Musculoskeletal Bullets

8/3/2019 Musculoskeletal Bullets

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MUSCULOSKELETAL

DISEASES

SIGNS AND SYMPTOMSHeberdens nodes

Osteoarthritis Painless bony enlargement of DIP (Distal interphalangeal joint)Swan neck deformity

Rheumatoid arthritis

Hyperextended PIP (Proximal Interphalangeal joint) Slightly flexed DIP

Also:

Volar subluxation of MCP( Metocarpophalangeal joint)

Ulnar deviation of fingers

Tophi

Gout Painless, nodular swelling (uric acid deposits)

Ears, hands, feet

ARTHRITIS

RHEUMATOID ARTHRITIS

Autoimmune disease

Morning stiffness

Swelling of 3 or more joints

Involves: wrist, MCP and PIP Subcutaneous nodules

Rheumatoid factor in serumCharacteristics hand deformity:

Ulnar deviation of digits


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swan neck deformity

X-ray:

Joint erosions

Periarticular bone erosion

OSTEOARTHRITIS

Degenerative disease

Progressive pain

Relieved by rest

Involves weight bearing jointship joint, knee joint(also DIP and PIP in women)

X-ray:

Loss of cartilage

Narrowed joint space

Subchondral cysts and sclerosis

New bone formation (marginal osteophytes)

OSTEOARTHRITIS

ANALYSIS

Impaired mobility > risk of injury

IMPLEMENTATION

Range of motion exercises Exercises to maintain muscle strength

(but minimize weight bearing activities)

Encourage weight loss to reduce stress on joints

Warm tub baths to relief stiffnessNote: proper use of cane: hold in hand opposite of bad leg.

RHEUMATOID ARTHRITIS

ANALYSIS


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Impaired mobility > risk of injuryIMPLEMENTATION

Range of motion exercises

Encourage self care: provide privacy and pain relief

Apply local heat or cold

MEDICATIONS

Analgesics

Anti inflammatory drugsCLIENT EDUCATION

Serious risk gastric ulceration from anti inflammatory drugs

GOUTDeposits of urate crystal in synovial tissue > acute inflammation

Note: 90% of cases are due to under-excretion of uric acid

10% of cases are due to over-production of uric acid

ASSESSMENT

May be asymptomatic for a long time Acute attack: pain in joint of great toe (podagra)

Elevate serum uric acid

Tophi: urate deposits in subcutaneous tissue

IMPLEMENTATION

Bed rest during acute attack

Use cradle to keep bedcovers elevated

Encourage fluid intake (3L/day) Hot packs (reduce muscles spasm and pain)

Cold packs (reduce swelling and pain)MEDICATIONS:

Asymptomatic hyperuricemia: no medication necessary Mild attacks: analgesics (acetaminophen)

Severe attacks: colchicine, NSAIDs

Allupurinol: reduces uric acid production

Probenecid: increases renal uric acid excretion


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CLIENT EDUCATION

Encourage weight loss but avoid crash diets

Avoid alcohol

Limit food high in purines (anchovies, shellfish, organ meats)

Factors that inhibit uric acid secretion

(increased risk of gout)

Alcohol - Aspirin Diuretics

SPONDYLO-

ARTHROPATHIES

Autoimmune diseases involving spine and sacroiliac joint

Ankylosing spondylitis(more common in young men)

Gradual onsetReiters syndrome

(more common in men)

Sudden onset

Urethritis

Arthritis (knees, ankle)follows dysentery (Shigella)

follows STD (Chamydia)

Psoriatic arthritis

(more common in women)

Variable onset

Occurs in 20% of psoriatic patients

Nail pitting

Sausage toes

NOTE: PHYSICAL THERAPY AND BREATHING EXERCISES AREEXTREMELY IMPORTANT TO MAINTAIN MOBILITY AND POSTURE

SYSTEMIC LUPUS ERYTHEMATOSUS

Chronic inflammatory disease of connective tissue(autoimmune)

Systemic lupus


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Weakness, fatigue Anorexia, weight loss Photosensitivity

Butterfly rash (spare nasolabial fold) Discoid rash

Anemia Arthritis

Nephrotic syndrome

LAB:

Leukopenia

Thrombocytopenia

Antinuclear antibodies False positive test for syphilis

Drug induced lupus

Often fairly mild

History of hydralazine, procainamide, other drugs Reversible after drug cessation

