45 alterations musculoskeletal

MATCHING Match the phrases with the corresponding characteristics. ______ A. Caused by sedatives and narcotics, particularly street heroin ______ B. Caused by viruses, bacteria, and parasites ______ C. Exercise intolerance with normal production of lactic acid ______ D. Impairment of the breakdown of glycogen and production of lactic acid ______ E. Autoimmune disease 43. McArdle disease 44. Myoadenylate deaminase deficiency 45. Rhabdomyolysis 46. Polymyositis 47. Myositis

43. ANS: D PTS: 1 REF: Page 1582 MSC: The individual with McArdle disease is not able to break down glycogen or produce lactic acid. 44. ANS: C PTS: 1 REF: Page 1583 MSC: Myoadenylate deaminase deficiency is an enzyme deficiency that produces changes in skeletal muscle and is associated with exercise intolerance. 45. ANS: A PTS: 1 REF: Page 1548 | Box 44-1 MSC: Sedatives and narcotics, particularly street heroin, clofibrate (a hypolipidemic agent), and the antifibrinolytic aminocaproic acid often cause rhabdomyolysis and myoglobinuria. 46. ANS: E PTS: 1 REF: Page 1584 MSC: Inflammation of connective tissue and muscle fibers that presumably causes the destruction of muscle fibers characterize polymyositis and dermatomyositis. The agent that causes the muscle inflammation has not been identified, but recent findings strongly suggest an autoimmune connection. 47. ANS: B PTS: 1 REF: Page 1583 MSC: Viral, bacterial, and parasitic infections of varying severity are known to produce inflammatory changes in skeletal muscle, a group of conditions collectively described by the term myositis.

5. Which structure attaches skeletal muscle to bone? a. Tendon c. Bursa b. Ligament d. Mesentery

ANS: A A tendon is fibrous connective tissue that attaches skeletal muscle to bone. None of the other options are associated with this function. PTS: 1 REF: Page 1545

11. By the time osteoporosis is visible on an x-ray examination, up to what percent of bone has been lost? a. 30% c. 50% b. 40% d. 60%

ANS: A Generally, osteoporosis is radiographically detected as increased radiolucency of bone. By the time abnormalities are detected by x-ray examination, as much as 25% to 30% of bone tissue may have been lost. PTS: 1 REF: Page 1555

22. When considering osteomyelitis, sequestrum is identified as what? a. An area of devascularized and devitalized bone b. An enzyme that phagocytizes necrotic bone c. A subperiosteal abscess d. A layer of new bone surrounding the infected bone

ANS: A Lifting of the periosteum disrupts blood vessels that enter bone through the periosteum, which deprives the underlying bone of its blood supply. This deprivation leads to necrosis and death of the area of infected bone, producing sequestrum, an area of devitalized bone. None of the other available options accurately identify the term sequestrum. PTS: 1 REF: Page 1559

23. What pattern of bone destruction is described as not well-defined and not easily separated from normal bone? a. Moth-eaten c. Geographic b. Permeative d. Porous

ANS: A Moth-eaten pattern is the only option that involves destruction that is not well-defined and not easily separated from normal bone. PTS: 1 REF: Pages 1562-1563 | Table 44-5

30. Which medical diagnosis is described as a chronic inflammatory joint disease characterized by stiffening and fusion of the spine and sacroiliac joints? a. Ankylosing spondylitis c. Paget disease b. Rheumatoid arthritis d. Fibromyalgia

ANS: A Of the options available, only ankylosing spondylitis (spondyloarthritis) is described as a chronic, inflammatory joint disease characterized by stiffening and fusion (ankylosis) of the spine and sacroiliac joints. PTS: 1 REF: Page 1572

27. What is a primary defect in osteoarthritis? a. Stromelysin and acid metalloproteinase break down articular cartilage. b. Immunoglobulin G (IgG) destroys the synovial membrane. c. Synovial membranes become inflamed. d. Cartilage-coated osteophytes create bone spurs.

