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MSK Biweekly #1

Terms in this set (355)

sources of cutaneous nerves in the lower limb

lumbar plexus
sacral plexus
posterior rami of lumbar and sacral nerves

Lumbar plexus cutaneous innervation

anterior and medial thigh
upper anterior leg; medial leg

sacral plexus cutaneous innervation

lower buttocks
posterior thigh and leg
lower anterior leg and foot

posterior rami of lumbar and sacral nerves cutaneous innervation

levels that contribute to the lumbar plexus

levels that contribute to the sacral plexus

contributions to sciatic nerve

contributions from L4/5 and S1/2/3

lumbosacral plexus

formed by anterior divisions of the lumbar nerves, sacral nerves, and coccygeal nerve

provides motor and sensory innervation for the posterior thigh, most of the lower leg, the entire foot and most of pelvis

fetal development of lower limbs

spiral in medial rotation at 6-8 weeks, causes dermatomes to travel from posterior to anterior

lumbar and sacral dermatomes

lumbar is basically the anterior and medial thigh and leg, plus bottom of foot

sacral is posterior thigh and leg, plus lateral foot

small saphenous vein

origin from lateral side of the dorsal venous arch of foot, ascends behind lateral malleolus along tendo calcaneus, crosses tend back to posterior middle of leg and runs upwards to pierce deep fascia in lower popliteal space

terminates in the popliteal vein

great saphenous vein

origin is dorsal venous arch in foot, ascents in front of medial malleolus, along medial leg posterior to medial condyles of the tibia and femur, to saphenous opening

why varicose veins

valves are incompetent and allow back flow causing veins to become tortuous and dilated

sends portions inward to attach to bone and make true muscle compartments

iliotibial tract

aka IT Band, reinforces fascia lata laterally

incision in skin and fascia to relieve pressure in compartment

compartments of the thigh

anterior (extensor), posterior (flexor) and medial (adductor)

joint blood supply

fed by branches of arteries passing the joint

periarticular anastomosis

blood vessels branch to supply joints as they pass

rich nerve supply to joints, innervated by all nerves which innervate muscles producing movement at that joint

bones of the coxal

ilium, ischium, pubis

depression in femoral head where round ligament connects

iliofemoral ligament

from AIIS to the intertrochanteric line, prevents over extension

pubofemoral ligament

from the superior pubic ramus, joins the iliofemoral ligament, checks abduction

ischiofemoral ligament

from ischium behind acetabulum to blend with the capsule, checks medial rotation

anterior compartment of thigh; action, innervation, blood supply

flexors of the hip, extensors of the leg
innervated by femoral nerve
supplied via femoral artery

saphenous nerve

anterior femoral nerve cutaneous branch, does not go through adductor haitus

medial compartment of the thigh; action, origin, innervation, supply

adductor compartment
origin around obturator foramen and insert into femur
innervated by obturator nerve
supplied via profunda femoris and obturator arteries

epidermis and dermis

layers of epidermis (top to bottom)

stratum corneum
stratum lumenis
stratum granulosum
stratum spinosum
stratum basale

layers of dermis

papillary dermis
reticular dermis
hypodermis

terminal hairs, thick and long; extend to hypodermic (scalp, axillary, pubis)

villous hair, shorter; extend only 1/2 way down reticular dermis

hair follicles, attached components

invaginations of epidermis; can have 3 structures attached: erector pills, sebaceous glands, eccrine gland

skin vascularization

confined to dermis, also applies to innervation

glands types found in skin

sebaceous glands, holocrine
apocrine gland, apocrine secretion (axila, pubic)
eccrine gland, merocrine secretion

other cell types found in skin

melanocytes, langerhans cells, merckle cells

types of basal epithelial cells

S cells, achnorage, found at top of ridges
NS cells, non-serrated, undergo mitosis; found in bottom of invaginations

day lifespan of keratinocyte

19 days to proliferate, another 28 days to differentiate

keratin filaments

20 closely related monomers, must combine acidic and basic group to make filament

molecularly distinct, morphologically and functionally identical; expression changes as keratinocyte matures

membrane coding graule, fuse with apical PM as SS migrates up releasing contents into EC matrix

proteolipids released, make covalent bonds with proteins in PM of other keratinocytes and makes connections

keratin-hyalin granule, filament aggregating factor, binds and coalesces keratin IF, important to protect IF from degradation

controls regulatory process of hair

fibroblasts in the bulb region

phases of hair grown

anagen (1000 days), catagen (14 days), telogen (100 days)

