overview of musculoskeletal disorders

1. An overview of musculoskeletal
disorders
(Arthritis)
Dr. Prasanna. C
Professor of Orthopaedics
KMCHIHSR

2. Objectives…
By the end of the session the learner should be able to:
1. Enumerate few musculoskeletal disorders.
2. Define arthritis and mention the common forms of arthritis.
3. List out the management options for osteoarthritis.

3. Contents…
1. Musculoskeletal system – an introduction.
2. Musculoskeletal disorders.
3. Arthritis : definition and classification.
4. Osteoarthritis.
5. Rheumatoid arthritis.
6. Gouty arthritis.

6. Musculoskeletal system…
• The musculoskeletal system provides form, support, stability, and
movement to the body.
• It is made up of the bones of the skeleton, muscles, cartilage,
tendons, ligaments, joints, and other connective tissue that supports
and binds tissues and organs together.

7. The human skeleton
• Contains 206 bones
•Initially: flexible cartilage
•Ossification

8. Process of ossification
• Approximately 20 years
• Growth plates
• Bone building: - Osteoblasts
- Osteocytes
- Osteoclasts

9. Structure of bones
Compact bone
• Outside part of the bone
• Extremely strong and hard
• Periosteum
Spongy bone
• Mesh-like network (trabeculae)
• Red marrow (blood cells)
• Yellow marrow (fat)

10. Anatomical classification of
bones
• Bones are characterized anatomically as:
– long bones (e.g. humerus, femur)
– flat bones (membrane bones)
– irregular bones (such as the vertebrae)
• All these bone types, regardless of their
anatomical form, are composed of both spongy
and compact bone.

11. Functions of the skeleton
• Bone provides the internal support of the body
and provides sites of attachment of tendons and
muscles, essential for locomotion.
• Bone provides protection for the vital organs of
the body: the skull protects the brain; the ribs
protect the heart and lungs.
• The hematopoietic bone marrow is protected by
the surrounding bony tissue.
• The main store of calcium and phosphate is in
bone. Bone has several metabolic functions
especially in calcium homeostasis.

12. • Meeting of two bones
• Make the skeleton flexible
• Types:
- Immovable or fibrous (skull)
- Partially movable, or cartilaginous (spine,ribs)
- Freely movable, or synovial (knee, hip)
Joints

13. Fibrous joints…

14. Cartilagenous joints…

15. Synovial joints

16. The Muscles
• Pull on the joints, allowing us to
move.
• Help the body perform other
functions.
• More than 650 muscles ( half of a
person's body weight)
• Tendons: tough, cord-like
tissues
• 3 different kinds of muscle

17. Musculoskeletal disorders…

18. Musculoskeletal disorders (MSDs) are injuries
or pain in the human musculoskeletal
system, including the joints, ligaments,
muscles, nerves, tendons, and structures that
support limbs, neck and back.

19. • Infections
• Osteomyelitis
• Septic arthritis
• Tumors
• Osteosarcoma
• Gaint cell tumor
• chondrosarcoma
• Congenital deformities
• Club foot
• Radial club hand
• Metabolic disorders
• Rickets & osteomalacia
• Osteoporosis
• Paget’s disease

20. Infection…
Osteomyelitis

21. Septic arthritis

22. Tumors…
Osteosarcoma

23. Gaint cell tumor

24. Congenital
deformities…
Club foot

25. Radial club hand

26. Metabolic disorders…
Rickets

27. Osteoporosis

28. The top three most common musculoskeletal
conditions are the following:
• Arthritis – all types of arthritis are considered MSDs, including
osteoarthritis, rheumatoid arthritis, , psoriatic arthritis, etc.
• Lower back and neck pain – includes conditions like a ruptured or
herniated spinal disc, ligament sprain, muscle or tendon strain,
degenerative disc disease, etc.
• Trauma – trauma occurring from falls, auto accidents, workplace
injuries, repetitive motions, etc. can lead to bone fractures and
damage to soft tissues (tears, sprains, strains)

29. Arthritis…

31. Arthritis …
Arthritis is the swelling and tenderness of one or more joints.
‘itis ‘- inflammation

35. The 3 most common forms of arthritis are
Osteoarthritis
Rheumatoid arthritis &
Gouty arthritis.

36. Osteoarthritis
(Degenerative
arthritis/osteoarthrosis/hypertrophic
arthritis)

37. Osteoarthritis
■ Osteoarthritis is a non-inflammatory,
degenerative condition of joints
Characterized by degeneration of articular
cartilage and formation of new bone i.e.
osteophytes.

