CHAPTER 50 Care of Patients with Musculoskeletal Problems

Considerations for Older Adults: Osteomyelitis

Malignant external otitis media involving the base of the skull is sometimes seen in older adults with diabetes. The most common cause of contiguous spread in older adults, however, is found in those who have slow-healing foot ulcers. Multiple organisms tend to be responsible for the resulting osteomyelitis

Dupuytren's Contracture: Disorder of the Hand

Dupuytren's contracture, or deformity, is a slowly progressive thickening of the palmar fascia, resulting in flexion contracture of the fourth (ring) and fifth (little) fingers of the hand. The third or middle finger is occasionally affected. Usually occurs in older Euro-American men, tends to occur in families, and can be bilateral. When function becomes impaired, surgical release is required. A partial or selective fasciectomy (cutting of fascia) is performed. After removal of the surgical dressing, a splint may be used. Nursing care is similar to that for the patient with carpal tunnel repair.

Drug Therapy: Osteoporosis

Drug therapy is used when the BMD T-score for the hip is below −2.0 with no other risk factors or when the T-score is below −1.5 with one or more risk factors or previous fracture. Provider may prescribe calcium and vitamin D3 supplements, bisphosphonates, or estrogen agonist/antagonists (formerly called selective estrogen receptor modulators) or a combination. Estrogen and combination hormone therapy are not used solely for osteoporosis prevention or management because they can increase other health risks such as breast cancer and myocardial infarction.

Home Care Management: Bone Cancer

Evaluate the patient's home environment for structural barriers that may hinder mobility. The patient may be discharged with a cast, walker, crutches, or a wheelchair. Assess the patient's support system. Accessibility to eating and toileting facilities is essential to promote ADL independence. The patient with metastatic disease is susceptible to pathologic fractures, remove hazards.

Key Points: Psychosocial Integrity

• Assess the patient's and family's responses to a diagnosis of bone cancer and treatment options. Be aware that they will progress through the grieving process.

Key Points: Safe and Effective Care Environment

• Coordinate with health care team members when assessing patients with osteoporosis for risk for falls. • In coordination with the physical and occupational therapists, educate the patient and family on home safety when the patient has a metabolic bone disease, such as osteoporosis.

Other Interventions: Paget's Disease of the Bone

Include application of heat and gentle massage. An exercise program may be started. Non-impact exercise should be used, but the patient may benefit from strengthening and weight-bearing exercises. Teach the patient about ROM and gentle stretching. Additional interventions for pain relief, such as relaxation techniques. Diet rich in calcium and vitamin D.

Chart 50-2 Common Examples of Drug Therapy Osteoporosis

PG 1034 IGGY

TABLE 50-2 Differential Features of Osteoporosis and Osteomalacia

PG 1036 IGGY

Radiation Therapy: Bone Cancer

Radiation, either brachytherapy or external radiation, is used for selected types. With Ewing's sarcoma and early osteosarcoma, radiation may be the treatment of choice in reducing tumor size and thus pain. For patients with metastatic disease, radiation is given primarily for palliation. The therapy is directed toward the painful sites to provide a more comfortable life.

Key Points: Physiological Integrity

• Remind patients taking bisphosphonates (BPs) to take them early in the morning, at least 30 to 60 minutes before breakfast, with a full glass of water and to remain sitting upright during that time to prevent esophagitis, a common complication of BP therapy. • Most patients are unaware that they have osteoporosis until they experience a fracture, the most common complication of the disease. • Osteomalacia, the result of a deficiency in vitamin D, can be caused by the factors listed in Table 50-3. • Priority care for patients with osteomyelitis is to treat the infection and maintain Contact Precautions for open wounds. For patients having surgical intervention, assess the affected extremity for neurovascular status to ensure adequate tissue perfusion. • For patients who have surgery for bone cancer, report postoperative manifestations of infection, dislocation, or neurovascular compromise to the surgeon promptly. • Assess for key features of Paget's disease as summarized in Chart 50-3. • Remember that bone tumors can be benign or malignant. • Remember that severe chronic pain is a priority for patients with metastatic bone disease. • Be aware that even minor hand and foot problems can be very painful. Common foot problems are described in Table 50-4. • In collaboration with the health care team (physical therapist, occupational therapist, neurologist), provide supportive care for patients with muscular dystrophy and bone cancer. • Recognize that most major types of muscular dystrophy are genetic and manifest usually in childhood. Care is supportive. • Foot disorders can be treated with custom-made shoes or surgery to repair deformities. Recall that foot disorders are painful, and a plan for pain management is essential.tial.

What might you NOTICE if the patient has impaired mobility as a result of chronic musculoskeletal disorders?

• Spinal deformity (e.g., kyphosis, lateral deviation) • Bone malalignment (e.g., leg bowing) • Muscle weakness • Bone swelling or deformity • Fracture • Joint inflammation • Flushed skin (Paget's disease) • Fever (bone infection) • Report of pain • Report of weight loss

Key Points: Health Promotion and Maintenance

• Teach patients at risk for osteoporosis to minimize risk factors, such as stopping smoking, decreasing alcohol intake, exercising regularly, and increasing dietary calcium. • Remind patients at risk for osteoporosis to have regular screening tests, such as the DXA scan. • Instruct older adults to have at least 5 minutes of sun per day and to eat vitamin D-fortified foods to prevent osteomalacia. • Assess the genetic risk for patients who have parents with muscular dystrophy, and refer them for genetic testing and counseling if the patient desires.

Ganglion: Disorder of the Hand

A ganglion is a round, benign cyst, often found on a wrist or foot joint or tendon. The synovium surrounding the tendon degenerates, allowing the tendon sheath tissue to become weak and distended. Ganglia are painless on palpation, but they can cause joint discomfort after prolonged joint use or minor trauma or strain. The lesion can rapidly disappear and then recur. Likely to appear 15-50 years of age. With local or regional anesthesia, the fluid within the cyst can be aspirated through a small needle. A cortisone injection may follow. If the cyst is very large, it is removed using a small incision. Patients should avoid strenuous activity for 48 hours after surgery and report any signs of inflammation.

Laboratory Assessment: Osteoporosis

A number of biochemical markers can provide information about bone resorption and formation activity. Bone-specific alkaline phosphatase (BSAP) is found in the cell membrane of the osteoblast and indicates bone formation status. Osteocalcin is a protein substance in bone and increases during bone resorption activity. Pyridinium (PYD) cross-links are released into circulation during bone resorption. N-telopeptide (NTX) and C-telopeptide (CTX) are proteins released when bone is broken down. Some laboratories require a 24-hour urine collection for testing, whereas others use a double-voided specimen. Some markers, like NTX and CTX, can also be measured in the blood using immunoassay techniques. Increased levels of any of these markers indicate a risk for osteoporosis. Increased levels are found in patients with osteoporosis, Paget's disease, and bone tumors. Serum calcium and vitamin D3 levels should be routinely monitored (at least once a year) for all women and men older than 50 years. Measurements of serum calcium, vitamin D, and phosphorus. Urinary calcium levels may also be assessed.

