Musculoskeletal Disorders notes for EMT students

Musculoskeletal disorders

1. A 57 year old man presented to you during your night shift with a c/o severe pain on the right big toe which was of sudden onset. He further reported that there was insidious pain on the ipsilateral knee and swelling. Prior to the onset of the complain, he was attending her daughters ruracio where they were served with a lot of smoked meet among other menu. Oe ; sick looking, in a gonizing pain, holding a half full tumbler with a concussion of unlabeled hard drink. DDX, MNX Aa a

2. MUSCULOSKELETAL SYSTEM DISORDERS Mike Mutua , Msc -TID, BCM, DCM/S

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4. Anatomy and physiology review of MSS Assessment of pt with MSS problem Interv e ntion for cli ents with musculoskeletal disorders 4 cli ents with Intervention for musculoskeletal trauma: Soft tissue injuries Sprain

5. Dislocations Fracture Amputation Joint and connective tissue diseases Rheumatoid arthritis Gouty Arthritis Osteomyelitis Osteoporosis Osteoarthritis septic arthritis 5

6. Anatomy and ph y siol o g y o f t h e musculoskeletal system 6

7. Anat o my an d ph y siolog y o f the M S S Musculoskeletal system includes: Bones Joints Muscles Tendons Ligaments bursae Musculoskeletal system 7

8. Anatomy and physiology of the MSS (cont’d…) Their functions are highly integrated Therefore, disease in or injury to one adversely affects the others. For instance, an infection in a joint (septic arthritis) causes degeneration of the articular surfaces 8

9. Bones 9 At birth ≈ 270 bones Adult ≈ 206 bones through ossification and divided in five shape categories: Long bones (e.g., Femur), Short bones (e.g., Metacarpals), Flat bones (e.g., Sternum) Irregular bones (e.g., Vertebrae). Sesamoid bones(e.g. patella & the pisiform bone of carpals )

10. 10

11. Bo n e s (co n t’d…) Arranged in two divisions: Axial skeleton ( 80 bones) Appendicular skeleton (126 bones) 11

12. Bone s (cont’d…) Bone is composed of cells, protein matrix, and mineral deposits. Three bone cells:- Osteoblasts Osteocytes Osteoclasts 12

13. Bo n e s (co n t’d…) 13 Osteoblasts Bone formation by secreting bone matrix. Matrix consists of collagen & ground substances (glycoprotein & proteoglycans) Osteocytes – Mature bone cells Involved in bone maintenance ; Osteoclasts Multinuclear cells Involved in dissolving & desorbing bone.

14. Parts of Bones 14

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16. 16

17. Bone Healing Gross injuries(fractures ) heal by stages with new bone with no scar 15 Inflammation/ hematoma formation Precallus formation Callus formation Replacement of callus Remodeling of bone

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19. Muscle Tissue 19

20. Types of Muscle Tissue 20 Skeletal muscle >650 muscles & located throughout the body Striated in appearance ,multi- nucleated Under voluntary nervous control. Smooth or visceral muscle Located in the walls of organs No striations, & under involuntary control. Cardiac muscle o Located only in the heart, striated ,1-3 central nuclei & involuntary control.

21. Structur e of a j o int an d surrou n ding tissues. 21

22. Type of Joint Extent of Mov e ment Example Synovial Freely movable. Bones do not Touch each other Knee, shoulder Cartilaginou s Slightly movable Vertebral bodies of the spine Fibrous Immovable Skull sutures 20

23. So m e mov e me n ts a t s y n o via l j o in t s Rotation Movement : Internal or medial rotation External or lateral rotation Angular Movements: Flexion Extension Abduction Adduction Special movements: Pronation Supination Dorsiflexion Plantar flexion Inversion Eversion Protraction Retraction 21

24. Test ROM of elbow

25. Supination and pronation

26. Test ROM of wrist

27. TEST ROM Ask the client to: Spread the fingers apart.

28. ROM of fingers

29. TEST ROM

30. Abduction and adduction

31. Internal rotation

32. External rotation

33. Flexion and extension

34. TEST ROM

35. Connective tissues Ligaments( skeletal component ) Join bones to bones or cartilage to cartilage Joint capsule Stabilizer of joints (degree of stiffness or laxity of joints ) Limited ROM & not elastic Tendons(cord like) Connect muscle to Bone Inelastic and transmit muscle power/forces to bones Respond well to tensile stress. Read more : http://www.ehow.com/fac ts_5558153_functions- ligaments-tendons.html 35

36. Connective tissues (cont’d…) The point where a tendon or ligament joins a bone is called an enthesis and may be the site of inflammation 36

37. Cartilages Pad and cushion of the end of bone - protects the end of the bones. 37

38. Functi o n – Support Provides the framework to support the body’s fat, muscle, and skin. Protection Protects the body’s vital organs. Leverage Serves as a point of attachment for skeletal muscles responsible for movement. Storage Stores most of the body’s calcium supply. Blood cell production Forms red and white blood cell and platelets. Form Gives shape to the body. 36

39. Assessment of patient with Musculoskeletal system problems 39

40. MSS assessment methods 40 History Physical examination Inspection and palpation Diagnostic Evaluation Imaging Procedures Laboratory Studies

41. Diagnostic evaluation 41 Imaging procedures X-rays Computed tomography (CT) scan Magnetic resonance imaging Arthrography - Acute or chronic tears of the: Joint capsule / Supporting ligaments Bone densitometry Estimate bone mineral density (BMD). Bone scan

42. Diagnostic evaluation (cont’d..) 42 Arthroscopy Direct visualization of a joint Electromyography (EMG) Electrical potential of the muscles and the nerves Biopsy Determine the structure and composition of bone marrow, bone, muscle, or synovium

43. Laboratory studies 43 Coagulation studies - detect bleeding tendencies Serum calcium levels - altered in osteomalacia, parathyroid dysfunction,, metastatic bone tumors. Serum phosphorus levels - diminished in osteomalacia Acid phosphatase- elevated in paget’s disease and metastatic cancer. Alkaline phosphatase - elevated during early fracture healing

44. Labor a tor y (studies co n t’d) 44 Serum enzyme level- creatine kinase and aspartate aminotransferase become elevated with muscle damage Urine calcium levels - increase with bone destruction Complete blood count (CBC) Hgb- normochromic, normocytic anaemia occurs in chronic inflammatory and autoimmune diseases WBC - neutrophilia is seen in bacterial infection (e.g. Septic arthritis Platelets- thrombocythaemia in chronic inflammation

45. Labor a tor y (studies co n t’ d ) 45 ESR an d C - reactive protei n (CRP). increase reflects inflammation Uric acid for gout Serum auto antibody studies IgM rheumatoid factors Synovial fluid examination

