This document discusses various types of musculoskeletal trauma, diseases, and alterations. It covers bone fractures, dislocations, infections, tumors, and soft tissue injuries. Specific conditions covered include osteoporosis, rickets, Paget's disease, osteomyelitis, tuberculosis, osteosarcoma, ligament injuries, tendon injuries, and muscle strains. Treatment options are provided for many conditions, which may include surgery, antibiotics, chemotherapy, calcium supplements, and physical therapy.

1. CHAPTER 51
ALTERATIONS IN
MUSCULOSKELETAL FUNCTION:
TRAUMA, INFECTION, AND
DISEASE

2. BONE AND JOINT TRAUMA
• Bones protect internal organs, contribute to
mineral homeostasis, produce blood cells,
and provide muscle attachment sites that
facilitate body movement
• Bone is one of the body’s hardest structures,
and most dynamic and metabolically active
tissues
• It is vascular with a capacity for repair

3. TYPES OF BONE
• Cortical bone forms the cortex (outer shell) of
the bone; when tension stress exceeds the
tolerance of cortical bone, fracture can
occur on the convex side of the bend
• Cancellous bone is found in the interior of the
bone and has a spongy, or lattice-like
appearance; provides structural support but
does not tolerate compression stress

4. FRACTURE
• A fracture is a break in continuity of a bone,
an epiphyseal plate, or a cartilaginous joint
surface
• Trauma may also occur to adjacent tissue

5. FRACTURE (CONT.)

6. TYPES OF FRACTURE
• Different types of fracture depend on the
type of tension stress involved
• Fractures can be classified according to the
orientation of the break as transverse,
longitudinal, oblique, or spiral
• A comminuted fracture consists of more than
one fracture line and more than two bone
fragments
• A greenstick fracture is an incomplete break

7. EXTENT OF FRACTURE
• A nondisplaced fracture occurs when the
fragments remain in alignment and position,
whereas a displaced fracture is one in which
the ends of fracture fragments are separated
• Fractures are classified as open or compound
when the skin is penetrated and as closed or
simple when the skin is not broken

8. HEALING PROCESS
• Cortical bone fracture results in torn blood
vessels within the haversian system
• Clotting occurs at the fracture site
• Avascular bone is replaced by living bone
through resorption and bone deposition
• Callus formation leads to new bone formation
at the edges of the periosteum
• Remodeling occurs with replacement of
mature lamellar bone

9. HEALING PROCESS (CONT.)

10. COMPLICATIONS IN BONE
HEALING
• Delayed healing can include delayed union,
malunion, or nonunion
• Treatment includes bone grafting,
internal/external fixation, electrical bone
stimulation, or a mixture of these
• Soft tissue complications may include
compartment syndrome or neovascular injury

11. DISLOCATIONS AND
SUBLUXATIONS
• Complete separation of joint articulating
surfaces is termed dislocation
• Subluxation refers to partial separation
• A considerable amount of tissue damage
occurs with dislocation or subluxation
• Evaluation of fracture is necessary

12. SCOLIOSIS
• Lateral curvature of the spine resulting in an S-
or a C-shaped spinal column with vertebral
column
• Nonstructural scoliosis resolves when the
patient bends to the affected side; structural
scoliosis fails to correct itself on forced
bending against the curvature and has
vertebral rotation
• Treatment may include bracing, exercises, or
surgical interventions with spinal alignment,
fusion, and internal fixation

13. ALTERATIONS IN BONE MASS
AND STRUCTURE

14. OSTEOPOROSIS
• The most common metabolic disease that
occurs when the rate of bone resorption is
greater than that of bone formation
• Hormone deficiencies (estrogen, androgen),
poor calcium intake, and lack of use are
common factors in the rate of bone loss
• Treatment may include calcium and vitamin
D supplements, exercise, estrogen
replacement therapy, bisphosphonates, or
recombinant human parathyroid hormone

15. RICKETS AND OSTEOMALACIA
• Vitamin D deficiency is associated with rickets
and osteomalacia, disorders characterized
by soft, weak bones
• Osteomalacia due to an inadequate
concentration of vitamin D, calcium or
phosphorus, poor vitamin D metabolism,
and/or renal disease
• Treatment includes vitamin D, calcium, or
phosphorus supplementation

16. PAGET DISEASE
• May be genetic or due to a viral infection
that affects osteoclastic function leading to
aberrant bone remodeling
• Painful bone deformities or bone fractures
may develop
• During active stages treatment is focused on
preventing deformity and fracture with
calcitonin or bisphosphonates

17. INFECTIONS OF THE BONE
• Hematogenous osteomyelitis occurs when
the infectious agent is introduced by blood
from infection elsewhere in the body
• May occur due to burns, sinus disease,
trauma, malignant tumor necrosis,
periodontal infection or an infected pressure
ulcer
• Staphylococcus aureus most common
pathogen

