Ortho Lecture

8/4/2019 Ortho Lecture

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Orthopedic Nursing Mr. Hermie G. Siroy

1

Orthopedic Nursing

Hermie G. Siroy

OR Nurse

Class 78

CLMMH School of Nursing

NCM 204: Curative and Rehabilitative

Criteria for EvaluationQ 50

E 40%

Req 5%

Part 5%

Unit 1

Function of SS

1. Protects internal organs (heart, lungs, aorta, brain, spinal cord)protects:

rib cage protects thoracic organs: heart, lungs, aorta: A and Dskull protects the brain

vertebrae protects spinal cord

2. Facilitates movement3. Hematopoiesis/Hemopoiesis4. Storage of minerals Ca and Ph5. Support tissues of the body and provide them shape

Bone is living tissues, surrounded by soft tissue with vascular connections. Its also a dynamic in a constant state of

reforming, resorption (to remove), creation and destruction

The human skeleton has 206 bones

1. Axial 80 bones of the skull, vertebrae and rib care2. Appendicular skeleton with consists of 126 bones that make up the bones

Axial

Skull

The cranium has 8 bones

The face has 14 bones

2 palatine bones

2 nasal bones

2 inferior nasal conchae

1 vomer divides the nasal septum

2 maxilla

1 mandible


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2 lacrimal bones

2 zygomatic bones

The hyoid consists of 1 bone - not attached to other bones; holds the base of the tongue; only bone not attached to

another bone

The vertebral column has 26 bones

7Cervical C1Atlas C2Axix

12Thoracic

5Lumbar

1Sacrum 5 bones when born, fuse when adult

1Coccyx

Cartilage Separates vertebrae

Annulus fibrosus- outer layer

Nucleus pulposus inner layer

Thorax

12 pairs of ribs (24)

1-7 sternal

8-12 asternal

11-12 - floating

Sternum 1 bone(Manubrium, Suprasternal notch)

Xiphoid process

Ossicles of the Ear

Malleus - Hammer

Incus - Anvil

Stapes Stirrup

Eardrum -> Malleus -> Incus ->Stapes

Eustachian tube connection of the eardrum to the pharynx

Appendicular Skeleton

Shoulder girdle has 4 bones

2 scapula

2 clavicle


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The Upper Extremities has 60 bones

2 humerus

2 radius

2 ulna

16 carpals

10 metacarpals

28 phalanges

Head of the humerus fits into the Glenoid cavity

The Pelvic Girdle

2 innominate coxa

Hip (Left and Right)

Lower Extremities has 60 bones

2 femur

2 tibia

2 fibula

2 patella

14 tarsus

10 metatarsus

28 phalanges

Bones are Classified according to shape

1. Long bones humerus, femur, ulna, radius, tibia, fibula2. Short bones carpal tarsal3. Flat bones scapula, patella, sternum, cranium (Patella largest flat bone; sesamoid bones)4. Irregular bones vertebrae, coxa

The end of long bones epiphysis diaphysis shaft

2 Types of Bones

1. Cortical (Compact) thick ring surrounding a cavity with bone marrow, it is found on the exterior portion oall bones and the shaft (diaphysis) of long bones. It is dense. Look and feels like ivory.

2. Cancellous (trabeculae) soft, spongy, bony tissue, surrounded by blood vessels. It is located in flatirregular, short bones, cranial bones, ribs, sternum, and pelvis. Iliac bone and the end of long bones


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Covering the bones is a dense, fibrous membrane known as Periosteum. It nourishes bones and allows for it

growth, as well as, provide for the attachment of tensions and ligament. Contains nerves, blood vessels and

lymphatics.

Endosteum thin, vascular, membrane, covering the marrow cavity of long bones and the spaces in cancellous

bones

Bone marrow vascular tissues located in the medullary cavity, of long bones and in flat bones. Red Bonemarrow, located mainly in the sternum, ilium, vertebrae, and ribs, in adults responsible for producing RBC and

WBC. In adults, the longs bones, is filled with fatty and yellow marrow

Brown marrow 3rd type of BM; came from yellow marrow when you become older

Bone Has 3 Types of Cells

1. Osteoblasts (bone forming cells) secretes bones matrix collagen and ground substance (glycoproteinand proteoglycans). The matrix is a framework in which inorganic mineral salts are deposited

2. Osteocytes least function in the bone system. Mature bone cells that are found in the bone matrix. Itis involved in bones maintenance function

3. Osteoclasts located in (Howships lacunae) small pits in bones near the Endosteum, aremultinucleated cells involved in destroying, resorbing (removing) and remolding bone. The microscopic

functioning unite of mature cortical bone in the Osteon (Haversian system)

The center of the Osteon, the Haversian canal, contains a capillary. Around the capillary are circles o

mineralized bone matrix call lamellae. Within the lamellae are lacunae containing Osteocytes. These

are nourished through tiny structures, canaliculi (canals Volkmanns canal), which communicate with

adjacent blood vessel within Haversian system

Bone Formation

Bone begins to form long before birth (3-4 months)

Ossification process by which the bone matrix (e.g. Collagen fibers and ground substance) is formed and

hardening minerals (e.g. Ca Salts) are deposited on the collagen fibers. The collagen fibers give tensile strength to

the bones, and the Ca provides compressional strength.

There are 2 basic types of ossification.

Most bones in the body are formed by endochondral ossification in which a cartilage-like tissues (osteoid) is

formed, resorbed and replaced by bones.

Intramembranous ossification occurs when bone develops within membrane in the bones of the face and skull.


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Bone Maintenance

Bone is a dynamic tissue is a constant state of reforming and resorption, creation and destruction. The important

regulating factor that determine the balance between bone formation and bones resorption

1. Local stress- Weight bearing/exercise. Acts to stimulate bone formation and remodelling. Weight bearing bones are

thick and strong. Without weight bearing, or stress, as in prolonged bed rest, the bones loses Ca(resorption) and becomes osteoporotic and weak, the weak bones may fracture easily

2. Vitamin D- Functions to increase the amount of Ca in the blood by promoting absorption of Ca from the GIT. A

deficiency of vitamin D results in the bone mineralization deficit, deformity and fracture. It also

facilitates mineralization of osteoid tissue

3. Parathyroid hormone- Parathyroid and Calcitonin are the major hormonal regulators of Ca homeostasis. Parathyroid hormone

regulates the concentration of Ca in the blood, in part by promoting movement of Ca from the bone. In

response to low calcium level in the blood, increased level of parathyroid hormone prompt the

mobilization of Ca, the demineralization of bone, and the formation of bone cysts4. Calcitonin

- Secreted by the thyroid gland in response to elevated blood Ca levels increases the deposits of Ca in thebone

5. Blood supply- Affects bone formation. With diminished blood supply or hyperemia (congestion), osteogenic (bone

formation), and bone density decreases. Bone necrosis occurs when the bone is deprived of blood

Vit. D. Hydroxylized in liver and kidneys to form calcitriol the active form of Vit. D. Vit D3

5% Stored in the cytoplasmic reticulum

95% in bones

Anatomy and Function of the Articular System

o The junction of 2 or more bones is called a joint (articulation). There are 3 basic kinds of jointsA. Synarthrosis joints are immovable, as exemplified by the skull suturesB. Amphiarthrosis such as the vertebral joints and symphysis pubis, carpal, allow limited motion

(slightly moveable joints). Or Amphiarthrosis

C. Diarthrosis freely movable jointsTypes of Diarthoidal joints

o Ginglymoid or Hinge bone surface is concave and one surface is convex. Movement isgenerally flexion or extension. Ex. Knee, radial or humeral bones of the elbow and the ankle

o Trochoid or Pivot an articulating surface rotates around a peg or projection and movementEx. Proximal articulation of the radius on the ulna is rotation on one axis Ex. Rotation of the

atlas on the pelvis.

o Enarthroidal or Ball and Socket the head fits in a concave socket, allowing for the mostmovement. Flexion, extension and circumduction are the 3 planes of movement allowed. Ex

Hip and shoulder joints


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o Arthroidal or gliding articular surfaces are flat in the joint, with no axis of movement. Thesacrum, the ilium, and many of the carpal bones form this type of joint

o Ellipsoidal or Condyloid an oval condyle fits into an elliptic cavity. Movement is 2 planes thatare perpendicular to each other. Extension, flexion, adduction, abduction, and circumduction

are allowed, as in the movement of the radius on the carpal bones.

o Saddle the bone fits into a convex surface of another bone allowing for the same movementsas in with the condyloid joint but allowing no axial rotation. The articulation of the 1

s

metacarpals with the trapezium

Ligaments

- Fibrous connective tissue bands the articulating bone together. Ligaments and muscle tendons, whichpass over the joints, provide joint stability