Postoperative Care: Bone Cancer

A pressure dressing with wound suction is typically maintained for several days. The patient who has undergone a limb salvage procedure has some degree of impaired physical mobility and a self-care deficit. The patient can engage in active-assistive exercises by using the unaffected hand to help achieve motions such as forward flexion and abduction of the shoulder. Continuous passive motion (CPM) using a CPM machine may be initiated. After lower extremity surgery, the emphasis is on strengthening the quadriceps muscles by using passive and active motion. Maintaining muscle tone is an important prerequisite to weight bearing, which progresses from toe touch or partial weight bearing to full weight bearing by 3 mo. Abone graft may have a cast or other supportive device for several months. Weight bearing is prohibited until there is evidence that the graft is incorporated. Assist ADLs if needed, but at the same time encourage the patient to do as much as possible unaided. Some patients need assistive/adaptive devices. Assess the neurovascular status of the affected extremity and hand or foot every 1 to 2 hours immediately after surgery. Splinting or casting of the limb may also cause neurovascular (NV) compromise.

Chart 50-4 Key Features Acute and Chronic Osteomyelitis

Acute Osteomyelitis: • Fever; temperature usually above 101° F (38.3° C) • Swelling around the affected area • Erythema of the affected area • Tenderness of the affected area • Bone pain that is constant, localized, and pulsating; intensifies with movement Chronic Osteomyelitis: • Foot ulcer(s) (most commonly) • Sinus tract formation • Localized pain • Drainage from the affected area

Interventions: Scoliosis

Adults with less than 50 degrees of curvature of the spine may be treated conservatively with moist heat, pain medication, and exercise. Those with greater than 50 degrees of curvature may 1048require surgical intervention to prevent shortness of breath and fatigue, osteoarthritis, and severe back pain. Open surgical reconstructive procedure consists of surgical fusion and insertion of instrumentation, including plates, screws, or rods to stabilize the spine. The surgeon performs spinal fusion by packing cancellous bone chips, usually from the iliac crest, between the affected vertebrae for support and stabilization. Metal instrumentation supports the spine and immobilizes the fused area. For anterior thoracic surgery, a chest tube is in place for about 72 hours; for anterior abdominal surgery, the patient has a nasogastric tube for 24 hours. Other nursing care is similar to that for the patient undergoing a laminectomy or spinal fusion, including teaching the patient how to log roll, keeping the body in alignment. The traditional surgery for treating scoliosis has a high percentage of complications and results in major scarring. Teach patients and their families about home care, including how to care for the wound; body mechanics to prevent bending, twisting, and lifting; and how to adapt to achieve ADLs independently.

Critical Rescue

After surgery to treat osteomyelitis, frequently check for signs of neurovascular compromise, including the six Ps: pain that cannot be controlled, pressure, paresis or paralysis (weakness or inability to move), paresthesia (abnormal, tingling sensation), pallor, and pulselessness. If any of these findings occur, report them immediately to the surgeon.

Assessment: Osteomalacia

Age, ability to be exposed to sunlight, and skin pigmentation. The older adult who has been homebound or chronically institutionalized is at the greatest risk. People who have dark skin and who may consume minimal protein are more at risk than light-skinned people with the same diet. Dark-skinned people may avoid the sun and need protein for calcium binding. History of chronic disease processes of the GI tract including inflammatory bowel disease, gastric or intestinal bypass surgery, or any problem that interferes with absorption from the GI tract. A history of renal or liver dysfunction may lead to ineffective metabolism of vitamin D. Drugs such as phenytoin (Dilantin) or fluoride preparations may also interfere with metabolism of vitamin D. Osteomalacia and osteoporosis may occur at the same time. Muscle weakness and bone pain may be misdiagnosed as connective tissue disorder. In some cases, proximal muscle weakness in the shoulder and pelvic girdle area is the only presenting symptom. Muscle weakness in the lower extremities may cause a waddling and unsteady gait, which leads to falls. Hypophosphatemia leads to an inadequate production of muscle cell ATP. If hypocalcemia is present, muscle cramping may occur. Assess muscle strength and observe the patient's gait. Skeletal discomfort is often vague and generalized. The spine, ribs, pelvis, and lower extremities are most often affected. The patient usually describes the pain as aggravated by activity and worse at night. Palpate the affected bones for tenderness. Skeletal malalignment, like long-bone bowing or spinal deformity, may be similar to that seen in osteoporosis. In extreme cases, the pelvis narrows, so vaginal childbirth is difficult. X-rays of bone in patients with osteomalacia reveal a decrease in the cancellous bone and lack of osteoid sharpness. The classic diagnostic finding specific to the disease, however, is the presence of radiolucent bands (Looser's lines or zones). Looser's zones represent stress fractures that have not mineralized. They often appear symmetrically in the medial area of the femoral neck, ribs, and pelvis and may progress to complete fractures with minimal trauma. Bone biopsy of these areas may be needed for complete diagnosis. DXA scan may assist

Physical Assessment/Clinical Manifestations: Paget's Disease of the Bone 1

Ask the patient about a history of fracture and current bone pain. Common sites for pain are the hip and pelvis, but even the bones in the ear may be affected, causing hearing loss. The pain is usually described as aching, poorly defined, deep, and worsened by pressure. It is most noticeable at night or when resting. May report redness and warmth at affected sites. Pain may result from metabolic bone activity, secondary arthritis, impending fracture, or nerve impingement. Nerve impingement is particularly common in the lumbosacral area of the vertebral column, presenting as back pain that radiates along one or both legs. Observe posture, stance, and gait to identify gross bony deformities. Patient may have decreased height. Assess for kyphosis or scoliosis of the spinal column. Note any long-bone bowing in the legs with subsequent varus (bow-leg). Arms may also develop bowing. Flexion contracture in the hip joint is often present. Pay particular attention to the size and shape of the skull, which is typically soft, thick, and enlarged. Pressure from an enlarged temporal bone may lead to deafness and vertigo. Basilar (in the occipital area) complications can compress any of the cranial nerves and result in neurologic problems. Assess the patient for changes in vision, swallowing, hearing, and speech. Platybasia, or basilar invagination, causes brainstem (vital sign center) damage that threatens life. In some cases, the bony enlargement of the skull blocks cerebrospinal fluid (CSF), resulting in hydrocephalus.

Assessment: Bone Cancer

Ask whether the patient has had previous radiation therapy for cancer. Usually the patient has a group of nonspecific concerns, including pain, local swelling, and a tender, palpable mass. Marked disability and impaired mobility may occur in those with advanced. With Ewing's sarcoma, a low-grade fever may occur because of the systemic features of the neoplasm. For this reason, it is often confused with osteomyelitis. Fatigue and pallor resulting from anemia are also common. Inspect the involved area and palpate the mass for size and tenderness. Assess the patient's ability to perform mobility tasks and ADLs. Typically shows elevated serum alkaline phosphatase (ALP) levels, indicating the body's attempt to form new bone by increasing osteoblastic activity. The patient with Ewing's sarcoma or metastatic bone cancer often has anemia. In addition, leukocytosis is common with Ewing's sarcoma. The progression of Ewing's sarcoma may be evaluated by elevated serum lactic dehydrogenase (LDH) levels. With bone metastasis from the breast, kidney, or lung, the serum calcium level is elevated. Massive bone destruction stimulates release of the mineral into the bloodstream. In patients with Ewing's sarcoma and bone metastasis, the erythrocyte sedimentation rate (ESR) may be elevated because of secondary tissue inflammation. Routine x-rays and CT reveal malignant lesions. CT is helpful in determining the extent of soft-tissue damage. The patient may have an MRI for difficult-to-visualize areas such as the vertebrae. A needle bone biopsy may be performed, usually under fluoroscopy to guide the surgeon. Graded with one popular method: the TNM system, based on tumor size and number (T), the presence of cancer cells in lymph nodes (N), and metastasis (spread) to distant sites (M). Another method is to correlate the tumor grade (high or low), tumor site (intracompartmental or extracompartmental), and presence of metastatic disease (positive or negative).

