Calcitonin is a hormone that is produced in humans by the parafollicular cells (commonly known as C-cells) of the Thyroid Gland. Calcitonin is involved in helping to regulate levels of calcium and phosphate in the blood, opposing the action of Parathyroid Hormone. This means that it acts to reduce calcium levels in the blood. However, the importance of this role in humans is unclear, as patients who have very low or very high levels of calcitonin show no adverse effects.

1. Musculoskeletal System

2. Skeletal System
• Bone types
• Bone structure
• Bone function
• Bone growth and metabolism affected by
calcium and phosphorus, calcitonin, vitamin
D, parathyroid hormone, growth hormone,
glucocorticoids, estrogens and androgens,
thyroxine, and insulin

3. Calcitonin is a hormone that is produced in humans by the parafollicular cells
(commonly known as C-cells) of the Thyroid Gland. Calcitonin is involved in
helping to regulate levels of calcium and phosphate in the blood, opposing the
action of Parathyroid Hormone. This means that it acts to reduce calcium levels in
the blood. However, the importance of this role in humans is unclear, as patients
who have very low or very high levels of calcitonin show no adverse effects.
Calcitonin reduces calcium levels in the blood by two main mechanisms:
It inhibits the activity of osteoclasts, which are the cells responsible for breaking
down bone. When bone is broken down, the calcium contained in the bone is
released into the bloodstream. Therefore, the inhibition of the Osteoclasts by
calcitonin directly reduces the amount of calcium released into the
blood. However, this inhibition has been shown to be short-lived.
It can also decrease the resorption of calcium in the kidneys, again leading to
lower blood calcium levels.
Manufactured forms of calcitonin can be given to treat Paget’s Disease of bones
and sometimes Hypercalcemia and bone pain. However, with the introduction
of Bisphosphonates, their use is now limited.

4. Bone Structure

5. Joints
• Types include synarthrodial,
amphiarthrodial, diarthrodial.
• Structure synovial joint.
• Subtyped by anatomic structure:
– Ball-and-socket
– Hinge
– Condylar
– Biaxial
– Pivot

6. Structure Diarthrodial Joint

7. Muscular System Assessment
• Patient history
• Nutritional history
• Family history and genetic risk
• General inspection:
– Posture and gait

8. Muscular System Assessment
(Cont.)

9. Specific Assessments
• Face and neck
• Spine
• Hand
• Hip
• Ankles, feet
• Neurovascular assessment
• Psychosocial assessment

10. Diagnostic Assessment
• Laboratory tests—serum calcium and phosphorus,
alkaline phosphatase, serum muscle enzymes
• Radiographic examinations—standard
radiography, bone density, tomography and
xeroradiography, myelography, arthrography, and
CT (stands for computed tomography. The CT scan can
reveal anatomic details of internal organs that cannot be
seen in conventional X-rays. ... CT scan is also known as
CAT (computerized axial tomography) scan.
• Other diagnostic tests—bone and muscle biopsy

11. Electromyography
• EMG aids in the diagnosis of
neuromuscular, lower motor neuron, and
peripheral nerve disorders; usually with
nerve conduction studies.
• Low electrical currents are passed through
flat electrodes placed along the nerve.
• If needles are used, inspect needle sites for
hematoma formation.

12. EMG from gait termination, bottom
left is the raw EMG, right is the
rectified pattern
An illustration depicting an
electromyogram procedure.

13. Arthroscopy
• Fiberoptic tube is inserted into a joint
for direct visualization.
• Patient must be able to flex the knee;
exercises are prescribed for ROM.
• Evaluate the neurovascular status of
the affected limb frequently.
• Analgesics are prescribed.
• Monitor for complications.

14. Arthroscopy (Cont’d)

15. Other Tests
• Bone Scan Gallium or Thallium Scan
• Magnetic Resonance Imaging Ultrasonography
• Other names for these tests: nuclear imaging, radionuclide imaging &
Nuclear Scans
Nuclear medicine scans can help doctors find tumors and see how much the cancer has
spread in the body (called the cancer’s stage). They may also be used to decide if
treatment is working. These tests are painless and usually done as an outpatient
procedure. The specific type of nuclear scan you’ll have depends on which organ the
doctor wants to look into. Some of the nuclear medicine scans most commonly used for
cancer (described in more detail further on) are:
•Bone scans
•PET (positron emission tomography) scans
•Thyroid scans
•MUGA (multigated acquisition) scans
•Gallium scans

