Musculoskeletal Disorders Management - Chapters 35-37 PDF

Chapter 35: Musculoskeletal Function Protection of vital organs\ Framework to support body structures, mobility\ Movement; produce heat and maintain body temperature\ Facilitate return of blood to the heart\ Reservoir for immature blood cells\ Reservoir for vital minerals \*206 bones in the body\*...

Chapter 35: Musculoskeletal Function Protection of vital organs\ Framework to support body structures, mobility\ Movement; produce heat and maintain body temperature\ Facilitate return of blood to the heart\ Reservoir for immature blood cells\ Reservoir for vital minerals \*206 bones in the body\* Bone Cells: Osteoblasts- Function in bone formation\ Osteocytes- Mature bone cells that function in bone maintenance\ Osteoclasts- Multinuclear cells function in destroying, resorbing, and remodeling bone Bone Formation and Maintenance\ Ossification: the process of formation of the bone matrix\ and deposition of minerals - Osteogenesis: process of bone formation (begins before birth) Regulating factors: - Stress and weight bearing - Vitamin D - Parathyroid hormone and calcitonin - Blood supply Growth hormone promotes insulin-like growth factor I (IGF-I) production, essential for bone modeling in youth, while low levels with aging may lead to osteopenia. Estrogen enhances bone formation by stimulating osteoblasts and inhibiting osteoclasts, while testosterone supports bone growth and muscle mass. Bone Healing: - Stage I- Hematoma formation - Stage II -- Fibrocartilaginous callus formation - Stage III -- Bony callus formation - Stage IV- Remodeling Osteogenesis begins before birth through ossification, where mineral crystals bond to collagen fibers, giving bone strength Bone remodeling is a continuous process where old bone is replaced by new bone, influenced by factors such as physical activity, nutrition (especially calcium and vitamin D), and hormonal regulation (including parathyroid hormone and calcitonin). Bone remodeling involves osteoblasts producing RANKL to facilitate osteoclast maturation, leading to bone resorption, which can be inhibited by osteoprotegerin (OPG). Blood supply is crucial for bone density; reduced flow can lead to necrosis. Weight-bearing activities stimulate bone formation, while inactivity can lead to bone loss and increased fracture risk. Adequate calcium and vitamin D intake is essential for maintaining bone health Hormones like calcitriol, parathyroid hormone, and calcitonin play crucial roles in calcium absorption and homeostasis, impacting bone health significantly **Joints (Articulation): Junction of Two or More Bones** - Synarthrosis: immovable joints - Amphiarthrosis: allow limited movement - Diarthrosis: freely movable - Ball and socket - Hinge - Saddle - Pivot - Gliding **Other Structures of the Joint** - Joint capsule - Ligaments - Tendons - Bursa sac Fracture healing occurs in stages: hematoma formation, inflammation, reconstruction with a fibrocartilaginous callus, and remodeling, which restores the bone\'s original structure over time. Healing is influenced by blood supply, fracture type, and overall health. Joint types: synarthrosis (immovable), amphiarthrosis (limited motion), and diarthrosis (freely movable). **Types of Diarthrosis Joints**: - **Ball-and-socket joints** (e.g., hip, shoulder) allow full movement. -- - **Hinge joints** (e.g., elbow, knee) permit movement in one direction (flexion/extension). - **Saddle joints** (e.g., base of the thumb) allow movement in two planes. - **Pivot joints** enable rotation (e.g., radius and ulna). - **Gliding joints** allow limited movement (e.g., carpal bones). Joint capsule- surrounds the articulating bones. The capsule is lined with a membrane, the synovium, which secretes the lubricating and shock-absorbing synovial fluid into the joint capsule. Bursa- Sac is filled with synovial fluid that cushions the movement of tendons, ligaments, and bones over bones or other join structures. **Muscles:** - Muscle contraction starts with electrical stimulation from nerve cells, leading to depolarization and the generation of action potential. This action triggers the release of calcium ions from the sarcoplasmic reticulum, allowing myosin and actin filaments to slide over one another and cause contraction. - There are two types of muscle contractions: isotonic and isometric. Isotonic contractions involve the shortening of the muscle without an increase in tension, such as when flexing the forearm. In contrast, isometric contractions occur when muscle length remains constant, but force increases, like pushing against a wall. - Muscles need energy to contract and relax, which comes from a molecule called ATP. ATP is made through a process that uses oxygen. When you\'re not active, ATP is created from glucose. During intense exercise, if there isn\'t enough oxygen, glucose turns into lactic acid, which can lead to muscle fatigue. - **Myoglobulin**: This protein helps transport oxygen in muscle cells. Muscles with more myoglobulin (red muscles) tend to contract slowly and strongly, while those with less (white muscles) contract quickly. - **Muscle Tone**: Muscle tone is the slight contraction of muscles that helps maintain posture. It can change based on whether a person is awake or asleep and can increase when someone is anxious. - Conditions affecting the brain or nerves can lead to too much tone (hypertonic); too little tone (flaccid); muscle with a greater than normal tone (Spastic). Conditions characterized by lower motor neuron destruction, denervated muscle (Atonic); Decrease in the size of a muscle (atrophy). - **Muscle Actions**: Muscles work together to create movement. The main muscle doing the work is called the prime mover, while other muscles helping or opposing the movement are called synergists and antagonists, respectively. If someone has muscle paralysis, they may be able to retrain other muscles to help with movement. - **Exercise and Muscle Health**: Regular exercise is important for keeping muscles strong. When muscles work hard over time, they can grow larger (a process called hypertrophy), but this growth only lasts if the exercise continues. \- **Rotation:** Turning around a specific axis. \- **Adduction:** Moving toward the midline of the body. \- **Abduction:** Moving away from the midline. \- **Circumduction:** A conelike movement involving circular motion. \- **Protraction:** Pushing a body part forward. \- **Retraction:** Pulling a body part backward. \- **Inversion:** Turning a body part inward. \- **Eversion:** Turning a body part outward. \- **Pronation:** Turning a body part downward. \- **Supination:** Turning a body part upward. \- **Flexion:** Bending at a joint. \- **Extension:** Straightening at a joint. **Musculoskeletal disorders:** Common symptoms: pain, tenderness, and altered sensations. Pain is a predominant symptom in musculoskeletal conditions, characterized differently depending on its source: bone pain is a dull ache, muscular pain is soreness, fracture pain is sharp, and joint