Patient-Centered Collaborative Care: Benign Bone Tumors

Assess for pain, the most common manifestation. Can be caused by direct tumor invasion into soft tissue, compressing peripheral nerves, or by a resulting pathologic fracture. Observe and palpate the suspected involved area. Local swelling may be detected as the tumor enlarges. In some cases, muscle atrophy or muscle spasm may be present. Carefully palpate the bone and muscle to detect these changes and elicit tenderness. Routine x-rays and tomography are used to find bone tumors. CT is less useful except in complex anatomic areas, such as the spinal column and sacrum. MRI may be especially helpful in viewing problems of the spinal column. Non-drug pain-relief measures are also used. Depending on the patient's preference and tolerance, measures such as heat or cold may help relieve pain. In addition to prescribing analgesics to reduce pain, the health care provider usually prescribes one or more NSAIDs to inhibit prostaglandin synthesis that increases pain and inflammation. Give these drugs after meals or with food to reduce GI side effects. Teach patients to report any signs of bleeding. The most common surgical procedure used for benign bone tumors is removal. If the tumor is small, surgery may not be needed. When the tumor is very extensive, as in a giant cell tumor, it is removed with care to restore or maintain the function of the adjacent joint, most often the knee. In some cases, the knee is replaced with a prosthetic device and, less often, is fused (arthrodesis). Bone grafting may be needed.

Chart 50-1 Assessing Risk Factors for Primary Osteoporosis

Assess for: • Older age in both genders and all races • Parental history of osteoporosis, especially mother • History of low-trauma fracture after age 50 years • Low body weight, thin build • Chronic low calcium and/or vitamin D intake • Estrogen or androgen deficiency • Current smoking (active or passive) • High alcohol intake (3 or more drinks a day) • Lack of physical exercise or prolonged immobility

Preoperative Care: Bone Cancer

Assess the level of the patient's and family's understanding about the surgery and related treatments. As an advocate, encourage the patient and family to discuss concerns and questions about procedure. Anticipate postoperative needs as much as possible before the patient undergoes surgery. Remind the patient what to expect postoperatively and how to help ensure adequate recovery.

Genetic/Genomic Considerations: Paget's Disease of the Bone

Because Paget's disease is often present in identical twins, an autosomal dominant pattern has been suggested. The disease has been noted in up to 30% of people with a positive family history for Paget's disease. Several complex genetic factors have been identified in families with the disease, including mutations in the: • RANKL/RANK/OPG system, which is needed for osteoclast development and activity (see p. 1030 in the Osteoporosis section) • Valosin-containing gene of complement binding protein (valosin-containing protein [VCP]), an important inflammatory factor • Sequestosome 1 (SQSTM1) or p62, an expressed adaptor protein that can bind to ubiquitin and the atypical protein kinase C Teach patients the importance of genetics in familial Paget's disease, and refer them to the appropriate genetics counseling resource.

Benign Bone Tumors

Benign (noncancerous) bone tumors are often asymptomatic and may be discovered on routine x-ray examination or as the cause of pathologic fractures. The major classifications include chondrogenic tumors (from cartilage), osteogenic tumors (from bone), and fibrogenic tumors (from fibrous tissue and found most often in children). Most common benign bone tumor is the osteochondroma. The femur and the tibia are most often involved. The chondroma, or endochondroma, is a lesion of mature hyaline cartilage affecting primarily the hands and the feet. The ribs, sternum, spine, and long bones may also. Chondromas are slow growing and often cause pathologic fractures after minor injury. They are found in people of all ages and genders. The origin of the giant cell tumor remains uncertain. This lesion is aggressive and can be extensive and may involve surrounding soft tissue. Although classified as benign, giant cell tumors can metastasize (spread) to the lung.

Bisphosphonates: Osteoporosis

Bisphosphonates (BPs) slow bone resorption by binding with crystal elements in bone, especially spongy, trabecular bone tissue. Common drugs used for osteoporosis, but some are also approved for Paget's disease and hypercalcemia related to cancer. Three FDA approved BPs: alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel, Atelvia)—are commonly used for the prevention and treatment of osteoporosis. After taking any of these drugs for 3 years, the patient has a DXA scan. If bone density has improved or is maintained, the primary care provider may discontinue until next scan in 3 years. Oral BPs are commonly associated with a serious problem called esophagitis (inflammation of the esophagus). Esophageal ulcers have also been reported. IV zoledronic acid (Reclast) and IV pamidronate (Aredia). For management of osteoporosis, Reclast is needed only once a year and Aredia is given every 3 to 6 months. Both drugs have been linked to a complication called jaw osteonecrosis (also known as avascular necrosis, or bone death) in which infection and necrosis of the mandible or maxilla occur.

Cultural Considerations: Osteoporosis

Body build, weight, and race/ethnicity seem to influence who gets the disease. Osteoporosis occurs most often in older, lean-built Euro-American and Asian women, particularly those who do not exercise regularly. However, African Americans are at risk for decreased vitamin D, which is needed for adequate calcium absorption in the small intestines. Dietary preferences or intolerances or the inability to afford high-nutrient food may influence anyone's rate of bone loss. For example, many blacks have lactose intolerance and cannot drink regular milk or eat other dairy-based foods. Lactose-free milk (e.g., Lactaid) or soy milk provides calcium. Milk and cheese are good sources of protein, a nutrient needed to bind calcium for use by the body.

Assessment: Osteomyelitis

Bone pain, with or without other manifestations, is a common concern. Described as a constant, localized, pulsating sensation that worsens with movement. The patient with acute osteomyelitis has fever, usually with temperature greater than 101° F (38.3° C). Older adults may not have an extreme temperature elevation because of lower core body temperature and compromised immune system. Area around the infected bone swells and is tender. Redness and heat may also be present. When vascular compromise is severe, patients may not feel discomfort because of nerve damage from lack of blood. Assess circulation in the distal extremities. Ulcerations may be present on the feet or hands, indicating inadequate healing ability as a result of poor circulation. Fever, swelling, and erythema are less common in those with chronic osteomyelitis. Ulceration resulting in sinus tract formation, localized pain, and drainage is more characteristic of chronic infection. May have an elevated white blood cell (leukocyte) count. The erythrocyte sedimentation rate (ESR) may be normal early in the course of the disease but rises. A potentially life-threatening complication that could lead to septic shock, a blood culture identifies the offending organisms to determine which antibiotics should be used in treatment. Changes in blood flow can be seen early in the course of the disease by radionuclide scanning or MRI.

