Management of Patients Assessment RHEUMATOID ARTHRITIS (RA)

a. Pain and stiffness of joints

with Musculoskeletal b. Heberden’s and bouchard’s nodes Chronic, progressive, systemic, symmetric
Disorders c. Possible crepitation, decreased ROM autoimmune disease that primarily attacks
peripheral joints and surrounding muscles,
Diagnostic Test tendons, ligaments and blood vessels causing
ARTHRITIS
a. X-rays show JOINT DEFORMITY deformity
b. ESR may be slightly ELEVATED
OSTEOARTHRITIS (OA)
It usually affects joints symmetrically (on both
“Degenerative arthritis”
Formation of Joint Deformities sides equally), may initially begin in a couple of
● Heberden’s Nodes (hard nodes in the distal joints only, and most frequently attacks the
Chronic, non systemic disorder of joints
phalanges) wrists, hands, elbows, shoulders, knees, and
characterized by progressive degeneration of
● Bouchard’s Nodes (hard nodes in the ankles.
articular cartilage
proximal phalanges)
● Crepitus in the weight-bearing joints with Predisposing Factors
Women and men are affected equally;
movement. ● Age: May occur at any age
incidence increases with age
○ Peak: Middle age (35-45 years old)
Nursing Care ● Gender: 3x more in women than men
The most common form of arthritis that affects
1. Assess joints for pain and ROM
the weight-bearing joints (spine, knees, hips)
2. Prevent further trauma to joints Note:
a. Use cane or walker ❖ Onset is insidious, characterized by
Predisposing factors
b. Ensure proper posture and body remission and exacerbation
● Age: Middle age (40 and up)
mechanics ❖ Life expectancy may be short. Average
● Gender: occurs equally in both genders
c. Weight reduction of 5 years
○ incidence in women increases after 55
d. Avoid excessive weight-bearing
years old
activities ● Cause is unknown, but may be
● Hereditary
3. Maintain joint mobility autoimmune; genetic factors may also play
4. Prepare client for joint replacement surgery if a role
Precipitating Factors
necessary ● Joint distribution is bilateral; most commonly
Classification:
affects smaller peripheral joints of hands
1. Primary Idiopathic
and wrist
a. Unknown etiology
2. Secondary Disorder
Assessment Findings
a. RA
a. Joints are painful, swollen, limited in
b. DM
motion, stiff in the morning and may
c. Congenital deformities
show crippling deformity in long-
d. Joint trauma
standing disease
e. Repetitive movement of joints (sports
b. Fatigue, anorexia, slight elevation in
or work/occupation)
temperature
 c. Muscle weakness due to inactivity 4. Symmetric arthritis with simultaneous 2. Surgery
involvement of corresponding joints on To remove severely damaged joints (total hip
Joint Instability and Deformity both joints of the body. replacement); (Increased tension on abductor
a. Swan Neck - hyperextension of PIP 5. Rheumatoid nodule mechanism).
joints with flexion of DIP joints (fingers) 6. Positive serum rheumatoid factor
7. Characteristic radiologic changes of 3. Diet
b. Boutonniere Deformity - flexion of PIP rheumatoid arthritis in hands and wrists. High in vitamins, protein, and iron
joint and hyperextension of DIP joints
(thumb).
Medical Management Nursing Care
c. Ulnar Drift - ulnar deviation of the MCP 1. Assess joints for pain, swelling, tenderness,
1. Drug Therapy limitation of motion
d. Rheumatoid nodule over pressure area - Aspirin: mainstay of treatment, has both 2. Promote maintenance of joint mobility and
firm nontender subcutaneous mass on analgesic and anti-inflammatory effect muscle strength (perform ROM exercises
olecranon bursae or extension surface several times a day)
of forearm. NSAIDs: ibuprofen, ponstan; relieve pain and 3. Change position frequently
inflammation by inhibiting the synthesis of 4. Promote comfort and relief/control of pain
Diagnostic Test prostaglandins. (ensure balance between activity and rest.
a. Rheumatoid factor is positive
b. X-ray shows various stages of joint Gold compounds or God Salts
RA OA
disease (chrysotherapy):
c. CBC: Anemia is common Onset is early Onset is late
d. ESR is elevated Injectable form: sodium thiomalate,
e. ANA maybe positive aurothioglucose that stops cells from releasing Chronic systemic Degenerative disease
f. C-reactive protein is elevated disease
chemicals that can harm tissues; given IM once
a week; take 3-6 months to become effective; Involves the Involves the
Note: side effect is mouth ulcers and skin rash synovium cartilages
❖ The American Rheumatism Association has
developed a diagnostic criteria for RA. Oral form: Auranofin; smaller doses are Involved joints are Involves joints are
symmetrical-fingers, unilateral-weight
effective; take 3-6 months to become effective;
❖ Evidence of 4 out of 7 criteria must be cervical spine bearing knee, hips
side effect is diarrhea spine
present to confirm the diagnosis
1. Morning stiffness lasts for at least 1 hour Corticosteroids: Intra-articular injections Malaise, fever, No other s/sx
and persists over the last 6 weeks. temporarily suppress inflammation in specific anemia systemic
2. Arthritis of 3 or more joints persistent joints.
over last 6 weeks
3. Arthritis of wrist, MCP or POP persistent Methotrexate, Cytoxan: given to suppress
over the last 5 weeks. immune response; side effects include bone
marrow suppression.
 GOUT Medical Management OSTEOPOROSIS

