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Pagets Disease Osteitis Deformans

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Usually affects the axial skeleton, vertebrae and skull, although the pelvis, ... applied to bone, using pins (Steinmann), wires (Kirscher), or tongs (Crutchfield) ... – PowerPoint PPT presentation

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Title: Pagets Disease Osteitis Deformans


1
Pagets Disease (Osteitis Deformans)
  • Excess of bone destruction unorganized bone
    formation and repair. The 2nd most common bone
    disorder in the U.S.
  • The etiology is unknown
  • Usually affects the axial skeleton, vertebrae and
    skull, although the pelvis, tibia, femur are the
    other common sites of disease.
  • Most persons are asymptomatic diagnosis is
    incidental.

2
Pagets Disease (Osteitis Deformans)
  • 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.
  • Bone pain- is the most common symptom. Is is
    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.

3
Pagets Disease (Osteitis Deformans
  • 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.
  • 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.

4
Pagets Disease (Osteitis Deformans
  • Radiograph reveals radiolucent areas in the bone,
    typical of increased bone resorption. Deformities
    fractures may also be present.
  • 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.

5
Pagets Disease (Osteitis Deformans
  • 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.
  • 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.

6
Osteomyelitis
  • Infection of the bone, most often of the cortex
    or medullary portion. Is is commonly caused by
    bacteria, fungi, parasites viruses.
  • Classified by mode of entry- Contiguous or
    exogenous is caused by a pathogen from outside
    the body or the by the spread of infection from
    adjacent soft tissues. The organism is Staph
    aureus. Example- pathogens from open fracture.
    The onset is insidious initially cellulites
    progressing ti underlying bone.

7
Osteomyelitis
  • Hematogenous- caused by bloodborne pathogens
    originating from infectious sites within the
    body.Ex sinus, ear, dental, respiratory GU
    infections. The infection spreads from the bone
    to the soft tissues can eventually break
    through the skin, becoming a draining fistula.
    Again, Staph aureus is the most common causative
    organism.
  • Acute Osteomyelitis left untreated or unresolved
    after 10 days is considered chronic. Necrotic
    bone is the distinguishing feature of chronic
    osteomyelitis.

8
Osteomyelitis
  • The pathophysiology is similar to that infectious
    processes in any other body tissue.
  • Bone inflammation is marked by edema, increased
    vascularity leukocyte activity.
  • The patient report fever, malaise, anorexia,
    headache. The affected body may be erythematous,
    tender, edematous. There may be fistula
    draining purulent material.
  • Blood test- increase WBCs, ESR, C-protein
    levels.

9
Osteomyelitis
  • Treatment is difficult costly. The goal are
    complete removal of dead bone affected soft
    tissue, control of infection elimination of
    dead space (after removal of necrotic bone).
  • The nursing management-use of aseptic technique
    during dressing changes. Observed for S/S of
    systemic infection, administered antibiotic on
    time.
  • ROM exercises are encouraged to prevent
    contractures flexion deformities
    participation in ADL to the fullest extent is
    encouraged.

10
Tumor of the MSS
  • MSS constitute 3 of all malignant tumors.
  • Malignant tends to cause more bone destruction,
    invasion of the surrounding tissues metastasis.
  • Benign tumors- tend to be less destructive to
    normal bone.
  • The cause of bone tumors is unknown.
  • The tumor is defined as a new growth or
    hyperplasia of cells. This growth is in response
    to inflammation or trauma.

11
Tumor of the MSS
  • 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.
  • Pain and swelling at the site limitation of
    movement.
  • Bone biopsy is used to confirm the diagnosis.
  • X-ray films, CT scans, MRI bone scans show
    tumor location size.
  • Historically, the treatment of choice is
    amputation.

