmineralized osteoid around mineralized bone?

Osteomalacia or rickets

4

Does metabolic bone disease generally affect trabecular or compact bone first?

Trabecular

5

Why might osteoporosis be localized to one limb?

If the limb was immobilized, e.g. due to casting

6

What are the two types of primary osteoporosis?

Postmenopausal (type 1) and senile (type 2).

7

Does increased or decreased estrogen cause osteoporosis?  Hyper- or hypo-parathyroidism?

Decreased estrogen; hyperparathyroidism

8

What class of drugs can cause secondary osteoporosis?

Anticonvulsants

9

What is the average rate of age-related bone loss?

0.7% per year

10

Is postmenopausal osteoporosis a high turnover or low turnover form of osteoporosis?  What about senile osteoporosis?

Postmenopausal – high turnover; senile – low turnover

11

Why does decreased estrogen cause osteoporosis after menopause?

Marrow stromal cells produce cytokines in the absence of estrogen, and the cytokines recruit osteoclasts

12

In general, do blacks or caucasians have higher bone density?

Blacks

13

Can osteoporosis be reliably visualized on an X-ray?

No, because bone loss is not apparent on X-ray until up to 40% of the mass is gone

14

What is the definitive diagnostic procedure for osteoporosis following X-Ray, CT, or MRI?

Bone densitometry (DEXA)

15

Are blood levels of Ca++ or phosphates diagnostic for osteoporosis?

No

16

What is the most common type of fracture presenting with osteoporosis in women, occuring 8 times more frequently than in men?

Vertebral fractures

17

What is notable about this bone specimen?

The cortex is very thin and the interior is fatty, suggesting metabolic bone disorder, e.g. osteoporosis

18

What is the treatment for osteoporosis?

Bisphosphonates and calcitonin

19

Upon absorption from the intestine or creation from cholesterol via heat and UVB rays in the skin, vitamin D requires hydroxylation in which two organs?

Liver and kidney

20

What is the cause of rickets or osteomalacia?

A lack of vitamin D or disturbance of its metabolism

21

What is the difference between rickets and osteomalacia?

Rickets is osteomalacia in children, which results in overgrowth of epiphyseal cartilage and deformaties, while osteomalacia in adults results in weak bones and fractures.

22

What skin-related conditions might lead to rickets or osteomalacia?

Inadequate exposure to sunlight or dark skin pigmentation

23

What GI conditions can prevent absorption of vitamin D in the intestine?  What is the manifestation of this problem?

Cholestatic liver disease, pancreatic insufficiency, biliary tract obstruction, and small bowel disease; rickets or osteomalacia

24

What is the overall effect of vitamin D release in its double hydroxylated form from the kidney on serum concentrations?

Calcium and phosphate levels go up due to resorption from bones and increased absorption from the intestine

25

What produces phosphatonins at levels which can cause osteomalacia?

Bone and soft-tissue low-grade tumors

26

What do we see in this child's arms?

Prominence above the wrist due to flaring and poor mineralization, caused by rickets (vitamin D deficiency or metabolic defect)

27

Why do children show widening above the wrist during rickets?

The metaphysis of the radius and ulna flare as the growth plate widens and mineralization slows

28

What is the vitamin deficiency causing this?  What is it called?

Vitamin D deficiency, or rickets; this is the rachitic rosary

29

Do children with rickets have more or less cartilage at the growth plates of their long bones and costochondral junctions?

More

30

Does osteomalacia in adults cause deformities as seen with rickets?

No, but the bones are weaker and vulnerable to fractures

31

What is notable about the newly formed osteoid matrix in patients with osteomalacia?

It is inadequately mineralized

32

What disease is clearly visualized in this H&E section of bone?

Osteomalacia

33

What are these lines in an osteomalacia patient called?

Lucent lines representing pseudofractures

34

What mediators are used by osteoblasts to stimulate osteoclastic activity?  What hormone upregulates this pathway?

RANK-L; PTH

35

When histological studies show osteoclastic resorption of bones, tunneling and dissecting through trabeculae (dissecting osteitis), what hormonal imbalance may be suspected?

Hyperparathyroidism

36

Are these normal parathyroid glands?

No, there is hyperplasia in some of the glands

37

What is notable about this section of cortical bone?  What endocrine disorder may cause this?

Osteoclastic tunneling; hyperparathyroidism

38

What is this? Why do these associate with hyperparathyroidism?

A brown tumor, a bening lesion that develops in bone; overstimulation of osteoclastic activity by PTH leads to reactive changes and hemorrhage that the bone cannot handle

39

If the parathyroid glands are not overgrown (primary hyperparathyroidism), how could hyperparathyroidism still manifest secondarily?

Bone disease or chronic kidney disease that leads to low Ca++ levels

40

What is it called when renal failure leads to osteomalacia and hyperparathyroidism?  What serum ions are imbalanced in this situation?

Renal osteodystrophy; phosphate retention and low serum Ca++

41

What features of osteomalacia secondary to renal osteodystrophy are seen here?

From left to right, brown tumor, pseudofractures, and end plate sclerosis

42

What is Paget's disease—the one also called osteitis deformans? Are there other diseases named after Paget?

It is characterized by marked proliferation of bone cells with abnormal remodeling; yes, there are conditions of the breast and urogenital region that also use this name

43

What bone disease causes these facial deformities?

Paget's disease, or osteitis deformans

44

What disease is suggested by these radiological features?

Osteitis deformans (Paget's disease)

45

What disease is this histological pattern in adult bone most characteristic of?

The mosaic pattern of Paget's disease (osteitis deformans)

46

How is Paget's disease (osteitis deformans) treated?

Bisphosphonates and calcitonin

47

What is the most serious complication of Paget's disease (osteitis deformans)?

Sarcoma

48

How long have patients who present with vasculitis complain of being sick?

Usually months, with some kind of fever

49

In which size of vessels affected by vasculitis is there skin involvement?  Which sizes will cause marked internal organ involvement?

Small to medium vessel vasculitis: skin involvement; medium to large vessel vasculitis: internal organ involvement

50

What kind of vasculitis is represented by these lesions?  Describe them.

Small vessel vasculitis; palpable purpura with itching or stinging

51

How does this histological preparation of a skin lesion demonstrate vasculitis?

The inflammation is centered around the small vessels

52

In a small vessel vasculitis, where do the skin lesions appear?

Primarily on the lower extremities

53

What bacterial infections can cause small vessel vasculitis?

Meningococcemia, gonococcemia, endocarditis, Rocky Mountain spotted fever

54

What is a frequent iatrogenic cause of hypersensitivity small vessel vasculitis?  How long does it take to appear after exposure?

Drugs like penicillin which the patient is sensitive to; 1-2 weeks

55

How does hypersensitivity vasculitis manifest?

Maculopapular or palpable purpuric rash

56

What common viral infection is known to cause a vasculitis with dependent palpable purpura and some peripheral neuropathy?

Hepatitis C

57

What is the age group of Henoch-Schönlein purpura patients?  What is the common clinical presentation?