pain worsens with movement. Rest typically alleviates most musculoskeletal pain, while activity-related pain may indicate specific issues like sprains or infections. Pain patterns can also vary by time of day, with certain conditions exacerbating in the morning. Nursing assessments focus on evaluating the patient\'s pain, including body alignment, joint symmetry, signs of inflammation, and external pressures affecting the patient. **The Fracture Risk Assessment Tool (FRAX®)** is a tool created to help predict how likely a person is to break a major bone, like the hip, spine, forearm, or shoulder, over the next 10 years. It calculates their fracture risk based on certain factors. These factors include age, gender (with women at higher risk), body weight, previous fractures, family history of hip fractures, smoking, use of certain medications, rheumatoid arthritis, and heavy drinking. It also looks at other health issues that can increase the risk of osteoporosis, such as diabetes, certain bone diseases, untreated thyroid problems, hormonal issues, poor nutrition, and liver disease. **Common Spinal Abnormalities:** \- **Kyphosis**: Characterized by increased convexity or roundness of the thoracic spine. - It can occur at any age due to: Degenerative diseases (e.g., arthritis, disc degeneration); Osteoporosis-related fractures; Injury or trauma; neuromuscular diseases **- Lordosis**: - Known as \"swayback,\" this condition involves exaggeration of the lumbar spine curve. Common causes include Tight low back muscles, Excessive visceral fat, Pregnancy, occur due to changes in the center of gravity **- Scoliosis\***: - Defined as an abnormal lateral curve in the spine. Can be: Congenital (present at birth), Idiopathic (without an identifiable cause), Resulting from damage to paraspinal muscles (e.g., muscular dystrophy) **Color and Capillary Refill**: Observing the color of the affected area (Normal within 3 secs) **Pulse Assessment**: Checking if the pulse is palpable distal to the affected area and comparing it to the unaffected extremity. **Swelling and Compression**: Assessing for edema **Joint Function Evaluation**: Analyzing the range of motion, stability, tenderness, and deformity of joints through active and passive movements. Using a goniometer for precise measurement of motion is suggested. Limitations may indicate skeletal deformities or joint issues, especially in older adults with conditions like osteoarthritis. **Joint Effusion**: Identifying excessive fluid in the joint capsule, particularly in the knee, using techniques like the balloon sign and ballottement to assess for inflammation and possible consultation with specialists if necessary. Overall, the text emphasizes the importance of a thorough musculoskeletal assessment to identify potential issues affecting mobility and function. **Diagnostic Tests\ ** Radiographs\ Computed tomography\ MRI\ Arthrography\ Bone densitometry\ Bone scan\ Arthroscopy\ Arthrocentesis\ Electromyography\ Biopsy\ Laboratory studies **Clinical Indications for Diagnostic Tests**\ Study changes in the structure of the bone\ Assess for tumors, soft tissue injury, fractures\ Visualize torn muscles, ligaments, cartilage, herniated disks\ Identify cause of unexplained joint pain and joint disease progression\ Evaluation of bone mineral density **Nursing Interventions for Diagnostic Tests**\ MRI\ Arthrography\ Bone Scan\ Arthroscopy\ Arthrocentesis\ Electromyography\ Biopsy CT scans provide detailed cross-sectional images and can be done with or without contrast agents. MRI is highlighted as a noninvasive method that offers high-resolution images of bones and soft tissues Precautions regarding the removal of metal objects before an MRI are emphasized to prevent injuries and equipment damage. - **MRI**: It can involve sedation for claustrophobic patients, with open MRI systems providing comfort but lower image quality. - **Arthrography**: This technique injects a contrast agent into the joint to visualize structures like ligaments and cartilage, helping to diagnose joint pain and disease progression. - **Bone Densitometry**: Methods like DXA are used to measure bone mineral density (BMD) and predict fracture risk, particularly in osteoporosis. While peripheral tests exist, DXA is preferred for accurate assessments of hip and spine BMD. During the procedure, the patient may experience discomfort or tingling. Post-procedure, a compression elastic bandage may be applied if recommended, and the joint should be rested for 12 hours while avoiding strenuous activities until cleared by the primary provider. Nursing Interventions: Nurses must also evaluate any contraindications or special considerations, such as pregnancy, claustrophobia, and the presence of metal implants. Additionally, if contrast agents are to be used in certain studies, nurses must check for potential allergies. Providing comfort measures, such as mild analgesics and ice, and informing the patient that experiencing clicking or crackling sounds in the joint for 24 to 48 hours is normal as the contrast agent or air is absorbed. - **Bone Scans**: These detect tumors, infections, and fractures not visible on X-rays by measuring the uptake of a radioactive isotope injected into the body. Nursing Intervention: Prior to the procedure, the nurse checks for any contraindications, such as pregnancy or breastfeeding, and educates the patient on the importance of the scan for identifying bone diseases. The nurse reassures the patient that while some discomfort may occur from the isotope, it poses no radioactive hazard. Patients are encouraged to stay hydrated to help eliminate the isotope and are advised to empty their bladder before the scan to ensure accurate results. - **Arthroscopy**: This minimally invasive procedure visualizes joints using a fiberoptic endoscope, allowing for diagnosis and treatment of joint disorders. Nursing interventions are critical before these imaging studies, including patient preparation, assessment for allergies and contraindications, and providing comfort measures. Each procedure carries specific considerations and potential complications, which nurses must address to ensure patient safety and comfort. **Arthroscopy**: After the procedure, the joint is wrapped with a compression dressing, and ice is applied to reduce swelling. The joint should be elevated, and neurovascular status is monitored. Patients are advised to avoid strenuous activities and to report any signs of complications. Nursing Interventions: Post-arthroscopic includes dressings and ice for swelling control, monitoring neurovascular status, and administering analgesics. Patients should avoid strenuous activities and get exercise approval from their provider. They are also instructed to watch for complications like fever or excessive bleeding and to contact their provider if these occur. **Arthrocentesis**: This procedure involves aspirating synovial fluid for examination or relief from effusion. Nursing Interventions: The nurse must educate the patient about potential pain