Septic Arthritis

This is invasion of a joint by an infectious agent which produces arthritis. Joints become
infected through spread of pathogens from other parts of the body (hematogenous spread) or
directly through trauma or surgical instrumentation which causes septic arthritis.
Risk factors for septic arthritis
 Elderly people above 80yrs
 History of hip replacement surgery
 Diabetes mellitus
 Rheumatoid arthritis
 Skin infections
Causes
 Staphylococcal aureus- it’s the most common cause
 Spread of streptococcal infections from upper respiratory system via the blood stream
 Haemophillus influenza in children
 Escherichia coli
 Neiserria gonorrhea
 Mycobacteria which causes septic spinal arthritis
Clinical manifestation
 Painful swelling on the joints
 Increased warmth on the affected parts
 Decreased range of motion on the affected joints
 Systemic chills & fever
 Leukocytosis

Diagnostic findings
o Aspiration of synovial fluid shows a turbid non-viscous fluid
o M.R.I-reveals damage to the joint lining
o CT Scan
o X-ray –shows increase in joint space tissue
o Ultrasound may reveal effusion

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 Medical management

Prompt treatment is essential and may save the prosthesis for patients who have had joint
replacement surgery or avert severe sepsis.
Broad spectrum intravenous antibiotics are started promptly and then changed to organism
specific antibiotics after culture and sensitivity results are available.
Intravenous antibiotics should be continued until symptoms resolve.
The synovial fluid is aspirated and analyzed periodically for sterility and decrease in white
blood cells.
Aspiration of synovial fluid removes excessive fluid, exudates and debris which promotes
comfort and decreases joint destruction caused by the action of proteolytic enzymes in the
purulent fluid.
The inflamed joint is supported and immobilized in a functional position by a splint that
increases the patient’s comfort.
Analgesics to relieve pain and inflammation.
Nursing management.
Health education of the patient and family about septic arthritis physiologic process and
explaining to the patient importance of supporting the affected joint.
Administration of drugs
Monitoring the patient’s nutrition and fluid status.
Inspection of the skin that has splint splints to check for tissue perfusion.
Progressive range of motion exercises as soon as the patient can begin movement. This is
done without worsening the symptoms of acute pain. Exercise improve blood supply.
Educate the patient on risk of infection recurrence in the future and importance of hospital
follow up.
Complications
Joint fibrosis
Diminished function due to degeneration

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Osteomalacia.
This is a metabolic bone disease characterized by inadequate mineralization of the bone. As a
result the skeleton softens and weakens causing pain, tenderness to touch, bowing of the
bones and pathologic fractures.
Causes
There are two main causes of Osteomalacia;
i) Insufficient calcium absorption from the intestine because of a lack of dietary calcium or a
deficiency or resistance to the action of vitamin D
ii) Phosphate deficiency caused by increased renal losses in renal failure or decreased
intestinal obstruction.
Vitamin D deficiency is caused mostly by reduced vitamin D absorption as a result of biliary
tract or intestinal diseases that impair fat soluble vitamin absorption.
Pathophysiology.
The major defect in Osteomalacia is a deficiency of activated vitamin D which promotes
calcium absorption from the G.i.t and facilitates mineralization of bones. It may result from
failed calcium absorption or from excessive loss of calcium from the body in renal failure and
G.i.t disorders e.g chronic biliary tract obstruction, chronic pancreatitis, small bowel
obstruction in which fats are inadequately absorbed are likely to produce Osteomalacia
through loss of vitamin D.
Severe renal insufficiency results in acidosis. The body uses available calcium to combat
acidosis and the parathyroid hormone stimulates the release of skeletal calcium in an attempt
to re-establish a physiologic PH.
During this continual drain of skeletal calcium, bony fibrosis occurs and bony cysts form.
Chronic glomerulonephritis, obstructive uropathies and heavy metal poisoning result in a
reduced serum phosphate level and de-mineralization of bone.
Hyperparathyroidism leads to skeletal decalcification and thus to osteomalacia by increasing
phosphate excretion in urine.
Clinical features.
 Bone pain and tenderness
 Pathologic fractures especially in distal radius and proximal femur
 Muscle weakness
 Delayed healing and poor retention of internal fixation devices.

