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THEME CONVENOR MRS. L.MATAITINI.

YEAR 2 SEMESTER 2, 2011 08/08/11

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This week, we will introduce you to thedisorders of the musculoskeletal system.

Musculoskeletal system includes the bones,joints and muscles of the body togetherwith the associated structures such as theligaments and tendons. These disorders

affects person of all age groups and allwalks of life, causing pain and disability.

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At the end of this session the studentshould be able to:

Define the key terms

Discuss the different causes ofmusculoskeletal disorders.

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Explain the clinical manifestations of eachdisorders.

Discuss the pathophysiological problems ofeach musculoskeletal system.

Discuss the different types of therapeutic

procedures available for each disorders.

Discuss the different drugs available to treat

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Pathophysiological changes of themusculoskeletal.

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Musculoskeletal disorders divides up intothree according to the structures:

(i) Tissue(ii) Joints(iii) Bones

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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

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rugby

athletes

other sports

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SOFT TISSUE INJURY.

Contusion

Hematoma

Laceration

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It is the injury to softtissue that results fromdirect trauma and is

usually caused bystriking a body part

against a hard object.

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CLINICAL MANIFESTATIONS

ecchymosis-due to hemorrhagediscoloration gradually changes tobrown and yellow as the blood isreabsorbed.

Hematoma- blood accumulates and exertspressure on nerve endings.

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CLINICAL MANIFESTATIONpain- increases with movement ,swelling ,

infection due to bacterial growth, split skindue to increase pressures and produce

drainage of the hematoma

TREATMENT:apply cold compress during the 1

st

24hrs ofinjury.

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After the 1st 24hrs, heat or coldcompression to be done intermittentlyfor 20mins at a time.

Laceration:Injury in which the skin is torn or itscontinuity is disrupted. The

seriousness of the lacerationdepends on the size and depth of thewound.

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Punctured wounds from nails or rustedmaterial provide the setting for growth of

anaerobic bacteria such as those that causetetanus and gas gangrene.

TREATMENT:Wound closure after cleaning the wound well

and apply sterile dressing antibiotics.

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Strains

Sprains

Dislocation

Knee injuries

Meniscus injuries.

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STRAINS:A strain is a stretching injury to a muscle or amusculotendinous(joint)unit caused by amechanical overloading.

.

CAUSE : unusual muscle contraction.

excessive forcible stretch . overweight or excessive exercises.

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Pain.

Stiffness.

Swelling.

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Lower back Cervical region of the spine

Elbow

Shoulder foot

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TREATMENT:

Bed rest. traction.

application of heat.

massage.

cold compression for the 1st 24hrsto educe pain and swelling of the

affected area.

exercises, correct posture and goodbody mechanics.

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SPRAINS:Involves the ligamentous structuressurrounding the joints, resemble astrain, but the pain and swellingsubsides slowly.CAUSE:

abnormal and excessive movement ofthe joint.

CLINICAL MANIFESTATIONS:pain.

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Rapid swelling.

Heat. Disability.

Discoloration

Limitation of function

DIAGNOSTIC TESTS: history of the injury.

x-ray.

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TREATMENT: Bed rest. elevation of the injured part cold compression.

adhesive straps or removablesplint cast applied on severe sprains.

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Displacement or separation of the bone endsof the joint with loss of articulation.

Usually follows a severe trauma that disrupts

the holding ligaments.

Most common sites are the shoulders andacromioclavicular joints.

Sublaxation is a partial dislocation in which

the bone ends in the joint are still in partialcontact with one another.

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Dislocations can be congenital, traumatic orpathologic.

Traumatic dislocations occur after falls,blows, or rotational injuries.

CAUSE: trauma .

motor vehicle accidents. fall.

sports.

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CLINICAL MANIFESTATIONS.pain.limitation of movementswellingdeformity

DIAGONISTIC TESTS.history.physical examination

x-ray.TREATMENT.Bed rest.manipulationsurgical repair.

