Paget

1
Pagets Disease (Osteitis Deformans)

• Excess of bone destruction unorganized bone
  formation and repair. The 2nd most common bone
  disorder in the U.S.
• The etiology is unknown
• Usually affects the axial skeleton, vertebrae and
  skull, although the pelvis, tibia, femur are the
  other common sites of disease.
• Most persons are asymptomatic diagnosis is
  incidental.

2
Pagets Disease (Osteitis Deformans)

• Vascularity is increased in affected portions of
  the skeleton. Lesions may occur in one or more
  bones, does not spread from bone to bone.
• Deformities bony enlargement often occur.
  Bowing of the limbs spinal curvature in persons
  with advanced disease.
• Bone pain- is the most common symptom. Is is
  usually worse with ambulation or activity but may
  also occur at rest. Involved bones may feel
  spongy warm because of increased vascularity.
• Skull pain is usually accompanied with headache,
  warmth, tenderness enlargement of the head.

3
Pagets Disease (Osteitis Deformans

• Pathologic fractures- because of the increased
  vascularity of the involved bone-bleeding is a
  potential danger.
• Alkaline phosphatase levels- markedly elevated as
  the result of osteoblast activity.
• Serum calcium are normal except with generalized
  disease or immobilization.
• Gout and hyperurecemia may develop as a result of
  increased bone activity, which causes an increase
  in nucleic acid catabolism.

4
Pagets Disease (Osteitis Deformans

• Radiograph reveals radiolucent areas in the bone,
  typical of increased bone resorption. Deformities
  fractures may also be present.
• Goals of the treatment- to relieve pain prevent
  fracture deformities.
• Pharmacologic agents are used to suppress
  osteoclastic activity. Bisphosphonates
  calcitonin are effective agents to decrease bone
  pain bone warmth also relieve neural
  decompression, joint pain lytic lesions.
• Use of analgesics NSAIDs. Assistive devices,
  including cane, walker.

5
Pagets Disease (Osteitis Deformans

• Deformities may be corrected by surgical
  intervention (osteotomy). ORIF may be necessary
  for fractures.
• The patient may benefit from a PT referral. Local
  application of ice or heat may help alleviate
  pain.
• A regular exercise should be maintained walking
  is best. Avoid extended periods of immobility to
  avoid hypercalcemia.
• A nutritionally adequate diet is recommended.
  Assistance in learning to use canes or other
  ambulatory aids.
• The Arthritis Foundation Paget Foundation are
  useful resources for patients their families.

6
Osteomyelitis

• Infection of the bone, most often of the cortex
  or medullary portion. Is is commonly caused by
  bacteria, fungi, parasites viruses.
• Classified by mode of entry- Contiguous or
  exogenous is caused by a pathogen from outside
  the body or the by the spread of infection from
  adjacent soft tissues. The organism is Staph
  aureus. Example- pathogens from open fracture.
  The onset is insidious initially cellulites
  progressing ti underlying bone.

7
Osteomyelitis

• Hematogenous- caused by bloodborne pathogens
  originating from infectious sites within the
  body.Ex sinus, ear, dental, respiratory GU
  infections. The infection spreads from the bone
  to the soft tissues can eventually break
  through the skin, becoming a draining fistula.
  Again, Staph aureus is the most common causative
  organism.
• Acute Osteomyelitis left untreated or unresolved
  after 10 days is considered chronic. Necrotic
  bone is the distinguishing feature of chronic
  osteomyelitis.

8
Osteomyelitis

• The pathophysiology is similar to that infectious
  processes in any other body tissue.
• Bone inflammation is marked by edema, increased
  vascularity leukocyte activity.
• The patient report fever, malaise, anorexia,
  headache. The affected body may be erythematous,
  tender, edematous. There may be fistula
  draining purulent material.
• Blood test- increase WBCs, ESR, C-protein
  levels.

