Musculoskeletal Disorders

Physiology Functions Provide protection for vital organs o Bones ribs, sternum, thoracic vertebrae o Muscles internals and intercostal muscles, diaphragm Support body structures by providing a strong and sturdy framework Locomotion and movement Mineral storage o For metabolism o 99% of the total calcium content of the body is located in the bone Haematopoiesis o RBC and WBS are produced according to their nature stem cells Heat production o Through contraction = contain and control heat inside the body Anatomy 206 bones in total Classified according to their location o Axial (80) Skull Vertebral column o Appendicular (126) Pectoral girdle Scapula Clavicle Radius Ulna Pelvic girdle Iliac Ischium Femur Basic Cell types o Osteoblasts- the CARPENTER Bone formation Made possible through the secretion of matrix calcium is the main component Initiates bone formation via calcification Process where there is mineralization of the collagen fiber MATRIX and CALCIUM THE CEMENT; THE FOUNDATION o Osteocytes MAINTAINS THE HOUSE Mature type of the osteoblasts Main cell found in the bone Maintenance of bone Excretion of waste materials Is found inside the spaces called lacunae

Osteoclasts THE ANAYS (THE ONE THAT DESTROYS THE HOUSE) Huge cells derived from the fusion as many as 50 monocytes Usually concentrated at the endosteum of the bone Endosteum at the lumina area, where the medullary cavity is For bone resorption: bone destruction or bone remodelling Bone destruction Ca is removed According to General Features o Long Bone Longer than they are wide Upper and lower limbs Humerus and Femur o Short Bones As broad as they are long Wrist and Ankle o Flat Bones Relatively thin; flattened shape Certain skull bones, ribs, scapulae (shoulder bones, blades and sternum) o Irregular Do not fit readily into the other three categories Vertebrae and facial bones (mandible, maxillary, zygomatic arch, among others) o Each long bones consists of a central shaft called diaphysis o While the two ends is called epiphysis o A thin layer of the articular cartilage covers the end of the epiphyses where the bone articulates with other bones o A long plate that is still growing has an epiphyseal plate or growth plate, composed of cartilage, between each epiphyses and the diaphysis o Bones contain cavities such as the large medullary cavity in the diaphysis, as well as smaller cavities in the epiphyses of long bones and in the interior of other bones o These spaces are filled with either yellow ro red marrow o Marrow The soft tissue in the medullary cavities o Yellow marrow Consists of mostly fat o Red marrow Blood forming cells and is the only site of blood formation in adults o Most of the outer surface of the bone is covered by dense connective tissue called periosteum which contains blood vessels and nerves o The surface of the medullary cavity is lined with a thinner connective tissue membrane called endosteum o The periosteum and endosteum contain osteoblasts which function in the formation of bone as well as the repair and remodelling of the bones o When osteoblasts become surrounded by matric, they are referred to as osteocytes o Bones is formed in thin sheets of extracellular matrix called lamellae, with osteocytes located between the lamellae o The osteocytes are located with spaces called lacunae o Cell processes extend from the osteocytes across the extracellular matrix of the lamellae with tiny canals called canaliculi

Histological Structure Compact Bone o Forms most of the diaphysis of long bones and the thinner surfaces of all other bones

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Most of the lamellae of compact bone are organized into sets of concentric rings with each set surrounding a central or haversian canal Blood vessels that run parallel to the long axis of the bone are contained within the central canals Each canal with the lamellae and osteocytes surrounding it is called osteon or haversian system Each osteon looks like a microscopic target with the central canal as the bulls eye Osteocytes located in lacunae are connected to one another by cell process in canaliculi The canaliculi give the osteon the appearance of the having tiny cracks in lamellae

Cancellous Bone o Spongy bone because of its appearance o Located mainly in the epiphyses of long bones and it forms the interior of all other bones o Consists of delicate interconnecting rods or plates of bone called trabeculae which resemble the beams of scaffolding of a bulding

Articulations The site where bones meet with each other Joints o Synarthrosis (sutures) o Ampiarthrosis (vertebral and pelvic) o Diarthrosis (maximum movement) o Fibrous (sutures area: coronal, frontal, sagittal), cartilaginous and synovial o Prevent direct contact to two opposing bones o Provides gliding motion o Shock absorption o Bursa sock filled with synovial fluid; important for shock absorption o Position and movement of bones Ligaments retinaculum (hands) Tendon- structures that connects /attach muscles to bones o Specific Types Fibrous joints Consists of two bones that are united by fibrous tissue and exhibit little or no movement Sutures o Fibrous joints between the skull Gomphoses o Consists of pegs fitted onto sockets and held in place by ligaments Cartilagenous Joints Untie two bones by means of cartilage. Only slight movement can occur at these joints Fibrocartilage o Is a type of cartilage that reinforces by additional collagen fibers. It is the kind of cartilage where much strain is placed on the joint Synovial Joint Freely movable joints that contain synovial fluid in a cavity surrounding the ends of articulating bones Articular Cartilage o Provides a smooth surface where the bones meet Joint Cavity o Filled with synovial fluid Joint Capsule o Helps hold the bones together and allows movement Synovial Membrane

