NRSG 204 Advanced Medical- Surgical 1

Mary Khristine F. Adan, RN (1st year Graduate School)

Professor: Dr. Sofia Irene B. Bautista, LPT, RN

DISORDERS OF THE MUSCULUSKELETAL SYSTEM

TOPICS:

• PAGET'S DISEASE OF THE BONE

• DUPUYTREN'S DISEASE
• CARPAL TUNNEL SYNDROME

PAGET'S DISEASE OF BONE

DEFINITION

Also called osteitis deformans, a disorder of localized rapid bone turnover. Over time, bones can become
fragile and misshapen. most commonly affecting the skull, femur, tibia, pelvic bones and vertebrae.

ETIOLOGY

A family history has been noted, with siblings often developing the disease. The cause of Paget's disease
is not known. (Josse, Hanley, Kendler, et al., 2007).

PATHOPHYSIOLOGY

1. Primary proliferation of osteoclasts

2. Induce bone resorption
3. Compensatory increase in osteoblastic activity
4. Bone turnover continues
5. Disorganized pattern of bone develops
6. Pathologic fractures occur & malalignment of bones

CLINICAL MANIFESTATIONS

Most people who have Paget's disease of bone have no symptoms. When symptoms occur, the most
common complaint is bone pain.

Because this disease causes body to generate new bone faster than normal, the rapid remodeling
produces bone that's less organized and weaker than normal bone, which can lead to bone pain,
deformities and fractures.

The disease might affect only one or two areas of body or might be widespread. If any, will depend on
the affected part of the body.

• Pelvis. Can cause hip pain.

 • Skull. An overgrowth of bone in the skull can cause hearing loss or headaches.

• Spine. Nerve roots can become compressed. This can cause pain, tingling and numbness in an arm or
leg.

• Leg. As the bones weaken, they may bend — causing bowlegged. Enlarged and misshapen bones in
legs can put extra stress on nearby joints, which may cause osteoarthritis in knee or hip.

MEDICAL MANAGEMENT

• Pain usually responds to NSAIDs.

• Bowing of the legs are managed with walking aids, shoe lifts, and physical therapy.

• Weight is controlled to reduce stress on weakened bones & malaligned joints.

• Asymptomatic patients may be managed with diets adequate in calcium, vitamin D & periodic
monitoring.

• Fractures are managed according to location. Healing occurs if fracture reduction, immobilization and
stability are adequate.

• Severe degenerative arthritis may require total joint replacement.

• Loss of hearing is managed with hearing aids & communication techniques.

• Calcitonin, a polypeptide hormone, retards bone resorption by decreasing the number of osteoclasts.
(administered subcutaneously or by nasal inhalation)

• Bisphosphonates produce rapid reduction in bone turnover & relief of pain.

• Plicamycin (Mithracin), a cytotoxic antibiotic. This medication is reserved for severely affected
patients with neurologic compromise and those whose disease is resistant to other therapy.
(administered by IV infusion; hepatic renal, & bone marrow function must be monitored during
therapy).

NURSING INTERVENTION & PATIENT TEACHING

 Careful assessment of a patient's pain and discomfort is necessary.

 The home environment is assessed for safety to prevent falls and to reduce the risk of fracture.
 How to compensate for altered musculoskeletal functioning.
 Patient teaching on treatment regimen, the need for a diet with adequate calcium & Vitamin D.

PROGNOSIS

• The general outlook for patients with Paget's disease is good, especially if treatment is administered
before major changes have occurred in the bones. Treatment does not cure Paget disease, but it can
control it.
• Morbidity from Paget disease can be extensive. The excessive remodeling of bone associated with
Paget disease may result in pain, fractures, and bone deformities. Complications associated with
fractures, such as articular and neurologic problems, may increase mortality in patients with Paget
disease. The hypervascularity of bone that may result from Paget disease may cause excessive
bleeding following fractures or surgery.

