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Osteomyelitis, Osteoporosis, Low Back Pain,
Intervertebral Disk Disease
Zoya Minasyan, RN, MSN-Edu
Focus on
Osteomyelitis
• Severe infection of the
– Bone
– Bone marrow
– Surrounding soft tissue
• Caused by variety of microorganisms
• Most common microorganism is
Staphylococcus aureus.
Etiology and Pathophysiology
ORGANISM
POSSIBLE PROBLEM
Staphylococcus aureus
Pressure ulcer, penetrating wound, open
fracture, orthopedic surgery, vascular
insufficiency disorder
Staphylococcus epidermidis
Indwelling prosthetic device
Streptococcus viridans
Abscessed tooth, gingival disease
Escherichia coli
Urinary tract infection
Mycobacterium tuberculosis
Tuberculosis
Neisseria gonorrhoeae
Gonorrhea
Pseudomonas sp.
Puncture wounds, intravenous drugs
Salmonella sp.
Sickle cell disease
Fungi, mycobacteria
Immunocompromised host
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
3
Osteomyelitis
• Infecting microorganisms can invade by
– Indirect entry
– Direct entry
Osteomyelitis
– Indirect entry
• Associated with increased incidence of blunt trauma
• Most common sites of indirect entry
•
•
•
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Distal femur
Proximal tibia
Humerus
Radius
• Adults with increased risk
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Vascular disorders
Genitourinary and respiratory infections
Spread infection from blood to bone
Vascular-rich bone sites
– Pelvis
– Tibia
– Vertebrae
Direct entry
• Direct entry
Open wound
May also occur in presence of foreign body
– Implant,
– Orthopedic prosthetic device .
• After entry microorganisms grows causing increased
pressure, because most bone is nonexpanding.
• Increased pressure leads to ischemia and vascular
compromise.
• Eventually, infection passes through bone cortex and
marrow cavity.
• Results in cortical devascularization and necrosis
Direct Entry
• Once ischemia occurs, bone dies.
• Sequestrum forms
– Devitalized bone separates from living bone.
• Part of periosteum that continues to have
a blood supply forms new bone called
involucrum.
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Development of Osteomyelitis
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
8
Direct Entry
• Sequestrum continues to be an infected island of bone,
surrounded by pus.
• Difficult for blood-borne antibiotics or white blood cells
(WBCs) to reach sequestrum
• Sequestrum can move out of bone and into soft tissue.
• Once outside bone
– Sequestrum may
• Revascularize and then undergo removal by normal immune process
• Be surgically removed through debridement of necrotic bone
– If necrotic sequestrum is not resolved, develops a sinus tract,
resulting in chronic, purulent cutaneous drainage.
– Avascular scar tissue provides ideal site for continued
microorganism growth.
Clinical Manifestations
Acute Osteomyelitis
• Initial infection
– Infection of <1 month in duration
– Both systemic and local
• Systemic
– Fever, night sweats, chills, restlessness, nausea
• Local
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Constant bone pain that worsens with activity
Swelling, tenderness, warmth at infection site
Restricted movement of affected part
Later signs: drainage from sinus tracts
Clinical Manifestations
Chronic Osteomyelitis
• Bone infection lasting longer than a month
• Infection that has failed to respond to initial
course of antibiotic therapy
• Systemic signs may be diminished
Clinical Manifestations
Chronic Osteomyelitis
Diagnostic Studies
• Bone or soft tissue biopsy
– Definitive way to determine causative microorganism
• Patient’s blood and/or wound culture
– Frequently positive for microorganism
– Elevated WBC count
– Erythrocyte sedimentation rate (ESR)page 1579
• Magnetic resonance imaging (MRI)
• Computed tomography (CT)
– Help identify extent of infection, including soft tissue
involvement
Collaborative Care
• Intravenous (IV) antibiotic therapy
• Cultures or bone biopsy should be done if
possible.
• Delaying antibiotic treatment may require
surgical debridement and decompression.
