Transcript Musculoskeletal System Assessment and Disorders lecture

Musculoskeletal System
Assessment & Disorders
Dr Ibraheem Bashayreh, RN, PhD
Skeletal System
Bone types
 Bone structure
 Bone function
 Bone growth and metabolism affected by
calcium and phosphorous, calcitonin,
vitamin D, parathyroid, growth hormone,
glucocorticoids, estrogens and androgens,
thyroxine, and insulin.

Bones
Human skeleton has 206 bones
 Provide structure and support for soft tissue
 Protect vital organs

Figure 41-1 Bones of the human skeleton.
Figure 41-2 Classification of bones by shape.
Bones

Compact bone
◦ Smooth and dense
◦ Forms shaft of long bones and outside layer of
other bones

Spongy bone
◦ Contains spaces
◦ Spongy sections contain bone marrow
Bone Marrow

Red bone marrow
◦ Found in flat bones of sternum, ribs, and ileum
◦ Produces blood cells and hemoglobin

Yellow bone marrow
◦ Found in shaft of long bones
◦ Contains fat and connective tissue
Joints (Articulations)
Area where two or more bones meet
 Holds skeleton together while allowing
body to move

Joints

Synarthrosis
◦ Immovable (e.g., skull)

Amphiarthrosis
◦ Slightly movable (e.g., vertebral joints)

Diarthrosis or synovial
◦ Freely movable (e.g., shoulders, hips)
Synovial Joints
Found at all limb articulations
 Surface covered with cartilage
 Joint cavity covered with tough fibrous
capsule
 Cavity lined with synovial membrane and
filled with synovial fluid

Ligaments
Bands of connective tissue that connect
bone to bone
 Either limit or enhance movement
 Provide joint stability
 Enhance joint strength

Tendons
Fibrous connective tissue bands that
connect bone to muscles
 Enable bones to move when muscles
contract

Muscles

Skeletal (voluntary)
◦ Allows voluntary movement

Smooth (involuntary)
◦ Muscle movement controlled by internal
mechanism
◦ e.g., muscles in bladder wall and GI system

Cardiac (involuntary)
◦ Found in heart
Skeletal Muscle
600 skeletal muscles
 Made up of thick bundles of parallel fibers
 Each muscle fiber made up of smaller
structure myofibrils
 Myofibrils are strands of repeating units
called sarcomeres

Skeletal Muscle
Skeletal muscle contracts with the release
of acetylcholine
 The more fibers that contract, the
stronger the muscle contraction

Changes in Older Adult
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Musculoskeletal changes can be due to:
◦ Aging process
◦ Decreased activity
◦ Lifestyle factors
Changes in Older Adult
Loss of bone mass in older women
 Joint and disk cartilage dehydrates causing
loss of flexibility contributes to
degenerative joint disease (osteoarthritis);
joints stiffen, lose range of motion

Changes in Older Adult
Cause stooped posture, changing center
of gravity
 Elderly at greater risk for falls
 Endocrine changes cause skeletal muscle
atrophy
 Muscle tone decreases

Assessment
Health history
 Chief complaint
 Onset of problem
 Effect on ADLs
 Precipitating events, e.g., trauma

Assessment
Examine complaints of pain for location,
duration, radiation character (sharp dull),
aggravating, or alleviating factors
 Inquire about fever, fatigue, weight
changes, rash, or swelling

Physical Examination
Posture
 Gait
 Ability to walk with or without assistive
devices
 Ability to feed, toilet, and dress self
 Muscle mass and symmetry

Physical Examination
Inspect and palpate bone, joints for visible
deformities, tenderness or pain, swelling,
warmth, and ROM
 Assess and compare corresponding joints
 Palpate joints knees and shoulder for
crepitus

Physical Examination
Never attempt to move a joint past
normal ROM or past point where patient
experiences pain
 Bulge sign and ballottement sign used to
assess for fluid in the knee joint
 Thomas test performed when hip flexion
contracture suspected

Figure 41-4 Checking for the bulge sign.
Figure 41-5 Checking for ballottement.
Diagnostic Tests
Blood tests
 Arthrocentesis
 X-rays
 Bone density scan
 CT scan
 MRI
 Ultrasound
 Bone scan
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Diagnostic Evaluation
– CT, Bone Scan, MRI

