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Orthopedic Nursing UNIVERSITY OF LA SALETTE COLLEGE OF NURSING SANTIAGO CITY ORTHOPAEDIC NURSING Prepared by: Virgilio Dimalanta-Ganadin Jr. RN 1

Orthopedic Nurs1 CDN

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Orthopedic Nursing

UNIVERSITY OF LA SALETTECOLLEGE OF NURSING

SANTIAGO CITY

ORTHOPAEDIC NURSING

Prepared by:

Virgilio Dimalanta-Ganadin Jr. RN

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Orthopedic Nursing

ORTHOPEADIC NURSING

Orthopedic nurses care for patients of all ages with actual and potential musculoskeletal injuries and conditions. An orthopedic nurse may provide assessments and educate patients about braces, prosthetics and other orthopedic equipment. Orthopedic nurses must have the ability to relate well to other people, be considerate of their conditions and be able to communicate with patients in understanding their anxieties and fears.

Orthopaedic nursing is a nursing specialty focused on the prevention and treatment of musculoskeletal disorders. Orthopaedic issues range from acute problems such as fractures or hospitalization for joint replacement to chronic systemic disorders such as loss of bone density or lupus erythematosus.

Orthopaedic nurses have specialized skills such as neurovascular status monitoring, traction, continuous passive motion therapy, casting, and care of patients with external fixation.

Meet the Orthopedic TeamOrthopedic patients at Greenwich Hospital will receive care from a highly skilled orthopedic

team.

Orthopedic surgeons who perform patient admission assessments and the surgery examine the patient's progress every day and are on call 24 hours a day. Surgery takes place in state-of-the-art orthopedic surgery rooms.

Orthopedic nurses are specially trained to care for orthopedic patients. Many orthopedic nurses are involved in the National Association of Orthopedic Nurses and have received national orthopedic certification. All registered nurses, licensed practical nurses, and nursing assistants must complete a rigorous orthopedic training program, created in collaboration with physicians.

During surgery, surgeons are assisted by orthopedics nurses and dedicated orthopedic technicians. Skilled physician assistants provide surgical support and perform follow-up care in the hospital and back in the doctor's office.

An anesthesiologist, a physician who administers anesthesia and pain medication, monitors the patient during surgery. The anesthesiologist also makes arrangements for pain medications after surgery to keep the patient comfortable.

After surgery, physical therapists play an important role in recovery while the patient is still in the hospital and then on an outpatient basis. They help patients regain movement and teach them special techniques that help them get out of a bed, a chair or car and walk up and down stairs.

Occupational therapists teach patients how to use adaptive devices that make them more independent in performing tasks of daily living, such as getting dressed.

Social workers can help families make decisions about the type of care required after leaving the hospital. They can also help with emotional, financial, and family issues.

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Orthopedic Nursing A home care coordinator - a nurse who works with patients and families - develops an

appropriate plan of care to be delivered in the patient's home if indicated.

Respiratory therapists, pharmacists and dietitians round out the orthopedic team.

After SurgeryFollowing surgery, patients with hip, knee or shoulder replacement spend several nights in the

hospital. The orthopedic team continues to assess patient progress around the clock. Physical therapy may begin as early as the day of surgery.

Leaving the HospitalWhile some patients go home after surgery, others benefit from a stay in a rehabilitation hospital.

Physical therapy also continues after discharge, either at a physical therapy center or in the home, and continues on an outpatient basis for several weeks following surgery. During this time, the patient will be seen by the orthopedic surgeon at regular intervals to monitor the patient's recovery and progress.

The education and planning that occurs before surgery, combined with expert hospital care and skilled follow-up treatment, will put the patient on the road to a healthy recovery and more active and comfortable lifestyle.

“MUSCULOSKELETAL SYSTEM”

It is composed of various connective tissues, bones, muscles, cartilage, tendon, and ligament. The joint articulation of two or more bones represents the functional unit of the system

It can be divided into: Skeletal System (bones) Articular System (joints) Muscular System (muscles)

SKELETAL SYSTEM

The adult skeletal system consist of framework of approximately 206 bones arranged to form a strong, yet flexible,body framework and their associated connective tissues,cartilage,tendons and ligaments.

At birth the skeleton consist of about 270 bones.Bone development (ossification) occurs during infancy the number increases During adolescence,however the number of bones actually decreases as separate bones gradually fuse.

Osteology-the study of bones.

FUNCTIONS OF THE SKELETON

1. SUPPORT-The skeleton forms a framework that supports the softer tissues and organs of the body.

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Orthopedic Nursing2. PROTECTION-The skull vertebral column enclose the brain and spinal cord; the rib cage protects

the heart,lungs, great vessels, liver,and spleen;and the pelvic girdle supports and protects the pelvic viscera

3. BODY MOVEMENT-Bones acts as levers (with the joints functioning as pivots when muscles contract to cause body movement.

4. HEMOPOIESIS-It is the process of blood formation.It takes place in tissue called the red bone marrow located in the center of some bones.In an infant,the spleen and liver produce red blood cells, but as the bones mature,the bone marrow takes over this function.

5. MINERAL STORAGE-The inorganic matrix of bone is composed primarily of minerals calcium and phosphorus which gives its firmness and strength

DIVISIONS OF THE SKELETON

1. AXIAL SKELETON- It consists of the bones that form a vertical axis of the body and that supports and protects the organs of the head, neck, and trunk.

2. APPENDICULAR SKELETON-It is composed of the bones of the upper and lower limbs and the bony girdles that anchor the limbs to the axial skeleton.

SHAPES OF BONES

FOUR PRINCIPAL CATEGORIES1. Long bones-are longer than they are wide and function as a levers.(e.g. the

humerus,tibia,metacarpal bones,phalanges)2. Short bones-are cube-shaped and are found in tight spaces where theytransfer forces of

movement (e.g. the carpal and tarsal bones)3. Flat bones-have broad,dense surface for muscle attachment or protection of underlying organs

(e.g.bones in the cranium, the ribs, and the scapula)4. Irregular bones- have varied in shape and have many surface markings for muscle attachment

or articulation (e.g. the vertebrae and certain bones of the skull.

BONE GROWTH

Bone growth is an orderly process determined by genetics, diet and hormonesIn the adult, bone remodeling is a continual process involving osteoclasts in bone resorption and

osteoblasts in forming new bone tissue.

Osteoblast-are bone- forming cells that synthesize and secrete unmineralized ground substance.They are abundant in areas of high metabolism;for example under the periosteum and bordering the medullary cavity.

Osteocytes-are mature bone cells derived from osteoblast that deposit minerals around themselves.It maintains healthy bone tissue by secreting enzymes and influencing bone mineral content.They also regulate the calcium release from bone tissue to blood.

Osteoclasts-are large multinuclear cells that use enzymes to break down bone tissue.

ARTICULATIONS OR JOINTS

It permits movement of the body.The place of union or junction between two or more bones of the skeleton especially one that

admits of motion of one or more bones

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Orthopedic NursingCLASSIFICATION OF JOINTS Fibrous Joints-the bones are held together by fibrous connective tissue.These joints have no

joint cavities.

Cartilaginous Joints-the bones are held together with the cartilage.These joint also lack joint cavities.

Synovial Joints-have cartilage covering the articulating bones and ligaments that help to hold the joints together.These joints have fluid joint cavities.

Kinds of bony unions Synarthrosis- immovable e.g. sutures of the skull Amphiarthrosis-slightly movable e.g. interpubic joint symphysis pubis, intervertebral joints Diarthrosis-freely movable or true joints

FUNCTIONS OF FREELY MOVABLE JOINTS Abduction Adduction Circumduction

Extension Flexion External rotation

Internal rotation Supination Pronation

CARTILAGE

TYPES: Hyaline: pearly, blue cartilage covering articular bone surfaces Fibrocatilage: white, tough fibrous tissue found in knee Yellow: elastic, fibrous cartilage found in larynx, external ear

FUNCTIONS:1. Absorption of weight, shock, stress and strain2. Protecton of bones, joints and joint tissue

FUNCTIONS OF A MUSCLES

1. Motion- is to move the body or parts of the body, as in walking, writing, chewing and swallowing.2. Heat production - as an individual exercise the rate of heat production increases.3. Posture and Body support - The skeletal system provides a framework for your body , but as a

skeletal muscles maintain your posture and provide support around the flexible joints

The skeletal muscle system includes: Fasciculi: bundles of muscle fibers covered with connective tissue Muscle sheaths: connective tissue covering groups of muscle bundles

LIGAMENTS AND TENDONS

Ligaments are strong connective tissue binding bones. Provide joint stability and allow restricted joint movement.

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Orthopedic Nursing Tendons are strong, fibrous, nonelastic connective tissue extending from muscle sheaths. It binds

muscles to bones. Prepare the client for surgical repair in severe injury.

MUSCULOSKELETAL ASSESSMENT

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Inspection1. Inspect the upper and lower

extremities for size, symmetry, and deformity, and muscle mass.

2. Inspect the joints for range of motion (in degrees), enlargement, redness.

3. Note gait and posture; observe the spine for range of motion, lateral curvature, or any abnormal curvature.

4. Observe the patient for signs of pain during the examination.

For the purpose of this text, it is sufficient to say that during examination, the examiner should not find any compromise or restriction of the patient’s activities of daily living or any other normal activities. If any activity is restricted because of muscular or skeletal problems, the reader is referred to a more detailed text on physical examination.

