Musculoskeletal

Fracture

A break in the continuity of the bone caused by trauma twisting as a result of a muscle spasm or indirect loss of leverage or bone decalcification and disease that result in osteopenia Types: Close: skin over the fracture area remains intact Comminuted: the bone is crushed or splintered creating numerous fragments -may cause impinged nerves -need surgery wont heal on its own Complete: bone is separated completely by a break into 2 parts Compression: fractured bone is compressed by other bone Depressed: Bone fragment driven inward Greenstick: One side of the bone is broken and the other is bent these fractures occur mostly in children Impacted: A part of the fractured bone is driven into another bone -can cause injury to nerves Incomplete: Fracture line does not extend through the full transverse width of the bone Oblique: the fracture line runs at an angle across the axis of the bone Open or compound: the bone is exposed to air through a break in the skin, and soft tissue injury and infection are common -need surgery not going to heal on their own -splint the extremity and cover the wound with sterile dressing Pathological: fracture results from weakening of the bone structure by pathological processes such as neoplastic also called spontaneous fracture (Ex: pumping into the wall and getting a fracture) -a sign of osteoporosis or nutrient deficiency or cancer Spiral: The break partially encircles bone Transverse the Bone is fractured straight across -can cause injury to the nerve Assessment: -pain or tenderness over the involved area -decrease or loss of muscular strength or function -obvious deformity of the affected area -crepitation (rice crispy crunchy sound) -erythema, edema or bruising -muscle spasm and neurovascular impairment NEED CMS ASSESSMENT (color, motion, sensitivity) ***how do you handle someone with a suspected fracture? proximal distal Intervention: -immobilize the affected extremity with a cast or splint -Assess the neurovascular status of the extremity -Reduction, fixation, traction of cast

Gout

Accumulation of uric acid Primary Gout: -disorder of purine metabolism Secondary Gout: -involves excessive uric acid in the blood caused by another disease -alcohol intake -tumor lysis syndrome Hallmark sign: -pain in the big toe because of the deposits of urate crystals Phases -Asymptomatic: client has no symptoms but serum uric acid level is elevated -Acute: Client has excruciating pain and inflammation of 1 or more small joints especially the GREAT TOE -Intermittent: Client has intermittent periods without symptoms between acute attacks -Chronic :results from repeated episodes of acute gout a) results in deposits of urate crystals under the skin b) urate crystal deposits within major organs such as kidneys leading to organ dysfunction Assessment: -Swelling and inflammation of the joints lead to excruciating pain -Tophi: hard irregularly shaped nodules in the skin containing chalky deposits of sodium urate -low grade fever malaise and headache -Pruritis from urate crystals in the skin -Presence of renal stones from elevated uric acid levels Interventions: -provide low purine diets avoiding foods such as (organ meats, wines, aged cheeses) -encourage a HIGH fluid intake of 2000mL/day to prevent stone formation -encourage a weight reduction diet if required -instruct client to avoid alcohol and starvation diets because they may precipitate a gout attack -increase urinary pH above 6 by eating alkalin ash foods (green beans, broccoli) -Provide bed rest during acute attacks with the affected extremity elevated -Position the joint in mild flexion during acute attack -Monitor joint range of motion ability and appearance of joints -Protect the affected joint from excessive movement or direct contact with sheets or blankets -Provide heat or cold for local treatment to affected joint as prescribed -Administer medications such as analgesic anti-inflammatory and uricosuric agents as prescribed

Skeletal Traction

DESCRIPTION -Mechanically applied to the bone using pins, wires, or tongs -typical weight is 25 to 40 lbs Nursing Interventions -Monitor the color motion and sensation of the affected extremity -monitor the insertion sites of redness swelling drainage or increase pain -provide insertion site care as

