Musculoskeletal Disorders Part I

Degenerative & Metabolic bone disordersDegenerative & Metabolic bone disorders

Maria Carmela L. Domocmat, RN,MSNInstructorSchool of NursingNorthern Luzon Adventist College Artacho, Sison, Pangasinan

Overview

• Part 1: Degenerative & Metabolic bone disorders▫ OA

▫ Gout and gouty arthritis

▫ Osteoporosis

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▫ Osteoporosis

▫ Paget’s dse

▫ Osteomalacia

• Part 2: Bone infections• Part 3: Muscular disorders • Part 4: Disorders of the hand• Part 5: Spinal column deformities• Part 6 : Disorders of foot • Part 7: Sports Injuries

Osteoporosis

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Osteoporosis 3/5/2012Maria Carmela L.

Domocmat, RN, MSN

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SkeletonThe skeleton consists of groups of bones which protect and move the body.

Osteoporosis risk factors mnemonic

• ACCESS:

▫ Alcohol

▫ Corticosteroid▫ Corticosteroid

▫ Calcium low

▫ Estrogen low

▫ Smoking

▫ Sedentary lifestyle

http://www.myphysio.ca/site_assets/www.myphysio.ca/images/dynamic/osteoporosis.jpg

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http://healthinfo.fitnessguide101.com/wp-content/uploads/2010/10/Boneloss.jpg

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http://images.emedicinehealth.com/images/SlideShow/Osteoporosis_s1_bone_density.jpg

Osteoporosis Symptoms: Stress FractureA fracture that occurs during the course of normal activity is called a minimal trauma fracture or stress fracture. For example, some patients with osteoporosis develop stress fractures of the feet while walking or stepping off a curb.

Osteoporosis Symptoms: Hip FractureHip fractures typically occur as a result of a fall. With osteoporosis, hip fractures can occur as a result of trivial accidents. Hip trivial accidents. Hip fractures may also be difficult to heal after surgical repair because of poor bone quality

Orthotics (thoracolumbosacral

orthosis) • decrease flexion

forces

• prevent worsening

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• prevent worsening of kyphosis

• reduce pressure on fracture sites

Osteomalacia

• Osteomalacia means "soft bones".

• is softening of the bones due to a lack of vitamin D or a problem with the body's ability to break D or a problem with the body's ability to break down and use this vitamin.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

Osteomalacia

• characterized by incomplete mineralization of normal osteoid tissue following closure of the growth plates. growth plates.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

• Osteoid▫ bone protein matrix, composed primarily of type 1 collagen. ▫ When there is insufficient mineral or osteoblast

dysfunction, the osteoid does not mineralize properly, and it accumulates.dysfunction, the osteoid does not mineralize properly, and it accumulates.

• When the newly formed bone of the growth plate does not mineralize, the growth plate becomes thick, wide and irregular. This results in the clinical diagnosis of rickets, and is seen only in children because adults no longer have growth plates. When the remodeled bone does not mineralize, osteomalacia occurs, and this happens in all ages. Most of the hereditary causes of osteomalacia appear during childhood and cause rickets.

http://courses.washington.edu/bonephys/hypercalU/opmal2.html

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http://www.moondragon.org/health/graphics/osteomalaciaadult.jpg

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Looser’s zone

• xray showing a pseudofracture(red arrow) from an adult who has x-linked hypophosphatemic rickets.

• This is an xray of a child with bowed legs due to rickets

hypophosphatemic rickets.

• This is a classic pseudofractureand is pathognomonic for osteomalacia.

Treatment

• vitamin D, calcium, and phosphorus supplements, taken by mouth.

• Larger doses of vitamin D and calcium may be • Larger doses of vitamin D and calcium may be needed for people who cannot properly absorb nutrients into the intestines.

