1
Q
what muscles make up the rotator cuff muscles
A
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
2
Q
function of rotator cuff muscles
A
stabilise the glenohumeral joint
(glenoid fossa of SCAPULA
articulate w/ head of HUMERUS)
3
Q
at which parts of the humerus does each rotator cuff muscle attach to
A
- subscapularis: lesser tubercle
- supraspinatus: superior facet of greater tubercle
- infraspinatus: middle facet of greater tubercle
- teres minor: inferior facet of greater tubercle
4
Q
at which parts of the scapula is each rotator cuff muscle found
A
- subscapularis: anterior scapula
- supraspinatus: posterior scapula, above spine of scapula
- infraspinatus: posterior scapula, below spine of scapula
- teres minor: posterior scapula, below spine of scapula
5
Q
what type of synovial joint is the glenohumeral joint
(= shoulder joint)
A
ball-and-socket
6
Q
what structures help to strengthen the glenohumeral joint
A
- glenoid labrum,
which deepens glenoid cavity - glenohumeral and coracohumeral ligaments
- rotator cuff muscles
7
Q
which ligament prevent the superior displacement of the head of the humerus
(esp during forward abduction)
A
coracoacromial ligament
8
Q
what is a bursa
plura: bursae
A
sacs of serous fluid
which lie between bone and tendon
and function to protect the tendon from the bone
9
Q
what movements do each of the rotater cuff muscles help in
A
- subscapularis: medial rotation
- supraspinatus: INITIATION of abduction (0º-15º)
- infraspinatus and teres minor: lateral rotation
10
Q
which nerves innervate each of the rotator cuff muscles
A
- subscapularis: subscapular nerve (C5-C7)
- supraspinatus: suprascapular nerve (C4-C6)
- infraspinatus: suprascapular nerve (C5-C6)
- teres minor: axillary nerve (C5-C6)
11
Q
what type of synovial joint is the elbow joint
A
hinge
12
Q
what are the 8 carpal bones
A
“Some Lovers Try Positions That They Can’t Handle”
- proximal row (lateral to medial):
scaphoid,
lunate,
triquetrum,
pisiform - distal row (medial to lateral):
trapezium,
trapezoid,
capitate,
hamate
13
Q
what kind of tissue is bone
human body is made up of four basic tisssues:
1. epithelium
2. connective tissue
3. muscle tissue
4. nerve tissue
A
specialised type of CONNECTIVE tissue
14
Q
parts of a bone
A
15
Q
histology of psoriasis
A
- acanthosis ← psoriasiform epidermal hyperplasia
- parakeratosis ⇒ scales
- subcorneal neutrophilic aggregates (Munro microabscess)
16
Q
what can psoriasis predispose an inidivual to
A
metabolic syndrome
cos psoriasis results in:
* proinflammatory cytokines
* oxidative stress
* ER stress
* adipocytokine
* dysbiosis gut microbiota
17
Q
which immune cell mediates psoriasis
A
T cells
18
Q
what is a synovial sheath
A
- a protective, two-layered tube that completely surrounds a tendon
- and facilitates movement by relieving friction bet tendon and surrounding structures
How does it do so?
* Inner layer (visceral layer) is stuck tightly to the tendon surface
* Outer layer (parietal layer) is attached to surrounding tissue (e.g., fibrous tunnel)
* presence of synovial fluid BETWEEN the layers
→ lubricates the movement
19
Q
muscle attachments:
* bet origin and insertion, which one is the proximal attachment vs distal attachment of the muscle?
* bet origin and insertion, which one is movable?
* for muscles that cross multiple joints, on which joint does it have the greatest effect?
A
muscle attachments:
* origin is the proximal attachment of the muscle
while insertion is the distal attachment of the muscle
* insertion is the part that is movable
* muscles have the greatest effect at the joint closest to its insertion, and has weaker “secondary” effects on the others
20
Q
what is the difference bet these 2 set of actions of scapula, retraction/protraction
vs medial/lateral rotation
A
- retraction/protraction involves the WHOLE scapula moving medially or laterally
- medial/lateral rotation involves the INFERIOR ANGLE moving medially and downwards or laterally and upwards
21
Q
what muscles are involved in elevation of scapula
one of the more commonly tested qns!
A
- trapezius (upper fibers)
- levator scapulae
22
Q
what muscles are involved in depression of scapula
A
- trapezius (lower fibers)
- pectoralis minor
- latissimus dorsi
for lats, think of how scapula is depressed when you do PULL-UPS!
cos when arms are fixed,
contraction of lats
→ humerus is pulled
→ scapula dragged with it
⇒ indirectly depress scapula
23
Q
what muscles are involved in protraction of scapula
one of the more commonly tested qns!
A
- serratus anterior
- pectoralis minor
24
Q
what muscles are involved in retraction of scapula
one of the more commonly tested qns!
A
- trapezius (middle fibers)
- rhomboids
25
what muscles are involved in **lateral rotation** of scapula
## Footnote
one of the more commonly tested qns!
* trapezius (**upper AND lower** fibers)
* serratus anterior
## Footnote
NOT pectoralis minor as it also depresses scapula,
but impt function of lateral rotation is to move **glenoid cavity** so that it **faces UPWARDS**!
26
what muscles are involved in medial rotation of scapula
* rhomboids
* **latissimus dorsi**
## Footnote
* for lats, same concept as depression of scapula
in which when **arms are fixed**,
contraction of lats
→ humerus is pulled
→ scapula dragged with it
⇒ **indirectly** depress scapula
(importantly **glenoid cavity** moves to **face downwards**)
* NOT lower fibers of trapezius a while it does retract scapula, it does NOT bring glenoid cavity to face upwards!
27
what muscles are involved in abduction of shoulder joint
anything that inserts **superiorly or laterally**
* supraspinatus
(inserts at **superior facet**
of greater tuberosity of humerus)
* MIDDLE deltoid
(inserts at deltoid tubersity,
which is at **lateral side of humerus**)
28
what muscles are involved in adduction of shoulder joint
anything that inserts at **bicipital/intertubercular groove**
"**Lady** bet 2 *majors*"
* **Latissimus dorsi**
* Pectoralis *major*
* Teres *major*
29
what muscles are involved in medial rotation of shoulder joint
* **Latissimus dorsi**, pectoralis *major*, teres *major* (3)
("**Lady** bet 2 *majors*")
* ANTERIOR deltoid (1)
* subscapularis (2)
30
what muscles are involved in lateral rotation of shoulder joint
* posterior deltoid
* infraspinatus, teres minor
## Footnote
why is supraspinatus not involved?
