Family Nurse Practitioner, 6Ed, Chapter 14 Musculoskeletal Disorders PDF

CHAPTER 14 MUSCULOSKELETAL DISORDERS Courtney E. Reinisch, DNP, RN, APN-C, FNP-BC, DCC General Approach DESCRIPTION Exclude musculoskeletal emergencies, which include impairment of neurovascu- lar status. Proceed to evaluate for other diagnostic possibilities. Assess musculoskeletal complaints by determining the following: Acute or chronic Articular or nonarticular in origin Inflammatory or noninflammatory in origin Localized or systemic in distribution A thorough review of systems may provide clues to other systemic diseases such as: Fever (systemic lupus erythematosus [SLE], infection) Nervous system (Lyme disease, vasculitis) Eye (sarcoidosis, Reiter’s syndrome) Gastrointestinal (scleroderma, inflammatory bowel disease) Examine the uninvolved side initially and the painful area last. Diagnostic laboratory studies may be required in the evaluation of some musculoskel- etal complaints. As part of a conservative treatment regimen, cold/ice is usually recommended in the first 48 hours after an injury and then heat. Treatment decisions should use shared decision-making Use evidence-based guidelines to direct care. 1125 1 12 6 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Consult or refer to members of the multidisciplinary care team to achieve optimal outcomes. Systemic presentations in children may indicate a chronic pediatric condition such as inflammatory bowel disease, cystic fibrosis, juvenile arthritis, hemophilia, sickle cell disease, leukemia, osteosarcoma, and vitamin D–resistant rickets. In infants and children, obtain history of mother’s pregnancy and child’s birth and development. (Musculoskeletal problems comprise about 10% of childhood prob- lems and about 25% of primary care visits.) History includes mechanism of injury, occupation, any sports or exercise, repetitive use, duration, and aggravating and alleviating factors. Age is important in evalua- tion of any musculoskeletal findings. Observe gait, posture, guarding, and patient positioning; examine the affected side in comparison to the unaffected side. RED FLAGS Back pain with neurologic signs and or bowel and bladder dysfunction including urinary retention or incontinence, saddle anesthesia, decreased anal sphincter tone, or fecal incontinence may indicate cauda equina syndrome. This is a surgical emergency and requires immediate referral for evaluation and management. Back pain in children: urgent referral if constant, younger than age 11, lasts several weeks, wakes patient at night, limits motion, or includes fever, neurologic signs, weight loss, or history of malignancy Malignant bone tumors may present as unexplained pain and swelling over a bone, decreased range of motion (ROM), night pain, pain with weight-bearing, weight loss, night sweats, pallor, malaise, and fever; or have a high index of suspicion for bone metastasis in patients with previous breast, lung, or prostate cancer. Osteomyelitis may present as pain in bone, fever, difficulty bearing weight, and possible local warmth and swelling following recent trauma. Obtain a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level and refer to orthopedist. Radiologic evidence for infection changes may present 10 to 24 days after the onset of infection. MUSCULOSKELETAL DISORDERS 1 1 27 Arthritis OSTEOARTHRITIS (OA) Description Degenerative joint disease with progressive loss of articular cartilage in movable joints. Degeneration of cartilage, bone hypertrophy, formation of osteophytes and subchon- dral cysts, and development of subchondral sclerosis in synovial joints and vertebrae. Most common form of arthritis. Radiographic evidence does not equate with symptoms. Etiology Results from both mechanical and biologic events that lead to degradation of articular cartilage and subchondral bone in joint Incidence and Demographics Leading chronic condition among adults 65 years of age and older Incidence increases with advancing age and history of participation in contact sports 80% of adults in United States have radiographic evidence by age 75 Rates of symptomatic hand, hip, and knee increase rapidly at age 50 and level off after age 70 Women affected more than men Prevalence: Over 50 million U.S. adults are affected by osteoarthritis Risk Factors Advancing age; symptom onset typically 55 to 65 years Athletic overuse or repetitive