Peds; Fever with purpura on the skin, arthralgia, and GI pain

58

In Turkey, there is a variant of vasculitis that presents with the following ulcers.  What is the syndrome called?  What are the ulcers called?  Where else do the ulcers appear?

Behçet's syndrome; aphthous stomatitis or canker sores; genitals

59

Should normal periosteum ever be visible on X-ray?

No

60

A child presents with chronic pain in one extremity that increases at night but resolves with NSAID use.  X-ray followed by histological study finds a small (<1.5cm) yellowish to red nidus of osteoid and woven bone with interconnected trabeculae.  What does this patient have?  Is it malignant?

Osteoid osteoma; no, but if pain worsens surgical ablation may be considered

61

The two most common kinds of bone tumors, both benign, are seen below–what are they?

Left: osteochondroma; right: enchondroma

62

What condition characterized by episodic cartilaginous inflammation of both auricles, nasal cartilage polychondritis, and non-erosive polyarthritis sometimes associates with SLE (Lupus)?

Relapsing polychondritis

63

What is relapsing polychondritis caused by?

Antibodies for type II collagen

64

How can you treat small vessel vasculitis?

Eradicate the antigen, NSAIDs, steroids, and immunosuppression

65

What kind of viral infections are liable to cause medium vessel vasculitis?

HIV, Hep B, and Hep C

66

Four ANCA associated causes of medium vessel vasculitis are:
•  [...] Nodosa
•  Microscopic Polyangiitis
•  Granulomatous Polyangiitis (formerly Wegener’s)
•  Churg-Strauss Vasculitis

Four ANCA associated causes of medium vessel vasculitis are:
•  Polyarteritis Nodosa
•  Microscopic Polyangiitis
•  Granulomatous Polyangiitis (formerly Wegener’s)
•  Churg-Strauss Vasculitis


67

Four ANCA associated causes of medium vessel vasculitis are:
•  Polyarteritis Nodosa
•  [...] Polyangiitis
•  Granulomatous Polyangiitis (formerly Wegener’s)
•  Churg-Strauss Vasculitis

Four ANCA associated causes of medium vessel vasculitis are:
•  Polyarteritis Nodosa
•  Microscopic Polyangiitis
•  Granulomatous Polyangiitis (formerly Wegener’s)
•  Churg-Strauss Vasculitis


68

Four ANCA associated causes of medium vessel vasculitis are:
•  Polyarteritis Nodosa
•  Microscopic Polyangiitis
•  [...] Polyangiitis (formerly Wegener’s)
•  Churg-Strauss Vasculitis

Four ANCA associated causes of medium vessel vasculitis are:
•  Polyarteritis Nodosa
•  Microscopic Polyangiitis
•  Granulomatous Polyangiitis (formerly Wegener’s)
•  Churg-Strauss Vasculitis


69

Four ANCA associated causes of medium vessel vasculitis are:
•  Polyarteritis Nodosa
•  Microscopic Polyangiitis
•  Granulomatous Polyangiitis (formerly Wegener’s)
•  [...] Vasculitis

Four ANCA associated causes of medium vessel vasculitis are:
•  Polyarteritis Nodosa
•  Microscopic Polyangiitis
•  Granulomatous Polyangiitis (formerly Wegener’s)
•  Churg-Strauss Vasculitis


70

What is another name for Thromboangiitis Obliterans?

Buerger's disease

71

Are there systemic or visceral features of Buerger's disease?  If so, what are they?

No

72

What social history is a significant cause of Buerger's disease?

Smoking history

73

What cell type infiltrates the vessel wall with thrombosis in Buerger's disease?

Polymorphonuclear neutrophils

74

What is the most important component of treatment for Buerger's disease?

Smoking cessation

75

What kind of vasculitis is caused by microscopic polyangiitis and granulomatous polyangiitis?

A medium vessel, systemic necrotizing vasculitis

76

What does ANCA stand for?  What type of inflammatory disease does it help classify?

Anti-neutrophil cytoplasmic antibody; medium vessel vasculitis

77

Do ANCA associated causes of medium vessel vasculitis usually involve infection?

No

78

What is the postulated mechanism of immune complex mediated vasculitis?

Circulating immune complexes deposit in the vessel wall, increase permeability, and activate complement, which causes PMN's to move in and destroy the vessel wall

79

Where do focal lesions concentrate in polyarteritis nodosa?  Is there pulmonary vessel involvement?

Bifurcations of arteries; No

80

Is polyarteritis nodosa granulomatous?

No

81

Wrist drop or foot drop in the absence of trauma is a sign of what, until proven otherwise?

Medium vessel vasculitis

82

These pathological specimens are diagnostic of what condition?

Polyarteritis nodosa, due to the thrombus and asymmetric inflammatory infiltrate and/or fibrosis in a medium vessel

83

Could this angiographic study of mesenteric vessels differentiate between polyarteritis nodosa, granulomatous polyangiitis and Churg-Strauss vasculitis?

No

84

How is polyarteritis treated?

Steroids and immunosuppressants (cyclophosphamide)

85

Children's polyarteritis nodosa is also known by what name?  How is it treated?

Kawasaki's disease; IVIG

86

What differentiates microscopic polyangiitis from polyarteritis nodosa (PAN)?

In microscopic polyangiitis, there may be vasculitis in the pulmonary small vessels, which are spared in PAN

87

Are microscopic angiitis and polyarteritis nodosa granulomatous?

No

88

What organ system involvement distinguishes granulomatous vasculitis from polyarteritis nodosa?

Pulmonary and upper respiratory tract involvement points toward granulomatous vasculitis

89

What parts of the body show symptoms most frequently in Wegener's granulomatosis?

Head and neck (sinusitis, otitis, saddle nose), with pulmonary complaints (SOB, hemoptysis, cough)

90

What two medium vessel vasculitis syndromes associate with the "saddle nose" deformity?

Granulomatous polyangiitis and Churg-Strauss

91

What kind of biopsy is necessary to generate this sample which is diagnostic of granulomatous polyangiitis?

Open lung biopsy

92

What is another name for granulomatous polyangiitis?

Wegener's granulomatosis

93

What autoantibodies were noticed to be associated with necrotizing vascular inflammation, such as polyarteritis nodosa and Wegener's (granulomatous angiitis)?

ANCA (antineutrophil cytoplasmic autoantibodies)

94

Since medium vessel vascultis is ultimately diagnosed by tissue biopsy, what is the point of doing a test for ANCA?

It can narrow down the diagnosis in a critically ill patient, e.g. an infant with renal failure in the NICU with positive ANCA likely has some kind of necrotizing vasculitis

95

What major symptoms distinguish Churg-Strauss from Wegener's granulomatosis (granulomatous angiitis)?

Same manifestation but also with asthma, long history of allergy, and eosinophilia

96

How are Churg-Strauss and Wegener's granulomatosis treated?

Steroids and immunosuppressants

97

What new drug has changed the paradigm for treatment of granulomatous angiitis and microscopic angiitis?

Rituximab

98

Why is it counterintuitive that Rituximab has an effect on necrotizing vasculitis?

Rituximab is directed at CD20 and thereby wipes out B cells, but vasculitis typically involves neutrophils and T cells

99

What are the two forms of large vessel vasculitis?

