MUSCULOSKELETAL PART 2
1. OSTEOMYELITIS
- An infection of the bone that results in
inflammation, necrosis and formation of
new bone.
Classification:
 Hematogenous osteomyelitis- due to blood
borne spread of infection.
 Contiguous- focus myelitis- contamination
from bone surgery open fracture, or
traumatic injury (gun shot wound).
 Osteomyelitis with vascular insufficiency
in persons with DM, peripheral vascular
disease, most commonly affecting the feet.
High risk:
 Older adults
 Poorly nourished and obese
 Impaired immune system
 Chronic illness
 Long term use of corticosteroids therapy or
immunosuppressive agents
 Using IV drugs
NOTE!
- Postoperative surgical wound infections
typically occur within 30 days after
surgery.
- Classified as incisional or deep
PATHO
 More than 50% of bone infections are
caused by Staph. Aureus
 Increasingly of the variety that is
Methicillin Resistant Staphylococcus
Aureus.
 Gram positive- streptococci, enterococci
 Gram negative- pseudomonas
 The initial response to infection is
inflammation, vascularity, and edema.
 After 2-3 days, thrombosis of the local
blood vessels occur, resulting in ischemia
and bone necrosis.
 The infection extend into the medullary
cavity and under the periosteum to the
adjacent soft tissues and joints.
 Without prompt treatment, a bone abscess
forms.
 The abscess contains dead bone tissue (the
sequestrum), which does not easily liquify
and drain.
 The new bone growth (the involucrum),
forms and surrounds the sequestrum.
 Although healing appears to take place, a
chronically infected sequestrum remains
and produces recurring abscesses
throughout the patients life referred to as
Chronic Osteomyelitis.
Clinical Manifestation
  Bloodborne Infection  Central supportive measures
- Onset usually sudden with clinical and - Hydration
laboratory manifestations of sepsis (chills, - Diet high in vitamins and proteins
high fever, rapid pulse, general malaise) - Correction of anemia
- As infection extends to the cortex,
Pharmacologic Man
periosteum, and soft tissue: infected area is
painful, swollen and tender with purulent  Antibiotic therapy

discharge. - is longer than other infections. 3-6 weeks

 Chronic Osteomyelitis as the bone is less accessible to the body’s

- a nonhealing ulcer overlies the infected natural immune response.

bone with connecting sinus intermittently - After infection is controlled, antibiotic can

