Gout and Fibromyalgia Quiz

Musculoskeletal Injuries

• Fractures are breaks in bone continuity
• Classifications:
  • Complete or incomplete
  • Closed or open
  • Comminuted
  • Linear
  • Oblique
  • Spiral
  • Transverse
  • Greenstick
  • Torus
  • Bowing
  • Pathological
  • Stress
  • Fatigue

Fractures (Continued)

• Healing types:
  • Direct: Most often from surgical repair, with no callus formation and intramembranous bone formation
  • Indirect: Most often seen with casts or other nonsurgical treatments, with intramembranous and endochondral bone formation, callus formation, and remodeling of solid bone.

Bone Healing

• Images display the stages of bone healing

Callus Formation

• Images show callus formation in bone

Fractures (Manifestations and Treatment)

• Manifestations include unnatural alignment, swelling, muscle spasm, tenderness, pain, impaired sensation, and decreased mobility, often with transient numbness.
• Treatment includes immobilization, closed manipulation, traction, and open reduction, and internal and external fixation.

Fractures (Continued)

• Improper reduction and immobilization can lead to nonunion, delayed union, and malunion.

Dislocation and Subluxation

• Dislocation is the displacement of one or more bones in a joint.
• Loss of contact between articular cartilage occurs.
• Subluxation is a partial loss of contact between articular surfaces.
• Associated with fractures, muscle imbalance, rheumatoid arthritis, or other joint instability.

Support Structures

• Strain: Tearing or stretching a tendon or muscle.
• Sprain: Tear or injury to a ligament.
• Avulsion: Complete separation of a tendon or ligament from its bony attachment.

Support Structures (Continued)

• Tendon and ligament injuries typically lack sufficient strength for 4–5 weeks post-injury.
• Pain, soft tissue swelling, changes in tendon/ligament contour, and dislocation/subluxation of bones are common.
• Rehabilitation is key to regaining good function.

Tendinopathy, Epicondylopathy, and Bursitis

• Tendinopathy: Inflammation of a tendon.
• Epicondylopathy: Inflammation where a tendon attaches to a bone (e.g., tennis elbow, golfer's elbow).
• Bursitis: Inflammation of a bursa (tissue sac that cushions skin over bone, muscle, or tendon).

Tendinopathy, Epicondylopathy, and Bursitis (Continued)

• Bursitis inflammation often results from overuse or excessive pressure.

Muscle Strain

• Muscle strain is caused by sudden, forceful motion stretching the muscle beyond normal capacity; often includes tendons.
• Muscle strain proceeds through three phases (destruction, repair, and remodeling).

Muscle Strain (Continued)

• Myositis ossificans, aka heterotopic ossification, is a late complication of local muscle injury associated with burns, joint surgery, and musculoskeletal/central nervous system trauma.
• This leads to soft tissue calcification that causes stiffness or deformity.

Rhabdomyolysis

• Rapid muscle breakdown releases intracellular contents, including myoglobin, into the bloodstream.
• This can result in hyperkalemia, cardiac arrhythmia, or acute kidney failure.
• Muscle pain, weakness, and dark urine are common symptoms.

Rhabdomyolysis (Continued)

• Diagnosis is when CK levels are 5-10 times the upper limit of normal (around 1000 units/L); severe kidney failure is likely when CK reaches 15,000 units/L.
• Treatment aims to prevent kidney failure and maintain adequate urinary output.

Compartment Syndrome

• Increased pressure within muscle compartments can result from any condition disrupting vascular supply to an extremity, such as muscle ischemia causing edema and rising compartment pressure.
• This can lead to muscle infarction, neural injury, and "6 Ps" of compartment syndrome, including Volkmann ischemic contracture.

Compartment Syndrome (Continued)

• Diagnosis involves intracompartmental pressure measurement.
• Surgical intervention is needed when pressure reaches 30 mm Hg.

Malignant Hyperthermia

• A hypermetabolic reaction to certain anesthetic agents.
• Mutation in the skeletal muscle ryanodine receptor (RyR1) is a primary cause.
• Results in altered excitation-coupling, muscle rigidity, rhabdomyolysis, and potentially death if not promptly treated with dantrolene.
• Pre-operative evaluation and muscle-contracture testing are crucial for risk prediction.

Osteoporosis

• Poorly mineralized bone increases fracture risk due to alterations in bone microarchitecture (old bone resorbing faster than new bone is formed).
• This can lead to spontaneous fractures.