Takayasu's and Giant Cell Arteritis

100

What is the easiest differentiator between Takayasu's and Giant Cell Arteritis?  Which is more difficult to treat?

Patients' age: if age is >50, giant cell arteritis; Takayasu's is much more difficult to treat

101

What is the chronic phase of Takayasu's characterized by?

Ischemia

102

Which are the top three vessels that are most commonly involved in Takayasu's?

Subclavian, descending aorta, renal

103

What is the method of diagnosing Takyasu's?

Angiogram, since biopsy is usually too difficult

104

How is Takayasu's treated?

Steroids and immunosuppressants (cyclophosphamide or methotrexate)

105

Where does giant cell arteritis localize?  How does it present?

Temporal artery; New headache in temporal region, sometimes with palpable temporal artery

106

How is giant cell arteritis diagnosed?  Is this an risky procedure?

Positive biopsy; no, it is benign since we do not need our temporal artery (plenty of collateral supply)

107

Can temporal arteritis present without a headache?  In this case, what is the usual complaint?

Yes; fever of unknown origin

108

What is this an obvious sign of?  Does it typically present this grossly?

Temporal (giant cell) arteritis; rarely

109

This biopsy of a temporal artery is diagnostic of what disease?

Temporal (giant cell) arteritis because of intimal thickening, necrosis and disruption of the internal elastic lamina

110

How is giant cell arteritis treated?  Would you proceed with it if the biopsy turns out to be negative?

High dose steroids; No, although you may start steroids before the biopsy comes back, because eyesight can be lost

111

Vasculitis must be distinguished from the following mimics on a differential:
[...] syndrome
– Scleroderma
– Coumadin necrosis
– Scurvy

Vasculitis must be distinguished from the following mimics on a differential:
Antiphospholipid syndrome
– Scleroderma
– Coumadin necrosis
– Scurvy


112

Vasculitis must be distinguished from the following mimics on a differential:
– Antiphospholipid syndrome
[...]
– Coumadin necrosis
– Scurvy

Vasculitis must be distinguished from the following mimics on a differential:
– Antiphospholipid syndrome
Scleroderma
– Coumadin necrosis
– Scurvy


113

Vasculitis must be distinguished from the following mimics on a differential:
– Antiphospholipid syndrome
– Scleroderma
[...] necrosis
– Scurvy

Vasculitis must be distinguished from the following mimics on a differential:
– Antiphospholipid syndrome
– Scleroderma
Coumadin necrosis
– Scurvy


114

Vasculitis must be distinguished from the following mimics on a differential:
– Antiphospholipid syndrome
– Scleroderma
– Coumadin necrosis
[...]

Vasculitis must be distinguished from the following mimics on a differential:
– Antiphospholipid syndrome
– Scleroderma
– Coumadin necrosis
Scurvy


115

Scurvy causes collagen breakdown, which can create a purpuric rash reminiscent of what inflammatory condition?

Small vessel vasculitis

116

How many degrees of freedom does the knee have?

6: 3 translational and 3 rotational.  Obviously the flexion and extension is the "normal" degree of freedom, but the others are also significant particularly once ligaments are injured.

117

What is varus/valgus rotation of the knee?

Valgus means pointing the tibia/fibia outward (duck feet), except when this happens at the knee joint instead of the hip joint (varus is the opposite)

118

The ACL restrains the following movements, each of which can be the cause of an ACL injury:
[...]
– Internal rotation
– Varus and valgus angulation
– Hyperextension

The ACL restrains the following movements, each of which can be the cause of an ACL injury:
Anterior translation
– Internal rotation
– Varus and valgus angulation
– Hyperextension


119

The ACL restrains the following movements, each of which can be the cause of an ACL injury:
– Anterior translation
[...]
– Varus and valgus angulation
– Hyperextension

The ACL restrains the following movements, each of which can be the cause of an ACL injury:
– Anterior translation
Internal rotation
– Varus and valgus angulation
– Hyperextension


120

The ACL restrains the following movements, each of which can be the cause of an ACL injury:
– Anterior translation
– Internal rotation
[...] angulation
– Hyperextension

The ACL restrains the following movements, each of which can be the cause of an ACL injury:
– Anterior translation
– Internal rotation
Varus and valgus angulation
– Hyperextension


121

The ACL restrains the following movements, each of which can be the cause of an ACL injury:
– Anterior translation
– Internal rotation
– Varus and valgus angulation
[...]

The ACL restrains the following movements, each of which can be the cause of an ACL injury:
– Anterior translation
– Internal rotation
– Varus and valgus angulation
Hyperextension


122

What is the typical history for an ACL tear?

A pop or crack, pain and immediate swelling of the knee followed by instability

123

What other common injuries associate with an ACL tear?

Meniscal damage, chondral injuries, and MCL/PCL/LCL

124

Is the MRI useful for diagnosing possible ACL damage?

Yes, it can visualize the ligaments and the meniscus

125

Does the ACL always heal without surgery?  What about the MCL?

No, probably due to the synovial environment; the MCL does heal since it is outside the joint

126

Can the ACL be sewn together?  What is the typical surgery process?

There is low success rate with this; it is reconstructed through autograft or allograft

127

What are the two most common complications of ACL surgical repair?  What is their collective incidence?

Stiffness and the graft not healing correctly; 2%

128

What are two options for treating a diagnosed ACL injury?

Rehabilitation with modified patient activity and surgery

129

How long is rehab for an ACL surgery?

4-6 months

130

What bone does the talus attach to inferiorly within the ankle?

Calcaneus

131

Are these two little bumps on the first metatarsal normal?  What are they?

Yes; sesamoid bones (bones inside tendons)

132

What are the sensory innervations for these three areas of the anterior (dorsal) foot?

Top to bottom, sural, saphenous, and superficial peroneal

133

What nerve provides sensory innervation to the part of the foot stimulated in the Babinski test?

Lateral plantar branch of the the medial plantar nerve (from the tibial nerve)

134

Between toe fractures or metatarsal injuries, which are more likely to require surgery?

Metatarsals (they are often crush injuries of multiple bones)

135

Are the toe bones hollow?  What are the implications on surgical reduction?

Yes; a pin can be put in the medullary space

136

What kind of fracture is this?  Why might it not heal?

Jones fracture; poor blood supply to this region

137

What is a Lisfranc fracture?

A tarsometatarsal joint dislocation

138

What is the treatment for this kind of fracture?

Open reduction internal fixation (surgery)

139

What classification system is used for talus fractures?  For calcaneus fractures?

Talus–Hawkins; Calcaneus–Sanders

140

What bone is fractured in this CT?

The head of the talus, also causing a dislocation of the subtalar joint

141

Tearing of what ligament has allowed the tibia to shift medially in this fibular fracture?

Deltoid (or talocrural) ligament

142

What condition along with its associated neuropathy can cause progressive deterioration of the ankle joint, including fractures?

Diabetes

143

What are the two most common crystals found in synovial fluid that cause synovitis?

Monosodium urate (gout) and calcium pyrophosphate/dihydrate (pseudogout)

144

Is gout predisposition inheritable?  Does it occur more in men or women?

