Fichas
MSK-Connective tissue
Fichas del conjunto (84)
- 1ACL + PCL (goes from where to where)ACL
- lateral femoral condyle to anterior tibia
PCL
- medial femoral condyle to posterior tibia - 2Anterior Drawer sign (how? meaning?) Posterior Drawer sign (how? meaning?) Abnormal passive abduction/adduction?Anterior
- knee bent at 90 and foot placed on bed
- push knee forward...if it glides, ACL injury
Lachman test is at 30 degrees
Posterior
- knee bent at 90 and foot placed on bed
- push knee back...if it glides, PCL injury
Ab. passive abduction
- knee extended OR at 30...THEN
- lateral valgus force, and medial space widening --> this is MCL injury
Ab. passive adduction
- knee extended OR at 30...THEN
- medial varus force, and lateral space widening --> LCL injury - 3McMurray TestAs you flex and extend knee, you rotate the tibia and foot as well
- pain, "popping" on external rotation --> medial meniscal tear
- pain, "popping" on internal rotation --> lateral meniscal tear - 4—"terrible triad"
- contact sport --> lateral valgus force applied to a planted leg
- ACL, MCL, and medial meniscus (attached to MCL) damage
- acute knee pain + joint injury/instability
- 5—Prepatellar bursitis
- kneel too much --> inflammation of knee's largest sac of synovial fluid
- 6—"baker cyst"
chronic joint disease --> popliteal fluid collection in gastrocnemius-semimebranous bursa
it communicates with synovial space
- 7Rotator cuff muscles (what? action? nerve innervation?)SItS
Supraspinatus
- suprascapular nerve (C5-C6)
- abducts arm initially (before deltoid)
- most common rotator cuff injury (assessed by empty/full can test)
Infraspinatus
- suprascapular nerve
- laterally rotates arm
- pitching injury
Teres minor
- axillary nerve
- adducts + laterally rotates arm
Subscapularis
- upper + lower subscapular nerves
(both C5-C6)
- medially rotates and adducts arm
- 8Medial vs Lateral epicondylitisMedial - "golfer's elbow"
- repetitive flexion (forehand shots)
- pain near medial epicondyle
Lateral - "tennis elbow"
- repetitive extension (backhand shots)
- pain near lateral epicondyle - 9Wrist bonesScaphoid - Lunate - Triquetrum - Pisiform - Trapezium - Trapezoid - Capitate - Hamate
Scaphoid
- most commonly fractured carpal bone (fall on outstretched hand)
- avascular necrosis
Lunate
- dislocation --> acute carpal tunnel
Hamate
- damage --> acute ulnar nerve injury
- 10Carpal tunnel syndrome (symptoms? causes?)Entrapment of median nerve in carpal tunnel --> nerve compression --> paresthesia + pain + numbness in median nerve distribution (thenar atrophy but still has sensation - palmar cutaneous branch enters hand external to tunnel)
Causes:
1. Pregnancy
2. Rheumatoid arthritis
3. Hypothyroidism
4. Diabetes
5. Amyloidosis - 11Guyon Canal SyndromeCompression of ulnar nerve at wrist of hand
Seen in cyclists due to pressure from handlebars - 12—
- 13Injury to: 1. Axillary nerve 2. Musculocutaneous nerve 3. Radial nerveAxillary (C5-6)
- Fractures neck of humerus/anterior dislocation of humerus -->
1. Flattened deltoid
2. Loss of arm abduction at shoulder
3. Loss of sensation: deltoid + lateral arm
Musculocutaneous (C5-7)
- Upper trunk compression -->
1. Loss of forearm flexion and supination
2. Loss of sensation over lateral forearm
Radial (C5-T1)
- mineshaft humerus fracture OR axillary compression -->
1. Wrist drop (loss of elbow/wrist/finger extension)
2. Loss of grip strength
3. Loss of sensation over posterior arm/forearm and dorsal hand - 14Injury to: 1. Median nerve 2. Ulnar nerve 3. Recurrent median nerveMedian nerve (C5-T1)
- Proximal: supracondylar humerus fracture
- Distal: carpal tunnel syndrome-->
1. Loss of wrist/lateral fingers flexion
2. Loss of sensation over lateral 3.5 fingers
3. Tinel sign (tingling on percussion)
Ulnar nerve (C8-T1)
- Med humerus epicondyle fracture (prox)
- fractures hook of hamate (distal) -->
1. flexion --> radial deviation
2. Loss of wrist/medial fingers flexion
3. Loss of ab/adduction of fingers
4. Loss of sensation of medial 1.5 fingers
Recurrent median (C5-T1)
- superficial laceration of palm -->
1. Ape hand
2. Loss of thenar muscle group --> opposition, abduction, thumb flexion
