MUSCULOSKELETAL DISEASES

SIGNS AND SYMPTOMS Heberdens nodes

Osteoarthritis

Painless bony enlargement of DIP (Distal interphalangeal joint) Swan neck deformity Rheumatoid arthritis Hyperextended PIP (Proximal Interphalangeal joint) Slightly flexed DIP

Also:

Volar subluxation of MCP ( Metocarpophalangeal joint) Ulnar deviation of fingers

Tophi

Gout Painless, nodular swelling (uric acid deposits) Ears, hands, feet

ARTHRITIS RHEUMATOID ARTHRITIS Autoimmune disease

Morning stiffness Swelling of 3 or more joints Involves: wrist, MCP and PIP Subcutaneous nodules

Rheumatoid factor in serum Characteristics hand deformity:

Ulnar deviation of digits


X-ray:

swan neck deformity

X-ray:

Joint erosions Periarticular bone erosion

OSTEOARTHRITIS Degenerative disease Progressive pain Relieved by rest Involves weight bearing joints hip joint, knee joint (also DIP and PIP in women)

Loss of cartilage Narrowed joint space Subchondral cysts and sclerosis New bone formation (marginal osteophytes)

OSTEOARTHRITIS ANALYSIS

Impaired mobility > risk of injury

IMPLEMENTATION Range of motion exercises Exercises to maintain muscle strength (but minimize weight bearing activities) Encourage weight loss to reduce stress on joints

Warm tub baths to relief stiffness Note: proper use of cane: hold in hand opposite of bad leg. RHEUMATOID ARTHRITIS ANALYSIS

Impaired mobility > risk of injury IMPLEMENTATION Range of motion exercises Encourage self care: provide privacy and pain relief Apply local heat or cold

MEDICATIONS

Analgesics

Anti inflammatory drugs CLIENT EDUCATION Serious risk gastric ulceration from anti inflammatory drugs

GOUT Deposits of urate crystal in synovial tissue > acute inflammation Note: 90% of cases are due to under-excretion of uric acid 10% of cases are due to over-production of uric acid ASSESSMENT May be asymptomatic for a long time

Acute attack: pain in joint of great toe (podagra) Elevate serum uric acid Tophi: urate deposits in subcutaneous tissue

IMPLEMENTATION Bed rest during acute attack

Use cradle to keep bedcovers elevated Encourage fluid intake (3L/day) Hot packs (reduce muscles spasm and pain)

Cold packs (reduce swelling and pain) MEDICATIONS: Asymptomatic hyperuricemia: no medication necessary Mild attacks: analgesics (acetaminophen) Severe attacks: colchicine, NSAIDs Allupurinol: reduces uric acid production Probenecid: increases renal uric acid excretion

CLIENT EDUCATION Encourage weight loss but avoid crash diets

Avoid alcohol Limit food high in purines (anchovies, shellfish, organ meats)

Factors that inhibit uric acid secretion (increased risk of gout)

Alcohol - Aspirin Diuretics

SPONDYLOARTHROPATHIES Autoimmune diseases involving spine and sacroiliac joint Ankylosing spondylitis (more common in young men)

Gradual onset Reiters syndrome (more common in men) Sudden onset Urethritis Arthritis (knees, ankle) follows dysentery (Shigella) follows STD (Chamydia)

Psoriatic arthritis (more common in women)

Variable onset Occurs in 20% of psoriatic patients Nail pitting Sausage toes

NOTE: PHYSICAL THERAPY AND BREATHING EXERCISES ARE EXTREMELY IMPORTANT TO MAINTAIN MOBILITY AND POSTURE SYSTEMIC LUPUS ERYTHEMATOSUS Chronic inflammatory disease of connective tissue(autoimmune) Systemic lupus


LAB:

Weakness, fatigue Anorexia, weight loss Photosensitivity Butterfly rash (spare nasolabial fold) Discoid rash Anemia Arthritis Nephrotic syndrome

Leukopenia Thrombocytopenia Antinuclear antibodies False positive test for syphilis

Drug induced lupus Often fairly mild

History of hydralazine, procainamide, other drugs Reversible after drug cessation

