Fundamentals of Orthopedics

Bone scan

A __________ requires the injection of a radioisotope through an IV line; the scan is performed 2-3 hours afterward. At this point, distribution and concentration of the isotope in the bone are measured. The degree of nuclide uptake is related to the metabolism of the bone. Areas of abnormal bone formation will appear brighter. An increased uptake of the isotope is seen in primary skeletal disease (osteosarcoma), metastatic bone disease, inflammatory skeletal disease (osteomyelitis), and fractures that do not heal as expected.

Bone Densitometry (BD)

A ____________ is used to evaluate bone mineral density (BMD). This can be performed through a series of x-rays or ultrasound. The most common modalities used include the dual-energy x-ray absorptiometry (DXA or DXEA), quantitative computed tomography (QCT), and quantitative ultrasound (QUS( These predicts fracture risk through accurate monitoring of bone density changes in patients with osteoporosis who are undergoing treatment.

Bone scan

A _______________ is performed to detect metastatic and primary bone tumors, osteomyelitis, some fractures, and aseptic necrosis, and to monitor the progression of degenerative bone disease. This may accurately identify bone diseases before it can be detected on x-ray; as such, it may diagnose a stress fracture in a patient who continues to experience pain after x-ray findings are negative.

Stroke

A variety of neurological conditions are associated with an abnormal gait such as a hemiparesis gait which indicates a ____________.

Lower motor neuron disease

A variety of neurological conditions are associated with an abnormal gait such as a steppage gait which indicates a ____________.

Immobilization

Adequate ___________ is essential in the patient with a bone fracture until there is x-ray evidence of bone formation with ossification.

Drink plenty fluids

After a bone scan, patients are encouraged to ________ to help distribute and eliminate the radioisotope.

Arthroscopy

After the diagnostic ______________, the joint is wrapped with a compression dressing to control the swelling. In addition, ice may be applied to control edema and enhance comfort. Frequently, the joint is kept extended and elevated to reduce swelling. The nurse monitors and documents the neurovascular status. Analgesics are given as needed. The patient is instructed to avoid strenuous activity of the joint, and exercises must be approved by the primary provider.

Effusion

An _________ is suspected if the joint is swollen and the normal bony landmarks are obscured. The most common site for a joint _________ is the knee.

EMG

An __________ can be used to identify the extent of damage if nerve damage does not return within 4 months of injury. Needle electrodes are inserted into selected muscles and responses to electrical stimuli are recorded on an oscilloscope. Warm compresses may relieve residual discomfort after the study.

Increased

An __________ uptake of the isotope in a bone scan is seen in primary skeletal disease (osteosarcoma), metastatic bone disease, inflammatory skeletal disease (osteomyelitis), and fractures that do not heal as expected.

circulation, motion, sensation (CMS)

Assessment of neurovascular status is frequently referred to as assessment of _______________.

Empty bladder

Before a bone scan, the nurse should ask the patient to _________, because otherwise, this interferes with accurate scanning of the pelvic bones.

Anticoagulants; skin infections

Before the patient undergoes an EMG, the nurse inquires if the patient is taking any ____________ medications and assesses for any active ________________. An EMG is usually contraindicated in patience receiving these types of medications because the needle electrodes may cause bleeding within the muscle. These may be contraindicated in patients with _________ from the skin to the muscle. The nurse instructs the patient to avoid using any lotions or creams the day of the test.

Xray

Bone __________ studies determine: - Bone density - Texture - Erosion - Changes in bone relationships These reveal any widening, narrowing, or signs of irregularity.

Thyroid hormone

Both __________ and cortisol have multiple systemic effects with specific effects on bones. Excessive ___________ in adults (e.g., Graves' disease) can result in increased bon resorption and decreased bone formation.

Cortisol

Both thyroid hormone and _________ have multiple systemic effects with specific effects on bones. Increased levels of _________ have the effects of increased bon resorption and decreased bone formation. Thus, patients receiving long-term synthetic _______________, are at increased risk for steroid-induced osteopenia and fractures.

Arthroscopy

Complications of the diagnostic ______________ are rare but include: - Infection - Hemiarthrosis - Neurovascular compromise - Thrombophlebitis - Stiffness - Effusion - Adhesions - Delayed wound healing

Bone resorption

Conversely, osteoblasts may produce Osteoprotegerin (OPG), which blocks the effects of RANKL, thereby turning off the process of _______________.

Osteoprotegerin (OPG)

Conversely, osteoblasts may produce __________, which blocks the effects of RANKL, thereby turning off the process of bone resorption.

3-4th; remove the cast

During stage III (Bony callus formation [ossification]) of fracture healing, around the ____________ week, the fracture site feels immovable and appears aligned on x-ray. At this time, it is usually safe to ____________ if one is present.

