Common Muscuskeletal Problems

Acute Low Back Pain

The number of medical visits
resulting from low back pain is
second only to the number of visits
for upper respiratory illnesses.

Etiology
Most low back pain is caused by one of
many musculoskeletal problems, including:
acute lumbosacral strain
unstable lumbosacral ligaments and
weak muscles
osteoarthritis of the spine
spinal stenosis
intervertebral disk problems
unequal leg length.

Older patients may experience back pain

associated with osteoporotic vertebral
fractures or bone metastasis.
Other causes include:
kidney disorders
pelvic problems
retroperitoneal tumors
abdominal aneurysms
psychosomatic problems.

In
addition,
obesity,
stress,
and
occasionally depression may contribute to
low back pain.
Back
pain
due
to
musculoskeletal
disorders usually is aggravated by activity,
whereas pain due to other conditions is
not.
Patients with chronic low back pain may
develop a dependence on alcohol or
analgesics in an attempt to cope with and
self-treat the pain.

Clinical Manifestations
Acute or chronic back pain (lasting more
than 3 months without improvement) and
fatigue.
Pain that radiates down the leg; presence
of this symptom suggests nerve root
involvement.
Gait, spinal mobility, reflexes, leg length,
leg motor strength, and sensory perception
may be affected.
Paravertebral
muscle
spasm
(greatly
increased muscle tone of back postural
muscles) occurs with loss of normal lumbar
curve and possible spinal deformity.

Assessment and Diagnostic

Methods
Health history and physical examination
(back examination, neurologic testing)
Spinal x-ray
Bone scan and blood studies
Computed tomography (CT) scan
Magnetic resonance imaging (MRI)
Electromyogram and nerve conduction
studies
Myelogram
Ultrasound

Nursing Management
Assessment
Encourage patient to describe the discomfort
(location, severity, duration, characteristics,
radiation, associated weakness in the legs).
Obtain history of pain origin, previous pain
control, and how back problem is affecting
lifestyle; assess environmental variables, work
situations, and family relationships.
Observe patients posture, position changes,
and gait.
Assess spinal curves, pelvic crest, leg length
discrepancy, and shoulder symmetry.
Palpate paraspinal muscles and note spasm
and tenderness.

Note
discomfort
and
limitations
in
movement when patient bends forward
and laterally.
Evaluate nerve involvement by assessing
deep tendon reflexes, sensations, and
muscle strength; back and leg pain on
straight-leg raising (with the patient in
supine position, the patients leg is lifted
upward with the knee extended) suggests
nerve root involvement.
Assess for obesity and perform nutritional
assessment.
Assess patients response to analgesic
agents; evaluate and note patients
response to various pain management
modalities.

Interventions
With severe pain, limit activity for 1 to 2
days.
Advise patient to rest on a firm, nonsagging
mattress.
Help patient to increase lumbar flexion by
elevating the head and thorax 30 degrees
using pillows or a foam wedge and slightly
flexing the knees supported on a pillow.
Alternatively, the patient can assume a
lateral position with knees and hips flexed
(curled position) with a pillow between the
knees and legs and a pillow supporting the
head.
Instruct the patient to get out of bed by
rolling to one side and placing the legs down
while pushing the torso up, keeping the back

As the patient achieves comfort, help

patient gradually resume activities, and
initiate an exercise program; begin with lowstress aerobic exercises then after 2 weeks,
begin conditioning exercises; each exercise
period should begin with relaxation.
Encourage patient to adhere to the
prescribed exercise program.
Encourage patient to improve posture and
use good body mechanics and to avoid
excessive lumbar strain, twisting, or
discomfort (eg, avoid activities such as
horseback riding and weight lifting).

Teach patient how to stand, sit, lie, and lift

properly:
Shift weight frequently when standing and
rest one foot on a low stool; wear low
heels.
Sit with knees and hips flexed and knees
level with hips or higher. Keep feet flat on
the floor. Avoid sitting on stools or chairs
that do not provide firm back support.

supine with knees flexed and supported; avoid

sleeping prone.
Lift objects using thigh muscles, not back.
Place feet hipwidth apart for a wide base of
support, bend the knees, tighten the abdominal
muscles, and lift the object close to the body
with a smooth motion. Avoid twisting and
jarring motions.
Assist patient resume former
responsibilities when appropriate.

role-related

Refer patient to psychotherapy or counseling,

if needed.
If patient is obese, assist with weight reduction
through diet modification; note achievement,

OSTEOMYELITIS

Osteomyelitis is an infection of the

bone.

