Musculoskeletal (Ms. F) 3-8-23

total knee replacement/arthroplasty How often is Neurovascular-status assessed? Drain-removal within how many hours? How long is Prophylactic antibiotics administered postop?

+ Knee is replaced with artificial-joint • Performed when pain cannot be managed nonsurgically and for functional-disability R/T joint-destruction secondary to osteoarthritis, rheumatoid arthritis, posttraumatic-arthritis, or injury. Nursing-Interventions: • Knee is wrapped postoperatively with compression-bandage • Neurovascular-status assessed q2-4 hrs, as ordered by MD • Movement, sensation, color, pulse, capillary-refill ° Ice or cold-packs applied postop, to reduce swelling/bleeding • Post-op flexion of the foot every hour, while awake • Prevention of complications: • DVT, hypovolemic-shock, atelectasis/ pneumonia, infection, bleeding, limited ROM • Nursing-Interventions (cont.) • Drain-removal within 24-48 hrs, to reduce risk of infection • Prophylactic antibiotics for 24 hrs postop • Monitor drainage: amount, color, type • Continuous passive ROM-device • PT: Strength and ROM Exercises • Avoid positions of flexions: use of knee gatch/pillows behind knee • Ambulation first postop day/weight-bearing, per MD orders • Client-Teaching • Institute exercises and client-teaching (ROM) as ordered by physician • Weight-bearing limits • Wound observation and care • Notify MD of problems • Anticoagulant teaching • Recognition of complications

Common Orthopedic Surgical Procedures Terms

- Open reduction: Correction and alignment of the fracture after surgical dissection and exposure of the fracture - Internal fixation: Stabilization of the reduced fracture by the use of metal screws, plates, wires, nails, and pins - Arthroplasty: Repair of joint problems through the operating arthroscope (an instrument that allows the surgeon to operate within a joint without a large incision) or through open joint surgery - Hemiarthroplasty: Replacement of one of the articular surfaces (e.g., in a hip hemiarthroplasty, the femoral head and neck are replaced with a femoral prosthesis- the acetabulum is not replaced) - Joint arthroplasty or replacement: Replacement of joint surfaces with metal or synthetic materials - Total joint arthroplasty or replacement: Replacement of both articular surfaces within a joint with metal or synthetic materials - Meniscectomy: Excision of damaged joint fibrocartilage - Amputation: Removal of a body part - Bone graft: Placement of bone tissue (autologous or homologous grafts) to promote healing, to stabilize, or to replace diseased bone - Tendon transfer: Insertion of tendon to improve function - Fasciotomy: Incision and diversion of the muscle fascia to relieve muscle constriction, as in compartment syndrome, or to reduce fascia contracture

Potential-Complications R/T Cast, Splint, Brace What are 3 complications R/T Cast, Splint, Brace? What is the Most serious complication? What is an early indicator of compartment syndrome? What are late signs of compartment syndrome? The provider should be notified immediately with which complication? What does a Warm area on cast/brace suggest? How do you prevent disuse syndrome?

1. Compartment-Syndrome • Most serious complication • Increased-pressure within a confined anatomic-space • Compromises blood-flow and tissue-perfusion • Ischemia and irreversible-damage can occur within hours Diagnosis made by: • Assessment of the Six P's and intracompartmental-pressure • Early-indicator: relentless-pain that seems out of proportion to the injury • Late signs: pulselessness, paresthesia, paralysis • Client may complain that the cast is too tight • Notify provider immediately! • Delays in treatment results in poor-outcomes Treatment • If cast/splint too tight, it may be loosened, removed, or cast-bivalved, to release constriction • Elevation (avoid elevating above level of heart) • Fasciotomy (if pressure unrelieved and circulation not restored) • Possible amputation • Closely-monitor client's response to conservative and surgical-treatment • Record (frequently) neurovascular-assessment • Promptly report changes 2. Pressure-Ulcers • Prolonged-pressure results in tissue ischemia/anoxia; pressure-ulcer • Lower-extremity sites more susceptible • Client usually reports pain and tightness in area • Warm area on cast/brace may suggest underlying tissue-erythema (very painful 'hot spot') • Drainage may stain the cast/brace and emit an odor For inspection: • Brace may be removed, MD may bivalve cast (cut window-opening) • After area is inspected/treated, bivalved area is supported with elastic compression-wrap, to preven window-edema 3. Disuse Syndrome • Immobilization of extremity can result in atrophy and loss of muscle-strength • Prevention: Hourly isometric-exercises while awake

Structure of Skeletal System

206 Bones 4 Categories Long Bones • Rod-shaped with rounded ends; often bear weight Ex: Femur, humerus Short Bones • Small, bear little or no weight Ex: carpals, tarsals, phalanges Flat Bones • Protect vital-organs; sites for hematopoiesis (blood-forming cells) Ex: Sternum, ribs Irregular Bones • Unique shapes Ex: Vertebrae

Osteoporosis ADPIE Nursing Process: Patient With Osteoporosis-

Assessment • Occurrence of osteopenia and osteoporosis • Family history • Previous fractures • Dietary consumption of calcium • Exercise patterns • Onset of menopause • Use of corticosteroids as well as alcohol, smoking, and caffeine intake • Symptoms such as back-pain • Physical assessment may disclose: • Localized pain • Constipation • Altered body image Diagnoses • Deficient knowledge about the osteoporotic process and treatment-regimen •Acute pain related to fracture and muscle-spasm • Risk for constipation related to immobility or development of ileus (intestinal-obstruction) • Risk for injury: Additional fractures related to osteoporosis Osteoporosis -Planning • Major goals for patient include: • Knowledge about osteoporosis and treatment-regimen • Relief of pain • Improved bowel-elimination • Absence of additional-fractures Interventions • Promoting understanding of osteoporosis and treatment-regimen; education • Relieving pain • Short periods of rest • Supportive mattress • Intermittent local heat and back rubs • Improving bowel elimination • High fiber diet, increase fluids, stool softeners • Preventing injury • Physical activity to strengthen muscles, improve balance, and prevent disuse atrophy

Nursing process: patient with fracture of the hip/ the care

Assessment: • Health history and presence of concomitant problems • Pain • VS, respiratory status, LOC, and signs and symptoms of shock • Affected extremity including frequent neurovascular assessment • Bowel and bladder elimination; bowel sounds, I&Os • Skin condition • Anxiety and coping Planning: • Major goals include: • Relief of pain •Achievement of a pain-free, functional, and stable hip • Healed wound • Maintenance of normal urinary elimination pattern • Use of effective coping mechanisms •Absence of complications Relief of Pain (Hip fx) •Administer analgesics as prescribed • Use of Buck traction as prescribed •Handle extremity gently •Support extremity with pillows and when moving •Positioning for comfort • Frequent position changes •Alternative pain relief methods Promoting Physical-Mobility • Maintain neutral position of hip • Use trochanter rolls • Maintain abduction of hip •Isometric, quad-setting, and gluteal-setting exercises •Use of trapeze • Use of ambulatory aids •Consultation with physical therapy Interventions: • Use aseptic technique with dressing changes • Avoid or minimize use of indwelling catheters •Supporting coping Provide and reinforce information (Encourage patient to express concerns •Support coping mechanisms (Encourage patient to participate in decision making and planning Consult social services or other supportive services • Orient patient to and stabilize the environment • Provide for patient safety • Encourage participation in self-care • Encourage coughing and deep breathing exercises • Ensure adequate hydration • Apply TED hose or SCDs as prescribed • Encourage ankle-exercises • Patient and family teaching

Low back pain How long does acute low back pain last? How long does chronic low back pain last?

Back-pain: • Acute: Lasting less than 3 months • Chronic: Lasting more than 3 months without improvement Clinical-Manifestations: • Radiculopathy: pain radiating down leg or • Sciatica: inflamed sciatic-nerve suggesting nerve-root involvement • Gait, spinal-mobility, reflexes, leg length, motor strength, and sensory perception may be affected • Physical-exam may show paravertebral muscle-spasm (greatly-increased muscle-tone of postural-muscles of the back) with loss of normal lumbar-curve Assessment and Diagnostic-Findings • Initial-evaluation begins with focused history & physical-exam, including: • Observation of the patient • Gait evaluation • Neurologic testing Diagnostic-Procedures Include: • X-ray • Bone scan and blood-studies • CT Scan • MRI • Myelogram • EMG and nerve-conduction studies • Ultrasound Medical-Management • Most back pain is self-limiting; resolves within 4-6 weeks) with analgesics, rest, and avoidance of strain • Focuses on pain-relief, activity-modification, client-education Medications: • NSAIDs (can cause gi symptoms: bleeding and ⬆️ risk for CV events like MI) • Prescription muscle-relaxants: cyclobenzaprine (Flexeril) • Tricyclic antidepressants: amitriptyline (Elavil) • SSRIs: duloxetine (Cymbalta) • Opioids for short-term • gabapentin (Neurontin) • Steroids ⬆️ glucose ⬇️ immune system • acetaminophen (Tylenol) Nonpharmacologic approaches may include: • Application of superficial heat/cold • Spinal-manipulation (chiropractic therapy) • Behavioral therapy • Exercise • Physical therapy • Acupuncture • Massage • Yoga • Avoid twisting, bending, lifting, reaching - all stress the back • Limit sitting to 20 to 50 minutes • Resume ADLs as soon as possible • Quick return to normal activity • Low stress aerobic-exercises • Conditioning-exercises for back and trunk muscles, after 2 wks Nursing-Assessment • Detailed description of the pain: severity, duration, characteristics, radiation, associated symptoms (leg weakness), description of how the pain occurred, and how the pain has been managed • Type of work and recreational-activities of client • Effect of pain and/or movement limitation on lifestyle and ADLs • Assess posture, position-changes, and gait • Physical-Exam: assess spinal-curvature, DTRs, sensation, leg-length discrepancy, shoulder symmetry, and muscle-strength • If client is obese, complete a nutritional-assessment Nursing Management Pain-Management: • Assess response to pain-meds and other modalities Physical-Therapy: • Exercise gradually-initiated: • Low-stress aerobics • Short walks • Swimming • Good body-mechanics, posture and correct lifting-techniques (See Brunner Charts) Assisting with identifying stressors and ways to reduce stress • Make referrals to mental-health professionals as needed, if ordered • If obese, referral to dietician for assistance with dietary-plan and encouragement of weight-reduction

Bone Densitometry What is bone densitometry the gold standard for measuring? What can predict fracture risk? The Hip and Spine are best for predicting bore-fracture related to what? True or False? Bone densitometry works well with osteoporosis predictions. How are DEXA results reported? What is the BMD compared with?

