What is a Fracture?

• A break in the continuity of a bone
• Force is applied that exceeds the tensile or compressive strength of the bone

Which type of the fracture if you see in children, you should be concerned about child abuse?

a. Oblique

b. Spiral

C. Transverse

d. Greenstick

Answer is B!

Spiral involves twisting motion.

Type of fracture?
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Spiral ---> offen seen in child abuse, twisting motion

Cause: direct or indirect twisting energy, unable to move

 Complete V.S. Incomplete fracture?

Fractures can be classified in to Complete or incomplete....

Complete---> the bone that broke all the way through!

Incomplete---> the bone is damaged but still in one piece.

Q. If you broke your bone, which also causes skin to be broken, how would you classify this fracture?

a. Compound

b. Simple

Answer is Compound! 

Compound is also known as an open fracture where both bone and skin are broken.

Q. If pt. comes in with the broken bone that broke in to more than 2 fragments, what type of fracture does this pt. have?

a. Linear fracture

b. Spiral fracture

c.Transverse fracture

d. Comminuted fracture

Answer is D (comminuted fracture)[image]

Classify the fracture?

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Classify this fracture?

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Classify type of fracture?

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Classify type of the fracture?

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Which one is not correct about "Pathologic fracture"?

a. It is a break that occurs in either normal of abnormal bone.

b. It can be caused by any disease process that weakens a bone.

c. It's commonly associated with tumors, osteoporosis, infection, and metabolic bone disorder.

Answer is A!

Pathologic fracture is a break at the site of a preexisting abnormality only. Will not fracture a normal bone!!!!

1. Bone is broken the periosteum & blood vessels in the cortex, marrow, and surrounding tissue-->are disrupted.

2. Bleeding occurs from the damaged ends & neighboring tissue.

3. A clot (hematoma) forms within the medularry canal

4. The tissue around the fracture area dies (Necrosis tissue), which stimulates inflammatory response.

5. Inflam. response causes--> vasodilation, exudation of plasma, leukocytes, and infiltration by imflam leukocyte and mast cell.

6. Vascular tissue invades fracture area from surrounding soft tissue and marrow cavity

7. YaYYY!! Bone-forming cells are activated

Which bone cell synthesizes collogen and matrix, mineralizes to form callus?

a. Osteoblast

b. Osteoclast

Answer is A!

Remember, Osteoblast--> with the "B" meaning bone Building.

Osetoclast--> with the "C" meaning Cutting or breaking down the bone (mostly be utilized during bone remodeling)

Q. Which one connects bone to muscle?

a. Ligament

b. Tendon

Dislocation or Subluxation?

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Dislocation-->

• A temporary displacement of two bones
• Loss of contact between articular cartilage.

Location or Subluxation?

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Subluxation-->

• Contact between two articular surfaces is only partially loss.

Dislocation

• displacment of 2 bonesTemporary
• Loss of contact between articular cartiliage

Pathophysiology of bone

" when bone seperates from joint "

1. Bone seperates from joint ---> bruise, tear adjacent nerve, blood vessel, ligaments, supporting structures, soft tissue.
2. Bleeding from damaged periosteum--> muscle can compress the arteries causing ischemic injury ("ischemic paralysis")

Ex. - dislication of hand= permanent disbility from tendon damage, disruption of glading movement

- Avascular necrosis of the femoral head ** serious

Which organ heals and forms functional tissue, not scare?

a. Liver

b. Bone

C. Skin

D. Heart

e. a,b are correct

Answer E

Liver and bone are unigue as it heals and forms functional tissue and not scar.

