Alterations of Musculoskeletal Function PDF

7/24/24 List of disorders discussed 1. Bone fractures 2. Support structures disorders: strain, sprain, avulsion, tend...

7/24/24 List of disorders discussed 1. Bone fractures 2. Support structures disorders: strain, sprain, avulsion, tendon & ligament injuries, tendinopathy, epicondylopathy, bursitis, muscle strain, rhabdomylolysis, compartment syndrome 3. Bone disorders: osteoporosis, osteomalacia, Paget Alterations of Musculoskeletal disease of bone, osteomyelitis Joint disorders: osteoarthritis, rheumatoid arthritis, Function 4. ankylosing spondylitis, gout 5. Secondary muscular dysfunctions: contracture, stress-induced muscle tension 6. Fibromyalgia 7. Chronic fatigue syndrome 8. Bone tumors & muscle tumors 1 2 1  7/24/24 Fractures (1 of 5) Fractures (2 of 5) ˜ Break in the continuity of a bone ˜ Classifications Ø Complete or incomplete Ø Closed or open Ø Comminuted Ø Linear, oblique, spiral, or transverse Ø Greenstick, torus, or bowing Ø Pathologic, stress, fatigue, or transchondral Redrawn from Thompson JM et al, editors: Mosby’s clinical nursing, ed 7, St Louis, 2002, Mosby. 3 4 2  7/24/24 Fractures (3 of 5) ˜ Healing Ø Direct (primary) Most often occurs when surgical fixation is used to repair a broken bone Intramembranous bone formation No callus formation Ø Indirect (secondary) Most often observed when a fracture is treated with a cast or other nonsurgical method Intramembranous and endochondral bone formation Callus formation Remodeling of solid bone 5 6 3  7/24/24 Fractures (4 of 5) From Monahan FD et al: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8, St Louis, 2007, Mosby. 7 8 4  7/24/24 Fractures (5 of 5) Assessment ˜ Manifestations ˜ Pain – intensity, description, frequency, Ø Unnatural alignment, swelling, muscle spasm, location tenderness, pain, impaired sensation, and ˜ Pulses – description, rate, rhythm, intensity decreased mobility Ø Often transient numbness due to nerve trauma ˜ Paresthesia – numbness, tingling, tickling ˜ Treatment ˜ Paralysis – feeling to touch; to pain, lack of Ø Immobilization feeling Ø Closed manipulation, traction, and open reduction ˜ Pallor – capillary refill, color of extremities, Ø Internal and external fixation temperature Ø Improper reduction or immobilization Nonunion, delayed union, and malunion 9 10 5  7/24/24 Dislocation and Subluxation ˜ Dislocation Ø Displacement of one or more bones in a joint Ø Loss of contact between articular cartilage ˜ Subluxation Ø Contact between articular surfaces is only partially lost ˜ Associated with fractures, muscle imbalance, rheumatoid arthritis, or other forms of joint instability 11 12 6  7/24/24 Question 1 1. Which term is characteristic for a fracture in which one cortex is perforated and the spongy bone is splintered? A. Torus B. Spiral C. Bowing D. Greenstick Note: No input needed to proceed 13 14 7  7/24/24 Question 1 Answer Support Structures (1 of 10) Correct Answer: D ˜ Strain Ø Tearing or stretching to a tendon or muscle A greenstick fracture is one that perforates one cortex ˜ Sprain and splinters the spongy bone. In a torus fracture, the Ø Tear or injury to a ligament cortex buckles but does not break. Bowing fractures usually occur with longitudinal force; typically, this ˜ Avulsion occurs in paired bones. One is fractured and the other Ø Complete separation of a tendon or ligament from bows. A spiral fracture is