Nursing Study: Musculo

Orthopedic Nursing – application of good posture and body mechanics in all nursing activities

TERMINOLOGIES:

ADL- activities of daily living

AMBULATE – to walk

AMPUTATE – to remove a part of the body in any of the upper and lower extremity

AKA – above knee amputation

BKA below knee amputation

AEA- above elbow amputation

BEA- below knee amputation

APHASIA- inability to speak

ATAXIA- failure of muscle coordination

Atrophy –reduction in size of muscle organ

Atonic – absence of muscle tone

Arthro- joint ( articulation)

Arthritis – inflammation of the joint

Arthrometer/Ganiometer – instrument used to measure ROM of joints

Arthrodesis – surgical fusion of a joint

Arthtrotomy – surgical incision/opening of the joint

Contractures – loss of normal ROM due to shortening of tendons, ligaments and muscle, and due to immobility

Crutch – a supportive device for walking, having a padded crosspiece that rest on the chest wall next axilla and a grip for the hand

Cane – another supportive device for walking wherein it is grip by the hands

COXA – hip joint

COXA PLANA – indicates a flattening of the epiphysis of the head of the femur

CAVUS – hallow feet

CHONDRO – cartilage, connects bone to bone

CUBITUS – elbow

MYO- muscle

Syndactyly – webbing of fingers and toes

Macrodactyly- overdevelopment of one or more fingers and toes

Adactylism – absence of fingers and toes

Polydactylism- supernumerary digits of fingers and toes

OSTEO- bone

Osteoclasis- a surgical fracturing of bone by means of an osteoclast

Osteocyte – mature bone cell that maintain living bone but do not form new bone

OSTEOGENESIS IMPERFECTA – brittle bone-a congenital or inherited disease of the skeletal system characterized by bluish discoloration of sclera, curvature of the long bones, prone to be re-fractured so easily and calcium content is far below the normal level

OSTEOMALACIA – softening of bones, as in patient with Rickets in children.

Paralysis/plegia – complete loss of motor function or sensation

Paraparesis – incomplete loss of motor function and sensation of both lower extremities

Prosthesis – a replacement of a loss part of the body especially the limbs after has been healed

ROM – range of motion the degree of a joint that can attain

SPONDYL – vertebrae

SPONDYLOLISTHESIS –forward displacement of 5^th lumbar vertebrae on the sacrum a distance of half its width

Tenotomy – surgical incision of the tendon

Tenoclasis – Securing tendon to the bone

Talipes – ankle and foot-/ TALUS – ankle/PES- foot

Talipes Equinus – foot is in plantar flexion position ( foot drop)

Talipes calcaneus – foot is in dorsiflexion position, patient walk using his heel

Talipes Varus – foot inversion wherein sole of the foot is facing the medial direction

Talipes Valgus – foot eversion so that the sole of the foot is facing the lateral direction

Talipes Equino varus /Clubfoot – congenital deformity characterized by plantar flexion, forefoot adduction and inversion of taller joint

Talipes Equino Valgus – plantar flexion, forefoot abduction and eversion of ankle joint

Talipes Calcaneo Varus – dorsiflexion, inversion of the ankle

Talipes Calcaneo Valgus – dorsiflexion and eversion of ankle

T.A.L – tendon of Achilles Lengthening                                         R.A.E.F – Roger Anderson External Fixation

T.B.W- Tension Bond Wiring                                                            A.D.S.F – Anterior Decompression Spinal Fusion

P.S.R- Progressive Surgical Release                                  I.M – Nailing – Intra-medullary Nailing

S.T.S.G- Split Thickness Skin Grafting                                            B.G – Bone grafting

G.S.W – Gun shot wound                                                                   P.R.H.P – Partial Replacement of Hip Prosthesis

A.B. Beads – antibiotic beads                                                           G.C.T.- Giant Cell Tumor

P/3 – proximal third                                                                            M/3 – middle third

D/3 – distal third                                                                                  L.L.C.C- long leg circular cast

