Musculoskeletal disorders part 1 cld

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Musculoskeletal disorders
includes the following disorders:
Bone infections: Osteomyelitis, and Septic arthritis; Disorders of foot:
Hallux valgus (bunions), Morton’s neuroma (plantar neuroma), and
Hammer toe; Muscular disorders:
Muscular dystrophy, and Rhabdomyolysis

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Musculoskeletal disorders part 1 cld

  1. 1. Musculoskeletal Disorders Part I Maria Carmela L. Domocmat, RN,MSN Instructor, Curative and Rehabilitative Nursing Care Management II School of Nursing Northern Luzon Adventist College Artacho, Sison, Pangasinan
  2. 2. Overview Part I Part II Bone infections Degenerative bone disorders: Osteomyelitis OA Septic arthritis Metabolic bone disorders Disorders of foot Osteoporosis Hallux valgus (bunions) Paget’s dse Morton’s neuroma (plantar Osteomalacia neuroma) Gout and gouty arthritis Hammer toe Spinal column deformities Muscular disorders Scoliosis Muscular dystrophy Kyphosis Rhabdomyolysis Lordosis2 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  3. 3. Bone infections Osteomyelitis Septic arthritis3 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  4. 4. Bone infections: Osteomyelitis4 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  5. 5. Osteomyelitis is an acute or chronic bone infection or inflammatory process of the bone and its structures secondary to infection with pyogenic organisms.5 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  6. 6. Osteomyelitis Osteomyelitis is infection in the bones. Often, the original site of infection is elsewhere in the body, and spreads to the bone by the blood. Bacteria or fungus6 may sometimes be responsible for osteomyelitis. Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  7. 7. Causes, incidence, and risk factors Bone infection can be caused by bacteria (more common) or fungi (less common). Infection may spread to a bone from infected skin, muscles, or tendons next to the bone, as in osteomyelitis that occurs under a chronic skin ulcer (sore). The infection that causes osteomyelitis can also start in another part of the body and spread to the bone through the blood. A current or past injury may have made the affected bone more likely to develop the infection. A bone infection can also start after bone surgery, especially if the surgery is done after an injury or if metal rods or plates are placed in the bone. In children, the long bones are usually affected. In adults, the feet, spine bones (vertebrae), and the hips (pelvis) are most commonly affected.7 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  8. 8. Risk factors Diabetes Hemodialysis Injected drug use Poor blood supply Recent trauma People who have had their spleen removed are also at higher risk for osteomyelitis8 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  9. 9. Symptoms Bone pain Fever General discomfort, uneasiness, or ill-feeling (malaise) Local swelling, redness, and warmth Other symptoms that may occur with this disease: Chills Excessive sweating Low back pain Swelling of the ankles, feet, and legs9 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  10. 10. Osteomyelitis Osteomyelitis of diabetic Osteomyelitis of T10 foot secondary to streptococcal disease.10 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  11. 11. Osteomyelitis Osteomyelitis of the great Osteomyelitis of index toe finger metacarpal head secondary to clenched fist injury11 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  12. 12. Osteomyelitis Osteomyelitis of index Osteomyelitis of the elbow. finger metacarpal head secondary to clenched fist injury.12 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  13. 13. Dx tests A physical examination shows bone tenderness and possibly swelling and redness. Tests may include: Blood cultures Bone biopsy (which is then cultured) Bone scan Bone x-ray Complete blood count (CBC) C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR) MRI of the bone Needle aspiration of the area around affected bones13 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  14. 14. Dx tests Diagnosis requires 2 of the 4 following criteria: Purulent material on aspiration of affected bone Positive findings of bone tissue or blood culture Localized classic physical findings of bony tenderness, with overlying soft-tissue erythema or edema Positive radiological imaging study http://emedicine.medscape.com/article/785020-treatment14 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  15. 15. Emergency Department Care rarely requires emergent stabilization or resuscitation. The primary challenge for ED physicians is considering the appropriate diagnosis in the face of subtle signs or symptoms. Treatment for osteomyelitis involves the following: Initiation of intravenous antibiotics that penetrate bone and joint cavities Referral of the patient to an orthopedist or general surgeon Possible medical infectious disease consultation http://emedicine.medscape.com/article/785020-treatment15 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  16. 16. Emergency Department Care Select the appropriate antibiotics using direct culture results in samples from the infected site, whenever possible. Empiric therapy is often initiated on the basis of the patients age and the clinical presentation. Empiric therapy should always include coverage for S aureus and consideration of CA-MRSA. Further surgical management may involve removal of the nidus of infection, implantation of antibiotic beads or pumps, hyperbaric oxygen therapy, or other modalities. http://emedicine.medscape.com/article/785020-treatment16 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  17. 17. Treatment goal of treatment get rid of the infection reduce damage to the bone and surrounding tissues. Antibiotics are given to destroy the bacteria causing the infection. may receive more than one antibiotic at a time. Often, the antibiotics are given through an IV (intravenously, meaning through a vein) rather than by mouth. Antibiotics are taken for at least 4 - 6 weeks, sometimes longer.17 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  18. 18. Treatment Surgery to remove dead bone tissue if have an infection that does not go away. If there are metal plates near the infection, they may need to be removed. The open space left by the removed bone tissue may be filled with bone graft or packing material that promotes the growth of new bone tissue. Infection of an orthopedic prosthesis, such as an artificial joint, may need surgery to remove the prosthesis and infected tissue around the area. If have diabetes- need to be well controlled. If problems with blood supply to the infected area, such as the foot, surgery to improve blood flow may be needed.18 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  19. 19. Medication Summary The primary treatment for osteomyelitis is parenteral antibiotics that penetrate bone and joint cavities. for at least 4-6 weeks. After intravenous antibiotics are initiated on an inpatient basis, therapy may be continued with intravenous or oral antibiotics, depending on the type and location of the infection, on an outpatient basis.19 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  20. 20. Medication Summary The following are recommendations for the initiation of empiric antibiotic treatment based on the age of the patient and mechanism of infection: hematogenous osteomyelitis (newborn to adult), infectious agents include S aureus, Enterobacteriaceae organisms, group A and BStreptococcus species, and H influenzae. Primary treatment - combination of penicillinase-resistant synthetic penicillin and a third-generation cephalosporin. Alternate therapy - vancomycin or clindamycin and a third- generation cephalosporin, particularly if methicillin-resistant S aureus (MRSA) Linezolid ciprofloxacin and rifampin20 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  21. 21. Medication Summary with sickle cell anemia and osteomyelitis primary bacterial causes are S aureus and Salmonellae species. primary choice for treatment - fluoroquinolone antibiotic (not in children). alternative choice - a third-generation cephalosporin (eg, ceftriaxone)21 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  22. 22. Medication Summary nail puncture through an athletic shoe the infecting agents may include S aureus and Pseudomonas aeruginosa. primary antibiotics - ceftazidime or cefepime. alternative treatment - Ciprofloxacin osteomyelitis due to trauma infecting agents include S aureus, coliform bacilli, and Pseudomonas aeruginosa. Primary antibiotics - nafcillin and ciprofloxacin. Alternatives - vancomycin and a third-generation cephalosporin with antipseudomonal activity.22 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  23. 23. Antibiotics Nafcillin (Nafcil, Unipen) Initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections. Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants. Because of thrombophlebitis, particularly in elderly patients, administer parenterally for only the short term (1-2 d). Change to PO route as clinically indicated. Note: Administer in combination with a third-generation cephalosporin to treat osteomyelitis. Do not admix with aminoglycosides for IV administration.23 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  24. 24. Antibiotics Ceftriaxone (Rocephin) Third-generation cephalosporin with broad-spectrum gram- negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms; arrests bacterial growth by binding to one or more penicillin- binding proteins. Note: Administer with a penicillinase-resistant synthetic penicillin, when treating osteomyelitis.24 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  25. 25. Antibiotics Cefazolin (Ancef) First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth; primarily active against skin flora, including S aureus; typically used alone for skin and skin-structure coverage.25 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  26. 26. Antibiotics Ciprofloxacin (Cipro) Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram- negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth. Continue treatment for at least 2 d (typical treatment, 7-14 d) after signs and symptoms disappear.26 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  27. 27. Antibiotics Ceftazidime (Fortaz, Ceptaz) Third-generation cephalosporin with broad-spectrum gram- negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms; arrests bacterial growth by binding to one or more penicillin- binding proteins.27 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  28. 28. Antibiotics Clindamycin (Cleocin) Lincosamide for the treatment of serious skin and soft-tissue staphylococcal infections; also effective against aerobic and anaerobic streptococci (except enterococci); inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, arresting RNA-dependent protein synthesis.28 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  29. 29. Antibiotics Vancomycin (Vancocin) Potent antibiotic directed against gram-positive organisms and active againstEnterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who can not receive or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients with renal impairment. Used in conjunction with gentamicin for prophylaxis in penicillin- allergic patients undergoing gastrointestinal or genitourinary procedures.29 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  30. 30. Antibiotics Linezolid (Zyvox) Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process. Bacteriostatic against staphylococci. The FDA warns against the concurrent use of linezolid with serotonergic psychiatric drugs, unless indicated for life- threatening or urgent conditions. Linezolid may increase serotonin CNS levels as a result of MAO-A inhibition, increasing the risk of serotonin syndrome.[14]30 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  31. 31. (prognosis) Expectations (prognosis) The prognosis for osteomyelitis varies but is markedly improved with timely diagnosis and aggressive therapeutic intervention. The outlook is worse for those with long-term (chronic) osteomyelitis, even with surgery. Amputation may be needed, especially in those with diabetes or poor blood circulation. The outlook for those with an infection of an orthopedic prosthesis depends, in part, on: The patients health The type of infection Whether the infected prosthesis can be safely removed31 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  32. 32. Complications When the bone is infected, pus is produced in the bone, which may result in an abscess. The abscess steals the bones blood supply. The lost blood supply can result in a complication called chronic osteomyelitis. This chronic infection can cause symptoms that come and go for years. Other complications include: Need for amputation Reduced limb or joint function Spread of infection to surrounding tissues or the bloodstream32 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  33. 33. Complications Complications of osteomyelitis may include the following: Bone abscess Paravertebral/epidural abscess Bacteremia Fracture Loosening of the prosthetic implant Overlying soft-tissue cellulitis Draining soft-tissue sinus tracts33 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  34. 34. Prevention Prompt and complete treatment of infections is helpful. People who are at high risk or who have a compromised immune system should see a health care provider promptly if they have signs of an infection anywhere in the body.34 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  35. 35. Deterrence/Prevention Acute hematogenous osteomyelitis can potentially be avoided by preventing bacterial seeding of bone from a remote site. This involves the appropriate diagnosis and treatment of primary bacterial infections. Direct inoculation osteomyelitis can best be prevented with appropriate wound management and consideration of prophylactic antibiotic use at the time of injury.35 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  36. 36. References Espinoza LR. Infections of bursae, joints, and bones. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 293. Gutierrez KM. Osteomyelitis. In: Long SS, ed. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2008:chap 80. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH000147 3/36 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  37. 37. Bone infections: Septic arthritis37 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  38. 38. Septic arthritis Septic arthritis is inflammation of a joint due to a bacterial or fungal infection. AKA: infectious arthritis Bacterial arthritis Non-gonococcal bacterial arthritis Reactive arthritis a sterile inflammatory process that usually results from an extra-articular infectious process. Bacteria are the most significant pathogens because of their rapidly destructive nature.38 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  39. 39. Causes Septic arthritis develops when bacteria or other tiny disease- causing organisms (microorganisms) spread through the bloodstream to a joint. It may also occur when the joint is directly infected with a microorganism from an injury or during surgery. most common sites - knee and hip. acute septic arthritis bacteria such as staphylococcus or streptococcus. chronic septic arthritis – less common caused by organisms such as Mycobacterium tuberculosisand Candida albicans.39 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  40. 40. Risk factors Artificial joint implants Bacterial infection somewhere else in your body Chronic illness or disease (such as diabetes, rheumatoid arthritis, and sickle cell disease) Intravenous (IV) or injection drug use Medications that suppress your immune system Recent joint injury Recent joint arthroscopy or other surgery40 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  41. 41. Risk factors seen at any age. Children occurs most often in those younger than 3 years. The hip is often the site of infection in infants. uncommon from age 3 to adolescence. Children - more likely than adults infected with Group B streptococcus or Haemophilus influenza, if they have not been vaccinated.41 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  42. 42. Symptoms Symptoms usually come on quickly. Fever joint swelling - usually just one joint. intense joint pain- gets worse with movement.42 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  43. 43. 43 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  44. 44. Symptoms in newborns or infants: Cries when infected joint is moved (example: diaper change causes crying if hip joint is infected) Fever Inability to move the limb with the infected joint (pseudoparalysis) Irritability44 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  45. 45. Symptoms in children and adults: Inability to move the limb with the infected joint (pseudoparalysis) Intense joint pain Joint swelling Joint redness Low fever Chills may occur, but are uncommon45 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  46. 46. Exams and Tests Aspiration of joint fluid for cell count, examination of crystals under the microscope, gram stain, and culture Blood culture X-ray of affected joint46 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  47. 47. 47 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  48. 48. Treatment Antibiotics are used to treat the infection. Resting, keeping the joint still, raising the joint, and using cool compresses may help relieve pain. Exercising the affected joint helps the recovery process. If synovial fluid builds up quickly due to the infection, a needle may be inserted into the joint often to aspirate the fluid. Severe cases may need surgery to drain the infected joint fluid.48 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  49. 