Orthopedic

Common Lab tests 1. 2. 3. 4. 5. 6. 7. ESR C-reactive protein CBC Serum cultures Serum Calcium ANA Creatinine

X-rays (roentgenograms) 1. Noninvasive test in which radiation is passed through a specific body part to display a picture of the internal aspects of that part 2. Used to 1. determine shape, size and position of organs 2. indicate presence of fluid lines, foreign bodies, infiltrates 3. determine configuration, density and vascular markings of organs 4. determine injury, fracture, degeneration, inflammation, perforations, calculi (stones) or masses 5. types of x-ray 1. chest 2. musculoskeletal 3. skull 4. spine 5. mastoid 6. sinus 7. breast 8. kidneys, ureters, bladder (KUB) 3. Nursing interventions for x-ray procedures 1. instruct client about procedure 2. shield the client's genitals with lead drape 3. ask if pregnant prior and do not x-ray if pregnant 4. for chest x-ray, assist to dress in institution clothing Contrast radiography 1. 2. 3. 4. 5. Casts 1. Externally applied structure that holds bone in one position 2. Uses a. immobilization b. prevent bone or muscle deformity c. support of a weakened limb d. promote healing e. permit early weight bearing on affected limb 3. Types of casting materials a. plaster of paris i. natural material ii. indicated in cases of severely displaced fractures unstable fracture fragments iii. when multiple castings are indicated: serial casting iv. application: takes at least 24 hours to dry v. advantages Visualization of x-ray enhanced by using contrast medium Contrast medium may be ingested, injected through a tube or catheter or given intravenously Contrast medium may be barium, iodine, or air Cineradiography: rapid sequence x-rays that film motion Fluoroscopy: projection of x-rays onto screen for continuous observation of motion

low allergic response offers rigid protection easy to apply inexpensive vi. disadvantages long drying time (24 to 48 hours) - gives off heat while drying (exothermic) weight - plaster casts are heavy materials may crumble and disintegrate at edges not waterproof b. fiberglass i. synthetic material ii. indicated in cases of non-displaced fractures long term casting iii. advantages light weight easy to apply moisture-proof fast: dries in 15 minutes, cures in one hour colors and patterns help client adjust to immobilization iv. disadvantages short drying time requires speed and accuracy more rigid than plaster; may bind if tissues swell extra rigidity may cause tissue breakdown under the cast more expensive than plaster castings 4. Types of casts a. short arm/leg i. cylindrical cast ii. allows for flexion or extension of elbow and knee b. long arm/leg i. cylindrical cast ii. does not allow elbow or knee to move c. spica arm/hip i. support bar is applied between extremities ii. permits greater stabilization iii. cut window over epigastrium for patient comfort after eating 5. Cast application a. cast must extend to the joint above and below the point of fracture b. assessment prior to cast application i. skin: inspect for irritation, laceration, skin breakdown ii. neurovascular status check iii. edema/swelling c. windowing: i. square or diamond hole cut in cast over certain area ii. indications observation of surgical incision observation of skin relieve pressure over bony prominence iii. nursing interventions cast may crack at window site - weakest part of the cast appropriate padding/petaling of open window d. bivalving i. indications swelling infection or high potential for infection pain ii. techniques lengthwise splitting of the cast with cast saw apply ace wrap or tape to hold cast together still immobilizes e. petaling i. edging the cast with soft padding or moleskin

ii.

indications prevent irritation or skin breakdown at rough edges of cast protect cast from perspiration, feces, urine protect perineal area

6. Nursing interventions: post cast application a. plaster of paris casts i. handle fresh cast carefully (first 48 hours) indentations may cause pressure points under the cast handle the cast with open palms of hands ii. do not apply pressure to the cast iii. do not cover the cast - allow to air dry iv. do not use heat to dry b. all casts i. repeated neurovascular checks capillary refill time warmth color motion checks 1. patient can move toes and fingers of affected limb 2. if not, a nerve is compressed 3. sensation: numb or tingling may mean nerve compressed ii. drainage observe for wound drainage record size, color, amount; and circle area on cast with felt tipped marker and date and time check odor of drainage c. teach client i. keep cast dry and intact ii. to avoid placing any objects, powders, or lotions inside of or through cast iii. describe indications and therapeutic use of casting for immobilization iv. proper use of assistive devices v. how to assess environment for potential mobility hazards vi. to inspect cast daily for foul odor, cracks 7. Nursing interventions for cast removal with a mechanical saw a. explain procedure to client b. inform client that i. cast removal is painless ii. client will feel heat and vibration iii. saw is noisy but will not cut client iv. inspect tissue under cast for signs of inflammation or infection v. if skin is intact apply lotion to moisturize skin c. teach client i. underlying skin may be scaly and dry ii. to perform range of motion exercises as ordered iii. to use moisturizing lotion on dry skin

Traction - pulling force and opposing force applied to injured extremity 1. Longitudinal - when only one force is applied 2. Traction angle - direction of the force in relation to the affected extremity 3. Countertraction - opposing force to the pull of the traction; most often is provided by the person's body weight 4. Vector force - resultant force produced when two traction forces are applied to a limb 5. Purposes a. reduce, realign and promote healing of fractured bones b. decrease muscle spasms c. immobilize area of body d. rest inflamed, diseased or painful joint e. treat/correct deformities f. reduce and treat dislocations

g. prevent the development of contractures h. expand a joint space during arthroscopy i. reduce muscle spasms in low back pain or cervical whiplash 6. Types of traction a. manual traction i. use of the hands to exert a pulling force ii. generally used during an emergency iii. temporary measure - cannot be maintained for extended periods b. skin traction i. pulling force is applied directly to the skin through the use of foam splints, skin traction strips and tape ii. temporary measure MECHANICS OF TRACTION EQUIPMENT 1. Frame - Should be loaded to maximize its stability before adding additional traction systems 2. Plain Bars 3. Cross Clamps - Positioned so that turn knobs are on top of horizontal bars 4. Traction Bars 5. Pulleys a. do not lubricate- Decreased friction markedly changes the line of pull b. must move freely PRINCIPLES OF TRACTION A. Maintain the prescribed line of pull 1. Especially important in patients with fractures 2. Maintain proper body alignment B. Always maintain continuous pull unless intermittent traction is prescribed C. Prevent friction 1. Friction will alter the line of pull 2. Friction will impair the traction's efficiency 3. But never lubricate pulleys D. Identify and maintain counteraction 1. Countertraction is the force opposing the pull of traction 2. Generally provided by the patient's body 3. If countertraction is not maintained the patient is not in traction 4. Sign of loss of countertraction is that the patient slides down in bed 5. Especially problematic with Buck's Traction 6. Keep bed flat 7. Elevate the foot of the bed with shock blocks E. Counter traction for pelvic traction is generally achieved by putting the bed in the William position (both knees and hips are flexed at 30 degrees)

iii.

types of skin traction

iv.

c.

d.

v. vi. skeletal traction i. traction applied directly to the bone \ ii. pins are placed through the affected limbs and attached to pulling force iii. can be tolerated for longer periods - up to four months iv. greater weight can be used - 15-40 lbs. v. types of skeletal traction balanced suspension 1. used for displaced, overriding or comminuted fractures 2. preoperative treatment prior to surgical pinning skull tong/halo traction i. burr holes drilled into skull and tongs inserted and attached to weights or halo bolts inserted then attached to body cast ii. tongs used for cervical fractures preoperatively a. static traction b. continuous traction pull c. dynamic traction d. intermittent application of traction e. straight traction f. running

complications skin breakdown detachment of traction device limitation: can apply only five to seven lbs. loading force must remove traction and perform skin care

7.