and spontaneously draining pus. be given orally

 X-ray Surgical Man

- soft tissue edema; 2-3 weeks
 If chronic osteomyelitis, and not
- evidence of periosteal elevation and bone
responsive to antibiotic, surgical
necrosis.
debridement, and the area is irrigated with
 MRI
NSS.
- helps with early definitive diagnosis.
 Sequestrectomy
 Blood studies
- removal of enough involucrum. To enable
- Leukocytosis and elevation of ESR
surgeon to remove the sequestrum.
 Wound and blood cultures
 Saucerization
- Positive in 50% of cases.
- Sufficient bone is removed to convert a
 CHRONIC OSTEOMYELITIES
deep cavity into a shallow saucer.
- Large, irregular cavities, raised
 All dead, infected bone and cartilage must
periosteum, sequestra, or dense bone
be removed before healing can occur.
formation seen on x-ray.
 Microsurgery technique to enhance the
Prevention: blood supply, and improve bone healing.
 Internal fixator or external supportive
 Prevention of osteomyelitis is the goal.
devices may be needed to stabilize or
 Prompt management of soft tissue
support bone to prevent pathologic fracture
infections.
as debridement weakens the bone.
- Reduces extension to the bone or
hematogenous spread.
- Prophylaxis of antibiotic for surgical
Nursing Diagnosis:
procedures such as dental procedures.
 Acute pain related to inflammation and
Medical Man.
edema as evidenced by facial grimace.
  Impaired physical mobility related to pain,
use of immobilization device evidenced by
 Deficient knowledge related to treatment
regimen as evidenced by advanced
inflammation.
Intervention:
 mmobilized affected part with a splint
 Monitor skin and neurovascular status of
affected extremity.
 Elevate affected area.
 Analgesics per doctor’s order
2. BURSITIS AND TENDONITIS
- Are inflammatory conditions that
commonly occur in the shoulder.
- Bursae are fluid-filled sacs that prevent
friction between joint structures during
joint cavity and are painful when inflamed.
- Muscle tendon sheaths also become
inflamed with repetitive stretching.
- The inflammation causes proliferation of
synovial membrane and pannus formation
with restriction of joint mobility
CAUSES
Medical Man.
PHARM & THERAPEUTIC MAN
 Conservative Treatment
- Rest of the extremity.
- Intermittent ice and heat to the joint.
- NSAIDs to control inflammation and
pain.
- Corticosteroids injections remain more
effective for short-term, rapid
improvement.
 Newer therapies
- Laser phototherapy
- Radio frequency ablation
 Surgery
- Arthroscopic synovectomy
- done to remove inflamed joint tissue
(synovium) that is causing unacceptable
pain or is limiting your ability to function
or your range of motion.
BURSITIS
 Bursitis of the Elbow- inflammation of the
olecranon bursa
 Frozen Shoulder (Adhesive capsulitis)
- stiffness, pain and limited movement of
the shoulder
- The tissues around the joint stiffens, scar
tissue forms, and shoulder joint movement
becomes painful and difficult.
- The disease comes in slowly, then goes
away over the course of a year or more.
 If full range of motion is not performed
 Or when stop using the joint because of pain,
injury or chronic health condition such as after
surgery or injury.
 More common, among women.
 NSAIDs
  Gentle stretching  Purines are basic chemical compounds
 ICE found in high concentrations in meat
 Corticosteroid injection products.

 PT  Urate crystals formed when the uric acid

 Stretching light tissue while on anesthesia level in the blood is high.

 Arthroscopy to cut tight tissues and scar  The initial cause for gout attack occurs

tissues. when macrophages in the joint space

3. GOUT OR GOUTY ARTHRITIS
- The most common form of inflammatory
arthritis.
- Men are 3-4x likely to be diagnosed with
gout than women.
phagocytize urate crystals.
 Thru series of immunologic stress,
interleukin I beta is secreted, increasing
inflammation.
 The process is aggravated by the presence
of free fatty acids.
 Both alcohol and consumption of large

Risk Factors: meal with red meat can lead to increase

free fatty acids concentrations and triggers
 Age
acute gout attack.
 Body mass index  Repeated attacks cause accumulation of
 Alcohol consumption sodium urate crystals, called tophi,
 Hypertension deposited in the peripheral areas
 Diuretic use, patients with gout have an  Renal urate lithiasis
increased risk of cardiovascular dse.  Chronic renal disease secondary to urate
deposition.
 PRIMARY URICEMIA
- May be caused by severe
dieting/starvation.
- Excessive intake of foods that are high in
protein shellfish, organ meats
- Heredity
 SECONDARY URICEMIA
PATHO
- Leukemia, multiple myeloma, some type
 Gout is caused by increased serum uric of anemia.
acid (hyperuricemia)
CLINICAL MAN
 Serum concentration greater than 6.8
mg/dL.  Acute gouty arthritis
 Uric acid is a by-product of purine - Recurrent attacks of severe articular and
metabolism. periarticular inflammation
- Tophi
- Gouty nephropathy (renal impairment)
- Uric acid urinary calculi
 Four Stages
- Asymptomatic hyperuricemia the serum
urate concentration is elevated but in
which neither symptoms nor signs of
monosodium urate (MSU) crystal
deposition disease, such as gout, or uric
acid renal disease, have occurred.
- Acute gouty arthritis a form of arthritis,
hence it causes pain and discomfort in the
joints. A typical gout attack is
characterized by the sudden onset of
severe pain, swelling, warmth, and redness
of a joint. The clinical presentation of
acute gouty arthritis is not subtle with very
few mimics other than a bacterial
infection.
- Intercritical gout, the intervals between
DIAGNOSIS
attacks of gouty arthritis are referred to as
intercritical periods. A patient who has  Definitive diagnosis of gouty arthritis is
intercritical gout simply has gout that has established by polarized light microscopy
caused attack(s) of inflammation in a of the synovial.
joint(s) in the past, but it is not visibly  Uric acid crystals are seen within the
active at the time the doctor is evaluating polymorphonuclear leukocytes in the fluid.
the patient.
MEDICAL MAN
- Chronic tophaceous gout, Frequently, uric
acid tophi (hard, uric acid deposits under  Acute attacks
the skin) are present and contribute to bone - Colchicine (oral/parenteral)
and cartilage destruction. Tophi are - NSAID such as indomethacin
diagnostic for chronic tophaceous gout. - Corticosteroids
Tophi can be found around joints, in the - When acute attack subsides, uric acid
olecranon bursa, or at the pinna of the ear. lowering therapy Allopurinol (Zyloprim).
 Between attacks
 - Lifestyle changes: avoid purine-rich foods,
weight loss, decreasing alcohol
consumptions.

