Orthopedic Nursing

Prepared By: Prince Rener V. Pera

Review of Anatomy and
Physiology
 The musculo-skeletal system consists of the muscles, tendons,
bones and cartilage together with the joints

 The primary function of which is to:

1. Support the soft tissues of the body and provide form and
shape
2. Facilitate movement when overlying muscles contract
3. Afford protection to the underlying organs of the body
4. Produce blood cells
5. Store minerals for body use, especially Calcium and
Phosphorous
 The Skeletal system is the supporting
framework of the body is composed of 206
bones and intervening cartilages.

Skeletal Structure of Bones:

a) Appendicular Bones- 126 bones (pelvic
girdles)
b) Axial Bones- 80 Bones (midline of the
body)
Axial Bones

1. Skull
Cranium- 8
Face- 14
2. Hyoid- 1
3. Vertebral Column- 26
4. Thorax
Ribs- 12 pairs
Sternum- 1
5. Ossicles of the Ears- 6
Appendicular Bones
Shoulder Girdle Lower Extremity
Scapula- 2 Femur- 2
Clavicle- 2 Tibia- 2
Upper Extremity Fibula- 2
Humerus- 2 Patella- 2
Radius- 2 Tarsus- 14
Ulna- 2 Metatarsals- 10
Carpus- 16 Phalanges- 28
Metacarpals- 10
Phalanges- 28
Pelvic Girdle
Innominate, Coxa, Hip- 2
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
 Visceral, plain muscles
Muscle Types:
1. Skeletal Muscle
 accounts for at least 40% of body mass
 aids in the formation of the smooth contour of the body
Parts:
1.1 Epimysium
 Tough connective tissue covering of the entire muscle.
 It binds many fascicles together.
 Tendon/Apponeurosis : blending of the epimysia
1.2 Perimysium
 Fibrous membrane covering several sheathed muscle
fibers
 Fascicles – are bundles of muscle fibers covered by
perimysium.
1.3 Endomysium
 This is connective tissue sheath enclosing individual
muscle fiber.
Skeletal Muscle
Characteristics:
 Voluntary control

(but can also be

activated by
reflexes)
 (+) Striations

 Multinucleated

 Shape: Cylindrical

 Speed of

contraction:
Variable
2. Smooth Muscle
 Found mainly in the walls of hollow
visceral organs such as the stomach,
urinary bladder and respiratory passages.
 propels substances along a definite tract,
or pathway, within the body.
Smooth Muscle Characteristics:
 Involuntary control

 (-) Striations; no distinct sarcomeres

 Uninucleated

 Spindle-shaped

 Speed of Contraction: slow and sustained;

does not develop an oxygen debt
Smooth muscle
3. Cardiac Muscle
 Found only in the heart (cardiac).
 Heart – serves as a pump, propelling blood
into the blood vessels and to all tissues of the
body.
 Cardiac fibers are cushioned by small
amounts of soft connective tissue and
arranged in spiral or figure 8-shaped bundles.
Cardiac Muscle Characteristics:
 Involuntary control

 (+) Striations

 Multinucleated

 Branched

 Speed of contraction: Variable

Muscle Functions:
1) Production of movements/locomotion
2) Maintenance of posture
3) Joint stabilization
4) Generating heat
5) Energy production
Similarities of all Muscle Types:
a) All muscle cells are elongated (this
explains the term muscle fibers)
b) Muscle contractions depends on the
types of myofilaments (thin and thick
myofilaments)
c) Terminology (prefixed: myo, mys, &
sarco)
 SARCOMERE- functional unit of the muscle; extends from one Z-line
to another Z-line
- mainly composed of actin & myosin myofilaments

Z-disk or Z-line = anchors the actin myofilaments

M-line= holds the myosin filaments in place
 Muscle Physiology
Stimulation and Contraction of a Single Skeletal
Muscle Cell
 Functional Properties of Muscle Fibers:
1. Irritability – ability to react and respond to
stimulus
2. Contractility – ability to shorten when stimulated
by adequate stimulus
 The Nerve Stimulus and Action Potential
1. Motor Unit - single motor neuron and all of the
corresponding muscle fibers it innervates.
2. Action Potential - the electrical signal sent out
by the body to control bodily processes such as
muscular movement.
SKELETAL MUSCLE:

 LMN control
 Energy is consumed during muscle
contraction – LACTIC ACID (↓O2)
 MUSCLE FATIGUE:
 ↑ work of muscle with inadequate O2 supply
 Depletion of glycogen & energy stores
 Accumulation of lactic acid
 Structure and function of
the skeletal system
 Skeletal system consist of Axial and
Appendicular skeleton.

1. Axial Skeleton- which is composed of bones of

the skull, thorax and vertebral column which
forms the axis of the body.

2. Appedicular Skeleton- consist of bones of the

upper and lower extrimities, including the hip
and the shoulder.
 Two types of connective tissue found in
the skeletal system:

1. Cartilage – a semi-rigid and slightly flexible

structures that plays an essential role in prenatal
and childhood development of the skeleton and
as a surface for the articulating ends of the
skeletal joint.

