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Alterations of Musculoskeletal Function

This chapter discusses the classifications, manifestations, and treatment of musculoskeletal injuries, including fractures, dislocations, and bone disorders such as osteoporosis and osteomyelitis.

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Alterations of Musculoskeletal Function

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  1. Alterations of Musculoskeletal Function Chapter 42

  2. Musculoskeletal Injuries • Fractures • A fracture is a break in the continuity of a bone • Classifications • Complete or incomplete • Closed or open • Comminuted • Linear • Oblique • Spiral

  3. Fracture Classifications • Transverse • Greenstick • Torus • Bowing • Pathologic • Stress • Fatigue and insufficiency • Transchondral

  4. Fractures

  5. Bone Fractures • A broken bone can cause damage to the surrounding tissue, the periosteum, and the blood vessels in the cortex and marrow • Hematoma formation • Bone tissue destruction triggers an inflammatory response • Procallus formation

  6. Callus Formation

  7. Bone Fractures • Manifestations • Unnatural alignment, swelling, muscle spasm, tenderness, pain, impaired sensation, and possible muscle spasms • Treatment • Closed manipulation, traction, and open reduction • Improper reduction or immobilization • Nonunion, delayed union, and malunion

  8. Treatment

  9. Treatment

  10. Treatment

  11. Bone Fractures • Dislocation • Temporary displacement of two bones • Loss of contact between articular cartilage • Subluxation • Contact between articular surfaces is only partially lost • Dislocation and subluxation are associated with fractures, muscle imbalance, rheumatoid arthritis, or other forms of joint instability

  12. Support Structure Injuries • Strain • Tear or injury to a tendon • Sprain • Tear or injury to a ligament • Avulsion • Complete separation of a tendon or ligament from its bony attachment site

  13. Tendinopathy and Bursitis • Tendinitis • Inflammation of a tendon • Tendinosis • Painful degradation of collagen fibers • Bursitis • Inflammation of a bursa • Skin over bone, skin over muscle, and muscle and tendon over bone • Caused by repeated trauma • Septic bursitis is caused by a wound infection

  14. Tendinopathy and Bursitis • Epicondylitis • Inflammation of a tendon where it attaches to a bone • Tennis elbow (lateral epicondylitis) • Golfer’s elbow (medial epicondylitis)

  15. Tendinitis and Epicondylitis

  16. Tendinitis and Epicondylitis

  17. Muscle Strain • Sudden, forced motion causing the muscle to become stretched beyond its normal capacity • Local muscle damage • Muscle strains can also involve the tendons

  18. Myositis Ossificans • Complication of local muscle injury • Inflammation of muscular tissue with subsequent calcification and ossification of the muscle • “Rider’s bone” in equestrians • “Drill bone” in infantry soldiers • Thigh muscles in football players

  19. Rhabdomyolysis • Rhabdomyolysis (myoglobinuria) is a life-threatening complication of severe muscle trauma with muscle cell loss • Crush syndrome • Compartment syndromes

  20. Osteoporosis • Porous bone • Poorly mineralized bone • Bone density • Normal bone • 833 mg/cm2 • Osteopenic bone • 833 to 648 mg/cm2 • Osteoporosis • <648 mg/cm2

  21. Osteoporosis • Potential causes • Decreased levels of estrogen and testosterone • Decreased activity level • Inadequate levels of vitamins D and C, or Mg++ • Demonstrated by reduced bone mass/density and an imbalance of bone resorption and formation • Bone histology is usually normal but it lacks structural integrity

  22. Osteoporosis

  23. Osteoporosis

  24. Osteoporosis

  25. Osteoporosis • Perimenopausal osteoporosis • Iatrogenic osteoporosis • Regional osteoporosis • Postmenopausal osteoporosis • Glucocorticoid-induced osteoporosis • Age-related bone loss

  26. Osteomalacia • Deficiency of vitamin D lowers the absorption of calcium from the intestines • Inadequate or delayed mineralization • Bone formation progresses to osteoid formation but calcification does not occur; the result is soft bones • Pain, bone fractures, vertebral collapse, bone malformation

  27. Paget Disease • Also called osteitis deformans • Excessive resorption of spongy bone and accelerated formation of softened bone • Disorganized, thickened, but soft bones • Most often affects the axial skeleton • Thickened bones can cause abnormal bone curvatures, brain compression, impaired motor function, deafness, atrophy of the optic nerve, etc.