one that encircles the bone. its bony attachment site 15 16 8  7/24/24 Support Structures (2 of 10) Support Structures (3 of 10) ˜ Tendon and ligament injuries ˜ Tendinopathy Ø Can take more than 3 months to achieve Ø Inflammation of a tendon mechanical stability of a joint ˜ Epicondylopathy Ø Painful and are usually accompanied by soft Ø Inflammation of a tendon where it attaches to a tissue swelling, changes in tendon or ligament bone contour, and dislocation or subluxation of bones Tennis elbow (lateral epicondylopathy) Ø Rehabilitation is crucial to regaining good Golfer’s elbow (medial epicondylopathy) functional outcome 17 18 9  7/24/24 Support Structures (4 of 10) ˜ Bursitis Ø Inflammation of a bursa Skin over bone, skin over muscle, and muscle and tendon over bone Ø Inflammation caused by overuse or excessive pressure 19 20 10  7/24/24 Support Structures (5 of 10) Support Structures (6 of 10) ˜ Muscle strain Ø Sudden, forced motion causing the muscle to become stretched beyond its normal capacity Ø Can also involve the tendons Ø Healing in three phases Destruction Repair Remodeling From Hochberg MC et al: Rheumatology, ed 6 Philadelphia, 2015, Elsevier. 21 22 11  7/24/24 Support Structures (7 of 10) ˜ Rhabdomyolysis Ø Rapid breakdown of muscle that causes the release of intracellular contents, including the protein pigment myoglobin, into the extracellular space and bloodstream Ø Can result in acute renal failure and electrolyte imbalances Ø Triad of manifestations Muscle pain Weakness Dark urine 23 24 12  7/24/24 Support Structures (8 of 10) Support Structures (9 of 10) ˜ Rhabdomyolysis ˜ Compartment syndrome Ø Diagnosed when CK level five to ten times upper Ø Result of increased pressure within a muscle limit of normal (about 1000 units/L) compartment Ø Renal failure likely when CK reaches 15,000 Ø Can be caused by any condition that disrupts the units/L vascular supply to an extremity Ø Preventing kidney failure and maintaining Ø Muscle ischemia causes edema, rising adequate urinary output are goals of treatment compartment pressure, and tamponade that lead to muscle infarction and neural injury 25 26 13  7/24/24 Support Structures (10 of 10) ˜ Compartment syndrome Ø “6 Ps” of compartment syndrome Ø Volkmann ischemic contracture Ø Diagnosis confirmed by measurement of intracompartmental pressure Surgical intervention indicated when pressure reaches 30 mm Hg 27 28 14  7/24/24 Disorders of Bones ˜ Metabolic bone diseases Ø Osteoporosis Ø Osteomalacia Ø Paget disease of bone ˜ Infectious bone diseases Ø Osteomyelitis 29 30 15  7/24/24 31 32 16  7/24/24 Osteoporosis (1 of 11) Osteoporosis (2 of 11) ˜ Poorly mineralized bone and increased risk of fractures due to alterations in bone microarchitecture ˜ Old bone resorbed faster than new bone made Ø Loss of bone mass Ø Spontaneous fractures From Kumar V et al: Robbins & Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders. 33 34 17  7/24/24 Osteoporosis (3 of 11) Osteoporosis (4 of 11) ˜ Potential causes ˜ Postmenopausal osteoporosis Ø Endocrine dysfunction Ø Middle-aged and older women Parathyroid hormone, cortisol, thyroid hormone, and Ø Estrogen deficiency and secondary causes growth hormone Ø Remodeling imbalance between the activity of Ø Medications osteoclasts and osteoblasts Ø Vitamin D deficiency Ø Underlying diseases Ø Low physical activity Ø Abnormal BMI ˜ Fractures are the major complication 35 36 18  