powerpoint presentation · bios222 pathology and clinical science 2 & 3 session 10 disorders...

BIOS222

Pathology and Clinical Science 2 & 3

www.endeavour.edu.au

Session 10

Disorders of Musculoskeletal

System 1

Bioscience Department

© Endeavour College of Natural Health www.endeavour.edu.au 3

Session Learning Outcomes

At the end of the session, you should be able to:

o Revise and review anatomy and physiology of Musculoskeletal system.

o Identify a general clinical examination and investigations of the musculoskeletal system and relate the clinical findings to the underlying pathology.

o Describe the major musculoskeletal manifestations, and identify their underlying causes and diagnostic measures.

o Describe the causes, diagnostic measures and management for back pain.

o Describe the general principles of management of musculoskeletal disorders including the pharmacological and non-pharmacological interventions.


Session Plan

o Overview of the musculoskeletal system

o Examination and investigation of the

musculoskeletal system

o Presenting problems in musculoskeletal

disease

• Acute monoarthritis

• Polyarthritis

• Fracture

• Generalised musculoskeletal pain


Session Plan

• Back pain

• Regional musculoskeletal pain

• Muscle pain and weakness

o Principles of management of musculoskeletal

disorders

• Non pharmacological

• Pharmacological


Overview of the Musculoskeletal

System


Musculoskeletal System

o Function of The musculoskeletal system:

• Movement of the body

• Provides a structural framework to protect internal organs

• Acts as a reservoir for storage of calcium and phosphate in the

regulation of mineral homeostasis

o Components of the musculoskeletal system:

• Bones

• Joints

• Skeletal muscles


Bones

o Types of bones:

• Short bones

• Irregular bones

• Flat bones

• Long bones


Bones

o Cells of bone:

• Osteoclasts

• Osteoblasts

• Osteocytes

o Bone matrix and

mineral

o Bone remodelling


Jointso Classification of joints:

• Fibrous joints

• Fibrocartilaginous joints

• Synovial joints

Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson’s principles and practice of

medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh


Joints

o Structure of synovial joint

• Articular cartilage

• Synovial fluid

• Intra articular discs

• Joint capsule

• Synovial membrane


Skeletal muscleso Skeletal muscles: consists of bundles of myocytes

embedded in fine connective tissue containing nerves

and blood vessels.

o Functions of skeletal

muscle tissues

– Producing motions

– Stabilizing body

positions

– Storing and moving

substances within the

body

– Thermogenesis

http://training.seer.cancer.gov/anatomy/muscular/structure.html


Examination and investigation of

the Musculoskeletal System


Examination of Musculoskeletal

System

o Inspection at rest

• Skin changes

• Swelling

• Wasting of muscle

• Attitude

• Deformity

o Inspection during

movement

• Restriction

• Increased range

• Pain on usage

o Palpation with

movement

• Tenderness

• Increased warmth

• Swelling

• Crepitus

• Stability

• Resisted active

movements

• Stress tests


Investigation of Musculoskeletal

SystemInvestigation Conditions detected

Synovial fluid analysis Acute monoarthritis, suspected septic arthritis,

crystal arthritis or intra-articular bleeding.

Plain radiography Rheumatoid arthritis, Osteoporosis, Paget’s

disease, Spondyloarthritis, Osteoarthritis

Radionuclide bone scan Metastatic bone disease, Paget’s disease, stress

fracture

Magnetic resonance

imaging (MRI)

Intervertebral disc disease, Nerve root

entrapment, Spinal cord compression, Spinal

stenosis, Malignancy, Fractures

Ultrasonography Small joint synovitis and erosion, periarticular

lesions




Computed tomography

(CT)

When MRI is contraindicated, for evaluation of

articular regions in which an adjacent joint

replacement creates image artefacts on MRI

Bone mineral density Osteoporosis

Haematology Inflammatory rheumatic diseases

Routine biochemistry metabolic bone disease, Paget’s disease, renal

bone disease and osteomalacia, muscle

diseases and gout

Serum uric acid Gout

C-reactive protein (CRP) Infection and inflammation

Serum creatine kinase

(CK)

Myopathy, inflammatory myositis, Muscular

dystrophy, Motor neuron disease




Synovial biopsy Mycobacterial infections

Muscle biopsy Myopathy, Inflammatory myositis

Bone biopsy infiltrative disorders, Osteomalacia, Chronic

infections and Malignancy

Electromyography Myopathy, Inflammatory myositis



SystemAutoantibodies Conditions associated with positive

Autoantibodies

Rheumatoid factor (RF) Rheumatoid arthritis, Mixed essential

cryoglobulinaemia, Primary biliary cirrhosis,

Infective endocarditis, Systemic lupus

erythematosus, Tuberculosis

Anti-citrullinated peptide

antibodies (ACPA)

Rheumatoid arthritis

Antinuclear antibodies

(ANA)

Systemic lupus erythematosus, Systemic

sclerosis, Dermatomyositis or polymyositis,

Mixed connective tissue disease, Autoimmune

hepatitis

Anti-DNA antibodies Systemic lupus erythematosus


Presenting Problems in

Musculoskeletal Disease


Presenting Problems in

Musculoskeletal Disease

o Acute monoarthritis

o Polyarthritis

o Fracture

o Generalised

musculoskeletal pain

o Back pain

o Regional musculoskeletal

pain

• Neck pain

• Shoulder pain

• Elbow pain

• Hand and wrist pain

• Hip pain

• Knee pain

• Ankle and foot pain

o Muscle pain and weakness


Acute Monoarthritis o Definition: Sudden pain and swelling in a single joint.

o Diagnosis:

• Clinical assessment

– Clinical history

– Pattern of joint

involvement

– Speed of onset

– Age and gender of

the patient

• Synovial fluid

analysis

• Blood tests




Polyarthritis



o Diagnosis:

• Clinical presentation

– Pattern of joint

involvement

– Extra-articular

features

• Blood tests

• Ultrasound

examination

• MRI

o Definition: Pain and swelling affecting five or more joints

or joint groups.


