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Musculoskeletal DisordersOsteomyletisBone CancerOsteoporosis

Paget’s DiseaseOsteomalacia (Adult Rickets)

Musculoskeletal Disorders – Normal Bone

Normal bone remodeling process involves sequence of bone reabsorption and formation

• Adults replace about 25% of trabecular bone (the porous type of bone found in spine & articulating joints)

every 4 months through reabsorption of old bone by

osteoclasts (cells that resorb bone) and

formation of new bone by osteoblasts (cells that form bone)

Normal Serum Calcium Level range from 8.5 to 10.2 mg/dL

• Abnormal results

• Greater-than-normal levels may indicate:

• Hyperparathyroidism• Metastatic bone tumor• Paget’s disease• Vitamin D intoxication

• Lower than normal levels may indicate:

• Hypoparathyrodism• Malabsorption (inadequate

absorption of nutrients from the intestinal tract)

• Osteomalacia• Osteoporosis• Pancreatitis• Renal failure• Rickets• Vitamin D deficiency

Osteomyelitis•   Osteomyelitis= an infection of bone

• Can either be acute or chronic

• Bacteria are the usual infectious agents.– 1. primary infection of the bloodstream – 2. A wound or injury that permits bacteria to directly reach the bone.

• If not treated

• The infection and inflammation block blood vessels.

• Lack of oxygen & nutrients cause the bone tissue to die, which leads to chronic osteomyelitis.

• Other possible complications include blood poisoning and bone abscesses.

• Treatment options include intravenous and oral antibiotics, and surgical draining and cleaning of the affected bone tissue.

Causes of Osteomyelitis• An open injury to the bone, such as an open fracture with the bone

ends piercing the skin.

• An infection from elsewhere in the body that has spread to the bone through the blood.

• A minor trauma, which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria.

• Bacteria in the bloodstream, which is deposited in a focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone. However, new bone often forms around the site.

• A chronic open wound or soft tissue infection can eventually extend down to the bone surface, leading to a secondary bone infection.

Causes of osteomyelitis

Bones are infected by blood-borne micro-organisms.

In most cases, the micro-organisms are bacteria such as Staphylococcus aureus, but fungi can also cause osteomyelitis.

Conditions and events that can lead to osteomyelitis include: • Bacteria introduced during bone surgery. • Bacteria introduced by trauma to bone. • Infection of bone fractures. • Infection of prosthetic implants (such as an artificial hip joint). • Infections elsewhere in the body that reach the bones via the

bloodstream. • A primary infection of the blood (septicemia).

Osteomyelitis - Pathophysiology

`Usually bacterial in nature: most commonly Staphylococcus aureus

• Bone inflammation is marked by edema, increased vascularity & leukocyte

activity.

• 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

Symptoms of Osteomyelitis

• Localized bone pain and/or tenderness in the infected area

• Reduced movement of the affected body part

• The overlying skin may be red, hot and swollen – inflammatory response

• The overlying skin may contain pus/purulent drainage

• Spasms of associated muscles

• General malaise

• High temperature

• Excessive sweating

• Chills

• Nausea, secondarily from being ill with infection

• General discomfort, uneasiness, or ill feeling

Osteomyelitis - Risk factors•

Long term skin infections.

• Poor blood circulation (arteriosclerosis).

• Risk factors for poor blood circulation, which include high blood pressure, cigarette smoking, high blood cholesterol and diabetes.

• Prosthetic joints.

• Sickle cell anemia, Cancer, Diabetes

• Hemodialysis

• Weakened immune systems

• Intravenous drug abusers

• The elderly

Complications of Osteomyelitis

• Some Complications include:

• Bone abscess

• Bone necrosis (bone death)

• Spread of infection

• Inflammation of soft tissue (cellulitis)

• Blood poisoning (septicemia)

• Chronic infection that doesn't respond well to treatment.

Osteomyellitis

Osteomyellitis

Osteomyelitis - Tests

• Blood tests:• CBC- complete blood count (CBC), >WBC = infection• ESR (erythrocyte sedimentation rate) and/or CRP (creative protein) in the

bloodstream, which detects and measures inflammation in the body. • Blood culture: detect bacteria, identify infectious agent, order antibiotics• Needle aspiration: Remove a sample of fluid and cells from the vertebral

space, or bony area. Lab evaluates infectious agent . • Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested

for signs of an invading organism. • Bone scan:• During this test, a small amount of Technetium-99 pyrophosphate, a radioactive

material, is injected intravenously into the body.• If the bone tissue is healthy, the material will spread in a uniform fashion.• However, a tumor or infection in the bone will absorb the material and show an

increased concentration of the radioactive material, which can be seen with a special camera that produces the images on a computer screen.

