Spinal Disorders PDF

Spinal Disorders Lordosis DESCRIPTION CHAPTER 7 Diseases and Conditions of the Musculoskeletal System Lordosis is an exaggerated inward curvature of the spine. Lordosis is sometimes...

Spinal Disorders Lordosis DESCRIPTION CHAPTER 7 Diseases and Conditions of the Musculoskeletal System Lordosis is an exaggerated inward curvature of the spine. Lordosis is sometimes referred to as a sway- back or saddleback deformity. ICD-9-CM Code 737.20 ICD-10-CM Code M40.40 (Postural lordosis, site unspecifie d) (M40.40-M40.57 = 8 codes of specificity) ANTERIOR POSTERIOR - Cervical vertebrae (C1 - C7) -Thoracic vertebrae (T1-T12) SYMPTOMS AND SIGNS Vertebrae Intervertebral disk The lumbar spine normally curves inward. This normal anterior curve of the lumbar spine can become  exaggerated by a variety of conditions. Excessive inward the person compensates curvature, or lordosis, occurs as for added abdominal girth caused by pregnancy, obesity, or large abdominal tumors. Lordosis also can occur developmentally for unknown reasons. Lordosis may cause no symp- toms, or the patient may experience low back pain because of strains on the muscles and ligaments. As compared with normal spine posture (Figure 7-8), lordosis results in a protruding abdomen and but- tocks and an arched lower back (Figure 7-9). PATIENT SCREENING Schedule the patient complaining of persistent low back pain, but no history of injury or symptoms of infection, for the first convenient appointment. ETIOLOGY Excessive abdominal weight gain and mass cause an individual to compensate by unconsciously tightening muscles in the low back to maintain balance when standing. Lordosis often is noted in prepubescent girls. One possible cause is rapid skeletal growth that occurs without the necessary natural stretching of the posterior soft tissues. Osteoporosis, with resulting loss of bone mass, may cause lordosis in the older population. DIAGNOSIS Patients who have persistent low back pain should be evaluated for degenerative and congenital dis- eases of the spine, and inflammation of the spine - Lumbar vertebrae (L1-L5) Sacrum (5 fused vertebrae) Соссух (4 fused vertebrae) FIGURE 7-8 Normal spine. (spondylitis) and conditions involving adjacent internal organs, such as the kidneys, prostate gland, aorta, and pancreas. Observation of the spine in various postural positions and an examination of the lower spine are the primary steps in diagnosis. When the condi- tion is a result of pregnancy, no additional informa- tion usually is required to make the diagnosis. Further investigation can include radiographic  studies to determine the extent of lordosis, along with a thorough history and physical examination to discover the underlying cause of the condition. TREATMENT When lordosis is caused by pregnancy, delivery of the infant usually resolves the condition. When obesity is the cause, weight loss and exercises to strengthen abdominal muscles are beneficial. Per- forming pelvic tilt exercises and maintaining good posture help to correct the condition. Progressive 305 Spinal Disorders Spinal Disorders 306 CHAPTER 7 Diseases and Conditions of the Musculoskeletal System as well as specific exercise instructions. Recommen- dations on proper posturing and adjustments to their specific sitting environments can be extremely valuable. Normal spine position -Lordosis FIGURE 7-9 Lordosis. untreated lordosis can lead to degenerative lumbar disk disease or ruptured lumbar disks. Additional treatment of the condition can include the use of a brace. For severe lordosis, spinal fusion and dis- placement osteotomy are considered. This latter procedure requires the surgical division of a verte- bra with shifting of the bone segments to change the alignment of, or alter weight-bearing stress on, the spine.  PROGNOSIS Lordosis may never cause symptoms, but patients who do have symptoms usually respond to conser- vative management techniques. PREVENTION Optimal prevention measures center around devel- oping ideal posture habits, exercises, and support devices, such as braces and lumbar support when seated. PATIENT TEACHING Patients can benefit from a brief review of the normal anatomy of the affected areas, particularly addressing the spine and paraspinous musculature, Kyphos is DESCRIPTION Kyphosis is an abnormal outward curvature of the spine (convexity backward). ICD-9-CM Code 737.10 ICD-10-CM Code M40.00 (Postural kyphosis, site unspecifie d) M40.209 (Unspecified kyphosis, site unspecified) = (M40.00-M40.299 19 codes of specificity) SYMPTOMS AND SIGNS Kyphosis, an excessive posterior curve of the tho- racic spine, often has an insidious onset and is asymptomatic until the hump becomes obvious. As the curve progresses, the patient may begin to experience mild pain, fatigue, tenderness along the spine, and decreasing mobility of the spine. The shoulders appear rounded, and the head pro- trudes forward (Figure 7-10, A). PATIENT SCREENING Schedule the individual complaining of persistent upper back pain, without history of injury or symp- toms of infection, for an appointment at his or her convenience. ETIOLOGY  Kyphosis that occurs in very young children has no specific cause and is believed to be developmental. Adolescent kyphosis usually is related to Scheuer- mann's disease, a degenerative deformity of the thoracic vertebrae (Figure 7-10, B). Additional disease processes that contribute to the occurrence of kyphosis include tumors or tuberculosis of the vertebral bodies and ankylosing spondylitis. Col- lapse of vertebrae from the weakened bone of osteoporosis is often responsible for the hunch- back that develops in