• Patients are often discharged to home care or
skilled nursing facility with IV antibiotics delivered
via
– Central venous catheter
– Peripherally inserted central catheter (PICC)
Collaborative Care
• Antibiotic therapy may be continued at home
for 4 to 6 weeks or as long as 3 to 6 months.
• Variety of antibiotics may be prescribed.
– Penicillin; Neomycin, vancomycin ; Cephalexin
(Keflex); Cefazolin (Ancef)
– May be prescribed oral therapy for 6 to 8 weeks
instead of IV antibiotics.
• Patient’s response monitored through bone
scans and ESR tests.
Collaborative Care
• Surgical treatment for chronic osteomyelitis
– Removal of poorly vascularized tissue and dead bone
– Extended use of antibiotics
– Antibiotic-impregnated polymethyl meth-acrylate
bead chains may also be implanted.
• After debridement, wound may be closed and a
suction irrigation system inserted.
• Intermittent or constant irrigation of affected
bone with antibiotics
• Protection of limb or surgical site with casts or
braces.
Collaborative Care
• Hyperbaric oxygen therapy with 100% oxygen as
adjunct therapy
– Stimulate circulation and healing
• Orthopedic prosthetic devices
• Muscle flaps, skin grafting provide wound coverage
over dead space (cavity) in bone.
• Bone grafts may help restore blood flow.
• Amputation may be indicated if
– Extensive bone destruction
– Necessary to preserve person’s life and/or improve quality
of life
Nursing Assessment
– Past health history
• Bone trauma, open fracture, open or puncture wounds, other infections
– Medications
– Surgery or other treatments
– Subjective data
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IV drug use
Anorexia, weight loss, chills
Weakness, paralysis, muscle spasms
Local tenderness over affected area, increase in pain in affected area
– Objective data
• General: restlessness, high spiking temperature, night sweats
• Integumentary: diaphoresis, erythema, warmth, edema at infected bone
• Musculoskeletal: restricted movement, wound drainage, spontaneous
fractures
Nursing Diagnoses
• Acute pain
• Ineffective self-health management
• Impaired physical mobility
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Planning
• Overall goals
– Have pain and fever control.
– Do not experience any complications
associated with osteomyelitis.
– Maintain a positive outlook on outcome of
disease.
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Nursing Implementation
• Health promotion
– Control infections already in body
– Susceptible adults
• Immunocompromised
• Wear orthopedic prosthetic devices
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Nursing Implementation
• Acute intervention
– Some immobilization of affected limb will ↓
pain
– Limb should be handled carefully to avoid
excessive manipulation and ↑ pain
– Assess and manage patient’s pain level.
– Apply dressings
– Frequent bed rest in early stages
• Good body alignment and frequent position changes
prevent complications associated with immobility and
promote comfort.
• Footdrop can develop quickly in lower extremity if
foot is not supported in a neutral position by a splint,
or if there is excessive pressure from a splint.
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Nursing Implementation
– Instruct patient to avoid activities that ↑ circulation
and swelling and serve as stimuli to spread infection
• Exercise, heat application
– Teach patient potential adverse and toxic reactions
with prolonged and high-dose antibiotic therapy.
– Importance of continuing antibiotics after symptoms
have subsided should be stressed.
– Periodic nursing visits provide support and decrease
anxiety.
– Frequent dressing changes for open wounds
– May require supplies and instruction in technique
Osteoporosis
• Metabolic bone disease characterized by
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Porous bone
Low bone mass
Structural deterioration of bone tissue
Increased bone fragility
• More common in women than men for several reasons
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Lower calcium intake than men
Less bone mass because of smaller frame
Bone resorption begins earlier and accelerates after menopause.
Pregnancy and breast feeding deplete woman’s skeletal reserve of
calcium.
– Longevity increases likelihood of osteoporosis (women live longer
than men).
