142 – Unit II

Musculoskeletal System
The supporting framework of the body it consists of your bones, joints cartilage, tendons, muscle and
ligaments.

Purpose - Provides protection to vital organs (heart, lungs, brain etc..)

Provides sturdy framework to support body structures and voluntary movement
Stores minerals (Ca, Mg, Ph, Fl)
Hematopoiec tissue-allows for blood cell formation

Bones (206 bones)

Long – femur, humorous, radius
Short – carpals and metatarsal on both hands and feet
Flat – sternum, ribs, skull, scapula
Irregular – vertebral column, mandible, patella,sacrum

Bone cells Osteoblasts – bone-forming cells

Osteocytes – mature bone cells
Osteoclasts – bone reabsorbing cells
The process of bone formation is called osteogenesis

Joints
The junction where two or more bones that are articulated (close to each other) and provide motion and
flexibility in several directions.
Types of Joints
Synarthrosis – immovable (skull sutures, sacrum)
Amphiarthrosis – limited movement (vertebral joints, symphysis pubis)
Diarthrosis – freely movable
Ball & socket – full freedom of movement (hip, shoulder)
Hinge – bending in one direction (elbow, knee)
Saddle – movement in two planes at right angles (base of the thumb)
Pivot – rotation turning a door knob (articulation between radius & ulna)
Gliding – limited movement in all directions (wrist)
Cartilage
Connective tissue that provides support to soft tissue
Found in between articulated surfaces
Avascular (no blood supply) – fed by synovial fluid

Muscle
Used for body movement, posture and heat production
Skeletal- More than 55% of muscle in body
Smooth- Inside of arteries, inside of bladder, inside lining of GI tract
Cardiac- Found in heart
Causes spontaneous contractions and relaxations in the heart
When muscle contracts it brings two points of attachment closer together

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Ligaments and Tendons
Ligaments- attach bone to bone
Tendons – attach muscle to bone
Both are made up of connective tissue
Both have poor blood supply (avascular) so nutrition is gained from synovial fluid
Fascia
Think of an envelope
Fibrous connective tissue that encapsulates muscles
Smooth tissue that allows gliding of muscle over muscle

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Musculoskeletal Assessment
Patient History Past medical history- specifically:
Description of health problems
Family history of M.S. problems
Medication history (otc drugs, rx drugs, nutritional supplements)
Hx of bone infection (osteomylitis)
Assess for muscle spasms. What do they use to treat?
Surgical hx r/t m.s problems
Was patient ever immobilized for long periods of time (risk of renal
calculi and osteoporosis)
ADL assessment- independent, needs assistance
Are they able to move joints independently without restriction?
Elimination- can they get to the bathroom on time?
Use of assistive devices
Nutritional intake (24 hr recall, supplements, weight loss or gain.)
Pain
Assess for:
intensity - pain scale 1-10
quality - sharp, dull, throbbing, burning
onset – when did it start
timing – when is pain worse (morning, evening.)
aggravating factors – what seems to make it worse
association – is it linked to anything else
If unrelenting pain to an area after medication, it may indicate compartment
syndrome. This means device being used (traction, casts, splints etc.) will need
to be removed immediately. Neurovascular compromise is occurring.

Physical exam Inspection

Did patient walk in independently, or via wheelchair, assistive devices
used
Observe posture and gait:
Looking for abnormal walking pattern and spinal abnormalities
Kyphosis – hunchback, forward curvature, roundness of thoracic spine
Lordosis – swayback, exaggerated curve (inward) of lumbar spine
Scoliosis – lateral curvature of the spine
Palpation
Start at head downward
Compare sides to assess for symmetry.
Assess skin temp, tenderness, swelling or crepitation
Range of Motion
Active ROM – pt does independently w/o assistance
Passive ROM – pt able to perform with assistance
Assessment of:
Flexion – bending at a joint
Extension – straightening at a joint (ie-stretching)
Abduction – moving away form midline
Adduction – moving toward the midline
Pronation – turning palm downward
Supination – turning palm upward
Inversion – turning inward
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 Eversion – turning outward
Circumduction – Moving extremity full circumference
Muscle strength
Assess muscle strength bilaterally
Muscle strength scale
0 – no muscle contraction detected
1 – Barely detectable flicker or trace of contraction
2 – Active movement with no gravity
3 – Active movement against gravity
4 – Active movement against gravity and some resistance
5 – Active, against full resistance w/o evident of fatigue
This is normal muscle strength

Abnormal Findings -Crepitus (grating, crackling sound or sensation)

A lot of times heard in pt’s with fractures, or osteoarthritis
Kyphosis- “dowagers hump”. Convex shape to the thoracic region.
Abnormal muscle movement
Paralysis - loss of voluntary sensation or movement
Hemiplegia – paralysis of one side of the body
Paraplegia – paralysis of the of the lower half extremities
Quadriplegia – paralysis of all 4 extremities
Contractures- shortening of muscles or ligaments and as a result there will be
tightness, and alignment will be incorrect. Extremities will eventually become
immobilized
Additional Assessments to assess for neurological compromise:
6– P’s
Pain- ask patient to use pain scale to rate pain( See “pain” above)
Pressure –test to be sure fingers can fit under
Pallor – color (pale,cyanotic) , may feel cool or cold. Check cap refill
Pulselessness – an emergency. Pulses are strong or bounding, diminished,
absent or audible via doppler
Always check unaffected extremity first then check affected leg
Parasthesias – numbness, tingling, burning sensation (indicating circulation
problems, intermittent claudication)
Paralysis – loss of sensation or movement. Assesss by having pt exercise area
above or below injury (ie wiggle toes, move fingers)

Diagnostic evaluation of M.S. system

X-ray – Used to detect fractures can detect bone density, identify calcifications and tumors
CT scan - x-ray picture of internal M.S. structures can use contrast for definition
With contrast check for allergies! Pt has to lay still 20 – 60 min.
MRI - Visualize Soft tissue, such as cartilage
Visualization of cartilage tears, ligaments, tumors, and herniated disk
Non-invasive with or w/o contrast
No pacemakers, no metal clips or implants
Takes 1-2 hours, claustrophobia is a problem
Arthroscopy -scope inserted to examine joint disorders
Scope is used to insert air or fluid into joint, take film of joint, take biopsy
Sterile (done in OR under strict asepsis) invasive procedure
Sterile dressing
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 Elevate 24 hours post, limited action for few days post
Bone densitometry – osteoporosis check for bone density
Arthrocentesis- joint aspiration – Needle will be put into joint to extract synovial fluid
Usually clear or straw colored and transparent, abnormal would be blood, pus, cloudy or
uric acid crystals
Usually used to remove excessive fluid from an area, relive pain
Invasive – risk for infection, impaired skin integrity
Compression dressing post/op
Electromyography – EMG – painful, measures and records muscle activity with electrical
Stimulation

Lab Tests
CBC – WBC (infection), H&H (anemia)
Electrolyte imbalance – Ca (immobile pt, calcium leaves bone and enters blood),
Phosphorous, uric acid (gout)
Alkaline phosphatase – elevated during initial bone healing
Sedimentation rate – ESR elevated during inflammation

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Soft Tissue Injuries

Hot and cold therapy treatment for soft tissue injuries:

Cold Therapy
When – between the first 24-48 hours to prevent swelling, pain, and muscle spasms by promoting,
vasoconstriction
How –
Use ice bags, cold packs – 20 minutes on 20 minutes off
Compress with compression bandage
Elevate above level of heart b/c of swelling and excessive fluid to the area, elevation increases
venous return
RICE = R-rest, I-ice, C-compress, E-elevate ,
Hot Therapy
About 48 hours after injury
Promote circulation, analgesic, reduce muscle spasm, enhances flexibility
How – light/radiation, hot pack, heat pads
Use intermittent 15-30 minutes on and off
Not over 100 degrees
Care in elderly, young, diabetics or spinal injury patients due to loss of sensation in extremities.
NI -
Protect skin from irritation
Subjective info from pt to monitor response

Contusions
A soft tissue injury produced by blunt force trauma such as a blow, kick or fall
No damage to bones of the M.S. system

Bleeding from rupture of small blood vessels resulting in ecchymosis (bruise)

Or a hematoma when bleeding under the skin is excessive

Clinical manifestations
Pain
Swelling
Skin discoloration
Limited ROM
No loss of joint function

RICE – Rest. Ice, Compress, Elevate

*****WITH BOTH SPRAINS AND STRAINS THERE ARE THREE CLASSIC SYMPTOMS, PAIN,
TENDERNESS AND SWELLING.

Strains
An excessive stretching of the muscles and its facia sheath
May also involve tendons
Caused by overuse, over-stretching, twisting and excessive stress.
Tiny microscopic tears occur with some bleeding into the soft tissue
Heals in 2-6 weeks

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 S/S:
Sudden pain with out muscle movement
Muscle soreness and tenderness
Pain
Swelling,
Bruising and redness
Muscle spasms and decreased movement
Initially will not be able to bear weight on that extremity

Sprains
An injury to the ligament structures surrounding a joint
Caused by wrenching or twisting motion
May take weeks or months to heal
Joint is stretched beyond normal ROM tearing ligaments, capsule or synovium of joint
Blood vessel rupture and edema occurs
An avulsion may occur (bone fragment is pulled away by a ligament or tendon)
Common areas for sprains:
Ankles and wrists
Common in people who are in to sports
S/S:
Swelling
Joint tenderness
Limited joint mobility
Severe Pain with sprain b/c of amount of nerve endings where it occurs.

Diagnosis and treatment of Sprains and Strains:

Diagnosis:
History
Physical exam
X-ray to r/o fracture and to see if there is a widening of the joint area itself.

Treatment:
RICE technique in acute phase
Medications:
Mild analgesics (NSAID’s)
Heat in post-acute phase
Protected exercises
Surgical repair if necessary
Immobilize if necessary

ACL Injury–
Anterior cruciate ligament
A common sports injury in which the stabilizing ligaments of the knee are lost or compromised
S/S:
Snapping sound, pain, swelling
Unable to bear weight on that leg.

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 Management:
Surgical repair and use of full leg immobilization device

Torn meniscus
Tear in the fibro-cartilaginous semicircular structure of the knee joint
S/S:
Popping sound, tearing sensation, swelling, inability to extend knee
Management:
Surgery - total Menisectomy

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Joint Dislocations and Subluxations

Full Joint Dislocation

A condition in which the articular surfaces of your bones forming the joints are no longer in anatomical
contact. (Bones completely separate)
Severe injury of the ligament structures that surround a joint
• Orthopedic emergency to have dislocated joint because the following factors becomes distorted and severely
stressed:
o Blood supply to the area
o nerves running through that area
o soft tissue
If it goes untreated run the risk for developing avascular necrosis can occur
Due to insufficient or no blood supply going to area
There is also risk of developing nerve palsy
r/t pressure resting against nerve, and if continued for long period of time extremity may become
paralyzed, have weakness, numbness and tingling. Once nerve palsy develops it is very difficult to trea

Subluxation
Partial joint dislocation

Etiology 3 categories
• Congenital : Children or babies that are born with hip displasia
• Spontaneous: Actual disease osteoporosis, pagets disease, bone tumor or cyst
• Somatic: Sports injuries

Once dislocation occurs:

• Blood supply to area is compromised
• Nerves in area compromised
• Damage to surrounding ligaments

Signs & Symptoms of a dislocation:

• Severe pain to area
• Tenderness
• Swelling of soft tissue
• Limited ROM
• Numbness especially if there is nerve damage
• Asymmetry of MS contour (ie shortening of extremity)
• Loss of function to extremity
• Impaired neurovascular function
• Area distal to the joint may become cool, weak pulse, poor capillary refill
• Ecchymosis

Diagnosis:
• Patient hx
• Incident of what happened
• Physical exam
• X-ray to visualize how much structures have shifted

Treatment:
Orthopedic Emergency
Goal is to re-align dislocated portion and relieve pain
• Analgesics
• Muscle relaxants
• RICE
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 • Immobilize area to protect injured joint in acute phase
o Once joint is stabilized, gentle ROM exercises can be performed

Open –vs- Closed Reduction

• Closed reduction is accomplished by using hands to put the joint back into place manually
o Very painful procedure
o Medication or sedation (local or general) is required before the procedure b/c of the intensity of the pain.
• Open reductions means the joint is surgically repaired.
o Surgical realignment of joint
o Immobilization of area post-op (casts or splints) until fully healed.

Why do you think you want to reduce it immediately?

• To ensure circulation to that area especially if patient is complaining of numbness and tingling to the extremity
• With reduction many times you may have to provide splint, cast or traction for patient to help speed recovery.

Nursing Dx
• Acute Pain:
o Pt will be medicated
Be sure extremity is elevated because of swelling you want to decrease edema,
If patient is using an immobilizer make sure patient uses it correctly
• Impaired mobility
• Altered health maintenance
o Teach and demonstrate and have patient demonstrate back how to use an immobilizer

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Fracture
• It is a break in the continuity if bone and it is defined according to the type and extent.
• Occurs from trauma or a blow to a direct area
• Crushing sports injury and sudden

Pathophysiology
4 categories

 Closed fractures: bone is broken on the inside and there is no external injury, bone is broken
but skin is intact.

 Open fractures: There is a break in the skin causes by fractured bone protruding out.

 Stable fractures: break occurs, but bone is not completely broken off

 Unstable fractures: bones are grossly misplaced. Another name for this is an open fracture.

• Ie-Compound fracture

What Causes Fractures

• Trauma such as a direct blow

• Pathological bone diseases like osteoporosis where there is bone demineralization, bone tumors

• Taking meds that have S/E of depletion of bone or bone demineralization

• Long term steroid use makes your bones very porous and brittle which means more prone to breakage

Different types of fractures

Memorize picture in book( pg 2081) several questions on test

Stable fractures:
• Greenstick fracture: a fracture in which one side of a bone is broken and the other side is still stable
(not broken); seen in long bones

• Transverse fracture: a fracture that is straight across the bone; seen in long bones.

• Spiral fracture: a fracture that twists around the shaft of the bone; climbs or decends in a wrap around
fashion.
Unstable Fractures:
Compound Fracture: Bone is broken off altogether and is protruding out of the skin.

