THE SKELETAL SYSTEM

 Made up of 206 bones

 Two Major Divisions: axial skeleton and the appendicular skeleton
 AXIAL SKELETON: bones of the skull, the ribs and sternum and the vertebral column
 APPENDICULAR SKELETON: all bones of the limbs, the shoulder girdles and the pelvic girdle

THE SKELETAL SYSTEM

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 THE AXIAL AND APPENDICULAR SKELETON

BONE
 Composed of both living and non- living intracellular material.
 Living cells: osteoblasts, osteoclasts and osteocytes
 Non- living cells: mucoplysaccharides and collagen

THREE BASIC TYPES OF LIVING CELLS

OSTEOBLAST
 Bone-forming cells

OSTEOCYTES
 Mature bone cells involved in bone maintenance
 Located in the LACUNAE-bone matrix units

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OSTEOCLASTS
 Bone dissolving/resorbing/destroying, multi-nuclear cells

 Each bone is composed of CANCELLOUS/TRABECULAR/SPONGY BONE and

COMPACT/CORTICAL BONE
o SPONGY BONE: contains spaces between meshworks of bone
o COMPACT BONE: smooth and dense

 The bone is made up of an Osteon or Haversian units. The osteon or Haversian unit, which is the
basic/microspcopic structural unit of a compact bone is composed of the following structures:

o HAVERSIAN CANAL: center of the osteon that contains a capillary and that which receives its
nutrients
o LAMELLAE: concentric circles or cylindrical layers of calcified or miineralized bone matrix
o LACUNAE: small spaces between the rings of the lamellae, which are occupied by oscteocytes
o CANALICULI: very small/tiny channels that conncet the lacunae with the haversian system or
canal

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The PERIOSTEUM
 Is a white fibrous membrane that covers the bone, except on its articular surfaces.
 Nourishes bone and facilitates bone growth
 Contains nerves, blood vessels and lymphatics
 Provides for the attachment of:
o TENDONS-connects muscles to bones and;
o LIGAMENTS- connect bones to bones
.

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 BONE FORMATION
OSTEOGENESIS
 begins before birth

OSSIFICATION
 process by which the bone matrix/collagen fibers and ground substance is formed and hard mineral
crystals composed of Calcium and Phosphorus are bound to the collagen fibers

FACTORS AFFECTING BALANCE BETWEEN BONE RESORPTION AND FORMATION

A. DIETARY INTAKE OF CERTAIN NUTRIENTS ESPECIALLY CALCIUM

 1,500 mg Ca daily
 Calcium rich foods
 16-24 oz of milk daily

B. PHYSICAL ACTIVITY
 Weight bearing activities

C. SEVERAL HORMONES
 Ensure Ca is properly absorbed and available for bone mineralization and matrix formation

 BIOLOGICALLY ACTIVE VITAMIN D(CALCITROL)

o Functions to increase amount of Ca in the blood by promoting absorption of Ca from the GIT
o Facilitates mineralization of osteoid tissue
o Deficiency: fracture

 PARATHORMONE/CALCITONIN
o Major hormonal regulation of Ca homeostasis

 PARATHORMONE
o Regulates concentration of Ca in the blood promoting Ca movement from the bone

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  CALCITONIN
o Secreted by thyroid gland in response to increased blood Ca and inhibits bone resorption
o Increases deposit of Ca in bone
o Excessive thyroid hormone production in adults: Grave’s disease

 CORTISOL
o same effect as thyroid hormone
o Long term synthetic cortisol or corticosteroid: steroid induced osteopenia and fracture

 GROWTH HORMONE
o stimulates skeletal growth in children and adolescents
o Low levels of IGF-1 with aging: decreased bone formation and osteopenia

 SEX HORMONES
o ESTROGEN
o Stimulates osteobalsts and inhibits osteoclasts—enhanced bone formation

o TESTOSTERONE
o Causes skeletal muscle growth throughout lifespan
o Converts to estrogen in adipose tissue providing additional source of bone- preserving
estrogen for

LABORATORY /DIAGNOSTIC TESTS

BLOOD TESTS
 ESR: elevated in SLE and arthritis;
 Female: 20-30 mm/hr
Male: 15-20 mm/hr
 Rheumatoid factors: positive in rheumatoid arthritis; RA: 70%, Sjogrens: 90%
 Lupus erythematosus cells (LE cells)
 Antinuclear antibodies (ANA): positive in rheumatoid arthritis); SLE: 99%
 Anti - DNA (+ in SLE)
 C- reactive protein: positive in rheumatoid arthritis
 Uric Acid: 2.5- 8 mg/dl; elevated in gout
 MINERALS
 Calcium
 Decreased levels in osteomalacia, osteoporosis
 Increased levels in bone tumors, healing fractures, Paget’s disease
 Alkaline Phosphatase
 Elevated ievels in bone cancer, osteoporosis, osteomalacia, Paget’s disease
 Phosphorous
 Increased levels in healing fractures, bone tumors

