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Medical Surgical Nursing - Musculoskeletal Disorders
1. Musculoskeletal Disorders
Physiology
Functions
- Provide protection for vital organs
o Bones – ribs, sternum, thoracic vertebrae
o Muscles – internals and intercostal muscles, diaphragm
- Support body structures by providing a strong and sturdy framework
- Locomotion and movement
- Mineral storage
o For metabolism
o 99% of the total calcium content of the body is located in the bone
- Haematopoiesis
o RBC and WBS are produced according to their nature stem cells
- Heat production
o Through contraction = contain and control heat inside the body
Anatomy
- 206 bones in total
- Classified according to their location
o Axial (80)
Skull
Vertebral column
o Appendicular (126)
Pectoral girdle
Scapula
Clavicle
Radius
Ulna
Pelvic girdle
Iliac
Ischium
Femur
- Basic Cell types
o Osteoblasts- the CARPENTER
Bone formation
Made possible through the secretion of matrix – calcium is the main
component
Initiates bone formation via calcification
Process where there is mineralization of the collagen fiber
MATRIX and CALCIUM – THE CEMENT; THE FOUNDATION
o Osteocytes – MAINTAINS THE HOUSE
Mature type of the osteoblasts
Main cell found in the bone
Maintenance of bone
Excretion of waste materials
Is found inside the spaces called lacunae
2. o Osteoclasts – THE ANAYS (THE ONE THAT DESTROYS THE HOUSE)
Huge cells derived from the fusion as many as 50 monocytes
Usually concentrated at the endosteum of the bone
Endosteum – at the lumina area, where the medullary cavity is
For bone resorption: bone destruction or bone remodelling
Bone destruction
Ca is removed
- According to General Features
o Long Bone
Longer than they are wide
Upper and lower limbs
Humerus and Femur
o Short Bones
As broad as they are long
Wrist and Ankle
o Flat Bones
Relatively thin; flattened shape
Certain skull bones, ribs, scapulae (shoulder bones, blades and sternum)
o Irregular
Do not fit readily into the other three categories
Vertebrae and facial bones (mandible, maxillary, zygomatic arch, among others)
o Each long bones consists of a central shaft called diaphysis
o While the two ends is called epiphysis
o A thin layer of the articular cartilage covers the end of the epiphyses where the bone articulates
with other bones
o A long plate that is still growing has an epiphyseal plate or growth plate, composed of cartilage,
between each epiphyses and the diaphysis
o Bones contain cavities such as the large medullary cavity in the diaphysis, as well as smaller
cavities in the epiphyses of long bones and in the interior of other bones
o These spaces are filled with either yellow ro red marrow
o Marrow
The soft tissue in the medullary cavities
o Yellow marrow
Consists of mostly fat
o Red marrow
Blood forming cells and is the only site of blood formation in adults
o Most of the outer surface of the bone is covered by dense connective tissue called periosteum
which contains blood vessels and nerves
o The surface of the medullary cavity is lined with a thinner connective tissue membrane called
endosteum
o The periosteum and endosteum contain osteoblasts which function in the formation of bone as
well as the repair and remodelling of the bones
o When osteoblasts become surrounded by matric, they are referred to as osteocytes
o Bones is formed in thin sheets of extracellular matrix called lamellae, with osteocytes located
between the lamellae
o The osteocytes are located with spaces called lacunae
o Cell processes extend from the osteocytes across the extracellular matrix of the lamellae with
tiny canals called canaliculi
Histological Structure
- Compact Bone
o Forms most of the diaphysis of long bones and the thinner surfaces of all other bones
3. o Most of the lamellae of compact bone are organized into sets of concentric rings with each set
surrounding a central or haversian canal
o Blood vessels that run parallel to the long axis of the bone are contained within the central canals
o Each canal with the lamellae and osteocytes surrounding it is called osteon or haversian system
o Each osteon looks like a microscopic target with the central canal as the bull’s eye
o Osteocytes located in lacunae are connected to one another by cell process in canaliculi
o The canaliculi give the osteon the appearance of the having tiny cracks in lamellae
- Cancellous Bone
o Spongy bone because of its appearance
o Located mainly in the epiphyses of long bones and it forms the interior of all other bones
o Consists of delicate interconnecting rods or plates of bone called trabeculae which resemble the
beams of scaffolding of a bulding
Articulations
- The site where bones meet with each other
- Joints
o Synarthrosis (sutures)
o Ampiarthrosis (vertebral and pelvic)
o Diarthrosis (maximum movement)
o Fibrous (sutures area: coronal, frontal, sagittal), cartilaginous and synovial
o Prevent direct contact to two opposing bones
o Provides gliding motion
o Shock absorption
o Bursa – sock filled with synovial fluid; important for shock absorption
o Position and movement of bones
Ligaments – retinaculum (hands)
Tendon- structures that connects /attach muscles to bones
o Specific Types
Fibrous joints
Consists of two bones that are united by fibrous tissue and exhibit little or no
movement
Sutures
o Fibrous joints between the skull
Gomphoses
o Consists of pegs fitted onto sockets and held in place by ligaments
Cartilagenous Joints
Untie two bones by means of cartilage. Only slight movement can occur at
these joints
Fibrocartilage
o Is a type of cartilage that reinforces by additional collagen fibers. It is
the kind of cartilage where much strain is placed on the joint
Synovial Joint
Freely movable joints that contain synovial fluid in a cavity surrounding the
ends of articulating bones
