MUSCULAR-SKELETAL PATHOPHYSIOLOGY

A&P Janet J. Nelson RN,CMA

FORMAT FOR PATHOPHYSOLOGY

1. BRIEF DESCRIPTION 2. ETIOLOGY3. SYMPTOMS AND SIGNS (S&S)4. DIAGNOSIS (DX)5. PREVENTION AND TREATMENT (TX)6. PROGNOSIS (PX)

DIAGNOSTIC TOOLS•RADIOLOGY/X-RAYS

•CT SCANS (COMPUTERIZED AXIAL TOMOGRAPHY

•MRI (MAGNETIC RESONANCE IMAGING)

• Bone Scan

OSTEOPOROSIS• A systemic condition in which there is wasting or deterioration or bone mass and density.• Postmenopausal women• 4:1 female/male ratio• Asymptomatic unless involves vertebrae, or

weight bearing bones• Spontaneous fractures of vertebrae result in loss of height• Dx: Bone Density studies• Tx: Calcium with Vitamin D, exercise, and

estrogen replacement

Osteoporosis

Osteoporosis magnified

Osteoporosis of vertebrae

Spinal Disorders

Lordosis:•“Swayback”, exaggerated anterior curvature of lumbar spine, often caused by compensation for additional abdominal girth caused by pregnancy, obesity or abdominal tumor

Spinal Disorders continued

Kyphosis•“Hunchback”, excessive posterior curve of the thoracic spine. Rounded shoulders and forward protrusion of the head.

Spinal Disorders continued

Scoliosis:• Lateral curvature of the spine

frequently insidious onset.

ARTHRITIS-Osteoarthritis

•Degeneration of the joint: articular cartilage thins and degenerative changes occur. New bone accumulates (bone spurs) and motion is limited. Nonsystemic•AKA- “Wear and Tear” Arthritis•Most common type of arthritis•Etiology: idiopathic, autoimmune, past injury•S&S: stiffness, crepitance, limited joint movement• Tx: palliative, PT, NSAIDS, arthroplasty, • Px:chronic, most people function normally with treatment

ARTHRITIS-Rheumatoid •Inflammation of synovial membrane with granulation tissue forming on articular cartilage which leads to erosion of cartilage. Systemic•Autoimmune disorder affecting adults and children•Insidious onset, usually between ages of 30-40•S&S: fatigue, malaise, anorexia, low fever, weight loss, lymphadenopathy, and later joint pain, swelling, redness and deformity. Joint involvement is usually bilateral.•DX: RA factor in blood and/or synovial fluid, exam•Tx:ASA, NSAIDS, SAIDS, Gold, rest, PT, arthroplasty•PX: Chronic and progressive

Arthritis, Osteoarthritis, Fibromyalagia, and Rheumatoid Arthritis Info

Arthritis continued

ARTHRITIS-Juvenile (JRA)• AKA: “Stills disease”, a form of RA that affects

children. Usually involves the large joints and begins ages 2-5.

• S&S: onset is more acute and systemic effects are more marked. Fever, rash, lymphadenopathy and hepatomegaly, as well as joint involvement.

• Females are affected four times more than boys. With epiphyseal plate involvement, growth is affected.

• Px: Remissions and exacerbations occur with complete remission in 75% of children.

ARTHRITIS-Gout• A disease which uric acid (byproduct of purine metabolism) accumulates in the blood and may deposit crystals in soft tissues of joint. (Kidneys too)• Heredity plays a factor, “Rich Man’s Disease” (diet is key factor)• Attacks are usually sudden, with agonizing pain in a single joint. (Often the first metatarsal joint of the great toe). Heat, redness, swelling are typical.• Dx: Blood and synovial fluid exam for uric acid • Tx: Meds, low purine diet, no alcohol, rest• Px: Good with treatment and life style changes

Gout cont.-Tophus

Tophus (Tophi plural): is a large, hard nodule consisting of uric acid crystals. They occur several years after first attack and develop in joint bursae, extensor surface of forearm and pinna of ear.

