BIOS222 Pathology and Clinical Science 2 & 3

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2 BIOS222 Pathology and Clinical Science 2 & 3 Session 12 Disorders of Musculoskeletal System 3 Bioscience Department

3 Session Learning Outcomes At the end of the session, student should be able to: o Define Septic arthritis and Osteomyelitis. Discuss the causes, clinical features, investigations, and management for both conditions. o Define Osteoporosis. Explain the risk factors, pathophysiology, clinical features, investigations, and management of osteoporosis. o Define Osteomalacia and Rickets. Describe the causes of Osteomalacia and Rickets. o Discuss pathophysiology, clinical features, diagnosis and management of Vitamin D deficiency Osteomalacia and Rickets. Endeavour College of Natural Health 3

4 Session Learning Outcomes o Define Paget s disease and identify its clinical features. Explain its pathophysiology and discuss the investigation and management of Paget s disease. o Discuss primary and secondary bone tumours. Describe characteristic features of bone tumours. o Discuss the causes, pathophysiology, clinical features, investigations, and management of fibromyalgia. Endeavour College of Natural Health 4

5 Session Plan o Bone and Joint Infection Septic arthritis Osteomyelitis o Diseases of Bone Osteoporosis Osteomalacia and Rickets Paget s disease Bone tumours o Fibromyalgia Endeavour College of Natural Health 5

6 Bone and Joint Infection Endeavour College of Natural Health 6

7 Septic Arthritis o Definition: Septic arthritis is the invasion of the joint space by an infectious agent which produces arthritis o Aetiology: Staphylococcus aureus Neisseria gonorrhoeae Gram-negative bacilli Group A Streptococci Other Streptococci, Pneumococci, Meningococci Haemophilus influenzae (rare causes) o Risk factors: Increasing age Pre-existing joint disease (principally RA), Diabetes mellitus, Immunosuppression Intravenous drug misuse Endeavour College of Natural Health 7

8 Septic Arthritis o Clinical features: Acute or subacute monoarthritis with fever. Multiple joint involvement in patients with preexisting arthritis Swollen, hot and red joint with pain at rest and on movement. Lower limb joints, such as the knee and hip, are commonly targeted. o Diagnosis: Synovial fluid analysis Blood cultures Haematology: WBC, ESR, CRP Endeavour College of Natural Health 8

9 o Management: Septic Arthritis Treated as a medical emergency Hospitalisation Urgent investigations Intravenous antibiotic Pain relief through Oral and/or intravenous analgesics and local ice-packs Joint aspiration and arthroscopic drainage Physiotherapy Endeavour College of Natural Health 9

10 Osteomyelitis o Definition: Osteomyelitis represents an acute or chronic infection of the bone and bone marrow. o Aetiology: Staphylococci Pseudomonas Mycobacterium tuberculosis o Risk factors: Diabetes mellitus (especially involving the foot), Compromised immunity (including AIDS) and sickle cell disease Endeavour College of Natural Health 10

11 Osteomyelitis o Clinical features: Localised bone pain and tenderness, Often accompanied by malaise, night sweats and pyrexia. Adjacent joint may be painful to move and may develop a sterile effusion or secondary septic arthritis o Diagnosis: X-ray MRI Blood cultures o Management: Parenteral and oral antibiotics Bone resection and reconstruction Endeavour College of Natural Health 11

12 Diseases of Bone Endeavour College of Natural Health 12

13 Osteoporosis o Definition: It is a metabolic bone disease characterized by a loss of mineralized bone mass causing increased porosity of the skeleton and susceptibility to fractures. o Risk factors: Genetic predisposition Age Gender Hormonal Imbalance Activity level Nutritional status Endocrine disorders Malabsorption disorders Malignancies Smoking Alcoholism Certain medications Endeavour College of Natural Health 13

14 Osteoporosis o Include: Age related osteoporosis Post menopausal osteoporosis Osteoporosis in men Secondary osteoporosis Corticosteroid induced osteoporosis Juvenile osteoporosis o Pathophysiology: Defect in attaining peak bone mass and/or accelerated bone loss the bone mineral density (BMD) is reduced bone micro architecture is disrupted the amount and variety of non-collagenous proteins in bone is altered porous bones increased risk for fractures Endeavour College of Natural Health 14

