Musculoskeletal Assessment/Diagnostics PDF

Musculoskeletal Assessment / Diagnostics Subjective: Objective - Pain - Posture OLDCARTS Obvious curving of spine Bone...

Musculoskeletal Assessment / Diagnostics Subjective: Objective - Pain - Posture OLDCARTS Obvious curving of spine Bone pain: deep aching, dullness Symmetry - Muscle tone: Muscular pain: sore, achy Flaccid Fracture pain: sharp, piercing Spastic Joint pain: around the area, worse w/ - Muscle size: movement Hypertrophy Timeline: Atrophy - Worse in AM? Maybe - Gait inflam pain Have client walk short distance Smooth, Limping, Spastic, Shuffling - Pain that steadily increases: - Joint function infection, tumor Obvious deformity Rest improves most musculoskeletal pain with movement pain Nodules - Altered sensation: paresthesia- numbness, smooth movement burning, tingling ROM Cx by pressure on nerve or - Muscle strength Grade strength of movement in each circulatory issue extremity Timeline? - Bone integrity/Neurovascular check OLDCARTS Color - Social Hx capillary refill Occupation, ETHO, Tobacco, Edema exercise, Pulses diet: calcium, vit D Movement warm/cool - PMH comparison to other extremity Hx of trauma Med hx- rheumatic disease? - FMH: Genetic conditions? Grading muscle strength: Most common scale is the Oxford Rating Scale Score of 0-5 Score 0 = no movement Score 5 = normal movement both against gravity and resistance - Assess against gravity and then add resistance Diagnostics test includes: 1: X-ray: - common, quick way to identify MSK issues 2: CT scan: - Better for soft tissue, ligament, or tendon issues - Detect fracture not found on x-ray - Can use contract- allergies & fluid 3: MRI: - 60-90 min - More thorough picture - No metal 4: Bone density/DEXA: - Use of x-ray to detect osteoporosis - Bone density will vary based on skeletal areas - DXA measures BMD and predicts fracture risk through accurate monitoring of bone density changes in patients with osteoporosis 5: Bone Scan - Nuclear med tests - Inject radioisotope- iv & 2-3 hrs later do scan - Areas w/ high intake of isotope indicate problem: CA, infection, fractures - A bone scan is performed to detect metastatic and primary bone tumors, osteomyelitis, some fractures, and aseptic necrosis, and to monitor the progression of degenerative bone diseases 6: Arthrography - Inject contrast or air into the joint cavity - Move joint to distribute contrast - If contrast leaks, tear is likely present - Unexplained joint pain and progression of joint disease 7: Arthrocentesis - Aspiration of joint fluids (septic joint, effusion, blood) - Nml synovial fluid is clear, pale, straw colored, and scant - Can give steroid injection 8: Arthroscopy - Insertion of scope in the joint for direct visualization - Use of a fiberoptic endoscope. - compression dressing - Joint extended and elevated to reduce swelling 9: Electromyography - Evaluate muscle weakness & pain - Electrodes inserted into muscle to record response - Can differentiate b/w muscle & nerve issues 10: Biopsy - Bone marrow bone, muscle, synovial fluid - structure and composition - involves excising a sample of tissue - site is monitored for edema, bleeding, pain, hematoma formation, and infection 11: Labs - Infectious markers - Inflammatory markers - calcium/parathyroid fx - Phosphorus - Vit D Management and Care Modalities MSK Disorders 1) Lower Back Pain - This is the 2nd common chief complaint at primary care provider - Common causes: muscle strain, weak muscles, disk degeneration or other disc abnormality - Contributing factors: obesity, stress, poor posture - Aggravated by activity - CM: Decreased ROM, abnml gait, radiculopathy, decreased motor strength, decreased sensation, muscle spasm, loss of nml lumbar curve - Assessment: Pain Stress, emotional well being Gait, posture Spine curvature Palpate for tenderness & spasm Reflexes Sensation, muscle strength Effects on ADL - Diagnostic: X-ray- fracture, dislocation, infection, osteoarthritis, scoliosis Bone scan & blood studies- infections, tumors, bone marrow abnormalities CT- obscure soft tissues lesions adjacent to the vertebral column & problems of vertebral disks MRI- visualization of nature & location of spinal pathology Electromyogram & nerve conduction studies- spine root disorders (radiculopathies) Myelogram- visualization of segments of spinal