joint use in occupation Joint trauma from acute injury or metabolic disease Obesity, heredity, congenital musculoskeletal disorders 1 12 8 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Occupations increase risk—construction, firefighting, farming, mining, forestry Metabolic disorders (e.g., gout) or endocrine disorders (e.g., hyperparathyroidism) Prevention and Screening Maintain physical activity. Maintain ideal body weight; avoid obesity. Maintain control of metabolic and endocrine disorders. Assessment History (see Table 14–1) Gradual onset of joint pain, tenderness, and stiffness; worsens with activity and relieved by rest TABLE 14–1. DIFFERENTIATING CHARACTERISTICS OF OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS CHARACTERISTICS OSTEOARTHRITIS RHEUMATOID ARTHRITIS Radiographic Joint-space narrowing, Periarticular osteopenia or appearance osteophytes, subchondral bone osteoporosis, soft tissue swelling, sclerosis, subchondral cysts marginal bony erosions Morning stiffness Lasts more than 30 minutes Lasts less than 1 hour before improving Joint involvement Usually weight-bearing (spine, Multiple joints, symmetric joint hips, knees), or distal finger involvement (especially of hands) joints (DIP) Laboratory ESR less than 20–40 mm/hour; Positive serum RF, may have positive findings RF negative ANA, elevated ESR Clinical findings Joint pain, bony tenderness Joint deformity, muscle atrophy, soft and hypertrophy, crepitus, may tissue nodules (rheumatoid nodules), have some deformity; no soft tissue swelling, warmth, redness warmth or redness of joints ANA = antinuclear antibody; ESR = erythrocyte sedimentation rate; DIP = distal interphalangeal; RF = rheumatoid factor MUSCULOSKELETAL DISORDERS 1 1 29 Morning stiffness common; usually lasts less than 30 minutes Joint instability in later stages, especially with osteoarthritis of the knees Perform review of systems for systemic symptoms to exclude other types of arthritis. Physical Exam Usually localized to affected joints Bony hypertrophy of joint, tenderness at joint line; limited ROM Common in hands: proximal interphalangeal (PIP) joint swelling = Bouchard’s nodes; distal interphalangeal (DIP) joint swelling = Heberden’s nodes Coarse crepitus in joint with movement; soft tissue swelling may be present Joint effusion, if present, usually mild Evaluate cardiac and pulmonary status and other body systems as indicated by history to exclude other types of arthritis Diagnostic Studies Plain radiographs: unequal and narrowed joint space, subchondral bony sclerosis, sharp articular margins, cysts or osteophytes Bone densitometry (dual X-ray absorptiometry [DEXA] scans), peripheral ultrasonog- raphy, quantitative computed tomography (QCT) Laboratory findings may be normal or show markers of systemic inflammation or autoimmune disease. Differential Diagnosis Rheumatoid arthritis Psoriatic arthritis Gout, pseudogout Septic arthritis Reiter’s disease, lupus Fibromyalgia 1 13 0 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Tendonitis, soft tissue injury Osteoporosis Multiple myeloma is considered in a differential diagnosis of osteoarthritis. Note that multiple myeloma is now known as plasma cell myeloma. Management Goals are to relieve symptoms, maintain/improve function, and avoid adverse effects of medication. Nonpharmacologic Treatment Physical activity/therapy with supervised walking Occupational therapy Arthritis self-management programs and water aquatics courses Ambulation aids (canes, braces, walkers) Weight-loss of 10% of body weight is associated with 50% reduction in pain scores Refer for orthopedic consultation for surgical management if all other modalities fail and joint symptoms prevent normal activities. (Kolansinski et al., 2020) Pharmacological Treatment Use pharmacologic agents when nonpharmacologic methods do no provide adequate pain relief. Oral and topical nonsteroidal anti-inflammatories (NSAIDs) can be used. Selection of agent may be dependent on the number of joints involved. NSAID use can be limited by the presence of gastrointestinal (GI), renal, and cardiovas- cular symptoms. The risk of GI bleed is reduced with co-administration with a protein pump inhibitor (PPI) Cyclooxygenase 2 (COX-2) inhibitors may decrease risk of GI bleeding. Avoid NSAIDS and aspirin in patients taking anticoagulants and Monitor creatinine for patients taking angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBS) for hypertension. MUSCULOSKELETAL DISORDERS 1 1 31 Duloxetine maybe considered for patients who cannot tolerate NSAIDs. Oral duloxetine: Initial: 30 mg once daily for 1 week, then increase to 60 mg once daily as tolerated; maximum dose: 60 mg/day. Doses to 120 mg/day may increase benefit but are associated with an increase in adverse effects. Topical analgesic creams such as capsaicin 0.025% two to three times a day as needed Diclofenac gel 1% four times a day for knee or hand Narcotic analgesics are rarely indicated. Intra-articular corticosteroid injections for joint effusion and inflammation limited to a few joints Hyaluronic acid injections are considered controversial as have demonstrated only small benefit beyond placebo (Kolansinski et al., 2020) How Long to Treat While symptomatic Special Considerations Presence of radiographic changes does not correlate with presence or severity of symptoms. When to Consult, Refer, Hospitalize Consult with physician or orthopedic specialist for intra-articular corticosteroid or hyaluronic acid injections. Patients with functional impairment (i.e., inability to perform normal activities of daily living) and moderate to severe pain unrelieved by other nonpharmacologic and pharmacologic therapies should be considered for joint replacement; refer to ortho- pedic surgeon. Follow-Up Appointments as needed based on pain and disability If patient is taking NSAIDS, monitor for liver or kidney dysfunction and/or GI bleeding 1 13 2 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Expected Course Chronic, often progressive Complications Joint destruction, chronic pain, limitation of mobility RHEUMATOID ARTHRITIS (RA) Description Chronic, systemic, autoimmune inflammatory disease that affects mainly the synovial joints in a symmetric distribution; small-joint destruction and extra-articular symptoms are prominent. Juvenile idiopathic arthritis (JIA) is an autoimmune disorder with a genetic predisposi- tion; presentation is an interaction of genetic, immune, and environmental factors. Etiology Probably autoimmune but no specific inciting factor yet identified Genetic, environmental factors affect progression and extent of disease Pathology consists of initial changes in the synovium microvasculature, swelling of endothelial cells, and synovial hyperplasia forming a pannus. Inflammatory cells invade and joint symptoms develop secondary to the inflammatory process. Incidence and Demographics Worldwide incidence 0.24% to 1% Global prevalence is estimated as 0.24% In children symptoms are present in first 1 to 3 years; then a second, less-dominant wave in 8- to 10-year-olds with girls predominantly affected. JIA is a diagnosis of exclusion in children younger than 16 years of age who have chronic synovial inflammation of at least one joint for 6 weeks. JIA is categorized: Systemic arthritis: arthritis in one or more joints and fever of 2 weeks’ duration Polyarthritis, RF positive or negative: arthritis in five or more joints MUSCULOSKELETAL DISORDERS 1 1 33 Oligoarthritis, persistent or extended Enthesitis-related arthritis Psoriatic arthritis Undifferentiated arthritis Risk Factors Genetics Family history Age Gender, female to male ratio: 2:1 Lifestyle factors: cigarette smoking Assessment Early diagnosis (within first few months of symptoms) important for improved prognosis Important to exclude septic arthritis; typical presentation: sudden onset of pain, swell- ing, warmth, and redness in one large weight-bearing joint, may have fever History History of joint pain, swelling, location in peripheral joints, morning stiffness lasting more than 30 minutes Duration of symptoms; if fewer than 6 weeks an acute viral polyarthritis may be the cause. Prodromal systemic symptoms: malaise, fever, weight loss Articular inflammation, swelling, pain, erythema, and warmth Involvement usually symmetrical; 75% of joints involved are knees, followed by ankles and elbows. In children, joint pain, one or more joints affected, swelling or effusion, and two of the following: limitation of ROM, tenderness or pain in motion, warmth; usually involves large joints or hands; if systemic: fever, rash Perform review of systems to identify any associated symptoms of systemic involve- ment; physical/emotional stress may trigger 1 13 4 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Physical