Course: Pathophysiology I Date: 3/11/08 Doc: Study ...catstcmnotes.com/downloads/Pathophysiology/Pathophysiology 1... · Doc: Study Question – Exam 2 ... and skeletal muscle wasting

Course: Pathophysiology I Date: 3/11/08 Doc: Study Question – Exam 2 Define “nutritional status” The condition of the body related to the availability and use of nutrients Define metabolism Process in which nutrients (proteins, carbs, fats) are broken down into useable components and converted into energy. What is a calorie? What is a kcal? Calorie: energy measured as a unit of heat – heat production capacity A kcal is a kilocal, the amount of energy needed to raise the temperature of 1kg of water by 1 degree C. What is adipose tissue and what function does it have in the body? Adipose tissue is fat tissue. Fat 1) provides a source of energy, 2) cushions the body, and 3) provides insulation.

What are the two types of fat in the body and which is most prevalent? Brown fat and white fat. White fat is the most prevalent kind. What is white fat composed of? Triglycerides which are made up of dietary carbohydrates and fats. White fat is an efficient form of energy storage. What is the function of brown fat? Brown fat is more prevalent in neonates and hibernating mammals. It is responsible for generating heat and is more internal to the body. What should the ideal BMI be for males and females? Males: 10-20%. Females: 15-25%

Compare anabolism to catabolism Anabolism and catabolism are terms used in reference to the energy storage and usage of the body. Anabolism is metabolic storage, building up resources in the body…which also takes energy. Catabolism is the useage of stored energy, breakdown of complex products. Define Metabolite and ATP. A metabolite is a side product or substance of the breakdown process of catabolism. ATP is adenosine triphosphate, the fuel source needed by cells. It is produced by the breakdown of food that is stored and used as a fuel source. What is the primary fuel source for brain and nerve tissues? What organ regulates this fuel? The primary fuel source for brain and nerve tissue is glucose. Liver regulates the glucose levels in the blood

Pathophys I – Winter www.CatsTCMNotes.com

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How does this organ regulate this fuel? Dietary glucose is absorbed into the bloodstream and transported to the liver. When blood sugar levels are adequate/high, the liver removes the glucose from the bloodstream and stores it in the form of triglycerides (white fat) or glycogen (the stored form of glucose). When blood sugar levels are low glycogen is converted into glucose which the liver releases into the bloodstream.

Where is glycogen stored? Glycogen is stored in the skeletal muscles and in the liver. A small amount is stored in the skin and glands. What is glycogenolysis? What 2 hormones are involved? Glycogenolysis is the breakdown of glycogen into glucose. Two hormones are involved in this process: the liver uses the hormone glucagon and the muscles use epinephrine. Define gluconeogenesis. Where does this occur and when? This is the production of glucose by the liver in the event of food or carbohydrate deprivation. How many kcals in a gram of fat and a gram of glucose? 9kcals in a gram of fat, 4 in a gram of glucose. How are fats derived in the body? You can get fat from food or from breaking down the stored fat in the body. When stored fat is broken down it travels to the liver in the bloodstream and is used as energy. What are ketones, what organ can use them for fuel, and how does that relate to acidosis? Ketones are byproducts resulting from the breakdown of fats. The brain can use these as fuel. However, if the breakdown of fat by muscles exceeds the amount needed a condition called acidosis occurs and the extra ketones are blown off in the breath. What makes up the solid structure of a body and where do we get this substance? What does the liver do with this substance? Proteins (amino acid structures) make up our solid structure. We get proteins from diet. The liver can break down proteins to form glucose when needed. What is BMR (basal metabolic rate) what percentage of energy needs does it comprise? BMR is basal metabolic rate and describes the base line of energy needed to exist while the body is at rest. BMR is 50-70% of our energy needs. The higher the lean tissue in the body, the higher percentage needed. What are the 2 types of thermogenesis and why do we have this phenomenon? Thermogenesis is the production of energy. ♦ Diet-induced thermogenesis: energy used for digestion and usage of food ♦ Exercise-induced thermogenesis: amount of energy needed for activity.

What types of fats raise serum cholesterol? Which kinds lower it? Saturated fats saturate the blood, raising serum cholesterol. (these are generally solid at room temp)


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Unsaturated fats lower serum cholesterol. What is the difference between a simple and a complex carbo? Simple carbohydrates are basically sugars Complex carbohydrates are characterized by fiber. There’s no rule as to how many carbs you need in a day, but 50g will prevent ketosis. What is a vitamin? A catalyst in the body’s chem rx.

What are the fat soluble vitamins? A, D, E, and K. These get stored in your fats when the levels get too high. What are the water soluble vitamins? The B vitamins and vitamin C are water soluble vitamins.

What are the 5 anthropometric measurements?

1) height 2) weight 3) waist circumference 4) skinfold thickness 5) BMI, or body mass index. The formula is weight in kg divided by the height in meters squared or

Kg/M2

In regard to BMI, what is considered obese? Any number higher than 30 on the BMI scale. Discuss waist to hip ratio (slide 18, 20) Waist to hip ratio is another anthropometric measure. Ratio should be less than 1.0 in men and 0.8 in women. Anything higher than this indicates upper body or abdominal obesity which indicates higher risk of heart disease. Waist circumference Waist circumference should be less than 40” for men and less than 35” for women. The higher this number, the greater at risk for heart attack, stroke, etc.