7/24/24 Osteoporosis (5 of 11) Osteoporosis (6 of 11) ˜ Secondary osteoporosis ˜ Glucocorticoid-induced osteoporosis Ø Caused by other conditions Ø Type of secondary osteoporosis Hormonal imbalances Ø Glucocorticoids improve osteoclast survival, which Medications inhibits osteoblast formation and function Disease ˜ Age-related bone loss ˜ Regional osteoporosis Ø Cause unclear Ø Confined to a segment of the appendicular Ø Reduced physical activity is likely a factor skeleton Ø Men have 30% greater bone mass than women Ø Associated with disuse Men have later involvement with osteoporosis Ø May be transient 37 38 19  7/24/24 Osteoporosis (7 of 11) Osteoporosis (8 of 11) 39 40 20  7/24/24 Osteoporosis (9 of 11) Osteoporosis (10 of 11) ˜ Manifestations Ø Pain and bone deformity because of fracture Ø Lower back pain Ø Kyphosis Hunchback caused by vertebral collapse From Kamal A, Brocklehurst JC: Color atlas of geriatric medicine, ed 2, St Louis, 1992, Mosby. 41 42 21  7/24/24 Osteoporosis (11 of 11) Osteomalacia ˜ Dual x-ray absorptiometry (DXA) ˜ Inadequate or delayed mineralization of Ø Gold standard for detecting and monitoring osteoid osteoporosis ˜ Remodeling cycle proceeds through osteoid ˜ Trabecular bone score (TBS) formation but calcification does not occur; the Ø Evaluates pixel variations in the gray-level areas result is soft bones of lumbar spine images from DXA scans Ø Pain, bone fractures, vertebral collapse, bone Ø Enhanced predictions of fracture risk malformation ˜ Results from vitamin D deficiency ˜ Treatment varies by etiology 43 44 22  7/24/24 Paget Disease of Bone ˜ Also called osteitis deformans ˜ Chronic accelerated remodeling of spongy bone and deposition of disorganized bone Ø Enlarges and softens affected bones Ø Mostly affects vertebrae, skull, sacrum, sternum, pelvis, and femur ˜ Often symptomless ˜ Genetic and environmental factors ˜ Evaluation based on radiographic findings 45 46 23  7/24/24 Osteomyelitis (1 of 4) ˜ Bone infection often caused by bacteria, usually Staphylococcus aureus Ø Fungi, parasites, and viruses can cause infection ˜ Hematogenous Ø Pathogens carried through the bloodstream Cutaneous, sinus, ear, and dental infections Ø Insidious onset Ø Vague symptoms Fever, malaise, anorexia, weight loss, and pain 47 48 24  7/24/24 Osteomyelitis (2 of 4) Osteomyelitis (3 of 4) ˜ Contiguous ˜ Brodie abscesses Ø Infection spreads to an adjacent bone Ø Characterize subacute or chronic osteomyelitis Open fractures, penetrating wounds, surgical procedures Ø Circumscribed lesions, usually in the ends of long Ø Manifested by signs and symptoms of soft tissue bones infection ˜ Treatment Low-grade fever, lymphadenopathy, local pain, and swelling Ø Antibiotics, débridement, surgery, hyperbaric oxygen therapy 49 50 25  7/24/24 Osteomyelitis (4 of 4) 51 52 26  7/24/24 Disorders of Joints Osteoarthritis (1 of 6) Ø Osteoarthritis Characterized by Ø Rheumatoid arthritis Ø Ankylosing spondylitis Loss and damage of articular cartilage Ø Gout Inflammation New bone formation of joint margins Subchondral bone changes Variable degrees of mild synovitis Thickening of the joint capsule Prevalence increases with age 53 54 27  7/24/24 Osteoarthritis (2 of 6) ˜ Risk factors Ø Increased age Ø Joint trauma, long-term mechanical stress Ø Obesity 55 56 28  7/24/24 Osteoarthritis (3 of 6) ˜ Characteristics Ø Local areas of damage and loss of articular cartilage Ø New