Musculoskeletal Disorder

Naufal M. Nurdin
2012
Overview

• Normal review

• Osteoporosis
• Musculosceltal trauma
• Arthritis
o Osteoarthritis
o Rhemautoid Arthritis
o Gout Arthritis
Review

• Cartilage
Vitamin D
Synthesis and Metabolism
No Bones About It

9
Osteoporosis : Definition
• Definition
o the loss of bone mass and deterioration of bone microarchitecture,
o compromised bone strength, and
o an increased susceptibility to fracture and painful morbidity.

“a skeletal disorder characterized by compro- mised bone strength

predisposing a person to an increased risk of fracture. Bone strength reflects
the integration of two main features: bone density and bone quality.” (NIH)
Osteoporosis : Diagnosis

• Bone quality is influenced by

o bone architecture,
o bone turnover,
o Mineralization, and
o the accumulation of damage to the
bone (e.g., microfractures)
• diagnosing osteoporosis is
measurement of bone mineral
density.
• Bone mineral density (BMD)
accounts for approximately 70% of
bone strength,
Osteoporosis : Diagnosis
Osteoporosis : Patophysiology

• Bone resorption exceeds bone formation

o Leads to thin fragile bones subject to spontaneous fracture
• Early stages asymptomatic
o Back pain common sign
• Associated w. altered vert causing pressure on nerves
• Kyphosis and scoliosis common
• Diagnosed using bone density scans and X-rays 13
Risk Factor of Osteoporosis
Osteoporosis : Risk Factor for Fracture
Osteoporosis Prevention

• Intake of calcium, vitamin D, magnesium and possibly boron

• Regular, weight-bearing exercise
• Avoid tobacco and glucocorticoids
• No alcoholism
• Hormone replacement?
• Parathyroid hormone?
• Testosterone for men and possibly women

16
Osteoporosis—Treatment

• Bone cannot be restored to normal but therapy

to prevent further loss
• Fluoride supplements to promote bone deposits
• Estrogen replacement therapy
• Bisphosphates (Fosamax) to inhibit osteoclast
activity and bone resorption
• Calcitonin to decrease bone resorption
Diet Therapy - Osteoporosis

• Dietary supplements of calcium and vit D

• Protein
• Magnesium
• Vitamin K
• Trace minerals
• Avoid alcohol and caffeine
Fall Prevention - Osteoporosis
• Hazard-free environment
• High-risk assessment through programs such as Falling
Star protocol
• Hip protectors that prevent hip fracture in case of a fall
Musculoskletal Trauma

• Types Of Fracture
• Mechanism Of Injury
• Sign and Symptom
• Stage of Bone Healing
• Therapy
• Sprain
• Strain
Pathophysiology of the Musculoskeletal System

• Joint Injury
o Sprain
o Subluxation
o Dislocation
• Bone Injury
o Open Fracture
o Closed Fracture
o Hairline Fracture
o Impacted Fracture
Types of Fractures
Fracture

• Closed
o Overlying skin intact
• Open
o Wound extends from body surface to fracture site
o Produced either by bones or object that caused Fx
o Danger of infection
o Bone end not necessarily visible
Mechanism of Injury

• Direct
o Break occurs at point of impact
• Indirect
o Force is transmitted along bone
o Injury occurs at some point distant to point of impact
o Femur, hip, pelvic fracture due to knees hitting dash
• Twisting
o Distal limb remains fixed, Proximal part rotates, Shearing, fracturing occur:
Football. skiing accidents
• Avulsion
• Muscle and tendon unit with attached fragment of bone ripped off
bone shaft
• Stress
o Occur in feet secondary to prolonged running or walking
Mechanism of Injury

• Pathological
o Result of Fx with minimal force
o Cancer, osteoporosis
Fractures—Signs and Symptoms
• Some clearly present (compound fracture) or
obvious deformity
• Swelling, tenderness, altered sensation
• Inability to move limb
• Crepitus
o Grating sound heard if ends of bone fragments move over e/other
• Pain immediately after injury
o Can be delayed if nerve damage in area
• Diagnostic Tests
o X-rays
Stages of Bone Healing

1. Hematoma formation within 48 to 72 hr after

injury
2. Hematoma to granulation tissue
3. Callus formation
4. Osteoblastic proliferation
5. Bone remodeling
6. Bone healing completed within about 6 weeks;
up to 6 months in the older person
Fractures—Pathophysiology: Factors Affecting
Healing Process
• Amount of local damage to bone and soft tissue
o Major determining factor
o Prolonged inflammation or extensive damage to bv or periosteum
impairs healing
• Amount of realignment and approximation
o Closer the ends of the bones are, the smaller the gap to fill, the
faster the healing process
• Secondary problem
o Foreign material or infection delays healing
• Numerous systemic factors
o Delayed in the elderly, pts w/ circulatory problems, diabetes
mellitus, anemia, nutritional deficits, glucocorticoids
Musculoskeletal : Therapy

• External Fixation
• ORIF
o (Open Reduction, Internal Fixation)
• Nutrition
o Diet high in protein, calories,
and calcium, supplemental
vitamins B and C
o Frequent small feedings and
supplements of high-protein
liquids
o Intake of foods high in iron
 Tendon Vs Ligament
Strain Vs Sprain
 Strains
• Excessive stretching of a muscle or tendon when it is
weak or unstable
• Classified according to severity: first-, second-, and
third-degree strain
• Management: cold and heat applications, exercise and
activity limitations, anti-inflammatory drugs, muscle
relaxants, and possible surgery
 Sprains