- Bone to boneBursa

- Is a synovial fluid filled sac that cushions the movement of tendons, ligaments and bones at a point offriction. Bursa are generally found at the elbow, shoulder, knee and some other joints

Cartilage

- A smooth, relatively firm, compressible tissue, cushions most articular surfaces at the ends of thebones. It doesnt have a direct blood supply, devoid of lymphatics and nerves

Anatomy and Function of the Musculoskeletal System

Muscles are attached by tendons (cords of fibrous connective tissues) or aponeuroses (broad, flat sheets of

connective tissue, other muscles, soft tissue, or skin

Muscles vary in sharp and size according to the activities for which they are responsible

Skeletal (striated) muscles are involved in body movement, posture, and heat production functions

Muscles contract to bring the two points of attachment closer together, resulting in movement (origin and

insertion)

Skeletal Muscle Contraction

Each muscle cell (also referred to as a muscle fiber) contains myofibrils, which in turn are composed of sarcomeres,

the actualcontractile units of skeletal muscle. It contains thick myosin and thin actin filaments

Muscle fibers contract in response to electrical stimulation delivered by an effector nerve cell at the motor end

plate. When stimulated, the muscle cell depolarizes and generates an action potential. These action potentials


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propagate along the muscle cell membrane and lead to the release of calcium ions that are stored in specialized

organelles called sarcoplasmic reticulum (SR)(5-7% of Ca are stored in SR)

***Radical Mastectomyall pertoralis major and minor

***longest muscle Sartorius: insertion is in the interior iliac crest and goes medially and insert to the tibia aka

Tailor Muscle

***Hamstring semitendinosus, semimembranosus, biceps femoris function: FLEXOR MUSCLES

***Quadriceps EXTENSOR of muscles- vastus lateralis, vastus medialis, vastus intermedialis, rectus femoris

***Gracilis - originate in symphysis pubis

***Myosin and actin slide against each other

Calcium rapidly removed from the sarcomeres by active reaccumulation in the SR

When the Ca concentration in the sarcomeres decreases, the myosin and actin filaments cease to interact and the

SR returns to its original resting (place) length (relaxation). Actin and myosin do not interact in the absence of Ca.

Energy is consumed during muscle contraction and relaxation. The primary source of energy for the muscle cells is

ATP which is generated thru cellular oxidative metabolism

During periods of strenuous activity, when sufficient O2 may not be available, glucose is metabolized primarily to

lactic acid. Stored muscle glycogen is used to supply glucose during periods of activity.

Muscle fatigue is thought to be caused by depletion of glycogen and accumulation of lactic acid. As a result, the

cycle of muscle contraction and relaxation cant continue

Tendons are bands of extremely strong, flexible fibrous tissues that attach muscle bundles to the Periosteum ofthe bones

Fascia (epimysium) fibrous tissues that cover, supports and separate muscles

The peripheral attachment referred to the origin and the distal attachment is the insertion

3 Types of Muscle Tissue

1. Cardiac Muscle branching, heart muscles2. Smooth (non-striated) found in the walls of hollow structures such as the GIT, urinary bladder, uterus, and

blood vessels. Cardiac and smooth muscles is controlled by involuntary stimulation of the CNS

3. Most skeletal muscles are attached to bone. Contraction of skeletal muscles account for movement of thebody and can be controlled involuntarily

The structural unit of muscle is the muscle cell which is also call the muscle fiber. Muscle is composed call the

muscle fiber. Muscle is composed by tissues bound together by connective tissues.


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2 Types of Muscle Contraction

1. Isometric contraction increase the tension within a muscle but do not produce movement, repeatedisometric construction make the muscle grow larger and stronger (ex. Pushing table without moving it, no

movement of muscle)

2. Isotonic contraction and movement of muscleMuscle tone normal tension (resistance to stretch) in resting muscle. Relaxed muscles demonstrates a state ofreadiness to respond to contraction stimuli

A muscle that is lime and without tone is described as flaccid; a muscle with a greater than normal tone is described

as spastic

Hypertrophy enlargement or an increase in the size of individual muscles fibers with an increase in the number of

muscle fibers

The decrease in size of a muscle-atrophy

Muscle Contraction produces a variety ofmovements

o Flexion - bending at a joint (Elbow)o Extension straightening at a jointo Abduction moving away from midlineo Adduction moving toward midlineo Rotation turning around at a specific axis (Head movement left to right)o Circumductiono Supination turning upwardo Pronation turning downwardo Inversion turning outwardo Eversion turning outwardo Protraction pushing forward (ex. Face thrushed)o Retraction pulling backward (ex. Face pulled backward)

Unit II Assessment

Basic assessment -> dig up base line information and do interview, subjective and objective

Initial interview

o The nurse obtain a general impression of the patients health statuso Gathering subjective data concerning the onset of the problem and how it has been managed as well as the

patients perceptions and expectations related to health

o A history of medication used and response to pain medication aids in designing meds managementregimens

o Nurse notes allergies


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Health History

o Nursing assessment of the pt with MS dysfunction includes an evaluation of the effects of the MS problemon the pt. the nursing assessment is primarily a functional evaluation on the pts ability to perform ADL

o Nurse is concerned with assisting who have MS problems to maintain their general health accomplish theirADL, and manage their treatment program

o Through an individualized plan of nursing care the nurse helps the patient achieve maximum healthAssessment data

- The patient may report pain, tenderness, tightness and abnormal sensation. The nurse assess this anddocument this information

Pain

- Bone pain is characteristically described as dull, deep ache that is boring in nature - Muscular pain is described as soreness or aching and is referred to as muscle cramps- Fracture pain is sharp and piercing and is relieved by immobilization- Sharp pain may also result from bone infection with muscle spasm or pressure on a sensory nerve

Rest relieves most MS pain. Pain that inc with act may indicate joint sprain. Radiating pain may indicate nerve

compression.

Physical Assessment

Techniques of infection and palpation are used to evaluate patients:

1. Posture- The normal curvature of the spine is convex thru the thoracic portion and concave thru the cervical and

lumbar portions2. Gait

- Gait is assessed by having the patient walk away from the examiner for a short distance- Smoothness and rhythm of the gait- Limping motion due to painful weight bearing limp is also observed if on leg is shorter than the other

than the other as in scoliosis

- Limited motion affects gait- Spastic hemiparesis gait stroke- Shuffling gaitParkinsons disease. To move in sliding or dragging gait- 3 meters

3. Assessing Bone Integrity- The bony skeleton is assessed for deformities and alignment. Symmetric parts of the body are

compared

- Abnormal bony growth due to the bone tumors may be observed- Shortened extremities, amputations, and body parts that are not in anatomic alignment

4. Assessing Joint Function- ROM


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- Limited ROM may be the result of skeletal deformity, joint pathologyor contracture surrondin muscle,tendons and joint capsule. In elderly patients, limitation of ROM associate d with osteoarthritis may

reduce their ALD

- If joint is compromised or the joint is painful, the joint is examined fo0r effusion (excessive fluid withingthe capsule), swelling and increased temp that may reflect inflammation

- Knee is the common sire of effusion-

Joint deformity may be caused by contracture (Shortening of surrounding joint)- Joints are examined for nodules- RA nodules or Subcu are soft and occur within and along tendon- Gout nodules (tophi/tophus) are hard and lie within and immediately adjacent to the joint capsule

itself. They may rupture, exuding white uric acid crystals

- Osteoartrhitic nodules are hard and painless and represent bony over growth older adult5. Muscle Strength and Size

- Noting the ability to change position, muscular strength and coordination, and the size of individuamuscles

- The muscular system is assessed by noting the pts ability to change position, muscle strength andcoordination

- When the biceps are tested, the pt is asked to extend the arm fully and then to flex it against resistancesupplied by the nurse

- Handshake indication of strength- Biceps - weight

6. Skin- The nurse inspects the skin for edema, temperature and color- Palpation warmer suggesting increased perfusion or infection- Cooler decreased perfusion

7. NV Status- Assessment of CMS circulation, motion, and sensation- Ex. In case of fractured extremity for possible compartment syndrome assess for pulse distally

temperature, color of skin

- Pedal PulseDorsalis pedis

Posterior tibialis

A. Radiologic and Imaging Studies1. Standard Roentgenogram X-ray film is done to determine density and texture of bone. Study

evaluates structural or functional changes of bones and joint.

Ex. AP and Lateral viewCover pregnant women with lead and expose extremity to be x-rayed.

