Background of Anatomy and Physiology

1. Background of Anatomy and Physiology Human skeleton made up of 206 bones 1. Axial skeleton includes • a. Bones of skull • b. Ribs and sternum • c. Vertebral column 2. Appendicular skeleton includes • a. Bones of limbs • b. Shoulder girdles • c. Pelvic girdle

2. Classification of bones by shape

3. Functions of bones • 1. Form structure and provide support for soft tissues • 2. Protect vital organs from injury • 3. Serve to move body parts by providing points of attachment for muscles • 4. Store minerals • 5. Serve as site for hematopoiesis Bone cells include • 1. Osteoblasts: cells that form bone • 2. Osteocytes: cells that maintain bone matrix • 3. Osteoclasts: cells that resorb bone

4. Clients with Musculoskeletal Disorders Background • 1. Normal bone remodeling process involves sequence of bone reabsorption and formation • 2. Adults replace about 25% of trabecular bone (the porous type of bone found in the spine and all articulating joints) every 4 months through reabsorption of old bone by osteoclasts and formation of new bone by osteoblasts

5. Client with osteoporosis Definition • a. Disorder characterized by loss of bone mass, increased bone fragility, increased risk for fractures • b. Imbalance of processes that influence bone growth and maintenance; associated with aging, but may result from endocrine disorder or malignancy • c. Significant health threat for Americans: estimated 28 million persons; more common in aging women: half of women over 50 experience osteoporosis-related fracture in lifetime (hip, wrist, vertebrae)

6. Client with osteoporosis Risk Factors • a. Risk of developing osteoporosis depends on amount of bone mass achieved between ages 25 – 35 • b. Unmodifiable risk factors 1. Aging: decrease in osteoblastic and osteoclastic activity related to decreasing levels of hormones (estrogen in females; testosterone in males) 2. Gender: women have 10 – 15% less peak bone mass than men; bone loss begins earlier (30’s) and proceeds more rapidly (before menopause) 3. European Americans and Asians have less bone density than African Americans 4. Endocrine disorders affecting metabolism: hyperthyroidism, hyperparathyroidism, Cushing’s syndrome, diabetes mellitus

7. Client with osteoporosis Modifiable risk factors • 1. Calcium deficiency: insufficient calcium in diet results in body removing calcium from bones; diets high in protein lead to acidosis, and high in diet soda are high in phosphate • 2. Menopause, decreasing estrogen levels: estrogen replacement therapy can reverse bone changes but may increase risk for other diseases • 3. Cigarette smoking: decreased blood supply to bones • 4. Excessive alcohol intake: toxic effect on osteoblastic activity; high alcohol intake frequently associated with nutritional deficiencies • 5. Sedentary life style: weight-bearing exercise such as walking positively influences bone metabolism • 6. Use of specific medications: aluminum-containing antacids, corticosteroids, anticonvulsants, prolonged heparin therapy, antiretroviral

8. A normal spine at 40 years, and the osteoporotic changes at ages 60 and 70 years

9. Client with osteoporosis Pathophysiology • a. Diameter of bone increases, thinning outer supportive cortex • b. Trabeculae (spongy tissue) lost and outer cortex thins • c. Minimal stress leads to fracture 4. Manifestations (“silent disease”: bone loss occurs without symptoms) • a. Loss of height • b. Progressive curvature of spine (dorsal kyphosis, cervical lordosis, accounting for “dowager’s hump”) • c. Low back pain • d. Fractures of forearm, spine or hip

10. Client with osteoporosis Complications • a. Fractures (> 1.5 million fractures yearly), many spontaneous or resulting from everyday activities • b. Persistent pain and associated posture changes restrict client activities and ability to perform ADL 6. Collaborative Care • a. Stopping or slowing osteoporosis • b. Alleviating symptoms • c. Preventing complications

11. Client with osteoporosis Diagnostic Tests • a. Xrays: picture of skeletal structures but osteoporotic changes not seen until> 30% of bone mass lost • b. Quantitative computed tomography (QCT) of spine: measures trabecular bone within vertebral bodies • c. Dual-energy Xray absorptiometry (DEXA): measures bone density in lumbar spine or hip; highly accurate • d. Alkaline phosphatase (AST): elevated post fracture • e. Serum bone Gla-protein (osteocalcin) marker of osteoclastic activity and is indicator of rate of bone turnover; used to evaluate effects of treatment