Palpation1. Palpate the joints of the upper and

lower extremities and neck for tenderness, swelling, temperature, and range of motion

2. Hold the palm of the hand over the joint as it moves, or move the joint through the fullest range of motion and note any crepitation (crackling feeling within the joint).

3. Palpate the muscles for size, tone, strength, and tenderness.

4. Palpate the spine for bony deformities and crepitation. Gently tap the spine with the ulnar surface of your fist from the cervical to the lumbar region and note any pain or tenderness.

Technique Findings

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A. ASSESS NEEDS

The first step is to assess the patient’s needs by using an evaluation process that gathers subjective information and objective data about the patient and the problem.

1. Subjective information (case history) Ask questions to get the patient to:

a. Describes how he perceives his symptoms. Establish the location, type, and nature of the pain or symptoms. Determine if the pain and symptoms fit into the pattern related to segmental reference zones,

nerve root patterns, or extrasegmental reference patterns such as dural reference, myofascial pain patterns peripheral nerve patterns, or circulatory pain.

b. Describe the behavior of the symptoms through a 24-hour period. Identify which motions or positions cause and influence the symptoms. Determine how severe or how limiting the problem is. Determine how irritable the problem is by how easily the symptoms are evoked and how long

they last.c. Briefly describe his general health, medications being taken, and whether any x-ray studies have

been done.d. Describe any previous history of the condition. Find out if there nhas been previous treatment for

the problem and what the results of the treatment were.e. Describe related history, such as any medical or surgical intervention. Determine whether the

problem affects the patient’s occupation, family, social life, or other environmental situations.

2. Objective data (the clinical evaluation)Systematically administer tests that will define the anatomic structure(s) involved and the

functional limitations of the patient.

A. InspectionMake observations of activities and appearance of the body parts. Evaluate:(1) ADL such as gait; patient’s ability to sit, stand, or dress himself; and general ease of

movement.(2) Use of any adaptive aids.(3) Posture(4) Shape of body parts such as contour changes, swelling, atrophy, hypertrophy and asymmetry.(5) Appearance of skin, such as scars and discoloration.

B. FunctionUse the principle of selective tension by administering specific tests in a systematic

manner to determine if the tension is within an inert structures (joint, capsule, ligaments, bursae, fascia, dura mater, and dural sheaths around nerve roots) or a contractile unit (muscle with its tendons and attachments). Additional joint integrity tests are used to verify problems within the joints. Then, if possible identify the anatomic structure involved and its state of pathology so that an appropriate therapeutic exercise program can be designed. Functional tests include:

(1) Active Range of Motion (ROM)The patient is asked to move the body parts related to the symptoms through their

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ROM. From the way he moves and the amount of motion, determine if the patient is able and willing to move the part. Since both contractile and inert structures are influenced by active motion, specific problems are not isolated. Anything abnormal in the movement, any experience of pain, or any changes in sensation are noted.

(2) Passive Range of MotionThe same movements that the patient did actively are repeated passively. When the

end of the availablerange is reached, pressure is applied in order to get a feel of the resistance of the tissue; the pressure is called OVERPRESSURE and the feel is called END-FEEL. With the muscles relaxed, only inert structures are being stressed. Note if any of the tests provoke the patient’s symptoms.a. Measure the ROM and compare it with the active ROM. Determine if the limitation

follows pattern of restriction typical for that joint when a joint problem exists.b. Describe the end-feel (the feel the evaluator experiences at the end of the range when

overpressure is applied). Describe if the feel is soft (related to compressing or stretching soft tissues), firm (related to stretching joint capsules and ligaments), or hard (related to bony block), or if there is no end-feel (empty) because the patient will not allow movement to the end of the available range (related to an acutely painful condition in which the patient inhibits motion). Decide if the end-feel is normal or abnormal for the joint.

Abnormal end-feels include:

Springy (intra-articular block such as a torn meniscus or articular cartilage) Muscle guarding (involuntary muscle contraction in response to acute pain) Muscle spasm (prolonged muscle contraction in response to circulatory and

metabolic changes) Muscle spasticity (increased tone and contraction in muscle in response to CNS

influences) Any end-feel that is different than normal for that joint, or at a different part of the

range than normal for the joint being tested.

c. Determine the stage of pathology by observing when pain is experienced relative to the ROM. Is the pain or muscle guarding experienced before the end-feel (acute), concurrent with the end-feel (subacute), or after application of overpressure (Chronic).

d. Determine the staboloty and mobility of the joint. Record, using the following grades:Ankylosed 0Hypomobile

Considerable limitation 1Slight limitation 2

Normal 3Hypermobile

Slight increase 4Considerable increase 5Unstable 6

e. Note if there is a painful arc, which is pain experienced with either active or passive

motion somewhere within the ROM. It indicates that some sensitive structure(s) is being

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pinched during that part of the ROM. Sometimes pain-sensitive structures are pinched at the end of the range. This is not a painful arc, although such pain should be noted.

(3) Joint Integrity TestsThese are passive tests, used to rule out or confirm joint capsule lesions prior to testing

for muscle (contractile) lesions. The tests include:a. Traction

Separate the joint surfaces and note if the pain increases or decreases and how easily the bone moves apart.

b. CompressionApproximate the joint surfaces and note if the pain increases or decreases. If the

pain increases, the compressive force of muscle contraction may also caused increase pain. The source of the pain then is known to be some structure within the joint and not a muscle lesion.

c. Gliding Glide one of the joint surface on the other and note the quality and quantity of the

joint movement (how easily the bones move and whether or not the joint movement causes pain).

(4) Resisted TestsResist the related muscles so that they contract isometrically in mid-range in order to

determine if there is pain or decreased strength in the contractile units. Mid-range isometric contractions are used so that there is minimal movement or stress to the noncontractile structures around the joint.

Initially the tests are performed on groups of muscles; then are a problem is noted, each muscle potentially involved is isolated and tested.

C. PalpationPalpate, if possible, structures that are incriminated as the source of the problem(s).

Usually palpations are best done after the functional tests in order not to increase the irritability of the structures prior to testing. Include:

(1) Skin and subcutaneous tissue; note temperature, edema, and texture.(2) Muscles, tendons, and attachments; note tone, tenderness, trigger points, and

contractures.(3) Tendon sheathes and bursae; note tenderness, texture and crepitus.(4) Joints; note effusion, tenderness, changes in position or shape, and associated areas

such as ligaments.(5) Nerves and blood vessels; note presence of neuroma and pulse.

D. Neurologic testsAny indication of motor weakness or change in sensation directs the evaluator to specific

tests to determine nerve, nerve root, or CNS involvement. Evaluate:(1) Key muscles

Determine strength and reflexes of muscle related to specific spinal levels and nerve patterns.

MRC (Medical Research Council) grading scale for muscle power

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0 No muscle power1 Flicker of activity2 Movement with effect of gravity eliminated; i.e. in a plane at right angle to

gravity but not against resistance3 Movement against gravity but not against applied resistance.4 Movement against applied resistance but not less than full power5 Normal power

(2) Motor ability

Determine central versus peripheral control of muscles.(3) Sensory Testing

Note changes in temperature, perception, superficial and deep pressure, pain patterns, and proprioception.

(4) Nerve TrunkDetermine if there is pain or pressure or stretching of the trunks.

(5) Cranial Nerve Integrity

E. Additional Testsa. Special Tests, unique to the specific tissue in each region, are carried out if necessary in order

to confirm to rule out the structures in question.b. Tests performed by physicians or other health care personnel may be necessary to identify

the source of referred pain patterns and medical disorders.F. Diagnostic Procedures:

1. X-rays

2. Computed Tomography Scan- it is helpful in identifying the location and extent of fractures in areas difficult to define like acetabulum.

3. Magnetic Resonance Imaging (MRI)

4. Angiography- is the study of the vascular structures. It is useful for determining arterial perfusion and aids in determining the amount of an extremity that must be amputated.

5. Digital Subtraction Angiography (DSA)- uses computer technology to demonstrate the arterial system from a venous catheter access.

6. Myelography- the injection of contrast medium into the subarachnoid space of the lumbar spine, carried out to determine disc herniation, spinal stenosis (narrowing of the spinal canal, or the site of tumor.

7. Arthrography- it is useful in identifying acute or chronic tears of the joint capsule, or supporting ligaments of the knee, shoulder, ankle, hip, or wrist.

8. Arthrocentesis- is carried out to obtain synovial fluid. Normally, synovial fluid is clear, pale, and straw-colored, and scanty in volume. For RA and other inflammatory arthropathies it will reveal the presence of hemarthrosis (bleeding into the joint capsule), which suggests trauma or a tendency to bleed.

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9. Arthroscopy- complications: infection, hemarthrosis, thrombophlebitis, stiffness and delayed wound healing.

10. Bone scan

11. Thermography- measures the degree of heat radiating from the skin surface.

12. Electromyography- provides information about the electrical potential of the muscles and the nerves leading to them. The purpose of this procedure is to determine any physiological abnormality of a motor unit; the stimuli are recorded on an oscilloscope.

