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MUSC1_1
Lecture Objectives
Musculoskeletal System: Dermatology
Lecture 1 - Dermatology
Anatomy of the Epidermis
Stratum corneum
Stratum lucidum
Stratum granulosum
Stratum spinosum
Stratum basalis
Basement membrane
Review of epidermal anatomy
Epithelial cell junctions
Zona occludens
Zona adherens
Zona occludens versus zona adherens
Macula adherens (desmosome)
Macula adherens (desmosome)
Gap junctions
Basement membrane - 1
Basement membrane - 2
Hemidesmosome
Hemidesmosome – clinical correlate
Integrin
MUSC1_2
Macule versus patch
Papule versus plaque
Vesicles
Bulla
Keloid
Pustule
Hyperkeratosis - Callus
Parakeratosis
Parakeratosis - Psoriasis
Acantholysis
MUSC1_3
Common diseases of the skin
Verrucae
Nevus
Dysplastic nevus
Urticaria
Atopic dermatitis
Allergic contact dermatitis
Psoriasis
Psoriasis - histology
Psoriasis – clinical manifestations
Psoriasis – histology review
Psoriasis – other clinical manifestations
Psoriasis – characteristic lesion
Seborrheic keratosis
Albinism - characteristics
Albinism - types
Vitiligo
Melasma
Impetigo
Cellulitis
Necrotizing fasciitis
Staph scalded skin syndrome
Hairy leukoplakia
Pemphigus vulgaris
Pemphigus vulgaris - example
Pemphigus vulgaris - histology
Pemphigus vulgaris – clinically
Bullous pemphigoid
Bullous pemphigoid characteristics
Dermatitis herpetiformis
Erythema multiforme
Erythema multiforme - clinically
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Lichen planus
Actinic keratosis
Acanthosis nigricans
Erythema nodosum
Pityriasis rosea
Strawberry hemangioma
Cherry hemangioma
MUSC1_4
Squamous cell carcinoma
SSC - histology
BCC - characteristics
Melanoma
MUSC2_1
Learning objectives
Muscle cell membrane
Sarcoplasmic reticulum
Muscle cell receptors
Sarcomere
Muscle cell contraction -1
Muscle cell contraction - 2
Muscle cell contraction - 3
Muscle cell contraction - 4
Muscle cell contraction - 5
Muscle cell contraction - 6
Muscle cell contraction - 7
Muscle cell contraction - 8
Muscle cell contraction - 9
Skeletal Muscle red versus white fibrers
Skeletal muscle atrophy - 1
Skeletal muscle atrophy - 2
Smooth muscle contraction - 1
Smooth muscle contraction - 2
Smooth muscle contraction - 3
Smooth muscle contraction - 4
MUSC2_2
Thenar eminence
Hypothenar eminence
Thenar eminence innervation
Hypothenar eminence innervatinon
Interosseous muscles
Interosseous muscles
Lumbrical muscles
Interosseous muscle innervation
Lumbrical muscle innervation
MUSC2_3
Rotator cuff muscles
Deltoid muscle in abduction
Infraspinatus muscle
MUSC2_4
Ligaments - knee
Knee – collateral ligaments
Lateral collateral ligaments
ACL and PCL
Anterior cruciate ligament - 1
Anterior cruciate ligament - 2
Posterior cruciate ligament
Four major knee ligaments
Knee menisci
Knee injuries – unhappy triad
ACL injury on physical exam
MUSC2_5
Repetitive elbow injury
Lateral epicondylitis
Repetitive elbow injury - 1
Repetitive elbow injury - 2
Repetitive elbow injury - 3
MUSC3_1
Lecture Objectives
The brachial plexus - 1
The brachial plexus - 2
The brachial plexus - 3
Antebrachial musculocutaneous nerves
The brachial plexus review - 1
The brachial plexus review - 2
Upper trunk injuries
