ORTHOPEDIC

I.

Anatomy and Physiology

A.

Bone (illustration 1 illustration 2 ) 1. 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

2.

Joints (illustration ) a. bursa - enclosed cavity containing a gliding joint b. synovium - lining of joints which secretes lubricating fluid that nourishes and protects c. classification of joints - synarthrosis, amphiarthrosis, diarthrosis Cartilage - connective tissue covering the ends of bones (illustration Types of bones a. long - legs, arms )

3.
4.

B.

internal structure of bone - medullary cavity; cancellous bone; red marrow b. short - ankles, wrists c. flat - shoulder blades d. irregular - face, vertebrae Muscles - produce movement of the body

i. ii.

external structure - diaphysis, epiphysis, periosteum (illustration

)

II.

Types (illustration ) a. striated - controlled by voluntary nervous system b. smooth - controlled by autonomic nervous system c. cardiac - controlled by autonomic nervous system C. Fascia - surrounds and divides muscles D. Tendons - fibrous tissue between muscles and bones E. Ligaments - fibrous tissue between bones and cartilage; supports muscles and fascia 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 gresnish - yellow after three to five days

1.

B.

Strains 1. 2.

Definition - lesser injury of the muscle attachment to the bone 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 I. assessment of acute first-degree strain I. tenderness to palpation II. muscle spasm III. no loss of range of motion IV. little or no edema or ecchymosis II. management of acute first-degree strain I. comfort measures II. apply ice III. rest, possibly immobilize for short term ii. second degree: moderate stretching, sudden onset, with acute pain that eventually leaves area tender I. assessment of acute second-degree strain I. extreme muscle spasm II. passive motion increases pain III. edema develops early; ecchymosis later II. management of acute second-degree strain I. keep limb elevated II. apply ice for the first 24 to 48 hrs - then moist heat III. limit mobility IV. muscle relaxants, analgesics, NSAIDS V. physical therapy for strength and range of motion 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 Chronic strain

1.

2.

a. b. C. Sprains

long-term overstretching of muscle/tendon repeated use of the muscle beyond physiologic limits

D.

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 Fractures: pathophysiology 1. Predisposing factors a. biologic i. bone density ii. client's age 2. Extrinsic factors a. force - direct or indirect b. rate of loading (how fast the force strikes) 3. Intrinsic factors - bone capabilities

1.

E.

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 5. Behavioral factors - high-risk activities (such as football, ballet) Fractures: management 1. 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 2. Immobilization a. purposes i. relieve pain ii. keep bone fragments from moving b. methods: cast - synthetic or plaster, traction - skin or skeletal, splints, braces, c. and external fixation 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 open treatment (see orthopedic surgery that follows)

4.

d.

3.

Stages of bone healing hematoma formation fibrocartilage/granulation tissue formation callus formation d. ossification e. consolidation/remodeling Evidence of healed fracture b. c.

a.

4.

a.
b. c.

radiographic i. presence of external callus or cortical bone across the fracture site ii. fracture line may remain long after healing clinical i. pieces of bone no longer move at fracture site ii. no tenderness over fracture site weight bearing is pain free ORTHOPEDIC COMPLICATIONS

F.
A.

Fractures: complications

B.

C.

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 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) 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

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 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 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 Hemorrhage 1. Abnormal loss of blood from the body 2. Most common in fractures of bone marrow producing bones 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 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 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 deep venous thrombosis (DVT) e. pulmonary embolism - a complication of DVT 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

5.

c. d.

compartment syndrome - a nursing emergency

2.

f.

g. h.

prevention of malunion • reduce and immobilize properly • be sure client understands limits on activity and position 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 loss of adequate reduction refracture

ii.

G.

Nursing interventions 1. Risk for peripheral neurovascular deficit a. check neurovascular status often

b.
c. 2. Pain a. b.

elevate limb above level of heart (except with compartment syndrome) apply cold to minimize edema

3.

4.

5.

