MUSCULOSKELETAL DISORDERS full-mine.pptx

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UNIT THREE
MUSCULOSKELETAL DISORDERS
11/4/2012

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Outline
11/4/2012
 Anatomic and physiologic review of mss
 Assessment methods
 Soft tissue injuries
 Fractures
 Amputation
 Joint and Connective tissue diseases
 Others : osteomyelitis and bone tumor

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Anatomic and physiologic overview
11/4/2012
Musculoskeletal system consists of:
 Bone
 Skeletal muscle
 Tendons
 Ligaments
 Joints and
 Bursae of the body

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FUNCTIONS OF THE MSS
11/4/2012
1. Provides a framework that supports the body.
2. Protects some internal organs from mechanical injury;
3. Contains and protects the red bone marrow, the primary
hemopoietic (blood-forming) tissue.
4. Provides a storage site for excess calcium.
5. Joints hold the bones together and allow the body to move.
6. The muscles attached to the skeleton contract, moving the bones
and producing heat, which helps to maintain body temperature.

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Assessment of musculoskeletal disorder
11/4/2012
Health History= Subjective Data
 Chief Complaints
 Pain
 Weakness
 Altered sensation,
 Limited motion
 Family history, personal history, dietary history, socioeconomic
status
 Medications (steroids); Current health problems

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Assessment…cont’d
11/4/2012
Physical examination -Objective Data
 Posture (spine)
Common deformities of spine
 Kyphosis ,Scoliosis, Lordosis
 Gait -Smoothness and rhythm of patients gait
 Bone integrity-deformities and alignment
 Joint function-ROM
 Muscle strength and size-changing position ,muscular strength and
coordination
 Neurovascular status-CMS

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Diagnostic tests
11/4/2012
x- ray
 To determine density, texture, integrity, erosion, change in bone
relationships
 Medullary cavity – to detect any alteration in density.
 Joint –to show fluid, irregularity, narrowing change in joint contour.
Nursing responsibility
 Tell the patient the proper positioning is important to obtain a good
x-ray

Advise patient to remove all jewelry, clothing with zippers etc.

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Laboratory studies
11/4/2012
 Blood and urine- provide information about a primary musculoskeletal
problem ,infection .
 CBC- hemoglobin level (lower after bleeding )
 WBC -(elevate on acute infection trauma, acute hemorrhage and
necrosis)

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Blood chemistry
11/4/2012
 Serum calcium:- Altered in patients with osteomalacia,
parathyroid dysfunction, metastatic bone tumor or
prolonged immobilization.
 Serum phosphorous:- Inversely proportional with serum
calcium; are diminished in osteomalacia

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Managing soft tissue injuries
11/4/2012
Sprain
It is an injury to the ligaments and tendons that surround a joint.
Cause: - wrenching or twisting motion and results in decreased in
joint stability.
C/M
 Rapid swelling – due to extravasations of blood with in tissues
 Pain on passive movement of joint
 Increasing pain during first few hours due to continued swelling

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Cont’d
11/4/2012
Strain (muscle pull)
It is a microscope tearing of the muscle
Cause: - overuse, overstretching, excessive stress.
C/M
 Hemorrhage in to the muscle
 Swelling
 Tenderness
 Pain with isometric contraction

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Management for both sprain & strain
11/4/2012
 X- ray may be done to rule out fracture
 Immobilize in splint, elastic wrap.
 Apply ice for the first 24 hours
 Analgesics (NSAIDs)
 Sever sprains may require surgical repair and/or cast
immobilization.
 Apply cold and using compression bandage.

