Musculoskeletal Disorders

1
Musculoskeletal Disorders

• B. Pimentel, M.D.
• University of Makati
• College of Nursing

2
Bunions (Hallux valgus)

• What is it?
• When the big toe points toward the second toe
  causing a bump to appear on the outside edge of
  the toe.
• Caused by wearing narrow, high heeled shoes.
• Symptoms
• Red, calloused skin along the inside edge of the
  big toe
• A bony bump at the site
• Pain over the joint, which pressure from shoes
  makes worse
• Big toe turned toward the other toes

3
Bunions (Hallux valgus)

• Treatment
• Wear wide toed shoes
• Wear felt or foam pads on your foot to protect
  the bunion or a spacer to separate the first and
  second toes.
• Surgery if severe

4
Carpal Tunnel Syndrome

• What is it?
• Median nerve is compressed causing sensation and
  circulation to thumb and fingers is compromised
• Usually in women ages 30-60
• Increasing incidence
• Predisposing factors and causes
• Repetitive hand and wrist motions (sewing,
  painting, sports, playing musical instruments,
  typing)
• Bone fractures
• Diabetes, Obesity
• Rheumatoid arthritis, Lupus, Scleroderma

5
Carpal Tunnel Syndrome
6
Carpal Tunnel Syndrome

• Symptoms
• Numbness or tingling, weakness
• Pain
• Fine finger coordination problems
• Treatment
• Splinting
• Corticosteroid injections
• Surgery
• Medications Nonsteroidal anti-inflammatory
  (NSAIDS)

7
Carpal Tunnel Syndrome- Surgery
8
Fibromyalgia

• What is it?
• Syndrome in which the patient has long-term,
  body-wide pain and tenderness in the joints,
  muscles, tendons and other soft tissues.
• Linked to fatigue, sleep problems, headaches,
  depression and anxiety.
• Possible causes
• Physical and emotional trauma, stress
• Abnormal pain response
• Sleep disturbances
• Infection

9
Fibromyalgia

• Symptoms
• Painful areas called tender points
• May be localized or generalized
• Extreme fatigue, sleep problems
• Other Irritable bowel, memory probs,
  palpitations, headaches, tremors, bladder spasms,
  blurred vision
• Diagnosis
• Minimum of 3 months of widespread pain in at
  least 11 of 18 areas

10
Fibromyalgia

• Treatment
• Physical Therapy
• Exercise
• Light massage
• Relaxation techniques
• Medications antidepressants, anti-seizure,
  muscle relaxants, pain relievers, sleeping aids
• Cognitive behavioral therapy
• Support groups

11
Gout

• What is it? What causes it?
• Painful arthritic disease that occurs most often
  in men
• Disruption of body's control over uric acid
  production or excretion, resulting in high levels
  of uric acid in the blood
• When uric acid builds to a certain level, it
  crystallizes, and these crystals are deposited in
  connective tissue all over the body
• When crystals are deposited in the synovial
  fluid, they cause sudden sharp pain in the joint
  

12
Gout
13
Gout
14
Gout

• Symptoms
• Big toe, knee or ankle joints are most often
  affected.
• Pain starts suddenly, often during the night
• Joint appears warm and red, very tender
• Possible fever
• Treatment
• NSAIDs, Analgesics, Corticosteroids
• Allopurinol or probenecid to decrease uric acid
  levels
• Decrease consumption of purine-rich foods
  (sardines, organ meat, legumes, fatty foods,
  protein)

15
Ankylosing Spondylitis

• What is it?
• Rheumatic disorder causing inflammation of the
  axial skeleton and large peripheral joints
• Etiology unknown, but thought to have genetic
  basis with possible environmental influences
• More common in men usually begins at age 20-40
  when women have it, more peripheral involvement

16
Ankylosing Spondylitis

• Signs and symptoms
• Back pain
• Early morning stiffness, relieved by activity
• Pain is eased by assuming kyphotic posture
• Diminished chest expansion, fever, weight loss,
  fatigue
• Articular cartilage is destroyed causing fibrous
  adhesions, bone fusion, and calcification of the
  intervertebral disks

17
Ankylosing Spondylitis

• Treatment
• PT for postural training, especially to
  strengthen back extensors
• NSAIDs to reduce inflammation and pain
• Corticosteroids
• Surgery

18
Herniated Disk

• What is it?
• Lumbar radiculopathy, cervical radiculopathy,
  herniated intervertebral disk, prolapsed
  intervertebral disk, slipped disk, ruptured disk,
  herniated nucleus pulposus
• All or part of the disk in the spine is forced
  through a weakened part of the disk, placing
  pressure on the nearby nerves.
• Lumbar area is the most common area, followed by
  cervical.

