Unit 3: Diseases of the Integumentary & Musculoskeletal Systems

Atopic Dermatitis
Herpes Zoster (Shingles)
Decubitus Ulcers
Skin Lesions and Masses
Melanoma
Osteoarthritis
Gout
Osteoporosis
Fractures
Muscular Dystrophy

Atopic Dermatitis
Atopic Dermatitis

Atopic dermatitis, commonly known as eczema, is a chronic condition that causes itchy
inflammation of the skin. It can be associated with hay fever or asthma, although it can appear
in patients who do not have those conditions.

Causes

Dry, irritable, sensitive skin, combined with a glitch in the body’s immune system appears to
cause atopic dermatitis. Genetics may play a role in development of the condition. Atopic
dermatitis usually appears before age 5 and can last into adulthood. Eczema appearing in infants
is known as infantile eczema and can last throughout adolescence.

Eczema can affect any area of the body, but is usually located on the arms, behind the knees, on
the ankles, wrists, neck, upper chest, face, or area surrounding the eyes, including the eyelids.
The inflammation flakes, then subsides, and can subside for periods of time before flaring up.
Itching can lead to more inflammation, which can result in even more itchiness, creating a cycle
that is hard to break. Stress and emotional disorders can lead to flares of the disease, but are
not causes of the condition.

Symptoms

Atopic dermatitis is most recognizable due to the red to brownish-gray patches of dry, scaly skin.
Places of the skin may be thickened or cracked as well. Itching can be severe, especially at night.
Skin may have small, raised bumps that leak fluid when scratched and develop crusts. Scratching
can make the skin raw and sensitive.

Atopic dermatitis can become worse as a result of any of the following:

  Dry skin
 Stress
 Sweating
 Long, hot baths or showers
 Rapid changes in temperature
 Low humidity
 Harsh solvents, cleaners, soaps, or detergents
 Dust or sand
 Cigarette smoke
 Wool or man-made fabrics
 Levels of high pollution
 Ingestion of certain foods like wheat, eggs, milk, fish, or soy

Complications

Because the skin is itchy and irritated, complications can arise. Neurodermatitis happens when
the affected skin is scratched so much that it becomes thick and leathery. It can lead to scars
and/or changes in skin color. Itching can break the skin open, leading to open sores and fissures
that are susceptible to development of infections. Staphylococcus aureus lives on the skin, but
can infect the open sores resulting from the itching and scratching associated with eczema.
Severe atopic dermatitis can also lead to problems of the eyes such as inflammation of the
eyelid or lining of the eyelid. Such complications can lead to permanent eye damage and vision
impairment.

Diagnosis

Atopic dermatitis is diagnosed by the appearance of the skin. The medical practitioner will also
ask the patient about their symptoms, medical and family history, and lifestyle activities that
could contribute to the condition. A history of relatives with atopic dermatitis, asthma, or hay
fever could help with confidence in the diagnosis.

Treatment

While atopic dermatitis is associated with allergies, eliminating allergens or taking allergy shots
is usually not helpful. There is no cure for eczema, but the inflammation, itching, and flare-ups
can be controlled with the following:
 Corticosteroid creams or ointments: Ease scaling and itching, although prolonged use
can lead to skin irritation, discoloration, thinning, and infections.
 Antibiotics: Treat skin infections
 Oral antihistamines: Control itching
 Oral or injected corticosteroids: Reduces inflammation; used for a minimum amount of
time to treat severe cases or flares
 Immunomodulators: Affect the immune system to maintain skin texture and reduce
flares; they are only used when other treatments fail
  Phototherapy
 Lubrication of skin with lotions, oils, or creams
 Use of gentle soaps, cleaners, or detergents

Bathing can strip the skin of oils, contributing to dry, itchy skin. Bathing every other day for 15-
20 minutes can help the skin maintain moisture. Adding bleach to a warm, not hot, bath can
help kill bacteria on the skin that cause staph infections. Moreover, cool, wet compresses can
soothe the itching and irritation and help prevent scratching.

Herpes Zoster (Shingles)

Shingles

Herpes zoster is the medical name for the viral infection known as shingles. Shingles causes a
painful rash of blisters that typically affects the side of the torso. Herpes zoster is caused by the
same virus that cause chickenpox.

Causes

Varicella-zoster is part of a group of viruses called herpes viruses, which can lead to conditions
like cold sores, chickenpox, and genital herpes. As shingles is included in the grouping, it is
known as herpes zoster.

The virus that causes chickenpox (varicella) remains dormant in the body after infection clears
up. Years later, it is believed that a weakened immune system allows the virus to reactivate and
travel via nerve pathways to the skin, resulting in shingles. Shingles occurs mainly in older adults
over age 50 or those with weakened immune systems. Cancer treatments and use of certain
medications, like steroids, can trigger the development of shingles.

