Musculoskeletal Lecture

Prepared by:Edwin Jonathan A. Manlapas, DDM, R.N

“ Great Minds have purposes, others have wishes.”

Washington Irving

“ A winner has a plan, a loser has an excuse.”

Musculoskeletal system2nd largest body systemBones, joints & skeletal muscles

Anatomy & Physiology

Skeletal System206 bonesMultiple joints

Classification of bones by shape:

Long bones – cylindrical with rounded ends; often bear weight

Short bones – phalanges, small & bear little or no weight

Flat bones – scapulaProtect vital organs; often contain blood forming cells

Irregular bones – unique shapes; carpal bones of the wrist, bones in the inner ear

Classification of bone by structure:

Cortex – outer dense, compact bone tissue

Medulla – composed of spongy cancellous bone

Epiphyses – 2 knob-like ends

Diaphysis – bone shaftPlays a role in growth & development

Haversian system – structural unit of cortical, compact bone

Cancellous tissue – with trabecula; filled with red & yellow marrow

Hematopoiesis – production of blood cells; happen in the red bone marrow

Yellow marrow – contains fat cells

Osteoblasts – bone forming cellsOsteoclasts – bone destroying cells

Osteon – bone matrix; consists of collagen, mucopolysaccharides & lipids

Function of the skeletal system:

Provides a framework for the body.

Supports the surrounding tissues

Assists in movement (muscles, tendons)

Protect vital organs (heart, lungs)

Production of red blood cellsProvides storage for mineral salts (Ca & PO4)

Calcium & Phosphorus99% Calcium90% Phosphorus

Serum concentration of Ca & Phosphorus maintain an inverse relationship

Calcitonin Decreases the serum Ca concentration if increased above normal levels

Inhibits bone resorption

Increases renal excretion of Ca & Phosphorus

Vitamin D – promotes absorption of Ca & Phosphorus from the small intestine; enhance PTH activity

A decreased in Vitamin D can result in Osteomalacia among adults & Rickets in children

Parathyroid hormone (Parathormone, PTH) – stimulates bone’s osteoclastic activity & release calcium to the blood

Growth hormone – increase bone length; determines the amount of bone matrix formed before puberty

Glucocorticoids – regulate protein metabolism; regulate intestinal Ca & Phosphorus absorption

Estrogens & Androgens Estrogen stimulates osteoblastic activities & inhibit parathormone

Testosterone – increase bone mass by promoting anabolism

Thyroxine – increase the rate of protein synthesis

Insulin works with growth hormones to build & maintain healthy bone tissue

Joint – a space in which 2 or more bones come together

Provide movement & flexibility in the body

Types of joint:Synarthrodial – completely immovable joints (Ex. Joints in the cranium)

Ampiarthrodial – slightly movable joints (Ex. Pelvis)

Diarthrodial (Synovial) – freely movable joint (Ex.Elbow & knee)

Synovial joints are the only joints lined by synovium; a membrane that secretes synovial fluid for lubrication & shock absorption

consists of elongated cells called muscle fibers that utilizes ATP to generate force

produces heat, body movements & maintains posture

1. Skeletal muscle – attached to the bones of the skeleton; fibers with striations, voluntary controlled by CNS & PNS

2. Cardiac muscle – forms most of the wall of the heart; striated; involuntary, controlled by ANS

intercalated discs – unique structure of cardiac muscle

3. Smooth muscle – non-striated, involuntary, located in walls of hollow internal structures like blood vessels, airways of the lungs, stomach, intestine & gall bladder

Contraction helps constrict the lumen of blood vessels

CARTILAGECostal Cartilage – connects sternum to rib cage

Yellow Cartilage – external ear, epiglottis

Hyaline Cartilage – septum of nose, larynx, trachea

TENDONS – bands of tough, fibrous tissue that attach muscles to bones

LIGAMENTS – attach bones to other bones at joints

Decreased bone densityIncreased bone prominence

Kyphotic posture : widened gait, shift in the center of gravity

Cartilage degenerationDecreased ROMMuscle atrophy , decreased strength

Slowed movement

HistoryDemographic data:Young men – risk for trauma R/T motor vehicle crashes

Older adults – risk for falls fracture, soft tissue injury

Family history and genetic risk :

Osteoporosis – age related bone loss

Bone cancerOsteoarthritis

Personal History :Accidents, illnesses, lifestyle, medication

Level of physical activityTraumatic injuriesParticipation in sports/sports injuries

Diet History :Determine risk of inadequate nutrition

Lactose intolerance → affect Ca intake

Insufficient Vitamin C or D → inhibits healing of bone and tissue

Obesity→ places excess stress and strain on bones and joints

Socioeconomic Status:Computer related jobs→

carpal tunnel syndrome ( entrapment of median nerve in the wrist )

Construction worker, Health care workers → back injury

Athletes → joint dislocation, fractures

Current Health Problems:PAIN – most common complaint

- acute or chronic - best if client describes the pain in his/her own words

PQRST Model P rovoking incidentQ uality of painR egion, radiation and reliefS everity of painT ime

General InspectionPosture – body build and alignment when standing and walking

Gait – two phases of normal, automatic gait

1. Stance phaseAntalgic gait – abnormality in

the stance phase of gait Part of one leg is painful, the

person shortens the stance phase on the affected side

2. Swing phaseLurch – abnormality in the swing phase

Occur when muscles in the buttocks and/or legs are too weak to allow the person to change weight from one foot to the other

MobilityGoniometer – a tool use to provide an exact measurement of ROM

Assessment of the Head & Neck

- inspect, palpate the skull (shape, symmetry, tenderness and masses)

Common abnormal findings:1. tenderness and pain2. crepitus ( grating sound )

3. spongy swelling

Assessment of the spineBoth hands are placed over the lumbosacral area, apply pressure with thumb

Lordosis – in pregnancy , in abdominal obesity

Scoliosis – client flexes forward from the hip, inspect lateral curve

Assessment of the Upper Extremity

Assessment of the Lower Extremity

genu valgum ( “knock knee “)

genu varum ( “bow-legged )

Neurovascular Assessment

Lovett’s Scale for Grading Muscle Strength

5 Normal : ROM unimpaired against gravity with full resistance

4 Good : can complete ROM against gravity with some resistance

3 Fair : can complete ROM against gravity

2 Poor : can complete ROM with gravity eliminated

1 Trace : no joint motion and slight evidence of muscle contractility

0 Zero : no evidence of muscle contractility

LABORATORY PROFILESerum Calcium( 9-10.5 mg/dL )Hypercalcemia :• Metastatic cancers of the bone• Paget’s Disease• Bone fractures in healing stage

Hypocalcemia:• Osteoporosis• Osteomalacia

Serum Phosphorus ( 3–4.5 mg/dL )

Hyperphosphatemia:• Bone fracture in healing stage• Bone tumors• Acromegaly

Hypophosphatemia:• Osteomalacia

Alkaline Phosphatase, ALP (30-120 units/L)Elevations may indicate :• Metastatic cancers of the bone

• Paget’s Disease • Osteomalacia

Serum muscle enzymesCreatinine kinase ,CK Men : 55-170 units/L Women : 30-135 units/L

Elevations may indicate :Muscle trauma ; Effects of EMG

Progressive muscular dystrophy

Lactate dehydrogenase, LDH Total LDH: 100-190 units/LElevations may indicate:• Skeletal muscle necrosis• Extensive cancer• Progressive muscular dystrophy