Osteoporosis (Continued)

• Endocrine dysfunction (thyroid, parathyroid, growth hormone, and cortisol abnormalities), medications, vitamin D deficiency, underlying diseases, low physical activity, or abnormal BMI can cause osteoporosis.
• Fractures are the primary complication.

Osteoporosis (Continued)

• Postmenopausal osteoporosis is common in middle-aged and older women.
• Estrogen deficiency and the resulting imbalance between osteoclast and osteoblast activity is a contributing factor.

Osteoporosis (Continued)

• Secondary osteoporosis is caused by other conditions like hormonal imbalances, medications, or diseases.
• Regional osteoporosis confines to a segment of the appendicular skeleton, possibly related to disuse and potentially transient.

Osteoporosis (Continued)

• Glucocorticoid-induced osteoporosis is a secondary form caused by glucocorticoids affecting osteoclast survival, inhibiting osteoblast formation, and function. Reduced physical activity may contribute to age-related bone loss.

Osteoporosis (Continued)

• Bone loss appears different in men and women, although both experience a net bone loss over their life.

Osteoporosis (Continued)

• Key changes in bone include trabecular bone loss (thickness to perforation) varying in men and women, as evident in scans.
• Kyphosis (abnormal curvature of the spine) is a possible effect of osteoporosis.

Osteoporosis (Continued)

• Dual X-ray absorptiometry (DXA) is the gold standard diagnostic tool.
• Trabecular bone score (TBS), derived from DXA scans, further analyzes pixel variations for enhanced fracture risk prediction.

Osteomalacia

• Inadequate or delayed osteoid mineralization results in soft bones.
• This arises from vitamin D deficiency and can cause pain, fractures, vertebral collapse, and bone malformations.
• Treatment is contingent on etiology.

Paget's Disease

• Also known as osteitis deformans, this is a chronic condition of accelerated spongy bone remodeling and disorganized new bone deposition.
• It affects various bones, often leading to enlargement and softening.
• Symptoms are often absent, though pain and various clinical symptoms may present.
• Evaluation is based on radiographic findings.

Osteomyelitis

• Bone infection, typically caused by Staphylococcus aureus, spreads through the bloodstream.
• Symptoms include various vague symptoms such as fever, malaise, anorexia, weight loss, and pain, and are often gradual.

Osteomyelitis (Continued)

• Contiguous spread occurs via open fractures, penetrating wounds, and surgical procedures.
• These lead to symptoms of soft-tissue infection, such as low-grade fever, lymphadenopathy, and local pain and swelling.

Osteomyelitis (Continued)

• Brodie abscesses characterize subacute or chronic osteomyelitis.
• These usually manifest as circumscribed lesions near the ends of long bones.
• Treatment usually involves antibiotics, debridement, and surgical intervention as needed.

Osteomyelitis (Continued)

• The stages of osteomyelitis through soft tissue infection are presented in the images.

Osteoarthritis

• Characterized by articular cartilage damage/loss, inflammation, new bone formation at joint margins, subchondral bone changes, variable degrees of mild synovitis, and joint capsule thickening, increasing in prevalence with age.

Osteoarthritis (Continued)

• Risk factors include increased age, long-term mechanical stress on the joints, and obesity.

Osteoarthritis (Continued)

• Key characteristics include local areas of articular cartilage damage, new bone formation at joint margins, and subchondral bone changes within the joint.
• Signs and symptoms include pain (worse with activity), stiffness (better with activity), joint enlargement, tenderness, limited motion, muscle wasting, partial dislocation, and deformity.

Osteoarthritis (Continued)

• Conservative treatments include exercise and weight loss, pharmacological therapies (analgesics and anti-inflammatories), and nutritional supplements.
• Surgical treatment involves interventions to improve joint movement, correct deformity, or replace with artificial implants.

Osteoarthritis (Continued)

• Images of joint damage related to osteoarthritis, along with specific joint issues (e.g. Hebert/Bouchard's nodes in the hand), are presented.

Classic Inflammatory Joint Disease

• Inflammatory damage and destruction of synovial membrane and articular cartilage are characteristics.
• Systemic inflammation signs present as well.
• Infections are a possibility.

Rheumatoid Arthritis

• An inflammatory autoimmune joint disease primarily targeting connective tissue in synovial membranes within the joints.
• Symptoms can mimic osteoarthritis.
• Genetic predisposition is a significant factor.