Exam Edema, erythema, warmth, nodules in any joint; effervescent, pale-pink/salmon- colored macular rash Joints are tender, may feel warm to touch, bright erythema and significant palpable heat in joint usually indicative of infection Subcutaneous nodules over bony prominences or extensor surfaces Soft tissue swelling, vasculitis, palmar erythema As disease progresses, joint deformities become more pronounced and joint instability develops. Systemic manifestations may be seen in the pulmonary, cardiac, hepatic, renal, vascu- lar, and hematologic systems and the eyes (dry mucous membranes, ocular problems, splenomegaly, increased lymphocytes). In children with systemic juvenile rheumatoid arthritis (JRA), may have macular salmon-colored rash, splenomegaly, eye symptoms Diagnostic Studies No single test is adequate to make diagnosis. Rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA): positive result for either increases overall diagnostic sensitivity; specificity increases when both are positive. ESR and serum CRP:—both are typically elevated in RA. Antinuclear antibody (ANA) testing. ANA is positive in one-third of RA cases In children, RF and ANA may be positive. Synovial fluid shows inflammatory changes: sterile leukocytosis, increased polymor- phonuclear cells (PMNs), negative culture. CBC may show anemia and thrombocytosis consistent with inflammation. Obtain plain radiographs of hands, wrists, and feet for baseline monitoring. May show joint erosions in patient’s first presentation. (Fraekel et al., 2021) Differential Diagnosis Systemic lupus erythematosus (SLE) Seronegative spondyloarthropathy MUSCULOSKELETAL DISORDERS 1135 Psoriatic arthritis Septic arthritis Lyme disease Gout Osteoarthritis Lupus Management Goals are early diagnosis Care by an expert in rheumatic disease Shared decision making Early use of disease-modifying antirheumatic drugs (DMARDs) to limit disease activity Prevent irreversible joint damage, maximize mobility, limit pain. Nonpharmacologic Treatment Patient education regarding RA Rest, exercise, physical and occupational therapy Assistive devices (canes, splints) Refer to orthopedic surgeon for evaluation as needed for joint deformity. Pharmacologic Treatment Methotrexate is a conventional DMARD recommended as first-line monotherapy for patients with moderate to high disease activity who have not been treated previously with a DMARD. Monitor closely for bone marrow, pulmonary, hepatic, and renal toxicity. Administer folic acid to reduce adverse effects. Switch to subcutaneous methotrexate for patients who are not achieving target goals with oral monotherapy. Hydroxychloroquine (DMARD) is recommended for patients with mild symptoms. Monitor eye symptoms, neuropathy, and myopathy. 1 13 6 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Methotrexate + tumor necrosis factor (TNF) may be used if patient fails to response to methotrexate monotherapy. Methotrexate + biologic may be used if patient fails to respond to a monotherapy or methotrexate + TNF. Leflunomide (Arava), etanercept (Enbrel), and infliximab (Remicade) may cause hypersensitivity reaction, severe infections or sepsis, and autoimmunity (lupus-type syndrome). More costly and complicated to administer. Corticosteroids: recommend against long-term use; switch to DMARD (Fraekel et al., 2021). How Long to Treat Medications may be tapered if disease management activity goal is achieved and maintained for 6 months. In children, some have periods of long remissions. Special Considerations Women being treated with DMARDs require preconceptual counseling Pause treatment with methotrexate, hydroxychloroquine before conception to prevent fetal injury Pregnancy may result in remission and may allow temporary discontinuation of medications Exacerbations are common in first 6 months postpartum. Breastfeeding is not advised because antirheumatic medications are secreted in breast milk. When to Consult, Refer, Hospitalize Rheumatologic consultation or referral is appropriate (Fraekel et al., 2021) All children should be referred to a pediatric rheumatologist and ophthalmologist at diagnosis. MUSCULOSKELETAL DISORDERS 1 1 37 Follow-Up Clinical course is highly variable; until symptoms are controlled, frequent follow-up visits are indicated; then regular evaluations at 3- to 6-month intervals. Complications May be severe, including carpal tunnel