18. INFECTIONS OF THE BONE
(CONT.)
• Direct infection can occur due to open
fracture, penetrating wounds, surgical
contamination, or insertion of prostheses,
metal plates, or screws

19. OSTEOMYELITIS
• Severe pyogenic infection of bone and local
tissue
• Organisms reach the bone through the
bloodstream, adjacent soft tissue or direct
introduction of the organism into the bone
• Treatment: 4-6 wk of antibiotic therapy;
abscess formation may require debridement;
chronic infection may occur

20. TUBERCULOSIS
• Infection is spread via lung or
lymphohematogenous drainage due to
Mycobacterium tuberculosis
• Most common site is the vertebral column
• Treatment includes long-term combination
antibiotic therapy for 9-12 months; may be
complicated by drug resistance; surgical
intervention may be needed for severe
deformities or neurologic deficits

21. BONE TUMORS
• Neoplasms can be benign or malignant
• Malignant neoplasms are referred to as
sarcomas
• Metastatic lesions spread to bone from
primary carcinomas
• Common sites are the vertebral bodies,
pelvis, proximal ends of the femur and
humerus, and ribs

22. OSTEOCHONDROMA
• Most common bone tumor
• Cartilage-forming benign tumor that is
hereditary and usually occurs in those >30
years of age
• Pressure on surrounding tissue can cause pain
• Usually located on the metaphyses of long
bones, such as the proximal end of the tibia
and distal part of the femur, the shoulder,
and pelvis

23. CHONDROMA
• Cartilage-forming tumor in bone that can be
located in the medullary cavity or in the
subperiosteal layers of bone
• Arises from remnants of epiphyseal cartilage
• Typically located in the small bones of the
hands and feet
• May erode cortex of bone and expand the
contour
• Usually occurs in those 30-40 years of age

24. OSTEOID OSTEOMA
• A painful but benign bone-forming tumor
• Pain is usually sharp or dull, worse at night,
and alleviated by aspirin or NSAIDs
• Often found in the cortex of the tibia and
femur
• Usually occurs in those 10-20 years of age

25. GIANT CELL TUMOR
• A benign but aggressive tumor with richly
vascularized tissue consisting of plump
spindle-shaped cells and numerous giant cells
• Can undergo transformation to sarcomas
• Occurs between 20 and 40 years of age
• Located in distal end of the femur, proximal
end of the tibia, distal part of the radius, and
proximal end of the humerus

26. OSTEOSARCOMA
• Extremely malignant bone-forming tumor and
most common primary malignant bone tumor
• Formation of bone or osteoid by tumor cells
• Occurs in children and young adults
• Located in distal end of the femur, proximal
end of the tibia, fibula, humerus and flat
bones of the pelvis, skull, scapula, ribs, or
spine

27. OSTEOSARCOMA (CONT.)
• Treated with conservative surgery and
chemotherapy; may require amputation

28. CHONDROSARCOMA
• Malignant cartilage-forming tumor that
develops slowly; tends to develop in the
pelvic and shoulder girdles and the proximal
ends of long bones
• Characterized by formation of cartilage by
tumor cells
• Occurs in those 30-60 years of age

29. EWING SARCOMA
• Third most common primary sarcoma; a
rapidly growing malignant round cell tumor
• Develops in the long bones of children
• Composed of densely packed small cells with
round nuclei, may metastasize to lungs; pain
is a dominant symptom
• Treatment includes radiotherapy and possible
adjunct surgical therapy

30. MULTIPLE MYELOMA
• Slowly growing bone marrow malignancy
with neoplastic proliferation of a single clone
of plasma cells
• Homogeneous immunoglobulin is present in
urine and serum
• Pain is predominant symptom
• Treatment often requires aggressive
combination chemotherapy or local
radiation

31. SOFT-TISSUE INJURIES
• Contractile tissue is composed of structures
involved in the contraction of muscle and
includes not only the muscle belly but also the
tendon and bony insertion
• Inert tissue possesses no ability to contract or
relax

32. LIGAMENT INJURIES
• Occur when loading exceeds the physiologic
range of motion
• Microfailure precedes total failure
• Classified by extent of tear: mild, moderate,
or severe
• Symptoms occur as pain with weight bearing
and acute swelling
• Treatment dependent on degree of tear;
surgical restoration of ligament continuity
may be required in severe injury

33. JOINT CAPSULE INJURIES
• Injury causes increase in vascularity and
development of fibrous tissue leads to a thick
capsule
• Injury or edema in the joint that causes
scarring in the lax section of the capsule
prevents full range of motion
• Altered flow of synovial fluid prevents fluid
diffusion into and out of cartilage and causes
compression and distention

34. JOINT CAPSULE

35. INJURIES TO FASCIAE AND
BURSAE
• Fasciae are connective tissues of the body
arranged in sheaths that envelop muscles
• Bursae are pockets of connective tissue lined
with synovium in locations between muscles
or between muscle or tendon and bone