Articular Cartilage
o Provides a smooth surface where the bones meet
Joint Cavity
o Filled with synovial fluid
Joint Capsule
o Helps hold the bones together and allows movement
Synovial Membrane
4. o Produces synovial fluid
Bursa
Diarthrosis joint
Plane of gliding joints
o Joints in carpal bones
Saddle Joints
o Joints at the base of thumb
Hinge joints
o Elbow and knee joint
Pivot Joint
o Radius and ulna
Ball and socket
o Hip and shoulder
o Functions
Prevents direct contact btw two end bones
Allow gliding or sliding motions
Absorb shock
o Bone Maintenance and Healing
Regulatory factors determining both formation and resorption
Physical activity
Diet
Calcitonin
o For bone mineralization; stimulated if px is hypercalcemic
Parathyroid hormone
Thyroid hormone
o Hyperthyroidism = bone dimineralization
Cortisol
Growth hormone
Sex hormones
o Dec Estrogen = bone deminiralization = osteoporosis
Weight bearing stress stimulate local bone formation and resorption; in mobility, where
weight bearing is prevented, Calcium is lost in the bone
Vit. D promotes absoption of calcium from the GI and accelerates
Vit D – maintain increase Serum Ca levels
Types
Intramembranous
o Compact bone
Endochondreal
o Cancellous
Bone marrow osteoblast
Bone cortex osteon
Periosteum hard callus is formed (intramembranous)
Cartilage endochondrial ossification
Phases
Reactive
o Hematoma/recruitment of inflammatory cells. Angiogenesis and
granulation
Reparative
o Pre-callus precursor (3-4 weeks)
Remodelling
o Nursing Consideration
Age
5. Very young = immature bones give all supplements to promote bone growth
Very old = osteoporosis quite at risk for fractures consider displacement
and site of fracture
Displacement of fracture
Site of fracture
Nutritional level
Blood Supply to the area of injury
CAN AFFECT TIME REQUIRED FOR BONE HEALING
Anatomy of Muscular System
- 3 Types
o Smooth
Found in the hollow organs of the body
Eg. Stomach (capable of mixing waves), small and large intestine, airways
(capable of peristalsis), blood vessels
Slightly striated
involuntary
o Skeletal
Striated because of the alternating lines myocinand myofilaments
Voluntary
Lower neurons control the activity of the skeletal muscles
Energy is consumed when the skeletal muscles contract in response to stimulus
Lactic Acid
By-product of muscle metabolism when O2 available to cell is not sufficient
Muscle fatigue results from increased work of the muscle
o Depleted glycogen and energy stores
o Accumulation of lactic acid muscle cramps
o Cardiac
Exclusively found in the myocardium
Intercalated disks
gives automaticity
involuntary
- types of Muscle Contraction
o Isometric Contraction
Length of muscle remains constant but the force generated is increased
o Isotonic Contraction
Shortening if muscles, but no increase in muscle tension
- Muscle Tone
o Flaccid (Limp)
o Spastic
o Atonic (soft and flabby – px who are post-stroke)
- Muscle Action
o Prime Mover
Deltoid muscle
o Synergist
Same actions
Biceps
o Antagonist
Biceps
- Types of motions
o Flexion
o Extension
6. o Abduction
o Adduction
- Older Adult Care Focus
o Decreased bone density (most are osteoporotic)
Ensure safety
o Decreased in subcutaneous tissue less soft tissue over bony prominences
o Degenerative changes in the spine alter posture and gait
o Degenerative changes in cartilage and ligaments leads to decreased movement of joints
o ROM decreases
o Slowed movements and decreased muscle strength
Assessment
- Health history
- Past health, social and family history
- Physical Assessment
o Posture: Kyposis (forward curvature of the thoracic spine), lordosis (lumbar), scoliosis (lateral
curvature)
o Gait
o Bone integrity (crepitus)
o Joint function (contracture, dislocation, subluxation)
o Muscle strength and size (clonus/fasciculation)
o Skin
o Neurovascular status (circulation, motion, sensation)
Laboratory/Diagnostic Tests
- Blood Tests
o ESR (elevated in SLE and arthritis)
o Rheumatoid factors (+ in rheumatoid arthritis)
o Lupus erythematosus cells (LE Cells)
o Antinuclearantibodies (ANA) (+rheumatoid arthritis)
o Anti-DNA (+ in SE)
o C – Reactive protein (
o Minerals
Calcium
Decreased levels in osteomalacia, osteoporosis
Increased in levels in bone tumors, healing fractures, Paget’s disease
Alkaline Phosphatase
Elevated levels in bone cancer, osteoporosis, osteomalacia, Paget’s
disease/metastatic ca (acid phosphatase)
Phosphorous
Increased levels in healing fractures, bone tumors
o Muscle Enzymes
Aldolase
Elevated in muscle dystrophy, dermatomyositis
AST
CK (Creatine Phosphokinase)
Elevated in traumatic injuries
LDH (Lactic Dehydrogenase)
Elevated in skeletal muscle necrosis, extensive cancer
- X-Rays (Roentgenography)
- Bone Scan
7. o Measures radioactivity in bone 2 hours after IV injection of radio isotope; detects bone tumors,
osteomyelitis
o Nursing care:
Patient must void immediately before procedure
Determine allergies
Patient must remain still during scan
- Arthroscopy
o Insertion of fiberoptic scope into a joint to visualize it, perform biopsies or remove loose bodies
o Performed in OR under sterile technique
o Nursing care:
Pressure dressing for 24 hours
Patient must limit activity for several days
Assess neurovascular status
- Arthrocentesis: removal or synovial fluid, blood or pus from a joint
- Myelography
o Lumbar puncture used to withdraw a small amount of CSF, which is replaced with a radiopaqued
dye; used to detect tumors or herniated intervertebral discs
o Nursing care:
Consent must be signed
Check for iodine allergy
Keep NPO after liquid breakfast
o Nursing care post test:
If dye has been completely removed (oil dye), keep patient flat for 12 hours
If dye has not been completely removed (water based dye – Amipaque), keep head of
bed elevated (30- 45) to prevent causing meningeal irritation and seizures.
