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Osteoporosis
Definition Osteoporosis causes bones to become weak and brittle so brittle that a fall or even mild stresses like bending over or coughing can cause a fracture. Osteoporosis-related fractures most commonly occur in the hip, wrist or spine. Bone is living tissue, which is constantly being absorbed and replaced. Osteoporosis occurs when the creation of new bone doesn't keep up with the removal of old bone. Osteoporosis affects men and women of all races. But white and Asian women especially those who are past menopause are at highest risk. Medications, healthy diet and weightbearing exercise can help prevent bone loss or strengthen already weak bones. Risk factors

sex. Women are much more likely to develop osteoporosis than are men. Age. The older get, the greater risk of osteoporosis. Family history. Having a parent or sibling with osteoporosis puts at greater risk, especially if also have a family history of hip fractures. Frame size. Men and women who have small body frames tend to have a higher risk because they may have less bone mass to draw from as they age.

Hormone levels Osteoporosis is more common in people who have too much or too little of certain hormones in their bodies. Examples include:

Sex hormones. The reduction of estrogen levels at menopause is one of the strongest risk factors for developing osteoporosis. Women may also experience a drop in estrogen during certain cancer treatments. Men experience a gradual reduction in testosterone levels as they age. And some treatments for prostate cancer reduce testosterone levels in men. Lowered sex hormone levels tend to weaken bone. Thyroid problems. Too much thyroid hormone can cause bone loss. This can occur if thyroid is overactive or if take too much thyroid hormone medication to treat an underactive thyroid. Other glands. Osteoporosis has also been associated with overactive parathyroid and adrenal glands.

Dietary factors Osteoporosis is more likely to occur in people who have:

Low calcium intake. A lifelong lack of calcium plays a major role in the development of osteoporosis. Low calcium intake contributes to diminished bone density, early bone loss and an increased risk of fractures. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

Eating disorders. People who have anorexia are at higher risk of osteoporosis. Low food intake can reduce the amount of calcium ingested. In women, anorexia can stop menstruation, which also weakens bone. Gastrointestinal surgery. A reduction in the size of stomach or a bypass or removal of part of the intestine limits the amount of surface area available to absorb nutrients, including calcium.

Steroids and other medications Long-term use of corticosteroid medications, such as prednisone and cortisone, interferes with the bone-rebuilding process. Osteoporosis has also been associated with medications used to combat or prevent:

Seizures Depression Gastric reflux Cancer Transplant rejection

Lifestyle choices Some bad habits can increase risk of osteoporosis. Examples include:

Sedentary lifestyle. People who spend a lot of time sitting have a higher risk of osteoporosis than do their more-active counterparts. Any weight-bearing exercise is beneficial for bones, but walking, running, jumping, dancing and weightlifting seem particularly helpful for creating healthy bones. Excessive alcohol consumption. Regular consumption of more than two alcoholic drinks a day increases of osteoporosis, possibly because alcohol can interfere with the body's ability to absorb calcium. Tobacco use. The exact role tobacco plays in osteoporosis isn't clearly understood, but researchers do know that tobacco use contributes to weak bones.

Symptoms There typically are no symptoms in the early stages of bone loss. But once bones have been weakened by osteoporosis, may have signs and symptoms that include:

Back pain, caused by a fractured or collapsed vertebra Loss of height over time A stooped posture A bone fracture that occurs much more easily than expected

Complications

Bone fractures, particularly in the spine or hip, are the most serious complication of osteoporosis. Hip fractures often result from a fall and can result in disability and even death from postoperative complications, especially in older adults. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

In some cases, spinal fractures can occur even if haven't fallen. The bones that make up spine (vertebrae) can weaken to the point that they may crumple, which can result in back pain, lost height and a hunched forward posture.

Tests and diagnosis

bone density can be measured by a machine that uses low levels of X-rays to determine the proportion of mineral contained in bones. During this painless test, lie on a padded table as a scanner passes over body. In most cases, only a few bones are checked usually in the hip, wrist and spine.

Treatments and drugs For both men and women, the most widely prescribed osteoporosis medications are bisphosphonates. Examples include:

Alendronate (Fosamax, Binosto) Risedronate (Actonel, Atelvia) Ibandronate (Boniva) Zoledronic acid (Reclast, Zometa)

Side effects include nausea, abdominal pain, difficulty swallowing, and the risk of an inflamed esophagus or esophageal ulcers. These are less likely to occur if the medicine is taken properly. Injected forms of bisphosphonates don't cause stomach upset. And it may be easier to schedule a quarterly or yearly injection than to remember to take a weekly or monthly pill, but it can be more costly to do so. Long-term bisphosphonate therapy has been linked to a rare problem in which the middle of the thighbone cracks and might even break completely. Bisphosphonates also have the potential to affect the jawbone. Osteonecrosis of the jaw is a rare condition mostly occurring after a tooth extraction in which a section of jawbone dies and deteriorates. should have a recent dental examination before starting bisphosphonates. Hormone-related therapy Estrogen, especially when started soon after menopause, can help maintain bone density. However, estrogen therapy can increase a woman's risk of blood clots, endometrial cancer, breast cancer and possibly heart disease. Raloxifene (Evista) mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen. Taking this drug may also reduce the risk of some types of breast cancer. Hot flashes are a common side effect. Raloxifene also may increase risk of blood clots. In men, osteoporosis may be linked with a gradual age-related decline in testosterone levels. Testosterone replacement therapy can help increase bone density, but osteoporosis

Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

medications are better studied in men with osteoporosis and are recommended instead of or in addition to testosterone. Less common osteoporosis medications If can't tolerate the more common treatments for osteoporosis or if they don't work well enough might suggest trying:

Teriparatide (Forteo). This powerful drug is similar to parathyroid hormone and stimulates new bone growth. It's given by injection under the skin. After two years of treatment with teriparatide, another osteoporosis drug is taken to maintain the new bone growth. Denosumab (Prolia). Compared with bisphosphonates, denosumab produces similar or better bone density results while targeting a different step in the bone remodeling process. Denosumab is delivered via a shot under the skin every six months. The most common side effects are back and muscle pain.

Lifestyle and home remedies

Don't smoke. Smoking increases bone loss, perhaps by decreasing the amount of estrogen a woman's body makes and by reducing the absorption of calcium in intestine. Avoid excessive alcohol. Consuming more than one alcoholic drink a day may decrease bone formation and reduce body's ability to absorb calcium. Being under the influence also can increase risk of falling. Prevent falls. Wear low-heeled shoes with nonslip soles and check house for electrical cords, area rugs and slippery surfaces that might cause to trip or fall. Keep rooms brightly lit, install grab bars just inside and outside shower door, and make sure can get in and out of bed easily.

Prevention Calcium Men and women between the ages of 18 and 50 need 1,000 milligrams of calcium a day. This daily amount increases to 1,200 milligrams when women turn 50 and men turn 70. Good sources of calcium include:

Low-fat dairy products Dark green leafy vegetables Canned salmon or sardines with bones Soy products, such as tofu Calcium-fortified cereals and orange juice

Vitamin D Vitamin D is necessary for body to absorb calcium. Many people get adequate amounts of vitamin D from sunlight, but this may not be a good source if live in high latitudes, if 're

Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

housebound, or if regularly use sunscreen or avoid the sun entirely because of the risk of skin cancer. Exercise Exercise can help build strong bones and slow bone loss. Combine strength training exercises with weight-bearing exercises. Strength training helps strengthen muscles and bones in arms and upper spine, and weight-bearing exercises such as walking, jogging, running, stair climbing, skipping rope, skiing and impact-producing sports mainly affect the bones in legs, hips and lower spine. Swimming, cycling and exercising on machines such as elliptical trainers can provide a good cardiovascular workout, but because such exercises are low impact, they're not as helpful for improving bone health as weight-bearing exercises are.

Bone cancer
Definition Bone cancer is an uncommon cancer that begins in a bone. Bone cancer can begin in any bone in the body, but it most commonly affects the long bones that make up the arms and legs. The term "bone cancer" doesn't include cancers that begin elsewhere in the body and spread (metastasize) to the bone. Instead, those cancers are named for where they began, such as breast cancer that has metastasized to the bone. Bone cancer also doesn't include blood cell cancers, such as multiple myeloma and leukemia, that begin in the bone marrow the jellylike material inside the bone where blood cells are made. Causes It's not clear what causes most bone cancers. s know bone cancer begins as an error in a cell's DNA. The error tells the cell to grow and divide in an uncontrolled way. These cells go on living, rather than dying at a set time. The accumulating mutated cells form a mass (tumor) that can invade nearby structures or spread to other areas of the body. Risk factors

Inherited genetic syndromes. Certain rare genetic syndromes passed through families increase the risk of bone cancer, including Li-Fraumeni syndrome and hereditary retinoblastoma. Paget's disease of bone. This precancerous condition that affects older adults increases the risk of bone cancer. Radiation therapy for cancer. Exposure to large doses of radiation, such as those given during radiation therapy for cancer, increases the risk of bone cancer in the future. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

Types of bone cancer Bone cancers are broken down into separate types based on the type of cell where the cancer began. The most common types of bone cancer include:

Osteosarcoma. Osteosarcoma begins in the bone cells. Osteosarcoma occurs most often in children and ng adults. Chondrosarcoma. Chondrosarcoma begins in cartilage cells that are commonly found on the ends of bones. Chondrosarcoma most commonly affects older adults. Ewing's sarcoma. It's not clear where in bone Ewing's sarcoma begins. Scientists believe Ewing's sarcoma may begin in nerve tissue within the bone. Ewing's sarcoma occurs most often in children and adults.

Stages of bone cancer include:

Stage I. At this stage, bone cancer is limited to the bone and hasn't spread to other areas of the body. After biopsy testing, cancer at this stage is considered low grade and not aggressive. Stage II. This stage of bone cancer is limited to the bone and hasn't spread to other areas of the body. But biopsy testing reveals the bone cancer is high grade and considered aggressive. Stage III. At this stage, bone cancer occurs in two or more places on the same bone. Biopsy testing shows this bone cancer is high grade and considered aggressive. Stage IV. This stage of bone cancer indicates that cancer has spread beyond the bone to other areas of the body, such as the brain, liver or lungs.

Symptoms

Bone pain Swelling and tenderness near the affected area Broken bone Fatigue Unintended weight loss

Tests and diagnosis Imaging tests What imaging tests undergo depends on situation. may recommend one or more imaging tests to evaluate the area of concern, including:

Bone scan Computerized tomography (CT) Magnetic resonance imaging (MRI) Positron emission tomography (PET) X-ray

Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

Removing a sample of tissue for laboratory testing may recommend a procedure to remove (biopsy) a sample of tissue from the tumor for laboratory testing. Testing can tell whether the tissue is cancerous and, if so, what type of cancer have. Testing may also reveal the cancer's grade, which helps s understand how aggressive the cancer may be. Types of biopsy procedures used to diagnose bone cancer include:

Inserting a needle through skin and into a tumor. During a needle biopsy, inserts a thin needle through skin and guides it into the tumor. The needle is used to remove small pieces of tissue from the tumor. Surgery to remove a tissue sample for testing. During a surgical biopsy, makes an incision through skin and removes either the entire tumor (excisional biopsy) or a portion of the tumor (incisional biopsy).