Bone-Densitometry: Dual-Energy X-ray Absorptiometry aka DEXA* or DXA Evaluates (measures) BMD/Bone-Mineral Density Gold-Standard* for measuring the extent of & risk for osteoporosis; predicts fracture-risk Bone-density varies by location: Hip & Spine- Best for predicting bore-fracture risk r/t osteoporosis Wrist, Forearm, Fingers, Heel DEXA results are reported in T-scores - shows how ⬆️or ⬇️ BMD is, compared with healthy 30-yr old adult. BMD= Bone mineral density

Musculoskeletal system

Bones, joints, muscles, tendons, ligaments, bursae • Bones • Joints • Muscles • Tendons Tough, fibrous tissues; attach muscle-to-bone • Ligaments Dense, fibrous connective-tissue; attach bone-to-bone • Bursae Fibrous sacs filled with synovial-fluid; between certain tendons and bones

Question: How long does a patient taking bisphosphonates need to remain upright, after medication-administration?

C. 30 minutes Bisphosphonates are administered on arising in the morning with a full glass of water on an empty stomach, and the patient must stay upright for 30 to 60 minutes.

CT True or false? A CT is a invasive procedure performed with contrast given iv or oral? Does a CT help visualize tumors, visualize soft tissue injury, ligaments and tendons? A CT was used to help ID the location and extent of fractures not visible on x-ray. During this procedure, the client must remain still. True or false?

Computed Tomography (CT) Scan • Noninvasive procedure, detailed cross-section images • May be performed with or without contrast (verify no allergy to iodine or shellfish) • Contrast is given orally or intravenously Used to • Visualize and assess tumors • Injury to soft tissue • Ligaments or tendons " Severe trauma to chest, abdomen, pelvis, head, or spinal-cord • Identify location and extent of fractures not visible on X-ray • Client must remain still during procedure

Injuries of the Musculoskeletal System

Contusion: soft tissue injury produced by blunt force • Pain, swelling, and discoloration • Strain: injury to muscle or tendon from overuse/overstretching • Pain, edema, muscle spasm, ecchymosis, and loss of function • graded first (mild), second (moderate), and third degree (stretching with rupture & tearing) • Sprain: injury to ligaments & tendons around a joint • Joint is tender, and movement is painful, edema • disability and pain increases during the first 2 to 3 hours • Graded first, second, and third degree (ligament completely torn or ruptured) • Dislocation: articular surfaces of the joint are not in contact • A traumatic dislocation is an emergency with pain, change in contour, axis, and length of the limb and loss of mobility

Complications of Fractures

Early Complications • Shock/Hemorrhage • Fat Embolism Syndrome • Compartment Syndrome • Deep Vein Thrombosis (DVT) • Pulmonary Embolus PE • Disseminated Intravascular Coagulation (DIC) • Infection (Open fractures) Late Complications • Delayed Union, Malunion, Nonunion • Osteomyelitis • Avascular-Necrosis

Signs and Symptoms of Fractures

Fractures: Signs and Symptoms • Pain and tenderness • Muscle spasm, trauma, swelling, compression • shortening of extremity Secondary to compression of the fractured bone/muscle spasm • Deformity Occurs when muscles pull on the long axis of the extremity, causing fractured fragments to override each other (angulation, displacement • Crepitation . Grating or crumbling sound crated by bone fragments rubbing against each other, and can be felt under the skin • Edema and ecchymosis • Inflammation from trauma, bleeding into the tissue • Loss of function • False motion, does not function properly ***Not all s/s are present in all fractures

Management of musculoskeletal injuries and disorders

Frequently includes: • Casts • Braces • Splints/Immobilizers • Traction Surgery • External-fixation • Internal-fixation Or combination of above

Skeletal Muscle Functions

Functions • Covers bone • Provide bulk • Aids in holding body • Movement (contraction) • Heat-production • Posture

Fractures at specific sites include:

Humeral Neck Neurovascular assessment of the extremity is essential to evaluate the full extent of the injury • Arm supported and immobilized by sling and swathes • Limited motion and stiffness of the shoulder occur with disuse, therefore pendulum exercises are begun ASAP • Avoid vigorous arm activitv 4 weeks after healing Humeral Shaft • Well padded splints to immobilize arm and support arm in 90 degree flexion at the elbow • Sling or collar and cuff support the forearm • Functional bracing • External fixators are used for open fx ORIF of fx is necessary with nerve palsy, blood vessel damage, comminuted fracture, or displaced fracture Pendulum exercises are prescribed when possible to prevent frozen shoulder • Isometric exercises to prevent muscle atrophy Elbow • Monitor regularly for neurovascular compromise and signs of compartment syndrome (forearm and hand) • Consider potential for Volkmann's contracturel acute compartment syndrome resulting in antecubital swelling or damage to the brachial artery leading to contracture of forearm muscle • Encourage active exercises and ROM to prevent limitation of joint movement after immobilization and healing (4-6 weeks for nondisplaced, casted) or after internal fixation (about 1 week) Pelvis • Management depends upon type and extent of fracture and associated injuries • May be stable or unstable •Stable fractures are treated with a few days bedrest and symptom management • Early mobilization reduces problems related to immobility Hemorrhage and shock are two of the most serious consequences •Assessment of adjacent structures needed when pelvic fx is suspected (bladder injury, rectum, intestines, or other abd organs, pelvic vessels, nerves) Hip Elderly women with low bone density from osteoporosis are at increased-risk. • Types of hip-fx: • Extracapsular fx: fracture of trochanteric region & subtrochanteric region • Intracapsular fx: fracture of neck of the femur poses an increased risk for damage to the vascular system that supply blood to the femur head and neck resulting in avascular necrosis of the bone • Perprosthetic fx: fractures to the regions surrounding prosthetic joints • Surgery usually done to reduce and fixate the fracture • Care similar to that of client undergoing other orthopedic surgery or hip replacement surgery • Clinical Manifestations • In most femur neck fractures the leg is shortened, adducted, externally-rotated • Pain in hip and groin

Shock

Hypovolemic shock resulting from hemorrhage frequently noted in clients with pelvic-fractures, displaced/or open femoral-fracture (The femoral-artery may be torn by bone fragments.) Treatment aimed at stabilizing the fracture, restoring blood volume and circulation, relieving pain, providing proper immobilization, and protecting client from further injury/complications

Assessment of musculoskeletal system

Includes data related to function-ability; ADL p. 1104-1108 Health-History: occupation, exercise, alcohol, tobacco, diet • Assessment of pain and altered-sensation (parasthesias) Physical-Assessment: • Posture • Gait • Bone integrity • Joint-function • Muscle strength and size • Skin • Neurovascular-status

Osteomyelitis ADPIE Nursing Process: Patient With Osteomyelitis- Interventions

Interventions Relieving pain • Immobilization • Elevation • Handle with great care and gentleness • Administer prescribed analgesics Improving physical-mobility • Activity is restricted • Gentle ROM to joints above and below the affected part • Participation in ADLs within limitations • Prevention: Prophylactic antibiotics for orthopedic surgery • Encourage adequate hydration, vitamins, and protein • Administer and monitor antibiotic therapy Patient and family education • Long-term antibiotic-therapy; management of home IV-admin. • Mobility limitations • Safety and prevention of injury • Postoperative and follow-up care • Referral for home-health care

MRI In a hospital, a client is sent to MRI imaging. Will an MRI be able to visualize/ assess a herniated disc and hip/ pelvis conditions? An open system produces what kind of film quality? An MRI is not recommended for clients with metal implants, clips, or pacemakers, due to use of what kind device? What kind of clients may require sedation or open MRI? Is IV contrast used during an MRI? What will clients hear during the procedure?

Magnetic Resonance Imaging (MRI) visualizes/assesses: • Torn muscles • Soft tissue • Bone • Ligament • Nerve • Cartilage • Herniated-disc • Hip and pelvis conditions • Neurological and CNS lesions • Open and closed systems (open produces lower-quality films) • Not recommended for clients with metal implants, clips, or pacemakers, due to use of electromagnet-device • Clients with claustrophobia may require sedation or open MRI • May be used with or without IV-contrast • Client will hear rhythmic knocking during procedure

Biopsy Why is a biopsy performed? What two types meds will be administered? What will be used to control bleeding / swelling?

