MEDICAL SURGICAL NURSING WARNING!

USE AT YOUR
DE LA SALLE MEDICAL AND HEALTH SCIENCES INSTITUTE LECTURER: PROF. ROMMEL L. SALAZAR OWN RISK
COLLEGE OF NURSING ACADEMICS COMMITTEE TRANSCRIBED BY: Angelu Abad

PROFESSOR POWERPOINT TEXTBOOK FUNCTIONS OF THE SKELETAL SYSTEM

« Ï ➔
• Support
- Form a rigid framework of the body
THE SKELETAL SYSTEM - Supports the body against the pull of gravity
- Cartilage as support and cushion of the
TABLE OF CONTENTS
I. The Skeletal System bones
- Ligaments hold bones together
a. Functions of the Skeletal System
« Size of the body is dependent on the rigid
b. Classification of Bones (According to
framework of the skeletal system
Shape)
• Protection
c. Classification of bones (According to
- Protect vital organs
Nature of Matrix)
• Movement
d. Microscopic Anatomy
- Bones work together with muscles as simple
e. Structure of a Long bone
mechanical lever systems
f. Bone Marrow - Joints - enable back and forth movement
g. Bone Development and Growth « There are individuals who are born non-
h. Bone Markings locomotive (congenital anomalies of the
i. Articulating Projections skeletal system).
ii. Non-articulating Projections • Storage
iii. Depressions/Openings - Storage area for minerals and fats
iv. Others ➔ Calcium & Phosphorus
« Ex. A pt with spinal cord injury who is
THE SKELETAL SYSTEM bedridden for 6 months. The pt then became
• Accounts for about 20% of the very skinny; this is due to demineralization.
body weight « Demineralization - body’s not maximizing
• Consists of: the calcium, phosphorus, and other minerals
o Cartilages brought about by the inability to move by the
o Ligaments client
o Tendons • Hematopoiesis
o Bones - Red marrow - formation of blood cells
§ Axial Skeleton (80) « There are some CA prototypes which
• Skull necessitate the diagnostic procedure - Bone
• Thorax Marrow Aspiration (BMA)
• Vertebral Column « AP will inject a large needle into the spongy
§ Appendicular Skeleton part of the bone and aspirate RBM (red bone
(126) marrow) using a big needle to detect the
• Pectoral girdle integrity of the body and to r/o CA.
• Pelvic girdle
• Extremities

« Total: 206 bones (excluding teeth and

sesamoid bones -> small bones found in our
cartilages

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CLASSIFICATION OF BONES (According to
Shape)
1. Long bones
« Longer than it is wide
« Growth occurs by lengthening of the
diaphysis located at the center of the long
bones
« Hallmark of the lengthening of the diaphysis -
during adolescence
« Found in arms and legs MICROSCOPIC ANATOMY
« Clients suffering from traffic or VA experience • Bone cells
fractures on the femur, tibia, and/or fibula 1. Osteoblasts - for bone formation
« In our UE, long bones include the humerus, « Involved in mineralization - calcium
radius, ulna, and clavicles deposits
2. Short bones 2. Osteocytes - for bone maintenance
« About as wide as they are long 3. Osteoclasts - for bone breakdown and
« Ex. carpals and tarsals resorption
3. Flat bones « Osteo- = bone
« Broad bones which provide protection and
muscle attachment • Osteon/Haversian System
« Ex. cranium, ileum, sternum, ribcage, sacrum, - Microscopic unit of compact bone
and scapula - Central/Haversian canal and its contents
4. Irregular bones « It is very important; canal for blood and nerve
« Non-uniform shape supply to the bones
« Ex. vertebrae and facial bones « Runs along axis of the bone
5. Sesamoid bones
« Smaller that are fixed in tendons to protect • Volkmann’s canal
them - Communicating pathway/perforating canal
« Ex. Patella « A.k.a. perforating holes that run parallel to
the surface and the long axis of the bone
which assist in the blood and nerve supply
from the periosteum and the Haversian canal
« Maintains proper communication of blood
and nerve supply to the bone

• Lamellae
- Matrix circles/rings

• Lacunae
- Tiny cavities

CLASSIFICATION OF BONES (According to Nature • Osteocytes

of Matrix) • Canaliculi
1. Compact (Cortical) - Network of tiny canals
• Dense, hard; solid matrix and cells
• Forms most of the diaphysis of long bone • Trabeculae
• Forms the protective exterior portion of all - Delicate interconnecting rods or plates of
bones bones
2. Spongy (Cancellous) « Allows circulation around the bone
• Lighter and less dense than compact; consist ➔ Resemble beams of scaffolding.
of trabeculae
• Located mainly in the epiphyses of long
bones
• Forms the interior of all other bones

ABAD | A.Y. 2021 2 of 6

 BONE MARROW
• Yellow Marrow
- Medullary Cavity
- Storage area for adipose tissue
• Red Marrow
- Produces red and white blood cells
« Fills spaces in spongy bone and some long
bones
« Bone marrow aspiration (e.g. t/c
osteosarcoma, etc.)
➔ Only site of blood formation in adults.

BONE DEVELOPMENT AND GROWTH

• Three cell types involved:
1. Osteoblasts
- None-forming cells
- Synthesize and secrete the organic matrix
components
« Involved in mineralization or calcium
Cancellous bone deposit of the bone
2. Osteocytes
- Mature bone cell
- Maintain healthy bone tissue
- Control the calcium release from the bone
tissue to the blood
« >50 years old = Depletion of Ca deposits
3. Osteoclasts
- Break down and reabsorb bone
- Very important to bone growth, healing,
STRUCTURE OF A LONG BONE and remodeling
« Allows bone to regenerate

• Ossification = osteogenesis
« Bone formation by osteoblasts.
➔ After an osteoblast becomes completely
surrounded by bone matrix, it becomes a
mature bone cell (osteocyte)
« Distinct from the process of calcification
« Calcification takes place during the
ossification of bone; pag nagkaroon na ng
ossification, doon lang maghaharden yung
bone or the calcification of the bone

• End of 8th week after conception: ossification

begins
« Ossification begins as early as 6-8 weeks
after fertilization in the embryo (NIH, n.d.)

ABAD | A.Y. 2021 3 of 6

• Two types of ossification:
1. Intramembranous
« Development of one of fibrous
membranes
2. Endochondral
« Development of bone from hyaline
cartilage
« Board exam: bone growth continues until
approximately at 25 years old
➔ Epiphyseal plate -> Epiphyseal line

1. Intramembranous Ossification
• Occurs within connective tissue membranes
« Involved in the formation of the flat bones of
the skull, mandible, and clavicles
• Replacement of connective tissue membranes
with bony tissue
• Occurs primarily in the bones of the skull
• Also occurs in some irregular bones
3. Appositional growth
• Expansion & widening of bones
• Growth & Sex hormones
« Increases width of the bone
« Long bones stop growing at the age of 18
(females) and 21 (males) through the process
of epiphyseal plate closure
« Increase in the diameter of the bone by addition
of the bony tissue at the surface of the bone, it
can be in the endosteum or periosteum

« The compact and spongy bones develops

directly from the sheaths of mesenchymal or
undifferentiated connective tissue
« Begins in utero and continues to adolescence

2. Endochondral Ossification
• Occurs inside cartilage
• Replacement of hyaline cartilage with bony
tissue
• Most of the bones of the skeleton and the base of
the skull undergo endochondral ossification
« Process of bone development from the hyaline
cartilage BONE MARKINGS
« Board exam: Endochondral ossification takes • Articulating Projections
much longer than intramembranous ossification • Non-articulating Projections
• Depressions/Openings
• Others

1. Articulating Projections
• Head - expanded; with
neck
- Ex. Head of femur
- Ball-and-socket
relationship

ABAD | A.Y. 2021 4 of 6

• Condyle – round • Trochanter - Very LARGE, blunt

• Tubercle - Small, round

• Tuberosity - Roughened, LARGE, round

• Facet - smooth & flat

• Spine - sharp, slender, pointed

• Crest - narrow ridge; prominent

• Ramus - armlike bar

2. Non-articulating Projections
• Line - narrow ridge; less prominent
• Process - any bony PROMINENCE

3. Depressions/Openings
• Fossa - Shallow, basinlike
• Foramen - Round or oval
• Epicondyle - raised area

ABAD | A.Y. 2021 5 of 6

• Groove - Furrow
• Notch – Depressions

• Fissure - Narrow, slitlike

• Sinus – cavity

• Meatus - canal-like

4. Other Bone Markings

• Angles - junction between borders
• Borders - edge
• Neck - indented groove

ABAD | A.Y. 2021 6 of 6

 MEDICAL SURGICAL NURSING II WARNING!
USE AT YOUR
DE LA SALLE MEDICAL AND HEALTH SCIENCES INSTITUTE LECTURER: ASSOC.PROF. ANABELLE S. UMALI OWN RISK
COLLEGE OF NURSING ACADEMICS COMMITTEE TRANSCRIBED BY: ROSHELLE REVITA

PROFESSOR ONLINE REFERENCES TEXTBOOK RISK FACTORS/ INFECTIOUS AND INFLAMMATORY

★ + ➔ • Osteomyelitis
 Prone to infections in the musculoskeletal system:
MUSCULOSKELETAL DISORDERS o Poorly nourished
RISK FACTORS o Impaired immune system
o Obese
o Elderly
TABLE OF CONTENTS o Chronic illnesses
I. Risk Factors  E.g. Cancer
a. Fracture o Compound Fx
b. Infectious and Inflammatory • Pott’s Disease
c. Metabolic Bone Disorders  Tuberculosis infection/disease that is not confined
i. Osteomalacia/Rickets in the lungs.
ii. Gout/Gouty Arthritis  Commonly, Spine affectation.
iii. Osteoarthritis
iv. Congenital Talipes Equino-Varus (CTEV) RISK FACTORS/ METABOLIC BONE DISORDERS
v. Congenital Hip Dislocation • Paget’s Disease
vi. Bone Tumor o Age (50 Above)
vii. Polymyositis  Deformities of femur, tibia, etc.
• Osteoporosis
OBJECTIVES
On the completion of this topic, student will be able to:
• Identify modifiable and non-modifiable risk factors for
specific musculoskeletal disorders.
 As nurses, we need to know the risk factors
(modifiable and non-modifiable) since it’ll be
helpful for us in providing health teaching to our
patients.

RISK FACTORS/ FRACTURE

• Mechanical Overload of the bone
 Activities that are giving too much pressure or
stress to the bone that is more than it can handle.
• Metabolic bone disease
• Drug used (Steroids)
 This affects the bone density.
• High risk recreation
 Risky; prone to accidents.
• Domestic violence
 Rocks, steel, wood, or anything used in physical
abuse.
• Elderly
 Regular occurrence of bone destruction than bone
resorption.  Female > Male: due to smaller frame/bone
 Muscular disorders/conditions like osteoporosis, structure compared to males.
osteoarthritis.  Calcium and Vit.D - needed for bone
 Post-menopausal women: decreased bone mass formation.
• School age male  High phosphate – carbonated drinks
 Overactivity  Sedentary Lifestyle can affect the bone
maintenance.

REVITA | A.Y. 2021 1 of 3

OSTEOMALACIA/RICKETS OSTEOARTHRITIS
• Black than whites  Can be idiopathic or secondary.
• Premature  More common in women.
 Infants – Rickets  Can occur in people with history of joint injury.
• Poor Dietary Habits
 Vegetarians – inadequate intake of Vit. D. • Unknown
• Malabsorption • Age
 Calcium is absorbed in the GI; malabsorption • Genetic
problems in the GI tract affects the calcium  Faulty genes
absorption. • Mechanical Stressor
• Malnutrition o Obesity
 Lactose intolerance causes limitations in intake of o Athletes
Ca products, which may result in malnutrition. o Dancer
• Small bowel resection o Infection
• Renal insufficiency
 Kidney problems also affects the Vit. D in the CONGENITAL TALIPES EQUINO-VARUS (CTEV)
body. Some of these factors are:
• Hyperparathyroidism • Abnormal intrauterine forces
 Parathyroid hormone increases the Ca • Arrested fetal development.
concentrations. • Male
• Prolonged use of antiseizure drugs
 Can result to Vit. D deficiency. + Clubfoot (Congenital Talipes Equino-varus): idiopathic
deformity of the foot.
GOUT/GOUTY ARTHRITIS + Baby's foot is twisted out of shape or position.
• Men 8-9x more frequent than women + The tissues connecting the muscles to the bone
• Can occur at any age of life (Fifth decade) (tendons) are shorter than usual.
• 85% person with gout: + Clubfoot is a fairly common birth defect and is usually
o Family history an isolated problem for an otherwise healthy newborn.
• Dietary intake  Deformity in which the foot is adducted.
 Inwardly deviated.
 Primary gout  Foot deformity can be positional.
- Related to underexcretion or overproduction  Can be idiopathic or a result of another syndrome (e.g.
of uric acid, often associated with a mix of Spina bifida)
dietary excesses or alcohol overuse and
metabolic syndrome.
- Accumulation of the uric acid (by-product of
purine metabolism)
 Secondary gout
- Caused by other conditions like blood
problems (e.g., polycythemia vera, leukemia,
myeloma), which causes rapid destruction of CONGENITAL HIP DISLOCATION
the cells, causing increased production of the • Abnormal development of the joint caused by
uric acid. o Fetal position
- Can be caused by renal disorders due to o Genetic Factor
problems in the excretion of uric acid. • Hormonal factors (Abnormal relaxation of the
ligaments of the joints)
• Breech Delivery
• Female
 4x more likely to be affected than males.
 Uneven hips upon assessment
 Lim. ROM (Abduction)
 (+) Ortolani’s Sign – flex the leg, abduct the hip,
(+) clicking sound.

REVITA | A.Y.2021 2 of 3
BONE TUMOR
• Common in adolescents
• Genetic

 Pertains to either malignant or benign tumors.

 Malignant: osteosarcoma – most common bone
tumor found in childhood/adolescents because of
growth spurts (rapid growth), which increases
likelihood of mutations.
 15-19 years of age
 Molecular: chromosome 13 – identification of
tumor suppressor gene.

POLYMYOSITIS
• Affects adults sometime between their 40s and 50s
• Women are affected more often than men are.

 Group of diseases that are termed as idiopathic

inflammatory myopathies.
 2 cases per 10,000 adults

+ Polymyositis is a disease that causes muscles to

become irritated and inflamed. The muscles
eventually start to break down and become weak.
The condition can affect muscles all over the body.
This can make even simple movements difficult.

