RICARTE
Physiology of Musculoskeletal System
1. Provide protection of vital organs
2. Supports body structures by providing a strong and
sturdy framework
3. Locomotion or movements
4. Mineral storage: 99% of calcium (parathyroid and
calcitonin)
5. Hematopoiesis (red and yellow marrow at medullary
cavity)
6. Heat production (muscle contraction)
Three basic cell types
1. Osteoblasts: bone formation, remodel/repair bone
2. Osteocytes: mature type of osteoblasts (once
surrounded by lamellae/matrix), found within lacuna
3. Osteoclasts: resorption of bones, important in bone
formation, removes dead particles of the bones for
remodeling
Types of bones
1. Long
Longer than they are wide
Upper and lower limbs
2. Short
As broad as they are long
Wrist and ankle
3. Flat
Relatively thin, flattened shape
Certain skull bones, ribs, scapulae (shoulder blades, and
sternum)
4. Irregular
Do not fit readily into the other three categories
Vertebrae and facial bones
Compact bone
- It forms most of the diaphysis of long bones and the
thinner surfaces of all other bones
- Most of the lamellae of compact bone are organized
into set of concentric rings, with each set
surrounding a central or haversian canal
- Blood vessels that run parallel to the long axis of the
bone are contained within the central canals
- Each osteon looks like a microscopic target, with the
central canal as the bull's eye
- Osteocytes located in lacunae are connected to one
another by cell processes in canaliculi
- The canaliculi give the osteon the appearance of
having tiny cracks in the lamellae
- Nutrients leave the blood vessels of central canals
and diffuse to osteocytes through the canaliculi.
Waste products diffuse in opposite direction. The
blood vessels in the central canals , in turn are
connected to blood vessels in the periosteum and
endosteum.
Cancellous bone
- It is also called spongy bone because of its
appearance
- It is located mainly in the epiphyses of long bones,
and it forms the interior of all other bones
- It consists of delicate interconnecting rods or plates
of bone called trabeculae which resemble the beams
or scaffolding or a building
Articulations
Joint (articulation): junction of two or more bones
Tendon: cord of fibrous tissue connecting muscle to bone
Ligament: fibrous band connecting bones
Fibrous joints
- Consists of two bones that are united by fibrous
tissue and exhibit little or no movement
- Sutures (fibrous joints between the bones of the
skull), and gomphoses (consist of pegs fitted into
sockets and held in place by ligaments).
Cartilagenous
- Unite two bones by means of cartilage
- Only slight movement can occur at these joints
- Fibrocartiage: is a type of cartilage that reinforces by
additional collagen fibers. It is the kind of cartilage
where much strain is placed on the joint.
Synovial
- Freely movable joints that contain synovial fluid in a
cavity surrounding the ends of articulating bones
- Articular cartilage: provides a smooth surface where
bones meet
- Joint cavity: it s filled with synovial fluid
- Joint capsule: helps hold the bones together and
allows movement
- Synovial membrane: lines the joint cavity
everywhere except over the articular cartilage. It
also produces synovial fluid which forms a thing
lubricating film covering the surface of the joint
- Bursa: located between structures that rub together.
It reduces friction that could cause damage
Types of Diarthrosis Joint
Plane/gliding joints: consists of two opposed flat surface that
glide each other (carpal bones)
Saddle: consist of two saddle shaped articulating surfaces
oriented at the right angle to each other. Movement in these
joints can occur in two planes (joint at the base of the thumb)
Hinge joint: permits movement in one plane only. They
consist of a convex cylinder of one bone applied to a
corresponding concavity of the other bone (elbow and knee
joint)
Pivot: restricts movement rotation on a single axis. Each pivot
joint consist of a cylindrical bony process that rotates within a
ring composed partly of bone and partly of ligament. (radius
and ulna)
Ball and socket joint: consist of a ball (head) at the end of
one bone and a socket in an adjacent bone. This allows a wide
range of movement in almost an direction. (hip and shoulder)
Functions of the joints
1. Prevents direct contact between two ends of bones.
2. Allow gliding or sliding motion.
3. Absorb shock.
Bone maintenance and healing
- Regulatory factors determining both formation and
resorption (physical activity, diet, calcitonin, pth,
