Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN

MEDICAL AND SURGICAL NURSING Musculoskeletal System Lecturer: Mark Fredderick R. Abejo RN,MAN ______________________________________________________________________________________________
COMMON HEALTH PROBLEMS OF THE NEONATES AND INFANTS

DISEASES OF THE MUSCULOSKELETAL SYSTEM

I. COMMON HEALTH PROBLEMS OF THE NEONATES AND INFANTS DEVELOPMENTAL HIP DYSPLASIA (CONGENITAL HIP DYSPLASIA) CLUB FOOT (TALIPES DEFORMITIES) TORTICOLLIS (WRY NECK) II. COMMON HEALTH PROBLEMS OF THE CHILD DISORDERS OF BONE DEVELOPMENT A. FLAT FEET (PES PLANUS) B. BOWLEGS (GENU VARUM) C. BLOUNTS DISEASE (TIBIA VARA) D. KNOCK KNEES (GENU VALGUM) E. TOEING-IN (PIGEON TOE) F. LIMPS G. OSTEOGENESIS IMPERFECTA H. LEGG-CALV-PERTHES DISEASE (COXA PLANA) I. OSGOOD-SCHLATTER DISEASE J. SLIPPED CAPITAL FEMORAL EPIPHYSIS (COXA VERA) JUVENILE RHEUMATOID ARTHRITIS RICKETS

I.

CONGENITAL HIP DYSPLASIA Improper formation and function of the hip socket subluxation or dislocation of the head of femur acetabulum is either flattened or shallow SUBLUXATION femoral head is riding high in shallow acetabulum DISLOCATION femoral head out of acetabulum

III. COMMON HEALTH PROBLEMS OF THE ADOLESCENT SCOLIOSIS IV. COMMON HEALTH PROBLEMS OF THE YOUNG ADULT OSTEOGENIC SARCOMA V. COMMON HEALTH PROBLEMS OF ADULT RHEUMATIC DISEASES GOUT CARPAL TUNNEL SYNDROME DEGENERATIVE JOINT DISEASE

A.

ETIOLOGY 1. Unknown 2. Polygenic inheritance pattern 3. Uterine position (?) 4. Children of Mediterranean ancestry 5. 6x > in girls 6. Relaxin (?) 7. Unilateral 8. Socio-cultural 9. Manner of carrying infants SIGN AND SYMPTOMS Early detection is important 1. Affected leg shorter 1 knee lower: child supine, thigh flexed 90 Ortolanis sign Barlows sign Abejo

B.

VI. COMMON HEALTH PROBLEMS ACROSS LIFESPAN FRACTURE AMPUTATION 1 MS

Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN 2. 3. 4. Unequal number of skin folds on posterior thigh Prominence of trochanter Assessment of hip abduction during health maintenance visits (4-6 wks) h. Pavliks Harness adjustable chest halter that abducts legs method of choice for long term treatment reduces time interval for treatment to 3-4 wks

Ortolanis sign - Pull with click sound Barlows sign - Push back with click sound

C.

MANAGEMENT 1. Position hip into a flexed, abducted (externally rotated) position a. Traction b. Splints c. Halters d. Casts e. Pins to stabilize hips f. Multiple diapers (cloth) bulk separates legs frog-leg, externally rotated g. Hip abduction splint (Frejka) made of plastic and buckles keep splint in place at all times except when bathing/changing diapers firm pressure but caution vs. forcible abduction compromise of blood supply

i.

worn continually except when bathing assess skin under straps

Spica cast (6-9 months) if hip is fully dislocated or if with severe subluxation Bryants traction for 1 week assess hourly for circulatory constriction temperature and circulation in toes

good diaper care wash area w/ clear water A & D ointment Vaselin Desitin Padding edges of brace 2 Abejo

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN

II.

CLUB FOOT (TALIPES DEFORMITIES) 1/1000 children boys > girls polygenic inheritance pattern usually unilateral vs. pseudotalipes 2 to intrauterine position TRUE TALIPES (4 types): 1. Plantar flexion: (Talipes equinus) 2. Dorsiflexion 3. Varus 4. Valgus: Plantar flexion (Talipes Equinus) Foot lower than heel Dorsiflexion ( Talipes Calcaneus) heel lower than feet or anterior foot flexed toward anterior leg Talipes valgus foot turns out Talipes varus foot turns in

B.

