orthopedic problem and management

8/2/2019 Orthopedic Problem and Management

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Orthopedic

Common Lab tests

1. ESR2. C-reactive protein

3. CBC4. Serum cultures5. Serum Calcium6. ANA7. Creatinine

X-rays (roentgenograms)

1. Noninvasive test in which radiation is passed through a specific body part to display a pictureof the internal aspects of that part

2. Used to1. determine shape, size and position of organs2. indicate presence of fluid lines, foreign bodies, infiltrates3. determine configuration, density and vascular markings of organs4. determine injury, fracture, degeneration, inflammation, perforations, calculi (stones)

or masses5. types of x-ray

1. chest2. musculoskeletal3. skull4. spine5. mastoid6. sinus7. breast

8. kidneys, ureters, bladder (KUB)3. Nursing interventions for x-ray procedures

1. instruct client about procedure2. shield the client's genitals with lead drape3. ask if pregnant prior and do not x-ray if pregnant4. for chest x-ray, assist to dress in institution clothing

Contrast radiography

1. Visualization of x-ray enhanced by using contrast medium2. Contrast medium may be ingested, injected through a tube or catheter or given intravenously3. Contrast medium may be barium, iodine, or air

4. Cineradiography: rapid sequence x-rays that film motion5. Fluoroscopy: projection of x-rays onto screen for continuous observation of motion

Casts

1. Externally applied structure that holds bone in one position2. Uses

a. immobilizationb. prevent bone or muscle deformityc. support of a weakened limbd. promote healinge. permit early weight bearing on affected limb

3. Types of casting materialsa. plaster of paris

i. natural materialii. indicated in cases of

severely displaced fractures unstable fracture fragments

iii. when multiple castings are indicated: serial castingiv. application: takes at least 24 hours to dryv. advantages
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low allergic response offers rigid protection easy to apply inexpensive

vi. disadvantages long drying time (24 to 48 hours) - gives off heat while drying

(exothermic)

weight - plaster casts are heavy materials may crumble and disintegrate at edges not waterproof

b. fiberglassi. synthetic materialii. indicated in cases of

non-displaced fractures long term casting

iii. advantages light weight easy to apply moisture-proof

fast: dries in 15 minutes, cures in one hour colors and patterns help client adjust to immobilization

iv. disadvantages short drying time requires speed and accuracy more rigid than plaster; may bind if tissues swell extra rigidity may cause tissue breakdown under the cast more expensive than plaster castings

4. Types of castsa. short arm/leg

i. cylindrical castii. allows for flexion or extension of elbow and knee

b. long arm/leg

i. cylindrical castii. does not allow elbow or knee to move

c. spica arm/hipi. support bar is applied between extremitiesii. permits greater stabilizationiii. cut window over epigastrium for patient comfort after eating

5. Cast applicationa. cast must extend to the joint above and below the point of fractureb. assessment prior to cast application

i. skin: inspect for irritation, laceration, skin breakdownii. neurovascular status check

iii. edema/swellingc. windowing:i. square or diamond hole cut in cast over certain areaii. indications

observation of surgical incision observation of skin relieve pressure over bony prominence

iii. nursing interventions cast may crack at window site - weakest part of the cast appropriate padding/petaling of open window

d. bivalvingi. indications

swelling infection or high potential for infection pain

ii. techniques lengthwise splitting of the cast with cast saw apply ace wrap or tape to hold cast together still immobilizes

e. petalingi. edging the cast with soft padding or moleskin


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ii. indications prevent irritation or skin breakdown at rough edges of cast protect cast from perspiration, feces, urine protect perineal area

6. Nursing interventions: post cast applicationa. plaster of paris casts

i. handle fresh cast carefully (first 48 hours) indentations may cause pressure points under the cast handle the cast with open palms of hands

ii. do not apply pressure to the castiii. do not cover the cast - allow to air dryiv. do not use heat to dry

b. all castsi. repeated neurovascular checks

capillary refill time warmth color motion checks

1. patient can move toes and fingers of affected limb2. if not, a nerve is compressed3. sensation: numb or tingling may mean nerve compressed

ii. drainage observe for wound drainage record size, color, amount; and circle area on cast with felt tipped

marker and date and time check odor of drainage

c. teach clienti. keep cast dry and intactii. to avoid placing any objects, powders, or lotions inside of or through castiii. describe indications and therapeutic use of casting for immobilization

iv. proper use of assistive devicesv. how to assess environment for potential mobility hazardsvi. to inspect cast daily for foul odor, cracks

7. Nursing interventions for cast removal with a mechanical sawa. explain procedure to clientb. inform client that

i. cast removal is painlessii. client will feel heat and vibrationiii. saw is noisy but will not cut clientiv. inspect tissue under cast for signs of inflammation or infectionv. if skin is intact apply lotion to moisturize skin

c. teach clienti. underlying skin may be scaly and dryii. to perform range of motion exercises as orderediii. to use moisturizing lotion on dry skin

Traction - pulling force and opposing force applied to injured extremity

1. Longitudinal - when only one force is applied2. Traction angle - direction of the force in relation to the affected extremity3. Countertraction - opposing force to the pull of the traction; most often is provided by the

person's body weight4. Vector force - resultant force produced when two traction forces are applied to a limb5. Purposes

a. reduce, realign and promote healing of fractured bonesb. decrease muscle spasmsc. immobilize area of bodyd. rest inflamed, diseased or painful jointe. treat/correct deformitiesf. reduce and treat dislocations
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g. prevent the development of contracturesh. expand a joint space during arthroscopyi. reduce muscle spasms in low back pain or cervical whiplash

6. Types of tractiona. manual traction

i. use of the hands to exert a pulling force

ii. generally used during an emergencyiii. temporary measure - cannot be maintained for extended periods

b. skin tractioni. pulling force is applied directly to the skin through the use of foam splints,

skin traction strips and tapeii. temporary measure

PRINCIPLES OF TRACTION

A. Maintain the prescribed line of pull1. Especially important in patients with fractures

2. Maintain proper body alignmentB. Always maintain continuous pull unless intermittent traction is prescribedC. Prevent friction

1. Friction will alter the line of pull2. Friction will impair the traction's efficiency3. But never lubricate pulleys

D. Identify and maintain counteraction1. Countertraction is the force opposing the pull of traction2. Generally provided by the patient's body3. If countertraction is not maintained the patient is not in traction4. Sign of loss of countertraction is that the patient slides down in bed5. Especially problematic with Buck's Traction

6. Keep bed flat7. Elevate the foot of the bed with shock blocksE. Counter traction for pelvic traction is generally achieved by putting the bed in the

William position (both knees and hips are flexed at 30 degrees)

MECHANICS OF TRACTION EQUIPMENT

1. Frame - Should be loaded to maximize its stability before adding additional tractionsystems

2. Plain Bars3. Cross Clamps - Positioned so that turn knobs are on top of horizontal bars4. Traction Bars5. Pulleys

a. do not lubricate- Decreased friction markedly changes the line of pullb. must move freely
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iii. types of skin traction

iv. complications skin breakdown detachment of traction device

v. limitation: can apply only five to seven lbs. loading forcevi. must remove traction and perform skin care

c. skeletal tractioni. traction applied directly to the bone \ii. pins are placed through the affected limbs and attached to pulling forceiii. can be tolerated for longer periods - up to four months

iv. greater weight can be used - 15-40 lbs.v. types of skeletal traction

balanced suspension1. used for displaced, overriding or comminuted

fractures2. preoperative treatment prior to surgical pinning

d. skull tong/halo tractioni. burr holes drilled into skull and tongs inserted and attached to

weights or halo bolts inserted then attached to body castii. tongs used for cervical fractures preoperatively

a. static tractionb. continuous traction pull

c. dynamic tractiond. intermittent application of tractione. straight tractionf. running

