Ch. 68 Management of Pts w/ Musculoskeletal Disorders

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medsurg book

bursitis

inflammation of a fluid filled sac in a joint

contracture

abnormal shortening of muscle or fibrosis of joint structures

involucrum

new bone growth around a sequestrum

radiculopathy

disease of a nerve root

sciatica

sciatic nerve pain
travels down back of thigh into foot

sequestrum

dead bone in abscess cavity

tendinitis

inflammation of muscle tendons

back pain due to MS disorders is usually aggravated by what?

activity

pain due to other conditions is not

acute back pain

< 3 months

chronic back pain

> 3 months

what type of non-prescription and prescription agents are effective in treating acute back pain??

Tylenol (acetaminophen)
NSAIDS (ibuprofen, Motrin)

prescription muscle relaxants (Flexeril)

diagnostic procedures for low back pain:

X-ray of spine

fracture, dislocation, infection, osteoarthritis, scoliosis

diagnostic procedures for low back pain:

bone scan and blood studies

infections, tumors, bone marrow abnormalities

diagnostic procedures for low back pain:

CT

underlying problems such as obscure soft tissue lesions adjacent to the vertebral column and problems of vertebral discs

diagnostic procedures for low back pain:

MRI

visualization of the nature and location of spinal pathology

diagnostic procedures for low back pain:

EMG and nerve conduction studies

evaluate spinal nerve root disorders (radiculopathies)

diagnostic procedures for low back pain:

myelogram

visualization of segments of the spinal cord that may have herniated or may be compressed

diagnostic procedures for low back pain:

ultrasound

tears in ligaments, muscles, tendons, soft tissues in back

relief of chronic back pain

tricylcic anti-depressants (e,.g. amitriptyline (Elavil)

back and leg pain on straight leg test suggests what?

nerve root involvement

which position should a pt. with low back pain avoidand why?

prone because it accentuates lordosis

how should the pt. with low back pain sleep?

sleep on the side with knees and hips flexed or supine with knees supported in a flexed position

bursitis and tendinitis are inflammatory conditions that commonly occur in what part of the body?

shoulder

impingement syndrome occurs from

repetitive overhead movements of the arm or from acute trauma resulting n irritation or inflammation of rotator cuff.

carpal tunnel syndrome

entrapment neuropathy that occurs when the median nerve at the wrist is compressed by thickened flexor tendon sheath, skeletal encroachment, edema, or soft tissue mass.

which sign is used to help identify carpal tunnel syndrome?

Tinel's sign

Tx of Carpal Tunnel

- intraarticular injections of corticosteroids or oral corticosteroids
- application of wrist splints or prevent hyperextension and prolonged flexion of the wrist

Ineffective Tx of Carpal Tunnel

- yoga, laser therapy and ultrasound therapy are ineffective, as are use of NSAIDs, diuretics and Vitamin B6

dupuytren's disease

slowly progressive contracture of the palmar fascia

causes flexion of the 4th and 5th fingers and freq. middle finger.

inherited autosomal dominant trait > 50 y.o.

experiences dull aching discomfort, morning numbness, cramping and stiffness in the affected fingers.

what can prevent contractures if pt. is at risk

finger stretching exercises or intranodular injections of corticosteroids

how often are neurovasc assessments done post-op hand surgery?

every hour for the first 24 hours following surgery

should the pt elevate the hand below or above the elbow?

above the elbow

after hand surgery, how should the pt. be instructed to bath?

keep the dressing dry by covering it with a secured plastic bag

plantar fasciitis is experienced when?

the first steps in the morning

corn

area of hyperkeratosis (overgrowth of a horny layer of epidermis)

produced by internal pressure (underlying bone is prominent bc of a congenital or acquired abnormality, commonly arthritis)

or external pressure from ill fitting shoes

hallux valgus aka

bunion

deformity in which the great toe deviates laterally

factors contributing to a bunion
- hereditary
- ill fitting shoes
- gradual lengthening and widening of foot associated with aging
- osteoarthritis

pes cavus

aka clawfoot

foot with abnormally high arch and fixed equinus deformity of the forefoot

Charcot-Marie-Tooth disease (peripheral neuromuscular disease associated with familial degenerative disorder), DM, and tertiary syphilis are common causes.

which bone disease is the most prevalent in the world?

osteoporosis

osteopenia

precursor to osteoporosis

genetic risk factors for osteoporosis

caucasian or asian
female
family hx
small frame

- predisposes to low bone mass

age risk factors for osteoporosis

postmenopausal
advanced age
low testastorne in men
decreased calcitonin

- hormones (estrogen, calcitonin, testosterone) inhibit bone loss)

nutrition risk factors for osteoporosis

- low calcium intake
- low vitamin d intake
- high phosphate intake (carbonated beverages)
- inadequate calories