• Regular blood tests may be needed to monitor blood levels of phosphorus and calcium in persons with certain underlying conditions.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

Recommended Dietary Allowances

(RDAs) for Vitamin D

Age Male Female Pregnancy Lactation

0–12 months*400 IU

(10 mcg)400 IU

(10 mcg)

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http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

(10 mcg) (10 mcg)

1–13 years600 IU

(15 mcg)600 IU

(15 mcg)

14–18 years600 IU

(15 mcg)600 IU

(15 mcg)600 IU

(15 mcg)600 IU

(15 mcg)

19–50 years600 IU

(15 mcg)600 IU

(15 mcg)600 IU

(15 mcg)600 IU

(15 mcg)

51–70 years600 IU

(15 mcg)600 IU

(15 mcg)

>70 years800 IU

(20 mcg)800 IU

(20 mcg)

Tolerable Upper Intake Levels (ULs) for

Vitamin D

Age Male Female PregnancyLactation

0–6 months1,000 IU 1,000 IU

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0–6 months1,000 IU(25 mcg)

1,000 IU(25 mcg)

7–12 months1,500 IU(38 mcg)

1,500 IU(38 mcg)

1–3 years2,500 IU(63 mcg)

2,500 IU(63 mcg)

4–8 years3,000 IU(75 mcg)

3,000 IU(75 mcg)

≥9 years 4,000 IU

(100 mcg)4,000 IU

(100 mcg)4,000 IU

(100 mcg)4,000 IU

(100 mcg)

Selected Food Sources of Vitamin DFood

IUs per serving*

Percent DV**

Cod liver oil, 1 tablespoon 1,360 340

Swordfish, cooked, 3 ounces 566 142

Salmon (sockeye), cooked, 3 ounces 447 112

Tuna fish, canned in water, drained, 3 ounces 154 39

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http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

Tuna fish, canned in water, drained, 3 ounces 154 39

Orange juice fortified with vitamin D, 1 cup (check product labels, as amount of added vitamin D varies)

137 34

Milk, nonfat, reduced fat, and whole, vitamin D-fortified, 1 cup 115-124 29-31

Yogurt, fortified with 20% of the DV for vitamin D, 6 ounces (more heavily fortified yogurts provide more of the DV)

80 20

Margarine, fortified, 1 tablespoon 60 15

Sardines, canned in oil, drained, 2 sardines 46 12

Liver, beef, cooked, 3 ounces 42 11

Egg, 1 large (vitamin D is found in yolk) 41 10

Ready-to-eat cereal, fortified with 10% of the DV for vitamin D, 0.75-1 cup (more heavily fortified cereals might provide more of the DV)

40 10

Cheese, Swiss, 1 ounce 6 2

Expectations (prognosis)

• Improvement can be seen within a few weeks in some people with vitamin deficiency disorders. Complete healing with treatment takes place in 6 Complete healing with treatment takes place in 6 months.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

Prevention

• diet rich in vitamin D

• get plenty of sunlight

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

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Paget's disease

• AKA: Osteitis deformans

• is a disorder that involves abnormal bone destruction and regrowth, which results in destruction and regrowth, which results in deformity.

• there is an abnormal breakdown of bone tissue, followed by abnormal bone formation. The new bone is bigger, but weakened and filled with new blood vessels.

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Paget’s disease

• Sir James Paget first described chronic inflammation of bone as osteitis deformans in 1877. 1877.

• Paget disease, as the condition came to be known,

• second most common bone disorder (after osteoporosis) in elderly persons.

Paget’s Disease (Osteitis Deformans)

• Excess of bone destruction & unorganized bone formation and repair.

• 2nd most common bone disorder in the U.S.• 2nd most common bone disorder in the U.S.

• etiology is unknown

s/s

• Usually affects the axial skeleton, vertebrae and skull, although the pelvis, tibia, femur are the other common sites of disease.other common sites of disease.

Symptoms

• Most persons are asymptomatic & diagnosis is incidental.

• Old Hat don’t fit anymore! • Old Hat don’t fit anymore! ▫ hat gets tighter▫ head diameter becomes larger

• pathologic fractures• congestive heart failure• hearing loss• dysesthesias and weakness due to nerve-root

compression.

Symptoms

• Bone pain (may be severe and persistent)• Bowing of the legs and other visible deformities• Enlarged head• Fracture• Fracture• Headache• Hearing loss• Joint pain or stiffness• Neck pain• Reduced height• Skull deformities• Warmth of skin over the affected bone• Note: Most patients have no symptoms.

S/s

• Vascularity is increased in affected portions of the skeleton. ▫ Lesions may occur in one or more bones, does not ▫ Lesions may occur in one or more bones, does not

spread from bone to bone.

• Deformities & bony enlargement often occur. ▫ Bowing of the limbs & spinal curvature in persons

with advanced disease.