• Comminuted fracture: a fracture in which bone has splintered into several fragments. Most likely to
hear crepitus with this type of fracture.

• Depressed fracture: a fracture in which fragments are driven inward; skull and facial bones.
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 • Oblique fracture: a fracture occurring at a slant across the shaft of the bone

• Impacted fracture: a fracture in which a bone fragment is driven into another bone fragment; one bone
driven into another
Can be stable or unstable:
Compression fracture: a fracture in which bone has been compressed; seen in vertebral fractures; seen
in osteoporosis.

• Pathologic fractures: a fracture that occurs through an area of diseased bone, can occur without trauma
Can occur with osteoporosis, Paget’s disease, bone tumors, osteosarcoma, osteomalacia, bone cyst.

Which fracture is the worst one, the one you are prone to infection and takes a longer time to heal?
Compound fractures cause the bone to protrude out

Clinical Manifestations
• Pain
• Tenderness
• Muscle spasms

• Loss of function/immobilization of area

• Deformities where the extremity is just hanging

• Distal pulses may or may not be palpable

• Bone protrusion may be visible

• Crepitus: rubbing / grading sound, heard esp. with comminuted fractures

• Swelling w/numbness possible r/t nerve damage

• Ecchymosis
• Breaks in the skin especially if it is an open / compound fracture
• May or may not have damage to body organs
***ALWAYS ASSESS AREAS DISTAL TO BREAK FOR SIX P’S****************
If you fracture your ribs you will be compromising your lungs, heart, and spleen

Diagnosis of a fracture:
• X-ray
• Patient hx
• Physical exam
• MRI
• Ct-scan depending on the location and extent of the fracture

***before doing anything with a fracture you MUST take an X-ray***

***once fracture is corrected then another X-ray must be taken to confirm placement********

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How to manage a fracture:
• Do not realign a bone
• If it is an open fracture and you see bone sticking out = cover it w/sterile gauze or clean lint free material to
decrease risk of contamination
• Immobilize that part of the body and if you are moving that person you are going to support above and below the
area that is affected.
•

• Closed reduction: Non-surgical

o X-ray is taken , then fracture is manually put back together by hand, and then another x-ray is taken to
confirm placement. Bone is then immobilized with cast, splint or brace until area heals.

• Open reduction: ORIF (Open Reduction Internal Fixation) done in OR under general anesthesia,
o Patient is given pain meds, incision is made, bones are realigned, then insertion of pins, rods, nails, or
screws are used to put that bone back together into anatomical position
o Higher risk than closed reduction b/c of risk for infection, and riskd from anesthesia especially in young
and elderly.
Traction
The application of a pulling force on a fractured extremity to maintain alignment
Minimizes muscle spasms, reduces, aligns and aligns fractures & reduces deformities
Indications
Stabilize and reduce fractures
Increase space between opposing forces
Limb lengthening
Reduce deformities
Maintain anatomical alignment
Prevent contractions
Types of traction:
Skin –
Applied directly to Pts skin and soft tissue by use of ace bandages and traction boot
Pulley system at the end of the bed with weights
Weight 5-10 pounds maximum which hangs freely
Don’t put traction device on floor
Don’t cover device with sheets
Two forces working against each other- the weights, and the force of the body which is pulling back and
serving as counter traction.
Wrap and boot on extremity are not put over boney prominences
Short term use (will be used pre-op b/c pt is in a lot of pain with muscle spasms- traction helps to reduce the
muscle spasms and the pain

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 Assess area before applying, shave, avoid wrinkles in material used to wrap limb
Contraindications:
Rash, impaired circulation, varicose ulcers, and numbness
Complications
Allergies to tape, irritation, nerve palsy from pressure (foot drop), circulatory impairment (cold,
cap refill poor, poor pulse)

Skeletal –
Longer term use- can be weeks or months
Used to align joints, bones, restriction of movement
Traction applied directly to boney skeleton
Done surgically in OR
Pins inserted in bone distal to fracture
Weights are 5-45 pounds
Examples of skeletal traction: Halo traction, 4 pins in skull attached to vest
Cervical spine traction
NI:
Assess for six P’s every shift
Neuro assessment every hour post surgery than every 4 hours
Check for possibility of DVT’s with Homans sign (pain in calf with dorsiflexion)
Pin care
Risk for infection, osteomylitis(bone infection.)

Manual traction –
Traction applied with hands to realign a joint or fracture
While applying cast

Nursing Diagnosois:
Risk for infection
N.V. assessment
Wound drainage
Pain meds
S/S infection
Integrity of device

Anxiety R/T fear of equipment

Explain all procedures, monitor VS,

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 Teach relaxation (deep breathing, imagery)

Pain R/T inability to move or change position easily in bed

Reposition every 2 hours, use pain scale

Complications
Skin breakdown, circulation problems, foot drop, pneumonia, DVT, anorexia

Fracture immobilization
Once area has been fixed and back in place the patient may have to wear a cast, splint and they may have to
have internal or external fixation devices.

Splints
Immobilization device that supports one or both sides of a part of the body and is secured with tape or ace bandage plastic,
thermoplastic

Purpose –
In an emergency or for non rigid immobilization
To stabilize fracture during anticipated swelling and edema
Provide functional support & positioning before cast application

Nursing interventions
Well padded to prevent pressure and prevent skin abrasions & skin breakdown
Assess NV status frequently and 6 p’s
Wrap splint with elastic bandage
Teach patient to apply brace
Teach patient to protect skin
Teach patient to assess for 6p’s

Casts
Cast – rigid external immobilizing device molded to contours of the body
Purpose – immobilize part of body, support weakened joints, and treat deformities
Examples:
Short arm cast for fractures of the wrist area
Long arm cast for unstable wrist fracture or forearm fracture
Body jacket for fractures of thoracic or lumbar area to stabilize vertebral column
Hip/biker cast for pt’s that have suffered hip fractures

Types –
Plaster –
Does not have full strength until dry
Takes time to harden

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 Can be dented during hardening
New – white, shiny, odorless
Wet – grey, dull, musty

Fiberglass –
Better of the two choices
Light weight
Stronger, h2o resistant and durable
Hardens within minutes

Cast application
Skin assessment –
Clean and dry
Unusual swelling, bruising or edema
Body part in proper alignment
Marked area around bony prominences
Layer of stockingette to pt skin- make sure no wrinkles or creases
Thin layer of padding added especially over boney prominences
Apply cast material

Nursing interventions
Initially ice will be applied to areas above and below the cast to reduce swelling
Elevate cast limb on plastic covered pillow to encourage venous return to reduce edema
ROM exercises for joints above and below cast
Do skin assessment to assess for problems (ie discoloration of the toes, unusual pain, burning and tingling under cast, foul
odor coming from cast)****see complications below****
Check 6 P’s - pulse, pressure, pallor, pain, pulselessness, paresthesias, paralysis
Check for stain on casts- if present , circle it, time ,date and initial it. When re-checked later be sure stain has not spread
The best place to assess for bleeding w/in a cast is to lift the cast up, and check underneath.

Nursing Diagnosis
Risk for peripheral neurovascular dysfunction R/T cast too tight

Patient teaching
Itching under cast – do not stick sharp object, use cool blow drier
This is because you can’t see under cast, and an object can cut you and you wouldn’t know. May lead to
Osteomylitis
Do not get cast wet-only cover when showering b/c of risk of moisture build-up
If cast does get wet use hairdryer on cool setting to dry

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Do not remove any padding either above or below the cast.
Do not put powder in cast
Do not cover with plastic for long, only for showering.
Do not bear weight on it for first 48 hours.
Exercise unaffected limb to avoid disuse syndrome

Complications of cast wear:

Perineal nerve palsy-

Will most ofter be seen in arm or leg where perineal nerve is
Caused by:
Cast too tight
Cast put on prematurely (area is still swelling and edematous)
Your tissue will eventually press against perineal nerve
Once nerve palsy sets in there will be
Pain
Numbness and tingling to lower extremity.
Cast will have to be removed immediately.

Compartment syndrome –
Increase in tissue pressure within a limited space that compromises circulation and function of tissue within a confined area
Caused by cast that is too tight
Remove cast, considered a medical emergency
Symptoms – unrelenting pain not relieved by meds

Tissue necrosis / infection

Caused by avascular necrosis (sluggish or no blood supply to part of body, which causes cell and tissue death)
Warm musty odor coming from cast
Skin assessment – 1x per shift
Look down cast with flashlight, pull skin taught
Assess cast for staining on cast on top, sides and especially under the cast
If you do find drainage, circle it, date and time and initial, then check again later to be sure area hasn’t spread.

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 *******Do not cover cast with plastic or rubber except to take shower

Cast syndrome
Only with a body cast
Restricted chest expansion, compression of mesenteric artery causes decrease of GI motility
S/S:
Anorexia, accumulation of gas, N.V., abdominal discomfort
Risk of gangrene of intestines due to lack of blood supply to GI tract
Do thorough abdominal assessment every shift, best right lower quadrant at the ileocecal valve
Listen 3-5 minutes

Foot drop –
Caused by perineal nerve damage

Immobility problems r/t cast wear:

Deep Vein Thrombosis – DVT

Pressure ulcers
Pneumonia (elderly),
Constipation,
UTI
Bone demineralization

Internal Fixation
Used for stable fractures
Put the fracture back together internally with the use of pins, rods and screws attached permanently to bone
Products are mostly made out of stainless steel and titanium

Post-op:
X-ray to be sure has been correctly aligned
F/U X-rays over next few weeks or months to be sure alignment is maintained

External Fixation Device

************Look at pictures*****************
Used to realign crushing injuries, where the bone has been fragmented into pieces, and there is a lot of edema
and long bone injuries.
Surgical incision is made and rods pins and screws are used to realign fracture but area will not be closed completely.
Incisions are made coming out through the skin and an external metal frame attached
This holds the bone together on the inside of the extremity
Metal pins maintain position of the bone through attachment to a portable external frame
Usually applied in operating room
Sterile procedure, Patient is sedated; a nerve block will be given to extremity
Stays in place approx. 6-8 weeks

Indications
For stabile support of severe fractures, crushed or splintered bone while permitting active treatment of damaged
tissue
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 Provides access to open wounds for debridement, irrigation & skin grafts
Provides limb lengthening (telescoping rods, turned by pt)
Reduce, align & immobilize fracture by a series of pins inserted into bone
Position is maintained by attachment to external frame

Contraindications
Patients with diabetes
Elderly (esp. those that are confused)
Immunocompromised r/t high risk of infection.

Nursing assessment
Pin site assessment 1x/shift (redness, drainage, tenderness, pain & loosening of the pins)
Nurses do not tighten pins or clean device , patients are taught how to do this
If pins were to become loose, and patient is unsure of how to tigten, call Orthopedics, who will show
them
When Patient cleans device it will be with sterile water, and sterile cotton swabs
Extremity elevated to reduce swelling
Cover sharp points on External Fixator to reduce device induced injury to patient or others
Assess 6-P’s
Neurovascular status check q2-4 hours
Isometric and active exercise within limits of tissue damage
Encourage patient to adhere to weight bearing order from MD to avoid pin loosening
Do not pull on rods- lift extremity to move patients.

Complications
Anestesia (esp in older patients)
May prolong periods of immobility
Pt will not have a lot of use of this extremity- probably will only be able to move toes or fingers
Risk for infection (watch for purulent drainage( serous normal)
Administer antibiotics

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Complications with fractures:

Infection
Especially if it is an open (compound) fracture. If area is contaminated surgical debridement will be necessary.
Patient will be on antibiotics. When area is irrigated topical antibiotics will be used also.

Hypovolemic Shock
Shock from hemorrhage loss and from loss of extra-cellular fluid into damaged tissue. May occur from fracture to
extremities, thorax, pelvis or spine

Assessment
Decreased BP, increase HR & Resp, cool and clammy, restlessness and decreased LOC

Management
Replace fluid loss, keep warm, monitor V.S. & O2 status, restore blood volume and circulation, and monitor labs
especially hct, hmb

Fat Embolism
Fat globules in blood stream that results from a fracture of the long bones in the body (Tibia, Femur)
Fat globules lodge in the capillary bed of the lungs, and also may make it to the brain
Usually seen within 24-48 hours of fracture long bones
Seen frequently in young adults (20-30)

Assessment –
ARDS- acute respiratory distress syndrome:
Chest pain
Difficulty breathing /wheezing
Use of accessory muscles while breathing
Hypoxic
Headache
Change in mental status (memory loss, irritable, confused, agitated, sense of impending doom)
Increased HR (tachycardia) & Respirations (tachynpea)
Petechiea

Management – coughing
Deep breathing and coughing exercises (mainstream treatment)
Anti-coagulants (ie – lovenox)
Aspirin
Administer O2
Bed rest
Chest X-ray to visualize areas that have consolidated w/in the lung
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 Intubation if none of the previous interventions work.

Compartment Syndrome
Tissue perfusion in the muscles is less than that required for tissue viability
Rise in inter-compartmental pressure within the muscle itself that results in tissue damage. Usually associated with
IV infiltration into tissues instead of veins
Cast or splint too tight.
Tissue death within 4 hours
Normal pressure 8 mm of mercury, above 8mm tissue perfusion will be impaired.

