Orthopedic Nursing Mr. Hermie G.

Siroy

Orthopedic Nursing Hermie G. Siroy OR Nurse Class 78 CLMMH School of Nursing NCM 204: Curative and Rehabilitative Criteria for Evaluation Q 50 E 40% Req 5% Part 5% Unit 1 Function of SS 1. Protects internal organs (heart, lungs, aorta, brain, spinal cord) protects: rib cage protects thoracic organs: heart, lungs, aorta: A and D skull protects the brain vertebrae protects spinal cord 2. Facilitates movement 3. Hematopoiesis/Hemopoiesis 4. Storage of minerals Ca and Ph 5. Support tissues of the body and provide them shape Bone is living tissues, surrounded by soft tissue with vascular connections. Its also a dynamic in a constant state of reforming, resorption (to remove), creation and destruction The human skeleton has 206 bones 1. Axial 80 bones of the skull, vertebrae and rib care 2. Appendicular skeleton with consists of 126 bones that make up the bones Axial Skull The cranium has 8 bones The face has 14 bones 2 palatine bones 2 nasal bones 2 inferior nasal conchae 1 vomer divides the nasal septum 2 maxilla 1 mandible
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Orthopedic Nursing Mr. Hermie G. Siroy

2 lacrimal bones 2 zygomatic bones The hyoid consists of 1 bone - not attached to other bones; holds the base of the tongue; only bone not attached to another bone

The vertebral column has 26 bones 7Cervical C1Atlas C2Axix 12Thoracic 5Lumbar 1Sacrum 5 bones when born, fuse when adult 1Coccyx Cartilage Separates vertebrae Annulus fibrosus- outer layer Nucleus pulposus inner layer

Thorax 12 pairs of ribs (24) 1-7 sternal 8-12 asternal 11-12 - floating Sternum 1 bone(Manubrium, Suprasternal notch) Xiphoid process

Ossicles of the Ear Malleus - Hammer Incus - Anvil Stapes Stirrup Eardrum -> Malleus -> Incus ->Stapes Eustachian tube connection of the eardrum to the pharynx

Appendicular Skeleton Shoulder girdle has 4 bones 2 scapula 2 clavicle

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Orthopedic Nursing Mr. Hermie G. Siroy

The Upper Extremities has 60 bones 2 humerus 2 radius 2 ulna 16 carpals 10 metacarpals 28 phalanges

Head of the humerus fits into the Glenoid cavity

The Pelvic Girdle 2 innominate coxa Hip (Left and Right)

Lower Extremities has 60 bones 2 femur 2 tibia 2 fibula 2 patella 14 tarsus 10 metatarsus 28 phalanges

Bones are Classified according to shape 1. 2. 3. 4. Long bones humerus, femur, ulna, radius, tibia, fibula Short bones carpal tarsal Flat bones scapula, patella, sternum, cranium (Patella largest flat bone; sesamoid bones) Irregular bones vertebrae, coxa

The end of long bones epiphysis diaphysis shaft 2 Types of Bones 1. Cortical (Compact) thick ring surrounding a cavity with bone marrow, it is found on the exterior portion of all bones and the shaft (diaphysis) of long bones. It is dense. Look and feels like ivory. 2. Cancellous (trabeculae) soft, spongy, bony tissue, surrounded by blood vessels. It is located in flat, irregular, short bones, cranial bones, ribs, sternum, and pelvis. Iliac bone and the end of long bones

Orthopedic Nursing Mr. Hermie G. Siroy

Covering the bones is a dense, fibrous membrane known as Periosteum. It nourishes bones and allows for its growth, as well as, provide for the attachment of tensions and ligament. Contains nerves, blood vessels and lymphatics. Endosteum thin, vascular, membrane, covering the marrow cavity of long bones and the spaces in cancellous bones Bone marrow vascular tissues located in the medullary cavity, of long bones and in flat bones. Red Bone marrow, located mainly in the sternum, ilium, vertebrae, and ribs, in adults responsible for producing RBC and WBC. In adults, the longs bones, is filled with fatty and yellow marrow Brown marrow 3rd type of BM; came from yellow marrow when you become older Bone Has 3 Types of Cells 1. Osteoblasts (bone forming cells) secretes bones matrix collagen and ground substance (glycoprotein and proteoglycans). The matrix is a framework in which inorganic mineral salts are deposited 2. Osteocytes least function in the bone system. Mature bone cells that are found in the bone matrix. It is involved in bones maintenance function 3. Osteoclasts located in (Howships lacunae) small pits in bones near the Endosteum, are multinucleated cells involved in destroying, resorbing (removing) and remolding bone. The microscopic functioning unite of mature cortical bone in the Osteon (Haversian system) The center of the Osteon, the Haversian canal, contains a capillary. Around the capillary are circles of mineralized bone matrix call lamellae. Within the lamellae are lacunae containing Osteocytes. These are nourished through tiny structures, canaliculi (canals Volkmanns canal), which communicate with adjacent blood vessel within Haversian system

Bone Formation Bone begins to form long before birth (3-4 months) Ossification process by which the bone matrix (e.g. Collagen fibers and ground substance) is formed and hardening minerals (e.g. Ca Salts) are deposited on the collagen fibers. The collagen fibers give tensile strength to the bones, and the Ca provides compressional strength. There are 2 basic types of ossification. Most bones in the body are formed by endochondral ossification in which a cartilage-like tissues (osteoid) is formed, resorbed and replaced by bones. Intramembranous ossification occurs when bone develops within membrane in the bones of the face and skull.

Orthopedic Nursing Mr. Hermie G. Siroy

Bone Maintenance Bone is a dynamic tissue is a constant state of reforming and resorption, creation and destruction. The important regulating factor that determine the balance between bone formation and bones resorption 1. Local stress - Weight bearing/exercise. Acts to stimulate bone formation and remodelling. Weight bearing bones are thick and strong. Without weight bearing, or stress, as in prolonged bed rest, the bones loses Ca (resorption) and becomes osteoporotic and weak, the weak bones may fracture easily 2. Vitamin D - Functions to increase the amount of Ca in the blood by promoting absorption of Ca from the GIT. A deficiency of vitamin D results in the bone mineralization deficit, deformity and fracture. It also facilitates mineralization of osteoid tissue 3. Parathyroid hormone - Parathyroid and Calcitonin are the major hormonal regulators of Ca homeostasis. Parathyroid hormone regulates the concentration of Ca in the blood, in part by promoting movement of Ca from the bone. In response to low calcium level in the blood, increased level of parathyroid hormone prompt the mobilization of Ca, the demineralization of bone, and the formation of bone cysts 4. Calcitonin - Secreted by the thyroid gland in response to elevated blood Ca levels increases the deposits of Ca in the bone 5. Blood supply - Affects bone formation. With diminished blood supply or hyperemia (congestion), osteogenic (bone formation), and bone density decreases. Bone necrosis occurs when the bone is deprived of blood Vit. D. Hydroxylized in liver and kidneys to form calcitriol the active form of Vit. D. Vit D3 5% Stored in the cytoplasmic reticulum 95% in bones Anatomy and Function of the Articular System o The junction of 2 or more bones is called a joint (articulation). There are 3 basic kinds of joints A. Synarthrosis joints are immovable, as exemplified by the skull sutures B. Amphiarthrosis such as the vertebral joints and symphysis pubis, carpal, allow limited motion (slightly moveable joints). Or Amphiarthrosis C. Diarthrosis freely movable joints Types of Diarthoidal joints o Ginglymoid or Hinge bone surface is concave and one surface is convex. Movement is generally flexion or extension. Ex. Knee, radial or humeral bones of the elbow and the ankle o Trochoid or Pivot an articulating surface rotates around a peg or projection and movement. Ex. Proximal articulation of the radius on the ulna is rotation on one axis Ex. Rotation of the atlas on the pelvis. o Enarthroidal or Ball and Socket the head fits in a concave socket, allowing for the most movement. Flexion, extension and circumduction are the 3 planes of movement allowed. Ex. Hip and shoulder joints
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Orthopedic Nursing Mr. Hermie G. Siroy

o o

Arthroidal or gliding articular surfaces are flat in the joint, with no axis of movement. The sacrum, the ilium, and many of the carpal bones form this type of joint Ellipsoidal or Condyloid an oval condyle fits into an elliptic cavity. Movement is 2 planes that are perpendicular to each other. Extension, flexion, adduction, abduction, and circumduction are allowed, as in the movement of the radius on the carpal bones. Saddle the bone fits into a convex surface of another bone allowing for the same movements as in with the condyloid joint but allowing no axial rotation. The articulation of the 1 st metacarpals with the trapezium

