ORTHOPEDIC

I. Anatomy and Physiology

A. Bone (illustration 1 illustration 2 )
1. Functions
a. supports and protects structures of the body
b. anchors muscles
c. some bones contain hematopoietic tissue which forms blood cells
d. participates in the regulation of calcium and phosphorus
2. Joints (illustration )
a. bursa - enclosed cavity containing a gliding joint
b. synovium - lining of joints which secretes lubricating fluid that nourishes and
protects
c. classification of joints - synarthrosis, amphiarthrosis, diarthrosis
3. Cartilage - connective tissue covering the ends of bones (illustration )
4. Types of bones
a. long - legs, arms
i. external structure - diaphysis, epiphysis, periosteum (illustration )
ii. internal structure of bone - medullary cavity; cancellous bone; red
marrow
b. short - ankles, wrists
c. flat - shoulder blades
d. irregular - face, vertebrae
B. Muscles - produce movement of the body
1. Types (illustration )
a. striated - controlled by voluntary nervous system
b. smooth - controlled by autonomic nervous system
c. cardiac - controlled by autonomic nervous system
C. Fascia - surrounds and divides muscles
D. Tendons - fibrous tissue between muscles and bones
E. Ligaments - fibrous tissue between bones and cartilage; supports muscles and fascia
II. Trauma: Contusions, Strains, Sprains
A. Contusions (bruise)
1. Definition - a fall or blow breaks capillaries but not skin
2. Pathophysiology - extravasation (bleeding) under skin
3. Findings - ecchymosis (bruise) and pain when the contusion is palpated
4. Management
a. for first 24 to 48 hours, apply ice for 15 minutes, three times a day
b. then apply heat if necessary
c. wrap to compress
5. Resolution: should heal within seven to ten days
6. Color changes from a blackish - blue to a gresnish - yellow after three to five days
B. Strains
1. Definition - lesser injury of the muscle attachment to the bone
2. Etiology and pathophysiology
a. caused by overstretching, overexertion, or misuse of muscle
b. acute: recent injury to muscle or tendon; classified by degree
i. first degree: mild; gradual onset; feels stiff, sore locally
I. assessment of acute first-degree strain
I. tenderness to palpation
II. muscle spasm
III. no loss of range of motion
IV. little or no edema or ecchymosis
II. management of acute first-degree strain
I. comfort measures
II. apply ice
III. rest, possibly immobilize for short term
ii. second degree: moderate stretching, sudden onset, with acute pain
that eventually leaves area tender
I. assessment of acute second-degree strain
I. extreme muscle spasm
II. passive motion increases pain
III. edema develops early; ecchymosis later
II. management of acute second-degree strain
I. keep limb elevated
II. apply ice for the first 24 to 48 hrs - then moist
heat
III. limit mobility
IV. muscle relaxants, analgesics, NSAIDS
V. physical therapy for strength and range of motion

1. Third-degree: severe stretching with tear; sudden; snapping or burning sensation

a. assessment of acute third degree strain
i. muscle spasm
ii. joint tenderness
iii. edema (may be extreme)
iv. client cannot move muscle voluntarily
v. delayed ecchymosis
b. management of acute third degree strain
i. keep limb elevated
ii. apply ice for 24 to 48 hrs, then moist heat
iii. either immobilize or limit mobility of the limb
iv. medication - muscle relaxants, analgesics, NSAIDs
v. physical therapy for strength and range of motion
2. Chronic strain
 a. long-term overstretching of muscle/tendon
b. repeated use of the muscle beyond physiologic limits
C. Sprains
1. Definition - greater than strain; injury to ligament structures by stretching, exertion or
trauma
2. Classification/findings/assessment/management
a. first degree sprain
i. minimal tearing of ligament fibers
ii. localized edema or hematoma
iii. no loss of function
iv. no weakening of joint structure - joint integrity remains intact
v. mild discomfort at location of injury
vi. pain increases with palpation or weight bearing
vii. management of first degree sprain
• compress it with ace bandage to limit swelling
• keep limb raised to decrease edema
• apply ice 24 to 48 hours following injury
• analgesics for discomfort
• isometric exercises to increase circulation and resolve
hematoma
b. second degree sprain
i. up to half of the ligamentous fibers torn
ii. increased edema and possible hematoma
iii. decreased active range of motion
iv. increased pain
v. mild weakening of the joint and loss of function
vi. management
• protectively dress/splint the joint, immobilize it
• elevate the limb to decrease edema
• for 24 to 48 hours, alternate
o ice
1. to produce vasoconstriction to decrease
swelling
2. to reduce transmission of nerve
impulses and conduction velocity to
decrease pain
o moist heat
1. to reduce swelling and provide comfort
• analgesics for discomfort
• physical therapy to increase circulation and maintain
nutrition to the cartilage
c. third degree sprain
i. complete rupture of the ligamentous attachment
ii. severe edema with hematoma
iii. usually, severe pain
iv. dramatic decrease in active range of motion
v. loss of joint integrity and function
vi. management
• casting
• surgery to restore integrity of joint
• see second degree treatment
D. Fractures: pathophysiology
1. Predisposing factors
a. biologic
i. bone density
ii. client's age
2. Extrinsic factors
a. force - direct or indirect
b. rate of loading (how fast the force strikes)
3. Intrinsic factors - bone capabilities
 4. Pathological fractures
a. bone is weakened by disease
b. fractures occur in response to minimal or no applied stress
c. classification by cause: general or local disorder
i. general: developmental, nutritional, hormonally controlled
ii. local: neoplasm, infection, cystic lesion
5. Behavioral factors - high-risk activities (such as football, ballet)
E. Fractures: management
1. Closed reduction
a. purposes: realign bone fragments for healing, minimal deformity, minimal pain.
b. pre- and post-reduction x-rays are essential to determine successful reduction of
fracture
2. Immobilization
a. purposes
i. relieve pain
ii. keep bone fragments from moving
b. methods: cast - synthetic or plaster, traction - skin or skeletal, splints, braces,
and external fixation
c. types of traction
i. manual: applied by pulling on the extremity - may be used during
cast application
ii. skin: applied by pulling force through the client's skin - used to relax
the muscle spasm
iii. skeletal: applied directly through pins inserted into the client's bone -
used to align fracture
d. open treatment (see orthopedic surgery that follows)
3. Stages of bone healing
a. hematoma formation
b. fibrocartilage/granulation tissue formation
c. callus formation
d. ossification
e. consolidation/remodeling
4. Evidence of healed fracture
a. radiographic
i. presence of external callus or cortical bone across the fracture site
ii. fracture line may remain long after healing
b. clinical
i. pieces of bone no longer move at fracture site
ii. no tenderness over fracture site
c. weight bearing is pain free
F. Fractures: complications ORTHOPEDIC COMPLICATIONS

