Musculoskeletal Musculoskeletal DisordersDisorders

Part TwoPart Two

Osteoporosis Osteoporosis

Reduction in bone density Reduction in bone density & change in bone & change in bone structurestructureBone reabsorption > Bone reabsorption > bone formationbone formationPathological fractures can Pathological fractures can occur and collapse of occur and collapse of vertebraevertebraePostmenopausal women Postmenopausal women greatest risk due to greatest risk due to estrogen deficiencyestrogen deficiency

Affects 1.4 million Affects 1.4 million CanadiansCanadians

1 in 4 women over 501 in 4 women over 50

1 in 8 men over 501 in 8 men over 50

Silent Dx as bone loss is Silent Dx as bone loss is asymptomatic- 1asymptomatic- 1stst sign # sign #

Estimated cost 1.9 billionEstimated cost 1.9 billion

Metabolic Bone DisordersMetabolic Bone Disorders

Changes in the physical & chemical structure of Changes in the physical & chemical structure of the bone due to estrogen deficiency, parathyroid the bone due to estrogen deficiency, parathyroid disorders, Vitamin deficiency, malabsorption or disorders, Vitamin deficiency, malabsorption or physical inactivity.physical inactivity.

Types:Types:

OsteoporosisOsteoporosis

Paget’s DiseasePaget’s Disease

OsteomalaciaOsteomalacia

Gout & Gouty ArthritisGout & Gouty Arthritis

OsteoporosisOsteoporosis

Fragility fractures occur due to low trauma Fragility fractures occur due to low trauma (bending over to pick up a newspaper)(bending over to pick up a newspaper)Most common fractures: hip, vertebrae & radiusMost common fractures: hip, vertebrae & radiusOsteopenia- low bone mineral density compared Osteopenia- low bone mineral density compared with that expected for age & sex & risk factor for with that expected for age & sex & risk factor for fracturefractureAffects 13-18% of post-menopausal women & Affects 13-18% of post-menopausal women & 30-50% have osteopenia of the hip30-50% have osteopenia of the hip1 of every two women will experience a fracture 1 of every two women will experience a fracture at some point in their lifeat some point in their life

OsteoporosisOsteoporosis

The World Health Organization defines The World Health Organization defines osteoporosis as bone mass that is 2.5 osteoporosis as bone mass that is 2.5 standard deviations below the peak standard deviations below the peak normal value for a young adult (Dowd, normal value for a young adult (Dowd, 1999)1999)

Normal OsteoporoticNormal Osteoporotic

Osteoporotic ChangesOsteoporotic ChangesHeight– 59– 53– 5– 49– 46– 43

Osteoporosis: Risk FactorsOsteoporosis: Risk FactorsInsufficient Insufficient calcium & calcium & vitamin Dvitamin D

Life style Life style factors-smoking, factors-smoking, caffeine, alcoholcaffeine, alcohol

Lack of weight-Lack of weight-bearing exercisebearing exercise

Lack of sunshineLack of sunshine

Female Female

Caucasian, non-Hispanic, AsianCaucasian, non-Hispanic, Asian

Increased ageIncreased age

Low weight & BMILow weight & BMI

Estrogen deficiency or menopauseEstrogen deficiency or menopause

Family hxFamily hx

Low initial bone massLow initial bone mass

Long term use of certain Long term use of certain medications (corticosteroids, medications (corticosteroids, anticonvulsives)anticonvulsives)

Coexisting medical conditions Coexisting medical conditions (celiac)(celiac)

Osteoporosis Management:Osteoporosis Management:

Adequate intake calcium & vitamin D Adequate intake calcium & vitamin D throughout lifethroughout life

Regular wt bearing exercisesRegular wt bearing exercises

Avoid alcohol & smokingAvoid alcohol & smoking

Discuss: “Osteoporosis is a pediatric disease with geriatric consequences”.

MedicationsMedications

ERT (prevents bone loss) – decreased useERT (prevents bone loss) – decreased use

Bisphosphonates approved for the treatment of Bisphosphonates approved for the treatment of osteoporosis: alendronate (Fosamax), risedronate osteoporosis: alendronate (Fosamax), risedronate (Actonel), and etidronate (Didrocal). Absorption of (Actonel), and etidronate (Didrocal). Absorption of bisphosphonates by the oral route is poor, even when bisphosphonates by the oral route is poor, even when taken on an empty stomachtaken on an empty stomach

Calcitonin-hormone slows bone reabsorptionCalcitonin-hormone slows bone reabsorption

Evista (raloxifene) selective estrogen receptor Evista (raloxifene) selective estrogen receptor modulators (do not increase risk breast or uterine ca)modulators (do not increase risk breast or uterine ca)

