Musculoskeletal

• Disruption in the continuity of a bone
• Occurs when more stress is placed on the bone than it is able to absorb
• Three categories:
• 1.Fx caused by sudden injury
• 2.Fatigue stress fractures
• 3.Pathologic stress fractures

• Pain, tenderness at site of bone disruption, swelling, loss of function, deformity of the affected part, abnormal mobility
• Nerve function at the fracture site may be temporarily lost: numbness; called local shock; good time to reduce fx

• History and manifestations
• X-ray
• Treatment depends on location, any associated injuries, and whether fx is open or closed
• Splint can be used for immobilization

• Compartment Syndrome
• Fat Embolism Syndrome

• Increased pressure within a limited space (abdominal and limb compartments)
• Compromises circulation and function of the tissues within the space
• If pressure in the compartment is high, circulation is compromised, causing death of nerve and muscle cells
• Permanent loss of function can occur
• Causes can include tight dressings and casts, burns, and closure of fascial defects
• Bleeding and edema from fx and bone surgery
• Drug overdose or carbon monoxide poisoning when the extremity is compressed by the head or torso
• Fasciotomy may be needed: the fascia is incised longitudinally and separated so the compartment can expand and blood flow can be reestablished

• Presence of fat droplets in the vessels of the lung or other organs after a long bone fx or other major trauma
• Fat emboli are released from the bone marrow or adipose tissue at the fx site into the venous system

• respiratory failure
• cerebral dysfunction often seizures)
• skin/mucosal petechiae

• Osteomyelitis: acute or chronic infection of the bone and marrow
• Inspite of ABT, they are difficult to treat
• Can be caused by viruses, bacteria, fungi, parasites
• Microorganisms introduced during injury, during operations, or from blood-stream

Staphylococcus aureus

• Pain
• Fever
• Chills
• Malaise
• Local Tenderness and Loss of Movement

• Aseptic destruction of a bone segment due to an interruption in blood flow rather than an infection
• Bone necrosis results from ischemia; what causes the ischemia is varied: mechanical interruption such as occurs with fracture; thrombosis, embolism, vessel injury (radiation therapy)

• Depend on site and extent
• Usually pain that initially is with activity, but over time patient has pain at rest

• Depends on pathology: immobilization, NSAIDs, limitation of weight-bearing
• Joint replacement

• Aggressive, highly malignant bone tumor Most common malignant bone tumor
• 75% of cases are in persons younger than 20
• Cause is unknown
• Aggressive tumors that grow in a circular, ball-like mass in the bone tissue
• Early metastasis to the lung is common

• Deep, localized pain with nighttime awakening
• Swelling in the affected bone
• Skin over the tumor may be warm, shiny, and stretched
• ROM restricted

• Surgery with chemotherapy before and after surgery
• Amputation may be needed

• Idiopathic osteonecrotic disease of the proximal femoral epiphysis
• Affects kids, between 4-8 not exclusively
• Boys more than girls
• Cause unknown
• Insidious in onset and child is otherwise healthy

• Pain in the groin, thigh, knee and difficulty in walking
• Painless limp
• Limited abduction and internal rotation
• Flexion contracture of the affected hip

• Microfractures in the area where the patellar tendon inserts in to the tibial tubercle
• Condition most frequent in boys between 10 and 15 years
• Pain in the front of the knee associated with inflammation and thickening of the patellar tendon
• Sudden or continued strain from the patellar tendon during periods of growth while associated with running, bicycle riding, or stair climbing

Rest, restriction of activities and knee immobilizer

• Reduction in BMD greater than expected for age, race or gender and happens because of a decrease in bone formation, inadequate bone mineralization, or excessive bone deossification
• Is a term used to describe a lack of bone density on x-ray studies
• Can involve a decrease in bone matrix due to an imbalance between bone formation and destruction, or a decrease in mineralization

• Osteoporosis
• Osteomalacia
• Multiple myeloma
• Endocrine problems such as hyperparathyroidism and hyperthyroidism

• General bone condition in which there is inadequate mineralization of bone
• High incidence in the elderly because of diets deficient in calcium and vitamin D
• May also occur in patients on long-term treatment with medications such as anticonvulsants that decrease the activation of vitamin D

• Insufficient calcium absorption form the intestine due to lack of dietary calcium or a deficiency of vitamin D
• Pphosphate deficiency caused by increased renal losses or decreased intestinal absorption

• Bone pain, tenderness and fractures as the disease progresses
• Predisposes patient to pathologic fractures especially those in the distal radius and proximal femur
• Different from osteoporosis in that is does not significantly cause hip fractures
• Accompanied by compensatory hyperparathyroidism caused by low serum calcium levels

Determined by cause: if nutritional, restoring amounts of calcium and vitamin D to diet may be enough

• Metabolic bone disorder characterized by a failure or delay in calcification of the cartilaginous growth plate in kids whose epiphyses have not yet fused
• Nutritional rickets results from inadequate sunlight exposure, or inadequate intake of vitamin D, calcium or phosphate

• Bones are deformed
• Ossification at the epiphyseal plates is delayed and disordered; new bone is unmineralized
• Skull is enlarged and soft
• Fontanels are slow to close
• Teeth are slow to develop
• May have difficulty standing