Complications 1. infection at pin site 2. skin breakdown 3. muscle weakness

4. osteomyelitis 7. Patient positioning for traction 1. supine 2. perpendicular to the ends of the bed 3. affected limb in proper body alignment 4. head of the bed is flat or semi fowlers (maximum of 20 to 30 degrees elevation) 5. a trapeze for client to shift position and upper range of motion provided Nursing interventions a. explain procedure to client / assess neurovascular status of affected area/limb at least every four hours a. color b. temperature c. motion d. sensation e. pulse quality f. presence/absence of edema b. always compare affected limb to unaffected limb for baseline measurement c. skeletal cervical or halo traction: assess cranial nerves III - IX d. skin assessment i.high risk for developing pressure sores ii.remove Buck's traction boots every two hours to inspect skin integrity iii.assess pressure areas every two hours e. pin assessment: observe for drainage, signs of infection f. medical asepsis with open skin g. maintain principles of traction h. administer appropriate medications i. beware of immobility's multi-system effects j. allow patient to verbalize fear and concerns k. encourage involvement of family members l. provide diversional activities

8.

Mobilization devices: orthotic, prosthetic, crutch, cane, walker 1. Orthotic a. braces designed to prevent deformity, increase efficacy of gait, control alignment and/or promote ambulation b. types of orthotic i. ankle/foot (AFO) ii. knee/ankle/foot (KAFO) iii. hip/knee/ankle/foot (HKAFO) iv. thoracolumbar or sacral (TLSO) 2. Prosthetic: artificial limbs for all extremities 3. Crutches a. a wooden or metal staff b. used when no or minimal weight bearing is desired c. may be temporary or permanent d. types i. axillary: a padded curved surface at top which fits under the axilla and a crossbar forms the handgrip for axillary crutches, measure client's height; distance between crutch pad and axilla; distance from axilla to client's heel; Crutch pads should be three to four finger widths under axilla complication: crutch palsy--paralysis of elbow and wrist due to crutch pressure on axilla e. forearm (Lofstrand): an adjustable metal band that fits around the forearm with an adjustable handgrip

For client to navigate stairs with crutches, remember "up with the good, down with the bad." To go up stairs, lead with the unaffected "good" leg, and follow with the affected "bad" leg. To go down stairs, lead with the affected "bad" leg, and follow with the unaffected "good" leg.

4. Canes: straight-legged, quad; all need rubber tips 5. Walkers a. extremely light devices that have four widely placed legs and handgrips on an upper bar; need rubber tips. May have rollers instead of tips. b. client moves the walker forward and steps into it, then moves it forward again c. caution should be used to avoid overloading client's personal item baskets 6. Wheelchairs: manual, electric 7. Nursing interventions with mobilization devices a. explain procedure to client b. assess client's readiness including muscle strength and range of motion c. safety is prime issue d. observe client initially for orthostatic hypotension e. assess environmental risks f. nurse should stand close to client during initial attempts at using mobilization devices. g. use a gait belt for maximum support h. provide emotional support i. resize device as children grow j. teach client i. proper use of device ii. findings of complications iii. how to climb stairs, maneuver on various surfaces iv. how to maneuver on and off toilet, chair, tub, shower, car v. don't look at your feet, look ahead vi. how to troubleshoot equipment for defects, signs of wear vii. wear stable shoes, same heel height as when device fitted

I.

Anatomy and Physiology

A. Bone

1.

2.

Functions a. supports and protects structures of the body b. anchors muscles c. some bones contain hematopoietic tissue which forms blood cells d. participates in the regulation of calcium and phosphorus Joints

a. b. c.

bursa - enclosed cavity containing a gliding joint synovium - lining of joints which secretes lubricating fluid that nourishes and protects classification of joints - synarthrosis, amphiarthrosis, diarthrosis

3.

Cartilage - connective tissue covering the ends of bones

4.

Types of bones a. long - legs, arms i. external structure - diaphysis, epiphysis, periosteum

b. c. d. B.

internal structure of bone - medullary cavity; cancellous bone; red marrow short - ankles, wrists flat - shoulder blades irregular - face, vertebrae

ii.

Muscles - produce movement of the body 1. Types

a. b. c.

striated - controlled by voluntary nervous system smooth - controlled by autonomic nervous system cardiac - controlled by autonomic nervous system

C. D. E.

Fascia - surrounds and divides muscles Tendons - fibrous tissue between muscles and bones Ligaments - fibrous tissue between bones and cartilage; supports muscles and fascia

II.

Trauma: Contusions, Strains, Sprains

A. Contusions (bruise) 1. Definition - a fall or blow breaks capillaries but not skin 2. Pathophysiology - extravasation (bleeding) under skin 3. Findings - ecchymosis (bruise) and pain when the contusion is palpated 4. Management a. for first 24 to 48 hours, apply ice for 15 minutes, three times a day b. then apply heat if necessary c. wrap to compress 5. Resolution: should heal within seven to ten days 6. Color changes from a blackish - blue to a greenish - yellow after three to five days

B. Strains 1. Definition - lesser injury of the muscle attachment to the bone 2. Etiology and pathophysiology a. caused by overstretching, overexertion, or misuse of muscle b. acute: recent injury to muscle or tendon; classified by degree i. first degree: mild; gradual onset; feels stiff, sore locally assessment of acute first-degree strain o tenderness to palpation o muscle spasm o no loss of range of motion o little or no edema or ecchymosis management of acute first-degree strain o comfort measures o apply ice o rest, possibly immobilize for short term, elevate ii. second degree: moderate stretching, sudden onset, with acute pain that eventually leaves area tender assessment of acute second-degree strain o extreme muscle spasm o passive motion increases pain o edema develops early; ecchymosis later management of acute second-degree strain o keep limb elevated o apply ice for the first 24 to 48 hrs - then moist heat o limit mobility, ace wrap o muscle relaxants, analgesics, NSAIDS

physical therapy for strength and range of motion 3. Third-degree: severe stretching with tear; sudden; snapping or burning sensation a. assessment of acute third degree strain i. muscle spasm ii. joint tenderness iii. edema (may be extreme) iv. client cannot move muscle voluntarily v. delayed ecchymosis b. management of acute third degree strain i. keep limb elevated ii. apply ice for 24 to 48 hrs, then moist heat iii. either immobilize or limit mobility of the limb iv. medication - muscle relaxants, analgesics, NSAIDs v. physical therapy for strength and range of motion 4. Chronic strain a. long-term overstretching of muscle/tendon b. repeated use of the muscle beyond physiologic limits C. Sprains 1. Definition - greater than strain; injury to ligament structures by stretching, exertion or trauma 2. Classification/findings/assessment/management a. first degree sprain i. minimal tearing of ligament fibers ii. localized edema or hematoma iii. no loss of function iv. no weakening of joint structure - joint integrity remains intact v. mild discomfort at location of injury vi. pain increases with palpation or weight bearing vii. management of first degree sprain 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 b. second degree sprain i. up to half of the ligamentous fibers torn ii. increased edema and possible hematoma iii. decreased active range of motion iv. increased pain v. mild weakening of the joint and loss of function vi. management protectively dress/splint the joint, immobilize it elevate the limb to decrease edema for 24 to 48 hours, alternate o ice 1. to produce vasoconstriction to decrease swelling 2. to reduce transmission of nerve impulses and conduction velocity to decrease pain o moist heat 1. to reduce swelling and provide comfort analgesics for discomfort physical therapy to increase circulation and maintain nutrition to the cartilage c. third degree sprain i. complete rupture of the ligamentous attachment ii. severe edema with hematoma iii. usually, severe pain iv. dramatic decrease in active range of motion v. loss of joint integrity and function vi. management casting