Ligaments Bursa Is a synovial fluid filled sac that cushions the movement of tendons, ligaments and bones at a point of friction. Bursa are generally found at the elbow, shoulder, knee and some other joints Fibrous connective tissue bands the articulating bone together. Ligaments and muscle tendons, which pass over the joints, provide joint stability Bone to bone

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

Anatomy and Function of the Musculoskeletal System Muscles are attached by tendons (cords of fibrous connective tissues) or aponeuroses (broad, flat sheets of connective tissue, other muscles, soft tissue, or skin Muscles vary in sharp and size according to the activities for which they are responsible Skeletal (striated) muscles are involved in body movement, posture, and heat production functions Muscles contract to bring the two points of attachment closer together, resulting in movement (origin and insertion)

Skeletal Muscle Contraction Each muscle cell (also referred to as a muscle fiber) contains myofibrils, which in turn are composed of sarcomeres, the actual contractile units of skeletal muscle. It contains thick myosin and thin actin filaments Muscle fibers contract in response to electrical stimulation delivered by an effector nerve cell at the motor end plate. When stimulated, the muscle cell depolarizes and generates an action potential. These action potentials
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Orthopedic Nursing Mr. Hermie G. Siroy

propagate along the muscle cell membrane and lead to the release of calcium ions that are stored in specialized organelles called sarcoplasmic reticulum (SR)(5-7% of Ca are stored in SR) ***Radical Mastectomy all pertoralis major and minor ***longest muscle Sartorius: insertion is in the interior iliac crest and goes medially and insert to the tibia aka Tailor Muscle ***Hamstring semitendinosus, semimembranosus, biceps femoris function: FLEXOR MUSCLES ***Quadriceps EXTENSOR of muscles- vastus lateralis, vastus medialis, vastus intermedialis, rectus femoris ***Gracilis - originate in symphysis pubis ***Myosin and actin slide against each other Calcium rapidly removed from the sarcomeres by active reaccumulation in the SR When the Ca concentration in the sarcomeres decreases, the myosin and actin filaments cease to interact and the SR returns to its original resting (place) length (relaxation). Actin and myosin do not interact in the absence of Ca. Energy is consumed during muscle contraction and relaxation. The primary source of energy for the muscle cells is ATP which is generated thru cellular oxidative metabolism During periods of strenuous activity, when sufficient O2 may not be available, glucose is metabolized primarily to lactic acid. Stored muscle glycogen is used to supply glucose during periods of activity. Muscle fatigue is thought to be caused by depletion of glycogen and accumulation of lactic acid. As a result, the cycle of muscle contraction and relaxation cant continue Tendons are bands of extremely strong, flexible fibrous tissues that attach muscle bundles to the Periosteum of the bones Fascia (epimysium) fibrous tissues that cover, supports and separate muscles The peripheral attachment referred to the origin and the distal attachment is the insertion 3 Types of Muscle Tissue 1. Cardiac Muscle branching, heart muscles 2. Smooth (non-striated) found in the walls of hollow structures such as the GIT, urinary bladder, uterus, and blood vessels. Cardiac and smooth muscles is controlled by involuntary stimulation of the CNS 3. Most skeletal muscles are attached to bone. Contraction of skeletal muscles account for movement of the body and can be controlled involuntarily The structural unit of muscle is the muscle cell which is also call the muscle fiber. Muscle is composed call the muscle fiber. Muscle is composed by tissues bound together by connective tissues.

Orthopedic Nursing Mr. Hermie G. Siroy

2 Types of Muscle Contraction 1. Isometric contraction increase the tension within a muscle but do not produce movement, repeated isometric construction make the muscle grow larger and stronger (ex. Pushing table without moving it, no movement of muscle) 2. Isotonic contraction and movement of muscle Muscle tone normal tension (resistance to stretch) in resting muscle. Relaxed muscles demonstrates a state of readiness to respond to contraction stimuli A muscle that is lime and without tone is described as flaccid; a muscle with a greater than normal tone is described as spastic Hypertrophy enlargement or an increase in the size of individual muscles fibers with an increase in the number of muscle fibers The decrease in size of a muscle-atrophy Muscle Contraction produces a variety of movements o o o o o o o o o o o o Flexion - bending at a joint (Elbow) Extension straightening at a joint Abduction moving away from midline Adduction moving toward midline Rotation turning around at a specific axis (Head movement left to right) Circumduction Supination turning upward Pronation turning downward Inversion turning outward Eversion turning outward Protraction pushing forward (ex. Face thrushed) Retraction pulling backward (ex. Face pulled backward)

Unit II Assessment Basic assessment -> dig up base line information and do interview, subjective and objective Initial interview o o o o The nurse obtain a general impression of the patients health status Gathering subjective data concerning the onset of the problem and how it has been managed as well as the patients perceptions and expectations related to health A history of medication used and response to pain medication aids in designing meds management regimens Nurse notes allergies

Orthopedic Nursing Mr. Hermie G. Siroy

Health History o o o Nursing assessment of the pt with MS dysfunction includes an evaluation of the effects of the MS problem on the pt. the nursing assessment is primarily a functional evaluation on the pts ability to perform ADL Nurse is concerned with assisting who have MS problems to maintain their general health accomplish their ADL, and manage their treatment program Through an individualized plan of nursing care the nurse helps the patient achieve maximum health

Assessment data The patient may report pain, tenderness, tightness and abnormal sensation. The nurse assess this and document this information

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

Rest relieves most MS pain. Pain that inc with act may indicate joint sprain. Radiating pain may indicate nerve compression. Physical Assessment Techniques of infection and palpation are used to evaluate patients: 1. Posture - The normal curvature of the spine is convex thru the thoracic portion and concave thru the cervical and lumbar portions 2. Gait - Gait is assessed by having the patient walk away from the examiner for a short distance - Smoothness and rhythm of the gait - Limping motion due to painful weight bearing limp is also observed if on leg is shorter than the other than the other as in scoliosis - Limited motion affects gait - Spastic hemiparesis gait stroke - Shuffling gait Parkinsons disease. To move in sliding or dragging gait - 3 meters 3. Assessing Bone Integrity - The bony skeleton is assessed for deformities and alignment. Symmetric parts of the body are compared - Abnormal bony growth due to the bone tumors may be observed - Shortened extremities, amputations, and body parts that are not in anatomic alignment 4. Assessing Joint Function - ROM
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Orthopedic Nursing Mr. Hermie G. Siroy

Limited ROM may be the result of skeletal deformity, joint pathologyor contracture surrondin muscle, tendons and joint capsule. In elderly patients, limitation of ROM associate d with osteoarthritis may reduce their ALD - If joint is compromised or the joint is painful, the joint is examined fo0r effusion (excessive fluid withing the capsule), swelling and increased temp that may reflect inflammation - Knee is the common sire of effusion - Joint deformity may be caused by contracture (Shortening of surrounding joint) - Joints are examined for nodules - RA nodules or Subcu are soft and occur within and along tendon - Gout nodules (tophi/tophus) are hard and lie within and immediately adjacent to the joint capsule itself. They may rupture, exuding white uric acid crystals - Osteoartrhitic nodules are hard and painless and represent bony over growth older adult 5. Muscle Strength and Size - Noting the ability to change position, muscular strength and coordination, and the size of individual muscles - The muscular system is assessed by noting the pts ability to change position, muscle strength and coordination - When the biceps are tested, the pt is asked to extend the arm fully and then to flex it against resistance supplied by the nurse - Handshake indication of strength - Biceps - weight 6. Skin - The nurse inspects the skin for edema, temperature and color - Palpation warmer suggesting increased perfusion or infection - Cooler decreased perfusion 7. NV Status - Assessment of CMS circulation, motion, and sensation - Ex. In case of fractured extremity for possible compartment syndrome assess for pulse distally, temperature, color of skin - Pedal Pulse Dorsalis pedis Posterior tibialis A. Radiologic and Imaging Studies 1. Standard Roentgenogram X-ray film is done to determine density and texture of bone. Study evaluates structural or functional changes of bones and joint. Ex. AP and Lateral view Cover pregnant women with lead and expose extremity to be x-rayed. Nursing Responsibility i. Avoid excessive exposure of client and self ii. Remove radiopaque objects that can interfere wit iii. Explain the procedure to the client 2. Arthrogram study involves injection of contrast medium to a joint cavity permitting visualization of joint structures. Joint movement is followed with a series of x-rays
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Orthopedic Nursing Mr. Hermie G. Siroy