12. Client with osteoporosis Medications a. Estrogen replacement therapy reduces bone loss, increases bone density in spine and hip, reducing risk of fractures in postmenopausal women. • 1. Recommended for women who have undergone surgical menopause before age 50 • 2. Associated risk for estrogen therapy alone is increased risk of endometrial cancer • 3. Hormone replacement therapy (estrogen and progestin) associated with increased risk for cardiovascular disease and breast cancer b. Raloxifene (Evista): selective estrogen receptor modulator (SERM) that prevents bone loss by mimicking estrogen effects on bone density; side effects are hot flashes; contraindicated for women with history of blood clots c. Biphosphonates: potent inhibitors of bone resorption used to prevent and treat osteoporosis • 1.Alendronate (Fosamax) • 2.Risedronate (Actonel) • 3.Etidronate (Didronel) d. Calcitonin (Miacalcin): hormone increases bone formation and decreases bone resorption; available as nasal spray or parenteral e. Sodium fluoride: stimulates osteoblast activity, decreases risk of spinal fractures but associated with increased risk of other fractures including hip

13. Client with osteoporosis Nursing Care • a. Emphasis is prevention and education of clients under age of 35 • b. Prevention of complications in those with osteoporosis Health Promotion a. Calcium intake 1. Maintain daily intake of calcium at recommended levels, in divided doses • a. Age 19 – 50: 1000mg • b. Age 51-64: 1200 mg • c. Age 65 and >: 1500 mg) 2. Optimal intake before age 30 – 35 increases peak bone mass 3. Foods high in calcium include milk, milk products, salmon, sardines, clams, oysters, dark green leafy vegetables 4. Supplementation:calcium carbonate (Tums); calcium combined with Vitamin D for older adults

14. Client with osteoporosis Exercise • 1. Physical activity that is weight-bearing • 2. Walking 20 minutes, 4 or > times per week Health-related behaviors • 1. Include not smoking • 2. Avoid excessive alcohol • 3. Limit caffeine to 2 – 3 cups of coffee daily • 4. Limit diet soda

15. Client with osteoporosis Nursing Diagnoses • a. Health Seeking Behaviors • b. Risk for Injury • c. Imbalanced Nutrition: Less than body requirements • d. Acute Pain Home Care: Focus is on education including safety and fall prevention inside and outside the home

16. Client with Paget’s Disease (osteitis deformans) Description • a. Progressive skeletal disorder with excessive metabolic bone activity leading to affected bones becoming larger and softer • b. Affects femur, pelvis, vertebrae, sacrum, sternum, skull • c. Relatively rare • d. Occurs more often in whites • e. Slightly more common in males • f. Familial tendency

17. Client with Paget’s Disease (osteitis deformans) Pathophysiology a. Bones are initially soft and bowing occurs; then become hard and brittle leading to fractures b. Slow progression with 2-stage process • 1. Excessive osteoclastic bone resorption • 2. Excessive osteoblasticbone formation

18. Client with Paget’s Disease (osteitis deformans) Manifestations • a. Most are asymptomatic • b. Localized pain of long bones, spine, pelvis, cranium; pain is mild to moderate deep ache which is aggravated by pressure and weight-bearing noticed at night and when resting • c. Flushing and warmth over areas of bone involvement

19. Client with Paget’s Disease (osteitis deformans) Complications • a. Degenerative osteoarthritis • b. Pathological fractures • c. Nerve palsy syndromes from involvement of upper extremities • d. Compression of spinal cord causing tetraplegia • e. Mental deterioration from skull involvement and brain compression

20. Client with Paget’s Disease (osteitis deformans) Collaborative Care • a. Pain relief • b. Suppression of bone cell activity • c. Complication prevention Diagnostic Test • a. Xray (often incidental) slow localized areas of demineralization in early phase; later enlargement of bones with tiny cracks in long bones or bowing in weight-bearing bones • b. Bone scan: active Paget’s disease

21. Client with Paget’s Disease (osteitis deformans) • c. CT scans and MRI: show degenerative problems, spinal stenosis, nerve root impingement • d. Serum alkaline phosphatase: steady rise as disease progresses • e. Urinary collagen pyridinoline testing: indicator of rate of bone resorption

22. Client with Paget’s Disease (osteitis deformans) Medications • a. Mild symptoms relieved by aspirin or NSAIDs • b. Bone resorption retarded by 1. Biphosphonates: calcium supplements are prescribed in addition • a. Alendronate (Fosamax) • b. Pamidronate (Aredia) • c. Tiludronate (Skelid) 2. Calcitonic: works as analgesic for bone pain • a. Salmon calcitonin (Calcimar) • b. Human calcitonin (Cibacalcin)