thyroid hormones, cortisol, gh, sex hormones)
- Weight bearing stress stimulates local bone
formation and resorption; in immobility where
weight bearing is prevented, calcium is lost in the
bone.
- Vitamin D promoted absorption of calcium from the
GI and accelerates mobilization of calcium from the
bone to increase or maintain serum calcium levels
Bone healing
Phases:
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 - Reactive phase: hematoma/recruitment of - ROM decreases
inflammatory cells. Angiogenesis and granulation. - Slowed movement and decreased muscle strength
- Reparative phase: precallus precursor (3-4 weeks) Assessment
- Remodeling phase - Health history
- Bone damage – hematoma formation – hold bones - Pain, dec movement/rom, swelling, cramps,
together – inflammatory signs (takes about 24-48 abn sounds, abn gait
hours) - Chief complaint
- Fibrocartilage formation - Past health, social and family history
- Callus formation – minerals are deposited to - Physical assessment
organize a network for new bone - Posture: kyposis (forward curvature of the
- Callus forms initial clinical union and provides thoracic spine), lordosis (lumbar), scoliosis
enough stability to prevent movement when bones (lateral curvature)
are gently stressed - Gait
- Ossification and remodeling: continued bone healing - Bone integrity (crepitus)
– preinjury shape and structural strength - Joint function ( contracture, dislocation,
subluxation)
Nursing consideration - Muscle strength and size
- Age (clonus/fasciculation)
- Displacement of fracture - Skin
- Site of fracture - Neurovascular status (circulation, motion,
- Nutritional level sensation)
- Blood supply to the area of injury - Effects of the musculoskeletal problem
- Can affect time required for bone healing - Nurse is concerned with assisting patients
- General impression of patient’s health status
Muscles - Medication use and response
- Composed of parallel groups of muscle cells - Allergies
(fasciculi) encased in fibrous tissue (fascia or
epimysium)
General features of the bone
Anatomy of muscular system - Each long bone consist of a central shaft called the
Skeletal muscle diaphysis
- Lower motor neurons control the activity of the - While the two ends are called epiphysis
skeletal muscles - A thin layer of articular cartilage covers the end of
- Energy is consumed when skeletal muscles contract epiphyses where the bone articulates with other
in response to stimulus bones
- Lactic acid: by product of muscle metabolism when - A long plate that is still growing has an epiphyseal
o2 available to cell is not sufficient plate or growth plate composed of cartilage,
- Muscle fatigue results from increased work of the between each epiphysis and the diaphysis
muscle - The epiphyseal plate is the site of growth in bone
- *depleted glycogen and energy stores length
- *accumulation of lactic acid - When bone growth stops, the cartilage of each
Cardiac muscles epiphyseal plate is replaced by bone and is called
Smooth muscles epiphyseal line
- Most of the outer surface of bone is covered by
Types of muscle contraction dense connective tissue called the periosteum (peri
1. Isometric: length of muscle remains constant but the around, osteon bone) which contains blood vessels
force generated is increased and nerves
2. Isotonic: shortening of muscles: no increase in - The surface of the medullary cavity is lined with a
muscle tension thinner connective tissue membrane, the endosteum
(endo inside)
Muscle tone - The periosteum and endosteum contain contain
1. Flaccid (limp) osteoblasts (bone forming cells) which function in
2. Spastic the formation of bone, as well as in the repair and
3. Atonic (soft and flabby) remodeling of bone
- When osteoblasts become surrounded by matrix,
Muscle action they are referred to as osteocytes
1. Prime mover - Bone is formed in thin sheets of extracellular matrix
2. Synergist called lamellae, with osteocytes located between the
3. Antagonist lamellae
- The osteocytes are located with spaces called
Older adult care focus lacunae
- Decreased bone density - Cell processes extend from the osteocytes across the
- Decreased in subcutaneous tissue – less soft tissue extracellular matrix of the lamellae within tiny canals
over bony prominences called canaliculi
- Degenerative changes in the spine alter posture and
gait Assessment
- Degenerative changes in cartilage and ligaments - Effects of the musculoskeletal problem
leads to decreased movement of joints - Nurse is concerned with assisting patients