Rheumatoid Arthritis (Continued)

• Pathogenesis involves activated neutrophils and other synovial fluid cells, inflammatory cytokines (TNF-α, IL-1β, IL-6, IL-7, IL-21) inducing cartilage/bone breakdown, and T cells interacting with synovial fibroblasts to create pannus (granulation tissue).

Rheumatoid Arthritis (Continued)

• Symptoms often develop gradually, with notable systemic manifestations like inflammation, fever, fatigue, weakness, anorexia, weight loss, aching, and stiffness.
• Painful, tender, stiff joints and various rheumatoid nodules frequently accompany the disease.

Rheumatoid Arthritis (Continued)

• Diagnosis relies on autoantibodies (ACPA or RF).
• Early aggressive treatment with disease-modifying antirheumatic drugs is essential.
• Images illustrate key features of the disease.
• A key aspect is synovitis, which presents as inflammation of the synovial membrane.

Rheumatoid Arthritis (Continued)

• Images illustrate key features of the disease and its impact on the joints, including the effects of inflammation on the synovial membranes and the development of pannus.

Ankylosing Spondylitis

• A group of inflammatory arthropathies, also known as spondyloarthropathies, includes spinal inflammation/stiffening and sacroiliac joint disease.
• It's a systemic and autoimmune inflammatory condition centered on enthesis.
• Its final stage often entails fibrosis, ossification, and joint fusion.

Ankylosing Spondylitis (Continued)

• Etiology is unknown, though strong HLA-B27 antigen association exists.
• The inflammation initiates in and erodes the fibrocartilage within the vertebrae and sacroiliac joints.
• Ultimately, the inflammation scar tissue ossifies/calcifies, resulting in joint fusion.

Ankylosing Spondylitis (Continued)

• Early signs typically involve low back pain developing over time in the 20s, accompanied by pain, stiffness, restricted motion, loss of normal lumbar curvature, and increased spinal concavity.
• Imaging studies detect signs like sacroiliitis.

Ankylosing Spondylitis (Continued)

• Treatment often includes physiotherapy to maintain skeletal mobility and prevent contractures, along with NSAIDs for pain management.
• Images depict the structural changes that occur in chronic disease cases.

Gout

• A syndrome resulting from either overproduction or underexcretion of uric acid, manifesting as high uric acid levels in bodily fluids and crystallization.
• Gout symptoms typically appear when uric acid levels are high enough to crystallize.
• This triggers inflammation in connective tissues, particularly within the synovial fluid.

Gout (Continued)

• Risk factors include male sex, increasing age, high alcohol, red meat, and fructose intake, and certain medications.
• Gout often causes elevated serum urate, monoarticular attacks, and tophi depositions in and around the joints, leading to renal disease and renal stone formation.
• Treatment may be required.

Gout (Continued)

• The clinical course progresses through stages (asymptomatic hyperuricemia, acute gouty arthritis, and tophaceous gout).
• Common areas of initial and secondary gout attacks include the big toe, but other areas, such as the heel, ankle, instep of the foot, knee, wrist, and elbow, may also be involved.
• Trauma commonly exacerbates attacks and causes severe pain. Other symptoms include redness, heat, tenderness of joints, signs of systemic inflammation (increased sedimentation rate), and fever/leukocytosis.
• Images of affected areas and typical patterns of bone destruction associated with various connective tissue diseases are presented.

Gout (Continued)

• The metabolic pathways involved in uric acid synthesis, metabolism, and excretion are presented.

Secondary Muscular Dysfunction

• Contractures involve muscle fiber shortening without action potential, often due to calcium pump failure even with available ATP.
• Stress-related muscle tension is implicated in certain cases.
• Other contributors include neck stiffness, back pain, headaches, and chronic anxiety.

Secondary Muscular Dysfunction (Continued)

• Disuse atrophy involves reduced muscle cell size due to prolonged inactivity such as bed rest, trauma (e.g., casting), or nerve damage.
• Prevention strategies for disuse atrophy include isometric movements to maintain muscle strength and passive lengthening exercises for flexibility.

Fibromyalgia

• Symptoms include widespread, persistent diffuse pain (burning/gnawing in nature) commonly occurring for more than three months, increased sensitivity to touch, tenderness at multiple points (particularly neck/shoulders), and profound fatigue.
• Symptoms may be vague. A common exclusion criteria for diagnosis is inflammation.
• The condition often coexists with various other illnesses.