the older person, particularly the postmenopausal woman. Wearing away of the anterior portion of the vertebrae in a wedge type Kyphosis Normal spine position CHAPTER 7 Diseases and Conditions of the Musculoskeletal System 307  A B FIGURE 7-10 A, Kyphosis. B, Kyphosis associated with Scheuermann's disease. (B from Mourad LA: Orthopedic disorders-Mosby's clinical nursing series, St Louis, 1991, Mosby.) of manner (anterior wedging) or deterioration of the vertebrae, from whatever cause, results in the excessive curvature with kyphosis. DIAGNOSIS Visual inspection of the spine discloses the exces- sive curve in the thoracic region. Radiographic films and bone scans document the concave curva- ture of the thoracic spine along with the wedging of the anterior aspect of the vertebral bodies (see Figure 7-10, B). Older patients with osteoporosis have a loss of bone density. TREATMENT Exercises to strengthen the muscles and ligaments are prescribed. Back braces also are used to stabi- lize the condition. The underlying cause must be determined and treated. When other measures fail to produce results and when the respiratory and cardiac systems are compromised, spinal fusion with instrumentation and temporary immobi- lization is performed. Kyphosis that is caused by a sudden collapse of a vertebra because of osteoporosis is sometimes treated with a new procedure called vertebroplasty, in which a balloon is inflated within  the vertebra and methyl meth- acrylate is inserted to provide a “cement” founda- tion to maintain reestablished vertebral height. PROGNOSIS The outlook for patients with kyphosis depends on the cause. Optimal outcome results from accurate diagnosis and early treatment. PREVENTION Optimal prevention measures center around devel- oping ideal posture habits, exercises, and support devices, such as braces and back support when seated. Medications may be needed for osteoporo- sis, pain, or inflammation of the spine. PATIENT TEACHING Patients with kyphosis who are found to have sig- nificant osteoporosis should be instructed regard- ing exercise programs, calcium and vitamin D supplementation, and prescription medications. Spinal Disorders Spinal Disorders 308 CHAPTER 7 Diseases and Conditions of the Musculoskeletal System Scoliosis DESCRIPTION Scoliosis is a lateral (sideways) curvature of the spine. Scoliosis typically is congenital, but some diseases also can cause it. ICD-9-CM Code 737.30 (Acquired; postural) 754.2 (Congenital) ICD-10-CM Code M41.20 (Other idiopathic scoliosis, site unspecified) (M41.00-M41.9 = 55 codes of specificity) Q67.5 (Congenital deformity of spine) Q76.3 (Congenital scoliosis due to congenital bony malformation) Q76.425 (Congenital lordosis, thoracolumbar region) Q76.426 (Congenital lordosis,  lumbar region) Q76.427 (Congenital lordosis, lumbosacral region) Q76.428 (Congenital lordosis, sacral and sacrococcygeal region) SYMPTOMS AND SIGNS an Scoliosis, a lateral curvature of the spine, often has insidious presentation, possibly going unno- ticed for years before detection. In women, for example, the first indication is often unequal bra strap lengths. The patient, usually an adolescent female, reports back pain, fatigue, and sometimes shortness of breath with exertion. Observation of the back reveals a lateral curve of the spine, one shoulder higher than the other, one scapula more prominent than the other, one hip higher than the other, and when the patient bends over, an enlarged muscle mass on one side of the back (Figure 7-11). PATIENT SCREENING Referrals may come from school scoliosis screening programs that have detected possible scoliosis. ETIOLOGY Idiopathic scoliosis is the most common form; however, the cause is postulated to be genetic in some cases. Other suggested causes of scoliosis are deformities of the vertebrae, uneven leg lengths, and muscle degeneration or paralysis from dis- eases, such as poliomyelitis, cerebral palsy, and muscular dystrophy. DIAGNOSIS Patients with scoliosis are evaluated for muscle disease and weakness, congenital conditions, neu- rologic disorders, and degeneration of the bones. and disks of the spine. Diagnosis is made from visual examination of the back, which reveals uneven shoulder and hip heights, a prominent scapula on one side, an enlarged muscle mass on one side, and a definite torsional curve of the ver- tebral column. It is important to examine the lengths of the lower limbs because discrepancy of the leg lengths can lead to spinal curvature. Radio- graphic films not only confirm the diagnosis but also provide the physician with a means of measur- ing the degree of curvature. This is also useful for long-term monitoring. TREATMENT Treatment depends on the extent and cause of the curve. Mild scoliosis is treated with exercise to strengthen the weak  muscles. Bracing of the back with a Milwaukee brace or a molded plastic clam- shell jacket, along with an exercise program, is the suggested course of treatment for the growing girl Normal spine position Lateral curve FIGURE 7-11 Scoliosis. CHAPTER 7 Diseases and Conditions of the Musculoskeletal System 309 or boy. This bracing may take from 2 to 5 years to prevent further curvature. Curves that do not respond to the bracing or that are severe (greater than 40 degrees) need surgical intervention to decrease the curve and to realign and stabilize the spine. These procedures include fusion of the ver- tebrae and internal fixation with instrumentation by means of rods, wires, or plates and pedicle screws. Some patients are placed in body casts or plastic jackets to maintain the integrity of the fixa- tion until the fusion heals. The respiratory and cardiac systems may be compromised if the curva- ture is left untreated. PROGNOSIS The outlook for patients with scoliosis depends pri- marily on the severity of the curvature. Optimal outcome results from accurate diagnosis and early treatment.  