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 - General impression of patients health status 7. Uric acid (elevated in gout)
- Medication use and response 8. Minerals
Manifestations a. Calcium
- Bone pain Decreased levels in osteomalacia, osteoporosis
- Dull Increased levels in bone tumors, healing fractures,
- Deep ache Pagets dse
- Boring (drilling) b. Alkaline phosphatase
- Muscle pain Elevated levels in bone cancer, osteoporosis,
- Soreness or aching osteomalacia, Pagets dse/metastatic ca
- Muscle cramps (acid phosphatase)
- Fracture pain c. Phosphorous
- Sharp and piercing Increased levels in healing fractures, bone tumors
- Relieved by immobilization 9. Muscle enzymes
- Sharp pain a. Aldolase
- Bone infection with muscle spasm or Elevated in muscle dystrophy, dermatomyositis
pressure on a sensory nerve b. AST
- Osteomyelitis, those with pins c. CK (creatinine phosphokinase)
- Joint sprain or muscle strain Elevated in traumatic injuries
- Increases with activity d. LDH (lactic dehydrogenase)
- Radiating pain Elevated in skeletal muscle necrosis, extensive
- Pressure exerted on a nerve root cancer

Physical assessment Other diagnostic tests

Inspection and palpation 1. Arthroscopy
Evaluate: Insertion of fiberoptic scope into a joint to visualize
- Posture it, perform biopsies or remove loose bodies
- Gait Performed in the OR under sterile techniques
- Bone integrity Nursing care:
- Joint function Pressure dressing for 24 hours
- Muscle strength and size Must limit activity for several days
Assess neurovascular status
Achondroplasia 2. Myelography
- Autosomal dominant Lumbar puncture used to withdraw a small amount of CSF,
- Common cause of dwarfism which is replaced with a radiopaque dye; used to
detect tumors pr herniated intervertebral discs
Club foot If water based dye is used, put patient on seizure precaution
- Talipes equinovarus and do not administer any phenothiazine drugs
- Walk on their ankles 3. Electromyography (EMG)
Measures and records activity of contracting muscles in
Ehlers-Danlos syndrome response to electrical stimulation; helps differentiate
- Caused by a defect in the synthesis of collagen muscle disease from motor neuron dysfunction
- Faulty or reduced amounts of type III collagen Explain procedure to pt and prepare him for discomfort of
needle insertion
Stickler syndrome
- Affecting connective tissue specifically collagen Traumatic injuries
- Distinctive facial abnormalities, eye problems, 1. Strain
hearing loss and joint problems Is an injury to a muscle when it is stretched or pulled beyond
its capacity.
Posture Common cause: overstretching
Kyphosis 2. Sprain
An increased forward curvature of the thoracic spine Is an injury to the ligaments surrounding a joint
Lordosis or swayback Common cause: overtwisting
An exaggerated curvature of the lumbar spine 3. Contusion
Scoliosis Soft tissue injury with ecchymosis or bruising
Lateral curving deviation of the spine Common cause: blunt force

Joint function
- Limited ROM – contracture, OA, goniometer Grading
- Effusion, swelling, warmth crepitus 1. First degree: mild stretching
Ssx: minor edema, tenderness, mild muscle spasm
Lab dx test 2. Second degree: partial tearing
A. Blood tests Ssx: loss of load bearing strength, edema, tenderness, muscle
1. ESR (elevated in SLE and arthritis) spasm, ecchymosis
2. Rheumatoid factors (RA) 3. Third degree: severe damage with complete
3. Lupus erythematosus cells (LE cells) rupturing or tearing
4. Antinuclear antibodies (ANA) (RA) Ssx: severe pain, tenderness, increase edema, abnormal
5. Anti DNA (SLE) motion
6. C-reactive protein (RA)