REVITA | A.Y.2021 3 of 3
 MEDICAL SURGICAL NURSING II
DE LA SALLE MEDICAL AND HEALTH SCIENCES INSTITUTE
COLLEGE OF NURSING ACADEMICS COMMITTEE
PROFESSOR POWERPOINT
★ Í
MUSCULOSKELETAL ASSESSMENT
CONTENT OUTLINE
I. Subjective Data
II. Specific Assessment Regarding Pain
III. Objective Data
a. Physical Exam
>Fracture
>Ankylosis
>Heberden’s Node
>Bouchard’s Node
>Scoliosis
>Common Foot Disorders
>ROM
>Muscle Strength
>Grading Motor Strength
>Age Related Variations
b. Special Tests
>Snuffbox Tenderness
>Phalen’s & Tinel’s Sign (Carpal Tunnel
Syndrome)
>Drop Arm Test
>Impingement Sign
>Patient Standing Erect
>Patient Bending Forward
>Limb Measurement
>Adam’s Forward Bend Test
>Test for Effusion
>McMurray’s Test
>Varus & Valgus Stressing
>Drawer Test
>Thomas Test
>Trendelendburg Test
>”FABER” Test
>Ortolani’s Sign
>Barlow’s Test
>Allis Sign
SUBJECTIVE DATA
Í Chief Complaints
Í Pain - comprehensive pain assessment
« Usual complaints of pt.
o Location
AGCAMARAN • CUENO | 2021
WARNING!
USE AT YOUR
LECTURER: Anabelle Umali, RN, MAN OWN RISK
TRANSCRIBED BY: Krisha Agcamaran &
Cyrus Cueno
« Ask the pt if the pain radiates from other
TEXTBOOK parts of the body
➔
o Intensity
« It is important to know because the pt
might need urgent medical management
to lower the intensity of pain
« Use the pain scale from 1-10.
o Quality
« Description of pain ex. parang kinukurot,
parang sinasaksak, burning pain,
shooting, sharp, radiating, aching,
heavy, dull, cramping, and throbbing
pain.
« Muscular pain- aching pain
« Fracture pain- sharp, piercing pain and it
is relieved by immobilization
o Onset and Duration
« Onset- when was the pain felt or began?
« There are some musculoskeletal
conditions that are felt upon waking up
like tendonitis, rheumatic disorders. Pain
felt by the pt is worse in the morning.
« Osteoarthritis usually worsens as the day
progresses. It may not be painful early in
the morning, but intensifies in the
evening.
« Duration- how long the pain is
experienced and continues to be present
o Aggravating and Relieving Factor
« What condition makes the pain worse or
better?
« Pain that increases with activity may
indicate joint pain, muscle pain, or
compartment syndrome.
« Fracture- can be relieved by
immobilization
« Rheumatoid arthritis- joint pain being
relieved by inactivity
« Osteoarthritis- joint pain after period of
activity
Í Altered sensations
Physiological complaints
« Ex. Paresthesia, burning, tingling,
numbness
1 of 9
 « Sensation can be caused by a pressure
in the nerve or by impairment in the
circulation
Í Past Health, Social, and Family History
« We need to know the patient’s work to
know if there’s a connection to the pain
he is experiencing.
« Ask if there is hx of gout, arthritis, TB, CA
« Ask for hx of trauma or vehicular
accident
« Lifestyle – we need to know about this
because it can put a stress also on the
bones of the patient
« Medications- there are some
medications that affect musculoskeletal
Ex. Steroids- can cause osteoporosis
Anticonvulsants
SPECIFIC ASSESSMENT REGARDING PAIN
Í Is the body in proper alignment?
Í Are the joints symmetrical or are bony
deformities present?
Í Is there any inflammation or arthritis, swelling,
warmth, tenderness, or redness?
OBJECTIVE DATA
PHYSICAL EXAM
Í Mental Status 
 - abnormally rounded thoracic
« Check the level of consciousness
Í General inspection: Height, weight, nutritional
status, skin 
 - pt who has osteoarthritis are prone
« If it is possible while the pt is standing
look for the posture of the pt because
sometimes we can already see in the
posture of the pt if there is affectation on
the spine
Í Gait
« Sometimes we can see if there is an
affectation on the lower extremities on
how they execute their walking
« Ex. Waddling gait, spastic gait
Í Inspection and Palpation (alignment,
symmetry and deformities) 
 - the waist is lower than the other
« If it is possible do first the examination
on the normal extremities before
examining on the affected side because
by doing that you will know what
response is expected on the pt
a.1. Head 
- swelling, symmetry, evidence of
trauma
AGCAMARAN • CUENO | 2021
« after the inspection & palpation, do
ROM test usually TMJ is done to check
if there will be crepitus: (+) affectation on
TMJ
a.2. Neck- check the front, back and sides of
the pt’s neck for symmetry and masses
and palpate the processes of the cervical
or vertebral areas.
« Take note for any tenderness, swelling
or nodules
« For ROM- ask the patient to touch his
ears, shoulders etc.
a.3. Shoulder and upper extremities – check for
symmetry, muscle atrophy, deformity or
tenderness
« For ROM - flexion, extension,
circumduction
a.4. Wrist and hand - check the symmetry,
nodules, redness, swelling, and deformities
« For ROM: flexion, extension,
circumduction, abduction

b. Spine
« It is better to ask the pt to stand and
check the back of the pt to know if
there’s a presence of lordosis, scoliosis,
kyphosis
« Kyphosis
- common deformity thoracic is
abnormally rounded
to kyphosis
« Lordosis
- there is abnormally concave on
lumbar spine
- seen on patients who are pregnant
and sometimes teens.
« Scoliosis
- lateral curvature of the spine
- one of the shoulder is lower than the
other and if you will check the spine
is on a S form
c. Hips, knees, ankles and feet 

« check for contour and symmetry of the
hip area, position of the knees (note for:
bowleg, knees are pointing out and
watch the pt walk)
Í ROM ex., deep tendon reflexes, bone integrity,
muscle strength and tone 

Í Neurovascular Assessment 

2 of 9
 « For the pt who have previous fracture HEBERDEN’S NODE
- Check the skin of the pt., presence of
pulses, presence of pallor
« Done also to patients who have
musculoskeletal disorders

FRACTURE
Í Obvious deformity
Í Ecchymosis
Í Swelling
Í Tenderness
Í Pain
Í Impaired sensation
Í Decreased mobility
« In extremities, we don’t need to do ROM if the « Appears on the distal interphalangeal joints
deformities are already obvious because it can « Usually hard and with pain
aggravate the fracture of the pt « Typically seen with patients who have
« But for the deformities that are not obvious ex. osteoarthritis
Pelvis, still we need to check ROM if there is a
fracture on the hips BOUCHARD’S NODE
« Are similar but less common
ANKYLOSIS « It appears on the proximal interphalangeal
joints
« Abnormal findings are typically seen on
patients with osteoarthritis

SCOLIOSIS

« It is a fusion of joints seen in the elbow, ankle,

knee, shoulder, finger or even jaw bone
because of genetics, injury and sometimes
patients who suffer long immobility (bed-ridden
patients), infections or certain diseases « Kyphosis - seen in pts with Pott’s disease,
« Seen on pt who have osteoarthritis or osteoarthritis
rheumatoid arthritis.

AGCAMARAN • CUENO | 2021 3 of 9

COMMON FOOT DISORDERS « Neuroma/Morton’s neuroma
« Swelling on
the lateral
branch of the
median
plantar nerve
on the third
toe.

« Microscopically, there is a digital artery

that is passing the ischemia.
« Pt will complain of throbbing, burning pain
« Usually it is relieved with rest and
« Hammer toe massage
« There is a flexion deformity in the
interphalangeal joints which may involve RANGE OF MOTION
several toes
« Toes are pull upward forcing the
metatarsal joints or the ball of the foot
downward
« Treatment is open toe sandals

« Can be done after inspection and palpation

« Claw foot / Pes cavus
« Refers to the MUSCLE STRENGTH
abnormality of Í Usually integrated with exam of associated
the foot with joint for ROM 

abnormally « Do it first with the unaffected
high arc and a extremity before going to test the
deformity on affected extremity because we need to
the forefoot know the normal response we will see
« There is a on the pt
shortening of the foot and increases Í Compare bilaterally 

pressure produces callouses on the Í Full muscle strength requires complete active
metatarsals and dorsum ROM 

Í Grade strength on scale 1 - 5 


AGCAMARAN • CUENO | 2021 4 of 9

GRADING MOTOR STRENGTH Í Decreased agility, strength, endurance
« Consider this in assessing patient who
have musculoskeletal disorders
especially for older adults because we
cannot anymore elicit the maximum
score of the musculoskeletal ax

SPECIAL TESTS
SNUFFBOX TENDERNESS
Í Tenderness is suggestive of scaphoid fracture
« 0/5 - no movement « Press firmly the snuffbox
« 1/5 - nanginig ang kamay
« 2/5 - arm moved sideways CARPAL TUNNEL SYNDROME
« 3/5 - can raise hand then babagsak « Also known as median nerve
compression
AGE RELATED VARIATIONS « Condition that cause numbness, tingling or
Infants and Children sometimes weakness in hand
Í Legs Í A common cumulative-trauma disorder which
o Bowlegged (genu varus) until ~ 18 months causes hand/finger pain and tingling.
« Beyond 18 months- no longer Happens due to pressure
physiologic, medical management must
be done already Tinel’s sign
o Transition to knock- knee (genu valgus) « tap over the
« Legs usually straighten by 6-7 years carpal tunnel
« Beyond 7 years old – no longer (center of
physiologic, medical management plexor
must be done already surface of
Í Fontanels wrist joint)
o Anterior closed by 18-24 months « Pain, tingling
o Posterior closed by 2 months at thumb, index, or part of the middle
« If that’s not the case maybe your patient finger = (+) Carpal Tunnel Syndrome
might have CNS problem, increased
ICP, rickets, these are some of the Phalen’s sign
reasons why the fontanels of the infants « fully flex the
are not closing supposedly by this age wrists hold
Í Back for 60 secs.
o Check for scoliosis, especially 10-16 years « Pain, tingling
old at thumb,
index, or part
Older Adults of the middle
Í Osteoarthritis finger = (+)
« Common form arthritis Carpal
« Affecting millions of people worldwide Tunnel Syndrome
« The protective cartilage diminish that
supposedly protecting the ends of the
bones
Í Osteoporosis
« The density of the bones is affected that
is why patients who have this are prone
to develop fractures.

AGCAMARAN • CUENO | 2021 5 of 9

For Shoulder (rotator cuff):
DROP ARM TEST
« Extend the arm then drop it slowly
« Those with (+) drop arm test they cannot
do it slowly, they will drop their arm
quickly because of presence of pain
IMPINGEMENT SIGN
« Arms are bend, then the elbow will be
rotated internally
« Arms will be raised or cross overed and pull
forward
« If there’s pain or tenderness = (+)
impingement sign
For Scoliosis:
PATIENT STANDING ERECT
AGCAMARAN • CUENO | 2021
Í Shoulders, scapula & iliac crests symmetrical?
Í Spinal processes in straight line?
PATIENT BENDING FORWARD
Í Scapula symmetrical...rib hump?
Í Spinal processes in straight line?
LIMB MEASUREMENT
Í Leg length
« Measure with the anterior superior iliac
spine until medial malleolus
« If there is a 1 cm discrepancy, it is still
normal but beyond that there is already
problem
Í Arm length
« Measure the acromion process up to the
tip of the middle finger
« If there is a 1 cm discrepancy, it is still
normal but beyond that there is already
problem
ADAM’S FORWARD BEND TEST
Í For this test, the patient is asked to lean forward
with his or her feet together and bend 90
degrees at the waist. The examiner can then
easily view from this angle any asymmetry of
the trunk or any abnormal spinal curvatures.
6 of 9
For Knee Assessment: « If there is pain = (+) McMurray’s Test
TEST FOR EFFUSION
« In these we check for the fluids in the knees VARUS & VALGUS STRESSING
of the patient Í Collateral ligaments

« Some test:
• Bulge test
• Swipe test

McMURRAY’S TEST
Í Meniscus
« Usually done with pt’s who have possible
affectation on their meniscus
« Ask the patient to lie down and flex his leg. The
examiner braces lower leg while the one hand
holds ankle and other hand holds knee.
Palpate medial joint line with knee flexed. « If there is pain = (+) Varus stressing
Apply valgus stress to flexed knee. Externally
rotate leg (toes point outward). Slowly extend
the knee while still in valgus

« If there is pain = (+) Valgus stressing

DRAWER TEST
Í Cruciate ligaments
® used to test the stability of the knee's anterior
Í Lateral meniscus cruciate ligament (ACL)
« Repeat above with varus stress and internal « pt flex his leg and the examiner will put
rotation pressure on the knee, if there is pain
probably there is a problem on cruciate
ligaments

AGCAMARAN • CUENO | 2021 7 of 9

 “FABER” TEST
Í Limitation of hip motion
« Mnemonics
F-lexion
AB-duction
E-xternal
Rotation
- These are the three movements that
you will observe with the patient
« Patient lies supine while knee on affected side
flexed to 90 degrees and foot on affected
side rests on opposite knee
For Hip Assessment:
THOMAS TEST
Í Hip flexion contracture
« To test the flexibility of the hip, it involves the
iliopsoas muscle
« Patient sits at end of exam table with knees
bent over the edge of the table. Patient lies
back supine with one leg flexed holding with
his both arms. Observe position of opposite
thigh (one with knee not held against chest)
against the table it should not be raised
« If there is pain, (+)
TRENDELENBURG TEST
Í Assess hip dislocation « If the pt cannot do it, there is probably a hip
lumbar problem or problem in the sacroiliac
« Ask the patient to walk then if he use the
region
affected part in walking, you will see that
the waist of the patient will deviate.
ORTOLANI’S SIGN
« The waist and gluteus area becomes Í Detect congenital hip dislocation
asymmetrical because there is a weakness
on the affected side « The hip is abducted (away)
« A gentle pressure is applied to the proximal
thigh towards the midline
« (+) Ortolani’s Sign if you hear a clicking
sound or clank sound

« Suggestive for hip abnormalities such as

congenital hip dislocation, rheumatic
arthritis

AGCAMARAN • CUENO | 2021 8 of 9

BARLOW’S TEST
Í Dislocatable hip
« The examiner grasps the infant’s thigh near
the hip and with gentle posterior lateral
pressure attempts to dislocate the femoral
head from the acetabulum
« Normally there is no motion
« If the hip is dislocated, we will hear a distinct
clank sound (the femoral head popped (out)