Shingles cannot be passed from person to person; however, a person with shingles is contagious
to those who have not had the chickenpox. In those cases, chickenpox can be transmitted,
although the exposed person will not develop shingles. Patients with shingles should avoid
contact with newborns, people not immune to chickenpox, pregnant women, and those with
weak immune systems.

Two vaccines, the varicella vaccine and the varicella-zoster vaccine, can help prevent the
development of shingles. As these contain live virus, people with weakened immune systems
should abstain from the vaccines.

Symptoms
Shingles generally only affects a small area on one side of the body. Pain is usually the first sign
of the disease. Sometimes the shingles rash does not develop and pain is the only symptom.

Common signs and symptoms include the following:

 Pain, burning, numbness, or tingling in a specific area of the body, usually the side of the
torso
 A red rash develops a few days after onset of pain that wraps around the torso
 Sometimes the rash occurs on the side of the neck or face or around one eye
 A line of fluid-filled blisters that break open before crusting over
 Itching
 Fever
 Chills
 Headache
 Achiness
 Fatigue

Complications

The blisters associated with shingles are painful, and complications can result:
 Skin infections: Bacterial infections can develop from shingles blisters.
 Vision loss: Shingles can develop in or around the eye, causing infection in the eye and
potential vision loss.
 Neurological problems: Shingles affects the nerves, creating the potential for
encephalitis, hearing loss, balance problems, or facial paralysis.
 Postherpetic neuralgia: Damaged nerve fibers continue to send pain messages after the
blisters have healed.

Diagnosis

The rash and blisters combined with pain and age of onset make shingles an obvious diagnosis.
Doctors may culture the blisters or analyze a scraping of the blisters to confirm the diagnosis.

Treatment

Shingles cannot be cured, but prompt treatment can alleviate symptoms, speed healing, and
protect against complications. Any of the following may be prescribed:
 Acyclovir
 Famciclovir
 Valacyclovir
 Anticonvulsants
 Numbing agents
 Tricyclic antidepressants
 Narcotics, like codeine
Cool baths or compresses can relieve pain and itching.

Decubitus Ulcers
Decubitus Ulcers

Bedsores, pressure sores, and pressure ulcers are all forms of decubitus ulcers. Prolonged
pressure on an area leads to injury to the skin and tissue. Decubitus ulcers can develop quickly in
individuals who have limited ability to change positions and can be difficult to treat because of
continuous pressure on affected areas.

Causes

Prolonged pressure to a certain area reduced blood flow, leading to inadequate blood supply to
skin and tissues. There are three ways that bedsores can develop:
 Continuous pressure on an area: Skin and its underlying tissue that are sandwiched
between bone and a surface like a bed or wheelchair are under a great deal of pressure.
The pressure may more than the capillaries can handle, depriving the area of proper
blood flow and the associated oxygen and nutrients that come with it. Parts of the body
with limited padding from fat or muscle, like the coccyx, shoulder blades, hips, spine,
heels, and elbows are prone to decubitus ulcers.
 Friction: Friction between skin and surfaces when changing positions or being handled
by providers allows for more incidence of injury. Moist skin is more vulnerable to
friction than dry skin.
 Shear: Skin that pulls in the opposite direction than the bone can lead to damage of the
tissue and blood vessels. The damaged skin is then more susceptible to damage from
constant pressure.

Risk Factors

There are many risk factors associated with the development of pressure sores:
 Age: Older adult skin is thinner, drier, and less elastic than the skin of younger adults,
making it more fragile and vulnerable to injury.
 Weight loss: Less cushioning is present in people who have lost weight.
 Lack of sensory perception: Patients with loss of feeling or sensation in parts of the
body may not be aware of the pressure or feel the need to change positions.
 Skin moisture or dryness: Excessively dry skin or moist sweaty skin increases the
friction between skin and surfaces.
 Incontinence: Bladder incontinence can make the skin perpetually moist. Fecal
incontinence can lead to localized infections.
 Inadequate nutrition or hydration: A poor diet or an inadequate amount of fluid intake
can lead to unhealthy skin.
  Conditions of the circulatory system: Diseases like diabetes or vascular disease lead to
circulation problems and can cause decreased circulation in certain parts of the body.
 Muscle spasms: Frequent friction or shearing can result from involuntary muscle
movements.
 Limited mental awareness: Mental state affects whether or not an individual can
recognize, prevent, or care for pressure sores.
 Smoking: Smoking affects circulation and oxygen levels in the blood, making wounds
heal slower.

Symptoms

The location of the decubitus ulcer depends on the part of the body under the most pressure.
People who use wheelchairs often develop pressure sores on the tailbone, buttocks, spine,
shoulder blades, or backs of the arms and legs. People confined to a bed often develop them on
the back or side of the head, rim of the ears, hip, lower back, shoulders, shoulder blades,
tailbone, heels, ankles, or skin behind the knees.

