Orthopedic Handout

8/8/2019 Orthopedic Handout

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ORTHOPEDIC

I. Anatomy and Physiology

A. Bone (illustration 1 illustration 2 )1. Functions

a. supports and protects structures of the bodyb. anchors muscles

c. some bones contain hematopoietic tissue which forms bloodcellsd. participates in the regulation of calcium and phosphorus

2. Joints (illustration )a. bursa - enclosed cavity containing a gliding joint

b. synovium - lining of joints which secretes lubricating fluid thatnourishes and protects

c. classification of joints - synarthrosis, amphiarthrosis,diarthrosis

3. Cartilage - connective tissue covering the ends of bones (illustration )4. Types of bones

a. long - legs, arms

i. external structure - diaphysis, epiphysis,periosteum

(illustration )

ii. internal structure of bone - medullary cavity; cancellousbone; red marrow

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

B. Muscles - produce movement of the body

1. Types (illustration )a. striated - controlled by voluntary nervous system

b. smooth - controlled by autonomic nervous systemc. cardiac - controlled by autonomic nervous system

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

fasciaII. Trauma: Contusions, Strains, Sprains

A. Contusions (bruise)1. Definition - a fall or blow breaks capillaries but not skin2. Pathophysiology - extravasation (bleeding) under skin

3. 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 aday

b. then apply heat if necessaryc. wrap to compress5. Resolution: should heal within seven to ten days6. Color changes from a blackish - blue to a gresnish - yellow after three to

five days

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

a. caused by overstretching, overexertion, or misuse of muscle

b. acute: recent injury to muscle or tendon; classified by degreei. first degree: mild; gradual onset; feels stiff, sore locally

I. assessment of acute first-degree strainI. tenderness to palpation

II. muscle spasmIII. no loss of range of motionIV. little or no edema or ecchymosis

II. management of acute first-degree strainI. comfort measures

II. apply iceIII. rest, possibly immobilize for short term

ii. second degree: moderate stretching, sudden onset, with

acute pain that eventually leaves area tenderI. assessment of acute second-degree strain

I. extreme muscle spasmII. passive motion increases pain

III. edema develops early; ecchymosis laterII. management of acute second-degree strain

I. keep limb elevatedII. apply ice for the first 24 to 48 hrs - then

moist heatIII. limit mobilityIV. muscle relaxants, analgesics, NSAIDSV. physical therapy for strength and range

of motion

1. Third-degree: severe stretching with tear; sudden; snapping or burningsensation

a. assessment of acute third degree straini. muscle spasm

ii. joint tendernessiii. edema (may be extreme)iv. client cannot move muscle voluntarilyv. delayed ecchymosis

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b. management of acute third degree straini. keep limb elevated

ii. 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

2. 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 bystretching, exertion or trauma

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

i. minimal tearing ofligament fibersii. localized edema or hematoma

iii. no loss of functioniv. no weakening of joint structure - joint integrity remains

intactv. mild discomfort at location of injury

vi. 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 andresolve hematoma

b. second degree spraini. up to half of the ligamentous fibers torn

ii. increased edema and possible hematomaiii. decreased active range of motioniv. increased painv. mild weakening of the joint and loss of function

vi. management protectively dress/splint the joint, immobilize it

elevate the limb to decrease edema for 24 to 48 hours, alternate

o ice

1. to produce vasoconstriction todecrease swelling

2. to reduce transmission of nerveimpulses and conductionvelocity to decrease pain

o moist heat

1. to reduce swelling and providecomfort

analgesics for discomfort

physical therapy to increase circulation andmaintain nutrition to the cartilage

c. third degree spraini. complete rupture of the ligamentous attachment

ii. severe edema with hematomaiii. usually, severe painiv. dramatic decrease in active range of motion

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v. loss of joint integrity and functionvi. management

casting

surgery to restore integrity of joint see second degree treatment

D. Fractures: pathophysiology1. Predisposing factors

a. biologici. bone density

ii. client's age2. Extrinsic factors

a. force - direct or indirectb. rate of loading (how fast the force strikes)

3. Intrinsic factors - bone capabilities4. Pathological fractures

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, hormonallycontrolled

ii. local: neoplasm, infection, cystic lesion

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

1. 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 fracture2. Immobilization

a. purposesi. relieve pain

ii. keep bone fragments from moving

b. methods: cast - synthetic or plaster, traction - skin or skeletal,

splints, braces, and external fixationc. types of traction

i. manual: applied by pulling on the extremity - may beused during cast application

ii. skin: applied by pulling force through the client's skin -used to relax the muscle spasm

iii. skeletal: applied directly through pins inserted into theclient's bone - used to align fracture

d. open treatment (see orthopedic surgery that follows)