Treatments and drugs The treatment options for bone cancer are based on the type of cancer have, the stage of the cancer, overall health and preferences. Bone cancer treatment typically involves surgery, chemotherapy, radiation or a combination of treatments. Radiation therapy Radiation therapy uses high-powered beams of energy, such as X-rays, to kill cancer cells. During radiation therapy, lie on a table while a special machine moves around and aims the energy beams at precise points on body. Radiation therapy may be used in people with bone cancer that can't be removed with surgery. Radiation therapy may also be used after surgery to kill any cancer cells that may be left behind. For people with advanced bone cancer, radiation therapy may help control signs and symptoms, such as pain. Chemotherapy Chemotherapy is a drug treatment that uses chemicals to kill cancer cells. Chemotherapy is most often given through a vein (intravenously). The chemotherapy medications travel throughout body. Chemotherapy alone or combined with radiation therapy is often used before surgery to shrink a bone cancer to a more manageable size that allows the surgeon to perform a limbsparing surgery. Chemotherapy may also be used in people with bone cancer that has spread beyond the bone to other areas of the body. Surgery The goal of surgery is to remove the entire bone cancer. To accomplish this, s remove the tumor and a small portion of healthy tissue that surrounds it. Types of surgery used to treat bone cancer include:

Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

Surgery to remove a limb. Bone cancers that are large or located in a complicated point on the bone may require surgery to remove all or part of a limb (amputation). As other treatments have been developed, this procedure is becoming less common. 'll likely be fitted with an artificial limb after surgery and will go through training to learn to do everyday tasks using new limb. Surgery to remove the cancer, but spare the limb. If a bone cancer can be separated from nerves and other tissue, the surgeon may be able to remove the bone cancer and spare the limb. Since some of the bone is removed with the cancer, the surgeon replaces the lost bone with some bone from another area of body or with a special metal prosthesis. Surgery for cancer that doesn't affect the limbs. If bone cancer occurs in bones other than those of the arms and legs, surgeons may remove the bone and some surrounding tissue, such as in cancer that affects a rib, or may remove the cancer while preserving as much of the bone as possible, such as in cancer that affects the spine. Bone removed during surgery can be replaced with a piece of bone from another area of the body or with a special metal prosthesis.

Osteomyelitis
Definition Osteomyelitis is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Osteomyelitis can also begin in the bone itself if an injury exposes the bone to germs. In children, osteomyelitis most commonly affects the long bones of the legs and upper arm, while adults are more likely to develop osteomyelitis in the bones that make up the spine (vertebrae). People who have diabetes may develop osteomyelitis in their feet if they have foot ulcers. Once considered an incurable condition, osteomyelitis can be successfully treated today. Causes Most cases of osteomyelitis are caused by staphylococcus bacteria, a type of germ commonly found on the skin or in the nose of even healthy individuals. Germs can enter a bone in a variety of ways, including:

Via the bloodstream. Germs in other parts of body for example, from pneumonia or a urinary tract infection can travel through bloodstream to a weakened spot in a bone. In children, osteomyelitis most commonly occurs in the softer areas, called growth plates, at either end of the long bones of the arms and legs. From a nearby infection. Severe puncture wounds can carry germs deep inside body. If such an injury becomes infected, the germs can spread into a nearby bone. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

Direct contamination. This may occur if have broken a bone so severely that part of it is sticking out through skin. Direct contamination can also occur during surgeries to replace joints or repair fractures. Causative microorganisms o o o o Staphylococcus aureus Streptococcus viridans E. coli Neisseria gonorrhea o Pseudomonas o Fungi o Mycobactria

Risk factors Recent injury or orthopedic surgery A severe bone fracture or a deep puncture wound gives infections a route to enter bone or nearby tissue. Surgery to repair broken bones or replace worn joints also can accidentally open a path for germs to enter a bone. Deep animal bites also can provide a pathway for infection. Circulation disorders When blood vessels are damaged or blocked, body has trouble distributing the infectionfighting cells needed to keep a small infection from growing larger. What begins as a small cut can progress to a deep ulcer that may expose deep tissue and bone to infection. Diseases that impair blood circulation include:

Poorly controlled diabetes Peripheral arterial disease, often related to smoking Sickle cell disease

Problems requiring intravenous lines or catheters There are a number of conditions that require the use of medical tubing to connect the outside world with internal organs. However, this tubing can also serve as a way for germs to get into body, increasing risk of an infection in general, which can lead to osteomyelitis. Examples of when this type of tubing might be used include:

Dialysis machines Urinary catheters Long-term intravenous tubing, sometimes called central lines

Conditions that impair the immune system If immune system is affected by a medical condition or medication, have a greater risk of osteomyelitis. Factors that may suppress immune system include:

Chemotherapy Poorly controlled diabetes Having had an organ transplant Needing to take corticosteroids or drugs called tumor necrosis factor (TNF) inhibitors. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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For unclear reasons, people with HIV/AIDS don't seem to have an increased risk of osteomyelitis. Illicit drugs People who inject illicit drugs are more likely to develop osteomyelitis because they typically use nonsterile needles and don't sterilize their skin before injections. Symptoms Signs and symptoms of osteomyelitis include:

Fever or chills Irritability or lethargy in young children Pain in the area of the infection Swelling, warmth and redness over the area of the infection

Sometimes osteomyelitis causes no signs and symptoms or has signs and symptoms that are difficult to distinguish from other problems. Complications

Bone death (osteonecrosis). An infection in bone can impede blood circulation within the bone, leading to bone death. bone can heal after surgery to remove small sections of dead bone. If a large section of bone has died, however, may need to have that limb amputated to prevent spread of the infection. Septic arthritis. In some cases, infection within bones can spread into a nearby joint. Impaired growth. In children, the most common location for osteomyelitis is in the softer areas, called growth plates, at either end of the long bones of the arms and legs. Normal growth may be interrupted in infected bones. Skin cancer. If osteomyelitis has resulted in an open sore that is draining pus, the surrounding skin is at higher risk of developing squamous cell cancer.

Tests and diagnosis Blood tests Blood tests may reveal elevated levels of white blood cells and other factors that may indicate that body is fighting an infection. If osteomyelitis was caused by an infection in the blood, tests may reveal what germs are to blame. No blood test exists that tells whether do or do not have osteomyelitis. However, blood tests do give clues that uses to decide what further tests and procedures may need. Imaging tests

X-rays. X-rays can reveal damage to bone. However, damage may not be visible until osteomyelitis has been present for several weeks. More detailed imaging tests may be necessary if osteomyelitis has developed more recently. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Computerized tomography (CT) scan. A CT scan combines X-ray images taken from many different angles, creating detailed cross-sectional views of a person's internal structures. Magnetic resonance imaging (MRI). Using radio waves and a strong magnetic field, MRIs can produce exceptionally detailed images of bones and the soft tissues that surround them.

Bone biopsy A bone biopsy is the gold standard for diagnosing osteomyelitis, because it can also reveal what particular type of germ has infected bone. Knowing the type of germ allows to choose an antibiotic that works particularly well for that type of infection. An open biopsy requires anesthesia and surgery to access the bone. In some situations, a surgeon inserts a long needle through skin and into bone to take a biopsy. This procedure requires local anesthetics to numb the area where the needle is inserted. X-ray or other imaging scans may be used for guidance. Treatments and drugs Medications A bone biopsy will reveal what type of germ is causing infection, so can choose an antibiotic that works particularly well for that type of infection. The antibiotics are usually administered through a vein in arm for at least four to six weeks. Side effects may include nausea, vomiting and diarrhea. An additional course of oral antibiotics may also be needed for more-serious infections. Surgery Depending on the severity of the infection, osteomyelitis surgery may include one or more of the following procedures:

Drain the infected area. Opening up the area around infected bone allows surgeon to drain any pus or fluid that has accumulated in response to the infection. Remove diseased bone and tissue. In a procedure called debridement, the surgeon removes as much of the diseased bone as possible, taking a small margin of healthy bone to ensure that all the infected areas have been removed. Surrounding tissue that shows signs of infection also may be removed. Restore blood flow to the bone. surgeon may fill any empty space left by the debridement procedure with a piece of bone or other tissue, such as skin or muscle, from another part of body. Sometimes temporary fillers are placed in the pocket until 're healthy enough to undergo a bone graft or tissue graft. The graft helps body repair damaged blood vessels and form new bone. Remove any foreign objects. In some cases, foreign objects, such as surgical plates or screws placed during a previous surgery, may have to be removed. Amputate the limb. As a last resort, surgeons may amputate the affected limb to stop the infection from spreading further.

Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Hyperbaric oxygen therapy In people with very difficult-to-treat osteomyelitis, hyperbaric oxygen therapy may help get more oxygen to the bone and promote healing. Hyperbaric oxygen therapy is a means of delivering more oxygen than is normally available in the atmosphere. This is done using a pressure chamber that resembles a large, clear tube. Prevention Reducing risk of infection will also reduce risk of developing osteomyelitis. In general, take precautions to avoid cuts and scrapes, which give germs easy access to body. clean the area immediately and apply a clean bandage. Check wounds frequently for signs of infection. Osteomalacia Definition Osteomalacia refers to a softening of bones, often caused by a vitamin D deficiency. In children, this condition is called rickets. Soft bones are more likely to bow and fracture than are harder, healthy bones. Osteomalacia results from a defect in the bone-building process, while osteoporosis develops due to a weakening of previously constructed bone. Muscle weakness and achy bone pain are the major sign and symptom of osteomalacia. Treatment for osteomalacia involves replenishing low levels of vitamin D and calcium, and treating any underlying disorders that may be causing the deficiencies. Causes

Vitamin D deficiency. Sunlight produces vitamin D in skin. body needs vitamin D to process calcium. Osteomalacia can develop in people who spend little time in sunlight, wear very strong sunscreen, remain covered while outside, or live in areas where sunlight hours are short or the air is smoggy. Certain surgeries. Removing part or all of stomach (gastrectomy) can cause osteomalacia because stomach breaks down foods to release vitamin D and other minerals, which are absorbed in intestines. Surgery to remove or bypass small intestine also can lead to osteomalacia. Celiac disease. In this autoimmune disorder, the lining of small intestine is damaged by consuming foods containing gluten, a protein found in wheat, barley and rye. A damaged intestinal lining doesn't absorb nutrients, such as vitamin D, as well as a healthy one does. Kidney or liver disorders. Problems with kidneys or liver can interfere with ability to process vitamin D.

Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Drugs. Some drugs used to treat seizures, including phenytoin (Dilantin, Phenytek) and phenobarbital, can cause osteomalacia.

Risk factors

The risk of developing osteomalacia is highest in people who have both inadequate dietary intake of vitamin D and little exposure to sunlight, such as older adults and those who are housebound or hospitalized.

Symptoms Bone pain The dull, aching pain associated with osteomalacia most commonly affects the:

Lower spine Pelvis Hips Legs Ribs

Muscle weakness

Decreased muscle tone Weakness in arms and legs Reduced ability to get around A waddling gait

Complications

If have osteomalacia, 're more likely to experience broken bones, particularly in ribs, spine and legs.

Tests and diagnosis

Blood and urine tests. In cases of osteomalacia caused by vitamin D deficiency or by phosphorus loss, abnormal levels of vitamin D and the minerals calcium and phosphorus are often detected. X-ray. Slight cracks in bones that are visible on X-rays, referred to as Looser transformation zones, are a characteristic feature of people with osteomalacia. Bone biopsy. During a bone biopsy, inserts a slender needle through skin and into bone to withdraw a small sample for viewing under a microscope. Although a bone biopsy is very accurate in detecting osteomalacia, it's not often needed to make the diagnosis.