Pressure sores are categorized based on severity:

Stage 1:
 Skin is intact
 Area is red
 Skin does not blanch when touched
 Skin may look ashen, purple, or blue in people with darker skin
 Area is painful, firm, and soft
 Affected spot may be warmer or cooler than surrounding skin

Stage 2:
 Wound is open
 Epidermis and dermis is damaged
 Shallow, bowl-like wound
 Pinkish-red in color
 May look like a ruptured fluid-filled blister

Stage 3:
 Wound is deep enough to expose underlying fat
 Crater-like appearance
 Slough on the bottom of the wound
 Damage may extend beyond the wound into healthy layers of skin

Stage 4:
 Large-scale damage to tissue
 Muscle, bone, and tendon may be exposed
 Slough and eschar on the bottom of the wound
 Damage extends into and beyond layers of healthy skin
If proper treatment is not sought, pressure sores can serious complications including sepsis,
cellulitis, infections of the bones and joints, or cancer in the unhealed wound.

Diagnosis

The pressure sore is evaluated to determine size, depth, areas affected, and presence of
bleeding or signs of infection. Blood tests seek to understand nutrition levels and overall patient
health. Cultures are ordered to find bacterial or fungal infections or signs of cancer.

Treatment

Pressure wounds can be difficult to treat. Adjusting position so the affected area is free of
pressure is tantamount to treatment. Regular repositioning at least every 15 minutes and use of
supportive cushions, pads, mattresses, or beds can help. Antibiotics and pain management
medications are often prescribed. In extensive cases, debridement is necessary to rid the wound
of dead or damaged tissue or infection. Wound care involves regular cleaning and dressing to
promote healing.

Skin Lesions and Masses

Skin Lesions and Masses

The skin, accessory structures, and underlying soft tissue can be involved by various conditions.
These range from benign changes to those that may be pre-cancerous.

Wart

Warts are rough, grainy growths that most commonly affect the hands or fingers. Some warts
contain tiny black dots, referred to as seeds, which are actually blood vessels that have clotted.
Warts are the result of an infection with the Human papillomavirus (HPV) and can be spread
through touch. Common warts heal on their own, but sometimes treatment and removal is
necessary.

Hemangioma

A hemangioma, also known as a strawberry hemangioma, is a birthmark that grows over the
first year of life before receding and disappearing by age 10. Caused by a dense grouping of
extra blood vessels, it appears as a patch of bright red on the skin. It can also appear as a large,
red nodule on the skin. Hemangiomas are benign and usually do not require treatment.
Lipoma

Lipomas are the most common skin tumor, although they are not technically a tumor. They are
slow-growing, rubbery nodules that can sometimes be felt as firm masses below the skin.
Occurring in the shoulders, trunk, and back of the neck, they can cause pain when they
compress nerves.

Acrochordon

Acrochordon refers to the condition commonly known as skin tags. Skin tags are found in 25% of
people and can increase in number as a person ages. Obesity is associated with the
development of skin tags, although it is not always a factor. The tags can appear flesh-colored or
brown and can vary in diameter from less than 1 mm to 1 cm. Skin tags in children should be
evaluated for the presence of nevoid basal cell carcinoma syndrome.

Cherry Angioma

Cherry angiomas are also called Campbell de Morgan’s spot and occur in up to 50% of adults.
These round, red lesions most often appear on the trunk or extremities. Cherry angiomas
usually occur in early adulthood and increase with age, probably as a result of hormones. They
can be several millimeters in diameter, but are not cause for concern.

Sebaceous Hyperplasia

Sebaceous hyperplasia is also referred to as senile hyperplasia as it most commonly affects

middle-aged and elderly patients, although the condition can begin at puberty. Yellow, dome-
shaped papules develop on the forehead, nose, cheeks, and sometimes the vulva. Sebaceous
hyperplasia can be mistaken for early basal cell carcinoma. Aside from cosmetic concerns,
sebaceous hyperplasia is not problematic.

Seborrheic Keratosis

Seborrheic keratosis presents as lesions of the skin that look like they have been stuck on. Most
have a rough surface that can be tan, brown, or black. The border is well defined. Often
appearing on the trunk, face, scalp, or extremities, occurrence of seborrheic keratosis increases
with age. Seborrheic keratosis can be mistaken for melanoma as they share common
characteristics. The condition is not serious.

Dermatofibroma
Dermatofibroma is often associated with autoimmune disorders like lupus. They are firm, raised
papules that come in a range of colors, including red, yellow, purple, or pink. Dermatofibroma
often appear on the lower legs and are not concerning.

Pyogenic Granuloma

Pyogenic granuloma is a vascular lesion that appears within the first five years of life. They begin
as small red or yellow papules on the fingers, head, neck, extremities, or mucous membranes
and grow rapidly. The lesions are removed with curettage and cautery.

