1 Alterations of Musculoskeletal Function Chapter 42.

1 Alterations of Musculoskeletal Function Chapter 42

Mosby items and derived items © 2006 by Mosby, Inc. 2 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

Mosby items and derived items © 2006 by Mosby, Inc. 5 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

Mosby items and derived items © 2006 by Mosby, Inc. 7 Bone Fractures  Manifestations Unnatural alignment, swelling, muscle spasm, tenderness, pain, impaired sensation, and possible muscle spasms  Treatment Closed manipulation, traction, and open reduction  Improper reduction or immobilization Nonunion, delayed union, and malunion

Mosby items and derived items © 2006 by Mosby, Inc. 11 Bone Fractures  Dislocation Temporary displacement of two bones Loss of contact between articular cartilage  Subluxation 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

Mosby items and derived items © 2006 by Mosby, Inc. 12 Support Structure Injuries  Strain Tear or injury to a tendon  Sprain Tear or injury to a ligament  Avulsion Complete separation of a tendon or ligament from its bony attachment site

Mosby items and derived items © 2006 by Mosby, Inc. 13 Tendinopathy and Bursitis  Tendinitis Inflammation of a tendon  Tendinosis 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 © 2006 by Mosby, Inc. 14 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 © 2006 by Mosby, Inc. 17 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 © 2006 by Mosby, Inc. 18 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 © 2006 by Mosby, Inc. 19 Rhabdomyolysis  Rhabdomyolysis (myoglobinuria) is a life- threatening complication of severe muscle trauma with muscle cell loss Crush syndrome Compartment syndromes

Mosby items and derived items © 2006 by Mosby, Inc. 20 Osteoporosis  Porous bone  Poorly mineralized bone  Bone density Normal bone  833 mg/cm 2 Osteopenic bone  833 to 648 mg/cm 2 Osteoporosis  <648 mg/cm 2

Mosby items and derived items © 2006 by Mosby, Inc. 21 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

Mosby items and derived items © 2006 by Mosby, Inc. 25 Osteoporosis  Perimenopausal osteoporosis  Iatrogenic osteoporosis  Regional osteoporosis  Postmenopausal osteoporosis  Glucocorticoid-induced osteoporosis  Age-related bone loss

Mosby items and derived items © 2006 by Mosby, Inc. 26 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 © 2006 by Mosby, Inc. 27 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.

Mosby items and derived items © 2006 by Mosby, Inc. 28 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

Mosby items and derived items © 2006 by Mosby, Inc. 30 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

Mosby items and derived items © 2006 by Mosby, Inc. 33 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

Mosby items and derived items © 2006 by Mosby, Inc. 35 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 © 2006 by Mosby, Inc. 37 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 © 2006 by Mosby, Inc. 38 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 © 2006 by Mosby, Inc. 40 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 © 2006 by Mosby, Inc. 41 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

Mosby items and derived items © 2006 by Mosby, Inc. 42 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

Mosby items and derived items © 2006 by Mosby, Inc. 45 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

Mosby items and derived items © 2006 by Mosby, Inc. 46 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

Mosby items and derived items © 2006 by Mosby, Inc. 47 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

Mosby items and derived items © 2006 by Mosby, Inc. 48 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 © 2006 by Mosby, Inc. 51 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

Mosby items and derived items © 2006 by Mosby, Inc. 52 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

Mosby items and derived items © 2006 by Mosby, Inc. 54 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”

Mosby items and derived items © 2006 by Mosby, Inc. 55 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

Mosby items and derived items © 2006 by Mosby, Inc. 59 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

Mosby items and derived items © 2006 by Mosby, Inc. 60 Fibromyalgia  Chronic widespread joint and muscle pain  Vague symptoms Increased sensitivity to touch, absence of inflammation, fatigue, and sleep disturbances  Possible factors Flulike viral illness, chronic fatigue syndrome, HIV infection, Lyme disease, medications, physical or emotional trauma  Scientific studies are unclear

Mosby items and derived items © 2006 by Mosby, Inc. 62 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 © 2006 by Mosby, Inc. 64 Diseases of Energy Metabolism  McArdle disease Myophosphorylase deficiency  Acid maltase deficiency Pompe disease  Myoadenylate deaminase deficiency (MDD)  Lipid deficiencies

Mosby items and derived items © 2006 by Mosby, Inc. 65 Polymyositis and Dermatomyositis  Collectively described by the term myositis  Viral, bacterial, and parasitic myositis Staphylococcus aureus infections Trichinosis  Trichinella infection Toxoplasmosis  Polymyositis and dermatomyositis

Mosby items and derived items © 2006 by Mosby, Inc. 67 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

Mosby items and derived items © 2006 by Mosby, Inc. 68 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

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