68
Musculoskeletal Problems
Diane Ryzner
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Functional Ability Pain
Mobility Safety
LEARNING OUTCOMES
1. Describe the pathophysiology, clinical manifestations, and 5. Describe the postoperative nursing management of a
interprofessional and nursing management of osteomyelitis. patient who had spine surgery.
2. Discern among the types, clinical manifestations, and 6. Discuss the etiology and nursing management of common
interprofessional management of bone cancer. foot problems.
3. Discuss the genetic basis and clinical course of muscular 7. Describe the etiology, pathophysiology, clinical
dystrophy. manifestations, and nursing and interprofessional
4. Discern between the causes and characteristics of acute and management of osteomalacia, osteoporosis, and Paget
chronic low back pain. disease.
KEY TERMS
degenerative disc disease (DDD) osteomyelitis
hallux valgus osteopenia (Table 68.14)
herniated disc osteoporosis
low back pain osteosarcoma
muscular dystrophy (MD) Paget disease
osteochondroma sarcoma
osteomalacia
We were made to move! This chapter reviews a variety of acute osteomyelitis (Table 68.1).1 Staphylococcus aureus is the most
and chronic musculoskeletal problems unrelated to trauma that common cause.
affect the musculoskeletal system. These include osteomyelitis, Infecting microorganisms can invade by indirect or direct
bone cancer, foot problems, back pain, and metabolic bone dis- entry. Indirect entry (hematogenous) is usually from an infec-
eases. These problems can lead to changes in mobility that affect tion with 1 microorganism. Indirect injury accounts for only
almost every system in the body. They are a common source 20% of cases. It most often affects children younger than 17
of pain and physical limitations that restrict the ability to fully years. Risk factors in adults are older age, debilitation, hemodi-
take part in activities of daily living (ADLs), leading to disabil- alysis, sickle cell disease, and IV drug use. The vertebrae are the
ity. The nurse plays a key role in assessing pain and functional most common site of infection in adults.2
ability and initiating interventions to prevent injury and main- Direct entry (contiguous) osteomyelitis accounts for 80% of case.
tain mobility. It most often affects adults.2 It can occur when an open wound (e.g.,
penetrating wounds, fractures, surgery) allows microorganisms to
OSTEOMYELITIS enter the body. Osteomyelitis can be related to a foreign body, such
as an implant or an orthopedic prosthetic device (e.g., plate, total
Etiology and Pathophysiology joint prosthesis). It may occur in the feet of patients with diabetes
Osteomyelitis is a severe infection of the bone, bone marrow, or vascular disease–related ulcers or in the hips or sacrum near a
and surrounding soft tissue. A number of pathogens can cause pressure injury. More than 1 microorganism is usually involved.
1674
, CHAPTER 68 Musculoskeletal Problems 1675
TABLE 68.1 Organisms Causing
Osteomyelitis
Organism Predisposing Problem Blood supply
blocked
Escherichia coli Urinary tract infection Initial site
Fungi, mycobacteria Immunocompromised host of infection
Mycobacterium tuberculosis Tuberculosis Subperiosteal
Periosteum abscess (pus)
Neisseria gonorrhoeae Gonorrhea
Pseudomonas Puncture wounds, IV drug use
Salmonella Sickle cell disease
Staphylococcus aureus Pressure injury, penetrating wound, open
fracture, orthopedic surgery, vascular
insufficiency (e.g., diabetes, atherosclerosis)
Staphylococcus epidermidis Indwelling prosthetic devices (e.g., joint Epiphysis
replacements, fracture fixation devices)
Streptococcus viridans Abscessed tooth, gingival disease Sequestrum (dead bone)
Pus escape
After entering the blood, microorganisms grow, and pres- Involucrum
(new bone formation)
sure increases because of the nonexpanding nature of most
bone. This increased pressure eventually leads to ischemia and
vascular compromise of the periosteum. The infection spreads Fig. 68.1 Development of osteomyelitis infection with involucrum and
sequestrum.
through the bone cortex and marrow cavity, obstructing blood
flow and causing and necrosis.