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Nursing interventions
11/4/2012
 Elevate the affected part; maintain splint or immobilization as
prescribed.
 Apply cold compresses for the first 24hrs (20-30 minutes at a
time)
 Apply heat to affected area .
 Instruct the patient on use of pain medication

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contusion
11/4/2012
It is a soft tissue injury produced by blunt force, such as a
blow, kick, or fall causing small blood vessels to rupture
and bleed into soft tissues (ecchymosis, or bruising).
C/M
 Pain
 Swelling and
 Discoloration
Mg’t
 Intermittent application of cold
 Elevation of the extremity above the heart level

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Dislocations
11/4/2012
 A condition in which the articular surfaces of the bones forming the joint
are no longer in anatomic contact.
 This is an orthopedic emergency because of associated disruption of
surrounding blood and nerve supplies.
Cause: -
 May be congenital (present at birth)
 Spontaneous /pathologic
 Disease of the articular or periarticular structures.
 Traumatic – resulting from injury in which the joint is disrupted by
force.

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Cont’d
C/M: -
 Pain
 Change in contour of the
joint (deformity)
 Change in the length of the
extremity (shortening)
 Loss of normal movement
Diagnostic evaluation
x-ray
Management
 Immobilize part while the patient is
transported to emergency
department, x-ray department &
clinical unit.
 Secure reduction of dislocation
(bring displaced parts into normal
position), as soon as possible to
prevent circulatory or nerve
impairment. 11/4/2012

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fracture
11/4/2012
A fracture is a break in the continuity of bone.
Cause: - a fracture occurs when the stress placed on a bone is
greater than the bone can absorb
 Direct blows, crushing forces, sudden twisting motions, and
even extreme muscle contractions.
Muscles ,blood vessels, nerves, tendons, joints, and other
organs may be injured when fracture occurs.

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Types of fracture
11/4/2012
 Complete:- Involves the entire cross- section of the bone.
 Incomplete:- Involves a portion of the cross section of the bone or may be longitudinal.
 Closed (simple):- Skin (mucous membranes) has not broken.
 Open (compound) – skin broken
 Grade I- Minimal soft tissue injury
 Grade II- Laceration greater than 1 cm without extensive soft tissue flap.
 Grade III-Extensive soft tissue injury, including skin, muscle, neurovascular structures,
with crushing.

Pathologic: - Through an area of diseases bone (osteoporosis, bone tumor, bone
metastasis)

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Patterns of fracture
11/4/2012
 Greenstick: - One side of the bone is broken and the other side
is bent.
 Transverse:- Straight across the bone
 Oblique:- At an angle across the bone
 Spiral :- Twist around the shaft of the bone
 Comminuted: - Bone splintered on to more than three fragments.

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Cont’d
11/4/2012
 Depressed:- Fragments in driven ( in skull and facial bones)
 Compression:- Bone collapses in on itself (in vertebral
fractures)
 Avulsion: - Fragment of bone pulled off by ligament or
tendon attachment.
 Impacted: - Fragment of bone wedged in to other bone
fragment.

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C/M – Physical findings
11/4/2012
 Pain at site of injury
 Swelling
 Tenderness
 False motion and crepitus
 Deformity
 Loss of function
 Ecchymosis
 Paresthesia

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11/4/2012
 X- ray – to determine the integrity of bone
 Blood study (CBC, electrolyte)
 Hemoglobin and hematocrit

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Emergency management
11/4/2012
 Immobilize the body part
 Cover the wound with sterile dressing
No attempt is made to reduce the fracture
In emergency department:
 Evaluate the patient completely
 Gently remove the close

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Management
11/4/2012
 Management depends on
 Type, location and severity of fracture
 Soft tissue damage
 Age and health status of patient, including type and extent of other
injuries.
 Goals include :
 To regain and maintain correct position and alignment
 To regain the function of the involved part
 To return patient to usual activities

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Management cont’d
11/4/2012
 Reduction-setting the bone or restoration of fracture
fragments in to anatomic position and alignment.
 Immobilization-maintain reduction until bone healing
occurs.
 Rehabilitation-regaining normal function of the
affected part.

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Reduction
11/4/2012
Closed reduction
 Bony fragments are brought into apposition (ends in
contact) by manipulation and manual traction restoring
alignment.
 May be done under anesthesia for pain relief and
muscle relaxation
 Cast or splint applied to immobilize extremity and
maintain reduction.

