MMuussccuulloosskkeelleettaall SSyysstteemm

The musculoskeletal system consists of muscles, tendons, ligaments, bones, cartilage,

joints, and bursae.

These structures work together to produce skeletal movement.

The human skeleton contains 206 bones: 80 form the axial skeleton and 126 form the

appendicular skeleton.

FFUUNNCCTTIIOONNSS

MMoovveemmeenntt aanndd mmaaiinnttaaiinnss ppoossttuurree

SSuuppppoorrtt

PPrrootteeccttiioonn

HHeemmaattooppooiieessiiss

Mineral homeostasis

ANATOMY AND PHYSIOLOGY

Muscles: the body contains three major muscle types: visceral (involuntary, smooth),

skeletal (voluntary, striated), and cardiac.

Tendons: are bands of fibrous connective tissue that attach muscle to the periosteum

(fibrous covering the bone).

Enables the bone to move when skeletal muscles contract.

Ligaments: dense, strong, flexible bands of fibrous connective tissue that tie bones to

other bones.

Bones: perform anatomic (mechanical) and physiologic functions.

Protecting internal tissues and organs

Stabilizing and supporting the body

Providing a surface for muscle, ligament, and tendon attachment

Moving through ―lever‖ action when contracted

Producing red blood cells in the bone marrow (hematopoiesis)

Storing mineral salts

Bone formation

Cartilage composes the fetal skeleton at 3 months in utero.

By about 6 months, the fetal cartilage has been transformed into bony skeleton.

Two types of osteocytes, osteoblasts and osteoclasts, are responsible for

remodeling—the continuous process whereby bone is created and destroyed.

Osteoblasts deposit new bone.

Osteoclasts increase long-bone diameter through reabsorption of previously

deposited bone.

Cartilage: a dense connective tissue that consists of fibers embedded in a strong, gel-like

substance.

Avascular and lacks innervation

Fibrous cartilage: forms the symphysis pubis and the intervertebral disks.

Hyaline cartilage: covers the articular bone surfaces; connects the ribs to the

sternum; and appears in the trachea, bronchi, and nasal septum.

Elastic cartilage: located in the auditory canal, external ear, and epiglottis.

It cushions and absorbs shock, preventing direct transmission to the bone.

Joints: two or more bones meet a joint.

Synarthrodial joints, such as cranial sutures, permit no movement. This joint type

separates bones with a thin layer of fibrous connective tissue.

Amphiarthrodial joints, such as the symphysis pubis, allow slight movement. This

joint type separates bones with hyaline cartilage.

Diarthrodial joints, such as the ankle, wrist, knee, hip, and shoulder, permit free

movement

Bursae: located at friction points around joints between tendons, ligaments, and bones,

bursae are small synovial fluid sacs that act as cushions, thereby decreasing stress to

adjacent structures.

AASSSSEESSSSMMEENNTT

History

o Reason for seeking care

o Present illness

o Medical history

o Family history

o Psychosocial history

Physical Examination

o Observe posture, gait and coordination

o Inspect and palpate muscles: tone and mass; strength and joint ROM

o Inspect and palpate joints and bones

o Length of the extremities

DIAGNOSTIC TESTS

ASPIRATION

Arthrocentesis: helps to assess infection and distinguish forms of arthritis, such as

pseudogout and infectious arthritis.

o In joint infection, for example, synovial fluid looks cloudy and contains more

WBC and less glucose than normal.

o When trauma causes bleeding into a joint, synovial fluid contains red blood cells.

o In specific types of arthritis, crystals can confirm the diagnosis—for example,

urate crystals indicate gout.

o In symptomatic joint effusion, removing excess synovial fluid relieves pain.

Nursing considerations

o Describe this 10-minute procedure to the patient.

o Patient will assume a position depending on the joint being aspirated, and then

asked to remain still.

o After withdrawing the fluid, he’ll apply a small bandage to the puncture site.

o After the test, ice or cold packs may be applied to the joint to reduce pain and

swelling.

o Advise patient not to use the joint excessively after the test to avoid joint pain,

swelling, and stiffness.

o Report any increased pain, tenderness, swelling, warmth, or redness as well as

fever, these may signal infection.

Bone marrow aspiration: help diagnose many abnormalities, including rheumatoid

arthritis, tuberculosis, amyloidosis, syphilis, bacterial or viral infection, parasitic

infestation, tumors and hematologic problems.

o Aspiration usually involves the sternum or iliac crests.

o The site is prepared and then infiltrated with a local anesthetic such as lidocaine.

o The doctor inserts the marrow needle through the cortex; marrow cavity

penetration causes a collapsing sensation.

o Aspirates 0.2 to 0.5 ml of fluid.

Nursing considerations

o Inform patient that he’ll feel pressure as the doctor inserts the needle and that

aspiration may hurt.

o Procedure may last about 10 minutes that he’ll be sedated.

o Watch for signs of infection after the procedure and make sure bleeding stops.

ENDOSCOPY

Arthroscopy: helps to assess joint problems, plan surgical approaches, and document

pathology.

o Used to evaluate the knee.

Nursing considerations

o Explain to the patient that this test allows direct examination of the inside of a

joint and that it’s safe, convenient approach to surgery.

o Done in the operating room under general or local anesthesia and takes 30 to 60

minutes.

o Instruct NPO after midnight.

o Check hypersensitivity to local anesthetics.

o After the procedure patient can walk as soon as he’s fully awake and he’ll

experience mild soreness and a slight grinding sensation in his knee for 1 to 2

days.

o Instruct patient to notify doctor if he feels severe or persistent pain or develops a

fever with signs of local inflammation.

o Assess for signs of complications such as infection, hemarthrosis (blood

accumulation in the joint), or a synovial cyst.

LABORATORY TESTS

Blood tests: to rule out systemic infection, anemia, and white blood cell disorders as well

as studies to measure blood levels of alkaline phosphatase, calcium, creatine kinase, and

rheumatoid factor.

o Check blood levels of antinuclear antibodies, phosphorus, and serum uric acid

o Measure Erythrocyte Sedimentation Rate (ESR) — the rate at which red blood

cells settles in uncoagulated blood during a 1-hour period.

o Serial ESR measurements help monitor general or localized inflammation, which

cause the rate to increase.

Urine tests: 24-hour urine collection to check uric acid levels.

o Check for urine for Bence Jones protein, which may indicate a bone tumor,

hyperparathyroidism, or osteomalacia.

RADIOGRAPHIC AND IMAGING STUDIESS

Bone scan: detect bony metastasis, benign disease, fractures, avascualr necrosis, and

infection.

o IV introduction of a radioactive material, such as the radioisotope technetium

polyphosphate, the isotope collects in areas of increased bone activity or active

bone formation.

Nursing considerations

o Explain the procedure to the patient.

o Fasting isn’t necessary.

o Explain to the patient that there will be a 2- to 3- hour waiting period after the

isotope is injected.

o While waiting, the patient must drink four to six glasses of fluid.

o Lie supine on a table within the scanner and lie as still as possible and to expect to

assume various positions.

Computed tomography: aids diagnosis of bone tumors and other abnormalities.

o Helps to assess questionable cervical or spinal fractures, fracture fragments, bone

lesions, and intra-articular loose bodies.

Nursing considerations

o Explain to the patient that CT helps detect bone abnormalities and that it takes 30

to 90 minutes.

o If the patient is scheduled to receive a contrast medium, inform him that he must

not eat for 4 hours before the test.

o Instruct patient to remain still during the test.

o If the patient received a contrast medium by mouth, encourage him to drink plenty

of fluid after the test to help flush the contrast medium from his body.

Magnetic resonance imaging (MRI): show irregularities of the spinal cord and is

especially useful for diagnosing disk herniation.

Nursing considerations

o Explain that the procedure may take up to 90 minutes and advise the patient to use

the bathroom before the test.

o Ask the patient to remove all metal objects, including bobby pins, jewelry,

watches, eyeglasses, hearing aids, and dental appliances.

o Remove clothes with metal zippers, buckles, or buttons as well as credit, bank,

and parking cards because the scan could erase the magnetic codes.

X-rays: help diagnose traumatic disorders, such as fractures and dislocations.

o Reveal bone disease and joint disease

Nursing considerations

o Remove all jewelry.

o Verify that the X-ray order includes pertinent recent history, such as trauma, and

identifies the point tenderness site.

BONE DISORDERS

HALLUX VALGUS

o Lateral deviation of the great toe at the metatarsophalangeal joint

o Occurs with medial enlargement of the first metatarsal head and bunion

formation.

Causes: congenital or familial

o More commonly acquired from degenerative arthritis or from prolonged pressure,

especially form narrow-toed high-heeled shoes that compress the forefoot.

Assessment findings:

o May appear as a red tender bunion

o Angulation of the great toe away from the midline of the body toward the other

toes.

o Advanced stages: may develop a flat, splayed forefoot, severely curled toes

(hammertoes), and a small bunion on the fifth metatarsal.

Diagnostic test:

o X-rays confirm diagnosis by showing medial deviation of the first metatarsal and

lateral deviation of the great toe.

Treatment:

o good foot care and proper shoes

o felt pads to protect the bunion, foam pads or other devices to separate the first and

second toes at night

o supportive pad and exercises to strengthen the metatarsal arch.

o Early treatment is vital in patients predisposed to foot problems, such as those

with rheumatoid arthritis or diabetes mellitus.

o Severe deformity doctor may order bunionectomy

MMUUSSCCUULLOOSSKKEELLEETTAALL IINNJJUURRIIEESS

CCOONNTTUUSSIIOONNSS,, SSTTRRAAIINNSS,, AANNDD SSPPRRAAIINNSS

CCoonnttuussiioonn-- ssoofftt ttiissssuuee iinnjjuurryy pprroodduucceedd bbyy bblluunntt ffoorrccee..

Many small blood vessels rupture and bleed into soft tissues (ecchymosis or

bruising).

A hematoma develops when the bleeding is sufficient to cause an appreciable

collection of blood.

SSttrraaiinn-- ――mmuussccllee ppuullll‖‖ ffrroomm oovveerruussee,, oovveerrssttrreettcchhiinngg,, oorr eexxcceessssiivvee ssttrreessss..

Strains are microscopic, incomplete muscle tears with some bleeding into the

tissue.

The patient experiences soreness or sudden pain, with local tenderness on muscle

use and isometric contraction.

SSpprraaiinn-- iinnjjuurryy ttoo tthhee lliiggaammeennttss ssuurrrroouunnddiinngg aa jjooiinntt,, ccaauusseedd bbyy aa wwrreenncchhiinngg oorr ttwwiissttiinngg

mmoottiioonn..

The function of the ligament is to maintain stability while permitting mobility.

A torn ligament loses its stabilizing ability.

TTrreeaattmmeenntt:: ――RRIICCEE‖‖

RReesstt,, IIccee,, CCoommpprreessssiioonn,, EElleevvaattiioonn

Nursing interventions

o Immobilize the joint, using an elastic bandage or, if sprain is severe, a soft cast.

o Control pain and swelling by giving analgesics as prescribed and immediate

application of ice for up to 48 hours, followed by application of heat.

o Complete muscle rupture may require surgical repair

o Moist or dry cold applied intermittently for 20 to 30 minutes during the first 24 to 48

hours after injury produces vasoconstriction, which decreases bleeding, edema, and

discomfort.

o Care must be taken to avoid skin and tissue damage from excessive cold.

o Elevate the joint for 48 to 72 hours after the injury and apply ice intermittently for 24

to 48 hours after the injury

o After the acute inflammatory stage (eg, 24 to 40 hours after injury), heat may be

applied intermittently (for 15 to 30 minutes, four times a day) to relieve muscle spasm

and to promote vasodilation, absorption, and repair.

o Depending on the severity of injury progressive passive and active exercise may

begin in 2 to 5 days.

o Severe sprains may require 1 to 3 weeks of immobilization before protected exercise

are initiated.

o If an elastic bandage is applied, tell the patient to remove the bandage before going to

sleep and to loosen it if it causes the leg to become pale, numb or painful.

o Consult doctor if pain worsens or persists (X-ray may detect a fracture that was

missed originally)

FFRRAACCTTUURREE

BBrreeaakk iinn tthhee ccoonnttiinnuuiittyy ooff bboonnee

Arm and leg fractures can cause substantial muscle, nerve, and other soft-tissue

damage.