Treatments and drugs

Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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When osteomalacia arises from a dietary or sunlight deficiency, replenishing low levels of vitamin D in body usually cures the condition. Generally, people with osteomalacia take vitamin D supplements by mouth for a period of several weeks to several months. Less commonly, vitamin D is given as an injection or through a vein in arm. If blood levels of calcium or phosphorus are low, may take supplements of those minerals as well. In addition, treating any condition affecting vitamin D metabolism, such as kidney failure or primary biliary cirrhosis, often helps improve the signs and symptoms of osteomalacia.

Prevention

Spend a few minutes in the sun. Sun is a natural source of vitamin D. Although it's important to limit unprotected time in the sun, brief periods of direct sun exposure will help with vitamin D production. Eat foods high in vitamin D. These include foods that are naturally rich in vitamin D, including oily fish (salmon, mackerel, sardines) and egg yolks. Also look for foods that are fortified with vitamin D, such as cereal, bread, milk and yogurt. Take supplements, if needed. If don't get enough vitamins and minerals in diet or if have a medical condition affecting the ability of digestive system to absorb nutrients properly, ask about taking a vitamin D supplement and a calcium supplement.

Osteoarthritis
Definition Osteoarthritis is the most common form of arthritis, affecting millions of people around the world. Often called wear-and-tear arthritis, osteoarthritis occurs when the protective cartilage on the ends of bones wears down over time. While osteoarthritis can damage any joint in body, the disorder most commonly affects joints in hands, neck, lower back, knees and hips. Causes

Osteoarthritis occurs when the cartilage that cushions the ends of bones in joints deteriorates over time. Cartilage is a firm, slippery tissue that permits nearly frictionless joint motion. In osteoarthritis, the slick surface of the cartilage becomes rough. Eventually, if the cartilage wears down completely, may be left with bone rubbing on bone. Trauma Direct trauma Accidents Mechanical stress Sports activities Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Sternous activities Inflammatory diseases Lymes disease Repeated episodes of gout Skeletal deformities Congenital bone deformities Acquired bone deformities Endocrine disorders Diabetes mellitus Hyperparathyroidism Diabetic neuropathy Use of drugs Corticosteroids Others Obesity Orthodontic operations Idiopathic causes

Risk factors Factors that increase risk of osteoarthritis include:

Older age. The risk of osteoarthritis increases with age. Sex. Women are more likely to develop osteoarthritis, though it isn't clear why. Bone deformities. Some people are born with malformed joints or defective cartilage, which can increase the risk of osteoarthritis. Joint injuries. Injuries, such as those that occur when playing sports or from an accident, may increase the risk of osteoarthritis. Obesity. Carrying more body weight puts added stress on weight-bearing joints, such as knees. Certain occupations. If job includes tasks that place repetitive stress on a particular joint, that joint may eventually develop osteoarthritis. Other diseases. Having diabetes, underactive thyroid, gout or Paget's disease of bone can increase risk of developing osteoarthritis.

SIGN AND SYMPTOMS

1.

Bouchards nodes: bony swelling of proximal interphalangeal joints.

2.

Heberdens nodes: bony swelling of distal interphalangeal joints. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Pain and tenderness Loss of ability Stiffness of joints in morning and after exercise. Crepitus with movement Muscle spasm contractions in the tendons Effusion limited range of motion bony enlargement swelling at the base of the joints Joint pain Joint instability Loss of function

Complications

Osteoarthritis is a degenerative disease that worsens over time. Joint pain and stiffness may become severe enough to make daily tasks difficult. Some people are no longer able to work. When joint pain is this severe, s may suggest joint replacement surgery.

Tests and diagnosis Imaging tests Pictures of the affected joint can be obtained during imaging tests. Examples include:

X-rays. Cartilage doesn't show up on X-ray images, but the loss of cartilage is revealed by a narrowing of the space between the bones in joint. An X-ray may also show bone spurs around a joint. Many people have X-ray evidence of osteoarthritis before they experience any symptoms. Magnetic resonance imaging (MRI). MRI uses radio waves and a strong magnetic field to produce detailed images of bone and soft tissues, including cartilage. This can be helpful in determining what exactly is causing pain.

Lab tests Analyzing blood or joint fluid can help pinpoint the diagnosis. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Blood tests. Blood tests may help rule out other causes of joint pain, such as rheumatoid arthritis. Joint fluid analysis. may use a needle to draw fluid out of the affected joint. Examining and testing the fluid from joint can determine if there's inflammation and if pain is caused by gout or an infection.

Treatments and drug Medical management 1.) Analgesic therapy Acetaminophen. Acetaminophen (Tylenol, others) can relieve pain, but it doesn't reduce inflammation. It has been shown to be effective for people with osteoarthritis who have mild to moderate pain. Taking more than the recommended dosage of acetaminophen can cause liver damage 2.) NSAIDSs NSAIDs may reduce inflammation and relieve pain. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin, others) and naproxen (Aleve, others). Stronger NSAIDs are available by prescription. NSAIDs can cause stomach upset, ringing in ears, cardiovascular problems, bleeding problems, and liver and kidney damage. Older people have the highest risk of complications. 3.) Other medications or supplements Corticosteroids methylprednisolone injected right into the joint to reduce swelling and pain

Over-the-counter remedies such as glucosamine and chondroitin sulfate Capsaicin (Zostrix) skin cream to relieve pain Artificial joint fluid (Synvisc, Hyalgan) can be injected into the knee to relieve pain for 3 - 6 months Intra-articular Injections of Hyaluronic Acid

4.) Anti gout medication Allopurinol

5.) Recently used drugs COX-2 inhibitors eg. Celebrex It is a new class of NSAIDs Algaea-X is a topical cream for joint pains and arthritis. it also treats joint stiffness, muscle soreness, neck and back pain, strains and sprains, arthritis, tendonitis, frozen shoulder and other inflammation-associated diseases or conditions 4.) Antacid drugs Ranitidine Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Therapy

Physical therapy. A physical therapist can work with 3to create an individualized exercise regimen that will strengthen the muscles around joint, increase the range of motion in joint and reduce pain. Occupational therapy. An occupational therapist can help discover ways to do everyday tasks or do job without putting extra stress on already painful joint. For instance, a toothbrush with a large grip could make brushing teeth easier if have finger osteoarthritis. A bench in shower could help relieve the pain of standing if have knee osteoarthritis. Braces or shoe inserts. Consider trying splints, braces, shoe inserts or other medical devices that can help reduce pain. These devices can immobilize or support joint to help keep pressure off it. A chronic pain class. The Arthritis Foundation and some medical centers have classes for people with osteoarthritis and chronic pain. Ask about classes in area or check with the Arthritis Foundation. These classes teach skills that help manage osteoarthritis pain. And 'll meet other people with osteoarthritis and learn their tips and tricks for reducing and coping with joint pain.

Surgical and other procedures

Cortisone shots. Injections of corticosteroid medications may relieve pain in joint. During this procedure numbs the area around joint, then places a needle into the space within joint and injects medication. The number of cortisone shots can receive each year is limited, because the medication can worsen joint damage over time. Lubrication injections. Injections of hyaluronic acid derivatives (Hyalgan, Synvisc) may offer pain relief by providing some cushioning in knee. These agents are similar to a component normally found in joint fluid. Realigning bones. During a surgical procedure called an osteotomy, the surgeon cuts across the bone either above or below the knee to realign the leg. Osteotomy can reduce knee pain by shifting body weight away from the worn-out part of knee. Joint replacement. In joint replacement surgery (arthroplasty), surgeon removes damaged joint surfaces and replaces them with plastic and metal devices called prostheses. The hip and knee joints are the most commonly replaced joints. Surgical risks include infections and blood clots. Artificial joints can wear out or come loose and may need to eventually be replaced.

Lifestyle and home remedies

Rest. If 're experiencing pain or inflammation in joint, rest it for 12 to 24 hours. Find activities that don't require to use joint repetitively. Exercise. Exercise can increase endurance and strengthen the muscles around joint, making joint more stable. Stick to gentle exercises, such as walking, biking or swimming. If feel new joint pain, stop. New pain that lasts for hours after exercise probably means 've overdone it. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Lose weight. Being overweight or obese increases the stress on weight-bearing joints, such as knees and hips. Even a small amount of weight loss can relieve some pressure and reduce pain. Talk to about healthy ways to lose weight. Most people combine changes in their diet with increased exercise. Use heat and cold to manage pain. Both heat and cold can relieve pain in joint. Heat also relieves stiffness, and cold can relieve muscle spasms and pain. Apply over-the-counter pain creams. Creams and gels available at drugstores may provide temporary relief from osteoarthritis pain. Some creams numb the pain by creating a hot or cool sensation. Other creams contain medications, such as aspirinlike compounds, that are absorbed into skin. Pain creams work best on joints that are close to the surface of skin, such as knees and fingers. Use assistive devices. Assistive devices can make it easier to go about day without stressing painful joint. A cane may take weight off knee or hip as walk. Carry the cane in the hand opposite the leg that hurts. Gripping and grabbing tools may make it easier to work in the kitchen if have osteoarthritis in fingers. Occupational therapist may have ideas about what sorts of assistive devices may be helpful to . Catalogs and medical supply stores also may be places to look for ideas.

Alternative medicine

Acupuncture. Some studies indicate that acupuncture can relieve pain and improve function in people who have knee osteoarthritis. During acupuncture, hair-thin needles are inserted into skin at precise spots on body. Risks include infection, bruising and some pain where needles are inserted into skin. Glucosamine and chondroitin. Studies have been mixed on these nutritional supplements. A few have found benefits for people with osteoarthritis, while most indicate that these supplements work no better than placebo. Don't use glucosamine if 're allergic to shellfish. Glucosamine and chondroitin may interact with blood thinners such as warfarin (Coumadin) and cause bleeding problems. Tai chi and yoga. These movement therapies involve gentle exercises and stretches combined with deep breathing. Many people use these therapies to reduce stress in their lives, though small studies have found that tai chi and yoga may reduce osteoarthritis pain. When led by a knowledgeable instructor, these therapies are safe. Avoid moves that cause pain in joints. Rheumatoid arthritis

Definition Rheumatoid arthritis is a chronic inflammatory disorder that typically affects the small joints in hands and feet. Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of joints, causing a painful swelling that can eventually result in bone erosion and joint deformity. An autoimmune disorder, rheumatoid arthritis occurs when immune system mistakenly attacks own body's tissues. In addition to causing joint problems, rheumatoid arthritis Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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sometimes can affect other organs of the body such as the skin, eyes, lungs and blood vessels. Causes Rheumatoid arthritis occurs when immune system attacks the synovium the lining of the membranes that surround joints. The resulting inflammation thickens the synovium, which can eventually destroy the cartilage and bone within the joint. The tendons and ligaments that hold the joint together weaken and stretch. Gradually, the joint loses its shape and alignment. While genes don't actually cause rheumatoid arthritis, they can make more susceptible to environmental factors such as infection with certain viruses and bacteria that may trigger the disease. Risk factors

sex. Women are more likely to develop rheumatoid arthritis than men are. Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60. Family history. If a member of family has rheumatoid arthritis, may have an increased risk of the disease.