Metabolic disease or disorder of purine 1. Drug Therapy A musculoskeletal and metabolic disorder in
metabolism marked by increased serum uric a. Acute attacks: Colchicine IV or PO; NSAIDs which the rate of bone resorption (osteoclasts)
acid levels and joint inflammation and such as naproxen accelerates and the rate of bone formation
precipitation of urate crystals (tophi) deposited (osteoblasts) decelerates leading to loss of
in the joints. b. Prevention of attacks: bone mass and predisposing to an increased
-uricosuric agents (probenecid): increases renal risk in fracture.
Predisposing Factors excretion of uric acid
● Gender -allopurinol (Zyloprim): inhibits uric acid Predisposing Factors
○ Increase frequency in men formation ● Age: 80 years old
○ Postmenopausal women ● Age and Gender: Postmenopausal women
● Obesity 2. Low purine diet (may be recommended) (estrogen supports bone metabolism)
● Familial trait ● Low body weight
3. Joint rest ● Race: Asians and Caucasians Sedentary
Precipitating Factors lifestyle
● Heavy alcohol intake Nursing Care ● Low calcium intake
● Disorders: 1. Provide bed rest and joint immobilization as
○ Malignancy, HPN, Acidosis ordered Precipitating Factors
○ DM, Kidney Disease 2. Administer antigout medication as ordered ● Endocrine Disorders
● Medications: 3. Administer analgesics for pain ○ Hyperparathyroidism, Hyperthyroidism
○ Thiazide diuretics 4. Increase fluid intake to 2-3L/day ○ Cushing’s Syndrome
○ Cytotoxic drugs 5. Avoidance of purine rich foods ○ DM
○ Low dose aspirin 6. 6. Weight reduction and regular exercise ● Substances:
○ Ethambutol ○ Glucocorticoids - Oral corticosteroid for
more than 3 months
Assessment Findings ○ Caffeine
a. Joint pain, redness, heat, swelling; joints ○ Nicotine
of foot (great toe) and ankle most ○ Tetracycline
commonly affected (acute stage) ○ Aluminum containing antacids
b. Malaise and anorexia
c. Tophi in outer ear, hands, and feet Classifications
(chronic stage) 1. Type I
d. Diet - Early menopausal associated with estrogen
deficiency

