Board review

ORTHOPEDIC AND
TRAUMA NURSING
 Dynamic specialty with a history of changing in reaction to development
in the society, health care provision, disease patterns, technology,
medical and nursing development and of course the needs of the patient
with musculoskeletal disturbance.

 Changes have happened over the past 20 years:

 People are more active(prone to injuries)
 Family dynamics have changed
 Lifestyle has continued to evolve

The impact of these changes must be anticipated by the nurse

and the needs that goes with it.
 Orthopedic and Trauma Nurses must:
 Perform specialist roles
 Work on nursing development

 Work collaborately with the health care team

 Lead nsg practice (this ensures that an

appropriate action taken inspires and innovates,
supports and empowers the nursing team)
 
HISTORICAL
BACKGROUND
Greek Language

 Orthos = straight + paedios = child

 Orthopedic Nursing evolved from the

needs of children affected by crippling
musculoskeletal problems.
HISTORICAL
BACKGROUND
 1841 – first orthopedic nurse was appointed (children with congenital and
developmental disorders, nowadays, adult)

 Royal Orthopedic Hospital – the first ortho hosp in 1871

 
 Dame Agnes hunt (1867-1948) – opened her home to crippled children
 Sir Robert Jones – helped Hunt to turn her home into a hospital in 1900
 
 1900s – the start of the recruitment of more orthopedic nurses
 
 1937 – two-year training program for ONs, provides good training ground
ATTRIBUTES that enable the nurse to judge when to act and
when to empower patients:

 Good relationship and communication skills

 Intuitive nursing actions(develop to knowledge, skills, values and
beliefs) 
 The science of nursing involves the application of knowledge and
skills to specific patient needs.
 Nurses need to keep pace with changes in nursing and medical
knowledge and adapt to the technology involved in care.
 In addition, they need expert knowledge of the patient’s orthopedic
condition to understand how their needs are met and how
complications are prevented.
 EVOLUTION OF ORTHOPEDIC
NURSING
 From medical to a nursing model of care
 An illness-focused to a health-focused care

 Viewing the patient as a disease or

condition to a holistic patient-centered view
of care
HEALTH
 dynamic, changeable state which requires the
ability to adapt to circumstances, including
changes in quality of life and the interplay of
attitudes, emotions, thoughts and feelings.
  Dimensions of Health:
 Physical

 Social

 Mental

 Spiritual
HEALTH Trends
 Increased life expectancy
 Changes in workplace (musculoskeletal
stress, injury)
 Increased leisure time (sports injury)
 Changes in the infectious dse with the
emrgence of multiresistant pathogens
 Surgical and technological advances
ILL PREVENTION -- Health oriented approach to
nursing practice in promoting health and prevention of
illness

 Primary Prevention – actions taken before

disease or disability takes place; accident
prevention, immunization, and advice on
preventing sports injuries
 Secondary prevention – early detection and
the treatment of health problems
 Tertiary prevention -- Aims to avoid the
progression of ill health and potential
complications
HEALTH PROMOTION
 Health professionals have a moral and
professional responsibility to be involved
in maintaining and improving the health
of the patients and the community

 Healthpromotion is basically achieved

thru health education
5 Approaches to Health promotion accdg to
Kiger:

Political action – patient’s rights

 Media/propaganda – aims to persuade, motivate
and make people change their behavior
 Community models – accept that professional and
lay people can work together to create change
 Information-giving/medical models – provide info
through professional expertise
 Educational model – accepts that beliefs, values
and feelings influence behavior
CARE SETTINGS
 TRAUMA CARE
 Have led nurses to develop their skills in
identifying their emergency care

 MUSCULOSKELETAL CARE
 Specialist role continues to develop
 Pre-admission clinics – enables nurses to develop
their skills in patient assessment, diagnostic
process and interpretation of medical investigation.
 REHABILITATION
 Good rehabilitation reduces length of hospital stay
 Aim:
 To maximize the patient’s independence physically
and socially, allowing them to return to their normal
place of living.

Rehabilitation must include the cognitive and

emotional aspects of recovery.
THE SCOPE OF CARE
 Traditionally, orthopedic care has been delivered mainly within
in-patient setting. Over the years, provision of care has been
deinstitutionalized.
 
