Musculoskeletal Disorders

systemic lupus erythematosus (SLE) manifestations

Clinical Manifestations: can affect nearly any body system -Skin manifestations -Renal involvement -Pulmonary -Cardiac -Neurologic

Rheumatoid arthritis manifestations

Clinical presentation includes: symmetrical, swollen joints (mostly affecting fingers, wrists, knees, hips, and feet), stiff joints are usually worse in the morning and after long periods of rest; ulnar deviation of fingers, and swan neck deformity. Additional manifestations include systemic symptoms such as fatigue, anorexia, weight loss, weakness, and low grade fever.

Scoliosis

Scoliosis (1229-1230): lateral curvature of the spin in the upright position -Often identified due to deformities it causes: high shoulder, prominent hip, projecting scapula Scoliosis is a lateral or sideways curvature of the spine. It is most often diagnosed during the growth spurt just before puberty. Most cases are mild, but severe scoliosis can cause a rotation of the spine, leading to deformities and disability. Common manifestations include a spinal curvature to one side, uneven hips or shoulders, differences in leg length, tiredness of the spine, a prominent shoulder blade, and a rib lump. Back pain may accompany scoliosis. Severe scoliosis may cause heart and lung problems such as difficulty breathing and pneumonia or compression of the nerve roots may cause paralysis. Mild curves often do not progress and do not require treatment. Moderate and severe curves require treatment, especially if the curve continues to progress.

Rheumatoid arthritis 1

RA is a chronic systemic autoimmune disorders, which causes inflammation of connective tissue, primarily in the joints. The cause of RA is unknown, but genetic, environmental, and immunologic factors are thought to be involved. RA is believed to be caused the exposure to tan antigen that causes an unexpected response. Instead of responding normally by creating antibodies, the bod believes that normal tissue is foreign and begins to attack these tissues. The antibodies that rage this attack include rheumatoid factor. The antibodies in RA bind with other proteins (IgG) to create immune complexes that cause an inflammatory response in the synovial tissues, cartilage, bone, tendons, and ligaments. The body senses this inflammation and sends WBCs to the joint tissue, which release enzymes that cause further joint damage. The combination of immune response and inflammation harms the synovial membranes. In response, these membranes become hyperactive and form a new tissue called pannus. This tissue covers joint cartilage and produces enzymes that encourage additional tissue damage. Added to the immune complexes, the body activates osteoclasts, which cause underlying bone to demineralize.

Osteoporosis risk factors

Risk factors: -Advanced age -Female -Postmenopausal: due to estrogen deficiency which causes cytokines to be released that stimulate osteoclast recruitment and activity -Family history -Sedentary lifestyle -Calcium/Vitamin D Deficiency -Excessive alcohol intake, smoking -Medication and disease related: corticosteroid medications, hyperparathyroidism More than 35 million people in the US have osteoporosis or are at risk for developing it. OP is more common in non-Hispanic white women, although it can affect older people of any race or gender. Post-menopausal: OP is linked to estrogen deficiency resulting in increased calcium resorption from the bone as the lack of estrogen renders the body more sensitive to PTH.

systemic lupus erythematosus (SLE) manifestations 1

SLE can manifest in a variety of ways. The disease has been called the "great imitator" because it has the capacity to affect many different body systems and onset may be acute or insidious. Arthritis is the most common manifestation of SLE and is present in 90% of persons at some point during the course of the disease. Joint involvement usually includes the small joints of the hands, wrists and knees. MS complications are also include avascular necrosis and tendon rupture. Skin manifestations can vary greatly. The acute skin lesions include the class malar or butterfly rash on the nose and cheeks. Hair loss and sun sensitivity is also common. Renal involvement is also common in SLE and is a significant cause of morbidity and mortality. Several forms of renal involvement may occur, including glomerulonephritis and vascular disease. Nephrotic syndrome causes proteinuria and severe edema (we know this mechanism). Other clinical manifestations of renal involvement include minimal hematuria and loss of renal function. Cardiac complications include pericarditis, coronary heart disease, anemia, leukopenia, and thrombocytopenia. Neurological system complications: headaches, seizures, and psychotic manifestations such as depression, unnatural euphoria, mood disorders, and confusion.

