ch 63 musculoskeletal problems

Question 1

is a severe infection of the bone, bone marrow, and surrounding soft tissue. Although Staphylococcus aureus is the most common cause of infection, a variety of pathogens can cause osteomyelitis

Answer 1

Osteomyelitis

Question 2

indirect or direct entry

Answer 2

infecting microorganisms can invade by (Osteomyelitis)

Question 3

with infection with 1 microorganism. Indirect injury accounts for only 20% of all cases. It most often affects children younger than 17 years

Answer 3

Indirect entry (hematogenous) is usually associated (Osteomyelitis)

Question 4

older age, debilitation, hemodialysis, sickle cell disease, and IV drug use. The vertebrae are the most common site of infection in adults.2

Answer 4

Risk factors in adults are (Osteomyelitis)

Question 5

when an open wound (e.g., penetrating wounds, fractures, surgery) allows microorganisms to enter the body. Osteomyelitis also may be related to a foreign body, such as an implant or an orthopedic prosthetic device (e.g., plate, total joint prosthesis). It may occur in the feet of patients with diabetes or vascular disease–related ulcers or in the hips or sacrum near a pressure injury. More than 1 microorganism is usually involved

Answer 5

Direct entry osteomyelitis most often affects adults. It can occur

Question 6

The area of dead bone eventually separates from the surrounding living bone, forming

Answer 6

sequestra

Question 7

part of the periosteum that continues to have a blood supply forms new bone called

Answer 7

involucrum

Question 8

through the blood. Thus sequestrum may become a reservoir for microorganisms that spread to other sites, including the lungs and brain.

Answer 8

antibiotics or white blood cells (WBCs) have difficulty reaching the sequestrum

Question 9

to the initial infection or an infection of less than 1 month in duration

Answer 9

Acute osteomyelitis refers

Question 10

constant bone pain that worsens with activity and is unrelieved by rest; swelling, tenderness, and warmth at the infection site; and restricted movement of the affected part. Systemic manifestations include fever, night sweats, chills, restlessness, nausea, and malaise. Later signs include drainage from cutaneous sinus tracts or the fracture site.

Answer 10

Local manifestations of acute osteomyelitis include constant

Question 11

to a bone infection that lasts longer than 1 month or an infection that did not respond to initial antibiotic treatment.

Answer 11

Chronic osteomyelitis refers

Question 12

lessened. Local signs of infection become more common, including constant bone pain and swelling and warmth at the infection site. Over time, granulation tissue turns to scar tissue. The avascular scar tissue is an ideal site for continued microorganism growth because it cannot be penetrated by antibiotics

Answer 12

Systemic manifestations of Chronic osteomyelitis are

Question 13

septicemia, septic arthritis, pathologic fractures, and amyloidosis.

Answer 13

Long-term, and mostly rare, complications of osteomyelitis include

Question 14

is the definitive way to identify the causative agent.
-patient’s blood and wound cultures are often positive

Answer 14

Bone or soft tissue biopsy

Question 15

Increased WBC count and erythrocyte sedimentation rate (ESR) may occur. High C-reactive protein (CRP) may occur with acute infection.
-signs of osteomyelitis usually do not appear on x-rays until 2 to 4 weeks after the initial clinical symptoms.
- CT scan may be more helpful in assessing the extent of infection
-MRI may be more sensitive than CT in detecting bone marrow edema, which is an early sign of osteomyelitis.
-Radionuclide bone scans (technetium-99m) also show abnormalities earlier than x-rays. A WBC scan (indium-111–labeled cells) may help pinpoint the area of infection.2

Answer 15

diagnosis of osteomylitis

Question 16

edema

Answer 16

early sign of osteomyelitis

Question 17

Aggressive, prolonged IV antibiotic therapy is the treatment of choice for acute osteomyelitis if bone ischemia has not yet occurred.

Answer 17

acute osteomyelitis Tx choice

Question 18

Assess patient for dehydration before starting therapy.
* Ensure renal function testing is done before starting therapy, especially in older patients.
* Monitor peak and trough blood levels to achieve therapeutic effect and minimize renal and inner ear toxicity.
* Teach patient to notify HCP if any vision, hearing, or urinary problems develop.

Answer 18

Gentamicin Side effects

Question 19

(1) surgical removal of the poorly perfused tissue and dead bone and (2) extended use of antibiotics. In adults with chronic osteomyelitis, oral therapy with a fluoroquinolone (e.g., ciprofloxacin [Cipro]) for 6 to 8 weeks may be prescribed instead of IV antibiotics
- Oral antibiotics also may be given for 4 to 8 weeks after acute IV therapy is done to ensure the infection is resolved

Answer 19

Treatment of chronic osteomyelitis includes

Question 20

A implanted to help combat the infection. After debridement of the dead, infected tissue, a suction irrigation system may be inserted, and the wound closed.

Answer 20

crylic bead chains containing antibiotics may be

Question 21

may be given as an adjunct therapy in refractory cases of chronic osteomyelitis. It stimulates new blood growth and healing in the infected tissue

Answer 21

Hyperbaric O2

Question 22

wound coverage over the dead space (cavity) in the bone. Bone grafts may help to restore blood flow

Answer 22

Muscle flaps or skin grafts provide

Question 23

those who are immunocompromised or have diabetes, orthopedic prosthetic implants, or vascular insufficiency.

