Musculoskeletal disorders Part 1 Metabolic Bone Disorders: Osteoporosis, Osteomalacia, Paget's disease

1. Musculoskeletal Disorders Part I
Degenerative & Metabolic bone disorders
Maria Carmela L. Domocmat, RN,MSN
Instructor
School of Nursing
Northern Luzon Adventist College
Artacho, Sison, Pangasinan

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN
Overview
• Part 1: Degenerative & Metabolic bone disorders
▫ OA
▫ Gout and gouty arthritis
▫ Osteoporosis
▫ Paget’s dse
▫ Osteomalacia
• Part 2: Bone infections
• Part 3: Muscular disorders
• Part 4: Disorders of the hand
• Part 5: Spinal column deformities
• Part 6 : Disorders of foot
• Part 7: Sports Injuries

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Osteoporosis
Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

5. Skeleton
The skeleton consists of groups of bones
which protect and move the body.

7. Osteoporosis risk factors mnemonic
• ACCESS:
▫ Alcohol
▫ Corticosteroid
▫ Calcium low
▫ Estrogen low
▫ Smoking
▫ Sedentary lifestyle

13. http://www.myphysio.ca/site_assets/www.myphysio.ca/images/dynamic/ost
eoporosis.jpg

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

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

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

22. http://images.emedicinehealth.com/images/SlideShow/Osteoporosis_s1_bo
ne_density.jpg

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

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

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN
Orthotics (thoracolumbosacral
orthosis)
• decrease flexion
forces
• prevent worsening
of kyphosis
• reduce pressure on
fracture sites

32. Osteomalacia
• Osteomalacia means "soft bones".
• is softening of the bones due to a lack of vitamin
D or a problem with the body's ability to break
down and use this vitamin.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

33. Osteomalacia
• characterized by incomplete mineralization of
normal osteoid tissue following closure of the
growth plates.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

34. • Osteoid
▫ bone protein matrix, composed primarily of type 1 collagen.
▫ When there is insufficient mineral or osteoblast
dysfunction, the osteoid does not mineralize properly, and
it accumulates.
• When the newly formed bone of the growth plate does
not mineralize, the growth plate becomes thick, wide and
irregular. This results in the clinical diagnosis of rickets,
and is seen only in children because adults no longer
have growth plates. When the remodeled bone does not
mineralize, osteomalacia occurs, and this happens in all
ages. Most of the hereditary causes of osteomalacia
appear during childhood and cause rickets.
http://courses.washington.edu/bonephys/hypercalU/opmal2.html

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

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

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

41. Looser’s zone

42. • xray showing a pseudofracture • This is an xray of a child with
(red arrow) from an adult who bowed legs due to rickets
has x-linked
hypophosphatemic rickets.
• This is a classic pseudofracture
and is pathognomonic for
osteomalacia.

44. Treatment
• vitamin D, calcium, and phosphorus
supplements, taken by mouth.
• Larger doses of vitamin D and calcium may be
needed for people who cannot properly absorb
nutrients into the intestines.
• Regular blood tests may be needed to monitor
blood levels of phosphorus and calcium in
persons with certain underlying conditions.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

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http://ods.od.nih.gov/factsheets/VitaminD- Maria Carmela L. 3/5/2012
HealthProfessional/ Domocmat, RN, MSN
Recommended Dietary Allowances
(RDAs) for Vitamin D
Age Male Female Pregnancy Lactation
400 IU 400 IU
0–12 months*
(10 mcg) (10 mcg)
600 IU 600 IU
1–13 years
(15 mcg) (15 mcg)
600 IU 600 IU 600 IU 600 IU
14–18 years
(15 mcg) (15 mcg) (15 mcg) (15 mcg)
600 IU 600 IU 600 IU 600 IU
19–50 years
(15 mcg) (15 mcg) (15 mcg) (15 mcg)
600 IU 600 IU
51–70 years
(15 mcg) (15 mcg)
800 IU 800 IU
>70 years
(20 mcg) (20 mcg)

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN
Tolerable Upper Intake Levels (ULs) for
Vitamin D
Lactation
Age Male Female Pregnancy
1,000 IU 1,000 IU
0–6 months
(25 mcg) (25 mcg)
1,500 IU 1,500 IU
7–12 months
(38 mcg) (38 mcg)
2,500 IU 2,500 IU
1–3 years
(63 mcg) (63 mcg)
3,000 IU 3,000 IU
4–8 years
(75 mcg) (75 mcg)
4,000 IU 4,000 IU 4,000 IU 4,000 IU
≥9 years
(100 mcg) (100 mcg) (100 mcg) (100 mcg)

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http://ods.od.nih.gov/factsheets/VitaminD- Maria Carmela L. 3/5/2012
HealthProfessional/ Domocmat, RN, MSN
Selected Food Sources of Vitamin D
IUs per Percent
Food
serving* DV**
Cod liver oil, 1 tablespoon 1,360 340
Swordfish, cooked, 3 ounces 566 142
Salmon (sockeye), cooked, 3 ounces 447 112
Tuna fish, canned in water, drained, 3 ounces 154 39
Orange juice fortified with vitamin D, 1 cup (check product labels, as amount
137 34
of added vitamin D varies)
Milk, nonfat, reduced fat, and whole, vitamin D-fortified, 1 cup 115-124 29-31
Yogurt, fortified with 20% of the DV for vitamin D, 6 ounces (more heavily
80 20
fortified yogurts provide more of the DV)
Margarine, fortified, 1 tablespoon 60 15
Sardines, canned in oil, drained, 2 sardines 46 12
Liver, beef, cooked, 3 ounces 42 11
Egg, 1 large (vitamin D is found in yolk) 41 10
Ready-to-eat cereal, fortified with 10% of the DV for vitamin D, 0.75-1 cup
40 10
(more heavily fortified cereals might provide more of the DV)
Cheese, Swiss, 1 ounce 6 2

50. Expectations (prognosis)
• Improvement can be seen within a few weeks in
some people with vitamin deficiency disorders.
Complete healing with treatment takes place in 6
months.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

51. Prevention
• diet rich in vitamin D
• get plenty of sunlight
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001414/

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

55. Paget's disease
• AKA: Osteitis deformans
• is a disorder that involves abnormal bone
destruction and regrowth, which results in
deformity.
• there is an abnormal breakdown of bone tissue,
followed by abnormal bone formation. The new
bone is bigger, but weakened and filled with new
blood vessels.