46. Synovial fluid examination 46 Colour Diagnosis WBC per mm 3 Clear, yellow and viscous OA < 3000 Translucent and thin RA 3000-40 000 Very cloudy Seronegative arthritis Crystal arthritis Purulent Sepsis 750 000

47. MSS assessment methods (cont’d…) 45 Musculoskeletal assessment includes: Assessment of joint Assessment muscle and Assessment bones (Give attention to pain, tenderness, tightness, and abnormal sensations)

48. Assessme n t o f Joint 46 Joints are assessed for : Range of motion Any sign of inflammation Crepitation Deformities Condition of surrounding tissue Symmetry of involvement

49. TEMPOROMANDIBULAR JOINT(TMJ) Inspect, palpate, and test ROM

50. Assessme n t o f Muscle Assess muscles Bulk (Hypertrophy with proportionate strength ) Tone( resistance to passive stretch, Normal Decreased, Increased ( Spasticity ,Rigidity) Strength – Check each component in the arms, legs, and trunk. 48

51. Rating scale Movement Classification Score Active motion resistance against full Normal 5 Active motion resistance against some Slight weakness 4 Active motion against gravity Average weakness 3 Passive range of motion Poor ROM 2 Slighter flicker of contraction Severe weakness 1 No muscular contraction Paralysis

52. Asse s sme n t o f B o ne 51 Inspect Any deformity, Malalignment Abnormality in the cervical, thoracic or lumbar curvature . lateral curvature.

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54. Spinal deformities 53

55. Testing knee effusion 54 Patellar tap Ripple test: Empty the suprapatellar pouch, as for the patella tap test. Stroke the medial side of the joint to displace excess fluid to the lateral side of the joint. Stroke the lateral side while watching the medial side closely for a bulge or ripple as fluid re-accumulates.

56. Cruciate ligament stability Flex knee to 90° Anterior drawer sign Hands behind the upper tibia and both thumbs over the tibial tuberosity, pull the tibia anteriorly I f t h e re is signi f icant mo v e m ent t he anterior cruciate ligament is lax. Movement of >1.5 cm suggests ACL rupture. Posterior drawer sign Push tibia backwards Posterior movement of the tibia suggests PCL laxity 55

57. Patellar apprehension test /patellar stability Patient's knee fully extended Push the patella laterally and flex the knee slowly If the patient actively resists flexion, this suggests previous patellar dislocation or instability 56

58. WRIS T S INSPECT AND P AL P A TE I n spe c t f or size, sh a pe, symmet r y , c o lo r , and swelling. Palpate for tenderness and nodules.

59. test for carpal tunnel syndrome( phalen’s test)

60. Tinel’s sign

61. Thomas’s test.

62. trendelenberg test.

63. KNE E S I N S P ECT AN D P A L P A TE

64. TEST FOR SWELLING bulge test.

65. ballottment test.

66. AN K LES AND FEET Inspect and palpate With t h e cl i e n t s i t tin g , s t and i n g , and w a l k in g , inspect position, alignment, shape, and skin. P alp a t e f o r t ende r ne s s , he a t, s w el l in g , or nodules.

67. Abnormal spinal curvature

68. Abnormal Wrists, Hands, And Fingers Boutonniere and swan-neck deformities

69. Ganglion.

70. Osteoarthritis.

71. Tenosynovitis.

72. Acute rheumatoid arthritis.

73. Chronic rheumatoid arthritis

74. Thenar atrophy

75. Abnormal Ankles, Feet, And Toes Acute gouty arthritis .

76. Callus.

77. Corn.

78. Flat feet.

79. Hallux valgus

80. Hammer toe.

81. Test s for me n iscal tears 80 Meniscal provocation tests Medial meniscus Passively flex the knee to its full extent. Externally rotate the foot and abduct the upper leg at the hip, keeping the foot towards the midline (i.e. creating a varus stress at the knee). Extend the knee smoothly. In medial meniscus tears a click or clunk may be felt or heard, accompanied by discomfort

82. Meniscal tears… 81 Lateral meniscus / valgus stress Passively flex the knee to its full extent Internally rotate the foot and adduct the leg at the hip (i.e. creating a valgus stress at the knee). Extend the knee smoothly. In tears of the lateral meniscus a click or clunk may be felt or heard, accompanied by discomfort. Squat test Squat, keeping the feet & heels flat on ground. I f canno t - inc o m p l e te knee flexion on the affected side. May be- tear of the posterior horn of the menisci.

83. Interventi o n for client s with Musculo skeletal system trauma 82

84. Sprain…. Injury to the ligaments that surround a joint A torn ligament causes joint unstablility Cause - twisting motion/ hyperextension of a joint. Blood vessels rupture & edema forms Joint is tender, & movement of the joint becomes painful. 83

85. Sprains (cont’d…) 84 Sprains are graded as: Firs t - degree sprain Stretching the ligamentous fibers Minimum damage Mild edema, local tenderness , and pain Second-degree sprain Partial tearing of the ligament. Increased edema, tenderness, pain with motion, Joint instability Partial loss of normal joint function Third-degree sprain Completely ligament torn or ruptured. May cause bone avulsion. severe pain, tenderness, increased edema, and abnormal joint motion.

86. Sprains (cont’d…) 85

87. Strai n ( pulle d muscle o r ten d o n ) An injury caused by overuse, overstretching, or excessive stress of tendon . 86

88. Strain (cont’d…) 87 Three types of strain are recognized: First-degree strain Mild stretching of muscle/ tendon. Signs & symptoms: minor edema, tenderness, and mild muscle spasm, without noticeable loss of function. Second-degree strain Partial tearing of muscle/ tendon. Signs and symptoms: loss of load-bearing strength with edema, tenderness, muscle spasm, and ecchymosis. Third-degree strain Severe muscle or tendon stretching with rupturing and tearing of the involved tissue. Signs and symptoms : significant pain, muscle spasm, ecchymosis, edema, and loss of function.

89. Strain (cont’d…) 88 X-ray Should be obtained to rule out bone injury b/c of avulsion fracture in a third-degree strain. MRI Will reveal a third-degree strain , but x-rays do not reveal injuries to soft tissue or muscles, tendons, or ligaments.

90. M anagement 89 Treatment of strains, and sprains consists of the acronym “ RICE” R-Resting - Prevents additional injury& promotes healing I- Ice - produces vasoconstriction w/c decreases bleeding, edema & discomfort. C-Compression with bandage controls bleeding, reduces edema, and E-E levation - controls swelling

91. Nursing management (cont’d..) For third degree sprain or strain: Surgical repair Immobilization to keep joint stability by: Splint, Brace, or Cast 90

92. Joint dislocations 91

93. Joint dislocations 92 Dislocation of a joint : Articular surfaces of the distal and proximal bones that form the joint are no longer in anatomic alignment. Complete dislocation- bones are literally “ out of joint.”