3. Sensations spared - 15Erb palsy "waiter's tip" (injury - cause - muscle deficit - functional deficit)Injury (1):
1. Traction/tear of upper trunk: C5-6 roots
Causes:
1. Infants - lateral traction on neck during delivery
2. Adults - trauma
Muscle deficient:
1. Deltoid + supraspinatus
2. Infraspinatus
3. Biceps brachii
Functional deficit
1. Abduction (arm hands by side)
2. Lateral rotation (arm medially rotated)
3. Flexion, supination
- 16Klumpke palsy (injury - cause - muscle deficit - functional)Injury:
- Traction/tear of lower trunk (C8-T1 root)
Causes
- Infants - upward force on arm during delivery
- Adults - trauma (grabbing tree branch to break a fall)
Muscle deficits:
Intrinsic hand muscles (lumbricals, interossei, thenar, hypothenar)
Functional:
Total claw hand (since lumbricals normally flex MCP joints + extend DIP and PIP joints)
- 17Thoracic outlet syndrome (injury - cause - muscle - function)Injury
- Compression of lower trunk and subclavian vessels
Causes
- Cervical rib + pancoast tumor
Muscles
- Intrinsic hand muscles (lumbricals, interossei, thenar, hypothenar)
Function
- Intrinsic hand muscle atrophy - 18Winged Scapula (injury - cause - muscle - functional)Injury
- lesion of long thoracic nerve (C5-7)
Cause
- Axillary node dissection after mastectomy
- stab wound
Muscle
- Serratus anterior
Function
- inability to anchor scapula to thoracic cage --> cannot abduct arm above horizontal - 19—
- 20Hand muscles*OAF*
Thenar (median)
1. Opponens pollicis
2. Abductor pollicis brevis
3. Flexor pollicis brevis
Hypothenar (ulnar)
1. Opponens digiti minimi
2. Abductor digiti minimi
3. Flexor digiti minimi
Dorsal interossei - abduct fingers
"Dorsal ABduct = DAB"
Palmar interossei - adduct fingers
"Palmar Adduct = PAD"
Lumbricals - flex at MCP, extend at PIP, DIP
- 21Lower Extremity Nerves (roots - cause of injury - presentation) 1. Obturator 2. Femoral 3. Common peroneal 4. TibialObturator (L2-4)
- Pelvic surgery -->
1. Dec. thigh sensation (medial)
2. Dec. adduction
Femoral (L2-4)
- Pelvic fracture ->
1. Dec. thigh flexion
2. Dec. leg extension
Common Peroneal (L4-S2)
- Trauma/compression of lateral leg, fibular neck fracture -->
1. Foot drop (inverted/plantarflexed at rest)
2. Loss of eversion + dorsiflexion
3. Loss of sensation on dorsum of foot
PED = Peroneal Everts and Dorsiflexes
if injured --> foot dropPED
Tibial (L4-S3)
- Knee trauma
- Baker cyst (prox) or Tarsal Tunnel (distal)
1. Inability to curl toes + loss of sensation on sole of foot
2. Proximal lesions - foot everted at rest w/ loss of inversion and plantarflexion
TIP = Tibial Inverts and Plantarflexes
if injured, can't TIPtoe
Sciatic nerve (L4-S3) --> posterior thigh -->
1. Common peroneal
2. Tibial - 22Lower extremity nerves (roots - muscles innervated - cause of injury - presentation) 1. Superior gluteal 2. Inferior gluteal 3. Pudendal nerve (roots, innervation)Superior gluteal (L4-S1)
- Gluteus medius, minimus, tensor fascia lata
- Iatrogenic injury during intramuscular injection to upper medial gluteal region
1. Trendelenburg sign/gait (pelvis tilts because weight bearing leg/hip can't abduct pelvis - cont. to dropped side, ipsilateral to weight-bearing side)
*choose superolateral gluteal quadrant
Inferior gluteal (L5-S2)
- Gluteus maximus
- Posterior hip dislocation
1. Difficulty climb gin stairs/rising from seat
2. Loss of hip extension
Pudendal nerve (S2-S4)
- Perineum innervation - 23Signs of lumbosacral radiculopathy (what? presentation: L3-L4, L4-L5, L5-S1)- Paresthesias + weakness in distribution of specific lumbar/sacral spinal nerves
- due to intervertebral disc herniation
- Herniation often posterolaterally (thinner posterior longitudinal ligament)
L3-L4
- L4 affected --> weakness of knee extension
L4-L5
- L5 affected --> weakness of dorsiflexion, difficulty in heel-walking
L5-S1
- S1 affected --> weakness of plantarflexion, difficulty in toe walking - 24Muscle conduction to contraction1. action potential depolarize --> presynaptic voltage-gated Ca channels open --> neurotransmitters release
2. postsynaptic ligand binding --> muscle cell depolarization in motor end plate
3. Depolarization travels along muscle cell down T tubule