9
Osteomyelitis

• Treatment is difficult costly. The goal are
  complete removal of dead bone affected soft
  tissue, control of infection elimination of
  dead space (after removal of necrotic bone).
• The nursing management-use of aseptic technique
  during dressing changes. Observed for S/S of
  systemic infection, administered antibiotic on
  time.
• ROM exercises are encouraged to prevent
  contractures flexion deformities
  participation in ADL to the fullest extent is
  encouraged.

10
Tumor of the MSS

• MSS constitute 3 of all malignant tumors.
• Malignant tends to cause more bone destruction,
  invasion of the surrounding tissues metastasis.
• Benign tumors- tend to be less destructive to
  normal bone.
• The cause of bone tumors is unknown.
• The tumor is defined as a new growth or
  hyperplasia of cells. This growth is in response
  to inflammation or trauma.

11
Tumor of the MSS

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

12
Tumor of the MSS

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

13
Tumor of the MSS

• Chondrosarcoma- Usually affects persons 50-70
  years old. Accounts for 20 of all bone tumors
• Affect males than females.
• Slow growing, insidious onset. Most common in
  humerus, femur, pelvis.
• Localized pain, swelling. May have palpable mass.
  Severe, persistent pain. May infiltrate joint
  space soft tissue metastasize to the lungs.
• Treatment Surgical incision, amputation.

14
Tumor of the MSS

• Fibrosarcoma- Usually affects persons 30- 50
  years old. Affects females than males.
• Occurs in bony fibrous tissue of femur tibia.
• Accounts for 4 of primary malignant bone tumors.
• May result from radiation therapy, pagets
  disease or chronic osteomyelitis.
• Night pain, swelling, possible palpable mass. May
  cause pathologic fractures.
• May metastasize to the lungs.

15
Fractures

• A break in the continuity of bone caused by
  trauma, twisting or as a result of bone
  decalcification. Results when the bone is unable
  to absorb the stress. Result of an accident or
  injury, stress fracture occur as a result of
  normal activity or after minimal injury.
• Causes of Fracture Fatigue- muscles are less
  supportive to bone, therefore, cant absorb the
  force being exerted. Bone neoplasms- cellular
  proliferations of malignant cells replace normal
  tissue causing weakened bone. Metabolic
  disorders-poor mineral absorption hormonal
  changes decreases bone calcification which
  results in a weakened bone. Bedrest or disuse-
  atropic muscles osteoporosis causes decreased
  stress resistance.

16
Fractures (types)

• Greenstick- A crack bending of a bone with
  incomplete fracture. Only affects one side of the
  periosteum. Common in skull fractures or in young
  children when bones are pliable.
• Comminuted Bone completely broken in a
  transverse, spiral or oblique direction (
  indicates the direction of the fracture in
  relation to the long axis of the fracture bone).
  Bone broken into several fragments.
• Open or compound Bone is exposed to the air
  through break in the skin. Can be associated with
  soft tissue injury. Infection is common
  complication due to exposure to bacterial
  invasion.

17
Fractures (types)

• Closed or simple Skin remains intact. Chances
  are greatly decreased for infection.
• Compression Frequently seen with vertebral
  fractures. Bone has been compressed by other
  bones.
• Complete Bone is broken with disruption of both
  sides of the periosteum.
• Impacted one part of fractured bone is driven
  into another.
• Depressed Usually seen in skull or facial
  fractures. Bone or fragments of bone are driven
  inward.
• Pathological break caused by disease process.
• IntracapsularBone broken inside the joint.
• Extracapsular Fracture outside the joint.

18
Fractures (stages of bone healing)

• Occurs over several weeks
• New bone tissue occurs in region of break
• Repair is initiated by migration of blood vessels
  and connective tissue from periosteum in break
  area.
• Dense fibrous tissue fills from periosteum in
  break area. Osteoblast near the broken area.
  Chondroblast further away from broken area.
• Cells deposit cartilage between broken surfaces
• Cartilage is slowly replaced by mineralized bone
  tissue, which completes repair.

