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Last update: prof. MUDr. Valér Džupa, CSc. (12.06.2008)
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Last update: prof. MUDr. Valér Džupa, CSc. (12.06.2008)
The primary objective of the subject is to provide a comprehensive and interdisciplinary overview (morphology, physiology, patophysiology, syndromology) of disorders of active motion and locomotion disorders resulting from them. The secondary objective is to present within the course of pathological anatomy the macroscopic and microscopic findings of diseases manifested by disorders of motion. The tertiary objective is to present within the course of pharmacology an overview of pharmacotherapy (antiflogistics and analgesics) of diseases manifested by disorders of motion. The final objective is to acquaint students with the basic clinical terminology relating to syndromology and the therapy of diseases manifested by disorders of motion and locomotion. |
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Last update: prof. MUDr. Valér Džupa, CSc. (21.03.2010)
Literature for Course no. 12 (Locomotion disorders) of Module IIC "Basic clinical issues" of the reformed curriculum of 3rd Medical Faculty, Charles University (Krbec, Džupa)
Anatomy: Czech: Čihák I. a III. Petrovický - skripta II., III., VIII. a IX. English: Gray´s Anatomy Kahle, Martin: Neuroanatomy
Physiology: Czech: Trojan: Fyziologie Gannong: Lékařská fyziologie Hulín: Patofyziologia Skripta oddělení patofyziologie 3. LF UK Schmidt: Memorix-Fyziologie English: Porth: Patophysiology Kumar, Clark: Clinical medicine Cotran, Kumar, Robins: Pathologic basis of disease Guyton: Textbook of medical physiology
Neurology: Czech: Urbánek, K.: Symptomy a syndromy obecné neurologie. UP, Olomouc 1994 Tichý, J. a kol.: Neurologie (skripta). Karolinum, Praha, 1997 Ambler, Z.: Neurologie pro studenty všeobecného lékařství, Karolinum, Praha, 1997 English: Mumenthaler, M.: Neurology. 3rd Edit.. Georg Verlag, Stuttgard, 1990, ISBN 3-13-523903-9 Lindsay, K.W., Bone, I., Collander, R.: Meurology and neurosurgery illustrated. 2nd Edition. Churchill&Livingstone, Edinburgh, 1991, ISBN 0-443-04345-0
Pathology: Czech: Matějovský Z., Povýšil C., Kolář J.: Kostní nádory. Avicenum, 1988 Povýšil C. a kolektiv: Speciální patologie III.díl (skripta) Karolinum, nakladetelství UK, 1999 English: Cotram R.S., Kumar V., Collins T.: Robbins Pathologic, Basic of Dissease. 6th ed., Saunders Company, 1999 Kumar, V., Cotran, R.S., Robbins: Basic Pathology. Saunders Comp., 6th ed.1997
Radiology: Czech: Neuwirth, J.: Kompendium diagnostického zobrazování. Triton 1998. ISBN 80-85875-86-1 English: Sutton, D.: Radiology and imaging for medical students. Churchill Livingstone, London 1994. ISBN 0-443-04883-5
Farmacology: Czech: Katzung, B.G.: Základní a klinická farmakologie. Nakladatelství a vydavatelství H&H, 1994, ISBN 80-85787-35-0 English: Katzung, B.G.: Basic and clinical pharmacology. 7th edition. Prentice-Hall International, 1995 Rang, Dale, Ritter: Pharmacology. 3rd edition. Churchill&Livingstone, Edinburgh, 1995 Mycek, Harvey, Champ: Lippincott´s illustrated reviews Pharmacology. 2nd edition. Lippicontt-Raven, Philadelphia, 1997
Rehabilitation: Czech: Janda, V.: Základy kliniky funkčních poruch hybného systému, IDVZ, Brno, 1983 Lewit: Manipulační léčba, ČLS 1996, ISBN 3-335-00401-9 English: Janda, V.: Muscles and Motor control in cervicogenic disorders, In Grant, Physiotherapy of the cervical and thoracic spine, Churchill Livingstone 1994, ISBN 0-443-08918-3 Janda, V.: Evaluation of muscle imbalance, In Liebenson, Rehabilitation of the spine, Williams Wilkins 1996, ISBN 0-683-05032X Lewit: Manipulative therapy, Butterworth 1991, ISBN 0750611235