surgery to restore integrity of joint see second degree treatment D. Fractures: classification and diagnosis
ASSESSMENT AND EARLY MANAGEMENT OF THE TRAUMA CLIENT Primary survey: ABC A. Airway maintenance with spinal cord control - cervical stabilization B. Breathing C. Circulation Cognitive level: glasgow coma scale A. Eye opening B. Verbal response C. Motor response Ask about: A-M-P-L-E A. Allergies B. Medications C. Past illness D. Last meal E. Events preceding the injury Life threatening injuries of extremity A. Massive open comminuted fractures B. Bilateral femoral shaft fractures C. Vascular injuries D. Crush injuries of the abdomen or pelvis E. Traumatic amputation of the arm or leg Mechanism of injury A. Force: amount of energy transferred from one object to human body B. Injuring agent: sharp or blunt instrument C. Predictable musculoskeletal injuries 1. Child/pedestrian injuries "Waddell's triad": a. point of impact with the car bumper b. point of impact with the car hood c. point of impact where the body is thrown 2. Adult/pedestrian injuries a. point of impact with the car bumper b. point of impact with the car hood c. injuries to opposing ligaments 3. Unrestrained driver a. head b. larynx and sternum c. knee/femur d. posterior hip dislocation 4. Fall from a height (Don Juan syndrome) a. bilateral calcaneal fractures b. hyperflexion of the lumbar spine c. bilateral Colles' fractures d. compression fracture of vertebrae 5. Blast injuries a. gunshot/missile type injuries b. source of infection: when energy travels it leaves a vacuum behind it, drawing in debris/body hair c. results in both entry and exit wound d. shock waves throughout body Findings of trauma A. Deformity/angulation of extremity B. Swelling C. Pain D. Paresis/paralysis E. Paresthesia F. Pallor G. Absent pulses Goals of nursing care A. Sustain life B. Maintain function C. Preserve appearance Goals of rehabilitation A. Decrease pathology B. Prevent secondary disabilities C. Increase function of unaffected and affected systems

I.

II.

III.

IV.

V.

VI.

VII.

VIII.

1. Definition: fracture is any alteration in the continuity of a bone 2. Fracture dislocation a. a fracture in which the joint is dislocated in that position, fracture will not heal completely 3. By completeness a. complete (bone broken in two or more pieces) b. incomplete (bone broken but still in one piece) 4. By wound a. closed = simple; does not break skin b. open = compound = complex i. bone fragments break through skin ii. injures soft tissue and often infects tissue iii. subdivided by degree of soft tissue injury 5. By fracture line

a. longitudinal = linear fracture b. oblique is produced by a twisting force, and requires traction to heal properly. c. spiral also results from twisting force, may accompany damage to soft tissue, and requires traction or internal fixation. d. transverse is caused by angulation, common in pathological fractures, and generally stable after reduction. 6. By type of fracture a. avulsion fractures i. bone fragments and soft tissue are pulled away from the bone ii. results from a direct force on the bone b. comminuted fractures i. produced by high energy forces ii. results in two or more bone fragments iii. splinters the fragments iv. injures soft tissue severely c. compression fractures i. often seen in the lumbar spine ii. may be pathological (a disease weakens bone) d. greenstick fracture i. results in an incomplete fracture ii. caused by compression forces angulation forces iii. cortex of the bone bends to one side and buckles on the other iv. cortex stays intact on the side subject to tension forces and fractures on the opposing side v. requires reduction or completion of the fracture line through the cortex e. impacted fractures (telescoped) i. direct force breaks bone and telescopes the fragment with the smaller diameter into the fragment with the larger diameter ii. fracture fragments move in unison iii. rapid union occurs f. stress fracture i. incomplete fracture ii. result of repetitive trauma to region iii. two types: fatigue - from repeated trauma insufficiency - pathological fracture 7. Classification by location in the bone a. apophyseal b. articular c. condylar d. cortical e. diaphyseal f. epiphyseal g. extracapsular h. intraarticular i. intracapsular j. metaphyseal k. periarticular l. subperiosteal m. supracondylar 2. Fractures: pathophysiology 6. Predisposing factors a. biologic i. bone density ii. client's age 7. Extrinsic factors a. force - direct or indirect b. rate of loading (how fast the force strikes) 8. Intrinsic factors - bone capabilities 9. Pathological fractures

a. bone is weakened by disease b. fractures occur in response to minimal or no applied stress c. classification by cause: general or local disorder i. general: developmental, nutritional, hormonally controlled ii. local: neoplasm, infection, cystic lesion 10. Behavioral factors - high-risk activities (such as football, ballet) 3. Fractures: management 6. Closed reduction a. purposes: realign bone fragments for healing, minimal deformity, minimal pain. b. pre- and post-reduction x-rays are essential to determine successful reduction of fracture 7. Immobilization a. purposes i. relieve pain ii. keep bone fragments from moving b. methods: cast - synthetic or plaster, traction - skin or skeletal, splints, braces, and external fixation External Fixator: Ilizarov Device
A. The Ilizarov device is a specialized type of external fixator used for non-union fractures and limb lengthening needed due to congenital deformities. B. Tension wires are inserted into the bone and then attached to rings outside the body. These rings are joined by telescoping rods attached to a rigid frame. Daily adjustment of the rods causes the wires to turn, which stimulates bone formation. C. Ilizarov device lengthens limbs about one cm per month. D. Before discharge, teach clients 1. To care for pin 2. To adjust rod E. Clients may have the device on for several months.

c. types of traction i. manual: applied by pulling on the extremity - may be used during cast application ii. skin: applied by pulling force through the client's skin - used to relax the muscle spasm iii. skeletal: applied directly through pins inserted into the client's bone - used to align fracture d. open treatment (see orthopedic surgery that follows) 8. Stages of bone healing
I. STAGES OF BONE HEALING Hematoma formation A. One to three days B. Blood clot forms around the fracture site C. Bone necrosis occurs distal to the fracture site due to a loss of blood Granulation tissue formation A. Begins three days to two weeks after fracture B. Osteoclast formation in fibrous matrix of collagen C. Fibroblasts 1. From outer layer of the periosteum 2. From damaged connective tissue D. Osteoblasts 1. From the periosteum and marrow cavity 2. Develop collagen E. Vascular and mechanical factors affect healing 1. Motion 2. Distraction of fracture fragments Callus formation A. Two to six weeks B. Granulation material is matured into a callus C. Size and shape of callus in direct response to the amount of displacement of fracture fragments D. Phagocytosis breaks down and removes the formed hematoma E. Delay at this stage delayed union or nonunion of bone Ossification A. Three weeks to six months B. The gap in the bone is bridged and union occurs Consolidation /remodeling A. Six weeks to one year B. Callus becomes calcified and blends into the bone C. Fracture line may still be evidence on radiographs

II.

III.

IV.

V.

a. hematoma formation b. fibrocartilage/granulation tissue formation c. callus formation d. ossification e. consolidation/remodeling 9. Evidence of healed fracture a. radiographic

DIAGNOSTIC IMAGING 1. Radiographs a. two dimensional representation of the bone and soft tissue b. include joints above and below suspected fracture c. clinical evidence of fracture overrides negative x-ray analysis d. will also offer evidence of i. bone pathology ii. bone density (in advanced cases of osteoporosis) 2. Computerized tomogram (CT) scan - specialized tomograms

3. Magnetic resonance imaging (MRI) scan - clearer views of soft tissue structures

4. Bone scan - increased uptake of contrast may indicate a. fracture b. infection c. tumor growth

i.

ii. b. clinical i. pieces of bone no longer move at fracture site ii. no tenderness over fracture site c. weight bearing is pain free G. Fractures: complications
ORTHOPEDIC COMPLICATIONS

presence of external callus or cortical bone across the fracture site fracture line may remain long after healing

