Musculoskeletal Disorders

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Musculoskeletal Disorders

• Part Two

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Osteoporosis

• Reduction in bone density change in bone
  structure
• Bone reabsorption gt bone formation
• Pathological fractures can occur and collapse of
  vertebrae
• Postmenopausal women greatest risk due to
  estrogen deficiency

• Affects 1.4 million Canadians
• 1 in 4 women over 50
• 1 in 8 men over 50
• Silent Dx as bone loss is asymptomatic- 1st sign
  
• Estimated cost 1.9 billion

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Metabolic Bone Disorders

• Changes in the physical chemical structure of
  the bone due to estrogen deficiency, parathyroid
  disorders, Vitamin deficiency, malabsorption or
  physical inactivity.
• Types
• Osteoporosis
• Pagets Disease
• Osteomalacia
• Gout Gouty Arthritis

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Osteoporosis

• Fragility fractures occur due to low trauma
  (bending over to pick up a newspaper)
• Most common fractures hip, vertebrae radius
• Osteopenia- low bone mineral density compared
  with that expected for age sex risk factor
  for fracture
• Affects 13-18 of post-menopausal women 30-50
  have osteopenia of the hip
• 1 of every two women will experience a fracture
  at some point in their life

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Osteoporosis

• The World Health Organization defines
  osteoporosis as bone mass that is 2.5 standard
  deviations below the peak normal value for a
  young adult (Dowd, 1999)
• Normal
  Osteoporotic

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Osteoporotic Changes
Height 59 53 5 49 46 43

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Osteoporosis Risk Factors

• Female
• Caucasian, non-Hispanic, Asian
• Increased age
• Low weight BMI
• Estrogen deficiency or menopause
• Family hx
• Low initial bone mass
• Long term use of certain medications
  (corticosteroids, anticonvulsives)
• Coexisting medical conditions (celiac)

• Insufficient calcium vitamin D
• Life style factors-smoking, caffeine, alcohol
• Lack of weight-bearing exercise
• Lack of sunshine

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Osteoporosis Management

• Adequate intake calcium vitamin D throughout
  life
• Regular wt bearing exercises
• Avoid alcohol smoking

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Discuss Osteoporosis is a pediatric disease
with geriatric consequences.
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Medications

• ERT (prevents bone loss) decreased use
• Bisphosphonates approved for the treatment of
  osteoporosis alendronate (Fosamax), risedronate
  (Actonel), and etidronate (Didrocal). Absorption
  of bisphosphonates by the oral route is poor,
  even when taken on an empty stomach
• Calcitonin-hormone slows bone reabsorption
• Evista (raloxifene) selective estrogen receptor
  modulators (do not increase risk breast or
  uterine ca)

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Nursing Diagnoses

• Altered health maintenance
• Acute pain r/t fracture muscle spasm
• Risk for constipation
• Risk for injury

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Pagets Disease

• An idiopathic bone disorder characterized by
  abnormal accelerated bone reabsorption
  formation in one or more bones
• Normal bone is replaced by abnormal, structurally
  weaker bone that is prone to fractures
• Painful deformities are produced in femur, tibia,
  lower spine, pelvis cranium

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Pagets Disease Humerus
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Osteomalacia

• Disease which bone becomes abnormally soft due to
  disturbed calcium phosphorous balance secondary
  to Vit D deficiency
• Bones bend flatten
• Deformities wt bearing bones
• Affects women endemic in Asia
• Causes
• Chronic use anticonvulsants, strict vegetarian,
  very low fat diets, fibrous dysplasia,
  hyperthyroid induced osteopenia
• Treatment- Vit D, adequate Ca, P Protein

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Gout Gouty Arthritis

• Gout is a condition in which crystals of uric
  acid rise above normal levels deposit in the
  joints, causing inflammation.
• Crystals may also form under the skin as well as
  the kidneys or urinary tract.
• Tophi - with repeated attacks accumulations of
  sodium urate crystals, are deposited in
  peripheral areas of the body, such as the great
  toe, the hands, and the ear

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Gout is caused by

• an increase in production of uric acid
  under-elimination of uric acid by the kidneys
• increased intake of foods containing purines
  which are metabolized to uric acid
• dietary factors, some drugs toxins

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Purine in Food
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Gouty Arthritis
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Comparison of Normal /Gouty Joint
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Uric Acid Crystals

• These spiked rods are uric acid crystals
  photographed under polarized light.
• Increased uric acid blood levels and formation of
  uric acid crystals in the joints are associated
  with gout.

