Musculoskeletal

Musculo-skeletal SystemMusculo-skeletal System

Bone growthBone growth

Types of BonesTypes of Bones

1.1. Long bonesLong bones – femur – femur2.2. Short bonesShort bones – somewhat cubed- – somewhat cubed-

shaped as in the phalanges shaped as in the phalanges3.3. Flat bonesFlat bones – broad surface for – broad surface for

muscular attachment or protection muscular attachment or protection of organs; skull, ribs, shoulder of organs; skull, ribs, shoulder blades, & sternum.blades, & sternum.

4.4. Irregular bonesIrregular bones – wrist, vertebrae – wrist, vertebrae

Functions of BonesFunctions of Bones

Support & protect body tissues and organsSupport & protect body tissues and organs Provides the skeletal framework of the Provides the skeletal framework of the

bodybody Provides movement through the Provides movement through the

attachment of muscles attachment of muscles Storehouse for minerals: CAStorehouse for minerals: CA++ ++ 99% 99%

makeup of bones & POmakeup of bones & PO44 90% 90% Production of blood cells which takes place Production of blood cells which takes place

in the bone marrowin the bone marrow

Diarthrodial/Synovial Diarthrodial/Synovial JointsJoints

Ball & socketBall & socket i.e. shoulder & hip i.e. shoulder & hip which permits movement in any which permits movement in any directiondirection

HingeHinge i.e. elbow movement along one i.e. elbow movement along one plane & allows flexion & extensionplane & allows flexion & extension

CondylarCondylar – functions like a hinge joint – functions like a hinge joint but can rotate slightlybut can rotate slightly

Synovial Joint Synovial Joint CapsuleCapsule

Fibrous connective tissue Fibrous connective tissue covers the ends of covers the ends of bone.  Ligaments and bone.  Ligaments and tendons reinforce the tendons reinforce the joint capsulejoint capsule

Bundles of rich, white Bundles of rich, white fibrous tissue are supplied fibrous tissue are supplied with nerves. Nerves are with nerves. Nerves are sensitive to rate and sensitive to rate and direction of motion, direction of motion, compression, tension, compression, tension, vibration and painvibration and pain

Blood vessels, and Blood vessels, and lymphatic vessels. lymphatic vessels.

Skeletal MusclesSkeletal Muscles

Primary FunctionPrimary Function

Provides voluntary movementProvides voluntary movement Maintains postureMaintains posture Body Movement – contraction & Body Movement – contraction &

relaxationrelaxation

Skeletal MusclesSkeletal Muscles

Points of AttachmentPoints of Attachment

Point of origin – attachment of Point of origin – attachment of muscle to a more stationary bonemuscle to a more stationary bone

Point of insertions – attachment to Point of insertions – attachment to a more movable bonea more movable bone

Head to Toe Head to Toe AssessmentAssessment

Health HistoryHealth History

Musculoskeletal disordersMusculoskeletal disorders Nutritional statusNutritional status Pain HistoryPain History ADLs, endurance, assistive devicesADLs, endurance, assistive devices Medications – prescription and OTCMedications – prescription and OTC

Assessment SkillsAssessment Skills

Inspection – symmetry, body alignment, Inspection – symmetry, body alignment, function, skin changes, swelling, function, skin changes, swelling, deformity, contractures, gait, non-verbal deformity, contractures, gait, non-verbal indication of painindication of pain

Palpation – Skin temperature, swelling, Palpation – Skin temperature, swelling, nodules, masses, crepitusnodules, masses, crepitus

Joint Structure & ROMJoint Structure & ROM Muscle mass & strength (atrophy, Muscle mass & strength (atrophy,

flaccidly, spasticity, paralysis)flaccidly, spasticity, paralysis)

Connective Tissue Connective Tissue DisordersDisorders

Rheumatoid ArthritisRheumatoid Arthritis

OsteoarthritisOsteoarthritis

Lupus ErythematousLupus Erythematous

GoutGout

Rheumatoid ArthritisRheumatoid Arthritis

Autoimmune connective tissue Autoimmune connective tissue disorder characterized by disorder characterized by inflammatory destructive changes inflammatory destructive changes in the jointsin the joints

Systemic disease – Inflammatory Systemic disease – Inflammatory changes can affect skin, heart, changes can affect skin, heart, lungs, eyes, blood vessels & nerveslungs, eyes, blood vessels & nerves

Etiology of Rheumatoid Etiology of Rheumatoid ArthritisArthritis

Autoimmune theory – Normal Autoimmune theory – Normal antibodies become autoantibodies antibodies become autoantibodies (RH Factors) and attack the tissue. (RH Factors) and attack the tissue.

