Musculoskeletal System KNH 413. Skeletal System Cartilage, ligaments, tendons, bones Metabolically...
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Transcript of Musculoskeletal System KNH 413. Skeletal System Cartilage, ligaments, tendons, bones Metabolically...
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Musculoskeletal System
KNH 413
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Skeletal System
Cartilage, ligaments, tendons, bones
Metabolically active cells and tissue
Continual state of change
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Skeletal System
Cartilage – flexible yet firm connective tissue consisting of cells and collagen fibersChondroblasts/chondrocytes – cellsCollagen – fibrous protein, most common protein in
the bodyChondroitin sulphate – most common polysaccharide
of cartilage
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Skeletal System
Bone – osseous tissueOrganic – mineralized or calcified by inorganic
component; flexibility Inorganic - hydroxyapatite; stiffness, weight bearingReady source of calcium and phosphorus for
extracellular fluids Hydroxyapaptite (99%) Readily available pool (1%)
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Skeletal System
BoneAbnormalities in serum calcium critical
Hypocalcemia – excessive excitability of the nervous system, tetany , respiratory arrest, convulsions
Hypercalcemia – fatigue, depression, metal confusion, anorexia, nausea, vomiting, constipation, hypercalciuria
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Skeletal System
Cells of Osseous TissueOsteogenic cells – stem cells that differentiate into
osteoblastsOsteoblasts - bone-building cellsOsteocytes – mature osteoblasts, majority of cells in
boneOsteoclasts – bone-removing cells that secrete HCl;
bone resorption
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Skeletal System
Skeletal growth and developmentContinual state of change; linear and circumferential
growth, and in response to changes in forces applied to them - remodeling
Osteoclasts remove bone from low-stress areas, osteoblasts lay down new bone in high-stress areas
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Skeletal System
Cortical boneDense, outer surface of most bones, shafts of
long bones, and caps over end of long bones75% of skeletal weight
Trabecular boneLoosely organized with a sponge-like
appearance; lattice-like pattern“Ends” of long bones, primary bone of
vertebrae, pelvis, sternum, scapula25% of skeletal weight
© 2007 Thomson - Wadsworth
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© 2007 Thomson - Wadsworth
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© 2007 Thomson - Wadsworth
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Skeletal System
Hormonal control of bone metabolismCalcium and phosphorus homeostasis
Cortisol, growth hormone, thyroid hormones Primary regulators: parathyroid hormone (PTH),
calcitonin, vitamin D
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Skeletal System
PTH – increases blood calcium when low Increase in osteoclasts and bone resorption Inhibition of collagen synthesis and bone depositionCalcium resorption by kidneysFinal step in vitamin D synthesis, enabling intestinal
absorption of calcium
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Skeletal System
Calcitonin – decreases blood calcium when high Inhibits activity of osteoclastsStimulates osteoblastsReduces renal reabsorption of calcium and
phosphate
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Skeletal System
Vitamin D – increases blood concentrations of calcium and phosphorusPromotes their absorption in GIPromotes reabsorption by kidneysStimulates osteoclast formation and release of
calcium and phosphorus from bone
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Skeletal System
Vitamin D –
Ergocalciferol - dietaryCholecalciferol – dietary,
exposure to sunlightBoth biologically inactive until
modified by liver and kidney to 1,25-dihydroxyvitamin D
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© 2007 Thomson - Wadsworth
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Osteoporosis
Decreased bone mineral and organic matrix which weakens bones, making them more susceptible to fracture and pain
Bone strength reflects:Bone densityBone quality
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© 2007 Thomson - WadsworthHealthy (L) and osteoporotic (R) trabecular bone
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OsteoporosisDiagnosis
Measures of bone mineral density (BMD)DXA – dual-energy x-ray absorptiometry “T-score” – comparing patient’s BMD to healthy young
reference populationBMD assessed at hip and lumbar spineSee WHO criteria
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© 2007 Thomson - Wadsworth
DEXA scan of the left hip
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Osteoporosis
Diagnosis
Others:Quantitative ultrasound of the heel used in
conjunction with risk assessment – useful for screening
Osteopenia – bone mineral density is low but not low enough to be classified as osteoporosis, although fracture risk is increased
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Osteoporosis
BMD increases rapidly during growth spurt (ages 11-14 y)
Maximum density reached in late 20s or 30s
Females lose BMD at faster rate than men
