Back pain and bone problems

Question 1

Back pain

Answer 1

affects 80% of adults, 2nd most common complaint in primary care, can be acute or chronic, affects lumbar region, bears most of body weight and contains most nerve roots

Question 2

Back pain causes

Answer 2

lumbosacral strain
 muscle injury
 osteoarthritis of spine
 degenerative disc disease
 herniation of intervertebral disc
 neurological issue

Question 3

low back pain symptoms

Answer 3

muscle ache, shooting/stabbing pain, radiating
(More likely to radiate w/ herniated disc), limited mobility, gait difficulty

Question 4

low back pain diagnosis

Answer 4

subjective history, physical exam, X-ray, MRI to r/o complex etiology

Question 5

Low back pain treatment

Answer 5

NSAIDS, muscle relaxants, opioid analgesics,
massage, chiropractic manipulation, cold/hot
therapy, rest, gentle stretching

Question 6

low back pain prevention

Answer 6

weight loss, weight bearing exercise, improvement of body mechanics, muscle strengthening

Question 7

sciatica

Answer 7

compression of sciatic nerve by bulging disk

Question 8

Laminectomy

Answer 8

removal of larger portion of vertebra to relieve compression of cord and roots

Question 9

Discectomy

Answer 9

can either be the removal of herniated bone fragments or removal of the damaged portion of the herniated disc (can also have fusion of the vertebral spinous process with a bone graft)

Question 10

Osteoporosis

Answer 10

loss of bone mass and density, bone fragility, fracture, affects 50% women >50, affects them 8x more than men (lower calcium intake, less bone mass, accelerated bone loss after menopause

Question 11

Osteoporosis risk factors

Answer 11

> 65, female, low BMI, Caucasian/Asian, smoking, sedentary, postmenopausal, family history, diet low in calcium/Vit D, excessive alcohol, low testosterone, long term use of steroids and thyroid replacement, long term use of seizure meds

Question 12

Osteoporosis diagnosis

Answer 12

Not detectable with conventional X-ray until 25-40% calcium in bone is lost
 Women: initial bone scan or DXA before age 65
 Men: before age 70
 All: before age 45-50 if high risk

Question 13

Osteoporosis DXA

Answer 13

T-score -1 or greater = normal bone density
Osteopenia = T-score between -1 and -2.5- Precursor to osteoporosis
Osteoporosis = -2.5 or less

Question 14

Osteoporosis prevention

Answer 14

Adequate calcium intake:
 1000 mg/day pre-menopausal & postmenopausal women taking
Estrogen
 1500mg/day postmenopausal women NOT taking Estrogen
 Vitamin D Supplementation
 20 minutes sun exposure/day
 Vitamin D 800-1000 iu/day for postmenopausal women & men at
risk
 Quit smoking & decrease alcohol use

Question 15

Osteoporosis meds

Answer 15

Biphosphonates:
 alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel)
 GI side effects, need to be UPRIGHT 30 minutes; nephrotoxic if
GFR <30 ml/min
 Other Meds:
 Evista, Prolia, Forteo

Question 16

Osteomyelitis

Answer 16

severe bone infection (abscess)
vascular rich bones are the most common targets- pelvis, tibia, vertebrae, can lead to ischemia of bone (difficult to treat bc of difficulty for antibiotics to penetrate bone (usually chronic, lasts greater than 1 month

Question 17

Osteomyelitis causes

Answer 17

Staph aureus = most common organism**
 from wound, open fracture, surgery, indwelling prosthetic
device (joint replacement, fixation device)
 Other organisms:
 E. coli (from UTI)
 Pseudomonas (from wounds)
 Fungal source

Question 18

Osteomyelitis symptoms

Answer 18

Local: bone pain, swelling, tenderness, warmth,
restricted movement
Systemic: fever, chills, night sweats, nausea,
malaise

Question 19

osteomyelitis diagnosis

Answer 19

blood cultures
 wound cultures
 CBC - elevated WBC
 Erythrocyte sedimentation rate (ESR) - elevated
 Bone scan
 MRI
 bone biopsy to determine causative organism

Question 20

osteomyelitis treatment

Answer 20

IV antibiotic therapy, surgical intervention, hyperbaric O2 (slides 36 and 37)

Question 21

Osteomyelitis nursing care

Answer 21

pain management, infection control, improvement of mobility, DVT prevention, med admin, pt ed and support, long term care (slides 38 and 39)

Question 22

Osteoarthritis

Answer 22

degenerative joint disease- disease of aging
NOT autoimmune
NOT inflammatory
NOT systemic
Peaks @ ages 50-60
Affects women > men

Question 23

OA patho

Answer 23

breakdown of articular cartilage, formation of bone spurs protruding into joint space, decreases joint movement

