NSG210 Hinkle Ch. 36: Management of Patients With Musculoskeletal Disorders

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 36, pp. 1113-1151 (textbooks/HINKLE_MS_CH36.pdf, also in textbooks/exam03/). Week 08 reading (Oct 14 lecture, alterations in activity and rest); on Exam 3. Numbering note: the raw lecture plan lists “Ch. 37 - Osteoarthritis and Arthroplasty,” but in the 15th edition Ch. 37 is musculoskeletal trauma; osteoarthritis and joint replacement are in Ch. 36. For today’s lecture the high-yield sections are IV (osteoarthritis) and V (arthroplasty). RA, SLE, and gout are in nsg210-hinkle-ch34-inflammatory-rheumatic-disorders.

Learning Outcomes

1. Describe the pathophysiology, clinical manifestations, and medical and nursing management of low back pain.
2. Discuss common disorders of the hand, wrist, shoulder, and foot, and nursing management of the patient having surgery for them.
3. Identify the pathophysiology, clinical manifestations, and medical, surgical, and nursing management of osteoarthritis.
4. Explain metabolic bone disorders: osteoporosis, osteomalacia, Paget disease.
5. Explain musculoskeletal infections (osteomyelitis, septic arthritis) and bone tumors.
6. Use the nursing process for the patient having total hip arthroplasty, with osteoporosis-related vertebral fracture, or with osteomyelitis.

Key terms: abduction (away from midline); adduction (toward midline); arthroplasty (surgical joint replacement); avascular necrosis (tissue death from insufficient blood supply); bursitis; contracture; heterotopic ossification (misplaced bone formation); involucrum (new bone around a sequestrum); sequestrum (dead bone in an abscess cavity); osteolysis (bone lysis from reaction to polyethylene debris); osteopenia (low bone mineral density); osteophyte (bone spur); osteotomy (surgical cutting of bone); radiculopathy; sciatica; tendonitis.

I. Low Back Pain

A. Causes and pathophysiology

• Most low back pain is musculoskeletal: acute lumbosacral strain, unstable ligaments and weak muscles, disc problems, unequal leg length
• Comorbidities: obesity, stress, depression, smoking, alcohol abuse
• Musculoskeletal back pain is aggravated by activity; pain from other causes is not
• Nonmusculoskeletal causes: kidney, pelvic problems, retroperitoneal tumors, abdominal aortic aneurysm
• L4-L5 and L5-S1 discs take the most stress and degeneration; disc protrusion presses on nerve roots and causes radiating pain
• Older adults: osteoporotic vertebral fractures, spinal OA, spinal stenosis

B. Clinical manifestations

• Acute (less than 3 months) or chronic (3 months or longer without improvement); fatigue
• Radiculopathy (pain from a spinal nerve root) or sciatica (pain down the leg from the sciatic nerve) means nerve root involvement
• Paravertebral muscle spasm, loss of lumbar curve

C. Assessment and red flags

• Bruising, older age, prolonged corticosteroid use raise fracture risk; be alert to elder abuse
• Cauda equina syndrome: severe or progressive neurologic deficit, new bowel or bladder dysfunction, saddle anesthesia (perineal, inner thigh, buttock paresthesias) - medical emergency, immediate ED referral
• Red flags for imaging (Chart 36-1): suspected spinal infection, severe neurologic weakness, urinary or fecal incontinence, new back pain in a patient with cancer
• Straight-leg raise causing back and leg pain suggests nerve root involvement
• Diagnostics: x-ray, bone scan, CT, MRI, EMG and nerve conduction, myelogram (only when MRI is contraindicated), ultrasound

D. Medical management

• Most back pain resolves within 4-6 weeks with analgesics, rest, and avoiding strain
• Nonspecific pain: reassure; imaging not needed
• Acute: NSAIDs and short-term muscle relaxants (cyclobenzaprine); no one drug is superior
• Chronic: TCAs (amitriptyline), SNRIs (duloxetine), gabapentin for radiculopathy
• Opioids only short term (1-2 weeks) for acute moderate to severe pain
• Systemic corticosteroids and acetaminophen are not effective for acute low back pain
• Chronic pain goal: 30% reduction from baseline
• Nonpharmacologic: heat or cold, spinal manipulation; for chronic pain CBT, exercise, PT, acupuncture, massage, yoga
• Lumbar support belts not recommended for treatment
• Absolute bed rest no longer recommended; resume ADLs as soon as possible; limit sitting to 20-50 minutes; low-stress aerobic exercise after about 2 weeks