ANS: A Of the options available, the primary defect in osteoarthritis is the loss of articular cartilage. PTS: 1 REF: Pages 1565-1566

2. Which type of fracture usually occurs in an individual who engages in a new activity that is strenuous and repetitive? a. Stress c. Insufficiency b. Greenstick d. Pathologic

ANS: A Only a stress fracture occurs in normal or abnormal bone that is subjected to repeated stress, such as repetitive and strenuous activities that occur during athletics. PTS: 1 REF: Page 1541

7. Which medical diagnosis is characterized by tissue degeneration or irritation of the extensor carpi radialis brevis tendon? a. Lateral epicondylitis c. Bursitis b. Medial tendinitis d. Lateral tendinitis

ANS: A Only lateral epicondylopathy, commonly called tennis elbow, is the result of tissue degeneration or irritation of the extensor carpi radialis brevis tendon at its origin. PTS: 1 REF: Page 1546

15. Considering the pathophysiologic process of postmenopausal osteoporosis, which changes are believed to play a significant role in the development of age-related bone loss? a. Increased oxidative stress and increased intracellular reactive oxygen species b. Hypoparathyroidism c. Increased body weight d. Decreased formation and short life span of osteoclasts

ANS: A Postmenopausal osteoporosis occurs in middle-aged and older women. It can occur because of estrogen deficiency, as well as estrogen-independent, age-related mechanisms (e.g., secondary causes such as hyperparathyroidism and decreased mechanical stimulation). Recent studies indicate that increased oxidative stress (OS) and increased intracellular reactive oxygen species (ROS) play significant roles in the development of age-related bone loss, as well as other age-related changes in the body. Hormonal deficiency also can increase with stress, excessive exercise, and low body weight. Increased formation and longevity of osteoclasts results in increased bone resorption and is associated with a cascade of proinflammatory cytokines. PTS: 1 REF: Page 1552

33. People with gout are at high risk for which co-morbid condition? a. Renal calculi c. Anemia b. Joint trauma d. Hearing loss

ANS: A Renal stones are 1000 times more prevalent in individuals with primary gout than they are in the general population. This statement is not true of any of the other options. PTS: 1 REF: Page 1578

18. What is the most common clinical manifestation of osteoporosis? a. Bone deformity c. Pathologic fracture b. Bone pain d. Muscle strain

ANS: A The most common clinical manifestation of osteoporosis is bone deformity. PTS: 1 REF: Page 1555

35. The pathophysiologic presentation of gout is closely linked to the metabolism of which chemical? a. Purine c. Vitamin E b. Pyrimidine d. Amino acid

ANS: A The pathophysiologic presentation of gout is closely linked only to purine metabolism (or cellular metabolism of purines) and kidney function. PTS: 1 REF: Page 1575

40. What are the primary sources of bacterial infections that lead to hematogenous bone infection? (Select all that apply.) a. Sinus b. Ear c. Dental d. Cutaneous e. Throat

ANS: A, B, C, D Cutaneous, sinus, ear, and dental infections are all primary sources of bacteria in hematogenous bone infections. Throat infections are not generally associated with bone infections. PTS: 1 REF: Page 1559

41. Which structures are most often affected by Paget disease? (Select all that apply.) a. Vertebrae b. Skull c. Sternum d. Metacarpals e. Pelvis

ANS: A, B, C, E Paget disease most often affects the axial skeleton, especially the vertebrae, skull, sacrum, sternum, and pelvis. The metacarpals are not associated with the axial skeleton or Paget disease. PTS: 1 REF: Page 1558

32. In ankylosing spondylitis, the CD8+ T cells are presented with which antigen? a. Synovium c. Tendons b. Cartilage d. Ligaments

ANS: B Cartilage antigens are proposed as the targets for the immune response and the presentation of such antigens to CD8+ T cells. This statement is not true of any of the other options. PTS: 1 REF: Page 1573

3. Which term is used to identify the temporary displacement of two bones causing the bone surfaces to partially lose contact? a. Dislocation c. Malunion b. Subluxation d. Nonunion

ANS: B Dislocation is the temporary displacement of a bone from its normal position in a joint. If the contact between the two surfaces is only partially lost, then the injury is referred to as a subluxation. This selection is the only option that identifies the temporary displacement of two bones, causing the bone surfaces to partially lose contact. PTS: 1 REF: Page 1544

17. Considering the pathophysiologic process of osteoporosis, what are the effects of extracellular signal-regulated kinases (ERKs) and receptor activator of nuclear factor B ligand (RANKL) on osteoblasts and osteoclasts? a. ERKs increase the life span of osteoclasts, and RANKL decreases the life span of osteoblasts. b. ERKs and RANKL increase the life span of osteoclasts and decrease the life span of osteoblasts. c. ERKs and RANKL increase the life span of osteoblasts and decrease the life span of osteoclasts. d. ERKs increase the life span of osteoblasts, and RANKL decreases the life span of osteoclasts.

