 Poorly nourished

 Elderly
 Obese
 Impaired immune system
 Chronic illness
( Diabetes, Rheumatoid Arthritis)
 Receiving long term corticosteroid therapy
 Abrupt onset of high fever (fever is present
in only 50% of neonates with osteomyelitis)
 Fatigue
 Irritability
 Malaise
 Restriction of movement (pseudoparalysis of
limb in neonates)
 Local edema, erythema, and tenderness
 Radionuclide bone scanning - A 3-phase bone
scan with technetium 99m is probably the
initial imaging modality of choice.
 CT scanning - depict abnormal calcification,
ossification, and intracortical
abnormalities.
 Ultrasonography - demonstrate changes as
early as 1-2 days after onset of symptoms.
 Antibiotics – Clindamycin, Vancomycin,
Ceftriaxone, and Ciprofloxacin
 General Supportive measures
 Warm wet soaks – for 20 minutes several
times a day may be prescribed to
increase circulation.
 Antibiotic impregnated beads
may be placed in the wound
for direct application of
antibiotics for 2 to 4 weeks.
 A sequestrectomy ( removal of enough
involucrum to enable the surgeon to
remove the sequestrum)
 Closed suction irrigation system may be
used to remove debris.
 Wound irrigation using sterile physiologic
saline solution be performed for 7-8 days.
 CBC - The WBC, C-Reactive Protein and
erythrocyte sedimentation rate are
elevated.
 Radiography – there is overlying soft-tissue
edema at 3-5 days after infection.
 MRI - effective in the early detection and
surgical localization of osteomyelitis.
 Relieving Pain - immobilization of the affected
part with a splint to decrease pain and
muscle spasm.

 Controlling the infectious process - monitor

patient’s response to antibiotic therapy and
observe IV access site for evidence of
phlebitis, infection or infiltration
 Appropriate diagnosis and treatment of primary
bacterial infections to prevent bacterial
seeding of bone from a remote site

 Appropriate wound management and consideration

of prophylactic antibiotic use at the time of
injury.
 Bone abscess
 Bacteremia
 Fracture
 Loosening of the prosthetic implant
 Overlying soft-tissue cellulitis
 Draining soft-tissue sinus tracts
 Pott’s Disease
Definition:

An extra pulmonary tuberculosis that affects the spine.

Tuberculosis (TB) of the spine (Pott’s disease) is the

most common site of bone infection in TB; hips and
knees are also often affected.  The lower thoracic and
upper lumbar vertebrae are the areas of the spine
most often affected.
 Predisposing Factors
- Diabetes

- Steroid use

- Chronic disease

- Immunosuppression

- IV drug abuse

- Rheumatoid arthritis
 Clinical Manifestations
• Localised back pain
• Paravertebral swelling may be
seen
• Systemic signs and symptoms of
TB may be present
• Neurological signs may occur,
leading to paraplegia.
 Diagnostic Tests
• Blood tests - elevated ESR
(Erythrocyte Sedimentation Rate)
• Tuberculine test
• radiographs of the spine (vertebral
destruction)
• bone scan
• CT of the spine, MRI (spinal compression)
• bone biopsy
Microbiology

• Needle biopsy of bone or synovial tissue.

• Acid-fast stain and culture for Mycobacterium

tuberculosis, plus fungi and other pathogens
I. MEDICAL MANAGEMENT
MANAGEMENT

1. Immobilization using prolonged bed

rest or a body cast.
2. External Bracing
3. Chemotherapy for 9-12 months
4. Vitamin B Complex
 5. Pharmacologic Management
Therapy requires combination regimens with at least 3 anti -
tuberculous drugs:
(Duration of therapy should be individualized and based on the resolution of
active symptoms and the clinical stability of the patient.)

1. Isoniazid (Laniazid, Nydrazid) -- Highly active against

Mycobacterium tuberculosis. Good GI absorption; Penetrates well
into all body fluids and cavities.

2. Pyrazinamide -- Bactericidal against M. tuberculosis in an acid

environment (macrophages). Good GI absorption; Penetrates well
into most tissues, including CSF.
3. Ethambutol (Myambutol) -- Bacteriostatic activity against M
tuberculosis. Good GI absorption. CSF concentrations remain low, even
in the presence of meningeal inflammation.

4. Rifampin (Rifadin, Rimactane) -- Used in combination with at least

one other antituberculous drug; inhibits DNA-dependent bacterial but
not mammalian RNA polymerase. Cross-resistance may occur.

5. Streptomycin -- Bactericidal in an alkaline environment. Not absorbed

from the GI tract, must be administered parenterally. Exerts action
mainly on extracellular tubercle bacilli. Only about 10% of the drug
penetrates cells that harbor organisms. Enters the CSF only in the
presence of meningeal inflammation. Excretion is almost entirely renal.
 II. Surgical Management

(Surgery is required if there is spinal deformity or

neurological signs of spinal cord compression).

1. Anterior Decompression and Spinal Fusion

(Debridement and Fusion with bone grafting
treatment is usually six months)
 III. Nursing Management

1. Increase resistance of client through proper nutrition

2. Proper immobilization by bracing
3. Adequate rest
4. Strict compliance to therapy
5. Close monitoring regarding response to therapy
6. Observe for possibility of antimicrobial drug resistance
(development or progression of neurologic deficits, spinal
deformity, or intractable pain)
Septic Arthritis
Infectious Arthritis
Pyogenic Arthritis

A serious infection of the

joints which is considered a
medical emergency because
of the damage it causes to
bone as well as cartilage, and
its potential for creating septic shock, which is a
potentially fatal condition.
 Causes
• Previous trauma to joints

• Joint replacements

• Coexisting arthritis

• Diminished host resistance.

 Risk factors

• Advanced age
• Diabetes mellitus
• Rheumatoid arthritis
• Preexisting joint disease
• Joint replacement.
 Sign & Symptoms

• Warmth and pain in the joint

• Swollen joint
• Decreased range in motion.
• Systemic chills
• Fever
 Diagnostic Studies

• Physical Examination
• Aspiration of synovial fluid
• Culture of the synovial fluid.
• Radioisotope scanning
• Localization of the infectious process
 Management
• Prompt treatment

• Broad-spectrum IV antibiotics

• Analgesics are given to control pain

• NSAIDs to limit joint damages.