Osteoporosis
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Etiology and Pathophysiology
Risk factors
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Female gender
Increasing age
Low body weight
White or Asian ethnicity
Family history
Early menopause
Excess alcohol intake
Cigarette smoking
Sedentary lifestyle
Insufficient calcium intake
Long-term use of corticosteroids, thyroid replacement, antiseizure drugs
Low testosterone levels in menMany drugs can interfere with bone metabolism.
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Corticosteroids
Antiseizure drugs (e.g., valproate [Depakote], phenytoin [Dilantin])
Aluminum-containing antacids
Certain cancer treatments
Excessive thyroid hormones
Osteoporosis
Normal vs. Osteoporotic Bone
Osteoporosis
• In osteoporosis, bone resorption exceeds bone
deposition.
• Occurs most commonly in spine, hips, and wrist
• Diseases associated with osteoporosis
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Intestinal malabsorption
Kidney disease
Rheumatoid arthritis
Hyperthyroidism
Chronic alcoholism
Cirrhosis of the liver
Diabetes mellitus
Osteoporosis
• “silent disease” because there are no symptoms; the usual
first signs are back pain and spontaneous fractures
• Manifestations include
– Sudden strain, Fractures, Back pain, Loss of height, Spinal
deformities
• Good and poor sources of Ca
 Poor sources of calcium
– Eggs, Beef, Cream cheese, Poultry, Pork, Apples and bananas
 Good sources of calcium
– Milk , Yogurt, Turnip greens, Spinach, Cottage cheese, Ice cream,
Sardines
Collaborative Care: Osteoporosis
• Exercise should be encouraged to build up and
maintain bone mass
• Types of exercise
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Weight bearing
Walking
Stair climbing
Dancing
• Supplemental vitamin D may be recommended.
• Patients should be instructed to quit smoking or
cut down on alcohol intake to ↓ losing bone
mass
Collaborative Care
• Drug therapy
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Calcium
Vitamin D
Calcitonin
Bisphosphonates inhibit osteoclast-mediated bone
resorption
(e.g., etidronate [Didronel], alendronate [Fosamax]).
– Selective estrogen receptor modulators
• Raloxifene (Evista)
– Teriparatide (Forteo)
• Portion of parathyroid hormone
• First drug to stimulate new bone formation
Low Back Pain
• Low back pain common because lumbar region
– Bears most of the weight of body
– Is the most flexible region of the spinal column
– Contains nerve roots that are vulnerable to injury or disease
• Several risk factors
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Lack of muscle tone
Excess body weight
Poor posture
Cigarette smoking
Stress
• Associated with low back pain
– Prolonged periods of seating
– Repetitive heavy lifting
– Vibration
Low Back Pain
• Low back pain most often due to
musculoskeletal problems
1.
2.
3.
4.
5.
Acute lumbosacral strain
Instability of lumbosacral bony mechanism
Osteoarthritis of lumbosacral vertebrae
Degenerative disk disease
Herniation of intervertebral disk
Acute Low Back Pain
• Lasts 4 weeks or less
• Associated with some type of activity that causes
undue stress on tissues of lower back
• Symptoms often do not appear at time of injury
but develop later because of gradual ↑ in
paravertebral muscle spasms.
• One test is straight-leg raise.
– Positive for disk herniation when radicular pain occurs
• MRI and CT not done unless trauma or systemic
disease is suspected
Acute Low Back Pain
Collaborative Care
• Treated on an outpatient basis if acute muscle spasms and pain are not
severe and debilitating
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Analgesics
Muscle relaxants
Massage and back manipulation
Alternating use of heat and cold compresses
Opioid analgesics for severe pain
• Brief period of rest at home may be necessary.
• Most persons do better with continuation of their regular activities.
• All patients should avoid activities that aggravate pain:
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Lifting
Bending
Twisting
Prolonged sitting
• Most cases improve in 2 weeks.