• Finds abnormalities in their early stages, when X-ray findings may only show normal findings.

Osteomyelitis – Diagnostic Tests

• MRI and CT scans: show abscesses and soft tissue changes

• Radio nucleotides bone scans: determine whether infectious or inflammatory changes in bone

• WBC and ESR: WBC and ESR are elevated

• Blood and tissue cultures: identify infectious organism and determine appropriate antibiotic therapy

Treating and Managing Osteomyelitis

• The goals of treating osteomyelitis is to– Eliminate the infection and – Prevent the development of chronic infection.– Identify & treat the disease as soon as possible

• Chronic osteomyelitis can lead to – permanent deformity – chronic problems

• Nursing management• Use of aseptic technique during dressing changes.• Observed for S/S of systemic infection• ROM exercises are encouraged to prevent contractures &

flexion deformities & participation in ADL to the fullest extent is encouraged.

Treatment for Osteomyelitisdepends on severity

• Hospitalization and antibiotics, oral or IV, 4-6 weeks or more

• Pain meds.

• Lifestyle changes to improve blood circulation.

• Treatment for underlying cause, such as diabetes.

• Surgery to clean and flush out the infected bone (debridement).

• Splinting or cast immobilization: – Immobilize affected bone&

nearby joints in order to avoid further trauma

– Help the area heal adequately and as quickly as possible.

• Replacement of the infected prosthetic part, if needed.

• Skin grafts, if necessary.

• Amputation, in severe cases.

Osteomyelitis – Surgical Debridement

• Surgical debridement

• Specimen may also be obtained during debridement procedure

• Primary treatment for chronic cases

• Complete removal of dead bone & affected soft tissue

• Wound is opened, irrigated; drainage tubes may be inserted for irrigation, suction, and antibiotic instillation

• Antibiotics & sterile technique - control of infection

Osteomyelitis – Nsg Dx

Nursing Diagnoses• Risk for Infection• Hyperthermia: interventions include maintenance of adequate

fluid intake• Acute Pain: splinting or use of immobilizer may limit swelling

and improve pain• Anxiety

Home CareOften vital part of treatment of osteomyelitisReferral to home care agency for support with wound treatment, antibiotic administration, obtaining supplies, nutritional teaching

Neoplastic Disorders: Bone Tumors

Defined1. Tumors may be malignant or benign

– Benign tumors grow slowly and do not invade surrounding tissues, tend to be less destructive to normal bone.

– Malignant tumors grow rapidly and metastasize,tends to cause more bone destruction, invasion of the surrounding tissues & metastasis.

2. Tumors can be primary (rare) or metastatic lesions originating from primary tumors of prostate, breast, kidney, thyroid, lung

3. The tumor is defined as a new growth or hyperplasia of cells. This growth is in response to inflammation or trauma

Neoplastic Disorders: Bone TumorsPathophysiology

Pathophysiology

• Cause unknown, but connection exists between bone activity and development of primary bone tumors

• Primary tumors cause osteolysis, bone breakdown, which weakens bone and leads to bone fractures

• Malignant bone tumors invade and destroy adjacent bone tissue

Neoplastic Disorders: Bone TumorsS&S

Manifestations: often history of fall or blow to extremity brings mass to attention

• Pain

• Mass

• Impaired function

Osteosarcoma • A malignant tumor originating from osteoblast (bone-forming

cells). Occurs twice as frequently in males as in females.

• Usually located at the end of the long bones (metaphysis). Most frequently seen at – the distal end of the femur or – the proximal end of the tibia.

• Lungs, a common site of metastasis.

• S&S: Pain and swelling at the site & limitation of movement.

• Dx:– Bone biopsy is used to confirm the diagnosis.– X-ray films, CT scans, MRI & bone scans show tumor location & size &

bone involvement• Treatment: Historically, the treatment of choice is amputation.

Ewing’s Sarcoma • A malignant tumor of the bone originating from myeloblasts

with early metastases to lung, lymph nodes, & other bones.

• Location: Usually located on the shaft of the long bones. Femur, tibia, & humerus are common sites.

• Poor prognosis. Common in person> 40 years old. Affect males more than females.

