MUSCULOSKELETAL DISORDERS

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 Learning Objectives

I. Learning Objectives

Upon completing this chapter students should be able to

• Describe the anatomy and physiology of the musculoskeletal

system.

• Discuss about health assessment methods

• Specify the diagnostic tests used for musculoskeletal system

• Intervention for clients with musculoskeletal disorders

• Discuss Soft tissue injuries

 Learning Objectives
• Discuss varies types of fracture.
• Explain amputation
• Joint and connective tissue diseases:
 Osteomylitis
 Osteoporosis
 Rheumatoid arthritis
 Gouty arthritis
 Osteoarthritis
 Septic arthritis
 Anatomy and Physiologic overview..

The musculoskeletal system is composed of

Bones

Ligaments, tendons,

Muscles and joints.

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 Overview of Anatomy and Physiology
 Bone tissue makes up about 18% of the weight of the human body.

 Functions of the skeletal system

► Support. serves as the structural framework for the body by

supporting soft tissues and providing attachment points for the

tendons of most skeletal muscles.

► Protection. protects the most important internal organs from

injury.

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► Assistance in movement. Most skeletal muscles attach to
bones; when they contract, they pull on bones to produce
movement.
► Mineral homeostasis (storage and release). Bone tissue
stores several minerals, especially calcium and
phosphorus, which contribute to the strength of bone.
► Blood cell production. Within certain bones, a CT
called red bone marrow produces RBCs, WBCs, and
platelets, a process called hemopoiesis
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►Triglyceride storage. Yellow bone marrow consists
mainly of adipose cells, which store triglycerides.
• The stored triglycerides are a potential chemical energy
reserve.

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 Overview of Anatomy cont…
Structure of bones: Four classifications based on form and shape.

Long bones (e.g. femur)

 A long bone is one that has greater length than width.

 A typical long bone consists of the following parts:

 The diaphysis is the bone’s shaft or body—the long, cylindrical,

main portion of the bone

 Designed for weight bearing and movement.

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 The epiphyses are the proximal and distal ends of the bone.

 The metaphyses are the regions between the diaphysis and the

epiphyses.

 In a growing bone, each metaphysis contains an epiphyseal, a layer

of hyaline cartilage that allows the diaphysis of the bone to grow in

length.

 When a bone ceases to grow in length at about ages 18–21, the

cartilage in the epiphyseal plate is replaced by bone; the resulting

bony structure is known as the epiphyseal line.

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 The articular cartilage is a thin layer of hyaline
cartilage covering the part of the epiphysis where the
bone forms an articulation (joint) with another bone.
 Articular cartilage reduces friction and absorbs shock at
freely movable joints.
 Because articular cartilage lacks a perichondrium and
lacks blood vessels, repair of damage is limited.

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 The periosteum is a tough connective tissue sheath and
its associated blood supply that surrounds the bone
surface wherever it is not covered by articular cartilage
 Some of the cells enable bone to grow in thickness, but
not in length.
 The periosteum also protects the bone, assists in fracture
repair, helps nourish bone tissue, and serves as an
attachment point for ligaments and tendons.

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 Overview of Anatomy cont…

Short bones (e.g. metacarpals)

Flat bones (e.g. sternum): important sites for
hematopoiesis and frequently provide vital organ
protection
Irregular bones (e.g. vertebrae)

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 Site of haematopoiesis

 The spongy sections of long bones and flat bones

contain tissue for haematopoiesis.
 In the adult, in the spongy center of flat bones
(especially the sternum) and in only two long bones:
the humerus and the head of the femur.

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 Overview of Anatomy cont…
 Bone is composed of cells, protein matrix, and mineral
deposits.
 The cells are of three basic types:-

 Osteoblasts:- function in bone formation by secreting bone

matrix.
 Osteocytes:-mature bone cells involved in bone-maintenance
functions.
 Osteoclasts:- multinuclear cells involved in destroying,
reabsorbing, and remolding bone.
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 Cell of bone….
 Ground substance is a
gelatinous material
that facilitates
diffusion of nutrients,
wastes and gases
between the blood
vessels and bone
tissue.
• A mnemonic that will help you remember the difference
between the function of osteoblasts and osteoclasts is as
follows: osteoBlasts Build bone, while osteoClasts
Carve out bone.

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 Bone remodeling in adults

 Bones of adults do not normally increase in

length/size, but constant remodeling and repair

of damaged bone tissue, occurs throughout life.

 Hormones and forces that put stress = regulate

remodeling.
 Bone remodeling in adults….

 Bones that are in use, are subjected to stress,

– Increase their osteoblastic activity to increase

ossification (the development of bone).
 Bones that are inactive undergo

– Increased osteoclast activity and bone resorption.

Bone remodeling in adults….
 Overview of Anatomy cont…

 Articulations (joints) Allow movement.

 Three types according to degree of movement

Synarthrosis—no movement

Amphiarthrosis—slight movement

Diarthrosis—free movement

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 Overview of Anatomy cont…

 Skeletal Organization there are 206 bones in adults.

Axial skeleton

• Head, thorax, and spine

Appendicular skeleton

• Upper extremities
• Lower extremities

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 Overview of Anatomy and cont…

 Functions of the muscular system

– Motion
– Maintenance of posture
– Production of heat
 Types of Muscles

– Smooth (involuntary muscle)

– Striated (skeletal/voluntary)
– Cardiac
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Types of Muscle
Functional classification of the joints
 Role of the nervous system

 Nerve impulses originate in the motor areas of

the frontal lobes of the cerebral cortex.
 The coordination of voluntary movement is a
function of the cerebellum.
 Neurons in the CNS regulate muscle tone.
 Overview of Anatomy cont…

 Nerve and blood supply

 Blood vessels provide a constant supply of oxygen and

nutrition, and nerve cells/fibers supply a constant
source of information
 Muscle contraction

– Muscle stimulus—when a muscle cell is adequately

stimulated, it will contract
– Muscle tone—skeletal muscles are in a constant state
of readiness for action
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 – Types of body movements
• Flexion—bending at a joint
• Extension—straightening at a joint

Abduction: moving away from

midline
Adduction:moving toward midline
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Rotation: turning around a specific
axis (eg, shoulder joint)

Circumduction—cone-like movement

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 Gerontological Issues

 Age-related changes can lead to impaired mobility, an increased

risk for falls, and pain.

 Muscle mass and strength decline are replaced by fibrous

connective tissue.
 Elasticity of ligaments, tendons, & cartilage decrease
 Intervertebral spaces decrease from loss of water, causing a
loss of height.
 Posture and gait change.
 Gerontological Issues….

Factors
 Good nutrition, age is another, especially for women.
 Estrogen or testosterone is the maintenance of a strong
bone matrix.
– For women after menopause, bone matrix loses
more calcium.
Gerontological Issues….

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 Diagnostic tests

Diagnosis of musculoskeletal problems is

assisted by
– Laboratory tests and

– Diagnostic imaging (x-ray examinations

and nonradiological tests).
 Laboratory tests
CBC
Haemoglobin.
WBC =Neutrophilia =bacterial infection
(e.g.septic arthritis).
Lymphopenia = viral illnesses or active SLE.

Thrombocytopenia is seen in drug-induced bone

marrow suppression
 Laboratory tests…..
 RF (rheumatoid factor
 Erythrocyte sedimentation rate (ESR) and C-reactive
protein (CRP)
• An increase of these reflects inflammation
 Serum uric acid for gout.
 Antistreptolysin-O titre for rheumatic fever
 Laboratory Tests….