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Cont’d
11/4/2012
Open reduction with internal fixation
operative intervention to achieve reduction, alignment and
stabilization.
 Bone fragments are directly visualized .
 Internal fixation devices used to hold bone fragments in position
until solid bone healing occurs (may be removed when bone
healed) .
 After closure of the wound, splints or casts may be used for
additional stabilization and support .

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Cont’d
11/4/2012
Endoprosthetic replacement
 Replacement of a fracture fragment with an implanted metal device.
 Used when fracture disrupts nutrition of the bone or treatment of
choice is bony replacement.
External fixation device
 Stabilization of complex and open fracture with use of metal frame
and pin system.
 Permits active treatment of soft tissue injury.

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Cont’d
11/4/2012
Traction
 Pulling force applied to accomplish and maintain reduction and
alignment.
 Used for fractures of long bones
Techniques
 Skin traction: - force applied to the skin using rubber, tape
etc.
 Skeletal traction: - force applied to the bony skeleton directly,
using wires, pins or tongs placed into or through the bone.

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Traction care:
11/4/2012
 Maintain correct balance between traction pull and
countertraction force
 Care of weights
 Skin inspection
 Pin care
 Assessment of neurovascular status

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CAST
11/4/2012
 Rigid device that immobilizes the affected body part while
allowing other body parts to move.
 Cast materials: plaster, fiberglass, polyester-cotton.
Types of casts for various parts of the body
 Arm Casts
 Leg Casts
 Body or Spica Casts

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Cast care
11/4/2012
 Elevate Extremity
 Exercises – to unaffected side; isometric exercises to
affected extremity
 Handle with palms of hands if cast wet
 Turn every two hours till dry
 Notify MD at once of wound drainage
 Do not place items under cast.
 Neurovascular

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Rehabilitation
11/4/2012
Regaining normal function of the affected part
 Neurovascular status (circulation, movement, sensation) is
monitored.
 Restlessness, anxiety, and discomfort are controlled .

Isometric and muscle-setting exercises are encouraged .

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Fracture healing
11/4/2012
Occurs over three phases
 Reactive phase-formation of hematoma, angiogenesis ,granulation
tissue formation
 Reparative phase-callus formation ,and calcification of callus
 Remodeling phase-remodeling the new bone into its former
structural arrangement.
May take months to years based on extent of bone
modification needed ,function of bone and functional stress of
bone.

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Factors That Enhance Fracture Healing
11/4/2012
• Immobilization of fracture fragments
• Maximum bone fragment contact
• Sufficient blood supply
• Proper nutrition
• Exercise: weight bearing for long bones
• Hormones: growth hormone, thyroid, calcitonin, vitamin D, anabolic
steroids

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Factors That Inhibit Fracture Healing
11/4/2012
• Extensive local trauma
• Bone loss
• Inadequate immobilization
• Space or tissue between bone fragments
• Infection
• Local malignancy
• Metabolic bone disease (eg, Paget’s disease)
• Intra-articular fracture (synovial fluid contains fibrolysins, which
lyse the initial clot and retard clot formation)
• Age (elderly persons heal more slowly)
• Corticosteroids (inhibit the repair rate)

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Early complications
11/4/2012
Shock
 Shock results from hemorrhage and from loss of extracellular fluid
into damaged tissues .
 Because the bone is very vascular, large quantities of blood may be
lost as a result of trauma, especially in fractures of the femur and
pelvis.
 Treatment of shock consists of restoring blood volume and circulation,
relieving the patient’s pain, providing adequate splinting, and
protecting the patient from further injury and other complications.

