The lateral compartment contains the peroneus brevis.

Fascial Compartments of the Leg

The leg is divided into compartments by fascial septae, which are thin layers of connective tissue. In the thigh, there are three compartments: the anterior, medial, and posterior compartments. The anterior compartment contains the femoral nerve and artery, as well as the quadriceps femoris muscle group. The medial compartment contains the obturator nerve and artery, as well as the adductor muscles and gracilis muscle. The posterior compartment contains the sciatic nerve and branches of the profunda femoris artery, as well as the hamstrings muscle group.

In the lower leg, there are four compartments: the anterior, posterior (divided into deep and superficial compartments), lateral, and deep posterior compartments. The anterior compartment contains the deep peroneal nerve and anterior tibial artery, as well as the tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius muscles. The posterior compartment contains the tibial nerve and posterior tibial artery, as well as the deep and superficial muscles. The lateral compartment contains the superficial peroneal nerve and peroneal artery, as well as the peroneus longus and brevis muscles. The deep posterior compartment contains the tibial nerve and posterior tibial artery, as well as the flexor hallucis longus, flexor digitorum longus, tibialis posterior, and popliteus muscles.

The primary focus of pANCA is on myeloperoxidase (MPO), although it also targets lysosome, cathepsin G, and elastase to a lesser extent. Meanwhile, cANCA primarily targets PR3. All of these targets are located within the azurophilic granules of neutrophils.

ANCA testing can be done through ELISA or immunofluorescence, which can detect anti-MPO or anti-PR3 antibodies in the blood. The pattern of immunostaining would vary depending on the specific condition.

ANCA testing is useful in diagnosing and monitoring the disease activity of certain conditions, such as granulomatosis with polyangiitis (Wegner’s granulomatosis), eosinophilic granulomatosis with polyangiitis (EGPA), and microscopic polyangiitis. MPO antibodies are more sensitive in detecting microscopic polyangiitis compared to EGPA.

ANCA Associated Vasculitis: Types, Symptoms, and Management

ANCA associated vasculitis is a group of small-vessel vasculitides that are associated with anti-neutrophil cytoplasmic antibodies (ANCA). These include granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome), and microscopic polyangiitis. ANCA associated vasculitis is more common in older individuals and presents with symptoms such as renal impairment, respiratory symptoms, systemic symptoms, vasculitic rash, and ear, nose, and throat symptoms.

To diagnose ANCA associated vasculitis, first-line investigations include urinalysis for haematuria and proteinuria, blood tests for renal impairment, full blood count, CRP, and ANCA testing. There are two main types of ANCA – cytoplasmic (cANCA) and perinuclear (pANCA) – with cANCA being associated with granulomatosis with polyangiitis and pANCA being associated with eosinophilic granulomatosis with polyangiitis and other conditions.

Once suspected, ANCA associated vasculitis should be managed by specialist teams to allow an exact diagnosis to be made. The mainstay of management is immunosuppressive therapy. Kidney or lung biopsies may be taken to aid the diagnosis.

Neuroblastomas are a childhood tumour that frequently metastasizes widely and causes lytic lesions.

Secondary Malignant Tumours of Bone: Risk of Fracture and Treatment Options

Metastatic lesions affecting bone are more common than primary bone tumours, with typical tumours that spread to bone including breast, bronchus, renal, thyroid, and prostate. These tumours are more likely to affect those over the age of 50, with the commonest bone sites affected being the vertebrae, proximal femur, ribs, sternum, pelvis, and skull. The greatest risk for pathological fracture is osteolytic lesions, and bones with lesions that occupy 50% or less are prone to fracture under loading. The Mirel scoring system is used to determine the risk of fracture, with a score of 9 or greater indicating an impending fracture and requiring prophylactic fixation. Non-operative treatments for hypercalcaemia include rehydration and bisphosphonates, while pain can be managed with opiate analgesics and radiotherapy. Some tumours, such as breast and prostate, may benefit from chemotherapy and/or hormonal agents. In cases where the lesion is an isolated metastatic deposit, excision and reconstruction may be considered for better outcomes.

Axillary nerve palsy is most commonly caused by dislocation or fracture near the shoulder, rather than trauma to the axilla or chest wall. Medial epicondyle fractures do not typically result in axillary nerve palsy, but it is possible for trauma to the humerus to lead to this condition.

The shoulder joint is a shallow synovial ball and socket joint that is inherently unstable but capable of a wide range of movement. Stability is provided by the muscles of the rotator cuff. The glenoid labrum is a fibrocartilaginous rim attached to the free edge of the glenoid cavity. The fibrous capsule attaches to the scapula, humerus, and tendons of various muscles. Movements of the shoulder joint are controlled by different muscles. The joint is closely related to important anatomical structures such as the brachial plexus, axillary artery and vein, and various nerves and vessels.