* both infraspinatus and teres minor are attached more **posteriorly** and **inferiorly**
→ their pull is **directed backward**
⇒ causing lateral rotation
* supraspinatus is attached **on top (superior facet)**
→ its line of pull is **straight upward**,
not backward
31
types of contact dermatitis (2)
* **irritant** CD:
1. due to **direct injury** to skin by irritating or toxic substance
2. can occur in **any individual**
* **allergic** CD:
1. immune system response
(**type IV** delayed hypersensitivity reaction),
resulting in a **skin lesion**
2. associated with **history of atopy**
32
facts about Cutaneous Adverse Drug Reactions (CADRs):
* definition
* types
* what severe CADR involves
* adverse drug reaction occuring on **skin**
* can be classified as
1) immunologic: where damage to skin occurs occurs due to **immune response** to inciting agent
(e.g. hypersensitivity reactions)
2) non-immunologic: **direct damage** to skin cells by inciting agent
* severe CADR involves:
1) skin failure: failure of normal **skin functions**, including **thermoregulation, barrier to infection, water conservation**
2) involvement of **other organ systems**
33
features of exanthem
| a CADR
* type **IV** hypersensitivity rxn
* drug related:
NSAIDs,
Antibiotics,
Antiepiletics,
Allopurinol
* presents as **erythematous**, **non-scaly plaques and papules**
## Footnote
small numbers of lymphocytes go to the dermal-epidermal junction (interface dermatitis),
causing injury to the keratinocytes (basal vacuolar degeneration),
thus manifest as red patches
34
features of Steven-Johnson Syndrome (SJS)
* type **IV** hypersensitivity rxn
(specifically **Tc** cells — CD8+ cytotoxic lymphocytes)
* drug related:
NSAIDs,
Antibiotics,
Antiepileptics,
Allopurinol
* presents as
1) initially erythematous macules and papules
2) which turn into **violaceous or dusky** scaly **erosions**
← epidermis **dying** and **sloughing off**
3) also has **blister** formation
← epidermal **necrosis** and resultant **inflammation** UNDER dead epidermis
* causes **skin failure**
## Footnote
histology: dead epidermis is **PINK** in colour
35
difference bet Steven-Johnson Syndrome (SJS)
and Toxic Epidermal Necrolysis (TEN)
same disease process,
only diff is body **surface area** involved
(i.e. has **detached/detachable epidermis**)
* SJS: **< 10%**
* TEN: **> 30%**
## Footnote
detached/detachable epidermis = **dead** epidermis
36
features of Acute-Generalised Exanthem Pustulosis (AGEP)
* type **IV** hypersensitivity rxn
* drug related:
NSAIDs,
Antibiotics,
**Paracetamol**
* presents as erythematous non-scaly plaques and papules, with **pustules**
(look like **white dots** on top of pink patches)
37
features of Drug Hypersensitivity Syndrome (DHS)
* type **IV** hypersensitivity rxn
* drug related:
NSAIDs,
Antibiotics,
Antiepileptics,
Allopurinol
* presents as erythematous, non-scaly, maculopapular rash,
**a/w periorbital, facial or neck oedema**
38
differences bet DHS and exanthem
* **Latency** period: **DHS** relatively **longer**
* **Distribution**:
**face usually spared** in **exanthem**, more centripetal distribution affecting trunk and limbs
* **Systemic** symptoms: **DHS** can affect other organs
## Footnote
for latency period,
* exanthem: 4 DAYS to 2 weeks
* DHS 2-6 WEEKS
39
pathophysiology of acne vulgaris
* HYPER**keratin**isation
* ELEVATED **androgen** levels
=> **sebaceous gland** **hypertrophy** and seborrhoea
(= **excess sebum** production)
* **Cutibacterium acnes** colonises follicles
-> stimulate **immune response**
=> **inflammation**
## Footnote
microcomedome
(from hyperkeratinisation = cells stick tgt to form plug)
AND sebum collection
= comedome
40
treatment for acne vulgaris:
drugs used for different severity
AND their contraindications
* mild acne:
1) topical **retinoids**
(e.g. tretinoin, adapalene):
comedolytic > anti-inflammatory
=> prevent acne from even developing
2) topical **antimicrobials**
(e.g. **BPO**)
* moderate acne:
oral antimicrobials
(e.g. **tetracyclines**):
avoid in **pregnancy**
or **< 8 y/o**
* severe acne:
oral **isotretinoin**:
powerful comedolytic and anti-inflammatory agent ,
contraindicated in **pregnancy**
41
morphology of acne vulgaris
* non-inflammatory:
1. black, non-scaly, **papules**
(= blackheads)
2. OR white, non-scaly, **papules**
(= whiteheads)
* inflammatory:
1. **erythematous**, non-scaly, **papules and pustules**
2. **nodules and cysts** filled with pus or serosanguinous fluid
42
neurofibromatosis type 1:
* inheritance pattern: (...)
* presentation:
"FIBROMA"
F — (...)
I — Irish hamartoma
B — Bone lesion
R — (…)
O — Optic glioma
M — (…)
A — (…)
AND N for (…)
* inheritance pattern: AD
* presentation:
"FIBROMA"
F — **Fibroma**:
benign peripheral **nerve tumour**,
presents as skin-coloured, raised nodule
I — Irish hamartoma
B — Bone lesion
R — **Relatives**
O — Optic glioma
M — **Macules** (**CAFE-AU-LAIT**):
*flat*, uniformly **hyperpigmented *macules***,
**early** onset (1st yr after birth)
A — **Axillary freckling**:
**smaller** in size than cafe-au-lait macules,
**later** onset (3-5 yrs after birth)
AND N for **Neurological abnormalities**
(e.g. cognitive defects, motor developmental delays, headaches)
## Footnote
neurofibroma ≠ NF 1
(90% are solitary)
43
what drug should be given in infantile haemangioma
**beta-blockers**
* given ONLY if haemangioma is life-threatening, causing functional impairment, or potentially disfiguring
* **topical** given for small and superficial ones
(i.e. **less severe**)
while **oral** is given for large and deep ones
(i.e. **more severe**)
## Footnote
bcos β-blockade **reduces** adrenergic-mediated **vasodilation**
and also **↓ angiogenesis**
44
bullous pemphigoid:
* morphology (2)
* pathophysiology:
AUTOantibodies target (...)
→ loss of function and loss of adhesion of (...)
⇒ formation of (...)
* occurs over (...)
* morphology:
1. ***tense*** vesicles and **bullae**
2. (after rupture) **erythematous plaques and erosions**
* pathophysiology:
**AUTOantibodies** target ***BP180*** (*HEMIdesmosomes*)
→ loss of function and loss of **adhesion of *epidermis to BM***
⇒ formation of **blisters**
* occurs over **months**
## Footnote
recall!
* bullous = >1cm circumscribed, elevated, superficial cavity containing **fluid**
* pemphigus *vulgaris*:
*desomosomes* are targeted instead
→ loss of function and **adhesion bet *diff layers of the epidermis***
⇒ ***flaccid* blisters**
45
broad strokes for treatment of skin conditions
| specifically psoriasis, atopic dermatitis and contact dermatitis
1. glucocorticoids
2. immunosuppressants:
calcineurin inhibitors
3. PDE4 inhibitors
* glucocorticoids and calcineurin inhibitors:
**broadly** anti-inflammatory and **suppress T cells** respectively
=> used in all 3 bcos
* PDE4 inhibitors:
only reduce **certain pro-inflammatory cytokines**
=> used in AD and psoriasis only
46
shoulder dislocation:
* (anterior/posterior/lateral) dislocation is most common
* clinical presentation
* complications:
injury to which nerve
AND effects on sensory and motor functions
* **anterior** dislocation
← fall backwards on outstretched hand
* **squaring** of shoulder, **rounded contour loss**
* complications:
**axillary** nerve injury
(← stretch, compress, or tear of the nerve against the **surgical neck of the humerus**),
resulting in
1. sensory loss over **regimental badge area**
(= skin over lower half of deltoid)
← supplied by branch of axillary nerve
2. loss of **abduction** (past 15º)
← weakness of deltoid
← deltoid is supplied by axillary nerve
47
complications of recurrent shoulder dislocation
| common in younger patient (20-30 y/o)
1. Bankart lesion:
**tear** of anterior inferior **labrum** of glenoid
2. Hill-Sachs lesion:
**fracture** on posterior superior aspect of **humeral head **
48
a fracture in the following parts of the humerus
will result in a lesion of which nerve?
