Back pain and bone problems Flashcards
Back pain
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
Back pain causes
lumbosacral strain
muscle injury
osteoarthritis of spine
degenerative disc disease
herniation of intervertebral disc
neurological issue
low back pain symptoms
muscle ache, shooting/stabbing pain, radiating
(More likely to radiate w/ herniated disc), limited mobility, gait difficulty
low back pain diagnosis
subjective history, physical exam, X-ray, MRI to r/o complex etiology
Low back pain treatment
NSAIDS, muscle relaxants, opioid analgesics,
massage, chiropractic manipulation, cold/hot
therapy, rest, gentle stretching
low back pain prevention
weight loss, weight bearing exercise, improvement of body mechanics, muscle strengthening
sciatica
compression of sciatic nerve by bulging disk
Laminectomy
removal of larger portion of vertebra to relieve compression of cord and roots
Discectomy
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)
Osteoporosis
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
Osteoporosis risk factors
> 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
Osteoporosis diagnosis
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
Osteoporosis DXA
T-score -1 or greater = normal bone density
Osteopenia = T-score between -1 and -2.5- Precursor to osteoporosis
Osteoporosis = -2.5 or less
Osteoporosis prevention
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
Osteoporosis meds
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
Osteomyelitis
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
Osteomyelitis causes
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
Osteomyelitis symptoms
Local: bone pain, swelling, tenderness, warmth,
restricted movement
Systemic: fever, chills, night sweats, nausea,
malaise
osteomyelitis diagnosis
blood cultures
wound cultures
CBC - elevated WBC
Erythrocyte sedimentation rate (ESR) - elevated
Bone scan
MRI
bone biopsy to determine causative organism
osteomyelitis treatment
IV antibiotic therapy, surgical intervention, hyperbaric O2 (slides 36 and 37)
Osteomyelitis nursing care
pain management, infection control, improvement of mobility, DVT prevention, med admin, pt ed and support, long term care (slides 38 and 39)
Osteoarthritis
degenerative joint disease- disease of aging
NOT autoimmune
NOT inflammatory
NOT systemic
Peaks @ ages 50-60
Affects women > men
OA patho
breakdown of articular cartilage, formation of bone spurs protruding into joint space, decreases joint movement
OA symptoms and common joints
pain and stiffness worse in morning, decreased movement, heberdens nodes in hands
hips, knees, spine, hands
OA dx
x ray, physical exam
OA assessment
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
OA meds
tylenol, NSAIDs, celebrex, topical analgesics, topical voltaren gel, glucosamine and chondroitin, intra-articular joint injections (steroids, synivisc)
Other OA treatments
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 ???
OA health promotion
maintain healthy weight, avoid activities that promote stress on joints, limit recreational sports that damage joints
OA surgical management
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
Joint replacement components, fixations and expectations
stainless steel, cobalt, titanium
w/or w/o cement
pain relief, increased mobility, improved quality of life
THR
most commonly replaced joint, irreversible hip damage due to OA, RA, femoral neck fracture, avascular necrosis
Avascular necrosis
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
THR Pre op
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
THR procedure
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
THR post op
Pain management, prevention of dislocation/ subluxation, preventing DVT and bleeding, mainting neurovascular stability, preventing infection (slides 20, 21, 23, 24)
THR- avoiding
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
Dislocation of prosthesis
New joint dislocates
Assessment:
affected leg shorter length
external or internal rotation
worsening pain
Pt. may hear a “popping” sound
Maintain bedrest & notify surgeon
TKR
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
TKR care
pre op and post op similar to THR but positioning is different
TKR procedure
Central longitudinal incision
Most often, cement used for knees
but can use non-cemented joint
TKR post op
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
