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6
Musculoskeletal
System Diseases
and Disorders
Key Terms
Anaerobic (p. 101)
Arthroscopy (p. 90)
Bone mass density
(BMD) (p. 90)
Calcaneal (p. 113)
Computerized axial
tomography (CAT or
CT) (p. 90)
Densitometry (p. 90)
Diskectomy (p. 110)
Dowager’s hump (p. 94)
Types of Fractures
Articular (p. 97)
Avulsion (p. 103)
Closed (p. 103)
Colles’ (p. 103)
Comminuted (p. 103)
Complete (p. 103)
Compound (p. 103)
Dual-energy X-ray
absorptiometry
(DEXA) (p. 90)
Electromyography
(EMG) (p. 90)
Fascia (p. 113)
Interphalangeal (p. 97)
Kyphosis (p. 92)
Laminectomy (p. 110)
Lordosis (p. 93)
Compression (p. 94)
Displaced (p. 103)
Extracapsular (p. 103)
Femoral neck (p. 103)
Greenstick (p. 103)
Impacted (p. 103)
Incomplete (p. 103)
Magnetic resonance
imaging (MRI) (p. 90)
Meniscus (p. 114)
Metacarpophalangeal
(p. 97)
Metatarsophalangeal
(p. 98)
Mineralization (p. 96)
Myelogram (p. 109)
ORIF (p. 105)
Osteocyte (p. 88)
Intertrochanteric (p. 103)
Intracapsular (p. 103)
Longitudinal (p. 103)
Nondisplaced (p. 90)
Oblique (p. 103)
Open (p. 103)
Pathologic (p. 103)
Osteomyelitis (p. 95)
Osteoporosis (p. 90)
Radiologic (p. 90)
RICE (p. 107)
Sciatica (p. 109)
Scoliosis (p. 93)
Spasms (p. 109)
Tetany (p. 102)
Tophi (p. 99)
Pott’s (p. 103)
Simple (p. 103)
Spiral (p. 103)
Stellate (p. 103)
Stress (p. 103)
Subcapital (p. 103)
Transverse (p. 103)
Learning Objectives
Upon completion of the chapter, the learner should be able to:
1. Define the terminology common to the
musculoskeletal system and the disorders of the
system.
2. Discuss the basic anatomy and physiology of the
musculoskeletal system.
3. Identify the important signs and symptoms associated
with common musculoskeletal system disorders.
4. Describe the common diagnostics used
to determine the type, cause, or both of a
musculoskeletal system disorder.
87
5. Identify the common disorders of the
musculoskeletal system.
6. Describe the typical course and management of
the common musculoskeletal system disorders.
7. Describe the effects of aging on the
musculoskeletal system and the common
disorders associated with aging of the system.
Overview
T
he musculoskeletal system provides the structure and movement function for the individual. Because the
muscles and bones run throughout the body, disorders of the system can affect any other system, and dis
orders of other systems frequently affect the musculoskeletal system. This includes bones, joints, ligaments,
muscles, and tendons; each of these has a unique function but also interacts with the other components of
the system to support the person and provide for mobility. Problems with the musculoskeletal system fre
quently affect the individual’s independence and, thus, the quality of life. ■
Anatomy and Physiology
The skeletal component of the musculoskeletal system
is made up of bones and joints. The bones provide
the framework to support the body. They also produce
blood cells, store fat and minerals, protect soft tissues
(such as the brain), and help create body motion.
Bones are very vascular; blood circulates through
them, picking up or storing body minerals such as
calcium, phosphorus, magnesium, and sodium. Bones
also contain osteoblasts, active bone-building cells;
osteoclasts, cells that reabsorb bone; and osteocytes,
mature bone cells.
Bones are often classified by shape and composi
tion. For example, the skeletal system is composed of
long bones such as the femur in the leg, short bones
such as the carpal bones in the wrist and the tarsal
bones in the ankles, flat bones such as the sternum
or skull, irregular bones such as the vertebrae or pel
vic bones, and sesamoid bones such as the kneecap
(Figure 6-1). The composition of bone is either cor
tical or cancellous. Cortical bone is dense, smooth,
and compact, whereas cancellous bone is spongy,
with many open spaces throughout. The ligaments
are fibrous connective tissues that connect bones to
other bones and joints.
