2 Musculoskeletal Disorders

1. 2Musculoskeletal Disorders Osteomyletis Bone Cancer Osteoporosis Paget’s Disease Osteomalacia (Adult Rickets)

2. Musculoskeletal Disorders – Normal Bone Normal bone remodeling process involves sequence of bone reabsorption and formation • Adults replace about 25% of trabecular bone (the porous type of bone found in spine & articulating joints) every 4 months through reabsorption of old bone by osteoclasts (cells that resorb bone) and formation of new bone by osteoblasts (cells that form bone)

3. Abnormal results Greater-than-normal levels may indicate: Hyperparathyroidism Metastatic bone tumor Paget’s disease Vitamin D intoxication Lower than normal levels may indicate: Hypoparathyrodism Malabsorption (inadequate absorption of nutrients from the intestinal tract) Osteomalacia Osteoporosis Pancreatitis Renal failure Rickets Vitamin D deficiency Normal Serum Calcium Level range from 8.5 to 10.2 mg/dL

4. Osteomyelitis •  Osteomyelitis= an infection of bone • Can either be acute or chronic • Bacteria are the usual infectious agents. • 1. primary infection of the bloodstream • 2. A wound or injury that permits bacteria to directly reach the bone. • If not treated • The infection and inflammation block blood vessels. • Lack of oxygen & nutrients cause the bone tissue to die, which leads to chronic osteomyelitis. • Other possible complications include blood poisoning and bone abscesses. • Treatment options include intravenous and oral antibiotics, and surgical draining and cleaning of the affected bone tissue.

5. Causes of Osteomyelitis • An open injury to the bone, such as an open fracture with the bone ends piercing the skin. • An infection from elsewhere in the body that has spread to the bone through the blood. • A minor trauma, which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria. • Bacteria in the bloodstream, which is deposited in a focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone. However, new bone often forms around the site. • A chronic open wound or soft tissue infection can eventually extend down to the bone surface, leading to a secondary bone infection.

6. Causes of osteomyelitis Bones are infected by blood-borne micro-organisms. In most cases, the micro-organisms are bacteria such as Staphylococcus aureus, but fungi can also cause osteomyelitis. Conditions and events that can lead to osteomyelitis include: • Bacteria introduced during bone surgery. • Bacteria introduced by trauma to bone. • Infection of bone fractures. • Infection of prosthetic implants (such as an artificial hip joint). • Infections elsewhere in the body that reach the bones via the bloodstream. • A primary infection of the blood (septicemia).

7. Osteomyelitis - Pathophysiology `Usually bacterial in nature: most commonly Staphylococcus aureus • Bone inflammation is marked by edema, increased vascularity & leukocyte activity. • Infection develops in bone, which may interfere with vascular supply to bone, and necrosis occurs; difficult for antibiotics to reach the bacteria within the bone

8. Localized bone pain and/or tenderness in the infected area Reduced movement of the affected body part The overlying skin may be red, hot and swollen – inflammatory response The overlying skin may contain pus/purulent drainage Spasms of associated muscles General malaise High temperature Excessive sweating Chills Nausea, secondarily from being ill with infection General discomfort, uneasiness, or ill feeling Symptoms of Osteomyelitis

9. Osteomyelitis - Risk factors • Long term skin infections. • Poor blood circulation (arteriosclerosis). • Risk factors for poor blood circulation, which include high blood pressure, cigarette smoking, high blood cholesterol and diabetes. • Prosthetic joints. • Sickle cell anemia, Cancer, Diabetes • Hemodialysis • Weakened immune systems • Intravenous drug abusers • The elderly

10. Complications of Osteomyelitis • Some Complications include: • Bone abscess • Bone necrosis (bone death) • Spread of infection • Inflammation of soft tissue (cellulitis) • Blood poisoning (septicemia) • Chronic infection that doesn't respond well to treatment.

11. Osteomyellitis Osteomyellitis

12. Osteomyelitis - Tests • Blood tests: • CBC- complete blood count (CBC), >WBC = infection • ESR(erythrocyte sedimentation rate) and/or CRP (creative protein) in the bloodstream, which detects and measures inflammation in the body. • Blood culture: detect bacteria, identify infectious agent, order antibiotics • Needle aspiration: Remove a sample of fluid and cells from the vertebral space, or bony area. Lab evaluates infectious agent . • Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for signs of an invading organism. • Bone scan: • During this test, a small amount of Technetium-99 pyrophosphate, a radioactive material, is injected intravenously into the body. • If the bone tissue is healthy, the material will spread in a uniform fashion. • However, a tumor or infection in the bone will absorb the material and show an increased concentration of the radioactive material, which can be seen with a special camera that produces the images on a computer screen. • Finds abnormalities in their early stages, when X-ray findings may only show normal findings.