94. Types of dislocation 93 Traumatic dislocations orthopedic emergencies caused by trauma. Pathological /spontaneous dislocation Pathological condition in the joint causes abnormality the joint. e.g. Septic hip dislocation Recurrent dislocation Repeatedly occurs due to weakening of the supportive joint structures Congenital dislocation e.g. Congenital hip dislocation

95. Joint dislocations (cont’d…) 94 Signs and symptoms of a traumatic dislocation: Acute pain, Change in positioning of the joint, Shortening of extremity, Deformity, and Decreased mobility. X-rays confirm the diagnosis and associated fracture.

96. Diagnosis of dislocation 95 Limb assumes an abnormally fixed position with loss of normal ROM Associated soft tissue injuries e.g. Poplital artery in knee dislocation, sciatic nerve in posterior hip dislocation X-ray in various planes and views confirms diagnosis

97. Management joint dislocations 96 Medical Management Immobilized affected joint Displaced parts are placed back in proper anatomic position Closed reduction( analgesia, muscle relaxants, and possibly anesthesia) After reduction, if the joint is stable, progressive, active and passive movement to preserve ROM and restore strength.

98. Management joint dislocations (cont’d…) 97 Nursing management Frequent neurovascular assessment Education: Proper exercises and activities Danger signs and symptoms Increasing pain (even with analgesics), Numbness or Tingling, and Increased edema in the extremity.

99. Fracture 98

100. Fractures 99 A co m p l et e or inco m plete disr u ption i n t he continuity of bone structure (structural breech in normal contin u i ty of bone)

101. Fractured by compression Injuries from high impact sports Forceful movements and traumatic blows Overuse that causes bone stress Falls from heights Accidents Tumors growing near the bone - bone compression osteoporosis and other bone debilitating conditions 100

102. Complete fr a ctur e - entire cross - sec tion o f the bone and is frequently displaced. Incomp l et e f ra c t ur e - on l y par t o f the cross - section Comminuted fracture - several bone fragments. Closed f r actu r e(s i mple f r a ct u re ) - no t cause a break in the skin. Open fractur e (co mpound, o r comp l e x ) - skin or mucous membrane wound extends to the fractured bone. 101

103. Types of Fractures (Cont’d...) 102

104. Types of Fractures (Cont’d...) 103

105. Types of Fractures (Cont’d...) 104

106. Types of Fractures (Cont’d...) 105 Open fractures are graded as: Grade I is a clean wound less than 1 cm long. Grade II is a larger wound without extensive soft tissue damage. Grade III is highly contaminated, has extensive soft tissue damage, and is the most severe .

107. Path o ph y siolog y o f fracture 106 Fracture initiat e in f lamma t ory re s po n s e & hemostasis Bleeding Edema st r etche s periosteum an d swellin g o f s o ft tissues—pain Release of bradykinin an d ot h e r chemic a l mediators --- contrib u tes to pain Clot forms a t fracture sites S y stemi c sig n of inflammati o n may occur

108. Clinical manifestations of fractures 107

109. Clinical manifestations o f fractures 108 Pain Continuous and increases in severity until the bone fragments are immobilized. Loss of Function B/c normal function of the muscles depends on the integrity of the bones to which they are attached. Pain contributes to the loss of function.

110. C/M of fractures (cont’d...) 109 Deformity Dis p lac e m e n t , ang u l ations, o r r o tation o f t h e fragments Shortening B/C of the compression of the fractured bone. Muscle spasms can cause the distal & proximal site of the fracture to overlap, causing the extremity to shorten.

111. C/M of fractures (cont’d...) Crepitus Crumbling sensation f elt ca u sed b y the r u bbing of the bone fragments against each other. Localized edema and ecchymosis Loca l ized ed e m a & ecc h y m o s is occur a f ter a f rac t ure as a result o f tra u m a & b l e e ding into the tissues. 110

112. Clinical: - history of trauma - Pain, swelling, inability to use the injured part 111 (sure si g ns of - Tenderness, swelling and bruising Defo r m it y , abno r m a l m o v e m ent fracture) X-ray : A suspected fractured bone should be x-rayed. - X-ray should be taken in at least two planes (AP and lateral)

113. Management o f f ractures 112

114. 1 . Emergenc y Managemen t f racture 113 Immobilization Adequate splinting In open fracture, wound is covered with a sterile dressing No attempt is made to reduce the fracture The fractured extremity is moved as little as possible t o avoid more damage.

115. Immobilization (cont’d...) 114 Methods of immobilization: Plaster of Paris (POP) cast Safest and cheapest Traction III. Using gravity: Skin traction: using bandage,( children) max.wt = 2kg. Skeletal traction: via a pin Fixation External fixation Fixing by metal pins Mostly in compound fractures Internal fixation Operative fixation of fractures by plates, nails, screws, pins and wires Indicated in poly traumatized patients

116. Plaster of Paris (POP) cast 115

117. Tracti o n 116

118. 2 . Medical M ana geme n t o f fracture 117 a. Reduction R e st o rati o n o f t h e f r a c t u re f r ag m ents to anato m ic alignment and positioning. Can be closed or open reduction The patient is prepared for the procedure An analgesic is administered .

119. Reduction (cont’d...) 118 Closed reduction Fragments aligned into anatomic alignment through manipulation and manual traction with a cast, splint, or other device. X-rays are obtained to verify correct alignment. Traction (skin or skeletal) may be used until the patient is p h y s i o l o gi c al l y stab l e to u n de r go s u r g i c a l fi x atio n .

120. Reduction (cont’d...) 119 Open Reduction surgical aligning fracture fragments Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs. Devices may be attached to the sides of bone, or may be inserted through the bony fragments or directly into the medullary cavity of the bone.

121. Open reduction (cont’d...) Internal fixation devices ensure firm approximation and fixation of the bony fragments. External fixation -makes a small percutaneous incision so that pins may be implanted into the bone. Pins are held in place by an external metal frame to prevent bone movement. 120

122. Open reduction (cont’d...) External fixation indication Fracture with extensive soft tissue injury Unstable closed fractures Closed fractures with compartment syndrome, head injury, burns, or impaired sensation. Fracture with loss of bone 121

123. Open reduction (cont’d...) Internal fixation indication A displaced intra- articular fracture Metaphyseal junction fractures of the knee or ankle Mal-unions Non-unions . 122

124. Medical Management of fracture (cont’d...) 123 b. Immobilization After fracture reduction, the bone fragments must be immobilized and maintained in proper position and alignment until union occurs.