ALLIS SIGN
Í Hip dislocation
« (+) allis sign if both knees are flexed it
is asymmetrical

AGCAMARAN • CUENO | 2021 9 of 9

 MEDICAL SURGICAL NURSING II WARNING!
DE LA SALLE MEDICAL AND HEALTH SCIENCES INSTITUTE LECTURER: ASSOC.PROF. ROMMEL L. SALAZAR USE AT YOUR
TRANSCRIBED BY: ROSHELLE REVITA, CYRUSJEREMY OWN RISK
COLLEGE OF NURSING ACADEMICS COMMITTEE
CUENO, & TIFFANY LEGASPI

PROFESSOR ONLINE REFERENCES TEXTBOOK Common Acute Injuries:

★ +
TRAUMATIC SPORTS INJURY: FRACTURE
TABLE OF CONTENTS
➔ 1. Fracture
2. Shoulder Dislocation
3. Clavicular Fracture
4. Quadriceps Strain
5. Ankle Sprain

1. Direct/Contact Injury
I. Sports Injury
● A direct injury is
II. Acute Injuries caused by an
a. Direct/Contact Injury external blow or
b. Indirect/Contact Injury force (extrinsic
III. Overuse Sport Injury causes)
a. Fracture
● A collision with
i. Soft tissue involvement another person e.g ,
ii. Displacement during a tackle in
iii. Fracture Pattern rugby or football
iv. Fragments
● Being struck by an object e.g. a basketball or
IV. Fracture Healing hockey stick
V. Hematoma Formation
2. Indirect/Non-Contact Injury
VI. Fibrocartilaginous Callus Formation
● Intrinsic causes:
VII. Bony Callus Formation
a. The actual injury can occur some distance from
VIII. Bone Remodeling the impact site e.g. falling on an outstretched
IX. Bone anatomy and Stress
X. Local Factors in Bone Healing
XI. Systemic Factors in Bone Healing

OBJECTIVES
At the end of the session, the learners will be able to :
a. Define traumatic / sport injury and fracture
b. Identify the types of fracture
c. Discuss the pathophysiologic mechanisms
involved in fracture hand can result in a dislocated shoulder.
b. The injury does not result from physical contact
with an object or person, but from internal forces
SPORTS INJURY
built up by the actions of the performer, such as
● A damage to the tissues of the body that occurs as a
injuries that may be caused by over stretching,
result of sport or exercise.
poor technique, fatigue, and lack of fitness. (e.g.
● Acute Injuries muscle strain or ligament sprain)
● Overuse Injuries
★ Muscle or body conditioning is essential before an
ACUTE INJURIES activity to prevent possible tear of the ligaments
● An injury occurs suddenly to previously normal tissue. or tendons from overstretching, that may result in
● Principle: “ The force exerted at the time of injury on
muscle sprain or muscle strain.
the tissue (i.e. muscle, tendon, ligament, and bone)
exceeds the strength of that tissue.
● Either direct or indirect sport injury

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OVERUSE SPORT INJURY CLASSIFICATION OF FRACTURE
● Occur over a period of time, usually due to 1. Soft tissue involvement
excessive and repetitive loading of the tissue, ● Closed fracture
with symptoms presenting gradually ● Open fracture/compound fracture
★ Common: Weightlifters 2. Displacement
● Little or no pain might be experienced in the early ● Non-displaced
stages of these injuries and the athlete might ● Displaced
continue to place pressure on the injured site. 3. Fracture Pattern
● Principle: “ Repetitive microtrauma overloads the ● Linear
capacity of the tissue to repair itself ..” ● Transverse
● Oblique
COMMON OVERUSE INJURIES ● Spiral
★ This may be caused by unnoticed microtrauma ● Impacted
1. Bone strain/ stress reaction/stress fracture ● Avulsion
2. E.g. Metatarsal stress fracture in running, ballet 4. Fragments
3. Medial tibial stress syndrome in running and ● Incomplete
dancing ● Complete
4. Lumbar stress fracture in gymnastics, cricket fast ● Comminuted
bowling
A. SOFT TISSUE INVOLVEMENT
FRACTURE 1. Closed Fracture/Simple Fracture
● Fracture is a break in the structural continuity of ● The bone is broken, but the skin is intact
the bone (bone cortex) ★ To trace: X-ray
★ With a degree of injury in the surrounding
tissues
★ Common: clavicle, arm, hip
● A result of high force impact or stress - physical
force exerted on the bone is stronger than the
bone itself.
★ Most common: due to Traffic/ Vehicular
Accident 2. Open Fracture/Compound Fracture
● The ends of the broken bone tear the skin
★ ER duty
● They are at the risk of infection
● Pathologic fracture - a fracture as a result of
medical conditions that weaken the bone such as: ★ Has the high potential for infectious process
o Osteoporosis ★ Sepsis/septic shock is most likely to happen
★ Bone tissue too weak -> ➔ Open Fracture Grading (Schaller, 2012):
Susceptible to fractures ◆ Grade I - clean wound < 1 cm long
o Bone Cancer ◆ Grade II - larger wound without extensive
soft tissue damage
★ Ex. Osteosarcoma in patients can
cause the bone to burst when the ◆ Grade III - highly contaminated and has
tumor becomes larger than the extensive tissue damage; may be
bone itself causing fracture. accompanied by traumatic amputation
o Osteogenesis Imperfecta

REVITA • CUENO • LEGASPI | A.Y. 2021 2 of 6

B. DISPLACEMENT 3. Oblique Fracture
1. Non-displaced fracture ● The break is diagonal across the bone
● The bone cracks either part or all the way through, ★ Bending fracture
but does not move and maintains proper
alignment
★ Common: children
★ Heals faster than displaced fracture

4.. Spiral Fracture

● Caused by twisting force which results in a spiral-
shaped fracture line about the bone, like a
staircase.
★ Since the fracture is complicated, cast and braces
(Tibial fracture)
may not be enough.
2. Displaced fracture
● The bone snaps into two or more parts and moves ★ Surgical operation together with traction will 2be
so that the two ends are not lined up straight needed.
★ Needs surgical management

5. Impacted Fracture
● Bone breaks fragments are driven to other bone
fragments
C. FRACTURE PATTERN
1. Linear Fracture ★ Ex. vehicular accidents, gang war
● Break in a cranial bone resembling a thin line, ★ Usually affects the long bone
without splintering, depression, or distortion of
bone
★ Ex. accident in riding a bicycle without wearing a
helmet, blunt trauma

6. Avulsion Fracture
● Bone fracture which occurs when a fragment of
bone tears away from the main mass of bone as a
result of physical trauma
2. Transverse Fracture
● The break is in a straight line across the bone

REVITA • CUENO • LEGASPI | A.Y. 2021 3 of 6

D. FRAGMENTS FRACTURE HEALING
1. Incomplete Fracture
● The bone cracked but does not
completely break into pieces
★ Dangerous;
another break on
the same area
can cause
fracture to
worsen (crushed)

● Greenstick Fracture ★ Fracture- bridge in structural continuity of the

- This is an incomplete fracture
- A portion of the bone is broken, causing
the other side to bend.
bone cortex
★ Following the traumatic sports injury or fracture,
secondary healing will begin
★ All kinds of fracture in the body will undergo the
process of secondary healing
★ Ex. There is a vehicular accident and one of the

2. Complete Fracture
● The bone breaks into two or more
pieces.

3. Comminuted Fracture
● The bone has broken into 3 or more pieces and
fragments are present at the fracture site.
★ Most complicated
★ Needs surgical intervention, traction, and
hardware
★ Most common fracture in Philippine Orthopedic
Center
★ Manifestations of fracture: calor, dolor, rubor,
tumor, loss of function
★ Crepitus - snapping or breaking sound brought
about by the connection of two fractured bones
victims had his hand amputated. As a nurse, send
the patient in ER STAT with the amputated hand
stored with an ice. Do submerge the amputated
hand in alcohol or formalin.
4 steps/stages of secondary healing:
1. Hematoma Formation
2. Fibrocartilaginous callus formation
3. Bony callus formation
4. Bone remodeling

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HEMATOMA FORMATION BONY REMODELING
● Rupture of blood vessels causing ★ With the continued migration of
a hematoma around fracture osteoblasts and osteoclasts, the
● Secretion of proinflammatory hard callus undergoes repeated
cytokines like tumor necrosis remodeling - termed 'coupled
factor alpha (TNF α ), vascular remodeling.'
endothelial growth factor (VEGF) ★ Coupled remodeling - is a
, bone morphogenetic proteins balance of resorption by
(BMPs), and interleukins osteoclasts and new bone
★ These cells act together to formation by osteoblasts
remove the damaged necrotic tissue and ★ Treatment for Fracture
stimulate healing at the site. ○ Immobilization
● Days 1-5 (Hematoma formation) ○ Compression
★ Start of inflammatory process ○ Elevation
★ Hematoma clots and forms the temporary frame ○ Support
for subsequent healing ● Bone remodeling involves resorption by
osteoclasts and replacement by osteoblasts.
FIBROCARTILAGINOUS CALLUS FORMATION ● The purpose of bone remodeling is to regulate
● Osteoblasts and fibroblasts calcium homeostasis, repair micro damage to
migrate to the fracture and begin bones from everyday stress, and to shape the
reconstructing the bone skeleton during growth.
● Fibroblasts secrete collagen fibers
that connect broken bone ends BONE ANATOMY AND STRESS
● Osteoblasts begin forming spongy ★ Dr. Julius Wolff - German surgeon; conceptualized
bone the Wolff’s law
● Fibrocartilaginous callus forms
★ Chondrogenesis begins to occur
laying down a collagen-rich
fibrocartilaginous network spanning the fracture
ends, with a surrounding hyaline cartilage
● Granulation tissue (soft callus) forms a few days
after the fracture
● Capillaries grow into the tissue and phagocytic
cells begin cleaning debris

BONY CALLUS FORMATION

● New bone trabeculae appear in the
fibrocartilaginous callus ★ Bones will adapt based on the stress or demand
● Fibrocartilaginous callus placed on them
converts into a bony (hard) ★ Bone tissue remodels and become stronger
callus ★ Long bones like femur: longer healing ->
★ Cartilaginous callus undergo immobilization is needed with the use of
endochondral ossification orthopedic devices (traction, braces, casts)
★ At the end of this phase, a ★ Muscle wasting- occurs due to lack of physical
hard, calcified callus of activity
immature bone forms
● Bone callus begins 3-4 weeks after injury, and
continues until firm union is formed 2-3 months
later
★ Week 1: Hematoma formation
★ Week 2: Fibrocartilaginous callus formation
★ Week 3-4: Bony callus formation

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LOCAL FACTORS IN BONE HEALING
● Fracture characteristics
★ Comminuted fracture heals longer than linear
fracture
● Infection
★ Children in POC are required to wear face masks
due to the presence of Pseudomonas aeruginosa.
● Blood supply
★ Angiogenesis in fracture healing supports the
integrity of the bone marrow

SYSTEMIC FACTORS IN BONE HEALING

● Advanced age
★ Healing in older clients are more challenging than
the young ones due to comorbidity
● Obesity
● Anemia
★ Bone marrow of the long bone- “Mecca” or the
center of erythropoiesis
★ Anemic pt tends to have slower healing process
● Endocrine conditions
★ Diabetes mellitus
★ Parathyroid diseases
★ Client at menopausal stage
● Steroids
★ Immunodepressant
● Malnutrition
● Smoking

