Musculoskeletal Disorders

B. Pimentel, M.D.

University of Makati

College of Nursing

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

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

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

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

Symptoms Numbness or tingling, weakness Pain Fine finger coordination problems

Treatment: Splinting Corticosteroid injections Surgery Medications: Nonsteroidal anti-inflammatory

(NSAIDS)

Carpal Tunnel Syndrome- Surgery

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

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

Fibromyalgia

Treatment: Physical Therapy Exercise Light massage Relaxation techniques Medications: antidepressants, anti-seizure, muscle

relaxants, pain relievers, sleeping aids Cognitive behavioral therapy Support groups

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

Gout

Gout

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)

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

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

Ankylosing Spondylitis

Treatment PT for postural training, especially to

strengthen back extensors NSAIDs to reduce inflammation and pain Corticosteroids Surgery

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.

Herniated Disk

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 NSAID’s, narcotics/analgesics, muscle relaxants Steroid injections Physical Therapy Surgery

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

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

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

Osteoarthritis

Osteoarthritis

Osteoarthritis

Osteoarthritis

Osteoarthritis

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

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

Osteoporosis

Osteoporosis

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

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

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

Rheumatoid arthritis

Rheumatoid arthritis

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

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

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

Scoliosis

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

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)

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)

Greenstick Fracture of a Forearm

Transverse Fracture

Compound Fracture

Comminuted Fracture

Trauma: Fractures

Relationship of fracture fragments to each other Undisplaced Displaced

Shifted sideways Angulated Rotated Distracted Overriding Impacted

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

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

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

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

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

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

ORIF with pins & plate

ORIF

The End