3-j / Christian Dela Cerna
NCM 216-ORTHOPAEDIC NURSING
Orthopedics- branch of medicine that focuses
on the care of patients with musculoskeletal
disorders
Orthopedic Nursing- Specialty in nursing that
focuses on the prevention and treatment of
musculoskeletal disorders
ANATOMY & PHYSIOLOGY of the
MUSCULOSKELETAL SYSTEM
Musculoskeletal system- a.k.a. as the
locomotor system
3 primary functions:
- Support
- Allow motion
- Protect vital organs
FUNCTIONS:
1. Support body- provides sturdy framework to
support body structure
2. Protection- protection of vital organs
3. Body movement- makes mobility possible,
muscle and tendons hold bone together and
allow movement
4. Hemopoiesis- aids in the formation of blood
cells, hematopoiesis, Red Bone Marrow produces
RBC.
5. Fat storage- stored in yellow marrow
6. Mineral storage- reservoir for minerals such
Ca, P, Mg, Fl
SKELETON
▪ born with about 300-350 bones, as a person
matures some bones will fuse together;
▪ e.g., 5 sacrum bones at birth becomes
fused; another ex. 4 coccyx bones fuse into
a single bone between 3-5 years old
• Axial
- comprises of skull/cranium, vertebrae, ribcage,
hyoid bone
- located along the central axis of the body;
- 80 axial bones altogether;
✓ 22 bones from skull,
✓ 6 in ossicles (Malleus, Incus, Stapes) x 2,
✓ 1 hyoid bone,
✓ 26 in vertebral column,
✓ 25 in thoracic cage
- bones that form the longitudinal axis of the
body, it can be divided into three parts—
the skull, the vertebral column, and the
thoracic cage.
• Appendicular
- part that is joined to something larger
- involved in locomotion and manipulation of
objects
- bones in upper extremity= manipulation
- bones in lower extremity= locomotion
-126 bones altogether;
✓ 4 bones in pectoral girdle= 2 clavicle and 2
scapulae;
✓ 6 in arms and forearms= 2 humerus, 2
radius and 2 ulnae;
✓ 54 in hands;
✓ 2 in pelvis;
✓ 8 in thighs and legs= 2 femur, 2 tibia, 2
fibula, 2 patellae
- the bones of the limbs and girdles that
attach them to the axial skeleton, composed
of 126 bones of the limbs (appendages) and
the pectoral and pelvic girdles, which attach
the limbs to the axial skeleton.
A. TYPES OF BONE CELLS:
a) Osteoblasts
- responsible for bone formation;
- mononucleated cells; immature bone cells;
- number decreases with age; may lead to
osteoporosis=brittle bones;
- bone-building/forming cells
b) Osteocytes
- bone maintenance;
- most abundant/ numerous bone cells;
- live for as long as the organism lives
- a mature bone cell, found within the bone
matrix in tiny cavities called lacunae
c) Osteoclasts
- for bone resorption;
- in charge of remodeling of bone to reduce its
volume;
- bone destruction, bone resorption, and bone
remodeling;
- located in bone surfaces in resorption pits
(Howship’s lacunae)
- bone destruction cells; large cells that
resorb or break down bone matrix.
B. TYPES OF OSSEOUS TISSUE
a) Spongy/Cancellous
- forms the interior; can withstand forces in
many directions;
- located at the ends of long bones;

- where red marrow is located
- internal layer of bone in flat, short, and
irregular bones, and in the epiphyses of long
bones; spiky, open appearance like a
sponge
b) Compact
- outer shell of a bone; can withstand forces
predominantly in one direction;
- smooth and homogenous tissue
- dense and looks smooth, solid
and homogeneous with few holes
Osteon- functional unit of a compact bone
C. BONE CLASSIFICATION ACCORDING TO
SHAPE
1. long bones
- often bears weight
- e.g., humerus, radius and ulna, femur, tibia
and fibula
-typically, longer than they are wide. As a
rule, they have a shaft with enlarged ends.
Long bones are mostly compact bone but also
contain spongy bone at the ends. All the
bones of the limbs, except the patella
(kneecap) and the wrist and ankle bones, are
long bones; e.g., humerus and femur
2. short bones
- small and bear little or no weight
- sesamoid included in some literature
- e.g., patella, sesamoid, metacarpal, tarsal,
carpals
- cube-shaped and contain mostly spongy
bone with an outer layer of compact bone.
The bones of the wrist and ankle are short
bones.
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3. flat bones
- protect vital organs and often contain blood
forming cells
- e.g., bones of skull, ribs, sternum (breastbone)
- thin, flattened, and usually
curved. They have two thin layers of compact
bone sandwiching a layer of spongy bone
between them. Most bones of the skull, the
ribs, and the sternum (breastbone) are flat
bones
4. irregular bones
-has unique or peculiar shape
-vertebrae, hyoid bone
- Bones that do not fit in the other categories
are called irregular bones. The vertebrae,
which make up the spinal column, fall into
this group. Like short bones, they are mainly
spongy bone with an outer layer of compact
bone
D. LONG BONES HAVE SEVERAL
COMPONENTS
Diaphysis
- makes up most of bone’s length
- the shaft of the bone
- or shaft, makes up most of the bone’s length
and is composed of compact bone, covered
and protected by a fibrous connective tissue
membrane, the periosteum. Hundreds of
connective tissue fibers, called perforating
fibers, or Sharpey’s fibers, secure the
periosteum to the underlying bone.
Periosteum (covering)
- covers and protects the diaphysis
- covers outside of the bone
-The diaphysis is covered and protected by a
fibrous connective tissue membrane
Epiphysis
- ends of the long bone
- the ends of long bones. Each epiphysis
consists of a thin layer of compact bone
enclosing an area filled with spongy bone.
Instead of a periosteum, articular cartilage
covers its external surface. Because the
articular cartilage is glassy hyaline cartilage,
it provides a smooth surface that decreases
friction at the joint when covered by
lubricating fluid
Epiphyseal line
- Epiphyseal plates: important site of growth;
normally closes at the age of 17,
for female=13-15 years, male= 15-17 years
- remnant of the epiphyseal plate that closes
when the growing bone has reached its full
length
- a thin line of bony tissue spanning the
epiphysis that looks a bit different from the
rest of the bone in that area, a remnant of the
epiphyseal plate (a flat plate of hyaline
cartilage) seen in a young, growing bone.
Epiphyseal plates cause the lengthwise
growth of a long bone. By the end of puberty,

when hormones inhibit long bone growth,
epiphyseal plates have been completely
replaced by bone, leaving only the epiphyseal
lines to mark their previous location.
Endosteum (covering)
- covers the marrow cavity of the long bones
and the spaces in spongy bones
-covers the inside of the bone
- The inner bony surface of the shaft is
covered by a delicate connective tissue called
endosteum
E. BONE MARROW
- during birth, our bone marrow is all red; as the
person matures, some red marrow will be
converted into yellow marrow
1. Red bone marrow
- 1/2 of adult’s bone marrow
- produces RBC, WBC and platelets
- found at the ends of the long bones
- All the formed elements arise from a
common stem cell, the hemocytoblast resides
in the RBM, Blood cell formation, or
hematopoiesis occurs in red bone marrow
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2. Yellow bone marrow
- storage area for adipose tissue
- located in the medullary cavity of long bones
- in severe blood loss, yellow marrow will be
converted to red marrow to increase blood cell
production
- during starvation, yellow marrow will be
converted into energy
– a storage site for fat.
ARTICULATIONS (JOINTS)
- junctions or spaces between 2 or more bones
- are where 2 bones are attached for the
purpose of motion of body parts
Ligaments
- hold the bone & joint in the correct position
- strong, elastic bands of tissue that connect
bone to bone
- hold the bone and joint in the correct position
Joint capsules
- tough, fibrous sheath surrounding the
articulating bone
Synovium
- lined with synovial membrane which secretes
the synovial fluid into the joint capsule
Bursa
- sac filled with synovial fluid that cushions the
movement of tendons, ligaments, and bones at
a point of friction.
Muscle-Muscle= fascia
Bone-Muscle= tendons
Bone-Bone= ligaments
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TYPES OF JOINTS c.2. hinge