langerhans cells

supra basal dendritic cells, bone marrow derived, highly mobile APC, contain bierbeck granules

birbeck granules

dilated cisterns at one end, trilaminar handle at the other

responsible for integrating and processing Ag

basal dendritic cell, neural crest derived, produces melanin and gives to keratinocytes through processes which transport melanosomes

colored pigment, good scavenger of free radicals

basilar cell (lips, fingertips, genetalia), associated with axon terminal of a dermal nerve, contains NT and NP, dense core granuals

layers of basement membrane

lamina lumina, lamina densa

collagen types I, III, IV, V, VI, VII

I is most abundant in dermis
III is fetal
IV is basement membrane
VII is an anchoring fibril

types of cartilage

hyaline
elastic
fibrocartilage

nutrient diffusion in cartilage

cartilage is avascular, GAGS with hyaluronan center allow for diffusion

perichrondrium is highly vascular

types of cartilage growth

appositional, sides
intrastial, from within

isogenous group

aka isogenous nest, group of chondrocytes within cartilage

long, short, flat, irregular

parts of a long bone

epiphysis, rounded heads
metaphysis, growth plate
diaphysis, shaft

aka cortical bone

cancellous bone

aka trabecular bone and spongy bone

(primary) woven bone

not the same thing as spongy bone, found when bone is growing/healing

origin of 'bone cells'

osteoclasts are derived from hematopoietic stem cells

osteoblasts are derived from undifferentiated mesenchymal cells

histological appearance of *blasts

cuboidal cells found along surface of cell, lots of cytoplasmic basophilia

organic matrix of bone; made of >90% type I collagen, proteoglycans, and glycoproteins

hydrocyapatite crystals, take 2-3 weeks to form in humans

osteocytes; description and features

osteoblasts that have become surrounded by matrix, inactive, contact each other via processes within canulliculi

senses mechanical stress and signals blasts and clasts

channels formed between lacunae of osteocytes

bone-lining and osteoprogenitor cells

both are a source of new osteoblasts and are found inside and outside bone

Howship's lacunae

hole formed by *clast

derived from marrow precursors, fuse to form large multinucleated cells with eosinophilic cytoplasm

osteoclast secretions

secrete H+ to dissolve inorganics and lysosomal enzymes to degrade organic matrix

zones of osteoclast cytoplasm

ruffled border, site of resporbtion
clear zone, attachment site
basolateral zone, contains cellular organelles (exocytosis degraded material)

signals to release Ca

*blasts have receptors which cause them to release RANKL and M-CSF which cause pre-ostoclasts to fuse and become active

aka OPG; produced by osteoblasts, production stimulated by estrogen, prevents RANKL from activating *clasts

types of bone formation

intramembraneous, no cartilage precursor (flat bones of skull)
endochondral, cartilage converted to bone

steps of endochondral formation

ring formed around middle, cartilage calcifies, blood vessels invade and erode cartilage, primary center of ossification forms in primitave marrow cavity, osteoprogenitors differentiate into blasts and lay down osteod along spicules of remaining calcified cartilage [clasts removed the calcified cartilage]

2˚ centers of ossification form at proximal and distal end of bone

zones of activity for bone growth

zone of reserve cartilage, no activity

zone of proliferation, cell division and enlargment & organize into columns

zone of hypertrophy, increase in size

zone of calcified cartilage, cells degenerate and calcifies

zone of resporption, vessels invade and bring *progenitor cells [spicules of cartilage remain]

circumferential growth

osteoblasts grow the outside, while *clasts destroy the inside

keeps thickness of cortical bone the same

Haversian systems

aka osteons, bone remodeling system, basically *clasts lead by chewing through the bone and osteoblasts follow to reform it

looks like a cone shaped drill

refers to capacity for functional adaptation of bone

central DXA sites

hip and spine (lumbar)

WHO Fx risk assessment, provides 10y prob of fracture and hip fracture (treat if >20% OR >3%)

osteoporosis, when to treat

hip or vertebral fracture, FRAX, or if T-score < -2.5

osteoporosis, anabolic agent

Teriparatide [recombinant PTH]

osteoporosis, antiresorptive drugs

estrogen, calcitonin, bisphosphonates, raloxifene, denosumab

osteoporosis, 2nd or 3rd line drugs

calcitonin, raloxifene, ibandronate, teriparatide

approved only for prevention (w/ progestin)

