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2015-12-05

DIT Rheum and Derm


Video 1:
Bones:
Formation of Bone:
Endochondral ossification:
Membranous ossification:
Endochondral: chondrocytes lay cartilage frame first then osteoblasts
and osteoclasts come:
Axial skeletons and limbs
Membranous:
No cartilage frame
Flat Bones, Skull
Achondroplasia: FGF-3 mutation
Inhibits chondrocyte proliferation and mutations are associated with
advanced paternal age.

Mutations are past in autosomal dominant fashion


Pregnant women: pelvic outlet may not be wide enough
Primary Bone Tumors:
Osteochondroma: most common benign tumor (hemartoma)
Osteoclastoma: tumor of the osteoclasts: older individuals
Soap bubble : luscent lesion
Osteosarcoma: malignant tumor. 2nd most common after multiple myeloma.
Young
Caudmans triangle. Sunburst pattern
Ewing sarcoma:
Young boys under age of 15
Onion skin.
11 22 translocation
Clinical Manifestations of Bone METS

Permanently relocated tumors like bones


Prostate: Blastic
Renal Cell Cancer:
Testes/Thyroid:
Lung: Lytic
Breasts: Both
Present with:
Bone Pain
Epidural spinal cord compression: ( motor and sensory deficits)
Hypercalcemia
DIT Video 2:
Bone Biology:
Cellular Components:
Osteoblasts: lay down bone
Osteoblasts become osteocytes which live in lacunes and communicate via
cannaculi
Osteoclasts: found on surface of bone and formed from macrophage
derivatives that eat away at the bony matrix.
Osteoporosis:

Imbalance of osteoblasts and osteoclasts


When osteoblasts slow down compared to clasts=osteoporosis
Generally insidious
Bone Mineral Density Test ( DEXA SCAN)
Fractures: osteoporotic bones are weak
Vertebral disc compressions
Hip Fractures: require surgical pinning and immobilization.
Osteoporosis Treatment:
Smoking reduction
Alcohol reduction
Corticosteroids reduction
PPI and H2 blockers can also cause issues
Exercise and weight bearing will stimulate osteoblasts
Doing a fall home assessment
Vit D
Bisphosphanates
Teriparatade: recombinant PTH analogue (cant give for more than 2 years)
-dronate:
work by inhibiting osteoclasts
clinical uses:

Paget disease
Osteoporosis
Humoral hypercalcemia of malignancy
Long-term steroid use
Side effects:
Erosive esophagitis
Osteonecrosis of the jaw
Osteoporosis:
Estrogen
Calcitonin nasal spray
Denosumab: RANK-L inhibitor
Osteopetrosis:
Rock-like bones:
Defect of bone resorption
Osteoclasts are deficient in carbonic anhydrase
Prone to fractures because of disorganized bony matrix
Obliterate marrow space resulting in penias

Osteoporosis normal
Osteopetrosis normal
Paget Disease of Bone:
Localized disorder of the bony architecture
Increasing both osteoblastic and osteoclastic activivty
First osteoclasts are working then osteoblasts.
Increased hat size:
No major symptoms
Hearing loss
Bone pain, bone deformities and fractures
Alk phosp: shows turnover of bone
2 types of different alk phosph
Osteomalacia and Rickets
Vit D deficiency
Poor calcium absorption
Therefore poor bone mineraliation
Decrease calcium serum and increase PTH secretion

Decrease serum phosphate


Increase PTH results in increase bone turnover which means increase ALK
phos
Osteitis fibrosa cystica
Bony manifestation of endocrine disorder
Hyperparathyroidism
High PTH
PseduoHypoparathyroidism: renal tubules resistance at renal tubules
Polyostotic Fibrous Dysplasia
Bone is replaced by collagen and fibroblasts
Irregular bony trabculae
Bone Disorder Lab:

