FOR MEDICS-TOUGH MINDS

1. ORTHOPEDIC
NURSING

2. Course content
Review of anatomy and physiology of musculoskeletal system
Bone disorders
 Scoliosis
 Kyphosis
 Lumbar lordosis
 Osteoporosis

3. Osteomalacia and rickets
Bone tumors
Osteomyelitis
Fractures
Soft tissue injuries

4. Joint disorders
 Rheumatoid arthritis
 Osteoarthritis
 Amputation
 Gout

5. Review of A & P
Bone – type of connective tissue
Main components
 Water, living cells, calcium and phosphorus
 Cells that make up the bone
Osteoblasts and osteoclasts
 Hardest tissue in the body

6. Fully developed comprises of:
• Water 20 %
• Organic material 30% to 40%
• Inorganic materials 40% to 50%
Inorganic – calcium and phosphates
Organic materials comprise of bone cells

7. Two types of bone tissue
 Compact and cancellous.
 Covered by periosteum
 Periosteum gives attachment to muscles.
Types of Bones

8. Bone development
Process of bone formation
Ends at the age of 25 years
Osteoblasts and osteoclasts involved in bone
development
Osteoblasts present at centers of ossification
They are involved in bone building

9. Osteoclasts responsible for bone resorption
Maintain and shape the bone
The skeleton
 ٪into two:
• the axial skeleton and
• the appendicular skeleton

10. Axial skeleton – the central
Appendicular – the attachments
Axial skeleton made of:
 Skull, vertebral column,
 Ribs and the sternum

11. Appendicular skeleton consists of:
 Shoulder girdle, upper limbs,
 Pelvic girdle and lower limbs
Total bones at least 206

12. .

13. Functions of bones
1. Provide basic framework of the body
2. Provide points of attachments to muscles and tendons
3. Form a reservoir for calcium
4. Permit movement of the body
5. Contain red bone marrow

14. Joints
Def. Points of bone attachment
3 main types of joints:
 Fibrous joints
 Cartilaginous joints
 Synovial (diarthrosisl) joints

15. Movements of joints
Flexion
Extension
Abduction
Adduction
Eversion:
Inversion
Supination
Pronation
Rotation
Circumduction

16. DISORDERS OF BONES
Results from:
• Altered growth and development
• Disordered metabolism
• Neoplasm
• Injuries and their complications.

17. Scoliosis
Def: Lateral deviation of the spinal column
Causes
• Idiopathic
• Certain diseases e.g. poliomyelitis

18. Manifested by:
 Uneven shoulders
 Prominent scapula
 Asymmetry of the flanks
 Asymmetry of the thoracic cage.
 Rib humps

19. Scoliosis

20. Kyphosis
 An exaggeration in the curvature of the thoracic spine
Lumbar lordosis
 An exaggeration in the curvature of the lumbar spine

21. 1st – Lordiosis 2nd –Kyphosis

22. Osteoporosis
Definition:
 A disorder in which the rate of bone reshaping
(resorption) is greater than the rate of formation.

23. Major Risk Factors
 Personal history of fracture
 Cigarate smoking
 Low body weight
 > than 3/12 oral corticosteroid use
 Sex – > in female
 Increased age

24.  Inadequate intake of calcium & vitamin D
 Lack of physical activity
 Family history
Signs and symptoms
 Loss of height
 Bone and Back pain

25. Diagnosis
 X-ray studies – Determine bone density
 Ultrasonography
Management
 Calcium rich diet e.g.
Milk cheese & Yogurt

26. Exercise to increase bone density
Avoid alcohol, caffeine and smoking
Hormonal replacement therapy
Maintain optimum body weight

27.  Institute measures to avoid pathological fractures
 Prevention of home accidents
 Supplementation of vitamin D
 Calcium and phosphorous intake

28. Osteomalacia & rickets
Definitions
Rickets
 Disease of growing bones in children in which defective
mineralization occur bones and cartilage

29. Osteomalacia
 Disorder of mature bones in adults in which
mineralization of new osteoid bone is inadequate or
delayed.