Genetic Factor – 2-3 times > with Genetic Factor – 2-3 times > with family Hxfamily Hx

Virus – Epstein-Barr Virus – Epstein-Barr Stressful eventsStressful events

Stages of Joint Stages of Joint DeteriorationDeterioration

Stage 1Stage 1: Initiation - Some changes in the : Initiation - Some changes in the synovial lining – no loss of functional synovial lining – no loss of functional capacitycapacity

Stage 2Stage 2: Immune Response – Joint swells : Immune Response – Joint swells & thickens. Functional capacity impaired.& thickens. Functional capacity impaired.

Stage 3Stage 3: Inflammatory - Progressive : Inflammatory - Progressive involvement of blood vessels. Limited ADL.involvement of blood vessels. Limited ADL.

Stage 4Stage 4: Destructive – Granulation tissue : Destructive – Granulation tissue hardens (Pannus). Leads to ankylosis. hardens (Pannus). Leads to ankylosis. Confined to bed or wheel chair.Confined to bed or wheel chair.

Assessment DataAssessment Data

Subjective:Subjective: - Stiffness especially in a.m. or after- Stiffness especially in a.m. or after

inactivityinactivity

- Proximal joint pain in the fingers- Proximal joint pain in the fingers

- Fatigue, weakness, weight loss, - Fatigue, weakness, weight loss, low grade fever low grade fever

Assessment DataAssessment Data

Objective ManifestationsObjective Manifestations- Swollen, reddened, warm joints- Swollen, reddened, warm joints

- Weak hand grasp- Weak hand grasp- Deformities (late stages) - Deformities (late stages)

Swan Neck Swan Neck Ulnar DriftUlnar Drift Boutonnière (buttonhole)Boutonnière (buttonhole) Rheumatoid NodulesRheumatoid Nodules Vasculitis, Sjogren’s SyndromeVasculitis, Sjogren’s Syndrome

Diagnostic TestsDiagnostic Tests

Blood Tests:Blood Tests:- Rheumatoid Factor- Rheumatoid Factor

- Antinuclear Antibody Titer- Antinuclear Antibody Titer

- Erythrocyte Sedimentation Rate- Erythrocyte Sedimentation Rate

- CBC; WBC- CBC; WBC

Diagnostic TestsDiagnostic Tests

Radiographic: determines cartilage Radiographic: determines cartilage erosion, joint space narrowing, bone erosion, joint space narrowing, bone cystscysts

- Arthrography- x-ray with contrast - Arthrography- x-ray with contrast mediummedium

- Arthroscopy – endoscopic exam of joint- Arthroscopy – endoscopic exam of joint

- Arthrocentesis – needle aspiration of - Arthrocentesis – needle aspiration of

synovial fluidsynovial fluid

Nursing CareNursing CareArthroscopy Post-Arthroscopy Post-

procedureprocedure

Assess neurovascular status (sx of Assess neurovascular status (sx of thrombophlebitis)thrombophlebitis)

Monitor for bleeding or leakage at Monitor for bleeding or leakage at sitesite

Assess for pain, edema, rednessAssess for pain, edema, redness Ice for swelling, mild analgesic Ice for swelling, mild analgesic

painpain

Pain ManagementPain Management

Prescribed Drug Therapy on timely Prescribed Drug Therapy on timely basisbasis

Rest periodsRest periods Warm shower, hot packsWarm shower, hot packs Avoid sudden, jarring of jointAvoid sudden, jarring of joint Warn clients about “quacks” Warn clients about “quacks”

(miracle cures)(miracle cures)

Impaired Physical MobilityImpaired Physical Mobility

Exercise joint, but not beyond painExercise joint, but not beyond pain Positioning & body alignmentPositioning & body alignment Support joints for optimal function Support joints for optimal function Assistive Devices – proper fit & Assistive Devices – proper fit &

instructioninstruction

Self-care DeficitSelf-care Deficit

Routine that includes pacing Routine that includes pacing activitiesactivities

Encourage sleep routineEncourage sleep routine PT for conditioningPT for conditioning Occupational Therapy – Assistive Occupational Therapy – Assistive

devicesdevices

Drug TherapyDrug Therapy

Salicylates (ASA) Salicylates (ASA) – Side effects/PrecautionsSide effects/Precautions

Tinnitus, GI distress, prolonged bleeding. Give Tinnitus, GI distress, prolonged bleeding. Give with food, milk. Avoid anti-coagulants.with food, milk. Avoid anti-coagulants.

NSAID’s (Advil, Indocin, Toradol, NSAID’s (Advil, Indocin, Toradol, Naprosyn)Naprosyn)– Side effects/PrecautionsSide effects/Precautions

GI (do not crush enteric coated); give after meals GI (do not crush enteric coated); give after meals or with foodor with food

Dizziness, diarrhea, headache, rashDizziness, diarrhea, headache, rash

Drug TherapyDrug Therapy

Glucocorticoids (dexamethasone, Glucocorticoids (dexamethasone, hydrocortisone, prednisone)hydrocortisone, prednisone)– Side Effects/PrecautionsSide Effects/Precautions

– Depression, euphoria, anorexia, Depression, euphoria, anorexia, nausea, nausea,

weight gain, bruising. Taper dosage weight gain, bruising. Taper dosage when discontinuing.when discontinuing.

