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Disorders of the Skeletal System, Metabolic and Rheumatic Disorders

Terms in this set (93)

Differentiate among the types of soft tissue injuries and describe the healing process of these types of injuries
A contusion
Hematoma
A contusion: is an injury, or bruise, that results from direct trauma and is usually caused by striking the body part against a hard object. The injured tissue undergoes a well-defined sequence of events including microscopic rupture of blood vessels and damage muscle cells.

Hematoma: A large area of local hemorrhage. The pain and swelling of a hematoma take longer to subside than those accompanying a contusion
Strain definition and manifestations
Involves muscle/tendon

Partial tear, often during muscle contraction

Risk increases with age b/c collagen fibres less elastic

Common in back, cervical spine, elbow, shoulder

Sports injuries: strains of muscle units around the hip, hamstring, and quadriceps commonly associated with athletic injuries

Manifestations
-Often no visible signs unless inflammation
-Pain
-Stiffness, swelling, tenderness
Sprain definition and manifestation
Tearing or rupture of supporting ligament or capsule surrounding joint
d/t abnormal/excess joint movement
common - ankles

Diagnosis
Not visible on X-ray unless bone fragment

Manifestations
Pain
Rapid swelling limits movement
Discoloration
Last longer than strain
Ankle joint most commonly involved
Strain/Sprain Healing
-Able to heal to original tensile strength
-Capillaries bring oxygen/nutrients
-Fibroblasts produce collagen, capillaries infiltrate the injured are during the initial healing process and supply the fibroblasts with the materials they need to produce large amounts of collagen.
-Collagen bundles strengthen over time
-Compression, accomplished through the use of adhesive wraps, helps to reduce swelling and provide support. Immobilization may be required for severe sprains, especially those severe enough to warrant surgical repair

Complications:
Contraction can pull healing apart and result is lengthened position upon final healing
Adhesions
Dislocations:
Abnormal displacement of articulating surfaces of joint. Usually follows severe trauma that disrupts the holding ligaments

Diagnosis
History, assessment, x-rays

Manifestation
Pain, Deformity, Limited movement. Treatment depends on the site, mechanism of injury, and associated injuries such as fractures.
Subluxation dislocations
Partial dislocation
Some surface contact
Common joint dislocations
Shoulder
Acromioclavicular
Congenital (inherited) dislocations
Hip or knee usual
Traumatic dislocations
MVA: Due to the direction of impact - hip
Athletics: May become recurrent - shoulder, knee
Fall: elderly population - wrist ankle
Pathologic dislocations
Complication of infection, rheumatoid arthritis, neuromuscular disease
Shoulder injury
Composed of three bones: Scapula, Clavicle, and Humerus
Clavicle fracture common d/t childhood falls/blow
Most resolve without surgery
Immobilize with sling

two kinds
Acromioclavicular joint
Glenohumeral joint
Acromioclavicular joint
Common athletic injury: Classic cause; direct blow to the acromion with the humerus in an adducted position. Can also be caused by indirect trauma, such as falling on an outstretched arm or elbow.
Glenohumeral joint
Very common dislocation: Most common to likely develop problems with instability. Fall on an outstretched arm or elbow to the posterior shoulder.
- When arm is extended
Rotator Cuff Injury:
• Function of cuff is to stabilize the humoral head against the glenoid
• shoulder joints are inherently unstable
Rotator Cuff Injury: Common resulting conditions: account for substantial majority of shoulder problems.
and manifestations
• Tendinitis
• Subacromial bursitis
• Partial/complete tears
Manifestations of rotator cuff
• The major clinical features rotator cuff disorders are pain, tenderness, and occasionally muscle atrophy. Pain and impingement may be noted when motions of the arm squeeze and pinch cuff tendons between the humerus and the overlying arch
• At night time
• Difficulty abducting/rotating arm
• Muscle atrophy
Diagnosis for rotator cuff:
• Assessment of active & passive ROM
• History of injury
• MRI
• Arthroscopic examination
Knee injuries: kinds
Ligamentous injuries
• ACL rupture/tear is most common

Meniscus injuries Manifestations
Patellar subluxation and dislocations
Patellofemoral pain syndrome
Ligamentous injuries: Most serious of knee injuries - what one is most common and manifestations of it?
ACL rupture/tear is most common
o Primary knee stabilizer
Manifestations of ACL rupture/tear
o "Pop" or tearing sensation
o Sudden pain
o Loss of weight bearing
o Hemorrhage causes swelling
Meniscus injuries Manifestations
• Pain, especially on hyperflexion & hyperextension
• Edema
• Instability
• Locking d/t loose fragment
• Occur from rotational or blows to the knee

Complications: Loss of meniscal function is associated with progressive deterioration of knee function and osteoarthritic changes.
Patellar subluxation and dislocations
Usually sports related

Manifestations:
• Weakness
• Swelling
• Crepitus- a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone
• Stiffness
• Loss of ROM
Patellofemoral pain syndrome
Most common cause of anterior knee pain

Causes:
- Imbalance of forces controlling patella movement
- Contact of posterior surface of patella with femur
-Running, jumping, sitting

Manifestations:
¬ Pain
¬ Weakness
¬ Absence of edema
Hip:
risk factors of hip fracture
Dislocation: Is an emergency

Due to trauma: Accompanied by severe pain and inability to move the lower extremity

Disruption of blood and nerve supply
- Avascular necrosis -is the death of bone tissue due to a lack of blood supply

Risk Factors
- Age
- Women
- Physical inactivity
- Alcohol excess
- Psychotropic medications
- Visual impairments
- Polypharmacy
- Osteoporosis

Sudden Injury /or/ Stress Fractures
- Incomplete fractures
o Fatigue fracture
Any weight-bearing bone - e.g.,: tibia SF can be mistaken for "shin splint"
o Pathologic fracture Bone weakened by previous disease/tumor
- Names:
o Subcapital
o Neck
o Intertrochanteric
o Subtrochanteric
Compare muscle strains & ligamentous sprains
Muscle strain are much more minor than that of ligamentous sprains.

