Diseases of the musculoskeletal system
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Diseases of the Musculoskeletal System. Chapter 37. Skeletal. Skeletal trauma/fractures Incidence Young males and older adults Tibia, clavicle, lower humerus (young persons) Hands, feet -- workplace accidents Upper femur, upper humerus, vertebrae, pelvis (elderly) Osteoporosis

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Skeletal
Skeletal

  • Skeletal trauma/fractures

    • Incidence

      • Young males and older adults

      • Tibia, clavicle, lower humerus (young persons)

      • Hands, feet -- workplace accidents

      • Upper femur, upper humerus, vertebrae, pelvis (elderly)

        • Osteoporosis

    • Diff types (complete/incomplete, open/closed)

      • Incomplete -- bones of children

        • Flexible

        • Growing

      • Stress w/ repeated stress (ex athletics)

        • Fatigue

        • Insufficiency (weight bearing bones)


- Pathophysiology

  • Healing similar to soft-tissue injuries stages

    • No scar tissue

  • Periosteum, blood vessels disrupted

  • Bleeding  clot form=n (hematoma)

  • Stages

    • Hematoma

    • Procallus form=n

      • Intense inflammatory response

      • Fibroblasts, collagen, growth factors, osteoblasts impt

    • Callus

      • Hardened membr (woven bone)

    • Remodeling

      • Osteoclasts;  original shape

      • Resorption unneeded callus


  • Clinical

    • Signs/symptoms

      • Impaired function

      • Unnatural alignment; possible rotation, angulation

      • Swelling

      • Tenderness

      • Severe pain (trauma, muscle spasm)

    • Stress fractures -- pain with accelerated remodeling

      • Relieved by rest

  • Treatment

    • Realign to normal position (manipulation, traction)

    • Surgery

      • Prosthesis, screw, plate, etc., possible

    • Splints, casts


  • Metabolic bone disease (Osteoporosis)

    • remodeling imbalance favors bone resorption

    • Incidence

      • Common disorder of bone metabolism

      • Heredity evidence in women

    • Fracture due to bone weakness

      • Common -- vertebrae, distal radius, proximal femur

      • Fractures after trauma

      • Compression fractures (esp vertebral)

    • Non-symptomatic until indicated by fracture


  • Pathophysiology

    • Age 

      • Bone resorption exceeding bone growth

      •  Net bone mass loss

      • More rapid in women

        • Exaggerated at menopause

        • Type I (Postmenopausal)

      • Type II C both sexes over age 70

        • Neck, hip, humerus, tibia

    • May involve postaglandins, interleukins, various growth factors that affect osteoclasts

    • Estrogen decr w/ menopause  incr=d risk

      • Estrogen inhibits bone resorption

      • Also in young, female athletes

        • Training  decr=d estrogen

        • Found decr=d bone mass, incr’d fractures


  • Clinical

    • Pain

    • Bone deformity

    • Fractures

    • Vertebral collapse  hunchback, decr=d height

  • Treatment C slow rate of Ca, bone loss

    • Incr dietary Ca

    • Vit D  incr intestinal abs=n Ca

    • Regular, moderate exercise

    • Hormone treatment (estrogen, progesterone)

    • Reduce risk of falls


  • Bone tumors

    • Common secondary tumor site

      • Primary often prostate, breast, thyroid, lung, kidney

      • Access through blood

      • Often axial skeleton (not skull), proximal femur, humerus

      • May induce bone breakdown or bone growth


  • Primary tumors less common

    • Actively growing bone

    • Pain early indication

    • May  bone weakening

    • Pressure  adjacent bone deformed by abnormal remodeling

    • Metastasis often to lung

    • Most more in males than females

  • About 1/3 primary tumors benign

    • Ex: osteoma of skull and osteoid osteoma of long bone

    • Ex: chondroblastoma

      • Arises in cartilage of epiphyses of arm, leg bones

      • Rare


  • Malignant bone tumors

    • Osteogenic sarcoma (=osteosarcoma) most common

      • Usually age 10-20 years

      • Knee often

      • Common metastasis  lung

      • Previous metastasis by time of diagnosis  poor prognosis

      • Now better chemotherapy (80% 5 yr recovery rate)

      • Surgery often

    • Chondrosarcoma

      • Usually age 30-50 yrs

      • Slow-growing

      • May break through bone surface

      • Interior of pelvis, ribs, prox femur, humerus

      • Surgical excision


Diseases of the joints
Diseases of the Joints

  • Osteoarthritis = Degenerative Joint Disease

    • Incidence

      • Most common joint disease in US

      • Incr=s w/ age

        • Age 60 -- most affected

        • > 75 yrs -- 85% affected

    • Pathophysiology

      • Articular cartilage becomes thin, irregular, frayed

        • Probably enz breakdown of cartilage

      •  Cracks, fissures in articular cartilage

        • Fill w/ synovial fluid


  • Pathophys (cont’d)

    • Penetrates to underlying bone w/ progression

      • May  fluid-filled cysts

      • Bone forms around cysts

      • May  microfractures

    • Fibrocartilage plugs form for repair

      • Activyt  plugs stripped away, then reformed, then restripped

      •  Smooth bone surface

    • Fibrocartilage fragments may react at synovial membr surface

      •  inflamm response C> repair

      •  decr=d movement

    • Cells in synovial membr may dev into osteoblasts

      •  form=n bone spurs at joint

      •  pain, decr=d movement


  • Degeneration

    • Mostly at larger weight-bearing joints (also fingers)