If water based dye is used , put patient on seizure precaution and do not
administer any phenothiazine drugs (or any sedating drug to assess the level of
consciousness)
- CT Scan and MRI
o CT Scan – tumors
o MRI – any lesions concerning the posterior fossa
- Electromyography(EMG) – Lower motor neuron/Peripheral nervous system
o Measures and records activity of contracting muscles in response to electrical stimulation; helps
differentiate muscle disease from motor neuron dysfunction.
o Explain procedure to patient and prepare him for discomfortof needle insertion
Traumatic Injuries
Open type bone fracture – has a communication with the environment which orgs can enter osteomyelitis
- Strain
o Is an injury to the muscle when it is stretched or pulled beyond its capacity
o Common cause: overstretching
- Sprain
o Is injury to the ligaments surrounding a joint
o Common cause: over twisting
- Contusion
o Soft tissue injury with ecchymosis or bruising
o Common cause: blunt force
o Head trauma
o Opening concussion
Grading
- First Degree
8. o Mild stretching
o s/sx:
minor edema
tenderness
mild muscle spasm
o requires immobilization and NSAIDS
- Second Degree
o Partial tearing
o s/sx:
loss of load bearing strength
edema
tenderness
muscle spasm
ecchymosis
related to the partial tearing, expect blood vessel involvement
o requires surgical intervention
- Third Degree
o Sever damage with complete rupturing or tearing
o s/sx:
severe pain
tenderness
increase edema
abnormal motion
o requires surgical intervention
General Nursing Management:
R – rest
- immobilize patient
- check for neurovascular integrity (pulse, sensation and movement)
I – ice
- first 24 hrs, use Ice (vasocontrict blood vessel = minimize s/sx). After 24-48 hours, use warm compress
(absorb any ecchymosis/hematoma that accumulated because of vasodilation)
C – compress
E – elevate
Carpal Tunnel Syndrome
- compressed median nerve by the transverse carpal ligament (wrist)
- involves thumb, portion of the ring finger, middle finger and pointer finger
- causes:
o repetitive and constant flexion of the wrist
- s/sx:
o paresthesia
o muscle weakness
o “clumsiness” when using the hand
o PAIN
- Diagnosis:
o (+) Tinel’s Sign
o (+) Phalen’s Test
- Nursing management
o Goal no. 1: to prevent further compression of the nerves
Rest hands
Avoid excessive use of involved hand
Instruct patient not to sleep over the involved hand
9. Administer medication as ordered
NSAIDS
o Goal no. 2: to prevent injury
Instruct patient to wear gloves
- Medical Management:
o Analgesics
Minimize/relief pain
ASA (acetylsalicylic acid / aspirin)
NSAIDS
Taken with full stomach can cause hyperacidity
o Corticosteroids
Oral Prednisone
- Surgical Management:
o Carpal tunnel release
Fracture
- Is a break in the continuity of a bone
- Occurs when the bone is subjected to stress greater than it can absorb
- Mechanical overload to the bone
- Causes:
o Direct blows
vehicular accidents
o Crashing forces
o Sudden twisting motions
o Extreme muscle contractions
- Types
o According to skin involvement
Open / Compound
Communication to the skin
Seriousness depends to the degree of opening
Infection and bleeding
Closed / Simple
Patient just need to be immobilized
o According to Breaks
Complete
Up to the shaft
Incomplete
Linear break
o According to Line
Comminuted
Different angles
Greenstick
One side is fractured, other side is uninjured
Spiral/Torsion
Linear fracture that twisted
Transverse
Oblique
Can reach the skin
Impacted
Related to the skull and vertebrae
Depressed
Compression
10. Pathological/Spontaneous
Common to osteoporotic or malignancy of the bone
o Intracapsular and Extracapsular Hip Fracture
Require fixation
- Clinical Manifestation
o Pain
o Muscle spasm
There will be injury to the nerves
Nerves and blood vessels are located in the periosteum
o Loss of function
Particularly if complete fracture and it is an open type
o Deformity
o Shortening
Extremity and limb because of the muscle spasm
o Swelling and discoloration
o Crepitus / crepitations
Particularly of the joint area is involved
o Localized edema and ecchymosis
- Diagnostic tests
o Radiography /x-ray
fastest
o CT Scan
cranium
o MRI
Posterior fossa (brain stem, vertebra)
- Goal of interventions:
o To prevent further damage
Immobilization
Support extremity
Provide adequate splinting
Control bleeding
Leads to compartment syndrome
Check peripheral pulses distal to the injury
Cover wound with sterile or cleanest material available
To control / prevention osteomyelitis
- Medical management:
o Reduction
Closed
Casting, traction, manual manipulation
Open
Requires sterile area surgical procedure
2 types
o Open reduction with internal fixation (ORIF)
o Open reduction with external fixation (OREF)
At risk for infection
Complication for external fixator:
Infection
o Staph areus
o Nursing management:
Asses for redness, tenderness,
pain, swelling, and loosening of
pins.