MOA: suppresses clastic cytokine production in T cells and blasts, induces FasL to lead to *clast apoptosis

osteoporosis, estrogen issues

risk of breast cancer, CV disease, VTE

requirement for osteoporosis drugs

must decrease incidence of vertebral fractures

approved for post-menopausal osteoporosis treatment [5 years beyond]

dosed intranasally and IM/SQ

reserved as alternate for women who cannot take other agents

calcitonin issues

rhinitis, rarely epistaxis, nausea and flushing

approved for post-menopausal osteoporosis treatment

oral dosing, 60mg/day

prevents increased risk of breast and uterine cancer associated with estrogen

raloxifene issues

does not prevent hot flashes, same VTE risk as estrogen

2nd line bc only decreases vertebral fractures

bisphosphonates available (4)

alendronate, risendronate, ibandronate, zoledronic acid

bisphosphonate dosing

alendronate, daily/weekly
risendronate, daily/weekly/monthly
ibandronate, daily/monthly/IV
zolendronic acid, IV

if taken orally, food/drink/medications must be avoided for at least 30 mins after dosing

action of bisphosphonates

bind to bone and taken up by *clasts and inhibt synthesis of essential proteins for function [blocks farnesyl pyrophosphate synthase]

can cause apoptosis

describe structure of bisphosphonates

R1 PO3H2
\ /
C
/ \
R2 PO3H2

ring structures have higher potency [Zoledronic acid and Risedronate]

bisphosphonate PK

excreted by urine, cannot use in people with CrCl < 30-35 mL/min

bisphosphonate issues

Esophageal irritation
acute phase reaction
adverse renal effects
hypocalcemia
MSK pain
atrial fibrillation
ONJ (osteonecrosis of the jaw)
AFF (atypical femur fracture)

denosumab; description, dosing, safety

mAb to RANKL to reception on *clast

subQ every 6 months

URI/UTI, skin reactions, hypocalcemia, MSK pain, ONJ, AFF

teriparatide; description, dosing, safety

increases *blast activity more

subQ daily

hypercalcemia, muscle cramps, nausea, dizziness, osteosarcoma

BLACK BOX WARNING: risk of osteosarcoma, so do not prescribe to patients with already elevated risk

bone mineral density

aka BMD, areal density (mass/area)

BMD compared to SD for a young, female control population

>-1 SD, normal
-1 to -2.5, low BD
<-2.5 SD or lower

BMD compared with mean and SD for age-matched controls

WHO densitometric classification for low bone mass/density

BMD in postmenopausal women

T-score preferred

low body weight
prior fracture
high-risk medication
bone loss disease/condition

BMD in men >50yo

T-score preferred

low body weight
prior fracture
high-risk medication
bone loss disease/condition

BMD in young women

Z-score preferred

BMD in males <50yo

Z-score preferred

osteoporosis cannot be diagnosed on basis of BMD alone

uptake mechanism of bone imaging agent

bone-seeking radioactive compound is injected, 3 hours later image is taken

common indications for bone scan

evaluation for osteoblastic activity
osteomyelitis evaluation
stress/insufficiency fracture

forearm BMD measurement indications

Hip/spine can't be measured
hyperparathyroidism
obese patients

DXA Body Comp contraindication

only contraindication is pregnancy

types of eruptions

papular, vesicular, nodular, pustular

characteristics of distribution for skin diseases

extent, pattern, location

lesions in dermatomal pattern

herpes simplex lesions

grouped lesions

contact dermatitis (e.g. poison ivy)

morphology of lesions

size, shape, color, texture, 1˚ vs 2˚ lesion

tinea coporis (ring worm)

umbilicated lesion

central depression, molluscum

blue morphology cause

melanocytes, iron, medicine

minocycline can turn you blue

loss of melanin or melanocytes

independent risk factor for cardiac disease

xanthelesma, lipid deposits that causes yellow pigmentation

brown, black and blue lesion

melanoma, often sign of malignant melanocytes

1˚ vs 2˚ lesion

1˚ is macule/patch, papule/plaque, nodule, vesicle/bulla, pustule
2˚ is erosion, ulcer, fissure, eschar, scratch, excoriation

macules vs patches

macules ≤ 1cm, patches >1cm

completely flat

papule vs plaque

papule ≤ 1cm, plaque > 1cm

can feel

vesicle vs bulla

same sizes, filled with clear fluid

yellow filled areas

erosion vs ulcer

erosion is loss of some epidermis
ulcer is loss of all epidermis, into dermis

honey colored crust

sign of staph aureus infection

prep used for yeast or fungi

smear of base of blister looking for mlutinucleated giant cell

mineral oil prep

for scabies mites, eggs or feces

somites are derived from

paraxial mesoderm, about 37 somites

IV disc; part and derivation

annulus fibrosus forms from schlerotome
nucleus pulposus forms from notochord

when is ossficiation of the vertebrae complete

klippel-feil syndrome

abnormal fusion of vertebrae, shortened neck and other problems

derivation of skeletal muscle

mesenchyme and neural crest [neural crest plays a role in development of muscles in head and neck]