Medical ethics: Czech: Aplikace individuálních přístupů v péči o zdravotně postižené. Texty k semináři. Centrum liberálních studií, Praha, 1996, ISBN 80-85341-54-9 Standardní pravidla pro vyrovnávání příležitostí pro osoby se zdravotním postižením, dokument 48. Zasedání Valného shromáždění OSN z 28. října 1993, Sdružení zdravotně postižených v ČR, Karlínské nám. 12, 186 03 Praha 8 Národní plán vyrovnávání příležitostí pro občany se zdravotním postižením, Usnesení vlády ČR č. 256 z 14. dubna 1998 English: Šťastný, J.: The application of individual approaches to health and social care for people with disabilities. A summary to the paper. In: Aplikace individuálních přístupů v péči o zdravotně postižené. Texty k semináři. Centrum liberálních studií, Praha, 1996, ISBN 80-85341-54-9 Renwick, R., Brown, I., Nagel, M.: Quality of life in health promotion and rehabilitation. Sage Publications, 1996, ISBN 0-8039-5913-3
Neurosurgery: Czech: Haninec et. al.: Chirurgická léčba poranění pažní pleteně. Výsledky a přehled literatury. Čs. Rehabilitace - v tisku Stejskal, Haninec: Indikace k chirurgické rekonstrukci pažní pleteně. Výsledky rekonstrukcí. Čs. Neurol. Neurochir., 1996, 60/93: 126-133 Zvěřina, Stejskal: Poranění periferních nervů. Avicenum, Praha English: Haninec, Smrčka: Functional reconstruction of paralysed biceps brachii muscle by transposition of pediculated latissimus dorsi muscle. Acta chir. plasticae, 1998 Haninec: Undulating course of nerve fibres and bands of Fontana in peripheral nerves of the rat. Anat. Embryol., 1986, 174: 407-411 Haninec: Study of the origin of connective tissue sheaths of peripheral nerves in the limb of avian embryos. Anat. Embriol., 1988, 178: 553-557 Kline, Hudson: Nerve injuries. Sounders comp., Philadelphia, Pensylvania, 1995 Mackinnon, Delon: Surgery of the peripheral nerve. Thieme Medical Publishers, Inc, New York, 1988
Orthopaedics: Czech: Muller: Chirurgie pro studium a praxi, Goldstein a Goldstein, 1997 (ISBN 80-86094-10-3) Sosna: Základy ortopedie, Triton, 2001 (ISBN 80-7254-202-8) Třeška: Propedeutika vybraných klinických oborů, Grada, 2002 (ISBN 80-247-0239-8) Zeman: Speciální chirurgie, Galen, 2001 (ISBN 80-7262-093-2) English: McRae: Practical fracture treatment, Churchill Livingstone, 2002 (ISBN 0-443-07038-5) Adams, Hamblen: Outline of Orthopaedics, Churchill Livingstone, 2001 (ISBN 0-443-07024-5) Salter: Textbook of disorders and injuries of the musculoskeletal system, 1998 (ISBN 0-683-07499-7) Skinner: Current Diagnosis and Treatment in Orthopaedics, McGrawhill, 2003 (ISBN 0-071-12413-6) |
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Last update: prof. MUDr. Valér Džupa, CSc. (12.06.2008)
Included in the Syllabus. |
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Last update: prof. MUDr. Valér Džupa, CSc. (21.03.2010)
Master´s studies 3rd grade Credit will be awarded: 1. upon completion of 80% of the prescribed course attendance and passing of the final test, 2. in case of failure to comply with this condition, upon completion of a substitute individual clinical internship agreed in advance with the head of the course.
4th grade Colloquy (the so called sub-credit) will be awarded: 1. upon completion of both internships and one seminar, 2. in case of failure to comply with this condition, upon completion of a substitute individual clinical internship agreed in advance with the head of the course.
5th grade Credit will be awarded: 1. upon completion of four internships, one internship in the sonographic outpatients department and a night duty, 2. one of the mentioned duties may be replaced by internship in the Department of Anthropology in the National Museum, 3. seminars are optional, participation in 6 of 30 seminars offered is recommended in the course of the whole academic year, 4. in case of failure to comply with this condition, upon completion of a substitute individual clinical internship agreed in advance with the head of the course.
6th grade Colloquy (the so called sub-credit) will be awarded: 1. upon completion of 80% of the prescribed course attendance, seminars are optional, 2. in case of failure to comply with this condition, upon completion of a substitute individual clinical internship agreed in advance with the head of the course.