PREVENTION Prevention measures center around developing ideal posture habits, performing beneficial exer- cises, and wearing support devices, such as the braces described above. Timely surgical interven- tion is key for severely affected children. PATIENT TEACHING Posture training, regular use of proper bracing, and instructions for avoiding stresses to the affected spine are essential for ideal management. Children with significant scoliosis should avoid aggressive contact sports, such as football and rugby. Osteoarthriti s DESCRIPTION Osteoarthritis is a type of arthritis that results from the breakdown and eventual loss of the cartilage of one or more joints. ICD-9-CM Code 715.9 (Requires 5th digit) ICD-10-CM Code M15.9 (Polyosteoarthritis, unspecifie d) (M15.0-M15.9= 7 codes of specificity) M19.90 (Unspecified osteoarthritis, unspecified site) (M19.01-M19.93 = 49 codes of specificity) Osteoarthritis is coded according to the site affected. Refer to the physician's diagnosis and then to the current editions of the ICD-9-CM and ICD-10-CM coding manuals for most accurate specificity. SYMPTOMS AND SIGNS Osteoarthritis, also known as degenerative joint disease or degenerative arthritis, is by far the most common form of arthritis. It develops as a result of normal wear and tear on the joints and is most common in the elderly, being  almost universal in those older than 75 years. Osteoarthritis occurs mainly in the large weight-bearing joints, especially the knees and hips (Figure 7-12). There is a tendency for the smallest joints at the ends of the fingers to be affected by spur formation that leads to the classic bony enlargement referred to as a Heberden's node. To a lesser degree, involvement of the joints of the fingers at the proximal interphalangeal joints (Bouchard's nodes, Figure 7-13)-wrists, elbows, and ankles-can occur. Degenerative changes in the spinal vertebrae and the joints of the pelvis can lead to abnormal curvature and local pain. The onset of osteoarthritis is usually insidious, and the symptoms vary with the severity of the disease. Some of the common symptoms are joint soreness, aching, and stiffness, especially in the morning and with changes in the weather; edema; dull pain; and deformity. Stiffness is noted, particu- larly after the patient has been immobile for a period of time. Clicking or crackling sounds (crepi- tation) often are heard with joint movement. Decreased ranges of motion, joint instability, and an increase in pain with use of the joints are also common. PATIENT SCREENING When a patient develops a persistent joint problem, a thorough history and physical examination is essential. Schedule the first available appointment. Subsequently follow office policy for referral to a rheumatologist. ETIOLOGY The exact cause of most osteoarthritis is unknown, but it appears to be generally associated with aging. The tendency toward developing osteoarthritis is Osteoarthritis 310 CHAPTER 7 Diseases and Conditions of the Musculoskeletal System Osteoarthritis Bone Cartilage Joint capsule Bone cysts Sclerotic bone Osteophytes  Cartilage fragment s Periarticular fibrosis Calcified cartilage NORMAL OSTEOARTHRITIS Irregular joint space Fragmented cartilage Loss of cartilage OSTEOARTHRITIS - ADVANCED Osteophytes Periarticular fibrosis Calcified cartilage Sclerotic bone Cystic change FIGURE 7-12 Schematic presentation of the pathologic changes in osteoarthritis. Fragmentation and loss of cartilage denude the subchondral bone, which undergoes sclerosis and cystic change. Osteophytes form on the lateral sides and protrude into the adjacent soft tissues, causing irritation, inflammation, and fibrosis. (From Damjanov I: Pathology for the health professions, ed 4, St Louis, 2012, Saunders.) FIGURE 7-13 Bouchard's nodes. (From Monahan FD et al: Phipps' medical-surgical nursing, ed 8, St Louis, 2007, Mosby.) sometimes inherited. In some persons, osteoarthri- tis may  follow injury to the joint, or be associated with hormonal disorders or underlying diseases, such as diabetes and obesity. DIAGNOSIS Patients must be evaluated to exclude the morethan 100 other forms of arthritis, and any underly- ing diseases or conditions must be detected as well. The diagnostic investigation begins with physical examination and patient history. Radio- graphic films, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans confirm the presence and document the severity of osteoarthritis. Plain radiographic testing can be very helpful for excluding other causes of pain in a particular joint. Radiographic tests also can measure the severity of the osteoarthritis and assist in deciding when surgical intervention should be considered. CHAPTER 7 Diseases and Conditions of the Musculoskeletal System TREATMENT Because osteoarthritis cannot be cured, the goal of treatment is to reduce inflammation, to mini- mize pain, and to maintain functioning joints. Treatment of osteoarthritis involves physical and drug therapy, nutritional management, and sup- portive care. Surgery also may be needed in severe cases. Physical therapy includes range-of-motion exercises, alternation of moist heat and cold appli- cations, massage therapy, and the use of elastic bandages and splints for limb support. Drug therapy can include the use of analgesics, muscle relaxants, and NSAIDs. Intraarticular steroid injec- tions may be used for specific or individual joints. Intraarticular hyaluronic acid can be used to reduce pain in affected knee joints. Fish oils have been suggested to have some antiinflammatory properties. Food supplementation with glucos- amine and chondroitin may reduce pain and stiff- ness in some patients. For supportive care, it may be necessary to use a cane, walker, braces, or crutches to lessen the strain on some joints. Restricting physical activity or resting affected joints also may be necessary. Surgery for osteoar- thritis may involve total joint replacement. Joints commonly replaced are the base of the thumb, the hip, and the knee. Ankle, wrist, elbow, and shoul- der joints also can be replaced. Joint fusion may be done to increase stability for the cervical and lumbar vertebrae.  