Imaging Procedures
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Nuclear Studies - radioisotope bone density,
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Endoscopic Studies
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Other Studies
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venogram,
Electromyography
Myelography*
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Laboratory Studies
–arthrocentesis, arthroscopy
–biopsy, synovial fluid, Arthrogram,
Musculoskeletal
Assessment – Diagnostic Test

Laboratory
◦ Urine Tests
 24 hour creatinecreatinine ratio
 Urine Uric acid –24 hr
specimen
 Urine deoxypyridinoline
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Laboratory
◦ Blood Tests
 Serum muscle enzymes
 Rheumatoid Factor
 LE Prep/Antinuclear
Antibodies(ANA)
 Erythrocyte
Sedimentation Rate
 Calcium, Phosphorous,
Alkaline phosphatase
Muscoluloskeletal
Assessment – Diagnostic
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Blood Tests
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CBC – Hgb, Hct
Acid phosphatase
Metabolic/Endocrine
Enzymes
Increase creatine kinase,
serum increase glutaminoxaloacetic due to
muscle damage, aldolase,
SGOT
Musculoskeletal - Radiographic
Standard radiography, tomography and
xeroradiography, myelography,
arthrography and CT
 Other diagnostic tests: bone and muscle
biopsy

Arthroscopy
Fiberoptic tube is inserted into a joint for
direct visualization.
 Client must be able to flex the knee;
exercises are prescribed for ROM.
 Evaluate the neurovascular status of the
affected limb frequently.
 Analgesics are prescribed.
 Monitor for complications.

Bone Scan
Nuclear medicine procedure in which
amount of radioactive isotope taken up by
bones is evaluated
 Abnormal bone scans show hot spots due
to malignancies or infection
 Cold spot uptakes show areas of bone
that are ischemic
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Arthroscopy
Flexible fiberoptic endoscope used to
view joint structures and tissues
 Used to identify:
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Torn tendon and ligaments
Injured meniscus
Inflammatory joint changes
Damaged cartilage
Interventions for Clients with
Musculoskeletal Trauma
Musculoskeletal Trauma
Tissue is subjected to more force than it
can absorb
 Severity depends on:
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◦ Amount of force
◦ Location of impact
Musculoskeletal Trauma
Mild to severe
 Soft tissue
 Fractures

◦ Affect function of muscle, tendons, and
ligaments
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Complete amputation
Preventing Trauma

Teach importance of using safety
equipment
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Seat belts
Bicycle helmets
Football pads
Proper footwear
Protective eyewear
Hard hats
Soft Tissue Trauma
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Contusion
◦ Bleeding into soft tissue
◦ Significant bleeding can cause a hematoma
◦ Swelling and discoloration (bruise)
Soft Tissue Trauma - Sprain
Ligament injury (Excessive stretching of
a ligament)
 Twisting motion
 Overstretching or tear

◦ Grade I—mild bleeding and inflammation
◦ Grade II—severe stretching and some tearing
and inflammation and hematoma
◦ Grade III—complete tearing of ligament
◦ Grade IV—bony attachment of ligament broken
away
Sprains
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Treatment of sprains:
◦ first-degree: rest, ice for 24 to 48 hr,
compression bandage, and elevation
◦ second-degree: immobilization, partial
weight bearing as tear heals
◦ third-degree: immobilization for 4 to 6
weeks, possible surgery
Soft Tissue Trauma - Strain
Microscopic tear in the muscle
 May cause bleeding
 “Pulled muscle”
 Inappropriate lifting or sudden
acceleration-deceleration
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Soft Tissue Trauma
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To decrease swelling and pain, and
encourage rest
◦ Ice for first 48 hours
◦ Splint to support extremities and limit
movement
◦ Compression dressing
◦ Elevation to increase venous return and
decrease swelling
◦ NSAIDs
Soft Tissue Trauma
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Diagnosis
◦ X-ray to rule out fracture
◦ MRI
Fractures
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Break in the continuity of bone
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Direct blow
Crushing force (compression)
Sudden twisting motions (torsion)
Severe muscle contraction
Disease (pathologic fracture)
Fractures
Classification of Fractures
Closed or simple
 Open or compound
 Complete or incomplete
 Stable or unstable
 Direction of the fracture line
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◦ Oblique
◦ Spiral
◦ Lengthwise plane (greenstick)
Stages of Bone Healing
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Hematoma formation within 48 to 72 hr
after injury
Hematoma to granulation tissue
Callus formation
Osteoblastic proliferation
Bone remodeling
Bone healing completed within about 6
weeks; up to 6 months in the older
person
Fractures – Emergency Care
Immobilize before moving client
 Joint above and below
 Check pulse, color, movement, sensation
before splinting
 Sterile dressing for open wounds

