ORTHOPEDIC
I.
Anatom tomy and Phys hysiolog logy
A.
Bone (illustration 1 ) illustration 2 1. Functions a. supp suppor orts ts and and pro prote tect ctss stru struct ctur ures es of of the the body body b. anchors muscles c. some some bones bones con contai tain n hemato hematopoi poieti eticc tissu tissuee which which form formss blood blood cells cells d. parti particip cipate atess in the regula regulatio tion n of calc calciu ium m and and phos phosph phoru oruss
2.
Joints (illustration ) a. burs bursaa - enclo enclose sed d cavi cavity ty conta contain ining ing a glid glidin ing g join jointt b. synoviu synovium m - linin lining g of joints joints which which secret secretes es lubr lubricat icating ing fluid fluid that nou nourish rishes es and and protects
c. 3. 4.
classification of joints - synarthrosis, amphiarthrosis, diarthrosis
Cartilage - connective tissue covering the ends of bones (illustration Types of bones a. long - legs, arms
i. ii.
B.
)
external structure - diaphysis, diaphysis, epiphysis, periosteum (illustration
internal structure of bone - medullary cavity; cancellous bone; red marrow b. shor hort - ankles les, wrists ists c. flat - shoulder bl blades d. irre irregu gula larr - face face,, vert verteb ebra raee Musc Muscle less - prod produc ucee mov movem emen entt of of the the body body
1.
II. II.
Types (illustration ) a. stri striate ated d - contr controll olled ed by volun voluntar tary yn nerv ervou ouss sys system tem b. b. smoo smooth th - con contro trolle lled db by y auto autono nomi micc nerv nervou ouss sys syste tem m c. cardi cardiac ac - con contro trolle lled db by y auto autono nomi micc nerv nervou ouss sys syste tem m C. Fasc Fascia ia - sur surro roun unds ds and and div divid ides es musc muscle less D. Tend Tendons ons - fib fibrou rouss tis tissu suee betw between een musc muscles les and and bon bones es E. Ligamen Ligaments ts - fibro fibrous us tissu tissuee betwee between n bones bones and and cartila cartilage; ge; suppo supports rts musc muscles les and and fascia fascia Trau Trauma ma:: Cont Contus usio ions ns,, Str Strai ains ns,, Spr Sprai ains ns A. Contusions (bruise) 1. Defin Definiti ition on - a fall fall or or blow blow breaks breaks capill capillari aries es but but not not ski skin n 2. Patho Pathophy physi siolo ology gy - extra extravas vasati ation on (ble (bleedi eding) ng) under under skin skin
3. 4.
5. 6.
Findings - ecchymosis (bruise) and pain when the contusion is palpated Management a. for for firs firstt 24 to 48 hour hours, s, appl apply y ice ice for 15 minu minute tes, s, thr three ee time timess a day day b. b. then then appl apply y heat heat if nece necess ssar ary y c. wrap to compress Resol Resoluti ution: on: shoul should dh heal eal withi within n seve seven n to to ten ten days days Color Color changes changes from a blacki blackish sh - blue to a gresnis gresnish h - yello yellow w after after thre threee to five five days
)
B.
Strains 1. 2.
1.
2.
Defin Definiti ition on - les lesse serr injury injury of the the musc muscle le attac attachm hment ent to to the bon bonee Etio Etiolo logy gy and and path pathop ophy hyssiolo iology gy a. cause caused d by ove overs rstre tretch tching ing,, overex overexer ertio tion, n, or or misu misuse se of of musc muscle le b. b. acute: acute: rece recent nt inju injury ry to to muscl musclee or tend tendon on;; class classif ified ied by by degre degreee i. firs firstt degre degree: e: mild mild;; grad gradual ual ons onset; et; feel feelss stiff stiff,, sore sore loca locally lly I. asse assess ssme ment nt of of acu acute te fir first st-d -deg egre reee str strai ain n I. tende nderness ess to palp alpatio ation n II. muscle spasm III. II. no lo loss of of ra range of of mo motion ion IV. IV. litt little le or no edem edemaa or or ecc ecchy hymo mosi siss II. II. mana manage geme ment nt of acu acute te fir first st-d -deg egre reee str strai ain n I. comfort measures II. apply ice III. III. rest rest,, poss possib ibly ly imm immob obil iliz izee for for shor shortt term term ii. second second degree: degree: moderat moderatee stret stretchin ching, g, sudden sudden onset, onset, with with acute acute pain that eventually leaves area tender I. asse assess ssme ment nt of of acut acutee sec secon ondd-de degr gree ee str strai ain n I. extreme muscle spasm II. II. pass passiv ivee mot motio ion n inc incre reas ases es pain pain III. III. edem edemaa deve develo lops ps ear early ly;; ecch ecchym ymos osis is late later r II. II. mana manage geme ment nt of of acut acutee seco second nd-d -deg egre reee stra strain in I. keep limb elevated II. II. apply apply ice for the the firs firstt 24 24 to to 4 48 8h hrs rs - then then mois moistt heat III. limit mo mobility IV. IV. musc muscle le rela relaxa xant nts, s, anal analge gesi sics cs,, NSA NSAID IDS S V. phys physica icall ther therapy apy for for stre streng ngth th and range range of motio motion n Third-degree: Third-degree: severe stretching stretching with with tear; tear; sudden; sudden; snapping snapping or burning sensation sensation a. asse assess ssme ment nt of acute acute thir third d degre degreee strai strain n i. muscle spasm ii. joint tenderness iii. ii. edem dema (may be ext extreme eme) iv. iv. clie client nt cann cannot ot move move musc muscle le volu volunt ntar aril ily y v. delayed ec ecchymosis b. b. mana managem gemen entt of acut acutee third third degr degree ee stra strain in i. keep limb elevated ii. ii. appl apply y ice ice for for 24 24 to to 48 48 hrs hrs,, the then n moi moist st heat heat iii. iii. either either immo immobi biliz lizee or or lim limit it mobi mobilit lity yo off the the limb limb iv. iv. medic medicati ation on - musc muscle le relaxa relaxants nts,, anal analges gesic ics, s, NSAI NSAIDs Ds v. phys physica icall ther therapy apy for for stre strengt ngth h and and range range of motio motion n Chr Chronic strain ain
a. b. C.
long-te long-term rm overstr overstretch etching ing of muscle/ muscle/tend tendon on repeate repeated d use use of the the muscle muscle beyo beyond nd physi physiolog ologic ic limits limits
Sprains
1. 2.
Definition - greater than strain; injury to ligament structures by stretching, exertion or trauma Classifi Classificati cation/f on/find indings ings/ass /assessm essment/ ent/man managem agement ent a. firs firstt deg degre reee spr sprai ain n
i.
minimal tearing of ligament of ligament fibers loca locali lize zed d edem edemaa or hem hematom atomaa no loss of function no weak weakeni ening ng of join jointt struct structur uree - joint joint inte integri grity ty rema remains ins inta intact ct mild mild disc discom omfo fort rt at loca locati tion on of inju injury ry pain pain inc incre reas ases es with with p palp alpati ation on or weigh weightt bea beari ring ng mana manage geme ment nt of firs firstt degr degree ee spra sprain in • compress it with ace bandage to limit swelling keep limb raised to decrease edema • • apply ice 24 to 48 hours following injury • analgesics for discomfort isometric exercises to increase circulation and resolve • hematoma seco second nd degr degree ee spra sprain in i. up to half half of the the lig ligam amen ento tous us fibe fibers rs torn torn ii. ii. iii. iv. iv. v. vi. vi. vii. vii.
b. b.
ii.
increased edema and possible hematoma decr decrea ease sed d acti active ve ran rang ge of mot motio ion n increased pain mild mild weake weakenin ning go off the the joint joint and loss loss of of fun functi ction on management • protectively dress/splint the joint, immobilize it • elevate the limb to decrease edema for 24 to 48 hours, alternate • ice o 1. to prod produce uce vaso vasoco cons nstri tricti ction on to decre decreas asee swelling 2. to reduce reduce trans transmi miss ssion ion of nerve nerve impulses and conduction velocity to decrease pain moist heat o 1. to redu reduce ce swe swelli lling ng and and pro provid videe comf comfor ortt analgesics for discomfort • physical therapy to increase circulation and maintain • nutrition to the cartilage c. thir third d deg degre reee spr sprai ain n i. comple complete te ruptu rupture re of the ligam ligament entous ous attach attachme ment nt ii. ii. seve severe re edem edemaa with with hema hemato toma ma iii. usually, se severe pa pain iv. iv. dram dramat atic ic dec decre reas asee in acti active ve ran range ge of of mot motio ion n v. loss loss of join jointt int integ egri rity ty and and fun funct ctio ion n vi. management • casting • surgery to restore integrity of joint see second degree treatment • Fract Fracture ures: s: path pathoph ophys ysiol iolog ogy y 1. Pred Predis ispo posi sing ng fact factor orss a. biologic i. bone density ii. client's age 2. Extr Extrin insi sicc fac facto tors rs a. forc forcee - dire direct ct or indi indire rect ct b. rate of loading loading (how fast fast the the force force strikes strikes)) 3. Intrin Intrinsi sicc factor factorss - bone bone capab capabili ilitie tiess iii iii. iv. v. vi.
D.
4.
E.
Path Pathol olog ogic ical al frac fractu ture ress a. bone bone is is wea weake kene ned d by by dise diseas asee b. fractur fractures es occur occur in resp response onse to to minima minimall or no applie applied d stress stress c. classif classificat ication ion by cause cause:: general general or local local diso disorder rder i. gener general: al: devel developm opment ental, al, nutr nutriti ition onal, al, hor hormo monal nally ly contr controll olled ed ii. ii. loca local: l: neo neopl plas asm, m, inf infec ecti tion on,, cyst cystic ic les lesio ion n 5. Behavio Behavioral ral factor factorss - high-risk high-risk activi activities ties (such (such as footbal football, l, ballet) ballet) Frac Fractu ture res: s: man manag agem emen entt 1. Clos Closed ed redu reduct ctio ion n a. purposes: purposes: realign realign bone fragments fragments for healing, minimal deformity, deformity, minimal minimal pain. b. pre- and post-redu post-reduction ction x-rays are essential essential to determine determine successful successful reduction reduction of fracture 2. Immobiliza lizati tio on a. purposes i. relieve pain ii. ii. keep keep bone bone frag fragme ment ntss fro from m mov movin ing g
b. c.
d.
3.
methods: cast - synthetic or plaster, traction - skin or skeletal, splints, braces, and external fixation types of tr traction tion i. manu manual: al: app applie lied d by pul pullin ling g on the the extrem extremity ity - may may be be used used duri during ng cast application ii. skin: skin: appli applied ed by pulli pulling ng force force through through the client' client'ss skin skin - used used to to relax relax the muscle spasm iii. iii. skeleta skeletal: l: appl applied ied directly directly through through pins pins inser inserted ted into the client' client'ss bone bone used to align fracture open open treatme treatment nt (see (see ortho orthopedi pedicc surgery surgery that follows follows))
Stages of bone healing
a. b. c.
hematoma formation fibroca fibrocartil rtilage/ age/gran granulat ulation ion tissue tissue formati formation on call allus form ormatio ation n
d.