2. Bones – which provide the firm structure of the

skeleton and serve as reservoir for calcium and
phosphate storage.
Three types of cartilage
 Elastic Cartilage- Contain some elastin in each intracellualr
substance. ( ears)

 Hyaline Cartilage- Pearly white, found in the articulating

ends of the bones.
- form the fetal skeleton .

 Fibro cartilage- has a characteristic that are intermediate

between dense connective tissue and hyaline cartilage. It is
found in the intervertebral disks, in areas where tendons
are connective to bone and in the symphysis pubis.
- 65-80% are water.
 Bone- is a connective tissue in which the
intracellular matrix has been impregnated
with inorganic calcium salts so that it has a
great tensile and compressible strength but is
light enough to be move by coordinated
muscle contractions.
 BONES

 Variously classified according to shape, location

and size

 Functions
1. Locomotion
2. Protection
3. Support and lever
4. Blood production
5. Mineral deposition
Bone Classification According to Shape

1. Long Bones- Are found on the extremities

and consists of diaphysis with two expanded
epiphysis (e.g. Femur)

2. Short Bones- are cubed shaped and consist

mainly of spongy bone with compact shell
(eg. Carpal bones)

3. Flat Bones- thin and composed of two plates

of compact bone with an intervening layer
of cancellous bone (e.g. Scapula)
4. Irregular Bones- are of various shapes and do
not fill in the groups. (eg. Skull bones)

Other Bones not classified under shape:

 Sesamoid Bones- are free floating bones
usually found in tendons or joint capsules.
(e.g. Patella)
 Bone is made up of four major components:
 mineral (mainly calcium and phosphorus)
 matrix (collagen fibers)
 osteoclasts (bone-removing cells)
 osteoblasts (bone-producing cells).

 Osteocytes ( mature bone cells for bone

maintenance functions)
 SKELETAL SYSTEM:
BONE STRUCTURE
 PERIOSTEUM:
 Dense fibrous membrane covering the bone
 Periosteal vessels supply bone tissue
 EPIPHYSIS:
 Widened area at the end of the long bone
 EPIPHYSEAL PLATE (growth zone)
 Cartilage area in children w/c provides for longitudinal
growth of the bone
 ARTICULAR CARTILAGE:
 Provides smooth surface over the ends of the bone to
facilitate joint movement
 Type of bone cell

 Osteogenic cells- Undifferentiated cells that

differentiate into osteoblasts. They are found
in the periosteum, endosteum, and
epiphyseal growth plate of growing bones.

 Osteoblasts- Bone building cells that

synthesize and secrete the organic matrix of
bone. It also participate in the calcification of
the organic matrix.
 Osteocytes- Mature bone cells that function
in the maintenance of bone matrix.
Osteocytes also play an active role in
releasing calcium in the blood .

 Osteoclasts- Bone cells responsible for the

resorption of bone matrix and the release of
calcium and phosphate from bone.
 SKELETAL SYSTEM:
BONE STRUCTURE
 RED BONE MARROW:
 Hemopoietic tissue located in the central bone
cavities.
 Adults: ribs, sternum, vertebrae, portions of hips
& pelvic bones
 Long Bones filled with fatty, yellow marrow
 FUNCTIONS:
 Formation of RBC, WBC & platelets
 Destruction of old RBC (phagocytosis)
BONE FORMATION
(Osteogenesis)
 OSSIFICATION
 Process by which matrix (collagen fiber & ground
substance) is formed & hardening minerals are
deposited on collagen fibers (give tensile strength)
 ENDOCHONDRAL
 Osteoid (cartilage-like tissue) is formed, reabsorbed, &
replaced by bone
 INTRAMEMBRANOUS
 Bone develops within membrane (e.g. face, skull)
BONE MAINTENANCE & HEALING:

 REGULATORY FACTORS DETERMINING BOTH

FORMATION & RESORPTION:
 1. Weight-bearing (local stress)
 2. Vitamin D (Calcitrol) promotes absorption of
calcium from GIT
 3. Parathyroid Hormone regulates calcium
 4. Calcitonin & Amino biphosphate (e.g.
Alendronate [Fosamax]) increases production of
bone cells
BONE MAINTENANCE & HEALING:

 1. Weight-bearing (local stress)

 Stimulate bone formation & remodelling
 Prolonged bed rest: bone losses calcium (resorption)
& becomes osteopenia & weak
2. Biologically Active Vitamin D (Calcitrol)
 ↑ amount of Ca in blood by promoting absorption of
Ca from GIT
 Facilitates mineralization of osteoid tse
 Deficiency cause bone demineralization, deformity
& fracture
BONE MAINTENANCE & HEALING:

 3. Parathyroid Hormone (parathormone)

 regulates calcium in blood in part by promoting
mov’t of Ca from the bone
 ↓ Ca in blood ► ↑ PTH prompt demineralization of
the bone
 4. Calcitonin & Amino biphosphate (e.g.
Alendronate [Fosamax]) increases production of
bone cells
 Calcitonin- inhibits release of calcium from the bone
into the extracellular fluid and reduces the renal
tubular reabsorption of calcium
 Parathyroid hormone
Parathyroid gland

Bone – release of Kidney reabsorption

Ca and phosphate of Calcium

Calcium concentration Urinary excretion

in the extracellular of Phosphate
fluid

Activation of
Intestine
Vit.D
Reabsorption of Ca
via activated vit. D
BONE MAINTENANCE & HEALING:

 Estrogen & Androgen

 Stimulate osteoblastic activity & inhibit PTH
 Menopause/Andropause –
 ↓Ca ► bone loss ► osteoporosis
 Androgen-testosterone
 Promote anabolism
 ↑bone mass
 ESTROGEN-It appears that oestrogen deficiency
allows greater expression of these cytokines, all of
which are associated with increased stimulation of
bone resorption which then leads to increased bone
loss and a reduction in BMD.
 Androgens Androgens, like estrogens, can
directly affect and modulate bone cell function.
Androgen receptors are found on osteoblast cell
lines and they can cause osteoblast proliferation.
Hypogonadal men, in common with post-
menopausal women, have decreased calcium
absorption and low vitamin D levels. The
replacement of androgens with testosterone can
correct these abnormalities, suggesting again
that sex hormones are required for the
maintenance of bone health.
 BONE HEALING:
 STAGE 1. HEMATOMA FORMATION & INFLAMMATION
 When bone is damaged or injured, hematoma precedes new tissue
formation in the production of new bone substance
 STAGE 2. CELLULAR PROLIFERATION:
 Granular tissue formation where BV & cartilage overlie the fracture
 Callus forms as minerals are deposited to organize new network for the
new bone
 STAGE 3. PRECALLUS FORMATION: (2-6 wks)
 Callus forms the initial clinical union of the bone & provides enough
stability to prevent movement when bones are gently stressed
 STAGE 4. CALLUS FORMATION:
 Consolidation & Remodelling (complete healing- 3-6months)
 Continued bone healing provides for gradual return of the injured bone to
its pre-injury shape & structural strength
Bone healing
FACTORS AFFECTING TIME
REQUIRED FOR HEALING:
 1. age
 2. displacement
 3. site of fracture
 4. nutritional level
 5. blood supply to the area of injury
 JOINTS

 Permits bone to change

position & facilitate body
mov’t
 Diarthrodial (synovial)
joint is the most common
type of joint in the body
joints
joints
joints
Joints
joint
joints
CARTILAGE (hyaline)

 A dense connective tissue that consists of

fibers embedded in a strong gel-like
substance that cover the end of the bone
CARTILAGE

 ARTICULAR CARTILAGE
 Rigid, connective, avascular tissue that covers
each bone ends
 Damaged cartilage heals slowly (lacks direct blood
suply)
BURSAE

 Sac containing fluid that are located around

the joints to prevent friction
 A fibrous capsule of connective tissue joins
the 2 bones together

 1. SYNOVIUM (synovial membrane)

 Lines the capsule
 2. SYNOVIAL FLUID
 Secreted by the synovium & decreases friction by
lubricating the joints
TENDONS (aponeurosis)

 Bands of fibrous connective tissue that tie

bones to muscles
LIGAMENTS

 Strong, dense and flexible bands of fibrous

tissue connecting bones to another bone
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
 Injury, surgery, disability, inflammatory / metabolic
conditions
 Familial predisposition
 Level of normal activity (occupation, exercise,
recreation)
 2. Physical Examination
 Inspection for gross deformities, asymmetry,
swelling, edema
 Nutritional status: weight, body frame
 ASSESSMENT OF THE MUSCULO-
SKELETAL SYSTEM
 Gait (Antalgic); Genu Valgum (Knock-Knee),
Genu Varum (Bow-Legged)
 Posture (Kyphosis/Lordosis/Scoliosis)
 Muscular palpation
 Joint palpation (Crepitus-grating sound)
 Range of motion
 Muscle strength
Assessment Findings

 6 P’s of NEUROVASCULAR
DAMAGE
 Swelling
 Loss of function
 Deformity
 Crepitus
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,
 ambulation as soon as awake,
 mild soreness of joint for 2 days,
 joint rest for a few days & ice application to
relieve discomfort
 ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
 2. ARTHROSCOPY -
 C.I for pt who cannot flex @ 40° and with infected
knee
 Uses large pneumatic tourniquet to minimize
bleeding
 Apply dressing, neurovascular check, observe for
complications swelling,hyperthermia,
thrombophlebitis,infxn
KNEE ARTHROSCOPY
ARTHROSCOPY
KNEE ARTHROSCOPY
SHOULDER ARTHROSCOPY
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
BONE SCAN
– Radioisotope injected IV (technetium,
Gallium, Thalium)
 Adm. Isotope 1-2 days before scanning
 No radioactive threats
 Procedure lasts 30-60 min
 No special care after procedure
 Excreted in Urine & feces
 Encourage fluid
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
LABORATORY PROCEDURES
4. DEXA- 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
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
 5. Xray Films: Roentgenograms – plain xray
film is common APL (Antero-posterior lateral
views.
 6. ARTHROGRAPHY: injection of dye or air
in the joint for x-ray study
 7. MYELOGRAPHY: examines spinal cord
after introduction of contrast medium
Myelography
ARTHROGRAPHY

