1. Musculoskeletal Disorders
Part Two

2. Osteoporosis 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

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
Defined as a systemic skeletal disease characterized by low bone mass & microarchitectural deterioration of bone tissue that leads to increased fragility & susceptibility to fractures.

6. Osteoporotic Changes Height – 5¢9¢¢ – 5¢3¢¢ – 5¢ – 4¢9¢¢ – 4¢6¢¢
– 5¢9¢¢
– 5¢3¢¢
– 5¢
– 4¢9¢¢
– 4¢6¢¢
– 4¢3¢¢
Age 70-loss of height & may result in dorsal kyphosis.
Discuss: “Osteoporosis is a pediatric disease with geriatric consequences”- those who have not gained peak bone mass have “less in the bone bank” to draw upon once bone loss begins. Thus, peak bone mass as well later bone loss is a major determinant of osteoporectic fractures. For this reason osteoporosis has been described as a pediatric disorder. Strong adult skeleton is built during childhood.

7. 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
Dx: made after a fracture.
Gold standard measuring BMD is full table DXA (dual-photon absorptiometry. (p.569)
Commonly measured sites spine & hip.
BMD reported as a T-score, difference between patient’s BMD & BMD of young normal adults of the same gender.
The difference b/t patient’s score & young adult norm is expressed as SD below or above average.
BMD testing is recommended:
All postmenopausal women under age 65 who have one or more risk factors for osteo.
All women aged 65 & older
Postmenopausal women with fractures
Prolonged HRT

9. Osteoporosis Management:
Adequate intake calcium & vitamin D throughout life
Regular wt bearing exercises
Avoid alcohol & smoking
Promote healing after fracture, manage pain (NSAIDS), regain mobility & strength, prevent further fractures.

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
Unknown cause
Data suggests measles virus involvement, RSV (resp. virus) or canine distemper virus
More common men than women and less common Asis & Africia.
Clinical signs:
Deep aching bone pain, skeletal deformity, pathologic fractures, RA, gout & ankylosing spondylitis common with Paget’s
NSAIDA treat
Fosamax, Aredia & Actonil treat Paget’s- suppress abnormal bone turnover.

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 attacks accumulations of sodium urate crystals, are deposited in peripheral areas of the body, such as the great toe, the hands, and the ear
Gout classified:
Primary: caused by inherited defect of purine metabolism, leading to increased or decreased renal excretion(attact 30-40’s)
Secondary- acquired condition due to hematopoietic disorders (MM, leukemia) or renal disorder. In hematopoietic disorders there is increase cell turnover & increase uric acid production.
HEALTH IMPACT
Gout:
*Afflicts 840 out of 100,000 people
*More common and at a younger age in males
*Is strongly associated with obesity, hypertension, hyperlipidemia and diabetes
*Often in great toe

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.
Certain meats (liver), seafood, dried peas and beans are particularly high in purines. Alcoholic beverages may also significantly increase uric acid levels and precipitate gout attacks.
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
S spinal cord develops during fetal development & early childhood.
Scoliosis-lateral curvature of the spine in any area (cervical, thoracic, lumbar, thoracoclumbar)
Cause congenital ( formation (absence of a portion of vertebra) or segementation- absence of normal seperations b/t vertebrae or neuromuscular( cerebral palsy, polio, myelomengingocele, sp cd tumors, myopathic conditions (muscular dystrophy)
Non-surgery: observation, bracing & exercise
Surgical- instruments used to stabilize & correct deformity (Harrington rod) (p. 578)
Kyphosis- common in metabolic disorders osteoporosis & osteomalacia.
Treat –corsets or bracing to straighten spine.
Lordosis- see sagging shoulders, exaggerated pelvic angle, & medial rotation of the legs.
Treatment: brace, spinal fussion or osteotomy.

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
Treatment A/B, surgery to debride & drainage of infection to prevent deformity.
A/B alone rarely work require surgery.

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
Low grade fever & malaise in adult
Labs: CBC, ESR, ANA (antinuclear antibody test) & RF to differentiate septic arthritis from autoimmune diseases with joint involvement.
Aspirate for analysis, synovial BX, radioisotope scanning of infection.

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
60% MD rarely live to 21 but survival beyond 30 is unusual- death due to cardiac failure or resp failure.

34. Read
Bone tumors
Disorders of the foot

35. Berarducci, A. Lengacher, C. A. , Keller, R. (2002)
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
The Arthritis Society
Canadian Orthopedic Nurses Association