4.
ossification e. cons consol olid idat atio ion/ n/re remo mode deli ling ng Evid Eviden ence ce of of heal healed ed fra fract ctur uree
a. b.
c.
F. A.
B.
C.
radiographic i. presence presence of external external callus callus or cortical cortical bone across across the fractur fracturee site site ii. ii. frac fractu ture re lin linee may may rem remai ain n long long aft after er hea heali ling ng clinical i. piec pieces es of of bon bonee no no long longer er mov movee at fra fract ctur uree site site ii. ii. no tend tender erne nesss ove overr fra fract ctur uree sit sitee weig weight ht bear bearin ing g is is pai pain n fre freee
Fractures: complications
ORTHOPEDIC COMPLICATIONS
Venous Venous thrombo thromboemb embolic olic problem problemss 1. Thro Thromb mbop ophl hleb ebit itis is (TP) (TP) a. inflamm inflammatio ation n of a vein vein with with the the format formation ion of of a blood blood clot clot b. incidenc incidencee is greate greatest st after after traum traumaa or surge surgery ry to legs legs or feet feet Deep Deep ven venous ous throm thrombos bosis is (DV (DVT) T) 1. Anter Anterior ior tibial tibial or fem femor oral al vein veinss 2. May May be caus caused ed by by immo immobi bili lity ty 3. Finding Findingss include include calf pain, pain, posi positive tive Homan's Homan's sign sign 4. Imme Immedi diate ately ly after after opera operatio tions ns a. anti antico coag agul ulan antt ther therap apy y b. b. antiem antiembo boli li sto stocki cking ngss (us (usua ually lly)) c. sequenti sequential al compre compressi ssion on device device (possib (possibly) ly) Pulm Pulmon onary ary embo embolis lism m (PE) (PE) 1. Blood Blood clot from from systemi systemicc circulati circulation on enters enters pulmona pulmonary ry circulat circulation ion 2. Most Most commonly commonly seen seen after after hip fractur fractures es and total total hip/kn hip/knee ee replacem replacements ents 3. Occurs in approxim approximately ately ten percent percent of patients patients undergoing undergoing hip arthroplas arthroplasty ty 4. May be caused caused by femoral vein manipulatio manipulation n during surgery surgery and therefore therefore occur occur without without signs signs of DVT
5.
D.
E.
F.
G.
H.
Findings include chest pain (pleuritic), sudden shortness of breath, tachycardia, palpitations, or change in mental status 6. If PE is is suspected,do suspected,do not leave client. Get Get charge charge nurse to to notify health care care provider provider immediately immediately 7. Diagnosis Diagnosis confirmed confirmed via ventilation/perfu ventilation/perfusion sion scan or pulmonar pulmonary y angiograph angiography y 8. Continuo Continuous us IV IV hepar heparin in thera therapy py usual usually ly pres prescrib cribed ed Fat em embolism ism 1. Definit Definition: ion: fat cells cells enter enter pulm pulmonar onary y circul circulatio ation n 2. Associat iated with a. mult multip iple le trau trauma ma acci accide dent ntss b. b. multi multiple ple organ organ invol involvem vement ent c. fractu fractures res of marr marrow ow prod produc ucing ing bones bones d. join jointt repl replac acem emen ents ts e. inser insertio tion n of inter intermed medul ullar lary y rod rodss 3. Usually Usually occurs occurs 24 24 to 48 hours hours after after the the fractu fracture re Hemorrhage 1. Abno Abnorm rmal al los losss of blo blood od fro from m the the body body 2. Most Most common common in fract fracture uress of bone bone marrow marrow produ producing cing bones bones Wound ound infe infect ctio ion n 1. May May be super superfic ficial ial or deep deep wound wound 2. Deep wound wound infec infection tion may lead to osteo osteomye myeliti litiss 3. Findings Findings include include erythema erythema and and swelling swelling around around suture suture line, line, increased increased drainage and elevated elevated temperature 4. Treated with with antibiotics; antibiotics; may may require require incision incision and drainage drainage of wound or removal removal of prosthesi prosthesiss if severe infection is present Special Special complic complicatio ations ns in hip repla replacem cement ent 1. Femo Femora rall frac fractu turre a. occurs occurs near near distal distal end end of femor femoral-s al-shaft haft part part of prosthe prosthesis sis b. occurs more frequentl frequently y with elderly, elderly, clients clients with osteoporosis, osteoporosis, or after revision to total total hip replacement c. primary primary finding finding is sever severee pain pain with ambulat ambulation ion d. diagno diagnosi siss is confir confirme med d with with x-r x-ray ay e. depending depending on severity, severity, treatment treatment will be be immobilizati immobilization on or open reduction reduction with internal fixation 2. Dislo Dislocat cation ion of hip pros prosthe thesis sis a. greatest risk during the first first postoperati postoperative ve week but can occur at at any time time within within the first year. b. risk decreas decreases es as muscle muscle tone tone of the the hip increase increasess c. caused caused by flexion flexion of the the hip hip or poo poorr prosth prosthetic etic fit d. findings findings include include pain pain and and extern external al rotati rotation on of the leg leg e. treated by closed closed reduction reduction under under conscious conscious sedation or open open surgical surgical revision revision Special Special complic complicatio ation n in knee replaceme replacement: nt: flexion flexion failure failure 1. Client Client cannot cannot flex flex knee knee 90 degre degrees es two two weeks weeks posto postopera perative tively ly 2. Treated Treated with with closed closed manipu manipulati lation on of the knee knee joint joint under gener general al anesthes anesthesia ia 1.
Imme Immedia diate te comp complic licati ations ons of of the the injur injury y a. shoc shock k - highe higherr risk risk with with pelvi pelvicc and femu femur r
b. c. d.
2.
fat embolism - occurs after the initial 24 hours from the injury compartment syndrome - a nursing emergency
deep venous thrombosis (DVT) e. pulmon pulmonary ary embolis embolism m - a ccomp omplica lication tion of DVT Dela Delaye yed d comp compli lica cati tion onss a. joint int sti stifffness ess b. post-tr post-traum aumatic atic arthr arthritis itis (oste (osteoart oarthrit hritis, is, type type II) II)
c. d.
e.
reflex sympathetic dystrophy i. pain painfu full dysf dysfun unct ctio ion n and and disu disuse se synd syndro rome me ii. ii. charac character terize ized d by abno abnorm rmal al pain pain and swe swelli lling ng of of the extrem extremity ity myos myosit itis is ossi ossifi fica cans ns i. form formati ation on of of hyp hypert ertrop rophi hicc bone bone near near bone bone and musc muscles les ii. ii. form formss in resp respon onse se to trau trauma ma iii. iii. hyper hypertr troph ophic ic bon bonee is is rem remov oved ed when when bone bone is matu mature re malunion i. frac fractu ture re heal healin ing g is not not stop stoppe ped d but but slo slowe wed d
ii. ii.
f.
g. h.
G.
preve eventio tion of malun lunion • reduce and immobilize properly be sure client understands limits on activity and position • delayed union i. fracture do does no not he heal ii. ii. more more commo common n with with multi multipl plee fract fractur uree fragm fragmen ents ts iii. iii. no evid evidence ence of fract fracture ure healing healing four to six six month monthss after after the fracture fracture loss loss of of adeq adequa uate te red reduc ucti tion on refracture
Nursing interventions 1. Risk for periphe peripheral ral neurova neurovascul scular ar deficit deficit a. check check neur neurova ovasc scula ularr stat status us often often
b. c. 2.
elevate limb above level of heart (except with compartment syndrome) appl apply y cold cold to min minim imiz izee edem edemaa
Pain a. b.
3.
4.
5.
6.
assess assess level level of of pain pain with with a scale scale of one one to to ten ten manage pain i. with drugs ii. reposition cl client iii. ii. pad any b bo ony p pro rom mine inences c. teac teach h rela relaxa xati tion on tec techn hniq ique uess Cli Client ent te teachi ching a. how how frac fractu ture ress heal heal b. b. why why the the fract fractur uree is bein being g immo immobil bilize ized d c. how to bear bear weight weight and how much much (if (if perm permitte itted) d) d. how bo bones he heal e. how how to use use assi assisti stive ve devi devices ces to wal walk k Risk Risk for for infe infect ctio ion n a. related to i. open fr fractures ii. ii. surgica ical inte nterventi ntion iii. ii. superf erficia cial/d l/deep eep wounds b. b. monit monitor or for for find finding ingss of infect infection ion c. prov provid idee pro prope perr wou wound nd care care d. adminis administer ter antibiot antibiotic ic therapy therapy as indicate indicated d Risk Risk for for impair impaired ed skin skin integr integrity ity a. causes i. open fr fractures ii. soft ti tissue in injuries iii. pressure areas b. b. addi additi tion onal al fac facto tors rs i. age - elderly ii. ii. gene genera rall cond condit itio ion n of clie client nt iii. iii. pree preexi xist stin ing g skin skin con condi diti tion onss or dis disea ease sess c. inter tervent ention ions i. mobi mobili lize ze the the ccli lien entt as as soo soon n as as pos possi sibl blee ii. ii. turn turn the the cli clien entt ofte often n at leas leastt ever every y two two hou hours rs iii. iii. posit position ion the the clie client nt prope properl rly y with with align alignme ment nt in in mind mind iv. iv. use use orth orthope opedic dic device devicess to to lim limit it skin skin impai impairm rmen entt Impa Impair ired ed gas gas exch exchan ange ge a. acco accomp mpan anie iess che chest st trau trauma ma
b. c.
client risks deep venous thrombosis inter tervent ention ions i. mobi mobili lize ze as soon soon as pos possibl siblee ii. ii. freq freque uent nt and and eff effec ecti tive ve pul pulmo mona nary ry toi toile leti ting ng Fractur Fractures: es: factors factors that affect affect heal healing ing d.
H.
client risks fat embolism
III.
Degene enerativ ativee Dis Disorders ers A. Definition 1. Slowly Slowly progr progress essive ive disorde disorders rs of of artic articular ular cartilag cartilagee and and subcho subchondra ndrall bone bone 2. Do not not affect affect the the joints joints symmet symmetrica rically lly (e.g., (e.g., not necessa necessarily rily both both knees knees)) 3. Worsen pr progressively 4. Even Eventu tual ally ly inca incapa paci cita tate te,, despi despite te trea treatm tmen entt B. Osteoarthritis (OA)
1. 2.
3.