Bone can be damaged and repair itself. The steps
of bone repair include (1) bleeding at the site of injury
with clot and granulation tissue formation; (2) prolif
eration of cells at the site, forming a callus (soft bony
deposit) over the injury or fracture; (3) cells becoming
bone (osteoblasts) or cartilage at the site; (4) the bone
calcifying (hardened) by the deposit of inorganic salts
at the site; and (5) the remodeling of the bone to the
shape necessary to complete its designated function.
Bone repair depends on many factors, such as the gen
eral health status of the individual, their age, the degree
of injury, circulation to the site, and the presence of
other diseases or infection.
Short
Irregular
Long
Figure 6-1 Examples of types of bones.
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Musculoskeletal System Diseases and Disorders 89
Consider This...
Due to the fusion of bones as we age, a
baby has approximately 350 bones, while
the adult only has 206!
The joints are where two or more bones meet.
They are usually classified based on the amount of
movement of the joint, as described in Table 6-1, but
they also can be classified by their structure. Classifi
cation of joints by structure includes fibrous (such as
the joints of the skull), cartilaginous (such as the joints
of the vertebrae), and synovial (such as the joints of
the knee). The synovial joints are those separated by a
fluid-filled cavity.
The major movements of joints are flexion (bend
ing), extension (reaching or spreading out), abduction
(away from the body), adduction (toward the body),
rotation (turning on an axis), circumduction (circular
movement), and elevation (lifting).
Cartilage is collagen tissue that supports articu
lating (adjoining) bones. It provides protection and a
TABLE 6-1 Classification of Joints by Movement
Classification
Amount of
Movement
Example of
Joint
Synarthrosis No movement Suture of the
skull
Amphiarthrosis Some movement
but very limited
Pelvis
Diarthrosis Complete movement Knee, hip,
elbow
cushion to prevent friction between bones and acts like
a shock absorber to reduce stress on the bone surface.
The functions of the muscles of the body are to pro
vide structure and movement and to produce heat
(Figure 6-2). The muscles of the musculoskeletal system
are called striated because they look striped or banded
under a microscope. They are also called voluntary mus
cles because most are moved by conscious control as
opposed to other muscles, such as cardiac, that move
involuntarily. Skeletal muscles move in response to signals
from the central nervous system. Connective tissue holds
the muscle fibers together, and tendons, long, fibrous,
non-elastic connective tissues, attach muscle to bone.
Orbicularis oculi
Orbicularis oris-
Pectoralis major
Biceps brachii—
Serratus anterior--------
Triceps lateral head
Trapezius —
Deltoid----------
Infraspinatus
Latissimus dorsi —
Occipitalis
Teres major
-— Triceps
brachii
External oblique
Rectus abdominis
Aponeurosis
Adductor longus----------
Sartorius—
Vastus lateralis
Rectus femoris
Vastus medialis
Tibialis anterior
Achilles tendon
Biceps femoris
Gastrocnemius
Figure 6-2 The skeletal muscles.
90 Chapter 6
1
Consider This...
The muscles of the body give off enough
heat in 30 minutes to bring about half a
gallon of water to a boil.
Each muscle fiber in the body contains myofi
brils, which are composed of sarcomeres that are the
contracting and relaxing component of the muscle.
This contracting and relaxing characteristic provides
the smooth, elastic movement of the muscle.
Consider This...
When you take a step, you use approxi
mately 200 muscles.
The source of energy for the movement of mus
cles is the metabolism of adenosine triphosphate (ATP)
in the cell. ATP is produced from available glucose
and glycogen (stored glucose) in the cells. Adequate
amounts of oxygen and glucose are necessary for parts
of this process.
Common Signs and Symptoms
The most common signs and symptoms of bone and
joint disease are pain, swelling, decreased mobility,
and deformity. Most fractures are associated with pain
due to a disruption of the periosteum and related sen
sory nerves. Many fractures are easy to recognize due
to the obvious displacement and related deformity.
Nondisplaced (not out of place or position) fractures are
not as easy to recognize but can cause pain just the same.
Weakness is the most common sign or symptom of
muscle disorders and can be related to a primary disease of
the muscle or be secondary to a neurologic disorder. Mus
cle tissue will atrophy if weakness persists for an extended
length of time. On the other hand, just the reverse can also
occur, with muscle atrophy leading to muscle weakness.
