Lesson 1: Congenital, Metabolic and Joint Your muscles attach to your bones via

Disorders tendons. When your muscles contract, your

bones act as a lever while your joints form a
Bones also serve many other important pivot point.
biological functions, such as protecting your
internal organs from harm and storing The interaction of bones and muscles
essential nutrients. contributes to the wide range of movements
your body is capable of making.
Bone Function: Why Do We Have Bones?
Human beings are vertebrates, meaning that Protection
we have a spinal column, or backbone. Your bones also protect many of your internal
organs. Good examples of this include the
In addition to that backbone, we also have way your rib cage surrounds organs such as
an extensive skeletal system that’s made up your heart and lungs or how the bones of
of bones and cartilage as well as tendons your skull surround your brain.
and ligaments
Blood cell generation and maintenance
In addition to providing a framework for your The many cells of your blood — red blood
body, bones also serve many other important cells, white blood cells, and platelets — are
biological functions, such as protecting your formed within your bones. This process is
internal organs from harm and storing called hematopoiesis, and it occurs in a part
essential nutrients. of your bone marrow called the red marrow.

What does bone do? Storage

Bones serve many vital functions in your
body, including:
Support
Bone provides a rigid framework as well as
support for other parts of your body.
For example, the larger bones of the legs
offer support to your upper body while you’re
standing up. Without our bones, we’d have
no defined shape.
Important minerals, such as calcium and
phosphorus, are stored within your bones.
When your body needs more of these
resources, they can be released back into
your bloodstream for use.
In addition to red marrow, bones also contain
another type of marrow called yellow
marrow. This is where some fat tissue is stored.
The fats in this tissue can be broken down
and used for energy if required.

Movement
Bones also play an important role in the
movement of your body, transmitting the
force of muscle contractions.
Disturbances in Musculoskeletal Functions ● Osteoclasts are multinuclear cells
involved in bone destruction,
FUNCTIONS OF THE SKELETAL SYSTEM resorption and remodeling of the
● Support the soft tissue of the body bones
● Facilitate movement
● Afford protection to the underlying Bone marrow is a vascular tissue located in
organs the medullary (shaft) cavity if long bones and
● Produce blood cells flat bones
● Store minerals for body use
Red marrow (myeloid tissue) is found in
cancellous bone and contains immature red
Overview of the Skeletal System blood cells and manufactures blood cells
● The bone is enclosed by a dense layer and hemoglobin (sternum, ileum, vertebrae
of fibrous tissue called periosteum and ribs)
which is rich in blood and lymph
vessels and supplies the bone with Yellow marrow fills the medullary cavities and
nourishment composed mostly of fat cells and myelocytes
● Endosteum is a thin membrane that
lines the marrow cavities of long bone Regulating factors that determine the
and the spaces in cancellous bone balance between bone formation and bone
● Hambone as a cross- section of a resorption include the following:
typical bone ● Local stress
● Bone tissue is composed of repeating, ● Vitamin D
circular units called Haversian Systems. ● Parathyroid hormone
● In each Haversian system, there is a ● Calcitonin
central canal where blood vessels and ● Circulation
nerves can be found. ● Growth hormone
● Glucocorticoids
Bone Cells ● Estrogens and androgens
● Osteoblasts are involved in bone ● Thyroxine and Insulin
formation by secreting bone matrix
mostly collagen, in which inorganic
mineral such as calcium salts are
deposited
● Osteocytes are mature bone cells or
blast cells found in bone matrix units
which are involved in maintaining
bone tissue
○ The extracellular matrix of the
bone is composed of collagen
with Ca3(PO4)2 deposited in it.
Bones of the Skeletal System ○ sternum- breastbone

APPENDICULAR SKELETON
● clavicle - collar bone
● scapula- shoulder blade
● humerus- top of the arm
● ulna- little finger side of the lower arm
which also forms the elbow
● radius- thumb side of the lower arm
● carpals- wrist bones
● metacarpals- palm of the hand
● phalanges- fingers
● (os) coxa- hip bones
● ilium- big bone on top that we think of
as the hip
● ischium- bones on which we sit
● pubis- lower front hip bone
● femur- thigh bone
● patella- kneecap
AXIAL SKELETON ● tibia- thick, inside (big-toe side)
● cranium- bones of the skull surrounding shinbone
the brain, not including the face ● fibula- thin, outer (little-toe side)
bones shinbone
● mandible- jaw bone, so the hinge of ● tarsals- heel bones
the jaw is joined by the temporal bone ● metatarsals- arch of the foot, the sole
by the temporo-mandibular joint ● phalanges- toes
● vertebrae- bones which make up the
spine, which include: The Muscular System
○ cervical vertebrae - vertebrae ● more than 650 individual muscles
in the neck region which are attached to the skeleton,
○ thoracic vertebrae- vertebrae providing the pulling power for
with ribs attached movement.
○ lumbar vertebrae- vertebrae in
the lower back Function of the Muscles
○ sacrum- five fused as one ● Provide movement for the body
vertebra which are joined to
the pelvis Types of Muscle Tissues
○ coccyx- four fused as one ● Voluntary muscles: muscles controlled
vertebra which comprise the by the will
tailbone ● Involuntary muscles: muscles not,
○ ribs- bones protecting the chest controlled by the will
cavity (twelve pairs)
 KINDS OF MUSCLES Functional Classification of Joints
Cardiac Muscles: are involuntary muscles
found in the heart
a. striated
b. contracts through the sliding filament
c. it forms branching fibers
d. involuntary

Skeletal Muscles: are voluntary muscles and

make up about 40 % of an adult body
weight.
a. it has stripe-like markings, or striations
b. composed of long muscle fibers
c. muscle fiber that contain several
myofibers Assessment
d. controlled by the nervous system ● Chief Complaint and History
during contraction ○ Chronic Disorder (medical, drug
e. many of the skeletal muscle and allergy history)
contractions are automatic ○ Recent Injury (when and how
the trauma occurred)
Smooth Muscles: involuntary muscles found
mainly in the walls of certain organs or Physical Examination: focus on
cavities of the body. E.g. bladder, bronchi a. Inspection: color, size, alignment,
a. non-striated symmetry, posture, gait, body posture
b. controlled by the nervous system and and movement
hormones b. Palpation: swelling, warmth,
tenderness, degree of firmness,
Joints: also known as articulations, it is where involuntary movements
two bones meet
PHYSICAL ASSESSMENT IN TRAUMATIC INJURY
Tendons: cordlike structures that attach ● External bleeding or bruising
muscles to the periosteum of the bones; it ● Peripheral pulses and circulation
enables the bones to move when skeletal ● Sensation of the injured part
muscles contract ● Broken skin, open wounds, embedded
debris, protrusion of bone or tissue
Ligaments: dense bands of connective tissue ● Examining injury beyond the original
that connect bones to bones area (thoracic and head injury)
● Malalignment of injured limb
● Assessing pain noting type and
location
DIAGNOSTIC TESTS BLOOD TESTS
● RADIOGRAPHY ● CBC
● COMPUTED TOMOGRAPHY ● Phosphatase
● MAGNETIC RESONANCE IMAGING ● Calcium
● Phosphorus
ARTHROSCOPY ● Uric Acid
● is the internal inspection of a joint using
an instrument called an arthroscope URINE TESTS
● 24-Hour Urine Analysis
ARTHROGRAM
● a radiographic examination of a joint, Congenital Anomalies
usually the knee or shoulder.

ARTHROCENTESIS
Clubfoot
● is the aspiration of synovial fluid and
could be performed during
arthroscopy or arthrogram

SYNOVIAL FLUID ANALYSIS

● Aspirated and examined to diagnose
disorders such as traumatic arthritis,
septic arthritis, gout, rheumatic fever
and systemic lupus erythematosus ● Talipes disorder
● Varus: most common

BONE DENSITOMETRY ● TEV: talipes equinovarus

● Estimates bone density ● Feet point down and inward

● It does not cause pain in the newborn

BONE SCAN child

● Use of intravenous injection of a ● It can cause long-term abnormalities

radionuclide to detect the uptake of in gait

the radioactive substance by the ● It may lead to complications such as

bone chronic skin ulcers

ELECTROMYOGRAPHY MECHANISMS

● evaluate muscle weakness or ● The tendons on the inside and the

deterioration, pain and disability back of the foot are too short.
● The foot is pulled then toes point down

BIOPSY and in, and it is held in this position by

● this is done to identify the composition the shortened tendons.

of bone, muscle or synovium

Pathophysiology
● failure to keep pace with the
development of the foot; posterior
 and medial tendons and ligaments (in Denis browne bar or shoes:
the back and inside)
● tendons and ligaments tether Surgery
● posterior and medial parts of the foot; ● Tenotomy
point downwards and the twist ● Releasing all the tight tendons and
inwards ligaments in the posterior and medial
● Bones are mis-sharpened aspects of the foot, and repairing
them in the lengthened position.
Etiology ● The lateral ligaments are released to
● Associated with other congenital allow a complete release
malformations such as spina bifida ● Objective: Plantigrade and Flexible
● No known cause of the deformity has foot
been established a. "Plantigrade" means the child
stands with the sole of the foot
Prevalence on the ground, not on heels or
● It tends to be more common in boys, the outside of foot.
although girls are not exempted. b. "Flexible" means one can move
● A positive family history is a the foot around freely without
predisposition pain.
● After surgery, the foot needs to be
Manifestations casted at biweekly intervals for 6
● It does not cause pain in the infant weeks, followed by the use of a
● If uncorrected in the older child, it is thermoplastic brace known as
very unsightly and very crippling Wheaton brace.
● Patient walks on the outside of his foot
which is not meant for weight-bearing
● Skin breaks down, and the
development of chronic ulceration
and infection.