Nursing Responsibilities i. Assess for allergies (to crustaceans) 5% - ideal cleansing agent is povidone iodine 0.001% allergic to iodine ii. Explain procedure done in the ward or in the X-ray department iii. Prepare the area aseptically using sterile technique 3. Diskogram an x-ray film of cervical or lumbar intervertebral disk is done after injection of dye into nucleus pulposus. Study permits visualization of intervertebral disk abnormalities; done before spinal surgery NR Same as Arthrogram 4. CT Scan an x-ray beam is used with a computer to provide a 3 dimensional picture. It is used to identify soft tissue abnormalities, bony abnormalities, and various MS trauma Fluoroscopy can magnify image intensifier, C arm NR i. Explain the procedure painless ii. Importance of remaining still during the procedure for at least one hour, 5. MRI radio waves and magnetic field are used to view soft tissue. Study is especially useful diagnosis in the diagnosis of avascular necrosis, disk disease, tumor, ligament tears. Client is placed inside scanning chamber NR i. Explain procedure to client painless ii. Contra in clients with aneurysm clips, metallic implants, pacemaker, electronic devices, shrapnel, extreme obesity iii. Ensure that client has no metal on clothing. Ex snaps, zippers, jewelries iv. Remain still during or throughout the procedure v. Inform claustrophobic clients that they may experience symptoms dur9ing the exam. Administer anti-anxiety agent vi. If there is IV convert to heplock (1:20) B. Bone Mass Measurements or Bone Densitometry - Used to estimate bone density. Study evaluates bone mass of metacarpals. A very low dose of radiation is used - Can be used to calculate total body Ca concentration to estimate extent of osteoporosis (osteopenia low calcium) NR i. Explain the procedure-painless. Thru x-rays C. Radioisotopes Studies 1. Bone Scan technique involves injection IV of radioisotopes (usually Na Pertechnate) that is taken up by the bone. Camera scans the entire body (front and back) and records o Degree of uptake is related to blood flow to bone. Increase uptake is seen is osteomyelitis, osteoporosis ad primary and metastatic malignant lesions and with certain fractures NR i. Explain procedure to client painless
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Orthopedic Nursing Mr. Hermie G. Siroy

ii. Possibility of allergy to isotopes iii. Empty the bladder (to facilitate excretion of radioisotopes) D. Endoscopy 1. Arthroscopy insertion of arthroscope into the joint for visualization of structure and contents o It can be sued for removal of loose bodies for biopsy for diagnosis of abnormalities of meniscus (tears), cartilage, ligaments or joint capsule o Exsanguination Esmarchs bandage is used to exsanguinate a limb; done before/after prepping the skin or after draping; elevate the leg part same height as the heart. Bandage spirally, exert effort, squeezes the blood to give clear visualization of the site. o Dressing after surgery compressing dressing from midcalf to midthigh; purpose is to i. Distal application to proximal application of bandages will promote venous return ii. To Secure the dressing, preventing the leakage of synovial fluid, thus preventing infection (very difficult to heal, devoid of blood vessels, nerves and lymphatics); preventing leakage of blood iii. o Limited activity for few days NR o Explain procedure o OR set-up with strict asepsis o Anesthesia E. Mineral Metabolism 1. Alkaline Phosphatase this enzyme is produced by osteoblasts of bone and is needed for mineralization of organic bone matrix o Elevated level are found in healing fractures, bone CA, osteoporosis, osteomalacia, Pagets disease NR o Explain procedure o Obtain blood samples by venipunctures o Obs VNP site for bleeding or hematoma o No fasting 2. Ca bone is primary organ for Ca storage o Ca provide bone with rigid consistency o Dec level is found in osteomalacia, renal disease, hypoparathyroidism o Increase level is found in hyperparathyroidism, bone tumors and acute osteoporosis o Langenbeck UK Army-Navy in US- roux retractor -Germans NR o Explain procedure o Obtain blood sample thru the VNP o Obs for hematoma or bleeding o No fasting 3. Phosphorus amount present is directly related to Ca metabolism o Decrease level is found in osteomalacia o Increase level is found in chronic renal disease, healing fractures, osteolytic metastatic tumor
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Orthopedic Nursing Mr. Hermie G. Siroy

NR same as #2 F. Serological 1. Uric acid test-level usually elevated in gout NR o Explain procedure to client o No fasting o Obs for hematoma, bleeding on the VNP site (dry cotton and plaster) 2. ESR Erythrocyte Sedimentation Rate o Elevated level are seen with any inflammatory process esp. RA, R Fever and respiratory infections G. Muscle Enzymes 1. Creatine Phosphokinase o Highest concentration is found in skeletal muscle. Increased values found in progressive muscular dystrophy, polymyositis and traumatic injuries o NR same as serological H. Invasive Procedures 1. Arthrocentesis incision of puncture sire of joint capsule is done to obtain samples of synovial fluid NR o Explain procedure o Maybe done at bedside or examination room or in Day surgery o Samples send to lab for serology or C/S test or cytology o Compression dressing o Rest o Obs leakage of fluid or blood 2. Electromyogram test is done to evaluate muscle weakness, pain and disability to differentiate any abnormality of function and to differentiate muscle and nerve problems o Needle electrodes are inserted into selected muscles and responses to electrical stimuli are recorded by an oscilloscope NR o Explain procedure that to be done in the lave o Supine on special table o Apply warm compress (36.6-40.6C), after the procedure will have residual discomfort Biopsy to the area desired. Ex. Small part of the muscle or ligaments or bone marrow

I.

Unit 4: Common Health Problems A. Neonate and Infant I. Congenital Clubfoot o Clubfoot is a general term used to describe a common deformity in which the foot is twisted out of its normal shape or position. Any foot deformity involving the ankle is called TALIPES, derived from TALUS, meaning ankle and PES, meaning foot
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Orthopedic Nursing Mr. Hermie G. Siroy

II.

Deformity of foot and ankle are conveniently described according to the position of the ankle and foot. The more common position involved the following variations 1. TALIPES VARUS an inversion or a bending inward deformity 2. TALIPES VALGUS an eversion or bending outward; rare 3. TALIPES EQUINUS plantar flexion in which the toes are lower than the heel 4. TALIPES CALCANEUS dorsiflexion, in which the toes are higher than the heel o The most frequently occurring type of clubfoot (approximately 95%) is the composite deformity known as TALIPES EQUINOVARUS in which the foot is pointed downward and inward in varying degrees of severity o Unilateral clubfoot is somewhat more common than bilateral and may occur as an isolated defect or in association with other disorders or syndromes such as chromosomal aberrations o Arthrogryposis (congenital defects with chromosomal aberrations; of the limbs with a generalized immobility of the joints) o Boys are affected twice as often as girls o Pathophysiology The precise cause is unknown. There are those who attribute the defect to abnormal positioning and restricted movement in utero, although the evidence is not conclusive. Others implicate arrested or anomalous embryonic development. Since the foot normally goes through flexion and eversion during early development and gradually assumes a normal attitude by 7th month. Arrested development during this early stage tends to result in a rigid deformity, whereas mechanical pressures from intrauterine position are more likely to be operating in the more flexible deformities. Embryologists are divided in acceptance of the embryonic arrest theory. o Diagnostic Evaluation The deformity is readily apparent and easily detected at birth. The true clubfoot is fixed. o Therapeutic Management Treatment began as soon as the deformity is recognized and involves 3stages: 1. Correction of the deformity (corrective fixator, casts) 2. Maintenance of the correction until normal muscle balance is regained 3. Follow up observation to avert possible recurrence of the deformity. Nursing care of the child with nonsurgical correction of clubfoot is the same as it is for any child who has a cast. Conscientious observation of skin and circulation is particularly important in young infants because of their normally rapid growth rate. Parents need to understand the overall program, the importance of regular cast changes, and the role they play in long term effectiveness of the therapy. A cast may cause compartment syndrome if outgrown Zinc Oxide plaster used for petalling, used to smoothen edges of cast X ray is exact tool to confirm the diagnosis Ilizarov fixator surgical correction Congenital Hip Dysplasia o Describes imperfect development of that can affect the femoral head, the acetabulum, or both. More commonly known as Congenital His Dislocation or Congenital Dislocated Hip.
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Orthopedic Nursing Mr. Hermie G. Siroy

