Pathopharmacology 1: Musculoskeletal System (University of Toledo)

Procallus

"Temporary bone band-aid"

- Hyperuricemia from inadequate renal excretion or overproduction

Cause of Gout:

Primary: - obesity - aging Secondary: - injury

Cause of Osteoarthritis:

- autoimmune disease (genetic factor present and link to several viral infections)

Cause of Rheumatoid Arthritis:

- placement of hardware - infection elsewhere in body

Cause of osteomyelitis

- aging - menopause - decreased mobility or a sedentary lifestyle - hormonal factors (increased intake of glucocorticoids) - deficits of calcium, vit. D, or protein - Cigarette smoking - excessive caffeine - Asian and Caucasian ethnicity

Causes of osteoporosis:

once a week

DMARD 1 Methotrexate is given how often as an anti-rheumatic drug?

Methotrexate

DMARD 1 drug

Etanercept (Enbrel)

DMARD 2 drug

- SubQ injection twice a week - May give with methotrexate

DMARD 2 drug Etanercept administration:

- headache - heart failure - injection sit reactions and skin reactions - Pancytopenia (all cells low) - May increase risk of infections (no live vaccs)

DMARD 2 drug Etanercept adverse effects:

- active infection - Hematologic disease (anemia) - Malignancy - Latex allergy

DMARD 2 drug Etanercept contraindications:

methotrexate (bone marrow suppression increased)

DMARD 2 drug Etanercept interactions:

- blood test - examination of synovial fluid

Diagnosis of Gout:

- excluding other diseases - X rays - obvious changes in joints

Diagnosis of Osteoarthritis:

- modify the disease of Rheumatoid Arthritis - exhibit anti-inflammatory, anti-arthritic, and immunomodulating effects - inhibit the movement of various cells (neutrophils, monocytes, and macrophages) into an inflamed, damaged area - Slow onset of action: several weeks First: give NSAIDs then glucocorticoids during exacerbations

Disease-Modifying Antirheumatic Drugs (DMARDs) functions and characteristics:

osteocytes

Mature bone cells are called

First line of therapy: NSAIDs Allopurinol (Zyloprim): decreases uric acid production, prevents acute tumor lysis syndrome, and treats acute attacks Colchicine: reduces inflammatory response to the deposits of uric crystals in joint tissue. Is used for short-term management or prevention of gout Probenecid (Benemid): inhibits the reabsorption of uric acid in the kidney and thus increase the excretion of uric acid. ONLY USED FOR PREVENTION

Medications for Gout:

degenerative (wear and tear joint disease)

Osteoarthritis is a ____________ disease

calcitonin

Osteoblasts are stimulated by

parathyroid hormone

Osteoclasts are stimulated by

- Sudden rise in uric acid precipitates an attack of gout * often effects a single joint like toe

Pathophysiology of Gout:

- articular cartilage is worn down - tissue damage releases enzymes which accelerate disintegration of cartilage - osteophytes develop (bone spurs) - pieces of osteophytes and cartilage break off into synovial cavity - joint spaces become narrower - may be secondary inflammation of surrounding tissues (not systemic)

Pathophysiology of Osteoarthritis:

- abnormal immune response causing inflammation of synovial membrane w/ vasodilation, increased permeability, formation of exudate - Remissions and exacerbations lead to progressive damage to joints - other changes like atrophy of muscles, alignment of bones in the joints shifting, muscle spasms - mobility suffers as joints become damaged

Pathophysiology of Rheumatoid Arthritis:

autoimmune

Rheumatoid Arthritis is an __________ disorder

- Insidious onset - Inflammation may appear first in the fingers or wrists - joints are red, swollen, painful. Decreased movement - systemic symptoms are fatigue, anorexia, fever, generalized lymphadenopathy, and generalized aching

Signs and symptoms of Rheumatoid Arthritis:

Glucosamine-Chondroitin

Supplement given to help treat osteoarthritis

- balance between rest and activity - physical and occupational therapy - heat and cold modalities - splinting of joints during exacerbations - medications (NSAIDs, glucocorticoids, CELEBREX)

Treatment for Rheumatoid Arthritis:

- PT - Massage (decreases muscle spasms) - Glucosamine-Chondroitin supplements - Intra-articular injection of synthetic synovial fluid - Surgery (hip/knee replacements) - Pain relief (NSAIDs and Corticosteroids)

Treatment of Osteoarthritis:

the deposit of uric acid crystals in the joint which results in inflammation

What is Gout?

a break in the distal radius at the wrist

What is a Colles' fracture?

connects muscle to bone

What is a tendon?

break at an angle to the diaphysis on the bone

What is an Oblique fracture?

occurs when one end of the bone is forced into the adjacent bone

What is an impacted fracture?

