this ppt has 3 complete topics detaile of Paget's Disease, fracture of femur, care of the patient with plaster cast.

1. PAGET’S DISEASE
FRACTURE OF FEMUR
CARE OF THE PATIENT WITH PLASTER CAST
Presented by:
Monika
M.Sc Nursing final year
NINE, PGIMER, Chandigarh

2. PAGET’S DISEASE

4. ETIOLOGY
About 15% of people with Paget's disease have a
family history.
Both genetic and environmental factors
Autosomal dominant inheritance
Mechanical stress to bone
Vitamin D deficiency
Paramyxovirus infection
Most common in men

5. PATHOPHYSIOLOGY
• Paget's Disease Evolves Through Three
Distinct Phases
• An initial, short-lived burst of multinucleate
osteoblastic activity causing bone resorption
• A mixed phase of both osteoclastic and
osteoblastic activity, with increased levels of
bone turnover leading to deposition of
structurally abnormal bone
• A final chronic sclerotic phase, during which
bone formation outweighs bone resorption.

7. SIGNS AND SYMPTOMS
Most people who have Paget's disease of bone
experience no symptoms.
When symptoms do occur, the most common
complaint is bone pain which may includes:
Pelvis: hip pain.
Skull: hearing loss or headaches.
Spine:.tingling and numbness.
Leg: As the bones weaken, they may bend.

9. CONT….
Musculoskeletal Manifestation:
Bone and joint pain that is poorly described, and aggravated by walking
Low back and sciatic nerve pain
Loss of normal spinal curvature
Enlarged, thick skull
Pathological fracture
Osteogenic sarcoma.
 Skin Manifestation:
Flushed, warm skin.
 Other Manifestation:
Apathy, lethargy and fatigue

10. DIAGNOSTIC EVALUATIONS
Bone-specific alkaline phosphatase (BSAP) levels are raised.
Urinary excretion of deoxypyridinoline and N-telopeptide are elevated.
Serum calcium, phosphorus, and parathyroid hormone levels are
usually normal but immobilization may lead to hypercalcemia.
X-rays
Radionuclide bone scans
Bone biopsy

11. COMPLICATION
Fractures
Osteoarthritis
Deafness & Blurred vision or vision loss
Heart failure. Unusually extensive Paget's disease may force your heart to
work harder to pump blood to the affected areas of your body. In people
with pre-existing heart disease, this increased workload can lead to heart
failure.
Bone cancer. Bone cancer occurs in less than 1 percent of people with
Paget's disease

12. MANAGEMENT
NOON PHARMACOLOGICAL
Prevent fall
Exercise regularly
Eat well

13. PHARMACOLOGICAL MANAGEMENT
• NSAIDS effective for pain.
• Bisphosphonates or calcitonin
• They are thought to reduce bone turnover, improve bone pain,
promote healing of osteolytic lesions and restore normal bone
histology.
• Pamidronate, risedronate, and zoledronic acid are preferred.
• Any calcium and vitamin D deficiency needs to be corrected before
starting a bisphosphonate to avoid hypocalcemia.

14. SURGICAL MANAGEMENT
• In rare cases, you may require surgery to:
• Help fractures heal
• Replace joints damaged by severe arthritis
• Realign deformed bones
• Reduce pressure on nerve
• Orthopaedic surgical procedures to address symptoms include long bone
osteotomies, fracture fixation, spinal decompression, joint arthroplasty,
and tumour resection. The anatomical aberrations, abnormal bone
architecture.

15. NURSING DIAGNOSIS
• Acute pain r/t bone fracture s/t Paget's disease.
• Impaired physical mobility r/t disease process.
• Anxiety r/t disease process
• Risk for infection r/t surgical procedure.
• Risk for GIT ulcer r/t effect of the prescribe medication.
• Body image depict r/t disease process.

16. MANAGEMENT OF PATIENT WITH
PLASTER CAST

17. MANAGEMENT OF PATIENT WITH
PLASTER CAST
• Every orthopedic nurse must understand the basic principles of
plaster of Paris technique and identify complications and report
complications to the orthopedic surgeon immediately.

18. DRY SLAB
• Dry slab plaster is six
layers thick and 15 cm or
20 cm wide narrow slab.
Wet slabs are made when it is
required. Bandages are soaked in
plaster of paris mixture. It is
spread over the glass or enamel
surface and applied to the part of
the body.
WET SLAB
PLASTER SLAB

19. PLASTER OF PARIS
Plaster of Paris consists of calcium sulphate. It is also
called as gypsum. Gypsum swells up when water is
added. It becomes hard.
 PLASTER BANDAGE
Plaster bandage is the bandage when water is mixed in
gypsum and applied to a gauze bandage.