• S&S– Pain increased with weight bearing. – May complain of weight loss, malaise, or anorexia.– Causes pathologic fractures.

• Treatment: Palliative, radiation, chemotherapy.

Neoplastic Disorders: Bone TumorsDiagnostic Tests

• X ray: shows location of tumors and extent of bone involvement– Benign tumors show sharp margins separating from normal bones– Metastatic bone destruction: characteristic “moth-eaten” pattern

• CT scan: evaluation of extent of tumor invasion into bone, soft tissues, neurovascular structures

• MRI: determine extent of tumor invasion, response of bone tumors to radiation and chemotherapy, recurrent disease

• Needle biopsy to determine exact type of bone tumor

• Serum alkaline phosphatase: elevated with malignant bone tumors

• RBC elevation

• Serum calcium: elevated with massive bone destruction

Neoplastic Disorders: Bone TumorsTreatments

• Chemotherapy– Used to shrink tumor before surgery– Control reoccurrence– Treat metastasis

• Radiation– Often combined with chemotherapy– Used for pain control with metastatic carcinomas– Eliminate tumor remains after surgery

• Surgery– Eliminate primary bone tumors to eliminate tumors completely;

may involve excise tumor or amputate affected limb– With some surgeries, cadaver allografts or metal prostheses used

to replace missing bone to avoid amputation

Neoplastic Disorders: Bone TumorsNsg Management

Nursing Diagnoses• Risk for Injury (pathologic fractures)• Acute and Chronic Pain• Impaired Physical Mobility• Decisional Conflict: assist client in gaining information for

informed decisions regarding treatment options

Home Care• Client education regarding treatment plan, wound care,

activity and weight bearing restrictions• Support with referral to prosthetic specialist or hospice as case

indicates

What is Osteoporosis?

• Debilitating disease in which bones become fragile and are more likely to break

• Disorder characterized by (1)loss of bone mass (2) increased bone fragility (3) increased risk for fractures

• Imbalance of processes that influence bone growth and maintenance; associated with aging, but may result from endocrine disorder or malignancy

• 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) especially R/T falls

Osteoporosis – Risk FactorsOsteoporosis – Risk Factors

• Gender- women are more likely to develop than men due to thinner, lighter bones & the decrease in estrogen production that occurs during menopause.

• Age- the longer you live, the greater the likelihood of developing.• Family history-is due part to heredity.• Ethnicity-Caucasian & Asian women are at highest risk;African-

American & Hispanic women at lower but significant risk.• Body size- low body weight (< 127 lbs.) & a small-boned frame

place at increased risk.• Lifestyle- a diet low in CA, inadequate vitamin D, little or no

exercise, current cigarette smoking or excessive use of alcohol are all risk factors.

Osteoporosis- Modifiable Risk Factors• 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

• Menopause– decreasing estrogen levels: estrogen replacement therapy can reverse bone

changes but may increase risk for other diseases• Cigarette smoking

– decreased blood supply to bones• Excessive alcohol intake

– toxic effect on osteoblastic activity; high alcohol intake frequently associated with nutritional deficiencies

• Sedentary life style– weight-bearing exercise such as walking positively influences bone

metabolism• Use of specific medications

– aluminum-containing antacids, corticosteroids, anticonvulsants, prolonged heparin therapy, antiretroviral

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

Osteoporosis - Pathology

Pathophysiology• Diameter of bone increases, thinning outer supportive cortex• Trabeculae (spongy tissue) lost and outer cortex thins• Minimal stress leads to fracture

Manifestations (“silent disease”: bone loss occurs without symptoms)

• Loss of height• Progressive curvature of spine (dorsal kyphosis, cervical

lordosis, accounting for “dowager’s hump”)• Low back pain• Fractures of forearm, spine or hip

Osteoporosis - Prevention

• Prevention

• By age 20, the average woman has acquired 98% of her skeletal mass.

• Building strong bones during childhood & adolescence can be the best defense against developing osteoporosis.

Balanced diet rich in CA & Vitamin D. Weight-bearing exercises A healthy lifestyle with no smoking & limited alcohol intake. Bone density testing & medication when appropriate.

Osteoporosis – Assessmemt

• Assessment:

• Assess for backache with pain radiating around trunk

• Evaluate for skeletal deformities.

• Assess for pathologic fractures.

• Evaluate lab finding:– Serum CA, phosphorus & alkaline phosphatase are usually normal.– Parathyroid hormone may be elevated.