- permit movement in one plane only
a) Synarthroses - e.g., elbow, knee, ankle, and
- fixed joints interphalangeal joints
- permits no mobility - the cylindrical end of one bone fits
- sometimes called the Fibrous joints into a trough-shaped surface on
- e.g., skull sutures, Gomphosis=teeth anchored another bone. Angular movement is
to the jaw with periodontal ligament allowed in just one plane, like a door
- immovable joints hinge. Examples are the elbow joint,
ankle joint, and the joints between the
phalanges of the fingers. Hinge joints
are classified as uniaxial; they allow
movement around one axis only.
c.3. pivot
- allow for rotation, supination and
pronation
- proximal radioulnar joints
- Freely movable
c.4. saddle
- allows movement in 2 planes at right
angles to each other
- carpometacarpal joints
c.5. gliding
- allows limited movement in all
directions
- e.g., intercarpal and intertarsal joints,
acromioclavicular joints, sternoclavicular
joints, vertebrocostal joints, sacroiliac
joints
b) Amphiarthroses c.5. ellipsoid
- sometimes called Cartilaginous joints - allows movement in all angular
- slightly movable motions
- e.g., vertebrae, ribs, spine, pubic symphysis of - metatarsophalangeal joints
the pelvis
- has limited mobility

c) Diarthroses
- freely movable
- sometimes called the Synovial joints
- permits variety of movements
- e.g., shoulder, hips, knees
- freely movable
c.1. ball & socket
- permit full freedom of movement
- e.g., hip joints, shoulder joints
- multiaxial synovial
joint in which the rounded head of
one bone fits into a socket
(depression) on the other. Freely
movable
SKELETAL MUSCLES
- one of the three major muscle types
- the only muscle type subject to conscious
control
- muscles are attached by tendons to the bones
- under voluntary control in somatic nervous
system
Functions:
a) Provide the force to move bones
b) Assist in maintaining posture
c) Assist in heat production

TYPES OF MUSCLE CONTRACTION
1. Isometric
- “same length”
- length of the muscle remains constant but the
force generated by the muscle is increased;
“static”;
- increase workload of the muscle causes
contraction but the limb doesn’t move
- more muscle load but no muscle length change
- example: pushing against an immovable object
(wall), yoga poses
2. Isotonic
- “same tension”
- characterized by shortening of the muscle with
no increase in tension within the muscle;
“dynamic”
- muscle length changes; shorten and elongates
- 2 types: eccentric= lengthening of muscle
fibers and concentric=shortening of muscle
fibers
MINERALS & HORMONES AFFECTING
MUSCULOSKELETAL SYSTEM
1. Calcium
- 99 % is in the bones
- normal serum calcium= 8.6-10 mg/dl
- important for muscle contraction, blood
clotting, and nerve function
- small changes in Ca level is fatal since most
function of nerve cells depends on Ca ions
- coupled with vitamin D for increased uptake of
calcium
- deficiency of calcium in the blood may cause
tetany
- excessive calcium may cause calculi formation
- Sources: milk and milk products
2. Phosphorus
- 85% is in the bone
- important for energy conversion and storage in
the body
- normal values: 2.5-4.5 mg/dl
- sources: milk, meat, beans, nuts
3. Parathyroid Hormone (PTH)
- also called parathyrin
- secreted by parathyroid glands
- increase serum ca level and decrease serum
phosphate level
- How? Bones= release calcium to the blood
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Kidneys= reabsorption of Ca & urinary
excretion of phosphate
Intestine= reabsorption of Ca via
activation of Vitamin D
4. Calcitonin
- secreted by parafollicular cells (C cells) in the
thyroid
- lowers calcium and phosphates in the blood
- promotes formation of bone
- How? Bones= Inhibit release of ca from bone
Kidneys= increased renal excretion of ca
5. Vitamin D
- promotes intestinal absorption and metabolism
of Ca and phosphate
- Functions as a hormone regulating serum Ca
- Increases absorption of Ca from the intestine
- Promotes the action of PTH on bones
6. Growth hormone
- secreted by anterior part of the pituitary gland;
- increases bone length
7. Sex hormones
- controlling sexual development and
reproductive function
- initially cause “growth spurt” that occurs during
teenage years
MUSCULOSKEKETAL ASSESSMENT
During interview: do thorough assessment,
gather reports of episode of pain, tenderness,
tightness in the muscles, or abnormal sensations
- Individually assess patients and document;
management is individualized.
SUBJECTIVE DATA
PAIN
- present in patients with diseases and traumatic
conditions or disorders of muscles, bones, and
joints
Bone pain
- dull, deep ache that is “boring” in nature
- May be D/T tumors, or infection
- Osteodynia: medical term for bone pain
- patients cannot localize bone pain sometimes
Muscular pain
- Myalgia: medical term for muscular pain
- described as soreness or aching and is referred
to as “muscle cramps”
-May be D/T to injury, autoimmune reaction,
overexertion, tumor
Sharp pain
- more localized in a specific area
- sudden, intense spike of pain, “shooting” pain
- may be D/T bone infection with muscle spasm
or pressure on a sensory nerve, and fracture
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Pain that increases with activity BONE INTEGRITY

- indicate joint sprain or muscle strain - deformities and alignment
- symmetry
Radiating pain
- conditions in which pressure is exerted on a Genu valgum
nerve root - knock knees
- happens along pathway of nerves Genu varum
- bowleggedness
ALTERED SENSATIONS/ SENSORY - marked by medial angulation
CHANGES
Management: surgery(osteotomy), splinting,
Paresthesia wearing of brace
- caused by pressure on nerves or by
circulatory impairment,
- “pins and needles”; with no long-term
apparent effect on patients
-common cause is poor circulation

OBJECTIVE DATA

POSTURE

Kyphosis
- increased forward curvature of the thoracic JOINT FUNCTION
spine - Range of motion
- frequent in elderly patients or patients with - Deformity
osteoporosis
- Stability
- “Kuba”
- Nodular formation
Lordosis - Crepitus= the grating, crackling, or popping
- also called swayback sounds experienced under the skin or joints.
- an exaggerated curvature of the lumbar spine Deep knee bend (crouch down)- is performed;
- “Liyad’” hearing the popping/grating sound= (+)
crepitus BUT if suspected of a fracture, do not
Scoliosis
perform deep knee bend or check the crepitus
- a lateral curving deviation of the spine
as this will add insult to the injury

Goniometer
- a protractor designed for evaluating joint
motion
- precise measurement of ROM of major joints,
0-360 degrees
- if patient reports pain while assessing the
angle, record the angle of the extent of
movement
- full motion with 360 degrees: wrist, shoulder,
Milwaukee Brace
neck
- orthotic device that helps immobilize the torso
and neck of a patient in the treatment of
scoliosis, lordosis, and kyphosis
- made of light material and fiber glass
- worn everyday for full number of hours
prescribed by the physician
- usually worn by children for early correction of
abnormal posture
- also called the Thoracolumbosacral
orthosis (TLSO)
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NEUROVASCULAR STATUS - inform patient that he/she will hear

- assessment is important because risk of tissue buzzing/clicking during the procedure
and nerve damage is possible
- cause may be pressure within a muscle 3. Magnetic Resonance Imaging (MRI)
compartment that increases pain - patients with metal implants & pacemakers are
not candidates for the procedure
Indicators of Peripheral Neurovascular - allows study of soft tissue in multiple planes
Dysfunction (CMS) of the body
Circulation - may be performed with or without contrast
➢ Color: pale or cyanotic agents; lasts for 1-2 hours;
➢ Temperature: Cool - uses magnetic field
➢ Capillary refill: > 3 seconds Preparation:
Motion - remove metals
➢ Weakness - sedate patient with claustrophobia
➢ Paralysis - instruct patients that they must remain still
Sensation during the procedure
➢ Paresthesia - inform that he/she will hear rhythmic
➢ Unrelenting pain- persistent pain knocking sound during the procedure
➢ Pain on passive stretch - use of colored tattoos, not candidate because
➢ Absence of feeling in the coloring there is iron, during the
procedure area may heat up and cause burn
DIAGNOSTIC EXAMINATIONS
4. Arthrography
1. Radiography - injection of radiopaque
- an X-ray studies substance or air into the
- allows evaluation of disease progression joint cavity to identify acute
and treatment efficacy or chronic tears of the
- an instruction to remain still while the x-rays joint capsule or
are taken is necessary supporting ligaments
- detects musculoskeletal structure, integrity, - after injecting dye, the
texture or density problems joint is put through ROM
Preparation: while a series of x-rays are
- Remove jewelries and metal such as bra with obtained to spread the
underwire, radiopaque substance
- instruct patient to stay still, - if a tear is present,
- ask if pregnant, for female patients contrast agent leaks out of
the joint and will be evident
2. Computed Tomography (CT Scans) on the x-rays
- X-ray procedure that combines many images; -may be given local anesthetics
uses radiation Preparation:
- may be performed with or without contrast - Check for allergies, ask if pregnant
agents;
- lasts for 1 hour; patient must remain still 5. Arthrocentesis (also known as joint
during the procedure aspiration)
- show soft tissue, bone & spinal cord in 3 - involves aspirating of
dimensional, cross-sectional images synovial fluid, blood or
Preparation: pus via a needle inserted
- if with contrast, ask if the patient has allergies into a joint cavity for
especially to crustaceans; and NPO prior to the examination or to relieve
procedure; pain
- patients with metallic implants are allowed as - normal synovial fluid=
long as the part to be performed is without clear, pale, scanty in
metal so that nothing will block the image; volume
- inform the patient of the usual sensation after - after the procedure, apply
injection of contrast (warm feeling/flushing); compress bandage and rest
- for claustrophobic patients, inform the doctor the joints for 8-24 hours
for administration of sedative/ anti-anxiety - patient may be given local anesthetics before
meds; insertion of aspirating needle
- for pediatric patients, guardian is allowed
provided that he/she will wear a lead apron
(protective gear);
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6. Arthroscopy
- allows direct visualization of a joint;
treatment of tears, defects, and disease
may also be performed
- NPO for 8-12 hours
- patient is given anesthesia prior to procedure
- after the procedure, patient is to wear elastic
wrap for 2-4 days; limit activities for 1-4 days;
and put ice on and elevate extremity