19
Herniated Disk
20
Herniated Disk

• Symptoms
• Pain in one part of the leg, hip or buttocks.
• Numbness, tingling
• May worsen after standing or sitting or at night
• Diagnosis / Treatment
• Myelogram, MRI, CT scan, Bone scan
• NSAIDs, narcotics/analgesics, muscle relaxants
• Steroid injections
• Physical Therapy
• Surgery

21
Muscular Dystophy

• What is it?
• Group of inherited disorders that involve muscle
  weakness and loss of muscle tissue. Worsens over
  time.
• Genetic
• Symptoms
• Vary with the different types.
• Muscle weakness, delayed development of muscle
  motor skills, falls, loss of strength, atrophy

22
Muscular Dystophy

• Treatment
• No cure. Symptom management is the goal.
• Physical therapy to maintain muscle strength and
  function.
• Orthopedic appliances braces, wheelchair to
  improve mobility and self care.
• Complications
• Cardiomyopathy
• Decreased ability to care for self
• Lung failure
• Contractures, scoliosis

23
Osteoarthritis

• What is it?
• The most common joint disorder, due to aging and
  wear and tear on the joint.
• Cartilage breaks down and wears away causing the
  bones of the joint to rub together
• Bone spurs may form. Ligaments and muscles
  weaken and stiffen.
• Symptoms
• Pain and stiffness worse after exercise and
  with weight bearing
• Morning stiffness
• May be asymptomatic

24
Osteoarthritis
25
Osteoarthritis
26
Osteoarthritis
27
Osteoarthritis
28
Osteoarthritis
29
Osteoarthritis

• Prevention
• sensible exercise routines
• avoidance of activities that cause constant
  stress
• Treatment
• pain relievers
• rest
• surgery to correct deformity or replace joint
• weight loss if overweight
• Physical Therapy

30
Osteoporosis

• What is it?
• Most common form of metabolic bone disease
• Thinning of bone tissue and loss of bone density
  over time.
• Body fails to form enough new bone, when too much
  old bone is reabsorbed by the body.
• Commonly seen in people over 60 (50 of women
  over 60 have it)
• Linked to low levels of estrogen in women and
  testosterone in men.
• Other causes chronic RA, long term prednisone
  use, hyperparathyroidism, Vit D deficiency,
  Amenorrhea, smoking, low calcium

31
Osteoporosis
32
Osteoporosis

• Predisposing factors
• Caucasian, European nationality or descent
• Smoking
• Alcohol consumption
• Sedentary living
• Inadequate estrogen
• Underweight
• Low calcium intake

33
Osteoporosis

• Signs and symptoms
• Often diagnosed with fracture, often hip
• Back pain that radiates around to the front
• Kyphosis
• Prevention
• Exercise
• Adequate calcium intake
• Treatment
• Regular individualized activity program
  (weight-bearing activities) and increased dietary
  calcium
• Estrogen supplements, fluoride, calcium
  supplements and Vit D supplements

34
Rheumatoid arthritis

• What is it?
• Long term disease that leads to inflammation of
  the joints and surrounding tissues.
• Most dangerous, destructive, and crippling type
  of arthritis
• Particularly affect small joints of the hands and
  feet, can also affect large joints
• Autoimmune disease that causes the body to attack
  synovial membranes
• Chronic inflammation begins in the synovial
  membrane of the joints and spreads to other joint
  tissues

35
Rheumatoid arthritis
36
Rheumatoid arthritis
37
Rheumatoid arthritis

• Symptoms
• Chronic inflammation begins in the synovial
  membrane of the joints and spreads to other joint
  tissues
• Outgrowths of the inflamed tissue may invade and
  damage the cartilage of the joints, deforming and
  fusing the joints ligaments become softened and
  absorbed permanent joint injury
• Marked by periods of remission and exacerbation
• Stiffness, pain, decreased range of motion,
  deformities, decreased mobility, nodules under
  the skin

