Musculoskeletal and Trauma Flashcards
Sedentary behaviour and immobilisation result in (apart from DVT)
Muscle atrophy and insulin resistance (muscle less able to increase glucose uptake in response to elevated blood glucose)
State the two changes in protein balance during immobilisation (e.g. due to immobilisation)
Muscle protein synthesis declines
Muscle protein breakdown increases but not as much as the decrease in synthesis
Anabolic resistance - even if you eat more protein = protein synthesis still declines = atrophy
Describe the 3 cellular factors that induce muscle proteolysis
Increased Ca2+ = increased protein breakdown
Ubiquitin proteasome-dependent - breakdown of defective and old proteins
Lysosomal
Describe the pathway involved in increased muscle protein synthesis in response to exercise
increased phosphorylation of the Akt/mTOR pathway. Increased ATP demand = increased AMP = increased activation of glucose transporters = increased glucose uptake and Ca2+ release
Muscle protein breakdown is also inhibited
Post immobilisation , lean muscle and strength can be recovered by …
Isometric high load exercise
Trauma and inflammation
Inflammation induces muscle atrophy via elevation of muscle cytokines = increased muscle breakdown and inhibition of muscle protein synthesis
Muscle becomes resistant to the insulin and impairs carbohydrate oxidation
Roles of the different bone cells
Osteoclast - resorb bone; responds to calcitonin
Osteoblast - lay down bone; responsd to all hormones (PTH, Vit D)
Osteocyte - trapped osteoblast that has become a regulatory cell after it has laid down bone
Describe cortical bone
Compact
Found in mature bone
80% of the adult skeleton
Lamellae in concentric rings with lines of force (from exercise/activity)
Canals present (haversian canals) for blood vessels/lymph vessel/nerves
Primary bone healing
Requires stability - reduced motion and gap between the cells
Doesn’t occur naturally - operation induced
Secondary bone healing
Haematoma - pool of mostly clotted up
Nears blood vessels and spongy bone trabeculae form within the haematoma = fibrocartilaginous callus
Fibrocartilaginous callus becomes a bony callus
Bone remodelling
What is a fracture
Soft tissue damage along with bone break
Describing fractures
Bone
Location within a bone - proximal/middle/third ; intraarticular(inside joint or outside joint)
Fracture type - oblique/transverse/spiral
Complications of fractures
dislocation; ligament tear; rupture of tendon; internal bleeding (higher risk in patients taking anticoagulants); nerve damage; pulmonary embolism; fat embolism (fat released from interior of long bones); compartment syndrome - compression of blood vessels due to excessive swelling of muscles; scar tissue in cartilage can lead to osteoarthritis
What is traction ?
Pulling on the limb to reposition the bones and putting pins in to hold them in position
Traction allows control of haemorrhage
Complication - clots, pressure sores, atrophy of muscle, skin tears, pin site infection
External fixation and nails result in what type of healing
Secondary
Intermedullary nails
Running along the centre of the bone (medullary cavity)
Provide stability to whole bone
Minimal soft tissue dissection
Intermedullary nails
Running along the centre of the bone (medullary cavity)
Provide stability to whole bone
Minimal soft tissue dissection
Intervention techniques for fractures *
PRICE (protect by immoblising with splint or cast, rest, ice, elevate)
Hip fracture
Particularly dangerous because blood supply is compromised (no anastomosis) = femoral head dies if fracture occurs intracapsularly
The 4Ps of compartment syndrome
Pain on passive flexion and extension
Pallour
Paresthesia
Pulselessness
Fasciotomy
a surgery to relieve swelling and pressure in a compartment of the body. Tissue that surrounds the area is cut open to relieve pressure.
Skin graft may be given to replace the skin
Life long scarring
Define neuropraxia
Axonotmesis
Neurotmesis
Neuropraxia - loss of motor function without nerve degeneration
Axnotmesis - axon is damaged but the surrounding connecting tissue remains intact
Neurotmesis - both the axon and connective tissue are damaged is called neurotmesis.
