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HCR240-Chapter38DegenerativeDisordersoftheMusculoskeletalSystem2.pptx

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Chapter 38

Degenerative Disorders of the

Musculoskeletal System

Basic Concepts

Hydroxyapatite

Ca++ and phosphate crystals

Two types of bone

Cortical

Dense

Trabecular

Cancellous, spongy

Found in high amounts in the upper femur, vertebrae, and wrist

Osteoporosis of trabecular bone displays degeneration first

Bone Health

Constant remodeling

Dependent on calcium

Hormones

Vitamin D: calcium absorption

Calcitonin

Parathyroid hormone

Testosterone and estrogen

Mechanical stimulation

Bone Health (continued)

Overview

Osteoporosis

Most common degenerative disease of bone

Occurs with aging

Osteoclast activity greater than osteoblast activity

Osteoarthritis (OA)

Degeneration of joints with aging

Degenerative disc disease (DDD)

Discs between vertebrae become compressed or misaligned

Joint Health

Types of joints

Synarthrosis

No mobility

Diarthrosis

Most movement

Synovial joint

Amphiarthrosis

Moderately movable

Arthropathy

Joint disorder

Arthritis

Inflammation of joint

Degeneration of Bone

Bone remodeling

Destruction and reconstruction of bone

Involves osteoclasts and osteoblasts

Stimulated by stresses upon bone

Osteoporosis is elevated osteoclast activity without adequate bone replacement

Recommended calcium intake to maintain bone health: 1,000–1,200 mg/day

Degeneration of Joints

OA affects certain joints and not others

OA targets

Cervical and lumbosacral spine

Hip

Knee

1st metatarsal phalangeal joint

Wrist, elbow, and ankle are often spared

Articular Cartilage Deterioration

Chondrocytes produce cartilage

Cartilage loss in with age

Cartilage, along with synovial fluid, provides cushioning

Excessive force causes cartilage to breakdown

Subchondral bone deterioration

Articular Cartilage Deterioration (continued)

Osteophytes

Form at margin of cartilage loss

Hallmark of OA

In OA, synovial membrane often becomes inflamed

Concentration of lubricin (glycoprotein that acts as lubricant) declines

Osteoporosis

Osteoporosis: “porous bone”

Low bone density

Structural deterioration of bone

Breaks in trabecular matrix

Osteopenia

Thinning of trabecular matrix (occurs before osteoporosis)

Silent disease

May present with pathological fracture or height loss

Risk Factors of Osteoporosis

Female gender

Postmenopausal age in female

Lack of estrogen in female

Lack of testosterone in male

Family history

Asian and Caucasian women

Thin and small-framed women

Lack of recommended daily intake of calcium and vitamin D

Lack of weight-bearing exercise

Excess alcohol consumption

Excess caffeine consumption

Smoking

Long-term use of corticosteroids

Excess carbonated soft drink consumption

Gastric bariatric surgery

Eating disorders such as anorexia

Hyperthyroidism or excessive intake of thyroid medication

Hyperparathyroidism

Anticonvulsant medications

Hip Fracture and Mortality

Increased mortality risk with osteoporotic hip fractures

Risk of mortality is 2.8 to 4 times greater among hip fracture patients during the first 3 months after the fracture

Nearly 1 in 4 fracture patients will die within 12 months after fracture

Osteoporosis (continued_1)

Primary

Prolonged negative calcium balance

Poor dietary habits, lack of weight-bearing exercise, lack of daily exposure to sunlight

Secondary

Disorders that affect bone tissue

i.e., hyperparathyroidism, corticosteroids

Osteoporosis (continued_2)

Hormones play a role in BMD

Estrogen slows osteoclast activity

Postmenopausal women

Female triad

Amenorrhea, decreased body weight, excessive exercise

Osteoporosis Diagnosis

Dual energy x-ray absorptiometry (DEXA)

Measures BMD

Compared with reference population of healthy adults, age 30 years

Reported at T score

X-rays do not show osteoporosis until bone loss more than 40%

Blood tests

PTH, estradiol, osteocalcin (protein in bone, high level indicates bone breakdown)