Treatment
● Manipulating the foot to get it to the
best position possible, and then
holding the correction in a cast.
(Ponseti Method: manipulative but
conservative)
● The cast is changed on a weekly basis, Purpose: to hold the correction. The brace is

with manipulation before each used full-time for about 6 weeks, followed by

casting, to obtain further correction. night use only till the child starts to walk at

● After the first 6 weeks surgery can be one year of age

planned, the foot is manipulated and

cast applied every 2 weeks.
 infant's hips into extreme adduction
(brought together)
● higher in infants born by caesarian
Nursing Care and breech position births.
1. Check for NEUROVASCULAR Integrity ● greater chance in the first born
a. How: observe for color and compared to the second or third child.
sensation
2. Regularly inspect the cast for irritation Manifestations
3. Provide diversional activities ● Shorter limbs
● Uneven skin folds

Congenital Hip Dysplasia ● Lordosis

● Reduced joint mobility
● A low clunking sound can be heard
when the leg is gently rotated, which is
the sound of the femur engaging the
socket.
● The stretch of skin between the anus
and the genitals (perineum) are
unusually wide.

For unilateral dislocation symptoms include:

● Is a disorder in children that is either
a. The skin creases of the buttocks don’t
present at birth or shortly thereafter.
match.
● During gestation, the infant's hip
b. One knee joint looks higher than the
should be developing with the head of
other.
the thigh bone (femur) sitting perfectly
centered in its shallow socket
Diagnostic Test
(acetabulum).
● The acetabulum should cover the
head of the femur as if it were a ball
sitting inside of a cup.
● In congenital hip dysplasia, the
development of the acetabulum in an
infant allows the femoral head to ride
upward out of the joint socket,
especially when weight bearing
Ortolani Test
begins.
● Supine position
● begins with each of the examiner's
Prevalence
hands around the infant's knees, with
● more females affected than males.
the second and third fingers pointing
● related to common practice of
down the child's thigh. With the legs
swaddling and using cradleboards for
abducted (moved apart), the
restraining the infants. It places the
 examiner may be able to discern a Pavlik Harness
distinct clicking sound with motion.
● If symptoms are present with a noted
increase in abduction, the test is
considered positive for hip joint
instability.
Barlow Test
● with the infant's hip brought together
with knees in full bent position The
examiner's middle finger is placed over ● soft splint. It is most commonly used for

the outside of the hip bone while the treating infants with developmental

thumb is placed on the inner side of dysplasia of the hip (DDH).

the knee. The hip is abducted to ● The hip is abducted

where it can be felt if the hip is sliding ● 6 to 12 weeks

out and then back in the joint.

X-ray films Short Leg Hip Spica Cast

● can be helpful in detecting abnormal

findings of the hip joint.
● X rays may also be helpful in finding
the proper positioning of the hip joint
for treatments of casting.

Treatment
● Objective: is to replace the head of
the femur into the acetabulum and, ● used to keep the thigh bone (femur)
by applying constant pressure, to and pelvis still
enlarge and deepen the socket.
● In the past, stabilization was achieved Nursing Care
by placing rolled cotton diapers or a 1. Check for NEUROVASCULAR Integrity
pillow between the thighs, thereby a. How: observe for color and
keeping the knees in a frog-like sensation
position. 2. Regularly inspect the cast for irritation
3. Provide diversional activities
 when the moon is convex on both
sides, giving it a “hump” shape.)
Infectious Conditions
Signs and Symptoms
Pott’s Disease ● Back pain is localized.
● Fever, night sweats, anorexia and
weight loss.
● Signs may include kyphosis (common)
and/or a paravertebral swelling.
● Affected patients tend to assume a
protective, upright, stiff position.
● If there is neural involvement there will
be neurological signs.
● A psoas abscess may present as a
lump in the groin and resemble a
● Other Names: TB of the spine; Pott’s hernia:
Caries, David's Disease, and Pott's ○ A psoas abscess most often
Curvature; Tuberculous Spondylitis originates from a tuberculous
● Most common site of bone infection in abscess of the lumbar vertebra
TB that tracks from the spine inside
● Most common site: lower thoracic and the sheath of the psoas
upper lumbar vertebrae muscle.[9]
○ Other causes include extension
of renal sepsis and posterior
Pathophysiologic Mechanisms perforation of the bowel.
● results from haematogenous spread of ○ There is a tender swelling below
tuberculosis from other sites particularly the inguinal ligament and they
to the spine are usually apyrexial.
● infection then spreads from two ○ The condition may be confused
adjacent vertebrae into the adjoining with a femoral hernia or
disc space enlarged inguinal lymph nodes.
● the intervertebral disc, which is ● Spinal tuberculosis in children needs a
avascular, cannot receive nutrients particularly high index of suspicion for
and collapses. diagnosis.
● disc tissue dies and is broken down by
caseation Other Manifestations
● vertebrae collapses and spinal ● Localized back pain
damage occurs ● Para-vertebral swelling
● a dry soft tissue mass often forms ● Neurological signs like paraplegia
known as GIBBUS (“humpbacked”; the
lunar phase between half and full Diagnostic Tests
 ● Needle biopsy of bone or synovial Complications
tissue: ● Severe Kyphosis (excessive curvature)
● Numbers of tubercle bacilli present are ● Sinus Formation
usually low but are pathognomonic ● Paraplegia: Pott's Paraplegia
● Acid-fast stain and culture for
Mycobacterium tuberculosis Nursing Responsibilities on Drug Therapy
● Elevated ESR (At least 6 months- TUBERCULOSIS TREATMENT)
● INH: taken before meals; causes
Imaging peripheral neuropathy (competes with
● Spinal x-ray will show vertebral Vitamin B6 absorption)
destruction and narrowed disc space. ● Rifampicin: Best taken with empty
● MRI is useful to demonstrate the extent stomach but causes gastric irritation
of spinal compression and can show hence should be taken with food;
changes at an earlier stage than plain causes discoloration of urine; should
radiographs. Bone elements visible be kept in dark containers ( red
within the swelling, or abscesses, are orange urine)
strongly indicative of Pott’s disease as ● PZA: hepatotoxic, ototoxic,
opposed to malignancy. nephrotoxic, gastric irritation, protect
● CT scans and nuclear bone scans from light
● EMB: optic neuritis (causing red and
TREATMENT green color indiscrimination); skin
● Anti-infective agents rashes
○ Isoniazid (INH)
○ Rifampin (Rifadin) Prevention
○ Ethambutol (EMB) ● Respiratory Level Two
○ Streptomycin (SM) ○ Private room required: Keep the
○ Pyrazinamide (PZA) room door closed
○ Handwashing before and after
MANAGEMENT patient contact
● Surgery is required if there is spinal ○ Surgical masks required for all
deformity or neurological signs of persons entering room
spinal cord compression: debridement ○ Patient transport: minimize
and fusion with bone grafting patient’s activity outside of the
● Spinal immobilization with a brace: room. Patient and escort should
Jewett brace wear surgical mask when
patient is outside room
○ Nutrition department tray
service staff: surgical mask
required before entering the
room. Hand Washing
OSTEOMYELITIS ● Predisposition like: Open wound,
surgery, Soft tissue infection like boils,
venous stasis, DM
● Bacteria enters, lodge and multiply
● Phagocytes attempt to contain
infection by releasing enzymes that
destroys eventually bone tissue
● Pus forms, followed by edema and
vascular congestion
● Infection reaches outer surface or
margin of the bone, raising the
periosteum
● Disruption of blood supply and
Necrosis results
● Bacteria adheres to damaged bone
coating underlying bone with
● infection of the bone caused by a protective film
variety of microbial agents more
specifically staphylococcus aureus Manifestations
● Bacteria can travel into the bone
MODES through the bloodstream from other
● EXTENSION OF SOFT TISSUE INFECTION infected areas in the body
● DIRECT BONE CONTAMINATION ● Bacteria enter the body's tissues
(surgery & blood) through a wound and travel to the
● HEMATOGENOUS (BLOOD-HOME) bone (like after an injury or trauma)
● Blood supply to that area of the bone
is disrupted. (older people with
atherosclerosis)
○ Pain and/or tenderness in the
On predispositions infected area
● People with diabetes ○ Swelling and warmth in the
● Patients receiving hemodialysis infected area
● People with weakened immune ○ Fever
systems ○ Nausea, secondarily from being
● People with sickle cell disease ill with infection
● Intravenous drug abusers ○ General discomfort, uneasiness,
● Elderly or ill feeling
● Obese ○ Drainage of pus through the
● Impaired immune system skin
● Long term use of corticosteroid ○ Excessive sweating
○ Chills
Pathophysiology ○ Lower back pain
 ○ Swelling of the ankles, feet, and Needle aspiration: a needle is used to
legs remove a sample of fluid and cells from the
○ Changes in gait (walking vertebral space, or bony area.
pattern that is a painful, yielding
a limp) Biopsy: A biopsy (tissue sample) of the
infected bone may be taken and tested for
Typical Appearance of Osteomyelitis signs of an invading organism.