o Produces synovial fluid Bursa Diarthrosis joint Plane of gliding joints o Joints in carpal bones Saddle Joints o Joints at the base of thumb Hinge joints o Elbow and knee joint Pivot Joint o Radius and ulna Ball and socket o Hip and shoulder Functions Prevents direct contact btw two end bones Allow gliding or sliding motions Absorb shock Bone Maintenance and Healing Regulatory factors determining both formation and resorption Physical activity Diet Calcitonin o For bone mineralization; stimulated if px is hypercalcemic Parathyroid hormone Thyroid hormone o Hyperthyroidism = bone dimineralization Cortisol Growth hormone Sex hormones o Dec Estrogen = bone deminiralization = osteoporosis Weight bearing stress stimulate local bone formation and resorption; in mobility, where weight bearing is prevented, Calcium is lost in the bone Vit. D promotes absoption of calcium from the GI and accelerates Vit D maintain increase Serum Ca levels Types Intramembranous o Compact bone Endochondreal o Cancellous Bone marrow osteoblast Bone cortex osteon Periosteum hard callus is formed (intramembranous) Cartilage endochondrial ossification Phases Reactive o Hematoma/recruitment of inflammatory cells. Angiogenesis and granulation Reparative o Pre-callus precursor (3-4 weeks) Remodelling Nursing Consideration Age

Very young = immature bones give all supplements to promote bone growth Very old = osteoporosis quite at risk for fractures consider displacement and site of fracture Displacement of fracture Site of fracture Nutritional level Blood Supply to the area of injury CAN AFFECT TIME REQUIRED FOR BONE HEALING

Anatomy of Muscular System 3 Types o Smooth Found in the hollow organs of the body Eg. Stomach (capable of mixing waves), small and large intestine, airways (capable of peristalsis), blood vessels Slightly striated involuntary o Skeletal Striated because of the alternating lines myocin and myofilaments Voluntary Lower neurons control the activity of the skeletal muscles Energy is consumed when the skeletal muscles contract in response to stimulus Lactic Acid By-product of muscle metabolism when O2 available to cell is not sufficient Muscle fatigue results from increased work of the muscle o Depleted glycogen and energy stores o Accumulation of lactic acid muscle cramps o Cardiac Exclusively found in the myocardium Intercalated disks gives automaticity involuntary types of Muscle Contraction o Isometric Contraction Length of muscle remains constant but the force generated is increased o Isotonic Contraction Shortening if muscles, but no increase in muscle tension Muscle Tone o Flaccid (Limp) o Spastic o Atonic (soft and flabby px who are post-stroke) Muscle Action o Prime Mover Deltoid muscle o Synergist Same actions Biceps o Antagonist Biceps Types of motions o Flexion o Extension

o Abduction o Adduction Older Adult Care Focus o Decreased bone density (most are osteoporotic) Ensure safety o Decreased in subcutaneous tissue less soft tissue over bony prominences o Degenerative changes in the spine alter posture and gait o Degenerative changes in cartilage and ligaments leads to decreased movement of joints o ROM decreases o Slowed movements and decreased muscle strength

Assessment Health history Past health, social and family history Physical Assessment o Posture: Kyposis (forward curvature of the thoracic spine), lordosis (lumbar), scoliosis (lateral curvature) o Gait o Bone integrity (crepitus) o Joint function (contracture, dislocation, subluxation) o Muscle strength and size (clonus/fasciculation) o Skin o Neurovascular status (circulation, motion, sensation) Laboratory/Diagnostic Tests Blood Tests o ESR (elevated in SLE and arthritis) o Rheumatoid factors (+ in rheumatoid arthritis) o Lupus erythematosus cells (LE Cells) o Antinuclearantibodies (ANA) (+rheumatoid arthritis) o Anti-DNA (+ in SE) o C Reactive protein ( o Minerals Calcium Decreased levels in osteomalacia, osteoporosis Increased in levels in bone tumors, healing fractures, Pagets disease Alkaline Phosphatase Elevated levels in bone cancer, osteoporosis, osteomalacia, Pagets disease/metastatic ca (acid phosphatase) Phosphorous Increased levels in healing fractures, bone tumors o Muscle Enzymes Aldolase Elevated in muscle dystrophy, dermatomyositis AST CK (Creatine Phosphokinase) Elevated in traumatic injuries LDH (Lactic Dehydrogenase) Elevated in skeletal muscle necrosis, extensive cancer X-Rays (Roentgenography) Bone Scan