11. Prevent crust formation
- Nursing management:
o Closed fracture
Instruction on control of pain and edema
Use assistive device properly
Modify environment to provide safety
Self-care
o Open fracture
Risk of osteomyelitis (give antibiotics as ordered), tetanus (toxoids (preformed
antibodies and immediate protection) and vaccines), gas gangrene (clostridium tetani)
IV Antibiotics
Delayed primary wound closure
Elevate to minimize edema
Neuromuscular assessment
CMS (circulation, motion and sensation)
- Fracture Healing and Complication
o Early
Hypovolemic Shock
Femur femoral artery (is a very pulsatile artery, direct to the abdominal
aorta common iliac); high pressure
Resulting to massive bleeding
o Give fluids
o Blood transfusion
Fat Embolism ( 40 y/o, Male, multiple fracture)
Sx: sudden hypotension, sudden dyspnea
Compartment Syndrome
Sudden decrease in blood flow distally (PAIN)
Majority of the compartments of the body is found in the extremities
Venous Thromboembolism
DIC (Disseminated Intravascular Coagulopathy)
Decrease in platelet
o Delayed
Delayed Union
Malunion
Nonunion
o Nursing Management:
Pain control
- Fracture of Specific Sites
o Clavicle (Collar Bones): Middle 3
rd
of the clavicle
Figure of eight bandage
o Humerus (shaft or neck)
o Elbow: Supracondylar fracture of the humerus (Volkmann’s contracture)
Assess volkmann’t contracture
o Radial head: fall on an outstretched hand
o Radial/Ulnar shaft: common among childen
o Distal Radius (Colles Fracture): Open dorsiflexed hand, commonly in elderly
o Pelvic: rule out other internal damage because of the proximity of the two structures
o Femoral shaft: fall or motor vehicle crash
o Thoracolumbar spine: vertebral body, laminae, and articulating process, spinous process
Osteomyelitis
- Infection of the bone; Staphylococcus Aureus
12. - Haematogenous spread (infection elsewhere then septecemia then to the bone) / direct trauma / VI
- Acute / Chronic osteomyelitis
- Risk factors:
o Age
o Nutrition
o Blood vessels involvement
o Immune system
o Co morbidities (CM)
- Infection sets in inflammatory reaction (pain, swelling, heat) causes devascularisation of the bone,
bone ischemia and necrosis
- Sequestrum (cavity with abscess) abscess will be necrotic debris - necrotic bone tissue encased by
involucrum
- Pathologic fractures can occur
- Only when all dead bone tissue is removed will full healing occur
o Require surgical intervention
- Pathophysiology
o Risk factors: Acute OM inflammation (Increase vascularity and edema) 2-3 days:
thrombosis (ischemia then necrosis) medullary area and periosteum involvement
sequestrum (abscess cavity) surrounded by new bone growth: involucrum (new bone
growth) recurring abscess chronic osteomyelitis
- Assessment and Diagnostic
o Isotope labelled WBC, MRI
o X-ray: tissue edema
2-3 weeks: periosteal elevation and bone necrosis
Chronic OM: large irregular cavities, raised periosteum, sequestra, dense bone
formation
Blood culture
On two different sites
- Interventions
o Administer antibiotics
o Debridement / incision and drainage
o Antibiotic beads
Made up of Ca
Little to no systemic effect
Advantage: it is absorbed while being replaced by new bones. No need for grafting
anymore
o Sequestrectomy
o Saucerization
o Bone grafting/muscle flap
CAST
- A rigid external immobilizing device that is moulded to the contour of the body
- Purpose:
o To immobilize a reduced fracture
o To maintain body alignment
o To correct deformity
o To apply uniform pressure to underlying soft tissue
o To support and stabilize weakened joints
- When casting a joint, include the proximal as well at the distal area to stabilize the injured site / extremity
Types of Casting Materials
- Plaster of Paris
o Traditional cast
13. o Rolls of plaster bandage are wet in cool water and applied smoothly to the body
o Heavy and has a rough surface
o Crystallization: rigid dressing 15-20 mins
o Exposed to circulating air to dry
o Disadvantage: absorbs moisture
Avoid in water contact
o Complete dryness: 24-72 hours after application
No not cover with towel
o Lest costly
o Achieved a great mold; less durable (compared to fiber glass)
o Exothermic characteristic
When you apply it, it exclude heat and warm
Hindi nagkakaroonng panic o anxiety ang patient
DRY WET
Appearance White and shiny Grey
Percussion Resonant Dull
Odor Odourless Musty
Texture Firm, hard and rough Damp to touch
- Non –Plaster / Synthetic Cast
o Fiber Glass
Water activated polyurethane materials, lighter in weight, stronger and more durable
Lightweight and has smooth surface
Should never be exposed to any plastic surface (it will get deformed) because it is hot
Inform patient to prevent anxiety or panic attack
Make sure to prevent they are placed in edges or corner to prevent denting of the fiber
glass
Avoid denting any disfigurement to the fiber glass could lead to skin
irritation or breakage/lesion
Water-prof lining (Gore-Text)
Complete dry: 24-72 hours
o Splints
Used for conditions that do not require rigid immobilization