  28. Osteomyelitis • Osteomyelitis is most often caused by a staphylococcal infection • Most common cause is open wound (exogenous); also can be from a blood-borne (endogenous) infection • Manifestations • Acute and chronic inflammation, fever, pain, necrotic bone • Treatment • Antibiotics, débridement, surgery, hyperbaric oxygen therapy

  29. Osteomyelitis

  30. Bone Tumors • May originate from bone cells, cartilage, fibrous tissue, marrow, or vascular tissue • Osteogenic, chrondrogenic, collagenic, and myelogenic • Malignant bone tumors • Increased nuclear/cytoplasmic ratio, irregular borders, excess chromatin, a prominent nucleolus, and an increase in the mitotic rate

  31. Bone Tumors

  32. Bone Tumors • Patterns of bone destruction • Geographic pattern • Moth-eaten pattern • Permeative pattern

  33. Bone Tumors • Osteosarcoma • 38% of bone tumors • Predominant in adolescents and young adults; occurs in seniors if they have a history of radiation therapy • Contain masses of osteoid • “Streamers”: noncalcified bone matrix and callus • Located in the metaphyses of long bones • 50% occur around the knees

  34. Osteosarcoma

  35. Bone Tumors • Chondrosarcoma • Tumor of middle-aged and older adults • Infiltrates trabeculae in spongy bone; frequent in the metaphyses or diaphysis of long bones • The tumor contains lobules of hyaline cartilage that expand and enlarge the bone • Causes erosion of the cortex and can expand into the neighboring soft tissues

  36. Chondrosarcoma

  37. Bone Tumors • Fibrosarcoma • Firm, fibrous mass of collagen, malignant fibroblasts, and osteoclast-like cells • Usually affects metaphyses of the femur or tibia • Metastasis to the lungs is common

  38. Bone Tumors • Myelogenic tumors • Giant cell tumor • Causes extensive bone resorption due to the osteoclastic origin of the giant cells • Located in the epiphyses of the femur, tibia, radius, or humerus • The tumor has a slow, relentless growth rate • Myeloma

  39. Giant Cell Tumor

  40. Inflammatory vs. Noninflammatory Joint Disease • Differentiated by: • Absence of synovial membrane inflammation • Lack of systemic signs and symptoms • Normal synovial fluid analysis

  41. Osteoarthritis • Degeneration and loss of articular cartilage, sclerosis of bone underneath cartilage, and formation of bone spurs (osteophytes) • Also referred to as degenerative joint disease • Incidence increases with age • Primary disease is idiopathic

  42. Osteoarthritis • Osteoarthritis is characterized by local areas of damage and loss of articular cartilage, new bone formation of joint margins, subchondral bone changes, and variable degrees of mild synovitus and thickening of the joint capsule • Manifestations • Pain, stiffness, enlargement of the joint, tenderness, limited motion, and deformity

  43. Osteoarthritis

  44. Osteoarthritis

  45. Inflammatory Joint Disease • Commonly called arthritis • Characterized by inflammatory damage or destruction in the synovial membrane or articular cartilage and by systemic signs of inflammation • Fever, leukocytosis, malaise, anorexia, and hyperfibrinogenemia • Infectious or noninfectious

  46. Rheumatoid Arthritis (RA) • Inflammatory joint disease • Systemic autoimmune damage to connective tissue, primarily in the joints (synovial membrane) • Similar symptoms to osteoarthritis • Presence of rheumatoid factors (RA or RF test) • Antibodies (IgG and IgM) against antibodies • Joint fluid presents with inflammatory exudate

  47. Rheumatoid Arthritis (RA) • Pathogenesis • CD4 T helper cells and other cells in the synovial fluid become activated and release cytokines • Recruitment and retention of inflammatory cells in the joint sublining region • Viscous cycle of altered cytokine and signal transduction pathways • Possible immune complex deposition and inflammatory cytokine release • RANKL release and osteoclast activation • Angiogenesis in the synovium

  48. Rheumatoid Arthritis (RA) • Evaluation (4 or more of the following) • Morning joint stiffness lasting at least 1 hour • Arthritis of three or more joint areas • Arthritis of the hand joints • Symmetric arthritis • Rheumatoid nodules • Abnormal amounts of serum rheumatoid factor • Radiographic changes

  49. Rheumatoid Arthritis (RA)

  50. Rheumatoid Arthritis (RA)

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