muscle strain is an injury to a muscle in which the muscle fibers tear as a result of overstretching. A strain is also colloquially known as a pulled muscle or torn muscle.

uses RICE
Rest: Rest is necessary to accelerate healing and reduce the potential for reinjury.
Ice: Apply ice to reduce swelling by reducing blood flow to the injury site. Never ice for more than 20 minutes at a time.
Compression: Wrap the strained area to reduce swelling with a soft-wrapped bandage.
Elevation: Keep the strained area as close to the level of the heart as is conveniently possible to keep blood from pooling in the injure¬

Whereas ligamentous strains are usually accompanied by stiffness, pain and swelling, there is no real indicator that damage has occurred, unless inflammation is present. Fibroblasts produce collagen, capillaries infiltrate the injured are during the initial healing process and supply the fibroblasts with the materials they need to produce large amounts of collagen. Recurrence of the strain can happen with contraction or stress of the muscle/ligament.
d area.
Discuss causes and consequences of a joint dislocation
Wide range of causes for joint dislocation, such as: Motor vehicle accidents, sports related injuries, falls on specified joints, imbalance of forces, running, jumping, sitting, stretching, ect...

Consequences: Pain, swelling limits movement, complications of infection, rheumatoid arthritis, neuromuscular disease/degeneration, surgery, immobilization, subacromial bursitis, muscle atrophy, ect...
Compare shoulder and knee joint injuries
Shoulder: Most resolve W/O surgery, and can be immobilized with a sling.
¬ Acromioclavicular joint damage is most common with athletic injuries, as well as the glenohurmeral joint is also a very common injury
¬ Injuries are a result of a combination of direct blow or stretch, excessive use/repetition, altered blood supply to tendons, and age related degeneration.
¬ Common resulting conditions due to injury are: Tendinitis, subacromial bursitis, and complete/partial tears. Pain, tenderness, difficulty abducting and rotating arm and muscle atrophy are common manifestations.

Knee: 4 types: Ligamentous, meniscus, patellar subluxation/dislocation, and patellofemoral pain syndrome.
¬ ACL Rupture/tear is the most common, manifested by a tearing sensation, sudden pain, loss of weight bearing and hemorrhage.
¬ Causes of injuries vary from sports related, imbalance of forces, running, jumping, twisting and sitting.
¬ Surgery is most always used to replace/fix torn ligaments.
Compare hip dislocation and hip fracture with respect to risk factors and complications
Hip dislocation is an emergency. The disorder is typically accompanied by severe pain and inability to move the lower extremity.
¬ Cause is usually associated to trauma. Involves the disruption of blood and nerve supply, causing avascular necrosis to occur

A hip fracture is usually a fracture of the proximal femur. Such fractures are commonly categorized according to the anatomic site in which they occur.
¬ The primary goal of treatment for a hip fracture is to return to the pre-injury level of functionality as soon as possible. Surgery is the most common for of treatment amongst the elderly, whereas healthy young people are treated by reduction of the fracture (if needed) and internal fixation.
Discuss the differences between stress fractures and those caused by sudden injury
¬ Stress fractures are incomplete fractures. They may be described as either fatigue or pathologic fractures. Fatigue stress fractures occur when excess force is applied to normal bone. They may occur in any weight-bearing bone, but they are most common in the metatarsal, neck of the femur, calcaneus, tibia, fibula, and pelvis.
¬ Fatigue stress fractures usually occur in unconditioned athletes, and can commonly be mistaken for" shin splints "
¬ Pathologic stress fractures occur when normal stress is applied to bones that have been weakened by disease or tumors.

¬ A fracture represents the disruption in the continuity of a bone. A fracture occurs when more force is placed on a bone than it can withstand.
¬ Grouped according to cause, fractures can be placed into three categories... (1). Fractures caused by sudden injury, (2). Fatigue stress fractures, and (3). Pathological stress fractures.
¬ The most common fractures are those resulting from sudden injury. The force causing the fracture may be direct, such as a fall or a blow, or indirect, such as a massive muscle contraction or trauma transmitted along the bone.
Identify the classifications of fractures based on position on bone, degree of communication with the outside environment, degree of break, character of fracture pieces, and direction of break
¬ A fracture of the long bone is described in relation to its position in the bone—proximal, mid-shaft, and distal. A fracture can be classified as open or closed. When the bone fragments have broken through the skin, the fracture is called open. In closed fractures, there is no communication with the outside skin.
¬ A greenstick fracture, which is seen in children, is an example of a partial break in bone continuity and resembles that seen when a young sapling is broken
¬ A comminuted fracture has more than two pieces.
¬ A compression fracture, as occurs in the vertebral body, involves two bones that are crushed or squeezed together.
A fracture is called impacted when the fractured fragments are wedged together. This type usually occurs in the humerus, often in less serious, and usually treated without surgery.
¬ Reduction is the restoration of a fractured bone to its original/normal anatomic position
¬ Transverse fractures are caused by simple angulatory forces.
A spiral fracture results from a twisting motion, or torque.
A transverse fracture is not likely to become displaced or lose its position after it is reduced.
On the other hand, spiral, oblique, and comminuted fractures often are unstable and may change position after reduction.
List the signs and symptoms of a fracture
¬ The signs and symptoms of a fracture include pain, tenderness at the site of bone disruption, swelling, loss of function, deformity of the affected part, and abnormal mobility.
¬ In long bones, three types of deformities:
- Angulation, shortening, and rotation, are seen.
- Severely angulated fracture fragments may be felt at the fracture site and often push up against the soft tissue to cause a tenting effect on the skin. Bending forces and unequal muscle pulls cause angulation.
- Shortening of the extremity occurs as the bone fragments slide and override each other because of the pull of the muscles on the long axis of the extremity.
- Rotation deformity occurs when the fracture fragments rotate out of their normal longitudinal axis; this can result from rotational strain produced by the fracture or unequal pull by the muscles that are attached to the fractured fragments.
Describe the fracture healing process
Bone healing occurs in a manner similar to soft tissue healing, however, it is a more complex process and takes longer.
1. Hematoma formation occurs during the first 1-2 days after fracture. Disruption of blood vessels also leads to death of bone cells at the fracture site. In 2-5 days, the hemorrhage forms a large blood clot. Hematoma formation is thought to be necessary for the initiation of the cellular events essential to bone healing.
2. The next event in fracture healing is formation of granulation tissue or soft tissue callus. During this stage of bone heling, fibroblasts and osteoblasts migrate into the fracture site from the nearby periosteal and endosteal membranes and begin reconstruction of bone. Osteoblast begin depositing bone into the matrix.
3. Ossification represents the depositing of mineral salts into the callus. This stage usually begins during the third to fourth week of fracture healing. During this stage, mature bone gradually replaces the fibrocartilaginous callus, and the excess callus is gradually reabsorbed by the osteoclasts.
4. Remodeling involves resorption of the excess bony callus that develops in the marrow space and encircles the external aspect of the fracture site

