Musculo skeletal disorders

By
Michael Norbert L. De Guzman,
RN, MAN

Review of the Anatomy and

Physiology
Bone
Functions
supports and protects structures of the
body
anchors muscles
some bones contain hematopoietic
tissue which forms blood cells
participates in the regulation of calcium
and phosphorus

 Joints
bursa - enclosed cavity containing a gliding
joint
synovium - lining of joints which secretes
lubricating fluid that nourishes and
protects
classification of joints - synarthrosis,
amphiarthrosis, diarthrosis
Cartilage - connective tissue covering the
ends of bones

 Types of bones
a. long - legs, arms
external structure - diaphysis,
epiphysis, periosteum
internal structure of bone - medullary
cavity; cancellous bone; red marrow

b. short - ankles, wrists

c. flat - shoulder blades
d. irregular - face, vertebrae

 Muscles - produce movement of the

body
Types
striated - controlled by voluntary
nervous system
smooth - controlled by autonomic
nervous system
cardiac - controlled by autonomic
nervous system

 Fascia - surrounds and divides muscles

Tendons - fibrous tissue between
muscles and bones
Ligaments - fibrous tissue between
bones and cartilage; supports muscles
and fascia

 synarthrosis
A type of immovable joint with
fibrous connective tissue or cartilage
between the bone surfaces.
Movement is absent or limited, and a
joint cavity is lacking.

 amphiarthrosis
A form of articulation in which the
body surfaces are connected by
cartilage; mobility is slight but may
be exerted in all directions. The
articulations of the bodies of the
vertebrae are examples.

 diarthrosis
An articulation in which opposing
bones move freely (e.g., a hinge joint
or a pivot joint).

 diaphysis
The shaft or middle part of a long
cylindrical bone. SEE: apophysis;
epiphysis.

 periosteum
The fibrous membrane that forms the covering
of bones except at their articular surfaces;
consists of a dense external layer containing
numerous blood vessels and an inner layer of
connective tissue cells that function as
osteoblasts when the bone is injured and then
participate in new bone formation.
serves as a supporting structure for blood
vessels nourishing bone and for attachment of
tendons and ligaments.

 Contusions (bruise)
Definition - a fall or blow breaks capillaries
but not skin
Pathophysiology - extravasation (bleeding)
under skin
Findings - ecchymosis (bruise) and pain
when the contusion is palpated

1.Management
a.for first 24 to 48 hours, apply ice for 15 minutes, three
times a day
b.then apply heat if necessary
c. wrap to compress

2.Resolution: should heal within seven to ten days

3.Color changes from a blackish - blue to a gresnish
- yellow after three to five days

 Strains
Definition - lesser injury of the muscle attachment
to the bone
Etiology and pathophysiology
caused by overstretching, overexertion, or misuse of
muscle
acute: recent injury to muscle or tendon; classified by
degree
first degree: mild; gradual onset; feels stiff, sore locally
assessment of acute first-degree strain
tenderness to palpation
muscle spasm
no loss of range of motion
little or no edema or ecchymosis

 management of acute first-degree

strain
> comfort measures
> apply ice
> rest, possibly immobilize for short
term

second degree: moderate stretching, sudden

onset, with acute pain that eventually
leaves area tender
assessment of acute second-degree strain
o extreme muscle spasm
o passive motion increases pain
o edema develops early; ecchymosis later

 management of acute second-degree strain

o keep limb elevated
o apply ice for the first 24 to 48 hrs - then
moist heat
o limit mobility
o muscle relaxants, analgesics, NSAIDS
physical therapy for strength and range of
motion

 Third-degree: severe stretching with tear;

sudden; snapping or burning sensation
assessment of acute third degree strain
muscle spasm
joint tenderness
edema (may be extreme)
client cannot move muscle voluntarily
delayed ecchymosis

 management of acute third degree strain

keep limb elevated
apply ice for 24 to 48 hrs, then moist heat
either immobilize or limit mobility of the
limb
medication - muscle relaxants,
analgesics, NSAIDs
physical therapy for strength and range of
motion

 Chronic strain
long-term overstretching of
muscle/tendon
repeated use of the muscle beyond
physiologic limits

- Sprains
1.Definition - greater than strain; injury to ligament
structures by stretching, exertion or trauma
2.Classification/findings/assessment/management
a.first degree sprain
i. minimal tearing of ligament fibers
ii. localized edema or hematoma
iii.no loss of function
iv.no weakening of joint structure - joint integrity
remains intact
v.mild discomfort at location of injury
vi.pain increases with palpation or weight bearing

 management of first degree sprain

compress it with ace bandage to limit
swelling
keep limb raised to decrease edema
apply ice 24 to 48 hours following injury
analgesics for discomfort
isometric exercises to increase circulation
and resolve hematoma

b. second degree sprain

i. up to half of the ligamentous fibers torn
ii. increased edema and possible hematoma
iii.decreased active range of motion
iv.increased pain
v. mild weakening of the joint and loss of
function

 Management
protectively dress/splint the joint, immobilize it
elevate the limb to decrease edema
for 24 to 48 hours, alternate
ice
> to produce vasoconstriction to decrease swelling
> to reduce transmission of nerve impulses and
conduction velocity to decrease pain
moist heat
> to reduce swelling and provide comfort
analgesics for discomfort
physical therapy to increase circulation and
maintain nutrition to the cartilage

a. third degree sprain

i. complete rupture of the ligamentous
attachment
ii. severe edema with hematoma
iii.usually, severe pain
iv.dramatic decrease in active range of
motion
v. loss of joint integrity and function