Nursing DiagnosesNursing DiagnosesAltered health maintenanceAltered health maintenance

Acute pain r/t fracture & Acute pain r/t fracture & muscle spasmmuscle spasm

Risk for constipationRisk for constipation

Risk for injuryRisk for injury

Paget’s DiseasePaget’s Disease

An idiopathic bone disorder An idiopathic bone disorder characterized by abnormal & characterized by abnormal & accelerated bone reabsorption & accelerated bone reabsorption & formation in one or more bonesformation in one or more bones

Normal bone is replaced by Normal bone is replaced by abnormal, structurally weaker bone abnormal, structurally weaker bone that is prone to fracturesthat is prone to fractures

Painful deformities are produced in Painful deformities are produced in femur, tibia, lower spine, pelvis & femur, tibia, lower spine, pelvis & craniumcranium

Paget’s Disease HumerusPaget’s Disease Humerus

OsteomalaciaOsteomalacia

Disease which bone becomes abnormally soft due to Disease which bone becomes abnormally soft due to disturbed calcium & phosphorous balance secondary disturbed calcium & phosphorous balance secondary to Vit D deficiencyto Vit D deficiencyBones bend & flattenBones bend & flattenDeformities wt –bearing bonesDeformities wt –bearing bonesAffects women endemic in AsiaAffects women endemic in AsiaCauses:Causes:Chronic use anticonvulsants, strict vegetarian, very Chronic use anticonvulsants, strict vegetarian, very low fat diets, fibrous dysplasia, hyperthyroid induced low fat diets, fibrous dysplasia, hyperthyroid induced osteopeniaosteopeniaTreatment- Vit D, adequate Ca, P & ProteinTreatment- Vit D, adequate Ca, P & Protein

Gout & Gouty ArthritisGout & Gouty Arthritis•Gout is a condition in which crystals of uric acid rise above normal levels & deposit in the joints, causing inflammation.

• Crystals may also form under the skin as well as the kidneys or urinary tract.

• Tophi - with repeated attacks accumulations of sodium urate crystals, are deposited in peripheral areas of the body, such as the great toe, the hands, and the ear

Gout is caused by:Gout is caused by:

an increase in production of uric acid an increase in production of uric acid under-elimination of uric acid by the under-elimination of uric acid by the kidneyskidneys

increased intake of foods containing increased intake of foods containing purines which are metabolized to uric purines which are metabolized to uric acidacid

dietary factors, some drugs & toxins dietary factors, some drugs & toxins

Purine in FoodPurine in Food

Gouty ArthritisGouty Arthritis

Comparison of Normal /Gouty JointComparison of Normal /Gouty Joint

Uric Acid CrystalsUric Acid Crystals

These spiked rods are These spiked rods are uric acid crystals uric acid crystals photographed under photographed under polarized light.polarized light.

Increased uric acid blood Increased uric acid blood levels and formation of levels and formation of uric acid crystals in the uric acid crystals in the joints are associated with joints are associated with gout.gout.

The definitive diagnosis of gout is dependent on The definitive diagnosis of gout is dependent on finding uric acid crystals in the joint fluidfinding uric acid crystals in the joint fluid during an during an acute attackacute attack

TREATMENT of GOUT:TREATMENT of GOUT:

Colchicine (reduces uric acid and Colchicine (reduces uric acid and phagocytosisphagocytosisNSAIDs (the treatment of choice) NSAIDs (the treatment of choice) indomethacin & naproxen or steroids if indomethacin & naproxen or steroids if resistant to NSAIDSresistant to NSAIDSAllopurinol (blocks production of uric acid)Allopurinol (blocks production of uric acid)Aspirin and aspirin-containing products Aspirin and aspirin-containing products should be avoided during acute attacks & should be avoided during acute attacks & used only on the advice of physicianused only on the advice of physician

Gout Drugs Gout Drugs

In multiple gout attacks, or those that In multiple gout attacks, or those that developed kidney stones more aggressive developed kidney stones more aggressive drug management is necessary. drug management is necessary.

Drugs that block absorption by the kidney, Drugs that block absorption by the kidney, such as probenecid, and drug that block such as probenecid, and drug that block production of uric acid by the body, such as production of uric acid by the body, such as allopurinol are considered. allopurinol are considered.

The choice between these two types of drugs The choice between these two types of drugs depends on the amount of uric acid in the depends on the amount of uric acid in the urine. With correct treatment, gout should be urine. With correct treatment, gout should be well controlled in almost all cases.well controlled in almost all cases.