7. BONE SCAN
- imaging study with the use of a contrast
radioactive material
Pre-test:
- Painless procedure, IV radioisotope is
used, no special preparation, empty
bladder (may interfere scanning the
bone)
- Pregnancy is a contraindication
Intra-test:
- IV injection
- Waiting period of 2 hours before X-ray 10. Bone Densitometry
- Fluids are allowed - uses a scincillator camera that is passed
- Supine position for scanning over the patient and projected onto a computer
Post-test: screen
- Increase fluid intake to flush out - measures bone density of spine, hip,
radioactive material femur, or forearm
-helps in the diagnosis of metabolic bone
disease
Nursing Responsibilities:
1. If patient is taking Ca supplements,
instruct patient to stop it 24-48 hours
prior to procedure; as well as foods rich
in calcium. (obscure the view of one of
your spine bones)
2. Instruct patient to remove all metallic
8. Electromyography objects prior to procedure.
- measures muscle electrical impulses for 3. If patient underwent CT scan or MRI
diagnosing muscle or nerve disease with contrast, delay the bone
- continuous recording of the electrical activity densitometry (BD must be 5-7 days
of a muscle by means of electrodes inserted into after CT scan or MRI with contrast)
the muscle fibers
- instruct that needle insertion is uncomfortable
- slight bruising may occur at the needle
insertion sites
- Oscilloscope: instrument to view electrical
activity tracing
Preparation:
- Inform patient of possibile discomfort and
there may be possible bruising
9. BONE MARROW ASPIRATION
- usually involves aspiration of the marrow to COMMON SEROLOGIC STUDIES
diagnose diseases like leukemia, aplastic anemia 1. Serum Calcium
- usual site is the sternum and iliac rest - assess calcium availability and metabolism
Pre-test: Consent; Local anesthesia is given on 2. Serum Phosphate (Phosphorus)
the insertion site before inserting the aspirating - assess phosphorus levels in the body
needle 3. Alkaline Phosphatase (ALP)
Intra-test: Needle insertion; needle puncture - detects bone disorders;
may be painful - helpful in determining if primary or metastatic
Post-test: Maintain pressure dressing and watch cancer is present.
out for bleeding
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4. C Reactive Protein (CRP)

- detects active inflammation as in Rheumatoid
Arthritis
5. Anti Nuclear Antibody (ANA)
- a sensitive screening test used to detect
autoimmune diseases
- positive results are associated with SLE, RA, RF
6. Erythrocyte Sedimentation Rate (ESR)
- test that detects and is used to monitor
inflammation activity
- elevation is common in arthritic conditions,
infection, inflammation, cancer, or cell
destruction.
7. Rheumatoid Factor (RF)
- measures the presence of a macroglobulin
type of antibody found in Rheumatoid Arthritis &
other connective tissue disease
1-7. Without preparation unless procedure is
serum Ca and FBS; hence, NPO
8. Serum Uric Acid (SUA)
- used to detect gouty arthritis
NPO 12 hours prior to test
MUSCULOSKELETAL DISORDERS
INJURIES
1. Strain
- “muscle pull” from overuse, overstretching, or
excessive stress
- injury to muscle or tendon, where there is a
tear from overstretching or overuse
- small incomplete muscle tears with some
bleeding into the tissue
- usually happens in the hamstring
S/sx: mild-severe pain, swelling, tenderness,
decrease in function
3 types of sprain
1st degree- stretching of the ligamentous fiber
2nd degree- partial tearing of the ligament
3rd degree- when a ligament is completely torn
or ruptured
MANAGEMENT FOR STRAIN AND SPRAIN
(RICEHIS)
Rest- prevent additional injury and promote
healing
Ice- icepacks or cold packs: applied in the 1st
24-48 hours of injury= produce vasoconstriction
and reduce swelling/bleeding; Duration: 10-15
mins, for 4-8 times/day= beyond 20 mins: may
cause frostbite and cold injury
Compression- elastic bandage= control
bleeding, reduce edema, and provide support
for the injured part
Elevation- control swelling
Heat- after 24-48 hours, warm packs are
applied intermittently for 15-30 mins at least 4
times/day
Immobilization- prevent further injury
Surgery
- Brostrom Repair
- Repair of the damaged ligaments on the outer
side of the ankle
- Recovery: 3-6 months= bone cells are poorly
vascularized

3 types of strain:
1st degree- mild stretching of the
muscle/tendon
2nd degree- involves partial tearing
3rd degree- stretching with rupturing and
tearing

2. Sprain
- injury to the ligaments surrounding a joint,
caused by wrenching or twisting motion
- S/sx: edema, pain, discoloration, decrease in
function these are due to rupture of blood
vessels during the wrenching

Stretching- To lessen incidence of sprain or
strain, stretching is done before doing vigorous
exercises
Stretching exercises. Slow, gradual stretching
(after walking to warm the muscles) increases
flexibility and decreases the incidence of sprains
and strains
JOINT DISLOCATIONS
1. Dislocation- complete contact is lost
between articulating bones
2. Subluxation - partial loss of contact
between articulating joints
- S/sx: pain, change in contour of the joint,
change in length of extremity; loss of normal
mobility; “popping” at affected site
MANAGEMENT (PRIM)
• Passive ROM
- done several days to weeks after
reduction, 3-4 times a day
• Reduction
- displaced parts are brought into normal
position
• Immobilization
- 1st thing to do when there is dislocation or
subluxation
- in the scene & during transport to the
hospital
• Medications
- analgesics; muscle relaxants; anesthesia
(for relaxation, closed reduction)
***Traumatic dislocations
- are classified as emergencies because the
associated joint structures, blood supply, nerves
are distorted and severely stressed; if not
treated promptly, avascular necrosis may occur
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CARPAL TUNNEL SYNDROME
- a hand and arm condition that causes
numbness and tingling
- caused by a pinched nerve in the wrist
- Carpal tunnel: narrow passageway located
on the palm side of the wrist, it protects a main
nerve to the hand and the 9 tendons that bend
the fingers
- associated with signs and symptoms, which
are caused by compression of the median nerve
travelling through the carpal tunnel
Causes: repetitive motions (most famously, from
computer keyboard use); benign tumors such as
lipomas, ganglion, and vascular malformation
S/Sx: Pain, numbness and tingling sensations in
the arm
Diagnostic Tests:
➢ Phalen’s Maneuver (30-60 seconds)= flex
hand
➢ Electromyography
➢ MRI
➢ Ultrasound
CTS Treatments
- splinting or bracing,
- steroid injection,
- activity modification,
- physiotherapy (preferable),
- regular massage therapy treatments,
- Medications (NSAIDS), and
- surgical release of the transverse carpal
ligament
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FRACTURES Compound/Open
- break in the continuity of - skin surface over a broken bone is
the bone disrupted; open wound is at risk for
- fractures occur when the infection
bone is subjected to stress
greater than it can absorb.
- fractures are caused by
direct blows, crushing forces, sudden twisting
motions, extreme muscle contractions, sports
injury, and car accidents
- when the bone is broken, adjacent structures
are also affected, resulting in soft tissue edema,
hemorrhage into the muscles and joints, joint
dislocations, ruptured tendons, severed nerves,
and damaged blood vessels.
- painful injuries; takes time to heal
- ligaments and tendonds=take time to heal due
to limited blood supply in the bones

Open fractures are graded according to

the following criteria:
Grade I
- a clean wound less than 1 cm long
Grade II
- a larger wound without extensive soft tissue
damage
Grade III
- highly contaminated, has extensive tissue
damage, and is the most severe

c. According to LINES OF FRACTURE

CLASSIFICATION OF FRACTURES
Greenstick
1. According to TYPE
- other term is buckle fracture or torus
Complete
- fracture in which one side of the bone is
- complete separation of bone; produces 2
broken, other side is bent
fragments
- splintering on one side of the
Incomplete
bone
- break only occurs in a part of the bone
- common in children and infants
because they have soft bones

Spiral
- fracture where there is twisting around the
shaft of the bone
- other term is torsion fracture
- fracture in which at least 1 part of the bone is
2. According to EXTENT twisted
Simple/Closed - opposite direction of twisting
- skin over the fracture is intact
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- common causes are sports injuries and falls d. OTHER SPECIFIC TYPES:
- for toddlers, it is a common sign of abuse
➢ Segmental
- produce segments of bones