Osteoporosis – Dx Tests

Bone density test – most often used

• Xrays: picture of skeletal structures but osteoporotic changes not seen until> 30% of bone mass lost

• Quantitative computed tomography (QCT) of spine: measures trabecular bone within vertebral bodies

• Dual-energy Xray absorptiometry (DEXA): measures bone density in lumbar spine or hip; highly accurate

• Alkaline phosphatase (AST): elevated post fracture

• Serum bone Gla-protein (osteocalcin) marker of osteoclastic activity and is indicator of rate of bone turnover; used to evaluate effects of treatment

Osteoporosis - Complications

Fractures 1.5 million fractures yearly Many spontaneous or resulting from everyday activities• Persistent pain and associated posture changes restrict client

activities and ability to perform ADL

Collaborative Care• Stopping or slowing osteoporosis• Alleviating symptoms• Preventing complications

Osteoporosis – Nsg Management

• Prevent fractures:– Instruct in safety factors-watch steps, avoid use of scatter rugs. – Keep side rails up to prevent falls.– Move gently when turning & positioning.– Assist with ambulation if unsteady on feet.

• Provide pain control.

• Instruct in good use of body mechanics.

• Provide diet high in protein, vit. D

• Avoid excessive use of alcohol & coffee.

Osteoporosis - Meds

MedicationsEstrogen replacement therapy

(1)reduces bone loss, (2)increases bone density in spine and hip(3)reducing risk of fractures in postmenopausal women.

– Recommended for women who have undergone surgical menopause before

age 50– Associated risk for estrogen therapy alone is > risk of endometrial cancer– Hormone replacement therapy (estrogen and progestin) associated with

increased risk for cardiovascular disease and breast cancer

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

Osteoporosis - Meds

Medications

Biphosphonates: potent inhibitors of bone resorption used to prevent and treat osteoporosis

– Alendronate (Fosamax)– Risedronate (Actonel)– Etidronate (Didronel)

Calcitonin (Miacalcin):-Hormone increases bone formation and decreases bone resorption; available as

nasal spray or parenteral

Sodium fluoride: -stimulates osteoblast activity, decreases risk of spinal fractures but associated with

increased risk of other fractures including hip

Osteoporosis – Nsg ManagementOsteoporosis – Nsg Management

Nursing Care• Emphasis is prevention and education of clients under age of 35• Prevention of complications in those with osteoporosis

• Home Care: Focus is on education including safety and fall prevention inside and outside the home

• Administer & Instruct on Medications:• Estrogen & progesterone-

decrease rate of bone reabsorption at menopause.

• Calcium& vitamin D-support bone metabolism.

Osteoporosis – Nsg ManagementOsteoporosis – Nsg Management

Health Promotion

Calcium intake

1. Maintain daily intake of calcium at recommended levels, in divided doses

– Age 19 – 50: 1000mg

– Age 51-64: 1200 mg

– 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

Osteoporosis – Nsg ManagementOsteoporosis – Nsg ManagementHealth Promotion-continued

4. Supplementation: calcium carbonate (Tums); calcium combined with Vitamin D for older adults

• 5. Instruct in regular exercise program.– ROM exercise – Ambulation several times per day.– Physical activity that is weight-bearing– Walking 20 minutes, 4 or > times per week

• 6. Health-related behaviors– Include not smoking– Avoid excessive alcohol– Limit caffeine to 2 – 3 cups of coffee daily– Limit diet soda

Osteoporosis – Nsg Dx

1. Risk for injury- altered mobility, minimal trauma, falls, advanced age, previous fall.

2. Impaired physical mobility- decreased bone mass, decreased strength, musculoskeletal impairment, pain.

3. Situational low self-esteem- chronic illness,anxiety, loss of usual

role, body changes, limitation in mobility, chronic pain, loss of independence.

4. Imbalanced Nutrition: Less than body requirements

5. Acute Pain

6. Health Seeking Behaviors

Paget’s Disease (osteitis deformans)

Description• Excess of bone destruction & unorganized bone formation and

repair. • Progressive skeletal disorder with excessive metabolic bone

activity leading to affected bones becoming larger and softer• The 2nd most common bone disorder in the U.S. (see patho)

• Etiology – Unknown– Affects femur, pelvis, vertebrae, sacrum, sternum, skull– Relatively rare– Occurs more often in whites– Slightly more common in males– Familial tendency– Most persons are asymptomatic & diagnosis is incidental.