Answer 23

Persons at risk for osteomyelitis are

Question 24

common as the patient often positions the leg in a flexed position to promote comfort.

Answer 24

Flexion contracture of the affected lower extremity is

Question 25

quickly due to Achilles tendon contracture if the foot is not supported in a neutral position by a splint or boot.

Answer 25

Footdrop can develop

Question 26

and injure the peroneal nerve.

Answer 26

tight splint or dressing may compress

Question 27

include hearing deficit, impaired renal function, and neurotoxicity (e.g., limb weakness or numbness, cognitive changes, vision changes, headache, behavioral problems).

Answer 27

possible adverse and toxic reactions associated with prolonged high-dose antibiotic therapy

Question 28

hives, severe or watery diarrhea, blood in stools, and throat or mouth sores.

Answer 28

Reactions associated with cephalosporins (e.g., cefazolin) include

Question 29

Tendonitis or tendon rupture (especially the Achilles tendon) can

Answer 29

occur with use of fluoroquinolones (e.g., ciprofloxacin).

Question 30

Candida albicans and Clostridium difficile in the genitourinary (GU) and gastrointestinal (GI) tracts, especially in immunosuppressed and older adult patients. Teach the patient to report any changes in the oral cavity (e.g., whitish yellow, curdlike lesions) or the GU tract (e.g., perianal itching, discharge).

Answer 30

Lengthy antibiotic therapy can cause an overgrowth of

Question 31

in which cancer has spread from another site, is a more common problem.

Answer 31

Metastatic bone cancer,

Question 32

than primary malignant tumors.

Answer 32

Benign bone tumors are more common

Question 33

osteochondroma, osteoclastoma, and enchondroma

Answer 33

main types of benign bone tumors are

Question 34

is the most common primary benign bone tumor. It is characterized by an overgrowth of cartilage and bone near the end of the bone at the growth plate

Answer 34

Osteochondroma

Question 35

the pelvis, scapula, or long bones of the leg.

Answer 35

Osteochondroma most often occur in

Question 36

a painless, hard, immobile mass; shorter-than-normal height for age; soreness of muscles close to the tumor; one leg or arm longer than the other; and pressure or irritation with exercise. Some may be asymptomatic. Diagnosis is confirmed using x-ray, CT scan, and MRI.

Answer 36

Manifestations Osteochondroma include

Question 37

is a malignant tumor that develops in bone, muscle, fat, nerve, or cartilage.

Answer 37

sarcoma

Question 38

osteosarcoma, chondrosarcoma, and Ewing’s sarcoma

Answer 38

The most common types of sarcomas are

Question 39

childhood and young adulthood. They cause bone destruction and have rapid metastasi

Answer 39

Primary malignant tumors occur most often during

Question 40

is an extremely aggressive primary bone cancer that rapidly spreads to distant sites. It usually occurs in the pelvis or metaphyseal region of the long bones of extremities, especially in the distal femur, proximal tibia, and proximal humerus

Answer 40

Osteosarcoma

Question 41

of spread (metastasis) from a primary tumor at another site.

Answer 41

most common type of malignant bone tumor occurs because

Question 42

breast, colon, prostate, lungs, kidney, and thyroid.5

Answer 42

Common primary sites include

Question 43

the primary tumor to the bone via the lymph and blood supply

Answer 43

Metastatic cancer cells travel from

Question 44

the spine, ribs, or pelvis.

Answer 44

Metastatic bone lesions often occur in

Question 45

is a group of genetic diseases characterized by progressive symmetric wasting of skeletal muscles without evidence of neurologic involvement.

Answer 45

Muscular dystrophy (MD)

Question 46

is the most common type.

Answer 46

Duchenne MD

Question 47

are X-linked recessive disorders usually seen only in males

Answer 47

Duchenne and Becker MD (types of Muscular dystrophy)

Question 48

disorders are caused by a mutation of the dystrophin (DMD) gene.

Answer 48

Duchenne and Becker MD (types of Muscular dystrophy) defined

Question 49

is a protein that helps keep skeletal muscle fibers intact. Abnormal dystrophin can cause defects in the muscle fiber and muscle fiber degeneration.

Answer 49

Dystrophin

Question 50

Genetic testing can detect a mutation in the DMD gene and confirm a diagnosis.6
–Other diagnostic studies for MD include muscle serum enzymes (especially creatine kinase), electromyogram (EMG) testing, and muscle fiber biopsy. Classic findings on muscle biopsy include fat and connective tissue deposits, muscle fiber degeneration and necrosis, and a deficiency of dystrophin. An ECG may show abnormalities that suggest cardiomyopathy.

Answer 50

diagnostic studies for MD include

Question 51

Corticosteroid therapy is part of the standard of care. It may slow disease progression for up to 2 years.

Answer 51

Treatment for Muscular dystrophy

Question 52

is the first corticosteroid approved to treat Duchene

Answer 52

Deflazacort (Emflaza)

Question 53

first disease-modifying drug to treat Duchene

Answer 53

Eteplirsen (Exondys 51)

Question 54

is most often due to a musculoskeletal problem. It may be localized or diffuse.

Answer 54

Low back pain

Question 55

, patients feel soreness or discomfort when a specific area of the lower back is palpated or pressed.

Answer 55

localized pain

Question 56

over a larger area and comes from deep tissue.

