Musculoskeletal Disorders

Physiology

Functions- Provide protection for vital organs

o Bones – ribs, sternum, thoracic vertebraeo Muscles – internals and intercostal muscles, diaphragm

- Support body structures by providing a strong and sturdy framework- Locomotion and movement- Mineral storage

o For metabolismo 99% of the total calcium content of the body is located in the bone

- Haematopoiesiso RBC and WBS are produced according to their nature stem cells

- Heat productiono Through contraction = contain and control heat inside the body

Anatomy- 206 bones in total- Classified according to their location

o Axial (80) Skull Vertebral column

o Appendicular (126) Pectoral girdle

Scapula Clavicle Radius Ulna

Pelvic girdle Iliac Ischium Femur

- Basic Cell typeso Osteoblasts- the CARPENTER

Bone formation Made possible through the secretion of matrix – calcium is the main

component Initiates bone formation via calcification

Process where there is mineralization of the collagen fiber MATRIX and CALCIUM – THE CEMENT; THE FOUNDATION

o Osteocytes – MAINTAINS THE HOUSE Mature type of the osteoblasts Main cell found in the bone Maintenance of bone Excretion of waste materials Is found inside the spaces called lacunae

o Osteoclasts – THE ANAYS (THE ONE THAT DESTROYS THE HOUSE) Huge cells derived from the fusion as many as 50 monocytes Usually concentrated at the endosteum of the bone

Endosteum – at the lumina area, where the medullary cavity is For bone resorption: bone destruction or bone remodelling Bone destruction

Ca is removed- According to General Features

o Long Bone Longer than they are wide Upper and lower limbs

Humerus and Femuro Short Bones

As broad as they are long Wrist and Ankle

o Flat Bones Relatively thin; flattened shape Certain skull bones, ribs, scapulae (shoulder bones, blades and sternum)

o Irregular Do not fit readily into the other three categories Vertebrae and facial bones (mandible, maxillary, zygomatic arch, among others)

o Each long bones consists of a central shaft called diaphysiso While the two ends is called epiphysiso A thin layer of the articular cartilage covers the end of the epiphyses where the bone articulates

with other boneso A long plate that is still growing has an epiphyseal plate or growth plate, composed of cartilage,

between each epiphyses and the diaphysiso Bones contain cavities such as the large medullary cavity in the diaphysis, as well as smaller

cavities in the epiphyses of long bones and in the interior of other boneso These spaces are filled with either yellow ro red marrowo Marrow

The soft tissue in the medullary cavitieso Yellow marrow

Consists of mostly fato Red marrow

Blood forming cells and is the only site of blood formation in adultso Most of the outer surface of the bone is covered by dense connective tissue called periosteum

which contains blood vessels and nerveso The surface of the medullary cavity is lined with a thinner connective tissue membrane called

endosteumo The periosteum and endosteum contain osteoblasts which function in the formation of bone as

well as the repair and remodelling of the boneso When osteoblasts become surrounded by matric, they are referred to as osteocyteso Bones is formed in thin sheets of extracellular matrix called lamellae, with osteocytes located

between the lamellaeo The osteocytes are located with spaces called lacunaeo Cell processes extend from the osteocytes across the extracellular matrix of the lamellae with

tiny canals called canaliculi

Histological Structure- Compact Bone

o Forms most of the diaphysis of long bones and the thinner surfaces of all other bones

o Most of the lamellae of compact bone are organized into sets of concentric rings with each set surrounding a central or haversian canal

o Blood vessels that run parallel to the long axis of the bone are contained within the central canalso Each canal with the lamellae and osteocytes surrounding it is called osteon or haversian systemo Each osteon looks like a microscopic target with the central canal as the bull’s eyeo Osteocytes located in lacunae are connected to one another by cell process in canaliculio The canaliculi give the osteon the appearance of the having tiny cracks in lamellae

- Cancellous Boneo Spongy bone because of its appearanceo Located mainly in the epiphyses of long bones and it forms the interior of all other boneso Consists of delicate interconnecting rods or plates of bone called trabeculae which resemble the

beams of scaffolding of a bulding

Articulations- The site where bones meet with each other- Joints

o Synarthrosis (sutures)o Ampiarthrosis (vertebral and pelvic)o Diarthrosis (maximum movement)o Fibrous (sutures area: coronal, frontal, sagittal), cartilaginous and synovialo Prevent direct contact to two opposing boneso Provides gliding motiono Shock absorptiono Bursa – sock filled with synovial fluid; important for shock absorptiono Position and movement of bones

Ligaments – retinaculum (hands) Tendon- structures that connects /attach muscles to bones

o Specific Types Fibrous joints

Consists of two bones that are united by fibrous tissue and exhibit little or no movement

Sutureso Fibrous joints between the skull

Gomphoseso Consists of pegs fitted onto sockets and held in place by ligaments

Cartilagenous Joints Untie two bones by means of cartilage. Only slight movement can occur at

these joints Fibrocartilage

o Is a type of cartilage that reinforces by additional collagen fibers. It is the kind of cartilage where much strain is placed on the joint