Gout & Nursing CareGout & Nursing CareEpisodes may be triggered by surgery, heart Episodes may be triggered by surgery, heart attacks, trauma, alcohol use, some medsattacks, trauma, alcohol use, some meds

Pain management essential (acute pain often Pain management essential (acute pain often great toe)great toe)

TeachingTeaching Avoid certain diuretics such as thiazideAvoid certain diuretics such as thiazide Weight control without wide fluctuationsWeight control without wide fluctuations Avoid alcohol, caffeine, chocolate, organ Avoid alcohol, caffeine, chocolate, organ

foods, gravy, peasfoods, gravy, peas

Spinal Cord DeformitiesSpinal Cord Deformities

Scoliosis- lateral curvature of the Scoliosis- lateral curvature of the spine in any areaspine in any areaKyphosis-humpback , posterior Kyphosis-humpback , posterior rounding of thoracic spinerounding of thoracic spineLordosis- inward curvature of the Lordosis- inward curvature of the lumbar spine seen sometimes lumbar spine seen sometimes pregnant, obese or lg. abd. tumorspregnant, obese or lg. abd. tumors

ScoliosisScoliosis

Herrington Rod & ScoliosisHerrington Rod & Scoliosis

OsteomyelitisOsteomyelitis

Severe pyogenic infection of the bone Severe pyogenic infection of the bone & surrounding tissue& surrounding tissueBacterial mostly, can be viral or Bacterial mostly, can be viral or fungusfungusStaph most common (E-coli, Staph most common (E-coli, Pseudomonas, Klebsiella, Pseudomonas, Klebsiella, Salmonella, Proteus)Salmonella, Proteus)Femur & tibia malesFemur & tibia malesClinical manifestations:Clinical manifestations:

Acute, localized pain, reddness or Acute, localized pain, reddness or drainage, fever, malaise, elevated drainage, fever, malaise, elevated WBC, ESR, MRI to DxWBC, ESR, MRI to Dx

Septic ArthritisSeptic Arthritis

A closed-space infection, caused by A closed-space infection, caused by invasion of the synovial membrane invasion of the synovial membrane by pus-forming bacteria or other by pus-forming bacteria or other pathogenspathogens

Joints mostly affected; knee, hip, Joints mostly affected; knee, hip, shoulder, wrist & ankleshoulder, wrist & ankle

Most common cause neisseria Most common cause neisseria gonorrhoae & staphgonorrhoae & staph

Client has pain, swelling, warmth in Client has pain, swelling, warmth in joint & acute systemic reactionjoint & acute systemic reaction

Septic ArthritisSeptic Arthritis

Antibiotic therapy initiatedAntibiotic therapy initiatedPen G administered due to common Pen G administered due to common causal organismscausal organismsOpen synovectomy & debridement or Open synovectomy & debridement or repeated joint aspirations & irrigations repeated joint aspirations & irrigations maybe neededmaybe neededExercise & rehab. ImportantExercise & rehab. ImportantROM & CPM successful for someROM & CPM successful for some

SynovectomySynovectomy

Muscular DystrophyMuscular Dystrophy

Designates a group of genetic disorders involving Designates a group of genetic disorders involving gradual degeneration muscle fibersgradual degeneration muscle fibersProgressive weakness & skeletal muscle wasting, Progressive weakness & skeletal muscle wasting, disability & deformitydisability & deformityDuchenne’s MD most common & severe DxDuchenne’s MD most common & severe DxSex-linked recessive disorder affects males Sex-linked recessive disorder affects males exclusively (Xp21 gene)exclusively (Xp21 gene)Lab Dx: serum creatinine kinase analysis (levels Lab Dx: serum creatinine kinase analysis (levels elevated in MD due to abn of striated muscle elevated in MD due to abn of striated muscle function)function)Treatment symptomatic & supportiveTreatment symptomatic & supportive

ReadRead

Bone tumorsBone tumors

Disorders of the footDisorders of the foot

Berarducci, A. Lengacher, C.A., Keller, R. Berarducci, A. Lengacher, C.A., Keller, R. (2002). (2002). The impact of osteoporosis The impact of osteoporosis continuing education on nurses' knowledge continuing education on nurses' knowledge and attitudes. and attitudes. The Journal of Continuing The Journal of Continuing Education in Nursing, 33(5), retrieved from Education in Nursing, 33(5), retrieved from proquest http://proquest.umi.com/pqdweb?proquest http://proquest.umi.com/pqdweb?Did=000000184306351&Fmt=4&Deli=1&Mtd=1Did=000000184306351&Fmt=4&Deli=1&Mtd=1&Idx=14&Sid=1&RQT=309&Idx=14&Sid=1&RQT=309The Arthritis SocietyThe Arthritis SocietyCanadian Orthopedic Nurses AssociationCanadian Orthopedic Nurses Association