Question 24

OA symptoms and common joints

Answer 24

pain and stiffness worse in morning, decreased movement, heberdens nodes in hands
hips, knees, spine, hands

Question 25

OA dx

Answer 25

x ray, physical exam

Question 26

OA assessment

Answer 26

Pain
 Mobility
 Stiffness
 Inspect joint
 usually enlarged
 may appear deformed
 nodules may be noted
 Crepitus
 grating sensation caused by irregular cartilage
 felt or heard when joint is mobilized

Question 27

OA meds

Answer 27

tylenol, NSAIDs, celebrex, topical analgesics, topical voltaren gel, glucosamine and chondroitin, intra-articular joint injections (steroids, synivisc)

Question 28

Other OA treatments

Answer 28

Exercise
 Orthotic devices
 Walking aids
 Massage
 Yoga
 Accupuncture
 Stem cell research
 delivery of stem cells into B.M.
 may stimulate regeneration of
cartilage & inhibit bone
destruction ???

Question 29

OA health promotion

Answer 29

maintain healthy weight, avoid activities that promote stress on joints, limit recreational sports that damage joints

Question 30

OA surgical management

Answer 30

Last option…in presence of severe pain & limited
mobility
 Total Joint Arthroplasty (TJA)
 a.k.a. — Total Joint Replacement (TJR)
 replacement of diseased joint w/ prosthetic joint
 TKR – total knee replacement
 THR – total hip replacement

Question 31

Joint replacement components, fixations and expectations

Answer 31

stainless steel, cobalt, titanium
w/or w/o cement
pain relief, increased mobility, improved quality of life

Question 32

THR

Answer 32

most commonly replaced joint, irreversible hip damage due to OA, RA, femoral neck fracture, avascular necrosis

Question 33

Avascular necrosis

Answer 33

Blood supply to bone disrupted
 results in death of bone tissue
 a.k.a. – osteonecrosis
Most common w/ hip fractures & repairs
 can also occur w/ joint replacements
 hardware can interfere w/ circulation
 especially rods & nails

Question 34

THR Pre op

Answer 34

Patient teaching
 transfers, mobility, assistive/adaptive devices, exercises,
pain control, rehabilitation
 Autologous blood transfusions
 donate blood prior to surgery
 cost effective & safer
 IV antibiotics 1 hr. pre-op
 Cefazolin (Ancef)
 Vancomycin or Clindamycin if allergic

Question 35

THR procedure

Answer 35

General or Epidural anesthesia
Incisions: 1 or 2
 Newer technique = 2 incisions
 #1 acetabulum, #2 femoral
 decreases post-op complications, earlier ambulation, & discharge
Cement vs. Non-Cemented:
 Cement: more common with older pts.
 bonds to bone but may loosen over time
 Non-Cemented: more common with active, younger pts.
 increased stability
 facilitates growth of new bone into porous surface coating the
prosthesis

Question 36

THR post op

Answer 36

Pain management, prevention of dislocation/ subluxation, preventing DVT and bleeding, mainting neurovascular stability, preventing infection (slides 20, 21, 23, 24)

Question 37

THR- avoiding

Answer 37

Hip flexion > 90°
 X 4 months
Hip rotation inwards or outwards
Hip adduction
 not allowed to cross leg past body’s midline towards the opposite leg
 do not cross legs
No stair climbing x3-6 weeks

Question 38

Dislocation of prosthesis

Answer 38

New joint dislocates
 Assessment:
 affected leg shorter length
 external or internal rotation
 worsening pain
 Pt. may hear a “popping” sound
 Maintain bedrest & notify surgeon

Question 39

TKR

Answer 39

2nd most common joint replacement
 10-15 years expectancy
 depending on age, weight, usage, etc.
Indications:
 mobility significantly limited, prevents pts. from
participating in usual ADL’s
 Materials used:
 metal or ceramic

Question 40

TKR care

Answer 40

pre op and post op similar to THR but positioning is different

Question 41

TKR procedure

Answer 41

Central longitudinal incision
Most often, cement used for knees
 but can use non-cemented joint

Question 42

TKR post op

Answer 42

Abduction not necessary
Flexion & Extension encouraged (w/ limitations)
 CPM device may be used a few hours after surgery
 promotes ROM & circulation
 prevents scar tissue
Swelling & bruising common
 Apply ice packs
Hemovac drain 24-48 hrs.
 autotransfusion drainage system can be used
 transfuse within 6 hrs.
Prophylactic antibiotics x24 hrs.
Stand on new prosthetic within 24 hours
Allow PT to get patient OOB
Avoid internal & external rotation of knee
Teaching important….for correct movement