Epidermoid Cyst

Previously known as sebaceous cysts, epidermoid cysts are not associated with the sebaceous
glands. The cysts are round and filled with keratin. The cysts may be small for a long time before
rapidly growing, usually on the back, face, or chest. Pus can drain for the surface, or reabsorbed
by the cyst. The cyst can be drained or removed if it becomes painful or inflamed.

Melanoma
Melanoma

Melanoma develops in the melanocytes that produce melanin and is the most severe kind of
skin cancer. Melanomas usually develop in areas that have had significant sun exposure, such as
the face, arms, legs, and back. However, melanomas can also develop on areas that don’t
normally get a lot of sun exposure, like the palms of the hands, soles of the feet, or beds of the
fingernails or toenails. The risk of developing melanoma increases with age, although the
number of melanoma cases diagnosed in people under 40 is on the rise.

Causes

Damage to the DNA in skin cells causes melanoma. The damage allows the new cells to develop
out of control, eventually creating a mass of cancerous cells. Environmental and genetic factors
lead to the development of melanoma. Exposure to ultraviolet radiation from the sun, tanning
lamps, and tanning beds can contribute to the development of melanoma. However, melanoma
can form in parts of the body never exposed to the sun, like the vagina, and sometimes in
internal organs.

Risk Factors
People who are fair skinned contain less melanin in the skin, offering less protection from UV
radiation. Those with blonde or red hair, light-colored eyes, and freckles are more at risk of
developing melanoma. However, people with darker complexions, including blacks and
Hispanics, can and do develop melanoma. People who sunburn easily and/or have a history of
one or more severe sunburns, particularly a sunburn that produced blisters, are at risk for
development of melanoma. Even one severe sunburn over the course of a lifetime increases the
risk.

Other factors associated with melanoma include the following:

 Exposure to UV radiation from the sun, tanning lights, or tanning beds
 Geography: Living close to the equator or living at higher elevations experience higher
exposure to UV radiation.
 Family history: Having a close family member with melanoma increases risk.
 Moles: People with 50 or more ordinary moles on the body have an increased risk for
development of melanoma. A dysplastic nevus is an unusual type of mole that is larger
than regular moles and has an irregular border and variation of colors. Having this kind
of mole also increases the risk of melanoma.
 Weakened immune system

Symptoms

A change in an already existing mole is often the first sign of melanoma. Below are
characteristics of normal moles:
 Uniform color, usually tan, brown, or black
 Distinct border
 Oval or round
 Smaller than ¼ inch (the size of a pencil eraser)
 Between 10-45 moles developed by age 40

Moles can change or disappear over time. However, changes in or development of unusual
moles may signify melanoma. There are 5 criteria for evaluating moles, and correspond with the
letters A-B-C-D-E:
 A: Asymmetrical shape
 B: Irregular borders
 C: Changes in color
 D: Diameter (larger than ¼ inch)
 E: Evolving (changes over time, such as size, shape, color, itchiness, or bleeding)

Scaliness or pigment that spreads into the surrounding skin may also be indications of
melanoma. Malignant moles may have all the characteristics or only one or two. Moreover,
melanoma doesn’t always begin as a mole. The development of an unusual growth or new
pigment on the skin can also indicate the presence of melanoma.

Other Forms
Hidden melanomas develop in areas of the body not normally exposed to the sun. They can
develop in areas like the skin between the toes, scalp, palms, soles, or genitals. People with dark
skin who develop melanomas usually develop hidden melanomas:
 Subungual melanoma: This often appears under a nail or on the palms or soles. The
associated discoloration can be mistaken for a bruise.
 Mucosal melanoma: These melanomas develop in the mucous membranes of he
mouth, nose, esophagus, anus, urinary tract, vagina, or anus.
 Ocular melanoma: Melanoma of the eye occurs in the uvea and can lead to vision
changes. Ocular melanoma is often diagnosed during eye exams.

Diagnosis

Many experts recommend yearly screening by a health care professional as well as monthly self-
screenings to identify changes in moles. While changes to moles can indicate the possibility of
melanoma, melanoma can only be confirmed through a biopsy. There are three basic biopsies
that can be performed:
 Punch biopsy: A tool with a circular blade is used to remove a round piece of skin.
 Excisional biopsy: The entire mole, along with a small border of surrounding skin, is
removed.
 Incisional biopsy: The most irregular part of the mole is removed.

If it is determined that melanoma is present, the thickness will be assessed to determine how
serious the condition is. Thicker melanomas mean a more serious situation. Sentinel node
biopsy is performed to determine if the cancer has spread to surrounding tissue or lymph nodes.
The cancer is then staged I through IV, with a stage IV diagnosis indicating that the cancer has
spread from the skin to the organs of the body.