cord that may have herniated or may be compressed - done when MRI scan is contraindicated Ultrasound: detecting tears in ligaments, muscles, tendons, & soft tissues in the back - Medical & nursing mgt: Avoid strain: no twisting, bending, lifting, reaching Thermal application: hot and cold Spinal manipulation (chiropractor) Frequent position changes Cognitive therapy Analgesic: NSAIDS, opioids (if acute and severe) Exercise regimens Muscle relaxers: Cyclobenzaprine (Flexeril) Physical therapy Weight loss Encourage good body mechanics and posture Acupuncture,Yoga, Massage Chronic:  - Tricyclic antidepressants: amitriptyline (Elavil) - SSRI: duloxetine (Cymbalta) - Seizure medications: Gabapentin (Neurontin) - Prevention 2) Ankylosing Spondylitis - Chronic inflammatory disease of the spine - More prevalent in males 20-30’s - Have: Rigidity, decreased mobility, kyphosis; Severe back pain - Systemic effects: uveitis, osteoporosis, pulmonary fibrosis, aortic insufficiency, cardiac conduction abnormalities Uveitis: eye disease that causes inflammation of the uvea, the middle layer of the eye - Treatment: NSAIDS, corticosteroids, DMARDS, maintain mobility Bone Disorders 1) Osteoporosis - Osteopenia: a little bone loss - Osteoporosis: a lot bone loss - Primary: post-menopausal - Secondary: caused by disease or drugs Risk of fracture is 40-50% in women and 13-22% in men Increased health care cost, morbidity and mortality - DEXA scan for screening women age 65 and men age 70, earlier screening if increased risk factors. - Risk factors: Sedentary Lifestyle Age Diet: alcohol, caffeine, low CA, low Vit. D Smoking Post-Menopausal Small bone structure Genetics: Caucasian and Asian females Immobility Medications: corticosteroids, phenytoin, Synthroid, SSRIs, PPIs Comorbidities: malabsorption GI disorders - CF & Dx: Silent disease Loss of height Dowager hump- kyphosis - Tx: Calcium and Vitamin D supplementation: w/ meals, divided dose for optimal absorption Bisphosphonates: First Line treatment.  - Taken early in the morning, 30 minutes prior to eating or drinking, must sit up for 30 minutes after ingestion. Estrogen agonist/ antagonists: Raloxifene RANKL inhibitor: Denosumab Weight bearing exercise - Nursing interventions: Encourage: diet in CA & vit D Encourage regular weight bearing exercise Pain relief Assessment & teaching regarding in fall risk & prevention Limit excess caffeine, alcohol Reinforce exposure to sunlight - Patient teaching: Bisphosphonates-alendronate: Foramax - Take 30 min prior to eating, drink 8oz of water, - Avoid lying down immediately after taking - Adverse effects: ulceration, GI, musculoskeletal pain, osteonecrosis of the jaw 2) Paget Disease - Second most common bone disease - Local areas of excessive bone resorption and disorganized bone repair - Most common: skull, pelvis, spine, & legs - Middle age adults- seniors - Pathology Osteoclastic bone resorption Increase osteoblasts and chaotic bone formation (mosaic pattern) Poor quality of newly formed bones - CM: Variable, may be asymptomatic Skeletal expansion: distortion skull, jaw, clavicle, long bones Headaches, tinnitus, vertigo, hearing loss Kyphosis Bowing of femur and tibia Pain - worse with weight bearing Increased vasculature at the sites-increased risk of sarcoma - Dx & tx: Dx based on deformities noted on x-ray, increased levels of alkaline phosphatase and urinary hydroxyproline Bone scans or biopsy Treatment: antiosteoclastic therapy, pain control, weight control, fall preventions, hearing loss, adequate Vit D and calcium Bisphosphonates – cornerstone of therapy 3) Osteomyelitis - Infection of bone  - Direct contamination: MRSA Open fracture, wounds, surgery Contamination from skin lesions in individuals with diabetes and vascular insufficiency common - Dx: MRI & X-ray ↑ WBC & ESR - Tx: LT IV abx Surgical debridement, removal of foreign object: an infected prosthesis or at times amputation Bone impermeable to the cells of the body’s defenses Circulation is vulnerable to damage Slow replacement of old bone with new bone - NI: Pain relief - Analgesics as prescribed - Elevation of extremity Improving physical mobility - Activity may be limited - Encourage participation in ADL Controlling infectious process - Monitor for signs of worsening infection or necrosis - Administer antibiotics - Aseptic