Nursing Responsibility

i. Avoid excessive exposure of client and selfii. Remove radiopaque objects that can interfere wit

iii. Explain the procedure to the client2. Arthrogram study involves injection of contrast medium to a joint cavity permitting visualization

of joint structures. Joint movement is followed with a series of x-rays


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Nursing Responsibilities

i. Assess for allergies (to crustaceans)5% - ideal cleansing agent is povidone iodine

0.001% allergic to iodine

ii. Explain procedure done in the ward or in the X-ray departmentiii. Prepare the area aseptically using sterile technique

3.

Diskogram an x-ray film of cervical or lumbar intervertebral disk is done after injection of dye intonucleus pulposus. Study permits visualization of intervertebral disk abnormalities; done before

spinal surgery

NR Same as Arthrogram

4. CT Scan an x-ray beam is used with a computer to provide a 3 dimensional picture. It is used toidentify soft tissue abnormalities, bony abnormalities, and various MS trauma

Fluoroscopycan magnifyimage intensifier, C arm

NR

i. Explain the procedure painlessii. Importance of remaining still during the procedure for at least one hour,

5. MRI radio waves and magnetic field are used to view soft tissue. Study is especially usefudiagnosis in the diagnosis of avascular necrosis, disk disease, tumor, ligament tears. Client is placedinside scanning chamber

NR

i. Explain procedure to client painlessii. Contra in clients with aneurysm clips, metallic implants, pacemaker, electronic devices,

shrapnel, extreme obesity

iii. Ensure that client has no metal on clothing. Ex snaps, zippers, jewelriesiv. Remain still during or throughout the procedurev. Inform claustrophobic clients that they may experience symptoms dur9ing the exam

Administer anti-anxiety agentvi. If there is IVconvert to heplock (1:20)

B. Bone Mass Measurements or Bone Densitometry- Used to estimate bone density. Study evaluates bone mass of metacarpals. A very low dose of

radiation is used

- Can be used to calculate total body Ca concentration to estimate extent of osteoporosis (osteopenia low calcium)

NR

i. Explain the procedure-painless. Thru x-raysC. Radioisotopes Studies

1. Bone Scan technique involves injection IV of radioisotopes (usually Na Pertechnate) that is takenup by the bone. Camera scans the entire body (front and back) and records

o Degree of uptake is related to blood flow to bone. Increase uptake is seen is osteomyelitisosteoporosis ad primary and metastatic malignant lesions and with certain fractures

NR

i. Explain procedure to client painless


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ii. Possibility of allergy to isotopesiii. Empty the bladder (to facilitate excretion of radioisotopes)

D. Endoscopy1. Arthroscopy insertion of arthroscope into the joint for visualization of structure and contents

o It can be sued for removal of loose bodies for biopsy for diagnosis of abnormalities of meniscus(tears), cartilage, ligaments or joint capsule

oExsanguination Esmarchs bandage is used to exsanguinate a limb; done before/after prepping the skin or after draping; elevate the leg part same height as the heart. Bandage

spirally, exert effort, squeezes the blood to give clear visualization of the site.

o Dressing after surgery compressing dressing from midcalf to midthigh; purpose is toi. Distal application to proximal application of bandages will promote venous return ii. To Secure the dressing, preventing the leakage of synovial fluid, thus preventing

infection (very difficult to heal, devoid of blood vessels, nerves and lymphatics)

preventing leakage of blood

iii.o Limited activity for few days

NR

o Explain procedureo OR set-up with strict asepsiso Anesthesia

E. Mineral Metabolism1. Alkaline Phosphatase this enzyme is produced by osteoblasts of bone and is needed for

mineralization of organic bone matrix

o Elevated level are found in healing fractures, bone CA, osteoporosis, osteomalacia, Pagetsdisease

NR

o Explain procedureo Obtain blood samples by venipunctureso Obs VNP site for bleeding or hematomao No fasting

2. Ca bone is primary organ for Ca storageo Ca provide bone with rigid consistencyo Dec level is found in osteomalacia, renal disease, hypoparathyroidismo Increase level is found in hyperparathyroidism, bone tumors and acute osteoporosiso Langenbeck UKArmy-Navy in US- roux retractor -Germans

NR

o Explain procedureo Obtain blood sample thru the VNPo Obs for hematoma or bleedingo No fasting

3. Phosphorus amount present is directly related to Ca metabolismo Decrease level is found in osteomalaciao Increase level is found in chronic renal disease, healing fractures, osteolytic metastatic tumor


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NR same as #2

F. Serological1. Uric acid test-level usually elevated in gout

NR

o Explain procedure to cliento No fastingo Obs for hematoma, bleeding on the VNP site (dry cotton and plaster)

2. ESR Erythrocyte Sedimentation Rateo Elevated level are seen with any inflammatory process esp. RA, R Fever and respiratory

infections

G. Muscle Enzymes1. Creatine Phosphokinase

o Highest concentration is found in skeletal muscle. Increased values found in progressivemuscular dystrophy, polymyositis and traumatic injuries

o NR same as serologicalH. Invasive Procedures

1. Arthrocentesis incision of puncture sire of joint capsule is done to obtain samples of synovial fluidNR

o Explain procedureo Maybe done at bedside or examination room or in Day surgeryo Samples send to lab for serology or C/S test or cytologyo Compression dressingo Resto Obs leakage of fluid or blood

2. Electromyogram test is done to evaluate muscle weakness, pain and disability to differentiate anyabnormality of function and to differentiate muscle and nerve problems

o Needle electrodes are inserted into selected muscles and responses to electrical stimuli arerecorded by an oscilloscope

NR

o Explain procedure that to be done in the laveo Supine on special tableo Apply warm compress (36.6-40.6C), after the procedure will have residual discomfort

I. Biopsy to the area desired. Ex. Small part of the muscle or ligaments or bone marrow

Unit 4: Common Health Problems

A. Neonate and InfantI. Congenital Clubfoot

o Clubfoot is a general term used to describe a common deformity in which the foot is twistedout of its normal shape or position. Any foot deformity involving the ankle is called TALIPES

derived from TALUS, meaning ankle and PES, meaning foot


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o Deformity of foot and ankle are conveniently described according to the position of the ankleand foot. The more common position involved the following variations

1. TALIPES VARUS an inversion or a bending inward deformity2. TALIPES VALGUS an eversion or bending outward; rare3. TALIPES EQUINUSplantar flexion in which the toes are lower than the heel4. TALIPES CALCANEUS dorsiflexion, in which the toes are higher than the heelo

The most frequently occurring type of clubfoot (approximately 95%) is the composite deformityknown as TALIPES EQUINOVARUS in which the foot is pointed downward and inward in varying

degrees of severity

o Unilateral clubfoot is somewhat more common than bilateral and may occur as an isolateddefect or in association with other disorders or syndromes such as chromosomal aberrations

o Arthrogryposis (congenital defects with chromosomal aberrations; of the limbs with ageneralized immobility of the joints)

o Boys are affected twice as often as girlso Pathophysiology

The precise cause is unknown. There are those who attribute the defect to abnormapositioning and restricted movement in utero, although the evidence is not conclusiveOthers implicate arrested or anomalous embryonic development. Since the foot

normally goes through flexion and eversion during early development and gradually

assumes a normal attitude by 7th month.

Arrested development during this early stage tends to result in a rigid deformitywhereas mechanical pressures from intrauterine position are more likely to be

operating in the more flexible deformities. Embryologists are divided in acceptance of

the embryonic arrest theory.

o Diagnostic Evaluation The deformity is readily apparent and easily detected at birth. The true clubfoot is

fixed.o Therapeutic Management

Treatment began as soon as the deformity is recognized and involves 3stages:1. Correction of the deformity (corrective fixator, casts)2. Maintenance of the correction until normal muscle balance is regained3. Follow up observation to avert possible recurrence of the deformity.

Nursing care of the child with nonsurgical correction of clubfoot is the same as it is forany child who has a cast. Conscientious observation of skin and circulation is

particularly important in young infants because of their normally rapid growth rate.

Parents need to understand the overall program, the importance of regular cast

changes, and the role they play in long term effectiveness of the therapy. A cast may cause compartment syndrome if outgrown Zinc Oxide plasterused for petalling, used to smoothen edges of cast X ray is exact tool to confirm the diagnosis Ilizarov fixatorsurgical correction

II. Congenital Hip Dysplasiao Describes imperfect development of that can affect the femoral head, the acetabulum, or both

More commonly known as Congenital His Dislocation or Congenital Dislocated Hip.