DIT Video 3:
Joint Space: potential space with a negative hydrostatic pressure

Hip Dislocation:
Posterior dislocation. Motor vehicle accidents
Medial and lateral circumflex arteries.
Femoral vein and nerve.
Use traction to
Close reduction: without surgery
Open reduction: with surgery
ORIF:
Unhappy Triad:
Lateral aspect of the knew force while foot is planted:
MCL and ACL
Medial and Lateral Meniscus
Anterior Drawer Test used to check if ACL is injured.
Patellafemoral syndrome:
Leading cause of pain.
Strengthen quadricepts, stretching exercise
Bursitis:

Cartilage reduces friction between bones


Bursa reduces friction between tendons and bones.
Ankle Sprain:
Strech a ligament too far
Lateral sprains are more common
3 ligaments:
Anterior talofibular ligament, Calcaneofibular ligament and posterior
talofibluar ligament.
ATF(always tears first),
Deltoid ligament on medial side
RICE
Rest
Ice
Compression
Elevation
NSAIDs
Plantar Fasciitisi:

Characteristic features:
Pain beneath the calcaneus or in the medial arch with the first morning and
after weight bearing.
Local point tenderness at the medial tubercle
Rotator Cuff:
Sits
Supraspinaturs
Infrapsinatus
Teres Minor
Subscapularis:
Muscles of the Rotator Cuff
Abduction: supraspinatus: empty can test
Lateral: infraspinatus and teres minor
Internal : subscapularis
Impingement Syndrome:
When structures in the shoulder get trapped by the acromion process during
abduction

Can be caused by chronic overhead repetitive movements


Subacromial bursitis: NSAIDS or steroid njection
Shoulder dislocation and separation:
Shoulder dislocation: head of humeros rotates out of glenoid cavity
Shoulder separation: clavicle separating from acromion
Anterior shoulder dislocation: injury to axillary nerve, post circumflex artery,
supraspinatus tendon, anterior glenohumeral ligaments (Bankart) HillSachs( traumatic damage of the humoral lhead)
Sensation: axillary nerve injury
Adhesive capsulitis: sever adhesions. Pain or prolonged immobilization.
Present with ; restricted se of the shoulder, normal x-rays.
Treatment: injections, heat and analagesize, physical therapy. Break the
adhesions under the anesthesia.
Biceps tendon rupture:
Tear at the elbow or shoulder.
Tendinopathy: fluoroquinolones
Epicondylitis: lateral( tennis elbow)

Medial epicondylitis( golfers elbow)


Olecranon bursitis:
Bones of the Wrist:
So long the pinky here comes the thumb
Scaphoid
Lunate
Triquetrum
Pisiform
Hamate
Capitate
Trapezoid
Trapezium
So long the pinky here comes the thumb
Scaphoid
Lunate
Triquetram
Pisiform

Hamate
Capitate
Trapezoid
Trapezium
Avascular necrosis:
DUputryens contracture:
DIt Video 4:
Osteoarthritis:
Wear and tear disease.
Eburnation of the bone
Osteophytes (PIPs=bouchards nodes) DIPS(aberdeens nodes)
Booo = proooximal
Predisposing factors:
Age, obesity, joint trauma.
Pain in the joints after prolonged use
Non-inflammatory
No systemic symptoms

Treatments
Acetaminophen (4g/day)
NSAIDS and COX-2
Steroids
Hyaluronic Acid
Opiods
Joint Replacement
Acetaminophen: reversible inhibits COX:
Antipyretic and analgesic effects:
Ni anti-inflammator effects
Fewer side effects
Toxic Dose: NAPQI-depletes glutathione. Reacts with hepatocytes
Antidote:: N-acetylcysteine: mucolytic, acetaminophen overdose, prevention
of contrast nephropathy.
NAC: N-Acetyl Cysteine: nephropathy, Acetaminphe,, Cystic Fbros
NSAIDS:
Inhibit COX
Therefore inhibit prostaglandins