S.l.C.C – short leg circular cast

Musculoskeletal trauma

Contusion- injury of soft tissue- treated with cold application for 24 H followed by moist heat, apply elastic bandage

Strains- muscle pull-

Sprains- torn ligament

                - treated with rest and elevation of affected part, intermittent ice compress for 24 H, followed with heat application, apply elastic pressure bandage, minimize use

Dislocation- displacement of joint bones –considered orthopedic emergency, treated with immobilization and reduction, bandages, splints, immobilize

Fracture- any break/ discontinuity of the bone

                S/S- swelling, pallor, ecchymosis, loss of sensation to body parts, deformity, pain and acute tenderness, muscle spasm, loss of function, abnormal mobility,CREPITUS- grating sound, shortening of the affected limb, decreased or absent pulses, affected limb is colder than the contralateral limb

Etiology:

1. Pathologic fx – due to general bone loss or bone disease causing the bone to be unduly brittle which predisposes fx even with minimal traumatic force

2. Traumatic fx- can be violence, muscular action

S/S :  1. sx of local trauma or inflammation =pain ( dolor), swelling ( tumor ), redness (rubor),calor (heat) loss of fxn

          2. bruises or ecchymosis

          3. presence of deformity

          4. crepitus sound

Classifications:

1. Incomplete fx.- the bone is being bent and the convex part is fractured/ fissured fx, perforating fx, depressed fx, compression fx.

2. Complete fx – separation in the epiphysis/ simple/closed/compound,impacted, comminuted, complicated

3. transverse

4. oblique

5. spiral

6.avulsion – forcible tearing away of the bone fragments

7. Colles  fx – ( Silver Fork deformity ) fx of the distal epiphysis of radius within ½ to 1 inch of articular surface

8. Codylar fx- fx of round end of hinge joint usually occur at distal humerus or femur

9. Galleazi’s fx – fx of distal radius with dislocation of distal ulna

10. Hangman’s fx – fx of posterior elements of cervical vertebrae with anterior dislocation of 2^nd and 3^rd cervical vertebrae

11. Intercondylar fx – fx between condyles of bone

12. Intertrochanteric fx – fx of femur in the greater and lesser trochanter

13. Jefferson;s fx – bursting type of fx at the ring of atlas

14. Malgaine fx – fx both superior and inferior pubis rami of the pelvic bone

15. Monteggias’s fx – fx of proximal third of ulna associated with radial dislocation

16.Pillon fx – T-shaped fx of distal femur with displacement of condyle posterior to femoral shaft

17. Pott’s fx – fx. Dislocation of the ankle joint

18. Smith’s fx.- fx of the lower end of the radius with anterior displacement

Complications of Fracture

1. Fat emboli- caused by fracture of long bones
2. Hemorrhage
3. Delayed union-healing is slows, caused by infection or distraction of fractured fragments, increase in bone pain

4. Malunion- improper alignment of fracture fragments, may develop with premature weight bearing

5. Nonunion- healing has not occurred 4-6 months after fracture, insufficient blood supply, repetitive stress on fracture site, infection, inadequate internal fixation, treated by bone grafting, internal fixation, electric bone stimulation

6. Sepsis

7. Compartment syndrome- high pressure within a muscle compartment of an extremity compromises circulation, pressure may be internal or external, if untreated, neuromuscular damage occurs within 4-6 H, limb can become useless within 24-48 H, pain is unrelieved by medication

8. Peripheral nerve damage

Implementation

1. Provide emergency care- immobilization, open fracture- cover with sterile dressing, direct pressure, check temperature, color, sensation, capillary refill distal to fracture, emergency –give narcotic pain reliever
2. Treatment- splinting, internal fixations by use of screws, plates, nails etc., open reduction-surgical dissection, closed reduction-manual reduction or traction of fracture
3. Traction- purposes: reduce fracture, alleviate pain and muscle spasm, prevent or correct deformities, promote healing