MANAGEMENT 1. Cast application in overcorrected position; extends above knee 2. Frequent diaper changes prevent case soaked with urine/ meconium 3. Check the coldness & capillary refill 4. Circulatory compression change cast q1-2 weeks due to rapid growth 5. 6 weeks casting passive foot exercises 6. Denis Browne splints

7. III.

Surgery final option

TORTICOLLIS (WRY NECK) tortus twisted; collus neck congenital anomaly when sternocleidomastoid muscle is injured & bleeds during birth trauma delivery of shoulders head tilted to side of involved muscle; chin rotates to opposite side may not be immediately evident fibrous contraction age 1-2 mos. w/ thick mass over muscle

A.

ASSESSMENT 1. Early detection 2. Straighten all newborn feet to midline as part of initial assessment 3

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN C. BLOUNTS DISEASE (TIBIA VARA) retardation of growth of the epiphyseal line on the medial side of the proximal tibia (inside of the knee) bowed legs serious disturbance in bone growth

A.

MANAGEMENT 1. Parent to initiate passive stretching exercises & encourage infants to look in the direction of affected muscle, e.g. feeding position 2. If simple exercises not effective 1 year of age surgical correction followed by neck immobilizer 3. Adults Botox injections (not recommended for children)

COMMON HEALTH PROBLEMS OF THE CHILD

DISORDERS OF BONE DEVELOPMENT A. FLAT FEET (PES PLANUS) relaxation of the longitudinal arch of the foot; Normal newborn foot is flatter & proportionately wider than adults longitudinal arch rarely visible until child has been walking for months Assessment of Blounts disease X-ray shows medial aspect of the proximal tibia will show a sharp beaklike appearance Treatment of Blounts Disease: Osteotomy Bracing

Assess: ask child to stand on tiptoe visible longitudinal arch Exercises to strengthen Tiptoe walking 5-10 min Picking marbles w/ toes Sports shoes D. KNOCK KNEES (GENU VALGUM) opposite of Genu Varum medial surfaces of knees touch medial surfaces of ankle malleoli separated >3cm (7.5cm) children 3-4y/o; no treatment necessary

B. BOWLEGS (GENU VARUM) Lateral bowing of the tibia Malleoli are touching Medial surface of knees is >2in (5cm) apart Gradually corrects itself 2y/o If unilateral or worsening orthopedist

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN

E. TOEING-IN (PIGEON TOE) 2 foot, tibial, femoral or hip displacement awkward always falling over her feet

3.

INWARD FEMORAL TORSION Normal Internal rotation 30 Outward rotation 90 With Inward femoral torsion Internal rotation 90 No treatment required but w/ compensating tibial torsion

4 Cases of Toeing In: 1. METATARSUS ADDUCTUS turning in of forefoot heel has good alignment R/T Infants who sleep prone w/ feet adducted older children who watch TV kneeling, feet turned in >1year passive stretching exercises May require casts or splints Early detection & treatment before walking N

4.

DEVELOPMENTAL HIP DYSPLASIA

F. LIMPS may reflect serious bone or muscle involvement, e.g. CP, Osteomyelitis History: -- Pain measurement of leg length Range Of Motion growing pains (?) biphosphonates G. OSTEOGENESIS IMPERFECTA connective tissue disorder: fragile bone formation recurring pathologic fractures

2.

INWARD TIBIAL TORSION line drawn from anterior superior iliac crest through center of patella intersects 4th or 5th toe (normal = 2nd toe) No treatment required

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN

TYPE 1: Severe A.D. countless fractures related to birth trauma X-ray ribbon like or mosaic bone pattern blue sclera related to poor connective tissue formation TYPE 2: A.R. assoc deafness & dental deformities No treatment is curative preventive & safety measures Growth Hormone Calcitonin Biphosponates H. LEGG-CALV-PERTHES DISEASE (COXA PLANA) avascular necrosis of proximal femoral epiphysis related to unknown cause boys > girls peak incidence 4-8y/o unilateral but may be bilateral

J. SLIPPED CAPITAL FEMORAL EPIPHYSIS (COXA VERA) slipping of femur head in relation to neck of femur at the epiphyseal line Proximal femur head displaces posteriorly & inferiorly < preadolescence 2x African Americans 2x boys than girls more on obese & rapidly growing

Pain in hip joint w/ spasm & LOM Differential Diagnosis: Synovitis 1. Stage I: Synovitis stage 2. II: Necrotic stage 6-12 months 3. III: Fragmentation stage 1-2 yr 4. IV: Reconstruction stage Treatment for Legg Calve Perthes 1. NSAIDS 2. containment devices abduction braces, casts leather harness slings 3. reconstructive surgery osteotomy to center femoral head 4. in acetabulum cast JUVENILE RHEUMATOID ARTHRITIS collagen vascular disease; 1 involves joints also blood vessels and connective tissue symptoms before 16 y/o symptoms last longer than 3 months peak incidence: 1-3 y/o, 8-12 y/o slightly more common in girls acute changes rarely continue past 19 cause unknown probably autoimmune (+) ANA Some w/ genetic predisposition 6

