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Musculo-skeletal SystemMusculo-skeletal System
Bone growthBone growth
Types of BonesTypes of Bones
1.1. Long bonesLong bones – femur – femur2.2. Short bonesShort bones – somewhat cubed- – somewhat cubed-
shaped as in the phalanges shaped as in the phalanges3.3. Flat bonesFlat bones – broad surface for – broad surface for
muscular attachment or protection muscular attachment or protection of organs; skull, ribs, shoulder of organs; skull, ribs, shoulder blades, & sternum.blades, & sternum.
4.4. Irregular bonesIrregular bones – wrist, vertebrae – wrist, vertebrae
Functions of BonesFunctions of Bones
Support & protect body tissues and organsSupport & protect body tissues and organs Provides the skeletal framework of the Provides the skeletal framework of the
bodybody Provides movement through the Provides movement through the
attachment of muscles attachment of muscles Storehouse for minerals: CAStorehouse for minerals: CA++ ++ 99% 99%
makeup of bones & POmakeup of bones & PO44 90% 90% Production of blood cells which takes place Production of blood cells which takes place
in the bone marrowin the bone marrow
Diarthrodial/Synovial Diarthrodial/Synovial JointsJoints
Ball & socketBall & socket i.e. shoulder & hip i.e. shoulder & hip which permits movement in any which permits movement in any directiondirection
HingeHinge i.e. elbow movement along one i.e. elbow movement along one plane & allows flexion & extensionplane & allows flexion & extension
CondylarCondylar – functions like a hinge joint – functions like a hinge joint but can rotate slightlybut can rotate slightly
Synovial Joint Synovial Joint CapsuleCapsule
Fibrous connective tissue Fibrous connective tissue covers the ends of covers the ends of bone. Ligaments and bone. Ligaments and tendons reinforce the tendons reinforce the joint capsulejoint capsule
Bundles of rich, white Bundles of rich, white fibrous tissue are supplied fibrous tissue are supplied with nerves. Nerves are with nerves. Nerves are sensitive to rate and sensitive to rate and direction of motion, direction of motion, compression, tension, compression, tension, vibration and painvibration and pain
Blood vessels, and Blood vessels, and lymphatic vessels. lymphatic vessels.
Skeletal MusclesSkeletal Muscles
Primary FunctionPrimary Function
Provides voluntary movementProvides voluntary movement Maintains postureMaintains posture Body Movement – contraction & Body Movement – contraction &
relaxationrelaxation
Skeletal MusclesSkeletal Muscles
Points of AttachmentPoints of Attachment
Point of origin – attachment of Point of origin – attachment of muscle to a more stationary bonemuscle to a more stationary bone
Point of insertions – attachment to Point of insertions – attachment to a more movable bonea more movable bone
Head to Toe Head to Toe AssessmentAssessment
Health HistoryHealth History
Musculoskeletal disordersMusculoskeletal disorders Nutritional statusNutritional status Pain HistoryPain History ADLs, endurance, assistive devicesADLs, endurance, assistive devices Medications – prescription and OTCMedications – prescription and OTC
Assessment SkillsAssessment Skills
Inspection – symmetry, body alignment, Inspection – symmetry, body alignment, function, skin changes, swelling, function, skin changes, swelling, deformity, contractures, gait, non-verbal deformity, contractures, gait, non-verbal indication of painindication of pain
Palpation – Skin temperature, swelling, Palpation – Skin temperature, swelling, nodules, masses, crepitusnodules, masses, crepitus
Joint Structure & ROMJoint Structure & ROM Muscle mass & strength (atrophy, Muscle mass & strength (atrophy,
flaccidly, spasticity, paralysis)flaccidly, spasticity, paralysis)
Connective Tissue Connective Tissue DisordersDisorders
Rheumatoid ArthritisRheumatoid Arthritis
OsteoarthritisOsteoarthritis
Lupus ErythematousLupus Erythematous
GoutGout
Rheumatoid ArthritisRheumatoid Arthritis
Autoimmune connective tissue Autoimmune connective tissue disorder characterized by disorder characterized by inflammatory destructive changes inflammatory destructive changes in the jointsin the joints
Systemic disease – Inflammatory Systemic disease – Inflammatory changes can affect skin, heart, changes can affect skin, heart, lungs, eyes, blood vessels & nerveslungs, eyes, blood vessels & nerves
Etiology of Rheumatoid Etiology of Rheumatoid ArthritisArthritis
Autoimmune theory – Normal Autoimmune theory – Normal antibodies become autoantibodies antibodies become autoantibodies (RH Factors) and attack the tissue. (RH Factors) and attack the tissue.
Genetic Factor – 2-3 times > with Genetic Factor – 2-3 times > with family Hxfamily Hx
Virus – Epstein-Barr Virus – Epstein-Barr Stressful eventsStressful events
Stages of Joint Stages of Joint DeteriorationDeterioration
Stage 1Stage 1: Initiation - Some changes in the : Initiation - Some changes in the synovial lining – no loss of functional synovial lining – no loss of functional capacitycapacity
Stage 2Stage 2: Immune Response – Joint swells : Immune Response – Joint swells & thickens. Functional capacity impaired.& thickens. Functional capacity impaired.