Answer 56

Diffuse pain occurs

Question 57

radicular or referred

Answer 57

Low back pain may be

Question 58

irritation of a nerve root. Radicular pain is not isolated to a single location. Instead, it radiates or moves along a nerve distribution. Sciatica is an example of radicular pain.

Answer 58

Radicular pain is caused by

Question 59

is felt in the lower back, but the source of the pain is another location (e.g., kidneys, lower abdomen).

Answer 59

Referred pain

Question 60

second only to headache as the most common pain problem.

Answer 60

Backache is

Question 61

the leading cause of job-related disability and a major contributor to missed work days

Answer 61

Backache is

Question 62

(1) bears most of the weight of the body, (2) is the most flexible region of the spinal column, (3) has nerve roots that are at risk for injury or disease, and (4) has a naturally poor biomechanical structure.

Answer 62

Low back pain is common because the lumbar region

Question 63

lack of muscle tone, excess body weight, stress, poor posture, smoking, pregnancy, prior compression fracture of the spine, spinal problems since birth, and a family history of back pain. Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and extended periods of sitting are associated with low back pain.

Answer 63

Risk factors low back pain include

Question 64

(1) acute lumbosacral strain, (2) instability of the lumbosacral bony mechanism, (3) osteoarthritis of the lumbosacral vertebrae, (4) degenerative disc disease, and (5) herniation of an intervertebral disc.

Answer 64

causes of low back pain of musculoskeletal origin include

Question 65

. Lifting and moving patients, excessive bending or leaning forward, and frequent twisting can result in low back pain that causes lost time and productivity and disability.

Answer 65

Health care personnel who perform direct patient care activities are at high risk for developing low back pain

Question 66

4 weeks or less.

Answer 66

Acute low back pain lasts

Question 67

by trauma or an activity that produces undue stress (often hyperflexion) on the lower back.

Answer 67

Most acute low back pain is caused

Question 68

They develop later (usually within 24 hours) because of a gradual increase in pressure on the nerve from an intervertebral disc and/or associated edema. Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility or ROM, or an inability to stand upright.

Answer 68

sign/ symp of low back pain

Question 69

. One test is the straight-leg-raising test
-MRI and CT scans are not done unless trauma or systemic disease (e.g., cancer, spinal infection) is suspected.

Answer 69

Few definitive diagnostic abnormalities are present with nerve irritation and muscle strain

Question 70

” This formal program is usually taught by an HCP, nurse, or physical therapist. It is designed to teach the patient how to minimize back pain and avoid repeat episodes of pain.

Answer 70

“Back School.

Question 71

shoes with low heels and shock-absorbing shoe inserts for women.

Answer 71

Recommend flat shoes or

Question 72

excessive lumbar lordosis, placing stress on the lower back.

Answer 72

avoid sleeping in a prone position because it causes

Question 73

knees and hips flexed prevents pressure on support muscles, ligaments, and lumbosacral joints.

Answer 73

Sleeping in a supine or side-lying position with

Question 74

NSAIDs and muscle relaxants (e.g., cyclobenzaprine)
-Massage and back manipulation, acupuncture, and the application of cold and hot compresses may help some patients. Severe pain may require a brief course of corticosteroids or opioid analgesics.

Answer 74

drugs therapy treatment

Question 75

lumbosacral area is unstable, repeated episodes are likely. Obesity, poor posture, poor muscle support, older age, or trauma may weaken the lumbosacral spine, so it is unable to meet the demands placed on it without strain.

Answer 75

causes of lumbosacral area

Question 76

than 3 months or involves a repeated incapacitating episode.

Answer 76

Chronic low back pain lasts more

Question 77

(1) degenerative conditions, such as arthritis or disc disease; (2) osteoporosis or other metabolic bone diseases; (3) weakness from the scar tissue of prior injury; (4) chronic strain on lower back muscles from obesity, pregnancy, or stressful postures on the job; and (5) congenital spine problems.

Answer 77

Causes Chronic low back pain include

Question 78

is a narrowing of the spinal canal, which holds the spinal cord.

Answer 78

Spinal stenosis

Question 79

of chronic low back pain

Answer 79

stenosis in the lumbar spine is a common cause

Question 80

stenosis can be acquired or inherited
-common acquired cause is osteoarthritis.
-Arthritic changes (bone spurs, calcification of spinal ligaments, disc degeneration) narrow the space around the spinal canal and nerve roots, eventually leading to compression

Answer 80

causes of spinal stenosis

Question 81

narrow the space around the spinal canal and nerve roots, eventually leading to compression

Answer 81

Arthritic changes (bone spurs, calcification of spinal ligaments, disc degeneration)

Question 82

pain, weakness, and numbness.

Answer 82

Inflammation caused by the compression results in

Question 83

rheumatoid arthritis, spinal tumors, Paget’s disease, and traumatic damage to the vertebral column. Inherited conditions that lead to spinal stenosis include congenital spinal stenosis and scoliosis.

Answer 83

Other acquired conditions that may cause spinal stenosis include

Question 84

in the lower back and then radiates to the buttock and leg. It is worse with walking or prolonged standing. Numbness, tingling, weakness, and heaviness in the legs and buttocks may be present. History of decreased pain when the patient bends forward or sits is often a sign of spinal stenosis. In most cases, stenosis slowly progresses.

Answer 84

pain associated with lumbar spinal stenosis often starts

Question 85

Manage the patient’s pain and stiffness with mild analgesics, such as NSAIDs, for daily comfort. Antidepressants (e.g., duloxetine [Cymbalta]) may help with pain management and sleep problems. The antiseizure drug gabapentin (Neurontin) may improve walking and relieve leg symptoms.

