Musculoskeletal Disorders

1. Musculoskeletal Disorders Part Two

2. Reduction in bone density & change in bone structure Bone reabsorption > 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 Osteoporosis

3. 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 • Paget’s Disease • Osteomalacia • Gout & Gouty Arthritis

4. 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

5. 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

6. Osteoporotic Changes Height – 5¢9¢¢ – 5¢3¢¢ – 5¢ – 4¢9¢¢ – 4¢6¢¢ – 4¢3¢¢

7. Insufficient calcium & vitamin D Life style factors-smoking, caffeine, alcohol Lack of weight-bearing exercise Lack of sunshine 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) Osteoporosis: Risk Factors

9. Osteoporosis Management: • Adequate intake calcium & vitamin D throughout life • Regular wt bearing exercises • Avoid alcohol & smoking

10. Discuss: “Osteoporosis is a pediatric disease with geriatric consequences”.

11. 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)

12. Nursing Diagnoses • Altered health maintenance • Acute pain r/t fracture & muscle spasm • Risk for constipation • Risk for injury

13. Paget’s 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

14. Paget’s Disease Humerus

15. 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

16. 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 attacksaccumulations of sodium urate crystals, are deposited in peripheral areas of the body, such as the great toe, the hands, and the ear

17. 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

18. Purine in Food

19. Gouty Arthritis

20. Comparison of Normal /Gouty Joint

21. 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

22. 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

23. 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.

24. 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

25. 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

26. Scoliosis

27. Herrington Rod & Scoliosis

29. 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

30. 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

31. 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

32. Synovectomy

33. Muscular Dystrophy • Designates a group of genetic disorders involving gradual degeneration muscle fibers • Progressive weakness & skeletal muscle wasting, disability & deformity • Duchenne’s 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

34. Read • Bone tumors • Disorders of the foot

35. 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?Did=000000184306351&Fmt=4&Deli=1&Mtd=1&Idx=14&Sid=1&RQT=309 • The Arthritis Society • Canadian Orthopedic Nurses Association