Musculoskeletal Problems

Musculoskeletal Problems Overview

Chapter 68 - Musculoskeletal Problems

Osteomyelitis

Definition: Severe infection of bone, bone marrow, and surrounding soft tissue.
Causes:
- Most common microorganism: Staphylococcus aureus
- Other risk factors include:
- Older age
- Debilitation
- Hemodialysis
- Sickle cell disease
- IV drug use
- Presence of foreign bodies (e.g., implanted prosthesis)
- Diabetic or vascular ulcers, or pressure injuries

Etiology and Pathophysiology of Osteomyelitis

Microorganisms enter the bloodstream and proliferate, resulting in:
- Increasing pressure in the bone leads to ischemia and vascular compromise of the periosteum.
- The infection spreads through the bone, cortex, and marrow cavity, obstructing blood flow and causing necrosis.
- Ischemia ultimately results in bone death.

Acute Osteomyelitis

Definition: Initial infection lasting less than 1 month.

Clinical Manifestations

Local manifestations include:
- Constant pain that worsens with activity and is unrelieved by rest.
- Swelling, tenderness, and warmth at the site.
- Restricted movement of the affected part.
- Other systemic symptoms:
- Fever
- Night sweats
- Chills
- Restlessness
- Nausea
- Malaise

Complications

Possible complications include:
- Septicemia
- Septic arthritis
- Pathologic fractures
- Amyloidosis

Diagnostic Studies for Osteomyelitis

Diagnostic tools used include:
- Bone or soft tissue biopsy
- Blood and/or wound cultures
- White Blood Cell (WBC) count
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein
- Imaging studies including X-rays, MRI, and CT scans
- Bone scans and radionuclide WBC scans

Interprofessional Care for Acute Osteomyelitis

Antibiotic Therapy:
- Initial therapy via IV antibiotics, transitioning to oral agents.
- IV therapy for 4-6 weeks; some cases may require 3-6 months.
- Central venous access device (CVAD) requires follow-up in a skilled nursing facility or home care.
Prior to Antibiotics: Cultures or bone biopsy should be collected.
Surgical Interventions:
- Surgical debridement and drainage of abscess or ulcer.
- Negative-pressure wound therapy and hyperbaric oxygen therapy might be utilized.

Clinical Goals

Overall objectives include:
- Manage pain and fever satisfactorily
- Maintain freedom from complications
- Ensure adherence to the treatment plan
- Control other existing infections
- Identify and manage persons at risk including:
- Immunocompromised individuals
- Those with diabetes or orthopedic prosthetic devices
- Patients with vascular insufficiency

Bone Tumors

Overview:
- Primary bone tumors are rare in adults (constituting 3% of all tumors).
- Metastatic bone cancer is more prevalent.
- Benign tumors are more common than primary malignant tumors, including:
- Osteochondroma
- Osteoclastoma
- Enchondroma

Osteochondroma

Description: Most common primary benign bone tumor.
Locations: Frequently found in the pelvis, scapula, or long bones of the leg.
Manifestations:
- Painless, hard, immobile mass.
- Shorter-than-normal height for age.
- Muscle soreness adjacent to the tumor.
- Discrepancy in limb length (one arm or leg longer).
- Pressure or irritation during exercise.
- Often asymptomatic.

Diagnostic Studies

Imaging studies include X-ray, CT scan, or MRI.
Treatment:
- If asymptomatic, no treatment is required.
- Surgical removal is indicated when painful or if neurologic symptoms occur.
- Regular screenings may be necessary to detect potential progression to cancer.

Malignant Bone Tumors

Definition: Sarcoma, a malignant tumor found in bone, muscle, fat, nerve, or cartilage.
Demographics: More common in children and young adults.
Pathophysiology: These tumors lead to bone destruction and can metastasize quickly.

Osteosarcoma

Description: Very aggressive bone cancer.
Characteristics:
- Rapid metastasis, primarily occurring in the pelvis and metaphyseal region of long bones.
- Most common bone cancer in children and young adults; often associated with Paget’s disease or prior radiation exposure.
- Approximately 10% to 20% present with metastasis at diagnosis.
Manifestations:
- Pain and swelling gradually develop.
- Pain typically worsens at night and with increased activity.

Diagnostic Studies for Osteosarcoma

Recommended diagnostic tools include:
- Tissue biopsy.
- Elevated serum alkaline phosphatase and calcium levels.
- Imaging studies: X-ray, CT scan, PET scan, MRI.