 Management
casting
surgery to restore integrity of joint
see second degree treatment

B.Fractures: classification and diagnosis

1.Definition: fracture is any alteration in the
continuity of a bone
2.Fracture dislocation
a fracture in which the joint is dislocated in that
position, fracture will not heal completely

 Fractures are classified by these five parameters:

- completeness (complete or incomplete)

- wound in flesh (closed or open)
- fracture line in bone (4 lines)
- type (6 types of impact and damage)
- location in the bone

ASSESSMENT AND EARLY MANAGEMENT

OF THE TRAUMA CLIENT
Primary survey: ABC
Airway maintenance with spinal cord control - cervical stabilization
Breathing
Circulation

Cognitive level: glasgow coma scale

Eye opening
Verbal response
Motor response

Ask about: A-M-P-L-E

Allergies
Medications
Past illness
Last meal
Events preceding the injury

 Life threatening injuries of extremity

Massive open comminuted fractures
Bilateral femoral shaft fractures
Vascular injuries
Crush injuries of the abdomen or pelvis
Traumatic amputation of the arm or leg

type of fracture
a. avulsion fractures
i. bone fragments and soft tissue are pulled away
from the bone
ii. results from a direct force on the bone
b. comminuted fractures
i. produced by high energy forces
ii. results in two or more bone fragments
iii. splinters the fragments
iv. injures soft tissue severely

c. compression fractures
i. often seen in the lumbar spine
ii. may be pathological (a disease weakens bone)
d. greenstick fracture
iii. results in an incomplete fracture
iv. caused by
compression forces
angulation forces
v. cortex of the bone bends to one side and buckles on the other
vi. cortex stays intact on the side subject to tension forces and
fractures on the opposing side
vii. requires reduction or completion of the fracture line through
the cortex

e. impacted fractures (telescoped)

i. direct force breaks bone and telescopes the fragment with
the smaller diameter into the fragment with the larger
diameter
ii. fracture fragments move in unison
iii. rapid union occurs
f. stress fracture
iv. incomplete fracture
v. result of repetitive trauma to region
vi. two types:
fatigue - from repeated trauma

insufficiency - pathological fracture

Classification by location in the bone

apophyseal
articular
condylar
cortical
diaphyseal
epiphyseal
extracapsular

 Apophysis
an outgrowth without an
independent center of ossification
e.g. tubercle

 Articulation
A joint; the site of close
approximation of two or more bones.
The movement of articulating
surfaces through their available joint
play or range of motion, used to
determine joint mobility or to treat
joint pain.

 Condyle
A rounded protuberance at the end
of a bone forming an articulation
Diaphyseal
Part of or affecting the shaft of a
long bone.

 Epiphysis
A center for ossification at each
extremity of long bones.
Extracapsular
Outside a capsule
Intraarticular
Within a joint.

 Metaphysis
The portion of a developing long bone
between the diaphysis, or shaft, and the
epiphysis; the growing portion of a bone.
Periarticular
Circumarticular
Subperiosteal
Beneath the periosteum
Supracondylar
Above a condyle.

 Fractures: pathophysiology
Predisposing factors
biologic
bone density
client's age
Extrinsic factors
force - direct or indirect
rate of loading (how fast the force
strikes)

 Intrinsic factors - bone capabilities

Pathological fractures
bone is weakened by disease
fractures occur in response to minimal or no
applied stress
classification by cause: general or local
disorder
general: developmental, nutritional,
hormonally controlled
local: neoplasm, infection, cystic lesion

Fractures: management
1.Closed reduction
a.purposes: realign bone fragments for healing,
minimal deformity, minimal pain.
b.pre- and post-reduction x-rays are essential to
determine successful reduction of fracture

2. Immobilization
a.purposes
i. relieve pain
ii.keep bone fragments from moving
b.methods: cast - synthetic or plaster, traction skin or skeletal, splints, braces, and
external fixation

c. types of traction
i. manual: applied by pulling on the
extremity - may be used during cast
application
ii. skin: applied by pulling force through
the client's skin - used to relax the
muscle spasm
iii. skeletal: applied directly through
pins inserted into the client's bone used to align fracture
d. open treatment (surgery)

External Fixator: Ilizarov Device

A.The Ilizarov device is a specialized type of external
fixator used for non-union fractures and limb
lengthening needed due to congenital deformities.
B.Tension wires are inserted into the bone and then
attached to rings outside the body. These rings are
joined by telescoping rods attached to a rigid
frame. Daily adjustment of the rods causes the
wires to turn, which stimulates bone formation.
C.Ilizarov device lengthens limbs about one cm per
month.

A.Before discharge, teach clients

1.To care for pin
2.To adjust rod

B.Clients may have the device on for

several months.