The following circumstances are effects of the transference of
responsibility from secondary to primary care: 
 Early screening and pre operative assessment in primary care
for elective surgery
 More minor surgery in general practice more HaH
 More community hospital offer rehab
 Provision of health maintenance and health promotion services
in primary care
 ORTHOPEDIC LAIASON NURSE – a
specialist orthopedic nurse which lead and
coordinate the assessment process and
laiase between the primary and secondary
care environments
 The laiason nurse communicate with the
primary care team and hospital staff to ensure
the patient receives the required investigation
and treatment.
 MINORSURGERY IN GENERAL
PRACTICE
The shift in emphasis toward a primary care-led
health service has resulted in a more minor
orthopedic surgery being carried out in general
practice.
Minor procedures such as removal of ganglions
or removal of wires (managed in primary care).
 HOSPITAL-AT-HOME
This aims to facilitate early discharge of
patients from hospital, prevent admission
or provide palliative care in patient’s home.
 It aims to facilitate discharge for elective or trauma
patients as early as 3-4 days following a surgery.
 Such schemes provide intensive levels of care for
rehabilitation of acutely ill patients in their own home.
Effectiveness of HaH
 Lesscostly due to the reduction in
terms of access to health care facility in
case of emergency

 Givespatients and informal carer the

choice about whether to be involved in
an early discharge scheme
Considerations for HaH
 Appropriateness of home condition in
terms of accessibility in case of
emergency
 Patient’s over all health status
 Patient’s psychological aspect
 Ability of family members to take on the
role of informal carer.
 PatientSatisfaction – providers of health
services are increasingly expected to
supply information relating to patient
outcomes and clinical effectiveness
following various treatment and
intervention
 Patient’s participation in their care and
satisfaction with delivery directly influence
treatment compliance and patient well-being
 *Pre operative Assessment – traditionally,
orthopedic patients booked for elective surgery has been
assessed in hospital based pre operative assessment
units. This gives the nurse the opportunity to provide
detailed information for the patient and carer about the
surgery and post op care

 Done 2-4 weeks before the surgery date

 This also helps the nurse identify possible
problems or complications
Three importance of Patient
Satisfaction

 Patient satisfaction is known to be

associated with better health outcomes
 Dissatisfied patients are often unable to
take their custom elsewhere
 The need to develop a consumer based
service model of healthcare.
Positive Impact of Satisfaction
to Clients:
 Patients are more likely to adhere to
medical advice
 Satisfaction has a placebo effect or
psychological well-being

Patient outcomes – is necessary to

demonstrate clinical effectiveness.
Review of Anatomy and
Physiology
 The musculo-skeletal system consists
of the muscles, tendons, bones and
cartilage together with the joints

 Theprimary function of which is to

produce skeletal movements
The MUSCULAR SYSTEM
 FUNCTIONS
 Movement

 Posture

 Support

 Protection of vital organs

 Storage of minerals

 Heat production

 Propulsion of blood

 Movement of food in GIT and urine in the ureters

Muscles
Three types of muscles exist in the body
 1. Skeletal Muscles
 Voluntary and striated
 2. Cardiac muscles
 Involuntary and striated
 3. Smooth/Visceral muscles
 Involuntary and NON-striated
Structure of the Muscle
 Epimysium – outermost layer that
surrounds the muscle.

 Perimysium – separate the muscle tissue

into small sections.

 Endomysium – thin covering of a fascicle

Skeletal Muscles’ Actions
a. PRIME MOVERS – muscles whose contractions
actually produces the movement.

b. SYNERGISTS – muscles that contract at the same

time as the prime mover, helping it produce the
movement so the prime mover can produce a more
effective movement.

c. ANTAGONISTS – muscles that relax while the

prime mover is contracting.
Different Contractions of the
Skeletal Muscles
1. ISOTONIC CONTRACTIONS
-- shorten muscle length while maintaining
muscle tension generating movement.

2. ISOMETRIC CONTRACTIONS
-- tighten the muscle by increasing muscle
tension without shortening the muscle.
-- does not usually produce direct
movement.
Different Contractions of the
Skeletal Muscles

3. TWITCH CONTRACTIONS
-- quick, jerky reactions to a single stimulus.
-- muscle shortens for a fraction of a second.

4. TETANIC CONTRACTIONS
-- serial, continuous contractions, in which
individual contraction can’t be distinguished.
Different Contractions of the
Skeletal Muscles
5. TROPPE (Staircase Phenomenon)
-- series of increasingly stronger twitch
contractions occurring in response to
repeated stimuli of constant intensity.