49. Medical management of infective arthritis focuses adequate and timely drainage of the infected synovial fluid, administration of appropriate antimicrobial therapy immobilization of the joint to control pain.49 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  50. 50. Antibiotic Therapy In native joint infections, parenteralantibiotics - at least 2 weeks. Infection with either methicillin-resistant S aureus (MRSA) or methicillin-susceptible S aureus (MSSA) - at least 4 full weeks IV antibiotic therapy. Orally administered antimicrobial agents are almost never indicated in the treatment of S aureus infections. Gram-negative native joint infections with a pathogen that is sensitive to quinolones can be treated with oral ciprofloxacin for the final 1-2 weeks of treatment. As a rule, a 2-week course of intravenous antibiotics is sufficient to treat gonococcal arthritis.50 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  51. 51. Antibiotics linezolid with or without rifampin - for staphylococcal prosthetic joint infection (PJI). Ceftriaxone (Rocephin) drug of choice (DOC) against N gonorrhoeae. This agent is effective against gram-negative enteric rods. Monitor sensitivity data. Ciprofloxacin (Cipro) alternative antibiotic to ceftriaxone to treat N gonorrhoeae and gram-negative enteric rods.51 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  52. 52. Antibiotics Cefixime (Suprax) a third-generation oral cephalosporin with broad activity against gram-negative bacteria. Oral cefixime is used as a follow-up to intravenous (IV) ceftriaxone to treat N gonorrhoeae. Oxacillin useful against methicillin-sensitive S aureus (MSSA).52 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  53. 53. Antibiotics Vancomycin (Vancocin) anti-infective agent used against methicillin-sensitive S aureus (MSSA), methicillin-resistant coagulase-negative S aureus (CONS), and ampicillin-resistant enterococci in patients allergic to penicillin. Linezolid (Zyvox) an alternative antibiotic that is used in patients allergic to vancomycin and for the treatment of vancomycin-resistant enterococci. http://emedicine.medscape.com/article/236299- medication#showall53 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  54. 54. Joint Immobilization and Physical Therapy Usually, immobilization of the infected joint to control pain is not necessary after the first few days. If the patients condition responds adequately after 5 days of treatment, begin gentle mobilization of the infected joint. Most patients require aggressive physical therapy to allow maximum postinfection functioning of the joint. Initial physical therapy consists of maintaining the joint in its functional position and providing passive range-of-motion exercises. The joint should bear no weight until the clinical signs and symptoms of synovitis have resolved. Aggressive physical therapy is often required to achieve maximum therapy benefit.54 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  55. 55. Synovial Fluid Drainage The choice of the type of drainage, whether percutaneous or surgical, has not been resolved completely.[19, 25] In general, use a needle aspirate initially, repeating joint taps frequently enough to prevent significant reaccumulation of fluid. Aspirating the joint 2-3 times a day may be necessary during the first few days. If frequent drainage is necessary, surgical drainage becomes more attractive. Gonococcal-infected joints rarely require surgical drainage. Surgical drainage is indicated when one or more of the following occur: The appropriate choice of antibiotic and vigorous percutaneous drainage fails to clear the infection after 5-7 days The infected joints are difficult to aspirate (eg, hip) Adjacent soft tissue is infected Routine arthroscopic lavage is rarely indicated. However, drainage through the arthroscope is replacing open surgical drainage. With arthroscopic drainage, the operator can visualize the interior of the joint and can drain pus, debride, and lyse adhesions.55 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  56. 56. 56 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  57. 57. Surgical Intervention in Prosthetic Joint Infection In cases of prosthetic joint infection (PJI) that require surgery for cure, successful treatment requires appropriate antibiotic therapy combined with removal of the hardware. Despite appropriate antibiotic use, the success rate has been only about 20% if the prosthesis is left in place. In recent years, evidence has shown that debridement alone could yield a cure rate of 74.5% of patients with a prosthetic joint infection and a C-reactive protein (CRP) level of 15 mg/dL or less who are treated with a fluoroquinolone.[26] For the time being, a 2-stage approach should be regarded as the most effective technique. First, remove the prosthesis and follow with 6 weeks of antibiotic therapy. Then, place the new joint, impregnating the methylmethacrylate cement with an anti-infective agent (ie, gentamicin, tobramycin). Antibiotic diffusion into the surrounding tissues is the goal. The success rate for this approach is approximately 95% for both hip and knee joints. An intermediate method is to exchange the new joint for the infected joint in a 1-stage surgical procedure with concomitant antibiotic therapy. This method, with concurrent use of antibiotic cement, succeeds in 70-90% of cases.57 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  58. 58. (Prognosis) Outlook (Prognosis) Recovery is good with prompt antibiotic treatment. If treatment is delayed, permanent joint damage may result.58 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  59. 59. Possible Complications Joint degeneration (arthritis)59 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  60. 60. Prevention Strictly adhere to sterile procedures whenever the joint space is invaded (eg, in aspiration or arthroscopic procedures). Antibiotic prophylaxis with an antistaphylococcal antibiotic has been demonstrated to reduce wound infections in joint replacement surgery. Polymethylmethacrylate cement impregnated with antibiotics may decrease perioperative infections.60 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  61. 61. Prevention Treat any infection promptly to lessen the chance of bloodstream invasion. decreasing the incidence of underlying infections best prevents reactive arthritis61 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  62. 62. References Espinoza LR. Infections of bursae, joints, and bones. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 290. Ohl CA. Infectious arthritis of native joints. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennetts Principles and Practice of Infectious Disease. 7th ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 102. http://www.nlm.nih.gov/medlineplus/ency/article/00043 0.htm http://emedicine.medscape.com/article/236299- medication#showall62 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  63. 63. Disorders of foot Hallux valgus (bunions) Morton’s neuroma (plantar neuroma) Hammer toe63 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  64. 64. 64 Maria Carmela L. Domocmat, RN, MSN http://familyfootcarenj.com/web/images/layout/conditions_map.jpg 8/24/2011
  65. 65. Disorders of foot : Hallux valgus (bunions)65 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  66. 66. Hallux valgus is a condition that affects the joint at the base of the big toe. The condition is commonly called a bunion. bunion - refers to the bump that grows on the side of the first metatarsophalangeal (MTP) joint.66 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  67. 67. Hallux valgus (bunion) The deformity involves the big toe and the long bone behind the big toe, the 1st metatarsal. Over time, the 1st metatarsal will begin to move towards the other foot (medial) while the big toe will move out of joint towards the 2nd toe (lateral). As the end of the 1st metatarsal bone begins to stick out, it will be under pressure from shoes and the ground. this constant pressure and friction will cause extra bone formation, leading to the bump that is seen on the side of the foot. The big toe will continue to shift towards the second toe causing an unbalanced big toe joint. Over time arthritis can develop in the joint due to the mal- positioned joint. A bunion deformity is always progressive. It will always get worse over time. http://www.footankleinstitute.com/hallux-valgus-bunion-surgery/67 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  68. 68. 68 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  69. 69. 69 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  70. 