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Alterations of Musculoskeletal Function Chapter 42 1 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 2 Mosby items and derived items © 2006 by Mosby, Inc. Fracture Classifications Transverse Greenstick Torus Bowing Pathologic Stress Fatigue and insufficiency Transchondral 3 Mosby items and derived items © 2006 by Mosby, Inc. Fractures 4 Mosby items and derived items © 2006 by Mosby, Inc. 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 5 Mosby items and derived items © 2006 by Mosby, Inc. Callus Formation 6 Mosby items and derived items © 2006 by Mosby, Inc. Bone Fractures Manifestations Treatment Unnatural alignment, swelling, muscle spasm, tenderness, pain, impaired sensation, and possible muscle spasms Closed manipulation, traction, and open reduction Improper reduction or immobilization Nonunion, delayed union, and malunion 7 Mosby items and derived items © 2006 by Mosby, Inc. Treatment 8 Mosby items and derived items © 2006 by Mosby, Inc. Treatment 9 Mosby items and derived items © 2006 by Mosby, Inc. Treatment 10 Mosby items and derived items © 2006 by Mosby, Inc. 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 are associated with fractures, muscle imbalance, rheumatoid arthritis, or other forms of joint instability 11 Mosby items and derived items © 2006 by Mosby, Inc. 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 12 Mosby items and derived items © 2006 by Mosby, Inc. 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 13 Mosby items and derived items © 2006 by Mosby, Inc. Tendinopathy and Bursitis Epicondylitis Inflammation of a tendon where it attaches to a bone Tennis elbow (lateral epicondylitis) Golfer’s elbow (medial epicondylitis) 14 Mosby items and derived items © 2006 by Mosby, Inc. Tendinitis and Epicondylitis 15 Mosby items and derived items © 2006 by Mosby, Inc. Tendinitis and Epicondylitis 16 Mosby items and derived items © 2006 by Mosby, Inc. 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 17 Mosby items and derived items © 2006 by Mosby, Inc. 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 18 Mosby items and derived items © 2006 by Mosby, Inc. Rhabdomyolysis Rhabdomyolysis (myoglobinuria) is a lifethreatening complication of severe muscle trauma with muscle cell loss Crush syndrome Compartment syndromes 19 Mosby items and derived items © 2006 by Mosby, Inc. Osteoporosis Porous bone Poorly mineralized bone Bone density Normal bone Osteopenic bone 833 mg/cm2 833 to 648 mg/cm2 Osteoporosis <648 mg/cm2 20 Mosby items and derived items © 2006 by Mosby, Inc. Osteoporosis Potential causes Decreased levels of estrogen and testosterone Decreased activity level Inadequate levels of vitamins D and C, or Mg++ Demonstrated by reduced bone mass/density and an imbalance of bone resorption and formation Bone histology is usually normal but it lacks structural integrity 21 Mosby items and derived items © 2006 by Mosby, Inc. Osteoporosis 22 Mosby items and derived items © 2006 by Mosby, Inc. Osteoporosis 23 Mosby items and derived items © 2006 by Mosby, Inc. Osteoporosis 24 Mosby items and derived items © 2006 by Mosby, Inc. Osteoporosis Perimenopausal osteoporosis Iatrogenic osteoporosis Regional osteoporosis Postmenopausal osteoporosis Glucocorticoid-induced osteoporosis Age-related bone loss 25 Mosby items and derived items © 2006 by Mosby, Inc. 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 26 Mosby items and derived items © 2006 by Mosby, Inc. 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, etc. 27 Mosby items and derived items © 2006 by Mosby, Inc. Osteomyelitis Osteomyelitis is most often caused by a staphylococcal infection Most common cause is 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 28 Mosby items and derived items © 2006 by Mosby, Inc. Osteomyelitis 29 Mosby items and derived items © 2006 by Mosby, Inc. Bone Tumors May originate from bone cells, cartilage, fibrous tissue, marrow, or vascular tissue Osteogenic, chrondrogenic, collagenic, and myelogenic Malignant bone tumors Increased nuclear/cytoplasmic ratio, irregular borders, excess chromatin, a prominent nucleolus, and an increase in the mitotic rate 30 Mosby items and derived items © 2006 by Mosby, Inc. Bone Tumors 31 Mosby items and derived items © 2006 by Mosby, Inc. Bone Tumors Patterns of bone destruction Geographic pattern Moth-eaten pattern Permeative pattern 32 Mosby items and derived items © 2006 by Mosby, Inc. 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 33 Mosby items and derived items © 2006 by Mosby, Inc. Osteosarcoma 34 Mosby items and derived items © 2006 by Mosby, Inc. 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 35 Mosby items and derived items © 2006 by Mosby, Inc. Chondrosarcoma 36 Mosby items and derived items © 2006 by Mosby, Inc. 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 37 Mosby items and derived items © 2006 by Mosby, Inc. 