6. FASCICULATION
-- abnormal contraction visible through the
skin as a slight ripple.
-- occurs after neuron destruction
Different Contractions of the
Skeletal Muscles
7. CONVULSIONS
-- abnormal, violent rhythmic
contractions and relaxations of muscle
groups.
TENDONS
 Bands of fibrous connective tissue that
tie bones to muscles
LIGAMENTS
 Strong, dense and flexible bands of
fibrous tissue connecting bones to
another bone
The SKELETAL SYSTEM
 Variously classified according to shape,
location and size
 Functions
1. Locomotion
2. Protection
3. Support and lever
4. Blood production
5. Mineral deposition
BONES
 There are two divisions of the skeleton
 AXIAL– body upright structure with 80 bones
-- consists of the: skull, vertebral column,
and ribs

 APPENDICULAR – body appendages with 126

bones
-- consists of the arms, hips and legs
BONES
 FOUR MAJOR BONE TYPES

1. Long bones – length exceeds breadth and

thickness
2. Short bones – equal in main dimensions found
mainly on hands and feet
3. Flat bones – primarily made up of cancellous
bone tissue
4. Irregular bones – irregular in shape
Difference between Male and
Female Skeletons
 Male skeletons are larger and heavier
than female skeleton

 Male pelvis--deep and funnel shaped

with narrow pubic arc; female pelvis–
shallow, broad, and flaring with wider
pubic arc
JOINTS
 The
part of the Skeleton where two or
more bones are connected
CARTILAGES
A dense connective tissue that consists
of fibers embedded in a strong gel-like
substance
BURSAE
 Saccontaining fluid that are located
around the joints to prevent friction
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
The nurse usually evaluates
this small part of the over-all
assessment and concentrates
on the patient’s posture, body
symmetry, gait and muscle and
joint function
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
 1. HISTORY
 2. Physical Examination
 Perform a head to toe assessment
 Nurses need to inspect and palpate

 The special procedure is the

assessment of joint and muscle
movement
ASSESSMENT OF THE
MUSCULO-SKELETAL SYSTEM
 Gait
 Posture
 Muscular palpation
 Joint palpation
 Range of motion
 Muscle strength
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
 1. BONE MARROW ASPIRATION
 Usually involves aspiration of the marrow to
diagnose diseases like leukemia, aplastic
anemia
 Usual site is the sternum and iliac crest
 Pre-test: Consent
 Intratest: Needle puncture may be painful
 Post-test: maintain pressure dressing and
watch out for bleeding
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
 2. Arthroscopy
 A direct visualization of the joint cavity
 Pre-test: consent, explanation of
procedure, NPO
 Intra-test: Sedative, Anesthesia, incision
will be made
 Post-test: maintain dressing, assist in
ambulation as ordered, mild soreness of
joint for 2 days, joint rest for a few days,
ice application to relieve discomfort
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
3. BONE SCAN
 Imaging study with the use of a contrast radioactive
material
 Pre-test: Painless procedure, IV radioisotope is used,
no special preparation, pregnancy is contraindicated
 Intra-test: IV injection, Waiting period of 2 hours
before X-ray, Fluids allowed, Supine position for
scanning
 Post-test: Increase fluid intake to flush out
radioactive material
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
4. DXA- Dual-energy XRAY absorptiometry
 Assesses bone density to diagnose
osteoporosis
 Uses LOW dose radiation to measure bone
density
 Painless procedure, non-invasive, no special
preparation
 Advise to remove jewelry
Fracture
A break in the continuity of the bone
and is defined according to its type and
extent
Fracture
 Severe mechanical Stress to bone 
bone fracture
 Direct Blows
 Crushing forces
 Sudden twisting motion
 Extreme muscle contraction
 Pathologic conditions
Fracture
TYPES OF FRACTURE
 1. Complete fracture
 Involves a break across the entire cross-
section
 2. Incomplete fracture
 The break occurs through only a part of the
cross-section
Fracture
BROAD CLASSIFICATION OF
FRACTURE:
 1. Close or simple fracture
 The fracture that does not cause a break in
the skin
 2. Open or compound fracture
 The fracture that involves a break in the
skin
Fracture
Classification of Fracture as to Pattern:
 1. Transverse fracture
 The break runs across the bone

 2. Oblique fracture
 The break runs in slanting direction
 45 degrees angle
Fracture
 3. Spiral fracture
 The break coils around the bone

 4. Longitudinal fracture
 The break runs parallel to the bone
Fracture
Classification as to Appearance:
 Comminuted fracture
 Bone splintered into fragments

 Impacted fracture
 When fractured ends of the bone are
pushed into each other
Fracture
 Compressed fracture
A condition in which a bone, particularly
the vertebra collapses