Synovial Joint Freely movable joints that contain synovial fluid in a cavity surrounding the

ends of articulating bones Articular Cartilage

o Provides a smooth surface where the bones meet Joint Cavity

o Filled with synovial fluid Joint Capsule

o Helps hold the bones together and allows movement Synovial Membrane

o Produces synovial fluid Bursa

Diarthrosis joint Plane of gliding joints

o Joints in carpal bones Saddle Joints

o Joints at the base of thumb Hinge joints

o Elbow and knee joint Pivot Joint

o Radius and ulna Ball and socket

o Hip and shouldero Functions

Prevents direct contact btw two end bones Allow gliding or sliding motions Absorb shock

o Bone Maintenance and Healing Regulatory factors determining both formation and resorption

Physical activity Diet Calcitonin

o For bone mineralization; stimulated if px is hypercalcemic Parathyroid hormone Thyroid hormone

o Hyperthyroidism = bone dimineralization Cortisol Growth hormone Sex hormones

o Dec Estrogen = bone deminiralization = osteoporosis Weight bearing stress stimulate local bone formation and resorption; in mobility, where

weight bearing is prevented, Calcium is lost in the bone Vit. D promotes absoption of calcium from the GI and accelerates

Vit D – maintain increase Serum Ca levels Types

Intramembranouso Compact bone

Endochondrealo Cancellous

Bone marrow osteoblast Bone cortex osteon Periosteum hard callus is formed (intramembranous) Cartilage endochondrial ossification Phases

Reactiveo Hematoma/recruitment of inflammatory cells. Angiogenesis and

granulation Reparative

o Pre-callus precursor (3-4 weeks) Remodelling

o Nursing Consideration Age

Very young = immature bones give all supplements to promote bone growth Very old = osteoporosis quite at risk for fractures consider displacement

and site of fracture Displacement of fracture Site of fracture Nutritional level Blood Supply to the area of injury CAN AFFECT TIME REQUIRED FOR BONE HEALING

Anatomy of Muscular System- 3 Types

o Smooth Found in the hollow organs of the body

Eg. Stomach (capable of mixing waves), small and large intestine, airways (capable of peristalsis), blood vessels

Slightly striated involuntary

o Skeletal Striated because of the alternating lines myocin and myofilaments Voluntary Lower neurons control the activity of the skeletal muscles Energy is consumed when the skeletal muscles contract in response to stimulus Lactic Acid

By-product of muscle metabolism when O2 available to cell is not sufficient Muscle fatigue results from increased work of the muscle

o Depleted glycogen and energy storeso Accumulation of lactic acid muscle cramps

o Cardiac Exclusively found in the myocardium Intercalated disks

gives automaticity involuntary

- types of Muscle Contractiono Isometric Contraction

Length of muscle remains constant but the force generated is increasedo Isotonic Contraction

Shortening if muscles, but no increase in muscle tension- Muscle Tone

o Flaccid (Limp)o Spastico Atonic (soft and flabby – px who are post-stroke)

- Muscle Actiono Prime Mover

Deltoid muscleo Synergist

Same actions Biceps

o Antagonist Biceps

- Types of motionso Flexiono Extension

o Abductiono Adduction

- Older Adult Care Focuso Decreased bone density (most are osteoporotic)

Ensure safetyo Decreased in subcutaneous tissue less soft tissue over bony prominenceso Degenerative changes in the spine alter posture and gaito Degenerative changes in cartilage and ligaments leads to decreased movement of jointso ROM decreaseso Slowed movements and decreased muscle strength

Assessment- Health history- Past health, social and family history- Physical Assessment

o Posture: Kyposis (forward curvature of the thoracic spine), lordosis (lumbar), scoliosis (lateral curvature)

o Gaito Bone integrity (crepitus)o Joint function (contracture, dislocation, subluxation)o Muscle strength and size (clonus/fasciculation)o Skino Neurovascular status (circulation, motion, sensation)

Laboratory/Diagnostic Tests- Blood Tests

o ESR (elevated in SLE and arthritis)o Rheumatoid factors (+ in rheumatoid arthritis)o Lupus erythematosus cells (LE Cells)o Antinuclearantibodies (ANA) (+rheumatoid arthritis)o Anti-DNA (+ in SE)o C – Reactive protein (o Minerals

Calcium Decreased levels in osteomalacia, osteoporosis Increased in levels in bone tumors, healing fractures, Paget’s disease

Alkaline Phosphatase Elevated levels in bone cancer, osteoporosis, osteomalacia, Paget’s

disease/metastatic ca (acid phosphatase) Phosphorous

Increased levels in healing fractures, bone tumorso Muscle Enzymes

Aldolase Elevated in muscle dystrophy, dermatomyositis

AST CK (Creatine Phosphokinase)

Elevated in traumatic injuries LDH (Lactic Dehydrogenase)

Elevated in skeletal muscle necrosis, extensive cancer- X-Rays (Roentgenography)- Bone Scan

o Measures radioactivity in bone 2 hours after IV injection of radio isotope; detects bone tumors, osteomyelitis

o Nursing care: Patient must void immediately before procedure Determine allergies Patient must remain still during scan

