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Orthopedics
Musculo-skeletal Disorders
Semester 4
4 Major Areas of Orthopedic
Nursing
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Assessing and alleviating pain
Increasing patients mobility
Preventing complications
Providing patient teaching
Agenda
• A&P (you have already done this)
• Assessment (you have already done this)
• Causes of Disorders
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trauma
infection
abn cellular development
degeneration
inflammation
metabolic
Agenda
• Treatment:
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rest
traction
casts
internal/external fixation
assistive devices: ie crutches, walkers
surgical interventions
pharmacology
Pharmacology
• Classifications:
– muscle relaxants
– Anti-inflammatory agents: salicylates, nonsteroidal
– Corticosteroids
– gold treatment
– uricosuric drugs
– immunosuppressants
Physiology of Movement
• 3 systems
–skeletal
–muscular
–nervous
Bones
• Constantly changing - either breaking down
or renewing
• Osteoblasts
• Osteoclasts
• Osteoblast and osteoclasts work together to
achieve bone balance
• negative balance vs positive balance
Bone: classifications
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Long bones
short bones
flat bones
irregular bones
Bone: Function
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Support and protection
body movement (with CNS and muscles)
blood cell formation
inorganic salt storage - approx 70% of bone
weight is calcium phosphate
Muscles: Types
• 3 types:
–skeletal
–smooth
–cardiac
Assessment
• General observation
– uniformity of bones and muscles
– posture, body alignment
– balance and co-ordination
Assessing Posture
Congenital Deformities
Assessment
• Muscles
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size
tone
strength and endurance
hand grips, foot presses (weak, one-sides)
Assessment
• Bones and Joints
– palpate for prominence, contours, symmetry
– ROM upper and lower noting flexibility
– *never force the joint
Assessment
* Body Balance:
balance maintained - one foot, two feet
* Co-ordination:
fine motor skills - observe ADL
* Ability to transfer:
independent? Supervision? One or two person assist?
Assessment
• Musculo-skeletal + neuro-vascular
• Neuro-vascular includes colour, temp,
capillary refill distal to the injury
• Palpation of pulses; pain; sensation &
movement
• May need to use dopler for pulses
Changes Related to Aging
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Bone density decreases
Synovial joint cartilage less elastic
Muscle tissue atrophy (decreased strength)
Decreased ROM
Kyphotic posture; widened gait; shift in
centre of gravity
Disorders: Trauma (soft tissue)
Muscle Spasm:
• injury stimulates nerve endings in muscle
• causes excitation of nerve endings and
places muscles in spasm
S and S:
• pain, palpable muscle mass (knots)
• tenderness with decreased ROM and ADL
Muscle Spasm
Sites:
• any muscle
Treatment:
• physical therapy (physio)
• moist heat packs
• hydrotherapy
• bracing, analgesics, muscle relaxants
Trauma: contusion
Trauma: Contusion
• Soft-tissue injury or bruise produced by a
blunt force such as a blow, kick or fall
• hemorrhage into tissue
• tx: elevation, moist or dry cold x’s 8-10 hrs
20 mins on - 20 mins off
• after 24 hours, heat 20 on-off followed by
cold, elastic bandage
Trauma: Strain
• Injury to musculo-tendinous structures
surrounding a joint
• caused by over stretching or excessive force
• results in hemorrhage into the tissue
• 1st, 2nd, 3rd degree stains
• 2nd and 3rd involve tearing of musculotendonous fibers
• 3rd degree may require OR
Trauma: Sprains
• Injury to the ligamentous structures
surrounding the joint
• caused by a wrench or twist