Bone death occurs due to ischemia. The area of dead
bone eventually separates from the surrounding living bone,
forming sequestra. The part of the periosteum that continues
to have a blood supply forms new bone called involucrum
(Fig. 68.1). Antibiotics or white blood cells (WBCs) have
difficulty reaching the sequestrum through the blood. Thus
sequestrum may become a reservoir for microorganisms that Fig. 68.2 Left femur with severe bone damage due to osteomyelitis.
(From Trung DT, Dinh HN, Le NT, et al.: Total femur replacement in a
spread to other sites, including the lungs and brain. If the
patient with chronic persistence osteomyelitis, Int J Surg Case Rep
sequestrum does not resolve or is not debrided surgically, a 84:106067, 2021.)
sinus tract may develop. Chronic, purulent drainage from
the tract results.
Diagnostic Studies
Clinical Manifestations and Complications Bone or soft tissue biopsy is the definitive way to identify the
Acute osteomyelitis refers to the initial infection or an infection causative agent. Blood and wound cultures are often positive.
of less than 1 month in duration. Local manifestations include Increased WBC count and erythrocyte sedimentation rate (ESR)
constant bone pain that worsens with activity and is unre- may occur. High C-reactive protein (CRP) may occur with acute
lieved by rest; swelling, tenderness, and warmth at the site; and infection. Signs of osteomyelitis usually do not appear on x-rays
restricted movement of the affected part. Systemic manifesta- until 2 to 4 weeks after the initial clinical symptoms. By this
tions include fever, night sweats, chills, restlessness, nausea, and time, the disease will have progressed. Compared with x-rays,
malaise. Later signs include drainage from skin sinus tracts or CT scan may be better in assessing the extent of infection. In
the fracture site. the acute phase, MRI may be better than CT in detecting bone
Chronic osteomyelitis is a bone infection that lasts longer than marrow edema, an early sign of osteomyelitis. Radionuclide
1 month or an infection that did not respond to initial antibi- bone scans (technetium-99m) also show abnormalities earlier
otic treatment. Chronic osteomyelitis may be a continuous, per- than x-rays. A WBC scan (indium-111–labeled cells) may help
sistent problem or recurrent, with exacerbations and remissions pinpoint the area of infection.2
(Fig. 68.2). Systemic manifestations are lessened. Local signs of
infection become more common, including constant bone pain Interprofessional Care
and swelling and warmth at the infection site. Over time, gran- Prolonged antibiotic therapy is the treatment of choice for acute
ulation tissue turns to scar tissue. The avascular scar tissue is an osteomyelitis if bone ischemia has not yet occurred. Cultures or
ideal site for continued microorganism growth because it can- a bone biopsy should be done, if possible, before starting drug
not be penetrated by antibiotics. therapy. Any related soft tissue abscess or ulceration often needs
Long-term, and mostly rare, complications of osteomyelitis surgical debridement or drainage.
