PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya

School of Health Sciences – College of Nursing

Orthopedic Nursing

Ortho Lecture Series # 3 (Prepared By: Prince Rener V. Pera, RN)

Soft Tissue Injury & Metabolic Disorders

1. Sprain- complete or incomplete tear in the supporting ligaments surrounding a

joint that usually follows a sharp twist.

a) Ankle Sprain- An unnatural twisting motion can happen when the foot is
planted awkwardly, when the ground is uneven, or when an unusual amount
of force is applied to the joint. Ankle sprains are common sports injuries but
can also happen during everyday activities such as walking or even getting
out of bed.

The ankle joint is made up of three bones.

 The tibia is the major bone of the lower leg, and it bears most of the
body's weight. Its bottom portion forms the medial malleolus, the inside
bump of the ankle.
 The fibula is the smaller of the two bones in the lower leg. Its lower end
forms the lateral malleolus, the outer bump of the ankle.
 The talus is the top bone of the foot.

Signs and Symptoms

 Swelling, due to increased fluid in the tissue, is sometimes severe.

 Pain: The nerves are more sensitive. The joint hurts and may throb. The
pain can worsen when the sore area is pressed or the foot moves in
certain directions (depending upon which ligament is involved) and
during walking or standing.
 Redness and warmth: Caused by increased blood flow to the area

When to Consult

 Usually, an ankle sprain itself does not require a trip to the doctor. The problem is
how to tell a sprain from a more serious injury such as a fracture (break). If any of
the following occur, contact your doctor.
 Pain is uncontrolled, despite the used of over-the-counter medications,
elevation, and ice.
 One is unable to walk or cannot walk more than a few steps without severe pain.
 The ankle fails to improve within five to seven days. The pain need not be gone,
but it should be improving.
 The indications to go to a hospital's emergency department are similar to those
for which to call the doctor. The following conditions suggest a fracture or more
serious injury or that a splint may be needed for pain control:
 You feel severe or uncontrolled pain.
 You cannot move the injured ankle.
 The foot or ankle is misshapen beyond normal swelling.
 You cannot walk four steps, even with a limp.
 You experience severe pain when pressing over the medial or lateral malleolus,
the bony bumps on each side of the ankle.
 You experience loss of feeling in the foot or toes
 You have pain and swelling in the back of the ankle (heel pain), over the Achilles
tendon area, or the inability to push the toes down (forward-like pressing a gas
pedal).
 You have pain or swelling into the upper part of the lower leg just below the
knee or swelling of the calf muscle.
 Redness or red streaks spreading out from the injury are observed.
 You don't know how serious the injury may be or are unsure how to care for it

Diagnosis

 The doctor will perform a physical exam to see if a fracture or other serious injury
has happened that requires immediate care.
 The examination should check that the nerves or arteries to the foot have not
been injured and that the knee or the rest of the leg is not involved.
 The doctor will handle and move the foot and ankle to determine what bony
areas are involved.
 The Achilles tendon will be checked for signs of rupture.
 X-rays are often needed to confirm that a fracture is present. In some cases of
fracture, a CT scan may be needed.

Nursing Interventions

RICE

R-est= prevents further injury and avoids stress on already inflamed tissue
I-ce= will do more for most people than medications; increases blood flow to the
injured area
C-ompression=(sometimes called "strapping") provides support and helps
prevent inflammation
E-levation=(keeping the injured area up as high as possible) will help the body
absorb fluid that has leaked into the tissue.Ideally, prop the ankle up so that it is
above the level of the heart.Sit in a reclining chair or prop your legs up with
pillows.

Medical Treatment
 The doctor may elect to apply a brace or cast to reduce motion of the ankle.
Crutches are frequently provided so the patient does not have to bear weight
on the injured ankle.
 The most common medications used for ankle sprains are anti-inflammatory pain
medications that both reduce pain and help control inflammation.

Prevention

Ankle sprain prevention can be as simple as wearing the right shoes or as

complicated as balance training for athletes.
Keep the ankles strong and flexible.

 Wear proper shoes for the activity. High-top basketball shoes are a good choice.
 When participating in a sport, consider having a weak ankle taped to offer extra
support. If you have repeated sprains, wearing an ankle brace while playing
may help.
 Making sure that the playing field (or home environment) is clear of any holes or
obstacles also can help avoid injury.

2. Strain- Muscle strain or muscle pull or even a muscle tear implies damage to a
muscle or its attaching tendons. You can put undue pressure on muscles during
the course of normal daily activities, with sudden, quick heavy lifting, during
sports, or while performing work tasks.

Symptoms

Swelling, bruising or redness, or open cuts as a consequence of the injury

Pain at rest
Pain when the specific muscle or the joint in relation to that muscle is used
Weakness of the muscle or tendons (A sprain, in contrast, is an injury to a joint
and its ligaments.)
Inability to use the muscle at all

When to Consult

If you hear a "popping" sound with the injury, cannot walk, or there is significant
swelling, pain, fever, or open cuts, you should be examined in a hospital's
emergency department.