12
Tumor of the MSS
  • Ewings sarcoma- A malignant tumor of the bone
    originating from myeloblasts with early
    metastases to lung, lymph nodes, other bones.
  • 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.
  • Pain increased with weight bearing. May complain
    of weight loss, malaise, or anorexia.
  • Causes pathologic fractures.
  • Treatment Palliative, radiation, chemotherapy.

13
Tumor of the MSS
  • Chondrosarcoma- Usually affects persons 50-70
    years old. Accounts for 20 of all bone tumors
  • Affect males than females.
  • Slow growing, insidious onset. Most common in
    humerus, femur, pelvis.
  • Localized pain, swelling. May have palpable mass.
    Severe, persistent pain. May infiltrate joint
    space soft tissue metastasize to the lungs.
  • Treatment Surgical incision, amputation.

14
Tumor of the MSS
  • Fibrosarcoma- Usually affects persons 30- 50
    years old. Affects females than males.
  • Occurs in bony fibrous tissue of femur tibia.
  • Accounts for 4 of primary malignant bone tumors.
  • May result from radiation therapy, pagets
    disease or chronic osteomyelitis.
  • Night pain, swelling, possible palpable mass. May
    cause pathologic fractures.
  • May metastasize to the lungs.

15
Fractures
  • A break in the continuity of bone caused by
    trauma, twisting or as a result of bone
    decalcification. Results when the bone is unable
    to absorb the stress. Result of an accident or
    injury, stress fracture occur as a result of
    normal activity or after minimal injury.
  • Causes of Fracture Fatigue- muscles are less
    supportive to bone, therefore, cant absorb the
    force being exerted. Bone neoplasms- cellular
    proliferations of malignant cells replace normal
    tissue causing weakened bone. Metabolic
    disorders-poor mineral absorption hormonal
    changes decreases bone calcification which
    results in a weakened bone. Bedrest or disuse-
    atropic muscles osteoporosis causes decreased
    stress resistance.

16
Fractures (types)
  • Greenstick- A crack bending of a bone with
    incomplete fracture. Only affects one side of the
    periosteum. Common in skull fractures or in young
    children when bones are pliable.
  • Comminuted Bone completely broken in a
    transverse, spiral or oblique direction (
    indicates the direction of the fracture in
    relation to the long axis of the fracture bone).
    Bone broken into several fragments.
  • Open or compound Bone is exposed to the air
    through break in the skin. Can be associated with
    soft tissue injury. Infection is common
    complication due to exposure to bacterial
    invasion.

17
Fractures (types)
  • Closed or simple Skin remains intact. Chances
    are greatly decreased for infection.
  • Compression Frequently seen with vertebral
    fractures. Bone has been compressed by other
    bones.
  • Complete Bone is broken with disruption of both
    sides of the periosteum.
  • Impacted one part of fractured bone is driven
    into another.
  • Depressed Usually seen in skull or facial
    fractures. Bone or fragments of bone are driven
    inward.
  • Pathological break caused by disease process.
  • IntracapsularBone broken inside the joint.
  • Extracapsular Fracture outside the joint.

18
Fractures (stages of bone healing)
  • Occurs over several weeks
  • New bone tissue occurs in region of break
  • Repair is initiated by migration of blood vessels
    and connective tissue from periosteum in break
    area.
  • Dense fibrous tissue fills from periosteum in
    break area. Osteoblast near the broken area.
    Chondroblast further away from broken area.
  • Cells deposit cartilage between broken surfaces
  • Cartilage is slowly replaced by mineralized bone
    tissue, which completes repair.

19
Fractures (signs symptoms)
  • Pain or tenderness over involved area.
  • Loss of function of the extremity
  • Crepitation sound of grating bone fragments
  • Ecchymosis or erythema
  • Edema
  • Muscle spasm
  • Deformity Overriding Angulation- limb is in
    unnatural position.