A. Venous thromboembolic problems

1. Thrombophlebitis (TP)
a. inflammation of a vein with the formation of a blood clot
b. incidence is greatest after trauma or surgery to legs or feet
B. Deep venous thrombosis (DVT)
1. Anterior tibial or femoral veins
2. May be caused by immobility
3. Findings include calf pain, positive Homan's sign
4. Immediately after operations
a. anticoagulant therapy
b. antiemboli stockings (usually)
c. sequential compression device (possibly)
C. Pulmonary embolism (PE)
1. Blood clot from systemic circulation enters pulmonary circulation
2. Most commonly seen after hip fractures and total hip/knee replacements
3. Occurs in approximately ten percent of patients undergoing hip arthroplasty
4. May be caused by femoral vein manipulation during surgery and therefore occur without signs of
DVT
 5. Findings include chest pain (pleuritic), sudden shortness of breath, tachycardia, palpitations, or
change in mental status
6. If PE is suspected,do not leave client. Get charge nurse to notify health care provider immediately
7. Diagnosis confirmed via ventilation/perfusion scan or pulmonary angiography
8. Continuous IV heparin therapy usually prescribed
D. Fat embolism
1. Definition: fat cells enter pulmonary circulation
2. Associated with
a. multiple trauma accidents
b. multiple organ involvement
c. fractures of marrow producing bones
d. joint replacements
e. insertion of intermedullary rods
3. Usually occurs 24 to 48 hours after the fracture
E. Hemorrhage
1. Abnormal loss of blood from the body
2. Most common in fractures of bone marrow producing bones
F. Wound infection
1. May be superficial or deep wound
2. Deep wound infection may lead to osteomyelitis
3. Findings include erythema and swelling around suture line, increased drainage and elevated
temperature
4. Treated with antibiotics; may require incision and drainage of wound or removal of prosthesis if
severe infection is present
G. Special complications in hip replacement
1. Femoral fracture
a. occurs near distal end of femoral-shaft part of prosthesis
b. occurs more frequently with elderly, clients with osteoporosis, or after revision to total
hip replacement
c. primary finding is severe pain with ambulation
d. diagnosis is confirmed with x-ray
e. depending on severity, treatment will be immobilization or open reduction with internal
fixation
2. Dislocation of hip prosthesis
a. greatest risk during the first postoperative week but can occur at any time within the first
year.
b. risk decreases as muscle tone of the hip increases
c. caused by flexion of the hip or poor prosthetic fit
d. findings include pain and external rotation of the leg
e. treated by closed reduction under conscious sedation or open surgical revision
H. Special complication in knee replacement: flexion failure
1. Client cannot flex knee 90 degrees two weeks postoperatively
2. Treated with closed manipulation of the knee joint under general anesthesia

1. Immediate complications of the injury

a. shock - higher risk with pelvic and femur
b. fat embolism - occurs after the initial 24 hours from the injury
c. compartment syndrome - a nursing emergency
d. deep venous thrombosis (DVT)
e. pulmonary embolism - a complication of DVT
2. Delayed complications
a. joint stiffness
b. post-traumatic arthritis (osteoarthritis, type II)
c. reflex sympathetic dystrophy
i. painful dysfunction and disuse syndrome
ii. characterized by abnormal pain and swelling of the extremity
d. myositis ossificans
i. formation of hypertrophic bone near bone and muscles
ii. forms in response to trauma
iii. hypertrophic bone is removed when bone is mature
e. malunion
i. fracture healing is not stopped but slowed
 ii. prevention of malunion
• reduce and immobilize properly
• be sure client understands limits on activity and position
f. delayed union
i. fracture does not heal
ii. more common with multiple fracture fragments
iii. no evidence of fracture healing four to six months after the fracture
g. loss of adequate reduction
h. refracture
G. Nursing interventions
1. Risk for peripheral neurovascular deficit
a. check neurovascular status often
b. elevate limb above level of heart (except with compartment syndrome)
c. apply cold to minimize edema
2. Pain
a. assess level of pain with a scale of one to ten
b. manage pain
i. with drugs
ii. reposition client
iii. pad any bony prominences
c. teach relaxation techniques
3. Client teaching
a. how fractures heal
b. why the fracture is being immobilized
c. how to bear weight and how much (if permitted)
d. how bones heal
e. how to use assistive devices to walk
4. Risk for infection
a. related to
i. open fractures
ii. surgical intervention
iii. superficial/deep wounds
b. monitor for findings of infection
c. provide proper wound care
d. administer antibiotic therapy as indicated
5. Risk for impaired skin integrity
a. causes
i. open fractures
ii. soft tissue injuries
iii. pressure areas
b. additional factors
i. age - elderly
ii. general condition of client
iii. preexisting skin conditions or diseases
c. interventions
i. mobilize the client as soon as possible
ii. turn the client often at least every two hours
iii. position the client properly with alignment in mind
iv. use orthopedic devices to limit skin impairment
6. Impaired gas exchange
a. accompanies chest trauma
b. client risks fat embolism
c. client risks deep venous thrombosis
d. interventions
i. mobilize as soon as possible
ii. frequent and effective pulmonary toileting
H. Fractures: factors that affect healing
III. Degenerative Disorders
A. Definition
1. Slowly progressive disorders of articular cartilage and subchondral bone
2. Do not affect the joints symmetrically (e.g., not necessarily both knees)
3. Worsen progressively
4. Eventually incapacitate, despite treatment
B. Osteoarthritis (OA)
1. Definition - degeneration of the articular cartilage and formation of new bone in the
subchondral margins of the joint
2. Findings
I. primarily involves weight-bearing joints
II. non-inflammatory disorder
III. localized: no systemic effects
IV. results in an abnormal distribution of stress on the joint
3. Incidence
I. most common form of arthritis
II. may begin as early as the 20s and peaks in the 60s
III. by age 70, nearly 80% of afflicted people show findings
IV. over age 55, OA affects twice as many women as men
V. two types: primary and secondary Types of Osteoarthritis (OA)