Definition - degeneration of the articular cartilage and formation of new bone in the subchondral margins of the joint Findings I. prim primar aril ily y invo involv lves es wei weigh ghtt-be bear arin ing g join joints ts II. II. nonnon-in infl flam amma mato tory ry diso disord rder er III III. loca locali lize zed: d: no syst system emic ic effe effect ctss IV. IV. resu results lts in an an abno abnorm rmal al dis distri tribut bution ion of stre stress ss on on the the joint joint Incidence I. most ost com comm mon form form of arth arthri riti tiss II. II. may may b begi egin n as as earl early y as as the the 20s 20s and and peak peakss in in the the 60s 60s III. III. by age age 70, 70, near nearly ly 80% 80% of of affli afflicte cted d peop people le show show find finding ingss IV. IV. over over age 55, 55, OA OA aff affect ectss twic twicee as as many many wome women n as as men men
V. I.
II. II.
two types: primary and secondary Types of Osteoarthritis (OA)
Prim Primar ary y (Id (Idio iopa path thic ic)) Ost Osteo eoar arth thri riti tiss A. No known cause B. Classifications 1. Loca Locali lize zed d OA OA in in o one ne or two two joi joint ntss 2. Gene Genera rali lize zed d OA OA in in thr three ee or more more join joints ts.. C. Etiology 1. More More com common mon in in wom women en (sli (sligh ghtl tly) y) 2. More comm ommon in Cauc aucasi asians ans 3. Deve Develo lops ps in in midd middle le age age and and pro progr gres esse sess slow slowly ly 4. More More oft often en affe affect ctss cer certa tain in joi joint ntss a. weight-bearing j oi oints b. b. cerv cervic ical al and and lum lumbo bosa sacr cral al joi joint ntss c. inter terphal halang angeal eal joint ints 5. Hand Handss more more aff affec ecte ted d in wom women en aft after er men menop opau ause se 6. Hips Hips are are more ore affe affect cted ed in men Seco Second ndar ary y (Tra (Traum umat atic ic)) Oste Osteoa oart rthr hrit itis is A. Under Underly lying ing condit condition ion:: a trau trauma ma to to the the arti articul cular ar car cartil tilage age
B.
Etiology 1. Geneti Geneticc pre predi disp spos ositi ition, on, show shown nb by y the the pres presenc encee of of
Heberden's Nodes III. III. IV. IV. V. VI. VI.
Bony Bony oste osteop ophy hyte tess at the the DIP DIP join jointt Comm Common on pres presen enta tati tion on of OA in the the han hand d Indi Indica cate tess a stro strong ng here heredi dita tary ry tend tenden ency cy Seen Seen mor moree oft often en in in wom women en tha than n men men (te (ten n time timess
Bouchard's Nodes Accompany Heberden's nodes , Found at the PIP joint, Occur more often in women than men Increase in frequency with age 1. 2.
B.
More common in men Often occurs in a. wrists b. elbows c. shoulders Risk Risk fac facto tors rs for for tra traum umat atic ic ost osteo eoar arth thri riti tiss 1. Obesity 2. Fami Family ly his histo tory ry of of dege degene nera rati tive ve joi joint nt dis disea ease se 3. Excessive joint wear a. physical activity b. injury 4. Joint abnormality a. lax ligaments b. congen genital ital hip dysplas lasia 5. Lifes Lifesty tyle: le: cert certain ain occu occupat patio ions ns pred predis ispos posee to secon seconda dary ry OA. OA. 4.
Path Pathop ophy hysi siol olog ogy y a. stage stage one: one: microfr microfractu acture re of the the artic articular ular surface surface i. arti articu cula larr car carti tila lage ge is worn worn away away ii. ii. condy condyles les of bone boness rub rub toget together her:: joint joint swell swellss and and is painf painful ul iii. iii. cartil cartilage age los loses es cush cushio ionin ning g effect effect:: joint joint frict friction ion deve develop lopss iv. iv. pros prostag taglan landin dinss may may acce acceler lerat atee degen degener erati ative ve chan change gess b. b. stag stagee two two:: bone bone cond condens ensat ation ion i. erosion of cartilage ii. ii. cartil cartilage age may be dig diges ested ted by an an enzym enzymee in the the syn synov ovial ial fluid fluid c. stag stagee three three:: bone bone rem remod odel elin ing g i. matri matrix x syn synthe thesis sis and cellu cellular lar prolif prolifer erati ation on fail fail ii. ii. eventu eventuall ally y the the full full thick thicknes nesss of art articu icular lar car cartil tilag agee is lost lost
iii. iv. iv.
5. 1.
OSTEOARTHRITIS OF HIP/KNEE: SPECIFIC PHYSICAL FINDINGS
Hip a. b. c. d.
2.
Findings
bone beneath cartilage hypertrophy and osteophytes form at joint margins result: lt: jo joint int de degene enerates ates
Knee a. b. b.
contr contract actur uree in add adduct uction ion and flexi flexion on decrease decrease in interna internall and and exte external rnal rotatio rotation n limb imb shor horteni ening refe referr rred ed pain ain to to the the i. knee ii. groin iii. thigh decr decrea ease sed d ran range ge of moti motion on flex flexio ion n cont contra ract ctur uree i. h ip ii. knee
c. d. e.
varus varus defor deformi mity ty:: bow leg legge ged d appear appearanc ancee valgus valgus deformi deformity: ty: knock-kn knock-kneed eed appearan appearance ce posi positi tive ve appr appreh ehen ensi sion on sig sign n i. push push the the patel patella la late latera rally lly with with the the leg leg in in full full ext extens ensio ion n ii. ii. clien clientt will will stop stop the the exami examiner ner from from pus pushi hing ng the the pate patella lla fur furthe ther r a. b.
joint joint stiff stiffnes nesss after after peri periods ods of res restt pain in in a movable movable joint, joint, typic typically ally wors worsee with action action,, relieved relieved by by rest
c. d.
paresthesia joint enlargement: bones grow abnormally; spurs form and synovitis sets in.
i. ii.
e. f.
g. h.
Bouchard's nodes joint oint defo deform rmit itie iess tend tender erne ness ss on on palp palpat atio ion n i. may may inv invol olve ve widely widely separ separate ated d are areas as of the joint joint ii. ii. mild mild syno synovi vitis tis may may be felt felt - posit positive ive bulge bulge sign sign may may be foun found d pain pain on on pas passi sive ve mov movem emen entt limitat limitation ion in active active range range of motio motion n becaus becausee i. joint oint surfa urface cess no long longer er fit fit ii. ii. musc muscle less spasm pasm and and cont contra ract ct
iii. iv. v. i.
6.
Heberden's nodes
gait i. ii. iii. ii. iv.
joints are blocked by osteophyte, osteophyte, loose bodies crepitation, crepitation, crunching when joints are moved eventual ankylosis abnormal an antalgic ga gait shortened stance widene ened ba base of of support ort shortened st step le length
Diagnostics a. to rule rule out out autoim autoimmu mune ne disord disorder erss i. sedimentation ra r a te ii. rheumatoid fa factor iii. c-reactive pr protein b. CBC i. anal analyz yzee befo before re NSAI NSAID D ther therap apy y ii. within no normal li limits c. kidney ney and and liv liver i. especia especially lly in older older clients, clients, analyze analyze before before starting starting NSAID NSAID therapy therapy ii. ii. repeat peat every six months d. puri purifie fied d prot protein ein deriv derivati ative ve (PP (PPD) D)
i.
e.
f. g.
analyze before starting steroids ii. clients clients testing testing positiv positivee for for tuber tuberculo culosis sis must must recei receive ve INH at same same time as steroid. antin antinucl uclear ear antig antigen en (ANA (ANA)) tite titer r i. may be be low lower er in th the eeld ldeerly rly ii. ii. does does not not nec necess essar arily ily prove prove a conn connect ective ive-ti -tiss ssue ue dis diseas easee synovial fluid analysis distinguishes osteoarthritis from rheumatoid arthritis. radiographs i. take taken n in stan standi ding ng,, weig weight ht-b -bea eari ring ng con condi diti tion on ii. ii. show showss the the prim primee sign sign of OA: OA: join jointt spa space ce narr narrow owing ing iii. iii. x-ray x-ray does does not not nec neces essa saril rily y refl reflect ect sever severity ity of dise diseas asee iv. joint joint loses loses space space aasym symmet metrica rically lly because because cartilag cartilagee narr narrows ows from production of osteophytes or bone spurs
v.
h.
later stages may show bony ankylosis, ankylosis, spontaneous fusion bone scans
i. ii. ii. iii. iii.
radionuclide imaging show showss ske skelet letal al dist distrib ributi ution on of osteo osteoar arthr thriti itiss moni monitor torss comp complic licati ation onss of joint joint replac replacem ement ent surge surgery ry
i. 7.
MRI MRI scans scans show show the the exte extent nt of of joint joint destr destruct uction ion
j. computerized tomograms (CT) scans show cortical and cancellous bone density Manage Manageme ment: nt: con conse serva rvativ tivee treatm treatment ent a. educ educat atio ion n shou should ld cove cover r i. exercise patterns ii. ii. relaxa laxattion ion techn chniqu iques iii. ii. nutri tritio tional as assess essment ent iv. iv. couns counseli eling ng about about maint maintain aining ing a norma normall weight weight b. nutriti nutritional onal managem management ent - weight weight reductio reduction n c. acti activi vity ty and and res restt mana manage geme ment nt i. pres preserv ervati ation on of join jointt moti motion on throu through gh a bala balance nce of 1. rest rest (pro (prote tect ctio ion) n) 2. acti activi vity ty (reha (rehabi bili lita tati tion on)) ii. ii. indiv individu iduali alized zed activi activity ty rehab rehabili ilitat tatio ion n prog program ram iii. iii. phys physica icall or or occ occupa upatio tional nal thera therapis pistt may may b bee help helpful ful iv.