7. Complications1. infection at pin site2. skin breakdown3. muscle weakness
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4. osteomyelitis

7. Patient positioning for traction1. supine2. perpendicular to the ends of the bed3. affected limb in proper body alignment4. head of the bed is flat or semi fowlers (maximum of 20 to 30 degrees elevation)

5. a trapeze for client to shift position and upper range of motion provided

8. Nursing interventionsa. explain procedure to client / assess neurovascular status of affected area/limb at

least every four hoursa. colorb. temperaturec. motiond. sensatione. pulse qualityf. presence/absence of edema

b. always compare affected limb to unaffected limb for baseline measurement

c. skeletal cervical or halo traction: assess cranial nerves III - IXd. skin assessment

i.high risk for developing pressure soresii.remove Buck's traction boots every two hours to inspect skin

integrityiii.assess pressure areas every two hours

e. pin assessment: observe for drainage, signs of infectionf. medical asepsis with open sking. maintain principles of tractionh. administer appropriate medicationsi. beware of immobility's multi-system effects

j. allow patient to verbalize fear and concerns

k. encourage involvement of family membersl. provide diversional activities

Mobilization devices: orthotic, prosthetic, crutch, cane, walker

1. Orthotica. braces designed to prevent deformity, increase efficacy of gait, control

alignment and/or promote ambulationb. types of orthotic

i. ankle/foot (AFO)ii. knee/ankle/foot (KAFO)

iii. hip/knee/ankle/foot (HKAFO)iv. thoracolumbar or sacral (TLSO)

2. Prosthetic: artificial limbs for all extremities3. Crutches

a. a wooden or metal staffb. used when no or minimal weight bearing is desiredc. may be temporary or permanentd. types

i. axillary: a padded curved surface at top which fits under theaxilla and a crossbar forms the handgrip

for axillary crutches, measure client's height; distancebetween crutch pad and axilla; distance from axilla to

client's heel; Crutch pads should be three to four fingerwidths under axilla

complication: crutch palsy--paralysis of elbow and wristdue to crutch pressure on axilla

e. forearm (Lofstrand): an adjustable metal band that fits around theforearm with an adjustable handgrip


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4. Canes: straight-legged, quad; all need rubber tips5. Walkers

a. extremely light devices that have four widely placed legs and handgripson an upper bar; need rubber tips. May have rollers instead of tips.

b. client moves the walker forward and steps into it, then moves it forwardagain

c. caution should be used to avoid overloading client's personal itembaskets

6. Wheelchairs: manual, electric7. Nursing interventions with mobilization devices

a. explain procedure to clientb. assess client's readiness including muscle strength and range of motionc. safety is prime issued. observe client initially for orthostatic hypotension

e. assess environmental risksf. nurse should stand close to client during initial attempts at using

mobilization devices.g. use a gait belt for maximum supporth. provide emotional supporti. resize device as children grow

j. teach clienti. proper use of deviceii. findings of complicationsiii. how to climb stairs, maneuver on various surfacesiv. how to maneuver on and off toilet, chair, tub, shower, carv. don't look at your feet, look ahead

vi. how to troubleshoot equipment for defects, signs of wearvii. wear stable shoes, same heel height as when device fitted

For client to navigate stairs with crutches, remember "up with the good, down with the bad."

To go up stairs, lead with the unaffected "good" leg, and follow with the affected "bad" leg.

To go down stairs, lead with the affected "bad" leg, and follow with the unaffected "good" leg.


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I. Anatomy and PhysiologyA. Bone

1. Functionsa. supports and protects structures of the bodyb. anchors musclesc. some bones contain hematopoietic tissue which forms blood cellsd. participates in the regulation of calcium and phosphorus

2. Joints

a. bursa - enclosed cavity containing a gliding jointb. synovium - lining of joints which secretes lubricating fluid that nourishes

and protectsc. classification of joints - synarthrosis, amphiarthrosis, diarthrosis


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3. Cartilage - connective tissue covering the ends of bones

4. Types of bonesa. long - legs, arms

i. external structure - diaphysis, epiphysis, periosteum


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ii. internal structure of bone - medullary cavity; cancellous bone;

red marrowb. short - ankles, wristsc. flat - shoulder bladesd. irregular - face, vertebrae

B. Muscles - produce movement of the body1. Types

a. striated - controlled by voluntary nervous systemb. smooth - controlled by autonomic nervous systemc. cardiac - controlled by autonomic nervous system


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C. Fascia - surrounds and divides musclesD. Tendons - fibrous tissue between muscles and bonesE. Ligaments - fibrous tissue between bones and cartilage; supports muscles and fascia

II. Trauma: Contusions, Strains, SprainsA. Contusions (bruise)

1. Definition - a fall or blow breaks capillaries but not skin

2. Pathophysiology - extravasation (bleeding) under skin3. Findings - ecchymosis (bruise) and pain when the contusion is palpated4. Management

a. for first 24 to 48 hours, apply ice for 15 minutes, three times a dayb. then apply heat if necessaryc. wrap to compress

5. Resolution: should heal within seven to ten days6. Color changes from a blackish - blue to a greenish - yellow after three to five

days

B. Strains1. Definition - lesser injury of the muscle attachment to the bone2. Etiology and pathophysiology

a. caused by overstretching, overexertion, or misuse of muscleb. acute: recent injury to muscle or tendon; classified by degree

i. first degree: mild; gradual onset; feels stiff, sore locally assessment of acute first-degree strain

o tenderness to palpationo muscle spasmo no loss of range of motiono little or no edema or ecchymosis

management of acute first-degree straino comfort measureso apply iceo rest, possibly immobilize for short term, elevate

ii. second degree: moderate stretching, sudden onset, with acutepain that eventually leaves area tender

assessment of acute second-degree straino extreme muscle spasmo passive motion increases paino edema develops early; ecchymosis later

management of acute second-degree straino keep limb elevatedo apply ice for the first 24 to 48 hrs - then moist heato limit mobility, ace wrapo muscle relaxants, analgesics, NSAIDS


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o physical therapy for strength and range of motion3. Third-degree: severe stretching with tear; sudden; snapping or burning

sensationa. assessment of acute third degree strain

i. muscle spasmii. joint tendernessiii. edema (may be extreme)

iv. client cannot move muscle voluntarilyv. delayed ecchymosis

b. management of acute third degree straini. keep limb elevatedii. apply ice for 24 to 48 hrs, then moist heatiii. either immobilize or limit mobility of the limbiv. medication - muscle relaxants, analgesics, NSAIDsv. physical therapy for strength and range of motion

4. Chronic straina. long-term overstretching of muscle/tendonb. repeated use of the muscle beyond physiologic limits

C. Sprains

1. Definition - greater than strain; injury to ligament structures by stretching,exertion or trauma

2. Classification/findings/assessment/managementa. first degree sprain

i. minimal tearing of ligament fibersii. localized edema or hematomaiii. no loss of functioniv. no weakening of joint structure - joint integrity remains intactv. mild discomfort at location of injuryvi. pain increases with palpation or weight bearingvii. management of first degree sprain

compress it with ace bandage to limit swelling

keep limb raised to decrease edema apply ice 24 to 48 hours following injury analgesics for discomfort isometric exercises to increase circulation and resolve

hematomab. second degree sprain

i. up to half of the ligamentous fibers tornii. increased edema and possible hematomaiii. decreased active range of motioniv. increased painv. mild weakening of the joint and loss of functionvi. management

protectively dress/splint the joint, immobilize it elevate the limb to decrease edema for 24 to 48 hours, alternate

o ice1. to produce vasoconstriction to decrease

swelling2. to reduce transmission of nerve impulses

and conduction velocity to decrease paino moist heat

1. to reduce swelling and provide comfort analgesics for discomfort physical therapy to increase circulation and maintain

nutrition to the cartilagec. third degree spraini. complete rupture of the ligamentous attachmentii. severe edema with hematomaiii. usually, severe painiv. dramatic decrease in active range of motionv. loss of joint integrity and functionvi. management

casting
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surgery to restore integrity of joint see second degree treatment