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Fat Emboli Syndrome
11/4/2012
 Associated with embolization of marrow or tissue fat and free fatty acid to the
pulmonary capillaries, producing rapid onset of symptoms.
C/M
 Respiratory distress- tachypnea ,hypoxemia ,wheezes ,acute pulmonary edema
 Mental disturbance- irritability ,restlessness ,confusion ,
disorientation ,stupor ,coma.
 Fever
 Petechiae in buccal membrane ,hard palate , conjunctival sacs ,chest ,anterior
axillary folds..due to occlusion of capillaries

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Prevention and Management
11/4/2012
 Immediate immobilization of fractures (including early surgical
fixation),
 Minimal fracture manipulation,
 Adequate support for fractured bones during turning and
positioning, and
 Maintenance of fluid and electrolyte balance.

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Cont’d
11/4/2012
 Respiratory failure is the most common cause of death.
 Giving oxygen in high concentrations.
 Corticosteroids
 Vasoactive medications to support cardiovascular function are
administered to prevent hypotension, shock, and interstitial pulmonary
edema.
 Accurate fluid intake and output records .
 Morphine may be prescribed for pain and anxiety.
 Provides calm reassurance to allay apprehension.

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Acute compartment syndrome
11/4/2012
 Develops when tissue perfusion in the muscles is less than that
required for tissue viability.
 The patient complains of deep, throbbing, unrelenting pain, which is
not controlled by opioids.
This pain can be caused by :
(1) a reduction in the size of the muscle compartment because the
enclosing muscle fascia is too tight or a cast or dressing is constrictive,
or

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Cont’d
11/4/2012
(2) an increase in muscle compartment contents because
of edema or hemorrhage associated with a variety
of problems (eg, fractures, crush injuries).
 Within 4 to 6 hr after the onset of acute compartment
syndrome, neuromuscular damage is irreversible; the
limb can become useless within 24 to 48 hr.

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Medical Management
11/4/2012
 Elevation of the extremity to the heart level,
 Release of restrictive devices (dressings or cast), or
both.
 If conservative measures do not restore tissue
perfusion and relieve pain within 1 hour,
 Fasciotomy may be performed to relieve pressure.
 Pack and dress the wound after fasciotomy.

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Other acute complications
11/4/2012
 Venous stasis and thromboembaism (DVT)
 Neurovascular compromise
 Infection – especially with open fracture
Associated with immobility
 Muscle atrophy (loss of muscle strength)
 Loss of range of motion – joint contracture
 Pressure sore at bony prominences
 Orthostatic hypotension, constipation
 Diminished respiratory, cardiovascular and gastrointestinal function.

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Delayed complications
Bone union problems
11/4/2012
Delayed union
 Takes longer time to heal for the type and location of fracture.
Cause :
 Destruction (pulling apart) of bone fragments
 Systemic or local infection
 Poor nutrition
 Co morbidity
But the fracture eventually heals.

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Cont’d
11/4/2012
 No union -fails to unite
 Malunion -union occurs but is faulty – misaligned
 Patients usually complains in both
 Persistent discomfort
 Abnormal movement at fracture site
Mg’t
 Internal fixation
 Bone grafting
 Electrical bone stimulation or combination

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Amputation
11/4/2012
The removal of a body part, usually an extremity.
Etiology
 Progressive peripheral vascular disease
 Trauma
 Congenital deformity
 Chronic osteomyelitis
 Malignant tumor
Used to
 Relieve symptoms,
 Improve function ,and
 Save or improve the patient’s quality of life.

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Levels of amputation
11/4/2012
 The levels of some commonly planned amputation include
 Below & above the knee
 Below & above elbow
 Disarticulation
 The site of amputation is determined by two factors:
 circulation in the part, and
 functional usefulness (ie, meets the requirements for the use of
the prosthesis).
 Preservation of knee and elbow joints is desirable to apply
prosthesis.

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Amputation methods
11/4/2012
 Open amputation -in w/c the end of the residual limb
(stump) is temporarily open with no skin covering it.
 Usually performed in case of infection & skin traction
is applied on the infected area is allowed to drain.
 Closed amputation – in w/c skin flaps cover over the
several bone ends.

