4. Connective Tissue Disorders (Sprain)
Sprain (Etiology and Pathophysiology)
• A sprain is a partial or complete tearing of the
ligaments that hold various bones together to form a
joint.
• A sprain occurs during trauma when a joint is forced
or twisted past its normal range of motion (ROM).
• The ankle, knee, and wrist are most the commonly
sprained joints.
6. Sprain
Signs, Symptoms:
• Grade I (mild): Tenderness at site; minimal swelling and loss of
function; no abnormal motion.
• Grade II (moderate): More severe pain, especially with weight
bearing; swelling and bleeding into joint; some loss of function.
• Grade III (severe, complete tearing of fibers): Pain may be less
severe, but swelling, loss of function, and bleeding into joint are
more marked.
7. Sprain
Diagnosis: is by physical and radiographic examination to rule out a
fracture or other pathology.
8. Sprain
Treatment: Nonsteroidal anti-inflammatory drugs (NSAIDs) should be
prescribed on an around-the-clock basis for the first couple of days to decrease
swelling.
• Ibuprofen, naproxen, diclofenac, celecoxib, mefenamic acid, indomethacin
9. Sprain
6/21/2022
Nursing Management:
• RICE: Rest, Ice, Compression, Elevation
• Apply Ice immediately after injury (24-72hrs, 10-20mins every 1-2 hrs)
• Wrap the injured part snugly with an elastic bandage
• Grade III sprains often require a cast.
• Patients with grade II or grade III sprains need to rest the joint; crutches are
needed for a lower extremity sprain.
10.
11. Strain
Etiology and Pathophysiology:
• A strain is a pulling or tearing of a muscle, a tendon, or both.
• A strain occurs by trauma, overuse, or overextension of a joint.
• The most commonly strained muscles are the back muscles.
• Muscle strains also occur in other skeletal muscles.
• The most common sites are the hamstrings, quadriceps, and calf muscles.
13. Strain
Signs, Symptoms:
• Bleeding (ecchymosis, hemorrhagic area) will be present if a muscle is torn.
• Pain or tenderness. * Limited motion.
• Swelling. * Muscle weakness
Diagnosis:
• A history of overexertion or the presence of soft-tissue swelling and pain may
indicate a strain has occurred.
• Physical Examination
• X-Rays
14. Strain
6/21/2022
Treatment:
• Anti-inflammatory medications are used for discomfort.
• When spasm is present, a muscle relaxant may be prescribed.
Nursing Intervention:
• RICE
• When compression is used, the distal parts of the extremity must be checked
for sensation and adequate circulation.
• Heat can be applied after 48 hours.
• Time is the greatest healer.
• The patient is cautioned against re-injury and is taught proper ways to lift and
move.
15.
16. Carpal Tunnel Syndrome
Etiology, Pathophysiology:
• Carpal tunnel syndrome is a nerve problem that occurs when the median
nerve is compressed as it passes through the carpal tunnel in the wrist.
• Repetitive movements of the hands and wrists, particularly with constant
flexion of the wrist, are contributing causes.
• Such movement occurs in certain types of factory work and in computer
keyboarding.
• Sometimes there is no known cause.
17. Carpal Tunnel Syndrome
Signs, and Symptoms:
• Pain,
• numbness,
• and tingling of the hand, particularly at night
Diagnosis:
• physical examination,
• a compression test,
• and possibly electromyography to rule out other causes of symptoms.
18. Carpal Tunnel Syndrome
Treatment:
• Rest, splinting,
• Changing the angle of the wrist during repetitive movements,
• Steroid injection may solve the problem.
• If the symptoms are of long duration, muscle atrophy occurs; if sensory loss
in the fingers and hands is progressive, surgery is indicated.
• Surgical decompression of the medial nerve by transection of the carpal
ligament is performed, usually as an outpatient procedure.
20. Carpal Tunnel Syndrome
Nursing Intervention:
• Postoperatively, blood flow must be assessed hourly by checking color,
warmth of the fingertips, and capillary refill.
