MUSCULOSKELETAL DISORDERS

Bone Fracture
Description:
It’s a break or crack in a bone.

Causes of Bone Fractures:

Happens because the bone can NOT withstand the force.
• Trauma (Fall, car accident etc.)

• Twisting (sports injury, abuse etc.)

• Diseases (bone cancer or osteoporosis)
Children tend to heal faster than adults from bone fractures because the periosteum (the
dense fibrous membrane covering the bones) is stronger, more flexible, and thicker than
adults.

It can take anywhere from 3 to 12 weeks to heal from a bone fracture, depending on the
person’s age and health status.

Complications of a Bone Fracture:

• Infection (Osteomyelitis)
• Compartment Syndrome
• Fat Embolism

Signs and Symptoms of a Bone Fracture

“BROKEN”

Bruising over the site (discolored with swelling) and pain

Reduced movement of extremity or muscle

Odd appearance (looks abnormal)

Krackling sounds due to bone fragments rubbing together (crepitus)

Edema and erythema at the site

Neurovascular impairment…6 P’s (Ischemia: Pain, Pallor, Paralysis, Paresthesia,

Pulselessness (late sign), Poikilothermia)
Types of Bones Fractures:
**Remember these types!!

• Did it break through the skin? Open or closed

Open Fracture (“Compound”): a fractured bone that breaks through the skin

Closed Fracture (“Simple”): a fractured bone that does NOT penetrate through the skin
(skin remains intact)

• Is the bone completely broken or part of it? Complete or incomplete

Complete Fracture: the fracture completely separates the bone in two

Incomplete Fracture: the fracture does NOT break the bone all the way through

• What is the pattern or details or the fracture? Straight across, up and down, at an
angle, crushed in fragments
Greenstick: one side of the bone is bent while the other is broken…incomplete type of
fracture (most common in pediatric patients because their bones are more flexible
than an adults)

Comminuted: the bone is broken into many fragments (3 or more)

Transverse: the fracture is straight across the bone shaft

Oblique: the fracture is slanted across the bone shaft

Spiral: the fracture twists around the bone shaft (from a twisting injury)

Nursing Interventions for Fractures

• After a fracture, confirm the patient is safe (out of harm’s way) and stable.

• Then, Immobilize the fracture by using a device to splint it: (It keeps the patient
from using the affected extremity)
WHY is this important to do? The goal is to help a bone fracture heal properly by
putting it back in its original state (If it moves, this can causeimproper healing). In
addition, it prevents more surrounding tissue damage, bleeding, and pain.
• Stop bleeding, if present, by applying pressure with a clean cloth (Be sureyou know
if your patient takes blood thinners, and if possible, what their PT/INR (Coumadin)
and PTT (Heparin) values are.
• If the fracture is an opened “compound” fracture, cover with steriledressing!

• Elevate extremity to decrease swelling.

• Apply ice wrapped in towel to the injury to decrease swelling (want to prevent
excessive swelling due to the risk of compartment syndrome).
 • Keep NPO (nothing by mouth) until evaluated by surgeon…may need surgery.

• X-ray will be ordered to diagnose a possible fracture and what type.

• Pain management with prescribed medications: Document and closely monitor how
the medication is relieving the pain…very important!! Watch out for compartment
syndrome (Pain is not relieved with medication and it hurts with passive movement
like stretching or elevating the extremity).

• Monitor for fat embolism, especially if this is a long bone fracture: Assess mental
status and respiratory system: confusion, restless, increased respiration, difficulty
breathing.

• Assess neurovascular status! Assess the 6 P’s: This assesses the functionof the
nerves and blood flow for possible compartment syndrome (If not caught early, this
will lead to IRREVERSIBLE nerve, muscle, damage, and tissue death)

Compartment Syndrome:
Compartment syndrome occurs when too much pressure is exerted within the muscle
compartments found within the fascia.

This can occur when there is hemorrhaging (bleeding) or swelling present after an
injury, like with a bone fracture (or with external factors like a cast being too tight or
traction). All this can increase the pressure within the compartments. As the pressure
builds, this will cut off the blood supply and nerve function to this muscle. If not
corrected within 6 hours, the damage is permanent.

Remember from anatomy and physiology that in the leg and arm there are individual
compartments grouped together (but separated from one another) that contain bone,
muscle, nerves, and vessels. Each compartment usually has its own muscle, nerve, and
vessel supply. Fascia is what keeps all these structures in place and separated.