Yes; men

145

What serum abnormality precedes acute gout?

Asymptomatic hyperuricemia

146

In familial gout, what enzyme deficiency is likely?

HGPRT or G6PD

147

What social history is relevant to a diagnosis of gout?

Alcohol consumption, which can cause overproduction and underexcretion of uric acid

148

Is it more common for hyperuricemia to be caused by overproduction or underexcretion of uric acid?

Underexcretion (90%)

149

What drugs can cause underexcretion of uric acid?

Diuretics, low dose aspirin, heparin, cyclosporine

150

Which endocrine disorder can lead to hyperuricemia and gout?

Hypothyroidism

151

Are first attacks of gouts usually monarticular or polyarticular?  Which joint(s) are affected?

Monarticular; 1st MTP (podagra, big toe), dorsum of foot, ankle, knee

152

What time of day does gout usually start?

Night

153

What happens without treatment of acute gout or pseudogout?

It resolves by itself over ~1 week

154

What variant of gout is seen here?

Podagra: 1st MTP

155

What organ system insufficiency exacerbated by obesity contributes the most to development of gout?

Renal insufficiency

156

Is synovial fluid from gout inflammatory?  Are there increased WBCs?

Yes; yes, >5k up to 100k

157

What is this slide of synovial fluid diagnostic of?  Does it matter that the spikes are inside a cell?

Gout; yes, the uric acid crystals must be inside a neutrophil, because there are normally some free floating crystals in synovial fluid

158

With what drugs is acute gout treated?

NSAIDs, colchicine, and intra-articular or systemic steroids

159

Is uric acid lowering therapy indicated for acute monarticular gout?  Why or why not?

No, it is contraindicated–you only try it after recurrent attacks despite colchicine prophylaxis; trying to lower uric acid with drugs causes a large flux across plasma membranes, which can cause crystal formation in other joints

160

What prophylaxis can be used to treat intercritical gout?

Colchicine

161

What dietary modification may be suggested for somebody with intercritical gout?

Foods like red meat, seafood, or beans that are high in uric acid should be avoided, but most particularly alcohol

162

These small skin features are associated with what synovial disease?

Gout (these are small subcutaneous crystals of uric acid)

163

This is an extreme example of what joint disease?  The lesion has crystalline substance leaking from it.

Gout

164

What is the difference in function between a uricosuric agent and xanthine oxidase inhibitor?

Uricosuric agents increase excretion of uric acid, while xanthine oxidase inhibitors decrease production of uric acid

165

Would a gout patient who is an underexcreter receive a xanthine oxidase inhibitor or a uricosuric agent?

Uricosuric agent

166

Of the following, label which are uricosurics and which are xanthine oxidase inhibitors (XOI):
– Allopurinol
– Probenecid
– Oxypurinol
– Febuxostat

– Allopurinol: XOI
– Probenecid: uricosuric
– Oxypurinol: XOI
– Febuxostat: XOI

167

Does pseudogout usually present as a monarticular or polyarticular disease?  Is the first MTP a typical place for it?

Monarticular; no

168

What are the top four joints that pseudogout will present in?

Knee, ankle, hip, shoulder blade

169

Is synovial fluid in pseudogout inflammatory?  Is it typically higher or lower in WBCs than gout?

Yes; lower, around 20-40k

170

What crystalline substance is found intracellularly in synovial fluid for a pseudogout patient?

Calcium pyrophosphate

171

What is the clue on this X-ray that the patient might have pseudogout?  Is this clue specific for pseudogout in an older patient?

The thin line of calcification of cartilage along the joint margin (chondrocalcinosis); no, many older patients have it

172

What form of arthritis is a risk factor for pseudogout?

Osteoarthritis

173

What endocrine disorders associate with pseudogout?

Hyperparathyroidism and hypothyroidism

174

A young person with pseudogout may have one of three likely metabolic risk factors:
[...]'s disease
– Hemochromatosis
– Ochronosis

A young person with pseudogout may have one of three likely metabolic risk factors:
Wilson's disease
– Hemochromatosis
– Ochronosis


175

A young person with pseudogout may have one of three likely metabolic risk factors:
– Wilson's disease
[...]
– Ochronosis

A young person with pseudogout may have one of three likely metabolic risk factors:
– Wilson's disease
Hemochromatosis
– Ochronosis


176

A young person with pseudogout may have one of three likely metabolic risk factors:
– Wilson's disease
– Hemochromatosis
[...]

A young person with pseudogout may have one of three likely metabolic risk factors:
– Wilson's disease
– Hemochromatosis
Ochronosis


177

How is pseudogout treated?

NSAIDs, colchicine, and intra-articular steroids

178

This X-ray is from an elderly patient with localized tendonitis, with acute shoulder pain.  What happened?  What differentiates it from Milwaukee shoulder?

Calcific tendinitis: note the calcium hydroxyapatite deposition above the head of the humerus; it is in the tendon within the bursa, not the joint capsule

179

What is the typical gender and age for Milwaukee shoulder?  What arm is usually affected?

Elderly women; dominant arm

180

How is Milwaukee shoulder treated?

NSAIDs, colchicine, aspiration, intra-articular steroids

181

What is the name for crystal synovitis involving calcium hydroxyapatite deposition in the glenohumeral joint?  What muscles can be torn in association with it?

Milwaukee shoulder; rotator cuff

182

What are the three layers of connective tissue within a muscle, from outermost to innermost?  Which one surrounds individual fibers?

Epimysium, perimysium, endomysium; endomysium surrounds fibers

183

What is this circular structure within a ped patient's muscle?  Is it normal?

A muscle spindle (not a vessel! it contains muscle fibers and growing nerves); yes

184

How many types of myofibers are there?  Which one is "fast twitch"?   Which one has more fat?

Two types; fast twitch is type 2 (white); more fat is type 1 (red)

185

What are the two different kinds of fibers stained in this section of muscle?

Type 1 and type 2, which differentiates slow and fast twitch

186

Which type of muscle fiber has more mitochondria?

Type 1 (slow twitch)

187

What is one "motor unit"?

An anterior horn motor neuron, its axon, and the muscle fibers it innervates

188

What neurotransmitter receptor is highly concentrated in these invaginations of the cell membrane?  What enzyme is also there to prevent overstimulation?

ACh receptor; acetylcholinesterase

189

What construct is used by the muscle to produce a coordinated Ca++ efflux from the sarcoplasmic reticulum  in response to a propagated action potential?

T-tubules

190

Are neurogenic or myopathic causes of muscle disorders more common?

Neurogenic

191

What has happened to some of the myofibers in this muscle?

They have atrophied, becoming angular and shrunken

192

Why might a group of myofibers fail to show a typical even distribution between Type 1 and Type 2 fibers?

If one type of motor neuron dies and its cells become detached and atrophy, they send signals to regain collateral innervation from the other type

193

Will an ALS patient show fiber type grouping on histological study of atrophic muscles?

Yes

194

Do you get neurogenic atrophy with a stroke?  Why does atrophy occur on the side of the body contralateral side to the stroke?

No, because it is the UMN that is affected and not the LMN; atrophy occurs because of disuse

195

Does disuse atrophy preferentially affect type 1 or type 2 myofibers?