PROGNOSIS The outlook for patients with osteoarthritis depends primarily on the severity and location of the involved joints. Optimal outcome results from accurate diagnosis and early management. PREVENTION Avoiding injury and reinjury to joints is important in preventing future osteoarthritis. Persons with flaccid (overstretched) ligaments may require support devices to engage in some activities. Early contact with health care practitioners can optimize long-term health. PATIENT TEACHING Providing specific guidance on food supplemen- tation, medications, and proper exercise can sig- nificantly improve the quality of life for these patients. Lyme Disease DESCRIPTION Lyme disease is an infectious disease caused by the spirochete bacterium. Ticks that bite the skin. spread Lyme disease by injecting the bacterium from their gut into the human body. Lyme disease can affect the skin, joints, heart, and nervous system. ICD-9-CM Code 088.81 ICD-10-CM Code A69.20 (Lyme disease, unspecified) (A69.20-A69.29 = 5 codes of specificity) SYMPTOMS AND SIGNS Lyme disease, also known as Lyme arthritis, was first detected in 1975 in Lyme, Connecticut. Lyme disease is more prevalent in the northeast part of the United States, especially New York, New Jersey, and Connecticut, where large areas of forests and fields provide a habitat for ticks. The disease has been found, however, in all 50 states and on five continents. Lyme disease can occur in any age group, and no one is immune to the infection. Approximately half of all patients with Lyme disease have a char- acteristic red, itchy rash with a red circle center resembling the bull's eye on a target (target lesion) (Figure 7-14, A) early in the illness. Lyme disease can masquerade as arthritis and cause influenza- like symptoms, such as headache,  fever, fatigue, joint pain, and general malaise. If the person does not seek medical attention for the symptoms, com- plications of muscle weakness, paralysis, and neurologic conditions (e.g., learning difficulties, excessive fatigue, and muscle coordination prob- lems) can develop as the bacterium spreads unchecked internally. Encephalitis, gastritis, or car- ditis may develop in some patients. PATIENT SCREENING Early detection of Lyme disease is imperative because treatment can avoid more significant organ-threatening consequences. In areas where the deer tick is prevalent and/or the patient reports a "target lesion," a visual inspection and diagnostic 311 Lyme Disease Lyme Disease 312 CHAPTER 7 Diseases and Conditions of the Musculoskeletal System A B FIGURE 7-14 A, Target lesion of Lyme disease. B, Tick that causes Lyme disease. (From Stone DR, Gorbach SL: Atlas of infec- tious diseases, Philadelphia, 2000, Saunders.)  laboratory tests are necessary. Likewise, if a patient reports flulike symptoms 2 to 4 weeks after receiv- ing a tick bite, an appointment for prompt diagnos- tic evaluation is indicated. ETIOLOGY Lyme disease is caused by a spirochete bacterium, which is transmitted to humans by a bite from a small tick (Figure 7-14, B) that is carried by mice or deer. In the United States, the relia burgdorferi. In Europe, the bacterium is Bor- bacterium Borrelia afzelii also causes Lyme disease. The disease is usually transmitted to humans while they are camping or hiking in woods, fields, or other areas that ticks inhabit. After infiltrating the skin, the bacterium can infect internal organs of the body, causing a variety of symptoms, which often leads to delay in making the correct diagnosis. DIAGNOSIS The evaluation of patients with the nonspecific symptoms of early Lyme disease, such as headache, fever, fatigue, joint pain, and general malaise can be exhaustive. A complete history, physical exami- nation, and laboratory tests are important for excluding other infectious diseases, forms of arthri- tis, immune diseases, muscle diseases, and even cancer. The diagnosis of Lyme disease can be based on physical examination (the discovery of a tick on the skin), the presence of the classic target lesion, and the patient history. Confirmation is attained by positive test results for the Lyme antibodies or by directly identifying the bacterium in the infected skin via biopsy if necessary. TREATMENT Treatment of Lyme disease begins with removal of the tick, if it is found on skin or clothing. Early treatment is imperative because treatment in the early stages of disease leads to a complete cure with simple oral antibiotics. The drug of choice for Lyme disease is doxycycline. The CDC also recom- mends amoxicillin or cefuroxime. Lyme disease in the later stages requires intravenous antibiotics, such as ceftriaxone or penicillin, to cure the disease. Antipyretics are given for headache and fever. Bed rest is necessary if neurologic symptoms are present, and physical therapy is prescribed for impaired musculoskeletal mobility. Joint