The cause is unknown but it is one of the most common congenital defects, with an incidence of about 1:500 to 1:1000 births o The disorder occurs more frequently in females than in males. CHD is frequently associated with another conditions such as spina bifida o Pathophysiology a. Acetabular Dysplasia or Preluxation the mildest form, in which there is neither subluxation nor dislocation. The dysplasia reflects an apparent delay in acetabular development evidenced by osseous hypoplasia of the acetabular roof that is comparatively intact. The femoral head remains in the acetabulum b. Subluxation accounts for the largest percentage of CHD. Subluxation implies incompletes dislocation or dislocatable hip. The femoral head remains in contact with the acetabulum, but a stretched capsule and ligamentum teres cause the head of the femur to be partially displaced. c. Dislocation the femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim. The ligamentum teres is enlongated and taut Prenatal factor that are considered to influence development of hip abnormalities are: Maternal Hormone Secretion and Mechanical Factors of IU Posture toward the end of pregnancy there is increased maternal pelvic laxity (sacroiliac joint and symphysis pubis) mediated by maternal hormone secretion (Principally Estrogen) which affects the fetal joints as well. The position of the legs in frank breech position that is with the his acutely flexed and knees extended is an important factor in the aetiology of hip dislocation Other prenatal factor that contribute to hip dysplasia include twinning and large infant size Double hip spica after CR Broomstick plaster after femoral osteostomy Pavlik harness B. Adolescents - The characteristic S curve of the lateral spine develops during fetal life and early childhood - Scoliosis is the lateral curvature of the spine in any area cervical, thoracic, thoracolumbar or lumbar o Occurs most often in preadolescents and adolescents 3 Categories of Scoliosis 1. Idiopathic scoliosis most common form, appearing in growing children with no other apparent health problem 2. Congenital 3. Neuromuscular - Etiology o The cause of scoliosis can be congenital or neuromuscular o Congenital scoliosis results from a malformation of the bony vertebral segment of the spine, either because of: i. Formation (the absence of a portion of a vertebra) or ii. Segmentation (the absence of a normal separation between vertebrae)
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Orthopedic Nursing Mr. Hermie G. Siroy

Neuromuscular condition associated with spinal deformities include CO, Polio, myelomeningocele, spinal muscle atrophy, spinal cord tumors, trauma, and muscular dystrophy Congenital manifestation and a family history of spinal deformity are significant but diagnosis is confirmed by AP and L that reveal a curvature of 10 degrees or more X-ray are the only exact tool for monitoring changes in spinal deformity, but excessive radiation exposures is in appropriate in children 2 Other Non-invasive Dx Technique 1. More Topography 2. Integrated and imaging system (ISIS) Management Non Surgical 1. Observation 2. Bracing 3. Exercise Each client needs to be evaluated individually mot only for the medical problem but also for willingness to participate in any suggested therapy Sometimes conservative treatment failed-willing to undergo surgeries such as: 1. Spinal fusion attaching adjacent vertebrae to each other with a bone graft to prohibited motion between them; arthrodesis 2. Cotrel-Dubousset is commonly used for posterior approach of correcting scoliosis; rod system 3. Harrington Rod System develops in 1960 is still in use because of its availability and because many surgeons are familiar with it 4. Moss-Miami and Luque System posterior approach 5. Zielke and Harris System famous for anterior approach system; collapse the lungs; most stable Complications o Possible complication following scoliosis surgery include 1. Neurologic compromise 2. Infection (in the incision site) 3. Respiratory problems 4. Spinal fluid leakage 5. Phlebitis 6. Excessive blood loss 7. Implant problems 8. Pseudoarthrosis a false joint formed around a displaced bone end after dislocation or as the result of ailed union after surgery by fibrous tissue 9. Most devastating complications paralysis and death Postoperative Care o Post op nursing management focuses on usual post op care. Assessment of motor and sensory function in the lower extremity/ies is important because the nerves and muscles may have been stretched in surgery

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Orthopedic Nursing Mr. Hermie G. Siroy

Common Disorders in Children I. Juvenile Rheumatoid Arthritis Juvenile Chronic Arthritis Juvenile Arthritis - Terms used for this inflammatory autoimmune diseases causing many form of arthritis Incidence and Etiology JRA is the common pediatric connective tissue disease with arthritis being the principal manifestation 1:1000 African American Asian children are less likely to suffer from GRA 80-90% of children with JRA satisfactorily recovers and have no functional limitations. However 10% of children become adults with no moderate to significant functional impairment Overall Girls are affected twice as often as boys. The aetiology is unknown but it does not involve the interactions of genetic, environmental and immunologic factors

Pathophysiology Current research suggest that T-cell activation triggers development of antigen/antibody complexes which cause release of inflammatory substances called cytokines in targeted organs such as the joints and skin (heart, spleen, liver, joints). This causes inflammation of the synovial joint membrane and other Tissues leading to joint effusion and swelling. Chronic inflammation eventually evolves into erosion of articular cartilage and other symptoms of inflammatory diseases

Clinical Manifestation JRA is classified by symptoms at onset of disease: systemic, polyarticular, or pauciarticular The classical symptoms of arthritis are morning immobility, stiffness or gelling, Joint pain A. Systemic Onset o Fever high o Rash salmon pink, migratory, macular/popular. Most common late afternoon or early evening o Arthralgia/myalgia o Arthritis o Fatigue/malaise o Lymphadenopathy usually cervical, axillary, and inguinal o Hepatospleenomegally right hypochondriac (liver), left hypochondriac (spleen, filters dead RBC) o Can also present with signs of Carditis-chest pain, tachycardia B. Polyarticular Onset o Arthritis in many joints (5 or more) any joint can be affected, but most particularly the joints of the knees, wrists, ankles and proximal interphalangeal joints of the fingers. Often neck and Temporomandibular Joints (TMJ) o Low grade and occasional Fever

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Orthopedic Nursing Mr. Hermie G. Siroy

C. Pauciarticular Onset o Arthritis in a few joint (4 or fewer) often, though not exclusively, joints of the knees and ankles o Inflammation of the eyes Diagnosis The American College of Rheumatology has determined diagnostic criteria for JRA that included onset before 16 years of age. Objectively observed arthritis is defined as joint swelling or effusion, or two of the following: warmth, pain of motion, or limited ROM The diagnosis and categorization of the disease is based on history, physical exam, laboratory and radiologographic testing There are no specific lab tests for JRA. Nevertheless, they are used to help diagnosis and monitor rheumatological disease. It includes increased ESR, WBC, platelet count and decrease Hgb (lack of vitamin D and sunlight low calcitriol osteopenia dec RBC)

Treatment Treatment is best undertaken by a multidisciplinary team, including the child and family, nurse, physician, OT and PT and social worker. Overall goals include decreasing inflammation (NSAIDS and steroids), maintaining joint function (ROM, OT, PT) and preventing psychosocial complication (placed in the mainstream of education child must be exposed to peer group interact, relate to the environment) . Treatment includes medications, OT, PT, nutrition and education.