syndrome, pleuritis, pericarditis, vasculitis, iridocyclitis, disability, and adverse reactions from drugs, severe joint deformity, hip disease. GOUT Description A group of metabolic diseases producing inflammatory arthritis of peripheral joints caused by deposition of uric acid or monosodium urate crystals in extracellu- lar fluid. Etiology Inborn error of purine metabolism or uric acid excretion causing hyperuricemia and uric acid crystal deposition in the joint (acute gouty arthritis) May be primary (hereditary) or secondary (due to other conditions that cause underex- cretion or overproduction of uric acid) Overproduction: high intake of purine-rich foods (organ meats, shellfish, peas, lentils, beans), polycythemia vera, leukemia, multiple myeloma, hemolytic anemia, psoriasis, sarcoidosis Underexcretion of uric acid: reduced renal function, lactic acidosis, ketoacidosis, dehydration Secondary gout also associated with obesity, starvation, lead intoxication, ingestion of drugs (salicylates, diuretics, pyrazinamide, ethambutol, nicotinic acid) Combined overproduction/underexcretion: alcohol abuse, glucose-6-phosphatase deficiency (G-6PD), hypoxemia 1 13 8 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Incidence and Demographics Men affected nine times as often as women Rarely affects men before adolescence or women before menopause Peak incidence for men is fourth to fifth decades and women is sixth to seventh decades of life Prevalence: three to eight million Americans affected Approximately 3% of the adult American population is affected. Risk Factors Primary gout: Inherited Secondary gout: Acquired Certain medications increase the risk for gout including diuretics, low-dose aspirin, cyclosporine, and niacin. Urate-lowering therapy may incite a flare, particularly during the early phase of treatment. Hospitalization and surgery increase risk of gout flares. Illnesses such as plasma cell myeloma, chronic kidney disease, and hypothyroidism increase the risk of gout. Heredity Physiologic factors—obesity, dehydration, starvation Alcohol consumption and purine-rich diet Prevention and Screening Correct/control underlying problem. Avoid foods high in purines, alcohol, and causative medications. Maintain normal body weight. MUSCULOSKELETAL DISORDERS 1139 Assessment History Sudden attack of red, hot, swollen, exquisitely tender joint is common (first metatarsal phalangeal [MTP] joint very susceptible: podagra); feeling of malaise, fever; often no apparent cause Foot, ankle, knee, and shoulder are the most common sites; wrist, elbow, fingers also may be affected. Physical Exam During acute attack, joint is red, hot, swollen, exquisitely painful; low-grade fever Skin desquamation and pruritus during resolution of acute attack commonly seen Tophi (sodium urate crystals deposited in soft tissue) present in chronic tophaceous gout, usually after 2 to 10 years from onset of acute intermittent gout Joint swelling, restricted range of movement caused by chronic arthritis Diagnostic Studies Joint aspiration: Fluid shows presence of needle-shaped crystals (negatively birefrin- gent) on polarized light microscopy. Serum uric acid above 6.8 mg/dL supports diagnosis but is not specific; elevated ESR, elevated leukocytes X-ray: normal in early disease; shows punched-out lesions in subchondral bone, usually first seen in first MTP joint (“Mickey Mouse” ears); soft tissue tophi may be seen if at least 5 mm in diameter Ultrasound can support diagnosis. Dual-energy computed tomography (DECT) can specifically identify urate deposits. Differential Diagnosis Septic arthritis Trauma/stress fracture Cellulitis 1 140 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Rheumatoid arthritis Acute rheumatic fever Pyogenic arthritis Management Nonpharmacologic Treatment Dietary modification; increased fluid intake 3 liters or more per day Assistive devices if needed during acute phase Weight loss in obese patients Pharmacologic Treatment Acute Attack First-line for gout flares: oral steroids, NSAIDs, and colchicine are equivalent first-line choices. Corticosteroids, use with caution and depend on comorbidities, prednisone 20–40 mg orally once a day for 2 to 3 days, then taper over 10 to 14 days; intra- articular methylprednisolone (Depo-Medrol) one 20- to 40-mg dose; IM methyl- prednisolone, one 80- to 120-mg dose NSAIDs such as naproxen at full anti-inflammatory