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Confidential
Musculoskeletal System
Christina M. Henrich MSN, RN, ACNS-BCRobert Wood Johnson Foundation Future of Nursing Scholar
Clinical Nurse Specialist Orthopaedics
© Cleveland Clinic 2017
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• OLD CART
• O: Onset of complaint
• L: Location of symptoms
• D: Duration of symptoms
• C: Characteristics of the symptoms Health.clevelandclinic.org
• A: Aggravating factors
• R: Relieving factors
• T: Treatment tried and timing of symptoms
Musculoskeletal Assessment: Health History
DOS Course 20172
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• Typical musculoskeletal complaints include pain, loss of
function, joint instability or stiffness, loss of sensation, or
a newly discovered deformity
• An acute condition alerts the provider to a different set of
differential diagnoses than a chronic condition
• Acute conditions involving trauma are suggestive of a
fracture, dislocation, or rupture of tissue
• Mechanism of injury (twisting, blunt force, height of fall)
• Time of when pain occurs
• Location or distribution of pain
Components of Health History
DOS Course 20173
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• Initial observation/impression
• Any sign of potential loss of life or limb is an emergency
requiring immediate attention
• Attitude (position/posture of body part/extremity)
• Alignment (mal-alignment suggest soft tissue injury, fx, or
dislocation)
• Deformity
• Color (redness, ecchymosis, pallor, cyanosis)
• Swelling (diffuse or localized)
Physical Exam Techniques: Inspection
DOS Course 20174
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• Pain
• Tenderness
• Localized temperature changes
• Capillary refill
• Pulses
• Size of lymph nodes
• Muscle shape
• Tone
• Resistance myclevelandclinic.org
Physical Exam: Palpation
DOS Course 20175
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• Joint ROM
• Affected side is compared to the contralateral
• Active and passive ROM
• Note degree of ROM and pain
• Injuries to muscles (strains) or ligaments (sprains) may
result in deformity, weakness, or loss of strength, which
can impact ROM
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Physical Exam: Motion
DOS Course 20176
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Categories of Sprains and Strains
Degree of Strain (Muscle)
• 1st Mild
• Few muscle fibers torn
• 2nd Moderate
• Almost half of muscle torn
• 3rd Severe
• All ligament fibers torn/ruptured
Degree of Sprain (Ligament)
• 1st Mild
• Few ligament fibers torn
• 2nd Moderate
• Half of ligament torn
• 3rd Severe
• All ligament fibers torn or ruptured
DOS Course 20177
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• 5 - Normal strength
• 4 - Movement against gravity with some resistance
• 3 - No resistance, some movement against gravity is
possible
• 2 - Very weak motion, movement dependent on position or
gravity assisted
• 1 - Muscles contract but are ineffective with no movement
• 0 - No muscle contraction, no movement
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Strength Testing
DOS Course 20178
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• Localization of a peripheral or central nervous system
lesion
• Exam includes: sensory, motor, reflex, and cerebella
testing
• Presence of pain and a decrease in or loss of extremity
sensation, strength, or reflexes indicates nerve root
pathology
Neurological Assessment
DOS Course 20179
Health.clevelandclinic.org
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•Level of consciousness
•GCS
•Orientation and speech fluency
•Cranial nerves
•Strength
•Drift
•Sensation
•Ataxia
•Cerebellar signs
Neurological Assessment
DOS Course 201710
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• LOC
– Earliest indication of mental status changes
– Mood, behavior, alertness, awareness
– Orientation to person, place, time
Neurological Assessment
DOS Course 201711
Stimulation tothe Patient in Coma
From Hickey, J.V. (2003). The clinical practice of neurological and neurosurgical nursing.(5th ed.). Philadelphia: Lippincott. Reprinted with permission.