16. Common isotopes used in nuclear medicine [16][17]
isotope symbol Z T1/2 decay gamma (keV) positron (keV)
Imaging:
fluorine-18 18F 9 109.77 m β+ 511 (193%) 249.8 (97%)[18]
gallium-67 67Ga 31 3.26 d ec
93 (39%),
185 (21%),
300 (17%)
-
krypton-81m 81mKr 36 13.1 s IT 190 (68%) -
rubidium-82 82Rb 37 1.27 m β+ 511 (191%) 3.379 (95%)
nitrogen-13 13N 7 9.97 m β+ 511 (200%) 1190 (100%)[19]
technetium-
99m
99mTc 43 6.01 h IT 140 (89%) -
indium-111 111In 49 2.80 d ec
171 (90%),
245 (94%)
-
iodine-123 123I 53 13.3 h ec 159 (83%) -
xenon-133 133Xe 54 5.24 d β− 81 (31%) 0.364 (99%)
thallium-201 201Tl 81 3.04 d ec
69–83* (94%),
167 (10%)
-
Therapy:
yttrium-90 90Y 39 2.67 d β− - 2.280 (100%)
iodine-131 131I 53 8.02 d β− 364 (81%) 0.807 (100%)
Z = atomic number, the number of protons; T1/2 = half-life; decay = mode of decay
photons = principle photon energies in kilo-electron volts, keV, (abundance/decay)
β = beta maximum energy in mega-electron volts, MeV, (abundance/decay)
β+ = β+ decay; β− = β− decay; IT = isomeric transition; ec = electron capture
* X-rays from progeny, mercury, Hg

17. Nuclear medicine
Nuclear medicine is a medical specialty involving the application
of radioactive substances in the diagnosis and treatment of disease.
Nuclear medicine, in a sense, is "radiology done inside out" or
"endoradiology" because it records radiation emitting from within the
body rather than radiation that is generated by external sources like X-
rays. In addition, nuclear medicine scans differ from radiology as the
emphasis is not on imaging anatomy but the function and for such
reason, it is called a physiological imaging modality. Single Photon
Emission Computed Tomography or SPECT and Positron Emission
Tomography or PET scans are the two most common imaging
modalities in nuclear medicine

18. Diagnostic medical imaging
In nuclear medicine imaging, radiopharmaceuticals are taken
internally, for example, intravenously or orally. Then,
external detectors (gamma cameras) capture and form
images from the radiation emitted by the
radiopharmaceuticals. This process is unlike a diagnostic X-
ray, where external radiation is passed through the body to
form an image.
There are several techniques of diagnostic nuclear medicine.

19. 2D: Scintigraphy ("scint") is the use of
internal radionuclides to create two-
dimensional images.
A nuclear medicine whole body
bone scan. The nuclear medicine
whole body bone scan is
generally used in evaluations of
various bone-related pathology,
such as for bone pain, stress
fracture, non-malignant bone
lesions, bone infections, or the
spread of cancer to the bone.

20. Nuclear medicine myocardial
perfusion scan with thallium-201
for the rest images (bottom rows)
and Tc-Sestamibi for the stress
images (top rows). The nuclear
medicine myocardial perfusion
scan plays a pivotal role in the non-
invasive evaluation of coronary
artery disease. The study not only
identifies patients with coronary
artery disease; it also provides
overall prognostic information or
overall risk of adverse cardiac
events for the patient.

21. A nuclear medicine parathyroid
scan demonstrates a parathyroid
adenoma adjacent to the left
inferior pole of the thyroid gland.
The above study was performed
with Technetium-Sestamibi (1st
column) and iodine-123 (2nd
column) simultaneous imaging and
the subtraction technique (3rd
column).

22. Normal hepatobiliary scan (HIDA
scan). The nuclear medicine
hepatobiliary scan is clinically
useful in the detection of the
gallbladder disease.
A HIDA scan stands for
hepatobiliary iminodiacetic
acid scan, creates pictures of your
liver, gallbladder, biliary tract and
small intestine. A HIDA scan can
also be called cholescintigraphy,
hepatobiliary scintigraphy or
hepatobiliary scan. A HIDA scan is
a type of imaging study called a
nuclear medicine scan.

23. Normal pulmonary ventilation
and perfusion (V/Q) scan. The
nuclear medicine V/Q scan is
useful in the evaluation of
pulmonary embolism.
A ventilation/perfusion lung scan, also called a V/Q lung scan, is
a type of medical imaging using scintigraphy and medical
isotopes to evaluate the circulation of air and blood within a
patient's lungs in order to determine the ventilation/perfusion ratio.
The ventilation part of the test looks at the ability of air to reach all
parts of the lungs, while the perfusion part evaluates how well blood
circulates within the lungs. As Q in physiology is the letter used to
describe bloodflow the term V/Q scan emerged.