ANS: B In addition to ERKs, RANKL is required for the antiapoptotic effect and thus longer life span of osteoclasts. This effect also shortens the life span of the bone-forming cells, or osteoblasts. This process is not true of any of the other options. PTS: 1 REF: Page 1553

10. Which pathophysiologic alteration precedes crush syndrome after prolonged muscle compression? a. Muscle ischemia c. Volkmann contracture b. Myoglobinuria d. Neural injury

ANS: B Myoglobinuria is an excess of myoglobin (an intracellular muscle protein) in the urine. Muscle cell damage releases the myoglobin. The most severe form is often called crush syndrome. Less severe and more localized forms of muscle damage are called compartment syndromes. This selection is the only option that accurately identifies the pathophysiologic alteration that precedes crush syndrome. PTS: 1 REF: Pages 1547-1549

19. Which disorder is characterized by the formation of abnormal new bone at an accelerated rate beginning with excessive resorption of spongy bone? a. Osteomalacia c. Osteoporosis b. Paget disease d. Osteosarcoma

ANS: B Of the available options, only Paget disease (osteitis deformans) is a state of increased metabolic activity in bone characterized by abnormal and excessive bone remodeling, both resorption and formation. Chronic accelerated remodeling eventually enlarges and softens the affected bones. PTS: 1 REF: Pages 1557-1558

13. Which type of osteoporosis would a person develop after having the left leg in a cast for 8 weeks to treat a compound displaced fracture of the tibia and fibula? a. Iatrogenic c. Idiopathic b. Regional d. Osteoblastic

ANS: B Of the options available, only classic regional osteoporosis is associated with disuse or immobilization of a limb because of fractures, motor paralysis, or bone or joint inflammation. PTS: 1 REF: Page 1553

12. A bone density of 645 mg/cm2 would support which diagnosis? a. Osteoplasia c. Osteopenia b. Osteoporosis d. Osteomalacia

ANS: B The World Health Organization (WHO) has defined osteoporosis on the basis of bone density. Normal bone is greater than 833 mg/cm2; osteopenia, or decreased bone mass, is 833 to 648 mg/cm2; osteoporosis is less than 648 mg/cm2. This selection is the only accepted option. PTS: 1 REF: Page 1550

25. Which statement is false concerning giant cell tumors? a. Giant cell tumors are an overexpression of genes including osteoprotegerin ligand (OPGL). b. The tumors are malignant, solitary, and irregularly shaped. c. Giant cell tumors are typically located in the epiphysis in the femur, tibia, radius, and humerus. d. They are slow-growing tumors that extend over the articular cartilage.

ANS: B The giant cell tumor is generally a benign, solitary, circumscribed tumor that causes extensive bone resorption because of its osteoclastic origin. The other options are true statements concerning giant cell tumors. PTS: 1 REF: Pages 1564-1565

8. The pain resulting from tendon and ligament injuries is usually described as: a. Dull and diffuse, persisting over the distribution of the tendon or ligament b. Sharp and localized, persisting over the distribution of the tendon or ligament c. Pins-and-needle sensations that occur distal to the injury with movement d. Intermittent and aching, occurring over the distribution of the tendon or ligament

ANS: B The pain resulting from tendon and ligament injuries is usually described as being sharp and localized, persisting over the distribution of the tendon or ligament. This selection is the only option that accurately describes this type of pain. PTS: 1 REF: Page 1545

21. Bone death as a result of osteomyelitis is due to what? a. Formation of immune complexes at the site of infection b. Localized ischemia c. Tumor necrosis factor-alpha (TNF-) and interleukin 1 (IL-1) d. Impaired nerve innervation at the site of infection

ANS: B Vessel damage causes local thrombosis (blockage) of the small vessels, which leads to ischemic necrosis (death) of bone. This selection is the only option that is associated with bone death as a result of osteomyelitis. PTS: 1 REF: Page 1560

34. What causes the crystallization within the synovial fluid of the joint affected by gouty arthritis? a. Reduced excretion of purines b. Overproduction of uric acid c. Increase in the glycosaminoglycan levels d. Overproduction of proteoglycans

ANS: B When the uric acid reaches a certain concentration in fluids, it crystallizes, forming insoluble precipitates that are deposited in connective tissues throughout the body. Crystallization in synovial fluid causes acute, painful inflammation of the joint, a condition known as gouty arthritis. This selection is the only option that accurately identifies the cause of crystallization in synovial fluid associated with gouty arthritis. PTS: 1 REF: Pages 1574-1575