38. ■ Common in weight-bearing joints such as
hip and knee.
■ Also seen in spine and hands.
■ Both male and females are affected.
■ But more common in older women i.e.
above 50 yrs,particularly in
postmenopausal age.

39. Classification of OA
OA
Primary OA Secondary OA

40. Primary OA
■ More common than secondary OA
■ Cause –Unknown
■ Common-in elderly where there is
no previous pathology.
■ Its mainly due to wear and tear changes
occuring in old ages mainly in weight
bearing joints.

41. Secondary OA
■ Due to a predisposing cause such as:
1.Injury to the joint
2.Previous infection
3.CDH
4.Deformity
5.Obesity

42. Clinical features of OA
■ Pain
■ Stiffness
■ Muscle spasm
■ Restricted movement
Deformity
■
■ Muscle weakness or wasting
■ Joint enlargement and instability
■ Crepitus
• Joint Effusion

43. A patient with
typical OA of the
knees. In the normal
standing posture
there is a mild varus
angulation of the
knee joints due to
symmetrical OA of
the medial
tibiofemoral
compartments.

44. X-ray
changes
1. Joint space narrowing
2. Subchondral sclerosis
3. Osteophytes
4. Cysts

45. Management

46. Treatment Principles
• Education
• Physiotherapy
– Exercise program
– Pain relief modalities
• Aids and appliances
• Medical Treatment
• Surgical Treatment

47. Education..
Is aimed at prevention of disease
&
Delay the progression of disease

48. Physiotherapy…
• Physical therapy: To strengthen the muscles. Regular exercise can
improve strength of muscles around the joints.
• Occupational therapy: Helps perform daily tasks with ease.
• Pain relief with wax bath.

50. Aids and appliances..

51. Medications..
Analgesics: Drugs that are used to relieve pain.
Acetaminophen
Nonsteroidal anti-inflammatory drugs (NSAIDs): Reduces pain and
inflammation.
Ibuprofen
aceclofenac

52. Medications(cont)..
Steroids
Hyaluronic acid
Glucosamine sulphate

53. Surgical…
Arthroscopic debridement

54. High tibial osteotomy

55. partial knee replacement

56. Total knee replacement

57. Rheumatoid Arthritis…

58. Introduction
• RA is a chronic systemic autoimmune disorder
causing a symmetrical polyarthritis.
• Epidemiology
– RA affects 0.5–1% of the population world-wide
with a peak prevalence between the ages of 30
and 50 years.

59. Aetiology and pathogenesis
• Gender- Women before the menopause are
affected three times more often than men
with an equal sex incidence thereafter
suggesting an aetiological role for sex
hormones.
• Familial -There is an increased incidence in
those with a family history of RA.

60. • Genetic factors - Human leucocyte antigen
(HLA)-DR4 and HLA-DRB1* 0404/0401 confer
susceptibility to RA and are associated with
development of more severe erosive disease.

61. Pathology
• RA is characterized by synovitis with thickening of
the synovial lining and infiltration by
inflammatory cells.
• Generation of new synovial blood vessels is
induced by angiogenic cytokines
• Activated endothelial cells produce adhesion
molecules
• vascular cell adhesion molecule-1 (VCAM-1)
• Which expedite extravasation of leucocytes into
the synovium.

62. • The synovium proliferates and grows out over
the surface of cartilage, producing a tumour-
like mass called ‘pannus’
• Pannus destroys the articular cartilage and
subchondral bone, producing bony erosions

64. Clinical features
• Onset of pain
• Early-morning stiffness (lasting more than 30
minutes)
• Swelling in the small joints of the hands and
feet
• As the disease progresses there is weakening
of joint capsules
– joint instability
– Subluxation
– deformity

66. Non-articular manifestations of RA
•Systemic – Fever, Fatigue, Weight loss
•Eyes- Scleritis, Scleromalacia perforans
(perforation of the eye)
•Neurological- Carpal tunnel syndrome, Atlanto-
axial subluxation, Cord compression
•Haematological- Lymphadenopathy, Felty’s
syndrome (rheumatoid arthritis, splenomegaly,
neutropenia), Anaemia (chronic disease, NSAID-
induced, gastrointestinal blood loss, haemolysis,
hypersplenism), Thrombocytosis