What is the definition of obesity? What percentage of americans are obese? Obesity is excess body fat and is a leading cause of preventable death. 30% of Americans are obese and the numbers are increasing.

What are the 3 major factors that = obesity? 1) Genetic inheritance (30-40%) 2) Environmental factors 3) Increased calorie load with decreased activity load.

What are the risks of obesity? What kind of obesity does not increase one’s risk for heart disease?


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Increased ischemic heart disease, stroke, hypertension, elevated trigylcerides, diabetes, cancers (colon, prostate, breast), gallbladder disease, asthma, infertility, sleep apnea, arthritis. What are the treatment protocols in obesity? What is the weightloss goal? #1 is prevention. If it’s too late for that: ♦ Reduce caloric intake ♦ Increase activity ♦ Behavioral therapy ♦ Medications ♦ If severe, surgery (lapband)

A sane and sustainable weightloss goal is 1-2 lbs per week. What are the caloric reduction needs, fat intake, and activity levels recommended to treat obesity? ♦ Caloric reduction needs:

o 300-500 kcal per day reduction for overweight (25-29.9 BMI) o 500-1000 kcal per day reduction for obese (30+BMI)

♦ Fat intake: less than 30% of calories from fats ♦ Activity level: 30-60 minutes of moderately intense activity at a minimum

60-90 minutes per day is better. When is surgery recommeded to treat obesity? When the pt has a BMI of greater than 35 with co-factors or failed medical therapy.

What percentage of kids in the 6-19 age bracket are considered obese? 15%. The risk for childhood obesity is increased when one or both parents are obese.

What diseases does this place them at risk for? Diabetes, hyperlipidemia, hypertension What are the contributing factors to childhood obesity? ♦ Parental obesity (one or both parents) ♦ Diet and inactivity

What are the treatment plans for childhood obesity? ♦ If the child is young and not severely obese weight can be maintained. It will even out in

the puberty and adolescent growth processes ♦ If the child is severely obese or older, aim for a loss of 1 lb per month. Try getting them to

cut out juice, sodas, chips, empty calories, etc.

What is undernutrition or malnutrition? How many kids worldwide suffer from this? Deprivation of all foods or of one+ nutrients (proteins, fats, carbs, vitamins, minerals, fibers, etc.) 195 million kids suffer from malnutrition.

What are the 2 types of malnutrition? Define each.


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1) Marasmus Overall body wasting caused by inadequate calories. This causes a loss of muscle mass and fat stores, stunted growth, low body temps, low heart rate, and low b.p. Liver function is normal in Marasmus malnutrition.

2) Kwashiorkor Kwashiorkor results from a protein deficiency from an overly starchy diet. These are the kids you see with distended abdomens and skinny skinny limbs. Symptoms include edema, hair discoloration, and skeletal muscle wasting. The liver function is not normal and the liver is enlarged. This can be reversed, but must be done so gradually due to GI degeneration which occurs in malnutrition

When does protein-calorie malnutrition occur and what is it? What are the results? Occurs as a result of deprivation of these 2 nutrients, also in trauma, AIDS, sepsis, and cancer. Protein-calorie malnutrition results in ♦ Accelerated muscle/protein breakdn ♦ Edema as a result of loss of protein in blood ♦ GI tract atrophy causing malabsorption ♦ Decrease in immune cells and wound healing ♦ Decreased cardiac output ♦ Decreased respiratory muscle

What are the 3 signs of Female Athlete Triad?

1) Disordered eating (anorexia, bulemia or binge eating) to maintain weight for a sport 2) Amennorhea due to low estrogen levels (insufficient resources to support reproduction) 3) Osteoporosis due to low extrogen, low calcium, and stress fractures.

What are the characteristics of the following eating disorders:

Anorexia (include mortality rate) ♦ Intense fear of weight gain, becoming fat ♦ Refusal to maintain height/weight proportion ♦ Disturbance in perception of body image (don’t realize they have a problem, think they

are fat regardless of how skinny) ♦ Amennorhea ♦ Caloric restriction with increased activity

Mortality rate .56% per year, much higher than normal for women in the same age grouping. Anorexics are at risk for osteoporosis, vertebral compression frac’s, constipation, cold intolerance, bradycardia, hypotension, lanugo (fine hair growth all over), electrolyte imbalance and heart failure.

Bulemia (include the forms it takes, at-risk-for factors) Bulemia is 10 times more common in women than in men. It is characterized by recurrent binge eating coupled with inappropriate compensation for binging - purging (i.e, vomiting, laxatives, diuretics) or non-purging (excessive exercise and fasting). Unlike anorexics, bulemics are aware they have a problem.


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Bulemics are at risk for ♦ Dental disorders ♦ Parotitis ♦ Esophagitis and reflux disease ♦ Electrolyte imbalance, specifically potassium.