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Last update: prof. MUDr. Valér Džupa, CSc. (21.03.2010)
Structure Course no. 12 (Locomotion disorders) of Module IIC "Basic clinical issues" of the reformed curriculum of 3rd Medical Faculty, Charles University (Krbec, Džupa)
Instruction takes place in the summer term, in 6th, 8th and 9th weeks for the Czech speaking students and in 15th week for the English speaking students.
MONDAY
I. Tutorials at the Institute of Anatomy (2 lessons):
1. Introduction - scope of the issue, definition, clinical significance (Krbec, Stingl) 1.1. Reflex (the term, its significance for locomotion and location of disorders) (Mareš)
2. Anatomy and physiology of movement (Stingl) 2.1. Motor unit 2.1.1. CNS (including vision and hearing) 2.1.1.1. Location of central motoneuron disturbances 2.1.2. Spinal cord tracts 2.1.2.1.Localization of afflictions of spinal cord tracts 2.1.3. Peripheral nerve 2.1.3.1. Location of peripheral motoneuron disturbances 2.1.3.2. Conduction by peripheral nerve (Mareš) 2.1.4. Neuromuscular plate 2.1.5. Muscle 2.1.5.1. Muscular contraction (Mareš) 2.1.6. Tendon (synovial sheath) 2.1.7. Tendon - bone insertion (bursa) 2.1.8. Bone 2.1.9. Joint 2.2. Performance of motoric functions 2.2.1. Genesis of voluntary movement 2.2.1.1. Development of motor formula (Mareš) 2.2.2. Extrapyramidal control of movement
II.a Practical training at the Clinic of Neurology (4 lessons):
3. Basic semiology for the differentiation of components of the motor unit (Kellerová) 3.1. Test on strength and range of passive and active motion 3.2. Affection of central motoneuron 3.3. Affection of peripheral motoneuron (including EMG) 3.4. Types of muscular affection (including EMG)
4. Differential neurological diagnosis of locomotion disorders 4.1. Hemipareses of cerebral and spinal origin 4.2. Alternating hemipareses due to affliction of the brain stem 4.3. Monopareses and parapareses 4.4. Peripheral pareses and polyneuropathy 4.5. Myopathy and myositis 4.6. Myasthenia and myotony
II.b Practical at the Institute of Physiology (3 lessons):
5. Lesions of the central regulation of the locomotion - cortical regions, brainstem and spinal structures, with focusing on modulatory circuits - basal ganglia, cerebellum (Mareš) 5.1. Students will actively work with schemes and other study materials, which they will obtain in advance, on the lecture from special pathophysiology 5.2. Students will see the film Parkinson's disease, author E. Růžička and col., Sanofi
TUESDAY
I. + II. Tutorial (2 lessons) and practical training (4 lessons) at the Institute of Pathology:
6. Pathological anatomy of locomotion disorders (Mandys) 6.1. Pathology of bones 6.1.1. Osteochondrodysplasia 6.1.2. Necrosis 6.1.3. Atrophy 6.1.4. Dystrophy 6.1.4.1. Rachitis 6.1.4.2. Osteodystrophia fibrosa 6.1.5. Fractures 6.1.6. Non-specific and specific inflammations 6.1.7. Bone cysts 6.1.8. Hypertrophy and tumours 6.2. Pathology of joints 6.2.1 Dystrophy 6.2.1.1 Ostearthritis 6.2.1.2 Arthritis uratica (gout) 6.2.2 Trauma 6.2.3 Spinal deformities 6.2.4 Arthritis 6.2.5 Tumours 6.3 Pathology of tendons, fascia, synovial sheaths, bursae 6.3.1 Dystrophy 6.3.2 Inflammations 6.3.3 Tumours
WEDNESDAY
I. Tutorial at the Clinic of Radiology (2 lessons):
7. Imaging in locomotion disorders (Šprindrich) 7.1. CNS 7.1.1. X-ray, angiography 7.1.2. CT- myeolography 7.1.3. MRI 7.2. Spinal cord tracts and spinal roots 7.2.1. X-ray, angiography 7.2.2. CT 7.2.3. MRI 7.3.Muscle 7.3.1. Sonography 7.3.2. CT 7.3.3. MRI 7.4.Tendon 7.4.1. Sonography 7.4.2. MRI 7.5. Tendon - bone insertion 7.5.1. Sonography 7.5.2. X-ray 7.5.3. MRI 7.6.Bone 7.6.1. X-ray, angiography 7.6.2. CT 7.6.3. MRI 7.7. Joint 7.7.1. Sonography 7.7.2. X-ray, arthrography 7.7.3. CT 7.7.4. MRI
II.a Practical training at the Clinic of Neurology (4 lessons) + II.b practical at the Institute of Physiology (3 lessons).
