Musculoskeletal Disorders - PowerPoint Presentation

Slide1

Musculoskeletal Disorders

Psych Rehab Nursing

Fall 2009

Slide2

Outline

Overview of anatomy and physiology

Diagnostic tests

Musculoskeletal trauma

Problems of the musculoskeletal system

Osteoporosis

Osteoarthritis

Rheumatoid arthritis

Gout

Other musculoskeletal problems

Slide3

Review

Purpose of the musculoskeletal system

-

Supporting framework for attachment of muscles

and other tissues

- Protects vital organs and soft tissues

- Joints, bones, cartilage make up the skeletal

system

- Bones enable movement of the body by acting as

levers and points of muscle

attachments

(muscles ONLY contract: opposing muscles allow flexion & extension. Muscles are conductors of electrical energy)

Slide4

Bones

Function

Framework for the attachment of muscles and other tissues

Protection

Production of blood cells in the red marrow

-

Which bones are involved in the process?

-

Facilitate movement by contracting muscles

-

Storage area for calcium and phosphorus

-

Lipids (energy sources) are stored in adipose

cells of the yellow marrow

Slide5

Bones

Blood cells are produced in bone marrow (see below)

Red marrow in flat bones (sternum, scapulae, skull, ribs, vertebrae, pelvis, epiphyseal ends of long bones, i.e., femur and humerus (marrow runs all the way through the bone, but the cells are released from the epiphyseal ends)

Femur head; view of cortex; view of red bone marrow; view of yellow bone marrow (2009)

Slide6

Bones

Ligaments

(fibrous connective tissue connecting bone to bone)

Tendons

(connect muscle to bone) Example: Achilles tendon attaches calf muscles to the ankle bone while a ligament holds the calf and thigh bones together at the knee joint

(

Pollick

, 2008)

Slide7

Bones: Types

Long bones

Short bones

Flat bones

Irregular bones

Sesamoid (or round) bones

Sutural or Wormian bones

Slide8

Long Bones

Long bonesLonger than they are wideA shaft with two ends - the shaft widens at the end of the bone Contain yellow bone marrow and red bone marrowHumerus (proximal) ; radius and ulna (distal) of the upper extremity; femur (proximal), tibia (anterior/distal) and fibula (posterior/distal) of the lower extremity

Slide9

Long Bones

Examples of long bonesMetacarpals Phalanges9 14 10 1511 1612 13

Slide10

Red and Yellow Bone Marrow

Half of the bone marrow is red (in adults)Red marrow is found mainly in the flat bones (hip bone, sternum, skull, ribs, vertebrae and shoulder blades)Also found in the spongy material in the proximal ends of the long bones – femur and humerus Yellow marrow is found in the hollow interior of the middle portion of long bones

Femur head; view of cortex; view of red bone marrow; view of yellow bone marrow (2009)

Slide11

Bone Marrow

Hematopoesis (blood formation)RBC storageProduction of WBCsPlatelets (formed in bone marrow; aid in clotting)High fat content (long bones) fat embolus

“Fat embolism syndrome, a condition characterized by hypoxia, bilateral pulmonary infiltrates, and mental status change, is commonly thought of in association with long-bone trauma. … Although studies suggest that embolization events infrequently result in clinically apparent fat embolism syndrome, clinicians should be vigilant in considering fat embolism as a causative agent for postoperative respiratory distress.”(Glazer & Onion, 2001)

Slide12

Short Bones

Short bones

Cube-like; about as long as they are wide

Contain mostly spongy bone

Outside surface consists of a thin layer of compact bone

Located in the hands and feet (metacarpals)

Patella

Slide13

Long Bones

??

Slide14

Flat Bones

Flat bones

Thin and flat

Found where the need is for a broad surface area for muscular attachment or where extra protection is needed

Examples: Skull; Pelvis; Sternum; Rib cage; Scapula

In adults most RBCs are formed in flat bones

Slide15

Bones: Microscopic Anatomy

Osteoprogenitor

cells are

multipotential

skeletal cells; the stem cells for the skeletal system.