I. Primary (Idiopathic) Osteoarthritis

A. No known cause
B. Classifications
1. Localized OA in one or two joints
2. Generalized OA in three or more joints.
C. Etiology
1. More common in women (slightly)
2. More common in Caucasians
3. Develops in middle age and progresses slowly
4. More often affects certain joints
a. weight-bearing joints
b. cervical and lumbosacral joints
c. interphalangeal joints
5. Hands more affected in women after menopause
6. Hips are more affected in men
II. Secondary (Traumatic) Osteoarthritis
A. Underlying condition: a trauma to the articular cartilage
 B. Etiology
1. Genetic predisposition, shown by the presence of

Heberden's Nodes

III. Bony osteophytes at the DIP joint

IV. Common presentation of OA in the hand
V. Indicates a strong hereditary tendency
VI. Seen more often in women than men (ten times

Bouchard's Nodes

Accompany Heberden's nodes , Found at the PIP joint, Occur more often in women than men Increase in frequency
with age

1. More common in men

2. Often occurs in
a. wrists
b. elbows
c. shoulders
B. Risk factors for traumatic osteoarthritis
1. Obesity
2. Family history of degenerative joint disease
3. Excessive joint wear
a. physical activity
b. injury
4. Joint abnormality
a. lax ligaments
b. congenital hip dysplasia
5. Lifestyle: certain occupations predispose to secondary OA.

4. Pathophysiology
a. stage one: microfracture of the articular surface
i. articular cartilage is worn away
ii. condyles of bones rub together: joint swells and is painful
iii. cartilage loses cushioning effect: joint friction develops
iv. prostaglandins may accelerate degenerative changes
b. stage two: bone condensation
i. erosion of cartilage
ii. cartilage may be digested by an enzyme in the synovial fluid
c. stage three: bone remodeling
i. matrix synthesis and cellular proliferation fail
ii. eventually the full thickness of articular cartilage is lost
iii. bone beneath cartilage hypertrophy and osteophytes form at joint
margins
iv. result: joint degenerates
5. Findings OSTEOARTHRITIS OF HIP/KNEE: SPECIFIC PHYSICAL FINDINGS

1. Hip
a. contracture in adduction and flexion
b. decrease in internal and external rotation
c. limb shortening
d. referred pain to the
i. knee
ii. groin
iii. thigh
2. Knee
a. decreased range of motion
b. flexion contracture
i. hip
ii. knee
c. varus deformity: bow legged appearance
d. valgus deformity: knock-kneed appearance
e. positive apprehension sign
i. push the patella laterally with the leg in full extension
ii. client will stop the examiner from pushing the patella further

a. joint stiffness after periods of rest

b. pain in a movable joint, typically worse with action, relieved by rest
c. paresthesia
d. joint enlargement: bones grow abnormally; spurs form and synovitis sets in.
i. Heberden's nodes
ii. Bouchard's nodes
e. joint deformities
f. tenderness on palpation
i. may involve widely separated areas of the joint
ii. mild synovitis may be felt - positive bulge sign may be found
g. pain on passive movement
h. limitation in active range of motion because
i. joint surfaces no longer fit
ii. muscles spasm and contract
iii. joints are blocked by osteophyte, loose bodies
iv. crepitation, crunching when joints are moved
v. eventual ankylosis
i. gait
i. abnormal antalgic gait
ii. shortened stance
iii. widened base of support
iv. shortened step length