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Diagnosis
X-ray shows generalized demineralization
Bone biopsy shows increased amounts of osteid
Blood for calcium levels.

Medical management.
Treatment of Osteomalacia is directed at the underlying cause
If the cause is nutritional, restoring adequate amounts of calcium and vitamin D to the diet
will provide the nutrients.
If kidney disease prevents the activation of absorbed vitamin D, supplementation requires the
activated form (calcitriol)
If the cause is malabsorption, increased doses of vitamin D along with supplemental calcium
are used.
Exposure to sunlight is recommended as ultraviolet radiation transforms a cholesterol
substance (7-dehydrocholesterol) present in the skin into vitamin D
Long term monitoring of the patient to ensure stabilization or reversal of osteomalacia
Complications
 Pathologic fractures
 Hypocalcemia

PAGET’S DISEASE OF THE BONE

This is a disorder of localized rapid bone turnover which mostly affects the skull, femur,
tibia, pelvic bones and vertebrae.
Causes
The exact cause is unknown but it is associated with;
 Viral infections especially respiratory syncytial virus
 Genetics
Pathophysiology
A primary proliferation of osteoclasts occurs which induces bone resorption. This is followed
by a compensatory increase in osteoblast activity that replaces the bone.

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As bone turnover continues, a disorganized pattern of bone develops. Because the diseased
bone is highly vascularized and structurally weak, pathologic fractures occur.
Structural bowing of the legs causes mal-alignment of the hip, knee and ankle joints which
contributes to the development of arthritis, back and joint pain.
Clinical features.
Many people with Paget’s disease do not know they have the illness because its onset is
gradual.
Skeletal deformities which involve the skull thickening and a hat can no longer fit.
Impaired hearing due to cranial nerve compression and dysfunction.
Femur and tibia tend to bow.
The spine is bent forward, becomes rigid and the chin rests on the chest.
Tenderness and warmth over bones may be noted due to increased bone vascularity and
patients with large highly vascular lesions may develop high output cardiac failure due to
increased vascular bend and metabolic demands.
Pain which increases with weight bearing.
Diagnosis.
X-ray shows areas of bone demineralization.
Bone abscess
Bone scans
Blood for serum alkaline phosphate which is elevated.

Medical/nursing management.
Patients with moderate to severe disease may benefit from specific anti-osteoclast therapy.
These medications reduce bone turn over, reverse the course of the disease, relieve pain and
improve mobility.
These medications reduce bone turn over, reverse the course of the disease, relieve pain and
improve mobility.
Bisphosphonates are the corner stone of Paget’s therapy as they stabilize the rapid bone turn
over. Their use may not suppress all Paget’s symptoms but they reduce serum Alanine
Phosphate levels.
Plicamycin, a cytotoxic antibiotic may be used to control the disease but it is reserved for
severely affected patients with neurologic compromise and for those whose disease is
resistant to other therapy. Monitoring of hepatic, kidney and bone marrow function is done
when the patient is on the drug.

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Pain is managed using analgesics.
Gait problems are managed using walking aids.
Health education on how to compensate altered musculoskeletal function and risk of fall.
Control of weight to reduce stress on weakened bones and mal-aligned joints.
Asymptomatic patients are managed with diet rich in calcium and vitamin D.
Complications.
Fractures.
Arthritis
Deafness
Heartfailure
Paraplegia
Spinal stenosis.

Malignant bone tumors.