Expect swelling
It can be easily removed
Require special skin care
Overwrapped with an elastic bandage applied in spiral fashion
Short term in use
o Braces
Provide support, control, movement and prevent additional injury
Cervical brace, collar
Custom fitted to various parts of the body
Expensive
Indicated for longer use (at least 8 years)
Short Arm Cast
Long Arm Cast
- Elbow is at a right angle
Short Leg Cast
- Knee down to the sole/base of the toe
- Foot is at a right angle, neutral position
14. Long Leg Cast
- Extends from the upper, middle third of the thigh to the base of the foot
- Knees slightly flexed
Walking Cast
- Long and Short
- To re-enforce strength
Body Cast
- Encircles the trunk
Spica Cast
- At least two types:
o Shoulder
Body jacket that encloses the trunk, shoulder and elbow
o Pelvic
Shoulder, lower extremity (one or both)
Nursing Management
- Carry cast with palms of the hands when WET
- Elevate with pillow support
- Expose to dry environment
- Keep clean and dry
- Observe for signs of inflammation then infection
- Maintain skin integrity
- Neurovascular assessment meticulously and regularly
- Move patient every 2 hours (patient with body casts) to relieve pressure
- In turning, use of trapis or railings can be done
CAST SYNDROME
- Due to immobilization
- Decrease gastric mobility accumulation of air in the stomach and lung bloated patient gastric
acid reflux, constipation abdominal distention anorexia
COMPARTMENT SYNDROME
- Increase in pressure in a confined space there is decrease blood flow affecting important structures
such as blood vessels and nerves
- Asses neurovascular status
o Peripheral pulses
o Motion
o Sensation
- 5 P’s
o Pain – primary symptom
o Pallor
o Pulselessness
o Paresthesia
o Paralysis
- Management
o Assess neurovascular status
o Elevate the affected limb to the level of the heart
To minimize edema (normal reaction of body against trauma)
- Surgical Intervention
o Fasciotomy (opening of the fascia to relieve the pressure)
o Remove the tight cast or dressing
o Bivalving/Use of posterior mold
15. PRESSURE ULCERS
- Take note of the body prominence
- Inform patient that they should inform you if there is pain or tightness in the area
DISUSE SYNDROME
- Muscle atrophy and loss of strength
- Tense or contract muscle (isometric contraction) without moving the part
TRACTION
- Application of the pulling forces
- Short term intervention
- Purposes
o To reduce, align and immobilize fractures
o To minimize muscle spasms
o To reduce deformity
o To increase space between opposing surfaces
- Principles
o Continuous to be effective
o Never interrupted
o Weight are not removed unless it’s an intermittent traction
o Eliminate any factor that may reduce its effectively
o Good body alignment in the center of the bed
o Ropes must be un obstructed
o Weight must hang freely
o Knots in the ropes or foot plates must not touch the pulley or foot of the bed
- Types
o Straight or Running Traction
Applies the pulling force in a straight line with body part resting on the bed (Buck’s
Traction)
o Balance Suspension Traction
Supports the affected extremity off the bed and allows some movement without
disruption of the line of pull
Another Types
- Skin Traction
Buck’s Extension Traction (leg)
Indication: femur / hip involvement
Simplest form of traction
o Russel’s Traction
Indication: Femur/hip joint fracture
Incorporates the use of knee sling
Hip is flexed to 20 degrees from the mattress
o Bryant’s Traction
Indication: children with congenital Hip dislocation
For children below 2-3 years
For children weighing less than 30-40 lbs
N/R:
buttocks should not touch the mattress
assess neurovascular status of the lower extremity
o capillary refill
o Cervical Traction
Indication: cervical spine fracture
Make use of a cervical halter or cervical lining
16. HOB is elevated to 30-40 degrees
o Pelvic Traction
Indication: pelvic bone fracture
Used for lumbar fracture
Make use of a pelvic halter
Supine position
- Skeletal Traction
o Weights are attached directly to the bone
o Make use of pins, screws, wires or tongs
o At risk for osteomyelitis
o Balanced Suspension Traction
Make use of Thomas Splint with Pearson Attachment
Part of the body is off the bed
Hips are fixed 30 degrees
Care of pin site:
Clean with antiseptic
Apply antibiotic
No betadine rust pins
No peroxide aerobic infection
Nursing management
Principles of Effective Traction
o Continuous to be effective
o Never interrupted
o Weights are not removed
o Observe food body alignment
o Ropes must be unobstructed
Complications
o Atelectasis (inability of the patient to do deep breathing exercises) and
Pneumonia
Auscultate the lungs q 4-8 hours
Deep breathing and coughing exercise
o Constipation and anorexia
Diet must be high fiber and increase fluids
Stool softener as prescribed
Improve appetite
o Urinary Stasis and Infection
Observe the characteristic of the urine
Monitor fluid intake
Monitor s/sx of infection
Hesitancy
Urgency
Frequency
Dysuria
