Chapter 50: Care of Patients with Musculoskeletal Problems

 Musculoskeletal disorders include diseases of cellular regulation (osteoporosis), and a variety of

deformities and syndromes. 
 Almost all musculoskeletal health problems can cause the patient to have difficulty meeting the human
need of MOBILITY. 

 Osteoporosis CELLULAR REGULATION

 A chronic disease of CELLULAR REGULATION, bone loss causes decreased density and
increases the risk of fracture.
 Often referred to as a silent thief, the first indication of osteoporosis in most
people occurs as a fracture, often of the hip, spine, or wrist. 
 Hormones affecting 
 Parathyroid: Pulls calcium from the bone 
 Calcitonin: Deposits calcium into the bone 
 Bone mineral density (BMD) determines bone strength
 Before and during the peak years, which are 25 to 30 years of age, osteoclastic
activity and osteoblastic activity work at the same rate.
 After the peak years (mid 30’s), bone resorption activity exceeds bone-building
activity, and BMD decreases. (bone formation goes down)
 Fractures (B/C loss of bone density)
 as a result of osteoporosis and falling can decrease a patient's MOBILITY and
quality of life. 
 Osteoporosis and osteopenia (low bone mass) occur when bone resorption activity is
greater than bone-building activity. 
 Causes:
 combination of genetic, lifestyle, and environmental factors. 
 Osteoporosis may result from changes in hormones or other diseases. 
 Severe or established osteoporosis is defined as a person with osteoporosis plus one or
more fractures. 

Primary osteoporosis 

 is more common and occurs in postmenopausal women and in men in their 70s or 80s. 
 Density decreases rapidly in postmenopausal women as serum estrogen levels
diminish. Although estrogen does not build bone, it helps prevent bone loss. 
 Men also develop osteoporosis as they age because their testosterone levels
decrease although not at the rate of bone loss in postmenopausal women. 
 Prevention decrease modifiable risk factors such as inadequate calcium and vitamin D
intake, smoking, alcohol intake, and sedentary lifestyles. Lack of exercise, caffeine 
 Aging: 
 Hight decreases over time you can loss as much as 6 inches in Hight
 Symptoms:
 Acute backpain with activity 
 Compression fractures in vertebra: the bending causes problems with
constipation, abdominal discomfort, respiratory compromise 
  Fractures: Occur in vertebral column between Ta-L3 (thoracic to lumbar) 
 Other common fractures in Hip or wrist 

Secondary osteoporosis

• may result from other medical conditions, such as hyperparathyroidism, long-term

drug corticosteroids, or prolonged immobility.
 Interventions: directed toward the cause of the osteoporosis when possible.

Interprofessional Collaborative Care: Assessment

• Fall Risk Assessment

• Vison changes with age
• Analysis
• Diagnostic Testing
• Imaging
• Laboratory tests
• Imaging
• DXA: Measures bone mineral density (BMD) (Women 40+)
• Measured in T scores:
• Normal -1 and above
• Ex: -0.9 is greater than -1, - 0.9 is normal
• -2.5 osteopenia (low bone density) 
• Remind patients at risk for osteoporosis to have regular screening tests,
such as the dual x-ray absorptiometry (DXA or DEXA) scan.
• The spine and hip are most often assessed when a central DXA (cDXA)
scan is done. 
• Used for community screening purposes, a peripheral DXA (pDXA) scan
assesses BMD of the heel, forearm, or finger.
• Teaching Prevention 
• Diet, Calcium and Vitamin D intake: Supliments 
• Walking exercise, weight bearing exercise
• Lifestyle no smoking, environment fall risks 
• Medications
• Bisphosphonates: “onates”
• help with bone reabsorption, take AM 30-60 min before breakfast with 8
ounces of water and wait 30 to 60 minutes in an upright position before
eating to prevent gastritis, esophageal erosion, gastric ulcers
• Oral assessment before BP therapy
• Risedronate: jaw and maxillary osteonecrosis
• Recast: IV drug, over 15-30 to prevent A.fib
• Estrogen Agonist antagonist
• Raloxifene: mimics estrogen in the blood
• Used in menopause, reduce bone reabsorption, increases bone minieral
density. Causes venous thromboembolism VTE
 Other disorders

Osteomalacia 

• Bone softening, loss of bone related to a vitamin D deficiency caused by

inadequate deposits of calcium and phosphorus in the bone matrix. 
• It is the adult equivalent of rickets, or vitamin D deficiency, in children. 
• Normal bone remodeling, and calcification of the bone is disrupted. 
• Bone is constantly undergoing changes in a process referred to as bone
remodeling, a type of CELLULAR REGULATION. 
• Osteomalacia can be caused by liver and pancreatic disorders, chronic kidney
disease, and bone tumors. 
• The major treatment for osteomalacia is vitamin D through dietary intake, sun
exposure, and drug supplements such as ergocalciferol. 