30. Causes of rickets & osteomalacia
Nutritional deficiency – Lack of vitamin D
Malabsorption
Inherited rickets
Drugs
 Phynobarbitone, Phenytoin

31.  Renal causes – renal osteodystrophy
Rickets clinical feature
 Failure to thrive
 Apathetic; Anemic
 Lower body weight
 Excessive sweating especially face and hands

32. Rickets clinical feature
Widening of sutures
Delayed dentition
Respiratory infection
Pigeon chest
Widening of wrists and ankle

33. Abdomen prominent
Muscle weakness
Floppy & delayed walking

34. Deformity sets in
Toddlers have bow-legged legs

35. Osteomalacia clinical features
Bone pain, backache & bone tenderness
Proximal muscle weakness
Fracture
Kyphosis
Knock knee

36. Management
Diet changes.
 High doses of vitamin D
 Given for several months, depending on the severity
 Sunlight.
 Encouragement to get outside & get sunshine

37. Surgery
 Severe cases, children may need to wear braces
 Surgery may also be an option
Treatment of underlying cause
Mineral supplements

38. Bone tumors
 Bone tumors include:
Fibromas, chondrosarcoma,
Osteosarcoma
Multiple myeloma

39. Conditions associated with bone tumors:
 Infections,
 Pathological fractures
 Anemia among others
Manifestations
 Bone pain lasting >1/52

40. Unexplained swelling
Warm skin over affected bones
Prominent veins
Bone tumors are rare in adults

41. Management
 Chemotherapy
 Steroids
Goals of management
 Ensuring satisfactory pain relief
 Encouraging patient to accept body image
 Decreasing the possibility of injury

42. Osteomyelitis
Def: Infection of the bone.
Ways of bone infection:
 Extension of soft tissue infection
 Direct bone contamination
 Hematogenous spread from other sites

43. Pathophysiology
Initial response to infection is:
 Inflammation ↑ vascularity, and edema
 After 2 or 3 days, thrombosis occur
 Ischemia follows with bone necrosis.
 Infxn extends to:
Medullary cavity, under the periosteum

44. May spread into adjacent soft tissues & joints
Bone abscess forms with no Rx.
Abscess cavity contains dead bone tissue (the
sequestrum),
New bone growth (the involucrum) forms
Surrounds the sequestrum

45. Clinical manifestations
 Septicemia
 infected area becomes painful
 Warm, and tender to touch.
Diagnosis
 Magnetic resonance imaging

46.  Blood studies
 Wound and blood culture studies
 X-ray
Prevention
 Current infection postphone elective orthopedic
surgery

47. • Avoid direct bone contamination during surgery
• Prophylactic antibiotics be4 & after surgery
• Urinary catheters and drains removed immediately
• Aseptic postoperative wound care
• Prompt management of soft tissue infections

48. Goals of management
1. Pain and fever control
2. Prevents transmission to other areas
3. Decrease complications of bone fractures
4. Maintain positive outlook to Rx. plan

49. Medical management
 Antibiotic therapy depends on cuture
 Affected area immobilized
 Warm wet soaks for 20 minutes
Surgical management
 Antibiotic-impregnated beads
 Infected bone is surgically exposed

50.  Surgical debridement – Adjunctive(antibiotic)
 Sequestrectomy is performed.
Nursing management
• Close monitoring of the patient,
• Promotion of drainage,
• Use of fluids

51.  Immobilization,
 Good nutrition to the patient,
 Use of antibiotics,
 Use of assistive devices – crutches,
 Minimizing infection and
 Patient education

52. FRACTURES
Definition –A break in the continuity of a bone
Causes
 Direct blows
 Crushing forces
 Sudden twisting motions
 Extreme muscle contractions

53. Fractures ct….
Types of Fracture
 Avulsion

54. Compression

55. Stress fracture
 Tiny cracks in a bone results from repeated loading

56. Impacted fracture
Broken bone wedged into another

57. Green stick fracture
Crack on one side of a long bone

58. Closed fracture
Fracture with no open wound

59. Open fracture (compound, or complex
Fractured bone exposed to external environment

60. Extracapsular fracture
• Fracture near joint outside the capsule

61. Intracapsular fracture
• Occur within capsule of hip joint

62. Comminuted fracture
Bone splintered into fragments

63. Longitudinal fracture
Break runs parallel with the bone

64. Transverse fracture
Break runs across the bone

65. Oblique fracture
Break runs in a slanting direction

66. Spiral fracture
Break coils around the bone

67. Pathologic fracture
Break is at the site of bone disease

68. Depressed fracture
Piece of skull is broken off

69. Bone healing
Occurs in four areas
 Bone marrow
 Bone cortex
 Periosteum
 External soft tissue

70. Process of fracture healing
Hematoma and inflammation
Angiogenesis and cartilage formation
Cartilage calcification
Cartilage removal:
Bone/callus formation
Remodeling

71. Factors affecting bone healing
 Infection  Age
 Poor alignment
 Contuning movement of bone ends
 Poor blood supply
 Excessive bone tissue fragments
 Fat embolism in medullary canal