IMPLEMENTATION

Emotional support Protective clothing and sun screen if clients is photosensitive

Heat packs for joint pain Monitor for signs of renal damage: edema, hypertention

MEDICATIONS

Steroids (topical for skin, systemic if organ involvement)

OSTEOPOROSIS

Loss of the one mass > risk of fracture

Elderly persons are at risk

Bone loss is accelerated in postmenopausal women (lack of estrogen)


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ASSESSMENT

Backache Kyphosis

Los of height

Serum calcium and phosphate levels are normal

X-ray: decreased density of vertebrae

ANALYSIS

Risk of injury: femur (hip) fractures, vertebral compression fracturesIMPLEMENTATION

DIET:

High-protein diet

Calcium and vit. D

MEDICATIONS:

Estrogen replacement

CLIENT EDUCATION

Encourage physical activity to prevent atrophy

Prevent falls: slippery bathroom floors, loose rugs..

Note: Estrogen slightly increase the risk of endometrial cancer. Regular check-ups for

clients on estrogen replacement are recommended.

HERNIATED DISK

ASSESSMENT

Severe lower back pain Pain radiating down buttocks and legs

Usually unilateral Neurological exam: motor or sensory deficits are a serious sign

Diagnosis: CT or MRI

ANALYSIS

Risk of injury to spinal cord and nerve roots Level of mobilityIMPLEMENTATION

Apply local heat or coldCERVICAL:


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Cervical herniation: collar or traction requiredLUMBAR

Bed rest until inflammation is reduced

Provide firm mattress

Recommend high-fiber diet with plenty of fluid (to prevent constipation andstraining)

CLIENT EVALUATION

Avoid prolonged sitting

Use legs when lifting objects (keep spine straight) Exercise to strenghten abdominal and back muscles

CARPAL TUNNEL SYNDROME

Compression of median nerve at wrist joint

ASSESSMENT Pain in wrist or palm or hand

Paresthesias in radial palmar aspect of hand

Weakness of thumbIMPLEMENTATION

Relief pressure on median nerve:(hand elevation, splinting of hand andforearm)

Cortisone injections into carpal tunnelCLIENT EDUCATION

Avoid prolonged flexion of wrist Teach proper hand position when typing or using computer

OSTEOMYELITIS

Infection in bone, usually by staphylococcus aureus

ASSESSMENT

Malaise Pain and tenderness over bone

Swelling and redness over bone

Fever

Diagnosis: bone scan or culture from needle biopsy

IMPLEMENTATION

Immobilization of affected limb


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No weight-bearing on affected limb

Explain client need for long-term antibiotics (oral for 6 weeks after fevernormalizes)

LEG AMPUTATION

ASSESSMENT

Peripheral vascular disease > claudication(pain when walking, rapid relief when resting)

Cyanosis

Ulcer formation

Gangrene: foul smell, blackened wound

ANALYSIS

Risk of injury

Effective coping with altered body image

IMPLEMENTATION

Watch for signs of infection and sepsisPOSTOPERATIVE:

Bandages should be applied in a diagonal figure 8 pattern Elevate stump for first 12 hours

Monitor wound drainage (keep tourniquet at bedside for emergencies) Exercise to improve arm strength

CLIENT EDUCATON

Explain phantom pain

Encourage frequent repositioning in bed

Massage stump to improve vascularity

CRUTCHES & CANES

CRUTCHES

Fitting

Measure from anterior fold of axilla to heel, add 6 inches


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There should be 2 inch space between axillary fold and underarm piece toprevent damage to brachial plexus (clutch paralysis)

Basic stance

Crutches should rest in front and lateral of feet2-point gait

Advance right crutch and left foot together

Advance left crutch and right foot together

3-point gait (used if only one leg is injured)

Advance both crutches and involved leg forward

Advance healthy foot while keeping body weight on crutches

4-point gait (similar to 2-point gait, but slower and more stable)

Advance right crutch

Advance left foot Advance left crutch

Advance right foot

CANES

Fitting

Highest point should be at level of greater trochanter Handpiece should allow 30deg. Flexion at elbow

Use

Hold cane in hand opposite to injured leg

Advance cane and injured leg at same time

Dont lean body over cane

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Musculoskeletal Bullets