Drug TherapyDrug Therapy

Slow-acting Antimalarial drugs Slow-acting Antimalarial drugs (plaquenil)(plaquenil)– Side Effects/PrecautionsSide Effects/Precautions

Retinal edema, GI disturbanceRetinal edema, GI disturbance

Toxic – Gold Salts (solganol, Toxic – Gold Salts (solganol, myochrysine)myochrysine)– Side Effects/PrecautionsSide Effects/Precautions

Dizziness, flushing, metallic taste, skin rash; Dizziness, flushing, metallic taste, skin rash; assess CBC & UA prior to administrationassess CBC & UA prior to administration

Drug TherapyDrug Therapy

Cytoxic Drugs (Methotrexate, Cytoxic Drugs (Methotrexate, Imuran, Cytoxan)Imuran, Cytoxan)– Side Effects/PrecautionsSide Effects/Precautions

Pneumocystis Carinii pneumonia, mouth Pneumocystis Carinii pneumonia, mouth sores, bone marrow suppression, sores, bone marrow suppression, hepatotoxicity hepatotoxicity

Degenerative Joint DiseaseDegenerative Joint Disease(Osteoarthritis)(Osteoarthritis)

Non-inflammatory disease of the weight Non-inflammatory disease of the weight bearing joints (hips, knees, spine, bearing joints (hips, knees, spine, hands)hands)

Incidence: > in post-menopausal Incidence: > in post-menopausal womenwomen

Risk Factors: age, obesity, overuse of Risk Factors: age, obesity, overuse of joints, trauma (fractures, sports joints, trauma (fractures, sports injuries)injuries)

OsteoarthritisOsteoarthritis PathophysiologyPathophysiology – Articular cartilage – Articular cartilage

becomes yellow & opaque, joint space becomes yellow & opaque, joint space narrows, bone spurs (osteocytes), & cystsnarrows, bone spurs (osteocytes), & cysts

SymptomsSymptoms – Joint pain / diminishes on rest ; – Joint pain / diminishes on rest ; crepitus (grating sensation); joint crepitus (grating sensation); joint enlargement, Herberden’s nodes, enlargement, Herberden’s nodes, Bouchard’s nodules, decrease ROM, joint Bouchard’s nodules, decrease ROM, joint effusioneffusion

OsteoarthritisOsteoarthritis

Diagnostic Tests:Diagnostic Tests: X-rays of joints X-rays of joints indicates narrowing of joint spaces; indicates narrowing of joint spaces; CT Scan & MRI of spine; Bone ScanCT Scan & MRI of spine; Bone Scan

Differential features of RA & DJDDifferential features of RA & DJD

OsteoarthritisOsteoarthritis

Medical ManagementMedical Management Drug therapy for pain (NSAID’s), muscle Drug therapy for pain (NSAID’s), muscle

relaxants (Flexeril), injection of cortisonerelaxants (Flexeril), injection of cortisone Rest – immobilization with splint, brace, Rest – immobilization with splint, brace,

sleep (>8 hours/night)sleep (>8 hours/night) Position of joints to maintain alignment & Position of joints to maintain alignment &

avoid contracturesavoid contractures Heat – hot packs, PT diathermyHeat – hot packs, PT diathermy Exercise – walking, water aerobicsExercise – walking, water aerobics

OsteoarthritisOsteoarthritis

Surgical ManagementSurgical Management Hemiarthroplasty: one part of a joint Hemiarthroplasty: one part of a joint

is replaced, i.e. head of femuris replaced, i.e. head of femur Total Hip replacement: Head of Total Hip replacement: Head of

femur & the acetabulum replacedfemur & the acetabulum replaced Total Knee replacement: both Total Knee replacement: both

articular surfaces of the knee articular surfaces of the knee replacedreplaced

Interphalangeal joint replacementInterphalangeal joint replacement

Total Hip ReplacementTotal Hip Replacement

Preoperative Care – Skin preparation, IV Preoperative Care – Skin preparation, IV antibiotics, education re: nature of antibiotics, education re: nature of prosthesis, mobility restrictions, prosthesis, mobility restrictions, exercisesexercises

Types of ProsthesisTypes of Prosthesis

- Cemented – > 10 year life- Cemented – > 10 year life

- Uncemented – bone growth occurs into - Uncemented – bone growth occurs into the metallic surfaces within 6-12 weeksthe metallic surfaces within 6-12 weeks

THR - Postoperative THR - Postoperative

Pain controlPain control Wound & drain assessmentWound & drain assessment Neurovascular AssessmentNeurovascular Assessment Activity – bed rest with abduction Activity – bed rest with abduction

splint or pillow, OOB with PT (NO splint or pillow, OOB with PT (NO hip flexion > 90hip flexion > 90°°) weight bearing ) weight bearing dependent on type of prosthesisdependent on type of prosthesis

