BONE/CARTILAGE FORMATION AND REPAIR John May, a 31 year old
male, presents to the ED having fallen over his hamster at his
nursing home onto his outstretched hand. On examination there is
posterior displacement of the wrist. What is the name of this type
of fracture? (1) Colles fracture. What are the two main cells
involved in bone remodelling and what are their actions? (2)
Osteoclasts breakdown bone Osteoblasts lay down bone Explain
intramembranous ossification (4) Formation of ossification centres
(in connective tissue membrane) Matrix formation (osteoid secretion
by osteoblasts) Periosteum forms around embryonic arteries. Compact
bone formation around periosteum
Slide 4
BONE/CARTILAGE FORMATION AND REPAIR What factors improve the
rate of union of bone: (2) Stability Apposition Generally well
Blood supply Label the parts of the bone:
Slide 5
BONE/CARTILAGE FORMATION AND REPAIR Andy is pulled out of his
rugby game after complaining of knee pain after a dodgy tackle.
Name three types of cartilage and where they are found? (3) Hyaline
Articular surfaces, pubic symphysis Elastic External ear and
epiglottis Fibrocartilage Menisci and IV discs. Outline the
specific test(s) you would perform on examination of Andys knee:
(2) Drawer (anterior and posterior) McMurrays MCL/LCL Patellar
tap
Slide 6
BONE/CARTILAGE FORMATION AND REPAIR Andy was tackled from the
left and is has pain and swelling in his left knee: What is he
likely to have damaged? (3) Unhappy triad ACL MCL Medial meniscus
What nerve could be at risk and what might be the consequence of
damage to this structutre? (2) Common fibular nerve +
dropfoot.
Slide 7
BONE/CARTILAGE FORMATION AND REPAIR A man attends accident and
emergency following a gunfight in Leamington Spa. He is fine but
his friend has been hurt playing football earlier that day. The
patient explains that he fell over awkwardly on his ankle, bending
his foot outwards, he has been in severe pain since. What ligaments
are most likely to be damaged in this patient? (2) Anterior
tibiotalar, posterior tibiotalar, tibiocalcaneal,
tibionavicular
Slide 8
BONE/CARTILAGE FORMATION AND REPAIR On examination he has
tenderness and swelling around the medial malleolus with some signs
of bruising, but he can still bear weight on the injured leg. With
reference to the Ottawa ankle rules, explain under what
circumstances we would x- ray this patient. (2) Pain in malleolar
zone plus 1 of: Inability to weight-bear OR: Bone tenderness along
distal 6cm of posterior edge of tibia/medial malleolus or
fibula/lateral malleolus Which muscles of the leg are primarily
responsible for foot inversion and eversion? (2) Inversion =
Tibialis anterior and tibialis posterior Eversion = Fibularis
longus and fibularis brevis
Slide 9
BONE/CARTILAGE FORMATION AND REPAIR What is the nerve supply
(name and root) of fibularis longus and brevis? (2) Superficial
fibular nerve L5, S1, S2 The patient is given painkillers and
suffers an adverse drug reaction, how are ADRs classified? (3)
Dose-related Time related Susceptibility-related ADRs.
Slide 10
CALCIUM HOMEOSTASIS/VITAMIN D Amy Barrett, a 75 year old lady
comes in for a medication review. She is on alendronic acid,
fluoxetine and omeprazole. She lives alone with her cat and used to
be seamstress. List the hormones and that regulate calcium and
phosphate homeostasis and where they are made: (3) Calcitonin C
cells (parafollicular) in thyroid PTH Chief cells in parathyroid
Vitamin D made in liver, activated in the kidney. Briefly outline
the roles of parathyroid hormone in hypocalcaemia: (3) Kidney:
activate 1a-OHase activates vitamin D increase reabsorption of
calcium in kidney, absorption of from GI tract, and increased bone
resorption. Bone: increase bone resorption through increased
activation of osteoclasts.
Slide 11
CALCIUM HOMEOSTASIS/VITAMIN D The GP notes that Amy went
through the premature menopause. At what age is menopause
considered premature? (1) 40 and under What effect will this have
have on Gills bones and what will this put her in danger of? (2)
Osteoporosis Pathological fracture What is the definition of a low
impact fracture? (1) Fracture that occurs from a fall from your own
height.
Slide 12
OA/RA Hope presents to her GP complaining of morning stiffness
in her hands, swollen, red fingers, and tiredness. She reports that
her mother had joint problems, and her grandmother suffered from
SLE. What specific blood tests would you order? (1) ANA and
anti-CCP (most specific). NB RhF is a not a specific diagnostic
indicator of RA. Explain the mechanism of morning stiffness in RA:
(2) Cortisol has anti-inflammatory properties. Due to diurnal
variations there are low levels at night, therefore joints affected
by RA are more stiff in the morning. Outline some extra-articular
features of RA: (2) Systemic : malaise, fever, weight loss Skin :
rheumatoid nodules, vasculitis, leg ulcers Neurological : C1/C2
atlanto-axial subluxation, nerve compression Eyes : scleritis,
xerophthalmia (2 Sjgren's syndrome) Heart : pericarditis, valve
problems, atherosclerosis IHD & CVA Lungs : pleural effusions,
rheumatoid nodules, pulmonary fibrosis Blood : anaemia
(chronic/haemolytic), splenomegaly (Feltys synd.) Orthopaedic :
osteoporosis (localised)
Slide 13
OA/RA One examination of Hopes hands, what signs may be
present: (3) Swan Neck Ulnar deviation Boutonierres thumb Wrist
swelling MCP bogginess Z thumb Outline the treatment steps of RA?