A. Venous thromboembolic problems 1. Thrombophlebitis (TP) a. inflammation of a vein with the formation of a blood clot b. incidence is greatest after trauma or surgery to legs or feet B. Deep venous thrombosis (DVT) 1. Anterior tibial or femoral veins 2. May be caused by immobility 3. Findings include calf pain, positive Homan's sign 4. Immediately after operations a. anticoagulant therapy b. antiemboli stockings (usually) c. sequential compression device (possibly) C. Pulmonary embolism (PE) 1. Blood clot from systemic circulation enters pulmonary circulation 2. Most commonly seen after hip fractures and total hip/knee replacements 3. Occurs in approximately ten percent of patients undergoing hip arthroplasty 4. May be caused by femoral vein manipulation during surgery and therefore occur without signs of DVT 5. Findings include chest pain (pleuritic), sudden shortness of breath, tachycardia, palpitations, or change in mental status 6. If PE is suspected,do not leave client. Get charge nurse to notify health care provider immediately 7. Diagnosis confirmed via ventilation/perfusion scan or pulmonary angiography 8. Continuous IV heparin therapy usually prescribed D. Fat embolism 1. Definition: fat cells enter pulmonary circulation 2. Associated with a. multiple trauma accidents b. multiple organ involvement c. fractures of marrow producing bones d. joint replacements e. insertion of intermedullary rods 3. Usually occurs 24 to 48 hours after the fracture E. Hemorrhage 1. Abnormal loss of blood from the body 2. Most common in fractures of bone marrow producing bones F. Wound infection 1. May be superficial or deep wound 2. Deep wound infection may lead to osteomyelitis 3. Findings include erythema and swelling around suture line, increased drainage and elevated temperature 4. Treated with antibiotics; may require incision and drainage of wound or removal of prosthesis if severe infection is present G. Special complications in hip replacement 1. Femoral fracture a. occurs near distal end of femoral-shaft part of prosthesis b. occurs more frequently with elderly, clients with osteoporosis, or after revision to total hip replacement c. primary finding is severe pain with ambulation d. diagnosis is confirmed with x-ray e. depending on severity, treatment will be immobilization or open reduction with internal fixation 2. Dislocation of hip prosthesis a. greatest risk during the first postoperative week but can occur at any time within the first year. b. risk decreases as muscle tone of the hip increases c. caused by flexion of the hip or poor prosthetic fit d. findings include pain and external rotation of the leg e. treated by closed reduction under conscious sedation or open surgical revision H. Special complication in knee replacement: flexion failure 1. Client cannot flex knee 90 degrees two weeks postoperatively 2. Treated with closed manipulation of the knee joint under general anesthesia

1. Immediate complications of the injury a. shock - higher risk with pelvic and femur b. fat embolism - occurs after the initial 24 hours from the injury c. compartment syndrome - a nursing emergency d. deep venous thrombosis (DVT) e. pulmonary embolism - a complication of DVT 2. Delayed complications a. joint stiffness b. post-traumatic arthritis (osteoarthritis, type II) c. reflex sympathetic dystrophy i. painful dysfunction and disuse syndrome ii. characterized by abnormal pain and swelling of the extremity d. myositis ossificans i. formation of hypertrophic bone near bone and muscles ii. forms in response to trauma iii. hypertrophic bone is removed when bone is mature e. malunion i. fracture healing is not stopped but slowed ii. prevention of malunion reduce and immobilize properly be sure client understands limits on activity and position f. delayed union i. fracture does not heal ii. more common with multiple fracture fragments iii. no evidence of fracture healing four to six months after the fracture g. loss of adequate reduction h. refracture 2. Nursing interventions 2. Risk for peripheral neurovascular deficit a. check neurovascular status often b. elevate limb above level of heart (except with compartment syndrome)

COMPARTMENT SYNDROME I. II. Definition - increased pressure in a limited space (muscle compartment) cramps the circulation and function of the tissues within that space Types: acute and chronic (or exertional) A. Acute: 1. Following trauma to the muscle 2. External forces: casting/bracing compresses limb 3. Internal forces: compartment content increases; space does not 4. Results in necrosis of the tissue B. Chronic/exertional - when exercise of a limb raises intracompartmental pressure and produces pain and neurologic deficits Pathophysiology A. Ischemia-edema pathology cycle B. If cycle lasts more than six hours, neuromuscular damage irreversible C. Duration of 24 to 48 hours: extremity may be paralyzed D. May develop rapidly or for up to six days after initial trauma E. A nursing emergency F. Compression occurs of the vessels and nerves c. apply cold to minimize edema 3. Pain a. assess level of pain with a scale of one to ten b. manage pain i. with drugs ii. reposition client iii. pad any bony prominences c. teach relaxation techniques

III.

4. Client teaching a. how fractures heal b. why the fracture is being immobilized c. how to bear weight and how much (if permitted) d. how bones heal e. how to use assistive devices to walk 5. Risk for infection a. related to i. open fractures ii. surgical intervention iii. superficial/deep wounds b. monitor for findings of infection c. provide proper wound care d. administer antibiotic therapy as indicated 6. Risk for impaired skin integrity a. causes i. open fractures ii. soft tissue injuries iii. pressure areas b. additional factors i. age - elderly ii. general condition of client iii. preexisting skin conditions or diseases c. interventions i. mobilize the client as soon as possible ii. turn the client often at least every two hours iii. position the client properly with alignment in mind iv. use orthopedic devices to limit skin impairment 7. Impaired gas exchange a. accompanies chest trauma b. client risks fat embolism c. client risks deep venous thrombosis d. interventions i. mobilize as soon as possible ii. frequent and effective pulmonary toileting 3. Fractures: factors that affect healing

III.

Degenerative Disorders
A. Definition 1. Slowly progressive disorders of articular cartilage and subchondral bone 2. Do not affect the joints symmetrically (e.g., not necessarily both knees) 3. Worsen progressively 4. Eventually incapacitate, despite treatment Osteoarthritis (OA) 1. Definition - degeneration of the articular cartilage and formation of new bone in the subchondral margins of the joint 2. Findings I. primarily involves weight-bearing joints II. non-inflammatory disorder III. localized: no systemic effects IV. results in an abnormal distribution of stress on the joint 3. Incidence I. most common form of arthritis II. may begin as early as the 20s and peaks in the 60s III. by age 70, nearly 80% of afflicted people show findings IV. over age 55, OA affects twice as many women as men V. two types: primary and secondary Types of Osteoarthritis (OA)

B.

I.

II.

Primary (Idiopathic) Osteoarthritis A. No known cause B. Classifications 1. Localized OA in one or two joints 2. Generalized OA in three or more joints. C. Etiology 1. More common in women (slightly) 2. More common in Caucasians 3. Develops in middle age and progresses slowly 4. More often affects certain joints a. weight-bearing joints b. cervical and lumbosacral joints c. interphalangeal joints 5. Hands more affected in women after menopause 6. Hips are more affected in men Secondary (Traumatic) Osteoarthritis A. Underlying condition: a trauma to the articular cartilage B. Etiology 1. Genetic predisposition, shown by the presence of a. Heberden's Nodes b. Bouchard's Nodes 2. More common in men 3. Often occurs in a. wrists b. elbows c. shoulders C. Risk factors for traumatic osteoarthritis 1. Obesity 2. Family history of degenerative joint disease 3. Excessive joint wear a. physical activity b. injury 4. Joint abnormality a. lax ligaments b. congenital hip dysplasia 5. Lifestyle: certain occupations predispose to secondary OA.

4.

Pathophysiology I. stage one: microfracture of the articular surface I. articular cartilage is worn away II. condyles of bones rub together: joint swells and is painful III. cartilage loses cushioning effect: joint friction develops IV. prostaglandins may accelerate degenerative changes II. stage two: bone condensation I. erosion of cartilage II. cartilage may be digested by an enzyme in the synovial fluid III. stage three: bone remodeling I. matrix synthesis and cellular proliferation fail II. eventually the full thickness of articular cartilage is lost III. bone beneath cartilage hypertrophy and osteophytes form at joint margins IV. result: joint degenerates 5. Findings

OSTEOARTHRITIS OF HIP/KNEE: SPECIFIC PHYSICAL FINDINGS 1. Hip a. b. c. d. contracture in adduction and flexion decrease in internal and external rotation limb shortening referred pain to the i. knee ii. groin iii. thigh

2. Knee a. decreased range of motion b. flexion contracture i. hip ii. knee c. varus deformity: bow legged appearance d. valgus deformity: knock-kneed appearance e. positive apprehension sign i. push the patella laterally with the leg in full extension ii. client will stop the examiner from pushing the patella further

a. b. c. d.

joint stiffness after periods of rest pain in a movable joint, typically worse with action, relieved by rest paresthesia joint enlargement: bones grow abnormally; spurs form and synovitis sets in. i. Heberden's nodes HEBERDEN'S NODES

A. B. C. D.

Bony osteophytes at the DIP joint Common presentation of OA in the hand Indicates a strong hereditary tendency Seen more often in women than men (ten times)

ii.

