1. Class Five Part 2

2. Alterations of Musculoskeletal Function Chapter 37

3. Osteoporosis Porous bone Porous bone Poorly mineralized bone Poorly mineralized bone Bone density Bone density Normal bone Normal bone 833 mg/cm 2 833 mg/cm 2 Osteopenic bone Osteopenic bone 833 to 648 mg/cm 2 833 to 648 mg/cm 2 Osteoporosis Osteoporosis <648 mg/cm 2 <648 mg/cm 2

4. Osteoporosis Potential causes Potential causes Decreased levels of estrogen and testosterone Decreased levels of estrogen and testosterone Decreased activity level Decreased activity level Inadequate levels of vitamins D and C, or Mg ++ Inadequate levels of vitamins D and C, or Mg ++

5. Osteoporosis Demonstrated by reduced bone mass/density and an imbalance of bone resorption and formation Demonstrated by reduced bone mass/density and an imbalance of bone resorption and formation Bone histology is usually normal but it lacks structural integrity Bone histology is usually normal but it lacks structural integrity

6. Osteoporosis

7. Osteoporosis

8. Osteoporosis Iatrogenic osteoporosis Iatrogenic osteoporosis Regional osteoporosis Regional osteoporosis Postmenopausal osteoporosis Postmenopausal osteoporosis Glucocorticoid-induced osteoporosis Glucocorticoid-induced osteoporosis Age-related bone loss Age-related bone loss

9. Osteoporosis

10. Osteoporosis

11. Osteoporosis

12. Osteomalacia Deficiency of vitamin D lowers the absorption of calcium from the intestines Deficiency of vitamin D lowers the absorption of calcium from the intestines Inadequate or delayed mineralization Inadequate or delayed mineralization Bone formation progresses to osteoid formation but calcification does not occur; the result is soft bones Bone formation progresses to osteoid formation but calcification does not occur; the result is soft bones Pain, bone fractures, vertebral collapse, bone malformation Pain, bone fractures, vertebral collapse, bone malformation

13. Osteomyelitis Osteomyelitis is most often caused by a staphylococcal infection Osteomyelitis is most often caused by a staphylococcal infection Most common cause is open wound (exogenous); also can be from a blood-borne (endogenous) infection Most common cause is open wound (exogenous); also can be from a blood-borne (endogenous) infection

14. Osteomyelitis Manifestations Manifestations Acute and chronic inflammation, fever, pain, necrotic bone Acute and chronic inflammation, fever, pain, necrotic bone Treatment Treatment Antibiotics, débridement, surgery, hyperbaric oxygen therapy Antibiotics, débridement, surgery, hyperbaric oxygen therapy

15. Osteomyelitis

16. Osteomyelitis

17. Inflammatory vs. Noninflammatory Joint Disease Differentiated by: Differentiated by: Absence of synovial membrane inflammation Absence of synovial membrane inflammation Lack of systemic signs and symptoms Lack of systemic signs and symptoms Normal synovial fluid analysis Normal synovial fluid analysis

18. Inflammatory Joint Disease Commonly called osteoarthritis Commonly called osteoarthritis Characterized by inflammatory damage or destruction in the synovial membrane or articular cartilage and by systemic signs of inflammation Characterized by inflammatory damage or destruction in the synovial membrane or articular cartilage and by systemic signs of inflammation Fever, leukocytosis, malaise, anorexia, and hyperfibrinogenemia Fever, leukocytosis, malaise, anorexia, and hyperfibrinogenemia Infectious or noninfectious Infectious or noninfectious

19. Osteoarthritis Degeneration and loss of articular cartilage, sclerosis of bone underneath cartilage, and formation of bone spurs (osteophytes) Degeneration and loss of articular cartilage, sclerosis of bone underneath cartilage, and formation of bone spurs (osteophytes) Also referred to as degenerative joint disease Also referred to as degenerative joint disease Incidence increases with age Incidence increases with age Primary disease is idiopathic Primary disease is idiopathic

20. Osteoarthritis Osteoarthritis is characterized by local areas of damage and loss of articular cartilage, new bone formation of joint margins, subchondral bone changes, and variable degrees of mild synovitis and thickening of the joint capsule Osteoarthritis is characterized by local areas of damage and loss of articular cartilage, new bone formation of joint margins, subchondral bone changes, and variable degrees of mild synovitis and thickening of the joint capsule Manifestations Manifestations Pain, stiffness, enlargement of the joint, tenderness, limited motion, and deformity Pain, stiffness, enlargement of the joint, tenderness, limited motion, and deformity

