patho orthopedic nursing.pptx

Pathophysiology
Musculoskeletal Disorders
Prepare by Muhammad Azhar
Bsc Biochem, MSc Micro, BSN , MScN*
Oxford College of Nursing Karachi

By the end of this unit, learners will be able to:
1. Relate the normal anatomy and physiology of the Musculo-skeletal system to
alterations of normal structures and functions.
2. Briefly discuss the classification of Musculo-skeletal Disorders
3. Perform Examination of musculoskeletal system
4. Discuss etiology, pathophysiology, and clinical manifestations of
Soft tissue injury
Fracture.
 Amputation.
 Paget’s disease and Gout.
 Osteomyelitis.
Prepare by Muhammad Azhar Bsc Biochem, MSc Micro, BSN , MScN* Oxford College of Nursing Karachi

Osteoarthritis
Osteoporosis
Rheumatoid Arthritis
 Bone tumors.
Tuberculosis.

The word “orthopedic” was invented by French Surgeon Nicholas
Andry (1743).
It is derived from two Greek words: ‘ORTHOS’ meaning straight or
correct
and ‘pedios meaning’ of a child, and so can be taken to mean the
rearing of straight children.
Now ‘orthopedics’ emerged as a branch of surgery dealing with
correction of deformities of bone and muscles
Orthopedic Nursing’ refers to nursing management of disorders of
bones and muscles
 It can also be called as “musculoskeletal nursing”.

Functions of the Bones
Bones provides:
Form shape of the body.
Rigid framework that supports the internal organs and the
skin.
Protection.
Muscles attachments
Forms red blood cells, white blood cells, and platelets.
Store and release minerals , 98 % of body ca
Leverage for motion
Bone is maintained by remodeling: existing bone is resorbed
into the body and new bone is built by osteoblasts to replace
it.
Prepare by Muhammad Azhar Bsc Biochem, MSc Micro, BSN , MScN* Oxford College of Nursing
Karachi

Musculoskeletal Disorders
CAUSES:
Disease, trauma, malnutrition, and aging.
Trauma may cause bruising, strain, sprain, or fracture.
Poor nutrition
Inadequate protein intake
Malignant tumors
The decrease in estrogen.

Prevention
Preservation of motion and mobility
Weight-bearing exercise
Lifting and moving objects correctly
Seat belt/helmet use in an automobile/bikes.
Balanced diet (vit-D and Proteins).

Soft-Tissue Injuries:
Soft-tissue injuries are classified as the following:
A. Acute injuries
B. Overuse injuries
1. A sprain is a partial or complete tearing of fibrous ligament tissues that hold
various bones together to form a joint.
 A sprain occurs during trauma when a joint is forced or twisted past its normal
range of motion (ROM).
The ankle, knee, and wrist are most the commonly sprained joints.
 While the intensity varies, pain, bruising, swelling, and inflammation are common
 The treatment for a sprain includes rest, ice, compression, and elevation (R.I.C.E.).
 If the ligament is completely torn, surgical repair may be necessary.

Sprains Are Classified By Severity:
Grade 1 sprain (mild): Slight stretching and
some damage to the fibers of the ligament.
Grade 2 sprain (moderate): Partial tearing
of the ligament. There is abnormal looseness
(laxity) in the joint when it is moved in
certain ways.
Grade 3 sprain (severe): Complete tear of
the ligament. This may cause significant
instability.

Diagnosis: is by physical and radiographic examination to rule out a fracture
or other pathology.

Signs, Symptoms:
Grade I (mild): Tenderness at site; minimal swelling and loss of function; no
abnormal motion.
Grade II (moderate): More severe pain, especially with weight bearing; swelling
and bleeding into joint; some loss of function.
Grade III (severe, complete tearing of fibers): Pain may be less severe, but swelling,
loss of function, and bleeding into joint are more marked.

Etiology :
A strain is a pulling or tearing of a muscle, a tendon, or both.
A strain occurs by trauma, overuse, or overextension of a joint.
The most commonly strained muscles are the back muscles.
Muscle strains also occur in other skeletal muscles.
The most common sites are the hamstrings, quadriceps, and calf muscles.

Pathophysiology:
i. When a tendon or ligament is torn, an inflammatory exudate develops between
the torn ends.
ii. Within 4 to 5 days after the injury, collagen formation begins.
iii. As the collagen fibers interweave and connect with preexisting tendon fibers,
they become organized parallel to the lines of the musculotendinous unit.
iv. Eventually vascular fibrous tissue fuses the new and surrounding tissues into a
single mass.
v. Collagen fibers reconnect the tendon and bone, forming a new enthesis(the area
of attachment on a bone )

Signs, Symptoms:
Bleeding (ecchymosis, hemorrhagic area) will be present if a muscle is torn.
Pain or tenderness.
Limited motion.
Swelling
Muscle weakness
Diagnosis:
A history of overexertion or the presence of soft-tissue swelling and pain may indicate
a strain has occurred.
Physical Examination
X-Rays

Treatment:
Anti-inflammatory medications are used for discomfort.
When spasm is present, a muscle relaxant may be prescribed.

Bursitis:
Bursitis is an inflammation of the bursae, the saclike
structures that line freely movable joints.
It occurs from injury or overuse e.g. bursitis after
digging up the garden plot in the spring.
Bursitis may occur in any heavily used joint
Bursitis commonly affects the shoulder, elbow, knee,
hip, ankle, and foot.
Pathophysiology:
i. Overuse or excessive pressure , infection,
autoimmune diseases, crystal deposition, or acute
trauma cause inflammation
ii. Resulting inflamed and distended bursal sac

Symptoms:
Localized tenderness
Mild to moderate aching pain that is localized to the joint and is exacerbated by
activity of the joint.
Swelling may be present.
Diagnosis:
History of injury & Physical examination.
U/S or MRI

Treatment:
Treatment involves rest, compression, elevation, and anti-inflammatory medicine.
Ice may be used in the acute phase of injury to reduce swelling.
Injections may be needed if pain and swelling persist.
Although surgery is rarely necessary for bursitis, if the bursa becomes infected, an
operation to drain the fluid from the bursa may be necessary.