¬ Malunion is healing with deformity, angulation or rotation that is visible on x-ray films.
¬ Delayed union is the failure of a fracture to unite with the normal period.
¬ Nonunion is failure to produce union and cessation of the processes of bone repair.
¬ Diet is very important for bone healing
o Rich in protein and V-C to absorb the protein - green veg, oranges, supplements
Discuss the complications of fractures and the healing process
Fracture blisters
compartment syndrome
Fat Embolism Syndrome: (FES)
fracture blisters
Fracture blisters: they are seen with more severe, twisting types of injuries but can also occur with excessive joint manipulation, dependent positioning, and heat application, or from peripheral vascular disease. They can be solitary, multiple, or massive, depending on the extent of injury. Most fracture blisters occur in the ankle, elbow, foot, knee, or areas where there is a little soft tissue between the bone and the skin.
o Epidermal necrosis due to fluid separating it from the dermis
o Often where minimal s/c tissue between epidermis and bone
o Chance of infection if broken
Compartment syndrome: and differentiate between chronic and acute
Compartment syndrome: has been described as a condition of increased pressure within a limited space that compromises the circulation and function of the tissues within the space (Abdominal and limb compartments). Compartment syndrome can result from a decrease in compartment size, an increase in the volume of its compartments, or a combination of the two factors. Among the causes of decreased compartment size are constrictive dressings and casts, closure of facial defects, and burns. An increase in compartment volume can be caused by trauma, swelling, vascular injury and bleeding, and venous obstruction.
o Acute compartment syndrome can occur after a fracture crushing injury, when excessive swelling around the site of injury results in increased pressure in a closed compartment.
o Chronic compartment syndrome may develop in long-distance runners or others involved in a major change in activity level. Treatment consists of reducing compartmental pressures. This entails cast splitting or removal of restrictive dressings; However, excessive elevation should be avoided because the effects of gravity can lower the arterial pressure in the limb, thereby decreasing compartmental perfusion.

Manifestations:
Severe pain
Sensation change - burning/tingling/loss
Diminished reflexes, motor function loss
Decreases/loss peripheral pulses
fat embolism syndrome
Fat embolism syndrome refers to a constellation of clinical manifestations resulting from the presence of fat droplets in the small blood vessels of the lung or other organs after a long bone fracture or other major trauma.
o The main clinical features of FES are respiratory failure, cerebral dysfunctions, and skin mucosal petechiae. Cerebral manifestations include encephalopathy, seizures, and focal neurological deficits unrelated to head injury.
o The first symptoms include subtle change in behaviour and signs of disorientation resulting from emboli in the cerebral circulation combined with respiratory depression. Diaphoresis, pallor, and cyanosis become evident as respiratory function deteriorates. A petechial rash that does not blanch with pressure often occurs 2-3 days after the onset of the symptoms. This rash usually is found on the anterior chest, axillae, neck and shoulders.
o Common but few people have symptoms or complications
o Fat droplets from bone & adipose tissue circulate though venous system to body
o Not the same as a "fat emboli"

Manifestations
-Respiratory failure - Dyspnea, pallor, cyanosis, Angina, tachycardia, diaphoresis
-Cerebral dysfunction - Early or late sign - Mentation/behaviour changes - Focal deficits, encephalopathy, seizures
-Skin/mucosa petechiae - Rash 2 - 3 days post event
Explain the implications of bone infections
Osteomyelitis represents and acute or chronic infection of the bone marrow. Despite the common use of antibiotics, these infections remain difficult to treat and eradicate. All types of organisms, including parasites, viruses, bacteria and fungi, can cause osteomyelitis, but certain pyogenic bacteria and mycobacteria are the most common

Infection of bone
-Direct contamination
-Hematogenous (thru blood)
-Via skin lesion

Staphylococcus aureus most common
-Adheres to bone, attacks cells
-Evades host defenses and colonizes
compare the characteristics of hematogenous osteomyelitis and chronic osteomyelitis
Hematogenous Osteomyelitis: originates with infectious organisms that reach the bone via the bloodstream.
o Acute hematogenous osteomyelitis occurs predominantly in children.
o In adults, it is seen more commonly in debilitated persons and in those with a history of chronic skin infections, chronic urinary tract infections, and intravenous drug use in those who are immunologically suppressed.
o The pathogenesis of hematogenous osteomyelitis differs in children and adults.
♣ In children, the infection usually affects long bones of the appendicular skeleton. With advancement of the infection, purulent exudate collects in the rigidly enclosed bony tissue.
♣ In adults, the long bone microvasculature no longer favors seeding, and hematogenous infection rarely affects the appendicular skeleton. Instead, vertebrae, sternoclavicular and sacroiliac joints, and symphysis pubis are involved. Infection usually first involves subchondral bone, then spreads to the joint space.