21. Osteoarthritis

22. Osteoarthritis

23. Osteoarthritis

24. Osteoarthritis

25. Rheumatoid Arthritis Inflammatory joint disease Inflammatory joint disease Systemic autoimmune damage to connective tissue, primarily in the joints (synovial membrane) Systemic autoimmune damage to connective tissue, primarily in the joints (synovial membrane) Similar symptoms to osteoarthritis Similar symptoms to osteoarthritis

26. Rheumatoid Arthritis Presence of rheumatoid factors (RA or RF test) Presence of rheumatoid factors (RA or RF test) Antibodies (IgG and IgM) against antibodies Antibodies (IgG and IgM) against antibodies Joint fluid presents with inflammatory exudate Joint fluid presents with inflammatory exudate

27. Rheumatoid Arthritis Pathogenesis Pathogenesis CD4 T helper cells and other cells in the synovial fluid become activated and release cytokines CD4 T helper cells and other cells in the synovial fluid become activated and release cytokines Recruitment and retention of inflammatory cells in the joint sublining region Recruitment and retention of inflammatory cells in the joint sublining region Cycle of altered cytokine and signal transduction pathways Cycle of altered cytokine and signal transduction pathways

28. Rheumatoid Arthritis Pathogenesis Pathogenesis Possible immune complex deposition and inflammatory cytokine release Possible immune complex deposition and inflammatory cytokine release RANKL release and osteoclast activation RANKL release and osteoclast activation Angiogenesis in the synovium Angiogenesis in the synovium

29. Rheumatoid Arthritis Evaluation Evaluation Four or more of the following: Four or more of the following: Morning joint stiffness lasting at least 1 hour Morning joint stiffness lasting at least 1 hour Arthritis of three or more joint areas Arthritis of three or more joint areas Arthritis of the hand joints Arthritis of the hand joints Symmetric arthritis Symmetric arthritis Rheumatoid nodules Rheumatoid nodules Abnormal amounts of serum rheumatoid factor Abnormal amounts of serum rheumatoid factor Radiographic changes Radiographic changes

30. Rheumatoid Arthritis

33. Structure, Function, and Disorders of the Integument Chapter 39

34. Layers of the Skin Epidermis Epidermis Dermis Dermis Hypodermis Hypodermis

35. Layers of the Skin

36. Dermal appendages Dermal appendages Nails Nails Hair Hair Sebaceous glands Sebaceous glands Eccrine and apocrine sweat glands Eccrine and apocrine sweat glands Blood supply Blood supply Papillary capillaries Papillary capillaries

37. Clinical Manifestations of Skin Dysfunction Macule Macule Papule Papule Patch Patch Plaque Plaque Wheal Wheal Nodule Nodule Tumor Tumor Vesicle Vesicle Bulla Bulla Pustule Pustule Cyst Cyst Telangiectasia Telangiectasia Scale Scale Lichenification Lichenification Keloid Keloid Scar Scar Excoriation Excoriation Fissure Fissure Erosion Erosion Ulcer Ulcer Atrophy Atrophy

38. Pressure Ulcers Pressure ulcers result from any unrelieved pressure on the skin, causing underlying tissue damage Pressure ulcers result from any unrelieved pressure on the skin, causing underlying tissue damage Pressure Pressure Shearing forces Shearing forces Friction Friction Moisture Moisture

39. Pressure Ulcers

40. Stages Stages Nonblanchable erythema of intact skin Nonblanchable erythema of intact skin Partial-thickness skin loss involving epidermis or dermis Partial-thickness skin loss involving epidermis or dermis Full-thickness skin loss involving damage or loss of subcutaneous tissue Full-thickness skin loss involving damage or loss of subcutaneous tissue Full-thickness skin loss with damage to muscle, bone, or supporting structures Full-thickness skin loss with damage to muscle, bone, or supporting structures

41. Keloids Elevated, rounded, and firm Elevated, rounded, and firm Clawlike margins that extend beyond the original site of injury Clawlike margins that extend beyond the original site of injury Excessive collagen formation during dermal connective tissue repair Excessive collagen formation during dermal connective tissue repair Common in darkly pigmented skin types and burn scars Common in darkly pigmented skin types and burn scars Type III collagen is increased Type III collagen is increased

42. Keloids

43. Pruritus Itching Itching Most common symptom of primary skin disorders Most common symptom of primary skin disorders Itch is carried by specific unmyelinated C-nerve fibers and is triggered by a number of itch mediators Itch is carried by specific unmyelinated C-nerve fibers and is triggered by a number of itch mediators The CNS can modulate the itch response The CNS can modulate the itch response

44. Pruritus Pain stimuli at lower intensities can induce itching Pain stimuli at lower intensities can induce itching Chronic itching can result in infections and scarring due to persistent scratching Chronic itching can result in infections and scarring due to persistent scratching