24. Thyroid scan with iodine-123 for
evaluation of hyperthyroidism.

25. 3D: SPECT is a 3D tomographic technique that uses
gamma camera data from many projections and can be
reconstructed in different planes. Positron emission
tomography (PET) uses coincidence detection to image
functional processes
A nuclear medicine SPECT liver scan is
undertaken with technetium-99m labeled
autologous red blood cells. A focus of high
uptake (arrow) in the liver is consistent with a
hemangioma.
Maximum intensity projection (MIP) of a whole-
body positron emission tomography (PET)
acquisition of a 79 kg female after intravenous
injection of 371 MBq of 18F-FDG (one hour
prior measurement).

26. Radioactivity or the strength of radioactive source is
measured in units of becquerel (Bq). 1 Bq = 1 event
of radiation emission or disintegration per second. One
becquerel is an extremely small amount of radioactivity. ...
1 kBq = 1000 Bq, 1 MBq= 1000 kBq, 1 GBq =
1000 MBq.
The becquerel succeeded the curie (Ci), an older, non-SI
unit of radioactivity based on the activity of 1 gram of
radium-226. ... 1 Ci =3.7×1010 Bq = 37 GBq. 1 μCi =
37,000 Bq = 37 kBq. 1 Bq =2.7×10−11 Ci =2.7×10−5 µCi.
1 MBq = 0.027 mCi.

27. Nuclear medicine tests differ…
from most other imaging modalities in that diagnostic tests
primarily show the physiological function of the system being
investigated as opposed to traditional anatomical imaging such as
CT or MRI. Nuclear medicine imaging studies are generally more
organ-, tissue- or disease-specific (e.g.: lungs scan, heart scan,
bone scan, brain scan, tumor, infection, Parkinson etc.) than those
in conventional radiology imaging, which focus on a particular
section of the body (e.g.: chest X-ray, abdomen/pelvis CT scan,
head CT scan, etc.). In addition, there are nuclear medicine studies
that allow imaging of the whole body based on certain cellular
receptors or functions. Examples are whole body PET
scans or PET/CT scans, gallium scans, indium white blood cell
scans, MIBG and octreotide scans.

28. An MIBG Scan is a nuclear medicine scan which involves
an injection of a liquid radioactive material called iodine-123-
meta-iodobenzylguanidine – MIBG for short. The radioactive
material is injected into a vein on the front of your arm at the
level of your elbow or in the back of your hand.

29. Care of Patients with
Musculoskeletal Problems

30. Osteoporosis
• Chronic metabolic disease, in which bone
loss causes decreased density and possible
fracture
• Osteopenia (low bone mass), which occurs
when osteoclastic activity is greater than
osteoblastic activity

31. Osteoporosis (Cont’d)

32. Osteoporosis (Cont’d)
• Etiology and genetic risk
• Genetic considerations
• Incidence/prevalence
• Cultural considerations

33. Classification of Osteoporosis
• Generalized osteoporosis occurs most
commonly in postmenopausal women and
men in their 60s and 70s.
• Secondary osteoporosis results from an
associated medical condition such as
hyperparathyroidism, long-term drug
therapy, long-term immobility.
• Regional osteoporosis occurs when a limb
is immobilized.

34. Health Promotion/Illness
Prevention
• Teaching should begin with young women
who begin to lose bone after 30 years of
age.
• The focus of osteoporosis prevention is to
decrease modifiable risk factors.
• Ensure adequate calcium intake.
• Avoid sedentary lifestyle.
• Continue program of weight-bearing
exercises.

35. Assessment
• Physical assessment
• Psychosocial assessment
• Laboratory assessment
• Imaging assessment:
– DXA Bone Densitometry (DEXA, DXA), Dual-energy X-ray
absorptiometry
– QCT Computed Quantitative Computer Tomography (QCT) are
capable of measuring the bone's volume
– QUS……………………..

36. Osteoporosis: Interventions
• Nutrition therapy
• Exercise
• Other lifestyle changes

37. Osteoporosis: Drug Therapy
• Calcium and vitamin D supplements
• Estrogen or hormone therapy
• Bisphosphonates (drugs used to slow or prevent bone
damage) in early breast cancer.
• Selective estrogen receptor modulators
• Calcitonin
• Other agents used with varying results

38. Osteoporosis: Surgical
Interventions
• Vertebroplasty
• Kyphoplasty
Vertebroplasty and kyphoplasty are minimally invasive
procedures used to treat vertebral compression fractures
(VCF) of the spine. These painful, wedge-shaped fractures
can be caused by osteoporosis and injury. Left untreated,
they can lead to a humped spine (kyphosis).

39. Osteomalacia
• Loss of bone related to vitamin D
deficiency
• Bone softens because of inadequate deposits
of calcium and phosphorus in the bone
matrix
• Rickets
Rickets is defective mineralization or calcification of bones before
epiphyseal closure in immature mammals due to deficiency or
impaired metabolism of vitamin D, phosphorus or calcium,
potentially leading to fractures and deformity. Rickets is among the
most frequent childhood diseases in many developing countries.