TYPES OF Traction:

1. Skin- pulling force applied to skin
2. Skeletal- pulling force applied to bone

Principles in the treatment of Fracture ( 4 R’s)

1. Recognition – check

2. Reduction- restoration of bone fragments ( closed= external or manual manipulation) open- restoration of bone fragments by direct visualization and surgical operation and putting internal fixation device

3. Retention – immobilizing the affected part by the use of immobilizing device such as cast, braces and splints

4. Rehabilitation – restoration to normal fxn

Indications or purposes of traction

1. immobilization

2. to prevent and correct deformity

3. to maintain good body alignment

4. for support

5. to reduce pain and muscle spasm

6. to reduce fracture

Stages of Fracture Healing

1. Hematoma Formation – cleaning occurs from the damaged bone ends ( 24-72 H )

2. Cellular proliferation – during the first wk after injury the hematoma becomes invaded an replaced by granulation tissue that is organized into fibrous tissue after 3 wks

3. Callus formation – is formed by fibroblast transform into cells capable of producing a matrix called OSTEOID in 3 weeks in children but in adult especially in bones with poorer blood supply maybe delayed until 2-3 months after injury. Callus will be remodeled into formed  into…

4. Remodeling – of bone which is  the final stage of fracture healing, this process takes many months

Care

1. Maintain straight alignment of ropes and pulleys
2. Assure that weights hang freely
3. Frequently inspect skin for skin breakdown areas
4. Maintain position for counter-traction
5. Encourage movement of unaffected areas
6. Investigate every complaint immediately and thoroughly
7. Maintain continuous pull
8. Cleans pins with half strength peroxide or saline and sterile swabs 1-2 times a day as ordered

BRYANT’S traction- realigns fracture, minimizes pain and muscle spasms, legs should be at 90 degrees angle to buttocks, buttocks should be OFF THE BED slightly, used for children under 40 lb/ 1-3 year old, check sensation of feet, toe motion, circulation. Vest used to anchor active child less than 1 year old with fractured femur/ no traction used

BUCK’S Traction- relieves muscular spam of legs and back, if no fracture, may turn to either side, with fracture, turn to unaffected side, 8-20 lb used, 40 lb for scoliosis, elevate foot of bed for counter-traction, use trapeze for moving, place pillow beneath lower legs not heel, don’t elevate knee gatch

Russell’s traction- pulls contracted muscles, elevate foot of bed with shock blocks to provide countertraction

                -sling can be loosened for skin care, check popliteal pulse, place pillows under lower leg, make sure heel OFF the bed, must not turn from waist down, lift patient not leg.

Cervical/Skull tongs- realigns fracture of cervical vertebrae, relieves pressure on cervical nerve, nerve lift weights-traction must be continuous, no pillow under the head during feeding, hard to swallow, may need suctioning

Balance Suspension- realigns fractures of the femur, uses pulley to create balanced suspension by countertraction to the top of thigh splint, Thomas splint( positioned over anterior thigh) with Pearson Attachment( supports leg from knee down) frequently used

Halo jacket ( vest)-preoperative straightening of scoliosis curvature,pins are used to maintain traction, care of insertional site includes cleansing area around pins using sterile technique,

4. Casting- provides rigid rigid immobilization of affected body part for support and stability, use plaster or fiberglass ( lighter weight, stronger, water-resistant, porous, diminishes skin problems, does not soften when wet, thus allowing for hydrotherapy)

- is an immobilizing device which is made out of plaster of paris ( consist of calcium, gypsum sulfate) mixed with water, it spells and sets rapidly to form a hard cement

Materials:

- stockinette, wadding sheet, gauze bandage, plaster of paris, pail or bucket, trimming knife

- positioning, padding – stockinette, wadding, gauze)

- soaking of plaster of paris in water

- Applying

- handling

- cleaning

- drying

- turning

CAST syndrome – is observed only to patient with cast involving to trunk and abdomen