Bouchard's nodes BOUCHARD'S NODES

A. B. C. D.

Accompany Heberden's nodes Found at the PIP joint Occur more often in women than men Increase in frequency with age

e. joint deformities f. tenderness on palpation i. may involve widely separated areas of the joint ii. mild synovitis may be felt - positive bulge sign may be found g. pain on passive movement h. limitation in active range of motion because i. joint surfaces no longer fit ii. muscles spasm and contract iii. joints are blocked by osteophyte, loose bodies iv. crepitation, crunching when joints are moved v. eventual ankylosis i. gait i. abnormal antalgic gait ii. shortened stance iii. widened base of support iv. shortened step length 6. Diagnostics a. to rule out autoimmune disorders i. sedimentation rate ii. rheumatoid factor iii. c-reactive protein b. CBC i. analyze before NSAID therapy ii. within normal limits c. kidney and liver i. especially in older clients, analyze before starting NSAID therapy ii. repeat every six months d. purified protein derivative (PPD) i. analyze before starting steroids ii. clients testing positive for tuberculosis must receive INH at same time as steroid. e. antinuclear antigen (ANA) titer i. may be lower in the elderly ii. does not necessarily prove a connective-tissue disease f. synovial fluid analysis distinguishes osteoarthritis from rheumatoid arthritis. g. radiographs i. taken in standing, weight-bearing condition ii. shows the prime sign of OA: joint space narrowing iii. x-ray does not necessarily reflect severity of disease iv. joint loses space asymmetrically because cartilage narrows from production of osteophytes or bone spurs v. later stages may show bony ankylosis, spontaneous fusion h. bone scans i. radionuclide imaging ii. shows skeletal distribution of osteoarthritis iii. monitors complications of joint replacement surgery i. MRI scans show the extent of joint destruction j. computerized tomograms (CT) scans show cortical and cancellous bone density 7. Management: conservative treatment a. education should cover i. exercise patterns ii. relaxation techniques iii. nutritional assessment iv. counseling about maintaining a normal weight b. nutritional management - weight reduction c. activity and rest management i. preservation of joint motion through a balance of 1. rest (protection) 2. activity (rehabilitation) ii. individualized activity rehabilitation program iii. physical or occupational therapist may be helpful

iv.

passive range of motion exercises

v. active stretching d. protection from further injury by splinting or bracing 8. Medication a. aspirin - most often recommended i. advantages: relatively safe and inexpensive ii. disadvantage: GI problems may lead to ulcers and bleeding b. nonsteroidal anti-inflammatory medications (NSAIDs) i. reduce pain and inflammation ii. inhibit prostaglandin formation iii. may cause GI bleeding or gastric ulcers or cramping with diarrhea c. adrenocorticosteroid injections

d. remissive agents REMISSION-INDUCING MEDICATIONS IN ARTHRITIS A. Slow acting drugs - take several months to show results B. Hydroxychloroquine 1. Antimalaria drug 2. For use in severely destructive RA 3. Side effects a. GI irritation b. retinal changes c. depression of bone marrow 4. Nursing implications a. eye exam every four to six months b. monitor hepatic and renal function C. Gold salts and penicillamine 1. Antirheumatic 2. Used only after NSAID therapy fails to achieve relief 3. Suppresses inflammation a. remission inducing b. slow cumulative effect 4. Penicilliamine is more toxic than gold salts 5. Side effects a. GI irritation b. alteration in taste sensation c. urticaria 6. Nursing implications a. continual evaluation of renal/hepatic function b. appropriate skin care c. take medication on empty stomach i. ii. iii. gold penicillamine (cuprimine) hydrochloroquinine (plaquenil)

9. Nonmedication assistance a. assistive devices i. canes ii. walkers b. non-traditional techniques i. guided imagery - the use of one's imagination to acheve relaxation and control ii. therapeutic massage iii. biofeedback iv. hypnosis v. relaxation techniques 10. Surgical management a. arthrodesis b. arthroplasty c. osteotomy d. total joint replacement 11. Home care considerations in arthritis a. safety measures i. no scatter rugs at home ii. well-fitted, supportive shoes iii. night light, handrails at stairs and bathtub or shower iv. assistive devices 1. canes 2. walkers 3. elevated toilet seats 4. grab bars 5. handrails in stairways v. splints and orthotic devices b. management of surgical pain by patient controlled analgesia pumps

c. referral to agency and support group C. Charcot joints (also called neuropathic joint disease) 1. Definition - multicausal degeneration and deformation of joint, usually ankle.

2. Etiology a. diabetes mellitus leading to foot neuropathy b. syringomyelia results in Charcot's joint of the shoulder c. tertiary syphilis d. peripheral neuropathies e. spina bifida with myelomeningocele f. leprosy g. multiple sclerosis h. long term intra-articular steroid injections 3. Findings a. inspection: foot is everted, widened, and shorter than normal b. examination i. joint instability ii. soft tissue swelling iii. pain secondary to inflammation 4. Diagnostics a. laboratory analysis of synovial fluid i. fluid is non-inflammatory ii. low protein content iii. no hemorrhage noted b. radiographs i. chronic destructive arthritis of the foot ii. severe destruction of the articular cartilage, subchondral sclerosis iii. fragments of bone and cartilage in joint 5. Management a. conservative treatment i. protection from overuse/abuse ii. braces and splints b. surgical management: arthrodesis i. treatment of choice for unstable joints ii. fusion of the involved joint 6. Nursing interventions a. expected outcome: preserve the joint b. education can prevent further injury c. protection of the joint i. braces ii. orthopedic shoes d. prolonged immobilization i. eight to 12 weeks to decrease swelling ii. leads to minimal joint deformity and a functional painless foot

D.

Chondromalacia patellae (also called patellofemoral arthralgia) 1. Definition: progressive, degenerative softening of the bone; follows a knee injury

2.

3.

4.

Etiology I. lateral subluxation of the patella (kneecap) II. direct or repetitive trauma to the patella produces chondral fracture III. underdevelopment of the quadriceps muscles Findings I. pain with flexed knee activities (poorly localized) II. mild swelling III. occasional episodes of buckling of the affected knee IV. minimal joint effusion V. evidence of 'squinting kneecaps' VI. atrophy of quadriceps VII. inverted 'J' tracking of the patella in the final 30 degrees of extension VIII. excessive quadriceps angle IX. positive apprehension sign X. crepitation upon range of motion Diagnostics I. radiographs I. anterior posterior (AP) and lateral views are not helpful II. sunrise views with the knee in 30 degrees, 60 degrees and 90 degrees of flexion II. bone Scans III. MRI Scans IV. arthroscopy

5. Conservative management a. progressive resistive exercises i. quadriceps setting - isometric ii. hamstrings - isotonic b. medication: NSAIDs c. nonmedication assistance: application of ice or moist heat d. activity restriction 6. Surgical management a. indicated if findings remain after six months of conservative treatment b. arthroscopy (see Orthopedic Surgery section that follows) c. arthrotomy i. realignment of proximal and/or distal soft tissue ii. tibial tubercle elevation iii. patellectomy 7. Nursing interventions (see previous Osteoarthritis section)

IV.