and complications, and ice may be applied post-procedure. Antibiotics may be prescribed, and the patient should be aware of signs of infection. **Electromyography (EMG)**: EMG assesses muscle and nerve function Nursing Interventions: Before the test, the nurse checks for anticoagulant medications and skin infections, as these can be contraindications. Patients are instructed not to use lotions on the day of the test. **Biopsy**: A biopsy is conducted to analyze tissue samples for disease diagnosis. Nurse Interventions: The nurse provides education about the procedure, monitors the site for complications, and informs the patient about signs of infection or other issues. **Laboratory Studies**: Blood and urine tests help identify musculoskeletal issues, complications, or therapy responses. Key markers include serum calcium and phosphorus levels, alkaline phosphatase, and enzyme levels related to muscle damage. Ch. 36 **Low back pain** Most low back pain is caused by one of many musculoskeletal problems, including acute lumbosacral strain, unstable lumbosacral ligaments and weak muscle, intervertebral disc problems, and unequal leg length. Depression, smoking, alcohol abuse, obesity and stress are frequent comorbidities. Generally, back pain due to musculoskeletal disorders is aggravated by activity, whereas pain due to other conditions is not. **Clinical Manifestations:** - Acute back pain (lasting fewer than 3 months) - Chronic back pain (3 months or longer without improvement) and fatigue - Pain radiating down the leg, which is known as radiculopathy (pain from diseased spinal nerve root) or sciatica (inflamed sciatic nerve) - Gait, spinal mobility, reflexes, leg length, leg motor strength and sensory perception may be affected - Paravertebral muscle spasm (greatly increased muscle tone of the back postural muscles) with a loss of the normal lumbar curve and possible spinal deformity **Assessment of the patient with low back pain** - Location, severity, duration, characteristics, radiation, leg weakness - How the pain occurred and has been managed by the patient - Work and recreational activities - Spinal curvature, back and limb symmetry - Palpate paraspinal muscles - Movement ability and effects on ADLs - DTRs, sensation, and muscle strength - Assess posture, position changes, and gait The presence of bruising, older age and prolonged use of glucocorticoid medications increase the risk of a fracture posttraumatic injury. **Diagnostic procedures** for potentially serious or prolonged low back pain such as suspected spinal infection, severe neurologic weakness, urinary or fecal incontinence, and new onset of back pain in a patient with cancer. - X-ray of the spine - Bone scan and blood studies - Computed tomography (CT scan) - MRI - Electromyogram and nerve conduction studies - Myelogram - Ultrasound **Nursing Interventions for the Patient with Low Back Pain** - Pain management - Exercise - Body mechanics - Work modifications - Stress reduction - Health promotion; activities to promote a healthy back - Dietary plan and encouragement of weight reduction Most back pain is self-limited and resolves within 4 to 6 weeks with analgesics, rest, and avoidance of strain. Sitting should be limited to 20 to 50 minutes based on level of comfort. Absolute bed rest is no longer recommended; typical ADL's should be resumed as soon as possible. **Proper and Improper Standing Postures and Lifting Techniques** This Picture Describes about the Proper and Improper Standing Postures and Lifting Techniques  **Common Conditions of the Upper Extremities** - Bursitis and tendonitis - Loose bodies ("joint mice") - Impingement syndrome - Carpal tunnel syndrome - Ganglion - Dupuytren contracture **Tinel Sign: Assessment for Carpal Tunnel Syndrome** This Picture Describes about the Tinel Sign: Assessment for Carpal Tunnel Syndrome Percussing lightly over the median nerve. If the patient reports tingling, numbness and pain, the test for Tinel sign is considered positive. **Dupuytren Contracture**  A flexion deformity caused by an inherited trait, is a slowly progressive contracture of the palmar fascia, which severely impairs the function of the fourth, fifth, and sometimes middle finger. **Nursing Management of the Patient Undergoing Surgery of the Hand or Wrist** - Surgery is usually an ambulatory procedure - Patient education is a major nursing need for a patient undergoing outpatient surgery - Neurovascular assessment is vital - Pain control measures: medication, elevation, intermittent ice or cold - Prevention of infection - Assistance with ADLs and measures to promote independence **Bursitis and Tendonitis:** Inflammatory conditions that commonly occur in the shoulder. Bursae are fluid-filled sacs that prevent friction between joint structures during joint activity and are painful when inflamed. Bursitis is the consequence when these sacs become inflamed. Muscle tendon sheaths also become inflamed with repetitive stretching, causing tendonitis. **Treatment:** rest of the extremity, intermittent ice and heat to the joint, and NSAID's to control the inflammation and pain. Newer therapies are show waves, pulsed magnetic fields, laser phototherapy, radiofrequency, ablation and stem cell therapies. Corticosteroid injections. Treatments are primarily aimed at pain relief, not cure. **Loose Bodies:** Result of articular cartilage wear and bone erosion. They can interfere with joint movement. Removed by arthroscopic surgery if they cause pain or mobility issues. **Impingement Syndrome:** Impaired movement of the rotator cuff of the shoulder. Usually occurs from repetitive overhead movement of the arm or from acute trauma resulting in irritation and eventual inflammation of the rotator cuff tendons or the subacromial bursa as they grate against the coracoacromial arch. **Manifestations:** edema, pain, shoulder tenderness, limited movement, muscle spams, and eventual disuse atrophy. **Treatment:** NSAID's, intra-articular injections of corticosteroids, application of cold or heat, and therapeutic exercise program. **Carpal Tunnel Syndrome:** Occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema or a soft tissue mass. Commonly caused by repetitive hand and wrist movements, it is also associate with RA, diabetes, acromegaly, hyperthyroidism, or trauma. **Manifestations:** pain, numbness, paresthesia, and possibly weakness along the median nerve distribution (thumb, index, and middle fingers). Night pain and/or fist clenching upon wakening is common. Positive Tinel sign. **Treatment:** NSAID's, acupuncture, oral or intra-articular injections of corticosteroids, wrist splints to prevent hyperextension and prolonged flexion of the wrist is also effective. More serious treatment is surgery. **Ganglion:** Collection of neurologic gelatinous material near the tendon sheaths and joints-appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. Frequently occurs in women younger than 50. May cause aching pain. Weakness in fingers can occur. **Treatment:** aspiration, corticosteroid