2. Type II
- Senile osteoporosis associated with calcium
depletion
 OSTEOMALACIA PAGET’S DISEASE / OSTEITIS DEFORMANS
Nursing Care
1. Preventing loss of bone mass Is a metabolic bone disease characterized by Chronic bone disease with inflammation of the
● Calcium and Vit.D intake inadequate mineralization of bone bone, hypertrophy of long bones and deformity
● Exercise of flat bones
● Caffeine There is softening and weakening of the
● Low sodium skeleton Is a disorder of localized rapid bone turnover
● Alcohol and tobacco - HRT (skull, femur, tibia, pelvic bone and vertebrae)
● Alendronate, risedronate, ibandronate, and Is result in deficiency of activated Vitamin D
zoledronic acid (calcitriol), which promotes calcium absorption There is proliferation of osteoclasts, followed by
○ Oral form are poorly absorbed from the GI tract and facilitates mineralization of increase in osteoblastic activity that replaces
○ Must be taken early in the morning with bone the bone.
a full glass of water
○ Client should stay upright position for Liver and kidney problems may also cause Bone turnover continues and forms a classic
30-60 min after taking the medication osteomalacia mosaic (disorganized) pattern of bone formation
● Ibandronate IV – is given every 3 months that is highly vascularized and structurally weak
● Zoledronic acid – once a year Malabsorption and GI disorders
Cause is unknown/virus
Chronic use of anticonvulsants
More common in males, 40 years
Assessment Findings
a. Spinal kyphosis ASSESSMENT FINDINGS
b. Bowed legs a. Asymptomatic (x-ray)
c. X-ray: demineralization of bone, b. Waddling gait
compression fractures in the vertebrae c. Pain, tenderness over the bones may be
d. Laboratory studies: low serum calcium noted
d. Bowing of the legs
MEDICAL MANAGEMENT e. Impaired hearing
1. Increased doses of Vit D
2. Exposure to sunlight MEDICAL MANAGEMENT
3. Diet adequate with calcium and Vit D 1. NSAIDs for pain
4. Adequate CHON 2. Walking aids and physical therapy
3. Weight reduction
NURSING CARE 4. Diet adequate in calcium and Vit D
1. Handle the patient gently while changing 5. Cytotoxic Antibiotic (Mithracin) – to
position decrease Ca.
2. Health teachings
 6. Calcitonin
a. retards bone resorption by decreasing the
number and availability of osteoclasts.
b. Facilitates remodeling of abnormal bone into
normal, relieves bone pain
c. Is administered SC or by nasal inhalation
d. Side effects: flushing of face and nausea
e. Effect is evident to 3-6mos
7. Biphosponates (Fosamax)
a.Produce rapid reduction in bone turnover and
relief of pain
b.Food inhibits absorption of these drug
c. Adequate daily calcium and vitamin D is
required during therapy
NURSING CARE
1. Assessment of client’s pain and
discomfort
2. Patient teaching regarding the treatment
3. Home environment is assessed for
safety
OSTEOMYELITIS
Acute or chronic infection of the bone and
surrounding soft tissues characterized by
progressive inflammatory destruction
Predisposing Factors
● Age: Children under 10 years old
● Gender: Male
Note: (Common site per age group)
❖ Children: Metaphysis of lower end of femur,
upper end of tibia, humerus and radius
❖ Adult: pelvis, vertebrae (after surgery or
trauma
Precipitating Factors:
● Infection: Staphylococcus Aureus (most
common)
● Surgery, Trauma or fracture
● Skin, ear, infection URTI, UTI, Drug abusers
● Puncture or gunshot wound
Note:
❖ Early diagnosis is critical to prevent disease
progression
❖ Infection may reach bone through open
wound (fracture or surgery), through the
bloodstream, or by direct extension form
infected adjacent structures
❖ Infections can be acute or chronic; both
cause bone destruction
ASSESSMENT FINDINGS
a. Malaise and fever
b. Pain and tenderness of bone, redness
and swelling over bone, difficulty with
weight bearing; drainage from wound
site may be present
c. Diagnostic tests
i. WBC elevated
ii. Blood cultures may be positive
iii. ESR may be elevated
NURSING CARE:
1. Administer analgesics and antibiotics as
ordered
2. Use sterile technique during dressing
changes
3. Maintain proper body alignment and
change position frequently to prevent
deformities
4. Prepare client for surgery if indicated
5. Incision and drainage of bone abscess
6. Sequestrectomy: removal of dead,
infected bone and cartilage
7. Amputation
 Management of Patients SPRAINS MEDICAL MANAGEMENT
1. Immobilization (Splint, Cast or Traction)
with Musculoskeletal Excessive stretching of the LIGAMENTS 2. Reduction – (open or close)
Trauma  3. Analgesia
NURSING CARE 4. Muscle Relaxants
1. Immobilize extremity and advise rest
CONTUSIONS
2. Apply cold packs initially then heat packs NURSING CARE
3. Compression bandage may be applied to 1. Neurovascular check Q15 min until stable
Soft tissue injury produced by blunt force such
relieve edema 2. Assist in ROM Exercises
as blow, kick or a fall that causes small blood
4. Assist in cast application 3. Check for signs of compartment syndrome:
vessels to rupture and bleed into soft tissues
5. Administer NSAIDS a. Increase pain despite use of analgesics
Maybe minor or severe
b. numbness/tingling sensation

*REST – prevents additional injury and c. Increase edema
ASSESSMENT FINDINGS
promotes healing
1. Pain
FRACTURES
2. Swelling
*ICE – decreases bleeding, edema, and
3. Discoloration
discomfort A break in the continuity of bone, usually

caused by trauma
MANAGEMENT:
*COMPRESSION – controls bleeding, reduces
1. P- protection
edema Pathologic fractures: spontaneous bone break,
2. R - rest
found in certain diseases or conditions
3. I - ice
*ELEVATION – controls the swelling (osteoporosis, osteomyelitis, bone tumors)
4. C - compression
5. E - elevation
JOINT DISLOCATION Predisposing Factors:
● Age: Elderly client at risk of falls
STRAINS
A condition in which the articular surfaces of the ● Athletes
distal and proximal bones that form the joint are
Excessive stretching of a muscle or tendon
no longer in anatomical alignment Precipitating Factors:

 ● Accidents
NURSING CARE
ASSESSMENT FINDINGS ● Trauma
1. Immobilize affected part
1. Pain ● MVA
2. Apply cold packs initially, then heat packs
2. Change or awkward position of joint ● Abuse
3. Limit joint activity
3. Decreased ROM ● Neglect
4. Administer NSAIDs and muscle relaxant
4. Bilateral assessment will make apparent the ● Bone disease: Osteoporosis
abnormality in the affected joint
5. X-ray – confirm the diagnosis
Classification: ASSESSMENT FINDINGS 6. Encourage fluids to prevent constipation,
Depends on the location of break, angle of 1. pain, aggravated by motion; tenderness renal calculi, and UTI’s
break and/or relationship with the external 2. Loss of motion; edema, crepitus 7. Provide cast care/traction care
environment 
DIAGNOSTIC TEST: FRACTURE COMPLICATIONS
Client may be able to move the affected area a. X-ray reveals break in the bone Early
even though a fracture exists  1. Shock
MEDICAL MANAGEMENT 2. Fat embolism
Type of Break: 1. Traction 3. Compartment syndrome
1. Complete 4. Infection
Bone broken all the way through 2. Reduction 5. DVT
2. Incomplete a. Closed reduction through manual
Partially broken or splintered manipulation followed by application of cast Late
1. Delayed union
Relationship with External Environment: b. Open reduction requires surgery to 2. Avascular necrosis
1. Open or Compound realign bones; may include internal fixation with 3. Delayed reaction to fixation devices
Penetration of skin, bones protrude through pins, screws, wires, plates, rods, or nails; 
2. Closed or Simple indicated for: compound fractures, comminuted FAT EMBOLISM
No penetration of bone through skin fractures, fractures of the femur and fractures of
 joints Occurs usually in fractures of the long bones
Name of Fracture:
POST-OP NURSING CARE: Fat globules may move into the bloodstream
1. Comminuted 1. Provide routine pre-op and post-op because the marrow pressure is greater than
Bone shattered into pieces 2. Perform neurovascular checks capillary pressure
3. Observe for post-op infection
2. Compression Fat globules occlude the small blood vessels of
Bone is crushed 3. Application of cast the lungs, brain kidneys and other organs

3. Impacted NURSING CARE: Onset is rapid, within 24-72 hours
End of broken pieces are jammed together 1.Provide emergency care of fractures 
2.Perform neurovascular checks on affected ASSESSMENT FINDINGS
4. Spiral extremity 1. Sudden dyspnea and respiratory distress
Bone twists and causes jagged break 3.Observe for signs of compartment syndrome; 2. tachycardia
signs include weak pulse, pallor followed by 3. Chest pain
5. Greenstick cyanosis, paresthesias and severe pain 4. Crackles, wheezes and cough
Incomplete break 4. Observe for signs of fat emboli especially 
in the client with multiple long-bone fractures
6. Transverse 5. Encourage diet high in protein and vitamins
Complete break at right angle to long axis bone to promote healing
NURSING CARE
1. Support the respiratory function
a. Respiratory failure is the most common
cause of death
b. Administer O2 in high concentration
c. Prepare for possible intubation and
ventilator support
2. Administer drugs
a. Corticosteroids
b. Morphine
3. Institute preventive measures
a. Immediate immobilization of fracture
b. Minimal fracture manipulation
c. Adequate support for fractured bone
during turning and positioning
COMPARTMENT SYNDROME TOTAL HIP REPLACEMENT
A complication that develops when tissue Replacement of both acetabulum and head of
perfusion in the muscles is less than required femur with prostheses
for tissue viability
 Indications:
ASSESSMENT FINDINGS 1. Rheumatoid arthritis or osteoarthritis
1. Pain- Deep, throbbing and UNRELIEVED causing severe disability and intolerable
pain by opioids pain
a. Pain is due to reduction in the size of the 2. Fractured hip with nonunion
muscle compartment by tight cast
b. Pain is due to increased mass in the NURSING CARE:
compartment by edema, swelling or 1.Teach patient
hemorrhage 2. Prevention of adduction of affected limb and
hip flexion
2. Paresthesia- burning or tingling sensation 3. Do not cross legs
3. Numbness or stiffness 4. Use raised toilet seat
4. Motor weakness/paralysis 5. Do not bend down to put on shoes or
5. Pulselessness, impaired capillary refill time socks(90°)
and cyanotic skin 6. Do not sit in low chairs
6. Hot spot felt on cast over lesion 7. Assess signs of wound infection
NURSING CARE
1. Assess frequently the neurovascular status
of the casted extremity
2. Elevate the extremity above the level of the
heart
3. Assist in cast removal and FASCIOTOMY
4. Adequate hydration
5. Pain should be managed
6. Relief of the source of pressure
 AMPUTATION OF A LIMB
Nursing Intervention – Preoperative
● Establish open and honest
communication
● Offer support / encouragement and
accept patient’s response of anger /
grief
● Discuss:
○ Rehabilitation program & use of
prosthesis
○ Upper extremity exercise such
as push ups in bed
○ Crutch walking
○ Amputation dressing / cast
Phantom limb sensation as a
normal occurrence
 Teach the client to hold the cane in hand
NURSING CARE
POSTOPERATIVE
a. Observe stump dressing for signs of
hemorrhage and mark outside of
dressing so rate of bleeding can be
assessed (tourniquet at bedside)
b. Prevent edema
i. Raise extremity with pillow
support for the first 24 hrs.
c. Prevent hip / knee contractures –
prone position
d. Pain medication as ordered (Phantom
limb pain)
e. Ensure that stump bandages fit tightly
and are applied properly to enhance
prosthesis fitting
 REMEMBER!!!
Musculoskeletal and the tip of each crutch is 4-6 inches in front
and to the side of the feet.
Care Modalities b. Client’s elbows should be slightly flexed
 when hand is on hand grip
ASSISTIVE DEVICES WHEN WALKING c. Weight should not be borne by the axillae to
a. Cane avoid nerve injury
b. Walker
c. Crutches 2. Crutch Gaits
CANE A. FOUR-POINT GAIT
TYPES: used when weight bearing is allowed on both
a. SINGLE/STRAIGHT- LEGGED extremities
b. TRIPOD ● Advance right crutch
c. QUAD ● Step forward with left foot
 ● Advance left crutch
NURSING CARE: ● Step forward with right foot