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General nursing mx: Disuse syndrome
- Rest - Muscle atrophy and loss of strength
- Ice - Tense or contract muscle (isometric contraction)
- Compression without moving the part
- Elevate
- Activity limitation is necessary, anti inflam Types of traction
and muscle relaxants as prescribed - Straight or running traction: applies the pulling force
- Surgical repair might be included for severe in a straight line with body part resting on the bed
strain (ruptured muscle or tendon) or (Buck’s extension traction)
severe ligament damage - Balance suspension traction: supports the affected
extremity off the bed and allows some movement
Carpal tunnel syndrome without disruption of the line of pull
- Definition: median nerve compression at wrist joint
- Cause: repetitive and constant flexion of the wrist Skin
Ssx Bucks
- Paresthesia - Indication: femur/hip involvement
- Muscle weakness - Simplest form of traction
- Clumsiness when using the hand Russels
- Pain - Indication: femur/hip joint fracture
Dx test: - Incorporates the use of a knee sling
1. Tinel’s sign: tap - Hip is flexed to 20deg from the mattress
2. Phalen’s sign Bryants
Nmx - Indication: Children with congenital hip dislocation
Goal 1: prevent further compression of the nerves - For children below 2-3 years
1. Rest hands - For children weighing less than 30-40lbs
2. Avoid excessive use of involved hand - N/R: buttocks should not touch the mattress
3. Instruct patient not to sleep over the involved hand - Assess nv status
4. Adm meds as ordered Cervical
2: prevent injury - Indication: cervical bone fracture
1. Instruct to wear gloves - Make use of cervical halter or sling
Mmx - HOB is elevated to 30-40
1. Analgesics Pelvic
ASA, NSAIDS - Indication: pelvic bone fracture
2. Corticosteroids - Used for lumbar fracture
3. Surgical mgt - Make use of a pelvic halter
Carpal tunnel release - Supine position

Complication of external fixator Skeletal

1. Infection Balanced suspension traction
Nmx - Make use of the Thomas splint with Pearson
Assess for redness, tenderness, pain, swelling and loosening attachment
of pins - Hips are flexed 30deg from the mattress
Prevent crust formation
Notify the physician for signs of infection Care of the pin site
*Ilisarov external fixator - Clean with antiseptic
- Apply antibiotic
Open fracture nmx - No betadine (rust)
- Risk of osteomyelitis, tetanus, gas gangrene - No peroxide
- IV antibiotics - Aerobic: infection
- Delayed primary wound closure
- Elevate to minimize edema Complications
- Neuromuscular assessment Atelectasis and pneumonia
- Auscultate lungs q4-8 hours
Fractures of specific sites - DBCE
- Clavicle (collar bones) – middle 3rd of the clavicle Constipation and anorexia
- Figure of 8 bandage - High fiber diet, inc fluids
- Humerus (shaft or neck) - Stool softeners as prescribed
- Elbow: supercondylar fracture of the humerus - Improve appetite
(Volkmann’s contracture) Urinary stasis and infection
- Radial head: fall on an outstretched hand - Monitor fluid intake and character of urine
- Radial/ulnar shaft: children - Monitor ssx of infection
- Distal radius (colles fracture): open dorsiflexed hand,
elderly
- Pelvis: r/o other internal damage Venous thromboembolism
- Femoral shaft: fall or motor vehicle crash - Exercise muscles not in traction to prevent
- Thoracolumbar spine: vertebral body, laminae and deterioration, deconditioning and venous stasis
articulating process, spinous process - Monitor for calf tenderness, warmth, redness and
swelling