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o The cause is unknown but it is one of the most common congenital defects, with an incidenceof about 1:500 to 1:1000 births

o The disorder occurs more frequently in females than in males. CHD is frequently associatedwith another conditions such as spina bifida

o Pathophysiologya. Acetabular Dysplasia or Preluxation the mildest form, in which there is neither

subluxation nor dislocation. The dysplasia reflects an apparent delay in acetabuladevelopment evidenced by osseous hypoplasia of the acetabular roof that is comparatively

intact. The femoral head remains in the acetabulum

b. Subluxation accounts for the largest percentage of CHD. Subluxation implies incompletesdislocation or dislocatable hip. The femoral head remains in contact with the acetabulum

but a stretched capsule and ligamentum teres cause the head of the femur to be partially

displaced.

c. Dislocation the femoral head loses contact with the acetabulum and is displacedposteriorly and superiorly over the fibrocartilaginous rim. The ligamentum teres is

enlongated and taut

Prenatal factor that are considered to influence development of hip abnormalities are: Maternal Hormone Secretion and Mechanical Factors of IU Posture toward the

end of pregnancy there is increased maternal pelvic laxity (sacroiliac joint and

symphysis pubis) mediated by maternal hormone secretion (Principally

Estrogen) which affects the fetal joints as well. The position of the legs in frank

breech position that is with the his acutely flexed and knees extended is an

important factor in the aetiology of hip dislocation

Other prenatal factor that contribute to hip dysplasia include twinning andlarge infant size

Double hip spica after CR Broomstick plaster after femoral osteostomy Pavlik harness

B. Adolescents- The characteristic S curve of the lateral spine develops during fetal life and early childhood- Scoliosis is the lateral curvature of the spine in any area cervical, thoracic, thoracolumbar or lumbar

o Occurs most often in preadolescents and adolescents3 Categories of Scoliosis

1. Idiopathic scoliosis most common form, appearing in growing children with no otherapparent health problem

2. Congenital3. Neuromuscular

- Etiologyo The cause of scoliosis can be congenital or neuromuscularo Congenital scoliosis results from a malformation of the bony vertebral segment of the spine

either because of:

i. Formation (the absence of a portion of a vertebra) orii. Segmentation (the absence of a normal separation between vertebrae)


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o Neuromuscular condition associated with spinal deformities include CO, Polio,myelomeningocele, spinal muscle atrophy, spinal cord tumors, trauma, and muscular dystrophy

- Congenital manifestation and a family history of spinal deformity are significant but diagnosis isconfirmed by AP and L that reveal a curvature of 10 degrees or more

- X-ray are the only exact tool for monitoring changes in spinal deformity, but excessive radiationexposures is in appropriate in children

-

2 Other Non-invasive Dx Technique1. More Topography2. Integrated and imaging system (ISIS)

- ManagementNon Surgical

1. Observation2. Bracing3. Exercise

Each client needs to be evaluated individually mot only for the medical problem but also for willingness

to participate in any suggested therapy

Sometimes conservative treatment failed-willing to undergo surgeries such as:

1. Spinal fusion attaching adjacent vertebrae to each other with a bone graft to prohibitedmotion between them; arthrodesis

2. Cotrel-Dubousset is commonly used for posterior approach of correcting scoliosis; rod system3. Harrington Rod System develops in 1960 is still in use because of its availability and because

many surgeons are familiar with it

4. Moss-Miami and Luque System posterior approach5. Zielke and Harris System famous for anterior approach system; collapse the lungs; most stable

- Complicationso Possible complication following scoliosis surgery include

1. Neurologic compromise2. Infection (in the incision site)3. Respiratory problems4. Spinal fluid leakage5. Phlebitis6. Excessive blood loss7. Implant problems8. Pseudoarthrosis a false joint formed around a displaced bone end after dislocation or

as the result of ailed union after surgery by fibrous tissue

9. Most devastating complications paralysis and death- Postoperative Care

o Post op nursing management focuses on usual post op care. Assessment of motor and sensoryfunction in the lower extremity/ies is important because the nerves and muscles may have

been stretched in surgery


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Common Disorders in Children

I. Juvenile Rheumatoid ArthritisJuvenile Chronic Arthritis

Juvenile Arthritis

- Terms used for this inflammatory autoimmune diseases causing many form of arthritisIncidence and Etiology

- JRA is the common pediatric connective tissue disease with arthritis being the principal manifestation1:1000 African American

- Asian children are less likely to suffer from GRA- 80-90% of children with JRA satisfactorily recovers and have no functional limitations. However 10% of

children become adults with no moderate to significant functional impairment

- Overall Girls are affected twice as often as boys. The aetiology is unknown but it does not involve theinteractions of genetic, environmental and immunologic factors

Pathophysiology

- Current research suggest that T-cell activation triggers development of antigen/antibody complexeswhich cause release of inflammatory substances called cytokines in targeted organs such as the joints

and skin (heart, spleen, liver, joints). This causes inflammation of the synovial joint membrane and

other

- Tissues leading to joint effusion and swelling. Chronic inflammation eventually evolves into erosion ofarticular cartilage and other symptoms of inflammatory diseases

Clinical Manifestation

- JRA is classified by symptoms at onset of disease: systemic, polyarticular, or pauciarticular- The classical symptoms of arthritis are morning immobility, stiffness or gelling, Joint pain

A. Systemic Onseto Fever higho Rash salmon pink, migratory, macular/popular. Most common late afternoon or early eveningo Arthralgia/myalgiao Arthritiso Fatigue/malaiseo Lymphadenopathy usually cervical, axillary, and inguinalo Hepatospleenomegally right hypochondriac (liver), left hypochondriac (spleen, filters dead

RBC)

o Can also present with signs of Carditis-chest pain, tachycardiaB. Polyarticular Onset

o Arthritis in many joints (5 or more) any joint can be affected, but most particularly the jointsof the knees, wrists, ankles and proximal interphalangeal joints of the fingers. Often neck and

Temporomandibular Joints (TMJ)

o Low grade and occasional Fever


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C. Pauciarticular Onseto Arthritis in a few joint (4 or fewer) often, though not exclusively, joints of the knees and

ankles

o Inflammation of the eyesDiagnosis

- The American College of Rheumatology has determined diagnostic criteria for JRA that included onsetbefore 16 years of age. Objectively observed arthritis is defined as joint swelling or effusion, or two of

the following: warmth, pain of motion, or limited ROM

- The diagnosis and categorization of the disease is based on history, physical exam, laboratory andradiologographic testing

- There are no specific lab tests for JRA. Nevertheless, they are used to help diagnosis and monitorheumatological disease. It includes increased ESR, WBC, platelet count and decrease Hgb (lack o

vitamin D and sunlight low calcitriol osteopenia dec RBC)

Treatment

- Treatment is best undertaken by a multidisciplinary team, including the child and family, nurse,physician, OT and PT and social worker. Overall goals include decreasing inflammation (NSAIDS and

steroids), maintaining joint function (ROM, OT, PT) and preventing psychosocial complication (placed in

the mainstream of education child must be exposed to peer group interact, relate to the

environment) . Treatment includes medications, OT, PT, nutrition and education.

Medications are the primary mainstay for arthritis in children

1. NSAID2. Aspirin-side effects-stomach upset, ulcers, Reyes syndrome3. Sulfasalazine4. Hydrochloroquine-anti-malarial drug. Not well understood action in TA given if ASA can

adequately effect

5. Methotrexate folic acid antagonist-nausea6. Corticosteroids anti-inflammatory-round face, inc BP, weight gain, dec bone density7. Cytotoxines limited success in ra for primary treatment of neoplastic disease

II. Rickets- Is due to failure of calcification of growing bone in infancy and childhood and is seen most frequently in

the temperate zones. The unavailable of Ca for ossification can be caused by inadequate intake or by

failure of absorption due to chronic diarrhea, steatorrhea, or most importantly, a deficiency of Vit. Ddue to inadequate exposure to sunlight or failure of hydroxylation by the liver or kidneys


- When the concentrati0on of ionized serum Ca is very low in infants, tetany may develop, with spasmsof the hand and feet, and of the vocal cords, resulting in a high pitched, distressing cry and difficulty in

breathing (critical sx)

- Other sx may be present restlessness, pallor, flabby muscles and excessive sweating


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- After 6 months of age, it is more common to see, bossing of the forehead and parietal bones naddelayed closure the fontanels; bow legs