Serum Calcium and Phosphorus

 Ca 8.5–10. 5 mg/dL(normal)

 Serum Phosphorus 2.6–4.5 mg/dL(normal)

 Are regulated by thyroid gland and parathyroid hormone

from the parathyroid gland.

– When these glands are not functioning properly,

alterations in calcium and phosphorus levels can occur

 Laboratory Tests…

• Serum calcium tends to decrease in patients with

– Osteoporosis or

– Consume inadequate amounts of calcium

• Serum calcium levels increase in

– Patients with bone cancer, particularly those with

metastatic disease.
– Extended immobilization
 Laboratory Tests…
Alkaline Phosphatase
• 45–115 U/L (male) 30–100 U/L (female)
• Neonate: 50–300 U/L Growing child: 70–350 U/L

ALP is an enzyme that increases when bone or liver tissue is

damaged.
– In metabolic bone diseases and bone cancer, ALP
increases to reflect osteoblast (bone-forming cell)
activity.
• ALP is increased when new bone formed
 Laboratory Tests…
Myoglobin 50–120 μg/mL
• Myoglobin is a protein found in striated (skeletal or
cardiac) muscle.
• It is what causes the red color of muscle.
• When skeletal or cardiac muscle is damaged
myoglobin levels rise in the blood.
• Increased myoglobin can indicate MI or skeletal
muscle destruction
 Laboratory Tests…
Uric acid
• Normal value is 3.5–8.0 mg/dL for Male and 2.8–6.8 mg/dL
in Female
• To diagnose and monitor the treatment of gout.
• Panic level considered > 12 mg/dL.

Rheumatoid factor (RF)

• Normal value < 30 IU/L
• To diagnose rheumatoid, lupus erythematosus and
scleroderma.
 Laboratory Tests…
Creatine kinase (CK)
 To diagnose muscle trauma or disease, muscular dystrophy and
traumatic injuries Adult female: 30–180 U/L
 Adult male: 60–220 U/L

Examination of synovial fluid

Will be increased in rhabdomyolysis.

• Are always indicated when infected or crystal induced arthritis

• Normal fluid is straw coloured and contain <3000 WCC/mm3

• Inflammatory fluid is

– Cloudy, viscous and contains > 3000 WCC/mm3

 Examination of synovial fluid….

Septic fluid is Opaque and less viscous and contains up to 75000

WCC/m3

• Polarized light microscopy is performed for crystals.

 Standard X-Rays
Can detect
 Joint space narrowing
 Erosions in rheumatoid arthritis
 Calcification in soft tissue
 Fracture
 New bone formation, e.g. osteophytes and
 Decreased bone density (osteopenia) or
 Increased bone density (osteosclerosis).
 Computed Tomography

 Tomograms are radiographs that focus on a particular

slice of bone or soft tissue, such as ligaments and
tendons.
 It may be used with or without a contrast medium.
 Especially helpful for diagnosing problems of the
joints or vertebral column.
 Arthroscopy
 Is a direct means of visualizing a joint, particularly the knee
or shoulder.
 Biopsies can be taken, surgery performed in certain conditions
(e.g. repair or trimming of meniscal tears), and loose
bodies removed.
 Myelogram
 During a myelogram, a contrast medium is injected into the
subarachnoid space so that the spine and spinal cord can be
visualized.
 Inform patients that they may be positioned head down for a
short period to allow the contrast medium to flow up to the level
of the neck.
 It is usually reserved for those patients unable to have a CT or
MRI or for complicated spinal surgery revisions.
 Magnetic Resonance Imaging
• To diagnose musculoskeletal problems, especially
those involving soft tissue
• MRI is more accurate than CT for diagnosing many
problems of the vertebral column.
• Shows bone changes and intra-articular structures in
striking detail.
• MRI can also detect muscle changes, e.g. myositis
 Bone density (BD)

• Purpose and description

 To evaluate osteoporosis.
 Dual-energy x-ray absorptiometry (DEXA) can calculate the
size and thickness of bone and detect even a 1% loss of bone
mass.
 Ultrasound (US)

• US with Doppler measures blood flow and

hence inflammation.
• Useful for periarticular structures, soft
tissue swellings and tendons.
• US can be used to guide local injections.
 Orthopedic Emergencies

1.Soft tissue injuries

Sprain
Strain
Dislocations

2.Fractures
3.Amputation

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 Sprain

 It is a complete or incomplete tear in the supporting

ligaments surrounding a joint that usually follows a
sharp twist.
Cause:
 A sudden or unexpected twisting movement at the joint

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 Sprain….
Pathophysiology
 A torn ligament loses its stabilizing ability.
 Blood vessels rupture and edema occurs; the
joint is tender, and movement of the joint
becomes painful.
 Sign and symptoms

 Local pain
 Loss of mobility because a torn ligament loses its
stabilizing ability
 Edema or swelling because of ruptured blood vessels
 Black and blue discoloration (from blood
extravasation in to surrounding tissue).
 Sign and symptoms…

 The degree of disability and pain increases during

the first 2-3 hours after injury because of associated
swelling and bleeding
 A sprained ankle is the most common joint injury
Diagnosis: Clinical finding and X-ray.
 Management of sprain

 The acronym "RICE" (Rest, Ice, Compression, Elevation) is

helpful for remembering treatment interventions.
 Rest - prevents additional injury and promotes healing
 Ice pack- Apply cold compress intermittently for 20-30
minutes during the first 24-48 hours after injury produces
vasoconstriction, which decreases, bleeding, edema and
discomfort
 An elastic compression bandage controls: bleeding, reduces
edema and provides support for the injured tissues
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Management of sprain….
 Elevate the joint for 48-72 hours after the acute inflammatory
stage e.g. 24-48 hours after injury)
 Heat may be applied intermittently (for 15-30 minutes, four times
a day) to relieve muscle spasm and to promote vasodilatation,
absorption and repair.
 Immobilize the joint using elastic bandage
 Soft cast (for severe sprain)
 Tell the patient to remove the bandage if it causes pale,
numb, or pain.
 Provide strong analgesics.
 Management of sprain….
 Depending on the severity of injury, progressive
passive and active exercises may begin in 2 to
5 days.
 An immobilize sprain usually heals in 2-3
weeks.
 Torn ligaments do not heal properly and cause
recurrent dislocation and need surgical repair
 Strain

 It is an injury to a muscle that are microscopic,

incomplete muscle tears with some bleeding in
to the tissue.
Cause
 Vigorous muscle over use
 Over stretching
 Excessive stress
Sign and Symptoms
 Sharp pain
 Tender muscle
 Ecchymosis (bruise)
 Stiffness, soreness and generalized pain
 Diagnosis

 History of recent injury or chronic over use

 Clinical findings
 X-ray to rule out fracture
Management
 The same with sprain
 Complete muscle rupture require surgical repay
 Dislocations
 A condition in which the articular surfaces of the bones
forming the joint are no longer in anatomic contact.