Stage 3Stage 3: Inflammatory - Progressive : Inflammatory - Progressive involvement of blood vessels. Limited ADL.involvement of blood vessels. Limited ADL.
Stage 4Stage 4: Destructive – Granulation tissue : Destructive – Granulation tissue hardens (Pannus). Leads to ankylosis. hardens (Pannus). Leads to ankylosis. Confined to bed or wheel chair.Confined to bed or wheel chair.
Assessment DataAssessment Data
Subjective:Subjective: - Stiffness especially in a.m. or after- Stiffness especially in a.m. or after
inactivityinactivity
- Proximal joint pain in the fingers- Proximal joint pain in the fingers
- Fatigue, weakness, weight loss, - Fatigue, weakness, weight loss, low grade fever low grade fever
Assessment DataAssessment Data
Objective ManifestationsObjective Manifestations- Swollen, reddened, warm joints- Swollen, reddened, warm joints
- Weak hand grasp- Weak hand grasp- Deformities (late stages) - Deformities (late stages)
Swan Neck Swan Neck Ulnar DriftUlnar Drift Boutonnière (buttonhole)Boutonnière (buttonhole) Rheumatoid NodulesRheumatoid Nodules Vasculitis, Sjogren’s SyndromeVasculitis, Sjogren’s Syndrome
Diagnostic TestsDiagnostic Tests
Blood Tests:Blood Tests:- Rheumatoid Factor- Rheumatoid Factor
- Antinuclear Antibody Titer- Antinuclear Antibody Titer
- Erythrocyte Sedimentation Rate- Erythrocyte Sedimentation Rate
- CBC; WBC- CBC; WBC
Diagnostic TestsDiagnostic Tests
Radiographic: determines cartilage Radiographic: determines cartilage erosion, joint space narrowing, bone erosion, joint space narrowing, bone cystscysts
- Arthrography- x-ray with contrast - Arthrography- x-ray with contrast mediummedium
- Arthroscopy – endoscopic exam of joint- Arthroscopy – endoscopic exam of joint
- Arthrocentesis – needle aspiration of - Arthrocentesis – needle aspiration of
synovial fluidsynovial fluid
Nursing CareNursing CareArthroscopy Post-Arthroscopy Post-
procedureprocedure
Assess neurovascular status (sx of Assess neurovascular status (sx of thrombophlebitis)thrombophlebitis)
Monitor for bleeding or leakage at Monitor for bleeding or leakage at sitesite
Assess for pain, edema, rednessAssess for pain, edema, redness Ice for swelling, mild analgesic Ice for swelling, mild analgesic
painpain
Pain ManagementPain Management
Prescribed Drug Therapy on timely Prescribed Drug Therapy on timely basisbasis
Rest periodsRest periods Warm shower, hot packsWarm shower, hot packs Avoid sudden, jarring of jointAvoid sudden, jarring of joint Warn clients about “quacks” Warn clients about “quacks”
(miracle cures)(miracle cures)
Impaired Physical MobilityImpaired Physical Mobility
Exercise joint, but not beyond painExercise joint, but not beyond pain Positioning & body alignmentPositioning & body alignment Support joints for optimal function Support joints for optimal function Assistive Devices – proper fit & Assistive Devices – proper fit &
instructioninstruction
Self-care DeficitSelf-care Deficit
Routine that includes pacing Routine that includes pacing activitiesactivities
Encourage sleep routineEncourage sleep routine PT for conditioningPT for conditioning Occupational Therapy – Assistive Occupational Therapy – Assistive
devicesdevices
Drug TherapyDrug Therapy
Salicylates (ASA) Salicylates (ASA) – Side effects/PrecautionsSide effects/Precautions
Tinnitus, GI distress, prolonged bleeding. Give Tinnitus, GI distress, prolonged bleeding. Give with food, milk. Avoid anti-coagulants.with food, milk. Avoid anti-coagulants.
NSAID’s (Advil, Indocin, Toradol, NSAID’s (Advil, Indocin, Toradol, Naprosyn)Naprosyn)– Side effects/PrecautionsSide effects/Precautions
GI (do not crush enteric coated); give after meals GI (do not crush enteric coated); give after meals or with foodor with food
Dizziness, diarrhea, headache, rashDizziness, diarrhea, headache, rash
Drug TherapyDrug Therapy
Glucocorticoids (dexamethasone, Glucocorticoids (dexamethasone, hydrocortisone, prednisone)hydrocortisone, prednisone)– Side Effects/PrecautionsSide Effects/Precautions
– Depression, euphoria, anorexia, Depression, euphoria, anorexia, nausea, nausea,
weight gain, bruising. Taper dosage weight gain, bruising. Taper dosage when discontinuing.when discontinuing.