13. Single or dual Photon Absorptiometry- are noninvasive tests to determine bone mineral content at the wrist nor vertebrae. Osteoporosis may be monitored with this type of densitometry.

14. Bone biopsy- may be performed to determine the structure and composition of bone tissue, which may be helpful in diagnosing specific diseases. The biopsy site must be monitored for bleeding.

G. Laboratory studies:

1. Examination of the patient’s blood and urine

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SPRAINS AND STRAIN

A. Sprain - a complete or incomplete tear in the supporting ligaments surrounding a joint.

ETIOLOGY:Result from a wrenching or twisting motion that disrupts the stabilizing action of ligaments;

common locations include the ankle, knee, wrist, thumb, shoulder, neck and lower back.

MANIFESTATIONS:a. Pain and discomfort especially on joint movementb. Swelling possible ecchymosesc. Decreased joint motion and functiond. Feeling of joint looseness with severe sprain

MANAGEMENT FOR SPRAIN Elevate or immobilize the affected joint and apply ice pack immediately. Assist with tape, splint or cast application as necessary. Instruct with use of assistive device (e.g crutch) in indicated. Prepare for surgical repair if severe and if indicated. Instruct the client in prescribed weight bearing activities and activity restrictions. Instruct the client on how to take prescribed analgesics ( take as soon as pain starts; may cause

drowsiness). Elevate affected extremity. No weight bearing on affected extremity Apply cold and warm compress. X-ray exam to check bone injury

B. STRAIN- Is an overstretching injury to a muscle or tendon.

ETIOLOGY:Typically result from excessively vigorous movement in understretched or overstretched

muscles and tendons; commonly affected areas are the groin, hamstring, calf, shoulder and back muscles and the Achilles tendon.

MANIFESTATIONS:a. Pain: sudden, severe, incapacitating with acute strain; gradual onset of soreness and tenderness

with chronic strain.b. Swellingc. Ecchymoses developed several days after injury

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* Radiographs are done to rule out fracture or dislocation

MANAGEMENT OF STRAIN Instruct the client to allow the muscle or tendon to rest and repair itself by avoiding use for

approximately 1 week, then progressing activity gradually until healing is complete. Teach appropriate stretching exercises to be performed after healing to help prevent re-injury.

TRAUMATIC INJURIES AFFECTING THE MUSCULOSKELETAL SYSTEM

A. FRACTURE is an interruption and/or disruption on the normal continuity of the bone that results from excessive force/stress or pathology that has weakened the bone.

Definition

Fracture repair is the process of rejoining and realigning the ends of broken bones. This procedure is usually performed by an orthopedist, general surgeon, or family doctor. In cases of an emergency, first aid measures should be evoked for temporary realignment and immobilization until proper medical help is available.

Signs and Symptoms pain aggravated by motion loss of motion shortening of the extremity crepitus swelling/discoloration (ecchymosis) affected extremity colder than contralateral part

CLASSIFICATION OF FRACTURE

A. Open/Compound Fracture- is graded:I - a clean wound less than 1 cm longIII - is a larger wound without extensive soft-tissue damageFfl - is the most severe with extensive soft-tissue damage

B. Closed Fracture – does not produce a break in the skin

According to completenessIncomplete- the break occurs through only part of the cross section of the bone.A. Greenstick - splintering on one side; occurs in children, in which the bone is bent and

broken only part of the way through its shaft; because the periosteal covering of the children’s bone are not yet fully developed

B. Fissured- a mere split of the bone without displacement of the bone fragment.C. Perforating- (+) hole such as those made by bullets.D. Depressed - bone fragments are in-driven (seen frequently in fractures of skull and facial

bones), saucer or gutter shaped fracture, in which a fragment of bone is driven in ward towards the bone.

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Complete Fracture- involves a break across the entire section of the bone and is frequently displaced from the normal position.A. Impacted- a bone fragment is driven into another bone fragment; broken ends driven into

each otherB. Comminuted - bone broken into several fragmentsC. Complicated – (+) injury to some organs or important structures near the fracture site.

According to displacementA. Transverse fracture – Fracture surface is perpendicular to the long axis; caused by

angulatory force.B. Oblique- a fracture occurring at an angle across the bone (less stable than transverse)C. Spiral- a fracture twisting around the shaft of the bone; break coils around the bone due to

torsional force.D. Comminuted

D.1. Lateral displacementD.2. Angulated fractureD.3. Overlapped fractureD.4. Rotation Fracture

Note: a spiral fracture heals more rapidly than a transverse facture due to its greater surface area of contact.

Specific types of Fractureo Avulsion- pulling of a bone fragment by ligaments or tendon attachment; caused by tearing

away of bone fragment due to pull of strong ligamentous/tendinous attachement.o Butterfly fracture- a center fragment of 2 disruptions creates a triangular effecto Chauffer’s fracture- involves the distal sryloid process; produced by snapping/twisting

injury.o Chip fracture- usually involves a bony process and near a joint; (+) small fragmental

fractureo Compression - collapsed of a bone fragment; causes compaction of bone trabeculae which

results in shortening the width or length of the boneo Condylar fracture- fracture of round end of hinge joint, usually involves the femur and

humerus.o Epicondylar- fracture involves the epicondyleo Epiphyseal/ Epihyseal slip fracture/ Salter-Harris Fracture – a fracture through the

epiphysiso Greenstick/ Hickory-stick fracture/ Willow fracture/ infraperiosteal fractureo Smith’s fracture/ Reverse Colle’s fracture- volar displacement at the fracture siteo Subcapital fracture- involves the distal part of the head of the bone; usually occurring in the

humerus.o Supracondylar fracture- involves the area above the condyles o0f the femur and humerus.

Radiuso Barton’s fracture- involve’s the distal articular surface of eadius which may be

accompanied by dorsal dislocation of carpus of the radius.o Colle’s fracture- transverse fracture of the lower 3rd of the radius accompanied by a breaking

off of the ulnar styloid process.

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o Dinner fork/ Silver fork deformity- dorsal angulation and shortening result in a hump on the wrist

o Dupuytren’s fracture/ Galleazi’s fracture- fracture of distal radius with dislocation of distal ulna.

o Moore’s fracture- involves distal radius associated with dislocation of ulnar head.o Piedmont fracture- oblique fracture of distal radius with fragments pulled into the ulna

Ulnao Monteggia’s fracture- involves proximal 3rd of shaft of ulna associated with radial

dislocation or disruption of annular ligament.

Metacarpal o Bennet’s fracture- involves the first metatarsal bone that runs obliquely through the base of

the bone and CMC joint.o Boxer’s fracture- involves 1 or more metacarpal bone; especially the 4th and 5th.

Carpalo Quevair’s fracture- involves navicular bone with lunate bone dislocation.

Pelvis o Malgaines fracture- superior and inferior pubic rami with fracture dislocation of sacroiliac

joint

Femur o Pillion fracture- I-shaped fracture of distal femur with displacement of condyles posterior to

femoral shaft.o Panurels fracture- involves femoral neck on proximal side.

Tibia o Cotton’s fracture/ tri-malleoli fracture- medial and lateral malleoli and posterior lip of

tibiao Paratrooper fracture- involves the distal tibia and malleolus

Fibula o Pott’s fracture- involves fibular fracture a few inch above the ankle sometimes accompanied

by fracture of medial malleolus.o Montereoux fracture- involves the fibula associated with diastasis (separation) of ankle

mortise (talus, tibia, and fibula)

Metatarsal o March fracture- stress fracture of 1 or more metatarsal shaft due to excessive marching

Spineo Jefferson’s fracture- burst fracture of ring of atlaso Hangman’s fracture- posterior element of cervical vertebra with anterior dislocation of C2.

ETIOLOGY OF FRACTURE

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A. Pathologic Fracture- results from other primary disease (bone cyst, Paget’s disease, bony metastasis, tumor); can occur without trauma or fall.

1. Osteoporosis2. Bone Cyst3. Bone Tumor4. Paget’s Disease5. Multiple Myeloma

B. Traumatic Fracture1. Direct- fracture at the site of the impact2. Indirect fracture- fracture caused by a force transmitted to the bone from some part of the body.3. Muscular traction- fractures caused by sudden contraction of the muscle

Signs and Symptoms pain aggravated by motion and tenderness loss of motion due to pain deformity

1. angulation2. shortening3. rotation

Crepitus- heard at the fracture site; most reliable diagnostic sign of fracture. Swelling- due inflammation; obviously seen superficially and a vascular rupture occurs for gross

swelling. It takes some time to appear and may increase over the first 12-24 hours. It is sometimes associated with blistering of the skin. It is partly due to hematoma, and partly to inflammatory exudation. There may be obvious bruising and hemarthrosis (a fractured joint filled with blood).

Ecchymosis/bruising- purplish patch caused by extravasation of blood into the subcutaneous tissue.

Affected extremity colder than contralateral part- due to inflammatory response which occur immediately after injury and evident even if the damage is confined to the soft tissues.

Muscle spasm.

BONE HEALING

When forced applied to a bone exceeds maximum resistance, the bone breaks. Sudden direct force from a blow or fall causes most fractures; however, some result from indirect force, e.g. from a strong muscle contraction, such as, during seizures. A few fractures result from underlying weakness created by bone infections, bone tumors, or more bone resorption than production (as occurs in clients who are inactive or aging).