70. Hallux valgus (bunion) term hallux valgus actually describes what happens to the big toe. Hallux - medical term for big toe Valgus - anatomic term that means the deformity goes in a direction away from the midline of the body. hallux valgus - big toe begins to point towards the outside of the foot. As this condition worsens, other changes occur in the foot that increase the problem.70 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  71. 71. Hallux valgus (bunion) Changes include: bone just above the big toe, the first metatarsal usually develops too much of an angle in the other direction. This condition is called metatarsus primus varus. Metatarsus primus -means first metatarsal varus - medical term that means the deformity goes in a direction towards the midline of the body. This creates a situation where the first metatarsal and the big toe now form an angle with the point sticking out at the inside edge of the ball of the foot. The bunion that develops is actually a response to the pressure from the shoe on the point of this angle. At first the bump is made up of irritated, swollen tissue that is constantly caught between the shoe and the bone beneath the skin. As time goes on, the constant pressure may cause the bone to thicken as well, creating an even larger lump to rub against the shoe.71 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  72. 72. Etiology Contrary to common belief, high-heeled shoes with a small toe box or tight-fitting shoes do not cause hallux valgus. such footwear does keep the hallux in an abducted position if hallux valgus is present, causing mechanical stretch and deviation of the medial soft tissue. In addition, tight shoes can cause medial bump pain and nerve entrapment.72 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  73. 73. Etiology Biomechanical instability Arthritic/metabolic conditions Structural deformity Neuromuscular disease Traumatic compromise73 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  74. 74. Etiology Biomechanical instability most common yet most difficult to understand etiology Contributing factors, if present, include gastrocnemius or gastrocsoleus equinus, flexible or rigid pes plano valgus, rigid or flexible forefoot varus, dorsiflexed first ray, hypermobility, or short first metatarsal. Most often, excessive pronation at the midtarsal and subtalar joints compensates for these factors throughout the gait cycle.74 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  75. 75. Etiology Biomechanical instability Some pronation must occur in gait to absorb ground-reactive forces. However, excessive pronation produces too much midfoot mobility, which decreases stability and prevents resupination and creation of a rigid lever arm; these effects make propulsion difficult.75 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  76. 76. Etiology Biomechanical instability During normal propulsion approximately 65° of dorsiflexion is necessary at the first metatarsophalangeal joint, only 20-30° is available from hallux dorsiflexion. Therefore, the first metatarsal must plantarflex at the sesamoid complex to gain the additional 40° of motion needed. Failure to attain the full 65° because of jamming of the joint during pronation subjects the first metatarsophalangeal to intense forces from which hallux valgus develops. If the foot is sufficiently hypermobile as a result of excessive pronation, the metatarsal tends to drift medially and the hallux drifts laterally, producing hallux valgus. If no hypermobility is present, hallux rigidus develops instead.76 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  77. 77. Etiology Arthritic/metabolic conditions Structural deformity Gouty arthritis Malalignment of articular Rheumatoid arthritis surface or metatarsal shaft Psoriatic arthritis Abnormal metatarsal Connective tissue length disorders such as Ehlers- Metatarsus primus elevatus Danlos syndrome, Marfan syndrome, Down External tibial torsion syndrome, and Genu varum or valgum ligamentous laxity Femoral retrotorsion77 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  78. 78. Etiology Neuromuscular disease Traumatic compromise Multiple sclerosis Malunions Charcot-Marie-Tooth Intra-articular damage disease Soft-tissue sprains Cerebral palsy Dislocations78 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  79. 79. Symptoms Symptoms of Hallux valgus depending on the degree of severity: Aesthetic problem. Formation of calluses, chronic irritation of the skin and bursa. Increasing pain under load and when moving. Progressive arthrosis and stiffening in the base joint of the toe. Corollary deformities such as hammer and claw toe. http://www.hallufix.org/english/hallux_valgus.html79 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  80. 80. Types of Hallux valgus Degree 1 Degree 2 Toe malpositioning below Malpositioning between 20 20 degrees. No symptoms. and 30 degrees. Occasional pain.80 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  81. 81. Types of Hallux valgus Degree 3 Degree 4 Malpositioning between 30 Severest form with and 50 degrees. Regular malpositionings over 50 pain. Increasing restraints degrees and painful on activities. Pronounced restraints on the activities malpositioning! of everyday life. Surgical treatment81 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  82. 82. Treatment Medical Therapy Adapting footwear Pharmacologic or physical therapy Functional orthotic therapy Surgical Therapy Capsulotendon balancing or exostectomy Osteotomy Resectional arthroplasty Resectional arthroplasty with implant First metatarsophalangeal joint arthrodesis First metatarsocuneiform joint arthrodesis82 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  83. 83. 83 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  84. 84. 84 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  85. 85. Bunionectomy remove the bump that makes up the bunion. performed through a small incision on the side of the foot immediately over the area of the bunion. Once the skin is opened the bump is removed using a special surgical saw or chisel. The bone is smoothed of all rough edges and the skin incision is closed with small stitches. It is more likely that realignment of the big toe will also be necessary. The major decision that must be made is whether or not the metatarsal bone will need to be cut and realigned as well. The angle made between the first metatarsal and the second metatarsal is used to make this decision. The normal angle is around nine or ten degrees. If the angle is 13 degrees or more, the metatarsal will probably need to be cut and realigned. When a surgeon cuts and repositions a bone, it is referred to as an osteotomy. There are two basic techniques used to perform an osteotomy to realign the first metatarsal.85 Maria Carmela L. Domocmat, RN, MSN http://www.concordortho.com/patient-education/topic-detail- 8/24/2011 popup.aspx?topicID=a5cea3a8a6d8093483657c959125dbaf
  86. 86. Distal Osteotomy the far end of the bone is cut and moved laterally This effectively reduces the angle between the first and second metatarsal bones. usually requires one or two small incisions in the foot. Once the surgeon is satisfied with the position of the bones, the osteotomy is held in the desired position with one, or several,metal pins. Once the bone heals, the pin is removed. The metal pins are usually removed between three and six weeks following surgery.86 Maria Carmela L. Domocmat, RN, MSN http://www.concordortho.com/patient-education/topic-detail- 8/24/2011 popup.aspx?topicID=a5cea3a8a6d8093483657c959125dbaf
  87. 87. Proximal Osteotomy the first metatarsal is cut at the near end of the bone usually requires two or three small incisions in the foot. Once the skin is opened the surgeon performs the osteotomy. The bone is then realigned and held in place with metal pins until it heals. Again, this reduces the angle between the first and second metatarsal bones. Realignment of the big toe is then done by releasing the tight structures on the lateral, or outer, side of the first MTP joint. This includes the tight joint capsule and the tendon of the adductor hallucis muscle. This muscle tends to pull the big toe inward. By releasing the tendon, the toe is no longer pulled out of alignment. The toe is realigned and the joint capsule on the side of the big toe closest to the other toe is tightened to keep the toe straight, or balanced. Once the surgeon is satisfied that the toe is straight and well balanced, the skin incisions are closed with small stitches. A bulky bandage is applied to the foot before you are returned to the recovery room.87 Maria Carmela L. Domocmat, RN, MSN http://www.concordortho.com/patient-education/topic-detail- 8/24/2011 popup.aspx?topicID=a5cea3a8a6d8093483657c959125dbaf