➢ Avulsion
- pulling away of a fragment of bone by a
ligament or tendon
- small piece of bone breaks away and pulls
from a larger bone

➢ Compression
- bone is depressed;
common in vertebrae
(vertebral fractures); bone is
crushed
Comminuted
- fracture in which the bone is splintered into
several fragments ➢ Epiphyseal
- other term is Multifragmentary fracture - fracture through the
- common among elderly and patients with epiphyses
medical conditions such as cancer that causes
their bones to be brittle ➢ Pathologic
- spontaneous fracture, a fracture that occurs
through an area of diseased bone, can occur
without trauma or a fall (e.g., osteoporosis,
bone cyst, Paget’s disease, bony metastasis,
tumor)

➢ Impacted
- a fracture in which a bone fragment is driven
into another bone fragment

Transverse
- break is straight across a bone
- the bone is completely broken in a manner
that is perpendicular to the way that the bone
runs
- often as a result of direct blow or can happen
to people doing repetitive actions (runners)

➢ Stress
- a fracture that results from repeated loading
without bone and muscle recovery
- caused by repetitive force, often from overuse

Oblique
- fracture occurring at an angle across the bone;
less stable than transverse
- slanted fracture

SIGNS & SYMPTOMS (FRACTURE)
1. Pain or tenderness over the involved
area (may be due to muscle spasm that occurs
with the fracture; sometimes pain or tenderness
is a natural splinting= patient is unable to move
due to the pain; designed to minimize
movement to prevent further injury)
2. Loss of function- due to the pain
3. Obvious deformity
4. Crepitation
5. Erythema, edema, ecchymosis
- erythema=d/t dilation of blood capillaries;
- edema= d/t bleeding→torn blood vessels→
pressure pain;
- ecchymosis= there will be bruising
6. Muscle spasm and impaired sensation
Initial care of a fracture of an extremity
1. Immobilize the affected extremity
- PRIORITY
- Make use of what is available on emergencies/
use a make-shift splint such as a piece of wood
and a clean cloth to support affected part
2. Splint the extremity; cover the wound
with a sterile dressing
- if a compound/open fracture exists, splint the
extremity and cover the wound with a sterile
dressing (clean towel or cloth will do if sterile
dressing is unavailable) to prevent infection and
suppress bleeding
The principles of fracture treatment
include:
1. Reduction
2. Immobilization (use of cast)
3. regaining of normal function and strength
through Rehabilitation
3-j / Christian Dela Cerna
MEDICAL MANAGEMENT
1. REDUCTION
- restores the bone to proper alignment (manual
a. Closed reduction
- is performed by manual manipulation
- accomplished by bringing the bones to
anatomical alignment through manual
manipulation and manual traction
- may be performed under local or general
anesthesia or none
- after manual manipulation and traction; a cast
will be applied to the patient to maintain
corrected bone in position
b. Open reduction
- correction and alignment of the fracture after
surgical dissection and exposure of fracture
- fracture is anatomically aligned through a
surgical approach
- treatment of choice for compound fractures
- may be treated with internal fixators
- accomplished by bringing the bone fragments
into apposition (i.e., placing the ends in contact)
through manipulation and manual traction
2. FIXATION
a. Internal fixation
- follows open reduction
- involves the application of screws, plates, pins,
or nails to hold the fragments in alignment
- provides immediate bone strength
- plates and screws are partners; have different
number of holes in the plates and sizes
depending on the kind and location of fractures
 3-j / Christian Dela Cerna

D) Plate and six (6) screws for a short

butterfly fragment
E) Medullary nail for a segmental fracture.

Nursing Responsibilities
1. Monitor VS (include NVS esp. if the
cause of fracture is vehicular accident
every 2-4 hours), also check for pulse
and nerves close to the broken bone or
fracture
2. Elevate affected limb to decrease
swelling unless contraindicated
3. Check for signs of infection
4. Proper wound care

b. External fixation
- an external frame is used with multiple pins
applied through the bone
Advantages:
- minimal blood loss than internal fixators
- provides more freedom of movement than with
traction
- facilitates patient comfort; early mobility; and
active exercises for uninvolved joints
Disadvantage:
- prone to pin tract infection

Steinmann pins Ilizarov external fixator

Nursing Responsibilities
Intramedullary nail- usually used in fracture in 1. Never adjust pins and clamps on
long bones (e.g. tibia and femur) external fixators (just report to doctor if
patient reports discomfort)
2. Daily care of pin site
3. Monitor vital signs
4. Check signs of infection
5. Encourage isometric exercises to
strengthen the muscle (tolerable
exercises only)

Techniques of Internal Fixation

A) Plate and six (6) screws for a transverse
or short oblique fracture
B) Screws for a long oblique or spiral
fracture
C) Screws for a long butterfly fragment
 3-j / Christian Dela Cerna

3. TRACTION b.1. Buck’s traction

- is the exertion of a pulling force applied in
two directions to reduce and immobilize a
fracture
- provides proper bone alignment and reduces
muscle spasms
- for traction to be effective there must be a
countertraction= A pulling force applied in
the opposite direction
- alleviate muscle spasms and immobilizes
a lower limb by maintaining a straight
pull on the limb
- prescribed weight is only 5-8 lbs.
- immobilize fractures in the proximal
femur before surgical fixations
- (SPH= uses knee immobilizer/foam
boot)

a. Skeletal traction
- applied mechanically to the bone with pins,
wires, or tongs=instrument to treat cervical b.2. Russell’s traction
fracture (halo- treat cervical spine) - similar to buck’s traction, but a sling
- allows use of longer under the knee suspends the leg to
traction time and relieve the weight of the lower
heavier weight (15- extremities
30 lbs.) - usually used to treat fractured femur
- provide pin care
- countertraction is
heavier compared to
skin traction

b. Skin traction
- traction is applied by the use of elastic
bandages or adhesive or foam boot
- decreases painful muscle spasm that
accompany fractures
- countertraction weight is limited to 5-10 lbs.
(excess weight exceeds tolerance of the c. Balanced Suspension Traction
skin=irritation of the skin= sloughs off) - is used with skin & skeletal traction
- used to treat fractures of the femur, tibia or
fibula
- both the skin and skeletal traction is used
- pins are placed and skin traction is applied
 3-j / Christian Dela Cerna

d. Bryant’s Traction 4. CASTS

- used in young children with fractures of the
femur and congenital abnormalities of the
hip
- usually applied for 3-5 weeks depending on
the type of fracture
Interventions (immobilization)
1. Maintain proper body alignment
2. Ensure that the weights hang freely and do
not touch the floor
3. Do not remove or lift the weights without a
physician's order
4. Ensure that pulleys are not obstructed and
that ropes in the pulleys move freely
5. Check the ropes for fraying
6. Avoid moving or jarring the bed
7. Inspect traction sites for signs of irritation or
infection; do circulatory checks
- rigid/hard external immobilizing device that is
molded to the contours of the body
- permit mobility while immobilizing affected
part
- are made of plaster or fiberglass to provide
immobilization of bone and joints after a
fracture or injury
-before the doctor will apply: stockinette is first
applied, then orthopedic padding/ wadding
sheet will be applied to protect bony
prominences
-plaster of Paris is submerged first before
application
Fiberglass (different colors) Stockinette
Wadding sheet Plaster of paris (white)

CAST MATERIALS
Plaster of Paris Synthetic
Cost Less expensive but More expensive & lighter
heavier
Setting 3-15 mins. And 3-15 mins. Up to max. of
time drying time is 30 minutes of drying
about 24-72 hours (fiberglass)
Weight Not permitted until Permitted after 15-30
Bearing cast is totally dry minutes
 3-j / Christian Dela Cerna

COMMON TYPES OF CAST

TYPE LOCATION USES Shoulder Applied around Shoulder dislocations or
Short Applied below the Forearm or wrist fractures. Spica the trunk of the after surgery on the
Arm elbow to the hand Also used to hold the forearm Cast body to the shoulder area
Cast or wrist muscles and tendons shoulder, arm,
in place after surgery and hand
Long Applied from the Upper arm, elbow, or Minerva Applied around After surgery on the neck
Arm upper arm to the forearm fractures. Also used Cast the neck and or upper back area
Cast hand to hold the arm or elbow trunk of the body
muscles and tendons in place Short Applied to the Lower leg fractures, severe
after surgery leg Cast area below the ankle sprains/strains, or
Arm Applied from the To hold the elbow muscles knee to the foot fractures. Used to hold the
Cylinder upper arm to the and tendons in place after a leg or foot muscles and
Cast wrist dislocation or surgery tendons in place after
surgery to allow healing
Leg Applied from the Knee or lower leg fractures,
cylinder upper thigh to knee dislocations, or after
Cast the ankle surgery on the leg or knee
area

