Musculoskeletal

Disorders
Session 22
Learning Objectives:

At the end of the module, students will be able to:

1. Identify the medical and nursing management of bone
diseases;
2. Point out the causes and appropriate nursing interventions
for contusion, sprain, strain and joint dislocation;
3. Determine the test used to diagnose bone tumor; and,
4. Identify nursing diagnosis and medical management of
after
amputation.
ANATOMY OF THE
MUSCULOSKELETAL
SYSTEM
What is the function of
our bones?
What is the function of our bones?

It provides shape and support for

the body, as well as protection for
some organs.
ANSWER:

To provide the body with stability and mobility.

The musculoskeletal system has many other functions; the

skeletal part plays an important role in other homeostatic
functions such as storage of minerals (e.g., calcium) and
hematopoiesis, while the muscular system stores the majority
of the body's carbohydrates in the form of glycogen.
The musculoskeletal system (locomotor system) is a
human body system that provides our body with movement,
stability, shape, and support. It is subdivided into two broad
systems:

❖ Muscular system- the muscular system contains the tendons

which attach the muscles to the bones.

❖ Skeletal system- whose main component is the bone. Bones

articulate with each other and form the joints, providing our bodies
with a hard-core, yet mobile, skeleton.
Osteoclast - dissolve and
breakdown old or damaged bone
cells
Osteoblast - synthesize and secrete
bone matrix and participate the
mineralization of bone to regulate
the balance of calcium and
phosphate ions in developing bone.
QUESTION:

Which of the following is not a function of the

skeletal system?
a) Protection of internal organs
b) Production of hormones
c) Storage of minerals such as calcium and
phosphorus
d) Support for the body
ANSWER:

b) Production of hormones
OSTEOARTHRITIS
OSTEOARTHRITIS

Osteoarthritis (OA), also known as degenerative joint disease

or osteoarthrosis (even though inflammation may be present),
is the most common and most frequently disabling of the
joint disorders. OA occurs most often in weight-bearing joints
(hips, knees, cervical and lumbar spine), and may also involve
the proximal and distal finger joints
Classification of Osteoarthritis

PRIMARY (IDIOPATHIC) Risk Factors

- With no prior event or disease related to OA

- Increased age (between 50 to 60 years

SECONDARY old)
- Resulting from previous joint injury or - Genetic
inflammatory disease - Previous joint damage
- Congenital and developmental disorders
- Obesity
- Repetitive use (occupational or
recreational)
Clinical Manifestations
Assessment and Diagnostic Findings
Primary manifestations:
pain, stiffness, and
functional impairment Tender and enlarged joints
Painful body nodes when X-ray - progressive loss of the
inflamed joint cartilage
 Medical Management

1. Weight reduction
2. Prevention of injuries
3. Perinatal screening for congenital hip disease
4. Use of heat, joint rest and avoidance of joint overuse, orthotic devices
5. Isometric and postural exercises, and aerobic exercise
6. Massage, yoga, or music therapy
7. Pulsed electromagnetic fields, or Transcutaneous electrical nerve stimulation (TENS)
8. Occupational and physical therapy
9. Herbal and dietary supplements
10. Acupuncture, acupressure, wearing copper bracelets or magnets, and participation
in T’ai chi
Pharmacologic Initial analgesic therapy: Acetaminophen
Management Other analgesics: NSAIDs, COX-2 enzyme blockers, Opioids, Intra-articular
corticosteroids, Topical analgesic agents such as Capsaicin (Capsin, Zostrix), or
Methylsalicylate
Glucosamine and Chondroitin – modify cartilage structure
Intra-articular Viscosupplementation (hyaluronates) –

Surgical Osteotomy-surgical procedure in which a bone is cut, reshaped, or realigned

Management Arthroplasty- Is a surgical procedure that involves the reconstruction or
replacement of a damaged or diseased joint with an artificial prosthesis.