 Depressed fracture
 Usually
occurs in the skull with the broken
bone being driven inward
Greenstick fracture
Fracture
ASSESSMENT FINDINGS
 1. Pain or tenderness over the involved area
 2. Loss of function
 3. Deformity
 4. Shortening
 5. Crepitus
 6. Swelling and discoloration
Fracture
ASSESSMENT FINDINGS
1. Pain
 Continuous and increases in severity
 Muscle spasm accompanies the
fracture as a reaction of the body to
immobilize the fractured bone
Fracture
ASSESSMENT FINDINGS
2. Loss of function
 Abnormal movement and pain can
result to this manifestation
Fracture
ASSESSMENT FINDINGS
3. Deformity
 Displacement, angulations or rotation of
the fragments causes deformity
Fracture
ASSESSMENT FINDINGS
4. Crepitus
 A grating sensation produced when the
bone fragments rub each other
Fracture
 DIAGNOSTIC TEST
 X-ray
Fracture
EMERGENCY MANAGEMENT OF FRACTURE
 1. Immobilize any suspected fracture
 2. Support the extremity above and below
when moving the affected part from a vehicle
 3. Suggested temporary splints- hard board,
stick, rolled sheets
 4. Apply sling if forearm fracture is suspected
or the suspected fractured arm may be
bandaged to the chest
Fracture
EMERGENCY MANAGEMENT OF
FRACTURE
 5. Open fracture is managed by
covering a clean/sterile gauze to
prevent contamination
 6. DO NOT attempt to reduce the
fracture
Emergency First aid splinting
Fracture
MEDICAL MANAGEMENT
 1. Principles of fracture treatment
 Reduction of fracture
 Maintenance of realignment by
immobilization
 Restoration of function
Fracture
 2. Reduction
 Closed manipulation using casts or sling
 Open reduction
 External fixation
 Traction

 3. Immobilization
 the most important phase in obtaining union of
fracture fragments.
Fracture
General Nursing MANAGEMENT
 For CLOSED FRACTURE
 1. Assist in reduction and immobilization
 2. Administer pain medication and muscle
relaxants
 3. teach patient to care for the cast
 4. Teach patient about potential complication
of fracture and to report infection, poor
alignment and continuous pain
 Fracture
General Nursing MANAGEMENT
 For OPEN FRACTURE
 1. Prevent wound and bone infection
-Administer prescribed antibiotics
-Administer tetanus prophylaxis
-Assist in serial wound debridement

 2. Elevate the extremity to prevent edema

formation

 3. Administer care of traction and cast

Fracture
 Stages of Bone Healing
 1. Formation of hematoma
 When a bone is fractured, blood
extravasates between and around the
fragments and the bone marrow.
 2. Cellular proliferation
 Periostal elevation, granulation tissue
containing blood vessels, fibroblasts and
osteoblasts
Fracture
 3. Callus formation
 Differentiated tissue bridging the fracture

 4. Ossification
 Finallaying down of bone
 State in which the fracture ends have knit
together
Fracture
 5. Remodeling
 When consolidation is completed, the
excess cells are absorbed.
 Compact bone is being formed
Average period for firm union of
various bones are as follows:
 Clavicle 3-4 weeks
 Radius-ulna 6-13 weeks
 Metacarpals 4 weeks
 Femur 12 weeks
 Fibula 12-14 weeks
 Phalanges 3 weeks
 Humerus 6 weeks
 Lower 3rd radius 4 weeks
 Tarsals 6-8 weeks
 Metatarsals 5-6 weeks
 Fracture
FRACTURE COMPLICATIONS
●Early●
 1. Shock
 2. Fat embolism
 3. Compartment syndrome
 4. Infection
 5. DVT
 Fracture
 FRACTURE COMPLICATIONS
 Late
 1. Delayed union
 2. Avascular necrosis
 3. Delayed reaction to fixation devices
 4. Complex regional syndrome
 5. Heterotrophic ossification
 Fracture
 FRACTURE COMPLICATIONS: Fat
Embolism
 Occurs usually in fractures of the long
bones
 Fat globules may move into the blood
stream because the marrow pressure is
greater than capillary pressure
 Fat globules occlude the small blood
vessels of the lungs, brain kidneys and
other organs
 Fracture
 FRACTURE COMPLICATIONS: Fat
Embolism
 Onset is rapid, within 24-72 hours
 ASSESSMENT FINDINGS
 1. Sudden dyspnea and respiratory
distress
 2. tachycardia
 3. Chest pain
 4. Crackles, wheezes and cough
 Fracture
 FRACTURE COMPLICATIONS: Fat
Embolism
 Nursing Management
 1. Support the respiratory function
 Respiratory failure is the most common
cause of death
 Administer O2 in high concentration
 Prepare for possible intubation and
ventilator support
 Fracture
 FRACTURE COMPLICATIONS: Fat
Embolism
 Nursing Management
 2. Administer drugs
 Corticosteroids
 Dopamine
 Morphine
 Fracture
 FRACTURE COMPLICATIONS: Fat Embolism
 Nursing Management
 3. Institute preventive measures
 Immediate immobilization of fracture
 Minimal fracture manipulation
 Adequate support for fractured bone during
turning and positioning
 Maintain adequate hydration and electrolyte
balance
Fracture
 Early complication: Compartment
syndrome
 A complication that develops when
tissue perfusion in the muscles is less
than required for tissue viability
 Fracture
 Early complication: Compartment syndrome
 ASSESSMENT FINDINGS
 1. Pain- Deep, throbbing and UNRELIEVED
pain by opiods
 Pain is due to reduction in the size of the
muscle compartment by tight cast
 Pain is due to increased mass in the
compartment by edema, swelling or
hemorrhage
 Fracture
 Early complication: Compartment syndrome
 ASSESSMENT FINDINGS
 2. Paresthesia- burning or tingling sensation
 3. Numbness
 4. Motor weakness
 5. Pulselessness, impaired capillary refill
time and cyanotic skin
Fracture
 Early complication: Compartment
syndrome
 Medical and Nursing management
 1. Assess frequently the neurovascular
status of the casted extremity
 2. Elevate the extremity above the
level of the heart
 3. Assist in cast removal and
FASCIOTOMY
Strains