Aspartate aminotransferase, AST

( 0-35 units/L )Elevations may indicate:• Skeletal muscle trauma• Progressive muscular dystrophy

Aldolase, ALD ( 3-8.2 units/dL )

Elevations may indicate:• Polymyositis and dermatomyositis

• Muscular dystrophy

RADIOGRAPHIC EXAMINATIONS

Standard Radiography ; CT Scan

Tomography – produces planes or slices , for focus and blurs the image of other structures

Xeroradiography – highlights the contrast between structures

Myelography – involves injection of contrast medium or dye into the subarachnoid space of the spine usually by spinal puncture

Arthrography – x-ray study of the joint after contrast medium (air or solution ) has been injected to enhance its visualization

Other Diagnostic Tests:Bone biopsy – the doctor extracts a specimen of

bone for microscopic exam

Muscle biopsy – done for the diagnosis of atrophy and inflammation

Electromyography (EMG) – accompanied by nerve conduction studies for determining the electrical potential generated in individual muscle

-

Diagnosis of neuromuscular, lower motor neuron and peripheral nerve disorder

Client Prep: skeletal muscle relaxant is d/c by the doctor

Procedure: at bedside or EMG laboratory

Nerve conduction tested 1st – flat electrodes placed along the nerves

muscle potential – multiple needle electrodes , ½ -3 inches

Follow up care:• inspect needle site for hemato- ma formation→ apply ice• check complain of inc. pain and

anxiety

Arthroscopy – for diagnostic test or surgical procedure

Arthroscope – a fiberoptic tube inserted into a joint for direct visualization

Client Prep: client must be able to flex knee at least 40 degrees

- CI if client have joint infection - ambulatory basis/same day surgery

Procedure: - local, light general or epidural anesthesia

- knee flexed at 40 degrees, irrigated

- less than ¼ inch incision, insert arthroscope

Follow up care:1. evaluate neurovascular status of affected limb

2. monitor distal pulses, warmth, color, capillary refill, movement, pain, sensation of affected limb

3. Encourage client to perform appropriate exercises

4. Ice – used for 24 hrs5. Elevate extremity for 24-48 hrs

6. Monitor/ observe for:Swelling, HypothermiaIncrease joint pain due to mechanical injury

Thrombophlebitis, Infection

Bone scan – radionuclide test in which radioactive material is injected for visualization of the entire skeleton

- detect tumors, osteomyelitis,

arthritis,vertebral compression fracture, osteoporosis, unexplained bone pain

Gallium/Thallium Scan – similar to bone scan but more specific and sensitive in detecting bone problem

Radioisotopes used:Gallium citrate - most common

Thallium - osteosarcoma

Client prep: Doctor/technician administer isotope 1-2 days before scanning

Procedure: 30-60 minutes, mild sedation for older clients or in severe pain, lie still

Follow up care: encourage to push fluids

Magnetic Resonance Imaging – image produced through the interaction of magnetic fields, radio waves and atomic nuclei showing hydrogen density

- more accurate than CT scan and Myelography

- Gadolinium-DTPA (diethylenetriamine-pentacetid acid ) – contrast agent

- remove all metal objects, check clothing zippers and metal fasteners, surgical clip

Ultrasonography – sound waves produce an image of the tissue

Visualizes:• Soft tissue disorder • Traumatic joint injuries• Osteomyelitis• Surgical hardware placement

Common Health Problems of the Neonate & Infant:

Congenital Hip Displacement

Head of the femur is improperly seated in the acetabulum, or hip socket of the pelvis

Acetabulum of the pelvis is shallow.

Occurs most often among children of Mediterranean ancestry

6 times more frequently among girls than boys

Can be congenital or develop after birth

I. Dysplasia of the Hip

AssessmentNeonates: laxity of the ligaments around the hip

Infants beyond the newborn period

Affected leg appears shorter than the normal leg

Unequal number of skin folds on the posterior thigh

Asymmetry of the gluteal & thigh skin folds

Limited range of motion (ROM) in the affected hip

Asymmetric abduction of the affected hip

Apparent short femur on the affected side (Galeazzi sign, Allis sign)

Galeazzi sign – apparent shortening of the femur; as shown with the difference of knee levels with the knees & hips flexed at right angle when patient is lying on a flat table

The walking child: minimal to pronounced variations in gait w/ lurching toward the affected side; positive Trendelenburg sign

Positive Barlow or Ortolani’s maneuver

Barlow’s maneuver – performed by adducting the hip (bringing the thigh towards the midline) while applying a light pressure on the knees with the force directed posteriorly

Positive Barlow test – if the hip can popped out from the socket

Ortolani’s test or maneuver – physical exam for hip dysplasia

Performed by gently abducting the infant’s leg with the examiner’s thumb while placing an anterior pressure on the greater trochanter (index & forefinger)

Positive sign is a distinctive “clunk” which can be felt or heard as the femoral head relocates anteriorly into the acetabulum

Diagnotic tests:X-ray (shows shallow acetabulum)

SonogramMagnetic Resonance Imaging

ImplementationIn the neonatal period, splinting of the hips w/ Pavlik harness to maintain flexion & abduction & external rotation

Multiple diapers – effectively separates the legs

Frejka splint – parents must keep the splint at all times except when bathing or changing diapers

Following the neonatal period, traction &/or surgery to release muscles & tendons

Bryant’s skin traction

Following surgery, positioning & immobilization in a Spica cast

Osteotomy following traction in profoundly affected children

Pavlik Harness – an adjustable chest halter that abducts the legs

Method of choice for long term therapy; reduces therapy to 3-4 weeks, simplifies care

The defect may be unilateral or bilateral

Long-term interval follow-up is required

“Talus” – ankle“Pes” – foot1 in every 1000 children born with the defect

Boys are affected than girls

Congenital Clubfoot

AssessmentThe foot is plantar flexed w/ an inverted heel & adducted forefoot

ImplementationTreatment begins as soon after birth as possible

Serial manipulation & casting are performed weekly, if correction is not achieved in 3 to 6 months, surgery is indicated

Monitor neurovascular status of the toes

Instruct parents in cast care & the signs of neurovascular impairment that requires physician

Dennis Browne SplintFor clubfoot/congenital Talipes Equinovarus

Tendon is short – complete soft tissue release

Torticollis (wry neck) – head is tilted/turned to 1 side; chin is elevated & turned to the opposite side

Head position should be corrected before adulthood

Affects 2% of newborn

Diagnosis:History taking – determine circumstances surrounding birth, trauma or associated symptoms

Physical examination – shows decreased rotation & bending to the side opposite the muscle affected

Neck muscles/areas between

the neck & shoulder are tense & tender

Management:Medications (muscle relaxants/NSAIDs)

Physical devices

Botulinum toxinSurgery

Radiographic examination – radiographs of the cervical spine

MRI – for structural problems

Common health Problem of Young Adolescent

Scoliosis

Scoliosis A lateral curvature

of the spine

AssessmentVisible curve fails to straighten when the child, bends forward & hangs down toward feet

Hips, ribs, & shoulders are asymmetrical

Apparent leg length discrepancy

Assessment

ImplementationPrepare the child & parents for the use of a brace if prescribed

Prepare the child & parents for surgery (spinal fusion; placement of internal instrumentation rods) if prescribed