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN

59. Paget’s disease
• Sir James Paget first described chronic
inflammation of bone as osteitis deformans in
1877.
• Paget disease, as the condition came to be
known,
• second most common bone disorder
(after osteoporosis) in elderly persons.

60. Paget’s Disease (Osteitis Deformans)
• Excess of bone destruction & unorganized bone
formation and repair.
• 2nd most common bone disorder in the U.S.
• etiology is unknown

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

62. Symptoms
• Most persons are asymptomatic & diagnosis is
incidental.
• Old Hat don’t fit anymore!
▫ hat gets tighter
▫ head diameter becomes larger
• pathologic fractures
• congestive heart failure
• hearing loss
• dysesthesias and weakness due to nerve-root
compression.

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

64. S/s
• Vascularity is increased in affected portions of
the skeleton.
▫ Lesions may occur in one or more bones, does not
spread from bone to bone.
• Deformities & bony enlargement often occur.
▫ Bowing of the limbs & spinal curvature in persons
with advanced disease.

65. S/s
• Bone pain- is the most common symptom.
▫ usually worse with ambulation or activity but may
also occur at rest.
▫ Involved bones may feel spongy & warm because
of increased vascularity.
▫ Skull pain is usually accompanied with headache,
warmth, tenderness & enlargement of the head.

66. Dx
• Bone scan
• Bone x-ray
• Elevated markers of bone breakdown (for
instance, N-telopeptide)
• Elevated serum alkaline phosphatase
• This disease may also affect the results of the
following tests:
• ALP (alkaline phosphatase) isoenzyme
• Serum calcium

67. Dx
• Pathologic fractures- because of the increased
vascularity of the involved bone-bleeding is a
potential danger.
• Alkaline phosphatase levels- markedly elevated
as the result of osteoblast activity.

68. Dx
• Serum calcium are normal except with
generalized disease or immobilization.
• Gout and hyperurecemia may develop as a result
of increased bone activity, which causes an
increase in nucleic acid catabolism.

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

70. Management
• Not all patients need treatment.
▫ For example, patients who have abnormal blood
tests only may not need treatment.
• People with Paget's disease who are commonly
treated include:
• Patients with deformities
▫ Patients with no symptoms when certain bones
(such as weight-bearing bones) are involved,
especially if the bony changes are progressing
quickly, to reduce the risk of fractures

71. Management
• Patients with symptoms
• Bisphosphonates
▫ Alendronate (Fosamax)
▫ Etidronate (Didronel)
▫ Pamidronate (Aredia)
▫ Risedronate (Actonel)
▫ Tiludronate (Skelid)
▫ Zoledronic acid (Zometa)
• Calcitonin
▫ Intranasal (Miacalcin)
▫ Subcutaneous (Calcimar)
• Plicamycin (Mithracin)
• Analgesics or nonsteroidal anti-inflammatory medications
(NSAIDs)

72. Management
• Goals of the treatment- to relieve pain & prevent
fracture & deformities.
▫ Pharmacologic agents are used to suppress
osteoclastic activity. Bisphosphonates & calcitonin
are effective agents to decrease bone pain & bone
warmth & also relieve neural decompression, joint
pain & lytic lesions.
▫ Use of analgesics & NSAIDs. Assistive devices,
including cane, walker.

73. Management
• Deformities may be corrected by surgical
intervention (osteotomy).
• ORIF may be necessary for fractures.
• The patient may benefit from a PT referral.
• Local application of ice or heat may help
alleviate pain.

74. Management
• A regular exercise should be maintained;
walking is best. Avoid extended periods of
immobility to avoid hypercalcemia.
• A nutritionally adequate diet is recommended.
Assistance in learning to use canes or other
ambulatory aids.
• The Arthritis Foundation & Paget Foundation
are useful resources for patients & their families.

75. Treatment
• Patients with symptoms
▫ Drug therapy helps prevent further bone breakdown.
Currently, there are several classes of medications used to
treat Paget's disease. These include:
Bisphosphonates -- the first-line treatment; help increase bone
density.
Calcitonin – hormone involved in bone metabolism.
Plicamycin (Mithracin)
Analgesics or nonsteroidal anti-inflammatory medications
(NSAIDs) - for pain.
• Localized Paget's disease needs no treatment, if there are
no symptoms and no evidence of active disease.
• Orthopedic surgery may be needed to correct a deformity
in severe cases.

76. Outlook (Prognosis)
• Disease activity and symptoms can generally be
controlled with current medications.
• A small percentage of patients may develop a
cancer of the bone called osteosarcoma.
• Some patients will need joint replacement
surgery.

77. Possible Complications
• Bone fractures
• Deafness
• Deformities
• Heart failure
• Paraplegia
• Spinal stenosis

78. http://orthoinfo.aaos.org/topic.cfm?topic=A00076
Left, Paget's disease of the spine. The white, patchy appearance of the bone on
this X-ray is characteristic of the dense but disordered bone in this disease.
Right, Paget's disease of the pelvis. The bone is thick, wide, and patchy.

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Maria Carmela L. 3/5/2012
Domocmat, RN, MSN