Medications are the primary mainstay for arthritis in children 1. 2. 3. 4. NSAID Aspirin-side effects-stomach upset, ulcers, Reyes syndrome Sulfasalazine Hydrochloroquine-anti-malarial drug. Not well understood action in TA given if ASA cant adequately effect 5. Methotrexate folic acid antagonist-nausea 6. Corticosteroids anti-inflammatory-round face, inc BP, weight gain, dec bone density 7. Cytotoxines limited success in ra for primary treatment of neoplastic disease II. Rickets - Is due to failure of calcification of growing bone in infancy and childhood and is seen most frequently in the temperate zones. The unavailable of Ca for ossification can be caused by inadequate intake or by failure of absorption due to chronic diarrhea, steatorrhea, or most importantly, a deficiency of Vit. D due to inadequate exposure to sunlight or failure of hydroxylation by the liver or kidneys Clinical Manifestation When the concentrati0on of ionized serum Ca is very low in infants, tetany may develop, with spasms of the hand and feet, and of the vocal cords, resulting in a high pitched, distressing cry and difficulty in breathing (critical sx) Other sx may be present restlessness, pallor, flabby muscles and excessive sweating
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Orthopedic Nursing Mr. Hermie G. Siroy

After 6 months of age, it is more common to see, bossing of the forehead and parietal bones nad delayed closure the fontanels; bow legs In later infancy and childhood the softness of ten ones results in chest deformities, such as pigeon chest (Pectus carinatum), Harrisons sulcus, kyphosis, enlargement of the lower end of the femur, tibia, fibula, deformities of the shafts with knock knees and bow legs and pelvic deformities

Treatment Although appropriate treatment with supplementary dietary Ca and a single massive dose or prolonged moderate dosage of vitamin D brings prompt correction of the biochemical abnormality and epiphyseal widening, the skeletal deformities may persist. In some cases these deformities are amenable to corrective surgery

Common Health Problems is Adults I. Osteoarthritis (OA) aka Degenerative Joint Disease or Wear and Tear Arthritis is a slowly progressive noninflammatory disorder of mobile joints, particularly in weight bearing articulation - Characterized by degeneration of articular cartilage - Damage is confined to the joints and surrounding tissues - OA maybe primary or secondary. Primary cause is unknown. Secondary cause-previous fracture, infection or congenital deformities (Arthrogryposis) as precipitating factor - This disabling disease increase with age. Men and women are affected equally - Vertebra, knees, hip, and wrist Pathophysiology Usually smooth, white, translucent joint cartilage to become yellow and opaque, with rough surfaces and areas of malacia (softening). As layers of cartilage become thinner, bony surfaces are closer together. As cartilage breakdown, fissures may appear, fragments of cartilage become loose. Secondary inflammation of the synovial membrane may glow. As the articular surface became totally denuded, subchondral bone increases in density and becomes sclerotic. (Cartilage gets its nourishment from the synovial fluid contains a lot of important substances ground substances, hyaluronidase)

There are several theories concerning the cause of cartilage deterioration 1. The enzyme hyaluronidase, which is normally found in the synovial fluid may be responsible for digestion of proteoglycans 2. Another theory suggests, the inadequate nutrition of the cartilage may result in cartilage degeneration 3. Specific predisposing factors such as excessive use of stress on a joint such as knees of a football player; feet and ankle of a ballet dancer 4. Genetic factor Heberdens nodes 5. Congenital structural defects 6. Metabolic disturbances - diabetes mellitus 7. Repeated intraarticular hemorrhage haemophilia
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8. Neuropathic arthropathies (any disorder of the joint) 9. Inflammatory and septic arthritis Clinical Manifestation A. Fatigue, fever, is not present in OA, and other organ involvement is absent as well B. Pain in motion and weight bearing relieves by rest o Sleep may be disrupted by night pain and advance stage o Increasing pain accompanied by progressive loss of function and immobility. Asymmetric involvement of joints like the distal interphalangeal joint of the fingers, etc. Lower lumbar cervical vertebrae, hips and knees o Heberdens nodes are another common manifestation of OA particularly to women with OA, primary located at distal interphalangeal joints o Are palpable protuberances that are often associated with flexion and lateral deviation of thee distal phalanx o Bouchards nodes, less common in OA involve the proximal interphalangeal joints C. Hips (Malum Coxae Senilis) o Pain in the groin, buttocks or medial side of thigh o men o Disabling, difficult to sit D. Knees softening of posterior surface of the patella (Chondromalacia patellae) E. Vertebral Column o Degenerative disease of the intervertebral disks as the nucleus pulposus deteriorates, brittle, and inelastic, herniation of this occurs, anteroposteriorly o Slipped disc, herniated disc, intervertebral disc prolapse - Diagnosis o Complete hx and physical exam o X-ray (joints) o ESR (Normal) o Synovial fluid analysis (Arthrocentesis) - Therapeutics o Rest and joint protection o Heat and cold exercise o Mild analgesia o Assistive device o Stress management o Orthopedic surgery - NCM (by EBNEZAR p333) o To all surgical clients. Most importantly talk to the patients, keep their spirits high, pep and shower them with love and affection. This will definitely cheer them up and life their sagging morale. Rheumatoid Arthritis - RA is a chronic systemic disease characterized by recurrent inflammation of the diarthroidal joint and related structures. It is frequently accompanied by a variety of extracellular manifestations, such as rheumatoid nodules, neuropathy, pericarditis, Lymphadenopathy, and splenomegaly
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The course of illness varies, ranging from episodes of illness separated by periods of remission to amore continuous, progressive disease. Death from RA is rare.

Etiology cause remains unknown 1. Autoimmunity RA is an autoimmune disease 2. Genetic factors familial factors 3. Other factors metabolic and biochemical abnormalities, nutritional Pathophysiology 1. First stage the unknown etiological factors initiates joint inflammation or synovitis. Increase synovial fluid production 2. Second stage Pannus (granulation inflammatory tissue) is formed at the juncture of synovium and cartilage. This extends over the surface over the surface of the articular cartilage and eventually invades the joint capsules and subchondral bone (Chondros cartilage) 3. Third stage tough connective fibrous tissue replaces Pannus, occluding the joint space. Fibrous ankylosis results in decreased joint motion, malalignment and deformity o Fibrous ankylosis shortening of connecting fibrous tissue due to prolonged joint inflammation 4. Fourth stage as fibrous tissues calcifies, bony ankylosis, may result in total joint immobilization o Bony ankylosis pathological fusion of bones across a joint space Prolonged early morning immobility ***OA cartilage are denuded; contact of bone to bone; unilateral involvement of joint RA cartilage becomes bony; it stays there; inflammatory; ESR increased; Bilateral; symmetrical involvement of joint (common to them: pain) immobility is not common to them (morning = OA; prolonged early morning immobility = RA; stiffness = OA, prolonged in RA) Clinical Manifestations o Joints pain, stiffness, limitation of motion and signs of inflammation. As disease activity progresses, inflammation and fibrosis of the joint capsule and supporting structures may lead to deformity and disability Extraarticular manifestation rheumatoid nodules, small vessels vasculitis (inflammation of blood vessels) Complication infection, osteoporosis, spinal cord compression Amyloidosis (CHON deposits to all joints, purines) Intraarticular steroids decrease inflammation

o o

Diagnostic Studies o o o o ESR increased in 85% WBC inc X-ray joints CBC

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General Therapeutic Treatment o o o o o Education, including disease process and management at home Importance of nutrition (Vit D and Ca) Rest, exercise (physical) in water Pharmacotherapy systemic corticosteroid, NSAID (mainstream) Ortho surgery reconstructive joint replacement (OA and RA) Methyl methacrylate for hip joint (may cause cardiac arrest) ***classical symptoms of arthritis = pain, morning immobility, stiffness or gelling

III.

Gouty Arthritis - Is characterized by recurrent attacks of acute arthritis in association with increased levels of serum uric acid - In primary gout a hereditary error of purine metabolism lead to the over production or retention of uric acid Etiology and Pathophysiology Uric acid represents the major end product of the metabolism of purine and primarily excreted by the kidneys. Thus hyperurecemia resulting to increased purine synthesis, dec renal excretion or both

Clinical Manifestation Affected joints may appear dusky or cyanotic or extremely tenders

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

Symptoms Fever low grade, attacks subside (treated or untreated) in 2 10 days then affected joints returns to normal Chronic Gout multiple joint involvement and deposits of Sodium Urate Crystals (tophi/tophus). A hard deposit of crystalline uric acid and its salts in the skin, cartilage or joints

Diagnostic History and physical exam Finding urate crystals increase Uric acid increase 24 hour urine collection for uric acid levels

Therapeutic Management Anti-inflammatory drugs Colchicine, Allopurinol Avoidance of alcohol and high purine foods
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IV.

Bed rest and joint immobilization Intraarticular corticosteroids Analgesic

Bursitis and Tendinitis - Are inflammatory condition that commonly occurs in the shoulder - Similarly muscle tendon sheaths become inflamed with repetitive stretching. The inflammation causes proliferation of synovial membrane and Pannus formation which restricts joint movement - Similarly muscle tendon sheath become inflamed with repetitive stretching. The inflammation causes proliferation of synovial membrane and Pannus formation which restricts joint movement - Bursitis inflammation of bursa - Tendinitis inflammation of tendons or tenosynovitis since the sheath are line with synovial later. Aka called tendonitis Treatment Includes rest of the extremity Intermittent ice and heat to the joint NSAID to control pain and inflammation Arthroscopic synovectomy may be considered if shoulder pain and weakness persist Arthrotomy

V.