Prognosis varies with the extent of disability or deformity, amount of tissue and

vascular damage, adequacy of reduction and immobilization, and the patient’s age,

health, and nutrition.

Children’s bones usually heal rapidly and without deformity.

Bones of adults in poor health and who have impaired circulation may never heal

properly.

A history of trauma and suggestive findings on physical examination (including gentle

palpation and failure of a cautious attempt by the patient to move parts distal to the

injury) indicate a likely diagnosis of an arm or leg fracture.

Causes

o major trauma (fall on an outstretched arm, a skiing accident, or child abuse)

o pathologic bone weakening conditions (osteoporosis, bone tumors or metabolic

disease)

o prolonged standing, walking or running can cause stress fractures of the foot and

ankle, usually seen in nurses, postal workers, soldiers and joggers

Signs and symptoms

o pain and point tenderness

o pallor

o pulse loss distal to fracture site

o paresthesia or paralysis distal to fracture site

o deformity

o swelling

o discoloration

o crepitus

o loss of limb function

o substantial blood loss

o life threatening hypovolemic shock

Diagnostic test

o anteroposterior and lateral X-rays

o angiography

OOBBJJEECCTTIIVVEESS OOFF TTRREEAATTMMEENNTT

OOppttiimmaall rreeaalliiggnnmmeenntt

RRiiggiidd iimmmmoobbiilliizzaattiioonn

RReessttoorraattiioonn ooff ffuunnccttiioonn

Treatment

o splinting the limb above and below the suspected fracture

o applying a cold pack

o elevating the limb to reduce edema and pain

o severe fractures that cause blood loss: direct pressure should be applied to control

bleeding and fluid replacement

o reduction, followed by immobilization by splint, cast or traction

o Closed reduction: manual manipulation, a local anesthetic and an analgesic are

used to minimize pain and a muscle relaxant is used to facilitate muscle stretching

to realign the bone.

o Open reduction: reduces and immobilizes the fracture by means of rods, plates, or

screws.

o Skeletal traction: immobilization by the use of weights and pulleys; pin or wire is

inserted through the bone distal to the fracture and attached to a weight.

o Skin traction: elastic bandages and moleskin coverings are used to attach traction

devices to the patient’s skin.

o Treatment for open fractures also requires wound cleaning, tetanus prophylaxis,

antibiotics, and possibly surgery to repair soft tissue damage

Nursing interventions

o Monitor for signs of shock

o Analgesics as prescribed

oo DDiieett:: hhiigghh pprrootteeiinn,, iirroonn,, vviittaammiinnss ((ttiissssuuee rreeppaaiirr)),, mmooddeerraattee ccaarrbboohhyyddrraatteess ((pprreevveenntt

wweeiigghhtt ggaaiinn))

o For long-term immobilization with traction, reposition the patient frequently to

increase comfort and prevent pressure ulcers

o Assist with active range of motion exercises to prevent muscle atrophy

o Encourage deep breathing and coughing to avoid hypostatic pneumonia

o Monitor the patient for fat embolism, a complication that may occur as bone

marrow releases fat into the veins

o Increase fluid intake to prevent urine stasis and constipations

o Provide cast care: While cast is wet, support it with pillows.

o Watch for skin irritation near cast edges, and check for foul odors or discharge

o Monitor patient for compartment syndrome, watch for increasing pain in the limb;

skin color changes, absent pulse, or edema distal to the injury site; decreased

active and passive muscle stretching; and sensory changes, such as numbness or

tingling (late sign)

o Remove any obvious constriction, such as a dressing or wrap, and have the cast

cut to relieve pressure if necessary.

o If these measures don’t relieve the signs and symptoms in 4 to 6 hours, the doctor

may relieve the compression surgically.

TTYYPPEESS

CCoommpplleettee-- ffrraaccttuurree eexxtteennddss tthhrroouugghh eennttiirree bboonnee,, pprroodduucciinngg 22 oorr mmoorree ffrraaggmmeennttss

SSiimmppllee oorr CClloosseedd-- ffrraaccttuurreedd bboonnee ddooeess nnoott pprroottrruuddee tthhrroouugghh sskkiinn

CCoommppoouunndd oorr OOppeenn-- ffrraaccttuurreedd bboonnee eexxtteennddss tthhrroouugghh sskkiinn aanndd mmuuccoouuss mmeemmbbrraanneess

Open fractures are graded according to the following criteria:

Grade I is a clean wound less than 1 cm long

Grade II is a larger wound without extensive soft tissue damage.

Grade III is highly contaminated, has extensive soft tissue damage, and is the

most severe.

CCoommmmiinnuutteedd ffrraaccttuurree-- mmuullttiippllee bboonnee ffrraaggmmeennttss

OObblliiqquuee ffrraaccttuurree-- ffrraaccttuurree lliinnee aatt 4455--ddeeggrreeee aannggllee ttoo lloonngg aaxxiiss ooff bboonnee

SSppiirraall ffrraaccttuurree-- ffrraaccttuurree lliinnee eenncciirrcclliinngg tthhee bboonnee

TTrraannssvveerrssee ffrraaccttuurree-- ffrraaccttuurree lliinnee ppeerrppeennddiiccuullaarr ttoo lloonngg aaxxiiss ooff bboonnee

EExxttrraaccaappssuullaarr-- ffrraaccttuurree iiss cclloossee ttoo tthhee jjooiinntt bbuutt rreemmaaiinnss oouuttssiiddee tthhee jjooiinntt ccaappssuullee..

IInnttrraaccaappssuullaarr-- ffrraaccttuurree wwiitthhiinn tthhee jjooiinntt ccaappssuullee..

IInnccoommpplleettee-- wwhheenn oonnllyy ppaarrtt ooff tthhee bboonnee iiss bbrrookkeenn..

GGrreeeennssttiicckk ffrraaccttuurree-- ffrraaccttuurree ooff oonnee ssiiddee ooff bboonnee;; ootthheerr ssiiddee mmeerreellyy bbeennddss;; uussuuaallllyy

sseeeenn oonnllyy iinn cchhiillddrreenn

BBoowwiinngg ffrraaccttuurree-- bbeennddiinngg ooff bboonnee..

SSttrreessss ffrraaccttuurree-- mmiiccrrooffrraaccttuurree..

CCOOMMPPLLIICCAATTIIOONN OOFF FFRRAACCTTUURREE

SSHHOOCCKK ((EEAARRLLYY))

HHyyppoovvoolleemmiicc oorr ttrraauummaattiicc sshhoocckk rreessuullttiinngg ffrroomm hheemmoorrrrhhaaggee aanndd ffrroomm lloossss ooff

eexxttrraacceelllluullaarr fflluuiidd iinnttoo ddaammaaggeedd ttiissssuueess mmaayy ooccccuurr iinn ffrraaccttuurreess ooff tthhee eexxttrreemmiittiieess,,

tthhoorraaxx,, ppeellvviiss,, oorr ssppiinnee..

TTrreeaattmmeenntt ooff sshhoocckk ccoonnssiissttss ooff rreessttoorriinngg bblloooodd vvoolluummee aanndd cciirrccuullaattiioonn,, rreelliieevviinngg tthhee

ppaattiieenntt’’ss ppaaiinn,, pprroovviiddiinngg aaddeeqquuaattee sspplliinnttiinngg,, aanndd pprrootteeccttiioonn tthhee ppaattiieenntt ffrroomm ffuurrtthheerr

iinnjjuurryy aanndd ootthheerr ccoommpplliiccaattiioonnss..

FFAATT EEMMBBOOLLII ((EEAARRLLYY))

After fracture of long bones or pelvis, multiple fractures, or crush injuries, fat emboli

may develop.

Fat embolism syndrome occurs most frequently in young adults and elderly adults

who experience fractures of the proximal femur.

At the time of fracture, fat globules may move into the blood because the marrow

pressure is greater than the capillary pressure or because catecholamines elevated by

the patient’s stress reaction mobilize fatty acids and promote the development of fat

globule sin the bloodstream.

The fat globules (emboli) occlude the small blood vessels that supply the lungs, brain,

kidneys, and other organs.

The onset of symptoms is rapid, usually occurring within 24 hours to 72 hours, but

may occur up to a week after injury.

Clinical Manifestations: hypoxia, tachypnea, tachycardia, and pyrexia.

The respiratory distress response includes tachypnea, Dyspnea, crackles, wheezes,

precordial chest pain, cough, large amounts of thick white sputum, and tachycardia.

The chest x-ray shows a typical ―snowstorm‖ infiltrate.

Eventually, acute pulmonary edema, acute respiratory distress syndrome, and heart

failure develop.

Cerebral disturbances (due to hypoxia and the lodging of fat emboli in the brain) are

manifested by mental status changes varying from headache, mild agitation, and

confusion t delirium and coma.

Prevention and Management

Immediate immobilization of fractures, minimal fracture manipulation, adequate

support for fractured bones during turning and positioning, and maintenance of fluid

and electrolyte balance are measures that may reduce the incidence of emboli.

Support the respiratory system, to prevent respiratory and metabolic acidosis, and to

correct homeostatic disturbances.

Respiratory failure is the most common cause of death.

Respiratory support is provided with oxygen given in high concentration.

Controlled-volume ventilation with positive end-expiratory pressure may be used to

prevent or treat pulmonary edema.

Corticosteroids may be administered to treat the inflammatory lung reaction and to

control cerebral edema.

Vasoactive medications to support cardiovascular function are administered to

prevent hypotension, shock, and interstitial pulmonary edema.

Accurate fluid intake and output records facilitate adequate fluid replacement therapy.

Morphine may be prescribed for pain and anxiety for the patient who is on a

ventilator.

CCOOMMPPAARRTTMMEENNTT SSYYNNDDRROOMMEE ((EEAARRLLYY))

A complication that develops when tissue perfusion on 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 pain can be caused by (1) reduction in the size of the muscle compartment

because the enclosing muscle fascia is too tight or a cast or dressing is constrictive, or

(2) an increase in muscle compartment contents because of edema or hemorrhage

associated with a variety or problems.

The forearm and leg muscle compartments are involved most frequently.

Clinical Manifestation: sensory deficits include paresthesia, unrelenting pain, and

hypoesthesia.

Paresthesia and numbness along the involved nerve are early signs of nerve

involvement.

Peripheral circulation is evaluated by assessing color, temperature, capillary refill

time, swelling, and pulses.

Swelling (edema) reduces tissue perfusion.

Cyanotic (blue-tinged) nail beds suggest venous congestion.

Pale or dusky and cold finger or toes and prolonged capillary refill time suggest

diminished arterial perfusion.

Edema may obscure the present of arterial pulsation and Doppler ultraonography may

be used to verify a pulse.

Deep, throbbing, unrelenting pain, which is greater than expected and not controlled

by opioids.

Medical Management

Elevation of the extremity to the heart level, release of restrictive devices (dressing or

cast), or both.

If conservative measures do not restore tissue perfusion and relieve pain within 1

hour, a fasciotomy (surgical decompression with excision of the fibrous membrane

that covers and separates muscles) may be needed to relieve the constrictive muscle

fascia.

After fasciotomy, the wound is not sutured but instead is left open to permit the

muscle tissues to expand; it is covered with moist, sterile saline dressing. The limb is

splinted in a functional position and elevated, and prescribed passive ROM exercises

are usually performed every 4 to 6 hours.

In 3 to 5 days, when the swelling has resolved and tissue perfusion has been restored,

the wound is debrided and closed (possibly with skin graft).

Fasciotomy

OOTTHHEERR EEAARRLLYY CCOOMMPPLLIICCAATTIIOONNSS

Deep vein thrombosis (DVT), thromboembolism, and pulmonary embolus (PE) are

associated with reduced skeletal muscle contractions and bed rest.

Patient with fractures of the lower extremities and pelvis are at high risk for

thromboembolism.