Drug TherapyDrug Therapy
Slow-acting Antimalarial drugs Slow-acting Antimalarial drugs (plaquenil)(plaquenil)– Side Effects/PrecautionsSide Effects/Precautions
Retinal edema, GI disturbanceRetinal edema, GI disturbance
Toxic – Gold Salts (solganol, Toxic – Gold Salts (solganol, myochrysine)myochrysine)– Side Effects/PrecautionsSide Effects/Precautions
Dizziness, flushing, metallic taste, skin rash; Dizziness, flushing, metallic taste, skin rash; assess CBC & UA prior to administrationassess CBC & UA prior to administration
Drug TherapyDrug Therapy
Cytoxic Drugs (Methotrexate, Cytoxic Drugs (Methotrexate, Imuran, Cytoxan)Imuran, Cytoxan)– Side Effects/PrecautionsSide Effects/Precautions
Pneumocystis Carinii pneumonia, mouth Pneumocystis Carinii pneumonia, mouth sores, bone marrow suppression, sores, bone marrow suppression, hepatotoxicity hepatotoxicity
Degenerative Joint DiseaseDegenerative Joint Disease(Osteoarthritis)(Osteoarthritis)
Non-inflammatory disease of the weight Non-inflammatory disease of the weight bearing joints (hips, knees, spine, bearing joints (hips, knees, spine, hands)hands)
Incidence: > in post-menopausal Incidence: > in post-menopausal womenwomen
Risk Factors: age, obesity, overuse of Risk Factors: age, obesity, overuse of joints, trauma (fractures, sports joints, trauma (fractures, sports injuries)injuries)
OsteoarthritisOsteoarthritis PathophysiologyPathophysiology – Articular cartilage – Articular cartilage
becomes yellow & opaque, joint space becomes yellow & opaque, joint space narrows, bone spurs (osteocytes), & cystsnarrows, bone spurs (osteocytes), & cysts
SymptomsSymptoms – Joint pain / diminishes on rest ; – Joint pain / diminishes on rest ; crepitus (grating sensation); joint crepitus (grating sensation); joint enlargement, Herberden’s nodes, enlargement, Herberden’s nodes, Bouchard’s nodules, decrease ROM, joint Bouchard’s nodules, decrease ROM, joint effusioneffusion
OsteoarthritisOsteoarthritis
Diagnostic Tests:Diagnostic Tests: X-rays of joints X-rays of joints indicates narrowing of joint spaces; indicates narrowing of joint spaces; CT Scan & MRI of spine; Bone ScanCT Scan & MRI of spine; Bone Scan
Differential features of RA & DJDDifferential features of RA & DJD
OsteoarthritisOsteoarthritis
Medical ManagementMedical Management Drug therapy for pain (NSAID’s), muscle Drug therapy for pain (NSAID’s), muscle
relaxants (Flexeril), injection of cortisonerelaxants (Flexeril), injection of cortisone Rest – immobilization with splint, brace, Rest – immobilization with splint, brace,
sleep (>8 hours/night)sleep (>8 hours/night) Position of joints to maintain alignment & Position of joints to maintain alignment &
avoid contracturesavoid contractures Heat – hot packs, PT diathermyHeat – hot packs, PT diathermy Exercise – walking, water aerobicsExercise – walking, water aerobics
OsteoarthritisOsteoarthritis
Surgical ManagementSurgical Management Hemiarthroplasty: one part of a joint Hemiarthroplasty: one part of a joint
is replaced, i.e. head of femuris replaced, i.e. head of femur Total Hip replacement: Head of Total Hip replacement: Head of
femur & the acetabulum replacedfemur & the acetabulum replaced Total Knee replacement: both Total Knee replacement: both
articular surfaces of the knee articular surfaces of the knee replacedreplaced
Interphalangeal joint replacementInterphalangeal joint replacement
Total Hip ReplacementTotal Hip Replacement
Preoperative Care – Skin preparation, IV Preoperative Care – Skin preparation, IV antibiotics, education re: nature of antibiotics, education re: nature of prosthesis, mobility restrictions, prosthesis, mobility restrictions, exercisesexercises
Types of ProsthesisTypes of Prosthesis
- Cemented – > 10 year life- Cemented – > 10 year life
- Uncemented – bone growth occurs into - Uncemented – bone growth occurs into the metallic surfaces within 6-12 weeksthe metallic surfaces within 6-12 weeks
THR - Postoperative THR - Postoperative
Pain controlPain control Wound & drain assessmentWound & drain assessment Neurovascular AssessmentNeurovascular Assessment Activity – bed rest with abduction Activity – bed rest with abduction
splint or pillow, OOB with PT (NO splint or pillow, OOB with PT (NO hip flexion > 90hip flexion > 90°°) weight bearing ) weight bearing dependent on type of prosthesisdependent on type of prosthesis