injection, or surgical excision. **Dupuytren Disease:** Slowly progressive contracture of the palmar fascia that causes flexion of the fourth, fifth, and sometimes middle finger, rendering these fingers more useless. Link to an inherited autosomal dominant trait and occurs most frequently in men of Scandinavian or Celtic heritage who are older than 50 years. Associated with arthritis, diabetes, gout, cigarette smoking and alcoholism. **Manifestations:** Dull and aching discomfort, morning numbness, and stiffness in the affected fingers. Starts in one hand but will eventually be both hands. **Treatment:** finger stretching exercises, corticosteroid injections. **Comon Foot Problems:** - Callus - Corn - Hammer toe - Ingrown toenail: Onychocryptosis - Clawfoot: Pes cavus - Hallux valgus - Morton neuroma - Flatfoot: Pes planus - Plantar fasciitis **Common Foot Deformities** This Picture Describes about the Common Foot Deformities **Pes Cavus (clawfoot):** foot with an abnormally high arch and a fixed equines deformity of the forefoot. **Nursing Interventions for the Patient Undergoing Foot Surgery** - Neurovascular assessment is vital - Relieve pain related to inflammation and edema - Improving mobility - Measures to prevent infection - Patient education **Osteoarthritis** - **Primary does not involve autoimmunity or inflammation; can occur as an end result of an autoimmune disorder where joint destruction occurs** - **Noninflammatory degenerative disorder of the joints** - **Classified as either primary (idiopathic), or secondary,** **Pathophysiology of Osteoarthritis** - Articular cartilage breaks down, leading to progressive damage to the underlying bone and eventual formation of osteophytes (bone spurs) that protrude into the joint space - Joint space is narrowed, leading to decreased joint movement and the potential for more damage - Joint can progressively degenerate - Previously thought of as simply "wear and tear" related to aging **Risk Factors for Osteoarthritis** - Older age, female gender, and obesity - Certain occupations (e.g., those requiring laborious tasks) - Engaging in sport activities - History of previous injuries, muscle weakness, genetic predisposition, and certain diseases - Most prominent modifiable risk factor for OA is obesity - Diet and exercise can help minimize symptoms of OA in patients with obesity **Clinical Manifestations of Osteoarthritis** - Pain - Stiffness - Functional impairment - Aggravated by movement or exercise and relieved by rest - Morning stiffness that goes away within 30 minutes - Enlarged joint - Decreased range of motion **Management of Osteoarthritis** - Exercise - Supplements - NSAIDS **Nursing management:** - Pain management - Optimal functional ability - Pharmacologic and nonpharmacologic approaches - Education - Weight loss and exercise **Osteoporosis** - Normal homeostatic bone turnover is altered, and the rate of bone resorption is greater than the rate of bone formation, resulting in loss of total bone mass - Bone becomes porous, brittle, and fragile and breaks easily under stress **Typical Loss of Height Associated with Osteoporosis and Aging**  **Osteoporosis Prevention** - Balanced diet high in calcium and vitamin D throughout life - Use of calcium supplements to ensure adequate calcium intake: take in divided doses with vitamin C - Regular weight-bearing exercises: 20 to 30 minutes a day - Increases balance - Reduces incidence of falls and fractures - Weight training stimulates bone mineral density (BMD) **Pharmacologic Therapy for Osteoporosis** - Calcium and vitamin D - Bisphosphonates - Calcitonin - Estrogen agonists/antagonists - Parathyroid hormone - Receptor activator of nuclear factor kappa-B ligand inhibitors - Refer to Table 36-1 **Interventions:** - Diet rich in calcium and vitamin d - Weight-bearing exercises **Osteomalacia** - Osteomalacia is a condition where bones become soft due to a lack of calcium and phosphate. - A metabolic bone disease characterized by inadequate bone mineralization\ Softening and weakening of the long bones causes pain, tenderness, and deformities caused by the bowing of bones and pathologic fractures Major defect in osteomalacia is a deficiency of activated vitamin D, which promotes calcium absorption from the GI tract **Considerations -** Older adults need a nutritious diet rich in calcium and vitamin D. - Sunlight exposure is important for vitamin D production. -- Osteomalacia increases the risk of fractures, especially when combined with osteoporosis. **Assessment and Diagnostic Findings:** \- X-rays show general bone weakness and possible compression fractures. \- Blood tests reveal low levels of calcium and phosphorus, and a moderate increase in alkaline phosphatase (ALP). \- Urine tests typically show low calcium and creatinine levels. \- A bone biopsy may reveal demineralized bone tissue. **Medical Management of Osteomalacia** - **Vitamin D Supplementation**: - If kidney disease prevents the activation of vitamin D, the activated form (calcitriol) is necessary for supplementation. - In cases of malabsorption, higher doses of vitamin D and calcium supplements are typically prescribed. - **Sunlight Exposure**: - Patients are encouraged to get sunlight exposure, which helps convert a substance in the skin (7-dehydrocholesterol) into vitamin D - **Dietary Interventions**: - For dietary-related osteomalacia, management strategies are like those for osteoporosis, focusing on improving nutrient intake. - **Monitoring**: - Long-term monitoring is essential to ensure the stabilization or reversal of osteomalacia. - **Orthopedic Treatment**: - Persistent bone deformities may require additional treatments, such as braces or surgical procedures (e.g., osteotomy) to correct significant bone deformities. **Paget Disease of the Bone:** Paget disease, also known as osteitis deformans, is a condition characterized by localized rapid bone turnover, primarily affecting older adults. It occurs in about 2% to 3% of the population over 50, with a **slightly higher prevalence in men**. A family history of the disease is common, but its exact cause remains unknown. - **Pathophysiology:** \- This is followed by a compensatory increase in osteoblast activity, resulting in disorganized bone formation, described as a \"mosaic\" pattern. \- The affected bone becomes highly vascularized but structurally weak, making it prone to fractures. \- Patients may experience structural changes, such as bowing of the legs, which can lead to malalignment of joints and arthritis. - **Clinical Manifestations** **Common symptoms include:** - Skeletal deformities, particularly in the skull which may thicken, lead to a change in hat size. - The skull may enlarge without affecting the facial bones, resulting in a small, triangular facial appearance. - Impaired hearing due to compression of cranial nerves. - Bowing of the femurs and tibiae, causing a waddling gait. - Forward bending of the spine, resulting in a rigid posture and a chin resting on the chest. Warmth and tenderness over affected bones