Carpal Tunnel Syndrome - Is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, median, or soft tissue mass - The syndrome is commonly due to repetitive hand activities but maybe associated with arthritis, hypothyroidism or pregnancy Symptoms Pains, numbness, paresthesia, and possibly weakness along the median nerve (thumb, first and second finger) Neurolysis releasing a compressed nerve the Tinels sign may be used to help identify CTS Night pain is common. Rest splints to prevent hyperextension and prolonged flexion of the wrists, avoidance of repetitive flexion of the wrist Injection of cortisone to carpal may relieve symptom o ***press the superficial part of radial nerve; pain on that part means positive for radial canal syndrome; Ulnar tunnel syndrome = ulnar passes median; press superficial side and positive for pain and tingling on that side; median nerve passes on the medial goes down to the tunnel; use index finger and tap at middle Surgical release of the Transverse Carpal Ligament may be necessary

VI.

Osteoporosis metabolic bone disorder. The disorder is characterized by a reduction of total bone mass and a change in bone structure, which increases susceptibility to fracture
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The bone becomes porous and fragile

Pathophysiology Genetics, aging, nutrition, lifestyle choices (e.g. smoking, caffeine, and alcohol consumption) and physical activity influence the peak bone mass and development of osteoporosis o ***peak bone mass = (if adult have arrived at peak bone mass) Loss of bone mass and development of osteoporosis is a universal phenomenon associated with aging. Age related loss begins soon after the peak bone mass is achieved Calcitonin which inhibits bone resorption and promotes bone formation (***thyroid gland also degenerating) Estrogen inhibits bone breakdown dec with aging PTH increases with aging and inc bone resorption; inc production of Osteoclasts Women develop osteoporosis more frequently and more extensively because of the effect of estrogen loos during menopause

Risk Factors 1. Small framed, non obese white women are at greatest risk for osteoporosis 2. Nutritional factors - Vit D deficiency and Ca. Then must be adequate in promoting bone formation, remodelling, and body functions. The best source of Ca and Vit D is fortified milk 3. Immobility paralysis or general inactivity osteoporosis occurs 4. Co-existing medical disorder, malabsorption syndrome, lactose intolerance, alcohol abuse, renal failure, hyperthyroidism contribute to bone loss 5. Medicines steroids, isoniazed, heparin tetra, aluminium containing antacids, furosemide, anticonvulsant affect the bodys use and metabolism of Ca Diagnostics 1. X-ray 2. Lab studies. Serum Ca, Serum PO4, alkaline phosphatase, urine Ca excretion, ESR Medical Management 1. Adequate, balanced diet rich in Ca and Vit D throughout life (natural sunlight, fortified milk, cheese, butter, margarine, cereal, fish) 2. Regular weight-bearing exercise promotes bone formation VII. Pagets Disease or Ostitis Deformans - Define as an idiopathic bone disorder characterized by abnormal accelerated bone resorption and formation in one or more bones. The normal bone is replaced by abnormal. Structurally weaker bone that is prone to fractures - Most commonly affecting the skull, femur, tibia, pelvic bone and vertebrae - The Pagets disease bone is highly vascularised and structurally weak. Pathologic fracture occurs - Structural bowing of the legs causes mal-alignment of the hip, knee and ankle joints, which contributes to the development of arthritis and pain - Incidence is slightly greater in men and increases with aging
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Familial tendency Cause is not known

Clinical Manifestation Bowing of femur and tibia, enlargement of the skull and cortical thickening of the long bone are seen. Is insidious most patients never know they have it The skull may have thickened In some cases the cranium, but not the face, is enlarged The femur and tibia tend to bow, producing a waddling gait. The spine is bent forward and is rigid, the chin rests on the chest Pain and tenderness of the bones may be noted Hearing loss due to (enlarging bone, Ossicles are enlarged as well, part of the temporal bone) there is compression in the brain 8th cranial nerve, auditory nerve or vestibulocochlear nerves

Diagnostics 1. Serum alkaline phosphatase increase normal Ca level d/t increasing ossification 2. X-ray confirms Pagets Therapy Pharmacology Calcitonin is administered subcutaneously, it retards bone resorption by decreasing the number and availability of osteoclasts - Calcitonin therapy facilitates remolding of abnormal pagetic bone into lamellar bone, relieves bone pain - Calcitonin therapy facilitates remodelling of abnormal Pagetic bone into lamellar bone, relieves bone pain Malignant Bone Tumor Osteogenic Sarcoma (Osteosarcoma) - The most common and most often fatal primary malignant bone tumor. It carries a high mortality rate because the sarcoma often has spread to the lungs (coughing, backache, chest ache) by the time the patients seeks healthcare - It is manifested by pain, swelling, limitation of motion, and weight loss - The common site are the distal femur, the proximal tibia and humerus - Manifested by Cachexia very thin; skin and bones Treatment 1. The therapeutic goal is to relieve pain and discomfort while promoting quality of life 2. If metastasis weakens the bone, structural support and stabilization are needed to prevent pathologic fracture (very nasty) 3. Arthroplasty methyl methacrylate (bone cement) reconstruction of a joint 4. Opioids for pain or no-opioids 5. Chemotherapies

VIII.