Symptoms

Tender, warm, swollen joints Morning stiffness that may last for hours Firm bumps of tissue under the skin on arms (rheumatoid nodules) Fatigue, fever and weight loss

Early rheumatoid arthritis tends to affect smaller joints first particularly the joints that attach fingers to hands and toes to feet. As the disease progresses, symptoms often spread to the knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of body. Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity, called flares, alternate with periods of relative remission when the swelling and pain fade or disappear. Over time, rheumatoid arthritis can cause joints to deform and shift out of place. Complications

Osteoporosis. Rheumatoid arthritis itself, along with some medications used for treating rheumatoid arthritis, can increase risk of osteoporosis a condition that weakens bones and makes them more prone to fracture. Carpal tunnel syndrome. If rheumatoid arthritis affects wrists, the inflammation can compress the nerve that serves most of hand and fingers. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Heart problems. Rheumatoid arthritis can increase risk of hardened and blocked arteries, as well as inflammation of the sac that encloses heart. Lung disease. People with rheumatoid arthritis have an increased risk of inflammation and scarring of the lung tissues, which can lead to progressive shortness of breath.

Tests and diagnosis

Rheumatoid arthritis can be difficult to diagnose in its early stages because the early signs and symptoms mimic those of many other diseases. There is no one blood test or physical finding to confirm the diagnosis. During the physical exam, will check joints for swelling, redness and warmth. He or she will also check reflexes and muscle strength. Blood tests People with rheumatoid arthritis tend to have an elevated erythrocyte sedimentation rate (ESR, or sed rate), which indicates the presence of an inflammatory process in the body. Other common blood tests look for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies. X-rays may recommend X-rays to help track the progression of rheumatoid arthritis in joints over time.

Treatments and drugs There is no cure for rheumatoid arthritis. Medications can reduce inflammation in joints in order to relieve pain and prevent or slow joint damage. Occupational and physical therapy can teach how to protect joints. If joints are severely damaged by rheumatoid arthritis, surgery may be necessary. Medications

NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve). Stronger NSAIDs are available by prescription. Side effects may include ringing in ears, stomach irritation, heart problems, and liver and kidney damage. Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage. Side effects may include thinning of bones, cataracts, weight gain and diabetes. s often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication. Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Trexall), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). Side effects vary but may include liver damage, bone marrow suppression and severe lung infections. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Immunosuppressants. These medications act to tame immune system, which is out of control in rheumatoid arthritis. Examples include azathioprine (Imuran, Azasan) and cyclosporine (Neoral, Sandimmune, Gengraf). These medications can increase susceptibility to infection. TNF-alpha inhibitors. Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory substance produced by body. TNF-alpha inhibitors can help reduce pain, morning stiffness, and tender or swollen joints. Examples include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), golimumab (Simponi) and certolizumab (Cimzia). Potential side effects include nausea, diarrhea, hair loss and an increased risk of serious infections. Other drugs. Several other rheumatoid arthritis drugs target a variety of processes involved with inflammation in body. These drugs include anakinra (Kineret), abatacept (Orencia), rituximab (Rituxan), tocilizumab (Actemra) and tofacitinib (Xeljanz). Side effects vary but may include itching, abdominal pain, headache, runny nose or sore throat.

Therapy Assistive devices can make it easier to avoid stressing painful joints. For instance, a kitchen knife equipped with a saw handle helps protect finger and wrist joints. Tools such as buttonhooks can make it easier to get dressed. Catalogs and medical supply stores are good places to look for ideas. Surgery If medications fail to prevent or slow joint damage, and may consider surgery to repair damaged joints. Surgery may help restore ability to use joint. It can also reduce pain and correct deformities. Rheumatoid arthritis surgery may involve one or more of the following procedures:

Total joint replacement. During joint replacement surgery, surgeon removes the damaged parts of joint and inserts a prosthesis made of metal and plastic. Tendon repair. Inflammation and joint damage may cause tendons around joint to loosen or rupture. surgeon may be able to repair the tendons around joint. Joint fusion. Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn't an option.

Lifestyle and home remedies

Exercise regularly. Gentle exercise can help strengthen the muscles around joints, and it can help fight fatigue might feel. Check with before start exercising. If 're just getting started, begin by taking a walk. Try swimming or gentle water aerobics. Avoid exercising tender, injured or severely inflamed joints. Apply heat or cold. Heat can help ease pain and relax tense, painful muscles. Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms.

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Relax. Find ways to cope with pain by reducing stress in life. Techniques such as hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain. Paget's disease of bone

Definition Paget's disease of bone disrupts body's normal bone recycling process, in which old bone tissue is gradually replaced with new bone tissue. Over time, the affected bones may become fragile and misshapen. Paget's disease of bone most commonly occurs in the pelvis, skull, spine and legs. Causes Risk factors

Age. People older than 40 are the most likely to develop Paget's disease of bone. Sex. Men are more commonly affected than are women. National origin. Paget's disease of bone is more common in England, Scotland, central Europe and Greece as well as countries settled by European immigrants. It's uncommon in Scandinavia and Asia. Family history. If have a close relative who has Paget's disease of bone, are much more likely to develop the condition self.

Symptoms Most people who have Paget's disease of bone experience no symptoms. When symptoms do occur, the most common complaint is bone pain. The disease may affect only one or two areas of body or may be widespread. Signs and symptoms, if any, will depend on the part of body that's affected, including:

Pelvis. Paget's disease of bone in the pelvis can cause hip pain. Skull. An overgrowth of bone in the skull can cause hearing loss or headaches. Spine. If spine is affected, nerve roots can become compressed. This can cause pain, tingling and numbness in an arm or leg. Leg. As the bones weaken, they may bend causing to become bowlegged. Enlarged and misshapen bones in legs can put extra stress on nearby joints, which may cause wear-and-tear arthritis in knee or hip.

Complications In most cases, Paget's disease of bone progresses slowly. The disease can be managed effectively in nearly all people. Possible complications include:

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Fractures. Bones affected by Paget's disease break more easily. Extra blood vessels are created in these deformed bones, so they bleed more during repair surgeries. Osteoarthritis. Misshapen bones can increase the amount of stress on nearby joints, which can cause osteoarthritis. Heart failure. Unusually extensive Paget's disease may force heart to work harder to pump blood to the affected areas of body. In people with pre-existing heart disease, this increased workload can lead to heart failure. Bone cancer. Bone cancer occurs in less than 1 percent of people with Paget's disease.

Tests and diagnosis Imaging tests Bone changes common to Paget's disease can be revealed by:

X-rays. The first indication of Paget's disease is often one or more abnormalities found on X-rays done for other reasons. X-ray images of bones can show areas of bone reabsorption, enlargement of the bone and deformities that are characteristic of Paget's disease, such as bowing of long bones. Bone scan. In a bone scan, radioactive material is injected into body. This material travels to the spots on bones most affected by Paget's disease, so they light up on the scan images.

Lab tests People who have Paget's disease of bone usually have elevated levels of alkaline phosphatase in their blood. Treatments and drugs Medications Osteoporosis drugs (bisphosphonates) are the most common treatment for Paget's disease of bone. Some bisphosphonates are given as oral medications, while others are given by injection. Oral bisphosphonates are generally well tolerated, but may irritate gastrointestinal tract. Examples include:

Alendronate (Fosamax) Ibandronate (Boniva) Pamidronate (Aredia) Risedronate (Actonel) Zoledronic acid (Zometa, Reclast)

Long-term bisphosphonate therapy has been linked to a rare problem in which the upper thighbone cracks, but doesn't usually break completely. Bisphosphonates also may increase the risk of osteonecrosis of the jawbone a rare condition in which a section of jawbone dies and deteriorates after a tooth extraction.

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If can't tolerate bisphosphonates, may prescribe calcitonin (Miacalcin), a naturally occurring hormone involved in calcium regulation and bone metabolism. Calcitonin is a drug that administer to self by injection or nasal spray. Side effects may include nausea, facial flushing and irritation at the injection site. Surgery In rare cases, may require surgery to:

Help fractures heal Replace joints damaged by severe arthritis Realign deformed bones Reduce pressure on nerves

Paget's disease often causes the body to produce an excessive number of blood vessels in the affected bones. This change increases the risk of serious blood loss during an operation. If 're scheduled for surgery that involves bones affected by Paget's disease, may prescribe medications to reduce the activity of the disease, a step that tends to reduce blood loss during surgery. Lifestyle and home remedies

Prevent falls. Paget's disease puts at high risk of bone fractures. Ask for advice on preventing falls. He or she may recommend that use a cane or a walker. Take measures to fall-proof home. Remove slippery floor coverings, use nonskid mats in bathtub or shower, tuck away cords, and install handrails on stairways and grab bars in bathroom. Eat well. Be sure diet includes adequate levels of calcium and vitamin D, which facilitates the absorption of calcium. This is especially important if 're being treated with bisphosphonates. Review diet with and ask if should begin taking vitamin and calcium supplements. Exercise regularly. Exercising on a regular basis is essential for maintaining joint mobility and bone strength. Talk to before beginning an exercise program to determine the right type, duration and intensity of exercise. Some activities may place too much stress on affected bones. Spinal tumor

Definition A spinal tumor is a cancerous (malignant) or noncancerous (benign) growth that develops within or near spinal cord or within the bones of spine. Although back pain is the most common symptom of a spinal tumor, it's also an extremely common problem in people who don't have spinal tumors. In fact, most back pain isn't caused by a tumor. Symptoms

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Depending on the location and type of spinal tumor, various signs and symptoms can develop, especially as a tumor grows and affects spinal cord or on the nerve roots, blood vessels or bones of spine. Spinal tumor symptoms may include:

Back pain, often radiating to other parts of body Loss of sensation or muscle weakness, especially in arms or legs Difficulty walking, sometimes leading to falls Decreased sensitivity to pain, heat and cold Loss of bowel or bladder function Paralysis that may occur in varying degrees and in different parts of body, depending on which nerves are compressed

Back pain is a common symptom of both noncancerous and cancerous spinal tumors. Pain may also spread beyond back to hips, legs, feet or arms and may become more severe over time in spite of treatment. Spinal tumors progress at different rates. In general, cancerous spinal tumors grow more quickly, whereas noncancerous spinal tumors tend to develop very slowly. Causes it's usually not known whether such genetic defects are inherited, occur spontaneously or are caused by something in the environment, such as exposure to certain chemicals. In some cases, however, spinal tumors are linked to known inherited syndromes, such as neurofibromatosis 2 and von Hippel-Lindau disease. The parts of spine that are likely to be affected by a spinal tumor include the:

Vertebrae. spine is made up of small bones (vertebrae) stacked on top of one another that enclose and protect the spinal cord and its nerve roots. Spinal cord. spinal cord is a double-layered, long column of nerve fibers that carries messages to and from brain. Wrapped around the entire spinal cord are three protective membranes (meninges).

Risk factors

Neurofibromatosis 2. In this hereditary disorder, noncancerous tumors develop on or near the nerves related to hearing, which may lead to progressive hearing loss in one or both ears. Some people with neurofibromatosis 2 also develop tumors in the spinal cord. Von Hippel-Lindau disease. This rare, multisystem disorder is associated with noncancerous blood vessel tumors (hemangioblastomas) in the brain, retina and spinal cord and with other types of tumors in the kidneys or adrenal glands.

