Degenerative Bone Diseases

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• Degenerative Bone Diseases
• Deborah Cary, MSN
• Broward Community College

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OSTEOMYELITIS

• Infection of the bone, bone marrow and
  surrounding soft tissue
• Indirect entry
• boys
• Site distal femur
• proximal tibia
• humerus
• radius
• Adults pelvis,vertebrae most common

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• Direct Entry from fx, deep wounds, implants
  Indirect spread from systemic infection
• Acute osteo lasts
• Chronic osteo 1 month
• Pain is unrelieved by rest - with activity
• Dx bone scans, cultures, bx, gallium and
• indium scans (radionuclides),MRI, CT
• Sx WBC and sed rate
• TX long term drug rx, hyperbaric O2

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Treatment

• Prevention - controlling infections in body
• scrupulous pin care with
  external
• fixators and pinning
• Immobilize limbs, NSAIDS, Muscle relaxants
• Good alignment with freq position change
• Prevent contractures hips and knees secondary to
  patients assuming position of comfort
• Teach re side effects antibiotics
  aminoglycosides
• hearing , neurotoxicity, fluid retention
• Monitor peak/trough levels
• Lengthy rx candida albicans

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BONE MALIGNANCIES

• Adults multiple myeloma
• Most common primary bone tumor
• SX BACK PAIN, anorexia, wgt loss
• anemia, thrombocytopenia

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Diagnosis

• Bone Marrow Aspiration
• X-Rays
• Poor Prognosis
• Tx chemo, radiation, autologous
• cell transplants, Corticosteroids

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Osteogenic Sarcoma

• Extemely malignant
• Region of long bones, distal femur, proximal
  tibia , proximal humerus, pelvis
• Most common maligant bone tumor in children and
  young adults

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• SX gradual onset of pain and swelling
• Increase serum alkaline ptase, inc CA
• DX Xray, CT, PET, MRI
• Chemo pre-op
• Surgery contraindicated with major neurovascular
  involvement, pathological fx or infection

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OSTEOCLASTOMA

• Giant Cell tumor
• Long bones of adults distal ends of femur,
  tibia and radius
• Females 20-35
• SX swelling, pain, joint fx disturbances

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Ewings Sarcoma

• One of the most common primary malignant
  neoplasms of bone and soft tissue
• Boys 5-15
• Sx swelling affected part, wbc inc.,fever
• Tx wide resection, amputation
• 5 yr. survival 60

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Metastatic Bone Disease

• Ca of breast, prostate, GI, lungs
• kidneys, ovaries, thyroid
• Travel to vertebrae, pelvis, femur,
• humerus, ribs

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• DX - bone scan
• serum elevated Ca levels
• elevated ALP (alkaline ptase)
• Isoenzymes can distinguish from
• hepatic diseases (ALP1liver and
• ALP2bone

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LOW BACK PAIN
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Statistics

• 80 ADULTS have at least once in lifetime
• Second only to HA as the most common
• pain complaint
• One of the nations most costly health
  problems!!

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Risk Factors

• Lack of muscle tone
• Excess body weight
• Poor Posture
• Smoking
• Stress

• Prolonged periods of sitting
• Lifting heavy objects
• Vibration-type jobs
• Often due to a musculoskeletal
• problem

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• Most common cause of low back
• pain is mechanical strain of the
• paravertebral muscles

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Musculoskeletal Causes

• Acute LS Strain
• Instability of LS bony mechanism
• Osteoarthritis LS Vertebrae
• Intervertebral disc degeneration
• Herniation of the Intervertebral disc

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Acute Back Pain

• Lasts episode
• Degenerative Disc Disease
• Dx straight leg raise causes pain lumbar area
  without radiation along sciatic nerve

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Treatment

• IF pain is not severe or debilitating,
  treatment is as outpatient
• Analgesics
• Muscle Relaxants
• Massage
• Rest 1-2 days
• Corsets