Exams and Tests

Medical History and Physical Exam

X-Ray/Laboratory

Treatment
 The amount of swelling or local bleeding into the muscle (from torn blood
vessels) can best be managed early by applying ice packs and maintaining the
strained muscle in a stretched position. Heat can be applied when the swelling
has lessened. However, the early application of heat can increase swelling and
pain.
Take NSAID agents such as aspirin and ibuprofen to reduce the pain
Protection, rest, ice, compression, and elevation (known as the PRICE formula)
can help the affected muscle. Here's how: First, remove all constrictive clothing,
including jewelry, in the area of muscle strain.
Protect the strained muscle from further injury.
Ice the muscle area (20 minutes every hour while awake). Ice is a very effective
anti-inflammatory and pain-relieving agent. Small ice packs, such as packages
of frozen vegetables or water frozen in foam coffee cups, applied to the area
may help decrease inflammation.
Compression can be a gently applied with an Ace or other elastic bandage,
which can provide both support and decrease swelling. Do not wrap tightly.
Elevate the injured area to decrease swelling. Prop up a strained leg muscle
while sitting, for example..

Prevention

Avoid injury by daily stretching.

Stretch every time before you exercise.
Establish a warm-up routine prior to engaging in strenuous exercise.
Start an exercise program in consultation with your doctor.

3. Fractures or Dislocations

A fracture is a break or crack in the bone. Several types of fractures exist, but
fractures resulting in bone fragments that penetrate the surface of the skin (called
compound fractures or open fractures) are particularly dangerous. Poor positioning
of the fractured extremity can obstruct blood flow to the affected limb.

A dislocation occurs when 2 bones are out of place at the joint. Dislocation may
also cause injury to nerves and blood vessels. Joints that become dislocated and
later heal are more likely to become dislocated again.

Symptoms

Tenderness, swelling, deformity, and discoloration occur with fractures and/or

dislocations.
Bleeding occurs when a fractured bone pierces the skin (a compound fracture).
Sensation may be lost below the fracture or dislocation, indicating possible nerve
injury.

Treatment
If medical attention is not readily available, try the following guidelines to treat a
fracture or dislocation:
Apply a cold pack to the area of fracture or dislocation to decrease swelling
and to relieve pain.
Flush open wounds associated with compound fractures with clean, fresh water
and cover them with a dry dressing.
Splint the injured area to keep it from moving. Support a broken limb by using the
best material available for a splint, such as sticks, part of a backpack frame, or
other stabilizing device. Wrap tape around the splint and the extremity affected.
For example, if a forearm is broken, the splint should run from the wrist to the
upper arm and support the arm without repositioning it.
Monitor the extremity near the fracture or dislocation, assessing any loss of
sensation, decreased temperature, and pulse.
If medical attention is unavailable, realigning the fractured or dislocated extremity
may restore circulation and save the limb but may also result in further damage to
the tissue, blood vessels, or nerves.
Pain may be relieved with 1-2 tablets of acetaminophen (Tylenol) every 4 hours
or 1-2 tablets of ibuprofen (Advil, Motrin) every 6-8 hours.

When to Consult

Seek immediate medical attention if a fracture or dislocation penetrates the

skin, if the extremity feels cold, or if pulse or sensation decreases.
Seek prompt medical attention for elbow, knee, and hip dislocations
because nerve damage may occur.

4. Osteoporosis is a disease characterized by low bone mass and loss of bone tissue
that may lead to weak and fragile bones. If you have osteoporosis, you have an
increased risk for fractured bones (broken bones), particularly in the hip, spine,
and wrist.

Causes
Osteoporosis occurs when there is an imbalance between new bone
formation and old bone resorption. The body may fail to form enough new
bone, or too much old bone may be reabsorbed, or both. Two essential
minerals for normal bone formation are calcium and phosphate. Throughout
youth, the body uses these minerals to produce bones.
The leading cause of osteoporosis is a lack of certain hormones, particularly
estrogen in women and androgen in men. Women, especially those older
than 60 years of age, are frequently diagnosed with the disease. Menopause
is accompanied by lower estrogen levels and increases a woman's risk for
osteoporosis.
Lack of weight-bearing exercise, and other age-related changes in
endocrine functions (in addition to lack of estrogen).
Overuse of corticosteroids (Cushing syndrome)
Thyroid problems
Lack of muscle use,
 Bone cancer
Certain genetic disorders

Risk Factors
Women are at a greater risk than men, especially women who are thin or
have a small frame, as are those of advanced age.
Women who are white or Asian, especially those with a family member with
osteoporosis, have a greater risk of developing osteoporosis than other
women.
Women who are postmenopausal, including those who have had early or
surgically induced menopause, or abnormal or absence of menstrual periods
are at greater risk.
Cigarette smoking, eating disorders such as anorexia nervosa or bulimia, low
amounts of calcium in the diet, heavy alcohol consumption, inactive lifestyle,
and use of certain medications, such as corticosteroids and anticonvulsants,
are also risk factors.
Rheumatoid arthritis itself is a risk factor for osteoporosis.
Having a parent that has/had osteoporosis is a risk factor for the offspring.

