Chapter 64: Nursing Management: Musculoskeletal Problems

OSTEOMYELITIS • Osteomyelitis is a severe infection of bone, bone marrow, and surrounding soft tissue. • Infecting microorganisms can invade by indirect or direct entry. After entering the blood, they lodge in an area of bone and grow which results in increased pressure, eventually leading to bone ischemia. Once ischemia occurs, the bone dies. Chronic osteomyelitis is a continuous, persistent problem or a process of exacerbations and remission. Acute symptoms are fever, night sweats, malaise, and constant bone pain. Some immobilization of affected limb (e.g., splint, traction) is indicated to decrease pain. The patient is frequently on bed rest in the early stages of the acute infection. Vigorous and prolonged IV antibiotic therapy is treatment of choice for acute osteomyelitis. Oral antibiotics, hyperbaric oxygen therapy, and surgery may be prescribed for chronic disease.

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SARCOMA • Most primary bone cancer is called sarcoma. • • Sarcomas can also develop in cartilage, muscle fibers, fatty tissue, and nerve tissue. Common types are osteogenic sarcoma, chondrosarcoma, Ewing’s sarcoma, and chordoma.

OSTEOCHONDROMA • Osteochondroma is a primary benign bone tumor characterized by overgrowth of cartilage and bone near end of the bone at the growth plate. • • • Manifestations include painless, hard, and immobile mass, one leg or arm longer than other, and pressure or irritation with exercise. No treatment necessary if asymptomatic. If patient has pain or neurologic symptoms due to compression, surgical resection is usually done. Nursing care does not differ significantly from the care given to patients with a malignant disease of any other body system.

Osteogenic Sarcoma • Osteogenic sarcoma (osteosarcoma) is a primary bone tumor that is extremely aggressive and rapidly metastasizes to distant sites. • Manifestations are usually associated with gradual onset of pain and swelling, especially around the knee.

Preoperative (neoadjuvant) chemotherapy is used to decrease tumor size.

• Limb-salvage procedures are considered when there is a clear 6- to 7-cm margin surrounding the lesion. Metastatic Bone Cancer • The most common type of malignant bone tumor occurs as a result of metastasis from a primary tumor. • • • Metastatic bone lesion is commonly found in vertebrae, pelvis, femur, humerus, or ribs. Metastasis to bone may be suspected in patients with local bone pain and past cancer history. Treatment may be palliative and consists of radiation and pain management.

LOW BACK PAIN • Low back pain is common, affecting about 80% of adults during their lifetime. • Acute low back pain is usually associated with activity that causes undue stress (often hyperflexion) on the lower back. o If muscle spasms and pain are not severe, treatment includes avoiding activities that aggravate pain, analgesics, muscle relaxants, massage and back manipulation; and heat and cold compresses. o Most acute cases spontaneously improve. Chronic low back pain causes include degenerative disk disease, lack of physical exercise, prior injury, obesity, and structural and postural abnormalities. o Treatment can include weight reduction, analgesics, rest periods, heat or cold application, and exercise and activity to keep muscles and joints mobilized. o Surgery may be indicated for severe chronic low back pain that is not responding to conservative care.

INTERVERTEBRAL LUMBAR DISK DAMAGE • Structural degeneration of the lumbar disk is often caused by degenerative disk disease (DDD). • This is a normal process of aging, and results in intervertebral disks losing their elasticity, flexibility, and shock-absorbing capabilities. • An acute herniated intervertebral disk (slipped disk) can be the result of DDD or repeated stress and spinal trauma. • Radicular pain, which radiates down buttock and below the knee, generally indicates disk herniation. • Treatment initially is at least 4 weeks of conservative therapy including drug therapy, limitation of spinal movement with brace or corset, local heat or ice, ultrasound and massage, transcutaneous electrical nerve stimulation, and epidural steroid injections. If there is no improvement, various surgical techniques may be used. • Postoperative nursing interventions focus on maintaining proper alignment of the spine

at all times until healing has occurred. • Once symptoms subside, back strengthening exercises are begun twice a day and encouraged for a lifetime. FOOT DISORDERS • Most of the pain and disability is attributed to improperly fitting shoes, which cause toe crowding and inhibition of normal foot muscle movement. • The older adult is prone to foot problems because of poor circulation, atherosclerosis, and decreased sensation in lower extremities. • Therapy includes analgesics, shock-wave therapy, icing, physical therapy, alterations in footwear, stretching, warm soaks, orthotics, ultrasound, and corticosteroid injections. • If there is no relief, then surgery may be done.

OSTEOMALACIA • Osteomalacia is a rare condition of adult bone associated with vitamin D deficiency, resulting in decalcification and softening of bone. • • Common features are localized bone pain, difficulty rising from a chair, and walking. Care is directed toward correction of vitamin D deficiency. Vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol) can be supplemented. Calcium salts or phosphorus supplements may also be prescribed. Exposure to sunlight (and ultraviolet rays) is also valuable, along with weight-bearing exercise.

OSTEOPOROSIS • Osteoporosis is a chronic, progressive metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue. • Bones can eventually become so fragile that they cannot withstand normal mechanical stress. • At least 10 million persons in the United States (80% are women) have osteoporosis. • Risk factors are female sex, increasing age, family history of osteoporosis, white or Asian race, small stature, early menopause, sedentary lifestyle, and insufficient dietary calcium. • People may not know they have osteoporosis until their bones become so weak that a sudden fall causes a hip or vertebral fracture. • Collapsed vertebrae may initially be manifested as back pain, loss of height, or spinal deformities such as kyphosis or severely stooped posture. • Dual-energy x-ray absorptiometry (DEXA) studies are used in diagnosis and to assess the treatment effectiveness.

• Collaborative care focuses on proper nutrition, calcium supplementation, exercise, prevention of fractures, and drugs. PAGET’S DISEASE • Paget’s disease is a skeletal bone disorder in which there is excessive bone resorption followed by replacement of normal marrow by vascular, fibrous connective tissue. • The etiology is unknown, although a viral cause has been proposed. • Initial manifestations are usually insidious development of bone pain (may progress to severe intractable pain), fatigue, and progressive development of a waddling gait. • Pathologic fracture is the most common complication. • X-rays may demonstrate that the normal contour of the affected bone is curved and the cortex is thickened and irregular. • Care is usually limited to symptomatic and supportive care and correction of secondary deformities by either surgical intervention or braces. GERONTOLOGIC CONSIDERATIONS: METABOLIC BONE DISEASES • Metabolic bone diseases increase the possibility of pathologic fractures. • • The nurse must use extreme caution when patient is turned or moved. It is important to keep the patient as active as possible to retard demineralization of bone resulting from disuse or extended immobilization.