125. Medical Management o f fracture (cont’d...) 124 C. Maintaining & restoring function Reduction and immobilization Controlled edema Routine neurovascular status monitoring Control restlessness, anxiety, and discomfort Encouraged (ADLS) is to promote independent functioning & self-esteem .

126. 3. Nursing Management 125 I. Patients with closed fractures Instruct the pt regarding controlling edema & pain . Teach: Exercises Assistive devices crutches, walkers, and special utensils) Self-care, medication information, potential complications, Fracture healing and restoration(max.of 6 to 8 wks)

127. M anagement (cont’d...) 126 II. Patients With Open Fractures Risk for osteomyelitis, tetanus, and gas gangrene . Immediately Iv antibiotics- give upon arrival Wound irrigation and debridement are initiated Wound is cultured and bone grafting Carefully reduced and stabilized by external fixation & wound is usually left open for 5 to 7 days for intermittent irrigation and cleansing.

128. M ana g emen t ( co n t’d...) 127 Primary wound closure is usually delayed. Heavily contaminated wounds are left unsutured and dressed with sterile gauze Assess neurovascular status frequently. Monitored temperature & signs of infection at regular intervals In 4 to 8 weeks, bone grafting

129. Fra c ture Healing 128 Takes longer than soft tissue healing ( wks-months ) Long bone - 6-12 weeks to heal in an adult and 3-6 weeks in children Flat bones (pelvis, sternum, and scapula) heal rapidly. Comminuted fracture may heal slower. More vascular and cancellous, heal more quickly than fractures in dense and less vascular

130. Fractur e Healing 129 Factors that enhance fracture healing Factors that inhibit fracture healing

131. Factors that affect fracture healing 130 Factors that enhance fracture healing 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

132. Fac t or s that aff e c t fracture hea l ing (cont’d...) 131 Factors that inhibit fracture healing Extensive local trauma , bone loss Weight bearing prior to approval Malalignment of the fracture fragments Inadequate immobilization Space or tissue b/n bone fragment s Infection , local malignancy

133. Facto r s that inhibit fracture healing(cont’d..) 132 Metabolic bone disease Irradiated bone (radiation necrosis) Avascular necrosis Intra-articular fracture Age (elderly persons heal more slowly) Corticosteroids (inhibit the repair rate)

134. Complications of fractures Early (first 48 hours) Delayed/ Late (weeks, months, years) Systemic Hypovolaemia and shock Fat embolism Acute respiratory distress syndrome Venous thrombo- embolism(DVT) Chest infection Urinary tract infection Bone Osteomyelitis Bone healing abnormalities Delayed or non-union /Malunion Osteomyelitis Necrosis Heterotopic ossification Joint Stiffness O st e o ar t h r i t is Instability Soft tissues Compartment syndrome Muscular/tendon injury Neural injury Vascular injury Adjacent structural damage Complex regional pain syndrome (CRPS) (Reflex sympathetic dystrophy(RSD) Peripheral and cord injury Ischaemic contracture Pn e u m o t hora x 133

135. Amputation 134

136. Amp u tatio n … . 135 Amputation is the removal or excision of part or whole of a body part, often an extremity/limb. Frequency: upper extremity < a lower extremity ( often necessary b/c of progressive peripheral vascular disease

137. Causes of amputations Diabetes mellitus Fulminating gas gangrene Trauma (crushing injuries, burns, frostbite,etc Congenital deformities, Chronic osteomyelitis, Malignant tumor. Peripheral vascular d i sease a c cou n t s f o r m o s t amputations of lower extremities 136

138. Levels of amputation Performed at the most distal level that provide a functional stump & heal successfully Choice is determined by: Age Nature and extent of the pathology Circulation in the part Presence of infection Status of the joints Functional usefulness (Access to prosthesis) 137

139. Levels of amputation(cont’d…) A. Levels of amputation of upper extremity. B.Levels of amputation of lower extremity. 138

140. Low e r limb… 139

141. Levels of amputation(cont’d…) Upper limb: Attempt should be made to conserve every possible inch . Lower limb: Most important factor is to try & conserve the knee joint whenever possible. A mputation of toes & foot can cause changes in gait & balance A Syme amputation ( ankle disarticulation ) - extensive foot trauma 140

142. Levels of amputation(cont’d…) 141 Below-knee amputation (BKA) is preferred to above-knee amputation (AKA) b/c of : Importance of the knee joint Energy requirements for walking. Knee disarticulations - successful with: Young Active patients who can develop precise control of the prosthesis.

143. 142

144. Complications of amputation 143 Hemorrhage (secondary & reactionary) Edema & hematoma Ischemic necrosis Infection Skin breakdown Phantom limb Flexion contracture

145. Medical Management 144 Objective - to achieve healing Immediately after surgery, a sterilized residual limb sock is applied to the residual limb. Padding is placed over pressure-sensitive areas. Healing is enhanced by gentle handling of the residual limb, control edema, use of aseptic technique

146. Medical Management(cont’d…) 145 A closed rigid cast dressing/elastic residual limb shrinker that covers the residual limb may be used: To provide uniform compression, To support soft tissues, To control pain, and To prevent joint contractures.

147. Medical Management(cont’d…) 146 The cast is changed in about 10 to 14 days . Rigid dressing is removed several days after surgery An immobilizing splint may be incorporated in the dressing. Wound drainage devices to minimize infection

148. amputating 147 Nursing process for patient Assessment  Evaluate the neurovascular and functional status of the extremity Evaluates the nutritional status

149. Assessment… 148

150. Assessme n t co n t’d.. 149 Concurrent health problems Use of corticosteroids, anticoagulants, vasoconstrictors, or vasodilators (influence mg't and delay wound healing. Evaluation emotional reaction to amputation and grief responses

151. 150

152. 151

153. 152

154. Evaluate the neurovascular and functional status of the extremity( residual limb & unaffected extremity). Infection or gangrene status 153

155. Nursing diagnoses 154

156. Nur s ing diag n ose s … Acute pain related to amputation Disturbed sensory perception: phantom limb pain related to amputation Impaired skin integrity related to surgical amputation Disturbed body image related to amputation of body part Grieving and/or risk for complicated grieving related to loss of body part and resulting disability 155

157. Nursing diagnoses cont’d… 156 Self-care deficit: feeding, bathing/hygiene, dressing/grooming, or toileting, related to loss of extremity Impaired physical mobility related to loss of extremity Collaborative problems/potential complications Postoperative hemorrhage Infection Skin breakdown

158. Planning and goals(major) 157 Relief of pain Absence of altered sensory perceptions, Wound healing, Acceptance of altered body image, Resolution of the grieving process, Independence in self-care, Restoration of physical mobility, and Absence of complications.