Acute Low Back Pain
Nursing Assessment
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Subjective data
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Acute or chronic lumbosacral strain/ trauma
Osteoarthritis
Degenerative disk disease
Obesity
Use of opioid and nonopioid analgesics, muscle relaxants, nonsteroidal antiinflammatory drugs,
corticosteroids
Use of over-the-counter remedies
Previous back surgery, epidural or corticosteroid injections
Smoking
Lack of exercise
Poor posture
Muscle spasms
Activity intolerance
Constipation
Interrupted sleep
Pain in back, buttocks, or legs associated with walking, turning, straining, coughing, leg raising
Numbness or tingling of legs, feet, toes
Occupation requiring heavy lifting, vibrations, or extended driving
Change in role within family structure due to inability to work and provide income
Acute Low Back Pain
Nursing Assessment
• Objective data
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Guarded movement
Depressed or absent Achilles tendon reflex
Patellar tendon reflex
Positive straight-leg raise test
Positive crossover straight-leg test
Decreased range of motion of spine
Tense, tight vertebral muscles on palpation
Localization of site of lesion
CT scan
MRI
Acute Low Back Pain
Nursing Diagnoses
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•
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Acute pain
Impaired physical mobility
Ineffective coping
Ineffective self-health management
Planning
• Goals
– Have satisfactory pain relief.
– Avoid constipation secondary to medication and
immobility.
– Learn back-sparing practices.
– Return to previous level of activity within
prescribed restrictions.
Nursing Implementation
Health Promotion
• As a role model, nurse should use proper body
mechanics at all times.
– Primary consideration when teaching patients
transfer and turning techniques
• Assess patient’s use of body mechanics, and
offer advice when activities could produce
back strain.
Nursing Implementation
Acute Intervention
• Do’s
– Prevent lower back from straining forward by placing
a foot on a step or stool during prolonged standing
– Maintain appropriate body weight
– Sleep in a side-lying position with knees and hips bent
– Sleep on back with a lift under knees and legs or back
with 10-inch-high pillow under knees to flex hips and
knees
– Exercise 15 minutes in the morning and evening
regularly
– Use local heat and cold application
– Use a pillow for sitting
Nursing Implementation
Acute Intervention
• Don’ts
– Lean forward without bending knees
– Lift anything above level of elbows
– Stand in one position for prolonged time
– Sleep on abdomen or on back or side with legs out
straight
– Exercise without consulting health care provider if
having severe pain
Nursing Implementation
Acute Intervention
• Primary nursing responsibilities
– Educate patient about health problem.
– Educate patient on appropriate exercises.
– Use analgesics, NSAIDs, muscle relaxants, and
thermotherapy while avoiding bed rest.
Chronic Low Back Pain
• Lasts longer than 3 months or is a repeated
incapacitating episode
• Causes
– Degenerative disk disease
– Lack of physical exercise
– Prior injury
– Obesity
– Structural and postural abnormalities
– Systemic disease
Chronic Low Back Pain
• Osteoarthritis (OA) of lumbar spine is found in
patients over 50.
• Chronic back pain in younger patients with OA
usually involves thoracic or lumbar spine.
• Discomfort is ↑ following periods of
inactivity.
– Particularly on awakening or after long periods of
sitting
Chronic Low Back Pain
• Spinal stenosis
– Narrowing of vertebral or nerve root canals
– May be congenital
– More often acquired through degenerative or
traumatic changes to spine
– In lumbar area
• Compression of nerve roots can result with disk herniation.
Pain often starts in low back and radiates to buttock and leg.
• Worsens with walking, particularly standing without walking
Chronic Low Back Pain
• Treatment for chronic back pain
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Reduction in pain associated with daily activities
Rest and local heat application when cold, damp weather aggravates back pain
Mild analgesics to decrease pain and stiffness
Weight reduction
Sufficient rest periods
Local heat and cold application
Exercise and activity throughout day
Keep muscle and joints mobilized
Antidepressants
• Surgical interventions
– Indicated in patients
• With severe chronic low back pain
• Who do not respond to conservative care
• Who have neurologic deficits
Intervertebral Disk Disease
• Degenerative disk disease (DDD)
– Structural degeneration of lumbar disk
– is a normal process of aging; Common in persons by
age 60
– Results in intervertebral disks losing elasticity,
flexibility, and shock-absorbing capabilities
– Thinning of disks occurs as nucleus pulposus
(gelatinous center of disk) starts to dry out and shrink
– Compression of nerve roots and cord may occur.