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• 12 nerves in pairs (right and left)
• Nerves 3-12 originate in the brainstem
• Nerve function is a reliable indicator of brainstem function
Memory Jogger:
• “On Old Olympus Tiny Tops A Fin and German Viewed
Some Hops”
Cranial Nerve Assessment
DOS Course 201712
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• I Olfactory
– Smell
– Not often assessed
• II Optic
– Vision acuity
– Visual fields
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Cranial Nerves I, II
DOS Course 201713
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• Pupils
–Reaction
–Size
–Shape
–Equality
• EOMs
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Cranial Nerves III, IV, VI
DOS Course 201714
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• Cotton ball test
• Smile and show me your teeth
Cranial Nerves V and VII
DOS Course 201715
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• Whisper test
– Rare in the inpatient setting
• Balance
– Vertigo
– Nystagmus with EOMs
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Cranial Nerve VIII
DOS Course 201716
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• Gag and Swallow
– Can assess with mouth care and suctioning
• Shoulder shrug
• Tongue movement
– Side to side
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Cranial Nerve IX, X, XI, XII
DOS Course 201717
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• Ataxia – lack of voluntary coordination
– Present if unable to complete these tasks
–Finger to Nose
–Heel Down Shin
–Rapid Alternating Movements
–Gait Disturbance
–Abnormal Movements
Movement and Coordination
DOS Course 201718
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Sensory Testing
Sensory Description
• Sensitive to light touch
• Able to localize pain with
protective sensation
• Responds to deep pain
only, no response to light
touch or pin prick
• Absent response to all
stimuli
Significance of Finding
• Appropriate screening
exam
• Intact proprioception
• Indicates a severe injury or
comatose state
• Associated with loss of
nerve function and
complete nerve transection
DOS Course 201719
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Reflex Testing
Grade
• 0+
• 1+
• 2+
• 3+
• 4+
Response
• Absent
• Hypoactive
• Normal
• Brisk
• Hyperactive with clonus
DOS Course 201720
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• Note any recent trauma or injury involving the head
• Numbness, tingling, paralysis, and neck or arm positions
that aggravate or induce the symptom
• Radicular symptoms which spread down the arm
• Neck pain w/o hx of trauma (degenerative OA, or RA)
• Pain in C-spine region may originate from adjacent
structures (teeth, jaw, cardiovascular system, shoulders)
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Physical Assessment: Cervical Spine (Neck)
DOS Course 201721
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• Back pain typically fits into one of four categories: disk,
facet, nerve root involvement, or neurogenic intermittent
claudication
• Index of suspicion based on patient’s age, occupation,
description of symptoms, and pattern of symptom
presentation
• Serious spine pathology should be considered if any of
the following red flags are noted: symptoms in patient
younger than 20 or older than 55, history of violent
trauma, carcinoma, drug abuse, chronic systemic steroid
use, HIV, unintended significant weight loss, & neurologic
compromise
Lumbar Spine (Back)
DOS Course 201722
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• Oppenheim test
• Babinski reflex
• Beevor’s sign
• FABERE (Patrick’s) test
• Femoral nerve stretch
• Hoover test
• Valsalva maneuver
• Scoliosis test
• Straight leg test
• Brudzinski’s sign
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Special Spine Tests
DOS Course 201723
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• The most common outpatient hip problems are related to
bursitis, arthritis, avascular necroses of the hip, fractures,
metastatic disease, vascular occlusions, and or referred
pain from the low back
• Trauma related hip pain in the elderly is highly suggestive
of a hip fracture
• Younger patients with trauma-induced pain in the
absence of fracture are suspect for hip labral tears
• Structures adjacent to the hip (lumbar spine, knee, lower
GI tract and reproductive tract) should be evaluated for
referred pain
Hip
DOS Course 201724
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• Presence of knee pain associated with trauma
• Did the injury occur while suddenly accelerating or
decelerating after moving at constant speed?
• Was an audible pop heard?
• Did it occur while bearing weight and rotating the leg?
• Swelling in the knee immediately following an injury
signifies trauma within the joint
• Any functional limitation (kneeling, cutting, pivoting,
twisting, climbing)
Knee
DOS Course 201725
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• Is the pain worse after sitting for long periods of time?
• Has the knee been previously injured?
• Do medications relieve symptoms?
• Is there pain at rest or during the night?
