Musculoskeletal Flashcards
When do women begin experiencing greater bone loss?
post-menopause
Why do women reach a fracture earlier than men post menopause?
They have a lower peak density
Compared to women, men lose how much LESS bone mass?
1/3
When women pass 30, how does their osteoclast and osteoblast activity compare to one another?
Osteoclasts > osteoblasts
What is osteoporosis?
A bone mineral density 2.5 standard deviations below peak bone mass
Literally means porous bone
Characterized by low bone density and structural deterioration of the bone
Occurs when actual breaks in the trabecular matrix have occurred
How is bone mineral density usually tested?
With a DEXA scan
What is the average T-score for a normal bone mineral density?
-1 or greater
What is the average T-score for osteopenia?
-1 - -2.5
What is the average T-score for osteoporosis?
Less than or equal to 2.5
What is an example of a fragility fracture?
Falling from a standing position and breaking a bone
What is osteopenia?
Thinning of trabecular matrix of the bone before osteoporosis
A T score between -1 and -2.5
What bones are most likely to be affected by osteoporosis?
Hip, vertebrae, and wrists
Define trabecular matrices / bones?
Spongy bones, light, porous bones enclosing numerous large spaced that give a honeycombed or spongy appearance
What are 4 characteristics of osteoporosis?
- low bone mass
- micro-architectural deterioration
- increase in bone fragility
- leads to weak bones and fragility
What are the major risk factors for osteoporsis?
Aging
Female
White
History of fractures as adults
Family history (increased is a first degree relative that has had a fragility fracture is a very high factor)
Body weight less than 127 lb
Smoking
Alcohol use
Long term use of corticosteroids and immunosuppressive drugs
What are the minor risk factors for osteoporosis?
Thin, small frame
Lack of weight bearing exercises
Lack of calcium and vitamin D
Eating disorders
Gastric bypass
Lack of estrogen / testosterone
Excessive caffeine intake
What is the patho behind osteoporosis?
Increased bone resorption via increased osteoclast activity
Decreased bone formation via decreased osteoblast activity
Problems with failure to make new bone, too much bone resorption, or both
What are the early clinical manifestations of osteoporosis?
None
What are the late clinical manifestations for osteoporosis?
Fractures
Pain
Loss of height
Stooped posture - kyphosis
What are the clinical manifestations of a hip fracture?
Sudden onset of hip pain before or after a fall
Inability to walk
Severe groin pain
Tenderness
Typically little to no bruising
Affected leg externally rotated and shortened
What is typically the primary prevention of osteoporosis?
Calcium and vitamin D via diet and supplementation
What is the most common type of treatment for osteoporosis?
Decrease bone resorption
Define fracture
Any break in the continuity of bone that occurs when more stress is placed on the bone that is able to absorb
What are 3 causes of fractures?
Traumatic injury (falls)
Fatigue (repeated, prolonged stress like stress fracture)
Pathologic (weakened bones, sometimes spontaneous)
What is an open fracture?
A fracture in which the bone penetrates the skin
What is a closed fracture?
A simple fracture that does not break the skin
What is a comminuted break?
Broken in more places in the same bone - seen with patients from falls from high places when they land on their feet
Greenstick fractures are most common in what group of patients?
Peds
What are the clinical manifestations of a fracture?
Pain, edema, deformity, loss of function, abnormal mobility
What are the 5 phases of bone healing?
- hematoma
- fibrous cartilage
- callous
- ossification
- remodeling
What factors can cause delayed healing of fractures?
Infection, smoking, malnutrition, poor circulation, age, uncontrolled DM, hypothyroidism
What does delayed healing look like in fractures, when is it noticed?
Bone pain and tenderness when the bone should have been healed
Usually seen 3 months - 1 year after fracture
Delayed healing can lead to what 2 things?
malunion (improper alignment)
nonunion (not healed within 4-6 months)
What causes malunion or nonunion?
poor blood supply, repetitive stress
What scenarios would you see compartment syndrome?
Crush injuries, casts put on too tight
Why does compartment syndrome happen?
There is increased pressure within a limited anatomic space
Compression of internal structures (like blood vessels and nerves) to the extent of loss of circulation and the patient begins having numbness and tingling
What is the tourniquet effect from compartment syndrome?