6. Diagnostics
a. to rule out autoimmune disorders
i. sedimentation rate
ii. rheumatoid factor
iii. c-reactive protein
b. CBC
i. analyze before NSAID therapy
ii. within normal limits
c. kidney and liver
i. especially in older clients, analyze before starting NSAID therapy
ii. repeat every six months
d. purified protein derivative (PPD)
i. analyze before starting steroids
ii. clients testing positive for tuberculosis must receive INH at same
time as steroid.
e. antinuclear antigen (ANA) titer
i. may be lower in the elderly
ii. does not necessarily prove a connective-tissue disease
f. synovial fluid analysis distinguishes osteoarthritis from rheumatoid arthritis.
g. radiographs
i. taken in standing, weight-bearing condition
ii. shows the prime sign of OA: joint space narrowing
iii. x-ray does not necessarily reflect severity of disease
iv. joint loses space asymmetrically because cartilage narrows from
production of osteophytes or bone spurs
v. later stages may show bony ankylosis, spontaneous fusion
h. bone scans
i. radionuclide imaging
ii. shows skeletal distribution of osteoarthritis
iii. monitors complications of joint replacement surgery
 i. MRI scans show the extent of joint destruction
j. computerized tomograms (CT) scans show cortical and cancellous bone density
7. Management: conservative treatment
a. education should cover
i. exercise patterns
ii. relaxation techniques
iii. nutritional assessment
iv. counseling about maintaining a normal weight
b. nutritional management - weight reduction
c. activity and rest management
i. preservation of joint motion through a balance of
1. rest (protection)
2. activity (rehabilitation)
ii. individualized activity rehabilitation program
iii. physical or occupational therapist may be helpful
iv. passive range of motion exercises (illustration )
v. active stretching
d. protection from further injury by splinting or bracing
8. Medication
a. aspirin - most often recommended
i. advantages: relatively safe and inexpensive
ii. disadvantage: GI problems may lead to ulcers and bleeding
b. nonsteroidal anti-inflammatory medications (NSAIDs)
i. reduce pain and inflammation
ii. inhibit prostaglandin formation
iii. may cause GI bleeding or gastric ulcers or cramping with diarrhea
c. adrenocorticosteroid injections
d. remissive agents
i. gold
ii. penicillamine (cuprimine)
iii. hydrochloroquinine (plaquenil)
9. Nonmedication assistance
a. assistive devices
i. canes
ii. walkers
b. non-traditional techniques
i. guided imagery - the use of one's imagination to acheve relaxation
and control
ii. therapeutic massage
iii. biofeedback
iv. hypnosis
v. relaxation techniques
10. Surgical management
a. arthrodesis
b. arthroplasty
c. osteotomy
d. total joint replacement
11. Home care considerations in arthritis
a. safety measures
i. no scatter rugs at home
ii. well-fitted, supportive shoes
iii. night light, handrails at stairs and bathtub or shower
iv. assistive devices
1. canes
2. walkers
3. elevated toilet seats
4. grab bars
5. handrails in stairways
v. splints and orthotic devices
b. management of surgical pain by patient controlled analgesia pumps
c. referral to agency and support group
2. Charcot joints (also called neuropathic joint disease)
6. Definition - multicausal degeneration and deformation of joint, usually ankle.
(illustration )
7. Etiology
a. diabetes mellitus leading to foot neuropathy
b. syringomyelia results in Charcot's joint of the shoulder
c. tertiary syphilis
d. peripheral neuropathies
e. spina bifida with myelomeningocele
f. leprosy
g. multiple sclerosis
h. long term intra-articular steroid injections
8. Findings
a. inspection: foot is everted, widened, and shorter than normal
b. examination
i. joint instability
ii. soft tissue swelling
iii. pain secondary to inflammation
9. Diagnostics
a. laboratory analysis of synovial fluid
i. fluid is non-inflammatory
ii. low protein content
iii. no hemorrhage noted
b. radiographs
i. chronic destructive arthritis of the foot
ii. severe destruction of the articular cartilage, subchondral sclerosis
iii. fragments of bone and cartilage in joint
10. Management
a. conservative treatment
i. protection from overuse/abuse
ii. braces and splints
b. surgical management: arthrodesis
i. treatment of choice for unstable joints
ii. fusion of the involved joint
11. Nursing interventions
a. expected outcome: preserve the joint
b. education can prevent further injury
c. protection of the joint
i. braces
ii. orthopedic shoes
d. prolonged immobilization
i. eight to 12 weeks to decrease swelling
ii. leads to minimal joint deformity and a functional painless foot
3. Chondromalacia patellae (also called patellofemoral arthralgia)
6. Definition: progressive, degenerative softening of the bone; follows a knee injury
(illustration )
7. Etiology
a. lateral subluxation of the patella (kneecap)
b. direct or repetitive trauma to the patella produces chondral fracture
c. underdevelopment of the quadriceps muscles
8. Findings
a. pain with flexed knee activities (poorly localized)
b. mild swelling
c. occasional episodes of buckling of the affected knee
d. minimal joint effusion
e. evidence of 'squinting kneecaps'
f. atrophy of quadriceps
g. inverted 'J' tracking of the patella in the final 30 degrees of extension
h. excessive quadriceps angle
i. positive apprehension sign
 j. crepitation upon range of motion
9. Diagnostics
a. radiographs
i. anterior posterior (AP) and lateral views are not helpful
ii. sunrise views with the knee in 30 degrees, 60 degrees and 90 degrees
of flexion
b. bone Scans
c. MRI Scans
d. arthroscopy (see Orthopedic surgery)
10. Conservative management
a. progressive resistive exercises
i. quadriceps setting - isometric
ii. hamstrings - isotonic
b. medication: NSAIDs
c. nonmedication assistance: application of ice or moist heat
d. activity restriction
11. Surgical management
a. indicated if findings remain after six months of conservative treatment
b. arthroscopy (see Orthopedic Surgery section that follows)
c. arthrotomy
i. realignment of proximal and/or distal soft tissue
ii. tibial tubercle elevation
iii. patellectomy
12. Nursing interventions (see previous Osteoarthritis section)
2. Inflammatory Disorders
1. Rheumatoid arthritis (RA)
6. Definition - chronic systemic inflammatory disease of the connective tissue
7. Findings
a. starts in feet and hands, gradually destroys these peripheral joints
b. affects diarthroidial joints
c. bilateral involvement
8. Etiology
a. cause is not fully understood
b. rheumatoid arthritis is an autoimmune disorder
c. genetic tendency; but may involve bacteria, or viruses
d. may affect the connective tissue of the lungs, heart, kidneys, or skin
9. Incidence
a. two to three times more common in women than in men
b. strikes between the ages of 20 and 50 years of age
10. Pathophysiology
a. synovitis immune complexes initiate inflammatory response
i. IgB antibodies are formed
ii. rheumatoid factor (RF)
1. pannus formation
2. destruction of subchondral bone
3. present in 85 to 90% of all cases
4. worsens the inflammatory response - can go on indefinitely
5. irreversible - will lead to ankylosis of joint
11. Findings
a. in early RA joints will be