– Damage to spine by DDD contributes to osteoarthritis
of spine.
Causes of Degenerative Disk Damage
48
INTERVERTEBRAL LUMBAR DISK DAMAGE
ETIOLOGY AND PATHOPHYSIOLOGY
• Acute herniated intervertebral disk
Can be result of
• Natural degeneration with age
• Repeated stress or trauma to spine
– Nucleus may first bulge and then herniate, placing
pressure on nerves.
• Most common ruptures at lumbosacral disks
INTERVERTEBRAL LUMBAR DISK DAMAGE
CLINICAL MANIFESTATIONS
• Most common feature of lumbar disk damage is low back pain.
• Indications of disk herniation
– Pain that radiates down buttock and below knee
– Along distribution of sciatic nerve
• Straight-leg raising-test may be positive.
• Reflexes may be depressed or absent, depending on the spinal
nerve root involved
• Back or leg pain may be reproduced by raising leg and flexing foot
at 90 degrees.
• Paresthesia or muscle weakness in legs, feet, or toes may be
reported
• Multiple nerve root compression may be manifested as bowel and
bladder incontinence or impotence.
Cervical Disk Disease
• Pain radiating into arms and hands, following
the pattern of the nerve involved
• As in lumbar disk damage, reflexes may or
may not be present, and there is often
weakness of hand grip.
INTERVERTEBRAL LUMBAR DISK DAMAGE
DIAGNOSTIC STUDIES
• X-rays are done to note structural damage.
• MRI, or CT scan localizes damaged site.
• Epidural venogram or diskogram may be
necessary.
• EMG of extremities determines severity of
nerve irritation.
INTERVERTEBRAL LUMBAR DISK DAMAGE
COLLABORATIVE CARE
• Managed first with at least 4 weeks of conservative therapy
– Limitation of extremes of spinal movement
• Brace, corset, or belt
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Local heat or ice
Ultrasound and massage
Traction
Transcutaneous electrical nerve stimulation (TENS)
Drug therapy
• NSAIDs, short-term opioids, muscle relaxants
– Epidural corticosteroid injections
• Once symptoms subside, back-strengthening exercises begin.
– Twice a day
– Encouraged for a lifetime
INTERVERTEBRAL LUMBAR DISK DAMAGE
SURGICAL THERAPY
• Indicated when
– Diagnostic tests indicate problem is not responding to
conservative treatment
– Patient is in consistent pain
– Persistent neurologic deficit
• Intra-discal electro-thermoplasty (IDET)
– Minimally invasive outpatient procedure
– May help in treating back and sciatica pain
– Involves insertion of needle into affected disk with guidance of
an x-ray
– Wire is then threaded down through needle and into disk.
– Wire is heated, which denervates small nerve fibers that have
grown into cracks and invaded degenerating disk.
INTERVERTEBRAL LUMBAR DISK DAMAGE
SURGICAL THERAPY
• Radiofrequency discal nucleoplasty
– Needle is inserted into disk similar to IDET.
– Special radiofrequency probe is used.
– 20% of nucleus is removed.
• Decompresses disk
• Decreases pressure on both disk and surrounding nerve
roots
• Interspinous process decompression system (X
Stop)
– Made of titanium and fits into mount placed on
vertebrae in lower back
•
INTERVERTEBRAL LUMBAR DISK
DAMAGE
SURGICAL
THERAPY
Laminectomy
• Surgical excision of part of posterior arch of vertebra to gain access to
part of or entire protruding disk to remove it. Minimal hospital stay.
• Diskectomy
Microsurgical diskectomy
• Uses microscope to allow better visual of disk and disk space to aid in
the removal of damaged portion
• Helps maintain bony stability of spine
Percutaneous laser diskectomy
• Outpatient surgical procedure
• Uses tube passed through retroperitoneal soft tissues to lateral border
of disk with local anesthesia and aid of fluoroscopy
• Laser is then used on damaged portion.