Osteomyelitis • Is an infection of the bone and the marrow. It is most often an acute infection; however, may remain undetected and evolve into a chronic condition.• Staphylococcus aureus is the bacterial organism responsible for 90% of osteomyelitis.• Open injuries and/or fracture are common cause but can also be associated with sickle cell anemia.• Dx: C&S of drainage from site, Sedimentation rate (ESR), CBC with elevated WBC, MRI, CT or Bone Scans• S&S: local pain, swelling, redness, warmth, pain. Systemic symptomsas well (temp, malaise, leukocytosis)

                                  

Osteomyelitis cont.• Tx: Parental or local antibiotics. Long term

treatment with follow-up to prevent recurrent infections. Bed Rest….increase protein in diet

• Special attention to chronic conditions e.g. diabetes, peripheral vascular disease.

• If chronic infection it may be necessary to debride necrotic tissue and infected tissue.

• Px: is improved when treatment takes place early and without other disabling diseases.

             

FRACTURES

• Etiology is often trauma (abuse or accidental) but could be pathological.• S&S: pain, deformity, swelling, crepitus, loss of limb function. If pulse is loss distal to injury it is vital to get medical help.

Fractures cont.•Dx: Exam with X-Ray (bilateral for

comparison)•Tx: closed or open reduction with

or without internal or external fixation devices. Immobilization with cast/splint.

•Neurovascular Assessment: skin color and temperature, sensation, pulses and ability to move.

HIP FRACTURES

• Typically at surgical neck or between the two trochanters.

• Neck fractures are classified as displaced, impacted or comminuted.

• Intertrochanteric fractures are always comminuted and usually more severe than femoral neck injuries

• Intertrochanteric Fracture• Complications with aged: infection, embolus,

decubitus ulcers,constipation, pneumonia, confusion, bladder complications, anemia with blood loss.

SPRAINS/STRAINS/DISLOCATIONSREVIEW:• Sprain: ligaments or tendons reinforcing a joint

are damaged by excessive stretching, or they are torn away from bone. Follows a sharp twist.

• Strain: an injury to a muscle or tendinous attachment. Follows vigorous muscle overuse or overstress.

• Dislocation: separation of two bones at a joint with loss of contact between articulating bone surfaces.

• Subluxation: partial dislocation with articulating surfaces in partial contact with each other.

MARFAN’S SYNDROME• Is a hereditary group of connective tissue conditions.• Characteristic S&S:

• patient is tall with long, narrow digits• abnormal length to extremities• Scoliosis is common • Subluxation of lens of eye• Cardiac and vascular anomalies (especially aorta). Often the

first indication is a fatal ruptured aortic aneurysm• Mitral valve prolapse and thickening of the cardiac valves

• Dx: Difficult because few have major features. Positive family history or skeletal signs warrant investigation. S&S + history and genetic testing

• Tx: Treat the various conditions with close observation of the aorta. Surgical intervention with aorta can lengthen life. For very tall girls, inducing precocious puberty by age of 10 with estrogens and progesterone may reduce ultimate height.

PAGET’S DISEASE of the bone

• A chronic disorder of the adult skeleton in which localized areas of bone become hyperactive, with replacement of the normal matrix with softened and enlarged bone.

• Cause is unknown although a viral infection (possible mumps) is believed to lay dormant as a skeletal infection and may erupt many years later as Paget’s.

• S&S Classic: flattening of base of skull and widening of upper head (hat no longer fits), clavicular prominence, bowed legs and thoracic kyphosis.

• DX: X-Ray, bone scan, bone biopsy

Paget’s cont.

• Tx: Calciton to retard bone reabsoprtion. Attempt to reduce risk of fractures

• Note: Pathological fractures are common. Compression fractures of the vertebrae

result in kyphosis.• Paget’s disease also causes cardio- vascular disease and heart failure

RICKETS• A disease of infancy & early childhood in which bones do not properly ossify. • Caused by Vitamin D deficiency. (Calcium may be

adequate by in the absence of Vitamin D it can be used). Other causes are lack of sunlight and/or malabsorption

• Lack of calcification at the epiphyseal plate; leading to weak bones and classic “bowed legs”. Child height is below normal. “Rickety Rosary”-sternum projects anteriorly and nodules form on ribs.

• Tx: Calcium with Vitamin D and sunlight. Prevent with Vit D fortified milk.

