Class 20/21 - Alterations in MSK Flashcards
Bone and Muscle Changes Across the Lifespan
Infants (skull fontanels)
- Shaken baby syndrome causes bulging fontanels
- Dehydration causes sunken fontanels
Children
- Bones are porous, epiphyseal plates
- Fractures in and around the epiphyseal plate will affect the growth of the bone
Older Adults
- Loss of bone tissue, cartilage is more rigid
- More porous bones as we age
- Strongest bones round the age of 30
Musculoskeletal dysfunction due to Trauma
Risk Factors
- Male
- Elderly
- Activity/lifestyle
- Occupation
- Chornic Illness
When more force is applied to the bone or muscle tissue than can be tolerated
- Fractures
- Strains and sprains
- Dislocation and subluxation
Fractures
- Occult
- Hidden fracture - Open (compound)
- Bone has poked through the skin - Pathological
- Happens secondary to another disease (bone cancer) - Comminuted (segmented)
- In pieces, not just a straight fractrue - Oblique
- Angled - Transverse
- Straight across - Greenstick
- Will partly snap, shreds. Incomplete. Occurs with young bone - Stress or fatigue
- Due to overuse - Impacted (compression)
- Compressed bone, could occur in the vertebrae, impaction in the femur
Location
- Sports: tibia, clavicle, humerus
- Work: hands and feet
- Elderly with falls: wrist, hips femur, pelvis
Manifestations
- 5 signs of inflammation
- Deformity
Treatment
- Reduction: straightening out the bone
- Immobilization: cast/plaint, or internal/external fixation. Depends on the individual and type of fracture
Bone Healing
- Hematoma formation
- 2-3 days - Fibrocartilaginous callus formation
- Soft callus - fragile
- 1-2 weeks
- Fibroblasts
- If healing is interrupted during this stage, healing can stop or be severely slowed down - Bony callus formation
- Hard callus
- 2-4 weeks
- We overproduce bone - Bone remodeling
- 6-10 weeks
- Will get reabsorbed
Bone and liver are the only two places that we don’t replace withs scar tissue
Factors affecting healing time
- Age (children heal faster)
- Type of fracture (the further apart the pieces are, the more time it takes to heal)
- Medications. NSAID’s inhibit inflammation and bone healing
- Other diseases like diabetes
- Nutrition
- Smoking
- Immobility (impairs circulation and blood flow)
- Circulation
Complications of bone healing
- Malunion: doesn’t heal properly
- Delayed union: if it hasn’t healed over an extended period of time
- Non-union: failure to heal. Open fracture/compression
- Osteonecrosis: if blood flow to the bone is interrupted, the bone dies.
Osteomyelitis
Infection of the bone
Hematogenous
- Infection travels through the blood and infects the bone (could be from bladder infection
- More common in immunosuppressed individuals
Contiguous
- Came rom bone
- Could come from the environment, through the skin, to the bone
- Local
Pathophysiology
- Pathogen sets off inflammation (edema, WBC activity, abscess formation)
- Lifting of periosteum (outside of the bone, where the blood supply travels) disrupts blood supply. Leads to necrosis/death of the bone tissue (sequestrum). Causes and increased opportunity for fractures
- Osteoblasts lay down new bone around the dead bone (involucrum)
- Formation of fistulas and sinus tracts - pus drains from the bone to the skin surface
Manifestations
- Fever, chills, malaise
- Impaired movement
- Increased WBC count
- Pain
- Wound drainage
- Edema
Diagnosis
- Elevated WBC, blood and wound cultures, bone bipsy, bone scan, CT or MRI
Treatment:
- Long and vigorous antibiotic therapy (vancomycin, clindamycin)
- Debridement
- Antibiotic beads/scaffolds
- Hyperbaric oxygen therapy (hyper pressure oxygen that helps to oxygenate the infected tissue)
Soft Tissue Injuries
Can involve joints, muscles, tendons and or ligaments
- Hematomas
- Contusions
- Lacerations
- Sprains and strains
- Dislocation and subluxation
Complications
- Impaired mobility
- Impaired stability
- Compartment Syndrome*
Compartment Syndrome
Excessive edema causes increased pressure in a compartment
- Compromises circulation
- Damages nerves and muscles in the compartment
Can occur after a fracture or crush injury
Commonly affected sites
- Lower leg
- Arm
- Gluteal compartments
Due to the fascia not allowing for the swelling tos expand
- Extremely painful
- Open fascia with fasciotomy
- Nerves and blood vessels could be compressed to the point where they die
Immobility
Negative Impacts
- Respiratory
- GI (constipation)
- Cardiovascular
- Urinary
- Integumentary
- Cognition (more confusion)
Complications
- Muscle atrophy
- Impaired strength and stretch of muscles
- Contracture (a joint that is permanently less mobile)
- Loss of bone mass
i. We are constantly building up and breaking down bone cells
ii. Osteoblasts - build bones
iii. Osteoclasts - destroys bones
Osteoporosis
Decreased bone mass and increased porosity of the skeleton
Increases the risk of fracture
- Wrist, hip and spine
- Pathological fracture
Incidence