3. Stages of bone healinga. hematoma formation

b. fibrocartilage/granulation tissue formationc. callus formation

d. ossificatione. consolidation/remodeling

4. Evidence of healed fracture

a. radiographici. presence of external callus or cortical bone across the

fracture siteii. fracture line may remain long after healing

b. clinical

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

c. weight bearing is pain free

F. Fractures: complications ORTHOPEDIC COMPLICATIONS

A. Venous thromboembolic problems1. Thrombophlebitis (TP)

a. inflammation of a vein with the formation of a blood clot

b. incidence is greatest after trauma or surgery to legs or feetB. 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 DVT

5. Findings include chest pain (pleuritic), sudden shortness of breath, tachycardia,palpitations, or change in mental status

6. If PE is suspected,do not leave client. Get charge nurse to notify health careprovider immediately

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

D. Fat embolism1. 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 ambulationd. diagnosis is confirmed with x-ray

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e. depending on severity, treatment will be immobilization or openreduction with internal fixation

2. Dislocation of hip prosthesisa. greatest risk during the first postoperative week but can occur at any time

within the first 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

revisionH. Special complication in knee replacement: flexion failure

1. Client cannot flex knee 90 degrees two weeks postoperatively2. Treated with closed manipulation of the knee joint under general anesthesia

1. Immediate complications of the injurya. shock - higher risk with pelvic and femur

b. 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 dystrophyi. painful dysfunction and disuse syndrome

ii. characterized by abnormal pain and swelling of theextremity

d. myositis ossificansi. formation of hypertrophic bone near bone and muscles

ii. forms in response to traumaiii. hypertrophic bone is removed when bone is mature

e. malunion

i. fracture healing is not stopped but slowedii. prevention of malunion

reduce and immobilize properly be sure client understands limits on activity and

positionf. delayed union

i. fracture does not healii. more common with multiple fracture fragments

iii. no evidence of fracture healing four to six months afterthe fracture

g. loss of adequate reductionh. refracture

G. Nursing interventions1. Risk for peripheral neurovascular deficita. check neurovascular status often

b. elevate limb above level of heart (except with compartment

syndrome)c. apply cold to minimize edema

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

i. with drugs

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ii. reposition clientiii. pad any bony prominences

c. teach relaxation techniques3. Client teaching

a. 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

4. Risk for infectiona. related to

i. open fracturesii. surgical intervention

iii. superficial/deep woundsb. monitor for findings of infectionc. provide proper wound cared. administer antibiotic therapy as indicated

5. Risk for impaired skin integritya. causes

i. open fracturesii. soft tissue injuries

iii. pressure areasb. additional factors

i. age - elderlyii. general condition of client

iii. preexisting skin conditions or diseasesc. interventions

i. mobilize the client as soon as possibleii. turn the client often at least every two hours

iii. position the client properly with alignment in mindiv. use orthopedic devices to limit skin impairment

6. Impaired gas exchangea. accompanies chest trauma

b. client risks fat embolismc. client risks deep venous thrombosisd. interventions

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

H. 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 newbone in the subchondral margins of the joint

2. FindingsI. primarily involves weight-bearing joints

II. non-inflammatory disorderIII. localized: no systemic effectsIV. results in an abnormal distribution of stress on the joint

3. IncidenceI. most common form of arthritis

II. may begin as early as the 20s and peaks in the 60sIII. 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

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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

Heberden's Nodes

III. Bony osteophytes at the DIP jointIV. Common presentation of OA in the handV. Indicates a strong hereditary tendency

VI. Seen more often in women than men (ten times

Bouchard's Nodes

Accompany Heberden's nodes , Found at the PIP joint, Occur more often in women than menIncrease in frequency with age

1. More common in men

2. Often occurs ina. wristsb. elbowsc. shoulders

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

a. physical activityb. injury

4. Joint abnormalitya. lax ligaments

b. congenital hip dysplasia5. Lifestyle: certain occupations predispose to secondary OA.

