Musculokeletal

Question 1

What proportion of the population don’t have musculoskeletal symptoms?

Answer 1

42%

Question 2

What are the leading causes of sickness absence from work?

Answer 2

Back, neck and upper limb pain

Question 3

Name 5 bone diseases

Answer 3

Osteoporosis
Osteomalacia/rickets
Bone malignancy
Paget's disease
Osteomyelitis

Question 4

Name 5 joint disorders

Answer 4

Osteoarthritis
Inflammatory arthritis
Crystal arthritis
Septic arthritis
Haemarthosis

Question 5

Name 5 disorders of muscle

Answer 5

Polymyalgia rheumatica
Polymyositis
Dermatomyositis
Pyomyositis (abscesses)
Neurological issues

Question 6

Name 4 connective tissue disorders

Answer 6

SLE
Systemic sclerosis
Sjogren’s syndrome
Vasculitis

Question 7

What gait to people with severe OA have?

Answer 7

Antalgic gait
Weight bears on unaffected side
Decreased swing phase on unaffected side

Question 8

What are the 4 changes seen on xray in OA?

Answer 8

Joint space narrowing
Sclerosis
Subchondral cysts
Osteophytes

Question 9

Features of OA

Answer 9

Morning stiffness50yrs
Bony enlargements/tenderness
Symmetrical, polyarticular

Question 10

Pathophysiology of OA

Answer 10

Ligament damage
-> instability/malalignment
-> increased load and microtrauma
-> remodelling of adjacent bone (osteophytes)
2º synovial inflammation and crystal deposition

Question 11

Risk factors for OA

Answer 11

FH
Obesity
Ligament rupture/fracture through joint/malalignment
Occupation

Question 12

Assessment in OA

Answer 12

Effects on activities of daily living
(family duties, hobbies, sleep, occupation)
Pain medication, waking at night?
Self help strategies
Beliefs/expectations/mood

Question 13

Management of OA

Answer 13

Physio, exercise, weight loss
Local heat and cold
Supports, braces, insoles
Paracetamol and topical NSAIDs
Capsaicin, oral NSAIDs, opioids
Intra-articular joint injections
TENS (transcutaneous electrical nerve stimulation)
Joint arthroplasty

Question 14

What is DEXA?

Answer 14

Dual energy xray absorptometry

Question 15

What is normal with a DEXA scan?

Answer 15

T score of more than -1

Question 16

What DEXA reading counts as osteoporosis?

Answer 16

Less than -2.5

Question 17

Who should have a DEXA scan? (Give 8 indications)

Answer 17

Prior low trauma fracture
Height loss & kyphosis on examination
Vertebral deformity on spine xray
Steroid users
FH of fracture
Early menopause
Heavy smokers/excess alcohol/malabsorption
FRAX score

Question 18

What is FRAX?

Answer 18

Osteoporosis fracture predicting system
Age, DOB, sex, weight, height
Previous fracture?
Parental hip fracture?
Current smoker?
Glucocorticoids?
RA?
2º osteoporosis?
Alcohol>3units per day
Femoral neck BMD

Question 19

What does a FRAX score of 10% in a 80 yr old mean?

Answer 19

10 year probability of major osteoporotic fracture is 10%

Not within treatment level (Needs to be >30% in over 80yr olds)

Question 20

Why is HRT not recommended for osteoporosis anymore?

Answer 20

Increases risk of CHD, stroke, breast cancer and VTE

Question 21

What is recommended for treatment of osteoporosis?

Answer 21

Raloxifene
Bisphosphonates
Synthetic parathyroid
Dietary calcium, Vit D
Weight bearing exercise
Smoking cessation
Alcohol restriction

Question 22

What are the revision rates for arthroplasty?

Answer 22

5% at 7rs

15% at 7yrs is metal on metal

Question 23

How do you engineer tissue?

Answer 23

Bone stem cells + inductive agents + conductive scaffold/forces

Question 24

Where can you derive stem cells for bone grafts?

Answer 24

Embryonic
Induced pluripotent
Adult derived skeletal stem cells
Trabecular bone periosteum
Placental/umbilical cord blood
Foetal derived

Question 25

What can bone stem cells form?

Answer 25

Cartilage, bone and fat | Dependent on growth factors (BMPs, VEGF)

Question 26

Positives and negatives of allogenic bone grafts

Answer 26

Off the shelf Risk ratio life threatening situations Reduced manufacturing costs Process favoured

Question 27

Positives and negatives of autologous bone grafts

Answer 27

``` No infectious disease risk Patient specific therapy High manufacturing costs Custom variability Disease/previous therapy issues ```

Question 28

How has CAD CAM aided bone grafts?

Answer 28

3D printed hydroxyapatite scaffolds Bone stem cells can proliferate = bone formation 3D printed titanium constructs for hip revisions and osteointegration tailored to individual's bone

Question 29

What are osteoblasts derived from?

Answer 29

Mesenchymal stem cells

Question 30

What are the most abundant cells in bone? Function?

Answer 30

Osteocytes Can perceive changes in mechanical forces and transmit signals to other cells Central in bone remodelling

Question 31

What are osteoclasts derived from?

Answer 31

Macrophage lineage RANKL receptors lead to differentiation Osteoprotegrin-> stay as precursor

Question 32

Can osteoclasts work solo?

Answer 32

No, they need low pH for solubilisation of minerals and need factors from osteoblasts

Question 33

How does the matrix of bone versus cartilage differ?

Answer 33

Bone is heavily mineralised and mainly type 1 collagen | Cartilage is usually non organic and is formed of type II collagen and proteoglycans

Question 34

3 types of bone development

Answer 34

Intramembranous, endochondral, appositional

Question 35

Where does intramembranous ossification occur?

Answer 35

Flat bones (skull, clavicle)

Question 36

Where does endochondral bone formation occur?

Answer 36

In fetus Hyaline cartilage model of bones -> bone 1º ossification centre in diaphysis & cartilage anlage Death of chondrocytes in centre-> infiltration of marrow and blood vessels 2º ossification centre at birth

Question 37

Name the zone in a growth plate

Answer 37

``` Reserve zone Proliferation zone Transition zone Hypertrophic zone Calcification ```

Question 38

What causes growth of bones?

Answer 38

Proliferation of chondrocytes Synthesis of cartilage matrix Chondrocyte hypertrophy

Question 39

What happens with decreased weight bearing activity?

Answer 39

Decreased strain sensed by osteocytes Osteoprogenitors differentiate into osteoclasts -> bone resorption

Question 40

How often is the adult skeleton completely remodelled?

Answer 40

Every 10yrs

Question 41

Why is bone remodelling useful?

Answer 41

Allows adaption to mechanical loading Enables fracture healing Prevents bone fatigue by constantly renewing matrix

Question 42

Why do you prescribe differently for children?

Answer 42

``` Decreased body weight Different body composition Decreased surface area Nutritional status Organ maturation ```