MUSCLE ENZYMES
 Aldolase

 Aldolase is a protein (called an enzyme) that helps break down certain sugars into energy. It is found in
high amounts in muscle tissue.
 A test can be done to measure the amount of aldolase in your blood.
 A typical reference range is 1.0 to 7.5 units per liter.
 Elevated in muscle dystrophy, dermatomyositis-- connective-tissue disease related to polymyositis (PM)
that is characterized by inflammation of the muscles and the skin.
 The cause is unknown, but it may result from either a viral infection or an autoimmune reaction.

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  In the latter case it is a systemic autoimmune disease. Many people diagnosed with
dermatomyositis were previously diagnosed with infectious mononucleosis and Epstein-Barr
virus
 Dermatomyositis is an idiopathic inflammatory myopathy. This systemic disorder most frequently affects
the skin and muscles but may also affect the joints, the esophagus, the lungs, and, less commonly, the
heart.
 AST/SGOT: 7-40 mU/ml
 CK - MM (Creatine Phosphokinase)
 Elevated in traumatic injuries
 LDH (Lactic Dehydrogenase)
 Normal: 100-225 mU/ml
 Elevated in skeletal muscle necrosis, extensive cancer

FRACTURE
 A break in the continuity of bone
 Caused by direct blows, crushing forces, sudden twisting motions and extreme muscle contractions.

MAJOR TYPES OF FRACTURE

COMPLETE
 Involves a break across the entire cross-section of the bone and is frequently displaced

INCOMPLETE
 Involves a break through only part of the cross- section of the bone

CLOSED
 Is one that does not cause a break in the skin

OPEN
 One in which the skin or mucous membrane wound extends to the fractured bone

COMMINUTED
 Is one that produces several bone fragments

SPECIFIC TYPES OF FRACTURES

Avulsion
 a fracture in which a fragment of bone has been pulled away by a tendon and its attachment
Comminuted
 a fracture in which bone has splintered into several fragments

Compression
 a fracture in which bone has been compressed (seen in vertebral fractures)

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

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

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

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Pathologic
 a fracture that occurs through an area of diseased bone (eg, osteoporosis, bone cyst, Paget’ disease,
bony metastasis, tumor); can occur without trauma or a fall

Simple
 a fracture that remains contained, with no disruption of the skin integrity

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 shaft

CLINICAL MANIFESTATIONS
A. PAIN
o Continuous and increases in severity
o Muscle spasms begin within 20 minutes after the injury and result in more intense pain

B. SHORTENING
o Due to contraction of the muscles that are attached distal and proximal to the site of the fracture
o The fragments often overlap by as much as 2.5-5 cm (1-2 inches).

C. CREPITUS
o grating sensation can be felt upon examination with the hands.
o Caused by the rubbing of the bone fragments against each other.

D. SWELLING AND DISLOCATION

o Localized edema and discoloration of the skin occur after a fracture as a result of trauma and
bleeding into tissues.

COLLABORATIVE MANAGEMENT FOR FRACTURE

REDUCTION
 A.K.A: “setting” the bone
 refers to restoration of the fracture fragments to anatomic alignment and rotation.

CLOSED REDUCTION WITH EXTERNAL FIXATION (CREF)

 this is done through manual manipulation followed by application of cast

OPEN REDUCTION WITH INTERNAL FIXATION (ORIF)

 this is done through surgery that involves application of pins, wires, screws to the affected bone

CARE FOR A CLIENT WITH OPEN REDUCTION

 Check dressings for bleeding and infection.
 Empty hemovac. serosanguinous drainage is normal.
 Assess LOC. Bleeding causes altered LOC.
 Turn every 2 hours.
 Turn to unoperative side only. To prevent pressure on the operative site.
 Place 2 pillows between legs while turning and when lying on side.
 Implement measures as such: to prevent thrombus formation.
 Elastic hose
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  Dorsiflexon of foot.
 Anticoagulants such as aspirin as prescribed
 Encourage quadriceps and gluteal exercises.
 Observe for adequate bowel and bladder function.
 Assist patient in getting in and out of bed on first and second post - op day
 Avoid weight- bearing on affected leg until allowed.
 Provide care for the patient with a hip prosthesis if necessary {similar to care of patient with total hip replacement)

CAST
 a rigid external immobilizing device that is molded to the contours of the body.