Complications of plasters
Pressure sores
Respiratory complications
Clots
Muscle wasting
What are soft tissue injuries
Most common kind of injury
Soft tissue includes muscles, tendons, ligaments, fascia, nerves, fibrous tissue, bursa and fat pads , blood vessels, synovial membrane
Describe overuse injuries
If exercise is applied in a way that adaptation of the muscle and tendons cannot occur, microscopic injuries can occur leading to inflammation
Causes - training errors, improper form, excessive training, inadequate, rests muscle weakness
Overuse injuries associated with bone
Stress fracture
Osteitis - bone inflammation
Periostitis
Apophysitis
Overuse injuries associated with articular cartilage
Chondropathy
Overuse injuries associated with joints
Synovitis - inflammation of connective tissue lining the inside of a joint capsule
Osteoarthritis
Overuse injuries associated with muscles
Chronic compartment syndrome
DOMS
Focal tissue fibrosis
Describe the different types of mechanism of injury
Blunt or penetrating Direct or indirect trauma Torsion Shearing Hyperextension or hyperflexion
Describe the initial treatment of soft tissue injuries
Use acronyms PRICE and HARM
Protect - support or splint Rest Ice - 15-20 mins every 2-3 hours Compressed Elevate
Also avoid Heat Alcohol Running Massage
Later treatment for soft tissue injuries
Stretching, mobilisation, isometric and resistance exercise
Stretching, weighted exercise
Strengthening and proprioception training (injury cause nerve pathway damage that affects your ability to control joint position)
What are bursa
Tendons, ligaments, muscles, and skin must glide over bones during joint movement. Tiny, slippery sacs of synovial fluid called bursae facilitate this gliding motion
Energy deficiency syndrome
Disordered eating (or low energy availability), amenorrhoea/oligomenorrhoea (in women), and decreased bone mineral density (osteoporosis and osteopenia) are present.
Most common basketball and football injuries
Basketball - inversion
Football - ACL tear
Describe the features of sub-maximal exercise
Can be sustained between 30-180 minutes before fatigue
Rate of muscle ATP resynthesis is low, metabolic fuel integration occurs (carbs + fat both used)
Glycogen availability is an important determinant of fatigue
How can liver and muscle glycogen recovery be maximised? Why is this important?
By ingesting carbs immediately after glycogen-depleting exercise when insulin sensitivity is at its highest
Improves capacity for repeated exercise; useful for athletes
Describe chronic pain
>3 months Tissues have healed Pain is unhelpful Caused by changes to nerve network Medication has limited effectiveness
Pain is produced by
Receptors that detect damage produce threat signals
The brain has to decide , do i need to protect the threat with pain
Risk factors for DVT
> 60 , obesity, smoke, contraceptive pill/ HRT, cancer, CHF, varicose veins, dehydration, being bed-bound, long journeys, pregnancy
Describe cellulitis
What is it ?
Symptoms
Treatment
Bacterial deep infection of skin
usually affects arms and legs, sometimes eyes/mouth/anus/belly ;
can happen spontaneously but usually after skin break due to trauma or surgery
Makes affected areas red, painful and swollen ; swollen and painful glands
What does erythematous mean?
Superficial reddening of skin
Describe the diagnosis/symptoms and treatment for DVT
How does DVT treatment differ during pregnancy ?
Diagnosis via venogram (x-ray) or ultrasound
Anticoagulants; if they are not available - filter put into a large vein ; breaking up and suck out the clot through a small tube in the vein + anticoagulant after
Treatment during pregnancy is different - treated with anticoagulants injection for the rest of the pregnancy and until the baby is 6 weeks
Describe superfacial vein thrombosis (thrombophlebitis)
Symptoms
Risk factors
Treatment
Results in vein inflammation due to blood clotting inside damaged vein walls ; usually occurs at varicose veins
Symptoms - painful hard lumps under skin ; redness of skin on lower leg ; can also occur in arms, penis or breast
Not usually serious - typically clears by itself in a few weeks
risk factor - same as for DVT + thrombophilia (increased blood clotting), polycythaemia
Treatment - elevation of leg, compression stockings, keeping active, cold flannel, NSAIDs
Interpreting ultrasound imaging - main features of arteries and veins
-Veins generally have thinner walls and larger lumens when compared to the adjacent arteries
– Veins are compressible structures unlike arteries and should collapse when pressure is applied by the operator during the examination
- Vessels can be imaged in a transverse or longitudinal plane
Colour Doppler imaging techniques for ultrasound scans
The enables assessment of flow velocity and direction within a vessel. Absence of colour means there is lack of flow and could suggest an occlusion
Which blood tests should be ordered after commencing treatment for DVT?