Pulmonary emboli may cause death several days to weeks after injury.

DIC includes a group of bleeding disorders with diverse causes, including massive

tissue trauma.

Manifestations of DIC include ecchymosis, unexpected bleeding after surgery, and

bleeding from the mucous membranes, venipuncture sites, and gastrointestinal and

urinary tracts.

All open fractures are considered contaminated.

Surgical internal fixation of fractures carries a risk for infection.

The nurse must monitory for and teach the patient to monitor for signs of infections,

including tenderness, pain, redness, swelling, local warmth, elevated temperature, and

purulent drainage.

Infections must be treated promptly.

Antibiotic therapy must be appropriate and adequate for prevention and treatment of

infection.

AAVVAASSCCUULLAARR NNEECCRROOSSIISS ((DDEELLAAYYEEDD))

Avascular necrosis occurs when the bone loses its blood supply and dies.

It may occur after a fracture with disruption of the blood supply (especially of the

femoral neck).

It is also seen with dislocations, bone transplantation, prolonged high-dosage

corticosteroid therapy, chronic renal disease, sickle cell anemia, and other diseases.

The devitalized bone may collapse or reabsorb.

The patient develops pain and experiences limited movement.

X-rays reveal calcium loss and structural collapse.

Treatment generally consists of attempts to revitalize the bone with bone grafts,

prosthetic replacement, or arthrodesis (joint fusion).

REDUCTION

Reduction of a fracture (―setting‖ the bone) refers to restoration of the fracture

fragments to anatomic alignment and rotation.

Closed Reduction

Accomplished by bringing the bone fragments into apposition (ie, placing the

ends in contact) through manipulation and manual traction.

The extremity is held in the desired position while the physician applies a cast,

splint, or other device.

The immobilizing device maintains the reduction and stabilizes the extremity

for bone healing.

X-rays are obtained to verify that the bone fragments are correctly aligned.

Open Reduction

Through a surgical approach, the fracture fragments are reduced.

Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may

be used to hold the bone fragments in position until solid bone healing occurs.

These devices may be attached to the sides of bone, or they may be inserted

through the bony fragments or directly into the medullary cavity of the bone.

Internal fixation devices ensure firm approximation and fixation of the bony

fragments.

Internal and External Fixation Devices

TRACTION

oo MMeecchhaanniissmm bbyy wwhhiicchh aa sstteeaaddyy ppuullll iiss ppllaacceedd oonn aa ppaarrtt oorr ppaarrttss ooff tthhee bbooddyy

PRINCIPLES FOR EFFECTIVE TRACTION

o Whenever traction is applied, countertraction must be used to achieve effective

traction. Countertraction is the force acting in the opposite direction. Usually the

patient’s body weight and bed position adjustments supply the needed

countertraction.

o Traction must be continuous to be effective in reducing and immobilizing

fractures.

o Skeletal traction is never interrupted.

o Weights are not removed unless intermittent traction is prescribed.

o Any factor that might reduce the effective pull or alter the resultant line of pull

must be eliminated:

- The patient must be in good body alignment in the center of the bed when

traction is applied.

- Ropes must be unobstructed.

- Weights must hang free and not rest on the bed or floor.

- Knots in the rope or the footplate must not touch the pulley or the foot of

the bed.

SKIN TRACTION

-- AApppplliiccaattiioonn ooff wwiiddee bbaanndd ooff mmoolleesskkiinn,, aaddhheessiivvee,, oorr ccoommmmeerrcciiaallllyy aavvaaiillaabbllee ddeevviicceess

ddiirreeccttllyy ttoo tthhee sskkiinn aanndd aattttaacchhiinngg wweeiigghhttss ttoo tthheemm..

- Used to control muscle spasms and to immobilize an area before surgery.

- It is accomplished by using a weight to pull on traction tape or on a foam boot attached

to the skin. The amount of weight applied must not exceed the tolerance of the skin.

- No more than 2 to 3.5 kg (4.5 to 8 lb) of traction can be used on an extremity. Pelvic

traction is usually 4.5 to 9 kg (10 to 20 lb), depending on the weight of the patient.

BBuucckk’’ss eexxtteennssiioonn

A skin traction to the lower leg. The pull is exerted in one plane when partial or

temporary immobilization if desired.

It is used to provide immobility after fractures of the proximal femur before surgical

fixation.

RReelliieevvee mmuussccllee ssppaassmm

HHeeeell iiss ssuuppppoorrtteedd ooffff bbeedd ttoo pprreevveenntt pprreessssuurree oonn hheeeell,, wweeiigghhtt hhaannggss ffrreeee ooff tthhee bbeedd,,

aanndd ffoooott iiss wweellll aawwaayy ffrroomm ffoooottbbooaarrdd ooff bbeedd,, aanndd ppaarraalllleell ttoo tthhee bbeedd..

RRuusssseell ttrraaccttiioonn

UUsseedd iinn tthhee ttrreeaattmmeenntt ooff iinntteerrttrroocchhaanntteerriicc ffrraaccttuurree ooff tthhee ffeemmuurr wwhheenn ssuurrggeerryy iiss

ccoonnttrraaiinnddiiccaatteedd

HHiipp iiss sslliigghhttllyy fflleexxeedd.. PPiilllloowwss mmaayy bbee uusseedd uunnddeerr lloowweerr lleegg ttoo pprroovviiddee ssuuppppoorrtt aanndd

kkeeeepp tthhee hheeeell ffrreeee ooff tthhee bbeedd..

BBrryyaanntt’’ss ttrraaccttiioonn-- uusseedd ttoo rreedduuccee ffeemmoorraall ffrraaccttuurree iinn cchhiillddrreenn..

BBuuttttoocckkss aarree sslliigghhttllyy eelleevvaatteedd aanndd cclleeaarr ooffff tthhee bbeedd..

Nursing considerations

Check periodically to ensure that weights, ropes, and pulleys are in proper alignment

and functional.

Don’t manipulate the weights yourself; consult the doctor if you suspect the need for

any adjustment.

Avoid wrinkling and slipping of the traction bandage and to maintain countertraction.

POTENTIAL COMPLICATIONS

Skin breakdown

Remove the foam boots to inspect the skin, th ankle, and the Achilles tendon

three times a day. A second nurse is needed to support the extremity during

the inspection and skin care.

Palpate the area of the traction tapes daily to detect underlying tenderness.

Provide back care at least every 2 hours to prevent pressure ulcers.

Use special mattress overlays (eg, air-filled, high-density foam) to minimize

the development of skin ulcers.

Nerve pressure

Regularly assess sensation and motion.

Immediately investigate any complaint of burning sensation under the traction

bandage or boot.

Promptly report altered sensation or motor function.

Circulatory impairment

Peripheral pulses, color, capillary refill, and temperature of the fingers of toes.

Indicators of DVT, including calf tenderness, swelling, and positive

Homans’sign.

SSKKEELLEETTAALL TTRRAACCTTIIOONN

- Placement of a pin through the bone, to which the traction apparatus is attached

- Common types include: Gardner-Wells and Crutchfield tongs; halo vest; pin placement

through the femur, lower tibia, calcaneus, ulna, radius, or wrists; Kirschner wire; and

Steinmann pin

Purpose: to immobilize bones and allow healing of fractures, correction of congenital

abnormalities, or stabilization of spinal degeneration.

TTrraaccttiioonn aapppplliieedd ddiirreeccttllyy ttoo bboonnee..

NNuurrssiinngg ccoonnssiiddeerraattiioonnss

o Perform pin care daily with water and normal saline solution or hydrogen peroxide

o Observe the pin insertion site for signs of infection

o Check the pin for proper fit, making sure that it doesn’t move in the bone

o Teach the patient how to use the trapeze to lift himself off the bed, if permitted

o If cervical traction is being used, check the occipital area of the head for skin

breakdown.

o When caring for a patient in a halo vest, bathe under the vest daily.

CCRRUUTTCCHH WWAALLKKIINNGG

TThhee ddiissttaannccee bbeettwweeeenn tthhee aaxxiillllaa aanndd tthhee aarrmm ppiieeccee oonn tthhee ccrruuttcchheess sshhoouulldd bbee aatt lleeaasstt 33

ffiinnggeerrwwiiddtthhss bbeellooww tthhee aaxxiillllaa

TThhee eellbboowwss sshhoouulldd bbee sslliigghhttllyy fflleexxeedd,, 3300 ddeeggrreeeess

WWhheenn aammbbuullaattiinngg wwiitthh tthhee cclliieenntt,, ssttaanndd oonn tthhee aaffffeecctteedd ssiiddee..

CCrruuttcchh ssttaannccee:: ttrriippoodd ((ttrriiaannggllee)) ppoossiittiioonn..

IInnssttrruucctt tthhee cclliieenntt nneevveerr ttoo rreesstt tthhee aaxxiillllaa oonn tthhee aaxxiillllaarryy bbaarrss..

IInnssttrruucctt tthhee cclliieenntt ttoo llooookk uupp aanndd oouuttwwaarrdd wwhheenn aammbbuullaattiinngg..

IInnssttrruucctt tthhee cclliieenntt ttoo ssttoopp aammbbuullaattiioonn iiff nnuummbbnneessss oorr ttiinngglliinngg iinn tthhee hhaannddss oorr aarrmmss

ooccccuurrss..

CCrruuttcchh ggaaiittss

FFoouurr--ppooiinntt ggaaiitt

SSeeqquueennccee::

AAddvvaannccee lleefftt ccrruuttcchh 44--66 iinncchheess

AAddvvaannccee rriigghhtt ffoooott

AAddvvaannccee rriigghhtt ccrruuttcchh

AAddvvaannccee lleefftt ffoooott

AAddvvaannttaaggeess:: mmoosstt ssttaabbllee ccrruuttcchh ggaaiitt

RReeqquuiirreemmeennttss:: WWeeiigghhtt bbeeaarriinngg iiss ppeerrmmiitttteedd oonn bbootthh lleeggss

TThhrreeee--ppooiinntt ggaaiitt

SSeeqquueennccee::

AAddvvaannccee bbootthh ccrruuttcchheess ffoorrwwaarrdd wwiitthh tthhee aaffffeecctteedd lleegg aanndd sshhiifftt wweeiigghhtt ttoo ccrruuttcchheess..

AAddvvaannccee uunnaaffffeecctteedd lleegg aanndd sshhiifftt wweeiigghhtt oonnttoo iitt..

AAddvvaannttaaggeess:: aalllloowwss tthhee aaffffeecctteedd lleegg ttoo bbee ppaarrttiiaallllyy oorr ccoommpplleetteellyy ffrreeee ooff wweeiigghhtt bbeeaarriinngg

RReeqquuiirreemmeennttss:: FFuullll wweeiigghhtt bbeeaarriinngg oonn oonnee lleegg.. TThhee ootthheerr ffoooott ccaannnnoott ssuuppppoorrtt bbuutt mmaayy aacctt

aass aa bbaallaannccee..

TTwwoo--ppooiinntt ggaaiitt

SSeeqquueennccee::

AAddvvaannccee lleefftt ccrruuttcchh aanndd rriigghhtt ffoooott

AAddvvaannccee rriigghhtt ccrruuttcchh aanndd lleefftt ffoooott

AAddvvaannttaaggeess:: FFaasstteerr vveerrssiioonn ooff tthhee ffoouurr--ppooiinntt,, mmoorree nnoorrmmaall wwaallkkiinngg ppaatttteerrnn..

RReeqquuiirreemmeennttss:: PPaarrttiiaall wweeiigghhtt bbeeaarriinngg oonn bbootthh lleeggss

SSwwiinngg--tthhrroouugghh ggaaiitt

SSeeqquueennccee::

UUnnaaffffeecctteedd ffoooott bbeeaarrss wweeiigghhtt

MMoovvee bbootthh ccrruuttcchheess ffoorrwwaarrdd..

MMoovvee bbootthh lleeggss ffaarrtthheerr aahheeaadd tthhaann ccrruuttcchheess..