i. painful, stiff
ii. warm, red, swollen at capsules and soft tissues
iii. incapable of full range of motion
b. in late RA, joints will show
i. bony ankylosis
ii. destruction of joint - reactive hyperplasia
iii. adhesions
iv. inflammation and effusion that will be
1. symmetrical
2. polyarticular
c. general signs
 i. fatigue
ii. loss of appetite and weight
iii. enlarged lymph glands (illustration )
d. rheumatic nodules
i. in 20% of cases
ii. firm, oval, nontender masses under the skin
iii. presence indicates poor prognosis
e. physical assessment should also include
i. accurate patient history - history may include
1. malaise
2. fatigue
3. weakness
4. loss of appetite and weight
5. enlarged lymph glands
6. Raynaud's syndrome
ii. examination may reveal deformities
1. ulnar deviation
2. deformed hands: swan neck/boutonniere
f. neurological examination
i. foot drop
ii. evidence of spinal cord compression
12. Diagnostics
a. laboratory analysis
i. elevated ESR
ii. decreased RBC
iii. positive C-reactive protein
iv. positive antinuclear antibody in 20% of cases
v. positive rheumatoid factor (RF)
b. radiographic studies
i. bony erosion
ii. decreased joint spaces
iii. fusion of joint
c. aspiration of synovial fluid; analysis shows
i. cloudy appearance
ii. more white blood cells than normal
13. Management
a. (see previous Osteoarthritis section)
b. psychological support
c. splinting: resting, corrective, or fixation
2. Systemic lupus erythematosus (SLE)
6. Definition: chronic, systemic, inflammatory disease of the collagen tissues (illustration
)
7. Etiology unknown
a. most cases are women
b. African Americans, Hispanics, Asians, and Native Americans are two to three
times as likely as whites to have lupus
c. antigen stimulates antibodies, which form soluble immune complexes,
deposited in tissues; number of T suppressor cells dwindles. (illustration )
d. immune complex inflames tissue; inflammation creates findings
i. the intensity and location of the inflammation reflects findings and
organs involved.
ii. clients with central nervous system or renal involvement have poorer
prognosis
8. Findings: SLE is present if client has four or more of these:
a. arthritis: characterized by swelling, tenderness and effusion; involving two or
more peripheral joints
b. malar rash: characteristic butterfly rash over cheeks and nose
c. discoid lupus skin lesions
d. photosensitivity
e. oral ulcers
 f. serositis: pleuritis
g. renal disorder: persistent proteinuria
h. neurologic disorder: seizures or psychosis in the absence of drugs or pathology
i. hematologic disorder: hemolytic anemia with reticulocytosis or leukopenia
j. immunologic disorder: positive LE (lupus erythematosus) cell preparation or
anti-DNA or anti-Sm or false positive serologic test for syphilis
k. antinuclear antibody: abnormal titer of antinuclear antibody by
immunofluorescence or equivalent assay
l. positive LE cell reaction
9. Management
a. expected outcomes
i. control system involvement and symptoms
ii. induce remission
b. prevent bad effects of therapy
c. recognize flare-ups promptly
d. medical
i. salicylates
ii. nonsteroidal anti-inflammatory agents (NSAIDS)
iii. corticosteroids
iv. anti-infectives
e. antineoplastics
10. Nursing care
a. pain management strategies
b. strategies to combat weight loss
c. emotional support
3. Gout (illustration )
6. Definition
a. monoarticular asymmetrical arthritis
b. characterized by hyperuricemia
7. Etiology
a. primarily affects men
b. peak incidence 40 to 60 years of age
c. familial tendency
d. abnormal purine metabolism or excessive purine intake results in formation of
uric acid crystals which are deposited in the joints and connective tissue.
e. deposits are most often found in the metatarsophalangeal joint of the great toe
or in the ankle.
8. Findings
a. tight, reddened skin over the inflamed joint
b. elevated temperature
c. edema of the involved area
d. hyperuricemia
e. acute attacks commonly begin at night and last three to five days
f. gout attacks may follow trauma, diuretics, increased alcohol consumption, a
high purine diet, stress (both psychological and physical) or suddenly stopping
of maintenance medications
g. warning signs of flare-up include the exacerbation of previous findings or the
development of a new one
h. systemic manifestations may include fever, renal disease, tophus
9. Diagnostics: lab tests find -
a. increased urinary uric acid following a purine restricted diet
b. hyperuricemia
10. Management
a. expected outcomes: control symptoms; prevent attacks
b. medical
i. NSAIDs
ii. colchicine (used when NSAIDs are contraindicated) - enhances the
excretion of uric acid
iii. to prevent flareups: antihyperuricemic agents such as allopurinol
(lopurin) or probenecid (benemid) - minimize the production of uric
acid
iv. heat or cold therapy
 c. dietary
i. avoid purine foods such as meats, organ meats, shellfish, sardines,
anchovies, yeast, legumes
ii. control weight
iii. drink less alcohol - all types
11. Nursing care
a. pain management strategies
b. elevate the affected limb; provide bed rest and immobilize joint
c. avoid pressure or touching of bed clothing on affected joint
d. reinforce dietary management and weight control
e. administer anti-gout medications as ordered
f. increase fluid intake to prevent renal calculi (kidney stones)
3. Metabolic Bone Disorders
1. Osteomalacia
6. Definition - delayed mineralization; resulting bone is softer and weaker
7. Pathophysiology - similar to rickets
a. bones have too little calcium and phosphorus
b. vitamin D deficiency; possibly inadequate exposure to sunlight
i. less serum calcium than normal
ii. more parathyroid hormone
iii. more renal phosphorus clearance
8. Findings
a. accurate client history includes:
i. generalized muscle and skeletal pain in hips
ii. similar pain in low back
b. physical examination
i. gait
1. client unwilling to walk
2. wide stance
3. waddling gait
ii. muscle weakness
iii. bones
1. deformities of weight-bearing bones
2. scoliotic or kyphotic deformities of the spine
3. bones break easily
9. Diagnostic testing
a. radiographic findings
i. generalized demineralization
ii. pseudo fractures
iii. bending deformities
b. laboratory studies
i. decreased serum calcium
ii. decreased serum phosphorus
iii. alkaline phosphatase level is moderately elevated
10. Management
a. calcium gluconate
b. vitamin D daily until signs of healing take place
c. diet high in protein
d. ultraviolet radiation therapy
2. Osteoporosis (illustration )
6. Definition
a. multifactorial disease results in
i. reduced bone mass
ii. loss of bone strength
iii. increased likelihood of fracture
b. types
i. type one osteoporosis (estrogen related)
ii. type two osteoporosis (related to old age)
7. Etiology/epidemiology
a. most common metabolic disease of bone
i. affects an estimated 25 million Americans
ii. contributor of 50% of all adult fractures
 b. onset is insidious
c. women affected twice as often as men before the age of 70
d. skeletal changes result from the aging process
e. bone loss due to
i. immobilization
ii. lack of gravitational stress
8. Factors related to osteoporotic fractures