Osteoblasts

are bone forming cells; they lay down the bond tissue. Can be stimulated in cancer.

Osteocytes

are mature bone cells that become trapped at maturity in a matrix; they maintain the bone

Osteoclasts

are bone reabsorbing cells that destroy old bone. Slow process. Inc cancer, these cells are destroyed and not replaced (osteoporosis).

Collagen

is soft, strong connective tissue that supports and reinforces the mineralized matrix – stronger than steel.

Slide16

Irregular Bones

Examples are the vertebrae; sacrum; coccyx; temporal; sphenoid;

ethmoid

(in skull);

zygomatic

(cheek bone);

maxilla; mandible; palatine; inferior nasal

concha

; and hyoid

Serve as protection (example: vertebrae protects spinal cord)

Allowing multiple anchor points for skeletal muscle (example: sacrum)

Slide17

Bones

Ligaments (bone to bone): fibrous connective tissue connecting bone to bone

Tendons: (connect muscle to bone) Example:

achilles

tendon attaches calf muscles to the ankle bone while a ligament holds the calf and thigh bones together at the knee joint.

Slide18

Sesamoid (Round) Bones Sutural, or Wormian bones

An example of a Sesamoid bone is the patella Sesamoid bones are embedded within tendons; Act to protect tendonsSutural or Wormian bones occur between the sutures of the cranial bones

Slide19

Bones: Types

Long Bones: weight bearing, strong, curved

Short bones: compact on surface, spongy center &

cuboidal

(metatarsals)

Flat bones: parallel surfaces of the body,

protecitve

funciton

, broad attachment surface (ribs, pelvis, skull,

ilium

)

Irregular bones: various functions: vertebrae & some facial bones

Sesamoid

(or round) bones: embedded in tendons, allow change of direction of movement, like a pulley (patella)

Sutural

or

Wormian

bones: between sutures of skull (between large flat bones of skull)

Slide20

Joints

A

di

arthrosis

joint is a freely moveable joint – always a synovial joint

Types of synovial joints

Gliding

(Two sliding surfaces) (Example - between carpals)

Hinge

(Concave surface with convex surface) (Example – between

humerus

and ulna)

Pivot

(Rounded end fits into ring of bone and ligament (Example – between atlas (C1) and

axia

(C2) vertebrae

Slide21

Joints

Synovial Joint

Diarthrosis Joint

(all are synovial joints)

Slide22

Joints, Synovial types, cont.

Ball and socket joint

(Ball-shaped head with cup-shaped socket) (Example – Between femur and pelvis)

Condyloid

joint

(Oval

condyle

with oval cavity) (Example – between metacarpals and phalanges)

Saddle joint

(Each surface is both concave and convex) (Example – Between

carpus

and the first metacarpal)

Hinge joint

(

interphalangeal

joints)

Pivot joint

(able to rotate – neck, forearm, knees)

Slide23

Muscles

Source of power and movement

Three types…

Skeletal Muscle

Cardiac Muscle

Smooth Muscle

Slide24

Skeletal Muscle

Skeletal Muscle

Attached to bones and causes movements of the body.

Also called striated

muscle (

actin

&??)

because of its banding pattern, or voluntary muscle (because muscle contraction can be consciously controlled

)

Slide25

Cardiac Muscle

Cardiac muscle

Responsible for the rhythmic contractions of the heart

Muscle is involuntary

Generates its own stimuli to initiate muscle contraction

Microscopically striated like skeletal muscle

Striations join together in bundles to allow coordinated action

Involuntary and

autorhythmic

. Some cardiac muscles function as built in pacemakers.

Slide26

Smooth Muscle

Smooth Muscle

Lines the walls of hollow organs

(Example: lines the walls of blood vessels and of the digestive tract where it functions to advance the movement of substances.