I. OSGOOD-SCHLATTER DISEASE thickening and enlargement of tibial tuberosity resulting from microtrauma pain/swelling over tibial tubercle more during early adolescence Treatment: 1. Limiting strenuous physical exercises 2. Immobilization 6 wks 3. children

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN A. ASSESSMENT 1. persistent fever & rash joint involvement 2. medical diagnosis 3. Nursing Assessment: a. Effect on Individual & Family b. Self-care c. Ex: elevated toilet, Velcro strips d. Complications e. Ex: slit lamp examinations q6 months MANAGEMENT 1. - Long term illness a. Exercise b. Heat application c. Splinting d. Nutrition e. Medications 2. Exercise: Rationale to preserve muscle and joint function a. Daily ROM exercises b. Incorporate into dance routine or game c. Family participation d. Avoid excessive strain on joints Running Jumping Prolonged walking Kicking Shortened school day fatigue easily; start midmorning 3. Heat application: 4. Rationale reduces pain & inflammation, increases comfort & motion a. Warm water soaks 20-30 min b. Paraffin soaks for finger & wrists 5. Splinting: rarely prescribed because of more effective NSAIDS 6. Nutrition: Altered nutrition related to chronic pain a. GIT irritation NSAIDS b. Plan mealtimes 7. Medications c. Tolmetin d. Naproxen e. Ibuprofen f. Celecoxib less GIT irritation g. Rofecoxib h. NSAIDS: reduce/control pain & inflammation 6-8 wks Health teachings: GIT irritation (w/ meals) Give even if w/o pain to exert antiinflammatory action i. SAARDs (Slow Acting Anti-Rheumatic drugs) j. DMARDs (Disease Modifying Anti-Rheumatic drugs) Ex. Gold salts, Penicillamine, Hydroxychloroquinine k. Cytotoxic Drugs: side effects Cyclophosphamide Chlorambucil Methotrexate l. Steroids 7 MS Abejo

Nursing Diagnosis for Juvenile Rheumatoid Arthritis Deficient knowledge related to care necessary to control disease symptoms Health Teaching for Juvenile Rheumatoid Arthritis Active role in treatment Need for follow-up care Plan & schedule balance rest & exercise

B.

RICKETS disorder in which mineralization of organic matrix is defective assoc with Vit D deficiency or resistance growing skeleton; defective mineralization both in bones and cartilage vs. Osteomalacia mineralization disorder in adults in whom epiphyseal growth plates are closed Bowing deformities, knocked knees Stunting of growth of long bones Severe muscle weakness
A.

PATHOPHYSIOLOGY 1. Disorders causing alteration of Vit D nutrition or metabolism or phosphate wasting 2. Hypovitaminosis D 3. Inadequate prod. Vit D3 in skin 4. insufficient dietary supplementation 5. inability of small intestine to absorb Vit from diet 6. resistance to effects of Vit D drugs which interfere w/ Vit D action 7. anticonvulsants, glucocorticoids alteration in Vit D metabolism 8. Chronic renal failure 9. Intoxication cadmium, lead, expired tetracycline SIGN AND SYMPTOMS 1. Skeletal deformities children unable to walk 2. Susceptibility to fractures 3. Weakness & hypotonia 4. Growth disturbances 5. CRANIOTABES: soft calvariae, widening of sutures 6. RACHITIC ROSARY: prominence of costochondral junctions

B.

Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN 7. HARRISONS GROOVE: indentation of lower ribs at site of attachment of diaphragm family history = 30% but no specific inheritance pattern 5x more girls > boys Peak incidence 8-15 y/o Most marked during pre-puberty (rapid growth)

8. 9. 10. 11.

Bowing of tibia, femur, radius, ulna Flattening of pelvis Enamel defects Radiologic Features: Increased thickness of growth plate (physis) due to calcification & inadequate mineralization

C. TREATMENT

1. 2. 3.

Vit D2 (Ergocalciferol) 800-4000 IU Vit D3 (Cholecalciferol) (0.02-0.1 mg) daily for 612 wks followed by 200-600 IU daily Calcium supplements

A.

