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1. Discussion Question: Sixty-nine–year-old John awoke from his sleep last night and complained of excruciating pain in his left “big toe.” He said that he could not even tolerate the bed clothes on top of his foot. Today in clinic, his first metatarsophalangeal joint of his left foot is reddened, is warm to touch, and has a decreased range of motion.

a. How will you describe to John what is occurring and why?

b. How will John’s lifestyle be altered as a result of this condition?

2. 3 paragraphs of 3 sentences each

3. APA style

4. 2 references

Chapter 48:
Disorders of Musculoskeletal Function: Trauma, Infection, Neoplasms

5 Wolters Kluwer Health | Lippincott Williams & Wilkins

Causes of Musculoskeletal Injuries

Blunt tissue trauma

Disruption of tendons and ligaments

Fractures of bony structures

Athletic Injuries
Acute injuries
Caused by sudden trauma
Include injuries to soft tissues (contusion, strains, and sprains) and to bone (fractures)
Overuse injuries
Chronic injuries
Include stress fractures that result from constant high levels of physiological stress without sufficient recovery time

Types of Soft Tissue Injuries
Contusion
An injury to soft tissue that results from direct trauma and is usually caused by striking a body part against a hard object
Hematoma
A large area of local hemorrhage
Laceration
An injury in which the skin is torn or its continuity is disrupted

Types of Joint Injuries #1
Strain
A stretching injury to a muscle or a musculotendinous unit caused by mechanical overloading.
Sprain
Involves the ligamentous structures surrounding the joint, pain and swelling subside more slowly than in a strain
Caused by abnormal or excessive movement of the joint

Types of Joint Injuries #2
Dislocation
Displacement or separation of the bone ends of a joint with loss of articulation
Loose bodies
Small pieces of bone or cartilage within a joint space

Healing Process in Soft Tissue
Repair is accomplished by fibroblasts from the inner tendon sheath
Capillaries infiltrate the injured area during the initial healing process
Formation of the long collagen bundles

Question #1
Joint damage limited to ligamentous attachment occurs in which condition?
Strain
Sprain
Dislocation
Loose bodies

Answer to Question #1
B. Sprain
Rationale: Involves the ligamentous structures surrounding the joint, pain and swelling subside slowly

Classifications of Fractures
By cause
Sudden injury
Stress fractures
Pathologic fractures
Location
Proximal, midshaft, distal
Types
Open or closed
Pattern of fracture line
Comminuted, compression, greenstick

Signs and Symptoms of a Fracture
Pain
Tenderness at the site of bone disruption
Swelling
Loss of function
Deformity of the affected part
Abnormal mobility

Treatment of Fractures
Three objectives for treatment of fractures:
Reduction of the fracture
Closed manipulation or surgical reduction
Immobilization
Immobilization through the use of external devices
Preservation and restoration of the function
Therapy

Five Stages of Bone Healing
Hematoma formation
Cellular proliferation
Callus formation
Ossification
Remodeling

Factors Delaying Bone Healing
Patient’s age
Current medications
Debilitating diseases
Local stress around the fracture site
Circulatory problems
Coagulation disorders
Poor nutrition

Complications of Fractures
Loss of skeletal continuity
Injury from bone fragments
Pressure from swelling and hemorrhage
Fracture blisters, compartment syndrome
Involvement of nerve fibers
Reflex sympathetic dystrophy and causalgia
Development of fat emboli

Origin of Bone Infections
Microorganisms introduced during injury
Microorganisms introduced during operative procedures
Microorganisms from the blood stream

Actions of Microorganisms Localized in Bone
Proliferate
Produce cell death
Spread within the bone shaft
Incite a chronic inflammatory response with further destruction of bone

Types of Osteomyelitis
Hematogenous Osteomyelitis
Originates with infectious organisms that reach the bone through the blood stream
Contiguous Spread Osteomyelitis
Secondary to a contiguous focus of infection
Direct inoculation from an exogenous source or from an adjacent extraskeletal site
Chronic Osteomyelitis
Occur secondary to an open wound

Chronic Osteomyelitis
The hallmark feature of chronic osteomyelitis is the presence of infected dead bone, a sequestrum, that has separated from the living bone.
Chronic osteomyelitis includes all inflammatory processes of bone, excluding those in rheumatic diseases that are caused by microorganisms.
Chronic osteomyelitis usually occurs in adults. Generally, these infections occur secondary to an open wound, most often to the bone or surrounding tissue.