Diagnostic Tests
Radiologic examinations (X-rays) are the primary
tool in diagnosing bone and joint disorders, but
computerized axial tomography (CAT or CT) or
magnetic resonance imaging (MRI) might be needed
for more detailed studies.
CAT involves taking specialized X-rays of the affected
individual in a special tube-like scanner. The individual
must be able to lie still for approximately 30 minutes. The
results are detailed X-ray pictures that appear to cut the
area of consideration into slices, thus the name tomo
gram (tomo = cutting, gram = picture; Figure 6-3).
MRI is another detailed X-ray type of examination;
it uses a large magnet to make electromagnetic images.
Here also, individuals must be able to lie still and must
not wear any type of metal during the test. MRI is more
expensive to perform but takes more detailed images of
soft tissue than a CT scanner does.
The primary procedure used to evaluate joints is an
arthroscopy. This is a common procedure of looking
into a joint with a lighted scope. Arthroscopy is used to
diagnose and often treat injuries and arthritis.
Bone mass density (BMD) screening is used to con
firm low bone mass and the diagnosis of osteoporosis.
Bone densitometry testing techniques are simple radiol
ogy scans. The dual-energy X-ray absorptiometry
(DEXA scan) takes measurements at the spine, hip,
and wrist. A score above -1 is normal, a score between
-1 and -2.5 reflects osteopenia (low bone mass), and a
score below -2.5 is defined as osteoporosis.
Ultrasonography is used to identify inflammation in
joints or tendon tears. A bone scan may be used to diag
nose a fracture that is not seen using other methods or to
diagnose a bone tumor. An arthrocentesis (joint aspira
tion) can help the physician diagnose an infection, gout,
or other joint problems. The fluid is aspirated and exam
ined microscopically. Other tests such as a white blood
cell count and culture are also usually done on the fluid.
Consider This...
5
By weight, bone is five times stronger than
steel.
Blood studies, including calcium, vitamin D, phos
phorus, and an enzyme (alkaline phosphatase), also can
prove helpful with metabolic disorders. Infectious disor
ders can be cultured. Often, the specimen for culture is
obtained during surgical procedures such as debridement.
Muscle disorders are often evaluated by
electromyography (EMG), accomplished by inserting a
small needle into muscle tissue and recording the electri
cal activity. Electromyography can assist in determining
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Musculoskeletal System Diseases and Disorders 91
(A)
Figure 6-3 Computed tomography (CT scan) provides cross-sectional views of different body planes. (A) CT of chest and
abdomen. (B) MRI of head.
whether the disorder is muscular or neurologic in nature.
A muscle tissue biopsy can be performed for difficult
cases. Biopsy is the most definitive means of determining
cause of muscle disorder. Biopsy is also the most reliable
test for tumors of the musculoskeletal system.
Common Diseases of the
Musculoskeletal System
Diseases of the Bone
Diseases of the bone can range from mild to severe,
with the most serious causing extreme deformity or
disability. Many of the disorders are more common in
older adults because changes in the system can lead to
increased risk for skeletal problems. Individuals with
bone disease frequently need assistive devices such as
crutches, walkers, or canes to maintain mobility. Inter
nal devices such as artificial joints, pins, and braces also
might be necessary.
Spinal Deformities
■ Description. Deformities might be very obvious at onset,
as with congenital defects, but more commonly, they prog
ress slowly and are unnoticed until symptoms arise.
92 Chapter 6
■ Etiology. Deformities can be caused by a variety of
factors, including congenital defects, poor posture, bone
disease, and growth disorders.
■ Symptoms. Symptoms commonly include back pain
and fatigue. Diagnosis is generally confirmed by X-ray
and clinical examination.
■ Diagnosis. Spinal deformities are diagnosed by thor
ough physical examination and a series of X-rays of the
spine. A pulmonary function test might be needed if
breathing is affected. MRI scans can assist in identifying
a tumor or infection.
■ Treatment. Treatment includes eliminating or
treating causative factors, bracing, and spinal sur
gery. Untreated spinal deformities can progress to
life-threatening conditions when cardiac and respira
tory function is compromised.
■ Prevention. There is no known prevention for spinal
deformities.