D. Fractures: classification and diagnosis

ASSESSMENT AND EARLY MANAGEMENT OF THE TRAUMA CLIENTI. Primary survey: ABC

A. Airway maintenance with spinal cord control - cervical stabilization

B. BreathingC. Circulation

II. Cognitive level: glasgow coma scaleA. Eye openingB. Verbal responseC. Motor response

III. Ask about: A-M-P-L-EA. AllergiesB. MedicationsC. Past illnessD. Last mealE. Events preceding the injury

IV. Life threatening injuries of extremity

A. Massive open comminuted fracturesB. Bilateral femoral shaft fracturesC. Vascular injuriesD. Crush injuries of the abdomen or pelvisE. Traumatic amputation of the arm or leg

V. Mechanism of injuryA. Force: amount of energy transferred from one object to human bodyB. Injuring agent: sharp or blunt instrumentC. Predictable musculoskeletal injuries

1. Child/pedestrian injuries "Waddell's triad":a. point of impact with the car bumperb. point of impact with the car hoodc. point of impact where the body is thrown

2. Adult/pedestrian injuriesa. point of impact with the car bumperb. point of impact with the car hoodc. injuries to opposing ligaments

3. Unrestrained drivera. headb. larynx and sternumc. knee/femurd. posterior hip dislocation

4. Fall from a height (Don Juan syndrome)a. bilateral calcaneal fracturesb. hyperflexion of the lumbar spinec. bilateral Colles' fracturesd. compression fracture of vertebrae

5. Blast injuriesa. gunshot/missile type injuriesb. source of infection: when energy travels it leaves a vacuum behind it, drawing in

debris/body hairc. results in both entry and exit woundd. shock waves throughout body

VI. Findings of traumaA. Deformity/angulation of extremityB. SwellingC. PainD. Paresis/paralysisE. ParesthesiaF. Pallor

G. Absent pulsesVII. Goals of nursing care

A. Sustain lifeB. Maintain functionC. Preserve appearance

VIII. Goals of rehabilitationA. Decrease pathologyB. Prevent secondary disabilitiesC. Increase function of unaffected and affected systems
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1. Definition: fracture is any alteration in the continuity of a bone2. Fracture dislocation

a. a fracture in which the joint is dislocated in that position, fracture will notheal completely

3. By completenessa. complete (bone broken in two or more pieces)

b. incomplete (bone broken but still in one piece)4. By wound

a. closed = simple; does not break skinb. open = compound = complex

i. bone fragments break through skinii. injures soft tissue and often infects tissueiii. subdivided by degree of soft tissue injury

5. By fracture line


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a. longitudinal = linear fractureb. oblique is produced by a twisting force, and requires traction to heal

properly.c. spiral also results from twisting force, may accompany damage to soft

tissue, and requires traction or internal fixation.d. transverse is caused by angulation, common in pathological fractures,

and generally stable after reduction.

6. By type of fracturea. avulsion fractures

i. bone fragments and soft tissue are pulled away from the boneii. results from a direct force on the bone

b. comminuted fracturesi. produced by high energy forcesii. results in two or more bone fragmentsiii. splinters the fragmentsiv. injures soft tissue severely

c. compression fracturesi. often seen in the lumbar spineii. may be pathological (a disease weakens bone)

d. greenstick fracturei. results in an incomplete fractureii. caused by

compression forces angulation forces

iii. cortex of the bone bends to one side and buckles on the otheriv. cortex stays intact on the side subject to tension forces and

fractures on the opposing sidev. requires reduction or completion of the fracture line through the

cortexe. impacted fractures (telescoped)

i. direct force breaks bone and telescopes the fragment with the

smaller diameter into the fragment with the larger diameterii. fracture fragments move in unisoniii. rapid union occurs

f. stress fracturei. incomplete fractureii. result of repetitive trauma to regioniii. two types:

fatigue - from repeated trauma insufficiency - pathological fracture

7. Classification by location in the bonea. apophysealb. articular

c. condylard. corticale. diaphysealf. epiphysealg. extracapsularh. intraarticulari. intracapsular

j. metaphysealk. periarticularl. subperiostealm. supracondylar

2. Fractures: pathophysiology

6. Predisposing factorsa. biologici. bone densityii. client's age

7. Extrinsic factorsa. force - direct or indirectb. rate of loading (how fast the force strikes)

8. Intrinsic factors - bone capabilities9. Pathological fractures
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a. bone is weakened by diseaseb. fractures occur in response to minimal or no applied stressc. classification by cause: general or local disorder

i. general: developmental, nutritional, hormonally controlledii. local: neoplasm, infection, cystic lesion

10. Behavioral factors - high-risk activities (such as football, ballet)3. Fractures: management

6. Closed reductiona. purposes: realign bone fragments for healing, minimal deformity,

minimal pain.b. pre- and post-reduction x-rays are essential to determine successful

reduction of fracture7. Immobilization

a. purposesi. relieve painii. keep bone fragments from moving

b. methods: cast - synthetic or plaster, traction - skin or skeletal, splints,braces, and external fixation

c. types of tractioni. manual: applied by pulling on the extremity - may be used during

cast applicationii. skin: applied by pulling force through the client's skin - used to

relax the muscle spasmiii. skeletal: applied directly through pins inserted into the client's

bone - used to align fractured. open treatment (see orthopedic surgery that follows)

8. Stages of bone healing

External Fixator: Ilizarov DeviceA. The Ilizarov device is a specialized type of external fixator used for non-union fractures and limb

lengthening needed due to congenital deformities.B. Tension wires are inserted into the bone and then attached to rings outside the body. These rings are

joined by telescoping rods attached to a rigid frame. Daily adjustment of the rods causes the wires toturn, which stimulates bone formation.

C. Ilizarov device lengthens limbs about one cm per month.D. Before discharge, teach clients

1. To care for pin2. To adjust rod

E. Clients may have the device on for several months.

STAGES OF BONE HEALINGI. Hematoma formation

A. One to three daysB. Blood clot forms around the fracture site

C. Bone necrosis occurs distal to the fracture site due to a loss of bloodII. Granulation tissue formationA. Begins three days to two weeks after fractureB. Osteoclast formation in fibrous matrix of collagenC. Fibroblasts

1. From outer layer of the periosteum2. From damaged connective tissue

D. Osteoblasts1. From the periosteum and marrow cavity2. Develop collagen

E. Vascular and mechanical factors affect healing1. Motion2. Distraction of fracture fragments

III. Callus formationA. Two to six weeksB. Granulation material is matured into a callusC. Size and shape of callus in direct response to the amount of displacement of fracture fragmentsD. Phagocytosis breaks down and removes the formed hematomaE. Delay at this stage delayed union or nonunion of bone

IV. OssificationA. Three weeks to six monthsB. The gap in the bone is bridged and union occurs

V. Consolidation /remodelingA. Six weeks to one yearB. Callus becomes calcified and blends into the boneC. Fracture line ma still be evidence on radio ra hs
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a. hematoma formationb. fibrocartilage/granulation tissue formationc. callus formationd. ossificatione. consolidation/remodeling

9. Evidence of healed fracturea. radiographic

DIAGNOSTIC IMAGING

1. Radiographsa. two dimensional representation of the bone and soft tissueb. include joints above and below suspected fracturec. clinical evidence of fracture overrides negative x-ray analysisd. will also offer evidence of

i. bone pathologyii. bone density (in advanced cases of osteoporosis)