13. Osteomyelitis – Diagnostic Tests • MRI and CT scans: show abscesses and soft tissue changes • Radio nucleotides bone scans: determine whether infectious or inflammatory changes in bone • WBC and ESR: WBC and ESR are elevated • Blood and tissue cultures: identify infectious organism and determine appropriate antibiotic therapy

14. Treating and Managing Osteomyelitis • The goals of treating osteomyelitis is to • Eliminate the infection and • Prevent the development of chronic infection. • Identify & treat the disease as soon as possible • Chronic osteomyelitis can lead to • permanent deformity • chronic problems • Nursing management • Use of aseptic technique during dressing changes. • Observed for S/S of systemic infection • ROM exercises are encouraged to prevent contractures & flexion deformities & participation in ADL to the fullest extent is encouraged.

15. Hospitalization and antibiotics, oral or IV, 4-6 weeks or more Pain meds. Lifestyle changes to improve blood circulation. Treatment for underlying cause, such as diabetes. Surgery to clean and flush out the infected bone (debridement). Splinting or cast immobilization: Immobilize affected bone& nearby joints in order to avoid further trauma Help the area heal adequately and as quickly as possible. Replacement of the infected prosthetic part, if needed. Skin grafts, if necessary. Amputation, in severe cases. Treatment for Osteomyelitisdepends on severity

16. Osteomyelitis – Surgical Debridement • Surgical debridement • Specimen may also be obtained during debridement procedure • Primary treatment for chronic cases • Complete removal of dead bone & affected soft tissue • Wound is opened, irrigated; drainage tubes may be inserted for irrigation, suction, and antibiotic instillation • Antibiotics & sterile technique - control of infection

17. Osteomyelitis – Nsg Dx Nursing Diagnoses • Risk for Infection • Hyperthermia: interventions include maintenance of adequate fluid intake • Acute Pain: splinting or use of immobilizer may limit swelling and improve pain • Anxiety Home Care Often vital part of treatment of osteomyelitis Referral to home care agency for support with wound treatment, antibiotic administration, obtaining supplies, nutritional teaching

18. Neoplastic Disorders: Bone Tumors Defined 1. Tumors may be malignant or benign • Benign tumors grow slowly and do not invade surrounding tissues, tend to be less destructive to normal bone. • Malignant tumors grow rapidly and metastasize,tends to cause more bone destruction, invasion of the surrounding tissues & metastasis. • Tumors can be primary (rare) or metastatic lesions originating from primary tumors of prostate, breast, kidney, thyroid, lung • The tumor is defined as a new growth or hyperplasia of cells. This growth is in response to inflammation or trauma

19. Neoplastic Disorders: Bone TumorsPathophysiology Pathophysiology • Cause unknown, but connection exists between bone activity and development of primary bone tumors • Primary tumors cause osteolysis, bone breakdown, which weakens bone and leads to bone fractures • Malignant bone tumors invade and destroy adjacent bone tissue

20. Neoplastic Disorders: Bone TumorsS&S Manifestations: often history of fall or blow to extremity brings mass to attention • Pain • Mass • Impaired function

21. Osteosarcoma • A malignant tumor originating from osteoblast (bone-forming cells). Occurs twice as frequently in males as in females. • Usually located at the end of the long bones (metaphysis). Most frequently seen at • the distal end of the femur or • the proximal end of the tibia. • Lungs, a common site of metastasis. • S&S: Pain and swelling at the site & limitation of movement. • Dx: • Bone biopsy is used to confirm the diagnosis. • X-ray films, CT scans, MRI & bone scans show tumor location & size & bone involvement • Treatment: Historically, the treatment of choice is amputation.

22. Ewing’s Sarcoma • A malignant tumor of the bone originating from myeloblasts with early metastases to lung, lymph nodes, & other bones. • Location: Usually located on the shaft of the long bones. Femur, tibia, & humerus are common sites. • Poor prognosis. Common in person> 40 years old. Affect males more than females. • S&S • Pain increased with weight bearing. • May complain of weight loss, malaise, or anorexia. • Causes pathologic fractures. • Treatment: Palliative, radiation, chemotherapy.