Bone resorption

During the process for bone remodeling, the osteoblasts produce a receptor for Activated nuclear factor-kappa B ligand (RANKL) that binds to the receptor for activated nuclear factor-kappa B (RANK) present on the cell membranes of osteoclast precursors, causing them to differentiate and to mature into osteoclasts, which causes bone resorption.

Arthrocentesis

Examination of synovial fluid by way of an _______________ is helpful in the diagnosis of septic arthritis and other inflammatory arthropathies and reveals the presence of hemiarthrosis, which suggests trauma or a bleeding disorder. Normally synovial fluid is clear, pale, straw colored, and scanty in volume. Using aseptic technique, the physician inserts a needle into the joint and aspirates fluid. Anti-inflammatory medications may be injected into the joint. A sterile dressing is applied after aspiration. There is a risk of infection after this procedure.

6 hours

Function can be permanently lost if the anoxic situation continues for longer than _____________ in the patient with compartment syndrome.

Liver

Growth hormone is a hormone that has both direct and indirect effects on skeletal growth and remodeling. It stimulates the liver and to a lesser degree, the bones to produce insulin-like growth factor 1 (IGF-I), which accelerates bone remodeling in children and adolescents.

Insulin like growth factor I (IGF-1)

Growth hormone stimulates the liver and to a lesser degree, the bones to produce ____________ which accelerates bone remodeling in children and adolescents.

Joint effusion

If joint motion is compromised or the joint is painful, the joint is examined for _______________ which is excess fluid in the capsule resulting in swelling, and increased temperature that may reflect active inflammation.

Balloon sign; ballottment

If large amounts of fluid are present in the joint spaces beneath the patella, it may be identified by assessing for the _____________ and for ______________ of the knee. If inflammation or fluid is suspected in a joint, consultation with a specialist (e.g., orthopedic surgeon or rheumatologist) is indicated.

Symmetric

In RA, joint involvement assumes a ____________ pattern.

Brighter

In a bone scan, areas of abnormal bone formation will appear brighter

Ligament slipping over bony prominence

Normally the joint moves smoothly. A snap or a crack may indicate that a ________________

RA

Often, the size of the joint is exaggerated by atrophy of the muscles proximal and distal to that joint. This is seen in ___________ of the knees, in which the quadriceps may atrophy dramatically.

Joint sprain, muscle strain, compartment syndrome

Pain that increases with activity may indicate ________, ___________, or ___________________.

Goniometer

Precise measurement of range of motion can be made by using a ___________ which is a protractor designed for evaluating joint motion.

Bone scan

Prior to a ___________, the nurse inquires about: - Allergies to radiosiotope or dye - Conditions that would contraindicate the procedure such as pregnancy and breastfeeding.

Nodules

RA, gout, and osteoarthritis may produce characteristic _________________.

RANKL

Research focused on developing medication that block the effects of ______________ has resulted in the FDA approval of denosumab (Prolia) in treating menopausal women with osteoporosis.

Bone infection

Sharp pain may also result from ____________ with muscle spasm or pressure on a sensory nerve.

Arthritic conditions

Slightly roughened surfaces, as in ___________, result in crepitus as the irregular joint surfaces move across one another.

Alkaline phosphatase (ALP); osteocalcin, P1NP

Specific urine and serum biochemical markers can be used to provide information about the speed of bone resorption or bone formation, as well as to document the effects of therapeutic interventions prescribed for patients diagnosed with musculoskeletal disorders. Elevated serum levels of bone-specific ____________, _______, and ___________ (N-terminal propeptide of type 1 collagen) reflect an increased activity of the osteoblasts and enhance remodeling activity.

N-Tx; Dpd

Specific urine and serum biochemical markers can be used to provide information about the speed of bone resorption or bone formation, as well as to document the effects of therapeutic interventions prescribed for patients diagnosed with musculoskeletal disorders. These include ____________ ( N-telopeptide of type 1 collagen) and __________ (deoypyridinoline) , both of which reflect increased osteoclast activity and increased bone resorption.

Hematoma formation

Stage 1 of fracture healing is the ____________ that occurs during the first 1 to 2 days of the fracture. Bleeding into the injured tissue and local vasoconstriction occur, and a hematoma forms at the site of the fracture. Cytokines are released, initiating the fracture healing process by causing replicating cells known as fibroblasts to proliferate, which in turn cause angiogenesis to occur. Granulation tissue begins to form within the clot and becomes dense. At the same time, degranulated platelets and inflammatory cells release growth factor which stimulates the generation of osteoclasts and osteoblasts.