Answer 85

Treatment for chronic low back pain (drugs)

Question 86

Weight reduction, rest periods, local heat or cold application, physical therapy, and exercise and activity throughout the day help keep the muscles and joints mobilized. Cold, damp weather worsens the back pain. Pain can be decreased with rest and local heat application. Complementary and alternative therapies, such as biofeedback, acupuncture, and yoga, may help reduce the pain. “Back School” (discussed on p. 1485) can significantly reduce pain and improve body posture

Answer 86

Treatment for chronic low back pain (nonpharmacological)

Question 87

, such as epidural corticosteroid injections and implanted devices that deliver pain medication, are options for those with chronic low back pain that does not respond to the usual therapeutic options.

Answer 87

Minimally invasive treatments for chronic low back pain if other treatments not working

Question 88

the vertebrae and help absorb shock for the spine

Answer 88

Intervertebral discs separate

Question 89

the deterioration, herniation, or other dysfunction of the intervertebral discs.

Answer 89

Intervertebral disc disease involves

Question 90

the cervical, thoracic, and lumbar spine.

Answer 90

Disc disorders can affect

Question 91

loss of fluid in the intervertebral discs with aging.

Answer 91

Degenerative disc disease (DDD) results from

Question 92

elasticity, flexibility, and shock-absorbing abilities. Unless it is accompanied by pain, DDD is a normal process

Answer 92

discs lose their

Question 93

the nucleus pulposus (gelatinous center of the disc) starts to dry out and shrink. This change limits the disc’s ability to distribute pressure between vertebrae.

Answer 93

The discs become thinner as

Question 94

The pressure is then transferred to the annulus fibrosus (strong outside part of the disc), causing progressive destruction. When the disc is damaged, the nucleus pulposus may seep through a torn or stretched annulus. This is called a herniated disc(slipped disc),

Answer 94

When the disc is damaged,

Question 95

a condition in which a spinal disc bulges outward between the vertebrae

Answer 95

herniated disc(slipped disc),

Question 96

degeneration with age or repeated stress and trauma to the spine.

Answer 96

herniated disc can result from

Question 97

the lumbosacral discs, specifically L4-5 and L5-S1.

Answer 97

most common sites of herniation are

Question 98

C5-6 and C6-7

Answer 98

Disc herniation may also occur at

Question 99

spinal stenosis, in which narrowing of the spinal canal forces the intervertebral disc to bulge.

Answer 99

Disc herniation may also occur at C5-6 and C6-7. It may be the result of

Question 100

spinal nerves emerge from the spinal column through an opening (intervertebral foramen) between adjacent vertebrae. Herniated discs can press against these nerves (“pinched nerve”) causing radiculopathy (radiating pain, numbness, tingling, decreased strength and/or range of motion).

Answer 100

causing radiculopathy

Question 101

(radiating pain, numbness, tingling, decreased strength and/or range of motion).

Answer 101

sign/symp radiculopathy

Question 102

DDD and the stresses placed on the vertebrae.
- poorly lubricated joints rub against each other, the protective cartilage is damaged and painful bone spurs occur as one of the changes found in OA.

Answer 102

Osteoarthritis (OA) of the spine is associated with

Question 103

is low back pain

Answer 103

lumbar disc disease, the most common manifestation

Question 104

Radicular pain that radiates down the buttock and below the knee, along the distribution of the sciatic nerve, generally

Answer 104

indicates disc herniation.

Question 105

nerve root irritation ( Back or leg pain may be reproduced by raising the leg.)

Answer 105

positive straight-leg-raising test may indicate

Question 106

(1) severe low back pain, (2) progressive weakness, (3) increased pain, and (4) bowel and bladder incontinence or retention. Saddle anesthesia (loss of or altered sensation of the perineum, buttocks, inner thighs and back of the legs [saddle area]) may be present. Symptoms of cauda equina syndrome may develop suddenly or evolve slowly over time. They may vary in intensity. Cauda equina is a medical emergency that requires surgical decompression to reduce pressure on the nerves and prevent permanent paralysis.14

Answer 106

Multiple lumbar nerve root compressions (cauda equina syndrome) from a herniated disc, tumor, or an epidural abscess may be marked by

Question 107

into the arms and hands, following the pattern of the involved nerve. Like lumbar disc disease, reflexes may or may not be present. The handgrip is often weak.

Answer 107

cervical disc disease, pain radiates

Question 108

shoulder pain and dysfunction, the HCP must rule out shoulder disorders as part of the diagnosis.

Answer 108

manifestations of cervical disc disease may include

Question 109

X-rays are done to detect any structural defects. A myelogram, MRI, or CT scan is helpful in localizing the damaged site. An epidural venogram or diskogram may be needed if other diagnostic studies are inconclusive. An EMG of the extremities can be done to determine the severity of nerve irritation or to rule out other conditions, such as peripheral neuropathy.

Answer 109

diagnostics for know disc disease

Question 110

the patient is in constant pain and/or has a persistent neurologic deficit.