20
Fractures (Emergency care)
  • Immobilize affected extremity to prevent further
    damage to soft tissue or nerve.
  • If compound fracture is evident, dont attempt to
    reduce it. Apply splint. Cover open wound with
    sterile dressing.
  • Use splint External support is applied around a
    fracture area to immobilize the broken ends.
    Material used wood, plastic (air splints),
    magazines.
  • Function of the splinting Prevent additional
    trauma, reduce pain, decrease muscle spasm, limit
    movement, prevent complications, such as fat
    emboli if long bone fracture.
  • Provide specific care for fracture treatment
    traction, cast. Surgical intervention.

21
Traction
  • Force applied in two directions to reduce and/ or
    immobilize a fracture, to provide proper bone
    alignment and regain normal length, or to reduce
    muscle spasm.
  • Closed reduction Manual manipulation. Usually
    done under anesthesia to reduce pain relax
    muscles, thereby preventing complications. Cast
    is usually applied following closed reduction.
  • Open reduction Surgical intervention. Usually
    treated with internal fixation devices (screws,
    plates, wires). Cast application.

22
Traction
  • Skeletal Traction Mechanical applied to bone,
    using pins (Steinmann), wires (Kirscher), or
    tongs (Crutchfield). Most often used in fractures
    of femur, tibia, humerus.
  • Skin traction applied by use of elastic
    bandages, moleskin strips, or adhesive. Used most
    often in alignment or lengthening (for congenital
    hip displacement) or to relieve muscle spasms in
    preop hip clients. Most common types are
    Russell, Bucks, Cervical (used for whiplashes
    cervical spasm), -pull is exerted on one plane
    used for temporary immobilization Pelvic
    traction (used for low back pain).

23
Traction(Principles)
  • The line of pull must be maintained. Center the
    patient in the bed place in good alignment.
  • The pull of traction must be continuous. Remove
    or add weights only with MD order.
  • The ropes weights must be free of friction. Be
    certain the weights hangs free at all times
    that the ropes are over the center of the pulley.
  • There must be sufficient countertraction
    maintained at all times. Keep the patient from
    sliding to the foot of the bed.

24
Cast Care
  • After application of cast, allow 24 to 48 hours
    for drying. For synthetic cast, allow 30 minutes
  • Cast will change from dull to shiny substance
    when dry.
  • Dont handle cast during dying process, because
    indentation from fingermarks can cause skin
    breakdown under cast.
  • Keep extremity elevated to prevent edema.
  • Provide for smooth edges surrounding cast. Smooth
    edges prevent crumbling and breaking down of
    edges. Stockinet can be pulled over edge
    fastened down with adhesive tape to outside of
    cast.
  • Observe casted extremity for signs of circulatory
    impairment. Cast may have to be cut if edematous
    condition continues.
  • Always observe for sign symptoms of
    complications pain swelling, discolaration,
    tingling or numbness, diminished or absent pulse,
    paralysis, cool to touch.

25
Cast Care
  • If there is an open, draining area on the
    affected extremity, a window (cut out portion of
    cast) can be utilized for observation and/or
    irrigation of wound.
  • Keep cast dry. Breaks down when water comes in
    contact with plaster. Use plastic bags or Chux
    during bath or when using bedpan, to protect cast
    material.
  • Utilize isometric exercises to prevent muscle
    atrophy to strengthen the muscle. Isometrics
    prevent joint from being immobilized.
  • Position client with pillows to prevent strain on
    unaffected areas.
  • Turn every 2 hours to prevent complications.
    Encourage to lie on abdomen 4 hours a day.

26
Cast (complications)
  • Respiratory complications have client cough DB
    q 2 hours. Turn q 2 hours if not contraindicated.
  • Thrombus embolic formation. Apply SCD. Start
    anticoagulation therapy if needed. Observe for
    S/S of pulmonary and/or fat emboli.
  • Contractures Start ROM exercises to affected
    joints. Provide foot board.
  • Skin breakdown- massage with lotion once a day to
    prevent drying. Alternate pressure mattress,
    sheepskin. Use stryker boots or heel protectors.
  • Prevent urinary retention and calculi. Encourage
    fluids. Monitor intake output.