Knee
DOS Course 201726
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Diagnostic Studies in Orthopaedics: Serum
• Acid Phosphatase (ACP)
• Aldolase (ALD)
• Alkaline Phospatose
(ALPA)
• Anti-Nuclear Antibody
(ANA)
• Anti-Steptolysin O (ASO)
• Calcium
• Creatine Kinase (CK)
• Creatinine
• C-Reactive Protein (CRP)
• D-Dimer test
• Enzyme-Linked
Immunosorbent Assay
Test (ELISA)
• Erythrocytes/Red Blood
Cells
• Erythrocyte Sedimentation
Rate (ESR)
• Erythropoientin
• Hematocrit
DOS Course 201727
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Diagnostic Studies in Orthopaedics: Serum
• Hemoglobin
• Lyme Antibody
• Iron
• Leukocytes/WBCs
• Lupus Erythematous Cell
• Phosphorus
• Rheumatoid Factor (RF)
• Serum Osteocalcin
• Total Iron Binding Capacity
Health.clevelandclinic.org
DOS Course 201728
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• Bence Jones Protein
• Urinalysis
• Urine Calcium
• Urine Creatinine Clearance
• Urine Collagen-Linked N-Telpeptide
Diagnostic Orthopaedic Tests: Urine
DOS Course 201729
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• Angiography
• Arthrography
• Bone Scan
• Computed Tomography (CT)
• Positive Emission Tomography
• Duplex Ultrasound Imaging
• Indium WBC Scan
• Magnetic Resonance Imaging
• Musculoskeletal Ultrasound consultqd.clevelandclinic.org
Diagnostic Orthopaedic: Radiographic Tests
DOS Course 201730
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DOS CME Course 201131
Every Life Deserves World Class Care
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• Inflammatory disorder of bone caused by infection
• Can lead to necrosis and destruction of bone
• Infection may be acute or chronic
• Acute osteomyelitis infection occurs prior to necrosis or
bone destruction
• Chronic osteomyelitis symptoms present for >3 months
Orthopaedic Infections: Osteomyelitis
DOS Course 201732
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• Spread from soft tissues and joints via decubitis or
diabetic ulcers
• Hematogenous seeding (vertebral or long bone
metaphyses)
• Direct inoculation of a microorganism into the bone
• Prosthetic joint infections
Osteomyelitis
DOS Course 201733
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• Organism causes acute inflammation of the bone
• Inflammatory factors and leukocytes contribute to
necrosis and destruction of the bone
• Vascular channels are compressed leading to ischemia
and later bone necrosis
• Biofilm may lead to prosthetic orthopaedic infections
• Bacteria living in a biofilm can have a significantly
different properties than free floating bacteria
Pathophysiology
DOS Course 201734
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• Young age
• Predispose to bacteremia (indwelling intravascular
catheters, distant foci of infection, IV drug abuse)
• Distant site infections often associated with acute
osteomyelitis (skin, urinary tract, respiratory tract)
• Sickle cell anemia
• Chronic granulomatous dx
• Penetrating bites or puncture wounds
• Open bone fractures
• Pressure ulcers
Osteomyelitis Risk Factors
DOS Course 201735
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• Morbidity
• Mortality
• Bone loss
• Localized Osteoporosis
• Osteolysis
• Pathologic Fx
• Sepsis
Osteomyelitis Complications
DOS Course 201736
Ghr.nlm.nih.gov
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• Abrupt onset of high fever (only in 50% of neonates with
osteomyelitis)
• Fatigue
• Irritability
• Malaise
• Restriction of movement
• Local edema, erythema, and tendernessmy.clevelandclinic.org
Hematogenous Long Bone Osteomyelitis
DOS Course 201737
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• Insidious onset
• History of an acute bacteremia episode
• May be associated with continguous vascular
insufficiency
• Local edema, erythema, and tenderness
• Failure of a young child to site up normally
Hematogenous Vertebral Osteomyelitis
DOS Course 201738
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• Non-healing ulcer
• Sinus tract drainage
Chronic Osteomyelitis
DOS Course 201739
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• Signs or symptoms of soft tissue and bone tenderness
• Swelling and redness
• Prosthetic joint suspected (joint aspiration)
• X-ray (does not show changes to bone in early phase; it
can take 10-14 days after the start of an infection to show
bone lysis)
• CT & MRI are considered standard for dx
• WBC, erythrocyte sedimentation rate, c-reactive protein
(may be elevated in a patient with osteomyelitis)
• Needle bone aspiration
Osteomyelitis: Exam & Diagnostic Tests
DOS Course 201740
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• Non-surgical treatment for osteomyelitis starts with
improving any host deficiencies (anemia, hypoxia,
hyperglycemia, metabolic issues)
• Antibiotic tx
• More complex cases may require extensive surgical
debridement
consultqdclevelandclinic.org
Therapeutic Modalities
DOS Course 201741
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• Acute care setting (pain assessment)
• Activity intolerance (pressure ulcers)
• Office setting (reinforcement of discharge instructions)
• Long-term antibiotic therapy (reminders re: importance of
taking antibiotics as prescribed)
• Education re: signs and symptoms to report (fever, chills,
increased drainage, changes in tissues surrounding the
area, etc.)