8.
passive range of motion exercises (illustration ) v. active stretching d. protect protection ion from from further further injury injury by by splinti splinting ng or bracing bracing Medication a. aspi aspirin rin - mos mostt often often recom recomme mend nded ed i. adva advant ntag ages es:: rela relati tive vely ly saf safee and and inex inexpe pens nsiv ivee ii. ii. disadv disadvant antage age:: GI pro proble blems ms may may lead lead to ulce ulcers rs and and blee bleedin ding g b. non nonster steroida oidall anti-infl anti-inflamm ammator atory y medicatio medications ns (NSAID (NSAIDs) s) i. redu reduce ce pain ain and and infl inflam amma mati tion on
ii.
c.
inhibit prostaglandin inhibit prostaglandin formation iii. iii. may cause cause GI bleeding bleeding or gastric gastric ulcers ulcers or cramping cramping with diarrhea diarrhea adren adrenoco ocort rtico icoste stero roid id inject injection ionss
d.
remissive agents i. gold ii. ii. peni penici cill llam amin inee (cup (cupri rim mine) ine) iii. iii. hydr hydroc ochl hlor oroq oqui uini nine ne (pla (plaqu quen enil il)) 9. Nonm Nonmed edic icat atio ion n assi assist stan ance ce a. assi assist stiv ivee devi device cess i. canes ii. walkers b. b. nonnon-tra tradit dition ional al techn techniq iques ues i. guide guided d image imagery ry - the the use use of one' one'ss imag imagina inatio tion n to ach acheve eve rela relaxat xation ion and control ii. therapeutic ma massage iii. biofeedback iv. hypnosis v. relaxation t ec echniques 10. 10. Surgi Surgical cal manag manageme ement nt
a. b. c.
arthrodesis arthroplasty
osteotomy d. tota totall joi joint nt repl replac acem emen entt 11. Home Home care consid considerat eration ionss in arthritis arthritis a. safe afety measu asures i. no sc scatter ru rugs at at ho home ii. ii. well well-f -fit itte ted, d, supp suppor orti tive ve shoe shoess iii. iii. night night lig light ht,, hand handrai rails ls at sta stairs irs and and batht bathtub ub or or sho showe wer r iv. assistive de devices 1. canes 2. walkers 3. elev elevat ated ed toil toilet et seat seatss 4. grab bars 5. hand handra rail ilss in stai stairw rway ayss v. spli splint ntss and and orth orthot otic ic devi device cess b. managem management ent of surgic surgical al pain by patien patientt controlle controlled d analgesia analgesia pumps pumps c. refer referra rall to agenc agency y and and suppo support rt group group
2.
Charcot Charcot joint jointss (also (also called called neuro neuropath pathic ic joint joint disea disease) se)
6.
Definition - multicausal degeneration and deformation of joint, usually ankle.
7.
(illustration ) Etiology a. diabetes diabetes mellitu mellituss leadi leading ng to foot foot neuropat neuropathy hy
b. c. d.
e.
syringomyelia results in Charcot's joint of the shoulder tert tertia iary ry syph syphil ilis is peri periph pher eral al neu neuro ropa path thie iess spina bifida with myelomeningocele leprosy multi ultipl plee scle sclero rosi siss long long term term intra-ar intra-articu ticular lar steroid steroid injecti injections ons
f. g. h. 8. Findings a. inspect inspection ion:: foot is is everted everted,, widened widened,, and shor shorter ter than than norma normall b. examination i. joint instability ii. soft ti tissue sw swelling iii iii. pain pain sec secon onda dary ry to to inf infla lam mmati mation on 9. Diagnostics a. labor laborato atory ry analy analysi siss of syno synovi vial al flui fluid d i. fluid uid is is no non-inf inflamm ammator tory ii. low protein content iii. no h heemorrhage no noted b. radiographs i. chro chroni nicc dest destru ruct ctiv ivee arth arthri riti tiss of of the the foot foot ii. severe severe destruc destruction tion of the articula articularr carti cartilage lage,, subch subchondr ondral al scleros sclerosis is iii. iii. frag fragme ment ntss of of bon bonee and and car carti tila lage ge in joi joint nt 10. 10. Mana Manage geme ment nt a. cons conser erva vati tive ve trea treatm tmen entt i. prot protec ecti tion on from from over overus use/ e/ab abus usee ii. braces an and sp splints
b.
3.
surgical management: arthrodesis i. trea treatm tmen entt of of cho choic icee for for unst unstab able le join joints ts ii. ii. fusi fusion on of the the invo involv lved ed joint oint 11. Nursing Nursing interve interventio ntions ns a. expec expected ted outco outcome me:: pres preser erve ve the the joi joint nt b. b. educa educatio tion n can pre preven ventt furthe furtherr injury injury c. prot protec ecti tion on of the the join jointt i. braces ii. orthopedic shoes d. prol prolon onge ged d immob immobil iliz izat atio ion n i. eigh eightt to to 1 12 2 wee weeks ks to decr decrea ease se swel swelli ling ng ii. ii. leads leads to min minim imal al join jointt defor deformi mity ty and and a functi function onal al pain painle less ss foot foot Chondro Chondromala malacia cia patellae patellae (also (also called called patellof patellofemo emoral ral arthralg arthralgia) ia)
6.
Definition: progressive, degenerative softening of the bone; follows a knee injury
7.
(illustration Etiology
a. b. 8.
)
lateral subluxation of the patella (kneecap) direct direct or repetit repetitive ive traum traumaa to the patella patella produce producess chondral chondral fractu fracture re
c. underdevelopment of the quadriceps muscles Findings a. pain with flexed flexed knee knee activi activities ties (poorly (poorly localiz localized) ed) b. mild ild swellin lling g c. occasion occasional al episo episodes des of buckl buckling ing of of the the affecte affected d knee knee d. e. f. g. h. i.
minimal joint effusion evide evidence nce of 'squi 'squinti nting ng kneec kneecaps aps'' atro atroph phy yo off qua quadr dric icep epss inverte inverted d 'J' track tracking ing of the the patella patella in the final final 30 30 degrees degrees of extens extension ion exce excess ssiv ivee quadr quadric icep epss angle angle posi positi tive ve appr appreh ehen ensi sion on sign sign
9.
j. crepitation upon range of motion Diagnostics a. radiographs i. anteri anterior or pos poster terior ior (AP) (AP) and and late latera rall view viewss are are not not helpf helpful ul ii. ii. sunr sunris isee views views wit with h the knee knee in 30 degree degrees, s, 60 60 degre degrees es and and 90 deg degree reess of flexion b. bone Sc Scans c. MRI Scans d.
arthroscopy (see Orthopedic surgery) 10. Conserv Conservativ ativee managem management ent a. prog progres ressi sive ve resis resistiv tivee eexer xercis cises es i. quad quadri rice ceps ps setti etting ng - iso isome metr tric ic ii. ii. hams amstring ings - iso isotonic b. b. medi medica cati tion on:: NSAI NSAIDs Ds c. non nonmed medicat ication ion assis assistanc tance: e: applic applicatio ation n of ice ice or moist moist heat heat d. acti activi vity ty rest restri rict ctio ion n 11. 11. Surgi Surgical cal manag manageme ement nt a. indicat indicated ed if findings findings remai remain n after six six months months of conserv conservativ ativee treatment treatment b. arthros arthroscopy copy (see (see Orthop Orthopedic edic Surge Surgery ry section section that that follow follows) s) c. arthrotomy i. reali realign gnme ment nt of proxi proxima mall and/ and/or or distal distal soft soft tissu tissuee ii. ii. tibi ibial tub tubercl rcle el elevati vatio on
2.
iii. patellectomy 12. Nursing interventions interventions (see (see previous previous Osteoarthriti Osteoarthritiss section) section) Infl Inflam amma mato tory ry Diso Disord rder erss 1. Rheu Rheuma mato toid id art arthr hrit itis is (RA (RA)) 6. Definition Definition - chronic systemic systemic inflammato inflammatory ry disease disease of the connective connective tissue tissue 7. Findings a. starts starts in feet feet and hands hands,, graduall gradually y destroys destroys thes thesee peripher peripheral al joints joints b.
8.
9.
affects diarthroidial joints c. bila bilate tera rall invo involv lvem emen entt Etiology a. caus causee is not not ful fully ly und under erst stoo ood d b. rheumat rheumatoid oid arthr arthritis itis is an an autoimm autoimmune une disorde disorder r c. genetic genetic tende tendency; ncy; but may may involv involvee bacteri bacteria, a, or viruses viruses d. may affect affect the the connect connective ive tissu tissuee of the lungs, lungs, heart heart,, kidneys kidneys,, or skin skin Incidence a. two to three three times times more more comm common on in in women women than in men men b. strikes strikes between between the ages of 20 20 and and 50 years years of of age age
10. Pathophysiology a. synovitis immune complexes initiate inflammatory response i. ii. ii.
IgB an antibo ibodies ies are are form ormed rheum eumato atoid factor tor (RF) 1. pann pannus us form format atio ion n 2. destr destruct uction ion of subch subchon ondra drall bone bone 3. prese present nt in in 85 85 to to 90% 90% of all all case casess 4. worsens worsens the the inflam inflammat matory ory respo response nse - can can go on on indefini indefinitel tely y
5. irreversible - will lead to ankylosis of joint 11. 11. Find Findin ings gs a. in earl early y RA RA joi joint ntss wil willl be be i. painful, st stiff ii. ii. warm warm,, red, red, swol swollen len at capsu capsules les and soft soft tissu tissues es iii. iii. inca incapa pabl blee of full full rang rangee of moti motion on b. b. in late late RA, RA, joint jointss will will show show i. bony an ankylosis ii. ii. dest destru ruct ctio ion n of joi joint nt - rea react ctiv ivee hype hyperp rpla lasi siaa iii. adhesions iv.
inflammation and effusion that will be 1. symmetrical
2. c.
general si signs
polyarticular
i. ii. ii.
fatigue los loss of appe appeti tite te and weigh eightt
iii.
d.
e.
enlarged lymph glands (illustration ) rheu rheum matic atic nodu nodulles i. in 20% of cases ii. ii. firm firm,, oval oval,, nont nonten ende derr mass masses es und under er the the ski skin n iii. iii. pres presen ence ce indi indica cate tess poor poor prog progno nosi siss phys physica icall asses assessm smen entt shoul should d also also includ includee i. accura accurate te patien patientt his histor tory y - his histor tory y may inclu include de 1. malaise 2. fatigue 3. weakness 4. loss loss of app appet etit itee and and weig weight ht 5. enla enlarg rged ed lymp lymph h glan glands ds 6. Rayn Raynau aud' d'ss synd syndro rome me ii. ii. exam examin inat atio ion n may may reve reveal al defo deform rmit itie iess 1. ulna lnar de deviati iatio on
2.
f.
deformed hands: swan neck/boutonniere neur neurol olog ogic ical al exam examin inat atio ion n
i. ii. ii.
foot drop evid eviden ence ce of spin spinal al cord cord comp compre ress ssio ion n
12. 12. Diag Diagno nost stic icss a. labo labora rato tory ry an analys alysis is
i. ii. iii iii.
iv. v.
elevated ESR decreased RB RBC posi positi tive ve C-re C-reac acti tive ve prot protei ein n positive antinuclear antibody in 20% of cases
positive rheumatoid factor (RF) radi radiog ogra raph phic ic stud studie iess i. bony erosion ii. ii. decr ecreas eased joint int space aces iii. fusion of joint c. aspirat aspiration ion of synovia synoviall fluid fluid;; analy analysis sis shows shows i. cloudy appearance ii. ii. more more whit whitee bloo blood d cell cellss than than norm normal al 13. 13. Mana Manage geme ment nt a. (see (see prev previou iouss Osteoa Osteoarth rthri ritis tis sect section ion)) b. b. psyc psycho holo logi gica call sup suppo port rt c. splinti splinting: ng: resting resting,, ccorre orrectiv ctive, e, or fixation fixation Syst System emic ic lupu lupuss eryth erythem emato atosu suss (SLE (SLE)) b. b.
2.
6. 7.