Miscellaneous:
Tendinitis: is an inflammation or irritation of a tendon
or the covering of a tendon (called a sheath).
 It is caused by a series of small stresses that
repeatedly aggravate the tendon.
 Symptoms typically include swelling and pain that
worsens with activity.
Abrasion: Scrapes (can become easily infected)
Usually little bleeding.
Scrub and irrigate to remove debris and clean.
Allow to air dry before dressing.
May use antibiotic ointment.

Laceration: A cut or incision
Control bleeding.
Cleans with copious irrigation.
For large gaps, do not close tightly (call 1122).
Dress wound and seek medical attention (may need
stitches) unless minor wound.
Flap Avulsion: A three sided tear
Control bleeding.
Cleanse in anatomical position.
Call 1122 or seek immediate medical attention.

Punctures: Copious irrigation to cause wound
to bleed and flush debris.
Watch for infection.
Seek medical attention and tetanus shot.
Impaled Objects:
Remove if:
 In extremity
 Cheek
 Cold metal
 Too large to cut from site where object is
attached
Do not remove if:
 In neck or skull
 Chest
 Abdomen Prepare by Muhammad Azhar Bsc Biochem, MSc Micro, BSN , MScN* Oxford College of Nursing Karachi

Incised wound : A clean, straight cut caused by a
sharp edge (i.e. a knife).
Contusion: is the discoloration of the skin, which
results from underlying muscle fibers and connective
tissue being crushed.
This can happen in a variety of ways such as a direct
blow to the skin, or a fall taken against a hard surface.
Concussion: is a type of traumatic brain injury
caused by a bump, blow, or jolt to the head or by a hit to
the body that causes the head and brain to move rapidly
back and forth.

Carpal Tunnel Syndrome:
Etiology, Pathophysiology:
Carpal tunnel syndrome is a nerve problem that occurs
when the median nerve is compressed as it passes
through the carpal tunnel in the wrist.
Repetitive movements of the hands and wrists,
particularly with constant flexion of the wrist, are
contributing causes.
Such movement occurs in certain types of factory work
and in computer keyboarding.
Sometimes there is no known cause.

Signs, and Symptoms:
Pain
Numbness
And tingling of the hand, particularly at night
Diagnosis:
Physical examination
A compression test
And possibly electromyography to rule out other
causes of symptoms.

Treatment:
Rest splinting
Changing the angle of the wrist during repetitive movements,
Steroid injection may solve the problem.
If the symptoms are of long duration, muscle atrophy occurs; if sensory loss in the
fingers and hands is progressive, surgery is indicated.
Surgical decompression of the medial nerve by transection of the carpal ligament is
performed, usually as an outpatient procedure.

Fractures
Etiology and risk factors :
A fracture is a break or interruption in the continuity of a bone.
Fractures occur mostly From trauma when bone is subjected to
stress greater than it can absorb
I. Direct Force: It may occur when a moving object strikes the
body area over the bone.
II. Indirect Force:- It may occur when a powerful muscle
contraction pulls against the bone.
High risk recreation or employment related activities:
Skateboarding, rock climbing, etc.
Domestic violence: Victims of domestic violence are also among
people treated for traumatic injuries.
Road traffic accidents: Due to high traffic and high speed vehicle,
road conditions, etc.

Biological Conditions: Pre-disposition to fracture results from biological
conditions such as:
Osteopenia (caused by steroid use or Cushing's syndrome)
Osteogenesis imperfecta (a congenital bone disease characterized by defective
collagen production by osteoblasts).
Osteoporosis (metabolic bone disorder that causes a decrease in bone mass) or
another metabolic problem.
Neoplasms: It also weaken the bone and contribute to fracture (pathological
fracture).
Post menopausal estrogen loss: Release of estrogen stops after menopause, it can
make bone weaken.
Malnutrition: Due to protein malnutrition the strength and stiffness of bone
become lower, which lead to decreased bone mass and increased risk for fracture

i. Swelling at site of injury
ii. Joint dislocation
iii. Pain moderate to severe
iv. Loss of function
v. Deformity of bone
vi. Crepitation with movements
vii. Bruising
viii.Limited range of motion;
ix. Impaired sensation; tingling
Signs and Symptoms:

Fracture Classification :
i. A closed fracture (simple fracture) is one that does not cause a break in the
skin not communicating with the external environment
ii. Avulsion: A fracture in which a fragment of bone has been pulled away by a
ligament or tendon and its attachment comminuted: a fracture in which bone
has splintered into several fragments
iii. Transverse: A fracture that is straight across the bone, the fracture line is
perpendicular to the long axis of the bone. Such a fracture is caused by a
tapping or bending force.
iv. An open fracture: (compound, or complex fracture) is one in which the skin
or mucous membrane wound extends to the fractured bone
v. Oblique: A fracture occurring at an angle across the bone (less stable than a
transverse fracture)

Open fractures are graded according to the following criteria:
a) Grade I is a clean wound less than 1 cm long.
b) Grade II is a larger wound without extensive soft tissue damage.
c) Grade III is highly contaminated, has extensive soft tissue damage, and is the
most severe.
vi. Impacted: A fracture in which a bone fragment is driven into another bone
fragment
vii.Pathologic: A fracture that occurs through an area of diseased bone (e.g.,
osteoporosis, bone cyst, Paget’s disease, bony metastasis, tumor); can occur
without trauma or a fall
Fracture Classification

viii.Simple: a fracture that remains contained; does not break the skin
ix. Spiral: a fracture that twists around the shaft of the bone
x. Depressed: a fracture in which fragments are driven inward (seen frequently
in fractures of skull and facial bones)
xi. Compression: a fracture in which bone has been compressed (seen in
vertebral fractures)
xii. Epiphyseal: a fracture through the epiphysis
xiii.Greenstick: a fracture in which one side of a bone is broken and the other
side is bent, common in children
xiv.Comminuted fracture is one that produces several bone fragments.
Fracture classification