D-dimer test (determines if there is a blood clot or a condition causing inappropriate blood clots)
INR
Causes of leg pain
Vascular - limb ischaemia , DVT
Infection - cellulitis
Trauma - fracture, intramuscular haematoma
Autoimmune - myositis
Metabolic - myopathy
Iatrogenic - complex regional pain syndrome
Neoplastic - sarcoma
Degenerative - osteoarthritis, tendinopathy
which conditions can cause problems with bone healing
diabetes and peripheral vascular disease
nerve damage often results in
tingling, numbness and pins and needles in the affected areas; can lead to amputation if left untreated
damage to nerve often caused by
compression from misalignment of bones and joints post trauma
what is wallerian degeneration
loss of peripheral nerve function (peripheral nerve disease) through degeneration of neuron axons; can occur due to trauma or alzheimers or motor neurone disease (ALS) ; can occur 24-36 hours post injury ; regeneration occurs if lesion is outside cell body
treatments for nerve injuries
nerve grafts, nerve conduits (artificial grafts) to join the ends of nerves after the damage part has been removed
Define sarcopenia
What is the main cause
Loss of muscle mass and quality
Muscle less able to increase muscle protein synthesis in response to eating more protein = anabolic resistance (deficits in mTOR signalling pathway)
Changes in muscle mass/strength/fibre composition/oxygen utilisation with age
Decreased muscle mass/strength/oxygen consumption
Decreased oxygen consumption due to decreased CO of heart and decreased mitochondrial mass and function
Loss of fast-twitch fibres ; slow-twitch stays the same. This is due to loss of spinal motor neurones from 60+
Sarcopenia is due to anabolic resistance - can be overcome by high protein ingestion
Explain how exercise can reverse sarcopenia
Restores muscle insulin sensitivity
Increases muscle capillarisation/mitochondrial mass
Reduces muscle fat mass
Confounding variables that may explain age related muscle mass and quality
Muscle mass from degree of exercise
Change of liver size
Delay of carb absorption
Chewing problems - foods high in fibre are avoided
Salivary gland atrophy - difficulty eating
Decreased digestive enzyme conc and gastric acid - worsened absorption
Define glucose tolerance
Determined by balance of insulin secretion and insulin action
Deteriorates with age
Falls and older patients
All older patients should be asked how many times they have fallen in the last year
Causes of falls
Inactivity Lack of foot care Poor vision or hearing Medication adherence or taking drugs incorrectly Poor diet
Risk factors for falls
Vestibular Vitamin D insufficiency Polypharmacy - check interactions and especially psychotropic medication Orthostatic hypotension Vision loss Foot or ankle disorder Alcohol/drug misuse Parkinson’s Stroke Dementia Diabetes Arthritis Syncope Continence Low mood Extrinsic - poor lighting/difficulty reaching items
Medical and social history for a fall in an elderly patient
What was person doing before the fall
Direction of fall - fwd, bwd, sideways, vertical
Injuries caused - FOOSH, facial, head, LOC
Recovery?
Causes of dizziness in elderly patients
BPPV(benign paroxysmal positional vertigo) - dislodged calcium carbonate crystals in otoliths - causes ear to be sensitive to head position changes when it normally would not
Progressive spine degeneration causing peripheral sensitisation from inflammation
Orthostatic hypotension (also called postural hypotension) - sudden drop in BP when sitting up or down
Mental disorder - anxiety in particular
Polypharmacy - ACEIs, beta-blockers, Ca-blockers, psychotropics
Causes of syncope (temporary loss in consciousness)
Due to transient global cerebral hypo-perfusion
ID is more important
Can occur after standing up (postural syncope)
Or after meals (post prandial syncope)
Or the classic random faint (reflex syncope)
Describe the features of synovial joints
Consists of two bone ends separated by synovial fluid and enclosed in fibrocollagenous capsule with synovium secreting cells
Hyaline cartilage covers bone ends not perichondrium in order to reduce friction and absorb shock
Fibroelastic ligaments and tendon attachments prevent excessive movement
Describe hyaline cartilage
Resist compression: elasticity and stiffness of proteoglycans (hydrogel)
Tensile strength: collagen
Maintained and turned over by chondrocytes
Limited repair and regeneration capacity.
Most is avascular: nutrition is by diffusion-limits thickness
Bursitis
Swollen bursa cause pain by increasing the friction between bones/tendons/muscles
Typically occurs at shoulder, elbow and knee
Osteoarthritis - clinical presentation
Monoarticular - only one or a few
No morning stiffness
Crepitations - audible grinding when the joints are moved
Aching/enlarged/rigid/deviated joints; typically occurs at lumbar/cervical spine, proximal and distal hand joints, feet (metatarsophalangeal joint)
Joint effusion/warmth/tenderness
Functional impairement - poor hand grip/dexterity/walking/driving etc
X-ray - narrowing of joint space/osteophytes ; only order x-ray is referral for surgery is an option
No abnormalities in biochemistry/blood tests
Rheumatoid arthritis
What is it?