45. Inflammatory Disorders Allergic contact dermatitis Allergic contact dermatitis Caused by a hypersensitivity type IV reaction Caused by a hypersensitivity type IV reaction The allergen comes in contact with the skin, binds to a carrier protein to form a sensitizing antigen; Langerhans cells process the antigen and carry it to T cells, which become sensitized to the antigen The allergen comes in contact with the skin, binds to a carrier protein to form a sensitizing antigen; Langerhans cells process the antigen and carry it to T cells, which become sensitized to the antigen Manifestations: erythema, swelling, pruritus, vesicular lesions Manifestations: erythema, swelling, pruritus, vesicular lesions

46. Allergic Contact Dermatitis

47. Inflammatory Disorders Atopic dermatitis Atopic dermatitis Type I hypersensitivity—activation of mast cells, eosinophils, T-lymphocytes, and other inflammatory cells Type I hypersensitivity—activation of mast cells, eosinophils, T-lymphocytes, and other inflammatory cells Causes red, weeping crusts and chronic inflammation, lichenification Causes red, weeping crusts and chronic inflammation, lichenification

48. Inflammatory Disorders Irritant contact dermatitis Irritant contact dermatitis Nonimmunologic inflammation of the skin Nonimmunologic inflammation of the skin Chemical irritation from acids or prolonged exposure to irritating substances Chemical irritation from acids or prolonged exposure to irritating substances Symptoms similar to allergic contact dermatitis Symptoms similar to allergic contact dermatitis Treatment—remove stimulus Treatment—remove stimulus

49. Inflammatory Disorders Stasis dermatitis Stasis dermatitis Occurs in the legs as a result of venous stasis, edema, and vascular trauma Occurs in the legs as a result of venous stasis, edema, and vascular trauma Sequence of events: erythema, pruritus, scaling, petechiae, ulcerations Sequence of events: erythema, pruritus, scaling, petechiae, ulcerations

50. Inflammatory Disorders Seborrheic dermatitis Seborrheic dermatitis Inflammation of the skin involving the scalp, eyebrows, eyelids, nasolabial folds, and ear canals Inflammation of the skin involving the scalp, eyebrows, eyelids, nasolabial folds, and ear canals Scaly, white, or yellowish plaques Scaly, white, or yellowish plaques

51. Stasis and Seborrheic Dermatitis

52. Papulosquamous Disorders Psoriasis Psoriasis Chronic, relapsing, proliferative skin disorder Chronic, relapsing, proliferative skin disorder T cell immune–mediated skin disease T cell immune–mediated skin disease Scaly, thick, silvery, elevated lesions, usually on the scalp, elbows, or knees caused by a high rate of mitosis in the basale layer Scaly, thick, silvery, elevated lesions, usually on the scalp, elbows, or knees caused by a high rate of mitosis in the basale layer

53. Papulosquamous Disorders Psoriasis Psoriasis Shows evidence of dermal and epidermal thickening Shows evidence of dermal and epidermal thickening Epidermal turnover goes from 26 to 30 days to 3 to 4 days Epidermal turnover goes from 26 to 30 days to 3 to 4 days Cells do not have time to mature or adequately keratinize Cells do not have time to mature or adequately keratinize

54. Psoriasis

55. Papulosquamous Disorders Pityriasis rosea Pityriasis rosea Benign, self-limiting inflammatory disorder Benign, self-limiting inflammatory disorder Usually occurs during the winter months Usually occurs during the winter months Herald patch Herald patch Circular, demarcated, salmon-pink, 3- to 4-cm lesion Circular, demarcated, salmon-pink, 3- to 4-cm lesion

56. Papulosquamous Disorders

57. Lichen planus Lichen planus Benign, inflammatory disorder of the skin and mucous membranes Benign, inflammatory disorder of the skin and mucous membranes Unknown origin, but T cells, adhesion molecules, inflammatory cytokines, and antigen presenting cells are involved Unknown origin, but T cells, adhesion molecules, inflammatory cytokines, and antigen presenting cells are involved Nonscaling, violet-colored, 2- to 4-mm lesions Nonscaling, violet-colored, 2- to 4-mm lesions Wrists, ankles, lower legs, genitalia Wrists, ankles, lower legs, genitalia

58. Lichen Planus

59. Papulosquamous Disorders Acne vulgaris Acne vulgaris Inflammatory disease of the pilosebaceous follicles Inflammatory disease of the pilosebaceous follicles