Binge Eating Disorder Binge Eating Disorder is described as 1) recurrent episodes of binge eating (2 days per week for at least 6 months)

-and- 2) at least 3 of the following:

♦ eating rapidly ♦ eating until uncomfortably full ♦ eating large amounts when not hungry ♦ eating alone ♦ guilt, depression, shame, disgust over eating behavior.

Most binge eaters are overweight.

Define activity versus exercise. Activity is energy expenditure to accomplish an effect. Exercise is a different energetic: it is movement and energy expenditure on a regular basis for the purpose of conditioning the body.

What are the benefits of exercise? ♦ Slowing or reversal of atherosclerosis ♦ + HDL with – LDL ♦ Regulation of blood pressure and glucose levels ♦ Improved mood ♦ Weight control

What is the difference between anaerobic exercise and aerobic exercise? Aerobic exercise

♦ Uses oxygen to transform glucose, fats, etc into energy with changes in muscle length during activity

♦ Results: o Muscles use oxygen more efficiently o No muscle hypertrophy

Anaerobic exercise

♦ Muscles contract against an immobile force with no change in muscle length during activity.

♦ Results: o Muscle hypertrophy/mass o Increase in muscle tone

What are the 4 components of exercise?

1) Cardiopulmonary fitness Pathophys I – Winter

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2) Muscle strength, flexibility, endurance 3) Availability of energy to meet demands 4) Motivation and mental endurance

What are the cardiopulmonary responses to exercise?

♦ Heart, lungs, blood vessels ♦ Supplies oxygen to working muscles ♦ +Gas exchange ♦ +VO2 max ♦ Central nervous system and local neural regulation ♦ Vasodilation to skeletal muscles, vasoconstriction to kidneys and GI ♦ +Cardiac output, blood pressure, and heart rate. ♦ +Angiogenesis to muscles

What are the 3 neuromuscular responses to exercise? 1) Muscle strength (force against resistance) 2) Flexibility (range of joint movement) 3) Muscle endurance (perform increased activity over extended time)

What are the two types of skeletal muscle fibers?

1. Type I (slow twitch, red/dark) o Smaller, less force, more efficient: high concentrations of mitochondria,

myoglobin o Larger muscles: low-intensity, designed for endurance.

Deconditions easily with disuse. ♦ Type II (fast twitch, white/light)

Larger fibers, higher ATPase activity Smaller muscles: high intensity work. Arm and eye muscles are examples. Sprinting and weightlifting use these types of fibers.

What determines the distribution of each type of skeletal muscle fiber? Heredity and activity.

How do muscles power contraction and how long can they do that? ATP is the power unit in cells/muscles. There’s enough for just a few seconds of activity.

What does a muscle do when it runs out of ATP? More just be generated. After ATP is exhausted, creatine phosphate is used, then glycogen, and fatty acids during prolonged activity.

What is a “thermal response?” This is the response to the heat generated by exercise or activity. Blood flow is increased to the skin to vent heat, vasodilation occurs, and sweat pores open. Note: the more you exercise the better your sweat response gets.


What happens in the GI tract as a result of exercise?

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Blood flows away from the GI tract. There is decreased motility and absorption which can lead to reflux, ab pain, vomiting and cramping. Though that sounds really terrible, exercise still reduces the risk of colon cancer and inflammatory bowel diseases. What is fibrinolytic activity and how does exercise affect it? Exercise increases it. Fibrin is a byproduct of clot formation and contributes to clotting. Fibrinolytic activity thus breaks down fibrin and clots. How does the immune system rsvp to exercise? Overall increases immune response. Note that strenuous activity temporarily depresses immune system and mucosal immunity, but body responds by overall increase. What are the psychological benefits to exercise? Increased energy, motivation. Positive self image and increased self-esteem, improved mood, decreased anxiety. Better stress management How do you assess activity tolerance?

♦ Perceived level of activity ♦ Level of fatigue ♦ Ergometry with bicycle or treadmill, looking for target heart rate of 220 minus age. ♦ MET’s, or metabolic equivalents. One MET is the energy expended at rest.

What is fatigue? When is it normal and abnormal? Insufficient resources to endure desired activities. Normal fatigue happens in strenuous exercise. Abnormal fatigue occurs in cardiac disease, respiratory disease, and anemia, to name a few. It can also be caused by mental stress and lack of sleep. Abnormal fatigue persists despite adequate sleep.

What are the 5 causes of fatigue? Give examples. 1) Environmental

Temperature extremes, weather changes, noise.

2) Medication related Tranq’s and alcohol, i.e.

3) Treatments Chemotherapy, anesthesia

4) Psychological factors Stress and depression

5) Physical exertion

Define acute versus chronic fatigue.


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Acute fatigue is less than 4 weeks in duration. Chronic fatigue persists more than a month. In what diseases does fatigue routinely occur? Cancer, cardiac disease, renal disease, chronic lung disease, hep C, HIV/AIDS, MS, Parkinson’s, anemia, insomnia. Define Chronic Fatigue Syndrome. A disabling fatigue disorder of uncertain etiology with a duration of at least 6 months. It is associated with trouble thinking, sleep disturbances, and musculoskeletal pain. CFS often overlaps with fibromyalgia, depression, and IBS.