Diagnostic test:
X-ray shows fracture—may be displaced or not
CT scan shows fracture—useful when a patient’s body part cannot be turned or
positioned for imaging (e.g. the neck).
A bone scan will show increased cellular activity in the area of fracture—useful for
sites where fractures are not easily seen or for hairline fractures not previously
diagnosed.
Ultrasound scan to assess soft tissues and solid organs.
Dual-energy x-ray absorptiometry (DxA) to assess bone density
CBC and Urea and electrolytes (U&E) to check for anemia, blood loss, renal
function, and immune status.
Blood cultures to assess for sepsis

i. Resuscitation:
This involves the immediate care of life- threatening injuries while ensuring a care of the airway,
breathing, and circulation, and providing effective analgesia.
Fracture immobilization/Restriction:
Can be done by
Casting or splinting.
Traction.
External fixation.
Internal fixation
ii. Fracture reduction:
1. Closed reduction:
It is a non- surgical, manual realignment of bone fragments to their previous anatomic
position.
Under local or general anesthesia.
Medical Management Of Fracture

2. Open Reduction:
It is a correction of bone alignment through a surgical incision.
It usually includes the internal fixation of the fracture with use of wires, screws, pins,
plates, intra-medullary rods (or nails).
Surgical debridement and irrigation
Tetanus and diphtheria immunization.
Prophylactic antibiotic therapy.
Analgesic for pain.
iii. Restoration and rehabilitation:
Restoration of function and rehabilitation involves input from the multidisciplinary
team, including the medical team, nursing team, physiotherapists, occupational
therapists etc.
Focus on good nutrition, ensuring effective sleep and rest, and addressing
boredom, the psychological impact of trauma, possible altered body image, and
the potential social impact of injury upon the person.

Fracture Healing:

Amputation
Derived from the Latin Amputare - "to cut away“ From Ambi- (about, around)
and Putare (to-prune)
Amputation is the removal of a body part, usually an extremity. It may occur as
a result of trauma (traumatic amputation) or in an effort to control disease or
disability (therapeutic amputation).
Etiology:
The following are conditions for which an amputation may be performed:
•Malignant tumors
•Long-standing infections of bone and tissue that prohibit restoration of
function
•Extensive trauma to an extremity
•Death of tissues from peripheral vascular
•Thermal injuries
•Deformity of a limb, rendering it a useless hindrance
•Life-threatening disorders, such as arterial thrombosis
Traumatic Amputation

Of all these causes, peripheral vascular disease accounts for most amputations
of lower extremities.
Indication:
Amputation is used
To relieve symptoms
Improve function
And save or improve the patient’s quality of life
Levels of Amputation:
Amputation is performed at the most distal point that will heal successfully. The
site of amputation is determined by two factors:
i. Circulation in the part
ii. Functional usefulness (i.e., Meets the
requirements for the use of the prosthesis

Levels of Amputation:
Common sites/types of amputation are:
i. Above-knee amputation, removing part of the thigh, knee, shin,
foot and toes.
ii. Below-knee amputation, removing the lower leg, foot and toes.
iii. Arm amputation.
iv. Hand amputation.
v. Finger amputation.
vi. Foot amputation, removing part of the foot.
vii. Toe amputation

Tests:
i. X-ray: determines extent of bone damage.
ii. CT scan: determines extent of soft tissue damage.
iii. Bone scan: detects bone degeneration, inflammation, or tumor.
iv. MRI: identifies nerve damage
Pre-operative Assessment:
i. Age of patient and general health
ii. Current medications
iii. Psychological impact of proposed
surgery
iv. Circulatory status of affected limb:
v. Doppler flowmetry Segmental BP
vi. Transcutaneous partial pressure 02
(PaO2)

Surgical Management Of Amputation:
OPEN/GUILLOTINE AMPUTATION:
"An Amputation in which there is a direct cut instead of making flaps“
i. It is done due to presence of infection and performed until the infection become clear and
skin become healthy.
ii. Cross section of skin is left open for drainage and skin traction is applied to prevent
retraction.
CLOSED/FLAPAMPUTATION:
"An Amputation in which one or two broad flaps of muscular and cutaneous tissue are retained
to form the cover over the end of the bone“
i. It is done when there is no infection present.
ii. Also called Fish Mouth Technique.

POTENTIAL COMPLICATIONS:
Based on the assessment data, potential complications that may
develop include the following:
• Postoperative hemorrhage
• Infection
• Skin breakdown
• phantom limb Pain
Phantom limb pain : is an abnormal sensation(s) felt in a limb (or
other amputated body part), which is no longer a part of the body. This is
different from stump pain, which is pain that occurs in the remaining body
stump. Phantom pain is caused by a malfunction in the brain and nervous
system leading to the perception that the body part still exists.
Signs and symptoms of phantom pain are:
feelings of abnormal sensations heat, cold, touch, and pain.

Rehabilitation:
Multi-disciplinary rehabilitation team (patient, physician, nurse,
physiotherapist, psychologist, occupational therapist) Early application of
prosthesis as soon as stump formed
i. Early usage/ ambulation (↑ muscle tone)
ii. Counselling, encouragement, support for
grieving process, lifestyle changes

Traction is the application of a mechanical pull to a part of the body for the
purpose of extending and holding that part in a certain position during
immobilization.
The two general types of traction are skeletal traction and skin traction.
Skeletal traction uses 10 lb or more of weight.
No more than 7 to 10 lb of weight is used for skin traction.