Treatment

Often early stage melanoma requires only removing the melanoma, which can be accomplished
with the biopsy. If the melanoma has spread, other treatment is necessary, including:
 Removal of the lymph nodes
 Chemotherapy and radiation
 Biological therapy boosts the immune system to help fight the cancer.
 Targeted therapy is used to treat melanoma that has spread or cannot be treated with
surgery.

Osteoarthritis
Osteoarthritis
The most common form of arthritis is osteoarthritis, which results when the cartilage on the
ends of the bones deteriorates. Damage can occur in any joint of the body, but is most prevalent
in the hands, knees, neck, lower back, and hips.

Causes

Deterioration of the cartilage leads to development of osteoarthritis. Instead of a slick, firm

surface that allows the joints to move freely and without friction, the cartilage becomes rough
and worn down. Osteoarthritis can progress to the point where the cartilage has completely
deteriorated and the bones rub on each other.

Women are more prone to osteoarthritis than men, and the risk of development of the
condition increases with age. Conditions such as diabetes, gout, Paget disease of the bone, or an
underactive thyroid may increase the possibility of osteoarthritis. People with malformed joints,
defective cartilage, or those who have sustained injuries to the joints are also more likely to
develop the condition. As cartilage relies on joint use to receive nutrition, a sedentary lifestyle
can lead to osteoarthritis. The excessive pressure caused by obesity can lead to osteoarthritis in
the weight-bearing joints like the knees. Finally, occupations that require repetitive stress on the
joints can make the joint susceptible to osteoarthritis.

As osteoarthritis is a degenerative disease, the condition worsens over time, leading to joint
pain and stiffness that can impede with job performance or daily tasks.

Symptoms

Osteoarthritis develops slowly over time. Symptoms include pain, tenderness and stiffness in a
particular joint. The stiffness may be most noticeable in the mornings or when getting up. A loss
of flexibility and full range of motion may be present, as well as hearing or feeling a grating
sensation in the joint when moved or used. Bone spurs can form around joints with
osteoarthritis.

Diagnosis

Blood tests are used to rule out the possibility of other diseases that share the same set of
symptoms with osteoarthritis, like rheumatoid arthritis. Although cartilage cannot be detected
with x-rays, an x-ray can show narrowing spaces between the bones as a result of degenerating
cartilage. X-rays can also detect bone spurs around an affected joint. MRIs can detect cartilage
and may be used for a detailed view of the affected joint. Joint fluid analysis consists of a small
sample of fluid removed from the joint to test for inflammation. Joint fluid analysis can help
reveal other conditions, like infection or gout that may mimic symptoms of osteoarthritis.

Treatment
Because osteoarthritis worsens with age, the goal of treatment is to reduce pain and maintain
the joint’s range of motion. Medications can include the use of acetaminophen, NSAIDs, or
narcotics. Acetaminophen can reduce pain, but it does not reduce inflammation. NSAIDs can
reduce both pain and inflammation, but long-term use can lead to complications. Narcotics like
codeine are reserved for cases with severe pain as they can be addictive. Pain management
classes can also help patients learn how to cope with the pain.

Physical therapy can help people with osteoarthritis reduce pain and improve the range of
motion with strengthening exercises targeting the affected joint. Occupational therapy can help
patients avoid extra stress on the joints by altering the ways everyday tasks, like holding a
toothbrush, are performed. Braces, splints, or shoe inserts can provide support the affected
joints or redistribute weight to reduce pressure.

Corticosteroid injections can help relieve pain within the joint, although these shots are painful
and can lead to further joint damage if used too often. Certain injections of hyaluronic acid
derivatives can recreate cushioning between the joints. In some cases, surgery is necessary. In
these cases, osteotomy or arthroplasty is performed. Osteotomy results in realignment of the
bones so that body weight is redistributed away from the affected joint. Arthroplasty is joint
replacement surgery whereby damaged joints are replaced with artificial joints made from
plastic and metal.

Gout
Gout

Gout is a complex form of arthritis that affects synovial joints, but may be noticed first at joint at
the base of the big toe. While gout is more common in men, women are prone to gout after
menopause. Gout can be so painful that the pressure from a bed sheet can be excruciating.

Causes

Gout is the result of a build-up of uric acid in the body, leading to an accumulation of uric
crystals in the joints. Uric acid is produced when uric acid breaks down purines, which occur
naturally in the body and in foods like anchovies, herring, asparagus, mushrooms, and organ
meat. Uric acid usually passes through the kidneys into the urine, but if too much uric acid is
produced or the kidneys excrete too much uric acid, needle-shaped urate crystals can collect in
joints and surround tissues. The buildup leads to pain, swelling, and inflammation.