Edema at the fracture site puts intense pressure on soft tissues and can lead to tissue hypoxia of muscles and nerves
What are manifestations of compartment syndrome?
Edema, lost / weak pulse, pain not in proportion to injury (pain resolved and then severe immediate pain)
What is fat embolism syndrome?
Fat molecules get to the lungs following long bone fractures or major trauma due to release into the bloodstream
What are the clinical manifestations of fat embolism syndrome?
Hypoxemia, altered LOC, petechial rash (usually the last symptom)
Why does a petechial rash show up with fat embolism syndrome?
Occlusion of dermal capillaries by fat globules
What is the treatment for fat embolism syndrome?
Self limiting, mostly supportive care
Can need ECMO
Define osteomyelitis
An acute or chronic pyogenic (pus producing) infection of the bone
What is the usual cause of osteomyelitis?
A bacterial infection of staph aureus
What are the risk factors of osteomyelitis?
Recent trauma (particularly open fractures)
Diabetes
Hemodialysis
IV drug use
Splenectomy
What is the most common route of contamination for osteomyelitis?
Indirect, from the bloodstream
What are the local clinical manifestations of osteomyelitis?
Tenderness, warmth, redness, wound drainage, restricted movement, spontaneous fractures
What are the systemic clinical manifestations of osteomyelitis?
Fever, positive blood culture, leukocytosis
What is a synovial joint composed of?
Outer fibrous capsule, interior synovial membrane, articular cartilage, and synovial fluid
Why are bones able to glide across each other?
The smooth surfaces of the articular cartilage and the lubricating synovial fluid
What is arthropathy?
A joint disorder
What is arthritis?
When a joint disorder involves inflammation of one or more joints
What is osteoarthritis?
Degeneration of joints caused by agins and stress
What are the common joints affected by osteoarthritis?
Cervical spone
Lumbosacral spine
Hip
Knee
Hands
First metatarsal phalangeal joint (big toe)
What joints are typically spared of osteoarthritis?
Wrist, elbow, ankle
What are the risk factors of developing osteoarthritis?
Age (> 40)
Obesity
History of team sports (typically long term)
History of trauma / overuse of joint
Heavy occupational work
Misalignment of pelvis, hip, knee, ankle, or foot
What is the patho behind osteoarthritis?
Prolonged excess pressure on the joint wears away cartilage and the subchondral bone is exposed
Cysts development
Cysts move through the remaining cartilage and destroys it
Local inflammation leads to more damage
Chondrocytes synthesize proteoglycans to attempt to repair damage
Causes swelling
Osteoblasts create bone spurs and thickening of synovial fluid
Loss of cartilage creates a narrowing of space
= pain
What are clinical manifestations / physical assessment findings from osteoarthritis?
Deep, aching joint pain (especially with exertion - typically relieved with rest)
Joint pain with cold weather
Stiffness in the morning
Crepitus of joint during motion
Joint swelling
Altered gait
Joint deformity
Joint tenderness
Decreased ROM
Herbeden’s nodes (distal finger joint)
Bouchard’s nodes (proximal finger joint)
What are the goals of treatment for osteoarthritis?
Manage pain, maintain mobility, and minimize disability
What are the pharmacological treatments for mild to moderate osteoarthritis?
Acetaminophen, topical capsaicin, NSAIDS
What are the pharmacological treatments for moderate to severe osteoarthritis?
NSAIDS (rx strength), NSAIDS + colchicine, acetaminophen + tramadol, opioids, steroid injections
What dietary supplement may be added for a patient with osteoarthitis?
Chondroitin sulfate and glucosamine
What location is most commonly affected by degenerative disc disease?
Lumbar or cervical spine
How does degenerative disc disease happen?
With age, intervertebral discs dehydrate and vertebral bone become compressed and impinge on the entering and exiting nerves
This causes a dysfunction of motor and sensory spinal nerves and impedes movement and sensation
What are the clinical manifestations of degenerative disc disease in the lumbar region?
Pain in the lower back that radiates down the back of the leg (sciatica)
Pain in the buttocks or thighs
Worsens when sitting, bending, lifting, twisting
Minimized when walking, changing positions, or lying down
Numbness, tingling, or weakness in the legs
Foot drop
What are the clinical manifestations of degenerative disc disease when in the cervical region?
Chronic neck pain that can radiate to the shoulders and down the arms
Numbness or tingling in the arm or hands
Weakness of the arm or hands
What is rheumatoid arthritis?