Patient’s Needs with Traction
Explain the procedure to the parents and patient before commencing.
Plan appropriate distraction from play therapy, parents or other nursing staff.
Maintain skin integrity:
Rolled up towel/pillow under to relieve pressure.
Encourage the patient to reposition (4 hourly).
Remove the foam stirrup and bandage once per shift.
Keep the sheets dry.
Document the condition of skin.

Traction care:
Ensure that the traction weight bag is hanging freely, the bag must not rest on the
bed or the floor.
If the rope becomes frayed replace them.
The rope must be in the pulley tracks.
Ensure the bandages are free from wrinkles
Tilt the bed to maintain counter traction

Pain Assessment and Management:
Assessment of pain is essential to ensure that the correct analgesic is
administered for the desired effect.
Activity:
Help patient to sit up in bed and participate in quiet activities such as craft,
board games and watching TV.
Non-pharmacological distraction and activity will improve patient comfort.
The patient is able to move in bed as tolerated for hygiene to be completed.

Observations:
Check the patient’s neurovascular observations hourly and record in the
medical record.
Monitoring of swelling of the femur should also occur to monitor for
compartment syndrome.
If neurovascular compromise is detected remove the bandage and reapply
bandage not as tight.
If circulation does not improve notify the orthopedic team.

Paget’s disease, also known as osteitis deformans, is a chronic condition in which
areas of the bone undergo slow and progressive abnormal turnover characterized
by abnormal bone remodeling.
The skull, femur, tibia, pelvis, clavicle, humerus, and vertebrae are most
commonly affected.
The condition is most common in men after the age of 40.
Etiology and pathophysiology:
In Paget’s disease bones are marked by a disturbance in the ratio between bone
formation and reabsorption.
Paget’s disease,

i. The excessive osteoclastic activity causes the bones to become soft and bowed
initially.
ii. Later, the bones thicken when compensatory osteoblastic activity resumes
iii. The process of bone turnover continues, resulting in a classic mosaic pattern of
bone matrix development
iv. The new bone has high mineral content but is not well formed
v. This causes the bones to be weak and prone to fracture
vi. This is thought to be due to a defect in deposition of collagen protein.
The exact cause of the disease is unknown however it is a disease of osteoclasts.
Viral infection (paramyxovirus) in association with genetic susceptibility has been
postulated.

Most people with this disorder rarely experience any symptoms. The most common
symptoms, when they do occur, include:
i. Bone pain, joint pain and stiffness
ii. Fractures
iii. Pain, tingling and numbness in arms and legs due to compressed nerve roots of an
affected spine
Tests:
i. X-ray: shows bone deformity, expansion, and increased bone density.
ii. Blood tests: elevated serum alkaline phosphatase (enzyme involved in bone cell
formation); anemia.
iii. Urine tests: elevated 24-hour urine hydroxyproline level (chemical involved in
increased bone replacement).
iv. Bone biopsy: rules out infection or tumor; shows characteristic mosaic pattern of
bone tissue. Bone scan: indicates which bones are affected.
Signs and symptoms

Medical Management:
Treatments:
i. Calcitonin: slows rate of bone breakdown.
ii. Aspirin, acetaminophen, NSAIDs: reduce pain and inflammation.
iii. Heel lifts/walking aids: make walking easier.
iv. Physical therapy: improves mobility.
v. Fractures: managed according to location.
vi. Hearing aid/sign language/lip reading: communication for hearing
impaired.
vii. Surgery: relieves pinched nerves, replaces arthritic joints, reduces
pathological fractures, corrects secondary deformities.

Gout:
Medieval Latin Gutta, literally ‘drop’ (because gout was believed to be caused by
the dropping of diseased matter from the blood into the joints).
Gout, a painful metabolic disorder involving an inflammatory reaction in the
joints, usually affects the feet (especially the great toe), hands, elbows, ankles, and
knees
Affects more men than women.

Pathophysiology and Etiology:
Gout is characterized by hyperuricemia (accumulation of uric acid in the blood)
i. It caused by alterations in uric acid production, excretion, or both.
ii. Urate (a salt of uric acid) crystallizes in body tissues due to excessive uric acid
iii. It is deposited in soft and bony tissues causing local inflammation and
irritation.
iv. Collections of urate crystals, called tophi, are found in the cartilage of the outer
ear (pinna), the great toe, hands, and other joints, ligaments, bursae, and
tendons
v. They destroy the joint, producing a chronically swollen, deformed appearance.
The uric acid also may precipitate in urine, causing renal stones.
vi. Gout may occur secondary to other diseases marked by decreased renal
excretion of uric acid.
vii. It also has been identified among clients who have received organ transplants
and the antirejection drug cyclosporine.

Acute gout :
i. Painful arthritic attack of sudden onset.
ii. Usually occurring at night or in early morning
iii. Arthritic pain worsen progressively
iv. Generally involves one or few joints
v. Most common site of initial attack metatarsophalangeal joint.
vi. Other sites ankle, heel, knee, wrist, elbow and fingers.
Chronic gout:
i. Frequency of attacks increases, continuous deposit leads to damage joints and chronic
pain
ii. Patients may develop large subacutenous tophi (Stones) in pinna of external ear,
eyelids, nose and around joints
iii. The ureate crystals in kidney leads renal disease.
iv. Articular cartilage may be destroyed result in joint
deformities Prepare by Muhammad Azhar Bsc Biochem, MSc Micro, BSN , MScN* Oxford College of Nursing Karachi

Signs and symptoms:
Acute joint pain due to accumulation of uric acid within the joint
i. Redness due to inflammation around the joint
ii. Nephrolithiasis (kidney stones) due to uric acid deposits in the kidney
iii. Swelling in the joints
iv. Skin may be in red color and shiny appearance hypersensitive to touch
v. Formation of tophi Tophi around the fingers, great toes, or earlobes, particularly if
the client has chronic and severe hyperuricemia
The big toe is the most common site.