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A compromised immune system. Spinal cord lymphomas cancers that affect lymphocytes, a type of immune cell are more common in people whose immune systems are compromised by medications or disease. A prior history of cancer. Any type of cancer can travel to the spine, but the cancers that may be more likely to affect the spine include breast, lung, prostate and multiple myeloma.

Types of spinal tumors Spinal tumors are classified according to their location in the spine.

Extradural (vertebral) tumors. Most tumors that affect the vertebrae have spread (metastasized) to the spine from another site in the body often the prostate, breast, lung or kidney. Although the original (primary) cancer is usually diagnosed before back problems develop, back pain may be the first symptom of disease in people with metastatic spinal tumors. Cancerous tumors that begin in the bones of the spine are far less common. Among these are osteosarcomas (osteogenic sarcomas) and Ewing's sarcoma, a particularly aggressive tumor that affects ng adults. Multiple myeloma is a cancerous disease of the bone marrow the spongy inner part of the bone that makes blood cells. Noncancerous tumors, such as osteoid osteomas, osteoblastomas and hemangiomas, also can develop in the bones of the spine.

Intradural-extramedullary tumors. These tumors develop in the spinal cord's arachnoid membrane (meningiomas) and in the nerve roots that extend out from the spinal cord (schwannomas and neurofibromas). These tumors may be cancerous or noncancerous. Intramedullary tumors. These tumors begin in the supporting cells within the spinal cord. Most are either astrocytomas or ependymomas. Intramedullary tumors can be either noncancerous or cancerous. In rare cases, tumors from other parts of the body can metastasize to the spinal cord itself.

Complications

Both noncancerous and cancerous spinal tumors can compress spinal nerves, leading to a loss of movement or sensation below the level of the tumor and sometimes to changes in bowel and bladder function. Nerve damage may be permanent. However, if caught early and treated aggressively, it may be possible to regain nerve function. Depending on its location, a tumor that impinges on the spinal cord itself may be lifethreatening.

Tests and diagnosis complete medical history and perform both general physical and neurological exams

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Spinal magnetic resonance imaging (MRI). MRI uses a powerful magnet and radio waves to produce images of spine. MRI accurately shows the spinal cord and nerves and yields better pictures of bone tumors than computerized tomography (CT) scans do. A contrast agent that helps to highlight certain tissues and structures may be injected into a vein in hand or forearm during the test. Computerized tomography (CT). This test uses a narrow beam of radiation to produce detailed images of spine. Sometimes it may be combined with an injected contrast dye to make abnormal changes in the spinal canal or spinal cord easier to see. Myelogram. In this test, a contrast dye is injected into spinal column. The dye then circulates around spinal cord and spinal nerves, making them easier to see on an Xray or CT scan. Because the test poses more risks than does an MRI or conventional CT, a myelogram is usually not the first choice for diagnosis. However, it may be used to help identify compressed nerves and for those who can't have an MRI. Biopsy. The only way to determine whether a tumor is noncancerous or cancerous is to examine a small tissue sample (biopsy) under a microscope. If the tumor is cancerous, biopsy also helps determine the cancer's grade information that helps determine treatment options. Grade 1 cancers are generally the least aggressive, and grade 4 cancers, the most aggressive. How the sample is obtained depends on overall health and the location of the tumor. may use a fine needle to withdraw a small amount of tissue, or the sample may be obtained during surgery.

Treatments and drugs

Monitoring. Some spinal tumors may be discovered before they cause symptoms often when're being evaluated for another condition. If small tumors are noncancerous and aren't growing or pressing on surrounding tissues, watching them carefully may be all that's needed. This is especially true in older adults for whom surgery or radiation therapy may pose special risks. If decide not to receive treatment for a spinal tumor, will likely recommend periodic scans to monitor the tumor. Surgery. This is often the treatment of choice for tumors that can be removed with an acceptable risk of nerve damage. Newer techniques and instruments allow neurosurgeons to reach tumors that were once considered inaccessible. The highpowered microscopes used in microsurgery make it easier to distinguish tumor from healthy tissue. s also can test different nerves during surgery with electrodes, thus minimizing nerve damage. In some instances, they may use sound waves to break up tumors and remove the fragments. However, even with advances in treatment, not all tumors can be removed completely. When the tumor can't be removed completely, surgery may be combined with chemotherapy or radiation therapy. Recovery from spinal surgery may take weeks or longer, depending on the procedure, and may experience a temporary loss of sensation or other complications, including bleeding and damage to nerve tissue. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Standard radiation therapy. This may be used following an operation to eliminate the remnants of tumors that can't be completely removed or to treat inoperable tumors. It also may be the first line therapy for metastatic tumors. Radiation may also be used to relieve pain or when surgery poses too great a risk. Medications can help some of the side effects of radiation, such as nausea and vomiting. And depending on the type of tumor, may be able to modify therapy to help prevent damage to surrounding tissue and improve the treatment's effectiveness. Modifications may range from simply changing the dosage of radiation receive to using sophisticated techniques that offer better protection to healthy tissue, such as 3D conformal radiation therapy.

Stereotactic radiosurgery (SRS). This newer method of delivering radiation is capable of delivering a high dose of precisely targeted radiation. In SRS, s use computers to focus radiation beams on tumors with pinpoint accuracy and from multiple angles. This approach has proved effective in the treatment of brain tumors, and research is now under way to determine the best technique, radiation dose and schedule for SRS in the treatment of spinal tumors. Chemotherapy. A standard treatment for many types of cancer, chemotherapy uses medications to destroy cancer cells or stop them from growing. can determine whether chemotherapy might be beneficial for , either alone or in combination with radiation therapy. Side effects may include fatigue, nausea, vomiting, increased risk of infection and hair loss. Other drugs. Because surgery and radiation therapy as well as tumors themselves can cause inflammation inside the spinal cord, s sometimes prescribe corticosteroids to reduce the swelling, either following surgery or during radiation treatments. Although corticosteroids reduce inflammation, they are usually used only for short periods to avoid such serious side effects as osteoporosis, high blood pressure, diabetes and an increased susceptibility to infection. Potts disease

Pott's disease or Pott disease is a presentation of extrapulmonary tuberculosis which is called so when tuberculosis bacillus is seen in any organ other than lung. Extrapulmonary tuberculosis can affect the spine, a kind of tuberculous arthritis of the intervertebral jointsThe lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine. Signs and symptoms

Back pain Fever Night sweating Anorexia Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Spinal mass, sometimes associated with numbness, paraesthesia, or muscle weakness of the legs Difficulty standing

Diagnosis

Blood tests CBC: leukocytosis Elevated erythrocyte sedimentation rate: >100 mm/h

Tuberculin skin test Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84 95% of patients with Pott disease who are not infected with HIV.

Radiographs of the spine Radiographic changes associated with Pott disease present relatively late. The following are radiographic changes characteristic of spinal tuberculosis on plain radiography: 1. 2. 3. 4. 5. Lytic destruction of anterior portion of vertebral body Increased anterior wedging Collapse of vertebral body Reactive sclerosis on a progressive lytic process Enlarged psoas shadow with or without calcification

Additional radiographic findings may include the following: 1. 2. 3. 4. 5.

Vertebral end plates are osteoporotic. Intervertebral disks may be shrunk or destroyed. Vertebral bodies show variable degrees of destruction. Fusiform paravertebral shadows suggest abscess formation. Bone lesions may occur at more than one level.

Bone scan CT of the spine Bone biopsy MRI

Late complications

Vertebral collapse resulting in kyphosis Spinal cord compression Sinus formation Paraplegia (so called Pott's paraplegia) Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Prevention Controlling the spread of tuberculosis infection can prevent tuberculous spondylitis and arthritis. Patients who have a positive PPD test (but not active tuberculosis) may decrease their risk by properly taking medicines to prevent tuberculosis. To effectively treat tuberculosis, it is crucial that patients take their medications exactly as prescribed. Therapy

Non-operative antituberculous drugs Analgesics Immobilization of the spine region different types of braces and collars Surgery may be necessary, especially to drain spinal abscesses or debride bony lesions fully or to stabilize the spine. A 2007 review found only just two randomized clinical trial with at least one year-follow up found which compared chemotherapy plus surgery with chemotherapy alone for treating people diagnosed with active tuberculosis of the spine. As such there is no high grade evidence but the results of this study indicates that surgery should not be recommended routinely and clinicians have to selectively judge and decide on which patients to operate. [2] Thoracic spinal fusion with or without instrumentation as a last resort Physical therapy for pain-relieving modalties, postural education and teaching a home exercise program for strength and flexibility Amputation

Amputation is the removal of a body extremity by trauma, prolonged constriction, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. Amputation is a surgical procedure that involves removal of an extremity or limb (leg or arm) or a part of a limb (such as a toe, finger, foot, or hand), usually as a result of injury, disease, infection, or surgery (to remove tumors from bones and muscles). Amputation of the leg (above and below-knee) is the most common type of amputation procedure performed. Types Leg amputations

amputation of digits partial foot amputation ankle disarticulation below-knee amputation, abbreviated as BKA. knee disarticulation above-knee amputation

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hip disarticulation hemipelvectomy/hindquarter amputation

Arm amputations

amputation of digits metacarpal amputation wrist disarticulation forearm amputation (transradial) elbow disarticulation above-elbow amputation (transhumeral) shoulder disarticulation and forequarter amputation Krukenberg procedure

Other amputations

Face: amputation of the ears o amputation of the nose (rhinotomy) o amputation of the tongue (glossectomy). o amputation of the eyes (blinding). Many of these facial disfigurings were and still are done in some parts of the world as punishment for some crimes, and as individual shame and population terror practices. o amputation of the teeth. Removal of teeth, mainly incisors, is or was practiced by some cultures for ritual purposes (for instance in the Iberomaurusian culture of Neolithic North Africa). Breasts: o amputation of the breasts (mastectomy). Genitals amputation o amputation of the scrotum. o amputation of the testicles (castration). o amputation of the penis (penectomy). o amputation of the foreskin (circumcision). o amputation of the clitoris (clitoridectomy).
o

Causes Circulatory disorders

Diabetic foot infection or gangrene (the most frequent reason for infection-related amputations) Sepsis with peripheral necrosis

Neoplasm Transfemoral amputation due to liposarcoma Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Cancerous bone or soft tissue tumors (e.g. osteosarcoma, osteochondroma, fibrosarcoma, epithelioid sarcoma, Ewing's sarcoma, synovial sarcoma, sacrococcygeal teratoma, liposarcoma) Melanoma

Trauma

Severe limb injuries in which the limb cannot be saved or efforts to save the limb fail. Traumatic amputation (an unexpected amputation that occurs at the scene of an accident, where the limb is partially or entirely severed as a direct result of the accident, for example a finger that is severed from the blade of a table saw). Amputation in utero (Amniotic band)

Deformities

Deformities of digits and/or limbs (e.g., proximal femoral focal deficiency) Extra digits and/or limbs (e.g., polydactyly)

Infection

Bone infection (osteomyelitis) diabetes frostbite

Athletic performance

Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance. Australian Rules footballer Daniel Chick elected to have his left ring finger amputated as chronic pain and injury was limiting his performance.[9] Rugby union player Jone Tawake also had a finger removed.[10] National Football League safety Ronnie Lott had the tip of his little finger removed after it was damaged in the 1985 NFL season.