Measures radioactivity in bone 2 hours after IV injection of radio isotope; detects bone tumors, osteomyelitis o Nursing care: Patient must void immediately before procedure Determine allergies Patient must remain still during scan Arthroscopy o Insertion of fiberoptic scope into a joint to visualize it, perform biopsies or remove loose bodies o Performed in OR under sterile technique o Nursing care: Pressure dressing for 24 hours Patient must limit activity for several days Assess neurovascular status Arthrocentesis: removal or synovial fluid, blood or pus from a joint Myelography o Lumbar puncture used to withdraw a small amount of CSF, which is replaced with a radiopaqued dye; used to detect tumors or herniated intervertebral discs o Nursing care: Consent must be signed Check for iodine allergy Keep NPO after liquid breakfast o Nursing care post test: If dye has been completely removed (oil dye), keep patient flat for 12 hours If dye has not been completely removed (water based dye Amipaque), keep head of g meningeal irritation and seizures. If water based dye is used , put patient on seizure precaution and do not administer any phenothiazine drugs (or any sedating drug to assess the level of consciousness) CT Scan and MRI o CT Scan tumors o MRI any lesions concerning the posterior fossa Electromyography(EMG) Lower motor neuron/Peripheral nervous system o Measures and records activity of contracting muscles in response to electrical stimulation; helps differentiate muscle disease from motor neuron dysfunction. o Explain procedure to patient and prepare him for discomfort of needle insertion

Traumatic Injuries Open type bone fracture has a communication with the environment which orgs can enter osteomyelitis Strain o Is an injury to the muscle when it is stretched or pulled beyond its capacity o Common cause: overstretching Sprain o Is injury to the ligaments surrounding a joint o Common cause: over twisting Contusion o Soft tissue injury with ecchymosis or bruising o Common cause: blunt force o Head trauma o Opening concussion

Grading First Degree

Mild stretching s/sx: minor edema tenderness mild muscle spasm o requires immobilization and NSAIDS Second Degree o Partial tearing o s/sx: loss of load bearing strength edema tenderness muscle spasm ecchymosis related to the partial tearing, expect blood vessel involvement o requires surgical intervention Third Degree o Sever damage with complete rupturing or tearing o s/sx: severe pain tenderness increase edema abnormal motion o requires surgical intervention

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General Nursing Management: R rest immobilize patient check for neurovascular integrity (pulse, sensation and movement) I ice first 24 hrs, use Ice (vasocontrict blood vessel = minimize s/sx). After 24-48 hours, use warm compress (absorb any ecchymosis/hematoma that accumulated because of vasodilation) C compress E elevate Carpal Tunnel Syndrome compressed median nerve by the transverse carpal ligament (wrist) involves thumb, portion of the ring finger, middle finger and pointer finger causes: o repetitive and constant flexion of the wrist s/sx: o paresthesia o muscle weakness o clumsiness when using the hand o PAIN Diagnosis: o (+) Tinels Sign o (+) Phalens Test Nursing management o Goal no. 1: to prevent further compression of the nerves Rest hands Avoid excessive use of involved hand Instruct patient not to sleep over the involved hand

Administer medication as ordered NSAIDS o Goal no. 2: to prevent injury Instruct patient to wear gloves Medical Management: o Analgesics Minimize/relief pain ASA (acetylsalicylic acid / aspirin) NSAIDS Taken with full stomach can cause hyperacidity o Corticosteroids Oral Prednisone Surgical Management: o Carpal tunnel release

Fracture Is a break in the continuity of a bone Occurs when the bone is subjected to stress greater than it can absorb Mechanical overload to the bone Causes: o Direct blows vehicular accidents o Crashing forces o Sudden twisting motions o Extreme muscle contractions Types o According to skin involvement Open / Compound Communication to the skin Seriousness depends to the degree of opening Infection and bleeding Closed / Simple Patient just need to be immobilized o According to Breaks Complete Up to the shaft Incomplete Linear break o According to Line Comminuted Different angles Greenstick One side is fractured, other side is uninjured Spiral/Torsion Linear fracture that twisted Transverse Oblique Can reach the skin Impacted Related to the skull and vertebrae Depressed Compression

Pathological/Spontaneous Common to osteoporotic or malignancy of the bone o Intracapsular and Extracapsular Hip Fracture Require fixation Clinical Manifestation o Pain o Muscle spasm There will be injury to the nerves Nerves and blood vessels are located in the periosteum o Loss of function Particularly if complete fracture and it is an open type o Deformity o Shortening Extremity and limb because of the muscle spasm o Swelling and discoloration o Crepitus / crepitations Particularly of the joint area is involved o Localized edema and ecchymosis Diagnostic tests o Radiography /x-ray fastest o CT Scan cranium o MRI Posterior fossa (brain stem, vertebra) Goal of interventions: o To prevent further damage Immobilization Support extremity Provide adequate splinting Control bleeding Leads to compartment syndrome Check peripheral pulses distal to the injury Cover wound with sterile or cleanest material available To control / prevention osteomyelitis Medical management: o Reduction Closed Casting, traction, manual manipulation Open Requires sterile area surgical procedure 2 types o Open reduction with internal fixation (ORIF) o Open reduction with external fixation (OREF) At risk for infection Complication for external fixator: Infection o Staph areus o Nursing management: Asses for redness, tenderness, pain, swelling, and loosening of pins.