  88. 88. Good footwear is often all that is needed Wearing good footwear does not cure the deformity but may ease symptoms of pain and discomfort. Ideally, get advice about footwear from a podiatrist or chiropodist. Advice may include: Wear shoes, trainers or slippers that fit well and are roomy. Dont wear high-heeled, pointed or tight shoes. You might find that shoes with laces or straps are best, as they can be adjusted to the width of your foot. Padding over the bunion may help, as may ice packs. Devices which help to straighten the toe (orthoses) are still occasionally recommended, although trials investigating their use have not found them much better than no treatment at all. http://www.patient.co.uk/health/Bunions-(Hallux-Valgus).htm88 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  89. 89. Resectional arthroplasty is a joint-destructive procedure most commonly is reserved for elderly patients with advanced degenerative joint disease and significant limitation of motion. The typical resectional arthroplasty that is performed is known as a Keller procedure. It is performed when morbidity might be increased with the more aggressive osteotomy that would otherwise be selected. The procedure includes resection of the base of the proximal phalanx with reapproximation of the abductor and adductor tendon groups. The technique is inherently unstable and should be used judiciously. The postoperative course includes limited-to-full weight bearing in a surgical shoe immediately after the procedure. http://emedicine.medscape.com/article/1232902-treatment#showall89 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  90. 90. Resectional arthroplasty with implant is the same procedure as the resectional arthroplasty, with similar indications, but stability is markedly improved with the addition of the total implant. Preoperative radiograph shows Postoperative radiograph degenerative joint disease. obtained after resectional arthroplasty and total joint http://emedicine.medscape.com/article/1232902-treatment#showall implant placement.90 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  91. 91. First metatarsophalangeal joint arthrodesis First metatarsophalangeal joint arthrodesis (see images below) is a joint-destructive procedure that offers a higher degree of stability and functionality. It is considered the definitive procedure for degenerative joint disease. It results in complete loss of motion at the first metatarsophalangeal joint and is reserved for patients with high activity levels and functional demands. Preoperative Postoperative radiograph radiograph shows show arthrodesis. arthrodesis.91 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  92. 92. First metatarsocuneiform joint arthrodesis Significant and/or hypermobile hallux abductovalgus may be reduced with arthrodesis of the first metatarsocuneiform joint (see images below). Indications include metatarsus primus varus, hypermobility of the first ray, metatarsalgia of the lesser metatarsals, and degenerative joint disease of the metatarsocuneiform joint. Preoperative radiograph shows a Postoperative radiograph shows hypermobile first ray. arthrodesis of the first92 Maria Carmela L. Domocmat, RN, MSN metatarsocuneiform. 8/24/2011
  93. 93. How to Choose Shoes 1. Know your foot. Take a look at your old shoes. Look at what areas the most worn out shoes. A well- chosen shoes will help to endure the physical stress well. One way to determine your foots shape is to do a "wet test"--- wet your foot, step on a piece of brown paper and trace your footprint. Or just look at where your last pair of shoes shows the most wear. 2. Dont buy uncomfortable shoes even if they are hot! 3. Ideally, you should avoid wearing heels 4. Dont make shoes multitask. 5. Knowing your foots particular quirks is key to selecting the right pair of shoes. 6.You must find shoes with well cushioned soles and ideally, some type of soft arch-support. 7. Measure your foot frequently. Foot size changes as we get older. 8.You should not buy shoes in the morning. The size of our feet at night more than in the morning. Feet swell over the course of the day; they also expand while you run or walk, so shoes should fit your feet when theyre at their largest. http://hallux-valgus-rigidus.com/index.php?option=com_content&view=article&id=74&Itemid=8893 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  94. 94. How to Choose Shoes 9. Always buy shoes to fit the larger or wider foot. Buy well-fitting shoes with a wide toe box. 10. Use bunion shields, bunion pads or bunion cushions to protect the bunion when wearing shoes. A bunion sleeve can be especially effective at relieving shoe pressure when walking with a hallux valgus. 11. Utilize an orthotic device or insert, such as a bunion splint or bunion brace, to redistribute the pressure along the arch and ball of the foot and control the separation of the bones. These devices help support your foot and reduce the tendency toward hallux valgus formation. 12. Use a bunion regulator to stretch tight tendons and toe muscles overnight – especially if you want to avoid surgery. http://hallux-valgus-rigidus.com/index.php?option=com_content&view=article&id=74&Itemid=8894 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  95. 95. 95 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  96. 96. 96 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  97. 97. 97 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  98. 98. Marfan syndrome (MFS) is a spectrum disorder caused by a heritable genetic defect of connective tissue that has an autosomal dominant mode of transmission The defect itself has been isolated to the FBN1 gene on chromosome 15, which codes for the connective tissue protein fibrillin. Abnormalities in this protein cause a myriad of distinct clinical problems, of which the musculoskeletal, cardiac, and ocular system problems predominate. The skeleton of patients with MFS typically displays multiple deformities including arachnodactyly (ie, abnormally long and thin digits), dolichostenomelia (ie, long limbs relative to trunk length), pectus deformities (ie, pectus excavatum and pectus carinatum), and thoracolumbar scoliosis In the cardiovascular system, aortic dilatation, aortic regurgitation, and aneurysms are the most worrisome clinical findings. Mitral valve prolapse that requires valve replacement can occur as well. Ocular findings include myopia,cataracts, retinal detachment and superior dislocation of the lens98 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  99. 99. pectus carinatum pectus excavatum99 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  100. 100. Ehlers- Genetics of Ehlers-Danlos Syndrome Ehlers-Danlos family of disorders is a group of related conditions that share a common decrease in the tensile strength and integrity of the skin, joints, and other connective tissues. The first detailed clinical description of the syndrome is attributed to Tschernogobow in 1892. The syndrome derives its name from reports by Edward Ehlers, a Danish dermatologist, in 1901 and by Henri-Alexandre Danlos, a French physician with expertise in chemistry of skin disorders, in 1908. These 2 physicians combined the pertinent features of the condition and accurately delineated the phenotype of this group of disorders.100 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  101. 101. The amazing, almost unnatural, contortions that some patients with Ehlers-Danlos syndrome can perform often arouse curiosity. Historically, some patients with Ehlers- Danlos syndrome displayed the maneuvers publically in circuses, shows, and performance tours. Some achieved modest degrees of fame and bore titles such as "The India Rubber Man," "The Elastic Lady," and "The Human Pretzel." Such clinical features also raise suspicion of the diagnosis when identified upon physical examination. Unfortunately, patients often go many years before being diagnosed101 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  102. 102. Patient with Ehlers-Danlos syndrome mitis. Joint Patient with Ehlers-Danlos hypermobility is less intense than syndrome. Note the abnormal with other conditions. ability to elevate the right toe. Girl with Ehlers-Danlos syndrome. Dorsiflexion of all the fingers is easy and absolutely painless.102 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  103. 103. All forms of Ehlers-Danlos syndrome share the following primary features to varying degrees: Skin hyperextensibility Joint hypermobility and excessive dislocations Tissue fragility Poor wound healing, leading to wide thin scars: The classic description of abnormal scar formation in Ehlers-Danlos syndrome is "cigarette paper scars." Easy bruising103 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  104. 