technique - Monitor circulation Patient education Joint Disorders 1) Rheumatoid arthritis - Systemic Inflammatory Autoimmune Disease - More common in women - Synovial inflammation and eventually joint destruction - Irreversible Damage - Periods of exacerbation and remission - RA Manifestations: Usually begins in the small joints of the hand, but all joints may be involved. Swelling of the joint, warmth Morning stiffness which improves with activity As the disease progresses there's decreased range of motion, instability, joint effusion, partial dislocations, deformities, muscle atrophy and ligament and tendon involvement may occur - Clinical manifestations: Ulnar drift  Swan neck deformity - DX findings: Elevated SED rate Elevated CRP Positive Rheumatoid Factors X-rays show narrowed joint spaces Anemia - Tx: Goal: manage symptoms, control inflammation, modify disease if possible DMARDs—Disease modifying antirheumatic drugs - Suppress immune response and can stop disease progression - Can be biologic (engineered to target specific cell) or - nonbiologic (reduce cytokines) Salicylates NSAIDS Corticosteroids Heat therapy-relieve pain, stiffness, and spasms Mobility assistive devices Exercise as able to maintain joint function—pool exercise - Methotrexate: trexall, otrexup, rasuvo Used to treat RA & SLE DMARD—disease modifying anti-rheumatic drug Decreases joint damage and improves symptoms PO or SQ; given with folic acid to reduce adverse effects (GI upset) Causes immunosuppression—take precaution to prevent infection Can cause liver failure Do NOT drink alcohol Routine lab checks of liver function Teratogenic - Can cause birth abnormalities, stops cell growth, used for ectopic pregnancy - Must teach contraception/safe sex practices - Recommended to be off methotrexate for at least three months before trying to conceive - Rituximab Given with combination of medications (usually methotrexate) Used to treat autoimmune and inflammatory diseases and blood cancers Given as IV infusion Monoclonal antibody (biologic) Infusion related reactions: Hypotension, itching, angioedema Counseling to avoid pregnancy 2) Osteoarthritis - Noninflammatory, degenerative disorder of joints - Damage to the cartilage resulting in cracks, leakage of synovial fluid and bone spurs - Joint space narrowing and decreased shock absorption - CM: Pain and stiffness, usually in weight bearing joints Swelling, tenderness Worse with use- relief with rest Effusions Crepitus/grinding Hips/knees/lumbar and cervical vertebrae Limited ROM Diagnosis: physical exam and ruling out other causes - Med mgt: Weight loss Aerobic exercise Lower extremity weight bearing exercise Insoles, braces, other modalities Alternative Therapy: massage, yoga, music, herbals, dietary supplements, acupuncture, acupressure, copper bracelets, Tai chi, heat, cold Tylenol, NSAIDS, opioids Intra-articular corticosteroids Topical analgesics such as Capsaicin Glucosamine and chondroitin Surgical intervention: arthroplasty TENS: transcutaneous electrical nerve stimulation - Nursing mgt: Education Referral to exercise program or physical therapy Pain management Assessment for appropriate assistive devices Encourage maximal functionality 3) Gout - Increased serum uric acid → crystalize in joint→ Tophi deposits of monosodium urate crystals - Often a sudden onset - Usually involves only 1 joint - Warm, red, swollen, PAIN - Large toe joint = most common - May also occur ankles, heels, knees, wrist, and elbows - Mgt for acute attack: NSAIDS Colchicine Steroids - Mgt for chronic mgt:  Avoid foods high in purine: Alcohol, Organ meat (liver, kidney, sardines, salmon), Fructose sweetened beverages Avoidance of medications that may inhibit the excretion of uric acid (ex: diuretics) Stay well hydrated Control stress levels Maintain healthy weight Active lifestyle Medications to lower uric acid levels: Allopurinol (Zyloprim) - Medications 1) Allopurinol: for CHRONIC - Chronic gout - Decreases uric acid by inhibiting the action of an enzyme involved in the conversion to uric acid - Oral or IV - Few adverse reactions, monitor liver function - Take after meals 2) Colchicine: For ACUTE - Acute attacks - Oral or IV - Anti-inflammatory - Most common adverse reaction → GI upset 4) Septic arthritis - Infection in a joint - Usually single joint affected - spread of