PowerPoint Presentation
Management of Clients with Degenerative Bone Disorder,
Osteoporosis, Osteoarthritis, and Fracture
Kathleen Anne R. Sia, R.N.
Osteo is Latin for bone Porosis means porous or full of
holes
Osteoporosis means bones that are full of holes
Osteoporosis can develop without symptoms
You may not know you have the disease until a bone fractures
Bone is living tissue, which is constantly being broken down and
rebuilt, a process called REMODELING
Bone is renewed like skin, hair and nails
Healthy
Bone
Osteoporotic
Bone
The loss of living bone tissue makes bones fragile and more
likely to fracture
NOTE: arrow points to micro - fracture
Osteoporosis is the most prevalent bone disease in the
world.
More than 10 million Americans have osteoporosis and an
additional 33.6 million have osteopenia, the precursor to
osteoporosis.
The consequence of osteoporosis is bone fracture.
Incidence Rate
Risk Factors:
NonmodifiablePotentially modifiablePersonal history of fracture as
an adultCurrent cigarette smoking History of fracture in
first-degree relative. Low body weight [ 30%.
X-ray findings can also suggest other causes of metabolic bone
disease, such as the lytic lesions in multiple myeloma and the
pseudofractures characteristic of osteomalacia.
Bone densitometry is the only method for diagnosing or
confirming osteoporosis in the absence of a fracture.
The National Osteoporosis Foundation recommends that bone
densitometry be performed routinely in all women > 65,
particularly in those who have one or more risk factors.
Densitometry can also be used for monitoring the response to
therapy.
Screening - DEXA
Dual energy x-rau absorptiometry (DEXA) DEXA measures areal
density (ie, g/cm2) rather than true volumetric density.
The test is non-invasive and involves no special
preparation.
Radiation exposure is minimal, and the procedure is rapid. This
is the most popular and accurate test to date and the test only
takes about 20 to 40 minutes, with a 5mrem dose of radiation (a
full dental x-ray is 300 mrem).
Can be used to measure bone mineral density in the spine, hip,
wrist, or total body.
However, the standard apparatus is expensive and not portable.
Small DEXA machines that can measure the forearm, finger, or heel
are less expensive and are portable.
Screening - DEXA
DEXA of the proximal femur in a young woman, age 37, with
unsuspected femoral-neck osteopenia (T score, -1.6).
DEXA of the lumbar spine in a young woman, age 37, with
unsuspected lumbar spine osteopenia (T = -1.8)
Screening- Ultrasound Densitometry
Ultrasound densitometry can assess the density and structure of
the skeleton and appears to predict fracture risk in the elderly.
The apparatus is relatively inexpensive, portable, and uses no
radiation but can be used only in peripheral sites (eg, the heel),
where bone is relatively superficial.
Estrogen - ERT
Evista - Raloxifene
Bisphosphonates
Fosamax - Alendronate
Miacalcin - Calcitonin
Teriparatide (Forteo)
Medication
Most cost-effective prevention for osteoporosis
Slows bone loss and may slightly increase bone mass
Estimated to reduce hip fracture by 30-50%
ESTROGEN
SERMS-Selective Estrogen Receptor Modulators-designer drugs
SERMS act like estrogen but doesnt stimulate breast or uterine
tissue
Evista is the first and only SERM approved for the prevention
and treatment of osteoporosis
EVISTA (Raloxifene)
Fosamax and Actonel
Specifically designed to affect the skeleton, increase bone
density & reduce number of fractures
Must be taken correctly - on an empty stomach, first thing in
the morning with glass of plain water, fasting, & remain
upright for 30 minutes
BISPHOSPHONATES
Side effects of bisphosphonates include gastrointestinal
symptoms (eg, dyspepsia, nausea, flatulence, diarrhea,
constipation). Some patients may develop esophageal ulcers, gastric
ulcers, or osteonecrosis of the jaw related to bisphosphonate
use
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Approved for prevention and treatment
Approved for treatment of steroid induced osteoporosis in men
and women
Prevention 5 mg daily
Treatment 10 mg daily or
70 mg once weekly (for men and postmenopausal women)
FOSAMAX (Alendronate)
MIACALCIN (Calcitonin)
Is a naturally occurring hormone involved in calcium regulation
and bone metabolism
Available by injection or nasal spray
Side effects include nasal irritation, flushing,
gastrointestinal disturbances, and urinary frequency. It should not
be prescribed for patients with seafood allergies
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Teriparatide (Forteo)
Is a subcutaneously administered anabolic agent that is
administered once daily.