The flexor digitorum profundus muscle is primarily responsible for flexing the distal interphalangeal joint. It is located deep to the flexor digitorum superficialis muscle and is specific to each digit. The flexor digitorum superficialis muscle, on the other hand, flexes the metacarpophalangeal and proximal interphalangeal joints. The flexor carpi ulnaris muscle is responsible for flexing and adducting the wrist, while the flexor pollicis longus muscle flexes the thumb. It is important to note that the flexor digitorum superficialis muscle must be intact for its function to remain present.

The forearm flexor muscles include the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis, and flexor digitorum profundus. These muscles originate from the common flexor origin and surrounding fascia, and are innervated by the median and ulnar nerves. Their actions include flexion and abduction of the carpus, wrist flexion, adduction of the carpus, and flexion of the metacarpophalangeal and interphalangeal joints.

Only the abductor pollicis brevis is innervated by the median nerve, while the other muscles are innervated by different nerves. It is important to be careful not to confuse the terms adductor and abductor when discussing muscle innervation.

Abductor Pollicis Brevis: Anatomy and Function

The abductor pollicis brevis is a muscle located in the palm of the hand. It originates from the flexor retinaculum, scaphoid, and trapezium bones and inserts into the radial side of the proximal phalanx of the thumb via a short tendon. The muscle is innervated by the recurrent branch of the median nerve in the palm.

The main function of the abductor pollicis brevis is to abduct the thumb at the carpometacarpal and metacarpophalangeal joints. This causes the thumb to move anteriorly at right angles to the plane of the palm and to rotate medially, which is useful for activities such as typing. When the thumb is fully abducted, there is an angulation of around 30 degrees between the proximal phalanx and the metacarpal.

Abduction of the thumb involves medial rotation of the metacarpal, and the abductor pollicis brevis is used along with the opponens pollicis in the initial stages of thumb opposition. Overall, the abductor pollicis brevis plays an important role in the movement and function of the thumb.

Developmental dysplasia of the hip is more likely to occur in babies who were in a breech presentation during pregnancy. Neonatal hypoglycaemia can be a risk for babies born to mothers with gestational diabetes or those who are preterm or small for their gestational age. Asymmetrical growth restriction, where a baby’s head circumference is on a higher centile than their weight or abdominal circumference, is often caused by uteroplacental dysfunction, such as pre-eclampsia or maternal smoking.

Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be screened for using ultrasound in infants with certain risk factors or through clinical examination using the Barlow and Ortolani tests. Other factors to consider include leg length symmetry, knee level when hips and knees are flexed, and restricted hip abduction in flexion. Ultrasound is typically used to confirm the diagnosis, but x-rays may be necessary for infants over 4.5 months old. Management options include the Pavlik harness for younger children and surgery for older ones. Most unstable hips will stabilize on their own within 3-6 weeks.

The most likely cause of the patient’s pain in the anatomical snuffbox is a scaphoid fracture, which is often the result of falling onto an outstretched hand (FOOSH). Scaphoid fractures are the most common type of carpal fracture. In contrast, a boxer’s fracture involves the 5th metacarpal bone and is typically caused by punching something with a closed fist, while a Colles’ fracture affects the distal radius and causes a dorsal displacement of the fragments. A Galeazzi fracture involves the radial bone and dislocation of the distal radioulnar joint, and is typically caused by a fall on the hand with rotational force.

A scaphoid fracture is a type of wrist fracture that usually occurs when a person falls onto an outstretched hand or during contact sports. It is important to identify scaphoid fractures as they can lead to avascular necrosis due to the unusual blood supply of the scaphoid bone. Patients with scaphoid fractures typically experience pain along the radial aspect of the wrist and loss of grip or pinch strength. Clinical examination involves checking for tenderness over the anatomical snuffbox, wrist joint effusion, pain on telescoping of the thumb, tenderness of the scaphoid tubercle, and pain on ulnar deviation of the wrist. Plain film radiographs and scaphoid views are used to diagnose scaphoid fractures, but MRI is considered the definitive investigation. Initial management involves immobilization with a splint or backslab and referral to orthopaedics. Orthopaedic management depends on the type of fracture, with undisplaced fractures typically treated with a cast and displaced fractures requiring surgical fixation. Complications of scaphoid fractures include non-union and avascular necrosis.

Patients with osteogenesis imperfecta typically develop the condition during childhood, with a medical history of multiple fractures from minor trauma and potential dental problems. Blue sclera is a common characteristic. Additionally, these patients may experience deafness due to otosclerosis.