Answer 110

Surgery for a damaged disc is generally done if

Question 111

is a minimally invasive outpatient procedure for treatment of back and sciatic pain.
-needle is inserted into the affected disc with x-ray guidance. A wire is then threaded through the needle and into the disc. As the wire is heated, small nerve fibers that have invaded the degenerating disc are destroyed. The heat also partially melts the annulus fibrosus. This causes the body to generate new reinforcing proteins in the fibers of the annulus.

Answer 111

Intradiscal electrothermoplasty (IDET) (surgery damaged disc)

Question 112

A needle is inserted into the disc similar to IDET. Instead of a heated wire, a special radiofrequency probe is used. The probe generates energy that breaks the molecular bonds of the gel in the nucleus pulposus. Up to 20% of the nucleus is removed. This decompresses the disc and reduces pressure on the disc and surrounding nerve roots. Subsequent pain relief varies.

Answer 112

radiofrequency discal nucleoplasty (coablation nucleoplasty).(surgery damaged disc)

Question 113

This titanium device fits onto a mount that is placed on vertebrae in the lower back. The X-Stop is used in patients with pain due to lumbar spinal stenosis. The device works by lifting vertebrae off the pinched nerve.

Answer 113

interspinous process decompression system (X-Stop). (surgery damaged disc)

Question 114

It involves surgical excision of part of the vertebra (referred to as the lamina) to access and remove the protruding disc. Laminectomy is often done as an outpatient procedure. However, a hospital stay of 1 to 3 days is not uncommon.

Answer 114

Laminectomy is a common, traditional surgical procedure for lumbar disc disease.

Question 115

Microsurgical discectomy is a version of the standard procedure. The HCP uses a microscope to better see the disc and disc space, which helps in removal of the damaged portion. This helps maintain bony stability of the spine.

Answer 115

Discectomy also can be done to decompress the nerve root.

Question 116

is a safe and effective outpatient surgical procedure. A tube is passed through the retroperitoneal soft tissues to the disc with the aid of fluoroscopy. A laser is then used on the damaged part of the disc. Minimal blood loss occurs because of access through small stab wounds. The procedure decreases rehabilitation time.

Answer 116

Percutaneous discectomy (surgery damaged disc)

Question 117

to restore movement and eliminate pain

Answer 117

goals of artificial disc replacement surgery are

Question 118

used in patients with lumbar disc damage associated with DDD. This artificial disc has a high-density core sandwiched between 2 cobalt-chromium endplates. After removing the damaged disc, the device is surgically placed in the spine (usually through a small incision below the umbilicus). The disc restores movement at the level of the implant

Answer 118

Charité disc is (type of artificial lumbar disc used to treat DDD.)

Question 119

another type of artificial lumbar disc used to treat DDD.

Answer 119

ProDisc-L is

Question 120

the Prestige cervical disc, Mobi-C disc, and Secure-C artificial cervical disc.

Answer 120

Options for treatment of DDD of the cervical spine include

Question 121

-if the spine is unstable
-spine is stabilized by creating ankylosis (fusion) of adjacent vertebrae with a bone graft from the patient’s fibula or iliac crest (autograft) or from donated cadaver bone (allograft). Metal fixation with rods, plates, or screws may be placed to give more stability and decrease vertebral motion.the spine is unstable

Answer 121

spinal fusion may be needed if

Question 122

, place pillows under the patient’s thighs when supine and between the legs when in the side-lying position to provide comfort and ensure alignment.
*****-bed trapeze, if present, since use is contraindicated for spinal surgery patients.

Answer 122

After lumbar fusion (proper to way move around)

Question 123

After surgery, most patients need opioids, such as morphine IV, for 24 to 48 hours. Patient-controlled analgesia (PCA) allows maintenance of optimal analgesic levels and is the preferred method of continuous pain management. Once the patient receives oral fluids, oral drugs, such as acetaminophen with codeine, hydrocodone, or oxycodone (Percocet), may be used. Diazepam (Valium) may be prescribed for muscle relaxation.

Answer 123

Treatment after spinal surgery

Question 124

bony projections that develop along bone edges (in joint)

Answer 124

bone spurs (osteophytes)

Question 125

Immediately report leakage of CSF on the dressing or if the patient reports a severe headache

Answer 125

Because the spinal canal may be entered during surgery, cerebrospinal fluid (CSF) leakage is possible.

Question 126

clear or slightly yellow drainage on the dressing. It has a high glucose concentration and is positive for glucose when tested with a dipstick.

Answer 126

CSF appears as

Question 127

nerve damage

Answer 127

Loss of sphincter tone or bladder tone may indicate

Question 128

(thoracolumbar sacral orthosis [TLSO] or chairback brace)

Answer 128

rigid orthosis

Question 129

spinal cord edema, such as respiratory distress and a worsening neurologic condition of the upper extremities.

Answer 129

cervical spine surgery, be alert for signs of

Question 130

many different conditions, including benign (e.g., poor posture) and serious (e.g., herniated cervical disc)

Answer 130

Neck pain may result from

Question 131

• Degenerative disc disease, including herniation
• Meningitis
• Osteomyelitis
• Osteoporosis
• Poor posture
• Rheumatoid arthritis
• Spondylosis
• Strain or sprain
• Trauma (e.g., fractures, subluxation)
• Tumor

Answer 131

causes of neck pain

Question 132

hyperflexion and hyperextension injuries. Patients have stiffness and neck pain with possible radicular pain into the arm and hand.

Answer 132

Cervical neck sprains and strains occur from

Question 133

the head, anterior chest, thoracic spine region, and shoulders. Weakness or paresthesia of the arm and hand suggests cervical nerve root compression from stenosis, DDD, or herniation.