Type
 Congenital: present at birth (most often the hip)
 Spontaneous or pathologic: caused by disease of the
articular or periarticular structures
 Traumatic: resulting from injury in which the joint is
disrupted by force.
 Etiology
 Trauma
 Pathologic (caused by disease)
 Congenital as in congenital dislocation of
the hip
 Clinical manifestation

 Pain and deformity around the joint

 Change in the length of the involved extremity
 Impaired joint mobility
 The displaced bone which may damage surrounding
muscles, ligaments, nerves, & blood vessels
 Change in the axis of the dislocated bone
 Diagnosis
 Patient history
 X-rays
 Clinical examination
Medical management
 Immediate reduction (before tissue edema & muscle spasm
make reduction difficult) can prevent additional tissue
damage & vascular impairments
 Analgesia, muscle relaxants & anesthesia are used to
facilitate closed reduction
 Medical management….
 The joint is immobilized by bandages splints, casts,
or traction and is maintained in a stable positions
 Open reduction:
– Wire fixation of the joint
– Skeletal traction
– Ligament repair
 Medical Management

• Immobilized the joint

• The dislocation is promptly reduced (ie,
displaced parts are brought into normal
position) to preserve joint function.

• Analgesia, muscle relaxants

• Nursing Management
• Assess neurovascular status
 Nursing Intervention

• Until reduction, immobilize the dislocated

joint, do not attempt manipulation.
• Apply ice to ease pain & edema
• Splint the extremity as it lies, or indicated by
(pallor, pain, loss of pulses, paralysis &
paresthesia) then all immediate orthopedic
exam is necessary.
 Nursing Intervention…
 When the pt receives diazepam IV, may
develop respiratory depression or even
respiratory arrest.
 So keep an air way & hand-held resuscitator (AMBU bag)

 Instruct the patient to report numbness, pain

cyanosis or coldness of the extremity below
the cast or splint
 Nursing Intervention…

 To avoid skin damage, watch for signs of

pressure injury both inside or outside the
dressing
 After removal of the cast or splint inform the
patient that may gradually return to normal
joint activity.
 FRACTURES

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 Fractures
• A fracture is “any disruption in the continuity of the
bone, when more stress is placed on it than it can
absorb”.
• Breaks in the continuity of the bone.

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• When the bone is broken, adjacent structures are also
affected, resulting in soft tissue edema, hemorrhage into
the muscles and joints, joint dislocations, ruptured
tendons, severed nerves, and damaged blood vessels.
• Body organs may be injured by the force that caused the
fracture or by the fracture fragments.

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 Causes of fractures

Direct blow
Crushing force (compression)
Sudden twisting motions (torsion)
Severe muscle contraction
Disease (pathologic fracture)

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 Fracture Signs and Symptoms

• Deformity

• Tenderness

• Swelling

• Bruising: bleeding from broken

blood vessels into surrounding
tissue

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 Classification of fractures

Complete: break across entire cross-section of bone &

often displaced (removed from normal position)
• Fracture may also go all the way through a bone

Incomplete: break through only part of the cross-section

• Fracture that does not go all the way through the bone

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• Comminuted: a fracture in
which bone has splintered into
several fragments
• Compression: a fracture in
which bone has been
compressed (seen in vertebral
fractures)

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• Depressed: a fracture in which
fragments are driven inward
(seen frequently in fractures of
skull and facial bones)
• Epiphyseal fracture: a fracture
through the epiphysis

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• Greenstick: a fracture in which one
side of a bone is broken and the
other side is bent

• Impacted: a fracture in which a

bone fragment is driven into another
bone fragment

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• Oblique: a fracture occurring at an
angle across the bone (less stable
than a transverse fracture)

• Pathologic: a fracture that occurs

through an area of diseased bone

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• Spiral: a fracture that twists around
the shaft of the bone

• Stress: a fracture that results from

repeated loading without bone and
muscle recovery
• Transverse: a fracture that is straight
across the bone
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• Avulsion: a fracture in which a
fragment of bone has been
pulled away by a ligament or
tendon and its attachment

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 Classifications of fracture…

o Open fractures are graded according to the following

criteria:
• Grade I:- is a clean wound less than 1 cm long.
• Grade II:- is a larger wound without extensive soft tissue
damage.
• Grade III:- is highly contaminated, has extensive soft
tissue damage, and is the most severe.
 open fracture Classification

TYPE-I
Open fracture, clean wound,
wound <1 cm in length

TYPE-II
Open fracture, wound > 1 cm
but < 10 cm in length without
extensive soft-tissue damage
 open fracture….
TYPE-III: Open fracture with extensive soft-
tissue laceration (>10 cm), damage, or loss or
an open segmental fracture. Fractures
requiring vascular repair.

TYPE-IIIA
Type III fracture with adequate periosteal
coverage of the fracture bone despite the
extensive soft-tissue laceration or damage
 open fracture….
TYPE-IIIB: Type III fracture with
extensive soft-tissue loss and
periosteal stripping and bone damage.

Usually associated with massive

contamination.
 open fracture….

TYPE-IIIC: Type III fracture

associated with an arterial
injury requiring repair,
irrespective of degree of soft-
tissue injury.
 Assessment: Areas of Concern

• Edema • Pallor
• Color Changes • Confusion
• Deformity • Dyspnea
• Parasthesia • Shock
• Pain
• Changes in BP
• Limited Movement
• Diaphoresis
• Crepitation
• Bruising • Fear & Anxiety
• Bleeding
• Distal Pulse

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 Clinical Manifestation

 Deformity
 Swelling
 Bruising (ecchymosis)
 Muscle spasm
 Pain
 Tenderness
 Loss of function: paralysis may be caused by nerve
damage 88
 Clinical manifestation…

 Abnormal mobility and crepitus: create grating

sensations or sounds.
 Neurovascular changes
 Shock

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 DIAGNOSIS
• History
• Physical examination: Neuro vascular assessment:
(distal to fracture area) swelling, temperature, sensation,
movement , colour-cyanosis, pulse.
• X-Ray
• CT Scan
 Complication of fractures

1.Early complication
 Shock
 Fat embolism syndrome
 Compartment syndrome
 Deep vein thrombosis (DVT) & pulmonary embolism
 Infection

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 Early complication…

Shock - secondary to hemorrhage and loss of Eextracellular

fluid.
 More common in pelvis or femur fracture due to the capacity
of heavy bleeding.
Systemic comlications :
 Gangrene, tetanus, septicaemia
 Fear of mobilising
 Osteoarthritis
 Early complications

Local:

 Vascular injury causing haemorrhage, internal or external

 Visceral injury causing damage to structures such as brain,

lung or bladder

 Damage to surrounding tissue, nerves or skin

 Haemarthrosis

 Compartment syndrome (or Volkmann's ischaemia).

 Wound infection, more common for open fractures.

 Fat embolism

 Fat embolism is a relatively uncommon disorder that occurs in

the first few days following trauma with a mortality rate of 10-

20%.

 Fat drops from bone marrow following coalesce and form

emboli in pulmonary capillary beds and brain, with a 2º

inflammatory cascade and platelet aggregation.

 FFAs are released as chylomicrons following hormonal changes

due to trauma or sepsis.

 Also seen following severe burns, CPR, bone marrow transplant

 Early complication…
 Long bone fractures and other major trauma (hip
replacement surgery are common.
 Onset can be with in 24 to 72 hrs.
 Early immobilisation of the fracture and early
ambulation of the person are imperative.
 Anti-embolism stockings and compression boots
increase venous return and prevent stasis of blood
Risk factors for fat embolism
• Closed fractures
• Multiple fractures
• Pulmonary contusion
• Long bone/pelvis/rib fractures
Clinical Presentation
• Sudden onset dyspnoea
• Hypoxia
• Fever
• Confusion, coma, convulsions
• Transient red-brown petechial rash

Management of fat embolism

Supportive treatment
Corticosteroid drugs (used in treatment, more controversial in
prevention)
 Surgical stabilization of fracture
 Compartment syndrome
 Edema is a natural response of the tissue to trauma.
 The patient may complain that the cast, brace, or splint is too
tight.
 Usually develops within the first 48 hours of injury.
 It occurs when there is increased tissue pressure within a
limited space (eg, cast, muscle compartment) that compromises
the circulation and the function of the tissue within the confined
area.
 Compartment syndromes…….