Arthrography is the radiographic

examination of a joint, after the
injection of a dye-like contrast
material and/or air, to outline the soft
tissue and joint structures on the
images.
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
 8. BONE/MUSCLE BIOPSY: Iliac crest usual
puncture site; not commonly done today
 Local anesthesia, check PT & PTT
 Coagulant given 2-3 days before & after
procedure
 Pressure dressing after
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
 9. CT SCAN: assess bone & soft tse
tumors
 10. MRI: to assess soft tissue and joints
with myelography
 GANDOLINIUM DTPA
 (DiethyleneTriamine PentaAcetic Acid)
BLOOD STUDIES:
1. ESR (Erythrocyte Sedimentation Rate):
 non-specific test for inflammation F: 0-20 mm/hr
M: 0-10 mm/hr
2. URIC ACID: Elevated in gout
 Normal 2.2-7 mg/dl (F) ;4.2-8 mg/100 ml (M)
3. ANA (Anti-nuclear Anti-body):
 Measures the presence of antibodies that destroy
the nucleus of the body tissue cells in auto-immune
disorder;
 (+) in about 94% of clients w/ SLE
 Sjoren’s syndrome
 RA
BLOOD STUDIES:

 RHEUMATOID FACTOR (Latex Fixation):

 Determine presence of auto antibodies (RF) found in
clients with connective tissue dse
 (+) RF is suggestive of RA
 The higher the antibody titer the greater the degree of
inflammation
MINERAL METABOLISM:

 1. CALCIUM : ↓ in osteomalacia,
hypoparathyroidism; ↑bone tumors, acute
osteoporosis,bone fracture(healing phase)
 Normal: 4.5 – 5.8 mEq/L or 9-10.5 mg/dL
 2. PHOSPHORUS: ↓ in osteomalacia, ↑
healing fractures, CRF, bone tumor
Normal: 3 - 4.5 mEq/L
MUSCLE ENZYME TESTS:

 1. CREATININE PHOPHOKINASE (CK3 or

CK-MM)
 F: 30-135 U/L; M:55-170 U/L – highest
concentration in traumatic injuries, progressive
muscular dystrophy
 2. ALKALINE PHOSPHATASE (ALP-2) –
Increased in Cancer, Paget’s Dse &
Osteomalacia. Normal: 20-90 IU/L
 COMMON
MUSCULOSKELETAL
PROBLEMS
The Nursing Management
Nursing Management of common musculo-
skeletal problems
1. 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, guided imagery
Nursing Management

PAIN
 3. Administer analgesics as prescribed
 Usually NSAIDS
 Meperidine (demerol)can be given for
severe pain
 4. Assess the effectiveness of pain measures
Nursing Management

2. 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
3. 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 mealtime
 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
FRACTURES
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
fractures
Fracture
TYPES OF FRACTURE
 1. Closed fracture (SIMPLE)
 The fracture that does not cause a break in the skin
 2. Open fracture (COMPOUND or COMPLEX)
 The fracture that involves a break in the skin
3. Complete Fracture-involves entire cross section of
the bones
4. Incomplete Fracture – involves only a portion of the
cross section of the bone
Fracture
TYPES OF FRACTURE
 5. Comminuted fracture
 A fracture that involves production of several
bone fragments
 6. Greenstick Fracture
 One side is broken the other side is beat
 7. Depressed
fragment is driven inward (skull,facial bones)
TYPES OF FRACTURE

 8. Transversed
 Break straight across the bone
 9. Spiral
 Forms oblique angle to the bone
shaft
 Fracture: ASSESSMENT

 CLINICAL MANIFESTATIONS:
1. Pain: immediate, sever
2. Loss of function
3. Deformity; abnormal positioning of extremity
4. Shortening
5. Crepitation: palpable or audible
6. Edema
 Fracture

 7. Paresthesia- burning or tingling

sensation
 8. Numbness
 9. Motor weakness
 10. Pulselessness, impaired capillary
refill time and cyanotic skin
Fracture

ASSESSMENT FINDINGS
1. Pain
 Continuous and increases in severity
 Muscles spasm accompanies the
fracture is 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
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
 Support the extremity above and below when moving
the affected part from a vehicle
 Suggested temporary splints- hard board, stick,
rolled sheets
 Apply sling if forearm fracture is suspected or the
suspected fractured arm maybe bandaged to the
chest
Fracture