pathogens from other body parts or from trauma or surgical intervention - Diagnostics: MRI, elevated WBC - Management Broad spectrum antibiotic Possible aspiration with culture and sensitivity Monitor for sepsis Immobilization of inflamed joint followed by progressive ROM exercises and physical therapy if needed Occasional arthroscopy required to remove excess fluid and dead tissue Hands and Feet Disorders 1) Carpal Tunnel Syndrome - Entrapment neuropathy - Median nerve in wrist compressed by flexor tendon sheath, edema, or mass - Risk factors: Women Menopause estrogen or birth control pills RA  Diabetes Acromegaly Hyperthyroidism occupational risks - Cause: repetitive hand/wrist tunnel-syndrome/movement, trauma/injury - CM: pain, numbness, paresthesia, weakness in hand, night pain, fist clenching when waking + Tinel sign and + Phalen test - Treatment: corticosteroids, NSAIDs, acupuncture, electrical stimulation, splints, surgery - Long term risks: Tendon rupture 2) Ganglion Cyst - Collection of gelatinous material near tendon - Round, firm, cystic - Common on dorsum of wrist - Tender to palpation, aching pain - Treatment: aspiration, corticosteroid injection, surgical excision - Commonly recur after removal 3) Hammer Toe - Flexion deformity of toe(s) - Toe is usually pulled upward and ball of foot downward - Treatment: No restrictive shoes or socks, open box shoes, OTC pads and devices, surgery if severe 4) Hallux Valgus - Bunion - Deformity of great toe : deviates laterally - Common to get bursitis of great toe joint - Risk factors: genetics, OA, older age - Treatment: non-restrictive shoes, corticosteroid injection, surgery if severe 5) Plantar Fasciitis - Inflammation of fascia of foot - CM: pain in heel, worse first in morning or after periods of rest - Treatment: stretching, orthotic shoes or inserts, corticosteroid injection, no bare feet even indoors - Long term risks: fascial tears lead to heel spurs Post-op Management - Pain control - Neurovascular checks - Ice packs and elevation - Keep dressings dry - Pin care if indicated - Occupational and Physical therapy - Appropriate assistive devices - weight bearing status? MSK Trauma 1) Soft tissue trauma - Contusion = injury to soft tissue - Strain = injury to muscle or tendon from overuse: Muscle strain - Sprain = injury to ligaments and tendons around a joint: Caused by twisting of joint - RICE method: Rest, ice, compression, elevation - NSAIDS - Neurovascular status - May need immobilization and mobility assistive devices 2) Joint dislocation - Joint no longer in anatomic alignment - Subluxation = similar to dislocation but only partial/incomplete - Considered emergency as blood supply and nerves are displaced - CM: pain, change in positioning, decrease ROM - Diagnosis: x-ray - Immobilized on scene as able - Frequent neurovascular checks - Closed reduction: Moderate sedation & Joint realigned - Medical Management Reduction with dislocation with the aid of analgesics, muscle relaxants, and possibly conscious sedation Application of sling or splint following reduction to stabilize joint - Nursing Management: Frequent neurovascular assessment Pain management Nurses’ role in conscious sedation EKG monitor Administration of medication Frequent vital signs, LOC, O2 saturation, Cardiac and respiratory function Nurse presence throughout procedure and recovery period 3) Shoulders - Clavicle Fractures: treated with sling, rest, and pain management. *Sometimes surgery is warranted. - Rotator Cuff Injuries Rip in a tendon connecting rotator muscles to humeral head Risk factors: repetitive overhead motions, connective tissue disorder, aging, frequent shoulder dislocations NSAIDS CM: Decreased ROM, pain worsens with use Dx: MRI, x-rays, most accurate = arthroscopic Treatment: NSAIDS, restriction of activities, PT, corticosteroid injections, surgery if medical treatment fails  4) Knee injury - Ligament Injury (lateral, medial, cruciate) PRICE Hemarthrosis (bleeding in joint) Needs to be aspirated to lower pressure in joint-Arthrocentesis Non-weight bearing (slow progression to weight bearing) 8-12 week healing time Severe = surgical intervention Education = use of assistive devices, wound care, ice therapy, watch for complications (skin breakdown, infection, thrombi) ACL/PCL-may hear “pop” in joint - Meniscal Injury Prevent