PathophysiologyPaget’s Disease (osteitis deformans)

- Bones are initially soft and bowing occurs; then become hard and brittle leading to fractures

• 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

- Slow progression with 2-stage process• 1. Excessive osteoclastic- bone resorption• 2. Excessive osteoblastic - bone formation

S&S - Paget’s Disease (osteitis deformans)

Manifestations• Most are asymptomatic• Bone pain- is the most common symptom.

– Localized pain of long bones, spine, pelvis, cranium– Pain is mild to moderate deep ache which is aggravated by

pressure and weight-bearing– Is is usually worse with ambulation or activity but may

also occur at rest.– Pain is mild to moderate deep ache which is aggravated by

pressure and weight-bearing– Involved bones may feel spongy & warm because of

increased vascularity.

• Skull pain is usually accompanied with headache, warmth, tenderness & enlargement of the head.

• Flushing and warmth over areas of bone involvement

ComplicationsPaget’s Disease (osteitis deformans)

• Degenerative osteoarthritis

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

• Nerve palsy syndromes from involvement of upper extremities

• Compression of spinal cord causing tetraplegia which is also know as Quadriplegia

• Mental deterioration from skull involvement and brain compression

Diagnostic TestPaget’s Disease (osteitis deformans)

• X ray– Slow localized areas of demineralization in early phase

– Later enlargement of bones with tiny cracks in long bones or bowing in weight-bearing bones radiolucent areas in the bone, typical of increased bone resorption.

– Deformities & fractures may also be present.

• Bone scan: active Paget’s disease

• CT scans and MRI: show degenerative problems, spinal stenosis, nerve root impingement

• Serum alkaline phosphatase: steady rise as disease progresses

Diagnostic Tests Paget’s Disease (osteitis deformans)

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

• Urinary collagen pyridinoline testing: indicator of rate of bone resorption

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

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

Meds - Paget’s Disease

• Meds used to suppress osteoclastic (bone resorption) activity. • Mild symptoms relieved by analgesics, aspirin, NSAIDs. • Calcium supplements

• Bisphosphonates & calcitonin are effective agents to– decrease bone pain & bone warmth – relieve neural decompression, joint pain & lesions.

• Biphosphonates: Action: Slows Bone resorption – Alendronate (Fosamax)– Tiludronate (Skelid)– Pamidronate (Aredia)

Calcitonic: works as analgesic for bone pain– Salmon calcitonin (Calcimar)– Human calcitonin (Cibacalcin)

Surgery -Paget’s Disease (osteitis deformans)

Deformities may be corrected by surgical intervention (osteotomy).

ORIF Open Reduction Internal Fixation may be necessary for fractures.

Total hip or knee replacement is usually required when client with Paget’s disease develops degenerative arthritis of hip or knee

May require surgery for spinal stenosis, nerve root compression

Goals -Paget’s Disease (osteitis deformans)

• Goals of the treatment– Relieve pain – Prevent fracture & deformities.

• PT referral - ice or heat may help alleviate pain.• Regular exercise should be maintained; walking is best.

– Avoid extended periods of immobility to avoid hypercalcemia.• 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.

Collaborative Care• Pain relief• Suppression of bone cell activity• Complication prevention

Nsg Dx Paget’s Disease (osteitis deformans)

Nursing Diagnoses

• Chronic Pain

– May involve wearing a back brace for relief of back pain

– Heat therapy and massage

• Impaired Physical Mobility -Assistive devices, cane, walker.

• Potential for Injury - Fall precautions

Home Care: manifestations often relieved by treatment

Ostoemalacia – Adult Rickets

Defined: Metabolic bone disorder characterized by inadequate or delayed mineralization of bone matrix leading to marked deformities of weight bearing bone and pathologic fractures

• abnormal softening of bones caused by deficiencies of phosphorus or calcium or vitamin D

Pathophysiology• Primary causes are vitamin D & Calcium deficiency and

hypophosphatemia

• A disease occurring from a deficiency in vitamin D or calcium and is characterized by a softening of the bones with accompanying pain and weakness.

Osteomalacia (adult rickets)

Present in• Older adults• Very-low-birth weight infants• Strict vegetarians- little vitamin D in vegetables

Caused by (see next slides)

• Diet low in vitamin D –malnutrition or vegetarian• Impaired intestinal absorption of fats• Inadequate sun exposure• Some types of renal failure- vitamin D cannot be processed

properly • Hypophosphatemia: most commonly caused by alcohol abuse

Chronic alcoholism depletes liver stores of vitamin D

How is Vitamin D Supplied?