1. surgical neck
2. shaft
3. supracondylar
4. medial epicondyle
1. surgical neck
= axillary nerve
2. shaft (= radial groove)
= radial nerve
3. supracondylar
= median nerve
4. medial epicondyle
= ulnar nerve
49
which muscle is usually involved in rotator cuff tear
**supraspinatus**
due to it being in a narrow space
(underneath acromion and coracoacromial ligament)
→ more likely to be impinged
(= compressed, pinched or rubbed)
50
what nerve innervates teres **major**
inferior subscapular nerve
## Footnote
both superior and inferior subscapular nerve
branch out directly from posterior cord of brachial plexus!
* superior subscapular innervates subscapularis
* inferior subscapular innervates teres major
51
what nerves innervate pectoralis **major** and **minor** respectively
* pectoralis maj: LATERAL and MEDIAL **pectoral** nerve
* pectoralis min: MEDIAL **pectoral** nerve
52
what nerve innervates serratus anterior
**LONG thoracic** nerve
53
boundaries of axilla region:
* apex
* anteriorly
* posteriorly
* medially
* laterally
* apex: **1st rib, clavicle and superior border of scapula**
* anteriorly: pec maj and min
* posteriorly: subscapularis
and scapula
* medially: serratus anterior
and **1st-4th** ribs
* laterally: **intertubercular groove** of humerus
54
basic qn!
in the **elbow** joint,
1) what parts of humerus do the radius and ulna articulate with respectively?
2) which is more medial, radius or ulna?
*"TUMCLR"*
* ***T* rochlea** of humerus
→ ***U* lna** (trochlear notch)
→ ***M* edial**
* ***C* apitulum** of humerus
→ ***R* adius** (upper surface of head)
→ ***L* ateral**
55
factors contributing to stability of elbow joint:
* bony factors
* ligamentous factors
* muscular factors
* bony factors: trochlea of humerus **fits nicely**
into trochlea notch of ulna
* ligaments: ulnar (medial) and radial (lateral) **collateral** ligaments
* muscles:
brachialis, biceps brachii,
brachioradialis,
triceps brachii
56
relationship bet elbow and proximal radio-ulnar joint:
* capsule and synovial membrane
* ligaments
* movements
* **synovial membrane** of elbow joint
**continues inferiorly**
with synovial membrane of proximal radio-ulnar joint
← both joints are encapsulated by the **same capsule**
* **radial/lateral collateral** ligament of elbow joint
**blends with**
**annular** ligament of proximal radio-ulnar joint
* **elbow** joints can ONLY carry out **flexion and extension**
while **radio-ulnar** joints are in charge of **supination and pronation**
57
muscles involved in supination and pronation respectively of radio-ulnar joints
* supination:
1. **biceps brachii**: when **elbow is flexed**
2. supinator
* pronation:
1. pronator teres
2. pronator quadratus
## Footnote
note:
* **supination** > pronation
(think of how you turn a door knob)
* **biceps brachii** > supinator
during supination
58
radial head subluxation and dislocation:
* definition
* when it occurs
* pulling of radial head from **annular ligament**
* occurs when **PULLING a child's hand**
59
origin and insertions of arm muscles
* coracobrachialis:
O = coracoid process of scapula
I = mid part of humerus
* brachialis:
O = midshaft of humerus
I = **coronoid process and ulnar tuberosity of ulna**
* biceps brachii:
O = coracoid process of scapula (short head),
supraglenoid tubercle of scapula
(long head)
I = **radial tuberosity**
* triceps brachii:
O = infraglenoid tubercle of scapula (long head),
above radial groove of scapula (lateral head),
below radial groove of scapula
(medial head)
I = **olecranon** of ulna
60
bounderies of cubital fossa
* medial: **pronator teres**
* lateral: brachioradialis
* superior: imaginary line connecting medial and lateral epicondyles
* floor: **supinator and brachialis**
* roof: deep fascia and bicipital aponeurosis
61
content of cubital fossa
from medial -> lateral:
*"Mother Buys Ten Rabbits"*
* ***M* edian** nerve
* *B* rachial artery,
which **bifurcates** there to form ulna and radial artery
* *T* endon of biceps
* ***R* adial** nerve
62
which vein is commonly used as a venipuncture site
and why
* **median cubital** vein
* separated from **median nerve and brachial artery**
(contents of cubital fossa)
by **bicipital aponeurosis**
(roof of cubital fossa)
63
muscles in anterior compartment of forearm
(4, 1, 3)
* superficial (lateral -> medial):
pronator teres,
flexor carpi radialis,
palmaris longus,
flexor carpi ulnaris
* intermediate: flexor digitorum superficialis
* deep:
flexor digitorum profundus,
flexor pollicis longus,
pronator quadratus
64
muscles in posterior compartment of forearm
* thumbs up side (more lateral)
(lateral -> medial):
brachioradialis,
extensor carpi radialis longus,
extensor carpi radialis brevis
* pinky up side (more medial):
anconeus,
extensor carpi ulnaris,
*supinator*
* finger muscles:
extensor digitorum,
extensor digiti minimi,
*extensor indicis*
* thumb muscles
(lateral -> medial):
*abductor pollicis longus,
extensor pollicis brevis,
extensor pollicis longus*
## Footnote
*muscles are in deeper layer*
65
nerves innervating muscles in anterior compartment of forearm
* all innervated by **median** nerve
* except for **flexor carpi ulnaris** and **medial** half of **flexor digitorum profundus**,
which are innervated by **ulnar** nerve
66
nerve innervating muscles in posterior compartment of forearm
all innervated by **radial** nerve
67
which muscles are involved in flexion and extension respectively of the wrist
* flexion: all **flexor** muscles
(FCR, PL and FCU,
assisted by FDS, FDP and FPL)
* extension: all **extensor** muscles
(ECRL, ECRB and ECU,
assisted by, ED, EDM and EPL)
68
which muscles are involved in abduction and adduction respectively of wrist
* **abduction**: all **radialis** muscles
(FCR, ECRL and ECRB,
assisted by APL)
* *adduction*: all *ulnaris* muscles
(FCU and ECU)
69
movement done by
flexor digitorum SUPERFICIALIS
vs
flexor digitorum
PROFUNDUS
* FDS: flex ***MCP*** and ***P*IP** joints
← inserts at ***middle* phalanges**
* FDP: flex ***D*IP** joint
← inserts at ***distal* phalanges**
70
movement done by
flexor pollicis longus
vs
flexor pollicis brevis
* FPL: flexes thumb at ***IP*** and MCP joints
← inserts at ***distal* phalanx**
* FPB: flexes thumb at ***MCP*** joint
← inserts at ***proximal* phalanx**
## Footnote
* FPB is part of **thenar muscles**,
which all **originate from flexor retinaculum**
and **insert at proximal phalanx**
* FPL and APL
(which both have counterparts (FPB and APB) in thumb)
are both the **most lateral muscles**
(i.e. thumb side)
in anterior and posterior compartments respectively
71
movement done by
abductor pollicis longus
vs
abductor pollicis brevis
* APL: abducts and extends thumb at **CMC** joint
← inserts at metacarpal
⇒ moves WHOLE metacarpal away from palm
* APB: abducts thumb at **MCP** and CMC joints
← inserts at proximal phalanx
⇒ more PRECISE/fine-tuned abduction
## Footnote
* APB is part of **thenar muscles**,
which all **originate from flexor retinaculum**
and **insert at proximal phalanx**
* FPL and APL
(which both have counterparts (FPB and APB) in thumb)
are both the **most lateral muscles**
(i.e. thumb side)
in anterior and posterior compartments respectively
72
what movement is done by extensor digitorum
(and how)
extends medial **4** digits
at **MCP and IP** joints
← inserts into **extensor expansion**
73
radial nerve pathway:
pass through *axilla*
THEN
* give off motor branches to (...)