May be performed to determine structure and composition of bone-marrow, bone, muscle, or synovium; to diagnose specific diseases Nursing-interventions include patient-teaching • Explain procedure • Monitor operative-site (edema, bleeding, pain, infection) • Analgesics for pain/comfort • Antibiotics • Ice to control bleeding/swelling • S/S infection

Osteoporosis

Most prevalent bone-disease in the world • More than 1.5 million osteoporotic-fractures occur yearly • Normal homeostatic bone-turnover is altered; rate of bone-resorption is greater than the rate of bone-formation, resulting in loss of total bone-mass Bone becomes porous, brittle, fragile, breaks easily under stress •Frequently results in compression-fracturesof spine, fractures of the neck or intertrochanteric region of the femur, and Colles' fractures of the wrist

TABLE 35-1 Age-Related Changes of the Musculoskeletal System

Musculoskeletal System Structural Changes Functional Changes History and Physical Findings Bones Gradual, progressive loss of bone mass after 30 y of age Vertebral collapse Bones fragile and prone to fracture—vertebrae, hip, wrist Loss of height Postural changes Kyphosis Loss of flexibility Flexion of hips and knees Back pain Osteoporosis Fracture Muscles Increase in collagen and resultant fibrosis Muscles atrophy (diminish in size); wasting Tendons less elastic Loss of strength and flexibility Weakness Fatigue Stumbling Falls Loss of strength Diminished agility Decreased endurance Prolonged response time (diminished reaction time) Diminished tone Broad base of support History of falls Joints Cartilage—progressive deterioration Thinning of intervertebral discs Stiffness, reduced flexibility, and pain interfere with activities of daily living Diminished range of motion Stiffness Loss of height Ligaments Lax ligaments (less-than-normal strength; weakness) Postural joint abnormality Weakness Joint pain on motion; resolves with rest Crepitus Joint swelling/enlargement Osteoarthritis (degenerative joint disease)

Review Chart 36-6, p. 1148 50 Nursing-Care Plans for Total Hip Arthroplasty Clients

NURSING DIAGNOSIS: Acute pain associated with total hip arthroplasty GOAL: Relief of pain Nursing Interventions Rationale Expected Outcomes 1. Assess patient for pain using a standard pain intensity scale. 2. Ask patient to describe discomfort. 3. Acknowledge existence of pain; inform patient of available analgesic agents or muscle relaxants. a. Use pain-modifying techniques. Administer analgesic agents as prescribed. b. Change position within prescribed limits. c. Modify environment. d. Notify primary provider about persistent pain. 4. Evaluate and record discomfort and effectiveness of pain-modifying techniques. 1. Pain is expected after a surgical procedure because of the surgical trauma and tissue response. Muscle spasms occur after total hip replacements. Immobility causes discomfort at pressure points. 2. Pain characteristics may help to determine the cause of discomfort. Pain may be due to complications (hematoma, infection, dislocation). Pain is an individual experience—it means different things to different people. 3. The nurse can reduce the stress experienced by patient by communicating concern and availability of assistance to help the patient deal with the pain. a. Patient will require parenteral opioids during the first 24-48 hours and then will progress to oral analgesic agents. b. The use of pillows to provide adequate support and relief of pressure on bony prominences assists in minimizing pain. c. Interactions with others, distractions, and sensory overload or deprivation may affect pain experience. d. Surgical intervention may be necessary if pain is due to hematoma or excessive edema. 4. Effectiveness of action is based on experience; data provide a baseline about pain experiences, pain management, and pain relief. • Describes discomfort • Expresses confidence in efforts to control pain • States pain is reduced; pain intensity scores are decreasing • Appears comfortable and relaxed • Uses physical, psychological, and pharmacologic measures to reduce pain and discomfort Collaborative Problems: Hemorrhage; neurovascular compromise; dislocation of prosthesis; venous thromboembolism; infection associated with surgery Goal: Absence of complication

Nursing-Interventions for Clients with Skeletal-Traction How long should neurovascular-status be monitored (hourly)? After first 48-72 hours, pin-site-care performed _______? How often should pin-sites be inspected? How long are Prophylactic antibiotics administered?

Nurse properly-maintains the traction: • Ropes in wheel-grooves of the pulleys • Ropes not frayed • Weights hang freely Monitors and maintains positioning • Proper body-alignment • Positions foot in neutral-position, to prevent footdrop Prevents skin-breakdown: • Overhead trapeze to help client move about in bed • Assess pressure-points • Monitors neurovascular-status hourly, the first 24 hrs, & at least every 4 hrs thereafter. • Color • Temperature • Capillary-refill • Edema • Pulses • Ability to move • Sensation • Immediately report any changes in sensation/ movement • Promote exercise to maintain strength and tone. Prevention of DVT: • Encourage active exercises and isometric contractions • Elastic-hose, pneumatic-compression hose, or anticoagulant therapy may be prescribed Provide pin-site-care, to avoid infection and osteomyelitis: • Pins located in areas with soft-tissue are at greatest risk • After first 48-72 hours, pin-site-care performed daily or weekly • Chlorhexidine solution is most effective •Strict-handwashing before and after site-care • Inspect pin-sites every 8 hrs for reaction and infection • Prophylactic antibiotics, for 24-48 hrs

Nursing Process: Patient With an Amputation

Nursing Process: Patient With an Amputation Assessment: • Neurovascular status and function of affected extremity or residual limb and of unaffected extremity •Signs and symptoms of infection • Nutritional status • Concurrent health problems • Psychological status and coping Diagnosis: • Acute pain • Impaired skin integrity • Disturbed body image • Grieving •Self-care deficit • Impaired physical mobility Collaborative Problems; Potential Complications • Postoperative hemorrhage • Infection •Skin breakdown • Phantom limb pain •Joint contracture Planning Major goals include: • Relief of pain • Absence of altered sensory perceptions • Wound healing •Acceptance of altered body image • Resolution of grieving processes • Restoration of physical mobility •Absence of complications Interventions: • Relief of pain • Administer analgesic or other medications as prescribed • Changing position • Putting a light sand bag on residual limb • Alternative methods of pain relief: distraction, TENS unit • Promoting wound-healing • Handle limb gently • Residual limb shaping Resolving Grief and Enhancing Body-Image • Encourage communication and expression of feelings • Create an accepting, supportive atmosphere • Provide support and listen • Encourage patient to look at, feel, and care for the residual limb • Help patient set realistic goals • Help patient resume self-care and independence • Referral to counselors and support groups Achieving Physical-Mobility Proper positioning of limb; avoid abduction, external rotation and flexion • Turn frequently; prone positioning if possible • Use of assistive devices • ROM exercises • Muscle strengthening exercises • "Preprosthetic care"; proper bandaging, massage, and "toughening" of the residual limb Educating About Self-Care • Encourage active participation in care • Continue support in rehabilitation facility or at home •Focus on safety and mobility

Bone Formation and Maintenance What is Osteogenesis? When does Osteogenesis begin? Bone is in a constate of turnover/ remodeling. This is called? How long does complete skeletal turnover take?

Osteogenesis (bone-formation) begins before birth Bone is dynamic - in a constant state of turnover/remodeling • Complete skeletal-turnover occurs every 10 yrs Regulating/ Influencing Factors •Stress and weight-bearing (physical-activity) • Vitamin D - plays role in Ca*+ absorption, bone-formation Hormones ensure that calcium is properly-absorbed • PTH (parathyroid) • Calcitonin • Calcitrol (activated Vit. D) • Cortisol • Growth-hormone • Testosterone and estrogen •Blood-Supply Bone-necrosis occurs when bone deprived of blood. •Role of Cat+ Daily-intake essential to maintaining adult bone-mass Adults need 1500 mg/day - 16-24 oz. of milk or other calcium-rich foods [yogurt, aged cheese, liver, fatty fish, egg-yolks, fortified-juices (tomato, orange), low-oxalate greens, calcium-fortified foods such as certain ready-to-eat foods (breakfast-cereals)]

Delayed Complications: Osteomyelitis

Osteomyelitis • Infection within the bone secondary to penetration by infectious organisms • Severe pyrogenic infection of bone and surrounding tissue • Staphylococcus aureus most common organism • Infection can result from extension of soft-tissue infection, direct bone contamination or blood borne spread from another site of infection • Clients with increased-risk include poorly nourished, elderly, obese, impaired immune-system, chronic illnesses - Signs and Symptoms * Constant bone-pain that is worse with movement • Erythema and edema at the site of the infection • Fever, chills, pulse rate, general malaise • Leukocytosis and elevated sedimentation rate (ESR) • Many signs will disappear if infection becomes chronic • Treatment aimed at prevention • Long course (3 months) of IV and oral antibiotic therapy ° Surgical-debridement may be indicated; bone-graft may be needed • Hyperbaric oxygen treatment (wound care) may be indicated Unsuccessful treatment can result in amputation • Diet: hydration, 1 vitamins, 1 proteins; • Correction of anemia • Nursing-Management • Relieve pain by immobilization, elevation, handling with great care, and administering prescribed analgesics • Administering antibiotics as prescribed to maintain a constant blood level •Conduct neurovascular assessments if debridement is done • If wound is left open to heal, standard precautions are adequate and clean techniques are used during dressing change. • Remember to handle with care, client at risk for pathologic fracture • Promote good nutrition including vit. C and protein • Adequate hydration

Compartment syndrome

Pathophysiology • Edema/bleeding within a confined compartment • Increased pressure • Obstruction of circulation • Venous occlusion • Increased edema • Compromised arterial flow • Ischemia • Muscle/nerve cells destroyed • Replaced with fibrotic tissue • Contracture-loss of function • Delay in diagnosis/treatment=severely impaired limb • Seen with: fractures, trauma, leg surgery, crushing injuries of the limbs • May take up to 48 hrs for symptoms to present; • Typically develops quickly • Neuromuscular-damage occurs within 4 hrs Five P's • Early Signs "Pain: deep throbbing unrelenting pain not relieved by meds/elevation • Paresthesia: burning/tingling sensation • Paralysis: nerve damage Late Signs • Pallor: lack of perfusion •Pulselessness Fasciotomy • incision through skin and subcutaneous-tissue into the fascia of the affected-compartment • Relieves pressure • wound left open to allow muscle-tissue to expand • wound covered with moist, sterile saline-dressing • wound-vac may be used to hasten wound-closure • wound is usually debrided and closed after swelling resolved and tissue-perfusion restored; may require skin-graft Nursing Management • Assess at-risk clients frequently • Utilize pain-rating scale • Remove constricting material Avoid elevation of extremity above heart level - Maintain at the level of the heat and not above Assess urine-output: • Large amount of myoglobin released from damaged muscle can cause acute renal failure

Nursing management: clients with cast, splint, or brace What are the 5 P's?