42. Which clinical manifestations are characteristic of rheumatoid arthritis? (Select all that apply.) a. Subcutaneous tissue crystals b. Anorexia c. Painful, stiffening of joints d. Edema of the wrists e. Fever

ANS: B, C, E Rheumatoid arthritis begins with general systemic manifestations of inflammation, including fever, fatigue, weakness, anorexia, weight loss, and generalized aching and stiffness. Local manifestations also gradually appear over weeks or months. Typically, the joints become painful, tender, and stiff. Neither tissue crystals nor edema is associated with rheumatoid arthritis. PTS: 1 REF: Page 1571

31. What is the primary pathologic alteration resulting from ankylosing spondylitis (AS)? a. Inflammation of the sacroiliac joint b. Inflammation of the long bones c. Inflammation of fibrocartilaginous joints of the vertebrae d. Inflammation of the small hand and feet bones

ANS: C AS involves inflammation of fibrocartilage in cartilaginous joints, primarily in the vertebrae. The other options do not accurately describe the primary pathologic alterations of AS. PTS: 1 REF: Pages 1573-1574

24. Which statement accurately describes a characteristic of osteosarcoma? a. Slow-growing tumor that begins in the bone marrow and infiltrates the trabeculae b. Solitary tumor that most often affects the metaphyseal region of the femur or tibia c. Aggressive tumor most often found in the bone marrow of long bones d. Tumor that infiltrates the trabeculae in spongy bone and implants in surrounding tissue by seeding

ANS: C An osteosarcoma is a malignant bone-forming tumor. It is aggressive and most often found in bone marrow; it has a moth-eaten pattern of bone destruction. This selection is the only option that accurately describes a characteristic of osteosarcoma. PTS: 1 REF: Page 1563

37. At what age is peak bone mass and strength reached in women? a. 15 years c. 30 years b. 20 years d. 35 years

ANS: C Bone formation continues at a pace faster than resorption until peak bone mass—or maximum bone density and strength—is reached at approximately 30 years of age, after which bone resorption slowly exceeds bone formation. PTS: 1 REF: Page 1550

1. What type of fracture occurs at a site of a preexisting bone abnormality and is a result of a force that would not normally cause a fracture? a. Idiopathic c. Pathologic b. Incomplete d. Greenstick

ANS: C Only a pathologic fracture is a break at the site of a preexisting abnormality, usually by force that would not fracture a normal bone. PTS: 1 REF: Page 1541

29. Which joint disease is characterized by joint stiffness on movement and joint pain of weight-bearing joints that is usually relieved by rest? a. Gouty arthritis c. Osteoarthritis b. Rheumatoid arthritis d. Suppurative arthritis

ANS: C Pain and stiffness in one or more joints, usually weight-bearing or load-bearing joints, are the first symptoms of osteoarthritis. Use-related joint pain relieved by rest is a key feature. This selection is the only option that accurately identifies the disease associated with the described symptoms. PTS: 1 REF: Page 1567

39. What term is used to identify the calcium crystals that are associated with chronic gout? a. Stones c. Tophi b. Spurs d. Nodes

ANS: C With time, crystal deposition in subcutaneous tissues causes the formation of small white nodules, or tophi, that are visible through the skin. Crystal aggregates deposited in the kidneys can form urate renal stones and lead to renal failure. None of the other options are associated with the calcium crystals resulting from chronic gout. PTS: 1 REF: Page 1575

20. Which statement is false about factors that contribute to the difficulty in treating bone infections? a. Bone contains multiple microscopic channels that are impermeable to the cells and biochemicals of the body's natural defenses. b. Microcirculation of bone is highly vulnerable to damage and destruction by bacterial toxins, leading to ischemic necrosis of bone. c. Bone cells have a limited capacity to replace bone destroyed by infections. d. Bacteria are walled off by macrophages and T lymphocytes; consequently, the antibiotics cannot penetrate the infected area.

ANS: D Bacteria are not walled off by macrophages and T lymphocytes, thus inhibiting the effects of antibiotics. The other options are true statements regarding factors that contribute to the difficulty in treating bone infections. PTS: 1 REF: Page 1560

38. What event is associated with the beginning of bone loss in women? a. Puberty c. Childbirth b. Sexual activity d. Menopause

ANS: D Bone loss in women is associated with menopause. Bone loss is most rapid in the first years after menopause but persists throughout the postmenopausal years. The other options are not relevant as triggers for bone loss. PTS: 1 REF: Page 1550

28. In osteoarthritis, what is the effect of the disruption of the pumping action of proteoglycans? a. Pump malfunction stimulates the induction of nitric oxide synthase and nitric oxide, which degrades the cartilage. b. Cartilage is damaged by proteolytic enzymes because they cannot be pumped out of the joint. c. Cartilage becomes dry, brittle, and wears away because fluid cannot be pumped into the cartilage. d. Cartilage takes in too much fluid and is unable to withstand the stresses of weight bearing.