60. Papulosquamous Disorders Acne rosacea Acne rosacea Inflammation of the skin that develops in adulthood Inflammation of the skin that develops in adulthood Lesions Lesions Erythematotelangiectatic, papulopustular, phymatous, and ocular Erythematotelangiectatic, papulopustular, phymatous, and ocular Associated with chronic, inappropriate vasodilation resulting in flushing and sensitivity to the sun Associated with chronic, inappropriate vasodilation resulting in flushing and sensitivity to the sun

61. Papulosquamous Disorders Lupus erythematosus Lupus erythematosus Inflammatory, autoimmune disease with cutaneous manifestations Inflammatory, autoimmune disease with cutaneous manifestations Discoid lupus erythematosus Discoid lupus erythematosus Restricted to the skin Restricted to the skin Photosensitivity Photosensitivity Butterfly pattern over the nose and cheeks Butterfly pattern over the nose and cheeks Systemic lupus erythematosus Systemic lupus erythematosus

62. Vesiculobullous Disorders Pemphigus Pemphigus Rare, chronic, blister-forming disease of the skin and oral mucous membranes Rare, chronic, blister-forming disease of the skin and oral mucous membranes Blisters form in the deep or superficial epidermis Blisters form in the deep or superficial epidermis Autoimmune disease caused by circulating IgG autoantibodies Autoimmune disease caused by circulating IgG autoantibodies The antibodies are against the cell surface adhesion molecule, desmoglein in the suprabasal layer of the epidermis The antibodies are against the cell surface adhesion molecule, desmoglein in the suprabasal layer of the epidermis

63. Vesiculobullous Disorders Pemphigus Pemphigus Tissue biopsies demonstrate autoantibody presence Tissue biopsies demonstrate autoantibody presence Types Types Pemphigus vulgaris (severe) Pemphigus vulgaris (severe) Pemphigus foliaceus Pemphigus foliaceus Pemphigus erythematosus Pemphigus erythematosus

64. Vesiculobullous Disorders Bullous pemphigoid Bullous pemphigoid More benign disease than pemphigus vulgaris More benign disease than pemphigus vulgaris Bound IgG and blistering of the subepidermal skin layer Bound IgG and blistering of the subepidermal skin layer Subepidermal blistering and eosinophils distinguish pemphigoid from pemphigus Subepidermal blistering and eosinophils distinguish pemphigoid from pemphigus

65. Bullous Pemphigoid

66. Vesiculobullous Disorders Erythema multiforme Erythema multiforme Acute, recurring disorder of the skin and mucous membranes Acute, recurring disorder of the skin and mucous membranes Associated with allergic or toxic reactions to drugs or microorganisms Associated with allergic or toxic reactions to drugs or microorganisms Caused by immune complexes formed and deposited around dermal blood vessels, basement membranes, and keratinocytes Caused by immune complexes formed and deposited around dermal blood vessels, basement membranes, and keratinocytes

67. Vesiculobullous Disorders Erythema multiforme Erythema multiforme “Bull’s-eye” or target lesion “Bull’s-eye” or target lesion Erythematous regions surrounded by rings of alternating edema and inflammation Erythematous regions surrounded by rings of alternating edema and inflammation

68. Vesiculobullous Disorders Erythema multiforme Erythema multiforme Bullous lesions form erosions and crusts when they rupture Bullous lesions form erosions and crusts when they rupture Affects the mouth, air passages, esophagus, urethra, and conjunctiva Affects the mouth, air passages, esophagus, urethra, and conjunctiva Severe forms Severe forms Stevens-Johnson syndrome (bullous form) Stevens-Johnson syndrome (bullous form) Toxic epidermal necrolysis Toxic epidermal necrolysis

69. Infections Bacterial infections Bacterial infections Folliculitis Folliculitis Furuncles Furuncles Carbuncles Carbuncles Cellulitis Cellulitis Erysipelas Erysipelas Impetigo Impetigo

70. Furuncle

71. Infections Viral infections Viral infections Herpes zoster and varicella Herpes zoster and varicella

72. Herpes Simplex Virus

73. Disorders of the Nail Paronychia Paronychia Acute or chronic infection of the cuticle Acute or chronic infection of the cuticle Onychomycosis Onychomycosis Fungal or dermatophyte infection of the nail plate Fungal or dermatophyte infection of the nail plate

74. Benign Tumors Seborrheic keratosis Seborrheic keratosis Keratoacanthoma Keratoacanthoma Actinic keratosis Actinic keratosis Nevi (moles) Nevi (moles)

75. Benign Tumors

76. Cancer Basal cell carcinoma Basal cell carcinoma Squamous cell carcinoma Squamous cell carcinoma Malignant melanoma Malignant melanoma Kaposi sarcoma Kaposi sarcoma

77. Cancer

78. Cancer

79. Cancer

80. Cancer