2. Skeletal System - Pathologies Flashcards
Fractures
Any break in a bone
Causes include trauma, low bone density (osteoporosis), vitamin D deficiency
Fracture types
Complete - bone is broken in two of more fragments. Can be either open (perforated skin) OR closed (soft tissues not compromised)
Incomplete - not in fragments
Avulsion - tendon or ligament pulls off a piece of bone
Fracture repair
- Haematoma (and inflammation):
Blood vessels at fracture line are broken and blood leaks into site. Causes death of local cells and swelling. - Fibrocartilaginous callus information:
Phagocytes clean up the debris. Fibroblasts invade and lay down collagen forming a ‘soft callus’ (2-3 weeks) - Bony callus formation:
Osteoblasts replace soft callus with new bone (three months) - Bone remodelling:
The callus is mineralised and compact bone laid down. Then osteoclasts reshape the new bone. Remodelling occurs over three months to years.
Fracture treatment
Address potential causes of fracture (i.e. underlying nutritional deficiencies, osteoporosis, etc). Improve circulation and nutrients to the bone to aid repair
Nutrients: Calcium, Vitamin D, Vitamin C
Sprains
Involves a trauma that forces a joint beyond its normal range, over-straining / tearing ligaments
Sprain treatment
RICE: Rest, Ice, Compression, Elevation
Nutrients: Glucosamine, Vit C, Zinc, Vit E
Manual therapy & rehab / exercise is critical to ensure it repeat
Subluxation
Incomplete or partial joint dislocation
Dislocation
Complete separation of the two bones at a joint
Kyphosis
Rounding of the upper back
Lordosis
Increased concavity in the lumbar and cervical spine
Scoliosis
A lateral S-shaped curve in the spine
Osteoporosis
Osteoporosis describes chronic, progressive thinning of the bone (porous bone)
Characterised by decreased bone mineral density (BMD), leading to bone fragility & increased risk of fracture
Diagnosed by ‘dual x-ray absorptiometry’ (a DXA scan). T-Score lower than -2.5 indicates osteoporosis
Osteoporosis: Risk Factors
Increasing age -> over 30 Female and post-menopausal Poor diet Drugs -> long term corticosteroid therapy GIT diseases Genetics Sedentary lifestyle Endocrine pathologies (Cushings, hyperparathyroidism) Low body weight High alcohol consumption and smoking Toxins (heavy metals)
Osteoporosis: Signs & Symptoms
Asymptomatic until the bone has reached critical thinness
Fractures with minor trauma
Focal pain and kyphotic posture with loss of height
Pain is aggravated by prolonged sitting, standing or bending, relieved by lying on side with hips & knees flexed
Osteoporosis: Treatment
Bisphosphonates (Alendronic Acid)
HRT
Osteomalacia and Rickets
Inadequate mineralisation of the bone matrix in spongy and compact bone
Decalcification & softening of bone (spine, pelvis & legs)
Rickets - prior to epiphyseal plate closure (< 18yrs)
Osteomalacia - adult or adolescent
Osteomalacia and Rickets: Causes
Vitamin D deficiency, possibly due to:
Insufficient sunlight
Insufficient dietary vitamin D
Secondary deficiency: malabsorption disorders
Reduced receptor sites for vitamin D in tissues
Osteomalacia and Rickets: Signs and Symptoms
Deformed bones (bowed legs) & possible fractures Severe back pain & muscle weakness
In Rickets: Delayed closure of fontanelles and skull softening
Osteomyelitis
A bacterial infection of the bone marrow, resulting in necrosis and hence bone weakness.
Diagnosed by:
Bloods: Elevated inflammatory markers (ESR/CRP) & WBC’s.
X-ray, MRI.
Osteomyelitis: Signs and Symptoms
Presents as severe bone pain (often worse at night), with swelling, redness and warmth.
Osteomyelitis: Causes
Bacterial infection (staphylococcus aureus) through the blood supply or post-fracture
Immunosuppression, diabetes, IV drug users
Osteoarthritis
A degenerative wear & tear arthritis of the articular cartilage, typically affecting weight bearing (larger) joints in individuals typically over 50 years of age
Osteoarthritis: Signs and Symptoms
Onset is gradual, pain increasing (months –years).
Joint pain and stiffness
Not associated with systemic symptoms
Osteoarthritis: Causes
Primary: associated with ageing 80% of 65 year old’s have radiological signs of OA
Secondary: Associated with predisposing factors:
- Congenital ill-development.
- Trauma –e.g. fractures, surgery, meniscal injury, obesity.