(2) Steroids NSAIDs DMARDs MXT, gold injections Monoclonal
antibodies Infliximab
Slide 14
OA/RA Amy presents at 10am with a shortened, externally rotated
right leg after falling out of Altoria. On examination of her
medical notes, you find that she had a total hip replacement 4
weeks ago. What are 4 x-ray signs of OA? (2) Loss of joint space
Osteophytes Subchondral cysts Subchondral sclerosis What are the
risk factors for OA? (2) Previous injury, age, occupation, obesity,
genetic, bone mass, female. What are the steps of management of OA?
(2) Lifestyle advice LOSE WEIGHT. Physiotherapy Drugs:
NSAIDs/treatment of predisposing factors. Surgery
Slide 15
OA/RA Amy has an X-ray, and is diagnosed with a fractured neck
of femur. What are the two types of #NOF? (1) Extracapsular and
intracapsular. Which has a more dangerous outcome and why? (1)
Intracapsular: avascular necrosis due to femoral head only being
supplied circumflex arteries in adults. Which three bones make up
the acetabulum? (1) Pubis, ischium, ileum. Which ligaments joint to
form the joint capsule? (1) Ileofemoral Pubofemoral
Ischiofemoral
Slide 16
ANATOMY UPPER LIMB Allison fell off her rollerblades in the
skate-park and presents to the ED with pain in her forearm and
numbness on her hand. Which muscles bring about pronation and
supination and what is their nerve innervation? (2) Supination:
supinator (radial), biceps brachii (musculocutaneous) Pronation:
pronator teres (median), pronator quadratus (median) Outline the
innervation of the anterior compartment of the forearm: (2) Median
nerve except for flexor carpi ulnaris and flexor digitorum
profundus (digits 4 and 5) What areas of Allisons hand would you
use to test for sensory loss? (3) Radial over first dorsal
interosseus Median thenar eminence Ulnar - hypothenar eminance
Slide 17
ANATOMY UPPER LIMB Which root values are tested via wrist and
digit extension? (1) C5 T1 Radial nerve Outline the innervation of
the muscles of the hand. Everything is ulnar except for LOAF.
Lumbricals 3 and 4 Opponens Adductor pollicis longus Flexor
pollicis
Slide 18
ANATOMY - UPPER LIMB During a forceps delivery, Amy was found
to have damage to her right brachial plexus. Draw and label the
right brachial plexus? (4)
Slide 19
ANATOMY UPPER LIMB Which nerve roots are at risk in a forceps
delivery? (2) C5-6 Describe the presentation of this condition.(2)
Medially rotated shoulder. Limp, loss of shoulder contour. Pronated
forearm Partial wrist drop What is the resulting condition called?
(1) Erbs Palsy What is the dermatome of C6? (1) Inner forearm
Slide 20
AUTOIMMUNITY 54 year old lady presents to GP with difficulty
swallowing dry food, dry eyes. Define the terms: tolerance and
autoimmunity (2): Tolerance: unresponsiveness of the immune system
to an antigen. Autoimmunity: an immune response to self-antigens
due to a failure of tolerance leading to immune-mediated damage to
specific tissues. Tolerance gone wrong. What investigations would
you like to do? (2) ANA- Anti-ro and anti-la (most specific)
Genotyping HLA. Schirmers test paper strips inserted into the eye
to measure production of tears. Secondary Sjogrens is associated
with which diseases? (1) RA, SLE, primary biliary sclerosis.
Slide 21
AUTOIMMUNITY Outline central and peripheral tolerance (5)
Central tolerance Clonal deletion Negative selection- is
self-antigens are presented before birth during development of the
immune system, the B-cells directed against those antigens undergo
apoptosis. Clonal anergy regulatory T-cells inactivate immature
lymphocytes that are directed against self-antigens. Peripheral
tolerance Clonal suppression by regulatory T lymphocytes of mature
lymphocytes that recognise self-antigens in peripheral lymphoid
tissues.
PALPABLE MASSES Amy presents to her GP with a lump in her
groin, below the level of her inguinal ligament. Outline the
borders of the femoral triangle: (3) Lateral sartorius Superior
inguinal ligmanet Medial adductor longus What is the nerve
innervation (with root values) of the medial and lateral borders of
the femoral triangle: (2) Sartorius femoral nerve L2-4 Adductor
longus obturator L2-4 What are the contents (in order from lateral
to medial) (2) Femoral nerve Femoral artery Femoral vein
Slide 24
PALPABLE MASS What is your list of differential diagnosis for a
swelling in the femoral triangle: (3) Artery: aneurysm Vein:
Varicosity, DVT Lymph nodes: superficial inguinal nodes.
Slide 25
SOFT TISSUE INFECTION Hope has an infected earring, she goes to
her GP who starts her on antibiotics and takes a swab of the wound.
The swab shows gram positive cocci. What does the term commensal
organisms mean? (1) Organisms that lve and are supported by a host
(gaining shelter, nutrients etc ) but cause no harm to the host.
What micro-organism would the GP suspect? (1) Staph a. What
antibiotics would the GP commence? (1) Flucloxacillin, methacillin.
Hope returns in a week, saying that the infection has not yet
started to clear. By what mechanisms can microorganisms be
resistant to antibiotics? (3) Activation of efflux pumps Presence
of inactivating enzymes Decreased permability to drugs. Inhibit
drug uptake Alteration of drug target.
Slide 26
SOFT TISSUE INFECTION On inspect of the wound, the GP also
notices a mole that Hope says she hasnt noticed before: Define
papule, maccule: (2) Papule raised, solid lesion