72. Factors favorable for bone healing
Good application
Immobilization
Good blood supply
Absence of infection

73. Effects of fractures
Soft tissue edema
Hemorrhage into muscles and joints
Ruptured tendons
Severed nerve, Joint dislocation
Damaged blood vessels
Damaged body organs

74. Clinical features of fracture
Pain
Loss of normal function
Obvious deformity
Excessive motion at the site
Crepitus

75. Clinical features ct…
Soft tissue edema
Warmth over injured area
Ecchymosis
Impairment or loss of sensation/paralysis
Signs of shock
Evidence of fracture on X-ray film

76. Emergency management of a fracture
Assessing ABC
Assessing any bleeding sites and controlling bleeding
Treatment of any life threatening injury
Immobilization by use of splints
Applying cold compresses
Elevating the extremity

77. • Minimizing mobility
• Monitoring the patient closely
Principle management of fractures
a) Fracture reduction
b) Immobilization
c) Rehabilitation (restoration of function)

78. Reduction
Definition:
 Restoration of the fracture fragments to anatomic
alignment and rotation
Methods used
 Open reduction
 Closed reduction

79. Closed Reduction
 Manipulation and manual traction.
 Extremity held in position splint applied
 X-rays – verify the alignment

80. Open Reduction
 Fragments reduced through surgery
 Internal fixation devices used
 Advantage – direct visualization
 Disadvantage – Anesthesia & risk of infection

81. Immobilization
Prevent movement of injured parts
Accomplished through:
External devices
 External devices e.g. splints
 Internal devices e.g. plates

82. Splints

83. Plaster cast

84. Techniques of internal fixation. (A) Plate and six screws for a
transverse or short oblique fracture. (B) Screws for a long
oblique or spiral fracture. (C) Screws for a long butterfly
fragment.

85. (D) Plate and six screws for a short butterfly fragment. (E)
Medullary nail for a segmental fracture.

86. Rehabilitation
 Reduction and immobilization to promote healing
 Swelling controlled through elevation
 Monitor neurovascular status
 Cx. restlessness, anxiety, and discomfort
 Isometric and muscle-setting exercises

87. Specific care for a patient with an internal
fixation device
Patient Education
Promoting Mobility
Maintenance of immobilization
Prevention of neurovascular problems

88. Nursing management for Fracture
Patients with closed fractures
 Encourage return to usual activities
 Teaching how to cx swelling and pain
 Exercises to maintain health of unaffected muscles
 Teach use of assistive devices safely

89.  Modification of their home environment
Patients with open fractures
 Risk of osteomyelitis, tetanus, and gas gangrene.
 Administration of tetanus prophylaxis
 Serial irrigation and debridement
 Intravenous antibiotics
 Removed of devitalized bone fragments

90.  Treatment of any damage to:
Blood vessels, soft tissue
Muscles, nerves, & tendons
 Heavily contaminated wounds left unsutured
 Wound irrigation and debridement repeated
 Wound closed in 5 to 7 days

91. • Elevation
• Monitoring patient’s temperature regularly

92. Traction
Def” Steady pull on a body part
Method of reduction and immobilization
Skin traction pull transmitted to skin
Skeletal traction, force applied to bone
Weights are used to maintain traction
Traction force must be maintained throughout

93. Skin traction

94. Skeletal traction

95. Other forms of traction
Manual Traction
 Persons hands exerts a pulling force
Fixed Traction
 Pull is exerted against a fixed point
Balanced Traction
 Pull is exerted against an opposing force

96. Indications
To reduce a fracture
Maintain alignment
Overcome and minimize muscle spasm
Correct deformities
Immobilize fractures;
Increase space between opposing surfaces.

97. Principles of effective traction
1. Whenever traction is applied, counter-traction must be
used
2. Traction must be continuous to be effective
3. Skeletal traction is never interrupted
4. Weights are not removed unless intermittent traction is
prescribed

98. 5. Eliminate any factor that might reduce the effective
pull
6. Patient must be in good body alignment in the
center
7. Ropes must be unobstructed
8. Weights must hang free and not rest on the bed or
floor.

99. 9. Knots in the rope must not touch the foot of the bed.
Types of traction
oStraight or running traction
 Applies the pulling force in a straight line
oBalanced suspension
 Supports affected extremity off the bed

100. oSkin traction: Applied to the skin
oSkeletal traction
 Applied directly to the bony skeleton

101. Casts
Def: Rigid external immobilizing device
Purposes of a cast
• Immobilize a reduced fracture
• To correct a deformity
• Apply uniform pressure to underlying soft tissue
• Support and stabilize weakened joints

102. Casting materials
Non-plaster:
 Referred to as fiberglass casts
 Water-activated polyurethane materials
 Lighter in weight than plaster
 Stronger, water resistant, and durable

103. Non-plaster cast

104.  Do not soften when wet
Plaster
 Rolls of plaster bandage wet in cool water
 Applied smoothly to the body
 Crystallizing reaction occur hence rigid dressing
 While damp, its dented

105. Plaster cast

106.  Requires 24 –72 hours to dry completely
Specific casts mngt. considerations
Arm casts
Nursing interventions
 Elevating immobilized arm to cx. swelling
 Sling used when patient ambulates.

