Pathophysiology- Musculoskeletal System
Pathophysiology- Musculoskeletal System NUR 305
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This 15 page Study Guide was uploaded by Shelby Stephens on Wednesday December 9, 2015. The Study Guide belongs to NUR 305 at University of Alabama - Tuscaloosa taught by Owings in Fall 2015. Since its upload, it has received 55 views. For similar materials see Pathophysiology in Nursing and Health Sciences at University of Alabama - Tuscaloosa.
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Date Created: 12/09/15
Musculoskeletal System BONES and CARTILAGE Includes bones, joints, muscles, ligaments, tendons, and other connective tissue Axial Skeleton= Skull, thorax, vertebral column, (axis of the body) Appendicular Skeleton= upper and lower extremities, shoulders, and hips girdles Bones: Specialized form of connective tissue Site of fat and mineral storage as well as hematopoiesis 206 bones in the skeleton Skeletal divisions ◦ Axial skeleton forms the long axis of the body and includes the skull, vertebral column, and rib cage ◦ Appendicular skeleton consists of bones that form the arms, shoulders, pelvis, and legs The skeleton forms from hyaline cartilage during fetal development Cartilage – tough and flexible connective tissue PTH promotes bone resorption by decreasing calcium Calcitonin increases blood calcium levels Periosteum – layer of connective tissue that covers compact bone surfaces Serves as the site of muscle attachment (via tendons) The outer surface contains cells that aid in remodeling and repair (osteoblasts) Richly supplied with blood vessels and nerve fibers Bone Marrow – in the shaft of long bones Most infants have red marrow Red marrow is the site of hematopoiesis Red marrow is slowly replaced by fat with age, creating yellow marrow Yellow marrow begins to form during adolescence and is present in most bones by adulthood Hematopoiesis occurs in the vertebrae, pelvis, and a few other sites in adults The yellow marrow can be reactivated to produce blood cells when needed (e.g., after an injury) Types of Bones: Long bones ◦ Upper and lower extremities Short bones ◦ Ankle and wrist Flat bones ◦ Scapula, skull Irregular bones ◦ Jaw, vertebrae Sesamoid bones ◦ Knee cap Bone Remodeling: Osteoclasts – break down spongy bone Osteoblasts – rebuild new compact bone Osteocyte – osteoblasts surrounded by calcified extracellular material Matrix ◦ Extracellular material in which the osteocytes are embedded ◦ Consists of calcium phosphate crystals that make bones hard and strong ◦ Also contains collagen fibers that reinforce the bone to give flexible strength ◦ Balance between the mineral and collagen is necessary for optimal bone function Bone Growth: Bones grow in two ways ◦ Appositional growth – new bone forms on the surface of a bone ◦ Endochondral growth – bone eventually replaces new cartilage growth in the epiphyseal plate Proper nutrition and physical activity are essential for the development and maintenance of healthy bone Growth hormone works with thyroid hormones to control normal bone growth ◦ Causes cartilage and bone cells to reproduce and lay down their intercellular matrix ◦ Stimulating mineralization within the matrix Calcitonin and parathyroid hormone regulate bone remodeling and mineralization of calcium Estrogen inhibits formation of osteoclasts in women Testosterone increases bone length and density in men Vitamin D controls the absorption of calcium from the intestine and increases calcium and phosphate reabsorption in the kidneys Joints: • Structures that connect bones of the skeleton • Synovial joints – Most common type – Freely moveable – Contain cartilage that is lubricated by a transparent viscous fluid (synovial fluid) that contains leukocytes to fight infections and provides nutrients – Contains a joint capsule, a structure that joins one bone to another – Consists of dense connective tissue that attaches to the periosteum of adjacent bones – Many contain ligaments that connect bones to bones and provide support to the joint • Amphiarthroses joints (cartilaginous) – Slightly moveable – Found in the vertebral column • Synarthroses joints (fibrous) – Immoveable – Found in the skull and pubic symphysis Muscles: Skeletal muscles – voluntary muscles that connect to bone ◦ 350 skeletal muscles that are controlled by the brain Smooth muscles – involuntary muscles that line walls of hollow organs and tubes and are found in the eyes, skin, and glands Cardiac muscle – involuntary muscle that comprises the heart Tendons – tough bands of dense connective tissue that are continuous extensions of the periosteum ◦ Attaches muscles to bones Skeletal Muscles: Comprised of muscle fibers, connective tissue, blood vessels, and nerves Muscle fiber – muscle cell Myofibrils – threadlike structures that extend the entire length of the muscle fiber Myofibrils