Ehlers-Danlos syndrome is characterized by hyperflexible joints, stretchy skin, and fragility.

Wide spaced nipples are not typically associated with osteogenesis imperfecta, but rather with Turner syndrome.

Understanding Osteogenesis Imperfecta

Osteogenesis imperfecta, also known as brittle bone disease, is a group of disorders that affect collagen metabolism, leading to bone fragility and fractures. The most common type of osteogenesis imperfecta is type 1, which is inherited in an autosomal dominant manner and is caused by decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides.

This condition typically presents in childhood, with individuals experiencing fractures following minor trauma. Other common features include blue sclera, deafness secondary to otosclerosis, and dental imperfections. Despite these symptoms, adjusted calcium, phosphate, parathyroid hormone, and ALP results are usually normal in individuals with osteogenesis imperfecta.

Overall, understanding the symptoms and underlying causes of osteogenesis imperfecta is crucial for proper diagnosis and management of this condition.

The Koebner Phenomenon: Skin Lesions at the Site of Injury

The Koebner phenomenon refers to the occurrence of skin lesions at the site of injury. This phenomenon is commonly observed in various skin conditions such as psoriasis, vitiligo, warts, lichen planus, lichen sclerosus, and molluscum contagiosum. In other words, if a person with any of these skin conditions experiences trauma or injury to their skin, they may develop new lesions in the affected area.

This phenomenon is named after Heinrich Koebner, a German dermatologist who first described it in 1876. The exact mechanism behind the Koebner phenomenon is not fully understood, but it is believed to be related to the immune system’s response to injury. In some cases, the injury may trigger an autoimmune response, leading to the development of new lesions.

The Koebner phenomenon can be a frustrating and challenging aspect of managing skin conditions. It is important for individuals with these conditions to take precautions to avoid injury to their skin, such as wearing protective clothing or avoiding activities that may cause trauma. Additionally, prompt treatment of any new lesions that develop can help prevent further spread of the condition.

Bisphosphonates work by inhibiting osteoclasts, the cells responsible for bone resorption. Therefore, NICE recommends discharging patients on bisphosphonates after fragility fractures without the need for a DEXA scan. While vitamin D and calcium supplementation increase calcium availability to bone, bisphosphonates are the first-line treatment for fragility fractures. Inhibiting osteoblasts would decrease bone density, so promoting osteoclasts would lead to increased bone resorption, which is incorrect.

Bisphosphonates: Uses, Adverse Effects, and Patient Counselling

Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, the cells responsible for breaking down bone tissue. Bisphosphonates are commonly used to prevent and treat osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.

However, bisphosphonates can cause adverse effects such as oesophageal reactions, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which includes fever, myalgia, and arthralgia following administration. Hypocalcemia may also occur due to reduced calcium efflux from bone, but this is usually clinically unimportant.

To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or another oral medication and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment. However, calcium supplements should only be prescribed if dietary intake is inadequate when starting bisphosphonate treatment for osteoporosis. Vitamin D supplements are usually given.

The duration of bisphosphonate treatment varies depending on the level of risk. Some experts recommend stopping bisphosphonates after five years if the patient is under 75 years old, has a femoral neck T-score of more than -2.5, and is at low risk according to FRAX/NOGG.

Erysipelas is a skin infection that is localized and caused by Streptococcus pyogenes. It is often seen in elderly patients with weakened immune systems, such as those with diabetes mellitus. Symptoms include a raised, painful rash with clear boundaries.

Ringworm is commonly caused by Trichophyton rubrum. This results in a circular, scaly, and itchy rash that is red in color.

While Staphylococcus epidermidis is a normal part of the skin’s flora, it is more commonly associated with infections of foreign devices and endocarditis rather than skin infections.

Understanding Erysipelas: A Superficial Skin Infection

Erysipelas is a skin infection that is caused by Streptococcus pyogenes. It is a less severe form of cellulitis, which is a more widespread skin infection. Erysipelas is a localized infection that affects the skin’s upper layers, causing redness, swelling, and warmth. The infection can occur anywhere on the body, but it is most commonly found on the face, arms, and legs.

The treatment of choice for erysipelas is flucloxacillin, an antibiotic that is effective against Streptococcus pyogenes. Other antibiotics may also be used, depending on the severity of the infection and the patient’s medical history.

Osteoporosis is the diagnosis for this patient, as indicated by a T-score of less than -2.5 on their DEXA scan. Their lab results for serum calcium, serum phosphate, ALP, and PTH are all within normal ranges for osteoporosis.