Causes/pathogenesis
Risk factor
Chronic systemic inflammation involving synovial joints
Autoimmune cause ; rheumatoid factor present in most
Inflammation due to macrophages and neutrophils ; phagocytosis of IgG and release of lysosomal enzymes = destruction of joint cartilage and recruitment of inflammatory cells ; vasodilation, hyperplasia of synovium and angiogenesis = pannus ; ankylosis as well (stiffening and fusion)
Women far more prone
Symptoms of rheumatoid arthritis
Morning stiffness for at least 1 hour and present for at least 6 weeks
Simultaneous swelling of three or more joints for at least 6 weeks
Symmetric joint swelling for 6 or more weeks
Rheumatoid nodules anywhere on skin
Serum rheumatoid factor positive
Compare rheumatoid arthritis and osteoarthritis
RA is inflammatory always, osteoarthritis more due to normal wear and tear
Osteoarthritis often occurs in single joints; rheumatoid arthritis occurs in several joints and is symmetrical
fever, anemia, fatigue, loss of appetite also accompany the symptoms of RA
RA is two to three times more common in women; OA is more common in men before age 45. More common in women after age 45.
Genetic predisposition for OA; less of a genetic component for RA
OA often gets better after waking up, RA stays the same throughout the day
Gout
Pathogenesis
Symptoms
Treatment
Urate crystals in joints
Due to hyperuricaemia as a result of underexcretion of uric acid (primary gout) from breakdown of purines ; caused by excess consumption of red meat, shellfish
Leads to acute inflammation/arthritis at the joint often MP of big toe and soft tissues ; sudden severe joint pain lasting up to a week
Intermittent attacks destroy joint cartilage and soft tissue —> chronic gouty arthritis
Treatment - NSAIDs, steroid injection, avoiding kidney/liver/seafood/fatty foods/alcohol, uric acid lowering medications to prevent (uric acids crystal deposits under skin0 and kidney stones
Pseudogout
Causes and mechanism
Treatment
Aging cartilage degeneration
Age related type of osteoarthritis
calcium pyrophosphate crystals depositing in joint cavity
Called pseudogout as symptoms are similar - sudden onset of joint pain typically in knee
Treatment - NSAIDs, corticosteroids for long term symptoms, some gout medication also works
Inflammatory diseases of the joints has 4 main causes - identify them
Degeneration
Autoimmunity
Crystal deposition
Infection
Causes of osteoarthritis
Primary - wear, flare and repair
Secondary - trauma, inflammatory disease, joint defects
Pathogenesis of osteoarthritis
Damage leads to chondrocyte inflammatory response = release of cytokines
This results in the alteration in cartilage composition:
reduced proteoglycans and collagen; increased water, chondrocyte hypertrophy. Cartilage spilts and erodes
Surface cracks, and bone is exposed. Eburnation occurs - bone rubs against bone
Sclerosis(bone becomes more dense) and subchondral osteoporosis
Muscle weakness
bone shock absorbing properties reduced
Osteophytes: abnormal bony
outgrowths form in response to subchondral bone damage
Synovitis/inflammation of joint capsule with hyperplasia and oedema
What is the synovium?