6.

assess level of pain with a scale of one to ten manage pain i. with drugs ii. reposition client iii. pad any bony prominences c. teach relaxation techniques 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 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 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 Impaired gas exchange a. accompanies chest trauma b. client risks fat embolism

H.

client risks deep venous thrombosis interventions i. mobilize as soon as possible ii. frequent and effective pulmonary toileting Fractures: factors that affect healing d.

c.

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 B. 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) 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

I.

II.

B.

Etiology 1. Genetic predisposition, shown by the presence of

Heberden's Nodes III. IV. V. VI. 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

Bouchard's Nodes Accompany Heberden's nodes , Found at the PIP joint, Occur more often in women than men Increase in frequency with age More common in men Often occurs in a. wrists b. elbows c. shoulders 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 a. 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 b. stage two: bone condensation i. erosion of cartilage ii. cartilage may be digested by an enzyme in the synovial fluid c. 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 Findings OSTEOARTHRITIS OF HIP/KNEE: SPECIFIC PHYSICAL FINDINGS 1. 2.

B.

5.
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 decreased range of motion flexion contracture i. hip ii. knee

2.

Knee a. b.

c. d. e.

varus deformity: bow legged appearance valgus deformity: knock-kneed appearance 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. 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. Bouchard's nodes joint deformities tenderness on palpation i. may involve widely separated areas of the joint ii. mild synovitis may be felt - positive bulge sign may be found pain on passive movement 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

c. d.

i. ii.

Heberden's nodes

e. f. g. h.

iv. v.
i. gait i. ii. iii. iv.

crepitation, crunching when joints are moved eventual ankylosis abnormal antalgic gait shortened stance widened base of support 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.

h.

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 bone scans i. radionuclide imaging ii. shows skeletal distribution of osteoarthritis iii. monitors complications of joint replacement surgery

7.

MRI scans show the extent of joint destruction j. computerized tomograms (CT) scans show cortical and cancellous bone density 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 passive range of motion exercises (illustration ) v. active stretching d. protection from further injury by splinting or bracing 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

i.

iv.

8.

remissive agents i. gold ii. penicillamine (cuprimine) iii. 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 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

d.

b. c.

arthroplasty

2.

Charcot joints (also called neuropathic joint disease) 6. Definition - multicausal degeneration and deformation of joint, usually ankle. (illustration ) 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 8. 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 9. 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 10. 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 11. 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 Chondromalacia patellae (also called patellofemoral arthralgia) 6. Definition: progressive, degenerative softening of the bone; follows a knee injury 7. 7. (illustration ) Etiology a. lateral subluxation of the patella (kneecap) b. direct or repetitive trauma to the patella produces chondral fracture c. underdevelopment of the quadriceps muscles Findings a. pain with flexed knee activities (poorly localized) b. mild swelling c. occasional episodes of buckling of the affected knee d. minimal joint effusion e. evidence of 'squinting kneecaps' f. atrophy of quadriceps g. inverted 'J' tracking of the patella in the final 30 degrees of extension h. excessive quadriceps angle i. positive apprehension sign

3.

8.

2.

j. crepitation upon range of motion Diagnostics a. 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 b. bone Scans c. MRI Scans d. arthroscopy (see Orthopedic surgery) 10. 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 11. 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 12. Nursing interventions (see previous Osteoarthritis section) Inflammatory Disorders 1. Rheumatoid arthritis (RA) 6. Definition - chronic systemic inflammatory disease of the connective tissue 7. Findings a. starts in feet and hands, gradually destroys these peripheral joints b. affects diarthroidial joints c. bilateral involvement 8. Etiology a. cause is not fully understood b. rheumatoid arthritis is an autoimmune disorder c. genetic tendency; but may involve bacteria, or viruses d. may affect the connective tissue of the lungs, heart, kidneys, or skin 9. Incidence a. two to three times more common in women than in men b. strikes between the ages of 20 and 50 years of age
9.