Copyright © 2019 Wolters Kluwer • All Rights Reserved
Spread of Tuberculosis
Tuberculosis can spread from one part of the body to the bones and joints.
When this happens, it is called extrapulmonary or miliary tuberculosis.
It is caused by Mycobacterium tuberculosis.
The disease is localized and progressively destructive but not as contagious as primary pulmonary tuberculosis.

Osteonecrosis
Causes
Mechanical disruption of blood vessels
Thrombosis and embolism
Vessel injury
Increased intraosseous pressure
Blood Flow
Interconnecting plexus
Outer cortex receives supply form surrounding blood vessels.
Some sites have limited collateral circulation; interruption flow affects significant amount of bone tissue.

Question #2
Which of the following complication of healing may lead to osteonecrosis?
Loss of skeletal continuity
Injury from bone fragments
Involvement of nerve fibers
Development of fat emboli

Answer to Question #2
D. Development of fat emboli
Rationale: Development of fat emboli potentially will cause an infarct resulting in tissue anoxia and necrosis.

Diagnosis and Treatment of Osteonecrosis #1
Diagnosis of osteonecrosis is based on history, physical findings, radiographic findings, and results of special imaging studies, including CT scans and technetium-99m bone scans.
Treatment of osteonecrosis depends on the underlying pathologic process.
In some cases, only short-term immobilization, nonsteroidal anti-inflammatory drugs, exercises, and limitation in weight bearing are used.

Copyright © 2019 Wolters Kluwer • All Rights Reserved
Diagnosis and Treatment of Osteonecrosis #2
Osteonecrosis of the hip is particularly difficult to treat. In people with early disease, limitation of weight bearing through the use of crutches may allow the condition to stabilize.
Although several surgical approaches have been used, the most definitive treatment of advanced osteonecrosis of the knee or hip is total joint replacement.

Copyright © 2019 Wolters Kluwer • All Rights Reserved
Symptoms of Bone Tumors
Pain
Presence of a mass
Impairment of function

Characteristics of Benign Tumors
Limited to the confines of the bone
Well-demarcated edges
Surrounded by a thin rim of sclerotic bone

Types of Benign Bone Tumors
Osteoma
Chondroma
Osteochondroma
Giant cell tumor

Characteristics of Malignant Bone Tumors
Tend to be ill defined
Lack sharp borders
Extend beyond the confines of the bone

Types of Malignant Bone Tumors
Osteosarcoma
Aggressive and highly malignant
Ewing sarcoma
Peripheral primitive neuroectodermal tumor
Chondrosarcoma
Malignant tumor of cartilage

Metastatic Bone Disease
Metastatic lesions are seen most often in the spine, femur, pelvis, ribs, sternum, proximal humerus, and skull.
Tumors that frequently spread to the skeletal system are those of the breast, lung, prostate, kidney, and thyroid, although.

Treatment Goals for Metastatic Bone Disease
Preventing pathologic fractures
Promoting survival with maximum functioning
Allowing the person to maintain as much mobility and pain control as possible

Treatment Methods for Metastatic Bone Disease
Chemotherapy
Irradiation
Surgical stabilization

Question #3
Which of the following tumor types would most likely metastasize?
Osteoma
Chondroma
Osteochondroma
Osteosarcoma

Answer to Question #3
D. Osteosarcoma
Rationale: Osteosarcoma is the most aggressive type of malignant bone tumor.

