Soft tissue disorders Flashcards by patrick ellis

Describe the type of structure of tendon tissue [1]

Dense regular collagenous CT
Avsacular [1]

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Which region of the muscle tissue connects the muscle fibre to the tendon?

Endomysium is around each muscle fibre & blends into tendon

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Whats the difference between tendinitis and tendinosis? [2]

Tendinitis: acute inflammation of tendon, does not have microscopic tendon damage

Tendinosis: chronic inflammation of tendon; characterised by disorganised fibres and a hard, thickened, scared and rubbery appearance

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What is difference in structure between normal tendon and tendon with tendinosis? [2] Why is this clinically significant [1]

Normal structure: tendon allows contraction of muscle to cause movement of skeletal system

Tendinosis: disorganiesd collagen means that stresses are not transmitted efficiently: can lead to full thickness tear

Note the disorganise collagen

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Tendinitis & tendinosis

Name three causes of tendinitis & tendinosis [3]

Name three common site of tendinitis & tendinosis [3]

Causes:
* Overuse
* Collagen disorders
* Renal dialysis

Locations:
* Lateral epicondylitis
* Achilles tendonitis
* Supraspinatus tendinitis

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Which of the following is rotator cuff most likely to suffer from tendinitis & / or tendinosis?

Supraspinatous
Teres major
Infraspinatous
Subscapularis

Which of the following is rotator cuff most likely to suffer from tendinitis & / or tendinosis?

Supraspinatous
Teres major
Infraspinatous
Subscapularis

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tendinitis & / or tendinosis

Name 4 ways can treat tendinitis & / or tendinosis? [4]

RICE
Analgesia and NSAIDs
Stretching
Surgery

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Achilles tendinitis

Which physiological process may occur during the healing process? [1]

Form heterotopic calcified regions (formation of extraskeletal bone in muscle and soft tissues)

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Where in the tendon does tendonitis usually occur? [1]

Tendonitis usually occur in the middle of the tendon as this is the weakest spot [1]

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Explain the pathophysiology of heterotopic bone [3]

Fibroblasts, osteoblasts and chondroblasts come from same precursors

Tendon fibroblast differentiate into chondrocytes / hypertrophic chondrocyte and osteoblasts via COX-2

Pro-inflammtory cytokines like prostaglandin E2 induces osteoblasts to differentiate

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How can you treat heteropoic bone formation? [1]

NSAIDs

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Why is it heterotrophic tendon at increase risk of bone fracture? [1]

Previously damaged tendon that calcifies becomes more brittle and may rupture

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Explain how tendons enclosed by tendon sheats heal differently compared to open tendons [2]

Tendons enclosed by tendon sheaths:
* Local environment for tendon healing; problematic for healing as can only repair from fibroblasts within the the tendon sheath

Open Tendons
* Can recruit fibroblasts from other areas
* Heal quicker

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Describe how healing compares when undergo unloading by temporary paralysis versus overloading by active mobility or exercise for:

tendon-bone healing
flexor tendon healing

Complete unloading by temporary paralysis:
* Beneficial for tendon-bone healing
* Detrimental for flexor-tendon healing

Overloading by active mobility or exercise:
* Detrimental for tendon-bone healing
* Beneficial for flexor-tendon healing

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State which is more beneficial for shorter [1] or longer [1] tendons

Unloading by temporary paralysis

Overloading by active mobility or exercise

Short: Unloading by temporary paralysis / cast immobilisation

Long:loading by active mobility or exercise

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State the location of intrinsic tendons (covered by tendon sheath) [1]

Hand flexors

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Describe the different phases of tendon repair [3]

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Describe the different types of enthesis in body [2]

Fibrous
* tendon extends all way up to bone: collagen bundles extend all the way to periosteum & become calcified
* Both are made from type 1 collagen

Fibrocartilaginous: when want to dissapate the stress
* Small section of fibrocartilage at attachment site
* Fibrocartilage calcififies at insertion
* Helps stiffen the tendon / ligament and creates a gradual change in mechanical properties

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Name two locations of fibrous enthesis ligaments [2]

Name three locations of fibrocartilage enthesis ligaments [2]

Fibrous enthesis
* spring ligament
* periodontal ligament

Fibrocartilage enthesis
* rotator cuff muscles
* achilles tendon
* plantar fascia

What type of enthesis is depicted? [1]

Fibrous enthesis

Define sharpey fibres [1]

Sharpey’s fibres: are a matrix of connective tissue consisting of bundles of strong predominantly type I collagen fibres connecting periosteum to bone.