The important thing to remember about fascia when talking about compartment syndrome
is that it does NOT expand when pressure increases within a compartment(so there
will be no relief within the compartment from the fascia).
Instead, the pressure stays within the compartment and causes blood vessel and nerve
function to become compromised (diminished). So, ischemia is going to occur to the
muscle and distal extremity to the fracture.

Assess the 6 P’s:

1. Pain (Early sign)

2. Paresthesia (can be an early sign too)
3. Pallor
4. Paralysis
5. Poikilothermia
6. Pulselessness (Late sign)
Pain: Worst with passive touch or movement, elevating the limb, or any pressure,
stretching increases the pain. PAIN MEDICATION IS NOT RELIEVING IT!

Paresthesia: Patient may report it feels like the extremity distal to the fracture feels like it
is falling asleep or a “pin and needle” sensation. Can they feel you touching their
extremity? ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE!

Pallor: Extremity should be pink and have normal capillary refill less than 2 seconds. In
CS, it may appear pale or dusky and have a capillary refill greater than 2 seconds.
ALWAYS CHECK THE UNAFFECTED EXTREMITY TO COMPARE!

Paralysis: Can the patient move the distal extremity from the fracture or has the movement
decreased…this is a bad sign. ALWAYS CHECK THE UNAFFECTEDEXTREMITY TO
COMPARE!

Poikilothermia: This occurs when the affected extremity distal from the fracture feels
cooler to the touch compared to the unaffected extremity. The extremity can NOT
regulate its temperature.

Pulselessness: Always check the pulse and have a Doppler available to monitor the sound
of the pulse. (This is a late sign in compartment syndrome).

Nursing Interventions for Compartment Syndrome:

• Keep the extremity AT HEART level (NOT below…. remember you want to maintain
arterial pressure and elevating it above heart level will cause more ischemia)

• Loosen and remove restrictive items

• Notify the physician

• Perform neurovascular checks (6 P’s)

• Prepare the patient for possible bivalvement of the cast, reduction of weight in the
traction, or in severe cases fasciotomy.
Various Treatments for a Bone Fracture:
❖ Bone Reduction: Putting the fractured bone back in its original state.
➢ Closed Reduction done manually…. Non-surgical with general anesthesia.

Cast (plaster or fiberglass) placed to keep broken bone in place to allow it to heal.

➢ Things to remember about casts:

• Monitor for compartment syndrome: 6 P’s
• Monitor for infection: hotspots in the cast, severe pain, fever.
• Keep the cast and extremity elevated above the heart level (Decreases
swelling).
• Apply ice packs to the cast for the first 2 days to decrease swelling.
• Even drying for new cast by turning every 2 hours.
• Use palms of hand to handle (not fingertips) with a new wet plaster cast.

WHY? Prevents dent formation in the cast by handling with the palms of
hand, which can cause skin breakdown overtime.
• Maintain skin integrity: Petal the cast…. use soft tape called moleskin around
the edge to prevent skin breakdown.
• Keep cast dry and never stick anything inside to scratch an itch.
➢ Open Reduction: Done surgically to put fractured bone back in its original state and
a fixation device used.

• Internal: Attached to the bone inside the skin (Pins, rods, plates, screws)
• External: Fixture attached to the outside of the skin that helps with bone healing
(can be adjusted…metal braces, screws)
❖ Traction: Aligns the bone with a constant steady pulling action.
• Make sure the weights are hanging freely and not on floor.

• Never remove weights without a MD order.

• Pin care and monitor for infection (odorous draining, redness, pain).
• Neurovascular status: 6 P’s.
• Overhead trapeze bar to move around in bed.
TYPES OF TRACTION:
Bucks’ Traction

Russell Skin Traction

90 degree - 90 degree Traction

Balanced Suspension
 Assistive Devices
CRUTCH WALKING
Properly Fit?

Before a patient uses crutches for the first time, each crutch must be adjusted to the
patient’s height. Each crutch can be adjusted at the top and bottom.

Mains Points to Remember:

• There should be a 2-3 finger width (1-1.5 inches) gap between the armpit (axillae)
and crutch rest pad when the patient holds the crutches.
WHY? This prevents the patient from resting on the crutch rest pad while using the
crutches. The patient should place weight on the hand grips NOT the crutch rest
pad while ambulating. This prevents nerve damage that can occur within the axillae
region.