Lower trunk injuries – cervical rib
Lower trunk injuries – pancoast tumor
MUSC3_2
Axillary nerve - 1
Axillary nerve - 2
Radial nerve - 1
Radial nerve - 2
Median nerve - 1
Median nerve - 2
Median nerve injury - forearm
Carpel tunnel syndrome
Ulnar nerve
Sensory innervation of the arm - 1
Sensory innervation of the arm - 2
Sensory innervation of the arm - 3
Sensory innervation of the hand
MUSC3_3
Axillary nerve injury - 1
Axillary nerve injury - 2
Radial nerve injury - 1
Radial nerve injury - 2
Median nerve injury -1
Median nerve injury - 2
Ape hand injury
Median nerve injury - 3
Median nerve injury - 4
Median nerve injury – 5
Ulnar nerve injury - 1
Ulnar nerve injury - 2
Ulnar nerve injury - 3
Ulnar nerve injury - 4
Ulnar nerve injury - 5
Ulnar nerve injury - 6
Musculocutaneous nerve injury - 1
Musculocutaneous nerve injury - 2
Musculocutaneous nerve injury - 3
Brachial Plexus Injury
Thoracic outlet syndrome
Klumpke’s palsy - 2
Klumpke’s palsy - 3
Klumpke’s palsy - 4
Lumbrical Muscles
Ulnar claw
Median claw injury
Ape hand injury
Klumpke’s total claw
Long thoracic nerve injury - 1
Long thoracic nerve injury - 2
MUSC3_4
Lumbosacral plexus
Superior gluteal nerve injury
Inferior gluteal nerve injury - 1
Inferior gluteal nerve injury - 2
Lower extremity sensory dermatomes
Ankle anatomy - 1
Ankle anatomy - 2
Ankle anatomy - 3
Ankle injury- 1
Ankle injury- 2
Ankle injury- 3
Ankle injury- 4
Ankle injury - 5
MUSC4_1
Lecture Objectives
Histology and bone formation
Woven bone
Lamellar bone
The haversian canal
Canaliculi
Bone histology review
Spongy versus compact bone
Bone characteristics
Spongy bone locations
Endochondral ossification
Membranous ossification
Source of osteoblasts
MUSC4_2
Disorders of bones
Achondroplasia
Achondroplasia - epidemiology
Osteoporosis
Type 1 osteoporosis
Type 1 osteoporosis etiology
Type 2 osteoporosis
Osteoporosis – clinical manifestation
Osteoporosis management – 1
Osteoporosis management – 2
Osteoporosis management – 3
Osteoporosis management – 4
Osteoporosis – bisphosphonates - 1
Osteoporosis – bisphosphonates - 2
Osteoporosis – bisphosphonates - 3
Osteopetrosis
Osteopetrosis – x-ray
Osteopetrosis – symptoms
Osteomalacia versus osteoporosis
Osteomalacia - histology
Osteomalacia – etiology and treatment
Osteomalacia – exam signs
Paget’s disease
Paget’s disease - etiology
Paget’s disease - labs
Paget’s disease stages
Polyostotic fibrous dysplasia
Bone disorders review
Osteoporosis and osteopetrosis
Osteomalacia and osteoporosis
Osteitis fibrosa cystica
Paget’s disease of bone
MUSC4_3
Primary bone tumors
Osteoma
Osteoid osteoma
Osteoblastoma
Giant cell tumor
Giant cell tumor - histology
Osteochondroma
Enchondroma
Malignant bone tumors
Osteosarcoma
Ewing’s sarcoma
Chondrosarcoma
Primary bone tumors
MUSC5_1
Learning Objectives
Osteoarthritis - characteristics
Osteoarthritis – exam findings
MUSC5_2
Rheumatoid arthritis
Rheumatoid arthritis - 1
Rheumatoid arthritis - 2
Rheumatoid arthritis - 3
Rheumatoid arthritis - 4
Rheumatoid arthritis - 5
Rheumatoid arthritis - 6
MUSC5_3
Gout - characteristics
Gout - histology
Gout - etiology
Gout – treatment
Pseudogout
MUSC5_4
Infectious arthritis
Chronic infectious arthritis