When bone is partially broken

What is an incomplete fracture?

joint fixation and deformity

What is ankylosis?

complete separation from the bone.

What is avulsion?

weekly folic acid supplements

What is given with anti-rheumatic Methotrexate to decrease risk of toxicity?

purine foods; because uric acid is a byproduct of purine catabolism EX. bacon, beef, pork, wine, beer, yeast, gravy, etc.

What should a patient not eat a lot of while taking Probenecid?

hematoma

A basis for fibrin network for granulation tissue to grown

slightly movable

Amphiarthroses are joints that are

-dronate

Bisphosphonates suffix:

special connective tissue - intercellular matrix

Bone is made of

- striated muscle covered by CT - supplied with nerves and blood vessels which are stimulated to contract when an efferent impulse is conducted

Characteristics of skeletal muscles:

sternum and ilia

Common sites for bone marrow aspiration:

- muscle spasm; pull bone ends farther apart and more soft tissue damaged - Infections; osteomyelitis - ischemia - compartment syndrome - fat emboli (fatty marrow from bone marrow) - nerve damage - failure to heal - osteoarthritis - stunted growth (fracture of growth plate)

Complications of fractures:

skull

Example of a synarthrose

ribs, sternum, and symphysis pubis

Example of an amphiarthrose

shoulder, elbow, knee

Examples of diarthroses

- amount of damage - approximation of bone ends - Secondary issues (infection) - age - circulation issues - diabetes (poor circulation) - nutritional deficits

Factors effecting healing of fractures:

a few muscle fibers torn with little swelling

First degree muscle tear

inflammatory

Granulation tissue is an ___________ response.

soft bones of children *shaft of bone is bent *tearing on one side but not through the bone

Greenstick fracture occurs in

1 month

Healing of fractures in a child takes about

2 or more months

Healing of fractures in an adult takes about

many months

Healing of fractures in elderly takes

ischemic

Reduced blood flow causes what type of pain?

partial tear

Second degree muscle tear

- motor weakness and regression - waddling gait, weakness in climbing steps - Gower's Maneuver (using arms to push on thighs to stand up)

Signs and symptoms of Duchennes Muscular Dystrophy:

- fever - bone pain - chills - general malaise - local inflammation

Signs/Symptoms of Osteomyelitis

- body movement - body position - stabilizes joints - produces heat (shivering/contraction)

Skeletal muscle functions:

aging (from loss of calcium salts)

Something that negatively effects bone density and thickness:

contractions or spasms of muscle

Hypocalcemia causes

thyroid gland

If calcium is high, what gland releases calcitonin?

articulations

Joints are also called

aging *cartilage in joints degenerates and thins making difficulty with movement and alignment of joints

Joints are impacted by

stability

Ligaments are mainly for movement or stability?

growth hormone and sex hormones

Long bone growth is promoted by

osteoporosis

Metabolic bone disorder:

- calcium metabolism - housing of bone marrow

Metabolic functions of bone include:

- Metabolic defect: deficit of dystophin (cell membrane protein) which leads to degeneration and necrosis of cell - Replaced w/ fat and fibrous connective tissue

Pathophysiology of Duchennes Muscular Dystrophy:

Bone resorption more than bone formation

Pathophysiology of osteoporosis:

immovable

Synarthroses are joints that are

- growth hormone - parathyroid hormone - cortisol - stress (weight bearing/ muscle tension)

Positive changes in density or thickness of bone include:

fluid filled sacs located between tendons and ligaments

What are bursae?

- rigid support system - determines basic size & proportion of body - protects organs and spinal cord - metabolic functions

What are the functions of bone?

Complete, Incomplete, and Open

What are the three types of fractures?

movement

Tendons are mainly for movement or stability?

complete tear

Third degree muscle tear

osteoblasts

What cells are responsible for remodeling bone?

chondroblasts

What cells form new cartilage?

density of bone

What does a Dexa scan measure?

protect and cushions joint surface and bone ends EX. knee-- positioned between the ends of the upper femur and lower tibia

What does a meniscus do?