full extension of the knee due to loose cartilage in the joint May feel/hear “click” in knee Dx: MRI Treatment: NSAIDS, rest, immobilization, analgesics Arthroscopic surgery Non-weight bearing 4-6 weeks, then full weight bearing in knee brace 5) Fractures: *stress > ability to absorb - Closed fracture = simple fracture, no break in skin ➔ Closed Fracture ➔ Manage pain ➔ Manage edema ➔ Education—use crutches ➔ Can take up to 8 weeks or more to heal - Open fracture = compound, bone pierces skin ➔ Risks—osteomyelitis, tetanus, gangrene ➔ Tetanus shot if needed ➔ Wound irrigation and debridement ➔ Common to use wound vac Risk for osteomyelitis Type I: clean wound < 1 cm Type II: larger wound w/o a lot of soft tissue damage Type III: most severe, contaminated with extensive soft tissue damage - CM: pain, loss of function, deformity, shortening, crepitus, edema - Closed vs open reduction - Immobilization after reduction Casts Immobilize the area Plaster or fiberglass Fiberglass – more $, weigh less, water resistant Watch for pressure areas when putting on cast  Location is name of cast Short-arm: below elbow to palmar crease Long-arm: axillary fold to palmar crease Hip spica: trunk and one lower extremity Double hip spica: trunk, lower extremity, and both lower extremities Splints & Braces Splints used for stable fractures, sprains, soft tissue injury Splints - less chance of compartment syndrome Braces utilized for longer periods of time Braces used for deformity correction or support Nursing care Skin and neurovascular assessment prior to application Document edema, ecchymosis, skin integrity Consider Tetanus booster Care for open wounds Educate on care and when to call Provider (increased pain, increased swelling, loss of sensation, discoloration outside of area, purulent drainage, increased odor) Educate on expectations of process Complications & Care Monitor for compartment syndrome – the MOST SERIOUS COMPLICATION of casting/splinting Blood flow and tissue profusion interrupted Results in ischemia Control swelling of immobilized area Upper extremity: elevate above heart, each joint higher than next (elbow higher than shoulder), move extremities Lower extremity: level of the heart, move extremities Spica – superior mesenteric artery syndrome: GI motility decreases, gas increases, distention starts. Distention can cause ischemia from compression. External fixator Pins through skin and soft tissue and through bone Metal frame attached to pins to maintain alignment Better able to care for soft tissue damage Nursing Care Watch pin entry areas for signs of infection (can lead to osteomyelitis) Watch for compartment syndrome Neuro checks Q2-4hrs post-placement Assess pin site Q8-12 hrs for infection Serous drainage, skin warmth, mild redness expected only for first 48-72 hours Traction Usually until fixation can be used Countertraction must be used  Skeletal traction is never interrupted Weights are not removed unless prescribed Ropes and weights must be free Types of traction Skin: Buck's Skeletal Manual Nursing Interventions Skin Traction - Skin integrity/skin breakdown - Nerve damage - Circulatory impairment: 15-30 min assessments, then 1-2 hours Skeletal Traction - Positioning steady - Skin integrity/skin breakdown - Pin site skin care - Nerve damage - Circulatory impairment General Complications from Immobility Pneumonia Constipation DVT Urinary stasis/infection Pressure Injuries Surgeries (examples) ORIF (open reduction, internal fixation) Joint replacement Total knee Total hip arthroplasty Nursing Care DVT prophylaxis Infection prevention Pain management Gerontological consideration Prevention of dislocation (especially with hip) Hip - No more than 90 degrees - Affected leg – not turn inward or cross legs - Use pillow between legs for sleeping - No bending forward to pick up items Watch for pressure areas Keep nutrition optimal Educate on safe ambulation Exercise Monitor for hemorrhage Hip fracture: - 300,000 hip fractures in the US annually 95% caused by falling - More common in women - Women fall more than men - Women more likely to have osteoporosis - Gerontological considerations - Associated with mortality/morbidity - Nursing care: VS Monitor for infection Pain mgt Early ambulation physical therapy Assist w/ ADL’S Adequate nutrition and hydration Involve family in