* give off sensory branches (...)
pass through *radial groove*
THEN
* give off motor branch to (...)
pass through *elbow*
and wrap around *neck of radius*, where it
* where it gives off a sensory branch to (...) — superficial branch
* and a motor branch to (...) — deep branch (PIN)
deep branch immediately supplies muscles in the region,
while superficial branch continues on to *pass the wrist and into the hand*
pass through *axilla*
THEN
* give off motor branches to **triceps brachii**
* give off **sensory** branches **to posterior arm and forearm**
pass through *radial groove*
THEN
* give off motor branch to **ECRL**
pass through *elbow*
and wrap around *neck of radius*, where it
* where it gives off a **sensory** branch to **dorsum** of hand (esp 1st webspace)
+ **dorsal** surface of** lateral 3.5 fingers** (except nailbeds) — **superficial** branch
* and a motor branch to **muscles in the posterior forearm** — **deep** branch (**PIN**)
deep branch immediately supplies muscles in the region,
while superficial branch continues on to *pass the wrist and into the hand*
74
compare effects of a lesion at different sites of radial nerve:
* axilla
* mid-arm
* neck of radius
* near wrist
* axilla: **everything** affected
(triceps loss, triceps reflex absent,
wrist drop, finger drop,
sensory loss over arm, forearm and dorsum)
* mid-arm (= radial groove):
**triceps reflex intact**
(← branch out ABOVE radial groove),
but wrist and finger drop,
**no loss of sensation over arm and forearm**
(but this is a maybe
← posterior cutaneous nerve branches out WITHIN radial groove),
but loss of sensation over dorsum
* neck of radius (= PIN palsy):
triceps reflex intact,
**only finger drop but no wrist drop**,
← branch to ECRL is above elbow and thus not affected
**no sensation loss**
* near wrist (= superficial radial nerve):
ONLY **sensory loss over dorsum
(usually 1st dorsal webspace)**
## Footnote
* lesion near wrist (= superficial radial nerve)
= **wartenburg** syndrome
* lesion at axilla
= **saturday night** palsy
75
boundaries of carpal tunnel
* floor: concavity of **carpal bones**
* roof: **flexor retinaculum**
* medial: **H**amate hook AND **P**isiform
lateral: *S* caphoid AND
*T* rapezium
"*S* ome lovers try **P**ositions
*T* hat they can't **H**andle"
76
contents of carpal tunnel
* 9 tendons:
(basically flexor muscles in
intermediate and deep layers of
anterior compartment of forearm
— except PQ):
**FDS** (4),
**FDP** (4),
**FPL** (1)
* 1 nerve: **median** nerve
77
carpal tunnel syndrome:
* which nerve is affected
* effects
* risk factors
* **median** nerve is trapped in carpal tunnel
* numbness and/or
paraesthesia (= tingling)
over **lateral 3.5 fingers (palm side)**
(and their nailbeds)
* risk factors:
1. (most common) idiopathic
2. repetitive wrist movings (e.g. typing)
3. pregnancy
→ **fluid retention**
## Footnote
lateral aspect of skin of palm is SPARED
← supplied by palmar cutanous branch
← branches out at forearm
and thus BEFORE carpal tunnel
78
tests for carpal tunnel syndrome
* **Tinel's** test:
**tap** over carpal tunnel
⇒ (+) sign: **shooting sensation** down lateral 3.5 fingers
* **Durkan's** compression test:
apply **direct pressure** over carpal tunnel using **thumbs**
AND **flex wrist**
⇒ (+) sign: **numbness** in lateral 3.5 fingers
* **Phalen's** test:
put **hands tgt** to **flex wrist**
⇒ (+) sign: reproduction OR exacerbation of symptoms
79
movement done by lumbricals
* **flex MCP** joints
← **passes MCP** joint
* AND *extend IP* joints
← before inserting at *extensor hood*
80
claw hand vs ape hand vs hand of benediction
| think of position, nerve affected, muscles affected and finally effect!
81
compare effects of a lesion at different sites of median nerve:
* elbow
* mid-arm
* wrist
* elbow: **everything** affected
(**FULL benediction sign** and median claw,
sensory loss over **lateral 3.5 fingers and thenar eminence**)
* mid-arm (= **AIN palsy**):
**PARTIAL benediction sign** and median claw,
**NO sensory loss**
* wrist (= **carpal tunnel**):
**median claw**,
sensory loss over **lateral 3.5 fingers**
82
what is the ulnar claw
and ulnar paradox
* occurs upon **opening hand**
* **ring and little** fingers are **clawed**
(= MCP hyperextended, IPs flexed)
← paralysis of 3rd and 4th **lumbricals**,
resulting in **unopposed** action
of **extensor digitorum**
and **FDP & FDS**
* ulnar paradox =
the **lower** the lesion,
the **greater the clawing**
due to **medial half of FDP** still working
at a higher lesion
← supplied by motor branches which branch out **high in forearm**
83
compare effects of a lesion at different sites of ulnar nerve:
* high (medial epicondyle)
* low (wrist)
* high (medial epicondyle): **everything** affected
(loss of power to FCU and medial 1/2 of FDP, claw hand,
sensory loss to Volar + dorsal surface of ulnar 1.5 fingers and hypothenar eminence)
* low (wrist):
**claw hand**,
sensory loss ONLY to **pulp of medial 2 fingers**
84
boundaries of anatomical snuff box
* lateral: **APL, EPB**
* medial: **EPL**
* floor: *S* caphoid and
*T* rapezium bones
"*S* ome lovers try positions
*T* hat they can't handle"
85
contents of anatomical snuff box
* **radial** artery
* **radial** nerve
## Footnote
recall!
RADIAL nerve runs more towards **dorsal side** and laterally (**nearer to thumb**),
median nerve runs centrally,
ULNAR nerve runs more towards **palm side** and medially (**nearer to pinky**)
86
De Quervain Tenosynovitis
* pathophysio:
**repetitive** thumb movements (e.g. forceful gripping) or **direct trauma**
→ **thickening** of tendon sheath as the **microtears heal**
→ resulting **tendon friction** during movement once again causes microtrauma
AND **inflammation**
* **Finkelstein's** test:
patient makes a **fist with thumb inside** the fingers and examiner **ulnar-deviates wrist**
⇒ (+) sign: **sharp pain** over **1st dorsal compartment**
87
factors contributing to stability of wrist joint:
* bony factors
* ligamentous factors
* muscular factors
* bony factors: concave distal radius and convex proximal carpal bones are **snug**,
though not as congruent as in elbow joint
* ligaments:
palmar and dorsal **radiocarpal** ligaments,
radial (lateral) and ulnar (medial) **collateral** ligaments
* muscles: all **flexor and extensor** muscles
88
wrist joint:
* articular surfaces
* type of joint
* movements
* distal end of radius AND **articular disc**
with **scaphoid, lunate and triquetrum**
(pisiform is not involved!)