E. Nursing management

• Positioning for lumbar flexion: head and thorax up 30 degrees with knees slightly flexed on a pillow, or side-lying curled with a pillow between the knees; avoid prone (accentuates lordosis)
• Medium to firm nonsagging mattress
• Get out of bed by rolling to the side, legs down, push torso up with back straight
• Body mechanics (Chart 36-2): push rather than pull, keep load close, lift with leg muscles, squat with back straight, wide base of support, avoid twisting and reaching; do not lift more than one third of ideal body weight without help
• Standing: shift weight, rest one foot on a low stool; avoid locking knees; low heels
• Sitting: knees level with or higher than hips, feet flat
• Exercise: 30 minutes daily beginning and ending with stretching; avoid horseback riding and weight lifting
• Earlier return to work, even at reduced level, has better outcomes; watch for secondary gains
• Weight reduction

II. Common Upper Extremity Disorders

• Bursitis and tendonitis: inflammation of bursae or tendon sheaths, often shoulder; rest, intermittent ice and heat, NSAIDs; corticosteroid injection for short-term relief; usually self-limiting
• Loose bodies (“joint mice”): cartilage and bone fragments that can lock the joint; arthroscopic removal
• Impingement syndrome: rotator cuff irritation from repetitive overhead motion; NSAIDs, steroid injection, therapeutic exercise; rest arm on pillows when sleeping, avoid lifting above shoulder level (Chart 36-3); can progress to rotator cuff tear
• Carpal tunnel syndrome:
  • Median nerve compression at the wrist; women 30-60; highest risk in menopause or with estrogen or birth control pills
  • Causes: repetitive hand and wrist motion, vibration, RA, diabetes, acromegaly, hyperthyroidism, trauma
  • Pain, numbness, paresthesia, weakness in thumb, index, middle fingers; night pain
  • Positive Tinel sign (tap over median nerve causes tingling)
  • Treatment: oral or injected corticosteroids, NSAIDs, acupuncture, splints to prevent wrist hyperextension and prolonged flexion; laser, ultrasound, diuretics, vitamin B6 ineffective; long-term steroids not supported (tendon rupture)
  • Surgery: open nerve release or endoscopic laser release; splint afterward; recovery may take weeks to months
• Ganglion: gelatinous cyst on the dorsum of the wrist; women under 50; aspiration, steroid injection, or excision; may recur
• Dupuytren disease: progressive contracture of palmar fascia flexing fourth and fifth fingers; autosomal dominant; men of Scandinavian or Celtic heritage over 50; linked to diabetes, gout, smoking, alcoholism; stretching, injections, fasciotomy

Nursing care after hand or wrist surgery

• Hourly neurovascular checks of exposed fingers for the first 24 hours (especially if a tourniquet was used); compare with unaffected side and preop baseline
• Nonconstrictive dressing; ice for first 24-48 hours; active finger flexion and extension
• Pain out of proportion with neurovascular compromise suggests compartment syndrome
• Elevate hand to heart level; sling with hand at heart level when ambulatory
• Pin care if percutaneous pins
• Teach: report paresthesia, paralysis, uncontrolled pain, cool fingers, extreme swelling, bleeding, purulent drainage, fever; keep dressing dry with a plastic bag

III. Common Foot Problems

• Diabetes: corns and neuropathy lead to ulcers at pressure points; early intervention for corns
• Callus: thickened skin from pressure or friction; podiatrist, keratolytic ointment, padding
• Corn: hyperkeratosis from internal or external pressure; fifth toe most often; soft corns between toes - keep dry, separate with lamb’s wool
• Hammer toe: flexion deformity of the interphalangeal joint; open-toed sandals (unless diabetic), round toe box, pads; osteotomy
• Onychocryptosis (ingrown toenail): cut nails straight across; warm soaks
• Hallux valgus (bunion): great toe deviates laterally; exostosis of first metatarsal head; proper shoes, steroid injection, surgery
• Morton neuroma: third intermetatarsal space; throbbing, burning pain relieved by rest; metatarsal pads, injections, excision (permanent loss of sensation increases fall risk)
• Pes planus (flatfoot) and pes cavus (high arch, clawfoot)
• Plantar fasciitis: heel pain with first steps in the morning; stretching, supportive shoes, orthotics, night splints, steroid injections; can lead to heel spurs

