YEAR 2 SEMESTER 2, 2011

08/08/11

THEME CONVENOR

MRS. L.MATAITINI.

This week, we will introduce you to the disorders of the musculoskeletal system. Musculoskeletal system includes the bones, joints and muscles of the body together with the associated structures such as the ligaments and tendons. These disorders affects person of all age groups and all walks of life, causing pain and disability.

At the end of this session the student should be able to:

Define the key terms

Discuss the different causes of musculoskeletal disorders.

Explain the clinical manifestations of each disorders. Discuss the pathophysiological problems of each musculoskeletal system.
Discuss the different types of therapeutic procedures available for each disorders. Discuss the different drugs available to treat

Pathophysiological changes of the musculoskeletal.

Musculoskeletal disorders divides up into three according to the structures:

Tissue Joints Bones

(i) (ii) (iii)

Physical forces such as:

Blunt tissue trauma. Disruptions of tendons and ligaments Fractures of the bony structures. Other causes: Motor vehicle accident Motorcycle accident Falls

rugby athletes other sports

SOFT TISSUE INJURY.

Contusion

Hematoma
Laceration

 It

is the injury to soft tissue that results from direct trauma and is usually caused by striking a body part against a hard object.

CLINICAL MANIFESTATIONS
ecchymosis-due to hemorrhage discoloration gradually changes to brown and yellow as the blood is reabsorbed.

Hematoma- blood accumulates and exerts pressure on nerve endings.

CLINICAL MANIFESTATION pain- increases with movement ,swelling , infection due to bacterial growth, split skin due to increase pressures and produce drainage of the hematoma

TREATMENT: apply cold compress during the 1st 24hrs of injury.

After the 1st 24hrs, heat or cold compression to be done intermittently for 20mins at a time.
Laceration: Injury in which the skin is torn or its continuity is disrupted. The seriousness of the laceration depends on the size and depth of the wound.

Punctured wounds from nails or rusted material provide the setting for growth of anaerobic bacteria such as those that cause tetanus and gas gangrene.

TREATMENT: Wound closure after cleaning the wound well and apply sterile dressing antibiotics.

Strains
Sprains Dislocation Knee injuries Meniscus injuries.

STRAINS: A strain is a stretching injury to a muscle or a musculotendinous(joint)unit caused by a mechanical overloading. . CAUSE : unusual muscle contraction. excessive forcible stretch . overweight or excessive exercises.

Pain. Stiffness.
Swelling.

Lower back Cervical region of the spine Elbow Shoulder foot

TREATMENT: Bed rest. traction. application of heat. massage. cold compression for the 1st 24hrs to educe pain and swelling of the affected area. exercises, correct posture and good body mechanics.

SPRAINS: Involves the ligamentous structures surrounding the joints, resemble a strain, but the pain and swelling subsides slowly. CAUSE: abnormal and excessive movement of the joint.

CLINICAL MANIFESTATIONS: pain.

Rapid swelling. Heat. Disability. Discoloration Limitation of function

DIAGNOSTIC TESTS: history of the injury. x-ray.

TREATMENT:
Bed rest. elevation of the injured part cold compression. adhesive straps or removable splint cast applied on severe sprains.

Displacement or separation of the bone ends of the joint with loss of articulation. Usually follows a severe trauma that disrupts the holding ligaments. Most common sites are the shoulders and acromioclavicular joints. Sublaxation is a partial dislocation in which the bone ends in the joint are still in partial contact with one another.

Dislocations can be congenital, traumatic or pathologic. Traumatic dislocations occur after falls, blows, or rotational injuries.

CAUSE: trauma . motor vehicle accidents. fall. sports.

CLINICAL MANIFESTATIONS. pain. limitation of movement swelling deformity

DIAGONISTIC TESTS. history. physical examination x-ray. TREATMENT. Bed rest. manipulation surgical repair.

It is a common site of injury, particularly sport related injuries in which the knee is subjected to abnormal twisting and compression forces. These forces can result in injury to the meniscus, patella sublaxation and dislocation .

MENISCUS INJURY: Meniscus injury commonly occurs as the result of rotational injury from a sudden or sharp instrument or a direct blow to the knee, as in hockey, basketball or football.

CLINICAL MANIFESTATIONS. pain . swelling DIAGNOSTIC TEST: physical examination x-ray. arthroscopy TREATMENT: conservative rest

A break in the continuity of the bone. A fracture occurs when the stress placed on the bone is greater than the bone can absorb. TYPES OF FRACTURE: open fracture skin involve closed fracture-skin not involve complete fracture-involves the entire cross section of the bone pathologic fracture-through an area of diseased bone.