Fibromyalgia (Continued)

• Often affects women between 30 and 50 years of age; inflammation may play a role.
• Central sensitization, involving the amplification of pain transmission and interpretation, is implicated in the disorder.
• Underlying autoimmune disorders are common co-conditions, and genetic factors involving serotonin, catecholamines, and dopamine alterations are also suggested causes.
• The current diagnostic criteria help standardize diagnosis process.

Chronic Fatigue Syndrome

• This neuroimmunoendocrine disorder is characterized by cognitive impairment, debilitating post-exertional fatigue, non-refreshing sleep, reduced physical activity impeding daily functioning, and a diagnosis by exclusion.
• Psychological and physiological factors are implicated.

Muscle Membrane Abnormalities

• Myotonia involves inherited skeletal muscle sodium/calcium channel alterations causing delayed relaxation after voluntary contractions.
• Periodic paralysis results in episodic flaccid weakness, typically hereditary but also occurring as a thyrotoxic or hyperkalemic condition.

Metabolic Muscle Diseases

• Endocrine disorders causing hormonal imbalances often mask muscular symptoms.
• Energy metabolism disorders, like McArdle's disease (myophosphorylase deficiency), acid maltase deficiency (Pompe's disease), and myoadenylate deaminase deficiency (MDD), are potential causes of muscle diseases.
• Lipid deficiencies could also be contributing factors.

Inflammatory Muscle Diseases: Myositis

• Viral, bacterial, or parasitic infections of muscle (myositis), such as tuberculosis, sarcoidosis, trichinosis, toxoplasmosis, and Staph aureus infections, are examples of inflammatory myopathies.

Inflammatory Muscle Diseases: Myositis (Continued)

• Idiopathic inflammatory myopathies include polymyositis, dermatomyositis (which may involve skin changes), and inclusion body myositis.
• Proximal muscle weakness and myalgia are common symptoms.
• Malignancy risk is occasionally associated.
• Muscle biopsy may reveal inflammatory cells grouped around blood vessels and muscle fiber atrophy.
• Immunosuppressive drugs may be used as treatment.

Toxic Myopathies

• Alcohol abuse is a common cause of toxic myopathy.
• Muscle weakness, pain, and swelling are common symptoms.
• Severe cases involve necrosis, leading to rhabdomyolysis, myoglobinuria, and acute kidney failure.
• Lipid-lowering agents (fibrates and statins), antimalarial drugs, steroids, thiol derivatives, and narcotics are additional causes in certain cases.

Bone Tumors

• Bone tumors originate from various tissue types within bones including bone cells, cartilage, fibrous tissue, marrow, or vascular tissue.
• Key tumor types include osteogenic, chondrogenic, collagenic, and myelogenic tumors.

Bone Tumors (Continued)

• Malignant bone tumors have distinct features including an increased nuclear/cytoplasmic ratio, irregular borders, excess chromatin, and prominent nucleolus, with an elevated mitotic rate.
• Different types of bone tumors (osteosarcoma, chondrosarcoma, fibrosarcoma, and giant cell tumors) arise from specific cell lineages and have their specific distribution, growth patterns, and destruction patterns.

Bone Tumors (Continued)

• Tumor patterns such as geographical, moth-eaten, and permeative can be useful in imaging assessments and can also help discern benign from malignant bone tumors.
• Bone tumors can often be initially misdiagnosed owing to vague symptoms and require specialized radiographic and histological evaluation.
• Osteosarcoma is the most common malignant bone-forming tumor, often observed in adolescents/young adults or in older patients with existing radiation exposure.
• Chondrosarcoma appears more often in middle-aged and older adults, infiltrating trabeculae of spongy bone in the metaphyses/diaphysis of long bones, and often causes erosion of the cortex and can extend into neighboring soft tissues.
• Fibrosarcoma is characterized by a firm, fibrous collagen mass containing malignant fibroblasts and osteoclast-like giant cells, frequently appearing in the metaphyses of the femur or tibia, with lung metastasis being a common occurrence.
• Myelogenic (giant cell) tumors often cause extensive bone resorption due to osteoclastic origin/RANKL overexpression; they commonly appear as tumors in the epiphyses of the femur, tibia, radius, or humerus and are notable for their slow, unrelenting growth rate.

Muscle Tumors

• Rhabdomyosarcoma, a malignant striated muscle tumor, usually displays rapid metastasis, particularly impacting head, neck, and genitourinary tissues.
• It shows various sub-types like anaplastic, embryonal, and alveolar.