 Excessive stretching of a muscle or

tendon
 Nursing management
 1. Immobilize affected part
 2. Apply cold packs initially, then heat
packs
 3. Limit joint activity
 4. Administer NSAIDs and muscle
relaxants
Sprains
 Excessive stretching of the LIGAMENTS
Nursing management
 1. Immobilize extremity and advise rest
 2. Apply cold packs initially then heat packs
 3. Compression bandage may be applied to
relieve edema
 4. Assist in cast application
 5. Administer NSAIDS
Dislocation
 Displacement of a bone from its normal joint
position to the extent that articulating surface
partially lose contact.

 CAUSES
 Trauma
 Disease
 Congenital condition
Dislocation
 SIGNS AND SYMPTOMS

 Burning pain
 Deformity

 Stiffness and loss of joint function

 Moderate or severe edema around the joint

Dislocation
 NURSING MANAGEMENT
 To lessen swelling, elevate the affected
extremity.
 Assess affected extremity for signs for
neurovascular problems.
 Give pain medications as ordered by the
doctor.
 Provide appropriate care if patient is
immobilized.
 Encourage patient to exercise.
Common musculoskeletal
problems

The Nursing Management

Nursing Management of common musculo-
skeletal problems
PAIN
 These can be related to joint inflammation,
traction, surgical intervention
 1. Assess patient’s perception of pain
 2. Instruct patient alternative pain
management like meditation, heat and cold
application, TENS and guided imagery
Nursing Management
PAIN
 3. Administer analgesics as prescribed
 4. Assess the effectiveness of pain
measures
Nursing Management
IMPAIRED PHYSICAL MOBILITY
 1. Instruct patient to perform range of motion
exercises, either passive or active
 2. Provide support in ambulation with
assistive devices
 3. Turn and change position every 2 hours
 4. Encourage mobility for a short period and
provide positive reinforcements for small
accomplishments
 Nursing Management
SELF-CARE DEFICITS
 1. Assess functional levels of the patient
 2. Provide support for feeding problems
 Place patient in Fowler’s position
 Provide assistive device and supervise meal
time
 Offer finger foods that can be handled by
patient
 Keep suction equipment ready
Nursing Management
SELF-CARE DEFICITS
 3. Assist patient with difficulty bathing
and hygiene
 Assist with bath only when patient has
difficulty
 Provide ample time for patient to finish
activity
Musculoskeletal Modalities
Traction
Cast
Nursing Management
Traction
A method of fracture immobilization by
applying equipments to align bone
fragments
 Used for immobilization, bone alignment
and relief of muscle spasm
Nursing Management
TRACTION
 It is the act of pulling or drawing which
is associated with counter traction.
Traction means that a pulling force is
applied to a body part or extremity while
a counter traction pulls in the opposite
direction.
Nursing Management
TRACTION
 Purposes of Traction

1.Traction is often used in the treatment of

fractured extremities
 To lessen muscle spasm

 To reduce fracture

 To provide immobilization

 To maintain alignment
Nursing Management
TRACTION
2. Traction is also used to correct, lessen or prevent
deformities as in the case of arthritis patients with
flexion contraction.

3. Prior to total hip surgery, surgeons may apply

skeletal traction in an attempt to stretch muscles to
obtain more working space.