For 10-40 minutes after bone breaks, the muscles surrounding the bone are flaccid. Then they go into spasm, often increasing deformity and interfering with the vascular and lymphatic circulations. The tissue surrounding the fracture swells from hemorrhage and edema. Healing begins when the blood in the area clots and a fibrin network forms between the broken bone ends. The fibrin network changes into granulation tissue. Osteoblasts, which proliferate in the clot, increase the secretion of an enzyme that restores the alkaline pH. As a result, calcium is deposited and true bone forms. The healing mass is called callus. It holds the ends of the bone together but cannot endure strain. Bone repair is a local process. About 1 year of healing must pass before well consolidated and remodeled 9re-formed), and possesses fat and marrow.

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Stages of fracture healingA. fracture hematoma/ Inflammation phase- begins within 24 hoursB. Cellular Proliferation/ Granulation tissue formation- proliferation of young fibroblast and

ingrowth of loose meshwork of capillaries; 24-72 hoursC. callus formation- complex structure formed by the granulation tissue; osteoblasrs are the

type of cells proliferates in this stage; at the end of this stage, the 2 ends move as one but is not strong enough to withstand any stress; 3-14 days

D. Ossification/ consolidation- broken bone ends are bridged; there is already a well formed bone; 2-6 weeks.

E. Remodeling- final stage of bone healing where the broken bone are absorbed; 6 weeks- 2 years.

Factors affecting Bone Repair Age- younger patients have faster healing process because of their active periosteum

which accelerates the healing process. Type of fracture Vascularity/vascularization Immobilization Infection Severity of fracture Size and shape of bone General condition of the patient Location of fracture Limbs affected- upper extremity heals more rapidly than lower extremity due to:

a. UE has comparatively smaller bones than the LEb. UE receive more blood supplyc. UE are non-weight bearing

Types of Union: Delayed union – occurs when fracture fails to consolidate in the time required for union to

take place.- healing process is retarded, however, forming a firm union is still

possible in sufficient length of timeCauses:

1. inaccurate reduction- alignment of fracture2. inadequate or interrupted immobilization3. severe local traumatization4. impairment of bone circulation5. (+) infection6. loss of bone substance7. distraction or separation of bone fragments

Malunion- union in poor position1. Malalignment of fracture site at the time of immobilization2. Mobility of fracture site at the time of immobilization

Non-union- present when process of bone repair have ceased after having failed to form a

firm union.- No fracture should be considered ununited until at least 6 months

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- Lower 3rd of tibia – commonest site

Pseudoarthrosis- sometimes used interchangeably with non-union.- special form of non-union in which bone ends, covered by fibrocartilage,

are separated by a cleft or false joint, surrounded by a pseudicapsule that often contain synovial fluid.

FIRST AID FOR FRACTURE

I - ImmobilizationC - Control bleeding/ Cover open packsE - Elevate affected extremity

T - TransportE - Emotional or Psychological careA - Assess overall conditions

Complications of Fractures

A. HemorrhageB. ShockC. Avascular NecrosisD. Fat emboli (long bones)E. OsteomyelitisF. Gas gangrene

COMPLICATIONS OF FRACTURE

A. Avascular Necrosis - Any interference of the blood supply to a particular bone; most often affects head and neck of the

femur.Signs and Symptoms:

1. Asymptomatic during early stages2. Intermittent or constant pain on weight bearing3. Limitation of joint motion4. X-ray shows calcium loss and structural collapse

Treatment: 1. Surgery- Bone graft, prosthetic fitting/replacement- Arthrodesis (joint fusion)

B. Gas Gangrene - It is caused by the anaerobic-Gram positive saprophytic bacterium, Clostridium welchii or

Chlostridium perfringens.

Signs and Symptoms:1. Edema2. Profuse drainage of gas bubbles with characteristic fruity odor3. Vesicles filled with red, watery fluid, crepitus produced by gas; necrotic tissue

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Treatment:1. Wound irrigation with antiseptics and antibiotics2. Hyperbaric oxygen therapy

C. Osteomyelitis - It is an infection of osseous tissue involving the cortex of the bone and or marrow

Types:1. Exogenous-an infection that enters from outside the body2. Hematogenous-an infection that results from sites of infection elsewhere in the body

Signs and Symptoms:1. Low grade fever2. Malaise3. Pain, tenderness, increased swelling and warmth of the area and purulent drainage

from the sinus tract

Treatment:1. Antibiotics2. Debridement of open fractures to remove necrotic tissue

D. Fat Metabolism Syndrome - It results when the fracture occurs and fat globules are freed from the bone marrow and from the

tissue that has sustained damage.

Signs and Symptoms:1. Changes in mentation: confusion, apprehension, agitation, restlessness, lethargy,

delirium2. Respiratory manifestations: tachypnea over 30, dyspnea, wheezes, rales and scattered

infiltrates seen on x-ray3. Petechiae on neck, axillae, and upper chest4. Hypoxemia, hypocapnea, elevated blood PH

Treatment:1. Oxygen therapy by nasal cannula or Venturi mask2. Mechanical ventilation with PEEP3. IV Glucose and alcohol4. Heparin5. Low molecular weight dextran6. Steroids7. Immediate immobilization and adequate support during turning and positioning8. ABG analysis9. Morphine

Medical Interventions of Fracture A. Close reduction

- Realignment of bones without surgery.

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- The bone is restored to its normal position by external manipulation.- A bandage, cast or traction immobilizes the area.- An X-ray films are taken to ensure correct alignment of the bone

B. Open reduction- Surgical realignment of bone fragments.- Is performed in the operating room, the bone is surgically exposed and realigned.

o Internal Fixation - application of metal screws, pins, plates, nails, to hold fragments in

alignment

Open reduction is required:1. Soft tissue, such as nerves or blood vessels, is caught between the ends of the broken

pieces of bone.2. The bone has a wide separation.3. Comminuted fractures are present.4. Patella and other joints are fractured.5. Open fracture are evident.6. Wound debridement is necessary.7. Internal fixation is needed.

o External Fixation - sturdy external frame with multiple pins through bone; used with extensive open fractures with soft tissue damage, if infected fractures do not heal properly, with multiple trauma.

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Orthopedic Interventions :

A. CAST Cast- is a rigid mold that immobilizes an injured structure while it heals.

Three Types of Casts:1. Cylinder cast- encircles the arm or leg, leaving the fingers or toes exposed.2. Body cast- is a larger form of a cylinder cast that encircles the trunk from about the nipple line

to the iliac crests.3. Hips spica cast- surrounds one of both legs and the trunk

Cast Composition:1. Plaster of Paris

- traditional cast- Longer to dry- deforms easily

2. Synthetic Cast, e.g. fiberglass, plastics, polyester, thermoplastic

Purpose:a. Promote immobilityb. Support and protect during healing process.c. Prevent and correct deformity. d. Provide for early mobilization of unaffected body parts.e. Exert uniform compression to soft tissue

Contraindications:1. Pregnancy2. Skin disease3. Swelling/edema4. Open wound5. Infection

NURSING CARE FOR CASTa. Do not use heat lamps or hair dryer on plaster castb. Use palms of hands, not finger tips, to support cast when moving or lifting patientc. Elevate cast on pillowsd. Leave cast expose to air until drye. Tape edges of cast to prevent irritationf. Warn patient that heat is produced during the drying stage of the cast g. Relieve itchinessh. Check for tightness of cast applicationi. Continuously monitor for neurovascular status of the affected extremity (check for

Circulation, Motion and Sensation)- Absent or diminished pulse

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- cyanosis or blanching- coldness- swelling

- pain - inability to move fingers or toes

j. Encourage mobility and active participation in self-care.k. Apply cold packs as prescribed to reduce swelling.l. Provide client teaching:

- Isometric exercises- Muscle strengthening exercises for the upper body- Importance of never inserting sharp objects- Safety precautions

Complications of Casting

A. Compartment Syndrome - a condition involving increase pressure and constriction of nerves and vessels within an anatomic compartment.

B. Infection

Signs and Symptoms1. Foul-smelling odor2. Body temperature elevation.3. “Hot Spot”4. Drainage through cast ends.

C. Cast Syndrome1. Psychological- similar to claustrophobic reaction2. Physical- GI motility decreased with decreased mobility

B. TRACTION - the application of pulling force to a part of the body with the use of weights and pulleys.

Uses: Reduce/ fracture Immobilize fractures Relieve pain and muscle spasm Correct / prevent deformities

Principles of Effective Traction1. Ensure continuous traction2. Maintain counteraction3. See that the pull of traction and counteraction are in opposite directions but in straight alignment.4. Suspend splints and slings without interference.5. Be sure that ropes move freely through each pulley.6. Apply the exact amount of weight prescribed.7. Make sure that the weights hang freely.

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Types of TractionA. Skin Traction

- Traction applied to skin.- Cannot reduce fracture

a. Buck’s traction - for hip fractureb. Russell’s traction - for hip and knee fracture.c. Bryant’s traction - for hip fracture in children.d. Cervical traction

Uses: 1. For soft tissue damage or degenerative disc disease of the cervical spine 2. To relieve spasm and pain at the neck, shoulders and arms 3. To maintain alignment

e. Pelvic traction - for low back pain and to maintain alignment.