MUSC5_5
Seronegative spondyloarthropathies
Psoriatic arthritis
Ankylosing spondylitis – 1
Ankylosing spondylitis – 2
Reactive arthritis
Reactive arthritis – reiters syndrome
Reactive arthritis – review
MUSC5_6
Arthritis treatments: eicosanoids
Eicosanoids
Eicosanoids: cox 1
Ecosanoids: review
Eicosanoids: prostacyclin
Ecosanoids: cox enzyme review
Ecosanoids: Leukotrienes
Arachidonic Acid Pathway: Pharmacology
Zileuton
Leukotriene blockers
Non-steroidal anti-inflammatory drugs
COX 2 inhibitors
Aspirin – 1
Aspirin – 2
Other NSAIDs – 1
Other NSAIDs – 2
NSAIDs: Selective COX 2 inhibitors
NSAIDs: Acetaminophen – 1
NSAIDs: Acetaminophen – 2
Gout – treatment
Gout treatment: probenecid
Gout treatment: allopurinol - 1
Gout treatment: allopurinol - 2
MUSC6_1
Musculoskeletal and Connective Tissue
Sjögren’s syndrome
Sjögren’s syndrome
Sicca syndrome
MUSC6_2
Systemic lupus erythematosus
SLE – diagnostic criteria - 1
SLE – diagnostic criteria - 2
SLE – lupus nephritis
SLE – Lab findings
SLE – antibody review
MUSC6_3
Sarcoidosis
Sarcoidosis – signs and symptoms
Sarcoidosis – labs
Sarcoidosis – histology
Sarcoidosis – histo and treatment
MUSC6_4
Polymyalgia rheumatica
Myositis disorders
Polymyositis
Dermatomyositis - 1
Dermatomyositis – 2
MUSC6_5
Neuromuscular junction diseases
Myasthenia gravis
Lambert-Eaton syndrome - 1
Lambert-Eaton syndrome - 2
MUSC6_6
Scleroderma - 1
Scleroderma - 2
MUSC6_7
TNF alpha inhibitors
TNF alpha inhibitors - Etanercept
TNF alpha inhibitors - Infliximab
TNF alpha inhibitors - Adalimumab
MUSC6_8
Musculoskeletal summary
Nội dung
Musculoskeletal and Connective Tissue Stephen Bagley, M.D Resident Physician, University of Pennsylvania MUSC1_1MS01- Musculoskeletal System: Dermatology Anatomy, physiology, and disease of: – – – – – Skin Muscles and ligaments Peripheral nerves Bones Connective tissue MUSC1_1MS01- Musculoskeletal and Connective Tissue Lecture - Dermatology MUSC1_1MS01- Skin layers from surface to base Epidermal layers: Basement membrane C – Stratum corneum L – Stratum lucidum G – Stratum granulosum S - Stratum spinosum Stratum basalis B – Stratum basalis Mnemonic: Californians Like Girls in String Bikinis Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane C – Stratum corneum • Top layer • Continuously sloughed off Stratum basalis • Composed of keratin filled anucleate cells • Calluses: stratum corneum hypertrophy Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane L – Stratum lucidum • This layer is only found in thick skin (e.g palms and soles) Stratum basalis Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane G – Stratum granulosum Stratum basalis Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane S - Stratum spinosum Stratum basalis Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane B – Stratum basalis • Home to stem cells Stratum basalis Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Basement membrane: • Separates the epidermis from the dermis en:wp, commons.wikimedia.org Used with permission FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- 10 Myositis Disorders • Characteristics: • Ongoing inflammation of the muscles • Labs: • ↑ Creatinine kinase levels FA 2013: 