Manifestations-
Unrelenting deep throbbing pain not relived by meds
Swelling, numbness, tingling
Nail beds cyanotic, poor cap refill, loss of distal pulse
Paralysis

Management
Notify MD STAT- Medical emergency
Remove constricting dressing or cast
Measure pressure

Surgical Fasciotomy (surgical decompression)

Fascia and muscles are cut open to allow for swelling. This is left open for several
days.Prophlaxis antibiotics will be ordered ,and area will have to be debrided because of high
risk for infection. Once swelling is over, patient will go through another surgery to close the
area.
Cover limb with moist dressing
Elevate limb
If not treated immediately, pt may end up with contractures, limited ROM, or loss of use of extremity

Deep Vein Thrombosis – DVT

Related to bed rest, decreased mobility (immobility)& skeletal contracture
Prevention:
ROM (esp dorsiflex and plantar flex-which can not be done in a cast but can be done with external
fixator.
Prophalactic anticoagulants (Lovenox)
Anti-embolism stockings
Assess
Redness, tenderness, heat, pain and positive Homans sign

Management
Anticoagulant therapy

Avascular Necrosis
Caused by blood supply to bone being sluggish or lost, and as a result bone loses its blood supply
Occurs mostly at femoral head, talus bone of the ankle or lunate bone of the wrist
Occurs with steroid use, chronic renal failure, prior bone transplant, sickle cell disease

Assessment:
Pain numbness and tingling in extremity,
Limb unstable
Decreasing ROM

DX:
X-ray, bone scan, CT scan

21
 Management:
No weight bearing to bone
Removal of bone or bone graft or prosthesis
Joint fusion, replacement or amputation

Delayed Union
Healing does not occur at a normal rate for the type and location of fracture

Non-Union
Failure of the ends of the fractured bone to unite

Wrist Fracture (Colles Fracture)

Fracture of the distal radius
Seen in elderly with osteoporotic changes in the bone
Usually seen in someone who breaks fall with the hand and wrist ( esp elderly and people who play sports)

Manifestation
Painful fracture (localized pain to wrist)
Swelling to surrounding area
Dorsal displacement of the distal fragment (X-ray shows dinner fork deformity)
Loss of sensation due to pressure on median nerve

Complications
Vascular insufficiency

Management
Closed reduction (manipulation)- no surgery involved
Immobilized with splint or cast
Pain meds before reduction and prn.
Follow up with X-ray to be sure bones have been reduced to normal anatomic alignment
Elevate first 48 hours
Exercise immediately fingers and hands

Nursing Dx
Altered peripheral tissue perfusion
Risk for impaired skin integrity
Self care deficit

Hip Fractures
Most common fracture in older adults

Different types –
Intracapsular –
Occurs in hip join itself-( ie- head of femur,acetabulum area)
Harder fracture to heal b/c it it difficult for the blood supply to get to the
intracapsular area of the hip joint
Occult – Fracture, little trauma, minor discomfort
Impacted & Non-displaced – moderate pain, no deformities
Displaced – lot of groin pain, externally rotated leg, ORIF to fix
Causes:

22
 Osteoporosis
Extracapsular –
Occurs outside of joint capsule itself
Trochanteric
Subtrochanteric
Causes:
Falls (esp on snow or ice)
Direct trauma to hip (ie-car accidents
Manifestations
External rotation of leg
Lots of muscle spasms
Shortening of the affected leg
Excruciating pain (Localized) and tenderness at site of injury
Disruption of blood supply to area

Diagnosis:
X-ray- definitve test
CT scan
MRI
Patient History and physical exam- will note shortening of the affected leg, swelling

Medical Management :
Prior to surgery temporary skin traction (Bucks Traction- no more than 5-10 lbs, wrap is applied directly to
skin.) to relieve pain and spasms
Not left on for more than 48 hours.
Sand bags for alignment and prevention of rotation
Analgesics
Muscle relaxants r/t muscle spasms
Surgical repair
Pre-op-
Administer pain meds for pain management
Muscle relaxants
Teach use of overhead trapeze to maintain correct realignment achieved with traction
Post Surgery –
Monitor VS
Monitor I&O with foley
Lung assessment r/t risk of pneumonia- teach pt to cough and deep breathe, use of incentive spirometer
Continue to administer pain meds
Address dressing area for unusual drainage, bleeding or bulging
Neurovascular assessment- color, temp, cap refill, distal pulse (always assess good leg first to
get a feel for what the pulse should be and use that as a reference point to compare) edema, lack of
sensation or unusual sensation
Post-op teaching:
DO NOTS: ****Look at pictures in book****
Do not force into more than 90* of flexion
Can sit in an upright 90* angle, but no bending over more than 90*
Force hip into internal rotation (do not turn leg inward when lying down)
Force hip into adduction- leg must remain slightly abducted.
****All are achieved by use of an abductor pillow****
Never cross legs
Sit on chairs without arm rests
Arm rests are used for pt to push themselves out of chair.
DO:
Wear shoes, but adaptive devices are needed to put shoes on b/c no bending over
Elevated toilet seats
Abductor pillow b/t legs (while in bed ) for first 8 weeks s/p surgery***look at picture***
Keep hip in neutral position
Notify MD if severe pain, deformity or loss of function in leg (difficulty moving)
23
Complications of hip fractures:
Avascular necrosis (esp with intracapsular fractures where blood supply has been cut off)
Dislocation-
Patient will hear a popping sound
Will manifest as pain to buttocks area
Pt will have to be re-xrayed and f/u surgery may have to be done.
Leg shortening (pt. may end up with a deformity)
May need lift for shoe
Non-union
Failure of bones to heal and fuse and align appropriately
Bone infection (osteomylitis)
Osteomylitis is dangerous b/c bone is hard and dense and it is difficult for antibiotics to reach abscess
(casing around infection
Blood vessel and nerve damage as a result of avascular necrosis

Interventions
Post-op care
Medication, IV antibiotics
Deep breathing – strength exercises
Foot exercises, flexion, extension
Anti-embolic stockings to compress and increase circulation
Nutrition, urinary output,
Abductor pillow in proper alignment
Monitor for DVT, skin assessment, NV complications
Breath sounds every shift
Patient teaching prior to and post surgery

Nursing Dx-
Pain
Impaired Skin Integrity
R/F Infection
Self care deficit

24
Nursing Diagnosis for Fractures
Impaired skin integrity
Risk for impaired Skin Integrity
Acute Pain
Risk for infection
Impaired physical mobility
Risk for impaired peripheral vascular dysfunction

Positive aspects that influence bone healing:

• If you immobilize the area in a timely fashion and bones are connected back together in a timely fashion that
will contribute to faster bone healing.
• Apply ice to area
• Ensure sufficient blood supply by inspecting :Note if it is pink, pale, blue, check distal pulse, capillary refill,
touch it to see if it feels warm or cool to touch
• Nutrition: make sure patient is receiving adequate amount of protein, Vit C, Calcium, Vit D.
• Weight bearing exercises: especially if it is a fracture to the long bone.
• Hormones: Calcitonin, thyroid, estrogen, growth hormones.

Negative aspects that inhibit bone healing:

Extensive trauma to an area and it took a really long time to correct or make those bones come into contact with
each other that can negatively impact on bone healing
Infection that went to the bone and patient developed osetomyelitis
Decreased circulation to the area
Prone to certain bone diseases such as Paget’s disease, or if they already have osteoporosis
Not eating what they should be eating
Age- the older you are the harder it is for fractures to heal
Immunocompromised
Long term steroid use
Asthmatic

Nursing intervention for patient with fractures

Closed fractures
• You want to show your patient how to use assistive devices correctly.
• Return to ADL’s as ASAP
• Exercise affected and unaffected extremities

25
Open / Compound fractures
• Prevent infection
• Give patient prophylaxis direction
• Culture area to make sure there are no harmful organisms growing in there
• Elevate extremity: you want to eliminate edema to that area
• Neuro assessment a q4hrs
• Monitor v/s especially temp( first sign of a brewing infection an increase in temp)

Assistive Devices

Canes
Help pt walk with greater balance and support and relieves pressure from weight bearing joints by redistributing the
weight.
Types – single legged, tripod (three feet), quad (best stability)

Measurement –
Patient standing upright
Slightly flex elbow at 30* angle
Handle of cane at same level as greater trochanter
Tip of cane 6” to the right or left of the base of the 5th toe
Must have non skid rubber tip at base
Pt must wear good shoes
Hold cane in hand of good side (opposite side of affected extremity)
Advance cane at same time as affected leg to relieve pressure

Cane up and down stairs – “good to heaven, bad to hell”

When going up, lead with good leg
When going down lead with bad leg

Walker
A four point assistive device that provides a much broader base of support
With and w/o wheels

Measurement –
Standing upright
20 – 30* flex at elbow
Top of walker is level with thumb joints, and there should be NO flexion of thumb joints
Wear sturdy shoes
Use walker to assist in getting up with good leg assist
Push off bed/chair to stand- never pull walker towards them
Look up as you walk- towards the horizon, not down.

Crutches (see library packet)

For partial weight bearing or non weight bearing ambulation
To be a candidate for crutch use:
Pt must have adequate upper body strength and good arm control
Sufficient balance and erect posture
Must have adequate cardio reserve
Measurement –
Should be standing can be lying (standing is preferred)
Stand against wall with feet slightly apart and shoes ON.
26
 Measure from axilla to base of feet (in bed axilla to base of feet + 2”-don’t need shoes on in bed
Hand piece adjusted to allow 20-30* angle at elbow
Must have foam rubber upper arm piece to avoid crutch palsy (radial nerve pressure)
S/S: numbness, paralysis tingling to extermity
Patients arm should be at 20-30* angle
Weight of body carried on hands- not on arm piece
Hold crutches in tripod position 8-10” in front of body

Crutch Walking – tripod position-****Look at pictures in book***

2 pt gait –
Used for patients who are PWB on both legs, probably from injury
Resembles normal walking
Crutch is advanced then opposite leg
Crutch is used in place of swinging of arms

3 pt gait –
For no weight bearing on one leg
Think of patient with cast on.
There are three points on the floor (two crutches and one leg)
4pt gait –
PWB on both legs
Slow version of 2 pt for support
Reserved for pt’s with poor balance
Four points on floor at all times (two crutches and two feet)
Advance left foot, right crutch, then right foot, left crutch (one foot then crutch)

Swing through/Swing To –
Variation of three point gait for pt’s who are NWB to one leg
Swing To-
Usually used in the beginning, when pt’s are adjusting to crutches
Swing good extremity to the level of the crutch (tripod)
Swing Through-
Usually reserved for when pt can go faster, and it more sure of themselves on crutches
Swing good extremity through the crutches so it ends up in front of them.

Environmental safety
Avoid wet floors, polished floors, loose rugs, wear proper fitting shoes

Crutch up and down stairs same as cane (good to heaven, bad to hell)
******Look at pictures****
Up good leg 1st, then advance crutches
Down bad leg 1st with crutches

Complications R/T Immobility

Orthostatic hypotension – sudden drop of BP from supine to upright position
Prevention:
Parallel bars, overhead trapeze, dangle feet, tilt table

Nursing diagnosis:
Risk for falls

27
Amputations
Removal of body part, usually and extremity (arm or leg)
Indications depend on underlying disease or cause
May be traumatic or therapeutic
What is left? – Stump
BKA / AKA – below knee amputation, above knee amputation
AEA/BEA- above/below elbow amputation
Goal of Amputation:
Removal of as little of the extremity as possible to preserve function, but at the same time removal of
dead, infected or ischemic tissue
Relieve symptoms such as pain and compromised circulation, improves quality of life
Causes of amputations:
Traumatic accident, crushing injury, frostbite, gangrene
Therapeutic – diabetes with poor circulation

Indications
Peripheral vascular disease
Traumatic crushing injuries
Malignant tumors
Local or systemic infections
Congenital deformities
Chronic pain
Uncontrolled diabetes

Manifestations of patients who will require amputations

Excruciating pain (although this in itself is not always an indicator)
Numbness, tingling, loss of sensation to an area is indicative of impaired circulation.
Doppler study indicating decreased blood flow to area
Area may be dark or pale in color
Area may be cold or cool to touch
Will probably exhibit local or systemic signs of infection.

Types of amputations
Closed – remove bone, suture skin and put muscle flap over area
Open – remove everything bone, muscle soft tissue than corterise
Disarticulation – removal of an actual joint itself

Diagnosis
Patient history and physical exam
Physical appearance of soft tissue
Skin Temperature
Sensory function (using cold or hot, sharp or dull, tuning fork to see if vibration felt)
Presence of peripheral pulses ( if distal pulse can not be felt f/u with Doppler study)
28
 *****assess good leg first to get baseline and if deviation is noted in bad leg
Arteriography for circulatory status
Doppler Recording for info r/t blood flow to extremity

Pre-op Assessment and Preparation

Circulation of affected part via Doppler study
Baseline NV status pre and post to compare
Assess physical and emotional status
Stress importance of getting well post-surgery (usauuly therapist involved b/c many pt’s become
depressed)
Allow grieving and open communication
Discuss options re: prosthetics
Explain Phantom limb pain
Pain , cramping, burning sensation to area that is no longer there. This is normal for patient to feel
Will subside, but may last up to a year.

Medical management post-op

“Phantom limb pain”
Monitor pain and administer meds
Monitor respiratory status
Neuro-vascular monitoring (will now assess for a proximal pulse b/c not able to assess for distal. Ie- with a BKA
you would assess for the popliteal pulse, With AKA assess for femoral pulse)
Baseline VS (to assess for S/S of shock r/t hemorrhaging)
Assure proper healing
Prevent dependant edema to stump area

Care following amputations

Daily inspection for irritation, redness, abrasion to area
Post- surgery goal is to get pt in an upright position so they can dangle extremities
When starting ambulation, only ambulate for 5 minutes to prevent dependant edema to area
Stump care –
Wash daily
No lotions powders or oils- can cause skin breakdown
Phantom pain and pain meds
Proper use of prosthetics-
Correct fitting
Prosthesis should be put on before pt gets out of bed
Use of compression stockings to prevent edema to that area.
ROM everyday utilizing overhead trapeze to build upper body strength so pt will be able to use crutches
Prone position for 30-40 min x 3-4 times a day to prevent flexion contractures.