Definition: chronic, systemic, inflammatory disease of the collagen tissues (illustration ) Etio Etiolo logy gy unkn unknow own n a. most ost cas cases es are are wom women en b. African Americans, Americans, Hispanics, Hispanics, Asians, Asians, and Native Native Americans Americans are two two to three times as likely as whites to have lupus
c.
8.
antigen stimulates antibodies, which form soluble immune complexes,
deposited in tissues; number of T suppressor cells dwindles. (illustration ) d. immune immune complex complex inflam inflames es tissue tissue;; inflamma inflammation tion create createss findings findings i. the intensit intensity y and and location location of the inflamm inflammatio ation n refle reflects cts finding findingss and and organs involved. ii. clients clients with central central nervous nervous system system or renal renal invo involvem lvement ent have poorer poorer prognosis Findings Findings:: SLE is presen presentt if client client has has four four or more more of thes these: e: a. arthritis: arthritis: characteri characterized zed by by swelling, swelling, tenderness tenderness and effusion; effusion; involving involving two or more peripheral joints b. malar malar rash: rash: charact characteris eristic tic butter butterfly fly rash rash over over cheeks cheeks and nose nose c. disc discoi oid d lupu lupuss ski skin n les lesio ions ns d. phot photos osen ensi siti tivi vity ty e. oral ulcers
f. g. h.
serosi ser ositis tis : pleuritis renal disorder: persistent proteinuria neurologic neurologic disorder: disorder: seizures or psychosis psychosis in the absence of drugs drugs or or pathology pathology
i.
hematologic disorder: hemolytic anemia with reticulocytosis or leukopenia or leukopenia j. immunol immunologic ogic disord disorder: er: positiv positivee LE (lupus (lupus erythema erythematosu tosus) s) cell prepar preparatio ation n or anti-DNA or anti-Sm or false positive serologic test for syphilis k. antinucl antinuclear ear antibo antibody: dy: abnorm abnormal al titer titer of antinuc antinuclear lear antib antibody ody by immunofluorescence or equivalent assay l. posi positi tive ve LE cell cell reac reacti tion on 9. Management a. expe expect cted ed outc outcom omes es i. cont contro roll syst system em invo involv lvem emen entt and and sym sympt ptom omss ii. induce remission b. b. preve prevent nt bad bad effect effectss of of ther therap apy y c. recog recogniz nizee flare flare-u -ups ps promp promptly tly d. medical i. salicylates ii. ii. nons nonster teroid oidal al antianti-inf infla lamm mmato atory ry agent agentss (NS (NSAI AIDS DS)) iii. corticosteroids iv. anti-infectives e. antin tineop eoplas lastics ics 10. 10. Nurs Nursin ing g car caree a. pain pain man manag agem emen entt stra strate tegi gies es b. b. stra strateg tegies ies to com combat bat weigh weightt loss loss c. emot emotio iona nall supp suppor ortt
3.
Gout (illustration ) 6. Definition a. monoa monoarti rticul cular ar asym asymme metri trical cal arth arthrit ritis is
b. 7.
Etiology a. b. b. c. d. e.
8.
Findings a. b. b. c. d. e. f.
g.
characterized by hyperuricemia prim primar aril ily y affe affect ctss men men peak peak inci incide dence nce 40 to to 60 years years of age fami famili lial al tend tenden ency cy abnormal abnormal purine purine metabolism metabolism or excessive excessive purine intake results in formation formation of uric acid crystals which are deposited in the joints and connective tissue. deposits deposits are most often found in the metatarsophalang metatarsophalangeal eal joint joint of the great great toe toe or in the ankle. tight, tight, reddened reddened skin skin o over ver the inflamed inflamed joint joint elev elevat ated ed temp temper erat atur uree edem edemaa of of the the invo involv lved ed area area hyperu eruricem cemia acute acute attacks attacks comm commonly only begin begin at night night and last last three three to to five five days goutt attacks gou attacks may follow follow trauma trauma,, diuretics diuretics,, increase increased d alcohol alcohol consum consumptio ption, n, a high purine diet, stress (both psychological and physical) or suddenly stopping of maintenance medications warning signs of flare-up flare-up include the exacerbatio exacerbation n of previous previous findings findings or the development of a new one
h. systemic manifestations may include fever, renal disease, tophus Diagn Diagnos ostic tics: s: lab tests tests find find a. increas increased ed urinary urinary uric uric acid acid followi following ng a purin purinee restrict restricted ed diet diet b. hyperu eruricem cemia 10. 10. Mana Manage geme ment nt a. expecte expected d outcome outcomes: s: contr control ol sympt symptoms oms;; prevent prevent attacks attacks b. medical i. NSAIDs ii. ii. colchi colchicin cinee (used (used when when NSAI NSAIDs Ds are are contr contrain aindic dicate ated) d) - enha enhanc nces es the the excretion of uric acid iii. iii. to prevent prevent flareup flareups: s: antihype antihyperuri ruricemi cemicc aagent gentss such such as allopur allopurinol inol (lopurin) or probenecid (benemid) - minimize the production of uric acid iv. heat or cold therapy
9.
c.
dietary i.
avoid avoid p purin urinee foods foods such as meats, meats, organ organ meats meats,, shel shellfis lfish, h, sardine sardines, s, anchovies, yeast, legumes control weight drin drink k les lesss alc alcoh ohol ol - all all type typess
ii. iii iii. car caree pain pain man manag agem emen entt stra strate tegi gies es elevate elevate the the affected affected limb; limb; provi provide de bed rest rest and immo immobili bilize ze joint joint avoid avoid pressu pressure re or touch touching ing of bed clothi clothing ng on affec affected ted joint joint reinfor reinforce ce dietar dietary y manage managemen mentt and and weight weight control control adminis administer ter anti-gou anti-goutt medicati medications ons as ordered ordered increas increasee fluid fluid intake intake to preven preventt renal renal calcul calculii (kidney (kidney stone stones) s)
3.
11. 11. Nurs Nursin ing g a. b. c. d. e. f. Meta Metabo boli licc Bone Bone Dis Disor orde ders rs 1. Osteomalacia 6. Definiti Definition on - delayed delayed mineral mineralizat ization; ion; resul resulting ting bone bone is softer softer and weaker weaker
7.
Pathophysiology - similar to rickets a. bon bones es have too little little calcium calcium and phospho phosphorus rus b. vitamin vitamin D deficie deficiency; ncy; poss possibly ibly inadeq inadequate uate exposu exposure re to sunligh sunlightt i. less less seru serum m cal calci cium um than than norm normal al ii. ii. more par paraathy thyroid hormo rmone iii. iii. more more rena renall phos phosph phor orus us clea cleara ranc ncee 8. Findings a. accur accurate ate client client histo history ry inclu includes des:: i. gene genera rali lize zed d mus muscl clee and and ske skele leta tall pain pain in in hips hips ii. ii. similar lar pain ain in low low back b. b. phys physic ical al exam examin inat atio ion n i. gait 1. clie client nt unwi unwill llin ing g to to wal walk k 2. wide st stance 3. waddling ga gait ii. muscle weakness iii. bones 1. defor deformi mitie tiess of weigh weightt-bea bearin ring g bones bones 2. scolioti scolioticc or kyphotic kyphotic deform deformitie itiess of the spine spine 3. bone boness bre break ak easi easily ly 9. Diag Diagno nosstic tic tes testing ting a. radi radiog ogra raph phic ic find findin ings gs i. gene genera rali lize zed dd dem emin iner eral aliz izat atio ion n ii. pseudo fractures iii. bending d ef eformities b. b. labo labora rato tory ry stu studi dies es i. decr ecreas eased seru erum calc alcium ium ii. ii. decr decrea ease sed d serum erum phos phosph phor orus us iii. iii. alkali alkaline ne pho phosp spha hatas tasee level level is mode modera ratel tely y eleva elevated ted 10. 10. Mana Manage geme ment nt a. calc calciu ium m gluc glucon onat atee b. vitamin vitamin D daily daily until until signs signs of of healin healing g take take place place c. diet diet high high in prot protei ein n d. ultra ultravio violet let radia radiatio tion n therap therapy y
2.
Osteoporosis (illustration ) 6. Definition a. multi multifa facto ctoria riall dise diseas asee resu results lts in i. reduced bone mass ii. loss of of bo bone st strength iii. iii. incr increa ease sed d like likeli liho hood od of frac fractu ture re b. types
i. ii.
7.
type one osteoporosis
(estrogen related)
type two osteoporosis (related to old age) Etio Etiolo logy gy/e /epi pide demi miol olog ogy y a. most most com commo mon n metab metaboli olicc disea disease se of of bone bone i. affe affect ctss an an esti estima mate ted d 25 25 mil milli lion on Amer Americ ican anss ii. ii. cont contri ribu buto torr of of 50% 50% of of all all adul adultt fra fract ctur ures es
b. b. c. d. e.
8.
onse onsett is is ins insid idio ious us women women affect affected ed twice twice as as often often as men befor beforee the age of of 70 skeleta skeletall change changess resul resultt from from the the aging aging process process bone loss due to i. immobilization ii. ii. lack lack of grav gravit itat atio iona nall stre stress ss
Factors related to osteoporotic fractures ADDITIONAL RISK FACTORS FOR OSTEOPOROSIS
A.
B.
C. a. b. b. c. i. i i.
b. c.
Gene Geneti ticc risk risk fact factor orss 1. Fema Female le,, whit whitee or or Asia Asian n 2. Small Small fram frame, e, thinthin-bone boned; d; shor short; t; low low body fat 3. Women with post-men post-menopausal opausal osteoporosis osteoporosis may have have inherited inherited a lower peak peak bone bone mass mass 4. Daughters Daughters of women women with osteoporosis osteoporosis averaged averaged less less bone mass in lumbar spine spine and femoral femoral neck 5. Fami Family ly histor history yo off hip hip fract fractur uree Repr Reprod oduc ucti tive ve fac facto tors rs 1. Hypo-estrogenis Hypo-estrogenism m associated associated with increased increased bone bone remodeling, remodeling, faster bone loss 2. Early Early or or surg surgica ically lly ind induc uced ed meno menopau pause se 3. Amenor Amenorrhea rhea in athletes athletes/ano /anorexi rexiaa nervosa nervosa a. hypogonadism b. b. weak weaken enss the the bone boness c. decr decrea ease sess bon bonee mas masss 4. Dysmenorrhea hea 5. Nulli Nullipar parity ity (no (no pregn pregnan ancie cies) s) Endocr Endocrine ine factors factors in osteopo osteoporos rosis is premature me menopause hype hypert rthy hyro roid idis ism m incr increa ease sess bone bone turn turnov over er and and remo remode deli ling ng hyperparathyroidism increases bone tu turnover and re remodeling increased parathyroid hormone (PTH) stimulates osteoclast activity • • depresses osteoblast activity result is an increase in serum concentration of calcium • hyperadrenocorticalism type I diabetes mellitus a.
b. c.
low bo bone dens ensity history of scoliosis of scoliosis neuro neurolo logic gical al impa impairm irment ent after after
i. ii.