symptoms are often treated with antiinflammatory medications and hydroxychloroquine. PROGNOSIS Lyme disease is curable with antibiotics. The outlook for  patients with Lyme disease is a func- tion of how early it is detected. Early stage Lyme disease involves a minor skin rash with muscle aching that easily resolves with antibiotics. Later stage Lyme disease can cause residual damage to the joints, heart, or nervous system. Optimal outcome results from accurate diagnosis and early treatment. PREVENTION Avoiding tick bites is the best prevention of Lyme disease. When inhabiting locations known to harbor ticks, persons should wear long clothing to protect the skin. Carefully examine all clothing CHAPTER 7 Diseases and Conditions of the Musculoskeletal System first and then the entire body, including the scalp, to detect the presence of ticks after being in high- risk areas. Close inspection of children and pets is especially important. Ticks can be removed gently with tweezers and saved in a jar in case identification of the vector is needed later. Bathing the skin and scalp and washing clothing after possible exposure to ticks may prevent the bite and subsequent transmission of the disease. Vaccines were once available, but these have been removed from the market. Further studies of vac- cines are needed. PATIENT TEACHING Community awareness of tick-avoidance measures is essential for prevention. Patients who develop Lyme disease should be instructed to closely follow the specific instructions provided by their qualified health care practitioners regarding therapeutic medications. Bursitis DESCRIPTION Bursitis is inflammation of a bursa. A bursa is a tiny fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body. Bursae are found between muscles and tendons and cover bony prominences to facilitate movement. They can become inflamed, infected, or traumatized. The major bursae are located adjacent to the tendons of the large joints, such as the shoulders, elbows, hips, and knees.  ICD-9-CM Code 727.3 727.2 (Specific bursitis often of occupational origin) ICD-10-CM Code M71.50 (Other bursitis, not elsewhere classified, unspecified site) (M71.10-M71.19 = 24 codes of specificity; M71.50-M71.58 = 20 codes of specificity) M70.039 (Crepitant synovitis [acute] [chronic], unspecified wrist) = (M70.031-M70.049 6 codes of specificity) M70.30 (Other bursitis of elbow, unspecified elbow) (M70.30-M70.32 = 3 codes of specificity) M70.40 (Prepatellar bursitis, unspecified knee) (M70.40-M70.52 = 6 codes of specificity) SYMPTOMS AND SIGNS The classic symptoms of bursitis are tenderness, pain when moving the affected part, flexion and extension limitation, and edema at the site of inflammation. The most frequently affected bursae are those of the shoulder (Figure 7-15), elbow, knee, hip, and between the tendons and muscles of the tibia. Point tenderness may be present, in which case the patient actually can point to the spot of greatest tenderness. If bursae are continually or chronically irritated and inflamed, calcifications can develop. In addition, adhesions can occur around an affected bursa, which limits the move- ment of the tendons. PATIENT SCREENING Pain, swelling, or limitation of motion in any joint, with or without previous injury, requires an appoint- ment for diagnostic evaluation. Early treatment and relief from  pain are important measures. Subdeltoid bursa Subacromial bursa FIGURE 7-15 Bursae of the shoulder. Bursitis 313 314 CHAPTER 7 Diseases and Conditions of the Musculoskeletal System Osteomyelitis ETIOLOGY tion between the Bursitis can result from continual or excessive fric- bursae and the surrounding mus- culoskeletal tissues. Systemic diseases (e.g., gout and rheumatoid arthritis) and infection can lead to the development of bursitis. In addition, repeated trauma from overuse of a joint can cause bursitis (see “Cumulative Trauma" section in Chapter 15). DIAGNOSIS Bursitis is generally a straightforward diagnosis that can be made after evaluating information gained from the history and physical examination. However, in patients with bursitis that is not associ- ated with injury, possible underlying gout or arthri- tis should be considered. In patients with abrasion or puncture wounds of the overlying skin, infection also must be considered. Range of motion may be impaired, and the pain is acute. MRI indicates an enlarged bursa, and radiographic films may show calcified deposits at the affected site when the bur- sitis is chronic. Aspiration of fluid from an inflamed bursa can assist in diagnosing gouty or infectious bursitis (septic bursitis).  TREATMENT The treatment for traumatic bursitis may include avoidance of activities until acute pain subsides, the application of moist heat, immobilization of the affected part, the use of aspirin or acetaminophen for pain, the administration of nonsteroidal antiin- flammatory agents (e.g., ibuprofen and indometha- cin), and local injection of a corticosteroid. If infection is present, drainage of the inflamed bursa and the use of antibiotics specific to the infectious microbe are critical. Active range-of-motion exer- cises to prevent adhesions and to maintain or regain Surgical motion are needed after the acute pain subsides. excision of the bursa and any accompany- ing calcified deposits can be required for either chronic noninfectious or infectious bursitis. PROGNOSIS Bursitis is curable. With treatment and proper attention to any underlying cause, the outlook is excellent. PREVENTION Actions that initiate or promote tissue inflamma- tion, such as repetition of a throwing motion in the case of shoulder bursitis, prolonged