dose; naproxen 500 mg twice a day orally for first 2 to 3 days (until symptoms subside); then taper to cessation over 3 to 5 days. Indomethacin 50 mg orally three times a day in persons under 60 years old with neither renal nor cardiovascular comorbidities Colchicine—day 1 not to exceed 1.8 mg, 1.2 mg orally as soon as symptoms appear, then 0.06 mg 1 hour later, then continue 0.6 mg once or twice daily until flare resolves Contraindicated with renal or hepatic impairment Use colchicine therapy for patients on anticoagulation therapy Intraarticular glucocorticoids: option for those unable to take oral medications Parenteral glucocorticoids: option for those unable to take oral options and intraar- ticular glucocorticoids (FitzGerald et al., 2020) MUSCULOSKELETAL DISORDERS 1 1 41 Tophaceous gout, those with evidence of gouty joint damage on imaging, those with frequent flares, or chronic kidney disease: First-line urate-lowering therapy (ULT; allopurinol less than 100 mg/day) In patients with chronic kidney disease (stage ≥3), allopurinol or febuxostat are recommended Treat with ULT for 3–6 months Concomitant treatment with anti-inflammatory therapy is recommended when using ULT (Fitzgerald et al., 2020). Maintenance Manage lifestyle factors. Limit alcohol intake. Limit purine intake. Limit high fructose corn syrup intake. Weight loss program for those who are overweight/obese Manage concurrent medications. Switch antihypertensive from hydrochlorothiazide when possible Chose losartan for hypertension management in patients with gout when feasible (Fitzgerald et al., 2020). How Long to Treat Acute symptoms treated until flare resolves ULT is recommended at least 3–6 months, maybe indefinitely (Fitzgerald et al., 2020). Special Considerations Transplant patients treated with cyclosporine have increased incidence. Geriatric patients: NSAIDs less well-tolerated; dosages should be reduced. When to Consult, Refer, Hospitalize Consult for any complicated presentation, underlying metabolic pathology Refer for joint aspiration, unclear diagnosis, new/acute gout in transplant patient 1 142 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Follow-Up Expected Course Decrease in frequency, severity of attacks with appropriate treatment Complications Kidney stones, renal obstruction or infection; joint destruction if undertreated Conditions of the Bones OSTEOMYELITIS Description Inflammatory process of bone due to infection; can be acute or chronic Diagnosis is clinical with support of imaging and laboratory studies (Bury et al., 2021) Etiology Bacteremia with acute or subacute hematogenous spread to bone (most common form in pediatrics) Direct bacterial inoculation through trauma, contact with infected tissue (most com- mon in adults) Predominant organism is Staphylococcus aureus. Most common cause is contact with infected tissue, direct inoculation through trauma, and skin breakdown in vascular insufficiency. Methicillin-sensitive Staphylococcus aureus is most frequently found cause in all types of osteomyelitis (Bury et al., 2021). Followed by Pseudomonas aeruginosa and Methicillin-resistant S. aureus (Bury et al., 2021) MUSCULOSKELETAL DISORDERS 1 1 43 Incidence and Demographics Occurs in all ages, more common in children younger than 5 years of age More cases in men and boys than women and girls; cases increase with age. 90 per 100,000 cases in adults and 10–15 cases per 100,000 children Femur and tibia are most often infected, followed by humerus, calcaneus, and pelvis Risk Factors Chronic disease such as cancer, diabetes, hemodialysis; sickle-cell disease Smoking Peripheral vascular disease Intravenous drug use Prevention and Screening Careful treatment of comorbid conditions; appropriate wound care Assessment History 75% report recent trauma; 25% report recent respiratory tract infection. Sudden onset of high fever and pain in affected bone or joint; sudden refusal to bear weight or move extremity; localized warmth, swelling May have drainage from affected area (sinus tract develops). Physical Exam Swelling, erythema, possible abscess formation or purulent drainage; decreased ROM; fever; point tenderness over infected bone or site of surgical hardware 1 144 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Diagnostic Studies Imaging—plain film radiograph, magnetic resonance imaging (MRI), or bone scan demonstrating soft tissue infection or bony