Ischemia paralysis

Pathophysiology of

 bone fracture

1. Periosteum &blood vessels& surrounding tissue are disrupted.

2. Hematoma forms

3. Necrosis of bone tissue

4. Intense inflammatory response-> vasodilation, exudation of plasma, infiltration by imflam leukocyte & mast cells

5. Vascular tissue invades fracture area from surrounding soft tissue & marrow cavity

6. Bone-forming cells are activated

What could cause ischemia paralysis and avascular necrosis of the femoral head?

a. Bone fracture

B. Bone dislocation

c. Bone spiral

d. Bone Subluxation

e. B,C are correct

Answer E

What do we call tear or injury to a tendon?

a. Strain

b. Sprain

c. Avulsion

d. Tendinitis

Which one is defined as a complete separation of a tendon or ligament from its bony attachment site?

a. Sprain

b. Avulsion

c. Strain

d. Rhabdomyolysis

• General term for localized muscle damage
• Muscle becomes stretched beyond normal capacity
• Involve tendon
• Muscle regeneration may take up to 6 weeks.

Which syndrome can be caused by multiple musculoskeletal injuries, unresponsive,immobile peoson (drug, ETOH overdose)?

a. Compartment syndrome

b. Crush syndrome

Answer B

Crush symdrome --> more severe, diffuse. It has also been reported in individuals found unresponsive and immobile for long time often after overdose of drug or alcohol use!

Compartment symdrome--> more localized

Which muscle complication is associated with renal failure?

a. Compartment syndrome

b. Crush syndrome

1. Osteoclast recruitment
2. Resorption
3. Osteoblast recruitment
4. Osteoid formation
5. Mineralization
6. Mineral Maturation 
7. Quiescence

Which bone cell regulate the mineralization procress?

a. Osteoblast

b. Osteoclast

c. Osteoid

answer A --> Osteoblast

When the osteoid is about 6 microns thick, it begins to mineralize. This process, also, is regulated by the osteoblasts. Osteoblasts also primarily regulate phosphate metabolism through PHEX and FGF-23, whose mechanisms of action are still uncertain. Osteoblast life-span is regulated by estrogens and other hormones.

What is a normal value of bone density in healthy bone?

a. 833 mg/cm

b. 625 mg/cm

c. 725 mg/cm

Which pt is in a precursor state of osteoporosis?

a. Tom has bone density of 635 mg/cm

b. June has bone density of 658 mg/mm

c. May has bone density of 833 mg/cm

Answer B

• Precursor of osteoporosis (Osteopenic) = 833 to 648 mg/cm
• Normal value = 833 mg/cm
• Osteoporosis = <648 mg/cm

Which one is not a potential cause of Osteoporosis?

a. Decreased activity level

b. Inadequate level of vit. E and B

c. Decreased levels of estrogen

Answer B

Inadequate level of vit D, C, Mg can cause osteoporosis.

Which one is not correct about Osteoporosis?

a). Bone histology is abnormal and also lacks of structural integrity

b). Demonstrated by reduced bone mass/density

C). Demonstrated by imbalance of bone resorption and formation.

answer A,

Remember! Osteoporosis --> bone histology is usually normal but it lacks structural integrity.

Which one is a characteristic of Osteomalacia?

a. It's most often caused by staphylococcal infection

b. It's caused by imbalance of osteoclast ad osteoblast

c. Inadequate concentrations of calcium and phosphate leads to poor crystallization of mineral in osteoid

Answer C

Osteomalacia--->

• Metaboilic disease of inadequate or delayed mineralization
• Bone formation progresses to osteiod formation but calcification does not occur; the result is soft bone.

• Inadequate concentration of Ca and Phosphate leads to poor crystallization of minerals in osteiod
• Deficiency of vit. D lowers the absorption of Ca from intestines
• Low plasma Ca stimulate PTH
• PTH increases serum Ca but also increase renal clearance of phophate (losing too much phospate)

What causes an Osteomyelitis?