394.2 • FA 2012: 422.2 • FA 2011: 386.3 ME 3e: 450 • ME 4e: 450 MUSC6_4- Polymyositis • Characteristics: • Inflammation of multiple muscle groups • Progressive and symmetric • Proximal muscle groups affected the most (e.g hips and shoulders) • Etiology: • • CD8+ T-cell injury to myofibers Histology: • • Endomysial inflammation, within muscle fibers Labs: • ↑ Creatinine kinase levels Muscle biopsy on H&E showing endomysial inflammation Polymyositis HE.jpg, commons.wikimedia.org Used with permission FA 2013: 394.2 • FA 2012: 422.2 • FA 2011: 386.3 ME 3e: 450 • ME 4e: 450 MUSC6_4- Dermatomyositis • Characteristics: • Inflammation of multiple muscle groups • Proximal muscle groups affected the most (e.g hips and shoulders) • Histology: • • Perivascular (perimysial) inflammation, within muscle fibers Labs: • ↑ Creatinine kinase levels • ↑ Aldolase levels Perimysial inflammation Dermatomyositis – high mag.jpg, commons.wikimedia.org Used with permission FA 2013: 394.2 • FA 2012: 422.2 • FA 2011: 386.3 ME 3e: 450 • ME 4e: 450 MUSC6_4- Dermatomyositis: Signs and symptoms Signs/symptoms: • Heliotrope rash (periorbital) • “Shawl and face” rash • Gottron’s papules develop on the dorsal fingers, over joints • “Mechanic’s hands” (i.e callused hands) Other characteristics: • ↑ Risk of malignancy (e.g colon and ovarian cancer) • Antibodies: • ANA (sensitive yet non-specific) • Anti-Jo-1 (very specific) • Copyright Richard Usatine, M.D Used with permission • Copyright Richard Usatine, M.D Used with permission • Treatment: • Steroids to reduce inflammation Heliotrope rash FA 2013: 394.2 • FA 2012: 422.2 • FA 2011: 386.3 ME 3e: 450 • ME 4e: 450 MUSC6_4- Neuromuscular junction diseases Kaplan Pathology 2010 Figure 29.2 Neuromuscular Junction Physiology FA 2013: 394.3 • FA 2012: 422.3 • FA 2011: 386.4 ME 3e: 450 • ME 4e: 450 MUSC6_5- Myasthenia gravis • Etiology: • Antibodies against the post-synaptic acetylcholine receptors of the NMJ Bind to and inactivates the receptor • • Signs/symptoms: • • Muscle weakness that worsens with prolonged use Typically affects the facial muscles • Ptosis • Extraocular muscles • Double vision • • Respiratory muscle involvement Diagnostic tests: • Electromyography: repetitive nerve stimulation testing • • • Progressive decrease in action potential size of affected muscle groups Edrophonium (an achetylcholinesterase inhibitor) improves symptoms Other characteristics: • Associated with thymoma FA 2013: 394.3 • FA 2012: 422.3 • FA 2011: 386.4 ME 3e: 450 • ME 4e: 450 Kaplan Immunology-Microbiology 2010 Figure I-13-5 MUSC6_5- Lambert-Eaton syndrome • Etiology: • Antibodies against the presynaptic calcium channels of the neuromuscular junction Antibody mediated attack • • Decreased acetylcholine release with neuronal transmission Signs/symptoms: • • Proximal muscle weakness that improves with repeated use Other characteristics: • Associated with malignancy, occurring as a paraneoplastic syndrome (e.g small cell lung cancer) FA 2013: 394.3 • FA 2012: 422.3 • FA 2011: 386.4 ME 3e: 450 • ME 4e: 450 Kaplan Pathology 2010 Figure 29.2 MUSC6_5- Lambert-Eaton syndrome • Diagnostic tests: • Electromyography: repetitive nerve stimulation