- In later infancy and childhood the softness of ten ones results in chest deformities, such as pigeon chest(Pectus carinatum), Harrisons sulcus, kyphosis, enlargement of the lower end of the femur, tibia, fibula,

deformities of the shafts with knock knees and bow legs and pelvic deformities

Treatment

- Although appropriate treatment with supplementary dietary Ca and a single massive dose or prolongedmoderate dosage of vitamin D brings prompt correction of the biochemical abnormality and epiphysea

widening, the skeletal deformities may persist. In some cases these deformities are amenable to

corrective surgery

Common Health Problems is Adults

I. Osteoarthritis (OA) aka Degenerative Joint Disease or Wear and Tear Arthritis is a slowly progressive non-inflammatory disorder of mobile joints, particularly in weight bearing articulation- Characterized by degeneration of articular cartilage- Damage is confined to the joints and surrounding tissues- OA maybe primary or secondary. Primary cause is unknown. Secondary cause-previous fracture

infection or congenital deformities (Arthrogryposis) as precipitating factor

- This disabling disease increase with age. Men and women are affected equally- Vertebra, knees, hip, and wristPathophysiology

- Usually smooth, white, translucent joint cartilage to become yellow and opaque, with rough surfacesand areas of malacia (softening). As layers of cartilage become thinner, bony surfaces are close

together. As cartilage breakdown, fissures may appear, fragments of cartilage become loose

Secondary inflammation of the synovial membrane may glow. As the articular surface became totally

denuded, subchondral bone increases in density and becomes sclerotic. (Cartilage gets its nourishment

from the synovial fluidcontains a lot of important substances ground substances, hyaluronidase)

There are several theories concerning the cause of cartilage deterioration

1. The enzyme hyaluronidase, which is normally found in the synovial fluid may be responsible fordigestion of proteoglycans

2. Another theory suggests, the inadequate nutrition of the cartilage may result in cartilagedegeneration

3. Specific predisposing factors such as excessive use of stress on a joint such as knees of a footbalplayer; feet and ankle of a ballet dancer

4. Genetic factor Heberdens nodes5. Congenital structural defects6. Metabolic disturbances - diabetes mellitus7. Repeated intraarticular hemorrhage haemophilia


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8. Neuropathic arthropathies (any disorder of the joint)9. Inflammatory and septic arthritis


A. Fatigue, fever, is not present in OA, and other organ involvement is absent as wellB. Pain in motion and weight bearing relieves by rest

o Sleep may be disrupted by night pain and advance stageo Increasing pain accompanied by progressive loss of function and immobility. Asymmetric

involvement of joints like the distal interphalangeal joint of the fingers, etc. Lower lumbar

cervical vertebrae, hips and knees

o Heberdens nodes are another common manifestation of OA particularly to women with OA,primary located at distal interphalangeal joints

o Are palpable protuberances that are often associated with flexion and lateral deviation of theedistal phalanx

o Bouchards nodes, less common in OA involve the proximal interphalangeal jointsC. Hips (Malum Coxae Senilis)

o Pain in the groin, buttocks or medial side of thigho meno Disabling, difficult to sit

D. Knees softening of posterior surface of the patella (Chondromalacia patellae)E. Vertebral Column

o Degenerative disease of the intervertebral disks as the nucleus pulposus deteriorates, brittle,and inelastic, herniation of this occurs, anteroposteriorly

o Slipped disc, herniated disc, intervertebral disc prolapse- Diagnosis

o Complete hx and physical examo X-ray (joints)o ESR (Normal)o Synovial fluid analysis (Arthrocentesis)

- Therapeuticso Rest and joint protectiono Heat and cold exerciseo Mild analgesiao Assistive deviceo Stress managemento Orthopedic surgery

- NCM (by EBNEZAR p333)o To all surgical clients. Most importantly talk to the patients, keep their spirits high, pep and

shower them with love and affection. This will definitely cheer them up and life their sagging

morale.

II. Rheumatoid Arthritis- RA is a chronic systemic disease characterized by recurrent inflammation of the diarthroidal joint and

related structures. It is frequently accompanied by a variety of extracellular manifestations, such as

rheumatoid nodules, neuropathy, pericarditis, Lymphadenopathy, and splenomegaly


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- The course of illness varies, ranging from episodes of illness separated by periods of remission to amorecontinuous, progressive disease. Death from RA is rare.

Etiology cause remains unknown

1. Autoimmunity RA is an autoimmune disease2. Genetic factors familial factors3. Other factors metabolic and biochemical abnormalities, nutritionalPathophysiology

1. First stage the unknown etiological factors initiates joint inflammation or synovitis. Increasesynovial fluid production

2. Second stage Pannus (granulation inflammatory tissue) is formed at the juncture of synovium andcartilage. This extends over the surface over the surface of the articular cartilage and eventually

invades the joint capsules and subchondral bone (Chondros cartilage)

3. Third stage tough connective fibrous tissue replaces Pannus, occluding the joint space. Fibrousankylosis results in decreased joint motion, malalignment and deformity

o Fibrous ankylosis shortening of connecting fibrous tissue due to prolonged joint inflammation4. Fourth stage as fibrous tissues calcifies, bony ankylosis, may result in total joint immobilization

o Bony ankylosis pathological fusion of bones across a joint spaceProlonged early morning immobility

***OA cartilage are denuded; contact of bone to bone; unilateral involvement of joint

RA cartilage becomes bony; it stays there; inflammatory; ESR increased; Bilateral;

symmetrical involvement of joint (common to them: pain) immobility is not common to them

(morning = OA; prolonged early morning immobility = RA; stiffness = OA, prolonged in RA)

Clinical Manifestations

o Joints pain, stiffness, limitation of motion and signs of inflammation. As disease activityprogresses, inflammation and fibrosis of the joint capsule and supporting structures may lead

to deformity and disability

o Extraarticular manifestation rheumatoid nodules, small vessels vasculitis (inflammation ofblood vessels)

o Complication infection, osteoporosis, spinal cord compression Amyloidosis (CHON deposits to all joints, purines) Intraarticular steroids decrease inflammation

Diagnostic Studies

o ESR increased in 85%o WBC inco X-ray jointso CBC


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General Therapeutic Treatment

o Education, including disease process and management at homeo Importance of nutrition (Vit D and Ca)o Rest, exercise (physical)in watero Pharmacotherapy systemic corticosteroid, NSAID (mainstream)o Ortho surgery reconstructive joint replacement (OA and RA)

Methyl methacrylate for hip joint (may cause cardiac arrest) ***classical symptoms of arthritis = pain, morning immobility, stiffness or gelling

III. Gouty Arthritis- Is characterized by recurrent attacks of acute arthritis in association with increased levels of serum uric

acid

- In primary gout a hereditary error of purine metabolism lead to the over production or retention of uricacid

Etiology and Pathophysiology

- Uric acid represents the major end product of the metabolism of purine and primarily excreted by thekidneys. Thus hyperurecemia resulting to increased purine synthesis, dec renal excretion or both


- Affected joints may appear dusky or cyanotic or extremely tendersSites

- Big toe, midtarsal, knee, ankles and wrist joints and the olecranon bursa- Acute gouty arthritis is precipitated by trauma, surgery, alcohol ingestion or systemic infectionSymptoms

- Fever low grade, attacks subside (treated or untreated) in 2 10 days then affected joints returns tonormal

- Chronic Gout multiple joint involvement and deposits of Sodium Urate Crystals (tophi/tophus). Ahard deposit of crystalline uric acid and its salts in the skin, cartilage or joints

Diagnostic

- History and physical exam- Finding urate crystals increase- Uric acid increase- 24 hour urine collection for uric acid levelsTherapeutic Management

- Anti-inflammatory drugs Colchicine,Allopurinol- Avoidance of alcohol and high purine foods


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- Bed rest and joint immobilization- Intraarticular corticosteroids- Analgesic

IV. Bursitis and Tendinitis- Are inflammatory condition that commonly occurs in the shoulder-

Similarly muscle tendon sheaths become inflamed with repetitive stretching. The inflammation causesproliferation of synovial membrane and Pannus formation which restricts joint movement

- Similarly muscle tendon sheath become inflamed with repetitive stretching. The inflammation causesproliferation of synovial membrane and Pannus formation which restricts joint movement

- Bursitis inflammation of bursa- Tendinitis inflammation of tendons or tenosynovitis since the sheath are line with synovial later. Aka

called tendonitis

Treatment

- Includes rest of the extremity- Intermittent ice and heat to the joint- NSAID to control pain and inflammation- Arthroscopic synovectomy may be considered if shoulder pain and weakness persist- Arthrotomy

V. Carpal Tunnel Syndrome- Is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a

thickened flexor tendon sheath, skeletal encroachment, median, or soft tissue mass

- The syndrome is commonly due to repetitive hand activities but maybe associated with arthritis,hypothyroidism or pregnancy

Symptoms

- Pains, numbness, paresthesia, and possibly weakness along the median nerve (thumb, first and secondfinger)

- Neurolysis releasing a compressed nerve- the Tinels sign may be used to help identify CTS- Night pain is common. Rest splints to prevent hyperextension and prolonged flexion of the wrists

avoidance of repetitive flexion of the wrist

- Injection of cortisone to carpal may relieve symptomo ***press the superficial part of radial nerve; pain on that part means positive for radial cana

syndrome; Ulnar tunnel syndrome = ulnar passes median; press superficial side and positive for

pain and tingling on that side; median nerve passes on the medial goes down to the tunnel; use

index finger and tap at middle

- Surgical release of the Transverse Carpal Ligament may be necessaryVI. Osteoporosis metabolic bone disorder. The disorder is characterized by a reduction of total bone mass

and a change in bone structure, which increases susceptibility to fracture


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- The bone becomes porous and fragilePathophysiology

- Genetics, aging, nutrition, lifestyle choices (e.g. smoking, caffeine, and alcohol consumption) andphysical activity influence the peak bone mass and development of osteoporosis

o ***peak bone mass = (if adulthave arrived at peak bone mass)- Loss of bone mass and development of osteoporosis is a universal phenomenon associated with aging.