Kyphosis
Kyphosis (kie-FOE-sis) is a humped curvature of
the thoracic spine, commonly called humpback or
Pharmacology
Common Drugs for Musculoskeletal Disorders
■ ■ ■ Bill ^^1 f
Highlight
Category Examples of Medications
Antibiotics
Drugs used to prevent or
stop bacterial infections
Ampicillin, amoxicillin, ciprofloxacin, doxycycline,
erythromycin, penicillin, or tetracycline
Anti-inflammatories
Drugs used to reduce
inflammation
Hydrocortisone, beclomethasone, or amcinonide
(steroids) acetaminophen, aspirin, ibuprofen,
meloxicam (nonsteroidal)
Antipyretics/Analgesics
Drugs used to reduce fever
and pain
Acetaminophen, aspirin, ibuprofen, naproxen, or some
narcotic analgesics if necessary such as morphine
sulfate or oxycodone
Antirheumatics
Drugs to prevent some
rheumatic conditions and
symptoms
Adalimumab, celecoxib, glucosamine, ibuprofen,
indomethacin, infliximab, ocilizumab, or tocilizumab
Bone Resorption Inhibitors
Drugs used to prevent
bone loss
Alendronate, etidronic acid, denosumab, ibandronate,
raloxifene, risedronate, or zolendronic acid
Vitamins/Minerals
Supplements used to
support or replace low
levels
Calcium and vitamin D (especially D3); these may be
prescribed individually or in combination with other
vitamins and minerals
Muscle Relaxants and Antispasmodics
Drugs used to alleviate
pain and stiffness
Carisoprodol, chlorzoxazone, cyclobenzaprine,
diazepam, metaxalone, or orphenadrine
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Musculoskeletal System Diseases and Disorders 93
hunchback. Kyphosis often appears in postmenopausal,
osteoporotic women.
Lordosis
Lordosis (lor-DOE-sis) is an exaggerated anterior or
inward curve of the lumbar spine, also called swayback.
It normally occurs with pregnancy as the individual
compensates for the increased size of the abdomen.
When compared to the normal spine, lordosis results
in a protruding abdomen and buttocks and a swayed
lower back. Obesity is a common cause of lordosis.
Scoliosis
■ Description. Scoliosis (SKOLE-lee-OH-sis) is a lateral
curvature of the spine. It affects both sexes, but girls
usually have more severe curvatures and account for
approximately 90% of the cases. Scoliosis can occur at
any age but is usually noticed during the early teen years
when the growth rate is accelerated.
■ Etiology. The cause of scoliosis, in most cases, is
unknown.
■ Symptoms. Symptoms include (a) back pain due to
muscles trying to conform to the spinal curving, (b) a
rib or shoulder blade hump, and (c) uneven shoulders
and hips. Scoliosis is often noticed in girls when dresses
hang lower on one side or the other, and the brassiere
straps need to be adjusted to different lengths. In boys
and girls, it may also be noticed due to uneven pant leg
length or sleeve length.
■ Diagnosis. Scoliosis screening in school-aged chil
dren was initiated in the 1960s and is now mandated by
law in some states. Screening involves observation of
the spine as the individual bends forward. Scoliosis is
suspected if the spine curves to the side and the scapula
shifts upward (Figure 6-4).
■ Treatment. Treatment is aimed at preventing a wors
ening of the condition and often includes bracing.
Compliance with brace-wearing for female adolescents
is often poor, leading to the need for further treatment.
Most cases of scoliosis can be corrected if detected early
and treated properly and promptly.
■ Prevention. Scoliosis cannot be prevented.
Consider This...
The skeleton grows to about age 35, and
then it begins to shrink.
(A) (B) (C)
Figure 6-4 Spinal deformities: (A) kyphosis, (B) lordosis, and (C) scoliosis (S curvature). Note that the normal curvature
is shown in shadow.
94 Chapter 6
Other Diseases of the Bone
Osteoporosis
■ Description. Osteoporosis (OS-tee-oh-por-OH-sis) is
a metabolic bone disease that causes a porosity or Swiss-
cheese appearance of the bone, leading to a decrease in
bone mass. It is the most prevalent bone disease world
wide. It is estimated to cause major orthopedic prob
lems in approximately one-third of the women in the
United States.