bone formation of joint margins Ø Subchondral bone changes Ø Variable degrees of mild synovitis and thickening of the joint capsule 57 58 29  7/24/24 Osteoarthritis (4 of 6) ˜ Manifestations Ø Pain (worsens with activity) Ø Stiffness (diminishes with activity) Ø Enlargement of the joint Heberden and Bouchard nodes in hands Ø Tenderness Ø Limited motion Ø Muscle wasting Ø Partial dislocation Ø Deformity 59 60 30  7/24/24 Osteoarthritis (5 of 6) 61 62 31  7/24/24 Osteoarthritis (6 of 6) Classic Inflammatory Joint Disease ˜ Inflammatory damage or destruction in the Exercise and weight loss synovial membrane or articular cartilage Conservative Pharmacologic therapies treatment Analgesics and anti-inflammatories ˜ Systemic signs of inflammation Nutritional supplements ˜ Infectious or noninfectious Used to improve joint movement, Surgical correct deformity or malalignment, or treatment create a new joint with artificial implants 63 64 32  7/24/24 Rheumatoid Arthritis (1 of 6) ˜ Inflammatory autoimmune joint disease ˜ Systemic autoimmune damage to connective tissue, primarily in the joints (synovial membrane) ˜ Similar symptoms to osteoarthritis ˜ Cause unknown; multifactorial with strong genetic predisposition Ø Rheumatoid factors (RFs) 65 66 33  7/24/24 Rheumatoid Arthritis (3 of 6) Rheumatoid Arthritis (2 of 6) ˜ Cartilage damage from three processes Ø Neutrophils and other cells in the synovial fluid become activated Ø Inflammatory cytokines induce enzymatic breakdown of cartilage and bone Ø T cells also interact with synovial fibroblasts, converting synovium into a thick, abnormal layer of granulation tissue (pannus) 67 68 34  7/24/24 Rheumatoid Arthritis (4 of 6) Rheumatoid Arthritis (5 of 6) ˜ Insidious onset ˜ Systemic manifestations Ø Inflammation, fever, fatigue, weakness, anorexia, weight loss, and generalized aching and stiffness ˜ Painful, tender, stiff joints ˜ Joint deformities ˜ Rheumatoid nodules Ø Caplan syndrome (rheumatoid pneumoconiosis) – swelling and scarring of the lungs. It occurs in people with RA who have breathed in dust, such as from coal or silica. 69 70 35  7/24/24 Rheumatoid Arthritis (6 of 6) Ankylosing Spondylitis (1 of 5) ˜ Diagnosed by presence of autoantibodies ˜ Group of inflammatory arthropathies known (ACPA or RF) as spondyloarthropathies (SpA) ˜ Early treatment with disease-modifying ˜ Inflammatory joint disease of the spine or antirheumatic drugs sacroiliac joints causing stiffening and fusion of the joints ˜ Systemic, autoimmune inflammatory disease ˜ Primary pathologic site is the enthesis ˜ End result is fibrosis, ossification, and joint fusion 71 72 36  7/24/24 Ankylosing Spondylitis (2 of 5) Ankylosing Spondylitis (3 of 5) ˜ Cause unknown, but there is a strong ˜ Manifestations association with HLA-B27 antigen Ø Early symptoms ˜ Begins with the inflammation of fibrocartilage Low back pain that begins in early 20s and progresses over time Ø Particularly in the vertebrae and sacroiliac joint Stiffness ˜ Inflammatory cells infiltrate and erode Pain fibrocartilage Restricted motion ˜ As repair begins, the scar tissue ossifies and Ø Loss of normal lumbar curvature (lordosis) Ø Increased concavity of upper spine (kyphosis) calcifies; the joint eventually fuses ˜ Syndesmophyte 73 74 37  7/24/24 Ankylosing Spondylitis (4 of 5) Ankylosing Spondylitis (5 of 5) ˜ Sacroiliitis present on imaging ˜ Physical therapy to maintain skeletal mobility and prevent the natural progression of contractures ˜ NSAIDs for pain Redrawn from Mourad LA: Orthopedic disorders, St Louis, 1991, Mosby. 