159. Nursing interventions 158 Relieving pain Minimizing altered sensory perceptions- (phantom limb pain ) Promoting wound healing Enhancing body image- communicate to accept & to care the residual

160. Nursing interventions cont’d… 159 Helping the patient to resolve grieving Promoting independent self-care Helping the patient to achieve physical mobility Monitoring & managing potential complications Promoting home & community-based care

161. Join t an d co n nectiv e tissue diseases 160

162. Arthritis 161 Inflammation of joints & breakdown of cartilage, which normally protects the joint Women affected twice than men Acute forms - caused by bacteria & treated with antibiotics (septic arthritis ). Chronic forms ( os t eo a rt h ritis, r h eumat o id arthritis, and gouty arthritis )

163. 1. Osteoarthritis 162 Degenerative synovial joint disease(DJD) characterized by cartilage loss with an accompanying periarticular bone response No simple definition b/c of consideration of three overlapping areas – Pathologically - alteration in cartilage structure, Radiologically - osteophytes and joint space narrowing Clinically - complain of pain and disability.

164. Osteoarthritis (cont’d…) 163 Most common & frequent disabling joint disease and prevalence increases with age - Probably related to normal aging process “ Wear and tear ” arthritis; affects the articular cartilages, causing them to soften, fray, crack, and erode It is non inflammatory- only cartilage is affected, not synovial membrane

165. Osteoa r thritis (cont’d…) Deteriora t ion o f cart i lage p r oduc e s b o ne spurs- Restricts movement Pai n upo n a wakeni n g — disa p pe a rs wi t h movement 164

166. Os t eo a rt h ritis (co n t’d…) 165 Causes and types Osteoarthritis can be primary or secondary Primary /Idiopathic/ OA:- The cause is Unknown Genetic factors and allergy is the most common predisposing factors It is not inflammatory joint disease

167. Causes and types (cont’d...) 166 2. Secondary OA Caused by other conditions: Previous joint infection e.g. RA ,Gout, SA Inflammation Trauma , surgery Certain occupation or activities Endocrine is order (acromegally or hyperparathyroidism Skeletal deformity Hemophilia

168. Causes and types (cont’d...) 167 Other Predisposing factors to OA: Age Weight- Obesity genetic indisposition Sex - women; a higher after the menopause suggests a role for sex hormones. Hypermobility - Increased range of joint motion and reduced stability

169. Pathophysiology of osteoarthritis 168 Damage of articular cartilage Surface of cartilage becomes rough and wear Enzymes released - accelerate disintegration of cartilage Subchondral bone may be exposed Cysts/ oseophytes –new bone spurs developed Osteophytes and cartilages break of Joint space narrowed Secondary inflammation of surrounding tissues Loss of normal joint ROM Pain with weight bearing and use

170. Cli n ical manifestati on s OA 169 Symptoms Joint pain - improve with rest Joint gelling (stiffening and pain after immobility) Joint instability Loss of function Signs Joint tenderness Crepitus on movement Limitation of range of movement Joint instability Joint effusion and variable levels of inflammation Bony swelling Wasting of muscles due to disuse.

171. 170

172. Diagnosis of osteoarthritis 171 History Physical examination Investigations: Blood tests . No specific test ESR and CRP are normal. Rheumatoid factor and antinuclear antibodies are negative. X-rays - abnormal only when the damage is advanced. MRI - early cartilage and subchondral bone changes. Arthroscopy - reveals early fissuring and surface erosion of the cartilage.

173. Ma n ag e me n t (Medi c a l a n d Nur s ing care) of osteoarthritis 172 Objective : treat the symptoms and disability, not the radiological appearances Relief pain Restoration of joint functions Prevention of disability and complication

174. Management of osteoarthritis (cont’d..) 173 Pharmacological Rx: Acetaminophen NSAID Analgesics Intra articular steroid injection

175. Management of osteoarthritis (cont’d..) 174 Non-pharmacological mgt Weight reduction H e a t a p plic a ti o n to r elie f p a in an d relaxing mu s cles before exercise Application of cold after exercise to decrease pain and swelling Exercise and prevent injuries Surgical management like Arthrodesis or joint fusion Joint replacement

176. 2. Rheumatoid arthritis(RA) Sys t e mic,s y m et r ical dis e a s e characterised by chronic recurrent inflammation of joint and surrounding soft tissue . Has periods of remission & exacerbation. Remission-period when disease symptoms are reduced or absent. Exacerbation –a period when disease symptoms occur or increased. Ulnar deviation of the fingers, small muscle wasting and synovial swelling at carpus, metacarpophalangeal and proximal interphalangeal joints. 175

177. Rheumatoid arthritis (cont’d…) Symptoms begin with bilateral inflammation of certain joints Often leads to deformities Cartilage attacked Inflammation, swelling & pain Final step is fusion in joint 176

178. Rheumatoid arthritis (cont’d…) 177 Occurs in around 3% of women and 1% of men Caused by a cell-mediated (T-cell) autoimmune response Rheumatoid factor positive in 80% Often starts with symmetrical disease affecting small joints of the hands and feet

179. Etiology of rheumatoid arthritis 178 Cause unknown Suggested – response to an infectious agent in a genetically susceptible host. Predisposing includes Autoimmune reaction Genetic predisposition Infection – viral & bacterial (rubella, mycoplasma, CMV and EBV virus) Other factors such as metabolic ,nutritional & environmental factors.

180. Pathophysiology rheumatoid arthritis 179 Stage -1 : Unknown etiologic factor initiates joint inflammation with swelling of the synovial lining membrane & production of excess synovial fluid. Stage-2: Pannus formation (Proliferation of synovial membrane) Stage-3 : Pannus destroys the cartilage & erodes the bones results in loss of articular surfaces & loss of joint motion ,malignant & deformity Stage-4 :As fibrous tissue calcifies bony ankylosis may result. (Ankylosis –immobility of a joint)

181. C/F o f RA 180 Early symptoms include: Fatigue Weight loss Fever Malaise Morning stiffness of joints Pain at rest and with movement Edematous, Erythemataus “ baggy” joint

182. C/F of RA (cont’d…) 181 Late symptoms include Color changes of digitalis (bluish, rubor, pallor) Muscle weakness, atrophy Joint deformity Decreased joint mobility , Contractures Subluxation or complete dislocation Increasing pain Formation of rheumatoid nodules are aggregate of inflammatory cues