contain two types of myofilaments – actin and myosin Myofilaments are organized into repeated structural units called sarcomeres Muscle fibers contract by sliding actin filaments over myosin filaments Calcium and adenosine triphosphate is required for muscle contractions Skeletal Muscle Growth: • Growth hormone causes muscle growth • The number of muscle fibers in a muscle remains relatively constant throughout the life span • Increases in muscle sizes reflect increases in individual muscle fibers • When muscles work harder, they respond by becoming larger and stronger from an increase in contractile protein inside the muscle fiber • The muscle protein is produced and destroyed quickly, and the growth may be short lived Injury and Trauma Fracture: A break in the rigid structure of the bone Most common traumatic musculoskeletal disorders Manifestations: o Deformity (e.g., angulation, shortening, and rotation), o Swelling and tenderness at the site o Inability to move the affected limb o Crepitus o Pain o Paresthesia and muscle flaccidity progressing to spasms Diagnosis: o History/ physical examination o Xrays Treatment: o Immediate immobilization (e.g., splints or traction, reduction (closed or open) o Surgery (may include pins, plates, rods, or screws) o Debridement o Longterm immobilization (e.g., casts, splints, or traction) o Physical therapy Complications: o Fat embolism o Osteomyelitis o Osteonecrosis, or avascular necrosis o Delayed union, malunion, or nonunion o Compartment syndrome Types of Fractures: Simple fracture—a single break with bone ends maintaining their alignment and position Complete fractures Incomplete fractures partial break Open fractures, or compound fractures Closed fractures – skin is intact Comminuted fracture—multiple fracture lines and bone pieces Greenstick fracture—an incomplete break in which the bone is bent and only the outer curve of the bend is broken Compression fracture—bone is crushed or collapses into small pieces Impacted fractures Pathologic fractures Stress fractures, or fatigue fractures Depressed fractures Fracture Healing: 1. Hematoma formation 2. Necrosis of the broken bone ends 3. Fibroblasts invade the clot within a few days 4. Fibroblasts secrete collagen fibers, which form a mass of cells and fibers called a callus 5. Callus bridges the broken bone ends together inside and outside over 2–6 weeks 6. Osteoblasts invade the callus and slowly converts it to bone over 3 weeks to several months (usually 4–6 weeks) Dislocations: • Separation of two bones at a joint Manifestations: ◦ Visibly outofplace, discolored, or deformed joint ◦ Limited movement ◦ Swelling or bruising ◦ Intense pain, especially with movement or weight bearing ◦ Paresthesia near the injury Diagnosis: o History, physical examination o Xrays, and magnetic resonance imaging Sprains: • Injury to a ligament that often involves stretching or tearing of the ligament or the capsule surrounding the joint. Treatment: • RICE • Heal more slowly Strains: Injury to a muscle or tendon that often involves stretching or tearing of the muscle or tendon Treatment: o RICE o Possible surgery of severe tendon tears Osteomyelitis: Acute or chronic infection of the bone or marrow. Very difficult to treat Manifestations: ◦ Fever, redness, swelling ◦ Bacteremia Treatment: ◦ Treat causative agent ◦ Abx, possibly surgery for I & D Osteonecrosis: Avascular necrosis Caused by interruption in blood flow rather than infection ◦ Fractures, vessel injury (trauma), decompression sickness (SCUBA diving), sickle cell disease, radiation therapy, compartment syndrome. ◦ Can also be caused by corticosteroid therapy Neoplasms (Bone Tumors): More frequently benign than malignant Both can develop from the cartilage (chondrogenic), bone (osteogenic), and supporting elements of bone (fibrinogenic) Location of the tumor provides important diagnostic information. Manifestations: o Pain, presence of a mass, impairment of function. Some tumors are found incidentally Benign: Chondromas, osteochondromas, giant cell tumors Usually resolve in 23 years Giant cell tumors are classified as “intermediate” in nature between benign and malignant. Malignant: Osteosarcomas, chondrosarcoma, Ewing Sarcoma Can happen at anytime but certain tumors target age groups and anatomic sites Paget disease increases risk for development of bone cancer Osteosarcoma: Aggressive and highly malignant bone tumor Most common malignant bone tumor Typically occurs in persons younger than 20yo Men>Women Unknown cause (although some link it to age and period of maximum growth) Treatment: o Surgery and Chemotherapy Chrondrosarcoma: Malignant tumors of cartilaginous lineage and subclassified according to site of origin. Commonly arise in the central portions of the skeleton, pelvis, shoulders, and ribs. ½ as frequently as osteosarcomas Middle to later in life, slow growing often