(reduces nutrients needed for bone remodeling)

physical exercises risk factors for osteoporosis

sedentary
lack of weight bearing exercises
low weight and body mass index

- bone need stress for bone maintenance

lifestyle choices risk factors for osteoporosis

caffeine
alcohol
smoking
lack of exposure to sunlight

- reduces osteogenesis in bone remodeling

medication risk factors for osteoporosis

corticosteroids
anti-seizure meds
heparin
thyroid hormone

- affect calcium absorption and metab

comorbidity risk factors for osteoporosis

anorexia
hyperthyroidism
malabsorption syndrome
renal failure

-- affect calcium absorption and metab

primary osteoporosis occurs in women and men when?

after menopause (between ages 45 - 55 years old)

men - later in life

secondary osteoporosis

result of medications or other conditions and diseases that affect bone metabolism

discontinuation of meds halts osteoporosis progression but will not restore lost bone mass

post-menopausal women and the elderly need to consume how much calcium daily?

approx. 1200 mg

quantities larger than this for this population can lead to kidney stones

what does PTH do when it increases with age?

increases bone turnover and resorption (bad)

the RAI level of calcium for all individuals is

1,000 - 1,200 mg / daily

the recommended vitamin D intake for adults 50 y.o. and older is

800 - 1,000 IU daily

what should calcium supplemants be taken with?

a meal to increase absorption or a beverage high in vitamin C

calcium and vitamin D supplements should not be taken with ____________ at the same time of day?

biphosphates

how should patients take biphsophate supplements?

on an empty stomach
arising in the morning
full glass of water
sit upright for 30 - 60 minutes

-after administration

Calcitonin for inhibition of osteoclasts should be administered by

nasal spray or subcut / IM injection

SE: nasal irritation, flushing, GI disturbances, urinary frequency.

pts with seafood allergies should not take calcitonin

osteomalacia

metabolic bone disease

inadequate mineralization of bone

faulty mineralization causes softening and weakening of skeleton, causing pain tenderness to touch and bowing of the bones & patho fractures.

what is the primary defect in osteomalacia?

deficiency of activated vitamin D (calcitriol) which promotes calcium absorption from GI tract and facilitates mineralization of bone.

prolonged use of anti-seizure meds such as Dilantin poses a risk of what?

osteomalacia

paget's disease of the bone

localized rapid bone turnover

most commonly affects
- skull
- femur
- tibia
- pelvic bones
- vertebrae

post-op surgical wound infections occur within how many days after surgery?

30 days after

if an implant has been used, deep post-op infections may occur within how long?

1 year

over 50% of bone infections are caused by what organism?

Staphylococcus aureus

the initial response to infection is

inflammation
increased vascularity
edema

clinical and lab manifestations of sepsis

chills
high fever
rapid pulse
general malaise

TRUE OR FALSE: metastatic bone tumors are common than primary bone tumors

true.

TRUE OR FALSE: benign bone and soft tissue tumors and are more common than malignant primary bone tumors

true.

what is the most common type of benign bone tumor?

osteochondroma

Enchondroma

a common tumor of hyaline cartilage that develops in the hand, femur, tibia or humerus.

usually, the only Sx = mild ache

bone cyst

expanding lesion within the bone

osteoid osteoma

painful tumor that occurs in children and young adults

malignant primary MS tumors include

- osteosarcoma
- chondrosarcomas
- Ewing's sarcoma
- fibrosarcoma

TRUE OR FALSE: bone tumor metastasis to the lungs is common

TRUE

which primary malignant bone tumor is the most common and most often fatal?

osteosarcoma

second most common primary malignant bone tumor

chondrosarcoma (hyaline cartilage)

TRUE OR FALSE: metastatic bone disease (secondary bone tumor) is more common than primary bone tumors

true

Sx of hypercalcemia

muscle weakness
fatigue
anorexia
n/v
polyuria
cardiac dysrhytmias
seizures
coma

TRUE OR FALSE: there's an improved, long-term survival rate when a localized osteosarcoma is removed and chemotherapy in initiated

TRUE

Patients with metastatic disease are at higher risk then other pts for what post-op complications?

pulmonary congestion
hypoxemia
DVT
hemorrhage

what does hypercalcemia result from?

breakdown of bone

hypercalcemia is a dangerous complication of what?

bone cancer

hypercalcemia Sx

muscular weakness
incoordination
anorexia
n/v
constipation
ECG changes
altered mental status (confusion, lethargy, psychotic behavior)

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