WWeeiigghhtt bbeeaarriinngg rreettuurrnnss ttoo tthhee uunnaaffffeecctteedd lleegg

RReeqquuiirreemmeennttss:: wweeiigghhtt--bbeeaarriinngg iiss ppeerrmmiitttteedd oonn oonnllyy oonnee ffoooott

AAMMPPUUTTAATTIIOONN OOFF TTHHEE LLOOWWEERR EEXXTTRREEMMIITTYY

RReemmoovvaall ooff aa bbooddyy ppaarrtt,, uussuuaallllyy aann eexxttrreemmiittyy

Amputation is performed at the most distal point that will heal successfully.

The site of amputation is determined by two factors: circulation in the part, and

functional usefulness.

Amputee may experience phantom limb pain soon after surgery or 2 to 3 months after

amputation.

It occurs more frequently in above-knee amputations.

The patient describes pain or unusual sensation, such as numbness, tingling, or

muscle cramps, as well as a feeling that the extremity is present, crushed, cramped or

twisted in an abnormal position.

When a patient describes phantom pains or sensations, the nurse acknowledges these

feelings and helps the patient modify these perceptions.

Phantom limb sensation diminish over time

RRiisskk FFaaccttoorrss

AAtthheerroosscclleerroossiiss oobblliitteerraannss

UUnnccoonnttrroolllleedd DDMM

MMaalliiggnnaannccyy

EExxtteennssiivvee aanndd iinnttrraaccttaabbllee iinnffeeccttiioonn

SSeevveerree ttrraauummaa

CCoommpplliiccaattiioonnss ooff AAmmppuuttaattiioonn

IInnffeeccttiioonn

WWoouunndd nneeccrroossiiss

PPhhaannttoomm lliimmbb ppaaiinn

CCoonnttrraaccttuurreess

SSkkiinn bbrreeaakkddoowwnn

NNuurrssiinngg IInntteerrvveennttiioonn

AAsssseessss ssttuummpp aanndd mmoonniittoorr ccaatthheetteerr ddrraaiinnaaggee ffoorr ccoolloorr aanndd aammoouunntt;; rreeppoorrtt ssiiggnnss ooff

iinnccrreeaasseedd ddrraaiinnaaggee

BKA: keep knee extended to avoid hamstring contracture

IIff pprreessccrriibbeedd,, dduurriinngg tthhee ffiirrsstt 2244 hhoouurrss,, eelleevvaattee tthhee ffoooott ooff tthhee bbeedd ttoo rreedduuccee eeddeemmaa;;

tthheenn kkeeeepp tthhee bbeedd ffllaatt ttoo pprreevveenntt hhiipp fflleexxiioonn ccoonnttrraaccttuurreess

DDoo nnoott eelleevvaattee tthhee ssttuummpp iittsseellff——eelleevvaattiioonn ccaann ccaauussee fflleexxiioonn ccoonnttrraaccttuurree ooff tthhee hhiipp

jjooiinntt..

AAfftteerr 2244 aanndd 4488 hhoouurrss ppoossttooppeerraattiivveellyy,, ppoossiittiioonn tthhee cclliieenntt pprroonnee iiff pprreessccrriibbeedd,, ttoo

ssttrreettcchh tthhee mmuusscclleess aanndd pprreevveenntt fflleexxiioonn ccoonnttrraaccttuurreess ooff hhiipp

TToo pprreevveenntt lleegg aabbdduuccttiioonn,, kkeeeepp lleeggss cclloossee ttooggeetthheerr

EEnnccoouurraaggee eexxeerrcciisseess ttoo pprreevveenntt tthhrroommbbooeemmbboolliissmm

EEnnccoouurraaggee ppaattiieenntt ttoo aammbbuullaattee uussiinngg ccoorrrreecctt ccrruuttcchh--wwaallkkiinngg tteecchhnniiqquueess

Teach patient triceps strengthening exercises for crutch walking, such as pushups and

flexion and extension of the arms using traction weights.

Instruct the patient to rub the stump with alcohol daily to toughen the skin

Avoid applying powder or lotion

Massage the stump toward the suture line to mobilize the scar and prevent its

adherence to bone

To prepare the stump for prosthesis, teach progressive resistance maneuvers.

Stress the importance of performing prescribed exercises to help minimize

complications, maintain muscle strength and tone, prevent contractures, and promote

independence.

IINNFFLLAAMMMMAATTOORRYY DDIISSOORRDDEERRSS OOFF TTHHEE MMUUSSCCUULLOOSSKKEELLEETTAALL SSYYSSTTEEMM

RRHHEEUUMMAATTOOIIDD AARRTTHHRRIITTIISS

CChhrroonniicc ssyysstteemmiicc iinnffllaammmmaattoorryy ddiisseeaassee

DDeessttrruuccttiioonn ooff ccoonnnneeccttiivvee ttiissssuuee aanndd ssyynnoovviiaall mmeemmbbrraannee wwiitthhiinn tthhee jjooiinnttss

WWeeaakkeennss aanndd lleeaaddss ttoo ddiissllooccaattiioonn ooff tthhee jjooiinntt aanndd ppeerrmmaanneenntt ddeeffoorrmmiittyy

Spontaneous remissions and exacerbations mark the course of RA.

RRiisskk FFaaccttoorrss::

EExxppoossuurree ttoo iinnffeeccttiioouuss aaggeennttss

FFaattiigguuee

SSttrreessss

SSiiggnnss aanndd SSyymmppttoommss

IInniittiiaall ssyymmppttoommss:: ffaattiigguuee,, mmaallaaiissee,, aannoorreexxiiaa,, ppeerrssiisstteenntt llooww ggrraaddee ffeevveerr,, wweeiigghhtt

lloossss,, aanndd llyymmppaaddeennooppaatthhyy

joint pain, tenderness, warmth, and swelling

joint symptoms occur bilaterally and symmetrically

MMoorrnniinngg ssttiiffffnneessss

SSwwaann nneecckk ddeeffoorrmmiittyy--llaattee

DDiiaaggnnoossttiicc SSttuuddiieess

XX--rraayy,, sshhooww bboonnee ddeemmiinneerraalliizzaattiioonn aanndd ssoofftt ttiissssuuee sswweelllliinngg

EElleevvaatteedd EESSRR,, aanndd ppoossiittiivvee RRFF

TTrreeaattmmeenntt

Salicylates, to decrease inflammation and relieve joint pain.

NNSSAAIIDDss ((iinnddoommeetthhaacciinn,, kkeettoorroollaacc,, iibbuupprrooffeenn,, CCooxx--22 IInnhhiibbiittoorrss ((CCeelleeccooxxiibb,,

RRooffeeccooxxiibb))

oo IInnhhiibbiittss oonnllyy ccyyccllooooxxyyggeennaassee--22 eennzzyymmeess

Antimalarials (chloroquine and hydroxychloroquine)

Gold sodium thiomalate

penicilamine

Corticosteroids

Immunosuppressives (methotrexate, cyclophosphamide, azathioprine)

HHoott aanndd CCoolldd ppaacckkss ttoo aaffffeecctteedd jjooiinnttss

SSuurrggiiccaall PPrroocceedduurreess:: ssyynnoovveeccttoommyy,, aarrtthhrroottoommyy,, aarrtthhrrooddeessiiss,, aarrtthhrrooppllaassttyy

SSuuppppoorrttiivvee mmeeaassuurreess iinncclluuddee:: 88 ttoo 1100 hhoouurrss ooff sslleeeepp eevveerryy nniigghhtt,, aaddeeqquuaattee

nnuuttrriittiioonn,, ffrreeqquueenntt rreesstt ppeerriiooddss bbeettwweeeenn ddaaiillyy aaccttiivviittiieess,, aanndd sspplliinnttiinngg ttoo rreesstt

iinnffllaammeedd jjooiinnttss..

Swan neck deformity

NNuurrssiinngg MMaannaaggeemmeenntt

Assess all joints carefully

Monitor vital signs and note weight changes, sensory disturbances, and level of

pain.

Give meticulous skin care. Use lotion or cleansing oil, not soap, for dry skin

Apply splints carefully

Encourage a balanced diet.

Urge the patient to perform activities of daily living

BBeedd rreesstt

DDaaiillyy RROOMM eexxeerrcciisseess

RReelliieevviinngg ppaaiinn aanndd ddiissccoommffoorrtt

AAddmmiinniisstteerr ddrruuggss aass pprreessccrriibbeedd aanndd mmoonniittoorr eeffffeeccttss

NNuurrssiinngg DDiiaaggnnoossiiss

PPaaiinn rreellaatteedd ttoo jjooiinntt ddeessttrruuccttiioonn

IImmppaaiirreedd pphhyyssiiccaall mmoobbiilliittyy rreellaatteedd ttoo jjooiinntt ccoonnttrraaccttuurreess

RRiisskk ffoorr iinnjjuurryy rreellaatteedd ttoo tthhee iinnffllaammmmaattoorryy pprroocceessss

BBooddyy iimmaaggee ddiissttuurrbbaannccee rreellaatteedd ttoo jjooiinntt ddeeffoorrmmiittyy

SSeellff--ccaarree ddeeffiicciitt rreellaatteedd ttoo mmuussccuulloosskkeelleettaall iimmppaaiirrmmeenntt

OOSSTTEEOOAARRTTHHRRIITTIISS ((DDEEGGEENNEERRAATTIIVVEE JJOOIINNTT DDIISSEEAASSEE))

PPrrooggrreessssiivvee ddeeggeenneerraattiioonn ooff tthhee jjooiinnttss aass aa rreessuulltt ooff wweeaarr aanndd tteeaarr

AAffffeeccttss wweeiigghhtt--bbeeaarriinngg jjooiinnttss aanndd jjooiinnttss tthhaatt rreecceeiivvee tthhee ggrreeaatteesstt ssttrreessss,, ssuucchh aass tthhee

hhiippss aanndd kknneeeess

RRiisskk FFaaccttoorrss

AAggiinngg ((>>5500 yyrr))

RRhheeuummaattooiidd aarrtthhrriittiiss

AArrtteerriioosscclleerroossiiss

OObbeessiittyy

TTrraauummaa

FFaammiillyy hhiissttoorryy

SSiiggnnss aanndd SSyymmppttoommss

ppaaiinn,, tteennddeerr jjooiinnttss,, ppaarrttiiccuullaarrllyy aafftteerr eexxeerrcciissee oorr wweeiigghhtt bbeeaarriinngg aanndd iiss uussuuaallllyy

rreelliieevveedd bbyy rreesstt

stiffness in the morning and after exercise that is usually relieved by rest

achiness during changes in weather, cold intolerance

ffaattiiggaabbiilliittyy,, mmaallaaiissee

ccrreeppiittuuss

pprreesseennccee ooff HHeebbeerrddeenn’’ss nnooddeess oorr BBoouucchhaarrdd’’ss nnooddeess

lliimmiitteedd mmoovveemmeenntt

Diagnostic tests

X-rays of the affected joint help confirm diagnosis

Treatment

Palliative treatment

Medications include: aspirin (or other nonnarcotic analgesics), phenylbutazone,

indomethacin, ketorolac, ibuprofen, propoxyphene hydrochloride, rofecoxib, and

in some cases, intra-articular injections of corticosteroid

AAssppiirriinn

IInnhhiibbiittss ccyyccllooooxxyyggeennaassee eennzzyymmee,, ddiimmiinniisshheess tthhee ffoorrmmaattiioonn ooff pprroossttaaggllaannddiinnss

AAnnttii--iinnffllaammmmaattoorryy,, aannaallggeessiicc,, aannttiippyyrreettiicc aaccttiioonn

IInnhhiibbiitt ppllaatteelleett aaggggrreeggaattiioonn iinn ccaarrddiiaacc ddiissoorrddeerrss

AAddvveerrssee eeffffeeccttss::

EEppiiggaassttrriicc ddiissttrreessss,, nnaauusseeaa,, aanndd vvoommiittiinngg

IInn ttooxxiicc ddoosseess,, ccaann ccaauussee rreessppiirraattoorryy ddeepprreessssiioonn

HHyyppeerrsseennssiittiivviittyy

RReeyyee’’ss ssyynnddrroommee

IIbbuupprrooffeenn

UUssee ffoorr cchhrroonniicc ttrreeaattmmeenntt ooff rrhheeuummaattooiidd aanndd oosstteeooaarrtthhrriittiiss

LLeessss GGII eeffffeeccttss tthhaann aassppiirriinn

AAddvveerrssee eeffffeeccttss::

DDyyssppeeppssiiaa ttoo bblleeeeddiinngg

HHeeaaddaacchhee,, ttiinnnniittuuss aanndd ddiizzzziinneessss

IInnddoommeetthhaacciinn

IInnhhiibbiittss ccyyccllooooxxyyggeennaassee eennzzyymmee

MMoorree ppootteenntt tthhaann aassppiirriinn aass aann aannttii--iinnffllaammmmaattoorryy aaggeenntt

AAddvveerrssee eeffffeeccttss::

TThhee aaddvveerrssee eeffffeeccttss aarree ddoossee--rreellaatteedd..