• Removal of excessive fluid, exudates and debris.

• Support, Splinting, and immobilization of the inflamed

joint to increase patient comfort.
 PREDISPOSING FACTORS
1. Genetic Inheritance
2. Age
3. Sex
 Classification

1. Nonstructural Scoliosis
- postural scoliosis
- not fixed deformity
2. Structural Scoliosis
- idiopathic (70-80% of all cases)
- congenital
- paralytic
 ETIOLOGY
1. Idiopathic
a. accounts for 80% of cases
b. possible familial incidence

2. Congenital
a. failure of vertebral formation
b. failure of segmentation

3. Neuropathic- associated with conditions such as

poliomyelitis, cerebral palsy, paralysis, and
neurofibromatosis.

4. Myopathic- results from conditions such as muscular

dystrophy and myopathies.

5. Osteopathic- results from conditions such as fractures,

bones disease, arthritis, and infection.
Three General Causes of Scoliosis:

• Congenital scoliosis is due to a problem with the

formation of vertebrae or fused ribs during prenatal
development.

• Neuromuscular scoliosis is caused by problems

such as poor muscle control or muscular weakness or
paralysis due to diseases such as cerebral palsy,
muscular dystrophy, spina bifida, and polio.

• Idiopathic scoliosis is of unknown cause, and

appears in a previously straight spine.
SIGNS AND SYMPTOMS
1. Uneven musculature on
one side of the spine.
2. A rib “hump”
3. Uneven hip & shoulder
levels.
4. Asymmetric size or
location of breast in
females.
5. Unequal distance between
arms & body.
6. Clothes do not hang right.
 COMPLICATIONS
1. Emotional problems or lowered self-esteem

2. Spinal cord or nerve damage.

3. Failure of the bone to fuse together

4. Spine infection after surgery.

5. Low back arthritis & pain.

6. Respiratory problems.
 Diagnostic Test  
1. Physical Examination
a. Forward Bending Test
to define the curve. 
2. Spine X-Ray, MRI
3. Neurologic Examination
to look for any changes in
strength, sensation, or reflexes.
4. Scoliometer measurements
(a device for measuring the curvature
of the spine)
 Mild Curve:

• Less than 25 degrees

• Can be monitored by x-rays and an examination every 3
mos.
• An exercise program may strengthen torso-muscle and
prevent curve progression

Moderate curve:
• Curve of 25 – 40 degrees
• Requires spinal exercises and brace alternately the pt. may
undergo TENS
 Dangerous curve:

• 40 degrees or more
• Requires surgery (spinal fusion with
instrumentation)-because a lateral curve
progresses at the rate of one degree per year
even after skeletal maturity.
• Pre-op preparation include Cotrel-Dubousset
segmental instrumentation for 7-10 days
 NURSING INTERVENTIONS

1. Care for patient with cast for immobilization

2. Promote comfort with proper fit of brace or cast.
3. Assess skin integrity under and around the brace or
cast
4. Provide good skin care to prevent skin breakdown
around any pressure areas.
5. Support for body image disturbance
 Herniated Nucleus Pulposus
• Nucleus pulposus of
an intervertebral disc
protruded through the
surrounding fibro-
cartilage or annulus
fibrosus
Causes
– Repetitive stress
– Trauma
– Falls
– Work related
• C5-C6, C6-C7 and L4-L5, L5-S1
(most common levels of disc herniation

• Types
– Bulging (disc of annulus bulges)
– Protrusion (not through the post longitudinal
ligament
– Extrusion (w/ herniation through PLL)
– Sequestration (detached fragment of herniated
material)
 Clinical Manifestation

 Cervical Disc
 Pain and stiffness in neck, top of shoulder, and in
region of scapula.

 Pain in upper extremities and head.

 Paresthesia and numbness of upper extremities.

 LUMBAR DISC
 Low back pain accompanied by varying
degrees of sensory and motor impairment.

 Pain radiating from the low back into the

buttock and down the leg (sciatica).

 Postural deformity of lumbar spine.

 Weakness and asymmetric reflexes.

 Sensory loss.
 LUMBAR DISC

 Positive Straight-Leg Raising Test

a. Patient in supine position
b. Raise leg with knee extended
c. Test is positive
c.1. if pain occurs in leg below the knee or c.2. if radicular
(spinal nerve root) pain
ensues.
 Diagnostic Exam

• Myelogram – demonstrate area of pressure and

localizes herniation of disc.

• CT or MRI Scan

• Electromyography – localizes specific spinal nerve

involved.
 Surgical Treatment

Laminectomy
- Surgical excision of part of posterior
arch of the vertebra and removal of protruded
disc.
 Nursing Intervention

• Pre-op:
Teach log rolling and use of bedpan
• Post-op:
• Position as ordered
• Lower spinal surgery- flat
• Cervical spinal surgery- slight elevation of HOB
– Proper body alignment
• Cervical spinal surgery- avoid flexion of neck and apply cervical collar
– Turn patient every 2 hrs
• Use lo rolling
• Place pillow in b/n legs while on side
 Nursing Intervention

 Cervical Disc Herniations

 Immobilize and rest the cervical spine
a. Bedrest – to reduce inflammation and
edema in soft tissues around disc,
relieving pressure on nerve roots; relieves
cervical spine of supporting weight of head.
b. Cervical collar – allows maximum opening
of intervertebral foramina.
c. Cervical Traction – accomplished by head
halter traction, increases vertebral
separation and thus relieves pressure
on the nerve roots.
d. Brace - for proper body alignment and to
prevent fatigue
 Reduce Inflammation
a. Anti-inflammatory medications
b. Muscle Relaxant
c. Analgesics and sedatives
d. Apply moist hot compresses (10 – 20 min. several times daily) to back of neck, to
increase blood flow to muscles and promote relaxation of the patient and spastic
muscles.
Lumbar Disc Herniations
• Encourage to continually take prescribed muscle relaxant drugs.

1) Reducing Pain
• Bedrest
• Assume comfortable and proper position.
• Ambulate when inflammatory reaction & edema have subsided.
• Heat compress and massage to relax muscle spasm.
2) Self-monitoring for Neurologic
Deficit

• Diminishing or loss of neurologic function below level of disc,

including loss of bladder/bowel control.
• Unrelieved, acute pain.
• Muscle weakness and atrophy
3) Patient Education

• Exercises after acute symptoms subside.