opposite the affected (unaffected) extremity B. TWO-POINT GAIT
(strong side) and to advance the cane at the typical walking pattern, an acceleration of
same time the affected leg is moved forward. four-point gait
● Step forward moving both right crutch
WALKER and left leg simultaneously
Mechanical device with four legs for support ● Step forward moving both left crutch and
 right leg simultaneously
NURSING CARE: 
Teach the client to hold the upper bars of the C. THREE-POINT GAIT
walker at each side, then to move the walker used when weight bearing is permitted on one
forward and step into it. extremity only
Assistive Devices for Walking: ● Advance both crutches and affected
extremity several inches, maintaining
CRUTCHES good balance
teaching the client proper use of crutches is an ● Advance the unaffected leg to the
important nursing responsibility crutches, supporting the weight of the
 body on the hands.

1. Ensure proper length
a. When a client assumes an erect position, the
top of the crutch is 2 inches below the axilla,
D. SWING-TO GAIT ● The cast should not be covered with a CARE OF CLIENTS WITH EXTERNAL
used for clients with paralysis of both lower blanket or towel while it is drying FIXATOR
extremities who are unable to lift feet from floor ● Rapid drying with blow dryer is not advised
● Both crutches are placed forward  EXTERNAL FIXATOR
● Clients swings forward to the crutches 2. SYNTHETIC CASTS (fiberglass) ● used to manage fractures with soft tissue
● Strong, lightweight; sets in about 20 minutes damage
E. SWING-THROUGH GAIT ● Can be dried using cast dryer or hair ● provides skeletal stability for severe
same indications as for swing-to gait blow-dryer on cool setting; some synthetic comminuted fractures while permitting
● Both crutches are placed forward casts need special lamp to harden active treatment of extensive soft tissue
● Client swings body through the crutches ● Water-resistant; however, if cast becomes damage
 wet, must be dried thoroughly to prevent ● correct defects, treat nonunion and
CARE OF CLIENTS WITH CAST skin problems lengthens limbs
 ● surgical insertion of pins through the skin
A. TYPES OF CASTS: NURSING CARE: and soft tissue into and through the bone
● LONG LEG CAST 1. Perform Neurovascular Checks To Area
● SHORT LEG CAST distal to cast NURSING CARE:
● SHORT ARM CAST 2. Note Any Odor From The Cast That May 1. Elevate Affected Extremity Above Heart level
● LONG ARM CAST indicate infection to reduce swelling
● HIP SPICA 3. Note Any Bleeding On Casting Surgical client 2. Anysharppointsifthefixatororpinsare covered
● SHOULDER SPICA 4. Instruct Client To Wiggle Toes Or Fingers to with caps to prevent device- induced injuries
● BODY CAST improve circulation 3. Perform Neurovascular Checks(Q2Hto Q4H)
5. Elevate affected extremity above heart especially after fixator is applied
B. Casting Materials level to reduce swelling 4. Check Pin Sites For Signs Of Inflammation
6. Do not scratch or insert foreign bodies under and infection
1. PLASTER OF PARIS cast; may direct cool air from blow-dryer under 5. Assess pin sites for redness, swelling, pain
● Traditional cast cast for itching around the sites, warmth and purulent
● Takes 24-72 hours to dry 7. Assess for Hot Spots discharges ever 8 to12 hours
● Precautions must be taken until cast is dry 8. Assess for Wet Spots 6. NOTE: Serous drainage, skin warmth, mild
● to prevent dents, which may cause 9. Assess for Cast Syndrome - 24-48H redness at pin sites 48-72 hours post insertion
● pressure areas 10. Watch out for cast syndrome are expected but should subside after 72 hours.
● Handle casts using palm of the hand
● Signs of dry cast: shiny white, hard,
● resistant
● Must be kept dry since water can ruin a
plaster cast
● Towels may be placed under the cast to
absorb dampness
● Client should be instructed to expect
sensation of heat
 CARE OF CLIENTS IN TRACTION
TRACTION
A pulling force exerted on bones to reduce
and/or immobilize fractures, reduce muscle
spasm, correct or prevent deformities
 ● Cervical head halter attached to weights
PURPOSE OF TRACTION:
1. Reduce, realign, and promote healing of
fractured bones
2. Prevent soft tissue damage through
immobilization
3. Prevent or treat deformities
4. Prevent development of contractures