o Venous Thromboembolism
Exercise muscles not in traction to prevent deterioration,
deconditioning and venous stasis
Monitor for tenderness, warmth, redness and swelling
Check for Homan’s Sign
Fat Embolism
- An embolism originating in the bone marrow that occurs after a fracture
- Usually occurs 48 hours after a fracture and clients with long bone fractures are more at risk
- Restlessness, changes in LOC, tachycardia, tachypnea, dyspnea, petechial rash over upper chest
17. - Nursing Interventions
o Immediate Mobilization
o Minimal fracture manipulation
o Adequate support of fractures bones during positioning and turning
o Support respiratory function
o Initially administer oxygen then position in Fowler’s position
o 48-72 hours immediately immobilize
o In there is already management immediate mobilize
Hip Fractures
- Common among elderly women
- Affected leg is always adducted, externally rotated and the limb is shortened
o Nakalabas is femoral head
- Complaints of pain in the GROIN or in the medial side of the bone
- Same signs and symptoms with fractures
- Total or Partial Hip Replacement
o Intertrochanteric hip fracture
Metal ball and stem are inserted in the femur and a plastic socket
o Total Hip Replacement
- Post Op Care
o Maintain legs in abduction (place pillows between legs) – adduction will displace prosthesis
o Avoid bending
o Use trochanter roll to prevent external rotation
o No low chairs
DEVICES
- Purpose
o Widens base of support
o Reduce weight bearing on the affected leg
o Provide mobility to the patient
- Crutches
o 2 inches below axilla
o 6 inches front to foot
o 2 inches to the side of the foot
o Elbow flexion (20-30 degrees)
o Exercises to prepare for CW:
Hand muscle ex
Arm muscle ex
o Gaits
o Stair climbing
UP: good leg crutches with bad leg (Going to HEAVEN so use your GOOD leg)
DOWN: bad leg with crutched good leg (Going to HELL so use your BAD leg first)
o Important Muscles
Shoulder Depressor / LatissimusDorsi
Needed first to advance the body forward
Needed to lift the pelvis off the ground
Elbow Extensors / Triceps
Needed to prevent buckling of the elbow joint
Finger Flexors
Needed to grasp the hand grip
o Crutch Walking
Crutch gaits
18. When only one leg can bear weight
Swing to gait: crutches forward; swing body to crutches
Swing thru gait: crutches forward; swing body thru crutches
3 point gait
2 point gait
- Cane
o Held on the non-affected side
o Cane walked together with the weak leg
- Walker
o The most stable among the assistive devices
o Sequence:
Advance walker within arm’s length (Approx 10-20 inches in front of the patient
Walk beside the walker
OSTEOPOROSIS
- Abnormal increase in bone resorption causing a decrease in bone density
- Loss of bone mass with aging, decrease calcitonin and estrogen and increased parathormone
- Deminiralization (Loss of Ca and phosphate salts) bone becomes porous, brittle, fragile structural
weakness – pathologic fractures
- Fractures of thoracic, lumbar neck and intertrochanteric fx of femur and Coll’sfx of wrist
- Risk factors:
o Menopause
o Sedentary lifestyle
o Genetics
o Age
o Nutrition
o Physical Exercise
o Medications
- Dowager’s Hump / Kyposis
- Signs and Symptoms
o Usually asymptomatic
o Sudden onset of sever back pain
o Skeletal deformity
o Bone pain and tenderness
o May show s/sx of pulmonary insufficiency
o Dec calcitonin and estrogen
o Inc PTH
- Dx Assessment
o X-ray
o Bone scan
- Nursing management
o Recognize risk factors and prevent further injuries
o Adequate dietary intake of Ca and other minerals, CHON and CHO
o Calcium supplements with Vitamin D
o Physical therapy – moderate exercise – mechanical stress stimulates bone formation
o Fracture management
o Biphosphates – Etidronate (Didronel)
Nephrotoxic
Increase bone density and restore lost bone
Inhibit resoprtion of bone
Monitor for nephrotoxicity and seizures
o Fluoride – Alendronate (Fosamax)
19. Stimulate bone formation
Strict GI precautions
Causes GI distress, esophagealerosin
Administer on empty stomach
Do not eat or crink 30 mins
Take with water 6-8 onz not juice and
Remain upright for 30 mins after taking drug
Monitor: hypercalcemia and tetany serum electrolytes
Increase fluid intake and calcium rich foods
Rheumatoid Arthritis
- Autoimmune bone disease and hereditary
- Bilateral, symmetrical, inflammatory, systemic
- Progression through stages
o Synovitis – pannus formation (scar tissue) – fibrous ankylosis – bone alkylosis
- Signs
o Fatigue, anorexia, malaise, weight loss, slight temperature elevation
- Usually affects joints symmetrically (on both side equally)
- Pathophysio
o Presentation of antigen to T cell t and B cells proliferation, angiogenesis in synovial lining
swelling in small joints, associated with pain, stiffness and fatigue neutrophil accumulation in
synovial cell proliferation. No cartilage invasion 2 possibilities: 1) warm effusions, pain and
decreased motion with possible rheumatoid ndules 2) synovitis, early pannus invasion,
