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Disorder of Musculo - System. Leatest
Disorder of Musculo - System. Leatest
System
Set by Minichil G
2022
Learning Objectives
Physical Examination
Inspect and palpate
10. CBC
Rheumatoid Arthritis ( RA )
Learning objectives
At the end of this lesson the student will be able to:
Define Rheumatoid arthritis
Describe the etiology and pathogenesis of RA
Identify the clinical features of Rheumatoid arthritis
Explain the Dx method of RA
Manage a patient with Rheumatoid arthritis
Describe prognostic factors for Rheumatoid arthritis
Definition
Rheumatoid arthritis (RA) is a symmetric,
inflammatory, peripheral polyarthritis of
unknown etiology
Usually involving peripheral joints in a
symmetrical distribution
The potential of the synovial inflammation to
cause cartilage damage, bone erosion and
subsequent changes in joint integrity is the hall
mark of the diseases
Etiology:
The cause of RA remains unknown
Genetic factors
The presence of HLA-DR4 allogen is
associated with high incidence of RA.
Infectious agent:
May play a role in triggering an autoimmune
reaction
Epidemiology
The prevalence of RA is approximately 0.8 in
the population
Women are more affected than men with F: M
ratio of 3:1
The prevalence increases with age
Clinical Features
• Typical "classic" RA
The disease onset is usually insidious, with
the predominant symptoms being pain,
stiffness, and swelling of many joints
Articular ( joint ) manifestations
Result from persistent inflammatory synovitis
Digital gangrene
Visceral infarction
Eye involvement
patients on autopsy.
Thrombocytosis
arthritis
effects
may be used
anti-inflammatory effect
• Third line:
Disease modifying antirheumatic drugs- or slow
acting antirheumatic drugs
Methotrexate is the most frequently DMARD
used, which is relatively rapidly acting
Dose: given low dose: 7.5-30 mg once weekly
Non pharmacologic therapy
1) Patient education
The chronicity of the diseases
Rest and exercise
Patients should be advised to rest or splint
acutely involved joints
Exercise is advised to strengthen muscle
surrounding involved joints , when the
arthritis is resolved
2) Physiotherapy to reduce disability
• Assessment of response:
episodes
affected commonly
Gouty arthritis frequently begins at night with
dramatic joint pain and swelling.
Joints rapidly become warm, red, and tender,
with a clinical appearance that often mimics
that of cellulitis.
Early attacks tend to subside spontaneously
within 3–10 days
• Several events may precipitate acute gouty arthritis:
Dietary excess
Trauma
Surgery
and stroke
Diagnostic work up
Clinical presentation
7 days.
Intraarticular injections
• Uricosuric agents (probenicide)
This drugs facilitate the renal excretion of uric
acid.
It can be used in patients who excrete less
than 700 mg of uric acid daily, who have
normal renal function
Dose: Probenicide 200 mg PO Bid increased
gradually as needed up to 2 gm
• Xanthine Oxide inhibitors (allopurinol)
destruction
Hematogenous spreeding
tract
chronic osteomyelitis.
Diagnosis method
The white blood cell count was elevated in
only 35 %
The erythrocyte sedimentation rate (ESR)
was initially elevated (≥20 mm/h) in 92 % of
patients (mean 45 mm/h).
The serum C-reactive protein (CRP)
concentration was elevated in 98 % on
admission.
Joint fluid analysis
Gram staining
Culture
Biopsy
Radiological Finding
Management
Limb amputation
Complications
Loss of full function of the bone or supporting
tissues
Fractures are more likely with progressive
disease.
Local spread and dissemination of infection
May lead to malignant transformation into
squamous cell carcinoma or sarcoma
Septic Arthritis
Septic arthritis is also known as infectious
arthritis, and is usually caused by bacteria, or
fungus.
The condition is an inflammation of a joint
that's caused by infection.
Typically, septic arthritis affects one large joint
in the body, such as the knee or hip.
Less frequently, septic arthritis can affect
multiple joints.
What Causes Septic Arthritis?
Septic arthritis usually is caused by bacteria
that spread through the bloodstream from
another area of the body
It can also be caused by a bacterial infection
from an open wound or an opening from a
surgical procedure
• Septic arthritis can be caused by bacteria, viruses, and
fungi.
Mycobacterium tuberculosis.
Fungi that can cause septic arthritis include
HIV
Who's at Risk for Septic Arthritis?
joint
Is the Infected Fluid Drained?
• Tenderness
• Discoloration
It might be difficult to differentiate a sprain
from a closed fracture with out an X-ray.
Soft tissue injury…
3. Strain
“Pulled muscle”
Microscopic tear in the muscle
May cause bleeding
Causes:
– Lack of pre- exercise before doing sport activity
– Lifting of heavy weight
– Inappropriate lifting or sudden acceleration
– The most common one is back strain.
• Signs and symptoms
– Pain (sudden sharp pain at the site of the injury)
– Spasm of muscles
– Difficulty in moving the affected parts
– Localized swelling
Management of Soft Tissue Injury
/Trauma
Rest
Ice for first 24 - 48 hours- produces vasoconstriction,
which decrease bleeding, edema and discomfort.
- Intermittent application of cold
Compression with bandage controls bleeding,
reduces edema.
Elevation to increase venous return and decrease
swelling
Splint to support extremities and limit movement.