2. Computerized tomogram (CT) scan - specialized tomograms

3. Magnetic resonance imaging (MRI) scan - clearer views of soft tissue structures

4. Bone scan - increased uptake of contrast may indicatea. fractureb. infectionc. tumor growth
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i. presence of external callus or cortical bone across the fracturesite

ii. fracture line may remain long after healingb. clinical

i. pieces of bone no longer move at fracture siteii. no tenderness over fracture site

c. weight bearing is pain free

G. Fractures: complications

ORTHOPEDIC COMPLICATIONS

A. Venous thromboembolic problems1. Thrombophlebitis (TP)

a. inflammation of a vein with the formation of a blood clotb. incidence is greatest after trauma or surgery to legs or feet

B. Deep venous thrombosis (DVT)1. Anterior tibial or femoral veins2. May be caused by immobility3. Findings include calf pain, positive Homan's sign4. Immediately after operations

a. anticoagulant therapyb. antiemboli stockings (usually)c. sequential compression device (possibly)

C. Pulmonary embolism (PE)1. Blood clot from systemic circulation enters pulmonary circulation2. Most commonly seen after hip fractures and total hip/knee replacements3. Occurs in approximately ten percent of patients undergoing hip arthroplasty4. May be caused by femoral vein manipulation during surgery and therefore occur without

signs of DVT5. Findings include chest pain (pleuritic), sudden shortness of breath, tachycardia,

palpitations, or change in mental status6. If PE is suspected,do not leave client. Get charge nurse to notify health care provider

immediately

7. Diagnosis confirmed via ventilation/perfusion scan or pulmonary angiography8. Continuous IV heparin therapy usually prescribedD. Fat embolism

1. Definition: fat cells enter pulmonary circulation2. Associated with

a. multiple trauma accidentsb. multiple organ involvementc. fractures of marrow producing bonesd. joint replacementse. insertion of intermedullary rods

3. Usually occurs 24 to 48 hours after the fractureE. Hemorrhage

1. Abnormal loss of blood from the body2. Most common in fractures of bone marrow producing bones

F. Wound infection1. May be superficial or deep wound2. Deep wound infection may lead to osteomyelitis3. Findings include erythema and swelling around suture line, increased drainage and

elevated temperature4. Treated with antibiotics; may require incision and drainage of wound or removal of

prosthesis if severe infection is presentG. Special complications in hip replacement

1. Femoral fracturea. occurs near distal end of femoral-shaft part of prosthesisb. occurs more frequently with elderly, clients with osteoporosis, or after revision to

total hip replacementc. primary finding is severe pain with ambulation

d. diagnosis is confirmed with x-raye. depending on severity, treatment will be immobilization or open reduction with

internal fixation2. Dislocation of hip prosthesis

a. greatest risk during the first postoperative week but can occur at any time within thefirst year.

b. risk decreases as muscle tone of the hip increasesc. caused by flexion of the hip or poor prosthetic fitd. findings include pain and external rotation of the lege. treated by closed reduction under conscious sedation or open surgical revision

H. Special complication in knee replacement: flexion failure1. Client cannot flex knee 90 degrees two weeks postoperatively2. Treated with closed manipulation of the knee joint under general anesthesia
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1. Immediate complications of the injurya. shock - higher risk with pelvic and femurb. fat embolism - occurs after the initial 24 hours from the injuryc. compartment syndrome - a nursing emergencyd. deep venous thrombosis (DVT)e. pulmonary embolism - a complication of DVT

2. Delayed complicationsa. joint stiffnessb. post-traumatic arthritis (osteoarthritis, type II)c. reflex sympathetic dystrophy

i. painful dysfunction and disuse syndromeii. characterized by abnormal pain and swelling of the extremity

d. myositis ossificansi. formation of hypertrophic bone near bone and musclesii. forms in response to traumaiii. hypertrophic bone is removed when bone is mature

e. malunioni. fracture healing is not stopped but slowed

ii. prevention of malunion reduce and immobilize properly be sure client understands limits on activity and position

f. delayed unioni. fracture does not healii. more common with multiple fracture fragmentsiii. no evidence of fracture healing four to six months after the

fractureg. loss of adequate reductionh. refracture

2. Nursing interventions2. Risk for peripheral neurovascular deficit

a. check neurovascular status oftenb. elevate limb above level of heart (except with compartment

syndrome)

c. apply cold to minimize edema3. Pain

a. assess level of pain with a scale of one to tenb. manage pain

i. with drugsii. reposition clientiii. pad any bony prominences

c. teach relaxation techniques

COMPARTMENT SYNDROME

I. Definition - increased pressure in a limited space (muscle compartment) cramps thecirculation and function of the tissues within that space

II. Types: acute and chronic (or exertional)A. Acute:

1. Following trauma to the muscle

2. External forces: casting/bracing compresses limb3. Internal forces: compartment content increases; space does not4. Results in necrosis of the tissue

B. Chronic/exertional - when exercise of a limb raises intracompartmental pressure andproduces pain and neurologic deficits

III. PathophysiologyA. Ischemia-edema pathology cycleB. If cycle lasts more than six hours, neuromuscular damage irreversibleC. Duration of 24 to 48 hours: extremity may be paralyzedD. May develop rapidly or for up to six days after initial traumaE. A nursing emergencyF. Compression occurs of the vessels and nerves
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4. Client teachinga. how fractures healb. why the fracture is being immobilizedc. how to bear weight and how much (if permitted)d. how bones heale. how to use assistive devices to walk

5. Risk for infection

a. related toi. open fracturesii. surgical interventioniii. superficial/deep wounds

b. monitor for findings of infectionc. provide proper wound cared. administer antibiotic therapy as indicated

6. Risk for impaired skin integritya. causes

i. open fracturesii. soft tissue injuriesiii. pressure areas

b. additional factorsi. age - elderlyii. general condition of clientiii. preexisting skin conditions or diseases

c. interventionsi. mobilize the client as soon as possibleii. turn the client often at least every two hoursiii. position the client properly with alignment in mindiv. use orthopedic devices to limit skin impairment

7. Impaired gas exchangea. accompanies chest traumab. client risks fat embolism

c. client risks deep venous thrombosisd. interventions

i. mobilize as soon as possibleii. frequent and effective pulmonary toileting

3. Fractures: factors that affect healing


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III. Degenerative DisordersA. Definition

1. Slowly progressive disorders of articular cartilage and subchondral bone2. Do not affect the joints symmetrically (e.g., not necessarily both knees)3. Worsen progressively4. Eventually incapacitate, despite treatment

B. Osteoarthritis (OA)

1. Definition - degeneration of the articular cartilage and formation of new bone inthe subchondral margins of the joint

2. FindingsI. primarily involves weight-bearing jointsII. non-inflammatory disorder

III. localized: no systemic effectsIV. results in an abnormal distribution of stress on the joint

3. IncidenceI. most common form of arthritisII. may begin as early as the 20s and peaks in the 60s

III. by age 70, nearly 80% of afflicted people show findingsIV. over age 55, OA affects twice as many women as men

V. two types: primary and secondary

Types of Osteoarthritis (OA)

I. Primary (Idiopathic) OsteoarthritisA. No known causeB. Classifications

1. Localized OA in one or two joints2. Generalized OA in three or more joints.

C. Etiology1. More common in women (slightly)

2. More common in Caucasians3. Develops in middle age and progresses slowly4. More often affects certain joints

a. weight-bearing jointsb. cervical and lumbosacral jointsc. interphalangeal joints