• hemorrhage, decreased stability of joint
• surgical repair or immobilization
• 8 to 16 weeks in cast
Trauma: Meniscus injury
Meniscus: crescent shaped fibrous cartilege
in the knee
• stabilizes the knee
• shock absorber
• common in athletes
S and S: severe pain, non-functioning knee,
edema at knee
Meniscus injury
Treatment:
• physio to strengthen and increase stability
• menisectomy-surgical repair of cartilage by
arthroscopy
• recovery depends on degree of tear and
damage to surrounding tissue
Nursing Care: Crutches, Canes &
Walkers
• Crutches need strong upper extremities
• 2-3 finger spaces between crutch and axilla
• Elbow flexed no more than 30 degrees
when hands on handle
• Usually use 3 point gait
Canes and Walkers
• Walker used for older adults who need
support and balance
• Cane is used for minimal support; hemi
or quad cane offers more support
• Cane is placed on unaffected side and no
more than 30 degree flexion of elbow
• Top of cane is parallel to greater trochanter
Repetitive Strain Injury (Carpal Tunnel
Syndrome)
• Entrapment neuropathy that occurs when
the median nerve at the wrist is compressed
by a thickened flexor tendon sheath, bone
encroachment, edema or soft-tissue injury
• repetitive strain injury
S and S:
• pain, numbness, parasthesia, weakness
along median nerve which inervates the
thumb, 1st, 2nd fingers, common at night
Numbness
Median Nerve
Entrapment
Repetitive Strain Injury (Carpel Tunnel)
Treatment:
• splints to prevent hyperextension and
flexion of the wrist
• cortisone injections
• surgery of the transverse carpal ligament
• often confused with thoracic outlet
syndrome
Trauma: Epicondylitis (tennis
elbow)
• Damage to the tendons of the medial or
lateral radial and ulnar epicondyles
S and S: chronic pain that radiates down the
dorsal surface of the arm, weakness
Tx: rest in splint, ice, NSAIDS, corticosteroid
injections, gentle exercise to prevent
stiffness
Review of the Knee
Anterior and Posterior Cruciate
Ligaments
ACL/PCL
• Stabilize forward and backward motion of
the femur and tibia
• injured when foot is firmly planted, knee
hyperextended and person twists torso and
femur
• S&S: pain, joint instability, pain with
ambulation
ACL/PCL
• Treatment: RICE, r/o fracture, joint effusion
and hemarthrosis needs aspiration and
wrapping with compression dressing.
• Conservative: brace and physio
• Surgical reconstruction or repair followed
by 6 -12 weeks immobilization followed by
brace and physio
Trauma: Dislocations
• Occurs when articular surfaces of the bones
forming a joint are out of anatomical
position, subluxation = partial dislocation
• may be congenital, pathological or
traumatic
• S&S: pain changes in contour, length of
extremity, loss of mobility
• Tx: reduction, immobilization
Congenital Hip
• Often left hip, females, 1st born,
breach birth;
• First, Female, Foot, Family
• Legs are a different length, uneven thigh
skin folds, less mobility or flexibility in one
leg
Developmental Dysplasia of the Hip
Trauma: Dislocations
• Often recognized clinically
• Can occur at time of impact or during
application of splint at scene
• Orthopedic emergency when bone impinges
on nearby vessels and nerves, compression,
laceration, crushing, stretching
Neuro-vascular involvement
Shoulder:
Elbow:
Wrist:
Hip:
Knee:
Ankle:
brachial plexus, axillary artery
ulnar nerve, brachial artery
median nerve
sciatic nerve
tibial/peroneal nerve, popliteal
artery/vein
tibial artery
Trauma: dislocation, subluxation
• Dislocation:
• Subluxation
Assessment:
• neuro/vascular status
• elevate limb (caution above heart)
• compression bandage
• cold pack, immobilize, don’t wt bear
Dislocation, subluxation
• Did pt. or bystander hear popping or
snapping sound?