Fractures – Emergency Care

Fracture reduction
◦ Closed—external manipulation
◦ Open—surgery
Acute Compartment Syndrome
Serious condition in which increased
pressure within one or more
compartments causes massive
compromise of circulation to the
area
 Prevention of pressure buildup of
blood or fluid accumulation
 Pathophysiologic changes
sometimes referred to as ischemiaedema cycle

Emergency Care - Acute
Compartment Syndrome
Within 4 to 6 hr after the onset of
acute compartment syndrome,
neuromuscular damage is
irreversible; the limb can become
useless within 24 to 48 hr.
 Monitor compartment pressures.

(Continued)
Emergency Care (Continued)
Fasciotomy may be performed to
relieve pressure.
 Pack and dress the wound after
fasciotomy.

Possible Results of Acute Compartment
Syndrome
Infection
 Motor weakness
 Volkmann’s contractures: (a deformity of
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the hand, fingers, and wrist caused by a lack of blood flow
(ischemia) to the muscles of the forearm)
Other Complications of Fractures
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Shock
Fat embolism syndrome: serious
complication resulting from a fracture;
fat globules are released from yellow
bone marrow into bloodstream
Venous thromboembolism
(Continued)
Other Complications of Fractures
(Continued)
Infection
 Ischemic necrosis
 Fracture blisters, delayed union,
nonunion, and malunion

Musculoskeletal
Complications (continued)
Muscle Atrophy, loss of muscle strength range of
motion, pressure ulcers, and other problems
associated with immobility
 Embolism/Pneumonia/ARDS

◦ TREATMENT – hydration, albumin, corticosteroids
Constipation/Anorexia
 UTI
 DVT

Musculoskeletal Assessment - Fracture
Change in bone alignment
 Alteration in length of extremity
 Change in shape of bone
 Pain upon movement
 Decreased ROM
 Crepitation
 Ecchymotic skin

(Continued)
Musculoskeletal Assessment – Fracture
(Continued)
Subcutaneous emphysema with
bubbles under the skin
 Swelling at the fracture site
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Special Assessment Considerations
For fractures of the shoulder and upper
arm, assess client in sitting or standing
position.
 Support the affected arm to promote
comfort.
 For distal areas of the arm, assess client
in a supine position.
 For fracture of lower extremities and
pelvis, client is in supine position.

CAST
CAST
Casts
Rigid device that immobilizes the
affected body part while allowing other
body parts to move
 Cast materials: plaster, fiberglass,
polyester-cotton
 Types of casts for various parts of the
body: arm, leg, brace, body

(Continued)
Casts (Continued)
Cast care and client education
 Cast complications: infection, circulation
impairment, peripheral nerve damage,
complications of immobility

Managing Care of the Patient in a Cast
Casting Materials
 Relieving Pain
 Improving Mobility
 Promoting Healing
 Neurovascular Function
 Potential Complications

Cast, Splint, Braces, and Traction
Management Considerations
 Arm
Casts
 Leg Casts
 Body or Spica Casts
 Splints and Braces
 External Fixator
 Traction
POLYESTER/FIBERGLASS
UPPER EXTREMITY CAST
LOWER EXTREMITY CAST
Musculoskeletal
Nursing Care - Casts
◦ Neurovascular
 Check
color/capillary refill
 Temperature
 Pulse
 Movement
 Sensation