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 MEDICAL SURGICAL NURSING II
DE LA SALLE MEDICAL AND HEALTH SCIENCES INSTITUTE
COLLEGE OF NURSING ACADEMICS COMMITTEE
PROFESSOR POWERPOINT TEXTBOOK
« Ï ➔
DIAGNOSTIC AND LABORATORY EXAMINATIONS
CONTENT OUTLINE
I. Non-Invasive Procedures
a. Laboratory Studies
b. Radiographs (X-rays)
c. Bone Scan
d. Ultrasound
e. Magnetic Resonance Imaging (MRI)
f. Electromyography (EMG)
g. Nerve Conduction Study (NCS)
h. Bone Density Testing
II. Invasive Procedures
a. Joint Aspiration and Analysis
b. Discography
c. Arthrography
d. Myelogram
e. Bone biopsy
f. Muscle biopsy
DIAGNOSTIC AND LABORATORY PROCEDURES
« ROLE: it is very essential in confirming findings
« It is very important because we can identify
specific orthopedic disorder or conditions.
« Tells us also the exact location and severity of the
condition.
« Give us precise diagnosis.
NON-INVASIVE PROCEDURE
LABORATORY STUDIES
• Blood, urine or joint (synovial) fluids are used to
identify the presence and amount of chemicals,
proteins, and other substances.
• NOTE: Patient may be required to fast for a
specific number of hours before donating samples
for a laboratory test.
★ Usually the doctor may order several tests
★ Ex. If the doctor suspect that the patient has
gout, he will order to check for the uric acid.
★ Infection/inflammation he will order blood
count to check the levels of WBC.
★ And also if the patient is scheduled for
orthopedic surgery- blood test is needed to
check if there are other medical conditions
★ Take not that the patient may be required to
fast for a specific number of hours before
extracting specimen from the patient
ABAD • AGCAMARAN | A.Y. 2021
WARNING!
USE AT YOUR
LECTURER: PROF. MARIA BERNADETTE R. DAPLAS
OWN RISK
TRANSCRIBED BY: ANGELU ABAD & KRISHA
AGCAMARAN
★ It depends from the test on how many hours
for the patient to be placed on NPO status
★ Ex. FBS- usually 10 hours
RADIOGRAPHS (X-rays)
★ Most common, most available, less expensive
diagnostic imaging procedure
★ A procedure where in the patient’s body is placed
between the x-ray machine and the photographic
film
★ Once the x-ray machine activates it send
electromagnetic waves to the body thus it
exposes the photographic films. So this exposure
can create picture or images of the internal organ
of the body.
★ From the result of the x-ray usually what you will
see if the target part:
o Is a bone, looking for tumor and other dense
organ – the result will be white, because this
parts absorbs the radiation
o Soft tissues, breaks in the bone, fracture
usually the results is darker because the
radiation only passes in through these sites.
• Indicated to identify the following conditions:
- Presence of a fracture
- Arthritis
- Osteonecrosis
- Joint dislocation
- Joint space
- Rule out tumor
• NOTE: X-ray session takes 10 to 15 minutes to
complete and no specific preparations are
required
« But the radiologic technician will instruct
the patient to remove all the metals
(jewelries, watches, and for females (chest
x-ray) their brassiere must be removed
also due to the presence of metal
buttons/hooks)
CT SCAN
• Used to identify the ff:
- Areas with unusually active bone formation
- Fracture sites
- Presence of arthritis
- Infection
- Cancer
• Uses mildly radioactive substance (technetium,
barium sulfate, dye, radionuclide, tracer ) through
IV
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• The process takes 30 to 90 minutes
« In this procedure we obtain a cross-
sectional image
• 2 to 3 hours is allotted for the bone to absorb the
agent before a bone scan starts
« Normally there is greater absorption of dye
or radioactive substance in the “hotspots”
where in this is the area of the bone with
abnormal activity
NURSING CONSIDERATIONS
• Informed the doctor
- if the patient is pregnant
« Because this procedure uses
radioactive substance is very harmful to
developing fetus
- if the patient is a breastfeeding mother
« Radioactive substance can
contaminate the milk of the mother
• Notify the radiologist or technologist if the patient
is allergic to or sensitive to medications, contrast
dyes or iodine.
« Because this can cause allergic
reactions to the patient
• Patient is asked to change into a patient gown
and remove all piercings and jewelry.
« It can give inaccurate results if there’s a
presence of metals in the pt.’s body
• Generally, no prior preparation, fasting or sedation
is not required prior to a bone scan.
• Patient may feel some discomfort as the IV line is
placed. Some people may feel nauseous.
• During the waiting period, patient need to drink
several glasses of water (four to six glasses) to
help flush out any tracer that does not concentrate
into the bone tissue.
« Waiting period is 2-3 hrs. for the contrast
agent to be absorb by the bones.
• Patient will be asked again to empty his bladder
prior to the start of the scan.
« So the patient will be comfortable during
the procedure.
« Full bladder can distort the pelvic bone
and can give unclear result of pelvic scan
specifically if the scan is in the pelvic area.
ABAD • AGCAMARAN | A.Y. 2021
• Patient is asked to lie still on a scanning table.
« Patient is instructed to lie still in the table
because if the patient will not assume this
position it will result to unclear result of the
scan (low quality)
• Patient is instructed to drink plenty of fluids and
empty his bladder frequently for 24 to 48 hours
after the procedure .
« This will help flush the excess contrast in
the body.
• If any pain, redness, and/or swelling is noted at
the IV site at home following the procedure,
patient should notify his doctor.
« Because this is a sign of allergic reaction,
and other types of reactions.
• Patient should not have any other radionuclide
procedures for the next 24 to 48 hours after his
bone scan.
ULTRASOUND
• Uses high-frequency
sound waves that echo off
the body and produces an
image.
« Indicated to check for
blood clots especially
with blood clots in the
extremities (DVT, cyst
or swelling)
« A gel is placed on a the
pt.’s skin and an
ultrasound sensor will
be moved around the target area to be
examined and the high frequency soundwaves
produces and transmitted by a doppler audio.
This is converted into a image
• The test is usually 20-30 minutes and does not
produce discomfort.
MAGNETIC RESONANCE IMAGING (MRI)
« We use powerful magnetic field, radio waves and
sophisticated computer to create high-resolution
pictures or to obtain images of different areas of the
body
• Indicated to help diagnose torn muscles,
ligaments and cartilage, herniated disks, hip or
pelvic problems and other conditions.
• The procedure is noisy but painless.
• May takes 30 to 90 minutes to complete
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NURSING CONSIDERATIONS
• Notify the doctor if the patient have implants,
metal clips or other metal objects in the body
before undergoing an MRI scan.
« once the powerful magnetic field is
activated, it can pull all the metals from
the patient’s body
« You can see flying objects inside the
magnetic field room .
« Projectile flying objects are dangerous so
we need to remove all the metals
« If the metal can be removed from the
patient’s body, he can proceed with MRI.
« But if the metal cannot be removed
(permanent on the patient body) the
patient cannot proceed with the
procedure.
• People that are claustrophobic often have difficulty
with this test
« Patients with claustrophobia will
experience irritation and restlessness
(related to closed MRI)
« Use the open MRI because this procedure
can be more tolerated by the patient who
is claustrophobic but the result is not clear.
ELECTROMYOGRAPHY (EMG)
• This procedure records and analyzes the electrical
activity of the muscles and the functioning of
nerves.
• Small thin needles are placed in the
muscle/needle electrodes is attached in the skin
to record the electrical activity.
« The doctor will tell the patient to “ma’am/
sir please relax your muscle, and then
tense your muscle, relax you muscle, tense
your muscle, …..”
« The electrical signal will be recorded into
the screen , it will monitor the contraption
and relaxation of the muscle.
• The results can be obtained immediately after the
test.
« Usually this procedure can cause pain and
discomfort to the patient because of the
application of small needles
ABAD • AGCAMARAN | A.Y. 2021
NURSING CONSIDERATIONS
• Notify the physician if patient is taking blood-
thinning medications, have lung disease or are at
risk for infection
« Anticoagulant medications – with the
insertion of thin needles it can cause
bleeding so the pt. will be prone to
bleeding.
« Pt with lung diseases- according to the
researches, EMG can aggravate dyspnea.
• On the day of the test, patient is instructed not to
put any lotions or creams on the area to be tested
and not to wear any jewelry.
« Because it might affect the electrical
conduction in the area if there are creams,
lotions applied into the area to be tested.
« With the presence of jewelries, it can give
inaccurate result.
NERVE CONDUCTION STUDY (NCS)
« A.k.a NCVT (NERVE CONDUCTION VELOCITY
TEST)
• Nerve conduction studies are often done along
with an electromyogram to determine if a nerve is
functioning normally.
• Commonly recommended in case of presence of
symptoms of carpal tunnel syndrome or ulnar
nerve entrapment.
« Carpal Tunnel Syndrome - this is a
condition wherein there’s a compression
of nerves into the hands. There is a muscle
weakness or numbness of the arm or the
hands.
« The doctor attach tape electrodes on the
hand/arm of the pt. So, the doctor applies
electrodes in the skin at various places along the
deep nerve pathway. Nerve is being stimulated by
electric current. The current travels along the nerve
pathway while the current travels, the electrodes
in place will capture the signal of the electric
current and measure the speed of electric
currents.
• In healthy nerves, electrical signals can travel at
speeds of up to 120 miles per hour. If the nerve is
damaged, the signal is slower and weaker.
« Not painful and the patient is comfortable
during the procedure
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BONE DENSITY TESTING
• A bone density test is used to measure bone
mineral content and density.
- osteopenia
« A condition wherein there’s a low bone
density/mass. And it is already midway
to osteoporosis
- osteoporosis
- determine fracture risk
• Uses X-rays, dual-energy X-ray absorptiometry
(DEXA or DXA), or a special CT scan that uses
computer software to determine bone density of
the hip or spine.
« Among the three DEXA or DXA is
considered as the golden standard.
Because it gives the most accurate result
• This test is painless, non-invasive, and safe.
• They compare the patient’s bone density with
standards for his age, gender, and size, and to the
optimal peak bone density of a healthy young adult
of the same gender.
• NOTE: No preparation is required for this test, and
takes only a few minutes.
INVASIVE
JOINT ASPIRATION AND ANALYSIS
• May be both a diagnostic test and a treatment
option
« Once the fluid is aspirated, pressure is
relieved
• Aspiration, or removal of fluid through a syringe
« Clean with antiseptic/antibacterial solution
before insertion of needle
• Send the fluid to a laboratory for analysis
• Can reduce swelling and relieve pressure.
ABAD • AGCAMARAN | A.Y. 2021
DISCOGRAPHY
• A test used to determine whether
the discs, are the source of back
pain.
• The doctor inserts a needle into
one or more discs and injects a
contrast dye. Afterward, a CT
scan will show any changes in the
disc size or shape.
• NOTE: No special preparations are required for
this test but patient should not take any pain
relievers or anti-inflammatory medications on the
day of the procedure.
« Taking pain medications can mask the
symptoms; it will be difficult to confirm which
site is in pain
ARTHROGRAPHY
• It is often used to diagnose joint pain with
unknown cause.
• It involves placement of needle intra-articularly
with aspiration of joint fluid and injection of a
contrast agent to enhance imaging.
« Once agent is injected, the joint can now be
examined under x-ray
NURSING CONSIDERATIONS
• Patient may be asked to fast prior to the exam.
• During the examination, patient may be asked to
move the joint into various positions as the
images are taken.
• Notify your physician if:
- Patient is or may be pregnant
- Allergic to iodine or shellfish
« These 2 conditions may cause
complications to the patient
MYELOGRAM
• A special dye is injected into the spinal canal
through a hollow needle.
• An x-ray fluoroscope then records the images
formed by the dye or a computed tomography
(CT) to look for problems in the spinal canal.
« Warm sensation
4 of 6
• Myelograms may be used to evaluate many
diseases, including:
- Herniated discs
- Spinal cord or brain tumors
- Infection and/or inflammation of tissues
around the spinal cord and brain
- Spinal stenosis
« Narrowing of space in the spine
- Ankylosing spondylitis
« Form of arthritis in the spine
- Bone spurs
« Bone growth from a normal bone
- Arthritic discs
- Cysts
- Tearing away or injury of spinal nerve roots
- Arachnoiditis
« Inflammation of the membrane that
protects the neuron of the spinal canal
NURSING CONSIDERATIONS
• Notify the doctor
- If patient have ever had a reaction to
anesthetics (lidocaine) or any contrast dye
« Due to the possible risk of allergy
- On antibiotics or if with an active infection or
fever
« Procedure should be rescheduled or find
another alternative
- If the patient is pregnant
« Can cause harm to the developing fetus
- On anticoagulant therapy (blood thinners)
« Risk for bleeding
• Watch-out for
- Risk of seizure after the injection
- CSF can leak from the needle insertion site
which can cause headache
« Since dye is injected into the spinal canal,
it can cause breakage in the skin and CSF
could leak
- Risk of infection
- Risk of bleeding in the spinal canal.
- Short-term numbness of the legs or lower
back pain
• NPO for three hours before the procedure.
« To prevent vomiting and aspiration
• Empty the bladder prior to the start of the
procedure.
ABAD • AGCAMARAN | A.Y. 2021
• Patients are asked to lie down for two hours
after the procedure to reduce your risk of
developing a CSF (cerebral spinal fluid) leak.
• Inform the doctor if headaches develop and
persist for more than 24 hours after the
procedure, or when assuming change in
positions.
• Drink extra fluids to rehydrate after the
procedure.
« To replace the fluid loss and reduces the
chance to develop headache
BONE BIOPSY
• It is a procedure done to remove tissue or cells
from the body to be studied under a microscope.
« Histologic analysis of the bone
• Indications of bone biopsy are the following:
- Evaluate bone pain or tenderness
- Investigate an abnormality seen on X-ray
- Find out if a bone tumor is malignant or
benign
- Find the cause of an unexplained infection or
inflammation
RISKS of BONE BIOPSY
• Bruising and discomfort at the biopsy site
• Bone fracture
• Prolonged bleeding from the biopsy site
« Those that have hematologic d/o or patients
taking on anticoagulant therapy
• Infection near the biopsy site or in the bone
« Open for the microorganism to invade
• Other risks may exist, depending on the patient’s
specific health condition.
NURSING CONSIDERATIONS
• Notify the doctor of the following:
- If patient has allergy to any medicines, latex,
tape, or anesthesia (local and general).
- Taking medicines which includes prescribed
and over-the-counter medicines, and herbal
supplements.
« Can counteract the result of biopsy; may
have inaccurate results
- If with history of bleeding disorders, or if
taking any blood-thinner (anticoagulant)
medicines, aspirin, or other medicines that
affect blood clotting.
« Can aggravate bleeding
- If pregnant or suspect that patient is pregnant
5 of 6
• Maybe asked to fast for 8 hours before the
procedure
« To prevent aspiration as patient will be put
under general anesthesia
• Patient may get a sedative before the procedure
to help relax, but this can cause patient to feel
drowsy.
• After the procedure, instruct patient to keep the
biopsy area clean and dry.
• Observe for the following: fever or chills, redness,
swelling, bleeding, or other drainage from the
biopsy site or increased pain around the biopsy
site
• Avoid strenuous physical activity for a few days.
MUSCLE BIOPSY
• A procedure used to diagnose diseases involving
muscle tissue.
• A sample tissue and cells from a specific muscle
is obtained and view them microscopically.
• Indication of muscle biopsy are the following:
- To assess the musculoskeletal system for
abnormalities.
- To determine the source of the disease
process and ensures the proper treatment.
- To diagnose neuromuscular disorders,
infections that affect muscle, and other
abnormalities in muscle tissue.
« Muscle Dystrophy, Myasthenia Gravis,
Amyotrophic Lateral Sclerosis,
Polymyositis, etc.
RISKS of MUSCLE BIOPSY
• Bruising and discomfort
• Prolonged bleeding
• Infection
ABAD • AGCAMARAN | A.Y. 2021
NURSING CONSIDERATIONS
• Notify the doctor if: if patient is:
- Sensitive or allergic to any medicines, latex,
tape, or anesthetic agents (local and
general).
- Taking medicines (prescribed and over-the-
counter) and herbal supplements
- Have a history of bleeding disorders, or if
you take any anticoagulant (blood-thinning)
- Medicines, aspirin, or other medicines that
affect blood clotting.
- If or suspected to be pregnant.
• Patient may be asked to fast for several hours
before the procedure
• May receive a sedative before the procedure to
help patient relax and may feel drowsy
• Keep the biopsy area clean and dry.
• Observe for Fever, Redness, swelling, bleeding,
or other drainage from the biopsy site, Increased
pain around the biopsy site
• May restrict activity for 24 hours following the
procedure and instruct patient avoid excessive
use of the biopsied muscle.
6 of 6
 PRINCIPLES OF NURSING MANAGEMENT
FOR ALTERED COORDINATION
→ PLANNING
✓ Pain relief !!!
✓ Maintenance of adequate tissue perfusion
✓ Improved physical mobility
→ passive ROM and isometric contractions
✓ Prevention of infection and injury
✓ Achievement of maximum level of self-care
✓ Understanding the treatment regimen
✓ Decreased anxiety
→ IMPLEMENTATION
✧ Perform a neurovascular assessment
→ Pain, Pulse, Pallor, Paresthesia, Paralysis
→ S/Sx of Compartment Syndrome
→ Compartment Syndrome is caused by pressure
within a muscle compartment that increases to
such an extent that microcirculation diminishes,
leading to nerve and muscle anoxia and necrosis.
Function can be permanently lost if the anoxic
situation continues for longer than 6 hours.
✧ Provide pain relief
→ NSAIDs, muscle relaxants per DO
→ Non-pharmacologic methods (deep breathing
exercises, diversional activities, music therapy,
heat & cold application, massage, etc.)
✧ Administer prescribed medication
→ Antibiotics
➢ To prevent infections
→ Anti-TB / Antitubercular drugs
➢ Rifampin (orange urine, GI problems)
➢ Isoniazid (peripheral neuropathy)
➢ Pyrazinamide (hepatitis, arthralgia)
➢ Ethambutol (color blindness)
➢ Streptomycin (tinnitus, nerve damage)
→ NSAIDs
➢ given after meals
→ Calcium & Vitamin D – osteoporosis
→ Biphosophonates – Paget’s disease &
osteoporosis ; inhibits osteoclast activity
= slows down bone resorption
➢ Pamidronate (Aredia)
- once every 3-4 weeks
- IV infused 2-24 hours
➢ Alendronate (Fosamax)
- slows down bone loss
- prevents bone fractures
- given daily or once per week
→ Calcitonin (SubQ or nasal inhalation)
➢ hormone produced by thyroid gland
➢ stimulus: increased blood Ca levels
➢ action: ↑deposition of Ca & PO4 in
bones and lowers Ca levels in blood
➢ effectively inhibits Ca resorption
➢ also for Paget’s disease
➢ SEs: N/V, flushing of face
→ Hormonal replacement – osteoporosis
➢ Estrogen
➢ Progesterone
→ Anti-gout
➢ Colchicine
- for acute attacks of gout
D/C if with diarrhea
- initial dose: 1.2 mg @ 1st attack
- followed by 0.6 mg q1
➢ Probenecid
- reduces uric acid
- nausea, constipation, skin rash
➢ Allopurinol (Zyloprim)
- blocks formation of uric acid
- increase OFI
- give with meals
- measure I&O
→ Corticosteroids – i.e. prednisone
➢ give with antacids; with meals
➢ anti-inflammatory effect
➢ SE: immunosuppression,
gastric irritation, osteoporosis,
fractures, peptic ulcers
➢ taper doses before D/C
→ Antineoplastic agents
➢ Alkylating agents, antimetabolites, and
Anthracyclines
➢ i.e. Methotrexate, 5-FU, 6-MP
➢ cause myelosuppression
✧ Promote mobility
→ passive & active ROM (unaffected body parts)
→ isometric exercises for affected body part
once swelling and pain subsides
→ during 1st week: limit movement / immobilize
→ to prevent atrophy
✧ Prevent infection
→ frequently monitor VS (i.e. spike in temp.)
→ assess site for discharge, redness, swelling
→ inspect surr. tissues for S/Sx of infection
→ monitor WBC
✧ Protect client from injury
→ instruct pt regarding safe transferring
→ assist with turning, ambulating, and sitting
→ raise bed siderails
→ inspect common sites of pressure ulcers:
sacrum, heels, gluteal, elbows, shoulders
→ suggest using air mattresses & donuts
→ during transferring, slideboards can be used
✧ Promote client’s participation in self-care
activities within limitations of the injury and
treatment regimen
✧ Provide client and family teaching
→ explaining the cause, treatment, expected
course of the disease or disorder.
→ involve family members in the care of pt
✧ Minimize anxiety
→ therapeutic communication, distraction, meds
→ assist patient in identifying and addressing the
cause of anxiety (e.g. financial concern = refer)
→ OUTCOME EVALUATION ✧ Roger Anderson
– Reports reduced pain External Fixator
– States appropriated comfort enhancing and healing → fx of the humerus
promotion measures → for comminuted fx
– Exhibits adequate tissue perfusion & sensory
✧ Delta Fixator
function
– Has improved physical mobility → fx of the proximal
– Is able to transfer safely or distal part of the tibia
– Is able to make use of assistive devices correctly → pin is inserted and is
– Has NO S/Sx of infection connected to a triangle bar
– Resumes ADL’s without injury after healing
✧ Ilizarov Fixator
– Demonstrates proper performance of rehabilitative
→ many pins inserted,
exercises and safety precautions
indicated for multiple fractures
– Maintains independence and participates in ADL’s
→ look out for signs of infection due to the multiple pins
and in self-care activities
→ apply aseptic technique
– Verbalizes knowledge of medications, cast care,
diet and other prescribed treatments ● OPEN REDUCTION | reduction = realigning fragments
– Able to WOF s/sx of further complications and
report it accordingly → reduction is a surgical procedure to repair a fracture
or a dislocation to the correct alignment
– Reports decreased anxiety
→ surgeon makes an incision in the tissue to expose
SURGICAL PROCEDURES fracture fragments
FOR ORTHO CASES → the bone is realigned or held together using
orthopedic devices, tools or implants such as plates,
✓ Internal and External Fixation Surgery pins, wires, rods, screws (internal fixation)
✓ Open and Closed Reduction Surgery
✓ Amputation
✓ Bone Resection and Bone Grafting
✓ Tenorraphy
✓ Spinal fustion