• Teach appropriate use of mobility aids and weight
bearing limitations
Nursing Interventions & Patient Education
DOS Course 201742
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DOS CME Course 201143
Every Life Deserves World Class Care
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• Infection of synovium and joint space
• Knee (50% of cases)
• Hip (20% of cases)
• Inflammatory response
• Gonococcal vs Non-Gonococcal
• Patients at risk for septic arthritis have abnormal joints
because of arthritis (RA, osteoarthritis, injury induced
arthritis)
Septic Arthritis
DOS Course 201744
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• Bacteria or microorganisms spread through the
bloodstream to a joint
• In immunocompromised patients, bacteria that that
usually are not pathogenic can cause infection
• Staphylococcus aureus is the most common organism
• Symptoms usually develop quickly (fever, joint swelling,
joint pain)
• As the infection progresses, cartilage is destroyed
Septic Arthritis
DOS Course 201745
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• Failure to resolve infection
• Progression of articular cartilage damage
• Severe degenerative changes
• Children can develop limb deformities
• Patients with septic arthritis of the hip may later develop
avascular necrosis of the femoral head
• Renal, cardiac, or respiratory failure in the elderly
Septic Arthritis Complications
DOS Course 201746
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• Assessment of worsening infection (vital signs, changes
in mental status, pain)
• In office setting (observe for any signs or symptoms of
extended infection and assess the patient’s response to
antibiotic therapy)
• Allow patients to verbalize fears and apprehension to
assist with adherence to the treatment plan
Nursing Considerations
DOS Course 201747
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• Infection surrounding a prosthetic joint
• Classified into early, delayed, and late onset
• Hematogenous spread (IV catheters, pneumonia, UTI,
dental caries, gum disease, and skin conditions)
• Leads to seeding of the prosthetic joint
• In cases of TKR, progressive infections may lead to
amputation
Prosthetic Joint Infections
DOS Course 201748
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• Early onset
• Usually acquired during implantation
• Often due to virulent organisms (staph aureus or gram
negative bacteria)
• Present with acute onset pain, fever, drainage
Health.clevelandclinic.org
Classification Based on Onset of Infection
DOS Course 201749
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• Delayed onset
• >30 days post-operatively
• Up to 1 year is considered healthcare associated
• Less virulent organism
• Present with progressive pain
Classification Based on Onset of Infection
DOS Course 201750
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• Late onset
• >1 year after surgery
• Develop in the setting of infection at another site
• Associated with Streptococci, Staph, and gram neg
bacteria
• Presentation similar to acute onset in previously well-
functioning joint
Classification Based on Onset of Infection
DOS Course 201751
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• Common and usually uncomplicated
• Can worsen if not recognized and treated properly
• Impetigo
• Folliculitis
• Cellulitis
• Pyomyositis
• Clostridial myonecrosis
• Necrotizing fasciitis
Skin & Soft Tissue Infections
DOS Course 201752
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• Cellulitis (fever, hills, general malaise)
• Gas gangrene (toxins necrotize the muscle and release gas,
producing the classic symptoms of swelling with purple or
bronze discoloration) patients can become quickly toxic and
pain is usually severe
• Patients with necrotizing fasciitis may have skin
discoloration, blisters, skin drainage, crepitus, and swollen
gland near affected site
clevelandclinicmeded.com
Skin & Soft Tissue Infections
DOS Course 201753
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DOS CME Course 201154
Every Life Deserves World Class Care
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• Systemic autoimmune disease
• Characterized by chronic joint inflammation that most
commonly affects peripheral joints
• This process results in the development of pannus, a
destructive tissue that damages cartilage.