Prior to Casting, Splinting Application of Bracing • perform general health-assessment • Assess presenting signs and symptoms • Emotional status Clients must have an understanding of need for the device • Assess condition of body-part to be immobilized • Main concern is prevention of neurovascular-compromise or dysfunction of extremity • Physical-Assessment of the body-part • Neurovascular-status (circulation, movement, sensation) •Skin (degree of swelling, bruising, skin-abrasions) Most pain can be relieved /controlled by • Immobilizing and elevating involved part • Applying cold-packs • Administering analgesic-agents as prescribed • A client's unrelieved-pain must be immediately-reported to the physician, to avoid possible paralysis and necrosis of tissue, secondary to compromised neurovascular-status! • Never ignore complaints of pain from a client who has a cast/splint/brace because of possibility of problems, such as impaired tissue-perfusion or pressure-ulcer formation • Every joint that is not immobilized should be exercised and moved through ROM, to maintain function. • To promote healing, treat any skin laceration/abrasions, prior to application of the cast brace • Pad cast and cast-edges • Question client's need for tetanus-booster (for dirty wound or if last tetanus > 5 yrs) • Once cast is on, observe for systemic-signs of infection; odor from the cast, brace, or splint sign; and purulent drainage straining the cast • Monitor circulation, motion, and sensation of the affected extremity - perform frequent, routine assessment of neurovascular-status • 5 P's: assessment of pain, pallor, pulselessness, paresthesia, and paralysis • Instruct client to avoid scratching and/or sticking anything under the cast (FB or sharp objects) • To stimulate circulation, encourage movement of all fingers/toes hourly, while awake•

Review Chart 36-8, p. 1132 Promoting Home Care After Total Hip-Arthroplasty

Providing Home Care After Total Hip Arthroplasty Considerations- Pain management, Wound care, Mobility, Self-care (activities of daily living), Potential complications Nursing Interventions Discuss with patient the following methods to reduce pain: •Periodic rest •Distraction and relaxation techniques •Medication therapy (e.g., nonsteroidal anti-inflammatory drugs, opioid analgesic agents): actions of medications, administration, schedule, side effects Instruct patient in the following: •Keeping incision clean and dry •Cleansing incision daily with soap and water and changing the dressing •Recognizing signs of wound infection (e.g., pain, increased redness, swelling, purulent drainage, fever) Explain that sutures or staples will be removed 10 to 14 days after surgery. Educate patient about the following: •Safe use of assistive devices •Weight-bearing limits •How to change positions frequently •Limitations on hip flexion and adduction (e.g., avoid acute flexion and crossing legs) •How to stand without flexing hip acutely •Avoidance of low-seated chairs and toilets •Sleeping with pillow between legs to prevent adduction •Gradual increase in activities and participation in prescribed exercise regimen •Use of important medications such as warfarin and aspirin Assess home environment for physical barriers. Instruct patient to use elevated toilet seat and to use reachers to aid in dressing. Encourage patient to accept assistance with activities of daily living during early convalescence until mobility and strength improve. Arrange services and accommodations to address the patient's disability or illness, as appropriate. Assess patient for development of potential problems, and instruct patient to report signs of potential complications: •Dislocation of prosthesis (e.g., increased pain, shortening of leg, inability to move leg, popping sensation in hip, abnormal rotation) •Deep vein thrombosis (e.g., calf pain, swelling, redness) •Wound infection (e.g., pain, increased redness, swelling, purulent drainage, fever) •Pulmonary emboli (e.g., shortness of breath, tachypnea, pleuritic chest pain) Discuss with patient the need to continue regular health care (routine physical examinations) and screenings.

Medical-Management of Fracture

Reduction • Restoring fracture fragments to anatomic alignment and positioning • Closed or Open Reduction (depends on the fracture itself) • Closed-reduction done by manual manipulation or traction with casting or splinting • Open-reduction done surgically, fracture fragments are aligned and held in position with pins, screws, wires, plates, nails, or rods Immobilization • Bone-fragments must be immobilized after reduction and maintained in proper position/alignment until union occurs • May be done by either internal or external fixation devices Maintaining and Restoring Function • Reduction and immobilization maintained to promote bone and soft-tissue healing • Edema controlled by elevation/ice • Neurovascular status monitored (circ., motion, sensation) • Comfort promoted (restlessness, anxiety, pain) • Isometric and muscle-setting exercises encouraged to minimize atrophy and promote circulation • Encourage participation with ADLs to promote independence and self-esteem • Amount of movement and weight bearing ordered by MD

Skin traction

Skin-Traction • Applied to the skin • Used less-frequently • Short-term use • Used to stabilize a fractured-leg, control muscle-spasm, immobilize an area before surgery • The pulling-force is applied by weights that are attached to the client with Velcro, tape, straps, boots, or cuffs • No more than 4.5-8 Ibs.to extremities, 10-20 lbs, to pelvis Types of skin traction • Bucks: temporary measure to overcome muscle-spasms and promote preop-immobilization of hip-fractures (applied to lower leg). • Cervical Head-Halter (chin-halter strap): occasionally used to treat chronic neck-pain • Pelvic-Belt: sometimes used to treat back-pain

3 types of muscles Which muscle is involuntary muscle? Which muscle is controlled by the autonomic nervous system? Which muscle is voluntarily controlled by the central and peripheral nervous system?

Smooth Muscle 'Involuntary-muscle, contraction modulated by neuronal and hormonal influences Cardiac Muscle • Myocardium • Involuntary, controlled by autonomic nervous-system Skeletal Muscles • Voluntarily-controlled by central & peripheral nervous-systems •Function is movement of the body and its parts

Stages of bone healing What is the most painful stage when granulation tissue begins to form? 3-4 weeks post-injury bony callus calcifies and becomes bone in what stage? At what stage does bone gradually replace fibrocartilaginous callus? Which stage takes months to years to remodel the new bone into the former structural arrangement? What is used to monitor bone healing?

Stage 1 Hematoma-formation (most painful stage) Bleeding creates a hematoma at the site of the fracture • Granulation-tissue begins to form within the clot and becomes dense Stage 2 Fibrocartilaginous-callus formation • Granulation-tissue is initially replaced with a callus precursor • Callus is composed of fibrocartilage which is replaced with denser bony callus; bone then forms as bony callus calcifies (3 - 4 weeks post-injury) Stage 3 Bony-callus formation • Bone gradually replaces fibrocartilaginous callus • Safe to remove cast Stage 4 Remodeling • Results in remodeling the new bone into former structural arrangement • May take months-to-years • X-Rays used to monitor bone-healing progress

Common Musculoskeletal Sports-Injuries table__37-1___ page__1194_

TABLE 37-1 Common Musculoskeletal Sports Injuries Anatomic Area Mechanism of Injury Assessment Findings Sports Activity Acute Management Clavicle fracture Fall on shoulder or outstretched arm Direct blow to the clavicle Crepitus Holds arm closely to body Unable to raise affected arm above head Can feel movement of both ends of clavicle Football Rugby Hockey Wrestling Gymnastics Sling or shoulder immobilizer Ice NSAIDs Dislocated shoulder Anterior: Some combination of hyperextension, external rotation, and abduction Anterior blow to shoulder Posterior: Fall on flexed and adducted arm Direct axial load to humerus Pain Lack of motion May feel empty shoulder socket Uneven posture in comparison to other shoulder Affected arm appears longer Abduction limited Rugby Hockey Wrestling Skiing Closed reduction Immobilizer Pendulum exercises Dislocated elbow Falling on a hand with a flexed elbow Elbow overextended Intense pain Edema Limited motion Deformity Ecchymosis Football Gymnastics Squash Wrestling Cycling Skiing Immobilization Ice ROM exercises Wrist sprain or fracture Falling on an outstretched arm Pain Edema Ecchymosis Deformity Limited motion Skating Hockey Wrestling Skiing Soccer Handball Horseback riding Ice Elevation Immobilization Gentle ROM for 4-6 wks (for sprain only) Knee sprain Twisting injury that produces incomplete tear of ligaments and capsule around the joint Pain Limited motion Edema Ecchymosis Tenderness over joint Joint appears stable Basketball Football High jump Ice Elevation Compression wrap Active ROM exercises Isometric exercises May immobilize Knee strain Sudden forced motion causing muscle to be stretched beyond normal capacity Pain Limited motion Pain aggravated by activity Soccer Swimming Skiing Ice Elevation Rest Gradual return to activities Meniscal tears of knee Sharp, sudden pivot Direct blow to knee Forced internal rotation Wear from repetitive squatting or climbing Torsional weight-bearing force Edema Medial tear: Pain occurs with hyperflexion, hyperextension, and turning in of knee with knee flexed. Lateral tear: Pain occurs with hyperflexion and hyperextension and internal rotation of foot with knee flexed. Displaced fragment: Inability to extend knee; "locked" Positive McMurray signa Hockey Basketball Football Conservative: RICE Exercising of quadriceps and hamstrings Resistive exercising NSAIDs Physical therapy Surgical: Arthroscopy Ankle sprain Foot is twisted, causing stretching or tearing of ligaments. Pain Edema Limited motion Ecchymosis Tennis Basketball Football Skating Immobilization in cast or brace Ice Elevation Rest Ankle strain Sudden forced motion, stretching muscles beyond normal capacity Acute: Severe pain Chronic: Achy pain Running All ball sports Immobilization in cast or brace Ice Elevation Rest Ankle fracture Inward turning on sole of foot and front of foot Supination with internal rotation Pronation with external rotation Pain Edema Deformity Inability to bear weight Contact sports Tennis Basketball Ice Elevation Cast (4-6 wks) Surgery if fracture is displaced or unstable Metatarsal stress fracture Occurs with repeated loading of bone; often in an unconditioned extremity Forefoot pain that progressively worsens with activity Minimal or no forefoot swelling Running Dance Skating Rest Stop sports-related activity for 6 wks Ice Weight bearing as indicated

Question: True or False? Phantom limb pain is perceived in the amputated limb.