● INTERNAL FIXATION
→ method of physically reconnecting the bones
→ surgeon attaches screws, plates, rods, wires, or nails ● CLOSED REDUCTION
INSIDE the bones to realign them in the correct place → done by realigning the bone fragments back into its
→ allows shorter hospital stay + antibiotics proper position without surgical exposure of bones
→ allows patients to return to function earlier → example: application of cast
→ reduce incidence of non-union or malunion
→ durable & strong implants
→ made of stainless cobalt or titanium
→ compatible to the body = less likelihood of allergic rxn
→ implants can be left inside the body or removed
based on patient’s condition and discretion of doctor
Plates & screws – applied by exposing the bone

Nails / Rods – used in long bones

– prevents shortening of the bones
– prevents rotation of the bones

● AMPUTATION
Wires & Pins – fractured wrists → surgical removal of all or part of a limb or extremity
such as an arm, leg, foot, hand, toe, or finger
● EXTERNAL FIXATION
→ reasons for amputation:
→ method of of holding together the fragments of a ➢ poor circulation (necrosis occurs)
fractured bone by using metal pins through the ➢ severe injury from a vehicle accident, etc.
fragments and a compression device attached to the ➢ cancerous tumor in the bone or muscle of limb
pins OUTSIDE the skin surface
➢ serious infection that does not heal
→ pins & screws are attached to a bar outside the skin
with antibiotics or other treatment
→ often used as a temporary treatment for fractures
➢ neuroma – thickening of nerve tissue
especially when the skin and muscles have been injured
→ if patient has multiple injuries and not yet ready for ➢ frostbite
longer surgery to correct the fracture → 2 types: open/guillotine & closed/myoplastic/flap
✧ OPEN / GUILLOTINE
→ all of the tissues from the
skin to the bone are cut at
the level of the affected
bone without creating
flaps of soft tissue
→ leaves an open wound at
the end of the stump
covered by elastic
✧ CLOSED / MYOPLASTIC / FLAP
→ done involving a stump or
residual limb
→ site is closed with flap of skin,
sutured posteriorly
→ COMPLICATIONS
➢ Hemorrhage
➢ Infection
➢ Phantom limb
– pain on site even if limp is amputated
– burning crushing pain + site is distorted
– ax if real phantom pain or stump pain
– pain reliever, antispasmodics
– recognize that this can affect pt’s ADL
➢ Problems associated with immobility
➢ Flexion contracture
– inability to straighten the affected part
– limited ROM
→ NURSING CONSIDERATIONS | AMPUTATION
– Patient requires a hospital stay of 5 to 14 days or
more, depending on the surgery, complications and
the patient's general health
– Amputation may be done with general anesthesia
or spinal anesthesia
– Regular wound care and dressing changes
– Monitor wound healing and any conditions that
might interfere with healing (i.e., atherosclerosis)
– Monitor patient for phantom pain
– Provide emotional support, including counseling
– Activities to help restore the ability to carry out daily
activities and promote independence
– Exercises to improve muscle strength and control
(i.e., stretching and physical therapy)
– Use of artificial limbs and assistive devices may
begin as soon as 10 to 14 days after surgery
– The wound should fully heal in about 4 to 8 weeks
but the physical and emotional adjustment of losing
a part of the body may take a longer period
● BONE RESECTION
→ removal of a portion or growth of bone
→ simple case: in OPD / to treat CA: inside hospital
→ recuperation takes several days to weeks
→ indications:
➢ bone spurs – most commonly dx in the heel
➢ pain
➢ to increase joint range of motion
➢ bone graft
➢ biopsy
➢ plantar fascitis
● BONE GRAFTING
→ surgical procedure that
uses transplanted bone
to repair and rebuild
diseased or damaged
bones
→ bones may be obtained from patient’s own body
(autograft – i.e., pelvic bone), bone tissue from
cadavers, or synthetic material
→ RISKS FOR BONE GRAFTING
➢ Infection
➢ Bleeding
➢ Blood clot
➢ Nerve damage
➢ Complications from anesthesia
➢ Infection from the donated bone
→ NURSING CONSIDERATIONS | BONE GRAFTING
– Check for presence of pain
– Proper instruction about ambulation, immobilization
of affected part, wearing of brace or splint
– Avoid putting weight on the affected area
– Need for physical therapy to restore strength and
flexibility of the muscles
– Diet high in calcium and vitamin D as bone heals
– Check for presence of infection
● TENORRAPHY
→ surgical uniting of divided tendons
with sutures
→ NURSING CONSIDERATIONS | TENORRAPHY
– Keep affected part immobilized (splint can be used)
– Keep pain under control
– Instruct patient not to remove the dressing/splint
– Keep the wound and skin clean
– Patient is on a therapy program
● SPINAL FUSION
→ surgery to permanently connect
two or more vertebrae of the spine
→ surgeon places bone or an implant
or orthopedic device (metal plates, screws and rods)
within the space between two spinal vertebrae
→ improve stability, correct a deformity, or reduce pain
→ indications:
➢ deformities of spine (i.e. Harrington rod)
➢ spinal weakness or instability (i.e. arthritis)
➢ herniated disc
→ COMPLICATIONS OF SPINAL FUSION
➢ Infection
➢ Poor wound healing
➢ Bleeding
➢ Blood clots (i.e. pulmonary embolism)
→ DVT / Deep Vein Thrombosis
→ throbbing below the knee
→ swelling in the popliteal region and
cramps against the spine
➢ Injury to blood vessels or nerves in and
around the spine
➢ Pain at the site
→ NURSING CONSIDERATIONS | SPINAL FUSION
– Hospital stay of 2-3 days is usually required
– Monitor for presence of pain and discomfort
– Observe for signs of infection
– Observe for bleeding
– Check for presence of blood clots in the legs
Warning signs: swelling in the calf, ankle, or foot;
tenderness or redness – may extend above or
below the knee; pain in the calf
– It may take several months for the affected bones
in the spine to heal and fuse together
– Immobilize, wearing of a brace for a time to keep
spine aligned correctly
– Physical therapy can teach patient to assume
proper movement, sitting, standing, and walking in a
manner that keeps the spine properly aligned
RELEVANT LEGAL & ETHICAL BASIS
RELATED TO SAFE NURSING PRACTICE
● RA 7277 | Magna Carta for Disabled Persons
→ An act providing for the rehabilitation, self-
development and self-reliance of disabled person and
their integration
→ This law defines Disabled Persons as those people
suffering from restriction of different abilities as a
result of either mental, physical, or sensory
impairment
→ Orthopedic nursing = to the physically impaired (i.e.,
amputees, stroke patients, with difficulty in
ambulation, and those with fractures)
→ The grant of the rights and privileges for disabled
persons are guided by the following principles:
1. Disabled persons are part of the Philippine society
2. Disabled persons have the same rights as other
people to take their proper place in society
3. The rehabilitation of the disabled persons shall be
the concern of the Government
4. The State also recognizes the role of the private
sector in promoting the welfare of disabled persons
and shall encourage partnership in programs
5. To facilitate integration of disabled persons into the
mainstream of society, the State shall advocate for
and encourage respect for disabled persons
● Rights and Privileges of Disabled Persons
1. Employment – There should be an equal opportunity
for employment. No disabled persons shall be denied
access to opportunities for suitable employment
2. Education – There should be an access to quality
education and ample opportunities to develop their
skills
3. Health – Aim of national health program:
(a) prevention of disability, whether occurring
prenatally or post-natally
(b) recognition and early diagnosis of disability and
(c) early rehabilitation of the disabled
• Rehabilitation Centers – establish medical
rehabilitation centers in government provincial
hospitals, and annual funds for the operation
• Health Services – protect and promote the right
to health of disabled persons and adopt an
integrated and comprehensive approach to their
health development which shall make essential
health services available to them at affordable
cost
(a) prevention of disability through
immunization, nutrition, environmental
protection and preservation, and genetic
counselling; and early detection of disability
and timely intervention to arrest disabling
condition
(b) medical treatment and rehabilitation
• Assign medical personnel specializing in the
treatment and rehabilitation of disabled persons
to provincial hospitals and, when viable, to
municipal health centers
• Train field health personnel in the provision
of medical attention to disabled persons.
Ensure that its field health units have the
necessary capabilities to fit prosthetic and
orthotic appliances on disabled persons
4. Auxiliary Social Services – provided with the
necessary auxiliary services that will restore their
social functioning and participation in community
affairs such as assistance in the acquisition of
prosthetic devices and medical intervention of
specialty services
5. Telecommunications
→ Broadcast Media
Television stations shall be encouraged to
provide a sign language inset or subtitles in at
least one (1) newscast program a day and special
program covering events of national significance
6. Accessibility
→ Barrier-Free Environment
Ensure the attainment of a barrier-free
environment that will enable disabled persons to
have access in public and private buildings and
establishments and such other places mentioned in
Batas Pambansa Bilang 344, otherwise known as
“Accessibility Law”
→ Allocate funds for the provision of architectural
or structural features for disabled persons in
government buildings and facilities
7. Political and Civil Rights
– in terms of system of voting, assembly
and organization, recognize the rights of disabled
persons to form organizations or associations
that promote their welfare and advance or
safeguard their interests
● RA 9442 | Magna Carta for Disabled Persons and for
Other Purposes
(a) At least twenty percent (20%) discount from all
establishments relative to the utilization of all services in
hotels and similar lodging establishments; restaurants
and recreation centers for the exclusive use or
enjoyment of persons with disability
(b) A minimum of twenty percent (20%) discount on
admission fees charged by theaters, cinema houses,
concert halls, circuses, carnivals and other similar
places of culture, leisure and amusement for the
exclusive use of enjoyment of persons with disability
(c) At least twenty percent (20%) discount for the
purchase of medicines in all drugstores for the
exclusive use or enjoyment of persons with disability
(d) At least twenty percent (20%) discount on medical
and dental services including diagnostic and
laboratory fees such as, but not limited to, x-rays,
computerized tomography scans and blood tests, in
all government facilities, subject to guidelines to be
issued by the Department of Health (DOH), in
coordination with the Philippine Health Insurance
Corporation (PHILHEALTH)
(e) At least twenty percent (20%) discount on medical
and dental services including diagnostic and
laboratory fees, and professional fees of attending
doctors in all private hospitals and medical facilities,
in accordance with the rules and regulations to be
issued by the DOH, in coordination with the
PHILHEALTH
(j) To the extent possible, the government may grant
special discounts in special programs for persons
with disability on purchase of basic commodities,
subject to guidelines to be issued for the purpose by the
Department of Trade and Industry (DTI) and the
Department of Agricultural (DA)
(k) Provision of express lanes for persons with
disability in all commercial and government
establishments; in the absence thereof, priority shall be
given to them
● Ethical Basis of Care
→ AUTONOMY
➢ a person with disability as a research participant
➢ “their right to choose and to make decision for
themselves must be respected”
→ BENEFICENCE
➢ “be a patient advocate, upholding the patient’s rights
as stated in the Magna Carta for Person with Disability”
→ JUSTICE
➢ representation of person with disability
➢ consider their right to information
➢ informed consent
→ NON-MALEFICENCE
➢ informing the patient of possible risks of intervention
➢ patient’s safety for those who are at risk for falls

