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Musculoskeletal Disorders Psych Rehab Nursing Fall 2009

Musculoskeletal Disorders

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Musculoskeletal Disorders. Psych Rehab Nursing. Outline. Overview of anatomy and physiology Diagnostic tests Musculoskeletal trauma Problems of the musculoskeletal system Osteoporosis Osteoarthritis Rheumatoid arthritis Gout Other musculoskeletal problems. Review. - PowerPoint PPT Presentation

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Page 1: Musculoskeletal Disorders

Musculoskeletal Disorders

Psych Rehab Nursing

Fall 2009

Page 2: Musculoskeletal Disorders

Outline

• Overview of anatomy and physiology• Diagnostic tests• Musculoskeletal trauma • Problems of the musculoskeletal system

– Osteoporosis– Osteoarthritis– Rheumatoid arthritis– Gout– Other musculoskeletal problems

Page 3: Musculoskeletal Disorders

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)

Page 4: Musculoskeletal Disorders

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

Page 5: Musculoskeletal Disorders

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)

Page 6: Musculoskeletal Disorders

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)

Page 7: Musculoskeletal Disorders

Bones: Types

• Long bones• Short bones• Flat bones• Irregular bones• Sesamoid (or round) bones• Sutural or Wormian bones

Page 8: Musculoskeletal Disorders

Long Bones

• Long bones– 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

Page 9: Musculoskeletal Disorders

Long Bones

• Examples of long bones

• Metacarpals Phalanges• 9 14 • 10 15• 11 16• 12 • 13

Page 10: Musculoskeletal Disorders

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)

Page 11: Musculoskeletal Disorders

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)

Page 12: Musculoskeletal Disorders

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

Page 13: Musculoskeletal Disorders

Long Bones

• ??

Page 14: Musculoskeletal Disorders

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

Page 15: Musculoskeletal Disorders

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.

Page 16: Musculoskeletal Disorders

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)

Page 17: Musculoskeletal Disorders

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.

Page 18: Musculoskeletal Disorders

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

Page 19: Musculoskeletal Disorders

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)

Page 20: Musculoskeletal Disorders

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

Page 21: Musculoskeletal Disorders

Joints

Synovial Joint Diarthrosis Joint(all are synovial joints)

Page 22: Musculoskeletal Disorders

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)

Page 23: Musculoskeletal Disorders

Muscles

• Source of power and movement

• Three types… – Skeletal Muscle – Cardiac Muscle– Smooth Muscle

Page 24: Musculoskeletal Disorders

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)

Page 25: Musculoskeletal Disorders

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.

Page 26: Musculoskeletal Disorders

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)

Page 27: Musculoskeletal Disorders
Page 28: Musculoskeletal Disorders

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.

Page 29: Musculoskeletal Disorders

Diagnostic Tests forMusculoskeletal

• X-ray• Electromyogram (EMG)• Arthroscopy• Arthrogram• Computerized Axial Tomography (CT)• Magnetic Resonance Imaging (MRI)• Bone Scan• Arthrocentesis• Laboratory Testing

– Antinuclear Antibodies (ANA)– Ca+, P– Rheumatoid Factor (RF)– Erythrocyte Sedimentation Rate (ESR)– Uric Acid

Page 30: Musculoskeletal Disorders

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.

Page 31: Musculoskeletal Disorders

Soft Tissue Injuries• Sprains/Strains• Sports-related• Dislocation/Subluxation• Carpal Tunnel Syndrome• Rotator cuff• Repetitive Strain• Meniscus Injury• Bursitis• Muscle spasms

Page 32: Musculoskeletal Disorders

Dislocation / Subluxation

• Dislocation of joint• Subluxation (partial dislocation of joint)• Candidate joints are shoulders, fingers,

kneecaps

Page 33: Musculoskeletal Disorders

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

Page 34: Musculoskeletal Disorders

Rotator Cuff InjuryA 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)

Page 35: Musculoskeletal Disorders

Meniscus Injury• 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)

Page 36: Musculoskeletal Disorders

Muscle Spasm• Inflammation that occurs

when a muscle is over-stretched 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)

Page 37: Musculoskeletal Disorders

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.

Page 38: Musculoskeletal Disorders

Types of Complete Fractures

• Closed (Simple)• Open (Compound): riskiest due to infection, bone breaks through skin.

• 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.

Page 39: Musculoskeletal Disorders

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

Page 40: Musculoskeletal Disorders

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…..