► Fractures of the limbs can cause severe ischaemia by damage

to a major artery or by increasing the osteofascial

compartment pressure by swelling due to bleeding or oedema.

►↓capillary flow → muscle ischaemia. → more oedema →

more pressure → ↓capillary flow.
• Thus rapid pressure build-up, leading to muscle and nerve
necrosis.
 Clinical Presentation
 Signs of ischemia (5 P's: Pain, Paraesthesia, Pallor, Paralysis,
Pulselessness).
 but diagnosis should be made before all these features are present.
 The presence of a pulse does not exclude the diagnosis.
 Signs of raised intracompartmental pressure:
 Swollen arm or leg
 Tender muscle - calf or forearm pain on passive extension of digits
o Pain out of proportion to injury
o Redness, mottling and blisters
 Management
 Remove/relieve external pressures

 Prompt decompression of threatened compartments by open fasciotomy

 Debride any muscle necrosis

 Treat hypovolaemic shock and oliguria urgently

 Renal dialysis may be necessary

complications of compartiment syndrome

 Acute renal failure secondary to rhabdomyolysis

 DIC

 Volkmann's contracture (where infarcted muscle is replaced by inelastic

fibrous tissue)
 Early complication…

Intervention
 Fibrinolytic agents
 Anticoagulant= Heparin, warfarin

 A vena cava filter may be placed to prevent the

existing clot from entering pulmonary circulation .

 Early complication…

Infection - especially open fracture

Pseudomonas, Staphylococcus or Clostridium
organisms
 Clostridium infection is particularly serious (gas
gangrene and cellulitis)

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 Delayed complication
1) Delayed union - healing doesn't advance at normal rate.

2) Non-union - failure of the ends of a fracture bone to unite.

3) Mal-union - mal presentation of the bone after fracture healing.

 Nonunion may require surgical interventions, such as internal

fixation and bone grafting.

 Electrical stimulation of the fracture site may be as effective as

bone grafting.

 Delayed union is diagnosed by x-ray studies. 103

 Delayed complication…

Volkmann’s contracture
 Common complication of elbow fractures, can result
from unresolved compartment syndrome.
 Arterial blood flow decreases, leading to ischaemia,
degeneration and contracture of the muscle.
 Arm mobility is impaired and the person is unable to
completely extend the arm.
 Principles of fracture management

They can be considered into two heading:

1. Emergency care

2. The local management of the fracture itself

105
 Emergency care
Management of:
a) Pain - the primary responsibility done by splinting &
analgesia, immobilisation ( splint or cast) and blood loss
replacement.
 Control Bleeding
 Open wounds are covered with sterile dressings and
assessed pulses, movement and sensation
106
 Emergency care…

 Stool softeners = risk of constipation

secondary to narcotics and immobility.
 Antacids.

 NSAIDs may be order to decrease

inflammation (DVT, edema).
 Antibiotics =open or complex fractures.

 Anticoagulants = DVT 107

 2. Local management of fracture

It includes:

A. Reduction

B. Immobilization

C. Rehabilitation

108
 Reduction
 Is a restoration of fracture fragments in to
anatomical alignments as nearly as possible
Method of fracture reduction:
1. Closed reduction
2. Open reduction
3. Traction
109
 1. Closed reduction

 It accomplished by bringing the bone fragments

in to a position manual traction & CAST.

E.g. Applying a cast, splint or other device

 X-ray is obtained to verify that the bone
fragments are correctly aligned.

110
 1. Closed reduction …
Cast
 The cast immobilizes the joint above and the joint below the
fractured bone.
 A fracture is first reduced manually (by hand) and a cast is then
applied.
 Casts are applied on relatively stable fractures.

 The cast must be allowed to dry

 A plaster cast may require up to 48 hours to dry, whereas a

fibreglass cast dries in less than 1 hour.
 Cast care should be done
Cast…
 1. Closed reduction …

Traction
 Work as reduction as well as immobilization
 Is the application of a straightening or pulling
force to return or maintain the fractured bones in
normal anatomic position.
 Weights are applied to maintain the necessary force
 The Patient in Traction

 Traction is the application of a pulling force to a part of the body.

 it is used to minimize muscle spasms; to reduce, align, and

immobilize fractures; to reduce deformity; and to increase space
between opposing surfaces.

 Traction must be applied in the correct direction and magnitude to

obtain its therapeutic effects.

 As muscle and soft tissues relax, the amount of weight used may
be changed to obtain the desired effect.
 Traction…..
 At times, traction needs to be applied in more than one direction
to achieve the desired line of pull.
 When this is done, one of the lines of pull counteracts the other.
 These lines of pull are known as the vectors of force.
 The effects of traction are evaluated with x-ray studies, and
adjustments are made if necessary.
 Traction is used primarily as a short-term intervention until other
modalities, such as external or internal fixation, are possible.
 Principles of effective traction
 Whenever traction is applied, counter traction must be used to achieve

effective traction.

 Counter traction is the force acting in the opposite direction.

 Traction must be continuous to be effective in reducing and immobilizing

fractures.

 Skeletal traction is never interrupted.

 Weights are not removed unless intermittent traction is prescribed.

 Any factor that might reduce the effective pull or alter its resultant line of

pull must be eliminated.

 PRINCIPLES OF EFFECTIVE TRACTION…..

 The patient must be in good body alignment in the center of

the bed when traction is applied.
 Ropes must be unobstructed.
 Weights must hang freely and not rest on the bed or floor.
 Knots in the rope or the footplate must not touch the pulley or
the foot of the bed.
 TYPES OF TRACTION

I. Straight or running traction applies the pulling force in a

straight line with the body part resting on the bed.

II. Buck’s extension traction is an example of straight traction.

III. Balanced suspension traction supports the affected

extremity off the bed and allows for some patient movement

without disruption of the line of pull.

• Traction may be applied to the skin (skin traction) or directly

to the bony skeleton (skeletal traction).

 TYPES OF TRACTION…….

• The mode of application is determined by the purpose of

the traction.

• Traction can be applied with the hands (manual traction).

• This is temporary traction that may be used when

applying a cast, giving skin care under a Buck’s extension

foam boot, or adjusting the traction apparatus.

 Skin Traction
 Skin traction is used to control muscle spasms and to
immobilize an area before surgery.
 Skin traction is accomplished by using a weight to pull on
traction tape or on a foam boot attached to the skin.
 The amount of weight applied must not exceed the tolerance of
the skin.
 No more than 2 to 3.5 kg (4.5 to 8 lb) of traction can be used
on an extremity.
 Pelvic traction is usually 4.5 to 9 kg (10 to 20 lb), depending
on the weight of the patient.
 Skeletal Traction
 Skeletal traction is applied directly to the bone.
 This method of traction is used occasionally to treat fractures of
the femur, the tibia, and the cervical spine.
 The traction is applied directly to the bone by use of a metal
pin or wire (eg, Steinmann pin, Kirschner wire) that is inserted
through the bone distal to the fracture, avoiding nerves, blood
vessels, muscles, tendons, and joints.
 Tongs applied to the head (eg, Gardner-Wells or Vinke tongs)
are fixed to the skull to apply traction that immobilizes cervical
fractures.
 1. Closed reduction …

Nursing interventions for people in traction

 Maintain the line of pull:

a. Centre the person on the bed.

b. Ensure that weights hang freely.
 Ensure that nothing is obstructing the ropes.