Symptoms

Early in the course of the disease, osteoporosis may cause no symptoms. Later, it
may cause dull pain in the bones or muscles, particularly low back pain or neck
pain.
Later in the course of the disease, sharp pains may come on suddenly. The pain
may not radiate (spread to other areas); it may be made worse by activity that
puts weight on the area, may be accompanied by tenderness, and generally
begins to subside in one week. Pain may linger more than three months.
People with osteoporosis may not even recall a fall or other trauma that might
cause a broken bone, such as in the spine or foot. Spinal compression fractures
may result in loss of height with a stooped posture (called a dowager's hump).
Fractures at other sites, commonly the hip or bones of the wrist, usually result from
a fall.

When to Consult

If you are past menopause and have constant pain in areas such as the neck or
lower back, and you are at risk for developing osteoporosis, consult your doctor
for a medical assessment and bone density screening.
Go to the hospital if you feel severe pain in your muscles or bones that limits your
ability to function. Go to the hospital's emergency department if you have
sustained trauma or suspect fractures of your spine, hip, or wrist.

Exams and Tests

1. History taking to determine if you have osteoporosis or if you may be at risk for
the disease.
2. Blood tests are used to measure calcium, phosphorus, vitamin D, testosterone,
and thyroid and kidney function.
3. Bone mineral density test that can measure bone density in various sites of the
body. A bone mineral density test can detect osteoporosis before a fracture
occurs and can predict future fractures. A bone mineral density test can also
monitor the effects of treatment if the tests are performed a year or more apart
and may help determine the rate of bone loss.
4. Peripheral machines may measure density in the finger, wrist, kneecap,
shinbone, and heel.
5. DXA (dual-energy X-ray absorptiometry) measures the bone density of the spine,
hip, or total body. With your clothes on, you simply lie on your back with your legs
on a large block.
6. SXA (single-energy X-ray absorptiometry) is performed with a smaller X-ray
machine that measure bone density at the heel, shin bone, and kneecap.

Treatment
Focuses on slowing down or stopping the mineral loss, increasing bone density,
preventing bone fractures, and controlling the pain associated with the disease.
Diet: Young adults should be encouraged to achieve normal peak bone mass
by getting enough calcium (1,000 mg daily) in their diet (drinking milk or calcium-
fortified orange juice and eating foods high in calcium such as salmon),
performing weight-bearing exercise such as walking or aerobics (swimming is
aerobic but not weight-bearing), and maintaining normal body weight.
Specialists: People who have spinal, hip, or wrist fractures should be referred to a
bone specialist (called an orthopedic surgeon) for further management. In
addition to fracture management, these people should also be referred to a
physical and occupational therapist to learn ways to exercise safely.
Exercise: Studies show that exercises requiring muscle to pull on bones causes the
bones to retain, and perhaps even gain, density. Some of the recommended
exercises include weight-bearing exercise, riding stationary bicycles, using rowing
machines, walking, and jogging.

Medications

Estrogen: For newly menopausal women, estrogen replacement is one way to

prevent bone loss. It may be taken orally or as a transdermal (skin) patch (for
example, Vivelle, Climara, Estraderm, Esclim, Alora).
SERMs: For women who are unable to take estrogen or choose not to, selective
estrogen receptor modulators (SERMs) such as raloxifene (Evista) offer an
alternative.
Calcium: Calcium and vitamin D are needed to increase bone mass in addition
to estrogen replacement therapy.A daily intake of 1,200-1,500 mg (through diet
and supplements) is recommended. Take calcium supplements in doses of less
than 600 mg.
A daily intake of 800-1,000 IU of vitamin D is needed to increase bone mass.
Bisphosphonates: Taken by mouth include alendronate, risedronate, etidronate;
intravenous medications include bisphosphonate, zoledronate (Reclast). These
 drugs slow down bone loss.
Before beginning to take a bisphosphonate, your doctor will determine if you
have enough calcium in your blood and if your kidneys are functioning well.
Alendronate (Fosamax): This medication is used to treat osteoporosis and to
prevent bone loss in women. You must take this medication first thing in the
morning with a large glass of water and not lie down or eat for 30 minutes. Some
women find this restriction difficult. This medication is taken daily or once a week.
Other hormones: These hormones help regulate calcium and/or phosphate
levels in the body and prevent bone loss.
1. Calcitonin (Miacalcin): A hormone (extracted from salmon) that slows bone
loss and may increase bone density. You may be given this drug as an
injection (every other day or two to three times a week) or as a nasal spray.
2. Teriparatide (Forteo): Teriparatide contains a portion of human parathyroid
hormone. It primarily regulates calcium and phosphate metabolism in bones,
which promotes new bone formation and leads to increased bone density.
This drug is given as a daily injection.
Prevention

Building strong bones during childhood and adolescence can be the best defense
against developing osteoporosis later. The average woman has acquired 98% of her
skeletal mass by 30 years of age.There are four steps to prevent osteoporosis.