Usually, type 2

196

Do myopathies tend to be proximal or distal?  What about neuropathies?

Myopathies – proximal (left);
Neuropathies – distal (right, stocking/glove)

197

What is the inheritance pattern of Duchenne's muscular dystrophy?

X-linked recessive

198

When does Duchenne's present?

5 years old

199

Is a diagnosis of muscular dystrophy supported by a positive Gowen's sign?  What is Gowen's sign?

Yes; walking the body into an upright position with the arms and hands

200

What X-linked recessive condition is associated with the following presentation in a 5 year old?

Duchenne's muscular dystrophy

201

What gene is affected by Duchenne's muscular dystrophy?  Where is the gene within the genome?  Is it a large or small gene?

Dystrophin; small arm of X chromosome; very large

202

This mother was stained for the dystrophin protein and the following pattern results.  What is her likelihood for each of her sons in developing Duchenne's?

50%, since the mom is clearly a carrier (mosaic pattern), and the disease is X-linked recessive

203

Collectively, muscular dystrophies are diseases of what molecular complex?  What does it connect?

The dystrophin-glycoprotein complex; the basal lamina, sarcolemma, and F-actin

204

What is the difference between Becker's and Duchenne's muscular dystrophies?

The same gene (dystrophin) is involved, but the mutation causes a less severe phenotype

205

What is the most common dystrophy that presents in adults?

Myotonic dystrophy

206

What is the genetic basis for myotonic dystrophy?  What neurodegenerative disease is caused by a similar kind of mutation?

A mutation in the myotonin kinase gene, specifically an expansion of a trinucleotide repeat; Huntington's

207

Does the number of repeats in myotonin kinase correlate proportionally or inversely with the age of onset of myotonic dystrophy?

Inversely

208

What type of myofiber is preferentially affected by a congenital myopathy?  How does the patient present?

Type 1 myofiber; "floppy baby"

209

Malignant hyperthermia results from a mutation in what gene?  What tissue type causes the release of heat in this disease?

Ryanodine receptor; muscle fibers continuously burning energy and contracting

210

What is a "ragged red" segment of muscle?

An area where abnormal mitochondria have undergone extreme proliferation due to some abnormality in the mtDNA, and may be visible with red mitochondrial stains or with strange crystal inclusions under EM

211

What is an intrinsic inflammation of many skeletal muscles called?

Polymyositis

212

What is happening to this muscle fiber?  If this is happening throughout normal muscles in the body, what condition is this?

It is being invaded by immune cells, and will eventually become necrotic; polymyositis

213

What is the clinical opposite of myasthenia gravis, whereby the strength of an NMJ increases with repetitive stimulation?  What cancer does that disease associate with?

Eaton-Lambert, a disease of the presynaptic axon terminal; small cell lung carcinoma

214

What is the most often cause of cancer affecting the bone?

Metastatic bone disease

215

What are the two most common sources of cancer cells that metastasize to bone?

Prostate and breast

216

Bone metastases in children include:
•  [...]
•  Wilm’s tumor
•  Osteosarcoma
•  Ewing’s sarcoma
•  Rhabdomyosarcoma

Bone metastases in children include:
•  Neuroblastoma
•  Wilm’s tumor
•  Osteosarcoma
•  Ewing’s sarcoma
•  Rhabdomyosarcoma


217

Bone metastases in children include:
•  Neuroblastoma
•  [...]’s tumor
•  Osteosarcoma
•  Ewing’s sarcoma
•  Rhabdomyosarcoma

Bone metastases in children include:
•  Neuroblastoma
•  Wilm’s tumor
•  Osteosarcoma
•  Ewing’s sarcoma
•  Rhabdomyosarcoma


218

Bone metastases in children include:
•  Neuroblastoma
•  Wilm’s tumor
•  Osteosarcoma
•  [...]’s sarcoma
•  Rhabdomyosarcoma

Bone metastases in children include:
•  Neuroblastoma
•  Wilm’s tumor
•  Osteosarcoma
•  Ewing’s sarcoma
•  Rhabdomyosarcoma


219

Bone metastases in children include:
•  Neuroblastoma
•  Wilm’s tumor
•  [...]
•  Ewing’s sarcoma
•  Rhabdomyosarcoma

Bone metastases in children include:
•  Neuroblastoma
•  Wilm’s tumor
•  Osteosarcoma
•  Ewing’s sarcoma
•  Rhabdomyosarcoma


220

Bone metastases in children include:
•  Neuroblastoma
•  Wilm’s tumor
•  Osteosarcoma
•  Ewing’s sarcoma
•  [...]

Bone metastases in children include:
•  Neuroblastoma
•  Wilm’s tumor
•  Osteosarcoma
•  Ewing’s sarcoma
•  Rhabdomyosarcoma


221

What are the two most common primary malignant bone tumors?

Osteosarcoma and chondrosarcoma

222

Are osteoid osteomas and osteoblastomas benign or malignant?

Benign

223

Are osteosarcomas benign or malignant?

Malignant

224

Why are osteoid osteomas painful?  Why is this relieved by NSAIDs like ASA?

Prostaglandin E2 is secreted by proliferating osteoblasts; ASA inhibits prostaglandin production

225

What part of the bone are osteoid osteomas found in?

Diaphysis, cortical bone

226

What differentiates osteoid osteomas from osteoblastomas on histological examination?

They are similar in that the structure is disrupted within cortical bone, but osteoblastomas do not have a reactive periphery

227

Are osteoblastomas generally larger or smaller than osteoid osteomas?

Larger

228

Do osteosarcomas tend to present in teens or older patients?

Teens

229

What is this fluffy stuff surrounding the figure in this malignancy?

Osteoid depositing into the soft tissue by a osteosarcoma

230

Do osteosarcomas arise in the epiphysis, metaphysis, or diaphysis of a long bone?

Metaphysis

231

What kind of a bone tumor is this?  It is the most common primary malignancy of bone.

Osteosarcoma

232

How does osteosarcoma spread? Where is the typical metastatic destination? How is it treated?

Hematogenously; lungs; pre-op chemotherapy and surgery

233

As opposed to central osteosarcomas, where the tumor is within the metaphysis, what is an osteosarcoma that is on the surface of the bone called?

A parosteal osteosarcoma

234

What is the most common benign bone tumor? What does it look like?

Osteochondroma; A neoplastic outgrowth recapitulating the growth plate, usually with a stalk, from the metaphysis

235

How are osteochondromas treated?

Complete excision (surgical)

236

Do osteochondromas ever stop growing?

Yes, when skeletal maturity is reached

237

A bony outgrowth from a metaphysis is examined histologically and many features of the growth plate are found.  What sort of bone tumor is this?  Is it malignant?

Osteochondroma; no

238

What genes are mutated in hereditary osteochondromatosis, where osteochondromas occur simultaneously in multiple bones?

EXT1 or EXT2

239

What bone abnormality is seen here?  How do these patients present?

Enchondroma (cartilaginous tumor within metaphysis); sometimes asymptomatic, but usually with symptoms of stress fractures (swelling, pain)

240

What is Ollier disease?  Is it hereditary?  What is the primary manifestation?

