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Orthopedics Musculo-skeletal Disorders Semester 4.

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Presentation on theme: "Orthopedics Musculo-skeletal Disorders Semester 4."— Presentation transcript:

1 Orthopedics Musculo-skeletal Disorders Semester 4

2 4 Major Areas of Orthopedic Nursing Assessing and alleviating pain Increasing patients mobility Preventing complications Providing patient teaching

3 Agenda A&P (you have already done this) Assessment (you have already done this) Causes of Disorders –trauma –infection –abn cellular development –degeneration –inflammation –metabolic

4 Agenda Treatment: –rest –traction –casts –internal/external fixation –assistive devices: ie crutches, walkers –surgical interventions –pharmacology

5 Pharmacology Classifications: –muscle relaxants –Anti-inflammatory agents: salicylates, non- steroidal –Corticosteroids –gold treatment –uricosuric drugs –immunosuppressants

6 Physiology of Movement 3 systems –skeletal –muscular –nervous

7 Bones Constantly changing - either breaking down or renewing Osteoblasts Osteoclasts Osteoblast and osteoclasts work together to achieve bone balance negative balance vs positive balance

8 Bone: classifications Long bones short bones flat bones irregular bones

9 Bone: Function Support and protection body movement (with CNS and muscles) blood cell formation inorganic salt storage - approx 70% of bone weight is calcium phosphate

10 Muscles: Types 3 types: –skeletal –smooth –cardiac

11 Assessment General observation –uniformity of bones and muscles –posture, body alignment –balance and co-ordination

12 Assessing Posture

13 Congenital Deformities

14 Assessment Muscles –size –tone –strength and endurance –hand grips, foot presses (weak, one-sides)

15 Assessment Bones and Joints –palpate for prominence, contours, symmetry –ROM upper and lower noting flexibility –*never force the joint

16 Assessment * Body Balance: balance maintained - one foot, two feet * Co-ordination: fine motor skills - observe ADL * Ability to transfer: independent? Supervision? One or two person assist?

17 Assessment Musculo-skeletal + neuro-vascular Neuro-vascular includes colour, temp, capillary refill distal to the injury Palpation of pulses; pain; sensation & movement May need to use dopler for pulses

18 Changes Related to Aging Bone density decreases Synovial joint cartilage less elastic Muscle tissue atrophy (decreased strength) Decreased ROM Kyphotic posture; widened gait; shift in centre of gravity

19 Disorders: Trauma (soft tissue) Muscle Spasm: injury stimulates nerve endings in muscle causes excitation of nerve endings and places muscles in spasm S and S: pain, palpable muscle mass (knots) tenderness with decreased ROM and ADL

20 Muscle Spasm Sites: any muscle Treatment: physical therapy (physio) moist heat packs hydrotherapy bracing, analgesics, muscle relaxants

21 Trauma: contusion

22 Trauma: Contusion Soft-tissue injury or bruise produced by a blunt force such as a blow, kick or fall hemorrhage into tissue tx: elevation, moist or dry cold x’s 8-10 hrs 20 mins on - 20 mins off after 24 hours, heat 20 on-off followed by cold, elastic bandage

23 Trauma: Strain Injury to musculo-tendinous structures surrounding a joint caused by over stretching or excessive force results in hemorrhage into the tissue 1st, 2nd, 3rd degree stains 2nd and 3rd involve tearing of musculo- tendonous fibers 3rd degree may require OR



26 Trauma: Sprains Injury to the ligamentous structures surrounding the joint caused by a wrench or twist hemorrhage, decreased stability of joint surgical repair or immobilization 8 to 16 weeks in cast

27 Trauma: Meniscus injury Meniscus: crescent shaped fibrous cartilege in the knee stabilizes the knee shock absorber common in athletes S and S: severe pain, non-functioning knee, edema at knee


29 Meniscus injury Treatment: physio to strengthen and increase stability menisectomy-surgical repair of cartilage by arthroscopy recovery depends on degree of tear and damage to surrounding tissue