• Assess below injury, pulses etc
Trauma: Fractures (fx)
• Disruption of normal bone continuity
• 150 types of fractures
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open (compound), closed (simple)
complete, incomplete
impacted
comminuted
displaced
complicated
Trauma: Fractures
Fracture Direction:
• linear fracture
• oblique fracture
• spiral fracture
• transverse fracture
Trauma: Fractures
Assessment:
• Accident data base
• ABC’s (c-spine)
• Inspection and Palpation
– edema, deformity, ecchymosis, loss of function,
crepitation, muscle spasm, x-ray, CT/MRI,
angiograms, pulses, capillary refill
Goals of Fracture Repair
• Fracture reduction
• Maintenance of the fragments in the correct
position while healing takes place
• Prevention of excessive loss of joint
mobility and muscle tone
• Prevention of complications
• Maintenance of good general health to
promote healing
Complications of Fx
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Shock, which may be fatal
Hemorrhage
Acute Compartment Syndrome
Venous Thrombosis
Fat Embolism/PE
Infection
Nerve and organ damage
Shock
• Hypovolemic or traumatic shock
• Internal or external bleeding
• Tx: replacement, relieve pain, splinting of
fx, protection from further injury
Hemorrhage
• Bones are very vascular, surgery long, may
have been other surgery first
• Hemorrhage may occur as a result of
abnormal blood clotting i.e. DIC, or side
effect of meds
• Post-op assessment is critical
Fat Embolism
• Fat in blood becomes entrapped in the lung
capillaries and other small vessels that
supply the brain, kidneys and other organs
• Fat comes from bone marrow, stress may
cause alteration of lipid stability in the
blood
• Fat drops lodge in capillaries and then cells
accumulate and form plaque
Fat embolism
• Emboli may go to skin and petechiae
• Usually 12-48 hours post injury or OR
• Personality changes, ABG, increased resp,
chest pain,
• Tx: prevention, high Fowler’s, O2,
hydration; bedrest; steroids; reducing fx
• 10-15% mortality
Pulmonary Embolism
• Most common cause of immediate post-op
death on lower extremity OR
• Fx pelvis, hip, femur
• Clot comes from peripheral vein
Acute Compartment Syndrome
• Ischemic muscle necrosis and subsequent
contractures
• “circulation or function of tissues within a
closed space is compromised by increased
pressure within that space”
• Closed fascial space
• Pain, pain on passive motion, parasthia,
paralysis, pulselessness
Fasciotomy
Neurological Complications
• Satisfactory reduction of the fx relieves
stress placed on nerves
• Nerve damage is usually from stress versus
laceration
• Review sensory assessment
Infection at time of Injury
• Tetanus, gas gangrene
• Open fx, irrigated +++, debrided, may be
left open, prophylactic antibiotics
• Avascular Necosis caused by infection or
loss of blood supply.
• Dead bone is reabsorbed and replaced by
new bone, often in femoral head
Secondary Effects
• Respiratory complications due to meds,
immobility, pneumonia, pneumothorax,
• Circulatory complications: DVT, Postural
hypotension, venous stasis, circulatory
overload with IV fluids
• Gastrointestinal complications: PI, constip.
Secondary complications
• Genitourinary complications: infection,
prolonged catheter use
• Musculoskeletal: contactures,
• Integumentary: skin breakdown, bed sores,
often weight loss
PTSD
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Traumatic
Family loss
Loss of limb etc
Intrusive thoughts and dreams, exaggerated
startle reaction, anxiety, social withdrawal
Specific complications
Hip:
• Sciatic nerve damage
• avascular necorsis
Fractured Left Hip
Note external rotation
Fractures
Pelvis:
• bleeding
• bladder rupture, pancreas, spleen trauma
• bowel trauma (75% mortality)
Specific complications
Distal Femur and Knee:
• popliteal artery/nerve damage
• bleeding
Fibula:
• injury to peroneal nerve
Bone Healing
• Continuous process that begins at injury
• hemorrhage into the fracture site
• within 24 hours a hematoma is formed and
fills the fracture site
• coagulated blood results in loose fribrin
mesh that seals off the fracture site and
serves as a framework for ingrowth of
fibroblasts and capillary buds
Bone healing
• During first 24-48 hours inflammation
results in edema, vascular congestion and
infiltration of leukocytes
• 48 hours post injury macrophages begin
phagocytosis
• fibroblasts and chondroblasts begin to form
a soft tissue callus