Complications
Hemorrhage – major complication
Infection- may infect bone (osteomylitis)
Delayed healing – especially in pts with circulatory problems
Flexion contracture–Especially to hip area
We want patient to get OOB, and sit in chair, but for no longer than 1 hour b/c longer than an hour forces
hip into contracted state.
Place patient on stomach (prone position) for 20-30 minutes a day x 3-4 times a day. The rationale behind
this is to keep leg in extension
No elevation of stump
Skin irritations r/t prosthesis
Phantom limb pain – very real especially if traumatic injury
Pre-op – explain phantom pain
Edema
Compression dressing, NO elevation of stump

Nursing Dx
29
 Pain
Alteration in sensory perception
Impaired skin integrity
Body image disturbance
Dysfunctional grieving
Risk for infection
Impaired mobility
Risk for depression

Common Joint Surgical Procedures

******Look at pictures*********

Arthroplasty (Joint Replacement)

Can be full or partial replacement
Surgical removable of deformed or diseased joint surface with replacement by smooth artificial surfaces made of
metal or plastic (usually hips and knees)
Provides relief of pain, improve or maintain ROM and normal function, and correct deformities
Commonly replaced joints:
Hips
Knees
Fingers
Shoulders

Indications:
Osteoarthritis r/t excessive weight bearing on joints- seen in people who play sports- most common cause
Avascular necrosis
Rheumatoid arthritis
Failed prior reconstructive surgeries
Congenital hip disease
Fractures

Nursing intervention
Preop baseline assessment to compare to postop
Prevent infection, aseptic technique, antibiotic therapy, C&S
Promote ambulation ASAP per MD orders
Prevent dislocation:
Sit patient in high seats
Fracture pan for voiding
No driving
No adduction
No crossing legs
Bed elevation less than 60*
No hip bending more than 90*
Safe transfer OOB – get out of bed on either side with assist of 2
S/S of dislocation :
Shortening of leg
Leg not aligned
Abnormal rotation
Pain, pop heard by patient
Complications
Infection-considered most serious complication of joint surgery

30
 If infection occurs in area joint was replaced, further surgeries will need to be done, and the
following surgery will be more intense
If area becomes infected it will almost always lead to pain, loosening of prosthetic device and
dislocation
Bleeding - hip 200- 500cc drainage within first 24 hours
Within 48 hours down to less than 30cc
Knee 200-400cc first 24 hours
Within 48 hours down to 30cc
Injury to nerves
Excess wound drainage
Loosening of prosthetic
Shortening or misalignment of extremity
Heterotrophic ossification-development of new bone in space of device
Avascular necrosis
DVT
Pt’s will be on Lovenox post surgery to prevent DVT, and sent home on low dose aspirin
Important to note:
If patient returns home and starts running fever of unknown origin, increased pain
locally to replaced joint area, unusual drainage at incision site, these are all indications that there
is an infection. Notify MD ASAP.

Nursing Diagnosis:
Pain
-meds
Impaired physical mobility
-maintain alignment, assistive devices
Self care deficit
Impaired tissue integrity
Risk for infection
Risk for ineffective neurovascular dysfunction
Anxiety
-diversion therapy
Infection

31
Osteomylitis
A severe Infection of the bone, bone marrow and soft tissue surrounding bone

2 modes of bone infection

Direct bone contamination –
Open Fracture, bullet or stab wounds
Organism enters BS, makes its way to bone and multiplies. Abscessed area w/in bone in formed
S/S- Bone pain (dull,aching constant pain that is there all the time even at rest. Pain increases
w/ activity. Type of pain you can live with, annoying pain) and increased pressure b/c bone can
not expand
Indirect bone contamination-
Extension of soft tissue infection ( pressure ulcer, incision infections)
Blood borne spread ( boil, infected tooth that spreads, URI,UTI that spreads to BS)
Etiology
Bacterial – S.aureus(most common w/ direct contamination) S. pyogenes
Viral
Foreign material

Risk factors
Malnutrition
Obesity / elderly / children
Surgery
Impaired immune system, diabetics
Wound dehiscence
Long term steroid therapy

Diagnostic history
History (esp of previous surgeries)
Assess for recent trauma
Recent illness
S/S infection

Clinical manifestation
Localized:
Constant dull bone pain
**Bone pain is a dull, aching pain that is constant
Swelling
Tenderness
Warmth over site of infection
Restricted movement to area

32
 Muscle spasms
Thin, scarred skin
Systemic
Fevers
Nightsweats
Chills
Restlessness
Nausea
Malaise
Increased temp, pulse, heart rate
Fatigue,
Leukocytosis
Lymphademyopathy (swollen,tender lymph nodes)

Dx tests
*** MRI and CT scan (early definitive test)- Identifies area of infection in bone and soft tissue
Blood or wound cultures- to Id organism
Will show elevated WBC, ESR (Indicates infection in body, but not where)
X-ray irregular – decalcification of bone site will be seen
Radionuclide bone scan- Used to ID area within bone that is infected
Ultra sound – to visualize fluid abscess
Bone or soft tissue biopsy- to ID organism causing osteomylitis

Treatment
Treat aggressively with IV antibiotics for 6 weeks-3 months
Harsh antibiotics- aminoglycosides- (end in –ycin) which cause ototoxicity
Also preventing spread with prophylactic antibiotics
Surgical debridement
Hyperbaric O2 therapy
100% O2 administered directly to area that has osteomylitis
Believed to stimulate circulation and heal infected tissue
Bone Grafting
****If none of the above procedures work pt may be candidate for amputation.
Needle aspiration for sample for C&S
Pharmacology –
Antibiotics
NSAIDS
Narcotic Analgesics
Muscle Relaxants
Non-pharmacological-
Hypnosis
Guided imagery
Diet –
Increase protein, calories, vit C, calcium
Monitor for complications

Complications:
Flexion Contractures
Footdrop
High dose antibiotics adverse/toxic reactions
Ototoxicity, photosensitivity, GI Upset, colitis, Candida overgrowth (yeast infections, oral infections)
Use Probiotics, acidophillus ,yogurt to reintroduce yeast back into the body wile on antibiotics
Nursing Dx
Acute Pain
Impaired physical mobility
33
 Knowledge deficit
Risk for infection
Hyperthermia
Ineffective Therapeutic Regimen Management
R/t patient has an illness that they are going to be treated for long term. Will include a lot of patient
teaching re: medications, diet

Osteoporosis
A chronic, insidious progressive metabolic systemic bone disease characterized by low bone mass and structural
deterioration of bone tissue leading to bone fragility, and in turn fractures

Demineralization of bones resulting in porous, brittle, fragile bones

Also called “Silent Thief “ or “Silent” disease

Disease happens w/out you even knowing

A reduction of bone density and a change in bone structure both of which increase susceptibility to fractures

Not a disease of the elderly, can happen to anyone at any time

Risk factors
Pregnancy and lactation
Increased age increases risk
Females Increased risk (but males can get too, but they get a much higher intake and lower output of ca+)
Having a thin,small, frame
Family History of osteoporosis
Diet Low in CALCIUM
Lactointolerant, vegetarians
Race – White, Asian more susceptible
Endocrine – menopause r/t sharp decline in estrogen (rapid bone loss occurs at same time)
Neurological disease- Parkinson’s,
Medications –Long term use of corticosteroids, anti-seizure meds, aluminum containing antacids,
thyroid hormones

Secondary osteoporosis caused by external forces like meds, and diseases like Parkinson’s

Osteoblast and osteoclast imbalance causes osteoporosis

Modifiable factors – not genetic, only changeable factors

Hormones (see below)
Cigarette smoking
Caffeine excess
Low body weight
ETOH intake excess
Sedentary life style
Safety strategies to prevent falls

34
Hormones r/t osteoporosis
Calcitonin – (secreted by thyroid gland) maintain serum Calcium, phosphorous levels
To prevent bone destruction and promote bone formation
Calcitonin production deceases with age

Estrogen –To prevent bone breakdown

Estrogen production decreases with age
HRT (hormone replacement therapy) to replace estrogen during menopause

Parathyroid hormone–
Regulates calcium and phosphorous

Vitamin D – calcium absorption and bone health, comes from sunshine, and foods high in vit d.
You need Vit. D to absorb calcium

Phosphorous – mineral second most abundant in body

To build strong bones

Prevention:
Diet:
Calcium- 1,000 mg/day premenopausal
1,500 mg/day postmenopausal
Vitamin D- To ensure calcium absorption
Exercise:
Moderate weight bearing (walking 3-4 times a week,hiking,stairclimbing)
Medications:
Want to be sure they are using their medications correctly ***see medications below**

Manifestations
*****will not usually be able to see symptoms
Back pain
Loss of height
In severe cases Spinal deformities-
Dowgers hump – kyphosis
Very prone to fractures-
Vertebral fractures, or compression fractures (most common), hip, wrist
Severely stooped posture

Diagnosis
**Based on patient history and PE
Bone mineral density test (BMD)
– Measures how tightly packed bone is on the
X-ray
–Will only show after 30% of bone destroyed
Quantitative computer tomography (QCT)
– Good for spine
*** Dual energy x-ray absorptionmetry (DEXA)
-Reserved for patients who are on meds for osteoporosis to see if improvement in condition is occurring,
Lab studies
Serum calcium, phosphorous, alkaline phosphotate,These all work together for ca+ absorption.
calcitonin, vit.d ****look up levels****
Bone Biopsy

Medical Management
Biphosphonates – Fosomax, inhibits bone reabsorption to prevent osteoporosis, helps to build bone
Can be given daily or weekly PO
Give 30 min before meals on empty stomach

35
 Sitting in an upright position to lessen the change of esophageal irritation
Can be standing and moving around, just not lying or reclining
S/E- Anorexia, weight loss, gastritis, esophageal irritation
Calcitonin –Replacement hormone to increase bone mass
HRT - estrogen
Evista – SERM - selective estrogen receptor modulator, works like estrogen
Exercise – weight bearing (walking) and resistance training
Nutrition – calcium, vit D, milk, cheese, fish oil, supplements, green leafy veg.
Cut down/out drinking and smoking

Nursing Diagnosis:
Pain
Risk for injury
Knowledge deficit

Rheumatoid Arthritis ****Look at pictures****

A chronic systemic inflammatory disorder that’s characterized by:
Inflammation of connective tissue w/in joints
Pain
Changes in joint structure
Pathophysiology
Cause unknown
Genetic predisposition
May be autoimmune
Most widely accepted theory
Body produces antibodies Rheumatoid ((RF) factor which combines with IgG and deposit on Synovial membranes
and cartilage of joints, as a result of this erosion of articular cartilage occurs , and synovial lining thickens.
Immune system mistakes your tissue for foreign tissue and as a result of that, it tries to neutralize it and
get rid of it.
Inflammation of synovium- edematous, with a lot of excessive growth of inflamed membrane
As time goes by there is fusing and immobility of the joints
Incidence –
Seen more in females
Symptoms appear usually between 30-50 years old
Incidence increases with age
Periods of exacerbations and remissions – some good and some bad times with pain

Patient history
*** Generalized stiffness in morning lasts from an hour to several hours for more than 6 weeks
*** Symptoms bilateral and symmetrical
Joint pain w/warmth and tenderness to the touch
Swelling of 3 or more joints for more than 6 weeks
Nodules over joints as disease progresses
*** Acute- comes on quickly in starts in small joints of hand, wrist and feet
Manifestations
Systemic
Symptoms occur symmetrically
Onset is insidious
Systemic-
Low grade fevers, fatigue malaise, weight loss, sleep disturbances
Musculoskeletal –
Bilateral and symmetrical joint involvement, swelling, redness, heat, pain,. loss of function , limitation
of motion, contractures of the joint
Hands –
Ulna deviation, swan neck deformities (hands twist outward)
Exocrine –
36
 Dry eyes and dry mucous membranes
Respiratory –
Lung issues and pneumonia
C.V-
Rainards Disease – effect extremities r/t poor perfusion
Blood level –
anemic
Diagnosis
Patient Hx and PE
*** Blood test – rheumatoid factor, ESR, WBC, C-reative protein will be elevated
Normal ESR is
Elevated ESR indicates that there is an active inflammation somewhere , but not where.
Normal RH Factor is less than 60- anything over seven may indicate RA
In over 80% of patients with RA blood test for RF will come back positive indicating
autoimmune response, probably RA
Normal WBC is 5,000-10,000 mm3 in pt’s w/ RA WBC will be over 10,000
C - reactive protein elevated- Normal is <1.0 mg/dl or 10 mg/L (SI units)

*** Athrocentesis ( joint aspiration ) with synovial fluid analysis

WBC”S may be seen in Synovial fluid
Bone Scan- will be able to pick up changes early on in the disease
X-ray- will see joint space narrowing

Medical management
Pharmacology – early treatment
NSAIDS – inhibit prostaglandins
DMARDS – disease modifying anti-rheumatic drugs
Ie- Methotrexate, gold therapy
Goal of these drugs is to slow down or prevent progression of disease
Immunosuppressive therapy (corticosteroids)
IM injections into joints that should provide pain relief for several months
OT / PT therapy
PT- helps patient to maintain joint motion and muscle strength
OT-help patient to develop upper body strength to gain strength for the use of possible assistive devices
Apheresis –
Filtering of blood to remove antibodies (ie Rheumatoid factor). Remaining blood is reinfused back to
patient.
Done once a week for about 12 weeks
Similar to plasmaphoresis
Surgery

Patient teaching:
Rest- esp. during flare ups and in between activities such as ADL’s
Joint protection- esp about use of assistive devices to protect joints during periods of exacerbations
Heat and cold therapy- max 15-30 min
Heat seems to bring RA patients most relief (Warm shower in AM, hot packs to neck and shoulders
Exercise-
No aggressive exercise. Stationary bike, walking, gardening, swimming
Non-pharmacological techniques
Yoga, massage. Guided imagery
Nursing DX
Pain r/t chronic state of inflammation, joint overuse
Impaired physical mobility r/t pain, stiffness
Body image disturbance r/t nodules
Self care deficit r/t joint immobility, contractures, progression of disease

37
Osteoarthritis (aka Degenerative Joint disease)****Look at pictures***
Slowly progressive
A degenerative Non-Inflammatory joint disease characterized by:
Usually unilateral (but can be bilateral) degeneration of joints
Cartilage disruption-Loss of articular cartilage of weight bearing joints
Mostly affects adults usually in the 3 decade peaks around the 5th 6th decade
Incidence increases with age
Non-systemic

Etiology
Primary – genetics, female, congenital development, age, obesity
Secondary –
Mechanical stress to joint caused by repetitive motion (ie sports players)
Joint trauma such as dislocations, fractures, reductions or surgeries where avascular necrosis develops
Inflammation r/t release of enzymes locally at that site that causes further disruption of articular cartlidge
Joint instability esp. with damage to structures surrounding joint capsule itself
Skeletal deformities esp. congenital in nature
Risk factors –
Age, obesity, previous joint damage, repeated use, genetics