23. Neoplastic Disorders: Bone TumorsDiagnostic Tests • X ray: shows location of tumors and extent of bone involvement • Benign tumors show sharp margins separating from normal bones • Metastatic bone destruction: characteristic “moth-eaten” pattern • CT scan: evaluation of extent of tumor invasion into bone, soft tissues, neurovascular structures • MRI:determine extent of tumor invasion, response of bone tumors to radiation and chemotherapy, recurrent disease • Needle biopsyto determine exact type of bone tumor • Serum alkaline phosphatase: elevated with malignant bone tumors • RBCelevation • Serum calcium: elevated with massive bone destruction

24. Neoplastic Disorders: Bone TumorsTreatments • Chemotherapy • Used to shrink tumor before surgery • Control reoccurrence • Treat metastasis • Radiation • Often combined with chemotherapy • Used for pain control with metastatic carcinomas • Eliminate tumor remains after surgery • Surgery • Eliminate primary bone tumors to eliminate tumors completely; may involve excise tumor or amputate affected limb • With some surgeries, cadaver allografts or metal prostheses used to replace missing bone to avoid amputation

25. Neoplastic Disorders: Bone TumorsNsg Management Nursing Diagnoses • Risk for Injury (pathologic fractures) • Acute and Chronic Pain • Impaired Physical Mobility • Decisional Conflict: assist client in gaining information for informed decisions regarding treatment options Home Care • Client education regarding treatment plan, wound care, activity and weight bearing restrictions • Support with referral to prosthetic specialist or hospice as case indicates

26. What is Osteoporosis? • Debilitating disease in which bones become fragile and are more likely to break • Disorder characterized by (1)loss of bone mass (2) increased bone fragility (3) increased risk for fractures • Imbalance of processes that influence bone growth and maintenance; associated with aging, but may result from endocrine disorder or malignancy • Significant health threat for Americans: estimated 28 million persons more common in aging women half of women over 50 experience osteoporosis related fracture in lifetime (hip, wrist, vertebrae) especially R/T falls

27. Osteoporosis – Risk Factors • Gender- women are more likely to develop than men due to thinner, lighter bones & the decrease in estrogen production that occurs during menopause. • Age- the longer you live, the greater the likelihood of developing. • Family history-is due part to heredity. • Ethnicity-Caucasian & Asian women are at highest risk;African-American & Hispanic women at lower but significant risk. • Body size- low body weight (< 127 lbs.) & a small-boned frame place at increased risk. • Lifestyle- a diet low in CA, inadequate vitamin D, little or no exercise, current cigarette smoking or excessive use of alcohol are all risk factors.

28. Osteoporosis- Modifiable Risk Factors • Calcium deficiency • insufficient calcium in diet results in body removing calcium from bones; diets high in protein lead to acidosis, and high in diet soda are high in phosphate • Menopause • decreasing estrogen levels: estrogen replacement therapy can reverse bone changes but may increase risk for other diseases • Cigarette smoking • decreased blood supply to bones • Excessive alcohol intake • toxic effect on osteoblastic activity; high alcohol intake frequently associated with nutritional deficiencies • Sedentary life style • weight-bearing exercise such as walking positively influences bone metabolism • Use of specific medications • aluminum-containing antacids, corticosteroids, anticonvulsants, prolonged heparin therapy, antiretroviral

29. A normal spine at 40 years, and the osteoporotic changes at ages 60 and 70 years

30. Osteoporosis - Pathology Pathophysiology • Diameter of bone increases, thinning outer supportive cortex • Trabeculae (spongy tissue) lost and outer cortex thins • Minimal stress leads to fracture Manifestations (“silent disease”: bone loss occurs without symptoms) • Loss of height • Progressive curvature of spine (dorsal kyphosis, cervical lordosis, accounting for “dowager’s hump”) • Low back pain • Fractures of forearm, spine or hip

31. Osteoporosis - Prevention • Prevention • By age 20, the average woman has acquired 98% of her skeletal mass. • Building strong bones during childhood & adolescence can be the best defense against developing osteoporosis. Balanced diet rich in CA & Vitamin D. Weight-bearing exercises A healthy lifestyle with no smoking & limited alcohol intake. Bone density testing & medication when appropriate.