Traction Nursing Care
◦ Pin Site care
◦ Skin and neurovascular
check
Cast Care (continued)
Elevate Extremity
 Exercises – to unaffected side; isometric exercises to
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affected extremity
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Keep heel off mattress
Handle with palms of hands if cast wet
Turn every two hours till dry
Notify MD at once of wound drainage
Do not place items under cast.
Traction
Application of a pulling force to the
body to provide reduction,
alignment, and rest at that site
 Types of traction: skin, skeletal,
plaster, brace, circumferential

(Continued)
Traction (Continued)
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Traction care:
◦ Maintain correct balance between
traction pull and counter traction force
◦ Care of weights
◦ Skin inspection
◦ Pin care
◦ Assessment of neurovascular status
Musculoskeletal – Fractures
Treatment

Primary Goal – reduce fracture◦ Realign and immobilize
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Medications
◦ Analgesics, antibiotics, tetanus toxoid
Closed Reduction – Manual and Cast; External
Fixation Device
 Traction; Splints; Braces
 Surgery

◦ Open reduction with internal fixation
◦ Reconstructive surgery
◦ Endoprosthetic replacement
Figure 42-5 In external fixation, pins placed through the bone above and below the fracture are attached to external
fixation rods that hold the pins and bone in place.
Nursing Management
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Positioning
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Strengthening Exercises
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Potential Complications
Musculoskeletal
Nursing Care
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Promote comfort
Assess infection
Promote mobility
Teach safety
Vital Signs
Flotation, sheep skin
Nutrition
Vital Signs
Monitor elimination
Elevate extremity to
decrease swelling/ ice
pack
 Teach skin care, cast
care, diet,
complications

Operative Procedures
Open reduction with internal
fixation
 External fixation
 Postoperative care: similar to that
for any surgery; certain
complications specific to fractures
and musculoskeletal surgery include
fat embolism and venous
thromboembolism

Managing the Patient Undergoing
Orthopedic Surgery
 Joint
Replacement
 Total Hip Replacement
 Total Knee Replacement
Risk for Infection

Interventions include:
◦ Apply strict aseptic technique for
dressing changes and wound irrigations.
◦ Assess for local inflammation
◦ Report purulent drainage immediately
to health care provider.
(Continued)
Risk for Infection (Continued)
◦ Assess for pneumonia and urinary tract
infection.
◦ Administer broad-spectrum antibiotics
prophylactically.
Imbalanced Nutrition: Less Than Body
Requirements

Interventions include:
◦ Diet high in protein, calories, and
calcium, supplemental vitamins B and C
◦ Frequent small feedings and
supplements of high-protein liquids
◦ Intake of foods high in iron
Upper Extremity Fractures
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Fractures include those of the:
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Clavicle
Scapula
Humerus
Olecranon
Radius and ulna
Wrist and hand
Lower Extremity Fractures
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Fractures include those of the:
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Femur
Patella
Tibia and fibula
Ankle and foot
Fractures of the Hip
Intracapsular or extracapsular
 Treatment of choice: surgical repair,
when possible, to allow the older
client to get out of bed
 Open reduction with internal
fixation
 Intramedullary rod, pins, a
prosthesis, or a fixed sliding plate
 Prosthetic device

Fractures of the Pelvis
Associated internal damage the
chief concern in fracture
management of pelvic fractures
 Non–weight-bearing fracture of the
pelvis
 Weight-bearing fracture of the
pelvis

Compression Fractures of the Spine
Most are associated with
osteoporosis rather than acute
spinal injury.
 Multiple hairline fractures result
when bone mass diminishes.

(Continued)
Compression Fractures of the Spine
(Continued)
Nonsurgical management includes
bedrest, analgesics, and physical
therapy.
 Minimally invasive surgeries are
vertebroplasty and kyphoplasty, in
which bone cement is injected.

(Continued)
Amputations
Surgical amputation
 Traumatic amputation
 Levels of amputation
 Complications of amputations:
hemorrhage, infection, phantom
limb pain, problems associated with
immobility, neuroma (a growth or tumour of
nerve tissue), flexion contracture

Amputation
Nursing Management
◦ relieving pain
◦ minimizing altered sensory perception
◦ promoting wound healing
◦ enhancing body image
◦ self-care
Phantom Limb Pain
Phantom limb pain is a frequent
complication of amputation.
 Client complains of pain at the site
of the removed body part, most
often shortly after surgery.
 Pain is intense burning feeling,
crushing sensation or cramping.
 Some clients feel that the removed
body part is in a distorted position.