Nursing care after foot surgery

• Neurovascular checks of toes every 1-2 hours for the first 24 hours
• Elevate on several pillows, support the whole limb under the knee; ice first 24-48 hours
• Weight bearing per surgeon; crutches or walker; teach safe use before discharge
• VTE risk from immobility; pin care; keep dressing dry

IV. Osteoarthritis (Degenerative Joint Disease)

A. Definition and epidemiology

• Noninflammatory degenerative joint disorder; most common form of joint disease
• Primary (idiopathic) or secondary (prior joint injury or inflammatory disease such as RA)
• Primary OA does not involve autoimmunity or inflammation
• Limited to affected joints; no systemic symptoms (contrast RA)
• Begins in the third decade, peaks in the fifth and sixth decades
• By age 40, 90% have degenerative changes in weight-bearing joints (usually without symptoms)
• More than 85% over age 65 have radiographic OA
• Women more affected, especially Hispanic and African American women

B. Pathophysiology (Figs. 36-7, 36-8)

• Articular cartilage breaks down, leading to damage of underlying bone and osteophytes (bone spurs) protruding into the joint space
• Joint space narrows, movement decreases, joint progressively degenerates
• More than “wear and tear”

C. Risk factors

• Older age, female gender, obesity
• Laborious occupations, sports, prior injury, muscle weakness, genetics, certain diseases
• Obesity is the most prominent modifiable risk factor; diet and exercise help

D. Clinical manifestations

• Pain, stiffness, functional impairment
• Pain aggravated by movement or exercise, relieved by rest
• Morning stiffness, if present, is brief - less than 30 minutes (contrast RA, longer than 1 hour)
• Insidious onset over years
• Enlarged joint, decreased ROM
• Weight-bearing joints most often (hips, knees, cervical and lumbar spine)
• Heberden’s nodes (DIP joints) and Bouchard’s nodes (PIP joints)
• Crepitus, especially over the knee; mild effusion; no systemic manifestations

E. Assessment and diagnostics

• Blood tests and joint fluid are not useful for diagnosing OA; used only to rule out autoimmune causes such as RA
• X-ray: joint space narrowing, osteophytes, dense thickened subchondral bone

F. Medical management

• Goals: decrease pain and stiffness, maintain or improve joint mobility
• Exercise (aerobic and lower extremity strength training) prevents progression and decreases symptoms
• Weight loss decreases joint load
• OT and PT for self-management; orthotics, braces, wedged insoles, canes reduce force on the joint
• Complementary therapies (massage, yoga, TENS, tai chi, acupuncture) acceptable if they do not interfere with medications and improve comfort

Pharmacologic:

• Acetaminophen is the initial analgesic for most patients
• NSAIDs and COX-2 inhibitors (COX-2: cardiovascular risk, little to no decrease in GI upset)
• Tramadol; opioids only in severe cases; intra-articular corticosteroids
• Topical capsaicin, methylsalicylate; topical diclofenac gel FDA approved for hands and knees
• Methotrexate or colchicine for some refractory cases
• Glucosamine and chondroitin: not shown to be effective
• Viscosupplementation (intra-articular hyaluronates): weak evidence

G. Nursing management

• Goals: pain management and optimal function
• Patients are usually older, often overweight and sedentary; weight loss and exercise
• Canes and assistive devices; explore stigma
• Start walking in moderation, increase gradually; exercise when pain is least or after an analgesic

V. The Patient Undergoing Arthroplasty

A. Indications and types

• Severe pain or loss of function in moderate to severe OA; also RA, trauma, congenital deformity, femoral neck fracture with avascular necrosis
• Osteotomy alters weight distribution in the joint; arthroplasty replaces joint surfaces
• Total joint arthroplasty replaces all components; metal plus high-density polyethylene
• Fixation: cemented (PMMA bone cement), cementless (bone grows into porous-coated press-fit prosthesis), or hybrid; outcomes similar
• Most often replaced: hip, knee, finger joints
• PT started within the first 24 hours shortens length of stay and improves balance and gait

B. Preoperative and intraoperative management

Preventing blood loss:

• Transfusion rates fell from up to 50% to about 9% for THA and 4% for TKA
• Treat preop anemia (epoetin alfa, iron); pneumatic tourniquet (TKA); intraoperative red cell salvage (autologous); tranexamic acid