For details see the MONDAY schedule.
THURSDAY
I. Tutorial at the Dean´s Office (2 lessons - Institute of Pharmacology):
8. Treatment of locomotion disorders 8.1. Conservative treatment 8.1.1. Pharmacotherapy - analgesics, anti-inflammatory drugs, myorelaxants (Kršiak)
II. Tutorial at the Dean´s Office (1 lesson - Clinic of Rehabilitation Medicine):
8.1.2. Physiotherapy, balneotherapy and rehabilitation (Herbenová)
III.Tutorial at the Dean´s Office (2 lessons - Institute of Medical Ethics):
8.1.3. Ethical issues (Janečková) 8.1.3.1. Quality of life of the disabled 8.1.3.2. Integration of the disabled into the society 8.1.3.3. ???
IV. Tutorial at the Dean´s Office (1 lessons - Clinic of Neurosurgery):
8.2. Surgical treatment 8.2.1. Neurosurgical treatment (Haninec)
FRIDAY
Ia. Tutorial at the Institute of Physiology (3 lessons - Orthopaedic Clinic):
8.2.2. Orthopaedic surgical treatment (Skála, Bartoška)
Ib. Practical at the Institute of Physiology (2 lessons - Institute of Physiology):
9. Ontogenesis of the motor system (Mareš) 9.1. Ontogenesis of the human motor system (tutorial) 9.1.1. Theories of motor development (neuromaturational and systems theory) 9.1.2. Early developmental stages (new-born, suckling, toddler) 9.1.3. Changes of motor system in ageing 9.2. Ontogenesis of the rat motor system (practical) 9.2.1. Motor system of the rats pups before walking 9.2.2. Motor system of the freely mowing rats pups
Ic. Tutorial at the Institute of Physiology (1 lesson - Institute of Biochemistry and Pathological Biochemistry):
10. Pathological biochemistry (Čechák, Kopřivová) 10.1. Extracellular matrix 10.2. Pathologiocal markers
II.a Tutorial at the Institute of Physiology (3 lessons - Orthopaedic Clinic) and II.b practical at the Institute of Physiology (3 lessons - Institute of Pathological Physiology).
Syllabus Course no. 12 (Locomotion disorders) of Module IIC "Basic clinical issues" of the reformed curriculum of 3rd Medical Faculty, Charles University (Krbec, Džupa)
Anatomy: Optic pathway, auditory pathway, vestibular tract, proprioceptive and motor tracts including extrapyramidal ones, involvement of cerebellum and basal ganglia in the preparation and control of locomotion, plexus nervorum, innervation of individual muscle groups. Muscle, tendon, joint, bone.
Physiology: Reflex - explanation, types, significance for locomotion, reflex from the veiwpoint of diagnosis of locomotion disorders. Conduction by peripheral nerve, muscular contraction, development of motor formula.
Pathophysiology: Pathophysiology of motion: Regulation of the motor system in according to the descending parallel systems - dorsolateral (pyramidal) pathway, ventromedial (extrapyramidal) pathways and emotional motor pathways. Regulation of the motor system in according to the levels (series model) - upper an lower motor neurons and their lesions. Basal ganglia circuits, direct and indirect pathway, their function and disorders. Cerebellar circuits, disorders of vermis and cerebellar hemispheres. Upper motor neurons carry motor information down to the final common pathway (tractus corticospinalis, vestibulospinalis, reticulospinalis, and tectospinalis). These neurons connect the motor cortex to the spinal cord, from which point nerve signals continue to the muscles by means of the lower motor neurons. Lower (alpha) motor neurons innervate extrafusal muscle fibers of skeletal muscle and are directly responsible for initiating their contraction. Palsy (paresis) is defined as decrease or loss of voluntary, active movement of a body part often accompanied by loss of feeling. Paralysis (plegia) is defined as complete loss of strength and motion in an affected limb or muscle group. Spastic paralysis - an upper motor neuron lesion. Symptoms: "spastic" increase in tone in the extensor muscles (lower limbs) or flexor muscles (upper limbs), "clasp-knife" response where initial resistance to movement is followed by relaxation, brisk tendon jerk reflexes, but no muscle wasting, Babinski sign positive, where the big toe is raised rather than curled downwards on stimulation of the sole of the foot Flaccid (weak) paralysis - damage to ?-motor neurons, active muscle movement is impossible, passive movement is present, muscle tone is reduced, reflexes are depressed (hyporeflexia), Because muscle size and strength are related to the extent of their use, denervated muscles are prone to atrophy. A secondary cause of muscle atrophy is that denervated muscles are no longer supplied with trophic factors from the ?-motor neurons that innervate them. ?