Bone scan: a small amount of

Technetium-99m pyrophosphate, a
radioactive material, is injected intravenously
into the body. If the bone tissue is healthy, the
material will spread in a uniform fashion. A
tumor or infection in the bone will absorb the
material and show an increased
concentration of the radioactive material,
which can be seen with a special camera
that produces the images on a computer
screen

Diagnostic Tests
Blood tests: When testing the blood TREATMENT

measurements are taken to confirm an Drainage: needle aspiration of open wound.

infection: A needle is inserted into the infected area

1. complete blood count (CBC), which and the fluid is withdrawn

will show if there is an increased white

blood cell count Medications: Antibiotics help the body get rid

2. ESR (erythrocyte sedimentation rate) of bacteria in the bloodstream that may

and/or CRP (C- reactive protein) in the otherwise re-infect the bone. IV antibiotic

bloodstream, which detects and therapy is administered for 3-6 weeks and

measures inflammation in the body. oral antibiotics for as long as 3 months.

(NV=0-15mm/hr)
Blood culture: A blood culture is a test used to Splinting or cast immobilization: to immobilize

detect bacteria. A sample of blood is taken the affected bone and nearby joints in order

and then placed into an environment that to avoid further trauma and to help the area

will support the growth of bacteria. By heal adequately and as quickly as possible

allowing the bacteria to grow, the infectious

agent can then be identified and tested Surgery: 1) Debridement of the necrotic

against different antibiotics in hopes of tissue and sequestrum to remove infected

finding the most effective treatment areas, (2) Antibiotic-impregnated beads

may be directly applied in the wound for 2-
4 weeks. (3) Bone grafts for the debrided
cavity to stimulate growth, (4) Muscle flaps
grafted to the affected area to enhance
blood supply

Physiotherapy: to build up strength of the

muscles

NURSING CARE
● Risk for Infection related to
compromised immune system: Hand
washing and maintain dietary kcal
● A diffuse infection of connective tissue
and CHON intake
with severe inflammation of dermal
● Hyperthermia related to infection and
and subcutaneous layers of the skin
inflammatory process: maintain cool
environment; light clothing; ensure
MANAGEMENT
daily fluid intake of 3L
● Resting the affected limb or area
● Impaired physical mobility related
● Cleaning the wound site or
inflammation and use of immobilizers:
debridement of dead tissue if
maintain functional position; maintain
necessary
rest; elevate area and avoid weight
● Treatment with oral or intravenous
bearing activities; ensure PROME
antibiotics (IV then Oral)
● Pain related to swelling: splint area;
● Hyperbaric oxygen treatment
use of analgesics; use of distraction;
● Surgery: debridement (remove
minimal manipulation or handling of
necrotic skin)
affected area

Structural Defects

Scoliosis

CELLULITIS

● abnormal curvature of the spine

● "S" or a "C" curvature of the spine
● Lateral curvature of the spine
 ● bones are rotated slightly, making the Descriptions
person's waist or shoulders appear ● Shape: Curves develop side-to-side as
uneven a C- or S-shaped curve. The rotation of
the spine causes the ribs and muscles
Predispositions near the spine to move out of normal
● If someone in a family has scoliosis, the alignment.
likelihood of an incidence is much ● Location: The curve may occur in the
higher: approximately 20 percent upper back area (thoracic), the lower
● Children: It usually develops in middle back area (lumbar) or in both areas
or late childhood, before puberty, and (thoracolumbar)
is seen more often in girls than boys ● Direction: The curve can bend to the
● Adults: Degeneration as in left or to the right.
osteoporosis ● Angle: A normal spine, viewed from
the back, is at 0 degrees — a straight
Etiology line
● "idiopathic," meaning its cause is
unknown. TYPES
● MILD – less than 25 degrees curvature
MANIFESTATIONS ● MODERATE – 30 to 50 degrees
● Uneven shoulders curvature
● One shoulder blade that appears ● SEVERE – Cobb’s curvature with
more prominent than the other Kyphosis
● Uneven waist
● One hip higher than the other TREATMENT
● Leaning to one side ● Braces: prevents further progression of
● Ribs on one side of the body to stick the curve
out farther than on the other side ○ Underarm or low-profile brace:
● Back pain and difficulty breathing made of modern plastic
materials and is contoured to
Diagnostic Tests conform to the body. Also
● Physical examination: examination of called a thoracolumbosacral
the spine as well as the shoulders, hips, orthosis (TLSO), this closer- fitting
legs and the rib cage for signs of brace is less visible under the
scoliosis clothes as it fits under the arms
● X-rays: initial X-ray to confirm the and around the rib cage, lower
diagnosis and determine the curve back and hips
angle. Periodic X-rays are done to
monitor the curve and help make
treatment decisions.
 ○ Milwaukee brace. This full-torso difficult to breathe and harder for the
brace has a neck ring with rests heart to pump. In very severe scoliosis
for the chin and for the back of 2. a curve greater than 100 degrees —
the head. The brace has a flat damage to the lungs and the heart
bar in the front and two flat bars can occur. Any time breathing is
in the back. A Milwaukee brace compromised, the risk of lung
may be used for curves in the infections and pneumonia increases.
upper spine. This brace is not
commonly used Back problems: chronic back and if
untreated may develop arthritis of the spine.

Body image: child might feel isolated and

develop a poor body image from wearing a
brace during childhood and teenage years

COMPLICATIONS
● Nerve damage
TREATMENT
● Motor – Sensory Deficit
Surgery
● "Fusion" means joining two pieces
Conservative Treatment
together
● Traction
● Fusion involves connecting two or
● Active and Passive ROME
more vertebrae with pieces of bone
● Weight reduction
taken from the pelvis. Eventually, the
vertebrae and the pieces of bone fuse
Nursing Care
together preventing further
● Risk for injury related to bracing and
progression of the curve
other related factors: Assess for skin
irritation; use of undergarments to
It involves the use of metal rods, hooks,
reduce friction; frequent change of
screws or wires (instrumentation) to the spine
undergarments during warm weather;
to hold the vertebrae together during the
teach to avoid use of powders and
months after surgery while the bones fuse.
lotion; loosen brace during meals and
for the first 30 minutes after meals
The instrumentation is left in the body, even
● Risk for peripheral neurovascular
after the bones have fused, to avoid another
dysfunction related to brace and cast
surgery.
application: assess for movement,
color and sensation
COMPLICATIONS
Lung and heart damage:
1. a curve greater than 70 degrees —
the rib cage may press against the
lungs and heart, making it more
HERNIATED NUCLEUS PULPOSUS ● ANALGESICS
● NSAIDS
● ANTI – SPASMODICS (For muscles that
are contracted)
● MUSCLE RELAXANTS

TRACTION
● PELVIC GIRDLE

● PROLAPSED DISC; CERVICAL OR

LUMBAR RADICULOPATHY
● A CONDITION IN WHICH A PART OR
ALL OF THE SOFT GELATINOUS CENTRAL
PORTION OF AN INTERVERTEBRAL DISC
IS FORCED THROUGH A WEAKENED
PART OF THE LUMBAR AREA AND NECK
OR THE HARD OUTER COVERING
● HEAD HALTER / CRUTCHFIELD TONG