• The elbows should be flexed about 30 degrees when the hands are placed on the hand
grips.
Types of Gaits
When a patient is learning how to use crutches, the nurse should apply a gait belt to the
patient for safety. When a patient is ready to start ambulating with crutches, they will
start in the tripod position. Each tip of the crutch will be about 6 inches to the side
of the feet diagonally.

❖ Two-Point Gait:

The patient will move the injured side’s crutch (example right crutch) at the SAME
TIME as the non-injured leg (example left leg) AND then the patient willmove the
non-injured side’s crutch (example left crutch) at the SAME TIME as the injured
leg (example right leg).

So it goes: Move right crutch along with the left leg and

THEN, move the left crutch along with the right leg.

❖ Four-point gait:
This type of gait is similar to the two-point gait BUT the crutch and leg move
SEPARATELY rather than at the same time. For example, the patient will move the
injured side’s crutch (example right crutch), then move the non-injured leg
(example left leg), then move the non-injured side’s crutch (example left crutch),
and then move injured leg (example right leg).

So, it goes as: move right crutch, then move left leg, then move left crutch, and then
move the right leg.
❖ Three-point gait:
The patient will not let the injured leg touch the ground…. therefore,the patient
will move BOTH crutches and the injured leg forward together and then move the
non-injured leg.

So, it goes as: move both crutches and injured leg forward together and then
move the non-injured leg.
❖ Swing-to-gait:
The patient will move both crutches forward and then SWING bothlegs forward
to the same point as the crutches.
❖ Swing-through-gait:
The patient will move both crutches forward and then SWING both legs forward,
PAST the crutches.
Up and Down Stairs with Crutches?
The key to understanding what moves first (the good or bad leg) when either going up
or down the stairs is to remember:

“Good=UP” and “Bad=Down”

❖ Going UP the stairs:

The patient will move the “good” leg (hence non-injured leg) UP onto the step FIRST and
then will move the “bad” leg (hence injured leg) and crutches up onto the step.

❖ Going DOWN the stairs:

The patient will move both crutches down onto the step and then move the “bad”
leg (hence injured leg) DOWN and then move the “good” leg down.
Sitting Down and Getting Up from a Chair?
❖ Sitting Down:
― The patient will back up to the chair until they feel the chair with the back of their
non-injured leg.

― The patient will then move BOTH crutches on to the INJURED side and grip the
hand grips of the crutches for support.

― The patient will keep the injured leg extended out and slightly bend the non-
injured leg.

― Then the patient will feel for the chair’s seat with the non-injured side and sit
down…all while keeping the injured leg extended out.

❖ Getting Up:
― The patient will keep the injured leg extended out forward and put BOTH
crutches on the INJURED side and grip the hand grips of the crutches.
― Then the patient will lean forward and push up with the arm of the non-injured
site on the chair’s seat and by using the hand grips on the crutches, which is
on the injured side.
― Once standing, the patient will bring the crutches into the tripod position.
CANES
Properly Fit?

Before a patient uses a cane for the first time, the cane must be adjusted to the patient’s
height. Most canes can be adjusted at the bottom. Below are some key concepts to help
us tell if a cane fits our patient properly.

Mains points to remember:

• The top of the cane should be even with the greater trochanter (This is the
prominence of the top of the femur bone) OR

• When the patient holds the arms at their side, the top of the cane should be even
with the wrist crease closest to the hand.
• While gripping the cane, the elbow should be flexed at a 15-30 degree angle.

Ambulate?
When a patient is learning how to use a cane, the nurse should apply a gait belt to thepatient
for safety. In addition, the nurse should stand on the patient’s WEAK side during
ambulation. When a patient is ready to start ambulating with a cane, the patient should place
the tip of the cane about 4 inches from the side of the foot.

To walk (ambulate) with a cane, the patient will hold the cane on the STRONG side. Then,
the patient will move the cane and weak side TOGETHER forward, and then move the
strong side.
Up and Down Stairs with a Cane?
Again, the key to understanding what moves first (the good or bad leg) when either going
up or down the stairs is to remember:

“Good=UP” and “Bad=Down”

❖ Going UP the stairs:
The patient will move the “good” leg (hence non-injured leg) UP onto the step FIRST
and then will move the “bad” leg (hence injured leg)and the cane up onto the step.