4. Lessens muscle spasm in back pain

Nursing Management
Traction: General principles
 1. patient’s position must be supine
 2. avoid friction
 3. allow the weights to hang freely
 4. apply traction continuously
 5. there should be an adequate counter
traction
 6. line of pull must be in line with deformity
Nursing Management
Traction: What to watch out for?
 1. Impaired circulation in the extremities
 2. Observe for DVT, skin irritation and
breakdown
 3. Signs of infection
 Provide pin care
 4. Deformity like foot drop
 Provide foot board
Traction
 Skin traction
 Application of a pulling force to the skin
from where it is transmitted to the muscles
and then to the bones
 Uses adhesive and non-adhesive type of
materials
Traction
 Skeletal traction
 The pulling force is applied directly to the
bone using pins and wires such as
Kirshner’s wire, Steinman’s pin, Vinki’s
skull retractor and crutch field tongs.

 Manual traction
 Pullingforce is applied by hands of the
operator
Application of skeletal traction…
Traction
 Equipments for Balanced Skeletal Traction
 Thomas splint
 Pearson’s attachment
 Rest splint
 5 slings (different sizes)
 5 safety pins
 Cord
 pulleys
Traction
 Equipments cont’n
 Weight traction and suspension weight bag
 Steiman’s pin holder

 Kirshner’s wire holder

 Overhead trapeze

 Foot board

 Balkan frame
Traction
Different Kinds of Traction

1. Halo – femoral traction

 Skin
 Severe scoliosis

2. Head-halter traction
 Skin
 Several cervical sprains, cervical strains, mild
cervical trauma, Pott’s disease
Traction
Different Types of Traction

3. Dunlop traction
 Skin
 Supracondylar fracture of the humerus

4. Buck’s traction
 Skin (adhesive tape)
 Injuries to the hip and femur bone
Traction
Different Types of Traction

5. Halo-pelvic traction
 Skin
 Scoliosis

6. Pelvic traction
 Skin (non-adhesive)
 Low back pain
Traction
Different Types of Traction
7. Cotrel
 Skin (combination of head halter and pelvic
traction)
 Scoliosis

8. Pelvic traction
 Skin (non-adhesive)
 Low back pain, lumbar affection
Traction
Different Types of Traction
9. Bryant’s traction
 Skin (adhesive tape)
 Femur fracture, congenital hip dislocation in
infants less than 6 years old

10. Boot cast traction

 Skin
 Hip and femur fracture, post poliomyelitis with
residual paralysis
Traction
Different Types of Traction
11. 90-90 lower extremity traction
 Skin or skeletal
 Displaced femoral fracture

12. Stove-in Chest

 Skin
 Severe chest injury with multiple fracture
Traction
Different Types of Traction
12. Balance skeletal traction
 Skeletal
 Femoral affectation

13. Side arm traction (90-90 upper extremity

traction)
 Skeletal or skin
 Supracondylar fracture of the humerus
Traction
14. Crutchfield Tong and halo traction
 Skeletal
 Cervical fracture or subluxation

14. Russel traction

 Skin (adhesive)
 fracture of femur
Head-halter traction
Skull traction
Dunlop traction
Pelvic traction
Acetabular traction
Buck’s Traction And
Russel’sTraction
BRACES
 Banjo Splint
 Peripheral nerve injury

 Bilateral Long Leg Brace

 Polio

 Chair Back Brace

 Lumbo-sacral affectation
BRACES
 Cock-up Splint
 Wrist drop

 Dennis Brown Splint

 Congenital clubfoot or talipes

 Finger Splint
 Fractured digits
BRACES
 Forester Brace
 Cervico-thoraco-lumbar spine affectation

 Jewette Brace
 Lower thoracic and upper lumbar affectation

 Milwaukee Brace
 Scoliosis T9 and above
BRACES
 L-S Corset
 Thoraco-lumbar affectation
Philadelphia brace
L-S Corset
8 Figure Brace
Velpeau Brace
Nursing Management
CAST
 Immobilizing tool made of plaster of
Paris or fiberglass
 Provides immobilization of the fracture
Nursing Management
CAST: types
1. Long arm
2. Short arm
3. Spica
Casting Materials
 Plaster of Paris
 Drying takes 1-3 days
 If dry, it is SHINY, WHITE, hard and
resistant
 Fiberglass
 Lightweight and dries in 20-30 minutes
 Water resistant
Nursing Management
CAST: General Nursing Care
 1. Allow the cast to dry (usually 24-72
hours)
 2. Handle a wet cast with the
PALMS not the fingertips
 3. Keep the casted extremity
ELEVATED using a pillow
 4. Turn the extremity for equal
drying. DO NOT USE DRYER for
plaster cast
 Nursing Management
CAST: General Nursing Care
5. Petal the edges of the cast to
prevent crumbling of the edges
6. Examine the skin for
pressure areas and Regularly
check the pulses and skin
 Nursing Management
CAST: General Nursing Care
7. Instruct the patient not to
place sticks or small objects
inside the cast
8. Monitor for the following: pain,
swelling, discoloration,
coolness, tingling or lack of
sensation and diminished pulses
Different Kinds of Cast
Common Musculoskeletal
conditions