 The area of the fracture must be stabilized when the

person is repositioned.
 1. Closed reduction …

Nursing interventions for people in traction…

In skin traction:
 Frequently assess skin for evidence of pressure,
shearing or pending breakdown.
 Protect pressure sites with padding and
protective dressings as indicated
 1. Closed reduction …

Nursing interventions for people in traction…

In skeletal traction:
 Frequent skin assessments (pin care.

 Report signs of infection at the pin sites, such as

redness, drainage and increased tenderness.
 The person may require more frequent analgesic
 2. Open reduction

 Traction, internal fixation, external fixation (through

open surgery insertion screw and apply external plate
 Surgery is indicated for a fracture that requires

1. Direct visualization and repair

2. A fracture with common long term complications, or
3. A fracture that is severely comminuted and threatens
vascular supply.
 2. Open reduction…
A. Fixation of a short oblique fracture using a plate and
screws.
B. long oblique fracture using screws through the
fracture site.
C. Fixation of a segmental fracture using a medullary
nail.
 B. Immobilization
 After the fracture has been reduced, the bone fragment must
be immobilized, or held in correct position and alignment,
until union occurs.
 Immobilization may be accomplished by external or
internal fixation.

127
 B. Immobilization …

Methods of external fixation include:

Bandage, cast

Traction

 Splints

 External fixators

Metal implants used for internal fixation serve as

internal splints to immobilize the fracture.
128
 C. Electrical bone stimulation

 Is the application of an electrical current at the fracture

site.
 Painless method of treating fractures.

 For fructure not healing appropriately.

 The electrical stress increases the migration of

 Osteoblasts and osteoclasts to the fracture site.

 Mineral deposition increases, promoting bone

healing.
Invasive stimulation, inserts a Non- invasive inductive stimulation

cathode and a lead wire at the A treatment coil encircles the cast or skin

fracture site directly over the fracture site.

The lead wire is attached to The coil is attached to an external

generator, which delivers electricity generator that runs on batteries.

through the lead wire to the cathode The electricity goes through the skin to

24 hours a day. the fracture site.

Time period can vary from 3 to 10 hours

per day.
 Fracture healing
Fracture healing progresses over three phases:
1. The inflammatory phase
 Hematoma formation
 Cellular proliferation.

2. The reparative phase

 Callus formation
 Ossification

3. The remodeling phase

 Stages of healing process
Five stage of the healing process have been identified.
1. Hematoma formation.
 Occur 1st 48 to 72 hrs after fracture

 The osteocytes at the bone ends die due to haematoma clots,

obstructing blood flow
 Necrosis of the cells heightens the inflammatory response
(vasodilation and oedema)
Large hematoma - delay healing b/c macrophages, platelets,
oxygen, nutrients for callus formation are prevented from
entering the area. 132
 Stages of healing process…..
2. Cellular proliferation.
 Osteoblast - bone forming cells, multiply &
differentiated into cartilaginous callus
 Fibroblast and Osteoblast proliferate
 Fibroblasts form a fibrin meshwork and promote the
growth of granulation tissue and capillary buds.

133
 Stages of healing process…..
3. Callus formation
 The fracture become sticky
 Collagen formation and calcium deposition continue.
 The bone calcifies as mineral salts are deposited
 Occurs usually during 3rd to 4th wk of fracture healing.
 X-ray évidence of healing takes 3-4 wks
 Stages of healing process…..

4. Ossification
 The final laying down of the bone
 Fracture has been bridged and the fracture fragments
are firmly united.
 Mature bone replaces the callus.
 Safe to remove the cast
 Takes ~ 6 wks.
135
 Stages of healing process…..

5. Remodeling- resorption of the excess bony callus that

develops in the marrow space.
New bone is laid down along the fracture line.
Fracture haematoma  Fibrous callus Osteoid callus
 Temporary bone  Définitive Bône

136
 Healing time
Healing time varies with the individual.
 An uncomplicated fracture of the arm or foot can heal
in 6 to 8 weeks.
 A fractured vertebra will take at least 12 weeks to heal.
 Healing of a fractured hip may take from 12 to 16
weeks
 FACTORS AFFECTING BONE HEALING

Factors That Enhance Fracture Healing

 Immobilization of fracture fragments

 Maximum bone fragment contact

 Sufficient blood supply

 Proper nutrition: vitamin D.

 Exercise: weight bearing for long bones

 Hormones: growth hormone, thyroid.

 Moderate activity level prior to injury

138
 Factors That Enhance Fracture Healing…..

 Timely correction of displacement

 Application of ice
 Absence of infection or diseases
 Younger age
 Electrical stimulation
Factors That Inhibit Fracture Healing
 Extensive local trauma
 Inadequate immobilization
 Space between bone fragments
 Infection
 Avascular necrosis
 Malnutrition
 Osteoporosis
 Advanced age
 Immuno-compromised status (DM or peripheral vascular
disease)
STEPS
 Management of Fractures

• Antibiotic : Penicillin
• TT
• Calcium supplement
• Analgesic : Diclofenac sodium, Benzodiazepines
 TOTAL HIP REPLACEMENT
• Total hip replacement is the replacement of a
severely damaged hip with an artificial joint.
 INDICATIONS :

 Osteoarthritis
 Rheumatoid arthritis
 femoral neck fractures
 failure of previous reconstructive surgery

144
 NURSING INTERVENTIONS

• Examining the bedding under the

client for bleeding
• Should not sit on low chair, not
cross leg
• Preventing Dislocation of the
Hip Prosthesis-abduction

Abduction pillow
 Amputation is the removal of a body part, often an
extremity.
INDICATION
• Progressive peripheral
vascular disease, trauma,
crushing injuries, burns,
frostbite, or malignant tumor.
STUMP
 LEVELS OF AMPUTATION

 above-elbow (A-E) amputation :-

amputation of the upper limb between the
elbow and the shoulder.
 below-elbow (B-E) amputation:-
amputation of the upper limb between the
wrist and the elbow.
 above-knee (A-K) amputation ( trans
femoral amputation)
 amputation of the lower limb between the
knee and the hip.
 LEVELS OF AMPUTATION…………

 below-knee (B-K) amputation( trans tibial amputation)

 amputation of the lower limb between the ankle and

the knee.
 Syme's amputation:- disarticulation of the foot with
removal of both malleoli.
 Hey's amputation :-amputation of the foot between the

tarsus and metatarsus

 Complications of amputation

 Hemorrhage
 Infection
 skin breakdown
 phantom limb pain
 Joint contracture.
MUSCULOSKELETAL INFECTIONS
OSTEOMYELITIS
 OSTEOMYELITIS

 Osteomyelitis is a pyogenic infection of the bone marrow and

surrounding soft tissue.
 The bone becomes infected by one of three modes:

 Extension of soft tissue infection (eg, incisional infection)

 Direct bone contamination from bone surgery, open fracture, or

traumatic injury (eg, gunshot wound)
 Hematogenous (bloodborne) spread from other sites of
infection (eg, infected tonsils, boils, infected teeth, upper
respiratory infections).
151
 RISK

• Poorly nourished, elderly, or obese.