Patients with osteomalacia typically have decreased serum calcium and serum phosphate levels, along with increased ALP and PTH levels.

Paget’s disease is characterized by an isolated increase in ALP, while the rest of the lab values are normal.

Hyperparathyroidism is indicated by increased PTH levels, with the specific lab values depending on whether the patient has primary or secondary hyperparathyroidism.

Primary hyperparathyroidism is characterized by raised PTH, calcium, and ALP levels, as increased bone resorption leads to high serum calcium and ALP levels. PTH also causes increased phosphate excretion by the kidneys, resulting in low serum phosphate levels.

Secondary hyperparathyroidism is indicated by raised PTH, phosphate, and ALP levels, typically seen in patients with chronic kidney disease. In this case, the kidneys cannot excrete phosphate, leading to increased serum phosphate levels, which in turn causes increased PTH secretion. PTH causes bone resorption, leading to high ALP levels. Chronic kidney disease also impairs vitamin D activation, resulting in hypocalcemia.

Lab Values for Bone Disorders

When it comes to bone disorders, certain lab values can provide important information about the condition. In cases of osteoporosis, calcium, phosphate, alkaline phosphatase (ALP), and parathyroid hormone (PTH) levels are typically normal. However, in osteomalacia, calcium and phosphate levels are decreased while ALP and PTH levels are increased. Primary hyperparathyroidism, which can lead to osteitis fibrosa cystica, is characterized by increased calcium and PTH levels but decreased phosphate levels. Chronic kidney disease can result in secondary hyperparathyroidism, which is marked by decreased calcium levels and increased phosphate and PTH levels. Paget’s disease, on the other hand, typically shows normal calcium and phosphate levels but increased ALP levels. Finally, osteopetrosis is associated with normal levels of calcium, phosphate, ALP, and PTH. By analyzing these lab values, healthcare professionals can better diagnose and treat bone disorders.

There are a total of 8 muscles that are involved in the movement of the thumb. These include two flexors, namely flexor pollicis brevis and flexor pollicis longus, two extensors, namely extensor pollicis brevis and longus, two abductors, namely abductor pollicis brevis and longus, one adductor, namely adductor pollicis, and one muscle that opposes the thumb by rotating the CMC joint, known as opponens pollicis. The flexor and extensor longus muscles are responsible for moving both the MCP and IP joints and insert on the distal phalanx.

Anatomy of the Hand: Fascia, Compartments, and Tendons

The hand is composed of bones, muscles, and tendons that work together to perform various functions. The bones of the hand include eight carpal bones, five metacarpals, and 14 phalanges. The intrinsic muscles of the hand include the interossei, which are supplied by the ulnar nerve, and the lumbricals, which flex the metacarpophalangeal joints and extend the interphalangeal joint. The thenar eminence contains the abductor pollicis brevis, opponens pollicis, and flexor pollicis brevis, while the hypothenar eminence contains the opponens digiti minimi, flexor digiti minimi brevis, and abductor digiti minimi.

The fascia of the palm is thin over the thenar and hypothenar eminences but relatively thick elsewhere. The palmar aponeurosis covers the soft tissues and overlies the flexor tendons. The palmar fascia is continuous with the antebrachial fascia and the fascia of the dorsum of the hand. The hand is divided into compartments by fibrous septa, with the thenar compartment lying lateral to the lateral septum, the hypothenar compartment lying medial to the medial septum, and the central compartment containing the flexor tendons and their sheaths, the lumbricals, the superficial palmar arterial arch, and the digital vessels and nerves. The deepest muscular plane is the adductor compartment, which contains adductor pollicis.

The tendons of the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) enter the common flexor sheath deep to the flexor retinaculum. The tendons enter the central compartment of the hand and fan out to their respective digital synovial sheaths. The fibrous digital sheaths contain the flexor tendons and their synovial sheaths, extending from the heads of the metacarpals to the base of the distal phalanges.

The dorsalis pedis artery is located lateral to the extensor hallucis longus tendon.

The foot has two arches: the longitudinal arch and the transverse arch. The longitudinal arch is higher on the medial side and is supported by the posterior pillar of the calcaneum and the anterior pillar composed of the navicular bone, three cuneiforms, and the medial three metatarsal bones. The transverse arch is located on the anterior part of the tarsus and the posterior part of the metatarsus. The foot has several intertarsal joints, including the sub talar joint, talocalcaneonavicular joint, calcaneocuboid joint, transverse tarsal joint, cuneonavicular joint, intercuneiform joints, and cuneocuboid joint. The foot also has various ligaments, including those of the ankle joint and foot. The foot is innervated by the lateral plantar nerve and medial plantar nerve, and it receives blood supply from the plantar arteries and dorsalis pedis artery. The foot has several muscles, including the abductor hallucis, flexor digitorum brevis, abductor digit minimi, flexor hallucis brevis, adductor hallucis, and extensor digitorum brevis.