USES
 to immobilize a reduced fracture,
 to correct a deformity,
 to apply uniform pressure to underlying soft tissue,
 to support and stabilize weakened joints

CASTING MATERIALS
NONPLASTER
 fiberglass cast
 are porous: therefore diminish skin problems.
 They do not soften when wet.
 When wet, they are dried with a hair dryer on a cool setting; thorough drying is important to prevent
skin breakdown.

PLASTER
 traditional cast
 Rolls of plaster bandage are wet in cool water and applied smoothly to the body.
 the cast needs to be exposed to air (ie, uncovered) to allow maximum dissipation of the heat and
that most casts cool after about 15 minutes-20 minutes.
 To dry completely: The plaster cast requires 24 to 72 hours .
 A wet plaster cast: appears dull and gray, sounds dull on percussion, feels damp,

CARE OF THE CLIENT WITH CAST

 Carry the newly - casted body part with palms of the hand: to prevent indentation and pressure.
 Elevate the body part with pillow support: To prevent edema.
 Expose the cast to dry. Dry cast appears white, shiny, hard and resonant.
 The cast should not be covered with a blanket or towel while it is drying.
 Keep the cast clean and dry.
 Observe “hot spots” and musty odor, or drainage from the cast. These are signs and symptoms of
infection.
 Do neurovascular checks. The following findings distal to cast application indicate that the cast is too
tight.
 Skin color: pallor, cyanosis
 Skin temperature: cold skin
 Sensation :numbness, tingling
 Mobility: inability to move the body part
 Pulse: absence of pulse.

WINDOWING
 is done to facilitate observation under the cast.
 The procedure involves: removal of a part of the cast
 It is also done to assess pulse or to prevent “CAST SYNDROME.”
 manifested by bloated feeling, prolonged nausea, repeated vomiting, abdominal
distention, vague abdominal pain, shortness of breath.

BIVALVING
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  is done for wound care or X-rays.
 It is also done when the cast is too tight or when healing process has occurred.
 The procedure involves splitting of the cast.

TRACTION
 the application of a pulling force to a part of the body.

PURPOSES OF TRACTION
 minimize muscle spasms
 reduce, align, and immobilize fractures;
 reduce/correct deformity;
 relieve pain

PRINCIPLES OF EFFECTIVE TRACTION

 Whenever traction is applied, countertraction must be used to achieve effective traction.

Countertraction
 is the force acting in the opposite direction. Usually, the patient’s body weight and bed position
adjustments supply the needed countertraction.

 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:
o The patient must be in good body alignment in the center of the bed when traction is applied.
o Ropes must be unobstructed.
o Weights must hang freely and not rest on the bed or floor.
o Knots in the rope or the footplate must not touch the pulley or the foot

TYPES OF 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 to a foam boot attached to the
skin.
 The amount of tape 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 20lb) depending on the weight of the patient.

TYPES OF SKIN TRACTION

BUCK’S TRACTION
 Exerts straight pull on affected extremity; temporary intervention to immobilize the leg in patient with
a fractured hip.
 Shock blocks at the foot of the bed produce counter- traction and prevent the patient from sliding down
in bed.
 Has a horizontal weight. It can immobilize one bone only
 Turn client towards unaffected side.
 Check for pressure sore at the heel of the foot and signs and symptoms of thrombophlebitis.

RUSSEL TRACTION
 Knee is suspended in a sling attached to a rope and pulley on a Balkan frame, creating upward pull from the knee
(vertical traction).
 Weights are attached to the foot of the bed creating horizontal traction.
 It has vertical and horizontal weights.
 Used to treat fracture of the femur. It can immobilize more than one bone.
 Allows patient to move about in bed more freely and permits bending of the knee joint,

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  Hip should be flexed at 20°- 30°. Foot of bed usually elevated by shock blocks to provide counter traction
 Assess back of the knee for pressure sores; check the leg for signs and symptoms of thrombophlebitis.

BRYANT TRACTION
 Both legs are raised at 90° angle to bed. Because the weight of the child is not adequate to provide
countertraction.
 Used for children under 2 years or below 30 pounds to treat fractures of the femur and hip dislocation,
 Buttocks must be slightly off the mattress. To enhance efficacy of the weight as countertraction,
 Knees slightly flexed. To prevent hyperextension deformity of the knees. Hyperextension deformity of the knees
will make the child unable to bend the knees when walking.

CERVICAL TRACTION
 Cervical head halter attached to weights that hang over head of bed.
 Used for soft tissue damage or degenerative disc disease of cervical spine to reduce muscle spasm and
maintain alignment
 Usually intermittent traction, elevate head of bed to provide countertraction.