Prevent crust formation Nursing management: o Closed fracture Instruction on control of pain and edema Use assistive device properly Modify environment to provide safety Self-care o Open fracture Risk of osteomyelitis (give antibiotics as ordered), tetanus (toxoids (preformed antibodies and immediate protection) and vaccines), gas gangrene (clostridium tetani) IV Antibiotics Delayed primary wound closure Elevate to minimize edema Neuromuscular assessment CMS (circulation, motion and sensation) Fracture Healing and Complication o Early Hypovolemic Shock Femur femoral artery (is a very pulsatile artery, direct to the abdominal aorta common iliac); high pressure Resulting to massive bleeding o Give fluids o Blood transfusion Fat Embolism ( 40 y/o, Male, multiple fracture) Sx: sudden hypotension, sudden dyspnea Compartment Syndrome Sudden decrease in blood flow distally (PAIN) Majority of the compartments of the body is found in the extremities Venous Thromboembolism DIC (Disseminated Intravascular Coagulopathy) Decrease in platelet o Delayed Delayed Union Malunion Nonunion o Nursing Management: Pain control Fracture of Specific Sites o Clavicle (Collar Bones): Middle 3rd of the clavicle Figure of eight bandage o Humerus (shaft or neck) o Elbow: Supracondylar fracture of the humerus (Volkmanns contracture) Assess volkmannt contracture o Radial head: fall on an outstretched hand o Radial/Ulnar shaft: common among childen o Distal Radius (Colles Fracture): Open dorsiflexed hand, commonly in elderly o Pelvic: rule out other internal damage because of the proximity of the two structures o Femoral shaft: fall or motor vehicle crash o Thoracolumbar spine: vertebral body, laminae, and articulating process, spinous process

Osteomyelitis Infection of the bone; Staphylococcus Aureus

Haematogenous spread (infection elsewhere then septecemia then to the bone) / direct trauma / VI Acute / Chronic osteomyelitis Risk factors: o Age o Nutrition o Blood vessels involvement o Immune system o Co morbidities (CM) Infection sets in inflammatory reaction (pain, swelling, heat) causes devascularisation of the bone, bone ischemia and necrosis Sequestrum (cavity with abscess) abscess will be necrotic debris - necrotic bone tissue encased by involucrum Pathologic fractures can occur Only when all dead bone tissue is removed will full healing occur o Require surgical intervention Pathophysiology o Risk factors: Acute OM inflammation (Increase vascularity and edema) 2-3 days: thrombosis (ischemia then necrosis) medullary area and periosteum involvement sequestrum (abscess cavity) surrounded by new bone growth: involucrum (new bone growth) recurring abscess chronic osteomyelitis Assessment and Diagnostic o Isotope labelled WBC, MRI o X-ray: tissue edema 2-3 weeks: periosteal elevation and bone necrosis Chronic OM: large irregular cavities, raised periosteum, sequestra, dense bone formation Blood culture On two different sites Interventions o Administer antibiotics o Debridement / incision and drainage o Antibiotic beads Made up of Ca Little to no systemic effect Advantage: it is absorbed while being replaced by new bones. No need for grafting anymore o Sequestrectomy o Saucerization o Bone grafting/muscle flap

CAST -

A rigid external immobilizing device that is moulded to the contour of the body Purpose: o To immobilize a reduced fracture o To maintain body alignment o To correct deformity o To apply uniform pressure to underlying soft tissue o To support and stabilize weakened joints When casting a joint, include the proximal as well at the distal area to stabilize the injured site / extremity

Types of Casting Materials Plaster of Paris o Traditional cast

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Rolls of plaster bandage are wet in cool water and applied smoothly to the body Heavy and has a rough surface Crystallization: rigid dressing 15-20 mins Exposed to circulating air to dry Disadvantage: absorbs moisture Avoid in water contact Complete dryness: 24-72 hours after application No not cover with towel Lest costly Achieved a great mold; less durable (compared to fiber glass) Exothermic characteristic When you apply it, it exclude heat and warm Hindi nagkakaroon ng panic o anxiety ang patient DRY White and shiny Resonant Odourless Firm, hard and rough WET Grey Dull Musty Damp to touch

