Musculoskeletal Disorders
Psych Rehab Nursing
Fall 2009
Outline
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Overview of anatomy and physiology
Diagnostic tests
Musculoskeletal trauma
Problems of the musculoskeletal system
– Osteoporosis
– Osteoarthritis
– Rheumatoid arthritis
– Gout
– Other musculoskeletal problems
Review
• Purpose of the musculoskeletal system
- Supporting framework for attachment of muscles
and other tissues
- Protects vital organs and soft tissues
- Joints, bones, cartilage make up the skeletal
system
- Bones enable movement of the body by acting as
levers and points of muscle attachments
(muscles ONLY contract: opposing muscles allow flexion &
extension. Muscles are conductors of electrical energy)
Bones
• Function
• Framework for the attachment of muscles and other
tissues
• Protection
• Production of blood cells in the red marrow
- Which bones are involved in the process?
- Facilitate movement by contracting muscles
- Storage area for calcium and phosphorus
- Lipids (energy sources) are stored in adipose
cells of the yellow marrow
Bones
• Blood cells are produced
in bone marrow (see
below)
• Red marrow in flat bones
(sternum, scapulae, skull,
ribs, vertebrae, pelvis,
epiphyseal ends of long
bones, i.e., femur and
humerus (marrow runs all
the way through the
bone, but the cells are
released from the
epiphyseal ends)
Femur head; view of cortex; view of red bone
marrow; view of yellow bone marrow (2009)
Bones
Ligaments (fibrous connective tissue
connecting bone to bone)
Tendons (connect muscle to
bone) Example: Achilles tendon
attaches calf muscles to the ankle
bone while a ligament holds the
calf and thigh bones together at
the knee joint
(Pollick, 2008)
Bones: Types
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Long bones
Short bones
Flat bones
Irregular bones
Sesamoid (or round) bones
Sutural or Wormian bones
Long Bones
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Long bones
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Longer than they are wide
A shaft with two ends - the shaft widens at the end of the bone
Contain yellow bone marrow and red bone marrow
Humerus (proximal) ; radius and ulna (distal) of the upper extremity; femur (proximal), tibia
(anterior/distal) and fibula (posterior/distal) of the lower extremity
Long Bones
• Examples of long bones
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Metacarpals Phalanges
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14
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15
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Red and Yellow Bone Marrow
• Half of the bone marrow is red (in adults)
• Red marrow is found mainly in the flat bones (hip
bone, sternum, skull, ribs, vertebrae and shoulder
blades)
• Also found in the spongy material in the proximal
ends of the long bones – femur and humerus
• Yellow marrow is found in the hollow interior of the
middle portion of long bones
Femur head; view of cortex; view of
red bone marrow; view of yellow bone
marrow (2009)
Bone Marrow
• Hematopoesis (blood
formation)
• RBC storage
• Production of WBCs
• Platelets (formed in
bone marrow; aid in
clotting)
• High fat content (long
bones) fat embolus
•
“Fat embolism syndrome, a condition
characterized by hypoxia, bilateral
pulmonary infiltrates, and mental
status change, is commonly thought
of in association with long-bone
trauma. … Although studies suggest
that embolization events infrequently
result in clinically apparent fat
embolism syndrome, clinicians should
be vigilant in considering fat
embolism as a causative agent for
postoperative respiratory distress.”
(Glazer & Onion, 2001)
Short Bones
• Short bones
– Cube-like; about as long
as they are wide
• Contain mostly spongy bone
• Outside surface consists of a
thin layer of compact bone
• Located in the hands and
feet (metacarpals)
• Patella
Long Bones
• ??
Flat Bones
• Flat bones
– Thin and flat
– Found where the need is for a broad surface area
for muscular attachment or where extra
protection is needed
– Examples: Skull; Pelvis; Sternum; Rib cage; Scapula
– In adults most RBCs are formed in flat bones
Bones: Microscopic Anatomy
• Osteoprogenitor cells are multipotential skeletal cells;
the stem cells for the skeletal system.