• Patients with impaired immune systems/ chronic illness

(eg, DM, Rheumatoid arthritis), Receiving long term
corticosteroid therapy.
– Etiologic micro organisms : Staphylococcus
aureus(most common) , Proteus and Pseudomonas
species and Escherichia coli, Mycobacterium
tuberculosis and Salmonella
 1. Osteomyelitis…
 Occur at any age, but over age 50 are more.
 The older adult is at risk for several reasons.
Immune function tends to decline with ageing;
Circulatory status in older adults often is
compromised
Higher risk of pressure ulcers because of circulatory,
skin, sensation and mobility changes.
 PATHOPHYSIOLOGY

 Exposure to Staphylococcus aureus, Proteus and

Pseudomonas species and Escherichia coli.
 Infection cause inflammation, increased vascularity, and
edema.
After 2 or 3 days, thrombosis of the blood vessels occurs in
the area, ischemia with bone necrosis.
 The infection extends into the medullary cavity and under the
periosteum and may spread into adjacent soft tissues and
joints.
 PATHOPHYSIOLOGY…….

 If it is not treated, a bone abscess forms and it contains dead

bone tissue (the sequestrum), which does not easily liquefy
and drain.
 So the cavity cannot collapse and heal, New bone growth (the
involucrum) forms and surrounds the sequestrum.
 Chronically infected sequestrum remains and produces
recurring abscesses throughout the patient’s life.
 This is referred to as chronic osteomyelitis.
Pathophysiology……cont…
OSTEOMYELITIS
 CLINICAL MANIFESTATIONS

• Blood borne: septicemia (eg, chills, high fever, rapid pulse,

general malaise).
• The infected area becomes painful (a constant, pulsating pain
that intensifies with movement as a result of the pressure of
the collecting pus), swellon, and extremely tender.
• Chronic osteomyelitis: continuously draining sinus or
experiences recurrent periods of pain, inflammation,
swelling, and drainage.

158
 1. Osteomyelitis…
Manifestation
 Pain, tenderness and fever.
 Night sweats.
 Floppy in involved extremity.
 Drainage and ulceration at involved site.
 Swelling, erythema and warmth at involved site.
 Lymph node involvement, especially in the involved
extremity.
 Assessment and Diagnostic Findings

In acute osteomyelitis, early x-ray : soft tissue swelling.

 Magnetic resonance imaging (MRI).

 Blood studies: elevated WBC and ESR, Hgb

 Wound and blood culture .

Chronic osteomyelitis: x-ray: large, irregular cavities, raised

periosteum, sequestra, or dense bone formations.
• Bone scans may be performed to identify areas of infection.
• Culture: to determine the infective organism

160
 PREVENTION

• Use sterile techniques to decrease direct bone

contamination.(dressing)
• Prophylactic antibiotics: before and after surgery.
• Urinary catheters and drains are removed as soon as
possible to decrease the incidence of hematogenous
spread of infection.
 Medical Management

 IV antibiotic therapy: Penicillin or cephalosporin. 3-

6 weeks then orally up to 3 months.
 General supportive measures (eg, hydration, diet high
in vitamins and protein, correction of anemia) .
 The area affected with osteomyelitis is immobilized
to decrease discomfort.
 SURGICAL MANAGEMENT

• A sequestrectomy : purulent and necrotic material is

removed, and the area is irrigated with sterile saline
solution.

163
 1. Osteomyelitis…

Complication
 Chronic osteomycitis
 Pathologic fracture
 Joint destruction
 Skeletal deformity

164
 Chronic osteomyelitis
 Results from delayed or inappropriate treatment of
acute osteomyelitis.
 It may also follow direct infection of bone in
compound fracture.
Pathology:
 The dead bone (sequester) lies in an abscess cavity
surrounded by a newly formed bone (Involucrum)
under the elevated periosteum.
165
Diagnosis:
 The usual presentation is periods of dormancy and
acute exacerbation of persistently discharging
sinus.
 There may be skin hyper pigmentation around the
sinus and palpable bone thickening.
 X-ray may show sequester, abscess cavity,
involucrum or diffuse sclerosis.

166
 Chronic osteomyelitis …

Treatment
 Antibiotics: Used for acute exacerbation and
perioperate for about six weeks.

167
 Chronic osteomyelitis …

Surgery can be done:

 To remove a dead bone (sequesterectomy)
 To eliminate an abscess cavity (saucerization)

Amputation may be considered for:

-Extensive bone involvement

-Heavy discharge or frequent flare-ups

/recurrences/which incapacitate the patient 168
METABOLIC BONE DISORDERS
 OSTEOPOROSIS

 A systemic skeletal disease characterized by low bone mass and

micro architectural deterioration of bone tissue, with a consequent
increase in bone fragility and susceptibility to fracture.
 The normal homeostatic bone turnover is altered: the rate of bone
resorption is greater than the rate of bone formation, resulting in a
reduced total bone mass.
 RISK FACTORS AND ETHIOLOGY

1.Genetics 4.Physical exercise

• Family history • Sedentary
• Lack of weight-bearing exercise
• Low weight and body mass index
2.Age
Postmenopause 5.Lifestyle choices
• Caffeine • Alcohol
• Advanced age • Smoking
• Low testosterone in men • Lack of exposure to sunlight
• Decreased calcitonin

3.Nutrition 6. Medications
• Low calcium intake eg, corticosteroids
• Low vitamin D intake
• High phosphate intake
Antiseizure medications.
(carbonated beverages) Anticoagulant:Heparin
• Inadequate calories
171
 PATHOPHYSIOLOGY

► Calcitonin, which inhibits bone resorption and promotes bone

formation, is decreased.
• Estrogen, which inhibits bone breakdown, decreases with aging
whereas parathyroid hormone (PTH) increases with aging,
increasing bone turnover and reabsorption. The withdrawal of
estrogens at menopause or with oophorectomy causes an accelerated
bone resorption that continues during the postmenopausal years.

• The bones become progressively porous, brittle, and fragile; they

fracture easily under stresses.
172
 CLINICAL MANIFESTATIONS

 progressive kyphosis associated

with loss of height(vertebral
collapse.)
 Relaxation of the abdominal
muscles and a protruding
abdomen.
 Pulmonary insufficiency.
 Fatigue
 Fracture :compression fractures
of the thoracic and lumbar
spine, hip fractures, and Colles’
fractures of the wrist. (the first
clinical manifestation)
173
 ASSESSMENT AND DIAGNOSTIC FINDINGS

• x-rays: Demineralization.
• Laboratory studies
• Serum calcium, serum phosphate, serum alkaline
phosphatase.

175
  PREVENTION

 Calcium
 Vitamin D (400-800 IU)
 Regular weight bearing exercise
 Weight lifting, dancing
 walking, jogging, tennis
 Smoking cessation
 Fall prevention
 176
 MEDICAL MANAGEMENT

 Balanced diet rich in calcium and

vitamin D throughout life.
 Calcium19-50yrs-1000mg per day,
51 years and older is 1200 mg per
day.
 Calcium supplement (eg, Caltrate,
Citrocal) taken with vitamin C
 side effects of calcium
supplements:
 Abdominal distention and
177
 PHARMACOLOGIC THERAPY

 hormone replacement therapy (HRT) with estrogen and

progesterone –prevent fractures.
 Bisphosphonates (eg, Alendronate [Fosamax]; and calcitonin.

 Small daily subcutaneous injections of PTH or PTH bioactive

fragments have been found to stimulate bone formation.
 Fractures of the hip -joint replacement or by closed or open
reduction with internal fixation (eg, hip pinning).