- motor neuron lesions also result in abnormal EMG potentials (e.g., fibrillation potentials) and fasciculations, the latter being spontaneous, involuntary muscle contractions. Rigidity (stiffness or inflexibility) describes an increase in muscle tone, leading to a resistance to movement, that inhibits active and passive movements through out the range of motion, causes: peripheral (arthritis) and central (Parkinson's syndrome, meningitis). Decerebrate posturing (rigidity) - indicates brain stem (intercollicular) damage. In decerebrate, or extensor, posturing, the arms are extended by the sides, the head is arched back, and the legs are extended. The activating system of the reticular formation overbalances the inhibitory system of the reticular formation. Dyskinesia refers to an impairment of voluntary movement associated with the basal ganglia lesions. Hypokinesia is diminished or slow (bradykinesia) movement of body musculature. Hyperkinesis is a state of overactive restlessness. It is also a condition resulting in uncontrolled muscle movement. Akinesis is total lack of movement. Tremor is defined as the involuntary rhythmic movement of a body part, or parts. This occurs through the contraction of opposing muscle groups. Tremor may occur as an isolated symptom and usually of idiopathic (unknown) cause (essential tremor) or a part of the symptom constellation of another disorder (e.g. Parkinson's disease). Tremors may occur at rest (Parkinson's disease), during voluntary movements (intense cerebellar tremor) or during excessive activity of muscles (essential tremor, hyperthyroidism). Usually, tremors involve the hands, but they may also involve the head, face, trunk, neck, voice and legs. Peripheral neuropathy is a disease affecting one or more peripheral nerves. Function of the myelin sheath (demyelinisation) or of the axon (denervation) is damaged. Many polyneuropathies have both motor and sensory involvement and some have autonomic dysfunction. These disorders are often symmetric and frequently involve distal extremities. Neuromuscular junction disorders connected even with muscle weakness and fatigue or with spasms. Various toxins, such as botulinum toxin prevent the release of acetylcholine, resulting in muscle paralysis. Myasthenia gravis, typical neuromuscular disease is caused most commonly by auto-antibodies against the acetylcholine receptor. Myopathy is a disease in which is the muscle fibers dysfunction for any one of many reasons, resulting in muscular weakness. "Myopathy" simply means disorder of muscle. This implies that the primary defect is within the muscle, as opposed to the nerves Muscular dystrophies are a group of genetic and hereditary muscle diseases; characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue. Muscular atrophy (amyotrophy) - derangement in size and number of muscle fibers occurring with aging, reduction of blood supply, or following immobilization, prolonged weightlessness, malnutrition and particularly in denervation.
Neurology: Passive motility = extent of passive movements in the limits of joint and tendon freedom; excursions to the extreme positions, elicited by the examiner, active motility = extent of active movements both spontaneous and on demand to maximal extremes, tests on strength = "muscular test", or orientation tests of strength against counterpressure, fasciculation and fibrilation = spontaneous intermittent contraction of bundles of muscles, dystonia musculorum deformans = disorders of the performance, nutrition and vitality of the muscle fibres, muscular spasm = contraction which cannot be relaxed voluntarily, muscular contraction = usually as a consequence of a spasm, chronic, myotony - prolonged contraction period after a voluntary contraction; reduced and slowed decontraction, myasthenia = a stimulus transmission disorder on a neuromuscular junction; it causes a quicker exhausting of power in repetitive movements. Hemiparesis - palsy of one side of the body of vertical orientation; usually a consequence of contralateral hemispheral disturbance or the contralateral half of the brain stem; except for the initial stages (with transient suppression of spinal cord functions) it has a spastic character, alternating hemipareses - due to combined afflictions of the cerebral track in the brain stem with a simultaneous lesion of the cranial nerve nucleus; a homolateral cranial nerve lesion with a contrarateral hemiparesis (due to the crossing of the pyramidal track in decussation), monoparesis - one extremity palsy or one single nerve regional palsy, paraparesis - two-extremity palsy of horizontal orientation; in the overwhelming majority it is restricted to lower extremities (the disturbance is caused by a spinal cord or a cauda equina lesions with preservation of the upper extremities´ function), quadruparesis (tetraparesis) - palsy of all four extremities; it results from the upper cervical medulla lesions or brain lesions, triparesis - three-extremity palsy, usually of both lower and one upper extremity, peripheral pareses - a flaccid type palsy; according to the presence/absence of sensitive disturbances one can distinguish between the injury location in the nerve root or in the spinal nerve, polyneuropathy - a diffuse, general impairment of peripheral nerves with a diffuse sensitivity defects, usually accentuated in peripheral (acral) parts and under the appearance of a flaccid palsy and atrophies, myositis - inflammatory muscle affection; from the clinical point of view usually combined with a reduced power and a changed consistence of the muscle.