Eat a balanced diet rich in calcium and vitamin D.

Engage in weight-bearing exercise.
Adopt a healthy lifestyle with no smoking or excessive alcohol intake.
Take medication to improve bone density when appropriate.

5. Paget's Disease

Paget's disease of the bone is the second most common bone disorder in elderly
patients. It affects the normal remodeling process of bone. In normal bone, the
bone constantly remodels. In the remodeling process, old bone is removed and new
bone is formed. In patients with Paget's disease, this process is altered. These
patients have an excessive amount of bone resorption (removal) followed by an
even more excessive amount of new bone formation.

Men are affected by Paget's disease slightly more often than women (3:2 male-to-
female ratio). Paget's disease is more common in patients of Northern European
ancestry, most commonly in those from Great Britain. It is rare in Asia and Africa. It is
more common with increasing age, typically diagnosed in people in their 50s.

Causes

The exact cause of Paget's disease remains uncertain. Several theories have been
suggested, including a viral cause (such as paramyxovirus including measles,
respiratory syncytial virus, or canine distemper virus).There is also thought to be a
genetic link for Paget's disease; however, this has not been confirmed.
Symptoms

Most people with Paget's disease do not have symptoms. It is often discovered as
an incidental finding on routine x-ray films or blood tests.

When symptoms do occur, the most common ones include joint and low back pain.
Other less common symptoms include fractures, bowing deformities of the bones,
hearing loss, headaches, and muscle weakness. pagetic bone contains numerous
blood vessels, so a traumatic fracture through pagetic bone may result in significant
blood loss. A patient can rarely develop congestive heart failure because of the
increased vascularity.

When to Consult

People should seek medical care if they have increasing pain or dysfunction related
to Paget's disease. Also, people with weakness or a change in bowel or bladder
function should seek immediate care to assess for involvement of the spine leading
to compression of the spinal cord and nerve roots.

Exams and Tests

Laboratory studies include both blood and urine studies. Bone-specific alkaline
phosphatase is a specific laboratory study that provides information on the rate
of bone turnover.
Other laboratory studies include assessment of calcium, phosphate, and
parathyroid hormone levels. In many cases, these levels remain normal. Urine
tests include N-telopeptides and deoxypyridinoline, which measure bone
degradation products secreted in the urine.
Radiographic studies are often limited to plain radiographs (x-ray films).
Bone scans are useful in assessing the extent of disease throughout the entire
skeleton.
Magnetic resonance imaging (MRI) can be useful in the evaluation of patients
with neurologic dysfunction or muscle weakness to assess for involvement of the
spine and compression of the spinal cord or nerve roots.

Treatment

Medical treatment is geared toward pain relief and reducing the amount of
bone turnover with medications.
Nonsteroidal antiinflammatory drugs (NSAIDS) such as ibuprofen (Motrin, Advil) or
naproxen (Naprosyn, Aleve)
Bisphosphonates inhibit excessive bone loss. Examples of these medications and
typical doses for Paget's disease are:
1. Alendronate (Fosamax) 40 mg daily
2. Risedronate (Actonel) 30 mg daily
3. Tiludronate (Skelid) 400 mg daily
Surgery

Indications for surgery for Paget's disease include bony deformity, pathologic
fractures, and neurologic dysfunction due to spinal stenosis, degenerative joint
disease, or malignant transformation to sarcoma.

Patients with neurologic dysfunction due to involvement of the spine may benefit
from spinal decompression. This involves removing portions of the bone surrounding
the spinal cord and nerve roots to alleviate compression of these structures.

Cases of severe degenerative joint disease, most commonly the hip and knee, may
be treated with joint replacement surgery to relieve pain and improve function and
mobility.

In the rare cases of malignant transformation to sarcoma, removal of the affected

bones may be justified.

Other Therapy

Patients with involvement of the joints often benefit from a physical therapy and
muscle strengthening program.

“The more you humble yourself, the more GOD lifts you up….
The more you don’t expect GOD to reward you for serving Him,
the more you receive from Him..
The simplest way to please GOD is not to repay all the blessings we receive from HIM
but to simply pass them on to other.”
BE A BLESSING ALWAYS!!!

----principe