• After anesthesia has worn off, sensation of the fingers is assessed. The wrist is
immobilized in a splint and the arm is elevated on pillows to reduce edema.
• The patient is warned to avoid heavy gripping and pinching for up to 6 weeks.
22. Fractures
Etiology and Pathophysiology:
• A fracture is a break or interruption in the continuity of a bone.
• Fractures occur mostly from trauma but result from a pathologic process in
which bone has degenerated, such as in osteoporosis (metabolic bone disorder
that causes a decrease in bone mass) or another metabolic problem.
• The mechanism of injury, or how the injury occurred, can provide clues
about the type of fracture.
• For example, if a patient punches a wall or another solid surface, the fifth
metacarpal commonly breaks and the patient sustains a “boxer's fracture.”
23. Fractures
Etiology and Pathophysiology:
• Mechanism of injury is also important to help predict injury to the
neighboring tissues.
• Damage varies according to the type of fracture, but there is always some
degree of tissue destruction, interference with the blood supply, and
disturbance of muscle activity at the site of injury.
24. Fractures
Signs, Symptoms:
• Minimal to severe pain.
• Swelling
• Bleeding
• Tenderness
• deformity of the bone,
• Ecchymosis
• crepitation with any movement, and loss of function
26. Fractures
Types of Fractures:
• Complete fracture is when a bone breaks into two parts that are completely
separated.
• An incomplete fracture is when a bone breaks into two parts that are not
completely separated.
• A comminuted fracture is one in which the bone is broken and shattered into
more than two fragments.
27. Fractures
Types of Fractures:
A closed (simple) fracture is one in which there is no break in the skin.
• An open (compound) fracture is one in which there is a break in the skin
through which the fragments of broken bone protrude.
• A greenstick fracture, common in children, is one in which the bone is
partially bent and partially broken.
29. Fractures
Treatment:
• In ER on the basis of X-ray surgery will decided.
• In case of broken skin Inj tetanus.
• Analgesic for pain.
• In open fracture Prophylactic antibiotics.
30. Fractures
Nursing Intervention:
• Preventing shock
• Prevent hemorrhage.
• Immediate immobilization
• Inexperienced person should never attempt to straighten or set a broken bone
• Ice in a plastic bag can be applied to the fracture area to help minimize
swelling.
32. Amputation
• About 80% of all limb amputations involve lower extremities.
• The most common reasons for amputation of a lower limb are related to
peripheral vascular disease, often associated with diabetes mellitus, and
resultant gangrene.
• Other conditions necessitating lower-limb amputation include severe trauma,
malignancy, and congenital defects.
• Military injuries from shrapnel and land mines often result in amputation.
33. Amputation
• About 70% of upper-extremity amputations are brought on by crushing
blows, thermal and electrical burns, and severe lacerations, many from
military action.
• Vasospastic disease, malignancy, and infection also can necessitate
amputation of an upper extremity.
• The past 20 years have brought about major improvements in microvascular
surgery, making reattachment or re-implantation of amputated parts possible.
• Teach the public what to do if an accidental amputation occurs
34. Amputation
Preoperative Care:
• Pt should participate in decision (autonomy).
• Informed consent.
• Counseling regarding acceptance of a new body image.
• Physical preparation for muscle strengthening.
35. Amputation
Postoperative Care:
• Stump is elevated for 24 to 48 hours to prevent edema and hemorrhage.
• A lower extremity is not elevated for more than 24 hours.
• Frequently, check stump for excessive bleeding.
• In case of cast (pulse rate, blood pressure, increasing pain, restlessness, and
pallor) should be checked.
• Keep surgical tourniquet at bedside in case of hemorrhage.
• Prophylactic antibiotics are given for 3 or 4 days.
• Initial dressing should be removed by surgeon 48 to 72 hours postoperatively.
36. Amputation
Phantom Pain
• Mimics preoperative pain and that the peripheral nervous system and the
spinal cord send messages to the brain, which retains the memory of the pain.