Age related loss begins soon after the peak bone mass is achieved

- Calcitonin which inhibits bone resorption and promotes bone formation (***thyroid gland alsodegenerating)

- Estrogen inhibits bone breakdown dec with aging- PTH increases with aging and inc bone resorption; inc production of Osteoclasts- Women develop osteoporosis more frequently and more extensively because of the effect of estrogen

loos during menopause

Risk Factors

1. Small framed, non obese white women are at greatest risk for osteoporosis2. Nutritional factors - Vit D deficiency and Ca. Then must be adequate in promoting bone formation

remodelling, and body functions. The best source of Ca and Vit D is fortified milk

3. Immobility paralysis or general inactivity osteoporosis occurs4. Co-existing medical disorder, malabsorption syndrome, lactose intolerance, alcohol abuse, rena

failure, hyperthyroidism contribute to bone loss

5. Medicines steroids, isoniazed, heparin tetra, aluminium containing antacids, furosemideanticonvulsant affect the bodys use and metabolism of Ca

Diagnostics

1. X-ray2. Lab studies. Serum Ca, Serum PO4, alkaline phosphatase, urine Ca excretion, ESR

Medical Management

1. Adequate, balanced diet rich in Ca and Vit D throughout life (natural sunlight, fortified milk, cheesebutter, margarine, cereal, fish)

2. Regular weight-bearing exercise promotes bone formationVII. Pagets Disease or Ostitis Deformans

- Define as an idiopathic bone disorder characterized by abnormal accelerated bone resorption andformation in one or more bones. The normal bone is replaced by abnormal. Structurally weaker bone

that is prone to fractures

- Most commonly affecting the skull, femur, tibia, pelvic bone and vertebrae- The Pagets disease bone is highly vascularised and structurally weak. Pathologic fracture occurs- Structural bowing of the legs causes mal-alignment of the hip, knee and ankle joints, which contributes

to the development of arthritis and pain

- Incidence is slightly greater in men and increases with aging


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- Familial tendency- Cause is not knownClinical Manifestation

- Bowing of femur and tibia, enlargement of the skull and cortical thickening of the long bone are seen.Is insidious most patients never know they have it

- The skull may have thickened- In some cases the cranium, but not the face, is enlarged- The femur and tibia tend to bow, producing a waddling gait. The spine is bent forward and is rigid, the

chin rests on the chest

- Pain and tenderness of the bones may be noted- Hearing loss due to (enlarging bone, Ossicles are enlarged as well, part of the temporal bone) there is

compression in the brain 8th cranial nerve, auditory nerve or vestibulocochlear nerves

Diagnostics

1. Serum alkaline phosphatase increase normal Ca leveld/t increasing ossification2. X-ray confirms Pagets

Therapy Pharmacology

- Calcitonin is administered subcutaneously, it retards bone resorption by decreasing the number andavailability of osteoclasts

- Calcitonin therapy facilitates remolding of abnormal pagetic bone into lamellar bone, relieves bonepain

- Calcitonin therapy facilitates remodelling of abnormal Pagetic bone into lamellar bone, relieves bonepain

VIII. Malignant Bone TumorOsteogenic Sarcoma (Osteosarcoma)- The most common and most often fatal primary malignant bone tumor. It carries a high mortality rate

because the sarcoma often has spread to the lungs (coughing, backache, chest ache) by the time the

patients seeks healthcare

- It is manifested by pain, swelling, limitation of motion, and weight loss- The common site are the distal femur, the proximal tibia and humerus- Manifested byCachexia very thin; skin and bonesTreatment

1. The therapeutic goal is to relieve pain and discomfort while promoting quality of life2. If metastasis weakens the bone, structural support and stabilization are needed to prevent

pathologic fracture (very nasty)

3. Arthroplasty methyl methacrylate (bone cement) reconstruction of a joint4. Opioids for pain or no-opioids5. Chemotherapies


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Across the Life Span

Types of Musculoskeletal Trauma

1. Contusion is a soft tissue injury produced by blunt force (a blow, a kick or fall). Many small blood vesselsrupture and bleed into soft tissues. (ecchymosis, bruising)

- A hematoma develops- Local symptoms (pain, swelling, and discoloration) are controlled with intermittent application of cold

2. Concussion3. Sprain

- Injury to the ligaments surrounding a joint caused by a wrenching or twisting motion. A torn ligamentloses its stabilizing ability. Blood vessels rupture and edema occurs. The joint is tender and movement

of the joint becomes painful

- The function of a ligament is to maintain stability while permitting mobility4. Strain

- A muscle pull from overuse, overstretching or excessive stress. Strains are microscopic, incompletemuscle tears with some bleeding into the tissue. The patient experiences soreness or sudden pain with

local tenderness upon muscle use and isometric contraction (compression bandaging)

Nursing management

RICE Rest, Ice, Compression, Elevation

Rest resting and elevating the affected part. Rest prevents additional injury and promotes healing

I Moist or dry cold application after injury produces vasoconstriction which decreases bleeding, edema,

and discomfort

C Elastic compression bandage bleeding, edema and provides support

E Elevation controls the swelling (elevate at the level of the heart)

- After the acute inflammatory stage 24-48 hours, heat may be applied intermittently 15 to 30 minutes4x daily to relieve muscle spasm and to promote vasodilation, absorption and repair

5. Joint Dislocation- A dislocation of a joint is a condition in which the articular surfaces of the bones forming the joint are

no longer in anatomic contact. The bone literally out of the joint

- If dislocation is not treated promptly avascular necrosis (tissue death due to anoxia and diminishedblood supply) and nerve palsy may occur

- Dislocation may bei. Congenital, present at birth (most often the hip)ii. Spontaneous or Pathologic due to disease of articular or the periarticular structure

iii. Traumatic resulting from injury in which the joint is disrupted by forceNursing Management

- Providing comfort, evaluation the patients neurovascular status, protecting the joint during healingprocess, collaborative analgesic, muscle relaxant


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- Sling or underarm sling bandage6. Fracture

- Any break or disruption in teh continuity of the bone- Traumatic injuries account for the majority of fractures. Although some are caused by a disease

process (pathological) 5%

- Fractures are described and classified according to:1.

Type

2. Communication or non-communication with the external environment3. Location

- Fractures are also described as stable or unstable (cut through the Periosteum). A stable fracture occurswhen some of the Periosteum is intact across the fracture. Stable fractures are usually transverse

spiral or greenstick

- ***periosteum outer covering of bone; gives nourishment for bones; allows attachment for tendonsand ligament; contains blood vessels, nerve endings and lymphatics.; therefore if cut through and

through blood supply is diminished (fracture)

- ***transverse going across the bone and doesnt tear periosteum- An unstable fracture is grossly displaced during injury and a site of poor fixation. Unstable are usuallycomminuted and obliqueClinical Manifestation of Fracture

1. Edema and swelling2. Pain and tendernessnerve endings damaged; tender due to spasticity of muscles3. Muscle spasm - most of the time, few muscle spasms in stable fractures; unstable fractures =

formation of muscles are destroyed thus becomes spastic; therefore do not attempt to straighten it

4. Deformitymostly seen in unstable5. Ecchymosis discoloration of skin as a result of extravasation of blood in subcutaneous tissue o

soft tissue, contusion

6. Loss of function7. Crepitation (grating sound)8. Bleeding from an open and with protrusion of bone ends

Study Healing Process of Bones

Complication of Fractures

- Complication of fractures fall into 2 categories:- Early and Delayed.

