Musculoskeletal System

Monday, July 06, 2009

9:27 AM
• Osteoblast
○ bone marrow forming cells
○ Lay down new bone and become…
• Osteocytes
○ Parathyroid hormone.
○ Osteoblast - trapped in bone matrix
○ Maintains bone makers.
• Osteoclast
○ Removes bone during repair and remodeling process
○ Reabsorb bone - use citric and lactic acid to do it.
• Bone Matrix
○ Collagen fibers
• Give bone matrix strength
○ Proteoglycans
• Large polysacchrides give strength to bone.
• Important for movement of ions.
○ Glycoprotein complexes
• Bone Mineralization
○ Synthesized and bone minerals are laid down.
○ Final hardening of bone
• Types of bone
○ Compact Bone
• Highly organized, very strong
• Organized by haviristim system.
○ Spongy Bone
• Less complex organization of bone tissue
○ Periosteum
• Double layer of CT
 Outer layer has blood vessels and nerves.
 Inner layer has collagen fibers that penetrate into bone.
• Hormonal Control of Bone
○ Parathyroid Hormone
• Important Ca & phosphate regulator
• Helps Ca and phosphate be released from bone tissue.
○ Calcitonin
• Helps regulate release of Calcium (Ca) from bone.
• Released from thyroid gland.
○ Vitamin D
• Steroid hormone, helps absorb Ca from intestine, get from intestinal
digestion and sun.
• Activates Parathyroid Hormone.
• Maintenance of Bone Integrity
○ Remodeling: maintains internal structure
  Used for microscopic injuries in bone
• Phase 1 (activation)
 Stimulis - hormone, drug, physical stressor activates body to form
osteoclasts.
• Phase 2 (resorption)
 Osteoclasts gradually reabsorb bone
• Phase 3 (Formation)
 Laying down of new bone by Osteoblasts lining walls of injured
site.
○ Repair
 Larger wounds
• Hematoma formation
 Blood clot over ends of bony tissue
• Formation of procallus by osteoblasts
 Sits up from bone tissue, forms seal over end of bone (by
osteoblasts)
 Happens within days of injury
 Form bone matrix
• Callus formation
 Takes a few weeks to form.
 Structural integrity
• Replacement and contour modeling
 Can take years (up to 4 yrs)
 Bone broken down (lysed), then mineralized.
• Structure and Function of Joints
• Stabilize and move
○ Synarthrosis
• Completely immovable, i.e. Skull.
○ Amphiarthrosis
• Slightly movable, where sternum and ribs come together
○ Diarthrosis
• Freely movable, knees, hips, elbows.
○ Fibrous Joints
• Connected by fibrous CT, usually synarthrosis.
• Depends on how far apart the two bones are.
• Radius ulna, teeth to mandible.
○ Cartilaginous Joints
• Connected by cartilage.
• 2 types
 Symphysis type joints (pad or disc b/t bones, pubis, intervertebral
discs)
 Synchondrosis type joints (have hyaline cartilage, costal cartilage
b/t ribs and sternum)
○ Synovial Joints
• Diarthrosis joints, most movable and most complex.
• Uniaxial
 Move in one direction
 • Biaxial
 Move in two directions - finger
• Multi Axial
 Multiple planes - Hip
• MSK injuries and Skeletal Trauma classification
○ Fractures
• Complete Fracture
• Incomplete Fracture
• Open Fracture
• Closed Fracture
• Comminuted Fracture
 2 or more areas
• Liner Fracture
 Parallel to axis of bone
• Oblique Fracture
 Oblique angel to bone
• Spiral Fracture
 Encircles bone
• Tansverse Fracture
 Goes straight across bone
○ Pathologic Fracture
• Break in bone tissue where there has been a preexisting abnormality
or underlying disease issue.
 Tumors, osteoporosis, infex of bone, metabolic bone disorders.
○ Stress Fracture
• Occurs in normal or abnormal bones.
• Repeated stress on bone.
• Often in athletes
○ Repair is as described earlier.
• Fractures
○ Clinical Manifestations
• Pain, swelling, loss of function, deformity if not treated.
○ Diagnosis
• Xray and full history
• Underlying cause.
• Mechanism of injury
○ Treatment
• Reduction and internal fixation, manual pressure/manipulation, closed
procedure.
• Surgically, controlled situation
• Immobolization, splints, calfs, traction, external fixation devices
○ Bone Healing
• See above
• Osteoporosis
○ Pourous bone
• Structural integrity compromised, decreased mineralization.
 • Usually in cortical (compact) bones (more porous, thinner to start with)
 Compact bones - makes up majority of bone structure. Femur,
radius, ulna.
• More prone to fracture.
