Chapter 44: Alterations of Musculoskeletal Function

MULTIPLE CHOICE
1. What type of fracture occurs at a site of a preexisting bone abnormality and is a result of a

force that would not normally cause a fracture?

c. Pathologic
d. Greenstick

a. Idiopathic
b. Incomplete
ANS: C

Only a pathologic fracture is a break at the site of a preexisting abnormality, usually by force
that would not fracture a normal bone.
PTS: 1

REF: Page 1541

2. Which type of fracture usually occurs in an individual who engages in a new activity that is

strenuous and repetitive?

a. Stress
b. Greenstick

c. Insufficiency
d. Pathologic

ANS: A

Only a stress fracture occurs in normal or abnormal bone that is subjected to repeated stress,
such as repetitive and strenuous activities that occur during athletics.
PTS: 1

REF: Page 1541

3. Which term is used to identify the temporary displacement of two bones causing the bone

surfaces to partially lose contact?

a. Dislocation
b. Subluxation

c. Malunion
d. Nonunion

ANS: B

Dislocation is the temporary displacement of a bone from its normal position in a joint. If the
contact between the two surfaces is only partially lost, then the injury is referred to as a
subluxation. This selection is the only option that identifies the temporary displacement of two
bones, causing the bone surfaces to partially lose contact.
PTS: 1

REF: Page 1544

4. Improper reduction or immobilization of a fractured femur can result in which outcome after

cast removal?
The muscles around the fracture site are weak.
The fracture requires 6 to 8 weeks of physical therapy.
The skin under the cast is dry and flaky.
The bone is not straight.

a.
b.
c.
d.

ANS: D

Improper reduction or immobilization of a fractured bone may result in nonunion, delayed

union, or malunion. Malunion is the healing of a bone in a nonanatomic position that could
result in the bone not being straight. The other options are not outcomes of improper reduction
or immobilization.

PTS: 1

REF: Page 1543

5. Which structure attaches skeletal muscle to bone?

a. Tendon
c. Bursa
b. Ligament
d. Mesentery
ANS: A

A tendon is fibrous connective tissue that attaches skeletal muscle to bone. None of the other
options are associated with this function.
PTS: 1

REF: Page 1545

6. The tear in a ligament is referred to as a:

a. Fracture
b. Strain

c. Disunion
d. Sprain

ANS: D

Ligament tears are commonly known as sprains. None of the other options are associated with
this damage.
PTS: 1

REF: Page 1545

7. Which medical diagnosis is characterized by tissue degeneration or irritation of the extensor

carpi radialis brevis tendon?

a. Lateral epicondylitis
b. Medial tendinitis

c. Bursitis
d. Lateral tendinitis

ANS: A

Only lateral epicondylopathy, commonly called tennis elbow, is the result of tissue
degeneration or irritation of the extensor carpi radialis brevis tendon at its origin.
PTS: 1

REF: Page 1546

8. The pain resulting from tendon and ligament injuries is usually described as:
a. Dull and diffuse, persisting over the distribution of the tendon or ligament
b. Sharp and localized, persisting over the distribution of the tendon or ligament
c. Pins-and-needle sensations that occur distal to the injury with movement
d. Intermittent and aching, occurring over the distribution of the tendon or ligament
ANS: B

The pain resulting from tendon and ligament injuries is usually described as being sharp and
localized, persisting over the distribution of the tendon or ligament. This selection is the only
option that accurately describes this type of pain.
PTS: 1

REF: Page 1545

9. How is rhabdomyolysis characterized?

a. Paralysis of skeletal muscles, resulting from an impaired nerve supply
b. Smooth muscle degeneration, resulting from ischemia
c. Lysis of skeletal muscle cells through the initiation of the complement cascade
d. Release of myoglobin from damaged striated muscle cells

ANS: D

Rhabdomyolysis involves the release of myoglobin when muscle cells are damaged. This
selection is the only accurate description of rhabdomyolysis.
PTS: 1

REF: Pages 1547-1550

10. Which pathophysiologic alteration precedes crush syndrome after prolonged muscle

compression?
a. Muscle ischemia
b. Myoglobinuria

c. Volkmann contracture
d. Neural injury

ANS: B

Myoglobinuria is an excess of myoglobin (an intracellular muscle protein) in the urine.