15 o Clinical features: Osteoporosis Asymptomatic until a fracture occurs Spinal fracture: Acute back pain or gradual onset of height loss and kyphosis with chronic pain. Acute vertebral fracture: pain radiating to the anterior chest or abdominal wall Peripheral osteoporotic fractures: local pain, tenderness and deformity, often after an episode of minimal trauma. Hip fracture: the affected leg is shortened and externally rotated. Endeavour College of Natural Health 15

16 Osteoporosis Femoral head of an 82-year-old woman with osteoporosis and femoral neck fracture (right), compared with a normal control bone cut to the same thickness (left). Grossman, S, Porth, CM 2013, Porth s pathophysiology, Concepts of Altered Health States, 9th edn, Lippincott Williams & Wilkins Endeavour College of Natural Health 16

17 o Diagnosis: Osteoporosis Bone densitometry/dual energy X-ray absorptiometry (DEXA) Clinical history Investigations for suspected underlying risk factors Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Osteoporotic fractures: X- rays of Wrist (Colles fracture) and Hip. Endeavour College of Natural Health 17

18 Osteoporosis o Management: Non-pharmacological: smoking cessation, moderation of alcohol intake, adequate dietary calcium intake and exercise measures to prevent fractures Pharmacological Bisphosphonates Calcium and vitamin D Hormone replacement therapy Endeavour College of Natural Health 18

19 Osteomalacia & Rickets o Definition: Osteomalacia describes a syndrome in adults of defective bone mineralisation, bone pain, increased bone fragility and fractures. Rickets is the equivalent syndrome in children and is characterised by enlargement of the growth plate and bone deformity. o Aetiology: Vitamin D deficiency Failure of 1,25 vitamin D synthesis Vitamin D receptor defects Defects in phosphate and pyrophosphate metabolism Iatrogenic and other Endeavour College of Natural Health 19

20 Vitamin D deficiency Osteomalacia & Rickets o Pathophysiology: Prolonged vitamin D deficiency Reserves of 25(OH)D become progressively depleted (through increased conversion of 25(OH)D to 1,25(OH)2D), Hypocalcaemia and hypophosphataemia progressive demineralisation of the skeleton and the clinical syndromes of osteomalacia and rickets. Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 20

21 o Clinical features: In children Vitamin D deficiency Osteomalacia & Rickets Delayed development Muscle hypotonia Craniotabes Bossing of the frontal and parietal bones and delayed anterior fontanelle closure, Enlargement of epiphyses at the lower end of the radius Swelling of the rib costochondral junctions Endeavour College of Natural Health 21

22 o Clinical features: In adults: Vitamin D deficiency Osteomalacia & Rickets Mild osteomalacia: Asymptomatic or present with fractures and mimic osteoporosis Severe Osteomalacia: Muscle and bone pain, general malaise and fragility fractures. Proximal muscle weakness is prominent and the patient may walk with a waddling gait and struggle to climb stairs or get out of a chair. bone and muscle tenderness on pressure and focal bone pain can occur due to fissure fractures of the ribs and pelvis. Endeavour College of Natural Health 22

23 Vitamin D deficiency o Diagnosis: Osteomalacia & Rickets Serum 25(OH)D and PTH Serum ALP SERUM calcium and phosphate X-rays Radionuclide bone scan Bone biopsy o Management: Vitamin D Photomicrograph of bone biopsy from osteomalacic patient showing thick osteoid seams (stained light blue) that cover almost all of the bone surface. Calcified bone is stained dark blue. Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 23

24 Paget s Disease o Definition: Paget s disease of bone (PDB) is a common condition characterised by focal areas of increased and disorganised bone remodelling, mostly affecting the axial skeletal (pelvis, femur, tibia, lumbar spine, skull and scapula). o Aetiology: Genetic factors SQSTM1 gene mutation Environmental factors: Slow virus infection with measles (paramyxovirus) Endeavour College of Natural Health 24

25 Paget s Disease o Pathophysiology: Osteoclasts are increased in number, are unusually large and contain characteristic nuclear inclusion bodies Increased osteoclastic bone resorption Increased osteoblast activity V Poor quality and disorganized bone formation, marrow fibrosis, increased vascularity of bone Mosaic-like pattern in bone Abnormal bone with reduced mechanical strength o Clinical features: Bone pain Bone deformity Deafness Pathological fractures o Complications: Neurological problems Cardiac failure Osteosarcoma Endeavour College of Natural Health 25