• Osteoblasts are bone forming cells; they lay down the
bond tissue. Can be stimulated in cancer.
• Osteocytes are mature bone cells that become trapped
at maturity in a matrix; they maintain the bone
• Osteoclasts are bone reabsorbing cells that destroy old
bone. Slow process. Inc cancer, these cells are
destroyed and not replaced (osteoporosis).
• Collagen is soft, strong connective tissue that supports
and reinforces the mineralized matrix – stronger than
steel.
Irregular Bones
• Examples are the vertebrae; sacrum; coccyx;
temporal; sphenoid; ethmoid (in skull);
zygomatic (cheek bone); maxilla; mandible;
palatine; inferior nasal concha; and hyoid
• Serve as protection (example: vertebrae
protects spinal cord)
• Allowing multiple anchor points for skeletal
muscle (example: sacrum)
Bones
• Ligaments (bone to bone): fibrous connective
tissue connecting bone to bone
• Tendons: (connect muscle to bone) Example:
achilles tendon attaches calf muscles to the
ankle bone while a ligament holds the calf and
thigh bones together at the knee joint.
Sesamoid (Round) Bones
Sutural, or Wormian bones
• An example of a Sesamoid bone is the patella
• Sesamoid bones are embedded within
tendons; Act to protect tendons
• Sutural or Wormian bones occur between the
sutures of the cranial bones
Bones: Types
• Long Bones: weight bearing, strong, curved
• Short bones: compact on surface, spongy center &
cuboidal (metatarsals)
• Flat bones: parallel surfaces of the body, protecitve
funciton, broad attachment surface (ribs, pelvis, skull,
ilium)
• Irregular bones: various functions: vertebrae & some
facial bones
• Sesamoid (or round) bones: embedded in tendons,
allow change of direction of movement, like a pulley
(patella)
• Sutural or Wormian bones: between sutures of skull
(between large flat bones of skull)
Joints
• A diarthrosis joint is a freely moveable joint – always a
synovial joint
• Types of synovial joints
– Gliding (Two sliding surfaces) (Example - between carpals)
– Hinge (Concave surface with convex surface) (Example –
between humerus and ulna)
– Pivot (Rounded end fits into ring of bone and ligament
(Example – between atlas (C1) and axia (C2) vertebrae
Joints
Synovial Joint
Diarthrosis Joint
(all are synovial joints)
Joints, Synovial types, cont.
1. Ball and socket joint (Ball-shaped head with cup-shaped socket)
(Example – Between femur and pelvis)
2. Condyloid joint (Oval condyle with oval cavity) (Example – between
metacarpals and phalanges)
3. Saddle joint (Each surface is both concave and convex) (Example –
Between carpus and the first metacarpal)
4. Hinge joint (interphalangeal joints)
5. Pivot joint (able to rotate – neck, forearm, knees)
Muscles
• Source of power and movement
• Three types…
– Skeletal Muscle
– Cardiac Muscle
– Smooth Muscle
Skeletal Muscle
• Skeletal Muscle
– Attached to bones and causes movements of the
body.
– Also called striated muscle (actin &??) because of
its banding pattern, or voluntary muscle (because
muscle contraction can be consciously controlled)
Cardiac Muscle
• Cardiac muscle
– Responsible for the rhythmic contractions of the heart
– Muscle is involuntary
– Generates its own stimuli to initiate muscle
contraction
– Microscopically striated like skeletal muscle
– Striations join together in bundles to allow
coordinated action
– Involuntary and autorhythmic. Some cardiac muscles
function as built in pacemakers.
Smooth Muscle
• Smooth Muscle
– Lines the walls of hollow organs
– (Example: lines the walls of blood vessels and of
the digestive tract where it functions to advance
the movement of substances.