178
 Rheumatoid arthritis

• Rheumatoid arthritis is a chronic, systemic,

inflammatory disorder.
• primarily involves the connective tissues and
synovial membranes of the joints.
 Risk Factors & Etiology

 The cause is unknown.

 antigen-antibody complexes- that
are deposited within the cartilage.
 Infection by bacteria, mycoplasma,
and viruses -stimulate genetically
susceptible person.
 Fatigue and emotional stress
exacerbate the condition.
 Clinical Manifestation

1.Articular symptoms.
 Painful, red, swollen, warm, stiff joints.
 Morning stiffness, particularly in the hands and feet.
 Involvement of small joints.
 At initial presentation, hand, wrists, feet, and ankles are affected.
 As disease progresses, the shoulders, knees, hips, and jaw are
affected.
 Late stage: Boutonniere deformity, ulnar deviation, Swan- neck-
deformity.
1.Articular symptoms……
 2.Extra-articular symptoms.

 Painless subcutaneous nodules over prominences.

 Anemia.

 Chronic low-grade fever.

 Slight leukocytosis.

 Fatigue.

 Anorexia.

 Lymphadenopathy.

 Weight loss.
 Diagnosis

• Medical diagnosis is made when 5 of the following American College of

Rheumatology criteria are met and when these symptoms are present for 6 or
more weeks.

1. Morning stiffness that improves during the day.

2. Pain or tenderness in at least 1 joint.

3. Swelling of 2nd joint.

4. Symmetric joint swelling.

5. Presence of subcutaneous nodules.

6. Radiographic changes typical of rheumatoid arthritis.

7. Positive test result for rheumatoid factor.

8. Poor mucin precipitate in the synovial membrane.

 
Supporting diagnostic tests

 A decreased hematocrit

 An increased WBC count

 An elevated (ESR)

 A radiograph -narrowing of joint spaces

 Rheumatoid factor-positive
 

Management: non pharmacology

 Exercising
 Balancing periods of rest and activity
 orthopedic splints or braces, cane, crutches,
walker
 Pharmacological
• Nonsteroidal anti-inflammatory
agents (e.g. salicylates and non
salicylates).
• Corticosteroids.
 Calcium supplements
 Special medical-surgical procedures

 Arthroscopy: Synovectomy
 Arthrocentesis (i.e. the withdrawal of fluid from a joint)
 joint reconstruction and replacement
 GOUTY ARTHRITIS

 It is disorder or defect of purine metabolism

resulting in hyperuricemia elevation of serum
uric acid concentration above 7 mg/dl.
 It is characterized by elevated uric acid levels
and deposition of urate (usually in the form of
crystals) in joints and other tissues).
190
 GOUTY ARTHRITIS

Gout can also occur as a result of overproduction

of uric acid.

Gout is an attack of uric acid deposits in joints.

Usually found in joints of feet and legs.

Etiology
1) Overproduction:
 Excessive intake of foods that is high in purine
(shellfish, organ meats) or heredity.
 Disease which have cell turnover (leukemia,
multiple myeloma, some type of anemia’s, psoriasis,
alcohol use, )

192
 Gout …

2) Under secretion of Uric acid:

Altered renal tubular function (90%).

a) Drugs: Diuretics , alcohol , Aspirin interfere

with tubular handling of urate.

b) Renal diseases ; chronic renal failure , lead

nephropathy.
193
 The Four Stages of Gout

1. Asymptomatic
2. Acute
3. Inter-critical
4. Chronic
1.ASYMPTOMATIC
 A- meaning without indicates that there are no
symptoms associated.
 Patient will be unaware of what is happening.
 Gout can only be determined with the help of a
laboratory diagnosis.
 2. Acute
 Sever and sudden onset
 Involve one or a few joints
 Frequently starts
nocturnally
 Joint is warm, red, and
tender
3.Intercritical
More concentration of uric acid
crystals
Typically no need for drug
intervention at the time
4. Chronic
Continuous or persistent over a
long period of time
Treatment required
Not easily or quickly resolved
 Signs And Symptoms

Joint pain
 Affects one or more joints : hip,
knee, ankle, foot, shoulder,
elbow,wrist, hand, or other joints
 Great toe, ankle and knee are
most common
Swelling of Joint
 Stiffness Skin lump which may drain chalky material

 Warm and red

 Possible fever
 Diagnosing Gout

 Patient medical history

 X-rays

 Arthrocentesis- extraction of joint

fluid

 monosodium urate crystals

demonstrated in synovial fluid

leukocytes
 Diagnosing Gout…..

 Examination of joint

 An elevation of serum uric acid

 Aggregates of uric acid crystals (tophi) in and

around joints, soft tissues, and various organs

 TREATMENT

• Colchicine- reduces pain, swelling, and

inflammation
• Allopurinol- decreases the production of uric
acid
• Probenecid and sulfinpurazone- prevent
absorption of uric acid in the tubules of kidney
• Reduce alcohol intake
• Increase water intake
Rx
• Colchicine Dose: 0.6 mg is given every hr.

• NSAID: Drugs like Aspirin that affect uric acid

clearance should be avoided.
– Indomethacine: 25-50 mg PO TID,

– Ibuprofen: 800 mg Po TID

– Diclofenac: 25-50 mg PO TID

Rx…
Corticosteroids:
• Oral glucocorticoids: Prednisolone, 30-50 mg/day as
the initial dose and tapered over 5-7 days.
• Intraarticular injections of steroids can be used to
treat acute gout of single joint, particularly when the
use of other agents is contraindicated.
Chronic tophaceous gout: the aim to reduce serum urate
level to < 5 mg/dl

a) Uricosuric agents (E.g. probenicide).

• This drugs facilitate the renal excretion of uric acid.

• It can be used who excrete <700 mg of uric acid daily,

normal renal funnction, and no hx of urinary stones.

• Dose: Probenicide 200 mg PO Bid increased gradually

as needed up to 2 gm.
Rx ….
b) Allopurinol; competitively inhibits xanthine
oxidase.
• Is preferred for urate excretion >1000 mg/day,
creatinin clearance < 30 ml/min, tophaceous gout.
• Dose: 300 mg single morning dose -increased up to
800 mg
• Dosage is reduced in the presence of renal failure.
Non-pharmacological
• Avoidance of obesity

• Avoidance of alcohol, purine diets

207
 Prevention and Management

Avoid :
• ORGAN MEATS(liver-)

• SEAFOOD
• PEAS
• ASPARAGUS
• YEAST
• BEER
 Osteoarthritis
 Is a non-inflammatory joint disease characterized by
degenerative changes in the articular cartilage.
 it primarily affects weight-bearing joints in the hips, knees,
and vertebrae
 but may also affect the ankles, shoulders, wrists, fingers,
and toes
 Often called wear-and-tear arthritis,

 occurs when the protective cartilage on the ends of the

bones wears down over time.
 Causes
• Obesity. added stress on weight-bearing joints, such as knees.

• Other diseases. diabetes, underactive thyroid

• Bone deformities. born with malformed joints

• Joint injuries. sports or from an accident

• Older age. :increases with age.