A.Stages of bone healing

A.hematoma formation
B.fibrocartilage/granulation tissue formation
C.callus formation
D.ossification
E.consolidation/remodeling

A.Evidence of healed fracture

A.radiographic
A.presence of external callus or cortical bone
across the fracture site
B.fracture line may remain long after healing
B.clinical
A.pieces of bone no longer move at fracture site
B.no tenderness over fracture site
C.weight bearing is pain free

STAGES OF BONE
HEALING
I. Hematoma formation
A.One to three days
B.Blood clot forms around the fracture site
C.Bone necrosis occurs distal to the fracture
site due to a loss of blood

II. Granulation tissue formation

A.Begins three days to two weeks after fracture
B.Osteoclast formation in fibrous matrix of collagen
C.Fibroblasts
1.From outer layer of the periosteum
2.From damaged connective tissue

D.Osteoblasts
1.From the periosteum and marrow cavity
2.Develop collagen

E.Vascular and mechanical factors affect healing

1.Motion
2.Distraction of fracture fragments

III. Callus formation

A.Two to six weeks
B.Granulation material is matured into a callus
C.Size and shape of callus in direct response to the
amount of displacement of fracture fragments
D.Phagocytosis breaks down and removes the formed
hematoma
E.Delay at this stage delayed union or nonunion of bone

IV. Ossification
A.Three weeks to six months
B.The gap in the bone is bridged and union occurs

V. Consolidation /remodeling
C.Six weeks to one year
D.Callus becomes calcified and blends into the bone
E.Fracture line may still be evidence on radiographs

DIAGNOSTIC IMAGING
Radiographs
two dimensional representation of the
bone and soft tissue
include joints above and below
suspected fracture
clinical evidence of fracture overrides
negative x-ray analysis
will also offer evidence of
bone pathology
bone density (in advanced cases of
osteoporosis)

2. Computerized tomogram (CT) scan specialized tomograms

3. Magnetic resonance imaging (MRI) scan
- clearer views of soft tissue structures
4. Bone scan - increased uptake of contrast
may indicate
fracture
infection
tumor growth

Fracture: Complications
1.Immediate complications of the injury
a.shock - higher risk with pelvic and femur
b.fat embolism - occurs after the initial 24 hours
from the injury
c.compartment syndrome - a nursing emergency
d.deep venous thrombosis (DVT)
e.pulmonary embolism - a complication of DVT

ORTHOPEDIC
COMPLICATIONS
A.Venous thromboembolic problems
1.Thrombophlebitis (TP)
a.inflammation of a vein with the formation of a
blood clot
b.incidence is greatest after trauma or surgery to
legs or feet

B. Deep venous thrombosis (DVT)

1. Anterior tibial or femoral veins
2. May be caused by immobility
3. Findings include calf pain, positive
Homan's sign
4. Immediately after operations
a. anticoagulant therapy
b. antiemboli stockings (usually)
c. sequential compression device (possibly)

C. Pulmonary embolism (PE)

1.Blood clot from systemic circulation enters pulmonary circulation
2.Most commonly seen after hip fractures and total hip/knee
replacements
3.Occurs in approximately ten percent of patients undergoing hip
arthroplasty
4.May be caused by femoral vein manipulation during surgery and
therefore occur without signs of DVT
5.Findings include chest pain (pleuritic), sudden shortness of
breath, tachycardia, palpitations, or change in mental status
6.If PE is suspected,do not leave client. Get charge nurse to notify
health care provider immediately
7.Diagnosis confirmed via ventilation/perfusion scan or pulmonary
angiography
8.Continuous IV heparin therapy usually prescribed

D. Fat embolism
1.Definition: fat cells enter pulmonary circulation
2.Associated with
a.multiple trauma accidents
b.multiple organ involvement
c.fractures of marrow producing bones
d.joint replacements
e.insertion of intermedullary rods

3.Usually occurs 24 to 48 hours after the

fracture

E. Hemorrhage
1.Abnormal loss of blood from the body
2.Most common in fractures of bone marrow producing bones

F. Wound infection
3.May be superficial or deep wound
4.Deep wound infection may lead to osteomyelitis
5.Findings include erythema and swelling around suture line,
increased drainage and elevated temperature
6.Treated with antibiotics; may require incision and drainage
of wound or removal of prosthesis if severe infection is
present

G. Special complications in hip replacement

1.Femoral fracture
a.occurs near distal end of femoral-shaft part of
prosthesis
b.occurs more frequently with elderly, clients with
osteoporosis, or after revision to total hip
replacement
c.primary finding is severe pain with ambulation
d.diagnosis is confirmed with x-ray
e.depending on severity, treatment will be
immobilization or open reduction with internal fixation

1.Dislocation of hip prosthesis

a.greatest risk during the first postoperative week
but can occur at any time within the first year.
b.risk decreases as muscle tone of the hip increases
c.caused by flexion of the hip or poor prosthetic fit
d.findings include pain and external rotation of the
leg
e.treated by closed reduction under conscious
sedation or open surgical revision

H. Special complication in knee

replacement: flexion failure
1.Client cannot flex knee 90 degrees two weeks
postoperatively
2.Treated with closed manipulation of the knee
joint under general anesthesia

compartment syndrome
Elevation of tissue pressure within a
closed fascial compartment, causing a
decreased arteriovenous pressure and
decreased muscular perfusion.

Delayed complications
a.joint

stiffness
b.post-traumatic arthritis (osteoarthritis, type II)
c.reflex sympathetic dystrophy
i. painful dysfunction and disuse syndrome
ii.characterized by abnormal pain and
swelling of the extremity

d. myositis ossificans
i. formation of hypertrophic bone near bone
and muscles
ii.forms in response to trauma
iii.hypertrophic bone is removed when bone is
mature

e. Malunion
i. fracture healing is not stopped but slowed
ii.prevention of malunion
reduce and immobilize properly
be sure client understands limits on
activity and position

f. delayed union
i. fracture

does not heal

ii.more common with multiple fracture
fragments
iii.no evidence of fracture healing four to six
months after the fracture

g. loss of adequate reduction

h. refracture

reflex sympathetic dystrophy

An abnormal response of the nerves of the face or
an extremity, marked by pain, autonomic dysfunction,
vasomotor instability, and tissue swelling. Although the
precise cause of the syndrome is unknown, it often
follows trauma, stroke, neuropathy, or radiculopathy.