Manifestations
♣ Signs of bacteremia
♣ Fever, chills
♣ Pain on movement
♣ Tenderness
♣ Erythema
♣ Edema
♣ Malaise

- Chronic osteomyelitis: usually occurs in adults. Generally, these infections occur secondary to an open wound, most often to the bone or surrounding tissue. It may be the result of delayed or inadequate treatment of acute hematogenous osteomyelitis caused by direct contamination of bone or exogenous organisms. The hallmark feature of chronic osteomyelitis is the presence of infected dead bone., a sequestrum, that has separated from the living bone. The treatment for bone infections begins with wound cultures to identify microorganisms and its sensitivity to antibiotic therapy. Initial antibiotic therapy is often followed by surgery to remove foreign bodies or sequestra and by long-term antibiotic therapy.
o Usually adults
o Usually secondary to open wound
o Sequestrum - Infected dead bone , separated by sheath
o Difficult to detect when near a joint prosthesis (an artificial body part, such as a leg, a heart, or a breast implant)
Sequestrum
a piece of dead bone tissue occurring within a diseased or injured bone, typically in chronic osteomyelitis
Discuss the etiology and results of osteonecrosis
Osteonecrosis is an aseptic destruction of a segment of bone that is due to an interruption ion blood flow rather than an infection. It is a relatively common disorder and can occur in the medullary cavity of the metaphysis and the subchondral region of the epiphysis, especially in the proximal femur, and proximal humerus. Destruction of bone frequently is severe enough to require joint replacement surgery.
o Bone destruction d/t interruption in blood flow
♣ Idiopathic - relating to or denoting any disease or condition that arises spontaneously or for which the cause is unknown.
♣ Bone injury - fractures
♣ Thrombosis/embolism - Sycle cell disease - deep sea diving
♣ Vessel injury - radiation therapy
♣ Increased intraosseous pressure
♣ Corticosteriod associated (unclear)

Manifestations
- Chronic pain, unrelated to movement

- Although bone necrosis results from ischemia, the mechanisms producing the ischemia are varied and include mechanical interruption such as occurs with fracture; thrombosis and embolism, vessel injury, and increased intraosseous pressure with vascular compression.
- Other than vessel injury and obstruction, the most common causes of bone necrosis are idiopathic (those of unknown causes), and prior steroid therapy.
- The pathological features of bone necrosis are the same, regardless of cause. The site of the lesion is related to the vessels involved. There is necrosis of cancellous bone and marrow. The cortex usually is not involved because of the collateral blood flow.
- The symptoms associated with osteonecrosis are varied dependent on the site and extent of infarction. Typically, subchondral infarcts cause chronic pain that is initially associated with activity, but gradually becomes more progressive until it is experienced at rest. Subchondrial infarcts often collapse are predispose the patient to severe secondary osteoarthritis.
Osteopenia
X-ray evidence of decreased bone mineral density (BMD)

reduced bone mass of lesser severity than osteoporosis.
Causes
• Osteoporosis
• Osteomalacia
• Malignancies
• Endocrine disorders
osteoporosis
a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D.
osteomalacia
softening of the bones, typically through a deficiency of vitamin D or calcium.
Define osteopenia as it relates to osteoporosis and osteomalacia
X-ray evidence of decreased bone mineral density (BMD)

Therefore, osteoporosis and osteomalacia cause osteopenia - decrease bone matrix due to the imbalance between bone formation and destruction
- Endocrine disorders that alter calcium stores or uptake
Describe the risk factors and factors that contribute to the development of osteoporosis and relate them to the prevention of the disorder
Matrix is weakened and mineralization is decreased

Associated (risk factors):
-Gender
- Postmenopausal osteoporosis is when estrogen deficiency manifested by a loss of cancellous bone and predisposition to fractures of the vertebrae and distal radius
- Male hormone declination
-Genetics, Race
-Activity level
-Nutrition
-Body size (Smaller > chance than larger)
-Age-related changes because of decreased osteoblast activity (Decreased physical activity levelsPostmenopausal - Estro, gen lack - for bone formation ,Nutrition, Caffeine, smoking)

Female Athlete Triad
- Emphasis of leanness and low body weight: Eating disorders (i.e. dietary restrictions) combined with excess exercise result in weight (fluctuations effects gonadotropic hormones)
Decreased LH, FSH
Decreased estrogen
=
Amenorrhea - the absence of a menstrual period in a woman of reproductive age
Osteoporosis/osteopenia

MORE
-Fractures d/t
-Loss of trabeculae from cancellous bone
-Thinning of cortex
-Postmenopausal Osteoporosis
-Increased osteoclastic activity results in loss of trabeculae
-Microfractures occur, bone compresses
-Senile/age-related osteoporosis
-Haversian system widens d/t loss of trabeculae
-Silent disorder
-Sudden onset fracture
-Hip, pelvis, humerous, etc
-Wedging/collapse of vertebrae (loss of height and syphosis/dowager)
-No bone pain unless fracture

Secondary osteoporosis (factors) - have a direct defect on bone tissue
- Endocrine Disorders
• Hyper/hypothyroidism (high of low levels of thyroid hormone which regulate the body's metabolic rate as well as heart and digestive function, muscle control, brain development and bone maintenance. Its correct functioning depends on having a good supply of iodine from the diet)
• Hyperparathyroidism (Effects calcium balance)
• Cushing syndrome (when your body is exposed to high levels of the hormone cortisol for a long time. Cortisol, which is produced in the adrenal glands, plays a variety of roles in your body. For example, cortisol helps regulate your blood pressure and keeps your cardiovascular system functioning normally.)
• Diabetes Mellitus (Malabsorption Issues)
• Celiac disease - GI absorption (Malignancies)
• Multiple myeloma (a malignant tumor in the bone marrow)
- Alcoholism (Alcohol is a direct inhibitor of osteoblasts and may also inhibit calcium absorption)
- Medications
• Corticosteroids
• Antacids with aluminum
• Anticonvulsants
• Antiretroviral therapy
- Premature Infants (Issues that will pre-dispose)
- Cystic Fibrosis (Imbalance between bone reabsorption and formation such that bone resorption exceeds bone formation)

Diagnosis and treatment:
- Daul-energy x-ray absorptiometry (DEXA) of the spine and hip
- Prevention and early detection of osteoporosis are essential to the prevention of associated deformities and fractures
- Regular exercise
- Adequate Calcium and V-D intake
- Weight bearing exercises

