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Diseases of the Musculoskeletal System. Steve Sandiford MBBS DM I Candidate/QEH. http://healthlibrary.stanford.edu/resources/bodysystems/musc_muscle.html http://orthoinfo.aaos.org/menus/diseases.cfm. Definitions…. Bones Muscles, tendons, ligaments Connective tissue Joints, cartilage.
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Diseases of the Musculoskeletal System Steve Sandiford MBBS DM I Candidate/QEH http://healthlibrary.stanford.edu/resources/bodysystems/musc_muscle.html http://orthoinfo.aaos.org/menus/diseases.cfm
Definitions… • Bones • Muscles, tendons, ligaments • Connective tissue • Joints, cartilage
Topics… • Metabolic bone disease • Tumors • Arthritis • Repetitive stress injuries
Patient presentation… • 76 yo white f • Bending over in garden 3 days ago • Sudden back pain • Mid thoracic area
Physical examination Kyphosis Antalgic gait Tenderness at T9 Normal neuro exam
Xray T9 Normal bone: Abnormal loads Abnormal bone; Normal loads
Work up… TOMEO • Tumor screening • Osteopenia screening • Marrow screening • Endocrine screening • Osteomalacia screening Tumor Osteopenia Marrow Endocrine Osteomalacia Metabolic; Tumor; Haematologic
Work up… Tumor Osteopenia Marrow Endocrine Osteomalacia FBC, ChemistriesSerum electrophoresisBence Jones proteins (MM)Thyroid function testsDiabetes evaluation Tc bone scan (metastases?)CT, MRI
Osteoporosis Osteomalacia Decreased Normal Bone mass Decreased Decreased Mineralization(Calcium content) Osteoporosis: decreased bone formation…. osteoblasts; increased resorption…. osteoclasts
Osteoporosis Normal Osteoporosis Shoulder; wrist; hip; vertebrae
Osteoporosis Type 11 Senile: M:F 2:1Cortical & trabecular Type 1 Post menopausalEsp trabecular bone Secondary osteoporosisHigh turnover osteoporosis Diabetes mellitusHyperparathyroidism, Hyperthyroidism Cushing's, Corticosteroid use
Risk factors: osteoporosis CaucasianEarly menopauseCigarette smokingXS caffeineXS alcoholExercise induced amenorrheaInactivity DietaryHigh fibreHigh proteinHigh phosphate
Work up… Densitometry Site Distal radius, calcaneus Spine, radius, hip, total body Spine Phalanges Single energy x-rayabsorptiometry Dual energy x-rayabsorptiometry:DEXA QuantitativeCT... most accurate Radiographicabsorptiometry
Work up… Densitometry Physics Xray tube emits 1 or 2 beams;Attenuation detected by photon counter. 1-3 rads CT density calculations cp known phantom. 100-200 rads Xrays of hand and aluminum wedge reference. 1-3 rads Single energy x-rayabsorptiometry Dual energy x-rayabsorptiometry (DEXA) QuantitativeCT Radiographicabsorptiometry
Osteoporosis Rx… Increase bone mass Calcium 1500mg, Vit D 400 unitsDi-phosphonates Fluorides Calcitonin: nasal spray ( osteoclasts)Estrogen + progestin Exercise Fosamax(Alendronate) oral; 10mg/day; 10% increase bone mass Decrease bone loss
Estrogen & progesterone Contraindications Hx breast caThromboembolismEndometrial disease Pre-Rx gyn examination ES receptors on osteoblasts and osteoclasts
Osteomalacia (Adult rickets) Vit D deficiencyDietaryMalabsorption Impaired Vit D synthesisLiver diseaseRenal diseaseHypophosphatemia Decreased available Calcium
Osteomalacia … Pseudofracture (Looser’s zones) Osteomalacia Rx… Nutritional osteomalacia responds well to administration of 10,000 IU weekly of vitamin D for 4 to 6 weeks
Bone Tumors Margins Well defined Sclerotic(Benign) Poorly defined Cortical breakthrough(Malignant) Metastasis from: Breast Prostate KidneyThyroid GI tract Matrix AppearanceDensity +/- calcification Architecture Metastasis more common than primary bone tumors
Multiple myeloma Punched-out lesions Most common primary malignancy of bone (2.5-100,000)Malignant plasma cells.. Abnormal ImmunoglobulinsBence Jones proteins (urine); Serum Protein electrophoresis ChemoRx