Chapter 50:
Disorders of Musculoskeletal Function: Rheumatic Disorders

5 Wolters Kluwer Health | Lippincott Williams & Wilkins

Arthritis

Primary arthritis

Those affecting body systems in addition to the musculoskeletal system

Resulting from an immune response

Secondary arthritis

Rheumatoid conditions limited to a single or few diarthrodial joints

Resulting from a degenerative process and the resulting joint irregularities that occur as the bone attempts to remodel itself

Systemic Autoimmune Rheumatic Diseases
Rheumatoid arthritis
Systemic lupus erythematosus
Systemic sclerosis/scleroderma
Polymyositis
Dermatomyositis

Characteristics of Rheumatoid Arthritis
Associated with extra-articular as well as articular manifestations
Usually has an insidious onset marked by systemic manifestations such as fatigue, anorexia, weight loss, and generalized aching and stiffness.
Characterized by exacerbations and remissions
May involve only a few joints for brief durations, or it may become relentlessly progressive and debilitating

Systemic Autoimmune Rheumatic Diseases
A group of chronic disorders characterized by diffuse inflammatory lesions and degenerative changes in connective tissue
These disorders share similar clinical features and may affect many of the same organs

Treatment Goals for a Person with RA
Reduce pain
Minimize stiffness and swelling
Maintain mobility
Become an informed health care consumer

Criteria for Rheumatoid Arthritis
Morning stiffness at least 1 hour for at least 6 weeks
Swelling of three or more joints for at least 6 weeks
Swelling of wrist, metacarpophalangeal or proximal interphalangeal joints for 6 or more weeks
Systemic joint swelling
Hand roentgenogram changes typical of RA
Rheumatoid nodules
Serum rheumatoid factor

Results of Progressive Joint Destruction
May lead to subluxation (dislocation of the joint resulting in misalignment of the bone ends)
Instability of the joint
Limitation of movement

Symptoms of RA
Fatigue
Weakness
Anorexia
Weight loss
Low-grade fever
Anemia

Question #1
Is the following statement True or False?
Rheumatoid arthritis is a condition of individual joint deterioration and breakdown.

Answer to Question #1
False
Rationale: Usually has an insidious onset marked by systemic manifestations such as fatigue, anorexia, weight loss, and generalized aching and stiffness. It may involve joints sporadically or progressively.

Characteristics of Systemic Lupus Erythematosus (SLE) #1
Formation of autoantibodies and immune complexes
B-cell hyperreactivity
Increased production of antibodies against self- (autoantibodies) and nonself antigens

Characteristics of Systemic Lupus Erythematosus (SLE) #2
The autoantibodies can directly damage tissues or combine with corresponding antigens to form tissue-damaging immune complexes.
Autoantibodies
Antinuclear antibodies
Other antibodies
Platelets
Coagulation factors
Red blood cell surface antigens

Categories of Clinical Manifestations of SLE
Constitutional
Musculoskeletal
Dermatologic
Cardiovascular
Pulmonary
Renal
Neuropsychiatric

Systemic Sclerosis
Autoimmune disease of connective tissue characterized by excessive collagen deposition in the skin and internal organs
Diffuse or generalized form
Skin changes involve the trunk and proximal extremities.
Limited or CREST variant
Hardening of the skin (scleroderma) is limited to the hands and face.

Manifestations of the CREST Syndrome
Calcinosis (calcium deposits in the subcutaneous tissue that erupt through the skin)
Raynaud phenomenon
Esophageal dysmobility
Sclerodactyly (localized scleroderma of the fingers)
Telangiectasia

Types of Seronegative Spondyloarthropathies
Inflammation and involvement of the peripheral joints with an absence of RF
Ankylosing spondylitis
Juvenile ankylosing spondylitis
Reactive arthritis, enteropathic arthritis (i.e., inflammatory bowel disease)
Psoriatic arthritis

Methods of Assessing Mobility and Detecting Sacroiliitis
Pressure on the sacroiliac joints with the person in a forward-bending position to elicit pain and muscle spasm
Measurement of the distance between the tips of fingers and the floor in a bent-over position with straight knees,
Modified Schöber test in which contralateral flexion of the back is measured
Measurement of chest expansion may be used as an indirect indicator of thoracic involvement.