67. • Pulmonary - Pleural effusion, Lung fibrosis,
Rheumatoid nodules, Rheumatoid
pneumoconiosis
• Heart and peripheral vessels – Pericarditis,
Pericardial effusion, Raynaud’s syndrome
• Vasculitis - Leg ulcers, Nail fold infarcts,
Gangrene of fingers and toes
• Kidneys - Amyloidosis causes the nephrotic
syndrome and renal failure

70. Investigations
•Blood count- usually a normochromic,
normocytic anaemia, ESR and CRP are raised
•Serum autoantibodies - Anti-CCP has high
specificity (90%) and, Rheumatoid factor is
positive in 70% of cases sensitivity (80%) for RA.
•X-ray- joint narrowing, erosions at the joint
margins
•Synovial fluid - high neutrophil count in
uncomplicated disease

71. Radiology

72. Feet

73. Rheumatoid nodules

74. Hammer toes

76. Management
• No treatment cures RA
• Goals are
– Remission of symptoms
– Return of full function
– Maintenance of remission with disease-modifying agents
• Effective management of RA requires a
multidisciplinary approach

77. • NSAIDs and coxibs- effective in relieving the
joint pain and stiffness of RA
• Corticosteroids - suppress disease activity
• Disease-modifying anti-rheumatic drugs
(DMARDs)- act mainly through inhibition of
inflammatory cytokines (6 weeks to 6 months
of disease onset)
– Sulfasalazine, Methotrexate

78. • Sulfasalazine is used in patients with mild to
moderate disease and for many is the drug of
choice especially in younger patients and
women who are planning a family
• Methotrexate is the drug of choice for
patients with more active disease.
contraindicated in pregnancy (teratogenic)
• Leflunomide blocks T cell proliferation

79. • Azathioprine, gold (intramuscular or oral),
and penicillamine are used less
frequently.
• All drugs have serious side-effects

81. Gouty Arthritis…

82. GOUT
Defenition
• Gout is a hereditary condition of disturbed uric acid
metabolism in which urate salts gets deposited in articular,
periarticular and subcutaneous tissues.

83. • Clinically it is characterised by reccurring attacks
of acute arthritis by interval of freedom from pain
&
• In late stages by deforming arthritis, nephritis,
urinary calculi.

85. Etiology
• Idiopathic
• Hereditory :family members have hyperuricemia without
gout .
• Race : Whites> Blacks
• Sex : Males >Females
• Age :2nd to 4th decade common at 40years.

86. Common sites
Smaller joints:
First metatarsophalyngeal
joints
Interphalyngeal joints of
foot
Interphalyngeal joints of
the hands
Knee joint
Elbow joint

87. Gout staging
• Typical sequence involves progression
through:
– Asymptomatic Hyperuricemia
– Acute gouty arthritis
– Interval or Intercritical gout
– Chronic or tophaceous gout

88. Clinical features
Acute gout:
 Precipitated by local trauma
unaccustomed excercise and alcohol
consumption
 Acute arthritis is the most common
manifestation
 Excruciating pain over hours
frequently nocturnal
 Swelling, redness and tenderness
 Monoarticular and lower
extremities(MetatarsoPhalyngeal
joint, ankle and knee).
• 1st MTP classicpresentation
• May affect knees, wrist, elbow,
and rarely SI and hips.

89. Treatment for gout

90. Dr.Sandeep Agrawal,Agrasen Hospital,Gondia MS
Non pharmacological treatment

91. Dr.Sandeep Agrawal,Agrasen
Non-drug
Management:
31
Stop diuretics
Dietary changes
Stop alcohol weight loss

92. Dr.Sandeep Agrawal,Agrasen
Dietary advices:
32
Red meat/sea food.
Avoid:
Beer

93. Pharmacotherapy
• Non steroidal anti
inflamatory drugs
(NSAID’S)
• Colchicine,
• Corticosteroids
• Uricosurics
• Probenecid,
• Sulfinpyrazone.
• Synthesis inhibitor
• Allopurinol,
• Febuxostat .

94. • Intra-articularcorticosteroids.
• Surgical treatment
Excision of gout trophy.
Arthrodesis of the joint in functional position,
Removal of lesion adjacent to the joint preserves joint
function.
Orthopaedic Management…
tophi

96. Self care tips to manage joint pain due to
arthritis…
• Include a well balanced diet.
• Prioritize vit D & Calcium intake.
• Maintain an ideal weight.
• Practice regular physical activity.
• Engage in yoga & meditation.
• Stop smoking.