Muscle cell damage releases the myoglobin. The most severe form is often called crush
syndrome. Less severe and more localized forms of muscle damage are called compartment
syndromes. This selection is the only option that accurately identifies the pathophysiologic
alteration that precedes crush syndrome.
PTS: 1

REF: Pages 1547-1549

11. By the time osteoporosis is visible on an x-ray examination, up to what percent of bone has

been lost?
a. 30%
b. 40%

c. 50%
d. 60%

ANS: A

Generally, osteoporosis is radiographically detected as increased radiolucency of bone. By the

time abnormalities are detected by x-ray examination, as much as 25% to 30% of bone tissue
may have been lost.
PTS: 1

REF: Page 1555

12. A bone density of 645 mg/cm2 would support which diagnosis?

a. Osteoplasia
c. Osteopenia
b. Osteoporosis
d. Osteomalacia
ANS: B

The World Health Organization (WHO) has defined osteoporosis on the basis of bone density.
Normal bone is greater than 833 mg/cm2; osteopenia, or decreased bone mass, is 833 to 648
mg/cm2; osteoporosis is less than 648 mg/cm2. This selection is the only accepted option.
PTS: 1

REF: Page 1550

13. Which type of osteoporosis would a person develop after having the left leg in a cast for 8

weeks to treat a compound displaced fracture of the tibia and fibula?

a. Iatrogenic
c. Idiopathic
b. Regional
d. Osteoblastic
ANS: B

Of the options available, only classic regional osteoporosis is associated with disuse or
immobilization of a limb because of fractures, motor paralysis, or bone or joint inflammation.

PTS: 1

REF: Page 1553

14. Considering the pathophysiologic process of osteoporosis, after being activated by receptor

activator of nuclear factor B ligand (RANKL), receptor activator of nuclear factor B

(RANK) activates which of the following?
a. Osteoclast apoptosis
c. Osteoprotegerin
b. Osteoblast survival
d. Osteoclast survival
ANS: D

RANKL activates the receptor RANK, which is expressed on osteoclasts and their precursors
and suppresses apoptosis, which leads to activation and the prolongation of osteoclast
survival. This statement is not true of any of the other options.
PTS: 1

REF: Page 1553

15. Considering the pathophysiologic process of postmenopausal osteoporosis, which changes are

believed to play a significant role in the development of age-related bone loss?

Increased oxidative stress and increased intracellular reactive oxygen species
Hypoparathyroidism
Increased body weight
Decreased formation and short life span of osteoclasts

a.
b.
c.
d.

ANS: A

Postmenopausal osteoporosis occurs in middle-aged and older women. It can occur because
of estrogen deficiency, as well as estrogen-independent, age-related mechanisms (e.g.,
secondary causes such as hyperparathyroidism and decreased mechanical stimulation). Recent
studies indicate that increased oxidative stress (OS) and increased intracellular reactive
oxygen species (ROS) play significant roles in the development of age-related bone loss, as
well as other age-related changes in the body. Hormonal deficiency also can increase with
stress, excessive exercise, and low body weight. Increased formation and longevity of
osteoclasts results in increased bone resorption and is associated with a cascade of
proinflammatory cytokines.
PTS: 1

REF: Page 1552

16. Considering the pathophysiologic process of osteoporosis, which hormone exerts

antiapoptotic effects on osteoblasts but proapoptotic effects on osteoclasts?