(f) At least twenty percent (20%) discount on fare for

domestic air and sea travel for the exclusive use or
enjoyment of persons with disability

(g) At least twenty percent (20%) discount in public

railways, skyways and bus fare for the exclusive use
and enjoyment of person with disability

(h) Educational assistance to persons with disability,

for them to pursue primary, secondary, tertiary, post
tertiary, as well as vocational or technical education,
in both public and private schools, through the
provision of scholarships, grants, financial aids,
subsidies and other incentives to qualified persons with
disability, including support for books, learning
material, and uniform allowance to the extent feasible:
Provided that persons with disability shall meet
minimum admission requirements

(i) To the extent practicable and feasible, the

continuance of the same benefits and privileges
given by the Government Service Insurance System
(GSIS), Social Security System (SSS), and PAG-IBIG,
as the case may be, as are enjoyed by those in actual
service
 BALANCED
SKELETAL TRACTION
→ Balanced suspension traction is used to stabilize
fractures of the femur and requires an invasive
procedure in which pins, screws or wires are
surgically installed
→ Weights used in skeletal traction generally range
from 25-40 lbs (11-18kg)
→ Purpose: to maintain the anatomical position of the
fractured bone
● 5 PRINCIPLES IN THE APPLICATION OF SLINGS
→ Not too tight not too close
→ 1inch distance between the slings to promote
aeration or ventilation
→ Popliteal and heel portion should be from sling
→ Smooth and right side should come in contact
with the patient’s skin
→ (2) longer and wider slings for thigh portion and
(3) for the leg area
● HOW TO APPLY THE SLING

→ MATERIALS ➢ Start from the medial side to the lateral side

➢ Thomas splint – placement of the thigh ➢ Secure both ends together
➢ Pearson attachment – placement of the leg
➢ Fan fold nicely on the lateral aspect and secure
➢ Steinman holder
with pin or clip
➢ Steinman pin
➢ Observe the principle of not too tight and not too
➢ Traction weight – 10% of body weight
– inside the suspension rope
loose and avoid hitting the patient’s extremity
➢ Suspension weight – 50% of traction weight
with the pin
➢ Rest splint ➢ The thigh rope should be attached on the medial
➢ 3 ropes – thigh rope → shortest aspect to the lateral aspect
– suspension rope → longest
– traction rope
➢ Slings and pins 6) Insertion of the apparatus
➢ Foot board under the affected extremity:

Thomas Splint ● 3 MANPOWER NEEDED

→ To insert the whole apparatus under the affected

Pearson extremity
attachment → Manual traction to be released after the
completion of traction weight in the 3rd pulley
→ To lift the affected extremity
➢ Simultaneously at the count of three
Steinman Holder ➢ Instruction the patient:
- Hold on to the trapeze
- Flex unaffected leg at the count of 3
➢ The 3 manpower must do their work
Steinman Pin simultaneously

Rest splint 7) Application of traction weight

→ STEPS ● HOW TO APPLY THE TRACTION WEIGHT

1) Verify doctor’s order
2) Inform patient about the need and purpose of ➢ Rope attached to the Steinman pin holder to run
procedure along the 3rd pulley and attached the prescribed
3) Preparation: weight
→ identify different parts of orthopedic bed ➢ Check the principles of sling application and
→ assemble needed equipment: make the necessary adjustment and also check
➢ Thomas splint the correct alignment
➢ Pearson attachment
→ know the affected extremity 8) Apply suspension traction
→ where to stand – look for the last pulley
and stand on the side
4) Mount the Thomas & Pearson on the rest splint
5) Apply the sling:
● HOW TO APPLY SUSPENSION TRACTION
→ One end of the thigh rope to be attached to the lateral
aspect of the ischial ring with a slip knot
→ Attach suspension rope on the mid part of the thigh
rope, to the 1st pulley
→ Insert suspension weight, hang it on the 1st pulley
→ Pass it on the 2nd pulley under the rest splint and
close it with hitch knot on the Thomas splint
→ Another clobe hitch knot on the Pearson, and finally
close it with a knot to secure it
→ Be sure to maintain the traction rope inside, and the
suspension weight should be outside
9) Remove the rest splint
10) Apply foot support
11) Swing the patient to and from, side to side to
check the efficiency of traction
● 5 PRINCIPLES OF TRACTION
→ Patient should be on a dorsal recumbent position
→ Line of pull should be in line with the deformity
positioning of a diamond bar positioning of a pulley
➢ 1st pulley: in line with the thigh
➢ 2nd pulley: in line with the knee or screw
➢ 3rd pulley: in line with the 1st and 2nd pulley
→ Should always be continuous; emphasize the
importance of manual traction
→ Avoid friction
→ Provide counter traction – patient’s body weight will
serve as counter traction
→ REMOVAL OF TRACTION
➢ Potential complications
– Lower respiratory infection (i.e. pneumonia)
→ bronchial tapping and deep breathing
– Bedsores
→ good perineal care, proper skin care,
turning, lift buttocks once in a while
– Urinary & kidney problem
→ good perineal care, increase fluid intake
– Bowel complication (i.e. constipation)
→ fear of apparatus, no privacy, lack of fluids,
perineal care
– Pin site infection
→ observe for S/S of infection, loosening pin
tract, pus coming out, foul smelling, fever
→ aseptic technique, proper referral to DIC
– Deformity
→ contracted knee, atrophy of muscles,
foot drop, joint contractures
➢ Provision of exercises
– ROM exercises with the use of trapeze
– Deep breathing exercises
– Static quadriceps exercises, alternate contractions
and relaxation of quadriceps muscles
– Toes pedal exercise
➢ Nutritional status
– depending on the status of patient

1. Apply rest splint ➢ Psychological aspect

2. Hang suspension weight on the 1st pulley
3. Complete removal of suspension weight
→ Remove the knot on the Pearson attachment
and Thomas splint to completely remove
suspension weight
4. Apply manual traction on the Steinman pin holder
5. Remove the traction weight on the 3rd pulley
6. Secure the traction rope on the rest splint another
on the Thomas and Pearson attachment.
→ NURSING CARE | PATIENTS WITH TRACTION
➢ Assessment
- assess the patient as to level of
understanding, consciousness
– fear of unknown, fear of death, fear of apparatus,
fear of losing job, financial fear
➢ Provision of supportive therapy
– offer book to read, something to listen radio or T.V.,
discover interest
➢ Spiritual aspect
– know religion, encourages relatives to give
Spiritual support, communication, visiting chaplain
➢ Diversional activities
– divert attention

➢ Provision of general comfort

- Skin care
- Changing of linen
- Provide bedpan as needed
- Serve bedpan on the unaffected side,
provide pillow at the back and provide
privacy.
- Perineal care
 Suspension Rope

Traction Rope

Steinman Holder
Thigh rope

Steinman Pin

Thomas Splint

Rest Splint
Pearson Attachment

1st Pulley
2nd Pulley

1st Pulley
Suspension
Rope

Traction Rope
Suspension Weight Trapeze
Vertical Bar Horizontal Bar

Diagonal Bar

Vertical Bar

Traction Weight

The Thomas Splint (half ring) is applied in various ways: with the ring fitted posteriorly against the
ischium or anteriorly in the groin. The thigh rest in the canvas or bandage strip sling with the popliteal
space left free. The leather ring should not be wrapped or padded. If kept smooth, dry and polished, the
leather of the ring is being designed to rest against the skin and resist moisture.

The Pearson Attachment is attached by clamps to the Thomas Splint at the knee level. A canvas
or bandage-strip sling supports the lower leg and provides the desired degree of knee flexion. A footplate is
attached to the distal end of the Pearson Attachment to support the foot in a neutral position. The heel
should be left free.

The traction should be in line with the long axis of the femoral shaft and is maintained by the rope,
pulley and weights attached to the skeletal tractor, which is fitted onto the wire or pin. Counter traction and
balanced suspension are provided by the ropes, pulleys and weights attached to the Pearson
attachment. When all is operational the thigh and Thomas splint will be suspended at about 45 degree
angle with the bed and the lower leg and Pearson attachment will be suspended horizontally to the mattress.

The patient may sit up, turn toward the traction side and raise his hips above the bed by means
of the trapeze and still maintain the line of traction.
 MEDICAL SURGICAL NURSING II WARNING!
USE AT YOUR
DE LA SALLE MEDICAL AND HEALTH SCIENCES INSTITUTE LECTURER: Prof. Rommel L. Salazar, RN, OWN RISK
COLLEGE OF NURSING ACADEMICS COMMITTEE MAN, DrPH
TRANSCRIBED BY: Cyrus Jeremy Cueno

PROFESSOR POWERPOINT TEXTBOOK CASTS

★ Í
ORTHOPEDIC CAST, BRACES, AND
TRACTION APPLICATION
CONTENT OUTLINE
I. Casts II.
a. Splint
i. Body Cast
ii. Rizzer’s Jacket
Cast
iii. Minerva Cast
iv. Shoulder Spica
Cast
v. Shoulder Spica
Mold
vi. Single Hip Spica
Cast
vii. Single Hip Spica
Mold
viii. 1 ½ Hip Spica Cast
ix. 1 ½ Hip Spica Mold
x. Double Hip Spica
Cast
xi. Double Hip Spica
Mold
xii. Cylinder Cast
xiii. Short Leg Circular
Cast
xiv. Short leg Posterior III.
Mold
xv. Brace Cast
xvi. Long Leg Circular
Cast
xvii. Long Leg Posterior
Mold
xviii. Patellar Tendon
Bearing Cast
xix. Quadrilateral Cast
(Ischial Weight
Bearing Cast)
xx. Delvit Cast
xxi. Basket Cast
xxii. Pantalon Cast
xxiii. Frog Cast
xxiv. Short Arm Circular
Cast
xxv. Short Arm Posterior
Mold
xxvi. Long Arm Circular
Cast
xxvii. Long Arm Posterior
Mold
xxviii. Munster Cast
(Fuenster Cast)
xxix. Sugar Tong Cast
xxx. Hanging Cast
xxxi. Functional Cast
xxxii. Airplane Cast
(Abductor Splint)
xxxiii. Collar cast
➔
Í Supportive devices used
to help keep an injured
bone in place while it
heals.
« Cement-like being
applied in the
Braces
a. Shantz Collar Brace extremities or any body
b. Philadelphia Collar part. This is not the same as the cement
Brace available from the
c. Milwaukee Brace
d. Forester Brace construction
e. Taylor Brace « There could be a faster
f. Jewette Brace
g. Chair Back Brace
healing of the injured
h. Banjo Splint bone if the bones are
i. Bilateral Long Leg aligned or kept in a proper alignment
Brace
j. Dennis Browne Splint Í A hard circular dressing with soft padding inside
k. Cock-up Splint of it used to immobilize body parts
l. Roger Anderson « Immobilization is a key term in the bone healing
External Fixator
m. Tower’s External Í Immobilizes and protects until healing occurs
Fixation Í Usually made from Plaster of Paris or fiberglass
n. Four Poster Brace
o. Sterno Occipito
material
Mandibular « Fiberglass material is much more expensive
Immobilizer (SOMI) than the plaster of Paris. Available in different
Brace
Traction colors or design
a. Dunlop Traction « Plaster of Paris - white cement-like device;
b. Buck’s Extension better alternative
Traction
c. Modified Buck’s
Extension SPLINT
d. Bryant’s Traction
e. Head Halter Traction
Í A half cast used to
f. Pelvic Girdle temporarily immobilize and
g. Cotrel Traction protect body parts
h. Hammock
Suspension « It is also a cast but it is 50%
i. Boot Cast Traction application only to support
j. Halo-pelvic Traction the affected extremity
k. Halo-femoral Traction
l. 90-90 Degrees
Traction PURPOSES OF CAST AND SPLINT
m. Zero Degree
Í Promote healing

n. Overhead Skeletal
Traction « Children have faster and better recuperation
o. Stove in Chest than older adults when it comes to fracture
Traction
p. Balanced Skeletal
healing
Traction Í Provide immobilization

Í Protect the injury

Í Prevent further injury

« In the healing process, we are trying to heal the
totality of fracture such as the bones, blood
vessels, muscle, tendons, ligaments, and
affected nerves of the affected site

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Í Decrease pain
 PRECASTING PROCEDURE
« Especially if the client is/has complicated or
compound type of fracture where there is nerve
cells affectation
Í Maintain bone alignment
Í Help compensate for surrounding muscular
weakness
« Muscle will become weak when it is
immobilized (Wolff’s Law)
STANDARD MATERIALS AND EQUIPMENT FOR
SPLINT AND CAST APPLICATION
Í Plaster of Paris or fiberglass casting material
« Plaster of Paris has fragments; after
submerging in the water, it will be applied to
the affected site and allow it to dry and harden
Plaster of Paris Fiberglass
Í Wadding sheet
« Cotton-like protective material applied to
provide comfort to the client
Í Stockinette
« This is the material that touches the skin of the
patient. Stockinette is first applied and then it
will be covered with wadding sheet followed by
plaster of Paris or fiberglass material
Í Complete neurovascular assessment
Í Wounds should be covered with sterile dressing
Í For acute fractures, immobilize the joint above
(proximal) and below (distal) the fracture when
possible
Í Explain the procedure to the client
« Get the patient’s consent
GUIDELINES FOR PROPER CAST AND SPLINT
APPLICATION
Í Use appropriate amount of padding