leaning on the elbow in the case of elbow bursitis, or prolonged kneeling in the case of knee bursitis should be avoided. PATIENT TEACHING Patients can benefit from being given specific infor- mation regarding the cause of the inflamed bursa and from instructions regarding aggravating factors to avoid. For any recurrent inflammation, patients should be instructed to immediately apply ice packs to the area so that inflammation can be minimized. Those with past infectious bursitis should notify the office. Osteomyelit is DESCRIPTION Osteomyelitis is a serious infection of bone that requires aggressive antibiotic treatment. ICD-9-CM Code 730.20 (Unspecified, site unspecifie d) ICD-10-CM Code M86.9  (Osteomyelitis, unspecifi ed) = (M86.00-M86.9 189 codes of specificity) Refer to the physician's diagnosis and then the current editions of the ICD-9-CM and ICD-10-CM coding manuals for greatest specificity of site and stage (acute or chronic) of bone infection. SYMPTOMS AND SIGNS Inflammation, swelling, localized heat, redness, pain, and local tenderness over and around the affected bone are characteristic signs of osteomyeli- tis. Other symptoms of osteomyelitis include chills, fever, sweating, and malaise. As the infection pro- gresses, a purulent material called a subperiosteal abscess may develop, causing pressure and eventual fracturing of small pieces of the bone. These frac- tured, dead pieces of bone may in turn become surrounded by the purulent material and form a sequestrum (Figure 7-16). The most commonly involved bones in osteomy- elitic infections are the upper ends of the humerus and tibia, the lower end of the femur, and occasion- ally the vertebrae. Osteomyelitis most often begins as an acute infection; however, it can remain undetected for CHAPTER 7 Diseases and Conditions of the Musculoskeletal System FIGURE 7-16 Osteomyelitis. (From Cooke RA, Stewart B: Colour atlas of anatomical pathology, ed 3, London, 2003, Churchill Livingstone.) months or years and evolve into a chronic condi- tion. Both the acute and chronic forms can present the same clinical picture. PATIENT SCREENING Patients with localized bone inflammation and pain must be evaluated for possible fractures and bone tumors before the diagnosis of osteomyelitis can be ascertained. ETIOLOGY Staphylococcus aureus is the bacterial organism responsible for 90% of osteomyelitic infections. Streptococcal bacteria account for the next largest number of infections. Rarely, viruses and fungi also have been known to cause  osteomyelitis. Osteomy- elitis can develop when blood-borne pathogens are deposited in the metaphyseal area of a bone after physical trauma or surgery. Diabetes mellitus or peripheral vascular disease may predispose individuals to the development of osteomyelitis, as can the presence of prosthetic hardware (e.g., rods, screws, and plates within the bone) and total joint replacement. Osteomyelitis in infants and children develops as a secondary infec- tion from streptococcal pharyngitis (strep throat). Persons with sickle cell disease, immunodeficiency, or malignancies are also at increased risk for the development of osteomyelitis. The possible development of osteomyelitis must be the concern of any person who has an open wound, sore (strep) throat, or a systemic infection that could be transmitted to the bones. DIAGNOSIS Aspiration and culture of material taken from the site of the infection are essential to isolating the causative organisms. A blood culture, a white blood cell (WBC) count, and an erythrocyte sedimenta- tion rate (ESR) are also helpful for determining diagnosis and monitoring treatment. MRI, CT, or bone scans aid in determining the site and extent of acute or chronic infection. TREATMENT Osteomyelitis usually requires extensive, long-term antibiotic treatment with follow-up care to prevent recurrent infections. nistered antibiotics (e.g., Parenteral or locally admi- aqueous penicillin, cephalosporin, erythromycin [for penicillin-allergic individuals], tetracycline, and ampicillin), at a dosage specific to the patient's age and the patho- genic organism involved, are needed. Additional measures include increased intake of proteins and vitamins A, B, and C to promote cell regeneration; bed rest as needed to conserve energy; control of chronic conditions (e.g., diabetes); immobilization of the affected part to prevent fracture of weakened bones; and analgesics. Surgical drainage to remove purulent material and sequestrum also may be 315 Osteomyelitis Gout 316 CHAPTER 7 Diseases and Conditions of the Musculoskeletal System necessary, along with bone grafting. Hyperbaric oxygen treatments may prove beneficial as well. PROGNOSIS Osteomyelitis is curable. The long-term outcome depends on the  amount of bone and/or joint damage as a result of the infection. Damaged bone can lead to deformity and impaired function, espe- cially if growth plates are affected in children. PREVENTION For most patients, osteomyelitis cannot be pre- vented because it occurs randomly. However, patients with diabetes mellitus, sickle cell disease, or impaired immune systems should be particularly diligent about reporting to their doctors any signs of infections. PATIENT TEACHING Patients must be instructed on the specific details and importance of their antibiotic management. Long-term antibiotic treatments administered intravenously can require special catheters, such as a peripherally inserted central catheter ("PICC line"), which must be cared for according to spe- cific guidelines. Gout DESCRIPTION that manifests as an Gout is a chronic disorder of uric acid metabolism acute, episodic