IMPLEMENTATION

Emotional support Protective clothing and sun screen if clients is photosensitive Heat packs for joint pain Monitor for signs of renal damage: edema, hypertention

MEDICATIONS

Steroids (topical for skin, systemic if organ involvement)

OSTEOPOROSIS Loss of the one mass > risk of fracture

Elderly persons are at risk Bone loss is accelerated in postmenopausal women (lack of estrogen)

ASSESSMENT

Backache Kyphosis Los of height Serum calcium and phosphate levels are normal X-ray: decreased density of vertebrae

ANALYSIS Risk of injury: femur (hip) fractures, vertebral compression fractures IMPLEMENTATION DIET: High-protein diet Calcium and vit. D MEDICATIONS: Estrogen replacement

CLIENT EDUCATION Encourage physical activity to prevent atrophy

Prevent falls: slippery bathroom floors, loose rugs..

Note: Estrogen slightly increase the risk of endometrial cancer. Regular check-ups for clients on estrogen replacement are recommended. HERNIATED DISK ASSESSMENT

Severe lower back pain Pain radiating down buttocks and legs Usually unilateral Neurological exam: motor or sensory deficits are a serious sign Diagnosis: CT or MRI

ANALYSIS Risk of injury to spinal cord and nerve roots

Level of mobility IMPLEMENTATION Apply local heat or cold CERVICAL:

Cervical herniation: collar or traction required LUMBAR Bed rest until inflammation is reduced Provide firm mattress Recommend high-fiber diet with plenty of fluid (to prevent constipation and straining) CLIENT EVALUATION Avoid prolonged sitting

Use legs when lifting objects (keep spine straight) Exercise to strenghten abdominal and back muscles

CARPAL TUNNEL SYNDROME Compression of median nerve at wrist joint ASSESSMENT Pain in wrist or palm or hand

Paresthesias in radial palmar aspect of hand

Weakness of thumb IMPLEMENTATION Relief pressure on median nerve:(hand elevation, splinting of hand and forearm) Cortisone injections into carpal tunnel CLIENT EDUCATION Avoid prolonged flexion of wrist

Teach proper hand position when typing or using computer

OSTEOMYELITIS Infection in bone, usually by staphylococcus aureus ASSESSMENT

Malaise Pain and tenderness over bone Swelling and redness over bone Fever Diagnosis: bone scan or culture from needle biopsy

IMPLEMENTATION Immobilization of affected limb

No weight-bearing on affected limb

Explain client need for long-term antibiotics (oral for 6 weeks after fever normalizes) LEG AMPUTATION ASSESSMENT Peripheral vascular disease > claudication (pain when walking, rapid relief when resting) Cyanosis

Ulcer formation Gangrene: foul smell, blackened wound

ANALYSIS

Risk of injury Effective coping with altered body image

IMPLEMENTATION Watch for signs of infection and sepsis POSTOPERATIVE: Bandages should be applied in a diagonal figure 8 pattern Elevate stump for first 12 hours Monitor wound drainage (keep tourniquet at bedside for emergencies) Exercise to improve arm strength

CLIENT EDUCATON Explain phantom pain

Encourage frequent repositioning in bed Massage stump to improve vascularity

CRUTCHES & CANES CRUTCHES Fitting Measure from anterior fold of axilla to heel, add 6 inches

There should be 2 inch space between axillary fold and underarm piece to prevent damage to brachial plexus (clutch paralysis) Basic stance Crutches should rest in front and lateral of feet 2-point gait Advance right crutch and left foot together Advance left crutch and right foot together

3-point gait (used if only one leg is injured) Advance both crutches and involved leg forward

Advance healthy foot while keeping body weight on crutches

4-point gait (similar to 2-point gait, but slower and more stable)

Fitting

Advance right crutch Advance left foot Advance left crutch Advance right foot

CANES

Use

Highest point should be at level of greater trochanter Handpiece should allow 30deg. Flexion at elbow

Hold cane in hand opposite to injured leg Advance cane and injured leg at same time Dont lean body over cane