5. Hands more affected in women after menopause6. Hips are more affected in men

II. Secondary (Traumatic) OsteoarthritisA. Underlying condition: a trauma to the articular cartilageB. Etiology

1. Genetic predisposition, shown by the presence of

a. Heberden's Nodesb. Bouchard's Nodes2. More common in men3. Often occurs in

a. wristsb. elbowsc. shoulders

C. Risk factors for traumatic osteoarthritis1. Obesity2. Family history of degenerative joint disease3. Excessive joint wear

a. physical activityb. injury

4. Joint abnormalitya. lax ligamentsb. congenital hip dysplasia

5. Lifestyle: certain occupations predispose to secondary OA.
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4. PathophysiologyI. stage one: microfracture of the articular surface

I. articular cartilage is worn awayII. condyles of bones rub together: joint swells and is painful

III. cartilage loses cushioning effect: joint friction developsIV. prostaglandins may accelerate degenerative changes

II. stage two: bone condensation

I. erosion of cartilageII. cartilage may be digested by an enzyme in the synovial fluid

III. stage three: bone remodelingI. matrix synthesis and cellular proliferation failII. eventually the full thickness of articular cartilage is lost

III. bone beneath cartilage hypertrophy and osteophytes form atjoint margins

IV. result: joint degenerates5. Findings

a. joint stiffness after periods of rest

b. pain in a movable joint, typically worse with action, relieved by restc. paresthesiad. joint enlargement: bones grow abnormally; spurs form and synovitis sets

in.i. Heberden's nodes

ii. Bouchard's nodes

OSTEOARTHRITIS OF HIP/KNEE: SPECIFIC PHYSICAL FINDINGS

1. Hipa. contracture in adduction and flexionb. decrease in internal and external rotationc. limb shorteningd. referred pain to the

i. kneeii. groiniii. thigh

2. Kneea. decreased range of motionb. flexion contracture

i. hipii. knee

c. varus deformity: bow legged appearanced. valgus deformity: knock-kneed appearancee. positive apprehension sign

i. push the patella laterally with the leg in full extensionii. client will stop the examiner from pushing the patella further

HEBERDEN'S NODES

A. Bony osteophytes at the DIP jointB. Common presentation of OA in the handC. Indicates a strong hereditary tendencyD. Seen more often in women than men (ten times)

BOUCHARD'S NODES

A. Accompany Heberden's nodesB. Found at the PIP jointC. Occur more often in women than menD. Increase in frequency with age
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e. joint deformitiesf. tenderness on palpation

i. may involve widely separated areas of the jointii. mild synovitis may be felt - positive bulge sign may be found

g. pain on passive movementh. limitation in active range of motion because

i. joint surfaces no longer fit

ii. muscles spasm and contractiii. joints are blocked by osteophyte, loose bodiesiv. crepitation, crunching when joints are movedv. eventual ankylosis

i. gaiti. abnormal antalgic gaitii. shortened stanceiii. widened base of supportiv. shortened step length

6. Diagnosticsa. to rule out autoimmune disorders

i. sedimentation rateii. rheumatoid factoriii. c-reactive protein

b. CBCi. analyze before NSAID therapyii. within normal limits

c. kidney and liveri. especially in older clients, analyze before starting NSAID therapyii. repeat every six months

d. purified protein derivative (PPD)i. analyze before starting steroidsii. clients testing positive for tuberculosis must receive INH at same

time as steroid.e. antinuclear antigen (ANA) titer

i. may be lower in the elderlyii. does not necessarily prove a connective-tissue disease

f. synovial fluid analysis distinguishes osteoarthritis from rheumatoidarthritis.

g. radiographsi. taken in standing, weight-bearing conditionii. shows the prime sign of OA: joint space narrowingiii. x-ray does not necessarily reflect severity of diseaseiv. joint loses space asymmetrically because cartilage narrows from

production of osteophytes or bone spurs

v. later stages may show bony ankylosis, spontaneous fusionh. bone scans

i. radionuclide imagingii. shows skeletal distribution of osteoarthritisiii. monitors complications of joint replacement surgery

i. MRI scans show the extent of joint destructionj. computerized tomograms (CT) scans show cortical and cancellous bone

density7. Management: conservative treatment

a. education should coveri. exercise patternsii. relaxation techniques

iii. nutritional assessmentiv. counseling about maintaining a normal weightb. nutritional management - weight reductionc. activity and rest management

i. preservation of joint motion through a balance of1. rest (protection)2. activity (rehabilitation)

ii. individualized activity rehabilitation programiii. physical or occupational therapist may be helpful
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iv. passive range of motion exercises

v. active stretchingd. protection from further injury by splinting or bracing

8. Medicationa. aspirin - most often recommended

i. advantages: relatively safe and inexpensiveii. disadvantage: GI problems may lead to ulcers and bleeding

b. nonsteroidal anti-inflammatory medications (NSAIDs)i. reduce pain and inflammationii. inhibit prostaglandin formationiii. may cause GI bleeding or gastric ulcers or cramping with

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d. remissive agents

i. goldii. penicillamine (cuprimine)iii. hydrochloroquinine (plaquenil)

9. Nonmedication assistancea. assistive devices

i. canesii. walkers

b. non-traditional techniquesi. guided imagery - the use of one's imagination to acheve

relaxation and controlii. therapeutic massageiii. biofeedbackiv. hypnosisv. relaxation techniques

10. Surgical managementa. arthrodesisb. arthroplastyc. osteotomyd. total joint replacement

11. Home care considerations in arthritisa. safety measures

i. no scatter rugs at homeii. well-fitted, supportive shoesiii. night light, handrails at stairs and bathtub or showeriv. assistive devices

1. canes2. walkers3. elevated toilet seats4. grab bars5. handrails in stairways

v. splints and orthotic devicesb. management of surgical pain by patient controlled analgesia pumps

REMISSION-INDUCING MEDICATIONS IN ARTHRITIS

A. Slow acting drugs - take several months to show resultsB. Hydroxychloroquine

1. Antimalaria drug

2. For use in severely destructive RA3. Side effects

a. GI irritationb. retinal changesc. depression of bone marrow

4. Nursing implicationsa. eye exam every four to six monthsb. monitor hepatic and renal function

C. Gold salts and penicillamine1. Antirheumatic2. Used only after NSAID therapy fails to achieve relief3. Suppresses inflammation

a. remission inducingb. slow cumulative effect

4. Penicilliamine is more toxic than gold salts5. Side effects

a. GI irritationb. alteration in taste sensationc. urticaria

6. Nursing implicationsa. continual evaluation of renal/hepatic functionb. appropriate skin carec. take medication on empty stomach
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c. referral to agency and support group

C. Charcot joints (also called neuropathic joint disease)

1. Definition - multicausal degeneration and deformation of joint, usually ankle.

2. Etiologya. diabetes mellitus leading to foot neuropathyb. syringomyelia results in Charcot's joint of the shoulderc. tertiary syphilisd. peripheral neuropathiese. spina bifida with myelomeningocelef. leprosy

g. multiple sclerosish. long term intra-articular steroid injections3. Findings

a. inspection: foot is everted, widened, and shorter than normalb. examination

i. joint instabilityii. soft tissue swellingiii. pain secondary to inflammation

4. Diagnosticsa. laboratory analysis of synovial fluid

i. fluid is non-inflammatoryii. low protein contentiii. no hemorrhage noted

b. radiographsi. chronic destructive arthritis of the footii. severe destruction of the articular cartilage, subchondral

sclerosisiii. fragments of bone and cartilage in joint

5. Managementa. conservative treatment

i. protection from overuse/abuseii. braces and splints

b. surgical management: arthrodesisi. treatment of choice for unstable jointsii. fusion of the involved joint