- Arthroscopyo Insertion of fiberoptic scope into a joint to visualize it, perform biopsies or remove loose bodieso Performed in OR under sterile techniqueo Nursing care:

Pressure dressing for 24 hours Patient must limit activity for several days Assess neurovascular status

- Arthrocentesis: removal or synovial fluid, blood or pus from a joint- Myelography

o Lumbar puncture used to withdraw a small amount of CSF, which is replaced with a radiopaqued dye; used to detect tumors or herniated intervertebral discs

o Nursing care: Consent must be signed Check for iodine allergy Keep NPO after liquid breakfast

o Nursing care post test: If dye has been completely removed (oil dye), keep patient flat for 12 hours If dye has not been completely removed (water based dye – Amipaque), keep head of

bed elevated (30 - 45) to prevent causing meningeal irritation and seizures. If water based dye is used , put patient on seizure precaution and do not administer any phenothiazine drugs (or any sedating drug to assess the level of

consciousness)- CT Scan and MRI

o CT Scan – tumorso MRI – any lesions concerning the posterior fossa

- Electromyography(EMG) – Lower motor neuron/Peripheral nervous systemo Measures and records activity of contracting muscles in response to electrical stimulation; helps

differentiate muscle disease from motor neuron dysfunction.o Explain procedure to patient and prepare him for discomfort of needle insertion

Traumatic Injuries Open type bone fracture – has a communication with the environment which orgs can enter osteomyelitis

- Straino Is an injury to the muscle when it is stretched or pulled beyond its capacityo Common cause: overstretching

- Spraino Is injury to the ligaments surrounding a jointo Common cause: over twisting

- Contusiono Soft tissue injury with ecchymosis or bruisingo Common cause: blunt forceo Head traumao Opening concussion

Grading

- First Degreeo Mild stretchingo s/sx:

minor edema tenderness mild muscle spasm

o requires immobilization and NSAIDS- Second Degree

o Partial tearingo s/sx:

loss of load bearing strength edema tenderness muscle spasm ecchymosis

related to the partial tearing, expect blood vessel involvemento requires surgical intervention

- Third Degreeo Sever damage with complete rupturing or tearingo s/sx:

severe pain tenderness increase edema abnormal motion

o requires surgical intervention

General Nursing Management:R – rest

- immobilize patient- check for neurovascular integrity (pulse, sensation and movement)

I – ice- first 24 hrs, use Ice (vasocontrict blood vessel = minimize s/sx). After 24-48 hours, use warm compress

(absorb any ecchymosis/hematoma that accumulated because of vasodilation)C – compressE – elevate

Carpal Tunnel Syndrome- compressed median nerve by the transverse carpal ligament (wrist) - involves thumb, portion of the ring finger, middle finger and pointer finger- causes:

o repetitive and constant flexion of the wrist- s/sx:

o paresthesiao muscle weaknesso “clumsiness” when using the hando PAIN

- Diagnosis:o (+) Tinel’s Signo (+) Phalen’s Test

- Nursing managemento Goal no. 1: to prevent further compression of the nerves

Rest hands

Avoid excessive use of involved hand Instruct patient not to sleep over the involved hand Administer medication as ordered

NSAIDSo Goal no. 2: to prevent injury

Instruct patient to wear gloves- Medical Management:

o Analgesics Minimize/relief pain ASA (acetylsalicylic acid / aspirin) NSAIDS Taken with full stomach can cause hyperacidity

o Corticosteroids Oral Prednisone

- Surgical Management:o Carpal tunnel release

Fracture- Is a break in the continuity of a bone- Occurs when the bone is subjected to stress greater than it can absorb- Mechanical overload to the bone- Causes:

o Direct blows vehicular accidents

o Crashing forceso Sudden twisting motionso Extreme muscle contractions

- Typeso According to skin involvement

Open / Compound Communication to the skin Seriousness depends to the degree of opening Infection and bleeding

Closed / Simple Patient just need to be immobilized

o According to Breaks Complete

Up to the shaft Incomplete

Linear breako According to Line

Comminuted Different angles

Greenstick One side is fractured, other side is uninjured

Spiral/Torsion Linear fracture that twisted

Transverse Oblique

Can reach the skin Impacted

Related to the skull and vertebrae

Depressed Compression Pathological/Spontaneous

Common to osteoporotic or malignancy of the boneo Intracapsular and Extracapsular Hip Fracture

Require fixation- Clinical Manifestation

o Paino Muscle spasm

There will be injury to the nerves Nerves and blood vessels are located in the periosteum

o Loss of function Particularly if complete fracture and it is an open type

o Deformityo Shortening

Extremity and limb because of the muscle spasmo Swelling and discolorationo Crepitus / crepitations

Particularly of the joint area is involvedo Localized edema and ecchymosis

- Diagnostic testso Radiography /x-ray

fastesto CT Scan

craniumo MRI

Posterior fossa (brain stem, vertebra) - Goal of interventions:

o To prevent further damage Immobilization Support extremity Provide adequate splinting Control bleeding

Leads to compartment syndrome Check peripheral pulses distal to the injury

Cover wound with sterile or cleanest material available To control / prevention osteomyelitis

- Medical management:o Reduction

Closed Casting, traction, manual manipulation

Open Requires sterile area surgical procedure 2 types

o Open reduction with internal fixation (ORIF)o Open reduction with external fixation (OREF)

At risk for infection Complication for external fixator:

Infectiono Staph areuso Nursing management:

Asses for redness, tenderness, pain, swelling, and loosening of pins.