* **ellipsoid** synovial joint
* flexion/extension,
abduction/adduction,
pronation/supination
89
common injuries sustained from FOOSH
| **FOOSH** = **F**all **O**n **O**ut**S**tretched **H**and
* Colles fracture:
fracture of distal **radius**
→ **dorsal displacement** and angulation of **distal fragment**
⇒ "**dinner fork** deformity"
* Scaphoid fracture:
present with pain in **anatomical snuff box**,
may result in **avascular necrosis**
← disruption of **radial artery** which supplies scaphoid
90
metacarpophalangeal joint (MCP):
* type of joint
* movements
* ligaments strengthening it
* synovial **condyloid** joint
* flexion/extension,
abduction/adduction
* ligaments:
**palmar** ligament
and **collateral** ligaments
## Footnote
**PALMAR** ligament = only found **anteriorly**
91
interphalangeal joint (IP):
* type of joint
* movements
* ligaments strengthening it
* synovial **hinge** joint
* flexion/extension ONLY
* ligaments:
**palmar** ligament
and **collateral** ligaments
## Footnote
**PALMAR** ligament = only found **anteriorly**
92
what type of joint is the first CMC joint
**saddle** joint
## Footnote
* allows movement in **2 planes**
(flexion/extension AND abduction/adduction)
→ similar to **condyloid** joints
* diff is that it allows some **axial rotation** as well
⇒ allows **OPPOSITION**
(impt movement of thumb)
93
movements done by dorsal and palmar interossei respectively
"*PAD* *DAB*"
* *D* orsal: ***AB* ducts 2nd-4th** digits
(2nd and 4th digits move **AWAY from 3rd digit**,
while 3rd digit can move in **either direction**)
* *P* almar: ***AD* ducts 2nd, 4th and 5th** digits
(all 3 move **TOWARDS 3rd digit**)
## Footnote
* both the interossei and lumbricals insert at the extensor hood
* BUT interossei also additionally inserts at
**bases of proximal phalanges**
⇒ allowing it to abduct or adduct digits
94
trigger finger
**A1 pulley**
(**tendon sheath** at level of MCP joint) becomes **thickened**
→ **narrowed tunnel** for tendon
→ tendon struggles to glide through during **flexion**
⇒ **stuck or 'popping'** sensation when trying to **force tendon through**
95
axillary artery:
1. continues FROM (...) at (...)
2. has 3 parts, with each part giving rise to different arteries:
1st - (...)
2nd - (...) and (...)
3rd - (...) and (...)
3. continues AS (...) after (...)
1. continues FROM **subclavian** artery at **lateral border of 1st rib**
2. has **3** parts, with each part giving rise to different arteries:
*1st* - ***superior* thoracic** artery
*2nd* - ***lateral* thoracic** and **thoracoacromial** arteries
*3rd* - ***subscapular*** and
**anterior + posterior circumflex humeral** artery
3. continues AS **brachial** artery after **teres major**
96
Brachial artery:
* runs in (...) compartment of arm
* gives rise to (...)
→ runs in posterior compartment with radial nerve
* divides into (...) and (...) nerves at (...)
*B* rachial artery:
* runs in **anterior** compartment of arm
* gives rise to **profunda brachii**
→ runs in **posterior** compartment with radial nerve
* divides into **radial** and **ulnar** nerves at **cubital fossa**
(recall "Mother *B* uys Ten Roosters")
97
radial artery:
* runs in lateral side of (...) compartment
* best felt lateral to (...)
* continues as (...)
which anastamoses with branches of ulnar artery
ulnar artery:
* passes into (...) aspect of forearm to palm
(enters hand (...) to flexor retinaculum,
(...) to palmar aponeurosis)
* continues as (...),
which anastamoses with branches of radial artery
radial artery:
* runs in lateral side of **anterior** compartment
* best felt lateral to **FCR**
* continues as **DEEP palmar arch**
which anastamoses with branches of ulnar artery
ulnar artery:
* passes into **anterior** aspect of forearm to palm
(enters hand **anterior** to flexor retinaculum,
**deep** to palmar aponeurosis)
* continues as **SUPERFICIAL palmar arch**,
which anastamoses with branches of radial artery
98
Allen's test:
* aim
* procedure
* normal results
* aim: ensure **ulnar** artery can **supply hand**
just in case radial artery is damaged or used for a procedure
* procedure:
patient makes a **fist**,
examiner **compresses BOTH radial and ulnar** artery,
then **release ONE** and see if **colour returns**
* normal: colour returns in
**5-7s**
99
veins in upper limb:
* basilic vein:
1. (...) side
2. originates from (...)
3. joined by (...) to form (...)
* cephalic vein:
1. (...) side
2. originates from (...)
3. runs in (...)
4. communicates with basilic vein by (...) in cubital fossa
5. continues through (...) groove,
pierces (...) fascia
and drains into (...)
* basilic vein:
1. **medial** side
2. originates from **dorsal venous network**
3. joined by **deep venae comitantes** to form **axillary vein**
* cephalic vein:
1. **lateral** side
2. originates from **dorsal venous network**
3. runs in **anatomical snuffbox**
4. communicates with basilic vein by **median cubital vein** in cubital fossa
5. continues through **deltopectoral** groove,
pierces **clavipectoral** fascia
and drains into **axillary vein**
## Footnote
* deep venae comitants are **paired** veins that accompany **main arteries**
⇒ **pulsations** of artery **help to push** blood in the veins back to heart
* *deep* venae comitants drain muscles and *deep* tissues,
while cephalic and basilic veins drain skin and superficial tissues
100
brachial plexus:
* roots:
1. which nerve roots are involved?
* trunks:
1. what are the names of the 3 trunks?
2. where are they located?
3. what do they divide into as they become cords?
* cords:
1. what are the names of the 3 trunks?
(and WRT to what)
2. where are they located?
3. what forms the posterior cord?
* branches:
1. what are the names of the individual nerves?
* to draw brachial plexus:
1. roots and trunks:
**2 peaks** and **3 lines**
2. *D* ivisions:
In *D* ark *D* ingy bowling alley,
I score a **strike** then a **spare**
3. cords: 3 **waves**,
**2 short** and **1 long**
(*L* ong one is from *L* ateral)
* branches can be remembered as
**MARMU**,
like dor**mammu** from dr strange
101
types of 1º osteoporosis
* pathophysio
* bones affected and classical fractures
* type I (**postmenopausal**):
1. pathophysio:
**oestrogen** deficiency
→ increase in **inflammatory cytokines**
→ increase in **OSTEOCLAST** recruitment and activity
⇒ bone resorption > formation
2. usually affects **cancellous** bone
⇒ **vertebral compression** fractures
* type II (**senile**):
1. pathophysio:
normal osteoclast activity but decreased **OSTEOBLAST** activity
(due to low turnover)
2. usually results in thinning of **cortical** bones
⇒ femoral neck (= **hip**) fractures
| .
## Footnote
cancellous bone = **compact** bonoe
cortical bone = **spongy** bone
102
common causes of 2º osteoporosis:
* endocrine
* gastrointestinal disturbances
* drugs
* hyper**PTH**, hyper**thyroid**ism
* malnutrition
(reduced **Ca2+** intake)
* corticosteroids,
anticonvulsants,
PPIs
## Footnote
* thyroid hormones: excessive **thyroid hormone** (T3) directly **stimulates osteoCLASTs**,
while the low levels of **TSH**
(a hormone that normally **inhibits osteoCLASTs**)
further promote bone loss
* corticosteroids: directly **inhibit osteoBLASTs**
* anticonvulsants: affect **vit D** metabolism
* PPIs: decrease stomach acid
⇒ decrease **Ca2+** absorption
103
fragility fractures:
* defined as fracture caused by
(...), with (...)
* common locations:
1. (...):
presents with (...) and (...)
2. (...), wrist, ribs, long bones
* defined as fracture caused by
fall from **standing height**, with **minimal trauma**
* common locations:
1. **vertebral** compression fracture:
presents with *height loss* and **kyphosis**
(← fractured vertebra *shortening* and **tilting forward**,
leading to *loss of height* and an **exaggerated spinal curve**)
2. **hip**, wrist, ribs, long bones
## Footnote
vertebral compression fracture
= break in a vertebra (a spine bone)
and it then collapses
104
investigations for osteoprosis
1. **OSTA**
(= **age - weight**),
for **postmenopausal** women,
high risk: **> 20**
medium: 0-20
low: < 0
2. **DXA**,
osteoporosis: **T-score ≤ –2.5**
3. FRAX
105
features of articular cause:
* site of issue
* pain relative to movements (passive and active)
* tenderness and swelling
* pain relative to planes of movement
* site of pain
## Footnote
recall! approach to MSK pain = **ABCDE2**
* **A**rticular or not?