Uneven Shoulders Curve in Spine Uneven hips ASSESSMENT 1. Bra straps adjusted to unequal length 2. Difficulty buying jeans 3. Skirts & dresses hang unevenly 4. Bend forward 5. Scoliometer: reading >7 20 6. PPT 7. Chest Xray MANAGEMENT 1. Scoliosis (Long term) 2. <20 = no treatment; close observation until 18y/0 3. >20 = conservative non-surgical treatment, body brace, traction 4. >40 = surgery, spinal fusion 5. Bracing > 20 - 40 skeletally immature 6. Milwaukee brace (Thoracolumbar support) 7. worn under clothing 8. worn 23H/day 9. at night Charleston Bending brace 10. Milwaukee Brace

COMMON HEALTH PROBLEMS OF THE ADOLESCENT

I.

SCOLIOSIS lateral curvature of spine may involve all or only a portion of SC may be functional (2) or structural (1 deformity) I. FUNCTIONAL SCOLIOSIS II. STRUCTURAL SCOLIOSIS I. FUNCTIONAL SCOLIOSIS compensatory mechanism related to unequal leg length, EOR constantly tilt head sideways pelvic tilt related to unequal leg length & head tilt spinal deviation C shaped curve - little change in shape of vertebrae THERAPEUTIC MANAGEMENT of Functional Scoliosis 1. correct the difficulty causing spinal curvature 2. unequal leg length (as is to medial malleolus) 3. shoe lift 4. correct EOR 5. maintain good posture 6. sit-ups, pushups, swimming II. STRUCTURAL SCOLIOSIS idiopathic permanent curvature of spine accompanied By damage to vertebrae primary lateral curvature Thoracic convexity+ Compensatory second curve S-shaped curve appearance (rotation angulation) 8 MS
B.

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN
A.

11.

Braces 14 y/o 16 y/o

12. Halo Traction

ASSESSMENT 1. usually taller children (rapid bone growth) 2. pain & swelling at tumor site 3. History of recent trauma not the cause 4. Pathologic fracture 5. Diagnostic biopsy 6. alkaline phosphatase fm rapidly growing bone cells 7. Metastatic workup CBC, UA CXR Chest CT Scan Bone scan Therapeutic Management of Osteogenic Sarcoma 1. small tumor in leg child has reached adult size Surgical removal of bone + Bone or metal prosthesis If extensive total hip amputation lung managements thoracotomy - lobectomy, pneumonectomy 3. pre-op chemotherapy methotrexate cisplatin doxorubicin ifosfamide 4. present prognosis early detection 60-65% cure rate
2.

B.

C.

NURSING MANAGEMENT 1. Health teaching how to apply braces 2. Right fit 3. Adjustment q3mos

COMMON HEALTH PROBLEMS OF THE YOUNG ADULT

OSTEOGENIC SARCOMA malignant tumor of long bone involving rapidly growing bone tissue more commonly in boys > girls common sites Distal femur (40-50%) Proximal tibia (20%) Proximal humerus (10-15%) History of radiation Early metastasis 2 to vascularity of bones Lungs 25% brain, other bones Chronic cough Dyspnea Chest pains Leg pains

NURSING MANAGEMENT Post-op: swelling disrupting neurologic & circulatory function 2. proper position 3. monitor Capillary refill < 5s (-) numbness & tingling Warm, pink 4. Post-op: Phantom Pain Syndrome 5. Nerve trunks continue to report pain 6. Need analgesics!
1.

COMMON HEALTH PROBLEMS OF ADULT

I.

RHEUMATIC DISEASES Arthritis 1 affects skeletal MS, bones, cartilages, ligaments, tendons, joints of males & females of all ages. RHEUMATIC ARTHRITIS Inflammatory Arthritis 2-3x women > men Autoimmune reaction primarily occurs in synovial tissue
A.

PATHOPHYSIOLOGY 1. Phagocytosis produces enzymes within joint 2. Enzymes break down collagen 1. Edema 2. Proliferation of synovial membrane 3. Pannus formation Abejo

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN Destroys cartilage, erodes bones Loss of articular surfaces & joint motion Muscle degenerative s Tendon & ligament elasticity & contractile power lost
C.

3. 4.

Assessment & diagnostic of Rheumatoid Arthritis 1. Hx & PE Bilateral & symmetric stiffness Tenderness & swelling Temperature s in joints Extraarticular s 2. Rheumatoid Factor (+) 80% 3. ESR 4. RBC C4 & C4 complement 5. C Reactive proteins maybe (+) 6. ANA 7. Arthrocentesis: cloudy, milky, or dark yellow 8. X-ray: bone erosions, narrowed joint spaces

II.