What is the etiology of CFS? Uncertain. Thought to be associated with infectious diseases, immune system dysfunction, CNS abnormality, or autonomic nervous system disorder. Could also be psychological What are the major associated symptoms that occur in CFS?

Flu-like symptoms (at onset) Recurring symptoms Low grade fever Pharyngitis Tender cervical lymph nodes Headaches Myalgias Polyarthralgias (joint pains) Impaired cognition Sleep disruption Postexertional malaise

How does gravity/weightbearing activity affect the body? Why is it important to remobilize after an illness/surgery/trauma/etc? Gravity provides resistance for muscles to contract against, which helps blood pump thru the system. Weight-bearing activ builds bone. Early remobilization is the rule for most conditions so that muscle tone and bone mass are not compromised.

What are the cardiovascular effects of bedrest/inactivity? Blood volume is more centralized than on the periphery Heart is deconditioned due to inactivity Heartrate increases Orthostatic hypotension

It takes 5-10 weeks after prolonged inactivity before normal cardiac output resumes.

What is orthostatic hypotension? Blood flowing back to extremeties once you stand up from prolonged bedrest/inactivity. This decreases cardiac output, causes autonomic dysfunction, dizziness, tachycardia, fainting.


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How does bed/inactivity put one at risk for DVT? Veins have no musculature, so rely on pressure and muscular activity of skeletal muscles for venous return. With inactivity this doesn’t happen. Blood pools in extremeties and becomes more viscous. Pressure of tissues on bed increases this as well. These are all factors for a thombosis (deep vein thrombosis or DVT). Contributing factors: birth control meds and hypercoagulative states. What are the pulmonary effects of bedrest/inactivity? Decreased lung capacity. Don’t take as many deep breaths, must work harder to breathe. This leads to atelectasis (flattened alveoli), accumulated secretions, hypoxemia, pulmonary emboli What are the urinary tract effects of bedrest/inactivity? Decrease in urine clearance from kidneys. Increased risk of stones and infections (worse with dehydration). Increased incontinence due to decreased emptying of the bladder. What are the musculoskeletal effects of bedrest/inactivity? Disuse atrophy which 1/8 of the muscles’s strength lost per week – the bigger and stronger the muscle, the faster it is lost. Lean muscle mass is lost with fast twitch declining faster than slow twitch. Overall muscle shortening – most severe are contractures which develop when there is an imbalance in muscle groups (think stroke, hand curl, etc.). How does bedrest/inactivity impact bones? Increases bone loss and osteoporosis. Osteoblasts decline in activ during inactivity, but osteoclasts do not! As a results calcium and phosphorous are released into the blood stream which is filtered by the kidneys increasing the risk of kidney stones. What can happen at a skin level during prolonged bedrest/inactivity? Pressure sores leading to ischemia and necrosis. Discuss metabolic rates in light of prolonged bedrest/inactivity. BMR decreases, meaning your body burns off less calories at rest than before. Anabolic process slow, catabolic processes increase. Nitrogen builds up because of the protein breakdown, but you’re not blowing it off as well due to the pulmonary changes. Glucose intolerance and hyperinsulemia result. PTH (parathyroid hormone) increases which releases more calcium from bone and muscle into the blood stream, again contributing to kidney stones. How does this affect the GI tract? Appetite decreases, absorption slows. Constipation, bowel impaction due to muscle atrophy in the GI tract. How does it impair sensory responses? Visual and auditory hallucinations and vivid dreams increase. Thought processes decrease. Tactile sensation is altered. Loss of contact w/ reality. What are the psychosocial responses to bedrest/inactivity?


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Depression, anxiety, fear, hostility, abnormal sleep patterns, decreased ability to learn and problem solve.

<<CLASS 4 STARTS HERE>> What structure connects bone to bone? Ligaments What structure connects muscle to bone? Tendons What 3 components make up connective tissue (bone/cartilage)?

♦ Living cells ♦ Non-living intracellular protein fibers ♦ Shapeless ground substance

What are 2 types of intracellular fibers? Describe them

♦ Collagen – inelastic, fibrous, high tensile strength, white in color. ♦ Elastic fibers – contain elastin so can stretch and return to normal shape and length

repeatedly. Ligaments are an example.

What is cartilage? Firm, flexible connective tissue with a strong weight bearing capacity (2nd to bone) which contains no blood vessels or nerves. It is 65-80% water weight in a gel matrix allowing diffusion of gases, nutrients, wastes. Takes a long time to heal because of the slow diffusion of nutrients/wastes. Embryonic skeletons are made of this, then slowly calcified and made into bone as growth occurs. What are the 3 types of cartilage and what tissues do they make up?

♦ Elastic – contains some elastin like in the ear or nose end. ♦ Hyaline – pure cartilage, white in color. Fetal skeleton, joint surfaces, costochondral

junctions are made of this. Most of these surfaces are covered by a perichondrium, a fibrous connective tissue.

♦ Fibrocartilage – intermediate type between dense connective tissue and hyaline cartilage. Intervertebral discs are made of fibrocartilage.