A fracture of the 5th metacarpal, known as a ‘Boxer fracture’, is commonly caused by punching a hard surface. This type of fracture is typically minimally displaced. Fracture of the scaphoid bone in the wrist can lead to avascular necrosis. The 2nd metacarpal is not typically fractured in punching injuries, while the lunate and hamate bones in the wrist are not commonly affected by this type of injury.

Boxer fracture is a type of fracture that occurs in the fifth metacarpal bone. It is usually caused by punching a hard surface, such as a wall. The fracture is typically minimally displaced, meaning that the bone is still in its proper position but has a small crack or break. This injury is commonly seen in boxers, hence the name, but can also occur in other individuals who engage in activities that involve punching or striking objects. The treatment for a boxer fracture may involve immobilization of the affected hand with a cast or splint, and in some cases, surgery may be necessary.

Psoriatic arthritis is strongly linked to psoriasis, with skin and nail bed changes serving as indicators of this related pathological process. Diagnosis is made through clinical evaluation. For comprehensive information on these conditions, Arthritis Research UK is a valuable resource.

Psoriatic arthropathy is a type of inflammatory arthritis that is associated with psoriasis. It is classified as one of the seronegative spondyloarthropathies and is characterized by joint inflammation that often precedes the development of skin lesions. While it affects both males and females equally, only 10-20% of patients with psoriasis develop this condition. The presentation of psoriatic arthropathy can vary, with the most common types being symmetric polyarthritis and asymmetrical oligoarthritis. Other signs include psoriatic skin lesions, periarticular disease, and nail changes. X-rays may show erosive changes and new bone formation, as well as a pencil-in-cup appearance. Treatment is similar to that of rheumatoid arthritis, but mild cases may only require NSAIDs and newer monoclonal antibodies may be used. Overall, psoriatic arthropathy has a better prognosis than RA.

Golimumab is classified as a TNF alpha antagonist, which inhibits the action of tumour necrosis factor. It is prescribed for the treatment of ankylosing spondylitis and is administered subcutaneously every four weeks. Rituximab is an example of a CD20 antagonist, used for the management of rheumatoid arthritis and certain types of blood cancer. CD38 antagonists, such as daratumumab, are being studied in clinical trials and are currently used for the treatment of multiple myeloma. Anakinra is an interleukin-1 inhibitor used for rheumatoid arthritis, while secukinumab is an interleukin-17A inhibitor licensed for the treatment of ankylosing spondylitis under specialist use.

Understanding Tumour Necrosis Factor and its Inhibitors

Tumour necrosis factor (TNF) is a cytokine that plays a crucial role in the immune system. It is mainly secreted by macrophages and has various effects on the immune system, such as activating macrophages and neutrophils, acting as a costimulator for T cell activation, and mediating the body’s response to Gram-negative septicaemia. TNF also has anti-tumour effects and binds to both the p55 and p75 receptor, inducing apoptosis and activating NFkB.

TNF has endothelial effects, including increased expression of selectins and production of platelet activating factor, IL-1, and prostaglandins. It also promotes the proliferation of fibroblasts and their production of protease and collagenase. TNF inhibitors are used to treat inflammatory conditions such as rheumatoid arthritis and Crohn’s disease. Examples of TNF inhibitors include infliximab, etanercept, adalimumab, and golimumab.

Infliximab is also used to treat active Crohn’s disease unresponsive to steroids. However, TNF blockers can have adverse effects such as reactivation of latent tuberculosis and demyelination. Understanding TNF and its inhibitors is crucial in the treatment of various inflammatory conditions.

The trapezius muscle is supplied by the spinal accessory nerve (CN XI), while the levator scapulae muscle is innervated by the fourth and fifth cervical nerves (C4 and C5) as well as the dorsal scapular nerve. The middle scalene muscle receives innervation from the anterior rami of C3-C8. The sternohyoid and sternothyroid muscles, located in the muscular triangle of the anterior neck, are innervated by the ansa cervicalis, which is a component of the cervical plexus and responsible for raising the thyroid cartilage during talking and swallowing.

The trapezius muscle originates from the medial third of the superior nuchal line of the occiput, the external occipital protruberance, the ligamentum nuchae, the spines of C7 and all thoracic vertebrae, and all intervening interspinous ligaments. Its insertion points are the posterior border of the lateral third of the clavicle, the medial border of the acromion, and the upper border of the crest of the spine of the scapula. The spinal portion of the accessory nerve supplies this muscle. The trapezius muscle is responsible for elevating the shoulder girdle and laterally rotating the scapula.