Greenstick-one side of the bone is broken Transverse-straight across the bone. Oblique at an angle across the bone. Spiral-twists around the shaft of the bone. Comminuted-bone splinted into more than three fragments. Depressed-fragments indriven. Compression-bone collapses in on itself. Avulsion fragment of bone pulled of by ligament. Impacted-fragment of bone wedged into other bone fragment.

COMPOUND FRACTURE

Pain Tenderness Swelling Loss of function Deformity of the affected side Angulations Shortening of the bones Rotation deformity Crepitus or grating may be felt as the bone fragments rub each other. Bleeding

PATTERNS OF FRACTURE CONT

PICS SUPPLEMENT

Hypovolemic shock due to bleeding.

Numbness of the affected area.

DIAGNOSTIC AND THERAPEUTIC. history physical examination x-ray examination

Reduction-to align the bones Immobilization-prevents movement of the bones External fixation

COMPLICATIONS OF FRACTURES. fracture blisters Compartment syndrome Muscle wasting Fat embolism

 Osteomylitis: Acute and chronic infection of the bone.

Direct extension or contamination of

the open fracture. Wide variety of microorganisms introduced during injury, operative procedures or from the blood stream. Usually bacteria in origin; isolated organisms which include : staphylococcus aureus Escherichia coli

Pseudomonas Klebsiella Salmonella Proteus

2.Hematogenous Infection-through the bloodstream.

PATHOPHYSIOLOGY: 1. Site inoculated.

2.Inflammatory and immunologic response; pus formation edema. vascular congestion. 3. Vascular occlusion leads to ; ischemia bone necrosis. 4. Infections spread through the bone via Volkmann's and haversian canals, causing further vascular occlusions

Ischemia allows necrotic bone to separate from the living bone, forming sequestra. Sequestra enlarge, spreading toward and breaching the cortex, forming a subperiosteal abscess, further interfering with the vascular supply. Vascular supply may remain sufficient to maintain life of bone tissue.

New bone is created Bone healing occurs. Diminished vascular supply leads to dead bones and bones become inert. Small pieces of bone may be completely destroyed by granulation tissue.

Large pieces of dead bone cannot be destroyed . Central residual remains a sequestrum composed of cancellous New bone is laid down beneath the elevated periosteum and tends to form an encasement around the sequestrum. Pockets of infection are walled off in which organisms can lie dormant long periods Chronic sinuses may form that eventually reach the surface and drain

Drainage continues until infection quiets once more. Channels become plugged with granulations and remain closed until the pressure of the pus builds up and causes the sinuses to reopen or reach the surface through new channels(chronic osteomyelitis)
Complete healing takes place only when all the dead bone has destroyed, discharged or excised

COMPLICATIONS: Chronic osteomyelitis Pathological fracture Joint destruction Skeletal deformities Limb length discrepancies Life threatening if untreated

CLINICAL MANIFESTATIONS Localised pain Swelling Erythema Fever Malaise Irritability.

DIAGNOSTIC TESTS Blood culture Needle aspiration Full blood count X-ray. TREATMENT: Intravenous antibiotics-4to 8weeks Additional 4to8weeks oral antibiotics Surgical intervention(incision and drainage).

Development dysplasia of the hip: congenital dislocation of the hip.

CAUSE: Unknown Hereditory-high risk with family history Increased ligamentous laxity secondary to maternal hormones. Breach presentation First born In-utero restrictions to fetal movement

Joint Arthroplasty (Reconstruction or Replacement)

Swaddling in the postnatal period, where the hips are in abduction and extension

PATHOPHYSIOLOGY: Acetabelum tends to be shallow and oblique Head of the femur tends to smaller than normal. Ossification centers are delayed in appearance. Dysplasia-shallow acetabelum, roof slants upward

Sublaxation acetabular surface of the femoral head is in contact with shallow dysplastic. Dislocation-articular cartilage of completely displaced femoral head does not contact acetabular articular cartilage

COMPLICATION: Avascular necrosis of femoral head Loss of range of movement. Leg length inequality. Early osteoarthritis Recurrent dislocation or unstable hip.

CLINICAL MANIFESTATIONS: Asymmetry of high or gluteal folds Abnormal gait pattern Ortolanis sign and positive Barlows test.

DIAGNOSTIC TEST: X-ray-cartilagenous femoral head is difficult to visualise in the newborn Ultrasound examination Arthrogram- outline the cartilagenous portions of the acetabulum and femoral head Physical examination

TREATMENT: Splinting-Birth to 3months Close reduction3months to 2years. Surgical intervention -2yrs +

Congenital anomaly characterised by a three part deformity of the foot, consisting of the heel(varus), adduction and supination of the forefoot, and ankle equinus.

CAUSE: Unknown. Suggested contributing factor; .intrauterine position. .primary arrest in fetal development.

Familial tendency.