10. Pathophysiology a. synovitis immune complexes initiate inflammatory response
i. ii. IgB antibodies are formed rheumatoid factor (RF) 1. pannus formation 2. destruction of subchondral bone 3. present in 85 to 90% of all cases 4. worsens the inflammatory response - can go on indefinitely 5. irreversible - will lead to ankylosis of joint

11. 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 1. symmetrical 2. polyarticular c. general signs

i. ii. d.

fatigue loss of appetite and weight

iii. enlarged lymph glands (illustration ) 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 1. malaise 2. fatigue 3. weakness 4. loss of appetite and weight 5. enlarged lymph glands 6. Raynaud's syndrome ii. examination may reveal deformities 1. ulnar deviation 2. deformed hands: swan neck/boutonniere f. neurological examination i. foot drop ii. evidence of spinal cord compression 12. 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) 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 13. Management a. (see previous Osteoarthritis section) b. psychological support c. splinting: resting, corrective, or fixation Systemic lupus erythematosus (SLE) 6. Definition: chronic, systemic, inflammatory disease of the collagen tissues (illustration
b. 7. ) Etiology unknown a. most cases are women b. African Americans, Hispanics, Asians, and Native Americans are two to three times as likely as whites to have lupus c. antigen stimulates antibodies, which form soluble immune complexes, deposited in tissues; number of T suppressor cells dwindles. (illustration ) 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 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 d.

2.

8.

renal disorder: persistent proteinuria 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 9. Management a. expected outcomes i. control system involvement and symptoms ii. induce remission b. prevent bad effects of therapy c. recognize flare-ups promptly d. medical i. salicylates ii. nonsteroidal anti-inflammatory agents (NSAIDS) iii. corticosteroids iv. anti-infectives e. antineoplastics 10. Nursing care a. pain management strategies b. strategies to combat weight loss c. emotional support h.

f. g.

serositis: pleuritis

3.

Gout (illustration ) 6. Definition a. monoarticular asymmetrical arthritis b. characterized by hyperuricemia 7. 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. 8. 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 9. Diagnostics: lab tests find a. increased urinary uric acid following a purine restricted diet b. hyperuricemia 10. Management a. expected outcomes: control symptoms; prevent attacks b. medical i. NSAIDs ii. colchicine (used when NSAIDs are contraindicated) - enhances the excretion of uric acid iii. to prevent flareups: antihyperuricemic agents such as allopurinol (lopurin) or probenecid (benemid) - minimize the production of uric acid iv. heat or cold therapy

c.

dietary i.

3.

ii. iii. 11. 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) Metabolic Bone Disorders 1. Osteomalacia 6. Definition - delayed mineralization; resulting bone is softer and weaker 7. Pathophysiology - similar to rickets a. bones have too little calcium and phosphorus b. vitamin D deficiency; possibly inadequate exposure to sunlight i. less serum calcium than normal ii. more parathyroid hormone iii. more renal phosphorus clearance 8. Findings a. accurate client history includes: i. generalized muscle and skeletal pain in hips ii. similar pain in low back b. physical examination i. gait 1. client unwilling to walk 2. wide stance 3. waddling gait ii. muscle weakness iii. bones 1. deformities of weight-bearing bones 2. scoliotic or kyphotic deformities of the spine 3. bones break easily 9. Diagnostic testing a. radiographic findings i. generalized demineralization ii. pseudo fractures iii. bending deformities b. laboratory studies i. decreased serum calcium ii. decreased serum phosphorus iii. alkaline phosphatase level is moderately elevated 10. Management a. calcium gluconate b. vitamin D daily until signs of healing take place c. diet high in protein d. ultraviolet radiation therapy

avoid purine foods such as meats, organ meats, shellfish, sardines, anchovies, yeast, legumes control weight drink less alcohol - all types

2.