Pathophysiology
Cartilage damage triggers a metabolic response
Smooth white translucent articular cartilage becomes yellow, dull, and granular
Cartilage b/c soft, less elastic, and less able to resist wear on the joints
Erosion of cartilage
Cartilage becomes thin, less able to stand pressure.
Bony outgrowths on the corners of the bone itself (osteophites or spurs) later in disease
Cysts may develop in bone
Eventually you will lose most of cartilage in joint

Signs and symptoms

*** Gradual and insidious
Discomfort to joint- can be mild to severs depending on the stage of disease
Joint discomfort/stiffness usually in morning less than 15- 30 minutes- decreases with movement
*** Usually asymmetrical pain
Decreased ROM
Loss of function to extremity
Joint limitations
Crepitus (grating rubbing sound) r/t cartlidge in joints rubbing against each other
Boney out growths- nodules (HEBURDENS NODULES) under skin .
Joints cool to touch
38
*** No real test to diagnose

Assessment and Dx findings

Patient history and Physical exam
Compare to contralateral joint if not affected
Enlarged joints
CT Scan
X-ray images of thin slices of soft tissue and bone
MRI
Magnetic and radio waves to produce actual images of bone and soft tissue
Bone scan-
Nuclear scanning test that is used to ID new areas of bone growth or breakdown
Evaluation of damage to bones
Identifies sites of infection or trauma

X-ray –
Loss of joint cartilage- cartilage breakdown
Joint space narrowing b/t joints
Erosions
Later in disease bony outgrowths (osteophites)
Arthrocentesis with synovial fluid analysis
To differentiate b/t Osteo and RA (Pt’s with RA will have WBC’s in synovial fluid, and pt’s w/
OA fluid will usually be normal- clear, yellow, no WBC’s)

***********No blood test useful*********

Management
Rest and joint protection esp. during acute episodes of exacerbation
Heat and cold therapy
Heat is more effective for stiffness
20-30 minutes on then off for both
Nutritional therapy/ exercise
Limit weight bearing on joint
Isometric exercises (NWB exercises are best- ie swimming)
Complementary and alternative therapy
Acupuncture has been shown to be very effective for chronic pain
Yoga, massage, guided imagery
Glucosamine
It is believed that Glucosamine works by preventing breakdown of cartilage
Take with food
Use cautiously in pt’s who are diabetic b/c if they are taking oral hypoglycemics together
w/ glucosamine some reports have shown that it lowers blood sugar to a much lower level
Meds –, NSAIDS ie Motrin or ibuprophen
Three A’s- anti-inflammatory, anti-pyretic, analagesic
S/E GI Bleeding and erosion
Look for melena (dark tarry stool)
Corticosteroids- Given as an IM injection into the joint itself.
Usually lasts for several months
Reduces inflammation and relieves pain in patient
Topical analgesics
Surgery –
Arthroscopy
Osteomoty (incision in bone to realign joint)
Joint replacement

Patient Teaching
Lose or maintain weight to put less weight on joints

39
 Use of assistive devices esp. during acute flare up (ie-braces, splints, canes)
Avoid forceful repetitious movement
Use good posture and body mechanics
To pick up something from the floor do not bend at the waist, bend at the knees and use leg muscles
Pace activities and routine tasks to lace less stress on joints
Periods of rest

Nursing diagnosis
Pain (acute or chronic) r/t inflammation
Disturbed sleep pattern r/t pain
Impaired physical mobility r/t weakness or stiffness of joint
Self care deficit r/t joint deformity and pain.

***Note differences in osteoarthritis and Rheumatoid arthritis**************

Lab Values to Know for this unit

*****Normal values******
• WBC-
o 5,000-10,000
• HCT-
o Males- 42-52%,
o Females 37-47%
• HGB-
o Males- 14-18 g/dl
o Females 12-16 g/dl
• CA+-
o 9.0-10.5 mg/dl
• P (phosphorus)-
o 3.0-4.5 mg/dl
• Uric Acid-
o Males- 4.0-8.5 mg/dl
o Females 2.7-7.3 mg/dl
• Alkaline Phosphatase-
o 30-120 U/L
• ESR-
o Males up to 15mm/hr
o Females up to 20 mm/hr
• Calcitonin
o Males –less than or equal to 19 pg/ml
o Females- less than or equal to 14 pg/ml

40
Chapter 11

ADL’s – Activities of Daily Living

Assistive technology – item or piece of equipment used to improve the functional capability of individuals
with disabilities

Disability – restriction or lack of ability to perform an activity in a normal manner

Habilitation – making able – learning new skills and abilities to meet maximum potential

Impairment – loss or abnormality of psychological, physiologic or anatomic structure or function at the organ
level

Instrumental activities of daily living (IADLs) – complex aspects of independence including meal
preparation; grocery shopping, household management, finances and transportation

Rehabilitation – making able again – relearning.

Autonomic Hyperreflexia – a neurological disorder characterized by a discharge of sympathetic nervous

system impulses as a result of stimulation of the bladder, large intestine or other visceral organs. It occurs in
persons with certain spinal cord injuries. Symptoms may include bradycardia, profuse sweating, headache and
severe hypertension

Hardiness – a personality characteristic that is a buffer in the stress and depression dynamic and increases a
person’s capability of having a positive psychological reaction to a stressor

Different Scales/Scores
• Health-Related hardiness Scale (HRHS) – high score – hardiness
• Zung Self-Rating Depression Scale (ZSDS) – measured depression – high level – indicates
depression

41
 • Clinical Response Scale (CRS) – physical health status is measured – high measured worsened
health status
• Barthel Activities of Daily Living Index (BADL)– measured disability - a high score indicated
independence and a low sore indicated disability.
• FIM – measures level of independence
• PULSES – measures physical condition

Range of Motion Terminology

Abduction – away from body
Adduction – towards body
Flexion – bending of a joint to that the angle diminishes
Extension – the joint angle is increased
Rotation – turning of a part around its axis (neck)
Internal – turning inward
External – turning outward
Dorsiflexion – movement that flexes or bends the hand back toward the body or foot toward the leg
Palmar flexion – movement that flexes or bends the hands in the direction of the palm
Plantar flexion – movement that flexes or bends the foot in the direction of the sole
Pronation – hand/palm is down
Supination – hand/palm is up
Opposition – touching the thumb to each fingertip on same hand
Inversion – movement that turns the sole of the foot inward
Eversion – movement that turns the sole of the foot outward
Active – performed by patient under supervision
Active - Assisted – performed by patient with the nurse helping
Passive – performed by the nurse

A joint should be moved through its ROM three times – twice a day. The joint should be supported, the bones
above the joint stabilized and body part distal to the joins is moved through the range of motion of the joint.

Weight bearing exercises may slow the bone loss that occurs with disability. There are 5 types:
1. Passive – carried out by therapist without assistance from patient
2. Active-Assisted – both therapist and patient do together
3. Active – patient does it themselves
4. Resistive – carried out by the patient working against resistance produced by either manual or
mechanical means
5. Isometric – contracting and relaxing a muscle while keeping the part in a fixed position.
Performed by patient.

Orthostatic Hypotension may develop when the patient assumes a vertical position. Because of inadequate
vasomotor reflexes, blood pools in the splanchnic (visceral) area and in the legs, resulting in inadequate
cerebral circulation. Symptoms include: diaphoresis (sweating), nausea, tachycardia, dizziness, drop in blood
pressure & pallor).

Crutches & Canes

Crutch
Measuring laying down – from the anterior fold of the axilla to the sole of the foot and then 2 inches is
added. The hand piece should be adjusted to allow 20 t 30 degrees of flexion at the elbow. The wrist should

42
be extended and the hand dorsiflexed. A foam rubber crutch r pad on the underarm piece is used to relieve
pressure of the on the upper arm and thoracic cage.

Place patient against the wall with feet slightly apart and away from wall. A distance of 2 inches is
marked on the floor, to the side from the tip of the toe. 6 inches is measured straight ahead from the first
mark. Next 2 inches is measured below the axilla to the second mark for the approximate crutch length.

Crutch Gaits

4 point gait
PWB on both feet
Maximal support provided
Requires constant shift of weight
Right foot, left crutch, left foot, right crutch

2 point gait – like walking with arms swinging with crutch

PWB on both feet
Less support
Faster than a 4 point gait
Right foot & left crutch together
Left foot and right crutch together

3 point gait
NWB
Need good balance
Need good arm strength
Faster gait
Can use with walker
Right foot
Left foot (NWB) and both crutches

Swing To
WB both feet
Stability
Need arm strength
Both Crutches
Both Feet next to crutches

Swing through
WB
Need arm strength
Need coordination/balance
Most advanced gait
Both crutches
Swing both feet ahead of crutches

Stairs:
Up with the good, down with the bad
When going up the stairs, put the good foot up first or the crutches and follow with the bad
When going down the stairs, put the bad foot first and then down with the good.
43
Cane
To fit the patient with a cane, the patient is instructed to flex the elbow at a 30 degree angle, hold the
handle of the cane about level with the greater trochanter, and place the tip of the cane 6 inches lateral to the
base of the fifth toe.

Hold the cane in the hand opposite the affected extremity to widen the base of support and to reduce
the stress on the involved extremity. Advance the cane at the same time that the affected leg is moved.

Orthosis is an external appliance to provides support, prevents or corrects deformities and improves function.
They include braces, splints, collars, corsets or supports that are fitted an orthotist or prosthetist.
• Static orthoses (no moving parts) are used to stabilize joints and prevent contractures
• Dynamic Orthoses are flexible and are used to improve function by assisting weak muscles.
• prosthesis is an artificial body part; it may be internal or external

Nutritional Requirements to Promote healing of Wounds

Protein
Calories
Water
Multivitamin
Vitamin C – promote collagen synthesis
Zinc sulfate
Vitamin A – cautious amounts

44
Chapter 54

Arthritis – inflammation of a joint

Monoarticular – affects a single joint

Polyarticular – affects multiple joints Ankylosis – immobility of a joint

Antibody – protein substance developed by the body in response to and interacting with a specific antigen

Antigen – a substance that induces production of antibodies

Arthroplasty – replacement of a joint

Complement – a plasma protein associated with immunologic reactions

Cytokines – non-antibody proteins that act as intercellular mediators

Diarthrodial – a joint with two freely moving parts

Hemarthrosis – bleeding into the joints

Joint Effusion – the escape of fluid from the blood vessels or lymphatics into the joint space

Matrix – non-cellular components of tissue

Osteophyte – a bony outgrowth or protuberance; spur

Pannus – newly formed synovial tissue infiltrated with inflammatory cells

Prostaglandins – lipid-soluble molecules that mediate the inflammatory process

Subchondral bone – bony plate that supports the articular cartilage

Synovial – pertaining to the joint-lubricating fluid

Tophi – accumulation of crystalline deposit in articular surface, bones, soft tissue and cartilage

Rheumatic disease include common disorders such as osteoarthritis, systemic lupus erythematosus or
scleroderma. It affects skeletal muscles, bones, cartilage, ligaments, tendons and joints

Disarthrodial or synovial joints

• function is movement
• in normal joints – it is smooth, nearly friction-free, resilient surface for the movement is
provided by articular cartilage which covers the bone end of the joint.
• Lining the inner surface of the fibrous capsule is the synovial membrane, which secretes fluid
into the space between the bone ends. The synovial fluid functions as a shock absorber and a
lubricant, allowing the joint to move freely
• The joint is the area most commonly affected by the inflammation and degeneration seen in
rheumatic disease. They all involve some degree of inflammation and degeneration.
• Inflammation is manifested in the joints as synovitis.
45
 • In RD – the primary process is inflammation as a result of the immune response. Degeneration
occurs as a secondary process, resulting from the effect of pannus (proliferation of newly
formed synovial tissue infiltrated with inflammatory cells. The inflammation is a result of
altered immune function.
• Degenerative RD – inflammation occurs as a secondary process. This synovitis is usually
milder, more likely to be seen in advanced disease and is a reactive process.

Degeneration
• Mechanical Stress – wear and tear
• Altered lubrication – lessened lubrication of the joint
• Immobility – loss of pumping action because of immobility – encourage slow range of motion
to remobilize joint

Diagnostic Findings for RD

• Arthrocentesis – needle aspiration of synovial fluid to test and to relieve pain. Patient is
observed for infection and hemathrosis (bleeding into the joint).
o Fluid is clear, viscous, straw-colored and scanty when it is healthy
o Milky, dark yellow complement – usually is inflammatory
o Arthrocentesis of small joints is difficult. Mostly done in knee & shoulder
• X-ray
• Arthrography - a radiopaque substance or air is injected into the joint cavity to outline the
contour of the joint. The joint is then put through passive ROM while several x-rays are taken.
• Joint scan – most sensitive study, allows determination of joint damage through the body. Not
used often because of cost.
• Tissue Biopsies – done in surgery
• Muscle biopsy – to diagnosis myositis
• Skin biopsy – to confirm inflammatory tissues diseases such as lupus or scleroderma
• Blood Tests
o Creatine – may indicate renal damage in SLE, scleroderma and polyarteritis
o Erythrocyte Sedimentation Rate (ESR) – increase may indicate inflammatory connective
tissue disease
o Hematocrit decrease can be seen in chronic inflammation
o RBC – decrease can be seen in RA & SLE
o WBC – decrease can be seen in SLE

Gout or infectious arthritis – the presence of crystals or bacteria in the synovial fluids

NI
Heat application are helpful in relieving pain, stiffness & muscle spasm
Maximum benefit is achieved in 20 minutes
If acute – cold applications may be tried
Use one pillow under head to reduce dorsal kyphosis
Pillow should NOT be placed under knees because it will promote flexion contracture

Rheumatoid Arthritis
• Seen in women
• The prototype for inflammatory arthritis

46
 • Types
o Early stage RA –
o Moderate, Erosive RA
o Persistent, Erosive RA
o Advanced, unremitting RA

Systemic Lupus Erythematosus (SLE)

• Autoimmune systemic disease that can affect any body system. Involvement of the
musculoskeletal system is a common presenting feature
• Involved joint swelling, tenderness, pain and skin changes
• CNS involvement

Scleroderma
• Called Systemic Sclerosis
• Starts with Reynaud’s phenomenon and swelling in the hands
• Known as the “hard Skin” disease and is a rare disease

Polymyositis
• Shows first as muscle weakness
• Idiopathic
• Rare

Polymyalgia Rheumatica
• Severe proximal muscle discomfort with mild joint swelling.
• Severe aching the neck, shoulder & pelvic muscles.
• Mostly in people over 50

Osteoarthritis
• Known as degenerative joint disease or osteoarthrosis - without inflammation
• Most common and frequently disabling of the joint disorders
• Over diagnosed and trivialized
• Peaks in the 5th & 6TH decade of life
• Affects the articular cartilage, subchondral bone (the bony plate that supports the articular
cartilage) and synovium
• A combination of cartilage degradation, bone stiffening and reactive inflammation of the
synovium occurs
• Risks: age, obesity, previous joint damage, genetic susceptibility
• s/s are pain, stiffness & functional impairment
• Occurs in WB joints but also proximal and distal finger joints are involved
• Bony nodes may be present and are usually painless, unless inflamed
• Characterized by progressive loss of joint cartilage, which appears on an x-ray as a narrowing
of joint space.
• Osteotomy (to alter the force distribution in the joint) & arthroplasty (joint replacement) are
used to ease pain
• Viscosupplementation - the reconstitution of synovial fluid viscosity
• Hyaluronic acid is used in the procedure
• Tidal irrigation – intro and then removal of large volume of saline into the joint.