Traction IndicationsHead Halter…………........Pelvic Girdle……………...Overhead Skeletal………..Buck’s extension…………Bryant’s Traction…………Boot cast………………….Halo-Pelvic……………….Halo-Femoral……….........90 degrees………………...Stove-in-Chest……………Dunlop’s skin traction……Hammock Suspension……

Cervical spine affectionLumbo-Sacral affection, Herniated Nucleus PulposusFracture of humerusFemur and hip affectionFemoral fractures, Hip injuries among kids below 3 years oldHip and femoral affection; Post polio/Knee contractureScoliosisSevere scoliosisSubtrochanteric Fracture of FemurSevere chest injury with multiple rib fractureSupracondylar fracture of the humerusPelvic affection; Malgaine’s fracture

B. Skeletal Traction - Traction applied directly to the bone.- Capable of reducing fracture- Kirschner wire, Steinmann’s pin, Crutchfield tongs, Thoma’s splint, or Pearson attachment.

C. Balanced Suspension Traction- produced by a counter-force other than the client’s weight- allows greater freedom for patient to move body in bed

Provide Traction Care:a. Ensure effectiveness of therapy

- Weight should hang freely- Maintain proper alignment- Keep ropes and pulleys freely movable

b. Prevent complications of immobility- Encourage coughing and deep-breathing exercises- Increase fluid intake

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- Provide high fiber, low calcium, and high protein diet- Encourage exercises- Assess for thrombophlebitis

c. Monitor neurovascular status of immobilized extremity. If skeletal traction is applied to the lower extremity, observe foot position to prevent footdrop.

d. Monitor and prevent infection at the pin sitee. Involves patient in patient care and help avoid depression and boredom.f. If skeletal traction is applied, follow procedure for pin care.g. Cover tips of any protruding metal pins or rods with corks or other protective material.h. Assess for vascular occlusion (the five P’s)

Paralysis Paresthesia Pulselessness Pallor Pain

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ASSISSTIVE DEVICES

Assistive devices and Gait Patterns

There are 3 major categories of ambulatory assistive devices: canes, crutches, and walkers. Assistive devices are prescribed for a variety of reasons, including problems of balance, pain, fatigue, weakness, joint instability, excessive skeletal loading, and cosmetics. Another primary function of assistive devices is to eliminate weight bearing fully or partially from the extremity. This unloading occurs by transmission of force from the upper extremities to the floor by downward pressure on the assistive devixe.

A. Crutch

Principles:1. Measure for crutch length

- when the client assumes erect position the top of crutch is 2 inches below the axilla and the tip of each crutch is 6 inches in front and to the side of each crutch

- When lying down, measure from anterior fold of axilla to the sole of the feet and add 2 inches

- Subtract 40 cms (16 ins) from patient’s actual height2. Teach patient not to bear weight on the axilla3. For maximum stability, assume a tripod position4. Encourage exercises to strengthen certain groups of muscles before beginning the activity

Crutch WalkingIt is used most frequently to improve balance and to either relieve weight bearing fully or

partially on a lower extremity.

Principles:1. Measure for crutch length

- when the client assumes erect position the top of crutch is 2 inches below the axilla and the tip of each crutch is 6 inches in front and to the side of each crutch

- When lying down, measure from anterior fold of axilla to the sole of the feet and add 2 inches

- Subtract 40 cms (16 ins) from patient’s actual height2. Teach patient not to bear weight on the axilla3. For maximum stability, assume a tripod position4. Encourage exercises to strengthen certain groups of muscles before beginning the activity.5. Used bilaterally, and function to increase the base of support, to improve lateral stability, and to

allow the upper extremities to transfer body weight to the floor.

Types: Axillary Crutch aka Regular or Standard Crutch

- They are made of lightweight wood or aluminum. Their design includes an axillary bar, a handpiece, and double uprights joined distally by a single leg covered with a rubber suction tip.

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Advantages: Improve balance and lateral stability and provide for functional ambulation with restricted weight bearing. They easily adjusted, inexpensive when made of wood, and can be used for stair climbing.

Disadvantages: Because of the tripod stance required to use crutches and the resultant large BOS, crutches are awkward in small areas, and the safety of the user may be compromised when ambulating in crowded areas. The patient may have the tendency to lean on the axillary bar. This pressure creates the potential for damage to the nervous and vascular structures in the axilla.

Forearm Crutches aka Lofstrand and Canadian Crutches

Advantages: The forearm cuff allows use of hands without the crutches becoming disengaged. They are easily adjusted and allow functional stair-climbing activities. More cosmetic and fit more easily into an automobile. Most functional type of crutch stair climbing activities for individuals wearing bilateral knee-ankle-foot orthoses.

Disadvantages: Provide less lateral support owing to the absence of an axillary bar. The cuffs may be difficult to remove. These crutches are more costly than wooden axillary crutches.

Gait Patterns in Crutches:

Three-point gait (only one leg) - it is used when a non-weight-bearing status is required on one lower extremity. Body weight is borne on the crutches instead of on the affected lower extremity.

- Faster gait but requires more strength and balance- advance weaker legs and both crutches simultaneously, then advance stronger leg.

Partial-weight-bearing-gait- this gait is a modification of the three-point gait. During forward progression of the involved extremity weight is borne partially on both crutches and on the affected extremity

Four-point gait (weight -bearing is allowed for both legs) - provide a slow, stable gait. Used for muscle weakness, poor balance or coordination.

- Most stable, slow type- Right crutch, left foot, left crutch, right foot.

Two-point gait (weight bearing is allowed for both legs) – less stable compared to for-point-gait. It simulates normal gait.

- Faster gait and safer- Right crutch and left foot, then left crutch and right foot.

Swinging crutch (cant bear weight on both leg) A. Swing-to – land with feet in line with crutches. Typically used with severe involvement or

paralysis of both lower extremities.B. Swing-through gait – feet land ahead of crutches. Typically used with severe involvement

or paralysis of both lower extremities.

B. CANES

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Functions:1. Widen BOS2. Improve balance

Principle:1. Patients are typically instructed to hold a cane in the hand opposite the affected extremity.

Types:1. Standard Cane aka Regular or Conventional Cane

- It is made of wood or plastic and has a half circle (“crook”) handle. The distal rubber tip is at least 1 inch in diameter or larger.

Advantages: This cane is inexpensive and fits easily on stairs or other surfaces where space is limited.

Disadvantages: The standard cane is not adjustable and must be cut to fit the patient. Its point of support is anterior to the hand and not directly beneath it.

2. Standard Adjustable Aluminum Cane

Advantages: This cane is quickly adjustable. Facilitate ease of determining appropriate height. It is particularly useful for measurement prior to altering the length of a standard cane. It is lightweight and fits easily on stairs.

Disadvantages: The point of support is anterior to the hand and not directly beneath it. This cane is also more costly than a standard cane.

3. Adjustable Aluminum Offset Cane

Advantage: The design of this cane allows pressure to be borne over the center of the cane for greater stability. This cane also is quickly adjusted, lightweight, and fits easily on stairs.

Disadvantage: this cane is more costly than standard or adjustable aluminum canes.

4. Quad (Quadruped) Cane- the characteristic feature of these canes is that they provide a broad base with four points of floor contact. Each point (leg) is covered with a rubber tip. The legs closest to the patient’s body are generally shorter and may be angled to allow foot clearance. Some have offset designs.

Advantage: This cane provides a broad-based support. Bases are available in several different sizes. This cane is also adjustable.

Disadvantages: The pressure exerted by the patient’s hand may not be centered over the cane and may not centered over the cane and may result in patient complaints of instability. As a result of the wide BOS, quad canes are often not practical for use on stairs; they warrant use of slower gait pattern. If a faster forward progression is used, the cane often “rocks” from rear legs to front legs, which decreases effectiveness of the cane. Patients

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should be instructed to place all four legs of the cane on the floor simultaneously to obtain maximum stability.

5. Walk Cane

Advantages: Provide a very broad-based support and are more stable than a quad cane. These canes also fold flat for travel or storage.

Disadvantages: the design of walk cane or handgrip placement may not allow pressure to be centered over the cane. Walk canes cannot be used on most stairs. They are more costly than quad canes.

C. Walkers - Provide the greatest stability.- Provide BOS, improve anterior and lateral stability and allow the upper extremities to transfer body

weight to the floor- Relatively lightweight and easily adjusted

Disadvantages: awkward in confined areas, and are difficult to maneuver through doorways into the car. They eliminate normal arm swing and cannot be used safely on stairs.