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 - Fractures of thoracic, lumbar, neck and
Total hip replacement intertrochanteric fx of femur and Colle’s fx of the
Indications: arthritis, femoral neck fractures, failure of wrist
previous reconstructive surgeries and problems resulting - Risk factors: menopause, sedentary lifestyle,
from congenital hip dse malnutrition, small non-obese Caucasian women,
lifestyle choices
Assistive devices for walking Dx
Purposes: - Height loss and discovery of unsuspected fractures
- Widens base of support on xray may bye first dx clues
- Reduce weight bearing on the affected leg - Routine xrays 25-40% demineralization. There is
- Provide mobility radiolucency to the bones.
Measurement: - Vertebral collapse can lead to kyphosis (Dowager’s
- 2” below axilla hump)
- 6” front of foot - Dual energy x ray absorptiometry( DEXA) – BMD at
- 2” to the side of foot the spine and hip
- Elbow flexion (20-30 degrees) - Quantitative ultrasound studies (QUS) of the heel –
- Exercises to prepare for CW predicts osteoporosis and the risk of of hip and
- Hand muscle ex nonvertebral fracture
- Arm muscle ex Nmx
- Recognize risk factors and prevent further injuries
Crutches - Adequate dietary intake of Ca and other minerals,
Important muscles CHON and vit D
A. Shoulder depressor/ latissimus dorsi - Calcium supplements with vit D
Needed first to advance the body forward - Physical therapy – moderate exercise – mechanical
Needed to lift the pelvis off the ground stress stimulates bone formation
B. Elbow extensors/ triceps - Fracture management – ORIF or arthroplasty
Needed to prevent buckling of elbow joint - Hormone replacement therapy
C. Finger flexors Ndx
Needed to grasp the hand grip - Def knowledge about the osteoporotic process and
treatment regimen
Canes - Acute pain related to fracture and muscle spasm
o Cane held on non affected side - Risk for constipation related to immobility or
o Cane walks together with weak leg development of ileus (intestinal obstruction)
Cane foot sequence - Risk for injury: additional fractures related to
1. Hold the cane in the hand opposite the affected osteoporosis
extremity Medmx
Widen the base of support Biphosphonates – Etidronate (Didronel)
To reduce the stress on the involved extremity - Inc bone density and restore lost bone
If the pt for some reason is unable to use the cane in the - Inhibit resorption of bone
opposite hand, the cane may be used on the same - Monitor for nephrotoxicity and seizures
side Fluoride – Aledoronate (Fosamax)
2. Advance the cane at the same time the affected leg - Stimulate bone formation
is moved forward - Strict dosage precautions
3. Keep the cane fairly close to the body to prevent - Causes GI distress, esophageal erosion
leaning - Adm on empty stomach
4. Bear down on the cane when the unaffected - Do not eat or drink for 30min
extremity begins the swing phase - Take with water 6-8oz not juice and remain upright
To go up and down using the cane for 30min after taking drug
1. Step up on the unaffected extremity - Monitor: hypercalcemia and tetany
2. Place the cane and affected extremity up on the step - Serum electrolytes
3. Reverse this procedure for descending (up with the - Increase fluid intake and calcium rich foods
good, down with the bad)

Walker
- The most stable among the assistive devices
Sequence
A. Advance walker within arms length (approx 10-12in
in front of the patient)
B. Walk inside the walker
Osteoporosis
- Abn increase in bone resorption causing a decrease
in bone density
- Loss of bone mass with aging, dec calcitonin and
estrogen and inc parathormone
- Demineralization (loss of ca and phosphate salts) –
bone becomes porous, brittle, fragile – structural
weakness – pathologic fractures
Osteomalacia
- Deficiency of activated vit D (calcitriol) which
promotes calcium absorption from the
gastrointestinal tract and facilitates mineralization of
bone
- Failed calcium absorption (malabsorption syndrome)
- Excessive loss of calcium from the body.
Gastrointestinal disorders (celiac dse, chronic biliary
tract obstruction, chronic pancreatitis, small bowel
resection)
- Severe renal insufficiency results in acidosis
- Hyperthyroidism leads to skeletal decalcification and
thus to osteomalacia by increasing phosphate
excretion in the urine.

