Mbbs2 Wrist

Front 1

What are the four cardinal signs of inflammation?

Back 1

Rubor (redness), Calor (heat), Dolor (pain), Tumor (swelling)

Front 2

Name the inflammatory mediators.

Back 2

Histamine, bradykinin, NO, eicosanoids (prostaglandins & leukotrienes), substance P, TNF.

Front 3

What are eicosanoids and how are they derived?

Back 3

From metabolism of arachidonic acid. COX enzyme makes prostaglandins and thromboxanes. Lipoxygenase makes leukotrienes.

Front 4

What secretes prostaglandins and how do they act in inflammation?

Back 4

PG's released by endothelial and inflammatory cells. Increase sensitivity of local nerves, increase blood flow causing oedema.

Front 5

What is the difference between COX-1 and COX-2?

Back 5

COX-1 is released under normal physiological conditions - important for homeostasis.
COX-2 is released by inflammatory mediators causing high PG release.

Front 6

Where does TNF come from and what does it do in inflammation?

Back 6

TNF is secreted by macrophages and is a central pro-inflammatory mediator.

Front 7

Describe the therapeutic pyramid in rheumatoid arthritis?

Back 7

Patient education/physio/exercise
NSAIDs
Second line drugs DMARDs
Potent DMARDs
Steroids
Cytotoxics
Surgery considered from the potent DMARD stage, steroid injections into joints throughout.

Front 8

How do NSAIDs work?

Back 8

Inhibit PGH sythase (both Cox-1 and COX-2) - either irreversible (aspirin) or reversible (ibuprofen)

Front 9

What side effects are there for COX inhibitors like aspirin and ibuprofen?

Back 9

Causes inhibition of production of GI mucosa, leading to ulceration.

Front 10

Why aren't COX-2 selective inhibitors used more?

Back 10

Vioxx, a selective COX-2 inhibitor caused a greatly increased risk of MI

Front 11

What are DMARDs?

Back 11

Disease Modifying Anti-Rheumatic Drugs
Second line therapy, slow acting, serious side effects. Include some steroid treatments.

Front 12

Give an example of a DMARD and how it works.

Back 12

Methotrexate - actually a cancer chemotherapy drug. Inhibits action of folate, dampening immune response.

Front 13

How do steroids help in rheumatoid arthiritis?

Back 13

Inhibit arachidonic acid release, inhibit cytokines, down regulate adhesion molecules, inhibit COX, induces apoptosis

Front 14

What are the signs and symptoms of inflammatory arthritis?

Back 14

Pain and stiffness after waking up
Symmetrical polyarthritis
Rheumatoid factor (anti-IgG antibodies)
Nodules
Systemic disease (feeling unwell)
Joint destruction

Front 15

What is the pathophysiology of RA?

Back 15

Synovial swelling
Infiltration of lymphocytes and macrophages
New vascular supply to support swelling
Lots of inflammatory mediators

Front 16

What causes the functional impairment in RA?

Back 16

Erosion of the cartilage and bone by cells and enzymes associated with inflammation

Front 17

How would you diagnose RA?

Back 17

Serum test for rheumatoid factor, X-rays or MRI, other clinical signs.

Front 18

How do you distinguish osteoarthritis from RA?

Back 18

More common, but joint pain on movement, not stiff in morning, lasts less than 30 mins - common sites hands - DIP and CPC, feet and hips

Front 19

What are the signs of osteoarthritis?

Back 19

Tender around affected joints
Firm swellings (Heberden's nodes)
Locking
Restricted movements
Instability of joint

Front 20

What are the main risk factors for OA?

Back 20

Age, obesity, family history, trauma

Front 21

What is the pathophysiology of OA?

Back 21

Breakdown of cartilage first
Cartilage fragments in synvovium causes tissue damage and swelling
Chronic inflammation exacerbates this, bone overgrows to compensate

Front 22

How would you diagnose OA?

Back 22

X-ray - look for narrowing of joint space

Front 23

What other causes of inflammatory arthritis?

Back 23

Ankylosing Spondylitis, Psoriatic Arthritis, SLE

Front 24

Which nerve is affected by carpal tunnel syndrome and what does it supply?

Back 24

The median nerve runs in the carpal tunnel (C6-T1)
Motor supply to LOAF
Lateral Lumricals, Opponens Pollicis, Abductor Pollicis Brevis, and Flexor Pollicis Brevis

Front 25

How would you test for Carpal tunnel?

Back 25

Tinels test - tapping median nerve
Phalen's Manoeuvre - push backs of hands together for 1 minute

Front 26

How is carpal tunnel treated?

Back 26

Splinting, cortisone injection - or surgical pressure release.