Use of walker – crutches - caneUse of walker – crutches - cane

THR - Potential THR - Potential ComplicationComplication

ThromboembolismThromboembolism

Subluxation - Hip Dislocation Subluxation - Hip Dislocation

Neurovascular CompromiseNeurovascular Compromise

HemorrhageHemorrhage

THR – Hip PrecautionsTHR – Hip Precautions

Avoid hip flexion > 90Avoid hip flexion > 90°° Avoid low, soft chairsAvoid low, soft chairs Avoid excessive trunk flexion in Avoid excessive trunk flexion in

reachingreaching Maintain hip adductionMaintain hip adduction No leg crossing at kneeNo leg crossing at knee Use raised toilet seat Use raised toilet seat

Total Knee ReplacementTotal Knee Replacement

Preoperative Care – similar to THRPreoperative Care – similar to THR Postoperative CarePostoperative Care

- Pain control - Pain control

- Wound & drain assessment- Wound & drain assessment

- Neurovascular Assessment- Neurovascular Assessment

- Elevate leg on pillow for comfort - Elevate leg on pillow for comfort

- Head of bed elevated for comfort - Head of bed elevated for comfort

- Continuous Passive Motion Machine- Continuous Passive Motion Machine

TKR - Potential TKR - Potential ComplicationsComplications

DVT & pulmonary emboliDVT & pulmonary emboli

Prosthetic DislocationProsthetic Dislocation

InfectionInfection

Lupus ErythematousLupus Erythematous

Definition: Autoimmune disease Definition: Autoimmune disease involving diffuse inflammatory changes involving diffuse inflammatory changes in vascular connective tissuein vascular connective tissue

Pathophysiology: Antigen-antibody Pathophysiology: Antigen-antibody interactions results in deposits of interactions results in deposits of immune complexes in tissues & cells immune complexes in tissues & cells that damage the organs and or blood that damage the organs and or blood vesselsvessels

Discoid LupusDiscoid Lupus

Cutaneous Cutaneous manifestations – manifestations – butterfly rash on facebutterfly rash on face

Risk Factor: Sun Risk Factor: Sun exposure intensifiesexposure intensifies

Treatment: Cortisone Treatment: Cortisone creams, sun screens creams, sun screens > 30 SPF, avoid sun > 30 SPF, avoid sun at peak hoursat peak hours

Systemic LupusSystemic Lupus

Organs affected: Heart, lungs, Organs affected: Heart, lungs, kidneykidney,, brain, blood vessels, & jointsbrain, blood vessels, & joints

Systemic symptoms: Fatigue, myalgia, Systemic symptoms: Fatigue, myalgia, joint pain, low grade fever, anorexiajoint pain, low grade fever, anorexia

System specific symptoms: System specific symptoms: Tachycardia, chest pain, proteinuria, Tachycardia, chest pain, proteinuria, hip & knee necrosis, psychosis, seizureship & knee necrosis, psychosis, seizures

Laboratory Tests of SLELaboratory Tests of SLE

Skin biopsy & scrapings of skin Skin biopsy & scrapings of skin cellscells

Immune tests – RF, ANA, Sed RateImmune tests – RF, ANA, Sed Rate

CBC (pancytopenia), Sed Rate, CBC (pancytopenia), Sed Rate, Cardiac & Liver EnzymesCardiac & Liver Enzymes

Pharmacological Pharmacological Management Management

LupusLupus

NSAID’SNSAID’S

CorticosteroidsCorticosteroids

Immunosuppresive AgentsImmunosuppresive Agents

Nursing Care - LupusNursing Care - Lupus

Pain ManagementPain Management Encourage rest periodsEncourage rest periods Decrease protein in diet (kidney Decrease protein in diet (kidney

involvement) and sodium involvement) and sodium restriction (fluid retention)restriction (fluid retention)

Referral – Local & National Lupus Referral – Local & National Lupus FoundationFoundation

Potential Complications Potential Complications Lupus ErythematousLupus Erythematous

VasculitisVasculitis Cardiopulmonary – pericarditis, Cardiopulmonary – pericarditis,

pleural effusionpleural effusion CNS – psychosis, seizures, CNS – psychosis, seizures,

peripheral neuropathiesperipheral neuropathies Avascular NecrosisAvascular Necrosis

Gout Gout

Definition: Systemic disease Definition: Systemic disease involving pain & involving pain & inflammation of joints due inflammation of joints due to urate crystal depositsto urate crystal deposits

Pathophysiology: Imbalance Pathophysiology: Imbalance of purine metabolism & of purine metabolism & kidney functionkidney function

Incidence: Middle aged men Incidence: Middle aged men

Types of GoutTypes of Gout

Primary: Inherited defect in purine Primary: Inherited defect in purine metabolismmetabolism

Secondary: Disease i.e renal, Secondary: Disease i.e renal, diuretic therapy & diuretic therapy & chemotherapeutic agentschemotherapeutic agents