What is bone? What is it made up of? Connective tissue made up of an intracellular matrix containing 1/3 organic matter (cells, vessels, nerves) and 2/3 inorganic matter called hyroxyapatite which is an insoluble structure of calcium salts. The intracellular matrix may also take up lead (and other heavy metals) and tetracycline in newly formed bone. What are the 2 types of mature bone? Define each.

Cancellous or spongy. Trabecular bone which is compressible and filled with red or yellow bone marrow. Forms the centers of long bones.

Compact or cortical bone. These are the rigid outer shells of bone.


What are the 4 classifications of bones by structure?

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Long – like femur Short – ankle and wrist Flat – skull and ribcage Irregular – vertebrae and jaw

Where do you find red and yellow bone marrow? What is it composed of? In the trabecular interior of long bones as well as the vertebrae, ribs, sternum and ilia of adults.

Red marrow: contains red blood cells and forming blood cells. Yellow marrow: primarily adipose tissue.

Define diaphysis, metaphysis, and epiphysis.

Diaphysis: the shaft of a long bone. Compact bone with marrow in the shaft in a trabecular structure.

Metaphysis: the flared portion between the diaphysis and the epiphysis. Contains bony trabecula with cartilage.

Epiphysis: the ends of long bone. Cancellous. Contains the epiphyseal plate in kids or the epiphyseal line in adults. This is the line where bone growth occurs in kids.

What are the 4 types of bone cells and what does each do? (stems, blasts, cytes, clasts)

Osteogenic cells – the stem cells of bone. Undifferentiated cells that define into osteoblasts in normal growth, healing of fractures, etc.

Osteoblasts – bone building cells. Builds by 1) ossification and 2) calcification Osteocytes – bone cells. Maintain the bone matrix, arranged in layers called lamellae Osteoclasts – bone resorption cells formed in the bone marrow. Osteoclasts have receptors for

PTH, calcitonin and more. What are the 2 stages of bone building?

1) ossification – formaton of an osteoid made up of collagen and proteins 2) calcification – calcium is deposited into the osteoid. Alkaline phosphatase is an enzyme released

by osteoblasts to raise calcium and phosphate for this process. The level of alkaline phosphatase is high in fractures and other conditions.

Define lacuna, canaliculi, lamellae

lacuna: fluid in which the bone matrix lies. Canaliculi: the passage ways connecting the bone matrix. Lamellae: layers in which the bone matrix is arranged.

Define periosteum and endosteum

Periosteum: the outer covering of bones (except the articular portions). The outer layer of the periosteum is fibrous, the inner layer is made up of osteogenic cells.

Endosteum: membrane lining the spaces of spongy bones containing osteogenic cells. How do hormones control the formation of bone (in general)? Hormones are responsible for the deposit and resorption of bone matter. Imbalance of hormones can cause abnormal bone growth or destruction.


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What does the parathyroid hormone do in relation to bone formation? PTH or parathyroid hormone regulates the levels of calcium and phosphate in the blood and is secreted by the parathyroid glands. PTH is released into the blood stream when calcium levels fall. When calcium levels return to normal the parathyroid stops releasing the hormone. In order to raise the calcium level the body responds to PTH by 1) stopping the excretion of calcium by the kidneys, 2) increasing calcium absorption in the intestines by activating Vitamin D, 3) decreasing bone formation and 4) releasing calcium from bone – bone resorption. How does calcitonin affect bone formation? Calcitonin is released by the parafollicular thyroid cells when the blood calcium levels are too high, thus reducing the serum calcium level. This 1) inhibits bone resorption, 2) inhibits osteoclast activity, and 3) increases renal excretion of both calcium and phosphate. Discuss the effects of parathyroid hormone on the following:

Intestinal absorption of calcium and phosphates PTH increases intestinal absorption of calcium and phosphates by activating Vitamin D. Renal excretion of calcium and phosphates PTH triggers the kidneys to stop excreting calcium and phosphates in order to increase the serum calcium level. Bone resorption PTH activates bone resorption to release calcium and phosphate into the bloodstream. Bone formation PTH causes bone formation to stop.

Discuss the effects of calcitonin on the following: Renal excretion of calcium and phosphate Increases renal excretion to help bring serum calcium levels down. Bone resorption Inhibits resorption and osteoclast activity Bone formation Enhances bone formation as it inhibits osteoclast activity and bone resorption.

How does the body get Vitamin D? 1) Through the diet 2) From skin exposed to UV light.

How does Vitamin D regulate bone formation and mineralization:

Works with PTH… Increases intestinal absorption of calcium


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Increases osteoclastic activity and number of cells Increases osteoblast cell differentiation

Rickets and osteomalacia result without Vitamin D. Vitamin D2 comes from __________________. What happens to it then? Vitamin D2 comes from the diet and is also known as ergocalciferol. It is converted into Vitamin D3 by the liver and kidneys. Vitamin D3 is derived from __________________. How does it regulate bone formation? Vitamin D3 comes from sunlight or from Vitamin D2 which is converted into Vitamin D3 by the liver and kidneys. Vitamin D3 increases intestinal absorption of calcium, increases the number and activity of osteoclasts, increases osteoblast cell differentiation.