Management of Phantom Pain
Phantom limb pain must be
distinguished from stump pain
because they are managed
differently.
 Recognize that this pain is real and
interferes with the amputee’s
activities of daily living.

(Continued)
Management of Phantom Pain
(Continued)
Some studies have shown that
opioids are not as effective for
phantom limb pain as they are for
residual limb pain.
 Other drugs include intravenous
infusion calcitonin, beta blockers,
anticonvulsants, and antispasmodics.

Exercise After Amputation
ROM to prevent flexion
contractures, particularly of the hip
and knee
 Trapeze and overhead frame
 Firm mattress
 Prone position every 3 to 4 hours
 Elevation of lower-leg residual limb
controversial

Prostheses
Devices to help shape and shrink the
residual limb and help client readapt
 Wrapping of elastic bandages
 Individual fitting of the prosthesis;
special care

Crush Syndrome
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Can occur when leg or arm injury
includes multiple compartments
Characterized by acute compartment
syndrome, hypovolemia, hyperkalemia,
rhabdomyolysis, and acute tubular
necrosis
Treatment: adequate intravenous fluids,
low-dose dopamine, sodium
bicarbonate, kayexalate, and
hemodialysis
Metabolic Bone Disorders
 Osteoporosis
 Osteomalcia
 Paget’s
Disease
Osteoporosis
A disease in which loss of bone exceeds rate of
bone formation; usually increase in older
women, white race, nulliparity.
 Clinical Manifestations – bone pain, decrease
movement.
 Treatment – Calcium, Vit. D, estrogen
replacement, Calcitonin, fluoride, estrogen with
progestin, SERM (Selective Estrogen Receptor
Modulator) with anti-estrogens, exercise.
 Pathologic fracture-safety.

Classification of Osteoporosis
Generalized osteoporosis occurs most
commonly in postmenopausal women
and men in their 60s and 70s.
 Secondary osteoporosis results from an
associated medical condition such as
hyperparathyroidism, long-term drug
therapy, long-term immobility.
 Regional osteoporosis occurs when a
limb is immobilized.
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Health Promotion/Illness Prevention Osteoporosis
Ensure adequate calcium intake.
 Avoid sedentary life style (a type of
lifestyle with a lack of physical
exercise) .
 Continue program of weight-bearing
exercises.
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Osteoporosis - Assessment
Physical assessment
 Psychosocial assessment
 Laboratory assessment
 Radiographic assessment
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Drug Therapy
Osteoporosis
Hormone replacement therapy
 Parathyroid hormone
 Calcium and vitamin D
 Bisphosphonates
 Selective estrogen receptor
modulators
 Calcitonin
 Other agents used with varying
results

Diet Therapy - Osteoporosis
Protein
 Magnesium
 Vitamin K
 Trace minerals
 Calcium and vitamin D
 Avoid alcohol and caffeine

Fall Prevention - Osteoporosis
Hazard-free environment
 High-risk assessment through
programs such as Falling Star
protocol
 Hip protectors that prevent hip
fracture in case of a fall

Others - Osteoporosis
Exercise
 Pain management
 Orthotic devices

Osteomalacia
Softening of the bone tissue
characterized by inadequate
mineralization of osteoid
 Vitamin D deficiency, lack of sunlight
exposure
 Similar, but not the same as
osteoporosis
 Major treatment: vitamin D from
exposure to sun and certain foods

Paget’s Disease of the Bone

Metabolic disorder of bone remodeling, or
turnover; increased resorption (the process by
which osteoclasts break down bone and release the
minerals, resulting in a transfer of calcium from bone fluid
to the blood)
of loss results in bone deposits
that are weak, enlarged, and disorganized
 Nonsurgical management: calcitonin,
selected bisphosphonates, mithramycin
 Surgical management: tibial osteotomy or
partial or total joint replacement
Paget’s Disease
An imbalance of increase osteoblast and
osteoclast cells; thickening and
hypertrophy.
 Bone pain most common symptom; bony
enlargement and deformities usually
bilateral, kyphosis, long bone.
 Analgesics, meds bisphosphonates and
calcitonin, NSAID, assistance devices, and
hot/cold treatment.