PATHOPHYSIOLOGY: Foot is planter flexed at the ankle and the subtalar joints. Hind foot is inverted. Midfoot and hind forefoot are adducted and inverted. Contractures of the soft tissues maintain the malalignments.

COMPLICATIONS:

Deformity becomes fixed if untreated. Disturbances in epiphyseal plates from overaggressive manipulations Child bearing weight on lateral border of foot Gait is awkward Recurrent deformity

CLINICAL MANIFESTATION: Deformity is obvious at birth with varying degree rigidity and ability to correct position. DIAGNOSTIC TEST: clinical presentation Physical examination X-ray TREATMENT: Manipulation-pop cast Corrective footwear Surgical intervention

DEFINITION: Lateral curvature of the spine with vertebral body rotation. CAUSE: Unknown Classified into three groups. Infants-presentation 3years Juvenile -3to10years. Adolescents-10years

Congenital scoliosis exact cause is unknown Neuromuscular scoliosis-child has a definite neuromuscular condition that directly contributes to the deformity.

PATHOPHYSIOLOGY: Vertebral column develops lateral curvature Vertebral rotate to the convex side of the curve Vertebral become wedged shape Disk shape is altered

Deformity progress, changes in the thoracic cage worsened. Changes in the thoracic cage, ribs and sternum lead to further characteristics deformities such as rib hump. Neurological compromise-very rare.

COMPLICATION: Untreated progressive scoliosis may lead to significant deformity Cardiopulmonary compromise Shortened life expectancy Increased back pain

CLINICAL MANIFESTATIONS:

Poor posture Uneven should height One hip appears more prominent Crooked neck Lump on the neck Rib hump Uneven waistline Uneven breast size Visualization deformity Back pain

DIAGNOSTIC TEST: X-ray of the spine upright position Myelogram Tomograms C.T. Scan TREATMENT: Medical management Exercise therapy Surgical intervention

OSTEOPOROSIS: DEFINITION: Condition in which the bone matrix is lost, thereby weakening the bones and making them susceptible to fractures.

PATHOPHYSIOLOGY: The rate of bone resorption increases over the rate of bone formation, causing loss of bone mass . Calcium and phosphate salts are lost-creating brittle bones. Occurs most frequently in postmenopausal women.

Age Inactivity Chronic illness Medications such as corticosteroids Calcium and vitamin D deficiency Family history Smoking Diet caffeine is a risk factor Race white and Asians have higher risk

CLINICAL MANIFESTATIONS. Asymptomatic until later stages Fracture after minor trauma may be first indications. Vague complaints related to aging process. Stiffness Pain Weakness

DIAGNOSTIC TEST: X-ray-shows changes only after30% to60% of bone.

Computed Tomography (CT Scan) Bone biopsy.

COMPLICATION Fracture

DEFINITION: Degenerative joint disease is a chronic non inflammatory, slowly progressing disorder that causes deterioration of articular cartilage It affects weight- bearing joints( hips and knees) as well as joints of the distal interphalanges and of the fingers.

PATHOPHYSIOLOGY: Changes in particular cartilage occurs first Soft tissue changes may occur next.

Progressive wear and tear on cartilage leads to thinning of joint surface Ulceration into bone Inflammation of the joint and increased blood flow.. Hypertrophy of suprachondral bone . New cartilage and bone formation at joint margin results in osteophytosis altering the size and shape of bone

CAUSE: unknown Aging and obesity are contributing factors Previous trauma may cause secondary osteoarthritis

DIAGNOSTIC TESTS: Physical examination X-ray of affected joints Bone scan Analysis of synovial fluid differentiates osteoarthritis and rheumatoid arthritis

DEFINITION: Musculoskeletal neoplasm include primary sarcoma, metastic bone disease, and benign tumors of the bone.

PATHOPHYSIOLOGY Benign bone tissue Osteoid osteoma Chondroma Osteoclastoma

Malignant bone tumors Chondrosarcoma and osteosarcoma are examples of primary malignant bone tumors

Hematogenous spread to the lungs occurs Multiple myeloma is a malignant neoplasm arising from the bone marrow .

METASTATIC BONE TUMORS; Metastic bone tumors are most frequently associated with cancers of the breast, prostate and lung (primary malignancy site) . Bone metastasis most frequently occurs in the vertebrae and results in pathological fracture.

CLINICAL MANIFESTATIONS: Pain in the involved bone-worst at night. Swelling and limitations of motion and joint effusions Physical findings-palpable, tender fixed boney mass. Increase in skin temperature over the mass. Superficial veins dilated and prominent.

DIAGNOSTIC TEST X-ray CT Scan Bone scan bone biopsy blood test-serum alkaline phosphate chest x-ray and lung scan arteriography-to assess soft tissue

TREATMENT:
Surgery Chemotherapy Radiotherapy

QUESTION TIME? ? ?