Although Pectineus is a hip flexor, it is not as significant as iliopsoas in this function. Its origin is the pubic bone, and it inserts into the femur. Additionally, it assists in adducting and internally rotating the thigh.

The Psoas Muscle: Origin, Insertion, Innervation, and Action

The psoas muscle is a deep-seated muscle that originates from the transverse processes of the five lumbar vertebrae and the superficial part originates from T12 and the first four lumbar vertebrae. It inserts into the lesser trochanter of the femur and is innervated by the anterior rami of L1 to L3.

The main action of the psoas muscle is flexion and external rotation of the hip. When both sides of the muscle contract, it can raise the trunk from the supine position. The psoas muscle is an important muscle for maintaining proper posture and movement, and it is often targeted in exercises such as lunges and leg lifts.

The radial nerve supplies the extensor pollicis longus muscle, which can be injured in a fall onto an outstretched hand (FOOSH) resulting in a possible scaphoid fracture. The tendon of this muscle forms the medial border of the anatomical snuffbox and is responsible for extending the metacarpophalangeal and interphalangeal joints of the thumb. The abductor pollicis longus muscle, also supplied by the radial nerve, functions to abduct the thumb and its tendon forms the lateral border of the anatomical snuffbox. The extensor pollicis brevis muscle, also supplied by the radial nerve, extends and abducts the thumb at the carpometacarpal and metacarpophalangeal joints and its tendon forms the lateral border of the anatomical snuffbox. The extensor pollicis longus muscle is not innervated by the median nerve.

Upper limb anatomy is a common topic in examinations, and it is important to know certain facts about the nerves and muscles involved. The musculocutaneous nerve is responsible for elbow flexion and supination, and typically only injured as part of a brachial plexus injury. The axillary nerve controls shoulder abduction and can be damaged in cases of humeral neck fracture or dislocation, resulting in a flattened deltoid. The radial nerve is responsible for extension in the forearm, wrist, fingers, and thumb, and can be damaged in cases of humeral midshaft fracture, resulting in wrist drop. The median nerve controls the LOAF muscles and can be damaged in cases of carpal tunnel syndrome or elbow injury. The ulnar nerve controls wrist flexion and can be damaged in cases of medial epicondyle fracture, resulting in a claw hand. The long thoracic nerve controls the serratus anterior and can be damaged during sports or as a complication of mastectomy, resulting in a winged scapula. The brachial plexus can also be damaged, resulting in Erb-Duchenne palsy or Klumpke injury, which can cause the arm to hang by the side and be internally rotated or associated with Horner’s syndrome, respectively.

The correct answer is that the flexor digitorum profundus muscle is responsible for flexing the distal interphalangeal joint. The other options, such as the flexor digitorum superficialis and flexor pollicis longus, are responsible for different movements and are therefore incorrect. The palmar interossei are also not responsible for flexion at the distal interphalangeal joint. Lastly, there is no such muscle as the flexor digiti medius.

The forearm flexor muscles include the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis, and flexor digitorum profundus. These muscles originate from the common flexor origin and surrounding fascia, and are innervated by the median and ulnar nerves. Their actions include flexion and abduction of the carpus, wrist flexion, adduction of the carpus, and flexion of the metacarpophalangeal and interphalangeal joints.

Pemphigus is a skin disorder caused by autoimmune reactions where IgG antibodies attack the desmosomes that connect the skin cells. This results in acantholysis, where the keratinocytes detach from each other. In contrast, pemphigoid is another autoimmune blistering skin disorder, but it is caused by IgG autoantibodies targeting the basement membrane instead of the desmosomes.

Pemphigus vulgaris is an autoimmune condition that occurs when the body’s immune system attacks desmoglein 3, a type of cell adhesion molecule found in epithelial cells. This disease is more prevalent in the Ashkenazi Jewish population. The most common symptom is mucosal ulceration, which can be the first sign of the disease. Oral involvement is seen in 50-70% of patients. Skin blistering is also a common symptom, with easily ruptured vesicles and bullae. These lesions are typically painful but not itchy and may appear months after the initial mucosal symptoms. Nikolsky’s sign is a characteristic feature of pemphigus vulgaris, where bullae spread following the application of horizontal, tangential pressure to the skin. Biopsy results often show acantholysis.

The first-line treatment for pemphigus vulgaris is steroids, which help to reduce inflammation and suppress the immune system. Immunosuppressants may also be used to manage the disease.