27
Cast (complication)
  • Prevent constipation Encourage fluids, Provide
    high-fiber diet. Administer laxative or enema as
    ordered.
  • Provide psychological support Allow to ventilate
    feelings of dependence. Encourage independence
    when possible. Encourage visitors for short time
    periods. Provide diversionary activities.

28
Fractures (Complications)
  • Compartment Syndrome An increase in the pressure
    within the a fascial muscle compartment
  • Tissue damage can occur within 30 minutes
    elevated pressure for more than 4 hours can
    result in irreversible damage limb loss.
  • Signs symptoms 6 Ps. Pain-severe,
    unrelenting, unrelieved by analgesia increased
    by elevation of the extremity. Pallor- coolness,
    slow capillary refill. Pulselessness-diminished
    or absent pulses. Increase pressure and
    paresthesia paralysis.
  • Goals of treatment decreasing tissue pressure,
    restoring blood flow preserving function of the
    limb.
  • Diagnosis Intracompartment pressure 30 mm hg.

29
Fractures (Complications)
  • Treatment Fasciotomy-open the affected
    compartment, decrease the pressure restore
    normal perfusion. The wound is covered with wet
    saline dressing.
  • Fat embolism syndrome (FES)-fat globules tissue
    thromboplastin are released from the bone marrow.
    The fat molecules enter the venous circulation,
    travel to the lungs embolize the small
    capillaries arterioles.
  • S/S hypoxemia, tachypnea, fever, chest pain
    altered mental status.The presence of unexplained
    fever, accompanied by a change in mental status
    petechiae, shld. Alert the caregiver to the
    possibility of FES. The MD shld. Be notified
    immediately.

30
Fractures (Complications)
  • Infection leading cause of delayed union
    nonunion, occurs primarily in open or compound
    fractures. The most symptoms occur within 4 weeks
    of the injury.
  • S/S Pain, erythema edema.

31
HIP fractures
  • High incidence in elderly group-most common cause
    of traumatic death after age 75.
  • Fractures caused by brittle bones (osteoporosis)
    7 frequent falls in the elderly.
  • Elderly with hip fractures frequently have
    associated medical conditions (CAD, renal
    disorders).
  • Assessment Intracapsular-bone broken inside the
    joint-treated by internal fixation-replacement of
    femoral head with Austin Moore prosthesis.
  • Placed in skin traction first for immobilization
    relief of muscle spasm.

32
HIP fractures
  • Extracapsular trochanteric fracture outside the
    joint.
  • Can be treated by balanced suspension traction.
    Full weight-bearing usually in 6 to 8 weeks, when
    healing takes place.
  • Surgery usually internal fixation with wire.
  • Intertrochanteric fracture extends from medial
    region of the junction of the neck lesser
    trochanter toward the summit of the greater
    trochanter. Treated initially with balanced
    suspension traction. Internal fixation used with
    nailplate, screws wire. Not allowed to flex hip
    to the side, on the side of the bed, or in a low
    chair. When hip is flexed, displacement can occur.

33
Total hip replacement
  • Replacement of both the acetabulum the head of
    the femur with metal or plastic implants.
  • Used in degenerative diseases or when fracture of
    the head of femur has occurred with nonunion.
  • To prevent flexion, keep operative leg in
    abduction by use of pillow or abductor splints.
  • Keep hemovac in place until drainage has subsided
    (24 to 96 hours).
  • Prevent edema readjust SCD at least every 4 to 8
    hours.
  • Prevent infections- monitor prophylactic
    antibiotic.

34
HIP fractures
  • Continuous passive motion (CPM) first day postop
    with increasing degree of flexion to 90 degrees.
  • Ambulate client carefully at bedside-first or
    second day. Dont allow to bear weight on
    affected hip. Up with walker 2nd post.op day.
  • Prevent thrombus formation from venous
    stasis-promote leg exercises-flexing feet
    ankles.
  • Start physical therapy asap.
  • Instruct not to use low chairs or sit on edge of
    bed. Use commode extenders, high stools, no
    bending over activities.