36. INJURIES TO NERVES, NERVE
ROOTS, AND DURA MATER
• Trauma to any soft tissue may lead to
adhesive constriction of the nerve, nerve
root, or dura mater
• Irritation or entrapment of a nerve causes
pain that radiates along the structures
innervated by the nerve
• Symptoms include altered sensation, motor
weakness, and diminished reflexes

37. INJURIES TO NERVES, NERVE
ROOTS, AND DURA MATER
(CONT.)

38. INJURY TO TENDONS
• Range from mild to complete tear
• Tendinitis may develop from infection, direct
injury or injury from repetitive motion
• Tendons are injured when the stress placed
on them is greater than the fibers can
tolerate

39. MUSCLE AND TENDON
STRAINS
• Categorized by the severity of injury
• Grade I: minute tear of connective tissue and
muscle fiber
• Grade II: tear of a large portion of the contractile
unit, with a segment still intact
• Grade III: total rupture or loss of continuity of the
contractile structure

40. BLUNT TRAUMA
• Can cause bleeding into the muscle belly;
may lead to an inability to contract the
muscle; may coagulate and calcify; results in
myositis ossificans
• Calcification prevents a normal and strong
contraction of the muscle involved

41. COMPARTMENT SYNDROME
• Results from trauma to soft tissue caused by
the unyielding structure of inert tissue
• Causes: decreased compartment size,
increased compartment content, or
externally applied pressure
• Edema causes increase in pressure in the
compartment; pressure reduces capillary
flow; muscle and nerves become ischemic
• Symptoms may include pain, paresthesia,
pale skin, and diminished pulse

42. EVALUATION OF
CONTRACTILE INJURIES
• Patterns of function deal with pain and
strength rather than excessive motion noted
during evaluation of ligamentous injury
• Strong and pain free
• Strong and painful
• Weak and painful
• Weak and pain free

43. SOFT-TISSUE HEALING AFTER
TRAUMA
• Disruption of circulatory and lymphatic
systems; hemorrhage, fluid loss, cell death
• Norepinephrine causes constriction of vessels;
serotonin and platelets prolong
vasoconstriction
• Inflammation; release of histamines causes
vasodilation and increased permeability of
venules

44. WOUND REPAIR
• Inflammatory response prepares injured tissue
• Granulation tissue develops in the wound
space
• Reepithelialization of the wound surface
occurs; formation of basement membrane
• Wound tensile strength is a result of deposition
of collagen
• Revascularization ensures survival of the new
tissue

45. WOUND REPAIR (CONT.)
• Wound closure or contraction is the final
phase of healing

46. DISEASES OF SKELETAL MUSCLE
• Skeletal muscle most abundant tissue in the
body; accounts for 40% of body weight
• Skeletal muscle performs dynamic and static
work
• Muscle atrophies in response to disuse and
immobilization, and hypertrophies in response
to increased stress

47. MUSCULAR DYSTROPHY
• A group of genetically determined
myopathies characterized by progressive
muscle weakness and degeneration
• Muscle tissue is replaced by fat and fibrous
connective tissue
• Classified by the pattern of inheritance, age
of onset, and distribution of muscular
weakness

48. DUCHENNE MUSCULAR
DYSTROPHY
• Most common and most severe form
• Inherited as X-linked trait, thus affects only
men
• Muscle cells are deficient in the protein
dystrophin; weakens the cell membrane and
allows extracellular fluid to leak into the cell
• Calf muscles enlarged, distal muscle
involvement
• Treatment includes corticosteroid therapy
and preservation of function

49. BECKER MUSCULAR
DYSTROPHY
• Milder form of inherited muscle degeneration
• Genetic mutation leads to production of a
reduced amount of an abnormal dystrophin
protein and slower muscular degeneration
• Calf hypertrophy prominent, often painful,
with progressive loss of strength and ability to
ambulate

50. FACIOSCAPULOHUMERAL
MUSCULAR DYSTROPHY
• Rare inherited autosomal dominant trait that
affects the muscles of the shoulder girdle and
face
• Facial muscles involved early with later
involvement of scapular and upper arm
musculature
• Progresses slowly with periods of arrest and
can ultimately involve more distal muscles

51. MYASTHENIA GRAVIS
• Chronic autoimmune disease; affects the
neuromuscular function of voluntary muscles
and characterized by profound muscle
weakness and fatigability
• Acetylcholine receptor antibodies produced
that destroy or block acetylcholine receptors
of the muscle end-plate of the neuromuscular
junction

52. MYASTHENIA GRAVIS (CONT.)
• Anticholinesterase inhibitors, corticosteroids,
intravenous immune globulin, plasmapheresis,
and immunosuppressive agents may be used

53. FIBROMYALGIA SYNDROME
• Cause remains unknown
• Characterized by widespread pain in all
quadrants of the body; additional symptoms
may include fatigue, insomnia, depression,
and concentration problems
• Treatment is multidimensional including
exercise, counseling, and drug therapy to
improve sleep, mood, and pain