destruction, or both Laboratory studies—elevated CRP and ESR, leukocytosis, thrombocytosis, and positive blood cultures Note: bone biopsy with bacterial culture for definitive diagnosis (Bury et al., 2021) Differential Diagnosis Soft tissue infection, cellulitis Gout Charcot arthropathy Sickle cell vaso-occlusive pain crisis Synovitis Malignancy Fracture Management Nonpharmacologic Treatment Surgical debridement, splinting, local wound care, bed rest Pharmacologic Treatment Intravenous antibiotics are the mainstay of treatment; choice depends on infectious organism Delaying antibiotics until cultures are available is recommended except in patients in need of urgent intervention (Bury et al., 2021) How Long to Treat Antibiotic therapy for 4 to 6 weeks, targeted to specific organism Evidence suggests oral antibiotics having similar cure rates with fewer risks compared to intravenous antibiotics (Bury et al., 2021) MUSCULOSKELETAL DISORDERS 1 1 45 Special Considerations Culture of draining sinus tract or superficial wound does not correlate with actual infectious organism. Bone biopsy should be obtained before starting antibiotics. Children, patients with prosthetic joints, and persons with diabetes require specialty care (Bury et al., 2021), When to Consult, Refer, Hospitalize Orthopedics referral is necessary immediately. Consult infectious disease specialist for choice of antibiotic. Hospitalization as indicated for intravenous therapy or surgical management Follow-Up Diagnosis and treatment plan developed by orthopedic specialist Expected Course Clinical improvement should be seen within 24 to 48 hours, then gradual resolution of drainage, pain, white blood cell (WBC) count, ESR, and fever. Complications Chronic osteomyelitis, need for bone and/or skin grafting, structural weakening of bone DEVELOPMENTAL DYSPLASIA OF THE HIP Description Developmental dysplasia of the hip (DDH) is a broad category of anatomic abnormali- ties in which the femoral head and the acetabulum are not in alignment and grow abnormally. It develops in infancy or childhood and may be present for many years before diagnosis. 1 146 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Dislocation: a loss of contact between the femoral head and acetabulum Dislocatable hip: a hip with instability where the femoral head is reduced at rest, but can dislocate in other positions or with maneuvers Subluxation: the femoral head is partially outside the acetabulum but there still remains contact Subluxatable hip: a hip with mild instability or laxity where the head of femur slides in and out of the acetabulum Dysplasia: abnormality of the shape of the joint with a shallow acetabulum Reducible: the hip is dislocated at rest, but the femoral head can be manipulated into the acetabulum with flexion and abduction. Etiology Multifactorial (mechanical, physiologic, environmental, genetic) Mechanical: breech presentation, positioning of fetal hip against mother’s sacrum; tight maternal abdomen and uterine musculature; first-born Mechanical factors such as compression in utero if fetal position or oligohydram- nios restricts movement in utero Physiologic: ligamentous laxity due to estrogen exposure; collagen disorders Maternal hormones during pregnancy may cause temporary laxity of the hip joints. Environmental: swaddling of infant with legs in extension/adduction Prevalence higher in cultures that swaddle infants for extended periods or place them on cradleboards Genetic: 20% have positive family history. Incidence and Demographics Severe dysplasia in 3 to 5 per 1,000 births in the United States 1 to 2 per 1,000 births have DDH with dislocation Women more affected than men Risk Factors First-born, female, breech in third trimester Populations who use swaddling may limit hip mobility, which may play a role in DDH MUSCULOSKELETAL DISORDERS 1 1 47 Positive family history Torticollis, or lower limb disorders such as club foot Prevention, Screening, Physical Examination Avoid swaddling with legs in extension and adduction. Check hips at birth, 2-week, 2-month, and 4-months well baby exams. Routine screening up to 2 years old: Barlow and Ortolani tests in infants up to 2 or 3 months old Klisic and Galeazzi tests for older infants Chart screening at every visit 80% of abnormal hips resolve by 2 to 8 weeks. Asymmetry of the inguinal or gluteal folds is a sign. In children 6–18 months old, there