Inflammatory Disorders
A. Rheumatoid arthritis (RA) 1. Definition - chronic systemic inflammatory disease of the connective tissue 2. Findings I. starts in feet and hands, gradually destroys these peripheral joints II. affects diarthroidial joints III. bilateral involvement 3. Etiology I. cause is not fully understood II. rheumatoid arthritis is an autoimmune disorder III. genetic tendency; but may involve bacteria, or viruses IV. may affect the connective tissue of the lungs, heart, kidneys, or skin 4. Incidence I. two to three times more common in women than in men II. strikes between the ages of 20 and 50 years of age 5. Pathophysiology DISEASE PROCESS IN RA: RHEUMATOID FACTOR (RF)

A. RF factor in serum reacts against immunoglobulin G B. Inflamed synovial membrane C. Pannus 1. Vascularized fibrous scar tissue (pannus) 2. Erodes surface of articular cartilage D. Manifestations - early 1. Prominent joint margins erode 2. Synovial membrane thickens E. Manifestations - late 1. Fibrous adhesions 2. Bony ankylosis 3. Joint destruction 4. Fusion of opposing joint surfaces 5. Shortens tendon sheaths 6. Joint contractures I. synovitis immune complexes initiate inflammatory response I. IgB antibodies are formed II. rheumatoid factor (RF) I. pannus formation II. destruction of subchondral bone III. present in 85 to 90% of all cases IV. worsens the inflammatory response - can go on indefinitely V. irreversible - will lead to ankylosis of joint

6. Findings a. in early RA joints will be i. painful, stiff ii. warm, red, swollen at capsules and soft tissues iii. incapable of full range of motion b. in late RA, joints will show i. bony ankylosis ii. destruction of joint - reactive hyperplasia iii. adhesions iv. inflammation and effusion that will be symmetrical polyarticular c. general signs i. fatigue ii. loss of appetite and weight iii. enlarged lymph glands

d. rheumatic nodules i. in 20% of cases ii. firm, oval, nontender masses under the skin iii. presence indicates poor prognosis e. physical assessment should also include i. accurate patient history - history may include malaise fatigue weakness loss of appetite and weight enlarged lymph glands Raynaud's syndrome ii. examination may reveal deformities ulnar deviation deformed hands: swan neck/boutonniere f. neurological examination i. foot drop ii. evidence of spinal cord compression 7. Diagnostics a. laboratory analysis i. elevated ESR

ii. decreased RBC iii. positive C-reactive protein iv. positive antinuclear antibody in 20% of cases v. positive rheumatoid factor (RF) b. radiographic studies i. bony erosion ii. decreased joint spaces iii. fusion of joint c. aspiration of synovial fluid; analysis shows i. cloudy appearance ii. more white blood cells than normal 8. Management a. NSAIDS (see Osteoarthritis) b. hydroxychloroquine sulfate (Plaquenil) c. immunosuppressive agents i. azanthioprine (Imuran) ii. cyclophosphamide (Cytoxan, Procytox) iii. methotrexate (Rheumatrex) (most commonly used) d. prednisone e. sulfasalazine (Azulfidine) f. leflunomide (Arava) g. biological response modifiers (BRMs) i. etanercept (Enbrel) ii. infliximab (Remicade) iii. adalimumab (Humira) iv. anakinra (Kineret) h. psychological support i. splinting: resting, correction or fixation B. Systemic lupus erythematosus (SLE) 1. Definition: chronic, systemic, inflammatory disease of the collagen tissues

2.

Etiology unknown I. most cases are women II. African Americans, Hispanics, Asians, and Native Americans are two to three times as likely as whites to have lupus III. antigen stimulates antibodies, which form soluble immune complexes, deposited in tissues; number of T suppressor cells dwindles.

IV.

immune complex inflames tissue; inflammation creates findings I. the intensity and location of the inflammation reflects findings and organs involved. II. clients with central nervous system or renal involvement have poorer prognosis

3. Findings: SLE is present if client has four or more of these: a. arthritis: characterized by swelling, tenderness and effusion; involving two or more peripheral joints b. malar rash: characteristic butterfly rash over cheeks and nose c. discoid lupus skin lesions d. photosensitivity e. oral ulcers f. serositis: pleuritis g. renal disorder: persistent proteinuria h. neurologic disorder: seizures or psychosis in the absence of drugs or pathology i. hematologic disorder: hemolytic anemia with reticulocytosis or leukopenia j. immunologic disorder: positive LE (lupus erythematosus) cell preparation or anti-DNA or anti-Sm or false positive serologic test for syphilis k. antinuclear antibody: abnormal titer of antinuclear antibody by immunofluorescence or equivalent assay l. positive LE cell reaction 4. Management a. expected outcomes 1. control system involvement and symptoms 2. induce remission b. prevent bad effects of therapy c. recognize flare-ups promptly d. medical 1. salicylates 2. nonsteroidal anti-inflammatory agents (NSAIDS) 3. corticosteroids 4. anti-infectives e. antineoplastics 5. Nursing care a. pain management strategies b. strategies to combat weight loss c. emotional support C. Gout

a. Definition a. monoarticular asymmetrical arthritis b. characterized by hyperuricemia b. Etiology a. primarily affects men b. peak incidence 40 to 60 years of age c. familial tendency

d. abnormal purine metabolism or excessive purine intake results in formation of uric acid crystals which are deposited in the joints and connective tissue. e. deposits are most often found in the metatarsophalangeal joint of the great toe or in the ankle. c. Findings a. tight, reddened skin over the inflamed joint b. elevated temperature c. edema of the involved area d. hyperuricemia e. acute attacks commonly begin at night and last three to five days f. gout attacks may follow trauma, diuretics, increased alcohol consumption, a high purine diet, stress (both psychological and physical) or suddenly stopping of maintenance medications g. warning signs of flare-up include the exacerbation of previous findings or the development of a new one h. systemic manifestations may include fever, renal disease, tophus d. Diagnostics: lab test findings a. increased urinary uric acid following a purine restricted diet b. hyperuricemia e. Management a. expected outcomes: control symptoms; prevent attacks b. medical 1. NSAIDs 2. colchicine (used when NSAIDs are contraindicated) - enhances the excretion of uric acid 3. to prevent flareups: antihyperuricemic agents such as allopurinol (lopurin) or probenecid (benemid) - minimize the production of uric acid 4. heat or cold therapy c. dietary 1. avoid purine foods such as meats, organ meats, shellfish, sardines, anchovies, yeast, legumes 2. control weight 3. drink less alcohol - all types f. Nursing care a. pain management strategies b. elevate the affected limb; provide bed rest and immobilize joint c. avoid pressure or touching of bed clothing on affected joint d. reinforce dietary management and weight control e. administer anti-gout medications as ordered f. increase fluid intake to prevent renal calculi (kidney stones)

V.

Metabolic Bone Disorders

A. Osteomalacia 1. Definition - delayed mineralization; resulting bone is softer and weaker 2. Pathophysiology - similar to rickets I. bones have too little calcium and phosphorus II. vitamin D deficiency; possibly inadequate exposure to sunlight I. less serum calcium than normal II. more parathyroid hormone III. more renal phosphorus clearance 3. Findings I. accurate client history includes: I. generalized muscle and skeletal pain in hips II. similar pain in low back II. physical examination I. gait I. client unwilling to walk II. wide stance III. waddling gait II. muscle weakness III. bones I. deformities of weight-bearing bones

4.

5.

II. scoliotic or kyphotic deformities of the spine III. bones break easily Diagnostic testing I. radiographic findings I. generalized demineralization II. pseudo fractures III. bending deformities II. laboratory studies I. decreased serum calcium II. decreased serum phosphorus III. alkaline phosphatase level is moderately elevated Management I. calcium gluconate II. vitamin D daily until signs of healing take place III. diet high in protein IV. ultraviolet radiation therapy

B.

Osteoporosis

1.

