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Musculoskeletal Diseases and Disorders
Chapter 15
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Musculoskeletal System Bones
Long, short, flat, irregular Compact, spongy
Joints Bursae Muscles Tendons Ligaments
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Musculoskeletal System
Two divisions:Axial skeletonAppendicular skeleton (inc. pelvic girdle)
Muscle types:Skeletal muscle (voluntary, striated)Smooth muscle (involuntary, non-striated)Cardiac muscle (involuntary, striated)
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Disorders of Bone
Spinal deformities Herniated intervertebral discs Osteoporosis Osteomyelitis Paget’s Disease (osteitis deformans) Fractures
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Spinal Deformities
LordosisAbnormal “inward” or anterior curvatureAccentuation of normal curve of lumbar spineFrequently gradual onsetAffects lumbar spineAlso called “swayback”
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Spinal Deformities
KyphosisAbnormal “outward” curvature of the spineAccentuation of normal thoracic spine curvatureAlso called “humpback” or “roundback”Commonly due to pathological fractures of spine in
osteoporosis
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Spinal Deformities
ScoliosisLateral (sideways) curvature of the spineMay go to left or rightMay involve some rotation of spinal columnMay be caused by discrepancy in leg lengthsSurgery possible if interferes with breathing or mobility
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Spinal Deformities
EtiologiesPosture, leg length differences, congenital, epiphyseal
growth disturbance, trauma, tumors, infection, arthritis, TB, endocrine abn, aging
S/S: usually backache, fatigue, abnormal appearance or fitting of clothes
Treatment: PT, exercise, braces, surgery, pain relief
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Herniated Intervertebral Discs Disc Anatomy
Annulus fibrosisNucleus pulposis
HerniationNucleus pulposis pushes through annulus into spinal
canal Rupture
Pieces of the disc are free in the spinal canal
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Herniated Disc
S/S: Back painParesthesiasSciatica: inflammation of sciatic nerve, leg pain
Treatment:PT, exercise, pain relief meds, surgery (rarely), life
correctly
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Osteoporosis
Metabolic disorder of bonesLess bone mineral (calcium) than normal
Over 10 million in US affectedPost-menopausal females most commonly
Bones are brittle, porous, easily brokenMore prone to pathological fracture
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Osteoporosis
Etiology:Genetics, calcium intake & dietary, sedentary lifestyle,
estrogen, vit D, or adrenal deficiency, steroid use, alcoholism, etc
S/S: often asymptomatic until pathological fx. Treatment: calcium supplements, meds
(antiresorptive, restorative of lost bone, etc)
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Osteomyelitis Acute or chronic bone infection Inflammation, edema, circulatory problems More common in children Etiology:
Trauma most commonly with bacterial invasion from the skin
Infection may also spread from adjacent tissues or blood supply
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Osteomyelitis
Risk factors:Diabetes, orthopedic hardware, splenectomy & SSA,
hemodialysis, IV drug users S/S: may be asymptomatic for years Treatment:
Long-term antibiotics, sometimes surgical debridement
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Paget’s Disease
Osteitis Deformans Chronic metabolic bone disease
High rate of bone turnover (reabsorption & deposition) Thicker but softer bone is the result Patients typically over 40 YOA One or many bones
Usually lower torse involve
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Paget’s Disease
Etiology: Unknown S/S: graduation onset of swelling & pain Treatment:
PT, pain management, surgeryMedications (biphosphonates or calcitonin) Joint replacements
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Fractures Closed/simple Open/compound Greenstick Displaced Comminuted Segmental Spiral Pathological
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Fractures
Etiology: trauma or disease S/S: usually pain and swelling Treatment:
Rest, decreased useSplint, sling, castSurgery (ORIF, etc)
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Joint Diseases
Osteoarthritis Rheumatoid Arthritis Gout (gouty arthritis)
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Osteoarthritis
Most common form of arthritis Chronic inflammation causing degeneration and
new bone formation Weight-bearing joints most common
Knees, hips Common in older patients (over 55 YOA)
In over 70 YOA, females more frequently affected
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Osteoarthritis Etiology:
Mechanical, chemical, genetic, autoimmune, metabolic Aging seems to be important
S/S: May be asymptomatic indefinitely Pain, swelling, sometimes erythema, limitation of motion
Treatment: Anti-inflammatories, PT, exercise, surgical
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Rheumatoid Arthritis
Chronic, systemic, polyarticular inflammatioy diseaseDestruction (erosion) of bone & cartilageCauses ankylosis (fibrous fusion of joints, immobile)
Exacerbations and remissions unpredictable Affects mostly females
Increasing risk with advancing age
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Rheumatoid Arthritis (RA) Etiology: autoimmune, genetics S/S: symmetric pain, swelling of hands & fingers,
also other LE joints, systemic (fever, fatigue, wt. Loss)
Dx testing: Rheumatoid factor blood test Treatment:
Antiinflammatories, PT, antimetabolites, antirheumatic drugs
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Gout Gouty arthritis Chronic uric acid metabolism disorder
Uric acid crystals deposited in joints Tophi formation (urate compounds) around joints