Reiter Syndrome
Clinical manifestation of reactive arthritis
Accompanied by extra-articular symptoms such as uveitis, bowel inflammation, carditis
Develops in a genetically susceptible host after a bacterial infection due to Chlamydia trachomatis in the genitourinary tract
Salmonella, Shigella, Yersinia, or Campylobacter in the gastrointestinal tract

Subgroups of Psoriatic Arthritis
Oligoarticular or asymmetric (48%)
Spondyloarthropathy (24%)
Polyarticular or symmetric (18%)
Distal interphalangeal (8%)
Mutilans (2%)

Question #2
Which of the following conditions is caused by collagen deposition?
Rheumatoid arthritis
Systemic lupus erythematosus
Psoriatic arthritis
Systemic sclerosis

Answer to Question #2
D. Systemic sclerosis
Rationale: Autoimmune disease of connective tissue characterized by excessive collagen deposition in the skin and internal organs

Causes of Osteoarthritis
Postinflammatory diseases
Posttraumatic disorders
Anatomic or bony disorders
Metabolic disorders
Neuropathic arthritis
Hereditary disorders of collagen
Idiopathic or primary variants

Osteoarthritis
Degenerative joint disease
Primary variants of OA occur as localized or generalized syndromes
Secondary OA has a known underlying cause such as
congenital or acquired defects of joint structures, trauma, metabolic disorders, or inflammatory diseases.

Osteoarthritis-Induced Joint Changes
Progression
A progressive loss of articular cartilage
Synovitis
Osteophytes
Bone spurs
Manifestations
Joint pain
Stiffness
Limitation of motion
Joint instability
Deformity

Metabolic and Endocrine Diseases Associated with Joint Symptoms
Amyloidosis
Gout syndrome
Osteogenesis imperfecta
Diabetes mellitus
Hyperparathyroidism
Thyroid disease
AIDS
Hypermobility syndromes

Gout Syndrome
Acute gouty arthritis with recurrent attacks of severe articular and periarticular inflammation
Tophi or the accumulation of crystalline deposits in articular surfaces, bones, soft tissue, and cartilage
Gouty nephropathy or renal impairment
Uric acid kidney stones

Types of Gout
Primary gout
Designate cases in which the cause of the disorder is unknown or an inborn error in metabolism
Characterized primarily by hyperuricemia and gout
Secondary gout
The cause of the hyperuricemia is known but the gout is not the main disorder

Objectives for Treatment of Gout
Termination and prevention of the acute attacks of gouty arthritis
Correction of hyperuricemia
Inhibition of further precipitation of sodium urate
Absorption of urate crystal deposits already in the tissues

Question #3
Uric acid accumulation is involved in which condition?
Amyloidosis
Gout syndrome
Osteogenesis imperfecta
Diabetes mellitus
Hyperparathyroidism

Answer to Question #3
B. Gout syndrome
Rationale: Gout Syndrome is the result of hyperuricemia.

Juvenile Idiopathic Arthritis
JIA categories of diseases with three principle types of onset:
(1) Systemic onset disease
(2) Pauciarticular arthritis
(3) Polyarticular disease
Symptoms
Synovitis
Stunted growth also may occur
Influence epiphyseal growth by stimulating growth of the affected

Juvenile Rheumatoid Arthritis (JRA)
Definition
A chronic disease characterized by synovitis
Manifestations
Can influence epiphyseal growth by stimulating growth of the affected side
Generalized stunted growth also may occur.

Manifestations of Children with SLE
Constitutional symptoms
Fever, malaise, anorexia, weight loss
Symptoms of the integumentary, musculoskeletal, central nervous, cardiac, pulmonary, and hematopoietic systems are similar to those of adults.
Endocrine abnormalities include
Cushing syndrome from long-term corticosteroid use
autoimmune thyroiditis

Signs and Symptoms of Giant Cell Arteritis
Constitutional symptoms
Malaise, fatigue, fever, weight loss, cough, sore throat
Polymyalgia rheumatica syndrome
Manifestations related to vascular involvement
Ischemic optic neuropathy
Claudication of jaw or arm

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