Contraction is relatively slow and

involuntary

Microscopically smooth (not striated)

Slide27

Slide28

Basic components

Muscles are stimulated by motor neurons.

Richly supplied w/ arteries and veins and have intimate contact w/a rich capillary network b/c of high energy demands.

Slide29

Diagnostic Tests forMusculoskeletal

X-ray

Electromyogram (EMG)

Arthroscopy

Arthrogram

Computerized Axial Tomography (CT)

Magnetic Resonance Imaging (MRI)

Bone Scan

Arthrocentesis

Laboratory Testing

Antinuclear Antibodies (ANA)

Ca+, P

Rheumatoid Factor (RF)

Erythrocyte Sedimentation Rate (ESR)

Uric Acid

Slide30

Chemical action in muscle

ATP – ADP energy cycle. Critical to muscles ability to get energy they need to do the work they need to do.

Slide31

Soft Tissue Injuries

Sprains/Strains

Sports-related

Dislocation/Subluxation

Carpal Tunnel Syndrome

Rotator cuff

Repetitive Strain

Meniscus Injury

Bursitis

Muscle spasms

Slide32

Dislocation / Subluxation

Dislocation of jointSubluxation (partial dislocation of joint)Candidate joints are shoulders, fingers, kneecaps

Slide33

Trauma to Bone

Highest incidence

MALES 15-24 years of age

or

elderly females 65 years of age, or older

Why are females in this age group affected?

A result of a blow to the body, a fall, or another accident

Slide34

Rotator Cuff Injury

A rotator cuff injury includes any type of irritation or damage to the rotator cuff muscles or tendons. Causes of a rotator cuff injury may include falling, lifting and repetitive arm activities — especially those done overhead, such as throwing a baseball or placing items on overhead shelves (Mayo Clinic, 2008)

Slide35

Meniscus Injury

Symptoms of medial meniscus tear A history of trauma or twisting of the knee Pain on the inner surface of the knee joint Swelling of the knee within 24-48 hours of injury Inability to bend knee fully- this may be associated with pain or a clicking noise A positive sign (pain and/or clicking noise) during a "McMurrays test" Pain when rotating and pressing down on the knee in prone position (video). "Locking" of the knee Inability to weight bear on the affected side (SIC, 2008)

Slide36

Muscle Spasm

Inflammation that occurs when a muscle is over-stretched or tornThe back is a common area for inflammation to occurWhy? Poor body mechanics (cold or heat might be effective, reduce inflammation & relax muscles)

Slide37

Bursitis:Inflammation of the Bursa(Pain, fluid build up, calcium deposits & loss of motion in the joint. Prevention is to build up activity gradually. Treatment: avoid what is causing the problem, NSAIDS, steroids, ice. In some cases surgery might be necessary.

Slide38

Types of Complete Fractures

Closed (Simple)

Open (Compound

):

riskiest due to infection, bone breaks through skin.

Transverse

Oblique

Spiral

Comminuted

Colles

’ fracture:

fracture of wrist on inside portion of wrist. Treatment is reduce it & cast it. (happens when someone falls down). Responds well to cast.

Slide39

Fractures

Fractures commonly tear blood vessels, producing a hematoma

This area of hematoma is commonly used as an area to anesthetize the

periosteum

because

thisis

where the blood vessels are located.

Reduction usually requires anesthesia

Slide40

Healing stages

After several weeks the

periosteum

is beginning to heal & lay down scar tissue.

Trabecular

cone has begun to grow over the break. There is callus formation w/ the

osteoblasts

After several months…..

