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66 Cards in this Set

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List the 3 factors causing bone pain
1) Nociceptors at fracture ends
2) Haemorrhage and oedema
3) Muscle spasm
List the 4 aspects of classifying bone fractures
1) Extent- complete v incomplete
2) Soft tissue damage - open v closed
3) Alignment - stable v unstable
4) Comminuted (fragmented)
What is a pathologic fracture and typical causes
Caused by underlying disease - hyperparathyroidism, osteoporosis, malignancy, other metabolic bone diseases
What are the steps of fracture healing
1) haematoma formation, fibrin deposition
2) Inflammation: death of osteocytes and release of cytokines attracting osteoblasts and mesenchymal stem cells (fibroblast and osteoblast progenetors), PMN's, lymphocytes and macrophages
4) proliferation of fibroblasts producing cartilagenous callus
5) proliferation of osteoblasts calcifying callus into soft bone
6) remodelling by osteoclasts and osteoblasts producing hard bone with greater thickness than original bone
Factors promoting bone fracture healing
1) young age
2) immobilisation
3) maximising bone-bone contact
4) vascular supply
5) nutrition (A and D)
6) hormones - thyroxine, GH, calcitonin
7) exercise
Factors impeding bone healing
Age eg. complete femoral fracture (infant 4 weeks, teen 14 weeks, > 60 18-20 weeks)
2) osteomyolitis (infection)
3) Avascular necrosis caused by thrombosis
4) metabolic diseases
Give examples of the 4 categories of bone pathology
congenital - osteogenesis imperfecta
inflammatory - osteomyolitis
metabolic - osteoporosis
neoplastic - osteosarcoma and mets
Describe the timeline of fracture healing
Days 1-3 haematoma (fibrin clot)
3-7 inflammation: PMN's, lypmphocytes, macrophages
7-21 soft callus (osteoid)
3-6 weeks hard callus
6 weeks to 3 months - remodelling gives 80% strength
What 4 local (not systemic) factors delay/impede fracture healing
1) lack of immobilisation
2) infection
3) pathology (cancer)
4) misalignment
What 4 systemic factors delay/impede fracture healing
1) poor nutritional status
2) metabolic: osteoporosis, diabetes, smoking
3) old age
4) immune status (steroids, chemo)
What is the triple approach to breast cancer Dx
1) physical examination of lump (size, character, growth rate, attachment, skin changes, node involvement, systemic symptoms)
2) Imaging
3) Fine needle aspirate
List 4 benign breast lesion types and give examples
1) Infections: Mastitis (ductal), Adenitis (glandular)
2) Neoplasms: fibroadenoma, cystosarcoma phyllodes, intraductal pappiloma, Complex sclerosing lesion (radial scar - looks malignant but benign)
3) Fibrocystic disease (multiple cysts)
4) Mucocoele-like lesion
What grading system is used for breast cancer and what does it indicate
Nottingham: closeness to tissue of origin (number of tubules, nuclear pleomorphism, no of mitotic figures)
What does breast cancer tumour staging look at
1) size
2) extent (involvement of skin, chest wall, musculature, nodal involvement, metastases)
What are the main predictive factors for predicting the course of breast cancer
1) Grading (Nottingham 1-9)
2) Staging
3) Receptor status (oestrogen, progesterone, HER-2)
Describe the 2 main benign neoplasms of bone
1) Osteoid osteoma: nidus of osteoid and woven bone. Proximal femur & tibia
2) Osteochondroma: outgrowths of growth plates
Describe the 5 malignant neoplasms of bone
1) Osteosarcoma (20%), osteoblasts, affects metaphyses (knee, hip, shoulder), affects <20YO males (1.6:1) and Pagets
2) Chondrosarcoma: Middle age men, never in distal extremities (shoulder, pelvis, rib)
3) Giant cell, multinucleated osteoclasts, young adults, epiphyses
4) Ewings: < 20YO, small blue round cell tumour containing glycogen forming soft tissue in bone, systemic symptoms
5) metastatic lesions:BLT with a kosher pickle (breast, lung, thyroid, kidney, prostate)
List the spondylarthropathies and how are they differentiated from RA
AS, psoriatic arthritis, Reiter's syndrome (reactive arthritis), colitic arthritis (IBD) - all are seronegative for RF
Describe the clinical features of AS
1) Aching pain in adult 20-40 originating in sacroiliac, infrascapular, buttocks and progressing along spine
2) Nocturnal pain, morning stiffness, not relieved by rest, relieved by activity
What are the risk/prognostic factors for AS
1) smoking (respiratory insufficiency more likely when thoracic vertebra become fused)
2) low socioeconomic status
3) early age onset
4) Coexistant psoriasis and IBD (causes treatment resistance to TNF blockade)
Describe the joint involvement of RA
1) symmetrical
2) wrist, MCP, proximal interphalangeal joints
3) knee, elbow, ankle, spine
Primary causes of RA
1) ?EBC
2) HLA-DRB1 accounts for 20-50% risk
3) Anti-CCP - aggressive disease
List 8 clinical/diagnostic features of RA
1) Morning stiffness for at least one hour for > six weeks
2) Swelling of three or more joints for 6 weeks+
