Musculoskeletal Disorders Flashcards
Joints
Areas where two bones join together
- Surfaces are lined with articular cartilage
- Bursae are fluid filled sacs of connective tissue that protect and relieve friction around joints
Three Main Types of Joints
- Fixed - skull bones
- Slightly moveable - ribs/sternum
- Freely moveable - ankle, shoulder, elbow
Ligaments
Cross over the joint capsule and attach one bone to another
Skeletal Muscle
- Attached to the bones by bands of connective tissue called tendons
- Occasionally, skeletal muscles are attached to other muscles by a broad, flat sheet of tendon called an aponeurosis
Vital Functions of the Musculoskeletal System
- Protection
- Support
- Movement
- Heat production
- Calcium storage
- Production of blood cells
Musculoskeletal System: Health History
Pain or altered sensation
Musculoskeletal System: Physical Assessment
- Inspection
- Gait - leg length equality
- Posture - spinal curvature
- Joint function - ROM
- Muscle strength and size
- Neurovascular status
Muscle Strength Scale
0 - no detection of muscular contraction
1 - trace contraction with observation
2 - active movement with elimination of gravity
3 - active movement against gravity only
4 - active movement against some resistance
5 - active movement against full resistance
Musculoskeletal System: Imaging
- Radiographs or xrays - most common study
- CT
- MRI - shows hydrogen density of tissues; ideal for soft tissue (cartilage, ligament, disc); no metal objects allowed in room
- Arthrogram - injection of contrast material into joint; permits visualization of joint structure on xray, CT, or MRI
Laboratory Studies for Musculoskeletal System
- Calcium and phosphorus: primary minerals of bone
- Alkaline Phosphatase: enzyme elevated during bone formation
- Rheumatoid Factor: autoantibody seen in RA and other conditions
- Erythrocyte Sedimentation Rate (ESR): non-specific marker of inflammation
- C-Reactive Protein (CRP): used to diagnose inflammatory diseases; peaks at 18-24 hours after damage
Musculoskeletal System: Diagnostic Procedures
- Arthrocentesis
- Electromyogram (EMG)
- Arthroscopy
Arthrocentesis
Puncture of joint capsule to obtain sample of synovial fluid
- Normally clear viscous fluid
Electromyogram (EMG)
Evaluates skeletal muscle contraction using small needle probes
Arthroscopy
- Diagnostic or therapeutic
- Insertion of scope into joint to visualize structure and content
Contusion
Soft tissue injury (bruise)
Sprain
Ligament injury
Strain
Excessive stretching of a muscle
Diagnosing Contusions, Strains, and Sprains
Diagnosed primarily by H&P
** X-rays to rule out fracture
Musculoskeletal Injuries: Heat and Cold Applications
- Used to reduce or prevent tissue swelling, promote healing, ease pain, and promote comfort
- Risk factors for injury from heat and cold applications
- Very old or very young age
- Chronic illness
- Very fair skin
- Impaired sensation
- Disorientation
Cold Applications
- Used for people who have musculoskeletal injuries resulting from trauma, such as sprains and fractures
- Applications of cold reduces pain and swelling and decreases bleeding
- Cold applications can be either moist or dry
- Cold applications should not be left in place for longer than 20 minutes, and skin should be checked every 10 minutes
Heat Applications
- Relaxes the muscles, relieves pain, and promotes blood flow to the area
- Can be either moist or dry
- Should not be left in place for longer than 20 minutes, and the skin should be checked every 5 minutes
Dislocations
Complete displacement of articular surfaces
- Severe injury of ligamentous structures
Subluxation
Partial displacement
Dislocation and Subluxation: Orthopedic Emergency
Must maintain blood supply to joint
Musculoskeletal Injuries: Management
- Immobilization
- Provide comfort
- Ice packs
- Neurovascular status
- Protect joint
- Take steps to prevent infection
Fractures
- Broken bone caused by trauma
- Older people at increased risk
Types of Fractures
- Closed
- Open
- Greenstick
- Impacted
- Comminuted
- Spiral
Fractures: Non-Pharmacologic Management
Immobilization should precede:
- xray
- application of ice for 48-72 hours
- elevation of extremity
Fractures: Pharmacologic Treatment
- Analgesia: NSAIDs, acetaminophen, narcotics,
- Antibiotics for infections
- Tetanus toxoid for open wounds
Fractures: Reduction and Fixation
- Reduction may be closed or open
- Fixation may be external (cast) or internal (metal plates, screws, pin, wires, or rods)
Traction
Used to keep the ends of the bone in alignment until the fracture can be permanently repaired by casting or surgery
Musculoskeletal System: Age-Related Changes
- Leading cause of disability in older adults
- Age-related changes include
- loss of bone tissues
- loss of muscle mass
- wear and tear on joints (articular cartilage)
- intervertebral disc degeneration
Musculoskeletal System: Age-Related Changes Physical Findings
- Joints
- stiffness
- pain
- crepitation - Back pain
- Disc compression
- loss of height - Increased kyphosis (Dowager’s hump)
- Muscle
- decreased strength and bulk
Osteoporosis: What is it?