EMERGENCY MANAGEMENT:
OPEN FRACTURE
 1. Open fracture is managed by covering a
clean/sterile gauze to prevent contamination
 2. DO NOT attempt to reduce the facture
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.
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 COMPLICATIONS

Early
1. Shock (Hypovolemic Shock)
2. Fat embolism - 1st 48 hrs
3. Infection
4. Impaired Circulation (cast/edema)
5. Compartment syndrome
6. Venous Stasis & thrombus formation
 FRACTURE COMPLICATIONS

Late
 1. Delayed union / Nonunion
 2. Angulation (bone heals at a distorted angle)
 3. Delayed reaction to fixation devices
 4. Complex regional syndrome
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 COMPLICATIONS:
Fat Embolism
 Onset is rapid, within 24-72 hours

ASSESSMENT FINDINGS
A. 1. Sudden dyspnea and respiratory distress &
hypoxia
 2. tachycardia
 3. Chest pain
 4. Crackles, wheezes and cough
 5. Petechial rashes over the chest, axilla and
hard palate
Fat embolism

 classic triad: hypoxemia; neurologic

abnormalities; and a petechial rash.
 H- Hypoxemia
 N- N eurologic
 a-bnormalities
 P- Petechial rash
Fat embolism

 Assessment finding
 B. Neurological finding
 1. Cerebral emboli- frequently present after
early stages. 86 % after the respiratory
distress.
 - The more common presentation is with an
acute confusional statebut focal neurological
signs, including hemiplegia, aphasia,apraxia,
visual field disturbances, and anisocoria, have
beendescribed.
Fat embolism

 The characteristic petechial rash may be the last

componentof the triad to develop. It occurs in up
to 60% of cases andis due to embolization of
small dermal capillaries leading toextravasation
of erythrocytes. This produces a petechial rashin
the conjunctiva, oral mucous membrane, and
skin folds ofthe upper body, especially the neck
and axilla.[6] It does notappear to be associated
with any abnormalities in platelet function.The
rash appears within the first 36 h and is self-
limiting,disappearing completely within 7 days.
Nursing Management
Many studies shows that early
immobilization and fixation decrease the
incidence of pulmonary complication.
- Adequate fluid resuscitation, transfusion
and TPN could decrease the incidence of
FES ( Fat embolism syndrome )
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
2. Administer drugs

 Corticosteroids
 Dopamine
 Morphine
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
 Early complication:
 Compartment syndrome
 A complication that develops when tissue
perfusion in the muscles is less than required
for tissue viability
COMPARTMENT SYNDROME

 Muscles, nerves, vessels are restricted to

confined space (myofascial compartment)
within an extremity
 ETIOLOGY:
 Decreased Compartment size from cast, splints,
tight bandage, tight surgical closure
 Increase in compartment contents d/t edema or
hemorrhage
 Early complication:
 Compartment syndrome

ASSESSMENT FINDINGS
 1. Pain- Deep, throbbing and UNRELIEVED pain by
opioids
 d/t reduction in the size of the muscle compartment by
tight cast
 d/t increased mass in the compartment by edema,
swelling or hemorrhage
 Muscle ischemia (compression)
 Arterial compression may not occur; pulses
may be (+) – (early)
 Blisters
 Can result in permanent damage in a short
time (6-8 hrs)
 PARESTHESIA- first sign
 PULSELESSNESS - late sign
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
 Surgical Treatment
 If surgery is required to relieve the pressure,
the physician will make an incision and cut
open the skin and fascia covering the affected
compartment. This reduces the pressure in
the compartment. The skin incision is
surgically repaired when swelling recedes.
Sometimes a skin graft may be needed.
4 R’S IN MGMT OF FRACTURE

1. RECOGNITION of presence of fracture

2. REDUCTION:
 Closed Reduction (manipulation)
 Open Reduction (ORIF – surgery)
 Traction
4 R’S IN MGMT OF FRACTURE
3. RETENTION
 Cast
 Traction
 Braces / splints
 Bandage
4. REHABILITATION – restoration to normal fxn
 Walker
 Crutches
 Cane
CANES
 Should be used on
the side opposite
the affected leg
 Cane + Affected leg
move together
Canes

 Handle should be always level of clients

greater trochanter .
 Clients elbow should be flex at a 15- 30
degrees angle
 Instruct the client to hold the cane 4-6 inches
on the side of the client.
WALKERS

 LIFT the walker & place

it approx. 2 ft. in front
 Gain balance before
moving walker forward
again
 Balance provides
stability & equal wt.
bearing
PROSTHESIS
UP WITH THE GOOD
DOWN WITH THE BAD
 Indication:
Weakness in both legs or poor coordination

4-Point Crutch Gait

 Sequence:
1-Left crutch,
2-right foot,
3-right crutch,
4-left foot. Then repeat.
 Advantages:
Provides excellent stabilty as there are always three points in contact with the
ground
 Disadvantages:
Slow walking speed
Indication:
Inability to bear weight on one leg. (fractures, pain, amputations)

3-Point Crutch Gait

 Pattern Sequence:
1-move both crutches and
2- the weaker lower limb forward. Then bear all your weight down
through the crutches
3- move the stronger or unaffected lower limb forward. Repeat.
 Advantages:
Eliminates all weight bearing on the affected leg.
 Disadvantages:
Good balance is required.
 Indication:
Weakness in both legs or poor coordination.

