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Chapter 48: Disorders of Musculoskeletal Function: Trauma, Infection, Neoplasms

Causes of Musculoskeletal Injuries

Blunt tissue trauma

Disruption of tendons and ligaments

Fractures of bony structures

Athletic Injuries

Acute injuries

Caused by sudden trauma

Include injuries to soft tissues (contusion, strains, and sprains) and to bone (fractures)

Overuse injuries

Chronic injuries

Include stress fractures that result from constant high levels of physiological stress without sufficient recovery time

Types of Soft Tissue Injuries

Contusion

An injury to soft tissue that results from direct trauma and is usually caused by striking a body part against a hard object

Hematoma

A large area of local hemorrhage

Laceration

An injury in which the skin is torn or its continuity is disrupted

Types of Joint Injuries #1

Strain

A stretching injury to a muscle or a musculotendinous unit caused by mechanical overloading.

Sprain

Involves the ligamentous structures surrounding the joint, pain and swelling subside more slowly than in a strain

Caused by abnormal or excessive movement of the joint

Types of Joint Injuries #2

Dislocation

Displacement or separation of the bone ends of a joint with loss of articulation

Loose bodies

Small pieces of bone or cartilage within a joint space

Healing Process in Soft Tissue

Repair is accomplished by fibroblasts from the inner tendon sheath

Capillaries infiltrate the injured area during the initial healing process

Formation of the long collagen bundles

Question #1

Joint damage limited to ligamentous attachment occurs in which condition?

Strain

Sprain

Dislocation

Loose bodies

Answer to Question #1

B. Sprain

Rationale: Involves the ligamentous structures surrounding the joint, pain and swelling subside slowly

Classifications of Fractures

By cause

Sudden injury

Stress fractures

Pathologic fractures

Location

Proximal, midshaft, distal

Types

Open or closed

Pattern of fracture line

Comminuted, compression, greenstick

Signs and Symptoms of a Fracture

Pain

Tenderness at the site of bone disruption

Swelling

Loss of function

Deformity of the affected part

Abnormal mobility

Treatment of Fractures

Three objectives for treatment of fractures:

Reduction of the fracture

Closed manipulation or surgical reduction

Immobilization

Immobilization through the use of external devices

Preservation and restoration of the function

Therapy

Five Stages of Bone Healing

Hematoma formation

Cellular proliferation

Callus formation

Ossification

Remodeling

Factors Delaying Bone Healing

Patient’s age

Current medications

Debilitating diseases

Local stress around the fracture site

Circulatory problems

Coagulation disorders

Poor nutrition

Complications of Fractures

Loss of skeletal continuity

Injury from bone fragments

Pressure from swelling and hemorrhage

Fracture blisters, compartment syndrome

Involvement of nerve fibers

Reflex sympathetic dystrophy and causalgia

Development of fat emboli

Origin of Bone Infections

Microorganisms introduced during injury

Microorganisms introduced during operative procedures

Microorganisms from the blood stream

Actions of Microorganisms Localized in Bone

Proliferate

Produce cell death

Spread within the bone shaft

Incite a chronic inflammatory response with further destruction of bone

Types of Osteomyelitis

Hematogenous Osteomyelitis

Originates with infectious organisms that reach the bone through the blood stream

Contiguous Spread Osteomyelitis

Secondary to a contiguous focus of infection

Direct inoculation from an exogenous source or from an adjacent extraskeletal site

Chronic Osteomyelitis

Occur secondary to an open wound

Chronic Osteomyelitis

The hallmark feature of chronic osteomyelitis is the presence of infected dead bone, a sequestrum, that has separated from the living bone.

Chronic osteomyelitis includes all inflammatory processes of bone, excluding those in rheumatic diseases that are caused by microorganisms.

Chronic osteomyelitis usually occurs in adults. Generally, these infections occur secondary to an open wound, most often to the bone or surrounding tissue.

Spread of Tuberculosis

Tuberculosis can spread from one part of the body to the bones and joints.

When this happens, it is called extrapulmonary or miliary tuberculosis.

It is caused by Mycobacterium tuberculosis.

The disease is localized and progressively destructive but not as contagious as primary pulmonary tuberculosis.

Osteonecrosis

Causes

Mechanical disruption of blood vessels

Thrombosis and embolism

Vessel injury

Increased intraosseous pressure

Blood Flow

Interconnecting plexus

Outer cortex receives supply form surrounding blood vessels.

Some sites have limited collateral circulation; interruption flow affects significant amount of bone tissue.

Question #2

Which of the following complication of healing may lead to osteonecrosis?

Loss of skeletal continuity

Injury from bone fragments

Involvement of nerve fibers

Development of fat emboli

Answer to Question #2

D. Development of fat emboli

Rationale: Development of fat emboli potentially will cause an infarct resulting in tissue anoxia and necrosis.

Diagnosis and Treatment of Osteonecrosis #1

Diagnosis of osteonecrosis is based on history, physical findings, radiographic findings, and results of special imaging studies, including CT scans and technetium-99m bone scans.

Treatment of osteonecrosis depends on the underlying pathologic process.

In some cases, only short-term immobilization, nonsteroidal anti-inflammatory drugs, exercises, and limitation in weight bearing are used.

Diagnosis and Treatment of Osteonecrosis #2

Osteonecrosis of the hip is particularly difficult to treat. In people with early disease, limitation of weight bearing through the use of crutches may allow the condition to stabilize.

Although several surgical approaches have been used, the most definitive treatment of advanced osteonecrosis of the knee or hip is total joint replacement.

Symptoms of Bone Tumors

Pain

Presence of a mass

Impairment of function

Characteristics of Benign Tumors

Limited to the confines of the bone

Well-demarcated edges

Surrounded by a thin rim of sclerotic bone

Types of Benign Bone Tumors

Osteoma

Chondroma

Osteochondroma

Giant cell tumor

Characteristics of Malignant Bone Tumors

Tend to be ill defined

Lack sharp borders

Extend beyond the confines of the bone

Types of Malignant Bone Tumors

Osteosarcoma

Aggressive and highly malignant

Ewing sarcoma

Peripheral primitive neuroectodermal tumor

Chondrosarcoma

Malignant tumor of cartilage

Metastatic Bone Disease

Metastatic lesions are seen most often in the spine, femur, pelvis, ribs, sternum, proximal humerus, and skull.

Tumors that frequently spread to the skeletal system are those of the breast, lung, prostate, kidney, and thyroid, although.

Treatment Goals for Metastatic Bone Disease

Preventing pathologic fractures

Promoting survival with maximum functioning

Allowing the person to maintain as much mobility and pain control as possible

Treatment Methods for Metastatic Bone Disease

Chemotherapy

Irradiation

Surgical stabilization

Question #3

Which of the following tumor types would most likely metastasize?

Osteoma

Chondroma

Osteochondroma

Osteosarcoma

Answer to Question #3

D. Osteosarcoma

Rationale: Osteosarcoma is the most aggressive type of malignant bone tumor.