❖ Going DOWN the stairs:

The patient will move the cane down onto the step and then move the “bad” leg (hence
injured leg) DOWN and then move the “good” leg down.
Sitting Down and Getting Up from a Chair?

❖ Sitting Down:
The patient will back up to the chair until they feel the chair with the back of their
legs. The patient will then allow the cane to rest on the side of the chair. Then the
patient will place both hands on the chair’s arm rest and place weight on the hands
and bend the strong leg while keeping the weak leg slightly extended and sit
down in the chair.

❖ Getting Up:
The patient will place the cane on the strong side and keep the weak leg slightly
extended out. Then the patient will lean forward out of the chair and push down
on the cane’s hand grip and chair’s arm rest. Then the patient will put weight on
the strong leg and stand in position with the cane.
WALKER
Properly Fit?

Before a patient uses a walker for the first time, the walker must be adjusted to fit the
patient’s height. Walkers can be adjusted at the bottom via the legs of the walker (there
are four legs that will need to be adjusted).

Mains points to remember:

When the patient holds the arms at their side, the hand grips of the walker should be
even with the wrist / crease.
When the patient holds onto the hand grips of the walker, the elbows should flex at
about a 15-30 degree angle.

Ambulate?
When a patient is learning how to use a walker, the nurse should apply a gait belt to the
patient for safety. In addition, the nurse should stand on the patient’s WEAK side
during ambulation.

Before a patient starts ambulating with a walker, the patient should get into a starting
position by making sure that the middle of the foot lines up with the back tips of the
walker.

.
Also, tell the patient to look ahead while using the walker because some patients may
want to look down and stare at their feet while ambulating. This could lead to an injury
or fall.

How to ambulate with a walker??

First, the patient will lift and move the walker forward.

1. Stress to the patient to make sure ALL FOUR TIPS of the walker’s legs are
touching the ground after moving the walker forward before proceeding.
2. Then the patient will move the WEAK side forward.
3. Put weight on the hand grips via the hands.
4. Then the patient will move the STRONG side forward.
5. Repeat the steps above in order.

❖ Going Up and Down Stairs with a Walker?

It is not recommended a patient uses a walker to go up and down the stairs due to safety
issues. The patient should use another type of assistive device like a cane. However, the
patient should always consult with their doctor or physical therapist about this. For exams,
you will not have to know about going up and down stairs with a walker.
❖ Sitting Down and Getting Up from a Chair?
Sitting Down:

The patient will back up to the chair with the walker until they feel the chair with the
back of their legs. The patient will then slightly extend the weak leg and bend the
strong leg, while feeling for the chair’s arm rests with the hands. Once the arm
rests of the chair are felt, the patient will continue to bend the strong leg and sit
down in the chair.

Getting Up:

The patient will place the walker in front of them while in the chair. Then, the patient
will lean forward in the chair, keep the weak leg slightly extended out, and place
hands on the arm rests of the chair. Then, the patient will push up with the hands
on the arm rests of the chair and with the strong leg. Once standing, the patient
will firmly grip the hand grips of the walker and begin to ambulate with the walker.
 Osteoporosis
❖ Description
It’s a disease process that thins the bones to a point that the bones are not strong
enough to withstand everyday stress and it breaks/fractures.

Most common type of fracture seen in patient with osteoporosis is called Colles’
fracture. This is a fracture of the lower part (distal) of the radius at the wrist.

❖ What is happening to the bones in osteoporosis?

The inside of the bone (specifically the spongy bone) becomes very porous, and the
bone’s density decreases…. making it weak. Inside the spongy bone resides cells
called osteoblasts and osteoclasts.

Osteoclast CONSUME bone and osteoblasts BUILD bone. Normally, osteoblasts

and osteoclasts work at the same rate. However, in osteoporosis, the osteoclasts
start to outwork osteoblasts.

This disease suddenly sneaks up on a patient (in most cases without signs and
symptoms). The patient is usually surprised with a bone fracture.

Osteoporosis most commonly affects the wrists, hips, and spine.

❖ Role of the bones:

• Provides protection to our organs and supports them.