2-Point Crutch Gait

 Pattern Sequence:
1-Left crutch and right foot together, then the 2-right
crutch and left foot together. Repeat.
 Advantages:
Faster than the four point date.
 Disadvantages:
Can be difficult to learn the pattern.
 Indications:
Patients with weakness of both lower extremities.

SWING-TO Gait
 Pattern Sequence:
Advance both crutches forward then, while bearing all
weight down through both crutches, swing both legs
forward at the same time to (not past) the crutches.
 Advantage:
Easy to learn.
 Disadvantage:
Requires good upper extremity strength.
 Indications:
Inability to fully bear weight on both legs. (fractures, pain,
amputations)
SWING THROUGH GAIT

 Pattern Sequence:
Advance both crutches forward then, while bearing all weight
down through both crutches, swing both legs forward at the
same time past the crutches.
 Advantage:
Fastest gait pattern of all six.
 Disadvantage:
Energy consuming and requires good upper extremity strength.
TRAUMATIC CONDITIONS:

 1. CONTUSION – soft tissue injury produce by

blunt force, blow, kick or fall

 S/Sx:
 a. hemorrhage (ecchymosis) ruptured BV
 b. pain & swelling
 CONTUSION
 Mgmt:

 1. elevate affected part

 2. cold compress to diminish edema (1st 24H)
 3. apply pressure bandage to reduce swelling
 4. apply heat to affected area after 6 hrs to
promote absorption.
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
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
Traction

 Skin traction – applied at the surface of skin

& soft tissue & indirectly to the bone using
adhesive elastic bandage & spreader. max.
7lbs (e.g. Bryant, Russel Traction)

 Skeletal traction – applied directly to the

bone using wire, pins, tongs. max. 40 lbs.
(e.g. Halo pelvic, Crutchfield tong traction)
Traction

Skin
traction

Non-adhesive traction
Bryants traction Cervical traction
 Balance suspension traction
Position clients: low fowlers position
Maintain 20 degree angle at the thigh to bed
Protect the skin from break down
Provide pin care if pin is used with the skeletal traction
Clean the pin site with sterile normal saline and
hydrogen peroxide or povidone iodine
INDICATIONS/PURPOSES:

 For immobilization
 Prevent & correct deformity
 Maintain good alignment
 Give support to reduce pain & muscle spasm
 To reduce fracture
 Indications for Traction
 reduction, immobilisation & alignment of
fractures
 relieve muscle spasm & pain
 prevent further soft tissue damage
 to promote rest
ne
RUSSEL’S TRACTION
Russell’s traction

Commonly used to stabilized the fracture femur before

the surgery.
-Similar to bucks traction but provide double pull with
the use of knee sling
- traction pull’s the knee and the foot.
BALANCED SUSPENSION
 BUCK’S EXTENSION TRACTION

-Is used to alleviate muscle spasm and immobilized a lower

limb by maintaining a straight pull on the limb with the use of
weights.
- boot appliance is applied to attach to the traction.
-Not more than 8-10 lbs
-Elevate the foot of the bed to provide traction.
90-90 TRACTION
 Dunlop’s traction

Description: Horizontal traction used to align fractures of the

humerus.
Vertical traction: used to maintain forearm for proper alignment
Halo vest traction
Cervical traction
Nursing Management

Traction: General principles

1. ALWAYS ensure that the weights hang freely
and do not touch the floor
2. NEVER remove the weights
3. Maintain proper body alignment (dorsal
recumbent)
4. Ensure that the pulleys and ropes are properly
functioning and fastened by tying square knot
Nursing Management

Traction: General principles

5. Observe and prevent foot drop
 Provide foot plate
6. Observe for DVT, skin irritation and
breakdown
7. Provide pin care for clients in skeletal traction
EXTERNAL FIXATOR DEVICE
External frame with a lot of pins.
Provide more freedom compare to traction.
 Internal fixator

Provide immediate bone strength but risk

for infection.
Traction: General principles
8. For every traction, there is always a
counter traction – use shock blocks;
use half ring Thomas splint
9. The line of pull must be in line with
deformity
10. Friction should be eliminated
Nursing Management

CAST
 Immobilizing tool made of plaster of Paris or
fiberglass
 Provides immobilization of the fracture
PURPOSES:

 IMMOBILIZATION
 PREVENTION/CORRECTION OF DEFORMITY
 SUPPORT
 OBTAINING A HOLD OF A LIMB TO SERVE
AS MODEL FOR MAKING ARTIFICIAL LIMB
Nursing Management

CAST: types
1. TRUNK
Minerva Cast, Rizzers Jacket-Scoliosis,
2. UPPER EXTREMITY
3. LOWER EXTREMITY
4. Spica
 CASTS