PELVIC TRACTION
 Pelvic girdle is secured around iliac crest with extension straps attached to ropes and weights; used for low back to
reduce muscle spasm and maintain alignment.
 Usually intermittently applied; patient is placed in semi - Fowler’s position with knee gatched at 20 - 30° angle,
(William’s position),
 Encourage the client to use overhead trapeze.

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.
 The weights are attached to the pin or wire bow by a rope- and-pulley system that exerts the
appropriate amount and direction of pull for effective traction.
 Skeletal traction frequently uses 7 to 12 kg (15 to 25 lb) to achieve the therapeutic effect.

THOMAS SPLINT WITH PEARSON ATTACHMENT

 Used with skeletal traction in fractures of the femur; hip should be flexed at 20°.
 Use footplate: to prevent footdrop.
 Check pressure sore at the inguinal area (groin).

Pin site care for skeletal traction:

 Cleanse and apply antibiotic ointment as prescribed.
 Observe site for signs and symptoms of infection( e.g., redness, swelling, pain, warmth,
drainage. )Notify physician if these findings are noted.
 Do neurovascular check
 Prevent complications of immobility.

NURSING INTERVENTIONS FOR SKELETAL TRACTION

MAINTAINING EFFECTIVE TRACTION
 When skeletal traction is used, check traction apparatus to see that the weights hang freely, and that
the knots in the rope are tied securely.
 never remove weights from skeletal traction unless a life-threatening situation occurs. Removal
of the weights completely defeats their purpose and may result in injury to the patient.

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MAINTAINING POSITIONING
 maintain alignment of the patient’s body traction as prescribed: to promote an effective line of pull.
 position the patient’s foot to avoid footdrop (plantar flexion), inward rotation (inversion), and outward
rotation (eversion). The patient’s foot may be supported in a neutral position by orthopedic devices (eg,
foot supports).

PREVENTING SKIN BREAKDOWN

 protect the elbows and heels and inspect them for pressure ulcers.
 To encourage movement with using the elbows or heel, a trapeze can be suspended overhead head
within easy reach of the patient. The trapeze helps patient move about in bed and move on and off the
bedpan.

MONITORING NEUROVASCULAR STATUS

 assess the neurovascular status of the immobilized extremity at least every hour initially and every 4
hours.
 instruct the patient to report any changes in sensation or movement immediately
 encourage the patient to do active flexion-extension ankle exercises and isometric contraction of
the calf muscles 10 times an hour while awake to decrease venous stasis.
 elastic stockings, compression devices, and anticoagulant therapy may be prescribed to help prevent
thrombus formation.

PROVIDING PIN SITE CARE

 Goal: is to avoid infection and development of osteomyelitis.
 Signs of reaction may include redness, warmth, and serous or slightly sanguinous drainage at the
site. These signs subside after 72 hours.
 The patient is permitted to take showers within 5 to 10 days of pin insertion and is encouraged to
leave the pins open to water flow. The sites are dried with a clean towel and left open to air.
 The nurse must inspect the pin site at least every 8 hours for signs of inflammation and
evidence of infection.

ASSISTIVE DEVICES FOR WALKING

CANE
 The client must hold cane on the unaffected hand. The cane and the affected leg are advanced
together. To shift the weight unto the cane.

WALKER
 Instruct client to use “lift and walk” technique (lift the walker forward, then make few small steps
toward the walker).
 The height of the walker should be hip level.
 The client using the walker may go up and down the stairs. When going up, use the walker at the back.
When going down, use the walker in front. The walker is used to protect the client from falls.

CRUTCHES
Four point gait
 Advance the right crutch, followed by the left foot; then the left crutch, followed by the right foot. Weight
bearing is allowed.

Two point gait

 Advance the right crutch and left foot together, then the left crutch and the right foot together. Weight -
bearing is allowed.

Three point gait

 Advance both crutches and affected leg together, followed by the unaffected leg. Little or no weight -
bearing is allowed, e.g. after total hip replacement or total knee replacement.

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Swing - to gait
 Advance both crutches, swing the body so that the feet will be to the level of the crutches.

Swing - through gait

 Advance both crutches, swing the body so that the feet will be past the level of the crutches.

Going up and down the stairs using crutches.

 “Up with the good; down with the bad.”
 When going up the stairs, advance the “good leg” (unaffected leg) first, followed by the “bad leg”
and the crutches.
 When going down the stairs, advance the “bad leg” (affected leg) and the crutches first, followed
by the “good leg.”
 Note: The “bad leg” should always be with the crutches to provide support.

COMPLICATIONS OF FRACTURE
SHOCK
 resulting from hemorrhage (both visible and non-visible blood loss) and from loss of intravascular
volume into the interstitial space, particularly within damaged tissues, may occur in fractures of the
extremities, thorax, pelvis, or spine.