Prevent crust formation- Nursing management:

o Closed fracture Instruction on control of pain and edema Use assistive device properly Modify environment to provide safety Self-care

o Open fracture Risk of osteomyelitis (give antibiotics as ordered), tetanus (toxoids (preformed

antibodies and immediate protection) and vaccines), gas gangrene (clostridium tetani) IV Antibiotics Delayed primary wound closure Elevate to minimize edema Neuromuscular assessment

CMS (circulation, motion and sensation)- Fracture Healing and Complication

o Early Hypovolemic Shock

Femur femoral artery (is a very pulsatile artery, direct to the abdominal aorta common iliac); high pressure

Resulting to massive bleedingo Give fluidso Blood transfusion

Fat Embolism ( 40 y/o, Male, multiple fracture) Sx: sudden hypotension, sudden dyspnea

Compartment Syndrome Sudden decrease in blood flow distally (PAIN) Majority of the compartments of the body is found in the extremities

Venous Thromboembolism DIC (Disseminated Intravascular Coagulopathy)

Decrease in plateleto Delayed

Delayed Union Malunion Nonunion

o Nursing Management: Pain control

- Fracture of Specific Siteso Clavicle (Collar Bones): Middle 3rd of the clavicle

Figure of eight bandageo Humerus (shaft or neck)o Elbow: Supracondylar fracture of the humerus (Volkmann’s contracture)

Assess volkmann’t contractureo Radial head: fall on an outstretched hando Radial/Ulnar shaft: common among childeno Distal Radius (Colles Fracture): Open dorsiflexed hand, commonly in elderlyo Pelvic: rule out other internal damage because of the proximity of the two structureso Femoral shaft: fall or motor vehicle crasho Thoracolumbar spine: vertebral body, laminae, and articulating process, spinous process

Osteomyelitis- Infection of the bone; Staphylococcus Aureus- Haematogenous spread (infection elsewhere then septecemia then to the bone) / direct trauma / VI- Acute / Chronic osteomyelitis- Risk factors:

o Age o Nutritiono Blood vessels involvemento Immune systemo Co morbidities (CM)

- Infection sets in inflammatory reaction (pain, swelling, heat) causes devascularisation of the bone, bone ischemia and necrosis

- Sequestrum (cavity with abscess) abscess will be necrotic debris - necrotic bone tissue encased by involucrum

- Pathologic fractures can occur- Only when all dead bone tissue is removed will full healing occur

o Require surgical intervention- Pathophysiology

o Risk factors: Acute OM inflammation (Increase vascularity and edema) 2-3 days: thrombosis (ischemia then necrosis) medullary area and periosteum involvement sequestrum (abscess cavity) surrounded by new bone growth: involucrum (new bone growth) recurring abscess chronic osteomyelitis

- Assessment and Diagnostico Isotope labelled WBC, MRIo X-ray: tissue edema

2-3 weeks: periosteal elevation and bone necrosis Chronic OM: large irregular cavities, raised periosteum, sequestra, dense bone

formation Blood culture

On two different sites- Interventions

o Administer antibioticso Debridement / incision and drainageo Antibiotic beads

Made up of Ca Little to no systemic effect Advantage: it is absorbed while being replaced by new bones. No need for grafting

anymoreo Sequestrectomyo Saucerizationo Bone grafting/muscle flap

CAST- A rigid external immobilizing device that is moulded to the contour of the body- Purpose:

o To immobilize a reduced fractureo To maintain body alignmento To correct deformityo To apply uniform pressure to underlying soft tissueo To support and stabilize weakened joints

- When casting a joint, include the proximal as well at the distal area to stabilize the injured site / extremity

Types of Casting Materials

- Plaster of Pariso Traditional casto Rolls of plaster bandage are wet in cool water and applied smoothly to the bodyo Heavy and has a rough surfaceo Crystallization: rigid dressing 15-20 minso Exposed to circulating air to dryo Disadvantage: absorbs moisture

Avoid in water contacto Complete dryness: 24-72 hours after application

No not cover with towelo Lest costlyo Achieved a great mold; less durable (compared to fiber glass)o Exothermic characteristic

When you apply it, it exclude heat and warm Hindi nagkakaroon ng panic o anxiety ang patient

DRY WETAppearance White and shiny GreyPercussion Resonant DullOdor Odourless MustyTexture Firm, hard and rough Damp to touch