23. Client with Paget’s Disease (osteitis deformans) Surgery • a. Total hip or knee replacement is usually required when client with Paget’s disease develops degenerative arthritis of hip or knee • b. May require surgery for spinal stenosis, nerve root compression Nursing Diagnoses • a. Chronic Pain • 1. May involve wearing a back brace for relief of back pain • 2. Heat therapy and massage • b. Impaired Physical Mobility Home Care: manifestations often relieved by treatment

24. Client with osteomalacia (adult rickets) Metabolic bone disorder characterized by inadequate or delayed mineralization of bone matrix leading to marked deformities of weight bearing bone and pathologic fractures Pathophysiology • a. Primary causes are vitamin D deficiency and hypophosphatemia • 1. Vitamin D deficiency a. Present in • 1. Older adults • 2. Very-low-birth weight infants • 3. Strict vegetarians b. Caused by • 1. Diet low in vitamin D • 2. Impaired intestinal absorption of fats • 3. Inadequate sun exposure • 4. Some types of renal failure • 2. Hypophosphatemia: most commonly caused by alcohol abuse

25. Process of vitamin D metabolism in the body

26. Client with osteomalacia (adult rickets) Other causes 1. Insufficient calcium absorption in intestines, due to lack of calcium or resistance to action of Vitamin D 2. Increase loss of phosphorus through urine Manifestations • a. Bone pain and tenderness • b. Common fractures are distal radius and proximal femur Collaborative Care: requires differential diagnosis from osteoporosis

27. Client with osteomalacia (adult rickets) Diagnostic Tests • a. Xray demonstrates generalized bone demineralization • b. Serum calcium levels are normal or low • c. Serum parathyroid hormone is frequently elevated as compensatory response • d. Alkaline phosphatase level usually elevated

28. Client with osteomalacia (adult rickets) Medications • a. Treatment of underlying condition • b. Vitamin D therapy with calcium and phosphate supplements • c. Radiologic evidence of healing apparent within weeks of therapy

29. Client with osteomalacia (adult rickets) Nursing Care • a. Assessment of dietary intake of Vitamin D, calcium, phosphorus, exposure to ultraviolet light • b. Management of client responses to bone pain and tenderness, fractures, muscle weakness • c. Vitamin D sources include dairy products fortified with Vitamin D and cod liver oil • d. If client takes supplements, must be aware of potential for toxicity with fat soluble vitamins • e. Fall prevention

30. Client with osteomyelitis 1. Infection of the bone, may occur as acute, subacute, or chronic 2. Consequence of bacteremia, invasion from contiguous focus of infection, skin breakdown; more prevalent in adults over age of 50 3. Pathophysiology a. Usually bacterial in nature: most commonly Staphylococcus aureus b. Sources of infection • 1. Direct contamination of bone from open wounds (trauma) • 2. Complication of surgery • 3. Extension of chronic ulcers including venous, arterial, diabetic c. Infection develops in bone, which may interfere with vascular supply to bone, and necrosis occurs; difficult for antibiotics to reach the bacteria within the bone

31. Osteomyellitis Osteomyellitis

32. Client with osteomyelitis Collaborative Care • a. Pain relief • b. Infection elimination or prevention • c. Early diagnosis to prevent bone necrosis by early antibiotic therapy • d. Often requires bone debridement and long course of antibiotics

33. Client with osteomyelitis Diagnostic Tests • a. MRI and CT scans: show abscesses and soft tissue changes • b. Radionucleotides bone scans: determine whether infectious or inflammatory changes in bone • c. CBC and ESR: WBC and ESR are elevated • d. Blood and tissue cultures: identify infectious organism and determine appropriate antibiotic therapy

34. Client with osteomyelitis Medications • a. Antibiotics mandatory to prevent acute case from becoming chronic osteomyelitis • b. Initially treated as staph infection until results of culture are obtained • c. Definitive antibiotics prescribed according to culture results • d. Continued at least 4 – 6 weeks with intravenous or oral antibiotics

35. Client with osteomyelitis Surgery • a. Needle aspiration or percutaneous needle biopsy performed to obtain specimen; specimen may also be obtained during debridement procedure • b. Surgical debridement is primary treatment for chronic cases: wound is opened, irrigated; drainage tubes may be inserted for irrigation, suction, and antibiotic instillation

36. Client with osteomyelitis Nursing Care • a. Persons with chronic osteomyelitis face frequent and lengthy treatments • b. Client needs to be aware of manifestations of recurrent infection (inflammation in area, temperature elevation) • c. Prognosis is uncertain and client must be maintained under care to prevent amputation or functional deficits