32. Osteoporosis – Assessmemt • Assessment: • Assess for backache with pain radiating around trunk • Evaluate for skeletal deformities. • Assess for pathologic fractures. • Evaluate lab finding: • Serum CA, phosphorus & alkaline phosphatase are usually normal. • Parathyroid hormone may be elevated.

33. Osteoporosis – Dx Tests Bone density test – most often used • Xrays: picture of skeletal structures but osteoporotic changes not seen until> 30% of bone mass lost • Quantitative computed tomography (QCT) of spine: measures trabecular bone within vertebral bodies • Dual-energy Xray absorptiometry (DEXA): measures bone density in lumbar spine or hip; highly accurate • Alkaline phosphatase (AST): elevated post fracture • Serum bone Gla-protein (osteocalcin) marker of osteoclastic activity and is indicator of rate of bone turnover; used to evaluate effects of treatment

34. Osteoporosis - Complications Fractures • 1.5 million fractures yearly • Many spontaneous or resulting from everyday activities • Persistent pain and associated posture changes restrict client activities and ability to perform ADL Collaborative Care • Stopping or slowing osteoporosis • Alleviating symptoms • Preventing complications

35. Osteoporosis – Nsg Management • Prevent fractures: • Instruct in safety factors-watch steps, avoid use of scatter rugs. • Keep side rails up to prevent falls. • Move gently when turning & positioning. • Assist with ambulation if unsteady on feet. • Provide pain control. • Instruct in good use of body mechanics. • Provide diet high in protein, vit. D • Avoid excessive use of alcohol & coffee.

36. Osteoporosis - Meds Medications Estrogen replacement therapy (1)reduces bone loss, (2)increases bone density in spine and hip (3)reducing risk of fractures in postmenopausal women. • Recommended for women who have undergone surgical menopause before age 50 • Associated risk for estrogen therapy alone is > risk of endometrial cancer • Hormone replacement therapy (estrogen and progestin) associated with increased risk for cardiovascular disease and breast cancer Raloxifene (Evista) -selective estrogen receptor modulator (SERM) that prevents bone loss by mimicking estrogen effects on bone density; -side effects are hot flashes; -contraindicated for women with history of blood clots

37. Osteoporosis - Meds Medications Biphosphonates: potent inhibitors of bone resorption used to prevent and treat osteoporosis • Alendronate (Fosamax) • Risedronate (Actonel) • Etidronate (Didronel) Calcitonin (Miacalcin): -Hormone increases bone formation and decreases bone resorption; available as nasal spray or parenteral Sodium fluoride: -stimulates osteoblast activity, decreases risk of spinal fractures but associated with increased risk of other fractures including hip

38. Osteoporosis – Nsg Management Nursing Care • Emphasis is prevention and education of clients under age of 35 • Prevention of complications in those with osteoporosis • Home Care: Focus is on education including safety and fall prevention inside and outside the home • Administer & Instruct on Medications: • Estrogen & progesterone- decrease rate of bone reabsorption at menopause. • Calcium& vitamin D-support bone metabolism.

39. Osteoporosis – Nsg Management Health Promotion Calcium intake 1. Maintain daily intake of calcium at recommended levels, in divided doses • Age 19 – 50: 1000mg • Age 51-64: 1200 mg • Age 65 and >: 1500 mg 2. Optimal intake before age 30 – 35 increases peak bone mass 3. Foods high in calcium include milk, milk products, salmon, sardines, clams, oysters, dark green leafy vegetables

40. Osteoporosis – Nsg Management Health Promotion-continued 4. Supplementation: calcium carbonate (Tums); calcium combined with Vitamin D for older adults • 5. Instruct in regular exercise program. • ROM exercise • Ambulation several times per day. • Physical activity that is weight-bearing • Walking 20 minutes, 4 or > times per week • 6. Health-related behaviors • Include not smoking • Avoid excessive alcohol • Limit caffeine to 2 – 3 cups of coffee daily • Limit diet soda

41. Osteoporosis – Nsg Dx 1. Risk for injury- altered mobility, minimal trauma, falls, advanced age, previous fall. 2. Impaired physical mobility- decreased bone mass, decreased strength, musculoskeletal impairment, pain. 3. Situational low self-esteem- chronic illness,anxiety, loss of usual role, body changes, limitation in mobility, chronic pain, loss of independence. 4. Imbalanced Nutrition: Less than body requirements 5. Acute Pain 6. Health Seeking Behaviors

42. Paget’s Disease (osteitis deformans) Description • Excess of bone destruction & unorganized bone formation and repair. • Progressive skeletal disorder with excessive metabolic bone activity leading to affected bones becoming larger and softer • The 2nd most common bone disorder in the U.S. (see patho) • Etiology • Unknown • Affects femur, pelvis, vertebrae, sacrum, sternum, skull • Relatively rare • Occurs more often in whites • Slightly more common in males • Familial tendency • Most persons are asymptomatic & diagnosis is incidental.