4. Pathophysiologya. stage one: microfracture of the articular surface

i. articular cartilage is worn awayii. condyles of bones rub together: joint swells and is

painfuliii. cartilage loses cushioning effect: joint friction developsiv. prostaglandins may accelerate degenerative changes

b. stage two: bone condensationi. erosion of cartilage

ii. cartilage may be digested by an enzyme in the synovialfluidc. stage three: bone remodeling

i. matrix synthesis and cellular proliferation failii. eventually the full thickness of articular cartilage is lost

iii. bone beneath cartilage hypertrophy and osteophytesform at joint margins

iv. result: joint degenerates

5. Findings OSTEOARTHRITIS OF HIP/KNEE: SPECIFICPHYSICAL FINDINGS

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

i. kneeii. groin

iii. thigh2. Knee

a. 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

a. joint stiffness after periods of restb. pain in a movable joint, typically worse with action, relieved by

rest

c. paresthesiad. joint enlargement: bones grow abnormally; spurs form and

synovitis sets in.

i. Heberden's nodes

ii. Bouchard's nodese. 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 fitii. muscles spasm and contract

iii. joints are blocked by osteophyte, loose bodiesiv. crepitation, crunching when joints are movedv. eventual ankylosis

i. gaiti. abnormal antalgic gait

ii. shortened stanceiii. widened base of supportiv. shortened step length

6. Diagnosticsa. to rule out autoimmune disorders

i. sedimentation rateii. rheumatoid factor

iii. c-reactive proteinb. CBC

i. analyze before NSAID therapyii. within normal limits

c. kidney and liver

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i. especially in older clients, analyze before startingNSAID therapy

ii. repeat every six monthsd. 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 fromrheumatoid arthritis.

g. radiographsi. taken in standing, weight-bearing condition

ii. 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, spontaneousfusion

h. bone scansi. radionuclide imagingii. shows skeletal distribution of osteoarthritis

iii. monitors complications of joint replacement surgeryi. MRI scans show the extent of joint destruction

j. computerized tomograms (CT) scans show cortical andcancellousbone density

7. Management: conservative treatmenta. education should cover

i. exercise patternsii. relaxation techniques

iii. nutritional assessment

iv. 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

iv. passive range of motion exercises (illustration )v. active stretching

d. protection from further injury by splinting or bracing8. Medication

a. aspirin - most often recommendedi. advantages: relatively safe and inexpensive

ii. disadvantage: GI problems may lead to ulcers andbleeding

b. nonsteroidal anti-inflammatory medications (NSAIDs)i. reduce pain and inflammation

ii. inhibit prostaglandin formationiii. may cause GI bleeding or gastric ulcers or cramping

with diarrheac. adrenocorticosteroid injections

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d. remissive agentsi. gold

ii. 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 massage

iii. biofeedback iv. hypnosisv. relaxation techniques

10. Surgical management

a. arthrodesisb. arthroplastyc. osteotomyd. total joint replacement

11. Home care considerations in arthritisa. safety measuresi. no scatter rugs at home

ii. 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 devices

b. management of surgical pain by patient controlled analgesiapumpsc. referral to agency and support group

2. Charcot joints (also called neuropathic joint disease)

6. Definition - multicausal degeneration and deformation of joint, usually

ankle. (illustration )7. Etiology

a. diabetes mellitus leading to foot neuropathy

b. syringomyelia results in Charcot's joint of the shoulderc. tertiary syphilisd. peripheral neuropathies

e. spina bifida with myelomeningocele

f. leprosyg. multiple sclerosish. long term intra-articular steroid injections

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

i. joint instabilityii. soft tissue swelling

iii. pain secondary to inflammation9. Diagnostics

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a. laboratory analysis of synovial fluidi. fluid is non-inflammatory

ii. low protein contentiii. no hemorrhage noted

b. radiographsi. chronic destructive arthritis of the foot

ii. severe destruction of the articular cartilage, subchondralsclerosis

iii. fragments of bone and cartilage in joint

10. Managementa. conservative treatment

i. protection from overuse/abuseii. braces and splints

b. surgical management: arthrodesisi. treatment of choice for unstable joints

ii. fusion of the involved joint11. Nursing interventions

a. expected outcome: preserve the jointb. education can prevent further injuryc. protection of the joint

i. braces

ii. orthopedic shoesd. prolonged immobilization

i. eight to 12 weeks to decrease swellingii. leads to minimal joint deformity and a functional

painless foot3. Chondromalacia patellae (also called patellofemoral arthralgia)