3) Swelling of wrist, metacarpophalangeal, or proximal interphalangeal joints for 6 weeks+
4) Symmetric joint swelling
5) Hand x-ray showing erosions or bony decalcification
6) Rheumatoid nodules
7) RF or anti-CCP antibodies
8) Elevated ESR and CRP
Describe the pathogenesis of RA
1) Hyperplasia of synoviocytes, oedema and neovascularisation of the synovium
2) Infiltration of lymphocytes, macrophages and mast cells
3) Formation of pannus: fingerlike projections of synovial membrane into the bone causing osteoclast degradation
What is a rheumatoid nodule
Core of fibrin necrosis surrounded by epitheloid macrophages and giant cells
What are the extraarticular manifestations of RA
1) Acute necrotising vasculitis
2) Pulmonary fibrosis, Caplan's syndrome
3) Pericarditis, MI
4) Renal amyloidosis
What is the mechanism of senile osteoporosis
Decreased osteoblast activity
What are primary risk factors/causes of osteoporosis
Menopause
Smoking
Diet
Lack of exercise
What is the mechanism of post-menopausal osteoporosis
1) Lack of oestrogen prevents inhibition of production of IL1 and IL6, TNF an consequently RANKL secretion by osteoblasts
2) Lack of oestrogen decreases secretion of inhibitory OPG by osteoblasts
3) Increased osteoclast activity relative to osteoblasts
What are the secondary causes of osteoporosis
1) Hyperthyroidism
2) Hyperparathyroidism
3) Cushings, corticosteroids
4) GI malabsorption (coeliac, IBD)
How can kidney disease result in fractures
1) No production of calcitriol
2) Tubular disease results in lack of reabsorption of phosphate leading to phosphate depletion
Define osteomalacia and what are the causes
Osteomalacia - defective mineralisation due to absence of vitamin D due to:
diet, lack of sunlight, kidney or liver disease
What are the two forms of ossification during development
Endochondral
Intramembranous (clavicles, skull)
What are the 4 growth plates of the femur
At either end (primary growth plates) and at the greater and lesser trochanters (secondary)
What are teh 4 main layers of the growth plate
Resting zone
Proliferative zone
Hypertrophic zone
Calcification zone
Describe the two forms of enchondromal diseases that increase the risk of malignancy
Olllier's - multiple enchondromas
Mafucci's syndrome - multiple enchondromas with haemangioma
A mother believes that her child's legs are growing unevenly. How is this measured and what are possible causes
True leg length: ASIS to medial malleolus
Epiph plate damage: trauma, infection, avascular necrosis
Dislocated hip (DDH developmental hip dysplasia)
Bone dysplasia: Fibrous dysplasia, Ollier's/Mafucci's
How can you tell the difference between real and apparrent LLD
Apparrent LLD is measured by the apparrent leg length ie from naval to medial malleolus. If real leg lengths are same, then problem is scoliosis rotating the pelvis
Describe RA
HLA class 2: HLA-DRB1 - inflammation of synovium, thickening, pannus, erosion
Symmetric, inflammatory, polyarthritis affecting the MCP w ulnar deviation, DIP, radial ulnar carpal deviation, Boutonniere, Swan neck
Rheumatoid nodules, lung fibrosis, membranous glomerulonephropathy, Sjogren's
What are the diagnostic criteria for spondyloarthritis. What about AS specifically
3 months, age <45 with arthritis, enthesis, dactylitis plus HLAB27 or uveitis or sacrolilitis (MRI).
AS: loss of lumbar lordosis, restricted movement, joint fusion, Romanus lesions (fatty changes at vertebral corners), bone marrow oedema
Give 2 reasons why paeds have fractures rather than strains
1) Paed bone water content is high and mineral content is low, hence bone is softer relative to ligaments
2) Physis is cartilaginous and easily damaged
What is the most common type (classification) of fracture in paeds and explain why
Salter-Harris 2 because the metaphysis because of:
1) Decreased cortical bone thickness
2) Increased porosity
3) Increased bone turnover
What are the common locations of fractures in teh upper limb of children 3-11
Forearm - fracture of metaphysis, commonly a buckle but also SH2
Arm - supracondylar fracture of the humerus due to hyperextension of the elbow(Gartland Classification based on amount of displacement)
What is this, how is it caused
Gunstock deformity (cubitus varus) caused by a supracondylar fracture of the humerus in children
What are the 3 common childhoold elbow fractures
1) Supracondylar
2) Lateral condyle (capitulum) fracture
3) Fracture of the medial epicondyle
A child presents with an injury to the elbow and is unable to completely pronate/supanate his wrist. What is the likely injury
Radial head displacement (Salter-Harris 1) or displacement and fracture of the radius (SH 2)
A child falls on his forearm with excessive pronaion causing an upper ulna fracture. What type of fracture is this
Monteggia fracture of the proximal ulna causing dislocation of the radial head. On X-ray the radial shaft doesn't bisect the capitulum
What features of paediatric fractures indicate abuse and what needs to be done?
