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Chapter 42 Alterations of Musculoskeletal Function Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Overview Musculoskeletal injuries Alterations in bones, joints, and muscles Fractures, dislocations, sprains, and strains Cause: metabolic disorders, infections, inflammatory/noninflammatory diseases, or tumors Trauma: leading cause of death of people ages 1 to 44 years of all races and socioeconomic levels Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 2 Musculoskeletal Injuries Fracture A break in the continuity of a bone Occurs when force is applied that exceeds the tensile or compressive strength of the bone Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Musculoskeletal Injuries Fracture classifications Complete or incomplete • Closed or open Comminuted Linear Oblique Spiral Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Fracture Classifications Transverse Greenstick Torus Bowing Pathologic Stress Fatigue and insufficiency Transchondral Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Fractures Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Bone Fractures Broken bone can damage the surrounding tissue, the periosteum, and the blood vessels in the cortex and marrow Hematoma formation Bone tissue destruction triggers an inflammatory response Procallus formation Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Callus Formation Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Bone Fractures Manifestations Treatment Unnatural alignment, swelling, muscle spasm, tenderness, pain, impaired sensation, and possible muscle spasms Closed manipulation, traction, open reduction Improper reduction or immobilization Nonunion, delayed union, and malunion Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Bone Fractures Improper reduction or immobilization Nonunion • Failure of the bone ends to grow together • Gap between the broken ends of the bone fills with dense fibrous and fibrocartilaginous tissue • Occasionally the fibrous tissue contains a fluid-filled space that resembles a joint and is termed a false joint, or pseudarthrosis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Bone Fractures Improper reduction or immobilization Delayed union • Does not occur until about 8 to 9 months after a fracture Malunion • Healing of a bone in a nonanatomic position Treatment of delayed union and nonunion includes modalities designed to stimulate new bone formation Implantable or external electric current devices, electromagnetic field generations, and low-density ultrasound Gene therapy Large defects in bone can be filled with bone graft or synthetic materials, such as calcium phosphate cement Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Treatment Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Treatment Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Bone Fractures Dislocation Subluxation Temporary displacement of two bones Loss of contact between articular cartilage Contact between articular surfaces is only partially lost Dislocation and subluxation associated with fractures, muscle imbalance, rheumatoid arthritis, other joint instability Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Support Structure Injuries Strain Sprain Tear or injury to a tendon Tear or injury to a ligament Avulsion Complete separation of a tendon or ligament from its bony attachment site Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Tendinopathy and Bursitis Tendinitis Tendinosis Inflammation of a tendon Painful degradation of collagen fibers Bursitis Inflammation of a bursa • Skin over bone, skin over muscle, and muscle and tendon over bone Caused by repeated trauma Septic bursitis is caused by a wound infection Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Tendinopathy and Bursitis Epicondylitis Inflammation of a tendon where it attaches to a bone • Tennis elbow (lateral epicondylitis) • Golfer’s elbow (medial epicondylitis) Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Tendinitis and Epicondylitis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Tendinitis and Epicondylitis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 19 Muscle Strain Sudden, forced motion causing the muscle to become stretched beyond its normal capacity Local muscle damage Muscle strains can also involve the tendons Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 20 Myositis Ossificans Complication of local muscle injury Inflammation of muscular tissue with subsequent calcification and ossification of the muscle “Rider’s bone” in equestrians “Drill bone” in infantry soldiers Thigh muscles in football players Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Rhabdomyolysis Rhabdomyolysis (myoglobinuria) is a lifethreatening complication of severe muscle trauma with muscle cell loss Crush syndrome Compartment syndromes Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 22 Osteoporosis Porous bone Poorly mineralized bone Bone density Normal bone • 833 mg/cm2 Osteopenic bone • 833 to 648 mg/cm2 Osteoporosis • <648 mg/cm2 Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 23 Osteoporosis Potential causes Decreased levels of estrogen and testosterone Decreased activity level Inadequate levels of vitamins D and C, or Mg++ Reduced bone mass/density and an imbalance of bone resorption and formation Bone histology is usually normal but it lacks structural integrity Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 24 Osteoporosis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 25 Osteoporosis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 26 Osteoporosis Perimenopausal osteoporosis Iatrogenic osteoporosis Regional osteoporosis Postmenopausal osteoporosis