6. Definition: progressive, degenerative softening of the bone; follows a

knee injury (illustration )7. Etiology

a. lateral subluxation of the patella (kneecap)b. direct or repetitive trauma to the patella produces chondral

fracturec. underdevelopment of the quadriceps muscles8. Findings

a. pain with flexed knee activities (poorly localized)b. mild swellingc. occasional episodes of buckling of the affected knee

d. minimal joint effusione. evidence of 'squinting kneecaps'f. atrophy of quadricepsg. inverted 'J' tracking of the patella in the final 30 degrees of

extensionh. excessive quadriceps angle

i. positive apprehension signj. crepitation upon range of motion9. Diagnostics

a. radiographsi. anterior posterior (AP) and lateral views are not helpful

ii. sunrise views with the knee in 30 degrees, 60 degreesand 90 degrees of flexion

b. bone Scansc. MRI Scans

d. arthroscopy (see Orthopedic surgery)10. Conservative management

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a. progressive resistive exercisesi. quadriceps setting - isometric

ii. hamstrings - isotonicb. medication: NSAIDsc. nonmedication assistance: application of ice or moist heatd. activity restriction

11. Surgical managementa. indicated if findings remain after six months of conservative

treatment

b. arthroscopy (see Orthopedic Surgery section that follows)c. arthrotomy

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

iii. patellectomy12. Nursing interventions (see previous Osteoarthritis section)

2. Inflammatory Disorders1. Rheumatoid arthritis (RA)

6. Definition - chronic systemic inflammatory disease of the connectivetissue

7. Findingsa. starts in feet and hands, gradually destroys these peripheral joints

b. affects diarthroidial jointsc. bilateral involvement

8. Etiologya. cause is not fully understoodb. rheumatoid arthritis is an autoimmune disorderc. genetic tendency; but may involve bacteria, or virusesd. may affect the connective tissue of the lungs, heart, kidneys, or

skin9. Incidence

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

10. Pathophysiologya. synovitis immune complexes initiate inflammatory response

i. IgB antibodies are formedii. rheumatoid factor (RF)

1. pannus formation2. destruction of subchondral bone3. present in 85 to 90% of all cases4. worsens the inflammatory response - can go on

indefinitely

5. irreversible - will lead to ankylosis of joint11. Findings

a. in early RA joints will be

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

b. in late RA, joints will showi. bony ankylosis

ii. destruction of joint - reactive hyperplasiaiii. adhesions

iv. inflammation and effusion that will be1. symmetrical

2. polyarticularc. general signs

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i. fatigueii. loss of appetite and weight

iii. enlarged lymph glands (illustration )d. rheumatic nodules

i. in 20% of casesii. firm, oval, nontender masses under the skin

iii. presence indicates poor prognosise. physical assessment should also include

i. accurate patient history - history may include1. malaise2. fatigue3. weakness4. loss of appetite and weight5. enlarged lymph glands6. Raynaud's syndrome

ii. examination may reveal deformities1. ulnar deviation

2. deformed hands: swan neck/boutonnieref. neurological examination

i. foot drop

ii. evidence of spinal cord compression12. Diagnosticsa. laboratory analysis

i. elevated ESRii. decreased RBC

iii. positive C-reactive protein

iv. positive antinuclear antibody in 20% of casesv. positive rheumatoid factor (RF)

b. radiographic studiesi. bony erosion

ii. decreased joint spacesiii. fusion of joint

c. aspiration of synovial fluid; analysis showsi. cloudy appearance

ii. more white blood cells than normal13. Management

a. (see previous Osteoarthritis section)b. psychological supportc. splinting: resting, corrective, or fixation

2. Systemic lupus erythematosus (SLE)

6. Definition: chronic, systemic, inflammatory disease of the collagen

tissues (illustration )7. Etiology unknown

a. most cases are women

b. African Americans, Hispanics, Asians, and Native Americansare two to three times as likely as whites to have lupus

c. antigen stimulates antibodies, which form soluble immunecomplexes, deposited in tissues; number of T suppressor cells

dwindles. (illustration )d. immune complex inflames tissue; inflammation creates findings

i. the intensity and location of the inflammation reflectsfindings and organs involved.

ii. clients with central nervous system or renal involvementhave poorer prognosis

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8. 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 pathology

i. hematologic disorder: hemolytic anemia with reticulocytosis orleukopenia

j. immunologic disorder: positive LE (lupus erythematosus) cellpreparation or anti-DNA or anti-Sm or false positive serologictest for syphilis