• Sleep on side with knees and hips flexed.
• Avoid lifting until healing has taken place.
• Proper posture while standing. sitting, and working.
• Carry out a weight control program.
 Ankylosing Spondylitis
• Marie-Strumpell
• Rheumatoid
Spondylitis

• A complete cementing
together (fusion) of the
vertebrae
• affects all age groups
including children.
• genetic
 DIAGNOSIS
• Physical examination

• X-ray findings –
abnormalities of the spine

• Bloodtests
 TREATMENT
• Anti – inflammatory Drugs
• Rehabilitative Therapy
• Exercise Programs
• Orthopedic Surgery.
 Club Foot
Talipes Equinovarus
is a congenital deformity of the foot,
characterized by inward and downward
position of the foot.

 Congenital – means a deformity at birth.

 Talipes – the foot and ankle
 Equinovarus – refers to the position of the
foot, which points downwards and inwards.
 Predisposing Factors:
 Genetic

 Sex (likely affects males; male-female ratio 2:1)

 Ethnicity (Polynesian descent most at risk)

 Factors that may affect pre natal growth, such as infection, drugs,
smoking, disease or other factors in the uterine or outside environment
 Signs and Symptoms:
 Fixed Plantar Flexion
(equinus) of the ankle,
characterized by the
drawn up position of the
heel and inability to
bring the foot to a
plantigrade (flat)
standing position.
This is due to a tight
achilles tendon.
 Signs and Symptoms:
Adduction (varus), or
turning in of the heel or hindfoot

-Adduction (turning under),

of the forefoot and midfoot
giving the foot a kidney-
shaped appearance.

 Abnormal (slightly smaller)

size of foot & calf muscles
 Diagnostic Tests:
 Newborn Examination (Physical Exam)

 X-ray of the foot to see if bones in the foot are

abnormally shaped

 Ultrasound examination before birth

 Management / Treatment:
Treatment ideally starts immediately
after birth…

1. Casting – can be started on the day of birth or

within several weeks after birth. The orthopedist
pushes and twists the foot into an over corrected
position and then cast is applied to ensure
holding of foot in same manner. (Kite Method)
 Management / Treatment:

2. Physiotherapy – started after the child

becomes more than 3 months old.
The physiotherapist tapes or manipulates the foot.

3. Surgery – recommended for children

above 6 months of age.
Needed if cast treatment fails or the
club foot is rigid.
 Pharmacologic Management:

 NSAIDS – used mainly for management

of pain of low to moderate
intensity.

e.g. Ibuprofen
Nursing Intervention:
 Elevate child’s feet with pillows. Check the toes
every 1-2 hours for temperature, color, sensation,
motion, and capillary refill time.

 Insert plastic petals over the top edges of a new

cast while it is still wet to keep urine from soaking
and softening the cast.

 When the Kite casting method is being used, check

circulatory status frequently. Circulation maybe
impaired because of increased pressure on tissues
and blood vessels. The equinus correction specially
places considerable strain on ligaments, blood
vessels, and tendons.
DEFINITION-
COXA PLANA
When the head of the femur deteriorates due to insufficient blood supply
to the area.
Occurs most frequently in boys 4 to 10 years old. Recent research shows
that this disorder may reflect subtle disorders of blood clotting.

Etiology:
The blood flow to the femur is interrupted, and the tip of the bone
dies over a period of one to three weeks. The disorder causes a flattening
of the ball of the head of the femur. Usually just one hip is affected,
although it's possible for both to develop the condition.
 CAUSES
• Low birth weight

• Delayed bone maturity

• Short stature

• Abnormal birth presentation

• Being born to older parents

 SIGNS & SYMPTOMS
• knee pain
• persistent thigh or groin pain
• atrophy of muscles in the upper thigh
• muscle spasms
• legs of unequal length (asymmetry)
• hip stiffness that restricts movement in the hip
• difficulty with or limp during walking
• limited range of motion
 DIAGNOSTIC PROCEDURE

• X-rays

• Bone scans

• Magnetic Resonance Imaging (MRI)

• Arthrograms
 Four Stages of LCPD

I. Initial Phase
- Femoral head becomes more dense
with possible fracture of supporting
bone (6-2 mos)

II. Reabsorption Phase

- Fragmentation and reabsorption of
bone (one yr or more)

III. Reossification Phase

- when new bone has regrown

IV. Healing Phase

- when new bone reshapes.

Phase 3 and 4 may go on for many years.

Surgical Management
• Tenotomy
Performed to release an atrophied muscle that has shortened
due to limping. Then, cast is applied to allow the muscle to
regrow to a more natural length. Cast time is about six to
eight weeks.

• Osteotomy
Cutting the bone to reposition it depending on the need they
are performed at different stages of the disease. At times with
the softening of the ball, there is the possibility of the ball
slipping out of the socket. To protect it, a femoral varus
osteotomy, with or without rotation partially redirects the ball
into the socket.
 Nursing Intervention:

• Bed rest

• Care for a child on traction and spine cast

• Diversional activities

• Range of motion exercises

DEFINITION-OSTEOGENESISI IMPERFECTA

A genetic disorder characterized by bones that breaks

easily without a specific cause.

SYNONYMS:

Brittle-bone disease
Fragile bone disease
Broken bone
OI
 ETIOLOGY
 The specific cause of Osteogenesis Imperfecta is
unknown, but some cases are of congenital origin
and the hereditary factor is demonstrable in many,
with the disease usually transmitted as an
autosomal-dominant trait.

