Hths 2231 Laboratory 13 Alterations in Musculoskeletal

Transcription

1 Watch Movie: Osteoporosis Answer the movie questions on the worksheet. Complete activities 1-4. Activity #1: Click on the website link in activity 1 to review the structure and function of bone. Activity #2: Click on the website links in activity 2 to review the structure and function of muscle. Activity #3: Using the webpath link on activity 3, complete the musculoskeletal scavenger hunt on the laboratory worksheet. Activity #4: Complete the musculoskeletal case studies on the laboratory worksheet.

2 Osteoporosis Movie 1. Osteoporosis can be defined as 2. What three areas of the skeleton are especially weakened in osteoporosis? 3. During bone remodeling damaged bone is and is replaced with. 4. At approximately what age does bone resorption begin to exceed bone formation? 5. What cells are responsible for bone resorption? 6. What cells are responsible for bone formation? 7. Bones become more dense if subjected to such as weightbearing exercises. 8. List four functions of bone. 9. What tool is used to detect bone density with a 1% degree of accuracy? 10. What 5 genetic conditions affect osteoporosis? 11. What lifestyle changes can affect environmental risk factors for osteoporosis? 12. Although there is no satisfactory treatment for osteoporosis, what replacement therapy is often used?

3 Scavenger Hunt Click on the activity 3 WebPath link. Click on the radiology link. Click on the skeletal system link? Using the images on WebPath, can you find: 1. An x-ray of a boxer s fracture? Can you locate the fracture? 2. An x-ray of a tibial and fibular fracture? 3. An x-ray of a spiral comminuted fracture? 4. A radiograph, CT scan, MRI scan, and nuclear medicine scan of: a. A bone tumor primarily found in adolescents and young adults? What type of tumor is this? Where is it primarily found? Please review all slides that apply. b. A bone tumor that infiltrates spongy bone? What type of tumor is this? What age group is this primarily found in? Treatment of choice is often? Please review all slides that apply. 5. A tumor found in middle-aged adults that will often metastasize to the lungs? Where is the tumor found in this slide? 6. A radiograph and CT scan of a tumor that originates in the bone marrow? 7. Cancers that have metastasized to the bone? Please view all slides that apply. 8. Examples of trophy formed from uric acid crystal deposits. Please view all slides that apply. 9. Examples of a disease that causes excessive resorption of spongy bone and accelerated formation of softened bone. Describe the 3 phases of this disease. 10. A condition primarily found in older women involving a loss of bone mass. 11. Examples of non-inflammatory and inflammatory joint disease. How are these disease differentiated? 12. Examples of bone infection. What is the most common organism involved in bone infection?

4 Case Studies Case #1 Mr. Jones, his wife, and their child Sally were involved in an automobile accident. Each of them suffered broken bones, scrapes and bruises. Look at the slides and match the x-ray with the correct patient. Slide 1a, Slide 1b, and Slide 1c Mr Jones. Transverse tibial fracture Mrs. Jones. Pott s fracture Sally Jones. Colles fracture Case #2 An 18 year-old man presents with a six-month history of progressive pain in his left distal thigh. He had some moderate swelling about his knee. His pain was worse at night. He did not have pain with ambulation. Radiographs demonstrated a lesion of the distal femur. See slide 2a. This radiograph demonstrates a lesion in the metaphyseal region of the distal femur. See slide 2b This bone scan demonstrates a hot spot of increased uptake in the distal left femur. a. What is the diagnosis? b. In whom and at what sites is this lesion most common? Case #3 A 29 year-old woman complains to her physician that she hasn t felt well since having the flu several months ago. She is extremely tired but often doesn t sleep well at night. She complains of generalized aching and pain. She has experienced frequent migraines and is often incapacitated for days. Her bowel movements are irregular and fluctuate between constipation and diarrhea.