Etiology
Extension of soft tissue infections
Direct bone contamination (eg, bone surgery,
gunshot wound)
or hematogenous (bloodborne) spread from
other foci of infection.
Staphylococcus aureus causes more than 50%
of bone infections.
Other pathogenic organisms frequently found
include Gram-positive organisms that include
streptococci and enterococci, followed by
Gram-negative
bacteria
that
include
pseudomonas species.

Patients at risk include:

poorly nourished
Elderly
patients who are obese
those with impaired immune systems and
chronic illness (eg, diabetes)
those on long-term corticosteroid therapy
or immunosuppressive agents.

Pathophysiology
Staphylococcus aureus causes 70% to 80% of
bone infections.
Other pathogenic organisms include Proteus
and Pseudomonas species and Escherichia coli.
The initial response to infection is
inflammation, increased vascularity, and edema.
After 2 or 3 days, thrombosis of the blood
vessels occurs in the area, resulting in ischemia
with bone necrosis.
The infection extends into the medullary cavity
and under the periosteum and may spread into
adjacent soft tissues and joints.

Unless the infective process is treated

promptly, a bone abscess forms. The resulting
abscess cavity contains dead bone tissue (the
sequestrum), which does not easily liquefy and
drain.
Therefore, the cavity cannot collapse and heal,
as occurs in soft tissue abscesses.
New bone growth (the involucrum) forms and
surrounds the sequestrum.
Although healing appears to take place, a
chronically infected sequestrum remains and
produces recurring abscesses throughout the
patients life. This is referred to as chronic
osteomyelitis.

Clinical Manifestations
When the infection is bloodborne, onset is
sudden, occurring with clinical manifestations
of sepsis (eg, chills, high fever, rapid pulse, and
general malaise).
Extremity becomes painful, swollen, warm,
and tender.
Patient may describe a constant pulsating pain
that intensifies with movement (due to the
pressure of collecting pus).
When osteomyelitis is caused by adjacent
infection or direct contamination, there are no
symptoms of sepsis; the area is swollen, warm,
painful, and tender to touch.
Chronic
osteomyelitis
presents
with
a
nonhealing ulcer that overlies the infected
bone with a connecting sinus that will

Assessment and Diagnostic Findings

Acute osteomyelitis: Early x-ray films show
only soft tissue swelling.
Chronic osteomyelitis: X-ray shows large,
irregular cavities, a raised periosteum,
sequestra, or dense bone formations.
Radioisotope bone scans
resonance imaging (MRI).

and

Blood studies and blood cultures.

magnetic

Prevention
Prevention of osteomyelitis is the goal.
Elective orthopedic surgery should be
postponed if the patient has a current
infection (eg, urinary tract infection, sore
throat) or a recent history of infection.

During orthopedic surgery:

Careful attention is paid to the surgical
environment and to techniques to decrease
direct bone contamination.
Prophylactic antibiotics, administered to
achieve adequate tissue levels at the time
of surgery and for 24 hours after surgery
Urinary catheters and drains are removed
as soon as possible to decrease the
incidence of hematogenous spread of
infection.

Aseptic postoperative wound care reduces

the incidence of superficial infections and
osteomyelitis.
Prompt management of soft tissue infections
reduces extension of infection to the bone.
When
patients
who
have
had
joint
replacement
surgery
undergo
dental
procedures or other invasive procedures (eg,
cystoscopy), prophylactic
antibiotics are
frequently recommended.

Medical Management
The initial goal of therapy is to control and
halt the infective process. Antibiotic therapy
depends on the results of blood and wound
cultures. Frequently, the infection is caused by
more than one pathogen. General supportive
measures (eg, hydration, diet high in vitamins
and protein, correction of anemia) should be
instituted.
The area affected with osteomyelitis is
immobilized to decrease discomfort and to
prevent pathologic fracture of the weakened
bone. Warm wet soaks for 20 minutes several
times a
day may be prescribed to increase circulation.

General supportive measures (eg, hydration,

diet high in vitamins and protein, correction of
anemia) should be instituted; affected area is
immobilized.
Blood and wound cultures are performed to
identify organisms and select the antibiotic.
Intravenous antibiotic therapy is given aroundthe-clock; continues for 3 to 6 weeks.
Antibiotic medication is administered orally
(on empty stomach) when infection appears to
be controlled; the medication regimen is
continued for up to 3 months.
Surgical debridement of bone is performed
with irrigation; adjunctive antibiotic therapy is
maintained.

THE END