Use of walker – crutches - caneUse of walker – crutches - cane
THR - Potential THR - Potential ComplicationComplication
ThromboembolismThromboembolism
Subluxation - Hip Dislocation Subluxation - Hip Dislocation
Neurovascular CompromiseNeurovascular Compromise
HemorrhageHemorrhage
THR – Hip PrecautionsTHR – Hip Precautions
Avoid hip flexion > 90Avoid hip flexion > 90°° Avoid low, soft chairsAvoid low, soft chairs Avoid excessive trunk flexion in Avoid excessive trunk flexion in
reachingreaching Maintain hip adductionMaintain hip adduction No leg crossing at kneeNo leg crossing at knee Use raised toilet seat Use raised toilet seat
Total Knee ReplacementTotal Knee Replacement
Preoperative Care – similar to THRPreoperative Care – similar to THR Postoperative CarePostoperative Care
- Pain control - Pain control
- Wound & drain assessment- Wound & drain assessment
- Neurovascular Assessment- Neurovascular Assessment
- Elevate leg on pillow for comfort - Elevate leg on pillow for comfort
- Head of bed elevated for comfort - Head of bed elevated for comfort
- Continuous Passive Motion Machine- Continuous Passive Motion Machine
TKR - Potential TKR - Potential ComplicationsComplications
DVT & pulmonary emboliDVT & pulmonary emboli
Prosthetic DislocationProsthetic Dislocation
InfectionInfection
Lupus ErythematousLupus Erythematous
Definition: Autoimmune disease Definition: Autoimmune disease involving diffuse inflammatory changes involving diffuse inflammatory changes in vascular connective tissuein vascular connective tissue
Pathophysiology: Antigen-antibody Pathophysiology: Antigen-antibody interactions results in deposits of interactions results in deposits of immune complexes in tissues & cells immune complexes in tissues & cells that damage the organs and or blood that damage the organs and or blood vesselsvessels
Discoid LupusDiscoid Lupus
Cutaneous Cutaneous manifestations – manifestations – butterfly rash on facebutterfly rash on face
Risk Factor: Sun Risk Factor: Sun exposure intensifiesexposure intensifies
Treatment: Cortisone Treatment: Cortisone creams, sun screens creams, sun screens > 30 SPF, avoid sun > 30 SPF, avoid sun at peak hoursat peak hours
Systemic LupusSystemic Lupus
Organs affected: Heart, lungs, Organs affected: Heart, lungs, kidneykidney,, brain, blood vessels, & jointsbrain, blood vessels, & joints
Systemic symptoms: Fatigue, myalgia, Systemic symptoms: Fatigue, myalgia, joint pain, low grade fever, anorexiajoint pain, low grade fever, anorexia
System specific symptoms: System specific symptoms: Tachycardia, chest pain, proteinuria, Tachycardia, chest pain, proteinuria, hip & knee necrosis, psychosis, seizureship & knee necrosis, psychosis, seizures
Laboratory Tests of SLELaboratory Tests of SLE
Skin biopsy & scrapings of skin Skin biopsy & scrapings of skin cellscells
Immune tests – RF, ANA, Sed RateImmune tests – RF, ANA, Sed Rate
CBC (pancytopenia), Sed Rate, CBC (pancytopenia), Sed Rate, Cardiac & Liver EnzymesCardiac & Liver Enzymes
Pharmacological Pharmacological Management Management
LupusLupus
NSAID’SNSAID’S
CorticosteroidsCorticosteroids
Immunosuppresive AgentsImmunosuppresive Agents
Nursing Care - LupusNursing Care - Lupus
Pain ManagementPain Management Encourage rest periodsEncourage rest periods Decrease protein in diet (kidney Decrease protein in diet (kidney
involvement) and sodium involvement) and sodium restriction (fluid retention)restriction (fluid retention)
Referral – Local & National Lupus Referral – Local & National Lupus FoundationFoundation
Potential Complications Potential Complications Lupus ErythematousLupus Erythematous
VasculitisVasculitis Cardiopulmonary – pericarditis, Cardiopulmonary – pericarditis,
pleural effusionpleural effusion CNS – psychosis, seizures, CNS – psychosis, seizures,
peripheral neuropathiesperipheral neuropathies Avascular NecrosisAvascular Necrosis
Gout Gout
Definition: Systemic disease Definition: Systemic disease involving pain & involving pain & inflammation of joints due inflammation of joints due to urate crystal depositsto urate crystal deposits
Pathophysiology: Imbalance Pathophysiology: Imbalance of purine metabolism & of purine metabolism & kidney functionkidney function
Incidence: Middle aged men Incidence: Middle aged men
Types of GoutTypes of Gout
Primary: Inherited defect in purine Primary: Inherited defect in purine metabolismmetabolism