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Chronic Low Back Pain

• Lasts 3 months or is a repeated
• incapacitating episode
• Causes
• Degenerative disc disease
• Lack of physical exercise
• Prior Injury
• Obesity
• Structural/postural
  abnormalities
• Systemic Disease
• OA of lumbar spine in 50 yr old

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Treatment

• Pain medication
• Epidural injections
• Nerve Blocks

OFTEN DONE AS OUTPT
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Herniated Intervertebral DiscSlipped Disc

• Natural degeneration with age
• Repeated stress and trauma to spine
• Nucleus pulposus (gelatinous center of disc) may
  rupture and cause acute injury and back pain
• Common sites LS area (L4-L5 and L5-S1)
• C5-6 and C6-7 may occur (younger)

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Spinal Surgery

• Laminectomy most common
• removal of lamina
• Diskectomy decompress nerve root
• Percutaneous laser diskectomy outpt using a
  retroperitoneal approach
• Spinal fusion
• Log Roll post-op 1-2 days
• Pillows under thighs/between legs
• Narcotics 24-48hrs.
• Potential for CSF leak (HA)
• Freq. monitoring NV signs
• New weakness or paresthesias call MD

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OsteoporosisThe Silent Thief
Dowagers Hump
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Statistics

• 28 million women in US have some degree
  osteoporosis
• 13 million sustain an osteoporotic related fx
  annually
• 8X women than men

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Osteoporosis

• Means porous bone (fragile bone disease)
• Chronic and progressive
• Low bone mass
• Structural deterioration bone tissue

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• Increase in bone fragility
• Breast feeding and pregnancy deplete a
• womans skeletal reserves
• Longevity in women than men

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Risk Factors for Osteoporosis

• Gender
• Age
• Family Hx
• Whites of European Descent
• Asians
• Small stature
• Early Menopause

• Oophorectomies
• Breast Feeding
• Anorexia
• Low dietary Ca
• Smoking
• ETOH
• Chronic use of glucocorticosteroids,
  seizure/thyroid meds

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Pathophysiology

• Bone continously being deposited by osteoblasts
  and resorbed by osteoclasts (remodeling)
• In osteo, bone resorption exceeds bone deposition
• Bones of hips, spine and wrists affected

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Patho continued

• Wedging and fractures of vertebrae
• produce height loss and hump-shaped
• back (Dowagers hump, kyphosis)
• Back pain can lead to spinal compression
• spontaneous fx (pathological fx)

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Comorbidity

• Intestinal malabsorption
• Kidney diseases
• Rheumatoid arthritis
• Hyperthyroidism
• ETOH with cirrhotic liver
• Diabetes

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Diagnosis

• BMD bone mineral density measurement
• Definitive DEXA (dual energy x-ray
  absorptiometry)
• Measurement of T score
• Bone bx differentiates from osteomalacia
• Back Pain
• Loss height
• Kyphosis

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Treatment

• Adequate Ca intake (1000mg/day for premenopausal
  women
• 1500 mg postmenopausal women
• See Table 62-14 in textbook for types Ca
• Foods hi in Ca yogurt, whole and skim milk,
  squash, ice cream, sardines, turnip greens see
  chart
• Vitamin D 400 to 800 IU older adults and
  homebound
• Weight bearing exercise!!! Walking preferred

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Medications

• Biphosphonates
• FOSAMAX (Alendronate) strengthens bones
  and encourages mineral deposition in vertebrae
• Take with a full glass water
• Causes esophageal irritation MUST
  be able to stay upright for 30mins.
• Once weekly 30mgm
• BONVITA new once monthly
• CALCITONIN (Miacalcin) nasal spray QD AID IN
  PAIS
• CAlCIUM
• Parathyroid hormone injectable
• Raloxifene decreases risk breast Ca decreased
  LDH not to use

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Osteoarthritis

• Most common joint articular disease
• Slow, progress noninflammatory disorder of the
  joints
• Affects 90 of adults age 40
• Men before age 50, women after genetic
  component
• Low estrogen and obesity contribute
• Old soccer and football injuries
• Nodules/cysts appear
• Bone rubs against bone leading to pain
• Heberden nodes on fingers
• and interphalangeal joints