Osteoporosis (illustration ) 6. Definition a. multifactorial disease results in i. reduced bone mass ii. loss of bone strength iii. increased likelihood of fracture b. types type two osteoporosis (related to old age) Etiology/epidemiology a. most common metabolic disease of bone i. affects an estimated 25 million Americans ii. contributor of 50% of all adult fractures

i. ii.

type one osteoporosis

(estrogen related)

7.

b. c. d. e.

onset is insidious women affected twice as often as men before the age of 70 skeletal changes result from the aging process bone loss due to i. immobilization ii. lack of gravitational stress

8.

Factors related to osteoporotic fractures ADDITIONAL RISK FACTORS FOR OSTEOPOROSIS

A.

B.

C. a. b. c. i. ii.

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 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) Endocrine factors in osteoporosis premature menopause hyperthyroidism increases bone turnover and remodeling hyperparathyroidism increases bone turnover and 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. low bone density history of scoliosis neurological impairment after i. CVA Parkinson's disease decreased vision from macular degeneration, complications of diabetes, etc. best indicator of fracture risk in bone densitometry iii.

b. c.

b.
c.

ii.

9.

d. 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

loss of height i. two or more inches ii. usually precedes diagnosis of osteoporosis diagnosis 10. 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 11. 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 12. Nursing intervention: teach prevention of ssteoporosis and its damage a. education

e.

b.

i. increase awareness ii. discourage risk-related behaviors iii. reinforce positive behaviors and lifestyles reduce risk of falling )

3.

i. teach proper lifting and movement techniques (illustration ii. encourage proper footwear iii. install safety equipment in home Paget's disease (osteitis deformans) 6. Definition: a slowly progressing resorption and irregular remodeling of bone. 7. Etiology a. bone resorbed; new bone poorly developed, weak, easily fractured b.
c. d. e. Findings a. b. mainly affects major bones: skull, femur, tibia, pelvis, and vertebrae cause unknown possible viral implications family tendency - noted in siblings

8.

9.

asymptomatic initially musculoskeletal i. deformity of long bones ii. pain and point tenderness of affected limbs 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

VI.

Orthopedic Surgery

A.

Total hip replacement (illustration ) 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

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. 2. 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.

3.
A.

Postoperative complications

ORTHOPEDIC COMPLICATIONS

B.

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 Deep venous thrombosis (DVT)

C.

D.

E. F.

G.

H.

Anterior tibial or femoral veins May be caused by immobility Findings include calf pain, positive Homan's sign Immediately after operations a. anticoagulant therapy b. antiemboli stockings (usually) c. sequential compression device (possibly) 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 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 Hemorrhage 1. Abnormal loss of blood from the body 2. Most common in fractures of bone marrow producing bones 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 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 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 4. Nursing interventions an abduction device is used during the first postoperative week while the client is in bed or sitting in a chair to keep abduction device in place, turn client by logrolling to prevent flexion of the hip, use fracture bedpan client teaching I. use of assistive devices; crutches, walker, raised toilet seat

1. 2. 3. 4.

a.
b. c. d.

II. III. B.

methods to prevent dislocation can resume sexual activity when suture line heals. To avoid flexion of hip, client should be in dependent position for three to six months

a. b. c. a. b.

Total knee replacement 1. Indications for surgery osteoarthritis rheumatoid arthritis trauma 2. Surgical modalities metal or acrylic prosthesis, hinged or semiconstrained choice of prosthesis depends on the strength of surrounding ligaments to provide joint stability

3.
A.

Postoperative complications

ORTHOPEDIC COMPLICATIONS

B.

C.

D.

E. F.

G.

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 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) 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 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 Hemorrhage 1. Abnormal loss of blood from the body 2. Most common in fractures of bone marrow producing bones 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 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

H.

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 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 a. 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 a. Purpose: relieve findings; improve function; save or improve quality of life b. 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 c. Upper extremity indications A. trauma B. malignant tumor C. infection D. congenital malformations

e.

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 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 Staged amputation - used for infection. Guillotine amputation to remove infectious and necrotic tissue is performed. After intensive antibiotic therapy, a second operation is performed for skin closure. A. amputate to most distal point that will heal successfully B. determined by circulation and functional status Potential postoperative complications A. hemorrhage B. infection C. skin breakdown

e.

f.

g. h.

i. j.