• Excessive stretching of a ligament

• Treatment of sprains:
o first-degree: rest, ice for 24 to 48 hr, compression bandage,
and elevation
o second-degree: immobilization, partial weight bearing as tear
heals
o third-degree: immobilization for 4 to 6 weeks, possible surgery
Arthritic Condition

More than 100 different diseases

• Osteoarthritis
• Rheumatoid Arthritis
• Gout Arthritis
Osteoarthritis

• The progressive loss of articular cartilage

and the inflammation of the other tissues
composing the joint
• Clinical Manifestasion :
o joint pain,
o stiffness,
o limited joint movement,
o wasting of periarticular muscles, and
o in some instances joint instability and
deformity
• Most : Load bearing articular cartilage
Patophysiology
Osteoarthritis : Risk Factor
Risk Factor
• age (considered the most
powerful risk factor),
• female sex,
• family history,
• major trauma to a joint or to
soft tissues sur- rounding a
joint,
• repetitive joint stress related to
occupation, and
• obesity.
To Reduce Risk Factor
• Weight loss has great potential
for reducing risk of OA of the
knee.
• for reducing risk of OA of the
knee. A loss of only 5 kg (11 lb)
can reduce the risk of
symptomatic knee OA by 50%
Osteoarthrits : Treatment
TARGET
• reducing joint inflammation,
• reducing pain,
• maintaining joint mobility,
and
• minimizing disability.
Drugs :
NSAID
Non Streoid Anti-
Inflamatory Drug
Side effect: gastritis
Non Farmacologic Treatment
• improving body posture,
• proper footwear,
• weight reduction as
indicated,
• periodic rest of the affected
joint (but rarely is complete
immobilization advised), and
• application of heat to the
affected joint  Fisioteraphy
• Therapeutic exercises to
strengthen the periarticular
muscles
Rheumatoid
Arthritis
• chronic inflammatory
disease in which the
synovial membrane of the
joint
• Clinical manifestasion :
• swelling,
• stiffness,
• pain,
• limited range of
motion,
• joint deformity, and
• disability
Rheumatoid Arthritis : Patophysiology
• Autoimmune disease, causing chronic systemic inflammatory disease
• Affects children and adults
• Remissions and exacerbations lead to progressive damage to the joints
Patophysiology:
• 1st step is abnormal immune response
o Causes inflammation of synovial membrane
• Vasodilation, increased permeability, formation of exudate
• Causes red, swollen, painful jt
• Synovitis
– Results from immune abnormality
• Rheumatoid factor (RF)
o Antibody against immunoglobulin G
o Present in synovial fluid
• After 1st period of acute inflammation, jt may appear to recover fully
• During subsequent exacerbations process continues
• End stage:
o Pannus formation
o Cartilage errosion
o Fibrosis
o Ankylosis
Treatment

Goal
• to reduce pain and
inflammation,
• protect the joint from
destruction,
• maintain the function of the
joint and surrounding
structures,
• and control any systemic
manifestations
Drugs
• NSAIDs (discussed earlier in
this chapter),
• glucocorticoids,
• immunosupressive drugs, and
• what are referred to as disease-
modifying anti- rheumatic
drugs (DMARDs)
RA : Treatment, Nutrition

Risk Factor
o lower intakes of
• vegetables,
• fruits, and
• Dietary vitamin C
o associated with increased risk of developing RA
• dietary fish oil supplementation (EPA & DHA)
o effective in reducing the symptoms associated with chronic RA
• Omege-6-polyunsaturated fatty acid
o increase sintesis pro-inflamatory sitokin
GOUT
ARTHRITIS
Gout is one of the most painful
arthritic conditions,

Gout occurs when

1. the serum concentration of uric
acid becomes elevated
2. uric acid crystals begin to
precipitate in the synovial fluid,
3. initiating an inflam- matory
response within the joint and
surrounding tissues.
GOUT ARTHRITIS : Uric Acid

• Uric acid is the end product of the

metabolism of the purines adenine and
guanine from DNA and RNA
• the elevation of serum uric acid
(hyperuricemia)
o overproduction of uric acid,
o inadequate elimination of uric acid by
the kidney,
o or a combination of both.
Risk Factor

• more common in males

>40 years of age
• genetics,
• male sex,
• older age,
• overweight,
• excessive alcohol
consumption (three or
more drinks per day),
• a diet rich in purines
Gout Arthritis : Clinical Manifestations

• Most common : great toe, other :

ankles, heels, knees, wrists, fingers,
and elbows
• Symptom :
o Occur rapidly (overnight)
o shiny, red skin around the joint;
o and extreme tenderness around the joint
• typically go away within five to ten
days, even without treatment,
• Tophi : large deposit of uric acid
crystals because chronic hyperuricemia
Gout Arthritis : Treatment

• Initial treatment (when acute attack):

o NSAID (relieve pain and reduce inflamation)
o Glucocortivoids and colchicine (reduce inflamation)
• Second treatment (after acute attack):
o Control hyperuricemia with drug (allupurinol)
• Lifestyle Modification
o moderate alcohol consumption,
o avoiding purine-rich foods, and
o achieving and maintaining a healthy body weight
• Rapid weight loss can precipitate attack of gout
Appendix
Appendix

• Budget
• Design documents
• Marketing plan
• Supplemental documents
• Contact information