ADDITIONAL RISK FACTORS FOR OSTEOPOROSIS

A. Genetic risk factors

1. Female, white or Asian
2. Small frame, thin-boned; short; low body fat
3. Women with post-menopausal osteoporosis may have inherited a lower peak bone mass
4. Daughters of women with osteoporosis averaged less bone mass in lumbar spine and femoral neck
5. Family history of hip fracture
B. Reproductive factors
1. Hypo-estrogenism associated with increased bone remodeling, faster bone loss
2. Early or surgically induced menopause
3. Amenorrhea in athletes/anorexia nervosa
a. hypogonadism
b. weakens the bones
c. decreases bone mass
4. Dysmenorrhea
5. Nulliparity (no pregnancies)
C. Endocrine factors in osteoporosis

a. premature menopause
b. hyperthyroidism increases bone turnover and remodeling
c. hyperparathyroidism

i. increases bone turnover and remodeling

ii. increased parathyroid hormone (PTH)
• stimulates osteoclast activity
• depresses osteoblast activity
• result is an increase in serum concentration of calcium
b. hyperadrenocorticalism
c. type I diabetes mellitus

a. low bone density

b. history of scoliosis
c. neurological impairment after
i. CVA
ii. Parkinson's disease
iii. decreased vision from macular degeneration, complications of
diabetes, etc.
d. best indicator of fracture risk in bone densitometry
9. Findings
a. client history
i. acute fracture
ii. prior history of a traumatic fracture; no trauma
iii. history of falls
b. pain
i. greater when active, less while resting
ii. early in disease, pain in mid to low thoracic spine
c. anxiety
i. about further falls/fractures
ii. about ability to perform ADLs
d. kyphosis - 'Dowager's hump' may reflect multiple spinal fractures
 e. loss of height
i. two or more inches
ii. usually precedes diagnosis of osteoporosis diagnosis
10. Diagnostics
a. blood tests
i. complete blood counts
ii. serum levels
1. calcium
2. phosphate
3. alkaline phosphatase
b. x-rays
i. help identify fractures and kyphosis of spine
ii. less useful in the detection of pre-fracture osteoporosis
iii. detect osteoporosis only after 20% bone mineral content is lost
c. bone densitometry
i. best means of measuring risk for fracture
ii. quantitative computerized axial tomogram (CAT) measures pure
vertebral trabecular bone
iii. dual energy x-ray absorptionometry (DEXA)
1. technique of choice
2. assesses cortical and trabecular bone in spine and hip
3. single photon absorptionometry measures cortical bone in
long bones
11. Management
a. exercise
i. restorative - aims to increase bone density, decrease risk for fracture
ii. within the client's tolerance
iii. must be maintained throughout life
b. nutrition
i. calcium and vitamin D
ii. deficiencies increase risk of fracture
iii. sedentary older adults may need supplements
c. medication
i. anti-resorptive agents
1. do not increase bone mass - rather prevent further bone loss
2. estrogen therapy
3. calcitonin (Osteocalcin)
1. peptide hormone
2. powerful inhibitor of osteoclastic bone resorption
3. modestly increases bone mass in osteoporosis
4. not shown to decrease osteoporotic fractures
5. expensive
ii. biophosphonates
1. inhibit bone resorption
2. sustained use associated with osteomalacia and Paget's
disease
3. alendronate (Fosamax)
1. 100 to 500 times more potent than etidronate
2. non-hormonal agent
3. highly selective inhibitor
4. not associated with detrimental effects of
mineralization
5. expensive: average $41.70 per day for
osteoporosis
iii. bone-forming agents
1. sodium fluoride (Fluoritab)
2. androgens
1. taken long-term, increases bone mass in
osteoporotic women
2. but androgens virilize and elevate cholesterol
levels
12. Nursing intervention: teach prevention of ssteoporosis and its damage
a. education
 i. increase awareness
ii. discourage risk-related behaviors
iii. reinforce positive behaviors and lifestyles
b. reduce risk of falling
i. teach proper lifting and movement techniques (illustration )
ii. encourage proper footwear
iii. install safety equipment in home
3. Paget's disease (osteitis deformans)
6. Definition: a slowly progressing resorption and irregular remodeling of bone.
7. Etiology
a. bone resorbed; new bone poorly developed, weak, easily fractured
b. mainly affects major bones: skull, femur, tibia, pelvis, and vertebrae
c. cause unknown
d. possible viral implications
e. family tendency - noted in siblings
8. Findings
a. asymptomatic initially
b. musculoskeletal
i. deformity of long bones
ii. pain and point tenderness of affected limbs
9. Diagnostics
a. radiographic findings
i. bowing of long bones
ii. thickened areas of bone
iii. pathological fractures
iv. sclerotic changes
b. laboratory analysis
i. increased alkaline phosphatase means osteoblasts more active
ii. increased urinary hydroxyproline means osteoblasts more active
iii. serum calcium level will be normal

VI. Orthopedic Surgery

A. Total hip replacement (illustration )
1. Indications for surgery
i. osteoarthritis
ii. rheumatoid arthritis
iii. femoral neck fractures
iv. avascular necrosis of femoral head caused by steroids
v. failure of previous prosthesis
2. Surgical modalities

a. total hip replacement (hip arthroplasty) is the replacement of both articular surfaces of the hip joint, the
acetabular socket and the femoral head and neck.
b. hemiarthroplasty of the hip is the replacement of one of the articular surfaces, usually the femoral head and
neck.
2. Surgical and immediate postoperative care
a. in first 24 hours, expect wound to drain blood and fluid up to 500ml.
b. by 48 hours, wound drainage should be minimal
c. clients may require transfusions (autologous is preferred) due to blood loss during surgery.
d. best pain management is patient controlled analgesia (PCA) for the first 48 hours, advancing to non-narcotic
oral analgesics by the fourth or fifth postoperative day.
e. monitor for signs of deep venous thrombosis (DVT) and pulmonary embolism (PE) or fat embolism
f. monitor neurovascular status of affected limb; color, temperature, presence of pulses.
3. Postoperative complications ORTHOPEDIC COMPLICATIONS

A. Venous thromboembolic problems

1. Thrombophlebitis (TP)
a. inflammation of a vein with the formation of a blood clot
b. incidence is greatest after trauma or surgery to legs or feet
B. Deep venous thrombosis (DVT)
 1. Anterior tibial or femoral veins
2. May be caused by immobility
3. Findings include calf pain, positive Homan's sign
4. Immediately after operations
a. anticoagulant therapy
b. antiemboli stockings (usually)
c. sequential compression device (possibly)
C. Pulmonary embolism (PE)
1. Blood clot from systemic circulation enters pulmonary circulation
2. Most commonly seen after hip fractures and total hip/knee replacements
3. Occurs in approximately ten percent of patients undergoing hip arthroplasty
4. May be caused by femoral vein manipulation during surgery and therefore occur without signs of
DVT
5. Findings include chest pain (pleuritic), sudden shortness of breath, tachycardia, palpitations, or
change in mental status
6. If PE is suspected,do not leave client. Get charge nurse to notify health care provider immediately
7. Diagnosis confirmed via ventilation/perfusion scan or pulmonary angiography
8. Continuous IV heparin therapy usually prescribed
D. Fat embolism
1. Definition: fat cells enter pulmonary circulation
2. Associated with
a. multiple trauma accidents
b. multiple organ involvement
c. fractures of marrow producing bones
d. joint replacements
e. insertion of intermedullary rods
3. Usually occurs 24 to 48 hours after the fracture
E. Hemorrhage
1. Abnormal loss of blood from the body
2. Most common in fractures of bone marrow producing bones
F. Wound infection
1. May be superficial or deep wound
2. Deep wound infection may lead to osteomyelitis
3. Findings include erythema and swelling around suture line, increased drainage and elevated
temperature
4. Treated with antibiotics; may require incision and drainage of wound or removal of prosthesis if
severe infection is present
G. Special complications in hip replacement
1. Femoral fracture
a. occurs near distal end of femoral-shaft part of prosthesis
b. occurs more frequently with elderly, clients with osteoporosis, or after revision to total
hip replacement
c. primary finding is severe pain with ambulation
d. diagnosis is confirmed with x-ray
e. depending on severity, treatment will be immobilization or open reduction with internal
fixation
2. Dislocation of hip prosthesis
a. greatest risk during the first postoperative week but can occur at any time within the first
year.
b. risk decreases as muscle tone of the hip increases
c. caused by flexion of the hip or poor prosthetic fit
d. findings include pain and external rotation of the leg
e. treated by closed reduction under conscious sedation or open surgical revision
H. Special complication in knee replacement: flexion failure
1. Client cannot flex knee 90 degrees two weeks postoperatively
2. Treated with closed manipulation of the knee joint under general anesthesia