Preventing VTE:

• Risk factors: age over 40, obesity, hormonal medications, preop leg edema, prior VTE, varicose veins
• Hormones and NSAIDs may be stopped a week before surgery
• Prophylactic LMWH or another anticoagulant
• Preop neurovascular baseline (an absent postop pulse matters unless it was absent preop)

Preventing infection:

• Screen for infection, including UTI; infection within 2-4 weeks before surgery may postpone it
• Antiseptic shower the evening before and morning of surgery
• Broad-spectrum antibiotic within 60 minutes before incision, stopped within 24 hours after surgery
• Antibiotic-loaded cement, nasal screening for MRSA and MSSA

Managing pain:

• Assess preop pain and preferences; teach about incentive spirometry, pain control, activity limits; preop telephone support improves outcomes

C. Total Hip Arthroplasty (THA)

• Indications: OA, RA, femoral neck fracture, failed prior surgery, developmental dysplasia, Legg-Calve-Perthes disease
• Metal femoral stem with ball fitted into acetabular socket (Fig. 36-9)
• Complications: dislocation, excessive wound drainage, VTE, infection, heel pressure injury; long term heterotopic ossification, avascular necrosis, loosening

Plan of care (Chart 36-6):

• Pain: parenteral opioids for the first 24-48 hours, then oral; muscle spasms expected; persistent pain may mean hematoma, infection, dislocation
• Mobility: position in abduction, neutral rotation, limited flexion; keep pressure off heels; quad and gluteal setting exercises; progressive ambulation per weight-bearing order
• Hemorrhage: monitor VS for shock; drainage should decrease to 25-30 mL per 8 hours within 48 hours; more than 250 mL in the first 8 hours or bright red drainage suggests active bleeding; monitor H&H
• Neurovascular: color, temperature, capillary refill, edema, pain on passive flexion, sensation, movement, pedal pulses; peroneal nerve - sensation in the web between great and second toe, dorsiflexion and toe extension; tibial nerve - sensation on the sole, plantar flexion and toe flexion; elevate extremity but keep it lower than the hip in a chair; never flex hip more than 90 degrees
• VTE: anti-embolism stockings and SCDs; remove stockings 20 minutes twice a day for skin care; assess for unilateral calf pain every 8 hours; avoid pressure on popliteal vessels; ankle exercises hourly; fluids
• Infection: VS, aseptic dressing and drain care, prophylactic antibiotics; red, swollen, draining incision

Preventing dislocation (posterior or posterolateral approach):

• Dislocation most likely with full flexion, adduction, and internal rotation
• Supine, head slightly elevated, affected leg neutral
• Abduction splint, wedge pillow, or 2-3 pillows between legs; cradle boot to prevent rotation and float the heel
• Turn to the unaffected side with the operative hip kept in abduction; do not turn to the operative side unless the surgeon allows
• Never flex the hip more than 90 degrees; fracture bedpan - flex the unaffected hip and use the trapeze
• Transfers: keep abduction pillow between legs, keep affected hip extended, pivot on the unaffected leg
• High-seat chairs with arms, raised toilet seat; hips higher than knees when sitting; do not elevate the affected leg when sitting; knee may flex
• Hip precautions for 4 months or longer; anterior approach may not need them and has lower dislocation rates
• Risk highest in the first 8-12 weeks

Signs of dislocation - notify the surgeon immediately:

• Increased pain at the surgical site, swelling, immobilization
• Acute groin pain or increased discomfort
• Shortening of the affected leg
• Abnormal external or internal rotation
• Restricted ability or inability to move the leg
• “Popping” sensation in the hip
• After closed reduction, Buck’s traction or a brace may stabilize the hip

Ambulation:

• Walker or crutches within a day of surgery; orthostatic hypotension at first
• Weight bearing based on condition, procedure, fixation (may be limited to reduce micromotion)

Wound drainage:

• Closed suction drain; drains in more than 24 hours raise infection risk
• Measure each shift; report excessive or foul-smelling drainage

VTE after THA:

• Without prophylaxis, DVT can develop within 7-14 days and lead to fatal PE
• DVT: pain and tenderness at or below the clot, swelling or tightness, pitting edema, warmth or coolness, discoloration
• PE: sudden dyspnea, tachycardia, confusion, pleuritic chest pain
• SCDs on at all times, even out of bed
• Ankle and toe dorsiflexion and plantar flexion 10-20 times every half hour while awake
• Mobilize early, even with an epidural
• Aspirin, LMWH, or fondaparinux, usually up to 35 days after surgery
• Prophylaxis increases bleeding risk