INTERPRETING TEST RESULTS :
i. Elevated erythrocyte sedimentation rate (ESR).
ii. Elevated serum uric acid level—not seen in all patients with gout. Typical of
primary gout patients prior to episode of acute joint pain.
iii. Elevated urinary uric acid levels.
iv. Arthrocentesis shows uric acid crystals within the joint fluid.
TREATMENT:
Two main treatment approaches involve
i. Using uricosuric drugs that promote renal excretion of urates by inhibiting
the reabsorption of uric acid in the renal tubules
ii. Decreasing ingestion of purine. The regimen is individualized and may be
changed in response to the changes in the course of the disease.

i. The use of NSAIDs (2 to 5 days). such as indomethacin (Indocin) is
indicated for acute gout.
ii. Colchicine helps stop acute attacks within 24 to 48 hours
iii. Corticosteroids may also be used
iv. Chronic gout is treated with allopurinol or an uricosuric agent to reduce
the amount of uric acid in the system.
v. These medications are used in the long term to reduce the amount of
painful flares that occur.
vi. Low-fat, low-cholesterol diet—elevated uric acid levels accelerate
atherosclerosis.
vii. Immobilize the joint for comfort.

Osteomyelitis is an acute or a chronic infection of the bone or bone marrow caused
by bacteria, viruses or fungi.
i. The acute form may result from an infection in other tissues (hematogenic
osteomyelitis) or from an open fracture with bacterial contamination (Contiguous
osteomyelitis )
ii. The chronic form may result from inadequate initial antimicrobial therapy or lack
of response to treatment (relapse occurs when the patient’s resistance is lowered)
The bone becomes infected by one of three modes:
i. Extension of soft tissue infection (e.g., infected pressure or vascular ulcer,
incisional infection)
ii. Direct bone contamination from bone surgery, open fracture, or traumatic injury
(e.g., gunshot wound)
iii. Hematogenous (bloodborne) spread from other sites of infection (e.g., infected
tonsils, boils, infected teeth, upper respiratory infections). This typically occurs in
a bone area of trauma or low possibly from subclinical (nonapparent) trauma
Osteomyelitis

i. The causative organism is most often Staphylococcus aureus, (which causes 90% of
osteomyelitis)
ii. It is usually found in the tibia or fibula, in vertebrae, or at the site of a joint
prosthesis.
iii. Salmonella infection is associated with sickle cell anemia
iv. H. influenzae tend to infect young children
Pathophysiology:
i. First, the invading pathogen provokes an intense inflammatory response.( S. aureus)
ii. This include inflammation, increased vascularity, and edema.
iii. After 2 or 3 days, thrombosis of the blood vessels occurs in the area, resulting in
ischemia with bone necrosis.
iv. The infection may spread into adjacent soft tissues and joints.
Etiology & Pathophysiology

v. If the infective process is not treated , a bone abscess forms.
vi. The resulting abscess cavity contains dead bone tissue (the sequestrum),
which does not easily liquefy and drain.
vii. Therefore, the cavity cannot collapse and heal, as occurs in soft tissue
abscesses.
viii.New bone growth (the involucrum) forms and surrounds the sequestrum.
ix. Although healing appears to take place, a chronically infected sequestrum
remains and produces recurring abscesses throughout the patient’s life.
Pathophysiology:

Signs and symptoms
i. The patient may complain of site pain and pressure; heat, edema, and
tenderness may also be present
ii. Associated systemic signs and symptoms include chills, fever, malaise,
nausea, and tachycardia
iii. The affected limb may be sore with use
iv. An open, draining area may appear
Diagnosis :
i. Diagnosis may be based on patient history
ii. x- rays may show abnormalities, such as bone destruction, pathological
fracture, and sequestra formation, but in the early stages they may not show
any abnormality at all.
iii. CT scans can also highlight bone abnormalities

iv. MRI scans can detect any involvement of bone marrow and other tissue. MRI are
useful in definitive diagnoses.
v. Culture of the drainage, WBC count, and ESR
An antibiotic is administered I.V. in large doses after blood cultures are taken
Medical management:
i. Intravenous antibiotics are often needed, and antibiotics are prescribed for 4
to 6 weeks Aspirin or acetaminophen is given to control fever and pain
ii. Tetanus toxoid or antitoxin is given if the patient has an open wound
iii. Hyperbaric oxygen treatments at twice the atmospheric pressure for 2
hours/day up to six times per week may be prescribed
iv. After antibiotic therapy is completed, the bone is surgically scraped to clear
away the dead bone and residue of infection

v. Bone grafts may be used to aid bone healing and prevent fracture
vi. Tubes or catheters may be inserted to flush the site with an antibiotic
to clear any residual organisms
vii. An external fixator may be placed above and below the osteomyelitic
site to decrease the possibility of bone fracture
viii. Surgery to drain infection may be necessary
ix. Immobilization of the infected bone may be necessary using a cast,
traction, or bed rest
Bone infections are more difficult to treat than soft-tissue infections because the
infected bone and corresponding immune responses become walled off, thus
resisting antibiotics

Osteoarthritis is a non inflammatory slow progressive degenerative disorder of
articulating joints, particularly weight-bearing joints, and is characterized by
degeneration of articular cartilage.
It primarily affects weight-bearing joints in the hips, knees, and vertebrae but
may also affect the ankles, shoulders, wrists, fingers, and toes
Etiology:
Osteoarthritis has been associated with aging, obesity, and wear and tear on the
joints; however, a defective gene may account for many cases of idiopathic
osteoarthritis
Osteoarthritis may be:
a. Idiopathic (occurring without a previous injury or known cause)
b. Secondary (resulting from another injury or disease)