due to increased vascularity. - In severe cases, high-output cardiac failure may develop due to significant vascular lesions. **Assessment and Diagnostic Findings**: \- Elevated serum alkaline phosphatase (ALP) levels and increased urinary hydroxyproline which indicate heightened osteoblastic activity; higher values suggest more disease. **Blood Calcium levels remain normal** **Imaging**: - X-rays reveal localized areas of demineralization and bone overgrowth, presenting Paget disease. \- **Bone Biopsy**: - May be performed to differentiate Paget disease from other bone disorders. \- **Pain Management**: - Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly effective for pain relief. \- **Mobility Support**: - Gait issues from leg bowing can be managed with walking aids, shoe lifts, and physical therapy. \- Weight management is crucial to minimize stress on weakened bones and misaligned joints. **- Monitoring** - Asymptomatic patients may simply require monitoring of their condition. \- **Complications:** \- Fractures are treated based on location, with healing facilitated by proper reduction and immobilization. \- Severe arthritis may necessitate total joint replacement, although the quality of bone in Paget disease can complicate surgical outcomes. \- Hearing loss management includes hearing aids and alternative communication techniques. \- **Bisphosphonates**: - These are the primary treatment for Paget disease, helping to stabilize bone turnover, alleviate pain, and improve mobility. - They effectively lower serum ALP and urinary hydroxyproline levels. **Plicamycin**: - This cytotoxic antibiotic may be used in severe cases with neurologic compromise or resistance to other treatments. It significantly reduces pain and improves metabolic markers but has notable side effects, requiring monitoring of liver, kidney, and bone marrow function. Osteomyelitis is a bone infection characterized by inflammation, necrosis, and new bone formation. It is classified into three types: 1\. **\*Hematogenous Osteomyelitis\***: Infection spread through the bloodstream. 2\. **\*Contiguous-Focus Osteomyelitis\***: Infection resulting from contamination during surgery or trauma. 3\. **\*Osteomyelitis with Vascular Insufficiency\***: Common in patients with diabetes, affecting mainly the feet. **High-risk groups** for osteomyelitis include older adults, those with poor nutrition or obesity, individuals with weakened immune systems, chronic illness patients, and illicit IV drug users Postoperative infections can occur within 30 days and are categorized into superficial and deep infections, with deep infections potentially arising within a year if implants are involved. Chronic osteomyelitis can significantly impact quality of life. **s/s:** sudden onset symptoms resembling sepsis, including chills, fever, rapid pulse, and malaise. As the infection spreads through the bone, it leads to painful, swollen, and tender areas, often with a pulsating pain due to pus accumulation. Systemic sepsis symptoms may be absent, with local swelling and tenderness over the infected bone. **Chronic osteomyelitis** may be shown as a nonhealing ulcer with pus drainage. In diabetics, it can occur without visible wounds and may appear as a nonhealing fracture, worsened by poor immune responses. \*Foot ulcers over 2 cm in diameter\* **Nursing Interventions:** **Relieving Pain:** Immobilization of the affected area with a splint, careful handling to minimize discomfort, elevation to reduce swelling, and the use of prescribed analgesics. **Improving Physical Mobility:** Restrictions on weight-bearing activities to protect weakened bones, gentle movement of adjacent joints, and encouragement of participation in activities of daily living (ADLs) within physical limitations. **Controlling the Infectious Process:** Monitoring the patient\'s response to antibiotic therapy and observing IV access sites for signs of phlebitis. Nurses monitor patients for signs of superinfection during long-term antibiotic therapy and take measures to ensure proper circulation and immobility if surgery is needed. **Education for patients and families:** importance of adhering to antibiotic regimens, managing IV access, and understanding medication details and potential adverse reactions. The transitional care environment should support the patient\'s health and therapeutic needs. A home care checklist is provided to ensure patient education is completed effectively. Pt outcomes include: **Pain Relief**: Patients should report decreased pain at rest, show no tenderness at the infection site, and experience minimal discomfort during movement. **Increased Mobility**: Patients are expected to participate in self-care within their physical limitations, maintain functionality in unaffected limbs, safely use assistive devices, and adapt their environment to prevent falls. **Absence of Infection**: Successful outcomes include adherence to prescribed antibiotics, normal body temperature, absence of swelling and drainage, and laboratory results showing normal white blood cell counts and negative wound cultures. **Home Care Checklist** - **Understanding Osteomyelitis**: Patients will recognize how osteomyelitis affects physiological functioning, daily activities, roles, relationships, and spirituality. - **Home Modifications**: They will identify necessary changes in the home environment and strategies, including the use of durable and adaptive medical equipment, to aid recovery and rehabilitation. - **Wound Care**: Patients will demonstrate knowledge in obtaining medical supplies, performing dress changes, and managing wound care. - **Therapeutic Regimens**: They will describe ongoing postoperative care, including dietary recommendations, activities to engage in or avoid, and the importance of consuming a healthy diet for wound and bone healing. - **Mobility and Safety**: Patients will demonstrate proper wound care and the safe use of ambulatory aids and assistive devices. - **Medication Management**: They will state medication details (name, dose, side effects, frequency) and demonstrate safe administration practices. - **IV Therapy Knowledge**: When applicable, patients will identify the benefits of intravenous antibiotic therapy and demonstrate the maintenance of IV access. - **Recognizing Adverse Effects**: Patients will describe potential adverse effects of antibiotics and the appropriate actions to take, including who to contact for complications. **Septic Arthritis Summary:** - Joint infection caused by pathogens spreading from other body parts, trauma, injections, or surgery. - Most common pathogen: Staphylococcus aureus. - Other causes: gram-positive bacteria, gonococcal infections, and Pseudomonas aeruginosa (especially in IV drug users). **High-Risk Populations:** - Older adults (especially over 80 years). - Individuals with comorbidities: diabetes, rheumatoid arthritis, skin infections, alcoholism. - Those with a history of joint replacement or IV drug abuse. **Commonly Affected Joints:** - Primarily affects knee and