4. Nursing interventions
a. an abduction device is used during the first postoperative week while the client is in bed or sitting in a chair
b. to keep abduction device in place, turn client by logrolling
c. to prevent flexion of the hip, use fracture bedpan
d. client teaching
I. use of assistive devices; crutches, walker, raised toilet seat
 II. methods to prevent dislocation
III. can resume sexual activity when suture line heals. To avoid flexion of
hip, client should be in dependent position for three to six months
B. Total knee replacement
1. Indications for surgery
a. osteoarthritis
b. rheumatoid arthritis
c. trauma
2. Surgical modalities
a. metal or acrylic prosthesis, hinged or semiconstrained
b. choice of prosthesis depends on the strength of surrounding ligaments to provide joint stability
3. Postoperative complications ORTHOPEDIC COMPLICATIONS

A. Venous thromboembolic problems

1. Thrombophlebitis (TP)
a. inflammation of a vein with the formation of a blood clot
b. incidence is greatest after trauma or surgery to legs or feet
B. Deep venous thrombosis (DVT)
1. Anterior tibial or femoral veins
2. May be caused by immobility
3. Findings include calf pain, positive Homan's sign
4. Immediately after operations
a. anticoagulant therapy
b. antiemboli stockings (usually)
c. sequential compression device (possibly)
C. Pulmonary embolism (PE)
1. Blood clot from systemic circulation enters pulmonary circulation
2. Most commonly seen after hip fractures and total hip/knee replacements
3. Occurs in approximately ten percent of patients undergoing hip arthroplasty
4. May be caused by femoral vein manipulation during surgery and therefore occur without signs of
DVT
5. Findings include chest pain (pleuritic), sudden shortness of breath, tachycardia, palpitations, or
change in mental status
6. If PE is suspected,do not leave client. Get charge nurse to notify health care provider immediately
7. Diagnosis confirmed via ventilation/perfusion scan or pulmonary angiography
8. Continuous IV heparin therapy usually prescribed
D. Fat embolism
1. Definition: fat cells enter pulmonary circulation
2. Associated with
a. multiple trauma accidents
b. multiple organ involvement
c. fractures of marrow producing bones
d. joint replacements
e. insertion of intermedullary rods
3. Usually occurs 24 to 48 hours after the fracture
E. Hemorrhage
1. Abnormal loss of blood from the body
2. Most common in fractures of bone marrow producing bones
F. Wound infection
1. May be superficial or deep wound
2. Deep wound infection may lead to osteomyelitis
3. Findings include erythema and swelling around suture line, increased drainage and elevated
temperature
4. Treated with antibiotics; may require incision and drainage of wound or removal of prosthesis if
severe infection is present
G. Special complications in hip replacement
1. Femoral fracture
a. occurs near distal end of femoral-shaft part of prosthesis
b. occurs more frequently with elderly, clients with osteoporosis, or after revision to total
hip replacement
c. primary finding is severe pain with ambulation
d. diagnosis is confirmed with x-ray
 e. depending on severity, treatment will be immobilization or open reduction with internal
fixation
2. Dislocation of hip prosthesis
a. greatest risk during the first postoperative week but can occur at any time within the first
year.
b. risk decreases as muscle tone of the hip increases
c. caused by flexion of the hip or poor prosthetic fit
d. findings include pain and external rotation of the leg
e. treated by closed reduction under conscious sedation or open surgical revision
H. Special complication in knee replacement: flexion failure
1. Client cannot flex knee 90 degrees two weeks postoperatively
2. Treated with closed manipulation of the knee joint under general anesthesia
a. Nursing interventions (knee replacement)
A. for first 24 to 48 hrs, apply ice to the knee to minimize bleeding and edema
B. in first eight hours, expect wound drainage up to 200 ml.
C. by 48 hours, expect minimal wound drainage
D. transfusions are rarely required
E. within 24 hours, start aggressive physical therapy to promote knee flexion
F. frequently health care provider prescribes a continuous passive motion machine
(CPM)
G. health care provider prescribes the amount of flexion and extension, measured
in degrees, and increases that amount as client tolerates more
H. when the CPM machine is not in use, a knee immobilizer is used
I. keep leg elevated when the client is out of bed
J. on first post-op day, client will begin to use crutches or walker
K. best pain management is patient controlled analgesic (PCA) for the first 48 to
72 hours postoperatively. By fifth post-op day, nonnarcotic oral analgesia.
L. monitor limb's neurovascular status, color, temperature, and pulses
M. monitor for signs of DVT or PE
3. Amputation
a. Purpose: relieve findings; improve function; save or improve quality of life
b. Lower extremity indications
A. progressive peripheral vascular disease (often secondary to diabetes mellitus)
B. gangrene
C. trauma such as crushing injuries, burns, or frostbite
D. congenital deformities
E. malignant tumor
c. Upper extremity indications
A. trauma
B. malignant tumor
C. infection
D. congenital malformations
d. Levels of amputation Objective of surgery is to eradicate the disease process while
conserving as much of the extremity as possible

1. Toes and portion of the foot - usually as a result of trauma or infection. Causes minor changes in gait or
balance
2. Syme: disarticulation of ankle; stump can bear full weight, with prosthesis
3. Below knee (BK) - preserves knee joint which facilitates use of prosthesis
4. Knee disarticulation - at level of knee joint
5. Above knee (AK) - measures undertaken to provide as much length to limb as possible
6. Hip disarticulation - most often performed due to malignancy. Client cannot walk with prosthesis.
7. Below elbow (BE) - preserves elbow joint, thus eases use of prosthesis
8. Above elbow (AE) - measures undertaken to provide as much length to limb as possible
9. Staged amputation - used for infection. Guillotine amputation to remove infectious and necrotic tissue is
performed. After intensive antibiotic therapy, a second operation is performed for skin closure.