- Non –Plaster / Synthetic Casto Fiber Glass

Water activated polyurethane materials, lighter in weight, stronger and more durable Lightweight and has smooth surface Should never be exposed to any plastic surface (it will get deformed) because it is hot Inform patient to prevent anxiety or panic attack Make sure to prevent they are placed in edges or corner to prevent denting of the fiber

glass Avoid denting any disfigurement to the fiber glass could lead to skin

irritation or breakage/lesion Water-prof lining (Gore-Text) Complete dry: 24-72 hours

o Splints Used for conditions that do not require rigid immobilization Expect swelling It can be easily removed Require special skin care Overwrapped with an elastic bandage applied in spiral fashion Short term in use

o Braces Provide support, control, movement and prevent additional injury

Cervical brace, collar Custom fitted to various parts of the body Expensive Indicated for longer use (at least 8 years)

Short Arm CastLong Arm Cast

- Elbow is at a right angleShort Leg Cast

- Knee down to the sole/base of the toe- Foot is at a right angle, neutral position

Long Leg Cast- Extends from the upper, middle third of the thigh to the base of the foot- Knees slightly flexed

Walking Cast- Long and Short- To re-enforce strength

Body Cast- Encircles the trunk

Spica Cast- At least two types:

o Shoulder Body jacket that encloses the trunk, shoulder and elbow

o Pelvic Shoulder, lower extremity (one or both)

Nursing Management- Carry cast with palms of the hands when WET- Elevate with pillow support- Expose to dry environment- Keep clean and dry- Observe for signs of inflammation then infection- Maintain skin integrity- Neurovascular assessment meticulously and regularly- Move patient every 2 hours (patient with body casts) to relieve pressure- In turning, use of trapis or railings can be done

CAST SYNDROME- Due to immobilization- Decrease gastric mobility accumulation of air in the stomach and lung bloated patient gastric

acid reflux, constipation abdominal distention anorexia

COMPARTMENT SYNDROME- Increase in pressure in a confined space there is decrease blood flow affecting important structures

such as blood vessels and nerves- Asses neurovascular status

o Peripheral pulseso Motiono Sensation

- 5 P’so Pain – primary symptomo Palloro Pulselessnesso Paresthesiao Paralysis

- Managemento Assess neurovascular statuso Elevate the affected limb to the level of the heart

To minimize edema (normal reaction of body against trauma)

- Surgical Interventiono Fasciotomy (opening of the fascia to relieve the pressure)o Remove the tight cast or dressingo Bivalving/Use of posterior mold

PRESSURE ULCERS- Take note of the body prominence- Inform patient that they should inform you if there is pain or tightness in the area

DISUSE SYNDROME- Muscle atrophy and loss of strength- Tense or contract muscle (isometric contraction) without moving the part

TRACTION- Application of the pulling forces- Short term intervention- Purposes

o To reduce, align and immobilize fractureso To minimize muscle spasmso To reduce deformityo To increase space between opposing surfaces

- Principleso Continuous to be effectiveo Never interruptedo Weight are not removed unless it’s an intermittent tractiono Eliminate any factor that may reduce its effectivelyo Good body alignment in the center of the bedo Ropes must be un obstructedo Weight must hang freelyo Knots in the ropes or foot plates must not touch the pulley or foot of the bed

- Typeso Straight or Running Traction

Applies the pulling force in a straight line with body part resting on the bed (Buck’s Traction)

o Balance Suspension Traction Supports the affected extremity off the bed and allows some movement without

disruption of the line of pullAnother Types

- Skin Traction Buck’s Extension Traction (leg)

Indication: femur / hip involvement Simplest form of traction

o Russel’s Traction Indication: Femur/hip joint fracture Incorporates the use of knee sling Hip is flexed to 20 degrees from the mattress

o Bryant’s Traction Indication: children with congenital Hip dislocation For children below 2-3 years For children weighing less than 30-40 lbs N/R:

buttocks should not touch the mattress

assess neurovascular status of the lower extremityo capillary refill

o Cervical Traction Indication: cervical spine fracture Make use of a cervical halter or cervical lining HOB is elevated to 30-40 degrees

o Pelvic Traction Indication: pelvic bone fracture Used for lumbar fracture Make use of a pelvic halter Supine position

- Skeletal Tractiono Weights are attached directly to the boneo Make use of pins, screws, wires or tongso At risk for osteomyelitiso Balanced Suspension Traction

Make use of Thomas Splint with Pearson Attachment Part of the body is off the bed Hips are fixed 30 degrees Care of pin site:

Clean with antiseptic Apply antibiotic No betadine rust pins No peroxide aerobic infection

Nursing management Principles of Effective Traction

o Continuous to be effectiveo Never interruptedo Weights are not removedo Observe food body alignmento Ropes must be unobstructed

Complicationso Atelectasis (inability of the patient to do deep breathing exercises) and

Pneumonia Auscultate the lungs q 4-8 hours Deep breathing and coughing exercise

o Constipation and anorexia Diet must be high fiber and increase fluids Stool softener as prescribed Improve appetite

o Urinary Stasis and Infection Observe the characteristic of the urine Monitor fluid intake Monitor s/sx of infection