Answer 133

Pain from neck may radiate to

Question 134

history, physical examination, x-ray, MRI, CT scan, and myelogram. An EMG of the upper extremities may diagnose cervical radiculopathy.

Answer 134

cause of neck pain is diagnosed by

Question 135

head support using a soft cervical collar, gentle traction, heat and ice applications, massage, rest until symptoms subside, ultrasound, and NSAIDs. Therapeutic neck exercises and acupuncture also may be used for pain relief.19 Most neck pain resolves without surgical intervention.

Answer 135

Conservative treatment for neck pain in patients without an underlying disorder includes

Question 136

is the platform that supports the weight of the body and absorbs shock when the person ambulates

Answer 136

foot

Question 137

(1) congenital conditions; (2) structural weakness; (3) traumatic and stress injuries; and (4) systemic conditions, such as diabetes and rheumatoid arthritis.

Answer 137

foot can be affected by

Question 138

(1) provide support, foot stability, protection, shock absorption, and a foundation for orthotics; (2) increase friction with the walking surface; and (3) treat foot abnormalities.

Answer 138

Footwear is used to

Question 139

or worsen a great deal of the pain, deformity, and disability from foot disorders.20 Shoes may cause crowding and angulation of the toes and inhibit normal movement of foot muscles.

Answer 139

Poorly fitting shoes cause

Question 140

They cause compression of an intermetatarsal plantar nerve, resulting in paresthesia and burning. At first, patients with Morton’s neuroma may describe feeling as if a sock is rolled up under their toes. Neuromas usually occur between the third and fourth toes.

Answer 140

Prolonged use of improper footwear can also cause a Morton’s neuroma.

Question 141

include NSAIDs, ice, physical therapy, footwear changes, stretching, warm soaks, orthotics, ultrasound, and corticosteroid injections. If these methods do not help, surgery may be needed.

Answer 141

treatment for foot

Question 142

through the toes, or a protective splint may be placed over the end of the foot.

Answer 142

Depending on the type of foot surgery, pins or wires may extend

Question 143

the foot is usually immobilized by a bulky dressing, short leg cast, slipper (plaster) cast, or a platform shoe that fits over the dressing and has a rigid sole (also known as a bunion shoe).
-elevate foot with heel off bed (prevent edema)

Answer 143

After foot surgery,

Question 144

ingrown toenails and reduces the risk for infection.

Answer 144

Trimming toenails straight across helps prevent

Question 145

of poor circulation, atherosclerosis, and decreased sensation in the lower extremities.esp DM
-patient may develop an open wound but not feel it because of altered sensation from peripheral vascular disease or diabetic neuropathy.

Answer 145

older adult is prone to foot problems because

Question 146

hormones, nutrition, and genetics.

Answer 146

Normal bone metabolism is affected by

Question 147

, generalized reduction in bone mass and strength may result

Answer 147

dysfunction occurs in hormones, nutrition, and genetics. then

Question 148

osteomalacia, osteoporosis, and Paget’s disease.

Answer 148

Metabolic bone diseases include

Question 149

a vitamin D deficiency that causes bone to lose calcium and become soft.
-same disorder as rickets in children, except the epiphyseal growth plates are closed in adults.

Answer 149

Osteomalacia is caused by

Question 150

the absorption of calcium from the intestine. Insufficient vitamin D intake can interfere with normal bone mineralization. With little or no calcification, bones become soft.

Answer 150

Vitamin D is required for

Question 151

limited sun exposure (ultraviolet rays needed for vitamin D synthesis), GI malabsorption (post weight loss surgery, celiac disease), chronic diarrhea, and pregnancy. Residents of long-term care settings may have inadequate sun exposure and thus poor synthesis of vitamin D. Persons with dark skin do not synthesize vitamin D as easily as persons with fair skin. Obese persons are at higher risk because of decreased physical activity. Chronic liver, kidneys, and small intestine disease may contribute to vitamin D deficiency. Long-term use of antiseizure drugs (e.g., phenytoin) and phosphate-binding antacids (e.g., Maalox) may decrease calcium and vitamin D absorption.

Answer 151

Causes Insufficient vitamin D include

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are bone pain and muscle weakness. The pain is often worse at night and affects the lower back, pelvis, hips, legs, and ribs.23 Muscle weakness and progressive deformity of weight-bearing bones (e.g., spine, extremities) can lead to problems walking and a waddling gait. Fractures are common and indicate delayed bone healing.

Answer 152

Common manifestations of low calcium(insufficient Vit D) aka osteomalacia

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decreased serum calcium or phosphorus, decreased serum 25-hydroxyvitamin D, and increased serum alkaline phosphatase. X-rays may show effects of generalized bone demineralization, especially loss of calcium in the bones of the pelvis and associated bone deformity. Looser’s transformation zones (ribbons of decalcification in bone found on x-ray) are diagnostic of osteomalacia. However, significant osteomalacia may exist without x-ray changes.

Answer 153

Laboratory findings include (decrease Vit D aka osteomalacia)

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response when vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol) supplements are used. Calcium or phosphorus supplements may be prescribed. Encourage dietary intake of eggs, meat, and oily fish (e.g., salmon, tuna). Milk and breakfast cereals fortified with calcium and vitamin D should be part of the diet.