forms vertebrae

myotome splits into

epimere, which is the dorsal muscle group
hypomere, which is the ventral muscle group

segmented vs non-segmented muscles

thoracic muscles remain segmented (intercostal)
limb muscles fuse

epaxial vs hypaxial

back muscles innervated by dorsal rami
lateral and ventral muscles, including limbs, innverated by ventral rami

congenital arthrogryposis

muscle hypoplasia, stiff joints

congential torticollis

damage to SCM at birth, injury causes fibrosis

upper limb 1˚
grow laterally, turn medially
thumb and big toe are cranial (pre-axial)
palm and sole are ventral
widening at hand/foot plat

apical ectodermal ridge, thickening of ectoderm at limb bud tip that induces limb growth and sets up proximal-distal axis

secreted by AER

zone of polarizing activity, secretes Shh which dictates post-axial formation

expression drives doral (nail) formation

drives ventral (finger pad) formation

extensor vs flexor group

extensors are posterior and flexors are anterior [both are innervated by ventral rami]

[but remember the legs are rotated enough this is the opposite after development]

limb rotation during development

upper limb rotates laterally [slight]
lower limb rotates medially ['palms' turn all the way around and face down]

absence of proximal limb structures

absense of whole limb

absence of part of a limb

cleft hand/foot

absent third digit w/ fusion of 1/2 and 4/5

pre-axial vs post-axial

pre-axial is the thumb/great toe side

malposition of limb elements

abnormal angle of joints

varus, inward toward midline
valgus, turning away from midline

McCune-Albright Syndrome

fibrous dysplasia of the bone [shepard's crook] w/ café-au-lait skin pigmentation and findings of endocrinopathies

abnormal curvi-linear trabeculae surrounded by abnormal fibroblastic proliferation

mutation in GNAS, postzygotic mutation

Treacher Collins Syndrome

micrognathia [abnormal small jaw], microtia [small, malformed external ear], hypoplasia [cleft palat], downward slanting palpebral fissures

AD pattern of inheritance, mutation in TCOF1
thought too much apoptosis of neural crest cells

Holt-Oram Syndrome

skeletal abnormalities of upper limbs, often with congenital heart disease

AD pattern, mutation in TBX5

Achondroplastic Dwarfism

short stature, upper arm and thigh commonly most shortened, small nose

AD pattern, mutation in FGFR3 [most are de novo caused by old fathers]

Thantophoric dwarfism

more severe than achondroplastic dwarfism, most common lethal form

also mutation in FGFR3

feet turned inward, 50% bilateral

talus is malformed, get varus [bow-legged]

structure of 60-amino-acids that binds DNA

caused by low vitamin D, causes bowlegged and abnormal osteochondral junction

short stature and severe mental impairment, caused by iodine deficiency

osteogenesis imperfecta

4 subtypes, mutation in collagen chain, type I have blue sclera type II fatal in utero

pituitary dwarfism

growth hormone deficiency, short stature but normal body proportions maintained

renal osteodystrophy

skeletal changes of chronic renal disease, induces 2˚ hyperparathyroidism which stimulates osteoclast activity

causes short stature

bone weakening in adults due to lack of vitamin D, prone to vertebral and femoral fractures

markedly decreased bone mass, prone to fractures from mild stress

osteoclast dysfunction

"marble bone disease", brittle bones due to osteoclast dysfunction

paget's disease

effects elderly adults and can cause 'chalkstick fracture' mosaic pattern under microscope; increased osteoclast activity

alkaline phosphatase levels may rise, treat with bisphosphonates

abnormal bone growth in adults; enlarged jaw, hands, feet

caused by pituitary adenoma, in children this would cause gigantism

Salter Harris classification

I: between epihysys and diahpysis
II is diaphysis
III is epiphysis
IV is both
V is compression of the two

higher the number the worse it is

pathologic fracture

bone weakened by disease: neoplasm, vascular insult, infection, osteoporosis, osteogenesis imperfecta, etc

greenstick fracture

incomplete fracture with angular deformity

Colle's Fracture

fracture of distal radius with dorsal angulation of distal fragment

hangman's fracture

fracture of psoterior elements of C2 vertebrae, may be associated with anterior subluxation of C2 on C3