Definition I. multifactorial disease results in I. reduced bone mass II. loss of bone strength III. increased likelihood of fracture II. types I. type one osteoporosis (estrogen related) TYPE I OSTEOPOROSIS

A. Loss of trabecular bone after menopause B. Theoretically related to a lack of estrogen 1. Bilateral oophorectomy 2. Amenorrhea in younger women C. Results in 1. Loss of height 2. Kyphosis 3. Increased risk of fracture

II.

type two osteoporosis (related to old age) TYPE II OSTEOPOROSIS

A. Age-related loss of cortical/trabecular bone in men and women occurring after age 70 B. Long-term remodeling C. Results in fractures of humerus and femoral neck

a. Etiology/epidemiology a. most common metabolic disease of bone 1. affects an estimated 25 million Americans 2. contributor of 50% of all adult fractures b. onset is insidious c. women affected twice as often as men before the age of 70 d. skeletal changes result from the aging process e. bone loss due to 1. immobilization 2. lack of gravitational stress b. Factors related to osteoporotic fractures

ADDITIONAL RISK FACTORS FOR OSTEOPOROSIS A. Genetic risk factors 1. Female, white or Asian 2. Small frame, thin-boned; short; low body fat 3. Women with post-menopausal osteoporosis may have inherited a lower peak bone mass 4. Daughters of women with osteoporosis averaged less bone mass in lumbar spine and femoral neck 5. Family history of hip fracture B. Reproductive factors 1. Hypo-estrogenism associated with increased bone remodeling, faster bone loss 2. Early or surgically induced menopause 3. Amenorrhea in athletes/anorexia nervosa a. hypogonadism b. weakens the bones c. decreases bone mass 4. Dysmenorrhea 5. Nulliparity (no pregnancies) C. Endocrine factors in osteoporosis a. premature menopause b. hyperthyroidism increases bone turnover and remodeling c. hyperparathyroidism d. increases bone turnover and remodeling e. increased parathyroid hormone (PTH) stimulates osteoclast activity depresses osteoblast activity result is an increase in serum concentration of calcium f. hyperadrenocorticalism g. type I diabetes mellitus

a. low bone density b. history of scoliosis c. neurological impairment after 1. CVA 2. Parkinson's disease 3. decreased vision from macular degeneration, complications of diabetes, etc. d. best indicator of fracture risk in bone densitometry 4. Findings a. client history i. acute fracture ii. prior history of a traumatic fracture; no trauma iii. history of falls b. pain i. greater when active, less while resting ii. early in disease, pain in mid to low thoracic spine c. anxiety i. about further falls/fractures ii. about ability to perform ADLs d. kyphosis - 'Dowager's hump' may reflect multiple spinal fractures e. loss of height RECALL METHOD FOR HEIGHT DETERMINATION IN OSTEOPOROSIS A. Client is asked to recall maximum adult height B. Subtract current height from recall height C. A two-inch loss of height predicts osteoporosis

i. two or more inches ii. usually precedes diagnosis of osteoporosis diagnosis 5. Diagnostics a. blood tests i. complete blood counts ii. serum levels 1. calcium 2. phosphate 3. alkaline phosphatase b. x-rays i. help identify fractures and kyphosis of spine ii. less useful in the detection of pre-fracture osteoporosis iii. detect osteoporosis only after 20% bone mineral content is lost c. bone densitometry i. best means of measuring risk for fracture ii. quantitative computerized axial tomogram (CAT) measures pure vertebral trabecular bone iii. dual energy x-ray absorptionometry (DEXA) 1. technique of choice 2. assesses cortical and trabecular bone in spine and hip 3. single photon absorptionometry measures cortical bone in long bones 6. Management a. exercise i. restorative - aims to increase bone density, decrease risk for fracture ii. within the client's tolerance iii. must be maintained throughout life b. nutrition

i. calcium and vitamin D ii. deficiencies increase risk of fracture iii. sedentary older adults may need supplements c. medication i. anti-resorptive agents 1. do not increase bone mass - rather prevent further bone loss 2. estrogen therapy 3. calcitonin (Osteocalcin) 1. peptide hormone 2. powerful inhibitor of osteoclastic bone resorption 3. modestly increases bone mass in osteoporosis 4. not shown to decrease osteoporotic fractures 5. expensive ii. biophosphonates 1. inhibit bone resorption 2. sustained use associated with osteomalacia and Paget's disease 3. alendronate (Fosamax) 1. 100 to 500 times more potent than etidronate 2. non-hormonal agent 3. highly selective inhibitor 4. not associated with detrimental effects of mineralization 5. expensive: average $41.70 per day for osteoporosis iii. bone-forming agents 1. sodium fluoride (Fluoritab) 2. androgens 1. taken long-term, increases bone mass in osteoporotic women 2. but androgens virilize and elevate cholesterol levels 7. Nursing intervention: teach prevention of osteoporosis and its damage a. education i. increase awareness ii. discourage risk-related behaviors iii. reinforce positive behaviors and lifestyles b. reduce risk of falling i. teach proper lifting and movement techniques

ii. iii.

encourage proper footwear install safety equipment in home

C. Paget's disease (osteitis deformans) 1. Definition: a slowly progressing resorption and irregular remodeling of bone. 2. Etiology a. bone resorbed; new bone poorly developed, weak, easily fractured b. mainly affects major bones: skull, femur, tibia, pelvis, and vertebrae PAGET'S DISEASE EFFECTS SYSTEMIC SEQUELAE OF MALFORMATION OF BONE A. Skull 1. Cranial nerve damage 2. Hearing loss 3. Obstructive hydrocephalus B. Vertebrae a. Rigid forward bend of spine b. Compression of thoracic vertebrae c. Kyphosis d. Impaired respiratory ventilation Cervical Spine: spinal cord compression: spastic quadriplegia c. cause unknown d. possible viral implications e. family tendency - noted in siblings 3. Findings a. asymptomatic initially b. musculoskeletal i. deformity of long bones ii. pain and point tenderness of affected limbs 4. Diagnostics a. radiographic findings i. bowing of long bones ii. thickened areas of bone iii. pathological fractures iv. sclerotic changes b. laboratory analysis i. increased alkaline phosphatase means osteoblasts more active ii. increased urinary hydroxyproline means osteoblasts more active iii. serum calcium level will be normal 5. Management a. only treat if symptomatic b. conservative intervention i. medication 1. NSAIDs 2. calcitonin (osteocalcin)

1. slows bone resorption 2. allows normal lamellar bone development 3. disodium etidronate (EHDP) 1. rapidly slows bone resorption 2. lowers levels of alkaline phosphatase and urinary hydroxyproline 3. may relieve pain 4. plicamycin (mithracin) 1. antibiotic 2. used only when Paget's disease bone is damaging nerves c. surgery i. reduce pathological fractures ii. correct secondary deformity iii. relieve neurologic impairment iv. complications common 1. nonunion 2. malunion

VI.

Orthopedic Surgery
A. Total hip replacement 1. Indications for surgery i. osteoarthritis ii. rheumatoid arthritis iii. femoral neck fractures iv. avascular necrosis of femoral head caused by steroids v. failure of previous prosthesis 2. Surgical modalities SURGICAL MODALITIES FOR HIP REPLACEMENT A. There are a variety of hip prostheses. The choice is usually made by the health care provider. B. Prostheses have two components: acetabular socket and femoral shaft 1. Acetabular socket is screwed into pelvis 2. Femoral shaft may be cemented into femur or may have a special coating which promotes bone growth around prosthesis a. The femoral shaft of a prosthesis used for revision is much longer than that used for the original surgery