19
Fractures (signs symptoms)

• Pain or tenderness over involved area.
• Loss of function of the extremity
• Crepitation sound of grating bone fragments
• Ecchymosis or erythema
• Edema
• Muscle spasm
• Deformity Overriding Angulation- limb is in
  unnatural position.

20
Fractures (Emergency care)

• Immobilize affected extremity to prevent further
  damage to soft tissue or nerve.
• If compound fracture is evident, dont attempt to
  reduce it. Apply splint. Cover open wound with
  sterile dressing.
• Use splint External support is applied around a
  fracture area to immobilize the broken ends.
  Material used wood, plastic (air splints),
  magazines.
• Function of the splinting Prevent additional
  trauma, reduce pain, decrease muscle spasm, limit
  movement, prevent complications, such as fat
  emboli if long bone fracture.
• Provide specific care for fracture treatment
  traction, cast. Surgical intervention.

21
Traction

• Force applied in two directions to reduce and/ or
  immobilize a fracture, to provide proper bone
  alignment and regain normal length, or to reduce
  muscle spasm.
• Closed reduction Manual manipulation. Usually
  done under anesthesia to reduce pain relax
  muscles, thereby preventing complications. Cast
  is usually applied following closed reduction.
• Open reduction Surgical intervention. Usually
  treated with internal fixation devices (screws,
  plates, wires). Cast application.

22
Traction

• Skeletal Traction Mechanical applied to bone,
  using pins (Steinmann), wires (Kirscher), or
  tongs (Crutchfield). Most often used in fractures
  of femur, tibia, humerus.
• Skin traction applied by use of elastic
  bandages, moleskin strips, or adhesive. Used most
  often in alignment or lengthening (for congenital
  hip displacement) or to relieve muscle spasms in
  preop hip clients. Most common types are
  Russell, Bucks, Cervical (used for whiplashes
  cervical spasm), -pull is exerted on one plane
  used for temporary immobilization Pelvic
  traction (used for low back pain).

23
Traction(Principles)

• The line of pull must be maintained. Center the
  patient in the bed place in good alignment.
• The pull of traction must be continuous. Remove
  or add weights only with MD order.
• The ropes weights must be free of friction. Be
  certain the weights hangs free at all times
  that the ropes are over the center of the pulley.
• There must be sufficient countertraction
  maintained at all times. Keep the patient from
  sliding to the foot of the bed.

24
Cast Care

• After application of cast, allow 24 to 48 hours
  for drying. For synthetic cast, allow 30 minutes
• Cast will change from dull to shiny substance
  when dry.
• Dont handle cast during dying process, because
  indentation from fingermarks can cause skin
  breakdown under cast.
• Keep extremity elevated to prevent edema.
• Provide for smooth edges surrounding cast. Smooth
  edges prevent crumbling and breaking down of
  edges. Stockinet can be pulled over edge
  fastened down with adhesive tape to outside of
  cast.
• Observe casted extremity for signs of circulatory
  impairment. Cast may have to be cut if edematous
  condition continues.
• Always observe for sign symptoms of
  complications pain swelling, discolaration,
  tingling or numbness, diminished or absent pulse,
  paralysis, cool to touch.

25
Cast Care

• If there is an open, draining area on the
  affected extremity, a window (cut out portion of
  cast) can be utilized for observation and/or
  irrigation of wound.
• Keep cast dry. Breaks down when water comes in
  contact with plaster. Use plastic bags or Chux
  during bath or when using bedpan, to protect cast
  material.
• Utilize isometric exercises to prevent muscle
  atrophy to strengthen the muscle. Isometrics
  prevent joint from being immobilized.
• Position client with pillows to prevent strain on
  unaffected areas.
• Turn every 2 hours to prevent complications.
  Encourage to lie on abdomen 4 hours a day.