Pathological anatomy: Fibrous dysplasia (Jaffe - Lichtenstein) Non-tumour process of unknown aetiology. Congenital disorder of the development of bone tissue which ceased in the phase of the woven bone and the bone did not remodel into a lamellar one. The disease occurs in young people. Two forms: 1. monoosseous - affects one bone, 2. polyosseous - affects simultaneously more bones. The bones have a deformed outer shape, they are flexible. Microscopically, the cancellous bone is replaced in the focus by the cell fibrous connective tissues with irregularly distributed trabeculae of immature woven bone without osteoblastic lines. Trabeculae are O- or C-shaped. Fibrous osteodystrophy (Recklinghausen disease) It is a bone complication of primary hyperparathyroidism more frequently in case of adenoma, less often in case of hyperplasia, rarely in the carcinoma of parathyroid glands. Due to the excessive production of parathyroid hormone there occurs partial demineralization of bones resulting in the loss of the strength of bones leading to deformations or even pathological fractures. In more progressive cases there occur in the skeleton tumorous osteolytic lesions the so called brown tumours. Microscopically, the disease can be divided according to its progression into three stages: 1. osteoclastic resorption, 2. fibrous stage, 3. cystic phase. Union of bone fractures Phases of union: 1. inflammation phase - development of blood clot (bleeding from the ruptured vessels of periost) and inflammatory exudation to the fracture site, 2. reparative phase - fibroblasts and capillars are infiltrating the haematoma, there develops granulation tissue which fibrotizes and results in a provisional fibrous callus, 3. differentiation of osteoblasts which form the woven bone and there develops an internal and external provisional bone callus, 4. phase of remodelling - woven bone is resorbed by osteoclasts and replaced by lamellar bone. Osteomyelitis purulenta It is caused by pyogenic bacteria. In adults it occurs most often in case of trauma (open fracture) or infect. In children it develops in the hematogenous form in case of sepsis, pyemia. In the acute phase it is a pyogenic flegmonous and abscessing inflammation in intertrabecular spaces. The inflammation extends as far as under the periost where there can develop a subperiostal abscess sometimes with the pus penetrating through the fistula to the surface. In the chronic phase abscesses may be lined with pyogenic membrane and the necrotic bone separates in the form of the so called sequestra. Involcrum - a reactive newly developed woven tissue creates an envelope around the separating sequestrum. Osteocartilaginous exostosis - osteochondroma A cartilage-capped bony projection on the surface of the shafts of long bones. It is probably a disorder of growth rather than a true tumour. It may be solitary or multiple. Microscopically, on the surface there is a layer of hyaline cartilage which in the base passes to cancellous bone. On the interface between cartilage and bone there occurs enchondral ossification with proliferating chondrocytes. Giant-cell tumour of bone- osteoclastoma A potentially malignant tumour behaves in 95 % as a benign one, it often recurs. It occurs in the cancellous end of long bones. It is osteolytic. Morphologically, it is formed by multinucleated cells of the type of osteoclasts and by spindle stromal cells of the type of fibroblasts, with collagenous fibres and numerous blood vessels. Osteosarcoma A malignant tumour that arises most often in young individuals until the age of 20. It is located in the shaft of long bones. Classification: 1. Classic or conventional osteosarcoma, 2. Juxtacortical on the bone surface. Morphologically, the basic criterion for the diagnosis is the finding of a tumorous osteoid with tumorous osteoblasts and with atypical nuclei. Besides there may occur tumorous cartilaginous tissue and spindle cell fibrous connective tissue. 