Skin Traction

DESCRIPTION -Traction applied by the use of elastic bandages or adhesive •Cervical traction -relieves muscle spasms and compression in the upper extremities and neck -cervical skin traction uses a head halter and chin pad to attach the traction -use powder to protect the ears from friction rub -position the client with the HOB elevated 30-40 degrees and attach the weights to a pulley system over the head of bed •Buck's traction used to alleviate muscle spasms and immobilize a lower limb by maintaining a straight pull on the limb with the use of weights -Not more than 8-10lbs -the weights are attached to a pulley which allows the weights to hang freely over the edge of the bed •Pelvic traction •Used to relieve low back, hip, or leg pain and to reduce muscle spasm •Apply the traction snugly over the pelvis and iliac crest and attach to the weights •Prevent the client from slipping down in bed BALANCED SUSPENSION •DESCRIPTION -Used with skin or skeletal traction -Used to approximate fractures of the femur, tibia, or fibula -Produced by a counterforce other than client What are nursing Interventions? -Position client in the low fowlers position on their side or back -Maintain a 20 degree angle from the thigh to the bed -Protect the skin from breakdown -Provide pin care if pins are used with skeletal traction -Clean the pin sites with sterile normal saline, hydrogen peroxide or povidone-iodine Dunlop's Skin Traction •DESCRIPTION -Horizontal traction to align fractures of the humerus; vertical traction maintains the forearm in proper alignment •IMPLEMENTATION -Nursing care is similar to Buck's Buck's traction

Rotator Cuff Injuries

Description -Musculotendinous or rotator cuff of the shoulder sustains a tear usually as a result of trauma -Characterized by shoulder pain and the inability to maintain abduction of the arm at the shoulder (drop arm test) hold arm close to their bodies Management -NSAIDS -physical therapy -ice/heat applications -sling support -Surgery may be required if management is unsuccessful or a complete tear is present

Strains Injuries

Description -Trauma to muscle or tendon -excessive stretching, tissue tears or ruptures Management -Cold or heat applications, antiinflammatory medicine and muscle relaxants -Surgical repair may be required for a severe strain (ruptured muscle or tendon)

Sprains Injuries

Descriptions -Trauma to a joint, ligament injury -excessive stretching caused by twisting motion such as fall or stepping onto an even surface -by pain and swelling Management -RICE: Rest, Ice, Compression and Elevation, first aid treatment -Casting may be required for moderate sprains to allow the tear to heal -Surgery may be necessary for severe ligament damage

5 Ps of Circulatory Checks

Pain Paresthesia Paralysis Pulse Pallor if they have some of the other symptoms report them don't wait for them to become pulseless

Diagnostic Studies

Radiography and MRI -Commonly used procedures to diagnose problems of the musculoskeletal system Arthrocentesis -diagnose joint inflammation and infection -aspirating synovial fluid, blood or pus via a needle inserted into a joint cavity -Medication may be instilled into the joint if necessary to alleviate inflammation -Pain may continue for up to 2 days after administration of corticosteroids into a joint Arthroscopy -diagnose and treat acute and chronic problems of the joint -can be assessed, loose bodies removed and cartilage trimmed -instruct the client to fast for 8 to 12 hours before the procedure -elastic compression bandage should be worn for 3 to 4 days after surgery -notify HCP if fever or increased knee pain or edema continues for more than 3 days Bone density -diagnose metabolic bone disease and to monitor changes in bone density with treatment -procedure is painless Bone scan -identify, evaluate and stage bone cancer before and after treatment; used to detect fractures -following the injection, clients must drink 32oz of water to promote renal filtering of the excess isotope -from 1 to 3 hours after injection, have the client void to clear excess from the bladder -no special precautions after a bone scan, because only a minimal amount of radioactivity exist Electromyography -used to evaluate muscle weakness -muscular activity are traced on recording paper through an oscilloscope -needle is uncomfortable -no stimulants 24 hours before procedure -slight bruising may occur

Traction

exertion of a pulling force applied in two directions to reduce and immobilize a fracture -provides proper bone alignment and reduces muscle spasms Interventions: -maintain proper body alignment -ensure that the weights hang freely and DO NOT TOUCH THE FLOOR -Do NOT remove or lift the weights without HCP prescription -Ensure that pulleys are not obstructed and that ropes in the pulleys move freely -place knots in the ropes to prevent slipping -check the ropes for fraying -all same interventions apply to each type of traction

RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS CLIENT EDUCATION

•Assist the client to identify and correct hazards in the home •Instruct the client in the correct use of assistive adaptive devices •Instruct in energy conservation measures •Review prescribed exercise program •Instruct the client to sit in a chair with a high, straight back •Instruct the client to use a small pillow, only when lying down •Instruct the client in measures to protect the joints •Instruct the client regarding the prescribed medications •Stress the importance of follow-up visits with the health care provider

