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What is "Old Age"?

  • No consistent definition - issue between chronicity and physiology
  • WHO Criteria

- Age > 65 years (developed countries)




In a less developed country with a lower age expectancy, old age may be younger than 65 years.


What is the function of MSK?

  • Locomotion: enable efficient movement
  • Endoskeleton: protects and supports soft tissues
  • Homeostasis: Ca2+ regulation, temperature regulation, energy storage


Discuss Ageing and the Musculoskeletal System

  • Ageing begins when adulthood reached - bone mineral declines steadily after the age of 30 years
  • Rate of loss is ~0.5-1% per year
  • Peak bone density depends on exercise and diet etc. The higher the peak bone density, the better protected you are in old age.
  • Involves a loss of cells, reduction in cells ability to repair, increased genetic mutations (hence why cancer risk increases as you ger older)


What are the physical changes and their consequences of ageing?

  • Physical Changes; sarcpopenia, decreased bone mineral density
  • Consequences:

-Loss of muscle strength and endurance

 Loss of bone strength

Increased fall risk

Increased fracture risk

Reduction in ability to perform ADL's (activities of daily living e.g. bathing, eating, walking, dressing etc_


How is bone mineral density loss accelerated?

Loss accelerated with low reproductive hormone levels, poor calcium and/or vitamin D status, inactivity, endocrine or gastrointestinal pathologies.

Loss of bone mineral is often accompanired by changes in trabecular architecture making the bone less strong both as a material and as a structure. Trabecular patterns become more wispy, haphazard, less structured


What is Sarcopenia?

Loss of muscle mass due to loss of muscle fibers and reduced muscle cross-sectional area

Loss of muscle contractility

Loss of neuronal innervation (possibly higher in Type II fibres innervated by large alpha motor neurons)


Why do Falls occur?

  • Decreased mobility
  • MSK-related posture and gait changes e.g. due to hip replacement
  • Neuro-related gait and proprioception changes
  • Environmental hazards

These all increase fall risk which along with increased bone weakness --> fractures


What is Osteoporosis?

  • Women lose bone mass faster after menopause but it happens to men too.
  • A skeletal disease characterised by:

Low bone mass per unit volume

Deterioration of micro-architecture

Increased bone fragility

Increased suceptibility to low trauma fractures


Describe how bone mineral density is measured

Measured against population mean in young adults

  • Normal: within 1 Standard Deviation of mean
  • Osteopenia (low bone mass): 1-2.5 Standard Deviation below mean
  • Osteoporosis: >2.5 Standard Deviation below mean


What is a DEXA scan?

  • Dual Energy Xray Absorptiometry
  • Assess bone mineral density
  • Xrays of 2 different energies
  • Aimed at femur and L-spine (L3)


What are T and Z scores?

T score: number of SD below mean for SEX and RACE matched healthy young adult population (25-35y age)

Z Score: number of SD below mean for an AGE, SEX, and RACE matched young adult population

The difference between your measurement and that of a young healthy adult is known as a T score.

The difference between your measurement and that of someone of the same age is known as a Z score.


Risk Factors for Osteoporosis

  • Age
  • Low Bone Mass
  • Caucasian/Asian
  • Previous Fragility Fracture
  • Positive Family History
  • Low BMI (<19 kg/m2) e.g. due to anorexia
  • Lifestyle (smoking, alcohol, diet
  • Early menopause


What are Bisphosphonates?

Anti-resorptive agents

Effect osteoclasts (bone resorption)

Effect on bone:

  • decrease bone turnover
  • increase bone mineralisation
  • minimal effect on bone volume


How do Bisphosphonates work?

Taken up by osteoclasts

Inhibits mevalonate pathway

Osteoclasts lose ruffled border

Osteoclasts become inactivated (apoptosis) - stop working


Describe normal bone physiology

Normal Bone Physiology

  • Resorption: osteoclasts break down bone mineral and matrix creating an erosion
  • Reversal: mononuclear cells prepare bone surface for new osteoblasts to begin building bone
  • Formation: osteoblasts form a matrix to replace resorbed bone with new bone
  • Resting: a prolonged resting phase until a new remodelling cycle begins.