5 Physical exam revealed pain to the touch at the base of the neck, muscles in upper back, upper muscles of the buttocks, knee joints, and sides of the elbows. (See slide 3). Laboratory tests are unremarkable with normal chemistry, CBC, and thyroid function. ESR is within the normal range. ANA, RA, and mono tests are negative. What condition do you suspect? Case #4 A 35 year-old man complains of lower back pain, fatigue, and decreasing range of movement. Physical exam shows severely restricted forward flexion, rotation, and lateral flexion. See slide 4a A radiograph of the spine shows fusion of vertebrate. See slide 4b Laboratory Tests are remarkable for an elevated ESR, and elevated alkaline phosphatase. Serum analysis for HLA-B 27 is positive. Your diagnosis is? Case #5 A 65 year-old man complains of pain in his left elbow and right great toe. He has a history of kidney stones. Lab results show normal CBC and chemistry values other than an elevated uric acid. See slide 5 for a radiograph of the great toe. Your diagnosis? What causes the pain he is experiencing?

6 Case #6 A 70 year-old woman fell and broke her hip. Her daughter accompanies her to the emergency room. See slide 6 for a radiograph of her opposite hip. What is the most likely cause of her broken hip? Recommend a treatment regimen to improve her condition. Can you recommend preventative measures for her daughter? Case #7 A 46-year-old man presents with progressive pain and swelling of his right hip region. The swelling is worse than the pain. On physical examination, he is mildly obese and it is difficult to assess the right hip region. Slide 7a A bone scan showed a large area of increased uptake (a "hot spot") in the right pelvic wing (seen here on the left). Slide 7b A radiograph of the pelvis demonstrates an ill-defined mass eroding the right pelvic wing and extending into soft tissue. Note the fluffy calcifications within the mass. Slide 7c A pelvic CT scan reveals an ill-defined mass eroding the right pelvic wing and extending into soft tissue. Note the calcifications within the mass. A resection was performed. It was noted that the lesion had invaded the spongy bone. What type of tumor do you suspect?

7 Case #8 A 58-year-old woman has suffered from arthritis with pain and swelling of her hands and feet that is aggravated by movement. Over the past decade she has noted increasing deformity of her hands and feet, making it difficult to walk and to perform simple daily activities such as buttoning a blouse or even combing her hair. She has no history of any trauma. Radiographs show ankylosis of the carpals (immobility) with residual evidence of MP joint erosion and decreased bone mass of the metacarpals and carpals. Physical examination reveals firm, non-tender, less than 1 cm nodules over the elbows. Slide 8a Left hand of patient. Slide 8b Radiograph of hand shows joint narrowing with marginal erosions and osteoporosis, Slide 8c Synovial fluid shows mononuclear cells with numerous lymphocytes and some scattered plasma cells. Laboratory results are remarkable for elevated ESR, and positive RA. Your diagnosis is? Why are there numerous cells in the synovial exudates?

8 ANSWERS TO OSTEOPOROSIS MOVIE 1. Osteoporosis can be defined as: LOSS OF BONE TISSUE 2. What three areas of the skeleton are especially weakened in osteoporosis? SPINE, WRISTS, HIPS 3. During bone remodeling damaged bone is and is replaced with. RESORBED, NEW BONE TISSUE 4. At approximately what age does bone resorption begin to exceed bone formation? What cells are responsible for bone resorption? OSTEOCLASTS 6. What cells are responsible for bone formation? OSTEOBLASTS 7. Bones become more dense if subjected to such as weight-bearing exercises. STRESS 8. List four functions of bone. SUPPORT WEIGHT, CONNECT MUSCLES AND TENDONS, PROTECTS VITAL ORGANS, CA RESERVOIR 9. What tool is used to detect bone density with a 1% degree of accuracy? BONE DENSITOMETER 10. What 5 genetic conditions affect osteoporosis? GENDER, AGE, RACE, SIZE, HORMONAL CHANGES 11. What lifestyle changes can affect environmental risk factors for osteoporosis? INCREASE CALCIUM AND VITAMIN D, DECREASE USE OF ALCOHOL, CAFFEINE, AND PROTEIN, INCREASE PHYSICAL ACTIVITY 12. Although there is no satisfactory treatment for osteoporosis, what replacement therapy is often used? ESTROGEN