6. Nursing interventionsa. expected outcome: preserve the jointb. education can prevent further injuryc. protection of the joint

i. bracesii. orthopedic shoes

d. prolonged immobilizationi. eight to 12 weeks to decrease swellingii. leads to minimal joint deformity and a functional painless foot
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D. Chondromalacia patellae (also called patellofemoral arthralgia)1. Definition: progressive, degenerative softening of the bone; follows a knee

injury

2. EtiologyI. lateral subluxation of the patella (kneecap)II. direct or repetitive trauma to the patella produces chondral fracture

III. underdevelopment of the quadriceps muscles3. Findings

I. pain with flexed knee activities (poorly localized)II. mild swelling

III. occasional episodes of buckling of the affected kneeIV. minimal joint effusionV. evidence of 'squinting kneecaps'VI. atrophy of quadriceps

VII. inverted 'J' tracking of the patella in the final 30 degrees of extensionVIII. excessive quadriceps angleIX. positive apprehension signX. crepitation upon range of motion

4. DiagnosticsI. radiographs

I. anterior posterior (AP) and lateral views are not helpfulII. sunrise views with the knee in 30 degrees, 60 degrees and 90

degrees of flexionII. bone Scans

III. MRI ScansIV. arthroscopy

5. Conservative managementa. progressive resistive exercises

i. quadriceps setting - isometricii. hamstrings - isotonic

b. medication: NSAIDsc. nonmedication assistance: application of ice or moist heatd. activity restriction

6. Surgical managementa. indicated if findings remain after six months of conservative treatmentb. arthroscopy (see Orthopedic Surgery section that follows)c. arthrotomy

i. realignment of proximal and/or distal soft tissueii. tibial tubercle elevationiii. patellectomy

7. Nursing interventions (see previous Osteoarthritis section)
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IV. Inflammatory DisordersA. Rheumatoid arthritis (RA)

1. Definition - chronic systemic inflammatory disease of the connective tissue2. Findings

I. starts in feet and hands, gradually destroys these peripheral jointsII. affects diarthroidial joints

III. bilateral involvement

3. EtiologyI. cause is not fully understoodII. rheumatoid arthritis is an autoimmune disorder

III. genetic tendency; but may involve bacteria, or virusesIV. may affect the connective tissue of the lungs, heart, kidneys, or skin

4. IncidenceI. two to three times more common in women than in menII. strikes between the ages of 20 and 50 years of age

5. Pathophysiology

I. synovitis immune complexes initiate inflammatory responseI. IgB antibodies are formedII. rheumatoid factor (RF)

I. pannus formationII. destruction of subchondral bone

III. present in 85 to 90% of all casesIV. worsens the inflammatory response - can go on

indefinitelyV. irreversible - will lead to ankylosis of joint

6. Findingsa. in early RA joints will be

i. painful, stiffii. warm, red, swollen at capsules and soft tissuesiii. incapable of full range of motion

b. in late RA, joints will showi. bony ankylosisii. destruction of joint - reactive hyperplasiaiii. adhesions

iv. inflammation and effusion that will be symmetrical polyarticular

c. general signsi. fatigueii. loss of appetite and weightiii. enlarged lymph glands

DISEASE PROCESS IN RA: RHEUMATOID FACTOR (RF)

A. RF factor in serum reacts against immunoglobulin GB. Inflamed synovial membraneC. Pannus

1. Vascularized fibrous scar tissue (pannus)2. Erodes surface of articular cartilage

D. Manifestations - early1. Prominent joint margins erode2. Synovial membrane thickens

E. Manifestations - late1. Fibrous adhesions2. Bony ankylosis3. Joint destruction4. Fusion of opposing joint surfaces5. Shortens tendon sheaths6. Joint contractures
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d. rheumatic nodules

i. in 20% of casesii. firm, oval, nontender masses under the skiniii. presence indicates poor prognosis

e. physical assessment should also includei. accurate patient history - history may include

malaise fatigue weakness loss of appetite and weight enlarged lymph glands Raynaud's syndrome

ii. examination may reveal deformities

ulnar deviation deformed hands: swan neck/boutonniere

f. neurological examinationi. foot dropii. evidence of spinal cord compression

7. Diagnosticsa. laboratory analysis

i. elevated ESR
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ii. decreased RBCiii. positive C-reactive proteiniv. positive antinuclear antibody in 20% of casesv. positive rheumatoid factor (RF)

b. radiographic studiesi. bony erosionii. decreased joint spaces

iii. fusion of jointc. aspiration of synovial fluid; analysis shows

i. cloudy appearanceii. more white blood cells than normal

8. Managementa. NSAIDS (see Osteoarthritis)b. hydroxychloroquine sulfate (Plaquenil)c. immunosuppressive agents

i. azanthioprine (Imuran)ii. cyclophosphamide (Cytoxan, Procytox)iii. methotrexate (Rheumatrex) (most commonly used)

d. prednisone

e. sulfasalazine (Azulfidine)f. leflunomide (Arava)g. biological response modifiers (BRMs)

i. etanercept (Enbrel)ii. infliximab (Remicade)iii. adalimumab (Humira)iv. anakinra (Kineret)

h. psychological supporti. splinting: resting, correction or fixation

B. Systemic lupus erythematosus (SLE)1. Definition: chronic, systemic, inflammatory disease of the collagen tissues

2. Etiology unknownI. most cases are womenII. African Americans, Hispanics, Asians, and Native Americans are two to

three times as likely as whites to have lupusIII. antigen stimulates antibodies, which form soluble immune complexes,

deposited in tissues; number of T suppressor cells dwindles.

IV. immune complex inflames tissue; inflammation creates findingsI. the intensity and location of the inflammation reflects findings

and organs involved.II. clients with central nervous system or renal involvement have

poorer prognosis


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3. Findings: SLE is present if client has four or more of these:a. arthritis: characterized by swelling, tenderness and effusion; involving

two or more peripheral jointsb. malar rash: characteristic butterfly rash over cheeks and nosec. discoid lupus skin lesionsd. photosensitivitye. oral ulcers

f. serositis: pleuritisg. renal disorder: persistent proteinuriah. neurologic disorder: seizures or psychosis in the absence of drugs or

pathologyi. hematologic disorder: hemolytic anemia with reticulocytosis or

leukopeniaj. immunologic disorder: positive LE (lupus erythematosus) cell

preparation or anti-DNA or anti-Sm or false positive serologic test forsyphilis

k. antinuclear antibody: abnormal titer of antinuclear antibody byimmunofluorescence or equivalent assay

l. positive LE cell reaction

4. Managementa. expected outcomes

1. control system involvement and symptoms2. induce remission

b. prevent bad effects of therapyc. recognize flare-ups promptlyd. medical

1. salicylates2. nonsteroidal anti-inflammatory agents (NSAIDS)3. corticosteroids4. anti-infectives

e. antineoplastics

5. Nursing carea. pain management strategiesb. strategies to combat weight lossc. emotional support

C. Gout

a. Definitiona. monoarticular asymmetrical arthritisb. characterized by hyperuricemia

b. Etiologya. primarily affects menb. peak incidence 40 to 60 years of agec. familial tendency
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d. abnormal purine metabolism or excessive purine intake results information of uric acid crystals which are deposited in the joints andconnective tissue.

e. deposits are most often found in the metatarsophalangeal joint of thegreat toe or in the ankle.

c. Findingsa. tight, reddened skin over the inflamed joint

b. elevated temperaturec. edema of the involved aread. hyperuricemiae. acute attacks commonly begin at night and last three to five daysf. gout attacks may follow trauma, diuretics, increased alcohol

consumption, a high purine diet, stress (both psychological andphysical) or suddenly stopping of maintenance medications

g. warning signs of flare-up include the exacerbation of previous findingsor the development of a new one

h. systemic manifestations may include fever, renal disease, tophusd. Diagnostics: lab test findings

a. increased urinary uric acid following a purine restricted diet

b. hyperuricemiae. Management

a. expected outcomes: control symptoms; prevent attacksb. medical

1. NSAIDs2. colchicine (used when NSAIDs are contraindicated) - enhances

the excretion of uric acid3. to prevent flareups: antihyperuricemic agents such as allopurinol