CAUSES
● Trauma
● Strain (massage)
● Degenerative Changes

SIGNS AND SYMPTOMS

● LOW BACK PAINS
● TINGLING SENSATIONS
● NUMBNESS
● MUSCLE WEAKNESS (LUMBAR AREAS) SURGICAL MANAGEMENT
● NECK and ARM PAINS (CERVICAL ● LAMINECTOMY
AREAS) ● SPINAL FUSION / FIXATION
● MISS with CAT
DIAGNOSTIC EXAMS ○ SPINAL DISC REPLACEMENT
● SPINAL X – RAY ○ THERMODISKOPLASTY
● MAGNETIC RESONANCE IMAGING ○ ARTIFICIAL DISC IMPLANT
● SPINE CT
● MYELOGRAPHY LIFESTYLE MODIFICATION
● NERVE CONDUCTION VELOCITY TESTS ● AVOID CARRYING HEAVY OBJECT
● PHYSICAL EXAMINATION ● DIET
● EXERCISE
● PHYSICAL THERAPY
MEDICATIONS ● WEIGHT CONTROL
PREVENTION pancreas, an organ that produces
● SAFE WORK PRACTICES digestive enzymes and hormones. If
● SAFE PLAY PRACTICES the pancreas is inflamed, enzymes
● PROPER LIFTING TECHNIQUE responsible for breaking down food
● WEIGHT CONTROL and releasing nutrients don't flow as
freely into the intestines.

Metabolic Bone Disorders

DIAGNOSTIC TEST
Osteomalacia ● Blood and urine tests: In cases of
osteomalacia caused by vitamin D
deficiency or by phosphorus loss,
abnormal levels of vitamin D and the
minerals calcium and phosphorus are
often detected
● X-ray: Slight cracks in the bones that
are visible on X- rays, referred to as
● Looser transformation zones, is a
characteristic feature of person with

● A metabolic bone disease osteomalacia

characterized by inadequate ● Bone scan: It detects areas of

mineralization of bone causing increased and decreased bone

softening of the bones also known as metabolism in the body. During this

Rickets test, a radioactive dye is injected into

● Calcium absorption a vein and a camera takes pictures of

● Insufficient vit D intake how much radioactive dye collects in

the bones. If there is osteomalacia, the
radioactive dye may appear to be

CAUSES unevenly distributed in some areas of

● Insufficient exposure to sunlight the bones

● Removing part or all of the stomach ● Bone biopsy: During a bone biopsy, a

● Celiac sprue: an autoimmune disorder needle is inserted through the skin and

where the lining of the small intestine is into the bone to withdraw a small

damaged by consuming foods sample for viewing under a

containing gluten, a protein found in microscope

wheat, barley and rye. A damaged

intestinal lining doesn't absorb Physiology of Bone Remodelling

nutrients, such as vitamin ● Bone construction begins with a base

● Insufficient vitamin D intake: A diet low composed of collagen, a fibrous

in vitamin D is the most common connective tissue

cause of osteomalacia ○ As bone is formed, collagen

● Chronic pancreatitis. This refers to fibers adhere to each other in a

long-standing inflammation of the crisscross pattern (matrix)

 ○ Minerals including calcium are ● Bowed legs
incorporated into the matrix in
a process called mineralization.
○ The strength of new bone
depends on the amount of
minerals incorporated into the
matrix: The more minerals built
into the matrix, the stronger the Treatment
bone ● Replenishing low levels of vitamin D in
● Small areas of bone in the body are the body for several weeks or months
being broken down by specialized usually cures the condition
cells called osteoclasts and rebuilt by ● If blood levels of calcium or
cells called osteoblasts phosphorus are low, supplements are
● Bones are undergoing constant also given
remodeling
Prevention
Pathophysiology ● Spend a few minutes in the sun: Direct
● Deficiency in vitamin D (help the body sun exposure of the arms and legs for
absorb and retain calcium and five to 10 minutes daily is sufficient for
phosphorus) proper vitamin D production
● Non absorption of calcium and ● Eat foods high in vitamin D: These
● other minerals in the gastrointestinal include foods that are naturally rich in
tract vitamin D, including oily fish (salmon,
● Calcium not available for mackerel, sardines) and egg yolks. If
mineralization in the bone-building vegetarian, look for foods that are
process. fortified with vitamin D, such as cereal,
● Softening of bones bread, milk and yogurt
● Weight-bearing exercise, such as
Manifestations walking, helps strengthen bones
● Bone pain: especially in the lower
spine, pelvis and legs and feet. Nursing Care
● Pain is usually dull and aching and ● Emphasis on diet: high calcium and
worsens during physical activity; Vitamin D and Phosphorous
gently pressing on shin, for example, ● Assess for toxic level of Vitamin D
produces severe pain. supplements like anorexia, frequent
● Pathologic fracture urination, muscle weakness and
● Muscle weakness: weakness or constipation
stiffness in the arms and legs, ● Safety measures to prevent falls like
decreased muscle tone and night lamps, scatter rugs; use of grab
discomfort while moving. bars
● Waddling motion or gait
● Spinal kyphosis
 ● Use of assistive devices for those with
pain like the use of canes, walkers and
crutches
● Participate in exercise program like
aerobics
Causes
Osteoporosis
● Loss of height over time, with an
accompanying stooped posture
● Fracture of the vertebrae, wrists, hips or
other bones
● decreased estrogen production during
menopause
● poor dietary intake of Vitamin D and
Calcium
● Lack of weight bearing secondary to
paralysis
● Long term corticosteroid therapy
Negative calcium balance
●