The correct diagnosis for this patient is osteomalacia, which is characterized by low serum calcium, low serum phosphate, raised ALP, and raised PTH. It is important to identify the risk factors for osteomalacia, such as decreased sunlight exposure, which can lead to vitamin D deficiency and subsequent hypocalcaemia. In response to hypocalcaemia, PTH levels increase, as seen in this case.

Acute pancreatitis is an incorrect diagnosis as it does not fit the patient’s clinical picture. Osteoarthritis is also an incorrect diagnosis as it would not cause changes in serum calcium, ALP, or PTH levels. Primary hyperparathyroidism is also an incorrect diagnosis as it is associated with high levels of PTH and calcium, which is not seen in this patient.

Lab Values for Bone Disorders

When it comes to bone disorders, certain lab values can provide important information about the condition. In cases of osteoporosis, calcium, phosphate, alkaline phosphatase (ALP), and parathyroid hormone (PTH) levels are typically normal. However, in osteomalacia, calcium and phosphate levels are decreased while ALP and PTH levels are increased. Primary hyperparathyroidism, which can lead to osteitis fibrosa cystica, is characterized by increased calcium and PTH levels but decreased phosphate levels. Chronic kidney disease can result in secondary hyperparathyroidism, which is marked by decreased calcium levels and increased phosphate and PTH levels. Paget’s disease, on the other hand, typically shows normal calcium and phosphate levels but increased ALP levels. Finally, osteopetrosis is associated with normal levels of calcium, phosphate, ALP, and PTH. By analyzing these lab values, healthcare professionals can better diagnose and treat bone disorders.

Stone formation is favored by the thick consistency of submandibular gland secretions. Additionally, the majority of stones are visible on radiographs. During gland removal surgery, the facial artery is typically tied off as it runs between the gland and mandible. The lingual artery may also be encountered later in the procedure when Wharton’s duct is being moved.

Anatomy of the Submandibular Gland

The submandibular gland is located beneath the mandible and is surrounded by the superficial platysma, deep fascia, and mandible. It is also in close proximity to various structures such as the submandibular lymph nodes, facial vein, marginal mandibular nerve, cervical branch of the facial nerve, deep facial artery, mylohyoid muscle, hyoglossus muscle, lingual nerve, submandibular ganglion, and hypoglossal nerve.

The submandibular duct, also known as Wharton’s duct, is responsible for draining saliva from the gland. It opens laterally to the lingual frenulum on the anterior floor of the mouth and is approximately 5 cm in length. The lingual nerve wraps around the duct, and as it passes forward, it crosses medial to the nerve to lie above it before crossing back, lateral to it, to reach a position below the nerve.

The submandibular gland receives sympathetic innervation from the superior cervical ganglion and parasympathetic innervation from the submandibular ganglion via the lingual nerve. Its arterial supply comes from a branch of the facial artery, which passes through the gland to groove its deep surface before emerging onto the face by passing between the gland and the mandible. The anterior facial vein provides venous drainage, and the gland’s lymphatic drainage goes to the deep cervical and jugular chains of nodes.

The cubital fossa contains the following structures in order from lateral to medial: radial nerve, brachial tendon, brachial artery, and median nerve. A helpful mnemonic to remember this order is Really Need Beer To Be At My Nicest. It is important to note that the ulnar nerve is not part of the contents of the cubital fossa.

The Antecubital Fossa: Anatomy and Clinical Significance

The antecubital fossa is a depression located on the anterior aspect of the arm, between the arm and forearm. It is an important area for medical professionals as it is where venous blood samples are typically taken from. The borders of the antecubital fossa are the brachioradialis muscle laterally, the pronator teres medially, and a line between the medial and lateral epicondyles superiorly.

There are both deep and superficial structures found in the antecubital fossa. Deep structures include the radial nerve, tendon of the biceps muscle, brachial artery, and medial nerve. Superficial structures consist of a network of veins, including the cephalic vein and basilic vein, which come together as the median cubital vein.

The main clinical relevance of the antecubital fossa is its use for blood sampling and cannulation. However, it is also important to have a working knowledge of the anatomy as structures can become damaged. Excessive straining of the biceps tendon can cause it to rupture, leading to a ‘Popeye sign’. Damage to the medial nerve can also occur, resulting in muscle paralysis in the forearm and hand. Overall, understanding the anatomy and clinical significance of the antecubital fossa is crucial for medical professionals.