• Can affect organs
– Sjogren’s Syndrome (inflammation of glands)
– Lungs: pleuritis, nodules of lungs/scarring
– Cardiac: pericarditis
– Anemia/leuokopenia
– Felty’s syndrome (enlarged spleen)
– Vasculitis (necrosis)
Rheumatoid Arthritis
DOS Course 201755
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• Cause is unknown
• ? Genetic component
– HLA (human leukocyte antigen)
–rural Nigeria – no individuals are affected with RA
–Some Native American tribes – incidence 5%
• ? Infectious agent (viruses, bacteria, fungi)
• ? Environmental factors
– Smoking increases risk of developing RA
Rheumatoid Arthritis
DOS Course 201756
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RA Pathophysiology
DOS Course 201757
Source: Goldman: Cecil Medicine, 23rd ed
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• Prevalence:
– 5 to 10 cases/1000 adults.
– most common autoimmune disease in the world
– Affects approximately 1.2 million people in US
• PREDOMINANT SEX:
– Female/male ratio of 3:1
– After age 50 yr, sex difference less marked
• PREDOMINANT AGE:
– 35 to 45 yr
RA Epidemiology & Demographics
DOS Course 201758
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• Onset gradual
– common prodromal symptoms of weakness, fatigue, and
anorexia (can occur months before presentation of joint sx)
• Initial presentation:
– multiple symmetric joint involvement
–hands and feet, usually metacarpophalangeal, metatarsophalangeal,
and proximal interphalangeal joints
–Joint effusions, tenderness, and restricted motion usually present early
in the disease
– Eventual characteristic deformities: subluxations, dislocations, joint
contractures
RA Physical Findings & Clinical Presentation
DOS Course 201759
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Comparison of RA and OA
DOS Course 201760
Source: Goldman: Cecil Medicine, 23rd ed
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RA Physical Findings & Clinical Presentations
DOS Course 201761
Source: Moser & Riegel: Cardiac Nursing, 1st ed
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• Systemic lupus erythematosus (SLE)
• Seronegative spondyloarthropathies
• Polymyalgia rheumatica (PMR)
• Acute rheumatic fever
• Scleroderma
RA Differential Diagnosis
DOS Course 201762
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• ACR
– rheumatoid arthritis exists when four of seven criteria are present,
with criteria 1 to 4 being present for at least 6 wk:
1. Morning stiffness >1 hr
2. Arthritis in three or more joints with swelling
3. Arthritis of hand joints with swelling
4. Symmetric arthritis
5. Rheumatoid nodules
6. XR changes typical of RA
7. Positive serum rheumatoid factor
RA Diagnosis Criteria
DOS Course 201763
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• +RF (rheumatoid factor)
– RF is an antibody directed against the Fc region of the IgG that
has been used as a diagnostic marker for rheumatoid arthritis.
– 80% of cases positive in RA
–(rheumatoid factor also present in the normal population).
• Anti-CCP
• autoantibodies against cyclic citrullinated peptide (CCP).
• Anti-CCP autoantibodies are more specific than RF for diagnosing
rheumatoid arthritis and may better predict erosive disease.
• Sensitivity and specificity of the anti-CCP test for RA is 67%
RA Laboratory Tests
DOS Course 201764
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• CBC
– Possible mild anemia
– Possible mild leukocytosis
• Elevated acute phase reactants (erythrocyte
sedimentation rate, C-reactive protein)
• Arthrocentesis
– Assess for wbc/crystals/protein/glucose/cultured
RA Laboratory Test (con’t)
DOS Course 201765
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• CXR
• Plain radiography:
– Reveals soft tissue swelling and osteoporosis early
– Eventually, joint space narrowing, erosion, and deformity visible
as a result of continued inflammation and cartilage destructioN
RA Imaging Studies
DOS Course 201766
Source: Ferri: Ferri's Clinical Advisor 2011, 1st ed.