– Contraction is relatively slow and involuntary
– Microscopically smooth (not striated)
Basic components
• Muscles are stimulated by motor neurons.
• Richly supplied w/ arteries and veins and have
intimate contact w/a rich capillary network
b/c of high energy demands.
Diagnostic Tests for
Musculoskeletal
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X-ray
Electromyogram (EMG)
Arthroscopy
Arthrogram
Computerized Axial Tomography (CT)
Magnetic Resonance Imaging (MRI)
Bone Scan
Arthrocentesis
Laboratory Testing
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Antinuclear Antibodies (ANA)
Ca+, P
Rheumatoid Factor (RF)
Erythrocyte Sedimentation Rate (ESR)
Uric Acid
Chemical action in muscle
• ATP – ADP energy cycle. Critical to muscles
ability to get energy they need to do the work
they need to do.
Soft Tissue Injuries
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Sprains/Strains
Sports-related
Dislocation/Subluxation
Carpal Tunnel Syndrome
Rotator cuff
Repetitive Strain
Meniscus Injury
Bursitis
Muscle spasms
Dislocation / Subluxation
• Dislocation of joint
• Subluxation (partial dislocation of joint)
• Candidate joints are shoulders, fingers,
kneecaps
Trauma to Bone
• Highest incidence
– MALES 15-24 years of age or elderly females 65
years of age, or older
– Why are females in this age group affected?
• A result of a blow to the body, a fall, or
another accident
A rotator cuff injury
includes any type of
irritation or damage to
the rotator cuff muscles
or tendons. Causes of a
rotator cuff injury may
include falling, lifting
and repetitive arm
activities — especially
those done overhead,
such as throwing a
baseball or placing
items on overhead
shelves
(Mayo Clinic, 2008)
Rotator Cuff Injury
Meniscus Injury
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Symptoms of medial meniscus tear
A history of trauma or twisting of
the knee
Pain on the inner surface of the
knee joint
Swelling of the knee within 24-48
hours of injury
Inability to bend knee fully- this
may be associated with pain or a
clicking noise
A positive sign (pain and/or clicking
noise) during a "McMurrays test"
Pain when rotating and pressing
down on the knee in prone position
(video).
"Locking" of the knee
Inability to weight bear on the
affected side (SIC, 2008)
Muscle Spasm
• Inflammation that occurs
when a muscle is overstretched or torn
• The back is a common
area for inflammation to
occur
• Why? Poor body
mechanics
• (cold or heat might be
effective, reduce
inflammation & relax
muscles)
Bursitis:
Inflammation of the Bursa
(Pain, fluid build up, calcium deposits & loss of motion in the
joint. Prevention is to build up activity gradually. Treatment:
avoid what is causing the problem, NSAIDS, steroids, ice. In
some cases surgery might be necessary.
Types of Complete Fractures
• Closed (Simple)
• Open (Compound): riskiest due to infection, bone breaks through
skin.
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Transverse
Oblique
Spiral
Comminuted
Colles’ fracture: fracture of wrist on inside portion of wrist.
Treatment is reduce it & cast it. (happens when someone falls
down). Responds well to cast.
Fractures
• Fractures commonly tear blood vessels,
producing a hematoma
• This area of hematoma is commonly used as
an area to anesthetize the periosteum
because thisis where the blood vessels are
located.
• Reduction usually requires anesthesia
Healing stages
• After several weeks the periosteum is
beginning to heal & lay down scar tissue.
Trabecular cone has begun to grow over the
break. There is callus formation w/ the
osteoblasts
• After several months…..