Types of Traction
1. SKIN TRACTION
● Weights are attached to a moleskin or
adhesive strip secured by elastic bandage
or other special device used to cover the
affected limb.
● Used for severe strains or sprains,
cervical trauma, nerve root compression
A. BUCK’S TRACTION
● For fractured hip and knee
● Exerts straight pull on affected extremity
● Shock blocks at the foot of the bed produce
counter traction and prevent the client from
sliding down the bed
B. RUSSELL TRACTION
● for fractured femur
● Knee is suspended in a sling attached to a
rope and pulley on a Balkan frame, creating
upward pull from the knee; weights are
attached to the foot of bed creating a
horizontal force
● Head of bed should remain flat NURSING CARE:
● Elevating the foot of bed slightly provides 1. Check Traction Apparatus Frequently Ensure
counter traction. that ropes are aligned and weights are hanging
 freely
C. CERVICAL TRACTION 2. Maintain Client Proper Alignment (align in
● for cervical spine problems center of bed)
3. Perform Neurovascular Checks To Affected
that hang over HOB extremity
● Usually intermittent traction 4. Observe for and prevent DVT and foot
● Elevate HOB to provide counter traction drop
 5. Observe for and prevent skin irritation and
D. PELVIC TRACTION breakdown
● low back pain 6. Prevent complications of immobility
● Pelvic girdle with extension straps attached 7. Assist with ADL
to ropes and weights 8. Encourage active ROM exercises to
● Usually intermittent traction unaffected extremities
● Client in Semi-fowler’s position with knee 9. Check carefully for orders about turning
bent
● Secure pelvic girdle around iliac crest

2. SKELETAL TRACTION
● traction applied directly to the bones using
pins, wires, or tongs that are surgically
inserted; used for fractured femur, tibia,
humerus, cervical spine

3. BALANCED SUSPENSION TRACTION
● produced by a counterforce other than the
client’s weight; extremity floats or balances
in the traction apparatus; client may change
position without disturbing the line of
traction

D. THOMAS SPLINT AND PEARSON
ATTACHMENT
● usually used with skeletal traction in
fractures of the femur
● Hip should be flexed at 20°
● Use footplate to prevent foot drop
  
Common Upper Treatment: Treatment:
- Splinting the area - NSAIDs
Extremity Problems - applying moist heat or ice - intra-articular injections of
- using other forms of physical therapy are lidocaine plus a corticosteroids
1. Bursitis & Tendonitis helpful - application of hot & cold compress
- are both common conditions that cause - Medications can reduce inflammation and pain (improves patients’ symptoms)
swelling around muscles and bones - Steroid injections into the area are usually
- occur most often in the shoulder, elbow, wrist, helpful 4. Carpal Tunnel Syndrome
hip, knee, or ankle - a painful condition of the hand and fingers
2. Loose Bodies caused by compression of a major nerve
Bursa/bursae - “joint mice” - carpal tunnel is a narrow passageway on the
- a small, fluid-filled sac that acts as a cushion - occur in a joint space as a result of articular palm side of your wrist made up of bones and
between a bone and other moving body parts cartilage wear and bone erosion ligaments
such as muscles, tendons, or skin - fragments can interfere with the joint - the median nerve, which controls sensation
 movement “locking the joint” and movement in the thumb and first three
Tendonitis - remove by arthroscopic surgery if they cause fingers, runs through this passageway along
- inflammation or irritation of a tendon pain or mobility with tendons to the fingers and thumb
- tendons are thick, fibrous cords that connect  
muscles 3. Impingement Syndrome Causes:
to bone, they send the power caused by a - a common cause of shoulder pain - irritation of the median nerve at the wrist
muscle contraction to move a bone - occurs when there is impingement of tendons - repetitive movements over a long period
 or bursa in the shoulder from bones of the - by fluid retention
Symptoms of bursitis and tendonitis: shoulder - Some people may be born with a narrower
- Pain - overhead activity of the shoulder, especially than normal carpal tunnel
- stiffness repeated activity, is a risk factor for shoulder
 impingement syndrome Other factors such as:
Most common cause of tendonitis and - alcohol abuse
bursitis: Examples include: - tumor in the wrist
- injury - painting, lifting, swimming, tennis, and other - sprain or fractures of the wrist
- overuse during work or play overhead sports - infections
- rheumatoid arthritis
Tendonitis or bursitis may be linked to other Other risk factors include: - pregnancy
conditions such as: - bone and joint abnormalities 
- rheumatoid arthritis  Symptoms of Carpal Tunnel Syndrome
- Gout Diagnostic Test/Assessment Tingling Sensation
- psoriatic arthritis - medical history - the first symptoms
- thyroid disease - physical exam - pins and needles sensations that appear in
- diabetes - X-ray the thumb and fingers of the affected hand