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 A. may occur any time up to three months post amputation B. most common with above-knee (AK) amputations C. relieved with A. stump desensitization by kneading, or massage B. transcutaneous electrical nerve stimulation (TENS) C. distraction D. beta-adrenergic blocking agents for burning, dull pain E. anticonvulsants for sharp and cramping pain Wound healing A. aseptic dressing change technique B. compression dressing wrapped in a figure eight fashion or cast to control edema 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 Grief A. many clients go through a mourning process, shock, anger, and depression B. caregivers should support and listen actively Restoring physical mobility A. early rehabilitation B. muscle strengthening exercises

4.

5.

C. prosthetic preparation Types of prosthesis A. hydraulic B. pneumatic C. biofeedback - controlled D. myoelectrically controlled E. synchronized Arthroscopy a. Definition - endoscopic procedure that allows direct visualization of the joint, most often performed on knees and shoulders b. 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 c. Surgical procedure - most often, office surgery d. 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 e. Postoperative complications are rare A. infection B. thrombophlebitis C. stiffness External fixator
k.

Definition 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. C. D. E.

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. Ilizarov device lengthens limbs about one cm per month. Before discharge, teach clients 1. To care for pin 2. To adjust rod Clients may have the device on for several months. a. b.

Indication: the device will stabilize fracture with soft tissue injury like crush fractures Procedure: fracture aligned and immobilized by pins of Kirschner wires inserted in the bone and attached to a rigid frame outside the body c. 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 A. ambulation with assistive device (crutches, walker) B. care of pin site C. extremity is repositioned by lifting frame instead of extremity I. After hip replacements, pulmonary embolism may occur even without thrombosis in foot or leg. J. Clients should sit in a straight, high chair; use a raised toilet seat; and never cross their legs. K. In hip or knee replacement, clients will need assistive devices for walking until muscle tone strengthens and they can walk without pain. L. After an amputation, the home must be assessed for any modifications needed to ensure safety. M. Some clients will need transportation to continue rehabilitation. N. Amputee support groups can help clients and family. O. After arthroscopy, outpatient rehab may be prescribed depending on procedure; health care provider may prescribe knee immobilizer. P. External Fixator - If possible, prepare the client preoperatively to reduce anxiety. Device looks clumsy, but patient should be reassured that discomfort is minimal. Q. After a hip pinning or femoral-head prosthesis, caution client not to force hip into more than 90 degree of flexion, into adduction or internal rotation which will cause dislocation and severe pain and this would be a nursing emergency. R. Caution clients with a new prosthesis not to use any substances such as lotions, powders etc. unless prescribed by the health care provider. S. Osteoporosis cannot be detected by conventional X-ray until more that 30% of bone calcium is lost. T. Foods high in calcium include milk, cheeses, yogurt, turnip greens, cottage cheese, sardines, and spinach. U. 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. V. Clients at high risk for acute osteomyelitis are: elderly, diabetics, and clients with peripheral vascular disease. W. When clients receive corticosteroids long-term, evaluate them continually for side effects. X. Immunosuppressed clients should avoid contact with persons who have infections. Y. Steroids may mask the signs of infections, so client should promptly report slightest change in temperature or other complaints. Z. Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hours and wear sun block. Abduction device Adduction Ankylosing spondylitis ApophysealArticularArthroplasty Bursitis Calcaneal Carpal tunnel syndrome Charcot's joint Chondroma Circumduction Colles' Fracture CondylarCrepitation Cruciate ligament DiaphysealDiarthroidial joint Disarticulation Discoid Lupus Erythematosus EpiphysealEversion Ewing's Tumor ExtracapsularGanglion Haversian system Hyperextension Intra-articular soft tissue mass Intracapsular Inversion Isometric exercises Kirschner wire Laminectomy Lordosis Lyme Disease MetaphysealOsteoblastoma 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

• • • • • • • • • • • • •

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

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