Healing stages, cont
• Remodeling: over the next months or years, the
bone shape returns to normal as osteoclasts
absorb extra cells and osteoblsats generate new
cells and bone. The bone will be thickened
somewhat at the fracture…
• Fully healed fractures in children are
indistinguishable from the original bone b/c the
growth plates are open. However, multiple fxs in
various stages of healing are a strong indicator of
child abuse
Closed Simple Fracture
• Only bone damage
• Little or no soft tissue
damage
• Does not penetrate skin
Open Fracture
• Probably need surgery… lot of time spent
cleaning the wound
• Wound may be left open for a while…
Transverse Bone Fracture
• Often caused by direct
traumatic injury
• Bone has been broken
giving rise to a
transverse break or
fissure within the bone
at a right angle to the
long portion of the
bone
Oblique Bone Fracture
• Extremely rare type of
break
• An oblique break in the
bone which is very
unstable (break at an
angle)
• Bone still together…
Spiral Fractures
• Bone is broken due to
twisting-type motion
• Unstable fracture
• Looks like corkscrew –
runs parallel with the
axis of the broken bone
Comminuted (crushed) Fracture
• More than two
fragments of bone have
been broken off
• Highly unstable with
many bone fragments
• (Fixed w/ rods & screws
after taking all the
pieces out)
Types of Incomplete Fractures
• Greenstick
• Torus (closed) (side of the bone bends but
does not break)
• Bowing
• Stress
Greenstick fracture
• Usually seen in children
• Bone is usually “bent”
and broken on the
outside of the bend
• If kept straight, heals
quickly
• (sometimes doesn’t
need a cast…
sometimes overtreated)
Stress Fracture
• Incomplete fracture
• Most common
symptom is pain
• Caused by “unusual or
repeated” stress – this
• Most are not associated
in contrast to other type
with swelling or
fractures resulting from
redness, but tenderness
trauma
to palpation
• Common sports injury
• Tibia (shin splintsand among soldiers
runners) and
from marching
metatarsal bones
affected in runners
• Tiny hairline fractures
Stress Fracture
• Example of a stress
fracture
• Common runnertype fracture
Other Types of Fractures
• Pathologic Fracture
– May occur during normal activity or after minimal injury
(Is associated with what?) common in elderly w/
osteoarthrits or osteoporosis
• Fatigue or Stress Fracture
– The muscles associated with the bones are unable to
absorb energy as they usually do
• Avulsion Fracture
– A strong ligament or tendon pulls a fragment of the bone away from
the rest of it
• Impacted Fracture
– Fracture fragments are pushed into each other
Clinical Manifestations
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Pain
Loss of normal function
Obvious deformity
Excessive motion
Crepitus (fluid builds up on joint, can be felt at the joint)
Edema
Warmth
Ecchymosis
Loss of sensation
Signs of shock
X-ray evidence
Factors that hinder good callus
formation
• Inadequate reduction of the fracture
• Inefficient immobilization
• Excessive edema at the fracture site, impeding the
supply of nutrients
• Too much bone lost at time of injury to permit bridging
of broken ends
• Infection at the site of injury
• Bone necrosis
• Anemia or other systemic conditions
• Endocrine imbalance (parathyroid not enough Ca)
• Poor dietary intake
Neurovascular Assessment
(5 Ps)
• Pain
• Paresthesia (tingling, pricking, or numbness of
the skin)
• Pallor
• Pulses
• Paralysis
Goals
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Prevent injury
Maintain strength
Promote comfort
Maintain intact neurovascular status
Treatment Objectives for Fracture
• Reduction of fracture
• Maintenance of fragments in correct
alignment
• Prevention of excessive loss of mobility and
muscle tone
Collaborative Management
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Health History
X-ray/CT/MRI/Scan
Fx Reduction
Fx Immobilization
MEDS
– Analgesics
– Antibiotics
– Tetanus Toxoid (good for 10 years)
Immobilization of Bones
• 1) Physiologic Splintage- naturally occurring
phenomenon related to pain that causes guarding,
muscle spasms, and avoidance of further use. There
is a desire to rest the whole body until some repair
has occurred.
