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Locomotor Yr 1 14/11/2023 Tutors: Armina MahootchiMCQ 1 The major protein constituent of cortical bone is formed from the following repeat unit [A-X-Y] . What is A? n A: A. Glutamine B. Methionine C. Ascorbic Acid D. Glycine E. ProlineMCQ 1 The major protein constituent of cortical bone is formed from the following repeat unit [A-X-Y] . What is A? n A: A. Glutamine B. Methionine C. Ascorbic Acid D. Glycine E. ProlineConnective Tissue ▶ Epithelia, Neural, Muscular, Connective ▶ Connective tissues – more about the non-cellular function ▶ = Cells + ECM + Ground substance + interstitial fluid ▶ Resident cells – fibroblast, osteocytes, chondrocytes – collagen & PGs & enzymes ▶ Immigrant cells –cells derived from haemopoietic cells lines eg macrophages, lymphocytes, mast cells Extracellular Matrix (ECM) ▶ Major Components: Collagens, Elastins, (PGs) ▶ Collagens are a very diverse group of proteins that combine in different permutations of alpha chains to achieve desired structural outcome ▶ Bone - contains collagen types I, V, XII, XIV Cartilage - contains collagen types II, VII, IX, X, XI Skin - contains collagen types I, II, III, V, XI BM – Type IV ▶ General sequence: [Gly-X-Y] rnpeating unit X/Y are often 3/4-hydroxyproline but can be others ▶ Elastin provides elasticity as shown by exhalation Lungs very high in elastin which is why alpha1-antitrypsin inhibition by cigarette smoke (peroxynitrite) leads to uncontrolled loss of elastin and alveoli causing emphysema (COPD) ▶ Proteoglycans are big molecules that draw in water and form the ground substance, a kind of gel which has properties dependant on the ratio of various PGs for example in cartilage you want shock absorbing, low friction properties: glycosaminoglycan (chondroitin sulphate) + core protein backbone = aggrecan multiple aggrecans + hyaluronic acid backbone = major PG in cartilageMCQ 2 A 42-year-old man visits his GP complaining of difficulty using the right-handed twist throttle on his motorbike. He suffered a mid-shaft fracture of the right humerus after a road traffic collision 12 weeks ago. This was treated surgically at the time and the injury has healed well. What nerve injury is most commonly caused by this type of fracture? A. Axillary nerve injury B. Median nerve injury C. Ulnar nerve injury D. Radial nerve injury E. Musculocutaneous nerve injuryMCQ 2 A 42-year-old man visits his GP complaining of difficulty using the right-handed twist throttle on his motorbike. He suffered a mid-shaft fracture of the right humerus after a road traffic collision 12 weeks ago. This was treated surgically at the time and the injury has healed well. What nerve injury is most commonly caused by this type of fracture? A. Axillary nerve injury B. Median nerve injury C. Ulnar nerve injury D. Radial nerve injury E. Musculocutaneous nerve injuryMCQ 3 A 21-year-old man presents to the general practitioner with a 3-month history of lower back pain that radiates to the buttocks. This is worst in the morning, improves with exercise and occasionally wakes him at night. Which of the following is the most likely diagnosis? A. Intervertebral disc herniation B. Ankylosing spondylitis C. Reactive arthritis D. Rheumatoid arthritis E. Spinal stenosis MCQ 3 A 21-year-old man presents to the general practitioner with a 3-month history of lower back pain that radiates to the buttocks. This is worst in the morning, improves with exercise and occasionally wakes him at night. Which of the following is the most likely diagnosis? A. Intervertebral disc herniation B. Ankylosing spondylitis – chronic autoimmune inflammatory disease affecting vertebral joints. C. Reactive arthritis D. Rheumatoid arthritis E. Spinal stenosis Features of Ankylosing spondylitis: • typically a young man who presents with lower back pain and stiffness of insidious onset • stiffness is usually worse in the morning and improves with exercise • the patient may experience pain at night which improves on getting upMCQ 4 Scurvy is caused by which of the following nutritional deficiencies? a) Thiamine b) 25-dihydroxycholecalciferol c) Ascorbic acid d) Biotin e) 1,25-dihydroxycholecalciferolMCQ 4 Scurvy is caused