Osteoarthritis

•DESCRIPTION -Also known as degenerative joint disease (DJD) -Progressive degeneration of the joints caused by wear and tear -Causes the formation of bony build-up and the loss of articular cartilage in peripheral and axial joints -Affects the weight-bearing joints and joints that receive the greatest stress such as the knees, hips and lower spine Joint Changes: -loss of cartilage -bone hypertrophy can lead to bone spur •ASSESSMENT -Joint pain that diminishes after rest and intensifies after activity noted early in the disease process (joint pain gets WORST throughout the day) -The disease progresses pain occurs with slight motion or even at rest -aggravated by temperature change and climate humidity -presence of HEBERDEN nodes or BOUCHARDs nodes (hands) -Joint swelling may be minimal CREPITUS and limited range of motion -Difficulty getting up after prolonged sitting -skeletal muscle disuse atrophy -Inability to perform activities of daily living -Compression of the spine as manifested by radiating pain stiffness and muscles spasm in 1 or both extremities •Physical Mobility -Instruct the client to balance activity with rest and to participate in an exercise program that limits stressing affected joints -instruct the client that exercises should be ACTIVE rather than passive and to stop exercise if pain occurs -instruct the client to limit exercise when join inflammation is severe •Surgical Treatment Osteotomy: -bone is resected to correct joint deformity promote realignment and reduce joint stress Total joint replacement or arthroplasty: -performed when all measures of pain relief have failure -hips and knees are replaced most commonly -total joint replacement is contraindicated if presence of infection, advanced osteoporosis, or severe joint inflammation -Heberden's Nodes: Swelling of distal interphalangeal finger joints, characteristic of osteoarthritis -Bouchard's node: Osteoarthritis (PIP swelling 2° to osteophytes)

Crutch Walking

•DESCRIPTION -An accurate measurement of the client for crutches is important because an incorrect measurement could damage the brachial plexus -The distance between the axilla and the arm pieces on the crutches should be two fingerwidths in the axilla space -The elbows should be slightly flexed 20 to 30 degrees when walking -When ambulating with the client, stand on the affected side -Instruct the client never to rest the axilla on the axillary bars -Instruct the client to look up and outward when ambulating -Instruct the client to stop ambulation if numbness or tingling in the hands or arms occurs •How much distance between the crutch and the front of the foot? -6 inches or half a foot Assisting a client with crutches to the chair Place unaffected leg against the front of the chair Move the crutches to the affected side and group the arm of the chair with the hand on the unaffected side Flex the knee of the unaffected leg to lower self into the chair while placing the affected leg straight out in front reverse the steps to move from a sitting to standing position

TOTAL KNEE REPLACEMENT

•DESCRIPTION -Implantation of a device to substitute for the femoral condyles and the tibial joint surfaces •POSTOPERATIVE -Monitor the incision for drainage and infection -Maintain the Hemovac or Jackson-Pratt drain if in place -Begin continuous passive motion (CPM) 24 to 48 hours as prescribed to exercise the knee and provide moderate flexion and extension -Administer analgesics before CPM to decrease pain -The leg should not be dangled to prevent dislocation -Prepare the client for out-of-bed activities as prescribed -Avoid weight bearing and instruct the client in crutch walking

Canes

•DESCRIPTION -Made of a lightweight material with a rubber tip at the bottom -SINGLE- AND QUAD-FOOT CANES •IMPLEMENTATION -The handle should be at the level of the client's greater trochanter -The client's elbow should be flexed at a 15- to 30-degree angle Interventions: -Stand at the AFFECTED side of the client when ambulating use of a gait or transfer belt may be necessary -the handle should be at the level of the clients greater trochanter -the clients elbow should be flexed at a 15-30 degree angle -instruct the client to hold the cane in the hand on the UNAFFECTED SIDE so that the can and weaker leg can work together with each step -Instruct the client to inspect the rubber tips regularly for warm pieces HEMICANES OR QUAD-FOOT CANES •Used for clients who have the use of only one upper extremity •Hemicanes provide more security than a quad-foot cane; however, both types provide more security than a single-tipped cane •Position the cane at the client's unaffected side with the straight nonangled side adjacent to the body •Position the cane 6 inches from client's side with the handgrips level with the greater trochanter