    • Related to

      • Wear-and-tear OR

      • Biochem defect in joint cartilage OR

      • Excessive loading (malformed joint, postural defect, obesity) OR

      • Genetic

  • Clinical

    • Joint aches, stiffness

      • Incr w/ activity; diminish w/ rest

    • Progression w/ age

    • Loss of mobility if hip, knee affected

  • Therapy limited

    • Analgesics for pain

    • Reduce obvious stresses

    • Surgical removal of bone spurs or artificial joint replacement


  • Rheumatoid arthritis C systemic disease involving joints

    • Incidence

      • About 1% adult pop=n affected

      • 3 female: 1 male

      • Age of onset usually 20-30 (but also infancy  90's)

      • May be due to

        • Infection

        • Autoimmune disorder

        • Genetic predisposition


  • Get immune-mediated destruction of joints

    • Environmental stimulus immune response to Ag

    • If predisposed, Ab=s transform to Arheumatoid [email protected] (Rfs)

    • Rfs complex in blood, synovial fluid inflamm response at joint

    • Inflamm mediators breakdown joint tissue  joint tissue destroyed


  • Get pattern of chronic inflamm=n

    • Incr=d number of cells in synovium

    •  Thickening of synovium (maybe after cartilage destroyed by inflamm=n process)

    • Thickened synovium covers adjacent joint surfaces

      • Over time may enlarge, fill joint space

      • In late stage = ankylosis = fused joint

    • Causes swelling; stiffness; pain

    • Swelling also due to incr=d exudate in synovial membr

  • Joint deformities

    •  Loss of joint motion

    •  Muscular atrophy


  • Sytemic effects variable

    • Generalized weakness, malaise

    • Rheumatoid nodules form

      • Focal subcu swelling

      • Elbow, heel, dorsal surface of head; also internal

      • Made of macrophages, lymphocytes, collagen, cell debris

      • Typically painless

    • Rheumatoid vasculitis common

      • Systemic inflamm=n of blood vessels

      • May involve pericardium, pleural effusion

  • Therapy C no cure; can’t reverse destruction of structures

    • Relieve pain, reduce swelling (antiinflammatories)

    • Reduce stress

    • Strengthen assoc=d muscles

    • Replace severely effected joints


Diseases of skeletal muscle
Diseases of Skeletal Muscle

  • Disuse atrophy

    • Pathologic reduction in size of muscle fibers

      • Follows prolonged bed rest, trauma, nerve damage

    • Muscle strength decr=s from baseline

      • About 3% per day

    • To prevent

      • Frequent isometric muscle contractions

      • Passive lengthening exercise

    • If no reuse in 1 year, regen=n muscle fibers impaired


  • Fibromyalgia

    • Chronic musculoskel syndrome

    • Get diffuse chronic pain, tenderness w/ no inflamm=n, fatigue

      • Tenderness @ 9 common points in body (neck, shoulders, hips, knees)

      • Profound fatigue

      • May  depression

      • Also migraine, irritable bowel disease common

    • Incidence

      • Mostly women

      • Peak age = 30-50 yrs

      • Increases w/ age


  • Probably several causes

    • virus,

    • Phys/emotional trauma, emotional trauma,

    • medication

  • Found metab alterations in muscle

    • May  pain, fatigue

  • Also found diff blood flow to thalamus

    • May C> chronic stress response

  • Treatment

    • Antiinflammatories (not very effective)

    • CNS active agents somewhat helpful


  • Muscle Strains

    • Gen’l term for muscle damage

    • Seen after traumatic, sports injuries

      • Sudden, forced motion

      • Muscle becomes stretched beyond normal length

      • May include wounds

    • Often involves tendon also

    • May include hemorrhage, inflamm=n

    • Muscle cells usually regenerate in up to 6 weeks

    • Treatment

      • Ice relieves swelling

      • Analgesics

      • Alternating heat/cold if more severe form

      • Surgery, immobilization if tearing, bleeding


Musculoskeletal disorders
Musculoskeletal Disorders

  • May accompany fractures, dislocations

  • Ligament = fibrous connective tissue band joining bones @ joint

    • Needed to support bones, joints

  • Strain = tear in tendon

    • May be due to major trauma

    • Also spontaneous w/ corticosteroid admin, rheumatoid arthritis, lupus


  • Common sites

    • Tendons of hands, feet

    • Knee

    • Upper arm - w/ lifting excess wt

    • Thigh

    • Ankle

    • Heel - w/ forced flexion

  • Sprain = tear in ligament

    • Common sites

      • Wrist

      • Ankle

      • Elbow

      • Knee


    • Avulsion = total sep=n tendon/ligament from bone

      • Due to abnormal stress

      • Young athletes (sprinters, hurdlers, runners)

    • Pathophysiology

      • Tearing  inflamm response

      • Exudate forms @ torn ends

      • Macrophages, fibroblasts

      • Repair

        • Collagen form=n random, then organized

        • Vascular fibrous tissue fuses new, old tissues

        • Healing tendon separates from surrounding soft tissue

        • Can=t support strong pull for 4-5 weeks


    • Clinical

      • Pain C sharp, localized

      • Soft-tissue swelling

      • Joint swelling

      • Flexion deformities

      • If in extremities, motion affected

    • Treatment

      • Suture tendon/ligament

      • Tendon/ligament grafting


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