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 - Prolonged use of antiseizure medication (phenytoin,
phenobarbital) poses a risk for osteomalacia, as does
insufficient vit D (dietary, sunlight)
- The malnutrition type of osteomalacia (deficiency in
vit D often associated with poor intake of calcium) is
a result of poverty, food faddism, and lack of
knowledge about nutrition
Dx
- On xray generalized demineralization of bone is
evident. Studies of the vertebrae may show a
compression fracture with indistinct vertebral end
plates
- Lab studies show low serum calcium and phosphorus
levels and a moderately elevated alkaline
phosphatase concentration
- Urine excretion of calcium and creatinine is low
- Bone biopsy demonstrates an increased amount of
osteoid
- Tx – vit D replacement and treat underlying cause
Paget’s
- (Osteitis deformation) is a disorder of localized rapid
bone turnover
- Most commonly affecting the skull, femur, tibia,
pelvic bones and vertebrae
- There is a primary proliferation of osteoclasts, which
produces bone resorption
- As bone turnover continues, a classic mosaic
(disorganized) pattern of bone develops
- Elevated serum alkaline phosphatase concentration
and urinary hydroxyproline excretioon reflect
increased osteoblastic activity
- Pts with Paget’s disease have normal calcium levels
- Xrays confirm the diagnosis of Paget’s (local areas of
demineralization and bone overgrowth produce
characteristic mosaic patterns and irregularities)
- Bone scans demonstrate the extent of disease
- Bone biopsy may aid in differential diagnosis
Mx
- Pain usually responds to adm of NSAIDs
- Gait problems from bowing of the legs are managed
with walking aids, shoe lifts and physical therapy
- Weight is controlled to reduce stress on weakened
bones and malaligned joints
- Calcitonin: a polypeptide hormone, retards bone
resorption by decreasing the number and availability
of osteoclasts.
- Is adm subcutaneously or by nasal
inhalation
- Side effects to include flushing of the face
and nausea
- The effect of calcitonin therapy is evident in
3 to 6 mos
- Bisphosphonates: Etidronate disodium (Didronel)
and Alendronate sodium (Fosamax) – produce rapid
reduction in bone turnover and relief of pain
- They also reduce serum alkaline
phosphatase and urinary hydroxyproline
levels
- Food inhibits absorption of these
medications. Adequate daily calcium
(1500mg) and vit D (400-600IU) are
required during therapy
o Plicamycin (Mithracin): a cytotoxic antibiotic, is
reserved for severely affected pts wity neurologic
compromise and for those whose disease is resistant
to other therapy
- This medication has dramatic effects on
pain reduction and on serum calcium,
alkaline phosphatase, and urinary
hydroxyproline levels
- Is adm by IV infusion and requires that
hepatic, renal and bone marrow function be
monitored during therapy
RA
- Autoimmune and hereditary
- Bilateral, symmetrical, inflammatory, systemic
- Progression through stages
- Synovitis – pannus formation (scar tissue) – pannus
destroys cartilage and erodes the bone – fibrous
ankylosis – bone ankylosis
- Signs
- There is loss of articular surfaces and joint motion
- Muscle fibers undergo degenerative changes
- Tendon and ligament elasticity and contractile
power are lost
- Fatigue, anorexia, malaise, weight loss, slight
temperature elevation
- Most frequently attacks the wrists, hands, elbows,
shoulders, knees and ankles
Ssx
- Painful, warm, swollen joints with limited motion,
stiff in the morning and after periods of inactivity
- Crippling deformity/ swan neck deformity or
buotonierre’s
- Muscle weakness
- History of remissions and exacerbations
- Severe anemia
- Sjogren’s syndrome
- Felty’s syndrome
- Subcutaneous nodules
Sjogren’s
- Dry eyes, damage to eye surface
- Dry mouth, increased tooth decay
Felty’s
- A disorder that can affect people who have RA
- It is defined by the presence of three conditions:
RA, splenomegaly, low wbc
- Pt with felty’s may be at increased risk for infection
due to their low wbc
- Symptoms may include fatigue, loss of appetite and
weight loss, and eye burning or discharge
Dx
1. Clinical ssx: rheumatoid nodules, joint inflammation
detected on palpation, bilateral and symmetric
stiffness, tenderness, swelling and temperature
changes in the joints
2. Rheumatoid factor, ESR, C4 decreased, C reactive
protein, and ANA +
3. Xray: show characteristic bony erosions and
narrowed joint spaces
4. Arthrocentesis: synovial fluid that is cloudy, milky, or
dark yellow and contains numerous inflammatory
components such as leukocytes and complement
Nmx
1. Apply cold compress on the affected part
2. Minimize muscle spasms and joint stiffness
3. Avoid prolonged sitting or standing
4. Encourage ROM exercises after taking pain meds
Surgery
- Osteotomy, synovectomy or arthroplasty
Pharmacotherapy
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 - Aspirin, NSAIDS - Pruritus
- Indomethacin (Indocin) - Tophi formation (sodium urate crystals)
- Phenylbutazone (Butazolidine) - Skin ulceration
- Ibuprofen (Motrin) - Late stage: intolerance to bed linens
- Gold compounds (chrysotherapy) – arrest Mx
progression of the disease 1. Assess affected joint for pain motion and
- Sodium aurothiomalate (Myocrisin) appearance
- Aurothioglucose (Sofganal) 2. Educate patients in recognition of early symptoms
- Auranofin (Ridaura) 3. Increase fluid intake (3-5L)
- Corticosteroids 4. Encourage gradual weight loss
- Intra articular injections 5. Bed rest until pain subsides
- Biologic response modifiers: moderate erosive RA- 6. Report any decrease in urine output
Enatercept (Enbrel) and Inflximab (Remicade)- inhibit 7. Low purine diet
function of tumor necrosis factor- alpha, a key 8. Medications: aspirin, NSAIDs
cytokine Antigout
- High dose methotrexate (Rheumatrex), - Allopurinol (Zyloprim)
cyclophosphamide (Cytoxan), and azathioprine - Mechanism of action prevents formation of uric acid
(Imuran)- advanced, unremitting RA, has the ability - Probenicid (Benemid)
to affect the production of antibodies at the cellular - Uricosuric agent
level - Colchicine (Colgout)