As a recombinant PTH, it stimulates osteoblasts to build bone
matrix and facilitates overall calcium absorption
Teriparatide (Forteo) is a subcutaneously administered anabolic
agent that is administered once daily. As a recombinant PTH, it
stimulates osteoblasts to build bone matrix and facilitates overall
calcium absorption
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OA is wear and tear kind of arthritis.
It is a chronic condition characterized by the breakdown of the
joints cartilage which causes the bones to rub against each other,
causing stiffness, pain and loss of movement in the joint.
Osteoarthritis is by far the most common type of arthritis.
Osteoarthritis is known by many different names, including
Degenerative Joint Disease, Ostoarthritis, Hypertrophic Arthritis
and Degenerative Arthritis.
OSTEOARTHRITIS
Prevalence of OA
It is thought that OA dates back to ancient humans. Evidence of
OA has been found in ice-aged skeletons.
Today, an estimated 27 million Americans live with OA. It is the
#1 cause of disability in America.
According to National Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS), by 2030, 20% of Americans--- about 72
million people--- will have passed their 65th birthday and will be
at high risk for this disease.
Approximately 80-90% of individuals older than 65 years have
evidence of Primary Osteoarthritis.
The symptoms of OA usually appear in middle age and almost
everyone has them by age 70. Before age 55, the condition occurs
equally in both sexes. However, after 55 it is more common in
women.
JOINTS Affected by OA
OA most commonly occurs in Weight-Bearing Joints.
Most obvious Joints are-
Hip joint
Knee Joint
Finger Joint (Postmenopausal Women)
Toe Joints
Intervertebral Joints of the Spine
Less Common Joints are-
Wrist Joint
Ankle Joint
Shoulder Joint
CLASSIFICATION
PRIMARY OA
SECONDARY OA
Commonly Occurs
Without any type of injury or obvious case
Cause is Known
Due to another disease or condition
Injury or Overuse (Athletes, Patients having Surgery, Fracture,
or Soft tissue injury surrounding joint)
Other Types of Arthritis (RA, Septic Arthritis)
Other Diseases or Conditions (Hemochromotosis, Acromegaly)
PATHO-PHYSIOLOGY
Oa is primarily a disease of cartilage.
The exact initiating factor in Primary Osteoarthritis is not
known.
Interleukin-1 (IL-1) is a potent pro-inflammatory cytokine that,
in vitro, is capable of inducing chondrocytes and synovial cells to
synthesize MMPs.
These MMPs (Matrix Metallo Proteinases) are the primary enzymes
responsible for the degradation of articular cartilage.
In addition, IL-1 suppresses the synthesizes of type II collagen
and ptoteoglycans, and inhibits the transforming growth factor- B
stimulated chondrocyte proliferation.
This ultimately leads to the degeneration of articular cartilage
and thus OA.
Oa is primarily a disease of cartilage.
The exact initiating factor in Primary Osteoarthritis is not
known.
Interleukin-1 (IL-1) is a potent pro-inflammatory cytokine that,
in vitro, is capable of inducing chondrocytes and synovial cells to
synthesize MMPs.
These MMPs (Matrix Metallo Proteinases) are the primary enzymes
responsible for the degradation of articular cartilage.
In addition, IL-1 suppresses the synthesizes of type II collagen
and ptoteoglycans, and inhibits the transforming growth factor- B
stimulated chondrocyte proliferation.