183. C/F of RA (cont’d…) 182 Extra- articular manifestations of RA: Skin – subcutaneous nodules Eyes – scleritis, iritis Lungs – interstitial lung disease, pleural effusion Heart – myocarditis Kidneys – nephritis Amyloid – lungs, kidneys, heart, bowel Compression and vascular neuritis

184. C/F of RA (cont’d…) Problems in the hand and wrist caused by RA: Radial deviation of the wrist Extensor tendon ruptures Ulnar deviation metacarpophalangeal joints Z-deformity of the thumb Boutonnière deformity of the fingers Swan neck deformities Carpal tunnel syndrome 183

185. 184

186. C/F of RA (cont’d…) 185 Virtually all joints can be involved, but most commonly involved joints are: Hand joints, wrists , Ankles, Elbow and knees Most often it evolves bilaterally or symmetrical pattern

187. Diagno s is o f rheuma t oi d art h ritis 186 Clinical features Positive rheumatoid factor Titer increases at active diseases (antinuclear antibody) Lab finding Indicator of active inflammation ESR - increased, RBCS- decreased C-reactive protein (CRP) Abnormal synovial fluids X-ray study Biopsy

188. Dia g nosi s o f rheuma t oi d arthri t is (cont’d…) 187 Diagnostic Criteria: Morning stiffness > 1 hours & at least 6 weeks duration Soft tissue swelling of 3 or more joints for at least 6 weeks (wks) Swelling of wrist, metacarpophalangeal or proximal interphalangeal joints at least 6wks

189. Diagnosis of RA (cont’d…) Criteria for the diagnosis of rheumatoid arthritis (American College of Rheumatology, 1987 revision ) 188 Morning stiffness > 1 hour For ≥6 weeks Arthritis of three or more joints Arthritis of hand joints and wrists ,metacarpophalangeal or proximal interphalangeal Symmetrical arthritis Subcutaneous nodules A positive serum rheumatoid factor Typical radiological changes (erosions and/or periarticular osteopenia) N.B: four of the seven criterias are necessary to diagnosis RA

190. Diagnosis of RA (cont’d…) Rheumatoid nodules and olecranon bursitis 189

191. Mana g emen t o f rheumatoid art h ritis 190 Goals : Short term : Controlling pain and reducing inflammation without causing undesired side effects Long term: Preservation of joint function and the ability to maintain life-style

192. Mana g emen t o f R A (cont’d. . ) 191 Pharmacological Rx: 1) First line : NSAIDs Control symptoms & signs of local inflammatory process. Rapid alleviation pain and symptoms , Minimal long term effect Aspirin 900 mg PO TID, Ibuprofen 400 mg PO BID or T I D D i clo f en a c 5 m g P O B I D , indometacin 5 mg PO BID.

193. Pharmacological Rx RA (cont’d…) 192 2 ) Second line : Low dose potent anti-inflammatory oral corticosteroids Systemic administration in sever progressive articular diseases and extra articular involvement Start with 5-10 mg/day in the morning and taper the dose with improvement

194. Pharmacological Rx RA (cont’d…) 193 3) Third line: Disease modifying antirheumatic drugs- (DMARD) Methotrexate , gold compounds , d-penicillamine , antimalarials and sulfasalazine Have the capacity to alter the course of RA. Used in NSAIDS non -respondent Methotrexate is the most frequently used & relatively rapidly acting ( given in an intermittent low dose: 7.5-30 mg once weekly)

195. Pharmacological Rx RA (cont’d…) 194 Fourth line: Anti cytokine agents : Biological agents that bind & neutralize TNF. effective in controlling signs & symptoms failed to respond with DMARDs. Fifth line : immunosuppressive therapy : Include azathioprine, cyclsosporine, and cyclophosphamide. Same therapeutic effect as DMARDs

196. N o n pha r maco l ogi c the r ap y RA 195 Nursing management Health teaching about balance of rest and exercise, drug side effects Give the prescribed drugs Encourage physiotherapy & occupational therapy Physiotherapy Surgical mgt (Arthroplasty, synovectomy, tendon transplants)

197. C o mplic a tio n s o f rheumat o id art h ritis 196 Ruptured tendons Ruptured joints Joint infection Spinal cord compression (atlantoaxial or upper cervical spine) Amyloidosis (rare) Side-effects of therapy

198. 3. Gouty arthritis/Gout 197 Gout is a clinical syndrome resulting from the deposition of urate crystals in the synovial fluid, joints or articular cartilage Gout syndromes - serum uric acid concentration above 7 mg/dl. Results from prolong hyperuricemia (elevated serum uric acid) caused by Higher synthesis of purines or Poor renal excretion of uric acid

199. Gouty arthritis/Gout (cont’d…) ation and It Primary affects adult men & postmenopausal women Uric crystals build up in joints—pain Waste products of DNA & RNA metabolism Builds up in blood Deposited in cartilage causing inflamm swelling Bones fuse Middle-aged men with abnormal gene Can usually be controlled with diet 198

200. Causes of gouty arthritis/gout It can be primary or secondary gout In general: It is caused by excess levels of uric acid Primary gouty arthritis is caused by Sever dieting or starvation, Excessive intake of food that is high in purines (shellfish, organ meat) 199

201. Causes of gouty arthritis/gout (cont’d..) 200 Secondary gout is caused by: Over production of uric acid caused by: Polycythemia vera, cancer ,cytotoxic drugs Hemolytic anemia , leukemia ,multiple myeloma Decreased excretion uric acid by: Chronic renal insufficiency Lactic acids & Keto acidosis Drugs enhance under excretion of uric acid like diuretics like thiazides, frusomide.

202. Causes of gout (cont’d..) 201 Predisposing factors/Risk factors: Family history(18%) Men gender Obesity ,diabetes insipidus, psoriasis, preeclampsia Excessive alcohol in take Hypelipidemia Hypertension , diuretic uses down syndrome, hypothyroidism

203. C/F o f gout 202 It has four stages : 1. Asymptomatic hyperuricemia Increased serum uric acid level in the absence of clinical evidences 1. Acute gouty arthritis – Abrupt onset often at night, symptoms awakening: – Sever pain, swelling, erythematic of the involved joint, tenderness and warmth.

