Musculoskeletal System - UNIT 4

An x-ray is taken to determine density of bone. Study evaluates structural or functional changes of bones and joints. In anteroposterior view, x-ray beam passes from front to back, allowing one-dimensional view; lateral positioning provides 2-D.

Avoid excessive exposure of patient and self. Before procedure, remove any radiopaque objects that can interfere with results. Explain the procedure to the patient. Verify the patient is not pregnant

An x-ray of cervical or lumbar intervertebral disk is done after injection of contrast dye into nucleus pulposus. Study permits visualization of intervertebral disk abnormalities.

Assess patient for possible allergy to contrast medium

An x-ray beam is used with a computer to provide a 3-D picture. It is used to identify soft tissue & bony abnormalities and musculoskeletal trauma

A myelogram involves injecting a radiographic opaque dye into the sac around the nerve roots. CT scan may follow to show how the bone is affecting the nerve roots. Very sensitive test for nerve impingement and can pick up even very subtle lesions and injuries

Main risk is the potential for spinal headache. Inform patient that headache should resolve in 1-2 days with rest and fluids, but should be reported to HCP

Radio waves and magnetic field are used to view soft tissue. Study is especially useful in the diagnosis of avascular necrosis, disk disease, tumors, osteomyelitis, ligament tears and cartilage tears. Patient is placed inside scanning chamber. Gadolinium maybe injected into vein to enhance visualization of the structure. Open MRI does not require the patient to be placed inside a chamber.

Inform the patient that procedure is painless. Be aware that it is contraindicated in patient with: aneurysm clips, metallic implants, pacemakers, electronic devices, hearing aids and shrapnel. Ensure that patient has no metal on (snaps, zippers, jewelry, credit cards). Inform the patient of importance of remaining still throughout examination. Inform patients who are claustrophobic that they may experience symptoms during examination. Administer anti-anxiety agent if indicated and ordered. Open MRI may be indicated for obese patient or patient with large chest and abdominal girth or severe claustrophobia. Open MRI may not be available at all facilities.

Dual-energy x-ray absorptiometry (DEXA) & Quantitative Ultrasound (QUS)

Technique measures bone mass of spine, femur, forearm and total body. Allows assessment of bone density with minimal radiation exposure; used to diagnose metabolic bone disease and to monitor changes in bone density with treatment.

Inform patient the procedure is painless

Evaluates density, elasticity and strength of patella and calcaneus using ultrasound rather than radiation

Inform patient that procedure is painless

Technique involves injection of radioisotope (usually technetium-99m [99mTc]) that is taken up by bone. A uniform uptake of the isotope is normal. Increased uptake is seen in osteomyelitis, osteoporosis, primary & metastatic malignant lesions of bone and certain fractures. Decreased uptake is seen in areas of avascular necrosis.

Explain that technician gives calculated dose of radioisotope 2h before procedure. Ensure that bladder is emptied before scan. Inform patient that procedure requires 1h while patient lies supine and that no pain or harm will result from isotopes. Explain that no follow-up scans are required. Increase fluids after the exam to increase secretion of isotope from system. Isotope can cause renal damage/failure if not excreted promptly.

Study involves insertion of arthroscope into joint (usually knee) for visualization of structure and contents. It can be used for exploratory surgery (removal of loose bodies and biopsy) and for diagnosis of abnormalities of meniscus, articular cartilage, ligaments or joint capsule. Other structures that can be visualized through the arthoscope include: shoulder, elbow, wrist, jaw, hip and ankle.

This enzyme, produced by osteoblasts of bone, is needed for mineralization of organic bone matrix. Elavated levels are found in healing fractures, bone cancers, osteoporosis, osteomalacia and Paget's disease)

• NIC
• Obtain blood sample by venipuncture. Observe venipuncture site for bleeding or hematoma formation. Inform patient that procedure does not require fasting

• Bone is primary organ for calcium storage. Calcium provides bone with rigid consistency.
• Decreased serum level is found in osteomalacia, renal disease and hypoparathyroidism.
• Increased level is found in hyperparathyroidism and some bone tumors

• NIC
• Obtain blood sample by venipuncture. Observe venipuncture site for bleeding or hematoma formation. Inform patient that procedure does not require fasting

• Amount present is indirectly related to calcium metabolism.
• Decreased level is found in osteomalacia.
• Increased level is found in chronic renal disease, healing fractures, osteolytic metastatic tumor

• NIC
• Obtain blood sample by venipuncture. Observe venipuncture site for bleeding or hematoma formation. Inform patient that procedure does not require fasting