• Allows us to move with the assistance of muscles, tendons, and ligaments
• Gives our body its shape.
• Inside of the bones (specifically the bone marrow), there is an intricate system
maintaining our survival.
o It’s responsible for red blood cell, platelet, and white blood cell production
(red marrow).
o Storage of these blood cells along with storing our calcium and phosphorous
minerals for when we need them.
o Preserving lipids for energy when needed (yellow marrow).
❖ Compact Bone vs. Spongy Bone
Compact Bone is a strong, tight woven layer than protects the inside of the bone
and helps maintain bone strength and resistance to stress.

Spongy Bone is a matrix of pore like components (hence its name “spongy”), such
as proteins and minerals (calcium and phosphate). In osteoporosis, this matrix starts
to thin (it becomes more porous…making the bone weak).

Within the spongy bone are OSTEOCLASTS (they consume the bone matrix and
remove substances from the bone (calcium) and puts it in the bloodstream when we
need it).

OSTEOBLASTS (build up the bone matrix within the spongy bone by taking
substances (phosphate and calcium) from the blood and building up the bone.

These cells are majorly influenced by hormones (It is important to understand how
these hormones work because this will help us understand the medication treatment
which help slow down osteoclast activity).

❖ Hormones that play a role in Bone Health:

➢ Parathyroid hormone (PTH): When calcium levels are low, the parathyroid gland
secretes PTH (parathyroid hormone). This causes the osteoclasts to break down
the stores of calcium in the bone so it can be placed in the blood…. hence increasing
calcium levels. In addition, PTH increases the small intestine reabsorption of
calcium,and decreases the kidneys from excreting calcium.
 It is important to note that parathyroid hormone INDIRECTLY stimulates osteoclast
activity. It plays a role with osteoblasts as well because PTH binds to osteoblasts. In
a sense, the osteoblasts will control/regulate the activity of the osteoclasts under the
influence of PTH. Therefore, if extra doses of PTH are given (as with the medication
treatment drug Teriparatide “Forteo”) this can improve bone health by making the bone
stronger and more resistant to fractures.

➢ Calcitonin: When calcium levels are too high, the thyroid gland creates calcitonin
to decrease the activity of the osteoclasts…. less break down of bones, which
will keep calcium levels normal.
➢ Growth Hormone: Stimulates osteoblasts to build up bones

➢ Estrogen: Controls the activity of osteoblasts and osteoclasts by keeping the

bones strong and prevent bone resorption by the osteoclasts. Estrogen in a nutshell
prevents the osteoclasts from living too long.

Why is this important to know? Remember estrogen is secreted by the ovaries. When
a woman enters menopause, she will produce less estrogen, which places her at
risk for osteoporosis.

➢ Testosterone: This is converted into estrogen to keep bones stronger, as stated

above. As men age, testosterone levels decrease, and this puts them at risk for
osteoporosis.

It is important to note that during a person’s mid 30’s, most people reach peak bone
mass. The osteoclasts and osteoblasts are working at the same rate. BUT after the
mid 30’s, the bones are broken down faster than replaced…. hence, we see
osteoporosis in older age.
❖ Risk Factors for Osteoporosis:
Remember: “Calcium”
Calcium and vitamin D intake low (osteoclasts break down the bones more to
keep calcium levels normal)

Age (bones become weaker as your age and bone mass decreases after 30,
lower testosterone and estrogen levels)

Lifestyle (cigarette smoking, alcoholic, sedentary, immobile)

Caucasian and Asian women (women have less bone tissue than men)

Inherited (genetics)

Underweight BMI <19 (thin or small body frame. There is less bone mass, and the
person loses it quicker…anorexia)

Medications: glucocorticoids…three months or more (stimulates osteoclasts and

decreases osteoblast activity), anticonvulsants: phenobarbital, carbamazepine
(tegretol), phenytoin (Dilantin), valproate (Depakote) (affect the osteoclasts and
osteoblast activity)

❖ Signs and Symptoms of Osteoporosis:

“FRAIL”
Fracture (hip, wrist, spine) caused by normal regular activities

Rounding of the upper back Dowager’s Hump (spine deformity…stooped posture)

fromspine fracture

Asymptomatic until fracture

Inches of height lost overtime since a young adult (2-3 inches) …due to spinal
fracture…can be painless

Low back pain, neck, or hip pain (on palpation or with activity like bending or increase
stress put on the bone)
❖ Tests for Osteoporosis
➢ Bone density test (BMD bone mineral density test): also called DXA or DEXA
scan

• X-ray imaging taken to measure calcium and other bone minerals in the bones.
• Patient Education: No calcium supplements (TUMS, ROLAIDS, other vitamins
containing calcium etc.) 24 hours before the test.
❖ Nursing Interventions for Osteoporosis
• Assessing for risk factors: remember the mnemonic “CALCIUM”

• Discussing with patient how to change modifiable risk factors that can be changed.