c. Growth hormone
d. Estrogen

a. Parathyroid hormone
b. Glucocorticoid
ANS: D

Data reveal that sex steroids (e.g., estrogens) exert antiapoptotic effects on osteoblasts but
exert proapoptotic effects on osteoclasts; in both scenarios, activating the extracellular signalregulated kinases (ERKs) accomplish these effects. This process is not true of any of the other
options.
PTS: 1

REF: Page 1553

17. Considering the pathophysiologic process of osteoporosis, what are the effects of extracellular

signal-regulated kinases (ERKs) and receptor activator of nuclear factor B ligand (RANKL)
on osteoblasts and osteoclasts?

a. ERKs increase the life span of osteoclasts, and RANKL decreases the life span of

osteoblasts.
b. ERKs and RANKL increase the life span of osteoclasts and decrease the life span

of osteoblasts.
c. ERKs and RANKL increase the life span of osteoblasts and decrease the life span

of osteoclasts.
d. ERKs increase the life span of osteoblasts, and RANKL decreases the life span of

osteoclasts.
ANS: B

In addition to ERKs, RANKL is required for the antiapoptotic effect and thus longer life span
of osteoclasts. This effect also shortens the life span of the bone-forming cells, or osteoblasts.
This process is not true of any of the other options.
PTS: 1

REF: Page 1553

18. What is the most common clinical manifestation of osteoporosis?

a. Bone deformity
c. Pathologic fracture
b. Bone pain
d. Muscle strain
ANS: A

The most common clinical manifestation of osteoporosis is bone deformity.

PTS: 1

REF: Page 1555

19. Which disorder is characterized by the formation of abnormal new bone at an accelerated rate

beginning with excessive resorption of spongy bone?

c. Osteoporosis
d. Osteosarcoma

a. Osteomalacia
b. Paget disease
ANS: B

Of the available options, only Paget disease (osteitis deformans) is a state of increased
metabolic activity in bone characterized by abnormal and excessive bone remodeling, both
resorption and formation. Chronic accelerated remodeling eventually enlarges and softens the
affected bones.
PTS: 1

REF: Pages 1557-1558

20. Which statement is false about factors that contribute to the difficulty in treating bone

infections?
a. Bone contains multiple microscopic channels that are impermeable to the cells and

biochemicals of the bodys natural defenses.

b. Microcirculation of bone is highly vulnerable to damage and destruction by

bacterial toxins, leading to ischemic necrosis of bone.

c. Bone cells have a limited capacity to replace bone destroyed by infections.
d. Bacteria are walled off by macrophages and T lymphocytes; consequently, the

antibiotics cannot penetrate the infected area.

ANS: D

Bacteria are not walled off by macrophages and T lymphocytes, thus inhibiting the effects of
antibiotics. The other options are true statements regarding factors that contribute to the
difficulty in treating bone infections.

PTS: 1

REF: Page 1560

21. Bone death as a result of osteomyelitis is due to what?

a. Formation of immune complexes at the site of infection
b. Localized ischemia
c. Tumor necrosis factoralpha (TNF-) and interleukin 1 (IL-1)
d. Impaired nerve innervation at the site of infection
ANS: B

Vessel damage causes local thrombosis (blockage) of the small vessels, which leads to
ischemic necrosis (death) of bone. This selection is the only option that is associated with
bone death as a result of osteomyelitis.
PTS: 1

REF: Page 1560

22. When considering osteomyelitis, sequestrum is identified as what?

a. An area of devascularized and devitalized bone
b. An enzyme that phagocytizes necrotic bone
c. A subperiosteal abscess
d. A layer of new bone surrounding the infected bone
ANS: A

Lifting of the periosteum disrupts blood vessels that enter bone through the periosteum, which
deprives the underlying bone of its blood supply. This deprivation leads to necrosis and death
of the area of infected bone, producing sequestrum, an area of devitalized bone. None of the
other available options accurately identify the term sequestrum.
PTS: 1

REF: Page 1559

23. What pattern of bone destruction is described as not well-defined and not easily separated

from normal bone?