Legal punishment

Amputation is used as a legal punishment in a number of countries, among them Iran, Yemen, Saudi Arabia, Sudan, and Islamic regions of Nigeria.

Surgical amputation Method Curved knives such as this one were used, in the past, for some kinds of amputations. The first step is ligating the supplying artery and vein, to prevent hemorrhage (bleeding). The muscles are transected, and finally the bone is sawed through with an oscillating saw. Sharp Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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and rough edges of the bone(s) are filed down, skin and muscle flaps are then transposed over the stump, occasionally with the insertion of elements to attach a prosthesis. Traumatic amputation Traumatic amputation is the partial or total avulsion of a part of a body during a serious accident, like traffic, labor, or combat. Traumatic amputation of a human limb, either partial or total, creates the immediate danger of death from blood loss.

Amputations in traffic accidents (cars, motorcycles, bicycles, trains, etc.) Amputations in labor accidents (equipments, instruments, cylinders, chain saws, press machines, meat machines, wood machines, etc.) Amputations in agricultural accidents, with machines and mower equipments. Amputations from electric shock hazard Amputations from guns, weapons, and explosives, dynamite, bombs, fireworks, etc. Amputations from violent rupture of ship rope or industry wire rope. Amputations from ring traction (ring amputation, de-gloving injuries) Amputations from building doors and car doors. Amputations from other rare accidents

Treatment

1st choice: Surgical amputation - break - prosthesis 2nd choice: Surgical amputation - transplantation of other tissue - plastic reconstruction. 3rd choice: Replantation - reconnection - revascularisation of amputated limb, by microscope 4th choice: Transplantation of cadaveric hand

Prevention Methods in preventing amputation depend on the problems that might cause amputations to be necessary. Chronic infections, often caused by diabetes or decubitus ulcers in bedridden patients, are common causes of infections that lead to gangrene, which would then necessitate amputation. Crush injuries where there is extensive tissue damage and poor circulation also benefit from hyperbaric oxygen therapy (HBOT). The high level of oxygenation and revascularization speed up recovery times and prevent infections. Lower Limb Amputations Lower body, foot amputations commonly involve toe amputations that will affect walking and balance.

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Ankle disarticulations is an amputation of the entire ankle leaving a person still able to move around without a prosthesis. Below-knee amputations or transtibial amputations involve amputations above the ankle, but below the knee. Full knee use is retained, but it is difficult for these amputees to put any weight on the remaining stump. Knee-bearing amputations involve a complete removal of the lower leg. The remaining stump is still able to bear weight but it is difficult to create a prosthesis. Above knee amputations or transfemoral amputations are amputations made at thigh level. Entire body weight cannot be borne on the stump, but a person is still able to sit upright. Hip disarticulations involves removing the entire leg bone. Surgeons will commonly leave the upper femur for stability and a place for a prosthesis to be fitted. Upper Limb Amputations Hand and partial-hand amputations including digital amputations can include fingertips and parts of the fingers. The thumb is the most common single digit loss. The loss of a thumb inhibits grasping ability. When other fingers are amputated, the hand can still grasp but with less precision. Multiple-Digit Amputations are when more than one finger is amputated, surgical procedures are used to reconstruct muscles to help aid grasping capabilities. Wrist disarticulations involves the removal of the hand at the wrist joint. Plastic sockets can now be made to serve as wrists. Metacarpal Amputations involve removing the entire hand with the wrist still intact leaving the amputee completely unable to grab. Elbow disarticulations or transradial amputation is the removal of the whole forearm at the elbow. This amputation creates a bulb shaped stump that can bear weight. Transhumeral amputation is the removal of the arm from above the elbow. Shoulder disarticulation and forequarter amputation is the removal of the entire arm including the shoulder blade and collar bone Risks of the procedure Patients with diabetes, heart disease, or infection have a higher risk of complications from amputation than persons without these conditions. Serious traumatic injury increases the risk of complications. In addition, persons receiving above-knee amputations are more likely to be in poor health; therefore, these surgeries can be riskier than below-knee amputations. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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As with any surgical procedure, complications can occur. Some possible complications that can occur specifically from an amputation procedure include a joint deformity, a hematoma (a bruised area with blood that collects underneath the skin), infection, wound opening, or necrosis (death of the skin flaps). Deep vein thrombosis and pulmonary embolism pose a risk after an amputation primarily due to prolonged immobilization after surgery. There may be other risks depending on specific medical condition. Be sure to discuss any concerns with prior to the procedure. Before the procedure

explain the amputation procedure to and offer the opportunity to ask any questions that might have about the procedure. asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear. In addition to taking a complete medical history, may perform a complete physical examination to ensure are in good health before undergo the procedure. may undergo blood tests or other diagnostic tests. asked to fast for eight hours before the procedure, generally after midnight. Notify if are sensitive to or are allergic to any medications, latex, tape, or anesthetic agents (local and general). Notify of all medications (prescription and over-the-counter) and herbal supplements that are taking. Notify if have a history of bleeding disorders or if are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for to stop these medications prior to the procedure. may be measured for an artificial limb prior to the procedure. may receive a sedative prior to the procedure to help relax. Based on medical condition, may request other specific preparation.

During the procedure Generally, an amputation follows this process: 1. 2. 3. 4. 5. asked to remove any jewelry or other objects that may interfere with the procedure. asked to remove clothing and will be given a gown to wear. An intravenous (IV) line may be started in arm or hand. positioned on the operating table. The anesthesiologist will continuously monitor heart rate, blood pressure, breathing, and blood oxygen level during the procedure. 6. A urinary catheter (thin, narrow tube) may be inserted into bladder to drain urine. 7. The skin over the surgical site will be cleansed with an antiseptic solution.

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8. To determine how much tissue to remove, the will check for a pulse at a joint close to the site. Skin temperatures, color, and the presence of pain in the diseased limb will be compared with those in a healthy limb. 9. After the initial incision, it may be decided that more of the limb needs to be removed. The will maintain as much of the functional stump length as possible. The will also leave as much healthy skin as possible to cover the stump area. 10. If the amputation is due to trauma, the crushed bone will be removed and smoothed out to help with the use of an artificial limb. If necessary, temporary drains that will drain blood and other fluids may be inserted. 11. After completely removing the dead tissue, the may decide to close the flaps (closed amputation) or to leave the site open (open flap amputation). In a closed amputation, the wound will be sutured shut immediately. This is usually done if there is minimal risk of infection. In an open flap amputation, the skin will remain drawn back from the amputation site for several days so any infected tissue can be cleaned off. At a later time, once the stump tissue is clean and free of infection, the skin flaps will be sutured together to close the wound. 12. A sterile bandage or dressing will be applied. The type of dressing used will vary according to the surgical technique performed. 13. The may place a stocking over the amputation site to hold drainage tubes and wound dressings, or the limb may be placed in traction or a splint, depending on particular situation. After the procedure In the hospital After the procedure, will be taken to the recovery room for observation. recovery process will vary depending on the type of procedure performed and the type of anesthesia that is given. The circulation and sensation of the affected extremity will be monitored. Once blood pressure, pulse, and breathing are stable and are alert, will be taken to hospital room. may receive pain medications and antibiotics as needed. The amputation site dressing will be changed and monitored very closely. Physical therapy will usually begin soon after surgery. Rehabilitation will be designed to meet the needs of the individual patient. This may include gentle stretching, special exercises, and assistance in getting in and out of bed or a wheelchair. If a leg amputation was performed, will learn how to bear weight on remaining limb. There are specialists who make and fit prosthetic devices. They will visit soon after surgery and will instruct how to use the prosthesis. may begin to practice with artificial limb as early as 10 to 14 days after surgery, depending on comfort and wound healing process. After an amputation, depending on particular situation, will remain in the hospital for several days. will receive instructions as to how to change dressing. will be discharged home when the healing process is going well and are able to take care of self with assistance. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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After surgery, may experience emotional concerns, such as grief over the lost limb or a physical condition known as phantom pain (a sense of feeling pain or sensation in amputated limb). If this is the case, may receive medications or other types of nonsurgical approaches. At home Once are home, it is important to follow the instructions given to by. Will receive detailed instructions as to how to care for the surgical site, dressing changes, bathing, activity level, and physical therapy. Take a pain reliever for soreness as recommended by. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications. Notify to report any of the following:

Fever and/or chills Redness, swelling, or bleeding or other drainage from the incision site Increased pain around the amputation site Numbness and/or tingling in the remaining extremity

may resume normal diet unless advises differently. Following an amputation, may give additional or alternate instructions after the procedure, depending on particular situation. Long-term care There have been many advances over the past several years in the surgical techniques performed, postoperative rehabilitation, and prosthetic design and development. Proper healing and fitting of the artificial limb help to reduce the risk of long-term medical complications. An amputation requires a process of adaptation that can be helped with physical therapy. If the amputation was the result of PAD, continued steps will need to be taken to prevent the condition so that it does not affect other parts of body. may be advised to adopt the following lifestyle modifications to help halt the progression of PAD:

Maintain a healthy diet that does not exceed daily calorie requirement and that is low in saturated fat and cholesterol. Stop smoking. Work towards achieving or maintaining an ideal body weight. Maintain a regular exercise program.

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heart complications, such as heart attack or heart failure (when the heart has difficulty pumping blood around the body) blood clots (venous thrombosis) infection at the site of the surgery pneumonia (infection of the lungs) further surgery being required

Phantom limb pain Phantom limb pain is when a person experiences sensations of pain that seem to be coming from the limb that has been amputated. The term phantom does not mean that the symptoms of pain are imaginary and all in head. Phantom limb pain is a very real phenomenon which has been confirmed using brain imaging scans to study how nerve signals are transmitted to the brain. The symptoms of phantom limb pain can range from mild to severe. Some people have described brief flashes of mild pain, similar to an electric shock, that last for a few seconds. Other people have described constant severe pain. The causes of phantom limb pain are unclear. There are three main theories:

The peripheral theory argues that phantom limb pain may be the result of nerve endings around the stump forming into little clusters, known as neuromas. These may generate abnormal electrical impulses that the brain interprets as pain The spinal theory suggests that the lack of sensory input from the amputated limb causes chemical changes in the central nervous system. This leads to confusion in certain regions of the brain, triggering symptoms of pain The central theory proposes that the brain has a memory of the amputated limb and its associated nerve signals. Therefore, the symptoms of pain are due to the brain trying to recreate this memory but failing because it is not receiving the feedback it was expecting

Treating phantom limb pain Medications Medication which may be prescribed by to help relieve pain from nerve damage or to attempt to block pain signals include:

anticonvulsants such as carbamazepine or gabapentin antidepressants such as amitriptyline or nortriptyline opioids such as codeine or morphine

Noninvasive therapy

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applying heat or cold such as using heat or ice packs, rubs and creams massage to increase circulation and stimulate muscles acupuncture needles inserted into the skin at specific points on the body thought to stimulate the nervous system and relieve pain transcutaneous electrical nerve stimulation (TENS) involves using a small electric device connected to a series of electrodes. The electrodes deliver small electrical impulses to the site of stump. TENS is thought to work by disrupting the passage of pain signals to the brain and stimulating the release of natural painkilling chemicals known as endorphins