chondrocyteactiviation, degredation or cartilage subchondral bone erosion; pannus invasion
- Painful, warm, swollen joints with limited motion, stiff in the morning and after period of inactivity
- Crippling deformity/swan-neck or buotonierre’s deformity
- Muscle weakness
- History of remission and exacerbations
- Severe anemia
- Sjoren’s syndrome
- Felt’s syndrome
o A disorder that can affect people who have rheumatoid arthritis (RA)
o It is defined by the presence of three condition: RA, enlarged spleen and low WBC count
- Dx test
o X-ray
o Laboratory
(+) Rheumatoid Factor
- Nursing Management
o Apply cold compress to the affected part
o Minimize muscle spasms and joint stiffness
o Avoid prolonged sitting or standing
o Encourage ROM exercises after taking pain meds
- Surgical Management
o Osteotomy, synovectomy, or arthroplasty
- Pharmacotherapy
o Aspirin
o NSAIDs
Indomethacin (Indocin)
Phenylbutazone(Butazolidin)
Ibuprofen
o Gold Compounds (Chrysotheraphy)
Arrest progression of the disease
Sodium thiomalate
20. Aurothioglucose
Auranofin
o Corticosteroids
Intra-articular injections
Osteoarthritis
- Degenerative joint disease
- Idiopathic or secondary
- 3
rd
decadeof life and peaks between the 5
th
and 6
th
decades
- Affects the articular cartilage, subchondral bone and synovium
- Cartilage degeneration, bone stiffening, reactive inflammation
- “wear and tear”
- Risk factors: age, obesity, previous joint damage, repetitive use, anatomical deformity
- Manifestations
o Pain (osteophytes)
o Stiffening
o Functional impairment
- Dx
o Progressive loss of joint cartilage
o Osteophytes
o Joint space narrowing (x-ray)
- Management
o Relieve strain and further trauma to joints
o Cane or walker if indicated to relieve stress
o Proper body mechanics
o Avoid excessive weight bearing and standing
o Physical therapy
o Relief of pain (NSAIDS)
o Joint replacement as needed
Gouty Arthritis
- Classifications
o Primary
o Secondary
Due to acquire condition
Starvation
Alcohol intoxication
Renal failure
- Risk factors
o Common among males
o 20 x greater than females
o 30 y/o and above
- s/sx
o inflammation of the joint
o pruritus
o TOPHI formation
Subcutaneous nodules
o Skin ulceration
o Late Stage
Bone deformity
Intolerance to bed linens
- Management
o Asses affected joint for pain motion and appearance
21. o Educate patients in recognition of early symptoms
o Increase fluid intake (3-5 L)
o Bed rest until pain subsides
o Report any decrease in urine output
o Low purine diet
o Admin medications as ordered
Allopurinol (Zyloprim)
MOA: prevents formation of uric acid
Probenicid (Benemid)
Colchicine (Colgout)
MOA: dec deposition of uric acid to the joint
Drug of choice to prevent attacks
Amputation
- Surgical removal of a part of a limb
- Levels: Syme, BKA(Below the Knee Amputation), AKA (Above the Knee Amputation), stage amputation
- Guillotin Amputation
o Stage type amputation
- Post op care
o Monitor VS
o Evaluate for phantom limb sensation and pain; explain to the patient
o During the 1
st
24 hours, elevate stump; after that flat on bed to prevent flexion hip contractures
o After 48hours, instruct also to be one prone position several times a day
o Maintain application of ace wrap to promote stump shrinkage
- Stump Dressing
o Soft- greater potential for haemorrhage and rehabilitation is longer but easier to assess
o Rigid – facilitates earlier ambulation but difficult to assess
- Post op complications
o Haemorrhage
o Infection
o Contracture
Bone Tumors / Malignancy
- Classified according to its characteristics
o Benign
Most common: osteochondroma
Endochondroma: hyaline cartilage (joint spaces and synovial cavity)
Bone cyst (collection of fluids found in a confined area)
Osteoid osteoma
Giant Cell Tumors (osteoclastomas) – common in children
o Malignant
Most common: Osteosarcoma
Bone tumors: primary or secondary
Commonly seen to 10-25 years of age
Most of the time they are just accidental finding
o Suddenly there will be palpated mass; no pain
o Palpable mass or hard lump, pain, pathologic fractures, decreased
sensation, numbness and limited movements
Tumor erodes the bone cortex elevating the periosteum
Most common site: distal femur, proximal tibia and humerus
Increased serum alkaline phosphatase because of bone lysis
DX: bone biopsy
22. Radiation, chemotherapy, surgical removal or tumor
Radiological finding: periosteal elevation
o Demineralized bone
Pathognomonic hallmark: Codman’s Triangle and Sun Ray Spicules (both
suggests malignancy)
After surgery, potential complications:
o Delayed wound healing
Related to tissue trauma
Effect of Radiation therapy
Poor nutrition (with malignancy, there is hypercatabolic
anorexia effect of cytokines hyperleukines
Infection(wound)
o Inadequate nutrition
o Osteomyelitis and wound infection
o Hypercalcemia common problem is arrhythmia, clogging of the
blood vessel, calcium stone renal failure
Scoliosis
- Lateral curvature of the thoracic, lumbar or thoracolumbar spine. Rotation of the vertebral column causes
rib cage deformity.