Slide41

Healing stages, cont

Remodeling: over the next months or years, the bone shape returns to normal as

osteoclasts

absorb extra cells and

osteoblsats

generate new cells and bone. The bone will be thickened somewhat at the fracture…

Fully healed fractures in children are indistinguishable from the original bone b/c the growth plates are open. However, multiple

fxs

in various stages of healing are a strong indicator of child abuse

Slide42

Closed Simple Fracture

Only bone damageLittle or no soft tissue damage Does not penetrate skin

Slide43

Open Fracture

Probably need surgery… lot of time spent cleaning the wound

Wound may be left open for a while…

Slide44

Transverse Bone Fracture

Often caused by direct traumatic injuryBone has been broken giving rise to a transverse break or fissure within the bone at a right angle to the long portion of the bone

Slide45

Oblique Bone Fracture

Extremely rare type of breakAn oblique break in the bone which is very unstable (break at an angle)Bone still together…

Slide46

Spiral Fractures

Bone is broken due to twisting-type motionUnstable fractureLooks like corkscrew – runs parallel with the axis of the broken bone

Slide47

Comminuted (crushed) Fracture

More than two fragments of bone have been broken offHighly unstable with many bone fragments(Fixed w/ rods & screws after taking all the pieces out)

Slide48

Types of Incomplete Fractures

Greenstick

Torus (closed) (side of the bone bends but does not break)

Bowing

Stress

Slide49

Greenstick fracture

Usually seen in childrenBone is usually “bent” and broken on the outside of the bendIf kept straight, heals quickly(sometimes doesn’t need a cast… sometimes overtreated)

Slide50

Stress Fracture

Incomplete fractureCaused by “unusual or repeated” stress – this in contrast to other type fractures resulting from traumaCommon sports injury and among soldiers from marchingTiny hairline fractures

Most common symptom is pain

Most are not associated with swelling or redness, but tenderness to palpation

Tibia (shin splints-runners)

and metatarsal bones affected in runners

Slide51

Stress Fracture

Example of a stress fracture Common runner-type fracture

Slide52

Other Types of Fractures

Pathologic Fracture

May occur during normal activity or after minimal injury

(Is associated with what

?) common in elderly w/

osteoarthrits

or osteoporosis

Fatigue or Stress Fracture

The muscles associated with the bones are unable to absorb energy as they usually do

Avulsion Fracture

A strong ligament or tendon pulls a fragment of the bone away from the rest of it

Impacted Fracture

Fracture fragments are pushed into each other

Slide53

Clinical Manifestations

Pain

Loss of normal function

Obvious deformity

Excessive motion

Crepitus

(fluid builds up on joint, can be felt at the joint)

Edema

Warmth

Ecchymosis

Loss of sensation

Signs of shock

X-ray evidence

Slide54

Factors that hinder good callus formation

Inadequate reduction of the fracture

Inefficient immobilization

Excessive edema at the fracture site, impeding the supply of nutrients

Too much bone lost at time of injury to permit bridging of broken ends

Infection at the site of injury

Bone necrosis

Anemia or other systemic conditions

Endocrine imbalance (parathyroid not enough Ca)

Poor dietary intake

Slide55

Neurovascular Assessment (5 Ps)

Pain

Paresthesia (tingling, pricking, or numbness of the skin)

Pallor

Pulses

Paralysis

Slide56

Goals

Prevent injury

Maintain strength

Promote comfort

Maintain intact neurovascular status

Slide57

Treatment Objectives for Fracture

Reduction of fracture

Maintenance of fragments in correct alignment

Prevention of excessive loss of mobility and muscle tone

Slide58

Collaborative Management

Health History

X-ray/CT/MRI/Scan

Fx

Reduction

Fx

Immobilization

MEDS

Analgesics

Antibiotics

Tetanus

Toxoid

(good for 10 years)

Slide59

Immobilization of Bones

1)

Physiologic

Splintage

- naturally occurring phenomenon related to pain that causes guarding, muscle spasms, and avoidance of further use. There is a desire to rest the whole body until some repair has occurred.

2)

External orthopedic

splintage

- with devices such as casts

3)

Internal Fixation

with screws, pins, rods or plates to hold the opposing ends of the fracture in place

Slide60

Bone Healing

1.