Study assesses presence of auto-immune disorder

• Rest
• Ice
• Compression
• Elavation

Decreased bone mass

unknown

• - Menopause
• - Thin women
• - Sedentary lifestyle
• - Heredity

• - Dowager's Hump
• - pain is worse with activity and relieved with rest
• - Fractures

• - Multiple bone fractures from trivial trauma
• - X-Ray & Bone density tests

• - Estrogen
• - Calcium
• - Vita D
• - Fosamax
• - Weight bearing exercises

Indicated - treatment & prevention of postmenopausal osteoporosis, treatment of osteoporosis in men, treatment of Paget's disease, treatment of corticosteroid induced osteoporosis

Action - inhibits resorbtion of bone by inhibiting osteoclast activity

• Contraindicated - renal impairment
• Use caution in - pts. with GI pathology

S/E & A/R - Acid regurgitation

NIC - instruct pt. to remain upright for at least 30 minutes; instruct pt. on importance of taking early in morning with only water & avoid consumption of other liquids/foods for at least 30 minutes (the longer the better the absorption of Fosamax)

Reversible metabolic disease: defect in the mineralization of bone

Adult equivalent of rickets (Vitamin D deficiency)

• Primary - lack of sunlight
• Secondary - pathological malabsorption of small bowel (gastrectomy, Crohn's disease)

• - muscle weakness
• - bone pain
• - pain aggravated by activity & worse at night

• - X-ray (Looser's Zone)
• - Pseudo fractures

Vitamin D 400 iu

• Metabolic disorder or bone remodeling
• Increased resorption

• Active Phase - increase osteoclasts (bone cleaners)
• Mixed Phase - increase osteoblasts (bone builders)
• Inactive Phase - osteoblast > osteoclasts (more builders than cleaners)

• Unknown - questionable viral
• Most common area of involvement is vertebrae, femur, skull, sternum & pelvis

• - 80% asymptomatic
• - bone pain
• - skull soft, thick & enlarged
• Complication - osteogenic sarcoma (malignant bone tumor)

• Increased ALP and urinary hydroxyproline
• - 24 hour urine
• - X-ray

• - NSAIDS
• - Calcitonin
• - Didronel
• - Fosamax

Any infection of the bone

• Acute infection lasting less than 4 weeks - more often in children
• Chronic infection lasting more than 4 weeks
• Decreased blood flow to bone

• Bactetemia
• - Underlying disease: UTIs, IVs, drug users, sickle cell anemia, Staph aureus (usually minimal trauma)
• - Pseudomonas - Bone surgery

• - External otitis media
• - DM
• - peripheral vascular disease
• - surgery

• - Acute: fever >101, infected bone swells, bone pain, increase WBC
• - Chronic: ulceration, localized pain

• - ESR
• - CBC
• - Blood culture
• - Bone scan
• - MRI
• - Bone biopsy (definite Dx)

• - IV antibiotics
• - Hyperbaric oxygen
• - Bone graph
• - amputation

To control mild-moderate pain, fever and various inflammation conditions

NSAIDS have analgesic, antipyretic and anti-inflammatory properties

• Use cautiously in pts. with a history of bleeding disorders, GI bleeds and hepatic/renal/cardiovascular disease.
• Safe use in pregnancy is not established and should be avoided during 2nd half of pregnancy

- May cause prolonged PT

• - Acute pain
• - Risk for imbalanced body temperature
• - Deficient knowledge r/t disease process and medication regimen

• - Take with full glass of water and remain upright for 15-30 minutes to minimize gastric irratation
• - Avoid use of alcohol with NSAIDS
• - Avoid taking acetaminophen, salicylate or other NSAIDS concurrently for more than a few days

• Flexion of the wrist to assess for carpel tunnel
• Normal finding: NO PAIN

• Tappin on median nerve (in hand) to assess for carpel tunnel
• Normal finding: NO PAIN

• Milk the medial side of knee and then tap on the lateral side of patella
• Normal finding:

• Apply downward pressure above knee and push patella downward. It may appear to float or bounce back.
• Normal finding:

• Flex knee and rotate lower leg, listening for clicking and noting pt's tolerance.
• Used to evaluate torn miniscus (knee injury)

Used to detect flexion contractures of the hip

A metabolic bone disorder that is characterized by loss of bone mass, increased bone fragility and increased risk of bone fractures.