• Vitamin D is a fat-soluble vitamin, it is able to be dissolved in fat. • While some vitamin D is supplied by the diet absorbed from food by

the intestines, most of it is made in the body

• To make vitamin D, cholesterol, a sterol that is widely distributed in animal tissues and occurs in the yolk of eggs, as well as in various oils and fats, is necessary. – Once cholesterol is available in the body, a slight alteration in the

cholesterol molecule occurs, with one change taking place in the skin.

– This alteration requires the energy of sunlight (or ultraviolet light).

• In its active form, vitamin D acts as a hormone to regulate calcium absorption from the intestine and to regulate levels of calcium and phosphate in the bones

Vitamin D & Nutrition

• Vitamin D deficiency occurs most commonly as a result of extreme malnutrition, or even a poor or unbalanced diet.

• Vegetarians are particularly likely to develop it because there is little vitamin D in vegetables

• Good sources of calcium include • low-fat dairy products• dark green, leafy vegetables • calcium-fortified foods and beverages.

• Food sources of vitamin D include• egg yolks• saltwater fish• liver •

Vitamin D DeficiencyCalcium & Phosphate Levels

• When the body is deficient in vitamin D, it is unable to properly regulate calcium and phosphate levels.

• If the blood levels of these minerals become too low, other body hormones may stimulate release of calcium and phosphate from the bones

to the bloodstream to elevate the blood levels.

Vitamin D Deficiency & Sunlight

• Vitamin D deficiency, as well as rickets and osteomalacia, tends to occur in persons who– Do not eat foods that are rich in vitamin D.– Do not get enough sunlight

• Conditions that result in little exposure to sunlight include:– Living in northern countries– Having dark skin– Being elderly or an infant– Having little chance to go outside– Covering one's face and body, such as for religious reasons.

• Many Arab women cover the entire body with black cloth, and wear a veil and black gloves when they go outside. These women may acquire vitamin D deficiency, even though they live in a sunny climate.

Vitamin D Deficiency & AlcoholismImpaired Absorption of Fats

• Chronic Alcohol depletes the body of Vitamin D (fat soluble)

• The liver cells normally prefer fatty acids as fuel, and package excess fatty acids as triglycerides, which they then route to other tissues of the body.

• However, when alcohol is present, the liver cells are forced to first metabolize the alcohol, letting the fatty acids accumulate, sometimes in huge amounts. 

• Alcohol metabolism permanently changes liver cell structure, which impairs the liver’s ability to metabolize fats. 

• Fatty liver occurs in response to increased synthesis (manufacture) of fat and decreased utilization for energy eventually causing liver enlargement

Alcohol & Bone Health

• Alcohol negatively impacts bone health

– Excessive alcohol interferes with the balance of calcium, an essential nutrient for healthy bones.

– It also increases parathyroid hormone (PTH) levels, which in turn reduce the body’s calcium reserves.

– Calcium balance is further disrupted by alcohol’s ability to interfere with the production of vitamin D, a vitamin essential for calcium absorption.

Osteomalacia & Hypophosphatemia• Hypophosphatemia (low blood phosphate) causes

– Hyperparathyroidism, a condition in which the parathyroid gland produces too much PTH, is one primary cause.

– Poor kidney function, in which the renal tubules do not adequately reabsorb phosphorus

– Problems involving the intestinal absorption of phosphate, such as chronic diarrhea or a deficiency of vitamin D (needed by the intestines to properly absorb phosphates)

– Malnutrition due to chronic alcoholism can result in an inadequate intake of phosphorus.

• Symptoms generally occur only when phosphate levels have decreased profoundly. – muscle weakness– tingling sensations– tremors– bone weakness.

Osteomalacia &Impaired Absorption of FatsVit D = Fat Soluble Vitamin

• GI System (see next slides)– (1) Partial gastrectomy – (2) Small bowel malabsorption syndrome – (3) Hepatobiliary problems

• These may be due to either– disruption of normal physiology of GI motility – nutritional defects occurring due to gastrectomy.

• (1) Changes after gastrectomy : – Decreased absorption of proteins, calcium, Vitamin D & B, Fe, fat – Following gastric surgery, calcium absorption is even less efficient as a result

of rapid emptying of the stomach. – Calcium also binds tightly to unabsorbed dietary fat which further interferes

with its absorption.