■ Etiology. Many causative factors play a part in osteo
porosis. Age-related osteoporosis affects both men and
women equally and is due to normal age-related bone
loss. Osteoporosis occurs secondary to diseases that
affect mobility. For example, quadriplegia can lead to a
loss of 30% to 40% of bone mass after 6 months of immo
bility. The most common type of osteoporosis is seen in
women who are postmenopausal and estrogen-deficient.
It is believed that this osteoporosis is due to a combina
tion of factors, including a decrease in estrogen, calcium,
and exercise.
Osteoporosis is a slow, progressive disease that
robs skeletal bone of its mass and strength. It might
be decades before the bone becomes weak enough to
fracture. Most fractures in women older than age 50 are
related to osteoporosis.
■ Symptoms. Early signs of osteoporosis include
compression (bone mashed down on itself, common
in vertebra) fractures of the spine and pathologic wrist
fractures. Compression fractures of the spine lead to a
decrease in height and pain in the thoracic and lumbar
spine. Over time, the individual might lose 4 to 5 inches
of height, decreasing the thoracic and abdominal cavity
size. This decrease in chest cavity size leads to decreased
activity tolerance due to shortness of breath. A decrease
in the abdominal cavity size leads to feelings of fullness
after eating only small amounts of food and to a constant
bloated feeling. Other symptoms are kyphosis and the
appearance of a Dowager’s hump (abnormal curvature
in the upper thoracic spine; see Figure 6-5). Wrist frac
tures, especially of the distal radius, commonly occur in
osteoporotic individuals with only a slight fall. As the
disease progresses, the individual has an increased risk
for fracturing a hip. More than 1 million hip fractures
occur annually in the United States. Hip fractures in
frail older women often lead to complications that result
in mortality (Figure 6-6).
■ Diagnosis. Diagnosis can be confirmed by clinical
examination, X-rays, CT scans, and bone densitometry
(measurement of bone thickness).
■ Treatment. Currently, there is no treatment to reverse
osteoporosis, although the progression of osteoporosis
Normal spine
Beginning osteoporotic changes
L Curvature of spine
due to_osteoporosis
Dowager's
hump .■<=
Height
-5'6"
-5'3"
-5'
-4'9"
-4'6'
-4'3"
Age 40 Age 60 Age 70
Figure 6-5 Osteoporosis: loss in height and the Dowager’s hump.
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Distal radius
Spine—anywhere along spine
(Loss of height; kyphosis)
Figure 6-6 Fracture sites related to osteoporosis.
can be slowed and bone mass levels maintained by a
combination of therapies. Administration of the medica
tions Fosamax
®
(alendronate), Actonel
®
(risedronate),
Boniva
®
(ibandronate), and Reclast
®
(zoledronate)
appears to be helpful in preventing fractures. Reducing
risk factors includes decreasing alcohol and caffeine
consumption and not smoking (Table 6-2). Other ther
apies include increasing estrogen, increasing calcium
and vitamin D intake, and a daily exercise routine that
includes weight-bearing exercise. Much controversy
exists concerning the use of estrogen replacement ther
apy because it is associated with an increase in breast
and gynecologic malignancies. An increase in calcium
levels also might lead to the formation of kidney stones.
These treatments must be considered on an individual
TABLE 6-2 Risk Factors for Osteoporosis
The following are considered factors that increase
the risk of developing osteoporosis:
■ Family history of osteoporosis
■ Increased risk from aging
■ Medications—tetracycline, corticosteroids, aluminum
antacids, some diuretics, some anticonvulsants
■ Female, white or Asian
■ Lack of exercise
■ Lack of calcium in diet or supplements
■ Increased risk from postsurgery oophorectomy
(removal of ovaries)
■ Alcohol consumption
■ Caffeine consumption
■ Smoking
basis. The one treatment that is agreed on by most prac
titioners is the need for daily exercise.
■ Prevention. Preventive measures for osteoporosis need
to begin early because bone mass is built before age 30.
Young women should be encouraged to exercise daily,
eat a balanced diet, quit smoking, and limit caffeine and
alcohol consumption. Entering menopausal years with
good bone mass and maintaining as much of the bone as
possible is the best weapon against osteoporosis.
Osteomyelitis
■ Description. Osteomyelitis (OS-tee-oh-My-ull-LIE-tis;
osteo = bone, myel = marrow, itis = inflammation) is an
inflammation of the bone commonly caused by infection.