a. total hip replacement (hip arthroplasty) is the replacement of both articular surfaces of the hip joint, the acetabular socket and the femoral head and neck. b. hemiarthroplasty of the hip is the replacement of one of the articular surfaces, usually the femoral head and neck. 3. Surgical and immediate postoperative care a. in first 24 hours, expect wound to drain blood and fluid up to 500ml. b. by 48 hours, wound drainage should be minimal c. clients may require transfusions (autologous is preferred) due to blood loss during surgery. d. best pain management is patient controlled analgesia (PCA) for the first 48 hours, advancing to non-narcotic oral analgesics by the fourth or fifth postoperative day. e. monitor for signs of deep venous thrombosis (DVT) and pulmonary embolism (PE) or fat embolism f. monitor neurovascular status of affected limb; color, temperature, presence of pulses. 4. Postoperative complications 5. Nursing interventions a. an abduction device is used during the first postoperative week while the client is in bed or sitting in a chair b. to keep abduction device in place, turn client by logrolling c. to prevent flexion of the hip, use fracture bedpan d. client teaching i. use of assistive devices; crutches, walker, raised toilet seat ii. methods to prevent dislocation iii. can resume sexual activity when suture line heals. To avoid flexion of hip, client should be in dependent position for three to six months 2. Total knee replacement 3. Indications for surgery a. osteoarthritis b. rheumatoid arthritis c. trauma 4. Surgical modalities a. metal or acrylic prosthesis, hinged or semiconstrained b. choice of prosthesis depends on the strength of surrounding ligaments to provide joint stability 5. Postoperative complications 6. Nursing interventions (knee replacement) a. for first 24 to 48 hrs, apply ice to the knee to minimize bleeding and edema b. in first eight hours, expect wound drainage up to 200 ml. c. by 48 hours, expect minimal wound drainage d. transfusions are rarely required e. within 24 hours, start aggressive physical therapy to promote knee flexion f. frequently health care provider prescribes a continuous passive motion machine (CPM) g. health care provider prescribes the amount of flexion and extension, measured in degrees, and increases that amount as client tolerates more h. when the CPM machine is not in use, a knee immobilizer is used i. keep leg elevated when the client is out of bed j. on first post-op day, client will begin to use crutches or walker k. best pain management is patient controlled analgesic (PCA) for the first 48 to 72 hours postoperatively. By fifth post-op day, nonnarcotic oral analgesia. l. monitor limb's neurovascular status, color, temperature, and pulses m. monitor for signs of DVT or PE 3. Amputation 3. Purpose: relieve findings; improve function; save or improve quality of life 4. Lower extremity indications

a. progressive peripheral vascular disease (often secondary to diabetes mellitus) b. gangrene c. trauma such as crushing injuries, burns, or frostbite d. congenital deformities e. malignant tumor 5. Upper extremity indications a. trauma b. malignant tumor c. infection d. congenital malformations 6. Levels of amputation
LEVELS OF AMPUTATION
Objective of surgery is to eradicate the disease process while conserving as much of the extremity as possible 1. 2. 3. 4. 5. 6. 7. 8. Toes and portion of the foot - usually as a result of trauma or infection. Causes minor changes in gait or balance Syme: disarticulation of ankle; stump can bear full weight, with prosthesis Below knee (BK) - preserves knee joint which facilitates use of prosthesis Knee disarticulation - at level of knee joint Above knee (AK) - measures undertaken to provide as much length to limb as possible Hip disarticulation - most often performed due to malignancy. Client cannot walk with prosthesis. Below elbow (BE) - preserves elbow joint, thus eases use of prosthesis Above elbow (AE) - measures undertaken to provide as much length to limb as possible a. amputate to most distal point that will heal successfully Staged amputation - used b. infection. Guillotine circulation and functional status for determined by amputation to remove infectious and necrotic tissue is performed. After intensive antibiotic therapy,postoperative complications 7. Potential a second operation is performed for skin closure.

9.

a. hemorrhage b. infection c. skin breakdown 8. Nursing interventions a. pain management - usually relieved with narcotic analgesics b. may require evacuation of accumulated fluid or hematoma c. muscle spasms may be relieved by heat or changing position d. phantom limb pain i. may occur any time up to three months post amputation ii. most common with above-knee (AK) amputations iii. relieved with 1. stump desensitization by kneading, or massage 2. transcutaneous electrical nerve stimulation (TENS) 3. distraction 4. beta-adrenergic blocking agents for burning, dull pain 5. anticonvulsants for sharp and cramping pain 9. Wound healing a. aseptic dressing change technique b. compression dressing wrapped in a figure eight fashion or cast to control edema 10. Altered body image a. may take months to resolve b. must convey acceptance and respect for individual c. foster independence: encourage client to look at, feel, and eventually care for limb 11. Grief a. many clients go through a mourning process, shock, anger, and depression b. caregivers should support and listen actively 12. Restoring physical mobility a. early rehabilitation b. muscle strengthening exercises c. prosthetic preparation

PREPARING FOR A PROSTHESIS A. The residual limb must be shrunk and shaped into a conical form to secure a proper fit within the prosthesis, through 1. Proper bandaging of the stump in a figure eight manner 2. An elastic residual limb shrinker 3. An air splint B. Problems that delay prosthetic use are

13. Types of prosthesis a. hydraulic b. pneumatic c. biofeedback - controlled d. myoelectrically controlled e. synchronized D. Arthroscopy 1. Definition - endoscopic procedure that allows direct visualization of the joint, most often performed on knees and shoulders 2. Indications a. torn medial and lateral meniscus b. chondromalacia patellae c. synovitis d. torn cruciate ligament e. subluxation patella f. intra-articular soft tissue mass g. pyarthrosis 3. Surgical procedure - most often, office surgery 4. Postoperative care a. compression dressing wrapped in a figure eight fashion to control edema b. ice may be applied c. oral analgesics for pain management d. weight bearing depends on procedure 5. Postoperative complications are rare a. infection b. thrombophlebitis c. stiffness Nursing intervention obtain operative permit prior to procedure apply pressure dressing and ice caution client to avoid excess use of joints for 48 hours may permit bearing mild analgesics may relieve post-procedure pain

E. External fixator 1. Definition 2. Indication: the device will stabilize fracture with soft tissue injury like crush fractures 3. Procedure: fracture aligned and immobilized by pins of Kirschner wires inserted in the bone and attached to a rigid frame outside the body 4. Nursing interventions a. monitor neurovascular status every two hours b. elevate extremity to reduce edema c. assess pin insertion sites for infection: erythema, drainage and increased warmth d. isometric and active exercises as prescribed e. non-weight bearing ambulation depends on soft tissue injury f. discharge teaching 1. ambulation with assistive device (crutches, walker) 2. care of pin site 3. extremity is repositioned by lifting frame instead of extremity

Points to remember

After hip replacements, pulmonary embolism may occur even without thrombosis in foot or leg. Clients should sit in a straight, high chair; use a raised toilet seat; and never cross their legs. In hip or knee replacement, clients will need assistive devices for walking until muscle tone strengthens and they can walk without pain. After an amputation, the home must be assessed for any modifications needed to ensure safety. Some clients will need transportation to continue rehabilitation. Amputee support groups can help clients and family. After arthroscopy, outpatient rehab may be prescribed depending on procedure; health care provider may prescribe knee immobilizer. External Fixator - If possible, prepare the client preoperatively to reduce anxiety. Device looks clumsy, but patient should be reassured that discomfort is minimal. After a hip pinning or femoral-head prosthesis, caution client not to force hip into more than 90 degrees of flexion, into adduction or internal rotation which will cause dislocation and severe pain and this would be a nursing emergency. Caution clients with a new prosthesis not to use any substances such as lotions, powders etc. unless prescribed by the health care provider. Osteoporosis cannot be detected by conventional X-ray until more that 20% of bone calcium is lost. Foods high in calcium include milk, cheeses, yogurt, turnip greens, cottage cheese, sardines, and spinach. When performing a musculoskeletal assessment on a client with Paget's disease, note the size and shape of the skull. The skulls of these clients will be soft, thick and enlarged. Clients at high risk for acute osteomyelitis are: elderly, diabetics, and clients with peripheral vascular disease. When clients receive corticosteroids long-term, evaluate them continually for side effects. Immunosuppressed clients should avoid contact with persons who have infections. Steroids may mask the signs of infections, so client should promptly report slightest change in temperature or other complaints. Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hours and wear sun block.