Osteoarthritis Septic arthritis

- Degenerative joint disease - Joints can become infected: spread of infection from
- Idiopathic or secondary other parts of the body (hematogenous spread) or
- 3rd decade of life and peaks between the 5th and 6th through trauma or surgical instrumentation
decades - S. Aureus causes most adult joint infections,
- Affects the articular cartilage, subchondral bone and streptococci and gram negative organisms
synovium - Accumulating pus results in chondrolysis
- Cartilage degeneration, bone stiffening, reactive (destruction of hyaline cartilage)
inflammation Ssx
- Wear and tear - A warm, painful, swollen joint with decreased ROM
- Risk factors: age, obesity, previous joint damage, - Systemic: chills, fever, leukocytosis
repetitive use, anatomical deformity, genetic - Risk factors: advanced age, diabetes mellitus,
susceptibility rheumatoid arthritis and preexisting joint disease or
Ssx joint replacement
- Pain (osteophytes) Dx: aspiration, examination, and culture of the synovial fluid
- Stiffening CT scan and MRI may disclose damage to the joint lining
- Functional impairment Radioisotope scanning may be useful in localizing the infectious
Dx process
- Progressive loss of joint cartilage Tx
- Osteophytes 1. Broad spectrum IV antibiotics after culture results
- Joint space narrowing (xray) are available.
Mx 2. The synovial fluid is monitored for sterility and
- Relieve strain and further trauma to joints decrease in WBCs
- Cane or walker if indicated 3. Arthrocentesis – to remove excessive joint fluid,
- Proper body mechanics exudate and debris. This promotes comfort and
- Avoid excessive weight bearing and standing decreases joint destruction caused by the action of
- Physical therapy proteolytic enzymes in the purulent fluid
- Relief of pain (NSAIDS) 4. Arthrotomy or athroscopy is used to drain the joint
- Joint replacement as needed and remove dead tissue

Gouty arthritis Bone tumors

Classifications Benign
1. Primary 1. Osteochondroma – MC benign tumor
Faulty uric acid metabolism 2. Enchondroma: hyaline cartilage
2. Secondary 3. Bone cyst
Due to acquired conditions 4. Osteoid osteoma
Starvation 5. Giant cell tumors (osteoclastomas)
Alcohol intoxication Osteosarcoma
Renal failure - Bone tumors, primary or secondary
Risk factors - 10-25y most common
- Common among males - Palpable mass or hard lump pain, pathologic
- 20x greater than females fractures, decreased sensation, numbness and
- 30yo and above limited movement
Ssx - Tumor erodes the bone cortex elevating the
- Inflammation of the joints periosteum