GOUT

B. SIGNS AND SYMPTOMS

1. 2. 3. 4. 5. 6.

joint pain, swelling, warmth, erythema, lack of function joint fluid small joints in hands, wrists, hips, elbows, ankles, cervical spines, temporo-mandibular joint acute bilateral and symmetric joint stiffness in AM > 30min

Extra - Articular Manifestations of Rheumatoid Arthritis 1. fever, wt loss, fatigue, anemia, LN enlargement, Raynauds phenomenon, Arterities, Scleritis, Sjogrens pericarditis, splenomegaly 2. Rheumatoid nodules with Rheumatoid Factors 3. 50% of Patients 4. Usually non-tender & movable in subcutaneous tissues 5. Over bony prominences 6. May disappear spontaneously

heterogenous group of conditions related to genetic defect of purine metabolism hyperuricemia oversecretion of uric acid renal defect excretion of UA combination males > females incidence w/ age & Body Mass Index PRIMARY HYPERURICEMIA >7 mg/dl (0.4 fmol/L) usually faulty uric acid metabolism severe dieting or starvation food high in purines heredity SECONDARY HYPERURICEMIA cell turnover Leukemia Multiple myeloma Anemia Psoriasis Uric acid under excretion SE of drugs (thiazide & furosemides) Low dose salicylates PATHOPHYSIOLOGY 1. Hyperuricemia monosodium urate crystal deposition 2. Sudden or of serum acid levels 3. Inflammatory response 4. Tophi formation 5. great toe, hands, ear 6. Renal urate lithiasis 7. Chronic renal disease 8. IgG coating urate crystals immunologic Abejo

A.

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN Interrupts breakdown of purines before uric acid is formed Inhibits xanthine oxidase S.E. BM depression, vomiting, abdominal pain 10. Corticosteroids: Anti-inflammatory

B.

SIGNS AND SYMPTOMS 1. Acute Gouty Arthritis recurrent attacks of sever articular & periarticular inflammation 2. Tophi Crystalline deposits 3. Gouty Nephropathy 4. Uric Acid Calculi 5. Tophi in hand and ears

III.

CARPAL TUNNEL SYNDROME entrapment neuropathy; median nerve at the wrist is compressed by thickened flexor tendon sheath skeletal encroachment edema soft tissue mass

Stages of Gout a. Asymptomatic Hyperuricemia b. Acute Gouty Arthritis c. Intercritical Gout d. Chronic Tophaceous Gout 6. 7. 8. Metatarsophalangeal joint of big toe 75% of patients attack may be triggered by Trauma Alcohol Dieting Medications Surgical stress Illness Abrupt onset awakening patient at night Subdues within 3-10 days even w/o treatment Symptom free period (intercritical stage) Tophi also found in aortic walls, heart valves, etc Definite Diagnosis Polarized microscopy of synovial fluid Uric acid crystals (+) PMN Leukocytes
IV.

9. 10. 11. 12. 13.

repetitive hand activities also assoc w/ pregnancy, arthritis, hypothyroid characterized by pain & numbness, paresthesias, weakness along median nerve (thumb & 1st 2 fingers) (+) Tinels sign (+) Night pain Treatment for Carpal Tunnel Syndrome rest splints avoidance of repetitive flexion NSAIDs Cortisone injections Laser release

C.

MANAGEMENT 1. Colchicine, NSAIDs treatment of acute attack 2. Then management of Hyperuricemia after inflammatory process has subsided 3. Colchicine 4. lowers deposition of uric acid & interferes w/ leukocytes & kinnin formation, thus reducing inflammation 5. Does not alter serum or urine levels of uric acid, used in acute and chronic mgt. 6. administer until pain relief or diarrhea 7. prolonged use Vit B12 absorption, GI upset 8. Probenecid:Uricosuric agent Inhibits renal reabsorption of urates urinary excretion of UA Prevents tophi formation S.E. nausea, rash, constipation 9. Allopurinol: Xanthine oxidase inhibitor

DEGENERATIVE JOINT DISEASE (Osteoarthritis) functional impact on quality of life primary (idiopathic) no prior event/disease secondary: r/t previous joint disease or inflammatory disease increasing age often begins 34d decade peaks between 5th and 6th decade by age 75- 85 % either xray or clinical evidence But is 15-25% with significant symptoms ability of articular cartilage to resist microtrauma
A.

RISK FACTORS 1. increased age wear and tear 2. obesity 3. previous joint damage 4. repetitive use (occupational or recreational) 5. anatomic deformity Abejo

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN 6. 7. 8. 9. 10.
B.

genetic susceptibility congenital sublaxation-dislocation of hip acetabular dysplasia Legg-Calves Perthes slipped capital femoral epiphysis

D.