include septicemia, septic arthritis, pathologic fractures, and Most patients start on IV antibiotics then switch to oral ther-
amyloidosis. apy. However, some may only receive oral agents.3 The antibiotic
, 1676 SECTION 12 Problems Related to Movement and Coordination
used depends on culture results and the infection itself (e.g., TABLE 68.2 NURSING ASSESSMENT
complexity, cause). Common antibiotics used include oxacillin,
nafcillin, clindamycin, vancomycin, ceftriaxone, ciprofloxacin, Osteomyelitis
and linezolid (see Table 15.8). Subjective Data
IV antibiotic therapy may need to continue at home for 4 to Important Health Information
6 weeks. A few persons need therapy for 3 to 6 months. Patients Health history: Bone trauma, open fracture, open or puncture wounds, other
may be discharged to home care or a skilled nursing facility so infections (e.g., streptococcal sore throat, bacterial pneumonia, sinusitis,
the antibiotics can be given through a central venous access skin or tooth infection, chronic urinary tract infection)
device (CVAD). CVADs are discussed in Chapter 17. Medications: Analgesics or antibiotics
Surgery or other treatments: Bone surgery
Treatment of chronic osteomyelitis includes surgical removal
of the poorly perfused tissue and dead bone and extended use of Functional Health Patterns
antibiotics. In adults, oral therapy with a fluoroquinolone (e.g., Health perception–health management: IV drug and alcohol use. Malaise
ciprofloxacin) for 6 to 8 weeks may be prescribed instead of IV Nutritional-metabolic: Anorexia, weight loss. Chills
antibiotics. Oral antibiotics may be given for 4 to 8 weeks after Activity-exercise: Weakness, paralysis, muscle spasms around affected area
acute IV therapy is done, to ensure the infection is resolved. We Cognitive-perceptual: Local tenderness over affected area, ↑ pain with move-
monitor the patient’s response to drug therapy through bone ment of affected area
scans and ESR testing. Coping–stress tolerance: Irritability, withdrawal, dependency, anger
Acrylic bead chains containing antibiotics may be implanted to Objective Data
help treat the infection. After debriding the dead, infected tissue, a General
suction irrigation system may be inserted and the wound closed. Restlessness. High, spiking temperature. Night sweats
Intermittent or constant irrigation of the area with antibiotics may
be used. Another option for wound management is negative-pres- Musculoskeletal
sure wound therapy (discussed in Chapter 12). Casts or braces may Restricted movement; wound drainage. Spontaneous fracture
be applied to protect the limb or the surgical site.
Skin
Hyperbaric O2 may be given as an adjunct therapy in refrac- Diaphoresis. Redness, warmth, edema at site of infection
tory cases of chronic osteomyelitis. It stimulates new blood
growth and healing in the infected tissue. Possible Diagnostic Findings
If an orthopedic prosthetic device is the source of chronic Positive blood and/or wound cultures, ↑ ESR, ↑ WBC. Presence of sequestrum
infection, it must be removed. Muscle flaps or skin grafts pro- and involucrum on x-rays, radionuclide bone scans, CT, and MRI
vide wound coverage over the dead space in the bone. Bone
grafts may help to restore blood flow. However, flaps or grafts
should never be placed when there is an active or suspected Implementation
infection. Health Promotion
Amputation may be needed if bone destruction is extensive. Control of other current infections (e.g., urinary or respiratory
Amputation should improve quality of life and may save the tract, pressure injuries) is important in preventing osteomyeli-
patient’s life if systemic complications are developing. tis. Persons at risk for osteomyelitis are those who are immuno-
compromised or have diabetes, orthopedic prosthetic implants,
or vascular insufficiency. Teach the at-risk patient about the
NURSING MANAGEMENT: OSTEOMYELITIS signs of osteomyelitis. Encourage the patient to contact the HCP
about bone pain, fever, swelling, and restricted limb movement
Assessment so that they can start treatment. Teach caregivers about their
Subjective and objective data that you should obtain from a per- role in monitoring the patient’s health.
son with osteomyelitis are outlined in Table 68.2.
Acute Care
Clinical Problems Nursing care of the patient with osteomyelitis is outlined in
Clinical problems for the patient with osteomyelitis may include: Table 68.3. Some immobilization of the affected limb (e.g.,
• Pain splint, traction) is usually needed to decrease pain and reduce
• Musculoskeletal problems risk for further injury. Carefully handle the limb. Avoid undue
• Infection manipulation. This may increase pain and cause a pathologic
Additional information on nursing diagnoses and interven- fracture. Assess for pain. Muscle spasms may cause minor to
tions for the patient with osteomyelitis can be found in eNurs- severe pain. Nonsteroidal antiinflammatory drugs (NSAIDs),
ing Care Plan 68.1 (available on the website for this chapter). opioid analgesics, and muscle relaxants may be given.
Dressings are used to absorb drainage from wounds and
Planning debride dead tissue from the wound bed. These include dry,
The overall goals are that the patient with osteomyelitis will (1) sterile dressings; dressings saturated in saline or antibiotic solu-
have satisfactory pain and fever management, (2) be free from tion; wet-to-dry dressings; and dressings applied with nega-
complications, (3) and adhere to the treatment plan. tive-pressure wound therapy. Handle soiled dressings carefully
Musculoskeletal Problems
Diane Ryzner
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Functional Ability Pain
Mobility Safety
LEARNING OUTCOMES
1. Describe the pathophysiology, clinical manifestations, and 5. Describe the postoperative nursing management of a
interprofessional and nursing management of osteomyelitis. patient who had spine surgery.
