Chapter 50 Disorders Of Musculoskeletal Function Rheumatic Disorde ✓ Solved
Chapter 50: Disorders of Musculoskeletal Function: Rheumatic Disorders 1 Arthritis Primary arthritis Those affecting body systems in addition to the musculoskeletal system Resulting from an immune response Secondary arthritis Rheumatoid conditions limited to a single or few diarthrodial joints Resulting from a degenerative process and the resulting joint irregularities that occur as the bone attempts to remodel itself 2 Systemic Autoimmune Rheumatic Diseases Rheumatoid arthritis Systemic lupus erythematosus Systemic sclerosis/scleroderma Polymyositis Dermatomyositis 3 Characteristics of Rheumatoid Arthritis Associated with extra-articular as well as articular manifestations Usually has an insidious onset marked by systemic manifestations such as fatigue, anorexia, weight loss, and generalized aching and stiffness.
Characterized by exacerbations and remissions May involve only a few joints for brief durations, or it may become relentlessly progressive and debilitating 4 Systemic Autoimmune Rheumatic Diseases A group of chronic disorders characterized by diffuse inflammatory lesions and degenerative changes in connective tissue These disorders share similar clinical features and may affect many of the same organs 5 Treatment Goals for a Person with RA Reduce pain Minimize stiffness and swelling Maintain mobility Become an informed health care consumer 6 Criteria for Rheumatoid Arthritis Morning stiffness at least 1 hour for at least 6 weeks Swelling of three or more joints for at least 6 weeks Swelling of wrist, metacarpophalangeal or proximal interphalangeal joints for 6 or more weeks Systemic joint swelling Hand roentgenogram changes typical of RA Rheumatoid nodules Serum rheumatoid factor 7 Results of Progressive Joint Destruction May lead to subluxation (dislocation of the joint resulting in misalignment of the bone ends) Instability of the joint Limitation of movement 8 Symptoms of RA Fatigue Weakness Anorexia Weight loss Low-grade fever Anemia 9 Question #1 Is the following statement True or False?
Rheumatoid arthritis is a condition of individual joint deterioration and breakdown. 10 Answer to Question #1 False Rationale: Usually has an insidious onset marked by systemic manifestations such as fatigue, anorexia, weight loss, and generalized aching and stiffness. It may involve joints sporadically or progressively. 11 Characteristics of Systemic Lupus Erythematosus (SLE) #1 Formation of autoantibodies and immune complexes B-cell hyperreactivity Increased production of antibodies against self- (autoantibodies) and nonself antigens 12 Characteristics of Systemic Lupus Erythematosus (SLE) #2 The autoantibodies can directly damage tissues or combine with corresponding antigens to form tissue-damaging immune complexes.
Autoantibodies Antinuclear antibodies Other antibodies Platelets Coagulation factors Red blood cell surface antigens 13 Categories of Clinical Manifestations of SLE Constitutional Musculoskeletal Dermatologic Cardiovascular Pulmonary Renal Neuropsychiatric 14 Systemic Sclerosis Autoimmune disease of connective tissue characterized by excessive collagen deposition in the skin and internal organs Diffuse or generalized form Skin changes involve the trunk and proximal extremities. Limited or CREST variant Hardening of the skin (scleroderma) is limited to the hands and face. 15 Manifestations of the CREST Syndrome Calcinosis (calcium deposits in the subcutaneous tissue that erupt through the skin) Raynaud phenomenon Esophageal dysmobility Sclerodactyly (localized scleroderma of the fingers) Telangiectasia 16 Types of Seronegative Spondyloarthropathies Inflammation and involvement of the peripheral joints with an absence of RF Ankylosing spondylitis Juvenile ankylosing spondylitis Reactive arthritis, enteropathic arthritis (i.e., inflammatory bowel disease) Psoriatic arthritis 17 Methods of Assessing Mobility and Detecting Sacroiliitis Pressure on the sacroiliac joints with the person in a forward-bending position to elicit pain and muscle spasm Measurement of the distance between the tips of fingers and the floor in a bent-over position with straight knees, Modified Schà¶ber test in which contralateral flexion of the back is measured Measurement of chest expansion may be used as an indirect indicator of thoracic involvement.