Hesitancy Urgency Frequency Dysuria

o Venous Thromboembolism Exercise muscles not in traction to prevent deterioration,

deconditioning and venous stasis Monitor for tenderness, warmth, redness and swelling

Check for Homan’s SignFat Embolism

- An embolism originating in the bone marrow that occurs after a fracture- Usually occurs 48 hours after a fracture and clients with long bone fractures are more at risk- Restlessness, changes in LOC, tachycardia, tachypnea, dyspnea, petechial rash over upper chest- Nursing Interventions

o Immediate Mobilizationo Minimal fracture manipulationo Adequate support of fractures bones during positioning and turningo Support respiratory functiono Initially administer oxygen then position in Fowler’s positiono 48-72 hours immediately immobilizeo In there is already management immediate mobilize

Hip Fractures- Common among elderly women- Affected leg is always adducted, externally rotated and the limb is shortened

o Nakalabas is femoral head- Complaints of pain in the GROIN or in the medial side of the bone- Same signs and symptoms with fractures- Total or Partial Hip Replacement

o Intertrochanteric hip fracture Metal ball and stem are inserted in the femur and a plastic socket

o Total Hip Replacement- Post Op Care

o Maintain legs in abduction (place pillows between legs) – adduction will displace prosthesiso Avoid bendingo Use trochanter roll to prevent external rotationo No low chairs

DEVICES- Purpose

o Widens base of supporto Reduce weight bearing on the affected lego Provide mobility to the patient

- Crutcheso 2 inches below axillao 6 inches front to footo 2 inches to the side of the footo Elbow flexion (20-30 degrees)o Exercises to prepare for CW:

Hand muscle ex Arm muscle ex

o Gaitso Stair climbing

UP: good leg crutches with bad leg (Going to HEAVEN so use your GOOD leg) DOWN: bad leg with crutched good leg (Going to HELL so use your BAD leg first)

o Important Muscles Shoulder Depressor / Latissimus Dorsi

Needed first to advance the body forward Needed to lift the pelvis off the ground

Elbow Extensors / Triceps

Needed to prevent buckling of the elbow joint Finger Flexors

Needed to grasp the hand gripo Crutch Walking

Crutch gaits When only one leg can bear weight

Swing to gait: crutches forward; swing body to crutches Swing thru gait: crutches forward; swing body thru crutches 3 point gait 2 point gait

- Caneo Held on the non-affected sideo Cane walked together with the weak leg

- Walkero The most stable among the assistive deviceso Sequence:

Advance walker within arm’s length (Approx 10-20 inches in front of the patient Walk beside the walker

OSTEOPOROSIS- Abnormal increase in bone resorption causing a decrease in bone density- Loss of bone mass with aging, decrease calcitonin and estrogen and increased parathormone- Deminiralization (Loss of Ca and phosphate salts) bone becomes porous, brittle, fragile structural

weakness – pathologic fractures- Fractures of thoracic, lumbar neck and intertrochanteric fx of femur and Coll’s fx of wrist- Risk factors:

o Menopauseo Sedentary lifestyleo Geneticso Ageo Nutritiono Physical Exerciseo Medications

- Dowager’s Hump / Kyposis - Signs and Symptoms

o Usually asymptomatico Sudden onset of sever back paino Skeletal deformityo Bone pain and tendernesso May show s/sx of pulmonary insufficiencyo Dec calcitonin and estrogeno Inc PTH

- Dx Assessmento X-rayo Bone scan

- Nursing managemento Recognize risk factors and prevent further injurieso Adequate dietary intake of Ca and other minerals, CHON and CHOo Calcium supplements with Vitamin Do Physical therapy – moderate exercise – mechanical stress stimulates bone formationo Fracture managemento Biphosphates – Etidronate (Didronel)

Nephrotoxic Increase bone density and restore lost bone Inhibit resoprtion of bone Monitor for nephrotoxicity and seizures

o Fluoride – Alendronate (Fosamax) Stimulate bone formation Strict GI precautions Causes GI distress, esophageal erosin Administer on empty stomach Do not eat or crink 30 mins Take with water 6-8 onz not juice and Remain upright for 30 mins after taking drug Monitor: hypercalcemia and tetany serum electrolytes Increase fluid intake and calcium rich foods

Rheumatoid Arthritis- Autoimmune bone disease and hereditary- Bilateral, symmetrical, inflammatory, systemic- Progression through stages

o Synovitis – pannus formation (scar tissue) – fibrous ankylosis – bone alkylosis- Signs

o Fatigue, anorexia, malaise, weight loss, slight temperature elevation- Usually affects joints symmetrically (on both side equally)- Pathophysio

o Presentation of antigen to T cell t and B cells proliferation, angiogenesis in synovial lining swelling in small joints, associated with pain, stiffness and fatigue neutrophil accumulation in synovial cell proliferation. No cartilage invasion 2 possibilities: 1) warm effusions, pain and decreased motion with possible rheumatoid ndules 2) synovitis, early pannus invasion, chondrocyteactiviation, degredation or cartilage subchondral bone erosion; pannus invasion