TABLE 50-1 Causes of Secondary Osteoporosis

Diseases/Conditions: • Diabetes mellitus • Hyperthyroidism • Hyperparathyroidism • Cushing's syndrome • Growth hormone deficiency • Metabolic acidosis • Female hypogonadism • Paget's disease • Osteogenesis imperfecta • Rheumatoid arthritis • Prolonged immobilization • Bone cancer • Cirrhosis • HIV/AIDS • Chronic airway limitation Drugs(Chronic Use): • Corticosteroids • Anti-epileptic drugs (AEDs) (e.g., phenytoin) • Barbiturates (e.g., phenobarbital) • Ethanol (alcohol) • Drugs that induce hypogonadism (decreased levels of sex hormones) • High levels of thyroid hormone • Cytotoxic agents • Immunosuppressants • Loop diuretics • Aluminum-based antacids

Lifestyle Changes: Osteoporosis

Exercise is important in the prevention and management of osteoporosis. PT may prescribe exercises for strengthening the abdominal and back muscles for those at risk for vertebral fractures. These exercises improve posture and support for the spine. Abdominal muscle tightening, deep breathing, and pectoral stretching are stressed to increase lung capacity. Exercises for the extremity muscles include muscle-tightening, resistive, and range-of-motion (ROM) exercises. Encourage active ROM exercises, which improve joint mobility and increase muscle tone, as well as prescribed exercise activities. Swimming provides overall muscle exercise. General weight-bearing exercise program should be implemented. Teach patients that walking for 30 minutes 3 to 5 times a week is the single most effective exercise for osteoporosis prevention. Teach the patient to avoid tobacco. Remind women not to consume more than one alcoholic drink per day (5 ounces each); instruct men not to have more than two alcoholic drinks per day. Patients at high risk, communicate this information to other members of the health care team, using colored armbands or other.

Action Alert

For patients who have allografts, observe for signs of hemorrhage, infection, and fracture. Report these complications to the surgeon immediately.

Estrogen Agonist/Antagonists: Osteoporosis

Formerly called the selective estrogen receptor modulators (SERMs), estrogen agonist/antagonists are a class of drugs designed to mimic estrogen in some parts of the body while blocking its effect elsewhere. Raloxifene (Evista) is currently the only approved drug in this class and is used for prevention and treatment of osteoporosis in postmenopausal women. Raloxifene increases bone mineral density (BMD), reduces bone resorption, and reduces the incidence of osteoporotic vertebral fractures. The drug contraindicated for women who have a history of thromboembolism.

Physical Assessment/Clinical Manifestations: Paget's Disease of the Bone 2

Fragility (pathologic) fractures may be the presenting clinical manifestation. Femur and the tibia are most often affected, and fracture of these bones can result from minimal trauma. The fracture line is usually perpendicular to the long axis of the bone, and healing is unpredictable due to disease process. Bones affected by Paget's disease may develop malignant changes. The most dreaded complication of Paget's disease is cancer, most commonly osteogenic sarcoma. It affects the femur, humerus, and old fracture sites and has a grave prognosis because of early metastasis. Svere bone pain is present in a patient with Paget's disease, bone cancer is suspected. Assess the skin for its color and temp. The skin is typically flushed and warm because of increased blood flow. In addition, assess the patient's energy level because apathy, lethargy, and fatigue are common. Less common manifestations of Paget's disease include hyperparathyroidism and gout. Secondary hyperparathyroidism leads to an increase in serum and urinary calcium levels. Calcium deposits occur in joint spaces or as stones in the urinary tract. Hyperuricemia (serum uric acid excess) and gout occur because the increased metabolic activity of bone creates an increase in nucleic acid catabolism. Therefore kidney stones are more common. Increased blood flow causes the heart to work harder to increase cardiac output, resulting in heart failure if not treated. Cardiac complications tend to occur only when more than a third of the skeleton is involved.

Assessment: Scoliosis

Include onset of problem, in adolescence or adulthood, and what treatments may have been used in the past. Patients who had surgery for scoliosis during adolescence are returning with progressive, debilitating back pain from degenerative disk disease below the level of vertebral fusion. A loss of lumbar curvature, or lordosis, described as "flat back" syndrome, may also be present. Complete a thorough pain assessment. Observe the patient from the front and back, while standing and during forward flexion from the hips. Physical examination usually reveals asymmetry of hip and shoulder height, prominence of the thoracic ribs and scapula on one side, and visible curve in the spinal column. Observation from the side may reveal kyphosis of the thoracic spine. Assess for leg length differences. The adult spinal column is less flexible and therefore less likely to respond to exercises, weight reduction, bracing, and casting for correction of the deformity. In the adult, the disorder is progressive and can result in an additional one degree of deviation each year.

Diagnostic Assessment: Paget's Disease of the Bone

Increases in serum alkaline phosphatase (ALP) and urinary hydroxyproline levels are the primary laboratory findings indicating possible Paget's. ALP can be further evaluated by alkaline phosphatase isoenzymes. The isoenzyme testing can further break ALP into three fractions—liver, bone, and intestinal. Elevated bone isoenzymes can help in a more definitive diagnosis. The 24-hour urinary hydroxyproline level reflects bone collagen turnover and indicates the degree of disease severity. Higher the hydroxyproline, the more severe. The calcium levels in blood and urine may be low, normal, or elevated. The immobilized patient is more likely to have an increase in calcium levels. Paget's disease often causes an elevated uric acid because nucleic acid from overactive bone metabolism. X-rays are also used. Reveal characteristic changes including the presence of osteolytic lesions and enlarged bones with radiolucent, or punched-out, appearance. Decrease in joint space may be seen with arthritic changes. Malalignment deformities, fractures, and secondary arthritic changes may be present. Radionuclide bone scan may be most sensitive in detecting Paget's disease. A radiolabeled bisphosphonate is injected IV and shows pagetic bone in areas of high bone turnover activity. This test can determine the extent of Paget's disease in the skeleton. CT and MRI are useful in the detection of cancerous tumors, changes in the skull, and spinal cord or nerve compression

Osteomyelitis

Infection in bone, known as osteomyelitis. Inflammation produces an increased vascular leak and edema. Once inflammation is established, the vessels in the area become thrombosed and release exudate (pus) into bony tissue. Ischemia of bone tissue follows and results in necrotic bone. This area of necrotic bone separates from surrounding bone tissue, and sequestrum is formed. The presence of sequestrum prevents bone healing and causes superimposed infection, often in the form of bone abscess. The cycle repeats itself. Osteomyelitis is categorized as exogenous, in which infectious organisms enter from outside the body as in an open fracture, or endogenous (hematogenous), in which organisms are carried by the bloodstream from other areas of infection. Third category is contiguous, in which bone infection results from skin infection of adjacent tissues. Osteomyelitis can be further divided into two major types: acute and chronic. Acute hematogenous infection results from bacteremia, underlying disease, or nonpenetrating trauma. Urinary tract infections, particularly in older men, tend to spread to the lower vertebrae. Long-term IV catheters can be a source. Patients undergoing long-term hemodialysis and IV drug users also. Salmonella infections of the GI tract may spread. Patients with sickle cell disease and other hemoglobinopathies often have multiple episodes of salmonellosis. Poor dental hygiene and periodontal (gum) infection can be causative factors in contiguous osteomyelitis in facial bones. Minimal nonpenetrating trauma can cause hemorrhages or small-vessel occlusions, leading to bone necrosis. Many infections are caused by Staphylococcus aureus. Penetrating trauma leads to acute osteomyelitis by direct inoculation. The most common offending organism is Pseudomonas aeruginosa, but other gram-negative bacteria may be. Chronic osteomyelitis may develop, especially in older adults who have foot ulcers. Inadequate care management results when the treatment period is too short or when the treatment is delayed or inappropriate. About half of cases of chronic osteomyelitis are caused by gram-negative bacteria.

