1. Sc14 Wilmaʼs Woeful Wrist
Rheumatoid Arthritis and its Related Disorders
1. What are the main reasons for conducting a full blood count when investigating
symptoms of rheumatoid arthritis?1
2. What proportion of patients with rheumatoid arthritis will exhibit the rheumatoid factor
antibody in a blood test?2
3. List some of the non articular features of arthritis3
4. What is the more recent line of drug therapy introduced in preference to NSAIDs in
treating rheumatoid arthritis?4
5. What proportion of over 65s have osteoarthritis?5
6. What are Heberdenʼs and Bouchardʼs nodes?6
7. What is the main pathology of osteoarthritis that distinguishes is from RA? 7
8. How does this affect joints?8
9. What are the main treatments for osteoarthritis?9
10. What is the main complaint in ankylosing spondylitis and which demographic group are
most affected? 10
1
Evidence of anaemia? White cell count? (Inflammation)
2
70%
3
Pleurisy (inflammation of the pleural membranes) which causes SOB and chest pain, vasculitis,
neuropathy, Sjogrenʼs syndrome (dry, red eyes, dry mouth), Feltyʼs syndrome (splenomegaly and low
neutrophils)
4
Disease Modifying Anti-Rheumatic drugs (DMARDs), more effective because they target rheumatoid factor
5
50%
6
Bony prominences around joints, signs of osteoarthritis
7
Breakdown of the cartilage matrix rather than loss of bone mass per-se
8
Causes fibrillation and erosion of the cartilage surface so collagen fragments are released into the synovial
fluid within the joint, causing irritation. The bone overgrowth around the joints results from compensatory
repair (called osteophytes).
9
Weight loss, excercise, orthoses (external device worn to modify musculoskeletal system), surgery as a
final option (joint replacement).
10
Spinal pain and stiffness characterised by inflammation of the sacroiliac joint. May also affect large
peripheral joint and cause lung fibrosis. Young men.

2. 11.What is the difference between oligoarthritis and polyarthritis? 11
12.What is the main visible differentiating sign for psoriatic arthritis? 12
13.What is the main cause of death in lupus?13
The Inflammatory Response and its Role in Eicosanoids in Inflammation
1. What is angiogenesis?14
2. What are eicosanoids?15
3. Which polyunsaturated fatty acid is essential for the production of eicosanoids? 16
4. Which enzyme converts phospholipids into this essential fatty acid? 17
5. Which enzymes are used to convert arachidonic acid into (i) prostaglandins &
thromboxane and (ii) to leukotrienes?18
6. What are the main functions of prostaglandins at sites of inflammation?19
7. What are the main differences between COX-1 and COX-2? 20
8. List the (i) pro-inflammatory cytokines, (ii) anti-inflammatory cytokines21
9. Which cytokines influence bone and cartilage destruction and angiogenesis? 22
11
Oligoarthritis may affect up to four joints whereas polyarthritis is more than four
12
Plaques and nail changes
13
Cardiovascular disease because of chronic inflammation
14
The formation of new blood vessels, can occur around a joint as arthritis establishes.
15
Collective term for inflammatory mediators including prostaglandins and cytokines
16
Arachidonic acid
17
Phospholipase A2 (PLA2)
18
(i) Cyclo-oxygenase, (ii) Lipoxygenase
19
Sensitise nerves, increase blood flow (vasodilation), potentiate oedema formation
20
COX-1 = found in most cells, involved in normal physiology to maintain homeostasis. COX-2 = Induced in
inflammatory cells by prostaglandins at inflammatory sites.
21
Pro = TNF-alpha, IL-1, IL-6, IL17, Anti = IL-10, TGF-beta
22
IL-1 and TNF-alpha

3. Non Steroidal Anti-Inflammatory Drugs
1. What is the mechanism of most NSAIDs used in first line treatment of arthritis?23
2. What are the two main mechanisms of COX inhibitors? 24
3. Out of COX-1 and COX-2, which is the clinical target and why? 25
4. What structural difference allows COX-2 selective inhibitors to bind to COX-2 but not
COX-1? 26
5. Aspirin and Ibuprofen are non-selective COX inhibitors, name 3 COX-2 selective
ones27
6. What is the name for the group of drugs commonly used as second line treatments for
arthritis in conjunction with NSAIDS? 28
7. Name the most commonly used DMARD and its side effects and mechanism of
action.29
8. Name the 3 main anti-inflammatory steroids (corticosteroids) used in the treatment of
rheumatoid arthritis30
9. What are the 3 main side effects of these treatments in arthritis patients? 31
10. List the main positive effects anti inflammatory steroids have32
11. What are the two main types of TNF inhibitor in terms of mechanism33
23
Blocking COX and therefore the production of prostaglandins and thromboxanes
24
Blocking PGH synthase enzyme (with exception of paracetomol),either irreversibly (aspirin) or reversibly
(ibuprofen).
25
COX2 because it is the one responsible for inflammation whereas COX-1 is normal homeostasis
26
COX-2 has a hydrophobic side pocket which is not present in COX-1
27
Celecoxib, Rofecoxib/Vioxx (withdrawn due to cardiac risk) and Meloxicam
28
Disease Modifying Anti-Rheumatic Drugs (DMARDs), steroids and other immnosupressive drugs such as
cyclosporine may be used.
29
methotrexate - neg = hepatic fibrosis, myelosupression, pulmonary infiltrates (oedema of alveoli).
Mechanism of action = folate antagonist, fastest acting DMARD takes 1-2months to benefit.
30
hydrocortisone, dexamethosone, prednisolone
31
osteoporosis, increased risk of infection, adrenal atrophy (shrinking of adrenal glands), side effects
decreased if given locally (around joints) rather than systemically
32
Inhibit arachidonic acid secretion, reduce levels of COX and cytokines, inhibition of lymphocyte (t-cell)
proliferation (growth), induce apoptosis (programmed cell death).
33
Monoclonal antibodies to TNF (infliximab, adalimumab). Or soluble TNF recepto fusion protein, fuses with
TNF (etanercept)