Nursing Pain management and optimal functional ability are major goals of nursing
Management intervention.
1. Advise the patient to reduce weight and to exercise (walking).
2. Refer the patient for physical therapy or to an exercise program.
3. Encourage the patient to use canes or other assistive devices for ambulation.
4. Provide adequate pain management.
Gout
GOUT

- heterogeneous group of
conditions related to a
genetic defect of purine
metabolism that results
in hyperuricemia.
 Risk Factors:
Excessive intake of Risk Factors contributing to Hyperuricemia
foods high in purine
(shellfish, organ meats)
Alcohol ingestion
Dieting
Side effect of Inflammation ensues
medications
Trauma
Surgical stress
Elevated serum uric
Urate crystals precipitate within a joint acid (>7mg/dL)

Joint pains
(MCQ in big toes
Polarized light in 90% of
microscopy of synovial Accumulations of sodium urate crystals in patients)
fluid peripheral areas of the body Redness,
swelling, warm
affected joint

GOUT
 Medical Management
1. Acute attacks: Colchicine
(oral or parenteral), NSAID
(Indomethacin), or a
Corticosteroid
2. Uricosuric agents: Probenecid
(Benemid)
3. Allopurinol
4. Febuxostat (Uloric)
Nursing Management
1. Encourage the patient to restrict
consumption of foods high in
purines, especially organ meats,
and to limit alcohol intake.
2. Encourage the patient to increase
fluid intake.
3. Advise the patient to maintain
normal body weight.
4. In an acute episode: administer
analgesics and instruct the patient
to avoid factors that increase pain
and inflammation, such as trauma,
stress, and alcohol.
OSTEOPOROSIS
OSTEOPOROSIS

Osteoporosis is characterized by
reduced bone mass,
deterioration of bone matrix,
and diminished bone
architectural strength. The
consequence of osteoporosis is
bone fracture.
RISK FACTORS OF OSTEOPOROSIS
1. Women after menopause
(usually between the ages of 45
and 55 years) and in men later in
life
2. Low testosterone in men
3. Advanced age
4. Family history
5. Genetic
6. Small frame, lack of weight and
body mass index
7. Lifestyle (caffeine, alcohol,
smoking)
8. Sedentary, immobility, lack of
weight-bearing exercise
9. Lack of exposure to sunlight
10. Nutritional factors: decreased
calcitonin, low calcium intake, low
vitamin D intake, high phosphate
intake
(carbonated beverages),
inadequate calories
11. Medications: Corticosteroids,
Antiseizure medications, Heparin,
Thyroid hormone
12. Diseases/Conditions: Anorexia
nervosa, Hyperthyroidism,
Malabsorption syndrome, Renal
failure
 Increased rate of bone
resorption by osteoclasts

Decrease rate of bone

formation by osteoblasts
 Assessment and Diagnostic Tests

Dual-energy x-ray absorptiometry (DXA)

- testing is recommended for all women
older than 65 years of age, for all men
older than 70 years of age, for
postmenopausal women and men
older than 50 years of age with
osteoporosis risk factors, and for all
people who have had a fracture
thought to occur as a consequence of
osteoporosis
 Medical Management

A diet rich in calcium and

vitamin D throughout life (best
source: fortified milk) Includes
three glasses of skim or whole
vitamin D–enriched milk or other
foods high in calcium (cheese and
other dairy products, steamed
broccoli, canned salmon with
bones) daily.
Regular weight-bearing
exercise
Pharmacologic Therapy

Calcium and Vitamin D supplements

Biphosphonates: Alendronate (Fosamax) or Increases bone mass and decrease bone loss
Risedronate (Actonel), Ibandronate by inhibitibg osteoclast function
(Boniva) or Intravenous infusions of
Zolendronic acid (Reclast)

Calcitonin (Miacalcin) Directly inhibits osteoclasts, thereby reducing

bone loss and increasing BMD (Bone Mass
Density)

Selective estrogen receptor modulators Reduce risk of osteoporosis by pre-serving

(SERMs): Raloxifene (Evista) BMD without estrogenic effects on the uterus.
They are indicated for both prevention and
treatment of osteoporosis.
Fracture Management