Systemic, autoimmune disease
Type III hypersensitivity (body’s attack on the synovial tissue and deposits immune complexes)
Inflammatory disease of synovium
What are risk factors for rheumatoid arthritis?
40-60’s
Women
Tobacco
Family history
What cells produce rheumatoid factor?
B-cells (lymphocytes)
What is rheumatoid factor?
A special antibody against the body’s own IgG antibodies
What are the early manifestations of rheumatoid arthritis?
Little, maybe a little joint pain or discomfort
Joints are affected symmetrically
Fatigue, anorexia, weight loss, generalized stiffness
What are the joint manifestations of rheumatoid arthritis?
Symmetrical
Pain, stiffness, motion limitation
Inflammation - heat, swelling, tenderness
Soft and spongy inflammation
What is the most common systemic involvements with rheumatoid arthritis?
Destruction of moisture producing glands and rheumatoid nodules
What glands are affected with Sjorgen’s syndrome?
Lacrimal and salivary
What are rheumatoid nodules?
Immune mediated granulomas develop around inflamed joints
Subcutaneous and firm
Can be painful
What are the goals of pharmacological treatment of rheumatoid arthritis?
Relieve pain and swelling
Slow / stop progression of disease
What are the 3 common pharmacological treatments for rheumatoid arthritis?
NSAIDS
Glucocorticoids (short term)
Disease modifying anti-rheumatic drugs (DMARDS)
What is gout?
An inflammatory disease resulting from deposits of uric acid crystals in tissues and fluids within the body
In gout, what causes uric acid crystals to form?
Breakdown of purines, from organ meat, shellfish, anchovies, herring, asparagus, mushrooms, etc
How is uric acid usually gotten rid of?
Uric acid usually dissolves in the blood and is excreted by the kidneys
What are the risk factors for gout?
Men
Obesity
Pre existing disease
Alcohol use
Diet rich in seafood / meat
Use of diuretics
African american
What are the phases of gout?
1 = elevated serum uric acid levels and deposits in tissues but asymptomatic, crystals begin accumulating and damaging tissue, begins triggers inflammation
2 = acute flare / attach + hyperuricemia
3 = Clinically inactive until next flare, continued hyperuricemia
4 = Chronic arthritis - joint pain and other symptoms present most of the time
What are the clinical manifestations of gout?
Pain, burning, redness, swelling, warmth, fever
What are common complications from gout?
Tophi - large hard nodes composed of uric acid crystals deposited in soft tissues
Renal calculi
What is the patho behind lupus?
B-lymphocytes are hyperactive and produce autoantibodies which are activated against DNA
These form immune complexes and cause an inflammatory response that damages tissue
What is the most common site of damage for lupus?
The kidneys
What are predisposing factors to lupus?
Genetics
Female
20-40
Black / african american
Environmental triggers - questionable, sun exposure ?
Allergy to antibiotics
Hormonal factors (oral BC / estrogen, period before age 10)
smoking
What are the manifestations of lupus?
Extreme fatigue
Photosensitity
Butterfly rash
Fever
Weight changes
Unusual hair loss
Edema
Raynaud’s
If CNS = HA, dizziness, seizures, stoke
If lungs= pleuritis, pleural effusions
If heart = myocarditis, endocarditis
If kidneys = nephritis
If blood vessels = vasculitis
If blood = anemia, thrombocytopenia, leukopenia, blood clots
If joints = arthritis
What are typical warning signs as to a lupus flare up?
Fatigue, pain, headache
How can a patient prevent a lupus exacerbation?
Recognize warning signs and avoid triggers (sunlight, infection, abruptly stopping medications, stress)
For lupus, NSAIDS are beneficial to control symptoms associated with:
HA, musculoskeletal, pleuritis, pericarditis
For lupus, high dose steroids are beneficial to control symptoms associated with:
Severe kidney disease, CNS system
For lupus, low dose steroids are beneficial to control symptoms associated with:
Arthritis
For lupus, antimalarials (hydroxychloroquine) are beneficial to control symptoms associated with:
Skin, musculoskeletal, prevention of kidney / CNS organ damage
What is the major difference between RA and SLE?
RA focuses on the joints and sometimes has involvement with the organs, but SLE focuses on the organs and can sometimes affect the joints