CVA
Parkinson's disease decrea decrease sed d vision vision fro from m macula macularr degene degenera ratio tion, n, comp complic licati ations ons of of diabetes, etc. best best indicat indicator or of fractur fracturee risk risk in bone bone densi densitome tometry try iii. iii.
9.
d. Findings a. clie lient histo istorry i. acute fr fracture ii. ii. prior prior histo history ry of a tra traum umati aticc fra fractu cture; re; no traum traumaa iii. history of falls b. pain i. grea greate terr whe when n act activ ive, e, less less whil whilee res resti ting ng ii. ii. early early in in dise diseas ase, e, pain pain in in mid mid to low low thora thoracic cic spin spinee c. anxiety i. abou aboutt fur furth ther er fall falls/ s/fr frac actu ture ress ii. ii. abou aboutt abi abili lity ty to perf perfor orm m ADLs ADLs
d.
kyphosis - 'Dowager's hump' may reflect multiple spinal fractures
e.
loss of height i. two or more inches ii. ii. usual usually ly pre prece cedes des diagn diagnos osis is of of osteo osteopo poro rosis sis diagn diagnos osis is 10. 10. Diag Diagno nost stic icss a. blood tests i. complete bl blood counts ii. serum levels 1. calcium 2. phosphate 3. alka alkali line ne phos phosph phat atas asee b. x-rays i. help help ide identi ntify fy fract fractur ures es and and kyp kypho hosis sis of spin spinee ii. ii. less less usefu usefull in the the detec detectio tion n of prepre-fr fract actur uree osteo osteopor poros osis is iii. iii. detect detect ost osteop eopor oros osis is only only after after 20% 20% bone bone miner mineral al cont content ent is is lost lost c. bone bone dens densit itom omet etry ry i. best best mean meanss of of mea measu suri ring ng risk risk for for fra fract ctur uree ii. ii. quant quantita itativ tivee compu computer terize ized d axial axial tomo tomogr gram am (CAT (CAT)) measu measure ress pure pure vertebral trabecular bone iii. iii. dual dual energ energy y x-ray x-ray absorp absorptio tiono nome metry try (DEX (DEXA) A) 1. tech techni niqu quee of of cho choic icee 2. assess assesses es cortic cortical al and and trabecu trabecular lar bone bone in in spine spine and and hip 3. single single photon photon absor absorptio ptionom nometry etry measu measures res corti cortical cal bone bone in long bones 11. 11. Mana Manage geme ment nt a. exercise i. restora restorative tive - aims aims to incr increase ease bon bonee densit density, y, decre decrease ase risk risk for for fractu fracture re ii. ii. with within in the the ccli lien ent' t'ss tol toler eran ance ce iii. iii. must must be main mainta tain ined ed thro throug ugho hout ut life life b. nutrition i. calcium and vitamin D ii. ii. defi defici cien enci cies es incr increa ease se risk risk of frac fractu ture re iii. iii. seden sedentar tary y older older adult adultss may may need need supp supplem lemen ents ts c. medication i. anti nti-re -resorptiv tive agen gents 1. do not increas increasee bone bone mass - rather rather preven preventt further further bone bone loss loss 2. estr estrog ogen en ther therap apy y 3. calc calcit iton onin in (Ost (Osteo eoca calc lcin in)) 1. peptid tide ho hormone 2. powerf powerful ul inhibit inhibitor or of osteocl osteoclasti asticc bone bone resorp resorption tion 3. modestl modestly y increa increases ses bone mass mass in osteopo osteoporos rosis is 4. not shown shown to decre decrease ase osteopor osteoporotic otic fractur fractures es 5. expensive ii. biophosphonates 1. inhi inhibi bitt bon bonee res resor orpt ptio ion n 2. sustain sustained ed use asso associat ciated ed with with osteom osteomalac alacia ia and Paget Paget's 's disease 3. alen alendr dron onat atee (Fo (Fosa sama max) x) 1. 100 to 500 500 time timess more more potent potent than etidrona etidronate te 2. nonnon-ho horm rmon onal al age agent nt 3. high highly ly sele select ctiv ivee inhib inhibit itor or 4. not associa associated ted with detrimen detrimental tal effects effects of mineralization 5. expen expensi sive: ve: aver averag agee $41.70 $41.70 per per day day for for osteoporosis iii. ii. bone-f e-forming agent ents 1. sodiu sodium m fluo fluorid ridee (Flu (Fluori oritab tab)) 2. androgens 1. taken taken long long-ter -term, m, increas increases es bone mass mass in in osteoporotic women 2. but androgen androgenss viril virilize ize and elevate elevate choleste cholesterol rol levels 12. Nursing interventi intervention: on: teach prevention prevention of of ssteoporosis ssteoporosis and and its damage damage a. education
b. b.
3.
i. teach proper lifting and movement techniques (illustration ii. ii. enco encour urag agee prop proper er foot footw wear ear iii. iii. inst instal alll safe safety ty equi equipm pmen entt in home home Paget Paget's 's dise diseas asee (ostei (osteitis tis def deform orman ans) s) 6. Definition: Definition: a slowly progressing progressing resorption resorption and and irregular irregular remodeling remodeling of bone. 7. Etiology a. bon bonee resorbed resorbed;; new bone bone poorly poorly develo developed, ped, weak weak,, easily easily fracture fractured d b.
8.
9.
VI.
i. increase aw awareness ii. ii. disc discou oura rage ge risk risk-r -rel elat ated ed beha behavi vior orss iii. iii. reinf reinfor orce ce positi positive ve behav behavior iorss and and lifest lifestyle yless redu reduce ce risk risk of fall fallin ing g
c. d. e. Findings a. b. b.
)
mainly affects major bones: skull, femur, tibia, pelvis, and vertebrae cause un unknown poss possib ible le viral viral impl implica icatio tions ns fami family ly tend tenden ency cy - noted noted in sib siblin lings gs
asym asympt ptom omat atic ic init initia iall lly y muscu usculo losk skel elet etal al i. defo eformity ity of long ong bones ii. ii. pain pain and and poin pointt tend tender erne ness ss of of affe affect cted ed lim limbs bs Diagnostics a. radi radiog ogra raph phic ic find findin ings gs i. bowing o off lo long b bo ones ii. ii. thic hicken kened areas of bone iii. ii. path atholog logica ical frac fractu turres iv. sclerotic ch changes b. b. labo labora rato tory ry anal analys ysis is i. increa increase sed d alkal alkaline ine pho phosp sphat hatas asee means means oste osteobl oblas asts ts more more activ activee ii. increase increased d urinary urinary hydroxy hydroxyprol proline ine means means osteobl osteoblast astss more more active active iii. iii. seru serum m cal calci cium um leve levell will will be norm normal al
Orthopedic Surgery
A.
Total hip replacement (illustration ) 1. Indi ndicati catio ons for surg urgery i. osteoarthritis ii. rheumatoid a rt rthritis iii. femoral ne neck fra fracctur tures iv. iv. avasc avascula ularr necr necros osis is of of fem femor oral al head head cause caused d by ster steroid oidss v. fail failur uree of of pre previ viou ouss pro prost sthe hesi siss
2.
Surgical modalities
a. total total hip hip rep replac lacem emen entt (hip (hip arthr arthrop oplas lasty) ty) is the the repl replace aceme ment nt of of both both arti articul cular ar sur surfac faces es of the the hip join joint, t, the the acetabular socket and the femoral head and neck. b. hemi hemiart arthro hropl plast asty y of the the hip is is the repl replace aceme ment nt of one one of the the arti articul cular ar sur surfac faces es,, usuall usually y the fem femor oral al head head and and neck. 2. Surg Surgic ical al and and imm immed edia iate te pos posto tope pera rati tive ve car caree a. in firs firstt 24 24 hou hours rs,, exp expec ectt wou wound nd to drai drain n blo blood od and and flu fluid id up to 500m 500ml. l. b. by 4 48 8 ho hours, wo wound dr draina inage should be min minim imal al
c.
clients may require transfusions (autologous (autologous is preferred) due to blood loss during surgery. d. best best pain pain manag managem emen entt is patie patient nt cont contro rolle lled d analge analgesi siaa (PCA) (PCA) for for the the first first 48 hour hours, s, adv advanc ancing ing to to non-n non-nar arcot cotic ic oral analgesics by the fourth or fifth postoperative day. e. moni monitor tor for for sign signss of deep deep veno venous us thr throm ombo bosi siss (DVT (DVT)) and and pulm pulmon onary ary embo embolis lism m (PE) (PE) or or fat fat embo embolis lism m f. moni monitor tor neuro neurova vascu scula larr stat status us of aff affect ected ed limb; limb; color color,, tem tempe perat ratur ure, e, pres presenc encee of of puls pulses es..
3. A.
B.
Postoperative complications
ORTHOPEDIC COMPLICATIONS
Venous Venous thrombo thromboemb embolic olic problem problemss 1. Thro Thromb mbop ophl hleb ebit itis is (TP) (TP) a. inflamm inflammatio ation n of a vein vein with with the the format formation ion of of a blood blood clot clot b. incidenc incidencee is greate greatest st after after traum traumaa or surge surgery ry to legs legs or feet feet Deep Deep ven venous ous throm thrombos bosis is (DV (DVT) T)
1. 2. 3. 4.
C.
Anter Anterior ior tibial tibial or fem femor oral al vein veinss May May be caus caused ed by by immo immobi bili lity ty Finding Findingss include include calf pain, pain, posi positive tive Homan's Homan's sign sign Imme Immedi diate ately ly after after opera operatio tions ns a. anti antico coag agul ulan antt ther therap apy y b. b. antiem antiembo boli li sto stocki cking ngss (us (usua ually lly)) c. sequenti sequential al compre compressi ssion on device device (possib (possibly) ly) Pulm Pulmon onary ary embo embolis lism m (PE) (PE) 1. Blood Blood clot from from systemi systemicc circulati circulation on enters enters pulmona pulmonary ry circulat circulation ion 2. Most Most commonly commonly seen seen after after hip fractur fractures es and total total hip/kn hip/knee ee replacem replacements ents 3. Occurs in approxim approximately ately ten percent percent of patients patients undergoing undergoing hip arthroplas arthroplasty ty 4. May be caused caused by femoral vein manipulatio manipulation n during surgery surgery and therefore therefore occur occur without without signs signs of DVT
5.
D.
E.
F.
G.
H.