BracesUsually worn from 16 to 23 hours a day

Keep the skin clean & dry, avoiding lotions & powders

Advise the child to wear soft nonirritating clothing under the brace

Common Health Problem of the Young Adult:

Osteogenic Osteosarcoma

Osteosarcoma/Osteogenic sarcoma

Most common type of primary malignant tumor

50% occur in distal femur

Primary – those that originate in bone

Secondary – those that originate in other tissues & metastasize to bone

Clinical Manifestations:PainSwellingLarge lesionSclerotic central massSunburst appearance

Inward bony expansionIncidence:Occurs more often in males than females (2:1); 10-20 y/o

Older clients with Pagets disease

Primary tumors (breast, prostate, kidneys, thyroid, lungs) bone seeking tumor cells carried to bone (blood stream) pathologic fracture

Laboratory Assessment:Elevated serum alkaline phosphatase

Elevated serum Ca levelElevated ESR

Radiographic Assessment:Bone destructionIrregular periosteal new boneCortical breakthroughIncrease/decrease bone density

MRIBone scan

Nursing diagnoses:Acute/Chronic Pain r/t physical injury

Anticipatory grieving r/t change in body image

Disturbed body image r/t effects of illness, treatment including surgery

Interventions:Treatment is aimed at reducing the size/removing tumor

Drug therapy – analgesics, chemotherapeutic agents

Radiation therapy – reduce tumor size & pain

Surgery

Common Health Problems of the Adult:

Adult Rheumatoid Arthritis

Rheumatology – study of rheumatic disease

Rheumatic disease – disease/condition affecting the musculoskeletal system

Arthritis – inflammation of one or more joints

Rheumatoid Arthritis (RA)Most common connective tissue disease

Most destructive to the joints

Chronic, progressive, systemic inflammatory autoimmune disease affecting the synovial joints

characterized by remissions & exacerbations

Autoantibodies (rheumatoid factors RF’s) are formed attack healthy tissues (synovium) inflammation of synovial membrane synovium thickens fluid accumulates in joint space pannus formation erosion of cartillage bone erosion

Pannus – vascular granulation tissue composed of inflammatory cells; erodes the cartillage & eventually destroys bone

Etiology of RA is unclear; research suggests a combination of genetic & environmental factors

Some researchers suspect female reproductive hormones

Epstein Barr virusPhysical/emotional stress

Clinical Manifestations:Joint stiffnessSwelling Painfatigue

Generalized weaknessMorning stiffnessUpper extremity joints affected (proximal interphalangeal/metacarpophalangeal joints)

Bilateral/symmetric joint affectation; number of joints affected increases

Gel phenomenon – morning stiffness that lasts 45 minutes to several hours upon awakening

Swan neckUlnar deviation

Laboratory Assessment:No single test that confirms the disease

Rheumatoid factor – measures the presence of unusual antibodies IgM, IgG types

Antinuclear Antibody TiterErythrocyte Sedimentation Rate (ESR) – diagnosis of inflammatory CT disease

C Reactive Protein test

Standard X-ray – visualize joint changes & deformities

CT Scan – determines cervical spine involvement

Arthrocentesis – synovial fluid is analyzed for inflammatory cells & immune complexes; RF included

Nursing responsibility:Monitor insertion site for bleeding/leakage of synovial fluid

Teach the client to use ice & rest affected joint for 24 hrs.

Management:NSAID’sDisease-Modifying Anti-Rheumatic Drugs – hydroxychloroquine (Plaquenil)

Sulfasalazine (Azulfidine)Minocycline (Minocin)Methotrexate (Rheumatrex) – immuno suppressive medication

Gold therapyGold sodium thiomalate (Myochrysine)

Nonpharmacologic modalities:

Adequate restProper positioningIce & heat applications

Gouty Arthritis (Gout) – systemic disease in which urate crystals deposit in joints causing inflammation.

2 types of gout:1.Primary gout – most common type; results from 1 of several inborn errors of purine metabolism

Production of uric acid exceeds the excretion capability of the kidneys

Sodium urate is deposited in synovium causing inflammation

2. Secondary gout – involves hyperuricemia (excessive UA in blood) caused by another disease

Renal insufficiency, diuretic therapy, chemotherapeutic agents; multiple myeloma

4 phases of the primary disease:

1.Asymptomatic hyperuricemic phase – serum level elevated; no overt signs of disease

2. Acute phase – 1st attack of gouty arthritis; excruciating pain in 1 or more small joints (metatarsophalangeal joint of the great toe)

Podagra – 75% experience inflammation of this joint as the initial manifestation

Elevated ESR & WBC

3. Intercritical/Intercurrent state of the disease – attack occurs after months or years; asymptomatic; no abnormalities found in joints

4. Chronic tophaceous gout – deposits of urate crystals develop under the skin & major organs

Gout affects more men than women

Clinical Manifestations:Acute gout – Painful inflamed joints

Chronic gout – inspect for tophi

Tophi – deposits of Na urate crystals; commonly appear on the outer ear

Arms & fingers near the joints

Renal calculi

Diagnostic tests:Serum uric acid – more than 8 mg./100 ml.

Urinary uric acid levels – more than 600 mg./24 hr after a 5 day restriction of purine intake

Synovial fluid aspiration (arthrocentesis) – detect the presence of needle-like crystals

Drug therapy:Colchicine (Colsalide) – works within 12 hrs.

Repeated acute gout/chronic gout – Allopurinol (Zyloprim) – promotes uric acid excretion

Nurse monitors serum uric acid levels to check the effectiveness of medications

Diet therapy: Strict low-purine diet; avoid foods such as organ meats, shellfish, oily fish with bones (sardines)

Avoid aspirin & diureticsAvoid excessive physical/emotional stress

Force fluidsIntake of Alkaline ash foods – citrus foods & juices, milk

Carpal Tunnel SyndromeCarpal tunnel – rigid canal between the carpal bones and flexor retinaculum

Compressed median nerve in the wrist

Pain and numbnessParesthesia ( painful tingling )

Etiology and Genetic risk:Excessive hand exerciseEdema or hemorrhage into CT

Thrombosis of the median artery

CTS – most common repetitive strain injury (RSI)

- fastest growing type of occupational injury : factory worker, computer operators etc; sports activities ( golf, tennis )

Incidence and prevalence :Adults – bet 30-60 yrs oldWomenDominant handChildren and adolescent – computer use

Clinical Manifestation: Phalen’s maneuver/testRelax the wrist into flexion Place back of hands together and flex both wrist

(+) – paresthesia palmar side of thumb, index and middle finger, radial half of ring finger

Tinel’s signLightly tapping area of median nerve in the wrist

(+) – paresthesia

BP cuff placed on the upper arm , inflated to the client’s systolic pressure

(+) – pain and tingling

Diagnostic Assessment :Xray – bone changes, lesions, synovitis

EMG- nerve dysfunctionMRI ,UTZFinding : Enlarged median nerve within the carpal tunnel

Interventions: NonsurgicalDrug – NSAIDS Immobilization - splint

SurgicalOpen carpal tunnel release (OCTR)

Endoscopic carpal tunnel release ( ECTR )