True Phantom limb-pain is perceived in the amputated limb. Administer pain meds

X ray What is the most common diagnostic study used? What is x-ray used for? What kind of prep is needed? What views maybe taken?

X-Ray Studies • Most common diagnostic-study used • Used to determine fractures, degenerative-conditions, hereditary, developmental, structural changes, healing, bone-density infection, dislocations, inflammation, and to measure • Client must remain still during procedure • No prep required • Several views may be taken (anterior, posterior, lateral. . .) • Explain procedure to client

Risk factors for osteoporosis

age, skinny, smoking, alcoholics, steroids, menopause, malnutrition, family hx, Asian/Caucasian

Delayed complications

delayed union, malunion, and nonunion • Delayed union: Fracture that has not healed within expected time-frame • Nonunion: Failure of fractured bone to unite • Most common with tibial-fx • May be tx with electrical bone-stimulation & bone grafting • May occur more frequently in older adults due to impaired healing-process • Malunion: Healing of a fractured bone in malaligned-position Most common with hand-fx Malunion and/or nonunion may cause immobilizing deformity of involved bone.

Dislocations: Medical Management

• A traumatic dislocation is an orthopedic-emergency • Dislocation is reduced/placed back in proper anatomic position to preserve joint function. • If dislocation or subluxation not reduced immediately, my result in Lavascular-necrosis • After reduction the joint is immobilized by splint, cast, or traction • Neurovascular checks Q15 minutes Until stable: • Mobility Circulation and Sensation

Bone Tumor-Metastatic (Secondary)

• More common than primary bone tumors • Common primary-sites that metastasize: kidney, prostate, lung, breast, ovary, thyroid • Most frequently found: • Skull, Spine, Pelvis, Femur, Humerus • Often involve more than one bone (polyostotic / know this term) • Treatment is palliative • Goal: relieve pain and promote quality of life

Fractures ...

• A fracture is defined as a break in the continuity of the bone (complete or incomplete disruption) • Occur in all age groups • More common in elderly secondary to falls • May causes damage to adjacent-structures resulting in edema, hemorrhage, dislocations, and injuries to blood vessels, tendons, nerves, and body organs Causes • Direct blows • Crushing forces • Sudden twisting-motions • Extreme muscle contractions • Described by extent of associated soft-tissue damage • Open (compound or complex) • Broken ends of the bone penetrate the skin • Closed (simple) • Bone breaks but the skin remains intact • Location- Proximal, midshaft, distal Cause • Pathologic (spontaneous) • Fracture occurs after minimal-trauma • Fracture of a diseased-bone (Ca, osteoporosis, osteomyelitis, etc.) • Fatigue or stress-fractures • Fracture results from excessive strain and stress Stable or unstable • Stable fractures: usually transverse (straight across bone's shaft), spiral, greenstick • Unstable fractures: grossly-displaced during injury and a site of poor fixation-comminuted (produces several bone-fragments) or oblique (fracture occurs at an angle across the bone)

Rotator cuff tears

• A tear in a tendon that connects one of the rotator muscles to the humeral head (may result from acute injury or from chronic joint stress) • Aching pain, limited ROM, some joint dysfunction and muscle weakness • Client C/O pain at night, inability to lie on affected side, difficulty performing over-the-head motions. • Most accurate diagnostic modality arthroscope Treatment ranges from conservative with NSAIDs, PT, rest, corticosteroid-injections, exercises, surgical-repair via arthroscopic or open repair and physical therapy (stretching, ROM, lengthening exercises)

Rupture of the Achilles tendon:

• Achilles tendon attaches calf muscles to heel Occurs during activities when there is a sudden contraction of the calf muscle with the foot fixed firmly to the floor or ground (unable to plantar flex This causes sharp pain and the inability to flex the foot • Diagnosed by MRI or US (ultrasound) Treatment • Conservative: Casting • Immediate surgical repair with post-op application of a cast or brace to immobilize the joint • Cast may be left on for(2-8 wks -when removed heel lift is worn and progressive physical therapy is initiated to promote ROM and stretching

Fracture Healing

• Amount of time varies (weeks to months) • Fractures at ends of bones heal more rapidly than those at the midshaft • Flat bones heals faster • Factors that impair/delay fracture-healing: • Alignment, inadequate blood-supply, immobilization, multiple trauma, age, bone-loss, infection, noncompliance, malignancy, certain medications (steroids), & certain disease-processes (RA) Complications of fracture-healing • Acute or chronic • Early or late

Skeletal traction When is skeletal traction used?

• Applied when continuous-traction is needed to immobilize, position, and align a fracture of femur, tibia, cervical-spine • Used when traction needed for extended-period and when greater weight is needed • Used when greater than 20 lbs. of traction is needed • Requires insertion of pins or wire through the bone • Traction applied using ropes & weights attached to end of pins • Tongs applied to the head are affixed to skull and connected to traction/halo, to immobilize cervical-fractures

Emergency management

• Assessment of neurovascular status before and after splinting (distal to injury) - Immobilize body-part (before moving • Splinting • Immobilize joints proximal and distal to suspected fracture/injury to prevent movement and further injury • Opposite extremity of the legs may be used as a splint, and upper extremity • may be bandaged to the chest or use arm sling Open-fracture • Cover wound with sterile dressing to prevent contamination • DO NOT attempt to reduce fracture • IMMOBILIZE/SPLINT AS IS (do not try to straighten) • Clothing must be cut off injured extremity (uninjured side 1St)

Types of fractures

• Avulsion - a fragment of bone pulled away by a tendon • Complete - break is across entire width of the bone or cross-section • Incomplete - the fracture does not divide the bone into two portions (green stick fracture) • Simple (Closed)- has one fracture line, skin intact • Comminuted - bone is fragmented • Open - disrupts skin-integrity, causes open wound; † infection-risk Type / - minimal-trauma, clean; < 1 cm long Type I/ - larger wound; without extensive soft-tissue damage or avulsion Type III - highly-contaminated, with extensive soft-tissue damage; may be accompanied by amputation. • Intra-articular • Extends into joint-surface of a bone

Prevention of OA

• Balanced diet high in calcium and vitamin D, throughout life • Use of calcium-supplements with Vitamin D: Take in divided doses c Vitamin C, to promote absorption • Regular weight-bearing exercises: 20 to 30 minutes a day • Increases balance • Reduces incidence of falls and fractures • Weight-training stimulates bone mineral density (BMD)

Delayed complication: avascular necrotic

• Blood-flow is disrupted to the fracture site and the resulting ischemia leads to tissue (bone) necrosis • Also seen with prolonged corticosteroid use, radiation therapy, sickle cell, rheumatoid arthritis, and other diseases • Treatment: NSAIDs, exercise, and limited wt. bearing on region • Total joint replacement when hip or knee involved • Complex regional pain syndrome (CRPS) • Heterotopic ossification -benign bone growth

Pharmacologic therapy/ Drugs that treat osteoporosis

• Calcium and vitamin D • Bisphosphonates • Calcitonin • Estrogen agonists/antagonists • Parathyroid hormone • Receptor activator of nuclear factor kappa-B ligand inhibitors

Common foot problems include:

• Callus - thickened area of the skin • Corn • Bunion (hallux valgus) • Hammer toe • Ingrown toenail (onychocryptosis) • Morton's neuroma • Claw foot: pes cavus • Flatfoot: Pes planus • Plantar fasciitis Page 1119

Rib fractures

• Chest strapping to immobilize rib fracture no longer used result in decreased chest expansion, puncture lungs • Chest can be splinted with hands to cough and deep breathe (Tend not to breathe in deep or cough secondary to pain) Encouraged to cough and deep breathe • Pain usually diminishes greatly in 3-4 days, however fracture usually heals within 6 weeks

Nursing-Interventions Post Joint-Replacement

• Client require extensive PT to regain mobility • Usually ambulate within a day after surgery, using walker/crutches • Weight-bearing, as prescribed • Drain-use postoperatively • Assess for bleeding and fluid-accumulation • Monitor S/S incisional-infection and care of the incision • Managing Pain • Monitor for S/S deep vein thrombosis (DVT), pulmonary-embolism • Usually prescribed anticoagulants • Patient teaching/rehabilitation • Position-restrictions, if needed

Joint replacement Arthroplasty

• Clients with severe joint-pain and disability may undergo joint-replacement, particularly of the knees and hips • Conditions requiring joint-replacement include osteoarthritis, rheumatoid arthritis, trauma, congenital-deformities, and fractures that have disruption in blood-supply (avascular necrosis) • Arthroplasty refers to the surgical-removal of a diseased joint and replacement with prosthetics or artificial components made of metal and/or synthetic materials • Total joint-arthroplasty, aka total joint-replacement, involves replacement of all components of an articulating-joint

Ganglion How does this appear? How is it treated?