It is also called enchondromatosis, and is the presence of many enchondromas in the body; no; malformed limbs

241

When enchondromatosis presents with hemangiomas, what is the syndrome called?

Maffucci syndrome

242

This is a malignant tumor in which malignant cells produce condroid matrix—what is it called?

Chondrosarcoma

243

In a patient with enchondromatosis, what may some of the enchondromas develop into without treatment?

Chondrosarcoma

244

What can an enchondroma be indifferentiable by morphology alone on histological or imaging studies?

Grade 1 chondrosarcomas

245

Where will chondrosarcomas metastasize?

Lungs, skin and soft tissue

246

Is surgical excision or chemotherapy preferable when treating chondrosarcomas?

Excision, since chemotherapy response is poor.

247

What is the 2nd most common primary malignancy of bone in children, usually affecting the diaphysis of long bones and presenting as a painful and warm enlarging mass?

Ewing's sarcoma

248

What type of chromosomal abnormality is associated with Ewing's sarcoma?

Translocations

249

What is this bone tumor (more common in children than adults) which shows an "onion skin" periosteal reaction?

Ewing sarcoma

250

Why might you use FISH as a diagnostic tool when suspecting Ewing's sarcoma?

The typical cause of Ewing's is a translocation, which FISH is good at visualizing

251

Where will Ewing's sarcoma typically metastasize?  What are available treatments?

Lungs; chemotherapy and surgical resection

252

Are fibrous cortical defects common?  Is treatment necessary?

Yes, up to 50% of children; generally, no

253

What cell types comprise a fibrous cortical defect?

Fibrous tissue, histiocytes

254

When a fibrous cortical defect keeps growing instead of regressing, what is it called?  Would this fibroma require treatment?  Assuming no fracture, when must they be treated?

Non-ossifying fibroma; yes (there is a clear pathological fracture); when they reach >50% of the total bone diameter

255

What are these lesions characteristic of?

Non-ossifying fibromas (metaphyseal, eccentric, well-circumscribed, slightly sclerotic rim)

256

What common benign fibroosseous tumor that manifests with intramedullary proliferation of fibrous tissue and woven bone is also a component of McCune-Albright syndrome?

Fibrous dysplasia

257

When does monostotic fibrous dysplasia present?

Early adolescence

258

What fibroosseous tumors have caused the craniofacial abnormalities in this patient?

Polyostotic fibrous dysplasia

259

What two syndromes include polyostotic fibrous dysplasia?  What other symptoms are included in these syndromes?

McCune-Albright and Mazabraud; McCune-Albright: precocious puberty and cafe-au-lait spots, Mazabraud: soft tissue myxomas

260

What is the treatment for fibrous dysplasia?  Can anything be given for symptomatic pain relief?

Surgical resection or curettage; bisphosphonates

261

Giant cell tumors are different from other bone tumors in that they can be located in a unique part of the bone, which is where?  What joint are they most commonly in?

Epiphysis (which is unique) as well as metaphysis; knee

262

What kind of tumor is this, which is more common in women and presents with arthritis-like symptoms?  What information here is most suggestive of the type?

Giant cell tumor; this tumor is unique for invading the epiphysis, and being more common in females

263

What is the naming system for a mesenchymally derived malignant tumor?

It includes "sarcoma" in the name, which means fleshy (Greek)

264

With a below the knee amputation, can a patient live a normal life with a prosthesis?

Yes, they can run, play ball, etc. with a prosthesis and physical therapy

265

Is a giant cell tumor a benign indolent or a benign active/aggressive tumor?

Active/aggressive

266

Do giant cell tumors usually occur before or after the growth plates have sealed?  Where do they localize before the growth plates seal?

After; before (in a child), they are restricted to the metaphysis

267

What surgical technique is being used here?

Cryosurgery

268

Do small round blue cell tumors produce osteoid matrix?  What common sarcoma of the bone is comprised of this cell type?

No; Ewing's sarcoma

269

Does Ewing's sarcoma generally have a lytic or an overgrowth effect on a bone?

A lytic effect

270

What part(s) of the bone are Ewing's Sarcoma usually found in?

Diaphysis and metadiaphysis

271

How many Codman's triangles can be found in this osteosarcoma?

Four, one for each corner of the elevation of the periosteum where the sarcoma has penetrated the cortical bone

272

In this MRI, is the bone tumor in the top half or bottom half of the bone?  What kind of tumor is it?

Top half; Ewing's Sarcoma (it is in the diaphysis, in an adult, and the density is reduced)

273

Will osteosarcomas typically grow through the growth plate?

No

274

A patient has osteosarcoma. If there is neurovascular involvement and tumor fungation, how does this play into the decision on whether surgery will be limb sparing or involve amputation?

Both of those conditions are indications for amputation

275

Do you need serum rheumatoid factor to diagnose rheumatoid arthritis?

No

276

Does rheumatoid tend to affect the upper extremities or lower extremities more?

Upper extremities

277

Are gold, methotrexate, and D-Penacillamine palliative or remittive treatments for rheumatoid arthritis?

Remittive

278

Does aspirin, heparin, or diuretics change the risk profile for gout?

Yes, they are all risk factors for gout

279

What is ochronosis?  What crystal synovitis is it a risk factor for?

The accumulation of homogentisic acid in connective tissues; pseudogout

280

What is this condition, presenting with acute pain, limited range of motion and calcium hydroxyapatite deposition in this one joint?  Can it be treated with colchicine?

Milwaukee shoulder; yes

281

An elderly male patient with debilitating constitutional symptoms, arthritis/arthralgias, and serositis should be immediately screened for what history in order to rule out what poorly understood autoimmune condition?

Medication history, to rule out drug-induced lupus

282

Procainamide, hydralazine, isoniazid, phenytoin, chlropromazine and quinidine are all exposure risks for what autoimmune geriatric condition that prefers males?

Drug-induced lupus

283

How is drug-induced lupus treated?

Remove the drug that is inducing it

284

What syndrome (first described at Mount Sinai) presents in patient over 60 with nontender pain and stiffness of the pectoral and pelvic girdles but no evidence of synovitis?

Polymyalgia rheumatica

285

How is polymyalgia rheumatica treated?

Low dose prednisone

286

Does polymyalgia rheumatica follow the stocking glove pattern?

No, it is restricted to the pelvic and pectoral girdles

287

What serum test is elevated in polymyalgia rheumatica?

Erythrocyte sedimentation rate

288

Does polymyalgia rheumatica cause muscle atrophy?  What about limited range of motion?

No; and no

289

Of polymyalgia rheumatica, rheumatoid arthritis, polymyositis, and fibromyalgia, which is most likely to associate with elevated creatine kinase?   Elevated erythrocyte sedimentation rate?

Elevated creatine kinase: polymyositis;
Elevated ESR: polymyalgia rheumatica

290

What arteritis presenting in the elderly associates with an increased erythrocyte sedimentation rate?

Giant cell (temporal) arteritis

291

Are there alternatives to steroids for treating giant cell arteritis?

Yes, methotrexate and dapsone

292

Greater trochanteric bursitis presents with what chief complaint?  How is it differentiated from osteoarthritis of the hip?