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Complications of amputations
11/4/2012
 Hemorrhage-because major blood vessels have been
severed, massive bleeding may occur.
 Infection -a risk with all surgical procedure .
 Skin breakdown -skin irritation caused by the prosthesis,
 Phantom limb pain -severing of peripheral nerves, and
 Joint contracture -positioning and a protective flexion
withdrawal pattern associated with pain and muscle
imbalance.

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Medical Management
11/4/2012
 The objective of treatment is to achieve healing of the
amputation wound.
 The result being a nontender residual limb (stump) with healthy
skin for prosthesis use.
 Healing is enhanced by
 Gentle handling of the residual limb,
 Control of residual limb edema through rigid or soft
compression dressings, and
 Use of aseptic technique in wound care to avoid infection.

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Nursing Management
11/4/2012
 Relieving pain
 Minimizing altered sensory perception
 Promoting wound healing
 Enhancing body image
 Self-care

Joints and connective tissue diseases
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Osteoarthritis ( Degenerative Joint Disease )
 It is a chronic and slowly progressing disorder that causes deterioration of articular
cartilage typically seen middle-aged to elderly people.
 Most common type of arthritis
 Healthy cartilage allows bones to glide over each other. It also helps absorb the
shock of movement.
 In osteoarthritis, the top layer of cartilage breaks down and wears away.
 This allows bones under the cartilage to rub together.

Cause
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Osteoarthritis (OA) is idiopathic disease usually happens gradually
over time.
Some risk factors that might lead to it include:
 Older age
 Having family members with OA
 Obesity
 Joint injury or repetitive use (overuse) of joints
 Joint deformity such as unequal leg length, bowlegs or knocked knees.

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Circles indicate joints that
osteoarthritis most often affects
Commonly Affected Joints
Cervical and lumbar spine
First carpometacarpal
joint
Proximal interphalangeal
joint
Distal interphalangeal
joint
Hip
Knee
First metarsophalangeal
joint

Clinical Manifestations
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 Unlike some other forms of arthritis, osteoarthritis affects only
joints and not internal organs.
 Joint pain and stiffness,
 Swelling at the joint
 Cracking or grinding noise with joint movement
 Functional impairment
 X-ray- demonstrate narrowing of joint space
 No specific laboratory tests

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Management
 There is no proven treatment yet that can reverse joint damage
from OA.
 The goal of treatment is
• Improve joint function and
• Control pain
 Most often, this is possible with a mixture of physical measures
and drug therapy and, sometimes, surgery.

Management …cont’d
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Physical measures
 weight reduction, exercise
 Rest during acute painful episodes
 Support and alleviate weight bearing in affected joints
(assistive devise )
 Physiotherapy

Pharmacological therapy
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 Acetaminophen
 Non Steroidal Anti-Inflammatory Drugs (NSAIDs)
 COX-2 Inhibitors
 Intraarticular Injections:
 Glucocorticoids and Hyaluronic Acid
 Narcotics

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Surgery
 Surgical treatment becomes an option for severe cases.
 This includes when the joint has serious damage, or when
medical treatment fails to relieve pain and when there is major
loss of function.
 Surgery may involve arthroscopy, repair of the joint done
through small incisions (cuts).

If the joint damage cannot be repaired, joint replacement.

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Rheumatoid Arthritis
 RA is progressive and disabling autoimmune disease
characterized by:
 Persistent synovitis
 Systemic inflammation
 Auto antibodies
 Inflammation at joints can lead to long term damage, chronic
pain and restricted daily activity .
 Results in pain, disability, early mortality

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Cause
 The cause of RA remains unknown
Risk factors include:
 Genetic factors
 Gender : female >> male 3:1
 Life style risk factors :Smoking , obesity
 Infection

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 Pain in affected joints, aggravated by movement, is the most common
manifestation of established RA.
 Generalized stiffness is frequent and is usually greatest after
periods of inactivity.
 Morning stiffness of >1hr duration is an almost invariable feature of
inflammatory arthritis
 Swelling and temperature changes in joints
 Extraarticular changes –wt loss , sensory changes , lymph node
enlargement , fatigue.