Disease characterized by low bone mass and micro-architectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk.
- Osteoporotic fractures can lead to significant morbidity and mortality
- Declining estrogen levels in post-menopause increase bone resorption, thus increasing the risk of fractures in some women
- BMI influences risk; estrogen is produced peripherally by fat cells, leading to greater risk in women with lower BMI
** Increased osteoclast activity
Osteoporosis: Etiology
- Genetics, family history of osteoporosis
- Estrogen deficiency
- Calcium of vitamin D deficiency
- Use of alcohol and nicotine
- Immobilization
Osteoporosis: Which bones are most commonly affected?
Commonly affects the bones of the spine and pelvis and the long bones in the arms and legs
Osteoporosis: Risk Factors
- Family history
- Smoking
- Inactivity or immobility
- Diet lacking in calcium, vitamin D
- Certain drugs, such as steroids
- Diseases of the thyroid and adrenal glands
- White race
- Small bones
- Anorexia
Osteoporosis: Diagnostic Studies
- Diagnosis is difficult to establish by normal xray
- Labs are often normal
- DEXA scans (Dual Energy Xray Absorptiometry): measures bone mineral density
Osteoporosis: Prevention
Can be prevented by exercising regularly and eating a diet rich in calcium, protein, and vitamin D, starting early in life
Osteoporosis: Treatment
- Bisphosphonates (1st line treatment)
- Calcium and vitamin D supplementation
- Calcitonin
- Hormone replacement therapy (controversial due to risks for breast cancer and cardiovascular disease)
Four Types of Arthritis
Inflammation of the joints
1. Osteoarthritis
2. Rheumatoid arthritis
3. Gout
4. Infectious or Septic
Gout: What is it?
- Metabolic disease
- Increased uric acid levels
- Deposition of sodium urate crystals in joints and subcutaneous tissues (tophi)
Gout: Risk Factors
- More males than females affected
- Middle aged
Gout: Most Common Initial Manifestation
Inflammation of the great toe (podagra)
Gout: Drug Therapy
- NSAIDs
- Corticosteroids
- Allopurinol, colchicine (chronic)
Infectious (Septic) Arthritis: Route of Infection
- Hematogenous seeding of joint with bacterial microorganisms
- Trauma or surgical incision
Infectious (Septic) Arthritis: Organisms
- Staphylococcus aureus: most common overall
- Neisseria gonorrhea: most common among sexually active young adults
Infectious (Septic) Arthritis: Symptoms
- Pain and swelling
- Systemic signs of infection: fever, chills
Infectious (Septic) Arthritis: Diagnosis
Aspiration of joint fluid (arthrocentesis)
- Elevated WBC
- Culture and Gram stain
Infectious (Septic) Arthritis: Treatment
- Antibiotics
- Drainage sometimes required
Osteoarthritis: What is it?
Degenerative disease of the cartilage of joints
** No known cause
Osteoarthritis: Contributing Factors
- Decreased estrogen at menopause
- Genetics
Osteoarthritis: Risk Factors
- Obesity
- Extreme activities (overuse)
- Lack of exercise
- Family history
- Trauma
Osteoarthritis: Most Commonly Affected Joints
- DIP and PIP of fingers
- Heberden’s nodes (DIP)
- Bouchard’s nodes (PIP) - CMC of the thumbs
- Weight bearing joints (hips, knees)
- MTP of the foot
- Cervical and lower lumbar vertebrae
** Non-symmtetric
Osteoarthritis: Diagnostic Studies
- History and PE
- Xrays
- Include weight bearing films
- Confirmation and monitoring
- CT
- MRI
- May be useful in early OA
Osteoarthritis: Radiographic Changes
- Joint space narrowing
- Osteophyte formation
- Bony sclerosis
- Subchondral cysts
** No laboratory changes - Normal ESR
Osteoarthritis: Conservative Treatment
- Rest
- Exercise
- Drug therapy (tylenol, NSAIDs, glucosamine, chondroitin, COX-2 inhibitors)
4 Intraarticular injections (cortisone, hyaluronic acid)
Osteoarthritis: Operative Treatment
- Arthroscopy
- Arthroplasty (total, hemi, unicondylar)
Rheumatoid Arthritis (RA): What is it?