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It is a common site of injury, particularly sport

related injuries in which the knee is subjectedto abnormal twisting and compression forces.These forces can result in injury to themeniscus, 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 inhockey, basketball or football.

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CLINICAL MANIFESTATIONS.pain .swelling

DIAGNOSTIC TEST:physical examinationx-ray.arthroscopy

TREATMENT:conservativerest

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A break in the continuity of the bone. A fractureoccurs when the stress placed on the bone isgreater than the bone can absorb.

TYPES OF FRACTURE:open fracture skin involveclosed fracture-skin not involvecomplete fracture-involves the entire

cross section of the bonepathologic fracture-through an area of

diseased bone.

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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 threefragments.

Depressed-fragments indriven.

Compression-bone collapses in on itself.

Avulsion fragment of bone pulled of byligament.

Impacted-fragment of bone wedged into otherbone fragment.

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COMPOUND FRACTURE

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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 bonefragments rub each other.

Bleeding

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PICS SUPPLEMENT

PATTERNS OF FRACTURE CONT

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Hypovolemic shock due to bleeding.

Numbness of the affected area.

DIAGNOSTIC AND THERAPEUTIC.history

physical examination

x-ray examination

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

bones

External fixation

COMPLICATIONS OF FRACTURES. fracture blisters

Compartment syndrome Muscle wasting Fat embolism

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Osteomylitis:

Acute and chronic infection of thebone.

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Direct extension or contamination of

the open fracture.Wide variety of microorganisms

introduced during injury, operativeprocedures or from the blood

stream.Usually bacteria in origin; isolated

organisms which include :staphylococcus aureusEscherichia coli

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Pseudomonas

Klebsiella Salmonella

Proteus

2.Hematogenous Infection-through thebloodstream.

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PATHOPHYSIOLOGY:1. Site inoculated.

2.Inflammatory and immunologic response;pus formationedema.vascular congestion.

3. Vascular occlusion leads to ;

ischemiabone necrosis.

4. Infections spread through the bone viaVolkmann's and haversian canals,

causing further vascular occlusions

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Ischemia allows necrotic bone to separatefrom the living bone, forming sequestra.

Sequestra enlarge, spreading toward andbreaching the cortex, forming a subperiosteal

abscess, further interfering with the vascular

supply.

Vascular supply may remain sufficient to

maintain life of bone tissue.

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New bone is created

Bone healing occurs.

Diminished vascular supply leads to deadbones and bones become inert.

Small pieces of bone may be completelydestroyed by granulation tissue.

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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 encasementaround the sequestrum.

Pockets of infection are walled off in whichorganisms can lie dormant long periods

Chronic sinuses may form that eventuallyreach the surface and drain

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Drainage continues until infection quietsonce more. Channels become plugged withgranulations and remain closed until thepressure of the pus builds up and causes

the sinuses to reopen or reach the surfacethrough new channels(chronicosteomyelitis)

Complete healing takes place only when allthe dead bone has destroyed, discharged orexcised

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COMPLICATIONS: Chronic osteomyelitis

Pathological fracture

Joint destruction

Skeletal deformities

Limb length discrepancies

Life threatening if untreated

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CLINICAL MANIFESTATIONS Localised pain

Swelling

Erythema

Fever

Malaise

Irritability.

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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).

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

CAUSE: Unknown Hereditory-high risk with family history

Increased ligamentous laxity secondary tomaternal hormones.

Breach presentation First born

In-utero restrictions to fetal movement

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Joint Arthroplasty(Reconstruction or Replacement)

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Swaddling in the postnatal period, where thehips 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

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Sublaxation acetabular surface of thefemoral head is in contact with shallowdysplastic.

Dislocation-articular cartilage of completelydisplaced femoral head does not contactacetabular articular cartilage

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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.

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DIAGNOSTIC TEST: X-ray-cartilagenous femoral head is difficult

to visualise in the newborn

Ultrasound examination

Arthrogram- outline the cartilagenousportions of the acetabulum and femoral head

Physical examination

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TREATMENT: Splinting-Birth to 3months

Close reduction3months to 2years.