• Collection of gelatin material near tendon-sheaths and joints • Appears as round, firm, cystic swelling, usually on dorsum of wrist • Swelling, local tenderness, aching pain, possible finger-weakness • Treatment: ASA, corticosteroid-injection, surgical-excision

Hallucinating Valgus (Bunions)

• Common foot-deformity involving first metatarsal of great toe • More common in women • May be congenital or acquired • Caused by: • Ill-fitting shoes • Lengthening and widening of foot with aging • Heredity • Osteoarthritis Symptoms: • Reddened area • Edema • Tenderness Treatments: • Shoes that conform to foot to prevent pressure on protruding-portion; may be the only treatment necessary • Steroid injections • Surgery (in advanced cases)

Cruciate Ligament Injury

• Cruciate ligament stabilizes the knee • There is an anterior and posterior cruciate ligament • Injury occur when the foot is firmly planted and the leg sustains direct force, forward or backward • forward force affects the ACL • backward force affects the PCL Treatment • Depends on severity of injury - may require application of a brace and physical therapy or surgical reconstruction •Severe swelling may indicate a tear - joint pain and instability, difficulty with weight bearing •Surgery is usually ambulatory arthroscopic surgery to repair damage

deep vein thrombosis (DVT)

• DVT is most common complication following trauma, surgery, or disability related to immobility • Veins in lower extremities and pelvis are highly susceptible to thrombus formation after fracture • Factors are: venous stasis, local pressure on a vein, or immobility Nursing Management • Prophylactic anticoagulants: • ASA • Coumadin • Heparin • enoxaprin (Lovenox): more effective than Coumadin • Encourage intake of fluids to prevent hemoconcentration • Antiembolic hose (TEDs) • Sequential compression devices (SCDs) • Exercise by moving toes and fingers against resistance • ROM on unaffected side

Bone Scans What kind of tumors do bone scans detect? A bone scan can detect an inflamed bone called? Can all fractures be detected by bone scans? What type of tissue can be detected by a bone scan? DJD _____ can be detected by a bone scan? What should you assess before a bone scan? When should a client empty their bladder? What should you look for? An increased______ What helps distribute the isotope? What should you increase before and after the procedure?

• Detect metastatic or primary bone-tumors • Osteomyelitis (inflamed bone) • Some fractures (not all) • Necrosis (tissue death) • Progression of DJD/degenerative bone disease • Assess allergies to radioisotope (Preprocedural) • Radioisotope injected intravenously • Scan performed 2-3 hrs after injection • Client empties bladder prior to procedure (Preprocedural) • Look for increased uptake (absorption) • Encourage client to drink plenty of fluids before and after the procedure (helps to distribute isotope) (Postprocedural)

Dislocations and Subluxations

• Dislocation: condition in which the articular surfaces of the distal and proximal bones that form the joint are no longer in anatomic alignment (bone "out of joint") • Subluxation: partial or incomplete dislocation in which the ends of the bone are in partial contact with the joint • May be congenital or result from trauma or disease Common sites for dislocation: Hip, Knee, Shoulder, Thumb, elbow, patella

Arthroscopy What kind of procedure is an arthroscopy? What allows for direct visualization of the joint's interior cavity? True or False? Arthroscopy can treat tears, defects, biopsies, and disease processes. This is a safe and convenient alternative to what surgery? This is a sterile procedure performed under what two anesthesia (either or)? What is a Post-procedural (Arthroscopy) done to control swelling? Is ice or a warm compression applied during Post-procedure? A joint is elevated to decrease what? What should you monitor and document afterward? If need what type of med is administered? What should a patient avoid afterward? Who all should be educated? What are s/s of complications? Will cool or hot skin be felt during a complication?

• Endoscopic procedure; allows direct visualization of the joint's interior cavity, as well as treatment of tears, defects, biopsies, and disease processes. • A safe, convenient alternative to open surgery • Can be performed under local or general anesthesia (sterile procedure) Post-procedural (Arthroscopy) • Joint wrapped with compression wrap to control swelling • Application of ice • Joint kept extended & elevated, to ⬇️ swelling • Monitor and document neurovascular status • Administer analgesics, if needed • Instructed to avoid strenuous activity of the joint • Patient/family education Monitor for s/s of COMPLICATIONS: • Swelling ⬆️ • Pain • Fever • Bleeding • Numbness • Cool skin

Nursing-Interventions: Clients with Skin-Traction How often should skin that's in contact with tape, foam, shearing-forces be monitored/ assessed? How often should you Remove boots to inspect skin, ankle, and Achilles tendon? How often should pulses, color, cap-refill, temp. of fingers/toes be assessed?

• Ensure that traction is effective • Monitor for potential-complications Skin-Breakdown • Identify fragile/at-risk skin • Monitor skin that's in contact with tape, foam, shearing-forces at least q 8 hrs • Institute measures to prevent breakdown • Remove boots to inspect skin, ankle, and Achilles tendon 3 times/day • Palpate area of traction-tapes daily for tenderness • Frequent repositioning • Use static-mattresses or overlays Nerve-Damage • Assess sensation and movement of foot and toes • Promptly-report altered sensation or impaired motor-function Circulatory-Impairment • Assess pulses, color, cap-refill, temp. of fingers/toes every 1-2 hrs. • Assess for S/S of DVT: calf-tenderness, warmth, redness, swelling, pain

Carpal tunnel syndrome What is this commonly caused by? S/S include pain, numbness, paresthesia, weakness along median-_____? What is treatment based on?

• Entrapment-neuropathy occurring when median-nerve of wrist is compressed by thickened flexor-tendon sheath, skeletal encroachment, edema, or soft tissue mass • Commonly caused by repetitive hand and wrist movement. S/S. Manifestations: pain, numbness, paresthesia, weakness along median-nerve. Treatment: Based on condition - Intra-articular injections of corticosteroids, oral corticosteroids, NSAIDs, and/or application of wrist-splints are often effective

Skeletal-muscle contraction What do muscle cell fibers contract in response to? What two contractions can result from the contraction of muscle fibers? Which contraction is the shortening of the muscle length? Which contraction occurs when muscle length remains unchanged?

• Muscle cell-fibers contract in response to electrical-stimulation (voluntary-control) Contraction of muscle-fibers can result in either: •Isotonic-contraction: Shortening of the muscle with no increase in tension within the muscle. Ex: squats, bicep-curls, flexing the forearm •Isometric-contraction: Muscle-length remains unchanged but the force generated by the muscles is increased. Ex: Holding a position; pushing against a wall

Muscles

• Muscles are attached to bones by tendons, other muscles, connective-tissue, soft tissue, or skin • Muscles are encased in a fibrous-tissue called fascia. • Muscle-contraction causes movement.

Fat Embolism Syndrome (FES)

• FES describes the clinical-manifestations that occur when fat-emboli enters circulation following trauma (esp. of long bones). • Contributing-factor in many deaths associated with fractures -Femur, ribs, tibia, and pelvis most frequently cause FES • Also known to occur after total joint-replacement, spinal-fusion, liposuction, crush-injuries, bone-marrow transplantation • Fat-globules may occlude small blood-vessels that supply the lungs, brain, kidneys, and other organs Produces S/S of acute respiratory distress syndrome (ARDS): hypoxia, substernal chest-pain, tachypnea, cyanosis, dyspnea, hypoxia, apprehension, tachycardia, decreased Pa02 Triad of clinical manifestations • (Hypoxia, neurological compromise, petechial rash Observe for: • Signs of mental change, confusion • Respiratory distress/tachypnea • Restlessness, irritability, agitation • Low-grade fever, headache • Petechial- on neck, anterior chest, upper arms, abdomen • Coughing thick white sputum • Client has feeling of impending-disaster. • Skin color changes • Client has feeling of impending-disaster. • Skin color changes No specific test available but may see: • Fat-cells in blood, urine or sputum • Pa02 < 60 mm Hg • ST segment changes on EKG • Decreased HCT and platelet-count • Prolonged PT ° CXR areas of infiltrate or multiple areas of consolidation called the "Snowstorm effect" ("white out") Treatment is aimed at prevention • Careful immobilization of long bone fracture/minimal manipulation • Reposition as little as possible before fracture immobilization or stabilization because of danger of dislodging more fat-droplets into general circulation • Treatment is supportive, with management of symptoms: • Adequate fluid-intake • Correction of acidosis • Replacements for blood-loss • Coughing, deep-breathing • 02, intubation may be needed • Most clients survive FES

Hammer toe

• Flexion-deformity of interphalangeal-joint, may involve several toes • Results from improper fit of footwear • Corns develop on top of toes • Calluses develop under metatarsal area • Treatment: • Shoes that conform to the shape of the foot • Open-toed sandals • Manipulative-exercises • Protect protruding-joints with pads • Surgery: osteotomy

Collaborative problems/ potential complications

• Hemorrhage • Peripheral neurovascular dysfunction • DVT • Pulmonary complications • Pressure ulcers

Impingement-Syndrome What does this impair the movement of? How is it treated?

• Impaired-movement of the rotator cuff of the shoulder Treatment: • NSAIDs • intra-articular injections of corticosteroids • Application of cold or heat • PT

Specific-Fractures: Clavicle/Collar-Bone

• Important to immobilize the arm to prevent shoulder movement • Use clavicular strap or "figure of eight bandage" to pull shoulder back and thereby reducing and immobilizing the fracture • Important to exercise wrist, fingers, and elbow • When prescribed, shoulder exercises are performed to obtain full shoulder motion • Vigorous activities are limited for approximately 3 months • Avoid elevation of arm above shoulder level for 6 wks

Osteomyelitis

• Infection of the bone Occurs because of • Extension of soft tissue infection • Direct bone-contamination • Bloodborne: spread from another site of infection • Typically occurs in an area of bone that has been traumatized or has lowered resistance Causative organisms • Methicillin-resistant Staphylococcus aureus •Other: Proteus and Pseudomonas spp., Escherichia coli

Bursitis and Tendonitis: What parts of the shoulder are affected? How are they treated?