Findings include chest pain (pleuritic), sudden shortness of breath, tachycardia, palpitations, or change in mental status 6. If PE is is suspected,do suspected,do not leave client. Get Get charge charge nurse to to notify health care care provider provider immediately immediately 7. Diagnosis Diagnosis confirmed confirmed via ventilation/perfu ventilation/perfusion sion scan or pulmonar pulmonary y angiograph angiography y 8. Continuo Continuous us IV IV hepar heparin in thera therapy py usual usually ly pres prescrib cribed ed Fat em embolism ism 1. Definit Definition: ion: fat cells cells enter enter pulm pulmonar onary y circul circulatio ation n 2. Associat iated with a. mult multip iple le trau trauma ma acci accide dent ntss b. b. multi multiple ple organ organ invol involvem vement ent c. fractu fractures res of marr marrow ow prod produc ucing ing bones bones d. join jointt repl replac acem emen ents ts e. inser insertio tion n of inter intermed medul ullar lary y rod rodss 3. Usually Usually occurs occurs 24 24 to 48 hours hours after after the the fractu fracture re Hemorrhage 1. Abno Abnorm rmal al los losss of blo blood od fro from m the the body body 2. Most Most common common in fract fracture uress of bone bone marrow marrow produ producing cing bones bones Wound ound infe infect ctio ion n 1. May May be super superfic ficial ial or deep deep wound wound 2. Deep wound wound infec infection tion may lead to osteo osteomye myeliti litiss 3. Findings Findings include include erythema erythema and and swelling swelling around around suture suture line, line, increased increased drainage and elevated elevated temperature 4. Treated with with antibiotics; antibiotics; may may require require incision incision and drainage drainage of wound or removal removal of prosthesi prosthesiss if severe infection is present Special Special complic complicatio ations ns in hip repla replacem cement ent 1. Femo Femora rall frac fractu turre a. occurs occurs near near distal distal end end of femor femoral-s al-shaft haft part part of prosthe prosthesis sis b. occurs more frequentl frequently y with elderly, elderly, clients clients with osteoporosis, osteoporosis, or after revision to total total hip replacement c. primary primary finding finding is sever severee pain pain with ambulat ambulation ion d. diagno diagnosi siss is confir confirme med d with with x-r x-ray ay e. depending depending on severity, severity, treatment treatment will be be immobilizati immobilization on or open reduction reduction with internal fixation 2. Dislo Dislocat cation ion of hip pros prosthe thesis sis a. greatest risk during the first first postoperati postoperative ve week but can occur at at any time time within within the first year. b. risk decreas decreases es as muscle muscle tone tone of the the hip increase increasess c. caused caused by flexion flexion of the the hip hip or poo poorr prosth prosthetic etic fit d. findings findings include include pain pain and and extern external al rotati rotation on of the leg leg e. treated by closed closed reduction reduction under under conscious conscious sedation or open open surgical surgical revision revision Special Special complic complicatio ation n in knee replaceme replacement: nt: flexion flexion failure failure 1. Client Client cannot cannot flex flex knee knee 90 degre degrees es two two weeks weeks posto postopera perative tively ly 2. Treated Treated with with closed closed manipu manipulati lation on of the knee knee joint joint under gener general al anesthes anesthesia ia 4.
a. b. b. c. d.
Nursing i nt nterventions
an abduction device is used during the first postoperative week while the client is in bed or sitting in a chair to keep keep abdu abduct ctio ion n dev devic icee in in plac place, e, turn turn clie client nt by logr logrol olli ling ng to prev preven entt flex flexio ion n of the the hip, hip, use use frac fractu ture re bedp bedpan an client teaching I. use use of assi assist stive ive devi devices ces;; crutch crutches es,, walker walker,, raise raised d toilet toilet seat seat
II. II. III. III.
meth method odss to to pre preve vent nt disl disloc ocat atio ion n can resume resume sexual sexual activity activity when suture suture line heals. heals. To avoid avoid flexio flexion n of hip, client should be in dependent position for three to six months
B.
Total kn knee re replacement 1. Indi ndicati catio ons for surg urgery osteoarthritis rheumatoid arthritis trauma 2. Surgical modalities metal etal or or acr acryl ylic ic pros prosth thes esis is,, hin hinge ged d or or sem semic icon onsstrai traine ned d choic choicee of pros prosthe thesi siss depen depends ds on on the the streng strength th of of surr surrou ound nding ing ligame ligaments nts to prov provid idee join jointt stabil stability ity
a. b. c. a. b.
3. A.
B.
C.
E.
F.
G.
ORTHOPEDIC COMPLICATIONS
Venous Venous thrombo thromboemb embolic olic problem problemss 1. Thro Thromb mbop ophl hleb ebit itis is (TP) (TP) a. inflamm inflammatio ation n of a vein vein with with the the format formation ion of of a blood blood clot clot b. incidenc incidencee is greate greatest st after after traum traumaa or surge surgery ry to legs legs or feet feet Deep Deep ven venous ous throm thrombos bosis is (DV (DVT) T) 1. Anter Anterior ior tibial tibial or fem femor oral al vein veinss 2. May May be caus caused ed by by immo immobi bili lity ty 3. Finding Findingss include include calf pain, pain, posi positive tive Homan's Homan's sign sign 4. Imme Immedi diate ately ly after after opera operatio tions ns a. anti antico coag agul ulan antt ther therap apy y b. b. antiem antiembo boli li sto stocki cking ngss (us (usua ually lly)) c. sequenti sequential al compre compressi ssion on device device (possib (possibly) ly) Pulm Pulmon onary ary embo embolis lism m (PE) (PE) 1. Blood Blood clot from from systemi systemicc circulati circulation on enters enters pulmona pulmonary ry circulat circulation ion 2. Most Most commonly commonly seen seen after after hip fractur fractures es and total total hip/kn hip/knee ee replacem replacements ents 3. Occurs in approxim approximately ately ten percent percent of patients patients undergoing undergoing hip arthroplas arthroplasty ty 4. May be caused caused by femoral vein manipulatio manipulation n during surgery surgery and therefore therefore occur occur without without signs signs of DVT
5.
D.
Postoperative complications
Findings include chest pain (pleuritic), sudden shortness of breath, tachycardia, palpitations, or change in mental status 6. If PE is is suspected,do suspected,do not leave client. Get Get charge charge nurse to to notify health care care provider provider immediately immediately 7. Diagnosis Diagnosis confirmed confirmed via ventilation/perfu ventilation/perfusion sion scan or pulmonar pulmonary y angiograph angiography y 8. Continuo Continuous us IV IV hepar heparin in thera therapy py usual usually ly pres prescrib cribed ed Fat em embolism ism 1. Definit Definition: ion: fat cells cells enter enter pulm pulmonar onary y circul circulatio ation n 2. Associat iated with a. mult multip iple le trau trauma ma acci accide dent ntss b. b. multi multiple ple organ organ invol involvem vement ent c. fractu fractures res of marr marrow ow prod produc ucing ing bones bones d. join jointt repl replac acem emen ents ts e. inser insertio tion n of inter intermed medul ullar lary y rod rodss 3. Usually Usually occurs occurs 24 24 to 48 hours hours after after the the fractu fracture re Hemorrhage 1. Abno Abnorm rmal al los losss of blo blood od fro from m the the body body 2. Most Most common common in fract fracture uress of bone bone marrow marrow produ producing cing bones bones Wound ound infe infect ctio ion n 1. May May be super superfic ficial ial or deep deep wound wound 2. Deep wound wound infec infection tion may lead to osteo osteomye myeliti litiss 3. Findings Findings include include erythema erythema and and swelling swelling around around suture suture line, line, increased increased drainage and elevated elevated temperature 4. Treated with with antibiotics; antibiotics; may may require require incision incision and drainage drainage of wound or removal removal of prosthesi prosthesiss if severe infection is present Special Special complic complicatio ations ns in hip repla replacem cement ent 1. Femo Femora rall frac fractu turre a. occurs occurs near near distal distal end end of femor femoral-s al-shaft haft part part of prosthe prosthesis sis b. occurs more frequentl frequently y with elderly, elderly, clients clients with osteoporosis, osteoporosis, or after revision to total total hip replacement c. primary primary finding finding is sever severee pain pain with ambulat ambulation ion d. diagno diagnosi siss is confir confirme med d with with x-r x-ray ay
e.
H.
depending depending on severity, severity, treatment treatment will be be immobilizati immobilization on or open reduction reduction with internal fixation 2. Dislo Dislocat cation ion of hip pros prosthe thesis sis a. greatest risk during the first first postoperati postoperative ve week but can occur at at any time time within within the first year. b. risk decreas decreases es as muscle muscle tone tone of the the hip increase increasess c. caused caused by flexion flexion of the the hip hip or poo poorr prosth prosthetic etic fit d. findings findings include include pain pain and and extern external al rotati rotation on of the leg leg e. treated by closed closed reduction reduction under under conscious conscious sedation or open open surgical surgical revision revision Special Special complic complicatio ation n in knee replaceme replacement: nt: flexion flexion failure failure 1. Client Client cannot cannot flex flex knee knee 90 degre degrees es two two weeks weeks posto postopera perative tively ly 2. Treated Treated with with closed closed manipu manipulati lation on of the knee knee joint joint under gener general al anesthes anesthesia ia a. Nursing Nursing interve interventio ntions ns (knee (knee replacem replacement) ent) A. for first first 24 to 48 48 hrs, apply apply ice to to the knee knee to minimize minimize bleeding bleeding and edema B. in first first eight eight hours hours,, expect expect wound wound drain drainage age up to 200 ml. ml. C. by 48 48 hours hours,, expect expect minima minimall wound wound drainage drainage D. transfu transfusio sions ns are rarely rarely required required E. within 24 hours, hours, start start aggressiv aggressivee physical physical therapy therapy to promote knee flexion flexion F. frequently frequently health health care care provider provider prescribes prescribes a continuous continuous passive passive motion machine (CPM) G. health care care provider provider prescribes prescribes the the amount of flexion flexion and extension extension,, measured measured in degrees, and increases that amount as client tolerates more H. when when the CPM machi machine ne is not not in use, a knee knee immobi immobilize lizerr is used used I. keep keep leg leg ele elevat vated ed when when the the clien clientt is out out of of bed bed J. on first first postpost-op op day, day, client client will will begin begin to use use crutche crutchess or walker walker K. best pain management management is patient patient controlled controlled analgesic analgesic (PCA) for the first first 48 to 72 hours postoperatively. By fifth post-op day, nonnarcotic oral analgesia. L. monitor limb's neurovascular neurovascular status, color, temperature, temperature, and pulses pulses M. monitor monitor for signs signs of DVT or PE PE 3. Amputation a. Purpose: Purpose: relieve relieve findings; findings; improve improve function; function; save or or improve improve quality of life life b. b. Lowe Lowerr extrem extremit ity y indic indicati ation onss A. progressive progressive periphera peripherall vascular vascular disease disease (often (often secondary secondary to diabetes diabetes mellitus) mellitus) B. gangrene C. trauma trauma such such as crushi crushing ng injurie injuries, s, burns burns,, or frostb frostbite ite D. conge congenit nital al defo deform rmiti ities es E. malig aligna nant nt tum tumor c. Uppe Upperr extre extremi mity ty ind indic icat atio ions ns A. trauma B. malig aligna nant nt tum tumor C. infection D. conge congenit nital al malf malfor orma matio tions ns
d. 1. 2. 3. 4. 5. 6. 7. 8. 9.