Synovectomy – for rheumatoid arthritis , complication of CTS

Post Operative Care:Elevate hand and arm above heart level

Check neurovascular status

Move fingers of affected hand

Restrict hand movements, lifting heavy objects – 4 to 6 wks after surgery

Musculoskeletal disorders:Metabolic bone diseases (osteoporosis, Paget’s disease)

Bone tumors Bone deformities

Osteoporosis Metabolic diseasebone demineralizationDecreased bone densityFractures

“silent disease”Mostly affected are wrists, hip & vertebral column

Osteoclastic (bone resorption) activity exceeds osteoblastic (bone building) activity decreased bone mineral density (BMD) loss of spongy bone/cortical bone

fragile bone tissue Fracture

Diagnosis is based on BMD values using T-scores

T-score – the number of standard deviations above or below the average BMD for young, healthy white women

Osteopenia – T-score between 1 & 2.5

Osteoporosis among postmenopausal women BMD T-score more than 2.5 standard deviations below normal

2 theories in osteoporosis:May result from decreased osteoblastic activity

Increased osteoclastic (bone resorption) activity

Classification of osteoporosis:

1.Generalized osteoporosis:Involves many structures in the skeleton

Primary osteoporosis – occurs among postmenopausal women/men in 6th or 7th decade of life

Decrease estrogen/testosterone

Secondary osteoporosis – results from associated medical conditions (hyperparathyroidism, long term corticosteroid use, prolonged immobility)

2. Regional osteoporosis – occurs when limb is immobilized r/t fracture, injury, paralysis or joint inflammation

Immobilization greater than 8-12 weeks

Exact cause of osteoporosis is unknown

About 98% of peak bone mass achieved by 20 years of age

Building strong bone as a young person – best defense against osteoporosis in later adulthood

(National Osteoporosis Foundation 2003)

Most health care providers focus on the risk of osteoporosis in women older than 50 years old & do not assess risk as often in women 49 years of age & younger (Berarducci et.al 2000)

Risk factors:Postmenopausal womenBreast Ca survivorsGenetics – Hx of fracture among a 1st degree relative

Thin, lean built White, Asian women

Protein deficiencyAlcohol consumption/Cigarette smoking

IncidenceWomen are affected than men 80%

1.5 million fractures/year300,000 are hip fractures

Clinical Manifestations:“dowager’s hump” or kyphosis of the dorsal spine

Client verbalized that height has been shortened (2-3 inches)

Backpain occurs after lifting, bending or stooping

Pain is worsened by activity & relieved by rest

Laboratory Assessment:No definite laboratory test that confirm a diagnosis of primary osteoporosis

uPYR Crosslinks assay – measures urinary concentrations of pyridinium; a collagen substance found in bone & cartilage

Increased urinary levels indicate bone resorption

Radiographic AssessmentX-rays of the spine & long bones show loss of bone density & fractures

Bone density changes are evident if 25-40% of bone loss has occurred

Dual-energy x-ray absorptiometry (DEXA) – painless scan that measures

bone mineral density (BMD)

Physicians recommend that women in their 40’s have a baseline DEXA

Nursing diagnoses:Impaired physical mobility r/t decreased muscle strength, pain

Acute/Chronic pain r/t effects of acute physical illness

Interventions:MedicationsNutritional therapyExercise

Drug therapy:HRTCa supplementsVitamin D

BiphosphonatesSelective estrogen receptor moduloators (SERM’s)

Calcitonin

Hormone Replacement Therapy (HRT)

Used as primary prevention strategy for reducing bone loss among post menopausal woman

Long term effects of HRT include breast’s CA, CV disease & stroke

Parathyroid hormone – teriparatide (Forteo), SQ injection

Calcium – not a treatment for osteoporosis; it is an important part of the prevention program in promoting bone health

Ca carbonate (Tums, OsCal)

Teach clients to take Ca with food & 6-8 ounces of H20

Instruct clients to take foods rich in Ca (Milk & dairy products, green leafy vegetables)

Vitamin D for optimal Ca absorption in the small intestines

Bisphosphonates – inhibit bone resorption by binding with crystal elements in bone

alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel)

Nursing Alert:Instruct clients to take the drug early in the morning with 8 oz.

of H2O & wait 30 minutes before eating. Must remain upright during the 30 minutes before eating

Selective Estrogen Receptor Modulators (SERM’s)

Designed to mimic estrogen in some parts of the body & blocking its effect elsewhere

Raloxifene (Evista)

Calcitonin – inhibits osteoclastic activity

Diet therapy – Ca & Vitamin D intake must be increased; alcohol & caffeine consumption must be discouraged

Fall prevention – a hazard free environment is necessary

“Falling star protocol”Exercise – PT’s prescribed exercises that strengthen the

Abdominal & back muscles; active ROM exercises

Walking 30 minutes 3X a week, swimming & bicycling are recommended

Bowling & horseback riding are avoided – may cause vertebral compression

Orthotic devices or dorsolumbar orthoses – immobilize the spine during acute pain phase & provide spinal column support

Osteomalacia – softening of the bone tissue; characterized by inadequate mineralization of osteoid

EtiologyPrimary Vitamin D deficiency – lack of sunlight exposure, poor dietary intake, malabsorption of Vitamin D

HypophosphatemiaIntake of barbiturates, anticonvulsants & fluoride

Incidence:Common among non industrialized nations

Strict vegetarians without adequate supplement of Vitamin D

Muscle weaknessJoint painWaddling & unsteady gait (due to muscle weakness)

Diagnostic Assessment:X-ray – reveal a decrease in the trabeculae of cancellous bone & lack of osteoid sharpness

Classic diagnostic finding – presence of radiolucent bands (Looser’s lines/zones)

Looser’s zones – stress fractures that have not mineralized.

Bone biopsy will confirm the diagnosis

Interventions:Major treatment is Vitamin D

RDA – 400 IU

Meeting the RDA for Vitamin DAdvise clients to get sun exposure for at least 5 minutes weekly

Eat food high in Ca to promote Vitamin D absorption

Eat foods high in Vitamin D including milk & dairy products, ice cream, yogurt & cheese

Egg, swordfish, chicken, liver & cereals

Characteristic

Osteoporosis Osteomalacia

Definition Decreased bone mass

Demineralized bone

Pathophysiology

Lack of Ca Lack of Vitamin D

Radiographic Findings

Osteopenia/fractures

Pseudofractures, Looser’s zone, fractures

Calcium level Normal Low or Normal

Phosphate level

Normal Low or Normal

Parathyroid hormone

Normal High or Normal

Alkaline Phosphatase

Normal High

Osteoarthritis (Degenerative Joint Disease DGD)

most common arthritis2nd most common cause of disability among adults in U.S.