Glucocorticoid-induced osteoporosis Age-related bone loss Manifestations Pain, bone deformity, fractures, kyphosis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 27 Osteoporosis Postmenopausal osteoporosis Occurs in middle-aged and older women Serum androgens influence bone density Androgens (i.e., testosterone and dihydrotestosterone) stimulate bone formation • Testosterone converted to estradiol by the enzyme aromatase is associated with declining levels of estrogen • Progesterone deficiency may also be related to osteoporosis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 28 Osteoporosis Postmenopausal osteoporosis Probably caused by changes in osteoprotegerin, insulin-like growth factor (IGF), a combination of inadequate dietary calcium intake and lack of vitamin D, decreased magnesium, lack of exercise, decreased levels of estrogen, and family history IGF levels significantly decline by age 60. Excessive phosphorus intake, chiefly through sodas and junk foods, interferes with the calcium/phosphorus balance; results in increased risk of brittle bones Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 29 Osteomalacia Deficiency of vitamin D lowers the absorption of calcium from the intestines Inadequate or delayed mineralization Bone formation progresses to osteoid formation but calcification does not occur; the result is soft bones Pain, bone fractures, vertebral collapse, bone malformation Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 30 Paget Disease Also called osteitis deformans Excessive resorption of spongy bone and accelerated formation of softened bone Disorganized, thickened, but soft bones Most often affects the axial skeleton Thickened bones can cause abnormal bone curvatures, brain compression, impaired motor function, deafness, atrophy of the optic nerve Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 31 Osteomyelitis Usually caused by a staphylococcal infection Often from open wound (exogenous); also can be from a blood-borne (endogenous) infection Manifestations Acute and chronic inflammation, fever, pain, necrotic bone Treatment Antibiotics, débridement, surgery, hyperbaric oxygen therapy Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 32 Osteomyelitis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 33 Bone Tumors May originate from bone cells, cartilage, fibrous tissue, marrow, or vascular tissue Osteogenic, chondrogenic, collagenic, and myelogenic Malignant bone tumors Increased nuclear/cytoplasmic ratio, irregular borders, excess chromatin, a prominent nucleolus, and an increase in the mitotic rate Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 34 Bone Tumors Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 35 Bone Tumors Patterns of bone destruction Geographic pattern Moth-eaten pattern Permeative pattern Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 36 Bone Tumors Osteosarcoma 38% of bone tumors Predominant in adolescents and young adults; occurs in seniors if a history of radiation therapy Contain masses of osteoid • “Streamers”: noncalcified bone matrix and callus Located in the metaphyses of long bones • 50% occur around the knees Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 37 Osteosarcoma Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 38 Bone Tumors Chondrosarcoma Tumor of middle-aged and older adults Infiltrates trabeculae in spongy bone; frequent in the metaphyses or diaphysis of long bones The tumor contains lobules of hyaline cartilage that expand and enlarge the bone Causes erosion of the cortex and can expand into the neighboring soft tissues Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 39 Chondrosarcoma Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 40 Bone Tumors Fibrosarcoma Firm, fibrous mass of collagen, malignant fibroblasts, and osteoclast-like cells Usually affects metaphyses of the femur or tibia Metastasis to the lungs is common Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 41 Bone Tumors Myelogenic tumors Giant cell tumor • Causes extensive bone resorption due to the osteoclastic origin of the giant cells • Located in the epiphyses of the femur, tibia, radius, or humerus • The tumor has a slow, relentless growth rate Myeloma Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 42 Giant Cell Tumor Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 43 Inflammatory vs. Noninflammatory Joint Disease Differentiated by: Absence of synovial membrane inflammation Lack of systemic signs and symptoms Normal synovial fluid analysis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 44 Osteoarthritis Degeneration and loss of articular cartilage, sclerosis of bone underneath cartilage, and formation of bone spurs (osteophytes) Also called degenerative joint disease Incidence increases with age Primary disease is idiopathic Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 45 Osteoarthritis Local areas of damage and loss of articular cartilage, new bone formation of joint margins, subchondral bone changes, and variable degrees of mild synovitis and thickening of the joint capsule Manifestations Pain, stiffness, enlargement of the joint, tenderness, limited motion, and deformity Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 46 Osteoarthritis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 47 Osteoarthritis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 48 Inflammatory Joint Disease Commonly called arthritis Inflammatory damage or destruction in synovial membrane or articular cartilage and by systemic signs of inflammation Fever, leukocytosis, malaise, anorexia, and hyperfibrinogenemia Infectious or noninfectious Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 49 Rheumatoid Arthritis (RA) Inflammatory joint disease Systemic autoimmune damage to connective tissue, primarily in joints (synovial membrane) Similar symptoms to osteoarthritis Presence of rheumatoid factors (RA or RF test) Antibodies (IgG and IgM) against antibodies Joint fluid presents with inflammatory exudate Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 50 Rheumatoid Arthritis (RA) Pathogenesis CD4 T helper cells and other cells in the synovial fluid become activated and release cytokines Recruitment and retention of inflammatory cells in the joint sublining region Cycle of altered cytokine and signal transduction pathways Possible immune complex deposition and inflammatory cytokine release RANKL release and osteoclast activation Angiogenesis in the synovium Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 51 Rheumatoid Arthritis (RA) Evaluation (4 or more of the following) Morning joint stiffness lasting at least 1 hour Arthritis of three or more joint areas Arthritis of the hand joints Symmetric arthritis Rheumatoid nodules Abnormal amounts of serum rheumatoid factor Radiographic changes Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 52 Rheumatoid Arthritis (RA) Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 53 Rheumatoid Arthritis (RA) Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 54 Ankylosing Spondylitis (AS) Inflammatory joint disease of the spine or sacroiliac joints causing stiffening and fusion of the joints Systemic, immune inflammatory disease Primary proposed site is the enthesis Site where ligaments, tendons, and the joint capsule are inserted into bone Cause unknown, but strong association with HLA-B27 antigen Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 55 Ankylosing Spondylitis (AS) Begins with the inflammation of fibrocartilage, particularly in the vertebrae and sacroiliac joint Inflammatory cells infiltrate, erode fibrocartilage As repair begins, scar tissue ossifies and calcifies; joint eventually fuses Early symptoms Low back pain, stiffness, pain, and restricted motion Loss of normal lumbar curvature Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 56 Ankylosing Spondylitis (AS) Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 57 Gout Metabolic disorder that disrupts the body’s control of uric acid production or excretion Manifests high levels of uric acid in the blood and other body fluids Occurs when the uric acid concentration increases to high enough levels to crystallize Crystals deposit in connective tissues throughout the body When these crystals occur in the synovial fluid, the inflammation is known as “gouty arthritis” Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 58 Gout Related to purine (adenine and guanine) metabolism Affected people can have accelerated purine synthesis, breakdown, or poor uric acid secretion in the kidneys Mechanisms for crystal deposition Lower body temperatures, decreased albumin or glycosaminoglycan levels, changes in ion concentration and pH, and trauma Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 59 Gout Clinical stages Asymptomatic hyperuricemia Acute gouty arthritis Tophaceous gout Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 60 Gout Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 61 Gout Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 62 Disorders of Skeletal Muscle Contracture Muscle fiber shortening without an action potential Cause: failure of the sarcoplasmic reticulum (calcium pump) even with available ATP Stress-induced muscle tension Neck stiffness, back pain, clenching teeth, hand grip, and headache Associated with chronic anxiety Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 63 Fibromyalgia Chronic widespread joint and muscle pain Vague symptoms Possible factors Increased sensitivity to touch, absence of inflammation, fatigue, sleep disturbances Flu-like viral illness, chronic fatigue syndrome, HIV infection, Lyme disease, medications, physical or emotional trauma Scientific studies are unclear Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 64 Fibromyalgia Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 65 Disuse Atrophy Reduction in the normal size of muscle cells due to prolonged inactivity Bed rest, trauma, casting, or nerve damage Treatment Isometric movements and passive lengthening exercises Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 66 Muscle Membrane Abnormalities Myotonia Periodic paralysis Hypokalemic periodic paralysis Hyperkalemic periodic paralysis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 67 Diseases of Energy Metabolism McArdle disease Acid maltase deficiency Myophosphorylase deficiency Pompe disease Myoadenylate deaminase deficiency (MDD) Lipid deficiencies Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 68 Polymyositis and Dermatomyositis Collectively described as myositis Viral, bacterial, and parasitic myositis Staphylococcus aureus infections Trichinosis • Trichinella infection Toxoplasmosis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 69 Polymyositis and Dermatomyositis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 70 Toxic Myopathies Most common cause is alcohol abuse Acute attack of muscle weakness, pain, and swelling Chronic weakness in a drinker of long duration Necrosis of individual muscle fibers • Disturbance of energy turnover, gene dysregulation, and initiation of apoptosis Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 71 Muscle Tumors Rhabdomyosarcoma Malignant tumor of striated muscle Usually muscles of the tongue, neck, larynx, nasal cavity, axilla, vulva, and heart Highly malignant with rapid metastasis Types • Pleomorphic, embryonal, and alveolar Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 72