• Sex. Women are more likely to develop

 Signs and symptoms

• Sever joint Pain

• Tenderness
• Stiffness
• Bone spurs. Heberden's nodes Heberden's
(on the distal interphalangeal
joints) and/or
Bouchard's nodes (on the
Bouchard’s
proximal interphalangeal
joints)
 Pharmacological management

• Acetaminophen (first line)

• Nonsteroidal anti-inflammatory drugs
(NSAIDs). Eg:Ibuprofen,Diclofenac
• Opoid analgesic: Morphin
 Non pharmacological management
• Physical therapy.
• Occupational therapy
• Braces or shoe inserts
Surgical Mgt
• Joint replacement.
 SEPTIC (INFECTIOUS) ARTHRITIS

 Joints can become infected through spread of infection

from other parts of the body (hematogenous spread) or
directly through trauma or surgical instrumentation.
 It is the most rapid and destructive joint disease that cause
medical emergency
 Patients with septic arthritis inevitably have a
bacteraemia.
 Common site – lower limb, particularly knee and hip
 Septic arthritis…
Etiology
 Staphylococcus aurous, particularly in pt with RA and
diabetes
 Disseminated gonococcus infection.
 Gram-negative bacteria such as E. coli and Pseudomonas
and Group B,C and G streptococci

217
 Septic arthritis…
Risk factors
– Increasing age

– Pre-existing joint disease (E.g trauma or RA)

– Persistent bacteraemia (E.g. due to use of injectable

drugs, endocarditis) and
– Arthroscopic, surgery of joint replacements

– Diabetes mellitus

– Immuno suppression 218

 Septic arthritis…
 Pathophysiology occurs as a consequence of

1. Bacteraemia /blood stream/ URTI and UTI, soft tissue

infection, endocarditis & infected intravenous sites.
2. Invasion from a contiguous focus of infection
3. Skin break down ( open wound, surgery …)
 Inflammation of joint= synovitis = swell= and joint effusion =
Abscesses = destruction of the affected joint
 clinical manifestations
 Marked by pain and stiffness= rest pain and
stress pain on movement.
 Joint red and swollen and is hot and tender.

 Effusion.

 Painful pustular skin lesions esp. in gonococci

infection
 Clinical Manifestations

• Sever pain
• Sever swelling of one joint
with decreased range of
motion.
• Sever tenderness
• Warmth
• Sever effusion
• Systemic chills, fever, and
leukocytosis are present.
Diagnose
 fluid aspirate and send for Gram stain and
culture.
 Cultures also are obtained from blood,
sputum or wounds.
 Infected synovial fluid usually is cloudy,
high WBC count and a low glucose level.
223
Management: Aspirate the joint*
 Septic arthritis…

 Lactate dehydrogenase enzymes raise

 Glucose decrease

 Protein elevated

Joint x-ray films are

– Often normal in the initial stages,

• But soon show demineralization, bony

erosions and joint space narrowing.
 Septic arthritis…

Intervention
 Hospitalization is essential.

 Rest, immobilisation, elevation and systemic

antibiotics.

The principles of management are:

– Pain relief

– parenteral antibiotics
 Septic arthritis…

 The recommended first line antibiotic regimen in

adult is flucloxacillin (2g IV, 6 hourly) for 2 to 3
wks followed by oral Rx for 6 wks in total.
 Gonoccocal = 250 mg IM ceftria + 1gram po
azithro or doxy 100 mg BID for 7 days
 Cloxa + metronidazole or erythromycin
 Septic arthritis…
 Frequent joint aspirations
 To remove excess fluid and pus and
 Surgical drainage may be performed
 If hip joint is involved (because of difficulty of
aspirating) or
 When medical therapy does not rapidly
eliminate bacteria.
 Physical therapy during the recovery period
 Pyomyositis

 Pyomyositis (also known as tropical myositis,

temperate myositis, pyogenic myositis, suppurative
myositis, myositis purulenta tropica, and epidemic
abscess) is
– A primary infection of skeletal muscle and often
associated with abscess formation.
– A purulent infection of skeletal muscle that arises
from hematogenous spread.
Etiology
 Staphylococcus aureus up to 90%.
 The second most common type is group A streptococci.
 Streptococci (groups B, C, and G),
 Pneumococcus, Neisseria, Haemophilus,
 Pseudomonas, Klebsiella, and Escherichia
 M-Tuberculosis, fungi (Blastomycosis, Cryptococcus
neoformans, Aspergillus, Candida, Fusarium, Pneumocystis
Jiroveci), and
 Anaerobes(Salmonella, Vibrio, Enterococci,)
Pathophysiology
 Skeletal muscles are intrinsically very resistant to infections.
 The pathogenesis involves the presence of transient bacteremia in
a setting of muscle injury and blunt trauma.
 Asymptomatic episodes of bacteremia possibly from skin
abrasion
 Iron is released from myoglobin in traumatized muscles.
 This released iron provides a nutrient for rapid growth and
proliferation of organisms
• hence leading to the development of pyomyositis
Pathophysiology …
 In addition, formation of hematomas may provide

 A favorable site for the binding

 The surrounding damaged and devitalized tissue might also

impede the host immune response
 HIV Patients have an increased incidence of pyomyositis.

 Neutropenia, defective immune responses, use of

intravenous lines,
Clinical presentation
 Most common site of pyomyositis is the thigh.

 The evolution of myositis can be clinically divided into

three discrete stages.
1. The invasive stage

2. The suppurative stage

3. The late stage

1. The invasive stage
 Is sub-acute, occurring over 1 to 3 weeks

 Characterized by local painful swelling with or

without erythema (b/s infection is deep seated).
 Fever and leukocytosis are invariably present.

 Aspiration at this stage will not yield pus

 may resolve, remaining undiagnosed, or can

progress to the next stage.
2. The suppurative stage
 Is diagnosis of pyomyositis is usually established.

 High spiky swinging temperatures occurs between the

second and third weeks.
 The area is extremely painful and tender.
 An abscess is seen on imaging studies.
 Aspiration, if attempted at this stage, will yield pus.
 However, because it is deep seated, classical
characteristics of abscess, such as erythema, is
generally absent.
3. The late stage

If the suppurative stage remains undiagnosed

and untreated,
– the infection disseminates, leading to
multiple abscesses, septicemia, septic shock,
and multiorgan system failure
Diagnosis
 Clinical none demarcated swelling

 Blood tests

 Presence of eosinophilia suggests parasitic infection

 Blood cultures are sterile in approximately 90%

 Aspiration and culture of the pus remains the standard

diagnostic method, but in the early stages minimal or no
suppuration occurs.
Differential Diagnoses
DVT, cellulitis, muscle contusion, muscle
hematoma, muscle or tendon rupture
Septic arthritis, osteomyelitis

Osteosarcoma

Polymyositis (inflammatory myositis)

Septic arthritis of the hip

Osteomyelitis
Intervention…
 Cloxacillin is recommended as first-line therapy,
with first-generation
 Cephalosporins such as cefazolin as an
alternative for penicillin-sensitive individuals.
 Vancomycin should be considered in severely ill
patients
 Percutaneous drainage if abscess
• Black M J Medical Surgical Nursing. 7th ed. Philadelphia: W. B. Saunders
Company, P. 655 – 674.
• Lukman Joan. Saunders Manual of Nursing Care, Philadelphia: W. B.
Saunders Company 1997 P. 898.
• Lewis, Heitkemper, Dirksen. Medical Surgical Nursing. 6th ed. Missuri:
Mosby, 2003P. 594 – 599.
• Wilma J P, Sands K J, Casmayer J V. Medical Surgical Nursing. 5th ed.
Missuri: Mosby, 1991 P. 1012 – 1014.
• Suddarth S D, Brunner S L. The Text Book of Adult Nursing. London:
Chapman and Hall, 1992 P. 709.
• Suddarth S D, Brunner S L, The text book of medical surgical nursing, 12th
edi, 1631,2006-148
• Ignatavicius D D, Medical Surgical Nursing. Philadelphia: W. B. Saunders
Company, 1991 P. 915 – 918.