Physical Assessment/Clinical Manifestations: Osteoporosis

Inspect and palpate the vertebral column. The classic "dowager's hump," or kyphosis of the dorsal spine, is often present. May state that he or she has gotten shorter, perhaps as much as 2 to 3 inches (5 to 7.5 cm). TTake or delegate height and weight measurements, and compare with previous measurements. May have back pain, which often occurs after lifting, bending, or stooping. Pain is worse with activity and is relieved by rest. Palpation of the vertebrae, particularly the lower thoracic and lumbar vertebrae, can increase the patient's discomfort. Back pain accompanied by tenderness and voluntary restriction of spinal movement suggests one or more compression vertebral fractures—the most common type of osteoporotic fracture. Movement restriction and spinal deformity may result in constipation, abdominal distention, reflux esophagitis, and respiratory compromise. Likely area for spinal fracture is between T8 and L3. Fractures are also common in the distal end of the radius (wrist) and the upper third of the femur (hip). Observe for signs and symptoms of fractures, such as swelling and malalignment.

Calcium and Activated Vitamin D (D3): Osteoporosis

Intake of calcium alone is not a treatment for osteoporosis, but calcium is an important part of prevention. Calcium carbonate, found in over-the-counter (OTC) drugs such as Os-Cal, is one of the most cost-effective supplement formulas. Calcium citrate, available OTC as Citracal, is often recommended for those who have gastric upset when taking a calcium supplement. Teach patients to take calcium supplements with food and 6 to 8 ounces of water. Divide the daily dose, with at least one third of the daily dose being taken in the evening. Teach women to start taking supplements in young adulthood. Instruct patients of any age to take calcium supplements that also contain a small amount of activated vitamin D (D3), such as Os-Cal Ultra. Vitamin D3 supplementation is often indicated. Both calcium and vitamin D3 are OTC supplements. Hypercalcemia (excess serum calcium) can cause serious damage to the urinary system and other body systems. Teach patients to drink plenty of fluids to prevent urinary calculi (stones). Remind them to have regular labs for Ca and vit D.

Drug Therapy: Paget's Disease of the Bone

Management of mild to moderate pain may include the use of aspirin or NSAIDs such as ibuprofen. Calcium level is more than twice the normal value and the disease is widespread, the provider usually prescribes more potent drugs, such as selected bisphosphonates. Oral bisphosphonates are a first-line treatment choice for Paget's disease when alkaline phosphatase levels are at least twice the normal serum level. Alendronate (Fosamax), risedronate (Actonel), etidronate (Didronel), or tiludronate (Skelid) is given. Oral agents are not effective, pamidronate (Aredia) or zoledronic acid (Reclast, Zometa) is administered IV. Aredia is given once every 3 months, and Reclast is given once a year. Patients should receive 1500 mg of calcium daily in divided doses and 800 international units of vitamin D3 daily for at least 2 weeks after zoledronic acid infusion unless prone to kidney stones. Denosumab (Prolia) is a monoclonal antibody that is also approved for Paget's disease. Binds to a protein that is essential for the formation, function, and survival of osteoclasts and is given SQ 2x/yr. By preventing the protein from activating its receptor, the drug decreases bone loss and increases bone mass and strength. Calcitonin is a hormone that seems to reduce bone resorption and, subsequently, relieve pain. The drug often causes a dramatic decrease in the alkaline phosphatase level in a few weeks. Calcitonin is approved for subcutaneous administration in treating Paget's. The drug binds to osteoclast receptors. Side effects of calcitonin include nausea, flushing, and skin rash. Skin testing may be done before administration.

Progressive Muscular Dystrophies

Many types of muscular dystrophy (MD) have been categorized as slowly progressive or rapidly progressive. The slowly progressive types are most commonly seen in adults. The exact pathophysiologic mechanisms are unknown, but several causes are possible. These include: • Poor blood flow to muscle resulting in reduced tissue oxygenation • Disturbance in nerve-muscle interaction • Loss of cell membrane integrity as a result of increased enzyme activity The primary problem is progressive muscle weakness. The major cause of death is respiratory failure caused by profound respiratory muscle weakness. Cardiac failure also occurs because dystrophin activity is needed for cardiac muscle contraction and maintenance. Muscle biopsy often confirms the diagnosis. Muscle weakness 1049and trophic changes are characteristic of all types of MD. Serum muscle enzyme values, such as aldolase and creatine kinase, may be elevated, and electromyographic (EMG) findings are often abnormal. PT and OT help the patient maintain as much function, mobility, and independence. A neurologist is often the specialist who diagnoses and treats patients with MD. Major organ or body system involvement is medically managed, but the life span is often shortened. With the exception of steroids, no drug has been found to slow the progression of the disorder, although immunosuppressive agents, anabolic steroids, and growth factors have been tried. Nursing interventions focus on making the patient as comfortable as possible, providing supportive care, and reinforcing techniques and exercises taught in the physical therapy program.

Morton's Neuroma

Morton's neuroma, or plantar digital neuritis, a small tumor grows in a digital nerve of the foot. The patient usually describes the pain as an acute, burning sensation in the web space. The pain involves the entire surface of the third and fourth toes. Management involves surgical removal of the neuroma and application of a pressure dressing. Ambulation is usually permitted immediately after surgery.

Chart 50-3 Key Features Paget's Disease of the Bone

Musculoskeletal Manifestations: • Bone and joint pain (may be in a single bone) that is aching, poorly described, and aggravated by walking • Low back and sciatic nerve pain • Bowing of long bones • Loss of normal spinal curvature • Enlarged, thick skull • Pathologic fractures • Osteogenic sarcoma (bone cancer) Skin Manifestations: • Flushed, warm skin Other Manifestations: • Apathy, lethargy, fatigue • Hyperparathyroidism • Gout • Urinary or renal stones • Heart failure from fluid overload

Monoclonal Antibodies: Osteoporosis

Newer type of drug is denosumab (Prolia, Xgeva), a monoclonal antibody that has been approved 1035for treatment of osteoporosis when other drugs are not effective. The drug binds to a protein that is essential for the formation, function, and survival of osteoclasts and is given subcutaneously twice a year. By preventing the protein from activating its receptor, the drug decreases bone loss and increases bone mass and strength. The most common side effects of denosumab are back pain, high cholesterol, urinary tract infection, and muscle pain. The drug can also cause a decrease in serum calcium levels. Therefore patients who already have a low calcium level should not take the drug. Like other drugs used for osteoporosis, denosumab can cause fractures, especially of the femur, and jaw osteonecrosis.

Osteomalacia

Osteomalacia is loss of bone related to a vitamin D deficiency. It causes softening of the bone resulting from inadequate deposits of calcium and phosphorus in the bone matrix. Osteomalacia is the adult equivalent of rickets, or vitamin D deficiency, in children. Primary disease related to lack of sunlight exposure or dietary intake, vitamin D deficiency caused by various health problems may result in osteomalacia. Malabsorption of vitamin D from the small bowel is a common complication of partial or total gastrectomy and bypass or resection surgery. Disease of the small bowel may cause decreased vitamin and mineral absorption. Liver and pancreatic disorders disrupt vitamin D metabolism and decrease its production. Chronic kidney disease (CKD) interferes with the synthesis of calcitriol, the most active vitamin metabolite. Osteomalacia can also be caused by bone tumors. Phosphate depletion (hypophosphatemia) lead to osteomalacia because they stimulate movement from bone and prevent calcium uptake in the bone. Osteomalacia is also an adverse effect of long-term therapy with certain drugs such as antiepileptic drugs (AEDs) and barbiturates. Older adults are most at risk. This group may have inadequate exposure to sunlight or intake of vitamin D-fortified foods. People who adhere to very restrictive vegan diets without adequate supplement of vitamin D can also be at risk. Assess for the risk for osteomalacia in anyone who has poor nutritional intake related to homelessness, who severely abuses drugs or alcohol, or who is very poor.