1. Most often caused by Staphylococcal infection
2. Secondary to sickle cell anemia (Salmonella=most common cause of sickle cell disease)
3. Most common cause also "open wound" (exgenouse) or blood-borne (endogenous) infection

What is a pathophysiology of Osteomyelitis?

a. Inadequate concentration of Ca and phosphate leads to poor crytallization of minerals in osteoid

b. Necrosis of the infected bone

c. Imbalance of bone remodeling

What type of tumor is the majority tumor?

a. Chrondrogenic

b. Myelogenic

c. Collogenic

d. Osteogenic

Answer D

• Osteogenic--> 38% of bone tumor
• Chrondrogenic--> 20% of bone tumor
• Collagenic ---> 4% of primary malignant bone tumor
• Myelogenic --> 4-5% of bone tumor

• In the metaphyses of the long bone
• 50% occur around the knees
• "Bone-forming tumors"

• "Cartilage-forming tumor"
• Chondrosarcoma-->20% of bone tumor
• Infiltrates trabelae in sprongy bone; frequent in the metaphyses or diaphysis of long bone

Which type of bone tumors can metastasize to the lung and considered primary malignant?

a. Fibrosacromas

b. Osteosacromas

c. Chondrosacromas

d. Myelogenic tumors

• Tumors originating from variou bone marrow cells
• Giant cell tumors---> 4-5% of bone marrow

• Absence of synovial membrance unflamation
• Lack of systemic signs and symptom
• Normal synvial fluid analysis

Transudate is extravascular fluid with low protein content and a low specific gravity (< 1.012). It has low nucleated cell counts (less than 500 to 1000 /microlit) and the primary cell types are mononuclear cells: macrophages, lymphocytes and mesothelia cells. For instance, an ultrafiltrate of blood plasma is transudate. It results from increased fluid pressures or diminished colloid oncotic forces in the plasma

Source: Wikipedia

• Transudate of plasma
• Cellular content low (WBC<200 cells/mm³)
• Hyaluronan--> glycosaminoglycan, a major matrix element od  synovial fluid (High viscosity)

By using synovial fluid WBC count

• WBC <2000 =non-inflamation
• WBC>2000 = inflammation

• Vasodlation (of course due to inflamation)
• Edema
• Neutrophilic infiltration
• Depolymerization of hyaluronic (loss of viscosity in joint result)
• Synnovial fluid volum increases massively
• Synovial ischemia

• Neutrophils releases reactive oxygen species, which results in damaging--> causing hyaluronan depolymerized
• Proteolytic enzymes are released

Articular cartilage is found in all moving joints in the body (synovial joints). Its primary role is to protect the bones by keeping the surfaces apart from each other, absorbing shock and enabling smooth articulation.

Articular cartilage does this by providing a protective, wear resistant surface to the end of the moving bones, this particular type of cartilage is called hyaline cartilage (derived from the Greek word hyalos, meaning glass).

• Loss of articular cartilage
• Sclerosis (reconstruction of bone structure) of bone underneath cartilage
• Formation of bone spurs
• Refered to as "Degenerative joint"
• Primary disease is idiopathic
• Subchondral bone change
• Thickening of the joint capsule

1. Pain
2. Stiffness
3. Enlargement of joint
4. Tenderness
5. Limited motion
6. Deformity

Bruchard's node V.S. Heberden's node

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• They are sign of the onset of arthitis
• These 2 nodes are caused by formation of osteophytes (bony projections that form along joint margins)
• Heberden's node appears at the dital interphalangeal joint (or the finger joint next to the nail)
• Bruchard's node appears at proximal interphalangeal joint (the middle joint)

What are systematic signs of inflammatory joint

disease "Arthitis "?

What does " Arthritis " mean?

• Inflammatory joint disease
• Inflammatory damage or destrcution in the synovial membrane or articular cartilage
• Infectious or noninfectious

Which type of arthirtis is autoimmune damage?

a. Ankylosing Spomdalitis

b. Rheumatoid Arthritis

c. Gout

Answer B

Remember! IgM, IgG become autoantibodies

Rheumatoid arthritis

• Autoimmune damage to connective tissue, primarily in multiple joints (synovial membrane)
• Similar symptom to Osteoarthritis
• Presence of Rheumatoid factor
• IgM&IgG become autoantibiodies
• Transformed antibodies called " Rheumatoid factor"
• Bind to targets in blood and synovial membrane
• Joint fluid presents with inflammatory exudate
• Associated with Raynaud phenomenon

What are the characteristic of RA ?