4. The Wrist
1. What are the attachments for the flexor retinaculum? 34
2. What is the movement of palmiris longus?35
3. In the left hand in the anatomical position, which artery travels under the flexor
retinaculum on the medial side and which on the lateral side?36
4. What does the median nerve branch into under the flexor retinaculum?37
5. What are the branches of the median nerve following the carpal tunnel? 38
6. What is the carpal tunnel and what passes through it? 39
7. What is the flat tendon immediately below the skin on the inside of the hand? 40
8. Name 4 extrinsic muscles of the thumb 41
9. What is the group name for the intrinsic thumb muscles? 42
10. And the muscles of the little finger? 43
11. What area is covered by the common flexor synovial sheath or common bursa? 44
12. What is the name of the synovial sheath of the thumb?45
34
Ridge of trapezium and tubercle of scaphoid, pisiform and hook of hamate
35
Attached to the flexor retinaculum, it is a weak flexor of the wrist
36
Ulnar is on the medial side and the radial on the lateral
37
Splits into the palmar cutaneous nerve whilst the rest of the median nerve goes through the carpal tunnel
(the only nerve that goes through the carpal tunnel) to supply the thumb muscles and some of the flexors of
the digits
38
The recurrent branch, to the thenar (thumb) compartment. Digital cutaneous branches to the skin on the
fingers.
39
Bones and connective tissue between the forearm and the hand, tendons (flexor digitorum profundus,
superficialis, and flexor pollicis longus) and the median nerve pass through it.
40
Palmar aponeurosis
41
Flexor pollicis longus, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus
42
Thenar muscles
43
Hypothenar muscles
44
The whole inside of the palm of the hand and little finger, the thumb and fingers have their own individual
bursae called digital synovial sheaths which cover the fingers
45
Radial bursa

5. 13. What is the name of the structure
which prevents bowstringing of the
finger tendons?46
14. What are movements A and B of
the thumb in relation to the fingers?47
15.What are the approximate
attachments of abductor pollicis
brevis?48
16. Which muscle shares a
conjoined tendon with abductor
pollicis brevis?49
17.Which muscle exclusively rotates/circumducts the thumb to
touch the palmar surface of the fingers? 50
18.Which nerve is mostly responsible for movement of the thumb
and is compressed in carpal tunnel syndrome?51
19.Which thumb muscle not in the thenar (intrinsic group) is
controlled by the ulnar nerve?52
20. How many phylanges are there on the fingers and how many
on the thumb?53
21. Which nerve supplies the little finger muscles? 54
22. Label muscles A-C on the diagram of the little finger55
46
Fibrous flexor sheath
47
A = abduction and adduction, B = flexion and extension
48
Carpals (details of which doesnʼt matter), flexor retinaculum and proximal phalanx of the thumb
49
Flexor pollicis brevis
50
Opponens pollicis
51
Median nerve
52
Adductor pollicis
53
3 on fingers, 2 on thumb
54
Ulnar
55
A = flexor digiti minimi, B = opponens digiti, C = abductor digiti mini

6. The Hand
1. What is the name of the fibrocartilage around the edge of the metacarpal-pharyngeal
joint?56
2. What actions is the metacarpal-pharyngeal joint capable of? 57
3. ... and the intro-pharyngeal (between phalanges)? 58
4. Name the ligaments between the ends of the metacarpals59
5. Name muscle A and its nervous
innervation and movement60
6. Name muscle B, its movement and its nervous innervation61
7. Which tendon are the lumbicrals mostly attached to?62
8. What is bi-penate and unipenate in relation to lumbicral muscles?63
9. Which nerves are the lumbicrals supplied by? 64
10.Where is the patch of skin on the hand supplied by the radial nerve? 65
56
Palmar ligament
57
Flexion-extension and abduction-adduction
58
Flexion-extension only
59
Deep transverse palmar ligaments
60
Palmar interossei, ulnar nerve, flexion and extension, adduction (away from palm of hand)
61
Dorsal interossei, ulnar nerve, abduction (PAD, DAB = palmar adduction, dorsal abduction)
62
flexor digitorum profundis
63
Refers to the number of (proximal) attachments of the muscles. (2x are bipenate (on the auricular side),
the two closest to the thumb are unipenate).
64
2x Auricular side are ulnar, 2x thenar side are median
65
Around the base of the thumb anteriorly