Nursing management
METABOLIC BONE
DISORDERS
Osteoporosis
 A disease of the bone characterized by
a decrease in the bone mass and
density with a change in bone structure
METABOLIC BONE
DISORDERS
Osteoporosis: Pathophysiology
 Normal homeostatic bone turnover is
altered rate of bone RESORPTION is
greater than bone FORMATION
reduction in total bone mass
reduction in bone mineral density
prone to FRACTURE
METABOLIC BONE
DISORDERS
Osteoporosis: TYPES
 1. Primary Osteoporosis- advanced
age, post-menopausal
 2. Secondary osteoporosis- Steroid
overuse, Renal failure
METABOLIC BONE
DISORDERS
RISK factors for the development of
Osteoporosis
 1. Sedentary lifestyle
 2. Age
 3. Diet- caffeine, alcohol, low Ca and Vit D
 4. Post-menopausal
 5. Genetics- caucasian and asian
 6. Immobility
METABOLIC DISORDER
ASSESSMENT FINDINGS
 1. Low stature
 2. Fracture
 Femur

 3. Bone pain
METABOLIC DISORDER
LABORATORY FINDINGS
 1. DEXA-scan
 Provides information about bone mineral
density
 T-score is at least 2.5 SD below the young
adult mean value
 2. X-ray studies
METABOLIC DISORDER
Medical management of Osteoporosis
 1. Diet therapy with calcium and Vitamin D
 2. Hormone replacement therapy
 3. Biphosphonates- Alendronate, risedronate
produce increased bone mass by inhibiting
the OSTEOCLAST
 4. Moderate weight bearing exercises
 5. Management of fractures
METABOLIC DISORDER
Osteoporosis Nursing Interventions
1. Promote understanding of osteoporosis and
the treatment regimen
 Provide adequate dietary supplement of
calcium and vitamin D
 Instruct to employ a regular program of
moderate exercises and physical activity
 Manage the constipating side-effect of
calcium supplements
METABOLIC DISORDER
Osteoporosis Nursing Interventions
 Take calcium supplements with meals
 Take alendronate with an EMPTY
stomach with water
 Instruct on intake of Hormonal
replacement
METABOLIC DISORDER
Osteoporosis Nursing Interventions
2. Relieve the pain
 Instruct the patient to rest on a firm
mattress
 Suggest that knee flexion will cause
relaxation of back muscles
 Heat application may provide comfort
 Encourage good posture and body
mechanics
 Instruct to avoid twisting and heavy lifting
METABOLIC DISORDER
Osteoporosis Nursing Interventions
 3. Improve bowel elimination
 Constipation is a problem of calcium
supplements and immobility
 Advise intake of HIGH fiber diet and
increased fluids
METABOLIC DISORDER
Osteoporosis Nursing Interventions
 4. Prevent injury
 Instruct to use isometric exercise to
strengthen the trunk muscles
 AVOID sudden jarring, bending and
strenuous lifting
 Provide a safe environment
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS
 The most common form of degenerative
joint disorder
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Pathophysiology
 Injury, genetic, Previous joint
damage, Obesity, Advanced age 
Stimulate the chondrocytes to
release chemicals chemicals will
cause cartilage degeneration,
reactive inflammation of the synovial
lining and bone stiffening
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Risk factors
 1. Increased age
 2. Obesity
 3. Repetitive use of joints with previous
joint damage
 4. Anatomical deformity
 5. genetic susceptibility
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
 1. Joint pain
 2. Joint stiffness
 3. Functional joint impairment
 The joint involvement is ASYMMETRICAL
 This is not systemic, there is no FEVER
 Usual joint are the WEIGHT bearing joints
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
1. Joint pain
 Caused by
 Inflamed synovium
 Stretching of the joint capsule