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Across the Life Span Types of Musculoskeletal Trauma 1. Contusion is a soft tissue injury produced by blunt force (a blow, a kick or fall). Many small blood vessels rupture and bleed into soft tissues. (ecchymosis, bruising) - A hematoma develops - Local symptoms (pain, swelling, and discoloration) are controlled with intermittent application of cold 2. Concussion 3. Sprain - Injury to the ligaments surrounding a joint caused by a wrenching or twisting motion. A torn ligament loses its stabilizing ability. Blood vessels rupture and edema occurs. The joint is tender and movement of the joint becomes painful - The function of a ligament is to maintain stability while permitting mobility 4. Strain - A muscle pull from overuse, overstretching or excessive stress. Strains are microscopic, incomplete muscle tears with some bleeding into the tissue. The patient experiences soreness or sudden pain with local tenderness upon muscle use and isometric contraction (compression bandaging) Nursing management RICE Rest, Ice, Compression, Elevation Rest resting and elevating the affected part. Rest prevents additional injury and promotes healing I Moist or dry cold application after injury produces vasoconstriction which decreases bleeding, edema, and discomfort C Elastic compression bandage bleeding, edema and provides support E Elevation controls the swelling (elevate at the level of the heart) After the acute inflammatory stage 24-48 hours, heat may be applied intermittently 15 to 30 minutes 4x daily to relieve muscle spasm and to promote vasodilation, absorption and repair 5. Joint Dislocation - A dislocation of a joint is a condition in which the articular surfaces of the bones forming the joint are no longer in anatomic contact. The bone literally out of the joint - If dislocation is not treated promptly avascular necrosis (tissue death due to anoxia and diminished blood supply) and nerve palsy may occur - Dislocation may be i. Congenital, present at birth (most often the hip) ii. Spontaneous or Pathologic due to disease of articular or the periarticular structure iii. Traumatic resulting from injury in which the joint is disrupted by force Nursing Management Providing comfort, evaluation the patients neurovascular status, protecting the joint during healing process, collaborative analgesic, muscle relaxant
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- Sling or underarm sling bandage 6. Fracture - Any break or disruption in teh continuity of the bone - Traumatic injuries account for the majority of fractures. Although some are caused by a disease process (pathological) 5% - Fractures are described and classified according to: 1. Type 2. Communication or non-communication with the external environment 3. Location - Fractures are also described as stable or unstable (cut through the Periosteum). A stable fracture occurs when some of the Periosteum is intact across the fracture. Stable fractures are usually transverse, spiral or greenstick - ***periosteum outer covering of bone; gives nourishment for bones; allows attachment for tendons and ligament; contains blood vessels, nerve endings and lymphatics.; therefore if cut through and through blood supply is diminished (fracture) - ***transverse going across the bone and doesnt tear periosteum - An unstable fracture is grossly displaced during injury and a site of poor fixation. Unstable are usually comminuted and oblique Clinical Manifestation of Fracture 1. Edema and swelling 2. Pain and tenderness nerve endings damaged; tender due to spasticity of muscles 3. Muscle spasm - most of the time, few muscle spasms in stable fractures; unstable fractures = formation of muscles are destroyed thus becomes spastic; therefore do not attempt to straighten it 4. Deformity mostly seen in unstable 5. Ecchymosis discoloration of skin as a result of extravasation of blood in subcutaneous tissue or soft tissue, contusion 6. Loss of function 7. Crepitation (grating sound) 8. Bleeding from an open and with protrusion of bone ends Study Healing Process of Bones Complication of Fractures Complication of fractures fall into 2 categories: Early and Delayed. Early 1. Shock Epiphysis (traumatic or hypovolemic shock) 4-5L of blood in females; 6L for males; lose more blood if compounded; blood is oozing because bone is very vascular; bleeding comes from inside of intramedullary area; lose more red blood cells if from epiphysis o Hypovolemic or traumatic shock, resulting from hemorrhage and loss of extracellular fluid into damaged tissues, may occur in fractures of the extremities, thorax, pelvis and spine. Because the bone is very vascular, large quantities of blood may be lost as a result of trauma, especially in fracture of the femur and pelvis
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2. Fat Embolism o After fx of long bones or pelvis, multiple fx, or crushing injuries, fat emboli may develop at the time of fx., fat globules may move into the blood because the marrow pressure is greater than the capillary pressure or because catecholamines elevated by the patients stress reaction mobilize fatty acids and promote the development of fat globules combine with plate lets to from emboli which hen block the small blood vessels that supply the brain, lungs, kidneys and other organs ***fatty marrow very high in pressure than cut or veins; stress body releases catecholamines ***If fractured: dont move immediately -> may dislodge emboli ***emboli will dislodge in smaller arteries (capillary area) -> impede physiological structure; if in brain = hypoxia -> anoxia o Dislodge in smaller arteries/arterioles o Brain hypoxia o Clinical Manifestations Presenting features include hypoxia, tachypnea, tachycardia, and pyrexia. Cerebral disturbance (due to hypoxia) causes by lodging of fat emboli in the brain are manifested by mental status changes varying from mild agitation and confusion to delirium and coma. The respiratory response includes tachypnea, dyspnea, crackles, wheezes, pre cordial chest pain, cough, large amount of thick white sputum and tachycardia. Edema and hemorrhage in the alveoli impairs O2 transport leading ARDS if in the lungs; damage of alveoli ***weak or absent pulse due to hypovolemia, pale cold moist skin, nausea, shallow irregular breathing, vacant lackluster pupils dilated (eyes) o Prevention and Management (to prevent ARDS) 1. Immediately immobilization of fx, minimal fx manipulation and adequate support for fxd bones during turning and position are measure that may reduce the incidence of fat emboli 2. Support the respiratory system and to correct homeostasis disturbances. Respiratory failure is the most common cause of death. O2 is given in high concentration. 3. Corticosteroids to treat inflammatory lung reaction to control cerebral edema 4. Accurate intake of fluid and output records 5. Analgesics 6. Accurate intake fluid and output records 7. Analgesics 3. Compartment Syndrome o Is a complication that develops when tissue perfusion in the muscles is less than that required for tissue viability. The patient complains of deep, throbbing, unrelenting pain which is not controlled by opioids. This can be due to: 1. Reduction of the muscle compartment size because the enclosing muscle fascia is too tight or a cast or redressing is constrictive or 2. An increase in muscle compartment contents because of edema or hemorrhage associated with a variety of problems e.g. fxs, crushing injuries o Permanent function can be lost if teh anoxia situation continues from more than 6 hours
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***care must be noted in casting children or infants ***fascia outer covering of the muscle; separates the muscles ***in every muscle there is a compartment : muscle compartment ***bone fracture fascia intact but muscle is torn -> bleeding inside -> edema formation because blood cannot go out of fascia -> pressure increased inside -> blood seep into tissues Assessment o Frequent assessment of neurovascular function after fx is essential. Peripheral circulation is evaluated by assessing color, temperature, capillary refill time and feeling pulses ***elevate area to heart level: independent management if capillary refill more than 3 seconds

Management Prompt management of acute CS is essential. The physical need to be notified immediately when neurovascular compromise is suspected. Delay may result in permanent nerve and muscle damage or even necrosis, which requires amputation o Controlling swelling by elevation of the extremity at the cardiac level; releasing restrictive devices (dressing or cast) or both. If not relieved after 1 hour then FASCIOTOMY is done. Surgical decompression with excision of the membrane covering and separating muscles. ***fascia is not closed, it is drained afterwards (take time to remove clots, etc); place suction drains = after fasciotomy, patient relieved of compartment syndrome 4. Thromboembolism (pulmonary embolism) 5. Disseminated intravascular coagulopathy 6. Infection if compounded Delayed Complication 1. Delayed union and non-union occurs when healing does not advance at a normal rate for the location and type of fx. Delayed union may be associated with systemic infection and distraction (pulling apart) of bone fragment. Eventually, the fracture heals ***mgt for bone gap = internal self fixation-> align and immobilize -> remove portions of bones (trabeculae: spongy bone or red bone marrow) and undergo bone grafting ***fixation: heal first soft tissue before reparing the bone; just align bone first ***external fixators screws are placed into the bone above and below the fracture, and a device is attached to the screws from outside the skin Non-union o results from failure of the ends of a fractured bone to unite. Factors contributing to union problems include infection at the fracture site, interposition of tissue between the bone ends, inadequate immobilization or manipulation that disrupts callus formation, excessive space between bone fragments (bone gap,), limited bone contact and impaired blood supply resulting in avascular necrosis avascular necrosis of bone (worst thing to happen -> arthroplasty or amputation
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when the bone loses its blood supply and dies. It may follow a fracture with disruption o the blood supply (esp in the femoral neck) ***Intertrochanteric area or extratrochanteric area; intracapsular or extracapsular 2. Avascular necrosis of bone o When the bone losses its blood supply and dies. It may flow a fracture with disruption of blood supply. (esp in the femoral neck) 3. Reaction to external fixation devices o Allergy to metallic alloy used o Corrosion of the devise o Faulty or damaged devices o Mechanical failure, inadequate insertion and stabilization 4. Reflex Sympathetic Dystrophy Syndrome o Is uncommon, painful, sympathetic NS problem. It usually occurs in an extremity after trauma and is seen more often in women o Rare 5. Heterotrophic Ossification (myositis ossificans) o is the abnormal formation of bone near bones or in muscle in response to soft tissue trauma after blunt trauma, fracture or total joint replacement ***formation of bones outside of bones or ossification of bones near bones Other Early Complications Deep Vein Thrombosis (DVT), thromboembolism and pulmonary embolus are associated with reduced skeletal muscle contraction and bed rest. Patient with fxs of the lower extremities and pelvis are at high risk for thromboembolism. Pulmonary embolism may cause death several days to weeks after injury DIC (Disseminated Intravascular Coagulopathy) includes a groups of bleeding disorders with divers causes, including massive tissue trauma

Care of Clients in a Cast o o Cast is a rigid external immobilizing device that is molded to the contours of the body. The purpose of a cast are to immobilize a body part in a specific position and to apply uniform pressure on encased soft tissue A cast is used specifically to immobilize a reduced fx to correct a deformity, to apply uniform pressure to underlying soft tissue, or to support and stabilize weakened joints. Generally casts permit mobilization of the patient while restricting movement of a body part

Casting Materials 1. Non-plaster - Generally referred to as fibreglass casts. These water activated polyurethane materials have the versatility of plaster but are lighter in weight, stronger, water resistant and durable. These porous and therefore diminish ski problems 2. Plaster - Traditional
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Rolls of plaster bandage are wet in cool water and applied smoothly to the body, a crystallizing reaction occurs, and heat is given off (an exothermic reaction)

Before application of a cast: The nurses roles in the preparation of the patient. Prepare a basin with tap water. 4 inches plaster of paris if arm; 6 inches if leg Plaster of Paris Made of cotton cotton pad or wadding sheet Do not prepare splints! Remove splints and apply cast Clean the area Position client Apply stockinette first (with holes distally and proximal) Apply cotton pad apply 3 inches to protect skin of cast; apply 2-3 inches more than the cast Soak plaster of Paris in water; squeeze do not wring Assisting = hold with palm not fingers; smoothen area to make it dry using palms (not use fingers to prevent dents and compression areas) Dry outside right away and conforms to shape of leg 24 48 hours dry = plaster of paris Fully dry? Tap it if its resonant and hollow. Temperature is same with environment . While it is drying = exothermic thus emits heat energy; dont have to cover it with towels or blanket to prevent burns of skin Trim down edges with scissors to prevent abrasions on skin; place stockinette over edges; apply sticky plaster at edge of cast to smoothen it; finish the cast by petalling

Assessment After Cast Application A. Neurovascular assessment to a casted extremity - Color, warmth, pulses distal to the cast, capillary refill (circulatory function) - Movement of distal fingers or toes, awareness of light tough distal to the cast, changes in sensation (nerve function) B. Assessment of pain - If pain cannot be relieved = indication of compartment syndrome C. Assessment of cast assess for hot spots - Wet spots = may indicate drainage under the cast or a need for additional drying. Stains can indicate wound drainage or bleeding = must be documented - An older cast may develop a sour smell because of perspiration or normal sloughing of outer skin layers. Musty, offensive odors under the cast, however, may indicate tissue necrosis or infection.