Clinical Manifestations of Clinical Manifestations of GoutGout

Asymptomatic phaseAsymptomatic phase – – Elevated Uric Acid Elevated Uric Acid (.60-.75 gm)(.60-.75 gm)

Acute PhaseAcute Phase – Sustained – Sustained elevated Uric Acid elevated Uric Acid causing extremely causing extremely painful, swollen, and painful, swollen, and reddened jointreddened joint

Chronic PhaseChronic Phase – Urate – Urate crystal deposits appear crystal deposits appear in cartilage, synovial in cartilage, synovial membranes, tendons, & membranes, tendons, & soft tissues (tophi soft tissues (tophi formation)formation)

Drug Therapy - GoutDrug Therapy - Gout

Acute Phase – Colchicine, NSAID’S Acute Phase – Colchicine, NSAID’S

Chronic Phase – Allopurinol Chronic Phase – Allopurinol (Benemid);(Benemid);

ColbenemidColbenemid

Avoid aspirin & diureticsAvoid aspirin & diuretics

Diet Therapy - GoutDiet Therapy - Gout

Low purine (avoid organ meats, Low purine (avoid organ meats, shellfish, oily fish with bones)shellfish, oily fish with bones)

Avoid AlcoholAvoid Alcohol Increase fluid intake to 3,000 cc/dayIncrease fluid intake to 3,000 cc/day High alkaline ash foods – citrus fruits High alkaline ash foods – citrus fruits

and juices, certain dairy productsand juices, certain dairy products

Other Connective Tissue Other Connective Tissue DisordersDisorders

Polymyalgia Polymyalgia Rheumatica Rheumatica

Ankylosing Ankylosing Spongylitis (Marie-Spongylitis (Marie-StrStrüümpell Disease)mpell Disease)

SjSjöögren’s syndromegren’s syndrome Lyme’s DiseaseLyme’s Disease FibromyalgiaFibromyalgia

OsteoporosisOsteoporosis

TypesTypes Primary - Bone loss related to loss of Primary - Bone loss related to loss of

estrogen in menopausal women and estrogen in menopausal women and low testosterone levels in menlow testosterone levels in men

Secondary – Bone loss related to Secondary – Bone loss related to disease process (hyperthyroidism, disease process (hyperthyroidism, renal failure, GI malabsorption renal failure, GI malabsorption problems)problems)

PathophysiologyPathophysiology Bone Remodeling Bone Remodeling

Resorption – Worn out bone cells Resorption – Worn out bone cells are removed by bone-resorbing are removed by bone-resorbing cells called osteoclastscells called osteoclasts

Formation – New bone is laid down Formation – New bone is laid down by bone-forming cells called by bone-forming cells called osteoblastsosteoblasts

Incidence/Risk FactorsIncidence/Risk FactorsOsteoporosisOsteoporosis

AgeAge

RaceRace

GenderGender

Life StyleLife Style

Diet Diet

HeredityHeredity

Prevention of OsteoporosisPrevention of Osteoporosis

Exercise – weight bearing typesExercise – weight bearing types

Diet modifications Diet modifications

Calcium intake – OTC i.e. Tums, Calcium intake – OTC i.e. Tums, Oscal, Calcium carbonate, Dietary Oscal, Calcium carbonate, Dietary supplementsupplement

Clinical ManifestationsClinical ManifestationsOsteoporosisOsteoporosis

Height lossHeight loss

Vertebral deformitiesVertebral deformities

Restricted movementRestricted movement

Back painBack pain

Fractures Fractures

Diagnostic TestsDiagnostic TestsOsteoporosisOsteoporosis

Laboratory – serum calcium, Laboratory – serum calcium, Vitamin D, phosphorus, alkaline Vitamin D, phosphorus, alkaline phosphatasephosphatase

Radiological – X-ray, CT Scan, MRIRadiological – X-ray, CT Scan, MRI

- Dual energy x-ray absorptiometry- Dual energy x-ray absorptiometry

Medical ManagementMedical ManagementOsteoporosisOsteoporosis

Drug TherapyDrug Therapy

Estrogen replacement – PremarinEstrogen replacement – Premarin Calcium supplementsCalcium supplements Bone resorption inhibitor – Bone resorption inhibitor –

FosamaxFosamax Vitamin DVitamin D

Nursing ManagementNursing ManagementOsteoporosisOsteoporosis

High Risk for InjuryHigh Risk for Injury – Prevention of – Prevention of falls and fracturesfalls and fractures

- safe environment- safe environment

(non-skid slippers, shoes, clean spills, (non-skid slippers, shoes, clean spills, avoid scatter rugs, lighting, access to avoid scatter rugs, lighting, access to items for ADL, hand rails, avoiding items for ADL, hand rails, avoiding lifting heavy objects, use of walker, lifting heavy objects, use of walker, cane.)cane.)