2. Discern among the types, clinical manifestations, and 6. Discuss the etiology and nursing management of common
interprofessional management of bone cancer. foot problems.
3. Discuss the genetic basis and clinical course of muscular 7. Describe the etiology, pathophysiology, clinical
dystrophy. manifestations, and nursing and interprofessional
4. Discern between the causes and characteristics of acute and management of osteomalacia, osteoporosis, and Paget
chronic low back pain. disease.
KEY TERMS
degenerative disc disease (DDD) osteomyelitis
hallux valgus osteopenia (Table 68.14)
herniated disc osteoporosis
low back pain osteosarcoma
muscular dystrophy (MD) Paget disease
osteochondroma sarcoma
osteomalacia
We were made to move! This chapter reviews a variety of acute osteomyelitis (Table 68.1).1 Staphylococcus aureus is the most
and chronic musculoskeletal problems unrelated to trauma that common cause.
affect the musculoskeletal system. These include osteomyelitis, Infecting microorganisms can invade by indirect or direct
bone cancer, foot problems, back pain, and metabolic bone dis- entry. Indirect entry (hematogenous) is usually from an infec-
eases. These problems can lead to changes in mobility that affect tion with 1 microorganism. Indirect injury accounts for only
almost every system in the body. They are a common source 20% of cases. It most often affects children younger than 17
of pain and physical limitations that restrict the ability to fully years. Risk factors in adults are older age, debilitation, hemodi-
take part in activities of daily living (ADLs), leading to disabil- alysis, sickle cell disease, and IV drug use. The vertebrae are the
ity. The nurse plays a key role in assessing pain and functional most common site of infection in adults.2
ability and initiating interventions to prevent injury and main- Direct entry (contiguous) osteomyelitis accounts for 80% of case.
tain mobility. It most often affects adults.2 It can occur when an open wound (e.g.,
penetrating wounds, fractures, surgery) allows microorganisms to
OSTEOMYELITIS enter the body. Osteomyelitis can be related to a foreign body, such
as an implant or an orthopedic prosthetic device (e.g., plate, total
Etiology and Pathophysiology joint prosthesis). It may occur in the feet of patients with diabetes
Osteomyelitis is a severe infection of the bone, bone marrow, or vascular disease–related ulcers or in the hips or sacrum near a
and surrounding soft tissue. A number of pathogens can cause pressure injury. More than 1 microorganism is usually involved.
1674
, CHAPTER 68 Musculoskeletal Problems 1675
TABLE 68.1 Organisms Causing
Osteomyelitis
Organism Predisposing Problem Blood supply
blocked
Escherichia coli Urinary tract infection Initial site
Fungi, mycobacteria Immunocompromised host of infection
Mycobacterium tuberculosis Tuberculosis Subperiosteal
Periosteum abscess (pus)
Neisseria gonorrhoeae Gonorrhea
Pseudomonas Puncture wounds, IV drug use
Salmonella Sickle cell disease
Staphylococcus aureus Pressure injury, penetrating wound, open
fracture, orthopedic surgery, vascular
insufficiency (e.g., diabetes, atherosclerosis)
Staphylococcus epidermidis Indwelling prosthetic devices (e.g., joint Epiphysis
replacements, fracture fixation devices)
Streptococcus viridans Abscessed tooth, gingival disease Sequestrum (dead bone)
Pus escape
After entering the blood, microorganisms grow, and pres- Involucrum
(new bone formation)
sure increases because of the nonexpanding nature of most
bone. This increased pressure eventually leads to ischemia and
vascular compromise of the periosteum. The infection spreads Fig. 68.1 Development of osteomyelitis infection with involucrum and
sequestrum.
through the bone cortex and marrow cavity, obstructing blood
flow and causing and necrosis.