Osteoporosis

Osteoporosis is a chronic metabolic disease in which bone loss causes decreased density and possible fracture. It is often referred to as a "silent disease" or "silent thief". Spine, hip, and wrist are most often at risk, although any bone can fracture. Osteoporosis and osteopenia (low bone mass) occur when osteoclastic (bone resorption) activity is greater than osteoblastic (bone building) activity. The result is a decreased bone mineral density (BMD). BMD decreases most rapidly in postmenopausal women as serum estrogen levels diminish. Trabecular, or cancellous (spongy), bone is lost first, followed by loss of cortical (compact) bone. Standards for the diagnosis of osteoporosis are based on BMD testing that provides a T-score. Osteopenia is present when the T-score is at −1 and above −2.5. Osteoporosis is diagnosed in a person who has a T-score at or lower than −2.5. Generalized osteoporosis involves many structures in the skeleton and is further divided into two categories—primary and secondary. Primary osteoporosis is more common and occurs in postmenopausal women and in men(decreasing levels of testosterone [which builds bone] and altered ability to absorb calcium) in their 70s and 80s. Secondary osteoporosis may result from other: hyperparathyroidism; long-term drug therapy, such as with corticosteroids; or prolonged immobility, such as that seen with spinal cord injury. Regional osteoporosis, an example of secondary disease, occurs when a limb is immobilized related to a fracture, injury, or paralysis. Immobility for longer than 8 to 12 weeks can result in this type of osteoporosis. Bone loss also occurs when people spend prolonged time in a gravity-free or weightless environment (e.g., astronauts).

Bone Cancer

Osteosarcoma, or osteogenic sarcoma, is the most common type of primary malignant bone tumor. More than 50% of cases occur in the distal femur, followed by the proximal tibia and humerus. Tumor is relatively large, causing acute pain and swelling. The involved area is usually warm because the blood flow. Center of the tumor is sclerotic from increased osteoblastic activity. The periphery is soft, extending through the bone cortex in the classic sunburst appearance associated with the neoplasm. An inward spread into the medullary canal is also common. Osteosarcoma typically metastasizes (spreads). Ewing's sarcoma is not as common as other tumors, it is the most malignant. It causes pain and swelling. In addition, systemic manifestations, particularly low-grade fever, leukocytosis, and anemia, characterize the lesions. The pelvis and the lower extremity are most often affected. Death results from metastasis to the lungs and other bones. Usually occurs in children and young adults in their 20s. Men are affected more often. Patient with chondrosarcoma experiences dull pain and swelling for a long period. The tumor typically affects the pelvis and proximal femur. Arising from cartilaginous tissue, destroys bone and often calcifies. Occurs in middle-aged and older people, with predominance in men. From fibrous tissue, fibrosarcomas can be divided into subtypes, of which malignant fibrous histiocytoma (MFH) is the most malignant. Usually the clinical presentation of MFH is gradual, without specific symptoms. Local tenderness, with or without a palpable mass, occurs in the long bones of the lower extremity. As with other bone cancers, the lesion can metastasize to the lungs. Primary tumors of the prostate, breast, kidney, thyroid, and lung are called bone-seeking cancers. The vertebrae, pelvis, femur, and ribs are the bone sites commonly affected. Simply stated, primary tumor cells, or seeds, are carried to bone through the bloodstream. Fragility fractures caused by metastatic bone are a major concern.

TABLE 50-3 Causes of Osteomalacia

PG 1036 IGGY

TABLE 50-4 Treatment of Common Foot Problems

PG 1047 IGGY

TABLE 50-5 Differential Features of Common Muscular Dystrophies Seen in Adults

PG 1048 IGGY

Paget's Disease of the Bone

Paget's disease, or osteitis deformans, is a chronic metabolic disorder in which bone is excessively broken down (osteoclastic activity) and re-formed (osteoblastic activity). The result is bone that is structurally disorganized, causing bones to be weak with increased risk for bowing of long bones and fractures. Familial/Sporadic Active, mixed, and inactive. In the first phase (the active phase), a rapid increase in osteoclasts (cells that break down bone) causes massive bone destruction and deformity. The osteoclasts of pagetic bone are large and multinuclear, unlike the osteoclasts of normal bone tissue. In the mixed phase, the osteoblasts (bone-forming cells) react to compensate in forming new bone. The result is bone that is vascular, structurally weak, and deformed. Common areas of involvement are the vertebrae, femur, skull, clavicle, humerus, and pelvis. When the osteoblastic activity exceeds the osteoclastic activity, the inactive phase occurs. The newly formed bone becomes sclerotic and very hard. Disease is seen more frequently in people ages 50 years and older and in those of European heritage. Risk increases 80 years old and older. Men are affected twice as often.

Health Promotion and Maintenance: Osteoporosis

Peak bone mass is achieved by about 30 years of age. Building strong bone as a young person may be the best defense against osteoporosis in later adulthood. Teaching should begin with young women because they begin to lose bone after 30 years of age. Teach patients who do not include enough dietary calcium which foods to eat, such as dairy products and dark green leafy vegetables. Importance of sun exposure (but not so much as to get sunburned) and adequate vitamin D in the diet. Recommend taking a vitamin D3 supplement for all adults. Patients being treated for osteopenia or osteomalacia (vitamin D deficiency) may be prescribed high therapeutic doses up to 20,000 international units/week. Limit the amount of carbonated beverages. Importance of exercise and what types of exercise builds bone tissue. Weight-bearing exercises, such as regularly scheduled walking, are preferred. Teach high-risk people to avoid activities that cause jarring, such as horseback riding and jogging, to prevent potential vertebral compression fractures.

What should you INTERPRET and how should you RESPOND to a patient with impaired mobility as a result of chronic musculoskeletal disorders?

Perform and interpret focused physical assessment findings, including: • Ability to ambulate (with or without assistive device) • ADLs ability • Body weight • Pain intensity and quality • Neurovascular assessment findings • Ability to cope with decreased mobility Respond by: • Providing pain control interventions, including drugs and nonpharmacologic measures • Collaborating with members of the health care team, including physical therapist (PT), occupational therapist (OT), dietitian, as needed • Teaching about drugs that may be needed for long-term use, including side and toxic effects • Explaining about the need for adequate calcium and vitamin D for healthy bones and bone healing • Assisting with ADLs and ambulation as needed, but encouraging independence when possible • Implementing measures to prevent patient falls in the inpatient and home setting • Encouraging the patient to discuss feelings related to disorders causing impaired mobility

Drug Therapy: Bone Cancer

Physician may prescribe chemotherapy to be given alone or in combination with radiation or surgery. Certain proliferating tumors, such as Ewing's sarcoma, are sensitive to cytotoxic drugs. Others, such as chondrosarcomas, are often totally drug resistant. Chemotherapy seems to work best for small, metastatic tumors and may be administered before or after surgery. Other drugs are given for specific metastatic cancers, depending on the location of the primary site. For example, biologic agents, such as cytokines, are given to stimulate the immune system to recognize and destroy cancer cells, especially in patients with renal cancer. Zoledronic acid (Zometa) and pamidronate (Aredia) are two IV bisphosphonates that are approved for bone metastasis from the breast, lung, and prostate. These drugs help protect bones and prevent fractures. Inform patients that osteonecrosis of the jaw may also occur, especially in those who have invasive dental procedures. Monitor associated laboratory tests, such as serum creatinine and electrolytes, because these drugs can be toxic to the kidneys. Bisphosphonates are described earlier. Denosumab (Prolia) is a monoclonal antibody that is also approved for metastatic bone disease. The drug binds to a protein that is essential for the formation, function, and survival of osteoclasts and is given subcutaneously twice a year. By preventing the protein from activating its receptor, the drug decreases bone loss and increases bone mass and strength.

