FINALS PART 3 LONG BONES

MUSCULOSKELETAL DISORDERS  Shaped like rods or shafts with rounded

ends.
ANATOMY OF THE
 The shaft/body is known as the diaphysis
2 Divisions of Skeletal System:
is primarily a cortical bone/compact bone.
 Axial Skeleton  The ends are called epiphyses are
 Appendicular Skeleton primarily trabecular bones

BONE

 206 bones
 Four categories: long, short, flat, and
irregular.
 It is a connective tissue
 Needs adequate blood supply
 Capable of changing its form and structure
rapidly in response to changes in stress or
chemical composition in the blood
 It has structural elements: cell, protein
matrix
SHORT BONES
 Has: organic components→ CT proper,
interstitial matrix (ground substance and  Are irregular shaped bones located in the
fibers) ankle and hand

 Inorganic components→ bone salts (Ca,

PO4, Mg)
 FUNCTIONS OF THE BONES

Support

 Form the internal framework that supports

the body and cradles the organ
 Bones of the legs support the body when
we stand
 The rib cage supports the thoracic wall.

Protection

 Protect the soft body organs

 Bones of the skull protect the brain
 The vertebrae surround the spinal cord
 The rib cage helps protect the vital organs
of the thorax

FLAT BONES

 Located where extensive protection of Movement

underlying structures are needed
 Skeletal muscles, attached bones by
tendons, use the bones as levers to move
the body and its parts.

Storage

 fat is stored in the internal (marrow)

cavities of the bones
 storage of minerals, the most important are
calcium and phosphorus

IRREGULAR BONES
Blood cell formation (hematopoiesis)
 Cannot be categorized in any other groups
and include bones such as the vertebrae  Occur within the cavities of certain bones

and bones of the jaw  Bone marrow

BONE TISSUE  Are strong cords of fibrous tissue joint
capsule provides the primary connection
 Compact/cortical bone
between the bones, but ligaments bind the
 Spongy bone
joints more firmly.
CARTILAGE  Bone to Bone

 Contains a firm gel substance in its matrix, Tendon

which gives more flexibility the bone.
 also connect muscles to each other and to
 Avascular, so nutrient tissue fluids reach
other tissues.
its cells by diffusing through the matrix gel
 Fibrous tissue
from the capillaries in the cartilage’s
 Bone to Muscle
fibrous covering (perichondrium) or from
synovial fluid covering a bone’s joint MUSCLE TISSUE
surface.
 Attached to skeletons
3 TYPES OF CARTILAGE  Each muscle fiber is protected by

Fibrocartilage endomysium.
 Group of muscle fiber- fascicle
 Greatest tensile strength
 Group of fascicle- bundle of muscle
 Occurs in the intervertebral discs and
 Bundle of muscle is covered by
symphysis pubis
epimysium.
Elastic Cartilage  Myofilaments- where actin and myosin are
found
 Possesses firmness and elasticity
 Myofilaments give the muscle fiber its
 Occurs in the external ear and eustachian
stripe appearance
tube
 Sarcomere is the basic contractile unit of
Hyaline Cartilage
the muscle, allows the overall muscle
 Most common cartilage type contraction.

 Cushions most of the joints, to help soften  Each muscle fibers has myofibrils
any impact
 Firm yet slightly flexible
 Occurs also in part of the bronchial rings

LIGAMENTS AND TENDON

CONNECTORS

Ligaments
  Each myofibrils contains sarcomeres
 Sarcoplasmic reticulum is as equal to
endoplasmic reticulum.
JOINTS/ARTICULATION
 Site where two or more bones meet
 Every bone in the body forms a joint at
least with one other bone in the body.
Functions:
 Hold bones together securely
 To allow mobility to a rigid skeleton
Functional Classification:
 Synarthroses- (Skull) Made up of fibrous
tissue. Non-movable.
 Amphiarthroses- (ex. Spine). Slightly
movable
 Diarthroses- freely movable
Structural Classification:
 Fibrous- separates the body region of the
joints, such as in the skull.
 Cartilaginous- cartilage separates the body
region, such as intervertebral joints of the
spine.
 Synovial- articulating bone ends are
separated by joint cavity.
Four Distinguishing Features:
 Articular (hyaline) cartilage, covers the
ends of the bones forming the joints.
 Articular capsule, joint surfaces are
enclosed by a fibrous CT which are lined
by synovial membrane (thus the name
synovial joints). Prevents friction of bones.
 Joint cavity enclosed by a capsule, with
synovial fluid as lubricant
 Reinforcing ligaments that reinforces the
fibrous capsule.
DISORDERS IN MOBILITY
1. OSTEOARTHRITIS
 Non-inflammatory degenerative disorder
of the joints
 The most common form of joint disease
and routinely referred to as degenerative
joint disease.
 It does not involve autoimmunity or
inflammation, but it can occur as an end
result of autoimmune disorder where joint
destruction occurs.
 OA often begins in the 3rd decade of life
and peaks between fifth and sixth decades.
 By age 40, 90% of the population has
degenerative joint changes in the weight-
bearing joints, though clinical symptoms
are usually absent.
 Women are commonly affected.
Classification:
 Primary (idiopathic)- no prior event of
disease related to OA.
 Secondary- resulting from previous joint
injury or inflammatory disease, similar to
RA.
Risk Factors:
 Older age
 Female gender
 Obesity- most modifiable risk factor
  Certain occupations, like those requiring
laborious tasks
 Engaging in sport activities
 History of previous injuries
 Muscle weakness
 Genetic predisposition