Unilateral Applied from the Thigh fractures. Used to

Hip Spica chest to the foot on hold the hip/ thigh
Cast one leg muscles and tendons in
place after surgery to
allow healing
One and Applied from chest to Thigh fracture. Also TYPES (CAST)
One-half foot on one leg to used to hold the hip or Short arm cast:
Hip Spica knee of the other leg. thigh muscles and - Extends from below the elbow to the palmar
Cast A bar is placed b/w tendons in place after crease, secured around the base of the thumb.
both legs to keep hips surgery to allow - If the thumb is included, it is known as a
& legs immobilized healing. thumb spica or gauntlet cast.
Long arm cast:
Bilateral Applied from chest to Pelvis, hip, or thigh - Extends from the upper level of the axillary
Long leg feet. A bar is placed fractures. Used to hold fold to the proximal palmar crease.
Hip Spica b/w both legs to keep the hip or thigh - The elbow usually is immobilized at a right
cast the hips and legs muscles and tendons in angle.
immobilized place after surgery to Short leg cast:
allow healing - Extends from below the knee to the base of
the toes.
- The foot is flexed at a right angle in a netral
position.
Long leg cast:
- Extends from the junction of the upper and
middle third of the thigh to the base of the toes.
- The knee may be slightly flexed.
Walking cast:
- A short or long leg cast reinforced for strength.
Body Cast:
- Encircles the trunk.
 3-j / Christian Dela Cerna

Nursing Interventions Cast cutter

1. Inform the patient to expect sensation of
heat while the cast is drying (normal
sensation due to exothermic reaction of the
cast)
2. Keep the cast and extremity elevated. (for
venous return)
3. Handle with palms of the hands and not
with the fingertip. (in assisting with the
application of cast, handle with the palm of
your hands because the contour of the BIVALVING
fiberglass or plaster of Paris may change/ When cutting a cast in half (bivalving), the
the cast will be dented, the dented part may physician or nurse practitioner proceeds as
cause pressure) follows:
4. Turn the extremity unless contraindicated.
(for proper circulation)
1. With a cast cutter, a longitudinal cut is made
5. Expose the cast to air and avoid use of fans,
to divide the cast in half
heat lamps, hair drier to unnaturally dry the
cast. 2. The underpadding is cut with scissors
6. Petal edges when cast is totally dried. 3. The cast is spead apart with cast spreaders
7. Instruct the patient not to place sticks or to relieve pressure and to inspect and treat
any objects inside the cast the skin without interrupting the reduction
and alignment of the bone.
4. After the pressure is relieved, the anterior
and posterior parts of the cast are secured
together with an elastic compression
bandage to maintain immobilization
5. To control swelling and promote circulation,
the extremity is elevated (but no higher
than the heart level, to minimize the effect
of gravity on perfusion of the tissues)
8. Use additional padding around bony
prominences
9. Monitor for the presence of a foul odor or
hot spots (infection); wet spots (need for
drying / drainage)
10. Teach the client to keep the cast clean and
dry
11. Instruct the client in isometric exercises to
prevent muscle atrophy
12. Neurovascular checks; 6 P’s (poikilothermia,
pulselessness, pallor, paralysis, paresthesia,
pain)
13. Prepare for window or bivalving if circulatory
impairment occurs
A (bivalved cast)
14. Isometric/muscle-setting exercises: to
minimize disuse atrophy, to promote B (two haves are rejoined)
circulation
15. Participation in activities of daily living
(ADLs): to promote independent functioning
and self-esteem
16. Gradual resumption of activities is promoted
within the therapeutic prescription.
17. With internal fixation, the surgeon
determines the amount of movement and
weight-bearing stress the extremity can
withstand and prescribes level of activity

Window- often done to patients with cast to

assess the circulation or open wounds under the
cast.

PHYSIOLOGY OF BONE HEALING
- when bone is injured, bone regenerates itself,
no formation of scar tissue
1. Hematoma formation (inflammation
stage)
▪ occurs 1-3 days after fracture
▪ blood forms a clot
▪ migration of phagocytic cells (engulf or
absorb waste materials on fractured bone)
▪ similar to an injury elsewhere in the body;
hence there will be bleeding, extravasation,
and formation of fracture hematoma
2. Cellular proliferation
▪ 3 days to 2 weeks after fracture
▪ migration of fibroblasts & osteoblast
(fibroblasts produce collagen and fibrous
connective tissue, chondrocytes produce
cartilage)
3. Callus formation
▪ 2-6 weeks after fracture
▪ tissue growth continues
until the fracture gap is
bridged
▪ Granulation tissue
matures into a callus
(loosely woven mass of
bone and cartilage that is considerably wider
than the normal bone)
▪ Patient needs micromotion (small amount of
movement) to stimulate callus formation;
excessive motion can disrupt the callus
formation
▪ instruct patient not to move excessively
(i.e., vigorous exercise)
4. Ossification
▪ 3 weeks to 6 months after
fracture
▪ Permanent callus of rigid
bone crosses the fracture gap
to join the fragments
▪ Flat bone and spongy bones
are well-vascularized; other bones are
poorly-vascularized
3-j / Christian Dela Cerna
5. Remodeling
▪ 6 months to 1 year
▪ unnecessary callus is
reabsorbed or chiseled away
from the healing bone
▪ progress of bone healing is
monitored through serial X-
rays
FACTORS THAT AFFECT FRACTURE
HEALING
❖ Immobilization of fracture fragments
❖ Maximum bone fragment contact
❖ Sufficient blood supply
❖ Poor nutrition
❖ Exercise: weight bearing for long bones
❖ Hormones: growth hormone, thyroid,
calcitonin, Vitamin D, anabolic steroids
❖ Electric potentiontial across factures
FACTORS THAT INHIBIT FRACTURE
HEALING
❖ Extensive local trauma
❖ Bone loss
❖ Inadequate immobilization
❖ Space or tissue between bone fragments
❖ Infection
❖ Local malignancy
❖ Metabolic bone disease (e.g. Paget’s
disease)
❖ Irradiated bone (radiation necrosis)
❖ Avascular necrosis
❖ Intra-articular fracture (synovial fluid
contains fibrolysins, which lyse the initial
clot and retard clot formation)
❖ Age (elderly persons heal more slowly)
❖ Corticosteroids (inhibit the repair rate)
COMPLICATIONS OF FRACTURES
A. SHOCK
➔ COMMON: fractures of the extremities,
thorax, pelvis, or spine
➔ Because the bone is very vascular in such
areas, large quantities of blood may be lost
as a result of trauma, especially in fractures
of the femur and pelvis
➔ goal is to replace depleted blood volume by
giving IV fluids and blood transfusion to
reverse s/s of shock
➔ relieve pain by giving analgesics

➔ adequate splinting and protect patient from
further injury
Signs & Symptoms
 Weak rapid pulse, irregular breathing, dry
mouth, decreased urine output
Treatment of shock
- IVF and Blood transfusions
- Pain relievers
- adequate splinting
B. FAT EMBOLISM
➔ is the release of fat globules from the bone
marrow into the venous circulation after
fracture
➔ clients with long bone fractures and those
with multiple traumas are at greatest risk
➔ can occur within the first 72 hours following
the injury
➔ fat globules combine with platelets, forming
into an emboli= occlude blood vessels that
supply the brain, lungs, kidneys and other
vital organs
➔ onset of s/s is rapid, occurs within 72 hours
Signs & Symptoms
▪ Restlessness- earliest sign
▪ Respiratory Distress (dyspnea, crackles)
▪ Hypotension
▪ Hypoxia
▪ Tachycardia
▪ Tachypnea
▪ Irritability
▪ Confusion
▪ Petechial rash over the upper chest and
neck
▪ Chest X-ray- shows a typical “snowstorm”
infiltrate
Nursing alert:
➢ Subtle personality changes, restlessness,
irritability, or confusion in a patient who has
sustained a fracture are indications for
immediate arterial blood gas studies.
➢ Cerebral disturbances- indication for ABG to
check the paO2 (less than 60 mmHg in fat
embolism patients), patient will be prone to
respiratory acidosis
➢ Initially respiratory alkalosis, later on
becomes respiratory acidosis
3-j / Christian Dela Cerna
Management:
1. Prevention: careful handling, appropriate
splinting, & avoidance of unnecessary
manipulation of injured areas (movement
will cause more release of fat globules)
2. Bedrest
3. Oxygen
4. Intubation
5. Fluid volume replacement (I&O monitoring)
6. Corticosteroids (to treat inflammatory lung
reaction and to control cerebral edema)
C. COMPARTMENT SYNDROME
➔ is increased pressure within one or more
compartments, causing massive compromise
of circulation to an area (lead to
compression and then to tissue anoxia)
➔ limb and life-threatening condition
➔ leads to decreased perfusion and tissue
anoxia
➔ within 4 to 6 hours after the onset of
compartment syndrome, neuromuscular
damage is irreversible if not treated
Causes: Tight cast, bleeding, edema
Nursing responsibility: ask patient of his/her
feeling while cast is being dried (if cast is
tight=bivalving)
Signs & Symptoms:
▪ Pain -increasing and unrelieved by
analgesics (opioid); elicited with passive
motion
▪ Paresthesia
▪ Pallor
▪ Pulselessness
▪ Paralysis
Permanent function can be lost if the
anoxic situation continues for longer
than 6 hours.
Management:
1. Relief of the source of pressure: constrictive
bandage to be removed or cast to be bivalved
2. Elevation of affected extremity to heart level