Osteomyelitis
A condition caused by the invasion by
one or more pathogenic
microorganisms that stimulates the
inflammatory response in bone tissue
 Exogenous, endogenous,
hematogenous, contiguous
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Osteomyelitis
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Infection of bone; causative agent – Staph/Strept
Typical signs and symptoms : Acute osteomyelitis include:
Fever that may be abrupt
Irritability or lethargy in young children
Pain in the area of the infection
Swelling, warmth and redness over the area of the
infection
Chronic osteomyelitis include:
Warmth, swelling and redness over the area of the
infection
Pain or tenderness in the affected area
Chronic fatigue
Drainage from an open wound near the area of the
infection
Fever, sometimes
Treatment – IV antibiotic; long term for 4-6 months
Surgical Management
Osteomyelitis

Sequestrectomy (Surgical removal of a
sequestrum), a detached piece of necrotic bone that
often migrates to a wound, abscess, etc.
Bone grafts
 Bone segment transfers
 Muscle flaps
 Amputation

Bone Tumors
 Benign
Bone Tumors
 Malignant Bone Tumors
 Metastatic Bone Disease
Bone Tumors
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Benign bone tumors
(noncancerous):
◦ Chrondrogenic tumors:
osteochondroma, chondroma
◦ Osteogenic tumors: osteoid osteoma,
osteoblastoma, giant cell tumor
◦ Fibrogenic tumors
Interventions
Nondrug pain relief measures
 Drug therapy: analgesics, NSAIDs
 Surgical therapy: curettage (simple
excision of the tumor tissue), joint
replacement, or arthrodesis
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Malignant Bone Tumors
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Primary tumors, those tumors that
originate in the bone
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Osteosarcoma
Ewing’s sarcoma
Chondrosarcoma
Fibrosarcoma
Metastatic bone disease
Osteosarcoma
Cancer of the bone – metastasis to the
lung is common. Most in long bones.
 Clinical manifestations – dull pain,
swelling, intermittent but increases per
time; night pain common.
 Treatment – radiation, chemotherapy,
hormonal therapy, surgical excision with
prosthetics, assistance devices, palliative
measures.
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Treatment Cancer of Bone
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Interventions include:
◦ Treatment aimed at reducing the size or
removing the tumor
◦ Drug therapy; chemotherapy
◦ Radiation therapy
◦ Surgical management
◦ Promotion of physical mobility with ROM
exercises
Cancer of Bone
Anticipatory Grieving

Interventions include:
◦ Active listening
◦ Encouraging client and family to
verbalize feelings
◦ Making appropriate referrals
◦ Helping client and others to cope with
the loss and grieving
◦ Promoting the physician-client
relationship
Cancer of Bone
Disturbed Body Image

Interventions include:
◦ Recognize and accept the client’s view
of body image alteration.
◦ Establish and maintain a trusting nurseclient relationship.
◦ Emphasize the client’s strengths and
remaining capabilities.
◦ Establish realistic mutual goals.
Potential for Fractures
Bone Cancer

Interventions
◦ Nonsurgical management: radiation therapy
and strengthening exercises.
◦ Surgical management: replace as much of
the defective bone as possible, avoid a
second procedure, and return client to a
functioning state with a minimum of
hospitalization and immobilization.
Carpal Tunnel Syndrome
Common condition; the median
nerve in the wrist becomes
compressed, causing pain and
numbness
 Common repetitive strain injury via
occupational or sports motions
 Nonsurgical management: drug
therapy and immobilization
 Possible surgical management

Scoliosis
Abnormal spinal curvature of various
degrees or severity involving
shortening of muscles and ligaments.
 Milwaukee brace (a back brace used in the
treatment of spinal curvatures) , internal
fixative devices.

Scoliosis
Changes in muscles and ligaments on
the concave side of the spinal column
 Congenital, neuromuscular, or
idiopathic in type
 Assessment: complete history, pain
assessment, observation of posture
 Interventions: exercise, weight
reduction, bracing, casting, surgery