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Assessment and diagnostic findings
 RA is a clinical diagnosis with radiologic and laboratory
findings used to support the diagnosis.
 Rheumatoid nodule
 Lab tests : Rh factor 80% are positive-not specific for RA
 Elevated ESR
 X-ray-erosion of joints

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Management
Goals of RA treatment:
 No constitutional symptoms (fever, malaise)
 Returning to a normal work schedule
 Minimizing the impact on activities of daily living
 Changing the course of disease progression (slowing or
stopping the disease)
A multidisciplinary approach

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Mgt …cont’d
 Rest , Exercise , Ice and heat
 Assistive device and joint care
 Medications
 NSAID’s
 Steroids :oral , intra articular
 DMARD’s: Methotrexate, Leflunamide, Sulfasalazine, Hydroxychloroquine,
Minocycline, Gold compounds.
 Biologic agents : anti- TNF, Abatacept, Etanercept, Rituximab, Infliximab,
Adalimumab
 Surgery

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Septic arthritis
 It is bacterial arthritis that results from invasion of the synovial membrane.
 Cause : S.aureus -almost all
 Hematogenous or direct invasion
 Predisposing factors includes:-
High susceptibility of the pt, Recent surgery or trauma, Intraarticular injections
& history of RA.
C/m= Pain, swelling, & tenderness of the joint.
Fever, malaise, anorexia etc
Dx = Joint aspiration & X-ray examination.

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Management
Med.Mgt: –
 Appropriate Antibiotic therapy.
 Rest or immobilization of the joint.
 Surgical drainage/a system of irrigation/.
Nsg mgt:
 Promoting rest of the affected joint.
 Administering antibiotics as prescribed anti pains as necessary.
 Pt teaching & encourage self –care

79
Gouty Arthritis
 Gouty arthritis, more commonly referred to as gout, is a painful
condition caused by deposits of urate crystals in a joint, most
commonly the big toe.
 Uric acid is a by product of
‐ purine metabolism in the body.
 Purines come from foods such as red meat, herring, asparagus
and mushrooms.
 Uric acid has no biological function in humans

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Gout… cont’d
 It is dissolved in the blood, passes into the kidneys, and excreted
in the urine.
 An attack of gout occurs when the urate crystallizes into
monosodium urate (MSU) crystals, and deposits in a joint, or joints,
somewhere in the body.
 The build up of the
‐ sharp, needle like crystals
‐ causes pain and
inflammation.

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Cause
 Hyperuricemia is caused by increased production (10%) or
decreased excretion of urate in the body (90%).
 It is usually first seen between the ages of 40 and 50 in men,
and in post menopausal women.
‐
 certain conditions can contribute to the development of gout,
such as obesity, insulin resistance, hypertension, and
hyperlipidemia .

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Clinical manifestations
 Acute gout arthritis
 Affect on joint (often Metatarsophalangeal joint)
 Pain ,warmth, erythema, swelling of tissue surrounding the
affected joint.
 Onset of symptoms is sudden, intensity is sever.
 Duration of symptoms is self limiting (lasts 3-10 days) with out
treatment.