D. ISOMETRIC EXERCISES

A. QUADRICEPS-SETTING SUPINE,LEG EXTENDED PUSH KNEE BACK ONTO MATTRESS BY CONTRACTING THIGH MUSCLE HOLD POSITION 5 – 10 SECS

Repeat 10x each hr Pt is awake

B. GLUTEAL-SETTING SUPINE,LEGS EXTENDED CONTRACT MUSCLES OF BUTTOCKS AND ABDOMEN HOLD CONTRACTION 5-10 SECS

C. TRICEPS SETTING PRESS PALM AGAINST BED

SQUEEZING OF RUBBER BALL

Hip Fracture

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Types of Hip Fracture Intracapsular - involves the head and neck of the femur Extracapsular - affects the trochanteric regions

NURSING CARE FOR TOTAL HIP REPLACEMENT)A. Pre-operative care1. Placed in temporary skin traction to reduce muscle spasm, immobilize and relieve pain2. Sandbags, trochanter rolls to control external rotation 3. Teach partial weight-bearing, use of crutches, isometric exercises, and transfer techniques.4. Familiarize patient with over bed traction frame, trapeze, and abduction splint

B. Post-operative Care1. Ambulate patient 2-3 days post-op2. Advise the patient to avoid:

- Excessive hip flexion - Adduction of legs - Internal/external rotation of the legs

3. Position: Supine4. Report signs of prosthesis dislocation5. Exercise- with the use of the overhead trapeze

C. Post-operative discharge teaching1. Maintain abduction2. Avoid stooping3. Don’t sleep operative side until directed to do so4. Keep operated leg elevated when seated 5. Never cross legs6. Avoid position of flexion of hip 90 degrees or greater7. Walking is an excellent exercise; avoid over exertion 8. In 3 months will be able to resume ADLs except strenuous sports

Amputation - Surgical removal of disease limb

Indicationsa. Traumab. Peripheral vascular diseasec. Malignant Tumor

Criteria degree of vascularity presence/absence of infection proximity level of joint

Types of Amputation

A. Disarticulation - resection of an extremity through a jointB. Above-the-knee amputations (AKA) - necessitated by trauma or extensive diseaseC. Below-the-knee amputation (BKA) -common PVDsD. Upper extremity amputation

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Surgical approaches:A. Open or guillotineB. Closed or flap

PRE-OP AND POST-OP NURSING CARE

A. PRE-OP NURSING CARE1. Teach patient and initiate exercises to strengthen muscles of extremities in preparation of

crutch walking2. Teach about coughing and deep breathing exercises3. Provide emotional support for anticipated alteration in body image

B. POST-OP NURSING CARE1. Monitor V/S and stump dressing for signs of hemorrhage2. Elevate stump over a pillow3. Provide stump care:

- Maintain elastic bandage- Wash stump daily- Apply pressure to end of stump- Encourage the client to move the stump- Place the client with lower extremity amputation on prone position 2-3 times daily; generally flat position; ROM

4. Provide psychologic support5. Teach patient about phantom limb sensation. Provide care to minimize the sensation.

o Phantom limb - physiology reaction of the nerves in the stump causing an unpleasant feeling that the limb is still there; may or may not precipitated by a psychologic overlay.

o Phantom limb pain - when the unpleasant feelings become painful or disagreeable.

Selected Orthopedic Disorders

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A. CONGENITAL HIP DISLOCATION

GENERAL INFORMATION Acetabulum is unable to hold head of the femur

SIGNS AND SYMPTOMS: Uneven gluteal folds and thigh creases ( deeper on involved side ) Limited abduction and pain on abduction of involved hip Prominent trochanter Short limb on affected side Waddling gait with bilateral dislocation Limping gait with unilateral dislocation

Precipitating factorsa. Hip and leg positioning in the uterob. Effect of maternal estrogen on fetus, causing relaxation of the ligamentsc. Genetic factors

Diagnostic testsa. Radiographic examinations between 3 and 6 months after ossification of femoral head

to yield reliable data.b. Ultrasonography- slight subluxation and dislocationsc. Ct Scan- position of the femoral headd. Arthrography- confirms stability and is useful in evaluating reduction

Treatment and Management depends on type of dislocation

a. Newborn to 6 mos Splinting for partial dislocation by use of abduction splints- need Pavlik harness.

b. Infants 6-8 mos Traction for gradual reduction followed by close reduction with cast immobilization

until stable.c. Older child

Correction is difficult because secondary changes create complication. Surgical reduction is required. Successful reduction after 4 yrs of age is difficult; it is inadvisable after 6 years of age.

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HIP SPICA CAST

Plan and Implementationa. Encourage growth and development within physical limitations.b. Teach parents to reapply splints and explain rationale for maintaining abductionc. Encourage parents to provide variety of environmental stimuli (e.g., room changes )d. Discuss with parents modifications in bathing, dressing, and diaperinge. Tell parents to touch and hold child to express affection and reinforce security

Provide care to child in casta. Apply principles of cast care b. Teach parents cast care if child is being discharged with cast c. Use Bradford frame to allow urine and feces to drain into a bedpan below, without soiling cast

and surrounding aread. Support normal growth and development

Provide care to child in tractiona. Apply principles of traction careb. Explain to parents the principles of traction and how to care for child in traction

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B. RHEUMATOID ARTHRITIS

GENERAL INFORMATION It is a chronic, systemic, progressive inflammatory disease of connective tissue

characterized by symmetric involvement of the synovial lining with resulting destruction of joints.

ETIOLOGY: unknown

Epidemiology

☻ Women > Men (3:1; although occurs in all ages)☻ Peak onset: 20 – 50 years old☻ Women = Men (more than 60 years old)

THEORIES: 1. Autoimmune2. Heredity3. Psychophysiologic factors

STAGES:a. Synovitisb. Pannus formationc. Fibrous ankylosisd. Bony ankylosis

Stages according to disabilityStage 1: Disease present but no disabilityStage 2: Disease beginning to interfere with ADLStage 3: Major compromise in functionStage 4: Incapacitation

Hallmark of Persistent Synovial Inflammation• cartilaginous destruction• Bony erosions• Joint deformation

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Signs and SymptomsA. Systemic

1. Morning stiffness (lasting more than 3minutes) Hallmark symptoms of RA2. anorexia3. weight loss4. fatigue

B. Joint Involvement1. Bilateral and symmetrical pattern2. Crepitus3. Atlanto-axial and midcervical affectation (most common)4. Decrease ROM5. C1-C2 – 50%

C. TMJ- altered normal approximationD. Shoulder- degeneration, pain, and LOM;

Bursitis, and tendinitisE. Elbow- flexion contractureF. Wrist- Flexion contracture, volar subluxation, and Piano Key SignG. Hands Joint- Bowstring effect, Zigzag effect, Swan-neck deformity, Boutonniere deformity,

Bouchard’s nodes, Mutilan’s deformity or Opera H. Hip- Protrusio acerabuliI. Knee- most frequently affected jointJ. Ankles and Feet

- hindfoot pronation- flattening of the medial longitudinal arch- heel spurs- splay foot- hallux valgus- hammer toes

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- cock-up or claw toesK. Muscle involvement- muscle atrophyL. Tendons- Tenosynovitis and “Lag phenomenon”

Secondary Problems1. Rheumatoid nodules2. Vascular complications (malnutrition, infection, CHF, GIT bleeding)3. Neurologic manifestations (carpal tunnel syndrome)4. Cardiopulmonary complications- pericarditis, pleuritis5. Occular manifestations- Sjogren’s syndrome, scleritis, episcleritis

Diagnostic Test Diagnosis based on clinical picture: x-rays, blood studies, and joint fluid aspirate analysis

LABORATORY EXAMS: RA factor elevated ESR elevated Antinuclear antibodies present Synovial fluid changes Decreased complement Decreased hemoglobin

Treatment and Management1. Provide rest2. Provide warm and cold applications3. Drugs:

a. Aspirinb. NSAID’s: Ibuprofen (Motrin, Advil)

Indomethacin (Indocin) Sulindac (Clinoril) Phenylbutazone (Butazolidin) Piroxicam (Feldene) Diclofenac (Voltaren) Naproxen (Nasprosyn)

c. Corticosteroidsd. Golde. D-Penicillaminef. Antimalarials: Plaquenil (Hydroxychloroquine), Aralen (Chloroquine)

THERAPEUTIC MANAGEMENT4. Encourage exercises5. Promote activity during remissions6. Surgery

a. Synovectomy - removal of inflamed synovial lining - relieves pain and increases joint stability and mobility

b. Arthrodesis - fusion of joints - decreases joint instability and joint pain

c. Osteotomy - removal of bone thus changing the weight-bearing surfaces - relieves pain and increases joint stability

d. Implant Arthroplasty - increases joint mobility and stability and decreases pain

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C. Osteoarthritis a.k.a Degenerative Joint Disease (DJD)

GENERAL INFORMATION It is slowly progressive, chronic, non-systemic, non-inflammatory disease of primary

weight-bearing joints. Most common form of arthritis. It is slowly progressive, chronic, non-systemic, non-inflammatory disease of primary

weight-bearing joints. It has been known as a “wear and tear” disease or a “use and abuse” disease.