Osteoarthritis

• Progressive deterioration starts to lose cartilage and bone “wear and tear of joints”
• Caused by aging, genetics
• As cartilage disintegrates Symptoms:
• Joint pain, stiffness, decrease in mobility, muscle atrophy
• Eventually need joint replacement

OSTEOMYELITIS 

 Bone infection can result in chronic recurrence of infection, loss of function and
MOBILITY, amputation, and even death. Bacteria, viruses, or fungi can cause bone
infection, known as acute or chronic osteomyelitis, which can be a severe and difficult
problem to treat. 
 Symptoms:
 the inflammatory response in bone, producing vascular leak and edema.


 Acute
 PT has 101+ fever (older people might be less), swelling and tenderness to the
sight redness and heat, pain. Basically inflammation and systemic effect
 Chronic

 Recurring conditions, draining ulcers, sinuous tracts in the wound, tissue and bone
necrosis
 Management
 PT needs to be on antibiotics for several weeks, pain management, wound therapy
in chronic,
 Sequestrectomy: surgery remove necrotic bone & revascularize the tissue

 Osteomyelitis is categorized as exogenous, in which infectious organisms enter from outside the body, as in
an open fracture; endogenous, in which organisms are carried in the bloodstream from other areas of the
body; or contiguous, when bone infection results from skin infection of adjacent tissues.
o Bone infection can result in chronic recurrence of infection, loss of function, amputation, and even
death.
o Bacterial invasion stimulates the inflammatory response in bone tissue and causes NFLAMMATION.
o If bacteremia is present, septic shock may result and the patient may die. 
 Treatment of infection may be complicated further by the presence of methicillin- resistant Staphylococcus
aureus or other multidrug-resistant organisms. 
 One of the major desired outcomes in health care settings is to reduce the number of MRSA infections from
any source. To prevent the transmission of infection, follow Contact Precautions when caring for patients
with an open wound associated with osteomyelitis. 
 Teach family members or other caregivers in the home setting how to administer antimicrobials if they are
continued after hospital discharge or are used only at home. 

BENIGN BONE TUMORS

 Benign bone tumors are often asymptomatic and may be discovered on routine x-ray
examination or as the cause of pathologic fractures. 
 Tumors may arise from several types of tissues, including chondrogenic tumors (from
cartilage) osteogenic tumors (from bone,) and fibrogenic tumors from (fibrous tissue) 
 The most common benign bone tumor is the osteochondroma. 
 Meds:
 In addition to prescribing analgesics to reduce pain, nonsteroidal anti-
inflammatory drugs are given to inhibit prostaglandin synthesis that increases
PAIN and INFLAMMATION. 

MALIGNANT BONE TUMORS 

 Cancerous bone tumors may be primary or secondary. 

 Primary tumors (developed in the bone) occur most often in people between 10 and 30 years
of age and make up a small percentage of bone cancers. 
 Osteosarcoma, or osteogenic sarcoma,
 is a large tumor causing acute pain and swelling, and is the most common
primary malignant bone tumor. Can spread to the lungs 
 Systemic manifestations: fatigue, pallor anemia, fever, infect lower
extremities
 Secondary:
  (metastasized from some other part of the body)Previous radiation
therapy in the area is an increased risk factor. 
 Management 
 Diagnostic
 Needle bone biopsy to stage the size and degree of spread 
 Interventions 
 Chemo, surgery/ limb salvage using bone graft or implant, 
 Post op: Physical therapy, muscle strengthen, assist with ADL’s, ROM,
resource and support groups 

 Fibrosarcomas can be divided into subtypes, of which malignant fibrous histiocytoma is the most
worrisome. 
 Primary tumors of the prostate, breast, kidney, thyroid, and lung are called bone-seeking cancers because
they spread to the bone more often than other primary tumors. 
 The major complications of reconstructive surgery, such as a joint replacement, are superficial and deep
wound infection, dislocation or loosening of the implants, and rapid neurovascular compromise. 
 For patients who have surgery for bone cancer, report postoperative manifestations of infection,
dislocation, or neurovascular compromise to the surgeon promptly. 
 In addition to analgesics for local pain relief, chemotherapeutic agents and radiation therapy are often
administered to shrink the tumor. 
 A diagnosis of bone cancer is a major stressor that causes the patient and family or significant others to
grieve. Help identify available support systems as soon as possible. 
 Remember that managing the severe chronic pain is a priority for patients with metastatic bone disease. 

Other Musculoskeletal Disorders

 DISORDERS OF THE HAND 

Dupuytren’s contracture

• or deformity, is a slowly progressive thickening of the palmar (palm) fascia (connective

tissue), resulting in flexion contracture of the fourth and fifth fingers.
o This common problem usually occurs in older Euro-American men, in families, and can
be bilateral.
• Interventions
 Fasciectomy: cutting of the fascia a splint may be used after
o Nursing care is similar to that for the patient with carpal tunnel repair

A ganglion

• is a round, benign cyst, often found on a wrist or foot joint or tendon. painless
• o Synovium degenerates, allowing the tendon sheath tissue to become weak and
distended, and pain often occurs.
o If surgery is warranted, patients should avoid strenuous activity for 48 hours after
surgery and report any signs of inflammation.