30 Nursing Care: Crutches, Canes & Walkers Crutches need strong upper extremities 2-3 finger spaces between crutch and axilla Elbow flexed no more than 30 degrees when hands on handle Usually use 3 point gait

31 Canes and Walkers Walker used for older adults who need support and balance Cane is used for minimal support; hemi or quad cane offers more support Cane is placed on unaffected side and no more than 30 degree flexion of elbow Top of cane is parallel to greater trochanter

32 Repetitive Strain Injury ( Carpal Tunnel Syndrome) Entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, bone encroachment, edema or soft-tissue injury repetitive strain injury S and S: pain, numbness, parasthesia, weakness along median nerve which inervates the thumb, 1st, 2nd fingers, common at night

33 Median Nerve Entrapment Numbness

34 Repetitive Strain Injury (Carpel Tunnel) Treatment: splints to prevent hyperextension and flexion of the wrist cortisone injections surgery of the transverse carpal ligament often confused with thoracic outlet syndrome

35 Trauma: Epicondylitis (tennis elbow) Damage to the tendons of the medial or lateral radial and ulnar epicondyles S and S: chronic pain that radiates down the dorsal surface of the arm, weakness Tx: rest in splint, ice, NSAIDS, corticosteroid injections, gentle exercise to prevent stiffness

36 Review of the Knee





41 Anterior and Posterior Cruciate Ligaments

42 ACL/PCL Stabilize forward and backward motion of the femur and tibia injured when foot is firmly planted, knee hyperextended and person twists torso and femur S&S: pain, joint instability, pain with ambulation

43 ACL/PCL Treatment: RICE, r/o fracture, joint effusion and hemarthrosis needs aspiration and wrapping with compression dressing. Conservative: brace and physio Surgical reconstruction or repair followed by weeks immobilization followed by brace and physio


45 Nursing Care Potential fluid volume deficit r/t post op hematoma/hemorrahage Knowledge deficit: pain control measures Impaired physical mobility r/t adjustment of new walking gait Knowledge deficit: Potential for joint weakness and the techniques for applying brace

46 Nursing Care Potential alteration in tissue perfusion: r/t impaired circulation secondary to compression from brace, knowledge deficit: techniques for self- neurovascular assessment

47 Care Plans

48 Trauma: Dislocations Occurs when articular surfaces of the bones forming a joint are out of anatomical position, subluxation = partial dislocation may be congenital, pathological or traumatic S&S: pain changes in contour, length of extremity, loss of mobility Tx: reduction, immobilization

49 Congenital Hip Often left hip, females, 1 st born, breach birth; First, Female, Foot, Family Legs are a different length, uneven thigh skin folds, less mobility or flexibility in one leg

50 Developmental Dysplasia of the Hip

51 Trauma: Dislocations Often recognized clinically Can occur at time of impact or during application of splint at scene Orthopedic emergency when bone impinges on nearby vessels and nerves, compression, laceration, crushing, stretching

52 Neuro-vascular involvement Shoulder: brachial plexus, axillary artery Elbow: ulnar nerve, brachial artery Wrist: median nerve Hip: sciatic nerve Knee: tibial/peroneal nerve, popliteal artery/vein Ankle: tibial artery

53 Trauma: dislocation, subluxation Dislocation: Subluxation Assessment: neuro/vascular status elevate limb (caution above heart) compression bandage cold pack, immobilize, don’t wt bear

54 Dislocation, subluxation Did pt. or bystander hear popping or snapping sound? Assess below injury, pulses etc

55 Trauma: Fractures (fx) Disruption of normal bone continuity 150 types of fractures –open (compound), closed (simple) –complete, incomplete –impacted –comminuted –displaced –complicated