* **B**lazing (inflammatory) or Broken down (mechanical)?
* **C**hronology?
* **D**istribution?
* **E**xtra-articular features?
* **E**nabling factors?
* joints
* passive and active movements **BOTH painful**
* tender along joint line,
**swelling common**
* pain in **all planes** of movement
* **diffuse**, deep
106
features of inflammatory cause:
* morning stiffness?
* exacerbating and relieving factors of pain
* early morning stiffness
**> 1hr**
* pain **relieved by movement**,
worsens at rest
## Footnote
as compared to non-inflammatory,
which has early morning stiffness that is
**< 30 mins**
107
septic arthritis:
* infection of joint,
most classically by (...)
* routes of spread: (2)
* distribution:
usually affects (...) or (...) joints
* presentation:
1. either monoarticular or polyarticular
(but acute (...) DEF is)
2. classical triad: (...)
* investigations:
1. arthrocentesis (= **aspirate joint**): (...) and turbid
2. high (...) count
3. gram stain or culture
* management:
1. joint **washout**
2. min (...) weeks of **antibiotics**
* **infection** of joint,
most classically by **Staph aureus**
* routes of spread:
1. (most common) **hematogenous** spread:
from distant site or disseminated infection
2. **direct** contamination:
e.g. joint surgery
* distribution:
usually affects **hip** or **knee** joints
* presentation:
1. either monoarticular or polyarticular
(but acute **monoarticular** DEF is)
2. classical triad: fever, joint pain, restricted ROM
* investigations:
1. arthrocentesis (= **aspirate joint**): **yellow-green** and turbid
2. high **WBC** count
3. gram stain or culture
* management:
1. joint **washout**
2. min **6 weeks** of **antibiotics**
| can also be due to streptococci
or N. gonorrhoea
108
distribution of osteoarthritis:
* symmetric/asymmetric?
* can be mono or polyarticular
* usually found in hips, knees
or (..), (...) and (...) joints of hands
* **Asymmetrical**
* can be mono or polyarticular
* usually found in hips, knees
or **D**IP (**Heberden** nodes) ,
**P**IP (**Bouchard** nodes)
and **1st CMC** joints of hands
109
enabling factors of OA
1. age **> 60**
2. female
3. obesity
4. previous joint injury
110
presentation of OA
* decreased ROM
* **crepitus** on movement
111
imaging seen in OA
LOSS
* Loss of joint space
* Osteophytes
* Subchondral cysts
* Subchondral sclerosis
112
drug treatment for osteoarthritis (OA)
## Footnote
recall: OA is due to loss of cartilage
and is non-inflammatory
* **pain relief** and/or anti-inflammatory:
paracetamol,
non-selective NSAIDs,
corticosteroids
* **symptomatic slow-acting drugs for OA** (SYSADOA)
* can also give supplements
## Footnote
* anti-inflammatory given JIC
as inflammation can occur secondarily
* supplements: **chondroitin sulphate**
and **glucosamine**
113
SYSDOA:
* example
* MOA
* example: intra-articular hyaluronic acid
* MOA:
**restore** HA, a large glycosaminglucan, which is **normally present** in **synovial fluid**
⇒ a) mechanical effects:
**shock absorption**, traumatic energy dissipation,
**protective coating** of cartilage, lubrication,
**reduces pain & stiffness**
b) biological effect:
induces **biosynthesis** of **endogenous HA & extracellular matrix**
114
distribution of rheumatoid arthritis:
* symmetrical/asymmetric?
* usually polyarticular
* usually found in (...), (...), (...), (...), (...)
or (...) and (...) joints of hands
* **symmetrical**
* usually polyarticular
* usually found in shoulders, **elbows**, **wrists**, knees, **ankles**
or **MCP** and **PIP** joints of hands
115
enabling factors for RA
* age: **40-60** y/o
* genetics: "*1* room (rheum) has *4* walls"
HLA-DR***1***, HLA-DR***4***
* **SMOKING**
116
pathophysiology of RA
autoimmune synovitis
-> infiltration of synovium by CD4+ **Th** cells
-> secrete **cytokines**
->
1) inflammation
2) synovial proliferation
-> formation of **pannus**
(hyperplastic synovium infiltrated by inflammatory cells)
=> **cartilage** and **bone erosion**,
affect **capsule** and **ligaments**
and even destroy **adjacent bone**
3) activate **B cells**
=> secrete **antibodies**
(**RF** and **anti-CCP**)
## Footnote
* macrophages in pannus release e.g. MMPs
-> digest collagen in cartilage
* activated T cells in pannus stimulate osteoclasts via RANKL
-> bone resorption
* as cartilage and bone are destroyed,
the ligaments loosen and the capsule stretches
117
presentation of RA
* inflammatory type pain
* HANDS!
1. **ulnar deviation** of *MCP*
2. fingers:
**swan neck** (DIP flexion, PIP hyperextension),
**boutonnière** (DIP hyperextension, PIP flexion)
3. thumb:
**Z**-thumb deformity (MCP flexion, IP hyperextended)
118
systemic features of RA
* atlantoaxial subluxation
* carpal tunnel syndrome
* rheumatoid nodules
* pulmonary: interstitial lung disease
* cardiac: pericarditis, myocarditis, CAD
* anaemia of chronic disease
## Footnote
rheumatoid nodules = areas of fibrinoid necrosis with palisading histiocytes, often on **extensor** surfaces, **lungs**, **heart**
119
drug treatment for rheumatoid arthritis (RA)
* anti-inflammatory:
1. NSAIDs
⇒ short term relief of pain and stiffness
2. corticosteroids
⇒ control symptoms until DMARDs take effect
(bridging therapy)
* disease-modifying anti-rheumatic drugs (DMARDs):
1. conventional synthethic DMARD (csDMARD)
2. targeted synthetic DMARD (tsDMARD),
biologic DMARD (bDMARD)
120
first line csDMARD for RA
methotrexate
121
MOA of methotrexate
| major and minor action!
* major action: **inhibits ATIC**
→ accumulation of AICAR
⇒ **increased adenosine**
* minor action: inhibits **dihydrofolate reductase**
and **thymidylate synthetase**
impaire purine and thymidylate synthesis
→ reduce **DNA and RNA synthesis**
⇒ **anti-proliferative** effect
* overall:
1. anti-proliferative effects on T cells and inhibition of macrophage functions
2. decrease in **pro-inflammatory cytokines**, adhesion molecules, chemotaxis and phagocytosis
122
A/Es and contraindications of methotrexate
A/Es:
* nausea and vomiting
* mouth and GI ulcers
* hair thinning
* **leukopenia**
* **hepatic** fibrosis
* **pneumonitis**
contraindications:
* **pregnancy**
* use with cuation in **renal impairment**
123
how to keep A/Es of methotrexate to a minimum
* **concomitant FOLIC ACID** (high dose)
* given **12‐24 hours** after methotrexate
124
first line csDMARD for SLE
hydroxychloroquine
125
characteristics of hydroxychloroquine
* **LEAST potent** DMARD
* but **MOST well tolerated**
126
A/Es of hydroxychloroquine
* **OCULAR toxicity**
⇒ patients should go for a **baseline opthalmologic examination** within 1st few months of starting drug
* skin hyperpigmentation
## Footnote
other common side effects:
* n/v
* stomach pain
* dizziness
* hair loss
127
unique A/Es of sulfasalazine
* rash, **SJS/TEN**
⇒ Iimmediate **cessation** of SSZ, supportive care in **ICU**
* reversible **infertility** in **males**
* haemolytic anaemia
* neutropenia
128
unique A/Es of leflunomide
* **teratogenic**
⇒ contraindicated in pregnancy,
must do **cholestyramine washout**
## Footnote
cholestyramine required due to **long half-life** of drug!