Page 41: Musculoskeletal Disorders

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

Page 42: Musculoskeletal Disorders

Closed Simple Fracture

• Only bone damage• Little or no soft tissue

damage • Does not penetrate skin

Page 43: Musculoskeletal Disorders

Open Fracture

• Probably need surgery… lot of time spent cleaning the wound

• Wound may be left open for a while…

Page 44: Musculoskeletal Disorders

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

Page 45: Musculoskeletal Disorders

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…

Page 46: Musculoskeletal Disorders

Spiral Fractures

• Bone is broken due to twisting-type motion

• Unstable fracture• Looks like corkscrew –

runs parallel with the axis of the broken bone

Page 47: Musculoskeletal Disorders

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)

Page 48: Musculoskeletal Disorders

Types of Incomplete Fractures

• Greenstick • Torus (closed) (side of the bone bends but

does not break)• Bowing• Stress

Page 49: Musculoskeletal Disorders

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)

Page 50: Musculoskeletal Disorders

Stress Fracture

• Incomplete fracture• Caused by “unusual or

repeated” stress – this in contrast to other type fractures resulting from trauma

• Common sports injury and among soldiers from marching

• Tiny hairline fractures

• Most common symptom is pain

• Most are not associated with swelling or redness, but tenderness to palpation

• Tibia (shin splints-runners) and metatarsal bones affected in runners

Page 51: Musculoskeletal Disorders

Stress Fracture

• Example of a stress fracture

• Common runner-type fracture

Page 52: Musculoskeletal Disorders

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

Page 53: Musculoskeletal Disorders

Clinical Manifestations 1. Pain2. Loss of normal function3. Obvious deformity4. Excessive motion5. Crepitus (fluid builds up on joint, can be felt at the joint)6. Edema7. Warmth8. Ecchymosis9. Loss of sensation10. Signs of shock11. X-ray evidence

Page 54: Musculoskeletal Disorders

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

Page 55: Musculoskeletal Disorders

Neurovascular Assessment (5 Ps)

• Pain• Paresthesia (tingling, pricking, or numbness of

the skin)• Pallor• Pulses• Paralysis

Page 56: Musculoskeletal Disorders

Goals

• Prevent injury• Maintain strength• Promote comfort• Maintain intact neurovascular status

Page 57: Musculoskeletal Disorders

Treatment Objectives for Fracture

• Reduction of fracture• Maintenance of fragments in correct

alignment• Prevention of excessive loss of mobility and

muscle tone

Page 58: Musculoskeletal Disorders

Collaborative Management

• Health History• X-ray/CT/MRI/Scan• Fx Reduction• Fx Immobilization• MEDS

– Analgesics– Antibiotics– Tetanus Toxoid (good for 10 years)

Page 59: Musculoskeletal Disorders

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

Page 60: Musculoskeletal Disorders

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?

Page 61: Musculoskeletal Disorders

Bone Healing

Page 62: Musculoskeletal Disorders

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.

Page 63: Musculoskeletal Disorders

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

Page 64: Musculoskeletal Disorders

Immobilization and Care• 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

• Traction (weights should hang freely)– Skin traction– Skeletal traction– Balanced suspension– Counter-traction

• Internal Fixators– Plates and screws– Rods– Prosthetics

• Bone Stimulation

Page 65: Musculoskeletal Disorders

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)

Page 66: Musculoskeletal Disorders

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

Page 67: Musculoskeletal Disorders

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

Page 68: Musculoskeletal Disorders

Nursing Diagnoses• 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

Page 69: Musculoskeletal Disorders

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

Page 70: Musculoskeletal Disorders

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)

Page 71: Musculoskeletal Disorders

Deep Vein Thrombosis

Page 72: Musculoskeletal Disorders

Deep Vein Thrombosis

Route of DVT embolus Pulmonary embolism

Page 73: Musculoskeletal Disorders

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

Page 74: Musculoskeletal Disorders

Classification of Hip Fractures

• Intracapsular• Extracapsular• Intertrocanteric• Subtrocanteric• Transcervical• Impacted at base of the

neck• (Capsular refers to the

proximal 1/3 of bone)

Page 75: Musculoskeletal Disorders

Signs of Symptoms of Hip Fracture

• Medical emergency• Severe pain at the fracture site• Inability to move leg voluntarily• Classicshortening 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…

Page 76: Musculoskeletal Disorders

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

Page 77: Musculoskeletal Disorders

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

Page 78: Musculoskeletal Disorders

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

Page 79: Musculoskeletal Disorders

5 Ps of neurovascular assessment

• May be a test question• Pain • Paresthesia (tingling, prickling or numbness of

the skin) • Pallor • Pulses• paralysis

Page 80: Musculoskeletal Disorders

Hip Fracture

Page 81: Musculoskeletal Disorders

Hip Fracture

• Severe pain at the fracture site

• Inability to move leg voluntarily

• External Rotation

Page 82: Musculoskeletal Disorders

Total Hip Replacement

–Preoperative care-consider psychosocial issues-family support-comfort-safety

–Postoperative care-hip is kept in extension and abduction to prevent dislocation of the hip