26
Cast (complications)

• Respiratory complications have client cough DB
  q 2 hours. Turn q 2 hours if not contraindicated.
• Thrombus embolic formation. Apply SCD. Start
  anticoagulation therapy if needed. Observe for
  S/S of pulmonary and/or fat emboli.
• Contractures Start ROM exercises to affected
  joints. Provide foot board.
• Skin breakdown- massage with lotion once a day to
  prevent drying. Alternate pressure mattress,
  sheepskin. Use stryker boots or heel protectors.
• Prevent urinary retention and calculi. Encourage
  fluids. Monitor intake output.

27
Cast (complication)

• Prevent constipation Encourage fluids, Provide
  high-fiber diet. Administer laxative or enema as
  ordered.
• Provide psychological support Allow to ventilate
  feelings of dependence. Encourage independence
  when possible. Encourage visitors for short time
  periods. Provide diversionary activities.

28
Fractures (Complications)

• Compartment Syndrome An increase in the pressure
  within the a fascial muscle compartment
• Tissue damage can occur within 30 minutes
  elevated pressure for more than 4 hours can
  result in irreversible damage limb loss.
• Signs symptoms 6 Ps. Pain-severe,
  unrelenting, unrelieved by analgesia increased
  by elevation of the extremity. Pallor- coolness,
  slow capillary refill. Pulselessness-diminished
  or absent pulses. Increase pressure and
  paresthesia paralysis.
• Goals of treatment decreasing tissue pressure,
  restoring blood flow preserving function of the
  limb.
• Diagnosis Intracompartment pressure gt 30 mm hg.

29
Fractures (Complications)

• Treatment Fasciotomy-open the affected
  compartment, decrease the pressure restore
  normal perfusion. The wound is covered with wet
  saline dressing.
• Fat embolism syndrome (FES)-fat globules tissue
  thromboplastin are released from the bone marrow.
  The fat molecules enter the venous circulation,
  travel to the lungs embolize the small
  capillaries arterioles.
• S/S hypoxemia, tachypnea, fever, chest pain
  altered mental status.The presence of unexplained
  fever, accompanied by a change in mental status
  petechiae, shld. Alert the caregiver to the
  possibility of FES. The MD shld. Be notified
  immediately.

30
Fractures (Complications)

• Infection leading cause of delayed union
  nonunion, occurs primarily in open or compound
  fractures. The most symptoms occur within 4 weeks
  of the injury.
• S/S Pain, erythema edema.

31
HIP fractures

• High incidence in elderly group-most common cause
  of traumatic death after age 75.
• Fractures caused by brittle bones (osteoporosis)
  7 frequent falls in the elderly.
• Elderly with hip fractures frequently have
  associated medical conditions (CAD, renal
  disorders).
• Assessment Intracapsular-bone broken inside the
  joint-treated by internal fixation-replacement of
  femoral head with Austin Moore prosthesis.
• Placed in skin traction first for immobilization
  relief of muscle spasm.

32
HIP fractures

• Extracapsular trochanteric fracture outside the
  joint.
• Can be treated by balanced suspension traction.
  Full weight-bearing usually in 6 to 8 weeks, when
  healing takes place.
• Surgery usually internal fixation with wire.
• Intertrochanteric fracture extends from medial
  region of the junction of the neck lesser
  trochanter toward the summit of the greater
  trochanter. Treated initially with balanced
  suspension traction. Internal fixation used with
  nailplate, screws wire. Not allowed to flex hip
  to the side, on the side of the bed, or in a low
  chair. When hip is flexed, displacement can occur.

33
Total hip replacement

• Replacement of both the acetabulum the head of
  the femur with metal or plastic implants.
• Used in degenerative diseases or when fracture of
  the head of femur has occurred with nonunion.
• To prevent flexion, keep operative leg in
  abduction by use of pillow or abductor splints.
• Keep hemovac in place until drainage has subsided
  (24 to 96 hours).
• Prevent edema readjust SCD at least every 4 to 8
  hours.
• Prevent infections- monitor prophylactic
  antibiotic.