• 2) External orthopedic splintage- with devices such
as casts
• 3) Internal Fixation with screws, pins, rods or plates
to hold the opposing ends of the fracture in place
Bone Healing
• 1. Hematoma formation (situates between broken fragments)
• 2. Fibrin meshwork formation (blood vessels grow into a jelly-like matrix of
the blood clot – WBCs are brought to the site
• 3. Invasion of osteoblasts (produces matrix that becomes mineralized)
• 4. Callus formation (usually shows up by x-ray 6 weeks in adults/less time
in children
• 5. Remodeling (bones are constantly changing – osteoclasts break down
old bone so osteoblasts can replace it with new bone tissue – a process
called remodeling.
• What can impair bone healing?
Bone Healing
Fractures: terms commonly used
• Reduction: re-establishment of the normal
position of ..
• Dislocation
• Fracture
• Internal fixation is the surgical placement of
steel material into the bone to hold it in place.
Used when healing would be impaired or
immobility of the fx is a problem.
Factors that Hinder
Good Callus Formation
• Inadequate reduction of the fracture
• Inefficient immobilization
• Excessive edema at fracture site, impeding the supply of
nutrients
• Too much bone lost at time of injury to permit bridging of
broken ends
• Infection at the site of injury
• Bone necrosis
• Anemia or other systemic conditions
• Endocrine imbalance
• Poor dietary intake
Immobilization and Care
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External fixation devices
– Casts (plaster casts can be bi-valved to allow for swelling)-this means it is cut into two
pieces, lengthwise, so that the area beneath the cast can be observed.
– Splints
– Brace or cast-brace
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Traction (weights should hang freely)
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Skin traction
Skeletal traction
Balanced suspension
Counter-traction
Internal Fixators
– Plates and screws
– Rods
– Prosthetics
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Bone Stimulation
External Fixator
• Used when a cast would not allow proper
alignment/immobilization of the fracture
• Proper cleaning to prevent infection is
required
• No cast, just curlex (gauze)
Traction
• Aligns the ends of a fracture by pulling the limb
into a straight position
• Helps manage muscle spasm r/t fracture
• (weights should hang freely)
• Skin traction
• Skeletal traction
• Balanced suspension
• Counter – traction
• Skin integrity or back massage might be helpful.
Often used pre-op to keep them immobile
Bone Stimulation
• Used when satisfactory healing is not
occurring naturally
• Application of a low electrical current to the
fracture
• Promotes the speed of bone healing
Nursing Diagnoses
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Risk for Neurovascular Dysfunction
Pain
Risk for Infection
(Risk for) Impaired Skin Integrity
Risk for Nutrition Deficit
Risk for Injury
Knowledge Deficit (teaching about care of the
site)
• Risk for impaired perfusion
Complications
• Who is at risk?: 0.5%-2% long bones, 10% hip
• DVT Stroke or Pulmonary Embolus
– S/S of PE: Hemoptysis (coughing up of blood), pleuritic chest pain,
dyspnea, rales
• Fat Embolism Syndrome (When fat enters the circulation)
– 12-48 hrs after fracture
– Usually associated with fx of long bone or pelvis (fx of hip is at highest
risk)
– Men 20 to 40 years of age and older adults 70 to 80 years of age at
greatest risk for development
– Mental status changes (hypoxemia), tachypnea, dyspnea, tachycardia,
temperature, petechia of upper body and axilla, feeling of impending
doom
Complications
• Compartment Syndrome
– 4-12 hrs after fracture
– Compartments are areas of the body in which muscles, blood vessels,
and nerves are contained within fascia
– Progressive pain distal to fracture, 5 Ps (pain, pressure, paralysis,
paresthesia, pallor and pulselessness), pressure inside compartment
>30mmHg (normal 0-8 mmHg
– Fasciotomy (opening in the fascia)
Deep Vein Thrombosis
Deep Vein Thrombosis
Route of DVT embolus
Pulmonary embolism
Hip Fractures
• Currently more than 250,000 hip fractures
annually
• Associated costs exceed $7 billion
• Repair of a fractured hip is the most common
procedure performed in people over 85.