Common cause of disability worldwide

Progressive deterioration & loss of cartilage in 1 or more joints

Affects weight bearing joints (hips, knees, vertebral column)

Cartilage becomes soft fissures/pitting develop cartilage thins joint space narrows bone spurs formed

inflammatory enzymes enhance tissue deterioration

repair process fails

Causative mechanism of primary Osteoarthritis at the cellular level has not yet identified

Predisposing factors:DevelopmentalGeneticMetabolicTrauma

Age – strongest risk factorAbout ¾ of people older than 55 y/o has joint changes seen in X-rays

Health promotion/ Illness prevention:

Keep weight within normal limits

Avoid/limit activities that promote stress on joints (jogging)

Limit participation in recreational sports, risk seeking activities to prevent trauma

Assessment: Ask questions about the course of the disease

Collect information specific for OA (nature/location of joint pain)

Ask clients about their occupation, nature of work, Hx of trauma, weight history & exercise

Physical Assessment:Middle-aged/older women who complains of chronic joint pain or stiffness

Pain during palpation/ROM

CrepitusEnlarged jointsHeberden’s nodes – (distal interphalangeal joint)

Bouchard’s nodes – (proximal interphalangeal joint)

Atrophy of skeletal musclesHip/knee pain cause the client to limp

Laboratory assessment:Elevated erythrocyte sedimentation rate (ESR)

High-sensitivity C-Reactive Protein

Radiographic assessment:Structural joint changesCT scan MRI

Nursing Diagnoses:Chronic pain r/t muscle spasm, cartilage degeneration & joint inflammation

Impaired physical mobility r/t pain & muscle atrophy

Major concern is pain controlNon-surgical management:AnalgesicsRestPositioningThermal modalities

Acetaminophen (Tylenol) – drug of choice

NSAID’sDirect injection with cortisone

RestLocal rest – immobilizing a joint with a splint or brace

Systemic rest – immobilizing the whole body – nap

Psychological rest – relief from daily stress

Positioning – joint in functional position; small pillow under the neck or head

Elevate the legs (8-12 inches)Thermal modalities:Heat application (hot showers, baths, hot packs, compresses & moist heating pads)

Weight controlTranscutaneous Electrical Nerve Stimulation (TENS)

Stem cell therapy

Surgical Management:Total joint arthroplasty – surgical creation of a joint

Arthroscopy- less invasive procedure to remove damage cartilage

Total hip arthroplasty – performed among clients greater than 60 y/o

Common complication - subluxation

Position client in supine position with the head slightly elevated with abduction pillow in between the legs to prevent adduction

Life threatening complication – Deep Venous thrombosis (DVT) & pulmonary embolism

Use thigh high stockings & sequential compression devices

Anticoagulant:Low molecular weight heparin

Aspirin

Client getting out of bed – stand on the side of affected leg; client assumes sitting position, client stands on the unaffected leg & pivot to the chair with assistance

Client must not flex the hips more than 90 degrees

Partial weight bearing allowed for the 1st few weeks/x-ray evidence of bony growth

Characteristic Rheumatoid Arthritis (RA)

Osteoarthritis (OA)

Age of onset 35-45 y/o > 60 y/o

Gender Affected

Female (3:1) Female (2:1)

Risk factors/cause

Autoimmune (Genetic)

Aging, genetic factor, obesity, trauma, occupation

Disease process

Inflammatory Degenerative

Disease pattern

Bilateral, symmetric, multiple joints, usually affects upper extremities firstDistal interphalangeal joints of hands sparedSystemic

Unilateral, single joint, affects weight bearing joints & hands,spineMetacarpophalangeal joint sparedNon-systemic

Lab findings Elevated rheumatoid factor, antinuclear antibody, ESR

Normal or slightly elevated ESR

Dug therapy NSAID’s, Corticosteroids, Methotrexate, Leflunomide (Arava

NSAID’s, Acetaminophen

Osteomyelitis – inflammation/Infection of bone tissue

Exogenous osteomyelitis – infectious organisms enter from outside of the body (from open fracture)

Endogenous osteomyelitis (hematogenous osteomyelitis)– organisms are carried by the blood stream from other areas of infection

Contiguous bone infection results from skin infection of adjacent tissues

2 Major types of Osteomyelitis:Acute hematogenous infection – results from bacteremia, underlying disease or non- penetrating trauma

Subchronic/chronic osteomyelitis – due to inadequate treatment.

About 50% of cases due to gram negative bacteria

IncidenceHematogenous osteomyelitis is the most common type

More common among children; increasingly common in adults

Men experience osteomyelitis more frequently than women

Bone tissue in vertebrae & long bones are common sites of infection

AssessmentBone pain – common complaint of client’s with bone infection

Constant, localized, pulsating sensation that intensifies with movement

Fever (> 38° C)Area of infected bone swells; tender to palpation

ErythemaDraining ulcers

Elevated WBC countElevated ESR valueBone scan using technetium or gallium is helpful in the diagnosis

Definitive diagnosis – bone biopsy

Nursing Diagnoses:Acute/Chronic Pain r/t inflammation

Hyperthermia r/t pathogenic invasion of the bone

Ineffective tissue perfusion (peripheral) r/t tissue swelling

Interventions:IV antibiotics Hyperbaric Oxygen Therapy – affected area is exposed to a

high concentration of O2 that diffuses in the tissues to promote healing

Sequestrectomy – to debride the infected bone; allow revascularization of tissues

Common Health Problems Across the Life Span:FracturesTraction

Fracture – break or disruption in the continuity of bone

Caused by direct blow, crushing force, sudden twisting motion or extreme muscle contraction

Classification of fractures:According to the extent of the break:

Complete fracture – break is across the entire width; bone is divided into 2 distinct sections

Incomplete fracture – partial break in the bone; break is confined through only part of the bone

According to the extent of associated soft tissue damage:

Open (Compound) – skin over broken bone is disrupted; soft tissue injury & infection are common

These are graded to define the extent of tissue damage:

Grade 1 – least severe injury; skin damage is minimal

Grade 2 – accompanied by skin & muscle contusions

Grade 3 – damage to the skin, muscle, nerve tissue & blood vessels

Wound is more than 6-8 cms.

Closed (simple) fracture – skin over the fractured area remains intact

Pathologic ( spontaneous) – occurs after minimal trauma to a bone that has been weakened by a disease

Greenstick fracture – one side of bone is broken, the other is bent, most commonly seen in children

Classification According to pattern:

Transverse fracture – bone is broken straight across

Oblique fracture – the break extends in an oblique direction; slanting direction

Spiral fracture – the break partially encircles the bone

Classification as to appearance:

Comminuted – bone is splintered or crushed with 3 or more fragments

Impacted – when fractured end of bones are pushed into each other

Compression fracture – produced by a loading force applied to the long axis of cancellous bone

Depressed – usually occurs in the skull; broken bone driven inward

Longitudinal – break runs parallel with bone

Fracture dislocation – fracture is accompanied by a bone out of joint

Fatigue or stress fracture results from excessive strain or stress on the bone

Fractures

Classification in relation to the joint:

Intracapsular within the jointExtracapsular – outside the capsule

Intra-articular – within the joint

Classification as to Location:

ProximalDistalMid-shaft

Clinical Manifestations:Pain or tenderness over the involved area

SwellingLoss of function

Obvious deformityCrepitus – grating sensation either heard or felt

Erythema, EdemaMuscle spasm/impaired sensation

Bleeding from an open wound with protrusion of fractured bone

Principles of fracture treatment:

Reduction of bone fragments to normal position & immobilization

Maintenance of reduction until healing is sufficient to prevent displacement

Preservation & restoration of musculoskeletal function

Stages of bone healing: 1. Hematoma formation – blood accumulates into the area between & around the fragments. The clot begins 24 hrs after the fracture occurs

2. Cellular proliferation – (within 5 days) hematoma undergoes organization. Fibrin strand form with the clot creating a network for revascularization & invasion of fibroblast & osteoblast.

Beginning of external cartilaginous callus formation.(osteoid tissue)

3. Callus formation – (2-3 weeks) minerals are being deposited in the osteoids forming a large

mass of differentiated tissue bridging the fractured bone.