Weakness
- People may experience a loss of grip and drop
objects due to clumsiness
- results from a loss of fine motor skills in the
hands
 Numbness
- numbness and loss of sensation is felt in the
thumb and fingers, but some people might
experience loss of sensation in areas beyond
this region
Pain
- depending upon the severity of the nerve
damage
- a person suffering from carpal tunnel
syndrome may experience pain in the wrist that
may extend up towards the shoulders, or may
radiate towards the palm and fingers
- noticed after doing a repetitive activity or
using force with the affected hand

Swelling
- hand is swollen and the fingers feel thick with
swelling
- occurs due to the sensation of numbness
- in some cases, a mild swelling may be there
due to deformities of the hand joints or other
factors
Muscle Wasting
- thinning of muscles near the base of the
affected thumb
- sometimes, this could also be due to joint
diseases
Diagnosing Carpal Tunnel Syndrome
Tinel Test
– tapping on the median nerve to see if it
causes
Phalen Test
– the doctor will have you press the back of
your hands together for a minute to see if this
causes numbness or tingling
tingling in the fingers
 endoscopic surgery
Electro diagnostic test
- nerve conduction study
- electrodes are placed on the hands & wrists &
small electric shocks are applied to measure
how quickly the median nerve transmits
impulses
Electromyography
– uses a fine needle inserted to a muscle to
measure electrical activity & assess damage to
the median nerve
 • some swelling and stiffness right after surgery
Treatment:
Rest & immobilization
- resting the hand & wrist & wearing a brace to
limit movement
NSAIDs
- ibuprofen & naproxen, along with cd compress
to reduce pain
Corticosteroids (injection or oral)
Other things that may help include:
- diuretics, also known as “water pills,” which
reduce swelling supplements
- vitamin B6

Surgery for Carpal Tunnel Syndrome:
most common surgery for relieving carpal
tunnel symptoms involves cutting the transverse
carpal ligament to relieve pressure on the
median nerve in the wrist

Two approaches for surgery:
Open carpal tunnel release surgery
- open surgery requires a longer recovery
period and leaves a larger scar than
- but there may be less chance of other
complications
Endoscopic carpal tunnel release surgery
- recovery is quicker than with open surgery
- scars heal more quickly, are smaller, and tend
to be less painful at 3 months after surgery
- there may be a slightly higher chance of
needing another surgery later

What to Expect After Surgery
• relieved by elevating hand over heart and
moving fingers frequently
• need to wear a wrist brace for a few weeks
while healing,
but will still be able to use hands
• pain and weakness usually resolve within two
months after surgery
• it may take six months to a year to recover
completely

Strengthening Exercises
• once carpal tunnel symptoms subside,
physical therapist will teach client stretching &
strengthening exercises to help prevent pain,
numbness, and weakness from coming back
• physical or occupational therapist will also
teach the correct ways to perform tasks so that
the median nerve is less likely to become
inflamed again, causing symptoms to return
 range of motion
5. Ganglion/Ganglion Cyst
- collection of neurologic gelatinous material
near the tendon sheaths and joints
- not cancerous and in most cases are
harmless, and will not spread to other areas
- appear as round, firm, cystic swelling, usually
on the dorsum of the wrist
- also known as “Bible cysts or Bible bumps”
Causes
- is unknown although they may for in the
presence of joint or tendon irritation or
mechanical changes
- can occur in patients of all ages
- occurs in women younger than 50 years
Signs and Symptoms:
- usually appear oval or round and may
be soft or very firm, cystic swelling
- cysts at the base of the finger on the palm
side
- typically very firm, pea sized nodules that are
tender to applied pressure, such as when
gripping
- if tendon sheath is involved weakness of the
finger occurs
 - a very simple procedure
Diagnostic Tests
Trans-illumination
- light will often pass through these lumps, and
this can assist in the diagnosis
X - rays
- in order to look for evidence of problems in
adjacent joints
Note:
- diagnosis usually based on the location of the
lump and its appearance
- Cysts at the far joint of the finger frequently
have an arthritic bone spur associated with
them, the overlying skin may become thin, and
there may be a lengthwise groove in the
fingernail just beyond the cyst

Treatment: non-surgical
Observation
- ganglion is not cancerous and may disappear
in time