56 Trauma: Fractures Fracture Direction: linear fracture oblique fracture spiral fracture transverse fracture

57 Trauma: Fractures Assessment: Accident data base ABC’s (c-spine) Inspection and Palpation –edema, deformity, ecchymosis, loss of function, crepitation, muscle spasm, x-ray, CT/MRI, angiograms, pulses, capillary refill

58 Goals of Fracture Repair Fracture reduction Maintenance of the fragments in the correct position while healing takes place Prevention of excessive loss of joint mobility and muscle tone Prevention of complications Maintenance of good general health to promote healing

59 Complications of Fx Shock, which may be fatal Hemorrhage Acute Compartment Syndrome Venous Thrombosis Fat Embolism/PE Infection Nerve and organ damage

60 Shock Hypovolemic or traumatic shock Internal or external bleeding Tx: replacement, relieve pain, splinting of fx, protection from further injury

61 Hemorrhage Bones are very vascular, surgery long, may have been other surgery first Hemorrhage may occur as a result of abnormal blood clotting i.e. DIC, or side effect of meds Post-op assessment is critical

62 Fat Embolism Fat in blood becomes entrapped in the lung capillaries and other small vessels that supply the brain, kidneys and other organs Fat comes from bone marrow, stress may cause alteration of lipid stability in the blood Fat drops lodge in capillaries and then cells accumulate and form plaque

63 Fat embolism Emboli may go to skin and petechiae Usually hours post injury or OR Personality changes, ABG, increased resp, chest pain, Tx: prevention, high Fowler’s, O2, hydration; bedrest; steroids; reducing fx 10-15% mortality

64 Pulmonary Embolism Most common cause of immediate post-op death on lower extremity OR Fx pelvis, hip, femur Clot comes from peripheral vein

65 Acute Compartment Syndrome Ischemic muscle necrosis and subsequent contractures “circulation or function of tissues within a closed space is compromised by increased pressure within that space” Closed fascial space Pain, pain on passive motion, parasthia, paralysis, pulselessness

66 Fasciotomy

67 Neurological Complications Satisfactory reduction of the fx relieves stress placed on nerves Nerve damage is usually from stress versus laceration Review sensory assessment

68 Infection at time of Injury Tetanus, gas gangrene Open fx, irrigated +++, debrided, may be left open, prophylactic antibiotics Avascular Necosis caused by infection or loss of blood supply. Dead bone is reabsorbed and replaced by new bone, often in femoral head

69 Secondary Effects Respiratory complications due to meds, immobility, pneumonia, pneumothorax, Circulatory complications: DVT, Postural hypotension, venous stasis, circulatory overload with IV fluids Gastrointestinal complications: PI, constip.

70 Secondary complications Genitourinary complications: infection, prolonged catheter use Musculoskeletal: contactures, Integumentary: skin breakdown, bed sores, often weight loss

71 PTSD Traumatic Family loss Loss of limb etc Intrusive thoughts and dreams, exaggerated startle reaction, anxiety, social withdrawal

72 Specific complications Hip: Sciatic nerve damage avascular necorsis




76 Fractured Left Hip Note external rotation

77 Fractures Pelvis: bleeding bladder rupture, pancreas, spleen trauma bowel trauma (75% mortality)

78 Specific complications Distal Femur and Knee: popliteal artery/nerve damage bleeding Fibula: injury to peroneal nerve

79 Bone Healing Continuous process that begins at injury hemorrhage into the fracture site within 24 hours a hematoma is formed and fills the fracture site coagulated blood results in loose fribrin mesh that seals off the fracture site and serves as a framework for ingrowth of fibroblasts and capillary buds

80 Bone healing During first hours inflammation results in edema, vascular congestion and infiltration of leukocytes 48 hours post injury macrophages begin phagocytosis fibroblasts and chondroblasts begin to form a soft tissue callus

81 Bone healing After the first few days, newly formed cartilage and bone matrix are evident end of first week well-developed new bone and cartilage dispersed throughout soft- tissue callus provisional callus reaches maximal size in 2-3 weeks, strengthening and remolding continues