• Phantom limb sensations may or may not be painful.
• I/V infusion of ketamine.
• Transcutaneous electrical nerve stimulator (TENS).
• Stump stocking & virtual reality goggles.
41. Traction
• Traction is the application of a mechanical pull to a part of the body for the
purpose of extending and holding that part in a certain position during
immobilization.
• The two general types of traction are skeletal traction and skin traction.
• Skeletal traction uses 10 lb or more of weight.
• No more than 7 to 10 lb of weight is used for skin traction.
43. Traction
Patient’s Needs with Traction
• Explain the procedure to the parents and patient before commencing.
• Plan appropriate distraction from play therapy, parents or other nursing staff.
Maintain skin integrity
• Rolled up towel/pillow under to relieve pressure.
• Encourage the patient to reposition (4 hourly).
• Remove the foam stirrup and bandage once per shift.
Keep the sheets dry.
Document the condition of skin.
44. Patient’s Needs with Traction
Traction care
• Ensure that the traction weight bag is hanging freely, the bag must not rest on
the bed or the floor.
• If the rope becomes frayed replace them.
• The rope must be in the pulley tracks.
• Ensure the bandages are free from wrinkles
• Tilt the bed to maintain counter traction
45. Patient’s Needs with Traction
Observations
• Check the patient’s neurovascular observations hourly and record in the
medical record.
• Monitoring of swelling of the femur should also occur to monitor for
compartment syndrome.
• If neurovascular compromise is detected remove the bandage and reapply
bandage not as tight.
• If circulation does not improve notify the orthopedic team.
46. Patient’s Needs with Traction
Pain Assessment and Management
• Assessment of pain is essential to ensure that the correct analgesic is
administered for the desired effect.
Activity
• Help patient to sit up in bed and participate in quiet activities such as craft,
board games and watching TV.
• Non-pharmacological distraction and activity will improve patient comfort.
• The patient is able to move in bed as tolerated for hygiene to be completed.
48. Osteoarthritis
Etiology and Pathophysiology
• Non inflammatory degenerative joint disease characterized by breakdown of
cartilage in synovial joints.
• The exact cause is not known, but risk factors include
• heredity,
• aging,
• female gender,
• obesity, previous joint injury,
• recreational or occupational overuse of joints.
50. Osteoarthritis
• Signs, Symptoms
• Osteoarthritis occurs asymmetrically and typically affects only one or
two joints.
• The chief symptoms are aching pain with joint movement and stiffness, with
limitation of mobility.
• Joints may be deformed, and nodules may be present.
51. Osteoarthritis
Diagnosis:
• History
• Physical Examination
• X-ray
• Arthrocentesis
• Careful analysis of the location, duration, and character of the joint symptoms
and the appearance of the joints helps in diagnosing osteoarthritis.
52. Osteoarthritis
• Treatment
• Treatment consists of pain management,
• strengthening and low-impact aerobic exercise,
• weight reduction if the patient is overweight,
• and maintenance of joint function.
• Salicylates, acetaminophen, or NSAIDs may be used.
• Acetaminophen in doses of 1000 mg, up to 3000 mg/day, is the standard for
patients with mild to moderate chronic joint pain.
53. Osteoarthritis
• Corticosteroid injection into the arthritic joint may be performed if oral
medication does not control the problem.
• Exercises for joint mobility are encouraged.
• Surgery or joint replacement may be performed to relieve severe pain and
improve mobility.
• The hip and knee are the most common sites for joint replacement related to
osteoarthritis.
• Glucosamine and Chondroitin (1500mg/day)
• Yoga, Massage, & Capsaicin cream (4 times/day)
54. Osteoarthritis
• Nursing Management
• Teaching the patient to balance exercise and rest.
• The patient should avoid placing stress on affected joints.
• Suggest the use of assistive devices.
• Instruct in moist heat application, and encourage the patient to maintain
weight within normal limits.
• Weight reduction decreases joint stress.