Pathophysiology:
i. Both types of osteoarthritis begin with the breakdown of the hyaline cartilage
covering the ends of the bones on either side of the joint
ii. The underlying bones become roughened, and bone cysts, fissures, or spurs
develop on the bone surface
iii. The joint space is lost as cartilage loss increases, and the joint ROM is
progressively restricted
iv. Resulting stretching of the joint capsule or ligaments, irritation of nerve
endings in the periosteum, resulting muscle spasms .
There are several possible causes for cartilage deterioration, which is an active
process. The enzyme hyaluronidase, which is normally found in the synovial
fluid, may be responsible for digestion of proteoglycans via cracks in the surface
layer of articular cartilage. Another possible cause is that the inadequate
nutrition of cartilage may result in cartilage degeneration. Because cartilage is
avascular, nutrients are provided by the synovial fluid

HALLMARK SIGNS AND SYMPTOMS:
i. Stiff joints for short time in morning, usually 15 minutes or less due to changes
within joints
ii. Joint pain with movement or weight bearing due to joint remodeling
iii. Crepitus (grating feeling on palpation over joint during range of motion) due to
loss of articular cartilage
iv. Pain relief when joints are rested because lack of movements will relieve
irritation in joint space
v. Enlargement of joint due to bony overgrowth or remodeling
vi. Heberden’s nodes—swelling of the distal interphalangeal joints

Diagnosis:
Patient history, physical examination,
i. X-rays
ii. CT scan
iii. MRI
iv. Arthrocentesis
v. and bone scan may be ordered
Serologic studies:
i. Complete blood count
ii. Erythrocyte sedimentation rate (ESR)
iii. Creatinine level
iv. Mineral assays, and humoral tests for immunoglobulins, also may be
performed

Medical Management:
Initial treatment is usually with over-the-counter medications. The patients
respond well to these medications.
i. Administer acetaminophen for pain relief.
ii. Glucosamine and chondroitin sulfate for relief of pain and stiffness.
iii. Capsaicin cream topically.
iv. Intra-articular injections of corticosteroid up to 3 or 4 times in a year.
v. Intra-articular injections of:
vi. Hyaluronate sodium; series of 3 to 5 injections

Osteoporosis is a metabolic bone disorder that results in the loss of bone density
due to the rate of bone resorption exceeding the rate of bone formation making
the bone porous brittle leading easy bone fractures.
Occurs principally in older adults and affects more women than men.
Etiology :
i. Family history of osteoporosis.
ii. A parental history of hip fracture.
iii. A body mass index (BMI) of 19 or less.
iv. Long-term use of high-dose steroid tablets (these are widely used for health
conditions such as arthritis and asthma)

Pathophysiology

Signs and Symptoms:
i. Osteoporosis is a silent disease and there are no early signs or symptoms.
ii. Once the patient has developed osteoporosis, height loss, Dowager hump
(excessive curvature of the spine), and back pain may occur.
iii. Osteoporosis is commonly diagnosed after the patient sustains a fracture
from little or no known trauma.

Tests:
i. Dual energy x-ray absorptiometry (DEXA): detects bone mass and bone
density loss.
ii. Quantitative computed tomography (QCT): measures bone density.
iii. X-rays: identify suspected fractures.
iv. Quantitative ultrasound (QUS): shows injured or diseased areas.
v. Blood tests: measure calcium, phosphorus, and alkaline levels; elevated
parathyroid hormone.

Medical management:
i. Calcium and vitamin D supplements: promote normal bone metabolism
ii. Estrogen and progesterone are prescribed to restore hormonal balance
Testosterone therapy for men: reduces osteoporosis
iii. Calcitonin (Calcimar): reduces bone resorption and slow loss of bone mass.
iv. Bisphosphonates (etidronate [Didronel]): increase bone density and restore lost
bone.
v. Fluoride (alendronate [Fosamax]): stimulates bone formation.
vi. Back or neck supports are used to prevent stress fractures
vii.Analgesics: relieve pain
viii.Active exercises are encouraged to help retain calcium in the bones

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory autoimmune disease
distinguished by joint swelling ,tenderness and destruction of synovial joints leading
to disability.
It affects the small joints of the hands and wrists and several other tissues
The first joint tissue to be affected is the synovial membrane
Etiology:
i. The cause of rheumatoid arthritis is unknown.
ii. Auto-immunity: Although no virus particles have been identified, it is likely that an
antigenic stimulus such as a virus leads to the formation of an abnormal
immunoglobulin G (IgG .
iii. Antibodies from the bloodstream against this abnormal IgG move into the synovial
lining of joints, causing joints to swell. Antibodies to this altered IgG is termed
“Rheumatoid Factors".
iv. Genetic factors: A genetic predisposition has also been identified related to certain
human leukocyte antigen (HLA) known as the HLA-DR4.

Pathophysiology:
The disease progresses through four stages which include:
i. First State: The unknown etiologic factor initiates joints inflammation synovitis, with
swelling of the synovial lining membrane and production of excess synovial fluid.
ii. Second Stage: Pannus(Inflammatory granular tissue) is formed at the juncture of the
synovium and cartilage.
iii. Third Stage: Pannus lead to formation of scar tissue (fibrous tissue) that occupy the
joint space. This results in decreased joint motion mal-alignment and deformity.
iv. Fourth Stage: As fibrous tissue calcifies, bony ankylosis may result in total joint
immobilization.