104. Type Inheritance Previous Major Diagnostic Minor Diagnostic Nomenclature Criteria CriteriaKyphoscol Autosomal Type VI – lysyl Joint laxity, severe Tissue fragility,iosis recessive hydroxylase hypotonia at birth, easy bruising, arterial rupture, deficiency scoliosis, progressive marfanoid, scleral fragility or microcornea, rupture of globe osteopenia, positive family history (affected sibling)Arthrocha AutosomalArthrochaAutosomal Type VII A, B Congenital bilateral Skin hyperextensibility,lasia dominant dislocated hips, tissue fragility with atrophic severe joint scars, muscle hypotonia, hypermobility, easy bruising, recurrent subluxations kyphoscoliosis, mild osteopeniaDermatos Autosomal Type VII C Severe skin fragility; Soft, doughy skin;paraxis recessive saggy, redundant skin easy bruising; premature rupture of membranes; hernias (umbilical and inguinal)104 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  105. 105. Type Inheritanc Previous Major Diagnostic Criteria Minor Diagnostic Criteria e NomenclatureClassic Autosomal Types I and II Skin hyperextensibility, Smooth, velvety skin; easy bruising; dominant molluscoid pseudotumors; subcutaneous spheroids; joint hypermobility; muscle hypotonia; wide atrophic scars, joint postoperative complication hypermobility (eg, hernia); positive family history; manifestations of tissue fragility (eg, hernia, prolapse)Hypermobilit Autosomal Type III Skin involvement (soft, smooth and Recurrent joint dislocation; chronicy dominant velvety), joint hypermobility joint pain, limb pain, or both; positive family historyVascular Autosomal Type IV Thin, translucent skin; Acrogeria, dominant arterial/intestinal fragility or hypermobile small joints; rupture; extensive bruising; tendon/muscle rupture; clubfoot; characteristic facial appearance early onset varicose veins; arteriovenous, carotid-cavernous sinus fistula; pneumothorax; gingival recession; positive family history; sudden death in close relative105 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  106. 106. Down syndrome Down syndrome is by far the most common and best known chromosomal disorder in humans and the most common cause of intellectual disability.[3] Mental retardation, dysmorphic facial features, and other distinctive phenotypic traits characterize the syndrome106 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  107. 107. Disorders of foot : Morton’s neuroma (plantar neuroma107 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  108. 108. Neuromas are non-cancerous growths of the nerve tissue that develop in different parts of the body.108 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  109. 109. Mortons Neuroma affects a nerve in the foot, often times the nerve between the third and fourth toe. thickens the tissue around the nerves that lead to the toes, causing sharp, burning sensations in the ball of the foot, as well as a numbing or stinging feeling. AKA: plantar neuroma or intermetatarsal neuroma.109 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  110. 110. http://www.footdoc.ca/www.FootDoc.ca/Website _Neuroma.gif110 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  111. 111. 111 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  112. 112. Neuroma and adherent fibrofatty tissue. http://emedicine.medscape.com/article/308284-clinical#showall112 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  113. 113. Sex The female-to-male ratio for Mortons neuroma is 5:1. Age The highest prevalence of Mortons neuroma is found in patients aged 15-50 years, but the condition may occur in any ambulatory patient. http://emedicine.medscape.com/article/308284-clinical#showall113 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  114. 114. Causes Various factors have been implicated in the precipitation of Mortons neuroma. Mortons neuroma is known to develop as a result of chronic nerve stress and irritation, particularly with excessive toe dorsiflexion. Poorly fitting and constricting shoes (ie, small toe box) or shoes with heel lifts often contribute to Mortons neuroma. Women who wear high-heeled shoes for a number of years or men who are required to wear constrictive shoe gear are at risk. A biomechanical theory of causation involves the mechanics of the foot and ankle. For instance, individuals with tight gastrocnemius-soleus muscles or who excessively pronate the foot may compensate by dorsiflexion of the metatarsals subsequently irritating of the interdigital nerve. Certain activities carry increased risk of excessive toe dorsiflexion, such as prolonged walking, running, squatting, and demi-pointe position in ballet.[4] http://emedicine.medscape.com/article/308284-clinical#showall114 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  115. 115. Manifestations Obtaining an accurate history is important to making the diagnosis of Mortons neuroma. Possible reported findings provided by the patient with Mortons neuroma include the following: The most common presenting complaints include pain and dysesthesias in the forefoot and corresponding toes adjacent to the neuroma. Pain is described as sharp and burning, and it may be associated with cramping. Numbness often is observed in the toes adjacent to the neuroma and seems to occur along with episodes of pain. Pain typically is intermittent, as episodes often occur for minutes to hours at a time and have long intervals (ie, weeks to months) between a single or small group of multiple attacks. Some patients describe the sensation as "walking on a marble." Massage of the affected area offers significant relief. Narrow tight high-heeled shoes aggravate the symptoms. Night pain is reported but is rare. http://emedicine.medscape.com/article/308284-clinical#showall115 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  116. 116. Dx tests palpable mass or a "click" between the bones. Doctor put pressure on the spaces between the toe bones to try to replicate the pain and look for calluses or evidence of stress fractures in the bones that might be the cause of the pain. Range of motion tests will rule out arthritis or joint inflammations. X-rays may be required to rule out a stress fracture or arthritis of the joints that join the toes to the foot. http://emedicine.medscape.com/article/308284-clinical#showall116 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  117. 117. Treatment Rehabilitation Program Physical Therapy Treatment strategies for Mortons neuroma range from conservative to surgical management. The conservative approach to treating Mortons neuroma may benefit from the involvement of a physical therapist. The physical therapist can assist the physician in decisions regarding the modification of footwear, which is the first treatment step. Recommend soft-soled shoes with a wide toe box and low heel (eg, an athletic shoe). High-heeled, narrow, nonpadded shoes should not be worn, because they aggravate the condition. The next step in conservative management is to alter alignment of the metatarsal heads. One recommended action is to elevate the metatarsal head medial and adjacent to the neuroma, thereby preventing compression and irritation of the digital nerve. A plantar pad is used most often for elevation. Have the patient insert a felt or gel pad into the shoe to achieve the desired elevation of the above metatarsal head. Other possible physical therapy treatment ideas for patients with Mortons neuroma include cryotherapy, ultrasonography, deep tissue massage, and stretching exercises. Ice is beneficial to decrease the associated inflammation. Phonophoresis also can be used, rather than just ultrasonography, to further decrease pain and inflammation. http://emedicine.medscape.com/article/308284-clinical#showall117 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  118. 118. Treatment Initial therapies are nonsurgical and relatively simple. They can involve one or more of the following treatments: Changes in footwear. Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal. Orthoses. Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve. http://orthoinfo.aaos.org/topic.cfm?topic=a00158118 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  119. 119. Treatment Injection. One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief. Combination Several studies have shown that a combination of roomier, more comfortable shoes, nonsteroidal anti- inflammatory medication, custom foot orthoses and cortisone injections provide relief in over 80 percent of people with Mortons Neuroma. http://orthoinfo.aaos.org/topic.cfm?topic=a00158119 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  120. 120. Surgical Intervention When conservative measures for Mortons neuroma are unsuccessful, surgical excision of the area of fibrosis in the common digital nerve may be curative. Common adverse outcomes include dysesthesias radiating from a painful nerve stump. Dysesthesias may be treated as any other dysesthetic pain. Surgical options include the following: Neurectomy with nerve burial Transverse intermetatarsal ligament release, with or without neurolysis Endoscopic decompression of the transverse metatarsal ligament http://emedicine.medscape.com/article/308284-clinical#showall120 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  121. 