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 38 Mosby items and derived items © 2006 by Mosby, Inc. Giant Cell Tumor 39 Mosby items and derived items © 2006 by Mosby, Inc. Inflammatory vs. Noninflammatory Joint Disease Differentiated by: Absence of synovial membrane inflammation Lack of systemic signs and symptoms Normal synovial fluid analysis 40 Mosby items and derived items © 2006 by Mosby, Inc. Osteoarthritis 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 Primary disease is idiopathic 41 Mosby items and derived items © 2006 by Mosby, Inc. 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 synovitus and thickening of the joint capsule Manifestations Pain, stiffness, enlargement of the joint, tenderness, limited motion, and deformity 42 Mosby items and derived items © 2006 by Mosby, Inc. Osteoarthritis 43 Mosby items and derived items © 2006 by Mosby, Inc. Osteoarthritis 44 Mosby items and derived items © 2006 by Mosby, Inc. Inflammatory Joint Disease Commonly called arthritis Characterized by inflammatory damage or destruction in the synovial membrane or articular cartilage and by systemic signs of inflammation Fever, leukocytosis, malaise, anorexia, and hyperfibrinogenemia Infectious or noninfectious 45 Mosby items and derived items © 2006 by Mosby, Inc. Rheumatoid Arthritis (RA) Inflammatory joint disease Systemic autoimmune damage to connective tissue, primarily in the 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 46 Mosby items and derived items © 2006 by Mosby, Inc. 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 Viscous 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 47 Mosby items and derived items © 2006 by Mosby, Inc. 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 48 Mosby items and derived items © 2006 by Mosby, Inc. Rheumatoid Arthritis (RA) 49 Mosby items and derived items © 2006 by Mosby, Inc. Rheumatoid Arthritis (RA) 50 Mosby items and derived items © 2006 by Mosby, Inc. 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 there is a strong association with HLA-B27 antigen 51 Mosby items and derived items © 2006 by Mosby, Inc. Ankylosing Spondylitis (AS) 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 Early symptoms Low back pain, stiffness, pain, and restricted motion Patient demonstrates loss of normal lumbar curvature 52 Mosby items and derived items © 2006 by Mosby, Inc. Ankylosing Spondylitis (AS) 53 Mosby items and derived items © 2006 by Mosby, Inc. 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 Crystals deposit in connective tissues throughout the body When these crystals occur in the synovial fluid, the inflammation is known as “gouty arthritis” 54 Mosby items and derived items © 2006 by Mosby, Inc. 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 Mechanisms for crystal deposition Lower body temperatures, decreased albumin or glycosaminoglycan levels, changes in ion concentration and pH, and trauma 55 Mosby items and derived items © 2006 by Mosby, Inc. Gout Clinical stages Asymptomatic hyperuricemia Acute gouty arthritis Tophaceous gout 56 Mosby items and derived items © 2006 by Mosby, Inc. Gout 57 Mosby items and derived items © 2006 by Mosby, Inc. Gout 58 Mosby items and derived items © 2006 by Mosby, Inc. 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 59 Mosby items and derived items © 2006 by Mosby, Inc. Fibromyalgia Chronic widespread joint and muscle pain Vague symptoms Possible factors Increased sensitivity to touch, absence of inflammation, fatigue, and sleep disturbances Flulike viral illness, chronic fatigue syndrome, HIV infection, Lyme disease, medications, physical or emotional trauma Scientific studies are unclear 60 Mosby items and derived items © 2006 by Mosby, Inc. Fibromyalgia 61 Mosby items and derived items © 2006 by Mosby, Inc. 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 62 Mosby items and derived items © 2006 by Mosby, Inc. Muscle Membrane Abnormalities Myotonia Periodic paralysis Hypokalemic periodic paralysis Hyperkalemic periodic paralysis 63 Mosby items and derived items © 2006 by Mosby, Inc. Diseases of Energy Metabolism McArdle disease Acid maltase deficiency Myophosphorylase deficiency Pompe disease Myoadenylate deaminase deficiency (MDD) Lipid deficiencies 64 Mosby items and derived items © 2006 by Mosby, Inc. Polymyositis and Dermatomyositis Collectively described by the term myositis Viral, bacterial, and parasitic myositis Staphylococcus aureus infections Trichinosis Trichinella infection Toxoplasmosis Polymyositis and dermatomyositis 65 Mosby items and derived items © 2006 by Mosby, Inc. Polymyositis and Dermatomyositis 66 Mosby items and derived items © 2006 by Mosby, Inc. Toxic Myopathies The most common cause of toxic myopathy 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 67 Mosby items and derived items © 2006 by Mosby, Inc. 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 68 Mosby items and derived items © 2006 by Mosby, Inc.