What is the pathophysiology of osteoporosis?

Bone resorption > bone formation


What is Type 1 and Type 2 Osteoporosis?

Type 1

  • Post-menopausal
  • Loss of Oestrogen - accelerated loss (2-3%) over next 6-10 years

Type 2

  • Senile
  • Age related, hyperparathyroidism, Ca2+ deficiency


What are the Consequences of Hip Fractures?

  • High mortality rate (up to 30% at 1 year)
  • High morbidity rate

- PE/DVT/CVA (stroke)/MI

- Pressure sores

- Chest infections / UTIs

- Reduced mobility (only 50-60% regain their pre-injury ambulatory status) - 20% never walk again

- Confusion


What is OA?

Disorder of synovial joints that is characterized by

  • Focal areas of damage to the articular cartilage
  • Remodelling of underlying bone and the formation of osteophytes - new bone at joint margins (bone's unsuccessful attempt to heal itself)
  • Mild synovitis (synovium becomes inflamed)
  • Eventually everybody will get OA! (80% of >80 year olds)


What are the clinical feautres of OA?

  • Pain
  • Stiffness
  • Deformity
  • Join swelling


What are the Radiological features of OA?

  • Decreased joint space
  • Sclerosis
  • Osteophytes
  • Bone cysts


What is the Non-operative treatment for OA?

  • Weight loss
  • Exercise / Physiotherapy (increase muscle mass, increase proprioceptors)
  • Analgesia / NSAIDs
  • Joitn injection


What is the Operative treatment of OAs?

Arthroscopy (joint keyhole surgery)

Osteotomies (a formal cut in bone --. helps offload pressure in the medial compartment of the leg)

Arthrodesis (bones are fused together - good for pain relief, bad for function)


Why perform a hip replacement?

  • Relief of Pain
  • Get back to work
  • Improve function
  • Return to leisure activities
  • Better range of motion


What are local complications of a knee replacement?

  • Leg length inequality (slight difference)
  • Dislocation (3%)
  • Infection (2-3%)
  • Loosening (usually after 10-15 years(
  • Neurovascular damage

- Sciatic/femoral nerve, common peroneal nerve


Describe the femoral artery

The femoral artery is a continuation of external iliac artery (when the external iliac artery crosses under the inguinal ligament, it becomes the femoral artery)

The femoral artery continues down the anterior surface of the thigh, via the adductor canal. During its descent the artery supplies the anterior thigh muscles. The adductor canal ends at an opening in the adductor magnus, called the adductor hiatus. The femoral artery moves through this opening and becomes the popliteal artery after entering popliteal fossa.


Describe the deep artery of the thigh


Femoral artery gives off a branch called the deep artery of the thigh which in turn gives off three main branches: perforating branches (3 or 4 arteries that perforate the adductor magnus, contributing to the supply of the muscles in the medial and posterior thigh), lateral femoral circumflex arteryand medial femoral circumflex artery.




What does the popliteal artery birfucate into?

Anterior and Posterior Tibial arteries


Describe the Obturator Artery

The obturator artery, branch of internal iliac artery and enters thigh through obturator foramen and descends via the obturator canal to enter the medial thigh, bifurcating into two branches:

~Anterior branch supplies the pectineus, obturator externus, adductor muscles and gracilis.

~Posterior branch supplies some of the deep gluteal muscles.

The gluteal region is largely supplied by the superior and inferior gluteal arteries.

These arteries also arise from the internal iliac artery, entering the gluteal region via the greater sciatic foramen. In addition to the gluteal muscles, the inferior gluteal artery also contributes towards the vasculature of the posterior thigh.


Why is there a risk of intracapsular fracture of neck of femur?

Due to rupture of retinacular arteries (mostly from medial circumflex femoral artery)

The artery to the head of femur (branch of obturator artery) is more important in children à less important blood supply in adults

To find the femoral pulse, place little finger on ASIS and thumb on Pubic Tubercle. The femoral pulse should be palpated 2 or 3 fingers just below inguinal ligament. The femoral artery is a common site for insertion of catheter to gain access to left side of the heart – for a coronary artery.

NOTE: brachial or radial arteries could also be used.

Use the femoral vein to access the right side of heart.