204. C/F o f gou t (cont’d. . ) or 3. Intercritical gout stage Symptom free period after the attack until the next attack, may stay for months years Chronic tophaceous gout stage Tophi (crystalline deposits in the articular tissue, soft tissue & cartilage) Gouty nephropathy (renal impairment) 203

205. Diagnostic work u p o f gout 204 Acute gouty arthritis ; Serum uric acid value - nonspecific (normal in 10 %) & often is not helpful . used to assess the effectiveness of hypouricemic therapy. special urate crystals WBC of 10,000- 60,000 /μl (predominant neutrophils) in Synovial fluid analysis:

206. Diagnostic work u p o f gout B) chronic tophaceous gout: Physical appearance of tophi Firm movable and superficial located. Chalky material if ulcerate and extrudes. Radiologic findings: Tophaceous deposits appear Punched out erosions of the subchondral bone. In first metatarso phalangal joint (MTP) 205

207. Ma n ageme n t o f gout 206 Asymptomatic hyperuricemia : No need for treatment Correction of the underlying causes. Acute gouty arthritis : Drug treatment is most effective if started early a) Colchicine Given early, it is effective in 85 % of patients. 0.6 mg is given every hr until the relief of symptoms or GIT toxicity occurs.

208. Management of acute gouty (cont’d...) 207 NSAID: Used in high but quickly tapered dose. Drugs that affect uric acid clearance should be avoided like aspirin Indomethacine: 25-50 mg PO TID, ibuprofen: 800 mg po TID, Diclofenac: 25-50 mg PO TID Corticosteroids: Prednisolone, 30-50 mg/day as the initial dose & tapered over 5-7 days.

209. Management of gout(cont’d...) 208 Intercritical gout : Prophylactic treatment small dose of colchicines ( 0.6 mg once or 2X per day) small doses of a NSAID

210. Management of gout(cont’d...) 209 Chronic tophaceous gout : Uricosuric agents (E.G. Probenicide, sulfinpyrazone). Facilitate the renal excretion of uric acid. Probenicide 200 mg po bid increased up to 2 gm xanthine oxide inhibitors : include allopurinol; Drug competitively inhibits xanthine oxidase. 300 mg single morning dose initially and may be increased up to 800 mg

211. Management o f gou t (cont’d…) 210 Nursing management Monitor drug side effects Avoid the predisposing factors Advise the patient to avoid alcohol intake Rest and immobilization until the acute attack subside Avoid heat application since of increase the inflammation Encourage life style modification

212. 4. Septic(infectious) arthritis Septic arthritis is inflammation of the joint that resulted of invasion of the synovial membrane by microorganisms. 211

213. Causes o f septi c art h ritis 212 Neisseria gonorrheal Meningococcal Streptococci Staphylococcus aureus Salmonella Haemophilus influenza

214. Causes of septic arthritis (cont’d…) 213 S . aureus causes at least 50% of all joint infections, and 80% of cases of septic arthritis in pts with RA and diabetes. knee is the joint - most commonly infected (50% of cases ), followed by the hip & the shoulder ,respectively.

215. Causes of septic arthritis (cont’d…) 214 Method of entry for the bacteria in to the joints include: Hematogenous spread/blood the most common Direct inoculation Extension from an adjacent infection

216. Risk factors for septic arthritis 215 Advanced age Immunodeficiency Chronic diseases e.g., diabetes Rheumatoid arthritis Preexisting joint disease or joint replacement Intravenous drug abuse (corticosteroid or immunosuppressive drugs Local joint surgery or trauma Intraarticular injection

217. Path o ph y siolog y septi c arth r itis 216 Bacterial invasion of synovial space inflammation of the synovial tissue Accumulation pus in the synovial membrane and synovial fluid Abscess accumulation in the synovium and subchondral bone Destroying of the cartilage and ankylosis of joints.

218. C/Ms of septic arthritis Pain, swelling and tenderness of the joint Pus in the synovial membrane Abscess in the synovium and subchondral bone Ankylosis of joints, Loss of the normal joint motion, erythema 217

219. Diagno s is o f septi c art h ritis 218 Joint aspiration/synovial fluid analysis WBC count X-ray Culture CT scan & MRI may reveal damage to the joint lining Radioisotope scanning may be useful in localizing the infectious process.

220. M a na gem e n t septi c arth r itis 219 Antibiotics e.g. cloxacillin Pain control Immobilization Aspiration & drainage when indicated (atrthrocentesis) When infection subside and motion is tolerated initiate active ROM

221. Bone disorders 220

222. Bone disorders.... 221 Bone is a specialized connective tissue, serving three major functions : Mechanical - providing structure and muscular attachment for movement Metabolic - as a reserve of calcium and phosphate Protective - enclosing bone marrow and vital organs

223. Bone disorders.... 222 Bone disorders includes : Metabolic bone disorders Osteoporosis Osteomalacia Infectious bone disorders Osteomyelitis

224. Metabolic bone disorders Osteo poro sis Most prevalent bone disease in the world. It is a disease characterized by: Reduced bone quantity and quality Low bone mass & density Micro architectural deterioration of bone tissue Leading to: Enhanced bone fragility Increase in fracture risk 3

225. Osteoporosis (cont’d…) WHO defines osteoporosis as a condition in which a BMD is less than -2.5 standard deviations (SD) below peak bone mass The consequence of osteoporosis is bone fracture . 224

226. Osteoporosis (cont’d…) Peak adult bone mass at ages of 18 & 25 years Bone mass during these years is affected by: Nutrition, Physical activity, Medications, endocrine status, & general health Failure to develop optimal peak bone mass contributes to the development of osteoporosis . 225

227. Oste o por o si s (cont’d…) 226 Primary osteoporosis Occurs women after menopause ( 45 -55 years) Men later in life, but it is not merely a consequence of aging.

228. Osteoporosis (cont’d…) 227 Secondary osteoporosis Is the result of medications or other conditions & diseases that affect bone metabolism. Metabolic problem

229. Osteoporosis (cont’d…) 228 Women develop osteoporosis more frequently and more extensively than men b/c of Lower peak bone mass and The effect of estrogen loss during menopause. More than half of all women older than 50 years show evidence of osteopenia .

230. Risk factors f o r o steop o rosis. Predisposes to low bone mass Hormones (estrogen, calcitonin, & testosterone) leads to bone loss Reduces nutrients needed for bone remodeling Genetics Caucasian or Asian Female Family history Small frame Age Post menopause Advanced age Low testosterone in men Decreased calcitonin Nutrition Low calcium intake Low vitamin D intake High phosphate intake (carbonated beverages) Inadequate calories 229

231. Risk factors for osteoporosis. Bones need stress for bone maintenance Physical exercise Sedentary Lack of weight-bearing exercise Low weight and body mass index Reduces osteogenesis in bone remodeling Affects calcium absorption and metabolism Lifestyle choices Caffeine Alcohol Smoking Lack of exposure to sunlight Medications e.g., corticosteroids, antiseizure medications, heparin, thyroid hormone Co-morbidity e.g., anorexia nervosa, hyperthyroidism, malabsorption syndrome, renal failure 230

232. 231

233. Pathophysiology of osteoporosis 232 Osteoporosis is characterized by Reduced bone mass, Deterioration of bone matrix, and Diminished bone architectural strength. Normal homeostatic bone turnover is altered; Rate of bone resorption > rate of bone formation Resulting in a reduced total bone mass.