Acute, severe episodes of arthritis Mostly male patients Other associated problems:
Kidney stones, renal failure, hyperuricemia
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Gout Etiology:
Metabolic, renal, some genetics S/S:
Severe signs & symptoms of inflammationBig toe is classical site
Treatment:Pain relief, antiinflammatories, colchicine, diet low in
purines, alopurinol
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Muscles & Connective Tissue Diseases
Sprains & strains Bursitis & tendonitis Carpal Tunnel Syndrome Myasthenia Gravis (MG) Polymyositis Systemic Lupus Erythematosus (SLE) Duchenne’s Muscular Dystrophy
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Sprains & Strains
SprainLigamentous tearing/stretching after a tortion injury
StrainTearing/stretching of tendon or muscle
Etiology: trauma or overuse S/S: localized pain, swelling, limitation of motion Treatment: supportive, pain relief
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Bursitis & Tendonitis Bursitis
Inflammation of fluid-filled bursae near joints Shoulder, hip, elbow, knee
Tendonitis Inflammation of tendon or tendon-muscle attachementShoulder, wrist, Achilles, hamstring
Etiology: trauma, excessive use, other diseases S/S: pain, swelling, LOM, fluid accumulation
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Bursitis & Tendonitis
TreatmentVaries with anatomic location & degree of disabilityAnti-inflammatories & pain relievers, splinting,
exercise, orthotics, steroid injections, PT
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Carpal Tunnel Syndrome
Compression of median nerve within the carpal tunnel of the wrist
Common syndrome with repetitive use work Involves pain, sensory & motor symptoms Etiology: edema within the carpal tunnel, causing
inflammation of the nerve & other structures there
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Carpal Tunnel Syndrome
S/S:Wrist pain, burning or tingling paresthesias, numbnessWeakness of hand graspTinel’s sign
Treatment:Wrist immobilization, anti-inflammatoriesRarely surgery
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Myasthenia Gravis
Rare, autoimmune disorder of the neuromuscular junction
Antibodies against the acetylcholine receptors (post-synaptic)
Chronic, progressive disease causing sporadic weakness of the skeletal muscles
Most common in females, ages 20-40 YOA
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Myasthenia Gravis (MG)
Reduced muscle strength & longer recovery time with repeated useSymptoms late in the dayBulbar (eye & facial) muscles involved firstFacial expression, drooping lids, etc.
Thymomas in 15% MG patients75% have some thymic abnormality (hyperplasia)
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MG Diagnostic testing:
Tensilon test (edrophonium challenge will increase muscle strength)
Treatment: Oral anticholinergic meds (pyridostigmine,
neostigmine), immune suppressives, cholinesterase inhibitors like edrophonium
Prognosis: normal life expectancy in modern times
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Polymyositis
Chronic, idiopathic inflammatory disease of connective tissues and muscles
Exacerbations & remissions May have skin involvement (dermatomyositis) females more than males Bimodal peak of onset: 5-15 YOA & 50-70YOA
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Polymyositis S/S: sudden or slow weakness of muscle group over
weeks to months Often have trouble arising from sitting or raising arms above
head, also voice changes Fever, fatigue, weight loss Skin: lilac-colored rash of eyelids, nose and face
Dx via EMG & muscle biopsy Treatment: immune suppressive
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Systemic Lupus Erythematosus
Lupus or SLE Multisystem, autoimmune, inflammatory disease
due to antibodies against cell nuclei Females outnumber male patients ( 9 to 1) Genetics may also be involved Arthralgias are first complaint in most patients
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SLE
Organ involvement:Skin, renal, CNS, GI, blood, musculoskeletal, CV,
pulmonary, vascular endothelium (Raynaud’s) Four criteria at any time:
Malar rash or discoid rash, photosensitivity, arthritis, renal disease, neuro, skin, hematologic, or immune disorders, +ANA blood test
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SLE
Treatment:Anti-inflammatories, pain relief, immune suppressives
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Duchenne’s Muscular Dystrophy Inherited, x-linked, recessive disorder
Seen only in malesOccasionally no family history
Rapidly progressive wasting of skeletal musclesFirst in lower extremity & pelvis, then generalizes
Usually appears by 6 YOA Cause of death: respiratory insufficiency usually
by 25 YOA
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Duchenne’s Muscular Dystrophy
At first muscles appear largerDue to fat and CT infiltration
Then atrophy (wasting, decrease in size) Then scarring & contractures Cardiomyopathy present in almost all cases
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Neoplasms
Osteogenic sarcoma Chondrosarcoma Malignant giant-cell tumor
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Osteogenic Sarcoma
Most common bone cancer 3rd most common cancer in adolescence Slightly more males Risk factors: radiation therapy, genetics Treatment: surgical, but mets later in 80% Most in long bones
Femur, tibia, humerus (in that order)
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Chondrosarcoma
2nd most frequent primary bone cancer (25%) Malignant tumor of cartilage Mostly over 40 YOA (mostly geriatric) Affects pelvis, femur, humerus, ribs
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Giant Cell Tumor
Multinucleated cells 5-10% of all giant cell tumors are malignant Recurs locally about 50% of the time Only 4-5% of all bone tumors Mostly long bones Mostly 20-40YOA Relatively good Px after tumor excision