Hip pain and trouble walking; This bursitis will localize to the outside of the hip, while true osteoarthritis will localize to the inside of the groin

293

For pain in an elderly patient that localizes to the outside of the hip by the greater trochanter, what else is on the differential besides greater trochanteric bursitis?

Referred lumbar pain

294

What bursitis is this?  Does it present with limited range of motion or weakness?

Olecranon bursitis; no to both

295

What is this condition, perhaps presenting with a complaint of "hot knee"?  How do you know if it is extra-articular or not?

Prepatellar bursitis; if the patient is flexing and extending without pain, they do not have septic arthritis, otherwise they would hold the knee in one position

296

If a patient presents with diffuse medical knee pain, but exam of the knee is normal (typical range of motion, no tenderness, no swelling except perhaps on the anteromedial leg 5 cm below knee) what bursitis is likely?

Anserine bursitis

297

What is SPONK?  What is the age and gender of the typical patient?  How does it present?

Spontaneous osteonecrosis of the knee (usually femoral condyles, as in the right of the image); elderly woman; hyperacute onset of severe knee pain

298

What is the difference between a strain and a sprain?

Strain: musculo-tendonous injury; sprain: ligamentous injury

299

If the patient has weakness on one side of the hip, how can this be elicited when telling the patient to stand on one leg?

The patient's iliac crest on the side opposite to the weak leg will sag

300

What is this condition?  What are three classifications of its cause?

Scoliosis; idiopathic, congenital, and neurogenic

301

What variant of scoliosis is caused by cerebral palsy, spina bifida, or spinal cord injury?  Is this variant braceable?

Neurogenic scoliosis; no

302

What is this cause for this variant of scoliosis?

Failure of formation of certain vertebrae, causing congenital scoliosis

303

Is this variant of scoliosis congenital or idiopathic?

Idiopathic, since the bones themselves are formed correctly

304

Above what age does idiopathic scoliosis become more common in girls than boys?

6 years old

305

Explain the Risser sign.  For what skeletal abnormality is it used in formulating a prognosis?

The Risser sign is based on a line in a child's pelvis signifying its stage of calcification; it is used in prognosing idiopathic scoliosis

306

For what degrees of curvature will bracing be used to treat adolescent idiopathic scoliosis?  At what curvature will surgical fusion be considered?

25-45°; 50° will allow consideration of fusion

307

This 13 year old overweight boy complains of right hip and knee pain for four months.  On physical exam, moving the right hip is painful and it can't rotate internally more than 10 degrees.  Here is the X-ray: what is the condition?  What is the most straightforward surgical treatment?

Slipped capital femoral epiphysis (the growth plate is slipping), shown by the Klein's lines not being symmetrical, and it is more typical in obese adolescent males; in situ pinning to stabilize the growth plate

308

What are possible complications of in situ pinning for slipped capital femoral epiphysis?

Avascular necrosis, incorrect pin placement, chondrolysis

309

Torticollis (tight SCM muscle) and metatarsus adductus are associated with what congenital problem of the hips?

Developmental dysplasia of the hips

310

What are the Ortolani, Galeazzi, and Barlow tests used to diagnose?  Do they elicit pain?

Developmental dysplasia of the hips; no pain

311

What skeletal abnormality of an infant is demonstrated here, with Shenton's lines drawn over the medial sides of the heads of the femurs and the acetabular index overlaid in yellow?

Developmental dysplasia of the hip

312

What is an osteotomy?

A surgical procedure whereby a bone is cut to shorten, lengthen, or change its alignment.

313

By what age is the majority of acetabular shape development determined?

8 years old

314

With what complaint did this 16 year old patient present?  What developmental abnormality is probable?

Left groin pain and problems abducting hip; developmental dysplasia of the hip

315

What is the mnemonic for diagnosing clubfoot?

CAVE: Cavus, adductus, fixed varus, fixed equinus

316

Can clubfoot be treated by casting?

Yes, it is called the Ponseti technique

317

Children typically have tremendous remodeling potential after bone fractures.  Which fractures in long bones can affect proper growth?  They are classified using a system by Salter-Harris.

Fractures of the growth plate

318

Are buckle fractures and greenstick fractures more common in adults or peds?

Peds

319

How many subtypes of juvenile idiopathic arthritis are there?

3

320

What social history among adults is associated with an increased likelihood of acute rheumatic fever?

Exposure to many children, e.g. schoolteachers and daycare workers

321

Loss of function of what HEENT system is linked to cases of pauciarticular juvenile idiopathic arthritis?

Eyesight, because of scarring in the iris

322

Out of iridocyclitis and sacroiliitis, which is more likely to affect males?  What are both of these subtypes of?

Sacroiliitis; juvenile idiopathic arthritis

323

Is the variant of juvenile idiopathic arthritis that is positive for rheumatoid factor a systemic or polyarticular arthritis?  Is it more severe or less severe than the other variants?

Polyarticular; more severe

324

With the onset of juvenile idiopathic arthritis, what extra-articular manifestations can result?

Iridocyclitis (anterior uveitis), fever, anemia, malaise, rash, organomegaly

325

Are children with polyarticular juvenile idiopathic arthritis at greater risk for shorter stature?

Yes

326

What is the abnormality of the jaw seen here?

Micrognathia

327

What is a rare adult disease that mirrors the features of juvenile idiopathic arthritis?

Adult Still's disease

328

What is the criteria used for diagnosing rheumatic fever called?  What are the five major criteria?

Revised Jones Criteria; Arthritis, carditis, chorea, erythema marginatum (pink rings on the trunk and limbs), nodules

329

What lab test is used to diagnose rheumatic fever?

Evidence of recent strep infection, such as antistreptococcal antibodies, group A strep on throat culture

330

What is this skin condition called?  What bacterial infection related condition is it related to?

Erythema marginatum; rheumatic fever (group A strep)

331

Sometimes confused with the erythema marginatum of rheumatic fever, what skin condition actually is this, which presents often well-localized on somebody who has been outdoors?  What disease is it indicative of?  Does this disease cause arthritis in its initial stages like rheumatic fever does?

Erythema migrans (bullseye spreading rash); Lyme disease; no, only in later stages

332

If somebody has carditis causing secondary heart blocks, some arthritis, and peripheral neuropathies like Bell's palsy, what insect-borne bacterial infection can be suspected?

Borellia burgdorferi (Lyme)

333

When does the incidence of arthritis peak throughout the course of Lyme disease?

Midcourse

334

For early Lyme disease in children, what is usually prescribed?  Why can't you prescribe tetracycline?  If Lyme disease shows cardiac involvement, how does the treatment regimen change?

Doxycycline or amoxicillin 10-21 days; side effect of yellowing teeth; IV ceftriaxone or penicillin

335

What is the most common gram positive cocci to be observed in septic arthritis?

S. aureus

336

What are the most common gram negative cocci to be found in septic arthritis in adults?  In children?

Adults: N. gonorrhoeae and meningitidis; children: H. influenzae

337

These symptoms are all diagnostic criteria for what arteritis presenting in children?