Surgical intervention -2yrs +

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Congenital anomaly characterised by a threepart deformity of the foot, consisting of theheel(varus), adduction and supination of theforefoot, and ankle equinus.

CAUSE: Unknown.

Suggested contributing factor;

.intrauterine position..primary arrest in fetaldevelopment.

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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.

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COMPLICATIONS: Deformity becomes fixed if untreated.

Disturbances in epiphyseal plates fromoveraggressive manipulations

Child bearing weight on lateral border of foot

Gait is awkward

Recurrent deformity

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CLINICAL MANIFESTATION:

Deformity is obvious at birth with varying degreerigidity and ability to correct position.

DIAGNOSTIC TEST: clinical presentation

Physical examination X-ray

TREATMENT: Manipulation-pop cast Corrective footwear Surgical intervention

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DEFINITION:Lateral curvature of the spine with vertebralbody rotation.

CAUSE: Unknown Classified into three groups.

Infants-presentation 3years

Juvenile -3to10years.Adolescents-10years

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Congenital scoliosis exact cause is unknown Neuromuscular scoliosis-child has a definite

neuromuscular condition that directlycontributes 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

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Deformity progress, changes in the thoracic

cage worsened.

Changes in the thoracic cage, ribs andsternum lead to further characteristicsdeformities such as rib hump.

Neurological compromise-very rare.

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COMPLICATION: Untreated progressive scoliosis may lead to

significant deformity

Cardiopulmonary compromise

Shortened life expectancy

Increased back pain

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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

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DIAGNOSTIC TEST: X-ray of the spine upright position

Myelogram

Tomograms

C.T. Scan

TREATMENT: Medical management

Exercise therapy

Surgical intervention

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OSTEOPOROSIS: DEFINITION:

Condition in which the bone matrix is lost,thereby weakening the bones and makingthem susceptible to fractures.

PATHOPHYSIOLOGY: The rate of bone resorption increases over the

rate of bone formation, causing loss of bonemass .

Calcium and phosphate salts are lost-creatingbrittle bones.

Occurs most frequently in postmenopausalwomen.

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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

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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.

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Computed Tomography (CT Scan) Bone biopsy.

COMPLICATION

Fracture

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DEFINITION:

Degenerative joint disease is a chronic noninflammatory, slowly progressing disorderthat causes deterioration of articular cartilage

It affects weight- bearing joints( hips and

knees) as well as joints of the distalinterphalanges and of the fingers.

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PATHOPHYSIOLOGY:Changes in particular cartilage occurs first

Soft tissue changes may occur next.

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Progressive wear and tear on cartilage leads

to thinning of joint surface Ulceration into bone

Inflammation of the joint and increased bloodflow..

Hypertrophy of suprachondral bone .

New cartilage and bone formation at jointmargin results in osteophytosis altering the

size and shape of bone

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CAUSE:

unknown

Aging and obesity are contributing factors

Previous trauma may cause secondaryosteoarthritis

DIAGNOSTIC TESTS: Physical examination

X-ray of affected joints

Bone scan Analysis of synovial fluid differentiates

osteoarthritis and rheumatoid arthritis

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DEFINITION:Musculoskeletal neoplasm include primary

sarcoma, metastic bone disease, and benigntumors of the bone.

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PATHOPHYSIOLOGY Benign bone tissue

Osteoid osteoma Chondroma

Osteoclastoma

Malignant bone tumors Chondrosarcoma and osteosarcoma are

examples of primary malignant bonetumors

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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 ofthe breast, prostate and lung (primarymalignancy site) .

Bone metastasis most frequently occursin the vertebrae and results inpathological fracture.

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CLINICAL MANIFESTATIONS:

Pain in the involved bone-worst at night. Swelling and limitations of motion and joint

effusions

Physical findings-palpable, tender fixedboney mass. Increase in skin temperatureover the mass. Superficial veins dilated andprominent.

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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

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TREATMENT: Surgery

Chemotherapy

Radiotherapy

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QUESTION TIME? ? ?