• Minimal blood loss
INTERVERTEBRAL LUMBAR DISK DAMAGE
SURGICAL THERAPY
• Charité disk
– Artificial disk made up of high-density core
sandwiched between two
cobalt-chromium end plates
– Surgically placed in spine through small
incision below umbilicus after damaged disk
is removed
– Allows for movement at level of implant
– Goals of artificial disk replacement surgery
are to restore movement and eliminate pain.
57
Charité Disk
Fig. 64-6. The Charité artificial disk, used in degenerative disk disease to replace a damaged
intervertebral disk. The Charité artificial disk consists of two cobalt-chromium alloy endplates
sandwiched around a movable high-density plastic core. The design of the disk helps align the
spine and preserve its natural ability to move.
58
INTERVERTEBRAL LUMBAR DISK DAMAGE
SURGICAL THERAPY
• Spinal fusion
– Spine is stabilized with a bone graft from
patient’s fibula or iliac crest or from a
donated cadaver bone
– Metal fixation with rods, plates, or screws
• Provides stability and decreases vertebral motion
59
Nursing Management
Spinal Surgery: Postoperative
• Maintain proper alignment of spine
• Patient may be able
– To dangle legs at side of the bed
– To stand
• To ambulate first day after surgery
• Logroll patient when turning
• Pillows under thighs of each leg when supine
and between legs when side-lying
• Most patients will require opioids for 24 to 48
hours.
• Preferred method is patient-controlled analgesia
(PCA).
60
Nursing Management
Spinal Surgery: Postoperative
• If spinal canal was entered during surgery, potential for
cerebrospinal fluid (CSF) leakage
• Severe headache or leakage of CSF on dressing should be
reported.
– CSF appears as clear or slightly yellow drainage on dressing.
•
•
•
•
•
CSF has high concentrations of glucose.
A dipstick test for glucose will be positive.
Document amount, color, and characteristics of drainage.
Frequently monitor peripheral neurologic signs.
Movement of arms and legs and assessment of sensation
should be unchanged vs. preoperative status.
– Repeat assessments every 2 to 4 hours during first 48 hours
post surgery.
– Extremity circulation should be assessed by temperature,
capillary refill, and pulses.
61
Nursing Management
Spinal Surgery: Postoperative
– Manifestations
• Nausea
• Abdominal distention
• Constipation
– Stool softeners may aid in relief and
prevention.
62
Nursing Management
Spinal Surgery: Postoperative
• Adequate bladder emptying may be altered.
• Patients should use commode or ambulate to bathroom
when allowed.
• Intermittent catheterization or indwelling catheter may be
necessary.
• Surgeon will decide activity needed.
• Patient usually ambulates early in postoperative period.
• Nurse’s responsibility to know specific orders related to
activity
• Instruct patient to avoid sitting for prolonged periods of
time. Encourage
– Walking
– Lying down
– Shifting weight from one foot to the other when standing
63
Surgery on Cervical Spine
• Be alert for symptoms of spinal cord edema
such as respiratory distress and worsening
neurologic status of the upper extremities.
• After surgery, patient’s neck is immobilized
in soft or hard cervical collar.
• Patient should learn to mentally think
through activities that may cause injury:
– Bending
– Lifting
– Stooping
• Twisting of spine is contraindicated
64
Osteosarcoma
Fig. 64-3. Osteosarcoma of the tibia. Tumor has infiltrated the cortex and formed
soft-tissue masses on both sides of the bone.
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
65
Osteosarcoma
Fig. 64-4. Chondrosarcoma in a 92-year-old woman.
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
66
Intervertebral Disk Disease
Fig. 64-7. A, Severe hallux valgus with bursa formation. B, Postoperative correction.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
67
Foot Disorders
Fig. 64-8. Claw-toe deformity. A type of hammer toe caused by chronic irritation from poorly fitting shoes.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
68