■ Etiology. Infection by Staphylococcus aureus bacte
ria is the most common cause of osteomyelitis. This
bacterium can enter the bone through a wound, spread
from an infection nearby, or come from a skin or throat
infection. Osteomyelitis usually affects the long bones of
the arms and legs. It most often occurs in children and
adolescents as a result of a throat infection. In severe
cases, it can affect the growth plate of the bones, leading
to shortening of the limb.
■ Symptoms. Symptoms of osteomyelitis can include
sudden onset of high fever, chills, tenderness over the
affected bone, leukocytosis (leuko = white, cyto = cell,
osis = condition of increase), and bacteremia (bacte
ria = microscopic organism, emia = blood, bacteria in
the blood). In adults, osteomyelitis often occurs follow
ing a traumatic accident involving the bone or following
bone surgery, especially when implants such as screws,
plates, or other hardware are needed.
96 Chapter 6
■ Diagnosis. Physical examination revealing pain in a
bone along with an elevated white blood cell count can
suggest osteomyelitis. An indicative test is an elevated
erythrocyte sedimentation rate (ESR), and an X-ray exam,
an MRI scan, or a CT scan can also reveal an abnormality.
Diagnosis can be confirmed by taking samples of bone,
pus, blood, or joint fluid to identify infective organisms.
■ Treatment. Treatment for osteomyelitis is aggressive
intravenous antibiotic therapy. The affected bone is
often debrided surgically to speed the healing process.
Surgical hardware is often removed for this same reason.
Acute osteomyelitis, if not treated effectively, can become
chronic and lead to a lifetime of problems for the affected
individual. Chronic osteomyelitis can lead to large, gap
ing scar tissue and chronic wound drainage (Figure 6-7).
■ Prevention. Cleansing and properly treating wounds,
especially deep wounds, aids in the prevention of osteo
myelitis. Blood-borne bacteria must also be promptly
diagnosed and treated. Individuals with artificial joints
or metal components should take preventive antibiotics
prior to any surgery or dental procedure.
Osteomalacia
■ Description. Osteomalacia (OS-tee-oh-muh-LAY-
shuh; osteo = bone, malacia = softening) is the gen
eral term for softening of the bones due to defective
mineralization and the general term for softening of
the bones in adults; in children, it is called rickets.
Figure 6-7 Chronic osteomyelitis scar of the lower leg.
■ Etiology. Osteomalacia is caused by a deficiency of
vitamin D, which aids in the bone mineralization that
causes their characteristic hardness. Without this pro
cess, the bone becomes soft and weak. To mineralize,
bones need calcium, phosphorus, and vitamin D.
Vitamin D deficiency in adults can be due to inad
equate nutritional intake, inadequate exposure to sun
light (skin exposed to sunlight synthesizes vitamin D),
or a malabsorption problem.
■ Symptoms. Symptoms and signs of osteomalacia
include bone pain, loss of height, bending, and defor
mity in weight-bearing bones such as the spine, pelvis,
and legs.
■ Diagnosis. A thorough history of diet and amount of
time in the sun is helpful in diagnosis, followed by blood
testing to measure vitamin D levels and X-rays to look
for cracks in the bone. A bone biopsy is quite definitive
but often not needed for diagnosis.
■ Treatment. Correction of the deficiency potentially
cures the problem. Administering 200,000 IU weekly of
vitamin D for 4 to 6 weeks, followed by an oral dose of
1,600 IU daily, is usually an adequate treatment. How
ever, bones that have bowed, shortened, or flattened
might not regain normal appearance and function.
■ Prevention. Vitamin D deficiency can usually be
avoided by
■ exposing arms and legs to sunlight for 5 to 10 min
utes a day.
■ eating foods high in vitamin D such as oily fish
(salmon, sardines, mackerel) and egg yolks.
■ taking vitamin supplements if needed.
Diseases of the Joints
Most of the diseases of the joints occur as a slow, degen
erative process, so they tend to be more common with
age. As with diseases of the bones, diseases of the joints
often result in the individual requiring assistive devices
or artificial parts to maintain mobility. Frequently,
damage to joints occurring during youth is not appar
ent until middle or older adulthood.
Arthritis
Arthritis (arthro = joint, itis = inflammation) and
rheumatism are terms commonly used to describe a
variety of conditions that cause pain and stiffness in
the musculoskeletal system. Both terms cover a broad
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