4. Voltage-sensitive dihydropyridine receptor depolarize --> mechanically cause Ryanodine receptor on Sarcoplasmic Reticulum to open --> release calcium
5. Ca binds troponin C --> conformational change that moves tropomyosin out of the myosin-binding groove on actin filaments
6. Myosin (attached to actin) releases ADP + P --> power stroke (H, I bands shorten)
7. Myosin binds new ATP --> myosin detach
8. ATP hydrolyze --> myosin ready for attachment
- 25Types of muscle fibers (1 vs 2)Type 1 - slow twitch
- red fibers: high [mitochondria] + [myoglobin ] --> sustained contraction
Type 2 - fast twitch
- white fibers from dec. [mitochondria] + [myoglobin]
- inc. anaerobic glycolysis
- proportion inc. after weight training - 26Smooth Muscle Contraction (key enzymes, molecules)
- 27effect of estrogen on boneEstrogen :
1. inhibit osteoblast apoptosis
2. promotes osteoclast apoptosis
Estrogen deficiency --> osteoporosis - 28Achondroplasia (cause? genetics? association? presentation?)Constitutive activation of fibroblast growth factor receptor (FGFR3) inhibits chondrocyte proliferation
- 85% of mutations occur sporadically
- autosomal dominant w/ full penetrance (homozygosity is lethal)
- assoc. w/ increased paternal age
Most common cause of dwarfism
1. Failure of longitudinal bone growth (endochondral ossification)
2. Short limbs
3. Intact membranous ossification (large head relative to limbs)
4. Mental function, life span, and fertility are not affected - 29Osteoporosis (causes - drugs/medical conditions, process, diagnosis, labs, prophylaxis, treatment, complications)Cause
- dec. estrogen = inc. bone resorption
- drugs:
1. Corticosteroids
2. Alcohol
3. Anticonvulsants
4. Anticoagulants
5. Thyroid replacement therapy
- medical condition
1. Hyperparathyroidism
2. Hyperthyroidism
3. Multiple myeloma
4. Malabsorption syndromes
Process:
trabecular (spongy) and cortical bone lose mass + interconnections --> bone pain + fractures in weight bearing areas (vertebrae, hip, distal radius)
Diagnosis:
bone mineral density scan w/ a T-score < -2.5
Labs
Serum Ca, PO4, PTH, Alk Phos - all normal
Prophylaxis:
1. Regular weight-bearing exercise
2. Adequate Ca and Vit D intake
Treatment:
1. Bisphosphonate (kills osteoclasts)
2. Exercise, Vit D, and calcium (limit loss)
3. Denosumab (RANKL antibody)
4. Glucocorticosteroids - contraindicated - 30Osteopetrosis (marble bone disease) (Cause, process, complications)Cause:
Carbonic anhydrase II mutation --> osteoclasts can't make acidic environment
Process
W/o acidic environment --> osteoclasts can't resorb bone --> abnormally thick heavy bone that fractures easily
Complications
1. Fractures
2. Bone fills marrow space --> pancytopenia
3. (hence) extra medullar hematopoiesis
4. Vision + hearing impairment (impingement on cranial nerves)
5. Hydrocephalus (narrowing of foramen magnum)
6. Metabolic acidosis (due to lack of carbonic anhydrase)
Cure
Potentially bone marrow transplant --> since osteoclasts are from monocytes - 31Osteomalacia (rickets) (cause - process - findings (children vs adults) - x-ray)Rickets in children, osteomalacia in adults
Cause
poor diet, malabsorption, liver failure, renal failure -->
Vit - D deficiency --> dec. serum Ca --> inc. PTH secretion --> dec. serum PO4
Hyperactivity of osteoblasts --> inc. Alk Ph
Process
Osteoids are formed by osteoblasts --> cartilaginous growth plates are formed --> with low Vit D, they're not mineralized
Findings - Children
1. Bow legs
2. Bead-like costochondral junctions (rachitic rosary)
3. Craniotabes (soft skulls) + frontal bossing (osteoid deposition)
4. Pigeon-breast deformity (inward bending of ribs w/ anterior protrusion of sternum)
Findings - Adults
1. weak bone w/ increased risk for fracture
X-ray findings:
1. Epiphyseal widening + metaphysical cupping - 32Paget disease of bone (osteitis deformans) (process? lab findings? x-ray? complications?)Process:
- localized disorder of bone remodeling:
inc. Osteoclast --> inc osteoblast --> poor bone formation --> thick/sclerotic bone that fractures easily
lytic --> mixed --> sclerotic --> quiescent
Lab findings
1. normal: Ca, PO4, PTH
2. inc. Alk Phos
X-ray
1. Mosaic pattern of woven and lamellar bones
Complications
1. Arteriovenous shunts (in bone) --> inc blood flow through these leads to high-output cardiac failure