43. PathophysiologyPaget’s Disease (osteitis deformans) • Bones are initially soft and bowing occurs; then become hard and brittle leading to fractures • Vascularity is increased in affected portions of the skeleton. Lesions may occur in one or more bones, does not spread from bone to bone. • Deformities & bony enlargement often occur. Bowing of the limbs & spinal curvature in persons with advanced disease • Slow progression with 2-stage process • 1. Excessive osteoclastic- bone resorption • 2. Excessive osteoblastic - bone formation

44. S&S - Paget’s Disease (osteitis deformans) Manifestations • Most are asymptomatic • Bone pain- is the most common symptom. • Localized pain of long bones, spine, pelvis, cranium • Pain is mild to moderate deep ache which is aggravated by pressure and weight-bearing • Is is usually worse with ambulation or activity but may also occur at rest. • Pain is mild to moderate deep ache which is aggravated by pressure and weight-bearing • Involved bones may feel spongy & warm because of increased vascularity. • Skull pain is usually accompanied with headache, warmth, tenderness & enlargement of the head. • Flushing and warmth over areas of bone involvement

45. ComplicationsPaget’s Disease (osteitis deformans) • Degenerative osteoarthritis • Pathological fractures- because of the increased vascularity of the involved bone-bleeding is a potential danger. • Nerve palsy syndromes from involvement of upper extremities • Compression of spinal cord causing tetraplegia which is also know as Quadriplegia • Mental deterioration from skull involvement and brain compression

46. Diagnostic TestPaget’s Disease (osteitis deformans) • X ray • Slow localized areas of demineralization in early phase • Later enlargement of bones with tiny cracks in long bones or bowing in weight-bearing bones radiolucent areas in the bone, typical of increased bone resorption. • Deformities & fractures may also be present. • Bone scan: active Paget’s disease • CT scans and MRI: show degenerative problems, spinal stenosis, nerve root impingement • Serum alkaline phosphatase: steady rise as disease progresses

47. Diagnostic Tests Paget’s Disease (osteitis deformans) • Alkaline phosphatase levels- markedly elevated as the result of osteoblast activity. • Urinary collagen pyridinoline testing: indicator of rate of bone resorption • Serum calcium are normal except with generalized disease or immobilization. • Nucleic acid catabolism -Gout and hyperurecemia may develop as a result of increased bone activity, which causes an increase in nucleic acid catabolism.

48. Meds - Paget’s Disease • Meds used to suppress osteoclastic (bone resorption) activity. • Mild symptoms relieved by analgesics, aspirin, NSAIDs. • Calcium supplements • Bisphosphonates & calcitonin are effective agents to • decrease bone pain & bone warmth • relieve neural decompression, joint pain & lesions. • Biphosphonates: Action: Slows Bone resorption • Alendronate (Fosamax) • Tiludronate (Skelid) • Pamidronate (Aredia) Calcitonic: works as analgesic for bone pain • Salmon calcitonin (Calcimar) • Human calcitonin (Cibacalcin)

49. Surgery -Paget’s Disease (osteitis deformans) Deformitiesmay be corrected by surgical intervention (osteotomy). ORIF Open Reduction Internal Fixation may be necessary for fractures. Total hip or knee replacement is usually required when client with Paget’s disease develops degenerative arthritis of hip or knee May require surgery for spinal stenosis, nerve root compression

50. Goals -Paget’s Disease (osteitis deformans) • Goals of the treatment • Relieve pain • Prevent fracture & deformities. • PT referral - ice or heat may help alleviate pain. • Regular exercise should be maintained; walking is best. • Avoid extended periods of immobility to avoid hypercalcemia. • Nutritionally adequate diet is recommended. • Assistance in learning to use canes or other ambulatory aids. • The Arthritis Foundation & Paget Foundation are useful resources for patients & their families. Collaborative Care • Pain relief • Suppression of bone cell activity • Complication prevention