hip joints. - Up to 20% of cases can involve multiple joints (polyarticular disease). **Importance of Prompt Treatment:** - Early recognition and treatment are crucial to prevent complications like chondrolysis (destruction of cartilage) and sepsis. - Mortality rates: about 11% for single joint infections; up to 50% for polyarticular disease or immunocompromised patients. **Clinical Manifestations:** - Symptoms include warm, painful, swollen joints with decreased range of motion. - Possible systemic symptoms: chills, fever, leukocytosis (increased white blood cells). - Fever may be absent in older patients. - Approximately half of the cases involve the knee joint. **Nursing Management of Septic Arthritis:** - Explain the physiological process of septic arthritis to the patient and family. - Emphasize the importance of supporting the affected joint during recovery. **Medication Adherence:** - Instruct the patient on the necessity of following the prescribed antibiotic regimen carefully to combat the infection. - Advise inspecting the skin under any splints that may be applied to prevent skin breakdown and complications. - Inform the patient about weight-bearing and activity restrictions to avoid further injury to the affected joint. - Educate the patient about the possibility of recurrence of infection in both the near and distant future. - Teach signs and symptoms to monitor and report to the primary healthcare provider. **Bone Tumors Overview:** **Types of Neoplasms:** - Osteogenic (bone-forming) - Chondrogenic (cartilage-forming) - Fibrogenic (fibrous tissue-forming) - Rhabdomyogenic (muscle-forming) - Marrow (reticulum) cell tumors - Nerve, vascular, and fatty cell tumors. - They can be primary tumors or metastatic tumors originating from other cancers (e.g., breast, lung, prostate, kidney). - More common than malignant primary bone tumors. - Generally slow-growing. - Well-circumscribed and encapsulated. - Present few symptoms and are not life-threatening. - Osteochondroma - Enchondroma - Bone cysts - Osteoid osteoma - Rhabdomyoma - Fibroma. - Some benign tumors have the potential to become malignant. - Most common benign bone tumor. - Typically appears as a large bone projection at the ends of long bones (such as the knee or shoulder). - Develops during growth and becomes a static bony mess. - In fewer than 1% of cases, it turn to malignancy. **Primary Malignant Tumors:** - Rare tumors from connective tissue or bone marrow, including: - Most common and often fatal, primarily in children and adolescents, localized bone pain, common in distal femur and proximal tibia. - The second most common, affects middle-aged and older adults, variable growth rates, better prognosis for low-grade tumors, commonly found in the pelvis and femur. **Ewing Sarcoma and Fibrosarcoma:** Other types affecting younger populations and soft tissues, respectively. **Metastatic Bone Disease:** - More prevalent than primary tumors, arising from cancers in other body tissues leading to secondary bone tumors. **Metastatic Bone Disease:** - Common sites for metastasis include the kidney, prostate, lung, breast, ovary, and thyroid. - Frequently found in the skull, spine, pelvis, femur, and humerus, often affecting multiple bones (polyostotic). - Tumors can cause localized bone destruction (osteolytic lesions) or overgrowth (osteoblastic lesions). **Pathophysiology:** - Tumors cause normal bone tissue to respond with either bone destruction (osteolytic) or formation (osteoblastic). - Malignant tumors invade and weaken adjacent bone tissue, leading to pathologic fractures, while benign tumors grow symmetrically and place pressure on surrounding tissues. **Clinical Manifestations:** - Symptoms can vary widely; some patients may be asymptomatic, while others experience mild to severe pain, disability, or noticeable bone growth. - Additional symptoms may include weight loss, malaise, and fever. - Diagnosis often occurs after pathological fractures or as incidental findings. - Spinal metastasis can lead to spinal cord compression, requiring early intervention to prevent permanent injury, with symptoms like pain, weakness, gait issues, and loss of bowel or bladder control. **Assessment:** - Gather information on symptom onset, coping strategies, and pain management while documenting the mass\'s characteristics and neurovascular status. **Post-Operative Care:** - Provide care like other skeletal surgeries, explaining treatments, expected outcomes, and reinforcing information from the surgeon. **Pain Management:** - Accurately assess and manage challenging oncology-related pain, utilizing radiation therapy and systemic isotopes as needed. **Support and Handling:** - Gently support affected extremities to prevent fractures, adhere to weight-bearing restrictions, and educate on the safe use of assistive devices. **Emotional Support:** - Encourage open communication about fears and concerns, offering support and referrals to mental health professionals when necessary. **Chapter 37: Management of Patients with Musculoskeletal Trauma** **Injuries of the Musculoskeletal System** - **Contusion- SOFT TISSUE INJURY** - A soft tissue injury produced by blunt force, such a blow, kick, or fall, causing blood vessels to rupture and bleed into the soft tissues - Minor or severe - Black and blue appearance, pain, swelling - Usually resolves within 1 to 2 weeks - **Strain- SOFT TISSUE INJURY** - An injury to a muscle or tendon from overuse, overstretching or excessive exercise - Acute strain- from one incident - Chronic strain- results from repetition injuries, result from improper treatment for acute strains - 1^st^ degree- mild stretching of the muscle or tendon with no loss of ROM - 2^nd^ degree- involves moderate stretching or partial tearing of the muscle or tendon - 3rd degree- severe muscle or tendon stretching with rupture and complete tearing involves tissue - **Sprain- SOFT TISSUE INJURY** - An injury to the ligaments and tendons that surround a joint - Caused by a twisting motion or hyperextension of a joint - Grade 1- stretching or slight tearing in some fibers of the ligament and mild, localized hematoma formation - Grade 2- more severe and involves partial tearing of the ligament - Grade 3-complete tear or rupture of the ligament - **Dislocation- JOINT DISLOCATIONS** - Joint is a condition in which the articular surfaces of the distal and proximal bones that form that joint are no longer in anatomical alignment - **Subluxation -JOINT DISLOCATIONS** - Partial or incomplete dislocation and does not cause as much deformity as a complete dislocation - **Management of soft tissue injuries** - Contusions, strains, and sprains - RICE- Rest, Ice, Compression, Elevation - Rest-promotes healing - Ice- helps with vasoconstriction which decreases bleeding, edema,and discomfort - Compression- Controls bleeding, reduces edema, provides support - Elevation-controls swelling - Immobilize - **Types of fractures** - **Closed or simple** - Is one that does not cause break in the skin - **Open or compound/complex** - Is