PATHO

 All joints consists of bone, a subchondral

bone where articular cartilage is attached. CLINICAL MANIFESTATION

 The cartilage is lubricated, smooth tissue  Pain, stiffness, and functional

that protects the bone from damage with
physical activity.
 Between the articular cartilage of the bone
is a space, the joint space that allows for
movement and contains synovial fluid to
help lubricate and protect joint’s
movement.
 With OA, the articular cartilage breaks
down leading to progressive damage of the
underlying bone and eventual formation of
osteophyte (bone spurs) that protrude to
the joint space.
 The results are narrowed joint space,
decreased joint movement and potential
for ore damage.
impairment→ main clinical manifestations
 Joint pain is aggravated by movement or
exercise and relieved by rest.
 Morning stiffness is usually brief resting
less than 30 minutes.
 On physical examination, joint may be
enlarged with decreased range of motion.
 Although common in weight-bearing
joints, proximal and distal interphalangeal
joints are often involved.
 HERBERDEN’S NODES- enlargement of
DIP
 BOUCHARD’S NODES- enlargement of
PIP

DIAGNOSTIC FINDING
  X-rays may show narrowing of the joint
space.
 Osteophyte formation
 Osteophytes is a distinct feature of OA
 Dense, thickened subchondral bone

MEDICAL MAN

 The goal is to decrease pain and stiffness

and to maintain/improve joint mobility.
 Exercise, weight loss, OT and PT.
 Wedged insoles, knee braces, canes, etc.

PHARMA MAN

 NSAIDs NURSING INT

 COX-2 enzymes blockers- a type of  Abduction pillow when patient is lying to
NSAID that directly target the maintain the legs in a split position (knee
cyclooxegenase, an enzyme responsible replacement) (turn to unaffected side).
for inflammation and pain.
 If ambulatory, prevent bending.
 Celecoxib (Celebrex)
 Deep breathing/coughing exercises
 Rofecoxib (Vioxx)
 Passive-Active Exercises
 Etoricoxib (Arcoxia)
 Application of foot board to prevent foot
SURGICAL MAN drop that can cause complication.
 Be careful in transferring patient to prevent
 Osteotomy- surgical removal or cutting of
dislocation of implants
a bone.
 Patients are prone to pulmonary embolism.
 Arthroplasty- the surgical reconstruction or
- CPM (continuous passive machine) to
replacement of a joint (hip replacement,
prevent complication.
knee replacement).
- Follow prescribed therapy by physical
 Rehabilitation and PT which is initiated
therapist.
within 24 hours.

2. OSTEOPOROSIS
 Is a medical condition in which the bone
becomes brittle and fragile from loss of
tissue, typically as a result of hormonal
changes or deficiency of calcium or
Vitamin D.
  The most prevalent bone disease in the PATHO
world.
 Characterized by reduced bone mass,
 More than 1.5 million osteoporotic
deterioration of bone matrix, and
fractures occur every year.
diminished bone architectural strength.
Risk Factors:  The rate of bone resorption by osteoclasts
is greater than the rate of bone formation
 Genetics: Caucasian, Asian, Female,
by osteoblasts.
Family History
 The bones become progressively porous,
 Age: Post menopausal, advanced age, low
brittle, and fragile.
testosterone in men, low estrogen in
 They fracture easily, most commonly as
women.
compression fractures of the thoracic and
 Nutrition: Low calcium intake, low
lumbar spine, hip fracture, Colles fracture.
vitamin D intake, low calcitonin
 Lifestyle choices: caffeine, smoking, lack
of exposure to sunlight
 Medications: corticosteroids, antiseizure

ASSESSMENT & DAIGNOSTIC

 When the vertebrae collapse, the thoracic

vertebrae become wedge shaped and
lumbar vertebrae biconcave.
 Undetectable in routine x-ray until 25% to
40% demineralization has occur.
 Dual energy x-ray absorptiometry (Dexa)
which provides information about BMD at
the spine and hip.

medications, heparin, thyroid hormone  Baseline DEXA testing is recommended

 Physical exercise: sedentary, lack of for all women older than 65 years, for

weight-bearing exercises women who are postmenopausal older

 Comorbidity: Anorexia nervosa, than 50 years with OP risk factor.

hyperthyroidism, kidney failure

  Laboratory studies: serum calcium, serum ALENDRONATE (FOSAMAX)
phosphate, urine calcium excretion, ESR
 Prevention and treatment of OP in women
(Erythrocyte Sedimentation Rate), x-ray
who are postmenopausal
studies are used to exclude other possible
 PO daily/weekly
disorders.
 10 mg/ 70 mg
MEDICAL MAN  Take in the am on empty stomach with 250

 A diet rich in calcium and vitamin D ml of water while sitting upright and

throughout life. remain upright for 30 mins.