Secondary: Disease i.e renal, Secondary: Disease i.e renal, diuretic therapy & diuretic therapy & chemotherapeutic agentschemotherapeutic agents
Clinical Manifestations of Clinical Manifestations of GoutGout
Asymptomatic phaseAsymptomatic phase – – Elevated Uric Acid Elevated Uric Acid (.60-.75 gm)(.60-.75 gm)
Acute PhaseAcute Phase – Sustained – Sustained elevated Uric Acid elevated Uric Acid causing extremely causing extremely painful, swollen, and painful, swollen, and reddened jointreddened joint
Chronic PhaseChronic Phase – Urate – Urate crystal deposits appear crystal deposits appear in cartilage, synovial in cartilage, synovial membranes, tendons, & membranes, tendons, & soft tissues (tophi soft tissues (tophi formation)formation)
Drug Therapy - GoutDrug Therapy - Gout
Acute Phase – Colchicine, NSAID’S Acute Phase – Colchicine, NSAID’S
Chronic Phase – Allopurinol Chronic Phase – Allopurinol (Benemid);(Benemid);
ColbenemidColbenemid
Avoid aspirin & diureticsAvoid aspirin & diuretics
Diet Therapy - GoutDiet Therapy - Gout
Low purine (avoid organ meats, Low purine (avoid organ meats, shellfish, oily fish with bones)shellfish, oily fish with bones)
Avoid AlcoholAvoid Alcohol Increase fluid intake to 3,000 cc/dayIncrease fluid intake to 3,000 cc/day High alkaline ash foods – citrus fruits High alkaline ash foods – citrus fruits
and juices, certain dairy productsand juices, certain dairy products
Other Connective Tissue Other Connective Tissue DisordersDisorders
Polymyalgia Polymyalgia Rheumatica Rheumatica
Ankylosing Ankylosing Spongylitis (Marie-Spongylitis (Marie-StrStrüümpell Disease)mpell Disease)
SjSjöögren’s syndromegren’s syndrome Lyme’s DiseaseLyme’s Disease FibromyalgiaFibromyalgia
OsteoporosisOsteoporosis
TypesTypes Primary - Bone loss related to loss of Primary - Bone loss related to loss of
estrogen in menopausal women and estrogen in menopausal women and low testosterone levels in menlow testosterone levels in men
Secondary – Bone loss related to Secondary – Bone loss related to disease process (hyperthyroidism, disease process (hyperthyroidism, renal failure, GI malabsorption renal failure, GI malabsorption problems)problems)
PathophysiologyPathophysiology Bone Remodeling Bone Remodeling
Resorption – Worn out bone cells Resorption – Worn out bone cells are removed by bone-resorbing are removed by bone-resorbing cells called osteoclastscells called osteoclasts
Formation – New bone is laid down Formation – New bone is laid down by bone-forming cells called by bone-forming cells called osteoblastsosteoblasts
Incidence/Risk FactorsIncidence/Risk FactorsOsteoporosisOsteoporosis
AgeAge
RaceRace
GenderGender
Life StyleLife Style
Diet Diet
HeredityHeredity
Prevention of OsteoporosisPrevention of Osteoporosis
Exercise – weight bearing typesExercise – weight bearing types
Diet modifications Diet modifications
Calcium intake – OTC i.e. Tums, Calcium intake – OTC i.e. Tums, Oscal, Calcium carbonate, Dietary Oscal, Calcium carbonate, Dietary supplementsupplement
Clinical ManifestationsClinical ManifestationsOsteoporosisOsteoporosis
Height lossHeight loss
Vertebral deformitiesVertebral deformities
Restricted movementRestricted movement
Back painBack pain
Fractures Fractures
Diagnostic TestsDiagnostic TestsOsteoporosisOsteoporosis
Laboratory – serum calcium, Laboratory – serum calcium, Vitamin D, phosphorus, alkaline Vitamin D, phosphorus, alkaline phosphatasephosphatase
Radiological – X-ray, CT Scan, MRIRadiological – X-ray, CT Scan, MRI
- Dual energy x-ray absorptiometry- Dual energy x-ray absorptiometry
Medical ManagementMedical ManagementOsteoporosisOsteoporosis
Drug TherapyDrug Therapy
Estrogen replacement – PremarinEstrogen replacement – Premarin Calcium supplementsCalcium supplements Bone resorption inhibitor – Bone resorption inhibitor –
FosamaxFosamax Vitamin DVitamin D
Nursing ManagementNursing ManagementOsteoporosisOsteoporosis
High Risk for InjuryHigh Risk for Injury – Prevention of – Prevention of falls and fracturesfalls and fractures
- safe environment- safe environment
(non-skid slippers, shoes, clean spills, (non-skid slippers, shoes, clean spills, avoid scatter rugs, lighting, access to avoid scatter rugs, lighting, access to items for ADL, hand rails, avoiding items for ADL, hand rails, avoiding lifting heavy objects, use of walker, lifting heavy objects, use of walker, cane.)cane.)