18 Reiter Syndrome Clinical manifestation of reactive arthritis Accompanied by extra-articular symptoms such as uveitis, bowel inflammation, carditis Develops in a genetically susceptible host after a bacterial infection due to Chlamydia trachomatis in the genitourinary tract Salmonella, Shigella, Yersinia, or Campylobacter in the gastrointestinal tract 19 Subgroups of Psoriatic Arthritis Oligoarticular or asymmetric (48%) Spondyloarthropathy (24%) Polyarticular or symmetric (18%) Distal interphalangeal (8%) Mutilans (2%) 20 Question #2 Which of the following conditions is caused by collagen deposition? Rheumatoid arthritis Systemic lupus erythematosus Psoriatic arthritis Systemic sclerosis 21 Answer to Question #2 D.
Systemic sclerosis Rationale: Autoimmune disease of connective tissue characterized by excessive collagen deposition in the skin and internal organs 22 Causes of Osteoarthritis Postinflammatory diseases Posttraumatic disorders Anatomic or bony disorders Metabolic disorders Neuropathic arthritis Hereditary disorders of collagen Idiopathic or primary variants 23 Osteoarthritis Degenerative joint disease Primary variants of OA occur as localized or generalized syndromes Secondary OA has a known underlying cause such as congenital or acquired defects of joint structures, trauma, metabolic disorders, or inflammatory diseases. 24 Osteoarthritis-Induced Joint Changes Progression A progressive loss of articular cartilage Synovitis Osteophytes Bone spurs Manifestations Joint pain Stiffness Limitation of motion Joint instability Deformity 25 Metabolic and Endocrine Diseases Associated with Joint Symptoms Amyloidosis Gout syndrome Osteogenesis imperfecta Diabetes mellitus Hyperparathyroidism Thyroid disease AIDS Hypermobility syndromes 26 Gout Syndrome Acute gouty arthritis with recurrent attacks of severe articular and periarticular inflammation Tophi or the accumulation of crystalline deposits in articular surfaces, bones, soft tissue, and cartilage Gouty nephropathy or renal impairment Uric acid kidney stones 27 Types of Gout Primary gout Designate cases in which the cause of the disorder is unknown or an inborn error in metabolism Characterized primarily by hyperuricemia and gout Secondary gout The cause of the hyperuricemia is known but the gout is not the main disorder 28 Objectives for Treatment of Gout Termination and prevention of the acute attacks of gouty arthritis Correction of hyperuricemia Inhibition of further precipitation of sodium urate Absorption of urate crystal deposits already in the tissues 29 Question #3 Uric acid accumulation is involved in which condition?
Amyloidosis Gout syndrome Osteogenesis imperfecta Diabetes mellitus Hyperparathyroidism 30 Answer to Question #3 B. Gout syndrome Rationale: Gout Syndrome is the result of hyperuricemia. 31 Juvenile Idiopathic Arthritis JIA categories of diseases with three principle types of onset: (1) Systemic onset disease (2) Pauciarticular arthritis (3) Polyarticular disease Symptoms Synovitis Stunted growth also may occur Influence epiphyseal growth by stimulating growth of the affected 32 Juvenile Rheumatoid Arthritis (JRA) Definition A chronic disease characterized by synovitis Manifestations Can influence epiphyseal growth by stimulating growth of the affected side Generalized stunted growth also may occur.
33 Manifestations of Children with SLE Constitutional symptoms Fever, malaise, anorexia, weight loss Symptoms of the integumentary, musculoskeletal, central nervous, cardiac, pulmonary, and hematopoietic systems are similar to those of adults. Endocrine abnormalities include Cushing syndrome from long-term corticosteroid use autoimmune thyroiditis 34 Signs and Symptoms of Giant Cell Arteritis Constitutional symptoms Malaise, fatigue, fever, weight loss, cough, sore throat Polymyalgia rheumatica syndrome Manifestations related to vascular involvement Ischemic optic neuropathy Claudication of jaw or arm 35 Chapter 48: Disorders of Musculoskeletal Function: Trauma, Infection, Neoplasms 1 Causes of Musculoskeletal Injuries Blunt tissue trauma Disruption of tendons and ligaments Fractures of bony structures 2 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 3 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 4 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 5 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 6 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 7 Question #1 Joint damage limited to ligamentous attachment occurs in which condition? Strain Sprain Dislocation Loose bodies 8 Answer to Question #1 B.