Infection:

• Serious; may require removal of the prosthesis
• High risk: older, poorly nourished, smokers, corticosteroids, obesity, diabetes, RA, concurrent infection (UTI, dental abscess), MRSA carriers, hematoma
• One in five THA patients eventually needs revision (aseptic loosening, infection, instability, mechanical failure)
• Acute infection within 3 months; delayed 4-24 months; after 2 years usually hematogenous
• Routine dental antibiotic prophylaxis not recommended (may be given if immunosuppressed)

Home care and teaching (Charts 36-7, 36-8):

• Keep knees apart; pillow between legs when sleeping; never cross legs; do not bend forward when seated or to pick up objects; high chair and raised toilet seat; do not flex the hip to put on pants, socks, shoes - use reachers, long shoehorns, dressing sticks
• No crossing legs or flexing hip past 90 degrees for the first 4 months
• Avoid low chairs and sitting more than 45 minutes
• Stairs usually in 3-6 weeks; driving 4-6 weeks; ADLs by about 3 months; sexual activity typically 3-6 months per surgeon
• Avoid tub baths, jogging, heavy lifting, excessive bending and twisting
• Sutures or staples removed 10-14 days
• Clean incision daily with soap and water; report infection signs
• Good exercises: walking, swimming, high rocking chair
• Joint replacement card for airport screening
• Report dislocation, DVT, infection, PE signs

Gerontologic considerations:

• Early surgery for hip fracture (within 24-36 hours) once stabilized
• LMWH for VTE unless contraindicated; mechanical devices otherwise
• Pain management is harder with cognitive impairment and comorbidities
• Higher-specification foam pressure-relieving mattress, not an air mattress
• Early mobilization on the day of surgery

D. Total Knee Arthroplasty (TKA)

• For severe pain and disability from OA, RA, or posttraumatic arthritis not managed nonsurgically
• Constrained (hinged) or semi-constrained prosthesis if ligaments are weak
• Compression dressing; ice to reduce swelling and bleeding
• Neurovascular checks every 2-4 hours compared with the other leg; active foot flexion hourly while awake
• Prevent VTE, peroneal nerve palsy, infection, bleeding, limited ROM
• Drain more likely if BMI over 35; left in 24-48 hours
• Antibiotics continued 24 hours postop
• CPM devices do not improve recovery but some surgeons still use them
• Goal flexion about 125 degrees; if not achieved, manipulation under anesthesia about 2 weeks postop
• Ambulate by postop day 1; knee immobilizer; elevate when sitting
• Discharge criteria: stable wound, INR 1.5-2, progress in PT (walker use), pain controlled with oral medications
• Acute rehab 1-2 weeks; full recovery 6 weeks or more (longer over age 75)
• Late complications: osteolysis, periprosthetic infection, aseptic loosening
• More than 82% still have a functioning prosthesis at 25 years

VI. Metabolic Bone Disorders

A. Osteoporosis

Epidemiology:

• Most prevalent bone disease; more than 10 million Americans, plus 33.6 million with osteopenia
• One in three women and one in five men over 50 will have an osteoporotic fracture

Prevention (Chart 36-10):

• Peak bone mass at 18-25 years
• Calcium 1000-1300 mg/day for adolescents and young adults; daily weight-bearing exercise; avoid smoking, alcohol, caffeine, carbonated drinks
• Primary osteoporosis: postmenopausal women (usually by 51)
• Secondary: medications or disease; more common in men; corticosteroids (more than 5 mg prednisone daily for more than 3 months), excess alcohol, celiac, hypogonadism, anticonvulsants (phenytoin), levothyroxine, medroxyprogesterone, leuprolide, SSRIs, PPIs

Pathophysiology:

• Reduced bone mass, deteriorated matrix, weakened architecture; resorption by osteoclasts exceeds formation by osteoblasts
• Compression fractures of thoracic and lumbar spine, hip fractures, Colles (wrist) fractures - may be the first sign
• Kyphosis (dowager hump), height loss, protruding abdomen, pulmonary insufficiency, fall risk
• Aging: calcitonin and estrogen decrease, PTH increases
• Menopause: accelerated loss in the first 5 years; most women lose 10% of bone mass