NNaauusseeaa,, vvoommiittiinngg,, aannoorreexxiiaa,, ddiiaarrrrhheeaa

HHeeaaddaacchhee,, ddiizzzziinneessss,, vveerrttiiggoo,, lliigghhtt--hheeaaddeeddnneessss,, aanndd mmeennttaall ccoonnffuussiioonn

HHyyppeerrsseennssiittiivviittyy rreeaaccttiioonn

Effective treatment also reduces joint stress by supporting or stabilizing the joint

with crutches, braces, a cane, a walker, a cervical collar, or traction.

Other supportive measures include massage, moist heat, paraffin dips for hands,

protective techniques for preventing undue stress on the joints

Those with severe osteoarthritis with disability or uncontrollable pain may undergo:

arthroplasty- replacement of a deteriorated joint with a prosthetic appliance

arthrodesis- surgical fusion of bones, which is used primarily in the spine

(laminectomy)

osteoplasty- scraping of deteriorated bone from a joint

osteotomy- excision of bone to change alignment and relieve stress

NNuurrssiinngg IInntteerrvveennttiioonn

PPrroommoottee ccoommffoorrtt:: rreedduuccee ppaaiinn,, ssppaassmmss,, iinnffllaammmmaattiioonn,, sswweelllliinngg

MMeeddiiccaattiioonnss aass pprreessccrriibbeedd..

HHeeaatt ttoo rreedduuccee mmuussccllee ssppaassmm

CCoolldd ttoo rreedduuccee sswweelllliinngg aanndd ppaaiinn

PPrreevveenntt ccoonnttrraaccttuurreess:: eexxeerrcciissee,, bbeedd rreesstt oonn ffiirrmm mmaattttrreessss,, sspplliinnttss ttoo mmaaiinnttaaiinn

pprrooppeerr aalliiggnnmmeenntt

WWeeiigghhtt rreedduuccttiioonn

IIssoommeettrriicc aanndd ppoossttuurraall eexxeerrcciisseess

Firm mattress or bed board to decrease morning pain

Assist with ROM and strengthening exercises

Instruct patients to wear well-fitting supportive shoes, install safety devices at

home, maintain proper body weight to lessen joint stress, avoid overexertion.

NNuurrssiinngg DDiiaaggnnoossiiss

PPaaiinn rreellaatteedd ttoo ffrriiccttiioonn ooff bboonneess iinn jjooiinnttss

RRiisskk ffoorr iinnjjuurryy rreellaatteedd ttoo ffaattiigguuee

IImmppaaiirreedd pphhyyssiiccaall mmoobbiilliittyy rreellaatteedd ttoo ssttiiffff,, lliimmiitteedd mmoovveemmeenntt

GGOOUUTTYY AARRTTHHRRIITTIISS

MMeettaabboolliicc ddiissoorrddeerr tthhaatt ddeevveellooppss aass aa rreessuulltt ooff pprroolloonnggeedd hhyyppeerruurriicceemmiiaa ccaauusseedd

bbyy pprroobblleemmss iinn ssyynntthheessiizziinngg ppuurriinneess oorr bbyy ppoooorr rreennaall eexxccrreettiioonn ooff uurriicc aacciidd..

aaccuuttee oonnsseett,, ttyyppiiccaallllyy nnooccttuurrnnaall aanndd uussuuaallllyy mmoonnaarrttiiccuullaarr,, oofftteenn iinnvvoollvviinngg tthhee ffiirrsstt

mmeettaattaarrssoopphhaallaannggeeaall jjooiinntt

RRiisskk FFaaccttoorrss

MMeenn

AAggee 3300 oorr oollddeerr aanndd iinn ppoossttmmeennooppaauussaall wwoommeenn

GGeenneettiicc//ffaammiilliiaall tteennddeennccyy

Causes

Unknown

Linked to a genetic defect in purine metabolism, which causes overproduction of

uric acid, retention of uric acid, or both.

Secondary gout, which develops during the course of another disease (such as

obesity, DM, HPN, sickle cell anemia, renal disease, myeloma, leukemia)

Following drug therapy, hydrochlorothiazide or pyrazinamide, which interferes

with urate excretion

SSiiggnnss aanndd SSyymmppttoommss

AAffffeecctteedd jjooiinnttss aappppeeaarr hhoott,, tteennddeerr,, iinnffllaammeedd,, dduusskkyy rreedd,, oorr ccyyaannoottiicc

Metatarsophalangeal joint of the great toe usually becomes inflamed first

(podagra), then the instep, ankle, heel, knee or wrist joints

EExxttrreemmeellyy ppaaiinnffuull

FFeevveerr

IInnccrreeaasseedd ccoonncceennttrraattiioonn ooff uurriicc aacciidd lleeaaddss ttoo uurraattee ddeeppoossiittss,, ccaalllleedd TToopphhii

Diagnostic tests

((++)) uurraattee mmoonnoohhyyddrraattee ccrryyssttaallss iinn ssyynnoovviiaall fflluuiidd ttaakkeenn ffrroomm aann iinnffllaammeedd jjooiinntt oorr

ttoopphhuuss aassppiirraattiioonn ooff ssyynnoovviiaall fflluuiidd ((aarrtthhrroocceenntteessiiss)) oorr ooff ttoopphhaacceeoouuss mmaatteerriiaall

rreevveeaallss nneeeeddlleelliikkee iinnttrraacceelllluullaarr ccrryyssttaallss ooff ssooddiiuumm uurraattee

EElleevvaatteedd sseerruumm uurriicc aacciidd

EElleevvaatteedd uurriinnaarryy uurriicc aacciidd eessppeecciiaallllyy iinn sseeccoonnddaarryy uurriicc aacciidd lleevveellss

IInn cchhrroonniicc ggoouutt,, XX--rraayyss sshhooww aa ppuunncchheedd--oouutt llooookk wwhheenn uurraattee aacciiddss rreeppllaaccee bboonnyy

ssttrruuccttuurreess

TTrreeaattmmeenntt

AAllllooppuurriinnooll

oo AA ppuurriinnee aannaalloogg

oo RReedduucceess tthhee pprroodduuccttiioonn ooff uurriicc aacciidd bbyy ccoommppeettiittiivveellyy iinnhhiibbiittiinngg uurriicc aacciidd

bbiioossyynntthheessiiss wwhhiicchh iiss ccaattaallyyzzeedd bbyy xxaanntthhiinnee ooxxiiddaassee..

EEffffeeccttiivvee iinn tthhee ttrreeaattmmeenntt ooff pprriimmaarryy hhyyppeerruurriicceemmiiaa ooff ggoouutt aanndd hhyyppeerruurriicceemmiiaa

sseeccoonnddaarryy ttoo ootthheerr ccoonnddiittiioonnss ((mmaalliiggnnaanncciieess))..

AAddvveerrssee eeffffeeccttss:: hhyyppeerrsseennssiittiivviittyy rreeaaccttiioonnss,, nnaauusseeaa aanndd ddiiaarrrrhheeaa

CCoollcchhiicciinnee

EEffffeeccttiivvee ffoorr aaccuuttee aattttaacckkss

Taken every hour for 8 hours, until pain subsides or until signs of overdose such

as nausea, vomiting, cramping or diarrhea develop

AAnnttii--iinnffllaammmmaattoorryy aaccttiivviittyy aalllleevviiaattiinngg ppaaiinn wwiitthhiinn 1122 hhoouurrss

AAddvveerrssee eeffffeeccttss:: nnaauusseeaa,, vvoommiittiinngg,, aabbddoommiinnaall ppaaiinn,, ddiiaarrrrhheeaa,, aaggrraannuullooccyyttoossiiss,,

aappllaassttiicc aanneemmiiaa,, aallooppeecciiaa

PPrroobbeenneecciidd//SSuullffiinnppyyrraazzoonnee

UUrriiccoossuurriicc aaggeennttss

IInnccrreeaasseess tthhee rreennaall eexxccrreettiioonn ooff uurriicc aacciidd aanndd iinnhhiibbiitt aaccccuummuullaattiioonn ooff uurriicc aacciidd

SSuullffiinnppyyrraazzoonnee uusseedd aass aa pprreevveennttiivvee aaggeenntt..

AAddvveerrssee eeffffeeccttss:: nnaauusseeaa,, rraasshh && ccoonnssttiippaattiioonn

Don’t administer these drugs to patient with calculi

Corticosteroids or joint aspiration and an intra-articular corticosteroid injection

For resistant inflammation

Analgesics, such as acetaminophen or ibuprofen

Relieve pain associated with mild attacks

NNuurrssiinngg IInntteerrvveennttiioonnss

BBeedd rreesstt,, iimmmmoobbiilliizzaattiioonn,, aanndd pprrootteeccttiioonn ooff iinnffllaammeedd,, ppaaiinnffuull jjooiinnttss;; llooccaall

aapppplliiccaattiioonn ooff hheeaatt oorr ccoolldd..

MMaaiinnttaaiinn aa fflluuiidd iinnttaakkee ooff aatt lleeaasstt 22000000 ttoo 33000000 mmLL aa ddaayy ttoo aavvooiidd kkiiddnneeyy ssttoonnee..

AAvvooiidd ffooooddss hhiigghh iinn ppuurriinnee ssuucchh aass wwiinnee,, aallccoohhooll,, oorrggaann mmeeaattss,, ssaarrddiinneess,, ssaallmmoonn,,

aanncchhoovviieess,, sshheellllffiisshh aanndd ggrraavvyy..

TTaakkee mmeeddiiccaattiioonn wwiitthh ffoooodd..

HHaavvee aa yyeeaarrllyy eeyyee eexxaammiinnaattiioonn bbeeccaauussee vviissuuaall cchhaannggeess ccaann ooccccuurr ffrroomm pprroolloonnggeedd

uussee ooff aallllooppuurriinnooll

CCaauuttiioonn cclliieenntt nnoott ttoo ttaakkee aassppiirriinn wwiitthh tthheessee mmeeddiiccaattiioonn bbeeccaauussee iitt mmaayy ttrriiggggeerr aa

ggoouutt aattttaacckk aanndd mmaayy ccaauussee aann eelleevvaatteedd uurriicc aacciidd lleevveellss..

EEnnccoouurraaggee rreesstt aanndd iimmmmoobbiilliizzee tthhee iinnffllaammeedd jjooiinnttss dduurriinngg aaccuuttee aattttaacckkss

AAvvooiidd eexxcceessssiivvee aallccoohhooll iinnttaakkee

NNoottiiffyy pphhyyssiicciiaann iiff rraasshh,, ssoorree tthhrrooaatt,, ffeevveerr oorr bblleeeeddiinngg ddeevveellooppss..

Nursing Diagnosis

Chronic pain

Impaired physical mobility

Risk for injury

OOSSTTEEOOMMYYEELLIITTIISS

PPyyooggeenniicc iinnffeeccttiioonn ooff tthhee bboonnee.. TThhee bboonnee bbeeccoommeess iinnffeecctteedd bbyy oonnee ooff tthhrreeee mmooddeess::

Extension of soft tissue infection (eg, infected pressure or vascular ulcer, incisional

infection)

Direct bone contamination from bone surgery, open fracture, or traumatic injury (eg,

gun shot wound

Hematogenous (bloodborne) spread from other sites of infection (eg, infected tonsils,

boils, infected teeth, upper respiratory infections).