Understanding Perthes’ Disease

Perthes’ disease is a condition that affects the hip joints of children between the ages of 4-8 years. It is caused by a lack of blood supply to the femoral head, leading to bone infarction and degeneration. Boys are five times more likely to develop this condition, and around 10% of cases are bilateral. Symptoms include hip pain, limping, stiffness, and reduced range of hip movement. Early changes can be seen on x-rays, such as widening of the joint space, while later changes include decreased femoral head size and flattening.

Diagnosis is typically made through a plain x-ray, but a technetium bone scan or magnetic resonance imaging may be necessary if symptoms persist despite a normal x-ray. Complications of Perthes’ disease can include osteoarthritis and premature fusion of the growth plates.

The Catterall staging system is used to classify the severity of the disease, with Stage 1 being the mildest and Stage 4 being the most severe. Management options include casting or bracing to keep the femoral head within the acetabulum, observation for children under 6 years old, and surgical intervention for severe deformities in older children.

Overall, most cases of Perthes’ disease will resolve with conservative management, and early diagnosis can improve outcomes. It is important for parents and healthcare providers to be aware of the symptoms and seek medical attention if they suspect a child may be affected by this condition.

The Antecubital Fossa: Anatomy and Clinical Significance

The antecubital fossa is a depression located on the anterior aspect of the arm, between the arm and forearm. It is an important area for medical professionals as it is where venous blood samples are typically taken from. The borders of the antecubital fossa are the brachioradialis muscle laterally, the pronator teres medially, and a line between the medial and lateral epicondyles superiorly.

There are both deep and superficial structures found in the antecubital fossa. Deep structures include the radial nerve, tendon of the biceps muscle, brachial artery, and medial nerve. Superficial structures consist of a network of veins, including the cephalic vein and basilic vein, which come together as the median cubital vein.

The main clinical relevance of the antecubital fossa is its use for blood sampling and cannulation. However, it is also important to have a working knowledge of the anatomy as structures can become damaged. Excessive straining of the biceps tendon can cause it to rupture, leading to a ‘Popeye sign’. Damage to the medial nerve can also occur, resulting in muscle paralysis in the forearm and hand. Overall, understanding the anatomy and clinical significance of the antecubital fossa is crucial for medical professionals.

Oesophageal problems can be caused by bisphosphonates, which are commonly used to prevent and treat osteoporosis. These drugs can lead to gastrointestinal issues, including oesophagitis, which should prompt discontinuation of the medication. Long-term use of bisphosphonates can also result in atypical femoral fractures and osteonecrosis of the jaw. Therefore, patients should be periodically re-evaluated to assess the benefits and risks of continuing treatment, especially after five or more years of use. Before starting bisphosphonate treatment, patients should have a dental check-up and any necessary dental work should be performed.

Gliclazide, a sulfonylurea drug, can cause hypoglycemia symptoms such as dizziness, lack of energy, drowsiness, headache, and sweating.

Metformin is associated with lactic acidosis and gastrointestinal problems.

Bisoprolol can cause erectile dysfunction, cold hands and feet, bradycardia, and hypotension.

Paracetamol, unlike NSAIDs, is not known to cause indigestion.

Bisphosphonates: Uses, Adverse Effects, and Patient Counselling

Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, the cells responsible for breaking down bone tissue. Bisphosphonates are commonly used to prevent and treat osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.

However, bisphosphonates can cause adverse effects such as oesophageal reactions, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which includes fever, myalgia, and arthralgia following administration. Hypocalcemia may also occur due to reduced calcium efflux from bone, but this is usually clinically unimportant.

To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or another oral medication and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment. However, calcium supplements should only be prescribed if dietary intake is inadequate when starting bisphosphonate treatment for osteoporosis. Vitamin D supplements are usually given.

The duration of bisphosphonate treatment varies depending on the level of risk. Some experts recommend stopping bisphosphonates after five years if the patient is under 75 years old, has a femoral neck T-score of more than -2.5, and is at low risk according to FRAX/NOGG.

After the primary infection (usually chickenpox during childhood), the herpes zoster virus remains inactive in the dorsal root or cranial nerve ganglia. The patient’s rash, which appears in the left T1 dermatome, indicates that the virus has been dormant in the T1 dorsal root ganglion. Although herpes zoster can reactivate at any time, it is more commonly associated with older age, recent viral infections, periods of stress, or immunosuppression.

Shingles is a painful blistering rash caused by reactivation of the varicella-zoster virus. It is more common in older individuals and those with immunosuppressive conditions. The diagnosis is usually clinical and management includes analgesia, antivirals, and reminding patients they are potentially infectious. Complications include post-herpetic neuralgia, herpes zoster ophthalmicus, and herpes zoster oticus. Antivirals should be used within 72 hours to reduce the incidence of post-herpetic neuralgia.