• Assessing for possible signs and symptoms.

• Education about tests: DEXA scan: no calcium supplements 24 hours before

test.

• Safety! Major concern…very simple fall can lead to a fracture…Patient always

needs the call light in reach, room need to be clutter free, assistive devices (use
correctly),non-slip sock, avoid rugs, watch pets getting around feet, using eyewear
to see.

• Good body mechanics, ROM exercise

❖ Prevention:
➢ Weight-bearing exercise (helps increase bone mass)
Lifting weights, hiking, tennis…need stress of gravity on the bones to build them
up…low impact not as beneficial but good for cardiovascular health.
➢ Eating foods rich in calcium:
• Yogurt
• Sardines
• Cheese
• broccoli
• Collard greens
• Tofu
• Rhubarb
• Milk
➢ Sufficient Vitamin D intake (helps body absorb calcium): salmon, tuna, cheese,
eggyolks

➢ Smoking cessation, limiting ETOH intake

❖ Medications for Osteoporosis:
➢ Calcium and Vitamin D supplements

➢ Bisphosphonates slows bone break down. Alendronate (Fosamax), Risedronate

(Actonel), Ibandronate (Bonvia)

GI upset and esophagus problems: IMPORTANT!! Take with full glass of water
in morning on empty stomach with NO other medications and sit up for 30 minutes
or more… (60 minutes with Bonvia) after taking and don’t eat anything for 1 hour. Helps
the body absorb more of the medicine.
➢ Calcitonin: made from salmon calcitonin, decreases osteoclast activity.
Remember calcitonin is secreted by the thyroid gland naturally.

At risk for HYPOcalcemia

➢ Hormone replacement therapy (HRT) (estrogen): used for short-term due to other
effects on the body: stroke, blood clots, breast cancer
• Raloxifene (Evista): selective estrogen receptor modulator…. monitor for
deep vein thrombosis.
• Teriparatide (Forteo): severe cases of osteoporosis…it provides extra
parathyroidhormone which stimulates osteoblasts and make them live longer.
 Osteoarthritis and Rheumatoid Arthritis

Osteoarthritis
❖ Description
• A form of arthritis (MOST COMMON TYPE) that causes deterioration of the
articular hyaline cartilage of the bones.
• Affects the joints…mostly weight-bearing joints: Hands, knees, hips, and spine
• Does NOT affect other systems of the body and is Asymmetrical (RA is
symmetrical) with joint involvement (can be in both related joints but NOT a
requirement.)
• Happens due to “wear and tear” on the joints (Risk factors: older age, being
overweight, repeated injuries, strenuous jobs, genetics)
• Inflammation not present: Joint pain due to grating of bones, bone break
down, bone spur formation, and cartilage/bone spurs floating in the joint
space.
❖ How it Happens?
• Hyaline cartilage breaks down and wears away (affects the inside and outside
of the bone)
o Inside: Sclerosis of the bone (abnormal hardening of the bone)
o Outside: Osteophytes formation-> grating “crepitus” of the bones due to loss
ofjoint space.
• Parts of the cartilage, bone spurs, and underlying bone can break off and float
around in the joint space. All of this will lead to pain, stiffness, deformity, and limited
mobility.

❖ Signs and Symptoms:

“Osteo”

➢ Outgrowths on Hands: Nodes (bony outgrowths) on fingers from bone spurs:

• Heberden’s Node (more common): found on the distal interphalangeal joint

• Bouchard’s Node: found on the proximal interphalangeal joint

➢ Sunrise Stiffness (morning time): Less than 30 minutes (RA greater than 30 minutes)
…pain will be the worst at the end of day from overuse than compared to morning
time.

➢ Tenderness when touching the joint site with bony outgrowths. NOT warm or boggy
with synovitis as with RA.

➢ Experience grating (crepitus) of the bones when moving/flexing joint from bones
rubbing together and joint pain with activity that goes away with rest.