47
Spondyloarthropathies – another category of systemic inflammatory disorders
• Medical Management is treating pain and maintaining mobility by suppressing inflammation.
• Ankylosing Spondylitis – affects the cartilaginous joints of the spine and surrounding tissues
o Usually diagnosed in 20 – 30’s
o Not as severe in females
o Back pain is a feature
o Can lead to respiratory compromise and complications
o Good body position is important in case ankylosis (fixation) occurs
• Reactive arthritis (Reiter’s syndrome)
o Arthritis occurs following an infection.
o Affects young adult males and is characterized by urethritis, arthritis and conjunctivitis
o Dermatitis of the mouth & penis may be present
• Psoriatic arthritis
o Characterized by Synovitis, polyarthritis & spondylitis.
o Psoriasis and arthritis are common conditions

Metabolic and Endocrine Diseases with RD

• Amyloidosis, scurvy, diabetes, HIV infection, AIDS
• Gout is the most common – crystal in the joints
o Hyperuricemia may be due to severe dieting or starvation, excessive intake of foods that are
high in purines (shellfish, organ meats)
o Over secretion of uric acids or a renal defect resulting in secretion of uric acid occurs
o Seen in the great toe, hands and ear. Kidney stones deposits
• Fibromyalgia – involves chronic fatigue, generalized muscle aching and stiffness

Other types of arthritis

Tenosynovitis
Bursitis
Bacterial
Neisseria gonorrhea
Nongonococcal bacterium
Staphylococcus aureas – most common
The results of the cultures are used to determine the appropriate antibiotic therapy.
Immobilization of joint and repeated joint aspiration may be necessary along with IV
antibiotics

Neoplasms & Neurovascular, Bone and Extra-Articular Disorders

• Lipoma, hemangioma and fibroma such as ganglion, bursitis & synovial cyst
• Neurovascular disorders include
o Compression syndrome
 Carpal Tunnel Syndrome
 Radiculopathy
 Spinal Stenosis
 Raynaud’s Phenomenon
 Erythromelalgia
 Bone & cartilages disorders
 Osteoporosis
 Osteomalacia
48
 Hypertrophic
 Oseioarthropathy
 Diffuse idiopathic skeletal hyperostosis
 Paget’s disease
 Osteonecrosis
 Avascular necrosis
 Costochondritis
 Osteolysis

49
Chapter 66

Definitions:

Atonic – without tone

Atrophy – shrinkage-like decrease in the size of a muscle

Bursa – fluid filled sac found in connective tissue, usually in the area of joints

Callus – cartilaginous/fibrous tissue at fracture site

Cartilage – touch, elastic avascular tissue at end of bone

Contracture – abnormal shortening of muscle or joint

Crepitus – grating or crackling sound or sensation; may occur with movement of ends of broken bone or
irregular joint surface

Diaphysis – shaft of long bone

Effusion – excess fluid in joint

Endosteum – thin, vascular membrane covering the marrow cavity of long bones and the spaces in cancellous
bone

Epiphysis – end of long bone

Fascia – fibrous tissue that covers, supports & separates muscles

Fasciculation – involuntary twitch of muscle fibers

Flaccid – limp – without muscle tone

Hypertrophy – enlargement; increase in size of muscle

Isometric contraction – muscle tension – no joint muscle

Isotonic contraction – muscle tension unchanged, muscle shortened, joint moved

Joint capsule – fibrous tissue that encloses bone ends and other joint surfaces

Kyphosis – increase in thoracic curvature of the spine

Ligament – connects bones

Lordosis – increase in lumbar curvature of the spine

Ossification – calcium is deposited in bone matrix

Osteoarthritis – degenerative joint disease characterized by destruction of the cartilage and overgrowth of
bone.

50
Osteoblast – bone-forming cell

Osteoclast – bone resorption cell – destroys bone

Osteocyte – mature bone cell

Osteogenesis – bone formation

Osteoid – pre-bone

Osteoporosis – loss of bone mass and strength

Paralysis – absence of muscle movement suggesting nerve damage

Paresthesia – abnormal sensation (burning, tingling, numbness)

Periosteum – connective tissue covering bone

Scoliosis – lateral curving of the spine

Spastic – greater than normal muscle tone

Synovium – membrane in joint that secretes lubricating fluid

Tendon – connects muscle to bone

Tone – normal tension in resting muscle

Hematopoeiesis – red bone marrow located w/in the bone cavities produces red and white blood cells

Joints - hold the bones together and allow the body to move

Muscles attached to the skeleton contract, moving bones and producing heat, which helps maintain body temp.

Skeletal System – 206 bones in the human body

• Long bones (femur)
• Short bones (metacarpals)
• Flat bones (sternum)
• Irregular Bones (vertebrae)

Bones are made of cancellous (trabecular) or cortical (compact) bone tissue.

Flat bones – provide organ protection and are am important site for hematopoiesis. They are made up of
cancellous bone layered between compact bone.

51
Important regulating factors in bone include:
• Stress
• Vitamin D
• Calcium
• Calcitonin
• Parathyroid hormone
• Blood supply

Weight bearing is important. Without it, the bones loses calcium (resorption) and become osteopenic and
weak which may fracture easy

Parathyroid hormone and Calcitonin are the major hormonal regulators of calcium homeostasis. Parathyroid
hormone regulates the concentration of calcium in the blood, in part by promoting movement of calcium from
the bone.

Calcitonin, secreted by the thyroid gland in response to elevate blood calcium levels, inhibits bone resorption
and increase the deposit of calcium in bone

Blood supply to the bone also affects bone formation. With diminished blood supply or hyperemia
(congestion), Osteogenesis and bone density decrease. Bone necrosis occurs when the bone is deprived of
blood.

Bone Healing
1. Hematoma and inflammation – last several days
2. Angiogenesis and cartilage formation – blood vessels and cartilage overlie the fracture
3. cartilage calcification -
4. cartilage removal – calcified cartilage is removed by Osteoclast and replaced by woven bone
5. bone formation – ossification
6. remodeling – may take months or years

Bone mass peaks at about 35 years of age, after which there is a universal gradual loss of bone

Pain:
Bone Pain – dull, deep ache – that is boring in nature
Muscular Pain – soreness or aching – muscle cramps
Fracture Pain – sharp and piercing and relieved by immobilization
Bone infection with muscle spasm or pressure on sensory nerve may be sharp
Pain that increases with activity may indicate joint sprain or muscle strain
Steadily increasing pain points to progression of an infection, a malignant tumor or neurovascular
complication
Radiating Pain – when pressure is exerted on a nerve root.

52
Joints:
• Synarthrosis – immovable – skull
• Amphiarthrosis – vertebral & symphysis – allow limited movement
• Diarthrosis – freely movable
o Ball & Socket – hip and shoulder
o Hinge – bending in one direction – elbows & knee
o Saddle joint – movement in 2 planes at right angles to each other – thumb
o Pivot joint – permit rotation – ex turning a doorknob – wrist
o Gliding joint – limited movement in all directions – carpal bones of the wrist

Muscle Actions
• Synergists – muscles assisting the prime mover
• Antagonists – muscles causing movement opposite that of the prime mover – when biceps are
contracted – triceps is the antagonist

Gait – assessed by having the patient walk away from the examiner for a short distance. It is examined for
smoothness and rhythm. Any unsteadiness or irregular movements are considered abnormal.

Joint Deformity:
Contracture – shortening of surrounding joint structure
Dislocation – complete separation of joint surfaces
Subluxation – partial separation of articular surfaces

RA – subcutaneous nodules are soft and occur within and along tendons
Gout – nodules are hard and lie within and adjacent to joint capsule
Osteoarthritic nodules are hard and painless and represent bony overgrowth from destruction of cartilaginous
surface of bone within the joint capsule.

Muscle Strength/weakness/disease
• Polyneuropathy
• Electrolyte disturbances – potassium & calcium
• Myasthenia gravis
• Poliomyelitis
• Muscular dystrophy

Clonus – rhythmic contractions of a muscle

Fasciculations – involuntary twitching of muscle fiber groups

Neurovascular status
• Compartment syndrome – pressure within a muscle that increases to such an extent that
microcirculation diminishes, lead nerve damage and muscle anoxia and necrosis. Function can
be permanently lost if the anoxic situation continues for longer than 6 hours. CMS is an
assessment – Circulation, Motion, Sensation

Diagnostic Procedures
• X-ray
• CT – can reveal tumors of the soft tissue or injuries to ligaments or tendons

53
• MRI – uses magnetic fields, radio waves to show, tumors or narrowing of tissue pathways
through bone & soft tissue
• Arthrography – radiopaque substance or air is injected into a joint cavity to outline the soft
tissue structures and the contour of the joint. The joint is put through ROM to distribute the
contract agent while a series of x-rays are obtained. If a tear is present the agent leaks out of
the joint
o Joint is rested for 12 hour after procedure and an compression bandages is applied. Normal
to hear clicking up to 2 days
• Bone Densitometer – used to estimate bone mineral density (BMD). Done using X-rays or
ultrasound
• Bone Scan – detects metastasis and primary bone tumors, osteomyelitis, certain fractures and
aseptic necrosis. A bone-seeking radioisotope is injected intravenously. The scan is performed
2 to 3 hours after the injection. An increased uptake of isotope is seen in primary skeletal
disease (osteosarcoma), metastatic bone disease, inflammatory skeletal disease (osteomyelitis)
and fractures
o Need to check if patient is allergic to radioisotope. Patient needs to drink plenty of fluid to
help distribute and eliminate the isotope
• Arthroscopy – camera to look at the joint. Done in the operating room. Injection of a local
anesthetic into the joint or general anesthesia is used. A large bore needle is inserted and the
joint is distended with saline. Complications are infection, Hemarthrosis, neurovascular
compromise, etc..
• Arthrocentesis (joint aspiration) – obtain synovial fluid for examination or to relieve pain due
to effusion. Helps to diagnose septic arthritis. Reveals Hemarthrosis (bleeding into the joint
cavity). Normal fluid is scanty, clear, pale or straw-colored
• EMG (Electromyography) provides information about the electrical potentional of the muscles
and the nerves leading to them
• Biopsy – determines the structure and composition of bone marrow, muscle or synovium to
help diagnose disease
• Blood/Urine – can provide info about primary skeletal disease (Paget’s), a developing
complication (infection, baseline for therapy (anticoagulant) or response to therapy

54
Chapter 67

Definitions

Abduction – away from body

Adduction – toward body

Arthrodesis – surgical fusion of joint

Arthroplasty – surgical repair of joint; joint replacement

Avascular necrosis – death of tissue due to insufficient blood supply

Cast syndrome – psychological and physiologic response to confinement in body cast

CPS device – Continuous Passive Motion – promotes ROM –

Edema – soft tissue swelling due to fluid accumulation

External fixator – external metal frame attached to and stabilizing bone fragments – used to manage open
fractures with soft tissue damage. Used for severe comminuted (crushed or splintered) fractures. Fractures of
the humerus, forearm, femur, tibia and pelvis are managed by external fixator
• Monitoring of neurovascular status of the extremity is every 2-4 hours and assessment of pin
sites for infection and loosening.
• Nurse NEVER adjusts the clamps on the external fixator
• Encourage isometric and active exercise
• Ilizarov EF used to correct angulations and rotational defects to treat nonunion fracture and to
lengthen limbs

Fasciotomy – surgical procedure to release constricting muscle fascia to relieve muscle tissue pressure

Fracture – break in the continuity of the bone

Heterotrophic ossification – misplaced formation of bone

Hemiarthroplasty – replacement of one of the articular surfaces – not all

Joint Arthroplasty or replacement – replacement of joint surfaces with metal or synthetic materials

Meniscectomy – excision of a damaged joint fibro cartilage

Bone graft – placement of bone tissue to promote healing, to stability or replace diseased boned

Tendon Transfer – movements of tendon insertion to improve function

PMMA – bone –bonding agent that has properties similar to bone. Loosening of the prosthesis due to
cement-bone interface failure is a common reason for prosthesis failure

Neurovascular status – neurological and circulatory function of body part

ORIF – Open reductions with internal fixator – surgery to repair and stabilize a fracture

55
Osteomyelitis – infection of bone

Osetotomy – surgical cutting of bone

Traction – application of pulling force to a part of the body

Cast – a rigid immobilizing device that is molded to the contours of the body. The purpose is to immobilize a
body part in a specific position and to apply uniform pressure on encased soft tissue.
• Cracking or denting of the cast is prevented by supporting the patient on a firm mattress and
with flexible, waterproof pillows until the cast dries. The nurse turns the patient to a prone
position, twice daily, to provide postural drainage of the bronchial tree and to relive pressure on
the back.

Traction – application of a pulling force to a part of the body.