Nursing interventions
1.Risk for peripheral neurovascular deficit
a.check neurovascular status often
b.elevate limb above level of heart (
except with compartment syndrome)
c.apply cold to minimize edema

2. Pain
a.assess level of pain with a scale of one to ten
b.manage pain
i. with drugs
ii.reposition client
iii.pad any bony prominences
c.teach relaxation techniques

3. Client teaching
a.how fractures heal
b.why the fracture is being immobilized
c.how to bear weight and how much (if permitted)
d.how bones heal
e.how to use assistive devices to walk

4. Risk for infection

a.related to
i. open fractures
ii.surgical intervention
iii.superficial/deep wounds
b.monitor for findings of infection
c.provide proper wound care
d.administer antibiotic therapy as indicated

 COMPARTMENT SYNDROME
I. Definition - increased pressure in a limited
space (muscle compartment) cramps the
circulation and function of the tissues
within that space

I. Types: acute and chronic (or exertional)

A.Acute:
1.Following trauma to the muscle
2.External forces: casting/bracing compresses limb
3.Internal forces: compartment content increases; space
does not
4.Results in necrosis of the tissue

B. Chronic/exertional - when exercise of a

limb raises intracompartmental pressure and
produces pain and neurologic deficits

I. Pathophysiology
A.Ischemia-edema pathology cycle
B.If cycle lasts more than six hours,
neuromuscular damage irreversible
C.Duration of 24 to 48 hours: extremity may be
paralyzed
D.May develop rapidly or for up to six days after
initial trauma
E.A nursing emergency

A.Compression occurs of the vessels and nerves

1.Risk for impaired skin integrity
I. causes
I. open fractures
II.soft tissue injuries
III.pressure areas
II.additional factors
I. age - elderly
II.general condition of client
III.preexisting skin conditions or diseases

III. interventions
I. mobilize the client as soon as possible
II.turn the client often at least every two hours
III.position the client properly with alignment
in mind
IV.use orthopedic devices to limit skin
impairment

2. Impaired gas exchange

I. accompanies chest trauma
II.client risks fat embolism
III.client risks deep venous thrombosis
IV.interventions
I. mobilize as soon as possible frequent and
effective pulmonary toileting

Degenerative Disorders
A.Definition
1.Slowly progressive disorders of articular cartilage
and subchondral bone
2.Do not affect the joints symmetrically (e.g., not
necessarily both knees)
3.Worsen progressively
4.Eventually incapacitate, despite treatment

Osteoarthritis (OA)
1.Definition - degeneration of the articular cartilage
and formation of new bone in the subchondral
margins of the joint
2.Findings
I. primarily involves weight-bearing joints
II.non-inflammatory disorder
III.localized: no systemic effects
IV.results in an abnormal distribution of stress on
the joint

3. Incidence
I. most common form of arthritis
II. may begin as early as the 20s and peaks in
the 60s
III. by age 70, nearly 80% of afflicted people
show findings
IV. over age 55, OA affects twice as many
women as men
V. two types: primary and secondary

Types of Osteoarthritis (OA)

Primary (Idiopathic) Osteoarthritis
No known cause
Classifications
Localized OA in one or two joints
Generalized OA in three or more joints.

Etiology
1.More common in women (slightly)
2.More common in Caucasians
3.Develops in middle age and progresses slowly
4.More often affects certain joints
a.weight-bearing joints
b.cervical and lumbosacral joints
c. interphalangeal joints

5.Hands more affected in women after menopause

6.Hips are more affected in men

Secondary (Traumatic) Osteoarthritis

Underlying condition: a trauma to the articular
cartilage
Etiology
1.Genetic predisposition, shown by the presence of
a.Heberden's Nodes
b.Bouchard's Nodes

2.More common in men

3.Often occurs in
a.wrists
b.elbows
c. shoulders

Risk factors for traumatic osteoarthritis

1.Obesity
2.Family history of degenerative joint disease
3.Excessive joint wear
a.physical activity
b.injury

4.Joint abnormality
a.lax ligaments
b.congenital hip dysplasia

5.Lifestyle: certain occupations predispose to

secondary OA.

HEBERDEN'S NODES
A.Bony osteophytes at the DIP joint
B.Common presentation of OA in the hand
C.Indicates a strong hereditary tendency
. Seen more often in women than men (ten
times)

BOUCHARD'S NODES
A.Accompany Heberden's nodes
B.Found at the PIP joint
C.Occur more often in women than men
D.Increase in frequency with age

Pathophysiology
A.stage one: microfracture of the articular
surface
A.articular cartilage is worn away
B.condyles of bones rub together: joint swells
and is painful
C.cartilage loses cushioning effect: joint
friction develops
D.prostaglandins may accelerate
degenerative changes

B. stage two: bone condensation

A.erosion of cartilage
B.cartilage may be digested by an enzyme in
the synovial fluid

C. stage three: bone remodeling

A.matrix synthesis and cellular proliferation
fail
B.eventually the full thickness of articular
cartilage is lost
C.bone beneath cartilage hypertrophy and
osteophytes form at joint margins
D.result: joint degenerates