This ultimately leads to the degeneration of articular cartilage
and thus OA.
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STAGES of OA (Stage 1)
At the earliest stages of OA, joints look like this:
In a normal joint, healthy cartilage, lubricated by synovial
fluid cushions the bones and allows them to move easily.
STAGES of OA (Stage 2)
As Osteoarthritis progresses, it looks like this.
Osteoarthritis causes the cartilage to begin breaking down,
first making it thinner and then creating cracks in its
surface.
STAGES of OA (Stage 3)
Advancing Osteoarthritis it looks like this.
Gaps in the cartilage can expand until they reach the bone
itself.
STAGES of OA (Stage 4)
Patients with this level of OA usually have pain most of the
time:
Synovial fluid leaks into cracks which can form in the bones
surface when this replacement cartilage wears away. This causes
further damage and in some cases can lead to cysts in the bone or
other deformities.
STAGES of OA (Stage 5)
This is the end stage of disease. Note that there is no
cartilage left on the end of the bone:
If not treated, damage can progress to the point where the bones
in the joint become seriously and permanently deformed.
Increases
Crunching noise heard when joint is moved
How Weakened Ligaments Lead to Arthritis
Prolotheraphy stops arthritis from forming by healing the
ligaments weakness that started and perpatuated the cycle.
How Weakened Ligaments Lead to Arthritis
Prolotheraphy stops arthritis from forming by healing the
ligaments weakness that started and perpatuated the cycle.
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Ligament Weakness
Excessive Joint Movement
Joint Bones Start Colliding
Overgrowth of Bone called Arthritis
More Strain on Ligaments
Joint soreness after periods of overuse or inactivity
Stiffness after periods of rest that goes away quickly when
activity resumes.
Morning stiffness, which usually last no more than 30
minutes.
Pain caused by the weakening of muscles surrounding the joint
due to inactivity.
Joint pain is usually less in the morning and worse in the
evening after a days activity.
Joint swelling
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If OA in Hips, you may experience:
Pain in groin, inner thigh and buttock
Referred pain in knee and side of thigh
Limping when walking
Pain in groin, inner thigh and buttock
Referred pain in knee and side of thigh
Limping when walking
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If OA in Knees, you may experience:
Pain when moving the knee
Gratting or catching when moving the knee
Pain when walking up and down stairs or getting up from a
chair
Weakened large thigh muscles
If OA in Fingers, you may experience:
Pain and Swelling of the finger joints
Bony growth spurs at the joint at the end of the finger, called
Heberdens Nodes, or at the middle joint, called Bouchards Nodes
Difficulty with Pinching Movements, such as picking an item up
from a table or grasping a pencil or pen.
If OA in Spine, you may experience:
Stiffness and pain in the neck and lower back
Pain in the neck, shoulder, arm, lower back and legs
Weakness or numbness in arms and legs due to pinched nerves
result in inflammation
If OA in Fingers, you may experience:
Damage to cartilage triggers inflammation as the tissues tries
to repair itself.
This inflammation causes pain, which can lead to a decrease in
exercise and, in turn, to a loss in muscle tone and strength.
Less exercise combines with muscle loss can lead to weight
problems or obesity, which can increase stress on the damaged joint
and more cartilage breakdown.
PAIN
Reduced mobility and activity and thus WEIGHT GAIN
Increased joint stress
Cartilage Deteriotion
Synovitis
Deformities in knee OA
As the opposing cartilage surfaces wear away, the knee collapses
causing deformities such as-
Bowleggedness (Genu Varus)
Knock knees (Genu Valgus)
These deformities can contribute to pain and functional losses
of the knee
DIAGNOSIS
Early diagnosis and treatment is the key to controlling
Osteoarthritis.
No single test can diagnose Osteoarthritis. Most doctors use a
combination of the following methods to diagnose the disease and
rule out other conditions.
Medical History
Physical
Examination
Laboratory
Test
MEDICAL HISTORY
The doctor begins by asking the patient to describe the
symptoms, and when and how the condition started, as well as how
the symptoms have changed over time.