INCIDENCE
 Osteogenesis Imperfecta is relatively rare, with the
congenital type occurring in approximately 1 of every
40,000 births. It is somewhat more frequent in
females than in males.
Signs and Symptoms

Type I: (Most Common & Mildest)

• Bones fracture easily

• Usually hereditary
• Near normal stature or slightly shorter
• Blue sclera
• Triangular face
• Dental problems
• Tendency toward spinal curvatures
• Hearing loss beginning in the early 20s and 30s
• Most fractures occur before puberty and
usually after menopause in women
Type II: (Most Severe)

• Newborns severely affected; frequently fatal

• Usually resulting from a new gene mutation
• Very small stature with extremely small chest and
under developed lungs
Type III: (isolated family incidents )

• Very small in stature - some only 3 feet tall

• Barrel-shaped rib cage
• Triangular face
• Severe early hearing loss
• Loose joints and poor muscle development in
arms and legs
• Fractures at birth very common
• X-ray may reveal healing of in - utero fractures
Type IV:

• Frequently traced through the family

• Bones fracture easily - most before puberty
• Normal or near normal colored sclera
• Problems with teeth - more than Type I
• Spinal curvatures
 Diagnostic Procedure

• Physical examination
• Family’s medical history
• Blood & urine test
• Collagen synthesis analysis
• Prenatal DNA
- Ultrasound
- Amniocentesis
- Chorionic Villus Sampling
(10-13 weeks of pregnancy)
• Bone mineral density analysis
Treatment for Osteogenesis Imperfecta

Specific treatment will be determined by physician

based on:

• Age, overall health, and medical history

• Extent of the disease
• Tolerance for specific medications, procedures, or
therapies
• Expectations for the course of the disease
• Own opinion or preference
 Treatments for preventing or correcting
symptoms may include:

• Care of fractures
• Surgery
• Rodding - a procedure to insert a metal bar the
length of a long bone to stabilize it and prevent
deformity
• Dental procedures
• Physical therapy
• Assistive devices, such as wheelchairs, braces, and
other custom-made equipment
 NSG. MANAGEMENT
• Support limbs. Do not pull on arms or legs
to prevent fractures.
• Position with care
• Check circulatory and motor sensory abilities
• Provide emergency care of fractures
• High protein, high vitamins diet
to promote healing.
• Increase fluids to prevent constipation ,
renal calculi and UTI’s.
• Care for client with traction, cast or
open reduction.
 NSG. MANAGEMENT

• Care for client with traction, cast or

open reduction.
• Psychological support and diversional activities.
• Encourage mobility when possible.
• Refer parents and child for genetic counseling
• Promote preventive dental care and
repair of dental caries.
• Monitor hearing needs.
• Avoid activities which have a negative impact on
bone density such as smoking, drinking and taking
steroids.
 Definition

Congenital hip dysplasia

- an abnormal formation of the hip joint in which the ball
at the top of the thighbone (femoral head) is not stable in
the socket (acetabulum).
Also, the ligaments of the hip joint may be loose and
stretched. The degree of instability or looseness varies.
A baby born with DDH may have the ball of his or her hip
loosely in the socket, the looseness may worsen as the
child grows and becomes more active, or the ball may be
completely dislocated at birth.
 CLASSIFICATION

1. Acetabular Dysplasia – deficient development of

the acetabulum & femoral head.

2. Subluxation - partial displacement of a joint

with some contact remaining between the
articular surface.

3. Dislocation - complete displacement of a joint

with no contact between the articular surface.
 Female Gender

Oligohydramnios
Can result in fetal compression
and diminished movement.
 Ortolani Test - “hip click” on routine post – natal exam
 Galleazzi Sign - knee appears shorter on the side of the
dislocated hip.
 Reduced movement in the affected side.
 Asymmetric leg positions
 Uneven extragluteal skin folds of the thigh or buttocks
 After 3 months of age, the affected leg may turn outward
or be shorter than the other leg.
 Space between the legs may look wider than normal.
 Nursing Management :

> After casting, use your palms to avoid making dents

in the cast.
> Position the child on pillows to support the child’s legs.
keep the cast dry, and change the diapers often.
> Wash and dry the skin under the cast edges every 2 to 4
hrs, and rub it with alcohol. Do not use oil or powder;
they can macerate skin.
> Turn the child every 2 hrs during the day and every 4 hrs.
at night. Check color, sensation, and motion of the
infant’s legs and feet.
> Shine a flashlight under the cast every four hrs to check
for objects and crumbs.
> Give diphenhydramine if child complains of itching.
> Adequate nutrition, and maintain adequate fluid intake
to avoid renal calculi and constipation
> Apply a jacket restraint if restless, to keep her from
falling out of bed or off the frame.
> Adequate stimuli to promote growth and development.
Definition:RA
An autoimmune inflammatory
diseases of the joints and various organ
systems.
Synovial inflammation produces
antigens and inflammatory by-
products leading to destruction of joint
cartilage, edema, and production of
granulation tissue (pannus).
It maybe a result of a combination of the
following factors:

• Environment

• Demography

• Infection

• Genetic
Predisposing Factors include:
• Fatigue

• Cold

• Emotional stress

• Infection
 Signs & Symptoms

• Joint pain and swelling

• Generalized aching or stiffness of the joints
and muscles
• Loss of motion
• Fatigue
• Low-grade fever
• Deformity of joints overtime
• Malaise
• Small lumps (rheumatoid nodules)
 Diagnostic Test

• CBC
• Rheumatoid factor
• ESR
• Synovial fluid analysis
• X-rays
• MRI
• Bone scan
• Synovial Fluid biopsy
 Therapeutic Intervention

• Heat & cold to relieve pain and inflammation

• Use of splints to prevent contractures

• Use of Transcutaneous Electrical Nerve

Stimulation unit (TENS) to treat chronic pain

• Lontophoresis (delivery of medication through the

skin using direct electrical current) to relieve pain.

• Behavior modification, biofeedback, and relaxation

techniques.
 Nursing Intervention
• Monitor length of time of stiffness on arising.

• Pain control measures.

• Monitor for signs and symptoms indicating adverse

reaction to medications, such as rash, visual
symptoms, GI distress.

• Preserve functional ability.

 Medical Intervention

• Aspirin – Both for analgesic and

anti-inflammatory effects.

• Nonsteroidal anti-inflammatory drugs

(NSAIDs):

• Indomethacin (Indocin)
• Phenylbutazone (Butazolidin)
• Ibuprofen (Motrin)
• Fenoprofen (Nalfon)
• Naproxen (Naprosyn)
• Sulindac (Clinoril)
 Medical Intervention

Gold compounds (chrysotherapy)

Injectable form:
Sodium Thiomalate (Myochrysine).
Aurothioglucose (Solganal); given IM once a week; takes 3-6 months – to
become effective.
Oral form:
Auranofin (Ridaura); smaller doses are
effective; diarhhea is a common side effect.
Corticosteroids (intra-articular injections)
 Surgical Intervention

Osteotomy
Surgical removal of a wedge from the joint.