Anti-inflammatory medication
– to decrease pain associated with activities
Corticosteroid injection
 - hand deformity usually develops over years
Aspiration
- performed to remove the fluid from the cyst
and decompress it
- requires placing a needle into the cyst
- can be performed in most clinic/ OPD
- recurrence of the cyst is common
Immobilization (use of splints)
- activity often causes the ganglion to increase
in size and also increases pressure on nerves,
causing pain
- wrist brace or splint may relieve symptoms
and cause the ganglion to decrease in size
- as pain decreases, doctor may prescribe
exercises to strengthen the wrist and improve

Treatment: surgical
Surgical excision
- removing the cyst as well as part of the
involved joint capsule or tendon sheath, which
considered the root of the ganglion
- generally successful & there is a small chance
of ganglion to return
- Excision is typically an outpatient procedure
- patients may go home after a period of
observation in the recovery area
- there may be some tenderness, discomfort,
and swelling after surgery
- normal activities usually may be resumed 2 to
6 weeks after surgery

6. Dupuytren’s Disease
- abnormal thickening of the tissue beneath the
skin known as fascia
- thickening occurs in the palm and can extend
into fingers
- condition affects a layer of tissue that lies
under the skin of your palm
- Knot soft tissue form under the
Skin—eventually creating thick cord that can
pull one or more fingers into a bent position
- affected fingers can’t be straightened
completely,which can complicate everyday
activities such as placing your hands in your
pockets, putting on gloves or shaking hands

Symptoms:
• condition usually begins as a thickening of the
skin on the palm of your hand
• it progresses, the skin on your palm might
appear puckered or dimpled.
• A firm lump of tissue can form on your palm.
• This lump might be sensitive to the touch but
usually isn't painful.
Causes:
• Unknown
• There's no evidence that hand injuries or
occupations that involve vibrations to the hands
cause the condition
 your palms. He or she will also press on parts of
Risk factors:
• Age. Dupuytren's contracture occurs most
commonly after the age of 50.
• Sex. Men are more likely to develop
Dupuytren's and to have more severe
contractures than are women.
• Ancestry. People of Northern European
descent are at higher risk of the disease.
• Family history. Dupuytren's contracture often
runs in families.
• Tobacco and alcohol use. Smoking is
associated with an increased risk of
Dupuytren's contracture, perhaps because of
microscopic changes within blood vessels
caused by smoking. Alcohol intake also is
associated with Dupuytren's.
• Diabetes. People with diabetes are reported
to have an increased risk of Dupuytren's
contracture.
Complications:
• Dupuytren's contracture can make it difficult to
perform certain functions using your hand.
Since the thumb and index finger aren't usually
affected, many people don't have much
inconvenience or disability with fine motor
activities such as writing. But as Dupuytren's
contracture progresses, it can limit your ability
to fully open your hand, grasp large objects or
to get your hand into narrow places.
Tests and Diagnosis:
• In most cases, doctors can diagnose
Dupuytren's contracture by the look and feel of
your hands. Other tests are rarely necessary.
• Your doctor will compare your hands to each
other and check for puckering on the skin of
your hands and fingers to check for toughened
knots or bands of tissue.
• Your doctor also might check to see if you can
put your hand flat on a tabletop or other flat
surface. Not being able to fully flatten your
fingers indicates you have Dupuytren's
contracture.
 skin. In these cases a skin graft is needed to
Treatments and drugs
• Treatment involves removing or breaking apart
the cords that are pulling your fingers toward
your palm. This can be done in several ways.
The choice of procedure depends on the
severity of your symptoms and other health
problems you may have.
Needling/Needle Aponeurotomy
• This technique uses a needle, inserted
through your skin, to puncture and break the
cord of tissue that's contracting a finger.
Contractures often recur but the procedure can
be repeated.
• The main advantages of the needling
technique are that there is no incision, it can be
done on several fingers at the same time, and
usually very little physical therapy is needed
afterward. The main disadvantage is that it can't
be used in some places in the finger because it
could damage a nerve or tendon.

Surgery - Dupuytren's Fasciectomy
• Another option for people with advanced
disease, limited function and progressing
disease is to surgically remove the tissue in
your palm affected by the disease. The main
advantage to surgery is that it results in a more
complete and longer-lasting release than that
provided by the needle or enzyme methods.
The main disadvantages are that physical
therapy is usually needed after surgery, and
recovery can take longer.
• In some severe cases, especially if surgery
has failed to correct the problem, surgeons
remove all the tissue likely to be affected by
Dupuytren's contracture, including the attached
cover the open wound. This surgery is the most
invasive option and has the longest recovery
time. People usually require months of intensive
physical therapy afterward.

Enzyme injections
• Injecting a type of enzyme into the taut cord in
your palm can soften and weaken it — allowing
your doctor to later manipulate your hand in an
attempt to break the cord and straighten your
fingers. The advantages and disadvantages of
the enzyme injection are similar to needling, but
the enzyme injection can be more painful
initially.