A. Joint replacement or by closed or

open reduction with internal
fixation (hip pinning)

B. Percutaneous vertebroplasty or
kyphoplasty (injection of
polymethylmethacrylate bone
cement into the fractured vertebra,
followed by inflation of a pressurized
balloon to restore the shape of the
affected vertebra)
Nursing Diagnoses

1. Deficient knowledge about the osteoporotic process

and treatment regimen
2. Acute pain related to fracture and muscle spasm
3. Risk for constipation related to immobility or
development of ileus (intestinal obstruction)
4. Risk for injury: additional fractures related to
osteoporosis
OSTEOMALACIA
OSTEOMALACIA

Osteomalacia is a metabolic bone disease

characterized by inadequate mineralization of bone.
As a result of faulty mineralization, there is softening
and weakening of the skeleton, causing pain,
tenderness to touch, bowing of the bones, and
pathologic fractures.
RISK FACTORS

1. Deficiency of activated vitamin D (calcitriol)

2. Calcium deficiency
3. Malnutrition
4. Malabsorption syndrome
5. Gastrointestinal disorders (celiac disease, chronic
biliary tract obstruction, chronic pancreatitis, small
bowel resection)
6. Liver and kidney diseases
7. Hyperparathyroidism
8. Prolonged use of antiseizure medications: Phenytoin
(Dilantin), Phenobarbital
Clinical 1. Skeletal deformities (spinal
Manifestations kyphosis and bowed legs):
waddling or limping gait
2. Muscle weakness, and
unsteadiness

Assessment and 1. X-ray studies - generalized

Diagnostic demineralization of bone
Findings 2. Low serum calcium and
phosphorus levels
3. Moderately elevated alkaline
phosphatase
4. Low urine calcium and creatinine
5. Bone biopsy - increased amount of
osteoid, a demineralized
cartilaginous bone matrix
 Medical Management

1. Assist the patient in changing positions, and use pillows to

support the body.
2. Increased doses of vitamin D with supplemental calcium.
3. Exposure to sunlight may be recommended.
4. Adequate protein, and increased calcium and vitamin D
(dietary sources of calcium and vitamin D (fortified
milk and cereals, eggs, chicken livers).
5. Monitoring serum calcium levels is important.
6. Persistent orthopedic deformities: braces or surgery
(osteotomy).
Paget’s Disease
Paget’s Disease

Paget’s disease (osteitis deformans) is a disorder of

localized rapid bone turnover, most commonly
affecting the skull, femur, tibia, pelvic bones, and
vertebrae.
RISK FACTORS:
1. Older than 50 years
2. Greater in men than in women and increases with aging
3. Family history
 Increase bone resorption

Disorganized and increased bone

growth

Skeletal deformities, fragile bones

and potential fractures

Paget’s Disease
 Remember:
*Disorder with excessive bone
resorption and growth
Leading to deformities and
potential fractures

*May affect single bone or

several bones
Medical Management

1. Walking aids, shoe lifts, and physical therapy –

for Gait problems from bowing of the legs
2. Weight control - to reduce stress on weakened
bones and misaligned joints
3. Adequate daily intake of calcium and vitamin
D and periodic monitoring
 Pharmacologic Therapy
NSAIDs For pain relief

Calcitonin Retards bone resorption by decreasing the number and availability of osteoclast
Facilitates remodeling of abnormal bone into lamellar bone, relieves bone pain, and
helps alleviate neurologic and biochemical signs and symptoms

Biphosphonates Produce rapid reduction in bone turnover and relief of pain and reduces serum
alkaline phosphatase and urinary hydroxyproline levels

Plicamycin May be used to control the disease.

(Mithracin) - Is reserved for severely affected patients with neurologic compromise and for
those whose disease is resistant to other therapy.
- Have dramatic effects on pain reduction and on serum calcium, alkaline
phosphatase, and urinary hydroxyproline levels.
 GUESS THE PICTURE
1. 2.

3.
Osteomyelitis
OSTEOMYELITIS

Osteomyelitis is an infection of the bone that

results in inflammation, necrosis, and formation of
new bone.

