Musculoskeletal - Conditions

Question 1

Rheumatoid Arthritis

Answer 1

• chronic, systemic inflammatory disease, characterised by persistent synovitis of multiple joints
• autoimmune response to an antigen triggering the formation of an abnormal immunoglobulin G

Question 2

RA - Risk Factors

Answer 2

• gender - women more likely to get RA
• age - most common 35-50
• family history

Question 3

RA - Clinical Manifestations

Answer 3

• sudden or insidious onset
• tender, warm, swollen joints
• polyarticular (affects numerous joints)
• symmetrical
• joint inflammation
• fever / fatigue
• pain and stiffness

Question 4

RA - Deformities

Answer 4

• Boutonniere deformity
  
  • hyperextension of the distal interphalangal joint (bends opposite direction to usual)
• hallux valgus deformity
  
  • lateral deviation of the thumb (away from midline)
• swan neck deformity
  
  • hyperextension of the proximal interphalangal joint & flexion of the DIP
• ulnar drift deformity
  
  • fingers drift towards ulnar (outwards)

Question 5

RA - Diagnosis

Answer 5

• morning stiffness that lasts 1 hour and persists over 6 weeks
• arthritis with swelling / effusions in over 3 joints
• arthritis of hand joints
• symmetrical arthritis
• rheumatoid nodules
• positive serum rheumatoid factor
• x-ray changes

Question 6

RA - Complications

Answer 6

• joint destruction
• deformities
• cataracts
• skin ulceration
• cardiopulmonary effects
  
  • pleurisy
  • pleural effusion
  • pericarditis

Question 7

RA - Nursing Management

Answer 7

• relieve pain & reduce inflammation
• medication regieme
  
  • PQRST
  • anti-inflammatory drugs
  • encourage decreased activity / increased rest
  • supportive splints
• reduce fatigue
  
  • encourage sleep routine
  • plan morning activity (improve condition & alleviate pain)
  • rest periods & prioritize activities
  • reduce stressors
• physical mobility & self care
• preserve joint function
  
  • discuss limitations with patient, individualise care
  • OT/physio referral
  • devices to assist with ADL’s (frames, walkers, canes)
  • exercise programs, including hydrotherapy
• surgical interventions if required

Question 8

Osteoarthritis

Answer 8

• degenerative joint disease characterised by degeneration & loss of articular cartliage in synovial joints
• idopathic
  
  • no known precipitating factors
  • most common type
• secondary
  
  • identifiable cause (ie - joint trauma, inflammation, skeletal disorder)

Question 9

OA - Risk Factors

Answer 9

• older age
• gender (women more likely)
• obesity
• physical inactivity
• joint damage / trauma

Question 10

OA - Clinical Manifestations

Answer 10

• progressive loss of articular cartilage and synovitis
• joint pain & stiffness (does not have to be just morning stiffness)
• pain worsens during day, is relieved by rest
• stiffness after rising & inactivity
• limitation of movement
• functional impairment
• joint instability / disformity

Question 11

OA - Joint Specific Clinical Manifestations

Answer 11

• hands
  
  • heberden’s & bouchard’s nodes
• spine
  
  • pain & stiffness, limited ROM
  • muscle spasms, nerve root compression
• hips
  
  • referred pain to groin, buttock, thigh or knee
  • loss of internal rotation, limited extension, adduction & flexion
• knees
  
  • pain & bony enlargement
  • effusions (synovial fluid build up)
  • crepitus (grinding sensation)
  • instability & deformity

Question 12

OA - Deformities

Answer 12

• Heberden’s nodes
  
  • nodes on distal interphalangal joints (DIP)
• Bouchard’s nodes
  
  • nodes on proximal interphalangal joints (PIP)

Question 13

OA - Diagnosis

Answer 13

• no specific test available
• need to rule out other conditions
• MRI - joint degeneration (late feature)
• synovial fluid analysis
• arthroscopy
• x-ray (evidence of joint narrowing, osteophytes)

Question 14

OA - Nursing Management

Answer 14

• pain control
  
  • analgesia, anti-inflammatories (NSAIDs, DMARDs)
  • non-pharmacological - heat
• prevention of progression
  
  • preventative measures:
  • weight reduction
  • decrease load on joints
  • rest, splints & braces
  • exercises
• restoration of joint function
  
  • surgical interventions:
  • osteotomy - cutting into the bone
  • arthrodesis - fusing / fixing the joint
  • joint replacement

Question 15

Osteoporosis

Answer 15

• decrease in bone mass & density
• dependent partly on how much bone mass you attain in your youth
• occurs with age due to rate of bone reabsorption is greater than the rate of bone formation

Question 16

Osteoporosis - Risk Factors

Answer 16

• modifiable
  
  • diet (calcium, vitamin D)
  • high alcohol intake
  • smoking
  • physical inactivity
  • medications: steroids, heparin, antacids
  • oestrogen deficiency
• un-modifiable
  
  • genetics / body type
  • gender (equal till after menopause)
  • premature menopause
  • amenorrhoea
  • caucasion

Question 17

Osteoporosis - Clinical Manifestations

Answer 17

• most people unaware until fracture occurs
• fractures (wrist, spine & hip most common)
• pain, weakness, stiffness, unsteady gait
• loss of height
• khyphosis forming

Question 18

Osteoporosis - Diagnosis

Answer 18

• bone mass density testing (BMD testing)
  
  • usual sites, hips, spine, wrist or whole body
  • T score & Z score: normal = +1 to -1, osteoporosis = -2.5
• x-ray - fracture detection
• serum calcium, phosphorus & alkaline phosphorus levels
• dexa scan - duel energy xray absorbtiometry: two types of energy measuring the rate of absorbtion

Question 19

Osteoporosis - Nursing Management

Answer 19

• management aimed at:
  
  • preventing bone loss
  • reducing risk of fractures
• Hormone Replacement Therapy
  
  • prevents bone loss during & after menopause
  • use for less than 5 years, long term use associated with heart disease, DVT, breast cancer
• nursing aims:
  
  • education
  • managing pain
  • physiotherapy
  • dietary & vitamin supplements
  • exercise
  • avoid smoking & alcohol
  • getting support

Question 20

Paget’s Disease

Answer 20

• disorder of bone remodelling, leads to thickened and enlarged bones, structurally abnormal & brittle
• localised increase in osteoclast formation leads to bone reabsorption, formation increases, osteoblasts deposit bone chaotically leading to poor quality bone without lamellar structure
• leads to pain, fractures & deformity, higher risk of developing bone cancer

Question 21

Paget’s Disease - Manifestations & Management

Answer 21

• insidious onset
• pain in affected bone
• on x-ray bone may appear enlarged & bowed
• overlying skin warm, but not tender
• bowed legs & kyphosis noticed over time
• drug therapy: bisphosphonates (reduce bone turnover), calcitonin (inhibit osteoclast activity), NSAIDs, analgesia
• exercise programs

Question 22

Rickets & Osteomalacia

Answer 22

• known as Rickets in children, & osteomalacia in adults
• vitamin D deficiency
• leads to softening of bones, bones become deformed

Question 23

Rickets - Causes

Answer 23

• insufficient calcium absorption from the gut due to a lack of dietary calcium or resistance to vitamin D
• lack of exposure to sunlight (vitamin D deficiency)
• phosphate deficiency due to altered elimination by the kidney or decreased intestinal absorption

Question 24

Rickets - Treatment

Answer 24

• improved diet, including calcium & vitamin D
• large doses of vitamin D
• treatment for any underlying disorder
• surgery to correct bone deformities