Casts

•DESCRIPTION -Made of plaster or fiberglass to provide immobilization of bone and joints after a fracture or injury Interventions: -Keep cast and extremity elevated -Allow wet plaster cast 24-72 hrs to dry until it dries handle it with your palm(synthetic cast dry in 20 minutes) -Turn the extremity every 1-2 hrs unless contraindicated to allow air circulation and promote drying -A hair dryer can be used on a cool setting to dry a plaster cast (heat cannot be used on plaster cast because the cast heats up and burns the skin) -Monitor closely for circulatory impairment prepare bivalving or cutting the cast if circulatory impairments occur -Petal the cast or apply moleskin to the edges to protect the clients skin (maintain smooth edges around the cast to prevent crumbling of the cast material) -Monitor for signs of infection such as (increased temperature, hot sopots on the cast, foul odor, changes in pain) -if an open drainage area exists on the affected extremity the HCP will make a cutout portion of the cast known as a window for assessment and wound care purposes -instruct the client NOT TO STICK OBJECTS INSIDE THE CAST -Teach the client to keep the cast clean and dry -instruct the client in ISOMETRIC exercise to prevent muscle atrophy Monitor a casted extremity for circulatory impairment such as: -pain -swelling -discoloration -tingling -numbness -coolness -diminished pulse NOTIFY HCP IMMEDIATELY

Herniation: Intervertebral Disc

•DESCRIPTION -Nucleus of the disc protrudes into the annulus causing nerve compression •TYPES -Cervical occurs at C5 to C6 and C6 to C7 -causes pain radiation to shoulder arms, hands, scapulae and pectoral muscles -motor and sensory deficits can include paresthesia, numbness, and weakness of UPPER EXTREMITIES Interventions: -conservative management is used unless client develops neuro deterioration -Bed rest is prescribed to decrease pressure, inflammation, and pain -Immobilize the cervical area with cervical collar or brace -Apply heat to reduce muscle spasms and apply ice to reduce inflammation and swelling -Maintain head and spine alignment -Instruct the client in the use of analgesics, sedatives, anti-inflammatory agents, corticosteroids, as prescribed -Prepare the client for corticosteroid injection into epidural space -Assist and instruct the client in the use of cervical collar or cervical traction as prescribed Cervical collar -limits neck movement -may be worn intermittently or 24 hours a day -inspect skin under the collar for irritation -after pain decreased exercises are done to strengthen the muscles Client education related to rotating the neck -Avoid the prone position and maintain the neck, spine, and hips in a neutral position while sleeping (don't want them to twist and avoid flexing) -minimize long periods of sitting -instruct the client regarding medications Lumbar -occurs at L4 to L5 or L5 to S1 interspace -produces muscle weakness, sensory deficits, and diminished DTRS -The client experiences pain and muscle spasms in the lower back and radiation of pain to hip and down the leg (sciatica) -Pain is relieved by bed rest -Pain is aggravated by: movement, lifting, straining and coughing Interventions: -Monitor for neurological deterioration -instruct client of sleep on the side with the knees and hips flexed place a pillow between the legs -Apply pelvic traction to relieve muscle spasms and decrease pain -apply ice to decrease inflammation -apply heat to decrease muscle spasms -being progressive ambulation as inflammation edema and pain subside Client Education: -instruct in the use of prescribed medications -instruct about application techniques for corsets or braces to maintain immobilization and proper spine alignment -instruct the client in correct posture while sitting, standing, walking, and working -correct techniques when lifting objects such as being the knees maintaining a straight back and avoiding lifting objects above the elbow level -instruct in weight control program as prescribed -instruct in exercise program to strengthen back and abdominal muscles as prescribed Surgical Interventions •Diskectomy: removal of herniated disk tissue and related matter •Diskectomy with fusion: fusion of vertebrae with bone graft •Laminectomy: excision of part of the vertebrae lamina to remove the disk •Laminotomy: division of the lamina of a vertebra •Pre-Post Op Concerns Post Op Cervical: -monitor respiratory difficulty inflammation or hematoma -encourage coughing deep breathing and early ambulation as prescribed -monitor for hoarseness and inability to cough effectively because this may indicate laryngeal nerve damage -Use throat sprays or lozenges for sore throat avoiding anesthetic lozenges that may numb the throat and increase choking risks -Assess the surgical dressing monitor the surgical wound for infection, swelling, redness, drainage, or pain and manage surgical drains accordingly -provide a soft diet if the client complains of dysphagia -monitor for sudden return of radicular pain which may indicate cervical spin instability Post Op: Lumbar -Assess surgical dressing monitor wound drainage and bleeding and monitor surgical drains -monitor lower extremities for sensation movement color temperature and paresthesia -monitor for urinary retention, paralytic ileus, and constipation which can result from decreased movement, opioid administration or spinal cord compression -Prevent constipation by encouraging high fiber diet increased fluid intake and stool softeners -administer opioids and sedatives as prescribed to relieve pain and anxiety -assist and instruct the client to use a prescribed back brace or corset and to wear cotton underwear to prevent skin irritation