75 76 38  7/24/24 Gout (1 of 7) ˜ Inflammatory response to excessive quantities of uric acid Ø Blood (hyperuricemia) Ø Other body fluids, including synovial fluid ˜ Elevated levels lead to formation of monosodium urate crystals in joints Ø Cause acute, painful inflammation Ø Joint damage: gouty arthritis ˜ Crystals under subcutaneous tissues Ø Tophi 77 78 39  7/24/24 Gout (2 of 7) Gout (3 of 7) ˜ Risk factors ˜ Manifestations Ø Male sex Ø An increase in serum urate concentration Ø Increasing age (hyperuricemia) Ø High intake of alcohol, red meat, and fructose Ø Recurrent attacks of monoarticular arthritis (inflammation of a single joint) Ø Deposits of monosodium urate monohydrate (tophi) in and around the joints Ø Renal disease involving glomerular, tubular, and interstitial tissues and blood vessels Ø Formation of renal stones 79 80 40  7/24/24 Gout (4 of 7) Gout (5 of 7) ˜ Clinical stages ˜ Trauma is most common aggravating factor Ø Asymptomatic hyperuricemia ˜ Primary symptom is severe pain Ø Acute gouty arthritis ˜ Approximately 50% of the initial attacks occur Ø Tophaceous gout in the metatarsophalangeal joint of the great toe Ø Other areas include the heel, ankle, instep of the foot, knee, wrist, or elbow ˜ 1000 times more likely to develop renal stones than general population 81 82 41  7/24/24 Gout (6 of 7) Gout (7 of 7) ˜ Manifestations of acute gouty attack Ø Severe pain, especially at night Ø Hot, red, tender joint Ø Signs of systemic inflammation Increased sedimentation rate Fever Leukocytosis ˜ Tophaceous deposits can cause limitation of joint movement and grotesque deformities From Dieppe PA et al: Arthritis and rheumatism in practice, London, 1991, Gower. 83 84 42  7/24/24 Secondary Muscular Dysfunction (1 of 2) ˜ Contractures Ø Lack of full passive range of motion of a joint because of muscle/soft tissue limitations Ø Physiologic Muscle fiber shortening without an action potential Caused by failure of the calcium pump, even with available ATP Ø Pathologic Permanent muscle shortening caused by muscle spasm or weakness 85 86 43  7/24/24 Secondary Muscular Dysfunction (2 of 2) ˜ Stress-induced muscle tension Ø Neck stiffness, back pain, and headache Ø Associated with chronic anxiety Ø Abnormalities in CNS, reticular activating system, and autonomic nervous system 87 88 44  7/24/24 Fibromyalgia (1 of 4) Fibromyalgia (2 of 4) ˜ Chronic widespread diffuse joint and muscle ˜ 80% to 90% of individuals affected are pain, fatigue, and tender points women, and the peak age is 30 to 50 years ˜ Common symptoms ˜ Inflammation may play a role Ø Increased sensitivity to touch ˜ Studies of genetic factors have implicated Ø Absence of inflammation alterations in genes affecting serotonin, Ø Fatigue and nonrestorative sleep catecholamines, and dopamine Ø Anxiety and depression 89 90 45  7/24/24 Fibromyalgia (3 of 4) Fibromyalgia (4 of 4) ˜ Manifestations Ø Prominent symptom of fibromyalgia is diffuse, chronic pain Ø Profound fatigue ˜ Diagnosis Ø Axial pain, left- and right-sided pain, and upper and lower segment pain; and a symptom severity (SS) score SS score includes symptoms such as fatigue, waking unrefreshed, and cognitive difficulty 91 92 46  7/24/24 93 94 47  7/24/24 Chronic Fatigue Syndrome (1 of 2) Chronic Fatigue Syndrome (2 