FAT EMBOLISM SYNDROME

 After fracture of long bones or pelvic bones, multiple fractures, or crush injuries, The fat globules
(emboli) may occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs.
 The onset of symptoms is rapid, usually within 24 to 72 hours of injury, but may occur up to a week
after injury

Clinical Manifestations
 hypoxia, tachypnea, tachycardia, and pyrexia: greater than 39.5°C (about 103°F).
and tachycardia, pallor
 acute pulmonary edema: dyspnea, crackles, wheezes, cough, large amounts of thick white sputum
 acute respiratory distress syndrome (ARDS), heart failure
 Cerebral disturbances: mental status changes varying from headache and mild agitation to delirium
and coma: due to hypoxia and the lodging of fat emboli in the brain)
 Subtle personality changes, restlessness, irritability, or confusion: indications for immediate arterial
blood gas studies.
 Petechiae at buccal membranes and conjunctival sacs, on the hard palate, and over the chest and
anterior axillary folds: due to a transient thrombocytopenia

COMPARTMENT SYNDROME
 Anatomic compartment: an area of the body encased by bone or fascia (eg, the fibrous membrane
that separates muscles) that contains muscles, nerves and blood vessels.
 The human body has 46 anatomic compartments
 36 anatomic compartments: located in the extremities.
 Compartment syndrome
o is a complication that develops when pressure within a compartment is greater than normal
o Acute compartment syndrome: involves a sudden and severe decrease in flow to the tissues
distal to an area of injury
o Chronic compartment syndrome: is characterized by pain, aching, and tightness in a muscle
or group that has been subjected to stress or exercise.

CLINICAL MANIFESTATIONS OF ACUTE COMPARTMENT SYNDROME

 hallmark sign: deep, throbbing, unrelenting pain unrelieved by opioids and that occurs or
intensifies with passive ROM.
 This pain can be caused by

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 o (1) a reduction in the size of the muscle compartment: muscle fascia is too tight or a cast or
dressing is constrictive
o (2) an increase in compartment contents: edema or hemorrhage

ASSESSMENT AND DIAGNOSTIC FINDINGS

 “5 P’s
o pain, paralysis paresthesias, pallor, and pulselessness.
 Paresthesia: early signs of nerve involvement
 Hypoesthesia
o diminished sensitivity to stimulation and then absence of feeling: continued nerve ischemia
and edema
 Motor weakness: late sign of nerve ischemia.
 No movement (paralysis): suggests nerve damage.
 Peripheral circulation: color, temperature, capillary refill time, swelling, and pulses.
 Edema: reduces tissue perfusion.
 Cyanotic (blue-tinged) nail beds : suggest venous congestion.
 Pallor or dusky and cold fingers or toes and prolonged capillary refill time suggest diminished
arterial perfusion.

COLLABORATIVE MANAGEMENT FOR COMPARTMENT SYNDROME

 Elevate extremity above the level of the heart: to prevent further edema.
 Notify physician: evaluate for tissue ischemia and necrosis.
 Remove tight dressings or cast.
 fasciotomy
 surgical decompression with excision of the fascia
 to relieve the constrictive muscle fascia.
 If conservative measures do not restore tissue perfusion and relieve pain within 1 hour,
 fasciotomy with delayed primary closure of wound
 done 3-5 days after to allow edema of compartment to subside.

DELAYED COMPLICATIONS
Delayed Union, Malunion, and Nonunion
 Delayed union
o occurs when healing does not occur at a normal rate for the location and type of fracture.
o associated with pulling apart of bone fragments, systemic or local infection, poor nutrition or co-
morbidity (eg, diabetes mellitus, autoimmune disease).
 Nonunion
o results from failure of the ends of a bone to unite
 malunion
o results from failure of the ends of a fractured bone to unite in normal alignment.

MEDICAL MANAGEMENT
 Internal fixation: to stabilize the bone fragments and ensures bone contact.
 Bone grafts

OSTEOPOROSIS
 Is a systemic skeletal disease characterized by a low bone mass/ reduction of bone density and a
change in bone structure, leading to enhanced bone fragility and a consequent increased susceptibility
to fracture.
 the rate of bone resorption is greater than the rate of bone formation: resulting in reduced total bone
mass.
 the bones become progressively porous, brittle, and fragile; they fracture easily
 results in compression fractures of the thoracic and lumbar spine,
 Progressive kyphosis: The gradual collapse of a vertebra
 Kyphosis: (“dowager’s hump”): associated loss of height.
 Primary osteoporosis: women menopause; 45-55; men- later in life,

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  Secondary osteoporosis: result of medications or other conditions and diseases that affect bone
metabolism.