care Discharge planning Monitor for blood loss- check for hematoma, don’t forget retroperitoneal Assess for urinary retention Monitor I & O Encourage cough, deep breathing, and out of bed Monitor respiratory status Assess neurovascular status Monitor for DVT & PE Frequent position changes to prevent skin breakdown Hip precautions to prevent dislocation Delirium prevention strategies What is Arthroplasty - Surgical removal of unhealthy joint and replacement with synthetic material - RA, trauma, OA, congenital deformity, fractures - Total joint arthroplasty = total joint replacement (common in knees and hips) - Physical therapy on POD 0 - Post-op risks: VTE, infection, pain, mobility limitations (falls, dislocation), discharge planning (REHAB!) - What are mobility restrictions? - Weight bearing restrictions? Total knee arthroplasty - Surgical repair of damaged knee - Common in OA and RA - Done after medical management has failed - PT to start promptly after surgery - Discharge planning - CPM: Continuous passive motion  - TENS: Transcutaneous electrical nerve stimulation Amputations - Surgical removal of part or all of a limb - Causes: Traumatic Injury & Complications of vascular disease - Common in clients with diabetes and PAD - Level of amputation: Goal with amputation is leave as much tissue as possible - Distal - Nursing mgt: Treat pain Post-op pain Phantom limb pain Stump care Dressing changes Drainage devices Compression No pillows! Risk of flexion contracture Promote self care and mobility Discharge planning - Prosthetics: Fitting an AKA is harder than BKA Prosthesis often has to be adjusted for the first six months to ensure no skin rubbing PT / OT rehabilitation Complications of Fractures ➔ Infection, both local and systemic ➔ Pulmonary Embolism ➔ DVT ➔ Bleeding ➔ Compartment Syndrome ➔ Impaired Healing ➔ Fat Embolism Syndrome ➔ Avascular necrosis ➔ Complex Regional Pain - Compartment Syndrome Elevated pressure in compartment d/t edema OR bleeding OR edema with restriction (cast) Time sensitive, critical emergency Compromises perfusion leading to cell death and tissue necrosis S/Sx: 5Ps, pain, cyanosis (venous congestion) or pallor, cold digits (atrial insufficiency), pulselessness - late sign Prevention is key Fasciotomy is treatment—emergency (remove cast if one is present) - Initial Management post fasciotomy  1. NV checks - 5 P’s: Pain, Pulse, Pallor, Paresthesia, Paralysis - Used to assess for impaired perfusion to extremities or damage to nerves after ortho injury - IMPORTANT! - Usually serial checks (q15-q1 hr) - Hospital protocol - Ortho injuries can lead to compartment syndrome 2. Cover open fasca with sterile dressing 3. Maintain limb at level of heart 4. Pain management 5. I/Os (look for rhabdomyolysis) Muscle trauma, exercises too vigorously, has hyperthermia, sepsis, prolonged seizures, etc. myoglobin gets into the circulation and is rapidly filtered in the glomerulus.; obstruction in renal tubules S/S: Myalgia, weakness, edema, SOB, lethargy, N/V, confusion, dysrhythmia, red-brown urine, fever - Bleeding Major risk with pelvic fracture Stable vs unstable Bleeding and shock are common Caused by laceration of major vessel Pelvic binder Surgery ASAP - Impaired bone healing - Fat Embolism Syndrome Fat emboli enter circulation Following ortho trauma Most common in long bone (femur) and pelvic fractures Rapid onset Triad of FES: hypoxemia, neuro compromise, petechial rash Labs: Elevated ESR and IgM, thrombocytopenia Treatment: immobilization, supportive care: Fluids, oxygenation, vasopressors, steroids - Complex Regional Pain Syndrome Dysfunctional peripheral and central nervous system responses that mount an excessive response to the precipitating event Frequently chronic Not clearly understood Pain even to mild touch May also see change in skin color, temperature, or edema Treatment: pain control (PO and topical), anticonvulsants (gabapentin), antidepressants (amitriptyline), nerve blocks - Avascular Necrosis Death of bone tissue due to loss/decrease in perfusion Common in acute trauma May also see in chronic steroid use, radiation exposure, RA, sickle cell disease, chronic ETOH, cigarettes Dx: x-ray, CT, bone scan Treatment aims to revascularize bone by drilling into avascular bone or bone graft. Untreated AVN may lead to need for joint replacement