a. Moth-eaten
b. Permeative

c. Geographic
d. Porous

ANS: A

Moth-eaten pattern is the only option that involves destruction that is not well-defined and not
easily separated from normal bone.
PTS: 1

REF: Pages 1562-1563 | Table 44-5

24. Which statement accurately describes a characteristic of osteosarcoma?

a. Slow-growing tumor that begins in the bone marrow and infiltrates the trabeculae
b. Solitary tumor that most often affects the metaphyseal region of the femur or tibia
c. Aggressive tumor most often found in the bone marrow of long bones
d. Tumor that infiltrates the trabeculae in spongy bone and implants in surrounding

tissue by seeding
ANS: C

An osteosarcoma is a malignant bone-forming tumor. It is aggressive and most often found in

bone marrow; it has a moth-eaten pattern of bone destruction. This selection is the only option
that accurately describes a characteristic of osteosarcoma.

PTS: 1

REF: Page 1563

25. Which statement is false concerning giant cell tumors?

a. Giant cell tumors are an overexpression of genes including osteoprotegerin ligand

(OPGL).
b. The tumors are malignant, solitary, and irregularly shaped.
c. Giant cell tumors are typically located in the epiphysis in the femur, tibia, radius,

and humerus.
d. They are slow-growing tumors that extend over the articular cartilage.
ANS: B

The giant cell tumor is generally a benign, solitary, circumscribed tumor that causes extensive
bone resorption because of its osteoclastic origin. The other options are true statements
concerning giant cell tumors.
PTS: 1

REF: Pages 1564-1565

26. Which is a characteristic of inflammatory joint disease?

a. Unilateral joint involvement
b. Normal joint synovial fluid
c. Absence of synovial membrane inflammation
d. Systemic symptoms of inflammation
ANS: D

Inflammatory joint disease is characterized by systemic signs of inflammation (fever,

leukocytosis, malaise, anorexia, hyperfibrinogenemia) and inflammatory damage or
destruction in the synovial membrane or articular cartilage. This selection is the only option
that accurately describes a characteristic of inflammatory joint disease.
PTS: 1

REF: Page 1568

27. What is a primary defect in osteoarthritis?

a. Stromelysin and acid metalloproteinase break down articular cartilage.
b. Immunoglobulin G (IgG) destroys the synovial membrane.
c. Synovial membranes become inflamed.
d. Cartilage-coated osteophytes create bone spurs.
ANS: A

Of the options available, the primary defect in osteoarthritis is the loss of articular cartilage.
PTS: 1

REF: Pages 1565-1566

28. In osteoarthritis, what is the effect of the disruption of the pumping action of proteoglycans?
a. Pump malfunction stimulates the induction of nitric oxide synthase and nitric

oxide, which degrades the cartilage.

b. Cartilage is damaged by proteolytic enzymes because they cannot be pumped out

of the joint.
c. Cartilage becomes dry, brittle, and wears away because fluid cannot be pumped

into the cartilage.

d. Cartilage takes in too much fluid and is unable to withstand the stresses of weight

bearing.

ANS: D

Changes in the conformation of proteoglycans disrupt the pumping action that regulates the
movement of water and synovial fluid into and out of the cartilage. Without the regulatory
action of the proteoglycan pump, cartilage imbibes too much fluid and becomes less able to
withstand the stresses of weight bearing. This selection is the only option that accurately
describes the disruption of the pumping action of proteoglycans when considering
osteoarthritis.
PTS: 1

REF: Page 1566

29. Which joint disease is characterized by joint stiffness on movement and joint pain of weight-

bearing joints that is usually relieved by rest?

a. Gouty arthritis
b. Rheumatoid arthritis

c. Osteoarthritis
d. Suppurative arthritis

ANS: C

Pain and stiffness in one or more joints, usually weight-bearing or load-bearing joints, are the
first symptoms of osteoarthritis. Use-related joint pain relieved by rest is a key feature. This
selection is the only option that accurately identifies the disease associated with the described
symptoms.
PTS: 1