The doctor will also ask about any other medical problems the
patient and close family members have and about any medications the
patient is taking.
Accurate answers to these questions can help the doctor make a
diagnosis and understand the impact the disease has on patients
life.
PHYSICAL EXAMINATION
Doctor will be looking for common features reported in OA,
including:
Joint swelling
Joint tenderness
Crepitus
Loss of ROM in joints (joint stiffness)
Muscle weakness
Joint damage caused by bony growths in or around the joint
Pattern of affected joints
LABORATORY TEST
Your doctor will probably use these lab tests to confirm a
diagnosis of osteoarthritis (OA):
Joint aspiration or Arthrocentesis
X-rays
MRI
The doctor may order blood tests to rule out other causes of
symptoms
How is OA Treated?
To date, no definitive treatment or cure of OA has been
identified.
Most successful treatment programs involve a combination of
treatment tailored to the patients need, lifestyle, and health.
The Programs include ways to manage pain and improve
function.
Treatment GOALS
Control pain
Improve Joint Function
Improve ability to do ADLs
Maintain normal body weight
Slow down the disease progress
Treatment PLANS
Patient education by counseling
Exercises
Weight control
Joint protection (rest and relief from stress in the joints)
Physical therapy and occupational therapy
Medications
Surgery
Complementary and alternative therapies (acupuncture, folk
remedies)
TREATMENT PLANS
Patient education by counselling
Exercises
Weight control
Joint protection (rest and relief from stress in the joints)
Physical therapy and occupational therapy
Medications
Surgery
Complementary and alternative therapies (acupuncture, folk
remedies)
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MEDICATIONS
Most people with Ostheroarthritis will use Drug Therapy to ease
the symptoms of the disease.
Most drugs focus mainly an Relieving pain, but some are targeted
at other symptoms and slowing disease progression.
MEDICATIONS
Most people with Ostheroarthritis will use Drug Therapy to ease
the symptoms of the disease.
Most drugs focus mainly an Relieving pain, but some are targeted
at other symptoms and slowing disease progression.
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GROUP of DrugsEXAMPLESAnalgesicsAcetaminophen, Propoxyphene
Hydrocholoride, TramadolNSAIDsAspirin, Ibuprofen, Ketoprofen,
Naproxen, MeloxiacamCox-2 DrugsCelecoxib, ValdecoxibTopical
AnalgesicsIn the form of cream, rub or spray:Zostrix, Icy Hot,
Therapeutic Mineral Ice, AspercremeCorticosteroidsInjectables
GlucocorticoidsViscosupplementsHyaluronic Acid Substitutes:
Synvisc, Hyalgan
Non-Drug Pain Relief
Hot or Cold Packs
TENS
MASSAGE
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Hot and Cold Packs
TENS
Massage
Weight Control
Weight Loss can reduce stress on weight-bearing joints, limit
further injury, and increase mobility.
A Dietician can help you develop healthy eating habits.
A healthy diet and regular exercise can reduce weight.
Weight Loss can reduce stress on weight-bearing joints, limit
further injury, and increase mobility.
A Dietician can help you develop healthy eating habits.
A healthy diet and regular exercise can reduce weight.
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Surgical Treatment Options in OA
Surgical Treatment options in OA
ARTHROSCOPY
It is most commonly performed on the Knee and Shoulder.
Removal of loose pieces of bone and cartilage from the joint if
they are causing symptoms of buckling or locking.
OSTEOTOMY
Osteotomy is useful in people with U/L Hip or Knee OA, who are
too young for a Total Joint Replacement.
Reposotioning of Bones.
JOINT REPLACEMENT SURGERY
This procedure is usually recommended for people over 50 or who
have severe disease progression.
The Surgical Reconstruction or Replacement of Joint.
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ARTHROSCOPY
It is most commonly performed on the Knee and Shoulder.
Removal of loose pieces of bone and cartilage from the joint if
they are causing symptoms of buckling or locking.
