lecture 2 pathologies

Pathologies 

Lecture 2 - skeletal system

Skeletal System Pathologies: 

Fractures 

A fracture describes any break  

in a bone. 

• Causes include trauma, low bone  

density (associated with  

osteoporosis), vitamin D deficiency. 

• Can damage blood vessels that  

supply bone and surrounding nerves. 

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Fracture Classification

▪ Complete — bone is broken into two or more  

fragments. Can be either open (perforated skin)  

or closed (soft tissues not compromised). 

▪ Incomplete — bone is fractured but not into  

fragments. 

• Fractures can be linear (along the bone length)  

or transverse — dissect across the bone). 

• Another type is an avulsion fracture, which  

occurs when a tendon or ligament pulls off a  

piece of bone. 

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Fracture Repair 

1. Haematoma (and inflammation): 

callus = mass of tissue

Blood vessels at fracture line are broken and blood  

leaks into site. Causes death of local cells and swelling.  2. Fibrocartilaginous callus formation: 

Phagocytes clean up the debris. Fibroblasts invade and  lay down collagen forming a soft callus (two–three weeks). 3. Bony callus formation: 

Osteoblasts replace soft callus with new bone (< three months). 4. Bone remodelling: 

The callus is mineralised and compact bone laid down.  Then osteoclasts reshape the new bone. Remodelling  

occurs over months to years. 

© CNM: Human Sciences – The Skeletal System. BQ. 

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Fractures: Treatment 

• Address potential causes of fracture (i.e. underlying  nutritional deficiencies, osteoporosis, etc). Improve  

circulation and nutrients to the bone to aid repair. 

• Creams and ointments can be very  

effective — they get absorbed into the area. 

• Herbs — comfrey, gotu kola. 

• Nutrients — calcium, vitamin D, vitamin C. 

• Homeopathic — arnica for bruising, ruta for  injured nerves. Calc phos 4c should be given for two weeks to help fuse bones together. 

© CNM: Human Sciences – The Skeletal System. BQ. 

Arnica

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Sprains 

A sprain involves a trauma that forces a joint  

beyond its normal range, over-straining /  

tearing ligaments. This often leads to joint  

instability. 

TREATMENT: 

• First aid — RICE (Rest, Ice, Compression,  

Elevation). 

• Herbs locally and internally — tissue repair,  

e.g. comfrey. Manual therapy and rehab. 

• Nutrients — glucosamine, vit. C, zinc, vit. E 

• Homeopathy (e.g. arnica, ruta) and acupuncture.₅₀ Ligaments are tough bands of connective tissue that attach bone to bone. 

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Subluxation and Dislocation 

SUBLUXATION: 

• Incomplete or partial joint dislocation. 

DISLOCATION: 

• Complete separation of two bones at a joint. 

• A dislocation leads to reduced strength and  

compromised joint function (movement).  

Associated with a high risk of reoccurrence  

unless sufficiently strengthened.  

• Commonly occurs in the shoulder and knee  (patella). May be accompanied by damage to  soft tissues, nerves and blood vessels. 

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Should the  

patella be there?51 

X-rays 

X-rays are commonly used to visualise the skeletal  

system, lungs, heart and teeth. 

• X-rays pass through less dense matter (air, fat, muscle,  and other tissues) but are absorbed or scattered by  

denser materials (bones, tumours, lungs affected by  

severe pneumonia), appearing white. 

• Blood clots (thromboses) can also be detected by x 

ray, due to the accumulation of RBCs (and hence iron). 

• Adverse effects: Cancer (induces DNA damage /  

genetic mutations) — discussed further in oncology. 

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Kyphosis 

A healthy spine will include a thoracic spine  

kyphosis. This is important as it can help  

distribute forces through the spine. 

• However, some individuals can become hyper 

kyphotic. This may be a result of poor posture  

(due to occupation, stress, body language, etc). 

• A hyper-kyphosis can also occur secondary to  

a disease (e.g. osteoporotic spinal fractures). 

• May cause muscular fatigue around the  

scapula (shoulder blade) or even irritation of  

the rib joints. May also interfere with breathing. 

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Lordosis 

A lordosis describes an increased concavity, as  

seen in the lumbar and cervical spine. 

• A healthy spinal curve will include a cervical spine  

and a lumbar spine lordosis. However, individuals  

can become hyper-lordotic, which can cause pain. 