Bone tumors are abnormal growths of the musculoskeletal system that invade causing either
bone obstruction or exaggerated formation. Malignant tumors arise from bone tissue cells
(sarcoma) or bone marrow (myeloma). These malignant tumors include osteosarcoma,
chondrosarcoma, Ewing’s sarcoma and fibrosarcoma.
Osteosarcoma is the most common and most often fatal primary malignant bone tumors since
it metastasizes to the lungs.
Pathophysiology
A tumor in the bone causes the normal bone tissue to react by osteolytic response (bone
destruction) or osteoblastic response (bone formation). Adjacent normal bone responds to the
tumor by altering its normal pattern of remodeling. The bone’s surface changes and the
contours enlarge in the tumor area.
Malignant bone tumors invade and destroy adjacent bone tissue by weakening the structure of
the bone until it can no longer withstand the stress of ordinary use hence pathologic fractures.
Clinical features
Varying degree of pain from mild to severe
Weight loss
Limited mobility
Bony mass may be palpable, tender and fixed with an increase in skin temperature over the
skin.

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With spinal metastasis, spinal cord compression occur leading to neurologic deficits of
urinary retention, loss of bowel or bladder control, paresthesia and paraplegia.

Diagnostic evaluation.
Bone CT scan
M.R.I
Bone biopsies for histology
Chest X-ray to check for lung metastases
Serum Alanine Phosphate
Hypercalcemia.
Medical management.
Primary bone tumors:
It’s a tumor that forms first in the bone. The goal of treatment is to destroy the tumor rapidly.
This may be accomplished through surgical excision ranging from local excision to
amputation and disarticulation.
Radiation therapy.
Chemotherapy
Survival and quality of life are important considerations in procedures that attempt to save the
involved extremity but surgical removal of the tumor may require amputation of the affected
extremity with the amputation extending well above the tumor to achieve a local control of
the primary lesion.
Limb sparing procedures are used to remove the tumor and adjacent tissue. A customized
prosthesis, total joint arthroplasty or bone tissue from the patient (autograft) replaces the
resected tissue.
Because of the danger of metastases with malignant bone tumors, chemotherapy is started
before and continued after surgery in an effort to eradicate micrometastatic lesions. The goal
of combined chemotherapy is greater therapeutic effect at a lower toxicity rate with reduced
resistance to the medications.
Secondary bone tumors.
Treatment of advanced metastatic bone cancer is palliative. The therapeutic goal is to relieve
the patient’s pain and discomfort while promoting quality of life. If the bone is weakened,
structural support and stabilization are needed to prevent pathologic fractures.
Bones are strengthened by internal fixation arthroplasty.

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Hematopoesis is frequently disrupted by tumor invasion of the bone marrow or by treatment
with radiotherapy, chemotherapy and surgery hence blood component therapy restores
hematologic factors.
Pain management with narcotic and non narcotic analgesics.
Bisphosphonates.
Nursing management.
Assessing the patient’s understanding and ability to cope with the illness and pain associated
with the tumors.
Assessing the size of the tumors and soft tissue swelling, pain and tenderness through
palpation.
Evaluate how the patient’s mobility is affected and the ability to adjust to activities of daily
living.
Explaining to the patient the importance of wound care and the expected result of surgery e.g
decreased range of motion, numbness or change of body contours. This helps the patient deal
with the procedures and body changes that result.
Accurate pain assessment and use of pharmacologic and non pharmacologic pain
management techniques.
Bone tumors weaken the bone to a point at which normal activities or even position changes
can result in fracture. During nursing care, the affected extremities must be supported and
handled gently.
External supports e.g. splints may be used for additional protection.
Weight bearing restrictions be followed to prevent fractures.
Encourage the patient to verbalize their fears, concerns and feelings. They need to be
supported as they deal with the impact of malignant bone tumors.
Complications.
Delayed wound healing
Pathologic fractures
Anaemia
Infections e.g oseomyelitis
Hypercalcemia due to bone resorption