Psychological impact of amputation Loss of a limb can have a considerable psychological impact. Many people who have had an amputation report feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one. Coming to terms with the psychological impact of an amputation is therefore often as important as coping with the physical demands. Having an amputation can have an intense psychological impact for three main reasons:

have to cope with the loss of sensation from amputated limb have to cope with the loss of function from amputated limb sense of body image, and other peoples perception of body image, has changed

Common negative emotions and thoughts experienced by people after an amputation include:

depression anxiety denial (refusing to accept they need to make changes, such as having physiotherapy, to adapt to life with an amputation) grief (a profound sense of loss and bereavement) feeling suicidal

may require additional treatment, such as antidepressants or counselling, to improve ability to cope with living with an amputation. Spinal disc herniation A Spinal disc herniation (prolapsus disci intervertebralis) is a medical condition affecting the spine in which a tear in the outer, fibrous ring (annulus fibrosus) of an intervertebral disc (discus intervertebralis) allows the soft, central portion (nucleus pulposus) to bulge out beyond the damaged outer rings. Some of the terms commonly used to describe the condition include herniated disc, prolapsed disc, ruptured disc and slipped disc. Other phenomena that are closely related include disc Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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protrusion, pinched nerves, sciatica, disc disease, disc degeneration, degenerative disc disease, and black disc. Cause Location Cervical Cervical disc herniations occur in the neck, most often between the fifth & sixth (C5/6) and the sixth and seventh (C6/7) cervical vertebral bodies. Symptoms can affect the back of the skull, the neck, shoulder girdle, scapula, shoulder, arm, and hand. The nerves of the cervical plexus and brachial plexus can be affected. Lumbar Lumbar disc herniations occur in the lower back, most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum. Symptoms can affect the lower back, buttocks, thigh, anal/genital region (via the Perineal nerve), and may radiate into the foot and/or toe. The sciatic nerve is the most commonly affected nerve, causing symptoms of sciatica. The femoral nerve can also be affected and cause the patient to experience a numb, tingling feeling throughout one or both legs and even feet or even a burning feeling in the hips and legs. Signs and symptoms Symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue that become involved. They can range from little or no pain if the disc is the only tissue injured, to severe and unrelenting neck or lower back pain that will radiate into the regions served by affected nerve roots that are irritated or impinged by the herniated material. Other symptoms may include sensory changes such as numbness, tingling, muscular weakness, paralysis, paresthesia, and affection of reflexes. If the herniated disc is in the lumbar region the patient may also experience sciatica due to irritation of one of the nerve roots of the sciatic nerve. Unlike a pulsating pain or pain that comes and goes, which can be caused by muscle spasm, pain from a herniated disc is usually continuous or at least is continuous in a specific position of the body.

Diagnosis Physical examination The Straight leg raise may be positive, as this finding has low specificity; however, it has high sensitivity. Thus the finding of a negative SLR sign is important in helping to "rule out"

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the possibility of a lower lumbar disc herniation. A variation is to lift the leg while the patient is sitting. However, this reduces the sensitivity of the test. Imaging

X-ray: Although traditional plain X-rays are limited in their ability to image soft tissues such as discs, muscles, and nerves, they are still used to confirm or exclude other possibilities such as tumors, infections, fractures, etc. In spite of these limitations, X-ray can still play a relatively inexpensive role in confirming the suspicion of the presence of a herniated disc. If a suspicion is thus strengthened, other methods may be used to provide final confirmation. Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads x-rays. It can show the shape and size of the spinal canal, its contents, and the structures around it, including soft tissues. However, visual confirmation of a disc herniation can be difficult with a CT. Magnetic resonance imaging (MRI): A diagnostic test that produces threedimensional images of body structures using powerful magnets and computer technology. It can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. It shows soft tissues even better than CAT scans. An MRI performed with a high magnetic field strength usually provides the most conclusive evidence for diagnosis of a disc herniation. T2-weighted images allow for clear visualization of protruded disc material in the spinal canal. Myelogram: An x-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces. By revealing displacement of the contrast material, it can show the presence of structures that can cause pressure on the spinal cord or nerves, such as herniated discs, tumors, or bone spurs. Because it involves the injection of foreign substances, MRI scans are now preferred for most patients. Myelograms still provide excellent outlines of space-occupying lesions, especially when combined with CT scanning (CT myelography). Electromyogram and Nerve conduction studies (EMG/NCS): These tests measure the electrical impulse along nerve roots, peripheral nerves, and muscle tissue. This will indicate whether there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether there is another site of nerve compression. EMG/NCS studies are typically used to pinpoint the sources of nerve dysfunction distal to the spine.

Treatment Initial treatment usually consists of non-steroidal anti-inflammatory pain medication (NSAIDs), but the long-term use of NSAIDs for patients with persistent back pain is complicated by their possible cardiovascular and gastrointestinal toxicity. An alternative often employed is the injection of cortisone into the spine adjacent to the suspected pain generator, a technique known as epidural steroid injection.

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Epidural steroid injections "may result in some improvement in radicular lumbosacral pain when assessed between 2 and 6 weeks following the injection, compared to control treatments." Rehabilitation, physical therapy, anti-depressants, and, in particular, graduated exercise programs, may all be useful adjuncts to anti-inflammatory approaches. Indicated 1. Patient education on proper body mechanics 2. Physical therapy, to address mechanical factors, and may include modalities to temporarily relieve pain (i.e. traction, electrical stimulation, massage) 3. Non-steroidal anti-inflammatory drugs (NSAIDs) 4. Oral steroids (e.g. prednisone or methylprednisolone) 5. Epidural cortisone injection 6. Intravenous sedation, analgesia-assisted traction therapy (IVSAAT) 7. Weight control 8. Tobacco cessation 9. Lumbosacral back support 10. Spinal manipulation: Moderate quality evidence suggests that spinal manipulation is more effective than placebo for the treatment of acute (less than 3 months duration) lumbar disk herniation and acute sciatica. Surgical Surgical options

Chemonucleolysis - dissolves the protruding disc IDET (a minimally invasive surgery for disc pain) Discectomy/Microdiscectomy - to relieve nerve compression Tessys method - a transforaminal endoscopic method to remove herniated discs Laminectomy - to relieve spinal stenosis or nerve compression Hemilaminectomy - to relieve spinal stenosis or nerve compression Lumbar fusion (lumbar fusion is only indicated for recurrent lumbar disc herniations, not primary herniations) Anterior cervical discectomy and fusion (for cervical disc herniation) Disc arthroplasty (experimental for cases of cervical disc herniation) Dynamic stabilization Artificial disc replacement, a relatively new form of surgery in the U.S. but has been in use in Europe for decades, primarily used to treat low back pain from a degenerated disc. Nucleoplasty

Surgical goals include relief of nerve compression, allowing the nerve to recover, as well as the relief of associated back pain and restoration of normal function. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Complications

Cauda equina syndrome Chronic pain Permanent nerve injury Paralysis Erectile Dysfunction

Rehabilitation Rehabilitation of a herniated disc varies greatly upon a patients condition. Major factors taken into consideration are the patients pain threshold and severity of injury. Degree of injury ranges from some minor discomfort to immense pain that causes movement restrictions *. Possible sciatica symptoms are also taken into account when discussing a patients discomfort and should always be considered for possible MRI investigation. Electrostimulation A module of rehabilitation is electrostimulation which is commonly used in the physical therapy field. Electrostimulation therapy includes placement of electrode pads proximal to the strained or weakened erector spinae surrounding the herniated disc. Laser Light Therapy Laser light therapy is a light utilizing module with an instrument that emits the therapeutic light directly onto the injured area. Ultrasound Therapy Ultrasound is similar to laser therapy in its direct application to damaged tissues but utilizes vibrations in a crystal-containing handheld unit. Hot/Cold Therapy A general form of therapy is the use of ice packs and heat packs which are usually wrapped in a towel and applied directly. Prevention Because there are various causes for back injuries, prevention must be comprehensive . Back injuries are predominant in manual labor so the majority low back pain prevention methods have been applied primarily toward biomechanics Prevention must come from multiple sources such as education, proper body mechanics, and physical fitness. Education

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Education should emphasize not lifting beyond ones capabilities and giving the body a rest after strenuous effort. Over time, poor posture can cause the IVD to tear or become damaged. Striving to maintain proper posture and alignment will aid in preventing disc degradation. Exercise Exercises that are used to enhance back strength may also be used to prevent back injuries. Back exercises include the prone press-ups, transverse abdominus bracing, and floor bridges. Abdominal bracing protects against joint and disc injury. If pain is present in the back, it can mean that the stabilization muscles of the back are weak and a person needs to train the trunk musculature. Lumbar (Intervertebral) Disk Disorders Lumbar (intervertebral) disk disease is a frequent source of low back pain. Bulging, protruding, extruding, or sequestered disks can result in lumbar disk disease. Signs and symptoms

Sharp (rather than dull) pain Typically, bilateral pain located at the posterior belt line Referred pain rather than radicular Usually preceded by multiple episodes of less severe low back pain Localized to the lower back and gluteal area Pain with flexion, rotation, or prolonged sitting or standing Pain relieved in a recumbent position Pain of sudden onset or gradual onset after injury

Diagnosis Examination in a patient with suspected lumbar (intervertebral) disk disease may feature the following:

Abnormal gait Abnormal postures Decreased lumbar range of motion Positive straight leg raising test: Indicative of nerve root involvement Usually negative nerve root stretch test results

Perform the usual motor, sensory, and reflex examinations (including perianal sensation and anal sphincter tone when appropriate). It is also mandatory to perform a careful abdominal and vascular examination. Testing

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Laboratory tests are generally not helpful in the diagnosis of lumbar disk disease. For an otherwise healthy individual, unless the patient is immobilized completely by the pain and requires admission or the pain has been present for more than 6 weeks, diagnostic studies are not recommended.

Complete blood count with differential Erythrocyte sedimentation rate Alkaline and acid phosphatase levels Serum calcium level Serum protein electrophoresis

Imaging studies

Magnetic resonance imaging: Imaging modality of choice Computed tomography scanning: Useful but less sensitive than MRI Myelography: May provide definitive diagnosis itself, but technique is invasive Plain lumbar films: Generally not helpful in the diagnosis, except to rule out other diseases and to evaluate for possible skeletal etiology as the cause of the patient's symptoms Bone scanning: To rule out tumors, trauma, or infection

Management Pharmacotherapy Salicylates, acetaminophen, and nonsteroidal anti-inflammatory drugs appear about equally effective for the treatment of pain from lumbar disk disease. Opioids provide very effective acute pain relief, but they should not be used in patients with chronic pain. Muscle relaxants such as benzodiazepines, methocarbamol, and cyclobenzaprine are not only of limited use but also sedating. Nonsteroidal anti-inflammatory drugs such as the following may be used in patients with lumbar (intervertebral) disk disorders to reduce pain and inflammation:

Ibuprofen Ketoprofen Flurbiprofen Naproxen

Surgical option Patients with lumbar disk disorders who have not had a response with 6 weeks of conservative therapy may consider surgical intervention, such as the following: Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Discectomy Spinal fusion Injection of chymopapain

FRACTURE
Fracture : fracture is defined as the break in the continuity of the bone results from direct or indirect force impact or stress, or trivial injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, bone cancer, or osteogenesis imperfecta Risk factors and causes of fracture: 1) Mechanical and traumatic causesa) Road side accidents b) Violence c) Falls d) Sports 2) Diseases of musculoskeletal system a) Osteoporosis b) Bone cancer c) Osteogenesis imperfecta d) Congenital bone defects e) Osteopenia due to steroid use 3) Dietary and Metabolic causes a) Nutritional deficiencies b) Diabetes mellitus c) Calcium, phosphorus and vitamin D deficiency d) obesity 4) Factors affecting bone mineralization a) Hormonal imbalances like parathyroid hormone and mineralocorticoids, low level of estrogen. b) Cushing syndrome 5) Developmental causes: a) Congenital weakness of bones b) Malnutrition c) Early childhood infections and diseases like poliomyelitis d) Bone deformities 6) Others: 1) Belongs to high risk groups like sportsmen, police, and army and vehicle drivers, those who are working on complex machinery. 2) Elderly persons.