129
tofacitinib:
* type of DMARD
* clinical indications
(out of OA, RA and PsA)
* MOA
* A/Es
* cautions
* **ts**DMARD
* clinical indications:
1. **RA**:
EITHER used **alone** if **MTX is contraindicated**
OR used in **combination with MTX** for **moderate-severe RA**
2. PsA
* MOA: janus kinase **(JAK) pathway** inhibitor
→ block JAK/STAT activation of **gene transcription**
⇒ decreased transcription of **pro-inflammatory cytokinrd**
* A/Es:
1. **cytopenia** including neutrophils, lymphocytes, platelets and natural killer cells
2. **anaemia**
3. **immunosuppression** resulting in opportunistic infections, esp **herpes zoster** in **asians**
4. hyperlipidaemia
* CANNOT be used in combination with **bDMARDs**
⇒ dramatically decreases immunity, and INCREASES RISK OF **OPPORTUNISTIC INFECTIONS**
## Footnote
all JAK inhibitors end with **"-tinib"**!
130
cautions for TNF blockers
## Footnote
e.g. Infliximab, Adalimumab, Golimumab, Etanercept
principle: can **reactivate** infections!
* should screen for **latent TB**
← TNF-α is essential for the formation and maintenance of **granulomas**,
which** wall off mycobacterium tuberculosis** and keep latent infection under control
* contraindications: **live** vaccines, **Hep B**
131
which muscle relaxant is useful in managing **acute** muscle pain
| only 1!
orphenadrine
* bcos it is a **NMDA** receptor antagonist
=> interrupts **central** pain sensitisation
* used in **combination with paracetamol/NSAIDs**
132
A/Es of orphenadrine
**anticholinergic** profile
← orphenadrine is an **anti-muscarinic**
(e.g. dilated pupils, dry mouth,
higher doses — tachycardia, drowsiness)
## Footnote
recap: cholinergic system has 2 types of receptors, nicotinic and muscarinic!
133
benzodiazepine:
* example
* MOA
* clinical indications
* A/Es
* cautions
(hint: due to DDIs!)
* **diazepam**
* MOA: (positive) **allosteric modulator** of **GABA(A)** receptors
→ increasing frequency of **Cl-** channel **openings**
→ increased **inhibitory** neurotransmission
(i.e. harder to fire neuron)
⇒ suppression of brain **reticular activating system**
* clinical indications:
1. muscle relaxant
2. **antiepileptic**
3. anxiolytic (= sedative)
4. induction of anaesthesis
5. **subacute** MUSCLE pain
* A/Es:
1. **drowsiness**
2. impared judgement
3. reduced motor skills
4. dependence
* DDIs with
1. **CNS depressants**
2. alcohol
## Footnote
recall:
* GABA is
main inhibitory neurotransmitter in CNS,
maintains balance with glutamate
→ prevent overexcitation
* binds to 2 types of GABA Receptors
1. GABA-**A** receptor:
ligand-gated **Cl⁻** channel,
binding of GABA → channel opens → Cl⁻ influx → hyperpolarisation (cell becomes more negative) → neuronal inhibition,
**fast inhibitory** action.
2. GABA-**B** receptor:
G-protein coupled,
binding of GABA → opens **K⁺** channels, closes **Ca²⁺** channels→ hyperpolarisation + ↓ neurotransmitter release,
**slow, prolonged inhibition**
134
baclofen:
* MOA
* clinical indications
* A/Es
* cautions
* MOA: **GABA analogue**
selectively activates **GABA(B)** receptors in CNS
⇒ decrease in **tonic neural stimulation** to muscles
* clinical indications:
1. **chronic** MUSCLE *spasticity*
+/- pain
(used in **combination with paracetamol/NSAIDs**)
2. *spasticity* in patients with **multiple sclerosis** or **spinal cord lesions**
* A/Es:
1. sedation
2. weakness
3. CNS effects
* caution: **abrupt cessation**
→ rebound *excitability*
⇒ *hyperthermia*, *pruritus*, increased *spasticity*
## Footnote
spasticity = certain muscles **contracting all at once** when you try to move or even at rest
135
gabapentinoids:
* examples
* MOA
* clinical indications
* A/Es
* caution
(hint: related to DDI)
* gabapentin, pregabalin
* MOA: **GABA analogues** that act on **Ca2+ channels**
⇒ decrease in **tonic neural stimulation** to muscles
* clinical indications:
1. **chronic** MUSCLE pain
OR **refractory** pain OR **NEUROPATHIC** pain (1st line!)
2. antiepileptic
* A/Es:
*"SAD"*
1. *S* omnolence (= excessive drowsiness)
2. *A* taxia (= lack of voluntary **coordination of muscle** movements)
3. *D* rowsiness
* caution: renally cleared (AND w/o metabolites)
⇒ DDIs with drugs **altering renal function**
## Footnote
* refractory pain = pain that **persists** despite optimal treatment with conventional therapies
neuropathic pain = abnormal pain caused by **damage/dysfunction of the nervous system itself**
* i think it's 2nd-line as antiepileptic
as compared to benzodiazepine lol
136
vit D:
* formulation
* MOA
* contraindications
* A/Es
* **colecalciferol**
with **calcium carbonate / alendronic acid**
* MOA:
1. colecalciferol
—(metabolised in liver)→
calcifedil
—(metabolised in kidney)→
calcitriol
2. promotes **Ca 2+ absorption** in gut,
regulates **PTH** levels,
maintains **serum Ca 2+ and PO4 2-** levels for bone mineralisation
* A/Es:
1. hypercalcaemia and hypercalciuria
2. GI effects
3. allergies
* contraindications:
1. hypercalcaemia
2. hypervitaminosis D
3. **renal imparirment**
← kidneys needed for activation od drug
137
bisphosphonates:
* examples
* MOA
* A/Es
* cautions:
* drugs that end with *"dronate/dronic*"
(e.g. risedronate, zoledronic acid)
* MOA: increase **OSTEOCLAST cell death**
⇒ decrease bone **resorption**
* A/Es:
1. common: MSK aches
2. serious: **atypical FEMORAL fractures**,
**osteonecrosis of JAW**
* precautions:
1. hypocalcaemia
2. severe renal impairment
3. pregnancy
4. **esophageal** impairment
← drug causes **UGIT irritation**
(via directly damaging mucosal lining)
138
How would you counsel a patient on how to take his bisphosphonate medication (oral)?
* take medication on **EMPTY stomach** with at least **240ml of PLAIN water**
* wait **30 mins** before consuming **food**
* **do NOT lie down** after taking medication
## Footnote
basically want to get the drug down into body and absorbd asap!