[image]

• Inflammation causes hemorrhage, coagulation, fibrin deposition on the synovial membrane, matrix, fluid
• Pannus -->Fibrin develops into granulation tissue over denuded areas of synovial membrane
• Pannus leads to scar formation that immobilizea joint

What is Ankylosing Spondylitis (AS)?

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Chronic inflammation joint disease of the spine or sacroiliace joint causing stiffness and fusion (ankylosis) of these joints

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Bruchard's node & Heberden's node are sign of which joint disease?

a. Rheumatoid Arthritis

b. Ankylosing Spondylitis

c. Osteoarthritis

d. Gout

Answer A

[image]

• Begins w/inflammation of fibrocartilage at spine &sacroiliac joint
• As repair begin, the scar tissue ossifies&calcifies--> the joint eventually fuses
• Early symptom:
• Low back pain, stiffness, pain, and restricted motion
• Pt. demostrate loss of normal lumbar curvature

What is a Uric acid?

Uric acid is a heterocyclic compound of carbon, nitrogen, oxygen, and hydrogen with the formula C₅H₄N₄O₃. It forms ions and salts known as urates and acid urates such as ammonium acid urate. Uric acid is a product of the breakdown of purine nucleotides. High blood concentrations of uric acid can lead to a type of arthritis known as gout. The chemical is associated with other medical conditions like ammonium acid urate kidney stones

Source: Wikipedia

What cause Gout?

• Primary cause -->idiopathic
• Secondary cause--> Accelerated purine synthesis or breakdown, poor uric acid secretion in kidney
• High level of URIC acid that become crytal and deposite in connective tissues througout the body. When the crytal occur in synovial fluid, it causes gout arthritis

Gout arthritis

Describe the characteristic of Gout

• Metabolic disorder that disrupts the body's control of uric acid production or excretion
• High level of uric acid in the blood (hyperuricemia)
• Crystals deposit to connective tissue throughout the body
• Crytal occurs at synovial joint cause Gout arthritis

What is a pathophysiology of Gout?

• Gout is related to purine (adenine & guanine) metabolism
• Affected patients can have accelerated purine synthesis, breakdown, or poor uric acid secretion in the kidney

If Mrs. Lin has been in cast for 4 months from serious car accident, what muscle condition should you be concerned the most?

a. Contracture

b. Atrophy

c. Rhabdomyosarcoma

d. Polymyositis

Answer A---> Atrophy or disuse atrophy

• Pathologic reduction in normal size of muscle cells due to prolonged inactivity
• Ex. bed rest, trauma, casting, nerve damage
• May be apparent within days of inactivity
• Loss of baseline levels of muscle strength at the rate 3% per day

• Muscle fiber shortening w/o an action potential
• Caused by failure of the sarcoplamic reticulum even when ATP is available

What is the most common cause of Toxic Myopathies?

a. Tobacco use

b. Alcohol abuse

c. Inactivity lifestyle

Toxic myopathies

• The most common cause is Alcohol abuse

1. Acute attack of muscle weakness, pain, swelling
2. Chronic weakness in a drinker of long duration

• Necrosis of individual muscle fibers--> Disturbance of energy turnover, gene dysregulation, and initiation of apoptosis

What is Rhabdomyoma?

What are the characteristic of Rhabdomyosarcoma?

• Malignant tumor of striated muscle
• Muscles of head, neck, GU tract in 75% cases
• Trunk, extremities
• Highly malignant with rapid matastasis
• Pleomorphic, embryonal, alveolar

What is a pathophysiology of Myositis?

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• Inflammation of connective tissue & fiber tissue
• Extensive necrosis
• Destruction og muscle fiber
• Believed to be autoimmune
• Cytokines play a role

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Polymyositis V.S. Dermatomyositis

Polymyositis = generalized muscle inflammation (many muscles)

Dermatomyositis = polymyositis with skin lesion

• Viral, bacterial, and parasitic myositis
• Staphy. aureus infection
• Trichinosis
• Toxoplasmosis