Bone healing
• After the first few days, newly formed
cartilage and bone matrix are evident
• end of first week well-developed new bone
and cartilage dispersed throughout softtissue callus
• provisional callus reaches maximal size in
2-3 weeks, strengthening and remolding
continues
Managing a Cast
Managing a Cast
• Casts immobilize reduced fractures
• correct a deformity
• apply uniform pressure to underlying soft
tissue
• support and stabilize weakened joints
• permit mobilization of pt, while restricting
movement of a body part
Managing Cast
• Types: short arm or leg, long arm or leg
• Walking cast, body cast, shoulder spica, hip
spica
Assessment and Complications:
Casts
Assess:
• Circulation
• Movement
• Sensation
Cast Care
• Impaired blood flow d/t pressure from cast
• Nerve damage from nerve over bony
prominence
• Infection, tissue necrosis from skin
breakdown
• Compartment syndrome; delayed, mal- and
non-union
Traction
• Three types, manual, skin and skeletal
Purposes of Traction
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Reduce a fx and realign bone fragments
Maintain skeletal length and alignment
Reduce and treat dislocations
Immobilize to prevent further soft-tissue
damage
• Prevent the development of contractures
• Relieve muscle spasm
Purposes of Traction
• Lessen deformities
• Rest a diseased joint
Skin Traction
Balanced Skeletal Traction
Traction Care
• Keep patient clean, comfortable and free of
pressure sores
• Assess (q2-3h or more frequently prn)
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wts from traction are hanging freely
pts body weight is counteracting pull of wts
that traction boot is not slipping off of pt
all bony prominences, skin, circulation
pt posture in bed, position of joints for
alignment
– slings, ropes, sheets are not cutting into skin
and creating sores
– pin sites for infection
Osteomyelitis
• Inflammation and infection of bone tissue
and bone marrow
• Retards healing by destroying newly
forming bone, disrupts blood supply
• Usually caused by hemolytic staphlococcus
aureus bacteria, e-coli, pseudomonas
• Risk: immune suppressed, long term CS,
IDDM and NIDDM
Disorders of the Musculoskeletal
System
Due to Degeneration
Muscular Dystrophy
• Neuromuscular disease
• Genetically determined, progressive disease
of specific muscle groups
• Progressive weakness of the voluntary
muscles
• Many types
• Usually male, female carry the gene
Types of MD
• Duchenne’s (pseudohypertrophic)
– onset rapid, usually by age 5, cardiac
involvement, mental retardation, death by adult
• Becker’s
– age 5-15, rare cardiac, usually normal lifespan
Muscular Dystrophy
• Facio-scapulo-humeral:
– age 10-30, inability to raise arms above head,
eyes remain partially open during sleep
• Limb-girdle
– age 10-30, weakness in proximal muscles of the
upper and lower extremities, gradual atrophy
and weakness then loss of function
Signs and Symptoms
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Generally: muscle fiber atrophy
Necrosis of muscle tissue
Fibrosis
Increase serum creatine phosphotinase
(CPK)
• Replacement of muscle tissue with
connective tissue
• Weakness, some immobility
Treatment
• Physio to prevent muscle tightness,
contractures, disuse atropy
• Night splints for contractures in ankles, hips
and knees
• Braces for muscle weakness to increase
mobility
• Orthotic jacket for spinal support
Nursing implementations
• Physical and psychological support
including ROM
• Reinforce PT and OT
• Encourage independence
• Teach use of equipment
Disorders of the Musculoskeletal
System
Osteoporosis
Osteoporosis
• Causes skeleton weakness and fractures
during routine activites
• between age 20 and 40 bones reach
maximum density
• after that resorption > than formation
• after bone peak, loss is about 1% / year
• lifetime losses may reach 30 - 40%
Osteoporsis
• In osteoporosis, osteoblasts do not replace
resorbed bone
• usually first sign is a fx, kyphosis and loss
of height, bone density test
Interventions
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Estrogen
dietary supplements
exercise
pharmacologic therapy
alternative therapies
Community care
• Assessment
• monitoring
• prevention
Prognosis
• Not curable
• can prevent bone loss
• early detection results in preventing further
loss and life-threatening fx
• prevent pain and immobility
Orthopedics - Amputations
Amputations
Amputation