2. Inc. osteosarcoma
3. Increasing cranial size --> buy new hat
4. Hearing loss (narrow auditory foramen)
5. Lion-like facies - craniofacial bones
Treatment
1. Calcitonin - inhibits osteoclast function
2. Bisphosphonates - apoptosis of osteoclasts - 33Osteonecrosis (process? causes? presentation? location?)Process
- infarction of bone and marrow --> very painful
- common site - femoral head
Causes (BIG CASTS)
1. Corticosteroids
2. Alcoholism
3. Sickle Cell Disease
4. Trauma
5. Bends (caisson/decompression disease)
6. LEgg-Calve-Perthes (idiopathic)
7. Gaucher's disease
8. Slipped capital femoral epiphysis
- 34Lab values in bone disorders
- 35OsteochondromaMost common benign bone tumor
Males
< 25 years old
- Arises from a lateral projection of the growth plate (metaphysis)
- Overlying cartilage can transform rarely transforms into chondrosarcoma
NOT CHONDROMA
- 36Giant Cell Tumor (epidemiology? location? x-ray?)20-40 years old
Occurs at the epiphyseal end of long bones, often around knee
"osteoclastoma"
Locally aggressive benign tumor
"soap bubble" appearance on X-ray
Multinucleated giant cells + stromal cells
- 37Osteosarcoma (osteogenic sarcoma) (pathogenesis? epidemiology? predisposing factors? x-ray? characteristics?)Osteosarcoma (osteogenic sarcoma)
Pathogenesis
- malignant proliferation of osteoblasts
Epi
- 2nd most common primary malignant bone tumor (after multiple myeloma)
- bimodal age distribution: 10-20, > 65
Predisposition:
1. Paget disease of bone
2. bone infarcts
3. radiation
4. Familial retinoblastoma
5. Li-Fraumenia syndrome
X-ray
1. Codman triangle (periosteum is lifted)
2. sunburst (a destructive mass)
Characteristics
1. Usually at metaphysics of long bones, often around knee
2. Aggressive --> treat w/ surgical en bloc resection + chemo - 38Ewing Sarcoma (Epidemiology, histology, genetics, x-ray, characteristics)Epidemiology
1. Boys < 15 years old
Histology
1. Anaplastic small blue cell tumor (that resembles lymphocytes)
2. Arises from neuroectoderm
Genetics
1 t(11:22) --> EWS-FLI 1
X-ray
"onion skin periosteal reaction in bone"
Characteristics
1. Appears in diaphysis of long bones, pelvis, scapula, ribs
2. Extremely aggressive w/ early metastasis
3. Responsive to chemotherapy - 39Osteoarthritis (pathogenesis, predisposing factors, presentation, joint findings, treatment)Pathogenesis
- mechanical wear/tear destroys articular cartilage
- chondrocytes mediate degradation and inadequate repair
Predisposing factors
1. Age
2. Female
3. Obesity
4. Trauma
Presentation
1. Pain in weight bearing joints after use
- improves with rest
2. Asymmetric joint involvement
3. Medial knee cartilage loss first --> bow legged
Joint findings
1. Osteophytes (bone spurs)
2. Joint space narrowing
3. Subchondral sclerosis + cysts
4. DIP (Heberden nodes), PIP (Bouchard nodes), 1st CMC - not MCP
Treatment
1. Acetaminophen/NSAIDs
2. Intra-articular glucocorticoids
- 40Rheumatoid arthritis (pathogenesis - predisposing factors - Labs - presentation - joint findings - treatment)Pathogenesis:
Autoimmune inflammatory cytokines + cells --> PANNUS (proliferative granulation tissue) --> erode articular cartilage + bones
Predisposing factors:
1. Female
2. HLA-DR4
3. Smoking
4. Factors
Labs
1. 80% patients --> + Rheumatoid factor (IgM autoantibody against Fc of IgG)
2. specific --> anti-cyclic citrullinated peptide antibody
Presentation
1. Pain + swelling
2. Morning stiffness > 1 hr improves w/ use
3. Symmetric joint involvement
4. Systemic symptoms (fatigue, fever, weight loss)
5. Extra-articular manifestations common*
Joint findings
1. erosions
2. juxtaarticular osteopenia
3. joint space narrowing
4. Subchondral cysts
5. Deformities (subluxation, ulnar deviation, swan neck, boutonniere)
6. Synovial fluid: WBC > 2000/ml
7. MCP, PIP, not DIP or 1st CMC
Treatment
1. NSAIDS
2. Glucocorticoids
3. DMARDS (methotrexate, sulfasalazine, leflunomide, hydroxychloroquine)
4. Biologics - TNF-a inhibitors
- 41Rheumatoid arthritis (extra-articular manifestations)1. Rheumatoid nodules (fibrinoid necrosis w/ palisading histiocytes) in
a) subcutaneous tissue
b) lung
2. Interstitial lung disease
3. Pleuritis
4. Pericarditis