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C/m…cont’d
Chronic Tophaceous gout
 Characterized by development of tophi or deposition of uric acid
around joints, cartilage, and soft tissue.
 Arthritis is more chronic and can produce bone erosions and
subsequent bony deformities that can resemble RA.
Renal disease
 Hyperuricemia (persistent elevation of uric acid in the blood)
 Kidney stones are composed of uric acid

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Diagnosis
 Synovial fluid analysis
 Monosodium urate crystal (MUC)
 increased WBC count
 24 hrs urine for uric acid
 ESR – elevated
 X-ray affected joints

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Management
 Pharmacologic
 NSAIDS – for acute attacks to relieve pain swelling
 Colchicine – for prevention of acute attack.
 IV for acute attack
 Oral at the onset of attack taken Until first signs of toxicity.
 Corticosteroids
 Intra-articular if attack confined to one joint

86
Mgt …cont’d
 Urate lowering agents
 Uricosuric drugs (probenacid) interfere with tubular reabsorption
of uric acid
 Allopurinol–interferes with conversion of hypoxanthine and
xanthine to uricacid
 Non pharmacologic
 Avoidance of obesity
 Avoidance of alcohol
 Low purine diet (egg, milk products ...)

87
Ankylosing spondylitis
 It is a chronic connective tissue disorder of the spine & surrounding
cartilaginous joints, such as the sacroiliac joints & soft tissue around the
vertebrae.
 As a result of infection of the spine, the bones of the spine grow together
or fuse (ankylose).
 Usually begins in early adulthood & is more common in man than female.
 Etiology – unknown, but kelbsiella is though to be causative agent.
 Altered immune response is believed.

There is also strong familial tendency. I.e. genetics is predisposing factor.

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Clinical Feature
 Initially low back pain, pain and swelling of the hips, knees & shoulder, mild
fever loss of appetite and fatigue.
 But later pain subsides & motion of back restricted by fusion of the joints.
 The spine loses its normal lordotic curve, kyphosis deformity & knee flexed.
 The neck can be permanently flexed.
Dx
 Elevated ESR as evidence of inflammation & culture of synovial fluid.
 X-ray films or CT scan show erosion, ossification & fusion of the joint in the
spine & hips.

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Management
Med. Mgt – Rx is supportive. ASA, Indomethacin or NSAIDs are usually
prescribed for relieving inflammation & pain.
 Extra rest is recommended
 Physical therapy to maintain mobility and reduce severity of
deformity. I.e firm mattress & heat application to relieve the
symptoms.
Surg mgt –Thoracic –lumbar –sacral orthosis/surgical appliance to
support the spine/.
-Spinal osteotomy and fusion.

90
Mgt …cont’d
Nsg Mgt
 Administers prescribed drugs and clarifies information about
the disease
 Promote possible mobility/exercise/ to reduce severity of
deformity, increase pain & stiffness.
 Promoting comfort & relieving pain.
 Emotional support.

91
Osteomyelitis
 Osteomyelitis (Osteo- bone, Myelo- Marrow, and –itis -Inflammation)
 It is an infection of the of the bone or bone marrow which leads to a
subsequent Inflammatory process.
 Staphylococcus aureus causes 70%to 80% of bone infection.
 Risk groups include those who are poorly nourished, elderly, obese,
those with impaired immunity, with chronic illness& receiving long
term corticosteroid therapy.
 The femur, tibia, humerus & radius are commonly affected.

92
PATHOGENESIS
 Microorganisms enter bone by the hematogenous route, by direct
introduction from a contiguous focus of infection, or by a penetrating
wound.
 Trauma, ischemia, and foreign bodies enhance the susceptibility of bone
to microbial invasion by exposing sites to which bacteria can bind.
 Phagocytes attempt to contain the infection and, in the process, release
enzymes that lyse bone.
 Bacteria escape host defenses by adhering tightly to damaged bone,
by entering and persisting within osteoblasts, and by coating themselves
and underlying surfaces with a protective polysaccharide-rich biofilm.

93
Patho…cont’d
 Pus spreads into vascular channels, raising intraosseous pressure and
impairing the flow of blood; as the untreated infection becomes
chronic, ischemic necrosis of bone results in the separation of large
devascularized fragments (sequestra).
 When pus breaks through the cortex, subperiosteal or soft tissue
abscesses form, and the elevated periosteum deposits new bone (an
involucrum) around the sequestrum.
 Microorganisms, infiltrates of neutrophils, and congested or
thrombosed blood vessels are the principal histologic findings of
acute osteomyelitis.
 The distinguishing feature of chronic osteomyelitis is necrotic bone,
which is characterized by the absence of living osteocytes.