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Osteomyelitis.
Its an infection of the bone that results in inflammation and necrosis. Infections of the bone
are more difficult to cure than soft tissue infections because of limited blood supply. This
infection can be acute or chronic.
Sources of infections
 Hematogenous spread. The spread of infection is through the blood stream e.g from
infected tonsils, teeth, abscesses, u.r.t.i etc.
 Erosion to the bone or extension of adjacent soft tissue infections. e.g middle ear
infection.
 Direct bone contamination e.g open fracture, bone surgery or gunshot wound.
Causes;
Staphylococcal aureus- causes most infections
Hemophilus influenza-common in children who are not immunized.
Neiserria gonorrhea- in people with multiple sexual partners.
E.coli
Pseudomonas.
Patients at risk of Osteomyelitis.
Poorly nourished patients
Elderly
Diabetic and obese patients
Patients with rheumatoid arthritis
Patients who are hospitalized for a long time
Patients on long corticosteroid therapy
Patients with previous joint surgery
Patients with concurrent infections
Patients who have undergone lengthy orthopedic surgery
Pathophysiology
Osteomyelitis due to hematogenous spread occurs in a bone area where there is lowered
resistance. The initial response to infection is inflammation leading increased to increased

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vascularity and edema. After 2-3 days, thrombosis of blood vessels occurs resulting to
ischemia. Infective pus forms and may spread the infection into adjacent soft tissue and joints
and unless the infective process is controlled early, bone abscess forms.
The resulting abscess cavity has dead bone tissue called sequestrum which does not easily
liquefy and drain therefore the cavity cannot collapse and heal as other soft tissue abscesses.
A bone sheath is formed and surrounds the sequestrum and its called involucrum thus
although healing appears to take place, a chronically infected sequestrum remains which is
prone to producing recurring abscesses throughout life. This is chronic Osteomyelitis.
Clinical features.
 In hematogenous spread, onset is usually sudden with signs of septicemia. They
include fever, rapid pulse, chills and general malaise.
 In children, it begins as an infection of the epiphysis and the general inflammation
signs may overshadow the local signs.
 Patients complains of constant pulsating pain that intensifies with movement.
 When infection occurs from adjacent abscesses or direct bone contamination, there is
no septicemia but the local area is warm, painful and tender.
Diagnosis.
X-ray shows soft tissue swelling, large irregular cavities and sequestrum.
Blood and pus swab for culture and sensitivity
M.R.I
Bone scan
Management
The initial goal of therapy is to control and arrest the infective process.
Broad spectrum antibiotic therapy is started intravenously and later changed to a more
specific antibiotic as per culture as sensitivity result. When the infection is controlled, drugs
are changed to orals and continued for 2-3 months.
Analgesic to relieve pain and inflammation
Aspiration of pus from localized infected areas to promote comfort.
If there is no response to treatment, surgery is performed;
i)Sequestrestomy- the infected bone is exposed, purulent and necrotic material removed
including the sequestrum and the area irrigated directly with nrmal salinr solution then the
patient is maintained on intravenous antibiotics.

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ii) Saucerization- sufficient bone is removed to convert a deep cavity into a shallow cavity.
this may be covered by a bone graft or muscle flap to enhance blood supply and hasten
recovery.

Nursing interventions.
The affected part may be immobilized with a splint or bed cradle may be used to keep the
linen off the affected limb. This decreases pain and muscle spasms.
Elevating the affected limb which reduces swelling and discomfort.
Relieve of pain by administration of analgesics PRN
Care of intravenous therapy to ensure that sterility is observed during drug administration.
Aseptic technique is used during wound care and observe for drainage, foul smell and
additional swelling.
A balanced diet with high protein, vitamin D and calcium
Encourage oral fluids.
Complications.
Septic arthritis
Impaired growth in children
Bone death due to impaired circulation
Skin cancer in cases of open sores that drain pus may lead to squamous cell cancer.

Amputation
It’s a surgical removal of a part of the body.
Indications
 Peripheral vascular disease affecting blood vessels e.g a complication of D.M,
arteriosclerosis, thrombosis/embolism
 Severe trauma e.g. crash injuries or gunshot wounds
 Acute or chronic infections e.g esteomyelitis or gas gangrene
 Congenital malformation where normal function cannot be obtained
 Grossly deformed limb which seriously interferes with patients function or one which
circulation is impaired.
 Malignant tumors
 In children due to paraplegia especially in spinal bifida when a paralyzed limb is
severely deformed or infected thereby interfering with normal function.