Bone death occurs due to ischemia. The area of dead
bone eventually separates from the surrounding living bone,
forming sequestra. The part of the periosteum that continues
to have a blood supply forms new bone called involucrum
(Fig. 68.1). Antibiotics or white blood cells (WBCs) have
difficulty reaching the sequestrum through the blood. Thus
sequestrum may become a reservoir for microorganisms that Fig. 68.2 Left femur with severe bone damage due to osteomyelitis.
(From Trung DT, Dinh HN, Le NT, et al.: Total femur replacement in a
spread to other sites, including the lungs and brain. If the
patient with chronic persistence osteomyelitis, Int J Surg Case Rep
sequestrum does not resolve or is not debrided surgically, a 84:106067, 2021.)
sinus tract may develop. Chronic, purulent drainage from
the tract results.
Diagnostic Studies
Clinical Manifestations and Complications Bone or soft tissue biopsy is the definitive way to identify the
Acute osteomyelitis refers to the initial infection or an infection causative agent. Blood and wound cultures are often positive.
of less than 1 month in duration. Local manifestations include Increased WBC count and erythrocyte sedimentation rate (ESR)
constant bone pain that worsens with activity and is unre- may occur. High C-reactive protein (CRP) may occur with acute
lieved by rest; swelling, tenderness, and warmth at the site; and infection. Signs of osteomyelitis usually do not appear on x-rays
restricted movement of the affected part. Systemic manifesta- until 2 to 4 weeks after the initial clinical symptoms. By this
tions include fever, night sweats, chills, restlessness, nausea, and time, the disease will have progressed. Compared with x-rays,
malaise. Later signs include drainage from skin sinus tracts or CT scan may be better in assessing the extent of infection. In
the fracture site. the acute phase, MRI may be better than CT in detecting bone
Chronic osteomyelitis is a bone infection that lasts longer than marrow edema, an early sign of osteomyelitis. Radionuclide
1 month or an infection that did not respond to initial antibi- bone scans (technetium-99m) also show abnormalities earlier
otic treatment. Chronic osteomyelitis may be a continuous, per- than x-rays. A WBC scan (indium-111–labeled cells) may help
sistent problem or recurrent, with exacerbations and remissions pinpoint the area of infection.2
(Fig. 68.2). Systemic manifestations are lessened. Local signs of
infection become more common, including constant bone pain Interprofessional Care
and swelling and warmth at the infection site. Over time, gran- Prolonged antibiotic therapy is the treatment of choice for acute
ulation tissue turns to scar tissue. The avascular scar tissue is an osteomyelitis if bone ischemia has not yet occurred. Cultures or
ideal site for continued microorganism growth because it can- a bone biopsy should be done, if possible, before starting drug
not be penetrated by antibiotics. therapy. Any related soft tissue abscess or ulceration often needs
Long-term, and mostly rare, complications of osteomyelitis surgical debridement or drainage.