What 2 structures do tendons connect? Muscle and bone.

Ligaments connect what to what? Bone to bone What are tendons and ligaments composed of? Tendons and ligaments are composed of collagen fibers and fibrocartilage. There is limited blood supply to both, so they heal slowly.

What are the two classes of joints (by type of movement) and where do you find each?

1. Synarthroses – no joint capsule and very limited movement 2. Diarthoses

Define the following: Synostoses: nonmoveable joint with dense connective tissues (skull) Synchrondoses: bones connected with hyaline cartilage with very limited movement (ribs/sternum) Syndesmoses: some movement in the joint. Fibrous disks joined by ligaments (spine) What types of joints are covered by cartilage and have joint capsules? Diarthoses. Wide range of motion. How are joints supplied by nerves and blood? How does referred pain fit into this picture? Vessels for blood enter near the joint capsule and blood supply is rich to the joint capsule. The nerve supply to the joint capsule is the same nerve trunk that supplies the muscles which connect to it. Pain fibers are present in the joint capsule and ligaments which are sensitive to stretching and twisting. Because the joint and the attached muscle have the same nerve supply an injury in a joint can express not only in that joint, but in adjacent joints. What are bursae? Bursae are fluid filled sacs in the synovial membrane which cushion the tendons, preventing friction damage and irritation


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What are menisci? Fibrocartilaginous structures that develop from an articular disk. Lies between the articular cartilage surfaces.

What sorts of musculo-skeletal trauma routinely occur? MVA’s, motorcycle accidents, falls, bicycle accidents, sports injuries. Abuse. Briefly discuss types of athletic injuries and prevention thereof.

Acute: injuries to soft tissues and bones. Chronic: overuse type injuries resulting in stress fractures and tendinitis.

Can be prevented with training, safety equipment, warmup and cooldown, hydration, proper nutrition for the activity. Define the 5 different types of soft tissue injuries?

1. Contusion - bruise resulting from direct trauma against a hard object, overlying skin is intact

2. Hematoma – area of local hemorrhage. Good possibility of infection. Treat with elevation, cold, possible aspiration.

3. Laceration – disruption in skin continuity (can be a tear, cut, or puncture). Treat by closure. In the event of a puncture wound, possibility of contamination by tetanus or anaerobic bacteria.

4. Sprain – injury to a ligament. Ankle, knee, elbow and wrist are the most common sites. Swelling and pain subside more slowly in a sprain than in a strain due to the way blood, nutrients and wastes enter and leave ligaments.

5. Strain – stretching injury to a muscle or muscle/tendon unit. Can include injury to the fascia. Most common in the lumbar and cervical areas.

What is the difference between sprain and strain? A strain occurs in muscles and/or the attached tendons and may include the fascia of a muscle. Sprains are ligamentous injuries and as a result remain painful and swollen longer than strains. What are common sites for both above? Sprains are most common at ankles, knees, elbows and wrists. Strains are most common in the lumbar and cervical areas. What type of fracture is a complication of a sprain? Avulsion fractures are associated with sprains – rather than the ligament tearing, it pops off the bit of bone to which it is attached. Discuss the healing process for sprains and strains: what happens, length of time needed, treatment required. Takes time to heal and regain tensile strength. Fibroblasts from the tendon sheath or from connective tissues produce collagen. Takes about 6-8 weeks for total restoration.


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Treatment is 1) elevation and cold to reduce swelling, 2) compression to reduce swelling and provide support against reinjury, 3) gradual return to exercise and rehabilitation. What is the cause of joint dislocation? Dislocation is a separation of articular bones due to the disruption of surrounding ligaments. This can be a total dislocation or a “subluxation” (partial dislocation, partial contact).

Why should joints be “reduced” (re-located) within 30 minutes if possible? Pain doesn’t generally occur if the joint is relocated or reduced within 30 minutes. Reduction can be spontaneous, manual, or may need to be surgical. What’s the difference between a traumatic and pathologic dislocation? A traumatic dislocation occurs due to a high force. This can be recurrent as the ligaments are compromised. Pathologic dislocations can be due to infection, rheumatoid arthritis, or paralysis. Where do congenital dislocations routinely occur? In the hip and knee.

What is a “loose body?” Small pieces of bone or cartilage in a joint occurring from trauma or worn cartilage. These can be common in the knee, hip, ankle, and elbow, causing the joint to catch or lock. Treated arthroscopically. What are the 3 bones and 3 joints in the shoulder? What muscles make up the rotator cuff?

3 bones: scapula, clavicle, humerus. 3 joints: AC(acromioclavicular), glenohumeral, and sternoclavicular Muscles of the rotator cuff (SITS): supraspinatous, infraspinatous, teres minor, subscapularis

Describe the common shoulder injuries, both acute and overuse types. Rotator cuff injuries can be acute or due to overuse. Common overuse injuries are: tendinitis, bursitis, frozen shoulder, and impingement.

What are common knee injuries and when do they happen? Injuries can be to tendons, ligaments, patella, or menisci. Often happen during twisting or compression.