• 30% of patients with a hip fracture die within
1 year r/t surgery (complications) &
immobility
• Osteoporosis is biggest risk factor
Classification of Hip Fractures
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Intracapsular
Extracapsular
Intertrocanteric
Subtrocanteric
Transcervical
Impacted at base of the
neck
• (Capsular refers to the
proximal 1/3 of bone)
Signs of Symptoms of
Hip Fracture
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Medical emergency
Severe pain at the fracture site
Inability to move leg voluntarily
Classicshortening and external rotation of the
leg
• One-third of elderly individuals with hip fracture
die within one year of injury
• Typically the bone is rotated externally &
shortening of the leg… try to get the leg back into
allignment…
Medical Management –
Hip Fracture
• Conservative management
– Prolonged immobility - 12-16 wks BR(avoids the risks
associated with anesthesia)
• Surgical Management
– Reduction and stabilization of fracture with insertion of
internal fixation device
• Stable plate and screw (non-w/b 6 weeks to 3 months)
• Telescoping nail (minimal to partial w/b 6 weeks3 months)
– Prosthetic implant -replaces femoral head and neck
• position restriction 2 weeks->2 months
• partial weight bearing 2 months
Follow-up Instructions –
Hip Fracture
• DO NOT
– flex more than 90o
– force hip into adduction or internal rotation
– cross legs
– put on own shoes and socks x 8 weeks
– sit in chairs that do not have armrests
Follow-up Instructions –
Hip Fracture
• DO
– Keep in extension and abduction
– use toilet seat raiser
– place/use shower chair
– use pillow between legs x 8 weeks
– notify of increased pain
– inform dentist of prosthetic device
5 Ps of neurovascular assessment
• May be a test question
• Pain
• Paresthesia (tingling, prickling or numbness of
the skin)
• Pallor
• Pulses
• paralysis
Hip Fracture
Hip Fracture
• Severe pain at the
fracture site
• Inability to move leg
voluntarily
• External Rotation
Total Hip Replacement
–Preoperative care-consider
psychosocial issues-family supportcomfort-safety
–Postoperative care-hip is kept in
extension and abduction to
prevent dislocation of the hip
Osteomyelitis
• Acute or chronic infection of bone (confirmed by positive
wound culture)
– Usually staph aureus
– Direct or indirect
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Pain, temperature, swelling, warmth, redness
Wound culture, bone scan, CT, MRI
Aggressive antibiotics 6-8 wks (my pt at Speciality)
Nursing diagnoses: Pain, Impaired physical mobility,
Ineffective therapeutic regimen, Risk for impaired skin
integrity
• Nursing care: Aseptic technique, no heat or exercise to
affected area which will increase circulation
Osteomyelitis
Osteoporosis
• A disorder in which bone mass is lost to the
point where the skeleton is no longer able to
withstand unexpected or normal mechanical
forces. Most common skeletal disorder and
second only to arthritis as a cause of
musculoskeletal morbidity in the elderly.