5. Anemia of chronic disease
6. AA amyloidosis
7. Neutropenia + splenomegaly (Felty)
8. Sjogren syndrome
9. Scleritis
10. Carpal tunnel syndrome - 42Gout (causes, pathogenesis, symptoms, treatment)Uric acid from purine metabolism --> kidney excretion
Causes:
1. Renal insufficiency - underexcretion of uric acid (thiazide diuretic) --> 90%
2. Overproduction of uric acid
a) Lesch-Nyhan syndrome
b) PRPP (phosphoribosyl pyrophosphate) excess
c) tumor lysis syndrome
d) von Gierke disease (glucose-6-phosphate deficiency --> liver can't make glucose) --> 10%
Pathogenesis
hyperuricemia --> Na-Urate precipitate --> acute inflammatory monoarthritis
(neg. birefringent - yellow under parallel light, blue under perpendicular light)
Symptoms
1. Asymmetric joint distribution
2. Joint is swollen, red, painful
3. Podagra (painful MTP joint of big toe)
4. Tophi (achilles tendon, olecranon bursa)
5. Occurs after large meal/binge alcohol
Treatment
acute - NSAIDs, glucocorticoids
Chronic - XO inhibitors (allopurinol, febuxostat), colchicine - 43Calcium Pyrophosphate deposition disease (pseudogout) (epidemiology, pathogenesis, findings, lab, treatment)Epidemiology
1. Age > 50
2. Male = female
3. Assoc. w/ hemochromatosis, hyperparathyroidism
Pathogenesis
1. Deposition of calcium pyrophosphate crystals within the joint space
Findings
1. Pain + swelling w/ acute inflammation (pseudogout) +/-
2. Chronic degeneration (pseudoosteoarthritis)
3. Knee most commonly affected
Lab
1. X-ray --> chondrocalcinosis (cartilage calcification)
2. Rhomboid, + birefringent crystals
Treatment
acute - NSAIDs, glucocorticoids
prophylaxis - colchicine - 44Sjogren Syndrome (epidemiology, pathogenesis, findings, labs, complications)Epidemiology
1. Females 40-60
Pathogenesis
1. Lymphocytic infiltrates --> destruction of exocrine glands --> autoimmune
could be 1* disorder
could be 2* disorder assoc. w/
a) Rheumatoid arthritis
b) SLE
c) systemic sclerosis
Findings
1. Inflammatory joint pain
2. Keratoconjunctivitis sica (dec. tear production --> corneal damage)
3. Xerostomia (dec. saliva production)
4. Bilateral parotid enlargement
Labs
anti-nuclear antibodies:
1. SS-A (Ro)
2. SS-B (La)
Complications
1. Dental caries
2. MALT
3. Lymphoma (masquerade as parotid enlargement) - 45Septic arthritis (organisms - findings - lab - if gonococcal)Organisms:
1. Staph aureus
2. Streptococcus
3. Neisseria gonorrhoeae
Findings:
1. Swollen - red - painful (single) joint
Lab
1. Purulent synovial fluid (WBC > 50,000/ml)
If gonococcal:
1. Purulent arthritis (of the knee) OR
2. Triad:
a) polyarthralgias
b) tenosynovitis (tendon sheath inflammation of the hand)
c) dermatitis (pustules - 46Seronegative spondyloarthritis (what is it? which syndromes? common findings?)Group of chronic inflammatory diseases w/ shared features w/o rheumatoid factor
1. Psoriatic arthritis
2. Ankylosing spondylitis
3. IBD (crohn's, ulcerative colitis)
4. Reactive arthritis
Genetics - HLA-B27
1. Chromsome 6
2. Inuit, ethnic russians, alaskans, germans
3. Strongest association w/ ankylosing spondylitis
Findings
1. Inflammatory back pain (improves w/ use, age < 40)
2. Sacroiliitis (inflammation of one/both sacroiliac joints)
3. Spinal ankylosis (spinal stiffness from vertebrae fusion)
4. Multiocular enthesitis (periosteolar bone forming and invading tendons)
5. Syndesmophytes (bony growth inside a ligament)
6. Uveitis, colitis, etc - 47Ankylosing spondylitis (epidemiology, presentations, X-ray, treatment)*seronegative spondyloarthropathy*
Epidemiology
1. Young men (10-30)
2. HLA-B27 positive
3. Will have family history of it
4. Frequent GI tract infections (IBD)
Presentations
1. Inflammatory back pain (insidious, > 3 mo)
2. Spinal ankylosis (joint fusion --> morning stiffness that improves w/ use)
3. Limited chest expansion w/ breaths
4. Uveitis/iritis
5. Aortic regurgitation
6. Psoriasis
Radiographics
1. Sacroiliitis on X-ray
Treatment
GOLD --> exercise
1. NSAIDs for symptoms
2. DMARDs (methotrexate, sulfasalazine, hydroxychloroquine, leflunomide)
3. Biologics (TNF-a inhibitor) - 48Psoriatic arthritis (epidemiology, findings, treatments)*seronegative spondyloarthritis*
Epidemiology
1. Men = women
2. late 20s to 30s