Risk Factors
● Sex: Fractures from osteoporosis are
about twice as common in women as
they are in men.
○ Rationale: a sudden drop in
estrogen at menopause that
accelerates bone loss. Slender,
small-framed women are
particularly at risk.
● means "porous bones," causes bones ○ Men who have low levels of the
to become weak and brittle — so male hormone testosterone also
brittle that even mild stresses like are at increased risk. From age
bending over, lifting a vacuum 75 on, osteoporosis is as
cleaner or coughing can cause a common in men as it is in
fracture women.
● Primary: elderly woman or menopause ● Age: The older, the higher the risk of
● Secondary: renal failure, corticosteroid osteoporosis
therapy, hyperthyroidism ● Race: White or of Southeast Asian
● Low density of bones descent. Black and Hispanic men and
women have a lower but still
Manifestations significant risk.
● In the early stages of bone loss, no ● Family history: Osteoporosis runs in
pain or symptoms families, having a parent or sibling with
● Back pain, which can be severe if it puts one at greater risk, especially if
there is a fractured or collapsed there is also a family history of
vertebra fractures.
● Frame size: Men and women who are ● Some diuretics: Drugs that prevent
exceptionally thin or have small body buildup of fluids in the body causes the
frames tend to have higher risk kidneys to excrete more calcium,
because they may have less bone leading to thinning bones. Diuretics
mass to draw from as they age. that cause calcium loss include
● Tobacco use: The exact role tobacco furosemide (Lasix), bumetanide
plays in osteoporosis isn't clearly (Bumex), ethacrynic acid (Edecrin)
understood, but researchers do know and torsemide (Demadex)
that tobacco use contributes to weak ● Other medications: Long-term use of
bones. the blood-thinning medication
● Lifetime exposure to estrogen: The heparin, the drug methotrexate, some
greater a woman's lifetime exposure to anti-seizure medications and
estrogen, the lower her risk of aluminum-containing antacids also
osteoporosis. can cause bone loss.
○ For example, there is a lower risk ● Breast cancer: Postmenopausal
if one has a late menopause or women who have had breast cancer
one begins menstruating at an are at increased risk of osteoporosis,
earlier than average age. But if especially if they were treated with
there is a history of abnormal chemotherapy or aromatase inhibitors
menstrual periods, experience such as anastrozole, letrozole and
menopause earlier than late 40s exemestane, which suppress estrogen.
or had ovaries surgically ● Low calcium intake: A lifelong lack of
removed before age 45 without calcium plays a major role in the
receiving hormone therapy, the development of osteoporosis. Low
risk is increased calcium intake contributes to poor
● Eating disorders: Women and men bone density, early bone loss and an
with anorexia nervosa or bulimia are at increased risk of fractures.
higher risk of lower bone density in their ● Medical conditions and procedures
lower backs and hips. that decrease calcium absorption:
● Corticosteroid medications: Long-term Stomach surgery (gastrectomy) can
use of corticosteroid medications, affect the body's ability to absorb
such as prednisone, cortisone, calcium and conditions such as
prednisolone and dexamethasone, is Crohn's disease, hyperparathyroidism,
damaging to bone. anorexia nervosa and Cushing's
● Thyroid hormone: Too much thyroid disease — a rare disorder in which the
hormone also can cause bone loss. adrenal glands produce excessive
This can occur either because the corticosteroid hormones
thyroid is overactive (hyperthyroidism) ● Sedentary lifestyle: Bone health begins
or intake of excess amounts of thyroid in childhood. Children who are
hormone medication to treat an physically active and consume
underactive thyroid (hypothyroidism) adequate amounts of
calcium-containing foods have the
 greatest bone density. Any Bisphosphonates: Much like estrogen, this
weight-bearing exercise is beneficial, group of drugs can inhibit bone breakdown,
but jumping and hopping seem preserve bone mass, and even increase
particularly helpful for creating healthy bone density in the spine and hip, reducing
bones. Exercise throughout life is the risk of fractures
important ● Taken once a week or once a month
● Excess soda consumption: The link may cause fewer stomach problems. If
between osteoporosis and can't be tolerated intravenous
caffeinated sodas isn't clear, but infusions can be used
caffeine may interfere with calcium Side effects
absorption and its diuretic effect may ● nausea, abdominal pain, and the risk
increase mineral loss. In addition, the of an inflamed esophagus or
phosphoric acid in soda may esophageal ulcers, especially if there is
contribute to bone loss by changing history of acid reflux or ulcers in the
the acid balance in the blood. past.
● Chronic alcoholism: For men,
alcoholism is one of the leading risk Raloxifene: belongs to a class of drugs called
factors for osteoporosis. Excess selective estrogen receptor modulators
consumption of alcohol reduces bone (SERMs). It mimics estrogen's beneficial
formation and interferes with the effects on bone density in postmenopausal
body's ability to absorb calcium. women, without some of the risks associated
● Depression: People who experience with estrogen, such as increased risk of
serious depression have increased uterine and, possibly, breast cancers.
rates of bone loss
Side effect
Diagnostic Tests ● Hot flashes are a common
● The best screening test is dual energy ● This drug is approved only for women
X-ray absorptiometry (DEXA) with osteoporosis and is not currently
● It measures the density of bones in the approved for use in men.
spine, hip and wrist — the areas most
likely to be affected by osteoporosis — Calcitonin: A hormone produced by the
and it’s used to accurately follow thyroid gland, calcitonin reduces bone
changes in these bones over time resorption and may slow bone loss. It also
● Ultrasound and quantitative prevents spine fractures, and may even
computerized tomography (CT) provide some pain relief from compression
scanning fractures.
● Bone mineral density test: screening for
bone density to diagnose osteoporosis Teriparatide: an analog of parathyroid
Treatment hormone, treats osteoporosis in
● Hormone therapy (HT): oral, patches, postmenopausal women who are at high risk
creams and the vaginal ring of fractures. It works by stimulating new bone
growth, as opposed to preventing further
bone loss. Teriparatide is given once a day by Combine strength-training exercises
injection under the skin on the thigh or with weight-bearing exercises.
abdomen ○ Strength training helps
strengthen muscles and bones
Emerging Therapy in the arms and upper spine,
● A new physical therapy program has and weight- bearing exercises
been shown to significantly reduce — such as walking, jogging,
back pain, improve posture and running, stair climbing, skipping
reduce the risk of falls in women with rope, skiing and
osteoporosis who also have curvature impact-producing sports —
of the spine. mainly affect the bones in the
● The program combines the use of a legs, hips and lower spine.
device called a spinal weighted ● Don't smoke: Smoking increases bone
kypho-orthosis (WKO) — a harness with loss, perhaps by decreasing the
a light weight attached — and amount of estrogen a woman's body
specific back extension exercises. makes and by reducing the
● The WKO is worn daily for 30 minutes in absorption of calcium in the intestine
the morning and 30 minutes in the
afternoon and while performing 10 Nursing Care
repetitions of back extension exercises. ● Maintain good posture. Good posture
— which involves keeping the head
Prevention held high, chin in, shoulders back,
● Getting adequate calcium and upper back flat and lower spine
vitamin D is an important factor in arched — helps avoid stress on the
reducing the risk of osteoporosis spine.
● Premenopausal women and ● When sitting or driving, place a rolled
postmenopausal women who use HT towel in the small of the back.
should consume at least 1,200 ● Don't lean over while reading or doing
milligrams (mg) of calcium and a handwork.
minimum of 400 international units (IU) ● When lifting, bend at your knees, not
of vitamin D every day your waist, and lift with your legs,
● Diet: Vitamin D: oily fish such as tuna keeping your upper back straight
and sardines and in egg yolks ● Prevent falls: Wear low-heeled shoes
● Calcium: dairy products, almonds, with nonslip soles
broccoli, canned salmon with the ● Check the house for electrical cords,
bones, oats and soy products such as area rugs and slippery surfaces that
tofu might cause a trip or fall.
● Protein ● Keep rooms brightly lit, install grab bars
● Bisphosphonates: Increase bone mass just inside and outside the shower
and decrease bone loss ● Manage pain: Don't ignore chronic
● Exercise: Exercise can help build pain, it can limit mobility and cause
strong bones and slow bone loss. even more pain.
Gout ● TOPHI in outer ear, hand, and feet:
Deposits of uric acid, can cause
further inflammation m

The pain and swelling associated with gout

are the result of the body's response to the
accumulation of urate crystals in the
affected joint. The view in the enlarged circle
shows how urate crystals look under a
microscope

Diagnosis
● A form of arthritis
● Arthrocentesis: Tophi Formation
● Inflammatory condition of the joints
● Blood Studies: High Uric Acid
● Chronic problem
● X-Ray

Types:
Pathophysiology
● Primary gout- Diet: Tahong, Legumes
● Increase intake of liver, brains, kidney,
● Secondary gout- Blood problem
sweetbreads anchovies, asparagus
(Anemia, Leukemia)
and mushrooms
● Uric acid as a waste product formed
Causes
from the breakdown of purines
● Build up of uric acids leading to
● Uric acid dissolves in the blood and
formation of urate crystals in the joints
passes through the kidneys into urine.
● Uric acid builds up, forming sharp,
Manifestations
needle-like crystals (urate) in a joint or
● Intense joint pain: Gout usually affects
surrounding tissue
the large joint of the big toe but can
occur in the feet, ankles, knees, hands
Risk Factors
and wrists.
● Lifestyle factors: Excess consumption of
● The pain typically lasts five to 10 days
alcohol is a common lifestyle factor
and then stops.
that increases the risk of gout.
● Pain because of swelling
● Excess alcohol generally means more
● 5 cardinal inflammation
than two drinks a day for men and
● The discomfort subsides gradually over
more than one for women.
one to two weeks, leaving the joint
● Gaining 30 pounds or more than ideal
apparently normal and pain-free.
weight during adulthood also
● Inflammation and redness. The
increases your risk.
affected joint or joints become
● Medical conditions: untreated high
swollen, tender and red.
blood pressure (hypertension) and
● Tachycardia
chronic conditions, such as diabetes,
● Increased Uric Acid: Hyperuricemia
high levels of fat and cholesterol in the
 blood (hyperlipidemia), and narrowing ● Acetaminophen (Analgesics)
of the arteries (arteriosclerosis) ○ Side Effects: stomach pain,
● Certain medications: The use of bleeding and ulcers
thiazide diuretics used to treat ● Corticosteroid such as prednisone
hypertension; low-dose aspirin also ○ Injection of cortisone into the
can increase uric acid levels. affected joint and generally
● Genetics: About one out of five limited to no more than three a
people with gout has a family history year.
of the condition. ○ Side Effects: thinning bones,
● Age and sex. Gout occurs more often poor wound healing; water
in men than it does in women, retention and decreased ability
primarily because women tend to to fight infection
have lower uric acid levels than men ● Allopurinol (Zyloprim, Aloprim) and
do. probenecid. Taken daily, these slow
○ After menopause, however, the rate at which uric acid is
women's uric acid levels produced and speed its elimination
approach those of men. from the body. Prevent breakdown of
○ Men also are more likely to uric acid before it turns to purine.
develop gout earlier —usually ● Colchicine :Lower deposits of Uric acid
between the ages of 40 and 50 (Long-Term Therapy) - Be alert of GI
— whereas women generally disturbances
develop symptoms after
menopause. Nursing Care
● Bed Rest
Urine test: to measure the amount of uric ● Warn and Cold Compress
acid being excreted ● Immobilization and Protection of the
inflamed joint
Blood test: to measure the uric acid level in ● Maintain a healthy weight: Gradual
the blood weight loss will lessen the load on
affected weight-bearing joints.
Complications ● Losing weight may also decrease uric
● Development of a chronic form of acid levels.
arthritis, often with discolored deposits ● Avoid fasting or rapid weight loss
under the skin called tophi. because doing so may temporarily
● A small number of people with gout raise uric acid levels
also develop kidney stones ● Avoid excessive amounts of animal
protein: Although medications have
Treatment decreased the need for severe dietary
● nonsteroidal anti-inflammatory drugs restrictions in people with gout, some
(NSAIDs) such as ibuprofen (Advil, dietary changes can help lessen the
Motrin, others) and naproxen (Aleve, severity of gout attacks
others) may provide relief of pain
 ● Advise eating no more than 5 to 6 Types
ounces of lean meat, poultry or fish a ● Primary: Idiopathic
day ● Secondary: Inflammatory diseases
● Limit or avoid alcohol: Consuming too (Psoriasis, Gout)
much alcohol can inhibit the excretion
of uric acid, which in turn can lead to Risks
gout ● Age
● Drink plenty of liquids: Fluids help dilute ● Obesity
uric acid in the blood and urine ● Joint Injury
● Diet changes ● Repetitive use of joint (Basketball
● Bed cradle Players)
● Anatomical Deformity