(2) Malabsorption of small bowel

• Defined: Malabsorption means the failure of the GI tract, usually the small intestine, to absorb one or more substances from the diet. – Defect or damage to the mucosal lining of the small intestine

where most of our nutrient absorption takes place.

• S/S of malabsorption –

• Initial S/S-diarrhea, bloating, flatulence, cramping and weight loss. • Chronic S/S- deficient in iron, proteins, various vitamins and

minerals and this can lead to degrees of malnutrition & anemias.

• Protein depletion leads to impaired bone formation & osteoporosis

• Calcium deficiency leads to weakening & demineralization of the bone, causing osteomalacia.

(3) Hepatobiliary Function & MetabolismVit D = Fat Soluble Vitamin

• The liver plays a central role in carbohydrate, protein and fat metabolism

• Vitamin D deficiency is common in children with liver and kidney disorders.

• Example: In cholestatic liver disorders where there is significant jaundice, bile salts necessary for the absorption of fat and fat soluble vitamins (including vitamin D) do not get into the intestine. Vitamin D is then lost or not absorbed.

• In addition, the liver processes vitamin D into an active form, so as the liver disease advances, even if vitamin D is absorbed it is not activated.

Process of vitamin D metabolism in the body

Cause of Rickets Symptoms

• Symptoms of rickets include bowed legs and bowed arms. • The bowed appearance is due to the softening of bones, and their

bending if the bones are weight-bearing.

• Bone growth occurs through the creation of new cartilage, a soft substance at the ends of bones.

– When the mineral calcium phosphate is deposited onto the cartilage, a hard structure is created.

– In vitamin D deficiency, though, calcium is not available to create hardened bone, and the result is soft bone.

Adult Rickets -Symptoms - continued 

• Bone Pain or Tenderness– Arms – Legs – Spine – Pelvis

• Increased tendency toward bone fractures

• Dental deformities

• Muscle cramps

• Impaired growth

• Skeletal deformities – Bowlegs

– Forward projection of the breastbone (pigeon chest)

– Bumps in the rib cage (rachitic rosary)

– Asymmetrical or odd-shaped skull

– Spine deformities (spine curves abnormally, including scoliosis-S curve or kyphosis-bow back lean forward, slouch position)

– Pelvic deformities

Osteomalacia -tests   

A musculoskeletal examination reveals tenderness or pain of the bone itself, rather than in the joints or muscles.

• Calcium levels may be low. – Tetany (prolonged muscle spasm) may occur if serum

levels of calcium are low.

– Chvostek's sign may be positive (a spasm of facial muscles occurs when the facial nerve is tapped) indicating low serum levels of calcium.

– Serum calcium will confirm calcium levels normal or low

Osteomalacia -tests   

• Serum parathyroid hormone is frequently elevated as compensatory response to hypocalcemia in client with renal failure or vitamin D deficiency.

• Alkaline phosphatase level usually elevated

• Serum phosphorus- typically is low may be up –renal failure.

• Arterial blood gases may reveal metabolic acidosis.

Osteomalacia -tests 

   Bone x-rays may show decalcification or changes in the shape or structure of the bones.

• Other tests and procedures

• PTH

• Urine calcium

• Calcium (ionized)

• ALP (alkaline phosphatase) isoenzyme

Osteomalacia - Treatment• Oral supplements of vitamin D,

calcium, and phosphorus may be given depending on the underlying cause of the disorder.

• Larger doses of vitamin D and calcium may be needed for people with intestinal malabsorption.

• Monitoring of blood levels of phosphorus and calcium may be indicated for certain underlying conditions

• Regular daily supplements of vitamin D and calcium are usually used for simple vitamin D deficiency

• Vitamin D deficiency due to intestinal problems are best treated with calciferol injection

• A single injection vitamin D, in the form of calciferol (vitamin D2), is stored in the body and can last up to a year before another injection may be needed.

• Most people with osteomalacia find their pain is reduced about two weeks after the injection.

• Extra calcium may also be needed while bone is healing.

• Radiologic evidence of healing apparent within weeks of therapy

Osteomalacia & Exercise

• Like muscle, bone is living tissue that responds to exercise by becoming stronger.

• The best exercise for bones is weight-bearing exercise that forces you to work against gravity.

• Some examples include walking, climbing stairs, lifting weights, and dancing.

• Regular exercises such as walking may help prevent bone loss and provide many other health benefits.