Gout tends to run in families, but it can be a result of other factors. Hypertension, diabetes,
arteriosclerosis, and hyperlipidemia are all associated with gout. Medications to treat
hypertension, low-dose aspirin, and anti-rejection drugs can allow uric acid levels to increase,
possibly contributing to gout. Finally, excessive use of alcohol can lead to development of gout.
A person can have one attack of gout in his or her lifetime and never have the condition again.
However, some individuals experience recurring gout, having several attacks each year. If gout is
left untreated, deposits of urate crystals can accumulate under the skin, leading to development
of tophi. Tophi are generally not painful, but can swell and become painful during a gout attack.
Tophi usually develop in the feet, hands, fingers, elbows, or Achilles tendons. Sometimes uric
acid crystals accumulate in the urinary tract, leading to kidney stones.

Symptoms

Gout attacks usually begin at night and come on suddenly. While gout is most prevalent in the
large joint of the big toe, it can also appear in the feet, hands, wrists, ankles, and knees. Pain is
acute, with the most severe pain occurring within the first 12 to 24 hours of the attack. The joint
is tender, red, and swollen.

Even after the attack subsides, pain continues to linger for a few days to a few weeks.
Subsequent attacks generally last longer and affect more joints. Hot, inflamed joints could
signify an infection and should be evaluated by a doctor immediately.

Diagnosis

Onset of symptoms is often a reliable indication of gout. Beyond that, blood tests measure the
level of uric acid in the blood. However, some people with high levels of uric acid in the blood
never develop gout. Moreover, some people with uric acid levels that fall within normal ranges
can have attacks of gout. For this reason, blood tests are not entirely reliable. Joint fluid test,
whereby fluid is drawn from the affected joint for analysis, can reveal the tell-tale needle-like
urate crystals.

Treatment

Medications seek to treat gout attacks, prevent future attacks, and reduce the risk of
complications. NSAIDs can be taken to alleviate pain and inflammation associated with gout and
may be prescribed in higher doses than normal for use during an attack. Individuals unable to
tolerate NSAIDs may be prescribed use of the drug colchicine for use as soon as symptoms
appear. A daily dose of colchicine may protect against future onset of gout. Corticosteroids
taken orally or through injection can be used in patients unable to tolerate either NSAIDs or
colchicine.

For people susceptible to repeated and severe gout attacks, drugs that block production of uric
acid can be prescribed. These are known as xanthine oxidase inhibitors and limit the body’s
production of uric acid. Care must be taken with this medication as it can trigger a new attack if
taken before an onset hasn’t fully resolved. For this reason, xanthine oxidase inhibitors are
generally used in conjunction with colchicine. Probenecid can help the kidneys remove uric acid
from the body, but results in increased levels of uric acid in the urine, possibly leading to the
development of kidney stones.
While vitamin C foods and supplements can possibly lower levels of uric acid in the body, huge
doses can have the opposite affect and actually increase uric acid in the body. Coffee has been
shown to possibly contribute to lower levels of uric acid in the blood. Finally, eating cherries,
drinking unsweetened cherry juice, or consuming other dark-skinned fruits like blueberries or
purple grapes may reduce uric acid levels in patients with gout.

Osteoporosis
Osteoporosis

Osteoporosis is a common condition in older adults whereby the bones become brittle and weak
leading to fractures. Bones can become so vulnerable that simple tasks like bending over or
coughing can lead to a fracture. The most common sites of osteoporosis involve the hip, spine,
or wrist.

Causes

Bone is a living tissue that the body constantly renews. In healthy individuals, healthy bone is
made at the same rate as old bone is broken down. Peak bone mass is achieved by the early 20s.
After that, bone is lost quicker than the body can replace it. Osteoporosis results when the
removal of old bone happens faster than the body’s ability to create new bone. The amount of
bone mass at its peak time can help determine how vulnerable a person is to later development
of osteoporosis.

Other factors determine development of osteoporosis:

 Women are more at risk of osteoporosis than men.
 Age increases the risk of osteoporosis.
 Whites and Asians develop osteoporosis more than other racial groups.
 Small body frames contribute to osteoporosis because of limited bone mass.
 A family history of osteoporosis or fractures is an associated risk factor of the condition.
 Reduction of sex hormones like estrogen or testosterone weakens bone.
 Overactive thyroid or too much thyroid hormone in the system contributes to bone loss.
 Overactive adrenal glands can lead to osteoporosis.

A chronic lack of calcium intake over the course of a lifetime can lead to diminished bone
density and early bone loss. People with anorexia are at risk of osteoporosis due to low food
intake and cessation of menstruation. Weight-loss surgery that reduces the stomach or bypasses
the intestines limits the body’s ability to absorb calcium, which can contribute to osteoporosis.
Excessive alcohol consumption interferes with calcium absorption, and tobacco use also
weakens bones. As weight-bearing exercise is beneficial to bone growth, a sedentary lifestyle
can lead to osteoporosis.
Certain medications can interfere with bone development, including medications for the
following conditions:
 Depression
 Cancer
 Gastric reflux
 Seizures
 Transplant rejection

Additionally, prolonged use of corticosteroid medications can contribute to osteoporosis.