Osteoarthritis Manifestations
● Often develops slowly, and some
people may not experience any signs
or symptoms
● Pain in a joint during or after use, or
after a period of inactivity
● Discomfort in a joint before or during a
change in the weather
● Swelling and stiffness in a joint,
particularly after using it
● Bony lumps on the middle or end joints
of the fingers or the base of the thumb
● Also known as degenerative joint known as Heberden’s node
disease or osteoarthrosis ● Loss of joint flexibility
● characterized by the breakdown of ● Heberden’s Nodes (Only on small
joint cartilage and may affect any joints)
joint in the body, including those in ● Crepitus
fingers, hips, knees, lower back and ● Enlarged, edematous joints
feet. Initially osteoarthritis may strike
only one joint. But if fingers are Areas
affected, multiple hand joints may ● Fingers: Bony knobs called nodes can
become arthritic. enlarge in the finger joints, creating a
gnarled appearance.
Causes ● Painful or stiff and numb.
● combination of factors: including ● Nodes tend to run in families and
being overweight, the aging process, affect more women than men.
joint injury or stress, heredity, and ● Spine: Slow deterioration of discs
muscle weakness. between the bones along the spine
 can lead to back and neck pain and ● X-rays, bone scans, computerized
stiffness tomography (CT) scans, magnetic
resonance imaging (MRI) scans
In osteoarthritis, disks narrow and spurs form. ● Arthrography — an image taken after
Where bone surfaces rub together (facets), dye has been injected into the joint.
cartilage becomes worn and may be painful Imaging techniques can reveal bone
spurs, worn-down cartilage and loss of
● Weight-bearing joints: The parts of the joint space, indicating the presence of
body that bear the majority of your osteoarthritis
weight like hips, knees and feet
● As cartilage slowly deteriorates over Treatment
the years, chronic pain or varying Medications: to treat pain and mild
amounts of discomfort when standing inflammation and therefore improving joints'
and walking functioning
1. Topical pain relievers: creams, gels,
The hip joint on the left is normal, but the hip ointments and sprays to temporarily
joint on the right shows deterioration of relieve arthritic pain,
cartilage due to osteoarthritis. Examples: trolamine salicylate include
Pathophysiology Aspercreme and Sportscreme; methyl
● mechanical stress salicylate, menthol and camphor like Icy Hot
● imbalance of enzymes released from and Ben-Gay.
the cartilage cells or from the lining of
the joint Capsaicin: a cream made from the seeds of
● joint cartilage; breaks down faster hot chili peppers, may relieve pain in joints
● cartilage wears down completely, close to the skin surface, such as fingers,
leaving the bone rubbing on the other knees and elbows.
bone
● damaged end of the bones 2. Acetaminophen: Acetaminophen
(Tylenol) can relieve pain but doesn't
Risks reduce inflammation.
● 45 years old or older and female a. It has been shown to be
● hereditary conditions like defective effective to relieve mild to
cartilage and malformed joints moderate pain.
● joint injuries caused by physical activity b. Side Effect: liver damage,
or sports especially if taken with
● obese alcoholic beverages
● weak thigh (quadriceps) muscles 3. NSAIDs: Nonsteroidal
leading to osteoarthritis of the knees anti-inflammatory drugs (NSAIDs): It
relieves pain and fight inflammation
Diagnostic Tests a. Examples: aspirin, ibuprofen
● Fluid may be withdrawn from a joint for (Advil, Motrin IB) and naproxen
analysis (joint aspiration) sodium (Aleve); ketoprofen
 (Orudis), diclofenac (Cataflam, 7. Injections of pain relievers: injecting
Voltaren) and nabumetone corticosteroid in a joint space which
(Relafen). can offer some pain relief and reduce
b. Side Effects: ringing in your ears, inflammation.
gastric ulcers, cardiovascular a. Example: Injecting hyaluronic
problems, gastrointestinal acid derivatives into knee joints
bleeding, and liver and kidney known as
damage. (viscosupplementation) can
c. Consuming alcohol or taking relieve pain from osteoarthritis.
corticosteroids while using b. Hyaluronic acid is a component
NSAIDs increases the risk of of joint fluid, and hylan G-F20
gastrointestinal bleeding (Synvisc) and sodium
4. COX-2 inhibitors: Considered as hyaluronate (Hyalgan, Supartz,
effective for managing pain and Nuflexxa) are sample
inflammation derivatives
a. Example: celecoxib (Celebrex)
b. Side Effects: fluid retention and
causing or exacerbating high Surgery
blood pressure; has been linked ● Joint replacement (Arthroplasty):
to an increased risk of heart damaged joint is removed and
attack and stroke. replaces it with a plastic or metal
5. Tramadol: (Ultram) centrally acting device called a prosthesis; hip and
analgesic; has no anti-inflammatory knee joints common sites
effect ○ Joint replacement is most
a. Used for short-term treatment of successful in large joints, such
acute flare-ups; given in as hips and knees — these
combination with replacement joints last at least
acetaminophen to increase 20 years in about 80 percent of
pain relief those who had replacements.
b. Side Effect: nausea and ○ Joint replacement surgery can
constipation. help resume an active,
6. Antidepressants: tricyclics pain-free lifestyle. In smaller
a. It reduces chronic pain. hand joints, it also can improve
b. Examples: amitriptyline and appearance and comfort and
nortriptyline (Pamelor, Aventyl). may improve joint's mobility.
c. Some people with arthritis also ● Knee replacement surgery can repair
experience symptoms of damage from osteoarthritis and other
depression. inflammatory conditions. The artificial
d. Antidepressant medications joint has metal alloy caps for
can treat the sleep disturbance thighbone and shinbone and
that can accompany arthritis high-density plastic to replace eroded
 cartilage within the joint and on the
kneecap

During arthroscopy, lavage and debridement

or both are done.
● Lavage involves using saline to flush
out blood, fluid or loose debris inside
the joint.
● Debridement removes loose fragments
of bone or cartilage inside the joint.
● These procedures may provide
short-term pain relief and improved
● Gradual deterioration of cartilage that joint function
occurs in osteoarthritis is the most
common reason for hip replacement
surgery. Implanting an artificial joint
eliminates pain and restores
near-normal movement
Repositioning bones: known as osteotomy

Arthroscopic lavage and debridement:

Fusing bones: known as arthrodesis to ○ One of the easiest and most
increase stability and reduce pain. The fused effective ways to apply heat: a
joint, such as an ankle, can then bear weight 15-minute hot shower or bath.
without pain, but has no flexibility. ○ Other options: hot pack, an
electric heating pad on its
lowest setting or a radiant heat
lamp with a 250-watt reflector
heat bulb.
○ Precautions: If the skin has poor
sensation or have poor
circulation, don't use heat
treatment.
● Choose appropriate footwear:
Wearing comfortable cushioned shoes
Nursing Care that properly support the weight
● Emphasize benefits of Exercise ● Apply cold for occasional flare-ups:
regularly: walking is a good starter Cold may dull the sensation of pain
exercise; stationary bicycle or do hand during the first day or two.
or arm exercises. ○ Cold also has a numbing effect
● Instruct the patient as she moves, and decreases muscle spasms.
maintain a slow, steady rhythm. No ● Precaution: Don't use cold treatments
jerk or bouncing. if there is poor circulation or numbness
● Instruct not to hold your breath, as this ● Practice relaxation techniques:
can temporarily deprive muscles of Hypnosis, guided imagery, deep
oxygen and tire them. breathing and muscle relaxation can
● Maintain good posture while doing all be used to control pain.
exercise. ● Take your medications as
● Avoid exercising tender, injured or recommended: By taking medications
severely inflamed joints. regularly instead of waiting for pain to
● If there is new joint pain, stop! build, will lessen the overall intensity of
● Control weight: Excess weight puts your discomfort.
added stress on joints of the back, ● Teach to use assistive devices: painful
hips, knees and feet. knees may need a brace for support.
● Eat a healthy diet: A healthy diet a. Teaching to use a cane to take
emphasizing fruit, vegetables and weight off the joint when
whole grains can help control the walking.
weight and maintain overall health i. How: The cane should be
● Apply heat: Heat will ease pain, relax used in the hand
tense, painful muscles and increase opposite the affected
the regional flow of blood. joint.
○ Instruct patients to apply heat b. If the hands are affected,
before exercising. various helpful tools and
 gadgets are available to help 5. Take a break. Periodically relax and
maintain an active lifestyle stretch.
● Assess pain (Pain scale) 6. Use the strongest muscles and favor
● Keep joints extended large joints. Don't push open a heavy
● Last option: JOINT REPLACEMENT glass door. Lean into it.
● Provide periods to conserve energy a. To pick up an object, bend the
● Paraffin baths knees and squat while keeping
● Proper body mechanism (Avoid the back straight.
stooping)
● Passive ROM exercises for joint mobility Complementary and Alternative Therapy
● Common forms of complementary
Use of Coping Skills and alternative medicine for
● Osteoarthritis can affect everyday treatment of osteoarthritis include:
activities and overall quality of life. As ○ Acupuncture
a result, it's important to adopt coping ○ Copper jewelry
strategies for dealing with the disease ○ Homeopathy
1. Keep a positive attitude. Make a plan ○ Magnets
for managing arthritis. Studies show
that people who take control of their
treatment and actively manage their
arthritis experience less pain and
function better.
2. Know limitations. Rest when tired.
Arthritis can make one prone to
fatigue and muscle weakness
a. A rest or short nap that doesn't
interfere with nighttime sleep
may help.
3. Avoid grasping actions that strain
finger joints: For example, instead of a
clutch-style purse, select one with a
shoulder strap.
a. Use hot water to loosen a jar lid Musculoskeletal Trauma and
and avoid pressure from the
palm to open it, or use a jar
Oncologic Disorder
opener. Musculoskeletal Trauma is a common type of

b. Don't twist or use your joints human injuries that can result from the

forcefully. damage of muscular or skeletal systems (i.e.,

4. Spread the weight of an object over bones, muscles, tendons, ligaments, nerves,

several joints: Use both hands, for blood vessels, etc.); they usually occur due to

example, to lift a heavy pan. Try using a strenuous and/or repetitive activity and

a walking stick or cane. can result into a variety of complaints,

complications, and deformities
 Slightly. Slight tear
SPRAINS
Characteristics:
● area is somewhat painful, especially
with movement.
● tenderness.
● not a lot of swelling.

MODERATE (Grade 2): The fibers in ligament

tear, but they don't rupture completely.
Ligament then fibers are torn (not completely
● Stretching or tearing of ligaments. ruptured)
● Ligaments are tough bands of fibrous
tissue that connect one bone to Characteristics:
another. ● joint is tender, painful and difficult to
● They help to stabilize joints, preventing move.
excessive movement. ● area is swollen and may be discolored
● Sprains are frequently caused by rapid from bleeding in the area.
changes in direction or by a collision. ● unsteady when moving
● Common locations for sprains are the
ankles, wrists and knees. SEVERE (Grade 3): One or more ligaments
tear completely. One or more ligaments are
Manifestations: completely torn.
● Pain at joint (PAIN NUMERIC SCALE)
● rapid swelling around joint Characteristics:
(Vasodilation due to inflammatory ● area is painful.
response: 5 CARDINAL SIGNS, ● can't move joint normally or put
Production of bradykinins-- Invites weight on it.
histamines for vasodilation for ● joint becomes very swollen and also
increased blood flow) can be discolored.
● Discoloration around joint, Bruising due ● injury may be difficult to distinguish
to breakage of capillaries from a fracture or dislocation, which
● Decreased joint function, Impaired requires medical care.
mobility ● a brace to stabilize the joint or surgical
● Popping sound (Joint) repair in certain ligament injuries is the
● NOTE: The greater the pain and treatment
swelling, the more severe the injury.
Causes
● Sudden twisting of joint beyond its
Classification normal range or motion
MILD (Grade 1): ligament stretches ● overextending or tearing a ligament
excessively or tears while severely stressing a joint
 ● walking or exercising on an uneven ○ cast or brace around the
surface affected area to protect
● landing awkwardly, either at the end ○ use a cane or crutches
of a jump or while pivoting during an ● REST: Avoid activities that cause pain,
athletic activity. swelling or discomfort.
● ICE: Use an ice pack for 15 to 20
Treatment minutes each time and repeat every
● §pain reliever such as ibuprofen (Advil, two to three hours for the first 48 to 72
Motrin, others) or acetaminophen hours.
(NSAIDS) ○ Rationale:
● Short-term treatment of NSAIDS ■ Cold reduces pain,
● apply ice to the area as soon as swelling and
possible to minimize swelling. inflammation in injured
● immobilize the area with a brace or muscles, joints and
splint. connective tissues.
● PRICE: Protection, Rest, Ice, ■ It slows bleeding if a tear
Compression, Elevation has occurred.
● NO WARM COMPRESS WITHIN 48 ● COMPRESSION: compress the area
HOURS with an elastic bandage until the
● Cold compress only within 15-20 swelling stops.
minutes ○ Rationale: To help stop swelling,
○ Instructions:
Prevention ■ Don't wrap it too tightly
● taping, bracing or wrapping knees, or it may hinder
ankles, wrists or elbows circulation.
● use footwear that offers support and ■ Begin wrapping at the
protection. end farthest from the
heart.
■ Loosen the wrap if the
pain increases, the area
becomes numb or
swelling is occurring
below the wrapped
area.
● ELEVATION: elevate the injured area
above the level of the heart,
especially at night. Gravity helps
reduce swelling by draining excess
Nursing Care
fluid.
● PROTECTION: Immobilize the area to
○ Rationale: To reduce swelling
protect it from further injury.
○ use an elastic wrap, splint or
sling to immobilize the area.
PREVENTION: Classifications
● Wear proper footwear ● Mild: Pain and stiffness that occur with
● Taping, bracing, wrapping of knees, movement and may last a few days.
ankles Visible patches on muscle strain.
● Moderate: Partial muscle tears result in
more extensive pain, swelling and

STRAINS bruising. The pain may last one to

three weeks. Has extensive pain due to
visible tear in muscle.
● Severe: The muscle is torn apart or
ruptured. There may be significant
bleeding, swelling and bruising around
the muscle. The muscle may not
function at all. Visible complete
muscle rupture (BLEEDING, BRUISING).
Muscles cannot be used properly.

Manifestations:
● Sudden and severe pain at the time of
injury.
● Local tenderness
● Swelling
● Strain is a stretching or tearing of
muscle (OVERLY STRETCHED)
Nursing Intervention:
● Back muscles are among the most
● PRICE: Protection, Rest, Ice,
common areas of strains.
Compression, Elevation
● Small blood vessels in the muscle
● Muscle rested over a MONTH
rupture and muscle fibers sustain tiny
● Ice pack for 48 hours
tears
● Apply warm treatment after swelling
● Client experiences inflammation, local
subside
tenderness and muscle spasms
● Rest for 4 to 6 weeks
● Any muscle can be strained
● Permit minimal movement

Causes
● muscles suddenly and powerfully
contract
● when a muscle stretches unusually far
● overuse of certain muscles over time
● When one slips on ice, runs, jumps,
throws, lifts a heavy object or lifts in an
awkward position
DISLOCATION ● Assess affected extremity for sign of
neurovascular problem such as pain,
absent of pulse, paresthesia, pallor,
and paralysis.
● Give pain medication as ordered
● Encourage patient to do exercise

FRACTURE

● Displacement of a bone from its

● Break in the continuity of the bone
normal joint position, to the extent
● Accidents, Trauma, Osteoporosis
that, articulating surfaces loss contact.
● Extend deformity on the bone
● Improper alignment causing
inflammation
Types of Fracture
1. Complete fracture – bone completely
Causes:
separated into two parts; may be
● Trauma
transverse or spiral.
● Disease (e.g., Bone disorder)
2. Incomplete fracture – only part of the
● Congenital condition
bone is broken
3. Greenstick fracture – splintering on
Signs and Symptoms
one side of the bone, with bending of
● 5 Cardinal Signs
the other side, occurs only in pliable
● Burning pain at joint
bones, usually in children. One side of
● Deformity of joint
the bone has a tear (LAMAT), Bending
● Stiffness and loss of joint function
of the bone
● Moderate or severe edema around
4. Simple (closed) fracture – bone
joint
broken but no break in the skin
5. Compound (open) fracture – break in
Nursing Intervention:
the skin at the time of fracture with or
● PRICE: Protection, Rest, Ice,
without protrusion of the bone.
Compression, Elevation
● Determine circulation on dislocated
area (e.g.,Move dislocated fingers to
determine if paralyzed or not)
● Check color of dislocated area
● Elevate the affected extremity.
FRACTURE EPONYMS 4. Cotton’s Fracture – trimalleolar ankle
fracture of the distal tibia

5. Galeazzi’s Fracture – fracture of the

1. Barton’s Fracture – dorsal rim fracture distal third of the radius with radioulnar

of the radius. dislocation.