Synovectomy
Removal of synovia.

Arthroplasty
Replacement of joints with prostheses
OSTEOARTHRITIS:
• the most common of all joint diseases.

• A type of arthritis that is caused by the breakdown and

eventual loss of the cartilage of one or more joints.

• Derived from Greek word

“osteo” - “bone”;
“arthro” - “joint”
“itis” - “inflammation”.
 Types of Osteoarthritis

1. Primary Osteoarthritis
Osteoarthritis with no known cause but mostly
related to aging.

2. Secondary Osteoarthritis
Osteoarthritis with known cause such as
obesity, trauma or surgery, congenital
abnormalities (hip dysplacia), gout and diabetes.
 Predisposing Factors
1. Aging
2. Anatomic abnormality; mal-alignment
3. Joint injury / Trauma / Surgery
- Stresses at the joints from certain jobs and
sports activities
4. Obesity
5. Systemic diseases
6. Genetic factors
7. Other form of arthritis
(like gout, rheumatoid arthritis)
 SIGNs AND SYMPTOMS

1. Pain and swelling

2. Stiffness
3. Enlargement of joint
-Heberden’s nodes
- nodular bony enlargement (spurs) that form
on the distal joints of some or all of the fingers
-Bouchard’s nodes
- nodular bony enlargements that form on the
proximal joints of some or all of the fingers
4. Crepitus
- audible grating sound produced by bony
irregularities with joints
5. Discomfort in the joint before or during a change in the
weather
 MEDICAL MANAGEMENT

1. Symptomatic relief
- osteoarthritis is irreversible; goal of treatment is to
reduce joint pain and inflammation while improving and
maintaining joint function.

2. Injection of hyaluronic acid into the joint

- temporarily restore the thickness of the joint
fluid.
 SURGICAL MANAGEMENT

1. Excision Arthroplasty
- excising the joint margins, e.g. in the metatarsals
2. Osteotomy
- realignment of bone surfaces
3. Fusion/Arthrodesis
- fusing the joint
4. Arthroscopic joint debridement
- removal of loose bodies and smoothing articular surfaces
5. Total joint arthroplasty
- surgical replacement of destroyed joint
 PHARMACOLOGY

1. NSAIDS
- aspirin, ibuprofen, naproxen.
2. Topical
- creams and lotion containing capsaicin,
ex.: methyl salicylate (bengay).
3. Analgesic like paracetamol or acetaminophen.
4. Dietary Supplements
- Glucosamine - provides the building blocks for the body to
make and repair cartilage
- Chondroitin - contribute to cartilage elasticity
 NURSING MANAGEMENT
1. Assess joints for pain and ROM
2. Relieve strain and prevent further trauma to joints:
- use cane or walker when indicated
- correct posture and body mechanics
- avoid weight bearing and continuous standing
- promote relief of pain
3. Avoid activities that precipitate pain
4. Provide rest for involved joints
5. Maintain proper weight
6. Use heat as prescribed
 SYMPTOMS-GOUTY A.
• Joint pain
• Joint swelling of the affected joint
• Stiffness of the joint
• Fever may be present
• Skin lump which may drain chalky
material.
 MOST AFFECTED…..

• Men are more likely to develop than

women.

• It is rare in children and young

adults.
1. ASYMPTOMATIC HYPERURICEMIA

• Stage which
usually doesn’t
require
treatment,
Elevated blood
uric levels but no
other symptoms.
 2. ACUTE GOUTY ARTHRITIS

• In this stage,
hyperuricemia
has caused
deposits of uric
acid crystals in
joint spaces
leading to Gouty
attacks.
 3. INTERVAL / INTERCRITICAL

• In this stage,
person has no
symptoms
during the
periods between
acute Gouty
attacks
 4. CHRONIC TOPHACEOUS GOUT

• In this stage, the

disease has caused
permanent
damage; treatment
never progress to
this advanced
stage.
 DIAGNOSTIC TEST
• Synovial (joint)
analysis - detects • OTHERS
uric acid crystals  Uric Acid test –
• Elevated Uric Acid urine
level - blood test
• Joint X-ray - which  Synovial biopsy
shows damage
consistent with  Blood differential
Gouty Arthritis.
Medical Management
Medications

Colchicine

Phenybutazone (Butazolidin)

Indomethacin (Indocin)

Absolute joint rest

Surgical Management

The removal of detached

osteophytes and advance tophi can
reduce the articular destruction
taking place.
Anthroplasty or Anthrodesis should
be considered if there is a severe
pain associated with the movement
of the joint in a digit.
Triple Anthrodesis is the last resort
Patient teaching

 Instruct about the nature of the disease

 Instruct for proper use of medication
 Encourage to lose weight
 Encourage to take sufficient fluids to assure daily
intake of 2-3 liters

Promoting comfort

 Provide absolute rest until pain of acute attack

subsides.
 Heat and Cold Application
 DIET-food to avoid
• Foods high in PURINE
 Sweet breads, kidneys, liver, brains or
other organ meats
 Sardines
 Anchovies or dilis
 Scallops, prawns and crabs
 Alcohol
 Moderate intake of purine-rich vegetables
if not associated with increased Gout.
 VITAMINS AND SUPPLEMENTS
• The following is based on information from
a Naturopathic Physician….
 Quercetin- inhibits Uric Acid production
 Bromelain- anti-inflammatory
 Vitamin E
 Flaxseed Oil
 Avoid high doses of Vit. C and
Niacin (B3)- may increase uric acid
DEFINITION-BUERGER”S DISEASE
an obliterative disease of arteries and veins
characterized by acute and chronic
inflammation in the blood vessels of the
lower and upper extremities which begins in
the small arteries and progresses to the
larger vessels that result in thrombus
formation and occlusion of the vessels.
 PREDISPOSING FACTORS
• SMOKING:
 Cause is unknown but heavily linked to
tobacco use.

• RACE:
 Less common in people of northern European
descent. Natives of India, Korea, and Japan,
and Israel have the highest incidence
 PREDISPOSING FACTORS
• SEX:
 More common in males
(male-to-female ratio, 3:1), but incidence is
increasing among women, and this trend is
postulated to be due to the increased prevalence
of smoking among women.