REF: Page 1567

30. Which medical diagnosis is described as a chronic inflammatory joint disease characterized by

stiffening and fusion of the spine and sacroiliac joints?

a. Ankylosing spondylitis
c. Paget disease
b. Rheumatoid arthritis
d. Fibromyalgia
ANS: A

Of the options available, only ankylosing spondylitis (spondyloarthritis) is described as a

chronic, inflammatory joint disease characterized by stiffening and fusion (ankylosis) of the
spine and sacroiliac joints.
PTS: 1

REF: Page 1572

31. What is the primary pathologic alteration resulting from ankylosing spondylitis (AS)?
a. Inflammation of the sacroiliac joint
b. Inflammation of the long bones
c. Inflammation of fibrocartilaginous joints of the vertebrae
d. Inflammation of the small hand and feet bones
ANS: C

AS involves inflammation of fibrocartilage in cartilaginous joints, primarily in the vertebrae.

The other options do not accurately describe the primary pathologic alterations of AS.
PTS: 1

REF: Pages 1573-1574

32. In ankylosing spondylitis, the CD8+ T cells are presented with which antigen?
a. Synovium
c. Tendons
b. Cartilage
d. Ligaments
ANS: B

Cartilage antigens are proposed as the targets for the immune response and the presentation of
such antigens to CD8+ T cells. This statement is not true of any of the other options.
PTS: 1

REF: Page 1573

33. People with gout are at high risk for which co-morbid condition?
a. Renal calculi
c. Anemia
b. Joint trauma
d. Hearing loss
ANS: A

Renal stones are 1000 times more prevalent in individuals with primary gout than they are in
the general population. This statement is not true of any of the other options.
PTS: 1

REF: Page 1578

34. What causes the crystallization within the synovial fluid of the joint affected by gouty

arthritis?
Reduced excretion of purines
Overproduction of uric acid
Increase in the glycosaminoglycan levels
Overproduction of proteoglycans

a.
b.
c.
d.

ANS: B

When the uric acid reaches a certain concentration in fluids, it crystallizes, forming insoluble
precipitates that are deposited in connective tissues throughout the body. Crystallization in
synovial fluid causes acute, painful inflammation of the joint, a condition known as gouty
arthritis. This selection is the only option that accurately identifies the cause of crystallization
in synovial fluid associated with gouty arthritis.
PTS: 1

REF: Pages 1574-1575

35. The pathophysiologic presentation of gout is closely linked to the metabolism of which

chemical?
a. Purine
b. Pyrimidine

c. Vitamin E
d. Amino acid

ANS: A

The pathophysiologic presentation of gout is closely linked only to purine metabolism (or
cellular metabolism of purines) and kidney function.
PTS: 1

REF: Page 1575

36. Which clinical manifestations are associated with fibromyalgia?

a. Hot, tender, and edematous muscle groups bilaterally
b. Fasciculations of the upper and lower extremity muscles
c. Exercise intolerance and painful muscle cramps
d. Sensitivity at tender points and profound fatigue
ANS: D

Widespread joint and muscle pain, fatigue, and tender points are characteristics of
fibromyalgia, a chronic musculoskeletal syndrome. Increased sensitivity to touch (i.e., tender
points), the absence of systemic or localized inflammation, and fatigue and sleep disturbances
are common. Fatigue is profound. The remaining options include symptoms not generally
associated with fibromyalgia.
PTS: 1

REF: Pages 1579-1580

37. At what age is peak bone mass and strength reached in women?
a. 15 years
c. 30 years
b. 20 years
d. 35 years
ANS: C

Bone formation continues at a pace faster than resorption until peak bone massor maximum
bone density and strengthis reached at approximately 30 years of age, after which bone
resorption slowly exceeds bone formation.
PTS: 1

REF: Page 1550

38. What event is associated with the beginning of bone loss in women?
a. Puberty
c. Childbirth
b. Sexual activity
d. Menopause
ANS: D