Rate of loss increases during menopause
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Osteoporosis
FracturesMost common sites: hip, spine, wristKyphosis – unnatural curvature of back, and loss of
height d/t compression fractures of spineHip fractures have severe impact on morbidity and
mortality 20% die within first year, 20% end up in nursing homes
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Osteoporosis
EtiologyPrimary – disease of elderly, cumulative impact of
bone mineral loss and deterioration of bone with age; “age-related,” “postmenopausal”
Secondary - disease and drug associated 2/3 of cases in men
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© 2007 Thomson - Wadsworth
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Osteoporosis
Risk factors
Genetic susceptibilityFamily hxFemale sexCaucasian racePremenopausal amenorrheaPhysical inactivityLow calcium and vitamin D intakes
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© 2007 Thomson - Wadsworth
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Osteoporosis
Prevention strategiesRisk reduction in adolescence and early adulthoodAdequate calcium and vitamin D intakeWeight-bearing exerciseFall preventionSmoking cessationAvoidance of excessive alcohol intake
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© 2007 Thomson - Wadsworth
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Osteoporosis
Calcium Maintenance of serum calcium levels to
combat bone resorptionAchieve peak bone mass and minimize bone
mineral lossLower intakes of animal protein, sodium,
caffeineIncreased consumption of fruits, vegetables,
legumes, whole grainsMore physical activitySun exposure
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OsteoporosisCalcium
Consume calcium-rich foodsCalcium-fortified foodsCalcium supplements
Calcium carbonate – least expensive, taken with meals, not at the same time as iron
Calcium citrate – taken any time Calcium with vitamin D Avoid dolomite and bonemeal – lead contamination Divided doses to improve absorption
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© 2007 Thomson - Wadsworth
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OsteoporosisVitamin D
Overt deficiency – rickets in children, osteomalacia in adults
Insufficiency found in dark-skinned, older, in northern latitudes (above 40 degree N)
Supplementation with vitamin D and calciumFortified dairy products Exposure to adequate sunlight
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OsteoporosisPhysical activity
BMD increases with weight-bearing or impact-type activity
Very high levels can be detrimental if oligomenorrhea or amenorrhea present
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OsteoporosisCigarette smoking
Lower BMD, increased bone mineral loss, increased risk of fractures
Nicotine and cadmium toxic to osteoblastsReduced intestinal calcium absorptionLower intakes of vitamin D, and lower serum vitamin
D
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OsteoporosisAlcohol
Decreased BMD, reduced bone formation, increased risk of fractures
Increased calcium and magnesium lossesAdversely impacts vitamin D and overall nutritional
status Increased risk of falls
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OsteoporosisPhosphorus – essential for bone formation
Carbonated soft-drinks have negligible effect on calcium excretion
High protein or sodium - increase urinary calcium losses
Potassium, magnesium, fruits, vegetables associated with higher BMD
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OsteoporosisMedical management
Risk factor modificationDietary treatmentDrug therapy
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© 2007 Thomson - Wadsworth
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OsteoporosisPharmacologic prevention and treatment
Estrogens/ hormone therapySelective estrogen receptor modulators (SERMs)BisphosphonatesTeriparatide (synthetic PTH)Drug-nutrient interactions
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Paget Disease
Localized, progressive, crippling disorder of bone remodeling d/t overactive osteoclasts and bone resorption followed by rapid formation of new bone which is structurally inferior
Bowing, deformity, fracture, poor healing
Upper femur, pelvis, vertebral bodies, skull, tibia
Genetic and viral factors
Adequate intake of vitamin D and calcium important
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Rickets Inadequate maturation and
mineralization of bone in children
d/t vitamin D deficiency
Risk factors – Table 27.10
Symptoms: lethargy, weakness, growth stunting, enlargement of ends of long bones and ribs, abnormally shaped thorax, bowing of legs
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Rickets
PreventionExclusively breast fed infants should receive
supplement of 200 IU vitamin DFortified infant formulas
If receiving less than 500 mL/day, should be given multivitamin supplement
After 1 year – vitamin D-fortified cow’s milk
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Rickets
TreatmentBalanced, age-appropriate dietAdequate vitamin D, calcium, phosphorus
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Osteomalacia
Organic matrix of bones inadequately mineralized in adults
Muscular weakness, bone pain, deformities of ribs, pelvis, legs