MINERVA CAST SCOLIOSIS BRACE

 BODY BRACES

SCOLIOSIS BRACE
 Casting
Materials
Plaster of Paris
• Drying takes 1-3
days
• If dry, it is SHINY,
WHITE, hard and
resonant.
Fiberglass
• Lightweight and
dries in 20-30
minutes
• Water resistant
CHARACTERISTICS OF GOOD
CAST:
 White, shiny
 Odorless
 Light in wt
 Not too tight
 Not too loose
 Resonant on
percussion
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. Use
low cool drier.
CAST: General Nursing Care
 5. Petal (cutting the edges) 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
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
CAST: General Nursing Care
9. Observe for signs of plaster sore:
itchiness/burning sensation, sever pain, rise of
temp, disturbed sleep, restlessness, offensive
odor, discharges(windowing-exposing a tight
area to relieve edema/pain, petalling)
10. Observe for signs of cast syndrome:
prolonged N/V, repeated vomiting,
abd.distention, vague abd.pain, (-)bowel sound
PLASTER CAST SAW
Specific Fractures:

 COLLE’S FRACTURE
 Distal radius
 PELVIC FRACTURE:
 Freq in elderly
 Can cause intra abd injury and urinary tract injury
 Turn pt only on specific orders
 HIP FRACTURE
 Common in elderly women
 Clinical manifestation:
 External rotation & adduction of affected extremity
 Shortening of the length of the affected extremiety
 Severe pain & tenderness
 Treatment:
 Initially- Buck’s traction
 Surgery
AFTER SURGERY
 Neurovascular check
 Position: PREVENT FLEXION ADDUCTION &
INTERNAL ROTATION
 Do not adduct past neutral position
 Maintain in abducted position with A-frame pillow
or pillows between legs
 Avoid flexion of hip of more than 90 degrees
 Prevent internal or external rotation by using
sandbags, pillows, trochanter rolls at the thigh
After surgery

 Extreme external rotation accompanied by

severe Pain ---displaced hip prosthesis
Amputation

 Etiology and pathophysiology

 1. Refers to the removal of a body part as a
result of trauma or
 surgical intervention
 2. Necessitated by:
 a. Malignant tumor
 b. Trauma
 c. Acute arterial insufficiency
Amputation
 Therapeutic interventions
 1. Below-the-knee amputation (BKA) common in
peripheral
 vascular disease; facilitates successful
adaptation to prosthesis
 because of retained knee function
 2. Above-the-knee amputation (AKA)
necessitated by trauma or
 extensive disease
 3. Upper extremity amputation usually
necessitated by severe
 trauma, malignant tumors, or congenital
malformation
Amputation

 Assessment
 1. Neurovascular status of involved extremity
 2. History to determine
 a. Causative factors
 b. Health problems that can compromise
recovery
 3. Client's understanding of the extent of the
surgery
 4. Client's coping skills
 5. Client's support system
Amputation

 Assessment
 1. Neurovascular status of involved extremity
 2. History to determine
 a. Causative factors
 b. Health problems that can compromise
recovery
 3. Client's understanding of the extent of the
surgery
 4. Client's coping skills
 5. Client's support system
Amputation
 Planning/Implementation
 1. Provide care preoperatively
 a. Initiation of exercises to strengthen muscles of
extremities in
 preparation for crutch walking
 b. Coughing and deep-breathing exercises
 c. Emotional support for anticipated alteration in body
image
 2. Monitor vital signs and stump dressing for signs of
hemorrhage
 3. Elevate stump for 12 to 24 hours to decrease edema;
remove
 pillow after this time to promote functional alignment
and prevent
Amputation
 4. Provide stump care
 a. Maintain elastic bandage to shrink and shape stump in
 preparation for prosthesis
 b. When wound is healed, wash stump daily, avoiding the
use of oils, which may cause maceration
 c. Apply pressure to end of stump with progressively
firmer surfaces to toughen stump
 d. Encourage client to move the stump
 e. Place the client with a lower extremity amputation in a
prone position twice daily to stretch the flexor muscles
and prevent hip flexion contractures
 5. Teach client about phantom limb sensation
Rheumatoid Arthritis

 Etiology and pathophysiology

 1. Chronic disease characterized by
inflammatory changes in the
 body's connective tissue, particularly areas that
have a cavity
 and easily moving surfaces
 2. Cause unknown, although theories include
autoimmunity,
 heredity, and psychophysiologic factors
 3. Exacerbations are linked to physical and
emotional stress
Rheumatoid arthritis

 Clinical findings
 1. Subjective
 a. Fatigue
 b. Malaise
 c. Joint pain
 d. Stiffness after periods of inactivity,
particularly in the morning
 e. Paresthesia
 f. Anorexia
Rheumatoid arthritis