Remodeling

Stage IV of fracture healing occurs as necrotic bone tissue is removed by the osteoclasts. Compact bone replaces spongy bone around the periphery of the fracture. Although the final structure of the remodeled bone resembles the original unbroken bone, a thickened area on the surface of the bone may remain after healing. _____________ may take months to years, depending on the extent of bone modification needed, the function of the bone, and the functional stress on the bone.

RANKL

T cells that may become activated in times of stress and injury during the inflammatory process may also produce ______________, overriding the effects of OPG and causing continued bone resorption which can lead to a loss of bone matrix and fractures.

Fracture Risk Assessment Tool (FRAX)

The ______________ assesses the following: - Age - Gender - BMI - Hx of previous - Parental hx - Current smoker - Use of corticosteroids - Hx of RA - Alcohol intake of >3 drinks/day - T1DM - Osteogenesis imperfecta - Hyperthyroidism - Hypogonadism or premature menopause - Chronic malnutrition or malabsorption syndromes - Chronic liver disease

Subcutaneous nodules

The ______________ of RA are soft and occur within and along tendons that provide extensor function to the joint.

Arthroscopy

The diagnostic test ___________ takes place in the operating room under sterile conditions with either injection of a local anesthetic agent into the joint or general anesthesia. A large-bore needle is inserted, and the joint is distended with saline. The arthroscope is introduced, and joint structures, synovium, and articular surfaces are visualized. After the procedure, the puncture wound is closed with adhesive strips or sutures are covered with a sterile dressing.

Gout

The nodules of ______________ are hard and lie within and immediately adjacent to the joint capsule itself. These may rupture, exuding white uric acid crystals onto the skin surface.

Arthrography

The nurse should explain to the patient that it is normal to experience clicking or crackling in the joint for 24 to 48 hours after a ___________ until the contrast agent or air is absorbed.

Arthroscopy

The patient and family are instructed to monitor for the signs and symptoms of complications after _________ such as: - Fever - Excessive bleeding - Swelling - Numbness - Cool skin The nurse should notify the PCP if any of these occur.

Arthrogram

The patient having a _____________ may feel some discomfort or tingling during the procedure. Afterwards, a compression elastic bandage may be applied if prescribed, and the joint is usually rested for 12 hours. Strenuous activity should be avoided until approved by the HCP. The nurse provides additional comfort measures (e.g., mild analgesia, ice) as appropriate.

Testosterone

The sex hormone _________ has both direct and indirect effects on bone growth and formation. It directly causes skeletal growth in adolescence and has continued effects on skeletal muscle growth throughout the lifespan. Increased muscle mass results in greater weight-bearing stress on bones, resulting in increased bone formation. In addition, ___________ converts to estrogen in adipose tissue, providing an additional source of bone-preserving estrogen for aging men.

Estrogen

The sex hormone _________ stimulates osteoblasts and inhibits osteoclasts; therefore, bone formation is enhanced and resorption is inhibited.

RA

The subcutaneous nodules of ___________ are soft and occur within and along tendons that provide extensor function to the joint.

Tendonitis

The time of day the pain occurs may be important to evaluate. ____________ worsens during the early morning and eases by midday.

Osteoarthritis

The time of day the pain occurs may be important to evaluate. _______________ worsens as the day progresses.

Morning

The time of day the pain occurs may be important to evaluate. Those experiencing pain with a rheumatic disorder typically experiences pain that is worse in the ________________.

Upper motor neuron

Typically, ____________ motor neuron lesions produce increased tone (e.g., spasticity). Example would be the destruction of the ___________ as seen in cerebral palsy where the muscle becomes hypertonic and reflexes become hyperactive.

Lower motor neuron

Typically, _____________ motor neuron lesions produce decreased tone (e.g., flaccidity). This is seen in conditions such as muscular dystrophy where the denervated muscle becomes atonic (soft and flabby) and atrophies.

Marfan Syndrome

Unusually tall stature, pectus excavatum (funnel chest), scoliosis, and long fingers may be related to ______________.

Internal or external fixation

When fractures are treated with either ____________________ or ______________ techniques, the bony fragments are placed in direct contact. Primary bone healing occurs through the cortical bone (Haversian) remodeling. Little or no cartilaginous callus develops.

Isotonic exercise

_________ activity that combines muscle contraction with a change in muscle length.

Isometric exercise

_________ is exercise in which muscle tension occurs without a significant change in muscle length

Joint pain

_________ pain is typically felt around the joint and worsens with movement.

Steadily increasing

_____________ pain points to the progression of an infectious process (osteomyelitis), a malignant tumor, or neurovascular complications.

Arthrography

______________ is a diagnostic to identify the cause of any unexplained joint pain and the progression of joint disease. A contrast agent or air is injected into the joint cavity to visualize the joint structures such as the ligaments, cartilage, tendons, and joint capsule. The joint is put through a range of motion to distribute the contrast agent while a series of x-rays are obtained. If a tear is present, the contrast leaks out of the joint and is evident on the x-ray image.