3 subtypes: 1. osteoplastic osteosarcoma (50%), 2. chondroplastic (25%), 3. fibroplastic (25%). Chondrosarcoma A malignant tumour which has a more favourable prognosis than osteosarcoma. It occurs between 2nd and 7th decade. Most frequently it is located in pelvis, femur, shoulder. Morphologically, chondrosarcoma is divided into: classic (conventional), juxtacortical (periostal), mesenchymal (highly malignant), non-differentiated (highly malignant), light-cell (a very good prognosis). Metastasis of Grawitz carcinoma of kidney Osteolytic metastasis of the carcinoma from light cells Eosinophilic granuloma (histiocytosis X) A benign osteolytic lesion of bone. It occurs mainly in young individuals until the age of 15. Location - skull, scapula, ribs, pelvis, vertebrae, femur. It may be solitary or multiple. Morphologically, there are in the focus numerous eosinophiles, histiocytic elements (Langerhans cells) in which the positivity of S-100 protein in ELMI Bierbeck granula can be detected by immunohistochemical techniques. Myeloma (multiple myeloma, Kahler disease) A malignant tumour of the bone marrow - non Hodgkin´s lymphoma: in older people. It creates osteolytic foci in the spine, sternum, ribs, calvaria, pelvis. Morphological classification: plasmocytic, plasmoblastic, combined form. Tumorous cells produce immunoglobulines (paraproteins) most often IgG. There may occur pathological fractures. Giant cell tumour of synovial sheath A benign tumour, mostly solitary, not well defined, of the size of up to several cm. It may recur. Most frequent incidence on the digits, in the region of the wrist. Morphologically, it is a fibrohistiocytic tumour with the presence of multinucleated cells similar to osteoclasts. Ganglion A ball-shaped formation containing jelly-like and mucinous fluid defined by a fibrous capsule. Most frequently it occurs on hands, arising from the synovium of a tendon. It results from the trauma of fibrous connective tissue. Productive tenovaginitis (palmar fibromatosis, Dupuytren contracture) It is fibromatosis, more often it develops in men. It is characterized by active proliferation of fibrous tissue in the palmar aponeurosis resulting in the flexion of fingers. Fibromatosis Fibroblastic and myofibroblastic proliferation of fascia and aponeuroses in various locations. It is either congenital or develops in childhood or adulthood. Surface fibromatoses: palmar (Dupuytren), plantar (Ledderhose), f. of penis (Peyronye). Deep fibromatoses: abdominal - desmoid. Morphologically, the lesion is not clearly defined as it infiltrates in the surrounding tissues. Chronic bursitis (hygroma) Swelling of bursal sacs with the accumulation of fluid serous exudate. Incidence - often in the prepatellar bursa in women. Morphologically, it is a chronic fibrine productive inflammation. Nodular fasciitis A nodular grey-white formation of up to several cm fixed to fascia most often in the region of extremities. Morphologically, it is formed by bundles of fibroblasts and collagenous fibres with unclear definition on the periphery. Juxtaarticular nodosity In case of rheumatic osteoarthritis in the periarticular connective tissue greater rheumatic nodes - rheumatismus nodosus. Morphologically, it is a fibrinoid necrosis of the connective tissue with palisade histiocytes around. They may occur also in case of rheumatoid arthritis. Rheumatoid arthritis (polyarthritis progressiva primaria chronica) Incidence mainly in middle-aged women, it afflicts joints of hands and legs. Manifestations: stiffness of joints, swelling, pain, limitation of the range of motion, deformity or even ankylosis. Morphologically, there is thickening of the synovial membrane, villous, with proliferation of synovialocytes and with fibrin exudation. Inflammatory infiltrations in the lymphoplasmocytous connective tissue. In the plasmatic cells the production of IgG and IgM immunoglobulines. Complexes of rheumatoid factor and IgG both in the synovial membrane and the articular cartilage. Panus is formed on the surface of articular cartilage and fills the joint cavity. Both panus and synovial membrane fibrotize and the joint changes into fibrous ankylosis.
