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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

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.

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.

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.

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
A nutritionally adequate diet is recommended.
Assistance in learning to use canes or other ambulatory
The Arthritis Foundation & Paget Foundation are
useful resources for patients & their families.


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

Hematogenouscaused 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.


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


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.

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.

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
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.

Ewings Tumor
sarcoma- of
A malignant
tumor of the
the MSS
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 person> 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.

Chondrosarcomaaffects persons
Tumor ofUsually
the MSS
50-70 years old. Accounts for 20% of all bone
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
Treatment: Surgical incision, amputation.

Tumor of the MSS

Fibrosarcoma- Usually affects persons 3050 years old. Affects females than males.
Occurs in bony fibrous tissue of femur & tibia.
Accounts for 4% of primary malignant bone
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.


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 disorderspoor mineral absorption & hormonal changes
decreases bone calcification which results in a
weakened bone. Bedrest or disuse- atropic muscles
& osteoporosis causes decreased stress resistance.

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.

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
Depressed: Usually seen in skull or facial fractures.
Bone or fragments of bone are driven inward.
Pathological: break caused by disease process.
Intracapsular:Bone broken inside the joint.
Extracapsular: Fracture outside the joint.

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
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.

Fractures (signs & symptoms)

Pain or tenderness over involved area.

Loss of function of the extremity
Crepitation: sound of grating bone fragments
Ecchymosis or erythema
Muscle spasm
Deformity: Overriding; Angulation- limb is in
unnatural position.

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
Provide specific care for fracture treatment: traction,
cast. Surgical intervention.


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
Open reduction: Surgical intervention.
Usually treated with internal fixation devices
(screws, plates, wires). Cast application.


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


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.

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.

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.

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.

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.

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
Diagnosis: Intracompartment pressure > 30 mm hg.

Fractures (Complications)

Treatment: Fasciotomy-open the affected

compartment, decrease the pressure & restore normal
perfusion. The wound is covered with wet saline
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.

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.

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.

HIP fractures

Extracapsular: trochanteric fracture outside the

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.

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
Prevent infections- monitor prophylactic antibiotic.

HIP fractures

Continuous passive motion (CPM) first day

postop with increasing degree of flexion to 90
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 &
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.

HIP fractures

Observe for neurovascular problems in

affected leg: Color and temperature, edema in
leg, pain on passive flexion of foot, numbnessability to move leg, pedal pulses & capillary

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 & extensionincrease circulation & movement.
Perform quad-setting & straight-leg raising
exercises every hour.
Perform ROM.
Do not dangle to prevent disclocation.

Total Knee
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.


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
More than 110,000 are performed each year in
the U.S. & 91% of them are lower extremity
Occurs in patients with diabetes 15 times more
frequently than in other patients with chronic
arterial occlusive disease.

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.

Amputations (Assessment)

Evaluate dressing for signs of infection or

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.


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.


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.