Risk factors (Chart 36-11):

• Small-framed women; Asian and Caucasian women highest risk
• 3 or more drinks daily; corticosteroids longer than 3 months; tobacco; family history; prior adult fracture; diabetes; rheumatoid disease; sedentary; low calcium and vitamin D; low BMI; malabsorption (celiac, eating disorders, bariatric surgery); men over 60; postmenopausal women
• Immobility (casts, paralysis) speeds resorption; resistance and impact exercise build bone

Gerontologic:

• 50% of women over 80; average 75-year-old woman has lost 25% cortical and 40% trabecular bone
• One third of hip fractures occur in men; men have higher mortality after hip fracture
• Fragility fracture: from a fall from standing height or less
• Vertebral fracture risk 5 times higher after prior fracture; 20% of postmenopausal women with a vertebral fracture have another within 1 year
• Nurses often detect vertebral fractures by noting height loss
• Postmenopausal women and older adults need about 1200 mg calcium daily; more may increase renal calculi and CVD risk

Diagnostics:

• Routine x-ray may not show it until significant demineralization
• DEXA scan measures BMD at spine and hip; reported as T-scores (SD from a healthy 30-year-old of the same sex)
• Baseline DEXA: all women over 65, postmenopausal women over 50 with risk factors, anyone with a fragility fracture; repeat 3 months after an osteoporotic fracture
• FRAX tool (underestimates in men; MORES for men); treat if 10-year hip fracture risk over 3% or other major fracture risk over 20%
• Labs (calcium, phosphate, ALP, urine calcium, hydroxyproline, Hct, ESR) to rule out other causes; low testosterone in men

Medical management:

• Calcium-rich diet (milk, cheese, broccoli, canned salmon with bones); 1 cup milk or fortified OJ about 300 mg
• Calcium: men 50-70, 1000 mg/day; women 51 and older and men 71 and older, 1200 mg/day
• Vitamin D 400-1000 IU/day; 15-30 minutes of sun daily
• Weight-bearing exercise 20-30 minutes daily (swimming is not weight bearing); weight training
• Estrogen therapy not recommended for primary prevention
• Calcium supplements: split doses, take with meals or vitamin C; side effects abdominal distention and constipation

Fracture management:

• Hip fractures: joint replacement or ORIF
• Vertebral compression fractures: conservative; vertebroplasty or kyphoplasty (PMMA cement, balloon) for rapid pain relief - contraindicated with infection, multiple old fractures, some coagulopathies

Nursing process - spontaneous vertebral fracture:

• Assess family history, fractures, calcium intake, exercise, menopause, corticosteroids, alcohol, smoking, caffeine; back pain, constipation, body image
• Diagnoses: knowledge deficit, acute pain, risk for constipation (immobility, ileus), risk for injury
• Pain: short bed rest supine or side-lying, knee flexion, heat, backrubs; move trunk as a unit, no twisting; trunk orthosis when up
• Bowel: high fiber, fluids, stool softeners; T10-L2 vertebral collapse can cause paralytic ileus - monitor intake, bowel sounds
• Prevent injury: walking, isometrics, good posture, daily weight-bearing activity outdoors; avoid sudden bending, jarring, strenuous lifting; home safety (rugs, clutter, lighting, grab bars)

B. Osteomalacia

• Inadequate bone mineralization from deficient activated vitamin D; bones soften and weaken
• Causes: GI malabsorption (celiac, biliary obstruction, pancreatitis, bowel resection), liver and kidney disease (cannot activate vitamin D), renal acidosis, hyperparathyroidism, anticonvulsants (phenytoin, phenobarbital), dietary deficiency, lack of sunlight
• Signs: bone pain, tenderness, bowing, kyphosis, waddling gait, pathologic fractures (distal radius, proximal femur)
• Labs: low serum calcium and phosphorus, moderately elevated ALP, low urine calcium; bone biopsy shows increased osteoid
• Treatment: correct cause; calcitriol (active vitamin D) if kidney disease; vitamin D and calcium for malabsorption; sunlight; braces or osteotomy for deformities