testing • Progressive increase in action potential size of affected muscle groups Antibody mediated attack • Edrophonium does not improve symptoms Kaplan Pathology 2010 Figure 29.2 FA 2013: 394.3 • FA 2012: 422.3 • FA 2011: 386.4 ME 3e: 450 • ME 4e: 450 MUSC6_5- Scleroderma (progressive systemic sclerosis – PSS) • Two types • Diffuse scleroderma • Excessive fibrosis and collagen deposition throughout the body • Rapidly progressive • Sites of involvement: • Skin involvement (thick and leathery) • Visceral organ involvement • Lungs involvement (interstitial lung fibrosis) is usually the cause of death • Etiology: • Anti Scl-70 antibodies against topoisomerase FA 2013: 395.1 • FA 2012: 423.1 • FA 2011: 387.1 ME 3e: 107, 264 • ME 4e: 107, 264 Perioral Scleroderma Involvement Copyright Richard Usatine, M.D Used with permission MUSC6_6- Scleroderma (progressive systemic sclerosis – PSS) • Two types Diffuse scleroderma: CREST syndrome: • Sites of involvement: • • • • • Calcinosis Raynaud’s phenomenon Esophageal dysmotility (associated with GERD) Sclerodactyly Telangiectasia • Limited skin involvement • More benign course • Etiology: • Telangiectasias fingers scleroderma Copyright Richard Usatine, M.D Used with permission Anti centromere antibodies FA 2013: 395.1 • FA 2012: 423.1 • FA 2011: 387.1 ME 3e: 107, 264 • ME 4e: 107, 264 MUSC6_6- Tumor Necrosis Factor Alpha (TNF-α) Inhibitor: • General characteristics: • A class of drugs that inhibit the affects of TNF-α • TNF-α is an important inflammatory mediator FA 2013: 406.2 • FA 2012: 432.1 • FA 2011: 393.1 ME 3e: 448 • ME 4e: 448 MUSC6_7- Etanercept • Mechanism: • Recombinant form of the human TNF receptor that binds TNF • Decreases the net effect of TNF-α • Clinical Use: • Rheumatoid arthritis • Psoriasis • Ankylosing spondylitis FA 2013: 406.2 • FA 2012: 432.1 • FA 2011: 393.1 ME 3e: 448 • ME 4e: 448 MUSC6_7- Infliximab • Mechanism: • Anti-TNF antibody • Decreases the net effect of TNF-α • Clinical use: • Crohn’s disease • Rheumatoid arthritis • Ankylosing spondylitis • Adverse effects: • Predisposition to infections • Particularly latent tuberculosis reactivation • It’s important to assess for signs of TB prior to initiating Infliximab FA 2013: 406.2 • FA 2012: 432.1 • FA 2011: 393.1 ME 3e: 448 • ME 4e: 448 MUSC6_7- Adalimumab • Mechanism: • Anti-TNF antibody • Decreases the net effect of TNF-α • Clinical use: • Rheumatoid arthritis • Psoriasis • Ankylosing spondylitis FA 2013: 406.2 • FA 2012: 432.1 • FA 2011: 393.1 ME 3e: 448 • ME 4e: 448 MUSC6_7- Musculoskeletal and Connective Tissue: Summary • Anatomy, physiology, and disease of: • Skin • Muscles and ligaments • Peripheral nerves • Bones • Connective tissue MUSC6_8- ... patients Copyright Richard Usatine, M.D Used with permission FA 2013: 3 95. 2 • FA 2012: 423.2 • FA 2011: 387.2 ME 3e: 157 • ME 4e: 157 MUSC1_2- Pustule Name Description Pustule Blister containing pus... Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane C – Stratum... Kaplan Pathology 2010: Figure 11-1 FA 2013: 378.1 • FA 2012: 404.1 • FA 2011: 370.1 ME 3e: 451 • ME 4e: 451 MUSC1_1- Skin layers from surface to base Epidermal layers: Basement membrane L – Stratum