Bone loss in women is associated with menopause. Bone loss is most rapid in the first years
after menopause but persists throughout the postmenopausal years. The other options are not
relevant as triggers for bone loss.
PTS: 1

REF: Page 1550

39. What term is used to identify the calcium crystals that are associated with chronic gout?
a. Stones
c. Tophi
b. Spurs
d. Nodes
ANS: C

With time, crystal deposition in subcutaneous tissues causes the formation of small white
nodules, or tophi, that are visible through the skin. Crystal aggregates deposited in the kidneys
can form urate renal stones and lead to renal failure. None of the other options are associated
with the calcium crystals resulting from chronic gout.
PTS: 1

REF: Page 1575

MULTIPLE RESPONSE
40. What are the primary sources of bacterial infections that lead to hematogenous bone

infection? (Select all that apply.)

a. Sinus
b. Ear
c. Dental
d. Cutaneous
e. Throat

ANS: A, B, C, D

Cutaneous, sinus, ear, and dental infections are all primary sources of bacteria in
hematogenous bone infections. Throat infections are not generally associated with bone
infections.
PTS: 1

REF: Page 1559

41. Which structures are most often affected by Paget disease? (Select all that apply.)
a. Vertebrae
b. Skull
c. Sternum
d. Metacarpals
e. Pelvis
ANS: A, B, C, E

Paget disease most often affects the axial skeleton, especially the vertebrae, skull, sacrum,
sternum, and pelvis. The metacarpals are not associated with the axial skeleton or Paget
disease.
PTS: 1

REF: Page 1558

42. Which clinical manifestations are characteristic of rheumatoid arthritis? (Select all that apply.)
a. Subcutaneous tissue crystals
b. Anorexia
c. Painful, stiffening of joints
d. Edema of the wrists
e. Fever
ANS: B, C, E

Rheumatoid arthritis begins with general systemic manifestations of inflammation, including

fever, fatigue, weakness, anorexia, weight loss, and generalized aching and stiffness. Local
manifestations also gradually appear over weeks or months. Typically, the joints become
painful, tender, and stiff. Neither tissue crystals nor edema is associated with rheumatoid
arthritis.
PTS: 1

REF: Page 1571

MATCHING

Match the phrases with the corresponding characteristics.

______ A. Caused by sedatives and narcotics, particularly street heroin
______ B. Caused by viruses, bacteria, and parasites
______ C. Exercise intolerance with normal production of lactic acid
______ D. Impairment of the breakdown of glycogen and production of lactic acid
______ E. Autoimmune disease
43.
44.
45.
46.
47.

McArdle disease
Myoadenylate deaminase deficiency
Rhabdomyolysis
Polymyositis
Myositis

43. ANS: D
PTS: 1
REF: Page 1582
MSC: The individual with McArdle disease is not able to break down glycogen or produce lactic acid.
44. ANS: C
PTS: 1
REF: Page 1583
MSC: Myoadenylate deaminase deficiency is an enzyme deficiency that produces changes in skeletal
muscle and is associated with exercise intolerance.
45. ANS: A
PTS: 1
REF: Page 1548 | Box 44-1
MSC: Sedatives and narcotics, particularly street heroin, clofibrate (a hypolipidemic agent), and the
antifibrinolytic aminocaproic acid often cause rhabdomyolysis and myoglobinuria.
46. ANS: E
PTS: 1
REF: Page 1584
MSC: Inflammation of connective tissue and muscle fibers that presumably causes the destruction of
muscle fibers characterize polymyositis and dermatomyositis. The agent that causes the muscle
inflammation has not been identified, but recent findings strongly suggest an autoimmune connection.
47. ANS: B
PTS: 1
REF: Page 1583
MSC: Viral, bacterial, and parasitic infections of varying severity are known to produce inflammatory
changes in skeletal muscle, a group of conditions collectively described by the term myositis.