Treatment of Osteosarcoma

Strategies:
- Preoperative chemotherapy is standard.
- Limb salvage procedures if a clear 6 to 7 cm margin around the lesion is achievable.
- Contraindications for limb salvage: nerve, blood vessel involvement, extensive muscle involvement, pathologic fracture, or infection.
- Limb salvage or amputation followed by adjunct chemotherapy has increased the 5-year survival rate to 70% without metastasis.

Muscular Dystrophy (MD)

Definition: A group of genetic diseases characterized by symmetric wasting of skeletal muscles without neurologic involvement.
Variability: Types of MD vary based on the groups of muscles affected, age of onset, rate of progression, and mode of genetic inheritance.
Diagnosis:
- Genetic testing.
- Muscle serum enzyme analysis.
- Electromyography (EMG) and biopsy.
Treatment:
- There is no cure; however, corticosteroids can slow progression for up to two years and improve survival.
- Continuous monitoring of cardiac and respiratory function is necessary.

Low Back Pain

Prevalence: Affects approximately 80% of adults in the US at least once.
Ranking: It is the second most common pain problem after headaches.
Impact: It is a leading cause of job-related disability and a major contributor to missed workdays.
Cause: Often attributed to musculoskeletal problems.
Anatomical Factors:
- The lumbar region bears the majority of body weight.
- It is the most flexible region of the spinal column.
- Contains nerve roots that are vulnerable to injury or disease.
- Has a naturally poor biomechanical structure.

Risk Factors for Low Back Pain

Contributing factors include:
- Lack of muscle tone
- Excess body weight
- Pregnancy
- Stress
- Poor posture
- Cigarette smoking
- Prior compression fractures
- Congenital spinal problems
- Family history of back pain
- Professions requiring heavy lifting or prolonged sitting (e.g., nursing).

Etiology of Low Back Pain

Common musculoskeletal causes involve:
- Acute lumbosacral strain
- Instability of the bony lumbosacral mechanism
- Osteoarthritis of lumbosacral vertebrae
- Degenerative disc disease
- Herniation of intervertebral discs

Acute Low Back Pain

Definition: Lasts 4 weeks or less and is caused by trauma or undue stress.
Symptoms:
- May not be evident immediately after injury, typically appearing within 24 hours from nerve pressure or edema.
- Symptoms can range from muscle ache to shooting/stabbing pain.
- Limited flexibility and range of motion (ROM).
- Inability to stand upright.
Straight-leg Raising Test:
- A positive result for disc herniation occurs when radicular pain is elicited.
Imaging: MRI and CT scans are indicated only for trauma or suspected systemic disease.

Assessment of Acute Low Back Pain

Subjective Data:
- Health history might indicate lumbosacral strain/trauma, osteoarthritis, or degenerative disc disease.
- Medication history should include opioids, NSAIDs, muscle relaxants, corticosteroids, and any over-the-counter treatments.
- Previous surgeries or treatments like epidural injections should be noted.
Management:
- Typically treated on an outpatient basis unless severe.
- Options include: NSAIDs, muscle relaxants, massage, acupuncture, cold and hot compresses.
- Severe pain may require corticosteroids and opioids.
- Patients should avoid activities that may exacerbate pain (e.g., lifting, bending, twisting, prolonged sitting).
- Acute low back pain usually resolves within 2 weeks, often without treatment.

Goals for Acute Low Back Pain Management

Aim to prevent recurring episodes of acute low back pain.
Referral:
- Refer to physical therapy or a personal trainer for posture and core strength assessment.
Education:
- Instruction on proper body mechanics through programs like “Back School.”
Prevention Tips:
- Opt for flats or low heels with shock-absorbing inserts.
- Encourage smoking cessation.
- Maintain a healthy body weight.
- Sleep on a firm mattress, adopting a proper position.
Support:
- Offer occupational counseling and emotional support.
- Provide education for patients and caregivers.

Spinal Stenosis

Definition: Narrowing of the spinal canal, a common cause of chronic low back pain.
Acquired Conditions:
- Osteoarthritis, rheumatoid arthritis, tumors, Paget’s disease, trauma.
Inherited Conditions:
- Congenital spinal stenosis, scoliosis.
Symptomatology:
- Pain starts in the low back and radiates to the buttocks and legs.
- Pain intensifies with walking or prolonged standing.
- Accompanied by numbness, tingling, weakness, and heaviness in the legs and buttocks.
- Pain generally lessens when the patient bends forward or sits down, often exacerbated in cold, damp weather.
- Progresses slowly over time.