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Types of fracture Open fracture: An open fracture is a fracture where the broken bone is exposed. That is dangerous because of increased chances of infection. It is also called compound fracture.

Closed fracture: Also known as simple fracture, a closed fracture is a fracture where the bone is broken, but the skin is intact.

Complete fracture: The two pieces of the bone, resulting from the fracture, completely separate from each other.

Incomplete fracture: In this, the two pieces of bone, resulting from the fracture do not completely separate from each other; the bone pieces are still joined to some extent. This happens when the crack (or fracture) does not traverse along the entire width of the bone.

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Compression fracture: A compression fracture is a closed fracture that occurs when two or more bones are forced against each other. It commonly occurs to the bones of the spine and may be caused by falling into a standing or sitting position, or a result of advanced osteoporosis.

Avulsion fracture: An avulsion fracture is a closed fracture where a piece of bone is broken off by a sudden, forceful contraction of a muscle. This type of fracture is common in athletes and can occur when muscles are not properly stretched before activity. This fracture can also because of an injury.

Stress fracture: It is a common overuse injury. It is most often seen in athletes who run and jump on hard surfaces such as runners, ballet dancers and basketball players.

Linear fracture: In this the fracture is parallel to the bone's long axis.

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Transverse fracture: In this the fracture is at a right angle to the bone's long axis.

Oblique fracture: In this the fracture is diagonal to a bone's long axis.

Spiral fracture: In this at least one part of the bone has been twisted.

Comminuted fracture: In this the fracture results in several fragments.

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Compacted fracture: In this the fracture is caused when bone fragments are driven into each other.

Greenstick or crush fracture - meaning the bone has not snapped, it's been stretched or crumpled like soft chalk. Great prognosis and common in kids.

Hairline fracture - this is a small crack in the bone from a repetitive action like running which is so tiny you may not see it on X-ray, but it hurts! This has an excellent prognosis if you give the bone a rest from repetitive injury as the damage is mild.

Pathological fracture: A pathological fracture is a fracture that occurs at a site where the bone is weakened by a pathological process.

Pathophysiology: refer table-1 Clinical manifestations: 1. Pain- pain is continuous and increase in severity until the bone fragments are mobilized. 2. Loss of function- the affected extremity cannot function properly, because the normal functions of the extremities depend upon the action of muscles and bones to which they are attached. In addition abnormal movements (false motion) may be present. 3. Deformity- displacement, angulation or rotation of the fragments in the fracture of the Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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4. 5. 6.

7. 8.

limbs causes deformity either visible or palpable that is detected when the limb is compared with the uninjured limb. Deformity can also result from soft tissue swelling. Shortening- in fracture of the long bones the shortening occurs due to contraction of muscles above and below the site of fracture. The fragments often overlap by 1-2 inches. Crepitus- when the extremity is examined with the hands, a grating sensation called crepitus is felt. It is caused by rubbing of the bone fragments against each other. Swelling and discoloration- localized swelling and discoloration of the skin (ecchymosis) occurs after fracture as a result of trauma and bleeding into the tissues. These signs may not develop for several hours after injury. Edema may occur as a result of accumulation of serous fluid at the fracture site. Tenderness- tenderness over the fracture site occurs caused by underlying injury. Neurovascular changes- it may occur due to injury to peripheral nerves. The client may complaints of numbness and tingling or has no palpable pulse distal to the fracture.

Diagnostic Evaluations: 1) History collection: collect baseline data from patient and relatives regarding clients problem. History of falls and accidents is collected in detail. Concurrent health problems eg diabetes, bone disorders etc is collected. 2) Physical examination: Normal movement of body Assess for the posture, gait, bone integrity and joint function. Assess for muscle strength and size. Assess the size shape functions of affected extremity. 3) Imaging procedure X-ray Studies- It is important in evaluating patient with fracture. It determines bone density textures, erosions and changes in bone relationship. Multiple x-rays are needed to evaluate fracture. It helps to evaluate type, severity and extent of the fracture. Computed tomography-it is used to identify the location and extent of the fracture in areas that are difficult to evaluate. It provides us a clear view of fracture site; it may be used with or without the contrast agent. MRI- It is the non-invasive technique that use magnetic field to demonstrate the abnormalities. Moreover it is used safely in pregnant women where x ray and CT scan is contraindicated. Arthrography- It is useful in indentifying tears of the joint capsule or ligaments of the bone. Complications of fracture: Early complications: Shock Fat embolism Compartment syndrome Deep vein thrombosis Pulmonary embolism

Delayed complications: Delayed union Mal union Non union Avascular necrosis of bone Complex regional pain syndrome.

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DIC

Reaction to internal fixation devices. Heterotopic ossification

Management: The goals of fracture treatment are (1) Anatomic realignment of bone fragments. (2) Immobilization to maintain realignment. (3) Restoration of function of the part. Emergency management of fracture: Immobilization of the part: immediately after injury when fracture is suspected the part must be immobilized. Splints can be applied to the affected part. Movement of the part leads to additional pain, soft tissue injury and bleeding. Neurovascular status: must be assessed as soon as possible. The part is assessed for peripheral tissue perfusion and sensation. The affected extremity should be placed on flat and comfortable fracture. Prevention of infection: in open fracture, cover the site with clean dressing. No attempt should be made to reduce the fracture. Other measures: include hospital formalities, documentation and consent, changing clothes, providing room/bed etc. Medical management: it include following aspects: Reduction Immobilization Medication Rehabilitation Reduction of fracture: Reduction of fracture means restoration of the fracture fragments to anatomical alignment and rotation. Two types of reduction are used mainly i.e. open reduction and closed reduction. The physician performs reduction as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage. Before reduction anesthesia or analgesic medications are given. a) Closed reduction: it is done by bringing bone fragments into alignment through manipulation and cast, splint or other devices are applied to immobilize the part. Reduction under anesthesia with percutaneous pins may be used. Traction may also be used for this purpose. b) Open reduction: some fractures require reduction through surgical approach. Internal fixation devices such as pins, wires, screws, plates, nails and rods are used to hold the bone fragments in position until healing occurs. Application of cast: a cast is a rigid external immobilizing device that is molded to the counters of the body. The purpose of a cast is to maintain alignment and apply a uniform pressure on the soft tissues. Immobilization: after the bone fragments have been reduced the immobilization of the part is needed until union occurs. Immobilization may be achieved by bandages, splints, casts and traction etc. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Medications: medications are of limited use in fracture and depend upon severity of fracture. The commonly used medications are analgesics, antibiotics and NSAIDS, central and peripheral muscle relaxants eg. Cyclobenzaprin, methocarbamol are also prescribed. Nutritional management: proper nutrition is an essential component of treatment. Dietary requirements of the client include ample protein 1g/kg body weight vitamins ( B,C and D) calcium, phosphorus and magnesium adequate fluid and fibres.

Surgical management: Open Reduction Internal Fixation (ORIF) Open Reduction Internal Fixation (ORIF) involves the implementation of implants to guide the healing process of a bone, as well as the open reduction, or setting, of the bone itself. Open reduction refers to open surgery to set bones, as is necessary for some fractures. Internal fixation refers to fixation of screws and/or plates, intramedullary bone nails (femur, tibia, and humerus) to enable or facilitate healing. Rigid fixation prevents micro-motion across lines of fracture to enable healing and prevent infection, which happens when implants such as plates (e.g. dynamic compression plate) are used. Open Reduction Internal Fixation techniques are often used in cases involving serious fractures such as comminuted or displaced fractures, intramedullary bone nails (femur, tibia, and humerus). Risks and complications can include bacterial colonization of the bone, infection, stiffness and loss of range of motion, non-union, mal-union, damage to the muscles, nerve damage and palsy, arthritis, tendonitis, chronic pain associated with plates, screws, and pins, compartment 3yndrome, deformity, audible popping and snapping, and possible future surgeries to remove the hardware. Closed Reduction Internal Fixation (CRIF) Closed Reduction Internal Fixation (CRIF) is reduction without any open surgery, followed by internal fixation. It appears to be an acceptable alternative in unstable displaced lateral condylar fractures of the humerus in children, but if fracture displacement after closed reduction exceeds 2 mm, open reduction and internal fixation is recommended. Current trends in fracture treatment: Electrical stimulation and pulsed electromagnetic field: it is used for facilitating in fracture healing. It acts by modifying cell mechanisms and causing bone remodeling. Bone grafts: Autografts: Bone from the same individual Allografts: Bone from a different individual

Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Nursing Management: Goal: The patient with a fracture will have no associated complications, obtain satisfactory pain relief, and achieve maximal rehabilitation potential. Nursing assessment: Assess the five Ps. , pulse, pallor, paresthesia, and paralysis are seen with all types of fractures Assess for history of the injury, presence of factors that may cause pathologic fractures (osteoporosis, osteomyelitis, neoplastic diseases, etc.). Assess presence of signs of fracture (edema, pain, loss of motion, crepitus, extremity disproportion or abnormal positioning). Assess presence of signs and symptoms of soft tissues involvement (swelling, hemorrhage, impaired sensation in the extremity). Assess extremity for presence of open fracture and severe external hemorrhage. Assess vital signs, fluid balance and urine output. Assess diagnostic tests and procedures for abnormal values. Assess routine preoperative history.

Nursing diagnosis: Acute pain related to soft tissue damage, muscle spasm secondary to bone injury as evidenced by verbal expression of pain and behavioral signs. Impaired physical mobility related to loss of integrity of bone structure, movements of bone fragments as evidenced by limited range of motion, difficulty in ambulating and crepitus. Impaired skin integrity related to skin rashes, inflammation secondary to application of fixators as evidenced by rashes, skin breakdown and redness. Disturbed body image related to stiffness, inability to perform activities, application of fixators as evidenced by reduced self concept and behavioral changes. Risk for peripheral neurovascular dysfunction related to nerve injury, penetration of bone fragments as evidenced by tingling and numbness. Risk for infection related to open wound and penetration of bone fragments secondary to open fracture as evidenced by skin breakdown, redness local discharge. Anxiety related to surgical procedure, fixation devices as evidenced by behavioral signs and verbal expressions. Knowledge deficient related to care of cast, diet and treatment regimen as evidenced by confusion, nervousness.

Rehabilitation: maintaining and restoring functions of the extremity is very important. Proper home care and care of cast is very significant in restoring functions. Active and passive exercises are indicated for the client, activities are directed from gradual progression from light movements to heavy weight bearing movements. Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.

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Prepared by kawaljit Kang, Lecturer M.Sc. Med. Surg.