3. 1/3 of psoriasis patients get this
Presentation
1. Salmon patching (silver scale)
2. Erosive arthropathies of hands, spine --> debilitating
3. Sausage fingers (DIP, PIP synovitis)
4. Dactylitis (inflammation of toes)
5. Sacroiliitis
6. Arthritis mutilans (pencil in cup erosions)
Treatment
1. NSAIDs for symptomatic relief
2. Corticosteroids - swelling reduction
3. DMARDs (methotrexate, sulfasalazine, hydroxychloroquine, leflunomide)
4. TNF-a inhibitors - 49Reactive arthritis (causative organisms, presentation, treatment)*seronegative spondyloarthropathy*
Causes:
1. Chlamydia
2. Salmonella
3. Shigella
4. Campylobacter
5. Yersinia
6. Strep
usually 2-3 weeks after prolonged diarrhea
can't see, can't pee, can't climb tree
1. Conjunctivitis/anterior uveitis --> can't see
2. Urethritis --> can't pee
3. Arthritis --> can't climb tree
4. Sausage fingers - DIP and PIP synovitis
5. Sacroiliitis
Treatment
1. NSAIDs - symptomatic
2. Corticosteroids - topical for uveitis/conjunctivitis
3. DMARDs (for ppl likely to move onto chronic arthritis)
4. TNF-a blocker --> if axial skeleton involved - 50Systemic Lupus erythematous (epidemiology, presentations, labs, treatment)Epidemiology
Black reproductive age female
RASH OR PAIN
Rash - malaria or discoid
Arthritis - nonerosive
Serositis - (i.e. pleuritis, pericarditis, etc)
Hematologic disorder (i.e. cytopenias)
Oral/nasaopharyngeal ulcers
Renal disease (lupus nephritis, glomerular deposition of anti-DNA immune complexes --> nephritic or nephrotic)
Photosensitivity
Antinuclear antibodies
Immunologic disorder (anti-dsDNA, anti-Sm, antiphospholipid)
Neurologic disorders (seizures, psychosis)
Antibodies:
1. ANA - sensitive, not specific
2. Anti-dsDNA - specific, poor prognosis (renal disease)
3. Anti-Sm - specific, not prognostic
4. Anti-histone antibodies - drug-induced lupus
5. Dec. C3, C4, from immune complex formations
Treatments
1. NSAIDs
2. Steroids = immunosuppressants
3. Hydroxychloroquine - 51Antiphospholipid syndrome (epidemiology - antibodies - symptoms - diagnosis - treatment)Epidemiology
- 1* or 2* autoimmune disorder
- most commonly assoc. w/ Lupus
Antibodies
- Anti-Cardiolipin Antibody (ACA)
- Anti-Beta-2 glycoprotein Antibody
- Lupus anticoagulant
Symptoms
1 Arterial AND venous thrombosis
2 Recurrent pregnancy loss
3 Thrombocytopenia
4 CNS syndromes (stroke, chorea)
5 Libman Sacks endocarditis (sterile cardiac valve disease)
6. Livedo reticularis (connected string-patterned erythema)
Diagnosis
1. Lupus anticoagulant -->
a) prolonged DRVVT (viper venom)
b) prolonged PTT
2. Elisa --> detect anti-cardiolipin antibody
Treatment
- systemic anticoagulation
Beware:
1. false positive on RPR/VDRL test - 52Mixed Connective tissue diseaseFeatures of SLE, systemic sclerosis, and/or polymyositis
assoc. w/ anti-U1 RNP antibodies (speckled ANA) - 53Sarcoidosis (epidemiology, what, assoc. findings, lab findings, treatment)Epidemiology
- Assoc. w/ Black females
What:
- immune-mediated widespread non-caseating granulomas
Assoc. findings (HE BULL)
1. Restrictive lung disease (interstitial fibrosis)
2. Erythema nodosum
3. Lupus pernio (skin lesions on face looking like lupus)
4. Bell palsy
5. Uveitis
6. Hypercalcemia (inc. 1-a-hydroxylase-mediated Vit D activation in macrophages)
Lab Findings
- often asymptomatic except for:
1. Bilateral adenopathy + coarse reticular opacities (CXR)
2. Hilar and mediastinal adenopathy (CT)
3. Elevated serum [ACE]
4. Elevated CD4/CD8 ratio on BAL
Treatment: steroids - 54Polymyalgia rheumatica (epidemiology, symptoms, lab findings, assoc. w/, treatment)Epidemiology
- common in women > 50 yrs old
Symptoms
1. Fever + malaise + weight loss
2. Pain + stiffness in shoulders and hips
3. No muscular weakness
Lab findings
1. Inc. ESR
2. Inc. CRP
3. normal CK (creatinine kinase)
Assoc. w/ giant cell (temporal) arteritis
Treatment
low-dose corticosteroids --> rapid response - 55Fibromyalgia (epidemiology, symptoms, treatment)Epidemiology
- Females 20-50 yrs old
Symptoms
- Widespread musculoskeletal pain assoc. w/:
1. Stiffness
2. Paresthesia
3. Cognitive disturbances (foggy)
4. Poor sleep
5. Fatigue
Treatment
1. Regular exercise
2. Antidepressants (TCAs, SNRIs)