Nursing ManagementNursing ManagementOsteoporosisOsteoporosis
Impaired Physical MobilityImpaired Physical Mobility
Increase mobility to level of Increase mobility to level of independence in ADLindependence in ADL
Interventions Interventions
1.1. Physical therapy program Physical therapy program (strengthening & weight bearing (strengthening & weight bearing exercises)exercises)
2.2. Occupational Therapy (Adaptive Occupational Therapy (Adaptive Devices)Devices)
Nursing ManagementNursing ManagementOsteoporosisOsteoporosis
Pain Management - reduce & Pain Management - reduce & alleviate painalleviate pain
InterventionsInterventions1.1. Drug Therapy - opioid, non-opioid Drug Therapy - opioid, non-opioid
analgesics, muscle relaxants, analgesics, muscle relaxants, anti-inflammatory agentsanti-inflammatory agents
2.2. Use of heatUse of heat3.3. Orthotic devices – braces, splintsOrthotic devices – braces, splints
Other Metabolic & Other Metabolic & Degenerative Bone Degenerative Bone
DisordersDisorders
OsteomalaciaOsteomalacia
Paget’s DiseasePaget’s Disease
Herniated Nucleus Pulposus Herniated Nucleus Pulposus
- Laminectomy- Laminectomy
- Spinal Fusions- Spinal Fusions
Fracture PatternsFracture Patterns
Oblique – Line of fx angledOblique – Line of fx angled Transverse – Across the boneTransverse – Across the bone Longitudinal – Length of boneLongitudinal – Length of bone Spiral – Twisting or rotation of boneSpiral – Twisting or rotation of bone Comminuted – broken in > 2 placesComminuted – broken in > 2 places Impacted – Fragments driven into each Impacted – Fragments driven into each
otherother Displaced or Avulsed – torn away by a Displaced or Avulsed – torn away by a
ligament or tendonligament or tendon
FracturesFractures
Classification by Classification by Anatomical LocationAnatomical Location
HumerusHumerus Tibia, FibulaTibia, Fibula PelvisPelvis HipHip SkullSkull MandibleMandible RibsRibs VertebraeVertebrae
FracturesFractures
Definition: Interruption in normal Definition: Interruption in normal bone continuity, which is bone continuity, which is accompanied by soft tissue injuryaccompanied by soft tissue injury
Classification:Classification:
- Simple or closed- Simple or closed
- Open or compound- Open or compound
Stages of Bone HealingStages of Bone Healing
1.1. HematomaHematoma
2.2. GranulationGranulation
3.3. Callus FormationCallus Formation
4.4. Osteoblastic ProliferationOsteoblastic Proliferation
5.5. Bone RemodelingBone Remodeling
6.6. Complete HealingComplete Healing
Bone Healing ProblemsBone Healing Problems
Delayed Union - > 6 months to a Delayed Union - > 6 months to a yearyear
Nonunion - < ½ of bone fragments Nonunion - < ½ of bone fragments joined togetherjoined together
Malunion – Bone healed in state of Malunion – Bone healed in state of deformitydeformity
Assessment of FracturesAssessment of Fractures
Subjective Data – History, Subjective Data – History, complaints of pain, loss of complaints of pain, loss of sensation, movementsensation, movement
Objective Data – Warmth, edema, Objective Data – Warmth, edema, ecchymosis, neurovascular ecchymosis, neurovascular impairment, splinting, anxiety, fearimpairment, splinting, anxiety, fear
Emergency Care Emergency Care
Inspect areaInspect area Control bleedingControl bleeding Immobilize/splintImmobilize/splint Prevent shockPrevent shock Transport safely to ERTransport safely to ER
INTERVENTIONSINTERVENTIONS RR - -
Rest/immobilizeRest/immobilize I I - Ice- Ice CC - Compression - Compression EE - Elevation - Elevation SS - Support - Support
Nursing DiagnosesNursing Diagnoses
Acute PainAcute Pain Risk for Neurovascular DysfunctionRisk for Neurovascular Dysfunction Risk for InfectionRisk for Infection Altered Mobility Altered Mobility Activity IntoleranceActivity Intolerance
Complications of FracturesComplications of Fractures
ShockShock Neurovascular CompromiseNeurovascular Compromise DVT & Pulmonary EmboliDVT & Pulmonary Emboli Aseptic NecrosisAseptic Necrosis Acute Compartment SyndromeAcute Compartment Syndrome Fat Embolism SyndromeFat Embolism Syndrome OsteomyelitisOsteomyelitis
ShockShock
Etiology: Hemorrhage into Etiology: Hemorrhage into damaged tissues, especially damaged tissues, especially thorax, pelvis, & extremitiesthorax, pelvis, & extremities
Treatment: Control bleeding and Treatment: Control bleeding and restore blood volumerestore blood volume
Neurovascular Neurovascular CompromiseCompromise
Etiology: Damage to nerves from Etiology: Damage to nerves from fragments of bone, pressure from fragments of bone, pressure from casts, splints, & tractioncasts, splints, & traction