20. EQUIPMENT REQUIRED FOR APPLICATION OF PLASTER
Bandage and slab of correct size
Bowls or bucket of water
Warm water
Padding materials
Gloves, cotton and polythen sheet
Waterproof material
Plaster cutting knives.

21. METHOD
•Wear apron and gloves, spread polythen sheet over the
bed sheet to protect the bed linen and pillow.
•Soak plaster bandage in warm water soaked in
gypsum.
•Lift the bandages from the water and squeeze water.
•Free the end hand over the same to the operator.

22. CONT….
•Avoid hard lumps on the bandages which causes pressure
sores.
•Padding under the plaster is used when there is injury or after
surgery.
•Plaster is also applied over the stockinette.
•Bony prominence are also protected by applying padding.

23. POINTS TO BE REMEMBERED WHILE APPLYING PLASTER
Suitable padding to be applied
Position the patient
Hold the patient in correct position throughout the procedure
Avoid correction of position when plaster is partly applied
Edges should be smooth
Avoid pressure sores by applying padding under the skin
Protect bony prominence

24. A wet plaster must be handled with care
Do not attempt to transfer the patient when plaster is wet
Place fracture board under the mattress
Turn patient every 2-3 hours to prevent pressure sores.
Allow 48 hours for drying
Avoid walking with newly applied plaster for three days

25. IMPORTANT POINTS
Note temperature and color of the fingers and toes
Note pallor, cyanosis, swelling or loss of movements
Report all findings to the orthopedic surgeon
Observes nails for changes in color.

26. CAUSES OF PLASTER SORES
•Irritation caused by insects, bed bugs.
•Friction caused by the plaster against bony prominence.
•Foreign bodies are inside the plaster such as coins, beads,
food particles.
•Pressure is caused due to careless handling during molding
and drying.

27. TREATMENT OF PLASTER SORE
• Cut a window in the plaster, remove padding and expose the skin.
Daily moist dressing is done till the wound is healed.
• To prevent dermatitis, blow talcum powder through the window in
the plaster.
• If there is blister formation, blister is aspirated and antibiotic
powder is applied.
• Once the wound is healed window opening is closed with felt or
wool.

28. INSTRUCTION GIVEN TO THE PATIENTS
Inform date of next visit to the hospital
The patient is advised to remain recumbent if there is
swelling of the extremities
Allow the limbs to hang down
Report to a doctor if fingers or toes become blue or cold
Exercise non immobilized join

29. FRACTURE OF FEMUR

30. ANATOMY OF FEMUR
The femur is the longest and heaviest
bone in the body.
• The femur consists of
A shaft (body)
Superior or proximal end
Inferior or distal end

32. FRACTURE SITES
• The neck of the femur is most frequently fractured because it is the narrowest
and weakest part of the bone and it lies at a marked angle to the line of weight-
bearing.
• Fractures of the femoral neck often disrupt the blood supply to the head of the
femur.
• Fractures of the greater trochanter and femoral shaft usually result from direct
trauma.
• Intertrochanteric fractures usually runs from the greater trochanter through to
the lesser trochanter and does not involve the femoral neck.

33. DEFINITION
• A femur fracture is a break in the femur bone, the leg bone that extends from
the hip down to the knee joint. Since the femur is one of the largest and
strongest bones in the human body, it is not a common break and usually
occurs only after a serious trauma like a car accident or sporting injury.
• A femoral shaft fracture is defined as a fracture of the diaphysis occurring
between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor
tubercle occurs by chronic, repetitive activity that is common to runners and
military.

34. CLASSIFICATION OF FEMUR HEAD
FRACTURE
Pipkin Classification JBJS, 1957
• I Fracture inferior to fovea (Fx below fovea/ligamentum (small)
Does not involve the weightbearing portion of the femoral head)
• II Fracture superior to fovea (Fx above fovea/ ligamentum (larger)
Involves the weightbearing portion of the femoral head)
• III Fracture of femoral head with fracture of femoral neck (Type I or
II with associated femoral neck fx High incidence of AVN)
• IV Fracture of femoral head with fracture of acetabulum (Type I or
II with associated acetabular fx (usually posterior wall fracture))

35. CLASSSIFICATION FEMORAL NECK
FRACTURE
Garden classification
This is based on the degree of valgus displacement
• Type I Incomplete/valgus impacted
• Type II complete and nondisplaced on AP and lateral views
• Type III complete with partial displacement; trabecular pattern of
the femoral head does not line up with that of the acetabulum.
• Type IV complete displaced; trabecular pattern of the head assumes
a parallel orientation with that of the acetabulum

36. INTERTROCHANTERIC FRACTURES
•Extracapsular fracture of the proximal femur between the
greater and lesser trochanters.