Polyarthritis



o Patterns of joint involvement in different forms of

polyarthritis:

Rheumatoid arthritis Psoriatic arthritis Ankylosing spondylitis Osteoarthritis


Fractureo Definition: Discontinuity or breech in the bone tissue,

breaking of bone

o Diagnosis:

• Clinical presentation

– bone pain,

worsened by

movement of the

affected part

– history of trauma

• Radiographs

• MRI




Generalised Musculoskeletal

Paino Definition: pain that affects the muscles, ligaments and

tendons, and bones.

o Diagnosis:

• Clinical history and

examination

• Radiological skeletal

survey

• Radionuclide bone

scanning

• Routine

biochemistry



Causes of generalised pain

Metastatic bone

disease

Osteomalacia

Fibromyalgia Osteoarthritis

Joint

hypermobility

Polymyalgia

rheumatica

Paget’s disease Myositis


Back Pain

o Diagnosis:

• Clinical assessment

• MRI

• Plain radiographs

• Radionuclide bone

scan

• Routine biochemistry

and haematology




Back Pain




Neck Pain




Shoulder Pain




Elbow Pain




Other Regional Pain



Region Causes

Hand and wrist

pain

Osteoarthritis, De Quervain’s tenosynovitis, Raynaud’s

phenomenon, C8/T1 radiculopathy, Reflex sympathetic

dystrophy

Hip pain Trochanteric Bursitis, Gluteal enthesopathy, Adductor

tendinitis

Knee pain Osteoarthritis, Bursitis, Popliteal cyst

Ankle and foot

pain

Osteoarthritis, Plantar fasciitis, Subcalcaneal bursitis,

Achilles tendinitis/bursitis


Muscle Pain and Weakness




Principles of Management of

Musculoskeletal Disorders


General Aims of Management

o Educate the patient

o Control pain

o Optimise function

o Modify the disease process where this is possible

o Identify and treat related comorbidity


Education and Lifestyle

Interventionso Patient education:

• Nature of the condition and its investigation, treatment and

prognosis

o Exercise:

• Aerobic fitness training

• Local strengthening exercise

o Joint protection:

• Shock-absorbing footwear

• A walking stick

o Weight loss:

• Strategies for weight loss and maintenance


Pharmacological Treatment

o Analgesics:

• Paracetamol

o Non-steroidal anti-inflammatory drugs (NSAIDs):

• Traditional NSAIDs

• COX-2 selective NSAIDs

o Topical agents:

• Topical NSAID creams and gels

• Capsaicin


Non-pharmacological

Interventionso Physical and occupational therapy:

• Local heat, ice packs, wax baths

• Hydrotherapy

• Various manipulative techniques

• Splints

• Orthoses

• Aids and appliances

o Surgery

o Self-help and coping strategies


Reading and Resourceso Crowley LV, 2012, An Introduction to Human Diseases – Pathology and

Pathophysiology Correlations, 9th edn, Jones and Bartlett Learning

o Grossman SC & Porth CM 2014, Porth’s Pathophysiology- Concepts of

Altered Health States, 9th edn. Wolters Kluwer Health - Lippincott, Williams

& Wilkins

o Hinson, J, Raven, P & Chew, S 2010, The endocrine system: basic science

and clinical conditions, 2nd edn, Churchill Livingstone Elsevier, Edinburgh

o Jamison, JR 2006, Differential diagnosis for primary care: a handbook for

health care practitioners, 2nd edn, Churchill Livingstone Elsevier,

Edinburgh.

o Jarvis, C, 2012 Physical Examination & Health Assessment, 6th ed.,

Elsevier Saunders, Philadelphia.

o Kumar, P & Clark, M 2012, Kumar and Clark’s clinical medicine, 8th edn,

Saunders Elsevier, Edinburgh.

o Kumar, V, Abbas, AK & Aster, JC 2015, Robbins & Cotran pathologic basis

of disease, 9th edn, Elsevier Saunders, Philadelphia.


Reading and Resourceso Lee, G & Bishop, P 2009, Microbiology and infection control for health

professionals, 4th edn, Pearson Education, Frenchs Forest, NSW.

o McCance, KL, Heuther, SE, & Brashers, VL 2014, Pathophysiology: the

biologic basis for disease in adults and children, 7th edn, Elsevier.

o Michael-Titus, A, Revest, P & Shortland, P 2010, The nervous system: basic

science and clinical conditions, 2nd edn, Churchill Livingstone Elsevier,

Edinburgh

o Mosby’s dictionary of medicine, nursing and health professions 2013, 9th

edn, Elsevier, St. Louis, MO.

o Tortora, GJ & Derrickson, B 2014, Principles of anatomy and physiology,

14th edn, John Wiley & Sons, Hoboken, NJ.

o VanMeter, KC & Hubert, RJ 2014, Gould's pathophysiology for the health

professions, 5th edn, Elsevier, St Louis, MO.

o Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014,

Davidson’s principles and practice of medicine, 22nd edn, Churchill

Livingstone Elsevier, Edinburgh.


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