- When deviates to the RIGHT: DEXTROscoliosis
- When deviates to the LEFT: LEVOscoliosis
- Types:
o Functional: poor posture or discrepancy in the leg length
o Structural: deformity of the vertebral bodies
Loss in the height of the vertebral bodies
Common with those with osteoporosis or congenital, neuromuscular idiopathic scoliosis
(infantile, juvenile and adolescent)
Can happen anytime during bone formation
o Different stresses on the vertebral bodies causes imbalance of osteoblastic activity; curve
progresses rapidly during adolescent growth spurt
- Signs
o Uneven hemlines, one hip higher than the other, unequal shoulder, heights and iliac crests,
asymmetric thoracic cage
- Sugrical
o Posterior fusion
o Harrington Rod instrumentation
Wisconsin wire technique and Luque technique
o Zielke System
For thoracolumbar scoliosis (severe)
Makes use of wiring to maintain alignment of the thoracic spine
- Dx
o Observation / Inspection
o Thoracic X-Ray (Cobb’s Method) – done to see R or L deviation of the spine
o Adam’s Forward Bending Test
o Scoliometer – to look at the angle of the scoliosis (>30 percent: not only deformity but also sever
pain because of the compression of the spinal nerves)
- Complications
o Pulmonary insufficiency, back pain, HPN, sciatica (Radiating pain, back to foot), degenerative
arthritis of the spine
- Tx
o Depends on the age where is was diagnosed
23. 10-20 y/o – leg exercises and pelvic tilt: strengthen torso muscles
20-40 y/o – exercises + braces: worm until the bone growth is complete
40 y/o and above: spinal surgery – instrumentation with fusion
Cannot bend much because of the instrumentation with fusion
- Nursing Consideration
o Suggest loose, fitting clothes – wear undergarments when wearing the brace
o Wear the brace for 23 hours a day (1 hour for taking a bath) for 7 days
o Advise to increase activities gradually
o After corrective surgery
Check neurovascular status q 2-4 hrs, logroll
Monitor I and O, watch out for signs of bleeding
Patient will have splinting, so teach deep breathing exercises to prevent atelectasis
pneumonia
Medicate for pain, do ROM
Offer emotional support for altered body image
o Crankshaft Phenomenon
Observed after spinal fusion there is continuous growth of anterior vertebral body
Prevention:
Delayed the surgery until the child is older than 10 years
Addition of anterior fusion plate
Use of specialized instrumentation that allows subsequent expansion of the
vertebra
TB of the Spine
- Pott’s disease is a presentation of extrapulmonary (originates from the lungs, hematogenuous spread)
tuberculosis that affects the spine, a kind of tuberculosis arthritis of the intervertebral joints.
- s/sx
o back pain
o fever
o night sweating
o anorexia
o weight loss
o massive destruction of the vertebra – swelling
o spinal mass sometimes associated with numbness, tingling sensation or muscle weakness of the
legs
- infections
o Pott’s disease
Organism: TB Bacilli
Primary Focus: Lungs
Pathology:
Infection bone destruction collapse of the vertebrae Gibbus Formation
Spinal Cord compression
Mgmt
Anti-Koch’s medicaiotns, spinal brace
Tx minimum of 12 months
Surg
Anterior Decompression Spinal Fusion
Bone infections are difficult to treat because they are relatively inaccessible to
protective macrophages and antibodies
24. PediatricOrthopedic Conditions
Congenital Clubfoot
- Congenital malformation of the lower extremities
- Unilateral or bilateral
- Defects are rigid and cannot be manipulated into a neutral position
- Talipesvarus – an inversion or bending inward
- Talipes valgus – eversion or bending outward
- Talipesequinus – plantar flexion in which the toes are lower than the heels
- Talipes calcaneus – dorsiflexion
- Nursing care and treatment
o Serial manipulation and casting weekly and if correction not achieved in 3-6 months then surgery
is indicated
- Surgical
o Usually done 4-12 months of age (Kyzer, 1991)
o After surgery, a cast holds the clubfoot still while it heals
o Special shoes or braces will likely be used for up to a year or more after surgery
o Same as any child with a cast
Congenital Hip Dislocation
- Dysplasia of the hip wherein the head of the femur is not properly anchored in the acetabulum
- Can be congenital or develop after birth
- Assessment
o Asymmetry of the gluteal and thigh skin folds when child is placed prone
o Limited ROM on affected hip
o Apparent short femur on the affected side
o Positive Ortolani or Barlow Maneuver
o Waddling gait; positive Trendelenburg sign
- You see that the head of the femur is far from the acetabular fossa
- Nursing care and treatment
o Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotation
o Traction and surgery to release muscles and tendons
o Following surgery, positioning and immobilization in a spica cast then use of abduction splint
*READ ACUTE LOW BACK PAIN
*READ BRURITIS and TENDINITIS
*READ Ganglion Cyst
*READ DUPUYTREN’S CONTRACTURE
FOOT PROBLEMS
- Plantar Fasciitis
- Corn
- Callus
- Ingrown Toenail
- Hammer Toe
- Hallux Valgus
- PesCavus
- Flatfoot (PesPlanus)