« Stockinette will allow proper blood circulation
of the extremity or the affected part
« Stockinette is only applied in the upper and
lower extremity
Í Properly pad bony prominences and high
pressure areas
« Upper extremity: arms, elbow
« Lower extremity: knees, olecranon process
Í Properly position the extremity before, during
and after application of materials
« Client should stay still and should not make
unnecessary movements
Í Avoid tension and wrinkles on padding, plaster
and fiberglass
Í Avoid excessive molding and indentation
PATIENT EDUCATION
Educate client on basic signs of Compartment
syndrome:
Í Pain,

Í Pressure,

Í Paresthesia

Í Pulselessness,
Í Swelling
(+) Signs of Compartment
syndrome =>
« Immediately inform the
attending physician
« First nursing
consideration:
Immediately elevate the part of the cast and
maintain the safety of the client
« BOARD EXAM: Always prioritize independent
nursing function

Í Basin of water at room temperature

Í Bandage scissor

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COMPARTMENT SYNDROME TYPES OF CAST
Í A condition where there is increasing pressure WINDOW
within a muscle compartment, which eventually A window may be cut
leads to the death of into the cast:
muscle tissue Í Wound care

« Masyadong mahigpit Í Pressure sores

ang pagkaka-apply Í Checking pulse

=> nawawalan ng Í Breathing
blood supply => window in a
nawawalan ng body cast
oxygen => CAST IMMOBILIZATION
magsusugat => Body
infection will occur Í circumferential cast enclosing the trunk of
=> will eventually the body
lead to the death of the muscle tissue Í may extend from the head or upper chest
« If the part of the muscle is already dead, the cast to groin or thigh
should be opened and the patient should Spica
undergo surgical procedure Í immobilizes an appendage by incorporating
a part of the body proximal to that
TAKING CARE OF YOUR SPLINT OR CAST appendage
Í Keep your splint or cast dry Limb
« It is common in the ward that friends and Í involves the upper and lower extremities
relatives are writing messages on the patient’s
cast but it is NOT IDEAL and could harbor BODY CAST
infection since different people are touching the
cast Í For affections of lower
« Patients with cast are NOT ALLOWED to swim, thoracic and upper lumbar
but they are ALLOWED to take a bath provided spine
that the cast should be covered with plastic in
order to avoid the cast from being soaked with
water
Í Do not walk on a walking cast until it is
completely dry and hard
Í Keep dirt, sand, and powder away from the
inside of your splint or cast
« There are times that the affected body part gets
itchy. It will be difficult for the patients to RIZZER’S JACKET CAST
scratch the itchy part since it is enclosed with Í For severe scoliosis
the cast. Applying sand, lotion or powder in the
cast may develop infectious process.
Í Do not pull out the padding from your splint or
cast
Í Do not stick objects inside the splint or cast
Í Do not apply powders, lotion or deodorants to
itching skin

CUENO | 2021 3 of 11
MINERVA CAST SINGLE HIP SPICA MOLD
Í For affections of cervical Í For affections of hip and femur with infection,
and upper dorsal spine swelling or open wound

SHOULDER SPICA CAST

Í For affection of 1 ½ HIP SPICA CAST
upper portion of Í For affections of hip and femur
humerus and
shoulder joint

SHOULDER SPICA MOLD

For affection of upper portion 1 ½ HIP SPICA MOLD
of humerus and shoulder joint Í For affections of hip and femur with infection,
swelling or open wound
with infection, swelling &
open wound
DOUBLE HIP SPICA CAST
« MOLD:
Í For affections of hip and femur
o Infection
o Swelling
o Open
o Wound

SINGLE HIP SPICA CAST

Í For affection of hip and femur

DOUBLE HIP SPICA MOLD

Í For affections of hip and femur with infection,
swelling or open wound

CUENO | 2021 4 of 11
CYLINDER CAST LONG LEG CIRCULAR CAST
Í For patellar affections Í For affections of tibia and fibula

LONG LEG POSTERIOR MOLD

Í For affections of tibia, fibula with infection,
swelling or open wound
SHORT LEG CIRCULAR CAST
Í For affections of ankle, tarsals and metatarsals

PATELLAR TENDON BEARING CAST

Í For affections of tibia – fibula with callus
formation

SHORT LEG POSTERIOR MOLD

Í For affections of ankle, tarsals and metatarsals
with infection, swelling or open wound

QUADRILATERAL CAST (ISCHIAL WEIGHT

BEARING CAST)
Í For affections of hip and femur with callus
formation

BRACE CAST
Í For affections of distal 3rd of femur and proximal
3rd of tibia with callus formation

CUENO | 2021 5 of 11
DELVIT CAST SHORT ARM CIRCULAR CAST
Í For affections of distal 3rd tibia – fibula with Í For affections of the wrist,
callus formation to allow foot exercises carpals and metacarpals

BASKET CAST SHORT ARM POSTERIOR MOLD

Í For massive or severe bone injuries of tibia Í For affections of the wrist,
carpals and metacarpals with
infection, swelling and open
wound

PANTALON CAST
Í For affections of the pelvis LONG ARM CIRCULAR CAST
Í For affections of radius and ulna

FROG CAST LONG ARM POSTERIOR MOLD

Í For congenital hip Í For affections of radius and ulna
dislocation with infection, swelling or open
wound

CUENO | 2021 6 of 11
MUNSTER CAST (FUENSTER CAST) COLLAR CAST
Í For affections of the radius and ulna with callus Í For cervical spine affections
formation

SUGAR TONG CAST

Í For humerus swelling, infection and
inflammation
BRACES
Í A device used to restrict or assist body
movement

SHANTZ COLLAR BRACE

Í For cervical spine affections
« Commonly used for patients who experienced
motorbike/road accident to align the part of the
HANGING CAST cervical spine
Í For affections of shaft of
humerus

FUNCTIONAL CAST PHILADELPHIA COLLAR BRACE

Í For affections of the Í For cervical spine affections
shaft of humerus with
callus formation

AIRPLANE CAST (ABDUCTOR SPLINT)

Í For affections of the neck of the humerus or for MILWAUKEE BRACE
the recurrent shoulder dislocation Í For scoliosis

CUENO | 2021 7 of 11
FORESTER BRACE BANJO SPLINT
Í For affections of cervico-thoraco-lumbar spine Í For peripheral nerve injuries

BILATERAL LONG LEG BRACE

Í For post-poliomyelitis with residual paralysis
TAYLOR BRACE
Í For affections of upper thoracic spine

JEWETTE BRACE
Í For affections of lower thoracic and lumbar
spine DENNIS BROWNE SPLINT
Í For clubfoot

COCK-UP SPLINT
Í For wrist drop deformity
CHAIR BACK BRACE « Used by patients with carpal tunnel syndrome
Í For affections of lumbosacral spine

CUENO | 2021 8 of 11
ROGER ANDERSON EXTERNAL FIXATOR TRACTION
Í For comminuted fracture Í The act of pulling or drawing which is
associated with counter traction

SKIN TRACTION
Í Applied using a bandage to pull on the skin
when the light traction is required (Indirect
traction)

DUNLOP TRACTION
Í Supracondylar affection of the humerus

TOWER’S EXTERNAL FIXATION

Í For fracture of the mandible

BUCK’S EXTENSION TRACTION

Í For hip and femur affection

FOUR POSTER BRACE

Í For cervical and upper thoracic spine affection

MODIFIED BUCK’S EXTENSION

Í For hip and femur affection

SOMI (STERNO OCCIPITO MANDIBULAR

IMMOBILIZER) BRACE BRYANT’S TRACTION
Í For cervical spine affections Í For congenital hip dysplasia
Í For fracture of hip and femur among children 6
years old and below
« Be sure that the buttocks is slightly elevated
from the mattress so that there will be a traction

CUENO | 2021 9 of 11
HEAD HALTER TRACTION ZERO DEGREE
Í For cervical affection of the spine Í For affection of neck of humerus and shoulder
joints

PELVIC GIRDLE
Í For lumbar spine affection
Í For Herniated Nucleus Pulposus
SKELETAL TRACTION
Í Uses pin or wires inserted through bone and is
attached to weights, pulleys, and ropes (Direct
traction)

HALO-PELVIC TRACTION
Í For scoliosis

COTREL TRACTION
Í Combination of head-halter and pelvic girdle
Í For scoliosis

HALO-FEMORAL TRACTION
HAMMOCK SUSPENSION Í For severe scoliosis
Í For fracture of the pelvis

90-90 DEGREES TRACTION

Í For subtrochanteric fracture of the femur

BOOT CAST TRACTION

Í For post-poliomyelitis with residual paralysis

OVERHEAD SKELETAL TRACTION

Í For supracondylar affectation of the humerus

CUENO | 2021 10 of 11
STOVE IN CHEST TRACTION
Í For multiple rib fracture

BALANCED SKELETAL TRACTION

Í For hip and femur affectation

CUENO | 2021 11 of 11
 MEDICAL SURGICAL NURSING II LECTURER: PROF. ANABELLE S. UMALI RN, MAN
WARNING!
USE AT YOUR
DE LA SALLE MEDICAL AND HEALTH SCIENCES INSTITUTE OWN RISK
TRANSCRIBED BY: Krisha Agcamaran and Tiffany
COLLEGE OF NURSING ACADEMICS COMMITTEE Legaspi

WALKER: AMBULATION/ACTION USED

PROFESSOR POWERPOINT TEXTBOOK Í Instruct patient to:
★ Í ➔ • Pick-up walker: lift device and move it
forward with each step.
AMBULATING WITH AN ASSISTIVE • Rolling walker: roll device forward and
DEVICE walk automatically
« NR: Make sure the path is clear and
CONTENT OUTLINE watch the pt.
I. Walker « The elbow must be flexed @ 30 degrees
II. Cane « Advance the walker, then the affected leg then
III. Crutches the unaffected leg

WALKER
Í A metal frame with handgrips, four legs and
open side ; used for patients who need greater
stability than that provided by other ambulatory
aids.

TYPES:
PICK UP WALKER
Í best for patients with poor balance and poor
cardiovascular reserve. CANE
« patient must lift the walker for her to walk Í A cane helps the patient walk with balance and
support and relieves the pressure on weight-
bearing joints by redistributing weight
« to prevent pressure from the affected
extremity

TYPES:
SINGLE
ROLLING WALKER Í only one leg
Í allows automatic walking, is best for patients TRIPOD
who cannot lift Í base is triangular with three legs
QUADRI
Í four-legged rectangular base of support

PATIENT PREPARATION:
Í Adjust height to individual patient
« because it may strain the pt if it’s not in
proper size
Í Patient’s arms should be in 20 to 30 degrees of
flexion at elbows when hands are resting on
hand grips
« The wrist must be on the level of the
handgrips

AGCAMARAN • LEGASPI | 2021 1 of 3

PATIENT PREPARATION:
Í With patient flexing
elbow at 30-degree angle,
hold handle of cane level
with greater trochanter and
place tip of cane 15 cm (6 in.)
lateral to base of 5th toe.
« Cane must be place
opposite of the affected
or weaker extremity.

CANE: AMBULATION/ACTION USED

Í Instruct patient to:
• Advance cane at same time that affected
leg is moved forward.
• Keep cane fairly close to body to prevent CRUTCHES
leaning. Í Are for partial weight bearing or non-weight
• Bear down on cane when unaffected bearing ambulation
extremity begins swing phase. « Partial weight bearing – we can put some
pressure on the affected extremity
GOING DOWN THE STAIRS « Non-weight bearing – it’s not advisable
Í Instruct patient to: to put weight on the affected extremity
• Step down on Í Good balance, adequate cardiovascular
affected extremity reserve, strong upper extremities, and erect
first together with posture are essential for crutch walking
the cane « The force must be on the hand-grip
• Then unaffected
extremity on down PATIENT PREPARATION
step Í With patient standing,
« Always the bad leg first • Set crutch length approximately 5 cm (2-3 in)
below axilla
GOING UP THE STAIRS « If the size is not appropriate it can
Í Instruct patient to: give pressure on the axilla area
• Step up first on the unaffected extremity • The patient first assumes the tripod position
first together with the cane by placing the crutches about 20 to 25 cm (8
• Then affected extremity up on step to 10 inches) in front and to the side of his or
« Always the good leg first her toes
• Adjust hand grip to allow 20 to 30 degrees
of flexion at elbow
• Weight must not be
borne by axillae. But on
palms of the hand to
prevent crutch palsy
« Or brachial
plexus injury
• Use foam rubber pad
on underarm piece to
relieve pressure of
crutch

AGCAMARAN • LEGASPI | 2021 2 of 3

AMBULATION/GAIT ACTION USED
Í Determine which gait is the best
• Four-point
« Used for partial weight bearing on
both feet
1. Advance the right crutch, then GOING DOWN THE STAIRS
advance the left foot Í Instruct patient to:
2. Advance the left crutch, then • Advance crutches to lower step;
advance the right foot advance affected leg; then unaffected
• Three-point leg
« Non-weight bearing it means that we
can’t give pressure on the affected GOING UP THE STAIRS
extremity Í Instruct patient to:
« So we will use the 2 crutches and the • Advance unaffected leg first up
un affected extremity • Advance crutches and affected
1. Both crutches and the foot of the extremity
affected extremity are advanced • Unaffected leg goes up first
together
• Two-point
« Used for partial weight bearing on
both feet, but it is faster compared to
4-point gait
1. The crutch on the affected side and
the unaffected extremity advanced at
the same time.
2. The crutch on the unaffected side
and the affected extremity advanced
at the same time
• Swing-to
« Weight bearing on both feet
1. Bot crutches are advanced together
2. Both legs are lifted to and place on
the spot behind the crutch
• Swing-through
« Weight bearing on both feet
1. Bot crutches are advanced together
2. Both legs are lifted through and place
on beyond the crutches

AGCAMARAN • LEGASPI | 2021 3 of 3

 Orthopedic
Hardware

College of Nursing
De La Salle Medical and Health Sciences Institute
 Orthopedic Hardware

• a medical device used to replace or support a damaged

bone

• can be made of stainless steel, titanium alloys or with

plastic coating

• “ implants”
Review of the Skeletal System
Functions:
> supports the body
> facilitates movement
> protects internal organs
> produces blood cells

Total number of bone= 270 at birth

= 206 by adulthood
 division:

> axial - vertebral column, rib cage,

skull & other associates

> appendicular - shoulde girdle, pelvic

girdle , the upper and lower limb
Parts of femur 1
2 3
1. head of femur
2. neck of femur 4