Joint injuries

Strain: stretching or partial tear in a muscle or muscle-tendon unit -Often occur from sudden stretch of muscle that is contracting -Example: Hamstring strain Sprain: joint ligaments or capsule surrounding joint usually caused by abnormal or excessive movement of joint -Most common site is lateral ankle when foot is turned inward with inversion beyond its structural limits Dislocations: abnormal displacement of articulating surfaces of a joint Strain injuries occur when the muscles to tendon is forced to extend beyond capacity. Microscopic tears develop in the muscle tissue, leading to acute injury. For example, bending at the waist to lift a heavy object can cause strains to the lower back and hamstring muscles. That's why we lift with our legs! A sprain injury commonly occurs when oppositional force cause the ligament to overstretch and tear. The most common sites are the ankle and the knee.

Rheumatoid arthritis

Systemic Autoimmune Rheumatic Diseases Rheumatoid Arthritis (RA) -Chronic autoimmune systemic disease -Etiology: genetic predisposition with joint inflammation that is immunologically mediated -Patho: aberrant immune response leading to synovial inflammation and destruction of architecture of the joint + Approx. 70-80% of patients have an antibody called Rheumatoid factor (RF) - RF reacts with IgG to form immune complexes + Destructive changes are irreversible

Scleroderma 1

Systemic sclerosis, commonly called scleroderma, is an autoimmune disease of connective tissues that causes extensive fibrosis throughout the body. The cause of scleroderma is poorly understood, although there is evidence of both humoral and cellular immune system abnormalities. Fibroblast activation with excessive fibrosis is a hallmark of the disease. Skin involvement is the usual presenting symptom, but it is the involvement of organs such as the GI tract, heart, lungs, and kidneys that produces the major morbidity and mortality. Scleroderma presents as two major clinical subsets: Limited and diffuse. In limited scleroderma, the skin changes are limited to the fingers, forearms, and face. Some person with limited involvement also have Raynaud's phenomenon, and esophageal dysmotility. Diffuse scleroderma is characterized by severe, widespread, and progressive skin involvement and early onset organ involvement. The typical person has a stone face, due to the tightening of the facial skin with restricted mouth movement. Raynaud's phenomenon and esophageal dysmotility is also seen in diffuse scleroderma. Heart issues consist of pericarditis, heart block, and myocardial fibrosis. Vascular involvement of the kidneys is responsible for malignant hypertension and progressive renal insufficiency. Finally, pulmonary involvement leads to dyspnea and respiratory failure.

Fracture Healing: Remodeling

The final phase is the remodeling phase. In the remodeling phase, the woven bone is replaced with lamellar bone, which is stronger and more compact with better blood circulation. Because bones are continually being remodeled, fractures usually heal without a scar. However, it may take several years before the bone returns to tis original strength.

Fracture healing process: Hematoma formation

The first stage of bone healing is called the inflammatory phase. In this phase, damage to the bone, blood vessels, and surrounding tissues causes bleeding and the formation of a hematoma around the injury. Inflammatory cells, mainly macrophages and neutrophils, then enter the wound and degrade debris and bacteria in the area. This phase usually lasts until the osteoblasts and endothelial cells begin to proliferate at the fracture site, usually a few days.

Fracture Healing process: Fibrocartilaginous callus

The healing process then moves into the reparative phase. In this phase, fibroblasts, osteoblasts, and chondroblasts begin to secrete collagen for fibrocartilage. This develops into s soft callus that joins that joins the fractured bone. Endothelial cells begin to form blood vessels in the damaged area. Once the soft callus is formed, it is replaced by woven bone through endochondral ossification, which results in a hard callus (shown on next slide). The reparative phase lasts about 6-8 weeks.

Osteoporosis

decreased bone density and strength in which the bone matrix and mineralization are decreased Osteoporosis is the most commonly diagnosed metabolic bone disorder. It is caused by low bone density that occurs because of low intake of nutrients for bone growth or an increase in bone resorption that naturally occur with aging. OP causes weak bones that increase the risk of fracture.