Drugs:
• Bisphosphonates - inhibitor of bone reabsorption = most effective
• Recombinant parathyroid hormone
• Selective estrogen receptor modulators - raloxifene - specific estrogen receptor PM women
• Calcitonin - inhibits osteoclastic activity
Describe the primary features of osteoporotic bone and resulting manifestations of this disease
Primary features
- Changes occurs in the diaphysis and metaphysis of bone. Loss of trabeculae from cancellous bone and thinning of cortex occurs.
-
-2 distinct disease processes:
•Postmenopausal Osteoporosis increases osteoclastic activity results in loss of trabeculae
and microfractures occur, and bone compresses.
•Senile/age-related osteoporosis. the Haversian system widens d/t loss of trabeculae

Manifestations
- Silent disorder
- Sudden onset fracture
- Wedging/collapse of vertebrae
- No bone pain unless fracture
Compare the pathogenesis and manifestations of osteomalacia
Softening of bones d/t inadequate mineralization (is deposition of calcium hydroxyl apatite salts converting osteoid to rigid bone) - adult condition

Manifestations
- Bone pain, tenderness
- Muscle weakness an early sign
- Fractures of radius, femur But not a significant cause of hip fractures
- Delayed healing of fractures and deformities
- Hyperparathyroidism d/t low calcium levels

Causes
- Insufficient Ca+2 absorption from intestines d/t: lack of dietary calcium or a deficiency of or resistance to the action of V-D
- Phosphate deficiency d/t: increased renal losses or decreased intestinal absorption
- Anticonvulsant use (long term)
Adult Rickets (type of Osteomalacia)
Renal rickets
• Occurs with chronic renal failure
• d/t inability of kidney to activate Vitamin D & excrete phosphate

Vitamin D resistant rickets
• Familial renal tubular defect
Rickets (childhood disease)
- Inadequate calcium absorption from diet
- Lack of Vitamin D
- Failure/delayed calcification of cartilaginous growth plate = overgrowth
- Metaphyseal regions of long bones widen/deform as unmineralized
Rickets (Causes, risks and manifestations)
-Nutritional deficits
-Kidney failure
-Malabsorption syndromes, GI loss
-Medications (anticonvulsants, aluminum antacids)
-Genetic

Risks for Rickets
- Breast fed only (need a V-D supplement - 2 months)
-Dark-skinned
-Limited sunlight

Manifestations
-Enlarged skull
-Oversized joints
-Delayed fontanel closure
-Slow tooth growth
-Abnormal shaped thorax
-Bowed legs
-Difficult ambulation
-Stunted growth
discuss the etiology and general manifestations of rheumatoid arthritis
Autoimmune systemic disease
- HT cells activate and the local inflammatory mediators and cytokines destroy the joint and formation of antibodies directed against joint-specific and systemic autoantigens

Polyarticular
- arthritis affects five or more joints within the first six months of having JIA.

Etiology
- Uncertain
- Genetic predisposition and development of joint inflammation that is immunologically mediated
- Women > men
- Peak incidence 40-75 years of age
Describe the pathologic changes that can be found in the joint of a person with rheumatoid arthritis
T-cell mediated response to trigger and Inflammatory mediators released. Antibodies form against auto antigens.

Rheumatoid factor (RF) is high RF titer is associated with severe and unremitting disease, mainly systemic complications . RF is an antibody - occurs in 70-80% of patients.

o Synovial inflammation and joint destruction result
o Fluid accumulates (inflammatory process)

o Neovascularization (is the formation of functional microvascular networks with red blood cell perfusion) in synovial membrane

o Pannus: vascular granulation (specific to RA). It is destructive and extends from the synovium to involve the bare area a region of unprotected bone at the junction between cartilage and subchondral bone. The tissue is formed that is destructive to joint. Results in Inflammatory erosion of cartilage/bone. This is irreversible.
Pannus:
vascular granulation (specific to RA). It is destructive and extends from the synovium to involve the bare area a region of unprotected bone at the junction between cartilage and subchondral bone. The tissue is formed that is destructive to joint. Results in Inflammatory erosion of cartilage/bone. This is irreversible.
Neovascularization
(is the formation of functional microvascular networks with red blood cell perfusion) in synovial membrane
List the extra-articular manifestations of rheumatoid arthritis
Articular manifestations:
-Symmetrical
-Polyarticular - arthritis that affects five or more joints within the first six months of having JIA. It is the second most common type of JIA in children and teenagers. There are two types of polyarticular arthritis: The first type has a positive rheumatoid factor (RF) result on a blood test, and the second type has a negative RF result. RF is an antibody that is present in the blood in certain types of JIA.
-Diarthrodial/synovial a form of articulation that permits maximal motion, as the knee joint. Joins bones with a fibrous joint capsule that is continuous with the periosteum of the joined bones, constitutes the outer boundary of a synovial cavity, and surrounds the bones' articulating surfaces
-Joint pain
-Joint swelling
-Limited joint movement
-Wrists, finger joints common (Pain when turning doorknob, opening jars, buttoning shifts, etc. )
-Feet (Pain on ball of feet when rising in morning and Widening of forefoot d/t inflammation)
-Ankles, knees, elbows, shoulders, spine
-Subluxation (a partial dislocation)
-Joint instability
-Swelling and thickening of synovium stretches joint capsule and ligaments ( results in Deformities, Muscle imbalances, Swan neck deformities of hand)

Extra- Articular manifestations:
-Fatigue, weakness, anorexia, weight loss
-Elevated ESR & C-reactive protein (CRP)
-Rheumatoid nodules (Granulomatous lesions with central necrotic core. They are either tender, or not; Moveable, or immovable; Small or large; Numerous other but they are more rare)
- Discuss the parameters for diagnosing rheumatoid arthritis
Four or more:
-Morning stiffness of > 1 hour x 6 weeks
->3 joint swelling x 6 weeks (simultaneous)
-Swelling of wrist or finger joints x 6 weeks
-Symmetric joint swelling x 6 weeks
-Rheumatoid nodules are firm lumps under the skin
-Serum RF - Rheumatoid factor (RF) is the autoantibody (antibody directed against an organism's own tissues) that was first found in rheumatoid arthritis
-Radiographic evidence
Discuss the risk factors and typical triggers associated with systemic lupus erythematous
systemic lupus erythematous
-Chronic inflammatory disease affecting entire body!
-Unknown cause