Plantar Fasciitis

Plantar fasciitis is an inflammation of the plantar fascia, which is located in the area of the arch of the foot. Middle-aged and older adults, as well as in athletes, especially runners. Obesity is also a contributing factor. Patients report severe pain in the arch of the foot, especially when getting out of bed. The pain is worsened with weight bearing. Conservative management, which includes rest, ice, stretching exercises, strapping of the foot to maintain the arch, shoes with good support, and orthotics. NSAIDs or steroids may be needed to control pain and inflammation. If conservative measures are unsuccessful, endoscopic surgery to remove the inflamed tissue may be required.

Gender Health Considerations: Osteoporosis

Primary osteoporosis most often occurs in women after menopause as a result of decreased estrogen levels. Women lose about 2% of their bone mass every year in the first 5 years after natural or surgical (ovary removal) menopause. Obese women can store estrogen in their tissues for use as necessary to maintain a normal level of serum calcium. Men also develop osteoporosis after the age of 50 years because their testosterone levels decrease. Testosterone is the major sex hormone that builds bone tissue. Men are often underdiagnosed, even when they become older adults.

Nonsurgical Management: Osteomyelitis

Provider starts antimicrobial (e.g., antibiotic) therapy ASAP. Presence of copious wound drainage, Contact Precautions are used. Teach family members or other caregivers in the home setting how to administer antimicrobials if they are continued after hospital discharge. Prolonged therapy for more than 3 months may be needed for chronic osteomyelitis. After discontinuation of IV drugs, oral therapy may be needed for weeks or months. Patients and families must understand the complications of inadequate treatment or failure to follow up with health care providers. Teach them that drug therapy must be continued over a long period to be effective. The wound may be irrigated, either continuously or intermittently, with one or more antibiotic solutions. A medical technique in which beads made of bone cement are impregnated with an antibiotic and packed into the wound can provide direct contact of the antibiotic with the offending organism. Drugs are also needed to control pain. A treatment to increase tissue perfusion for patients with chronic, unremitting osteomyelitis is the use of a hyperbaric chamber or portable device to administer hyperbaric oxygen (HBO) therapy.

Scoliosis

Scoliosis occurs when the vertebrae rotate and begin to compress. The spinal column begins to move into a lateral curve, most commonly in the right lateral thoracic area. When degree of curvature increases, damage to the vertebral bodies results. The degree of the curvature increases during periods of growth. Curvature of greater than 50 degrees results in an unstable spine, and curvature of greater than 60 degrees in the thoracic spine results in compromise of cardiopulmonary function. Females are affected more often with onset in adolescence. Adults often develop scoliosis as a result of spinal degeneration. Three types of scoliosis can be described: congenital, neuromuscular, and idiopathic; the most common curve pattern in adults is idiopathic. Congenital scoliosis occurs during embryonic development. Neuromuscular scoliosis can result from a neuromuscular condition in childhood or adulthood, such as cerebral palsy or spinal cord tumors. Untreated scoliosis can lead to back pain, deformity, and cardiopulmonary complications.

Interventional Radiology: Bone Cancer

Several noninvasive procedures to help relieve pain in the patient with metastasis to the spinal column. Two types of thermal ablation techniques, radiofrequency ablation (RFA) and cryoablation, can be done under moderate sedation or general anesthesia. RFA kills the targeted tissue with heat using a small needle inserted into the tumor. Cryoablation is similar to RFA, but the radiologist uses an extremely cold gas through a probe into the tumor. May also perform a vertebroplasty if the patient with spinal metastasis has pathologic compression fractures. After making a small incision, bone cement is injected through a needle into the fractured area. The cement hardens within 15 minutes. Like thermal ablation, this procedure is done in an ambulatory care setting and the patient is placed under moderate sedation.

Genetic/Genomic Considerations: Osteoporosis

Strong evidence demonstrates that genetics is a significant factor, with a heritability of 50% to 90%. Changes in the vitamin D3 receptor (VDR) gene and calcitonin receptor (CTR) gene have been found in some patients with the disease. Receptors are essential for the uptake and use of these substances. The bone morphogenetic protein-2 (BMP-2) gene has a key role in bone formation and maintenance. Some osteoporotic patients who had fractures have changes in their BMP-2 gene. Alterations in growth hormone-1 (GH-1) have been discovered in petite Asian-American women. Hormones, tumor necrosis factor (TNF), interleukins, and other substances in the body help control osteoclasts in a very complex pathway. The identification of the importance of the cytokine receptor activator of nuclear factor kappa-B ligand (RANKL), its receptor RANK, and its decoy receptor osteoprotegerin (OPG) has helped researchers understand more about the activity of osteoclasts in metabolic bone disease. Disruptions in the RANKL, RANK, and OPG system can lead to increased osteoclast activity.

Surgical Management: Osteomyelitis

Surgery is reserved for patients with chronic osteomyelitis. A sequestrectomy may be performed to débride the necrotic bone and allow revascularization of tissue. The excision of dead and infected bone often results in a sizable cavity, or bone defect. Bone grafts to repair bone defects are also widely used. If bone is extensively resected, reconstruction with microvascular bone transfers may be done. This procedure is reserved for larger skeletal defects. The most common donor sites are the patient's fibula and iliac crest. The bone graft may have an attached muscle or skin flap. Important difference is that neurovascular (NV) assessments must be done frequently because the patient experiences increased swelling after the surgical procedure. Elevate the affected extremity to increase venous return and thus control swelling. Assess and document the patient's NV status, including: • Pain • Movement • Sensation • Warmth • Temperature • Distal pulses • Capillary refill (not as reliable as the above indicators) Bony defect is small, a muscle flap may be the only surgery required. Local muscle flaps are used in the treatment of chronic osteomyelitis when soft tissue does not fill the dead space, or cavity, that results from bone débridement. The flap provides wound coverage and enhances blood flow to promote healing. A split-thickness skin graft is often applied several days after the muscle flap. As a last resort, the affected limb may need to be amputated.

Nutrition Therapy: Osteoporosis

Teach patients about the adequate amounts of protein, magnesium, vitamin K, and trace minerals that are needed for bone formation. Calcium and vitamin D intake should be increased. Teach patients to avoid excessive alcohol and caffeine. Patient who has sustained a fracture, adequate intake of protein, vitamin C, and iron is important to promote bone healing. People who are lactose intolerant can choose a variety of soy and rice products that are fortified. Calcium and vitamin D are added to many fruit juices, bread, and cereal products. The promotion of a single nutrient will not prevent or treat osteoporosis. Help the patient develop a nutritional plan that is most beneficial in maintaining bone health; the plan should emphasize fruits and vegetables, low-fat dairy and protein sources, increased fiber, and moderation in alcohol and caffeine.

