Musculoskeletal Organ System Course 2005-2006

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Musculoskeletal Organ SystemCourse2005-2006
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Course Requirements
To satisfactorily complete this course, a student
must pass the final examination. A passing
grade on the final examination will be awarded to
all students having a score which is
75 or higher
or within 2 standard
deviations of the class mean. No Honors
designation will be given for this course.
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Final
Exam
Wednesday, November 23rd Last name A K
800 AM HSEB 1730 Last name L Z
1110 AM HSEB 1730 Those wishing to
change times need to make
arrangements with Mary Bouck
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Course Remediation
Any student failing the final examination or who
fails to take the examination may receive a
passing grade for the course by submitting a
satisfactory written response to a) the
examination questions answered incorrectly
or b) the lecture
objectives for all the lecturesas determined by
the course director. Written responses must be
received by January 1, 2006. Any student
failing the final examination and not submitting
a satisfactory written response will be given a
failing grade for the course.
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Course Organization Fac
ulty Rheumatology, Orthopedic Surgery, Physical
Medicine Rehabilitation, Pathology, and
Pharmacology Scope
Overview Emphasis Pathophysiology
Clinical Expression/Diagnosis
Natural Course/Prognosis Therapeutic
Intervention Attenuation of Symptoms
Disease Modification
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Clinical Evaluation of Musculoskeletal Disease

• Christopher G. Jackson, M.D.
• Division of Rheumatology

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Objectives 1. Understand
the basic anatomy and histology of connective
tissue. 2. Understand the importance of a
complete history and a careful physical exam in
diagnosing musculoskeletal disease. 3.
Understand the principal clinical manifestations
of inflammatory disease. 4. Understand the
major laboratory and radiographic features of
mechanical and inflammatory arthropathies.
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History of Rheumatic Disease
Hippocrates, 4th Century Thomas
Sydenham, 1624-1689 William Heberden,
1710-1801 AJ Landre-Beuvais, 1782-1840
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Connective Tissue Histology
Cellular Constituents
Interstitial Fluid
Macromolecules
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Connective Tissue Histology Cellular
Constituents Circulating
Lymphocytes, Monocytes, PMNs Resident
Fibroblasts Chondrocytes,
Osteoblasts, Endothelial Cells Interstitial
Fluid Cell Metabolism and Lubrication
Macromolecules Collagen - support,
20 of body mass Elastin - elasticity,
primary component of ligaments
Proteoglycans - compressibility Hyaluronic
acid - synovial fluid Chondroitin sulfates
- bone cartilage
Keratin sulfate - cartilage cornea
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Anatomy Synarthroses -
fibrous union, little motion, skull suture
lines Amphiarthroses - fibrocartilaginous
union, slightly more motion than
synarthroses, pubic symphysis lower 1/3 of
SI joints Diarthroses - synovial lining,
greatest motion Ball and Socket (hip)
Hinge (knee)
Saddle (first
carpometacarpal)
Plane (patellofemoral)
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Schematic Diagram of a Diarthrodial
Joint
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Pathologic Classification
Mechanical Cartilage Degeneration
(OA) Trauma Inflammatory Synovial
Proliferation (RA) Axial Ankylosis
(Spondyloarthropathy) Crystal-induced (Gout/
Pseudogout) Infectious Nonarticular
Rheumatism Tendinitis/Bursitis Fibromyalgia
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Clinical History
Listen to the patient
hes telling you the diagnosis!

(attributed to Sir William Osler)
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Clinical History1. Character of
Pain Joint/muscle pain usually described as
being achy, crampy, or throbbing. AM
stiffness greater than 1 hour suggests synovial
disease. Mechanical pain usually worse with
activity and improved with rest.
Inflammatory pain usually worse following
rest and improved with activity.2.
Distribution of pain Monoarticular or
polyarticular, symmetric or asymmetric, large
joint or small joint,axial or appendicular.3.
Onset and duration of symptoms Abrupt or
insidious, self-limited, episodic, or chronic.4.
Presence or absence of extra-articular disease
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Axes of Joint Motion
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Cardinal Manifestations of Inflammatory
Arthritis
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Joint Swelling
Bony or synovial?
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Laboratory
Evaluation Hematologic, Serum Chemistries,
Urinalysis Anemia, Thrombocytosis typically
present in inflammatory disease Acute
Phase Reactants Erythrocyte Sedimentation Rate
(ESR) C-Reactive Protein (CRP) typically
elevated in inflammatory disease Serology
(Antinuclear Antibody, Rheumatoid
Factor) Sensitivity and Specificity Synovial
Fluid Analysis
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Arthrocentesis Synovial Fluid
Analysis Appearance, Viscosity,
Microscopy, and Culture
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Appearance of Synovial FluidTransparent,
translucent, turbulent, or opaque?
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Viscosity of Synovial FluidString sign
present or absent?
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Snovial Fluid Leukocyte Counts

• Type of Fluid Characteristics Leukocyte
  Count
• Normal Clear, Colorless, Viscous lt200
• Noninflammatory Clear, Yellow, Viscous
  200-2,000
• Inflammatory Cloudy, Yellow, Watery
  2,000-75,000
• Septic Purulent gt75,000
• gt75 PMNs
• gt100,000 or gt90 PMNs should be
  considered septic
• 
  until proven otherwise

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Synovial Fluid Crystal ExamMonosodium urate
calcium pyrophosphate crystals
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Imaging Modalities

• Plain Radiographs
• Computed Tomography
• Magnetic Resonance Imaging
• Arthrography
• Nuclear Medicine/Ultrasound

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Plain Radiographs Is there joint space
narrowing? Is bone added, subtracted, or
neither?
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Osteoarthritis Joint space narrowing with
productive change
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Rheumatoid Arthritis Joint space narrowing
with erosive change
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Magnetic Resonance Imaging Provides much
better resolution of both bone and soft tissue
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Magnetic Resonance Imaging

• Elderly female with undiagnosed hip pain after
  plain films subsequently found to have a femoral
  neck fracture by MRI

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Clinical Evaluation of Musculoskeletal
Disease A competent clinical
evaluation of musculoskeletal
symptoms requires thoughtful synthesis of data
from the
patients history,
the physical exam,
laboratory studies,
imaging techniques.
No single modality, in and of itself,
is sufficient.