TYPES1. Primary Osteoarthritis

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2. Secondary Osteoarthritis

Two Features:1. Progressive destruction of articular cartilage (hallmark of OA)2. Formation of bone

EPIDEMIOLOGY Common condition after 40 years of age (F≥M) 18-24 year old (M ≥ F) 75-79 year old (M = F) Younger than 40 year old (M ≥ F) Asymmetrical involvement

TYPES1. Primary / Idiopathic Osteoarthritis

– unknown2. Secondary Osteoarthritis

- Usually follows an identifiable predisposing factors like congenital abnormalities (Leg- Calves-Perthes disease, diabetes mellitus, trauma, metabolic factors/decreased bone density, genetics, chemical factors and mechanical factors

Signs and SymptomsEarly Stage

Stiffness of one or more joints and joint pain at rest (monoarticular arthralgia) Slight enlargement of the affected joints with tenderness (common in fingers

and knees) Bony enlargement of DIP joints: Heberden’s nodes (one of the commonest sign)-

nodular enlargement on distal interphalangeal joints and Bouchard’s nodes - nodular enlargement on proximal-interphalangeal joints

Late Stage LOM and disability (larger weight bearing joints) Pain (present during motion and even at rest) Malalignment of joint Crepitus Loss of intraarticular fragments

Diagnostic & Laboratory Procedure X-ray

- narrowing of the joint space or margins- cystlike bony deposits in joint space or margins- sclerosis of the subchondral space- joint deformity due to degeneration or articular damage- Bony growths at weight bearing areas- Fusion of joints

ESR- normal Hemoglobin- normal Platelet count- normal Synovial fluid- remains its viscosity

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THERAPEUTIC MANAGEMENT:Non-pharmacologic Treatment:1. Promote balance between rest and activity2. Encourage to maintain ideal body weight3. Advise weight reduction for obese clients4. Provide splints, braces, canes, or crutches as necessary.5. Provide pain-relieving interventions

e.g. cold packs/heat, moist compressesTENS, relaxation techniques

4. Encourage exercises (ROM, Isotonic, Isometric, quadriceps)5. Provide emotional support6. Inform about possible surgeries

e.g. Arthrodesis, Osteotomy, synovectomy, replacement Arthroplasty

Pharmacological interventions: Provide pain-relieving interventions

e.g. analgesics, NSAIDs, corticosteroid aspirin (drug of choice) Glucosamine and chondroitin Therapy (⇧ tissue function and interfere with the

breakdown of cartilage) Viscosupplementation

Surgical Interventions: Osteotomy Arthrodesis Arthroplasty

D. GoutGENERAL INFORMATION

- A monoarticular, asymmetric arthritis characterized by hyperuricemia.

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A metabolic disease, marked by monoarticular, asymmetric arthritis characterized by hyperuricemia.

Common location: Great toe

TYPES 1. Primary Gout – a genetic increase in purine metabolism and production

2. Secondary Gout – disorder characterized by increased rate in cell change or breakdown, impairment in uric acid excretion.

Epidemiologyo Primary gout: men older than age 30 postmenopausal women who take diureticso high incidence with men 20-60 years old (20:1)

Etiology UNKNOWN (Primary gout) Secondary Gout

- obesity- Dm- HPN- leukemia- other blood disorders- bone CA- kidney disease

Risk factors Lifestyle factors. Excessive alcohol use Medical conditions. These include untreated high blood pressure (hypertension) and

chronic conditions, such as diabetes, high levels of fat and cholesterol in the blood (hyperlipidemia), and narrowing of the arteries (arteriosclerosis).

Certain medications. thiazide diuretics and low-dose aspirin also can increase uric acid levels. So can the use of anti-rejection drugs prescribed for people who have undergone an organ transplant.

Family history of gout Age and sex Fever Dehydration Recent surgery Excessive dining Excessive intake of purine rich foods

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Four Stages of GoutFirst Stage: Hyperuricemia

No Signs/SymptomsSecond Stage: Marked acute gouty arthritis

painful swelling and tendernessSeek medical help

Third Stage: Interictal StageLast for months to yearsClient may be asymptomatic or experience exacerbations

Fourth Stage: Chronic StageIf without treatment, ⇧ urate productionTophi productionTophaceous gout

Signs and Symptoms1. Hyperuricemia2. Joint pain3. Tophi4. Increased ESR5. Increased WBC

Diagnostic Test• Arthrocentesis of synovial fluid or tophi• Blood and urine analysis• Radiographic exam

Predisposition - Genetic defect of purine metabolism- High incidence with men 20-60 years old (20:1)

Plan and ImplementationACUTE ATTACK Elevation of extremity Immobilization and protection of the inflamed, painful joints Local application of cold Bed cradle ⇧ OFI (2 L/day) Medications: Analgesics (acetaminophen)

NSAIDs (corticosteroids)Colchicine

CHRONIC GOUT Allopurinol Probenecid/sulfinpyrazone Monitor client serum uric acid daily and sodium bicarbonate

ADJUNCTIVE THERAPY Avoiding alcohol (especially beer and wine) Avoiding purine-rich foods (anchovies, liver, sardines, kidneys, sweetbreads, and

lentils)

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Weight reduction program Encourage client to express his concerns about his condition

Provide joint rest during acute phase. Drugs: Colchicine, Allopurinol (Zyloprim), Probenecid (Benemid), NSAIDs Maintain dietary restrictions in purine-rich foods Encourage high fluid intake Teach patient to avoid:

a. Alcoholb. Diureticsc. Traumad. Stresse. Fastingf. Xanthine-containing food

Maintain alkaline urine

Metabolic Bone Disorders

E. Osteoporosis

GENERAL INFORMATION- generalized loss of bone density and tensile strength

EPIDEMOILOGY F ≥ M (4x more common in females) White & Asian women ≥ Black or Hispanic women

Types of OsteoporosisA. Primary Osteoporosis

- UNKNOWN- Contributing factors include:

» Mild but prolonged lack of calcium due to poor dietary intake or poor absorption by the intestine secondary to age.

» Hormonal imbalance due to endocrine dysfunction.» Faulty metabolism of protein due to estrogen deficiency» A sedentary lifestyle

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Classification of Primary OsteoporosisType I - Postmenopausal Osteoporosis

- women (51-75 year old)- due to estrogen loss- vertebral and wrist fracture

Type II - Senile Osteoporosis- age: 70-85 year old women- due to osteoblest/osteoclast shrinkage or decreased physical activity- Humerus, tibia, femur, and pelvis

Type III - Premenopausal Osteoporosis- due to ⇧ estrogen levels that may inhibit bone resorption by affecting the

sensitivity of osteoclasts to parathryroid hormone.

B. Secondary Osteoporosis Prolonged therapy with steroids or heparin Immobility/ disuse Alcoholism Malnutrition Rheumatoid arthritis Liver disease Calcium malabsorption Scurvy/Deficiency of vitamin D Lactose intolerance Hyperthyroidism Osteogenesis imperfecta Sudeck’s disease Smoking Malabsorptive disease of GI tract Cushing’s disease

Signs and Symptoms Lower back pain Kyphosis Decrease in height

ComplicationsFractures (vertebrae, femur, and distal radius)

S/Sx: redness, warmth, and new sites of pain

Diagnostic tests: x-rays

Treatment and Management Diet – high calcium; high vitamin D Medication – Calcium carbonate supplement; oral analgesics for back pain

Physiotherapy 1. Regular weight bearing exercise such as walking2. Back rubs to promote muscle relaxation

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Plan and Implementation Provide optimal nutrition Assist in restoring hormonal balance

Promote mobility and strength a. Encourage weight-bearing on the long bonesb. ROM exercisec. Use of back brace or splint for supportd. Use of bedboards or hard mattress

Prevent pathological fractures-safety precautions

F. Paget’s Disease aka Osteitis Deformans

Disease of unknown cause characterized by increase bone remodeling, enlargement of bones, bone deformities, and increased vascularity of bones

Bones commonly affected:- pelvis, long bones, spine and cranial bones

EPIDEMIOLOGY Fifth decade of life Male > Female Common in whites(England, France,Austria,regions of Germany,Australia,New Zealand

& US)

Types of Paget’s Disease An initial osteoclastic stage A mixed osteoclastic-osteoblastic stage A burnt-out quiescent osteosclerotic stage

Signs and Symptoms- Pain and tenderness- Enlarged skull - Kyphosis- Bowed legs- Waddling gait- Decrease in height - Barrel shaped chest

Complications: Osteoarthritis Chalkstick-type fractures Spinal cord injury Kyphosis Increase cardiac output Exacerbations of underlying cardiac disease Tumors( sarcoma)

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Diagnostic Procedures:1. Bone Scan2. Laboratory: anemia, increase serum alkaline phosphatase

Treatment and Implementationa. Symptomatic- can be treated by surgery and bracesb. Administration of specific drugs

Developmental Conditions of the Spine

G. LOW BACK PAIN

Types of Low Back Pain Static Low Back Pain Kinetic Low Back Pain

- due to impaired lumbar pelvic rhythm

Diseases Associated with Low Back Pain

H. SPONDYLOLYSISGeneral Information

Fracture of the pars interarticularis Commonly bilateral that lead to spondylolisthesis L5 and L4 vertebrae Incidence: Male > Female

ETIOLOGY Stress fracture Congenital failure of fusion during maturation of the bones Birth fracture Increased lumbar lordosis Dysplasia Axial loading

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Signs and Symptoms Localized lumbosacral pain Local tenderness Spasm