Nursing ManagementNursing ManagementOsteoporosisOsteoporosis

Impaired Physical MobilityImpaired Physical Mobility

Increase mobility to level of Increase mobility to level of independence in ADLindependence in ADL

Interventions Interventions

1.1. Physical therapy program Physical therapy program (strengthening & weight bearing (strengthening & weight bearing exercises)exercises)

2.2. Occupational Therapy (Adaptive Occupational Therapy (Adaptive Devices)Devices)

Nursing ManagementNursing ManagementOsteoporosisOsteoporosis

Pain Management - reduce & Pain Management - reduce & alleviate painalleviate pain

InterventionsInterventions1.1. Drug Therapy - opioid, non-opioid Drug Therapy - opioid, non-opioid

analgesics, muscle relaxants, analgesics, muscle relaxants, anti-inflammatory agentsanti-inflammatory agents

2.2. Use of heatUse of heat3.3. Orthotic devices – braces, splintsOrthotic devices – braces, splints

Other Metabolic & Other Metabolic & Degenerative Bone Degenerative Bone

DisordersDisorders

OsteomalaciaOsteomalacia

Paget’s DiseasePaget’s Disease

Herniated Nucleus Pulposus Herniated Nucleus Pulposus

- Laminectomy- Laminectomy

- Spinal Fusions- Spinal Fusions

Fracture PatternsFracture Patterns

Oblique – Line of fx angledOblique – Line of fx angled Transverse – Across the boneTransverse – Across the bone Longitudinal – Length of boneLongitudinal – Length of bone Spiral – Twisting or rotation of boneSpiral – Twisting or rotation of bone Comminuted – broken in > 2 placesComminuted – broken in > 2 places Impacted – Fragments driven into each Impacted – Fragments driven into each

otherother Displaced or Avulsed – torn away by a Displaced or Avulsed – torn away by a

ligament or tendonligament or tendon

FracturesFractures

Classification by Classification by Anatomical LocationAnatomical Location

HumerusHumerus Tibia, FibulaTibia, Fibula PelvisPelvis HipHip SkullSkull MandibleMandible RibsRibs VertebraeVertebrae

FracturesFractures

Definition: Interruption in normal Definition: Interruption in normal bone continuity, which is bone continuity, which is accompanied by soft tissue injuryaccompanied by soft tissue injury

Classification:Classification:

- Simple or closed- Simple or closed

- Open or compound- Open or compound

Stages of Bone HealingStages of Bone Healing

1.1. HematomaHematoma

2.2. GranulationGranulation

3.3. Callus FormationCallus Formation

4.4. Osteoblastic ProliferationOsteoblastic Proliferation

5.5. Bone RemodelingBone Remodeling

6.6. Complete HealingComplete Healing

Bone Healing ProblemsBone Healing Problems

Delayed Union - > 6 months to a Delayed Union - > 6 months to a yearyear

Nonunion - < ½ of bone fragments Nonunion - < ½ of bone fragments joined togetherjoined together

Malunion – Bone healed in state of Malunion – Bone healed in state of deformitydeformity

Assessment of FracturesAssessment of Fractures

Subjective Data – History, Subjective Data – History, complaints of pain, loss of complaints of pain, loss of sensation, movementsensation, movement

Objective Data – Warmth, edema, Objective Data – Warmth, edema, ecchymosis, neurovascular ecchymosis, neurovascular impairment, splinting, anxiety, fearimpairment, splinting, anxiety, fear

Emergency Care Emergency Care

Inspect areaInspect area Control bleedingControl bleeding Immobilize/splintImmobilize/splint Prevent shockPrevent shock Transport safely to ERTransport safely to ER

INTERVENTIONSINTERVENTIONS RR - -

Rest/immobilizeRest/immobilize I I - Ice- Ice CC - Compression - Compression EE - Elevation - Elevation SS - Support - Support

Nursing DiagnosesNursing Diagnoses

Acute PainAcute Pain Risk for Neurovascular DysfunctionRisk for Neurovascular Dysfunction Risk for InfectionRisk for Infection Altered Mobility Altered Mobility Activity IntoleranceActivity Intolerance

Complications of FracturesComplications of Fractures

ShockShock Neurovascular CompromiseNeurovascular Compromise DVT & Pulmonary EmboliDVT & Pulmonary Emboli Aseptic NecrosisAseptic Necrosis Acute Compartment SyndromeAcute Compartment Syndrome Fat Embolism SyndromeFat Embolism Syndrome OsteomyelitisOsteomyelitis

ShockShock

Etiology: Hemorrhage into Etiology: Hemorrhage into damaged tissues, especially damaged tissues, especially thorax, pelvis, & extremitiesthorax, pelvis, & extremities

Treatment: Control bleeding and Treatment: Control bleeding and restore blood volumerestore blood volume

Neurovascular Neurovascular CompromiseCompromise

Etiology: Damage to nerves from Etiology: Damage to nerves from fragments of bone, pressure from fragments of bone, pressure from casts, splints, & tractioncasts, splints, & traction