SIGNS AND SYMPTOMS 1. pain 2. stiffness 3. functional impairment 4. PAIN inflammation of synovium 5. inflammation of nerve endings in periosteum over osteophytes 6. stretching of joint capsules or ligaments 7. trabecular microfracture 8. intraosseous hpn 9. bursitis 10. tendinitis 11. muscle spasm 12. STIFFNESS morning or after awakening<30 min/ decreases with movement

ASSESSMENT 1. Physical Exam 2. tender and enlarged joints 3. X-Ray 4. 30-50% progressive loss of joint cartilage narrowing of joints spaces 5. spur=ostephyte formation -> cartilage attempts to regenerate MEDICAL MANAGEMENT of Osteoarthritis 1. Preventive measures to slow progress b. weight reduction c. prevention of injuries d. joint rest e. perinatal screening (congenital hip dysplasia) f. ergonomic modification 2. Conservative Measures to Slow Progress of Osteoarthritis a. use of heat b. weight reduction c. joint rest d. avoidance of joint overuse e. orthostatic devices (splints, braces) f. isometric and postural exercises g. aerobic exercises h. OcTherap and PhysTher SURGICAL MANAGEMENT 1. use of heat 2. weight reduction 3. joint rest 4. avoidance of joint overuse 5. orthostatic devices (splints, braces) 6. isometric and postural exercises 7. aerobic exercises 8. OcTherap and PhysTher 9. Osteotomy- to alter the force distribution of the joint 10. Arthroplasty- to replace diseased joint compnonents 11. Viscosupplemetation-reconstitution of joint fluid viscosity using hyaluronic acid 12. (Hyalgan, Synvise Rx) 13. Tidal Lavage of Knee stimulate production of synoviocytes 14. Approximately 6 months pain relief NURSING MANAGEMENT 1. Pain management 2. Optimizing functional ability 3. Pt referral 4. Lifestyle changes 5. Planning daily activities

E.

F.

C.

PATHOPHYSIOLOGY
Mechanical injury Others Chondrocyte response Release of cytokines Stimulation, production and release of proteolytic enzymes, metalloproteases, collagensase Resulting damage predisposes to more,,, Previous joint damage

Genetic and hormonal factors

G.

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN 14. Open, Compound, Complex skin or muscle extends thru fractured bone COMMON HEALTH PROBLEMS ACROSS LIFESPAN

I.

FRACTURE FRACTURE- break in the continuity of bone and adjacent structures soft tissue edema hemorrhage into muscles and joints joint dislocation ruptured tendons severed nerves damaged blood vessels body organ damage secondary to force or fracture fragments Types of fractures 1. Complete break across entire cross section of bone (displacement) 2. Open, Compound, Complex skin or muscle extends thru fractured bone a. Grade I clean wound <1cm b. Grade II larger wound without extensive soft tissue damage c. Grade III highly contaminated d. Compressed bone has been compressed (ie. Vertebral fractures) 3. Depressed- fragments driven inwards e. (ie. Skull and facial bones) 4. Epiphyseal- fracture thru epiphysis 5. Impacted- bone fragment is driven thru another bone fragment 6. Pathologic- occurs thru an area of diseased bone 7. Stress- results from repeated loading without bone and muscle recovery 8. Incomplete (greenstick) break thru only part of cross section of bone 9. Transverse-fracture straight across the bone 10. Closed (simple)- no break in skin

A.

CLINICAL MANIFESTATIONS 1. pain 2. loss of function, abnormal movement 3. deformity: displacement, angulation, rotation, swelling VISIBLE or PALPABLE 4. shortening- 2.5-5cm r/t contraction of muscles 5. crepitus grating sensation 6. swelling and discoloration MANAGEMENT OPEN FRACTURE 1. cover wound with a clean / sterile dressing 2. do not attempt to reduce fracture 3. ASSESS NEUROVASCULAR STATUS DISTAL TO INJURY MEDICAL MANAGEMENT 1. Reduction setting the bone 2. restore the fracture fragments to anatomical alignment and rotation OPEN CLOSED 3. early Fracture reduction, gentle manipulation 4. Nursing consideration written consent / analgesia CLOSED REDUCTION -bring bone fragments into apposition (ends in contact) via a. manipulation b. traction and counter traction (thru patients weight and bed position) c. splint or cast d. x-rays e. traction (skin or skeletal) for fracture reduction/ for fracture immobilization

B.

C.