AMPUTATION OF A LOWER EXTREMITY

•DESCRIPTION -The surgical removal of a lower limb or part of the limb -LEVELS OF LOWER EXTREMITY AMPUTATION Complications: -Contractures -Phantom limb sensation and pain -neuroma -infection -hemorrhage •POSTOPERATIVE: -Monitor for signs of complications -Evaluate phantom limb sensation and pain explain sensation and pain to the client and medicate the client as prescribed -To prevent Hip flexion: contractures do not elevate the residual limb on a pillow First 24hrs: -elevate the foot on the bed to reduce edema -keep the bed flat to prevent hip flexion contractures After 24-48hrs: -position the client prone to stretch the muscles and prevent hip flexion contractures -maintain surgical application of dressing -elastic compression wrap or elastic stump shrinker as prescribed to reduce swelling pain and mold the residual limb in preparation for prosthesis -As prescribed wash the residual limb with milk soap and water and dry completely -Massage the skin toward the suture line if prescribed to mobilize scar tissue and prevent its adherence to underlying tissue -prepare prosthesis and instruct the client in progressive resistive techniques by gently pushing the residual limb against pillows and progressing to firmer surfaces -Encourage verbalization regarding loss of the body park and assist the client to identify coping mechanisms to deal with the loss BELOW-THE-KNEE AMPUTATION •POSTOPERATIVE -Prevent edema -Do not allow the stump to hang over the edge of the bed -Do not allow the client to sit for long periods of time to prevent contractures ABOVE-THE-KNEE AMPUTATION •POSTOPERATIVE -Prevent internal or external rotation of the limb -Place a sandbag or rolled towel along the outside of the thigh to prevent rotation •REHABILITATION -Instruct the client in crutch walking -Prepare the stump for prosthesis -Prepare the client for the fitting of the stump for prosthesis -Instruct the client in exercises to maintain range of motion -Provide psychosocial support to the client

Complications of Fractures

•Fat embolism -An embolism originating in the bone marrow that occurs after a fracture -Clients with long bone fractures are at the greatest risk for the development of fat embolism -Usually occurs within 48-72 hours following the injury -Assessment: restlessness and apprehension, sudden onset of dyspnea and chest pain, cough, hemoptysis, hypoxemia or crackles ****Notify the HCP (first action for any of the fracture complications) Admin oxygen Admin IV fluids as prescribed Monitor vital signs and respiratory status Prepare for intubation and mechanical ventilation if necessary as indicated by ABG Follow up on results of dx tests such as chest xray or CT scan •Compartment syndrome -Tough fascia surround muscle groups forming compartments from which arteries veins and nerves enter and exit at opposite ends -pressure increases within 1 or more compartments leading to decreased blood flow tissue ischemia and vascular impairment -no room to swell clamps down on the circulation -Neurovascular damage may be irreversible if not treated within 4-6 hour after onset of compartment syndrome Assessment: -unrelieved or increased pain in the limb -tissue that is distal to the involved are becomes pale, dusky or edematous -pain with passive movement -loss of sensation -pulselessness *late sign -loss of sensation (paresthesia) -5ps Interventions: -notify HCP immediately and prepare to assist -continue to elevate the affected extremity -if severe assist the HCP with fasciotomy to relieve the pressure and restore tissue perfusion -loosen tight dressings or bivalve restrictive cast as prescribed •Infection and osteomyelitis -Can be caused by the interruption of the integrity of the skin -The infection invades bone tissue Assessment: -tachycardia and fever above 101F -Erythema and pain in the area surrounding the infection -leukocytosis and elevated erythrocyte sedimentation rate -confirmed by radiographic assessment such as plain radiographs MRI or bone scan Interventions: -Notify HCP -Prepare to initiate aggressive long term IV antibiotic therapy A central venous access ling will likely be required -Surgery is performed for resistant osteomytelitis with sequestrectomy and or bone grafts -for unrelenting infection and osteomyelitis HYPERBARIC oxygen therapy is used if available to promote healing •Avascular necrosis -An interruption in the blood supply to the bony tissue, which results in the death of the bone -death of an extremity from lack of blood flow •Assessment Findings -Pain -Decreased sensation -Confirmed by radiographic assessment such as plain radiographs, MRI, or bone scan •Interventions -Notify the HCP if pain or numbness occurs -Prepare the client for removal of necrotic tissue because it serves as a focus for infection •Pulmonary emboli -Caused by immobility precipitated by a fracture -foreign particles (blood clot, fat, or air) into pulmonary circulation Hallmark findings -SOB -Red sputum -Hemoptysis -Restlessness -Apprehension KEY -Sudden onset of dyspnea and chest pain -hypoxemia -crackles Interventions: -Notify HCP if signs of emboli are present -administer oxygen and other prescriptions IV anticoagulant therapy may be prescribed