form of arthritis; chronic deposits of uric acid forming hard nodules in tissues; and/or kidney impairment or stones. ICD-9-CM Code 274.9 (Unspecified) ICD-10-CM Code M10.9 (Gout, unspecified) (M1a.00-M10.9243 codes of specificity) Gout is coded according to site and type of pathologic involvement. Refer to the physician's diagnosis and then to the current editions of the ICD-9-CM and ICD-10-CM manuals for greatest specificity. SYMPTOMS AND SIGNS Gout involves an overproduction or decreased excretion of uric acid and urate salts. This leads to high levels of uric acid in the blood and also in the synovial fluid of joints. Deposits of other urate com- pounds can be found in and around the joints of extremities, often leading to joint deformity and disability (Figure 7-17, A and B). E7-2 Typically, gout affects the first metatarsal joint of the great toe, causing severe to excruciating pain when an attack  occurs. The joints of the feet, ankles, knees, and even hands also can be affected. Pain usually peaks after several hours, and then subsides gradually. A slight fever, chills, headache, or nausea may accompany an acute attack. Between attacks, the person is characteristically free from any symp- toms. Gout also is characterized by renal dysfunc- tion, hyperuricemia, and renal calculi (kidney stones). The disease is uncommon in children; gout gen- erally appears in men after puberty. Men are affected more often than women. In women, gout generally appears after menopause. Gout also can develop secondary to cell breakdown resulting from drug therapy, especially with chemotherapy for malignant diseases (e.g., leukemia). PATIENT SCREENING The patient with gout may complain of severe, acute joint pain and possibly mild systemic symp- toms. Schedule an urgent appointment (especially if acute gouty arthritis is present) so treatment can begin and medication that will relieve the pain can be prescribed. ETIOLOGY The cause of this disorder is most often an inher- ited abnormality of metabolism. It may result from a lack of an enzyme needed to completely metabo- lize purines in foods for excretion from the kidneys. This incomplete metabolism leads to the buildup of uric acid in the tissues of the body. Uric acid is a breakdown product of purines that are digested in foods. Renal gout is caused by some forms of kidney dysfunction. The body may produce levels of uric acid that are normal, but kidney function is insufficient to remove the product from the blood. Excessive weight gain, leukemias and lymphomas, and certain drugs including diuretics and tubercu- losis medications also can precipitate gout. DIAGNOSIS Patients with new-onset joint inflammation are evaluated to exclude many types of arthritis, such as rheumatoid arthritis, spondylitis, reactive arthri- tis, and joint infection. Microscopic examination of  A CHAPTER 7 Diseases and Conditions of the Musculoskeletal System Chemotaxis attracts leukocytes Inflammation Phagocytosis of crystals Rupture of leukocytes Release of: Cytokine  s Enzymes Uric acid crystal Deposits of urate Joint space Uric acid crystals B Blood vessel FIGURE 7-17 A, Gout. B, Gouty arthritis. Deposits of uric acid crystals in the connective tissue have a chemotactic effect and cause exudation of leukocytes into the joint. The inflammation most often affects the metatarsophalangeal joint. (B from Damjanov I: Pathology for the health professions, ed 4, St Louis, 2012, Saunders.) aspirated synovial joint fluid or material from soft tissue uric acid deposits (called tophi) demon- strates the presence of urate crystals (see Figure 7-17, B). A serum uric acid test can indicate hyper- uricemia. Radiographic films may be used to assess the amount of damage to affected joints. TREATMENT General treatment of an acute attack of gout can involve bed rest to lessen pressure on affected joints, immobilization  of the affected limb, and the application of cold packs to the inflamed joints, if the patient is able to tolerate the pressure of an ice bag. An antiinflammatory agent (NSAIDs) and cor- ticosteroids taken orally or injected into the gouty area are options that can reduce inflammation. Dietary modifications include a low-purine diet and adequate fluid intake. Dairy products have been shown to reduce the frequency of attacks of gouty arthritis. For chronic gout, after the acute attack has subsided, the patient may be given anti- hyperuricemic medications, such as probenecid (Benemid), allopurinol (Zyloprim), febuxostat (Uloric). Gradual weight reduction can be helpful for those patients who are overweight. PROGNOSIS proper management, potential damage to the bones and joints can be avoided. Chronic gouty deposits of uric acid (tophi) can be difficult to treat, so if they do not shrink with medication, they can be surgically resected. 317 Gout Paget's Disease (Osteitis Deformans) 318 CHAPTER 7 Diseases and Conditions of the Musculoskeletal System PREVENTION Limiting alcohol intake, avoiding dehydration, and eating a proper (low purine, high dairy) diet are keys to prevention of gout attacks. PATIENT TEACHING Patients should understand that early measures to treat inflammation, such as ice packs and antiin- flammatory medication, may help them avoid prolonged pain and dysfunction. Specific dietary instructions should be given to any patient with gout. E7-3 Paget's Disease (Osteitis Deformans) DESCRIPTION Paget's disease is a chronic bone disorder that typi- cally results in enlarged, deformed bones due to irregular breakdown and formation of bone tissue. Paget's disease can cause bones to weaken and may result in bone pain, arthritis, bone deformities, and fractures. Paget's disease is also known as osteitis deformans.  