3. Anticonvulsants (phenytoin, carbamazepine, topiramate, etc) - 56Idiopathic Inflammatory Myopathies (which diseases? systemic complications? epidemiology, symptoms, disease mechanism, labs)Idiopathic Inflammatory Myopathies (IIM) (Myositis):
1. Polymyositis
2. Dermatomyositis
Systemic complications:
1. Raynaud’s phenomenon
2. Skin rash
3. Arthritis
4. Cardiac dysfunction
5. Interstitial lung disease
Epidemiology
1. Bimodal incidence (5-15, 35-50)
2. Females > Males, blacks
Symptoms
1. Proximal muscle weakness (painless)
2. Fatigue + fever
3. Organ involvement
Disease mechanisms
Muscle cells:
1. Express MHC I AND II → T cell interaction
2. Express surface Fas receptor → Fas-L engagement → cell death via apoptosis
3. Express pro-inflammatory cytokines (TNF-a, IL’s)
Labs:
1. Anti-Jo-1
2. Anti-SRP
3. Anti-Mi-2 antibodies
4. ANA+
5. Inc. CK (and other muscle enzymes) - 57Polymyositis (what is it? pathogenesis? findings? treatment?)an idiopathic inflammatory myopathy
Pathogenesis
1. Endomysial CD8 infiltration --> inflammation
Findings:
1. Progressive symmetric proximal muscle weakness (shoulders)
Treatment
1. Steroids --> 2. immunosuppressant (methotrexate) - 58Dermatomyositis (what is it? pathogenesis? findings? complications, treatment?)an idiopathic inflammatory myopathy
Pathogenesis:
1. Perivascular infiltrate (perimysial) of CD4 cells around fascicle
Findings:
1. Bilateral proximal muscle weakness
2. Malar rash
3. Gottron papules (pathognomonic)
4. Heliotrope rash (pathognomonic)
5. Mechanic's hands
Complications
1. Occult malignancy
Treatment
1. Corticosteroids (gold)
2. Immunosuppressants
- 59Myasthenia gravis (frequency? pathogenesis? symptoms? assoc. w/? diagnosis? treatment?)Most common NMJ disorder
Pathogenesis
1. Autoantibodies to postysynaptic ACh receptors (blockage + destruction)
Symptoms
1. Ptsosis
2. Diplopia
3. Weakness worsening with use
Assoc. w/
1. Thymoma
2. Thymic hyperplasia
Diagnosis
1. Edrophonium test
Treatment
1. Pyridostigmine - 60Lambert Eaton myasthenic syndrome (frequency, pathogenesis, symptoms, assoc. w/?)uncommon
Pathogenesis
1. autoantibodies to presynaptic Ca channel --> dec. ACh release
Symptoms
1. Proximal muscle weakness
2. Autonomic symptoms (dry mouth, impotence)
3. Weakness improves w/ use
Assoc. w/ (SCALP)
1. Small cell lung cancer
2. Cervical cancer
3. Adenocarcinomas
4. Lymphomas (H + NH)
5. Prostate cancer
Minimal effect with AChE inhibitor - 61Myositis ossificansHeterotopic ossification of skeletal muscle following muscle trauma
Most often seen in upper or lower extremity
"suspicious mass" at site of trauma OR incidental finding - 62Scleroderma (systemic sclerosis) (epidemiology, about, symptoms, types)Epidemiology
- 75% female
About:
Triad of:
1. Autoimmunity
2. Noninflammatory vasculopathy
3. Collagen deposition w/ fibrosis
Symptoms
1. Sclerosis of skin (puffy, taut skin w/o wrinkles)
2. Fingertip pitting
3. Renal sclerosis
4. Pulmonary sclerosis (death)
5. Cardiovascular sclerosis
6. Sclerosis of GI systems
Types:
1. Diffuse scleroderma
- Widespread skin involvement
- Rapid progression, early visceral symptoms
- Anti-Scl-70 (anti-DNA topoisomerase I)
2. Limited scleroderma
- Limited skin involvement confined to fingers + face, benign clinical course
- CREST
Calcinosis
Raynaud phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia - 63Raynaud Phenomenon (pathogenesis, types, treatment)Pathogenesis
- arteriolar (small vessel) vasospasm due to cold --> dec blood flow to skin --> color change (white, blue, red)
- often in fingers and toes
if 1* --> Raynaud disease
if 2* --> Raynaud syndrome
1. Mixed connective tissue disease
2. SLE
3. CREST (limited scleroderma)
- digital ulceration seen
Treatment
1. Ca channel blockers - 64Skin Layers, epidermis layersSkin: epidermis, dermis, subcutaneous fat
Epidermal layers (surface to base):
Californians Like Girls in String Bikinis
1. Corneum
2. Lucidum
3. Granulosum
4. Spinosum
5. Basale
- 65Epithelial cell junction proteins (tight junction? adherens junction? desmosome? gap junction? integrins? hemidesmosomes?)
- 66—
- 67What is: hyperkeratosis Parakeratosis Hypergranulosis Spongiosis Acantholysis Acanthosis
- 68—
- 69—
- 70—
- 71angiosarcoma? glomus tumor? kaposi sarcoma?