3. greater trochanter
4. lesser trochanter
5. body or shaft
- proximal 3rd of femur 5
- middle 3rd of femur
- distal 3rd of femur
6. medial condyle
7. lateral condyle
6 7
types of orthopedic hardware
 BELOW SITE OF FX

Steinman pin & Steinman pin holder

steinman pin introducer
kirschner wire & kirschner wire holder
Screws
- cortical screw (hard bone)
- cancellous screw( spongy bone)
- pedicle screw (spine)
- cannulated screw
- herbert screw (for internal
fixation)
-malleolar screw (ankle)
Plates
- buttress plate
- compression plate
- locking compression
plate
-T-plate
Roger Anderson
External Fixator
(RAEF)

> for comminuted fracture of

the long bone
Spanning External Fixator

> for fracture of femur extended

to tibia
Delta Frame Fixator

> for fracture of proximal / distal

tibia
 Ilizarov
> for comminuted fracture
> for bone lengthening
> for mal union/non union
Hybrid External Fixator

> for periarticular fracture of the

ankle or the knee joint
Luque Rod

• > for scoliosis

Harrington Rod
Instrumentation (HRI)

> for scoliosis

Intra Medullary Nail
(IMN)

> fracture of middle 3rd femur/

long bone only
IMN Extractor

> use for removal of IMN

Removal of tibial IMN
Towers External Fixator/ Interdental Wiring
> for fracture of the mandible
Osteotome
• “chisel”
• used to obtain bone chips for
spinal fusion
• used for scraping ( dead or
necrotic bone)
 Gigli Saw

> for amputation

 Antibiotic beads
2 Functions:
> therapeutic effect
for osteomyelitis
> prophylactic effect
for plating, IMN, and all types
of internal and external
fixators

rifampicin + tobramycin
Total Hip Replacement Arthroplasty (THRA)

Replacement of :

> acetabulum
> head of femur
> neck of femur
Partial Hip Replacement Arthro plasty (PHRA)
• Replacement of :

> head of femur

> neck of femur
Spacer Antibiotic
- replacement of infected hip
prosthesis
Total Knee Arthroplasty

• Replacement of femoral and

tibial component
X pinning/ Y pinning

> Supra condylar fracture of

the humerus
Hoffmann's External Fixator

* for pelvic affection

- hip dislocation
Compression Hip Screw
Fixation

* for intertrochanteric frature of

femur
Crutchfield Tong

- for cervical spine affection

Nursing Responsibility
• Assessment for possible pin site complication
> Infection – both pin site and osteomyelitis
> Deep vein thrombosis (DVT) and pulmonary embolisms (PE)
> Aseptic loosening
> Fracture or non-union of existing fracture; and
> Loss of reduction.
• Observe basic principles of wound care
> aseptic technique, antiseptic solutions, pressure dressings
• Educated patients on the signs and symptoms of infection
END................
 ORTHOPEDIC HARDWARE and TERMS

HARDWARE INDICATION (S)

RAEF(Roger Anderson External Fixator) * for comminuted fracture of the long bone

Delta Frame External Fixator * for fracture of proximal/ distal tibia

Spanning External Fixator * for fracture of femur extended to tibia

Hoffmann’s External Fixator * for pelvic affection

Hybrid External Fixator *for periarticular fracture of the ankle or knee joint

CHSF ( Compression Hip Screw Fixation) * for intertrochanteric fracture of femur

Buttress Plate/ T- Plate * Proximal 3rd tibia

X-Pinning/ Y-Pinning * for supracondylar fracture of the humerus

HRI (Harrington Rod Instrumention) * for scoliosis

Luque Rod * for scoliosis

THRA ( Total Hip Replacement Arthroplasty) * replacement of femoral head, neck and acetabulum

PHRA (Partial Hip Replacement Arthroplasty) * replacement of femoral head and neck

IMN (Intra Medullary Nailing) * fracture of middle 3rd femur/ long bone only
IMN Extractor * Used for removal of IMN

Spacer Antibiotic * replacement of infected hip prosthesis

Hemovac * for collection of drainage under negative pressure

Gigli Saw * for amputation

Antibiotic Beads * for osteomyelitis ( Therapeutic Effect)

for plating, IMN and all types of Internal and
External Fixators ( Prophylactic Effect)

Tower External Fixator/ Interdental Wiring * for fracture of the mandible

TBW ( Tension Bond Wiring) * for fracture of the patella

with the use of Cerclage Wire

Total Knee Arthroplasty/ Prosthesis * for fracture of the patella, femoral and
tibial component; Osteoarthritis Bone

Crutchfield Tong * for cervical spine affection

Steinmann’s Pin * for fracture of femur and hips for BST

Mini RAEF * for fracture of carpals , metacarpals

Osteotome (Chisel) * used for obtaining bone chips for spinal fusion
- used for scraping ( dead or necrotic bone)

Ilizarov External Fixator * for comminuted fracture

- non union/mal union
- bone lengthening
 TERMS DEFINITION
ADSF (Anterior Decompression Spinal Fusion) * Surgical Intervention for Pott’s Disease

Gibbus Formation * Progressive desctruction of the anterior

spine leading to collapse and kyphosis
- classical sign of Pott’s Disease

Sequestrum * dead or necrotic bone

Sequestrectomy * removal of dead or necrotic bone

Debridement * removal of dead or necrotic tissue

Axis * 2nd cervical bone

Atlas *1st cervical bone

Intertrochanteric Fracture * fracture within the greater and lesser trochanter

Supracondylar Fracture * fracture above the condyle

Subcondylar Fracture * fracture under or below the condyle

Involucrum * new bone

SURGERY ABBREVIATION and MEANING

ACL Anterior Cruciate Ligament TRHP Total Hip Replacement Prosthesis

AEA Above Elbow Amputation VDO Varus Derotation Osteotomy

BKA Below Knee Amputation ADSF Anterior Decompression Spinal Fusion

CHSF Compression Hip Screw Fixation AKA Above Knee Amputation

CSTR Complete Soft Tissue Release BG Bone Grafting

CW Cerclage Wiring DCS Dynamic Compression Screw

FTSG Full Thickness Skin Grafting HRI Harrington Rod Instrumentation

IMN Intra Medullary Nailing ORSF Open Reduction Screw Fixation

ORIF Open Reduction Internal Fixation

PHRP Partial Hip Replacement Prosthesis
PLBG Postero-Lateral Bone Grafting
PSTR Postero-Soft Tissue Release
PMR Postero-Medial Release
RAEF Roger Anderson External Fixation
PSF Posterior Spinal Fusion
RFS Rush Frozen Section
PSR Progressive Surgical Release
TAR Tendon Achilles Repair
ROI Removal of Implant
STSG Split Thickness Skin Grafting
SSI Segmental Spinal Instrumentation
RCHSF Richard Compression Hip Screw
TBW Tension Bond Wiring Fixation
BALANCE SKELETAL TRACTION APPLICATION
Traction : is the act of pulling or drawing which is associated with counter traction. The pulling force is applied to a part of the body
while a counter traction pulls in the opposite direction. In straight or running traction coutertraction is supplied by the patient’s
body with the bed in one of the following positions;

1. Flat
2. Tilted away from the traction pull
3. Altered by elevating the head and / or knee gatch

THE PROCEDURE
I. Purpose and identification of traction
a. Purpose: used in the treatment or fractured extremities;
1. To lessen muscle spasm
2. To reduce fracture
3. To provide immobilization
4. To maintain alignment
5. To correct or prevent deformities in the case of arthritis patient with flexion contraction
6. To help lessen the curvature of the spine before correction surgery
b. Basic types of traction;
1. Skin traction
2. Skeletal traction
3. Manual traction
2. Check for Doctor’s Order
3. Identification of parts
a. Orthopedic bed/ Balkan frame
- 2 horizontal bars
- diagonal bar
- 4 vertical bars
- 3 pulleys
- Clamps
- Overhead trapeze
- Cross bar
- Firm mattress
- Fracture board
- Shock blocks / lock
b. BST equipments
- Thomas splint
- Pearson attachment
- Rest splint
- Cord/Sash
- Foot rest
- Safety pins/ paper clips
- Thigh rope(shortest)
- Suspension rope(longest)
- Traction rope(longer)
- Traction weight
- Suspension weight
4. Traction set-up

Prepared by: James M. Alo, R.N, MAN, MAPsycho, PhD, Page 1

 a.
Thomas splint and pearson splint
1. Attach the rest splint to the Thomas splint with Pearson attachment
2. Upper part is the Thomas splint which will support the thigh and lower part is the Pearson attachment
that will support the leg.
3. Tie the short rope to the medial upright of the Thomas splint with slip-knot to ensure privacy to the
patient.
b. Application of slings to the Thomas splint and Pearson attachment.
1. Start from the large and wide slings (at least 2 pcs) to the Thomas splint and 3 slings smaller and
narrower to the Pearson attachment.
c. Principles of sling application
1. Smooth side should be touching the patient skin for comfort
2. At least 1 inch apart in between slings for ventilation
3. Not to tight not too loose to support the normal structure of the leg
4. Provide space at the popliteal and heel area to provide ventilation and prevent irritation.
5. Insertion of apparatus
a. Patient’s instructions
1. Instruct the patient to flex the unaffected leg and hold on the overhead trapeze bar
b. 3 manpower team
1. Apply manual traction (1st nurse) of the affected leg
2. In the count of 1,2, & 3 with the coordination in movement, simultaneously, 2nd nurse lifting the
affected leg and
3. 3rd nurse removing the Braun Bohler while inserting the assembled apparatus (Thomas splint, Pearson
attachment & rest splint).
6. Application of traction weight
a. Application of traction weight (10% of the body weight)
1. There should be continuous traction, so don’t remove the manual traction until kthe longer rope has
been tied to the steinman pin holder (club hitch knot/ eight knot), then insert the other end of the rope
to the third pulley to the traction weight(club hitch knot) and securely tied.
2. Check the groin part of the thigh if resting on the half ring to promote comfort.
b. Application of suspension weight (50% of the traction weight)
1. Tie first the other end of the short rope on the lateral aspect of the Thomas splint.
2. Tie the longest rope to the middle of the short rope with slip knot.
3. Insert the other end of the rope to the first pulley, passing through the hanged suspension weight, to
the 2nd pulley
4. Prior in tying the rope make it sure the rope is inside thetraction rope for support and prevent the
affected leg from swaying sideways. Then tie to the Thomas splint using clove hitch knot then to the
Pearson attachment.
5. Release the suspension weight
c. Removal of the rest splint
d. Applying of foot support
1. You may start applying ribbon knot at the lateral and medial side of the Thomas splint, then to Pearson
attachment.
7. Checking efficiency of traction
a. Principles of Skeletal Traction
1. Have an opposite pull or counter traction.
2. The application of shock block or lock and weight of the patient serve as the counter traction .
3. Line of pull should be in line with the deformity. The 1st pulley should be in line with the groin. The 2nd
pulley should be in line with the knee, and traction line should be straight with the deformity.
4. Traction should be continuous and weights should be hanging freely.

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 5.
The position of the patient should be in dorsal recumbent or supine position .
6.
It should be free from friction;
- Weights should be hanging freely.
- Observe for signs of wear and tear on the ropes and bags.
- Ropes should run freely along the grove of the pulley.
- Knots should be away from the pulley.
8. Transport/removal of traction ( what is being 1st assembled should be the last to remove);
a. Attach the rest splint,
b. Anchor the suspension weight,
c. Remove the suspension rope,
d. Apply manual traction,
e. Remove traction weight, then tie the rope to the rest splint, Thomas and Pearson using the clove hitch knot
f. Patient is ready for transfer to the stretcher, and
g. Instruct the patient to flex his unaffected leg while holding on the trapeze bar and simultaneously helping the
patient transfer to the stretcher.
9. Nursing care to patient in traction
a. Should be free from any of the following;
1. Impaired circulation of the extremeties,
2. Respiratory distress,
3. Emphasize good condition of the skin particularly at ischial, sacral, poplitieal, dorsum of foot, and heel
part,
4. Contracture of joint like footdrop
5. Signs of infection;
- Assess skin integrity
- Traction pin site dressing regularly
- Monitor for temperature, color, odor of the affected part.
b. Should have bone alignment and position of extremity in which the purpose of traction should be accomplished.
c. Provide patient’s comfort such as;
1. Traction should never be a source of undue discomforrt,
2. Care of the skin, mouth, hair, nails, toes, and genitals should be included in the plan of daily care.
d. Provide exercises such as;
1. ROM exercise of all the unaffected joints
2. Static quadriceps exercises,
3. Flexion and extension of the toes and fingers in traction.
e. Provide supportive therapy
f. Monitor the nutritional status of the patient
g. Complaint of the patient should be assess
h. Check the traction set-up if;
1. The apparatus is accomplishing each purpose of traction,
2. The equiments are safe as possible,
3. Sash, cords and pulleys is unobstructed,
4. Knots, clamps, and weighs are secured, and
5. Weights are free from any friction,
10. What are the complications to patient with traction?
a. Fat embolism
1. Patient with long bone fracture is prone like; tibia, fibula, radius, ulna, femur, and humerus. Fatty
globules from the bone goes to the lungs and usually occurs within 48 hours.
2. Signs/symptoms: restlessness, altered LOC, tachycardia, tachypnea, ŒBP, petichial rash over the upper
chest/neck.

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 3. Nursing consideration: inform the doctor.
b.
Compartment syndrome
1. Increase pressure within one or more compartment causing massive compromise circulation, leading to
Œtissue perfusion Šanoxia. This is w/n 4-6 hrs pc the onset neurovascular damage F irriversible.
2. Sx/Sy: ›pain & swelling, pain unrelieved by analgesic, Œdistal pulse, & loss of sensation.
3. Nsg consideration: Assess VS, & notify the doctor.
c. Infection/ osteomyelitis
1. Is an acute/chronic inflammatory process of the bone and its structures secondary to infection with
pyogenic organisms.
2. Sx/Sy: fever, pain, edema, warmth, tender, reduction in the use of extremity, ›WBC & pulse.
3. Nsg consideration: Assess, notify the doctor.
d. Avascular necrosis
1. Interruption of the blood supply to the bone tissue Šbone death.
2. Sx/Sy: pain & Œsensation
3. Nsg consideration: assess & notify doctor
11. What are the possible nursing diagnosis?
a. Pain
b. Highrisk for infection
c. Impaired physical mobility
d. High risk for skin integrity
e. High risk for injury
f. High risk for altered tissue perfusion
g. High risk for self-esteem disturbance

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