Diagnosis: X-ray CT-scan MRI

TREATMENT Rest Restriction of activity/rigid immobilization

- Modified Boston Overlap Brace Hot moist pack

I. SPONDYLOLISTHESIS

General InformationForward or backward shearing subluxation of the body of a superior vertebrae on its intermediate

caudal counterpart. L5 on S1 and L4 on L5

ETIOLOGY Backward bending Obesity and disk degeneration Congenital asymmetrical facets Pathologic diseases Traumatic Injury

Grade 1: 1- 25% slippage Grade 2: 26-50% slippage Grade 3: 51-75% slippage Grade 4: 76-100% slippage Grade 5: Greater than 100% slippage

TYPESType I: Congenital spondylolisthesis. Type II: Isthmic spondylolisthesis Type III: Degenerative spondylolisthesis Type IV: Traumatic spondylolisthesis Type V: Any bone disorder

Signs and Symptoms LBP with referred pain on the hips, thigh, and even to the feet Lordosis tenderness Stiffness with limited flexibility

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Presence of palpable “ledge” Segmental lordosis

Diagnostic Procedure X-ray CT-scan

TREATMENT Bracing for acute isthmic spondylolysis/spondylolisthesis, thoracolumbosacral spinal

orthosis or modified Boston Brace Steroid injections Treatment for degenerative spondylolisthesis may include bracing, facet or epidural

steroid injections, along with the above mentioned physical therapy approach. Pelvic tilting Corset or brace Buck’s technique Surgery

J. HERNIATED NUCLEUS PULPOSUS Ruptured Disc Prolapsed Disc Cervical or Lumbar Radiculopathy

General Information-this involves protrusion of the nucleus polposus into the spinal canal with subsequent

compression of the cord or nerve roots.- most common site of involvement is the lumbosacral area (between L4 and L5; L5-S1) but

herniation can also occur in the cervical region (between C5 and C6 or C6 and C7)

ETIOLOGY:1. Trauma2. Aging3. Degenerative process4. Poor conditioning and faulty biomechanics

Disc herniation classificationA: Disc protrusionB: Disc ProlapseC: Disc extrusion D: Disc sequestration

SIGNS AND SYMPTOMS

A. LUMBAR 1. Low back pain2. Sciatica/ radicular pain3. Positive Lasegue’s sign4. Weakness of the foot5. Sensory Alterations6. Increase intraspinal pressure

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B. CERVICAL1 Neck Pain that may radiate down to the arm and to the hand2. Weakness of the affected upper extremity

Risk factorsSex: The male-to-female ratio is approximately 1:1. Age: The group most commonly affected is adults aged 25-45 years.ActivitySmokingObesityVibration (e.g., driving a car)Sedentary lifestylePsychosocial factors

DIAGNOSTIC TESTS1.Magnetic Resonance Imaging- most useful non-invasive diagnostic tool.2. Myelogram3. Electromyography (EMG)- assess function of certain weak muscles.4. CT Scan- usually done in conjunction with myelogram

Complications of Cervical and Lumbar HNP Intractable neck and back pain Intractable radicular pains down the arm or leg Muscle contraction headache Regional hyperesthesia, hypesthesia, dysesthesia, motor weakness, sensory loss, reflex

changes, and/or sympathetic dystrophy Sphincter dysfunction Myelopathy, paraparesis, and quadriparesis Complications of immobility Respiratory compromise, even death

THERAPEUTIC MANAGEMENTA. NON SURGICAL MANAGEMENT

1. Bed rest- 2-6 weeks; may include use of support devices such as corset, brace or cervical collar; firm mattress; skin traction

2. Heat application3. Drugs:

Analgesics Muscle RelaxantsNSAIDs e.g Phenylbutazone (Butazolidin); IbuprofenSteroids e.g Dexamethasone (Decadron)

4. Exercises5. Chemonucleolysis - injection of chymopapain into the affected area6. Traction: Pelvic girdle and crutchfield tong7. Braces: Back brace

B. Surgical: • Diskectomy• Laminectomy

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• Spinal Fusion• MISS (Minimally Invasive Spinal Surgery)- with CAT

NURSING CARE TO PATIENT WITH LAMINECTOMY1. Maintain in flat bed rest with supportive pillows or devices per physician orders.2. Explain that pain may persist post-operatively for some time.3. Place the bedside table, phone and call bell within reach of the patient; assist the patient with

turns; use log-rolling method.4. Observe dressing for hemorrhage and leakage of CSF5. Encourage patient to avoid sitting; use fracture bed pan (avoids lifting of hips)6. Apply elastic hose as ordered; Encourage ROM, deep breathing and coughing exercise7. Monitor bowel and bladder function8. Ambulate patient as soon as effects of anesthesia dissipates9. Teach patient about proper body mechanics.

C. LIFESTYLE MODIFICATION- Avoid carrying heavy objects, diet and exercise, physical therapy and weight control

D. PREVENTION- Safe work and play practices, proper lifting technique and weight control

E. Medication: Muscle relaxants are of limited use, and clinical studies have not proven their efficacy. Opioids Salicylates, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs)

B. Scoliosis GENERAL INFORMATION

It is the lateral curvature of the spine usually associated with a rotary deformity that eventually causes cosmetic and physiologic alternations in the spine, chest, and pelvis.

Signs and Symptoms1. Prominence of one hip2. Deformity of the rib cage3. Prominence of one scapula4. Difference in shoulder height5. Unequal breast size6. Clothes that do not fit right, skirt hems are uneven

TYPES OF SCOLIOSIS:a. Functional Scoliosis- Postural scoliosis

- C shape curvature - corrected by improving posture, exercise

b. Structural Scoliosis - permanent, hereditary deviation - S shape curvature - require braces and surgery

ETIOLOGY STRUCTURAL SCOLIOSIS

1. Idiopathic

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a. Adolescent - most common - 10 to 15/16 - F > M

b. Juvenile - age 4 – 9 - F > M

c. Infantile – from birth to 3 - M > F

Theories of structural Scoliosis Asymmetric muscle weakness Bone malformation Minor disorder of proprioception and balance due to labyrinthine disorder Abnormal distribution of muscle spindle of the paraspinal muscle

2. NEUROMUSCULAR/PARALYTIC SCOLIOSIS- due asymmetrical paralysis of the muscles that stabilizes the spine.- e.g. CP, traumatic quadriplegia, poliomyelitis spinal muscular atrophy,

progressive muscular dystrophy, Friedreich’s ataxia, myelomeningocoele, Charcot-Marie Tooth, etc.

3. OSTEOPATHIC (Congenital) SCOLIOSIS- hemivertebra - failure of segmentation producing 2 or more vertebral bodies united in a single

mass of bone (block vertebra).

B. NON-STRUCTURAL SCOLIOSIS Leg Length Discrepancy

1. True2. Apparent

Spasm of the Back1. Sciatic scoliosis- may be due to posterolateral disc protrusion in the lumbar

spine Habitual asymmetric posture Nerve root irritation Contracture of the hip

DIAGNOSTIC TESTS:1. X-ray2. Scoliometry

MEASUREMENT TECHNIQUE1. RISSER-FERGUSSON METHOD2. COBB METHOD3. Greenspan Technique4. NASH-MOLE SCALE

Treatment and THERAPEUTIC MANAGEMENT

A. NON-SURGICAL1. Bracing

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a. Milwaukee brace- an individually adapted steel and leather brace that extends from a chin cup and neck pads to the pelvis, where lumbar pads rest on the hips

b. Low profile or underarm brace- absence of neck ring

NURSING CARE TO PATIENT WITH BRACES:a. Patient should wear braces continuously for 23 hours a dayb. Encourage the patient to complete the therapyc. Advice patient to wear cotton undershirts under braces; loose garments over bracesd. Inform patient about some activity restrictionse. Inform patient about weaning period

2. Exercises Pelvic Tilt Abdominal exercises Swinging Hanging on a bar

3. Electrical Stimulation- used in conjunction with exercise or brace regimen or alone4. Casts- Reiner or Turnbuckle cast5. Traction- Halo traction to immobilize the head and neck

B. SURGICAL MANAGEMENT1. Harrington rods2. Dweyer instrumentation3. Lugue rods

C. POTT’S DISEASEIs the most common site of tuberculosis in children and adults usually occurring in the thoracic

or cervical regions. It tends to start in the vertebral end-plate and spreads to the adjacent disc.

Etiology Home environment Family history of pulmonary tuberculosis Nutritional status History of trauma

TYPES Cervical Thoracic Lumbo-sacral

Signs and Symptoms Weakness of the lower extremities Kyphosis deformity Low grade afternoon fever Pain and malaise with weight loss accompanied by wasting of the back muscles. Limited neck movement Swelling and abscess Gibbus formation

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TREATMENT Head halter traction Anti-TB drugs Bracing Build up resistance of the patient through:

- Vitamins- Isoniazid- Pyrazinamide- Etambutol- Rifampicin- Streptomycin

Surgical fusion

Congenital Malformations

Talipes Calcaneo-Valgus Talipes Equino-Valgus or VerticalTalus Talipes Equino-Varus Metatarsus Adductus Infantile (CONGENITAL) Coxa Vara Slipped Upper Femoral Epiphysis Recurrent Dislocation of the Patella Genu Valgum (Knock-Knee) Tibia Vara (Blount’s Disease) Pseudoarthrosis of the Tibia Pes Planus Calcaneal and Navicular Exotoses