3.Avoid cold application
4.Analgesics
5.Fasciotomy
▪ surgical decompression; incise affected part
with excision of the fibrous membrane that
covers and separate muscles; relieve the
constricted muscle fascia;
▪ after, muscle is released and left (not
sutured) but covered with moist sterile
saline dressing
▪ doctor will check again after 3-5 days; if
pain is already gone it will be sutured back
or grafting will be done to facilitate healing
DELAYED COMPLICATIONS
A. AVASCULAR NECROSIS
➔ is an interruption in the blood supply to the
bony tissue, which results in the death of
the bone
➔ occurs when bone loses blood supply and
eventually bone will die
Signs & Symptoms:
 Pain
 Decreased sensation
Management:
1. Removal of necrotic tissue
- necrotic tissue will cause bone infection
(harder to treat than soft tissue infections),
gap of necrotic tissue= doctor will do bone
graft (doctor will use synthetic bone graft
2. Bone grafts
- others are made of corals
- used to patch up gaps
- if the head of the femur; dili na madala og
bone graft= patient will receive prosthetic
replacement made of steel
3. Prosthetic replacements
3-j / Christian Dela Cerna
B. DELAYED UNION
➔ occurs when healing does not occur at a
normal rate for the location and type of
fracture
➔ may be associated with
distraction (pulling apart) of
bone fragments, systemic or
local infection, poor nutrition,
or comorbidity (e.g., diabetes
mellitus, autoimmune disease)
➔ Eventually, the fracture heals.
C. NONUNION
➔ results from failure of the ends of a
fractured bone to unite.
➔ fibrous tissue exists between the bone
fragments; no bone salts have
been deposited
➔ a false joint (pseudoarthrosis)
often develops at the site of
the fracture.
➔ commonly occurs with factures
of the middle third of the
humerus; the lower third of
tibia; and in elderly people, the
neck of the femur
Symptom
 The patient complains of
persistent discomfort and
abnormal movement at the
fracture site.
Risk Factors
1. Infection
2. Interposition of tissue between the bone
ends
3. Inadequate immobilization
4. Bone gaps
5. Limited bone contact
6. Impaired blood supply
Management
➢ Internal Fixation- stabilizes the bone
fragments and ensures bone contact
➢ Bone grafting- provide for osteogenesis,
osteoconduction, or osteoinduction
Osteogenesis (bone formation) occurs after
transplantation of bone containing osteoblasts
Osteoconduction is provision by osteoblasts
Osteoinduction is the stimulation of host stem
cells to differentiate into osteoblasts by several
growth factors, including bone morphogenic
proteins.
Bone transplants undergo creeping substitution,
a reconstructive process in which the bone
transplant is gradually replaced by a new bone.
➢ Electrical bone stimulation- enhance
mineral deposition and bone formation

Nursing Management
1. Emotional support and encouragement
2. Compliance with the treatment regimen
3. Periodic/ Serial Xrays to check and monitor
for bone healing
Nursing care for the patient with a bone
graft
1. Pain management
2. Monitoring the patient for signs of infection
at the donor and recipient sites
3. Immobilization
4. Non-weight bearing activities
5. Wound care
6. Follow-up care with the orthopedic surgeon
METABOLIC DISORDERS OF THE BONE
A. OSTEOPOROSIS
➔ an age-related metabolic disease
➔ most prevalent bone disease in the world
➔ reduction of total bone mass that causes
thinning of bones, becoming brittle, fragile,
and less solid → prone to fractures
➔ bone demineralization results in the loss of
bone mass, leading to subsequent fractures
➔ greater bone resorption than bone formation
occurs
Risk factors:
1. Aging- degeneration/ inhibition of body
systems that produces hormones; bone
mass= affected
2. Gender- women are more prone
3. Family history
4. Immobility; Sedentary lifestyle- bone needs
movement, small amount of stress is
needed for bone maintenance
5. Medications (corticosteroids, heparin)-
affects calcium absorption and metabolism
6. Diet- low calcium and vitamin D reduces
nutrients for bone remodeling
7. Prolonged Use of caffeine, cigarettes,
alcohol)- reduces osteogenesis (responsible
for bone remodeling)
8. Other diseases (osteomalacia,
hyperthyroidism)- affect bone absorption
and metabolism
Signs & symptoms:
 Possibly asymptomatic- Osteoporosis is
usually diagnosed when patients already
have fractures or if there is already 20-40%
demineralization
 Back Pain
3-j / Christian Dela Cerna
 “Dowager’s hump” kyphosis
of dorsal spine- may be due
to collapse of vertebrae that
leads to deformity
 Pathologic fracture- first
clinical manifestation of
osteoporosis
 Constipation
- postural change → distention,
abdominal distention → immobility, and
respiratory impairment =deformity→
pulmonary deficiency (lungs may be
compressed)
Management:
a. Institute safety measures.
• make sure that floor is not wet/slippery,
avoid clutter on the floor (toys etc.)
• make sure that room is well-lit
• installation of railings or grab bars on
staircases
• instruct patient to use properly fitting
footwear
b. Provide range of motion exercises.
• to strengthen muscles and prevent
atrophy of muscles, encourage walking
& isometric exercises,
• instruct patient to observe body
mechanics, tell patient not to bend or
stoop, instruct patient not to lift heavy
objects
c. Provide a diet high in protein, calcium,
vitamins C and D, and iron.
d. Encourage adequate fluid intake & high fiber
diet
e. Instruct the client to avoid alcohol and
coffee.
Medications:
a. Exogenous calcium
• calcium carbonate; calcium citrate
b. Vit. D supplements
c. Bisphosphonates
• inhibit bone resorption
• alendronate (Fosamax)
d. Selective Estrogen Receptor Modulators
(SERM)
• reduces bone resorption and lowers
serum cholesterol
• promote bone density w/out exogenic
effect to uterus
• raloxifene (Evista)
e. Calcitonin
• inhibits osteoclastic activity
f. Hormone Replacement Therapy:
• methyl progesterone= to retire the bone
loss and prevent occurrence of
additional fracture
 3-j / Christian Dela Cerna

B. OSTEOMALACIA 2. adequate intake of calcium, phosphorus &

➔ bone becomes abnormally soft because of a protein
disturbed calcium & phosphorus balance
secondary to Vit D deficiency
➔ similar condition in children is called rickets;
more severe in adult

3. Braces
4. Surgery (osteotomy)

C. PAGET’S DISEASE (osteitis deformans)

Etiology:
➔ unknown cause
*deficiency in activated Vitamin D (calcitriol)
➔ primarily, there is proliferation of osteoclasts
related to:
causing bone resorption
a. lack of sunlight exposure
➔ Then osteoblasts are stimulated as a
b. dietary intake- lack in vit. D
compensatory mechanism that replaces
c. Crohn’s disease- example of inflammatory
bone
bowel disease
➔ End result will be a disorganized pattern of
d. complication of surgeries of small intestines-
bone develops
fats are inadequately absorbed and likely
➔ disorder of localized rapid bone turn over
cause osteomalacia because of fat-soluble
affecting skull, femur, tibia, and vertebrae
vitamins (ADEK)
e. chronic use of anticonvulsant- interfere with
calcium absorption

Signs & symptoms:

➢ bone pain
- most common and distressing
symptom of osteomalacia
- which increases with activity due to
softening and weakening of skeleton d/t
faulty mineralization
➢ Muscle weakness- calcium deficiency
➢ Spinal deformity
➢ unsteady gait- waddling and limping gait
Signs & Symptoms:
➢ compressed vertebrae
• 10-20% are asymptomatic
➢ pelvic flattening
• deep, aching bone pain
➢ bowing of legs
• skeletal deformity- if bone turnover happens
in skull, there will be instances wherein
cranial nerve compressions occur

Management:
• Daily Vitamin D supplementation

•
• pathologic fracture
• vertigo, hearing loss with tinnitus, &
blindness
Diagnosis:
➢ X-ray -confirm diagnosis
➢ bone biopsy
➢ serum alkaline phosphatase
(increased/elevated)
 3-j / Christian Dela Cerna