B. Findings
A.joint stiffness after periods of rest
B.pain in a movable joint, typically worse with action,
relieved by rest
C.paresthesia
D.joint enlargement: bones grow abnormally; spurs form
and synovitis sets in.
A.Heberden's nodes
B.Bouchard's nodes
E.joint deformities

F. tenderness

on palpation
A.may involve widely separated areas of the joint
B.mild synovitis may be felt - positive bulge sign
may be found
G. pain on passive movement
H. limitation in active range of motion because
C.joint surfaces no longer fit
D.muscles spasm and contract
E.joints are blocked by osteophyte, loose bodies
F.crepitation, crunching when joints are moved
G.eventual ankylosis

I.

gait
A. abnormal antalgic gait
B. shortened stance
C. widened base of support
D. shortened step length

OSTEOARTHRITIS OF HIP/KNEE: SPECIFIC PHYSICAL FINDINGS

1.Hip
a.contracture in adduction and flexion
b.decrease in internal and external rotation
c.limb shortening
d.referred pain to the
i. knee
ii.groin
iii.thigh

2.Knee
a.decreased range of motion
b.flexion contracture
i. hip
ii.knee

c.varus deformity: bow legged appearance

d.valgus deformity: knock-kneed appearance
e.positive apprehension sign
i. push the patella laterally with the leg in full extension
ii.client will stop the examiner from pushing the patella
further

Diagnostics
1.to rule out autoimmune disorders
1.sedimentation rate
2.rheumatoid factor
3.c-reactive protein
2.CBC
1.analyze before NSAID therapy
2.within normal limits
3.kidney and liver
1.especially in older clients, analyze before starting
NSAID therapy
2.repeat every six months

4. purified protein derivative (PPD)

1.analyze before starting steroids
2.clients testing positive for tuberculosis must
receive INH at same time as steroid.
5. antinuclear antigen (ANA) titer
3.may be lower in the elderly
4.does not necessarily prove a connectivetissue disease
6. synovial fluid analysis distinguishes
osteoarthritis from rheumatoid arthritis.

7.radiographs
1.taken in standing, weight-bearing condition
2.shows the prime sign of OA: joint space
narrowing
3.x-ray does not necessarily reflect severity of
disease
4.joint loses space asymmetrically because
cartilage narrows from production of
osteophytes or bone spurs
5.later stages may show bony ankylosis,
spontaneous fusion

8. bone scans
1.radionuclide imaging
2.shows skeletal distribution of osteoarthritis
3.monitors complications of joint replacement
surgery
9. MRI scans show the extent of joint destruction
10. computerized tomograms (CT) scans show
cortical and cancellous bone density

Management: conservative treatment

1.education should cover
1.exercise patterns
2.relaxation techniques
3.nutritional assessment
4.counseling about maintaining a normal
weight
2.nutritional management - weight reduction

3. activity and rest management

1.preservation of joint motion through a balance of
1.rest (protection)
2.activity (rehabilitation)
2.individualized activity rehabilitation program
3.physical or occupational therapist may be helpful
4.passive range of motion exercises
5.active stretching
4. protection from further injury by splinting or bracing

REMISSION-INDUCING MEDICATIONS IN ARTHRITIS

A.Slow acting drugs - take several months to show

results
B.Hydroxychloroquine
1.Antimalaria drug
2.For use in severely destructive RA
3.Side effects
a.GI irritation
b.retinal changes
c.depression of bone marrow

4.Nursing implications
a.eye exam every four to six months

. monitor hepatic and renal function

C. Gold salts and penicillamine

1.Antirheumatic
2.Used only after NSAID therapy fails to achieve relief
3.Suppresses inflammation
a.remission inducing
b.slow cumulative effect

4.Penicilliamine is more toxic than gold salts

5.Side effects
a.GI irritation
b.alteration in taste sensation
c.urticaria

1.Nursing implications
a.continual evaluation of renal/hepatic function
b.appropriate skin care
c.take medication on empty stomach

8.Medication
a.aspirin - most often recommended
i. advantages: relatively safe and inexpensive
ii.disadvantage: GI problems may lead to ulcers
and bleeding
b.nonsteroidal anti-inflammatory medications
(NSAIDs)
i. reduce pain and inflammation
ii.inhibit prostaglandin formation
iii.may cause GI bleeding or gastric ulcers or
cramping with diarrhea

c. adrenocorticosteroid injections
d. remissive agents
i. gold
ii.penicillamine (cuprimine)
iii.hydrochloroquinine (plaquenil)

9. Nonmedication assistance
a.assistive devices
i. canes
ii.walkers
b.non-traditional techniques
i. guided imagery - the use of one's imagination
to acheve relaxation and control
ii.therapeutic massage
iii.biofeedback
iv.hypnosis
v.relaxation techniques

10. Surgical management

a.arthrodesis fusion of two bones
b.arthroplasty
c.osteotomy
d.total joint replacement

additional
1.Charcot joints (also called neuropathic joint
disease)

Definition - multicausal degeneration and

deformation of joint, usually ankle.
- Bone decalcification occurs on the joint
surfaces, accompanied by bony overgrowth
about the margins. Pain is usually absent

Etiology
a.diabetes mellitus leading to foot neuropathy
b.syringomyelia results in Charcot's joint of the
shoulder
c.tertiary syphilis
d.peripheral neuropathies
e.spina bifida with myelomeningocele
f. leprosy
g.multiple sclerosis
h.long term intra-articular steroid injections