ANS: D Changes in the conformation of proteoglycans disrupt the pumping action that regulates the movement of water and synovial fluid into and out of the cartilage. Without the regulatory action of the proteoglycan pump, cartilage imbibes too much fluid and becomes less able to withstand the stresses of weight bearing. This selection is the only option that accurately describes the disruption of the pumping action of proteoglycans when considering osteoarthritis. PTS: 1 REF: Page 1566

16. Considering the pathophysiologic process of osteoporosis, which hormone exerts antiapoptotic effects on osteoblasts but proapoptotic effects on osteoclasts? a. Parathyroid hormone c. Growth hormone b. Glucocorticoid d. Estrogen

ANS: D Data reveal that sex steroids (e.g., estrogens) exert antiapoptotic effects on osteoblasts but exert proapoptotic effects on osteoclasts; in both scenarios, activating the extracellular signal-regulated kinases (ERKs) accomplish these effects. This process is not true of any of the other options. PTS: 1 REF: Page 1553

4. Improper reduction or immobilization of a fractured femur can result in which outcome after cast removal? a. The muscles around the fracture site are weak. b. The fracture requires 6 to 8 weeks of physical therapy. c. The skin under the cast is dry and flaky. d. The bone is not straight.

ANS: D Improper reduction or immobilization of a fractured bone may result in nonunion, delayed union, or malunion. Malunion is the healing of a bone in a nonanatomic position that could result in the bone not being straight. The other options are not outcomes of improper reduction or immobilization. PTS: 1 REF: Page 1543

26. Which is a characteristic of inflammatory joint disease? a. Unilateral joint involvement b. Normal joint synovial fluid c. Absence of synovial membrane inflammation d. Systemic symptoms of inflammation

ANS: D Inflammatory joint disease is characterized by systemic signs of inflammation (fever, leukocytosis, malaise, anorexia, hyperfibrinogenemia) and inflammatory damage or destruction in the synovial membrane or articular cartilage. This selection is the only option that accurately describes a characteristic of inflammatory joint disease. PTS: 1 REF: Page 1568

6. The tear in a ligament is referred to as a: a. Fracture c. Disunion b. Strain d. Sprain

ANS: D Ligament tears are commonly known as sprains. None of the other options are associated with this damage. PTS: 1 REF: Page 1545

14. Considering the pathophysiologic process of osteoporosis, after being activated by receptor activator of nuclear factor B ligand (RANKL), receptor activator of nuclear factor B (RANK) activates which of the following? a. Osteoclast apoptosis c. Osteoprotegerin b. Osteoblast survival d. Osteoclast survival

ANS: D RANKL activates the receptor RANK, which is expressed on osteoclasts and their precursors and suppresses apoptosis, which leads to activation and the prolongation of osteoclast survival. This statement is not true of any of the other options. PTS: 1 REF: Page 1553

9. How is rhabdomyolysis characterized? a. Paralysis of skeletal muscles, resulting from an impaired nerve supply b. Smooth muscle degeneration, resulting from ischemia c. Lysis of skeletal muscle cells through the initiation of the complement cascade d. Release of myoglobin from damaged striated muscle cells

ANS: D Rhabdomyolysis involves the release of myoglobin when muscle cells are damaged. This selection is the only accurate description of rhabdomyolysis. PTS: 1 REF: Pages 1547-1550

36. Which clinical manifestations are associated with fibromyalgia? a. Hot, tender, and edematous muscle groups bilaterally b. Fasciculations of the upper and lower extremity muscles c. Exercise intolerance and painful muscle cramps d. Sensitivity at tender points and profound fatigue

ANS: D Widespread joint and muscle pain, fatigue, and tender points are characteristics of fibromyalgia, a chronic musculoskeletal syndrome. Increased sensitivity to touch (i.e., tender points), the absence of systemic or localized inflammation, and fatigue and sleep disturbances are common. Fatigue is profound. The remaining options include symptoms not generally associated with fibromyalgia. PTS: 1 REF: Pages 1579-1580