4. Ossification – mineral deposition continues & produces a firmly reunited bone. Final ossification takes

3-4 months.

5. Consolidation & remodeling – final stage of fracture repair consists of removal of any remaining devitalized tissue & reorganization of new bone

Interventions for Fracture:ReductionFixationTractionCasts

Reduction – restoring the bone to proper alignment

Closed Reduction – performed by manual manipulation

Maybe performed under local/general anesthesia

Open Reduction – involves surgical intervention

Treated with internal fixation devices

Client may be placed in traction or cast following the procedure

Fixation Internal fixation – follows open reduction

Involves the application of screws, plates, pins, nails to hold the bone fragments in alignment

May involved the removal of damaged bone & replacement with a prosthesis

Provides immediate bone strength

Risk of infection is associated with this procedure

External fixation – an external frame is utilized with multiple pins applied through the bone

Provides more freedom of movement than with traction

Roger Anderson External Fixator (RAEF)

For fracture of the tibia, radius, ulna done under anesthesia

Ilizarov fixator – for severe comminuted fracture, bone lengthening

Plaster cast – a temporary immobilization device which is made up of gypsum sulfate

Undergoes unhydrous calcinations when mixed with water, swells & forms into a hard cement

Made of rolls of plaster bandage, wet in cool water & applied to the body

Cools after 15 minutesRequires 24-72 hrs to dry completely

Non-plaster cast –(fiberglass cast)

Lighter in weight, stronger, water resistant & durable

Impregnated with cool water-activated hardeners & reach full rigidity in minutes

Diminish skin problems

Functions:To immobilizeTo prevent or correct deformity

To support, maintain & protect realigned bone

To promote healing & early weight bearing

Materials for casting:StockinetteWadding sheetPlaster of Paris

Complications of cast:1.Neurovascular compromise

Watch out for 6 P’s:PainPulselessnessPallor

ParesthesiaParalysisPoikilothermia

2. Incorrect alignment3. Cast syndrome – (Superior

mesenteric artery syndrome) occurs with body casts; any cast that involves the abdomen

Decreases the blood supply to the bowel

Signs/Symptoms:Abdominal pain, nausea & vomiting

4. Compartment syndrome –increased pressure within a limited space, compromises the function & circulation in the area

Long arm posterior moldFracture of radius/ulna with open wound, swelling or infection

Mechanical Aids for Walking:Canes:Standard straight-legged caneTripod or crab caneQuad cane – provides the best support

Standard cane – 36 inches in length

The length should permit the elbow to be slightly flexed

Health Teachings:Hold the cane with the hand on the stronger side of the body

Position the standard cane 6 inches to the side & 6 inches in front of the near foot.

When Maximum Support is Required:

Move the cane forward 1 foot while the body weight is borne by both legs

Move the weak leg forward to the cane while weight is borne by the cane & stronger leg

Move the stronger leg forward ahead of the cane & weak leg while the weight is borne by the cane & weak leg.

Walkers – for ambulatory clients needing more support than a cane provides.

Client needs to bear at least partial weight on both legs

Hand bar below the client’s waist & client’s elbow slightly flexed

Crutches Axillary crutch with hand bars

Loftstrand bar – extends only to the forearm; substitute to cane

Canadian or Elbow Extensor Crutch – made of single tube of aluminum with lateral attachments, a hand bar, cuff for the forearm & has a cuff for the upper arm

Nursing Alert:The weight of the body must be borne by the arms rather than the axillae (can injure the radial nerve, eventually can cause crutch palsy)

Crutch Palsy – weakness of the muscles of the forearm, wrist & hand

Measuring Clients for Crutches:

To obtain the correct length for the crutches & the correct placement of the handpieces

2 ways to measure the crutch length:

Client in supine position, the nurse measures from the anterior axillary fold to the heel of the foot & add 1 inch.

The client stands erect. The shoulder rest of the crutch is at least 3 finger widths, that is 1-2 inches below the axilla.

The angle of the elbow flexion must be 30 degrees.

Tip of the crutch is 6 inches from the side & 4 inches from the front of the foot.

Crutch stance (Tripod Position) –proper standing position with crutches.

Crutches are placed 6 inches in front of the feet & 6 inches laterally.

Crutch gait – gait a person assumes on crutches by alternating body weight on one or both legs & the crutches.

5 Standard Crutch Gaits:Four Point GaitThree Point Gait2 Point GaitSwing toSwing through

Four Point- Alternate Gait – most elementary, safest gait; client needs to bear weight on both legs

The nurse ask the client to:Move the right crutch ahead 4-6 inches.

Move the left front foot forward, to the level of the left crutch

Move the left crutch forward

Move the right foot forward

3 Point GaitClient bears entire body weight on the unaffected leg

Both crutches & affected leg advances

Unaffected leg advances

Two-Point Alternate Gait Partial weight bearing on each foot

Faster than 4 point gait

Move the left crutch & the right foot together

Move the right crutch & the left foot ahead together

Swing – To Gait – paralysis of the legs & hips

Move both crutches ahead together

Lift body weight by the arms & swing to the crutches

Swing –Through Gait Move both crutches forward together

Lift body weight by the arms & swing through beyond the crutches

Going up the StairsNurse stands behind the client

Placing weight on crutches while moving the unaffected leg onto the step

Going down the StairsThe nurse stands 1 step below

Moving the crutches & affected leg to the next step

Traction – is the act of pulling and drawing which is usually associated with counter traction

Provides proper bone alignment & reduces muscle spasm

For support, reduce bone fracture

Nursing responsibility:Maintain proper body alignment

Ensure that the weights are hanging freely

Ensure that pulleys are not obstructed; pulleys move freely

Place knots in the ropes to prevent slipping

Types of traction:Manual traction – done with the use of the hands of the operator

Skeletal traction – pin is driven across the bone to provide an excellent hold while a weight is attached

Use of pins, tongs & wires

Crutchfield tongsFor fracture of cervical spineC1-C5 cervical spine tensionUse for 4 weeks

Vinke’s skull caliperC1-C5 cervical spine tension

Use for 4 weeks

Nursing responsibility:Monitor color, motion & sensation of affected extremity

Monitor the insertion site for redness, swelling or infection

Provide insertion site care as prescribed

Skin traction – applied by the use of elastic bandages or adhesive straps to the skin while a pull is applied by a weight

2 Types:Non-adhesive type – uses laces, buckles, leather & canvas

Ex. Head halter strap

Adhesive type – uses adhesive tape or elastic bandages

Ex. Dunlop skin traction

Cervical skin traction – relieved muscle spasm & compression in the upper extremities & neck

Uses a head halter & chin pad

For cervical spine affectation

For Pott’s disease

Principles of traction:1.Patient must be in dorsal recumbent position

2.Line of pull should be in line with the deformity. Consider the position of diagonal bar & positioning of pulley.

1st pulley in line with the thigh, 2nd pulley in line with the knee or screw, 3rd pulley in line with the 2nd & 3rd pulleys

Weight bag must be at the level of the bed frame

3.Traction must be continuous. Emphasized the importance of manual traction.

4. Avoid friction – rope should be running along the groove of the pulley, knots away from the pulley. Weights should be hanging freely. Observe for wear & tear of ropes.