Early

1. Shock Epiphysis (traumatic or hypovolemic shock) 4-5L of blood in females; 6L for males; losemore blood if compounded; blood is oozing because bone is very vascular; bleeding comes from

inside of intramedullary area; lose more red blood cells if from epiphysis

o Hypovolemic or traumatic shock, resulting from hemorrhage and loss of extracellular fluid intodamaged tissues, may occur in fractures of the extremities, thorax, pelvis and spine. Because

the bone is very vascular, large quantities of blood may be lost as a result of trauma, especially

in fracture of the femur and pelvis


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2. Fat Embolismo After fx of long bones or pelvis, multiple fx, or crushing injuries, fat emboli may develop at the

time of fx., fat globules may move into the blood because the marrow pressure is greater than

the capillary pressure or because catecholamines elevated by the patients stress reaction

mobilize fatty acids and promote the development of fat globules combine with plate lets to

from emboli which hen block the small blood vessels that supply the brain, lungs, kidneys and

other organs***fatty marrow very high in pressure than cut or veins; stress body releases catecholamines

***If fractured: dont move immediately-> may dislodge emboli

***emboli will dislodge in smaller arteries (capillary area) -> impede physiological structure; if

in brain = hypoxia -> anoxia

o Dislodge in smaller arteries/arterioleso Brain hypoxiao Clinical Manifestations

Presenting features include hypoxia, tachypnea, tachycardia, and pyrexia. Cerebradisturbance (due to hypoxia) causes by lodging of fat emboli in the brain are

manifested by mental status changes varying from mild agitation and confusion todelirium and coma. The respiratory response includes tachypnea, dyspnea, crackles

wheezes, pre cordial chest pain, cough, large amount of thick white sputum and

tachycardia. Edema and hemorrhage in the alveoli impairs O2 transport leading

ARDS if in the lungs; damage of alveoli ***weak or absent pulse due to hypovolemia, pale cold moist skin, nausea, shallow

irregular breathing, vacant lackluster pupils dilated (eyes)

o Prevention and Management(to prevent ARDS)1. Immediately immobilization of fx, minimal fx manipulation and adequate support for

fxd bones during turning and position are measure that may reduce the incidence of fat

emboli2. Support the respiratory system and to correct homeostasis disturbances. Respiratory

failure is the most common cause of death. O2 is given in high concentration.

3. Corticosteroids to treat inflammatory lung reaction to control cerebral edema4. Accurate intake of fluid and output records5. Analgesics

6. Accurate intake fluid and output records7. Analgesics

3. Compartment Syndromeo Is a complication that develops when tissue perfusion in the muscles is less than that required

for tissue viability. The patient complains of deep, throbbing, unrelenting pain which is not

controlled by opioids. This can be due to:

1. Reduction of the muscle compartment size because the enclosing muscle fascia is tootight or a cast or redressing is constrictive or

2. An increase in muscle compartment contents because of edema or hemorrhageassociated with a variety of problems e.g. fxs, crushing injuries

o Permanent function can be lost if teh anoxia situation continues from more than 6 hours


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***care must be noted in casting children or infants

***fascia outer covering of the muscle; separates the muscles

***in every muscle there is a compartment : muscle compartment

***bone fracture fascia intact but muscle is torn -> bleeding inside -> edema formation

because blood cannot go out of fascia -> pressure increased inside -> blood seep

into tissues

Assessment

o Frequent assessment of neurovascular function after fx is essential. Peripheral circulation ievaluated by assessing color, temperature, capillary refill time and feeling pulses

***elevate area to heart level: independent management if capillary refill more than 3

seconds

Management

o Prompt management of acute CS is essential. The physical need to be notified immediatelywhen neurovascular compromise is suspected. Delay may result in permanent nerve and

muscle damage or even necrosis, which requires amputation

o Controlling swelling by elevation of the extremity at the cardiac level; releasing restrictivedevices (dressing or cast) or both. If not relieved after 1 hour then FASCIOTOMY is done

Surgical decompression with excision of the membrane covering and separating muscles.

***fascia is not closed, it is drained afterwards (take time to remove clots, etc); place suction

drains = after fasciotomy, patient relieved of compartment syndrome

4. Thromboembolism (pulmonary embolism)5. Disseminated intravascular coagulopathy6. Infection if compoundedDelayed Complication

1. Delayed union and non-union occurs when healing does not advance at a normal rate for thelocation and type of fx. Delayed union may be associated with systemic infection and distraction

(pulling apart) of bone fragment. Eventually, the fracture heals

***mgt for bone gap = internal self fixation-> align and immobilize -> remove portions of bones

(trabeculae: spongy bone or red bone marrow) and undergo bone grafting

***fixation: heal first soft tissue before reparing the bone; just align bone first

***external fixators screws are placed into the bone above and below the fracture, and a

device is attached to the screws from outside the skin

Non-union

o results from failure of the ends of a fractured bone to unite. Factors contributing to unionproblems include infection at the fracture site, interposition of tissue between the bone ends,

inadequate immobilization or manipulation that disrupts callus formation, excessive space

between bone fragments (bone gap,), limited bone contact and impaired blood supply resulting

in avascular necrosis

o avascular necrosis of bone (worst thing to happen -> arthroplasty or amputation


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o when the bone loses its blood supply and dies. It may follow a fracture with disruption o theblood supply (esp in the femoral neck)

***Intertrochanteric area or extratrochanteric area; intracapsular or extracapsular

2. Avascular necrosis of boneo When the bone losses its blood supply and dies. It may flow a fracture with disruption of blood

supply. (esp in the femoral neck)

3.

Reaction to external fixation deviceso Allergy to metallic alloy usedo Corrosion of the deviseo Faulty or damaged deviceso Mechanical failure, inadequate insertion and stabilization

4. Reflex Sympathetic Dystrophy Syndromeo Is uncommon, painful, sympathetic NS problem. It usually occurs in an extremity after trauma

and is seen more often in women

o Rare5. Heterotrophic Ossification (myositis ossificans)

o is the abnormal formation of bone near bones or in muscle in response to soft tissuetrauma after blunt trauma, fracture or total joint replacement***formation of bones outside of bones or ossification of bones near bones

Other Early Complications

- Deep Vein Thrombosis (DVT), thromboembolism and pulmonary embolus are associated with reducedskeletal muscle contraction and bed rest. Patient with fxs of the lower extremities and pelvis are at

high risk for thromboembolism. Pulmonary embolism may cause death several days to weeks afte

injury

- DIC (Disseminated Intravascular Coagulopathy) includes a groups of bleeding disorders with diverscauses, including massive tissue trauma

Care of Clients in a Cast

o Cast is a rigid external immobilizing device that is molded to the contours of the body. The purpose of a castare to immobilize a body part in a specific position and to apply uniform pressure on encased soft tissue

o A cast is used specifically to immobilize a reduced fx to correct a deformity, to apply uniform pressure tounderlying soft tissue, or to support and stabilize weakened joints. Generally casts permit mobilization o

the patient while restricting movement of a body part

Casting Materials

1. Non-plaster- Generally referred to as fibreglass casts. These water activated polyurethane materials have the

versatility of plaster but are lighter in weight, stronger, water resistant and durable. These porous and

therefore diminish ski problems

2. Plaster- Traditional


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- Rolls of plaster bandage are wet in cool water and applied smoothly to the body, a crystallizingreaction occurs, and heat is given off (an exothermic reaction)

Before application of a cast: The nurses roles in the preparation of the patient.

- Prepare a basin with tap water. 4 inches plaster of paris if arm; 6 inches if leg- Plaster of Paris- Made of cotton cotton pad or wadding sheet- Do not prepare splints! Remove splints and apply cast- Clean the area- Position client- Apply stockinette first (with holes distally and proximal)- Apply cotton pad apply 3 inches to protect skin of cast; apply 2-3 inches more than the cast- Soak plaster of Paris in water; squeeze do not wring- Assisting = hold with palm not fingers; smoothen area to make it dry using palms (not use fingers to

prevent dents and compression areas)

- Dry outside right away and conforms to shape of leg- 24 48 hours dry = plaster of paris- Fully dry? Tap it if its resonant and hollow. Temperature is same with environment .- While it is drying = exothermic thus emits heat energy; dont have to cover it with towels or blanket to

prevent burns of skin

- Trim down edges with scissors to prevent abrasions on skin; place stockinette over edges; apply stickyplaster at edge of cast to smoothen it; finish the cast by petalling

Assessment After Cast Application

A. Neurovascular assessment to a casted extremity- Color, warmth, pulses distal to the cast, capillary refill (circulatory function)- Movement of distal fingers or toes, awareness of light tough distal to the cast, changes in sensation

(nerve function)

B. Assessment of pain- If pain cannot be relieved = indication of compartment syndrome

C. Assessment of cast assess for hot spots- Wet spots = may indicate drainage under the cast or a need for additional drying. Stains can indicate

wound drainage or bleeding = must be documented

- An older cast may develop a sour smell because of perspiration or normal sloughing of outer skinlayers. Musty, offensive odors under the cast, however, may indicate tissue necrosis or infection.