• Imagery, relaxation, and diversion are helpful to reduce pain.
• Quadriceps strengthening exercises may relieve pain and disability of the
knee
56. Rheumatoid Arthritis
Etiology and Pathophysiology
• Rheumatoid arthritis (RA) is an inflammatory disease of the joints. It can
occur at any age but is most common among older women.
• The cause is not known, but hormonal, environmental, genetic, or infectious
agents may trigger an underlying autoimmune reaction.
• An abnormal immune response causes an inflammatory reaction of the
synovial membrane.
• Vasodilation, increased permeability, and the formation of exudate cause red,
swollen joints.
• Rheumatoid factor (RF), which is an antibody against immunoglobulin G,
appears in the blood and synovial fluid in many patients.
58. Rheumatoid Arthritis
Signs, Symptoms
• Joint pain, warmth, edema, limitation of motion, and multiple joint stiffness in
the morning lasting more than 1 hour.
• Systemic symptoms of low-grade fever, anorexia with weight loss, malaise.
• Joint deformity and consequent dysfunction can occur
59. Rheumatoid Arthritis
Diagnosis
• History of morning stiffness that lasts more than 30 minutes
• Arthritis pain in three or more joints that lasts more than 6 weeks (Venables et
al, 2013).
• Blood tests for rheumatoid factor (RF), anticitrullinated peptide/protein
antibody test (anti-CCP), C-reactive protein, and erythrocyte sedimentation
rate are ordered.
• Radiographs confirm the cartilage destruction and bone deformities.
60. Rheumatoid Arthritis
• Treatment
• Acetaminophen is the first-line agent used for rheumatoid arthritis pain
(Kelly, 2012) . Other medications include salicylates, corticosteroids,
hydroxychloroquine, methotrexate, and disease-modifying antirheumatic
drugs (DMARDs). Tumor necrosis factor (TNF) inhibitors are a newer type of
medication.
• Rest and exercise, medication, immobilization with splints and use of other
supportive devices during periods of severe inflammation,
• Hot and cold treatments are standard treatments.
• Surgical joint repair or replacement can reduce pain and improve mobility.
61. Rheumatoid Arthritis
6/21/2022
Nursing Interventions
• Relieving Pain and Discomfort
• Reducing Fatigue by comfort measures & increase sleep.
• Encourage adherence to the treatment program.
• Encourage independence in mobility and assist as needed.
• Monitor for medication side effects, including GI tract bleeding or irritation,
bone marrow suppression, kidney or liver toxicity, increased incidence
of infection, mouth sores, rashes, and changes in vision.
63. Gout
6/21/2022
Etiology and Pathophysiology
• Gout is arthritis of a joint caused by high serum levels of uric acid.
• Uric acid crystals precipitate from the body fluids and settle in joints and
connective tissue.
• The big toe is the most common site.
• Incidence is high in men (middle aged).
• Due to genetic increase purine metabolism and high protein diet.
• Excessive alcohol consumption.
• Diuretic therapy
67. Gout
Treatment
• NSAIDs for pain (2 to 5 days).
• Colchicine given orally may bring dramatic pain relief within 24 to 48 hours.
• Oral prednisone or cortisone injection into the joint may be used.
• Allopurinol (Zyloprim) or probenecid (Benemid).
• Febuxostat (Uloric).
68. Gout
Nursing Management
• Teach the patient about gout medication side effects and dosage.
• Dietary management includes weight control and restriction of high-purine
foods.
• Alcohol should be restricted.
• Teach the patient that a fluid intake of 2000 to 3000 mL per day.
• Periodic liver function testing is needed for taking Allopurinol.
70. Osteoporosis
Etiology and Pathophysiology
• Osteoporosis is a health condition that weakens bones, making them fragile
and more likely to break.
• Osteoporosis makes the person more susceptible to fractures because of the
decrease in bone mass.
• Fragility fractures are often atraumatic.
• Starting at age 35 years, most women lose bone mass at a rate of 1% per year.