Infection causes tissue necrosis, breakdown of bone structure, and decalcification

SSttaapphhyyllooccooccccuuss aauurreeuuss iiss tthhee mmoosstt ccoommmmoonn ppaatthhooggeenn.. OOtthheerr oorrggaanniissmmss iinncclluuddee

PPrrootteeuuss,, PPsseeuuddoommoonnaass aanndd EE.. ccoollii

Pathophysiology

Staphylococcus aureus causes 70% to 80% of bone infections. Other pathogenic

organisms frequently found in osteomyelitis include Proteus and Pseudomonas

species and Escherichia coli. The incidence of penicillin-resistant, nosocomial, gram-

negative, and anaerobic infections is increasing.

Initial response to infection is inflammation, increased vascularity, and edema. After

2 or 3 days, thrombosis of the blood vessels occurs in the area, resulting in ischemia

with bone necrosis.

The infection extends into the medullary cavity and under the periosteum and may

spread into adjacent soft tissues and joints.

Unless the infective process is treated promptly, a bone abscess forms.

The resulting abscess cavity contains dead bone tissue (the sequestrum), which does

not easily liquefy and drain.

SSiiggnnss aanndd ssyymmppttoommss

SSuuddddeenn ppaaiinn iinn tthhee aaffffeecctteedd bboonnee;; tteennddeerrnneessss,, hheeaatt aanndd sswweelllliinngg oovveerr tthhee aaffffeecctteedd

aarreeaa,, aanndd rreessttrriicctteedd mmoovveemmeenntt..

CClliinniiccaall mmaanniiffeessttaattiioonnss ooff sseeppttiicceemmiiaa ((ffeevveerr,, cchhiillllss,, ttaacchhyyccaarrddiiaa,, ggeenneerraall mmaallaaiissee))

DDiiaaggnnoossttiicc SSttuuddiieess

XX--rraayy:: ddeemmoonnssttrraattee ssoofftt ttiissssuuee sswweelllliinngg

BBoonnee SSccaann aanndd MMRRII:: hheellpp wwiitthh eeaarrllyy ddeeffiinniittiivvee ddiiaaggnnoossiiss

BBlloooodd aanndd wwoouunndd ccuullttuurree:: iiddeennttiiffyy aapppprroopprriiaattee aannttiibbiioottiicc tthheerraappyy

Elevated WBC and ESR

Treatment

o Administration of large doses of antibiotics I.V. after blood cultures are taken

o Early surgical drainage to relieve pressure buildup and sequestrum formation

o Immobilization of the affected bone by plaster cast, traction, or bed rest

o Supportive measures: analgesics and I.V. fluids

o If an abscess forms, incision and drainage, followed by a culture of the drainage

matter

o Antibiotic therapy to control infection

o Local application of packed, wet, antibiotic-soaked dressings

o Surgery to remove dead bone and to promote drainage

NNuurrssiinngg iinntteerrvveennttiioonnss

oo PPrroommoottee ccoommffoorrtt

IImmmmoobbiilliizzeedd aaffffeecctteedd bboonnee bbyy mmaaiinnttaaiinniinngg sspplliinnttiinngg..

EElleevvaattee aaffffeecctteedd lleegg ttoo rreedduuccee sswweelllliinngg

AAddmmiinniisstteerr aannaallggeessiiccss aass nneeeeddeedd..

oo CCoonnttrrooll iinnffeeccttiioouuss pprroocceessss

MMoonniittoorr ssiiggnnss ooff ssuuppeerriinnffeeccttiioonn ((eegg,, oorraall oorr vvaaggiinnaall ccaannddiiddiiaassiiss,, lloooossee oorr ffoouull--

ssmmeelllliinngg ssttoooollss))

AAddmmiinniisstteerr aannttiibbiioottiiccss aass pprreessccrriibbeedd..

UUssee aasseeppttiicc tteecchhnniiqquuee wwhheenn ddrreessssiinngg tthhee wwoouunndd ttoo pprroommoottee hheeaalliinngg aanndd ttoo pprreevveenntt

ccrroossss ccoonnttaammiinnaattiioonn..

oo EEnnccoouurraaggee ppaarrttiicciippaattiioonn iinn AADDLL wwiitthhiinn tthhee pphhyyssiiccaall lliimmiittaattiioonnss ooff tthhee ppaattiieenntt ttoo

pprroommoottee ggeenneerraall wweellll bbeeiinngg..

o Administer I.V. fluids to maintain adequate hydration as needed

o Provide a high protein and vitamin C

o Support the affected limb with firm pillows.

o Provide good cast care. Support the cast with firm pillows and ―petal‖ the edges with

pieces of adhesive tape or moleskin to smooth rough edges

o Check circulation and drainage every 4 hours for the first 24 hours postoperatively.

OOSSTTEEOOPPOORROOSSIISS

TThhee rraattee ooff bboonnee rreessoorrppttiioonn aacccceelleerraatteess wwhhiillee tthhee rraattee ooff bboonnee ffoorrmmaattiioonn sslloowwss ddoowwnn,,

ccaauussiinngg aa lloossss ooff bboonnee mmaassss

BBoonneess lloossee ccaallcciiuumm aanndd pphhoosspphhaattee ssaallttss aanndd bbeeccoommee ppoorroouuss,, bbrriittttllee,, aanndd aabbnnoorrmmaallllyy

vvuullnneerraabbllee ttoo ffrraaccttuurree

Affects weight bearing vertebrae, ribs, femurs, and wrist bones.

Vertebral and wrist fractures are common.

RRiisskk FFaaccttoorrss

PPoossttmmeennooppaauussaall wwoommeenn

SSmmaallll--ffrraammeedd,, nnoonn--oobbeessee

AAggeess 5500--7700

LLoonngg tteerrmm ccoorrttiiccoosstteerrooiidd tthheerraappyy

HHiigghh ccaaffffeeiinnee iinnttaakkee

SSmmookkiinngg

HHiigghh aallccoohhooll iinnttaakkee

SSeeddeennttaarryy lliiffeessttyyllee oorr iimmmmoobbiilliittyy

IInnssuuffffiicciieenntt ccaallcciiuumm iinnttaakkee oorr aabbssoorrppttiioonn

SSmmaallll tthhiinn ffrraammee

HHeerreeddiittaarryy pprreeddiissppoossiittiioonn

CCooeexxiissttiinngg mmeeddiiccaall ccoonnddiittiioonnss ((hhyyppeerrppaarraatthhyyrrooiiddiissmm,, hhyyppeerrtthhyyrrooiiddiissmm))

Causes:

o Primary osteoporosis- unknown

o Secondary osteoporosis- prolonged therapy with steroids, heparin, anticonvulsants, or

thyroid preparations; from aluminum-containing antacids; or total immobility or

disuse of a bone.

o Linked also to alcoholism, malnutrition, malabsorption, scurvy, lactose intolerance,

hyperthyroidism, and osteogenesis imperfecta

AAsssseessssmmeenntt FFiinnddiinnggss

Develops insidiously, an elderly person bends to lift something, hears a snapping

sound, then feels a sudden pain in the lower back.

LLoossss ooff hheeiigghhtt

FFrraaccttuurreess ooff tthhee wwrriisstt,, vveerrtteebbrraall ccoolluummnn aanndd hhiipp

LLoowweerr bbaacckk ppaaiinn

KKyypphhoossiiss

RReessppiirraattoorryy iimmppaaiirrmmeenntt

DDiiaaggnnoossttiicc tteessttss

XX--rraayyss:: ddeeggeenneerraattiioonn iinn tthhee lloowweerr tthhoorraacciicc aanndd lluummbbaarr vveerrtteebbrraaee;; vveerrtteebbrraall bbooddiieess mmaayy

aappppeeaarr ffllaatttteenneedd,, wwiitthh vvaarryyiinngg ddeeggrreeeess ooff ccoollllaappssee aanndd wweeddggiinngg..

DDuuaall--eenneerrggyy xx--rraayy aabbssoorrppttiioommeettrryy ((DDEEXXAA))

SSeerruumm ccaallcciiuumm-- nnoorrmmaall

SSeerruumm aallkkaalliinnee pphhoosspphhaattaassee-- nnoorrmmaall

Serum phosphorus- normal

Treatment

Physical therapy program

Doctor may order estrogen to decrease the rate of bone resorption and calcium and

vitamin D to support normal bone metabolism

Surgery: correct pathologic fractures of the femur be open reduction and internal

fixation

Adequate intake of dietary calcium and regular weight bearing exercise may reduce a

person’s chances of developing senile osteoporosis

Hormone treatments

Decreased alcohol consumption

Prompt treatment of hyperthyroidism

NNuurrssiinngg iinntteerrvveennttiioonnss

PPrreevveennttiioonn

AAddeeqquuaattee ddiieettaarryy oorr ssuupppplleemmeennttaall ccaallcciiuumm

RReegguullaarr wweeiigghhtt bbeeaarriinngg eexxeerrcciissee

MMooddiiffiiccaattiioonn ooff lliiffeessttyyllee

CCaallcciiuumm wwiitthh vviittaammiinn DD ssuupppplleemmeennttss

AAddmmiinniisstteerr HHRRTT,, aass pprreessccrriibbeedd

RReelliieevviinngg ppaaiinn

IImmpprroovviinngg bboowweell eelliimmiinnaattiioonn

PPrreevveennttiinngg iinnjjuurryy

NNuurrssiinngg AAccttiivviittiieess

EEnnccoouurraaggee uussee ooff aassssiissttiivvee ddeevviicceess wwhheenn ggaaiitt iiss uunnssttaabbllee

PPrrootteecctt ffrroomm iinnjjuurryy ((ssiiddee rraaiillss,, wwaallkkeerr))

EEnnccoouurraaggee aaccttiivvee//ppaassssiivvee RROOMM

PPrroommoottee ppaaiinn rreelliieeff

EEnnccoouurraaggee ggoooodd ppoossttuurree aanndd bbooddyy mmeecchhaanniiccss

DEXA scan

PPAAGGEETT’’SS DDIISSEEAASSEE

PPrrooggrreessssiivvee sskkeelleettaall ddiisseeaassee wwiitthh ddeeffoorrmmiittyy

EExxcceessssiivvee bboonnee rreessoorrppttiioonn ((oosstteeooccllaassttiicc pphhaassee)),, ffoolllloowweedd bbyy aa rreeaaccttiivvee pphhaassee ooff

eexxcceessssiivvee aabbnnoorrmmaall bboonnee ffoorrmmaattiioonn ((oosstteeoobbllaassttiicc pphhaassee))

Chaotic, fragile, and weak, the new bone structure causes painful deformities of

external contour and internal structure

IItt ccaann bbee ffaattaall,, ppaarrttiiccuullaarrllyy iiff aassssoocciiaatteedd wwiitthh hheeaarrtt ffaaiilluurree,, bboonnee ssaarrccoommaa,, oorr ggiiaanntt cceellll

ttuummoorrss

Causes

Unknown

One theory holds that early viral infection (possibly with mumps virus) causes a

dormant skeletal infection that erupts many years later as Paget’s disease.

CClliinniiccaall MMaanniiffeessttaattiioonn

EEaarrllyy ssttaaggeess:: sseevveerree,, ppeerrssiisstteenntt ppaaiinn iinntteennssiiffiieess wwiitthh wweeiigghhtt bbeeaarriinngg aanndd mmaayy iimmppaaiirr

mmoovveemmeenntt

AAssyymmmmeettrriiccaall bboowwiinngg ooff ffeemmuurr aanndd ttiibbiiaa

EEnnllaarrggeemmeenntt ooff tthhee sskkuullll ((ffrroonnttaall aanndd oocccciippiittaall aarreeaa)),, hhaatt ssiizzee iinnccrreeaasseess

CCrraanniiaall nneerrvvee ccoommpprreessssiioonn

Kyphosis

Barrel shaped chest

RReessppiirraattoorryy ddiissttrreessss

PPaaiinn

DDiiaaggnnoossttiicc FFiinnddiinnggss

XX--rraayyss

EElleevvaatteedd sseerruumm aallkkaalliinnee pphhoosspphhaattaassee

Elevated serum calcium

BBoonnee ssccaann

Treatment

Drug therapy: calcitonin and etidronate or plicamycin

Calcitonin and etidronate: retard bone resorption and reduce serum alkaline

phosphatase levels and urinary hydroxyproline secretion

Plicamycin: decreases calcium, urinary hydroxyproline and serum alkaline

phosphatase levels.