C. Paget Disease of Bone (Osteitis Deformans)

• Localized rapid bone turnover: skull, femur, tibia, pelvis, vertebrae; 2-3% over 50; slightly more men; familial
• Osteoclast proliferation, then compensatory osteoblast activity, leading to a disorganized mosaic pattern; highly vascular, weak bone
• Skull thickens (hat no longer fits), hearing loss from cranial nerve compression; bowed femurs and tibias, waddling gait; warmth over bones; high-output heart failure possible
• Labs: elevated ALP and urinary hydroxyproline; normal serum calcium
• Treatment: NSAIDs for pain; bisphosphonates are the cornerstone; plicamycin (cytotoxic, severe cases; monitor liver, kidney, marrow)
• Complications: fractures, arthritis, hearing loss; fall prevention

VII. Musculoskeletal Infections

A. Osteomyelitis

• Bone infection with inflammation, necrosis, new bone formation
• Types: hematogenous; contiguous-focus (surgery, hardware, open fracture, trauma); with vascular insufficiency (diabetes, PVD, feet)
• Risk: older, poorly nourished, obese, immunocompromised, diabetes, RA, long-term corticosteroids, IV drug use
• More than 50% caused by Staphylococcus aureus, increasingly MRSA
• Postop wound infections within 30 days; with an implant, deep infection may occur within a year
• Pathophysiology: inflammation, then thrombosis of local vessels after 2-3 days leads to ischemia and bone necrosis; abscess with sequestrum (dead bone) that cannot drain; involucrum forms around it; chronic osteomyelitis with recurring abscesses
• Hematogenous: sudden onset with sepsis signs (chills, high fever, rapid pulse, malaise); constant pulsating pain worse with movement
• Contiguous: no sepsis; local swelling, warmth, pain, tenderness
• Chronic: nonhealing ulcer with a sinus that drains pus
• Diabetic: may occur without a wound; foot ulcer over 2 cm is highly suspicious
• Diagnostics: early x-ray only soft tissue edema; periosteal elevation and necrosis after 2-3 weeks; bone scan and MRI for early diagnosis; leukocytosis, elevated ESR; cultures positive in only 50%; biopsy before antibiotics when possible; chronic - ESR and WBC usually normal, anemia
• Prevention: postpone elective surgery with active infection (UTI, sore throat); prophylactic antibiotics; remove catheters and drains early; aseptic wound care
• Treatment: immobilize affected area; hydration, high-protein and vitamin diet, correct anemia; IV antibiotics 6-12 weeks, then oral; surgical debridement, sequestrectomy, saucerization, irrigation, bone graft or muscle flap; may need internal or external fixation
• Nursing: handle extremity gently; splint and elevate; restrict weight bearing; ROM of joints above and below; monitor IV site for phlebitis and infiltration; watch for superinfection (oral or vaginal candidiasis, loose foul stools); teach home IV antibiotic management

B. Septic (Infectious) Arthritis

• Joint infection by hematogenous spread or direct (trauma, injection, surgery)
• Risk: over 80, diabetes, RA, skin infection, alcoholism, prior joint surgery or replacement, IV drug use
• S. aureus most common; gonococcal; Pseudomonas in IV drug users
• Usually a single knee or hip; about half involve a knee; up to 20% polyarticular
• Mortality about 11% for single joint, near 50% if polyarticular or immunocompromised
• Warm, painful, swollen joint with decreased ROM; chills, fever, leukocytosis (fever may be absent in older adults)
• Diagnosis: aspiration and culture of synovial fluid
• Treatment: prompt broad-spectrum IV antibiotics, then organism-specific; joint aspiration, arthrotomy or arthroscopy; splint in functional position; progressive ROM when tolerated
• Monitor for recurrence over the next year

VIII. Bone Tumors

• Benign: more common than malignant primaries; slow growing, encapsulated
  • Osteochondroma: most common benign bone tumor; under 1% become malignant
  • Bone cysts (aneurysmal, unicameral), osteoid osteoma (painful, young), enchondroma, giant cell tumor (may become malignant)
• Malignant primary:
  • Osteosarcoma: most common and most often fatal; children, adolescents, young adults; Paget disease; prior radiation; distal femur, proximal tibia, proximal humerus; prognosis depends on lung metastasis
  • Chondrosarcoma: second most common; middle-aged and older; pelvis, femur, humerus
  • Ewing sarcoma, fibrosarcoma; lung metastasis common
• Metastatic bone disease: more common than primary; from kidney, prostate, lung, breast, ovary, thyroid; skull, spine, pelvis, femur, humerus
• Malignant tumors weaken bone and cause pathologic fracture
• Spinal metastasis can cause cord compression - early decompression laminectomy for neurologic deficits
• Diagnostics: CT, MRI, PET, biopsy (careful to avoid seeding), chest x-ray; elevated ALP; hypercalcemia with breast, lung, kidney metastases
• Treatment: primary - excision, radiation, chemotherapy before and after surgery; amputation or limb-sparing (salvage) surgery; metastatic - palliative, prophylactic fixation, bisphosphonates, RANKL inhibitors, strontium-89 for pain
• Nursing: limit palpation of the mass (seeding); handle affected limb gently; follow weight-bearing restrictions; psychological support; wound healing, nutrition, infection prevention
• Hypercalcemia: muscle weakness, incoordination, anorexia, nausea, vomiting, constipation, ECG changes (shortened QT and ST, bradycardia, heart block), confusion, lethargy; treat with IV normal saline, diuresis, mobilization, IV bisphosphonates (zoledronic acid), denosumab