by which of the following nutritional deficiencies? a) Thiamine b) 25-dihydroxycholecalciferol c) Ascorbic acid d) Biotin e) 1,25-dihydroxycholecalciferolMCQ 5 A 54 year old man with long standing alcohol dependency cut his finger 2 weeks ago and has failed to heal. On further examination you notice his gums to be swollen with purplish spots on both upper limbs. Which of the following is mostly likely to be the cause of his complaints? a) Pellagra b) Scurvy c) Ehlers-Danlos syndrome d) Osteogenesis imperfecta e) Lesch-Nyhan syndromeMCQ 5 A 54 year old man with long standing alcohol dependency cut his finger 2 weeks ago and has failed to heal. On further examination you notice his gums to be swollen with purplish spots on both upper limbs. Which of the following is mostly likely to be the cause of his complaints? a) Pellagra b) Scurvy c) Ehlers-Danlos syndrome d) Osteogenesis imperfecta e) Lesch-Nyhan syndromeMCQ 6 The most common form of osteogenesis imperfecta is due to reduced production of a) Type 1 collagen b) Type 2 collagen c) Type 3 collagen d) Type 4 collagenMCQ 6 The most common form of osteogenesis imperfecta is due to reduced production of a) Type 1 collagen b) Type 2 collagen c) Type 3 collagen d) Type 4 collagenMCQ 8 Vascular Ehlers Danlos syndrome characterised by fragile vessels, muscles and organs is due to deficiency in a) Type 1 collagen b) Type 2 collagen c) Type 3 collagen d) Type 4 collagen e) Type 5 collagenMCQ 8 Vascular Ehlers Danlos syndrome characterised by fragile vessels, muscles and organs is due to deficiency in a) Type 1 collagen b) Type 2 collagen c) Type 3 collagen d) Type 4 collagen e) Type 5 collagen Remember the extremely stretchy skin and severe joint hypermobility associated with classic EDS, and the thin translucent skin and blood vessel rupture associated with vascular EDS. Patients are monitored for vascular abnormalities and told to seek urgent medical attention for sudden unexplained pain or bleeding.MCQ 9 Arachnodactyly (long fingers) can be described as long spider like thin fingers. In which of the following is this characteristic of? a) Osteopetrosis b) Achondroplasia c) Neurofibromatosis type 1 d) Marfan's syndrome e) Ehlers Danlos syndromeMCQ 9 Arachnodactyly (long fingers) can be described as long spider like thin fingers. In which of the following is this characteristic of? a) Osteopetrosis b) Achondroplasia c) Neurofibromatosis type 1 d) Marfan's syndrome e) Ehlers Danlos syndromeMCQ 10 A 37 year old man present to A&E with a dissecting abdominal aortic aneurysm (AAA). On examination patient appears evidently thin and tall with abnormally long limbs. Past medical history reveals complaints of nearsightedness and sleep apnea. Which of the following deficiencies is the most likely explanation for his AAA? a) Type 1 collagen b) Type 2 collagen c) Type 3 collagen d) Elastin e) FibrillinMCQ 10 A 37 year old man present to A&E with a dissecting abdominal aortic aneurysm (AAA). On examination patient appears evidently thin and tall with abnormally long limbs. Past medical history reveals complaints of nearsightedness and sleep apnea. Which of the following deficiencies is the most likely explanation for his AAA? a) Type 1 collagen b) Type 2 collagen c) Type 3 collagen d) Elastin e) Fibrillin Marfan syndrome Associated Conditions Marfan syndrome is an autosomal dominant condition •Lens dislocation in the eye •Joint dislocations and pain due to affecting the gene responsible for creating fibrillin. hypermobility •Scoliosis of the spine Fibrillin is an important component of connective tissue. •Pneumothorax This means people with Marfan syndrome have features •Gastro-oesophageal reflux •Mitral valve prolapse (with regurgitation) resulting from abnormal connective tissue. •Aortic valve prolapse (with regurgitation) •Aortic aneurysms Features • Tall stature Management: • Aim is to minimise blood pressure and • Long neck HR to minimise stress on the heart • Physiotherapy – strengthening the joints • Long limbs • Genetic counselling – before having children • Long fingers (arachnodactyly) • Should be monitored for valvular diseases of the heart via ECHO • High arch palate • Ophthalmology check ups • Hypermobility • Pectus