5. Provide counter traction. For every traction there must be a counter traction (Patient’s body weight)

Nursing Care of Patients with Traction:

1. AssessmentAssess patient as to level of understanding/consciousness

2. Provision of general comfort

Skin care – head to toe; focus on the sponging of affected extremity

3. Potential Complications:Upper respiratory – Pneumonia – back tapping & deep breathing

Bed sore – good perineal care; proper skin care, turning, lift buttocks once in a while

Urinary & kidney problem – good perineal care, increase fluid intake

Bowel complication – fear of apparatus, no privacy, lack of fluids/perineal care

Pin site infection – observe for signs & symptoms of infection; loosening pin tract, pus coming out from insertion site, foul smelling odor, fever

Deformity – contracted knees, atrophy of muscles, foot drop, joint contractures

4. Provision of Exercises:ROM exercises with the use of trapeze

Deep breathing exercisesStatic quadriceps exercise – alternate contraction & relaxation of quadriceps muscles

Toe pedal exercises

5. Nutritional status6. Psychological aspectFear of the unknown, fear of death, fear of apparatus, fear of losing a job, financial fear

7. Provision of supportive therapy

Offer books to read, listen to radio or TV, discover interest

8. Spiritual aspect

Know patient’s religion, encourage relatives to give spiritual communication, visiting chaplain

Divertional activities – divert attention for any pain

Knee Injuries Medial/lateral meniscus – act as shock absorbers; can tear.

Tearing – result of twisting the leg when the knee is flexed & foot is placed firmly on the ground.

Medial meniscus tear – due to internal rotation

Lateral meniscus tear – due to external rotation

“Bucket handle injury” – causes the knee to lock; torn cartilage jams between the femur & tibia thus preventing the extension of knees.

Diagnostic tests:McMurray test – examiner flexes & rotates the knee & then presses on the medial aspect while slowly extending the leg.

Positive test – if clicking is palpated or heard

Clinical manifestations:PainSwelling

Tenderness in the kneeClicking/snapping sound

Management:Locked knee – manipulation; casting for 3-6 weeks

Meniscectomy – Partial/total

Open meniscectomy – requires a surgical incision

for the removal of all or the part of the meniscus

Closed meniscectomy – accomplished through an arthroscope

Client begins leg exercises immediately after the procedure to strengthen the leg, prevent thrombophlebitis & reduce swelling.

Elevate the affected leg to 1 or 2 pillows

Apply ice to reduce swellingFull weight bearing restricted for several weeks

Dislocations/Subluxations Occurs when articulating surfaces are no longer in proximity

Common in shoulder, hip, knee & fingers

Etiology:TraumaCongenital/pathologic - arthritis

Clinical manifestations:PainImmobilityAlteration in contour of jointDeviation in length of extremityRotation of extremity

Management:Closed manipulation/reduction

Cast – immobilized the joint until healing

Traction/splint

Strain (muscle pull) – excessive stretching of a muscle or tendon when weak or unstable

Etiology:FallsLifting of heavy itemsExercise

Classification according to severity:

1.1st degree (mild) strain – mild inflammation, little bleeding, swelling, ecchymosis & tenderness

2. 2nd degree (moderate) strain – tearing of muscle or tendon fibers without complete disruption; muscle function might be impaired

3. 3rd degree (severe) strain – ruptured muscle or tendon, involving separation of muscle to muscle, muscle to tendon or tendon from bone

ManagementCold & heat applicationsExerciseActivity limitationsNSAIDs

Muscle relaxantSurgical repair

Sprains – excessive stretching of a ligament

Etiology : twisting motion from falls; sports activity

Classification according to severity:

1.1st degree (mild) sprain – involves tearing of a few fibers of a ligament; joint function not affected

2. 2nd degree (moderate) sprain – more fibers are torn; stability of joint remains intact

3. 3rd degree (severe) sprain – marked instability of joint

Clinical manifestations: Pain Swelling

Management:1st degree sprain:RestIce (24-48 hrs.)

Application of compression bandage (reduce swelling; provide support)

Elevation

2. 2nd degree sprain – immobilization (elastic bandage, splint or cast), partial weight bearing until ligament heals

3. 3rd degree (severe) sprain – immobilization (4-6 weeks); surgery

Amputation – removal of the part of the body

Note: The nurse recognizes that the psychosocial effect of the procedure is more devastating than the physical impairment

Loss experienced is complete & permanent causing a change in body image & self esteem

Amputation – ranges from removal of part of a digit to removal of nearly half of the entire body.

1. Open (guillotine) method – for clients with infection, for those who most likely to develop infection

Wound remains open, drains allow exudates to escape until infection clears

Surgeon suture the skin flaps over the wound at a later time

2. Closed (flap) method – surgeon pulls the skin flaps over the bone end & sutures them in place. 1 or more drains are inserted.

Traumatic amputation – occurs when body a part is severed unexpectedly; attempt of replantation is possible

Levels of amputation:Lower extremity amputation performed frequently

Syme amputation – most of the foot removed; ankle preserved

for peripheral vascular disease

Advantage – weight bearing can be achieved without the use of prosthesis & without pain

Below knee amputation (BKA) – preserve the knee joints

Above knee amputations – cause of amputation extends beyond the knee

The higher the level of amputation more energy is required for ambulation

Complications of amputations:

HemorrhageInfection

Phantom limb painNeuroma – sensitive tumor found in severed nerve endings

Flexion contractures

Phantom limb pain – frequent complication of amputation

More often after AKAFelt during the early post op period

Common among clients who experienced chronic limb pain before the surgery

Client complains of pain (intense crushing/burning) in the removed body part most often shortly after surgery

Incidence/Prevalence:More than 100,000 amputations yearly in US

Half of these among clients with DM

Middle aged or older man with DM & a lengthy history of smoking

2nd largest group affected young men involved in vehicular accidents (Motorcycle)

Injury at work (industrial equipment)

Diagnostic assessment:Measurement of segmental limb BP – Ankle-brachial index – Ankle systolic pressure/Brachial systolic pressure

Normal ABI=1 or greater

Doppler ultrasonographyLaser Doppler flowmetryTranscutaneous Oxygen Pressure

Angiography

Ultrasonography – measures the velocity of blood flow in the limbs

TcPO2 – measures the oxygen pressure to indicate blood flow in the limb

Nurse’s Primary Focus:Monitor for signs that there is sufficient tissue perfusion but no hemorrhage

Pain Management:Phantom limb pain – recognize that pain is real; It is not therapeutic that the limb can’t hurt because it is missing.

Drug therapy:IV Infusion of Calcitonin (Calcimar) – during the week of amputation

Alternative treatment:Transcutaneous Electrical Nerve Stimulation (TENS)

MassageDistraction therapyPrevention of Infection:Initial pressure dressings/drains usually removed in 48-72 hrs after surgery.