• The definitive diagnosis of gout is dependent on
  finding uric acid crystals in the joint fluid
  during an acute attack

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TREATMENT of GOUT

• Colchicine (reduces uric acid and phagocytosis
• NSAIDs (the treatment of choice) indomethacin
  naproxen or steroids if resistant to NSAIDS
• Allopurinol (blocks production of uric acid)
• Aspirin and aspirin-containing products should be
  avoided during acute attacks used only on the
  advice of physician

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Gout Drugs

• In multiple gout attacks, or those that
  developed kidney stones more aggressive drug
  management is necessary.
• Drugs that block absorption by the kidney, such
  as probenecid, and drug that block production of
  uric acid by the body, such as allopurinol are
  considered.
• The choice between these two types of drugs
  depends on the amount of uric acid in the urine.
  With correct treatment, gout should be well
  controlled in almost all cases.

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Gout Nursing Care

• Episodes may be triggered by surgery, heart
  attacks, trauma, alcohol use, some meds
• Pain management essential (acute pain often great
  toe)
• Teaching
• Avoid certain diuretics such as thiazide
• Weight control without wide fluctuations
• Avoid alcohol, caffeine, chocolate, organ foods,
  gravy, peas

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Spinal Cord Deformities

• Scoliosis- lateral curvature of the spine in any
  area
• Kyphosis-humpback , posterior rounding of
  thoracic spine
• Lordosis- inward curvature of the lumbar spine
  seen sometimes pregnant, obese or lg. abd. tumors

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Scoliosis
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Herrington Rod Scoliosis
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Osteomyelitis

• Severe pyogenic infection of the bone
  surrounding tissue
• Bacterial mostly, can be viral or fungus
• Staph most common (E-coli, Pseudomonas,
  Klebsiella, Salmonella, Proteus)
• Femur tibia males
• Clinical manifestations
• Acute, localized pain, reddness or drainage,
  fever, malaise, elevated WBC, ESR, MRI to Dx

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Septic Arthritis

• A closed-space infection, caused by invasion of
  the synovial membrane by pus-forming bacteria or
  other pathogens
• Joints mostly affected knee, hip, shoulder,
  wrist ankle
• Most common cause neisseria gonorrhoae staph
• Client has pain, swelling, warmth in joint
  acute systemic reaction

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Septic Arthritis

• Antibiotic therapy initiated
• Pen G administered due to common causal organisms
• Open synovectomy debridement or repeated joint
  aspirations irrigations maybe needed
• Exercise rehab. Important
• ROM CPM successful for some

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Synovectomy
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Muscular Dystrophy

• Designates a group of genetic disorders involving
  gradual degeneration muscle fibers
• Progressive weakness skeletal muscle wasting,
  disability deformity
• Duchennes MD most common severe Dx
• Sex-linked recessive disorder affects males
  exclusively (Xp21 gene)
• Lab Dx serum creatinine kinase analysis (levels
  elevated in MD due to abn of striated muscle
  function)
• Treatment symptomatic supportive

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Read

• Bone tumors
• Disorders of the foot

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• Berarducci, A. Lengacher, C.A., Keller, R.
  (2002). The impact of osteoporosis continuing
  education on nurses' knowledge and attitudes. The
  Journal of Continuing Education in Nursing,
  33(5), retrieved from proquest http//proquest.umi
  .com/pqdweb?Did000000184306351Fmt4Deli1Mtd1
  Idx14Sid1RQT309
• The Arthritis Society
• Canadian Orthopedic Nurses Association