S/s

• Bone pain- is the most common symptom. ▫ usually worse with ambulation or activity but may

also occur at rest. ▫ Involved bones may feel spongy & warm because

of increased vascularity.▫ Skull pain is usually accompanied with headache,

warmth, tenderness & enlargement of the head.

Dx

• Bone scan

• Bone x-ray

• Elevated markers of bone breakdown (for • Elevated markers of bone breakdown (for instance, N-telopeptide)

• Elevated serum alkaline phosphatase

• This disease may also affect the results of the following tests:

• ALP (alkaline phosphatase) isoenzyme

• Serum calcium

Dx

• Pathologic fractures- because of the increased vascularity of the involved bone-bleeding is a potential danger.potential danger.

• Alkaline phosphatase levels- markedly elevated as the result of osteoblast activity.

Dx

• Serum calcium are normal except with generalized disease or immobilization.

• Gout and hyperurecemia may develop as a result • Gout and hyperurecemia may develop as a result of increased bone activity, which causes an increase in nucleic acid catabolism.

Dx

• Radiograph reveals radiolucent areas in the bone, typical of increased bone resorption. Deformities & fractures may also be present.Deformities & fractures may also be present.

Management

• Not all patients need treatment. ▫ For example, patients who have abnormal blood

tests only may not need treatment.

• People with Paget's disease who are commonly treated include:

• Patients with deformities▫ Patients with no symptoms when certain bones

(such as weight-bearing bones) are involved, especially if the bony changes are progressing quickly, to reduce the risk of fractures

Management

• Patients with symptoms• Bisphosphonates

▫ Alendronate (Fosamax)▫ Etidronate (Didronel)▫ Pamidronate (Aredia)▫ Etidronate (Didronel)▫ Pamidronate (Aredia)▫ Risedronate (Actonel)▫ Tiludronate (Skelid)▫ Zoledronic acid (Zometa)

• Calcitonin▫ Intranasal (Miacalcin)▫ Subcutaneous (Calcimar)

• Plicamycin (Mithracin)• Analgesics or nonsteroidal anti-inflammatory medications

(NSAIDs)

Management

• Goals of the treatment- to relieve pain & prevent fracture & deformities.

▫ Pharmacologic agents are used to suppress ▫ Pharmacologic agents are used to suppress osteoclastic activity. Bisphosphonates & calcitonin are effective agents to decrease bone pain & bone warmth & also relieve neural decompression, joint pain & lytic lesions.

▫ Use of analgesics & NSAIDs. Assistive devices, including cane, walker.

Management

• Deformities may be corrected by surgical intervention (osteotomy).

• ORIF may be necessary for fractures.• ORIF may be necessary for fractures.

• The patient may benefit from a PT referral.

• Local application of ice or heat may help alleviate pain.

Management

• A regular exercise should be maintained; walking is best. Avoid extended periods of immobility to avoid hypercalcemia.immobility to avoid hypercalcemia.

• A nutritionally adequate diet is recommended. Assistance in learning to use canes or other ambulatory aids.

• The Arthritis Foundation & Paget Foundation are useful resources for patients & their families.

Treatment

• Patients with symptoms▫ Drug therapy helps prevent further bone breakdown.

Currently, there are several classes of medications used to treat Paget's disease. These include:

Bisphosphonates -- the first-line treatment; help increase bone � Bisphosphonates -- the first-line treatment; help increase bone density.

� Calcitonin – hormone involved in bone metabolism. � Plicamycin (Mithracin)� Analgesics or nonsteroidal anti-inflammatory medications

(NSAIDs) - for pain.

• Localized Paget's disease needs no treatment, if there are no symptoms and no evidence of active disease.

• Orthopedic surgery may be needed to correct a deformity in severe cases.

Outlook (Prognosis)

• Disease activity and symptoms can generally be controlled with current medications.

• A small percentage of patients may develop a • A small percentage of patients may develop a cancer of the bone called osteosarcoma.

• Some patients will need joint replacement surgery.

Possible Complications

• Bone fractures

• Deafness

• Deformities• Deformities

• Heart failure

• Paraplegia

• Spinal stenosis

http://orthoinfo.aaos.org/topic.cfm?topic=A00076

Left, Paget's disease of the spine. The white, patchy appearance of the bone on this X-ray is characteristic of the dense but disordered bone in this disease. Right, Paget's disease of the pelvis. The bone is thick, wide, and patchy.

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