Interventions for Spinal Stenosis

Pharmacological Treatment:
- Mild analgesics (NSAIDs), and antidepressants (e.g., duloxetine).
Other Therapies:
- Gabapentin (Neurontin) to improve walking and relieve leg symptoms.
- Weight reduction and sufficient rest periods.
- Application of local heat, physical therapy, and exercise throughout the day.
- Participation in “Back School.”
Minimally Invasive Treatments:
- Epidural corticosteroid injections and implanted devices for analgesia.
Surgery:
- Considered for severe pain.

Intervertebral Disc Disease Overview

Definition: Involves deterioration, herniation, or other problems with intervertebral discs.
Degenerative Disc Disease (DDD):
- Associated with loss of fluid, leading to decreased elasticity, flexibility, and shock-absorbing abilities.
- Aging is a normal process unless pain is present.
- The disc becomes thinner as the nucleus pulposus dries out.
- Load is prematurely shifted to the annulus fibrosus.

Etiology of Intervertebral Disc Disease

Contributing factors include:
- Age-related degeneration
- Repeated stress and trauma
- Spinal stenosis

Lumbar Disc Disease Clinical Manifestations

Symptoms may include:
- Low back pain is most common.
- Radicular pain that follows the sciatic nerve.
- Positive straight leg raise test.
- Presence of decreased or absent reflexes.
- Paresthesia and muscle weakness.
Emergency:
- Compression of multiple nerve roots may develop either slowly or abruptly and require immediate surgical decompression to prevent permanent paralysis.

Diagnostic Studies for Intervertebral Disc Disease

Diagnostic tools may involve:
- X-rays to assess structural defects.
- Myelogram, MRI, or CT scan to localize the damaged site.
- Epidural venogram or discogram when other studies are inconclusive.
- Electromyography (EMG) for assessing nerve irritation severity or ruling out other conditions (e.g., peripheral neuropathy).

Interprofessional Care for Intervertebral Disc Disease

Conservative Therapy:
- Restrict extreme spinal movements.
- Apply local heat or ice.
- Utilize ultrasound and massage therapies.
- Consider skin traction and transcutaneous electrical nerve stimulation (TENS).
Drug Therapy:
- Options include NSAIDs, short-term corticosteroids, opioids, muscle relaxants, antidepressants, and epidural injections.
Education:
- Back-strengthening exercises and teaching good body mechanics are crucial.
- Promote avoidance of extremes of flexion and torsion.
- Most patients experience healing within 6 months.

Surgical Therapy for Intervertebral Disc Disease

Indications:
Surgical intervention is indicated when:
- Conservative treatment fails.
- Radiculopathy worsens.
- Bowel or bladder control is lost.
- Constant pain and persistent neurologic deficits occur.

Surgical Options

Possible procedures include:
- Laminectomy
- Discectomy: removal of the damaged part to decompress the nerve root.
- Artificial disc replacement
- Spinal fusion

Nursing Management for Spine Surgery

Postoperative Care:
- Focus on maintaining proper alignment post-surgery.
- Activity level varies depending on specific surgical procedures.
- For lumbar fusion:
- Use pillows under thighs when supine.
- Place pillows between legs when side-lying.
- Utilize log rolling techniques to change positions.
- Reassurance for Patient:
- Provide emotional support and education regarding expected recovery.

Postoperative Pain Management for Spinal Surgery

Medications:
- Opioids may be utilized for 24 to 48 hours.
- Consider patient-controlled analgesia (PCA).
- Transition to oral medications when appropriate.
- Muscle relaxants may also be provided.
Monitoring:
- Assess and document pain intensity and the effectiveness of pain management.
- Monitor for potential cerebrospinal fluid (CSF) leakage, specifically checking for headache or clear/yellow drainage.
- In the presence of suspected leakage, place the patient in a flat position.
- Continually assess circulation and neurologic status, monitoring GI and bowel function, and assisting with bladder emptying as necessary.

Foot Problems

Foot problems may be impacted by:
- Congenital disorders
- Structural weaknesses
- Traumatic injuries or stress injuries
- Systemic conditions

Management Strategies

Proper Footwear:
- Adequate footwear provides support, stability, protection, shock absorption, and can treat some foot problems.
Conservative Treatments:
- Include NSAIDs, ice, changes in footwear, and warm soaks.
Surgical Interventions:
- Postoperative care should include elevating the foot with the heel off the bed and conducting neurovascular assessments.
- Daily foot hygiene and toenail care are paramount.
Increased Risk Considerations:
- Factors like poor circulation and atherosclerosis lead to decreased sensation, especially in diabetics.