None to cure; disorder is progressive till death around age 20 by respiratory or cardiac failure ** moderate exercise and supportive appliances can help

Treatment for Duchennes Muscular Dystrophy:

- immediate splinting and immobilization - reduction of fracture (bones to normal place) - Medication: NSAIDs, analgesics, antispasmonic

Treatment for fracture:

- limit loss of bone - take supplements for vit D., calcium, or protein - fluoride supplements - regular weight bearing exercises - surgery to reduce curvature of spine

Treatment of Osteoporosis:

break along the axis of the bone

What is a Linear fracture?

synapse between end of motor nerve and receptor site in muscle fiber steps: - synapse - acetylcholine released to initiate muscle contraction - acetylcholinesterase function to inactive acetylcholine (muscle relaxes) - skeletal muscle relaxing drugs act by blocking acetylcholine at muscle receptor sites

What is a Neuromuscular junction?

a fracture of the lower fibula due to excessive stress on the ankle.

What is a Pott's fracture?

a break that angles around the bone, usually due to a twisting injury

What is a Spiral fracture?

fracture across the bone

What is a Transverse fracture?

break in which there are multiple fracture lines and bone fragments.

What is a comminuted fracture?

When bone is broken and forms 2 separate pieces

What is a complete fracture?

occurs when a bone is crushed or collapses into small pieces * Common in vertebrae

What is a compression fracture?

Fracture that occurs in the skull when the broken section is forced inward on the brain

What is a depressed fracture?

separation of two bones at a joint with loss of contact between the articulating bone surfaces

What is a dislocation?

a clot that forms after bleeding from broken blood vessels

What is a hematoma?

connects bone to bone

What is a ligament?

a piece of cartilage found where two bones meet

What is a meniscus?

fracture that results from a weakness in the bone structure due to conditions such as a tumor or osteoporosis. *Break occurs spontaneously or w/ little stress on the bone

What is a pathologic fracture?

a single break in the bone in which the bone ends maintain their alignment and position.

What is a simple fracture?

tear in ligament (bone to bone)

What is a sprain?

tear in tendon (bone to muscle)

What is a strain?

fracture that results from repeated excessive stress * common in tibia, femur, and 2nd or 3rd metatarsal

What is a stress fracture?

partial displacement

What is a subluxation?

When the bone penetrates the skin and is broken * this causes more damage to blood vessels and nerves * HIGH risk of infection

What is an open fracture?

infection of bone

What is osteomyelitis?

Dexa scan

What is the diagnostic test used for osteoporosis?

dantrolene

What is used to treat malignant hyperthermia?

Synovial fluid

What lines the space between the articulating ends of bones, prevents damage and provides nutrients?

after the growth plate (epiphyseal cartilage) ossifies during puberty/adulthood

When does long bone growth cease?

Rest, Ice, Compression, Elevation ** Surgery for third degree tear

Treatment of muscle tears

- remove hardware - antibiotics -amputation

Treatments of Osteomyelitis

- compression and spontaneous fractures

signs and symptoms of osteoporosis:

- Pancytopenia - exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis

Adverse effects of Allopurinol (Zyloprim):

- Short term leukopenia - bleeding into the gastrointestinal or urinary tracts (look for black tarry stool)

Adverse effects of Colchicine:

- Kidney stones

Adverse effects of Probenecid (Benemid):

- pain - joint movement limited - Heberden's nodes (distal) - Bouchard's nodes (proximal)

Signs and Symptoms of Osteoarthritis

- elevated creatinine kinase (CK) levels - electromyography - muscle biopsy

Diagnostic tests for Duchennes Muscular Dystrophy:

- Arthroscopy - MRI - Xray - Serum calcium, phosphate and parathyroid hormone levels - Dexa scan

Diagnostic tests for bone:

X-ray

Diagnostic tests for fractures

- Xrays - Arthroscopy -MRI - Synovial fluid aspiration

Diagnostic tests for joints:

- Electromyograms - Biopsy - Serum enzyme level (Creatinine Kinase -CK)

Diagnostic tests for muscles:

freely movable

Diarthroses are joints that are

pressure and traction **mod. sedation

For a close fracture, what is used to put bones back in place?

pins, plates, screws

For an open fracture, what is used to put bones back in place?

osteoblasts and osteoclasts

Homeostasis of a bone is kept in balance by what two cells?

6 weeks

How long does it take for a sprain or strain to heal approximately?

elevated **DANGEROUS AT HIGH LEVELS

If there is muscle damage, the enzyme Creatinine Kinase is (decreased/elevated)?

Duchennes Muscular Dystrophy

Most common muscular dystrophy, effects young boys

in the cranium, bodies of vertebrae, ribs, sternum, and ilia

Where is bone marrow found?