37. SUBTROCHANTERIC FRACTURE
(RUSSELL-TAYLOR CLASSIFICATION)
• Based on integrity of the piriformis fossa.
Type 1 - intact piriformis fossa
• A - lesser trochanter attached to proximal fragment
• B - lesser trochanter detached from proximal fragment
Type II - fracture extends into piriformis fossa
• A - stable posterior-medial buttress
• B-comminution of lesser trochanter

38. FEMORAL SHAFT FRACTURES
• -femoral shaft fracture is defined as a fracture of the diaphysis
occurring between 5 cm distal to the lesser trochanter and 5 cm
proximal to the adductor tubercle
• -High energy injuries frequently associated with life threatening
conditions
DISTAL FEMUR FRACTURES
• Defined as fracture from articular surface to 5cm above
metaphysical flare
• -supracondylar fracture and intercondylar distal fracture

39. FEMUR FRACTURE CLASSIFICATION
• Type 0 - No comminution
• Type 1 - Insignificant butterfly fragment with transverse or short oblique
fracture
• Type 2 - Large butterfly of less than 50% of the bony width, > 50% of cortex
intact
• Type 3 - Larger butterfly leaving less than 50% of the cortex in contact
• Type 4 - Segmental comminution >> Winquist and Hansen 66A, 1984

40. RISK FACTORS AND ETIOLOGY
Fracture neck of femur:
90% occur to those over the age of 50.
Risk doubles every decade after fifty.
- These include the following:-
• Osteoporosis
• Female sex, increased age
• Excessive coffee or alcohol
consumption
• Smoking
• Dementia
• Defective vision
• Physical inactivity
• Arthritis
• Low BMI
• Living in an institution

41. RISK FACTORS ASSOCIATED WITH FEMORAL SHAFT
FRACTURES INCLUDE:
• Participation in rough, high-impact contact sports, such as football, basketball
• Advanced age (elderly adults are higher prone)
• Reduced bone mass (osteoporosis)
• Reduced muscle mass
• Excess body weight associated with obesity, which can cause increased pressure
on the joints
• High energy accidents
• Direct fall on the greater trochanter

42. CLINICAL MANIFESTATION
Sharp and sudden pain in the leg.
Swelling, tenderness, and possible bruising around the injury site
Noticeable deformity of the leg
Reduced range of motion of the knee or hip
Inability to put weight or pressure on the injured leg

43. Difficulty walking
Excessive pain
excruciating groin pain,
inability to bear weight
the extremity held in external rotation and mild adduction.
The pain is exacerbated by motion, particularly internal
rotation.
loss of internal rotation are also symptoms.

44. DIAGNOSTIC EVALUATION
History taking
Physical examination
X-ray
Bone scanning
MRI
CT scan

45. MANAGEMENT
• Femoral Shaft Fractures usually require surgical treatment. However,
children may occasionally be treated with a cast.
Intramedullary nailing: During an intramedullary nailing procedure, once
the bone is realigned, a specialized metal rod is placed within the bone
marrow canal of the femur. This metal rod is designed to hold the femur
bone in its original position
Physiotherapy
Open reduction and internal fixation (ORIF)
Hip replacement surgery: the acetabulum, and femoral head and neck are
all replaced

46. NURSING CARE
It is essential that the patient does not slip down the bed or the angle of
traction is altered.
External rotation of the limb must be prevented.
The sling under the knee must not become crumpled, or pressure-sores will
result. Foot exercises are practiced regularly.
The patient is at once made to sit up and is made comfortable on pillows
and a bed-rest.
The sitting posture is maintained continuously, and the patient can be lifted
on to a bedpan and turned from one side to the other.

47. SUMMARIZE THE TOPIC

48. REFERENCES
1. Sudddarth ‘s & brunner, “A Textbook of Medical-Surgical-Nursing”, Edition ten,
published by lippncott Williams & Wilkins,2008 pp 2018-2025.
2. Dewit,Stromberg,dallred, “Medical-Surgical-Nursing concepts and practice”,
edition 3rd , published by Elsevier, pp.1.
3. https://www.medindia.net/surgicalprocedures/fracture-neck-of-femur.htm
4. https://www.dovemed.com/diseases-conditions/fracture-of-the-femoral-shaft/