11. Oblique occur at an angle across the bone (less stable than transverse) 12. Comminuted one that produces several bone fragments 13. Spiral fracture that twists around shaft of bone 13 MS

PRINCIPLES OF TRACTION 1. traction must be continuous to be effective 2. skeletal muscle traction is never interrupted 3. do not remove weights unless intermittent is prescribed 4. eliminate any factor that reduces effective pull or alter resultant line of pull good body alignment in center of bed ropes unobstructed weights should hang free

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN 5. 6. 7. knot in rope or footplate must not touch pulley or foot of bed VECTOR OF FORCE RESULTANT LINE OF PULL Types of Traction 1. Straight or running traction 2. balanced suspension traction 3. skeletal 4. skin: traction tape/foam boot 5. manual 6. SKELETAL TRACTION 7. BUCKS EXTENSION TRACTION OPEN REDUCTION (ORIF) Open reduction internal fixation
D.

EARLY COMPLICATIONS SHOCK FAT METABOLISM SYSTEMIC EMBOLIZATION

SHOCK

hypovolemia, traumatic shock leads to blood loss and ECF extracellular fluid -restore blood volume and circulation -pain relief -splint -protect from other injuries

NURSING MANAGEMENT 1. encourage patient to return to usual activity as rapidly as possible 2. teach patient to control selling and pan 3. teach exercises, use assistive devices 4. environmental modification 5. self-care, medications, potential complications 6. open fracture a. prevent infection (monitor) b. delayed closure (5-7 days) c. bone grafting (4-8 weeks to bridge defects)

FRACTURE HEALING AND COMPLICATIONS

Factors that Enhance Fracture Healing 1. immobilization of fracture fragments 2. maximum bone fragment contact 3. sufficient blood supply 4. nutrition 5. exercise: weight bearing for long bones 6. Hormones: GH, Thyroid, Calcitonin, Vit. D. anabolic Steroids 7. electric potential across fracture Factors that Inhibit Fracture Healing 1. extensive local trauma 2. bone loss 3. inadequate mobilization 4. space between fragments 5. infection 6. local malignancy 7. Metabolic bone disease (ie. Pagets disease) 8. irradiated bone (radiation necrosis) 9. avascular necrosis 10. intra-articular fracture (synovial fluid contains fibrolysis, which lyse initial clot and retard clot formation) 11. age 12. steroids 13. flat bones heal rapidly (pelvis, scapula) 14. fx at ends of ling bones heal rapidly than midshaft fracture more vascular and cancellous 15. weight bearing stimulates healing of stabilized fractures 14

FAT METABOLISM -usually young adults (20-30%) and elderly adults with fracture proximal femur fat globules blood As marrow pressure > capillary pressure secondary to increase catecholamines mobilization of fatty acids Occlude small blood vessel lungs, brain, kidney, etc. usuall approx. 24-48 degrees ~ week after injury Hypoxia, tachypnea, pyrexia Dyspnea, crackles, wheezes Chest pain, thick white sputum, tachycardia r/t increase pulmonary pressure ABG PaO2 < 60 mmHg Respiratory alkalosis ~ respiratory acidosis Chest XRay: Snowstorm infiltrates ~> pulmonary edema. AARDS, CHF CNS: r/t fat emboli in brain and hypoxis SYSTEMIC EMBOLIZATION pale thrombocytopenia- petechiae hyperpyrexia (39.5C) fat emboli kidney failure PREVENTION 1. immediate immobilization 2. minimal fracture manipulation 3. adequate support 4. fluid and electrolyte 5. prompt invitation of respiratory support- high oxygen MANAGEMENT 1. respiratory support controlled volume ventilation PEEP (positive expiratory e pressure) 2. prevents respiratory and metabolic acidosis 3. steroids- inflammatory lung reaction and cerebral edema 4. vasoactive meds 5. accurate fluid Input and Output 6. morphine 7. nursing reassurance

1.

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN EARLY COMPLICATIONS: Compartment Syndrome Tissue Perfusion < tissue viability Signs and Symptoms unrelenting pain resistant to opioids r/t reduction in size of muscle compartment because enclosing muscle fascia is too tight or constricting cast or dressing increase in muscle compartment because of edema or hemorrhage Esp. forearm, leg muscle decrease microcirculation nerve, muscle anoxia necrosis Loss of function > 6 hours BONE GRAFT osteogenesis-bone formation occurs after transplantation of bone containing osteoblasts osteoconduction-provision by graft of structural matrix for ingrowth of blood vessels and osteoblasts osteoinduction-stimulation of host stem cells to differentiate into osteoblasts b several growth factor including bone morphogenic proteins autograft- tissue harvested from the donor to the donor Allograft: tissue harvested from donor other than the person who will receive the tissue Healing= 6-12 months Problems: 1. Wound or graft infection 2. Graft fracture 3. Non-union 4. Partial acceptance 5. Graft rejection 6. Transmission of disease (rare) Electrical Bone Stimulation Modifies tissue environment making it electronegative enhances mineral deposition and bone formation Non-invasive inductive coupling Pulsing electromagnetic field delivered to fracture approximately 10 hours each day with electromagnetic coiled over non-union site 3-6 months