72. Osteoporosis
Etiology and Pathophysiology
• Risk factors for osteoporosis include age, chronic disease (e.g., liver, lung,
kidney), medications (e.g. Steroids, anticonvulsants, anticoagulants, PPIs,
selective serotonin inhibitors), long-term calcium deficiency, vitamin D
deficiency, smoking, excessive caffeine or alcohol intake, and sedentary
lifestyle.
• Eating disorders and inflammatory bowel disease.
73. Osteoporosis
6/21/2022
Signs and Symptoms
• Osteoporosis is a silent disease and there are no early signs or symptoms.
• Once the patient has developed osteoporosis, height loss, kyphosis (excessive
curvature of the spine), and back pain may occur.
• Compression fractures of the spine may cause debilitating pain.
• Osteoporosis is commonly diagnosed after the patient sustains a fracture from
little or no known trauma.
74. Osteoporosis
6/21/2022
Diagnosis
• On radiographs the bone of the patient with osteoporosis appears porous.
• Dual-energy x-ray absorptiometry (DEXA) is used to assess loss of bone
density.
• DEXA is reported as a T score.
• Normal bone density: T score of greater than 1 standard deviation from a
healthy young adult
• Osteopenia: T score of −2.5 or more.
• Osteoporosis: T score of −2.5 or below
75. Osteoporosis
6/21/2022
Treatment
• Adequate dietary or supplemental calcium and vitamin D.
• Weight bearing exercise.
• Estrogen replacement therapy.
• Vitamin K is essential for calcium utilization.
• Walking down stairs.
• Salicylates and NSAIDs are prescribed to control back pain.
• Hormones: Estrogen (women), Testosterone (men),
• Bisphosphonates: Alendronate (Fosamax), Risedronate (Actonel, Atelvia)
76. Osteoporosis
6/21/2022
Nursing Intervention
• Teaching about the benefits
• Healthy lifestyle
• Calcium and vitamin D
• Advantages of weight-bearing exercise
• Harmful effects of smoking and excessive alcohol
• Medications prescribed for the disorder and their side effects and measures
to halt or reverse the disease process.
78. Paget Disease
Etiology & Pathophysiology
• Problem of abnormal bone resorption followed by replacement of normal
marrow with fibrous connective tissue.
• Old age increase risk.
• The abnormal bone is weak and prone to fractures.
• The cause of Paget disease is unknown, although it does occur in clusters in
some families.
• Often the disease is found at the time a fracture occurs when radiographs
reveal the abnormality of the bone.
80. Paget Disease
6/21/2022
Signs & Symptoms
• The main problem is pain.
• Fatigue
• Weakness
• Loss of appetite
• Abdominal pain
• Constipation
81. Paget Disease
6/21/2022
Diagnosis
• Radiograph and laboratory testing.
• Bone scan
• A 24-hour urine collection for hydroxyproline, which indicates osteoclastic
activity, may be performed.
• Serum alkaline phosphatase is elevated if the disease is active.
82. Paget Disease
6/21/2022
Treatment
• Miacalcin or a bisphosphonate may be given to slow bone resorption.
• NSAID for pain.
• Assistive devices.
• Incase of fracture, internal fixation.
• Osteotomy.
83. Paget Disease
6/21/2022
Nursing Management
• Education about condition and mean of preventing deterioration.
• Adequate dietary intake.
• Weight control.
• Psychological & Emotional Support.
• Administration of analgesic medicines.
84.
85. Bone Tumors
Etiology & Pathophysiology
• Bone tumor develop when cells within a bone divide uncontrollably, forming
a lump or mass of abnormal tissue.
• Bone is subject to both benign and malignant tumors.
• Tumors arise from several different types of tissue, including cartilage
(chondromas), bone (osteomas), and fibrous tissue (fibromas).
• Benign tumors often are found on radiograph or at the time of fracture.
• Malignant bone tumors are either primary or secondary to metastatic disease.