Drug Alert

Teach patients to have an oral assessment and preventive dentistry before beginning any bisphosphonate therapy. To promote safety, instruct them to inform any dentist who is planning invasive treatment, such as a tooth extraction or implant, that they are taking a BP drug

Health Promotion and Maintenance: Osteomalacia

Teach patients to increase vitamin D through dietary intake, sun exposure, and drug supplements. Instruct the at-risk patient about foods high in vitamin D, such as milk and food that are fortified. Cheese and yogurt rarely contain vitamin D although they are rich in calcium. Importance of daily sun exposure (at least 5 minutes each day) for the most important source of vitamin D. Products are available for people who avoid dairy products. Soy and rice milk, tofu, and soy products are substitutes, but they are expensive. Teach patients to choose those products that are fortified with vitamin D. Other foods rich in the vitamin are eggs, swordfish, chicken, and liver, as well as enriched cereals and bread products. The at-risk patient should also take vitamin D supplements.

Foot Deformities

The hallux valgus deformity is a common foot problem in which the great toe drifts laterally at the first metatarsophalangeal (MTP) joint. The first metatarsal head becomes enlarged, resulting in a bunion. As the deviation worsens, the bony enlargement causes pain, particularly when shoes are worn. Women are affected more often. Hallux valgus often occurs as a result of poorly fitted shoes—in particular, those with narrow toes and high heels. Other causes include osteoarthritis, rheumatoid arthritis, and family history. Custom-made shoes can be made to fit the deformed feet and provide comfort and support. A plaster mold is made to conform to each foot from which shoes can be made. Teach the patient to consult with a podiatrist. A simple bunionectomy, involves removal of the bony overgrowth and bursa and realignment. When other toe deformities accompany the condition or if the bony overgrowth is large, several osteotomies, or bone resections, may be performed. Fusions may also be performed. Screws or wires are often inserted to stabilize. If both feet are affected, one foot is usually treated at a time. Patients are allowed partial weight bearing while wearing an orthopedic boot or shoe. Often patients have hammertoes and hallux valgus deformities at the same time. As shown in Fig. 50-4, a hammertoe is the dorsiflexion of any MTP joint with plantar flexion of the proximal interphalangeal (PIP) joint next to it. The second toe is most often affected. As the deformity worsens, uncomfortable corns may develop on the dorsal side of the toe and calluses may appear on the plantar surface. Patients are uncomfortable when wearing shoes and walking. Hammertoe may be treated by surgical correction of the deformity with osteotomies (bone resections) and the insertion of wires or screws for fixation. Crutches until full-weight bearing allowed.

Genetic/Genomic Considerations: Progressive Muscular Dystrophies

The major pathologic change that occurs in most types of MD is the production or faulty action of a muscle protein called dystrophin. The purpose of this protein is to maintain muscle integrity by sending signals to coordinate smooth, synchronous muscle fiber contraction. The coding of this protein is by a large gene that has many parts located on the X chromosome. Different mutations of the gene where dystrophin is located determine the degree of muscle weakness. Because this protein connects with other substances for final muscle action, genetic mutations of these other substances can make dystrophin fail to work properly. The most common forms of MD are Duchenne MD (DMD) and Becker MD (BMD). Both are X-linked recessive disorders. Women who are carriers (able to pass on the gene without having the disorder) have a 50% chance of passing the MD gene to their daughters, who are then carriers, and to their sons, who then have the disease. These types of MD, then, affect only males. In DMD, most patients die very young and therefore do not have children. In BMD, the patient lives longer and may have children. None of these men's sons will have the disease, but their daughters will be carriers.

Interventions: Osteomalacia

The major treatment for osteomalacia is vitamin D in an active form, such as ergocalciferol. Vitamin D is needed to adequately absorb and utilize calcium in the body. Nurses play a vital role in educating other health care professionals about the need to screen patients for low vitamin D levels. For all at-risk patients, teach them about which high calcium and vitamin D foods to eat and the importance of adequate daily sunlight.

Self-Management Education: Bone Cancer

The patient receiving intermittent chemotherapy or radiation on an ambulatory care basis, emphasize the importance of keeping appointments. Teach how to treat less serious side effects and when to contact HCP. Explain and demonstrate the care involved with daily dressing changes and potential catheter complications. Teach the patient, family, and/or significant others how to care for the wound. Help the patient learn how to perform ADLs and mobility activities independently. Discuss the various options for pain relief, including relaxation and music therapy. Emphasize the importance of those techniques that worked during hospitalization. Help the patient with advanced metastatic bone disease prepare for death.

Etiology and Genetic Risk: Osteoporosis

The relationship of osteoporosis to nutrition is well established. Excessive caffeine in the diet can cause calcium loss in the urine. A diet lacking enough calcium and vitamin D stimulates the parathyroid gland to produce parathyroid hormone (PTH). Malabsorption of nutrients in the GI tract also contributes to low serum calcium levels. Institutionalized or homebound patients who are not exposed to sunlight may be at a higher risk. Calcium loss occurs at a more rapid rate when phosphorus intake is high. Drinking large amounts of carbonated beverages each day (over 40 ounces) are at high risk for calcium loss and subsequent osteoporosis. Protein deficiency may also reduce bone density. Because 50% of serum calcium is protein bound, protein is needed to use calcium. However, excessive protein intake may increase calcium loss in the urine. For instance, people who are on high-protein, low-carbohydrate diets, like the Atkins diet. Excessive alcohol and tobacco use.

Drug Alert

To promote safety, teach patients to take bisphosphonates (BPs) early in the morning with 8 ounces of water and wait 30 to 60 minutes in an upright position before eating. If chest discomfort occurs, a symptom of esophageal irritation, instruct patients to discontinue the drug and contact their health care provider. Patients with poor renal function, hypocalcemia, or gastroesophageal reflux disease (GERD) should not take BPs.

Operative Procedures: Bone Cancer

Wide or radical resection procedures are used for patients with bone sarcomas to salvage the affected limb. Wide excision is removal of the lesion surrounded by an intact cuff of normal tissue and leads to cure of low-grade tumors only. A radical resection includes removal of the lesion, the entire muscle, bone, and other tissues directly involved. It is the procedure used for high-grade tumors. Large bone defects that result from tumor removal may require either: • Total joint replacements with prosthetic implants, either whole or partial • Custom metallic implants • Allografts from the iliac crest, rib, or fibula An allograft may be implanted with internal fixation for those patients who do not have metastases. This is a common procedure for sarcomas of the proximal femur. Allograft procedures for the knee are also performed, particularly in young adults. Preoperative chemotherapy is given to enhance the likelihood of success. Allografts with adjacent tendons and ligaments are harvested from cadavers and can be frozen or freeze-dried for a prolonged period.

Imaging Assessment: Osteoporosis

X-rays of the spine and long bones show decreased bone density but only after a 25% to 40% bone loss has occurred. Fractures can also be x-ray'd. Screening and diagnostic tool for measuring bone mineral density (BMD) is dual x-ray absorptiometry (DXA, or DEXA). Physicians recommend that women in their 40s have a baseline screening DXA scan so that later bone changes can be evaluated. Emits less radiation than a chest x-ray. It is the best tool currently available for a definite diagnosis of osteoporosis. A height is taken prior to performing the test. The patient stays dressed but is asked to remove any metallic objects. The results are displayed on a computer graph, and a T-score is calculated. No special follow-up care. A peripheral DXA (pDXA) scan assesses BMD of the heel, forearm, or finger. Peripheral quantitative ultrasound (pQUS) is an effective and low-cost peripheral screening tool that can detect osteoporosis and predict risk for hip fracture. The heel, tibia, and patella are most commonly tested. The procedure requires no special preparation, is quick, and has no radiation exposure or specific follow-up care.