○ Peak bone mass reached at age 30
• Start to reabsorb bone mass.
• Slow at first, then increases as we age.
○ Progressive bone loss
• Can fracture spontaneously
• Most pronounced in wrist, hip, spine.
 Will scan in wrist to check (cheaper)
○ Risk Factors?
• Post-menopausal women.
 Possibly due to Drop in Estrogen production, increases amount of
osteoclasts.
• Increased age
• Not active.
• Women.
• Caucasian or Asian increased chance.
• Smaller body build.
○ Manifestations: pain and bone deformity.
• Silent process - don't know unless get a scan. Until bone deformity
occurs. Microfractures in spine, shorter, pain.
• Simple fall can break hip, shoulder, arm, etc.
• Osteomyelitis
• Infex of bone tissue
○ Endogenous and Exogenous source
• From in or outside body.
• Usually by bacteria, sometimes funguses, parasites, viruses.
• From skin, sinus, ear, and dental infex's.
○ Travel by arteries, veins, lymph
○ Provokes and intense inflammatory response in bone tissue
○ Disrupts/weakens the (bone) cortex, predisposing to fracture.
○ Manifestations vary with age, site, initiating event, infecting organism, and
whether it is acute, sub-acute, or chronic.
• Fever, malaise, fatigue, some anorexia, weight loss, pain around
infected area, edema at area (maybe).
• Common in people with Wounds that don't heal.
• Ankle, toe, knee.
• Osteoarthritis (OA)
○ Degenerative Joint Disease
• Non-inflammatory joint disease.
• Loss of articular cartilage.
○ Pathologic Characteristics
• Erosion of Articular Cartilage
• Sclerosis of bone underneath the cartilage
  Cause pain.
• Formation of bone spurs.
 Cause pain.
○ Risk Factors?
• More severe in women.
• Joint stress, repetitive
• Trauma leading to joint instability.
• Idiopathic forms - don't know why it occurs (most common)
• Age increases risk.
○ Signs/Symptoms?
• Neck and back, wrists/hands, legs feet.
• Larger joints then moving to smaller joints.
○ A slow progressive disease
○ Affects weight-bearing joints.
○ Pain with activity
○ <30 minutes of morning stiffness
○ Crepius
• Popping sensation
• Rheumatoid Arthritis (RA)
○ A Systemic. chronic auimmune disorder of unknown etiology
• Think neutrophils, macrophages, etc come to effected joints and start
phagocytosis on immune complexes at joint, releasing enzymes that
destroy joint cartilage.
• Inflammatory response - perpetuates immune response.
○ Primary site of pathology is the synovium of the joints
○ Begins Insidiously
• Slower onset
○ Pain with movement and joint tenderness
○ Criteria for RA
• Morning stiffness for at least an hour.
• Symmetrical, happens on both wrists.
• Often effects hands
• Get subcutaneous nodules
• Positive blood markers (rheumatoid factor)
• Fibromyalgia
○ Chronic M/S Syndrome
• Unknown cause, flu like symptoms beforehand.
• Some tie in to chronic fatigue syndrome.
• Some also have HIV, Lime's disease.
○ Diffuse Pain, Fatigue, Tender points
• Parts on body, buttocks, shoulder where pain is diffuse, won't correlate
with any other process that is occurring.
• Debilitating chronic lfatigue syndrome.
○ Always have normal lab test (ESR.ANA,RA)
○ Other Symptoms?
• Headache, memory loss, irritable bowel symptoms
 • Sensitivity to cold (Reynod's Syndrome?), hands blanch.
• Depression and anxiety.
• Congenital Defects Osteogenesis Imperfecta
• Brittle bone Disease
• Genetic, either autosomal dominant or autosomal recessive process
determines how disease is classified and how severe.
○ Clinical Maniestations
• Osteopenia
 Recurring fractures, can happen when picking up child.
 Short triangular shaped face.
 Blue sclera (white part of eye), poor dentition of teeth.
 Increased rate of aortic aneurisms.
• Increased rate of fractures
○ Treatment: Surgery
○ Often mistaken as child abuse in mild cases of OI.
• Juvenile Rheumatoid Arthritis
○ Like adult version
○ Large joints most commonly affected
• Can stiffen and contracture.
• Can be damaged or altered altering how joint grows as child ages.
• Joint stiffness following rest.
• Decreased physical activity, weakness in muscles.
• Effects all children differently - some will have many symptoms, some
will have mild cases.
○ Chronic Uveitis (in eye) is common
○ Serum test for RF (Rheumatoid Factor) may be negative
○ Subluxation and ankolysis may occur in cervical spine
• Deformity of cervical spine, not aligned properly.
○ RA that continues through adolescence can have severe effects in growth
and morbidity.