Assessment: 6 P’s – Pain, Assessment: 6 P’s – Pain, Pulselessness, Paresthesia, Pallor, Pulselessness, Paresthesia, Pallor, Paralysis, Poikilothermia Paralysis, Poikilothermia

INSPECTION/PALPATION INSPECTION/PALPATION FIVE P’SFIVE P’S

PPAINAIN PPULSEULSE PPALLORALLOR PPARASTHESIARASTHESI

AA PPARALYSISARALYSIS

Fat Embolism SyndromeFat Embolism Syndrome

Etiology: Release of particles of fat Etiology: Release of particles of fat into the blood stream from the into the blood stream from the yellow marrow at site of injuryyellow marrow at site of injury

Risk Factors: Fx. of long bones, Risk Factors: Fx. of long bones, multiple fx., high serum glucose or multiple fx., high serum glucose or cholesterol levelcholesterol level

DVT & Pulmonary EmboliDVT & Pulmonary Emboli

Etiology: Immobility, Etiology: Immobility, trauma, surgerytrauma, surgery

Risk Factors: Incidence Risk Factors: Incidence in fractures of the lower in fractures of the lower extremities; smoking, extremities; smoking, obesity, heart diseaseobesity, heart disease

Treatment: Treatment: anticoagulantsanticoagulants

Avascular NecrosisAvascular Necrosis

Etiology: Loss of blood supply to boneEtiology: Loss of blood supply to bone

Risk Factors: Hip fractures or any Risk Factors: Hip fractures or any fracture where this bone displacementfracture where this bone displacement

Treatment: Surgical joint replacement Treatment: Surgical joint replacement

Compartment SyndromeCompartment Syndrome

Etiology: Massive compromise in Etiology: Massive compromise in circulation from external (tight, circulation from external (tight, bulky dressings, casts) & internal bulky dressings, casts) & internal (blood & fluid)(blood & fluid)

Treatment: Immediately loosen Treatment: Immediately loosen any tight dressings & MD can any tight dressings & MD can bivalve castbivalve cast

Surgery – Decompression Surgery – Decompression fasciotomy for edema and bleedingfasciotomy for edema and bleeding

Surgical ManagementSurgical Management

Fasciotomy to relieve pressure. The fascia is divided along the length of the compartment to release pressure within.

OsteomyelitisOsteomyelitis

Acute – infection in another part of Acute – infection in another part of the body invades bone tissue or the body invades bone tissue or occurs from penetrating traumaoccurs from penetrating trauma

Chronic – Infection persists Chronic – Infection persists especially in a patient with especially in a patient with compromised circulationcompromised circulation

Medical Management of Medical Management of FracturesFractures

Closed reduction & immobilization – Manual traction Closed reduction & immobilization – Manual traction to align the boneto align the bone

External Fixation – Percutaneous placement of pins External Fixation – Percutaneous placement of pins implanted into boneimplanted into bone

- Kronner 4-Barr Compression Frame- Kronner 4-Barr Compression Frame- Hex-Fix External device for tibial fractures- Hex-Fix External device for tibial fractures- Halo Traction – Cervical spinal fractures- Halo Traction – Cervical spinal fractures

Nursing Care – External Nursing Care – External FixationFixation

Teach patient patient to grasp frame Teach patient patient to grasp frame when moving, rather than limbwhen moving, rather than limb

Frequent observation & neurovascular Frequent observation & neurovascular assessmentsassessments

Pin Care – Note symptoms of infectionPin Care – Note symptoms of infection Assess for loosening or shifting of Assess for loosening or shifting of

devicesdevices

External FixatorExternal Fixator

External FixationExternal Fixation

External FixatorExternal Fixator

CastsCasts

Purpose: Immobilze, correct Purpose: Immobilze, correct deformity, allow early mobility, & deformity, allow early mobility, & provide support & protectionprovide support & protection

Types: Plaster of Paris & FiberglassTypes: Plaster of Paris & Fiberglass

Plaster Cast CarePlaster Cast Care

Instruct that cast will feel warmInstruct that cast will feel warm Handle cast with palms of handsHandle cast with palms of hands Turn client q 1-2 hours for dryingTurn client q 1-2 hours for drying Elevate on pillow Elevate on pillow higher than hearthigher than heart Pedal rough edges with moleskinPedal rough edges with moleskin Inspect q 4-8 hours – drainage, Inspect q 4-8 hours – drainage,

cracking, odor, alignment & fitcracking, odor, alignment & fit

Cast ComplicationsCast Complications

Circulatory impairmentCirculatory impairment Peripheral nerve damagePeripheral nerve damage Impaired skin integrityImpaired skin integrity Pneumonia, DVT, ConstipationPneumonia, DVT, Constipation Compartment SyndromeCompartment Syndrome Cast Syndrome – Body castCast Syndrome – Body cast Fracture blistersFracture blisters

TractionTraction

Definition: Pulling force that is applied Definition: Pulling force that is applied to part of an extremity while a counter to part of an extremity while a counter traction pulls in the opposite directiontraction pulls in the opposite direction