Label A

sharpey fibres

State the 4 zones of the fibrocartilage enthesis [4]

Tendon proper
Fibrocartilage
Mineralised fibrocartilage
Bone

Label which type of enthesis A & B are [2]

A: fibrous
B: fibrocartilage

What is name for inflammed enthesis? [1]

Enthesitis

Name an autoimmune diseases that can cause / associated with enthesitis [1]

ankylosing spondylitis

Ankylosing spondylitis is associated with which HLA? [1]

**HLA B27**

Describe enthesitis pathogenesis: Normal enthesitis insertion occurs at a location with lots of which structure? [1] How does this influence enthesitis pathogenesis? [3]

Normal enthesis inserts into porous bone at a location with lots of small **transcortical vessels (TCV)** Mechanical trauma; **TCVs become inflammed**: * **Vasodilation** * **Efflux** of **immune** cells (**neutrophils**) * **Osteoblasts** form **bone at enthesis** - causes **bone to be formed**

Which IL is specifically associated with enthesitis? [1]

**IL-23**

Enthesitis is associated with which three conditions? [3]

Ankylosing spondylitis Psoriatic arthritis IBD

Where does enthesitis bone formation occur? [1]

**At the insertion point**

How do you differentiate between enthesophytes and osteophytes? [2]

Enthesophytes: **originate from insertion of the joint capsule, ligament or tendons**: no articular border involvement Osteophytes: **orginate from border of articular cartilage**

How do you treat enthesitis: - If mechanical? [2] - If Inflammatory [5]

**Mechanical**: * RICE * NDSAIDs **Inflammatory**: * Sulfasalazine * Methotrexate * Anti-TNF therapy (restricted use for severe autoimmune enthetitis) * Local radiotherapy * Corticosteroid injection * Hyperosmolar dextrose (initiates proliferation of intrinsic fibroblasts - race to repair damage c.f. osteoblasts)

Which drug class is used for ankylosing spondylitis enthesitis? [1]

**Anti-TNF treatment**

What are the names for arteries that supply tendons (of the hands)? [1]

**Vincular arteries**

Name two tenosynovitis conditions [2]

**De Quervain's tenosynovitis** **Trigger finger**

Explain pathophysiology of De Quervien tenosynovitis [3]

Fibrosis and narrowing of tendon sheath: **extensor retinaculum** Around anatomical snuffbox Causes tendons and sheath **rubbing over radial styloid process** **Thickening and narrowing of tendon sheath** **Lymphocyte inflammation**

State and describe the name for test of De Querviens tensynovitis [1]

**Finkelstein test**: * Patient **resting their forearm on a surface in a neutral position** with the wrist hanging off and unsupported * The examiner **holds** the **patient’s thumb and passively flexes the thumb into the palm,** causing the **wrist to adduct** (ulnar deviation), putting **strain on the APL and EPB tendons. ** * If this **causes pain at the radial** aspect of the wrist, the **test** is **positive**, indicating De Quervain’s tenosynovitis.

Describe pathophysiology of trigger finger

Enlargement of tendon within sheath

Treatment for tenosynovitis? Treatments [4] Surgery - for trigger finger [1] and De Quervains [1]

Treatment: * RICE * Splinting * Anti-inflam * Corticosteroids Surgery: * TF: **cut annular ligament** * DQ: **shave styloid processs or cut sheath**

Describe pathophysioloy of SLE [1]

Antibodies agaisnt a wide range of self antigens: * **Anti-nuclear antibodies (ANA):** intranuclear and cytoplasmic proteins (95% are positive) * Anti-Histone * Anti-Ro * Anti-La * (loads of antibodies due to B cell hyperactivity)

Describe lesions seen in SLE [1]

**Discoid lesions**

Describe the arthritis seen in SLE patients [1]

**Jaccoud arthropathy**: due to tendinitis Can move back into the correct position.

DMARD treatments for SLE? [4]

**Cylcophosphamide** **Mycophenolate mofetil** **Methotrexate** **Tacrolimus**

Describe two biological DMARDs for SLE? [2]

**Belimubab:** inhibits BAFF (B cell activating factor) **Rituximab**: CD20 blocker