5. CARPAL TUNNEL SYNDROME

- is an entrapment neuropathy that occurs
when the median nerve at the wrist is
compressed.
- It frequently occurs in women between 30
and 60 years of age.
- Commonly caused by repetitive hand and
wrist movements, it is also associated with
rheumatoid arthritis, diabetes, acromegaly,
hyperthyroidism, or trauma
- The patient experiences pain, numbness,
paresthesia, and, possibly, weakness along
the median nerve distribution (thumb,
index, and middle fingers).
- Night pain and/or fist clenching upon
awakening is common.
- A positive Tinel sign helps identify
4. CONGENITAL DEFORMITIES patients requiring intervention
 Scoliosis- lateral curvature of the spine.
 Kyphosis- increase in the convex curvature
of the thoracic spine.
 Lordosis- increase in concave curvature of
the spine.

MAIN PROBLEM= PAIN

Treatment= surgery and braces.

  Treatment consists of eliminating the
underlying causes and having a painful
callus treated by a podiatrist.
 Keratolytic ointment may be applied
 Felt padding

7. CORN
 is an area of hyperkeratosis produced by
internal pressure or external pressure (ill-
fitting shoes).
 The fifth toe is most frequently involved,
but any toe may be involved.
 Injection of bleomycin (Blenoxane; a
chemotherapy drug) is being evaluated as a
solution for hard to treat corns that are
surgically treated

TREATMENT:

 oral or intra-articular injections of

corticosteroids, use of NSAIDs and
acupuncture with and without electrical
stimulation (attached to the needles).
 Traditional open nerve release or
endoscopic laser surgery are the two most
common surgical management options
8. HALLUX VALGUS
when nonsurgical treatments fail.
 is a deformity in which the great toe
deviates laterally.
 There is a marked prominence of the
6. CALLUS
medial aspect of the first
 is a thickened area of the skin that has
metatarsophalangeal joint.
been exposed to persistent pressure or
 There is also osseous enlargement
friction.
(exostosis) of the medial side of the first
 Faulty foot mechanics usually precede the
metatarsal head, over which a bursa may
formation of a callus.
form (secondary to pressure and
inflammation).
  Acute bursitis symptoms include a
reddened area, edema, and tenderness.

Risk factors:

 Hereditary
 Osteoarthritis
 Wrong size of shoes

9. HAMMER TOE
- is a flexion deformity of the
interphalangeal joint, which may involve
several toes.
- Tight socks or shoes may push an
overlying toe back into the line of the other
toes.
- The toes usually are pulled upward,
forcing the metatarsal joints (ball of the
foot) downward.