A/K/A porous bone
• Bone resorption > bone formation
Osteoporosis
Osteoporosis Risk Factors
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Aging
Gender (female)
Race (white)
Family History
Postmenopausal (and not taking calcium supplement)
Chronic calcium deficiency
Sedentary lifestyle (wt bearing exercise)
Small frame-low body weight
Osteoporosis –
Related Risk Factors
• Chronic smoking
• Diet high in protein and fat (phosphorous depletes calcium –
found in animal fat/protein)
• Chronic alcohol use
• Excessive caffeine intake (phosphorous depletes calcium)
• Postmenopausal (estrogen helps body absorb calcium)
• Glucocorticoids (involved in protein and fat metabolism;
Aluminum containing antacids (reduce amount of calcium in
the body)
• Horonal imbalances (estrogen and testosterone) are the
primary causes of osteoporosis
Osteoporosis –
Secondary Risk Factors
• Endocrine disorders: Hyperthyroidism,
hyperparathyroidism
• GI Disorders
– malabsorption syndrome, Hyperthyroidism,
parathyroidism
• COPDglucocorticoids
• Drug
– Glucocorticoids, heparin, anticonvulsants, loop diuretics,
barbiturates
Osteoporosis
Clinical Manifestations
• Back Pain- (fx of vertebra)
– Chronic dull ache
– Sudden onset of acute pain greatly intensified with
coughing, sneezing or movement
• Fracture
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Proximal femur
Distal radius
Proximal humerus
Ribs
• Thoracic kyphosis (Dowager’s hump)
• Loss of more than 2 in. standing height
Osteoporosis
Collaborative Management
• Diagnosis
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Labs may not be helpful
X-rays (at 30-50% loss)
CT , MRI, Bone Scan
Bone Mineral Density Measurement
• Medication
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Estrogen Replacement: Prevention
Calcium Supplements
Calcitonin : Nasal spray->irritating
Fosamax, Boniva (1X/ month) Actonel: Before breakfast without food,
sit upright X 30 min., full glass water
• Vertebroplasty, Kyphoplasty
Osteoporosis
Nursing Management
• Nursing diagnoses: Pain, Impaired physical mobility,
Risk for injury, Imbalanced nutrition: less than body
requirements
• Promote calcium intake
• Review diet to include:
– Decrease caffeine
• Excess calcium loss
– Decrease protein and fat
• High protein diet causes bone loss secondary to calcium loss
• Promote exercise
– active weight bearing, walking
Paget’s Disease
• Excessive bone resorption followed by bone formation leading
to weakened bone, bone pain, arthritis, deformity leading to
pathologic fractures and osteogenic sarcoma
• Bone marrow replaced by vascular fibrous connective tissue
leading to formation of larger, disorganized, weaker bone
• X-ray, increased alkaline phosphatase, positive bone scan
• Medication (Fosamax, Actonel) with slowing of disease with
early diagnosis
Paget’s Disease
Osteoarthritis (DJD)
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Degenerative Joint Disease
Most common form of arthritis in the elderly
#1 cause of disability and limitation in those over 74
Non-inflammatory disease of moveable joints
– Deterioration in articular cartilage and formation of new
bone at the joint
Osteoarthritis (DJD)
Osteoarthritis
Osteoarthritis
Risk Factors
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Age
Obesity
Repetitive joint injuries
Genetics
Osteoarthritis Cardinal Symptoms
• Pain
– After movement relieved by rest
– Characterized as aching
– Poorly localized
– On motion with weight bearing
Osteoarthritis Cardinal Symptoms
• Stiffness
– On awakening and in AM
– After activity
– Of relatively short duration
Osteoarthritis
Other Signs and Symptoms
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Crepitus
Limitation of motion
Weight-bearing joints weaken (asymmetrical)
Heberden nodes
– Lateral enlargements of the distal phalangeal joints
• Bouchard’s nodes (found at the proximal
interphalangeal joints)
Bouchard Nodes
Heberdan Nodes
Osteoarthritis – Diagnosis
• X-Ray
