1 Alterations of Musculoskeletal Function Chapter 42.

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Alterations of Musculoskeletal FunctionChapter 42

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

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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


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Fracture Classifications Transverse Greenstick Torus Bowing Pathologic Stress

Fatigue and insufficiency Transchondral


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Fractures


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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


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Callus Formation


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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


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Treatment


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Treatment


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Treatment


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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


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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


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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


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Tendinopathy and Bursitis Epicondylitis

Inflammation of a tendon where it attaches to a bone Tennis elbow (lateral epicondylitis) Golfer’s elbow (medial epicondylitis)


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Tendinitis and Epicondylitis


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Tendinitis and Epicondylitis


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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


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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


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Rhabdomyolysis Rhabdomyolysis (myoglobinuria) is a life-

threatening complication of severe muscle trauma with muscle cell loss Crush syndrome Compartment syndromes


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Osteoporosis Porous bone Poorly mineralized bone Bone density

Normal bone 833 mg/cm2

Osteopenic bone 833 to 648 mg/cm2

Osteoporosis <648 mg/cm2


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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


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Osteoporosis


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Osteoporosis


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Osteoporosis


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Osteoporosis Perimenopausal osteoporosis Iatrogenic osteoporosis Regional osteoporosis Postmenopausal osteoporosis Glucocorticoid-induced osteoporosis Age-related bone loss


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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


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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.


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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


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Osteomyelitis


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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


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Bone Tumors


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Bone Tumors Patterns of bone destruction

Geographic pattern Moth-eaten pattern Permeative pattern


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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


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Osteosarcoma


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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


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Chondrosarcoma


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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


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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


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Giant Cell Tumor


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Inflammatory vs. Noninflammatory Joint Disease

Differentiated by: Absence of synovial membrane inflammation Lack of systemic signs and symptoms Normal synovial fluid analysis


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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


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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


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Osteoarthritis


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Osteoarthritis


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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


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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


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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


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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


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Rheumatoid Arthritis (RA)


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Rheumatoid Arthritis (RA)


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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


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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


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Ankylosing Spondylitis (AS)


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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”


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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


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Gout Clinical stages

Asymptomatic hyperuricemia Acute gouty arthritis Tophaceous gout


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Gout


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Gout


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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


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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


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Fibromyalgia


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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


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Muscle Membrane Abnormalities Myotonia Periodic paralysis

Hypokalemic periodic paralysis Hyperkalemic periodic paralysis


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Diseases of Energy Metabolism McArdle disease

Myophosphorylase deficiency Acid maltase deficiency

Pompe disease Myoadenylate deaminase deficiency (MDD) Lipid deficiencies


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Polymyositis and Dermatomyositis Collectively described by the term myositis Viral, bacterial, and parasitic myositis

Staphylococcus aureus infections Trichinosis

Trichinella infection

Toxoplasmosis Polymyositis and dermatomyositis


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Polymyositis and Dermatomyositis


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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


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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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1 Alterations of Musculoskeletal Function Chapter 42.

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