234. Path o ph y siolog y o f o s teo p or o sis (cont’d...) The bones become progressively porous, brittle, & fragile; Fracture easily under stresses that would not break normal bone. T hi s fractures may b e the first c / of osteoporosis. 233

235. 234

236. Pathoph y siolog y o f osteop o rosis (cont’d...) 235 Increase susceptibility to fracture – Compression fractures of thoracic and lumbar spine, hip fractures, & colles’ fractures of wrist. Gradual collapse of a vertebra - progressive kyphosis. Associated loss of height. Postural changes result in relaxation of the abdominal muscles & a protruding abdomen. Produce pulmonary insufficiency .

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238. Diagnosis of osteoporosis 237 Osteoporosis may be undetectable on routine x-rays until there has been 25% to 40% demineralization Dual-energy x-ray absorptiometry (DXA), provides information about BMD at the spine and hip.

239. Diagnosis of osteoporosis(cont’d...) 238 P/E Height loss Body weight Kyphosis Tooth loss Skin fold thickness Arm span-height difference Wall- occiput distance Rib-pelvis distance

240. Medical Management of osteoporosis 239 Diet (rich in calcium & vitamin D) Throughout life, During adolescence, young adulthood, & the middle years, protects against skeletal demineralization. Regular weight-bearing exercise promotes bone formation .

241. Medical Management of osteoporosis(cont’d..) 240 Pharmacologic Calcium and vitamin D Hormone replacement therapy Selective estrogen receptor modulators Bisphosphonates Calcitonin Parathyroid hormone

242. Infectious bone disorder 241 Bone infections are more difficult to eradicate than soft tissue infections because : Infected bone is mostly avascular & not accessible to the body’s natural immune response. There is decreased penetration by antibiotic

243. Infectious bone disorder (cont’d...) Osteomyelitis Is an infection of the bone that results in inflammation, necrosis, and formation of new bone. 242

244. Osteomyelitis (Cont’d...) 243 Severe infection of the – Bo n e – Bon e marr o w – Surr o un d ing s o ft tis s ue Caused by a variety of microorganisms Most common infecting microorganism is Staphylococcus aureus

245. Osteomyelitis (Cont’d...) 244 Osteomyelitis is classified as : Hematogenous - due to blood borne spread of infection Contiguous-focus - from contamination of bone( surgery, open fracture, or traumatic injury) Osteomyelitis with vascular insufficiency , Seen most commonly among patients with diabetes & peripheral vascular disease, most commonly affecting the feet .

246. Osteomyelitis (Cont’d...) 245 Patients at high risk for osteomyelitis : Poorly nourished, elderly, or obese. Impaired immune systems, Chronic illnesses (e.g., Diabetes, rheumatoid arthritis), Receiving long-term corticosteroid therapy or other immunosuppressive agents.

247. Pathophysiology of osteomyelitis 246 Pathogens entered to bone and infection Initial response to infection is inflammation, increased vascularity, & edema. After 2 or 3 days, thrombosis of the local blood vessels → ischemia with bone necrosis. Infection extends into the medullary cavity & may spread into adjacent soft tissues and joints. A bone abscess forms.

248. Pathophysiology of osteomyelitis (cont’d...) 247 Abscess cavity contains dead bone tissue (sequestrum), w/c does not easily liquefy and drain. New bone growth forms and surrounds the sequestrum. Although healing appears to take place, a chronically infected sequestrum remains & produces recurring abscesses throughout the patient’s life. This is referred to as chronic osteomyelitis.

249. Pathophysiology of osteomyelitis (cont’d...) 248

250. Clinical manifestations of osteomyelitis 249 When the infection is blood borne , the onset is usually sudden, Chills, high fever, rapid pulse, general malaise. The infected area becomes painful, swollen, & extremely tender. constant, pulsating pain that intensifies with movement (i.e., due to pus).

251. Clinical manifestations of osteomyelitis(cont’d...) 250 When osteomyelitis occurs from spread of adjacent infection or from direct contamination, There are no symptoms of sepsis. The area is swollen, warm, painful, and tender to touch

252. C/M of acute osteomyelitis 251 Initial infection Infection of <1 month in duration Both systemic and local Systemic Fever , Night sweats , Chills Restlessness , Nausea Local Constant bone pain that worsens with activity Swelling, tenderness, warmth at infection site Restricted movement of affected part Later signs: drainage from sinus tracts

253. C/M of chronic osteomyelitis 252 A non healing ulcer with sinus that will intermittently and spontaneously drain pus . Lasting longer than a month Infection failed to respond to initial antibiotic Systemic signs may be diminished Local signs of infection more common Constant bone pain Swelling, tenderness, warmth at infection site

254. Diagnostic findings of osteomyelitis 253 X-ray Demonstrate soft tissue edema - early acute osteomyelitis Large, irregular cavities; raised periosteum; sequestra; or dense bone formations in chronic osteomyelitis , Blood studies- leukocytosis & elevated ESR. Wound and blood culture performed, although they are only positive in 50% of cases .

255. Medical Management of osteomyelitis 254 Initial goal of therapy is to: – Control & halt the infective process. Antibiotic therapy depends on the results of blood and wound cultures. Supportive measures (e.g., Hydration, diet high in vitamins and protein, correction of anaemia) should be instituted. Immobilized affected area

256. Medical Management osteomyelitis (cont’d..) 255 Pharmacologic Therapy Culture specimens are obtained, IV antibiotic After results of the culture and sensitivity studies are known, an antibiotic to which the causative organism is sensitive is prescribed. Iv antibiotic therapy continues for 3 to 6 weeks . After the infection appears to be controlled, the antibiotic may be administered orally for up to 3 months.

257. Surgical Management osteomyelitis 256 Chronic & does not respond to antibiotic, surgical debridement – Infected bone is surgically exposed, and irrigated with sterile saline solution. Iv antibiotic therapy is continued. A sequestrectomy is performed. A closed suction irrigation system may be used to remove debris. Wound irrigation using sterile physiologic saline solution may be performed for 7 to 8 days.

258. Surgic a l Ma n ag e me n t o f OM (co n t’d . . . ) 257 The débrided cavity may be packed with cancellous bone graft to stimulate healing. With a large defect, the cavity may be filled with a vascularized bone transfer or muscle flap These microsurgery techniques enhance the blood supply.

259. Nursing management osteomyelitis 258 Relieving pain Improving physical mobility Controlling the infectious process Promoting home and community-based care

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