9.3 Musculoskeletal Symptoms
Key Takeaways
- Pathologic fracture care starts with stabilization and pain control; radiation and surgery follow only when prognosis and goals support them.
- Bone-metastasis pain is mechanism-matched: NSAID or dexamethasone when safe, a strong opioid, and palliative radiation; bisphosphonates and denosumab are a months-of-life context, not an acute-fix-the-fracture drug.
- Dexamethasone is a bone-pain adjuvant here; the spinal cord-compression emergency pathway was already taught in Chapter 8.
- Do not stretch a pathologic femur as if it were a cramp, and do not splint a calf cramp as a fracture; baclofen or a benzodiazepine treat spasm after the bone is cleared.
- New level-specific weakness is not automatically dying; use two-person or lift transfers and never pull on a metastatic humerus.
9.3 Musculoskeletal Symptoms
Domain 3 letter F is musculoskeletal: pathologic fracture, bone pain, spasm, cramps, weakness, deconditioning, and safe movement. Spinal cord compression and the dexamethasone-plus-imaging pathway already live in Chapter 8; this section is bone metastases, the broken bone, and the transfer. Passing remains a scaled score of 500. Drugs remain generic (dexamethasone, ibuprofen, morphine, zoledronic acid, baclofen).
Pathologic fracture: stabilize first, then match treatment to goals
A pathologic fracture occurs through bone weakened by metastasis, myeloma, or severe osteoporosis. Femur, humerus, vertebrae, and pelvis are the usual hospice sites. The first nursing action is stop unsafe movement and stabilize: pillows, splint, traction as ordered, log-roll for spine, no yanking on a metastatic arm. Pain control is an opioid plus an anti-inflammatory adjuvant when organs allow (Chapter 6). Then match disease-modifying options to prognosis and goals.
- Palliative radiation therapy treats local bone pain and can reduce local tumor. For many painful bone metastases, a single fraction (commonly 8 Gy in published palliative trials) is not inferior to longer courses for pain relief and is kinder when travel is hard and life is short.
- Orthopedic surgery (intramedullary nailing of a femur, pinning, decompression) is for patients with weeks to months, adequate performance status, a lesion that hardware can actually help, and goals that include mobility or a bed-to-chair life. Oncology uses cortical-involvement and pain grading (Mirels-type thinking) to decide prophylactic fixation before the bone snaps; CHPN items more often present the bone that already failed.
- If the patient is imminently dying, surgery is not comfort. Splint, medicate before turns, and teach the family that the “repair” is positioning, not the operating room.
Bone pain: NSAID, steroid, opioid, radiation, bisphosphonate context
Osteolytic and mixed bone metastases generate prostaglandins and periosteal stretch. Mechanism-matched drugs:
- An NSAID if platelets, GI mucosa, and glomerular filtration rate can tolerate it.
- Dexamethasone when an NSAID is unsafe or when there is inflammatory bone pain or liver-capsule stretch. Chapter 8 already taught dexamethasone for cord compression; here the same steroid is a bone-pain adjuvant, not only a cord drug. New back pain plus weakness still triggers the cord pathway—do not “only treat bone pain” past a sensory level.
- A strong opioid for moderate-to-severe intensity. Incident pain around transfers needs a premedication plan, not a lecture to lie still.
- Radiation as above.
- Bone-modifying agents—zoledronic acid, pamidronate, denosumab—reduce skeletal-related events in patients with months of expected survival. They do not knit an acute fracture today. They carry renal limits (zoledronic acid), hypocalcemia, flu-like infusion reactions, and osteonecrosis of the jaw. In the last days to a short two-week hospice enrollment, starting a bisphosphonate is usually the wrong use of a visit. In a still-ambulatory patient with prostate or breast metastases and a longer palliative course, they remain part of the oncology context you should recognize.
Spasm, cramps, and the fracture-versus-spasm exam trap
Muscle spasm is involuntary contraction: after a stroke, in amyotrophic lateral sclerosis or spinal disease, around a joint, or from a pulled catheter. Baclofen, a benzodiazepine such as diazepam or lorazepam, stretching, heat, and positioning treat spasm. Cramps at night in dying or diuretic-treated patients often track potassium, magnesium, and volume; stretch the muscle, replete electrolytes when labs and goals support venipuncture, and do not diagnose a new femur fracture from a calf cramp.
The exam trap is calling a pathologic femur fracture “spasm” and stretching the leg, or calling myoclonus from opioid metabolites (Chapters 7 and 8) a “cramp” and giving more morphine.
Fracture versus spasm table
| Feature | Pathologic fracture | Muscle spasm or cramp |
|---|---|---|
| Trigger | Weight bearing, transfer, fall, or spontaneous through a known metastasis | Stretch, fatigue, electrolyte shift, upper-motor-neuron disease |
| Exam | Point tenderness, deformity, inability to bear weight, shortened or rotated limb | Palpable tight muscle, no bony deformity, often relief with stretch |
| Wrong move | Transfer without stabilization; “walk it off” | Splinting a cramp as a femur and withholding stretch forever |
| Right move | Stabilize, opioid plus NSAID or steroid if safe, radiation or surgery if goals | Stretch, heat, baclofen or benzodiazepine, electrolytes, treat the neurologic cause |
| Related look-alikes | Cord compression (weakness, sensory level, bowel or bladder change)—Chapter 8 | Opioid myoclonus (multifocal jerks)—rotate the opioid, do not stretch a fracture |
Weakness versus dying
Weakness is not automatically “they are dying.” Reversible or semi-reversible causes the CHPN registered nurse is expected to name: cord compression, hypercalcemia, anemia, hypokalemia, steroid myopathy (proximal, after prolonged dexamethasone), infection, and deconditioning. Global decline with mottling, Cheyne–Stokes respirations, cool extremities, and decreasing consciousness is the dying process (Chapter 4). Treating dying as a potassium problem delays comfort; treating cord compression as “just dying” misses a last window for dexamethasone and radiation.
Deconditioning and activity intolerance are Domain 3-F items too: energy conservation, therapy when goals include function, and not promising a gym program to a patient whose trajectory is days. Immobility still produces pressure injury (Chapter 10), constipation, and retention; the musculoskeletal add-on is do not cause the next fracture on the way to preventing a pressure injury.
Safe transfers
Assume every patient with known bone metastases has a weight-bearing restriction until the team says otherwise. Use a gait belt only if the bone can take it; many hospice transfers need a two-person assist or a mechanical lift. Do not pull on the arms of a patient with humeral metastases. Log-roll spinal disease. Premedicate for incident pain before the move. Teach family that a cracked femur is not a failure of love—it is diseased bone—and that the next transfer will be planned, not hurried.
A hospice patient with a known femoral metastasis hears a snap during a transfer, the thigh is rotated, and the patient cannot bear weight. What is the correct sequence?
Which statement about metastatic bone pain is the one CHPN Domain 3-F expects?
A patient with spinal metastases has new bilateral leg weakness. Another patient with a calf cramp after diuretics has no bony deformity. Which pairing is correct?