Musculoskeletal Disorders Part I

Degenerative & Metabolic bone disorders

Maria Carmela L. Domocmat, RN,MSN Instructor School of Nursing Northern Luzon Adventist College Artacho, Sison, Pangasinan

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Overview
Part 1: Degenerative & Metabolic bone disorders
OA Gout and gouty arthritis Osteoporosis Pagets dse Osteomalacia

Part 2: Bone infections Part 3: Muscular disorders Part 4: Disorders of the hand Part 5: Spinal column deformities Part 6 : Disorders of foot Part 7: Sports Injuries

Osteoporosis
Maria Carmela L. Domocmat, RN, MSN 3/5/2012

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Skeleton The skeleton consists of groups of bones which protect and move the body.

Osteoporosis risk factors mnemonic

ACCESS:
Alcohol Corticosteroid Calcium low Estrogen low Smoking Sedentary lifestyle

http://www.myphysio.ca/site_assets/www.myphysio.ca/images/dynamic/ost eoporosis.jpg

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

http://healthinfo.fitnessguide101.com/wpcontent/uploads/2010/10/Boneloss.jpg

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

http://images.emedicinehealth.com/images/SlideShow/Osteoporosis_s1_bo ne_density.jpg

Osteoporosis Symptoms: Stress Fracture A fracture that occurs during the course of normal activity is called a minimal trauma fracture or stress fracture. For example, some patients with osteoporosis develop stress fractures of the feet while walking or stepping off a curb.

Osteoporosis Symptoms: Hip Fracture Hip fractures typically occur as a result of a fall. With osteoporosis, hip fractures can occur as a result of trivial accidents. Hip fractures may also be difficult to heal after surgical repair because of poor bone quality

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Orthotics (thoracolumbosacral orthosis)

decrease flexion forces prevent worsening of kyphosis reduce pressure on fracture sites

Osteomalacia
Osteomalacia means "soft bones". is softening of the bones due to a lack of vitamin D or a problem with the body's ability to break down and use this vitamin.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

Osteomalacia
characterized by incomplete mineralization of normal osteoid tissue following closure of the growth plates.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

 Osteoid
bone protein matrix, composed primarily of type 1 collagen. When there is insufficient mineral or osteoblast dysfunction, the osteoid does not mineralize properly, and it accumulates.

When the newly formed bone of the growth plate does not mineralize, the growth plate becomes thick, wide and irregular. This results in the clinical diagnosis of rickets, and is seen only in children because adults no longer have growth plates. When the remodeled bone does not mineralize, osteomalacia occurs, and this happens in all ages. Most of the hereditary causes of osteomalacia appear during childhood and cause rickets.
http://courses.washington.edu/bonephys/hypercalU/opmal2.html

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

http://www.moondragon.org/health/graphics/osteomalaciaadult.jpg

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Loosers zone

 xray showing a pseudofracture (red arrow) from an adult who has x-linked hypophosphatemic rickets. This is a classic pseudofracture and is pathognomonic for osteomalacia.

This is an xray of a child with bowed legs due to rickets

Treatment
vitamin D, calcium, and phosphorus supplements, taken by mouth. Larger doses of vitamin D and calcium may be needed for people who cannot properly absorb nutrients into the intestines. Regular blood tests may be needed to monitor blood levels of phosphorus and calcium in persons with certain underlying conditions.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

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http://ods.od.nih.gov/factsheets/VitaminDHealthProfessional/
Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Recommended Dietary Allowances (RDAs) for Vitamin D

Age 012 months* 113 years 1418 years 1950 years 5170 years >70 years Male 400 IU (10 mcg) 600 IU (15 mcg) 600 IU (15 mcg) 600 IU (15 mcg) 600 IU (15 mcg) 800 IU (20 mcg) Female 400 IU (10 mcg) 600 IU (15 mcg) 600 IU (15 mcg) 600 IU (15 mcg) 600 IU (15 mcg) 800 IU (20 mcg) 600 IU (15 mcg) 600 IU (15 mcg) 600 IU (15 mcg) 600 IU (15 mcg) Pregnancy Lactation

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Tolerable Upper Intake Levels (ULs) for Vitamin D

Age 06 months 712 months 13 years 48 years 9 years Male 1,000 IU (25 mcg) 1,500 IU (38 mcg) 2,500 IU (63 mcg) 3,000 IU (75 mcg) 4,000 IU (100 mcg) Female 1,000 IU (25 mcg) 1,500 IU (38 mcg) 2,500 IU (63 mcg) 3,000 IU (75 mcg) 4,000 IU (100 mcg) 4,000 IU (100 mcg) 4,000 IU (100 mcg) Pregnancy Lactation

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http://ods.od.nih.gov/factsheets/VitaminDHealthProfessional/
Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Selected Food Sources of Vitamin D

Food Cod liver oil, 1 tablespoon Swordfish, cooked, 3 ounces Salmon (sockeye), cooked, 3 ounces Tuna fish, canned in water, drained, 3 ounces Orange juice fortified with vitamin D, 1 cup (check product labels, as amount of added vitamin D varies) Milk, nonfat, reduced fat, and whole, vitamin D-fortified, 1 cup Yogurt, fortified with 20% of the DV for vitamin D, 6 ounces (more heavily fortified yogurts provide more of the DV) Margarine, fortified, 1 tablespoon Sardines, canned in oil, drained, 2 sardines Liver, beef, cooked, 3 ounces Egg, 1 large (vitamin D is found in yolk) Ready-to-eat cereal, fortified with 10% of the DV for vitamin D, 0.75-1 cup (more heavily fortified cereals might provide more of the DV) Cheese, Swiss, 1 ounce IUs per Percent serving* DV** 1,360 340 566 142 447 112 154 39 137 115-124 80 60 46 42 41 40 6 34 29-31 20 15 12 11 10 10 2

Expectations (prognosis)
Improvement can be seen within a few weeks in some people with vitamin deficiency disorders. Complete healing with treatment takes place in 6 months.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

Prevention
diet rich in vitamin D get plenty of sunlight

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Paget's disease
AKA: Osteitis deformans is a disorder that involves abnormal bone destruction and regrowth, which results in deformity. there is an abnormal breakdown of bone tissue, followed by abnormal bone formation. The new bone is bigger, but weakened and filled with new blood vessels.