Osteoporosis Diagnosis (continued)

Urine

Telopeptides, bone breakdown product

FRAX risk assessment

Self-assessment tool to predict a person’s risk of fracture

Gives a 10-year probability of a fracture in the spine, hip, shoulder, or wrist

Ages 40–90 years

Osteoporosis Treatment

Lifestyle changes

Diet

1,000 mg of calcium and 400 IU vitamin D

UV light, appropriate weight-bearing exercise

Anti-resorption

Bisphosphonates

Have been associated with atypical fractures

SERM’s (selective estrogen receptor modulators)

Denosumab

Osteoporosis Treatment (continued)

Calcitonin

Increases bone formation (effective vertebral compression)

Teriparatide

Stimulates osteoblasts

Vertebroplasty

Injecting bone cement into the fractured area of the vertebrae

Osteoarthritis (OA)

Individuals older than age 40 years

Associated with trauma to joints over course of life

Slowly progressive, degenerative, and inflammatory condition

Changes in cartilage lead to inflammation and changes in joint surfaces

Excess weight increases risk for OA in weight-bearing joints

Risk Factors of OA

Aging

Obesity

History of participation in team sports

History of trauma or overuse of a joint

Heavy occupational work

Misalignment of the pelvis, hip, knee, ankle, or foot

Osteoarthritis (OA) (continued_1)

Patient presents with following:

Deep, aching joint pain

Pain relieved with rest

Joint pain during cold weather

Stiffness when arising in the morning

Crepitus of the joint during motion

Joint swelling

Altered gait

Limited range of motion

OA Physical Examination

Joint deformity

Joint tenderness

Decreased range of motion

Fingers are often involved in OA

Swellings

Heberden’s nodes

Distal interphalangeal joint (DIP)

Bouchard’s nodes

Proximal interphalangeal joint (PIP)

Osteoarthritis (OA) (continued_2)

OA Diagnosis

Diagnosis

No specific laboratory test

Serum markers

Osteocalcin and hyaluronic acid

Physical examination

X-rays confirm diagnosis

Joint space narrowing

Osteophytes

OA Treatment

Treatment

NSAID’s

Oral steroids not recommended

Intra-articular injections or topical may help

Maintain mobility

Moderate exercise

Dietary supplements

Chondroitin sulfate

Reduce stress on joints

OA Surgical Options

Osteotomy

Excision of bone spurs

Osteoplasty

Scraping and removal of deteriorated tissue from the joint

Arthrodesis

Surgical fusion of bone (spine)

Partial or total joint arthroplasty

Deteriorated bone replaced with a prosthetic device

Degenerative Disc Disease (DDD)

Common cause of pain, motor weakness, and neuropathy

Nervous system affected as vertebral disc distortions compromise spinal nerves

Cervical and lumbar regions

L4, L5, and S1 most commonly affected

Signs and Symptoms of DDD

Signs and symptoms of lumbar DDD

Pain in the lower back that radiates down the back of the leg (also called “sciatica”)

Pain in the buttocks or thighs

Pain that worsens when sitting, bending, lifting, or twisting

Pain that is minimized when walking, changing positions, or lying down

Numbness, tingling, or weakness in the legs

Foot drop

Signs and Symptoms of DDD (continued)

Signs and symptoms of cervical DDD

Chronic neck pain that can radiate to the shoulders and down the arms

Numbness or tingling in the arm or hand

Weakness of the arm or hand

Spinal Nerve Impingement

Herniated disc

Bulging disc

Degenerated disc

Osteophyte formation

Bony formations can narrow the spinal canal

Spinal stenosis

Slippage of disc and vertebrae

Spondylolisthesis: forward

Retrolisthesis: backward

Spinal Nerve Impingement (continued)

DDD Physical Examination

The clinician should test:

Muscle strength

Deep tendon reflexes

Sensory dermatomes

Give information about which spinal nerve is affected

DDD Diagnosis and Treatment

Diagnosis

Physical examination tests

X-ray

MRI

EMG

Treatment

Physical therapy

Pain management

Epidural steroid injection

Chiropractic care

Surgery

asignment 6

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