Findings
a.inspection: foot is everted, widened, and
shorter than normal
b.examination
i. joint instability
ii.soft tissue swelling
iii.pain secondary to inflammation

syringomyelia
A disease of the spinal cord characterized
by the development of a cyst or cavities with
the cord. It usually begins at the site of a
congenital malformation of the cerebellum

Diagnostics
a.laboratory analysis of synovial fluid
i. fluid is non-inflammatory
ii.low protein content
iii.no hemorrhage noted
b.radiographs
i. chronic destructive arthritis of the foot
ii.severe destruction of the articular cartilage,
subchondral sclerosis
iii.fragments of bone and cartilage in joint

Management
a.conservative treatment
i. protection from overuse/abuse
ii.braces and splints
b.surgical management: arthrodesis
i. treatment of choice for unstable joints
ii.fusion of the involved joint

Nursing interventions
a.expected outcome: preserve the joint
b.education can prevent further injury
c.protection of the joint
i. braces
ii.orthopedic shoes
d.prolonged immobilization
i. eight to 12 weeks to decrease swelling
ii.leads to minimal joint deformity and a
functional painless foot

Chondromalacia patellae (also called

patellofemoral arthralgia)
Definition: progressive, degenerative softening of the
bone; follows a knee injury
Etiology
a.lateral subluxation of the patella (kneecap)
b.direct or repetitive trauma to the patella produces
chondral fracture
c. underdevelopment of the quadriceps muscles

Findings
a.pain with flexed knee activities (poorly localized)
b.mild swelling
c. occasional episodes of buckling of the affected knee
d.minimal joint effusion
e.evidence of 'squinting kneecaps'
f. atrophy of quadriceps
g.inverted 'J' tracking of the patella in the final 30
degrees of extension
h.excessive quadriceps angle
i. positive apprehension sign
j. crepitation upon range of motion

Diagnostics
a.radiographs
i. anterior posterior (AP) and lateral views are
not helpful
ii.sunrise views with the knee in 30 degrees,
60 degrees and 90 degrees of flexion
b.bone Scans
c.MRI Scans
d.arthroscopy

Conservative management
a.progressive resistive exercises
i. quadriceps setting - isometric
ii.hamstrings - isotonic
b.medication: NSAIDs
c.nonmedication assistance: application of ice or
moist heat
d.activity restriction

5.Surgical management
a.indicated if findings remain after six months of
conservative treatment
b.arthroscopy (see Orthopedic Surgery section that
follows)
c.arthrotomy
i. realignment of proximal and/or distal soft tissue
ii.tibial tubercle elevation
iii.patellectomy
d. Nursing interventions (see previous Osteoarthritis
section)

Rheumatoid arthritis (RA)

Definition - chronic systemic inflammatory disease of
the connective tissue
Findings
a.starts in feet and hands, gradually destroys
these peripheral joints
b.affects diarthroidial joints
c.bilateral involvement

Etiology
a.cause is not fully understood
b.rheumatoid arthritis is an autoimmune disorder
c.genetic tendency; but may involve bacteria, or
viruses
d.may affect the connective tissue of the lungs,
heart, kidneys, or skin
Incidence
e.two to three times more common in women
than in men
f. strikes between the ages of 20 and 50 years of
age

Pathophysiology
a.synovitis immune complexes initiate inflammatory
response
i. IgB antibodies are formed
ii.rheumatoid factor (RF)
1.pannus formation
2.destruction of subchondral bone
3.present in 85 to 90% of all cases
4.worsens the inflammatory response - can
go on indefinitely
5.irreversible - will lead to ankylosis of joint

DISEASE PROCESS IN RA: RHEUMATOID

FACTOR (RF)

A.RF factor in serum reacts against

immunoglobulin G
B.Inflamed synovial membrane
C.Pannus
1.Vascularized fibrous scar tissue (pannus)
2.Erodes surface of articular cartilage

D.Manifestations - early
1.Prominent joint margins erode
2.Synovial membrane thickens

E. Manifestations - late
1.Fibrous adhesions
2.Bony ankylosis
3.Joint destruction
4.Fusion of opposing joint surfaces
5.Shortens tendon sheaths
6.Joint contractures

Findings
a.in early RA joints will be
i. painful, stiff
ii.warm, red, swollen at capsules and soft tissues
iii.incapable of full range of motion
b.in late RA, joints will show
i. bony ankylosis
ii.destruction of joint - reactive hyperplasia
iii.adhesions
iv.inflammation and effusion that will be
symmetrical
polyarticular

c. general signs
i. fatigue
ii.loss of appetite and weight
iii.enlarged lymph glands (illustration )
d. rheumatic nodules
iv.in 20% of cases
v.firm, oval, nontender masses under the skin
vi.presence indicates poor prognosis

e. physical assessment should also include

i. accurate patient history - history may include
malaise
fatigue
weakness
loss of appetite and weight
enlarged lymph glands
Raynaud's syndrome
ii.examination may reveal deformities
ulnar deviation
deformed hands: swan neck/boutonniere

f. neurological examination
i. foot drop
ii.evidence of spinal cord compression

Diagnostics
a.laboratory analysis
i. elevated ESR
ii.decreased RBC
iii.positive C-reactive protein
iv.positive antinuclear antibody in 20% of
cases
v.positive rheumatoid factor (RF)

b. radiographic studies
i. bony erosion
ii.decreased joint spaces
iii.fusion of joint
c. aspiration of synovial fluid; analysis shows
iv.cloudy appearance
v.more white blood cells than normal