Radiology: Indication according to the level of a lesion (central or peripheral): Most frequent brain lesions inducing locomotion disorders: Localised lesions: ischemia - infarction, hemorrhage, tumors axial and extraaxial Disseminated lesions: metastatic tumors, demyelinisation processes Imaging: Plain CT , event. after intravenous administration of iodinated contrast agent Plain MRI in T1 and T2 weigted images
Angiography in subarachnoidal bleeding (aneurysms), event. in tumors (possibly CT-angiography with contrast administration, or MR-angiography without contrast administration). Vertebral lesions (trauma, tumor, inflammation, disc herniation or sequestration), inducing spinal cord or nerve roots lesions. Imaging: Plain radiography with standard views, dynamic views for differenciation between stable and instable lesions, CT in bony or soft-tissue window Spinal cord can be affected by an extradural, intradural or intramedullar process, event. transsected. Imaging: CT for differentiation between an extradural and intradural lesion, event. myelography or radiculography. In intramedullary processes MRI is essential. Spinal angiography is indicated in spinal agiomatous malformations. Nerve roots can be touched in avulsion trauma or in degenerative stenotic lesions of neural foramina, event. in nerve root tumors. Imaging: CT-myelography, MRI Muscles: mostly degenerative, inflammatory, tumoral or traumatic lesions Imaging: Ultrasonography as first choice examination, followed by MRI, event. CT (plain and contrast-enhanced). Ligaments and tendons - mostly trauma - sprains, degenerative lesions, peritendinitis Imaging: Stress X-ray views, ultrasonography, MRI Bones: fractures, deformations (shortening, bowing), dysplasias Imaging: Radiography, plain CT Joints: trauma - dislocation, arthritis, degeneration, laxity, ankylosis Imaging: Radiography, arthrography, ultrasonography (effusion, hematoma), CT, MRI
Pharmacology: Analgesics and anti-inflammatory drugs. Analgesics: opioid analgesics - strong agonists (Morphine, Methadon), mild to moderate agonists (Codeine), mixed agonists-antagonists (Bupremorphine), non-opioid analgetics, anti-inflammatory drugs - non-opioid analgetics with anti-inflammatory effect (non-steroidal anti-inflammatory drugs, NSAIDs) (Aspirin, ibuprofen, indomethacin, tolmetin, Piroxicam, Diclofenac), analgesics without anti-inflammatory effect (Acetaminophen). Non-steroidal anti-inflammatory drugs (NSAIDs): see above (non-opioid analgetics with anti-inflammatory effect), slow acting anti-inflammatory drugs (antimalarial drugs, gold, immunosuppressants, immunostimulants . Steroides (Glucocorticoids): prednison. Skeletal muscle relaxants with central nervous action (spasmolytic drugs). (Diazepam, Baclofen and others).
Rehabilitation: The term of functional disorders of musculoskeletal system, analysis of posture and gait = basic clinical examination. Shortened and weakened muscles, the term of muscle imbalance. Basic changes in statics = proximal cruciate syndrome, distal cruciate syndrome.
Medical ethics: Impairment = any loss or abnormality of psychological, physiological or anatomical structure or function - external manifestation of health affection, disaptibility??? = functional limitation, profile of preserved functional abilities, handicap = loss or limitation of an adequate involvement in the life of the society, a set of objective obstacles and subjective feelings resulting from health affection.
Neurosurgery: Basic structure of peripheral nervous system from the clinical viewpoint. Prerequisites of a successful reconstruction of the nerve. Regeneration of the peripheral nerve. Compressive syndrome of peripheral nerves. Exo- and endoneurolyses.
Orthopaedics: Tendon Surgery: Suture = tendon suture, prolongation = prolongation of the tendon (Z-plasty), abbreviation = shortening of tendon, plastic surgery = correction of the defect of the tendon, transplantation = tendon replacement, transposition = transfer of the origin of the tendon. Bone surgery: Reduction = realignment of fragments (closed = conservative, i.e. without a skin incision, open = surgical, i.e. requiring skin incision), osteotomy = surgical sectioning or cutting of the bone (abbreviation o. = shortening, prolongation o. = lengthening, correction o. = realigning), osteosynthesis = bone suture, fixation of fragments (internal fixation - transfixtion = fixation by a wire, loop = fixation by a wire loop, tension wire loop = fixation by wires and a wire loop, o. by means of screws = fixation of fragments by means of different types of screws, o. by plates = fixation of fragments by different types of plates, intramedullary nailing= fixation of fragments by means of nails inserted in the intramedullary canal of the bone and external fixation = fixation of fragments by means of devices placed above the skin of the affected limb and connected to the affected bone by means of screws and nails penetrating the skin), transplantation = bone replacement (bone grafting = bone grafts). Joint Surgery: Arthroplasty = surgery of articular ends of bones and ligaments of the joint with the intent to restore or improve the function of the joint or its stability, arthroereisis = surgical procedure limiting the amount of motion in a joint, arthrodesis = immobilization of the joint, endoprosthesis (total replacement) = replacement of the joint by an alloplastic implant. Limb Surgery: Amputation = excision of a limb or its part, exarticulation = amputation of a limb or its part through a joint. |