• Second most common bone disease after osteoporosis
• “collage of matrix madness”
• Areas of excessive osteoclast-mediated bone reabsorption preceding disorganized osteoblast-mediated bone repair
• Men twice as likely as women to have
• Probably genetic and environmental component
• The poor quality of new bone that is formed accounts for bowing and fractures of the bones

• Often asymptomatic and may be discovered incidentally on x-ray
• Kyphosis caused by enlargement, weakening, and collapse of the vertebrae
• Weight bearing causes bowing of the femur and tibia
• Mild to moderate pain, aching in nature, persists thru the day and at rest and becomes worse at night
• Tumors often develop in pagetic bones, especially sarcoma

• Based on bone deformities and x-ray changes
• Elevated levels of serum alkaline phosphatase
• Bone scans
• Pain can be reduced with NSAIDs
• Bisphosphonates and calcitonin prevent spread of disease
• Need adequate doses of calcium and vitamin D

• Chronic autoimmune systemic disease
• Affects women 2.5 times more than men
• Peak incidence is between 40 and 50 years of age
• Cause is uncertain; thought to be genetic predisposition and the development of joint inflammation that is immunologically mediated

• Joint involvement is symmetric and polyarticular
• c/o joint pain and stiffness that lasts for 30 minutes and often several hours Limitation of joint motion that occurs early in the disease is due to pain; later on it is due to fibrosis
• Pain in the ball of foot upon arising
• Pain with turning door knobs, opening jars, buttoning shirts due to swelling of the wrists and small joints of the hand
• •May be fatigued, weak, anorexia, weight loss due to systemic inflammation
• ESR and C-reactive protein (CRP)
• Rheumatoid nodules: granulomatous lesions that may be tender or nontender, movable or nonmovable, small or large
• Dryness of eyes, mouth, and other mucous membranes

• Findings on the history
• Physical examLab tests criteria for RA developed by the American Rheumatism Association: at least 4 criteria must be present to make diagnosis of RA
• Goals are to reduce pain, minimize stiffness and swelling, maintain mobility
• Physical rest and therapeutic exercise
• Proper posture, positioning, body mechanics, supports
• NSAIDs and corticosteroids will help

• Chronic inflammatory disease
• Can affect almost any organ system, including the MS system
• Primarily a disease of young women
• Peak incidence between ages 15 and 40 years
• More common in African-Americans, Hispanics, and Asians
• Characterized by formation of autoantibodies and immune complexes (type III hypersensitivity)

• -“great imitator” because it can affect many body systems, including the MS, skin, CV, lungs, kidneys, CNS, RBC’s and platelets
• -Characterized by exacerbations and remissions
• -Arthralgias and arthritis are among the most commonly occurring symptoms
• -Skin lesions include a “butterfly” rash on the nose and cheeks
• -Hair loss is common
• -Sun sensitivity even with mild exposure
• -Renal involvement in ½ to 2/3 of persons with SLE: glomerulonephritis may occur
• -May have nephrotic syndrome with edema in the legs and abdomen and around the eyes
• -Pulmonary involvement occurs in about 30% of patients and results primarily in pleural effusions or pleuritis
• -Pericarditis is most common CV problems
• -CNS: seizures can occur and are more frequent when renal problems exist

• Complete history, physical exam, labwork
• ANA most common test: 95% of patients have high ANA levels: not specific for SLE
• Treatment focuses on symptoms of disease
• Goal is to prevent loss of organ function and reducing exacerbations

• Autoimmune disease of connective tissues that causes fibrosis throughout the body
• Women 4 times as frequently as men
• Peak age: 35-50 year olds
• Skin involvement is usually the first symptom: but involvement with other organs is what causes morbidity

• Dkin changes limited to the fingers, forearms, and face
• May develop CREST syndrome:
• C= calcinosis (calcium deposits in the subcutaneous tissue
• R= Raynaud’s phenomenon
• E= esophageal dysmotility
• S= sclerodactyly Scleroderma of fingers
• T= telangiectasia

• Severe, widespread, progressive skin involvement
• Face is described as “stone facies”
• Restricted movement of the mouth
• Raynaud’s
• Hair loss on involved skin
• Telangiectasis on the face, chest, hands
• Difficulty swallowing

• Symptomatic and supportive
• Category of ACE inhibitors in those with renal problems as decreased mortality with hypertensive renal disease

• Cause is unknown or an inborn error in metabolism and is characterized by hyperuricemia and gout
• Primarily a disease of men
• Pathogenesis: elevation of serum uric acid levels (uric acid is the end product of purine metabolism)
• An attack occurs when monosodium urate crystals precipitate in the joint and initiate an inflammatory response
• Large, hard nodules called tophi can result; they are found on the synovium, Achilles tendon, and forearm and may be mistaken for rheumatoid nodules

• Initial attack affects one joint, usually the first metatarsophalangeal joint
• Onset of pain is abrupt
• Redness and swelling
• May be precipitated by exercising, alcohol, dieting, certain meds or foods

• Hyperuricemia is the hallmark of gout, but many people have hyperuricemia and never develop gout
• Diagnosis can only be made when urate crystals are present in the synovial fluid or in tissue sections of tophi
• Goal: prevent attacks of gouty arthritis and correcting hyperuricemia
• Pharmacological management is aimed at reducing joint inflammation
• NSAID’s good
• Avoid purine-rich foods (liver, kidney, sardines, anchovies)
• Meds such as Allopurinol and colchichine