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Levels of amputation
Amputation is performed at the most distal point that will heal successfully. The site of
amputation is determined by two factors;
 Circulation in the part
 Functional usefulness.
These are to meet the requirements for the use of prosthesis. Circulatory status of the limb
is evaluated through physical examination and diagnostic studies. Muscle and skin
perfusion is important for healing.
Ankle level disarticulation
Below knee amputation
Above knee amputation
Knee disarticulation
Hip disarticulation
Wrist disarticulation
Below elbow amputation
Elbow disarticulation
Above elbow amputation
Characteristics of a good stump
Should be conical in shape
Be smooth with no wrinkles under the stump
Should be mobile
Be free from contractures
Painless after healing.
Types of amputation
Circular amputation- normally done when there is severe trauma or infection
Flap type- a long flap of full thickness of skin is loosened so that it covers the stump. The
wound is then drained for 48hrs by use of corrugated rubber tube.
Factors affecting amputation.
Psychological aspect
Age- the young are generally healthy and heal rapidly and participate more in the
rehabilitation programme. However, they are not psychologically ready to cope with
psychological changes in body image. The old are not healthy enough but heal very fast and

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having passed through other chronic diseases and hardships before, they are usually ready to
adjust to the new body image easily.
Pre-operative care
Psychological care;
Since amputation destroys the ideal body image and temporarily or permanently disrupts
patients’ lifestyle, psychological preparation is very important.
Establish an open and honest communication
Make the patient understand and be able to establish expectations e.g. changing his job as this
helps build confidence, hope and optimism in his life.
The preparation should be done early unless in an emergency situation.
The next of kin be informed if necessary.
Physical preparation
Any underlying infection be treated.
Nutritional status be improved
Blood for urea and electrolytes and full blood count taken.
Correcting anemia.
If the patient is diabetic, control of blood sugars be achieved.
Exercises.
Patient is taught some of the exercises he is to perform after operation e.g. how to transfer
himself from bed to a wheelchair and wheeling himself to the toilet.
Learning how to walk with crutches.
Skin care.
Thorough cleaning especially on the operation site.
Shaving is done on the operation site.
Other general preoperative care: consent, identification, vital observations, premedication.
Post operative care.
Immediate care is to ensure a clear airway
Observe for hemorrhage from the operation site
Incase of bleeding, apply a tourniquet and alert the surgeon immediately.
Watch for swelling from the operation site
Half hourly vital observations
The stump is elevated on a soft pillow for the first 24-48hrs to reduce edema or bleeding of
the wound.
Analgesics to relieve pain

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Prophylactic antibiotics
Limb is kept in a neutral position to prevent contractures and flexion deformities. It is
supported with sand bags.
If drainage tube is used, its removed after 48 hrs
A crepe bandage is applied evenly and firmly on the stump to encourage even shrinkage of
the stump.
Muscles of the stump are exercised to prevent muscle wastage and contractures. These
exercises include; active range of motion, isometric exercises, strengthening exercises for
upper and lower extremity.
Encourage ambulation of the patient on the 2 nd-3rd day post operatively. The patient can sit on
a wheel chair and wheel himself to the toilet.
The patient can start walking using crutches until a permanent prosthesis will be made.
Removal of stitches 8-10th day post operative depending on the surgeons instruction.
Assist in fitting and walking with the prosthesis.
Health education to the patient.
When the wound is healed, the stump is washed with soap and warm water. The patient is
instructed to avoid oils and powders because they may soften the skin extensively.
The stump is properly rinsed and thoroughly dried
If the patient is using bandages, you should open them and expose the stump to air for 20min
to keep the skin healthy so that there is no problem in fixing the prosthesis.
Appointment for prosthesis fitting.
Complications.
Hemorrhage.
Infections
The skin may become adherent to the bone
Contractures due to immobility
Gangrene due to inadequate blood supply
necrosis

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