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• NSAIDS
– Initial tx to relieve inflammation
• Prednisone
– Oral
– Intrasynovial steroid injections
RA Treatment
DOS Course 201767
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• Diet
– No special diet
– ?anti-inflammatory diet
• Rest and Exercise
• OT/PT
• Education
• Joint Protection
• Surgical intervention
RA Treatment Non Pharmacological
DOS Course 201768
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DOS Course 201769
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DOS Course 201770
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DOS Course 201771
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DOS Course 201772
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DOS Course 201773
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DOS Course 201774
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• DMARDS
– Gold
– Azathioprine (Imuran)
– Cyclosporine
– Hydroxychloroquine sulfate (Plaquenil)
– Leflucomide (Arava)
– Methotrexate (Rheumatre, Trexall)
– Minocycline (Minocin)
– Sulfasalazine (Azulfidine)
RA Treatment
DOS Course 201775
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• Biologic DMARDS
– Abatacept (Orencia) T Cell- IV infusion Monthly
– Adalimumab (Humira) TNFa-(SQ inj q 2 weeks)
– Anakinra (Kineret) IL-1-injected daily
– Certolizumab pegoi (Cimzia) –TNFa- SQ monthly
– Etanercept (Enbrel) TNFa- (SQ weekly or twice weekly)
– Golimumab (Simponi) TNFa-SQ monthly
– Infliximab (Remicade) TNFa-IV infusion q6-8 weeks
– Rituximab (Rituxan) B cell- IV infusion
– Tocilizumab (Acterma) IL-6 (IV monthly)
RA Treatment
DOS Course 201776
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DOS CME Course 201177
Every Life Deserves World Class Care
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• Pathophysiology:
• Cartilage degeneration
• Thickening of subchondral bone
• Formation of osteophytes
Cause:
• No single cause
• Idiopathic or Secondary
Risk Factors:
• Age, Sex hormones, Genetic
• Modifiable - ↑ weight, ↓ activity
DOS Course 201778
Osteoarthritis-OA
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• Joint Pain - 1° Symptom
– Localized, asymmetrical
– Increases with use
• Stiffness - Gelling
– Improves with activity, <30 mins
– May have crepitus, effusion
• Joint Deformity
– Heberdens, Bouchards
– Leg deformities
OA- Clinical Manifestations
DOS Course 201779
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• H & P – Most often sufficient
to diagnose OA
• Labs – CBC
Renal & Liver panel
RF & ESR
• X-Ray - Osteophytes,
narrowing joint space
• MRI
Diagnosis
DOS Course 201780
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• Exercise – Walking, swimming, water aerobics, Yoga
Activity Modification – Periods of activity followed by rest
• Weight Reduction
• Heat & Cold
• Pharmacologic – Acetaminophen recommended
NSAIDS – Salicylates
COX-2 Inhibitors
Intra-articular Corticosteroids
• Surgical - Osteotomy, Arthrodesis, Arthroplasty
.
OA - Management
DOS Course 201781
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• Idiopathic Scoliosis
• Congenital Scoliosis
• Neuromuscular Scoliosis
• Post-irradiation Scoliosis
• Non-structural Scoliosis
CCF
Spinal Column Deformities: Scoliosis
DOS Course 201782
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• Lateral curvature of the spine with vertebral rotation
• Curvature described as structural or non-structural
• A structural curvature does not correct itself on forced
bending against the curvature
• A non-structural curvature is one that is corrected on
forced bending
Scoliosis
DOS Course 201783
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• Most common form of scoliosis
• Cause is unknown
• Occurs in normal, healthy growing children who have no
other apparent issues
• Preadolescents and adolescents most common
• Progressive idiopathic scoliosis occurs more often in girls
Health.clevelandclinic.org
Idiopathic scoliosis
DOS Course 201784
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• Malformation of the body vertebral segment of the spine
• Cause is unknown
• Failure of formation (absence of a portion of vertebra)
• Failure of segmentation (absence of normal separation
between vertebrae)
• Incidence is less than 0.5%
Congenital Scoliosis
DOS Course 201785
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• Cerebral Palsy
• Syringomyelia
• Polio
• Myelomeningocele
• Spinal muscular atrophy
• Spinal cord tumors
• Muscular Dystrophy
• Myotonia
• Hypotonia
Neuromuscular Scoliosis
DOS Course 201786
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• Partial or complete paralysis or the trunk musculature can
cause long, sweeping scoliosis
• Higher incidence of compromised health
• Often frail and have decreased pulmonary function
• Surgery is treatment of choice
Neuromuscular Scoliosis
DOS Course 201787
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• Spina bifida occulta
• Incomplete closure of laminae, one or more vertebrae
• Absence of protrusion of intraspinal contents to surface
• Possible overlying cutaneous defect, neurologic deficit,
spinal cord dysplastic changes
Classifications of Spina Bifida
DOS Course 201788
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• Meningocele
• Unfused vertebral arches
• Visible meningeal sac filled with cerebral fluid and
composed of dura mater or arachnoid, no nerve tissue
• Sensory, motor, reflex status intact
• No sphincter disturbance
Classifications of Spina Bifida
DOS Course 201789
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• Myelomeningocele
• Unfused vertebral arches
• Cystic distention of meninges, nerve tissue within or
adherent to sac
• Spinal cord myelodysplasia
• Neurologic deficits (sensory, motor, reflex, sphincter)
caudal to level of lesion
Classifications of Spina Bifida
DOS Course 201790
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• Diagnosis is often made when there is a history of back