• Removal of a body part
• Often necessary as a result of progressive
PVD (diabetes), gas gangrene, trauma
(injury, frostbite, electrical burn), congenital
deformities, chronic osteomylitis, or
malignant tumor
• Relieves symptoms, improves function,
save or improve quality of life
Amputation
• Performed at the most distal point that will
heal successfully
• Determined by circulation in the part and
functional usefullness
• Objective is to conserve as much length as
possible, try and preserve knee and elbow
• May use staged amputation
Amputation sites
Complications
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Hemorrhage
Infection
Skin breakdown
Phantom limb pain
As well as other we have discussed related
to immobility
Post op objective
• In addition to everything else
• a non-tender residual limb with healthy skin
for prosthesis use
Nursing Diagnosis
• Pain related to amputation
• Sensory/perceptual alteration: phantom pain
r/t amputation
• Impaired skin integrity r/t surgical
procedure
• Body image disturbance r/t amputation
• Coping, ineffective amputation
• Grieving r/t amputation
Nursing Diagnosis
• Self care deficit: bathing, feeding, toileting,
grooming
• Impaired physical mobility r/t amputation
Nursing Intervetions
• Pain: identify hematoma, muscle spasm as
possible cause
• Phantom pain and sensation: occurs more
frequently in AKA, Nurse offers support,
distractions,
• Wound healing: usual wound care,
compression or limb shaping dressing,
plaster slab, physio,
Nursing Interventions
• Body image: accepting and supportive
atmosphere, social worker, physio, family,
• Independent self care: OT, time, encourage
independence, assistive devices
• Increase physical mobility: Trapeze, arm
strengthening, avoid hip and knee
contractures, limb should not be up on a
pillow, roll from side to side and prone
Interventions
• Amputation changes center of gravity
• some may not have prosthesis and will use
wheelchair, special chair so it won’t tip
• Post op complication: hemorrage, infection,
skin breakdown
• Home Care:
Orthopedics
Back injury
Acute Low Back Pain
Etiology:
• acute lumbosacral strain
• unstable lumbosacral ligaments
• weak muscles
• osteoarthritis of the spine
• spinal stenosis
• intervertebral disk problems
• unequal leg length
Low Back Pain
• Disk degeneration is a common cause of
back pain
• Lower lumbar disks L4-5 and L5-S1
• complains of acute or chronic pain
• radiating pain
• assessment may show changes in reflexes,
gait, mobility, paravertebral muscle spasm,
loss of lumbar curve.
ALB pain
• Usually self limiting - one month
• rest, analgesics, stress reduction, heat or
cold therapy, muscle relaxants
• limit sitting to 20-50 mins, slow movement
and twisting, begin muscle strengthening
• should be preventable!
Nrsg Dx
• Pain r/t
• impaired physical mobility r/t pain, muscle
spasm, decreased flexibility
• knowledge deficit r/t back-conserving body
mechanics
• self-concept deficit
• altered nutrition: greater than
Total Knee/Hip Arthroplasty
PN 4 2007
Case Study, Total Knee
Arthroplasty
Patient:
75 yr old male
Hx: osteoarthritis (pain, stiffness
and difficulty moving lt knee)
Meds at home: ASA,
Activity: walks 1 mile/day, rides
bike
Other: nil
What is the difference between OA
and RA?
Pre op
Blood Work (CBC, Electrolytes, ECG, UA, Bld
screen, clotting/bleeding times)
Xrays: Knee, chest?
Pre and post-op teaching
Discharge Planning
Pre Op health Teaching
Clinical Pathway
Deep breathing/coughing; incentive spirometer
Type of anesthetic, post op pain management
Practice the post op exercises (foot and ankle; static
quads; static gluts)
What to bring to the hospital
The morning of surgery…(NPO,meds, where to check in)
Dental work
Day of Surgery
NPO (morning meds with a sip of water)
IV started
Leg prep’ed
Surgery
PACU
Return to the unit
Vital signs
Back on the Unit
Pain
Assessment of Knee (dressing)
IV
Chest
Food
Bath
Family
Nausea/vomiting
Voiding
Days 1-3
Home Care
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Bathing
Anti Em stockings
Incision care
Dressing
Toileting
Getting on and off a chair
Stairs
Sexual activity
Driving a car
Avoid jarring or twisting of
Knee/hip
Who will visit? Physio, lab,
Things to avoid with a total hip
• NO hip bending (flexing) beyond 70
degrees (90)
• NO crossing legs
• NO rolling kneecap in
• Limit car rides x 6 weeks
• When sitting, including toilet:
• When sleeping:
• When walking/stairs: