LOCO revision

29 April 2015

22:00

EXTERNAL ILIAC -> FEMORAL -> PROFUNDA FEMORIS

LUMBAR PLEXUS T12 L1-L4

GENITOFEMORAL passes through PSOAS

SACRAL PLEXUS L4-L5 S1-S4

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TERRIBLE TRIAD ACL, MED MENISCUS, MED COLAT

LAT COLAT STRONGER - ROUND VS FLAT
MEDIAL COLAT attaches to joint capsule (MM)

DAMAGE TO COMMON PERONEAL -> FOOT DROP (BROKEN FIBULA)

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CLAVICULAR BREAK -> BRACHIAL ARTERY DAMAGE

BRACHIAL PLEXUS C5-T1

LAMELLAR -> ORGANISED (CORTICAL/ TRABECULAR)

WOVEN -> IMMATURE/ HEALING
BONE TYPE 1 COLLAGEN
OSTEOCLAST FROM HAEMATOPOETIC BONE MARROW LINEAGE
BONE REMODELLING -> OC forms LEAK PROOF seal, secretes collagenase and HCl, ions secreted into IF, OBs
fill lacuna with osteoid
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fill lacuna with osteoid

NORMAL SERUM CALCIUM 2.2 - 2.6 mmol/L

PHOSPHATE necessary for formation of CALCIUM HYDROXYAPATITE via ALKALINE PHOSPHATASE

OPG = OSTEOPROTEGRIN decoy RANKL recepotor

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BONE LOSS PER YEAR = 0.7%

POST MENOPAUSE = 2 - 9%
T SCORE = compares bone density (SD) to 30 y/o matched for sex and ethnicity
Z SCORE = compares bone density (SD) to individual matched for age, sex, ethnicity
T SCORES - OSTEOPENIA -1 to -2.5, OSTEOPEROSIS -2.5 onwards
OP DX - low impact fractures (ESP NoF)
BONES with more TRABECULAR BONE more susceptible to OP due to high turnover & TRABECULAR bone
occupies more SA

TX = ALENDRONATE/ RESEDRONATE (BISPHOSPHONATES)

RALOXIFENE (OESTROGEN R modulator)
HRT
Calcium Vit D
TERIPARATIDE = recombinant PTH (given intermittently stimulates Obs more than Ocs)
BISPHOSPHONATES inhibit osteoclasts, are released locally during bone resorption, and modulate signalling
from OBS to OCS
SE = atypical fractures, giant osteoclasts, osteonecrosis of jaw
DENOSUMAB (RANK L mAb, acts osteoprotegrin)
OSTEOMALACIA Tx = Vit D, UV, Ca

COMPLICATION = OSTEOSARCOMA
TX = BISPHOSPHONATES
DE QUERVAIN'S TENOSYNOVITIS - thumb tendons - EXTENSOR POLLICIS LONGUS/ BREVIS, ABDUCTOR
POLLICIS LONGUS
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POLLICIS LONGUS
TRIGGER FINGER - FLEXOR TENDINOSIS
CARPAL TUNNEL - FLEXOR RETINACULUM AND CARPAL BONES -> MEDIAN N COMPRESSION
(hypothyroidism, pregnancy, idiopathic, diabetes)
DUPUYTREN'S - PALMAR APONEUROSIS (heavy drinking, smoking, diabetic, men)
TENNIS ELBOW - lateral epicondylitis (forearm extensors)
SHOULDER IMPINGEMENT - SUPRASPINATUS tendon

NSAIDs prevent HETEROTROPIC calcification of tendon in TENDONITIS

NSAIDS inhibit COX2 (prevents chondrocyte hypertrophy induced by prostaglandins)
TENDON HEALING - EXTRINSIC (peripheral fibroblasts, tendons without sheaths)
INTRINSIC (fibroblasts from within tendon, tendons WITH sheaths)
ENTHESES - fibrous/ fibrocartilaginous (gradient from tendon to cartilage to bone, moving enthesis)
FIBROUS ENTHESIS - sharpey's fibers (teeth)
ENTHESITIS - HLA B27 arthropathy associated, TX = RICE, NSAIDS, anti TNF

SLE - 95% pts ANA positive, homogeneous/ speckled

TX - NSAIDS, DMARDS, CORTICOSTEROIDS, IV IMMUNOGLOBULINS

RA joint distribution

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CARTILAGE TYPE II COLLAGEN (and IX/ XI)

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NB: aggrecan = HA aggregates, ADAMTS-4 .: damages synovial fluid

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NB: aggrecan = HA aggregates, ADAMTS-4 .: damages synovial fluid

MICROSCOPIC CHANGES: chondrocyte necrosis, focal clumps, larger isogenic clusters, type I collagen not
type II, hyaline becomes fibrocartilage
SYNOVIOCYTES - TYPE A = MAE TYPE B = FIBROBLAST, no BM b/w synovium and subintima (allows free
passage of water)

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SYNOVIAL FLUID - less viscous, neutrophils (mount respiratory burst)

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TRANSVERSE - DIRECT FORCE

SPIRAL/ OBLIQUE - TRANSMISSION/ TWISTING
CRUSH - COMPRESSION/ OP
BURST - VERTEBRA, HIGH FORCE
AVULSION - TRACTION from MUSCLE
IMPACTED - forcing bone ends together
COMMINUTED - Multiple fragments, high impact trauma
STRESS FRACTURE - FATIGUE (abnormal stress), INSUFFICIENCY (normal stress, poor bone)
PELVIC # - EMERGENCY, BLOOD LOSS
SARCOPENIA - muscle loss post age 30 (3 - 5% per year)
CAMPTOCORMIA - THORACOLUMBAR flexion due to sarcopenia
SPONDYLOSIS - OA of spine
OA - HEBERDEN's = DIPS BOUCHARD's = PIPS
PREMATURE OA - PREVIOUS MENISECTOMY, HAEMOCHROMATOSIS

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CORE TX - EXERCISE
DIET, NUTRICEUTICLES (CS and GLUCOSAMINE)
NSAID/ PARACETEMOL/ CAPSAICIN
COX 2 - CELECOXIB
INTRA ARTICULAR - CORTICOSTEROID

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NODAL OA = DIPS and PIPS

EROSIVE OA = DIPS

RF = IgM against IgG

MUSCLE - 40% body mass

Stores glucose and potassium (and other ions)
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Stores glucose and potassium (and other ions)

Loss of motor neuron -> small angulated fibres

Infantile hypotonia - loss of type 1/2

DERMATOMYOSITIS - HELIOTROPE rash on eyelids, STREAKY rash elsewhere
SUBCUTANEOUS CALCIFICATIONS- AI condition, ANA positive/ anti-Jo1 (90%, 20 - 40%)
TX = prednisone, azathioprine, methotrexate (immune suppressants)
INCLUSION BODY MYOSITIS - old people, amyloid vacuoles on biopsy (contain beta amyloid,
hyperphosphorylated tau, apolipoprotein E, presenillin) muscle weakness in finger and wrist flexors,
dysphagia, knee extensor weakness
MUSCULAR DYSTROPHIES - X LINKED, proximal muscle weakness, raised CK
DUCHENNE/ BECKER - DYSTROPHIN lost, endomysial fibrosis in DUCHENNE, muscle undergoes
MYOPHAGOCYTOSIS, muscle later replaced with fat and fibrotic material
FIBROMYALGIA - women, AI, TCAs, SSRIs

RA - SCLERITIS, CARPAL TUNNEL, ATLANTO-AXIAL SUBLUXATION, IHD

METHOTREXATE = 1st choice RA drug
SE - liver problems, affects blood count
FOLIC acid antagonist, limits DNA and RNA synthesis (inhibits dihydrofolate reductase, thymidylate
synthetase)
SULFASALAZINE - Antibiotic (Tx of underlying UC)
HYDROXYCHLOROQUINE - Anti malarial, accumulates in lysozomes, blocks Toll-like R 9

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LEFLUNOMIDE - alternative to MTX, inhibits pyrimidine synthesis via inhibition of DIHYDROOROTATE

DEHYDROGENASE
AZATHIOPRINE - immune suppressant (transplant PTS), pro-drug, interferes with purine synthesis
GOLD salts - injections, 4 - 6 month latency, painful

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