7. 11. Name muscles A-B and tendons i-iii66
12. What is the name of the structure containing the flexor
digitorum profundis and flexor digitorum superficialis? 67
13. Name the nerves A-I and their vertebral level or place in the brachial plexus 68
14. Name the cutaneous innervation of the hand (posterior) A, B and C
66
A = Lumbicral, B = Palmar interosseus, i = Extensor digitorum, ii = Flexor digitorum profundis, iii = Flexor
digitorum superficialis
67
68
Fibrous ʻflexor sheathʼ (attached to phalanx)
A = Supraclavicular plexus (C3-4), B = Upper lateral cutaneous nerve (axillary C5-6), C = Med cutaneous
nerve of arm (medial cord (C8-T1)), D = lower lateral cutaneous nerve of arm (radial C5-6), E = medial
lateral cutaneous nerve of forearm (medial cord C8-T1), F = lateral cutaneous nerve of the forearm
(musculocutaneous C5-6), G = upper lateral cutaneous nerve of the arm (C5-6), H = posterior cutaneous
nerve of arm (radial C5-C8), I = posterior cutaneous nerve of forearm (radial C5-8).

8. Neurology of the Upper Limb
1. Name cords A-C69
2. Name terminal branches 1-470
3. Name intermediate nerves i-xii71
4. What is the action/purpose of the long thoracic nerve? 72
5. So what pathology would result from damage to the long thoracic nerve? 73
6. What is a dermatome?74
69
A = lateral, B = posterior, C = Medial
70
1 = Musculocutaneous, 2 = Median, 3 = Radial, 4 = Ulnar
71
i = dorsal scapular, ii = suprascapular, iii = subclavius, iv = lateral pectoral, v = axillary, vi= inferior
subscapular nerve, vii = thoracodorsal, viii = inferior subscapular, viii = superior subscapular, ix = medial
cutaneous nerve of the forearm, xi = medial pectoral, xii = long thoracic nerve
72
Innervates the serratus anterior muscle for protraction of the scapula
73
winging of the scapula
74
An area of skin supplied by a single spinal root

9. 7. What is a myotome?75
8. What are the symptoms associated with Erb-Duchenne’s palsy and which nerve
roots are damaged to inflict this?76
9. What are the symptoms associated with Klumpke’s palsy and which nerve roots
are damaged to inflict this? 77
10. Which nerve wraps around the surgical neck of the humerus?78
11.Which spinal segments does the axiliary nerve derive from?79
12.Which area of skin is supplied by the axiliary nerve? 80
13. What muscles have motor supply from the axiliary nerve? 81
14. What is the clinical sign of radial nerve palsy?82
15.What is the motor supply and spinal nerve root of the musculocutaneous nerve?
83
16.Where is the ‘cutaneous’ innervation from the musculocutaneous nerve?84
17. Which muscles are supplied by the ulnar nerve?85
18. Which nerve becomes compressed in carpal tunnel syndrome?86
75
A collection of all muscles sharing a block of mesodermal tissue as their origin and innervated by the motor
fibres of a single spinal nerve root
76
Injury to C5-C6, ʻwaiterʼs tip deformityʼ (medial rotation of the shoulder, pronation of the forearm, flexion of
the hand)
77
Injury to C8-T1, No opposition or adduction of thumb, hyperextension at metacarpophalyngeal joints,
flexion at interphalyngeal joints ʻclawed hand deformityʼ
78
Axillary nerve
79
C5-6
80
The ʻregimental patchʼ
81
Deltoid and teres major
82
ʻwrist dropʼ
83
C5-C6, all flexor compartment of arm (biceps, brachialis, coracobrachialis)
84
lateral cutaneous nerve of forearm
85
Everything except LOAF (lateral two lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis
brevis), i.e. flexor carpi ulnaris, flexor digitorum profundis, medial two lumbricals, opponens digiti minimi,
abductor digiti minimi, flexor digiti minimi, interossei, abductor pollicis)
86
Median nerve

10. 19.And which muscles does this affect?87
20.What is the clinical sign of medial nerve compression/damage88
21.What is the clinical sign of ulnar nerve compression/damage89
22.How can you tell the difference between ulnar claw and hand of benediction?90
87
LOAF muscles (lateral two lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis)
88
Hand of Benediction, lack of flexor muscles so fingers are outstretched or abducted
89
Ulnar claw
90
Ulnar claw occurs at rest, hand of benediction only when making a fist