OSTEOTOMY
Osteotomy is useful in people with U/L Hip or Knee OA, who are
too young for a Total Joint Replacement.
Reposotioning of Bones.
JOINT REPLACEMENT SURGERY
This procedure is usually recommended for people over 50 or who
have severe disease progression.
The Surgical Reconstruction or Replacement of Joint.
FRACTURE \frak-chr, -shr\
Fracture is a complete or incomplete disruption in the
continuity of bone structure and is defined according to its type
and extent
Fractures
Avulsion
Impacted
Comminuted
Greenstick
Compression
Depressed
Spiral
Simple
Oblique
Open
Pathologic
Epiphyseal
Stress
Transverse
Avulsion
Comminuted
Compression
Depressed
Epiphyseal
Greenstick
Impacted
Oblique
Open
Pathologic
Simple
Spiral
Stress
Transverse
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Avulsion Fracture:
A fracture in which a fragment of bone has been pulled away by a
tendon and its attachment.
Comminuted Fracture:
A fracture in which bone has splintered into several
fragments.
Compression Fracture:
A fracture in which bone has been compressed.
A fracture in which bone has been compressed.
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Depressed Fracture:
A fracture in which fragments are driven inward (seen frequently
in fractures of skull and facial bones).
Epiphyseal Fracture:
A fracture through the epiphysis
Greenstick Fracture:
A fracture in which one side of a bone is broken and the other
side is bent.
The fracture in which one side of the bone is broken and the
other side is bent.
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Impacted Fracture:
A fracture in which a bone fragment is driven into another bone
fragment.
A fracture in which a bone fragment is driven into another bone
fragment
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Oblique Fracture:
A fracture occurring at an angle across the bones (less stable
than a transverse fracture).
Open Fracture:
A fracture in which damage also involves the skin or mucous
membranes, also called a compound fracture
A bone with several fracture. It can also mean several fractures
in one patient but on separate bones but generally due to the same
injury.
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Pathologic Fracture:
A fracture that occurs through an area of diseased bone (eg,
osteoporosis, bone cyst, Pagets disease, bony metastasis, tumor);
can occur without trauma or fall
An unstable fracture is generally a broken bone which is
comminuted, oblique or a spiral fracture requiring external or
internal fixation.
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Simple Fracture:
A fracture that remains contained, with no disruption of the
skin integrity
Spiral Fracture:
A fracture that twists around the shaft of the bone
Stress Fracture:
A fracture that results from repeated loading of bone and
muscle
Transverse Fracture:
A fracture that is straight across the bone shaft
5 Ps: Pain and point tenderness
Pallor
Pulse loss
Paresthesia
Paralysis
Sign and Symptoms of Fracture:
Arm and Leg Fractures
5 Ps: Pain and point tenderness
Pallor
Pulse loss
Paresthesia
Paralysis
Deformity
Swelling
Discoloration
Crepitus (grating, Crackling or popping sounds)
Loss of limb function
Cool skin at the end of extremity
Loss of pulse
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Deformity
Swelling
Discoloration
Crepitus (grating, Crackling or popping sounds)
Loss of limb function
Cool skin at the end of extremity
Deformity
Swelling
Discoloration
Crepitus (grating, Crackling or popping sounds)
Loss of limb function
Cool skin at the end of extremity
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Skull Fracture:
Bleeding
Hyperternsion
Loss of consciousness
Agitation
Irritability
Changes in responses
Seizures
Vomiting
Facial ecchymosis
CSF leaskage from ears and nose
Altered pupillary and motor responses
Abrasion
Laceration
Bleeding
Hyperternsion
Loss of consciousness
Agitation
Irritability
Changes in responses
Seizures
Vomiting
Facial ecchymosis
CSF leaskage from ears and nose
Altered pupillary and motor responses
Abrasion
laceration
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Jaw Dislocation or Fracture:
Mal occlusion
Mandibular s/s: pain, swelling, ecchymosis, loss of function,
asymetry, paresthesia of chin and lower lip
Maxillary s/s: infra orbital paresthesia, nasal and orbital
fracture
Mal occlusion
Mandibular s/s: pain, swelling, ecchymosis, loss of function,
asymetry, paresthesia of chin and lower lip
Maxillary s/s: infra orbital paresthesia, nasal and orbital
fracture
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Diagnostic Evaluation
X-ray
X-ray
MRI, CT-scan
Blood studies
Arthroscopy
Angiography
Nerve conduction/ electromyogram studies
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Blood studies
Arthroscopy
Angiography
Nerve conduction/ electromyogram studies
Management of Fracture
Assessment
Type, Location and Severity of Fracture
Soft Tissue Damage
Age and health status of patient
Extend of other parts of organs
Assessment
Type, Location and Severity of Fracture
Soft Tissue Damage
Age and health status of patient
Extend of other parts of organs
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Approaches to Management
Management
Closed
Open
Bandages
Splints
Casts
Traction
Internal Fixation
External Fixation
Closed Reduction
In the most common on surgical method for managing a simple
fracture.