Answer 154

Tx supplement for Calcium/ osteomalacia and diet

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is a chronic, progressive metabolic bone disease marked by low bone mass and deterioration of bone tissue, leading to increased bone fragility

Answer 155

Osteoporosis

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it slowly robs the skeleton of its banked resources. Bones eventually become so fragile that they cannot withstand normal mechanical stress.

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Osteoporosis is known as the “silent thief” because

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(1) women tend to have lower calcium intake than men throughout their lives (men between 15 and 50 years of age consume twice as much calcium as women); (2) women have less bone mass because of their generally smaller frames; (3) bone resorption begins at an earlier age in women and becomes more rapid at menopause; (4) pregnancy and breastfeeding deplete a woman’s skeletal reserve unless calcium intake is adequate; and (5) longevity increases the risk for osteoporosis.

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Osteoporosis is more common in women. This is for several reasons:

Question 158

. If results are normal and the person is at low risk for osteoporosis, another test is not needed for 15 years. Women who are younger than 65 and at high risk (e.g., low body weight, smoker, prior fractures) should have a bone density test earlier.

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Current guidelines recommend an initial bone density test in all women over age 65 years

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• Advancing age (>65 yr)
• Female gender
• Low body weight
• White or Asian ethnicity
• Cigarette smoking
• Sedentary lifestyle
• Estrogen deficiency in women (surgical or age-related menopause)
• Family history of osteoporosis
• Diet low in calcium or vitamin D deficiency
• Excess use of alcohol (>2 drinks/day)
• Low testosterone in men
• Long-term use of corticosteroids, thyroid replacement, heparin, long-acting sedatives, or antiseizure drugs

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Risk Factors for Osteoporosis

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age 20

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Peak bone mass (maximum bone tissue) is typically achieved before

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heredity, nutrition, exercise, and hormone function.

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Peak bone mass largely determined by 4 factors:

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Bone is continuously being deposited by osteoblasts and resorbed by osteoclasts, a

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process called remodeling.

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exceeds bone deposition.

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In osteoporosis, bone resorption

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inflammatory bowel disease, intestinal malabsorption, kidney disease, rheumatoid arthritis, hyperthyroidism, alcohol use disorder, cirrhosis, hypogonadism, and diabetes.

Answer 164

Diseases associated with osteoporosis include

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corticosteroids, antiseizure drugs (e.g., divalproex sodium [Depakote], phenytoin), aluminum-containing antacids, heparin, some chemotherapy drugs, and excess thyroid hormones.
-Long-term corticosteroid use is a major contributor to osteoporosis.

Answer 165

Many drugs can interfere with bone metabolism, including

Question 166

spine, hips, and wrists.

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Osteoporosis occurs most often in bones of the

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are back pain and spontaneous fractures. The loss of bone mass causes the bone to become mechanically weaker and prone to spontaneous fractures or fractures from minimal trauma. A person who has a vertebral fracture due to osteoporosis has an increased risk for having a second vertebral fracture within 1 year. Over time, vertebral fractures and wedging cause gradual loss of height and a humped thoracic spine (kyphosis, or “dowager’s hump”)

Answer 167

Typical early manifestations of Osteoporosis

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peak bone mass and amount of bone loss.

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BMD is determined by

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measures bone density in the spine, hips, and forearm.
-represent the most common sites of fragility fractures from osteoporosis.

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DEXA (considered the gold standard of BMD studies by the World Health Organization)

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uses sound waves to measure bone density in the heel, kneecap, or shin.

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QUS BMD may be measured by quantitative ultrasound

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in bone density over time and assess effectiveness of osteoporosis treatment.

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DEXA studies are useful to evaluate changes

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of a healthy 30-yr-old adult and reported as T-scores. A T-score of 0 means the BMD is equal to the norm for a healthy young adult.

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BMD test results are compared to the ideal or peak bone mineral density

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Differences between the BMD and that of the healthy young adult norm are measured in units called standard deviations (SDs). The more standard deviations below 0 (indicated as negative numbers), the lower the BMD and the higher the risk for fracture.

Answer 173

standard deviations (SDs)

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A T-score between +1 and –1 is normal. A T-score between –1 and –2.5 indicates osteopenia (bone loss that is more than normal, but not yet at the level for a diagnosis of osteoporosis)

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indicates osteopenia (bone loss that is more than normal, but not yet at the level for a diagnosis of osteoporosis)

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osteoporosis. The greater the negative number, the more severe the osteoporosis

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T-score of –2.5 or lower indicates

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-their own age, gender, and/or ethnic group instead of a healthy 30-yr-old person
-compared with someone their own age, gender, and/or ethnic group instead of a healthy 30-yr-old person.
-If the Z-score is –2 or lower, it may suggest that something other than aging is causing abnormal bone loss.

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Z-score instead of a T-score. In this case a person is compared with someone

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(1) a T-score of less than −2.5, (2) a T-score between −1 and −2.5 with additional risk factors or (3) prior history of a hip or vertebral fracture.

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national Osteoporosis Foundation recommends treatment for osteoporosis for postmenopausal women with

Question 178

patient’s risk for fracture from osteoporosis also can be calculated with the

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Fracture Risk Assessment (FRAX) tool

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1000 mg/day for women ages 19 to 50 years and men ages 19 to 70 years and 1200 mg/day in women age 51 years or older and men 71 years or older

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recommended calcium intake is

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milk, yogurt, turnip greens, cottage cheese, ice cream, sardines, and spinach
-If dietary intake of calcium is inadequate, supplemental calcium may be given.