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Pagets disease
Sir James Paget first described chronic inflammation of bone as osteitis deformans in 1877. Paget disease, as the condition came to be known, second most common bone disorder (after osteoporosis) in elderly persons.

Pagets Disease (Osteitis Deformans)

Excess of bone destruction & unorganized bone formation and repair. 2nd most common bone disorder in the U.S. etiology is unknown

s/s
Usually affects the axial skeleton, vertebrae and skull, although the pelvis, tibia, femur are the other common sites of disease.

Symptoms
Most persons are asymptomatic & diagnosis is incidental. Old Hat dont fit anymore!
hat gets tighter head diameter becomes larger

pathologic fractures congestive heart failure hearing loss dysesthesias and weakness due to nerve-root compression.

Symptoms
Bone pain (may be severe and persistent) Bowing of the legs and other visible deformities Enlarged head Fracture Headache Hearing loss Joint pain or stiffness Neck pain Reduced height Skull deformities Warmth of skin over the affected bone Note: Most patients have no symptoms.

S/s
Vascularity is increased in affected portions of the skeleton.
Lesions may occur in one or more bones, does not spread from bone to bone.

Deformities & bony enlargement often occur.

Bowing of the limbs & spinal curvature in persons with advanced disease.

S/s
Bone pain- is the most common symptom.
usually worse with ambulation or activity but may also occur at rest. Involved bones may feel spongy & warm because of increased vascularity. Skull pain is usually accompanied with headache, warmth, tenderness & enlargement of the head.

Dx
Bone scan Bone x-ray Elevated markers of bone breakdown (for instance, N-telopeptide) Elevated serum alkaline phosphatase This disease may also affect the results of the following tests: ALP (alkaline phosphatase) isoenzyme Serum calcium

Dx
Pathologic fractures- because of the increased vascularity of the involved bone-bleeding is a potential danger. Alkaline phosphatase levels- markedly elevated as the result of osteoblast activity.

Dx
Serum calcium are normal except with generalized disease or immobilization. Gout and hyperurecemia may develop as a result of increased bone activity, which causes an increase in nucleic acid catabolism.

Dx
Radiograph reveals radiolucent areas in the bone, typical of increased bone resorption. Deformities & fractures may also be present.

Management
Not all patients need treatment.
For example, patients who have abnormal blood tests only may not need treatment.

People with Paget's disease who are commonly treated include: Patients with deformities
Patients with no symptoms when certain bones (such as weight-bearing bones) are involved, especially if the bony changes are progressing quickly, to reduce the risk of fractures

Management
Patients with symptoms Bisphosphonates
Alendronate (Fosamax) Etidronate (Didronel) Pamidronate (Aredia) Risedronate (Actonel) Tiludronate (Skelid) Zoledronic acid (Zometa)

Calcitonin
Intranasal (Miacalcin) Subcutaneous (Calcimar)

Plicamycin (Mithracin) Analgesics or nonsteroidal anti-inflammatory medications (NSAIDs)

Management
Goals of the treatment- to relieve pain & prevent fracture & deformities.
Pharmacologic agents are used to suppress osteoclastic activity. Bisphosphonates & calcitonin are effective agents to decrease bone pain & bone warmth & also relieve neural decompression, joint pain & lytic lesions. Use of analgesics & NSAIDs. Assistive devices, including cane, walker.

Management
Deformities may be corrected by surgical intervention (osteotomy). ORIF may be necessary for fractures. The patient may benefit from a PT referral. Local application of ice or heat may help alleviate pain.

Management
A regular exercise should be maintained; walking is best. Avoid extended periods of immobility to avoid hypercalcemia. A nutritionally adequate diet is recommended. Assistance in learning to use canes or other ambulatory aids. The Arthritis Foundation & Paget Foundation are useful resources for patients & their families.

Treatment
Patients with symptoms
Drug therapy helps prevent further bone breakdown. Currently, there are several classes of medications used to treat Paget's disease. These include:
Bisphosphonates -- the first-line treatment; help increase bone density. Calcitonin hormone involved in bone metabolism. Plicamycin (Mithracin) Analgesics or nonsteroidal anti-inflammatory medications (NSAIDs) - for pain.

Localized Paget's disease needs no treatment, if there are no symptoms and no evidence of active disease. Orthopedic surgery may be needed to correct a deformity in severe cases.

Outlook (Prognosis)
Disease activity and symptoms can generally be controlled with current medications. A small percentage of patients may develop a cancer of the bone called osteosarcoma. Some patients will need joint replacement surgery.

Possible Complications
Bone fractures Deafness Deformities Heart failure Paraplegia Spinal stenosis

http://orthoinfo.aaos.org/topic.cfm?topic=A00076

Left, Paget's disease of the spine. The white, patchy appearance of the bone on this X-ray is characteristic of the dense but disordered bone in this disease. Right, Paget's disease of the pelvis. The bone is thick, wide, and patchy.

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012