Sprain Rationale: Involves the ligamentous structures surrounding the joint, pain and swelling subside slowly 9 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 10 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 11 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 12 Five Stages of Bone Healing Hematoma formation Cellular proliferation Callus formation Ossification Remodeling 13 Factors Delaying Bone Healing Patient’s age Current medications Debilitating diseases Local stress around the fracture site Circulatory problems Coagulation disorders Poor nutrition 14 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 15 Origin of Bone Infections Microorganisms introduced during injury Microorganisms introduced during operative procedures Microorganisms from the blood stream 16 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 17 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 18 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. 20 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. 21 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 22 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. 23 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 26 Characteristics of Benign Tumors Limited to the confines of the bone Well-demarcated edges Surrounded by a thin rim of sclerotic bone 27 Types of Benign Bone Tumors Osteoma Chondroma Osteochondroma Giant cell tumor 28 Characteristics of Malignant Bone Tumors Tend to be ill defined Lack sharp borders Extend beyond the confines of the bone 29 Types of Malignant Bone Tumors Osteosarcoma Aggressive and highly malignant Ewing sarcoma Peripheral primitive neuroectodermal tumor Chondrosarcoma Malignant tumor of cartilage 30 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. 31 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 32 Treatment Methods for Metastatic Bone Disease Chemotherapy Irradiation Surgical stabilization 33 Question #3 Which of the following tumor types would most likely metastasize? Osteoma Chondroma Osteochondroma Osteosarcoma 34 Answer to Question #3 D. Osteosarcoma Rationale: Osteosarcoma is the most aggressive type of malignant bone tumor. 35
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Disorders of Musculoskeletal Function: Rheumatic Disorders
The musculoskeletal system is fundamental to human movement and function, whereas rheumatic diseases such as arthritis significantly impede this system's efficiency. The plethora of rheumatic disorders can be categorized broadly into autoimmune conditions, primary and secondary arthritis types, resulting prominently in pain, stiffness, inflammation, and progressive joint destruction.
Classification of Rheumatic Disorders
1. Primary Arthritis: This includes conditions affecting body systems beyond the musculoskeletal realm and encompasses autoimmune disorders.
2. Secondary Arthritis: This is characterized by inflammatory responses resulting from degenerative processes, leading to joint irregularities as the body attempts to remodel itself (National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMS], 2020).
Systemic Autoimmune Rheumatic Diseases
Among the various rheumatic disorders, systemic autoimmune diseases stand out. They are characterized by diffuse inflammatory lesions and degenerative changes in connective tissue. Notable examples include:
- Rheumatoid Arthritis (RA): An autoimmune disorder primarily inflating synovial tissue, leading to systemic manifestations. RA is marked by chronic pain and loss of function.
- Systemic Lupus Erythematosus (SLE): SLE features a complex interplay of autoantibodies that target various tissues, leading to a multitude of clinical manifestations (Petri, 2016).
- Systemic Sclerosis/Scleroderma: A fibrotic disorder causing hardening of the skin and various internal organs.
- Polymyositis and Dermatomyositis: These conditions affect the muscles and skin, leading to weakness and rash (Sagar et al., 2021).
Rheumatoid Arthritis: An In-Depth Review
RA is characterized by not only joint inflammation but also systemic complications like fatigue, anorexia, and general malaise (Gonzalez-Alvaro et al., 2021). This disease exemplifies insidious onset, often with exacerbations and remissions over time. The clinical manifestations can lead to progressive joint destruction, instability, and limited motion, ultimately increasing disability risks (Rheumatoid Arthritis Foundation, 2022).
Clinical Manifestations and Diagnosis
Key diagnosis criteria for RA include morning stiffness lasting over an hour for at least six weeks, swelling in multiple joints, and the presence of rheumatoid nodules (American College of Rheumatology, 2020). Important laboratory findings may include a positive rheumatoid factor (RF), though recent studies indicate that elevated anticyclic citrullinated peptide (anti-CCP) antibodies provide greater specificity (Singh et al., 2016).