PREVENTION
 Vitamin D
o for calcium absorption and for normal bone mineralization.
o The best source of calcium and vitamin D: fortified milk.
o A cup of milk or calcium-fortified orange juice: 300 mg of calcium.
o The recommended adequate intake (RAI) level of calcium for young adulthood(9-19 years
of age): 1300 mg per day
o The RAI level for adults 19 to 50 years of age: 1000 mg per day,
o The RAI level for adults 51 years of age and older: 1200 mg per day.
o The actual estimated average daily intake: 300 to 500 mg.
o The recommended adult vitamin D intake: 400 to 600IU per day.

RISK FACTORS
 Female
 Caucasian, non-Hispanic, or Asian
 Increased age
 Low weight and body mass index
 Estrogen deficiency or menopause
 Family history
 Low bone mass
 Contributing, coexisting medical conditions (eg, celiac disease) and medications (eg, cortico-
steroids, antiseizure medications), thyroid hormone
 Diet low in calcium and vitamin D
 Cigarette smoking
 Use of alcohol and/or caffeine
 Lack of weight-bearing exercise
 Lack of exposure to sunshine

MANIFESTATIONS
 Decreasing height (10 to 15 cm): due to collapsing vertebrae
 Back pain (T5 to L5)
 Dowager’s hump (curved upper back)
 Fracture with minimal trauma

COLLABORATIVE MANAGEMENT
 calcium and vitamin D-rich drinks/diet: protects against skeletal demineralization.
o three glasses of skim or whole vitamin D-enriched milk
o foods high in calcium: cheese and other dairy products, steamed broccoli, canned salmon
with bones
 Increased Phytoestrogen in diet
o beans, cabbage, rice, berries, sesame seeds and grains
 Calcium Supplements
o Caltrate, Citracal with Vitamin Dtaken
o Taken with meals or with a beverage high in vitamin C: to promote absorption.
 Common side effects of calcium supplements:abdominal distention and constipation.

 Regular weight-bearing exercise:

o from 20 to 30 minutes of aerobic exercise (eg, walking) done for 3 days or more a week (5
days),then work up to 60 minutes: promotes bone formation.

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PHARMACOLOGIC THERAPY
 hormone therapy with estrogen and progesterone: to retard bone loss and prevent occurrence of
fractures.
o Side effects: stroke, venous thromboemboli, and breast cancer
 Selective estrogen receptor modulators (SERMs)
o raloxifene (Evista): reduce the risk of osteoporosis by preserving BMD without estrogenic
effects on the uterus.
 Bisphosphonates
o alendronate [Fosamax], risedronate [Actonel], ibandronate [Boniva]) and calcitonin
o reduce spine and hip fractures associated with osteoporosis by increasing bone mass and de-
creasing bone loss
o Alendronate and risedronate: approved for the prevention and treatment of corticosteroid-
induced osteoporosis
o Alendronate: given weekly
o Ibandronate: requires only once-monthly administration.
o Side effects of bisphosphonates:
 gastrointestinal symptoms like dyspepsia, nausea, flatulence, diarrhea, constipation);
 esophageal ulcers, gastric ulcersers, or osteonecrosis of the jaw
o take these medications on an empty stomach on arising in the morning with a full glass of
water and must sit up right for 30 to 60 minutes after their administration.
o Should not eat or drink anything for 30 minutes following administration of the medication: to
increase absorption of the drug.

 Calcitonin (Miacalcin)
o inhibits osteoclasts thereby reducing bone loss and increasing BMD.
o administered by nasal spray or by subcutaneous or intramuscular injection.
o Side effects include nasal irritation, flushing, gastrointestinal disturbances, and urinary
frequency.
 Teriparatide (Forteo)
o Administered by subcutaneousonce daily
o a recombinant PTH that stimulates osteoblasts to build bone matrix and facilitates over- all
calcium absorption.
 antilipid medications
o such as statins: HMG- CoA reductase inhibitors
o reduce the incidence of fractures in patients who take these medications to control their
hyperlipidemia.
o promote bone growth

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.
 As a result of calcium deficiency, muscle weakness, and unsteadiness, there is an increased risk for
falls and fractures.

Assessment and Diagnostic Findings

 physical examination: skeletal deformities (spinal kyphosis and bowed legs) and a waddling or
limping gait.
 x-ray studies: generalized demineralization of bone is evident.
 Laboratory studies: low serum calcium and phosphorus levels and a moderately elevated alkaline
phosphatase concentration.

MEDICAL MANAGEMENT
 Assist to position changes by handling pillows used to support the body..