How do you treat a meniscal tear? A meniscal tear can be treated conservatively (rest and rehab) or with surgery. What is patellar subluxation and how is it treated? Knee cap slides out of its’ groove either partially (subluxation) or totally (dislocation). Conservative treatment is recommended first. What is chondromalacia? A knee cap injury usually on the underside of the patella. Characterized by pain in the front of the knee when sitting or when climbing stairs.

What disease are you at risk for long after a knee injury?


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Osteoarthritis. What is the most common form of bone lesion? Fractures

What 3 ways can fractures occur? 1. acute injury 2. pathologic cause 3. stress fracture

How are fractures categorized?

Location of fracture Type of fracture

What the five stages of fracture healing and the general timeline (where info was given)?

1. Hematoma – 48-72 hours after fracture. Blood encapsulates in a kind of splint and releases cell signals to begin repair

2. Cellular proliferation of osteoblasts as well as cellular proliferation in periosteum, endosteum, and medullary canal.

3. Callus formation – cartilage forms first (called a “collar”), then is calcified. Occurs in 3rd and 4th week after injury.

4. Ossification – formation of cortical bone with final layers of bone placed. Casts are removed at this point.

5. Remodeling – resorption of bony callus by the osteoclasts. How are fractures treated? By immobilization:

Splints Casts Traction External fixation (device with pins sticking into the bone from outside) Internal fixation (surgery to place plates/wires/screws in to fix bone in place..do this for

avulsion fractures) What are the three basic types of complications of fractures? Malunion, delayed union, nonunion. Discuss these more specific complications of fractures:

Fracture blister Caused by a separation of the epidermis around the fracture, usually around the elbow, ankle, knee, foot where there is very little cushion.


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Compartment syndrome Increased pressure in a limited space due to inelastic fascia. Neurologic symptoms occur and if not treated can lead to ischemia and necrosis of distal tissues. Treated by a fasciotomy. Reflex sympathetic dystrophy Can happen months or years after a fracture. Severe pain and autonomic nervous dysfunction. Characterized by temperature changes, localized sweating (hyperhydrosis), skin color changes, skin atrophy and a lack of hair growth. Fat embolism Happens with long bone fractures or major trauma. Fat droplets are released into the bloodstream, can lodge in lung causing respiratory failure, cerebral dysfunction, petechial rash.

What is the definition of “osteomyelitis” and what is it most often caused by? Osteomyelitis is an acute or chronic bone infection. Most often caused by the spread of the Staphylococcus aureus bacteria in the bloodstream which picks a bone and lodges there. Usually from a chronic infection elsewhere. Characterized by fever, chills, pain. Found more quickly via bone scan than by xray. Treatment is based on the cultures, but usually by IV antibiotics and surgery. Tuberculosis can cause bone infection.

What does hematogenous mean? Generating from the blood – refers to how osteomyelitis spreads from infection site to blood to bone. How does the bacteria get to the bone in osteomyelitis? Via the blood stream. What are the symptoms of osteomyelitis? How do you confirm that a patient has it? How is it treated? Pain, fever, chills. Treated based on the bacteria causing the infection, but generally with i.v. antibiotic infusion then surgery if needed. What does “contiguous spread” mean in light of it’s relationship with osteomyelitis? Infection from an adjacent site like a puncture wound, open fracture or diabetic ulcer. Characterized by a recurrent, persistent fever and poor wound healing. Diagnosed with biopsy and imaging, treated with antibiotics and surgery. What is chronic osteomyelitis? What are the symptoms and therapy? Infection persisting 6-8 weeks. Dead bone separates from living bone. Patient may not have fever, chills, or abnormal WBC count. Requires IV therapy for 6-8 weeks and probable surgery.


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Define osteonecrosis. Include causes and treatment. Death of a segment of bone due to interrupted blood supply. Can be caused by trauma, fracture, surgery, sickle cell anemia, alcoholism, corticosteroid use with high doses and long use. Treatment ranges from rest and anti-inflammatories to joint replacement. Discuss 4 types of childhood alterations in skeletal formation.

• Toe-in/toe-out • Bowlegs • Knock-knees • Flat foot

All can start in utero, but usually correct during normal growth.

What is osteogenesis imperfecta? What type of genetic categorization does it have? A hereditary (autosomal dominant) disorder – brittle bone disease. Define developmental dysplasia of the hip in light of 1) what it can cause, 2) how it is detected and treated, 3) what type of genetic inheritance it is. Developmental dysplasia of the hip of multifactoral inheritance. Can cause instability, subluxation, and dislocation of the hip. As early diagnosis is important, newborns are checked for this and it is treated by harnessing, traction, and casting. Define congenital clubfoot. Include 1) type of genetic inheritance, 2) risk factors, and 3) treatments. A condition of multi-factorial inheritance which can involve one or both feet. There is increased risk with family history and maternal smoking. Treatment is with manipulation, casting, surgery. What is Legg-Calve-Perthes disease? Osteonecrosis of the proximal femoral epiphysis found in children ages 2-13, predominantly in overweight boys. Symptoms include pain in the groin, hip, thigh or knee or a painless limp. Treatment ranges from observation to bracing to surgery. Define Osgood-Schlatter disease. Osgood-Schlatter disease includes micro-fracture where the patellar tendon inserts into the tibial tuberosity/tubercle. It is characterized with pain in the front of the knee, exacerbated by running, jumping, biking or stair climbing. It is treated with rest, bracing, cold, and anti-inflammatories. Discuss Slipped Capital Femoral Epiphysis. The femoral epiphysis unites around 14-16 years of age. Slippage can occur before this. Involves the epiphysis and diaphysis actually slipping apart. Seen in boys (usually overweight) more often than girls. Symptoms are knee pain, pain with walking, stiffness. It is treated with rest, traction, surgery. What is scoliosis?