DUPUYTREN'S DISEASE

DEFINITION

A slowly progressive contracture of the palmar fascia, called Dupuytren's (du-pwe-TRANZ) contracture,
which causes connective tissue (fascia) under the skin of the palm to thicken and become scar-like. It
causes flexion of the fourth & fifth fingers and frequently the middle finger.

ETIOLOGY

It is caused by inherited autosomal dominant trait and occurs most frequently in men who are older
than 50 years and who are of Scandinavian or Celtic origin. It is also associated with arthitis, diabetes,
gout, cigarette smoking, and alcoholism.

PATHOPHYSIOLOGY

1. Fibroblast proliferation
2. Collagen deposition
3. Contractures of the palmar fascia

CLINICAL MANIFESTATION

 The condition usually begins as a thickening of the skin on the palm of hand. As it progresses, the skin
might appear puckered or dimpled. A firm lump of tissue can form on the palm. This lump might be
sensitive to touch but usually isn't painful.

 In later stages, cords of tissue form under the skin on palm can extend up to the fingers. As these
cords tighten, fingers can be pulled towards the palm.

 It can become difficult to grasp large objects and make simple movements like washing the face or
putting on gloves. The condition usually doesn't affect the ability to write and grasp small objects,
because the thumb and index finger aren't usually affected.

MEDICAL MANAGEMENT

 Needling. This technique uses a needle, inserted through skin, to puncture and break the cord of
tissue that's contracting a finger. Contractures often recur but the procedure can be repeated. The
main advantages of this technique are that there is no incision, it can be done on several fingers at
 the same time, and usually very little physical therapy is needed afterward. The main disadvantage
is, it can't be used in some places in the finger because it could damage a nerve or tendon.

 Enzyme injections. (collagenase clostridium histolyticum)Doctors can also inject enzymes into the
palm to weaken the collagen bands. Then the hand is moved by the doctor until the bands are
broken and the fingers can be straightened.

 If contracture symptoms are bad enough to interfere with daily life, surgery may help. During the
procedure, the surgeon removes the thickened tissue in the palm, which allows the fingers to move
again. Surgery usually can give normal movement back, but risks may include infection and nerve
damage.

NURSING INTERVENTION

• Before surgery, the nurse assesses the patient's level and type of discomfort and limitations in
function caused by Dupuytren's contracture.

• Neurovascular assessment of the exposed fingers every hour for the first 24 hours following surgery
is essential for monitoring function of the nerves and perfusion of the hand.

• The nurse instructs the patient and any family caregivers on these parameters for periodic
neurovascular assessment and gives instructions on when to notify the physician.

• Temperature of the affected hand is assessed. Dressings provide support but are non constrictive.

• To control swelling, the nurse instructs the patient to elevate the hand to heart level with pillows. If
patient is ambulatory, the arm is elevated in a conventional sling with the hand at heart level.

• Intermittent use of ice packs to the surgical area during the first 24 to 48 hours may be prescribed to
control edema.

PATIENT TEACHING

• After the patient has undergone hand surgery, the nurse teaches the patient how to monitor
nerovascular status and the signs of compications that need to be reported to the surgeon. (eg.,
paresthesia, paralysis,uncontrolled pain, coolness of fingers, extreme swelling, excessive bleeding,
purulent drainage, fever).

• The nurse teaches the patient to elevate the hand above the elbow and to apply ice (f prescribed) to
control swelling.

• Unless contraindicated, the nurse encourages extension and flexion exercises of the fingers to
promote circulation.

• For bathing, the nurse instructs the patient to keep the dressing dry by covering it with a secured
plastic bag.

• Generally, the wound is not redressed until the patient's follow- up visit with the surgeon.