Patient Education

Educate patients and caregivers on:
- Daily foot inspections and reporting of open areas to health care providers.
- Understanding the consequences of untreated wounds which may lead to infection, osteomyelitis, and potentially surgical interventions such as debridement or amputation.

Metabolic Bone Diseases

Osteomalacia:
Etiology:
- Vitamin D deficiency resulting from limited sun exposure, gastrointestinal malabsorption, chronic diseases (liver, kidney, small intestine), or long-term use of antiseizure drugs and phosphate-binding antacids.
Clinical Manifestations:
- Bone pain, muscle weakness, progressive deformity, and fractures may occur.
Diagnostics:
- Laboratory analysis and X-rays are common assessments.
Treatment:
- Correcting vitamin D deficiency through supplementation, ensuring adequate calcium or phosphorus intake, dietary adjustments including eggs, meat, oily fish, fortified milk, and cereals, and encouraging sunlight exposure and weight-bearing exercises.

Osteoporosis

Definition: Chronic and progressive metabolic bone disease characterized by low bone mass and the deterioration of bone tissue, leading to increased fragility.
Prevalence: Over 54 million individuals are affected in the US; termed the "silent thief" due to its asymptomatic nature until severe fractures occur.
Risk Factors:
- Advancing age (>65 years).
- Female gender (greater prevalence in women).
- Ethnic predisposition (white or Asian individuals).
- Low body weight and estrogen deficiency.
- Current cigarette use.
- Prior fractures.
- Sedentary lifestyle.
- Family history of osteoporosis.
- Poor dietary intake of calcium and vitamin D.
- Excessive alcohol consumption (>2 drinks/day).
- Low testosterone levels in men.
- Long-term use of glucocorticoids, thyroid replacement medications, heparin, long-acting sedatives, or antiseizure drugs can significantly elevate risk.

Preventive Factors for Osteoporosis

Include:
- Engaging in regular weight-bearing exercise.
- Adequate intake of fluoride, calcium, and vitamin D.
Medications that impair bone metabolism:
- Corticosteroids, anti-seizure medications, aluminum-containing antacids, heparin, certain chemotherapy agents, and excess thyroid hormones can exacerbate bone density reduction.
Women experience rapid bone loss at menopause, which slows and eventually equates with men ages 65 to 70.

Management of Osteoporosis

Focus areas include:
- Proper nutrition emphasizing calcium and vitamin D supplementation.
- Regular exercise.
- Preventing falls and fractures.
- Drug therapy to ensure adequate calcium intake.
- Good sources of calcium include milk, yogurt, turnip greens, cottage cheese, ice cream, sardines, and spinach.
- Vitamin D is essential for calcium absorption and use; adequate sunlight exposure for 20 minutes is recommended.
- Weight-bearing exercises, quitting smoking, and decreasing alcohol intake contribute to better management.
- Minimally invasive procedures (vertebroplasty and kyphoplasty) may be recommended for osteoporotic vertebral fractures.

Drug Therapy for Osteoporosis

Bisphosphonates:
- Inhibit bone resorption and slow down remodeling processes.
- Administration protocols:
- Take with a full glass of water, 30 minutes before food or other medications, and remain upright for at least 30 minutes.
- Recommended continuation of treatment for 5 years.
Estrogen Therapy:
- No longer recommended post-menopause due to increased risk of cardiovascular and certain cancers (breast and uterine).
Corticosteroids:
- Administer at the lowest effective dose for the shortest period possible, alongside adequate calcium and vitamin D intake.

Audience Response Questions

Question: Alendronate (Fosamax) is prescribed for a patient with osteoporosis. The nurse teaches the patient that:
- a. the drug must be taken with food to prevent GI side effects.
- b. bisphosphonates prevent calcium from being taken from the bones.
- c. lying down after taking the drug prevents light-headedness and dizziness.
- d. taking the drug with milk enhances the absorption of calcium from the bowel.
Answer: B (bisphosphonates prevent calcium from being taken from the bones).

Question: Which patient would be at the greatest risk for developing osteoporosis?
- a. A 73-year-old man who has five alcoholic drinks per week and limits sun exposure to prevent recurrence of skin cancer.
- b. An 84-year-old man who has recently been diagnosed with hypothyroidism and is prescribed levothyroxine (Synthroid).
- c. A 69-year-old woman who had a renal transplant 5 years ago and has been taking prednisone to prevent organ rejection.
- d. A 55-year-old woman who recently had a hysterectomy with bilateral salpingo-oophorectomy and refuses estrogen therapy.
Answer: C (A 69-year-old woman who had a renal transplant and has been taking prednisone).