Assessment: 6 P’s – Pain, Assessment: 6 P’s – Pain, Pulselessness, Paresthesia, Pallor, Pulselessness, Paresthesia, Pallor, Paralysis, Poikilothermia Paralysis, Poikilothermia
INSPECTION/PALPATION INSPECTION/PALPATION FIVE P’SFIVE P’S
PPAINAIN PPULSEULSE PPALLORALLOR PPARASTHESIARASTHESI
AA PPARALYSISARALYSIS
Fat Embolism SyndromeFat Embolism Syndrome
Etiology: Release of particles of fat Etiology: Release of particles of fat into the blood stream from the into the blood stream from the yellow marrow at site of injuryyellow marrow at site of injury
Risk Factors: Fx. of long bones, Risk Factors: Fx. of long bones, multiple fx., high serum glucose or multiple fx., high serum glucose or cholesterol levelcholesterol level
DVT & Pulmonary EmboliDVT & Pulmonary Emboli
Etiology: Immobility, Etiology: Immobility, trauma, surgerytrauma, surgery
Risk Factors: Incidence Risk Factors: Incidence in fractures of the lower in fractures of the lower extremities; smoking, extremities; smoking, obesity, heart diseaseobesity, heart disease
Treatment: Treatment: anticoagulantsanticoagulants
Avascular NecrosisAvascular Necrosis
Etiology: Loss of blood supply to boneEtiology: Loss of blood supply to bone
Risk Factors: Hip fractures or any Risk Factors: Hip fractures or any fracture where this bone displacementfracture where this bone displacement
Treatment: Surgical joint replacement Treatment: Surgical joint replacement
Compartment SyndromeCompartment Syndrome
Etiology: Massive compromise in Etiology: Massive compromise in circulation from external (tight, circulation from external (tight, bulky dressings, casts) & internal bulky dressings, casts) & internal (blood & fluid)(blood & fluid)
Treatment: Immediately loosen Treatment: Immediately loosen any tight dressings & MD can any tight dressings & MD can bivalve castbivalve cast
Surgery – Decompression Surgery – Decompression fasciotomy for edema and bleedingfasciotomy for edema and bleeding
Surgical ManagementSurgical Management
Fasciotomy to relieve pressure. The fascia is divided along the length of the compartment to release pressure within.
OsteomyelitisOsteomyelitis
Acute – infection in another part of Acute – infection in another part of the body invades bone tissue or the body invades bone tissue or occurs from penetrating traumaoccurs from penetrating trauma
Chronic – Infection persists Chronic – Infection persists especially in a patient with especially in a patient with compromised circulationcompromised circulation
Medical Management of Medical Management of FracturesFractures
Closed reduction & immobilization – Manual traction Closed reduction & immobilization – Manual traction to align the boneto align the bone
External Fixation – Percutaneous placement of pins External Fixation – Percutaneous placement of pins implanted into boneimplanted into bone
- Kronner 4-Barr Compression Frame- Kronner 4-Barr Compression Frame- Hex-Fix External device for tibial fractures- Hex-Fix External device for tibial fractures- Halo Traction – Cervical spinal fractures- Halo Traction – Cervical spinal fractures
Nursing Care – External Nursing Care – External FixationFixation
Teach patient patient to grasp frame Teach patient patient to grasp frame when moving, rather than limbwhen moving, rather than limb
Frequent observation & neurovascular Frequent observation & neurovascular assessmentsassessments
Pin Care – Note symptoms of infectionPin Care – Note symptoms of infection Assess for loosening or shifting of Assess for loosening or shifting of
devicesdevices
External FixatorExternal Fixator
External FixationExternal Fixation
External FixatorExternal Fixator
CastsCasts
Purpose: Immobilze, correct Purpose: Immobilze, correct deformity, allow early mobility, & deformity, allow early mobility, & provide support & protectionprovide support & protection
Types: Plaster of Paris & FiberglassTypes: Plaster of Paris & Fiberglass
Plaster Cast CarePlaster Cast Care
Instruct that cast will feel warmInstruct that cast will feel warm Handle cast with palms of handsHandle cast with palms of hands Turn client q 1-2 hours for dryingTurn client q 1-2 hours for drying Elevate on pillow Elevate on pillow higher than hearthigher than heart Pedal rough edges with moleskinPedal rough edges with moleskin Inspect q 4-8 hours – drainage, Inspect q 4-8 hours – drainage,
cracking, odor, alignment & fitcracking, odor, alignment & fit
Cast ComplicationsCast Complications
Circulatory impairmentCirculatory impairment Peripheral nerve damagePeripheral nerve damage Impaired skin integrityImpaired skin integrity Pneumonia, DVT, ConstipationPneumonia, DVT, Constipation Compartment SyndromeCompartment Syndrome Cast Syndrome – Body castCast Syndrome – Body cast Fracture blistersFracture blisters