pain and an associated onset of spinal deformity
• Scoliosis in young clients is rarely accompanied by pain
• If pain is present and consistent, further work-up to rule
out spinal tumors should occur
• Osteoid osteoma is a benign bone tumor often appears
as painful scoliosis first
• Localized back pain that is exacerbated at night
Tumors
DOS Course 201791
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• Spinal deformities may occur after radiation therapy
• Higher incidence after treatment for Wilms’ tumor or
neuroblastoma
• Leads to asymmetrical growth in adjacent growth plates
and soft tissues
• Radiation oncologists are able to develop a treatment
plan to reduce risk for development
Post irradiation Scoliosis
DOS Course 201792
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• Posterior rounding at the thoracic level of the spine
• Curvatures greater than 45 degrees
• Considered postural if an individual can voluntarily
hyperextend the spine to correct the curvature
Kyphosis
DOS Course 201793
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• Kyphosis can be associated with neuromuscular
disorders such as:
• Cerebral Palsy
• Spinocerebral degeneration
• Spinal muscle atrophy
• Muscular Dystrophy
Neuromuscular Kyphosis
DOS Course 201794
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• Developmental milestones
• Onset of deformity
• Leg length discrepancies
• Symptoms of pain or weakness
• Family history
• Patient perception of problem and/or concerns
Nursing History: Spinal deformity
DOS Course 201795
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• Complete orthopaedic and neurologic examination should
be performed
• Any evidence of unusual gait, weakness, abnormal
reflexes or sensation should be a cause for concern and
evaluated
• Cysts, tumors, or herniated nucleus pulposus can cause
spinal deformity
Nursing Assessment: Spinal Deformity
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• The patient is first observed from the back
• Standing with equal weight on both feet, arms hanging
freely at the sides and relaxed
• Evaluation of symmetry of the shoulders, scapula, waist,
and arm length
• Ask patient to place fingertips together (as if diving into a
pool) and bend forward
• Observation for thoracic rib prominence or paravertebral
prominence can be used
• Facing the examiner look for symmetry of the shoulders,
breasts, anterior rib cage, waist creases, and arm length
Screening Assessment
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• Nonsurgical treatment includes: observation, braces,
exercise regimens
• Individual traits and personalities must be considered for
treatment to be successful
• Braces (best known Milwaukee)
• Bracing for scoliosis or kyphosis is complex
• A full-time brace program can place emotional stress on
an adolescent
Treatment Modalities and Nursing Management
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• Common problems with braces is skin irritation and
breakdown
• Meticulous skin care
• Cotton T-shirts should be worn under the brace
• Patients are told to gradually increase the time spent
each day wearing the brace
• Some patients may have difficulty eating with a brace on
Treatment Modalities and Nursing Management
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• Hygiene – daily shower and changing T-shirt under brace
• Watch for skin irritation
• If a sore develops, discontinue brace and call the nurse or
physician immediately
• Do not use lotion or power under the brace
• Bracing is necessary until growth is complete, which
usually occurs 2 years after the onset of menses in
females
Patient education
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DOS CME Course 2011101
Every Life Deserves World Class Care
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• Low back strain
• Herniated nucleus pulposus
• Spondylolysis
• Spondylolisthesis
• Spinal stenosis
Health.clevelandclinic.org
Low Back Disorders
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• Most common cause of back pain
• Often occurs following a change in activity, and not
necessarily related to trauma to the lower back
• An activity as common as house cleaning could trigger a
bout of low back pain
Low Back Strain
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• Narrowing of the spinal canal and bulging or extrusion of
the disc material into the canal
• The disc then exerts direct contact on neural structures
• The nucleus pulposus (termed bulging) may or may not
cause significant problems
• The size of the spinal canal, the location of the defect,
and the relative quantity of nucleus pulposus present all
influence the treatment plan
• If neurologic deficit is present (marked weakness, bowel
or bladder difficulties) surgical intervention may be
necessary
Herniated Nucleus Pulposus
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• Defect or break in the neural arch between the superior
and inferior articulating processes
• The union between these two areas is normally bone
• In spondylolsis it is composed of fibrocartilaginous tissue
Spondylolysis
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• Forward subluxation of one vertebra on another
• The condition can develop at an early age, but does not
usually become symptomatic until later childhood or
adolescence
Spondylolisthesis
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• Narrowing of the spinal canal
• CT scan or myelogram
• Stenosis can be congenital or degenerative
• Can occur in any region of the spine
• Significant neurologic compromise may occur if a
narrowed canal is invaded by disc material
• Higher incidence with older adults due to natural
degeneration and arthritic changes
Spinal stenosis
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• Focus on chief complaint symptoms such as: back or leg
pain, numbness, weakness, etc.