chalkstick fracture

bone snapped like a piece of chalk, common cause is Paget's syndrome

blowout fracture

bone fracture at medial orbit wall and orbit floor, may exhibit diplopia

Pott's fracture

fracture of medial and lateral malleoli

Legg-Calve-Perthes disease

involves child's hip joint, boys > girls
loss of blood supply to femoral head

may have a subcorticle fracture with fragmentation of epiphysis

fracture callus steps

hemorrhage, attract inflammatory cells, *clasts arrive and remove necrotic bone, granulation tissue is layed down, soft callus layed down and osteoblasts form woven bone, hard callus forms with more woven bone, remodeling over months

solitary, slow growing lesion in skull and facial bones of middle-aged adults [multiple may appear in people with Gardner syndrome, or with adenomatous polyposis epidermal cysts, and fibromatosis]

osteoid osteoma

occurs in adolescents, causes nocturnal pain releived by aspirin [osteoblastoma is similar but > 2cm]

occur in 20 to 40 years, disorganized but not atypical chondrocytes

tumor arises near growth plates, stops when growth plates fuse [inherited]

low-grade axial skeleton tumors, surgical exicison

bone has cartilagenous type appearance, shows increased cellularity and atypical cells

fibrous dysplasia

marrow is much more fibrous that it should be, 'chinease characters' of trabecula

common in young, occurs in medulla of long bones and pelvic flat bones

histologically tumor looks like lots of lymphocytes, stains with CD99 antibody

giant cell tumor

many multinucleated giant cells contain > 40 nuclei

rhapdomyosarcoma

malignant soft tissue tumor that resembles skeletal muscle [it really doesn't but whatever] [dont' confuse with rhabdomyoma which is benign]

most common soft tissue sarcoma in children, occurs with increased rate in Li-Fraumeni syndrom (muttation in p53)

Epidermolysis Bullosa

mutation in K5 or 14, will expose dermis upon rupture; 5/14 found in the stratum basale

keratinopathic ichthyosis

mutation in K1 or 10, causes superficial blisters as these are found in the stratum spinosum

Ichthyosiform erythroderma

loss of lamellar bodies and reduction in KH granules; results in thick skin all over body [gene is ARCI2, but can't diff between mild and severe]

Mild form can be controlled with retinoic acid
Severe form is lethal, thick skin will crack and peel during child birth

Cutatneous manifestations of AIDS

Melanocytes derivation

come from the neural crest

converts tyrosine to DOPA and to pigment using tyrosinase

TYROSINE AND TYROSINASE ARE NEEDED

Test by incubating hair follicle in substrate

Ty negative, no tyrosinase produced will retain for life and probably become blind

Ty positive, minimal amounts of pigmentation will appear

Blistering disorders of the basement membrane

bullousa pemphigoid

distribution of the femoral cutaneous nerve

back of the thigh and popliteal fossa

anatomic name of three conjoined tendons on the medial aspect of the knee

A-->P
sartorius, gracillus, semitendinosus

pes anserinus bursitis

bursa lies between pes anserinus tendons and the more deeply located semimembranosus tendon; bursa can becomes inflamed and symptomatic

SGT FOT
Sartorius, Gracillus, semiTendinosus
femoral nerve -sartorius
obturator nerve - gracillus
tibial nerve - semitendinosus

components of capsule of knee joint

fascia lata, IT tract, vasti tendons, hamstrings, and sartorius muscles

semitendonosus, semimembranosus, biceps femoris

oblique popliteal ligament

from lateral femur to posterior tibia

reinforces posterior surface of the joint capsule

arcuate popliteal ligament

from the lateral condyle of the femur to the head of the fibula; arches over tendon of the popliteus muscle

stabilizes the posterior aspect of the knee joint

anterior cruciate ligament
from the front of intercondylar eminence to the medial surface of the lateral femoral condyle posteriorly

checks extension and anterior slipping of tibia on femur

posterior cruciate ligament
from the posterior intercondylar fossa and to the lateral surface of the medial femoral condyle anteriorly

checks flexion and posterior slipping of tibia on femur

anterior drawer sign

ACL is torn and tibia can be displaced on femur anteriorly

posterior drawer sign

torn PCL permits posterior displacement of tibia on femur

medial meniscus

cresent shaped; attached to tibia anterior to the ACL and to the posterior intercondylar area; deepens the medial tibial condyle;

the medial (tibial) collateral ligament is firmly attached to the medial meniscus