carinatum or pectus excavatum • Downward sloping palpable fissuresMCQ 11 A 3 month old baby has been admitted into A&E due to multiple fractures in their upper extremity. History is unremarkable according to the parents although they have notice the infant doesn't respond to loud noises and is usually very quiet. This raises suspicion in the on call registrar who begins to consider possible child abuse. On further examination however the infant displays blue sclera. Which of the following is the most likely cause of the infants fractures? a) Child abuse b) Ehlers-Danlos c) Marfans syndrome d) Osteogenesis imperfecta e) Menkes diseaseMCQ 11 A 3 month old baby has been admitted into A&E due to multiple fractures in their upper extremity. History is unremarkable according to the parents although they have notice the infant doesn't respond to loud noises and is usually very quiet. This raises suspicion in the on call registrar who begins to consider possible child abuse. On further examination however the infant displays blue sclera. Which of the following is the most likely cause of the infants fractures? a) Child abuse b) Ehlers-Danlos c) Marfans syndrome d) Osteogenesis imperfecta e) Menkes diseaseOsteogenesis imperfecta AKA ‘brittle bone disease’ is caused by mutations in collagen I. ▶ OI type I - (commonest and least severe): collagen I is deficient but of normal structure. ▶ OI type II - (perinatal lethal: ‘crumpled bones’ in utero): there is abnormal collagen structure. There are 8 types of osteogenesis imperfecta depending on the underlying genetic mutation, and they vary in their severity. Presentation - recurrent and inappropriate fractures. Associated features: • Hypermobility Management: • Blue / grey sclera (the “whites” of the eyes) The underlying genetic condition cannot be cured. Medical treatments include: • Triangular face •Bisphosphates to increase bone density • Short stature •Vitamin D supplementation to prevent deficiency • Deafness from early adulthood • Dental problems, particularly with formation of teeth • Bone deformities, such as bowed legs and scoliosis • Joint and bone pain MCQ 12 A 37-year-old woman is brought to the emergency department following a fall on an outstretched hand that occurred when she fell off her bike. On examination, there is tenderness in the anatomical snuffbox. She is treated conservatively and sent home. A number of weeks later she returns for outpatient follow-up and complains of persistent wrist pain. She is systemically well. What is the most likely complication that has developed as a result of her initial condition? A. Avascular necrosis B. Carpal tunnel syndrome C. Compartment syndrome D. Guyon canal syndrome E. Osteomyelitis MCQ 12 A 37-year-old woman is brought to the emergency department following a fall on an outstretched hand that occurred when she fell off her bike. On examination, there is tenderness in the anatomical snuffbox. She is treated conservatively and sent home. A number of weeks later she returns for outpatient follow-up and complains of persistent wrist pain. She is systemically well. What is the most likely complication that has developed as a result of her initial condition? A. Avascular necrosis B. Carpal tunnel syndrome C. Compartment syndrome D. Guyon canal syndrome E. OsteomyelitisMCQ 12 A complication of proximal scaphoid fracture is avascular necrosis. The scaphoid is palpable in the anatomic snuffbox and frequently injured due to a fall on an outstretched hand. This fracture is also often not immediately visible on X-ray. Carpal tunnel syndrome is caused by the compression of the median nerve in the carpal tunnel in the wrist. It presents with pain, numbness and paraesthesia in the distribution of the median nerve, but rarely complicates a scaphoid fracture or a fall on an outstretched hand. Compartment syndrome is due to increased pressure within a fascial compartment of a limb, which can cause reduced blood flow and necrosis. It is commonly caused by long bone fractures, rather than a scaphoid fracture and presents more acutely than avascular necrosis. Guyon canal syndrome is compression of the ulnar nerve in the guyon canal in the wrist. It is classically seen in cyclists