• Osteomalacia is term used to describe softening of bones in the adult .

KNEE INJURY• http://www.scoi.com/kneeanat.htm• The knee is a hinge joint and not designed for

side to side movement• Twisting usually results in injury to anterior or

posterior cruciate ligaments. • ACL tears result in a wobbly knee (View ACL

Reconstruction on hyperlink)• Meniscus tears are common with sport injuries.

When a piece tears off it can lodge in the joint and prevent normal movement. (View Arthroscopic Surgery on hyperlink)

ROTATOR CUFF TEAR

• SCOI Presents Anatomy of the Shoulder• Tears in the tendons of the rotator cuff

muscles produce an immediate snapping sound, acute pain and leave the person unable to abduct their arm

• Dx: Exam, history and arthroscopic exam• Tx: Repair with shoulder immobilization for 3

weeks and PT

                           

CARPAL TUNNEL SYNDROME

• SCOI Presents Carpal Tunnel Syndrome• CTS is the most common nerve entrapment

syndrome• The median nerve and blood vessels become

compressed• Compression neuropathy causes sensory and

motor changes in the median nerve distribution of the hand

• Dx: EMG with nerve conduction study• View carpal tunnel release in hyperlink

OSGOOD-SCHLATER DISEASE• Osteochondiritis of the tibial tuberosity.• Occurs between ages 10-15 years and more

common in males than females• Etiology is believed to be trauma from excessive

traction by the patella tendon on its immature epiphyseal insertion. Commonly unilateral.

• S&S: pain, swelling tenderness over tibial tuberosity• Dx: History, exam and X-ray showing fragmentation of tibial tuberosity• Tx: Immobolize, rest from sports etc., relief of pain, cortisone injection prn

OSTEOMA• The most common benign tumor of the bone• Tumor consists of hard, bony material, usually

develops at the end of a long bone. Often without symptoms

• Tx; Surgical removal is often used to remove discomfort and improve mobility

             

OSTEOGENIC SARCOMA

• A primary malignancy of the bone• Generally effects the epiphysis of long bones• Most common in young people (knee is

common)• Dx: Medical Imaging reveals osteonecrosis

and/or increase ossification and calcification• Rx: Chemotherapy until tumor stops shrinking.

Then surgical removal with possible amputation

• Metastasis often involves ribs, sternum or skull

MUSCULAR DYSTROPHY

• MD is a group of inherited disorders characterized by degeneration of skeletal muscle.

• The disorders differ in type of inheritance, area affected, age at onset, and rate of progression.

MD cont.• Basic pathophysiology is same for all types. A

metabolic defect, a deficit of dystrophin, a muscle cell membrane protein, leads to degeneration and necrosis of the cell. Skeletal muscle fibers are replaced by fat and fibrous connective tissue.

• Dx; Family history, muscle biospy, EMG, & elevated creatine kinase (CK) in blood

• No known treatment but PT, surgery and orthopedic devices reduce deformity and increase mobility

• Px: Poor, with Duchenne’s (common type) the child is in WC by age 9-12. Death results from cardiac or respiratory complications within 10-15 years of onset

HERNIATED DISC

The spinal column is made up of vertebrae that are cushioned by small disks consisting of a tough outer layer (annulus) and a soft, jelly-like inner layer (nucleus). These disks act as shock absorbers, protecting the spine and nerves from the stress of everyday tasks as well as strenuous work such as heavy lifting. When a disk herniates, a tear or weakness in the annulus allows the jelly-like nucleus to push out into the spinal canal. If it puts pressure on a spinal nerve, the herniated disk can cause pain, numbness or weakness in the back, legs or arms, depending on where the disk is located

HERNIATED DISC

MRI OF HERNIATED DISC

HERNIAA hernia occurs when part of an internal organ or body part protrudes through an opening into another area where it ordinarily should not be located. There are many different types of hernias, but the most common is when a portion of the intestine protrudes through a weak area in the muscular wall of the abdomen. This causes an abnormal bulge under the skin of the abdomen, usually near the groin or the navel.

HERNIAS

INQUINAL HERNIA VENTRAL HERNIA

Hernia Continued

UMBILICAL HERNIA HIATAL HERNIA

The End