Page 83: Musculoskeletal Disorders

Osteomyelitis • Acute or chronic infection of bone (confirmed by positive

wound culture)– Usually staph aureus– Direct or indirect

• 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

Page 84: Musculoskeletal Disorders

Osteomyelitis

Page 85: Musculoskeletal Disorders

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

Page 86: Musculoskeletal Disorders

Osteoporosis

Page 87: Musculoskeletal Disorders

Osteoporosis Risk Factors

• 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

Page 88: Musculoskeletal Disorders

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

Page 89: Musculoskeletal Disorders

Osteoporosis – Secondary Risk Factors

• Endocrine disorders: Hyperthyroidism, hyperparathyroidism

• GI Disorders – malabsorption syndrome, Hyperthyroidism,

parathyroidism• COPDglucocorticoids• Drug

– Glucocorticoids, heparin, anticonvulsants, loop diuretics, barbiturates

Page 90: Musculoskeletal Disorders

OsteoporosisClinical Manifestations

• Back Pain- (fx of vertebra)– Chronic dull ache– Sudden onset of acute pain greatly intensified with

coughing, sneezing or movement• Fracture

– Proximal femur– Distal radius– Proximal humerus– Ribs

• Thoracic kyphosis (Dowager’s hump)• Loss of more than 2 in. standing height

Page 91: Musculoskeletal Disorders

Osteoporosis Collaborative Management

• Diagnosis– Labs may not be helpful– X-rays (at 30-50% loss)– CT , MRI, Bone Scan – Bone Mineral Density Measurement

• Medication– 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

Page 92: Musculoskeletal Disorders

OsteoporosisNursing 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

Page 93: Musculoskeletal Disorders

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

Page 94: Musculoskeletal Disorders

Paget’s Disease

Page 95: Musculoskeletal Disorders

Osteoarthritis (DJD)• 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

Page 96: Musculoskeletal Disorders

Osteoarthritis (DJD)

Page 97: Musculoskeletal Disorders

Osteoarthritis

Page 98: Musculoskeletal Disorders

OsteoarthritisRisk Factors

• Age• Obesity• Repetitive joint injuries• Genetics

Page 99: Musculoskeletal Disorders

Osteoarthritis -Cardinal Symptoms

• Pain– After movement relieved by rest– Characterized as aching– Poorly localized– On motion with weight bearing

Page 100: Musculoskeletal Disorders

Osteoarthritis -Cardinal Symptoms

• Stiffness– On awakening and in AM– After activity– Of relatively short duration

Page 101: Musculoskeletal Disorders

OsteoarthritisOther Signs and Symptoms

• 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)

Page 102: Musculoskeletal Disorders

Bouchard Nodes

Page 103: Musculoskeletal Disorders

Heberdan Nodes

Page 104: Musculoskeletal Disorders

Osteoarthritis – Diagnosis

• X-Ray– Decreased joint space, bony sclerosis, spur

formation• Fluid analysis

Page 105: Musculoskeletal Disorders

Osteoarthritis - Treatment

• Symptomatic relief and minimization of further joint destruction– Exercise– Rest– Weight-loss– NSAIDs

• Gastric irritation, bleeding• Disturbance in platelet formation

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Rheumatoid Arthritis

• Chronic, systemic inflammatory disease of moveable joints

• 6 million Americans• Prevalence increases with age for both men

and women

Page 107: Musculoskeletal Disorders

Rheumatoid Arthritis

Page 108: Musculoskeletal Disorders

Rheumatoid Arthritis

Page 109: Musculoskeletal Disorders

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

Page 110: Musculoskeletal Disorders

Rheumatoid Arthritis –Cardinal Symptoms

• Abnormal labs– Elevated ESR (sed rate)– Rheumatoid factor – Anemia– WBC in synovial fluid

• X-Ray– Bone degeneration

Page 111: Musculoskeletal Disorders

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

Page 112: Musculoskeletal Disorders

Rheumatoid ArthritisTreatment 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

Page 113: Musculoskeletal Disorders

Rheumatoid Arthritis –Management

• Rest• PT• Aspirin• Corticosteroids• Gold salts• Disease modifying antirheumatic drugs (DMARDs)

– Plaquenil, Azulfadine– Methotrexate

Page 114: Musculoskeletal Disorders

Rheumatoid Arthritis

Page 115: Musculoskeletal Disorders

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

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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)

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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)

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Mandibular Fracture

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Amputation – Preoperative care-nurse does history(how it

occurred if trauma), concurrent illnesses, habits, ie. Smoking, current meds, psycho-social

– 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…

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Amputation

Accidental Surgical

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Bone Cancer

–Multiple Myeloma–Osteogenic

sarcoma,Osteoclastoma, Ewing’s Sarcoma, Metatastic Bone Disease

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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

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Other Musculoskeletal Problems

• Muscular Dystrophy• Low Back Pain-Laminectomy• Herniated Intervertebral Disk