Hematoma formation

(situates between broken fragments)

2.

Fibrin meshwork formation

(blood vessels grow into a jelly-like matrix of the blood clot – WBCs are brought to the site

3.

Invasion of

osteoblasts

(produces matrix that becomes mineralized)

4.

Callus formation

(usually shows up by x-ray 6 weeks in adults/less time in children

5.

Remodeling

(bones are constantly changing –

osteoclasts

break down old bone so

osteoblasts

can replace it with new bone tissue – a process called remodeling.

What can impair bone healing?

Slide61

Bone Healing

Slide62

Fractures: terms commonly used

Reduction: re-establishment of the normal position of ..

Dislocation

Fracture

Internal fixation is the surgical placement of steel material into the bone to hold it in place. Used when healing would be impaired or immobility of the

fx

is a problem.

Slide63

Factors that Hinder Good Callus Formation

Inadequate reduction of the fracture

Inefficient immobilization

Excessive edema at fracture site, impeding the supply of nutrients

Too much bone lost at time of injury to permit bridging of broken ends

Infection at the site of injury

Bone necrosis

Anemia or other systemic conditions

Endocrine imbalance

Poor dietary intake

Slide64

Immobilization and Care

External fixation devices

Casts (plaster casts can be bi-

valved

to allow for swelling)-this means it is cut into two pieces, lengthwise, so that the area beneath the cast can be observed.

Splints

Brace or cast-brace

Traction (weights should hang freely)

Skin traction

Skeletal traction

Balanced suspension

Counter-traction

Internal

Fixators

Plates and screws

Rods

Prosthetics

Bone Stimulation

Slide65

External Fixator

Used when a cast would not allow proper alignment/immobilization of the fractureProper cleaning to prevent infection is required No cast, just curlex (gauze)

Slide66

Traction

Aligns the ends of a fracture by pulling the limb into a straight position

Helps manage muscle spasm r/t

fracture

(weights should hang freely)

Skin traction

Skeletal traction

Balanced suspension

Counter – traction

Skin integrity or back massage might be helpful. Often used pre-op to keep them immobile

Slide67

Bone Stimulation

Used when satisfactory healing is not occurring naturally Application of a low electrical current to the fracturePromotes the speed of bone healing

Slide68

Nursing Diagnoses

Risk for Neurovascular Dysfunction

Pain

Risk for Infection

(Risk for) Impaired Skin Integrity

Risk for Nutrition Deficit

Risk for Injury

Knowledge

Deficit (teaching about care of the site)

Risk for impaired perfusion

Slide69

Complications

Who is at risk?

: 0.5%-2% long bones, 10% hip

DVT



Stroke or Pulmonary Embolus

S/S of PE:

Hemoptysis

(coughing up of blood),

pleuritic

chest pain,

dyspnea

,

rales

Fat Embolism Syndrome (When fat enters the circulation)

12-48 hrs after fracture

Usually associated with

fx

of long bone or pelvis (

fx

of hip is at highest risk)

Men 20 to 40 years of age and older adults 70 to 80 years of age at greatest risk for development

Mental status changes (hypoxemia),

tachypnea

,

dyspnea

, tachycardia, temperature,

petechia

of upper body and

axilla

, feeling of impending doom

Slide70

Complications

Compartment Syndrome 4-12 hrs after fractureCompartments are areas of the body in which muscles, blood vessels, and nerves are contained within fasciaProgressive pain distal to fracture, 5 Ps (pain, pressure, paralysis, paresthesia, pallor and pulselessness), pressure inside compartment >30mmHg (normal 0-8 mmHgFasciotomy (opening in the fascia)

Slide71

Deep Vein Thrombosis

Slide72

Deep Vein Thrombosis

Route of DVT embolus

Pulmonary embolism

Slide73

Hip Fractures

Currently more than 250,000 hip fractures annually

Associated costs exceed $7 billion

Repair of a fractured hip is the most common procedure performed in people over 85.