• Used to minimize muscle spasms
• To reduce, align and immobilize fractures
• To reduce deformity
• To increase space between opposing surfaces
• Vectors of Force – the lines of pull in traction
• Short-term – helps to reduce disuse syndrome
• Counter traction is the force acting in the opposite direction and must be maintained for
effective traction
• Weigh are never removed unless intermittent traction is prescribed
o Buck’s Traction – straight or running. Skin Traction – directly to skin
 No more than 4.5 to 8 lbs can used on extremity
 Pelvic traction is 10-20 lbs
 Buck’s traction, cervical head halter & pelvic belt
 Unilateral or bilateral is skin traction to the lower leg. The pull is exerted in one
plane when partial or temporary immobilization is desired. Used after fractures of
the proximal femur before surgical fixation
 Skin breakdown, nerve pressure and circulatory impairment are complication
 Foot drop may occur because of pressure on the peripheral nerves
 DVT is another complication
 Patient should not turn from side to side
 Check skin three times a day – remove boot
 Assess nerves and sensation
 Check circulation, including DVT assessment, every 1-2 hours
o Balanced suspension – skeletal traction – supports the extremity off the bed
 Skeletal Traction that is applied directly to the bone
 Used to treat fractures of the femur, tibia and cervical spine
 Doctor applies using surgical asepsis
 Uses 15-25 lbs
 Supports the affected extremity, allows patient movement
 Thomas splint with a Pearson attachment is frequently used for fractures of the
femur.
 Nurse must never removed weights from skeletal traction unless a life-threatening
situation occurs. May result in injury to patient.
 Check for skin breakdown on elbows as well as nerve damage, heals
56
  Check pin site to avoid infection and development of osteomyelitis every 8 hours

Complications of Traction
• Pneumonia – ausculate lungs every 4 to 8 hours to determine respiratory status and teach
patient deep breathing and coughing exercise to fully expand lung and moving pulmonary
secretions
• Constipation and Anorexia – reduced gastrointestinal motility results in constipation and
anorexia – a diet high in fiber may help gastric motility
• Urinary Stasis and Infection – lots of liquid and urinate every 3 to 4 hours
• Venous Stasis & DVT – check every 1 to 2 hours

Brace – Orthoses – for long-term use

Hip Precautions
• Never cross legs
• Never bend at hip more than 90 degrees
• Do not elevate head of bed more than 60 degrees
• Keep legs abducted (apart)
• When sitting patient’s hips should be higher than knees
• Avoid internal and external rotation, hyperextension and acute flexion
• Needed for 4 months following surgery
• Dislocation can occur
o Increased pain at surgical site
o Acute groin pain in affected hip
o Shortening of the leg
o Abnormal external or internal rotation
o Restricted ability or inability to move leg
o “popping” sensation in hip
o If it happens, hip must be stabilized to legs does not sustain circulatory and nerve damage.
o After closed reduction, limb may be stabilized with bucks traction or brace to prevent
recurrent dislocation.

DVT – Deep Vein Thrombosis

• Occurs 5 to 7 days after surgery
• 45% to 70% chance
• 20% of those that develop DVT also develop pulmonary emboli
• Signs include, calf pain, swelling and tenderness and negative Homan’s signs
• Encourage patient to consume adequate amounts of fluid, perform ankle and foot exercises
hourly
• Low dose heparin or Lovenox (enoxaparin) is prescribed prophylaxis after hip surgery
• Patients who have diabetes, RA, infections or large hematomas are high risk
• Acute infections may occur 3 months after surgery

Knee Replacement
• Post-op – knee is in a compression bandage
• Ice may be applied to control edema and bleeding
• Assess neurovascular status of leg

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 • Encourage active flexion of foot every hour when patient is awake
• Wound drainage is 200-400 ml first 24 hours and then 25ml by 48 hours
• CPM device -10 degrees of extension and 50 degrees of flexion are prescribed initially,
increasing to 90 degrees of flexion with full extension by discharge
• Pre-op – ask patient about occurrence of colds, dental problems, UTI and other infections 2
weeks before surgery. Osteomyelitis could develop through hematologous spread

Post Op Concerns with Orthopedic surgery

• Hypovolemic shock because of blood loss
o Pulse rate increase, respiratory rate decreases, BP low, pallor, urine output less than 30 ml
per hour, restlessness, decreased hemoglobin and hematocrit
• Atelectasis (collapsed lung) and pneumonia may be related to preexisting pulmonary disease,
deep anesthesia, decreased activity, , underlying musculoskeletal disorder. Monitor breath
sounds and encourage the accumulation of secretions. Insensitive spirometer is encouraged.
coughing exercises. Full expansion of the lungs prevent
• Fat Embolus may occur with orthopedic surgery. Be alert to changes in respiration, behavior
and LOC
• DVT’s -
• Infection
• Urinary Retention – encourage patient to void every 3 to 4 hours
• Well-balanced diet is important for wound healing. Large amts of milk should not be given
because this adds to calcium pool in the body and requires that the kidneys excrete more
calcium, which increases the risk for urinary calculi

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Chapter 68

Definitions

Bursitis – inflammation of a fluid-filled sac in a joint

Contracture – abnormal shortening of muscle or fibers of joint structures

Involucrum – new bone growth around sequestrum

Radiculopathy – disease of a nerve root

Sciatica – sciatic nerve pain; pain travels down back of thigh into foot

Sequestrum – dead bone in abscess cavity

Tendonitis – inflammation of muscle tendons.

Osteoporosis
• Reduction in bone density and bone structure
• Bone resorption is greater than the rate of bone formation
• Bones become porous, brittle and fragile
• Results frequently in compression fractures
• Higher in caucasion & Asian, small framed, older women
• Sometimes develops Kyphosis – dowager’s hump
• Loss of height
• Protruding abdomen
• Reduce caffeine, cigarettes and alcohol early
• Some diseases bring on osteoporosis – celiac disease and hypogonadism and medications
(corticosteroids and anti-seizure)
• Calcitonin, which inhibits bone resorption is decreased in the elderly
• Estrogen, which inhibits bone breakdown, decreases with age
• PTH –parathyroid hormone – increases with aging, increasing bone turnover and resorption.
• Need to exercise with WB exercise
• Co-morbidity – anorexia, hyperthyroidism, malabsorption syndrome, renal failure
• Relieve pain
• High fiber diet to reduce constipation
• Reduce risk of falls

Osteomyelitis
• Bone infection
• Three modes:
o Extension of soft tissue infection
o Direct bone contamination from bone surgery, open fracture of traumatic injury
o Hematogenous – blood born spread from other sites and infections
• Stage I – acute, occurring during first 3 months
• State II – delayed onset – occurring between 4 and 24 months
• State III – late onset – occurring 2 or more years after surgery – usually as a result of
Hematogenous spread
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• Staphylococcus auerus causes 70-80%
• S/s of osteomyelitis
o Inflammation
o Edema
o Thrombosis of the blood vessels occurs in the area, resulting in ischemia with bone necrosis
o Bone abscess can form if not treated
o Onset is sudden when it is blood borne
 Chills, high fever, rapid pulse, general malaise
o patient may complain of a constant, pulsating pain that intensifies with movement as a
result of the pressure of the collecting pus.
• If patient does not respond to therapy, infected bone is surgically exposed, and purulent and
necrotic material is removed and area is irrigate with sterile saline solution.
• IV Therapy can be done at home.

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Chapter 69

Definitions

Allograft – tissue harvested from a donor for use in another person

Amputation – removal of a body part, usually a limb or part of a limb

Arthroscope – surgical instrument used to examine internal joint structures

Autograft – tissue harvested from one are of the body and used for transplantation to another are of the body

Contusion – a soft tissue injury produced by blunt force. Small blood vessels rupture and bleed into soft
tissues.

Debridement – surgical removal of a contaminated and devitalized tissues an foreign material

Dislocation – separation of joint surfaces

Fracture – a break in the continuity of a bone

Fracture reduction – restoration of fracture fragments into anatomic alignment and rotation

Melana – dark stool with upper GI blood from Ibuprofen

Malunion – healing of a fractured bone in a misaligned position

Meniscus – crescent shaped fibrocartilage found in certain joints, such as the knee joint

Nonunion –failure of fragments of fractured bone to heal together

Phantom limb pain – pain perceived as being in the amputate limb

RICE – Rest, Ice, Compression, Elevation24- 48 hours

• Cold applied for 20 to 30 min during first 24 – 48 hours to produce vasoconstriction
• Elevation controls the swelling
• After 48 hours – heat can be applied for 15 to 30 min to relive muscle spasms and to promote
vasodilatation, absorption and repair

Rotator Cuff – shoulder muscles and their tendons

Sprain – an injury to ligaments and other soft tissues at a joint

• Treat with RICE

Strain – a muscle pull or tear

• Treat with RICE
• Muscle tears with some bleeding into the tissue.
• Sore and sudden pain with local tenderness on muscle use and isometric contraction
• Caused by overuse, overstretching or excessive stress

Subluxation – partial separation or dislocation of joint surfaces

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Tendonitis – inflammation of a tendon

Types of Fractures
Greenstick – where one side of the bone is broken and the other side is bent.
Transverse – fracture is straight across bone – mostly seen in long bones
Oblique – Fx line slants on an angle across shaft of bone
Spiral – like oblique but wraps around and climbs
Comminuted – bone splinters – not good
Depressed – skull – bone fragments are inward (facial & cranial)
Compression – vertebral – fragments are pushed together
Pathologic – disease – Paget’s, Osteomylitis – bone infection
Impacted – one bone fragment is impacted to another
Compound – worst – breaks through the skin

Signs & symptoms

• Pain
• Loss of Function
• Deformity
• Crepitus – grinding – rubbing
• Swelling
• Ecchymosis – bruise
• Break in skin
• Damage to organs

DX of fracture
History of incident
Assessment
CT or X-ray

Manage
• Emergency Care
• Cover open wounds with sterile, lint-free materials to prevent infection.
• DO NOT REALIGN
• Closed reduction – done manually and bone set in place. X-ray first – closed reduction – x-ray
again
• Open reduction – Surgery – ORIF
• FX immobilization – casts
• Exercises – isometric exercises of affected and unaffected
• Help patient – with ADL’s

Bone Healing
• Immobility/timely correction
• Ice
• Sufficient Blood Supply
• Sufficient Nutrition
• WB exercises
• Hormones

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Bone Healing Complications
Extensive trauma/delay
Infection
Declining Circulation
Bone disease
Malnutrition
Age/Immune
Open Fracture
Closed Fx:
Self care
Meds
Possible complications
Open Fx:
Possible Complications
Wound Irrigation
Osteomyelitis – bone infection

Complications of Bone:

Hypovolemic Shock – resulting from hemorrhage and from loss of extra-cellular fluid into damaged tissues

Assessment/Signs & Symptoms of Shock

• Decreased BP
• Tachycardia
• Tachypnea – fast breathing
• Skin Color
• Restlessness
• Decreased LOC

Nursing Interventions for Shock

• Keep patient warm
• Monitor VS and O2 status
• Restore blood volume and circulation
• Monitor labs

Fat embolism
• Fat globule in blood stream
• Seen within 24-72 hours with fracture of long bones
• Seen frequently in young adults (20 – 30 years old)

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Assessment/Signs & Symptoms of Fat Embolism
• Hypoxia – inadequate oxygen
• Headache/Pyrexia
• Irritability, confusion & agitation
• Feelings of Doom
• Tachycardia
• Tachypnea
• Wheezing
• Petechia – red spots on skin
• Use of accessory muscle/ARDS

NI for Fat Embolism

• Teach to cough, deep breath
• Heparin
• Aspirin
• O2
• Bed rest
• Corticosteroid
• I&O
• Prevent metabolic acidosis

Compartment Syndrome
• Tissue perfusion in the muscle is less than required for tissue viability
• Rise in the intra-compartmental pressure with tissue damage (30 min) and death (4 hours)
• Average 8 or less
• 30 bad

Signs & Symptoms of Compartment Syndrome

• unrelenting deep throbbing pain
• swelling, numbness & tingling
• cyanotic nail beds
• paralysis
• above heart level

NI for Compartment Syndrome

• Notify MD
• Remove any constrictions
• Measure pressure
• Surgical fasciology – to remove pressure
• Decompress with excision of the fibrous membrane that covers and separates muscles

DVT ((Deep Vein Thrombosis)

• related to bed rest and reduction in skeletal contraction
• redness, tender, heat, pain and negative Homan’s signs

Vascular Necrosis
• Bones loses its bloods supply

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 • Bones cells die
• Frequently seen in femoral head, talus bone of ankle and lunate? bone of the wrist
• Steroid Therapy – Tape

Assessment/Signs & Symptoms for Vascular Necrosis

• Pain, ______ unstable and decreasing function

DX for Vascular Necrosis

• X-ray, bone scan & CT Scan

NI for Vascular Necrosis

• Non-weight bearing
• Removal of bone (tape)

Delayed union – healing does not occur at a normal rate

Non-union -Failure to unite

Other FX complications
• Infection
o Organ injury
o Ruptured tendons
o Severed (tape)_
• Hip Fx
o Fx of proximal end of femur
 Etiology
• Weak muscle
• Decreased cerebral blood flow
• Renal disorder
• Osteoporosis
2 Types of Hip Fx
Intracapsular
• Occult – groin pain & weight bearing
• Impacted and non-displaced moderate discomfort, groin & knee pain – non visible
• Displaces leg externally, rotated, painful
Extra capsular
• Trochanteric
• Subtrochanteric

Signs & Symptoms of Hip Fracture

• Muscle spasms
• Shortened leg with adduction and external rotation
• Pain
• Tenderness at site

NI for Hip Fx
• Temporary Skin Traction (Bucks)
• Sandbags
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 • Surgical repair

Post Op Care for Hip Fx:

Repositioning
Strengthening Exercises
Monitor for:
DVT
Skin Assessment
Pulmonary Complications
Neurovascular complications
Dislocation

Wrist FX
• Fx of distal radius (Polle’s Fx) and Ulnar

Signs & Symptoms of Wrist Fx

• Dinner fork deformity/deformed wrist
• Proximal depression and fullness to distal aspect of wrist
• Loss of sensation and feelings to fingers due to (tape)

NI for Wrist Fx.