94
Clinical Feature
 Evidence of acute infection such as high fever, chills, rapid pulse,
and tenderness/ pain, redness & swelling on the affected area
appears suddenly.
 Anorexia & malaise may occur.
 May open to skin & drain purulent discharge.

95
Diagnosis
 B/d test  increased WBCs & ESR.
 B/d culture & sensitivity test and Bone scanning can be performed.
 Diagnosis requires 2 of the 4 following criteria:
◦ Localized classic physical findings of bony tenderness, with
overlying soft-tissue erythema or edema.
◦ Purulent material on aspiration of affected bone.
◦ Positive findings of bone tissue or blood culture.
◦ Positive radiological imaging study.

96
Management
Principles of treatment:
1. Analgesia an general supportive measures.
2. Rest of the affected part
3. Antibiotic treatment.
4. Surgical eradication of pus and necrotic tissue(debridement)
Nsg Mgt
 Administering antibiotics, analgesic & antipyretics on time & as
prescribed
 Promoting rest of affected joint or limb
 Providing information regarding follow up care.

97
Prevention
 Improve immunity.
 Post-traumatic infection (regular wound dressing for established
infection):
1. Debridement of open fractures.
2. Stabilization of fractures.
3. Antibiotics.
4. Closure of exposed bone surfaces.
 Postoperative infection:
1. Cleanest possible surgical environment.
2. Careful haemostasis.
3. Suction drainage.
4. Prophylactic antibiotics in high risk surgeries.

98
Bone Tumors
 Neoplasms of the musculoskeletal system are of various types,
including osteogenic, chondrogenic, fibrogenic, muscle
(rhabdomyogenic) and marrow (reticulum) cell tumors as well as
nerve, vascular and fatty cell tumors.
 They may be primary tumors or metastatic tumors from primary
cancers elsewhere in the body (e.g. breast, lung, prostate, kidney)
 Metastatic bone tumors are more common than primary bone
tumors.

99
Types of bone tumors
1. Benign bone tumors
 More common than malignant primary bone tumors.
 Slow growing and well circumscribed, present few symptoms and are not
a cause of death.
 Osteochondroma (most common)
 Osteoclastoma (benign giant cell tumor)
 Enchondoma (tumor of the hyaline cartilage that develop in the hand,
femur, tibia or humerus.)
 Malignant transformation occurs with some.

100
Types…cont’d
2. Malignant bone tumors
 Chondrosarcoma and osteosarcoma are the example of primary
malignant bone tumors.
 Multiple myeloma is a malignant neoplasm arising form the bone marrow.
3. Metastatic bone tumors
 Most frequently associated with cancers of the breast, prostate, and lung
(primary malignancy site)
 Bone metastasis most frequently occurs in the vertebrae and results in
pathologic fracture.

101
 Pain in the involved bone – from effects of tumor (destruction, erosion, and
expansion of tumor)
 Mild to constant pain which may be worsen at night or with activity.
 Pain will be acute with fracture.
 Neurologic symptoms may present with nerve root compression
 Swelling and limitation of motion.
Physical findings
 Palpable, tender, fixed bony mass
 Increased in skin temperature over mass
 Superficial veins dilated and prominent

102
 X-ray – reveal bone tumor
- may show increased or decreased bony density
 Serum alkaline phosphate – usually increased
 Biopsy of bone – to confirm suspected diagnosis

103
Managment
 The basic objective to halt the progression of tumor by destroying
or removing the lesion.
Treatment depends on type of tumor
 Surgery – tumor curettage or resection with bone grafting may be
used.
- Amputation may be necessary in some cases.
 Chemotherapy – to shrink the tumor (before surgery)
- to destroy metastases (after surgery)
 Radiotherapy:- tumor irradiation

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