• Inflammatory -conditions that commonly affect shoulder (bursae and tendon) Treatment: • Rest of extremity • Intermittent ice and heat • NSAIDs

Thoracolumbar spine fractures

• Involves fracture of vertebral body, laminae, and articulating and spinous transverse processes (T12 to L2 most vulnerable to fractures) • Usually treated conservatively with limited bed-rest • Avoid sitting •Progressive ambulation • Emphasize good posture and body mechanics • Implement back strengthening exercises

Arthrocentesis What kind of fluid is aspirated from the joint? What kind of med is injected? What can be examined in the fluid aspirated? Nursing inventions include education on pre/post procedure, application of ice to decrease or prevent swelling, and report s/s of infection which include?

• Joint-aspiration • Aspiration of fluid (synovial-fluid) • Can also inject medication (anti-inflammatory) • Fluid examined for WBCs, blood, crystals Nursing-Interventions • Education pre and post procedure • Report S/S infection, ⬆️ bleeding, numbness, etc • Application of ice to decrease/prevent swelling

Articulate system Immovable joints are called? Joints with limited motion are called? Freely movable joints are called?

• Junction of two or more bones is a joint (aka, articulation) • Primary-function of joints provide movement & flexibility Joint-capsules are lined with synovium. 3 Basic Types Joints: 1. Synarthrosis (fibrous) - Immovable-joints (e.g., skull-sutures) 2. Amphiarthrosis (cartilaginous) joints - Allow limited-motion (vertebral joints; symphysis pubis) 3. Diarthrosis (synovial) joints - Freely-movable (ball-and-socket, hinge, pivot, saddle, gliding

Splints/ Braces

• May be made-to-fit or prefabricated (standard) • Generally indicated for short-term use • Removable; allows monitoring of skin-integrity or swelling /•Immobilizes and supports body-part in functional-position • Noncircumferential; does not impair circulation • May be made of plaster or pliable thermoplastic-material • Must be well-padded, to prevent pressure, skin-abrasions, or skin- breakdown • Overwrapped with elastic-bandage, applied in spiral-fashion with uniformly-distributed pressure

Meniscal injuries

• Menisci: cartilages located in the knee on both sides of the proximal tibia, between the tibia and femur •Act as shock absorbers in the knee Twisting of the knee or repetitive squatting and impact may result in either tearing or detachment of cartilage which weakens the knee and prevents full extension of leg and as a result leg gives away (knee locks) • MRI is diagnostic method of choice Treatment ranges from conservative immobilization, cryotherapy, anti-inflammatory agents, analgesics, modifying activities (home exercises and PT) or surgery (arthroscopic)

Bone Tumors - Benign

• More common • Generally slow growing • Usually does not cause pain (Painless) • Present few symptoms • Most common is osteochondroma • Bone-cysts: expanding lesions within the bone • Osteoid osteoma: Painful tumor in children and young adults • Osteoclastomas: benign for long periods but may invade local tissue and cause destruction

Lateral and medial collateral ligament knee injury

• Occurs when the foot is firmly planted and the knee is struck, causing stretching and tearing injury to the lateral or) medial collateral ligaments of the knee • Client experiences acute onset of pain, joint-tenderness, joint-instability, and inability to walk without assistance (Bleeding into joint may occur.) Treatment include any one of a combination of: • Pain management • Joint-aspiration if indicated • Limited weight-bearing and use of a brace/crutch, etc • If severe, surgical reconstruction with immob. for 6-8 wks • Requires months of rehab

Effects Of Aging

• Pain • Joint-limitations (enlargement, decreased ROM) • Osteoporosis: loss of height, kyphosis = forward thoracic curvature • Decrease in muscle mass/strength • Decrease in bone-density • Older adults have higher incidence of DID • Limited mobility • Fractures are common • Loss of elasticity of ligaments & tendons • Slowed muscle-reflexes & endurance • Progressive-deterioration of cartilage in weight-bearing areas • Table 35-1, p. 1103

Nursing management for bone tumors

• Pain assessment • Administer pain meds • Relaxation techniques • Prevention of pathologic fractures Support affected extremities at all times; handle gently • External supports or fixation devices may be required Restrict weight-bearing and activity as prescribed • Use of assistive-devices • Encourage client and family to express fears and concerns Monitor for complications: • Delayed wound-healing, due to tissue trauma (surgery, radiation) • Minimize pressure on wound, to promote circulation • Repositioning to prevent skin-breakdown • Adequate nutrition and hydration: •Side-effects of chemo: N/V, loss of appetite •Antiemetics •Nutritional-supplements, parenteral-nutrition Monitor for complications (cont.) • Osteomyelitis and wound-infection • Prophylactic AB • Strict aseptic dressing-changes • Prevention of other infections (pneumonia, resp infections) • Hypercalcemia: • Caused by breakdown of bone • S/S: muscle-weakness, incoordination, anorexia, n/v, constipation, ECG changes, altered mental-status • Treatment: • Hvdration with IV NS • IV bisphosphonates • Increase ambulation and activity (inactivity promotes bone breakdown) • Education about self-care, home-health

Loose Bodies: How are they a result of and how are they removed?

• Presence of loose fragments in joint; result of articular cartilage wear and bone-erosion • Removal by arthroscopic-surgery

Bone Tumors-Malignant (Primary)

• Primary tumors (rare) • Osteosarcoma-most common and most often fatal • Chondrosarcoma, Ewing sarcoma, fibrosarcoma • Soft-tissue sarcomas • Liposarcoma, fibrosarcoma of soft tissue, rhabdomyosarcoma • Prognosis depends on type and if metastasized • Usually metastasizes to lungs

Functions of the skeletal system

• Protects internal vital-organs & tissues • Serves as framework to support body-structures & surrounding tissues • Allows for mobility and movement • Reservoir for immature blood-cells • Mineral-storage: • Stores Cat+ (98% total body Cat* present in bone) • Phosphorus, Mgt • Fluoride

Dislocations Nursing Management

• Provide comfort • Monitor neurovascular-status • Immobilize the joint (splints, casts, or traction) Patient-teaching • Appropriate exercises for strengthening the muscles to prevent recurrences • S/S of complications: increasing pain, numbness/tingling, increased edema of extremity • S/S compartment syndrome • Instruct on using brace for activity

Traction What is a Pulling-force that promotes and maintains alignment to injured part of body? What is traction used for? Traction is used as a short or long term treatment? What are the principles of effective traction?

• Pulling-force; promotes and maintains alignment to injured part of body. Goals • Decrease muscle spasm/pain • Realignment of fractures • Correct/prevent deformity • Used as short-term intervention, until other modalities possible: external/internal fixation • At times, traction may need to be applied in two directions: • One of the lines-of-pull counteracts the other • These lines-of-pull are known as vectors of force • Effects of traction evaluated with x-ray studies Principles of effective traction • Whenever traction is applied, countertraction must be applied. - Frequently, patient's body-weight and bed-position adjustments supply the counterforce (opposite-pull). • Traction must be continuous, to reduce/immobilize fractures • Skeletal-traction is never interrupted • Weights are not removed, unless intermittent-traction is ordered. • Any factor that reduces the effective pull of traction must be eliminated (weights on floor, knots in ropes, etc.) • Client must be in good body-alignment; in center of the bed • Ropes must be unobstructed and weights hanging freely • Knots or the footplate must not touch the bed or pulley

Nursing Interventions: Contusions, Strains, and Sprains

• RICE: Limits inflammation and tissue destruction, decreases pain, reduces muscle spasm/bleeding/edema • Rest • Ice • Compression • Elevation • Immobilize • Anti-inflammatory medications • Protection from further injury (sling and/or splint) •Apply intermittent cold-packs for 15-20 minute-itervals during the first (24-72 hr not to exceed 20 min at a time • Neuro-checks every 15 mins for first 1-2 hr after injury then extend time as applicable

Casts (Fiberglass and plaster) How long does Fiberglass/ Synthetic Casts take to Reaches full rigid-strength? Plaster Casts do not achieve full-strength until completely dry and may take how long?

• Rigid external-device; immobilizes affected body-part (molded to fit the body-part) • Mainstay of treatment for many fractures • Uses - Immobilize a reduced-fracture - Prevent or correct deformity - Apply uniform-pressure to soft tissues - Support and stabilize a weakened-joint • Type: Depends on condition treated, availability and cost - Fiberglass Cast - Plaster Cast (can be molded better) Fiberglass/ Synthetic Casts • Lighter weight, stronger, more durable than plaster • Water-resistant • Can be used in hydrotherapy - then dried with a hair-dryer on cool setting • Must allow water to drain out in order to dry • Activated with warm water • Gives off heat when drying • Reaches full rigid-strength (usually) within 30 minutes. Plaster Casts • Less costly and achieve better molds • Takes longer to dry • Goes on wet (activate with clean, tepid water) and gives off heat while drying • Does not achieve full-strength until completely dry, may take 24-72 hrs • Handle with palms (flat palmer-surface), while drying • Drying cast should not be covered with linens, etc. • Cast appears dull gray; has a musty-smell (while drying) • Dry cast is white, shiny, odorless

Laboratory studies

• Serum calcium 9-11 mg/dl • Serum phosphorus 2.8-4.5 mg/dI • Acid Phosphatase (ALP) 30-120 U/L - Enzyme normally-present in blood - Elevated during early fracture-healing, diseases with increased osteoblastic-activity (metastatic bone tumors) • Rheumatoid Factor (RF) Negative • Parathyroid Hormone (PTH) 15 - 65 ng/L • Creatine Kinase (CK) - Men 15-105 U/L - Women 10-80 U/L - Elevated in muscle disease, trauma - Rises 2 - 4 hrs after muscle-injury • Vitamin D levels

Dupuytren's contracture Which fingers are flexed during the slow progressive contractures?