is limited abduction and shortening of the thigh of the affected hip. Short leg with toe walking on the affected side Assessment History Prenatal and birth history Positive family history Physical Exam Limited abduction of hip; hip instability; asymmetry of thigh folds; femoral shortening on affected side Unequal leg lengths; unequal knee heights when supine (Galeazzi sign); limp or “duck-like” waddle Diagnostic Studies Provocation tests: click (hip relocation) felt with Ortolani maneuver; clunk felt (hip dislocation) with Barlow maneuver 1 148 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Ultrasound, which is done after 4 weeks of age to prevent false positives, is superior to radiographs. Radiographs may be used after 4 months of age when proximal epiphysis ossifies. (Yang et al., 2019) Differential Diagnosis Unstable hip in newborn period Management Goal is to prevent long-term complications and pathologic changes through early diagnosis and treatment in infancy. Prompt referral to an orthopedist Pavlik harness, worn 24 hours per day, is the treatment of choice with success rate of 80%–97%. Weekly follow-ups needed. Proper skin care while wearing harness. Surgery recommended if harness treatment is unsuccessful. Nonpharmacologic Treatment Birth up to 6 months: Pavlik harness 6 to 18 months: Pavlik harness, closed reduction with cast Older than 18 months: open reduction with casting (Yang et al., 2019) How Long to Treat Until corrected Special Considerations About 60% of unstable hips in newborns spontaneously become normal in the first 2 to 4 weeks of life. MUSCULOSKELETAL DISORDERS 1 1 49 When to Consult, Refer, Hospitalize Infants or children older than 1 year with findings suggestive of DDH should be referred to a pediatric orthopedic surgeon. Follow-Up Orthopedic specialist Recurrent DDH may occur after treatment so children will require imaging regularly until they are skeletally mature. Expected Course Most cases respond to treatment. Earlier treatment results in better outcomes. Complications Untreated cases result in permanent dislocation. Osteoarthritis, pain, abnormal gait, decreased agility Even with treatment, avascular necrosis of the femoral head may occur. SCOLIOSIS Description Lateral curvature of the spine with rotation of spinal column Adolescent idiopathic scoliosis (AIS) is most common type. Adult scoliosis is associated with degenerative changes. Etiology Unclear etiology for AIS Genetic component Familial AIS 1 15 0 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 2 Incidence and Demographics 2%–3% of the population Estimated 6–9 million U.S. population (American Association of Neurological Surgeons [AANS], 2022) Risk Factors Female gender Women and girls are eight times more likely than men and boys to progress to curva- ture requiring treatment. Family history Prevention and Screening Screen during routine school age and adolescent physical exams with back fully exposed and no shoes. Observe for asymmetry of shoulders, scapulae, and pelvis. Assessment History Asymmetry of shoulder and or hip height; shirts or hemlines may be uneven Positive family history Complaints of pain Physical Exam Screening done with back fully exposed and without shoes Observe for asymmetry of shoulders, scapulae, and hip/pelvis. Check for leg-length discrepancy, which may be present. Have patient bend forward at waist to 90° and slowly return to upright (Adams test). MUSCULOSKELETAL DISORDERS 1 1 51 Assess for prominence of scapula or lateralization of spine. 90% thoracic with right curve; left thoracic curve more likely to progress. Diagnostic Studies Routine X-rays are not required for mild scoliosis. More-severe cases require X-ray of entire length of spine (Cobb method). X-ray determines location and direction of curvature, measures degree of asymmetry, and evaluates vertebral bodies; view entire spine from C7 to S1. Repeat X-rays to monitor progression of curve. Consider bone age. Scoliometer may be helpful to detect and follow smaller curves Genetic testing—The ScoliScore screens for 50 genetic markers that predict wors- ening curves. Differential Diagnoses Neuromuscular scoliosis Congenital scoliosis Syndromic scoliosis Management Goal is to prevent further deformity. Use Cobb method for evaluating degree of curvature; follow every 4 to 6 months in children

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