87. Bone Tumors
• The most common type is osteosarcoma, or osteogenic sarcoma.
• Mostly effect knee area but the distal femur, humerus, and proximal tibia are
other common sites of occurrence.
• Osteosarcoma may occur in men older than 60 years as a complication of
Paget disease.
• Other types of primary malignant tumors include Ewing sarcoma,
chondrosarcoma, and fibro-sarcoma.
88. Bone Tumors
Signs and symptoms
• Pain, warmth, and swelling.
• Malignancies of the prostate, kidney, thyroid, breast, and lung commonly
metastasize to bone.
• Sites of metastases are usually the
• Knee,
• vertebrae,
• pelvis,
• ribs,
• femur.
90. Bone Tumors
Treatment
• Surgery, radiation, and chemotherapy.
• Osteosarcoma has a 60% to 80% cure rate when surgery and chemotherapy
are combined for treatment.
• Chemotherapy is given for about 10 weeks before surgery and then for up to a
year after surgery.
• A combination of a variety of chemotherapeutic agents are used depending on
the tumor size, location, and physician decision.
• Zoledronic acid (Zometa) may be used to treat hypercalcemia associated with
bone tumors.
91. Bone Tumors
Nursing Intervention
• Includes helping the patient with the anxiety and fear.
• Nurses have a responsibility in educating the patient/family and in providing
supportive care.
• Treat pain with pharmacological and non pharmacological methods.
• State weight bearing & activity restrictions.
• If a bone tumor is in an extremity, amputation may be part of the treatment.
• Demonstrate use of ambulatory & assistive devices.
• Adequate diet.
93. Bone Tuberculosis
• Etiology & Pathophysiology
• Bone tuberculosis affects your skeletal system, which consists of bones and
joints.
• The most common type is spinal tuberculosis.
• This happens when the mycobacterium infection spreads into your spinal
cord. Spinal tuberculosis is also called Pott’s disease.
• This type of tuberculosis is rare and is typically seen most often in places with
widespread AIDS infections.
95. Bone Tuberculosis
6/21/2022
Signs & Symptoms
• Severe back pain
• Inflammation in back or joints
• Stiffness
• Trouble moving or walking,
especially in children
• Spinal abscess
• Soft tissue swelling
• Neurological disorders
• Tuberculosis-related meningitis
• Muscle weakness
• Paralysis
• Kyphosis, also known as hunchback
• Bone or spinal deformities
100. Osteomyelitis
Etiology & Physiology
• Bacterial infection of the bone. It is common in diabetic ulcers left
untreated or that won't heal.
• The causative organism is most often Staphylococcus aureus, which
enters the bloodstream from a distant focus of infection, such as a boil or
furuncle, or from an open wound, as in an open (compound) fracture.
• It is usually found in the tibia or fibula, in vertebrae, or at the site of a
joint prosthesis.
102. Osteomyelitis
Signs & Symptoms
• severe pain and marked tenderness at the site
• high fever with chills
• swelling of adjacent soft parts
• headache
• malaise
104. Osteomyelitis
Treatment
• Intravenous antibiotics are often needed, and antibiotics are prescribed
for 4 to 6 weeks;
• The abscess is incised and drained.
• Dead bone and debris are debrided from the site.
• The affected limb is immobilized for complete rest.
• Sometimes amputation is the only cure.
105. Osteomyelitis
6/21/2022
Nursing Intervention
• Promote bed rest.
• Assess nutritional needs.
• Administer antibiotics as ordered.
• Administer pain medications as ordered.
• Monitor and dress wound as ordered.
• Encourage out of bed activity.
• Provide deep venous thrombosis and pressure sore prophylaxis.
• Educate patient about medication compliance.
106. Nursing Diagnosis for Orthopedic Disorders
The most frequent diagnoses are
• Risk of infection
• Impaired skin integrity
• Severe pain
• Self-care deficit relating to bathing and basic hygiene
• Impaired physical mobility
• Lack of knowledge
• Risk of peripheral neurovascular dysfunction.