Kawasaki's disease

338

What is this X-ray pathognomonic for?  Is it more common in children or adults?

Dermatomyositis; children

339

The appearance of calcified lesions underneath the skin and in muscle are characteristic of what childhood condition?  What facial symptom usually presents along with it?

Dermatomyositis; periorbital edema

340

Is this more likely to be associated with dermatomyositis or polymyositis?

Dermatomyositis

341

What systemic disease risk is increased by the presence of dermatomyositis and polymyositis, requiring increased regular scrutiny?

Cancer

342

Does myositis necessarily present with pain?  Is active or passive range of motion affected?  Are the symptoms in proximal or distal joints?

Not always; Active range of motion is affected, not passive; proximal joints

343

What two diseases are diagnosed by a muscle biopsy showing this result?

Polymyositis or dermatomyositis

344

What are the most common prescribed drugs that can instigate myositis as an adverse effect?

Statins, steroids, colchicine

345

What is this kind of fracture called?  Is this more common in adults or children?

A greenstick fracture; children

346

Is surgery required to correct a buckle fracture in a child?

No

347

What is this?  How is it treated?

Ganglionic cyst, usually appearing on the dorsum of the hand and seems to be an outpouching of the synovium; it is drained

348

Does this fracture, called a Boxer's fracture, need casting?

Typically, no

349

Which carpal bone fracture, corresponding to pain in the anatomical snuffbox, has occurred here?

Scaphoid (lower left), compare with the following after healing

350

What nodes corresponding to symptoms of osteoarthritis are seen in these hands, and in what joints?

Heberden's nodes in the DIPs, Bouchard's nodes in the PIPs

351

What is "tennis elbow"?

Lateral epicondylitis, corresponding to pain here:

352

In the case of irritation of the ulnar nerve after an elbow injury, what surgical technique can be used to preserve its function?

It can be moved under a muscle for better protection

353

What is this?  Is it a common cause of shoulder pain?

Calcification of the bursa causing bursitis; yes, the most common

354

The patient complains that this bump has appeared in their biceps–is it cancerous?  What is the treatment?

No, this is a result of a tear of the long head of the biceps; usually untreated, but can reattach the long head with surgery

355

What is wrong with this shoulder?

It has been dislocated anterioinferiorly

356

If a patient has a seizure, will the seizing rotator cuff muscles more likely cause an anterior or posterior dislocation of the shoulder?

Posterior, which is the opposite of the typical dislocation from a fall or injury

357

How are tears of these two ligaments best diagnosed on X-ray if the initial presentation is subtle?

Have the patient hold weights in both arms and note the distance from the scapula to the clavicle

358

What disease presents with diffuse aching for three months, local tenderness over many points of the body, disturbed sleep with morning stiffness, and has an incidence of 2-4% of industrialized countries?


Fibromyalgia

359

What part of the brain is suspected to be defective in fibromyalgia, leading to improper processing of pain pathways?

Thalamus

360

Does fibromyalgia tend to develop in the young or the elderly?  What psychiatric disorder does it associate with?

Young only; depression

361

A patient is carrying their arm in to see you, and has a swelling in the distal part of the limb.  It is extremely painful, and sometimes follows trauma or MI.  What is the likely diagnosis?  How is it treated?

Reflex sympathetic dystrophy, also called Complex Regional Pain Syndrome; steroids

362

What syndrome of the median nerve leading to numbness or tingling in the hands commonly results from rheumatoid arthritis?

Carpal tunnel

363

Two kinds of tenosynovitis affecting the wrist are ...?

DeQuervain's and nodular

364

Chronic corticosteroid use (in e.g., a patient with SLE) can lead to what joint disease that manifests with severe acute pain and this radiographic presentation?

Osteonecrosis (avascular necrosis of bone)

365

Young boys, age 3-10, are at risk of developing what condition seen here?

Avascular necrosis of the femoral head

366

What are clinical symptoms of a meniscal tear in the knee?

Pain, effusion, tenderness, clicking, (pseudo) locking and instability

367

What is visualized on this arthroscopy of the knee?

Meniscal tear

368

What ligament of the knee has been damaged here?

Medial collateral ligament

369

Which tendon is torn to cause the patella to move inferiorly?  Which ligament to move it superiorly?

Quadriceps tendon tear – inferiorly; patellar ligament – superiorly

370

What side of the ankle (medial or lateral) has only one ligament?  What is it called?  What is the effect on the likelihood of injury to either side?

Medial; deltoid ligament; medial is more concerning if it is sprained/swollen

371

What is the pathology of a mild sprain?

Hemorrhage in the ligament

372

Does a partial tear of a ligament (moderate sprain) require surgery?

Usually, no, only complete separations of the ligament do

373

What tendon connects to the fifth metatarsal at the site of this fracture?  Does the fracture therefore occur during inversion or eversion stress?

Peroneus brevis; inversion stress

374

This is a heel spur, caused by calcification from stress on what fascia?

Plantar fascia

375

What is this called?  What shoewear is a risk factor?

Bunion; high heels and pointy shoes

376

Out of the types of seronegative spondylarthritis, which must be preceded by an infection (typically GI or genitourinary)?

Reiter's (reactive) arthritis

377

How can psoriatic arthritis be differentiated from rheumatoid arthritis?

Psoriatic is typically asymmetrical, presents with "sausage fingers," onycholytic nails, and involves the DIPs

378

In a patient with asymmetric symptoms of arthritis, axial skeleton involvement, and opthalmologic involvement, is the disease more likely to be rheumatoid arthritis or a seronegative spondylarthropathy?

Seronegative spondylarthropathy

379

What is the "seronegative" in seronegative spondylarthropathies referring to?

Rheumatoid factor is absent

380

Severe pitting of the nails like this, in association with asymmetric arthritis and no evidence of prior infection, is highly suggestive of what type of arthritis?

Psoriatic arthritis

381

Are these knees on a 40 yo patient consistent with rheumatoid arthritis, and why or why not?

No, there is asymmetrical swelling of the left knee, so it is more likely a seronegative spondylarthropathy (e.g. psoriatic, reactive) or septic

382

What is the most common nerve injury of the shoulder?  What does it innervate?

Axillary nerve; deltoid and teres minor

383

How is bursitis treated pharmacologically?

Cortisone injection

384

What are bursae filled with?  What differentiates them from synovial cavities?

Synovial fluid; they do not include articulating edges of bones, but just tendons, muscles, and bone that slide over each other near a joint

385

Is the synovial fluid in an SLE (Lupus) patient inflammatory?  Are glucose and protein normal?

No (WBC <3000); yes

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Is vasculitis an expected complication of scleroderma?

No

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Are pericarditis and myocarditis more suggestive of SLE (Lupus), scleroderma, or neither?

Neither, since they are possible consequences of both

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Why are GI symptoms so common in patients with scleroderma?

Dysmotility results from the obliteration of autonomic nervous function

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What is the "physis" of a bone referring to?

The growth plate

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How can a patient rupture a Baker's cyst during typical daily activities?  What will it manifest as?

Kneeling (e.g. scrubbing floor) or overuse of knee joint; it would manifest as a painful swelling of the knee, but with full range of motion