30% of patients with a hip fracture die within 1

year r/t surgery (complications) & immobility

Osteoporosis is biggest risk factor

Slide74

Classification of Hip Fractures

IntracapsularExtracapsularIntertrocantericSubtrocantericTranscervicalImpacted at base of the neck(Capsular refers to the proximal 1/3 of bone)

Slide75

Signs of Symptoms of Hip Fracture

Medical emergency

Severe pain at the fracture site

Inability to move leg voluntarily

Classic



shortening

and external rotation of the leg

One-third of elderly individuals with hip fracture die within one year of injury

Typically the bone is rotated externally & shortening of the leg… try to get the leg back into

allignment

…

Slide76

Medical Management –Hip Fracture

Conservative management

Prolonged immobility - 12-16 wks BR(avoids the risks associated with anesthesia)

Surgical Management

Reduction and stabilization of fracture with insertion of internal fixation device

Stable plate and screw (non-w/b 6 weeks to 3 months)

Telescoping nail (minimal to partial w/b 6 weeks3 months)

Prosthetic implant -replaces femoral head and neck

position restriction 2 weeks->2 months

partial weight bearing 2 months

Slide77

Follow-up Instructions –Hip Fracture

DO NOT

flex more than 90

o

force hip into adduction or internal rotation

cross legs

put on own shoes and socks x 8 weeks

sit in chairs that do not have armrests

Slide78

Follow-up Instructions –Hip Fracture

DO

Keep in extension and abduction

use toilet seat raiser

place/use shower chair

use pillow between legs x 8 weeks

notify of increased pain

inform dentist of prosthetic device

Slide79

5 Ps of neurovascular assessment

May be a test question

Pain

Paresthesia

(tingling, prickling or numbness of the skin)

Pallor

Pulses

paralysis

Slide80

Hip Fracture

Slide81

Hip Fracture

Severe pain at the fracture siteInability to move leg voluntarilyExternal Rotation

Slide82

Total Hip Replacement

Preoperative care-consider psychosocial issues-family support-comfort-safety

Postoperative care-hip is kept in extension and abduction to prevent dislocation of the hip

Slide83

Osteomyelitis

Acute or chronic infection of bone (confirmed by positive wound culture)

Usually staph

aureus

Direct or indirect

Pain, temperature, swelling, warmth, redness

Wound culture, bone scan, CT, MRI

Aggressive antibiotics 6-8

wks

(my pt at

Speciality

)

Nursing diagnoses: Pain, Impaired physical mobility, Ineffective therapeutic regimen, Risk for impaired skin integrity

Nursing care: Aseptic technique, no heat or exercise to affected area which will increase circulation

Slide84

Osteomyelitis

Slide85

Osteoporosis

A disorder in which bone mass is lost to the point where the skeleton is no longer able to withstand unexpected or normal mechanical forces. Most common skeletal disorder and second only to arthritis as a cause of musculoskeletal morbidity in the elderly. A/K/A porous bone

Bone resorption > bone formation

Slide86

Osteoporosis

Slide87

Osteoporosis Risk Factors

Aging

Gender (female)

Race (white)

Family History

Postmenopausal

(and not taking calcium supplement)

Chronic calcium deficiency

Sedentary

lifestyle (wt bearing exercise)

Small frame-low body weight

Slide88

Osteoporosis – Related Risk Factors

Chronic smoking

Diet high in protein and fat (phosphorous depletes calcium – found in animal fat/protein)

Chronic alcohol use

Excessive caffeine intake (phosphorous depletes calcium)

Postmenopausal (estrogen helps body absorb calcium)

Glucocorticoids

(involved in protein and fat metabolism; Aluminum containing antacids (reduce amount of calcium in the body

)