Front 27

What is a pannus?

Back 27

Big mass of synovium which grows over articular surface in RA

Front 28

What destroys cartilage in RA?

Back 28

Collagenases - enzymes which break down cartilage

Front 29

What are the boundaries of the snuff box?

Back 29

Posterior - Extensor Pollicis Longus
Anterior - Extensor Pollicis Brevis and Abductor Pollicis Longus
Proximal - Styloid process of Radius
Distal - Apex of tendons
Floor - Scaphoid and Trapezium

Front 30

What is in the snuff box?

Back 30

Radial artery - hence a broken risk can cause avascular necrosis.

Front 31

How do you measure chronic disease and disability?

Back 31

Activities of daily living - a score of a patients ability to complete everyday tasks.

Front 32

What classes as disability for the UK national disability survey?

Back 32

Considered disabled if you needed help with one or more essential tasks.

Front 33

Define disability (current legal definition)

Back 33

A physical or mental impairment that has substantial and long-term effects on ability to carry out normal day-to-day activities.

Front 34

What are the Townsend and Jarman scores?

Back 34

Measures of social deprivation.

Front 35

What is the gold standard for social deprivation measurement?

Back 35

Index of Multiple Deprivation.

Front 36

What prevents bowstringing of the flexor muscles?

Back 36

Flexor retinaculum.

Front 37

Flexor Digitorum Superificialis inserts to which part of each digit?

Back 37

Proximal end of the intermediate phalanges

Front 38

Flexor digitorum profundus originates and inserts where?

Back 38

Originates on the Ulna/Interosseus membrane, and inserts onto the proximal part of the distal phalanges

Front 39

Flexor pollicis longus originates on the radius and interosseus membrane. Where does it insert?

Back 39

Proximal aspect of the distal phalanx of the thumb.

Front 40

Where is the common extensor origin?

Back 40

Posterior aspect of the lateral humerus

Front 41

Name the superficial extensors of the wrist

Back 41

Extensor digitorum, Extensor Carpi Ulnaris, Extensor Carpi Radialis Longus and Extensor Carpi Radialis Brevis

Front 42

Where does extensor digitorum insert?

Back 42

2 attachments on the proximal aspects of the intermediate and distal phalanges.

Front 43

What prevents bowstringing of the extensor muscles?

Back 43

Extensor retinaculum.

Front 44

What are the deep extensors of the forearm?

Back 44

Extensor digiti minimi and extensor indicis

Front 45

Where does extensor digiti minimi insert?

Back 45

Either side of the expansor hood of the intermediate phalanx

Front 46

Where does extensor indicis insert?

Back 46

Proximal aspect of the proximal phalanx.

Front 47

Where does the flexor retinaculum attach?

Back 47

Hook of Hamate, Pisiform, Ridge on Trapezium and tubercle of Scaphoid

Front 48

Which nerve innervates the palm of the hand?

Back 48

Palmar cutaneous nerve of the median nerve

Front 49

What connects the 4 metacarpals?

Back 49

Deep transverse palmar ligaments

Front 50

What are the intrinsic thenar muscles?

Back 50

Abductor pollicis brevis, flexor pollicis brevis and opponens pollicis. Originate on Flexor ret. Scaphoid and Trapezius and insert onto proximal phalanx of thumb.

Front 51

Where does adductor pollicis originate and insert?

Back 51

Originates on the Capitate and Trapezius bones and inserts onto the intermediate phalanx of the thumb.

Front 52

Where does abductor digiti minimi originate and insert?

Back 52

Originates between the Pisiform and the Hamate and inserts onto the proximal lateral aspect of the proximal phalanx of the little finger.

Front 53

Which interossei do what?

Back 53

PAD and DAB: Palmar - Adduct, Dorsal - Abduct

Front 54

What is thumb flexion, extension, adduction and abduction?

Back 54

Flexion is bringing the thumb to the palm when flat, extension is pulling the thumb away. Abduction is bringing the thumb away from the palm at right angle, adduction is bringing it to the palm.

Front 55

8 muscles move the thumb, name them

Back 55

Flexor pollicis longus and brevis (2) - Median
Extensor pollicis longus and brevis (2) - Radial
Adductor pollicis (1) - Ulnar
Adbuctor pollicis longus and brevis (2) - Radial and Median
Opponens pollicis (1) - Median

Front 56

What are the radial and ulnar bursae?

Back 56

Radial covers the thumb, Ulnar the index, middle and ring fingers.

Front 57

How do the superficial and deep palmar arches lie to each other?

Back 57

Superficial lies narrow and extends further towards the phalanges, the deep arch is wider and shallower.