- Painful, warm, swollen joints with limited motion, stiff in the morning and after period of inactivity- Crippling deformity/swan-neck or buotonierre’s deformity- Muscle weakness- History of remission and exacerbations- Severe anemia- Sjoren’s syndrome- Felt’s syndrome

o A disorder that can affect people who have rheumatoid arthritis (RA)o It is defined by the presence of three condition: RA, enlarged spleen and low WBC count

- Dx testo X-rayo Laboratory

(+) Rheumatoid Factor- Nursing Management

o Apply cold compress to the affected parto Minimize muscle spasms and joint stiffnesso Avoid prolonged sitting or standingo Encourage ROM exercises after taking pain meds

- Surgical Managemento Osteotomy, synovectomy, or arthroplasty

- Pharmacotherapyo Aspirino NSAIDs

Indomethacin (Indocin) Phenylbutazone(Butazolidin) Ibuprofen

o Gold Compounds (Chrysotheraphy) Arrest progression of the disease Sodium thiomalate Aurothioglucose Auranofin

o Corticosteroids Intra-articular injections

Osteoarthritis- Degenerative joint disease- Idiopathic or secondary- 3rd decadeof life and peaks between the 5th and 6th decades- Affects the articular cartilage, subchondral bone and synovium- Cartilage degeneration, bone stiffening, reactive inflammation- “wear and tear”- Risk factors: age, obesity, previous joint damage, repetitive use, anatomical deformity- Manifestations

o Pain (osteophytes)o Stiffeningo Functional impairment

- Dxo Progressive loss of joint cartilageo Osteophyteso Joint space narrowing (x-ray)

- Managemento Relieve strain and further trauma to jointso Cane or walker if indicated to relieve stresso Proper body mechanicso Avoid excessive weight bearing and standingo Physical therapyo Relief of pain (NSAIDS)o Joint replacement as needed

Gouty Arthritis- Classifications

o Primaryo Secondary

Due to acquire condition Starvation Alcohol intoxication Renal failure

- Risk factorso Common among maleso 20 x greater than femaleso 30 y/o and above

- s/sxo inflammation of the jointo prurituso TOPHI formation

Subcutaneous noduleso Skin ulcerationo Late Stage

Bone deformity Intolerance to bed linens

- Managemento Asses affected joint for pain motion and appearanceo Educate patients in recognition of early symptomso Increase fluid intake (3-5 L)o Bed rest until pain subsideso Report any decrease in urine outputo Low purine dieto Admin medications as ordered

Allopurinol (Zyloprim) MOA: prevents formation of uric acid

Probenicid (Benemid) Colchicine (Colgout)

MOA: dec deposition of uric acid to the joint Drug of choice to prevent attacks

Amputation- Surgical removal of a part of a limb- Levels: Syme, BKA(Below the Knee Amputation), AKA (Above the Knee Amputation), stage amputation- Guillotin Amputation

o Stage type amputation- Post op care

o Monitor VSo Evaluate for phantom limb sensation and pain; explain to the patiento During the 1st 24 hours, elevate stump; after that flat on bed to prevent flexion hip contractureso After 48 hours, instruct also to be one prone position several times a dayo Maintain application of ace wrap to promote stump shrinkage

- Stump Dressingo Soft- greater potential for haemorrhage and rehabilitation is longer but easier to assesso Rigid – facilitates earlier ambulation but difficult to assess

- Post op complicationso Haemorrhageo Infectiono Contracture

Bone Tumors / Malignancy- Classified according to its characteristics

o Benign Most common: osteochondroma Endochondroma: hyaline cartilage (joint spaces and synovial cavity) Bone cyst (collection of fluids found in a confined area) Osteoid osteoma Giant Cell Tumors (osteoclastomas) – common in children

o Malignant Most common: Osteosarcoma

Bone tumors: primary or secondary Commonly seen to 10-25 years of age Most of the time they are just accidental finding

o Suddenly there will be palpated mass; no paino Palpable mass or hard lump, pain, pathologic fractures, decreased

sensation, numbness and limited movements Tumor erodes the bone cortex elevating the periosteum Most common site: distal femur, proximal tibia and humerus Increased serum alkaline phosphatase because of bone lysis DX: bone biopsy Radiation, chemotherapy, surgical removal or tumor Radiological finding: periosteal elevation

o Demineralized bone Pathognomonic hallmark: Codman’s Triangle and Sun Ray Spicules (both

suggests malignancy) After surgery, potential complications:

o Delayed wound healing Related to tissue trauma Effect of Radiation therapy Poor nutrition (with malignancy, there is hypercatabolic

anorexia effect of cytokines hyperleukines Infection(wound)

o Inadequate nutritiono Osteomyelitis and wound infectiono Hypercalcemia common problem is arrhythmia, clogging of the

blood vessel, calcium stone renal failure

Scoliosis- Lateral curvature of the thoracic, lumbar or thoracolumbar spine. Rotation of the vertebral column causes

rib cage deformity.- When deviates to the RIGHT: DEXTROscoliosis- When deviates to the LEFT: LEVOscoliosis- Types:

o Functional: poor posture or discrepancy in the leg lengtho Structural: deformity of the vertebral bodies