- 72—A) - impetigo
- superficial skin infection
- S. aureus OR S. pyogenes
- highly contagious
B) - Bullous impetigo
- has bull
- usually caused by S. aureus
C) - Erysipelas
- infection of upper dermis + superficial lymphatics
- S. pyogenes
- well-defined demarcation between infected + normal skin
D) - Cellulitis
- acute/painful spreading infection of deeper dermis and subcutaneous tissues
- S. aureus or S. pyogenes
E) Abscess
- collection of pus from a walled-off infection within deeper skin
- almost always S. aureus
F) - necrotizing fasciitis
- Deeper tissue injury
- anaerobes or S. pyogenes
- crepitus from methane/CO2 production
G) - Staph scalded skin syndrome
- exotoxin destroys keratinocyte attachments in strum granulosum ONLY
- there's fever
- erythematous rash + sloughing off upper epidermis
- 73—H) herpetic whitlow
I) molluscum contagiosum
- umbilicate papule caused by poxvirus
- pox virus
J) - hairy leukoplakia
- lateral tongue painless plaques
- can't be scraped off
- EBV + HIV
- not thrush (scrapable) or leukoplakia (precancerous)
- 74—
- 75—
- 76—Basal Cell Carcinoma
- most common skin cancer
- sun-exposed areas of body
- locally invasive, but rarely metastasizes
A) rolled borders + central ulceration + telangiectasia
OR
B) non healing ulcers w/ infiltrating growth
OR
C) Scaling plaque (superficial BCC)
D) BCC has palisading nuclei
- 77—Squamous cell carcinoma
Second most common skin cancer
Assoc. w/
1. Excessive exposure to sunlight
2. Immunosuppression
3. Arsenic exposure
Characteristics
1. Locally invasive
2. May spread to lymph node
3. RARELY metastasize
G) - keratin pearls
Actinic keratosis - scaly plaque --> precursor to squamous cell carcinoma
Keratoacanthoma - a variant that grows rapidly (4-6 weeks) and may regress spontaneously over months
- 78—I) - flat melanoma
J) - nodular melanoma (more dangerous)
K) - lentigo maligna
L) - aural lentiginous (in asians and blacks)
Pathogenesis
1. Often - BRAF kinase driving mutation
Risk factors
1. pale skin
2. sunlight exposure
Prognosis
1. Depth of tumor correlates w/ risk
2. Significant risk of metastasis
ABCDE's
Asymmetry
Border irregularity
Color variation
Diameter > 6 mm
Evolution over time
Treatment
1. Excision with wide margins
2. If BRAF V600E mutation --> vemurafenib
- 79osteogenesis imperfecta (causes, genetics, findings)Autosomal dominant defect in collagen type I synthesis --> structurally weak bone
Findings
1. Multiple fractures of bone (can mimic child abuse, but bruising is absent)
2. Blue sclera (thinning of scleral collagen)
3. Hearing loss (bones of middle ear fracture easily) - 80Osteomyelitis (about, pathogenesis, causes, symptoms, diagnosis)About
infection of marrow + bone (mostly in children)
Pathogenesis
transient bacteremia (children) --> seeds metaphysis
open-wound bacteremia (adults) --> seeds epiphysis
Causes:
S. aureus - most common cause
N. gonorrhoeae - sexually active young ppl
Salmonella - sickle cell patients
Pseudomonas - diabetics/IV drug users
Pasteurella - cat/dog bites
My. tuberculosis - Pott's disease
Symptoms
1. Bone pain w/ signs of infection (fever)
2. Lytic focus (abscess) surrounded by sclerosis of bone on x-ray
Diagnosed via blood culture - 81Osteoid osteoma + osteoblastomaOsteoid osteoma
- benign tumor of osteoblasts
- young adults
- bony mass < 2 cm in diaphysis w/ radiolucent core
- bone pain that resolves w/ aspirin
Osteoblastoma
- bony mass > 2 cm in vertebrae
- bone pain that does not resolve w/ aspirin - 82chondroma (what? where?)- benign tumor of cartilage
- arises in the medulla of small bones of the hands and feet - 83chondrosarcoma (what? where?)- malignant cartilage-forming tumor
- arises in medulla of pelvis or central skeleton - 84X-linked muscular dystrophy (types? presentation?)Causes
Spontaneous mutation --> Deletion of dystrophin --> muscle cytoskeleton can't be anchored to extracellular matrix
A) Duchenne muscular dystrophy
- dystrophin deletion
1. proximal muscle weakness at 1 yr -->
2. Cal pseudhypertrophy (replacement of calf muscle w/ fat)
3. Serum creatinine kinase elevated (meaning there's damaged muscles)
Death:
- cardiac failure (myocardium affected)
- respiratory failure
B) Becker muscular dystrophy
- mutated dystrophin
- milder presentation
Información
- Descripción
- Organ modules Fichas sobre MSK-Connective tissue, creado por Eric Zhang el 27/02/2017.
- Creado por
- Eric Zhang
- Visitas
- 1
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