- Affects 1.4 million Canadians
- More common in women
Patho
- Imbalance between bone resorption and formation
Risk factors
- Older adults
- Female
- Genetic predisposition
- Bone size (women have smaller bones)
- Activity level: using bone/weight bearing activites increases bone building processes
- Nutrition
- Other diseases (COPD, cancer, thyroid, diabetes)
Manifestations
- Silent disorder
- Fracture (vertebral, hip, pelvis, wrist) occurs with less force than usual
- Loss of heigh
- Kyphosis (dowager humps)
Diagnosis:
- Measurement of bone mass (x-ray of spine/hip and bone density screening)
- Serial height measurements
Management:
- Prevention and early detection
1. Weight-bearing exercise
2. Calcium intake
3. Vitamin D
4. Medications to block bone resorption or to stimulate formation
Osteoarthritis
Most common form of arthritis
Combination of inflammation and degeneration
Because it’s rarely seen in young people, it’s known as the “wear and tear disease”
Incidence
- Similar rates in men and women
- Women are more severly affected
Progressive disruption of the smooth articular cartilage
- Erosion of cartilage
- Exposure of bone
- Dislodgement of bone/cartilage fragments
- Development of bone spurs
Commonly affected joints
- Spine
- Hip
- Knee
- Hand
- Foot
Typically 1-2 joints are affected at a time
Risk factors
- 80% of people over 65 will have some OA
- Women have more severity
- Previous joint trauma
- Obesity - promotes inflammation everywhere including the joints
Manifestations
- Stiffness, pain, usually get’s better once moving
- Hip
i. decreased mobility
ii. shuffling gait
iii. difficulty getting out of chairs - Knee (crepitus/grinding)
- Hands (bouchard and heberden nodes)
Management
- Start with non-drug therapy
- Education
- Exercise
- Weight control
- Physical therapy
- Occupational therapy
- Assistive devices - Pharmacologic therapy
- Intra-articular injections
- Opioid analgesic
- Surgery
Rheumatoid Arthritis
Inflammatory damage or destruction of the synovial membrane and or cartilage with systemic signs of inflammation
- Starts in the synovial membrane
- Multiple joints are affected
- Starts in multiple joints at the same time
Involves a systemic autoimmune process
- Epstein-barr virus trigger
- Body wide process
- Can be accompanies by Chron’s disease
Risk factors
- Female 3x more likely to be affected
- Older adult
- Family history - Genetics
- Smoking
- Hormonal involvement (?) Increase incidence in postpartum period
Pathophysiology
- Neutrophils activated in synovial fluid
- Inflammation breaks down cartilage and bone
- Hemorrhaging and Pannus formation (Pannus is an abnormal layer of fibrovascular tissue or granulation tissue)
- Pain and stiffness of the joints
Systemic Manifestations
- Fever
- Fatigue
- Weight loss
- General aching and stiffness
Local manifestations
- Pain
- Boggy swelling
- Swan neck deformity of fingers
- Ulnar deviation (when the pinkie finger and hand start to rotate towards the ulnar side of the wrist
Treatments
- Reduce pain, minimize stiffness, maintain mobility, slow degeneration
i. Rest, exercise
ii. Heat/cool
iii. Relaxation
iv. Posture, joint protection, shoes - Medications
i. Reduce pain and inflammation
ii. NSAID’s, COX-2 inhibitors, disease modifying anti=rheumatic drugs (DMARDS), corticosteroids
Gouty Arthritis
Inflammation of joints due to increased uric acid levels
- Uric acid (urate) crystals are deposited in tissues including the synovial fluid resulting in an acute inflammatory response
Gout management
- High fluid intake
- Low-purine diet (no red meats)
- Anti-hyperurcemia drugs
- NSAID’s
- Hydrocortisone injections
- Ice
- Rest
Club Foot
- Abnormal positions of the foot
- 1-2/100
- Double the males
- Bilateral 50% of the time
Caused by:
- Genetic component (17x greater incidence in families with one affected members
- Abnormal intrauterine positioning?
- Neuromuscular or vascular problems?
- Maternal smoking?
Congenital equinovarus
- Most common form
- Heel is inwardly deviated (varus)
- And the plantar is flexed (equinus)
Managements
- Casting
- Braces
Developmental Hip Dysplasia (DHD)
Femoral head and the acetabulum are not properly aligned due to variations
- Disloacted hip
- Subluxation
- Acetabular dysplasia
Incidence
- Instability 3-7/100
- True location 1/1000 births
- Girls are 4-6 times more often than boys
Etiology
- 20-50x more common in 1st degree relatives
- Mechanical forces of breech birth
- Maternal hormones (girl babies may be affected by mother’s hormones that loosen the ligaments of the hips)
Manifestations
- Asymmetry of gluteal fold and thigh fat folds
- Difference in knee height and limping in older hildren
- Barlow maneuver: you bend the knee towards the the belly, place fingers on the hip and feel for a click
- Orolani’s click test (turn hip outwards, push towards belly and feel for a click
Management:
- Trying to keep the head of the femur int he socket
- Pavlik harness
- Spica cast