• May be a genetic / ethnic cause (i.e. Afro-Caribbean  

women) or secondary to other musculoskeletal  

changes. More common in obese individuals. It is  

also a normal adaptation for pregnancy. 

• A hyper-lordotic posture can cause muscular fatigue 

and also encourage the vertebral joints to move  

closer, causing inflammation. 

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Scoliosis 

A scoliosis describes a lateral ‘S’ shaped  

curve in the spine. 

• Generally, the more pronounced the abnormal  

curve, the more clinically relevant. People often  

live with scoliosis and are asymptomatic. 

• People can be born with scoliosis or develop  

it throughout their life (often adolescent onset). 

• Scoliosis can develop as a result of everyday  

imbalances, e.g. carrying rucksack on one  

shoulder. Also common with leg length discrepancies. 

• Severe scoliosis can cause spinal nerve compression. 

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Osteoporosis 

Osteoporosis describes chronic,  progressive thinning of the bone  (porous bone). 

• Characterised by decreased bone  mineral density (BMD), leading to  bone fragility and an increased risk  of fracture. 

• Diagnosed conventionally by dual  x-ray absorptiometry (a DXA scan).  

osteo- = bone -porosis = porous

On this test, a T-Score lower than  -2.5 indicates osteoporosis. 

Osteoporosis animation:  www.youtube.com/watch?v=c5tc01WFYks 

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Osteoporosis Risk Factors 

• Increasing age — over 30 years of age, ability  

to retain calcium lowers. 

• Female and post-menopausal — oestrogen  

would normally suppress osteoclast activity. 

• Poor diet — high acid-forming diet (high in sugars  

and proteins), low in minerals, malnourished,  

excess sodium, caffeine, fizzy drinks. 

• Drugs — long-term corticosteroid therapy  

(> six months). 

• GIT diseases — liver disease, malabsorption  

syndromes, low stomach acidity (gastric acid is  

needed to ionise calcium and assist absorption). 

© CNM: Human Sciences – The Skeletal System. BQ. 

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Osteoporosis Risk Factors 

• Genetics — family history. 

• Sedentary lifestyle. 

• Endocrine pathologies, e.g. Cushing’s  

Syndrome, hyperparathyroidism,  

hyperthyroidism, inability to produce  

oestrogen. 

• Low body weight. 

• High alcohol consumption and smoking. 

• Toxins (heavy metals). 

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Osteoporosis

SIGNS AND SYMPTOMS: 

• Asymptomatic until the bone has reached critical thinness  whereby fractures occur spontaneously with minor trauma.  Commonly affecting spine and hips. 

• Focal pain and kyphotic posture with loss of height. 

• Pain is aggravated by prolonged sitting, standing or bending.  It is relieved by lying on side with hips and knees flexed. 

TREATMENT:  

• Allopathic: Bisphosphonates (alendronic acid) - can cause  muscle & joint pains, fractures, oesophagitis and gastritis. HRT. • Natural: Healthy alkaline diet and no caffeine / alcohol.  Calcium, magnesium, increase vitamin D₃ and K₂^{, weight} bearing exercise, herbs (hormone balancing), avoid toxins. 59 

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Osteomalacia and Rickets 

Osteomalacia and rickets describe  inadequate mineralisation of the bone  matrix in spongy and compact bone. 

• Characterised by decalcification and  hence softening of bone. It is seen  

especially in the spine, pelvis and legs. 

• Rickets: Prior to epiphyseal plate  

closure (< 18yrs). 

• Osteomalacia: As an adolescent or adult. © CNM: Human Sciences – The Skeletal System. BQ. 

osteo- = bone 

-malacia = 'softening'

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Osteomalacia and Rickets

CAUSES:  

• Vitamin D deficiency, possibly due to: 

• Insufficient sunlight. 

• Insufficient dietary vitamin D. 

• Secondary deficiency: Malabsorption disorders. 

• Reduced receptor sites for vitamin D in tissues. 

SIGNS AND SYMPTOMS: 

• Deformed bones (bowed legs) and possible fractures. 

• Severe back pain and muscle weakness. 

• In rickets: Delayed closure of fontanelles and skull softening. 

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osteo- = bone 

Osteomyelitis 

myelo- = marrow -itis = inflammation

A bacterial infection of the bone marrow, resulting in necrosis  and hence bone weakness. 

• Presents as severe bone pain (often worse at night),  with swelling, redness and warmth. 

CAUSES:  

• Bacterial infection (Staphylococcus aureus)  

through the blood supply or post-fracture. 