9 ANSWERS TO SCAVENGER HUNT WORKSHEET 1. An x-ray of a boxer s fracture? Can you locate the fracture? SLIDE 141. FRACTURE OF 5 TH METACARPAL OF THE HAND 2. An x-ray of a tibial and fibular fracture? SLIDE An x-ray of a spiral comminuted fracture? SLIDE 147, A radiograph, CT scan, MRI scan, and nuclear medicine scan of: a. A bone tumor primarily found in adolescents and young adults? What type of tumor is this? Where is it primarily found? Please review all slides that apply. SLIDES 28-31, OSTEOSARCOMA. FOUND IN THE METAPHYSES OF LONG BONES. 50% ARE FOUND AROUND THE KNEE b. A bone tumor that infiltrates spongy bone? What type of tumor is this? What age group is this primarily found in? Treatment of choice is often? Please review all slides that apply. SLIDES CHONDROSARCOMA. FOUND IN MIDDLE-AGED AND OLDER ADULTS. AMPUTATION IS OFTEN TREATMENT OF CHOICE 5. A tumor found in middle-aged adults that will often metastasize to the lungs? Where is the tumor found in this slide? SLIDE 45. DISTAL FEMUR 6. A radiograph and CT scan of a tumor that originates in the bone marrow? SLIDES Cancers that have metastasized to the bone? Please view all slides that apply. SLIDES Examples of trophy formed from uric acid crystal deposits. Please view all slides that apply. SLIDES Examples of a disease that causes excessive resorption of spongy bone and accelerated formation of softened bone. Describe the 3 phases of this disease. SLIDES PAGET S DISEASE HAS AN INITIAL OSTEOLYTIC PHASE FOLLOWED BY A MIDDLE PHASE WITH

10 OSTEOSCLEROSIS AND OSTEOLYSIS. OSTEOSCLEROSIS OCCURS IN THE FINAL STAGE 10. A condition primarily found in older women involving a loss of bone mass. SLIDES Examples of non-inflammatory and inflammatory joint disease. How are these disease differentiated? SLIDES Rheumatoid Arthritis Osteoarthritis Inflammatory Yes No Etiology Systemic autoimmune damage to connective Degeneration and loss of cartilage tissue in joints. Joint fluid Inflammatory exudates Few cells and proteoglycan fragments from cartilage breakdown 12. Examples of bone infection. What is the most common organism involved in bone infection? SLIDES STAPHYLOCOCCUS AUREUS IS THE MOST COMMON ORGANISM CAUSING AN OSTEOMYELITIS

11 ANSWERS TO CASE STUDIES Case #1 Mr. Jones, his wife, and their child Sally were involved in an automobile accident. Each of them suffered broken bones, scrapes and bruises. Look at slides 1-4 and match the x-ray with the correct patient. Slide 1a - MRS. JONES Slide 1b - SALLY Slide 1c - MR. JONES Mr Jones - Transverse tibial fracture Mrs. Jones - Pott s fracture Sally Jones. - Colles fracture Case #2 An 18-year-old man presents with a six-month history of progressive pain in his left distal thigh. He had some moderate swelling about his knee. His pain was worse at night. He did not have pain with ambulation. Radiographs demonstrated a lesion of the distal femur. See slide 2a. This radiograph demonstrates a lesion in the metaphyseal region of the distal femur. See slide 2b. This bone scan demonstrates a hot spot of increased uptake in the distal left femur. a. What is the diagnosis? OSTEOSARCOMA IN THE METAPHYSEAL REGION b. In whom and at what sites is this lesion most common? THERE IS A SLIGHT MALE PREDOMINANCE, WITH PEAK INCIDENCE FROM TEENAGE TO YOUNG ADULTHOOD. THE MOST COMMON SITES ARE IN LONG BONES, PARTICULARLY AROUND THE KNEE Case #3 A 29 year-old woman complains to her physician that she hasn t felt well since having the flu several months ago. She is extremely tired but often doesn t sleep well at night. She complains of generalized aching