Levels of amputation Objective of surgery is to eradicate the disease process while conserving as much of the extremity as possible
Toes and and portion portion of the foot foot - usually usually as a result of trauma trauma or infection. infection. Causes minor minor changes changes in gait or balance Syme: disarticulation disarticulation of ankle; ankle; stump stump can bear bear full full weight, weight, with prosthes prosthesis is Below Below knee (BK) (BK) - preserve preservess knee joint joint which which facilita facilitates tes use of of prosthesi prosthesiss Knee Knee disart disarticu iculati lation on - at level level of knee knee joint joint Above knee knee (AK) (AK) - measures measures undertaken undertaken to to provide provide as much length to to limb as possible possible Hip disarticulati disarticulation on - most most often performed performed due to malignancy. malignancy. Client Client cannot walk with prosthesis. prosthesis. Below Below elbow (BE) (BE) - preser preserves ves elbow elbow joint, joint, thus thus eases eases use of prosth prosthesis esis Above elbow elbow (AE) (AE) - measures measures undertaken undertaken to provide provide as much length length to limb as possible possible Staged amputation amputation - used for for infection. infection. Guillotine Guillotine amputation amputation to remove remove infectious infectious and necrotic necrotic tissue tissue is performed. After intensive antibiotic therapy, a second operation is performed for skin closure.
e.
A. amputat amputatee to most most distal distal point point that that will heal heal succes successfu sfully lly B. determi determined ned by by circula circulation tion and funct functiona ionall status status Poten Potentia tiall postop postopera erativ tivee complic complicati ation onss A. hemorrhage age B. infection C. skin kin brea breakd kdow own n
f.
g.
h.
i.
j. j.
Nurs Nursin ing g inte interv rven enti tion onss A. pain management management - usually usually relieved with narcotic narcotic analgesics analgesics B. may requir requiree evacuati evacuation on of accum accumulat ulated ed fluid fluid or hematom hematomaa C. muscle muscle spasm spasmss may be relie relieved ved by heat heat or changi changing ng positio position n D. phan phanto tom m limb limb pain pain A. may occur occur any any time time up to to three three months months post post amputa amputation tion B. most most common common with above-kn above-knee ee (AK) (AK) amputa amputation tionss C. reliev lieveed wit with h A. stump stump desensit desensitizat ization ion by kneadin kneading, g, or massa massage ge B. transcut transcutaneo aneous us electric electrical al nerve nerve stimulat stimulation ion (TENS (TENS)) C. dist istract action ion D. beta-ad beta-adrene renergi rgicc blocking blocking agents agents for for burning, burning, dull dull pain E. anticon anticonvuls vulsants ants for sharp sharp and and crampi cramping ng pain pain Wound he healing A. aseptic aseptic dressi dressing ng change change techniq technique ue B. compression compression dressing dressing wrapped wrapped in a figure eight fashion fashion or cast cast to control control edema edema Alte Altere red d bod body y imag imagee A. may may take take month monthss to to res resolv olvee B. must must convey convey accept acceptance ance and respe respect ct for indiv individua iduall C. foster independence: independence: encourage encourage client to look at, feel, feel, and eventually eventually care for limb Grief A. many clients clients go through through a mourning mourning process, process, shock, shock, anger, and depression depression B. caregive caregivers rs shoul should d support support and listen listen actively actively Rest Restor orin ing g phys physic ical al mob mobil ilit ity y A. earl early y rehab rehabil ilit itat atio ion n B. muscl musclee stren strength gtheni ening ng exerc exercise isess
C. prosthetic preparation Type Typess of of pro prost sthe hesi siss A. hydraulic B. pneumatic C. biof biofeed eedba back ck - contr controll olled ed D. myoel myoelect ectri rical cally ly contr control olled led E. sync ynchroni onized zed Arthroscopy a. Definition Definition - endoscopi endoscopicc procedure procedure that that allows allows direct direct visualization visualization of the joint, most often often performed on knees and shoulders b. Indications A. torn torn medi medial al and and later lateral al menis meniscus cus B. chond chondro roma malac lacia ia patell patellae ae C. synovitis D. torn torn crucia cruciate te ligam ligamen entt E. subl sublux uxat atio ion n pate patell llaa F. intra intra-ar -artic ticula ularr soft soft tiss tissue ue mas masss G. pyarth rthrosis c. Surgica Surgicall proced procedure ure - most most often, often, offi office ce surge surgery ry d. Post Postop oper erat ativ ivee car caree A. compression compression dressing dressing wrapped in a figure figure eight eight fashion fashion to control edema B. ice ice may may be appl applie ied d C. oral oral analg analgesi esics cs for pain managem management ent D. weight weight bearing bearing depends depends on procedu procedure re e. Posto Postope perat rative ive com compl plic icati ation onss are are rare rare A. infection B. thro thromb mbop ophl hleb ebit itis is C. stiffness Exte Extern rnal al fixa fixato tor r k.
4.
5.
Definition External Fixator: Ilizarov Device A.
The Ilizarov Ilizarov device is is a specialized specialized type of external external fixator fixator used for non-union non-union fractures fractures and limb limb lengthening lengthening needed due to congenital deformities.
B.
C. D.
E.
Tension Tension wires are inserted into into the bone and and then attached attached to rings outside the the body. These These rings are are joined joined by telescoping rods attached to a rigid frame. Daily adjustment of the rods causes the wires to turn, which stimulates bone formation. Ilizarov Ilizarov devi device ce lengthen lengthenss limbs limbs about about one cm cm per month. month. Befor Beforee disch discharg arge, e, teach teach cli client entss 1. To ca care fo for pi pin 2. To adjust rod Clients Clients may may have have the the device device on on for several several months months.. a. b.
I. J. K. L. M. N. O. P. Q.
R. S. T. U. V. W. X. Y. Z.
Indication: Indication: the device will stabilize stabilize fracture fracture with soft soft tissue tissue injury injury like like crush crush fractures fractures Procedure: Procedure: fracture fracture aligned aligned and and immobilized immobilized by pins pins of Kirschner Kirschner wires inserted inserted in the the bone and attached to a rigid frame outside the body c. Nurs Nursin ing g inte interv rven enti tion onss A. monitor monitor neuro neurovas vascul cular ar status status ever every y two hours hours B. elevat elevatee extre extremi mity ty to red reduce uce edem edemaa C. assess pin insertion insertion sites for infection: infection: erythema, erythema, drainage drainage and and increased increased warmth D. isometr isometric ic and and active active exerc exercise isess as pres prescrib cribed ed E. non non-wei -weight ght bearin bearing g ambulati ambulation on depends depends on soft soft tissue tissue injury injury F. disc discha harg rgee teac teachi hing ng A. ambulat ambulation ion with with assistiv assistivee device device (crutche (crutches, s, walker walker)) B. care care of pin pin sit sitee C. extremity extremity is repositioned repositioned by lifting lifting frame instead of extremity extremity After hip hip replacements replacements,, pulmonary pulmonary embolism embolism may occur even even without without thrombos thrombosis is in foot or leg. Clients should sit in a straight, straight, high high chair; chair; use a raised raised toilet toilet seat; and never never cross cross their their legs. legs. In hip or knee knee replacement, replacement, clients clients will need need assistive assistive devices for walking walking until muscle muscle tone strengthens strengthens and they can walk without pain. After an amputation, amputation, the home must must be assessed assessed for for any modificati modifications ons needed needed to ensure ensure safety. safety. Some clients clients will need need transportatio transportation n to continue continue rehabilitation. rehabilitation. Amputee Amputee suppo support rt groups groups can can help client clientss and famil family. y. After arthroscopy arthroscopy,, outpatient outpatient rehab may may be prescribed prescribed depending depending on procedure; procedure; health health care provider provider may may prescribe knee immobilizer. External External Fixator - If If possible, possible, prepare prepare the client preoperat preoperatively ively to reduce reduce anxiety. anxiety. Device looks looks clumsy, clumsy, but patient should be reassured that discomfort is minimal. After a hip pinning pinning or femoralfemoral-head head prosthesis, prosthesis, caution client client not to force force hip into more more than 90 degree degree of flexion, into adduction or internal rotation which will cause dislocation and severe pain and this would be a nursing emergency. Caution clients clients with a new new prosthesis prosthesis not to to use any substances substances such as lotions, lotions, powders powders etc. unless unless prescribed by the health care provider. Osteoporosis Osteoporosis cannot cannot be detected by by conventional conventional X-ray X-ray until until more that that 30% of of bone calcium calcium is lost. Foods high high in calcium include milk, milk, cheeses, cheeses, yogurt, yogurt, turnip turnip greens, greens, cottage cheese, cheese, sardines, sardines, and spinach. spinach. When performing performing a musculoskeletal musculoskeletal assessm assessment ent on a client with Paget's Paget's disease, disease, note the size size and shape shape of the skull. The skulls of these clients will be soft, thick and enlarged. Clients at high risk risk for acute osteomyelit osteomyelitis is are: elderly, elderly, diabetics, diabetics, and clients with with peripheral peripheral vascular disease. disease. When clients clients receive corticostero corticosteroids ids long-term, long-term, evaluate evaluate them continually continually for side effects. effects. Immunosuppre Immunosuppressed ssed clients clients should should avoid avoid contact with persons persons who who have infections infections.. Steroids Steroids may mask mask the signs of of infections, infections, so client client should promptly promptly report slightest slightest change change in temperature temperature or or other complaints. Photosensitive Photosensitive clients clients should should avoid the the sun, limit limit outdoor activities during peak peak sun hours hours and wear sun sun block.
Abduction device Adduction Ankylosing spondylitis Apophyseal ApophysealArticular Articular Arthroplasty Arthroplasty Bursitis Calcaneal Carpal tunnel syndrome Charcot's joint Chondroma Circumduction Colles' Fracture Condylar Crepitation Crepitation Cruciate ligament Diaphyseal DiaphysealDiarthroidial Diarthroidial joint Disarticulation Discoid Lupus Erythematosus Epiphyseal EpiphysealEversion Eversion Ewing's Tumor Extracapsular Tumor Extracapsular Ganglion Ganglion Haversian system Hyperextension Intra-articular soft tissue mass Intracapsular Inversion Isometric exercises Kirschner wire Laminectomy Lordosis Lyme Disease MetaphysealOsteoblastoma Metaphyseal Osteoblastoma Osteochondroma Osteosarcoma Pronation Pyarthrosis Scleroderma Swan-neck deformity Systemic Lupus Erythematosus • • •
Acetabulum Antibody - schematic structure of IgG antibody Bone tissue Bones Bones of foot and ankle
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Calcitonin Connective tissues Endochondral ossification Gout L.E. cell Lymphatic system Muscle tissue types Osteoporosis Passive range of motion excercises Proper standing and lifting techniques Supporting structures of knee Synovial joint Types of fractures