lateral meniscus

nearly circular; attached to the tibia anterior to the ACL; posteriorly attached to intercondylar eminence anterior to the medial meniscus

medial (tibial) collateral ligament

broad flat bond located slightly posterior on the medial side of the knee joint; attached proximally to the medial epicondyle of the femur right below the adductor tubercle; distal attachment is the the medial condyle of the tibia

resists forces that would push the knee joint medially; it is fused to the medial meniscus

lateral (fibular) collateral ligament

rounded, more narrow, and less broad than the medial collateral ligament, the lateral collateral ligament stretches downward from the lateral epicondyle of the femur above, to the head of the fibular below

not fused with meniscus, less susceptible to injury

tearing of meniscus and the medial collateral ligament. ACL may also tear

bursitis of the knee

constant irritation of a bursa may lead to over secretion and enlargment of the bursa, a condition known as bursitis

medial deviation of the tibia, bow-legged

lateral deviation of the tibia, knock-kneed

genu recurvatum

knee is hyperextended such that the lower extremity curves; convexivity of the curve is posterior and can be symmetrical or unilateral

contents of the popliteal fossa

small saphenous vein
popliteal artery and vein
tibial and common fibular nerves
posterior cutaneous nerve of the thigh
popliteal lymph nodes and lymphatic vessels

superior vs inferior extensor retinaculum

extends across the the tendons superior to the ankle join; the inferior extensor retinaculm is at the level of the ankle joint

superior and inferior fibular retinacula

found on fibular side below lateral malleolus

superficial fibular nerve innervation

supplies lateral compartment muscles; skin on distal third of anterior surface of leg and dorsum of foot

deep fibular nerve innervation

supplies anterior compartment of the leg muscles; skin on first interdigital cleft on the dorsum of the foot

anterior tibial artery origin and detail

originates from popliteal artery

passes through interosseus membrane and descends between the tibialis anterior and the extensor digitorum longus muscles; becomes DORSALIS PEDIS ARTERY

supplies the anterior compartment [NOTE THE LATERAL COMPARTMENT DOES NOT HAVE AN ARTERY IN IT]

Tom, Dick And A Very Nervous Harry

tibialis posterior, flexor Digitorum longus, artery, nerve, vein, flexor Hallicus longus

flexor retinaculum

sheath of fascia which vessels and nerves travel under

posterior tibial artery

terminal branch of popliteal artery; supplies posterior compartment of the leg; gives off fibular artery close to origin; terminates distal to the flexor retinaculm by dividing into med. and lat. planter arteries

descends in the posterior compartment of the leg adjacent to the posterior intermuscular septum; supplies muscles of the posterior compartment and perforates to supply muscles of the lateral comparment

palpating the posterior tibial artery

posterior to medial malleolus

caused by injury to the common fibular nerve, muscles of the anterior and lateral compartments are paralyzed

intermittent claudication

ischemia of the muscle calf; cramp-like pain during exercise due to insufficient blood supply; rest corrects

edema and pain in the distal two-thirds of the tibia; arises from repetitive microtrauma of the tibialis anterior and small tears in the periosteum of the tibia

odd use of extensor digitorum brevis

used to cover wounds and make repairs to the hand

blood supply to the dorsum of the foot

dorsalis pedis artery; division of anterior tibial artery; palpated lateral to the extensor hallucis longus tendon

cutaneous innervation of dorsum of foot

superficial fibular does lateral and dorsum of foot
deep fibular does space between 1st and 2nd

medial and lateral plantar nerves

supplies plantar foot surface; comes from tibial nerve which passes posterior to the medial malleolus

can develop where the intrinsic muscles of the foot originate

Ca abs in the body

when low we rely upon active transport which takes place in the duodenum and the jejunum and is vitamin D dependent [calbindin]

passive abs is used when we have adequate levels of calcium

bioavailability/abs of calcium

abs increased by need

abs decreased by low gastric acidity, phytates, oxylates, high fiber, and lack of vitamin D

major dietary sources of calcium

dairy products, legumes, fortified foods, nuts, and green leafies

phosphorus sources

meat, poultry, fish, eggs, milk

phosphorus toxicity

hyperparathyroidism which leads to excessive bone reabsorption

regulates serum phosphorus levels

role of Mg in bone health

affects [PTH] and active vitamin D; regulates Ca abs and transport

Mg food sources

whole grains, dark green veggies, seeds, nuts, legumes, milk

severe deficiency of Mg

hypocalcemia, decreased serum PTH & vitamin D3 alterted hydroxyapatite, impaired growth, osteoporosis

vitamin D activation

hydoxylated in the liver and then the kidney

major sources of vitamin D

recommending vitamin D supplements

infants who are exclusively breast fed
older adults due to decreased exposure to sun and renal dysfunction