ICD-9-CM Code 731.0 ICD-10-CM Code M88.9 (Osteitis deformans of unspecified bone) (M88.0-M88.9 = 27 codes of specificity) SYMPTOMS AND SIGNS In patients with Paget's disease, affected areas of bone produce new bone tissue faster than the old bone can be broken down. Paget's disease occurs characteristically in two stages. The initial stage is called the vascular stage. Bone tissue is broken down, but the spaces left are filled with blood vessels and fibrous tissue instead of new strong bone. In the second, or sclerotic, stage, the highly vascular fibrous tissue hardens and becomes similar to bone, but it is fragile instead of strong. This can lead to pathologic fractures. This disease can occur in a part of one bone, all of one bone, or many bones throughout the skel- etal system. The most common sites of the disease are the pelvis and the tibia. Other sites often affected are the femur, spine, skull, and clavicle. Paget's disease usually affects individuals older than 40 years of age and becomes increasingly more common with advancing age. Paget's disease often causes no symptoms. When symptoms do occur, they usually include local bone pain. The pain can become disabling. Aching is almost continuous and is often worse at night. Some patients may have edema or deformity in one of the bones or may notice that they need a larger hat size because the bones of the skull have enlarged. If the ossicles of the ear are involved, hearing loss or deafness may occur. Other compli- cations of Paget's disease can include frequent frac- tures, spinal cord injuries, hypercalcemia, renal calculi, and infrequently a serious form of cancer- bone sarcoma. PATIENT SCREENING A patient having bone pain must be evaluated for fracture and infection of bone along with blood calcium and alkaline phosphatase levels. ETIOLOGY The cause of Paget's disease is not known. DIAGNOSIS A physical examination and a history of the patient's symptoms are needed. The physician then orders several graphic imaging, bone scanning, tests and blood work. Radio- and possibly a bone marrow biopsy assist in the diagnosis. Blood analysis will indicate an elevated serum  concentra- tion of alkaline phosphatase, and urinalysis reveals an elevated hydroxyproline concentration. Both of these findings are produced by the high rate of bone production. TREATMENT Patients with Paget's disease who have no symptoms require no treatment. With symptoms, treatment options include analgesics, antiinflammatory drugs, cytotoxic agents, or injections of a hormone called calcitonin. Calcitonin is produced naturally by the thyroid gland and works with parathyroid hor- mone (parathormone) and vitamin D to regulate the level of calcium in the blood. Increased amounts of calcitonin can reduce pain for some patients and prevent bone loss. Eating a high- protein, high-calcium diet, with vitamin D supple- mentation may be advised as well. Newer treatments include bisphosphonate medications, such as CHAPTER 7 Diseases and Conditions of the Musculoskeletal System 319 Marfan's Syndrome alendronate (Fosamax), risedronate (Actonel), tiludronate, pamidronate (Aredia), and zoledronic acid (Reclast). PROGNOSIS For most patients with Paget's disease, few if any symptoms are noted. If needed, medications can relieve persistent bone pain. Complications includ- ing hypercalcemia, fractures, heart failure, gout, and bone cancer (sarcoma) can lead to increased morbidity. PREVENTION Patients with Paget's disease should receive 1000 to 1500 mg of calcium, adequate exposure to sun- shine, and at least 400 units of vitamin D daily. This is especially important for patients being treated. with bisphosphonates. Patients with a history of kidney stones should discuss calcium and vitamin D intake with their physician. PATIENT TEACHING Exercise is an important part of maintaining skeletal health, as are avoiding weight gain and maintaining joint mobility. Because undue stress on affected bones should be avoided, patients should discuss any planned exercise program with their physician before beginning.  Marfan's Syndrome DESCRIPTION Marfan's syndrome is a group of inherited condi- tions featuring abnormal connective tissue with weakness of blood vessels and excessive length of the extremities (Figure 7-18). ICD-9-CM Code 759.82 ICD-10-CM Code Q87.40 (Marfan's syndrome, unspecified) (Q87.40-Q87.43 = 5 codes of specificity) SYMPTOMS AND SIGNS Marfan's syndrome is characterized by abnormally long extremities and digits. Additional deformities. include subluxation of the lens of the eyes and heart and vascular anomalies. This condition may go Eye : subluxation of lens retinal detachment cataract Vertebral deformity Long fingers (arachnodactyly ) Elongated head (dolichocephaly) with cerebral bosselation Aortic aneurysm Floppy valves Dissecting aortic aneurysm with exsanguination FIGURE 7-18 Typical features of Marfan's syndrome. (From Damjanov I: Pathology for the health professions, ed 4, St Louis, 2012, Saunders.) undetected until harmful complications are pre- cipitated. The person with Marfan's syndrome is tall and slender with long, narrow digits. An asym- metry of the skull may be noted. Visual difficulties are encountered when lens dissociation occurs. Scoliosis is another manifestation. Joints can be hyperextensible in those with Marfan's syndrome. Mitral valve prolapse and thickening of the heart valves and aortic aneurysm may be present, but frequently go undetected (see "Valvular Heart Disease" section in Chapter 10). Often, the first indication of the syndrome occurs during exercise