Horonal

imbalances (estrogen and testosterone) are the primary causes of osteoporosis

Slide89

Osteoporosis – Secondary Risk Factors

Endocrine disorders: Hyperthyroidism, hyperparathyroidism

GI Disorders

malabsorption syndrome, Hyperthyroidism, parathyroidism

COPD

glucocorticoids

Drug

Glucocorticoids

, heparin, anticonvulsants, loop diuretics, barbiturates

Slide90

OsteoporosisClinical Manifestations

Back Pain- (

fx

of vertebra)

Chronic dull ache

Sudden onset of acute pain greatly intensified with coughing, sneezing or movement

Fracture

Proximal femur

Distal radius

Proximal

humerus

Ribs

Thoracic

kyphosis

(Dowager’s hump)

Loss of more than 2 in. standing height

Slide91

Osteoporosis Collaborative Management

Diagnosis

Labs may not be helpful

X-rays (at 30-50% loss)

CT , MRI, Bone Scan

Bone Mineral Density Measurement

Medication

Estrogen Replacement: Prevention

Calcium Supplements

Calcitonin

: Nasal spray->irritating

Fosamax

,

Boniva

(1X/ month)

Actonel

: Before breakfast without food, sit upright X 30 min., full glass water

Vertebroplasty

,

Kyphoplasty

Slide92

OsteoporosisNursing Management

Nursing diagnoses: Pain, Impaired physical mobility, Risk for injury, Imbalanced nutrition: less than body requirements

Promote calcium intake

Review diet to include:

Decrease caffeine

Excess calcium loss

Decrease protein and fat

High protein diet causes bone loss secondary to calcium loss

Promote exercise

active weight bearing, walking

Slide93

Paget’s Disease

Excessive bone resorption followed by bone formation leading to weakened bone, bone pain, arthritis, deformity leading to pathologic fractures and osteogenic sarcoma

Bone marrow replaced by vascular fibrous connective tissue leading to formation of larger, disorganized, weaker bone

X-ray, increased alkaline phosphatase, positive bone scan

Medication (Fosamax, Actonel) with slowing of disease with early diagnosis

Slide94

Paget’s Disease

Slide95

Osteoarthritis (DJD)

Degenerative Joint Disease

Most common form of arthritis in the elderly

#1 cause of disability and limitation in those over 74

Non-inflammatory disease of moveable joints

Deterioration in articular cartilage and formation of new bone at the joint

Slide96

Osteoarthritis (DJD)

Slide97

Osteoarthritis

Slide98

OsteoarthritisRisk Factors

Age

Obesity

Repetitive joint injuries

Genetics

Slide99

Osteoarthritis -Cardinal Symptoms

Pain

After movement relieved by rest

Characterized as aching

Poorly localized

On motion with weight bearing

Slide100

Osteoarthritis -Cardinal Symptoms

Stiffness

On awakening and in AM

After activity

Of relatively short duration

Slide101

OsteoarthritisOther Signs and Symptoms

Crepitus

Limitation of motion

Weight-bearing joints weaken (asymmetrical)

Heberden nodes

Lateral enlargements of the distal phalangeal joints

Bouchard’s nodes (found at the proximal interphalangeal joints)

Slide102

Bouchard Nodes

Slide103

Heberdan Nodes

Slide104

Osteoarthritis – Diagnosis

X-Ray

Decreased joint space, bony sclerosis, spur formation

Fluid analysis

Slide105

Osteoarthritis - Treatment

Symptomatic relief and minimization of further joint destruction

Exercise

Rest

Weight-loss

NSAIDs

Gastric irritation, bleeding

Disturbance in platelet formation

Slide106

Rheumatoid Arthritis

Chronic, systemic inflammatory disease of moveable joints

6 million Americans

Prevalence increases with age for both men and women

Slide107

Rheumatoid Arthritis

Slide108

Rheumatoid Arthritis

Slide109

Rheumatoid Arthritis –Cardinal Symptoms

Unexplained periods of exacerbation and remission

Painful, swollen joints,

Bilateral, symmetrical

Morning stiffness

Lasting longer than 1 hour

In AM and after inactivity

Slide110

Rheumatoid Arthritis –Cardinal Symptoms

Abnormal labs

Elevated ESR (

sed

rate)