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

l. positive LE cell reaction9. Management

a. expected outcomesi. control system involvement and symptoms

ii. induce remissionb. prevent bad effects of therapyc. recognize flare-ups promptlyd. medical

i. salicylatesii. nonsteroidal anti-inflammatory agents (NSAIDS)

iii. corticosteroidsiv. anti-infectives

e. antineoplastics10. Nursing care

a. pain management strategiesb. strategies to combat weight lossc. emotional support

3. Gout (illustration )6. Definition

a. monoarticular asymmetrical arthritis

b. characterized by hyperuricemia7. Etiology

a. primarily affects menb. peak incidence 40 to 60 years of agec. familial tendencyd. abnormal purine metabolism or excessive purine intake results in

formation of uric acid crystals which are deposited in the jointsand connective tissue.e. deposits are most often found in the metatarsophalangeal joint of

the great toe or in the ankle.8. Findings

a. tight, reddened skin over the inflamed jointb. elevated temperaturec. edema of the involved aread. hyperuricemiae. acute attacks commonly begin at night and last three to five days

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f. gout attacks may follow trauma, diuretics, increased alcoholconsumption, a high purine diet, stress (both psychological andphysical) or suddenly stopping of maintenance medications

g. warning signs of flare-up include the exacerbation of previousfindings or the development of a new one

h. systemic manifestations may include fever, renal disease, tophus9. Diagnostics: lab tests find -

a. increased urinary uric acid following a purine restricted dietb. hyperuricemia

10. Managementa. expected outcomes: control symptoms; prevent attacksb. medical

i. NSAIDsii. colchicine (used when NSAIDs are contraindicated) -

enhances the excretion of uric acidiii. to prevent flareups: antihyperuricemic agents such as

allopurinol (lopurin) or probenecid (benemid) -minimize the production of uric acid

iv. heat or cold therapyc. dietary

i. avoid purine foods such as meats, organ meats, shellfish,

sardines, anchovies, yeast, legumesii. control weight

iii. drink less alcohol - all types11. Nursing care

a. 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)

3. Metabolic Bone Disorders1. Osteomalacia

6. Definition - delayed mineralization; resulting bone is softer and weaker7. Pathophysiology - similar to rickets

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

i. less serum calcium than normalii. more parathyroid hormone

iii. more renal phosphorus clearance8. Findings

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

ii. similar pain in low backb. physical examination

i. gait1. client unwilling to walk2. wide stance3. waddling gait

ii. muscle weaknessiii. bones

1. deformities of weight-bearing bones2. scoliotic or kyphotic deformities of the spine3. bones break easily

9. Diagnostic testing

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a. radiographic findingsi. generalized demineralization

ii. pseudo fracturesiii. bending deformities

b. laboratory studiesi. decreased serum calcium

ii. decreased serum phosphorusiii. alkaline phosphatase level is moderately elevated

10. Management

a. calcium gluconateb. vitamin D daily until signs of healing take placec. diet high in proteind. ultraviolet radiation therapy

2. Osteoporosis (illustration )6. Definition

a. multifactorial disease results ini. reduced bone mass

ii. loss of bone strengthiii. increased likelihood of fracture

b. types

i. type one osteoporosis (estrogen related)ii. type two osteoporosis (related to old age)7. Etiology/epidemiology

a. most common metabolic disease of bonei. affects an estimated 25 million Americans

ii. contributor of 50% of all adult fracturesb. onset is insidiousc. women affected twice as often as men before the age of 70d. skeletal changes result from the aging processe. bone loss due to

i. immobilizationii. lack of gravitational stress

8. Factors related to osteoporotic fractures

ADDITIONAL RISK FACTORS FOR OSTEOPOROSIS

A. Genetic risk factors1. Female, white or Asian2. Small frame, thin-boned; short; low body fat3. Women with post-menopausal osteoporosis may have inherited a lower peak

bone mass4. Daughters of women with osteoporosis averaged less bone mass in lumbar spine

and femoral neck5. Family history of hip fracture

B. Reproductive factors1. 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 osteoporosis

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a. premature menopauseb. hyperthyroidism increases bone turnover and remodelingc. hyperparathyroidism

i. increases bone turnover and remodelingii. increased parathyroid hormone (PTH)

stimulates osteoclast activity

depresses osteoblast activity

result is an increase in serum concentration of calciumb. hyperadrenocorticalismc. type I diabetes mellitus