Fixation

•INTERNAL FIXATION -Follows open reduction -Involves the application of screws, plates, pins, or nails to hold the fragments in alignment intramedullary -Can have immediate use 2 days after -can have physical therapy immediately because they are fixed •EXTERNAL FIXATION -An external frame is utilized with multiple pins applied through the bone -Provides more freedom of movement than with traction -commonly used when massive tissue trauma is present -monitor pin stability and provide pin care to decrease infection risk Can be temporary waiting for surgery if swelling is too bad so may wait a couple weeks Pin Site Care: -have to worry about signs of infection like (redness, purulent drainage, foul odor) -will be slight amount of redness (not significant or spreading) due to the pins being there -Acceptable drainage: is serous or clear like plasma exudate -clean pin sites with chlorohexidine or normal saline -will form crust on its own so clean the crust off Risk of infection exists for both fixation methods

Types of Hip Fractures

•Intracapsular -femoral head and neck receive decreased blood supply and heal slowly -skin traction is applied preopertative to reduce the fracture and decrease muscle spasm -treatment includes total hip replacement or ORIF with femoral head replacement -To prevent hip displacement postoperative AVOID EXTREME HIP FLEXION and check the surgeons prescriptions regarding positioning •Extracapsular -fracture is outside of the joint capsule -can occur at the greater trochanter or can be an intertrochanteric fracture -preoperative treatment includes balanced suspension or skin traction to relieve muscle spasms and reduce pain -surgical treatment includes ORIF with nail plate, screws, pins, or wires •What are concerns? -At risk for DVT because they are bed bound and on traction •Treatment •POSTOP Interventions: ALL ABOUT POSITIONING -legs need to stay align and prevent ADDUCTION or putting the legs together -prevent external rotation -Elevate the head of the bed 30-45 degrees for meals only -follow HCPs prescriptions regarding turning and repositioning usually turning to the UNAFFECTED side is allowed protective devices may be prescribed -Maintain leg and hip in proper alignment and prevent internal or external rotation to avoid extreme hip flexion -Monitor for signs of delirum and institute safety measures -Assist the client to ambulate as prescribed by the HCP -Avoid weight bearing on the affected leg as prescribed instruct the client in the use of a walker to avoid weight bearing -Weight bearing is often restricted after ORIF and may not be restricted after total arthroplasty -Keep operative leg extended supported elevated (preventing hip flexion) when getting the client out of bed -avoid hip flexion greater than 90 degrees and avoid low chairs when out of bed -monitor for wound infection or hemorrhage -neurovascular assessment of affected extremity check color pulses cap refill movement and sensation -Maintain compression of the drain if present to facilitate wound drainage 80ml/8 hrs for first couple days is normal should be no drainage after 2 days -Antiembolism stockings or Sequentiual compression stocks as prescribed and encourage the client to flex and extend feet to reduce risk of DVT -Instruct client avoid crossing legs and activities that require bending over

Reduction

•Restoring the bone to proper alignment •CLOSED REDUCTION -non surgical intervention performed by manual manipulation local or general anesthesia -a cast may be applied following reduction •OPEN REDUCTION: -involves surgical intervention the fracture may be treated with internal fixation devices

Walker

•Stand adjacent to the client on the AFFECTED side •Instruct the client to put all four points of the walker flat on the floor before putting weight on the hand pieces •Instruct the client to move the walker forward and to walk into it HJ How do you know the client understands the proper use of canes/walkers? -safety is the primary concern when client uses crutches, cane, or walker so need to make sure they demonstrate back how to use it