82 Managing a Cast

83 Casts immobilize reduced fractures correct a deformity apply uniform pressure to underlying soft tissue support and stabilize weakened joints permit mobilization of pt, while restricting movement of a body part

84 Managing Cast Types: short arm or leg, long arm or leg Walking cast, body cast, shoulder spica, hip spica

85 Assessment and Complications: Casts Assess: Circulation Movement Sensation

86 Cast Care Impaired blood flow d/t pressure from cast Nerve damage from nerve over bony prominence Infection, tissue necrosis from skin breakdown Compartment syndrome; delayed, mal- and non-union

87 Traction Three types, manual, skin and skeletal

88 Purposes of Traction Reduce a fx and realign bone fragments Maintain skeletal length and alignment Reduce and treat dislocations Immobilize to prevent further soft-tissue damage Prevent the development of contractures Relieve muscle spasm

89 Purposes of Traction Lessen deformities Rest a diseased joint

90 Skin Traction

91 Balanced Skeletal Traction

92 Traction Care Keep patient clean, comfortable and free of pressure sores Assess (q2-3h or more frequently prn) –wts from traction are hanging freely –pts body weight is counteracting pull of wts –that traction boot is not slipping off of pt –all bony prominences, skin, circulation –pt posture in bed, position of joints for alignment –slings, ropes, sheets are not cutting into skin and creating sores –pin sites for infection

93 Osteomyelitis Inflammation and infection of bone tissue and bone marrow Retards healing by destroying newly forming bone, disrupts blood supply Usually caused by hemolytic staphlococcus aureus bacteria, e-coli, pseudomonas Risk: immune suppressed, long term CS, IDDM and NIDDM

94 Disorders of the Musculoskeletal System Due to Degeneration

95 Muscular Dystrophy Neuromuscular disease Genetically determined, progressive disease of specific muscle groups Progressive weakness of the voluntary muscles Many types Usually male, female carry the gene

96 Types of MD Duchenne’s (pseudohypertrophic) –onset rapid, usually by age 5, cardiac involvement, mental retardation, death by adult Becker’s –age 5-15, rare cardiac, usually normal lifespan

97 Muscular Dystrophy Facio-scapulo-humeral: –age 10-30, inability to raise arms above head, eyes remain partially open during sleep Limb-girdle –age 10-30, weakness in proximal muscles of the upper and lower extremities, gradual atrophy and weakness then loss of function

98 Signs and Symptoms Generally: muscle fiber atrophy Necrosis of muscle tissue Fibrosis Increase serum creatine phosphotinase (CPK) Replacement of muscle tissue with connective tissue Weakness, some immobility

99 Treatment Physio to prevent muscle tightness, contractures, disuse atropy Night splints for contractures in ankles, hips and knees Braces for muscle weakness to increase mobility Orthotic jacket for spinal support

100 Nursing implementations Physical and psychological support including ROM Reinforce PT and OT Encourage independence Teach use of equipment

101 Disorders of the Musculoskeletal System Osteoporosis

102 Causes skeleton weakness and fractures during routine activites between age 20 and 40 bones reach maximum density after that resorption > than formation after bone peak, loss is about 1% / year lifetime losses may reach %

103 Osteoporsis In osteoporosis, osteoblasts do not replace resorbed bone usually first sign is a fx, kyphosis and loss of height, bone density test

104 Interventions Estrogen dietary supplements exercise pharmacologic therapy alternative therapies

105 Community care Assessment monitoring prevention

106 Prognosis Not curable can prevent bone loss early detection results in preventing further loss and life-threatening fx prevent pain and immobility

107 Orthopedics - Amputations Amputations

108 Amputation Removal of a body part Often necessary as a result of progressive PVD (diabetes), gas gangrene, trauma (injury, frostbite, electrical burn), congenital deformities, chronic osteomylitis, or malignant tumor Relieves symptoms, improves function, save or improve quality of life