(lopurin) or probenecid (benemid) - minimize the production ofuric acid

4. heat or cold therapyc. dietary

1. avoid purine foods such as meats, organ meats, shellfish,sardines, anchovies, yeast, legumes

2. control weight3. drink less alcohol - all types

f. Nursing carea. pain management strategiesb. elevate the affected limb; provide bed rest and immobilize jointc. avoid pressure or touching of bed clothing on affected jointd. reinforce dietary management and weight controle. administer anti-gout medications as orderedf. increase fluid intake to prevent renal calculi (kidney stones)

V. Metabolic Bone DisordersA. Osteomalacia

1. Definition - delayed mineralization; resulting bone is softer and weaker2. Pathophysiology - similar to rickets

I. bones have too little calcium and phosphorusII. vitamin D deficiency; possibly inadequate exposure to sunlight

I. less serum calcium than normalII. more parathyroid hormone

III. more renal phosphorus clearance3. Findings

I. accurate client history includes:I. generalized muscle and skeletal pain in hips

II. similar pain in low backII. physical examinationI. gait

I. client unwilling to walkII. wide stance

III. waddling gaitII. muscle weakness

III. bonesI. deformities of weight-bearing bones


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II. scoliotic or kyphotic deformities of the spineIII. bones break easily

4. Diagnostic testingI. radiographic findings

I. generalized demineralizationII. pseudo fractures

III. bending deformities

II. laboratory studiesI. decreased serum calciumII. decreased serum phosphorus

III. alkaline phosphatase level is moderately elevated5. Management

I. calcium gluconateII. vitamin D daily until signs of healing take place

III. diet high in proteinIV. ultraviolet radiation therapy

B. Osteoporosis

1. DefinitionI. multifactorial disease results in

I. reduced bone massII. loss of bone strength

III. increased likelihood of fractureII. types

I. type one osteoporosis (estrogen related)

TYPE I OSTEOPOROSIS

A. Loss of trabecular bone after menopauseB. Theoretically related to a lack of estrogen

1. Bilateral oophorectomy2. Amenorrhea in younger women

C. Results in1. Loss of height2. Kyphosis3. Increased risk of fracture
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II. type two osteoporosis (related to old age)

a. Etiology/epidemiologya. most common metabolic disease of bone

1. affects an estimated 25 million Americans2. contributor of 50% of all adult fractures

b. onset is insidiousc. women affected twice as often as men before the age of 70

d. skeletal changes result from the aging processe. bone loss due to1. immobilization2. lack of gravitational stress

b. Factors related to osteoporotic fractures

TYPE II OSTEOPOROSIS

A. Age-related loss of cortical/trabecular bone in men and women occurring after age 70B. Long-term remodelingC. Results in fractures of humerus and femoral neck

ADDITIONAL RISK FACTORS FOR OSTEOPOROSIS

A. Genetic risk factors1. Female, white or Asian2. Small frame, thin-boned; short; low body fat

3. Women with post-menopausal osteoporosis may have inherited a lower peak bonemass

4. Daughters of women with osteoporosis averaged less bone mass in lumbar spineand femoral neck

5. Family history of hip fractureB. Reproductive factors

1. Hypo-estrogenism associated with increased bone remodeling, faster bone loss2. Early or surgically induced menopause3. Amenorrhea in athletes/anorexia nervosa

a. hypogonadismb. weakens the bonesc. decreases bone mass

4. Dysmenorrhea5. Nulliparity (no pregnancies)

C. Endocrine factors in osteoporosisa. premature menopauseb. hyperthyroidism increases bone turnover and remodelingc. hyperparathyroidismd. increases bone turnover and remodelinge. increased parathyroid hormone (PTH)

stimulates osteoclast activity depresses osteoblast activity result is an increase in serum concentration of calcium

f. hyperadrenocorticalism

g. type I diabetes mellitus
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a. low bone densityb. history of scoliosisc. neurological impairment after

1. CVA2. Parkinson's disease3. decreased vision from macular degeneration, complications of

diabetes, etc.d. best indicator of fracture risk in bone densitometry

4. Findingsa. client history

i. acute fractureii. prior history of a traumatic fracture; no traumaiii. history of falls

b. pain

i. greater when active, less while restingii. early in disease, pain in mid to low thoracic spine

c. anxietyi. about further falls/fracturesii. about ability to perform ADLs

d. kyphosis - 'Dowager's hump' may reflect multiple spinal fracturese. loss of height

i. two or more inchesii. usually precedes diagnosis of osteoporosis diagnosis

5. Diagnosticsa. blood tests

i. complete blood countsii. serum levels

1. calcium

2. phosphate3. alkaline phosphataseb. x-rays

i. help identify fractures and kyphosis of spineii. less useful in the detection of pre-fracture osteoporosisiii. detect osteoporosis only after 20% bone mineral content is lost

c. bone densitometryi. best means of measuring risk for fractureii. quantitative computerized axial tomogram (CAT) measures pure

vertebral trabecular boneiii. dual energy x-ray absorptionometry (DEXA)

1. technique of choice

2. assesses cortical and trabecular bone in spine and hip3. single photon absorptionometry measures cortical bonein long bones

6. Managementa. exercise

i. restorative - aims to increase bone density, decrease risk forfracture

ii. within the client's toleranceiii. must be maintained throughout life

b. nutrition

RECALL METHOD FOR HEIGHT DETERMINATION IN OSTEOPOROSIS

A. Client is asked to recall maximum adult height

B. Subtract current height from recall heightC. A two-inch loss of height predicts osteoporosis
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i. calcium and vitamin Dii. deficiencies increase risk of fractureiii. sedentary older adults may need supplements

c. medicationi. anti-resorptive agents

1. do not increase bone mass - rather prevent further boneloss

2. estrogen therapy3. calcitonin (Osteocalcin)

1. peptide hormone2. powerful inhibitor of osteoclastic bone resorption3. modestly increases bone mass in osteoporosis

4. not shown to decrease osteoporotic fractures5. expensive

ii. biophosphonates1. inhibit bone resorption2. sustained use associated with osteomalacia and Paget's

disease3. alendronate (Fosamax)

1. 100 to 500 times more potent than etidronate2. non-hormonal agent3. highly selective inhibitor4. not associated with detrimental effects of

mineralization5. expensive: average $41.70 per day for

osteoporosisiii. bone-forming agents

1. sodium fluoride (Fluoritab)2. androgens

1. taken long-term, increases bone mass inosteoporotic women

2. but androgens virilize and elevate cholesterollevels

7. Nursing intervention: teach prevention of osteoporosis and its damagea. education

i. increase awarenessii. discourage risk-related behaviorsiii. reinforce positive behaviors and lifestyles

b. reduce risk of fallingi. teach proper lifting and movement techniques


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ii. encourage proper footweariii. install safety equipment in home

C. Paget's disease (osteitis deformans)1. Definition: a slowly progressing resorption and irregular remodeling of bone.

2. Etiologya. bone resorbed; new bone poorly developed, weak, easily fracturedb. mainly affects major bones: skull, femur, tibia, pelvis, and vertebrae

c. cause unknownd. possible viral implicationse. family tendency - noted in siblings

3. Findingsa. asymptomatic initially

b. musculoskeletali. deformity of long bonesii. pain and point tenderness of affected limbs