CT scan

___________ are diagnostics that may be used to visualize and assess: - Tumors - Injury to soft tissue - Ligaments - Tendons - Severe trauma to the chest, abdomen, pelvis, head, or spinal cord. It is also used to identify the location and extent of fractures in areas that are difficult to evaluate (e.g., acetabulum) and not visible on x-ray.

Fasciculation

____________ is involuntary twitching of muscle fiber groups.

Fibrocartilaginous callus formation

Stage II of fracture healing is __________________ which occurs from the formation of granulation tissue. Fibroblasts and osteoblasts migrate into the fracture site and begin the reconstruction of bone. The fibroblasts produce a fibrocartilaginous soft callus bridge that connects the bone fragments. Although tissue repair may reach maximum girth by the end of the second or third week, it is still not enough for strong weight bearing.

Arthroscopy

_____________ allows direct visualization of a joint through the use of a fiberoptic endoscope. Thus, it is a useful adjunct to diagnosing joint disorders. Biopsy and treatment of tears, defects, and disease processes may be performed through the ____________.

Growth hormone

_____________ is a hormone that has both direct and indirect effects on skeletal growth and remodeling. It stimulates the liver and to a lesser degree, the bones to produce insulin-like growth factor 1 (IGF-I), which accelerates bone remodeling in children and adolescents. It is believed that low levels of both ___________ and IGF-I that occur with aging may be partly responsible for decreased bone formation and resultant osteopenia.

Activated nuclear factor-kappa B ligand (RANKL)

During the process for bone remodeling, the osteoblasts produce a receptor for __________________ that binds to the receptor for activated nuclear factor-kappa B (RANK) present on the cell membranes of osteoclast precursors, causing them to differentiate and to mature into osteoclasts, which causes bone resorption.

Rest

___________ relieves most musculoskeletal pain.

Bony callus formation (ossification)

Stage III of fracture healing usually begins during the third or fourth week of fracture healing and continues until a firm bony union is formed. During this stage, mature bone gradually replaces the fibrocartilaginous callus and the excess callus is gradually reabsorbed by the osteoclasts. During this stage, the fracture site feels immovable and appears aligned on x-ray. At this time, it is usually safe to remove a cast if one is present.

Bone pain

___________ is a pain that is typically described as dull, deep ache that is "boring" in nature. This pain is not typically related to movement and may interfere with sleep.

Fracture pain

___________ is pain that is typically described as sharp and piercing and is relieved by immobilization.

Joint X-ray

____________ is a diagnostic that reveals: - Fluid - Irregularity - Spur formation - Narrowing - Changes in joint structure.

Calcitonin

____________ is a hormone that is secreted by the thyroid gland in response to elevated blood calcium levels, and functions to inhibit bone resorption and increases the deposit of calcium in the bone.

Muscular pain

____________ is pain that is typically described as soreness or aching and is referred to as "muscle cramps."

Paresthesias

____________ may be caused by pressure on nerves or by circulatory impairment.

Primary bone healing

____________ occurs through the cortical bone (Haversian) remodeling. Little or no cartilaginous callus develops. Immature bone develops from the endosteum. There is an intensive regeneration of new osteons, which develop in the fracture line by a process similar to normal bone maintenance. Fracture strength is obtained when the new osteons have become established.

Radiating pain

_____________ pain occurs in conditions in which pressure is exerted on a nerve root.

Arthrocentesis

______________ is a joint aspiration and is carried out to obtain synovial fluid for purposes of examination or to relieve pain due to the effusion. Examination of synovial fluid is helpful in the diagnosis of septic arthritis and other inflammatory arthropathies and reveals the presence of hemiarthrosis, which suggests trauma or a bleeding disorder.

Electromyography

______________ is a procedure that provides information about the electrical potential of the muscles and nerves leading to them. The test is performed to evaluate muscle weakness, pain, and disability. The purpose is to determine any abnormality of function and to differentiate muscle or nerve problems.

MRI

_______________ is a diagnostic used that uses radio waves to create high-resolution pictures of bone and soft tissues. It can be used to visualize and assess: - Torn muscles, ligament, and cartilage - Herniated discs - Hip and pelvic conditions. This may take about 30-90 minutes to complete.

PTH

_______________ is the hormone that regulates concentration of the calcium in the blood, in part by promoting movement of calcium from the bone and into the blood stream. In response to low serum calcium levels in the blood, increases of this hormone prompt the mobilization of calcium, the demineralization of bone, and the formation of bone cysts.

Osteoarthritis

________________ nodules are hard and painless and represent bony overgrowth that has resulted from the destruction of the cartilaginous surface of bone within the joint capsule. They are frequently seen in older adults.