• Immunosuppression, diabetes, IV drug users. 

INVESTIGATIONS:  

• Bloods: Elevated inflammatory markers (ESR / CRP) and WBCs. • X-ray, MRI. 

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Osteoarthritis  

arthritis = disease  causing painful joints

A degenerative wear-and-tear arthritis of the articular  cartilage, typically affecting weight-bearing (larger)  joints in individuals typically over 50 years of age. 

SIGNS AND SYMPTOMS:  

• Onset is gradual, pain increasing  

(months / years). 

• Joint pain and stiffness. 

• Not associated with systemic  

symptoms. 

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Osteoarthritis  

CAUSES:  

• Primary: Associated with ageing. 80% of 65- year olds have radiological signs of OA. 

• Secondary: Associated with predisposing  factors: 

⮚ Congenital ill-development. 

⮚ Trauma — e.g. fractures, surgery,  

meniscal injury, obesity. 

DIAGNOSIS: 

• X-ray — revealing joint space narrowing,  osteophyte (bone spur) formation,  

squaring of rounded joint surfaces. 

© CNM: Human Sciences – The Skeletal System. BQ. 

arthritis = disease  causing painful joints 

Consider  

the side  

effects. 

Does your  

patient  

really  

need an  

x-ray?

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Osteoarthritis 

PATHOPHYSIOLOGY: 

1. Articular cartilage wears away; underlying bone is exposed. 2. Subchondral bone becomes hard and glossy (eburnation). 3. Remodelling of underlying bone (i.e. thickening) occurs. 4. Compensatory bone overgrowth in an  

attempt to stabilise joint = osteophytes (spurs). 

TREATMENT: 

• Allopathic: NSAIDs, joint replacement. 

• Natural: Nutrition (glucosamine and chondroitin to  

improve cartilage and synovial fluid health / vitamin C / MSM),  Herbs (comfrey, turmeric), Acupuncture, manual therapy (e.g.  osteopathic / chiropractic), homeopathy, weight loss. 

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Rheumatoid Arthritis 

Autoimmune inflammation of the synovium,  

potentially affecting ALL organs except the  

brain (systemic inflammation). 

• Affects 1% of people worldwide, ↑ in women. 

• Peak occurrence between 30–50 years of age.  

AETIOLOGY: 

• Genetic markers (HLA-DR4 and DR1). 

• Infectious agents, e.g. EBV, rubella. 

• Abnormal intestinal permeability, small  

intestinal bacterial overgrowth (SIBO), smoking. 

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Rheumatoid Arthritis  

SIGNS AND SYMPTOMS: 

• Symmetrical / bilateral arthritis of  

small joints (hands and feet mostly).  

• Gradually spreads through more  

proximal structures. 

• Progressive morning stiffness (> one hour). 

• Deformity of joints, e.g. swan neck, ulnar deviation. 

• General malaise and fatigue.  

• Subcutaneous nodules (around fingers and elbows). 

• C1/C2 subluxation and compression of the spinal cord  leading to paralysis and neurological complications. 

• Kidney problems. 

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Rheumatoid Arthritis 

ALLOPATHIC TREATMENT: 

• Anti-inflammatories and immunosuppressants  

(significant implications of immune suppression). 

• Surgery. 

NATURAL TREATMENT: 

• Nutrition: Anti-inflammatory and reducing  

intestinal permeability: Increasing antioxidants,  

Mediterranean diet / increase omega-3, vit. D₃. 

• Herbs for pain, inflammation and immune  

modulation: Turmeric, boswellia, devil’s claw 

• Homeopathy (e.g. rhus tox) and acupuncture. 

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Rheumatoid v. Osteoarthritis  

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Rheumatoid v. Osteoarthritis 

© CNM: Human Sciences – The Skeletal System. BQ. ⁷⁰ 

Ankylosing Spondylitis (AS) 

AS is a systemic autoimmune disease  associated with chronic inflammation of the  spine and sacroiliac joints, often leading to  spinal fusion (ankylosis) and stiffness. • Age of onset is typically between 15–30 years  

of age, more commonly affecting males. • Strong genetic association with HLA-B27  (present in 95% of AS patients). 