– Decreased joint space, bony sclerosis, spur
formation
• Fluid analysis
Osteoarthritis - Treatment
• Symptomatic relief and minimization of
further joint destruction
– Exercise
– Rest
– Weight-loss
– NSAIDs
• Gastric irritation, bleeding
• Disturbance in platelet formation
Rheumatoid Arthritis
• Chronic, systemic inflammatory disease of
moveable joints
• 6 million Americans
• Prevalence increases with age for both men
and women
Rheumatoid Arthritis
Rheumatoid Arthritis
Rheumatoid Arthritis –
Cardinal Symptoms
• Unexplained periods of exacerbation and
remission
• Painful, swollen joints,
– Bilateral, symmetrical
• Morning stiffness
– Lasting longer than 1 hour
– In AM and after inactivity
Rheumatoid Arthritis –
Cardinal Symptoms
• Abnormal labs
– Elevated ESR (sed rate)
– Rheumatoid factor
– Anemia
– WBC in synovial fluid
• X-Ray
– Bone degeneration
Rheumatoid Arthritis –
Diagnosis
• Based on cluster (4 for 6 weeks)
– Morning stiffness
– Arthritis in three or more joints
– Arthritis of hand joints
– Symmetrical
– Rheumatoid nodules
– Serum rheumatoid factor
– Radiographic changes
Rheumatoid Arthritis
Treatment Goals
•
•
•
•
•
•
Reduce inflammation
Alleviate pain
Preserve function
Prevent deformity
(treatment is the same as OA, pretty much)
Both RA & OA cause severe loss of quality of
life
Rheumatoid Arthritis –
Management
•
•
•
•
•
•
Rest
PT
Aspirin
Corticosteroids
Gold salts
Disease modifying antirheumatic drugs (DMARDs)
– Plaquenil, Azulfadine
– Methotrexate
Rheumatoid Arthritis
Comparison of OA to RA
OA
• Degenerative joint dz
• Affects articular cartilage
• Need to add more
RA
• Autoimmune joint dx
“inflammatory arthritis”
• Affects synovial membrane
• Membrane thickens and
immobilizes the joint
Gout: Gouty Arthritis
• Affects middle aged to elderly men
• Associated with renal stones r/t sodium urate crystal
deposition
• Treated with drugs that promote uric acid excretion
(allopurinol and probenicid)
• Treated with diet-limiting protein(organ meats, red meats,
i.e., high purine food) (Gout is associated with increased uric
acid in the body; Purines increases uric acid levels in the body)
• Unlike other forms of arthritis absolute rest of the joint is
necessary. So painful it causes extreme pain just to touch the
joint.
• Primary form is inherited
• (aspirin not indicated, can make the uric levels higher)
Mandible Fracture
– Preoperative care-history of injury, pain
control, gentle oral care, psycho-social
– Postoperative care-pain control, observe for
s/s infection, suction equipment at bedside,
liquid diet, careful monitoring of airway,
ready to cut wires if client vomits or has
respiratory emergency(wirecutters at
bedside)
Mandibular Fracture
Amputation
– Preoperative care-nurse does history(how it
occurred if trauma), concurrent illnesses,
habits, ie. Smoking, current meds, psychosocial
– Postoperative care-pain management
including phantom pain, prevent infection,
observe for adequate tissue perfusion
– Nursing dx: prevention of infection,
promotion of mobility, preparation for
prosthesis…
Amputation
Accidental
Surgical
Bone Cancer
–Multiple Myeloma
–Osteogenic
sarcoma,Osteoclastoma, Ewing’s
Sarcoma, Metatastic Bone Disease
Primary Bone Cancer
– Multiple Myeloma (Plasma cell myeloma)
• Invades sternum, ribs, spine, clavicles, pelvis, long bones. Sx: back pain, anemia,
thrombocytopenia.
– Osteogenic sarcoma
• Metaphyseal area of long bones, esp. distal femur, proximal tibia, proximal
humerus.
• 10-25 y/o males
– Osteoclastoma (Giant cell tumor)
• Cancellous bone: distal femur, proximal tibia, distal radius.
• 20-35 y/o.
• Swelling local pain, bone destruction on Xray
– Ewing’s Sarcoma 3rd most common
• Males under age 30
• Medullary cavity of long bone esp. femur, pelvis, tibia, ribs.
• Mets to lung
– Metastatic bone lesions from breast, GI tract, lungs, prostate, kidney, ovary,
and thyroid
Other Musculoskeletal Problems
• Muscular Dystrophy
• Low Back Pain-Laminectomy
• Herniated Intervertebral Disk