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A lateral deviation of the spine that includes rotation or deformity of the vertebrae. Most curves are minor. It is more common in girls than in boys. There are 2 basic types: postural, which can be corrected with exercise, and structural.

Is scoliosis more common in boys or girls? Girls. What is the difference between postural and structural scoliosis? Postural can be corrected with exercises to retrain the muscles to be upright. Structural is fixed. It can be congenital, neuromuscular or idiopathic. Idiopathic scoliosis is of unknown etiology and is often classified by when it occurred (i.e., infantile, adolescent, etc.) or as a 2ndary cause of another condition such as cerebral palsy. What are the 3 causes of structural scoliosis? Congenital Neuromuscular Idiopathic What degree of curve is considered a normal variant? 10 degrees. What degree of curve is severe? 40 percent or greater. At what degree of curvature do you treat conservatively? 20 degree curvature or less are treated conservatively. What degree of curvature needs bracing? 30 to 40 degree curvatures require bracing. What degree of curvature requires surgical intervention? 40+ degrees of curvature requires surgical intervention. What are some signs of scoliosis? Shoulder height discrepancy, scapular differences, clothes fitting differently. Usually no pain unless severe. How is scoliosis diagnosed? With Xrays, CT and MRI scans, usually between the ages of 10 and 16.

What is osteopenia? Reduction of bone mass. Define osteoporosis. How is that different from osteopenia? Osteoporosis progresses from osteopenia. Osteoporosis is loss of bone architecture and increased fragility. It is most often due to aging, but could also be caused by conditions such as anorexia.


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What is the most common cause of osteoporosis? Aging: decrease in osteoblast/increase in osteoclast activity, lower estrogen levels in women and low testosterone levels in men. What are the contributing secondary factors? Endocrine disorder, cancer, malabsorption, alcoholism, corticosteroids (high doses, long time), prolonged medication use of anti-convulsants and steroids. At what age does the average person have optimal bone mass? Age 30 or so. Who is most at risk for osteoporosis? Postmenopausal white females with small frames, family history of the disease. Greater risk if a smoker, excessive alcohol or caffeine drinker, low calcium intake or sedentary lifestyle. What is the manifestation in the bone that indicates osteoporosis? Thin outer cortex, loss of trabecular bone. Painless until a fracture occurs What are some common types of fractures seen in osteoporosis? Hip, often at the femoral neck. Another common fracture are vertebral compression fractures. Wrist fractures too due to falls. How do you dx osteoporosis? Bone mineral density scan (BMD), scans hip and lumbar spine. Heel scans are a quick, inexpensive way to test as well, though not as thorough as the BMD. How do you prevent osteoporosis?

• Regular weight bearing activity • Calcium and vitamin D intake

How do you treat it? Best treated by prevention. Other methods include estrogen supplementation, intake of calcitonin, biophosphonates (which inhibit osteoclastic activity) and fall prevention.

Define osteomalacia. Include causes, symptoms, detection, and treatment. Osteomalacia is the softening of bone without loss of bone matrix. In children the condition is called rickets and is usually dietary and lack of sun exposure. Osteomalacia is caused by inadequate calcium absorption and/or reduced vitamin D activity (renal failure and inability of kidney to activate vitamin D for example). Symptoms of osteomalacia include bone pain, fractures, and muscle weakness. It is diagnosed via X-rays and lab work. It is treated by determining and treating the underlying cause and supplementing with Vitamin D and calcium. What is Paget’s Disease? Include age of onset, causes. Paget’s disease is a progressive disorder of unknown etiology with excessive bone destruction as well as structural change in long bones, skull and pelvis. There is increased osteoclast activity w/rapid bone resorption and irregular bone formation. The result is thick, coarse bone with a pitted outer surface.


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Onset is mid-adult age with increased risk with increasing age. Though some people are asymptomatic, when symptoms and complications do appear, they include:

• Skull: headaches, tinnitus, hearing loss • Kyphosis of the spine • Bowing of femur and tibia • Pathologic fractures, usually of femur, spine, and pelvis. • Cardiac failure, the most mortality factor in this disease, because blood flows to affected tissues

and away from heart resulting in high-output failure. • Osteogenic sarcomas in severe cases (5-10%)

How do you dx and treat Paget’s? Paget’s is diagnosed on X-ray and via lab work. Sometimes by bone biopsy. Treatment includes pain reduction, supression with calcitonin and biphosphonates to reduce osteoclastic activity, and supplementation with adequate portions of vitamin D and calcium.


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