"other" nutrient for bone health

protein and vitamin K

clay shoveler's fracture

fracture of the C6/7; supraspinous ligament avulsion

stable w/ no neurologic impairment

chance fracture

flexion distraction injury or the thoracolumbar vetebrae; posterior elements break: pedicles, SP, ST, lamina

like hangman but more in the thoracolumbar area

comminuted verticle fracture caused by axial load

marginal syndesmophytes

bony growth originating inside a ligament; causes the fusion in anklyosing spondylosis and the 'bamboo' look

expands symmetrically and circumferetially by more than 2mm

disk protrusion

focal, asymmetric extension of disk tissue beyond vertebral body usually into spinal canal or neural foramen

more pronounced protusion and is often responsible for symptoms

spinal stenosis types and causes

central canal stenosis, usually result of facet joint osteophyte and inward bucking of the ligamentum flavum

neural foramen stenosis

lateral recess stenosis (nerve roots lie in this joint after leaving the thecal sack but before exiting neural foramen)

spondylolisthesis

narrowing of intervertebral foramena caused by spondlyosis or retrolisthesis due to bad facet joint

'scotty dog', breaking scotty's neck

describe synovial joint

layers of cartilage in synovial fluid which is trapped by the synovial lining that filters blood from vessels in the subsynovium, both of which are protected by a fibrous capsule

forms boundary of joint space, lined by synoviocytes and does not contain a basement membrane

type A synoviocytes

macrophage like [phagocytic]

type B synoviocytes

fibroblast like, make hyaluronic acid and enzymes that degrade cartilage matrix

mucin clot test

clots mucin, normal synovial fluid is rich in it

viscosity is decreased due to inflammatory process

aka degenerative joint disease, most common form and happens equally in males and females

deep pain which increases during the day, morning stiffness, asymmetric with only a few joints involved, crepitus, decreased range of motion, spinal nerve root compression by osteophytes, and joint space narrowing

rheumatoid factor, Ab to the Fc portion of IgG/M

ACPA (anti-CCP)

anti-cyclic citrulllinated peptide IgG antibody

arginine to citrulline post translational change, highly specific marker for RA

RA associated gene

pathogenesis of RA

synovium thickens, villi develop synoviocytes proliferate, inflammatory cells [T and neutro], clasts activated, synovium penetrates bone

mass of inflamed, abnormal synovium drapes over and causes degradation of cartilage surface

juveninle idiopathic arthritis

begins before 16 years, large joints more likely to be effected, ANA test is generally postive

inflammation fo the entheses, sites where tendons or ligaments insert into bone

Reiter syndrome

Arthritis, urethritis, conjunctivitis
Autoimmune reaction post infection, often symmetric

psoriatic arthritis

7% of psoriatic population

Arthritis associated with IBD

still mostly HLA-B27, pathology similar to RA

bowel resection relieves the arthritis

Infectious arthritis

sudden swelling, fever
granulomatous inflammation

aggregates or urate cyrstals surrounded by inflammation

small cyst, can be at joint capsule, arises from degeneration of connective tissue

from herniation of synovium through joint capsule

Tenosynovial giant cell tumor

benign, treat with surgical excision

synovial sarcoma

malignant, 30% 10 year survival

acute arthritis

severe joint pain, swelling, warmth, redness, decrease in range of motion

septic joint, common organisms

nongonococcal (+)
gonococcal (more common in young patients preceded by gonhheria) (pustules)

1˚ vs 2˚ gout

1˚: obesity, hyperlipidemia, DM, hypertension, and atherosclerosis

2˚: alcoholism, drug therapy, myeloproliferative disorders, chronic renal failure

CPPD, crystal deposition disease, most common in knee and wrist and often precipitated by illness or surgery

definite inflammation of > 5 joints; 2-4 said to have oligoarticular arthritis

symptoms of SLE

rash, oral ulcerations, photosensitive, allopecia, malar rash

causes of polyarthritis

infection, RA, JRA, SLE, reactive arthritis, psoriatic arthritic, polyarticular gout, sarcoid arthritis

note about reactive arthritis

only psoriatic arthrisits

test for anklyosing spondylitis

arthritis, nail changes

reactive and psoriatic artritis

arthritis mutilans

where the bones of the digits just erode and are totally gone

staphylococci characteristic

gram (+) cocci in clusters

"school sores"; staph. aureus or strep pyogenes only epidermal deep

only treat in severe cases with oral antibiotics

4 major toxins from staph aureus

alpha-toxin, the major one, lyses cells [not made by CoNS]
exfoliative toxins, distrupt epidermis at the granular layer
superantigen toxins, mitogenic for T cells, stimulates cytokine storm
enterotoxins (staph food poisoning)

bullous impetigo

like impetigo, except bacteria releases exfoliative toxin; more likely to be seen in newborns