Surgery: to reduce or prevent pathologic fractures, correct secondary deformities, and

relieve neurologic impairment

Aspirin, indomethacin, or ibuprofen usually controls pain

NNuurrssiinngg iinntteerrvveennttiioonnss

Monitor serum calcium and alkaline phosphatase levels

Monitor intake and output

Change position to prevent pressure ulcers

Provide high topped sneakers to prevent foot drop.

Demonstrate to patient how to inject calcitonin and rotate injection sites

Warn the patient that adverse effects (nausea, vomiting, local inflammation at

injection site, facial flushing, itching of hands, and fever) may occur.

Tell the patient receiving etidronate to take this medication with fruit juice 2 hours

before or after meals (milk or other high-calcium fluids impair absorption)

Tell patient receiving plicamycin to watch for signs of infection, easy bruising, and

bleeding and temperature elevation and to report for regular follow-up laboratory

tests.

Suggests firm mattress or a bed board to minimize spinal deformities

Prevent injury

PPrreevveenntt ppaatthhoollooggiiccaall ffrraaccttuurreess

CCoonnttrrooll ppaaiinn

AAddmmiinniisstteerr ddrruuggss aass pprreessccrriibbeedd

BBOONNEE TTUUMMOORRSS

OOSSTTEEOOSSAARRCCOOMMAA

MMoosstt ccoommmmoonn pprriimmaarryy bboonnee ttuummoorr

OOccccuurrss bbeettwweeeenn 1100--2255 yyeeaarrss ooff aaggee,, wwiitthh PPaaggeett''ss ddiisseeaassee aanndd eexxppoossuurree ttoo rraaddiiaattiioonn

EExxhhiibbiittss aa mmootthh--eeaatteenn ppaatttteerrnn ooff bboonnee ddeessttrruuccttiioonn..

MMoosstt ccoommmmoonn ssiitteess:: mmeettaapphhyyssiiss ooff lloonngg bboonneess eessppeecciiaallllyy tthhee ddiissttaall ffeemmuurr,, pprrooxxiimmaall

ttiibbiiaa aanndd pprrooxxiimmaall hhuummeerruuss

CClliinniiccaall MMaanniiffeessttaattiioonn

llooccaall ssiiggnnss –– ppaaiinn ((dduullll,, aacchhiinngg aanndd iinntteerrmmiitttteenntt iinn nnaattuurree)),, sswweelllliinngg,, lliimmiittaattiioonn ooff

mmoottiioonn

PPaallppaabbllee mmaassss nneeaarr tthhee eenndd ooff aa lloonngg bboonnee

ssyysstteemmiicc ssyymmppttoommss:: mmaallaaiissee,, aannoorreexxiiaa,, aanndd wweeiigghhtt lloossss

DDiiaaggnnoossttiicc FFiinnddiinnggss

BBiiooppssyy-- ccoonnffiirrmmss tthhee ddiiaaggnnoossiiss

XX--rraayy

MMRRII

BBoonnee SSccaann

IInnccrreeaassee aallkkaalliinnee pphhoosspphhaattaassee

Treatment

RRaaddiiaattiioonn

CChheemmootthheerraappyy

SSuurrggiiccaall mmaannaaggeemmeenntt::

AAmmppuuttaattiioonn

LLiimmbb ssaallvvaaggee pprroocceedduurreess

PPrrooggnnoossiiss:: ppoooorr pprrooggnnoossiiss ((rraappiidd ggrroowwtthh rraattee))

NNuurrssiinngg iinntteerrvveennttiioonnss

PPrroommoottee uunnddeerrssttaannddiinngg ooff tthhee ddiisseeaassee pprroocceessss aanndd ttrreeaattmmeenntt rreeggiimmeenn

PPrroommoottee ppaaiinn rreelliieeff

PPrreevveenntt ppaatthhoollooggiicc ffrraaccttuurree..

PPrroommoottee ccooppiinngg sskkiillllss aanndd sseellff eesstteeeemm

AAsssseessss ffoorr ppootteennttiiaall ccoommpplliiccaattiioonnss ((iinnffeeccttiioonn,, ccoommpplliiccaattiioonnss ooff iimmmmoobbiilliittyy))..

EEnnccoouurraaggee eexxeerrcciissee aass ssoooonn aass ppoossssiibbllee ((11sstt oorr 22nndd ppoosstt--oopp ddaayy))

DDaannggllee aanndd ttrraannssffeerr ppaattiieenntt ttoo wwhheeeellcchhaaiirr aanndd bbaacckk wwiitthhiinn 11sstt oorr 22nndd ddaayy ppoosstt--oopp;;

ccrruuttcchh wwaallkkiinngg ssttaarrtteedd aass ssoooonn aass ppaattiieenntt ffeeeellss ssuuffffiicciieennttllyy ssttrroonngg

TTOOTTAALL HHIIPP RREEPPLLAACCEEMMEENNTT

aa ppllaassttiicc ssuurrggeerryy tthhaatt iinnvvoollvveess rreemmoovvaall ooff tthhee hheeaadd ooff tthhee ffeemmuurr ffoolllloowweedd bbyy

ppllaacceemmeenntt ooff aa pprroosstthheettiicc iimmppllaanntt

NNuurrssiinngg iinntteerrvveennttiioonnss

TTeeaacchh cclliieenntt hhooww ttoo uussee ccrruuttcchheess

TTeeaacchh cclliieenntt mmeecchhaanniiccss ooff ttrraannssffeerrrriinngg..

DDiissccuussss iimmppoorrttaannccee ooff ttuurrnniinngg aanndd ppoossiittiioonniinngg ppoosstt--oopp..

PPllaaccee aaffffeecctteedd lleegg iinn aann aabbdduucctteedd ppoossiittiioonn aanndd ssttrraaiigghhtt aalliiggnnmmeenntt ffoolllloowwiinngg ssuurrggeerryy

PPrreevveenntt hhiipp fflleexxiioonn ooff mmoorree tthhaann 9900 ddeeggrreeeess..

AAppppllyy ssuuppppoorrtt ssttoocckkiinnggss

AAddvviissee cclliieenntt ttoo aavvooiidd eexxtteerrnnaall//iinntteerrnnaall rroottaattiioonn ooff aaffffeecctteedd eexxttrreemmiittyy ffoorr 66 mmoonntthhss ttoo

11 yyeeaarr aafftteerr ssuurrggeerryy

IInnssttrruucctt cclliieenntt ttoo aavvooiidd eexxcceessssiivvee bbeennddiinngg,, hheeaavvyy lliiffttiinngg,, jjooggggiinngg,, jjuummppiinngg

EEnnccoouurraaggee iinnttaakkee ooff ffooooddss rriicchh iinn VViittaammiinn CC,, pprrootteeiinn,, aanndd iirroonn..

AAddmmiinniisstteerr pprreessccrriibbeedd mmeeddiiccaattiioonnss..

CCoommpplliiccaattiioonnss

IInnffeeccttiioonn

HHeemmoorrrrhhaaggee

TThhrroommbboopphhlleebbiittiiss

PPuullmmoonnaarryy eemmbboolliissmm

PPrroosstthheessiiss ddiissllooccaattiioonn

PPrroosstthheessiiss lloooosseenniinngg

DDEEVVEELLOOPPMMEENNTTAALL DDYYSSPPLLAASSIIAA OOFF TTHHEE HHIIPP ((DDDDHH))

ccoonnddiittiioonn iinn wwhhiicchh tthhee hheeaadd ooff tthhee ffeemmuurr iiss iimmpprrooppeerrllyy sseeaatteedd iinn tthhee aacceettaabbuulluumm,, oorr

hhiipp ssoocckkeett,, ooff tthhee ppeellvviiss..

Most common disorder that affects the hip joints of children under age 3.

The abnormality may be unilateral or bilateral.

It occurs in 3 forms of varying severity:

o Unstable hip dysplasia- the hip is positioned normally but can be dislocated by

manipulation

o Subluxation or incomplete dislocation- the femoral head rides on the edge of the

acetabulum.

o Complete dislocation- the femoral heads is totally outside the acetabulum.

CCaauusseess::

o Unknown

o One theory: hormones that relax maternal ligaments in preparation for labor may also

cause laxity of infant ligaments around the capsule of the hip joint.

o Dislocation occurs 10 times more often after breech delivery (malpositioning in

utero) than after cephalic delivery.

o Occurs 3x more often to the left hip than the right hip

AAsssseessssmmeenntt

NNeeoonnaatteess::

Experience no gross deformity of pain

In complete dysplasia, the hip rides above the acetabulum, causing the leg on the

affected side to appear shorter or the affected hip more prominent

To test for Ortolani’s sign, place the infant on his back, with his hip flexed and in a

neutral position. Grasp the legs just below the knees, then gently abduct the hip form

a neutral position.

If you exert slight pressure upward and inward beneath the greater trochanter, the

dislocated head of the femur may slip into the acetabulum with a palpable click.

IImmpplleemmeennttaattiioonn:: iinnffaannttss yyoouunnggeerr tthhaann 33 mmoonntthhss

SSpplliinnttiinngg ooff tthhee hhiippss wwiitthh PPaavvlliikk hhaarrnneessss ttoo mmaaiinnttaaiinn fflleexxiioonn aanndd aabbdduuccttiioonn aanndd

eexxtteerrnnaall rroottaattiioonn ((nneeoonnaattaall ppeerriioodd)) tthhee iinnffaannttss mmuusstt wweeaarr tthhiiss aappppaarraattuuss

ccoonnttiinnuuoouussllyy ffoorr 22 ttoo 33 mmoonntthh aanndd tthheenn wweeaarr aa nniigghhtt sspplliinntt ffoorr aannootthheerr mmoonntthh ssoo tthhee

jjooiinntt ccaappssuullee ccaann ttiigghhtteenn aanndd ssttaabbiilliizzee iinn ccoorrrreecctt aalliiggnnmmeenntt..

Gentle manipulation to reduce the dislocation

IInnffaannttss bbeeyyoonndd tthhee nneewwbboorrnn ppeerriioodd aanndd cchhiilldd

AAsssseessssmmeenntt

TThhee wwaallkkiinngg cchhiilldd:: mmiinniimmaall ttoo pprroonnoouunncceedd vvaarriiaattiioonn iinn ggaaiitt,, mmaayy ccaauussee tthhee cchhiilldd ttoo

sswwaayy ffoorrmm ssiiddee ttoo ssiiddee ((――dduucckk wwaaddddllee‖‖)) ffoorr uunnccoorrrreecctteedd bbiillaatteerraall ddyyssppllaassiiaa;; uunniillaatteerraall

ddyyssppllaassiiaa mmaayy pprroodduuccee aa lliimmpp

AAssyymmmmeettrryy ooff tthhee gglluutteeaall aanndd tthhiigghh sskkiinn ffoollddss wwhheenn tthhee cchhiilldd iiss ppllaacceedd pprroonnee aanndd tthhee

lleeggss aarree eexxtteennddeedd aaggaaiinnsstt tthhee eexxaammiinniinngg ttaabbllee ssuuggggeessttiinngg ssuubblluuxxaattiioonn oorr ddiissllooccaattiioonn

LLiimmiitteedd rraannggee ooff mmoottiioonn iinn tthhee aaffffeecctteedd hhiipp..

AAssyymmmmeettrriicc aabbdduuccttiioonn ooff tthhee aaffffeecctteedd hhiipp wwhheenn tthhee cchhiilldd iiss ppllaacceedd ssuuppiinnee wwiitthh tthhee

kknneeeess aanndd hhiippss fflleexxeedd..