Osteomalacia

softening of bones resulting from inadequate mineralization of newly formed bone matrix A disease characterized by softening of the bones caused by impaired bone metabolism due to inadequate levels of available phosphate, calcium, and vitamin D, or because of resorption of calcium. The most common cause is vitamin D deficiency. The impairment of bone metabolism causes inadequate bone mineralization. OM is children is known as rickets. S/S include diffuse body pains, muscle weakness, and fragility of the bones. Additional S/S include difficulty walking-children may end to bow-legged, hypocalcemia (positive Chvostek sign), pelvic flattening, and diminished stature. Treatment involves vitamin d and calcium supplementation.

Osteomyelitis

A bone infection, or osteomyelitis, can occur after a penetrating would, as a result of a blood infection, or from skin breakdown. OM can also develop following a joint replacement or internal fixiation device surgery. The most common bacterial offender is staph, but the infection can stem from other bacteria, viruses, fungi, or parasites. The microorganism causes inflammation and an immune response with the formation of purulent tissue drainage, vascular edema, and vascular congestion occurs. The canals within the bone permit the infection to move to other bone areas, which could potentially disrupt blood supply to the bone tissue. If left untreated, ischemia and necrosis will occur. Individuals with chronic health problems such as DM are prone to developing OM from an infected foot wound. Manifestations can be local or systemic. Local manifestations include bone pain, drainage, ulceration at the site, swelling, redness, warmth, and tenderness. Systemic manifestations include swelling of the lymph nodes, fever and chills, tachycardia, general malaise, nausea/vomiting and anorexia.

Fractures classifications

A few others that I'll mention are stress fractures (we have probably all had one at some point), which are fractures caused by small repetitive forces on the bone, often from exercise or sports. Depression fractures occur when the skull is forced inward, commonly occurring in skull fractures. Compression fractures occur when the bone is crushed, most commonly the vertebrae. Again, we can also have pathologic fractures, meaning fractures caused by weakened bones related to disease such as osteoporosis or cancer.

Fractures 1

A fracture is a break in the bone that occurs as a result of an increase in energy, more than the bone can tolerate. Fractures can be caused by either direct or indirect force. With direct force, the bone is exposed to energy near to or directly over the bone area that breaks. With indirect force, the bone in exposed to energy, however, the bone break occurs at a location weakness. The primary risk factors associated the bone fractures are age, presence of bone disease, and poor nutrition. Younger patients are more likely to sustain fractures related to sports injures; older patients are at higher risk of fractures related to falls and disease, as bone disease decreases the strength of the bone. Disease include osteoporosis, osteogenesis imperfecta, and bone cancer. Of note, open or compound fractures are especially problematic due to impaired skin integrity and the risk of bacterial contamination, resulting in infection. Common organisms include pseudomonas, staph, or clostridium. The greater the soft tissue damage, the higher the risk for infection,. Additionally, those that are immunocompromised with open fractures are at high risk for infection. Signs and symtpoms of infection include warmth, redness pain, stiffness, swelling (sound familiar?), possible fever and chills, and purulent drainage.

Osteogensis imperfecta

Also known as "brittle bone disease" -Inherited disorder involving deficiency of type I collagen synthesis -Manifestations: extreme skeletal fragility prone to fractures + Also may have thin skin, hypotonic muscles, abnormal tooth development, loose joints, tendency for hernias

Osteogensis imperfecta 1

Also known as brittle bone disease, is a group of genetics disorders that mainly affect the bones, resulting in bones that break easily. The severity can be mild to severe. Other symptoms include a blue tinge to the whites of the eye, short height, loose joints, hearing loss, breathing problems, and tooth problems. Complications include cervical artery dissection and aortic dissection. There is not cure. Treatments include care of broken bones, physical therapy, braces/wheelchairs, or surgery where metal rods are inserted through the long bones to strengthen them. In type I, collagen is normal in quality, but produced in insufficient amounts. S/S include bone fractures easily, spinal curvature, loos joints, poor muscle tone, blue discoloration of the sclera, hearing loss, and slight protrusion of the eyes.