A. amputate to most distal point that will heal successfully

B. determined by circulation and functional status
e. Potential postoperative complications
A. hemorrhage
B. infection
C. skin breakdown
 f. Nursing interventions
A. pain management - usually relieved with narcotic analgesics
B. may require evacuation of accumulated fluid or hematoma
C. muscle spasms may be relieved by heat or changing position
D. phantom limb pain
A. may occur any time up to three months post amputation
B. most common with above-knee (AK) amputations
C. relieved with
A. stump desensitization by kneading, or massage
B. transcutaneous electrical nerve stimulation (TENS)
C. distraction
D. beta-adrenergic blocking agents for burning, dull pain
E. anticonvulsants for sharp and cramping pain
g. Wound healing
A. aseptic dressing change technique
B. compression dressing wrapped in a figure eight fashion or cast to control edema
h. Altered body image
A. may take months to resolve
B. must convey acceptance and respect for individual
C. foster independence: encourage client to look at, feel, and eventually care for
limb
i. Grief
A. many clients go through a mourning process, shock, anger, and depression
B. caregivers should support and listen actively
j. Restoring physical mobility
A. early rehabilitation
B. muscle strengthening exercises
C. prosthetic preparation
k. Types of prosthesis
A. hydraulic
B. pneumatic
C. biofeedback - controlled
D. myoelectrically controlled
E. synchronized
4. Arthroscopy
a. Definition - endoscopic procedure that allows direct visualization of the joint, most often
performed on knees and shoulders
b. Indications
A. torn medial and lateral meniscus
B. chondromalacia patellae
C. synovitis
D. torn cruciate ligament
E. subluxation patella
F. intra-articular soft tissue mass
G. pyarthrosis
c. Surgical procedure - most often, office surgery
d. Postoperative care
A. compression dressing wrapped in a figure eight fashion to control edema
B. ice may be applied
C. oral analgesics for pain management
D. weight bearing depends on procedure
e. Postoperative complications are rare
A. infection
B. thrombophlebitis
C. stiffness
5. External fixator

Definition External Fixator: Ilizarov Device

A. The Ilizarov device is a specialized type of external fixator used for non-union fractures and limb lengthening
needed due to congenital deformities.
 B. Tension wires are inserted into the bone and then attached to rings outside the body. These rings are joined by
telescoping rods attached to a rigid frame. Daily adjustment of the rods causes the wires to turn, which
stimulates bone formation.
C. Ilizarov device lengthens limbs about one cm per month.
D. Before discharge, teach clients
1. To care for pin
2. To adjust rod
E. Clients may have the device on for several months.

a. Indication: the device will stabilize fracture with soft tissue injury like crush fractures
b. Procedure: fracture aligned and immobilized by pins of Kirschner wires inserted in the
bone and attached to a rigid frame outside the body
c. Nursing interventions
A. monitor neurovascular status every two hours
B. elevate extremity to reduce edema
C. assess pin insertion sites for infection: erythema, drainage and increased
warmth
D. isometric and active exercises as prescribed
E. non-weight bearing ambulation depends on soft tissue injury
F. discharge teaching
A. ambulation with assistive device (crutches, walker)
B. care of pin site
C. extremity is repositioned by lifting frame instead of extremity
I. After hip replacements, pulmonary embolism may occur even without thrombosis in foot or leg.
J. Clients should sit in a straight, high chair; use a raised toilet seat; and never cross their legs.
K. In hip or knee replacement, clients will need assistive devices for walking until muscle tone strengthens and
they can walk without pain.
L. After an amputation, the home must be assessed for any modifications needed to ensure safety.
M. Some clients will need transportation to continue rehabilitation.
N. Amputee support groups can help clients and family.
O. After arthroscopy, outpatient rehab may be prescribed depending on procedure; health care provider may
prescribe knee immobilizer.
P. External Fixator - If possible, prepare the client preoperatively to reduce anxiety. Device looks clumsy, but
patient should be reassured that discomfort is minimal.
Q. After a hip pinning or femoral-head prosthesis, caution client not to force hip into more than 90 degree of
flexion, into adduction or internal rotation which will cause dislocation and severe pain and this would be a
nursing emergency.
R. Caution clients with a new prosthesis not to use any substances such as lotions, powders etc. unless
prescribed by the health care provider.
S. Osteoporosis cannot be detected by conventional X-ray until more that 30% of bone calcium is lost.
T. Foods high in calcium include milk, cheeses, yogurt, turnip greens, cottage cheese, sardines, and spinach.
U. When performing a musculoskeletal assessment on a client with Paget's disease, note the size and shape of
the skull. The skulls of these clients will be soft, thick and enlarged.
V. Clients at high risk for acute osteomyelitis are: elderly, diabetics, and clients with peripheral vascular disease.
W. When clients receive corticosteroids long-term, evaluate them continually for side effects.
X. Immunosuppressed clients should avoid contact with persons who have infections.
Y. Steroids may mask the signs of infections, so client should promptly report slightest change in temperature or
other complaints.
Z. Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hours and wear sun
block.

Abduction device Adduction Ankylosing spondylitis ApophysealArticularArthroplasty Bursitis Calcaneal

Carpal tunnel syndrome Charcot's joint Chondroma Circumduction Colles' Fracture CondylarCrepitation Cruciate
ligament DiaphysealDiarthroidial joint Disarticulation Discoid Lupus Erythematosus EpiphysealEversion
Ewing's Tumor ExtracapsularGanglion Haversian system Hyperextension Intra-articular soft tissue mass Intracapsular
Inversion Isometric exercises Kirschner wire Laminectomy Lordosis Lyme Disease
MetaphysealOsteoblastoma Osteochondroma Osteosarcoma Pronation Pyarthrosis Scleroderma Swan-neck deformity
Systemic Lupus Erythematosus

• Acetabulum Antibody - schematic structure of IgG antibody Bone tissue

• Bones
• Bones of foot and ankle
• Calcitonin
• Connective tissues
• Endochondral ossification
• Gout
• L.E. cell
• Lymphatic system
• Muscle tissue types
• Osteoporosis
• Passive range of motion excercises
• Proper standing and lifting techniques
• Supporting structures of knee
• Synovial joint
• Types of fractures