Managing a Patient with External Fixator External, fixators are used to manage open fxs with soft tissue damage. They provide stable support for severe comminuted (crushed or splintered) fxs while permitting active tx of damaged soft tissue The potential for neurovascular deficit or CS is high. It could still develop in an open fx to another compartment in the same site.
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***do not allow to crust pin site area; remove oozing and let dry; do not allow oozing to crust (area where bacteria will invade -> can lead to osteomyelitis) Nursing Interventions Pre-op: prepare the client psychologically for application of the external fixator Reassurance that the discomfort associated with the device is minimal (will weigh more than 3 kilos) After the ex fix is applied the extremity is elevated to reduce swelling Monitors the neurovascular status of the extremity every 2 to 4 hours Check pins for loosening Bleeding persistently at the sites where pins are must be reported Antibiotic open wounds In sites and wound must be constantly assessed for signs of infection Wound healing must be carefully assessed and documented Note for any skin tension or puckering (tenting or wrinkling) at the insertion site Adhering to any weight bearing restrictions and correct use of ambulatory aids Nutritional status increase fluid intake, vitamin D and Calcium

Client and family education: 1. 2. 3. 4. Hygiene Nutrition How to use analgesic and its alternative method of pain management such as diversion Could resume sexual activities

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

Principles of Effective Traction Whenever traction is applied, countertraction must be used to achieve effective traction. Countertraction in the force acting the opposite direction. Usually, the px body weight and bed position adjustments supply the needed counter traction May put bed in trendelenburg to help in countertraction Types of Traction Straight or running traction applies the pulling force in a straight line with the body part resting on the bed. BUCKs extension traction is an example of straight traction. Balanced suspension traction supports the affected extremity off the bed and allows for some patient movement without disruption of the line of pull. - Skin traction applied to the skin o Hanging o Flat
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Possible complications of skin traction 1. Nerve pressure - Nerve Function 1. Dorsiflexion of the foot demonstrate function of the peroneal nerve 2. Plantar flexion demonstrates function of the TIbial nerve 2. Skin breakdown happens to old clients or babies 3. Circulatory impairment Skeletal traction directly to the bony skeleton o Applied directly to the bone by the use of metal pin or wire (e.g. Steinmann pin, or Kirshcnerwire or K-wire) that is inserted through the bone distal to the fracture, avoiding nerves, blood vessels, muscles, tendons and joints. ***apply to shin bone ***apply on metatarsals if fracture in ulna ***Bucks Skin traction most often seen in wards. Put nerve pressure in area causing numbness. ***Skeletal traction with cast ***Bryant Traction skin traction; doesnt involve the bone; good for babies with hip dislocation ***Russel Traction skin traction; ***Dunlop Traction skin traction

Nursing Intervention 1. Maintaining effective traction the N checks the apparatus to see that the ropes are in the wheel grooves of the pulleys, ropes not frayed, weights hang free, evaluate patient position 2. Maintaining position the nurse must maintain alignment of the clients body in traction as prescribed to promote an effective line of pull. The clients foot may be supported in a neutral position by orthopedic devices to prevent foot drop or plantar flexion, inversion or eversion of foot. 3. Preventing skin breakdown the nurse should protect the elbows and heels, inspect them for pressure areas. By using a trapeze overhead, elbows and heels will be protected from overuse or from using it every time the client moves that would create undue pressure to these sensitive bony prominence 4. Monitoring neurovascular status every hour initially and then every 4 hours 5. Providing pin site care our goal is to avoid infection and development of osteomyelitis. Slight serous oozing at the pin site is expected but crusting should be prevented. ***Nursing Alert: the nurse must inspect the pin site at least every 8 hours for signs of inflammation and evidence of infection. ***Promoting exercises isometric exercises of the immobilized extremity (quadriceps-setting and gluteal-setting) ***How do you exercise your client with traction? Isometric (contraction but no movement) ***Arthrokinematics; ROM

Care of the Amputee or Managing an Amputated Client Amputation is the removal of a body part, usually an extremity. Amputation of a lower extremity. Amputation of a lower extremity is often made necessary by progressive PVD (often sequela of DM)
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Orthopedic Nursing Mr. Hermie G. Siroy

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

Indications for Amputation 1. Trauma an extremity that has been severely damaged as a result of a crushing injury explosion, or armed conflict is likely to require amputation 2. Thermal injuries injuries from frostbite or burns may necessitate amputation 3. Infection such as osteomyelitis 4. Gangrene vascular disease duty to DM or arteriosclerosis may result in an inadequate blood supply to the tissues, causes a gangrenous limb 5. Congenital deformity 6. Tumor the possibility of metastasis in the case of a malignancy makes amputation of the affected limb desirable 7. Pain an extremity may be painful because of a circulatory problem. If relief is not obtainable any other way, amputation may be indicated Types of Amputation 1. Open or Guillotine Method is generally performed in the presence of infection or when infection is inevitable. The stump is not suture allowing for an open drainage of any purulent exudate, the stump end is then covered with bulky soft compression dressing - Antibiotic is an integral. Healing is by granulation and is prolonged. 2. Closed Amputation or Flap Method or Myoplastic Amputation the muscles are divided at least 2 inches distal to the level of intended bone section. They are then sutured under tension to the bone or opposing muscle group. - Not suturing in the middle for prosthesis preparation Levels or Sites of Amputation 1. Foot or Chopart Amputation loss of balance and possible deformity must be considered when part of a foot or toes are removed. 2. Ankle (Syme) removes the foot and the ankle and can be very satisfactory operation, since it produces a stump that is ideal for weight bearing. 3. Below the Knee an ideal stump for prosthetic fitting should include 5-7 inches of the tibia. Inadequate circulation may cause problems in a stump that is much longer and stump fitting can be a problem. 4. Knee disarticulation the patella is either removed, with the quadriceps tendon brought over the end of the femur, or else the patella is fixed at the condyles. 5. Above the knee 3 inches above the knee joint usually provides a good length for control of a prosthesis 6. Hip disarticulation amputation through the hip or pelvis is a rare and is used in instances of malignant tumors and extensive injuries or gangrene.

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Orthopedic Nursing Mr. Hermie G. Siroy

7. Hemipelvectomy removal of the entire extremity and a half of the pelvis is a shocking procedure and is done rarely even in the cases of malignancy. 8. Fingers when any part or all of a finger is removed, the stump must be designed. So it will not interfere with the function of other fingers. 9. Wrist disarticulation 10. Below the Elbow about 7 inches form the elbow, or the junction between the middle and lower thirds of the forearm is the ideal site for this amputation. 11. Above the elbow as much length as possible is saved in order to preserve arm strength 12. Elbow disarticulation infrequently done because the shape of the end of the humerus.. 13. Shoulder disarticulation rarely done because it is disabling and traumatic Nursing Process: The patient undergoing an amputation o Assessment Before surgery, the nurse must evaluate the neurovascular status and functional status of the extremity through history and physical assessment. The nurse evaluates the patients nutritional status The nurse assesses the patients psychological status. Determination of the patients emotional reaction to amputation is essential for nursing care. o Nursing Diagnosis Impaired physical mobility related to loss of extremity Planning and Goals Restoration of physical mobility Nursing interventions Helping patient achieve physical mobility. Evaluation (expected outcome) Achieves maximum independent mobility

Review warm compress = 36.5 40.5 C How do you apply hot packs? Place towels on the bed; place hot packs on towel and roll it and place it on joint (temp very high more than 40 C); placed only for 5-10 minutes and depends on clients feeling of warmth; if too hot: place another towel
Purpose of hot packing? Vasodilation and improved circulation; do ROM after hot packs Temp for trauma is different. 36.5 40.5 BKA 5-7 inches ideal stump 35