• AGE:
 20-40 years.
 SIGNS AND SYMPTOMS

• PAIN / CLAUDICATION
 Pain induced by insufficient blood flow during
exercise in the feet and / hands.

 This pain typically begins in the extremities but

may radiate to other (more central) parts of
the body.
 SIGNS AND SYMPTOMS

• NUMBNESS

• RAYNAUD’S PHENOMENA
 Distal extremities — fingers, toes, hands, feet —
turn white upon exposure to cold.

• ISCHEMIC ULCERATIONS
• GANGRENE
 DIAGNOSTIC TESTS
• Age younger than 45 years.

• Current (or recent) history of tobacco use.

• Presence of distal extremity ischemia

(indicated by claudication, pain at rest,
ischemic ulcers or gangrene)
(documented by noninvasive vascular testing
such as ultrasound)
 DIAGNOSTIC TESTS

• Exclusion of autoimmune diseases, hypercoagulable

states, and diabetes mellitus by laboratory tests.

• Exclusion of a proximal source of emboli by

echocardiography and arteriography.

• Consistent arteriographic findings in the clinically

involved and noninvolved limbs.
 IMAGING TESTS

• Angiography/Arteriography

• Digital Subtraction

• Doppler Ultrasound

• Exercise Testing
 MANAGEMENT

 Goal of treatment is to control symptoms

• Immediate and absolute

cessation of tobacco use

• Early and aggressive treatment injuries to

protect against infections.
 PHARMACOLOGIC
• Analgesics

• Antibiotics

• Anticoagulation Drugs

 Strategies of anticoagulation (thinning of the

blood with aspirin or other agents to prevent
clots) have not proven effective.
 PHARMACOLOGIC
• Anti-inflammatory Drugs

• Prostaglandin Analogs
 Intravenous ILOPROST use is probably of greatest value in
slowing progressive tissue loss and reducing the need for
amputation in patients with Buerger’s Disease during the
period when they first discontinue cigarette smoking.

• Vasodilators

• Vitamins
 Nursing Management
• Adequate hydration and scrupulous attention to cleanliness.

• Gentle massaging and warming of patient to increase

circulation.

• Avoid conditions that reduce circulation to the extremities

(cold temperatures, use of vasoconstrictors and tight or
restrictive clothing).

• Avoid sitting or standing in one position for long periods of

time

• Avoid walking Barefoot

 SURGICAL
• AUTOLOGOUS VEIN BYPASS
To improve distal arterial flow, and consider
autologous vein bypass of coexistent large-vessel
atherosclerotic stenoses in patients with severe
ischemia who have an acceptable distal target
vessel.
 SURGICAL

• AMPUTATION
Indications for amputation:
a. Severe Rest Pain
b. Sepsis Secondary to Gangrene
c. Worsening Gangrene
 Risk Factors-Raynauds disease

• About 3 out of 4 cases of primary Raynaud's occur in

WOMEN between the ages of 15 and 40 years, although the
reason is unknown.
• People in COLDER CLIMATES are also more likely to develop
Raynaud's than people in warmer areas.
• Risk factors for secondary Raynaud's include associated
DISEASES, such as scleroderma and lupus, and smoking.
• People in certain occupations, such as WORKERS WHO
OPERATE TOOLS THAT VIBRATE, also may be more
vulnerable to secondary Raynaud's
 Signs & Symptoms
• Attacks in response to cold or emotional stress. The attacks can affect the
fingers and toes, and rarely the nose, ears, nipples, or lips. The affected
body parts will usually have two or more of the following changes:
– Look pale due to lack of blood flow
– Look bluish due to a lack of oxygen
– Feel numb, cold, or painful
– Redden and throb or tingle as blood returns to the
affected area
• Attacks usually last about 15 minutes. They can last less than a minute or
as long as several hours. Attacks can occur daily or weekly.
• Attacks can cause sores or tissue death (gangrene) in people with severe
secondary Raynaud's. However, severe Raynaud's is very uncommon.
 Diagnostic Tests
• Cold Simulation Test - This test can trigger an attack that is
typical of the disorder. Temperature sensors are taped to the
fingers of the hand. The hand is then briefly exposed to the
cold, usually by dunking it in ice water. If the patient likely has
Raynaud's, it will take more than the normal time for the finger
temperature to return to what it was at the start of the test.
• Tests For Inflammatory Disorders that damage blood
vessels or nerves. Having these conditions along with Raynaud's
symptoms makes it more likely that a patient has secondary
Raynaud's disease.
• Nailfold Capillaroscopy (Kap-i-lar-os-ko-pe). For this
test, the doctor puts a drop of oil on the skin at the base of the
fingernail and then looks at it under a microscope. If the doctor
sees abnormal looking blood vessels, this suggests an
inflammatory disorder such as scleroderma.
 Diagnostic Test (cont..)

• Antinuclear antibodies (ANA) test.

A positive test for the presence of these antibodies —
produced by your immune system — indicates a stimulated
immune system and is common in people who have
connective tissue diseases or other autoimmune disorders.

• Erythrocyte sedimentation rate (ESR).

This blood test determines the rate at which red blood cells
settle to the bottom of a tube in the space of an hour. A
faster than normal rate may signal an underlying
inflammatory or autoimmune disease. Autoimmune diseases
are commonly associated with Raynaud's.
 Complications
• If Raynaud's is severe — WHICH IS RARE — blood
circulation to your fingers or toes could
permanently diminish, causing deformities of your
fingers or toes.

• If an artery to an affected area becomes blocked

completely, sores (skin ulcers) or dead tissue
(gangrene) may develop. Ulcers and gangrene can
be difficult to treat.
 Treatment

Self-care and preventive treatment usually are effective in

alleviating mild symptoms of Raynaud's.

The goals of treatment are to reduce the number and

severity of attacks and to prevent tissue damage.
Doctors also want to treat any underlying disease or
condition

Medications
To widen (dilate) blood vessels and
promote circulation, your doctor may
prescribe:
 Medical Management
Calcium channel blockers.
To relax and open up small blood vessels in your hands and feet.
Examples: Nifedipine (Adalat, Procardia), Amlodipine (Norvasc), Diltiazem
(Cardizem, Dilacor), Felodipine (Plendil), Nisoldipine (Sular) and Isradipine
(DynaCirc Cr).