107. Leg casts
Nursing interventions
 Supporting leg on pillows to heart level
 Elevate casted leg when seated
 Recumbent position several times a day
 Assessment of circulation

108.  Assessment of nerve function
 When hard and dry teach ambulation
Body or spica casts
Nursing interventions
 Preparing and positioning the patient
 Explaining the procedure

109. Reassuring the patient
Medications for pain relief and relaxation
Pillows positioned next to each other
pillow not placed under head & shoulders
Turning towards uninjured side 2 hourly
Avoid twisting the patient’s body

110. Pt. to assist in repositioning – trapeze or bed rail
Inspect skin around cast edges
Bath & massage under the cast edges
Perineal opening large enough for hygienic.
 Teaching family members how to care

111. Managing a patient with splints and braces
Contoured splints of plaster used for conditions:
 Don’t require rigid immobilization
 Anticipation of swelling
 Require special skin care.
Splint must be well padded to prevent pressure
Overwrapped with an elastic bandage

112. Assessment of the neurovascular status and skin integrity
For long-term braces are used to:
Provide support,
Control movement, and
Prevent additional injury

113. Braces may be constructed of:
 Plastic materials, canvas,
 Leather, or metal.
Orthotist adjusts the brace for fit
The nurse :
 Teaches pt. how to apply

114. Assesses neurovascular integrity and comfort
Encourages the patient to wear the brace
Reassures that adjustments ↑ comfort

115. Complications of fractures
Two categories:
Early and delayed
Early complications include:
 Shock
 Fat embolism
 Compartment syndrome

116. Deep vein thrombosis
Thrombo-embolism(pulmonary embolism),
Disseminated intravascular coagulopathy,
Infection

117. Compartment syndrome
Pressure build up to dangerous levels
Reduces blood floor – reduced muscle nourishment
Medical emergency
Caused by:
Fracture; badly bruised muscles
Crush injuries; constricting bandage

118. Compartment syndrome

119. Delayed complications include:
• Delayed union and nonunion,
• Avascular necrosis of bone,
• Reaction to internal fixation devices,
• Complex regional pain syndrome
• Heterotrophic ossification.

120. Nursing intervention to prevent fracture
complications
Promoting self-care:
 Proper use of ambulatory aids
 Proper positioning of the affected extremity
 Pain and discomfort relief measures
Mobility/promoting activity
 Perform muscle toning exercises

121.  ADL within limits of immobilization
Promoting comfort
 Administration of antispasmodics
 Reposition the patient frequently
 Apply ice compression

122. Maintaining intact neurovascular status& tissue perfusion
Palpating for warmth
Observing for color
Assessing for positive Homan’s sign
Measures to promote venous blood flow

123. Preventing infection
 Observe aseptic technique
 Monitoring drains for correct placement
 Performing pin site care
 Balanced diet

124. Maintaining skin integrity
 Care of bony prominences
 Inspecting skin for signs of pressure
 Turning the patient 2 hourly

125. Soft Tissue Injuries
Contusion,
 Produced by blunt force
 Blood vessels rupture & bleed to STI (ecchymosis)
 Cold application necessary
 Resolve in 1 to 2 weeks

126. Strain (muscle pull)
 Incomplete muscle tears with some bleeding
 Caused by:
Overuse, overstretching, or excessive stress.
 Strains are microscopic

127. Sprain
 Injury to ligaments surrounding joints
 Caused by wrenching or twisting motion
 Blood vessels rupture and edema occurs
 Joint tender, & movement becomes painful
 X-ray obtained to r/o bone injury

128. Avulsion
 Bone fragment pulled away by ligament or tendon
 May be associated with a sprain.
Treatment of STI
 Acronym RICE
 Rest, Ice, Compression, Elevation

129. oRest
 Prevents additional injury
 Promotes healing
oIce application
 Moist or dry cold applied intermittently

130. oCompression,
 Elastic compression bandage controls bleeding,
 Reduces edema,
 Provides support for the injured tissues
oElevation controls the swelling