• Include history of how patient is coping with the problem
or disability
• Patients with chronic pain often have a difficult time
coping with the situation
Nursing History Assessment: Spinal Stenosis
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• Include orthopaedic and neurologic examination
• Observe ease with which patient is able to move around
the examination room
• Evaluate gait (limp, lurch, weakness)
• Reflex testing
• Motor strength of all muscle groups in the lower
extremities
• Lower extremity pulses (vascular dx can mimic spinal
radiculopathy)
Physical Assessment
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• A patient with a herniated nucleus pulpolsus may
describe a specific incident that led to immediate leg pain
and is typical of the acute disc rupture
• A small tear in the annulus may allow the nucleus to
rupture slowly, giving a picture of gradual but persistent
onset of radicular pain
• The patient may also note increased pain with sneezing,
coughing, or the Vasalva’s maneuver
Physical Assessment
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• Spondylolistesis patients usually have a history of low
back pain, sometimes radiating into the lower extremities
• Increased lumbar lordosis and a waddling gait are
common with more severe subluxation
• Most patients will be unable to touch their toes, and
straight leg raise is limited
• Bowel and bladder difficulties, as well as decreased
motor reflex and sensation may be present
• A patient with spinal stenosis may describe leg pain that
begins after walking a short distance
Physical Assessment
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Acute Low Back Pain
• Measures to decrease inflammation
Analgesics – Tylenol
NSAIDS - COX-2 Inhibitors
Muscle relaxants
• Bed Rest – Short term
• Heat & Cold
• Exercises – Aerobics
Abdominal strengthening
• Physical Therapy – Reconditioning Exercises
• Walking
• Acupuncture
Management
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Surgical Interventions
• Laminectomy
• Spinal Fusion
• Microdiskectomy
Mangement
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• The cervical spine is reliant on the tendons, muscles,
bony anatomy, and disc bonds for stability
• It lacks the additional protection of the visceral organs,
ribs, and large groups of muscles, as are found in the
thoracic and lumbar spine
• Smaller diameter of spine canal
• Cervical spine disease can have potential catastrophic
outcomes if undetected and untreated
Cervical Spine Disorders
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• An examination of both the upper and lower extremities
should be performed after any spinal surgical procedure
• For lumbar surgery, the examination can be focused on
the lower extremities
• Any deviation from normal should be reported
• Sensory and motor function should be assessed every 2
hrs in the first 24 hrs
• Neurologic assessments should be made every 4-8 hrs
until discharge
Neurologic Monitoring
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• Dutton, M. (2012). Dutton's Orthopaedic Examination
Evaluation and Intervention 4/E. McGraw Hill
Professional.
• Maher, A. B., Salmond, S. W., & Pellino, T. A. (2002).
Orthopaedic nursing. Saunders.
• NAON (2013). Core Curriculum for Orthopaedic Nursing.
• Swiontkowski, M. F., & Stovitz, S. D. (Eds.). (2006).
Manual of orthopaedics. Lippincott Williams & Wilkins.
References
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