Alpha blockers.
To counteract the actions of norepinephrine, a hormone that constricts
blood vessels. Examples: Prazosin (Minipress) and Doxazosin (Cardura).

Vasodilators.
Relaxes blood vessels
Examples: Nitroglycerin cream. Apply to fingers to help heal skin
ulcers.
 Surgical Management
Nerve surgery (Sympathectomy)
Through small incisions in the affected hands or feet, a
doctor strips away these tiny sympathetic nerves around the
blood vessels to interrupt their exaggerated response.
Sympathetic nerves in your hands and feet control the opening
and narrowing of blood vessels in your skin.
Chemical injection
Injection of chemicals to block sympathetic nerves in
affected hands or feet.
Amputation.
Done when blood supply has been completely blocked and
the tissue has developed gangrene.
 Prevention
Dress warmly outdoors.
Wear a hat, scarf, socks and boots, and mittens or gloves
under mittens

Take precautions indoors.

Wear socks, use insulated drinking glasses.
When taking food out of the refrigerator or freezer, wear
gloves,
Turning down the air conditioning to prevent attacks.

Consider moving to a location with a milder

climate.
 DEFINITION
• Osteogenic sarcoma is a primary
malignant tumour of the skeleton
characterised by the direct formation of
immature bone or osteoid tissue by the
tumour cells. More rarely Osteogenic
sarcoma may arise in the soft tissue.
 Etiology

• The exact cause of osteosarcoma is unknown.

However, a number of risk factors are
apparent, as follows:

• Male between the ages of 10 – 25 years

• Heredity
• Exposure to radiation
 Etiology
• Genetic predisposition: Bone dysplasias, including
Paget disease, fibrous dysplasia, enchondromatosis,
and hereditary multiple exostoses and
retinoblastoma (germ-line form)

• Rapid bone growth: Rapid bone growth appears to

predispose persons to osteosarcoma, and
osteosarcoma's typical location in the metaphyseal
area adjacent to the growth plate (physis) of long
bones.
 Osteosarcoma
• A tumor in the bone causes the normal bone
tissue to react by osteolytic response (bone
destruction) or osteoblastic response (bone
formation)

• Can cause bone destruction, which weakens the

bone, resulting in bone fracture.

• Adjacent normal bone responds to the tumor by

altering its normal pattern of remodeling, the
bone’s surface changes, and the contours enlarge
in the tumor area.
 Most common sites of
Osteosarcoma

• Femur
• Tibia
• Humerus
• Skull
• Jaw
• Pelvis
 Signs & Symptoms
• Pain, particularly pain with activity

• Swelling

• Weight loss

• Fever

• Night sweats

• Decreased range of motion

 Complications
• Pathologic fractures

• Lung metastasis

• Limb removal
 Diagnosis
• CT scan; bone scans

• MRI

• Biopsy

• Laboratory findings: hyperphosphotemia

• Chest x-ray – performed to determine the

presence of lung metastasis.
 Treatment
Medical Management:

• Radiation therapy and / or chemotherapy

Surgical Management:

1. Surgical excision (ranging from local excision to

amputation and disarticulation)
2. Limb-sparing (salvage) procedures- used to remove
the tumor and adjacent tissue
 Surgical Treatment

3. Total joint prosthesis, total joint arthroplasty – to

replace the resected tissue

4. Rotationplasty- distal portion of the leg then is

rotated 180 degrees and reattached to the thigh at
the proximal edge of the resection.

• Other osteosynthesis variations also are possible.

The rotation allows the ankle to become a
functional knee joint, so the length of the leg should
be adjusted to match the contralateral knee.
 Nursing Interventions
• Support and handle gently the affected extremity; external
supports (splint) may be used for additional protection.

• Teach patient how to use assistive devices safely and how

to strengthen unaffected extremities.

• Monitor full cycles of chemotherapy

• Monitor IV antibiotics, fever and neutropenia

• Assist in passive ROM and consider some restrictions

 Osteoporosis

is a disease of the bone in which:

1. bone mineral density (BMD) is reduced,

2. bone microarchitecture is disrupted, and

3. the amount and variety of non-collagenous

proteins in the bone is changed
 Osteoporosis

• Osteoporosis is a condition that causes

thinning and weakening of normal bone; a
decrease of the density of bone mass; thus
patient has increased risk of bone fracture
 Osteoporosis

• The underlying mechanism in all cases of

osteoporosis is an imbalance between bone
resorption and bone formation.

• Either bone resorption is excessive, or bone

formation is diminished.
 Osteoporosis

Two main categories of osteoporosis:

• Type I - only in post-menopausal women, and is

due to estrogen deficiency.

• Type II - occurs in both men and women (about

two times more frequently in women), and is due
to aging, and calcium deficiency over many years.
 Etiology

• Estrogen deficiency

• Testosterone deficiency

Estrogen and testosterone increase osteoblast

activity, causing bone growth.

The loss of estrogen following menopause

causes a phase of rapid bone loss. Similarly,
testosterone levels in men diminish with
advancing age and are related to male
osteoporosis.
 Etiology

• Glucocorticoid or thyroxine excess

Cause osteoclast activity to increase, causing
bone resorption.

• Calcium and/or vitamin D deficiency

Calcium and vitamin D are nutrients required for
normal bone growth.
 Risk Factors
Non modifiable:
• History of fracture

• Female gender - rate of bone loss in women is

greater than men
• Advanced age - bone mass peaks in both men
and women between the ages of 25 and 35,
• European or Asian ancestry
Potentially modifiable:
Risk factors
• Tobacco smoking

• Intake of soft drinks

• Low body weight <58 kg (127 lb),

• Estrogen deficiency,

• Early menopause (<45 years) or bilateral

oophorectomy
 Risk factors

Potentially modifiable:
• Premature ovarian failure

• Prolonged premenstrual amenorrhea (>1 year),

• Low calcium and vitamin D intake,

• Alcoholism

• Recurrent falls,

• Inadequate physical activity

 Clinical Picture

• Osteoporotic fractures - those that occur under

slight amount of stresses that would not normally
lead to fractures in non osteoporotic people.
Common sites are: the wrist, the hip and the spine

• Collapse of a vertebra ("compression fracture") can

cause : acute onset of back pain, a hunched forward
or bent stature; loss of height; limited mobility and
possibly disability and bedrest.
 Diagnosis