Risk factors:
-Young women (15-40)
-African, Hispanic, Asian descent
-Familial
-Genetic

Type III hypersensitivity response is Formation of autoantibodies & immune complexes which results in immune response

Triggers:
-Ultraviolet light
-Chemicals - Toxic, drugs
-Specific foods
-Infectious agents

Common complaints
-Arthralgia - Pain in joints
-Myalgia - Tenderness in pain in muscles
-Fever
-Malaise, fatigue
-Temporary loss of cognitive abilities
Describe the immunologic process that occurs in systemic lupus erythematosus
Formation of autoantibodies and immune complexes

Defective elimination of self-reactive B cells with a resultant increase in prodection of antibodies that can directly damage tissues or combine with corresponding antigens to form tissue-damaging immune complexes

Acute
-Skin lesions: malar or butterfly rash on the nose and cheeks
-Fingertip lesions
-Nail fold
-Splinter hemorrages
-Hair loss
-Sun sensitivity
-Insidious is the typical course of SLE is insidious, slow, and progressive, with potential exacerbations and remissions, and even dramatically acute and rapidly fatal outcomes. Recently, infections have been shown to be highly associated with the onset and/or exacerbations of SLE
-Exacerbations = Worsening
-Remissions are periods of time where you don't have any symptoms
Identify and discuss the major organ systems that may be involved in systemic lupus erythematosus
Skeletal
-Arthralgias/arthritis common early symptom
Most often hands, wrists, knees
Ligaments, tendons, joint capsules also
-No articular destruction like other arthritis'
-Avascular necrosis (usually in femoral head) a condition that results when bones do not get enough blood
-Contractures, tendon rupture, subluxation

Integument
-Butterfly rash on nose/cheeks
-Fingertip lesions
-Hair loss - quite common
-Muscous membrane lesions - usually only happens during exacerbations
-Sunlight sensitivity

Renal
-Glomerulonephritis is an Infection in the kidneys also called nephritis, is a disease of the kidneys in which the glomeruli, the tiny filters in the kidneys that help to clean the blood, become inflamed or damaged. This allows protein and red blood cells that normally circulate in the bloodstream to pass into the urine. If glomerulonephritis does not respond to treatment, the glomeruli may slowly be destroyed. The kidneys will then lose their ability to clean your blood and this will lead to kidney failure.
-Interstitial nephritis is a kidney disorder in which the spaces between the kidney tubules become swollen (inflamed)

Pulmonary
-Pleural effusion is excess fluid builds around the lung
-Pleuritis is an inflammation of the pleura, or the lining of the lungs

Cardiac
-Pericarditis is an inflammation of the pericardium (the fibrous sac surrounding the heart). A characteristic chest pain is often present
-Heart block is a disease or inherited condition that causes a fault within the heart's natural pacemaker due to some kind of obstruction (or "block") in the electrical conduction system of the heart
- Hypertension
- Ischemic heart disease is reduced blood supply to the heart. It is the most common cause of death

CNS
-Photosensitivity: Headache (migraine)
-Hemorrhage is an escape of blood from a ruptured blood vessel, especially when profuse
stroke
-Thrombus is a blood clot formed in situ within the vascular system of the body and impeding blood flow
-Seizures are more frequent with renal disease
-Psychotic symptoms such as depression, euphoria, confusion, etc.
Compare rheumatoid arthritis and osteoarthritis in terms of joint involvement, level of inflammation, and local and systemic manifestations
Rheumatoid arthritis
-T-cell mediated response to trigger and Inflammatory mediators released. Antibodies form against autoantigens
-Rheumatoid factor (RF) High RF titer is associated with severe and unremitting disease, mainly systemic complications. Synovial inflammation and joint destruction result and also Fluid accumulates.
-Neovascularization (is the formation of functional microvascular networks with red blood cell perfusion) in synovial membrane
-Pannus: vascular granulation
Destructive - extends from the synovium to involve the bare area a region of unprotected bone at the junction between cartilage and subchondral bone
tissue is formed that is destructive to joint
Inflammatory erosion of cartilage/bone

Manifestations
-Joint pain
-Joint swelling
-Limited joint movement
-Wrists, finger joints common
-Feet
-Ankles, knees, elbows, shoulders, spine
-Subluxation
-Joint instability
-Swelling and thickening of synovium stretches joint capsule and ligaments which cause deformities, muscle imbalances and swan neck deformities of hand

Osteoarthritis (OA)
-Degenerative changes to articular cartilage of joints. it is One of the 10th most disabling conditions. It involves the loss of cartilage, thickening of subchondral bone, osteophyte bone outgrowths at joint margins and mild synovial inflammation.
It can happen to any synovial joint in the body

Manifestations
-Insidious - proceeded in a gradual, subtle way but with harmful effects
-Joint pain, stiffness, motion limitations
-Crepitus, grinding
-Instability and deformity can occur - increased inflammation in the joint
describe the metabolism and elimination of uric acid to the pathogenesis of crystal-induced arthropathy
Uric acid is a chemical created when the body breaks down substances called purines. Purines are found in some foods and drinks. These include liver, anchovies, mackerel, dried beans and peas, and beer.