High-Yield Numbers

• Low back pain: acute under 3 months; resolves in 4-6 weeks; opioids 1-2 weeks only; sit no more than 20-50 minutes; aerobic exercise after about 2 weeks; head of bed 30 degrees with knees flexed; lift no more than one third of ideal weight
• Hand surgery: neurovascular checks hourly for 24 hours; foot surgery every 1-2 hours for 24 hours; ice 24-48 hours
• OA: morning stiffness under 30 minutes; 90% have changes by 40; 85% over 65 on x-ray
• Arthroplasty: antibiotic within 60 minutes before incision, stop within 24 hours; infection 2-4 weeks before surgery may postpone it
• THA: hip flexion never more than 90 degrees; precautions 4 months or longer; dislocation risk highest first 8-12 weeks; drainage over 250 mL in first 8 hours is excessive, should drop to 25-30 mL per 8 hours by 48 hours; DVT can form in 7-14 days; anticoagulant up to 35 days; ankle pumps 10-20 times every 30 minutes; sit no more than 45 minutes; stairs 3-6 weeks, driving 4-6 weeks, ADLs 3 months; staples out 10-14 days; 1 in 5 need revision
• TKA: neurovascular checks every 2-4 hours; drain 24-48 hours; goal flexion about 125 degrees; manipulation at about 2 weeks; INR 1.5-2 for discharge; recovery 6 weeks or more; 82% functioning at 25 years
• Osteoporosis: calcium 1000 mg (men 50-70), 1200 mg (women 51 and older, men 71 and older), 1000-1300 mg for adolescents; vitamin D 400-1000 IU; steroids over 5 mg prednisone for over 3 months; alcohol 3 or more drinks daily; bisphosphonate - 250 mL water, upright 30 minutes; zoledronic acid contraindicated with CrCl under 35
• Osteomyelitis: IV antibiotics 6-12 weeks; cultures positive in 50%; x-ray changes after 2-3 weeks; diabetic foot ulcer over 2 cm suspicious
• Septic arthritis: mortality 11% single joint, about 50% polyarticular

Priority Nursing Actions and Red Flags

• Cauda equina syndrome (saddle anesthesia, new bowel or bladder dysfunction, progressive weakness): emergency
• Hip dislocation after THA (shortening, rotation, groin pain, popping, cannot move leg): notify surgeon immediately
• Pain out of proportion or pain on passive stretch with neurovascular changes: compartment syndrome or nerve ischemia
• Postop hemorrhage: excessive or bright red drainage, signs of shock, falling H&H
• DVT and PE after joint replacement: unilateral calf pain, swelling; sudden dyspnea, tachycardia, pleuritic chest pain, confusion
• Infection: fever, red draining incision, increasing pain; screen and treat preop infections
• Absent pulse postop is concerning unless absent preop - always compare to baseline
• Osteoporotic T10-L2 collapse: watch for paralytic ileus
• Bisphosphonates: upright 30 minutes, water only, empty stomach; report jaw pain or thigh pain
• Spinal metastasis: new weakness, gait change, urinary retention - cord compression
• Hypercalcemia in bone cancer: weakness, confusion, constipation, ECG changes
• Septic arthritis in older adults may present without fever

Medications

Related

• nsg210-hinkle-ch34-inflammatory-rheumatic-disorders - RA, SLE, gout (same lecture)
• nsg210-dvt-simulation-prep - DVT and PE content that overlaps arthroplasty VTE prevention
• INDEX - NSG210 chapter index
• nsg210-textbook-chapter-crosswalk