Bandages: are elastic or muslin bandage used to immobilize the
bone during healing
Splints: as upper extremity bones do not bear weight, splints
may be sufficient to keep bone fragments in place.
In the most common on surgical method for managing a simple
fracture.
Bandages: are elastic or muslin bandage used to immobilize the
bone during healing
Splints: as upper extremity bones do not bear weight, splints
may be sufficient to keep bone fragments in place.
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Casts: A casts is an immobilizing device made up of layers of
plaster or fiber glass. A cast also allows early mobility and
reduces pain
Types of cast:
arm cast
leg cast
cast braces
body or spica cast
Casts: A casts is an immobilizing device made up of layers of
plaster or fiber glass. A cast also allows early mobility and
reduces pain
Types of cast: arm cast, leg cast, cast braces, body or spica
casr
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Traction: its the application of a pulling force to a part of
the body. It uses a system of ropes, pulleys, and weights to
provide reduction, alignment and rest
Traction: its the application of a pulling force to a part of
the body. It uses a system of ropes, pulleys, and weights to
provide reduction, alignment and rest
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External Fixation: Open reduction with external fixation. The
physician makes small percutaneous incisions so that pins may be
implanted into the bone. The pins are held in place by a large
external metal frame to help in bone healing.
External Fixation: Open reduction with external fixation. The
physician makes small percutaneous incisions so that pins may be
implanted into the bone. The pins are held in place by a large
external metal frame to help in bone healing.
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Goals of Management
To regain and maintain correct position and alignment.
To regain the function of involved part.
To return the patient to usual activities in the shortest time
and at the least expenses.
To regain and maintain correct position and alignment.
To regain the function of involved part.
To return the patient to usual activities in the shortest time
and at the least expenses.
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Complications of Fractures
Acute Compartment Syndrome
Acute compartment syndrome occurs when the tissue pressure
within a closed muscle compartment exceeds the perfusion pressure
and results in muscle and nerve ischemia. It typically occurs
subsequent to a traumatic event, most commonly a fracture.
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Fat embolism syndrome
Throbo-embolic syndrome
A fat embolism is a type of embolism that is often caused by
physical trauma such as fracture of long bones, soft tissue trauma
and burns.
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Infection
Avascular necrosis
Infection is the invasion of a host organism's bodily tissues by
disease-causing organisms, their multiplication, and the reaction
of host tissues to these organisms and the toxins they produce.
Infections are caused by microorganisms such as viruses, prions,
bacteria, and viroids, and larger organisms like macroparasites and
fungi.
Avascular necrosis (also osteonecrosis, bone infarction, aseptic
necrosis, ischemic bone necrosis, and AVN) is a disease where there
is cellular death (necrosis) of bone components due to interruption
of the blood supply. Without blood, the bone tissue dies and the
bone collapses. If avascular necrosis involves the bones of a
joint, it often leads to destruction of the joint articular
surfaces. (see Osteochondritis dissecans).
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