40. Collaborative Care
• Assessment
• The major treatment for osteomalacia is
vitamin D

41. Paget’s Disease of the Bone
• Chronic metabolic disorder in which bone is
excessively broken down and reformed
• Genetic considerations
• Collaborative care:
– Physical assessment
– Diagnostic assessment
Paget's disease of bone interferes with your body's normal
recycling process, in which new bone tissue gradually replaces old
bone tissue. Over time, the disease can cause affected bones to
become fragile and misshapen. Paget's disease of bone most
commonly occurs in the pelvis, skull, spine and legs.

43. Paget’s Disease: Nonsurgical
Management
• Analgesics
• Decrease bone resorption
• Selected bisphosphonates
• Calcitonin
• Plicamycin
• Diet therapy
• Nonpharmacologic pain-relief measures

44. Paget’s Disease: Surgical
Management
• Tibial osteotomy
• Partial or total joint replacement
• Surgical decompression and stabilization of
the spine

45. Osteomyelitis
• Infection in bony tissue
A sequestrum (plural: sequestra) is a piece of dead bone that has
become separated during the process of necrosis from normal or
sound bone. It is a complication (sequela) of osteomyelitis.

46. Osteomyelitis: Collaborative Care
• Assessment
• Antibiotic therapy
• Hyperbaric oxygen therapy
• Surgical management:
– Sequestrectomy
– Microvascular bone transfers
Hyperbaric oxygen therapy is a well-
established treatment for decompression sickness, a hazard of
scuba diving. Other conditions treated with hyperbaric oxygen
therapy include serious infections, bubbles of air in your blood
vessels, and wounds that won't heal as a result of diabetes or
radiation injury.

47. Benign Bone Tumors
• Often asymptomatic and may be discovered
on routine x-ray or as a cause of pathologic
fracture:
– Chrondrogenic tumors—from cartilage
– Osteogenic tumors—from bone
– Fibrogenic tumors—from fibrous tissue; most
commonly found in children
(Chondrification (also known as chondrogenesis) is the process
by which cartilage is formed from condensed mesenchyme tissue,
which differentiates into chondrocytes and begins secreting the
molecules that form the extracellular matrix.)

48. Interventions
• Non-drug pain-relief measures
• Drug therapy—analgesics, NSAIDs
• Surgical therapy—curettage (simple
excision of the tumor tissue), joint
replacement, or arthrodesis
Curettage in medical procedures, is the use of a curette (French,
meaning scoop) to remove tissue by scraping or scooping.
Curettages are also a declining method of abortion. It has been
replaced by vacuum aspiration over the last decade.
Arthrodesis, also known as artificial ankylosis or syndesis, is
the artificial induction of joint ossification between two bones by
surgery. This is done to relieve intractable pain in a joint which
cannot be managed by pain medication, splints, or other
normally indicated treatments.

49. Bone Cancer
• Primary tumors
• Metastatic lesions
• Pathophysiology
• Assessment
• Nonsurgical management:
– Drug therapy
– Radiation therapy

50. Bone Cancer: Surgical
Management
• Preoperative care
• Operative procedure
• Postoperative care

51. Bone Cancer: Community-
Based Care
• Home care management
• Health teaching
• Health care resources

52. Disorders of the Hand
• Dupuytren's contracture—slowly
progressive contracture of the palmar fascia
resulting in flexion of the fourth or fifth
digit of the hand

53. Ganglion
• Round, benign cyst often found on a wrist
or foot joint or tendon

55. Disorders of the Foot
• Hallux valgus
• Hammertoe
• Morton’s neuroma
• Tarsal tunnel syndrome
• Plantar fasciitis
• Other problems of the foot
Morton's neuroma is thickening of the tissue around the nerve
between the bases of the toes (usually between the third and fourth
toes). Foot pain, odd sensations, or numbness over the ball of the
foot are the usual symptoms. It is more common in women and can
be a result of wearing high heels or tight shoes.

56. Tarsal tunnel syndrome (TTS), also known as posterior tibial
neuralgia, is a compression neuropathy and painful foot condition
in which the tibial nerve is compressed as it travels through
the tarsal tunnel. This tunnel is found along the inner leg behind
the medial malleolus (bump on the inside of the ankle).
Plantar fasciitis (say "PLAN-ter fash-ee-EYE-tus") is the most
common cause of heel pain. The plantar fascia is the flat band of
tissue (ligament) that connects your heel bone to your toes. It
supports the arch of yourfoot. If you strain your plantar fascia, it
gets weak, swollen, and irritated (inflamed).

57. Scoliosis
• Changes in muscles and ligaments on the
concave side of the spinal column
Pathophysiology
History
Treatment of children
Treatment of adults

58. Progressive Muscular
Dystrophies
• Pathophysiology
• Genetic considerations
• Diagnosis
• Management
• Nursing interventions