metastasize late and are often painless. Early dx is important because radical surgery excision tends to have better outcomes. Treatment: o Radical surgery excision, combo chemotherapy. o Typically does NOT respond to radiation Ewing Sarcoma: A member of the family of tumors that include primitive neuroectodermal tumor (PNET) Densely packed, regularly shaped, small cells with round or oval nuclei, reciprocation of chromosome 11 and 31. Primarily seen in children, and usually located in the femur and pelvis, but can be found in other bones. Treatment: o Multiagent chemo for shrinking of tumor, surgery, and radiation therapy Skeletal Disorders in Children: Osteogenesis Imperfecta ◦ “brittle bone disease” ◦ Autosomal recessive trait that causes deficiencies in the synthesis of type I collagen ◦ Extreme skeletal fragility ◦ No definitive treatment for correction Genu Varum ◦ “Bowlegs” ◦ Bowing of the knees greater than 1inch when the medial malleoli of the ankles are touching. Genu Valgum ◦ “Knock knees” ◦ Deformity in which there is decreased space between the knees Developmental Dysplasia of the Hip (DDH) ◦ “congenital dislocation of the hip” ◦ Can lead to unstable, malformed, subluxed, or dislocated hip in severe cases. ◦ Newborn screening includes Barlow test. Confirmation of dysplasia is obtained with Ortolani “click” LeggCalvePerthes Disease. ◦ Idiopathic osteonecrotic disease of the proximal femoral epiphysis. Avascular necrosis of the bone and marrow involving the epiphyseal growth center. ◦ Main symptoms are pain in the hip and groin area ◦ Unknown cause ◦ Typically treated with surgery to reduce deformity and preserve femoral head. Osgood Schlatter Disease ◦ Micro fractures in the area where the patellar tendon inserts to the tibial tubercle. ◦ Pain in the front of the knee associated with inflammation and thickening of the patellar tendon. ◦ Treatment is rest, activity restriction, and occasional knee immobilization Slipped Capital Femoral Epiphysis (SCFE) ◦ “coxa vera” disorder of the growth plate that occurs near the age of skeletal maturity. ◦ Three dimensional displacement of the epiphysis (posteriorly, medially, and inferiorly) ◦ Pain usually in the knee area with fatigue and difficulty walking. ◦ Diagnosis is made by xray and treatment is determined by severity of slippage. Scoliosis (also seen in adults) ◦ Curvature of the spine in the upright position ◦ Affects the thoracic or lumbar area ◦ Congenital, neuromuscular, and idiopathic Complications: o Pulmonary compromise, o Chronic pain, o Degenerative arthritis of the spine, o Intervertebral disk disease, and o Sciatica Manifestations vary depending on the degree of curvature and are exaggerated when an affected person bends over o Asymmetrical hip and shoulder alignment o Asymmetrical thoracic cage o Asymmetrical gait o Back pain or discomfort, fatigue o Indications of respiratory compromise Kyphosis: • Increase in the curvature of the thoracic spine outward Lordosis: Exaggerated concave of the lumbar spine Osteoporosis: Metabolic condition characterized by a progressive loss of bone calcium that leaves the bones brittle Complications: o Pathological fractures (typically in the wrist, hip, and spine) Manifestations: o Often asymptomatic in early stages o Osteopenia o Bone pain or tenderness o Fractures with little or no trauma o Low back and neck pain, kyphosis o Height reduction (as much as 6 inches) over time Diagnosis: o Conducted screening periodically on those persons at risk o History, physical examinations, o Bone density scans, Xrays, and spinal computed tomography o Advances in diagnostic methods of bone mass density have made early detection possible Rickets and Osteomalacia: Rickets (pediatric form)– soft, weak bones in children, usually because of an extreme and prolonged vitamin D, calcium, or phosphate deficiency Osteomalacia – adult form Manifestations: o Becomes apparent in children as the soft bones cannot support the growing child o Skeletal deformities (e.g., bowed legs, asymmetrical skull, scoliosis, kyphosis, pelvic deformities, sternum projection) o Delayed growth in height or limbs o Dental problems o Bone pain o Muscle cramps or weakness Paget’s Disease: Progressive metabolic condition characterized by excessive bone destruction that occurs along with the replacement of bone by fibrous tissue and abnormal bone The new bone is bigger but weakened and filled with new blood vessels Manifestations: o Vary depending on the area affected o Often insidious in onset and may be asymptomatic early o Skeletal deformities (e.g., bowing of the legs, asymmetrical skull, and enlarged head) o Headache, Hearing and vision loss o Joint pain or stiffness, Neck pain, bone pain, fractures o Reduced height o Warmth over the affected bone o Paresthesia or radiating pain in the affected region o Hypercalcemia Osteoarthritis: Degenerative joint disease