Assessment and Diagnostic findings 1. paresthesis early sign 2. motor weakness: late sign of nerve ischemia 3. paralysis nerve damage Assessment of peripheral circulation 1. color- cyanotic- venous congestion, 2. pale, cold 3. prolonged capillary refill 4. decrease arterial perfusion 5. pulselessness if with arterial occlusion, not compartment syndrome 6. Doppler ultrasound 7. Pain 8. Hypoesthesia 9. Anesthesia 10. Nerve tissue pressure = 8 mmg Hg or less Compromised = 30 mmHg MEDICAL MANAGEMENT of Compartment Syndrome 1. elevate above level of heart 2. release restrictive dressings 3. if unsuccessful fasciotomy 1 hour 4. splint and elevate 5. Passive range of motion Q 4-6Hours 6. Deep vein thrombosis 7. Thromboembolism 8. Pulmonary Embolism 9. DIC

NURSING MANAGEMENT 1. Provide emotional support and encouragement 2. encourage compliance 3. pain management 4. monitor for signs and symptoms of infection 5. health teaching-reinforcement 6. Immobilization

REACTION TO INTERNAL FIXATION DEVICES 1. usually not removed unless with symptoms 2. pain and decreased function 3. mechanical failure: inadequate insertion and stabilize 4. material failure 5. corrosion 6. allergic reaction 7. osteoporotic remodeling adjacent to fixation device r/t disuse osteoporosis COMPLEX REGIONAL PAIN SYNDROME (CRPS) reflex sympathetic dystrophy (RSD) upper extremity > women painful sympathetic nervous system problem CLINICAL MANIFESTATIONS of Complex Regional Pain Syndrome 1. severe burning pain 2. local edema 3. hyperesthesia 4. stiffness 5. discoloration 15 Abejo

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Medical and Surgical Nursing Musculoskeletal Disorder Prepared: Mark Fredderick Abejo RN, MAN vasomotor changes trophic changes NURSING DIAGNOSIS of AMPUTATION acute pain r/t amputation Risk for disturbed sensory perception: phantom limb pain r/t amputation impaired skin integrity r/t surgical amputation disturbed body image r/t amputation of body part self-care deficit r/t loss of extremity impaired physical mobility r/t loss of extremity NURSING INTERVENTION after Amputation 1. PAIN RELIEF opioid analgesics non pharmaceutical evac of hematoma / fluid counteract muscle spasm may be expression of grief 2. Minimizing altered sensory perceptions phantom limb approx. 2-3 months post-op acknowledge feelings keep patient active early intensive rehab and stump desensitization with kneading massage distraction activities 3. TENS (transcutaneous electrical stimulation) 4. Ultrasound 5. local anesthetics 6. identify patients strength and resource to facilitate rehab 7. help patient resolve grieving 8. promote independent self-care 9. help patient achieve physical mobility

Management of Complex Regional Pain Syndrome 1. -elevation 2. -immobility device with greatest ROM 3. -pain control 4. -NSAIDS 5. -Steroids 6. -anti-depressants 7. -avoid BP and venipuncture

AMPUTATION removal of body parts (extremity) peripheral vascular disease * folminating gas gangrene trauma-crushing, frostbite, electrical malignant tumor chronic osteomyelitis

LEVEL OF AMPUTATION 1. circulation 2. functional usefulness (prosthesis)

COMPLICATIONS OF AMPUTATION 1. hemorrhage 2. infection 3. skin break down 4. phantom limb: r/t severing of peripheral nerves 5. joint contracture: r/t positioning and protective flexion withdrawal pattern associated with pain and muscle imbalance MEDICAL MANAGEMENT of Amputation 1. Objective healing of amputation wound Non-tender stump health skin for prosthesis 2. 1. gentle handling of stamp 3. 2. control of edema by rigid or soft compression dressings 4. 3. use of aseptic technique in wound care 5. CLOSED RIGID CAST DRESSINGS: uniform compression for support soft tissues, control pain and prevent joint contractures 6. SOFT DRESSINGS- if there is significant wound drainage require frequent inspection 16 MS Abejo