Problems of the Musculoskeletal System

Mona Garrett NURS 210

Review of Skeletal System

Functions of bone Structure of bone Cancellous (spongy) or cortical (compact) Haversian system Bone remodeling Osteoblasts and osteoclasts Long bones and short bones Joints

Review of Muscular System

Function Assessment Muscle strength, muscle size, ROM Abduction and adduction Flexion and extension Effects of aging and disuse

Osteoporosis
Most common metabolic bone disease Rate of resorption > rate of bone formation Primary versus secondary Affects 50% of women; 20% of all men S/S: Loss of height Progressive curvature of spine Low back pain Fractures especially wrist, hip, vetebral

Risk Factors of Osteoporosis

Increasing age Family history of osteoporosis Female Postmenopausal Caucasian or Asian Thin, lean body build Long term use of steroids Calcium deficiency Estrogen deficiency Androgen deficiency Smoking High caffeine intake High alcohol intake Sedentary life style or prolonged immobility

Diagnosis of Osteoporosis
History and physical exam Xrays CT scan Dual-Energy Xray Absorptiometry (DEXA) Bone biopsy Serum calcium, vit D, phosphorous, ALP MRI, Ultrasound

Treatment of Osteoporosis
Diet: Foods high in calcium and Vit D Medications Hormone Replacement Therapy Parathyroid Hormone (Forteo) Calcium Vit D Biphosponates (Fosamax, Boniva, Actonel) Calcitonin SERMs: Evista (Raloxifene)

Treatment of Osteoporosis
Prevention of falls Weight bearing exercise Pain management Orthotics Health teaching: Medications, diet, disease process, prevention of falls, exercise, psychosocial support

Osteomalacia
Reversible metabolic bone disorder; inadequate mineralization of bone matrix Patients at risk: Elderly Strict vegetarians Vitamin D deficiencies Limited exposure to sunlight Meds that increase degradation of Vit D Impaired intestinal absorption of Ca & P Renal or liver disease

Osteomalacia
S/S: Bone pain and tenderness, muscle weakness, waddling gait, pathologic fractures Diagnosis: Xrays, low Ca and P, elevated parathyroid and alkaline phosphase (ALP) Treatment: Vitamin D supplements Calcium and phosphorous supplements Sunlight at least 5 minutes/week Diet high in calcium and exercise

Pagets Disease
Metabolic bone disease of unknown etiology; excessive osteoclastic activity Familial tendency; men > women 3:2 S/S: 80% asymptomatic Bone pain of spine, cranium, pelvis Flushing and warmth of overlying skin Headache, hearing loss, vertigo Neuro compromise, pathologic fracture CHF, hypertension, arteriosclerosis

Pagets Disease
Diagnosis: Xrays, bone scan, CT, elevated serum alkaline phosphatase, elevated urinary Ca & hydroxyproline, bone biopsy Treatment NSAIDS and analgesics Calcitonin and Didronel Mithramycin - antineoplastic & antibiotic Other biphosphonates (Fosamax) Other pain relief measures Joint replacement or repair

Osteomyelitis
Infection of the bone; usually bacterial (primarily staph aureus) Can be exogenous, hematogenous, or extension from adjacent soft tissue infection S/S: Fever; bone pain; redness, tenderness, warmth, and swelling of affected area Diagnostic Tests: Blood & wound cultures, Xrays, bone scan, MRI, bone biopsy Elevated ESR & WBC if acute; normal if chronic

Treatment of Osteomyelitis
Meds: Aggressive long term antibiotics Surgery: Needle biopsy or aspiration Surgical debridement Bone graft or muscle flap to replace deficit Hyperbaric oxygen therapy Nursing Diagnoses: Pain, impaired physical mobility, anxiety & powerlessness Teaching: Home administration of antibiotics and dressing changes

Bone Tumors
Primary vs secondary tumors (metastasize from breast, lung, thyroid, kidney, prostate) Primary bone tumors are benign (most common osteochondroma) or malignant (most common osteosarcoma) S/S: Usually associated with fall or injury; may have pathologic fracture; pain Diagnosis: Xrays, CT, MRI, Needle biopsy, CBC, ESR, Chems Rx: Removal of tumor, radiation, chemo

Bone and Soft Tissue Tumors in Children

Osteosarcoma - most frequent bone cancer in children; usually 10-25 yrs old Rx: Amputation or limb salvage; chemo Prognosis: 50% expect long term survival Ewing Sarcoma - affects ages 4-25 yrs old Treatment: Radiation, chemo Rhabdomyosarcoma - most common soft tissue sarcoma in children; usually head and neck especially orbit; children under 5 Treatment: Surgery, chemo, radiation

Hand Disorders
Carpal Tunnel Syndrome compression of median nerve as a result of inflammation Repetitive use injury or R/T other disorder S/S: Numbness, tingling, pain at night Dupuytrens Contracture progressive contracture of palmar fascia Ganglion cyst on tendon or wrist joint Treatment: Immobilization, NSAIDS, ice, splinting rest, corticosteroid injections, surgery as last resort

Foot Disorders
Hallux Valgus - enlargement and lateral displacement of first metatarsal (bunion) Can be congenital; usually due to footwear Hammertoe - dorsiflexion of big toe with plantar flexion of 2nd and 3rd toes Mortons Neuroma - tumor like mass; usually only in one foot and 3rd web space

Diagnosis: Inspection and xrays Rx: Orthotics, analgesics, surgery, casts

Foot Disorders
Tarsal Tunnel - compressed posterior tibial nerve in ankle; causes numbness & pain Rx: NSAIDS, cortisone injection, OR Plantar Fasciitis - inflammation of plantar fascia; pain in arch of foot and/or heel Affects runners, obese, adults over 40 Treatment: Rest, ice, stretching exercises, NSAIDS, cortisone injections, orthotics

Congenital Clubfoot
Common deformity with foot twisted from normal shape and position Talipes equinovarus most common Treatment Serial casting begun after birth; casted every 1-3 weeks for 3 months Surgery a possibility if casting not working Reverse last shoes Surgery at 4 months to 1 year old

Spinal Disorders
Scoliosis - lateral curvature of the spine Kyphosis excessive angulation of normal posterior curve of thoracic spine (hunchback) Lordosis lumbar curvature (swayback) Diagnosis - Inspection, curvature > 5o by scoliometer, xrays Conservative treatment: Braces, traction, exercises, weight reduction, casting OR: Spinal fusion and instrumentation

Muscular Dystrophy
Group of inherited muscular disorders that cause progressive muscle degeneration Duchennes dystrophy most common S/S: Progressive muscle weakness, can involve cardiac and endocrine systems, mental retardation Diagnosis: Serum creatine phosphokinase, muscle biopsy, electromyogram (EMG) Treatment: None available to cure Goal is to preserve and promote mobility