Appearance Percussion Odor Texture -

Non Plaster / Synthetic Cast o Fiber Glass Water activated polyurethane materials, lighter in weight, stronger and more durable Lightweight and has smooth surface Should never be exposed to any plastic surface (it will get deformed) because it is hot Inform patient to prevent anxiety or panic attack Make sure to prevent they are placed in edges or corner to prevent denting of the fiber glass Avoid denting any disfigurement to the fiber glass could lead to skin irritation or breakage/lesion Water-prof lining (Gore-Text) Complete dry: 24-72 hours o Splints Used for conditions that do not require rigid immobilization Expect swelling It can be easily removed Require special skin care Overwrapped with an elastic bandage applied in spiral fashion Short term in use o Braces Provide support, control, movement and prevent additional injury Cervical brace, collar Custom fitted to various parts of the body Expensive Indicated for longer use (at least 8 years)

Short Arm Cast Long Arm Cast Elbow is at a right angle Short Leg Cast Knee down to the sole/base of the toe Foot is at a right angle, neutral position

Long Leg Cast Extends from the upper, middle third of the thigh to the base of the foot Knees slightly flexed Walking Cast Long and Short To re-enforce strength Body Cast Encircles the trunk Spica Cast At least two types: o Shoulder Body jacket that encloses the trunk, shoulder and elbow o Pelvic Shoulder, lower extremity (one or both) Nursing Management Carry cast with palms of the hands when WET Elevate with pillow support Expose to dry environment Keep clean and dry Observe for signs of inflammation then infection Maintain skin integrity Neurovascular assessment meticulously and regularly Move patient every 2 hours (patient with body casts) to relieve pressure In turning, use of trapis or railings can be done CAST SYNDROME Due to immobilization Decrease gastric mobility accumulation of air in the stomach and lung bloated patient gastric acid reflux, constipation abdominal distention anorexia COMPARTMENT SYNDROME Increase in pressure in a confined space there is decrease blood flow affecting important structures such as blood vessels and nerves Asses neurovascular status o Peripheral pulses o Motion o Sensation 5 Ps o Pain primary symptom o Pallor o Pulselessness o Paresthesia o Paralysis Management o Assess neurovascular status o Elevate the affected limb to the level of the heart To minimize edema (normal reaction of body against trauma) Surgical Intervention o Fasciotomy (opening of the fascia to relieve the pressure) o Remove the tight cast or dressing o Bivalving/Use of posterior mold

PRESSURE ULCERS Take note of the body prominence Inform patient that they should inform you if there is pain or tightness in the area DISUSE SYNDROME Muscle atrophy and loss of strength Tense or contract muscle (isometric contraction) without moving the part TRACTION Application of the pulling forces Short term intervention Purposes o To reduce, align and immobilize fractures o To minimize muscle spasms o To reduce deformity o To increase space between opposing surfaces Principles o Continuous to be effective o Never interrupted o Weight are not removed unless its an intermittent traction o Eliminate any factor that may reduce its effectively o Good body alignment in the center of the bed o Ropes must be un obstructed o Weight must hang freely o Knots in the ropes or foot plates must not touch the pulley or foot of the bed Types o Straight or Running Traction Applies the pulling force in a straight line with body part resting on the bed (Bucks Traction) o Balance Suspension Traction Supports the affected extremity off the bed and allows some movement without disruption of the line of pull Another Types Skin Traction Bucks Extension Traction (leg) Indication: femur / hip involvement Simplest form of traction o Russels Traction Indication: Femur/hip joint fracture Incorporates the use of knee sling Hip is flexed to 20 degrees from the mattress o Bryants Traction Indication: children with congenital Hip dislocation For children below 2-3 years For children weighing less than 30-40 lbs N/R: buttocks should not touch the mattress assess neurovascular status of the lower extremity o capillary refill o Cervical Traction Indication: cervical spine fracture Make use of a cervical halter or cervical lining

 HOB is elevated to 30-40 degrees Pelvic Traction Indication: pelvic bone fracture Used for lumbar fracture Make use of a pelvic halter Supine position Skeletal Traction o Weights are attached directly to the bone o Make use of pins, screws, wires or tongs o At risk for osteomyelitis o Balanced Suspension Traction Make use of Thomas Splint with Pearson Attachment Part of the body is off the bed Hips are fixed 30 degrees Care of pin site: Clean with antiseptic Apply antibiotic No betadine rust pins No peroxide aerobic infection Nursing management Principles of Effective Traction o Continuous to be effective o Never interrupted o Weights are not removed o Observe food body alignment o Ropes must be unobstructed Complications o Atelectasis (inability of the patient to do deep breathing exercises) and Pneumonia Auscultate the lungs q 4-8 hours Deep breathing and coughing exercise o Constipation and anorexia Diet must be high fiber and increase fluids Stool softener as prescribed Improve appetite o Urinary Stasis and Infection Observe the characteristic of the urine Monitor fluid intake Monitor s/sx of infection Hesitancy Urgency Frequency Dysuria o Venous Thromboembolism Exercise muscles not in traction to prevent deterioration, deconditioning and venous stasis Monitor for tenderness, warmth, redness and swelling Check for Homans Sign Fat Embolism An embolism originating in the bone marrow that occurs after a fracture Usually occurs 48 hours after a fracture and clients with long bone fractures are more at risk Restlessness, changes in LOC, tachycardia, tachypnea, dyspnea, petechial rash over upper chest o