due to pressure from handlebars, rather than a fall on an outstretched hand. (bonus) Osteomyelitis is a deep-seated infection of the bone which can occur post-traumatically, due to an implant or through haematogenous spread. It can complicate long bone fractures but rarely affects the carpal bones such as the scaphoid. It also usually has more signs of systemic infection compared to avascular necrosis.MCQ 13 A 64-year-old man presents to his GP with left hip pain and stiffness. He plays golf regularly and he finds that this makes the pain worse. The pain is relieved by rest. He describes stiffness in his left hip joint in the morning, this settles after 5 minutes. No other joints are affected and he is systemically well. The GP advises the patient on appropriate lifestyle changes and also prescribes an NSAID. What additional medication must the GP prescribe for this patient? A. Alendronic acid B. Aspirin C. Lansoprazole D. Paracetamol E. Vitamin DMCQ 13 A 64-year-old man presents to his GP with left hip pain and stiffness. He plays golf regularly and he finds that this makes the pain worse. The pain is relieved by rest. He describes stiffness in his left hip joint in the morning, this settles after 5 minutes. No other joints are affected and he is systemically well. The GP advises the patient on appropriate lifestyle changes and also prescribes an NSAID. What additional medication must the GP prescribe for this patient? A. Alendronic acid B. Aspirin C. Lansoprazole D. Paracetamol E. Vitamin D When prescribing a NSAID for osteoarthritis it is important to co-prescribe a PPI to decrease the risk of GI complications such as reflux and ulcers.MCQ 14 A 68-year-old woman presents to the clinic with a gradual onset of pain and stiffness in her hands, mainly affecting the base of her thumbs. On examination, you notice that the base of both of her thumbs appears broader and more square. She also has a family history of a similar presentation. She is concerned about what could be causing these changes. What is the most likely diagnosis? A. Gout B. Osteoarthritis C. Psoriatic arthritis D. Rheumatoid arthritis E. Systemic lupus erythematosus (SLE)MCQ 14 A 68-year-old woman presents to the clinic with a gradual onset of pain and stiffness in her hands, mainly affecting the base of her thumbs. On examination, you notice that the base of both of her thumbs appears broader and more square. She also has a family history of a similar presentation. She is concerned about what could be causing these changes. What is the most likely diagnosis? A. Gout – sudden severe pain B. Osteoarthritis - Squaring of the thumbs is a characteristic feature C. Psoriatic arthritis – distal interphalangeal joints and pitting nails D. Rheumatoid arthritis – swelling, warmth, morning stiffness lasting more than 30 mins E. Systemic lupus erythematosus (SLE) – with Other systemic features such as rash, renal involvement, and photosensitivityMCQ 15 A 60-year-old woman presents to her GP with pain, stiffness and swelling in the joints of her fingers. It occurs bilaterally particularly affecting the metacarpophalangeal (MCP) joints, the distal interphalangeal (DIP) joints are unaffected. On examination, there is prominent ulnar deviation at the MCP joints and a Z-shaped deformity of the thumb. Given the likely diagnosis, what is the first-line medication? A. Adalimumab B. Etanercept C. Infliximab D. Methotrexate E. RituximabMCQ 15 A 60-year-old woman presents to her GP with pain, stiffness and swelling in the joints of her fingers. It occurs bilaterally particularly affecting the metacarpophalangeal (MCP) joints, the distal interphalangeal (DIP) joints are unaffected. On examination, there is prominent ulnar deviation at the MCP joints and a Z-shaped deformity of the thumb. Given the likely diagnosis, what is the first-line medication? A. Adalimumab B. Etanercept C. Infliximab D. Methotrexate E. Rituximab most likely diagnosis is rheumatoid arthritis, which is an inflammatory symmetrical polyarthritis. It typically spares the DIP joints, which are more commonly affected in osteoarthritis. The first line of medication is a DMARD, with the most commonly used being methotrexateThank you for your attention