Rheumatoid

factor

Anemia

WBC in synovial fluid

X-Ray

Bone degeneration

Slide111

Rheumatoid Arthritis –Diagnosis

Based on cluster (4 for 6 weeks)

Morning stiffness

Arthritis in three or more joints

Arthritis of hand joints

Symmetrical

Rheumatoid nodules

Serum rheumatoid factor

Radiographic changes

Slide112

Rheumatoid ArthritisTreatment Goals

Reduce inflammation

Alleviate pain

Preserve function

Prevent

deformity

(treatment is the same as OA, pretty much)

Both RA & OA cause severe loss of quality of life

Slide113

Rheumatoid Arthritis –Management

Rest

PT

Aspirin

Corticosteroids

Gold salts

Disease modifying antirheumatic drugs (DMARDs)

Plaquenil, Azulfadine

Methotrexate

Slide114

Rheumatoid Arthritis

Slide115

Comparison of OA to RA

OA

Degenerative joint dzAffects articular cartilageNeed to add more

RA

Autoimmune joint

dx

“inflammatory arthritis”

Affects synovial membrane

Membrane thickens and immobilizes the joint

Slide116

Gout: Gouty Arthritis

Affects middle aged to elderly men

Associated with renal stones r/t sodium

urate

crystal deposition

Treated with drugs that promote uric acid excretion (

allopurinol

and

probenicid

)

Treated with diet-limiting protein(organ meats, red meats, i.e., high

purine

food)

(Gout is associated with increased uric acid in the body;

Purines

increases uric acid levels in the body)

Unlike other forms of arthritis absolute rest of the joint is necessary. So painful it causes extreme pain just to touch the joint.

Primary form is inherited

(aspirin not indicated, can make the uric levels higher)

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Mandible Fracture

Preoperative care-history of injury, pain control, gentle oral care, psycho-social

Postoperative care-pain control, observe for s/s infection, suction equipment at bedside, liquid diet, careful monitoring of airway, ready to cut wires if client vomits or has respiratory emergency(wirecutters at bedside)

Slide118

Mandibular Fracture

Slide119

Amputation

Preoperative care-nurse does history(how it occurred if trauma), concurrent illnesses, habits,

ie

. Smoking, current meds, psycho-social

Postoperative care-pain management including phantom pain, prevent infection, observe for adequate tissue perfusion

Nursing

dx

: prevention of infection, promotion of mobility, preparation for prosthesis…

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Amputation

Accidental

Surgical

Slide121

Bone Cancer

Multiple Myeloma

Osteogenic

sarcoma,Osteoclastoma

, Ewing’s Sarcoma,

Metatastic

Bone

Disease

Slide122

Primary Bone Cancer

Multiple Myeloma (Plasma cell myeloma)

Invades sternum, ribs, spine, clavicles, pelvis, long bones.

Sx

: back pain, anemia, thrombocytopenia.

Osteogenic

sarcoma

Metaphyseal

area of long bones, esp. distal femur, proximal tibia, proximal

humerus

.

10-25 y/o males

Osteoclastoma

(Giant cell tumor)

Cancellous

bone: distal femur, proximal tibia, distal radius.

20-35 y/o.

Swelling local pain, bone destruction on

Xray

Ewing’s Sarcoma

 3

rd

most common

Males under age 30

Medullary

cavity of long bone esp. femur, pelvis, tibia, ribs.

Mets to lung

Metastatic bone lesions

from breast, GI tract, lungs, prostate, kidney, ovary, and thyroid

Slide123

Other Musculoskeletal Problems

Muscular Dystrophy

Low Back Pain-Laminectomy

Herniated Intervertebral Disk