Soft tissue injuries

- Bruise: contusion injury + Bruises, known as ecchymosis or a contusion, that results in discoloration of the skin. Blood from damaged blood cells deep beneath the skin collects near the surface of the skin, resulting in the typical black and blue mark that we think of. Besides the skin, bruises can occur anywhere, even organs such as the brain which we will discuss in neuro. -Hematoma: a large area of local hemorrhage + A hematoma is localized bleeding outside of the blood vessels, usually due to trauma (injury or surgery), and involves blood continuing to seep from broken capillaries. A hematoma is initially in liquid form and spreads among the tissues including in sacs between tissues where it may coagulate. They are typically reabsorbed into the blood vessels.

Fractures

- Manifestations: pain, tenderness at site, swelling, loss of function, deformity, abnormal mobility; possible shortening of extremity -Diagnostics: x-ray

Paget's disease

- excessive osteoclast-mediated bone reabsorption preceding disorganized osteoblast-mediated bone repair -Manifestations are extremely variable and due to skeletal expansion and distortion Paget disease is a metabolic disorder that causes select bones to overgrow and become weak. The bones most often affected include the skull, pelvis, and femur. It can occur in more than one bone in the body, but it does not affect every bone in the body. Paget disease affects approximately one million people in the US. It is most frequently diagnosed in older people of Northern European descent and the incidence in higher in men than women. In this disorder, bone resorption is faster than bone formation. The body compensates by accelerating the creation of new bone. However, the new bone is weak, brittle, and easily fractured. Paget disease is believed to be a genetic disorder triggered by an environmental factors, such as a virus. The vast majority of people are unaware of having the disease. Other may have mild or more exaggerated symptoms that depend on the bone affected. General manifestations include pain, enlarged bones, fractures, or damaged joint cartilage. If it affects the femurs, the person may have bowed legs. If in the spine, the spine may be curved. If in the skull, then the person may experience headaches, hearing loss, and large head size. In general , the symptoms progress slowly and the disease does not metastasize to other areas of the body.

Neoplasms: malignant bone tumors

-Osteosarcoma: aggressive and highly malignant bone tumor + Manifestations: localized bone pain and swelling of affected bone -Ewing Sarcoma: primitive neuroectodermal tumor + Primarily a disease of children + Manifestations: bone pain, limited movement, tenderness; systemic symptoms -Metastatic bone disease: bones are a common site for metastasis

Impaired bone healing

-Process of healing + Impaired bone healing: factors that may influence this include type of fracture, age, diabetes, local stress, circulatory disorders, coagulation disorders, and poor nutrition There are a few factors that can affect bone healing, as listed here on the slide. If a bone does not heal properly, it may be classified as: A nonunion, meaning that the fracture show no clinical progress towards healing for at least 3 months A delayed union, meaning the healing process takes longer than expected. A malunion, meaning the bone fragments join in a position that is not anatomically correct.

osteroarthritis (OA)

-also known as degenerative joint disease -Most prevalent joint disease Etiology: genetic and environmental risk factors -Increased risk with age -Obesity -Repetitive activities -Patho: often known as "wear and tear" arthritis + Osteophytes (spurs) are abnormal bony outgrowths

systemic lupus erythematosus (SLE)

-chronic inflammatory disease that can affect any organ system including musculoskeletal system -Etiology: largely unknown—genetic, environmental factors -Patho: formation of autoantibodies and immune complexes (type III hypersensitivity) - damage to the tissue results SLE is a chronic inflammatory disease that can affect virtually any organ system, including the MS system. The cause of SLE is largely unknown. It is characterized by the formation of autoantibodies and immune complexes. Persons with SLE appear to have defective elimination of self-reactive B cells with a resultant increase in production of antibodies that can cause tissue damage. The development of these antibodies can result from a combination of genetic, hormonal, and environmental factors.