• Dual energy X-ray absorptiometry (DXA, formerly

DEXA)
- gold standard for diagnosis of osteoporosis.
• Diagnosis is made when the bone mineral density
is equal to or greater than 2.5 standard deviations
below that of a young adult reference population.
This is translated as a T-score.
• T-score -1.0 or greater is "normal“
• T-score between -1.0 and -2.5 is "low bone mass"
(or "osteopenia")
• -2.5 or below as osteoporosis.
 Medical Management

Bisphosphanates (Fosamax)
regulate calcium and prevent bone breakdown

Calcitonin (Miacalcin)
slow bone loss, and also decrease pain associated
with osteoporosis fractures

Raloxifene
Similar effects with estrogen; increases bone mass
 Treatment

• Hormonal replacement therapy (HRT)

increase bone mass after menopause

• Calcium supplementation - at least 1200 to

1500 mg every day = 5 glasses of milk each
day
 Nursing Interventions

• Daily weight-bearing exercises to maintain and

increase bone mass
• Encourage high calcium and high fiber diet
• Encourage vitamin D supplementation.
• Advice to avoid smoking and reduce use of
caffeine (e.g. coffee, soda) and alcohol. – it
decrease calcium absorption
 Nursing Interventions

• For relief of back pain:

a. Rest in bed in a supine or side-lying position.
b. Mattress should be firm and non-sagging.
c. Intermittent local heat and back rubs to
promote muscle relaxation.
d. Encourage good posture and good body
mechanics.
 Osteomalacia
• is a metabolic bone disease characterized by
inadequate mineralization of bone

• results from the deficiencies of vitamin D in

adults, characterized by deficient calcification of
bone and softening of bone to osteoid failing to
ossify

• Softening and weakening of the skeleton

 Signs and Symptoms
• Muscular weakness and softening of the skeleton,
resulting from decalcification

• Skeletal pains and swelling and numerous fracture

• Brittleness of bone

• Waddling or limping gait

 Diagnostic Tests
• X-ray: generalized demineralization of bone

• Laboratory studies: low serum calcium and

phosphorus levels, and moderately elevated
alkaline phosphatase concentration

• Urine: low excretion of calcium and creatinine

• Bone biopsy: increased amount of osteoid.

 Medical Management

• Administration of adequate amount of vitamin D,

calcium salts and phosphates

• Splintage – braces to correct deformities

• Surgery – osteotomy to correct deformity.

 Nursing Management
• Advise adequate exposure to sunlight
(for ultraviolet radiation to transform cholesterol
substance (7- dehydrocholesterol) present in the
skin into vitamin D.)
• Encourage adequate protein and increased
calcium and vitamin D diet.
• Monitor serum calcium levels
• Assist in position changes, handle gently, and use
pillows to support the body
 CARPAL TUNNEL SYNDROME
• A disorder caused by compression at the wrist, of
the median nerve supplying the hand, causing
numbness and tingling
• At the base of the palm is a tight canal or “tunnel”
through which tendons and nerves must pass.
• Median Nerve
• narrow passage between the forearm and hand
“The Carpal Tunnel”.
• It is most commonly caused by:
*Repetitive activities, those who do repetitive
movement more than 6 hours per day are at a higher
risk
*May be associated with Arthritis, Hypothyroidism
or pregnancy
* diabetes or other metabolic disorders that directly
affect the body's nerves and make them more
susceptible to compression are also at high risk. Carpal
Tunnel Syndrome usually occurs only in adults.
 Clinical Manifestation
• Pain (at night)
• Numbness
• Paresthesia
• Possibly weakness alomg the median nerve
(thumb & first two fingers)
Pain, tingling, and numbness in the thumb, index, middle, or ring fingers,
or tingling in the entire hand.
+ Pain that shoots from the hand up the arm as far as the shoulder.
+ A swollen sensation in your fingers, even though they may not be visIbly
swollen.
+ symptoms are worse at night.
+hands feel weak in the morning.
+ drop objects more than usual.
+have trouble grasping or pinching objects.
+have trouble using your hands for certain tasks, such as buttoning a
shirt, handwriting, or opening a jar lid.
+ The muscles at the base of your thumb are smaller and weaker than
they used to be.
 Early diagnosis and treatment are
important to avoid permanent damage to the
median nerve. A physical examination of the
hands, arms, shoulders, and neck can help
determine if the patient's complaints are
related to daily activites or to an underlying
disorder
 Diagnostic Test
• Tinel’s Sign-
The doctor will gently tap the front of your
wrist to see if you feel tingling or pain in your
hand or forearm.
• + Phalen's Sign Test: The doctor will ask you to bend
your wrist down as far as it will go and hold this position
up to 3 minutes to see if you feel tingling or pain.

• + Nerve Conduction Velocity Study: This test measures

the nerve's ability to send electrical impulses to the
hand muscles, to see if the electrical impulses slow
down the carpal tunnel.
 Treatment

Rest Splint (to prevent hyperextension &

prolonged flexion of the wrist
• Use of Ergonomic changes at work to reduce wrist
strain ( avoidance of repetitive flexion of the wrist)
• NSAIDs
• Carpal Canal Cortisone injections may relieve the
symptoms
•
• Specific Yoga postures, relaxation &
acupuncture may provide non traditional
alternatives to relieve CTS
• Traditional or endoscopic laser surgical release
of the transversecarpal ligament may be
necessary.( pt wears a hand splint after
surgery & limits hgand use during healing)
 CAUSES / RISK FACTORS
• Edema from trauma which can compress median
nerve
• Obesity
• Acromegaly
• Rheumatoid arthritis
• Gouty arthritis
• Hypothyroidism
• Women more than men
• Age 40 to 60
• Intake of caffeine, tobacco smoking
 Signs & Symptoms
• A tingling or numbness in the hand and/or fingers
• Shooting extending to the shoulder, neck and chest,
or foot
• Difficulty clenching the fist or grasping small or
heavy objects
• Cold intolerance
• Pain usually bilateral, worse at night after strenuous
activity
• Affects the thumb, index, middle finger
• Atrophy of the padded area below the thumb
(Thenal Eminence )
 Treatment:
• Splints worn during the day decrease the muscle
pumping action of the hand, cause more swelling in
the hand 

• Steroid injections

• Open carpal tunnel release