Osteoarthritis: Diagnosis
X-ray - revealing joint space narrowing, osteophyte (bone spur) formation, squaring of rounded joint surfaces
Osteoarthritis: Pathophysiology
- Articular cartilage wears away; underlying bone is exposed
- Subchondral bone becomes hard and glossy (‘eburnation’)
- Remodelling of underlying bone (i.e. thickening) occurs
- Compensatory bone overgrowth in an attempt to stabilise joint = Osteophytes (spurs)
Osteoarthritis: Treatment
NSAIDs, joint replacement
Rheumatoid Arthritis
Autoimmune inflammation of the synovium, potentially affecting ALL organs except the brain (systemic inflammation)
- Affects 1% of people worldwide, higher in women.
- Peak occurrence between 30–50 years of age
Rheumatoid Arthritis: Causes
Genetic markers (HLA-DR4 & DR1). Infectious agents e.g. EBV, rubella.
Abnormal intestinal permeability, Small Intestinal Bacterial Overgrowth (SIBO), smoking.
Rheumatoid Arthritis: Signs and Symptoms
- Symmetrical/bilateral arthritis of small joints (hands and feet mostly)
- Gradually spreads through more proximal structures
- Progressive morning stiffness (>1 hour)
- Deformity of joints e.g. swan neck, ulnar deviation
- General malaise and fatigue
- Subcutaneous nodules (around fingers and elbows)
- C1/C2 subluxation & compression of the spinal cord leading to paralysis neurological complications
- Kidney problems
Rheumatoid Arthritis: Treatment
Anti-inflammatories and immunosuppressants (significant implications)
Surgery
Ankylosing Spondylitis (AS)
AS is a systemic autoimmune disease associated with chronic inflammation of the spine & sacroiliac joints, often leading to spinal fusion (‘ankylosis’) & stiffness
Ankylosing Spondylitis (AS): Causes
Age of onset is typically between 15-30 years (more commonly affecting males)
Strong genetic association with HLA-B27 (present in 95% of AS patients)
Links with inflammatory bowel diseases (& leaky gut), as well as urogenital or intestinal infections such as Salmonella & Shigella cross-reacting with HLA-B27
Ankylosing Spondylitis (AS): Signs and Symptoms
Typically begins with sacroiliac and low lumbar
spine pain, before progressing up the spine. Associated with worsening morning stiffness.
Lower back symptoms often improve with activity.
The lumber lordosis flattens & patients often
become kyphotic.
Hip and heel (Achilles) pain are common.
20% suffer acute iritis –(HLA-B27diseases)
Systemic symptoms: fever, fatigue & malaise
Ankylosing Spondylitis (AS): Diagnosis
Elevated blood inflammatory markers (ESR/CRP), HLA-B27 positive.
X-Ray/MRI – identifies characteristic ‘bamboo spine’.
Ankylosing Spondylitis (AS): Treatment
Surgery
Anti-inflammatories (including non-steroidal and steroids).
Gout
Gout is a type of monoarthritis, characterised by uric acid crystal deposition in synovial joints.
- One of the most common forms of arthritis in men (10:1 women), over 40 years of age.
- Excess uric acid forms solid crystals (monosodium urate) on cartilage surfaces.
- This causes white blood cells to infiltrate activating an acute inflammatory response.
- ‘Hyperuricaemia’ = elevated blood uric acid levels due to overproduction or underexcretion.
- Uric acid is derived from the breakdown of ‘purines’.
Gout: Causes
Increased intake of purine rich foods (red meat, organ meats, shellfish etc)
Dehydration, kidney disease, medications, obesity, excessive alcohol consumption (competes with uric acid for elimination by the kidneys & accelerates purine breakdown), hypertension, type II diabetes
Gout: Diagnosis
Blood serum for uric acid (not definitive/fluctuates) but can be useful to monitor treatment
Analysis of synovial fluid (needle aspiration).
Gout: Signs and Symptoms
Most often affects the big toe. Can affect the mid-feet, ankles, knees, elbows, hands
Usually monoarticular (one joint)
Sudden onset of intensely painful, red, hot & swollen joints, often lasting 12-24 hours
Shiny skin over joint
Urate crystals can deposit under the skin and produce ‘tophi’.
Gout: Treatment
‘Allopurinol’ to prevent episodes (hepatotoxic)
Corticosteroid injection(side effects: indigestion, rapid heartbeat, nausea, insomnia, mood changes, diabetes, glaucoma, mood changes)
Disc Herniation
The nucleus pulposus of the intervertebral disc leaks out through the annulus fibrosis
This tends to affect discs with the highest fluid content, most commonly lumbar spine (L5/S1), then cervical spine. (30-40 years)
The classic injury mechanism is combined lumbar spine flexion (bending) and rotation
A herniated disc can compress spinal nerves
Disc Herniation - Treatment
Manual therapy & exercise
Acupuncture
Bursitis
Inflammation of the bursae
Bursae are located around many joints in the body. Commonly affects the shoulder ‘sub-acromial’ & hip ‘trochanteric’
Bursitis: Causes
Repetitive use (overhead work) Sudden trauma, infection, wear and tear