Scleroderma

-systemic sclerosis -autoimmune disease of connective tissues leading to extensive fibrosis throughout the body -Manifestations: initial presenting symptom is often in the skin but it can involve other organs including GI tract, heart, lung, kidneys

Gout

Gout is actually a group of diseases known as the gout syndrome. It includes gouty arthritis with recurrent attacks of severe articular and periarticular inflammation, tophi accumulation or the accumulation of crystalline deposits in articular surfaces, bones, soft tissue, and cartilage; gouty nephropathy or renal impairment, and uric acid kidney stones. The term primary gout is used to designate cases in which the cause of the disorder is unknown an an inborn error in metabolism and is primarily characterized by hyperuricemia and gout. Primary gout is predominantly a disease of men. The pathogenesis of gout resides in an elevation of serum uric acid levels. Uric acid is the end product of purine metabolism. The elevation of uric acid and the subsequent development of gout can result from overproduction of purines, decreased salvage of free purine bases, augmented breakdown of nucleic acid as a result of increased cell turnover, or decreased urinary excretion of uric acid. An attack of gout occurs when monosodium urate crystals precipitate in the joint and initiate inflammation. Synovial fluid is a poorer solvent for uric acid than plasma. Furthermore, uric acid crystals are less soluble at temperatures below 37 degrees C and typically deposit in peripheral areas such as the great toe. With prolonged hyperuricemia, crystal and microtophi accumulate in the synovial lining cells and in the joint cartilage. Repeated attacks of acute arthritis eventually lead to chronic arthritis and the formation of large, hard nodules called tophi.

Orthopedic injury complications

Individual muscles are surrounded by fascia and the muscle tissue, nerves, and blood vessels in the fascia are part of a compartment. The fasciae are designed to hold the muscle in place, therefore, they do not expand readily and pressure can build up within the compartment. Compartment syndrome occurs when edema and swelling cause increased pressure in a muscle compartment, leading to decreased blood flow and nerve and muscle damage. If the ischemia the the compartment persists for a significant amount of time, the muscles and nerves may die and limb amputation may be necessary. The major symptom is pain that is out of proportion to the injury. Also, edema, pallor, paresthesia, weak distal pulses or pulselessness. Treatment: First, remove the cast. Then, the MD will do a fasciotomy, in which the fascia is cut open to allow the return of blood flow (kind of like removing part of the skull in cases of brain swelling). Then, when the swelling reduces, the fascia is reattached.

osteroarthritis (OA) manifestations

Manifestations: may affect a single joint or several -aching joint pain + worsened with activity, relieved with rest -audible crepitus: cracking of joints -Bouchard and Heberden nodes on interphalangeal joints OA manifests as deep, aching joint pain, especially after exertion. Pain may be relieved by rest. A person may also experience pain and stiffness following prolonged periods of inactivity, such as sleeping or a long car ride. Crepitus: Crackling or grating of the joint due to the rough surfaces rubbing against each other. Bouchard nodes: Nodes that occur at the proximal interphalangeal joint Heberden nodes: Nodes that occur at the distal interphalangeal joint

Gout manifestations

Manifestations: pain is abrupt with redness and swelling -early on, symptoms are not present in between attacks -overtime joint changes occur and are permanent The typical acute attack of gout is monoaticular (a single joint) and usually affects the first metatarsophalangeal joint, this could include the great toe, insteps, ankles, heels, knees, wrists, fingers, and elbow. Attacks begin at night and may be precipitated by excessive exercise, medications, foods, alcohol, and dieting. The onset of pain is typically abrupt, with redness and swelling. The attack may last for days or weeks. Pain may be severe enough to be aggravated even by the weight of a bedsheet on the affected area. In early stages of gout after the initial attack has subsided, the person is asymptomatic and joint abnormalities are not evident. After the first attack, it may be months or years before another attack. As attack recur with increased frequency, joint changes occur and become permanent.

osteroarthritis (OA) 1

OA is the most common form of arthritis, affecting 50% of the world's population that are 65 or older. OA develops as wear and tear on the joint, with the breakdown of cartilage in the joint. This causes bone to rub on bone, OA can affect any joint, but the hands, feet, and hips are the most commonly affected. In healthy joints, the slick surface of articulation cartilage covers the ends of the bones, allowing the bones to glide over each other without friction during joint movement. As the individual ages, the cartilage begins to break down and eventually wears away, allowing the bones to rub against each other. Bone spurs, called osteophytes, or particles that break off in the joint and irritate the synovial tissue, cause pain, inflammation, and swelling that are characteristic of OA