AAppppaarreenntt sshhoorrtt ffeemmuurr oonn tthhee aaffffeecctteedd ssiiddee

To test for Trendelenburg’s sign, have the child rest his weight on the side of the

dislocation and lift his other knee. His pelvis drops on the normal side because of

weak abductor muscles in the affected hip.

When the child stands with his weight on the normal side and lifts the other knee, the

pelvis remains horizontal or is elevated; these phenomena make up a positive

Trendelenburg’s sign.

IImmpplleemmeennttaattiioonn

TTrraaccttiioonn aanndd//oorr ssuurrggeerryy ttoo rreelleeaassee mmuusscclleess aanndd tteennddoonnss

Bilateral skin traction (in infants) or skeletal traction (in children who have started

walking) in an attempt to reduce the dislocation by gradually abducting the hips.

Closed reduction, if traction fails.

FFoolllloowwiinngg ssuurrggeerryy,, ppoossiittiioonniinngg aanndd iimmmmoobbiilliizzaattiioonn iinn aa ssppiiccaa ccaasstt uunnttiill hheeaalliinngg iiss

aacchhiieevveedd,, ffoorr 44 ttoo 66 mmoonntthhss

If closed treatment fails, open reduction, followed by immobilization in a hip-spica

cast for an average of 6 months.

The earlier the infant receives treatment, the better the chances for normal

development

Treatment varies with the patient’s age.

NNuurrssiinngg IInntteerrvveennttiioonnss

When transferring the child after casting, use your palms to avoid making dents in the

cast. Such dents predispose the patient to pressure ulcers. (the casts needs 24 to 48

hours to dry naturally)

Immediately after the cast is applied, use a plastic sheet to protect it from moisture

around the perineum and buttocks.

Turn the child every 2 hours during the day and every 4 hours at night.

Check color, sensation, and motion of the infant’s legs and feet.

Check the cast daily for odors which may signify infection.

If the child complains of itching, she may benefit from diphenhydramine. You may

aim a blow-dyer set on cool at the cat edges to relieve itching.

Provide adequate nutrition, and maintain adequate fluid intake to avoid complication

of immobility, such as renal calculi and constipation.

SSCCOOLLIIOOSSIISS

LLaatteerraall ccuurrvvaattuurree ooff tthhee ssppiinnee

May occur in the thoracic, lumbar, or thoracolumbar spinal segment

There are 2 types of scoliosis: functional (postural) and structural.

Both types are commonly associated with kyphosis (humpback) and lordosis

(swayback)

Causes

Functional scoliosis: results from poor posture or a discrepancy in leg lengths

Structural scoliosis: involves deformity of the vertebral bodies.

It may be congenital, paralytic, or idiopathic.

SSuurrggiiccaall aanndd nnoonnssuurrggiiccaall iinntteerrvveennttiioonnss aarree eemmppllooyyeedd,, aanndd tthhee ttyyppee ooff ttrreeaattmmeenntt

ddeeppeennddss oonn tthhee ddeeggrreeee ooff ccuurrvvaattuurree,, tthhee aaggee ooff tthhee cchhiilldd,, aanndd tthhee aammoouunntt ooff ggrroowwtthh

tthhaatt iiss aannttiicciippaatteedd..

AAsssseessssmmeenntt

VViissiibbllee ccuurrvvee ffaaiillss ttoo ssttrraaiigghhtteenn wwhheenn tthhee cchhiilldd bbeennddss ffoorrwwaarrdd aanndd hhaannggss aarrmmss ddoowwnn

ttoowwaarrdd ffeeeett..

AAssyymmmmeettrryy ooff hhiipp hheeiigghhtt

PPeellvviicc oobblliiqquuiittyy

IInneeqquuaalliittiieess ooff sshhoouullddeerr hheeiigghhtt

SSccaappuullaarr pprroommiinneennccee

RRiibb pprroommiinneennccee

RRiibb hhuummppss

SSeevveerree ccaasseess,, ccaarrddiiooppuullmmoonnaarryy aanndd ddiiggeessttiivvee ffuunnccttiioonn mmaayy bbee aaffffeecctteedd bbeeccaauussee ooff

ccoommpprreessssiioonn oorr ddiissppllaacceemmeenntt ooff iinntteerrnnaall oorrggaannss..

Diagnostic tests

Anterior, posterior, and lateral spinal X-rays, taken with the patient standing upright and

bending, confirm scoliosis and determine the degree of curvature and flexibility of the

spine.

Treatment

close observation

exercise- to strengthen torso muscles and prevent curve progression

Brace, Milwaukee brace- a curve of 25 to 40 degrees requires spinal exercises and a

brace halts progression in most patients but doesn’t reverse established curvature.

Surgery- a curve of 40 degrees or more requires surgery (spinal fusion)

NNuurrssiinngg IInntteerrvveennttiioonnss

MMoonniittoorr pprrooggrreessssiioonn ooff tthhee ccuurrvvaattuurree

PPrreeppaarree tthhee cchhiilldd aanndd ppaarreennttss ffoorr tthhee uussee ooff aa bbrraaccee iiff pprreessccrriibbeedd

UUssuuaallllyy wwoorrnn 2233 hhoouurrss aa ddaayy aanndd ttoo rreemmoovvee oonnllyy ffoorr bbaatthhiinngg aanndd eexxeerrcciissee..

IInnssppeecctt tthhee sskkiinn ffoorr ssiiggnnss ooff rreeddnneessss oorr bbrreeaakkddoowwnn

KKeeeepp tthhee sskkiinn cclleeaann aanndd ddrryy,, aavvooiiddiinngg lloottiioonnss aanndd ppoowwddeerrss

Instead, suggest use of rubbing alcohol or tincture of benzoin to toughen the skin.

Increase activities gradually and avoid vigorous sports

aaddvviissee tthhee cchhiilldd ttoo wweeaarr ssoofftt nnoonniirrrriittaattiinngg ccllootthhiinngg uunnddeerr tthhee bbrraaccee

PPrreeppaarree tthhee cchhiilldd aanndd ppaarreennttss ffoorr ssuurrggeerryy iiff pprreessccrriibbeedd..

PPoossttooppeerraattiivvee::

MMaaiinnttaaiinn pprrooppeerr aalliiggnnmmeenntt;; aavvooiidd ttwwiissttiinngg mmoovveemmeennttss

LLooggrroollll tthhee cchhiilldd wwhheenn ttuurrnniinngg,, ttoo mmaaiinnttaaiinn aalliiggnnmmeenntt

IInnssttrruucctt iinn aaccttiivviittyy rreessttrriiccttiioonnss

IInnssttrruucctt tthhee cchhiilldd ttoo rroollll ffrroomm aa ssiiddee--llyyiinngg ppoossiittiioonn ttoo aa ssiittttiinngg ppoossiittiioonn,, aanndd aassssiisstt wwiitthh

aammbbuullaattiioonn

KYPHOSIS

an anteroposterior curving of the spine causes a bowing of the back, usually at the

thoracic level.

Occurs in children and adults

Causes

Congenital kyphosis leads to cosmetic deformity and reduced pulmonary function.

Appear in adolescence or adulthood

Adult kyphosis may result from aging and associated degeneration of intervertebral

disks, atrophy, and osteoporotic collapse of the vertebrae; from endocrine disorders,

such as hyperparathyroidism and Cushing’s disease; and from prolonged steroid

therapy

Assessment findings

Mild pain at the apex of the curve

Fatigue

Tenderness or stiffness in the involved area or along the entire spine

Prominent vertebral spinous processes at the lower dorsal and upper lumbar levels

Round back appearance associated with weakness of the back and generalized fatigue

Disk lesions called Schmorl’s nodes develops in the anteroposterior curving of the

spine

Diagnostic tests

On PE: curvature of the spine in varying degrees of severity.

X-ray: show vertebral wedging, Schmorl’s nodes, irregular end plates

Mild scoliosis of 10 to 20 degrees

Treatment

Therapeutic exercises

Bed rest on firm mattress (with or without traction)

Brace to straighten the kyphotic curve until spinal growth is complete

Pelvic tilt to decrease lumbar lordosis

Hamstring stretch to overcome muscle contractures

Thoracic hyperextension to flatten the kyphotic curve

Lateral X-rays taken every 4 months to evaluate correction

Gradual weaning from the brace

Surgery for spinal curve greater than 60 degrees or intractable and disabling back

pain in a patient with full skeletal maturity.

ANKYLOSING SPONDYLITIS

chronic, progressive inflammatory disease

affects the sacroiliac, apophyseal, and costovertebral joints and adjacent soft tissue

disease progresses unpredictably and can go into remission, exacerbation, or arrest at

any stage

Causes

unknown

more than 90% of patient with this disease exhibit the histocompatibility antigen

HLA-B27

Immunity activity by the presence of circulating immune complexes

Familial tendency

Assessment findings

Intermittent lower back pain, most severe in the morning or after a period of

inactivity

Stiffness and limited motion of the lumbar spine

Pain and limited expansion of the chest

Peripheral arthritis involving the shoulders, hips and knees

Kyphosis, in advanced stages, caused by chronic stooping to relieve symptoms

Hip deformity and limited range of motion

Tenderness over sites of inflammation

Tenderness over the sacroiliac joint

Mild fatigue, fever, anorexia, or weight loss

Occasional iritis

Aortic regurgitation and cardiomegaly

Diagnostic tests

X-ray findings: blurring of the bony margins of joints in the early stage, bilateral

sacroiliac involvement, patchy sclerosis with superficial bony erosions, eventual

squaring of the vertebral bodies, and ―bamboo‖ spine with complete ankylosis

confirms the diagnosis

Slightly elevated ESR and alkaline phosphatase and creatine kinase levels

Treatment

Management aims to delay further deformity by good posture, stretching and deep-

breathing exercises

Braces and lightweight supports

Anti-inflammatory analgesics, such as aspirin, indomethacin, and sulindac, control

pain and inflammation

Surgery

Nursing interventions

Promote patient comfort

Administer medications as ordered

Apply local heat and provide massage to relieve pain

Assess mobility and degree of discomfort frequently.

CARPAL TUNNEL SYNDROME

Most common nerve entrapment syndrome, results form compression of the median

nerve at the wrist, within the carpal tunnel.

The median nerve, along with blood vessels and flexor tendons, passes through this

tunnel to the fingers and thumb.

Occurs in women between ages 30 and 60 and poses a serious occupational health

problem

Causes

Some conditions can cause the contents or structure of the carpal tunnel to swell and

press the median nerve against the transverse carpal ligament

Conditions like: rheumatoid arthritis, flexor tenosynovitis, nerve compression,

pregnancy, renal failure, menopause, diabetes mellitus, acromegaly, edema following

Colle’s fracture, hypothyroidism, myxedema, benign tumors, and tuberculosis.

Dislocation or acute sprain of the wrist

Assessment findings

Weakness, pain, burning, numbness, or tingling in one or both hands

This paresthesia affects the thumb, forefinger, middle finger, and half of the fourth

finger

Decreased sensation to light touch or pinpricks in the affected fingers

Inability to clench the hand into a fist

Nail atrophy

Dry, shiny skin and pain

Diagnostic test

(+) Tinel’s sign: tingling over the median nerve on light percussion

(+) Phalen’s wrist-flexion test: holding the forearms vertically and allowing both

hand to drop into complete flexion at the wrists for 1 minute

Compression test: blood pressure cuff inflated above systolic pressure on the forearm

for 1 to 2 minutes provokes pain and paresthesia along the distribution of the median

nerve

Electromyography: detects a median nerve motor conduction delay of more than 5

milliseconds

Treatment

Resting the hands by splinting the wrist in neutral extension for 1 to 2 weeks

Correction of underlying disorder

Surgical decompression of the nerve by sectioning the entire transverse carpal tunnel

ligament

Nursing interventions

Mild analgesics

Apply splint.

Perform range of motion exercises

After surgery, monitor vital signs, and regularly check the color, sensation, and

motion of the affected hand

ptf 2005