 Objective
 a. Anemia
 b. Weight loss
 c. Joint inflammation and deformity
 d. Subcutaneous nodules
 e. Elevated sedimentation rate
 f. Low-grade fever
 g. Presence of rheumatoid factors in serum identified by
latex fixation test
 h. Positive C-reactive protein and antinuclear antibody
(ANA) tests
Rheumatoid arthritis

 Therapeutic interventions
 1. Corticosteroids, antiinflammatories, analgesics,
 immunosuppressive drugs; aspirin is drug of choice
followed by the addition of nonsteroidal
antiinflammatory drugs and then gold or
penicillamine, an oral chelating agent;
corticosteroids are reserved for acute inflammation,
if possible
 2. Physiotherapy to minimize deformities
 3. Surgical intervention to remove severely damaged
joints (e.g.,
 hip replacement)
Rheumatoid arthritis

 4. Application of heat or cold; paraffin dips of

affected extremity for
 relief of joint pain by providing uniform heat
 5. Plasmapheresis may be used when the
disease is advanced
Rheumatoid arthritis

 Assessment
 1. History of onset and progression of
symptoms, noting degree to
 which pain interferes with normal activities
 2. Family history of rheumatoid arthritis
 3. General physical health
 4. Coping skills
Rheumatoid arthritis

 Planning/Implementation
 1. Administer analgesics and other medications as
ordered
 2. Teach the client to take medications as ordered
and observe foraspirin toxicity (tinnitus, bleeding)
and other adverse effects of medications
 3. Apply heat and cold as ordered; heat paraffin to
125o to 129o F (52o to 54o C)
 4. Promote rest and position to ease joint pains
 5. Provide for range-of-motion exercises up to the
point of pain,
 recognizing that some discomfort is always present
Rheumatoid arthritis

 6. Emphasize the need to remain active, but

incorporate rest
 periods to avoid fatigue
 7. Encourage the client to verbalize feelings
 8. Help set realistic goals, focusing on strengths
 9. Encourage use of supportive devices to help
client conserve
 energy and maintain independence
 10. Provide care for the client following joint
replacement
Rheumatoid arthritis

 11. Encourage diet rich in nutrient-dense foods such

as fruits, vegetables, whole grains, and legumes to
improve and maintain nutritional status and
compensate for nutrient interactions of
corticosteroid and other treatment medications
 D. Evaluation/Outcomes
 1. Experiences a reduction in pain
 2. Completes activities of daily living using
supportive devices as needed
 3. Accepts life-style consistent with abilities
 4. Maintains or improves range of motion of involved
joints
Osteoarthritis (Degenerative
Joint Disease)
 Etiology and pathophysiology
 1. Etiology relates to wear and tear of joints;
predisposing factors
 include obesity, aging, and joint trauma
 2. A degeneration and atrophy of the
cartilages and calcification of
 the ligaments
 3. Primarily affects weight-bearing joints,
spine, and hands
Osteoarthritis (Degenerative
Joint Disease)
 Clinical findings
 1. Subjective
 a. Pain after exercise
 b. Stiffness of joints
 2. Objective
 a. Heberden's and Bouchard's nodes
symmetrically occurring
 on fingers (bony hypertrophy)
 b. Decreased range of motion
 c. Crepitus when joint is moved
Osteoarthritis (Degenerative
Joint Disease)
 Therapeutic interventions
 1. Weight reduction in instances of obesity
 2. Local heat to affected joints
 3. Medications to reduce symptoms, such as
analgesics, antiinflammatory agents, and
steroids
 4. Exercise of affected extremities
 Osteoarthritis
(Degenerative Joint Disease)
 5. Surgical intervention
 a. Synovectomy: removal of the enlarged synovial
membrane
 before bone and cartilage destruction occurs
 b. Arthrodesis: fusion of a joint performed when the
joint
 surfaces are severely damaged; this leaves the client
with no
 range of motion of the affected joint
 c. Reconstructive surgery: replacement of a badly
damaged
 joint with a prosthetic device
 Assessment
 1. History for risk factors such as obesity,
trauma, athletic
 involvement, and occupation
 2. Joints, noting evidence of deformities,
inflammation, and muscle
 atrophy
 3. Extent of range of motion of involved joints
 Planning/Implementation
 1. Assist client in activities that require using affected joints;
allow for rest periods
 2. Maintain functional alignment of joints
 3. Attempt to relieve the client's discomfort and edema by
the use of medications or the application of heat as ordered
 4. Allow client ample time to verbalize feelings regarding
limited motion and changes in life-style
 5. Support client through weight loss program if indicated
 6. Encourage client to follow physical therapist's instruction
regarding regular exercise program and use of supportive
 7. Provide care for the client requiring joint
replacement (see Nursing Care of Clients with
Fractures of the Hips)
 8. Refer client and family to the Arthritis Foundation
 D. Evaluation/Outcomes
 1. Reports a reduction in pain
 2. Completes activities of daily living using
supportive devices as needed
 3. Develops life-style consistent with limitations
 4. Follows daily program of prescribed exercise
 5. Complies with weight-loss program