Most uric acid dissolves in blood and travels to the kidneys. From there, it passes out in urine. If your body produces too much uric acid or does not remove enough if it, you can get sick. A high level of uric acid in the blood is called hyperuricemia.
Crystal-induced arthropathies are a group of disorders that involve deposition of crystals in joints and soft tissues, resulting in articular and periarticular inflammation and injury. Two types of crystals — monosodium urate (MSU) and calcium pyrophosphate dihydrate (CPPD) — are commonly involved in gout and CPPD disease

Elevated serum uric acid
Primary:
Unknown cause
Increase production, elimination or both
Secondary:
Nucleic acid breakdown (eg: tumor cell lysis)
Chronic kidney disease
metabolic and endocrine diseases associated with joint symptoms include
amyloidosis, osteogenesis, thyroid disease, diabetes, AIDS, and hypermobility syndrome
About gout
-Increase in the serum concentration of uric acid (Hyperuricemia); greater then 7mg/dl
-Recurrent attacks of inflammatory arthritis due to deposition of monosodium urate crystals in the joints and tissues; demonstrable in synovial fluid leukocytes
-Symptoms of the disease present maximally within 12-24 hours
-Peak incidence in the fifth decade; men > women; blacks > whites
-Most common joints: large toe (podagra)/first MTP joint (75%) > ankle; tarsal area; knee > hand; wrist (doesn't affect shoulder or hips)
-Peripheral joints common (they are cooler)
-Nodules form in synovial lining & cartilage of joint
-Enzymes are released and cause cell damage, inflammation
-Cartilage and subcondral bone is destroyed
-Deposition of aggregates of monosodium urate monohydrate crystals (tophi) chiefly in and around joints and in soft tissues- affects- ears, extensor tendons, finger tips
-Renal impairment- gouty nephropathy- urate crystals deposit into kidney tissue uric acid urolithiasis- kidney stores made of urate crystals
Describe the clinical manifestations of gouty arthritis
Manifestations
-Abrupt pain onset
-Redness, swelling
-Lasts days to weeks
-Remission can last months to years
-Tophi- Large hard nodules in the synovial joint

Triggers
-Excessive exercise
-Medications
-Foods
-Alcohol: Beer is bad
-Dieting
Differentiate between the properties of benign and malignant bone tumors
Benign bone tumor: usually are limited to the confines of the bone, have well-demarcated edges, and are surrounded by a thin rim of sclerotic bone. The most common benign tumors are of either fibrous or cartilaginous tissue origin. Benign fibrous tumors of the bone are common in growing bones. They are usually asymptomatic, resolve in 2-3 years, and do not require treatment. Common cartilaginous tumors include chondromas and osteochondromas. Giant cell tumors, which contain mono-nuclear and osteoclast-type giant cells, are often classified "intermediate" in nature between malignant and benign. Chondromas are benign tumors of hyaline cartilage that usually occurs in bones of endochondral origin. The endochondromas are the most common of the intraosseous cartilage tumors and are usually diagnosed in persons between ages 20-40. Occasionally they are painful and cause fractures. An osteochondroma, also known as an exostosis, is a benign cartilage-capped tumor that is attatched to the underlying bony stalk. It is the most common of benign tumors, accounting for 85% of which occur as solidary tumors.

Malignant bone tumors: in contrast to benign tumors, primary malignant tumors tend to be ill defined, lack sharp borders, and extend beyond the confines of the bone. Primary malignant bone tumors occur in all age groups, and may arise in any part of the skeleton. However, certain types of tumors tend to target certain age groups and anatomic sites.
Osteosarcoma
is an aggressive, highly malignant bone tumor. It is the most common malignant bone tumor, representing one fifth of all primary bone tumors. The tumor has a bimodal distribution, with 75% occurring in persons younger than 20 years of age. A second peak occurs in the elderly with predisposing factors such as paget disease, bone infarcts, or prior irradiation. Overall, men are more commonly affected than women.
Chondrosarcoma
consist of malignant cartilaginous lineage and is commonly subclassified according to site of origin as central (intramedullary) or peripheral (juxtacortical and surface). They tend to arise in central portions of the skeleton, including the pelvis, shoulder and ribs. They are slow growing and metastasize late, and are often painless.
Ewing Sarcoma
is a member of a family of tumors that include Ewing sarcoma and primitive neuroectodermal tumor (PNET). Both tumors are characterized by densely packed, regularly shaped, smalls cells with round or oval nuclei; and both share specific reciprocal translocation of chromosomes 11 and 31, or variants thereof. Ewing sarcoma is primarily a disease of children and young adults and is rarely seen in the older population.
Discuss the significance of metastatic bone disease
Skeletal metastases are the most common malignancy of osseous tissue. Approximately half of all people with cancer have bone metastasis at some point in their disease. Metastasis lesions are seen most often in the spine, femur, pelvis, ribs, sternum, proximal humerus, and skull, and are less common in anatomical sites more distant from the trunk of the body. Tumors that are frequently spread to the skeletal system are those of the breast, lung, prostate, kidney, and thyroid, although any cancer can ultimately involve the skeleton
What are the general characteristics of benign bone tumours? (include diagnosis information & clinical manifestations)
Characteristics
-Limited to the bone
-Well demarcated edges and are surrounded by a thin rim of sclerotic bone
-Either fibrous (Usually asymptomatic resolve in 2-3 years - no treatment) or cartilaginous (chondromas and osteochondromas , giant cell tumors) tissue origin
What is 'osteoma'?
is a new piece of bone usually growing on another piece of bone, typically the skull. It is a benign tumor.
Benign bone tumours
are diagnosed by medical examination and imaging tests, including x-ray, CT scan, MRI or bone scan.
Tumour that doesnt cause symptoms
Osteochondroma
is the most common type of benign bone tumour. It grows on the surface of a bone and may protrude as hard lumps. It occurs most often at the ends of long bones. Almost half of all osteochondromas are found around the knee. One or several tumours may develop. The tendency to develop several tumours may run in families.
Osteochondroma most often occurs in people aged 10-20 years.
Enchondroma
begins in cartilage.
It often occurs in the hands or feet, and less often at the end of the long bones. It is usually found in people aged 10-40 years. Enchondroma most often occurs as a single tumour. Many enchondromas may occur in people with Ollier disease and Maffucci syndrome (both of which are not hereditary conditions). Occasionally, enchondroma changes into a malignant (cancerous) tumour.
Surgery may be done if the bone is weakened or fractured.
Chondromas
are benign tumors of hyaline cartilage that usually occurs in bones of endochondral origin. endochondromas are the most common of the intraosseous cartilage tumors and are usually diagnosed in persons between ages 20-40
giant cell tumour (GCT)
Most GCTs occur as single tumours within the end of long bones.
About half of all GCTs develop around the knee.
It has a tendency for considerable bone destruction and local recurrence
It occurs slightly more often in females.
GCT occurs most often in people in their 20s and 30s.
It is treated with surgery to remove the tumour and replace the bone with a bone graft.
Radiation therapy and embolizationembolization
A procedure that blocks or slows down the blood supply to tissues or an organ.
may be used if surgery cannot be done because of the tumour's location or the person has existing health problems.
What are the general characteristics of malignant bone tumours?
Ill defined
Lack sharp boarders
Extend beyond the confines of the bone
Primary malignant - In all age groups and may arise in any part of the skeleton
Identify the pertinent facts, age groups affected, diagnostic information, clinical manifestations, and common areas of metastasis for the following bone tumours: Osteosarcoma, chondrosarcoma, and Ewing sarcoma.
Osteosarcoma