Nursing Interventions o Immediate Mobilization o Minimal fracture manipulation o Adequate support of fractures bones during positioning and turning o Support respiratory function o Initially administer oxygen then position in Fowlers position o 48-72 hours immediately immobilize o In there is already management immediate mobilize

Hip Fractures Common among elderly women Affected leg is always adducted, externally rotated and the limb is shortened o Nakalabas is femoral head Complaints of pain in the GROIN or in the medial side of the bone Same signs and symptoms with fractures Total or Partial Hip Replacement o Intertrochanteric hip fracture Metal ball and stem are inserted in the femur and a plastic socket o Total Hip Replacement Post Op Care o Maintain legs in abduction (place pillows between legs) adduction will displace prosthesis o Avoid bending o Use trochanter roll to prevent external rotation o No low chairs DEVICES Purpose o Widens base of support o Reduce weight bearing on the affected leg o Provide mobility to the patient Crutches o 2 inches below axilla o 6 inches front to foot o 2 inches to the side of the foot o Elbow flexion (20-30 degrees) o Exercises to prepare for CW: Hand muscle ex Arm muscle ex o Gaits o Stair climbing UP: good leg crutches with bad leg (Going to HEAVEN so use your GOOD leg) DOWN: bad leg with crutched good leg (Going to HELL so use your BAD leg first) o Important Muscles Shoulder Depressor / Latissimus Dorsi Needed first to advance the body forward Needed to lift the pelvis off the ground Elbow Extensors / Triceps Needed to prevent buckling of the elbow joint Finger Flexors Needed to grasp the hand grip o Crutch Walking Crutch gaits

When only one leg can bear weight Swing to gait: crutches forward; swing body to crutches Swing thru gait: crutches forward; swing body thru crutches 3 point gait 2 point gait

Cane o o Walker o o

Held on the non-affected side Cane walked together with the weak leg The most stable among the assistive devices Sequence: Advance walker within arms length (Approx 10-20 inches in front of the patient Walk beside the walker

OSTEOPOROSIS Abnormal increase in bone resorption causing a decrease in bone density Loss of bone mass with aging, decrease calcitonin and estrogen and increased parathormone Deminiralization (Loss of Ca and phosphate salts) bone becomes porous, brittle, fragile structural weakness pathologic fractures Fractures of thoracic, lumbar neck and intertrochanteric fx of femur and Colls fx of wri st Risk factors: o Menopause o Sedentary lifestyle o Genetics o Age o Nutrition o Physical Exercise o Medications Dowagers Hump / Kyposis Signs and Symptoms o Usually asymptomatic o Sudden onset of sever back pain o Skeletal deformity o Bone pain and tenderness o May show s/sx of pulmonary insufficiency o Dec calcitonin and estrogen o Inc PTH Dx Assessment o X-ray o Bone scan Nursing management o Recognize risk factors and prevent further injuries o Adequate dietary intake of Ca and other minerals, CHON and CHO o Calcium supplements with Vitamin D o Physical therapy moderate exercise mechanical stress stimulates bone formation o Fracture management o Biphosphates Etidronate (Didronel) Nephrotoxic Increase bone density and restore lost bone Inhibit resoprtion of bone Monitor for nephrotoxicity and seizures o Fluoride Alendronate (Fosamax)

Stimulate bone formation Strict GI precautions Causes GI distress, esophageal erosin Administer on empty stomach Do not eat or crink 30 mins Take with water 6-8 onz not juice and Remain upright for 30 mins after taking drug Monitor: hypercalcemia and tetany serum electrolytes Increase fluid intake and calcium rich foods