a. low bone density

b. history ofscoliosisc. neurological impairment after

i. CVAii. Parkinson's diseaseiii. decreased vision from macular degeneration,

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

9. Findingsa. client historyi. acute fracture

ii. prior history of a traumatic fracture; no traumaiii. history of falls

b. paini. greater when active, less while resting

ii. early in disease, pain in mid to low thoracic spinec. anxiety

i. 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

10. Diagnosticsa. blood tests

i. complete blood countsii. serum levels

1. calcium2. phosphate3. alkaline phosphatase

b. x-rays

i. help identify fractures and kyphosis of spineii. less useful in the detection of pre-fracture osteoporosis

iii. detect osteoporosis only after 20% bone mineral contentis lost

c. bone densitometryi. best means of measuring risk for fracture

ii. quantitative computerized axial tomogram (CAT)measures pure vertebral trabecular bone

iii. dual energy x-ray absorptionometry (DEXA)1. technique of choice

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2. assesses cortical and trabecular bone in spineand hip

3. single photon absorptionometry measurescortical bone in long bones

11. Managementa. exercise

i. restorative - aims to increase bone density, decrease riskfor fracture

ii. within the client's tolerance

iii. must be maintained throughout lifeb. nutrition

i. calcium and vitamin Dii. deficiencies increase risk of fracture

iii. sedentary older adults may need supplementsc. medication

i. anti-resorptive agents1. do not increase bone mass - rather prevent

further bone loss2. estrogen therapy3. calcitonin (Osteocalcin)

1. peptide hormone

2. powerful inhibitor of osteoclastic boneresorption

3. modestly increases bone mass inosteoporosis

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 elevatecholesterol levels

12. Nursing intervention: teach prevention of ssteoporosis and its damagea. education

i. increase awarenessii. discourage risk-related behaviors

iii. reinforce positive behaviors and lifestylesb. reduce risk of falling

i. teach proper lifting and movement techniques

(illustration )

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ii. encourage proper footweariii. install safety equipment in home

3. Paget's disease (osteitis deformans)6. Definition: a slowly progressing resorption and irregular remodeling of

bone.7. Etiology

a. bone resorbed; new bone poorly developed, weak, easilyfractured

b. mainly affects major bones: skull, femur, tibia, pelvis, and

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

8. Findingsa. asymptomatic initiallyb. musculoskeletal

i. deformity of long bonesii. pain and point tenderness of affected limbs

9. Diagnosticsa. radiographic findings

i. bowing of long bonesii. thickened areas of bone

iii. pathological fracturesiv. sclerotic changes

b. laboratory analysisi. increased alkaline phosphatase means osteoblasts more

activeii. increased urinary hydroxyproline means osteoblasts

more activeiii. serum calcium level will be normal

VI. Orthopedic Surgery

A. Total hip replacement (illustration )1. Indications for surgeryi. osteoarthritis

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

2. Surgical modalities

a. total hip replacement (hip arthroplasty) is the replacement of both articular surfaces of thehip joint, the acetabular socket and the femoral head and neck.b. hemiarthroplasty of the hip is the replacement of one of the articular surfaces, usually the

femoral head and neck.2. Surgical and immediate postoperative care

a. in first 24 hours, expect wound to drain blood and fluid up to 500ml.b. by 48 hours, wound drainage should be minimal

c. clients may require transfusions (autologous is preferred) due to blood loss duringsurgery.d. best pain management is patient controlled analgesia (PCA) for the first 48 hours,advancing to non-narcotic oral analgesics by the fourth or fifth postoperative day.e. monitor for signs of deep venous thrombosis (DVT) and pulmonary embolism (PE) or fatembolism

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

3. Postoperative complications ORTHOPEDIC COMPLICATIONS


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. multiple trauma accidentsb. multiple organ involvement

c. fractures of marrow producing bonesd. joint replacementse. insertion of intermedullary rods




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

reduction with internal fixation

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2. Dislocation of hip prosthesisa. greatest risk during the first postoperative week but can occur at any time

within the first 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



4. Nursing interventions

a. an abduction device is used during the first postoperative week while the client is in bedor sitting in a chairb. 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 toiletseat

II. methods to prevent dislocationIII. can resume sexual activity when suture line heals. To

avoid flexion of hip, client should be in dependentposition for three to six months