Management of Soft Tissue Trauma…
After 24-48 hours after injury heat may be
applied intermittently (for 15-30 minutes, 4
times a day) to relieve muscle spasm and to
promote vasodilatation, absorption and
repair
NSAIDs
Checking the neuromuscular status
Surgical repair for third degree sprain or strain
Joint Dislocations
Direct blow
– Forearm (radius/ulna)
– Wrist
– Ankle
Clinical Manifestations
Pain
loss of function
Deformity
Shortening of the extremity
Crepitus (a grating sensation palpation)
Swelling and discoloration.
False movement
Note: all of these clinical manifestations may not
present in every fracture.
Stages of Bone Healing
The process of fracture healing (bone healing) stages:
1. Hematoma formation:-blood collects in the
periosteal sheath or adjacent tissues within 48 to
72hr after injury fastens the broken ends together.
2. Granulation tissue formation:-
Fibroblasts;- invade the hematoma forming a fibrin
meshwork
Osteoblasts;- invade the fibrous union to make it
firm;
Blood vessels will develop from capillary buds.
These all form a granulation tissue.
Cont…
3. Callus formation:-osteoblasts form an
unorganized network of bone (callus) that is
woven about the fracture parts.
Callus is formed mainly by deposition of
minerals (calcium and phosphorous).
It begins to appear by the end of the first week
after injury.
The callus unites and helps to stabilize the
fragments
Not strong enough to bear weight or withstand
stress.
Cont….
4. Ossification (consolidation)
Begins with in 2-3 weeks after the fracture
and continues until the fracture heals.
Stage where restructuring of callus takes
place.
Collagenous fibrous net work is produced that
become impregnated with mineral salts
(calcium and phosphate) to form bone tissue.
5. Remodeling
The final stage of fracture healing.
Excess callus is reabsorbed and the union is
completed.
Osteoclasts are responsible for this action
• Decrease pain
B. Skeletal traction
Applied directly to the bone with local or general
anesthesia.
A pin is inserted through the bone distal to fracture.
It protrudes through the skin on both sides of the
extremity
The ends of the pin should be covered with cork or
metal protectors
A U shaped metal or a bow is attached to the pin,
which is tied to a rope on which the traction weight
hung.
Skeletal traction is used for fracture of tibia, femur,
humerus and cervical spine.
Skeletal Traction
Subsequent management…
II Open Reduction
the correction of bone alignment through a
surgical incision.
It is indicated for
Unstable or open fracture
Those with significant soft tissue injuries
Failed closed reduction
Intra articular fractures
Open reduction may include internal fixation of
the fracture.
Subsequent management…
III. Immobilization
After the fracture has been reduced, the bone
fragments must be immobilized, or held in correct
position and alignment, until union occurs.
Immobilization can be accomplished by:
A. External fixation devices
Cast, splint, Brace
Traction
External fixators
B. Internal fixation devices.
Cast
The most common external fixation device
Materials used for casts plaster of paris( POP)
less expensive, fiber glass and Plastic.
All of the materials are available in rolled
bandages, and are applied over the body part to
be immobilized
A cast may enclose – all or part of an extremity
- The trunk
- Trunk with all or a portion of
one or both extremities
Types of Casts
• Short arm cast: Extends from below the elbow
to the palmar crease and is secured around
the base of the thumb.
• Long arm cast: Extends from the upper level
of the axillary fold to the proximal palmar
crease. The elbow is usually immobilized at a
right angle.
Types of Casts (cont’d…)
• Short leg cast: Extends from below the knee to
the base of the toes.
• Others
– Body cast, Shoulder Spica cast, Hip spica cast
Types of Casts (cont’d…)
Cast are applied after the skin is cleansed and
examined for any potential areas of infection
or breakdown.
The part then enclosed in circular stockinette
for skin protection and extra padding is made
over bony prominences.
External Fixator
Internal fixation
Care of a patient with cast
Disuse syndrome
Immobilization in a cast can cause muscle
atrophy and loss of strength
While in a cast patient is taught to tense/
contract muscles. i.e muscle setting exercise
This helps to reduce muscles atrophy and
maintain muscle strength.
Monitor and manage potential
complications
Skin breakdown – monitor reaction of the skin
Provide back care
Nerve pressure – assess sensation, motion
(movement of toes and foot) and burning
sensation under the traction bandage.
Circulatory impairment - assess peripheral
pulses, color, capillary refill and temperature.
Assess indicators of DVT- calf tenderness,
swelling.
Monitor and manage potential complications
• Symptoms of ARDS:
• Chest pain
• Tachypnea
• Cyanosis
– Rapid and acute course
– Feeling of impending disaster
– Patient may become comatose in a short
time
Complications of Fractures(cont’d…)
Fat Embolism Syndrome (FES)
• Collaborative Care
– Treatment directed at prevention
– Careful immobilization of a long bone fracture
• Most important preventative factor
– Symptom management
– Fluid resuscitation and oxygen administration
– Steroids to treat the inflammatory lung reaction and
to control cerebral edema.
– Morphine for pain and anxiety
– Reposition as little as possible
Amputation
• An amputation is removal or excision of part or
whole of a limb, usually an extremity.
Indications
Progressive peripheral vascular disease . E.g.DM
Trauma / accident- (crushing injuries, burns,
frostbite, explosions, ballistic injuries)
Malignant tumors
Congenital deformity
Infection (fulminating gas gangrene, chronic
osteomyelitis, osteoarthritis. )
Thank You