Carpal tunnel
 • Risk: Typing occupations, repetative stress injuries, tingaling and numbing, occurs in the
dominant hand a compression of the median nerve in the wrist. Pregnant women may
develop this.
• Prevention
o Stretching, good ergonomics (posture), take breaks,
• Interventions
o NSAIDS, corticosteroids, brace, splint, severe = surgery to decompress pressure

DISORDERS OF THE FOOT

•The hallux valgus (hammer toe)

• deformity is a common foot problem in which the great toe deviates laterally at the first
metatarsophalangeal joint, resulting in a bunion.
o This occurs as a result of poorly fitted shoes (narrow), osteoarthritis, rheumatoid
arthritis, and family history. Can develop a hammer toe
o Women are affected more often than men.

 In Morton’s neuroma, or plantar digital neuritis, a small tumor grows in a digital nerve of the foot, causing
an acute, burning pain sensation in the web space. 

Plantar fasciitis 

 is an inflammation of the plantar fascia in the area of the arch of the foot, often
occurring in middle-aged and older adults, as well as in athletes. Usually on one
side of the body. Excruciating pain especially in the morning 
 Treatments
 Good supporting shoes, orthotics rest, ice, NSAIDS, steroid shots to the feet

Paget’s Disease

• Epidemiology
• Second-most common bone disease
• 1% to 2% of the white adult male population over 50 years of age affected
• Most common in older white males
• Clinical Manifestations
• Gradual and subtle when it starts
• Osteoclast increase in size and number causes bone to break down, the body then
tries to compensate.
• Osteoblast builds back at a rate that is very disorganized: structure will be messed
up. The new bone is weak and misshapen
• Eventually leads to fracture
• Affects skull cheek bones mouth jaw, pelvic bone, spine
• Bowlegged
• Pathophysiology
• Referred to as osteitis deformans
• Bone metabolism disorder
• Associated with accelerated bone remodeling
• Complication: Can result in bone tumors (r/t abnormal growth)

• Management
• Diagnosis
• History, physical exam, labs, bone scan,
• No effective treatment; 80% are asymptomatic
• Goal
• Reduce pain, maximize mobility,
• Treatment (pain management)
• Analgesics, opioids, biphosphates, surgery (remove damage from bone)

 Regional osteoporosis occurs when a limb is immobilized related to a fracture, injury, or paralysis for
longer than 8 to 12 week. Bone loss also occurs when people spend prolonged time in a gravity-free or
weightless environment (e.g., astronauts). 
 Because 50% of serum calcium is protein bound, protein deficiency may affect CELLULAR
REGULATION as protein is needed to use calcium. 
 People who drink large amounts of carbonated beverages each day (over 40 ounces) are at high risk for
calcium loss and subsequent osteoporosis, regardless of age or gender. 
 Most patients are unaware that they have osteoporosis until they experience a fracture, the most common
complication of the disease. 
 Inspection and palpation of the vertebral column usually reveal the classic dowager’s hump or kyphosis of
the dorsal spine. 
 Back pain accompanied by tenderness and voluntary restriction of spinal movement suggests one or more
compression vertebral fractures, the most common type of osteoporotic fracture. 
 Standards for the diagnosis of osteoporosis are based on BMD testing that provides a T- score for the
patient. A T-score represents the number of standard deviations above or below the average BMD for
young, healthy adults. 
 Dual x-ray absorptiometry is the most commonly used screening and diagnostic tool for measuring bone
mineral density. 
 Vertebroplasty and kyphoplasty are minimally invasive procedures used to treat vertebral body
compression and fracture found in persons with osteoporosis. 
 People with osteoporosis are at an increased risk for fracture if a fall occurs and can develop a fear of
falling (fallophobia), which prevents them from socializing or going outside their homes. 
 For those patients at high risk, communicate this information to other members of the health care team,
using colored armbands or other easy-to-recognize methods (National Patient Safety Goals). 
 In coordination with physical and occupational therapists, educate the patient and family on home safety
when the patient has a metabolic bone disease, such as osteoporosis. Exercises for the extremity muscles
will improve MOBILITY. Muscle strengthening, swimming, and a general weight-bearing exercise
program should be implemented. 
 Teach patients at risk for osteoporosis to minimize risk factors, such as stopping smoking, decreasing
alcohol intake, exercising regularly, and increasing dietary calcium. 
 Instruct older adults to have at least 5 to 10 minutes of sun per week and to eat vitamin D–fortified foods to
prevent osteomalacia, bone loss related to a lack of vitamin D causing bone softening. 
 Refer patients with genetic-associated diseases for genetic testing and counseling. 
 A newer type of drug is denosumab (Prolia, Xgeva), a monoclonal antibody that has been approved for
treatment of osteoporosis when other drugs are not effective. Patients who already have a low calcium level
should not take the drug and, like other drugs used for osteoporosis, denosumab can cause fractures. 