121. Other Treatment Perform injection into the dorsal aspect of the foot, 1-2 cm proximal to the webspace, in line with the MTP joints. Advance the needle through the midwebspace into the plantar aspect of the foot until the needle gently tents the skin. Then withdraw it about 1 cm to where the tip of the neuroma is located. Inject a corticosteroid/anesthetic mix. A reasonable volume is 1 mL of corticosteroid and 2 mL of anesthetic. T he anesthetic used should not contain epinephrine, as necrosis may result. Care also should be taken not to inject into the plantar pad. Adverse outcomes include plantar fat pad necrosis. Transient numbness of the toes also may occur. Although many practitioners use multiple injections, the likelihood of benefit from subsequent injections, after failure to achieve relief from the initial injection, is negligible. An Australian investigation using a single, ultrasonographically guided corticosteroid injection for Mortons neuroma found that 9 months after treatment, complete pain relief had occurred in 11 of the 39 neuromas studied.121 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  122. 122. Neurectomy: typical incision location. Neurectomy: superficial exposure.122 Maria Carmela L. Domocmat, RN, MSN Neurectomy: deeper dissection. Neuroma and adherent fibrofatty tissue. 8/24/2011 http://emedicine.medscape.com/article/308284-clinical#showall
  123. 123. Medication Summary Dysesthesias may be treated as any other dysesthetic pain. Tricyclic antidepressants, such as amitriptyline at 10-25 mg PO qhs, may be tried. If this approach is unsuccessful, anticonvulsants (eg, gabapentin, carbamazepine) often are effective.123 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  124. 124. Tricyclic Antidepressants Class Summary A complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission, and they block the active re-uptake of norepinephrine and serotonin. Amitriptyline (Elavil) Analgesic for certain chronic and neuropathic pain. Low doses, 10-25 mg qhs, may provide pain relief from burning and tingling occurring at rest but function only as an adjunct to definitive treatment.124 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  125. 125. Anticonvulsants Class Summary Use of certain antiepileptic drugs (AEDs), such as the GABA analogue Neurontin (gabapentin), has proven helpful in some cases of neuropathic pain. Thus, although unstudied, a trial of such an agent might conceivably provide analgesia for symptomatic neuropathy. Used for dysesthesias not controlled with definitive treatment plus tricyclic antidepressants (or in patients unable to take tricyclic antidepressants). Gabapentin (Neurontin) Neuromembrane stabilizer useful in pain reduction with dysesthetic pain. Has antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA, but does not interact with GABA receptors.125 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  126. 126. Anticonvulsants Pregabalin (Lyrica) Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2-delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.126 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  127. 127. Serotonin- Serotonin-Norepinephrine Reuptake Inhibitors Class Summary These agents inhibit neuronal serotonin and norepinephrine reuptake. Duloxetine (Cymbalta) Description Indicated for diabetic peripheral neuropathic pain. Potent inhibitor of neuronal serotonin and norepinephrine reuptake127 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  128. 128. Disorders of foot : Hammer toe128 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  129. 129. Hammer toe is a deformity of the toe, in which the end of the toe is bent downward.129 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  130. 130. Causes, incidence, and risk factors Hammer toe usually affects the second toe. However, it may also affect the other toes. The toe moves into a claw-like position. The most common cause of hammer toe is wearing short, narrow shoes that are too tight. The toe is forced into a bent position. Muscles and tendons in the toe tighten and become shorter. Hammer toe is more likely to occur in: Women who wear shoes that do not fit well or have high heels Children who keep wearing shoes they have outgrown The condition may be present at birth (congenital) or develop over time. In rare cases, all of the toes are affected. This may be caused by a problem with the nerves or spinal cord.130 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  131. 131. Symptoms The middle joint of the toe is bent. The end part of the toe bends down into a claw-like deformity. At first, you may be able to move and straighten the toe. Over time, you will no longer be able to move the toe. A corn often forms on the top of the toe. A callus is found on the sole of the foot. Walking or wearing shoes can be painful.131 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  132. 132. Dx tests physical examination of the foot decreased and painful movement in the toes. http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9360.jpg132 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  133. 133. 133 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  134. 134. http://www.myfootshop.com/images/medical/ortho/hammer_toe_differences_mod.jpg134 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  135. 135. 135 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  136. 136. http://www.family- foot.com/images/hammer_toe_whatis.jpg136 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  137. 137. Treatment Mild hammer toe in children can be treated by manipulating and splinting the affected toe.137 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  138. 138. Treatment The following changes in footwear may help relieve symptoms: Wear the right size shoes or shoes with wide toe boxes for comfort, and to avoid making hammer toe worse. Avoid high heels as much as possible. Wear soft insoles to relieve pressure on the toe. Protect the joint that is sticking out with corn pads or felt pads138 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  139. 139. Treatment A foot doctor can make foot devices called hammer toe regulators or straighteners for you, or you can buy them at the store. Exercises may be helpful. You can try gentle stretching exercises if the toe is not already in a fixed position. Picking up a towel with your toes can help stretch and straighten the small muscles in the foot.139 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  140. 140. Treatment For severe hammer toe, you will need an operation to straighten the joint. The surgery often involves cutting or moving tendons and ligaments. Sometimes the bones on each side of the joint need to be connected (fussed) together. Most of the time, you will go home on the same day as the surgery. The toe may still be stiff afterward, and it may be shorter.140 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  141. 141. Prevention and Cure of Hammer Toes with Products Hammer Toe Regulator Toe Rings Hammer Toe Cushion Toe Brace Foam Toe Tubes Toe Alignment Splint Gel Toe Cap Toe Trainers Toe Spreader Hammer Toe Straightener Silicone Toe Crest Toe Spacer Cushion Digital Toe Pad Yoga Toes Toe Stretcher141 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  142. 142. 142 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  143. 143. Pedifix Budin Hammer Toe Regulator, Single Loop Hammer Toe Splint aligns crooked, overlapping or hammer toes. Effective post-op splint. Encourages flexion and extension of flexible digits. Soft, durable, cotton covered. One size fits all. Price: $3.40143 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  144. 144. 144 Maria Carmela L. Domocmat, RN, MSN 8/24/2011 http://mdbuyinggroup.com/products/sites/default/files/productimages/pedifix%20budin%20hammer %20toe%20regulator.jpg