Management:
 Exercise
 Heat application; gentle massage
 Diet rich in Calcium
 Medications:
a. NSAID ex. Ibuprofen
b. Calcitonin
c. Bisphosphonates- reduce bone
turnover and help in relieving pain:
- etidronate disodium (Didronel)
- Alendronate sodium(Fosamax)
Diagnosis:
d. Mithramycin (Mithracin)
 Wound and blood culture studies
- potent antineoplastic (cytotoxic
▪ to identify appropriate antibiotic
antibiotics)
 Blood studies
- control Paget’s disease, reserved for
▪ reveal elevated WBC and ESR
patients with neurologic compromise
 X ray
and are resistant to other medications
▪ reveal soft tissue swelling
Management:
INFECTIOUS DISORDER OF THE BONE
➢ Prevention
• main goal
(Musculoskeletal infections)
• give antibiotics preoperatively usually an
hour prior to prevent infection
A. OSTEOMYELITIS
• assess wound for s/sx for infection
- infection of the bone
➢ Antibiotic therapy
INFECTION OF THE BONE ➢ Infection control
➢ Surgery (ex. Debridement)- scrape debris
Pathogen invasion and dead tissues using a curette until part is
already bleeding (indicates that tissue
reached is already alive)
Inflammation

Edema

Decreased blood
flow to bone

➢ General supportive measures:

Bone Necrosis
✓ Hydration
✓ Diet high in vitamins and protein
Bone Abscess ➢ Immobilize the affected area
➢ Warm wet soaks- to relieve pain
➢ Does not respond to antobiotic:
Debridement- infected bone is surgically
exposed, purulent and necrotic material is
removed and irrigated with sterile saline
solution
➢ Protein (for tissue repair)

AMPUTATION
- is the surgical removal of a part of the body

Performed for the following reasons:

1. To remove tissue that no longer has an
Signs & symptoms: adequate blood supply
 localized bone pain 2. To remove malignant tumors
 tenderness, heat & edema 3. Because of severe trauma to the body part
 restricted movement
 purulent drainage from a skin abscess 2 Types
 fever & chills 1. Above
 Elevated ESR & WBC 2. below
 3-j / Christian Dela Cerna

➢ Assist the client to identify coping

mechanisms to deal with the loss.
➢ Provide stump care:
1. inspect daily for signs of irritation
2. Wash the stump with mild soap and
water and apply lanolin to the skin if
prescribed.
3. Massage the skin toward the suture line
(to prevent dehiscence and cause
bleeding→ infection)
4. Avoid nylon socks (cotton socks are
recommended, nylon= cannot absorb
moisture)
FYI:Translumbar amputation- radical
5. Put on prosthesis upon arising (stump
surgery in which the body below the waist is
won’t fit on the prosthesis due to the
amputated, transecting the lumbar spine. This
pull of gravity in the afternoon; stump
removes the legs, the genitalia, urinary system,
will enlarge) and keep it on all day ( to
pelvic bones, anus, and rectum.
reduce stump swelling)
6. Continue prescribed exercises (when
Pre-operative interventions:
there is healing only; push stump
➢ Health teachings especially on acceptance of
against hard surface
situation- give ample time for acceptance
➢ Don’ts on the stump
➢ Establish open and honest communication
1. Hang stump over the bed (to avoid
➢ offer support and encouragement/accept
nerves being compressed)
patient’s response of anger and grief
2. Sit in wheelchair with stump flexed
➢ Strengthen extremities not affected, trunk
3. Place pillow under hip or knee or
and abdominal muscles
between thighs (improve circulation)
Discuss:
4. Rest stump on crutch handle
- rehabilitation program and use of prosthesis
5. Abduct stump
(teach how to apply and when to put/remove;
done pre-op because patient may be too
Complications:
distracted to listen post-operatively)
1. Hemorrhage
- crutch walking
2. Infection
- amputation dressing/cast
3. Phantom limb sensation
- phantom limb sensation as normal occurrence
- feeling that the amputated part is still
present; diminishes overtime
Postoperative interventions:
4. Phantom limb pain
➢ Monitor for infection and hemorrhage (in the
- pain felt by the patient in the part of
stump)
the body that has been amputated
➢ Keep a tourniquet at the bedside. (if the
- seen more frequently in above the
area bleeds and the patient is at home,
knee amputation
tourniquet will stop bleeding above the
Medications
stump=otherwise, may cause shock)
➢ Calcitonin; anticonvulsants; antispasmodics
➢ If prescribed, during the first 24 hours,
- relieve muscle spasm
elevate the foot of the bed (Done to prevent
➢ Transcutaneous Electrical Nerve Stimulation
contractures; do not elevate the stump
(TENS)- to help relieve the pain
itself)
➢ After 24 and 48 hours postoperatively,
DISORDERS OF THE JOINTS
position the client prone if prescribed.
A. OSTEOARTHRITIS (degenerative joint
arthritis, degenerative arthritis)
➔ is a slowly progressive, degenerative joint
disease characterized by variable changes in
weight-bearing joints (hips, knee,
lumbosacral spine, fingers
➔ degenerative: worsens with age
➔ common and frequently disabling joint
➢ In the prone position, place a pillow under
disorder
the abdomen and stump and keep the legs
➔ there is a breakdown/erosion of cartilage
close together. (prevent contracture)
(cushion joint surface, keep bones to move
➢ Teach how to ambulate using crutches. smoothly) → bone is exposed → pain
Encourage the client to look at the stump.

Etiology:
1. obesity (heavy weight causes increased
stress on the joints → injury to cartilage
(discomfort and pain)
2. aging (excessive and prolonged mechanical
stress to joint can damage the cartilage)
3. trauma
4. genetic predisposition
5. congenital abnormalities (e.g.,
congenital subluxation or acetabular
dyspersa=problems with hipjoint)
Signs & symptoms:
• Asymmetrical inflammation of joints in
the hips, knee, feet, and lumbosacral
spines.
• Joint pain that diminishes after rest and
intensifies after activity
• Crepitus
• Heberden's nodes (bony thickening in
distal interphalangeal joints) or
Bouchard’s nodes (proximal
interphalangeal joints)
Management:
1. Immobilization (the affected joint with a
splint or brace)
2. Heat applications (warm compress)
3. Adequate rest
4. Encourage weight loss if necessary
5. Instruct the client that exercises should be
active (more calories are burned) rather
than passive
6. Medications:
7. Analgesics (Acetaminophen), NSAIDS
(Celecoxib), corticosteroids (reduce pain and
inflammation)
8. Total Joint Arthroplasty / TJR- replacement
with a prosthesis
3-j / Christian Dela Cerna
Surgical Management
1. TOTAL HIP REPLACEMENT
Nursing Management:
1. Proper alignment (post-operatively, apply
leg abduction pillows to prevent dislocation
of preosthesis; if n/a, place 2-3 pillows
between the legs)
2. Prevent flexion, external/internal flexion
3. Avoid weight bearing on affected area
4. Monitoring wound drainage (normal for the
1st 24 hrs.: 200-500 ml; after 48 hours= 30
cc/8 hour-shift)
5. Preventing DVT (light exercises)
6. Preventing infection
7. Instruct patient not to cross his legs and
stooping is not allowed, flexion of the hip is
prohibited
Indicators
- Shortening of the leg, abnormal rotation of the
leg, increased discomfort, inability to move
2. TOTAL KNEE REPLACEMENT
Nursing Management:
1. CPM (continuous passive motion)
▪ using mechanical device that flexes and
extends the knee at a set range of
flexion and rate
▪ promotes healing by increasing
circulation and movement of the knee
joint
▪ applied up to 6 week post-operatively
 3-j / Christian Dela Cerna

Phagocytosis

Enzymes in the joint

Breakdown of collagen

Edema

Proliferation of synovial membrane

Pannus Formaton
2. Ice- control edema and bleeding Pannus
3. Neurovascular check – 6 Ps • proliferation of a newly formed synovial
4. Monitor for drainage: 200-400 ml/ 24 hours,
tissue infiltrated with inflammatory cells
decreases after 48 hours • Pannus will destroy the cartilage and
5. Neutral position, avoid internal/ external eventually erode the bone
rotation
6. Maintain abduction with pillows/ abductor
splint
7. Prevent hip flexion/ flat on bed as ordered
8. Get patient out of bed 2-4 days post op
9. Avoid weight bearing until ordered
10. Teach client:
- do not cross legs
- use raised toilet seat Signs & symptoms:
- do not bend down 1. Morning stiffness (lasting more than 30
mins)
B. RHEUMATOID ARTHRITIS 2. Symmetric joint swelling: finger joint or
➔ is a chronic systemic inflammatory disease wrist
(immune complex disorder) 3. Subcutaneous nodules
➔ leads to destruction of connective tissue and 4. Joint deformity
synovial membrane within the joints 5. Boutonniere deformity- PIP flexion, DIP
➔ the cause may be related to a combination hyperextension
of environmental and genetic factors 6. Swan neck deformity- PIP hyperextension,
DIP hyperflexion

7. Elevated ESR
8. (+) Rheumatoid Factor (RF)

Estrogen plays a role in affecting b and t cells

(immune response)

Etiology: Idiopathic

Risk Factors
 Gender: Female
 Age: 40 years old
 Genetics
 3-j / Christian Dela Cerna