Joint Dislocation and Subluxation

◦Dislocation: Bone is displaced from its position in the joint ◦Subluxation: Partial dislocation of the joint Cause ◦Trauma ◦Congenital Clinical Manifestations ◦Asymmetry of the contour of affected body parts ◦Pain, tenderness, dysfunction and swelling Diagnosis ◦X-ray Treatment -immediate treatment is done to reduce it through manipulation either manually or surgically (realigning it) ◦Replace bone in joint through manipulation of surgery ◦Immobilize joint until structures healed

Rheumatoid Arthritis

-leads to destruction of connective tissue and synovial membrane within the joints -weakens the joint leading to dislocation and permanent deformity of the joint -exacerbations and manifestations of the disease occur during periods of physical or emotional stress -vasculitis can impede blood flow leading to organ system malfunction and failure caused by tissue ischemia Flare ups caused by: -stress -infection Hallmark Signs and Symptoms: -pain when waking up without having used joint pain or muscles relieved with use Assessment: -inflammation, tenderness and stiffness of the joints -moderate to severe pain with morning stiffness lasting longer than 30minutes -Spongy soft feeling in the joints -LOW-GRADE FEVER because is systemic -fatigue and weakness -anorexia -weight loss -anemia -ELEVATED ESR and positive RHEUMATOID FACTOR -Radiographic study showing joint deterioration -synovial tissue biopsy reveals inflammation Rheumatoid Factor: -blood test used to assist in dx rheumatoid arthritis -negative or less than 60 Medications: -Combination of NSAIDs, disease modifying anti rheumatic drugs, and glucocorticoids -IMMUNSUPPRESSANTS Boutonniere Deformity: flexion of PIP joint and hyperextension of DIP joint Swan Neck Deformity: hyperextension of PIP joint and flexion of DIP joint •SELF-CARE -Assess the need for assistive devices such as higher toilet seats, chairs, and wheelchairs to facilitate mobility -Collaborate with occupational therapy to obtain assistive adaptive devices -Instruct the client in alternative strategies for providing activities of daily living -instruct the client in energy conservation measure -instruct the client to sit in a chair with a high, straight back -instruct the client to use only a small pillow when lying down

Osteoporosis

-metabolic disease characterized by bone demineralization with loss of calcium and phosphorous salts leading to fragile bones and the subsequent risk for fractures -bone resorption accelerates as bone formation slows -most commonly in the wrist hip and vertebral column -occurs postmenopausally (lack of estrogen-estrogen helps to grow bone) or as a result of metabolic disorder or CALCIUM DEFICIENCY -may be asymptomatic until the bones become fragile and minor injury or movement causes a fracture *Primary osteoporosis: postmenopausal women or men with low testosterone levels *Second osteoporosis: prolonged therapy with corticosteroids, thyroid-reducing medications, aluminum-containing antacids or anti-seizure medications. Associated with immobility, alcoholism, malnutrition or malabsorption Risk Factors: -decreased calcium intake -deficient estrogen -sedentary lifestyle (need to have impact exercise in order to increase bone density) -prolonged corticosteroid -prolonged thyroid reducing medications -aluminum containing antacids or antiseizure medications -cigarette smoking -alcohol use that cause nutritional imbalances -thin small frame Assessment: -possibly asymptomatic -back pain that occurs after lifting being or stooping -back pain that increases with palpation -pelvic or hip pain especially with weight bearing -problems with balance -decline in height from vertebral compression -kyphosis of the dorsal spine "dowagers hump"-due to vertebral bone loss -Degeneration of lower thorax and lumbar vertebrae on radiographic studies HIGH RISK FOR PATHOLOGICAL FRACTURES Interventions: -move client gently when turning and repositioning -assist with ambulation if client is unsteady -provide gentle range of motion exercises -apply a back brace as prescribed during an acute phase to immobilize the spine and provide spinal column support -provide the client with instructions to promote optimal level of health and function -instruct the client in the use of correct body mechanics -avoid activities that can cause vertebral compression -instruct the client to eat a diet high in protein calcium vitamin c and d and iron -instruct the client to avoid alcohol and coffee -instruct the client to maintain an adequate fluid intake to prevent renal calculi -administer medications as prescribed to promote bone strength to decrease pain