B. Total knee replacement1. Indications for surgery

a. osteoarthritisb. rheumatoid arthritisc. trauma

2. Surgical modalitiesa. metal or acrylic prosthesis, hinged or semiconstrainedb. choice of prosthesis depends on the strength of surrounding ligaments to provide jointstability

3. Postoperative complications ORTHOPEDIC COMPLICATIONS


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





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a. multiple trauma accidentsb. multiple organ involvement

c. fractures of marrow producing bonesd. joint replacementse. insertion of intermedullary rods




and elevated temperature

4. Treated with antibiotics; may require incision and drainage of wound or removalof prosthesis if severe infection is present

G. Special complications in hip replacement1. Femoral fracture

a. 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 ambulationd. 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 timewithin the first 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



a. Nursing interventions (knee replacement)A. for first 24 to 48 hrs, apply ice to the knee to minimize bleeding

and edemaB. 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)

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G. health care provider prescribes the amount of flexion andextension, measured in degrees, and increases that amount asclient tolerates more

H. when the CPM machine is not in use, a knee immobilizer is usedI. keep leg elevated when the client is out of bedJ. on first post-op day, client will begin to use crutches or walkerK. best pain management is patient controlled analgesic (PCA) for

the first 48 to 72 hours postoperatively. By fifth post-op day,nonnarcotic oral analgesia.

L. monitor limb's neurovascular status, color, temperature, andpulses

M. monitor for signs of DVT or PE3. Amputation

a. Purpose: relieve findings; improve function; save or improve quality oflife

b. Lower extremity indicationsA. progressive peripheral vascular disease (often secondary to

diabetes mellitus)B. gangreneC. trauma such as crushing injuries, burns, or frostbiteD. congenital deformities

E. malignant tumorc. Upper extremity indications

A. traumaB. malignant tumorC. infectionD. congenital malformations

d. Levels of amputation Objective of surgery is to eradicate the diseaseprocess 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 minorchanges in gait or balance

2. 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 joint5. 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 possible9. Staged amputation - used for infection. Guillotine amputation to remove infectious and

necrotic tissue is performed. After intensive antibiotic therapy, a second operation isperformed for skin closure.

A. amputate to most distal point that will heal successfullyB. determined by circulation and functional status

e. Potential postoperative complicationsA. hemorrhageB. infectionC. skin breakdown

f. 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 positionD. phantom limb pain

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A. may occur any time up to three months post amputationB. most common with above-knee (AK) amputationsC. relieved with

A. stump desensitization by kneading, or massageB. transcutaneous electrical nerve stimulation

(TENS)C. distractionD. beta-adrenergic blocking agents for burning, dull

pain

E. anticonvulsants for sharp and cramping paing. Wound healing

A. aseptic dressing change techniqueB. compression dressing wrapped in a figure eight fashion or cast to

control edemah. 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 limbi. Grief

A. many clients go through a mourning process, shock, anger, and

depressionB. caregivers should support and listen actively

j. Restoring physical mobilityA. early rehabilitationB. muscle strengthening exercises

C. prosthetic preparationk. Types of prosthesis

A. hydraulicB. pneumaticC. biofeedback - controlledD. myoelectrically controlledE. synchronized

4. Arthroscopya. Definition - endoscopic procedure that allows direct visualization of the

joint, most often performed on knees and shouldersb. Indications

A. torn medial and lateral meniscusB. chondromalacia patellaeC. synovitisD. torn cruciate ligamentE. subluxation patellaF. intra-articular soft tissue massG. pyarthrosis

c. Surgical procedure - most often, office surgery

d. Postoperative careA. compression dressing wrapped in a figure eight fashion to

control edemaB. ice may be appliedC. oral analgesics for pain managementD. weight bearing depends on procedure

e. Postoperative complications are rareA. infectionB. thrombophlebitisC. stiffness

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U. When performing a musculoskeletal assessment on a client with Paget's disease, note thesize and shape of the skull. The skulls of these clients will be soft, thick and enlarged.

V. Clients at high risk for acute osteomyelitis are: elderly, diabetics, and clients withperipheral vascular disease.

W. When clients receive corticosteroids long-term, evaluate them continually for side effects.X. Immunosuppressed clients should avoid contact with persons who have infections.Y. Steroids may mask the signs of infections, so client should promptly report slightest

change in temperature or other complaints.

Z. Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hoursand wear sun block.

Date post:	09-Apr-2018
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Orthopedic Handout

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