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  increased doses of vitamin D, along with supplemental calcium: If osteomalacia is caused by
malabsorption
 Exposure to sunlight: ultraviolet radiation transforms a cholesterol substance (7-
dehydrocholesterol) present in the skin into vitamin D.
 adequate protein, increased calcium and vitamin D diet: If osteomalacia is dietary in origin
 Dietary sources of calcium and vitamin D: fortified milk and cereals, eggs, chicken livers
 Monitor serum calcium levels: high doses of vitamin D are toxic and increase the risk for hypercalcemia
 Vitamin D: raises the concentrations of calcium and phosphorus

OSTEOMYELITIS
 infection of the bone
 infection may reach the bone through an open wound: compound fracture, surgery
 Causative organism: S. aureus

CLINICAL MANIFESTATIONS
 Sepsis: chills, high fever, rapid pulse, general malaise
 painful, swollen, and extremely tender of the infected area
 constant, pulsating pain: it intensifies with movement from pressure of the collecting pus.

ASSESSMENT AND DIAGNOSTIC FINDINGS

ACUTE OSTEOMYELITIS
 early x-ray findings: soft tissue swelling.
 Radioisotope bone scans, particularly the isotope-labeled white blood cell (WBC) scan, and magnetic
resonance imaging (MRI: early definitive diagnosis
 Blood studies: reveal leukocytosis and an elevated ESR.
 Wound and blood culture studies: to identify appropriate antibiotic therapy.

CHRONIC OSTEOMYELITIS
 X-ray: large, irregular cavities, raised periosteum, or dense bone formations
 Bone scans: to identify areas of infection.
 ESR and WBC count: usually normal.
 Anemia: associated with chronic infection.
 Abscess culture: to determine the infective organism and appropriate antibiotic therapy.

Prevention
 Prophylactic antibiotics: administered at the time of surgery and for 24 hours after surgery
 Aseptic postoperative wound care: reduces the incidence of superficial infections and osteomyelitis.

MEDICAL MANAGEMENT
 Antibiotic therapy: depends on the results of blood and wound cultures.
 General supportive measures: hydration, diet high in vitamins and protein, correction of anemia
 Immobilization of affected bone: to decrease discomfort and to prevent pathologic fracture of the
weakened bone.
 Warm wet soaks for 20 minutes several times a day: to increase circulation to the affected area.

PHARMACOLOGIC THERAPY
 IV antibiotic therapy: continues for 3 to 6 weeks.
o After the infection appears to be controlled, the antibiotic may be administered orally for up to 3
months.
o antibiotics should not be administered with food: To enhance absorption of the orally
administered medication

COLLABORATIVE MANAGEMENT
 Analgesics as prescribed
 Dressing changes—use of aseptic technique

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  exposure of infected bone, removal of purulent and necrotic material and irrigation of area with sterile
saline solution.
 Antibiotic-impregnated beads: may be placed in the wound for direct application of antibiotics
for 2 to 4 weeks.
 surgical debridement: If the infection is chronic,
 Sequestrectomy: removal of all dead, infected bone and cartilage
o A closed suction irrigation system may be used to remove debris.
 Incision and drainage of bone abscess
 Wound irrigation using sterile physiologic saline solution: may be performed for 7 to 8 days.
 Bone grafting: recommended after repeated infections

RHEUMATOID ARTHRITIS
 Chronic systemic disease characterized by inflammatory changes in joints and related structures, specifically the
synovial membrane.
 Incidence: more in women than men (3:1); peak incidence : 20- 40 years of age
 Cause is unknown
o May be autoimmune process or genetic in nature.
o Predisposing factors: fatigue, cold, emotional stress, infections.
o Joint distribution is symmetrical --most commonly affects smaller peripheral joints of hands; commonly
involves wrists, elbows, shoulders, knees, hips, ankles and jaws.

CLINICAL MANIFESTATIONS
 Fatigue, anorexia, malaise, weight loss, slight temperature elevation.
 Painful, warm, swollen joints with limited motion, stiffness in the morning and after periods of inactivity (non- use of
joints).
 Crippling deformity in long standing disease.
 Muscle weakness secondary to inactivity.
 Other manifestations: subcutaneous nodules, eye, vascular, lung or cardiac problems.
 Sjogren’s syndrome:
o Excessive dryness of the eyes, mouth and vagina.
 Felty’s Syndrome:
o Leukopenia : (causes low resistance to infection),
o Splenomegaly: (causes hemolytic anemia because trapped rbc’s in the spleen undergo hemolysis).