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Pathophysiology

• Cartilage damage at level of chondrocytes
• Cartilage becomes softer, less elastic and unable
  to resist the wear/tear or ADL
• Cartilage becomes eroded, thinner and causes a
  reduction in motion
• Synovitis due to phagocytes

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Manifestations

• Systemic fatigue, fever
• Joint stiffness after rest AM, but resolves
  after 30 mins. also stiffness due to
  crepitation
• Relieved by rest in beginning stages
• Heberden nodes on DIP joints and
  Bouchards nodes on the proximal
• interphalangeal digits (PIP)
• No cure for OA can replace hips/knees
• Knees joint malalignment may produce look of
  bowlegs teach to avoid prolonged sitting
  standing, kneeling or squatting
• Sx managed conservatively for many years
• TX OTC glucosamine and chondroitin
  play role in synthesis new cartilage
• Capsaicin cream local use
• Acetaminopen
• NSAIDS

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RHEUMATOID ARTHRITIS

• CHRONIC, SYSTEMIC, INSIDIOUS
• INFLAMMATION CONNECTIVE TISSUE
• SYNOVIAL JOINTS
• INCREASES WITH AGE PEAKS 4TH/6TH
• AUTOIMMUNE DISEASE

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INCIDENCE

• Affects women 3Xmen genetic predispo
• Smoking link
• Cause unknown
• Antigen triggers IgG
• T helper (CD4) cells decrease
• Cytokines of interleukin IL-6
• TNF (tumor necrosis factor) produced

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Manifestations

• Generalized morning stiffness 60mins or
• Hx precipitating stress
• Pain, hot, swollen, tender joints
• Joint sx appear symmetrically
• Affect small joints of hands (PIP and
  metacarpophalangeal) and feet

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Comorbidity

• Sjogren Syndrome
• Felty Syndrome
• R nodules (base spine/back neck)

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Pathophysiology

• Joint inflammation consequence of massive
  infiltration of immune cells, particularly T
  lymphocytes into synovial fluid
• from Feldman,Cell, 1996
• Macrophages release small proteins called
  cytokines (dominant is TNF) - this TNF (tumor
  necrosis factor) inhibits bone formation and
  bone-eating enzymes that eat away cartilage and
  destroy joint

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Diagnosis

• RF titers increased
• ANA (antinuclear antibodies)
• Presenting Hx
• Presence symmetric swelling

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• RA and DOA often confused, therefore the
  American College Rheumatology established 7
  criteria to identify RA pts
• 1. At least 1 hr. morning stiffness
• 2. Arthritis in 3 or more joints
• 3. Arthritis of hand joints
• 4. Symmetric swelling
• 5. Rheumatoid nodules
• 6. Presence of RF in serum
• 7. Radiographic changes in hand or wrist joints
• RA is defined by presence of 4 or more of these 7
  criteria

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Pharmacological treatments

• COX 2 inhibitors previously used, but just
  taken off market by FDA
• DMARDS disease modifying antirheumatic drugs
• Methotrexate alleviates pain and
• morning stiffness
• Tale 4-6wks for effectiveness and
  plateau after 6 months
• Many side effects MUST monitor CBC,
  LFT every 4-8wks, Renal fx tests every 3 months
  contraindicated in pregnancy and renal disease
• NEW Leflunomide immunosuppressant
• loading dose 100mg 3 days , then 20mg qd

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Meds continued

• Corticosteroids prednisone 5-10mgm qd
• Biologic Response Modifiers Etanercept
• Inhibits TNF
• good results with Methotrexate, however not a
  first line medication since concerns with its
  immunological suppression given via injection

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Pagets Disease

• Skeletal bone disorder with excess bone
  resorption
• Etiology unknown virus suspected
• Familial tendency
• Men women
• Rare under age 40
• Bone pain, fatigue, waddling gait
• Enlarged skull
• Pathologic fx most common complication
• Elevated serum alkaline phosphatase