Rheumatoid Arthritis Autoimmune bone disease and hereditary Bilateral, symmetrical, inflammatory, systemic Progression through stages o Synovitis pannus formation (scar tissue) fibrous ankylosis bone alkylosis Signs o Fatigue, anorexia, malaise, weight loss, slight temperature elevation Usually affects joints symmetrically (on both side equally) Pathophysio o Presentation of antigen to T cell t and B cells proliferation, angiogenesis in synovial lining swelling in small joints, associated with pain, stiffness and fatigue neutrophil accumulation in synovial cell proliferation. No cartilage invasion 2 possibilities: 1) warm effusions, pain and decreased motion with possible rheumatoid ndules 2) synovitis, early pannus invasion, chondrocyteactiviation, degredation or cartilage subchondral bone erosion; pannus invasion Painful, warm, swollen joints with limited motion, stiff in the morning and after period of inactivity Crippling deformity/swan-neck or buotonierres deformity Muscle weakness History of remission and exacerbations Severe anemia Sjorens syndrome Felts syndrome o A disorder that can affect people who have rheumatoid arthritis (RA) o It is defined by the presence of three condition: RA, enlarged spleen and low WBC count Dx test o X-ray o Laboratory (+) Rheumatoid Factor Nursing Management o Apply cold compress to the affected part o Minimize muscle spasms and joint stiffness o Avoid prolonged sitting or standing o Encourage ROM exercises after taking pain meds Surgical Management o Osteotomy, synovectomy, or arthroplasty Pharmacotherapy o Aspirin o NSAIDs Indomethacin (Indocin) Phenylbutazone(Butazolidin) Ibuprofen o Gold Compounds (Chrysotheraphy) Arrest progression of the disease Sodium thiomalate

Aurothioglucose Auranofin Corticosteroids Intra-articular injections

Osteoarthritis Degenerative joint disease Idiopathic or secondary 3rd decadeof life and peaks between the 5th and 6th decades Affects the articular cartilage, subchondral bone and synovium Cartilage degeneration, bone stiffening, reactive inflammation wear and tear Risk factors: age, obesity, previous joint damage, repetitive use, anatomical deformity Manifestations o Pain (osteophytes) o Stiffening o Functional impairment Dx o Progressive loss of joint cartilage o Osteophytes o Joint space narrowing (x-ray) Management o Relieve strain and further trauma to joints o Cane or walker if indicated to relieve stress o Proper body mechanics o Avoid excessive weight bearing and standing o Physical therapy o Relief of pain (NSAIDS) o Joint replacement as needed Gouty Arthritis Classifications o Primary o Secondary Due to acquire condition Starvation Alcohol intoxication Renal failure Risk factors o Common among males o 20 x greater than females o 30 y/o and above s/sx o inflammation of the joint o pruritus o TOPHI formation Subcutaneous nodules o Skin ulceration o Late Stage Bone deformity Intolerance to bed linens Management o Asses affected joint for pain motion and appearance

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Educate patients in recognition of early symptoms Increase fluid intake (3-5 L) Bed rest until pain subsides Report any decrease in urine output Low purine diet Admin medications as ordered Allopurinol (Zyloprim) MOA: prevents formation of uric acid Probenicid (Benemid) Colchicine (Colgout) MOA: dec deposition of uric acid to the joint Drug of choice to prevent attacks

Amputation Surgical removal of a part of a limb Levels: Syme, BKA(Below the Knee Amputation), AKA (Above the Knee Amputation), stage amputation Guillotin Amputation o Stage type amputation Post op care o Monitor VS o Evaluate for phantom limb sensation and pain; explain to the patient o During the 1st 24 hours, elevate stump; after that flat on bed to prevent flexion hip contractures o After 48 hours, instruct also to be one prone position several times a day o Maintain application of ace wrap to promote stump shrinkage Stump Dressing o Soft- greater potential for haemorrhage and rehabilitation is longer but easier to assess o Rigid facilitates earlier ambulation but difficult to assess Post op complications o Haemorrhage o Infection o Contracture Bone Tumors / Malignancy Classified according to its characteristics o Benign Most common: osteochondroma Endochondroma: hyaline cartilage (joint spaces and synovial cavity) Bone cyst (collection of fluids found in a confined area) Osteoid osteoma Giant Cell Tumors (osteoclastomas) common in children o Malignant Most common: Osteosarcoma Bone tumors: primary or secondary Commonly seen to 10-25 years of age Most of the time they are just accidental finding o Suddenly there will be palpated mass; no pain o Palpable mass or hard lump, pain, pathologic fractures, decreased sensation, numbness and limited movements Tumor erodes the bone cortex elevating the periosteum Most common site: distal femur, proximal tibia and humerus Increased serum alkaline phosphatase because of bone lysis DX: bone biopsy

Radiation, chemotherapy, surgical removal or tumor Radiological finding: periosteal elevation o Demineralized bone Pathognomonic hallmark: Codmans Triangle and Sun Ray Spicules (both suggests malignancy) After surgery, potential complications: o Delayed wound healing Related to tissue trauma Effect of Radiation therapy Poor nutrition (with malignancy, there is hypercatabolic anorexia effect of cytokines hyperleukines Infection(wound) o Inadequate nutrition o Osteomyelitis and wound infection o Hypercalcemia common problem is arrhythmia, clogging of the blood vessel, calcium stone renal failure