12 and pain. She has experienced frequent migraines and is often incapacitated for days. Her bowel movements are irregular and fluctuate between constipation and diarrhea. Physical exam revealed pain to the touch at the base of the neck, muscles in upper back, upper muscles of the buttocks, knee joints, and sides of the elbows. (See slide 3). Laboratory tests are unremarkable with normal chemistry, CBC, and thyroid function. ESR is within the normal range. ANA, RA, and mono tests are negative. What condition do you suspect FIBROMYALGIA. DIAGNOSIS OF FIBROMYALGIA IS BASED ON HAVING ALL 3 OF THE FOLLOWING MAJOR CRITERION: 1. Generalized aches or stiffness of at least three anatomical sites for at least three months 2. Six or more typical, reproducible tender points. (See slide 3) 3. Exclusion of other disorders that can cause similar symptoms. Four or more of the minor criteria must also be present for diagnosis. These include: 1. Generalized fatigue 2. Chronic headache 3. Sleep disturbance 4. Neurological and psychological complaints 5. Joint swelling 6. Numbing or tingling sensations 7. Irritable bowel syndrome 8. Variation of symptoms in relation to activity, stress, and weather changes

13 Case #4 A 35-year-old man complains of lower back pain, fatigue, and decreasing range of movement. Physical exam shows severely restricted forward flexion, rotation, and lateral flexion. See slide 4a. A radiograph of the spine shows fusion of vertebrate. See slide 4b. Laboratory Tests are remarkable for an elevated ESR, and elevated alkaline phosphatase. Serum analysis for HLA-B27 is positive. Your diagnosis is? ANKYLOSING SPONDYLITIS Case #5 A 65-year-old man complains of pain in his left elbow and right great toe. He has a history of kidney stones. Lab results show normal CBC and chemistry values other than an elevated uric acid. See slide 5 for a radiograph of the great toe. Your diagnosis? GOUT What causes the pain he is experiencing? PAIN IS CAUSED BY NODULES THAT FORM FROM URIC ACID CRYSTAL DEPOSITS Case #6 A 70 year-old woman fell and broke her hip. Her daughter accompanies her to the emergency room. See slide 6 for a radiograph of her opposite hip. What is the most likely cause of her broken hip? OSTEOPOROSIS. Recommend a treatment regimen to improve her condition. TREATMENT REGIMEN WOULD INCLUDE AN IMPROVED DIET WITH CA AND VITAMIN D SUPPLEMENTS. PHYSICAL THERAPY AND AN EXERCISE REGIMEN AS HER HIP HEALS. DRUG THERAPY TO DECREASE BONE RESORBTION

14 Can you recommend preventative measures for her daughter? HER DAUGHTER SHOULD INCORPORATE CALCIUM AND VITAMIN D IN HER DIET AND MAINTAIN A GOOD EXERCISE PROGRAM Case #7 A 46-year-old man presents with progressive pain and swelling of his right hip region. The swelling is worse than the pain. On physical examination, he is mildly obese and it is difficult to assess the right hip region. Slide 7a A bone scan showed a large area of increased uptake (a "hot spot") in the right pelvic wing (seen here on the left). Slide 7b A radiograph of the pelvis demonstrates an ill-defined mass eroding the right pelvic wing and extending into soft tissue. Note the fluffy calcifications within the mass. Slide 7c A pelvic CT scan reveals an ill-defined mass eroding the right pelvic wing and extending into soft tissue. Note the calcifications within the mass. A resection was performed. It was noted that the lesion had invaded the spongy bone. What type of tumor do you suspect? THIS IS A CHONDROSARCOMA. THE TUMOR WAS CAUGHT EARLY ENOUGH THAT RESECTION WAS POSSIBLE Case #8 A 58-year-old woman has suffered from arthritis with pain and swelling of her hands and feet that is aggravated by movement. Over the past decade she has noted increasing deformity of her hands and feet, making it difficult to walk and to perform simple daily activities such as buttoning a blouse or even combing her hair. She has no history of any trauma. Radiographs show ankylosis of the carpals (immobility) with

15 residual evidence of MP joint erosion and decreased bone mass of the metacarpals and carpals. Physical examination reveals firm, non-tender, less than 1 cm nodules over the elbows. Slide 8a Left hand of patient. Slide 8b Radiograph of hand shows joint narrowing with marginal erosions and osteoporosis, Slide 8c Synovial fluid shows mononuclear cells with numerous lymphocytes and some scattered plasma cells. Laboratory results are remarkable for elevated ESR, and positive RA. Your diagnosis is? RHEUMATOID ARTHRITIS Why are there numerous cells in the synovial exudates? THIS IS AN AUTOIMMUNE INFLAMMATORY PROCESS WITH CHARACTERISTIC CELLULAR SYNOVIAL FLUID