Osteomalacia – Nsg Dx & ManagementOsteomalacia – Nsg Dx & Management

• Nursing Diagnoses1. Alteration in nutrition < body requirements.2. Risk for injury- evaluate home for hazards.

PT consult-assistive devices.3. Impaired physical mobility-conserve energy,gait devices

Nursing Management• Assessment of dietary intake of Vitamin D, calcium, phosphorus,

exposure to ultraviolet light• Management of client responses to bone pain and tenderness,

fractures, muscle weakness• Vitamin D sources include dairy products fortified with Vitamin D

and cod liver oil• If client takes supplements, must be aware of potential for toxicity

with fat soluble vitamins• Fall prevention

Musculoskeletal System- Diagnostic tests:Diagnostic tests:•

X-ray- determine density of the bone.

Arthrogram- visualization of joint structure & movement.

Diskogram- vizualization of intervertebral disk abnormalitiy.

Sinogram- visualizes course of sinus & tissues involved.

CT- to identify soft tissue & bone abnormalities, and various MS trauma.

MRI- to view soft tissue- useful in the dx. Of ligament tears, osteomyelitis, disk

disease.

Musculoskeletal System – Dx Tests

• Bone Mineral Density (BMD) measurements:

• (1) Dual energy x-ray absorptiometry (DEXA)- allows assessment of bone density with minimal radiation exposure- to monitor changes in bone density with treatment.

• (2) Qualitative ultrasound (QUS)- evaluates density, elasticity & strength of patella & calcaneus using ultrasound rather than radiation.

Musculoskeletal System – Dx Tests

• Radioisotope StudiesRadioisotope Studies:

• Bone scan-Bone scan- injection of radioisotopes that is taken up by bone, then scan entire body for degree of uptake-related to blood flow.

• Increased uptake- osteoporosis, Ca of the bone, fractures.

• Decreased uptake-avascular necrosis.

Musculoskeletal System – Dx Tests

• Arthroscopy- insertion of arthroscope into joint (usually knee) for visualization of structure and contents.

• Used for exploratory surgery (removal of loose bodies & biopsy)

and• dx. of abnormalities of meniscus, articular cartilage, ligaments,

or joints capsule.

• Other structures that can be visualized include-shoulder, elbow, wrist, jaw, hip and ankle.

Musculoskeletal System – Dx Tests

Arthrocentesis- incision or puncture of joint capsule to

obtain sample of synovial fluid from joint cavity or to

remove excess fluid.

• Useful in dx. of joint inflammation, infection, and subtle fractures.

Electromyogram (EMG)- evaluates electrical potential associated with skeletal muscle contraction-useful in providing information related to lower motor neuron dysfunction and primary muscle disease.

Musculoskeletal System - Tests

• Muscle enzymes-Muscle enzymes- used to distinguish between muscle weakness that is due to nerve innervation problems and dystrophic disease of the muscle itself.

• The level of enzymes reflects the progress of the disorder and the effectiveness of treatment.

• Example- Creatine kinase (CK),aldolase.

Musculoskeletal System – Dx Tests

• Serologic Studies:• Rheumatoid factor(RF)- assess presence of autoantibody (RF)

in serum.

Erythrocyte sedimentation rate (ESR)- index of inflammation.

Antinuclear antibody (ANA)- assesses presence of antibodies capable of destroying nucleus of body’s tissue cells.

Anti-DNA antibody- detects serum antibodies that react with DNA. It is the most specific test for systemic lupus erythematosus.

Musculoskeletal System – Dx Tests

• Mineral Metabolism:

• Alkaline phosphatase-produced by osteoblast of bone-needed for mineralization of organic bone matrix.

Normal: 20 to 90 U/L (0.3 to 2,7 mmol/L).

• Calcium- bone primary organ for calcium storage. Normal: 9 to 11 mg/dl (2.3 to 2.7 mmol/L).

• Phosphorus- amount present indirectly related to calcium metabolism. Normal: 2.8 to 4.5 mg/dl (0.9 to 1,5 mmol/L)

Musculoskeletal System – Dx Tests

• Miscellaneous:• Thermograpgy- uses infrared detector, which measures

degree of heat radiating from skin surface. Useful in investigation of cause of inflamed joint and in following up pt.’s response to anti inflammatory drug therapy.

•

Somotosensory evoked potebtial (SSEP)-evaluates evoked potential of muscle contractions. Help to identify neuropathy and myopathy.