Aggressive and highly malignant
Osteosarcoma (osteogenic sarcoma) is the most common primary bone tumour.
Osteosarcoma starts in bone cells.
---It develops most often in the bones of the arms, legs and pelvis.
---About half of these tumours develop in or around the knee.

--It occurs most often between the ages of 10 and 30 years.
---75% <20 years old
Osteosarcoma occasionally develops in people in their 60s and 70s.
It is rare in middle-aged people.
It occurs more often in males than in females.
Osteosarcoma is seen more often in people with a history of Paget's disease of the bone, retinoblastoma and previous radiation therapy.

Chondrosarcoma

Chondrosarcoma is the second most common primary bone tumour.
--Chondrosarcoma starts in cartilage cells.
--It develops most often in the bones of the:
pelvis,
arms or
legs.
---It occurs most often in people over the age of 20 (one-half of all cases occur in people older than 40 years of age).
It occurs equally in males and females.
In very rare cases, benign tumours, such as enchondromas and osteochondromas, turn into chondrosarcoma.
Most chondrosarcomas are low or intermediate grade.
Some chondrosarcomas have different features under the microscope.
dedifferentiated
These tumours start out as typical chondrosarcomas, but some tumour cells change to look like those of an osteosarcoma or fibrosarcoma.
They usually occur in older people and are more aggressive than usual chondrosarcomas.

Ewing sarcoma

Ewing sarcoma is the third most common primary bone tumour in adults, but it occurs more often in children and teenagers.

--Most Ewing sarcomas develop in bones, but they can start in other organs or tissues.
--Ewing sarcoma of the bone occurs most often in the
---pelvis, bones of the chest wall (such as the ribs and shoulder blades) and in the long bones of the arms and legs.
--It develops most often in people under the age of 20 years, but can occur in adults over the age of 30.
It occurs more often in males than females.
Ewing sarcoma is an aggressive type of bone sarcoma that responds well to treatment.
All people with Ewing sarcoma will be given chemotherapy.
Discuss the significance of metastatic bone disease.
Bone metastasis occurs when cancer cells spread from their original site to a bone.
Nearly all types of cancer can spread (metastasize) to the bones. But some types of cancer are particularly likely to spread to bone, including breast cancer and prostate cancer.
Bone metastasis can occur in any bone but more commonly occurs in the spine, pelvis, thigh, ribs, sternum humerus and skull. Bone metastasis may be the first sign that you have cancer, or bone metastasis may occur years after cancer treatment.
pain and broken bones.
Develops gradually, over weeks and is more severe at night
Caused by stretching of the periosteum of the bone or nerve entrapment
_______________ is a skeletal disorder characterized by the loss of bone mass and deterioration of the architecture of cancellous bone with a subsequent increase in bone fragility and susceptibility to fractures.
osteoporosis
_______________ is a condition that is common to all metabolic bone diseases and is characterized by a reduction in bone mass greater than expected for age, race, or sex.
Osteopenia
____________ syndrome is a complication of fractures that involves increased pressure within a limited space that compromises the circulation and function of the tissues within the space
Compartment
Rheumatic disorders have signs and symptoms that are limited to the skeletal system

true
false
false
Osteomalacia is a generalized bone condition in which inadequate mineralization of bone results from a calcium or phosphate deficiency, or both.


True
False
osteomalacia - Softening of bones d/t inadequate mineralization (is deposition of calcium hydroxyl apatite salts converting osteoid to rigid bone)
Causes
Insufficient Ca+2 absorption from intestines d/t: lack of dietary calcium or a deficiency of or resistance to the action of V-D
Phosphate deficiency d/t: increased renal losses or decreased intestinal absorption
Anticonvulsant use (long term)

= true
_____________ represents an acute or chronic infection of the bone and is very difficult to treat and eradicate
Osteomyelitis
When the bone fragments have broken through the skin, the fracture is called an open or ____________ fracture.
compound
Instability, combined with its relatively exposed position, makes the shoulder extremely vulnerable to injuries.


True
False
true
A __________ is a stretching or partial tear in a muscle or a muscle-tendon unit.
strain
Osteogenesis imperfecta is a disorder involving the osteoblasts, creating a weak bone matrix.


True
False
true?
Rickets is a metabolic bone disorder characterized by a failure or delay in calcification of the cartilaginous growth plate in children whose epiphyses have not yet fused.


True
False
true
Systemic lupus erythematosus is a chronic inflammatory disease that can affect virtually any organ system, including the musculoskeletal system.


True
False
true
All persons affected with rheumatoid arthritis have the presence of the rheumatoid factor, an autoantibody that reacts with a fragment of immunoglobulin G to form immune complexes.


True
False
false
___________ is an aggressive and highly malignant bone tumour with primary symptoms of deep localized pain with nighttime awakening and swelling in the affected bone.
Osteosarcoma
Gout is associated with an overproduction of ________ acid or from the reduced ability of the kidney to rid the body of the excess of this acid.
uric
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