109 Amputation Performed at the most distal point that will heal successfully Determined by circulation in the part and functional usefullness Objective is to conserve as much length as possible, try and preserve knee and elbow May use staged amputation

110 Amputation sites

111 Complications Hemorrhage Infection Skin breakdown Phantom limb pain As well as other we have discussed related to immobility

112 Post op objective In addition to everything else a non-tender residual limb with healthy skin for prosthesis use

113 Nursing Diagnosis Pain related to amputation Sensory/perceptual alteration: phantom pain r/t amputation Impaired skin integrity r/t surgical procedure Body image disturbance r/t amputation Coping, ineffective amputation Grieving r/t amputation

114 Nursing Diagnosis Self care deficit: bathing, feeding, toileting, grooming Impaired physical mobility r/t amputation

115 Nursing Intervetions Pain: identify hematoma, muscle spasm as possible cause Phantom pain and sensation: occurs more frequently in AKA, Nurse offers support, distractions, Wound healing: usual wound care, compression or limb shaping dressing, plaster slab, physio,

116 Nursing Interventions Body image: accepting and supportive atmosphere, social worker, physio, family, Independent self care: OT, time, encourage independence, assistive devices Increase physical mobility: Trapeze, arm strengthening, avoid hip and knee contractures, limb should not be up on a pillow, roll from side to side and prone

117 Interventions Amputation changes center of gravity some may not have prosthesis and will use wheelchair, special chair so it won’t tip Post op complication: hemorrage, infection, skin breakdown Home Care:

118 Orthopedics Back injury

119 Acute Low Back Pain Etiology: acute lumbosacral strain unstable lumbosacral ligaments weak muscles osteoarthritis of the spine spinal stenosis intervertebral disk problems unequal leg length

120 Low Back Pain Disk degeneration is a common cause of back pain Lower lumbar disks L4-5 and L5-S1 complains of acute or chronic pain radiating pain assessment may show changes in reflexes, gait, mobility, paravertebral muscle spasm, loss of lumbar curve.

121 ALB pain Usually self limiting - one month rest, analgesics, stress reduction, heat or cold therapy, muscle relaxants limit sitting to mins, slow movement and twisting, begin muscle strengthening should be preventable!

122 Nrsg Dx Pain r/t impaired physical mobility r/t pain, muscle spasm, decreased flexibility knowledge deficit r/t back-conserving body mechanics self-concept deficit altered nutrition: greater than

123 Total Knee/Hip Arthroplasty PN

124 Case Study, Total Knee Arthroplasty Patient: 75 yr old male Hx: osteoarthritis (pain, stiffness and difficulty moving lt knee) Meds at home: ASA, Activity: walks 1 mile/day, rides bike Other: nil

125 What is the difference between OA and RA?

126 Pre op Blood Work (CBC, Electrolytes, ECG, UA, Bld screen, clotting/bleeding times) Xrays: Knee, chest? Pre and post-op teaching Discharge Planning


128 Pre Op health Teaching Clinical Pathway Deep breathing/coughing; incentive spirometer Type of anesthetic, post op pain management Practice the post op exercises (foot and ankle; static quads; static gluts) What to bring to the hospital The morning of surgery…(NPO,meds, where to check in) Dental work

129 Day of Surgery NPO (morning meds with a sip of water) IV started Leg prep’ed Surgery PACU Return to the unit


131 Back on the Unit Vital signs Pain Assessment of Knee (dressing) IV Chest Food Bath Family Nausea/vomiting Voiding

132 Days 1-3




136 Home Care Bathing Anti Em stockings Incision care Dressing Toileting Getting on and off a chair Stairs Sexual activity Driving a car Avoid jarring or twisting of Knee/hip Who will visit? Physio, lab,

137 Things to avoid with a total hip NO hip bending (flexing) beyond 70 degrees (90) NO crossing legs NO rolling kneecap in Limit car rides x 6 weeks When sitting, including toilet: When sleeping: When walking/stairs:

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