• Avoiding a tight grip on tools by building up the handles with pipe insulation or cushion tape
• Using gloves with heavy padding during heavy grasping tasks

PROGNOSIS

• In many cases, a Dupuytren's contracture progresses very slowly, over a period of years, and may
remain mild enough such that no treatment is needed. In moderate or severe cases, however, the
condition makes it difficult to straighten the involved digits. When this happens, treatment may be
needed to help reduce the contracture and improve motion in the affected fingers. Typically, as a
contracture worsens, the involvement of the fascia becomes more severe and treatment is less
likely to result in a full correction.

CARPAL TUNNEL SYNDROME

DEFINITION

Is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a
thickened flexor tendon sheath, skeletal encroachment, edema or a soft tissue mass.

ETIOLOGY

Repetitive movements or whose hands are repeatedly exposed to cold temperature, vibrations, or
extreme direct pressure. May also be associated with diabetes, arthritis, tumors, or trauma.

PATHOPHYSIOLOGY

1. Nerve compression and traction

2. Intraneural microcirculation
3. Entrapment of peripheral nerve
4. Narrow carpal tunnel
5. Dysfunction/ damage of the nerve from the site of compression & beyond

CLINICAL MANIFESTATIONS

SYMPTOMS INCLUDE:

• Burning, tingling, or itching numbness in palm and thumb or index and middle fingers.

• Weakness in hand and trouble holding things.

• Shock-like feelings that move into the fingers.

• Tingling that moves up into the arm.

The median nerve can't work the way it should because of the irritation or pressure around it. This
leads to:

• Slower nerve impulses

• Less feeling in your fingers

• Less strength and coordination, especially the ability to use the thumb to pinch.
MEDICAL MANAGEMENT

• Wrist splinting. A splint that holds wrist while you sleeping can help relieve nighttime symptoms
of tingling and numbness. It can also help prevent daytime symptoms.

• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen (Advil, Motrin,

others), may help relieve pain in the short term.

• Corticosteroids. Your doctor may inject your carpal tunnel with a corticosteroid such as cortisone
to relieve pain. It decreases inflammation and swelling, which relieves pressure on the median
nerve. Oral corticosteroids aren't considered as effective as corticosteroid injections for treating
carpal tunnel syndrome.

• Surgery. May be appropriate if symptoms are severe or don't respond to other treatments. The
goal of carpal tunnel surgery is to relieve pressure by cutting the ligament pressing on the median
nerve.

NURSING MANAGEMENT

• Monitor level of pain, numbness, paresthesias, and functioning.

• Monitor for adverse effects of NSAID therapy, especially in elderly. GI distress or bleeding,
dizziness, or increased serum creatinine.

• After surgery, monitor neurovascular status of affected extremity: pulses, color, swelling,
movement, sensation, or warmth.

• Apply wrist splint so wrist is in neutral position, with slight extension of wrist and slight abduction
of thumb; make sure that it fits correctly without constriction.

• Administer NSAIDs and assist with tendon sheath injections as required.

• Apply ice or cold compress to relieve inflammation and pain.

• Advise patient of NSAID therapy dosage schedule and potential adverse effects; instruct patient
to report GI pain and bleeding.

PATIENT TEACHING

• Teach patient the cause of condition and ways to alter activity to prevent flexion of wrists; refer
to an occupational therapist as indicated.

• Teach patient to gentle range-of-motion exercises; refer to a physical therapist as indicated.

• Take short, frequent breaks from repetitive activities involving the use of hands.

• Advice to lose weight if patient is overweight or obese.

• Rotate your wrists and stretch your palms and fingers.

 • Take a pain reliever, such as aspirin, ibuprofen (Advil, Motrin IB, others) or naproxen sodium
(Aleve).

• Wear a snug, not tight, wrist splint at night.

• Avoid sleeping on your hands.

PROGNOSIS

In general, carpal tunnel syndrome responds well to treatment, but less than half of individuals
report their hand(s) feeling completely normal following surgery. Some residual numbness or
weakness is common. Most people may need to modify work activity for several weeks following
surgery.