Answer 180

Foods high in calcium include

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Calcium carbonate has 40% elemental calcium. It should be taken with meals because stomach acid is needed to dissolve and absorb this supplement. Calcium citrate has about 20% elemental calcium but is less dependent on stomach acid for absorption. It is better absorbed by patients taking a proton pump inhibitor (e.g., esomeprazole [Nexium]) or histamine receptor blocker (e.g., cimetidine) for acid reflux.

Answer 181

amount of elemental calcium varies in calcium preparations.

Question 182

they have small amounts of elemental calcium.

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Calcium lactate and calcium gluconate are not recommended because

Question 183

postmenopausal women, older men, persons who are homebound or in long-term care settings, and those in northern climates due to decreased sun exposure.

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supplemental vitamin D (800 IU) is recommended for

Question 184

the bisphosphonates alendronate, risedronate, and zoledronic acid, or denosumab.

Answer 184

prevention and treatment of osteoporosis are

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is osteonecrosis (bone death) of the jaw. Its cause is unknown. Those with dental disease, cancer, Paget’s disease, or renal disease are most at risk for this complication.

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serious, side effect of bisphosphonates

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available as a daily or weekly oral tablet. Zoledronic acid (Reclast) is given as a once-yearly or every-other-year IV infusion.

Answer 186

Alendronate (Fosamax) is (biphosphate)

Question 187

The immediate-release form of risedronate (Actonel) is given daily, weekly, or monthly, based on the dose.

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risedronate (Actonel) (biphosphate)

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is given as a once-yearly or every-other-year IV infusion.

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Zoledronic acid (Reclast) (biphosphate)

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Renal function tests and serum calcium must be assessed before administration.

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test assessed before biphosphate adminstration

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may be given to postmenopausal women with osteoporosis who are at high risk for fractures.
-given as a subcutaneous injection every 6 months.

Answer 190

Denosumab (Prolia) (monoclonal antibody)

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It inhibits the action of sclerostin, a regulatory factor in bone metabolism. This increases bone formation and, to a lesser extent, decreases bone resorption. It is given by subcutaneous injection every month for a total of 12 doses.

Answer 191

new monoclonal antibody romosozumab (Evenity).

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of the increased risk for heart disease and breast and uterine cancer.

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Women no longer routinely use estrogen replacement therapy or estrogen with progesterone after menopause to prevent osteoporosis because

Question 193

treatment with bisphosphonates may be considered.

Answer 193

If osteopenia is present on bone densitometry in people who are taking corticosteroids,

Question 194

is a chronic skeletal bone disorder in which excessive bone resorption is followed by replacement of normal marrow by vascular, fibrous connective tissue.

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Paget’s disease(osteitis deformans)

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new bone is larger, disorganized, and weaker. Areas commonly affected include the pelvis, long bones, spine, ribs, sternum, and skull.

Answer 195

Paget’s disease(osteitis deformans) effect

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may be viral or genetic. Up to 40% of all patients with the disease have at least 1 relative with the disorder.

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cause Paget’s disease(osteitis deformans)

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-patients do not have any symptoms.
-disease may be found incidentally through x-ray or serum chemistry findings of high alkaline phosphatase.

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milder forms of Paget’s disease,

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Bone pain may develop gradually and progress to severe intractable pain. Other early manifestations include fatigue and progressive development of a waddling gait. Patients report becoming shorter or their heads are becoming larger. Headaches, dementia, vision deficits, and loss of hearing can result from an enlarged, thickened skull. Increased bone volume in the spine can cause spinal cord or nerve root compression.

Answer 198

sign/symp Paget’s disease(osteitis deformans)

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Pathologic fracture is the most common complication and may be the first sign of Paget’s disease. Other complications include osteosarcoma, fibrosarcoma, and osteoclastoma (giant cell) tumors

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most common complication of Paget’s disease,

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Serum alkaline phosphatase is markedly increased in advanced disease, showing high bone turnover.34 X-rays may show curvature of an affected bone. The bone cortex becomes thicker and irregular, especially in weight-bearing bones and the cranium. Bone scans using a radiolabeled bisphosphonate show increased uptake in the affected skeletal areas.

Answer 200

diagnosis of Paget’s disease(osteitis deformans)

Question 201

usually limited to symptomatic and supportive care, with correction of secondary deformities by surgical intervention or braces. Bisphosphonate drugs (Table 63.13) are used to slow bone resorption. Zoledronic acid may be given specifically to build bone. Calcium and vitamin D can decrease hypocalcemia, a common side effect of drug therapy. Monitor drug effectiveness by regular assessment of serum alkaline phosphatase.

Answer 201

treatment for Paget’s disease,

Question 202

is an option for patients who cannot tolerate bisphosphonates

Answer 202

Calcitonin

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osteoclastic activity, prevents bone resorption, relieves acute symptoms, and lowers serum alkaline phosphatase. This drug is available as a subcutaneous injection.

Answer 203

Human calcitonin inhibits

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a longer half-life and greater milligram potency than human calcitonin. Response to calcitonin therapy is not permanent and often ends when therapy stops.

Answer 204

Salmon calcitonin is 1 form. It has

Question 205

available components for bone formation.

Answer 205

Vitamin D, calcium, and protein are especially important to ensure