characterized by local deterioration of articulating cartilage and its underlying bone as well as bony overgrowth Results in joint space narrowing, joint instability, stiffness, and pain Manifestations: o Gradual onset, usually beginning after the age of 40 o Joint pain that worsens during or after movement or weight bearing o Joint tenderness with light pressure o Enlarged, hard joints o Limited joint range of motion o Hard nodules around the affected joint (bone spur) Rheumatoid Arthritis: Systemic, autoimmune condition involving multiple joints The exact cause is unknown, but it is thought to be caused a genetic vulnerability that permits a virus or bacteria to trigger the disease Risk factors: o Being female o Family history o Advancing age (however, there is a juvenile form) o Smoking Manifestations: o Usually insidious onset Progressively worsen o Anorexia o Lowgrade fever, malaise, fatigue o Lymphadenopathy o Muscle spasms o Morning stiffness lasting more than 1 hour o Warmth, tenderness, and stiffness in the joints when not used o Bilateral joint pain, Swollen and boggy joints, Limited joint range of motion o Contractures and joint deformity (e.g., boutonniere deformity and swan neck deformity) o Unsteady gait o Depression, Anemia Gout: Inflammatory disease resulting from deposits of uric acid crystals in tissues and fluids Phases: 1 . Asymptomatic Uric levels climb in the bloodstream and crystals deposit in the tissue Crystals accumulate, damaging tissue 2 . Acute flares or attack Tissue damage triggers an acute inflammation Characterized by pain, burning, redness, swelling, and warmth at the affected joint lasting days to weeks Most initial attacks occur in the lower extremities (most often the big toe) 3 . Intercritical period After the attack subsides and the disease is clinically inactive until the next flare Hyperuricemia and crystal accumulation continues These periods in between attacks become shorter as the disease progresses Reoccurring attacks are often precipitated by sudden increases in serum uric acid 4 . Chronic gouty arthritis Characterized by joint soreness and aching present most of the time May also develop tophi that can drain or renal calculi Manifestations: o Vary depending on the phase o Intense pain at the affected joint that frequently starts during the night and is often described as throbbing, crushing, burning, or excruciating o Joint warmth, redness, swelling, and tenderness (even to light touch) o Fever o Joint deformities o Limited joint mobility Ankylosing Spondylitis: Progressive inflammatory disorder affecting the sacroiliac joints, intervertebral spaces, and costovertebral joints Manifestations: o Intermittent lower back pain (early) o Pain and stiffness that typically worsens with inactivity and improves after activity o Lower back pain that evolves to include the entire back o Pain in other joints (especially the shoulders, hips, or lower extremities) o Muscle spasms o Fatigue, Lowgrade fever, Weight loss o Kyphosis Muscular Dystrophy: Group of inherited disorders characterized by degeneration of skeletal muscle Most types are inherited, but some occur because of a genetic mutation (often spontaneously) Some types cause tremendous disability and rapidly decline whereas others have minimal symptoms and hardly noticeable progression Manifestations: o All of the muscles may be affected or only a selected group o Mental retardation (in some types) o Muscle weakness and spasms that progresses o Delayed development of muscle motor skills o Difficulty using one or more muscle groups o Poor coordination, frequent falls o Drooling o Ptosis o Progressive loss of joint mobility and contractures (e.g., clubfoot and foot drop) o Unilateral calf hypertrophy o Scoliosis or lordosis Diagnosis: o History, physical examination o Muscle biopsy o Electromyelography, electrocardiogram o Serum creatine kinase levels, serum presence of defective dystrophin o Genetic testing o Fetal chorionic villus testing (as early as 12 weeks’ gestation) Treatment: o No cure for MD o Gene therapy may potentially be the answer o Goal is to maintain motor function and prevent deformities as long as possible o Includes: physical therapy, muscle relaxants, immunosuppressant agents, assistive devices (e.g., walker, braces, and splints), surgical contracture release, coping strategies, and support Fibromyalgia: Syndrome predominately characterized by widespread muscular pains and fatigue Affects muscles, tendons, and surrounding tissue, but it does not affect the joints Manifestations: o Vary depending on the weather, stress, fatigue, physical activity, and time of day o Widespread pain, typically described as a constant, dull muscle ache with trigger points o Fatigue, sleep disturbances, depression, irritable bowel syndrome, headaches, and memory problems
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