Anti-inflammatory, reduce pain and fever


Acute renal failure
Acute interstitial nephritis
Aplastic anemia
Fluid retention
GI upset
COX-2 inhibitors
meloxicam: cox-2
Inhibit cox-2
Fond in vascular epithelium and inflammatory cells
Cox-1 helps maintain gastic mucosa
Cox-2 less PUD than traditional NSAIDS
OA and RA, sprain anke.
Increased risk of thrombosis
Sulfa allergy
Aspirn: irreversibly inhibits platelets.
Analgesic effects at high dose
Inhibits COX-1 irreverisble

Aspirin:
Increase GI bleed
Tinnitus
Hyperventilation
Acute renal failure
RA:
Systemic autoimmune disease:
Synovial joints
Not D IP joints
MCPS and PIPS
Ulnar deviation and subluxation of joints
Baker cysts
Swan neck deformities: extension at the PIP and flexion at the DIP
Bouttoneir deformity: button hole. Extensor tendon splits and PIP joint splits
through making flextion and PIP and extension at the DIP
Type 3 hypersensitivty: formation of immune complexes that get deposited.
Soluble antigens in blood
More common in women
RF: iGM against igG

ACPA: anti-citrullinated protein in antibody used is more specific than RF


Presents: morning stiffness and improves with use
OA: pain with use at the end of the day
Symmetric joint involvement
Systemic symptoms
Treatment:
Acute: NSAIDS, COX-2, steroids
Long-term: DMARDS: methotrexate, hydroxychloroquine,
TNFinhibtors,sulfasalazine

DIT videos 5:
GOUT:
Hyperuricemia: monosodium urate in joints causing inflammation.
Needle shaped cyrstals:
Hyperuricemia:
Decreased exrection of uric acid
thiazide, loop diuretic,
Increased production of uric acid
production of uric acid too high via purine rich foods, or treatment for
leukemia and lymphoma, Lesch-Nyahn syndrome

Gout presentation:
Assymetric joint inflammation
Monoartciular joints
Inflamed joints are swollen,red and painful
Most common in : First Metatarsal pharlygeal joint: Podagra
Tofi: tendon, ear or olecranon bursa
Gout is cyclical: flares
Gout triggers:
Large meals
Alcohol consumption as alcohol metabolites compete with uric metabolits for
exrection
Gout Drugs:
Misoprostol:
ACUTE
Colchicine: inhibits microtubules: stabilized tubulin causing impaired
leukocyte chemotaxis. GI diarrhea. Low therapetuc dose
NSAIDS: indomethacin
Steroids:

Long Term: Chronic Gout: maintain uric acid levels


Increase renal excretion:
Probenecid: increases reneal exrection of uric acid and inhibit reabsorption
of uric acid in Proximal Convoluted Tubule
Reduce uric acid production:
Allopurinol: inhibits xanthine oxidase.
Febuxostat:

Pseudogout:
Different crystal:
Calcium pyrophosphate crystals
Large Joints: Kneww
Older Patients
Chondrocalcinosis: calficiatoin of the articular cartilage
Seronegative Spondylarthropathies:
Associated with arthritis specifcically with spine :spondy=spine
RF is negative
Strong association with HLA-B27
PAIR:
Psoriatic Arthritis

Ankylosing spondylitis
IBD spondylitis
Reactive Arthritis(reiters)
Psoriatic Arthritis:inflammatory arthritis associated with psoriasis
-assymetric
fingers specifically DIP
spine and sacroiliac joints Dactylitis
bony erosions
Ankylosing spondylitis:
Inflammatory disease of spine and sacroiliac joints
Ankyloses: fusion of joints.
Bamboo spine
Limit spine mobility
Stiffness of spine improves with exercise
Uveitis
Increased risk of CV disease
Aortic regurg and conduction

Inflammatory Bowel Disease:


Reactive Arthritis:
Occers following infection:
Chlamydia, GI infections
Conjunctivit, Urethritsi, Arthritsi
Treatment:
NSAIDS
Steroids
DMARDS
TNF_a inhibitors
TNF-a : cytokine that induces the immune system
TNF-a inhibitors: bind to TNF preventing it from activating immune system
Inflixamab, mab: Etanercept:recombinant TNF receptor
Increased risk of infection including TB
Juvenile Idiopathic Arthritis:
Children
Persistant joint swelling:

Polyarticular
Pauciarticular
Systemic-onset
Septic Arthritis:
Stap
Step
N.gonnorhea
Gonococcal Arthritis:
STD that presents with polyarticular, migratory arthritis with an assymetric
pattern
Synivitis and pustules
Arthrocentesis: pus ton of wbc. Septic arthritis can be very destructive. IV
antibiotics and surgical consult.
DIT Video 6:
SLE:

Vast majority of patients are women with African descent


Non-specific symptoms:
- Fatigue, weight loss and fever
- Lymphadenopayh
- Splenomegaly
- Endocarditits
- Raynaud phenomene
Skin Disorders
Malar rash
Discoid rash
Photosensitivity
Painless oral ulcers
Inflammatory:
Arthritis (2 joints) Non-erosive
Serositis (pleuritis and pericarditis)
ANA
dsDNA anti
anti-Smith

Organ System:
Renal (proteinuria, cellular casts)
Neuro(seizures,pyschosis)
Heme (penieas,
Immune (antiphospholipid antibodies)
SLE:
Immune complex
Wire loops
ENA PANEL:
Sjogren Syndrome
Scleroderma
RA
Mixed Connective Tissue Disorders
Drug
Sulfonamides
Hydralizines
Isonizaid
Phenytoin

Procainamide
Low levels of complement
Treatment
Steroids
NSAIDS
Hydroxychloroquine
Cyclophosphamide
Scleroderma:
Progressive systemic slceroris
Fibris and excess collagen deposition
Skin: tight, no wrinkles
Two types
Diffuse : wide spread sclerosis: anti-SCL-70 andi-DANtopoisomerase
CREST:
Calcinosis: subepithelial calcium deposits
R: Raynauld phenomen

E: esophagus dismotility
S:Sclerodactyly
T:Telangiactasis
Limited Skin involvement
Progress less
Centromere antibody
Sjogren:
Dry Eyes.
Dry Mouth
Sicca Symptoms
Dry eyes
Dry mouth
Chronic bronchitis
Reflux esophagitis
SS-A
SS-B
Paratid Gland enlargement
Cavities

B-cell lymphoma
Autoantibodies against: SSA, SSB
(+) RF
women above 40
Muscular Dystophies
Duchhnee: X-linked dystrophin gene mutation: dystrophin helps anchor
muscle fibers. Therefore without it you have accelerated muscle breakdown.
Therefore you have increased Creatine Kinase (CK) marker for muscle
breakdown.
Presents Early: weakness in pelvic muscles
Becker Muscular Dystrophy: inframe deletion
Polymyalgia Rheumatica:
Joint in shoulders and hips
Joint pain and joint stiffness
Systemic: malaise, weight loss, fever, no muscle weakness
Over 50
Women
Temporal arteritis:
Elevated ESR

Treatment: steroids
Polymyositis:
Muscle inflammation
Proximal muscle weakness:Muscle disease
Distal muscle weakness: neurological disease
Cd8_ t cell-induced injury
Muscle biopsy
Aldolase: enzyme from inflamed muscle
(anti-jo1)
Dermatomyositis:
Skin involvement as well as muscle inflammation.
Fibromyalgia:
Increased sensitivity to pain.
Excess muscular tenderness
Palpate trigger points
Chronic generalized pain, sleep, fatigure,
Treatment:
Pregabalin
Milnacipran
Serotonin-Norepinephrine reuptake inhibitor