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Alterations of Musculoskeletal Function Chapter 37 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. General Sickles Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Traumatic Fracture Battle of Gettysburg Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Musculoskeletal Injuries Fractures A fracture is a break in the continuity of a bone Classifications • Complete or incomplete • • • • • Closed or open Comminuted Linear Oblique Spiral Transverse Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Fracture Classifications Greenstick Torus Bowing Pathologic Stress Fatigue and insufficiency Transchondral Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Fractures Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Total Hip Replacement Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Fractures A broken bone can cause damage to 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Callus Formation Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Callus Formation Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Fractures Manifestations Unnatural alignment, swelling, muscle spasm, tenderness, pain, impaired sensation, and possible muscle spasms Treatment Closed manipulation, traction, and open reduction Internal and external fixation Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Fractures Improper reduction or immobilization Nonunion, delayed union, and malunion Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Fractures Dislocation Temporary displacement of two bones Loss of contact between articular cartilage Subluxation Contact between articular surfaces is only partially lost Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Fractures Dislocation and subluxation are associated with fractures, muscle imbalance, rheumatoid arthritis, or other forms of joint instability Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Support Structure Injuries Strain Sprain Tear or injury to a tendon or muscle Tear or injury to a ligament Avulsion Complete separation of a tendon or ligament from its bony attachment site Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Tendinopathy and Bursitis Tendinitis Inflammation of a tendon Tendinosis Painful degradation of collagen fibers Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Tendinopathy and Bursitis 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Tendinopathy and Bursitis Epicondylitis Inflammation of a tendon where it attaches to a bone • Tennis elbow (lateral epicondylitis) • Golfer’s elbow (medial epicondylitis) Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Tendinopathy and Bursitis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Myositis Ossificans Complication of local muscle injury Inflammation of muscular tissue with subsequent calcification and ossification of the muscle “Rider’s bone” in equestrians-tendon of adductor muscle of thigh “Drill bone” in infantry soldiers Thigh muscles in football players Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Rhabdomyolysis Rhabdomyolysis (myoglobinuria) is a lifethreatening complication of severe muscle trauma with muscle cell loss Crush syndrome Compartment syndromes • Volkmann ischemic contracture Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Compartment & Crush Syndrome Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoporosis Porous bone Poorly mineralized bone Bone density Normal bone • 833 mg/cm2 Osteopenic bone • 833 to 648 mg/cm2 Osteoporosis • <648 mg/cm2 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoporosis Potential causes Decreased levels of estrogen and testosterone Decreased activity level Inadequate levels of vitamins D and C, or Mg++ Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoporosis Demonstrated by reduced bone mass/density and an imbalance of bone resorption and formation Bone histology is usually normal but it lacks structural integrity Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoporosis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoporosis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoporosis Iatrogenic osteoporosis Regional osteoporosis Postmenopausal osteoporosis Glucocorticoid-induced osteoporosis Age-related bone loss Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoporosis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoporosis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoporosis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Paget Disease Thickened bones can cause abnormal bone curvatures, brain compression, impaired motor function, deafness, atrophy of the optic nerve, etc. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteomyelitis Osteomyelitis is most often caused by a staphylococcal infection Most common cause is open wound (exogenous); also can be from a bloodborne (endogenous) infection Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Staphylococcus stuck and Nose Cilia Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteomyelitis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteomyelitis Manifestations Acute and chronic inflammation, fever, pain, necrotic bone Treatment Antibiotics, débridement, surgery, hyperbaric oxygen therapy Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteomyelitis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Synovial cavity separates articulating bones Freely moveable (diarthroses) Articular cartilage Synovial Joints reduces friction absorbs shock Articular capsule surrounds joint thickenings in fibrous capsule called ligaments Synovial membrane Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Inflammatory vs. Noninflammatory Joint Disease Differentiated by: Absence of synovial membrane inflammation Lack of systemic signs and symptoms Normal synovial fluid analysis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Inflammatory Joint Disease Commonly called rheumatoid Characterized by inflammatory damage or destruction in the synovial membrane or articular cartilage and by systemic signs of inflammation arthritis Fever, leukocytosis, malaise, anorexia, and hyperfibrinogenemia Infectious or noninfectious Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoarthritis(noninflammatory) Degeneration and loss of articular cartilage, sclerosis of bone underneath