 Irritation of nerve endings

DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
2. Stiffness
 commonly occurs in the morning after
awakening
 Lasts only for less than 30 minutes
 DECREASES with movement
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Diagnostic findings
1. X-ray
 Narrowing of joint space
 Loss of cartilage
 Osteophytes
2. Blood tests will show no evidence of
systemic inflammation and are not
useful
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Medical management
 1. Weight reduction
 2. Use of splinting devices to support joints
 3. Occupational and physical therapy
 4. Pharmacologic management
 Use of NSAIDS
 Use of Glucosamine and chondroitin
 Topical analgesics
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Nursing
Interventions
 1. Provide relief of PAIN
 Administer prescribed analgesics
 Application of heat modalities
 Plan daily activities when pain is less
severe
 Pain meds before exercising
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Nursing
Interventions
 2. Advise patient to reduce weight
 Aerobic exercise
 Walking

 3. Administer prescribed medications

 NSAIDS
Rheumatoid arthritis
A type of chronic systemic inflammatory
arthritis affecting more women than men
Rheumatoid arthritis
Pathophysiology
 Immune reaction in the synovium 
attracts neutrophils  releases
enzymes  breakdown of collagen 
irritates the synovial liningcausing
synovial inflammation edema and
pannus formation and joint erosions
Rheumatoid arthritis
ASSESSMENT FINDINGS
 1. PAIN
 2. Joint swelling and stiffness-
SYMMETRICAL
 3. Warmth, erythema and lack of
function
 4. Fever, weight loss, anemia, fatigue
 5. Palpation of join reveals spongy tissue
 6. Hesitancy in joint movement
Rheumatoid arthritis
ASSESSMENT FINDINGS
 Joint involvement is SYMMETRICAL
and BILATERAL
 Characteristically beginning in the
hands, wrist and feet
 Joint STIFFNESS occurs early morning,
lasts MORE than 30 minutes, not
relieved by movement
Rheumatoid arthritis
ASSESSMENT FINDINGS
 Joints are swollen and warm
 Painful when moved
 Deformities are common in the hands
and feet causing misalignment
 Rheumatoid nodules may be found in
the subcutaneous tissues
Rheumatoid arthritis
Diagnostic test
 1. X-ray
 Shows bony erosion
 2. Blood studies reveal (+) rheumatoid factor,
elevated ESR and CRP
 3. Arthrocentesis shows synovial fluid that is
cloudy, milky or dark yellow containing WBC
and inflammatory proteins
Rheumatoid arthritis
MEDICAL MANAGEMENT
 1. Therapeutic dose of NSAIDS and
Aspirin
 2. Chemotherapy with methotrexate,
antimalarials, gold therapy and steroid
 3. For advanced cases- arthroplasty,
synovectomy
 4. Nutritional therapy
Rheumatoid arthritis
Nursing MANAGEMENT
1. Relieve pain and discomfort
 USE splints to immobilize the affected
extremity during acute stage of the
disease and inflammation
 Administer prescribed medications
 Suggest application of COLD packs during
the acute phase of pain, then HEAT
application as the inflammation subsides
Rheumatoid arthritis
Nursing MANAGEMENT
2. Decrease patient fatigue
 Schedule activity when pain is less severe
 Provide adequate periods of rests
3. Promote restorative sleep
4. Increase patient mobility
 Advise proper posture and body mechanics
 Support joint in functional position
 Advise ACTIVE ROME
Gouty arthritis
A systemic disease caused by
deposition of uric acid crystals in the
joint and body tissues
 CAUSES:
 1. Primary gout- disorder of Purine
metabolism
 2. Secondary gout- excessive uric acid
in the blood caused by other diseases
Gouty arthritis
 ASSESSMENT FINDINGS
 1. Severe pain in the involved joints,
initially the big toe
 2. Swelling and inflammation of the joint
 3. TOPHI- yellowish-whitish, irregular
deposits in the skin that break open and
reveal a gritty appearance
 4. PODAGRA
Gouty arthritis
ASSESSMENT FINDINGS
 5. Fever, malaise
 6. Body weakness and headache
 7. Renal stones
Gouty arthritis
DIAGNOSTIC TEST
 Elevated levels of uric acid in the blood
 Uric acid stones in the kidney
Gouty arthritis
 Medical management
 1. Allupurinol
 2. Colchicine
Gouty arthritis
Nursing Intervention
1. Provide a diet with LOW purine
 Avoid Organ meats, aged and processed
foods
2. Encourage an increased fluid intake
3. Instruct the patient to avoid alcohol
4. Provide alkaline ash diet to increase
urinary pH
5. Provide bed rest during early attack of gout
Gouty arthritis
Nursing Intervention
6. Position the affected extremity in mild
flexion
7. Administer anti-gout medication and
analgesics