Promotion of ambulation:Start muscle-strengthening exercises before the surgery

Arrange for a client to see a certified prosthetist-orthotist (CPO)

Older clients with PVD – fitted after the residual limb has healed

Wrapping with elastic bandages – to reduce the edema, shrink the limb & hold the wound dressing in place

Reapply the bandages every 4-6 hrs when loose

Figure 8 wrapping prevents restriction of blood flow

Common Health Problems of the Young Adult

Multiple SclerosisMyasthenia Gravis

Chronic, progressive neurologic disease of the CNS

Unknown etiology

Progressive demyelinization of the white matter of the CNS

Occurs between ages 20-40Affects women twice as often as men

Whites are affected compared to Hispanics, Blacks or Asians

Etiology: UnknownImmunogenetic viral disease

Inmmune mediated demyelination triggered by viral infection

15-20 times more common in primary relatives of affected patients

InfectionPhysical injuryEmotional stressPregnancyFatigue

Formation of plaque along myelin sheath

Inflammatory reaction; Edema

Scarring/destruction of myelin sheath

Primary demyelination

Death of oligodndrocyte

Incomplete remyelination of nerves

Optic nervesCerebrumCervical SC

WeaknessParesthesia of 1 or more extremities

Vision loss (optic neuritis)Incoordination

Bowel/bladder dysfunction (SC involvement)

Fatigue common symptom that worsens as the day progresses

History/ Clinical findings2 episodes of neurologic dysfunction in different locations in the CNS

Spinal fluid evaluationMRI- brain, SC – presence of MS plaques

Relieve symptomsHelp the patient to function

Corticosteroids

Chronic autoimmune disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body.

Antibody mediated attack against the acetylcholine receptors in the neuromuscular junction

Cardinal features:Muscle weakness/ fatigue

Worsens with exercise; improves with rest

Etiology: unknownOnset: early onset 20-30 yrs old

Predilection to womenLate onset: after age 50 men are more susceptible

Increasing weakness with sustained muscle contraction – primary feature

Depletion of Acetylcholine receptors (NMJ)

Elevated antibody titers

Muscle weakness

Clinical presentation – testing the response of anticholinergic drugs

Endrophonium – Tensilon test

Neostigmine methylsulfate (Prostigmin) longer duration of effect (1-2 hrs)

EMG – confirm the diagnosis

Muscle weaknessPtosisDiplopiaExpressionless face

Drooping eyelidsOpen mouthSevere cases respiratory muscle arrest

No treatment availableShort acting anticholinesterase compounds – achieved maximum muscle strength & endurance

Corticosteroids – prednisone – decrease levels of serum Ach receptor antibodies

Complications:Myasthenic crisis experience worsening condition

Increase dose on anticholinergic drugs

Cholinergic crisis – overmedication

Abdominal cramps, diarrhea, excessive pulmonary secretions

PlasmaphereisThymectomy – alter immunologic control mechanism that affect production of antibody to ACH receptor

Common Health Problems of the Older Adult:

Parkinson’s DiseaseAlzheimer’s disease

Parkinson’s disease- is a progressive neurological disorders that results from degeneration of neurons in a region of the brain that controls movement

Parkinson Disease (Paralysis agitans)

3rd most common neurologic disorder of older adult

Debilitating disease affecting motor ability

4 Cardinal Symptoms:TremorRigidityAkinesia (slow movement)Postural instability

Pathophysiology:Degeneration of Substantia Nigra

Decrease dopamine production

Decrease ability to refine voluntary movement

Organ/ System affected- Brain

( substantia nigra & basal ganglia)

- Neuromuscular system

Neuromuscular system- combination of the

nervous system & muscles.

- work together to permit movement.

Basal gangliaintegrates feeling and movement

shifts and smoothens fine motor behavior

suppression of unwanted motor behaviors

sets the body's idle or anxiety level

enhances motivation

CaudatePutamen

Globus pallidusSubstantia nigra

Substantia nigra- controls voluntary movement, regulates mood, and produces the neurotransmitter dopamine

Causative:ToxinsHead traumaCerebral anoxiaDrug-induced

Predisposing factor:- Age- Heredity- Sex- Exposure to toxins

Tremor] Rapid shaking of the hands, arms or legs

Arms and legs become stiff and hard to move

Difficulty starting or completing movements

Lack of balance or difficulty adjusting to sudden changes in position

is a nuclear medicine imaging technique which produces a three-dimensional image or map of functional processes in the body.

is a noninvasive transthoracic graphic produced by an electrocardiograph, which records the electrical activity of the heart over time.

High risk for injury related to postural, instability & muscular rigidity

Impaired verbal communication related slowness of movement

Altered nutrition: less than body req. related to poor or pharyngeal muscle control & coordination

Knowledge deficit related to the complexity of & fluctuations in the treatment regimen.

LevodopaDopamine agonistsAmantadineCOMT inhibitorAnticholinergicBromocriptine

Levodopa- a dopamine precursor, increases the dopamine supply in neurons making more availabale to stimulate dopaminergic receptors.

Dopamine agonists- directly stimulate nerves in the brain that are not naturally being stimulated by dopamine.

Amantadine- blocks acetylcholine receptors and promotes release of dopamine

Anticholinergic- block acetylcholine

receptors that help control the muscles of the arms, legs, and body.

Ablative surgerythis procedure locates, targets and then ablates or destroys a targeted area of the brain affected by Parkinson's.

Deep brain stimulation- treats the tremors and slowness associated with Parkinson's disease. This therapy has been shown to provide greater relief of symptoms with fewer side effects than other treatments.

Pallidotomy In this procedure, a surgeon selectively destroys a portion of the brain called the globus pallidus. 

can improve gait and balance.

Thalamotomy a related procedure that involves surgically destroying part of the brain's thalamus.

is useful primarily to reduce tremor. 

Transplantationcalled restorative surgery

dopamine-producing cells are implanted into a certain part of the brain.

Most common form of dementia

Progressive impairment in memory, cognitive function, language, judgment & ADL

Incidence:10-15% people older than age 65

19% older than 7547% older than 85

Etiology- unknownRisk factors:GeneticsIncreasing age

Female genderViruses, toxins & previous head injury

Changes in CHON of the nerve cells of

cerebral cortex

Accumulation of neurofibrillary tangles & neuritic plaques

Degenerating nerve terminals

Changes in CHON of the nerve cells of cerebral cortex

Neurotransmitter changes

Decrease in cholinergic neurons in basal nucleus

Loss of choline acetyltransferase

Cognitive decline(Learning, reasoning, memory , recall,

language recall)

Onset is subtle/insidiousGradual decline of cognitive functioning

Short term memory impairment

Impairment in decision making

Decrease cognition

ApraxiaHyperorality – desire to take everything in the mouth

Loss of self care abilities

•Patient history•EEG•CT Scan (Non contrast)•MRI•Neuropsychological evaluation

Maximize functional abilities

Improve quality of lifeCholinesterase inhibitors Tacrine(Cognex)

Donepezil (Aricept)Reminiscence therapyArt/recreational therapy

Common Health Problems Across the Life Span

Guillain-Barre Syndrome

PolyradiculoneuritisInflammatory disease of unknown cause/involves degeneration of myelin sheath of peripheral nerves

Affects people of all ages & races

Most common cause of acute general paralysis

.75 – 2 cases/ 100000 population

Predisposing factors:Respiratory/GI infectionsViral infectionsImmune reactionsvaccination

Viral infection

Autoimmune reactions

Damage to myelin sheath (Peripheral Nerves)

ParesthesiaSymmetric progressive muscle weakness

Loss of DTRAutonomic dysfunction (Increase HR/postural hypotension)

Deep aching muscle pain in shoulder girdle

Respiratory muscle weakness – cause of death

85-90 % recover completely

History/Physical ExamCSF analysisElectrophysiologic studies

PlasmapheresisSupportive care