26 Paget s Disease Grossman, S, Porth, CM 2013, Porth s pathophysiology, Concepts of Altered Health States, 9th edn, Lippincott Williams & Wilkins Endeavour College of Natural Health 26

27 Paget s Disease o Diagnosis: Serum ALP X-rays Radionuclide bone scan Bone biopsy o Management: Inhibitors of bone Resorption: Aminobisphosphonates Bisphosphonates Calcitonin Nonsteroidal or other antiinflammatory The typical radiographic features with expansion of the femur, alternating areas of osteosclerosis and radiolucency of the trochanter, and pseudofractures breaching the bone cortex (arrows). Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 27

28 Bone Tumours o Primary bone tumours: Rare, have a peak incidence in childhood and adolescence, and can be benign or malignant. Benign: Osteoid osteoma, Chondroma, Osteochondroma Malignant: Osteosarcoma, Chondrosarcoma o Secondary bone tumours: Metastatic tumours which have spread from other organs, such as the breast, lung, and prostate. o Clinical features: Pain Presence of a mass Impairment of function Endeavour College of Natural Health 28

29 Fibromyalgia Endeavour College of Natural Health 29

30 Fibromyalgia o Definition: It is a common cause of generalised regional pain and disability, and is frequently associated with medically unexplained symptoms in other systems. o Risk factors: Life events that cause psychosocial distress: Marital disharmony, Alcoholism in the family, Injury or assault, low income Self-reported childhood abuse Endeavour College of Natural Health 30

31 Fibromyalgia o Pathophysiology: Two consistently reported abnormalities: Sleep abnormality Abnormal peripheral and central pain processing Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 31

32 Fibromyalgia o Clinical features: Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 32

33 Fibromyalgia Diagnosis: There are no abnormalities on routine blood tests or imaging, but it is important to screen for other conditions that could contribute to some of the patient s symptoms. Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 33

34 Fibromyalgia o Management: Patient education Pain control Improve sleep: Sleep medication Aerobic exercise Self-help strategies Cognitive behavioural approach Appropriate counselling Endeavour College of Natural Health 34

35 Reading and Resources o o o o o o o Crowley LV, 2012, An Introduction to Human Diseases Pathology and Pathophysiology Correlations, 9th edn, Jones and Bartlett Learning Grossman SC & Porth CM 2014, Porth s Pathophysiology- Concepts of Altered Health States, 9th edn. Wolters Kluwer Health - Lippincott, Williams & Wilkins Hinson, J, Raven, P & Chew, S 2010, The endocrine system: basic science and clinical conditions, 2nd edn, Churchill Livingstone Elsevier, Edinburgh Jamison, JR 2006, Differential diagnosis for primary care: a handbook for health care practitioners, 2nd edn, Churchill Livingstone Elsevier, Edinburgh. Jarvis, C, 2012 Physical Examination & Health Assessment, 6th ed., Elsevier Saunders, Philadelphia. Kumar, P & Clark, M 2012, Kumar and Clark s clinical medicine, 8th edn, Saunders Elsevier, Edinburgh. Kumar, V, Abbas, AK & Aster, JC 2015, Robbins & Cotran pathologic basis of disease, 9th edn, Elsevier Saunders, Philadelphia. Endeavour College of Natural Health 35

36 o o o o o o Reading and Resources Lee, G & Bishop, P 2009, Microbiology and infection control for health professionals, 4th edn, Pearson Education, Frenchs Forest, NSW. McCance, KL, Heuther, SE, & Brashers, VL 2014, Pathophysiology: the biologic basis for disease in adults and children, 7th edn, Elsevier. Michael-Titus, A, Revest, P & Shortland, P 2010, The nervous system: basic science and clinical conditions, 2nd edn, Churchill Livingstone Elsevier, Edinburgh Mosby s dictionary of medicine, nursing and health professions 2013, 9th edn, Elsevier, St. Louis, MO. Tortora, GJ & Derrickson, B 2014, Principles of anatomy and physiology, 14th edn, John Wiley & Sons, Hoboken, NJ. VanMeter, KC & Hubert, RJ 2014, Gould's pathophysiology for the health professions, 5th edn, Elsevier, St Louis, MO. o Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh. Endeavour College of Natural Health 36

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