• Links with inflammatory bowel diseases  (and leaky gut), as well as urogenital or  intestinal infections such as salmonella  and shigella, cross-reacting with HLA-B27. © CNM: Human Sciences – The Skeletal System. BQ. 

ankylosis = fusion spondylo- = spine -itis = inflammation 

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Ankylosing Spondylitis (AS)

SIGNS AND SYMPTOMS: 

• Typically begins with sacroiliac and lower lumbar  

spine pain, before progressing up the spine. 

Associated with worsening morning stiffness.  

• Lower back symptoms often improve with activity. 

• The lumber lordosis flattens and patients often  

become kyphotic.  

• Hip and heel (Achilles) pain are common. 

• 20% suffer acute iritis — (HLA-B27 diseases) 

• Systemic symptoms: Fever, fatigue and malaise. 

© CNM: Human Sciences – The Skeletal System. BQ. ⁷² 

Ankylosing Spondylitis (AS)

DIAGNOSIS: 

• Elevated blood inflammatory markers  

(ESR/CRP), HLA-B27 positive. 

• X-ray / MRI — identifies characteristic  

bamboo spine. 

TREATMENT: 

• Allopathic: Surgery, anti-inflammatories  

(including non-steroidal and steroids). 

• Natural: Nutrition (remove pathogenic  

organisms / elimination diet / increase  

vitamin D₃ and antioxidants) and herbs  

(anti-inflammatory), homeopathy, acupuncture. 

© CNM: Human Sciences – The Skeletal System. BQ. ⁷³ 

Gout 

Gout is a type of monoarthritis, characterised by  uric acid crystal deposition in synovial joints. 

• One of the most common forms of arthritis in men  (10:1 women), over 40 years of age. 

• Excess uric acid forms solid crystals  

(monosodium urate) on cartilage surfaces. 

• This causes white blood cells to infiltrate  activating an acute inflammatory response. 

• Hyperuricaemia = elevated blood uric acid  levels, due to overproduction or underexcretion. 

• Uric acid is derived from the breakdown of purines. © CNM: Human Sciences – The Skeletal System. BQ. 

mono = one 

arthro- = joint

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Gout 

CAUSES:  

• Increased intake of purine-rich foods (red  

meat, organ meats, shellfish, etc).  

• Dehydration, kidney disease, medications,  

obesity, excessive alcohol consumption  

(competes with uric acid for elimination by the  

kidneys and accelerates purine breakdown),  hypertension, Type II diabetes. 

DIAGNOSIS: 

• Blood serum for uric acid (not definitive 🡪 

Uric acid crystals:

fluctuates) but can be useful to monitor treatment.  

• Analysis of synovial fluid (needle aspiration). 

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Gout 

SIGNS AND SYMPTOMS: 

• Most often affects the big toe. Can affect the  

mid-feet, ankles, knees, elbows, hands. 

• Usually monoarticular (one joint). 

• Sudden onset of intensely painful, red, hot  

and swollen joints, often lasting 12–24  

hours. Shiny skin over joint. 

• Urate crystals can deposit under the skin  

and produce tophi. 

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Gout 

ALLOPATHIC TREATMENT: 

• Allopurinol to prevent episodes (hepatotoxic).  

• Corticosteroid injections (adverse effects: 

indigestion, rapid heartbeat, nausea, insomnia,  

mood changes, diabetes, glaucoma, osteoporosis). 

NATURAL TREATMENT: 

• Nutrition (anti-inflammatory / alkaline,  

folate inhibits the production of uric acid,  

quercetin), weight loss, increase of water  

intake, natural diuretics. 

• Herbs (for inflammation), homeopathy,  acupuncture. 

Folate-rich foods

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Disc Herniation 

The nucleus pulposus of the intervertebral disc  

leaks out through the annulus fibrosus. 

• This tends to affect discs with the highest fluid  

content, most commonly lumbar spine (L5 /  

S1), then cervical spine. (Age 30–40 years).  

• The classic injury mechanism is combined:  

Lumbar spine flexion (bending) and rotation. 

• A herniated disc can compress spinal nerves. 

• Treatment: Manual therapy and exercise,  

homeopathy (arnica); anti-inflammatory nutrients  

and herbs (e.g. devil’s claw, ginger, boswellia). 

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Bursitis  

Bursitis describes inflammation of a bursa. 

• Bursae are located around many joints in  

the body. Commonly affects the shoulder  

(sub-acromial) and hip (trochanteric). 

CAUSES:  

• Repetitive use (for example: Sub-acromial  

bursitis might occur following lots of  

overhead work (e.g. decorating). 

• Sudden trauma, infection, wear and tear.