d/t vitamin D deficiency, impaired D action, calcium deficiency, hypophosphatemia
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Osteomalacia
TreatmentAddress underlying causeMultivitamin supplementationCalcium supplementationPharmacological doses of vitamin D
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Arthritic Conditions
Affect joints, tissues surrounding joints, and connective tissues
Osteoarthritis, rheumatoid arthritis, gout (affecting all ages)
Risk factors - modifiable:Overweight Joint injuries Infections
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Arthritic Conditions
Risk factors - nonmodifiable:Female sex – 60% of casesAgeFamily hx
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Osteoarthritis
Most common, leading cause of physical disability
Disease process involving all structures of the jointLoss of load-bearing articular cartilageInflammationJoint pain, stiffness, limited movement,
wasting of periarticular muscles, joint instability and deformity
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Osteoarthritis
Major risk factorsAgeFemale sexFamily hxMajor trauma to joint or soft tissueRepetitive joint stress related to occupation Obesity
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Osteoarthritis
TreatmentReduce joint inflammation & pain, maintain mobility,
minimize disability Improve body postureProper footwearWeight reductionPeriodic rest of affected jointHeatPhysical activity/ therapeutic exercise
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Osteoarthritis
TreatmentDrug therapy – pain relief
NSAIDs Glucosamine and chondroitin
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Rheumatoid Arthritis
Chronic inflammatory disease; synovial membrane becomes inflamed resulting in swelling, stiffness, pain, limited range of motion, joint deformity, disability
Characterized by periods of exacerbation and remission
Autoimmune response
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Rheumatoid Arthritis
Inflammation of joints of hands, wrists, knees, & feet results in warmth, redness, swelling, stiffness, and pain
Inflammation results in thickening of synovial membrane known as pannus – see Fig. 27.10
Enzymes from pannus digest adjacent bone and cartilage
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Rheumatoid Arthritis
TreatmentReduce pain and inflammation, protect joint,
maintain function, control systemic infectionsPharmacological agents: NSAIDs, glucocorticoids,
immunosuppressives, DMARDs
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Rheumatoid Arthritis
Diet Increase consumption of fruits and vegetables/
antioxidants Include sources of EPA and DHA (fatty acids)Fish oil supplementationExclusion of red meats, dairy, cereals, wheat glutenEvaluate and test for food allergy
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Gout
Inflammatory disease resulting in swelling, redness, heat, pain, and stiffness in affected joint
d/t elevated serum concentrations of uric acid, formation of uric acid crystalsEnd product of purine (adenine and guanine)
metabolism
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Gout
Hyperuricemia results from overproduction of uric acid, inadequate elimination by the kidneys, or combination
Most painful arthritic condition
Risk factors: genetics, male sex, older age, overweight, excessive alcohol consumption, eating foods rich in purines, exposure to lead, certain drugs
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GoutMost commonly affects great toe, instep, ankles,
heels, knees, wrists, elbows, fingers
Rapid occurrence
Sudden severe pain; swelling; shiny, red skin around joint; extreme tenderness
Typically resolves 5-10 days, may reoccur
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GoutAcute attack may be precipitated by:
Excessive exerciseCertain medications: aspirin, diuretics, nicotinic acid,
cyclosporine, levodopaPurine-rich foods Excessive alcohol consumptionCrash dieting
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© 2007 Thomson - Wadsworth
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GoutTreatment:
NSAIDs, glucocorticoids, colchicineTreat uricemiaLifestyle modifications
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FibromyalgiaChronic musculoskeletal disorder characterized by
widespread muscle pain, joint stiffness, disturbed sleep, fatigue, headache, cognitive and memory problems, paresthesias, & tender points
Not crippling, deforming, or disabling
Etiology unknown
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FibromyalgiaDg by ruling out other potential causes of
symptomsHx of pain that is widespread for at least 3 monthsExcessive tenderness or pain with pressure to at least
11 of 18 tender points
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© 2007 Thomson - Wadsworth
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FibromyalgiaTreatment
Improve sleep, treat depression, anxiety and pain, improve ability to relax
Antidepressants, counselingRegular physical activityCognitive behavioral therapy Intensive patient education
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FibromyalgiaDiet
Avoidance of certain foods has worked for someLow-sodium, uncooked vegan diet has shown promise ? MSG avoidanceLack of sound scientific evidence at this time