Scoliosis Lateral curvature of the thoracic, lumbar or thoracolumbar spine. Rotation of the vertebral column causes rib cage deformity. When deviates to the RIGHT: DEXTROscoliosis When deviates to the LEFT: LEVOscoliosis Types: o Functional: poor posture or discrepancy in the leg length o Structural: deformity of the vertebral bodies Loss in the height of the vertebral bodies Common with those with osteoporosis or congenital, neuromuscular idiopathic scoliosis (infantile, juvenile and adolescent) Can happen anytime during bone formation o Different stresses on the vertebral bodies causes imbalance of osteoblastic activity; curve progresses rapidly during adolescent growth spurt Signs o Uneven hemlines, one hip higher than the other, unequal shoulder, heights and iliac crests, asymmetric thoracic cage Sugrical o Posterior fusion o Harrington Rod instrumentation Wisconsin wire technique and Luque technique o Zielke System For thoracolumbar scoliosis (severe) Makes use of wiring to maintain alignment of the thoracic spine Dx o Observation / Inspection o Thoracic X-Ray (Cobbs Method) done to see R or L deviation of the spine o Adams Forward Bending Test o Scoliometer to look at the angle of the scoliosis (>30 percent: not only deformity but also sever pain because of the compression of the spinal nerves) Complications o Pulmonary insufficiency, back pain, HPN, sciatica (Radiating pain, back to foot), degenerative arthritis of the spine Tx o Depends on the age where is was diagnosed

10-20 y/o leg exercises and pelvic tilt: strengthen torso muscles 20-40 y/o exercises + braces: worm until the bone growth is complete 40 y/o and above: spinal surgery instrumentation with fusion Cannot bend much because of the instrumentation with fusion Nursing Consideration o Suggest loose, fitting clothes wear undergarments when wearing the brace o Wear the brace for 23 hours a day (1 hour for taking a bath) for 7 days o Advise to increase activities gradually o After corrective surgery Check neurovascular status q 2-4 hrs, logroll Monitor I and O, watch out for signs of bleeding Patient will have splinting, so teach deep breathing exercises to prevent atelectasis pneumonia Medicate for pain, do ROM Offer emotional support for altered body image o Crankshaft Phenomenon Observed after spinal fusion there is continuous growth of anterior vertebral body Prevention: Delayed the surgery until the child is older than 10 years Addition of anterior fusion plate Use of specialized instrumentation that allows subsequent expansion of the vertebra

TB of the Spine Potts disease is a presentation of extrapulmonary (originates from the lungs, hematogenuous spread) tuberculosis that affects the spine, a kind of tuberculosis arthritis of the intervertebral joints. s/sx o back pain o fever o night sweating o anorexia o weight loss o massive destruction of the vertebra swelling o spinal mass sometimes associated with numbness, tingling sensation or muscle weakness of the legs infections o Potts disease Organism: TB Bacilli Primary Focus: Lungs Pathology: Infection bone destruction collapse of the vertebrae Gibbus Formation Spinal Cord compression Mgmt Anti-Kochs medicaiotns, spinal brace Tx minimum of 12 months Surg Anterior Decompression Spinal Fusion Bone infections are difficult to treat because they are relatively inaccessible to protective macrophages and antibodies

Pediatric Orthopedic Conditions Congenital Clubfoot Congenital malformation of the lower extremities Unilateral or bilateral Defects are rigid and cannot be manipulated into a neutral position Talipes varus an inversion or bending inward Talipes valgus eversion or bending outward Talipes equinus plantar flexion in which the toes are lower than the heels Talipes calcaneus dorsiflexion Nursing care and treatment o Serial manipulation and casting weekly and if correction not achieved in 3-6 months then surgery is indicated Surgical o Usually done 4-12 months of age (Kyzer, 1991) o After surgery, a cast holds the clubfoot still while it heals o Special shoes or braces will likely be used for up to a year or more after surgery o Same as any child with a cast Congenital Hip Dislocation Dysplasia of the hip wherein the head of the femur is not properly anchored in the acetabulum Can be congenital or develop after birth Assessment o Asymmetry of the gluteal and thigh skin folds when child is placed prone o Limited ROM on affected hip o Apparent short femur on the affected side o Positive Ortolani or Barlow Maneuver o Waddling gait; positive Trendelenburg sign You see that the head of the femur is far from the acetabular fossa Nursing care and treatment o Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotation o Traction and surgery to release muscles and tendons o Following surgery, positioning and immobilization in a spica cast then use of abduction splint *READ ACUTE LOW BACK PAIN *READ BRURITIS and TENDINITIS *READ Ganglion Cyst *READ DUPUYTRENS CONTRACTURE FOOT PROBLEMS Plantar Fasciitis Corn Callus Ingrown Toenail Hammer Toe Hallux Valgus Pes Cavus Flatfoot (Pes Planus)