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 - MC sites: distal femur, proximal tibia and humerus - Nonapharmacologic approaches:
- Increased serum alkaline phosphatase because of distraction, relaxation, imagery, thermal
bone lysis interventions (eg ice, heat), stress reduction
- Interventions: - NSAIDs, muscle relaxants
- Bone biopsy - Exercise
- Radiation, chemotherapy, surgical removal of tumor - Body mechanics
Potential complication post op - Work modifications
1. Delayed wound healing - Stress reduction
Tissue trauma
Radiation therapy Proper body mechanics
Poor nutrition - Maintain proper posture
Infection - Low heels
2. Inadequate nutrition - Shift weight frequently for prolonged standing
3. Osteomyelitis and wound infection - Avoid sleeping prone
4. Hypercalcemia
Common problems of the upper extremity
- Bursitis and tendinitis
TB of the spine - Carpal Tunnel Syndrome
- Pott’s dse is a presentation of extrapulmonary tb - Ganglion
that affects the spine, a kind of tuberculous arthritis - Dupuytren's Contracture
of the intervertebral joints
Ganglion
Ssx - Collection of gelatinous material near the tendon
- Back pain sheaths and joints
- Fever - Round, firm, cystic swelling
- Night sweating - Dorsum of wrist
- Anorexia
- Weight loss Dupuytren’s contracture
- Spinal mass, sometimes associated with numbness, - Slowly progressive contracture of the palmar fascia
tingling sensation or muscle weakness of the legs - Flexion of the fourth and fifth fingers including
Organism: TB bacilli middle finger
Primary focus: lungs - Manifestations
Pathology: - Dull, aching discomfort
- Infection – bone destruction – collapse of vertebra – - Morning numbness
globus formation – spinal cord compression - Cramping
- Mgt: anti-koch’s medications, spinal brace - Stiffness in affected fingers
- Surg: anterior decompression spinal fusion Mgt: exercise, palmar and digital fasciectomies
- Bone infections are difficult to treat because they Causes
are relatively inaccessible to protective macrophages - Ill fitting shoes
and antibodies - Systemic diseases
- DM
Pediatric orthopedic - Peripheral vascular disease and arteriosclerosis
Trendelenburg: affected leg is shorter - RA
Prostatic* - Fungal infections

Developmental hip dysplasia Corn

Nmx - Area of hyperkeratosis
- Splinting of the hips with Pavlik harness to maintain - Mgt: soaking and scraping off the horny layer
flexion, abduction and external rotation
- Traction and surgery to release muscle and tendons Callus
- Following surgery, positioning and immobilization in - Thickened area of the skin due to persistent pressure
a spina cast then use of abduction splint or friction

Acute low back pain Ingrown toenail

Causes - Onychocryptosis
- Obesity - Painful, secondary infection or granulation
- Stress - External or internal pressure
- Osteoporotic vertebral fractures Mgt:
- Bone metastasis - Trimming the nails properly- clipping them straight
- Kidney disorders across
- Pelvic problems - Washing the foot twice a day
- Retroperitoneal tumors - Local antibiotic ointment
- Abdominal aneurysms - Warm, wet soaks
- Psychosomatic problems - Removal of nail
Mx
- Pain management Hammer toe
- Flexion deformity of the interphalangeal joint
- Tight socks or shoes

8
Mgt:
- Wearing open-toed sandals or shoes

Hallux valgus
- Aka bunion
- Great toe deviates laterally
- Marked prominence of aspect of 1st metatarsal-
phalangeal joint
Causes
- Hereditary
- Ill fitting shoes
- Gradual lengthening and widening of foot
- OA
Mgt:
- Comfortable footwear
- Corticosteroid injections
- Surgical removal of the bunion (exostosis)

Pes cavus (clawfoot)

- Abnormally high arch and fixed equinus deformity of
the forefoot
Causes:
- Charcot-Marie-Tooth disease
- DM
- Tertiary syphilis
Mgt:
- Exercises
- Bracing
- Arthrodesis (fusion)

Flatfoot (Pes planus)

- Longitudinal arch of the foot is diminished
Causes
- Congenital abnormalities
- Bone or ligament injury
- Muscle and posture imbalances
- Excessive weight
- Muscle fatigue
- Poorly fitting shoes
- Arthritis