Causative agents: Staphylococcus aureus

(common), Streptococci, Enterococci,
Pseudomonas species
CLASSIFICATIONS OF
OSTEOMYELITIS
Hematogenous Osteomyelitis Due to Bloodborne spread of infection

Contiguous- focus From contamination from bone surgery, open

osteomyelitis fracture, or traumatic injury (gunshot wound)
Osteomyelitis with vascular Seen most commonly among patients with
insufficiency diabetes and peripheral vascular disease,
most commonly affecting the feet
Clinical Manifestations

1. Affected bone is painful, swollen,

warm, and extremely tender
2. Chronic osteomyelitis: non-healing ulcer
that overlies the infected bone with a
connecting sinus that will
intermittently and spontaneously drain pus
3. Bloodborne (sepsis): chills, high fever,
rapid pulse, general malaise
Management

Medical 1. IV antibiotic therapy - Staphylococcal

organisms: Penicillin or Cephalosporin
2. Good hydration
3. Diet high in vitamins and protein
4. Correction of anemia
5. Immobilized affected area
Surgical 1. Debridement
2. Sequestrectomy - removal of enough involcrum
to enable the surgeon to remove the sequestum
Nursing Management

A. Relieve Pain
1. Immobilize the affected part with a splint to decrease
pain and muscle spasm.
2. Monitor the neurovascular status of the affected
extremity.
3. Handle wound gently and with great care (the
wounds are frequently very painful).
4. Elevate affected extremity to reduce swelling and
discomfort.
5. Administer analgesic agent.
Nursing Management

B. Improve Physical Mobility

1. Protect weakened bone by use of immobilization
devices and avoidance of stress on the bone.
2. Inform the patient the rationale for the activity
restrictions.
3. Gently move the joints above and below the affected
part through their range of motion.
4. Encourage full participation in ADLs within the
physical limitations to promote general well-being.
 Nursing Management
C. Control the Infectious Process
1. Monitor the patient’s response to antibiotic therapy and observe
the IV access site for evidence of phlebitis, infection, or infiltration.
2. With long-term, intensive antibiotic therapy: monitor the patient
for signs of superinfection
3. If surgery is necessary: ensure adequate circulation to the
affected area (wound suction to prevent fluid
accumulation, elevation of the area to promote venous drainage,
avoidance of pressure on the grafted
area), maintain needed immobility, and ensure the patient’s
adherence to weight-bearing restrictions.
Nursing Management

C. Control the Infectious Process

4. Change dressings using aseptic technique to
promote healing and to prevent cross-contamination.
5. Continue to monitor the general health and nutrition
of the patient.
6. Provide a diet high in protein to promote a positive
nitrogen balance and healing.
7. Encourage adequate hydration.
Nursing Management

D. Promote Home and Community-Based Care

1. Teaching patient self-care
- Teach the patient and family about the importance of strictly
adhering to the therapeutic regimen of antibiotics, aseptic
dressing and warm compress techniques, preventing falls or
other injuries that could result in bone fracture, and maintaining
and managing the IV access and IV administration equipment in
the home.
- Instruct the patient and family to observe for and report
elevated temperature, drainage, odor, signs of increased
inflammation, adverse reactions, and signs of superinfection.
Nursing Management

2. Continuing care
- Assess home to determine the patient’s and family’s
abilities regarding continuation of the therapeutic regimen.
- Monitor the patient for response to the treatment, signs
and symptoms of superinfections, and adverse drug
reactions.
- Stress the importance of follow-up health care
appointments and recommends age- appropriate health
screening.
QUESTION:

Which imaging modality is most commonly used for

diagnosing osteomyelitis?
a) Magnetic resonance imaging (MRI)
b) Computed tomography (CT) scan
c) X-ray
d) Ultrasound
ANSWER:

a) Magnetic resonance imaging (MRI)

Rationale: MRI is the preferred imaging modality for diagnosing

osteomyelitis because it provides excellent soft tissue contrast and can
detect early bone marrow changes characteristic of osteomyelitis.
END