TractionTraction
Definition: Pulling force that is applied Definition: Pulling force that is applied to part of an extremity while a counter to part of an extremity while a counter traction pulls in the opposite directiontraction pulls in the opposite direction
Purpose: Reduce Fracture, immobilize, Purpose: Reduce Fracture, immobilize, decrease pain & muscle spasm, correct decrease pain & muscle spasm, correct deformities, stretch tight musclesdeformities, stretch tight muscles
Types of TractionTypes of Traction Continuous or Running – Buck’s, RussellContinuous or Running – Buck’s, Russell
Circumferential – PelvicCircumferential – Pelvic
CervicalCervical
Suspension or Balanced – Thomas RingSuspension or Balanced – Thomas Ring
Skeletal – Steinmann pins, Kirschner wires, Skeletal – Steinmann pins, Kirschner wires, Crutchfield tongs Crutchfield tongs
Bucks TractionBucks Traction
Bryants TractionBryants Traction
Skeletal TractionSkeletal Traction
Nursing Assessment Nursing Assessment Equipment – weights, pulley’s, ropes, Balkan frameEquipment – weights, pulley’s, ropes, Balkan frame
MobilityMobility
Skin integrity Skin integrity
NeurovascularNeurovascular
GastrointestinalGastrointestinal
UrinaryUrinary
Fractured HipFractured Hip
Incidence: Prevalent women > 65; Incidence: Prevalent women > 65; 200,000 annually; by age 80 1 in 5200,000 annually; by age 80 1 in 5
Risk Factors: Falls, osteoporosis, Risk Factors: Falls, osteoporosis, age related changes in balanceage related changes in balance
Anatomy of HipAnatomy of Hip
Head of femurHead of femur
AcetabulumAcetabulum
Femoral neckFemoral neck
Greater trochanterGreater trochanter
Lesser or sub-trochanterLesser or sub-trochanter
Types of Hip FracturesTypes of Hip Fractures
Femoral Neck – displaced, Femoral Neck – displaced, impacted, comminutedimpacted, comminuted
Intertrochanteric (Intracapsular, Intertrochanteric (Intracapsular, Extracapsular)Extracapsular)
Subtrochanteric Subtrochanteric
Signs & Symptoms of Hip Signs & Symptoms of Hip FracturesFractures
Pain – hip or thighPain – hip or thigh
Adduction, external rotation Adduction, external rotation
Shortening of legShortening of leg
Inability to move or bear weight Inability to move or bear weight
Surgical InterventionSurgical Intervention
Total Hip Arthroplasty – Total Hip Arthroplasty – - Cemented allows full weight - Cemented allows full weight bearingbearing
- Uncemented – full weight bearing - Uncemented – full weight bearing not permitted for 6-8 weeksnot permitted for 6-8 weeks
ORIF – Intramedullay rods, plates, ORIF – Intramedullay rods, plates, compression screws; allows early compression screws; allows early ambulationambulation
Internal Fixation: Plates and Internal Fixation: Plates and PinsPins
Post-operative Care - ORIFPost-operative Care - ORIF
Bedrest 1Bedrest 1stst day; OOB with walker day; OOB with walker HOB HOB > 35 - 40°> 35 - 40° Avoid hip flexion > 90°Avoid hip flexion > 90° Trochanter roll for hip alignmentTrochanter roll for hip alignment Pillow splint when turning (per MD)Pillow splint when turning (per MD) Isometric exercisesIsometric exercises Pain control – narcotic analgesicsPain control – narcotic analgesics
Complications ORIFComplications ORIF
DVT, PEDVT, PE
HemorrhageHemorrhage
InfectionInfection
Subluxation or dislocationSubluxation or dislocation
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Definition: compression of the Definition: compression of the medial nerve in the wristmedial nerve in the wrist
Etiology: Repetitive motions, wear Etiology: Repetitive motions, wear & tear, fracture of wrist& tear, fracture of wrist
Symptoms: Pain, paresthesia, Symptoms: Pain, paresthesia, difficulty in grasping difficulty in grasping
Carpal tunnel syndrome - atrophy Carpal tunnel syndrome - atrophy and weakness of the handand weakness of the hand
Diagnostic Tests CTSDiagnostic Tests CTS
Phalen’s – wrist flexed back to back Phalen’s – wrist flexed back to back results in paresthesia >60 secondsresults in paresthesia >60 seconds
Tinel’s – Tapping over the median Tinel’s – Tapping over the median nerve pain, tingling, numbness or nerve pain, tingling, numbness or inflating a BP cuff will result in same inflating a BP cuff will result in same sx.sx.
X-rayX-ray EMGEMG
Interventions CTSInterventions CTS
Non-invasive – wrist support, Non-invasive – wrist support, immobilization with splint, frequent immobilization with splint, frequent breaks, cushion grippers on pencils breaks, cushion grippers on pencils & pens, rest, ice, heat, anti-& pens, rest, ice, heat, anti-inflammatory agentsinflammatory agents
Invasive – Cortisone Injections, Invasive – Cortisone Injections, SurgerySurgery