Musculoskeletal Disorders Part IDegenerative & Metabolic bone disorders Maria Carmela L. Domocmat, RN,MSN Instructor School of Nursing Northern Luzon Adventist College Artacho, Sison, Pangasinan
2 Maria Carmela L. 3/5/2012 Domocmat, RN, MSNOverview• Part 1: Degenerative & Metabolic bone disorders ▫ OA ▫ Gout and gouty arthritis ▫ Osteoporosis ▫ Paget’s 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
3Osteoporosis Maria Carmela L. 3/5/2012 Domocmat, RN, MSN
Osteoporosis Symptoms: Stress FractureA fracture that occurs during the course of normal activity iscalled a minimal trauma fracture or stress fracture. Forexample, some patients with osteoporosis develop stressfractures of the feet while walking or stepping off a curb.
OsteoporosisSymptoms: Hip FractureHip fractures typically occuras a result of a fall. Withosteoporosis, hip fracturescan occur as a result oftrivial accidents. Hipfractures may also bedifficult to heal after surgicalrepair because of poor bonequality
30 Maria Carmela L. 3/5/2012 Domocmat, RN, MSNOrthotics (thoracolumbosacralorthosis)• 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 bodys 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
• xray showing a pseudofracture • This is an xray of a child with (red arrow) from an adult who bowed legs due to rickets has x-linked hypophosphatemic rickets.• This is a classic pseudofracture and is pathognomonic for osteomalacia.
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/
47http://ods.od.nih.gov/factsheets/VitaminD- Maria Carmela L. 3/5/2012HealthProfessional/ Domocmat, RN, MSN Recommended Dietary Allowances (RDAs) for Vitamin D Age Male Female Pregnancy Lactation 400 IU 400 IU 0–12 months* (10 mcg) (10 mcg) 600 IU 600 IU 1–13 years (15 mcg) (15 mcg) 600 IU 600 IU 600 IU 600 IU 14–18 years (15 mcg) (15 mcg) (15 mcg) (15 mcg) 600 IU 600 IU 600 IU 600 IU 19–50 years (15 mcg) (15 mcg) (15 mcg) (15 mcg) 600 IU 600 IU 51–70 years (15 mcg) (15 mcg) 800 IU 800 IU >70 years (20 mcg) (20 mcg)
48 Maria Carmela L. 3/5/2012 Domocmat, RN, MSN Tolerable Upper Intake Levels (ULs) for Vitamin D LactationAge Male Female Pregnancy 1,000 IU 1,000 IU0–6 months (25 mcg) (25 mcg) 1,500 IU 1,500 IU7–12 months (38 mcg) (38 mcg) 2,500 IU 2,500 IU1–3 years (63 mcg) (63 mcg) 3,000 IU 3,000 IU4–8 years (75 mcg) (75 mcg) 4,000 IU 4,000 IU 4,000 IU 4,000 IU≥9 years (100 mcg) (100 mcg) (100 mcg) (100 mcg)
49http://ods.od.nih.gov/factsheets/VitaminD- Maria Carmela L. 3/5/2012HealthProfessional/ Domocmat, RN, MSN Selected Food Sources of Vitamin D IUs per PercentFood serving* DV**Cod liver oil, 1 tablespoon 1,360 340Swordfish, cooked, 3 ounces 566 142Salmon (sockeye), cooked, 3 ounces 447 112Tuna fish, canned in water, drained, 3 ounces 154 39Orange juice fortified with vitamin D, 1 cup (check product labels, as amount 137 34of added vitamin D varies)Milk, nonfat, reduced fat, and whole, vitamin D-fortified, 1 cup 115-124 29-31Yogurt, fortified with 20% of the DV for vitamin D, 6 ounces (more heavily 80 20fortified yogurts provide more of the DV)Margarine, fortified, 1 tablespoon 60 15Sardines, canned in oil, drained, 2 sardines 46 12Liver, beef, cooked, 3 ounces 42 11Egg, 1 large (vitamin D is found in yolk) 41 10Ready-to-eat cereal, fortified with 10% of the DV for vitamin D, 0.75-1 cup 40 10(more heavily fortified cereals might provide more of the DV)Cheese, Swiss, 1 ounce 6 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 sunlighthttp://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/
Pagets 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.
Paget’s 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.
Paget’s 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 don’t 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 Pagets 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• 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 Pagets 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 Pagets 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, Pagets 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, Pagets disease of the pelvis. The bone is thick, wide, and patchy.