Management
a.(see previous Osteoarthritis section)
b.psychological support
c.splinting: resting, corrective, or fixation

Systemic Lupus Erythematosus

(SLE)
Chronic, systemic, inflammatory disease of the collagen tissue

Etiology
- Unknown
- F>M
- Antigen stimulates antibodies, which form soluble immune
complexes, deposited in tissues;
- Number of T suppresor cells dwindles

- Immune complex inflames tissue

- Inflammation creates findings

+ the intensity and location of the

inflammation reflects findings and
organ involved
+ client with CNS or renal involvement
have poorer prognosis

Findings: SLE is present if client has four or more of

these:
a.arthritis: characterized by swelling, tenderness
and effusion; involving two or more peripheral
joints
b.malar rash: characteristic butterfly rash over
cheeks and nose
c.discoid lupus skin lesions
d.photosensitivity
e.oral ulcers

f. serositis: pleuritis
g. renal disorder: persistent proteinuria
h. neurologic disorder: seizures or psychosis in the
absence of drugs or pathology
i. hematologic disorder: hemolytic anemia with
reticulocytosis or leukopenia
j. immunologic disorder: positive LE (lupus
erythematosus) cell preparation or anti-DNA or antiSm or false positive serologic test for syphilis
k. antinuclear antibody: abnormal titer of antinuclear
antibody by immunofluorescence or equivalent assay
l. positive LE cell reaction

 Gout
Definition
monoarticular asymmetrical arthritis
characterized by hyperuricemia
Etiology

primarily affects men

peak incidence 40 to 60 years of age
familial tendency
abnormal purine metabolism or excessive purine
intake results in formation of uric acid crystals which
are deposited in the joints and connective tissue.
deposits are most often found in the
metatarsophalangeal joint of the great toe or in the
ankle.

3.Findings
a.tight, reddened skin over the inflamed joint
b.elevated temperature
c.edema of the involved area
d.hyperuricemia
e.acute attacks commonly begin at night and last
three to five days

f. gout attacks may follow trauma, diuretics,

increased alcohol consumption, a high purine diet,
stress (both psychological and physical) or
suddenly stopping of maintenance medications
g. warning signs of flare-up include the exacerbation
of previous findings or the development of a new
one
h. systemic manifestations may include fever, renal
disease, tophus

 Diagnostics: lab tests

increased urinary uric acid
following a purine restricted diet
hyperuricemia

3.Management
a.expected outcomes: control symptoms; prevent
attacks
b.medical
1.NSAIDs
2.colchicine (used when NSAIDs are
contraindicated) - enhances the excretion of uric
acid
3.to prevent flareups: antihyperuricemic agents such
as allopurinol (lopurin) or probenecid (benemid) minimize the production of uric acid
4.heat or cold therapy

c.

dietary
1. avoid purine foods such as
meats, organ meats, shellfish,
sardines, anchovies, yeast,
legumes
2. control weight
3. drink less alcohol - all types

Nursing care
a. pain management strategies
b. elevate the affected limb; provide bed rest
and immobilize joint
c. avoid pressure or touching of bed clothing
on affected joint
d. reinforce dietary management and weight
control
e. administer anti-gout medications as ordered
f. increase fluid intake to prevent renal calculi
(kidney stones)

2. Metabolic Bone
Disorders
Osteomalacia
Definition - delayed mineralization; resulting
bone is softer and weaker
Pathophysiology - similar to rickets
bones have too little calcium and phosphorus
vitamin D deficiency; possibly inadequate
exposure to sunlight
less serum calcium than normal
more parathyroid hormone
more renal phosphorus clearance

1.Osteoporosis
3.Definition
a.multifactorial disease results in
1.reduced bone mass
2.loss of bone strength
3.increased likelihood of fracture
b.types
1.type one osteoporosis (estrogen related)
2.type two osteoporosis (related to old age)

3.Etiology/epidemiology
a.most common metabolic disease of bone
1.affects an estimated 25 million Americans
2.contributor of 50% of all adult fractures
b.onset is insidious
c. women affected twice as often as men before the age of
70
d.skeletal changes result from the aging process
e.bone loss due to
1.immobilization
2.lack of gravitational stress

 TYPE I OSTEOPOROSIS
Loss of trabecular bone after menopause
Theoretically related to a lack of estrogen
Bilateral oophorectomy
Amenorrhea in younger women

Results in
Loss of height
Kyphosis
Increased risk of fracture

 TYPE II OSTEOPOROSIS
Age-related loss of cortical/trabecular bone in
men and women occurring after age 70
Long-term remodeling
Results in fractures of humerus and femoral
neck
Factors related to osteoporotic fractures
low bone density
history of scoliosis
neurological impairment after
CVA
Parkinson's disease
decreased vision from macular degeneration, complications
of diabetes, etc.
best indicator of fracture risk in bone densitometry

 ADDITIONAL RISK FACTORS FOR

OSTEOPOROSIS
A.Genetic risk factors
1.Female, white or Asian
2.Small frame, thin-boned; short; low body fat
3.Women with post-menopausal osteoporosis may
have inherited a lower peak bone mass
4.Daughters of women with osteoporosis averaged
less bone mass in lumbar spine and femoral neck
5.Family history of hip fracture

A.Reproductive factors
1.Hypo-estrogenism associated with increased
bone remodeling, faster bone loss
2.Early or surgically induced menopause
3.Amenorrhea in athletes/anorexia nervosa
a.hypogonadism
b.weakens the bones
c.decreases bone mass