one in which the skin or mucosa membranes would extend to the fractured bone - Classified by Gustilo-Anderson - Type 1- clean would less than 1 cm long and simple fracture pattern - Type 2- larger would with minimal soft tissue damage and no flaps or avulsions - Type 3- most severe, highly contaminated, and extension of soft tissue damage - Intra-articular - Extends into the joint surface of a bone - **Clinical Manifestations of Fractures** - Pain - Loss of function - Deformity - Shortening - Crepitus - Localized edema and Ecchymosis - Shortening of the extremity - Local swelling and discoloration - **Emergency Management** - Diagnosed by symptoms and radiography - Immobilize the body part - Splinting: joints distal and proximal to the suspected fracture site must be supported and immobilize - Assess neurovascular status before and after splinting - Open fracture- cover with sterile dressing to prevent contamination - Do not attempt to reduce the fracture - **Medical Management of fracture** - Fracture reduction: restoration of the fracture fragments to anatomic alignment and positioning - Closed- bringing bone fragments into anatomic alignment through manipulation and manual traction - Open- surgical approach - Immobilizations- bone fragments must be immobilized and maintained in proper position ( use of bandages, casts, splints, and continuous traction) - **Techniques of internal fixation** - Plate and six screws for a transverse or short oblique fracture - Screws for long oblique or spiral fracture - Screws for a long butterfly fragment - Plate and six screws for a short butterfly fragment - Medullary nail for segmental fracture - **Factors that effect Fracture Healing** - Inadequate fracture immobilization - Inadequate blood supply to the fracture site or adjacent tissue - Multiple trauma - Extensive bone loss - Infection - Poor adherence to prescribed restrictions - Malignancy - Certain Medications - Age greater than 40 - Comorbidities (Diabetes, rheumatoid arthritis) - **Complications of Fractures** - **Early complications** - Shock, fat embolism, acute compartment syndrome, VTE, pulmonary embolism, disseminated intravascular coagulation, and infection - **Delayed Complications** - Delayed union- healing does not occur within the expected timeframe - Malunion- healing of a fracture bone is maligned position - Nonunion- incomplete healing of fracture results from failure of the ends of a fractured bone - AVN of bone - Complex regional pain syndrome - Heterotopic ossification - **Rehabilitation Related to Specific Fractures** - **Clavicle** - Common injury that can result from a fall or a direct blow of the shoulder - Treatment goal is to align the shoulder in it normal position by means of closed reduction and immobilization - Surgical intervention is not a typical treatment - Patient usually is in a protective position, slumping the shoulders and immobilizing the arm to prevent shoulder movement A book with a diagram of the back of a person Description automatically generated - **Humeral neck and shaft fractures** - Fractures of the proximal humerus may occur through the neck of humerus and most often the results from a fall ontro an outstretched hand - Most common in 60 years of age - Moderate to severe shoulder pain with the affected arm hanging limp at the side or supported by the uninjured hand - Impacted with little to no displacement and do not require surgery - **Shaft Fracture** - Fractures of the midshalf are most frequent caused by either a direct blow or trauma that results in a transverse, oblique, or comminuted fracture or an indirect twisting force that results in a spiral fracture - Treated nonsurgical  - **Rehabilitation of Elbow fractures** - Involves distal part of the humerus - Most fractures result from high-energy mechanisms such as motor vehicle crashes, falls directly on elbow, or direct blow - Can be very painful, and may result in injury to the brachial artery and median nerves - Patient evaluated for paresthesia and signs of compromised circulation of the forearm and hand - Claw-like appearance - The goal of therapy is prompt reduction and stabilization of the distal humeral fracture, followed by controlled range of motion after swelling has subsided and healing has begun - **Rehabilitation of Radial, ulnar, wrist, and hand fractures** - Radial/ ulnar - If fragments are not displaced- treated by closed reduction with immobilization in bivalved long arm cast with wrist in slight extension - Circulation, motion, and sensation of the hand are assessed before and after cast is applied - Frequent finger flexion and extension to reduce edema - Active ROM is essential - Lifting and Twisting should be avoided - Displaced fractures of the radius and ulna require ORIF, using compression plate with screws, intramedullary nails or rods - **Wrist** - Treatment consists of closed reduction and immobilization with sugar thong splint until swelling subsides - The splint is placed so that it is extends from palm around the elbow to the back of the hand just below the fingers - Remains in place until edema lessens - The nurse assesses the sensory function of the median curve by pricking the distal aspect of the index finger - The motor function is assessed by the patient's ability to touch the thumb to the little finger - Diminished circulation and nerve function must be treated promptly - **Hand fractures** - The Neurovascular status of the injury is evaluated - Swelling is controlled by elevation - Functional use is encouraged - Assistive devices might be recommended - Falls and occupational injuries - Treatment- regain function, relieve pain and prevent of injuries, splinting or taping the fingers together, Displaced or open fractures get ORIF, using wires or pins - **Rehabilitation Related Specific to Pelvic and Hip Fracture** - **Pelvic Fracture** - **Stable Pelvic** - Treated within a few days of bed rest, analgesics, progressive immobilization, fluid, dietary fiber, ankle and leg exercises, anti-embolism stockings, log rolling, deep breathing, early immbolization, skin care - Donut cushion, sitz baths, stool softners - **Unstable pelvic** - Immediate treatment - Stabilize the pelvic bones and compressing bleeding vessels may be stopped through embolization using interventional radiology techniques prior to surgery - When patient is hemodynamically stable, treatment is enternal fixation or ORIF. These measure promote hemostasis, hemodynamic stability, comfort, and early mobilization - **Hip Fracture** - **Assessment** - Health history and presence of concomitant problems - Pain - VS, respiratory status, LOC, and signs and symptoms of shock - Affected extremity including frequent neurovascular assessment - Bowel and bladder elimination; bowel sounds, I&O - Skin condition - Anxiety and coping - **Collaborative Problems and Potential Complications for the Patient with a Fracture of the Hip** - Hemorrhage - Peripheral neurovascular dysfunction - VTE - Pulmonary complications - Skin breakdown - Loss of bladder control - Delayed: infection, nonunion, AVN - Planning and Goals for the Patient with Fracture of the Hip - **Surgery is indicated** - Obtain satisfactory fixation so that the patient can be mobilized quickly and avoid secondary medical complications - Open or closed reduction - Relief and pain management are most important - Neurovascular assessment is essential - The nurse encourages deep breathing and dorsiflexion and plantar flexion exercises every 1 to 2 hours - Thigh-high, anti-embolism stockings - Anticoagulants given to prevent VTE - Monitor patient hydration, nutritional status and urine output - Reposition patient- turn on uninjured side, place pillows between patient legs and make sure injured side is abducted - Promote exercise - Monitor and Manage complications - **Femoral shaft fractures** - Lower leg, foot, and hip exercises to preserve muscle function and improve circulation - Early ambulation stimulates healing - Physical therapy, ambulation, and weight bearing are prescribed - Active and passive knee exercises are begun as soon as possible to prevent restriction of knee movement - **Assessment of the Patient with a Brace, splint or cast** - **Before application** - Assessment of patient's general health, presenting signs and symptoms, emotional status, understanding of the need for the device, and condition of body part - Monitor of neurovascular status and potential complications (use 5 P's) - Treat lacerations and abrasians before cast, brace or spint - Provide information about purpose of treatment - Prepare patient for application by explaining procedure - **Monitoring and treating- describe exact site, character and intensify of pain** - Treat with elevation, ice packs and analgesics - **Potential Complications** - Acute Compartmental Syndrome - clinical Assessment of the 5 P's, pain is the early indicator - Treatment: notify provider, cast may be removed, and emergent surgery fasciotomy may be necessary - Pressure injuries- caused by inappropriate applied cast - Disuse syndrome- muscle atrophy and strength - Treatment- Isometric exercises, muscle setting exercises - **Education** - Impact of injury to physiologic functioning (ADL, IADL) - Activity, exercise, rest - Medications - Techniques for cast drying Controlling of swelling and pain - Care of minor skin irritation - Pad rough edges with tape or moleskin - Blow with hair dryer to relieve itching - Do not stick foreign objects into the cast - Signs and symptoms to report: - Persistent pain or swelling - Changes in sensation, movement, skin color, or temperature - Signs of infection or pressure areas - Required follow-up care - Cast removal and after care - **External Fixator Devices** - Used to manage open fractures with soft tissue damage - Provide support for complicated or comminuted fractures - Patient requires reassurance because of appearance of device - Discomfort is usually minimal, and early mobility may be anticipated with these devices - Elevate to reduce edema - Monitor for signs and symptoms of complications (infection) - Pin Care - Patient Education External fixation - Wikipedia - **Traction** - The application of pulling force to a part of the body - Purposes - Reduce muscle spasms - Reduce, align, and immobilize fractures - Reduce deformity - Increase space between opposing forces - Used as a short-term intervention until other modalities are possible - All traction needs to be applied in two directions. The lines of pull are "vectors of force." The result of the pulling force is between the two lines of the vectors of force  - Principles of Effective Traction - Whenever traction is applied, a counterforce must be applied. Frequently, the patient's body weight and positioning in bed supply the counterforce - Traction must be continuous to reduce and immobilize fractures - Skeletal traction is never interrupted - Weights are not removed unless intermittent traction is prescribed - Any factor that reduces pull must be eliminated - Ropes must be unobstructed, and weights must hang freely - Knots or the footplate must not touch the foot of the bed - **Types of Traction** - Skin traction - Buck's extension traction - Skeletal traction - Thomas Leg splint - **Nursing Interventions for the Patient in Skin Traction** - Proper application and maintenance of traction - Monitor for complications of skin breakdown, nerve damage, and circulatory impairment - **Nursing Interventions for the Patient in Skeletal Traction** - Evaluate traction apparatus and patient position - Maintain alignment of body - Report pain promptly - Trapeze to help with movement - Assess pressure points in skin at least every 8 hours - Regular shifting of position - Special mattresses or other pressure reduction devices - Perform active foot exercises and leg exercises every hour - Anti-embolism stockings, compression devices, or anticoagulant therapy may be prescribed - Pin care - Exercises to maintain muscle tone and strength - **Nursing Management of Patients in Traction** - Assessing anxiety - Assisting with self-care - Monitor and manage complications - Atelectasis and pneumonia - Constipation - Anorexia - Urinary stasis - Infection - VTE - **Common Sports-Related Injuries** - Fracture: clavicle, wrist, ankle, metatarsal stress - Dislocations: shoulder, elbow - Sprains: wrist, ankle - Knee: sprain, strain, and meniscal tears - **Prevention of Sports-Related Injuries** - Use of proper equipment; running shoes for runners, wrist guards for skaters, and so on - Effective training and conditioning specific for the person and the sport - Stretching - Hydration - Proper nutrition - **Amputation** - May be congenital or traumatic or caused by conditions such as progressive peripheral vascular disease, infection, malignant tumor, trauma - Performed to control pain or disease process, improve function, and improve quality of life - Health care team needs to communicate a positive attitude to facilitate patient acceptance and participation in rehabilitation - **Level of Amputation** - Performed at the most distal point that will heal successfully and should take into account the ability of the patient to achieve successful rehabilitation - **Assessment of the Patient with an Amputation** - Neurovascular and functional status of affected extremity or residual limb and of unaffected extremity - Signs and symptoms of infection - Nutritional status - Concurrent health problems - Psychological status, grief, and coping - **Collaborative Problems and Potential Complications of the Patient with an Amputation** - Postoperative hemorrhage - Infection - Skin breakdown - Phantom limb pain - Joint contracture - **Planning and Goals for the Patient with an Amputation** - **Major goals include:** - Relief of pain - Wound healing - Acceptance of altered body image - Resolution of grieving process - Independence in self-care - Restoration of physical mobility - Absence of complications - **Nursing Interventions for the Patient with an Amputation** - Relieving Pain - Promoting wound healing - Resolving grief and enhancing body image