Women are more prone to osteoporosis

• - age (older age, higher risk)
• - female
• - race (European & Asian Americans higher risk)
• - genetics (family tendency)
• - endocrine (low levels of estrogen, hyperthyroidism, Cushing's & DM)

wrists, hips and vertebrae

• - Body weight (thin individuals are at a higher risk for osteoporosis)
• - Calcium and vitamin D intake (increasing calcium and vitamin D intake will decrease risk)
• - Estrogen levels (decrease in estrogen levels after menopause will increase risk for osteoporosis)
• - Smoking & Alcohol use (avoidance of these will decrease risk)
• - Long term use of steroids (will increase risk for osteoporosis)
• - Sedentary lifestyle (activities such as walking decrease risk)

• - loss of height
• - curvature of spine (Dowager's Hump)
• - spontaneous fractures (wrist, hip)

• - Get your daily recommended amounts of calcium and vitamin D
• - Engage in regular weight-bearing exercise
• - Avoid smoking and excessive alcohol
• - Talk to your healthcare provider about bone health
• - When appropriate, have a bone density test and take medication

• - bisphosphonates
• - calcitonin
• - estrogens
• - raloxifene

Anti-resorptive medications slow or stop the bone resorbing portion of the bone-remodeling cycle but do not slow the bone formation potion of cycle. As a result, new formation continues at a greater rate than bone resorption and bone density may increase over time.

Inhibits osteoclastic bone resorption & promotes renal excretion of calcium

Decreased rate of bone turnover. Lowering serum calcium levels.

rhinitits (intranasal), N&V, injetion site reaction (IM & SubQ), facial flushing, anaphylaxis

• - monitor serum calcium and phosphate levels
• - rotate sites
• - store in refrigerator ( nasal spray bottles in use maybe stored at room temp)
• - Advise pt to exercise

• - dizziness
• - malaise
• - dyspnea
• - PANCREATITIS

• Manifested as hypercalcemia, hypercalciuria and hyperphosphatemia
• Assess for early symtoms...
• - N&V
• - anorexia
• - weakness
• - constipation
• - HA
• - bone pain
• - metallic taste
• later symptoms include: polydipsia, polyuria, photophobia, rhinorrhea, pruritus & CARDIAC ARRHYTHIMIAS - notify HCP immediately if these S&S of toxicity occur!

Approved for treatment and prevention of osteoporosis.

Reduce bone lose, increase bone density and reduce risk of spine, wrist and hip fractures

• GI problems, abdominal or musculoskeletal pain, nausea & heartburn.
• If osteonecrosis of jaw or visual disturbances occur it should be reported to HCP a.s.a.p.

• - Administer on empty stomach, first thing in AM, with 8oz of water at least 30-60 minutes before eating or drinking
• - Advise pt. to remain upright for at least 30-60 minutes after medication administration

• - Excitability: ability to receive & respond to stimuli
• - Contractility: ability to shorten
• - Extensibility: ability to extend
• - Elasticity: ability to resume resting lenght

A break in the continuity of a bone

The skin remains intact

There is a break in the skin leading to an increase in the risk for infection

Involves the entire length of the bone

• 1- inflammatory process
• 2- granulation
• 3- callus
• 4- ossification
• 5- consolidation
• 6- remodeling

The first phase is an inflammatory process with bleeding which surrounds the ends of the fragments. The formation of a hematoma occurs in the first 72 hours

Granulation tissue forms during days 3-14 post injury. Active phagocytosis absorbs the products of local necrosis. The hematoma converts to granulation tissue which consists of new blood vessels, fibroblasts and osteoblasts (builders)

Callus formation begins the repair with cartilage, osteoblasts, calcium and phosphorus which is woven into the fracture

Ossification will occur in 3 weeks - 6 months and continues until the fracture is healed. The fracture is still visible on an x-ray.

During consolidation callus continues to develop and the distance between bone fragments diminishes and closes.

Remodeling can take up to a year. As expected, there are varying factors involved in these processes such as: age, activity, general health and medications. An x-ray will show evidence of complete bony union at this phase.

Infection and longer healing time

Preoperatively

swelling to go down; alignment; decreasing muscle spasm

• - Maintaining traction alignment
• - Pain management
• - Neurovascular checks to the extremity

• Peripheral vascular assessment:
• - color
• - temperature
• - capillary refill
• - peripheral pulses
• - edema
• Peripheral neurologic assessment:
• - sensation
• - motor function
• - pain

palms; making indentations; pressure

• - Atrophy
• - some sloughing of skin

abnormal; not expected

LIFE THREATENING EMERGENCY

peripheral circulation; pulmonary vascular beds

• Neuro changes:
• - change in LOC
• - restlessness
• - confusion
• - HA
• Respiratory changes:
• - dyspnea and/or cyanosis
• - petechiae (small, red dots) located on the skin, buccal membranes and conjunctival sacs

• - application of oxygen with possible intubation
• - notification of HCP
• - maintaining fluid balance
• - administration of steroids (if ordered)

* most patients survive if treated promptly

changes in mental & respiratory status

constipation; pain medication