Purpose: Reduce Fracture, immobilize, Purpose: Reduce Fracture, immobilize, decrease pain & muscle spasm, correct decrease pain & muscle spasm, correct deformities, stretch tight musclesdeformities, stretch tight muscles

Types of TractionTypes of Traction Continuous or Running – Buck’s, RussellContinuous or Running – Buck’s, Russell

Circumferential – PelvicCircumferential – Pelvic

CervicalCervical

Suspension or Balanced – Thomas RingSuspension or Balanced – Thomas Ring

Skeletal – Steinmann pins, Kirschner wires, Skeletal – Steinmann pins, Kirschner wires, Crutchfield tongs Crutchfield tongs

Bucks TractionBucks Traction

Bryants TractionBryants Traction

Skeletal TractionSkeletal Traction

Nursing Assessment Nursing Assessment Equipment – weights, pulley’s, ropes, Balkan frameEquipment – weights, pulley’s, ropes, Balkan frame

MobilityMobility

Skin integrity Skin integrity

NeurovascularNeurovascular

GastrointestinalGastrointestinal

UrinaryUrinary

Fractured HipFractured Hip

Incidence: Prevalent women > 65; Incidence: Prevalent women > 65; 200,000 annually; by age 80 1 in 5200,000 annually; by age 80 1 in 5

Risk Factors: Falls, osteoporosis, Risk Factors: Falls, osteoporosis, age related changes in balanceage related changes in balance

Anatomy of HipAnatomy of Hip

Head of femurHead of femur

AcetabulumAcetabulum

Femoral neckFemoral neck

Greater trochanterGreater trochanter

Lesser or sub-trochanterLesser or sub-trochanter

Types of Hip FracturesTypes of Hip Fractures

Femoral Neck – displaced, Femoral Neck – displaced, impacted, comminutedimpacted, comminuted

Intertrochanteric (Intracapsular, Intertrochanteric (Intracapsular, Extracapsular)Extracapsular)

Subtrochanteric Subtrochanteric

Signs & Symptoms of Hip Signs & Symptoms of Hip FracturesFractures

Pain – hip or thighPain – hip or thigh

Adduction, external rotation Adduction, external rotation

Shortening of legShortening of leg

Inability to move or bear weight Inability to move or bear weight

Surgical InterventionSurgical Intervention

Total Hip Arthroplasty – Total Hip Arthroplasty – - Cemented allows full weight - Cemented allows full weight bearingbearing

- Uncemented – full weight bearing - Uncemented – full weight bearing not permitted for 6-8 weeksnot permitted for 6-8 weeks

ORIF – Intramedullay rods, plates, ORIF – Intramedullay rods, plates, compression screws; allows early compression screws; allows early ambulationambulation

Internal Fixation: Plates and Internal Fixation: Plates and PinsPins

Post-operative Care - ORIFPost-operative Care - ORIF

Bedrest 1Bedrest 1stst day; OOB with walker day; OOB with walker HOB HOB > 35 - 40°> 35 - 40° Avoid hip flexion > 90°Avoid hip flexion > 90° Trochanter roll for hip alignmentTrochanter roll for hip alignment Pillow splint when turning (per MD)Pillow splint when turning (per MD) Isometric exercisesIsometric exercises Pain control – narcotic analgesicsPain control – narcotic analgesics

Complications ORIFComplications ORIF

DVT, PEDVT, PE

HemorrhageHemorrhage

InfectionInfection

Subluxation or dislocationSubluxation or dislocation

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

Definition: compression of the Definition: compression of the medial nerve in the wristmedial nerve in the wrist

Etiology: Repetitive motions, wear Etiology: Repetitive motions, wear & tear, fracture of wrist& tear, fracture of wrist

Symptoms: Pain, paresthesia, Symptoms: Pain, paresthesia, difficulty in grasping difficulty in grasping

Carpal tunnel syndrome - atrophy Carpal tunnel syndrome - atrophy and weakness of the handand weakness of the hand

Diagnostic Tests CTSDiagnostic Tests CTS

Phalen’s – wrist flexed back to back Phalen’s – wrist flexed back to back results in paresthesia >60 secondsresults in paresthesia >60 seconds

Tinel’s – Tapping over the median Tinel’s – Tapping over the median nerve pain, tingling, numbness or nerve pain, tingling, numbness or inflating a BP cuff will result in same inflating a BP cuff will result in same sx.sx.

X-rayX-ray EMGEMG

Interventions CTSInterventions CTS

Non-invasive – wrist support, Non-invasive – wrist support, immobilization with splint, frequent immobilization with splint, frequent breaks, cushion grippers on pencils breaks, cushion grippers on pencils & pens, rest, ice, heat, anti-& pens, rest, ice, heat, anti-inflammatory agentsinflammatory agents

Invasive – Cortisone Injections, Invasive – Cortisone Injections, SurgerySurgery