131. Joint disorders
Rheumatoid arthritis
 Systemic inflammatory diseases affecting synovial
joints
oDiagnosis
 History
 X-ray – narrowing of joint spaces
 CBC – Mild leukocytosis

132. Clinical features of arthritis
Early Signs
 Fatigue
 Weight loss
 Pain at rest and with
movement
 Morning stiffness
Late Signs
 Pallor
 Anemia
 Joint deformities
 Contractures

133.  Rheumatoid factor
Nursing interventions
 Comfort/ Proper positioning of limb
 Independence
 Reducing fatigue
 Mobility and prevention of injury

134. Degenerative joint disease(osteoarthritis)
Def: A condition affecting one or more joints
characterized by degeneration of joint tissue
Classification
 Primary – Idiopathic
 Secondary – Resulting from previous joint injury

135. Risk factors
 Increased age
 Obesity
 Previous joint damage
 Repetitive use (occupational or recreational)
 Anatomic deformity

136.  Genetic susceptibility
Clinical Features
 Pain in affected joint
 Muscle spasms
 Stiffness
 Shortening ligaments

137.  Joint deformity
 Functional impairment
Diagnosis
 Based on evaluation and history
 X-ray – narrowing of joint space

138. Medical management
Analgesics, opioids and intra-articular corticosteroids
Glucosamine and chondroitin,
Viscosupplementation – Intra-articular injection of
hyaluronic acid

139. Conservative treatment
Use of heat,
Weight reduction,
Joint rest
Avoidance of joint overuse,
Orthotic devices to support inflamed joints (splints,
braces),
Isometric and postural exercises, & aerobic exercise.

140.  Occupational and physical therapy
Surgical management
 Osteotomy
 Arthroplasty.
 Viscosupplementation (Reconstitution of synovial fluid
viscosity).
 Tidal irrigation

141. Post-operative management
Proper positioning of the patient
Vital signs observation
O2 for 1st 6 hours to improve perfusion.
Observing incision site for bleeding
Pain management control
Ambulation & Nutrition

142. Joint dislocation
Definition
 A condition in which the articular surfaces of the bones
forming the joint are no longer in anatomic contact.

143.  Sub-luxation
 Partial dislocation of the articulating surfaces.
Traumatic dislocations are orthopedic emergencies
If not treated promptly, avascular necrosis

144. Dislocations may be:
 Congenital,
 Pathologic
 Traumatic;
 Weakened muscles
 Inflammatory conditions

145. Signs & symptoms
 Pain
 Change in contour of the joint,
 Change in the length of the extremity,
 Loss of normal mobility, and
 Change in the axis of the dislocated bones
 Swelling

146. Nursing management
Immobilization of the affected joint
Prompt reduction of the dislocation
Neurovascular status is monitored
Providing comfort
Teaching patient how to mx. immobilizing devices

147. Amputation
Def: Removal of a body part, usually a limb or part of a limb
Amputation is necessary due to:
 Progressive peripheral vascular disease
 Severe burns
 Severe congenital deformities
 Malignant tumors

148.  Fulminating gas gangrene,
 Trauma
 Chronic osteomyelitis
 Amputation is used to
• Relieve symptoms,
• Improve function,

149.  Save or improve the patient’s quality of life.
 Levels of amputation
 Performed at the most distal point
 Below-knee amputations
 Knee disarticulations
 Above-knee amputations

150.  Staged amputation
Post-operative care
 Ensure good wound drainage
 Administration of antibiotics
 Monitored for:
Hemorrhages, vital signs & wound drainage

151.  Physiotherapy.
 Pain management
 Care of skin at stump area
 Muscle strengthening
 Soft compression dressings - cx edema
 Education on use of prostheses

152. GOUT
Def: Condition characterised by the deposition of
monosodium urate crystals in joints or soft tissue
Accumulation of uric acid
Crystallize causing joint inflammation & destruction
Uric acid concentrations btn 3.6 and 8.3 mg/dL

153. Symptoms
 Joint pain starting with distal joints
 Aggravated by:
Infections, cold weather &
Consumption of meals rich in purines

154. Four phases of gout
1. Asymptomatic hyperurecemia (early phase)
2. Acute gouty arthritis (acute phase)
3. Intercritical gout (remission)
4. chronic tophaceous gout (chronic gout)

155. Causes of gout
 Raised levels of uric acid
 High intake of purine rich foods
 ↑ alcohol intake particularly beer & wine
 Genetics
 Obesity
 Drugs – chemotherapy

156. Management
 High blood pressure
 Drugs or medications-
Management
Mainly preventive
 Avoid acute gout attacks

157. • Anti-gout medication
• Avoid roasted meat
• Drinking lots of fluids