4.Nulliparity (no pregnancies)

A.Endocrine factors in osteoporosis

1.premature menopause
2.hyperthyroidism increases bone turnover and
remodeling
3.hyperparathyroidism
a.increases bone turnover and remodeling
b.increased parathyroid hormone (PTH)

stimulates osteoclast activity

depresses osteoblast activity
result is an increase in serum concentration of calcium

1.hyperadrenocorticalism
2.type I diabetes mellitus
a.Findings

client history
A.acute fracture
B.prior history of a traumatic fracture; no trauma
C.history of falls
pain
A.greater when active, less while resting
B.early in disease, pain in mid to low thoracic spine
anxiety
A.about further falls/fractures
B.about ability to perform ADLs

 kyphosis - 'Dowager's hump' may reflect

multiple spinal fractures
loss of height
two or more inches
usually precedes diagnosis of
osteoporosis diagnosis

 RECALL METHOD FOR HEIGHT DETERMINATION IN

OSTEOPOROSIS
A. Client is asked to recall maximum adult height
B. Subtract current height from recall height
C. A two-inch loss of height predicts osteoporosis
Diagnostics
a. blood tests
i. complete blood counts
ii. serum levels
calcium
phosphate
alkaline phosphatase

b. x-rays
i. help identify fractures and kyphosis of spine
ii. less useful in the detection of pre-fracture
osteoporosis
iii. detect osteoporosis only after 20% bone
mineral content is lost

c. bone densitometry
i. best means of measuring risk for fracture
ii.quantitative computerized axial tomogram (CAT)
measures pure vertebral trabecular bone
iii.dual energy x-ray absorptionometry (DEXA)
technique of choice
assesses cortical and trabecular bone in spine
and hip
single photon absorptionometry measures
cortical bone in long bones

5.Management
a.exercise
i. restorative - aims to increase bone density, decrease
risk for fracture
ii. within the client's tolerance
iii.must be maintained throughout life
b.nutrition
i. calcium and vitamin D
ii. deficiencies increase risk of fracture
iii.sedentary older adults may need supplements

c. medication
anti-resorptive agents
do not increase bone mass - rather prevent
further bone loss
estrogen therapy
calcitonin (Osteocalcin)
1. peptide hormone
2. powerful inhibitor of osteoclastic bone
resorption
3. modestly increases bone mass in
osteoporosis
not shown to decrease osteoporotic fractures
expensive

 biophosphonates

inhibit bone resorption

sustained use associated with osteomalacia and
Paget's disease
alendronate (Fosamax)
1. 100 to 500 times more potent than etidronate
2. non-hormonal agent
3. highly selective inhibitor
4. not associated with detrimental effects of
mineralization
5. expensive: average $41.70 per day for
osteoporosis

 bone-forming agents
sodium fluoride (Fluoritab)
androgens
taken long-term, increases bone mass
in osteoporotic women

 education
increase awareness
discourage risk-related behaviors
reinforce positive behaviors and lifestyles
reduce risk of falling
teach proper lifting and movement
techniques
encourage proper footwear
install safety equipment in home
cholesterol levels

5.Nursing intervention: teach prevention of

osteoporosis and its damage
a.education
i. increase awareness
ii. discourage risk-related behaviors
iii.reinforce positive behaviors and lifestyles
b.reduce risk of falling
i. teach proper lifting and movement techniques
ii. encourage proper footwear
iii.install safety equipment in home

Paget's disease (osteitis deformans)

1.Definition: a slowly progressing resorption and
irregular remodeling of bone.
2.Etiology
a.bone resorbed; new bone poorly developed, weak, easily
fractured
b.mainly affects major bones:
skull, femur, tibia, pelvis, and vertebrae
c. cause unknown
d.possible viral implications
e.family tendency - noted in siblings

1.Findings
a.asymptomatic initially
b.musculoskeletal
i. deformity of long bones
ii.pain and point tenderness of affected limbs

PAGET'S DISEASE EFFECTS SYSTEMIC SEQUELAE OF MALFORMATION OF BONE

A.Skull
1.Cranial nerve damage
2.Hearing loss
3.Obstructive hydrocephalus

B.Vertebrae
1.Rigid forward bend of spine
2.Compression of thoracic vertebrae
3.Kyphosis

. Impaired respiratory ventilation

A.Cervical Spine: spinal cord compression:

spastic quadriplegia
A.Diagnostics
A.radiographic findings
A.bowing of long bones
B.thickened areas of bone
C.pathological fractures
D.sclerotic changes

B. Laboratory analysis
A.increased alkaline phosphatase means
osteoblasts more active
B.increased urinary hydroxyproline means
osteoblasts more active
C.serum calcium level will be normal

A.Management
A.only treat if symptomatic
B.conservative intervention
A.medication
A.NSAIDs
B.calcitonin (osteocalcin)
A.slows bone resorption
B.allows normal lamellar bone development
C.disodium etidronate (EHDP)
A.rapidly slows bone resorption
B.lowers levels of alkaline phosphatase and
urinary hydroxyproline
C.may relieve pain
D.plicamycin (mithracin)
A.antibiotic
B.used only when Paget's disease bone is
damaging nerves

C. Surgery
A.reduce pathological fractures
B.correct secondary deformity
C.relieve neurologic impairment
D.complications common
A.nonunion
B.malunion

The End
Thank you!!!