• RICE
• Closed reduction
• Immobility – cast
• Fixation device
• Pain meds
• Elevate
• Exercise

Nursing Dx for Wrist Fx

• Altered peripheral tissue perfusion:
o Risk for impaired skin integrity
o Risk for infection
o Self care deficit

Amputations
• Closed – bone area is removed and muscle flap
• Open – all is removed – cauterize stump
• Disarticulation – removal of a body part through a joint
Performed at most distal site – determined by circulation

Complications of Amputation:
• Hemorrhage
• Infection
• Delayed healing
• Flexion deformity
• Skin irritation
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 • Phantom limb
• Sensation reduced

Assessment/Signs & symptoms for Amputation

• circulation to affected part
• baseline neurovascular assessment
• assess physical and emotional stress

NI & medical management of Amputation

• Healing of wound
• Limb edema
• Stump care
• Phantom pain
• Pharmacology
• Use of prostheses
• Refer to support group

Nursing DX for Amputation

• Pain
• Sensory perception alteration
• Impaired skin integrity
• Body image disturbance
• Dysfunctional grieving (tape)

Compare RA & OA
Rheumatoid Arthritis
• Chronic systemic inflammatory disorder characterized by swelling/pain and includes
• Symptoms are acute
• Autoimmune
• Seen mostly in females
• Symptoms appear between 30 & 50
• Exhabesence

Muscoskeletal
Bilateral, Symmetrical, swelling, joint pain, hot

Signs & Symptoms of RA

• Joint pain
• Joint stiffness

OA
Swimming is best

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Independent Study

Acute Lower Back Pain –

Causes:
Musculoskeletal Problems: Other Problems:
Acute lumbro-sacral strain Bone metastasis
Unstable lumber-sacral ligaments and joints Kidney disorders
Osteoarthritis of spine Pelvic problems
Spinal stenosis Retroperineal tumors
Disc problems (ie-degeneration or herniation) Abdominal aneurysms
Unequal leg length Psychosomatic problems (ie stress & depre
Osteporotic verterbral fx Obesity

• If r/t MS disorders, Pain will increase with activity

• If r/t other causes pain will not increase with activity
• Patients with chronic (more than 3 months) may develop dependence on ETOH or drugs to
cope with pain.
• Disk degeneration (esp L4-L5 and L5-S1) have greatest degenerative changes, and most often
contribute to low back pain.
Manifestations:
• Acute or chronic (longer than three months) low back pain
• Pt may c/o sciatica (pain down leg) which suggests nerve root involvement
• Pt’s gait, spinal mobility, reflexes, leg strength and length and sensory perception may be
altered
• Paravertebral muscle spasm (greatly increased muscle tone in the back muscles) is common
Medical Management:
• Most back pan is self limiting and resolves within 4 weeks with analgesics, rest, stress
reduction, and relaxation
• Twisting, bending lifting and reaching should be avoided
• Management focuses on pain relief, activity modification, and patient education.
• Patient taught to change positions frequently- sitting should be limited to 20-50 minutes based
on level of comfort
• With severe pain bed rest may be recommended for up to four days max. (usually 1-2)
• Avoid prone position
Proper Body Mechanics:
• Use low heeled shoes
• If you have to stand for long periods, shift weight frequently, and rest one foot on a stool
• Proper posture is chest up, and abdomen tucked in
• Do not lock knees when standing
• Keep feet flat on the floor while sitting, with back supported
• Pt should sleep on their side with hip and knees flexed
• Lifting should be done with quadriceps muscles of thighs, not back muscles, with feet apart for
a wide base of support.

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Disc Herniation
• Most back problems are r/t disc problems
Pathophysiology:
• In herniation of the disc (ruptured disc) the nucleus of the disc protrudes and causes nerve
compression.
• Propulsion or rupture is usually associated with degenerative changes that occur w/ aging
o Loss of protein
o Development of radial cracks in annulus
• Also , after falls, and repeated trauma, such as lifting cartlidge may be injured
o For most pt’s the immediate s/s of trauma are short lived, and injuries to the disc are not
apparent for months or years. When the disc starts to degenerate later on it may herniate or
rupture and compress spinal nerves
• A ruptured or herniated disc produces pain due to pressure on nerve endings (Radiculopathy)
• Continued pressure may produce degenerative changes in the involved nerve, such as changes in
sensation and deep tendon reflexes.

Manifestations:
o A herniated disc with accompanying pain may occur in any portion of the spine
o Spondylosis- degenerative changes occurring in disc and vertebrae which lead to herniation
o Cervical disc herniation usually occurs at the C5-6 and C6-7 spaces.
 Pain and stiffness may occur in the neck, shoulders, and scapula area
 Sometimes pts mistake this for heart trouble or bursitis
 Pain may also occur in the upper extremities and head accompanied by paresthesia and
numbness of UE
 Cervical MRI confirms dx
 Cervical spine may be immobilized by use of cervical collar, brace or traction
 Bed rest is important (1-2 days) b/c it eliminates the stress of gravity of the head on the
cervical spine
o Thoracic herniation is rare
o Lumbar disc herniation usually occurs at the L4-5or L5-S1 spaces
 Herniated lumber disc produces low back pain, and varying degrees of sensory and
motor impairment
 Low back pain may be accompanied by radiation of the pain into one hip and down the
leg (sciatica)
 Pain is aggravated by actions that increase intraspinal fluid pressure (lifting, bending,
sneezing and coughing and straining)
 Pain is usually relived by bed rest
 There is usually some sort of postural deformity associated w/ lumbar herniation r/t pain

Assessment and diagnostic findings:

 MRI tool of choice to locate even small herniations
 Neuro exam carried out to see if there is deficit from root compression

Medical management:
 Usually managed conservatively w/ bed rest and medication
 If this does not work, there are several surgeries available to correct disc herniation

69
  Surgical excision of a herniated disc is performed when there is evidence of a progressive neuro deficit
(muscle weakness and atrophy, loss of sensory and motor fxn, loss of spinchter control), or continuing
pain and sciatica that does not respond to conservative treatment.
 The goal of surgical tx is to reduce pressure on the nerve root, relive pain and reverse neuro deficits.
 Types of surgical interventions:
o Discectomy-
 Removal of herniated fragments of disc
 w/ fusion- bone graft is used to fuse the vertebral spinous process
• the object of spinal fusion is to bridge over the defective disc to stabilize the
spine and reduce the rate of reoccurance
Laminectomy-
Removal of part of vertebral bone in order to expose neural elements of spinal canal
Hemilaminectomy
Removal of a smaller part of the vertebrae
Partial laminectomy-
Creation of a hole in the vertebrae
Foraminotomy-
Removal of vertebral foramen to increase space for exit of the spinal nerve
Results in reduced pain, compression and edema.

Carpal Tunnel Syndrome –

An entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor
tendon sheath or soft tissue mass.
• Patient experiences pain, numbness, paratesia,along median nerve. Thumb and first two fingers are
most affected
• Repetitive work causes it for the most part (ie typing)
• Can also be caused by arthritis, hypothyroidism or pregnancy
• Tinels sign used to identify it
• Night pain is common

Sports Injuries
• Contusions, sprains, strains
• Tendonitis – inflammation of a tendon caused by overuse
o Tennis Elbow and Achilles tendonitis in runners and gymnasts and intrapatellar tendonitis in
basketball players
• Meniscal injuries of the knee occur with excessive rotational stress
• Fractures such as colles fx in skaters and bikers, metatarsal fx in ballet and track and field, stress fx
with repeated bone trauma from activities such as jogging, gymnastics, basketball or aerobics.
• Tibia, fibula and metatarsals are most likely to be fx’d

Gout
• Gouty arthritis – the presence of crystals in the synovial fluids r/t hyperuricemia (high uric
acid)
• Hyperuricemia may be r/t starvation, excessive intake of foods high in purines (shellfish, organ
meat) or genetic
Manifestations:
• High uric acid in blood
• First sign is usually acute arthritis in the big toe

70
 • Acute attack may be triggered by trauma, ETOH ingestion, dieting, medications and illness
• Pt may also have renal calculi

NI for Gout
• Heat application are helpful in relieving pain, stiffness & muscle spasm
• Maximum benefit is achieved in 20 minutes
• If acute – cold applications may be tried
• Use one pillow under head to reduce dorsal kyphosis
• Pillow should NOT be placed under knees because it will promote flexion contracture
• Crystals in synovial fluid are sodium urate crystals (Tophi)
• Tx w/ allpurinol, but cautiously b/c of s/e.
•

Paget’s Disease – (osteitis deforman)

• Disorder of localized rapid bone turnover, mostly commonly affecting the skull, femur, tibia,
pelvic bones and vertebrae.
• Primary proliferation of osteoclasts, they eat the bone
• Followed by osteoblastic activity that replaces the bone.
• As bone turner occurs, a disorganized pattern of bone develops
• Pathologic fractures occur
• Bowing of the legs causes misalignment of the hip, knee and ankle joints
o Misalignment causes development of arthritis, back and joint pain
• Occurs in people over 50 and men more often
• Cause not known but it is hereditary
• Insidious- patient may never know they have it until pathological fx occurs
• S/S :
o Bowing of femur and tibia
o Enlargement of skull
 Patient may report that hat no longer fits, face has a small triangular appearance
o Deformity of pelvic bones
o Thorax is compressed and immobile w/ respirations
o Cortical thickening of long bones
o May have cranial nerve compression that can affect hearing
o Waddling gait noticed because of femur and tibia bowing
o Trunk looks shortened and arms look long (ape-like)
o Pain, tenderness and warmth over bones may be noticed
 Pain increases with weigh bearing, esp. with LE involvement
 Temperature increases over affected bones b/c of increased vascularity
o Pt’s w/ large vascular lesions may develop high output cardiac failure
• Diagnosis
X-rays confirms diagnosis
Increased Alk. Phos. blood levels
Increased urinary hydroxyproline levels
Have normal blood calcium levels.
• Treatment:

71
 o Administration of NSAIDS, walking aids, shoe lifts and PT
o Administration of Calcitonin subq or nasal inhalation.
 S/E- flushing of face, nausea
o Fosamax & Didronel also used for rapid reduction in bone turnover.
o Mithracin – a cytotox antibiotic maybe be used to control the disease – IV
o Adequate calcium – 1500 mg and vit D (400-600 IU)

Osteomalacia
• Metabolic bone disease characterized by mineralization of bone. Because of faulty mineralization,
there is a softening and weakening of the skeleton, causing pain and tenderness to touch, bowing of
the bones and pathologic fractures.
• Pathophysiology:
o Deficiency of activated Vitamin D (calcitrol) which promotes calcium absorption
o May result from failed calcium absorption and from excessive loss of calcium
o GI disorders (celiac disease, chronic biliary tract obstruction, chronic pancreatitis, small bowel
resection) in which fats are not absorbed are likely to produce ostomalacia
o Also liver and kidney disease can produce a lack of vitamin D because these are the organs that
convert Vitamin D to its active form
o Hyperparathyroids leads to skeletal decalcification and then to osteomalacia by increasing
phosphate excretion in the urine
o Prolonged use of anti-seizure meds increases risk
• S/S
o Spinal Kyphosis and bowed legs
o X-rays show generalized demineralization of bone
o Decrease in serum CA+ and phosphorus levels, and mildly elevated alkaline phos.
•
• Nursing Interventions:
o Spend time in the sun to promote Vitamin D
o Increase Vitamin D and calcium.
o Eat eggs, chicken livers, milk and cereals high in Vitamin D
o Monitor serum calcium levels to reduce risk of hypercalcemia when vit d intake is increased
o Can be helped with diet control

Bone Tumors
****Primary complaint: Pain for all bone tumors
• Metastatic bone tumors are more common than primary bone tumors
• Benign bone tumors
o More common and not a cause of death
o Some benign tumors have the potential to become malignant
o Osterochondroma is the most common bone tumor
 Seen as a large project of bone at the end of a long bone (knee or shoulder)
o Enchodroma – common tumor of the hyaline cartilage that develops in the hand, femur, tibia
or humerus.
 Usual symptom is mild ache
o Bone cysts are expanding lesions within the bone.
 Seen in young adults who present with a painful, palpable mass of the long bones,
vertebral or flat bone

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  Unicameral bone cysts occur in children and cause mild discomfort and possible
pathologic fractures of the upper humerus and femur
o Osteoid Osteoma – painful tumor that occurs in children and young adults. Neoplastic tissue
is surrounded by reactive bone formation
o Osteoclastomas are giant cell tumors that are benign for long periods but may invade local
tissue and cause destruction.
 Occurs in young adults and are soft and hemorrhage
 May undergo malignant transformation and metastasize
•
•
• Malignant Bone Tumors
o Primary tumors that cause bone destruction, weakening of bones and fractures
o Rare that arise from sarcomas or bone marrow elements
 Osteogenic sarcoma (osteocarcome) is the most common and most fatal primary
malignant bone tumor.
• Prognosis depends on whether it has metastasized to the lungs
• Appears in males between 10 & 25 years old, in older people with Paget’s
disease and a result of radiation exposure.
• S/s – weight loss, pain, swelling, limited motion, Increased alk. Phos..
• Most common sites are distal femur, proximal tibia and proximal humerus
• Bony mass may be palpable, tender and fixed w/ venous distention
 Chondrosarcomas
• Tumor of the hyaline cartilage
• Common primarily malignant bone tumor
• Large, bulky, slow-growing tumors that affect adults
• Includes pelvis, femur, humerus, spine, scapula and tibia
• Large bloc excision or amputation of the affected extremity results in increased
survival rate

• Metastatic Bone Disease

o Secondary Bone Tumor
o More common than primary
o Most common primary sites of tumors that metastasize to bone are:
 Kidney
 Prostate
 Lung
 Breast
 Ovary
 Thyroid
o Most frequently attack the skull, spine, pelvis, femur and humerus and involve more than one
bone (polyostotic)
• Secondary Tumors cause bone destruction, which weakens the bones, resulting in bone fractures
• Places pressure on adjacent bone tissue
• Treatment of metastatic bone disease is pallatiative. It is to help reduce pain to help with the
quality of life
• Hypercalcemia results from breakdown of bone. Treatment includes hydration with IV
• Hematopoieis is interrupted by treatments for the cancer.
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• Pt’s w/ metastatic bone disease are at a much hight risk for pulmonary congestion, hypoxemia,
DVT’s and hemorrhage than others post-op.

Hypercalcemia is a dangerous complication of Bone cancer

S/S- muscle weakness, incoordination, anorexia, N/V, constipation, ECG changes, and altered mental
state.

74