4. Diagnosticsa. radiographic findings

i. bowing of long bonesii. thickened areas of boneiii. pathological fracturesiv. sclerotic changes

b. laboratory analysisi. increased alkaline phosphatase means osteoblasts more activeii. increased urinary hydroxyproline means osteoblasts more active

iii. serum calcium level will be normal5. Management

a. only treat if symptomaticb. conservative intervention

i. medication1. NSAIDs2. calcitonin (osteocalcin)

PAGET'S DISEASE EFFECTS -SYSTEMIC SEQUELAE OF MALFORMATION OF BONE

A. Skull1. Cranial nerve damage2. Hearing loss3. Obstructive hydrocephalus

B. Vertebraea. Rigid forward bend of spineb. Compression of thoracic vertebraec. Kyphosisd. Impaired respiratory ventilationCervical Spine: spinal cord compression: spastic quadriplegia
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1. slows bone resorption2. allows normal lamellar bone development

3. disodium etidronate (EHDP)1. rapidly slows bone resorption2. lowers levels of alkaline phosphatase and urinary

hydroxyproline3. may relieve pain

4. plicamycin (mithracin)1. antibiotic2. used only when Paget's disease bone is

damaging nervesc. surgery

i. reduce pathological fracturesii. correct secondary deformityiii. relieve neurologic impairmentiv. complications common

1. nonunion2. malunion

VI. Orthopedic SurgeryA. Total hip replacement

1. Indications for surgery

i. osteoarthritisii. rheumatoid arthritisiii. femoral neck fracturesiv. avascular necrosis of femoral head caused by steroidsv. failure of previous prosthesis

2. Surgical modalities

SURGICAL MODALITIES FOR HIP REPLACEMENT

A. There are a variety of hip prostheses. The choice is usually made by the health careprovider.

B. Prostheses have two components: acetabular socket and femoral shaft1. Acetabular socket is screwed into pelvis2. Femoral shaft may be cemented into femur or may have a special coating which

promotes bone growth around prosthesisa. The femoral shaft of a prosthesis used for revision is much longer than that

used for the original surgery
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a. total hip replacement (hip arthroplasty) is the replacement of botharticular surfaces of the hip joint, the acetabular socket and the femoralhead and neck.

b. hemiarthroplasty of the hip is the replacement of one of the articularsurfaces, usually the femoral head and neck.

3. Surgical and immediate postoperative carea. in first 24 hours, expect wound to drain blood and fluid up to 500ml.

b. by 48 hours, wound drainage should be minimalc. clients may require transfusions (autologous is preferred) due to blood

loss during surgery.d. best pain management is patient controlled analgesia (PCA) for the first

48 hours, advancing to non-narcotic oral analgesics by the fourth or fifthpostoperative day.

e. monitor for signs of deep venous thrombosis (DVT) and pulmonaryembolism (PE) or fat embolism

f. monitor neurovascular status of affected limb; color, temperature,presence of pulses.

4. Postoperative complications5. Nursing interventions

a. an abduction device is used during the first postoperative week whilethe client is in bed or sitting in a chair

b. to keep abduction device in place, turn client by logrollingc. to prevent flexion of the hip, use fracture bedpand. client teaching

i. use of assistive devices; crutches, walker, raised toilet seatii. methods to prevent dislocationiii. can resume sexual activity when suture line heals. To avoid

flexion of hip, client should be in dependent position for three tosix months

2. Total knee replacement3. Indications for surgery

a. osteoarthritisb. rheumatoid arthritisc. trauma

4. Surgical modalitiesa. metal or acrylic prosthesis, hinged or semiconstrainedb. choice of prosthesis depends on the strength of surrounding ligaments

to provide joint stability5. Postoperative complications6. Nursing interventions (knee replacement)

a. for first 24 to 48 hrs, apply ice to the knee to minimize bleeding andedema

b. in first eight hours, expect wound drainage up to 200 ml.

c. by 48 hours, expect minimal wound drainaged. transfusions are rarely requirede. within 24 hours, start aggressive physical therapy to promote knee

flexionf. frequently health care provider prescribes a continuous passive motion

machine (CPM)g. health care provider prescribes the amount of flexion and extension,

measured in degrees, and increases that amount as client toleratesmore

h. when the CPM machine is not in use, a knee immobilizer is usedi. keep leg elevated when the client is out of bed

j. on first post-op day, client will begin to use crutches or walker

k. best pain management is patient controlled analgesic (PCA) for the first48 to 72 hours postoperatively. By fifth post-op day, nonnarcotic oralanalgesia.

l. monitor limb's neurovascular status, color, temperature, and pulsesm. monitor for signs of DVT or PE

3. Amputation3. Purpose: relieve findings; improve function; save or improve quality of life4. Lower extremity indications
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a. progressive peripheral vascular disease (often secondary to diabetesmellitus)

b. gangrenec. trauma such as crushing injuries, burns, or frostbited. congenital deformitiese. malignant tumor

5. Upper extremity indications

a. traumab. malignant tumorc. infectiond. congenital malformations

6. Levels of amputation

a. amputate to most distal point that will heal successfullyb. determined by circulation and functional status

7. Potential postoperative complicationsa. hemorrhageb. infectionc. skin breakdown

8. Nursing interventionsa. pain management - usually relieved with narcotic analgesicsb. may require evacuation of accumulated fluid or hematomac. muscle spasms may be relieved by heat or changing position

d. phantom limb paini. may occur any time up to three months post amputationii. most common with above-knee (AK) amputationsiii. relieved with

1. stump desensitization by kneading, or massage2. transcutaneous electrical nerve stimulation (TENS)3. distraction4. beta-adrenergic blocking agents for burning, dull pain5. anticonvulsants for sharp and cramping pain

9. Wound healinga. aseptic dressing change techniqueb. compression dressing wrapped in a figure eight fashion or cast to

control edema10. Altered body image

a. may take months to resolveb. must convey acceptance and respect for individualc. foster independence: encourage client to look at, feel, and eventually

care for limb11. Grief

a. many clients go through a mourning process, shock, anger, anddepression

b. caregivers should support and listen actively12. Restoring physical mobility

a. early rehabilitation

b. muscle strengthening exercisesc. prosthetic preparation

LEVELS OF AMPUTATIONObjective of surgery is to eradicate the disease process while conserving as much of the extremity as possible

1. Toes and portion of the foot - usually as a result of trauma or infection. Causes minor changes in gait or balance2. Syme: disarticulation of ankle; stump can bear full weight, with prosthesis3. Below knee (BK) - preserves knee joint which facilitates use of prosthesis4. Knee disarticulation - at level of knee joint

5. Above knee (AK) - measures undertaken to provide as much length to limb as possible6. Hip disarticulation - most often performed due to malignancy. Client cannot walk with prosthesis.7. Below elbow (BE) - preserves elbow joint, thus eases use of prosthesis8. Above elbow (AE) - measures undertaken to provide as much length to limb as possible

9. Staged amputation - used for infection. Guillotine amputation to remove infectious and necrotic tissue is performed.After intensive antibiotic therapy, a second operation is performed for skin closure.

PREPARING FOR A PROSTHESIS

A. The residual limb must be shrunk and shaped into a conical form to secure a proper fit withinthe prosthesis, through

1. Proper bandaging of the stump in a figure eight manner2. An elastic residual limb shrinker

3. An air splintB. Problems that delay prosthetic use are
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13. Types of prosthesisa. hydraulicb. pneumaticc. biofeedback - controlledd. myoelectrically controllede. synchronized

D. Arthroscopy1. Definition - endoscopic procedure that allows direct visualization of the joint,

most often performed on knees and shoulders2. Indications

a. torn medial and lateral meniscusb. chondromalacia patellaec. synovitisd. torn cruciate ligamente. subluxation patellaf. in

orthopedic problem and management

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