Loss in the height of the vertebral bodies Common with those with osteoporosis or congenital, neuromuscular idiopathic scoliosis

(infantile, juvenile and adolescent) Can happen anytime during bone formation

o Different stresses on the vertebral bodies causes imbalance of osteoblastic activity; curve progresses rapidly during adolescent growth spurt

- Signso Uneven hemlines, one hip higher than the other, unequal shoulder, heights and iliac crests,

asymmetric thoracic cage- Sugrical

o Posterior fusiono Harrington Rod instrumentation

Wisconsin wire technique and Luque techniqueo Zielke System

For thoracolumbar scoliosis (severe) Makes use of wiring to maintain alignment of the thoracic spine

- Dxo Observation / Inspectiono Thoracic X-Ray (Cobb’s Method) – done to see R or L deviation of the spineo Adam’s Forward Bending Test

o Scoliometer – to look at the angle of the scoliosis (>30 percent: not only deformity but also sever pain because of the compression of the spinal nerves)

- Complicationso Pulmonary insufficiency, back pain, HPN, sciatica (Radiating pain, back to foot), degenerative

arthritis of the spine- Tx

o Depends on the age where is was diagnosed 10-20 y/o – leg exercises and pelvic tilt: strengthen torso muscles 20-40 y/o – exercises + braces: worm until the bone growth is complete 40 y/o and above: spinal surgery – instrumentation with fusion

Cannot bend much because of the instrumentation with fusion- Nursing Consideration

o Suggest loose, fitting clothes – wear undergarments when wearing the braceo Wear the brace for 23 hours a day (1 hour for taking a bath) for 7 dayso Advise to increase activities graduallyo After corrective surgery

Check neurovascular status q 2-4 hrs, logroll Monitor I and O, watch out for signs of bleeding Patient will have splinting, so teach deep breathing exercises to prevent atelectasis

pneumonia Medicate for pain, do ROM Offer emotional support for altered body image

o Crankshaft Phenomenon Observed after spinal fusion there is continuous growth of anterior vertebral body Prevention:

Delayed the surgery until the child is older than 10 years Addition of anterior fusion plate Use of specialized instrumentation that allows subsequent expansion of the

vertebra

TB of the Spine- Pott’s disease is a presentation of extrapulmonary (originates from the lungs, hematogenuous spread)

tuberculosis that affects the spine, a kind of tuberculosis arthritis of the intervertebral joints.- s/sx

o back paino fevero night sweatingo anorexiao weight losso massive destruction of the vertebra – swellingo spinal mass sometimes associated with numbness, tingling sensation or muscle weakness of the

legs- infections

o Pott’s disease Organism: TB Bacilli Primary Focus: Lungs Pathology:

Infection bone destruction collapse of the vertebrae Gibbus Formation Spinal Cord compression

Mgmt Anti-Koch’s medicaiotns, spinal brace Tx minimum of 12 months

Surg Anterior Decompression Spinal Fusion

Bone infections are difficult to treat because they are relatively inaccessible to protective macrophages and antibodies

Pediatric Orthopedic Conditions

Congenital Clubfoot- Congenital malformation of the lower extremities- Unilateral or bilateral- Defects are rigid and cannot be manipulated into a neutral position- Talipes varus – an inversion or bending inward- Talipes valgus – eversion or bending outward- Talipes equinus – plantar flexion in which the toes are lower than the heels- Talipes calcaneus – dorsiflexion- Nursing care and treatment

o Serial manipulation and casting weekly and if correction not achieved in 3-6 months then surgery is indicated

- Surgicalo Usually done 4-12 months of age (Kyzer, 1991)o After surgery, a cast holds the clubfoot still while it healso Special shoes or braces will likely be used for up to a year or more after surgery o Same as any child with a cast

Congenital Hip Dislocation- Dysplasia of the hip wherein the head of the femur is not properly anchored in the acetabulum- Can be congenital or develop after birth- Assessment

o Asymmetry of the gluteal and thigh skin folds when child is placed proneo Limited ROM on affected hipo Apparent short femur on the affected sideo Positive Ortolani or Barlow Maneuvero Waddling gait; positive Trendelenburg sign

- You see that the head of the femur is far from the acetabular fossa- Nursing care and treatment

o Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotationo Traction and surgery to release muscles and tendonso Following surgery, positioning and immobilization in a spica cast then use of abduction splint

*READ ACUTE LOW BACK PAIN*READ BRURITIS and TENDINITIS*READ Ganglion Cyst*READ DUPUYTREN’S CONTRACTURE

FOOT PROBLEMS

- Plantar Fasciitis- Corn- Callus- Ingrown Toenail- Hammer Toe- Hallux Valgus- Pes Cavus- Flatfoot (Pes Planus)