* lying down → gravity CAN'T help the drug go down
* food and water can affect absorption
139
RANKL inhibitors:
* example
* MOA
* administration
* A/Es
* contraindications
* example: **denosumab**
* MOA: binds RANKL and inhibit its function
→ prevent **stimulation of osteoclast**
⇒ decrease **bone resorption**
* administration: **SUBCUTANEOUS** injection every **6 months**
AND **DAILY vit D and Ca2+**
* A/Es and contraindications similar to bisphophonates,
but A/E includes **hypocalcaemia**
⇒ thus daily Ca2+ (and vit D) needed
140
when can RANKL inhibitors be discontinued
**NEVER**!
abruptly stopping them
can result in increased risk of **spinal column fractures**
141
# drugs for osteoporosis
under the category of oestrogen agonist/antagonist,
there are 2 drugs,
1. oestrogen
2. selective oestrogen receptor modulator (SERM)
(e.g. raloxifene)
compare their
* MOA
* A/Es
* MOA:
1. oestrogen: oestrogen receptor **agonist**
2. raloxifene: oestrogen receptor **agonist in bone**
AND **antagonist in breast/uterus**
* A/Es:
1. both **increase** risk of **blood clots and strokes**
2. **BREAST CANCER**:
oestrogen **increases** risk,
while raloxifene **DECREASES** risk
3. **hot flashes**:
oestrogen **reduces**
while raloxifene **increases**
## Footnote
* oestrogen is indicated for:
1. **younger women** with premature menopause
=> to protect their **bone health**
2. women with **menopausal symptoms**
* stroke risk < blood clot risk
142
PTH therapies:
* example
* MOA
* administration
* A/Es
* teriparatide
* MOA: **stimulate osteoblast** activity
⇒ new bone **formation** and increase in bone **strength**
* administration: **INTERMITTENT**,
**max** duration of **24 months**
← risk of **osteosarcomas**
* A/Es: hypercalcaemia,
serious **calciphuylaxis**
## Footnote
calciphylaxis: **calcium deposits** form in small blood vessels, blocking blood flow and leading to **necrosis**
143
sclerostin inhibitor:
* example
* MOA
* clinical indications
* A/Es and contraindications
* romosozumab
* MOA:
sclerostin inhibits the **Wnt** signaling pathway, which normally **drives osteoblast activity**,
thus blocking sclerostin
→ increase in osteoblast activity
⇒ increase in **bone formation**
and decrease in **bone resorption**
* clinical indications: **WOMEN**
1. at high risk of **fractures** OR
2. **failed/intolerant** to other osteoporosis therapies
* A/Es and contraindications:
1. major **CARDIOVASCULAR** risk (e.g. MI, stroke)
2. transient **hypocalcaemia**
3. hypersensitivity rxns
4. (rare) osteonecrosis of jaw, atypical femoral fracture
## Footnote
* in general, this drug and PTH therapies are used as a **last resort** in management of osteoporosis
when all else fails
* recall: **osteonecrosis ...** and **atypical ...**
are also seen in bisphosphonates and RANKL inhibitors
(oh wait so basically **all which are not naturally occuring hormones**!)
144
cutaneous complications of glucocorticoids
* cutanous **atrophy**
(i.e. thinning of skin):
atrophy, **striae**, pseudoscars
* vascular: **telangiectasis**, **purpura** (= easy bruising), facial plethora
* pigmentary: **HYPOpigmentation**
* **acneiform** eruptions: rosacea-like (erythema, papules, pustules)
* topical steroid withdrawal:
**erythema, oedema, papulopustules** and **burning sensation** on discontinuation
145
calcineurin inhibitors:
* example
* MOA
* clinical indications
* A/Es
* example: **tacrolimus**
* MOA: suppress **T cell activation**
-> modulate secretion of **PRO-inflammatory mediators**
=> decrease **mast cell and dendritic cell** activity
* clinical indications: **alternative** to topical steroids for **sensitive areas**
<- NO risk of cutaneous atrophy
* A/Es: **burning, stinging oe sensation of warmth** at sites of application
146
PDE4 inhibitors:
* examples
* MOA
* clinical indications
* A/Es
* crisaborole, roflumilast
* MOA: increases intracellular **cAMP**
=> downstream **ANTI-inflammatory** effects
* clinical indications:
1. **crisaborole** for **AD**
2. **roflumilast** for **psoriasis**
* A/Es:
GIT, headache,
**nasopharyngitis, URTI, UTI**
147
what is the most common benign bone tumour
osteochondroma
"osteo-*common*-droma is the most *common*"
148
# benign bone tumour
appearance of *Giant* Cell tumour on imaging
**soap** bubble appearance
"don't drop the **soap** or you'll get a *giant* surprise"
## Footnote
involves mononuclear **RANK-L** expressing cells
-> recall that it stimulates differentiation and activation of osteoclasts
=> resulting in areas of bone resorption
149
# malignant bone tumour
appearance of osteosarcoma on imaging
* **SUN**BURST appearance
"osteo-**sun**-coma"
* lifting of periosteum
150
which bone tumour has the highest propensity for response to chemotherapy
chondrosarcoma
| a malignant bone tumour!
151
characteristics of *Ew*ing sarcoma:
* gene
* cells involved
* appearance on imaging
* t(**11, 22**) translocation
leading to positive CD**99** immuno-expression
* involves **small round uniform BLUE** cells that resemble lymphocytes
* **onion** skin appearance on X-ray
"*Ew*, an **onion**!"
152
characteristics of fibrous dyplasia
* type of lesion
* simple pathophysiology
* features on imaging
* **benign** developmental lesion
* normal bone is **replaced** by **immature** woven bone + **fibrous stroma**
* features:
1. **ground-glass** appearance
2. woven bone in **curvilinear** shapes
(look like **chinese characters**)
3. fibroblastic proliferation
4. NO prominent osteoblastic rimming
## Footnote
osteoblastic rimming = a layer of osteoblasts lining newly formed bone trabeculae
153
distribution of spondyloarthropathies (SpA):
* symmetrical/asymmetric?
* oligoarticular
* usually found in (...)
or (...) and (...) joints or (...) of hands
* asymmetric
* oligoarticular
* usually found in **SACROILIAC** joint
or **DIP** and **PIP** joints or **WHOLE index finger** of hands
154
presenting features of SpA
* **enthesitis**: inflammation at tendon/ligament **insertion**
* dactylitis: **whole** finger is **swollen**
* extra-articular features:
**psoriasis plaques** on skin, **nail** changes (e.g. pitting)
155
presenting features of ankylosing spondylitis (AS)
* **enthesitis**: inflammation at tendon/ligament **insertion**
* dactylitis: **whole** finger is **swollen**
* **uveitis**
* inflammatory **back** pain, ALTERNATING **buttock** pain
156
enabling factor for both SpA and AS
| a gene!
HLA-B**27**
157
features of SpA on imaging
| X-ray!
acro-osteolysis
= "*pencil* in cup" deformity
* *more proximal* phalange undergoes resorption into a *sharp pencil*
* **more distal** phalange undergoes new bone growth and erosion into a **concave cup**
158
PE findings of AS
* question mark posture
* decreased **lumbar** flexion
* positive FABER test (on **hip**)
## Footnote
pathophysiology:
genetic disposition + trigger
-> chronic inflammation at **entheses**
-> **erosions AND REPAIR** with new bone
-> **ossification** and **fusion**
=> progression **stiffness** and fusion of spine and SI joint
159
classification criteria for AS
| 2 ways!
1. usually earlier in disease progression:
(+) test for **HLA**-B27
AND **≥ 2** SpA features
2. usually later in disease progression:
**inflammation** of **SI** joint seen on X-ray or MRI
AND **≥ 1** SpA feature
## Footnote
SpA features:
* good response to **NSAIDs** (since it is an inflammatory pathology)
* elevated **CRP** (inflammation marker)
* **IBD** (possible trigger for AS)
160
what demographic is AS usually seen in
* male
* 20 - 30 y/o
med
flashcards
Decks in class (23)
# Cards
-
embryology30
-
biochem1
-
immunology16
-
cvs pharm (DONT USE)9
-
blood86
-
cvs233
-
respi153
-
renal123
-
thorax anatomy181
-
lungs anatomy38
-
git355
-
foundation I10
-
biochem168
-
foundation II133
-
endocrine121
-
repro194
-
mskderm160
-
mskderm 2387
-
multisystem19
-
paediatrics24
-
PE42
-
approach to passing5
-
procedural skills4