of 2) ˜ Also called myalgic encephalomyelitis ˜ Disuse atrophy ˜ Characterized by Ø Reduction in the normal size of muscle fibers as a Ø Profound fatigue result of prolonged inactivity Bed rest Ø Musculoskeletal pain Trauma (casting) Ø Cognitive impairment Local nerve damage Ø Unrefreshing sleep Ø Prevention Ø Impaired neurologic energy production Isometric movements Ø Immune impairments Passive lengthening exercises ˜ Related to hypersensitivity of CNS Ø Central sensitization 95 96 48  7/24/24 Question 2 Question 2 Answer 2. Which disease is characterized by an increase in Correct Answer: A uric acid levels? Gout is a syndrome caused by incomplete purine A. Gout metabolism, resulting in excess uric acid levels. B. Fibromyalgia Fibromyalgia (FM) is a chronic musculoskeletal syndrome characterized by diffuse pain, fatigue, and C. Osteomalacia tender points. Osteomalacia is a metabolic disease D. McArdle disease characterized by inadequate and delayed mineralization of osteoid in mature compact and spongy bone. Note: No input needed to proceed McArdle disease is characterized by the inability to break down glycogen or produce lactic acid. 97 98 49  7/24/24 Bone Tumors (1 of 8) Bone Tumors (2 of 8) ˜ May originate from bone cells, cartilage, ˜ Criteria to identify malignant bone tumors fibrous tissue, marrow, or vascular tissue Ø Increased nuclear/cytoplasmic ratio ˜ Classifications based on tissue of origin: Ø Irregular borders Ø Osteogenic Ø Excess chromatin Ø Chondrogenic Ø A prominent nucleolus Ø Collagenic Ø An increase in the mitotic rate Ø Myelogenic 99 100 50  7/24/24 Bone Tumors (3 of 8) Bone Tumors (4 of 8) ˜ Patterns of bone destruction Ø Geographic pattern Ø Moth-eaten pattern Ø Permeative pattern ˜ Symptoms vague Ø May be attributed to trauma, degenerative changes, or inflammation 101 102 51  7/24/24 Bone Tumors (5 of 8) Bone Tumors (6 of 8) ˜ Osteogenic tumors: osteosarcoma ˜ Chondrogenic tumors: chondrosarcoma Ø Most common malignant bone-forming tumor Ø Cartilage-forming tumor Ø Predominantly in persons under 20 years Ø Tumor of middle-aged and older adults Ø Secondary peak in 60 and older if they have a Ø Infiltrates trabeculae in spongy bone; frequent in history of radiation therapy the metaphyses or diaphysis of long bones Ø Tumors contain osteoid produced by anaplastic Ø Typically implant in surrounding tissue stromal cells Deposited as thick masses or “streamers” Ø Located in the metaphyses of long bones 50% occur around the knees 103 104 52  7/24/24 Bone Tumors (7 of 8) Bone Tumors (8 of 8) ˜ Collagenic tumors: fibrosarcoma ˜ Myelogenic tumors Ø Firm, fibrous mass of collagen, malignant Ø Originate from various bone marrow cells fibroblasts, and osteoclast-like giant cells Ø Giant cell tumor Ø Usually affects metaphyses of the femur or tibia Causes extensive bone resorption because of the Ø Metastasis to the lungs is common osteoclastic origin Located in the epiphyses of the femur, tibia, radius, or humerus Slow, relentless growth rate 105 106 53  7/24/24 Muscle Tumors (1 of 2) Muscle Tumors (2 of 2) ˜ Rhabdomyoma ˜ Rhabdomyosarcoma Ø Extremely rare benign tumor of striated muscle Ø Malignant tumor of striated muscle Ø Occurs in tongue, neck muscles, larynx, uvula, Ø Highly malignant with rapid metastasis nasal cavity, axilla, vulva, and heart Ø Usually muscles of the head, neck, and genitourinary tract Ø Types Anaplastic Embryonal Alveolar 107 108 54