- Chronic systemic disease
- Inflammation of connective tissue
- Periods of remission and exacerbation
Rheumatoid Arthritis (RA): Risk Factors
- Female
- Native American
- Smoking
Rheumatoid Arthritis (RA): Cause
Cause unknown:
- Autoimmune etiology likely
- Genetic: HLA-DR4 in white RA patients
Rheumatoid Arthritis (RA): Manifestations
- Insidious onset
- Fatigue, anorexia, generalized stiffness in morning lasts 30-60 minutes or longer
- Articular changes
- pain and stiffness
- symmetric involvement (small joints) - Extraarticular
- rheumatoid nodules
- tenosynovitis
- Sjogren syndrome
Rheumatoid Arthritis (RA): Diagnostic Studies
- History and PE
- Laboratory Studies
- Synovial fluid analysis: straw-colored, elevated WBC
- Xrays: not specifically diagnostic; narrowing of joint space, erosion, subluxation
Rheumatoid Arthritis (RA): Laboratory Studies
- Rheumatoid factor: positive in about 75-80% of patients
- ESR: elevated
- CRP: elevated
- Anti-nuclear antibody (ANA): elevated in some
- Serum uric acid
Anatomic Stages of Rheumatoid Arthritis: Stage 1
No destructive changes on xray
Anatomic Stages of Rheumatoid Arthritis: Stage 2
- Xray evidence of osteoporosis and slight cartilage destruction
- No deformity
Anatomic Stages of Rheumatoid Arthritis: Stage 3
- Cartilage and bone destruction
- Some joint deformity
Anatomic Stages of Rheumatoid Arthritis: Stage 4
Fibrous or bony ankylosis
Deformities of RA
- Ulnar drift
- Boutonniere deformity (PIP flexion, DIP extension)
- Hallux valgus
- Swan-Neck deformity (PIP extension, DIP flexion)
Rheumatoid Arthritis: Treatment
- Similar to OA for pain management (ASA, NSAIDs)
- Addition of drugs specific to RA
- DMARDs
- Biologics
- Gold therapy
- Corticosteroids - Arthroplasty for large joints
DMARDs
** For Rheumatoid arthritis
1. Leflunomide
2. Sulfasalazine
3. Azathioprine
4. Methotrexate
5. Hydroxychloroquine
Biologics (Tumor Necrosing Factor Alpha Inhibitors)
** For Rheumatoid arthritis
1. Adalimumab
2. Certolizumab
3. Etanercept
4. Golimumab
5. Infliximab
Comparison of OA and RA
OA:
1. > 40 yo
2. Obese
3. Localized
4. Weight-bearing joints (hip, knee)
5. Morning stiffness, improves during the day
RA:
1. Occurs between ages 40 and 60
2. Thin
3. Systemic
4. Small joints first (PIP, MCP, MTP)
5. Progressive stiffness, worsens during the day
Low Back Pain
- Remains the number one cause of disability globally and is the second most common cause for primary care visits
- Low back pain is considered to be the most costly work related disability
** Cause is often unclear
Low Back Pain: Risk Factors
- Obesity
- Sedentary lifestyle
- Cigarette smoking
- Chronic occupational strain
- Leg length discrepancy
- Poor posture
- Age greater than 65 years
Low Back Pain: Assessment Findings
Pain
- back, buttocks, thighs
- muscle spasm in the lumbosacral area may also be present
- motor, sensory, reflex exams are essential, not and asymmetrical findings
Low Back Pain: Cauda equine syndrome
Is a surgical emergency that presents with back pain and urinary retention or incontinence, saddle anesthesia, decreased anal sphincter tone or fecal incontinence, bilateral lower extremity weakness, and progressive neurologic deficits
Low Back Pain: Diagnostic Studies
- Routine imaging are not recommended for patients with acute back pain
- In a patient older than 50 with new onset of back pain, most clinicians will obtain xrays (important to get an AP and Lateral view when doing so)
Low Back Pain: Reg Flags
- Cauda equine syndrome symptoms
- Fracture
- Malignancy
- Infection
Low Back Pain: Non-Pharmacologic Management
Conservative, non-pharmacological interventions are imperative here:
1. Provide patient education
2. PT, TENS unit, massage
3. Cold/heat application
4. Acupuncture
Low Back Pain: Pharmacologic Management
- NSAIDs
- Acetaminophen
- Muscle relaxants
- Opioids
- Tramadol