Osteopenia

Osteopenia: reduction in bone mineral density -not a diagnosis, but rather a term to describe loss of bone density on X-ray -Caused by disorders like osteoporosis, osteomalacia, and malignancies Osteopenia is a term used to describe a decrease in bone density. This disorder can lead to fractures. Not all people with osteopenia need extensive treatment, however interventions should be taken to strengthen the bone. Although osteopenia can occur in men, women are more prone to development because of hormonal changes that happen during menopause. Etiology: As people age, bone breakdown is greater then formation. This reduces the density of the bone and leads to bone weakness, which increases the risk of fractures. The most common reason for development include: Chronic eating disorders or metabolism issues that alter intake of vitamins Chemotherapy or glucocorticoid medications Radiation exposure Family history White and Asian descent Thin body structure Being sedentary, smoking, drinking cola-based beverages, and high alcohol intake There are usually no S/S and spontaneous fracture may be the first indication of an issue.

Neoplasms: malignant bone tumors 1

The incidence of malignant primary bone tumors are rare, only 0.2% of all cancers. However once they take hold, they metastasize incredibly quicikly. Osteosarcoma occurs mostly in the femur, tibia, and humerus and affects adolescents/young adults, along with more males than females. Ewing sarcoma occurs in the shafts of the long bones or flat bones and affects adolescents/young adults. The exact etiology of malignant bone tumors are unknown, but it is possible that these tumors are potentiated during periods of high bone growth or bone overstimulation by another disease. Radiation and bone marrow transplantation increases the risk for the development of these tumors. A primary malignant bone tumor causes osteolysis, or bone breakdown. This leads to bone weakening and fractures. The surface of the bone changes to permit the contours of the growing tumor. Further, the tumor destroys adjacent bone tissue, promoting bone resorption and interfering with bone blood supply. The clinical manifestation depend on the tumor location. Bone pain is common, with associated muscle weakness and atrophy. For tumor that affect the ends of bones, the skin over the mass may be warm and red. Metastatic bone disease: MBD occurs when a cancer in another body site migrates to a bone. Most commonly from the prostate, thyroid, lung, kidneys, and breast. MBD often affects older people and occurs when cancer cells from a tumor or other site break away and travel to a bone, where the cells grow and multiply. Metastasis commonly occurs in the spine, pelvis, and thigh. MBD does not always cause symptoms, so there may not always be indications that the cancer has spread to the bone. However, if symptomatic, the primary symptoms include bone pain and limb weakness.

Osteoporosis patho and manifestations

The most common manifestations of OP are loss of height, progressive curvature of the spine (Dowager hump), low back pain, and fractures of the forearm, spine, or hip. The patient may develop a Dowager hump between the shoulder blades. OP is often called a silent disease because bone occurs without symptoms. The problem may not become apparent until the patent has a fracture or findings on a diagnostic test.

Osteonecrosis (Avascular Necrosis)

When the blood supply to the bone is altered, the area is prone to developing necrosis. It most often affects the bones of the lower extremities, but can also occur in the shoulders. More than one area can experience ON at the same time. Normally, new bone replaces old bone. But if blood flow to a joint is reduced, bone breakdown occurs faster than replacement bone is made. Over time, the bone in the joints breaks down, leading to pain and alterations in joint mobility. Risk factors include long-term steroid use, heavy alcohol intake, cancer, osteoporosis, HIV, sickle cell disease, or direct injury to the bone or joint. This disorder may begin insidiously and have no symptoms. In time, the patient may begin to experience pain when pressure or weight is applied to the affected joint. As the necrosis progresses, pain increases and joint pain at rest occurs. Breakdown of the bone at a joint may render the limb unusable, affecting the patient's mobility. The onset of the disease process to complete loss of limb function may take months to over a year. Treatment involves medications and surgery, including decompression surgery, bone reshaping, or joint replacement.