35
HIP fractures
  • Observe for neurovascular problems in affected
    leg Color and temperature, edema in leg, pain on
    passive flexion of foot, numbness-ability to move
    leg, pedal pulses capillary refill.

36
Total Knee Replacement
  • Implantation of a metallic upper portion that
    substitutes for the femoral condyles a high
    polymer plastic lower portion that substitutes
    for the tibial joint surfaces.
  • Continuous passive motion(CPM) may be ordered
    postop.-moderate flexion extension-increase
    circulation movement.
  • Perform quad-setting straight-leg raising
    exercises every hour.
  • Perform ROM.
  • Do not dangle to prevent disclocation.

37
Total Knee Replacement
  • Hemovac is inserted to drain excessive blood and
    drainage. Maintain accurate I/O. Observe for
    hemorrhage infection.
  • Instruct client for crutch walking.
  • Complications wound infection, DVT, Pulmonary
    and fat embolism, dislocation of the prosthesis.

38
Amputations
  • The surgical removal of a limb, a part of a limb,
    or a portion of a bone elsewhere than at the
    joint site.
  • Removal of a bone at the joint site is termed
    disarticulation.
  • More than 110,000 are performed each year in the
    U.S. 91 of them are lower extremity
    amputations.
  • Occurs in patients with diabetes 15 times more
    frequently than in other patients with chronic
    arterial occlusive disease.

39
Amputations (types)
  • Below the Knee (BKA)
  • Above the knee (AKA)
  • Amputations of the foot and ankles (symes)
  • Amputation of the foot metatarsus and tarsus
    (heys or lisfrancs)
  • Hip disarticulation-removal of the limb from the
    hip joint.
  • Hemicorporectomy- removal of half of the body
    from the pelvis and lumbar areas.

40
Amputations (Assessment)
  • Evaluate dressing for signs of infection or
    hemorrhage.
  • Observe for signs of a developing necrosis or
    neuroma in incision.
  • Evaluate for phantom limb pain.
  • Observe for signs of contractures.
  • Provide preop. nursing care management. Have
    client practice lifting buttocks off bed while in
    sitting position. Provide ROM to unaffected leg.
    Inform about phantom limb sensation- pain
    feeling that amputated leg still there caused by
    nerves in the stump.

41
Amputations
  • Provide post. Op. care. Observe stump dressing
    for signs of hemorrhage infection.
  • Observe for symptoms of a developing necrosis or
    neuroma in area of incision.
  • Provide stump care rewrap ace bandage 3 to 4
    times daily. Wash stump with mild soap water.
    If skin is dry, apply lanolin or vaseline to
    stump.
  • Teaching related stump care. BKA-dont hang stump
    over edge of bed. Dont sit for a long periods of
    time.
  • Above the knee-prevent external or internal
    rotation of limb. Place rolled towel along
    outside of thigh to prevent rotation.

42
Amputations
  • Position in prone position to stretch flexor
    muscle to prevent flexion contractures of hip.
    Done usually after first 24 to 48 hours postop.
    Place pillow under abdomen 7 stump. Keep legs
    close together to prevent abduction.
  • Teach crutch-walking and wheelchair transfer.
  • Prepare stump for prosthesis. Stump must be
    conditioned for proper fit. Shrinking shaping
    stump to conical form by applying bandages or an
    elastic stump shrinker. A cast readies stump for
    the prosthesis.
  • Provide care for temporary prosthesis which
    applied until stump has shrunk to permanent
    state.
  • Recognize respond to clients psychological
    reactions to amputation. Feelings of loss,
    grieving, loss of independence, lowered
    self-image, depression.
  • Continue discussing phantom limb pain with client.
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