Signs and Symptoms:
i. Morning stiffness in joints due to the inflammation
ii. Enlarged joints from swelling
iii. Pain when moving due to the stiffness
iv. Limited range of motion because of the inflammation and pain
v. Fever, malaise, and weight loss

Diagnosis
i. History of morning stiffness that lasts more than 30 minutes
ii. physical examination
iii. Serologic blood tests, including rheumatoid factor, CBC, erythrocyte
sedimentation rate (ESR), serum complement, and C-reactive protein
iv. Radiographs confirm the cartilage destruction and bone deformities.
75% to 80% of patients with a positive rheumatoid factors test have the disease

Medical management:
i. Reduction of pain and inflammation is the goal of treatment
ii. Administer nonsteroidal anti-inflammatory (NSAID) medication to decrease
inflammation and pain
iii. Administer antacids to coat the stomach: magnesium hydroxide aluminium
hydroxide
iv. Hot and cold treatments are standard treatments
v. Surgical interventions include joint repair or prosthetic replacement and
synovectomy (removal of the synovium)

A bone tumor is an abnormal growth of cells within the bone forming a lump or mass of
abnormal tissue, that may be noncancerous (benign) or cancerous (malignant).
A variety of benign and malignant tumors affect the musculoskeletal system, involving bone
(osteo- ), cartilage (chondro- ), smooth muscle (leio- ), skeletal muscle (rhabdo- ), and bone
marrow
Benign tumors of the bone are more common than malignant bone tumors.
Malignant tumors are of two types:
i. Primary Malignant tumors: Originating in the bone
ii. Secondary Malignant Tumors: Originating from elsewhere in the body (e.g.,
breast, lung, prostate, or kidney) and travel to the bone (metastasis).
Secondary or metastatic bone tumors are more common than primary bone tumors

Riske factors:
i. Certain factors can predispose to musculoskeletal tumor development.
ii. These include Paget's disease of bone,
iii. Previous trauma,
iv. Radiation
v. Injury,
vi. Chronic bone infection,
vii. Osteogenesis imperfecta (Brittle bone disease),
viii.And some genetic conditions (e.g. Ollier’s disease, retinoblastoma).
Bone cancers affect males and females equally; they occur more
commonly in children and adolescents, although some types do occur in
patients ages 35 to 60 years
The most common sites for tumors are the femur, tibia, and humerus

Signs and Symptoms
These vary depending on the tumor type and location.
i. Pain— non- mechanical, night- time, ranging from deep aching to acute
ii. Palpable lump or swelling— hard or soft depending on the site, may be warm
and tender.
iii. Unexplained limp, and limited mobility if the tumor involved or is near a joint.
iv. Low- grade pyrexia.
v. Fatigue and recent weight loss— these are late signs
vi. Abnormal gait

BENIGN BONE TUMORS:
Benign bone tumors are noncancerous growths which have the potential to cause
fractures of bones.
i. Benign tumors are slow growing, encapsulated, present few signs and
symptoms, and are rarely associated with mortality
ii. Benign bone tumors include osteochondromas, bone cysts, osteoid osteomas,
and fibromas
iii. Giant cell tumors (osteoclastomas) may begin as benign tumors and remain
that way for long periods occurs in young adults; they have the potential to
eventually become malignant
iv. Osteochondroma is the most common benign bone tumor (at the knee or
shoulder)
v. Enchondroma is a common tumor of the hyaline cartilage that develops in the
hand, femur, tibia, or humerus
vi. Aneurysmal (widening) bone cysts are seen in young adults, who present with
a painful, palpable mass of the long bones, vertebrae, or flat bone.

BENIGN BONE TUMORS:
vii. Unicameral (single cavity) bone cysts occur in children and cause
mild discomfort and possible pathologic fractures of the upper
humerus and femur, which may heal spontaneously
viii.A painful tumor that occurs in children and young adults is the
Osteoid Osteoma
Pathophysiology:
i. Benign tumors usually are the result of misplaced or overgrown
clusters of normal bone or cartilage cells that cause the structure
to enlarge and impair local function.
ii. They grow slowly and do not metastasize.
iii. Their growth can weaken the bone structure by compressing or
displacing the normal tissue

STAGE OF BENIGN BONE TUMORS
Enneking described the most widely used staging system for benign bone tumors
given below
STAGE 1-LATENT:It do not have any characteristics of growth or progressive
change, may resolve spontaneously.
STAGE 2-ACTIVE:lesion deform the host bone but remain contained in bone,
require intralesional curettage.
STAGE 3-AGGRESSIVE: Tumor extend beyond the bone, require complete work-
up and a removal with wide margins to avoid possible local recurrence.

MALIGNANT BONE TUMORS
Malignant bone tumors are abnormal osteoblasts or myeloblasts (marrow cells) that
exhibit rapid and uncontrollable growth.
Two types Primary and Secondary
Primary malignant bone tumors are relatively rare including
A. Osseous origin
Osteogenic sarcoma:
a. Is the most common and most often fatal primary malignant bone tumor
b. Occurs most commonly in femur
c. Usually occurs in teens and young adults in their 20s
ii. Chondrosarcoma: Second Most
a. Is malignant tumors of the Hyaline Cartilage
b. Occurs most commonly in pelvis, proximal femur, ribs, and shoulder girdle

B. Non-Osseous Origin
Non-osseous bone tumors include
i. Ewing’s sarcoma :
a. Originates in bone marrow and invades shafts of long and flat bones
b. Usually affects lower extremities, most commonly femur,
c. Usually occurs in children, teens, and young adults in their early 20s
ii. Fibrosarcoma (fibroblastic):
a. Originates in fibrous tissue of bone
b. Invades long or flat bones (femur, tibia, mandible)
c. Usually occurs in people ages 30 to 40
iii. Chordoma:
a. Derived from embryonic remnants of notochord
b. Usually found at end of spinal column and in spheno-occipital
c. Usually occurs in people ages 50 to 60

Metastatic Bone Disease (Secondary Bone Tumor):
Tumors arising from tissues elsewhere in the body and invade the bone
producing localized bone destruction (lytic lesions) or bone overgrowth (blastic
lesions).
More common than primary bone tumor.
The most common primary sites of tumors that metastasize to bone are
i. The kidney
ii. Prostate
iii. Lung
iv. Breast
v. Ovary
vi. And thyroid
Metastatic tumors most frequently attack the skull, spine, pelvis, femur, and
humerus and involve more than one bone (polyostotic).

