DISORDERS OF THE

MUSCULUSKELETAL SYSTEM
TOPICS:

1. PAGET'S DISEASE OF THE BONE

2. DUPUYTREN'S DISEASE
3. CARPAL TUNNEL SYNDROME
Content
DEFINITION
ETIOLOGY AND PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONS
MEDICAL MANAGEMENT
NURSING INTERVENTIONS
PATIENT TEACHING
PROGNOSIS
QUESTION 1

A CHECKOUT CLERK IN A GROCERY STORE HAS MUSCLE AND

TENDON TEARS THAT HAVE BECOME INFLAMED, CAUSING PAIN
AND WEAKNESS IN THE LEFT HAND AND ELBOW. THE NURSE
IDENTIFIES THESE SYMPTOMS AS RELATED TO:

A. MUSCLE SPASMS.

B. MENISCUS INJURY.

C.REPETITIVE STRAIN INJURY.

D. CARPAL TUNNEL SYNDROME.

Correct Answer: C

Rationale: The patient's occupation and the inflammation,

pain, and weakness in the elbow and hand suggest a repetitive
strain injury. Muscle spasms would be characterized by a
palpable, firm muscle mass during the spasm. Meniscus injury
would affect the knee. Carpal tunnel syndrome is characterized
by weakness and numbness of the hand.
QUESTION 2

A patient with severe ulnar drift caused by rheumatoid arthritis (RA) is scheduled for an
arthroplasty of the right hand and fingers. The nurse determines that the patient has
realistic expectations of the outcome of surgery when the patient says:

a. "I will be able to use my fingers to grasp objects better."

b. "My fingers will appear normal in size and shape after this surgery."

c. "This procedure will prevent further deformity in my hands and fingers."

d. "I will not have to do as many hand exercises after the surgery."
Correct Answer: A

Rationale: The goal of hand surgery in RA is to

restore function, not to correct for cosmetic
deformity or treat the underlying process.
DEFINITION

PAGET'S DISEASE OF BONE

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

Primary proliferation of Disorganized pattern of bone

osteoclasts develops

Pathologic fractures occur &

Induce bone resorption
malalignment of bones

Compensatory increase in
osteoblastic activity

Bone turnover continues

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

The home environment is

Careful assessment of a
assessed for safety to
patient's pain and
prevent falls and to
discomfort is necessary.
reduce the risk of fracture.

How to compensate for Patient teaching on treatment

altered musculoskeletal regimen, the need for a diet with
functioning. 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.
QUESTION 3

How does Paget disease affect the body’s normal process of breaking
down and rebuilding bone?

A. The process greatly speeds up

B. The process greatly slows down

C. The process isn't affected

D. None of the above

Correct Answer: A

The process greatly speeds up.

Rationale: Throughout life, the body is continually absorbing
(breaking down) bone and building new bone. In people with Paget
disease, this process is greatly speeded up.
QUESTION 4

The symptoms of Paget disease are often confused with:

A. Influenza

B. Osteoarthritis

C. Diabetes

D. All of the above

Correct Answer: B

Rationale: Although it is not arthritis, Paget disease can lead to arthritis.

This happens as damaged bones put pressure on nearby joints or cause
excessive wear and tear on joints. In many cases, however, people don’t
know they have Paget disease because they have no symptoms. When
symptoms do appear, they include bone pain, fractures, headache (if
bones in the skull or spine are affected), hearing loss (because of
damage to the small bones in the ear), curvature of the spine, pressure
on nerves, and hip pain. Symptoms get worse slowly.
DEFINITION

DUPUYTREN'S DISEASE
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

Fibroblast proliferation

Collagen deposition

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 MANAGEMENT

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

Teaching patients Self-Care

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.
QUESTION 5

Following x-rays of an injured wrist, the patient is informed that it is badly

sprained. In teaching the patient to care for the injury, the nurse tells the patient
to:

A. Apply heating pad to reduce muscle spasm.

B. Wear an elastic compression bandage continuosly.

C. Use pillows to keep the arm elevated above the heart.

D. Gently exercise the joint to prevent muscle shortening.

Correct Answer: C
Use pillows to keep the arm elevated above the heart.

Rationale: Elevation of the arm will reduce the amount of swelling and
pain. For the first 24 to 48 hours, cold packs are used to reduce
swelling. Compression bandages are not left on continuously. The wrist
should be rested and kept immobile to prevent further swelling or
injury.
 DEFINITION
Is an entrapment neuropathy that occurs when the median nerve
at the wrist is compressed by a thickened flexor tendon sheath,
CARPAL TUNNEL skeletal encroachment, edema or a soft tissue mass.

SYNDROME ETIOLOGY
Repetitive movements or whose hands are re[peatedly
exposed to cold temperature, vibrations, or extreme direct
pressure. May also be associated with diabetes, arthritis,
tumors, or trauma.
PATHOPHYSIOLOGY

Nerve compression and Narrow carpal tunnel

traction

Dysfunction/ damage of the

Intraneural microcirculation nerve from the site of
compression & beyond

Entrapment of peripheral
nerve
 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.

Carpal tunnel release

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.
Advise 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.
QUESTION 6

As carpal tunnel progresses, what most likely happens?

A. Decreased grip and decreased hand strength

B. Burning, cramping, weakness, and wasting of the hand

C. Shooting pains in the forearm

D. All of the above

Correct answer: D
All of the above

Explanation:
Note: Carpal tunnel syndrome may be a temporary condition that completely
resolves or it can persist and progress.

As carpal tunnel syndrome progresses, patients can develop a burning

sensation, and/or cramping and weakness of the hand. Decreased grip
strength can lead to frequent dropping of objects from the hand. Additionally,
sharp, shooting pains can sometimes be felt in the forearm. Chronic carpal
tunnel syndrome can also lead to wasting (atrophy) of the hand muscles,
particularly those in the palm of the hand near the base of the thumb.
QUESTION 7

You are more likely to develop carpal tunnel syndrome if your job requires heavy
typing.

A. True
B. False
The correct answer is: B
False

Rationale: Despite the common belief that frequent typing can lead to
carpal tunnel syndrome, the relationship between heavy typing and
carpal tunnel syndrome is unclear. Actually, carpal tunnel syndrome is
three times more common among assembly line workers than it is
among data-entry personnel -- and frequent use of vibrating hand tools
increases the risk of carpal tunnel syndrome.

A 2001 study found that even heavy computer use -- up to seven hours a
day -- did not make people more likely to develop carpal tunnel
syndrome.
THANK YOU FOR YOUR
PARTICIPATION!

INTERACTIVE ORAL PRESENTATION II

BY: MARY KHRSTINE F. ADAN, RN