➢ Only the joints: Asymmetrical/Uneven, limited to joints (joint site will be hard and
bony, not system wide (no fever, anemia, fatigue, systemic inflammation…just joint)
❖ Testing:

➢ X-ray: remember shows bone NOT cartilage but is still very helpful in showing OA:

• presence of bone spurs or parts of bone deterioration

• sclerosis of the bone
• decreased joint space
• osteophytes or bone fragments in the joint

Rheumatoid Arthritis
❖ Description:
• A form of arthritis that is an autoimmune condition that causes inflammation
of the synovium within the joints.
• Affects the joints in a Symmetrical fashion: Most commonly affects the fingers
and wrist.
• It can also affect the neck, shoulders, elbows, ankles, knee, and feet.
• It is systemic and can extend to the heart, skin, eyes, mouth, lungs, and cause
fever and anemia.
• Cause unknown: affects women more than men and can happen at any age (20`
60 years old).
• Inflammation is present: joints will be warm/red joints
❖ How it Happens?

Rheumatoid Arthritis Stages:

➢ Synovitis: Inflammation of the synovium

WBCs invade the synovium, which causes it to become inflamed. This inflammation
leads to thickening, and the formation of a pannus.

➢ Formation of a Pannus:

A pannus is a layer of vascular fibrous tissue. The pannus will grow so large, it will
damage the bone and cartilage within the joint. The space in between the joints will
disappear and ankylosis will develop.

➢ Bone ankylosis:

This is the fusion of the bones. The patient will have major stiffness and
immobility of the joint.

Note: there is no formation of osteophytes as in OA.

❖ Signs and Symptoms:
“Seven S’s”
Sunrise Stiffness (severe pain) GREATER than 30 minutes

Soft, tender, and warm in joint

Swelling in the joint (warm)

Symmetrical

Synovium (affected and inflamed)

Systemic (affects not only the joint feels aches, tired, lungs, heart, anemia etc.)

Stages (Synovitis, Pannus, Ankylosis)

❖ Tests :
➢ Positive Rheumatoid factor, elevate erythrocyte sedimentation, C reactive
protein (inflammation in the body…higher in patients with RA),
➢ X-ray may show joint deterioration

❖ Management of OA and RA:

• No cure: becomes worst overtime…patient must learn how to manage correctly
to prevent further break down of the joint:

• Surgery: Joint replacement

o RA: Synovectomy (removal of the synovium), Arthrodesis (joint fusion)
o OA: Osteotomy (bone realignment…like a knee osteotomy to help alleviate
weight on affected knee)
❖ Exercise very important:
• Do NOT exercise if painful, irritated joints but let them rest.
• Patient goals are similar: preserve joint damage, exercising, managing pain,
improve mobility, heat, and cold compresses.
• Low impact (avoid high impact), strength training, ROM, using assistive devices,
Physiotherapy, Occupational Therapy
❖ Medications: NSAIDs, Corticosteroids (Intra-arthritic for OA)
• RA: DMARDS, anemia (supplements like iron, folic acid, vitamin B 12)
• OA: Topical creams, losing weight (BMI <25)
 Gout
❖ Description:
It’s a type of arthritis due to the accumulation of uric acid in the blood. This causes
uric acid crystals to form in the joints and the patient will experience severe pain,
inflammation, redness, and limited mobility.

Points to remember includes:

• The patient has issues with HIGH URIC ACID levels in the body because the patient
is producing too much uric acid or not excreting it normally.
• Sharp needle like urate crystals form around the joints causing intense
inflammation along with pain and redness.
• It tends to occur in the BIG TOE most commonly, but can affect the fingers, elbow,
knee, small toes, wrist.

• Diet management and losing weight plays a role in managing gout attacks.

❖ What is uric acid?

It is a waste product created from the purine breakdown during digestion. It enters
the blood stream and is filtered through the kidneys and excreted out in the
urine. The kidneys play a role in keeping the uric acid levels within normal range.
Therefore, if the kidneys are damaged, there is a high risk of uric acid levels
increasing.