Xray appearance.. bone tumors Cloudy, blotchy Matrix Speckled calcification Cloudy, blotchy Hazy ground glass Permeative Moth eaten Honeycomb, soap bubble Prostate ca. (Pagets)
Xray appearance.. bone tumors Matrix Speckled calcification Cloudy, blotchy Hazy ground glass Permeative Moth eaten Honeycomb, soap bubble Permeative motheaten met. breast
Xray appearance.. bone tumors Soap bubble Honeycomb Matrix Speckled calcification Cloudy, blotchy Hazy ground glass Permeative Moth eaten Honeycomb, soap bubble Chondromyxoid fibroma Non-ossifying fibromaAneurysmal bone cyst
Xray Unicameral bone cyst(well defined) Margins Well defined Sclerotic Poorly defined Cortical breakthrough
Xray appearance.. bone tumors Codman’s triangle (Seen also in osteomyelitis) Osteosarcoma
Number of disordersSoft tissuesNerve entrapmentsTendinitis Repetitive Stress Injuries Cumulative Trauma Disorders
Presentation Specific entities Carpal Tunnel Syndrome Tennis elbow De Quervains Sub-acromial syndromes Cervical radiculopathy Abnormal posture Repetitive micro-trauma
Cumulative trauma Occupational hazard? Hairdresser Computer keyboard
At risk! Power tools… Vibration
Cumulative trauma Entrapment neuropathiesCarpal Tunnel Syndrome
Carpal Tunnel Syndrome Night Sx: pain, dysesthesias Thenar Muscle wasting Tinnel’s test Phalen’s test Nerve conduction tests!!!Bilateral!!! Rx: NSAID’s.. Brace.. Steroid injection.. Surgery
Sub-acromial syndromes Younger… trauma Older… degenerative CausesPatient factors: arthritis, anatomy, shape of bones External factors: sports, injury, work activity 54% over 60yrs have partial/complete tears
Treatment Pain? Tear? If on exam.. cant abduct against resistance Sub acromial injection steroid+lidocaine Attempt abduction against resistance Surgery: Subacromial decompression
Cumulative trauma Lateral EpicondylitisTennis Elbow Which muscles involved??
Tennis elbow NSAID’sBracingSteroid injectionSurgery Extensor Carpi radialis brevis/longus
Arthritis Degenerative (Osteoarthritis)Joint space narrowing; sclerosis; sub-chondral cyst; osteophytes; joint deformity; wt bearing jointsRx: analgesics; steroid (joint) injection Inflammatory (Rheumatoid arthritis)Auto-immune; polyarthritis75%pts Rh Factor (Abnormal Ig)Rx: analgesics; splinting; methyltrexate; prednisone.
Joint Replacement Knee Hip http://www.bio.davidson.edu/Courses/Immunology/Students/Spring2003/Super/rheumatoidarthritis.htm
Idiopathic Congenital Neuromuscular Abnormal vertebral formation Atrial Septal defectAbnormal kidney Trauma Tumors
PA 15 yo 84R Observation… BracingSurgery: Arthrodesis & instrumentation
Child with a limp Spine.. Hip.. Knee.. Foot/ankle Abnl neuro exam:Reflexes, BabinskiBladder/bowelBalanceFocal WeaknessBack pain at nightFevers... Weight lossLeg length discrepancy SpineNeoplasmInfectionTraumaScoliosis
The hip Decreased ROM esp Internal Rotation Severe pain on ROM: Infection Transient synovitisSeptic hipSUFE AVN/ Sickle CellPerthes
The hip Slipped Upper Femoral Epiphysis Age 11-13Obese boysEndocrine (hypoTh) AP & lateral xrays
The hip SUFE Treatment
The hip CRP, ESR, WBC, Temp Septic Hip…. Transient synovitis Xray/UltrasoundAspirate C&S, Gm stain Cell Ct (>50,000) IV antibiotics (Staph) INCISION & DRAINAGE Pain, poor ROM WBC >12,000ESR >40FeverNot Wt.Bearing
The knee 12 year old boy LimpAnterior knee pain (tibial tubercle); worse when doing high jump; no night pain No trauma
The knee Osgood Schlatters Fatigue fractures at growth plate of Tibial Tubercle apophysis (11-13yo) Pain on flexion Rx: rest, bracing
The knee Blounts Infantile 3y Adolescent 10y Medial physis, epiphysis & metaphysis Varus deformity RX: Brace. Surgery (osteotomy)