Pathophysiology:
Absent or impaired tumor suppressor gene , prior exposure to radiation and toxic
chemicals associated with the genesis of some metastasizes in parts of body
Metastasis spreads to bone through the circulatory or lymphatic system effecting
bones
Malignant bone tumors invade and destroy adjacent bone tissue.
Invading bone tumors weaken the structure of the bone until it can no longer
withstand the stress of ordinary use
Metastasis to the lungs is common.

The staging system for malignant tumor adopted by the Musculoskeletal Tumor
Society, and originally developed by ( Enneking)
Is based on
i. The histological grade,
ii. The local extent(tumors whether they are intra compartmental or extra-
compartmental) and
iii. The presence or absence of metastasis
Stage Of Malignant Bone Tumors

Stage Of Malignant Bone Tumors
i. Stage IAis defined as G1 and Intra- compartmental
ii. Stage IB is G1 and extra-compartmental
iii. Stage IIA is G2 and Intra-compartmental
iv. Stage IIB is G2 and extra-compartmental
v. Stage III is G1 or G2, intra- or extra- compartmental, and has
evidence of metastasis

i. Plain X- ray— anterior, posterior, and lateral views
ii. CT scan— bone, soft tissue, and neural structures involved. Used to check
metastatic spread to the lungs
iii. MRI scan— more sensitive than CT scan for soft tissue tumors, to view tumor
extent and spread
iv. Bone scan— will detect asymmetrical ‘hot spots’ in the skeleton
v. Biopsy: Excision biopsy (for benign malignancies, to remove the tumor).
a. Open biopsy (under a general anaesthetic a section of the tumor is removed
for analysis).
b. Needle/ core biopsy (under imaging guidance, a needle or drill is used to
remove a core of the tumor; this is the least invasive method)
Diagnosis And Investigations

Treatment dependent on
i. Tumor type
ii. Histological staging and grading
iii. Extent of spread
iv. Age of the patient
v. Prognosis
vi. And lifestyle issues.
vii. Most benign tumors are treated by surgical excision, and further recurrence is
unlikely.
viii. Malignant tumor treatment may involve chemotherapy to shrink the tumor
ix. Bone excision with a cuff of healthy bone to reduce recurrence
x. Limb amputation is considered in patients in whom major vessels or nerves are
involved,
xi. Radiotherapy can be used in some cases to prevent recurrence

Bone Tuberculosis
Tuberculosis (TB) is an Infectious disease caused by the bacterium,
Mycobacterium tuberculosis an acid-fast bacillus
M. tuberculosis is spread by way of infected airborne droplets
i. TB bacteria, most commonly, attack the lungs; however, they can involve any
part of the body such as the kidneys, eyes, joints, spine, and brain.
ii. The most common type is spinal tuberculosis
iii. This happens when the mycobacterium infection spreads into spinal cord.
iv. Spinal tuberculosis is also called Pott’s disease.
v. This is typically seen most often in places with widespread AIDS infections

Pathophysiology
i. Bacilli are deposited in the lungs, the immune system responds by sending
leukocytes, and inflammation results.
ii. After a few days, leukocytes are replaced by macrophages.
iii. The organism may be killed in the process or exist in a dormant state.
iv. Dormant organisms may reactivate
v. If alive, these bacilli may spread by way of lymphatic channels or through the
bloodstream to more distant tissues and organs e.g. Lymph nodes, apex of the
lung, kidneys, brain, and bone
vi. And cause local disease in the presence of immunosuppression

Signs & Symptoms
i. Back pain is the earliest and most common symptom
ii. Inflammation in back or joints
iii. Stiffness
iv. Trouble moving or walking, especially in children
v. Spinal abscess
vi. Soft tissue swelling

Diagnosis
i. Bacterial culture
ii. Body fluid test (plural, CSF or synovial).
iii. Radiological tests
a. Plain radiograph
b. CT scan
c. MRI spine
d. Bone scan
TB bacilli are rarely found in CSF, therefore imaging plays pivotal role in
suggesting the diagnosis.

Treatment
i. Anti-tuberculosis drugs for 6 to 12 months
ii. Corticosteroids.
iii. Surgery

References:
1Taylor, C., et al. (2010). Fundamentals of nursing: The art and science of nursing care (7th ed.). Philadelphia, PA:
Lippincott Williams & Wilkins.
Smeltzer, S. C., et al. (2009). Brunner and Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia,
PA: Lippincott Williams & Wilkins.
Porth, C. M. (2010). Essentials of pathophysiology (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Nettina, S. (2009). Lippincott manual of nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins.
Medical-surgical nursing made incredibly easy! (3rd ed.). (2011). Philadelphia, PA: Lippincott Williams &
Wilkins.
Ignatavicius, D., & Workman, L. (2009). Medical-surgical nursing: Patient-centered collaborative care. Philadelphia,

References:
Bickley, L. (2008). Bates’ guide to physical examination and history taking (11th ed.).
Philadelphia, PA: Lippincott
Williams & Wilkins.
ACC Atlas of pathophysiology (3rd ed.). (2009). Philadelphia, PA: Lippincott Williams &
Wilkins
medical-surgical_nursing-10th-edition-by-brunner-suddarth
Medical-Surgical Nursing_ Assessment and Management of Clinical Problems
Lippincott-Visual-Nursing-A-Guide-To-Diseases-Skills-And-Treatments-Nursing-Workbook
Introductory Medical-Surgical Nursing, 10th Edition (Lippincott's Practical Nursing)
Delmar-Fundamentals-Of-Nursing. -Standards-Practices-Nclex-Workbook
Adult nursing _ preparing for practice Dave Barton, Andrée le May

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