1) Hx: does Hx from parent fit with clinical findings
2) Multiple injuries
3) Previous admissions, old injuries (callused fracture sites)
4) Paternal attitude and background
5) If suspicious - must report to DOCS
What are the common sites of apophysitis in children
1) tibial tuberosity
2) calcaneal
3) medial epicondyle
4) inferior patellar pole
Describe the 3 grades of sprain
Ligament:
Grade 1: partial tear, ecchymosis and swelling. Immobilisation only
Grade 2: partial significant tear, joint laxity, immobilise and refer
Grade 3: complete tear, unstable joint, surgical repair
What arethe complications of a fracture
1) Shock due to haemorrhage
2) Crush syndrome (myoglobinurea)
3) Fat embolism (lipidurea, PE)
4) Infection
5) Nerve injury (distal weakness, parasthaesia, numbness)
6) Vascular injury (major artery - haemorrhage -> shock, compartment syndrome
Which bones are prone to avascular necrosis following a fracture
1) Scaphoid as radial artery supply is interupted
2) Head of femur if NOF is fractured
What are the late complications of a fracture in children
1) Malunion resulting in joint disturbance
2) Growth arrest if Salter Harris 3-5 (ie epiphysis moves and damages growth plate)
Describe the features of osteosarcoma
1) Paeds and adolescents
2) Metaphyseal: proximal tibia and humerus, distal femur
3) Histology: malignant osteoblasts forming pleomorphic cells, mitoses, lots of osteoid
4) Clinical: night pain, pathological fractures, stage III metastasises to lungs
What are the DDx of a bony lump
1) Deformity: Osgood Schlatter's, callus, fracture maluniom
2) Benign Neoplasm: osteoid osteoma, osteochondroma, osteoblastoma
3) Malignant Neoplasm: osteosarcoma, chondrosarcoma, Ewing's disease (sarcoma)
A patient comes in with knee pain. What 5 broad areas are you investigating?
1) Mechanical: ligaments, tendons, muscles, meniscus, Osgood Schlatter, fractures, soft tissue, bursae, osteoarthritis
2) Inflamatory: RA, osteomyolytis, synovitis
3) Neoplasms: primary and mets
4) Neurological: referred from back and hip
5) Vascular: ischaemia
What are the key gross features of bone malignancy evident in x-rays
1) Irregular margin
2) Invasion of cortex and tissue
3) Periosteal reaction
Describe the pathogenesis of osteoarthritis
1) Loss of proteoglycan, weakening of collagen network and increased water content of joint cartilage
2) Formation of osteophytes, eburnation
3) Damage to articular surface allows sinovial fluid to form subchondral cysts
4) Heberden and Bouchard nodules form on phalangeal joints
Which other organs are affected in RA
1) Lymphocytic infiltration: lung fibrosis, Sjogren syndrome, pleural effusion, pericarditis, myocarditis, valvular disease
2) Kidneys: nephrotic syndrome due to membranous nephritis and membranoproliferative glomerulonephritis, analgesic nephropathy, vasculitis
What investigations indicate a poor prognosis of RA
High titres of:
1) RA
2) Anti cyclic citrullinated antibodies
3) CRP
Which cytokine is targeted by immunomodulating DMARDs
TNF-alpha, receptors are blocked by Enteracept, Infliximab
What is the DMARD of choice for RA and its mode of action
Methotrexate: dihydrofolate reductase inhibitor
What are 3 features of seronegative arthritis that differentiates them from RA
1) seronegative
2) Affect entheses
3) Cause joint ankylosis
What syndrome (triad) goes with a type of seronegative arthritis
Reiter's syndrome is associated with reactive arthritis following an STI of non-gonnococcal urethritis: arthritis (typically lower limb, assymetrical) and conjunctivitis
What are the aetiologies of septic arthritis
1) osteomyolitis
2) soft tissue abcess
3) haematogenous
4) penetrating injury/iatrogenic
What are 6 instances where a breach of confidentiality is allowed
1) Court order
2) Part of research
3) Minors
4) Statutory decision maker
5) Overwhelming public interest
6) Notifiable conditions