cartilage, and formation of bone spurs (osteophytes) Also referred to as degenerative joint disease Incidence increases with age Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Primary disease is idiopathic Osteoarthritis Osteoarthritis is characterized by 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoarthritis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoarthritis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteoarthritis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Rheumatoid Arthritis Inflammatory joint disease Systemic autoimmune damage to connective tissue, primarily in the joints (synovial membrane) Similar symptoms to osteoarthritis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Rheumatoid Arthritis Presence of rheumatoid factors (RA or RF test) Antibodies (IgG and IgM) against antibodies Joint fluid presents with inflammatory exudate Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Rheumatoid Arthritis 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Rheumatoid Arthritis Pathogenesis Possible immune complex deposition and inflammatory cytokine release RANKL release and osteoclast activation Angiogenesis in the synovium Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Rheumatoid Arthritis Evaluation Four 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Rheumatoid Arthritis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Rheumatoid Arthritis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Rheumatoid Arthritis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Ankylosing Spondylitis Inflammatory joint disease of the spine or sacroiliac joints causing stiffening and fusion of the joints Systemic, immune inflammatory disease Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Ankylosing Spondylitis Primary proposed site is the enthesis Site where ligaments, tendons, and the joint capsule are inserted into bone Cause unknown, but there is a strong association with HLA-B27 antigen Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Ankylosing Spondylitis Begins with the inflammation of fibrocartilage, particularly in the vertebrae and sacroiliac joint Inflammatory cells infiltrate and erode fibrocartilage As repair begins, the scar tissue ossifies and calcifies; the joint eventually fuses Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Ankylosing Spondylitis Early symptoms Low back pain, stiffness, pain, and restricted motion Patient demonstrates loss of normal lumbar curvature Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Ankylosing Spondylitis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Gout Metabolic disorder that disrupts the body’s control of uric acid production or excretion Gout 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Gout Crystals deposit in connective tissues throughout the body When these crystals occur in the synovial fluid, the inflammation is known as “gouty arthritis” Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Gout Gout is related to purine (adenine and guanine) metabolism Affected patients can have accelerated purine synthesis, breakdown, or poor uric acid secretion in the kidneys Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Gout Mechanisms for crystal deposition: Lower body temperatures, decreased albumin or glycosaminoglycan levels, changes in ion concentration and pH, and trauma Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Gout Clinical stages Asymptomatic hyperuricemia Acute gouty arthritis Tophaceous gout Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Gout Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of Skeletal Muscle Contracture Muscle fiber shortening without an action potential Caused by 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disuse Atrophy Reduction in the normal size of muscle cells as a result of prolonged inactivity Bed rest, trauma, casting, or nerve damage Treatment Isometric movements and passive lengthening exercises Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Fibromyalgia Chronic widespread joint and muscle pain Vague symptoms Increased sensitivity to touch, absence of inflammation, fatigue, and sleep disturbances Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Fibromyalgia Possible factors Flulike viral illness, chronic fatigue syndrome, HIV infection, Lyme disease, medications, physical or emotional trauma Scientific studies are unclear* *10/09:NPR…retrovirus(RNA) Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Fibromyalgia Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Polymyositis and Dermatomyositis Collectively described by the term myositis Viral, bacterial, and parasitic myositis Staphylococcus aureus infections Trichinosis • Trichinella infection Toxoplasmosis Polymyositis and dermatomyositis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Polymyositis and Dermatomyositis Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Toxic Myopathies The most common cause of toxic myopathy is alcohol abuse: Box 37-5 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 ofitems apoptosis Elsevier items and derived © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Tumors May originate from bone cells, cartilage, fibrous tissue, marrow, or vascular tissue Osteogenic, chondrogenic, collagenic, and myelogenic Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Tumors Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Tumors Malignant bone tumors Increased nuclear/cytoplasmic ratio, irregular borders, excess chromatin, a prominent nucleolus, and an increase in the mitotic rate Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Tumors Patterns of bone destruction Table 37-7 Geographic pattern Moth-eaten pattern Permeative pattern Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Tumors Osteosarcoma 38% of bone tumors Predominant in adolescents and young adults; occurs in seniors if they have 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Osteosarcoma Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bone Tumors Myelogenic tumors Giant cell tumor • Causes extensive bone resorption because of 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. 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 Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published.
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