Osteoporosis increases the possibility of fractures. Spine and hip fractures are especially serious
in older adults and can result in disability or death. Osteoporosis can cause the vertebrae to
weaken so much that lost height, a hunched back, and pain can be experienced.

Diagnosis

A dual energy x-ray measures bone density to determine if osteoporosis is present.

Treatment

Medications are widely used to treat osteoporosis. Some come in a pill form that is taken weekly
or monthly, while others are taken as an injection or intravenously. They include the following:
 Alendronate
 Ibandronate
 Risedronate
 Zoledronic acid

Hormone replacement therapy in both men and women can also offset osteoporosis due to
menopause or an age-related decline in testosterone. As estrogen replacement therapy carries
its own risks, raloxifene can be used instead.

Other medications for osteoporosis include:

 Calcitonin-salmon
 Denosumab
 Teriparatide

Prevention

People at risk of osteoporosis can help prevent fractures associated by limiting alcohol
consumption and avoiding smoking. Environmental aids like grab bars by the shower or bed, as
well as low-heeled or non-slip shoes, can help prevent falls. Adequate consumption of calcium
and vitamin D can also help protect against osteoporosis.

Calcium:
  People aged 18-50 need 1000 mg per day
 Women aged 50 and above need 1200 mg per day
 Men aged 70 and above need 1200 mg per day
 Good sources include low-fat dairy foods, dark green leafy vegetables, canned salmon,
sardines, soy products, or foods fortified with calcium

Vitamin D:
 Adults need 600-800 IU per day
 Sunlight naturally promotes production of vitamin D
 Milk is fortified with vitamin D

Exercise, particularly strength training and weight-bearing exercises like walking, jogging, and
stair climbing, help build bones and reduce bone loss. While swimming, cycling, and exercising
on machines is good for cardiovascular health, the low impact nature of such exercises does not
contribute to bone health.

Fractures
Fractures

Fractures refer to a break occurring in bone or cartilage. The average person sustains at least
two fractures over the course of a lifetime. While fractures are somewhat common during
childhood, fractures that occur in older adults are often more complicated due to bone loss.

Categories

There are four main categories for fractures:

 Displaced: The bone has broken into two sections where the sections are no longer
aligned.
 Non-displaced: The bone is partially or completely cracked, but has not moved in
alignment.
 Closed: The bone is broken but does not protrude through the skin.
 Open: The bone is broken and protrudes through the skin. Open fractures carry a high
risk of infection.

Types

Besides the four main categories, there are several kinds of fractures:
 Greenstick fracture: Greenstick fractures occur most often in children. This kind of
fracture is an incomplete break. The bone is bent.
 Transverse fracture: The fracture is at a right angle to the bone’s normal position.
 Oblique fracture: The fracture is curved or sloped.
  Comminuted fracture: The bone has fragmented into several pieces.
 Impacted fracture: Also known as a buckle fracture, the broken ends of bone are driven
into each other.
 Avulsion fracture: A tendon or ligament and the bone to which it is attached pulls away
from the main bone. Avulsion fractures are common in athletes and can fuse back
together naturally.
 Pathologic fracture: Fractures that result from weakening of the bone due to disease
are pathologic fractures. Cancer and osteoporosis can lead to pathologic fractures. This
kind of fracture can occur with little or no trauma, such as when someone bends over or
sneezes.
 Stress fracture: A hairline crack in the bone.

The location of a fracture and the amount of damage to the affected bone and surrounding
tissue help determine the severity of the fracture.

Symptoms

Symptoms of a fracture include the following:

 Pain the increases with movement or pressure
 Swelling
 Bruising
 Deformity
 Loss of function
 Bone protruding from the skin (in open fractures)

Complications from fractures include nerve damage, blood vessel damage, infection to tissues,
and osteomyelitis. Healing time varies by patient and severity of the fracture, with older adults
often taking months to heal.

Diagnosis

Fractures are generally diagnosed through x-rays, although some fractures do not show up on
regular x-rays, such as wrist fractures, stress fractures, and hip fractures in older adults. In those
cases, a CT scan, MRI, or bone scan may be necessary to view the fracture. Sometimes doctors
will immobilize the area for 10-14 days and repeat the x-ray as the break may be more visible
after the swelling has diminished. CT scans, MRIs and angiograms can help detect tissue damage
caused by the fracture.

Treatment

Bones must be returned to their natural placement for proper healing. The act of setting a bone
back in its normal position is known as reduction. Setting a bone without surgery is called closed
reduction; setting a bone with surgery is called open reduction. Some fractures require the use
of screws, pins, plates, rods, or glue to properly set the fracture in place.
After reduction, the affected area is placed in a cast, splint, or traction to promote healing and
reduce pain. Medication can be given for pain reduction, while antibiotics are sometimes
necessary to prevent infection. Physical therapy is often started while the fracture is still healing
in order to promote blood flow, avoid loss of muscle tone, and guard against blood clots and
stiffness.