• Slowly-progressive contractures of palmer fascia, causing flexion of 4th and 5th fingers; also middle-finger TX • Treatment: • Finger-stretching exercises or intra-nodular steroid-injections • Palmer and digital fasciotomies to improve function

Nursing Care of Client Undergoing Foot-Surgery: Pre and Post Care

• Surgery is usually outpatient-procedure. Pre-operatively, the nurse assesses: • Client's knowledge of condition and procedure • Assess neurovascular status • Assess gait and balance • Need for home-assistance; structural characteristics of home layout Post-operative nursing-interventions include: • Neurovascular-assessment • Assess swelling and neurovascular status q 1-2 hrs for first 24 hours (circulation, motion, sensation) • Patient-teaching includes neurovascular-assessments and monitoring edema at home • Compare bilaterally to unaffected foot • Prevention of DVT • Relleving pain (Related to inflammation/edema) • Elevate foot, use ice intermittently (18 24-48 hrs) • Administer oral-analgesics • Improving mobility • Instruct on weight-bearing restrictions as prescribed • Use assistive-devices (crutches or walker) • Implement measures to ensure patient safety • Implementing measures to prevent infection * Provide wound or pin care • Keep dressing clean and dry •Assess for S/S Infection • Instruct client s/s to report

Nursing-Care: Clients Undergoing Surgery of Hand/Wrist

• Surgery usually an outpatient-procedure (unless related to trauma) • Client-teaching is a major nursing-need for client undergoing outpatient surgery (neurovascular vs, when to notify MD, etc.) • Neurovascular-assessment is vital: every hr for first 24 hrs; assess motor-function only as prescribed • Pain-control measures: medication, elevation, intermittent ice or cold to control edema • Prevention of infection (pins, etc.): keep dressing clean and dry, provide wound/pin care, assess for S/S infection • Instruct in arm-support sling exercises, if ordered • Assist with ADLs, esp. in 1st few post-op days • Measures to promote independence (use hand within limits, unless contraindicated)

Morton's Neuroma (Plantar Neuroma)

• Swelling of 3rd branch of medial plantar-nerve (3rd intermetatarsal space) • Digital-artery changes cause nerve ischemia, results in throbbing, burning pain • Usually relieved with rest and massage • Pain increases with: • Shoes are tight-fitting • Hyperextension of metatarsophalangeal-joint • Repetitive-impact on the foot • Treatment: • inserting innersoles and metatarsal pads • injections of corticosteroids and local anesthetic • surgery when conservative measures fail

Total hip replacement Arthroplasty

• The replacement of a severely damaged hip with an artificial-joint I Indications: osteoarthritis, rheumatoid arthritis, femoral neck fx, failed prosthesis • Replacement-joint may be made of several components: metal, ceramic, plastic • Client-teaching very important both pre and post surgery Complications: • Dislocation of hip-prosthesis • Excess wound-drainage • DVT/ PE • Infection • Heel pressure-ulcer • Complications from immobility • Avascular-necrosis • Loosening of the prosthesis Preventing Dislocation of Hip-Prosthesis: Chart 36-7, p. 1131 • Supine position, HOB slightly-elevated, affected-leg in neutral-position • Prevent adduction with an abduction-splint or wedge-pillow • Cradle-boot may prevent leg-rotation • Do not turn to operative-side, keep operative-hip in abduction • Avoid flexing hip(> 90 degrees, limited-flexion during transfers • Avoid crossing legs (adduction of hip) • Avoiding bending at the waist • Use high-seat chairs, raised toilet-seats • Avoiding internal/external rotation of hip • Monitor for s/s of dislocation • Increased pain, swelling, immobilization • Acute groin pain in affected hip • Shortening of affected-extremity • Abnormal external or internal rotation • Restricted or inability to move the leg • Reported popping sensation • Rehabilitation within 24 hrs, to prevent complications Monitor wound-drainage • 200 to 500 mL in the first 24 hrs is expected • By 48 hrs total drainage usually decreases to 30 mL or less over an 8 hour period • Notify provider immediately for excessive or foul smelling drainage Preventing DVT: •Risk high after orthopedic-surgery • Intermittent compression-devices intraoperatively and postop • Anticoagulants: ASA, enoxaparin duration based on surgeon-preference Prevent infection: • Strict hand-hygiene and infection-control practices • Proper prep skin-cleansing • Appropriate AB administration • Monitor drains and wound-drainage • Prophylactic AB for future procedures

Bone tumors: Malignant

• Typically present with bone-pain • May report weight-loss, chills, fever, or pulmonary-manifestations • Most common sites: distal femur, proximal tibia, proximal humerus • Metastatic bone tumors more prevalent than sarcomas (primary bone tumors) and spread from other locations • Diagnosis usually by X-ray but definitive-diagnosis is by bone biopsy • Malignant bone tumors usually diagnosed after pathologic fractures (diseased bone) Malignant bone tumors. . . . • Treatment: remove or destroy • Surgery: Local excision or amputation • Chemotherapy • Radiation therapy • Combination therapy • Pain-meds around the clock (not PRN) • Treatment for metastatic bone disease is palliative (⬇️ pain and promote QOL)

Electromyogram An electromyogram is used to evaluate muscle weakness, pain, and disability by determining any ___________ of function. The extent of Nerve injury can be determined if function doesn't what? What is inserted into muscles and responses to stimuli are recorded? Will there be any discomfort with this procedure? What should be discontinued a few days before the test? Is a hot or cold compress applied for residual-discomfort after procedure? What should the client be instructed to monitor?

• Used to evaluate muscle-weakness, pain, and disability by determining any abnormality of function • Can be used to identify the extent of nerve-injury if function doesn't return • Needle-electrodes are inserted into muscles and responses to stimuli recorded • Instruct client that there is some discomfort with procedure, discontinue skeletal-muscle relaxants/anticoagulants few days before test • Apply warm compresses for residual-discomfort after procedure • Instruct client to monitor for S/S skin-infection

Arthrography Arthrogram) What is an Arthrography used to ID? What two things will be injected into the joint cavity to outline soft tissue structures and join contour? After injection, what is used for imaging? Tears in joint-lining, the supporting ligaments/cartilage/tendons of knee, shoulder, ankle, hip wrist are evaluated by an arthrography. True or false? How is contrast distributed? A meniscal tear can be evaluated by an Arthrogram. True or false? What are the post procedures for an Arthrogram? How long is a joint rested after the procedure? How long will clicking or cracking in the joint be heard for afterwards until air or contrast is absorbed? What maybe required for comfort? How long is a compression wrap applied?

• Used to identify cause of unexplained joint-pain; disease-progression • X-ray image made after radiopaque-contrast or air is injected into the joint-cavity to outline soft-tissue structures and joint-contour • Used to evaluate tears in joint-lining or the supporting ligaments/cartilage/tendons of knee, shoulder, ankle, hip wrist • Joint is put through range ROM, to distribute contrast. • Contrast/air leaks out, if tear present. • Ex: Rotator-cuff, meniscal-tear Post-procedural • Compression-wrap applied for about 12 hrs • May require mild analgesia and/or ice for comfort • Joint is rested for approx. 12 hours • Inform client that it is normal to hear clicking or cracking in joint for approx. 2 days (24 - 48 hrs), until air/contrast is absorbed

Braces

• Used to provide support, control movement, and prevent additional injury • Custom fitted to various parts of the body • Adjusted for fit, positioning, and motion so that movement is enhanced, deformities corrected, discomfort minimized • Most have Velcro-straps • Generally indicated for longer use than splints • Many braces are prefabricated then adjusted to fit; may be custom-made

Femoral shaft fractures

• Usually occur in young adults from trauma like MVA, or those who have fallen from high places due to the force needed to fracture this bone • Thigh is usually edematous, deformed, and painful • Client may even develop shock due to bleeding • Neurovascular status is closely-monitored • Immobilization is usually with skeletal traction until stable enough to perform ORIF usually within 24 hrs • Fracture usually heals in approximately 4-6 months

Amputation

• congenital or traumatic • or caused by conditions such as progressive peripheral vascular disease, infection, or malignant tumor Amputation is used to • relieve symptoms • improve function • improve quality of life •The health care team needs to communicate a positive attitude to facilitate acceptance and participation in rehabilitation Rehabilitation Needs • Psychological support • Prostheses fitting and use • Physical therapy • Vocational or occupational training and counseling • Use a multidisciplinary team approach • Patient teaching

Epicondylitis What is this chronic painful conditions caused by?

•A chronic, painful condition caused by excessive, repetitive extension, flexion, pronation, and supination motions of the forearm resulting in tendonitis and minor tears in the tendons at the origin of the muscle on the lateral or medial epicondyles •Examples include tennis elbow, golfer's or pitcher's elbow Treatment: • routine application of ice • NSAID's • immobilization may be necessary • May require injections with corticosteroids as last resort

Nursing-Management in Fractures

•Assessment: Neurovascular-assessment, pain, activity-limitations, patient-edu, home-environment, support • Goal: Client will return to usual level of activity, asap • Patient-teaching (include family) • Controlling edema, pain-control, exercises to maintain functioning of unaffected muscles, assessment of neurovascular status, self care activities, medications, and potential complications • Open fractures: importance of preventing complications (infection, etc.) - wound-closure may be delayed • Fracture healing 6-8 weeks in a normal healthy adult

Other fractures

•Radial head • Radial and ulnar shafts •Wrist (Colles fx, distal radius) •Hand •Femoral shaft •Knee •Tibia and fibula