37. Client with osteomyelitis Nursing Diagnoses • a. Risk for Infection • b. Hyperthermia: interventions include maintenance of adequate fluid intake • c. Acute Pain: splinting or use of immobilizer may limit swelling and improve pain • d. Anxiety Home Care • a. Often vital part of treatment of osteomyelitis • b. Referral to home care agency for support with wound treatment, antibiotic administration, obtaining supplies, nutritional teaching

38. Neoplastic Disorders: Bone Tumors Description 1. Tumors may be malignant or benign • a. Benign tumors grow slowly and do not invade surrounding tissues • b. Malignant tumors grow rapidly and metastasize 2. Tumors can be primary (rare) or metastatic lesions originating from primary tumors of prostate, breast, kidney, thyroid, lung

39. Neoplastic Disorders: Bone Tumors Pathophysiology • 1. Cause unknown, but connection exists between bone activity and development of primary bone tumors • 2. Primary tumors cause osteolysis, bone breakdown, which weakens bone and leads to bone fractures • 3. Malignant bone tumors invade and destroy adjacent bone tissue

40. Neoplastic Disorders: Bone Tumors Manifestations: often history of fall or blow to extremity brings mass to attention • 1. Pain • 2. Mass • 3. Impaired function

41. Neoplastic Disorders: Bone Tumors Diagnostic Tests • 1. Xray: shows location of tumors and extent of bone involvement • a. Benign tumors show sharp margins separating from normal bones • b. Metastatic bone destruction: characteristic “moth-eaten” pattern • 2. CT scan: evaluation of extent of tumor invasion into bone, soft tissues, neurovascular structures • 3. MRI: determine extent of tumor invasion, response of bone tumors to radiation and chemotherapy, recurrent disease • 4. Needle biopsy to determine exact type of bone tumor • 5. Serum alkaline phosphatase: elevated with malignant bone tumors • 6. RBC count elevation • 7. Serum calcium: elevated with massive bone destruction

42. Neoplastic Disorders: Bone Tumors Treatments • 1. Chemotherapy • a. Used to shrink tumor before surgery • b. Control reoccurrence • c. Treat metastasis • 2. Radiation • a. Often combined with chemotherapy • b. Used for pain control with metastatic carcinomas • c. Eliminate tumor remains after surgery • 3. Surgery • a. Eliminate primary bone tumors to eliminate tumors completely; may involve excise tumor or amputate affected limb • b. With some surgeries, cadaver allografts or metal prostheses used to replace missing bone to avoid amputation

43. Neoplastic Disorders: Bone Tumors Nursing Diagnoses • 1. Risk for Injury (pathologic fractures) • 2. Acute and Chronic Pain • 3. Impaired Physical Mobility • 4. Decisional Conflict: assist client in gaining information for informed decisions regarding treatment options Home Care • 1. Client education regarding treatment plan, wound care, activity and weight bearing restrictions • 2. Support with referral to prosthetic specialist or hospice as case indicates

44. Client with a Fracture Fracture: any break in continuity of bone 1. Occurs when bone is subjected to more kinetic energy than the bone can absorb 2. Mechanisms producing fracture • a. Direct: energy applied at or near site of fracture • b. Indirect: transmitted from point of impact to site where bone is weaker

45. Client with a Fracture Classifications of fractures a. Simple (closed) skin intact over fracture or compound (open) where skin is interrupted over injury and there is increased risk for infection b. Fracture line may be • 1. Oblique: at 45o angle to bone • 2. Spiral: curves around the bone • 3. Avulsed: occurs when fracture pulls bone and other tissues away from point of attachment • 4. Comminuted: bone breaks in many small pieces • 5. Compressed: bone is crushed • 6. Impacted: broken bone ends are forced into each other • 7. Depressed: broken bone is forced inward

46. Common types of fractures

47. Open fracture

48. Closed fracture

49. Client with a Fracture • c. Complete fracture involves entire width of bone; incomplete fracture does not involve the entire width of bone • d. Stable (nondisplaced) fracture is fracture in which bones maintain their anatomic alignment; unstable (displaced) fracture: fracture in which bones move out of correct anatomic alignment • e. Description according to point of reference i.e. midshaft, intrarticular

50. Client with a Fracture Manifestations • a. May be accompanied by soft tissue injuries involving muscles, arteries, veins, nerves, skin • b. May be alteration in circulation, sensation, swelling, pain • c. May be obvious deformity or fracture • d. May have felt the breakage of bone during the injury event