Specialised connective tissue that lines the inside of synovial joints
Risk factors for gout
Being male Being obese CHF Hypertension Insulin resistance Metabolic syndrome Diabetes Poor kidney function Using diuretics (water pills). Drinking excess alcohol. High fructose consumption Having a diet high in purines - red meat/organ meat/seafood
Ankylosing spondylitis
Erosion of sites where ligaments and tendons attach to bone in lumbar spine and sacroiliac joints
Eventual fusion of lower spine and sometimes upper spine/large joints
HLA-B27 antigen
Reactive arthropathies
Inflammatory joint disorders with an infective primary cause
Inflammation occurs long time after initial infection and distal from site of infection
Infectious arthritis
Infection of a single joint by Phoenician bacteria due to hameatigenous spread or trauma
Rapid joint destruction and deformity
Intervention for sarcopenia in elderly patients
Resistance exercise
Balance training
However contraindicated in patient with uncontrolled arrhythmia/tachycardia/hypotension/heart failure/unstable diabetes as you may cause them to have a traumatic injury
Normal bp readings
Systolic - 90-120
Diastolic - 60-80
Bisphosphotanes
Reduce bone turnover
Reduce risk of fracture
Used to treat postmenopausal women and elderly men
Cancer and osteoporosis
Chemotherapy can cause long term effects such as osteoporosis
Zoplicone
Uses
Side effects
Used to treat insomnia short-term
Side effects (in elderly patients even worse); dry mouth, bitter mouth, dizziness, anxiety, sleep disorders
Interacts with alcohol
What is a hemiarthroplasty
a procedure used to artificially replace the femur part of your hip joint. It is primarily used when a femur fracture occurs intra-capsularly and patient already had reduced mobility beforehand
Total hip replacement indications
Very active people
Patients with arthritis
Label the types of femur fracture
Counselling for alendronate and calcium supplements
Alendronate should be taken first thing in the morning on an empty stomach (if taken with food, irritation can occur to oesophagus - contraindicated for Barrett’s oesophagus)
Calcium supplements can interact with many different prescription medications, including blood pressure medications, synthetic thyroid hormones, bisphosphonates, antibiotics and calcium channel blockers. To avoid this, take calcium supplements hours before or after the interacting medication
Autoimmunity vs hypersensitivity
Hypersensitivity occurs where foreign material is recognised but self is damaged
Autoimmunity occurs when self material is recognised as foreign and self is damaged
What is the antigen of rheumatoid arthritis
IgG
Describe central tolerance
Occurs in the primary lymphoid organs ; bone marrow for B cells; thymus for T cells
Strong interaction with antigen in immature lymphocytes induces apoptosis
Clonal deletion of immature auto reactive lymphocytes that interact with autoantigens
Peripheral tolerance
Central tolerance is not totally effective so autoreactive mature B and T cells are still present ; peripheral tolerance inhibits autoreactive T cells via the action of Treg cells
Describe how genetic factors and environmental factors are associated with autoimmune diseases.
Much more common in women
HLA type
Fucntion of Cox 1 and Cox 2 enzymes
Cox 1 = protect stomach, kidney and blood vessels and produce prostaglandins; also involved in activating platelets and kidney function
Cox 2 = produce prostaglandins that promote inflammation, pain and fever
Adverse effects of NSAIDs
Stomach ulcers
Liver failure - Jaundice
Severe stomach pain
Constipations/diarrhoea
Vomiting
Kidney failure - inability to pass urine, bloody/cloudy urine,
CNS - blurred vision, severe headache, ear ringing, photosensitivity
Treatment for RA
Corticosteroids to reduce inflammation
Kinase/TNF-alpha inhibitors to control immune system activity
Diabetics and RA both have an increased risk of
Cardiovascular events
How do corticosteroids reduce inflammation?
Analogues of cortisol - hormone made by adrenal glands in response to metabolism, immune response, stress
Glucorticoids and corticosteroids are interchangeable
They work by suppressing multiple inflammatory genes and the immune system
Risk factors for osteoarthritis
Age
Women>men
Obesity
Previous damage to bone/cartilage/ligaments
Muscle strength
Virus/valgus knee deformities/hip dysplasia
Genetic
Occupation - prolonged lifting and standing
Non-pharmacological management for OA
Weight reduction for obese patients
Muscle strengthening - in particular quad exercises for knee OA
Heat or cold packs
Supports/braces/splints
Appropriate footwear with thick soles to provide support for arches of foot
Psychological support for stress, anxiety and depression
Pharmacological management of OA
Simple analgesia - paracetamol and topical NSAIDs; however risk of side effects with prolonged use
Glucocorticoid injection - however pain relief is often short lived And possible side effects can be dangerous (fat necrosis/tendon rupture, infection, increase in blood sugar levels/BP) also diminishing efficacy
Injection site for knee glucocorticoid injection
Contradictions for steroid injections
Superomedial - between patella and medial femoral condyle
6 weeks between injections
Contraindications - anticoagulant/awaiting joint replacement surgery/had their joints replaced
Pros and cons of knee replacement surgery
Pros - for most freedom from pain/ improved mobility and quality of life
Cons - restriction of movement/numbness/stiffness/only lasts 20 years; risk of infection/may need revision surgery/DVT post op/ long recovery period/ effectiveness relies on patient adherence to physiotherapy
Radiographic changes typical of rheumatoid arthritis on hand or wrist radiographs
erosion; reduced joint space in all joints
soft tissue swelling
osteoporosis: initially juxta-articular, and later generalised
PIP and MCP joints affected