                - s/s: vague abdominal pain, nausea and vomiting, pruritus

Casting Materials

1. Plaster of Paris- traditional cast

- Takes 24-72 hours to dry

-       Precautions must be taken until cast is dry to prevent dents which may cause pressure areas

-       Signs of a dry cast- shiny white, hard, resistant

-       Must be kept dry since water can ruin a plaster cast

2. Synthetic casts/ fiberglass

-       strong, lightweight, sets in about 20 minutes

-       Can be dried using cast dryer or hair blow dryer on cool setting

-       Water resistant, if becomes wet dry thoroughly

Cast drying- plaster paris

-       Use palms of hands, not finger tips

-       Support cast on rubber or plastic protected pillows with cloth pillow cases along length of cast until dry

-       Turn patient every 2 H to reduce pressure

-       Do not use heat lamp or hair dryer

Immediate Care:

                - avoid covering cast until dry( 48 H or longer), handle with palms not fingertips( plaster cast)

                - avoid resting cast on hard surfaces or sharp edges

                - keep affected limb elevated above heart on soft surfaces until dry, don’t use heat lamp

                -watch for danger signs- blueness or paleness, pain, numbness or tingling sensation on affected part + elevate casted area, persist, contact physician

Intermediate Care:

                - dry cast-patient should be mobilized

                - encourage prescribed exercises

                - REPORT ANY BREAK IN CAST OR FOUL ODOR FROM CAST

                - tell patient not to scratch skin underneath cast

                - + fiberglass gets wet, dry with hair dyer on cool setting

After Cast care

- wash skin gently

-apply baby powder, cornstarch, or baby oil

-inform swelling is common

- elevate limb and apply elastic bandage

- cast cleaning- use slightly damp cloth, mild soap can be use for fiberglass

-do not scratch or insert foreign bodies inside cast

- instruct 

DISORDERS:

1. Total Hip replacement- acetabulum, cartilage and head of femur replaced with artificial joint

1. Abduction of affected extremity use splints, wedge pillows
2. Turn patient as ordered
3. Ice to operative site
4. Overbed trapeze, initial ambulation use walker, 3 point gait
5. Don’t sleep on operated site
6. Don’t flex hip more than 45-60 degrees
7. Continuous passive motion device-used after knee replacement to prevent development of scar tissue, extends and flexes knee
8. Postoperative discharge teaching- maintain abduction, avoid stooping, never crosses the legs, avoid position of flexion during sexual activity, do not sleep on operated side until directed to do so, flex hip only to ¼ circle

2. Developmental Dysplacia of the Hip- acetabulum unable to hold head of femur

S/S-uneven gluteal folds and thigh creases/deeper on affected sites, limited abduction of hip with pain, ORTOLANI’s sign( seen-less than 24 mos.)- place infant on back, leg flexed, click sound heard when affected hip is moved to abduction)

                -shortened limb on affected side in older infant and child, delays in walking, limb, lordosis and waddling gait

Implementation:

1. Newborn 6 months- reduced by manipulation, splinting, use of Pavlik harness, encourage normal growth, maintain abduction
2. Discuss modification in bathing, dressing, diapering=harness not to be removed, sponge bath
3. Put undershirt chest straps and knee sox under foot and leg pieces
4. Check areas 2-3 times a day
5. Gentle massage, use of lotions/powders
6. Place straps under straps
7. Pad shoulders straps
8. 6-18 months- gradual reduction by traction, cast for immobilization
9. Older adult-traction, open reduction, hip spica cast

3. Scoliosis- lateral deviation of one or more vertebrae commonly accompanied by rotary motion

S/S- poor posture, uneven hips or scapulae, kyphosis lump on back, uneven waistline, visualization of deformity- bend at waist 90 degree

Types:

1. Functional – flexible deviation that corrects by bending
2. Structural- permanent, hereditary deviation

Care:

                - exercise, electrostimulation, surgery, Milwaukee brace-effective for 30-40 degrees curves not associated with extreme deformity, 4-6 year program, 23 H 1 H for personal hygiene, wear protective shirt under shirt, skin care for pressure areas, isometric exercises

4. Club Foot/ Talipes Equinovarus- rigid abnormality of talus bone at birth

S/S- inversion of heel, inversion/adduction of forepart of foot

Care:

                - foot exercises, casts/splints, surgery, use of DENIS_BROWNE- horizontal abduction bar with foot plates

Joint Disorders

1. Rheumatoid arthritis- systemic, pannus formation, bony ankylosis, progressive, remissions and exacerbations

S/S- joint pain, swelling, limitation of movement, contracture deformities, nodules over bony prominence, ulnar drift, high fever, rheumatoid rash in JRA, salmon-pink macular rash on chest, thighs and upper arms

Dx. Test

                - Latex fixation test-rheumatoid factor test, C-reactive CHON, ESR, aspiration of synovial fluid, x-rays

Care:

                - pain management, rest, activity, exercise, weight control, warm baths, splints, analgesics, anti-inflammatory

2. Osteoarthritis – non-systemic, spur formation, closure of joint spaces, degenerative, no remissions

S/S- joint pain, swelling, limitation of movement, Heberdene’s nodes of fingers

Dx. Test- x-rays, ESR, synovial aspiration

Care

                - pain management, rest, activity, heat application, analgesics, weight control

                -analgesics

3. Gout- non-systemic, disturbed purine metabolism, elevated uric acid in blood, tophi formation( deposits of urates in joints), exacerbations

S/S- joint pains, swelling, limitation of movement, contractures

Dx. Test- x-rays etc

Care:

                - pain management, diet avoid purine rich foods, analgesics

4. Paget’s Disease- unknown etiology, excessive bone resorption ( loss), occurs –males over 50 years old

S/S- pain, bowed legs, decreased height, shortened trunk with long appearing arms, enlarged skull, labored waddling gait, kyphosis

Implemenation:

                1. administer analgesics

                2. rest

                3. prevent pathological fracture, use safety devices

5. Bursitis – inflammation of connective tissues sac between muscles, tendons, bones, particularly affecting shoulder, elbow, and knee

S/S- pain, decreased mobility especially on abduction

Implementation:

1. Rest
2. Immobilize affected joint with pillows, splints,slings
3. Administer pain medication, muscle relaxants,steroids
4. Apply heat/cold packs
5. Promote exercise
6. Assist in performance of ADL
7. Assist with cortisone injection, draining of bursae

6. Osteoporosis – reduction in bone mass with no changes in mineral composition, degenerative disease characterized by generalized loss of bone density and tensile strength, common in females -45 years old

S/S – decreased height, low back pain, kyphosis

Implementation

1. diet- high in Calcium, CHON and Vit D
2. Estrogen
3. Weight bearing on long bones
4. ROM exercise
5. Physiotherapy
6. Safety precautions

7. Prevent bone resorption- administer calcitonin, a thyroid hormone that slows down bone loss

7. Osteomyelitis – infection of the bone caused by staphylococcus, carried by the blood from a primary site of infection

S/S- pain, swelling, redness, warmth on the affected site, fever, leukocytosis, elevated sidementation rate

Implementation

1. Bedrest
2. Medications, analgesics, antibiotics
3. Support affected extremity with pillows, splints,use room deodorant
4. Apply hear to affected area
5. Encourage fluid intake, monitor I and O
6. Asepsis in wound care
7. Provide diversionary activities
8. High CHON with sufficient CHO, vits. And minerals
9. Small frequent feedings

8. Osteomalacia- decalcification of bones due to inadequate intake of Vit D, absence of exposure to sunlight or intestinal malabsortion

S/S

                - bone pain and tenderness, muscle weakness, bowed legs, kyphosis, porous bones

Implementation

1. Analgesics
2. Bedrest
3. Maintain body alignment
4. Administer vit D, calcium and exposure to sunlight
5. ADL assistance

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