38
Rheumatoid arthritis

• Diagnosis
• Rheumatoid factor test, Anti CCP antibody test,
  MRI, X-ray, CBC, C reactive protein, Erythrocyte
  sedimentation rate, synovial fluid analysis
• Treatment
• Disease modifying antirheumatic drugs (DMARDs)
  Methotrexate, Leflunomide
• NSAIDs ibuprofen, naprosen, Aspirin, Celebrex
  (heart disease and stroke risk factors),
  analgesics
• Surgery (joint replacement), physical therapy
  (pain, gait training), nutrition, support groups

39
Scoliosis

• What is it?
• Abnormal curving of the spine. Cause is unknown
  (idiopathic).
• Symptoms
• Backache, low back pain, uneven hips or shoulders
• Treatment
• Back brace
• Surgery
• Physical therapy

40
Scoliosis
41
Trauma Fractures

• Fracture is described according to
• Site
• Extent
• Configuration
• Relationship of the fractured fragments to each
  other
• The relationship of the fracture to the external
  environment
• The presence or absence of complications

42
Trauma Fractures

• Fracture site
• Diaphyseal (shaft of long bone)
• Metaphyseal (wider part at the end of a long
  bone, adjacent to the epiphyseal disk)
• Epiphyseal (end of along bone, usually wider than
  the shaft entirely cartilaginous or separated
  from the shaft by a cartilaginous disk)
• Intra-articular (within the joint)
• Fracture-dislocation (associated with dislocation
  of the adjacent joint)

43
Trauma Fractures

• Extent of fracture
• Complete
• Incomplete
• Hairline
• Greenstick (in child's pliable bone)
• Configuration of fracture
• Transverse
• Oblique
• Spiral
• Comminuted (more than one fracture line and
  therefore more than two fragments)

44
(No Transcript)
45
Greenstick Fracture of a Forearm
46
Transverse Fracture
47
Compound Fracture
48
Comminuted Fracture
49
Trauma Fractures

• Relationship of fracture fragments to each other
• Undisplaced
• Displaced
• Shifted sideways
• Angulated
• Rotated
• Distracted
• Overriding
• Impacted

50
Trauma Fractures

• Relationship of the fracture to the external
  environment
• Closed (covering skin is intact)
• Open (either fracture fragment has penetrate the
  skin from within or a sharp object has penetrated
  the skin to fracture the bone from outside) risk
  of infection

51
Fractures

• When bone breaks, bleeding occurs from the blood
  vessels in the bone and periosteum
• Hematoma or clot forms in the medullary canal,
  under the periosteum and between the ends of the
  bone fragments
• Necrosis occurs at the ends of the bone because
  the torn blood vessels are unable to continue
  delivery of nutrients
• Inflammatory response develops as a reaction to
  the trauma and the presence of debris at the site
  
• Clot serves as the basis for a fibrin network
  into which granulation tissue grows

52
Fractures

• New capillaries grow into area and phagocytic
  cells and fibroblasts migrate to it
• Chondroblasts also begin to form new cartilage
  fibrocartilaginous callus holds bone ends
  together (not strong enough to bear weight)
• Osteoblasts from the periosteum and endosteum
  begin to generate new bone to fill in the gap
• Bony callus formed

53
Fractures

• During following months the repaired bone is
  remodeled by osteoblastic and osteoclastic
  activity in response to mechanical stresses on
  the bone
• Excessive bone in the callus is removed, more
  compact bone is laid down and eventually the bone
  assumes a normal appearance

54
Fractures

• Complications
• Uncomplicated
• Complicated
• Skin injuries, vascular injuries, neurologic
  injuries, any soft tissue injuries
• Mal-union (fracture heals in an unsatisfactory
  position with residual body deformity)
• Delayed union (fracture may heal eventually but
  takes considerably longer than expected)
• Non-union (fracture completely fails to heal)
• Complication of skull fracture hemorrhage or
  tear of meningeal artery

55
Fractures

• Treatment of fractures
• Reduction the correction of a fracture
• Closed manipulation reduction without incision
• Open reduction after incision into the fracture
  site
• Fixation holding or fastening in a fixed
  position
• External casting, splinting
• Internal surgically implanting rods, planes
  nails, or screws
• ORIF seen frequently in hip fractures

56
ORIF with pins plate
57
ORIF
58
The End