Muscular Dystrophy
Muscular Dystrophy

Muscular dystrophy is a genetic disease that causes progressive muscle damage that leads to
weakness, breathing difficulties, and disability. There are many different kinds of muscular
dystrophy, each with its own specific age of onset and sequence of symptom development.

Causes & Types

Muscular dystrophy results from a defective mutation on a gene. Most forms of muscular
dystrophy are inherited, although some forms spontaneously appear within the mother’s egg or
inside the developing embryo.

The most common form of the condition, Duchenne muscular dystrophy, is particularly
prevalent in young boys, although it can affect both boys and girls of all ages and races. Becker
muscular dystrophy typically shows signs beginning in the teenage years, although onset can be
occur as late as the mid to late 20s in rare cases. Other forms of muscular dystrophy are
identified by the location in the body affected by the condition or by a particular feature of each
form. They include:
 Steinert disease: This myotonic form of muscular dystrophy begins in the facial muscles.
Onset occurs in early adulthood.
 Limb-girdle: Symptoms present themselves anywhere from early childhood to early
adulthood and affect the hip and shoulder.
 Congenital: Congenital muscular dystrophy is evident prior to age 2. This form can vary
from mild disability with slow progression to severe disability with rapid progression.
 Fascioscapulohumeral (FSHD): In this form of muscular dystrophy, the contracture
causes the shoulder blades to jut out like wings when the arms are raised. Symptoms
appear during the teenage or young adult years.
 Oculopharyngeal: This form begins in adulthood, with drooping of the eyelids the first
sign of the disease. Weakness in the facial and throat muscles leads to difficulties eating
and swallowing.

Complications
All forms contribute to a shortened life span as muscular dystrophy compromises the
respiratory system. The heart is also affected, as well as the muscles associated with swallowing.
Many people with muscular dystrophy develop nutritional problems, and the most common
cause of death is respiratory failure before age 40.

Patients with muscular dystrophy often have limbs that draw inward and become permanently
fixed in that position. This is known as contracture. Contracture can lead to the development of
scoliosis, particularly in patients who are confined to a wheelchair because of mobility issues.

Symptoms

Symptoms vary according to the form of disease and are mentioned above. Progressive
weakness of the muscles is the most common feature of muscular dystrophy, with progression
and sequence of varying muscle groups determined by the disease type. The forms of muscular
dystrophy that develop during childhood are often noticed when a child begins to walk.

Muscular dystrophy that develops during childhood has the following symptoms:
 Frequent falls
 Difficulty running and jumping
 A waddling gait
 Large calf muscles
 Problems getting up from a sitting or lying position
 Learning disabilities

Myotonic muscular dystrophy causes patients to be unable to relax muscles. Limb-girdle

muscular dystrophy can make it difficult to lift and control the front part of the foot.

Diagnosis

Damaged muscles release certain enzymes into the bloodstream, making an enzyme test a
reliable method to use to diagnose muscular dystrophy. A high level of the enzyme creatine
kinase (CK) in the blood system of a person who has not recently experienced a traumatic injury
indicates muscular dystrophy.

Other tests used to diagnose muscular dystrophy include the following:

 Electromyography: Electrical activity in a muscle is tested through a needle electrode
inserted into the muscle. An odd electrical pattern confirms the presence of a muscle
disease.
 Muscle biopsy: A muscle biopsy can determine if the muscle is affected by muscular
dystrophy or another form of muscle disease.
 Genetic testing: Laboratory analysis of a blood sample can detect gene mutations that
lead to different forms of muscular dystrophy.

Treatment
There is no cure for muscular dystrophy. Rather, the goal of treatment is to maintain mobility
for as long as possible and reduce deformities caused by contracture. Prolonged use of
corticosteroid medications can lead to weakened bones, but such medicines can protect muscle
strength and delay progression of the condition. Certain therapies can be used to improve a
patient’s quality of life and lengthen lifespan. Physical therapy seeks to maintain range-of-
motion with flexibility exercises. Braces are used to support weakened muscles and keep
muscles and tendons stretched, while canes, walkers, and wheelchairs can aid in mobility.

As the condition progresses, sleep apnea devices can help a patient breath, especially at night as
respiratory muscles weaken and relax. Severe muscular dystrophy may necessitate the use of a
ventilator to assist with breathing. Surgery can be used to help with contracture, scoliosis
(especially if the curved spine is affecting the lungs), and heart problems (particularly a
pacemaker to keep the heart beating steadily despite muscle weakness).

The respiratory system is particularly vulnerable in patients with muscular dystrophy. For this
reason, pneumonia and influenza vaccines are important to prevent against respiratory diseases
or infections.