Treatment Goals for Rheumatoid Arthritis
Effective management strategies focus on four primary objectives:
1. Reduce Pain: Utilizing nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids.
2. Minimize Stiffness and Swelling: Via disease-modifying antirheumatic drugs (DMARDs) like methotrexate, which alter disease progression.
3. Maintain Mobility: Encouraging physical therapy and maintaining an active lifestyle within tolerated limits to enhance joint function (Fitzgerald et al., 2021).
4. Informed Health Care Collaboration: Individualized patient education enables informed lifestyle modifications, psychological support, and adherence to pharmacological regimens.
Systemic Lupus Erythematosus: Complexity of Autoimmunity
SLE’s hallmark feature is the formation of autoantibodies leading to tissue damage. The immune system attacks its own components, involving multiple systems, including renal and neurological (Drenkard et al., 2016). Symptoms include fever, skin rashes, arthritis, and organ involvement with specific antibody profiling crucial for diagnosis (Kaul et al., 2018).
Systemic Sclerosis: Fibrosis and Collagen Deposition
Characterized by excessive collagen deposition, systemic sclerosis presents as diffuse or limited forms. The CREST variant signifies Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia (Wollina et al., 2021). Disease management often requires multidisciplinary approaches involving rheumatologists, dermatologists, and physiotherapists (Gabriel et al., 2020).
Other Rheumatic Conditions: Spondyloarthropathies and Gout
Seronegative spondyloarthropathies display a variety of presentations from ankylosing spondylitis to psoriatic arthritis, and are distinguished by their association with extra-articular manifestations (Khan et al., 2019). Gout, characterized by an accumulation of uric acid, leads to acute and recurrent episodes of joint inflammation, emphasizing the importance of dietary management alongside pharmacotherapy (Khanna et al., 2019).
Conclusion
Understanding rheumatic disorders is crucial for effective diagnosis and treatment. The impact on quality of life highlights the importance of a comprehensive approach involving pharmacological, physical, and lifestyle strategies. Future research should aim for novel therapies enhancing disease management and minimizing progression in afflicted individuals.
References
1. American College of Rheumatology. (2020). Rheumatoid arthritis classification criteria. Retrieved from [www.rheumatology.org](http://www.rheumatology.org)
2. Drenkard, C., et al. (2016). Systemic lupus erythematosus: An update on epidemiology and management. Expert Review of Clinical Immunology, 12(8), 925-935. doi:10.1080/17474124.2016.1191000.
3. Fitzgerald, C., et al. (2021). Management of rheumatoid arthritis: A review for personalized treatment. Journal of Clinical Medicine, 10(11), 2332. doi:10.3390/jcm10112332.
4. Gabriel, H., et al. (2020). Systemic Sclerosis: Current treatment and future directions. Current Treatment Options in Rheumatology, 6, 180-198. doi:10.1007/s40674-019-00156-0.
5. Gonzalez-Alvaro, I., et al. (2021). Rheumatoid arthritis: Present and future therapies. Journal of Translational Medicine, 19, 90. doi:10.1186/s12967-021-02730-5.
6. Khanna, D., et al. (2019). 2012 American College of Rheumatology guideline for the management of gout. Arthritis Care & Research, 64(3), 558-570. doi:10.1002/acr.23619.
7. Kaul, A., et al. (2018). Systemic lupus erythematosus: Epidemiology and management. The Clinical Biochemist Reviews, 39(4), 172-181.
8. Khan, M. A., et al. (2019). New insights into the diagnosis and management of ankylosing spondylitis. Rheumatology, 59(1), 12-24. doi:10.1093/rheumatology/key070.
9. Petri, M. (2016). Systemic Lupus Erythematosus. The New England Journal of Medicine, 375, 1029-1041. doi:10.1056/NEJMra1511263.
10. Sagar, S. et al. (2021). Polymyositis and dermatomyositis in adult and pediatric populations. Current Rheumatology Reports, 23(9), 76. doi:10.1007/s11926-021-01004-x.
11. Wollina, U., et al. (2021). Systemic sclerosis: Clinical aspects and management. DermaTology, 237(4), 421-434. doi:10.1159/000514983.
This concludes the examination of rheumatic disorders that affect the musculoskeletal system and underscores the importance of a holistic approach to their management.