include septicemia, septic arthritis, pathologic fractures, and Most patients start on IV antibiotics then switch to oral ther-
amyloidosis. apy. However, some may only receive oral agents.3 The antibiotic
, 1676 SECTION 12 Problems Related to Movement and Coordination
used depends on culture results and the infection itself (e.g., TABLE 68.2 NURSING ASSESSMENT
complexity, cause). Common antibiotics used include oxacillin,
nafcillin, clindamycin, vancomycin, ceftriaxone, ciprofloxacin, Osteomyelitis
and linezolid (see Table 15.8). Subjective Data
IV antibiotic therapy may need to continue at home for 4 to Important Health Information
6 weeks. A few persons need therapy for 3 to 6 months. Patients Health history: Bone trauma, open fracture, open or puncture wounds, other
may be discharged to home care or a skilled nursing facility so infections (e.g., streptococcal sore throat, bacterial pneumonia, sinusitis,
the antibiotics can be given through a central venous access skin or tooth infection, chronic urinary tract infection)
device (CVAD). CVADs are discussed in Chapter 17. Medications: Analgesics or antibiotics
Surgery or other treatments: Bone surgery
Treatment of chronic osteomyelitis includes surgical removal
of the poorly perfused tissue and dead bone and extended use of Functional Health Patterns
antibiotics. In adults, oral therapy with a fluoroquinolone (e.g., Health perception–health management: IV drug and alcohol use. Malaise
ciprofloxacin) for 6 to 8 weeks may be prescribed instead of IV Nutritional-metabolic: Anorexia, weight loss. Chills
antibiotics. Oral antibiotics may be given for 4 to 8 weeks after Activity-exercise: Weakness, paralysis, muscle spasms around affected area
acute IV therapy is done, to ensure the infection is resolved. We Cognitive-perceptual: Local tenderness over affected area, ↑ pain with move-
monitor the patient’s response to drug therapy through bone ment of affected area
scans and ESR testing. Coping–stress tolerance: Irritability, withdrawal, dependency, anger
Acrylic bead chains containing antibiotics may be implanted to Objective Data
help treat the infection. After debriding the dead, infected tissue, a General
suction irrigation system may be inserted and the wound closed. Restlessness. High, spiking temperature. Night sweats
Intermittent or constant irrigation of the area with antibiotics may
be used. Another option for wound management is negative-pres- Musculoskeletal
sure wound therapy (discussed in Chapter 12). Casts or braces may Restricted movement; wound drainage. Spontaneous fracture
be applied to protect the limb or the surgical site.
Skin
Hyperbaric O2 may be given as an adjunct therapy in refrac- Diaphoresis. Redness, warmth, edema at site of infection
tory cases of chronic osteomyelitis. It stimulates new blood
growth and healing in the infected tissue. Possible Diagnostic Findings
If an orthopedic prosthetic device is the source of chronic Positive blood and/or wound cultures, ↑ ESR, ↑ WBC. Presence of sequestrum
infection, it must be removed. Muscle flaps or skin grafts pro- and involucrum on x-rays, radionuclide bone scans, CT, and MRI
vide wound coverage over the dead space in the bone. Bone
grafts may help to restore blood flow. However, flaps or grafts
should never be placed when there is an active or suspected Implementation
infection. Health Promotion
Amputation may be needed if bone destruction is extensive. Control of other current infections (e.g., urinary or respiratory
Amputation should improve quality of life and may save the tract, pressure injuries) is important in preventing osteomyeli-
patient’s life if systemic complications are developing. tis. Persons at risk for osteomyelitis are those who are immuno-
compromised or have diabetes, orthopedic prosthetic implants,
or vascular insufficiency. Teach the at-risk patient about the
NURSING MANAGEMENT: OSTEOMYELITIS signs of osteomyelitis. Encourage the patient to contact the HCP
about bone pain, fever, swelling, and restricted limb movement
Assessment so that they can start treatment. Teach caregivers about their
Subjective and objective data that you should obtain from a per- role in monitoring the patient’s health.
son with osteomyelitis are outlined in Table 68.2.
Acute Care
Clinical Problems Nursing care of the patient with osteomyelitis is outlined in
Clinical problems for the patient with osteomyelitis may include: Table 68.3. Some immobilization of the affected limb (e.g.,
• Pain splint, traction) is usually needed to decrease pain and reduce
• Musculoskeletal problems risk for further injury. Carefully handle the limb. Avoid undue
• Infection manipulation. This may increase pain and cause a pathologic
Additional information on nursing diagnoses and interven- fracture. Assess for pain. Muscle spasms may cause minor to
tions for the patient with osteomyelitis can be found in eNurs- severe pain. Nonsteroidal antiinflammatory drugs (NSAIDs),
ing Care Plan 68.1 (available on the website for this chapter). opioid analgesics, and muscle relaxants may be given.
Dressings are used to absorb drainage from wounds and
Planning debride dead tissue from the wound bed. These include dry,
The overall goals are that the patient with osteomyelitis will (1) sterile dressings; dressings saturated in saline or antibiotic solu-
have satisfactory pain and fever management, (2) be free from tion; wet-to-dry dressings; and dressings applied with nega-
complications, (3) and adhere to the treatment plan. tive-pressure wound therapy. Handle soiled dressings carefully