'deep impetigo', shallowed out ulcers with necrotic base that extends deeper into the dermis than impetigo

boils/furuncles

most common, bacteria enter via scrape, cut, hair follicle damate; pea-seized abscess or larger

clusters of boils connected under the epidermis; serious, risk for bacteremia; progressing case may require medical attention [i.e. incision and drainage]

serious spreading infection of the dermis/hypodermis; skin is red, tender, swollen; occurs most often in legs; treat with oral antibiotics

GAS is the most common cause; deper than erysipelas

staph scalded skin syndrome, localized infection but systemic spread of exfoliative toxin

staph aureus in oil glands

hot-tub folliculitis causitive agent

pseudomonas aerunginosa

acne causitive agent

proprionibacterium acnes

staph aureus colonized area

anterior nares and skin

gene for methicillin resistance

S. epidermidis vs S. saprophyticus

epidermidis can form biofilm
saprophyticus can be UTI [not aureus or epi]

necrotizing fasciitis causative agent

streptococcus pyogenes

Lancefield grouping of strep pyogenes

GAS, beta-hemolysis (the really bad kind)

skin wounds caused by GAS; shiny, raised tender plaque-like erythematous rash with distinct margins

skin rash & fever associated with strep throat (S. pyogenes)

predominant agent of osteomyelitis

SSA and salmonella

sickling causes GI damage, allows food-bourne bacteria in. sluggish flow in marrow facilitates bone infection

septic arthritis cause (not aureus)

neisseria gonorrhoeae

cause of tuberculous spondylitis

Mycobacterium tuberculosis

acetabular labrum

deepens acetabulum

transverse acetabular

crosses notch and completes rim of acetabulum

round ligament (ligamentum capitis femoris)

osteoporosis drug choices for men? glucocorticoid-induced osteoporosis?

alendronate, risedronate, zoledronic acid, denusomab, teraparatide

all except denosumab

adductor canal contents and borders

passage way for the femoral artery and vein, the saphenous nerve, and nerve to the vastus medialis

vastus medialis anteriorly and lateraly
adductor longus and magnus posteriorly
sartorius medially, forming its roof

iliotibial band syndrome

common cause of lateral knee pain, particularly among runners and cyclists

biomechanical abnormalities may lead to IT band problems also

superior/inferior gluteal nerve levels

superior is L4,5/S1
inferior is L5/S1,2

sciatic nerve levels

myoepithelial cells

cells flattened against the bottom of eccrine glands which contain contractile proteins

location of meissner's vs pacinian

meissners is in the dermal ridges
pacinians in the deep dermis/hypodermis

characteristic of developing cartilage

less isogenous groups, less basophilia

where to find fibrous cartilage

IV disc and pubic symphysis

EM of osteoclast

100s of clear vesicles lined along the border, plus the ruffled border

rings of bone; ones that don't form circles are called insterstitial

volkmann's canals

run perpendicular to long axis of bone; connects to outside and marrow cavity

what is located in a haversion canal

connective tissues and blood vessels

inherited development disorders

Treacher-Collins, Holt-Oram, and achondroplastic dwarfism

functions of vitamin D in regard to bone health

increases Ca and PO3 absorption
increases calcium and PO3 resporption
decreases Ca loss in urine

blood supply to posterior compartment/hamstrings

branches of the profunda femoris

capsule of the knee joint contributions

fascia lata, IT band, tendons of the vasti, hamstrings and sartorius

septa of the leg

interosseous membrane
anterior crural septa
posterior crural septa
intermuscular septum

gene for harlequin ichthyosis

ARCI2

autosomal recessive congenital ichthyosis

Spondylolytic spondylolisthesis

defect in bony pars interarticularis; when bilateral, posterior aspect of vertebral body separates from the anterior body

superficial clefting, softening (of cartilage at articular joint)

smooth bone surfaces, burnished from brinding against one another

subchondral cyst

fluid gets into subchondral bone after cartilage wears away

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