Managing a Patient with External Fixator

- External, fixators are used to manage open fxs with soft tissue damage. They provide stable support fosevere comminuted (crushed or splintered) fxs while permitting active tx of damaged soft tissue

- The potential for neurovascular deficit or CS is high. It could still develop in an open fx to anothecompartment in the same site.


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***do not allow to crust pin site area; remove oozing and let dry; do not allow oozing to crust (area where

bacteria will invade -> can lead to osteomyelitis)

Nursing Interventions

- Pre-op: prepare the client psychologically for application of the external fixator- Reassurance that the discomfort associated with the device is minimal (will weigh more than 3 kilos)- After the ex fix is applied the extremity is elevated to reduce swelling- Monitors the neurovascular status of the extremity every 2 to 4 hours- Check pins for loosening- Bleeding persistently at the sites where pins are must be reported- Antibiotic open wounds- In sites and wound must be constantly assessed for signs of infection- Wound healing must be carefully assessed and documented- Note for any skin tension or puckering (tenting or wrinkling) at the insertion site- Adhering to any weight bearing restrictions and correct use of ambulatory aids- Nutritional status increase fluid intake, vitamin D and Calcium

Client and family education:

1. Hygiene2. Nutrition3. How to use analgesic and its alternative method of pain management such as diversion4. Could resume sexual activities

Managing the Patient in Traction

- Traction is the application of a pulling force to a part of the body- Traction is used to minimize muscle spasms- To reduce, align, and immobilize fxs- To increase space between opposing surfaces- As muscle and soft tissue relax, the amount of weight used may be changed to obtained the desired effect

Principles of Effective Traction

- Whenever traction is applied, countertraction must be used to achieve effective traction. Countertractionin the force acting the opposite direction. Usually, the px body weight and bed position adjustments supply

the needed counter traction

- May put bed in trendelenburg to help in countertractionTypes of Traction

- Straight or running traction applies the pulling force in a straight line with the body part resting on thebed. BUCKs extension traction is an example of straight traction.

- Balanced suspension traction supports the affected extremity off the bed and allows for some patientmovement without disruption of the line of pull.

- Skin traction applied to the skino Hangingo Flat


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Possible complications of skin traction

1. Nerve pressure- Nerve Function

1. Dorsiflexion of the foot demonstrate function of the peroneal nerve2. Plantar flexion demonstrates function of the TIbial nerve

2. Skin breakdown happens to old clients or babies3.

Circulatory impairment -

- Skeletal traction directly to the bony skeletono Applied directly to the bone by the use of metal pin or wire (e.g. Steinmann pin, or

Kirshcnerwire or K-wire) that is inserted through the bone distal to the fracture, avoiding

nerves, blood vessels, muscles, tendons and joints.

***apply to shin bone

***apply on metatarsals if fracture in ulna

***Bucks Skin traction most often seen in wards. Put nerve pressure in area causing numbness.

***Skeletal traction with cast

***Bryant Tractionskin traction; doesnt involve the bone; good for babies with hip dislocation

***Russel Traction skin traction;***Dunlop Traction skin traction

Nursing Intervention

1. Maintaining effective traction the N checks the apparatus to see that the ropes are in the wheel groovesof the pulleys, ropes not frayed, weights hang free, evaluate patient position

2. Maintaining position the nurse must maintain alignment of the clients body in traction as prescribed topromote an effective line of pull. The clients foot may be supported in a neutral position by orthopedic

devices to prevent foot drop or plantar flexion, inversion or eversion of foot.

3. Preventing skin breakdown the nurse should protect the elbows and heels, inspect them for pressureareas. By using a trapeze overhead, elbows and heels will be protected from overuse or from using it every

time the client moves that would create undue pressure to these sensitive bony prominence

4. Monitoring neurovascular status every hour initially and then every 4 hours5. Providing pin site care our goal is to avoid infection and development of osteomyelitis. Slight serous

oozing at the pin site is expected but crusting should be prevented.

***Nursing Alert: the nurse must inspect the pin site at least every 8 hours for signs of inflammation and evidence

of infection.

***Promoting exercises isometric exercises of the immobilized extremity (quadriceps-setting and gluteal-setting)

***How do you exercise your client with traction? Isometric (contraction but no movement)

***Arthrokinematics; ROM

Care of the Amputee or Managing an Amputated Client

- Amputation is the removal of a body part, usually an extremity. Amputation of a lower extremityAmputation of a lower extremity is often made necessary by progressive PVD (often sequela of DM)


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- Fulminating gas gangrene, trauma (crushing injuries, burns, frost bite, electrical burns), congenitaldeformities, chronic osteomyelitis, or malignant tumor

Indications for Amputation

1. Trauma an extremity that has been severely damaged as a result of a crushing injury explosion, or armedconflict is likely to require amputation

2. Thermal injuries injuries from frostbite or burns may necessitate amputation3. Infection such as osteomyelitis4. Gangrenevascular disease duty to DM or arteriosclerosis may result in an inadequate blood supply to the

tissues, causes a gangrenous limb

5. Congenital deformity6. Tumor the possibility of metastasis in the case of a malignancy makes amputation of the affected limb

desirable

7. Pain an extremity may be painful because of a circulatory problem. If relief is not obtainable any otheway, amputation may be indicated

Types of Amputation

1. Open or Guillotine Method is generally performed in the presence of infection or when infection isinevitable. The stump is not suture allowing for an open drainage of any purulent exudate, the stump end

is then covered with bulky soft compression dressing

- Antibiotic is an integral. Healing is by granulation and is prolonged.2. Closed Amputation or Flap Method or Myoplastic Amputation the muscles are divided at least 2 inches

distal to the level of intended bone section. They are then sutured under tension to the bone or opposing

muscle group.

- Not suturing in the middle for prosthesis preparationLevels or Sites of Amputation

1. Foot or Chopart Amputation loss of balance and possible deformity must be considered when part of afoot or toes are removed.

2. Ankle (Syme) removes the foot and the ankle and can be very satisfactory operation, since it produces astump that is ideal for weight bearing.

3. Below the Knee an ideal stump for prosthetic fitting should include 5-7 inches of the tibia. Inadequatecirculation may cause problems in a stump that is much longer and stump fitting can be a problem.

4. Knee disarticulation the patella is either removed, with the quadriceps tendon brought over the end ofthe femur, or else the patella is fixed at the condyles.

5. Above the knee 3 inches above the knee joint usually provides a good length for control of a prosthesis6. Hip disarticulation amputation through the hip or pelvis is a rare and is used in instances of malignant

tumors and extensive injuries or gangrene.


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7. Hemipelvectomy removal of the entire extremity and a half of the pelvis is a shocking procedure and isdone rarely even in the cases of malignancy.

8. Fingers when any part or all of a finger is removed, the stump must be designed. So it will not interferewith the function of other fingers.

9. Wrist disarticulation10.Below the Elbow about 7 inches form the elbow, or the junction between the middle and lower thirds of

the forearm is the ideal site for this amputation.

11.Above the elbow as much length as possible is saved in order to preserve arm strength12.Elbow disarticulation infrequently done because the shape of the end of the humerus..13.Shoulder disarticulation rarely done because it is disabling and traumaticNursing Process: The patient undergoing an amputation

o AssessmentBefore surgery, the nurse must evaluate the neurovascular status and functional status of the extremity

through history and physical assessment.

The nurse evaluates the patients nutritional status

The nurse assesses the patients psychological status. Determination of the patients emotional reaction to

amputation is essential for nursing care.

o Nursing DiagnosisImpaired physical mobility related to loss of extremity

o Planning and GoalsRestoration of physical mobility

o Nursing interventionsHelping patient achieve physical mobility.

o Evaluation (expected outcome)Achieves maximum independent mobility

Review

warm compress = 36.5 40.5 C

How do you apply hot packs? Place towels on the bed; place hot packs on towel and roll it and place it on joint

(temp very high more than 40 C); placed only for 5-10 minutes and depends on clients feeling of warmth; if

too hot: place another towel

Purpose of hot packing? Vasodilation and improved circulation; do ROM after hot packs

Temp for trauma is different. 36.5 40.5

Documents

Ortho Lecture