 Increased calcium intake during RISEDRONATE (ACTONEL)

adolescence and middle years to protect
 Treatment of OP in men
against demineralization.
 Treatment of OP in men and women
 Calcium intake level for adults is 1000 to
taking corticosteroids
1300 mg.
 Given PO/weekly
 Vitamin D, 50 and older is 800 to 1000 IU
daily. IBANDRONATE (BONIVA)
 A cup of milk or calcium-fortified orange
 Treatment of OP in women who are
juice contains about 300 mg of Calcium
postmenopausal
 Regular weight-bearing exercises promote
 IV dosing may be good option for patients
bone formation.
either intolerant of PO bisphosphonate or
 20-30 minutes aerobic exercise. nonadherent to prescribed therapy.
 Given IV every 3 months
PHARMA MAN  Given PO monthly

 1ST line medication to treat and prevent ZOLEDRONIC ACID (RECLAST)

osteoporosis → calcium and vitamin D and
 Prevention and treatment of OP in women
biphosphates for both genders.
who are postmenopausal
 Vitamin D with meals of beverage high in
 Treatment of OP in men and women
Vitamin C to promote absorption.
taking corticosteroids for at least 12
Selected OP medication: months
 Given IV yearly
BISPHOSPHONATES
TERIPARATIDE (FORTEO)
 to increase bone mass, decrease bone loss
by inhibiting osteoclasts function.  For both genders given for those with high
 Shout not be taken with calcium and fractures risk→ given subcutaneously OD
vitamin D supplements. for two years.
 Side effects: GI symptoms
FRACTURE MAN  Risk for injury: additional fractures related
to osteoporosis.
 For Hip fracture:
- Joint replacement
- Closed reduction
- Open reduction with internal fixation
(ORIF)
 Compression fractures are treated
conservatively as most are asymptomatic.
 Percutaneous Vertebroplasty or
Kyphoplasty
- A medical grade cement is injected 3. OSTEOMALACIA
into a painful vertebral fracture to  A metabolic bone disease characterized by
stabilize the fracture and injection of inadequate mineralization of bone
pressurized balloon to restore the shape resulting to softening and weakening of the
of affected vertebrae. skeleton with pain and tenderness to touch.
 Spinal kyphosis and bowed legs, at risk for
falls and pathologic fracture.
 RICKET’S DISEASE in children

NURSING MAN

Health Teachings

 Emphasize need of sufficient calcium, vit.

D to slow progression of osteoporosis.
 Encourage to do weight-bearing exercises.
 Medication compliance.

NURSING DIAGNOSIS

 Deficient knowledge about osteoporotic  RICKET’S is the softening and weakening

process and treatment regimen of bones in children, usually because of an
 Acute pain related to fracture and muscle extreme and prolonged vitamin D
spasm deficiency. Rare inherited problems also
 Risk for constipation related to immobility can cause rickets.

or development of ileus PATHO

  The major defect is a deficiency of  If underlying cause is corrected, the
activated VITAMIN D, which promotes disorder may resolve.
calcium absorption from GIT and  If kidney disease prevents activation of
facilitates mineralization of bone. vitamin D, supplementation which
activated form (calcitriol).
CAUSES
 If cause by malabsorption, increased doses
 Failed calcium absorption or excessive of vitamin D and supplemental calcium.
loss of calcium from the body (kidney
 UV exposure transform 7-
failure).
dehydrocholesterol in the skin into
 GI disorders (celiac disease, chronic Vitamin D.
biliary tract obstruction, chronic
 Persistent orthopedic deformity may be
pancreatitis, small bowel resection) where
treated with braces and surgery.
fats are inadequately absorbed.
 Hyperthyroidism leads to skeletal
decalcification and thus to OM by
increasing phosphate excretion in the
urine.

ASSESSMENT & DIAGNOSIS

 Generalized demineralization is evident on

x-ray.
 Vertebral studies will show compression
of fracture.
 Laboratory studies show low serum
calcium and phosphorous level.
 Moderately elevated Alkaline Phosphatase
 Low urine excretion of calcium and
creatinine.
 Bone biopsy has increased amount of
osteoid.
 Osteoid is a demineralized, cartilaginous
bone matrix. Also referred to as prebone.

MEDICAL MAN

 Physical, psychological, pharmacological

measures.