❖ What is purine?
It’s a chemical compound used as a building block for nucleic acid (DNA and
RNA) in our body.
 Foods that are rich in purine include: (IMPORTANT)
• Internal organ meats (Liver, Kidneys) sweetbreads (Thymus and pancreas)
• Red meats
• Alcohol (especially beer)
• Seafood (anchovies, sardines, scallops)
❖ Causes of Gout:

➢ High consumption of:

• Purine rich foods

• High fructose corn syrup drinks (fruit juice and soda drinks)
• Alcohol…WHY? Alcohol and uric acid compete within the kidneys, and the
kidneys choose to excrete alcohol rather than uric acid, which leads to the
buildup of uric acid.
➢ Kidney problems: Kidneys are unable to filter out the uric acid in the blood, so it
accumulates in the blood as in conditions such as chronic kidney disease.

➢ Medications:
• Aspirin (increases uric acid levels…. EDUCATE patient to NOT take aspirin for
pain)
• Niacin
• Cyclosporine (Immune suppressor)
• Loop and thiazide diuretics…WHY? They can cause dehydration and reduce
the kidney’s ability to excrete urate, which is part of uric acid.
➢ Dehydration: Urine becomes concentrated allowing uric acid crystals to form

➢ Overweight: Increases uric acid levels…losing weight helps decrease level.

➢ Physical stress on the body: Hospitalization due to an illness, surgery. Stress

increases uric acid levels.

❖ Signs and Symptoms of Gout

➢ Acute gout attacks:

• Happen randomly…may only happen a few times or once in a person’s lifetime

and lasts 1-2 weeks.
• The joints tend to not become damaged.
• Some patients may have several months or a year between attacks.
• Tends to start out in the big toe…may also affect the fingers, elbows, wrists,
knees, heel, toes.
• The sudden swelling, redness and pain in a joint tends to awake the patient from
their sleep (middle of the night).
• Patient may have flu-like like symptoms…body aches.
• As the day progresses, the pain intensifies (4-24 hours), and the patient may have
joint stiffness. The affected area is VERY sensitive and the slightest pressure
on the joint causes intense pain.
➢ Chronic attacks:
• Happens because uric high acid levels constantly stay elevated which leads to
repeated acute attacks.
• Joints become permanently damaged because urate crystals start to form
together in large masses called Tophi.
• Tophi are white/yellowish nodules that can be found under the skin on the helix
ears, elbows, fingers, toes, joints, bursae, bones etc.

• Complications include itching, skin peeling and uric acid kidney stones.

❖ Nursing Interventions for Gout

• Assess patient’s joints, especially toes, fingers, elbows for warmth, redness, or
pain.

• Assess for a history of gout (especially if hospitalized) because remember illness

cancause a gout attack.

• Cold and warm compresses, if tolerated by the patient (alternate between cold and
warm).

• If gout is present:
o Assess events leading up to the flare up to help patient avoid these types of
events in the future (Example: Diet…Did the patient recently consume an
excessive amount of food rich in purine?)
o EDUCATE patient to determine what is causing their attacks so they can
avoid future attacks. Every patient varies with the cause of gout. Some patients
will only have a gout attack when they consume high amount of alcohol or
seafood while others experience gout due to an illness where they become
dehydrated.
o EDUCATE on low purine diet and to avoid foods rich in purine: red meats,
internal organ meats, seafood, alcohol (beer).
• Stay hydrated 2-3 liters per day, unless contraindicated: Remember dehydration
 further increases uric acid levels. In addition, staying hydrated helps prevent uric
acid crystals from forming within kidneys.

• Bed rest with affected extremities in a foot board or cradle to keep area from
pressure (bed linens and accidental bumps).

• Weight loss
❖ Medications to treat gout:
Medicines that help with an acute attack by relieving signs and symptoms:
➢ NSAIDs (To decrease inflammation)

Remember NO Aspirin…it increases uric acid level.

➢ Corticosteroids

➢ Colchicine: Used for both acute attacks and prevention of further attacks.

• It decreases swelling and lowers uric acid levels

• NURSE’S ROLE: Monitor for GI upset, neutropenia (sore throat, slow
woundhealing etc.), and toxicity. Muscle pain, tingling/numbness in finger
or toe, graylips, easy bleeding, bruising.
• NO grapefruit juice…. increases risk of toxicity

➢ Allopurinol (Zyloprim): Used for prevention of gout attacks. Doesn’t relieve

an acute attack

• Most taken with colchicine or NSAIDs.

• Works by decreasing the production of uric acid, hence preventing gout
attacks.
• NURSE’S ROLE: Patient needs regular eye exams to monitor for vision
changes and to avoid vitamin C supplements while taking due to risk for renal
calculi formation.