  145. 145. Hammer Toe Correction Bandage Price $14.95145 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  146. 146. Hammer Toe Regulator Toe regulator efficiently integrates the middle joint of toe with other joints. It reduces the pressure and irritation at toe tips and region over the toes. The toe regulator straightens the joint of hammer toes (or) claw toes with a slight and smooth pressure. Toe regulator is effective for pain relief and proper alignment of hammer toes.146 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  147. 147. Hammer Toe Cushion Hammer Toe Cushion provides ease feel over the contracted part and comforts Hammer toe with enough support. It assists for a stress free movement and aid in lifting the toe to normal position. Hammer toe cushion minimizes pressure at the top and tip of toes with a spongy effect. Toe cushion is provided with an adjustable toe loop for comfortable and secure fit.147 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  148. 148. Foam Toe Tubes The soft foam present in the tube safeguard toes from rash rubbing against footwear. Foam toe tube is easy to wear for getting effective pain relief from hammer toes. It reduce the pressure and swelling over Hammer toes for trouble free walks.148 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  149. 149. Gel Toe Cap Gel Toe Cap softens the Hammer toes giving excellent cushioning to the painful deformed toes. It also relieves extreme pain at the top and tip of toes effectively. Gel maintains the spongy comfort and reduces pressure all over the hammer toe.149 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  150. 150. Silicone Toe Crest The reinforced loop with elastic fabric of the toe crest holds the toe perfectly straight. The toe crest provides soft feel under three toes excluding the big and little toe. It relieves the pain caused by hammer toe. It adds strength to the toe and gives extra smoothness to the affected spot. Silicone soothes the toe for ease feel. Toe crest is durable and can be worn comfortably with a snug fit.150 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  151. 151. Toe Alignment Splint Toe alignment splint reduces the pressure and pain caused by Hammer toes and Bunions. It specifically aligns the toe placing it in correct position. The smooth cotton band with elastic property gives secure fit around the foot. Its thin straps can be placed over affected toes and the rigidity is adjustable using hook-and loop strap. Unique T-strap of the splint reduces the pain of bunion and prevents the big toe to slant over hammer toes (or) crooked toes. Toe alignment splint is comfortable to wear with casual shoes.151 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  152. 152. Toe Trainers Toe trainer comforts flexible hammer toes. It gives better relief against the pain and irritation. Toe trainer separates the toes and aligns them to look straight. It is an effective item to cure slightly movable Hammer toes. The cotton-covered foam provides secure feel to the crooked toes. Toe trainer is easy to wear and fits snugly for efficient correction of hammer toes.152 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  153. 153. Hammer Toe Straightener The toe Straightener perfectly aligns Hammer toes with little pressure. Its cotton-covered loop with elasticity holds the toe firmly in proper place and it can be easily adjusted for stress free movements. The smooth foam pad molds accordingly with the foot shape and renders superior cushioning at the bottom of the feet. It also stops the pain caused by hammer toes. The hook closure present in the toe straightener pulls down and aligns the deformed toes to keep you always smiling. Hammer toe Straightener assists for healthy feet by strengthening the toes and forefoot muscles.153 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  154. 154. Prevention Avoid wearing shoes that are too short or narrow. Check childrens shoe sizes often, especially during periods of fast growth.154 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  155. 155. (prognosis) Expectations (prognosis) If the condition is treated early, you can often avoid surgery. Treatment will reduce pain and walking difficulty.155 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  156. 156. Complications Foot deformity Posture changes caused by difficulty in walking156 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  157. 157. References Krug RJ, Lee EH, Dugan S, Mashey K. Hammer toe. In: FronteraWR, Silver JK, Rizzo TD Jr., eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa: Saunders Elsevier;2008:chap 82. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH000221 5/157 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  158. 158. Muscular disorders: Muscular dystrophy158 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  159. 159. The word "dystrophy" comes originally from the Greek "dys," which means "difficult" or "faulty," and "trophe," meaning "nourishment." This word was chosen many years ago because it was at first believed that poor nourishment of the muscles was in some way to blame for muscular dystrophy. Today we know that muscle wasting in the disorder is caused by defective genes rather than poor nutrition. http://www.humanillnesses.com/original/Men-Os/Muscular-Dystrophy.html159 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  160. 160. Muscular dystrophy(MD) refers to a group of more than 30 inherited diseases that cause muscle weakness and muscle loss. Some forms of MD appear in infancy or childhood, while others may not appear until middle age or later. The different muscular dystrophies vary in who they affect and the symptoms. All forms of MD grow worse as the persons muscles get weaker. Most people with MD eventually lose the ability to walk. http://www.nlm.nih.gov/medlineplus/musculardystrophy.html160 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  161. 161. http://www.humanillnesses.com/original/images/hdc_0001_0002_0_img0181.jpg161 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  162. 162. Muscular Dystrophies (MD) characterized by progressive weakness and degeneration of the skeletal muscles that control movement. Some forms seen in infancy or childhood- others may not appear until middle age or later. differ in terms of the distribution and extent of muscle weakness (some forms of MD also affect cardiac muscle) age of onset rate of progression, and pattern of inheritance http://www.ninds.nih.gov/disorders/md/md.htm162 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  163. 163. Etiology are a group of inherited conditions It’s caused by incorrect or missing genetic information that prevents the body from making the proteins needed to build and maintain healthy muscles. Many cases of MD occur from spontaneous mutations that are not found in the genes of either parent, and this defect can be passed to the next generation. http://pathologyproject.wordpress.com/2011/04/24/muscular-dystrophy/163 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  164. 164. Muscular dystrophy is a general term for a group of inherited diseases involving a defective gene. Each form of muscular dystrophy is caused by a genetic mutation thats particular to that type of the disease. The most common types of muscular dystrophy appear to be due to a genetic deficiency of the muscle protein dystrophin http://www.mayoclinic.com/health/muscular- dystrophy/DS00200/DSECTION=symptoms164 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  165. 165. Inheriting Duchennes or Beckers MD Duchennes and Beckers muscular dystrophies - passed from mother to son through one of the mothers genes in a pattern called X-linked recessive inheritance. Boys inherit an X chromosome from their mothers and a Y chromosome from their fathers. The X-Y combination makes them male. Girls inherit two X chromosomes, one from their mothers and one from their fathers. The X-X combination determines that they are female. The defective gene that causes Duchennes and Beckers muscular dystrophies is located on the X-chromosome. Women who have only one X-chromosome with the defective gene that causes these muscular dystrophies are carriers and sometimes develop heart muscle problems (cardiomyopathy) and mild muscle weakness. The disease can skip a generation until another son inherits the defective gene on the X- chromosome. In some cases of Duchennes and Beckers muscular dystrophies, the disease arises from a new mutation in a gene rather than from an inherited defective gene. http://www.mayoclinic.com/health/muscular- dystrophy/DS00200/DSECTION=symptoms165 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  166. 166. X-linked recessive inheritance pattern with carrier mother Women can pass down X-linked recessive disorders such as Duchennes muscular dystrophy. A woman who is a carrier of an X-linked recessive disorder has a 25 percent chance of having an unaffected son, a 25 percent chance of having an affected son, a 25 percent chance of having an unaffected daughter and a 25 percent chance of having a daughter who also is a carrier. http://www.mayoclinic.com/health/medical/IM02723166 Maria Carmela L. Domocmat, RN, MSN 8/24/2011
  167. 167. Patterns differ for other types of MD Myotonic dystrophy and most MFMs -passed along in a pattern called autosomal dominant inheritance. If either parent carries the defective gene for myotonic dystrophy, theres a 50 percent chance the disorder will be passed along to a child. Some of the less common types of muscular dystrophy are passed along in the same inheritance pattern that marks Duchennes and Beckers muscular dystrophies. Other types of muscular dystrophy can be passed on from generation to generation and affect males and females equally. Still others require a defective gene from both parents. http://www.mayoclinic.com/health/muscular- dystrophy/DS00200/DSECTION=symptoms167 Maria Carmela L. Domocmat, RN, MSN 8/24/2011

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