34
HIP fractures

• Continuous passive motion (CPM) first day postop
  with increasing degree of flexion to 90 degrees.
• Ambulate client carefully at bedside-first or
  second day. Dont allow to bear weight on
  affected hip. Up with walker 2nd post.op day.
• Prevent thrombus formation from venous
  stasis-promote leg exercises-flexing feet
  ankles.
• Start physical therapy asap.
• Instruct not to use low chairs or sit on edge of
  bed. Use commode extenders, high stools, no
  bending over activities.

35
HIP fractures

• Observe for neurovascular problems in affected
  leg Color and temperature, edema in leg, pain on
  passive flexion of foot, numbness-ability to move
  leg, pedal pulses capillary refill.

36
Total Knee Replacement

• Implantation of a metallic upper portion that
  substitutes for the femoral condyles a high
  polymer plastic lower portion that substitutes
  for the tibial joint surfaces.
• Continuous passive motion(CPM) may be ordered
  postop.-moderate flexion extension-increase
  circulation movement.
• Perform quad-setting straight-leg raising
  exercises every hour.
• Perform ROM.
• Do not dangle to prevent disclocation.

37
Total Knee Replacement

• Hemovac is inserted to drain excessive blood and
  drainage. Maintain accurate I/O. Observe for
  hemorrhage infection.
• Instruct client for crutch walking.
• Complications wound infection, DVT, Pulmonary
  and fat embolism, dislocation of the prosthesis.

38
Amputations

• The surgical removal of a limb, a part of a limb,
  or a portion of a bone elsewhere than at the
  joint site.
• Removal of a bone at the joint site is termed
  disarticulation.
• More than 110,000 are performed each year in the
  U.S. 91 of them are lower extremity
  amputations.
• Occurs in patients with diabetes 15 times more
  frequently than in other patients with chronic
  arterial occlusive disease.

39
Amputations (types)

• Below the Knee (BKA)
• Above the knee (AKA)
• Amputations of the foot and ankles (symes)
• Amputation of the foot metatarsus and tarsus
  (heys or lisfrancs)
• Hip disarticulation-removal of the limb from the
  hip joint.
• Hemicorporectomy- removal of half of the body
  from the pelvis and lumbar areas.

40
Amputations (Assessment)

• Evaluate dressing for signs of infection or
  hemorrhage.
• Observe for signs of a developing necrosis or
  neuroma in incision.
• Evaluate for phantom limb pain.
• Observe for signs of contractures.
• Provide preop. nursing care management. Have
  client practice lifting buttocks off bed while in
  sitting position. Provide ROM to unaffected leg.
  Inform about phantom limb sensation- pain
  feeling that amputated leg still there caused by
  nerves in the stump.

41
Amputations

• Provide post. Op. care. Observe stump dressing
  for signs of hemorrhage infection.
• Observe for symptoms of a developing necrosis or
  neuroma in area of incision.
• Provide stump care rewrap ace bandage 3 to 4
  times daily. Wash stump with mild soap water.
  If skin is dry, apply lanolin or vaseline to
  stump.
• Teaching related stump care. BKA-dont hang stump
  over edge of bed. Dont sit for a long periods of
  time.
• Above the knee-prevent external or internal
  rotation of limb. Place rolled towel along
  outside of thigh to prevent rotation.

42
Amputations

• Position in prone position to stretch flexor
  muscle to prevent flexion contractures of hip.
  Done usually after first 24 to 48 hours postop.
  Place pillow under abdomen 7 stump. Keep legs
  close together to prevent abduction.
• Teach crutch-walking and wheelchair transfer.
• Prepare stump for prosthesis. Stump must be
  conditioned for proper fit. Shrinking shaping
  stump to conical form by applying bandages or an
  elastic stump shrinker. A cast readies stump for
  the prosthesis.
• Provide care for temporary prosthesis which
  applied until stump has shrunk to permanent
  state.
• Recognize respond to clients psychological
  reactions to amputation. Feelings of loss,
  grieving, loss of independence, lowered
  self-image, depression.
• Continue discussing phantom limb pain with client.