STAGES ANATOMIC CHANGES 4. Positioning- no pillow under the affected

STAGE 1: 3. No destructive changes on X-ray joint to prevent contractures
Early 4. Possible X-ray evidence of 5. Exercise- gentle e.g., walking, aerobics
osteoporosis 6. Diet: High CHON (tissue building and
STAGE 2: ➢ X-ray evidence of osteoporosis, repair), iron, vitamins
Moderate with or without slight bone or
cartilage destruction MEDICATIONS:
➢ No joint deformity 1. Salicylates (acetylsalicylic acid [aspirin])
➢ Adjacent muscle atrophy 2. Nonsteroidal anti-inflammatory drugs
➢ Possible presence of (NSAIDs)- relieve pain and inflammation
extraarticular soft tissue lesion 3. Disease-Modifying Anti-Rheumatic Drugs
STAGE 3: ➢ X-ray evidence of cartilage and (DMARDs)
Severe bone destruction in addition to ❑ Hydroxychloroquine
osteoporosis ❑ Sulfasalazine
➢ Joint deformity (subluxation, ❑ Minocycline
ulnar deviation, or ❑ Leflunomide (Arava)- Newer DMARD
hyperextension)
➢ Extensive muscle atrophy Slow progression of RA and prevents permanent
➢ Possible presence of extra- damage
articular soft tissue lesions 4. Corticosteroids- reduce inflammation and
STAGE 4: ➢ Fibrous or bony Ankylosis pain
Terminal ➢ Stage 3 criteria 5. Methotrexate- antineoplastic drug, gold
standard for RA treatment because of its
Diagnostic Test success in preventing joint destruction
1. History Taking and Physical Assessment 6. Gold compounds (chrysotherapy) injectable-
2. Serum Studies: client is positive (+) Myochrysine; oral-auranofin
✓ Rheumatoid Factor (RF) ➢ Joint splinting
✓ C Reactive Protein (CRP) ➢ Assistive devices
✓ Erythrocyte Sedimentation Rate
(ESR)
✓ Antinuclear Antibody (ANA)
3. Complete Blood Count (CBC)
▪ RBC, C4 complements are
decreased
4. Synovial Fluid Analysis CHARACTERISTICS Rheumatoid Osteoarthritis
▪ milky, dark yellow color (pus, Arthritis
bacteria) Age of Onset 35-45 >60
5. X-ray Gender Female Female
▪ help and diagnose the progression Risk Factors ► Autoimmune ► Aging
► Emotional stress ► Genetic Factor
of disease (triggers ► Obesity
exacerbation) ► Trauma
CRITERIA FOR CLASSIFICATION OF occupation
RHEUMATOID ARTHRITIS Disease process ► Inflammatory ► Degenerative
Disease Pattern ► Bilateral, ► Unilateral
Note: Four or more of the following conditions to symmetric, multiple ► Single joint
establish the diagnosis joints ► Affects weight-
❑ Morning stiffness for at least 1 hour and present ► usually affects bearing joints,
for at least 6 weeks upper extremity hands, and spine
first
❑ Simultaneous swelling of 3 or more joints for at Lab findings ► Elevated ESR, ► Normal or slightly
least 6 weeks antinuclear elevated ESR
❑ Swelling of wrist, metacarpophalangeal, or antibodies, RF
proximal interphalangeal joints for 6 or more Common drug ► NSAIDs ► NSAIDs
therapy ► Methotrexate ► Acetaminophen
weeks
► Corticosteroids ► Analgesics
❑ Symmetric joints for 6 or more weeks
❑ Rheumatoid nodules
C. GOUTY ARTHRITIS
❑ Serum RF
➔ a genetic defect in purine metabolism that
❑ Radiographic changes
causes increased serum uric acid.
➔ monosodium urate or uric acid crystals are
MANAGEMENT: found in the joint activity
1. Rest ➔ over secretion of uric acid
2. Splinting
3. Heat or cold application: cold-
acute/swelling, heat- as it subsides/ pain
 3-j / Christian Dela Cerna

• increase intake of alkaline ash foods

TYPES
1. Primary gout- results from a disorder of
purine metabolism,
Causes: starvation, severe dieting, eating
foods high in purine (organ meats),
hereditary
2. Secondary gout- involves excessive uric
acid in the blood
Cause: another disease (leukemia, multiple
myeloma, anemia, renal defect)
(ABCDE Apple, Banana, Carrots, Date,
Eggplant)
• Avoid alcohol and starvation diets
Gout Diet- What to Avoid
- Any food high in purines
- Avoid asparagus, mushrooms, and spinach
- Avoid seafood and proteins
- Avoid alcohol and soda
B. Encourage a high fluid intake of 2000 ml.
C. Rest & elevate the affected extremity.
D. heat or cold application
E. Medications:
✓ NSAIDs
✓ Colchicine- to lower deposition of uric acid
and decrease inflammation (given during
acute attack of gout to decrease
inflammation and pain)
✓ Probenecid- uricosuric agent; increase
urinary excretion of uric acid
✓ Allopurinol- block uric acid formation
(medication of choice for gouty arthritis)

TOPHI FORMATION DISORDERS OF THE VERTEBRA

Increase in Uric Acid A. SCOLIOSIS
➔ lateral deviation of the spine from the
UA Crystal deposition in the joints (especially at the midline
peripheral areas) ➔ curve may be C or S-shaped
➔ may be congenital, neuromuscular,
Inflammatory Response
idiopathic

Recruitment of inflammatory cells

Signs & symptoms:
Release of enzymes and prostaglandins ✓ Asymmetry of hip or shoulder
✓ restricted respiration- advanced scoliosis
Destruction of articular cartilage and subchondral Risk Factors:
bone erosion ✓ Age
- s/sx typically begin during the growth
Repeated Attacks spurt that occurs prior to puberty
- between 9-15 yr.
Tophi Deposits
✓ Sex: females have higher risk
✓ Family History

MANAGEMENT:
 Exercise
 Weight reduction
 Brace
 Spinal fusion
SIGNS & SYMPTOMS
1. Excruciating pain & inflammation usually
small joints (PODAGRA- urate crystal
deposition in the big toes)
2. Tophi- urate crystals in the peripheral
3. Presence of renal stones
4. Elevation of Serum uric acid: >7.5 mg/dl

Management
A. Diet
• Provide a low-purine diet (decrease
B. KYPHOSIS
BLOSS Beer-Legumes-Organ Meat-
➔ increased forward curvature at the thoracic
Shellfish-Sardines);
spine
 3-j / Christian Dela Cerna

C. LORDOSIS
➔ exaggerated curvature at the lumbar spine
ASSISTIVE DEVICES - piece of equipment to
maintain or increase activity
CANES
 Indicated to patient with minimal
weakness of lower extremities, with
good balance and coordination
 Types: single, tripod, quadripod
CRUTCHES
 2 inches below the axillary folds
 6 inches diagonally from small toe
 Elbow is at approximately 30-degree
flexion
 Place the weight on the hand piece not
the axilla

Elbow/ Lofstrand crutches

 Place 4-6 inches to the side of the foot;

hand grips level with the greater
Hands-free/ knee crutches
trochanter
 Elbow should be flexed at 15–30 angles
 Cane is held on the hand opposite the
Affected Leg
 Gait: device & affected leg, then
unaffected leg
 Always place the
cane opposite to the CRUTCH GAITS
bad leg A. Four-point gait (crutch, bad leg)
 Cane first then bad 1. Advance left crutch
leg, then good leg 2. Advance right foot
 When going 3. Advance right crutch
upstairs 4. Advance left foot
❑ Good ones go ► Most stable crutch gaits
to heaven, bad ► Partial weight bearing on both legs
ones go to hell
❑ good leg→cane→ bad leg B. Two-point gait
 When going down stairs 1. Advance left crutch and right foot.
❑ cane→bad leg → good leg 2. Advance right crutch and left foot.
► More normal walking pattern
WALKERS ► Partial weight bearing on both leg
 Provides more support and stability than
canes or crutches C. Three-point gait
 Put all four points of the walker flat on 1. Advance both crutches & affected leg
the floor before putting weight on the (together)
hand pieces 2. Advance unaffected leg
 Instruct to move the walker forward & ► Non weight bearing
walk into it
 Slide the walker forward → bad leg → D. Swing to
good leg 1. Advance both crutches
2. Lift both feet
3. Swing forward
4. Place feet next to crutches
► Weight bearing on both feet
► Requires arm strength

E. Swing through
1. Advance both crutches
2. Lift both feet
3. Swing forward
4. Place feet in front of crutches
 3-j / Christian Dela Cerna

► Most advanced gait

► Weight bearing on both feet
► Requires coordination and balance

Assisting the client with crutches To Sit

1. Place the unaffected leg against the
front of the chair
2. Move the crutches to the affected side,
& grasp the arm of the chair with the
hand on the unaffected side
3. Flex the knee of the unaffected leg to
lower self into the chair while placing
the affected leg straight out in front

Assisting the client with crutches in going

up and down stairs

Up the stairs
1. the unaffected leg up first.
2. then affected leg and the crutches up

Down the stairs

1. crutches and the affected leg down first.
2. then unaffected leg down