COLLABORATIVE MANAGEMENT
 Bed rest during acute pain
 Passive ROM exercises of joints. To prevent contractures.
 Splint painful joints.
 Heat and cold application.
o Cold application during acute pain; 20 minutes at a time. Then followed by heat application.
 Warm bath in the morning. To relieve morning stiffness.
 Protect the client from infection.
 Provide well - balanced diet.
 Physical therapy as prescribed.

SURGERY
Osteotomy
 Surgical removal of a wedge from the joint,

Synovectomy
 Removal of synovia,

Arthroplasty
 Replacement of joints with prostheses.

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PHARMACOTHERAPY
 ASPIRIN
o mainstay of treatment,
o has both analgesic and anti - inflammatory effects

 Nonsteroidal anti - inflammatory drugs (NSAIDs):

o Indocin (Indomethacin)
o Butazolidin (Phenylbutazone)
o Motrin (Ibuprofen)
o Nalfon (Fenoprofen)
o Naprosyn (Naproxen)
o Clinoril (Sulindac)

GOLD COMPUNDS (chrysotherapy)

 Injectable forms:
o Myochrysine (gold sodium thiomalate)
o Solganal (aurothioglucose);
o given IM once a week; takes 3-6 months to become effective.
 Oral form:
o Ridaura (auranofin); smaller doses are effective;
o common side effect of the drug: diarrhea
 Corticosteroids
o intra - articular injections if pain becomes intolerable.

OSTEOARTHRITIS (Hypertrophic Arthritis)

 Chronic, nonsystemic disorder of joints characterized by degeneration of joint cartilage.
 Weight bearing joints - spine, knees, hips and ends of fingers are most commonly affected.

PREDISPOSING FACTORS
 Women and men affected equally
 incidence increases with age.
 obesity and joint trauma.

CLINICAL MANIFESTATIONS
 Pain: aggravated by use and relieved by rest.
 Stiffness of joints.
 Heberden’s nodes - bony overgrowth at terminal interphalangeal joints.
 Bouchard’s nodes - bony overgrowth at the proximal interphalangeal joints.
 Decreased ROM, crepitus

COLLABORATIVE MANAGEMENT
 Assess joints for pain and ROM.
 Relieve strain and prevent further trauma to joints:
 Use cane or walker when indicated.
 Maintain good posture and body mechanics
 avoid excessive weightbearing and continuous standing,
 Physical therapy: to maintain joint mobility and muscle strength,
 Promote comfort/ relief of pain : analgesics and NSAIDs
 Joint replacement as needed.

GOUTY ARTHRITIS
 a disorder of purine metabolism.
 characterized by high levels of uric acid in the blood and in the urine.
 precipitation of urate crystals (tophi) in the joints. This causes inflammation and pain.

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  Occurs most often in males; and it is familial.

CLINICAL MANIFESTATIONS
 Joint pain, redness, heat, swelling; great/ big toe and ankle: most commonly affected.
 Headache, malaise, anorexia.
 Tachycardia, fever, tophi in the great toe, outer ear, hands and feet.

COLLABORATIVE MANAGEMENT
 Drug Therapy
o Acute attack
 Colchicine: discontinue if diarrhea or nausea and vomiting occur
 NSAIDS - Indocin, Butazolidin.

o Prevention - uricosuric agents.

 increase excretion of uric acid in the urine.
 Benemid (Probenecid),
 Anturane (sulfinpyrazone).
 Zyloprim (Allopurinol): inhibits uric acid formation.

Nursing Interventions in antigout medications:

 Antigout medications: used cautiously with gastrointestinal, renal, cardiac or hepatic diseases.
 Maintain a fluid intake of at least 2000 to 3000 ml. a day: to avoid kidney stones.
 Instruct client to avoid alcoho! and caffeine. These products can increase uric acid level.
 Avoid purine - rich foods: caffeine, alcohol, organ meats, sardines, salmon, scallops and gravy
 Instruct client to take medications with food. To prevent Gi irritation.
 Instruct client to avoid large doses of Vitamin C while taking Allopurinol: to prevent kidney stones.
 Advise client to have yearly eye examination. Visual changes can occur from prolonged used of Allopurinol
 Do not take ASA with antigout medications. To prevent gout attack.
 Allopurinol may increase the effect of Coumadin and oral hypoglycemic agents.

 Observe for the following side - effects of antigout medications:

 Headache
 Nausea, vomiting, diarrhea
 Bone marrow depression
 Flushed skin and skin rash
 Uric acid kidney stone
 Sore gums
 Metallic taste

Low purine diet

Foods to avoid
 Organ meats
 Shellfish
 Legumes
 Sardines
 Salted anchovies
 Mushrooms
 Herring
 Sweetbreads
 Consomme Beer / wine

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