6. Malgaigne’s Fracture – bilateral

2. Bennett’s Fracture – fracture of the fracture of the pelvic ring causing
base of the thumb, acute with pelvic instability.
subluxation or dislocation of the
metacarpal joint of the thumb.

7. Monteggia’s Fracture – fracture of the

shaft of the ulna with displacement of
fragments.

3. Colle’s Fracture – fracture of the radius

and ulna that may or may not involve
the wrist joint, caused by extending
the hand.

8. Neer Fracture – shoulder and humeral

displacement results in fracture in
more than three fragments.
 Signs and Symptoms
● Subjective
○ Pain aggravating by motion
○ Tenderness
● Objective
○ Loss of motion
○ Edema
9. Pott’s Fracture – fracture of the fibula ○ Crepitus
including malleoli of the ankle. ○ ecchymosis

Stages of Bone Healing

10. Salter Harris Fracture – fracture that

separates apart the epiphysis from the
bone usually from crush injury.

11. Teardrop Fracture – compression

fracture of the body of a vertebrae
1. Haematoma- activation of
with separation of bone fragments.
coagulation cascade. Inflammatory
cells releases
2. Inflammation- Recruitment and
activation of inflammatory cells
3. Callus formation- Initial
stabilization:calcification of the bone
4. Granulation tissue: osteo cells takes
place; nitty maglagay ng hollowblukzz;
angiogenesis-new blood vessels
5. Remodeling
Nursing Interventions
1. Preventing Complications of
Immobility
a. ROM Exercises: Movement of
joint through its full ROM to
prevent contractures and
increase or maintain muscle
tone/strength
b. TYPES i. More accurately defined
i. ACTIVE ROM: carried out as the biomechanics of
the client walking
ii. PASSIVE ROM: carried out ii. GAIT: A complex process
by nurse without combining motor skills,
assistance from client balance and the
iii. ACTIVE ASSISTIVE: client musculoskeletal system
move body part as far/ to repeatedly complete
nurse completes a cycle comprised of a
remainder of movement "stance" phase and a
iv. ACTIVE RESISTIVE "swing" phase.
c. Isometric Exercises iii. CANE: A slender,
i. Active exercise through hand-held, curved stick
contraction/relaxation of or device meant to
muscle provide support while
ii. No joint movement walking
iii. Length of muscle does 1. Types
not change a. Standard
iv. Client increases tension straight-leg
in muscle for several ged cane
seconds and then b. Tripod
relaxes c. Quad cane
v. Maintains muscle iv. CRUTCHES
strength and size
d. Assistive Devices for Walking
Gait
Collaborative Management ● A rigid external immobilizing device
● Splint that is molded to the contours of the
● Cold Compress body.
● Analgesics: Codeine, Morphine ● Use specifically to immobilize a
● Prophylactic Antibiotic reduced fracture
● Tetanus prophylaxis ● Correct a deformity
● Apply uniform pressure to underlying
soft tissue
● Support and stabilize weakened joints
GAIT WITH A SINGLE CANE OR FOREARM ● The condition being treated influences
CRUTCH the types and thickness of the cast
● Recommended to people who need applied.
additional support when walking
● The crutch or cane should be used in
the hand opposite the weaker leg.
● Can use 2-point gait

GAIT WITH FOREARM CRUTCHES

● A person on forearm crutches (elbow,
lofstrand or canadian crutches) can
use all gait patterns
○ 2 point gait
○ 3 point gait
○ 4 point gait SHORT-ARM CAST
○ Swing to ● Extends from below the elbow to the
○ Swing through palmar crease, secured around the
base of the thumb
GAIT WITH UNDERARM CRUTCHES ● USES:
● A person on underarm crutches can ○ Forearm or wrist fractures.
use either 3 point, swing to, or swing ○ Also used to hold the forearm or
through wrist muscles and tendons in
place after surgery
WALKER
● A four-legged tubular device with LONG-ARM CAST
hand grips ● Extends from the axillary fold to the
● Provides sturdy support for clients who proximal palmar crease.
are unable or too unstable to walk ● The elbow usually is immobilized at the
with a cane. right angle.
● USES:
CAST ○ Upper arm, elbow, or forearm
fractures.
 ○ Also used to hold the arm or ○ Thigh fractures.
elbow muscles and tendons in ○ Hold the hip or thigh muscles
place after surgery and tendons in place after
surgery to allow healing.
SHOULDER SPICA CAST
● Applied around the trunk of the body ONE AND ONE-HALF HIP SPICA CAST
to the shoulder, arm, and hand. ● Applied from the chest to the foot on
● USES: one leg to the knee of the other leg.
○ Shoulder dislocations or after ● A bar is placed between both legs to
surgery on the shoulder area keep the hips and legs immobilized.
MINERVA CAST/ MINERVA JACKET ● USES:
● Applied around the neck and trunk of ○ Thigh fractures.
the body. ○ Hold the hip or thigh muscles
● USES: and tendons in place after
○ After surgery on the neck or surgery to allow healing
upper back area
○ Immobilizes the head and part BILATERAL LONG LEG HIP SPICA CAST
of the trunk ● Applied from the chest to the feet.
● A bar is placed between both legs to
SHORT-LEG CAST keep the hips and legs immobilized.
● Applied to the area below the knee to ● USES:
the foot ○ Pelvis, hip, or thigh fractures.
● USES: ○ Hold the hip or thigh muscles
○ Lower leg fractures, severe and tendons in place after
ankle sprains/strains, or surgery to allow healing.
fractures.
○ Also used to hold the leg or foot SHORT LEG HIP SPICA CAST
muscles and tendons in place ● Applied from the chest to the thighs or
after surgery to allow healing. knees.
● USES:
LEG CYLINDER CAST ○ Hold the hip muscles and
● Applied from the upper thigh to the tendons in place after surgery
ankle. to allow healing.
● USES:
○ Knee, or lower leg fractures, ABDUCTION BOOT CAST
knee dislocations, or after ● Applied from the upper thighs to the
surgery on the leg or knee area. feet.
● A bar is placed between both legs to
UNILATERAL HIP SPICA keep the hips and legs immobilized.
● Applied from the chest to the foot on ● USES:
one leg.
● USES:
 ○ Hold the hip muscles and 5. Do not use heat lamp or hair dryer on
tendons in place after surgery plaster cast
to allow healing
BODY CAST
● Cover the trunk of the body and hip 2. SYNTHETIC CASTS (FIBERGLASS CAST)
spica extend from the chest to below A. Composed of water-activated
the knees polyurethane materials
● USES: Immobilize the spine B. Lighter in weight stronger and more
durable than plaster
C. Sets in about 20 minutes

CASTING MATERIALS
1. PLASTER CASTS (ROLLS OF PLASTER OF FIBERGLASS
PARIS) ● Can be dried using cast dryer or hair
a. Made of plaster blow dryer on cool setting
b. Less costly ● Some synthetic casts need special
c. Achieve a better mold than lamp to harden
fiberglass ● Water-resistant; however, if cast
d. Traditional cast becomes wet, must be dried
e. Takes 24-72 hours to dry thoroughly to prevent skin problems
f. Precautions must taken until under cast
cast is dry
g. Precautions must taken until Assessment
cast is dry 1. Perform neurovascular checks to area
h. Signs of a dry cast: shiny white, distal to cast.
hard resistant 2. Note any odor from the cast that may
i. Must be kept dry because indicate infection.
water can ruin a plaster cast 3. Note any bleeding in a surgical client.
4. Check for “hot spots” that may
Cast Drying indicate inflammation under cast.
1. Use palms of hands, not fingertips, to 5. Report of pain due to inadequate
support cast when moving or lifting space for tissue swelling
client.
2. Support cast on rubber or General Nursing Management
plastic-protected pillows with cloth 1. Instruct client to wiggle toes or fingers
pillowcase along length of cast until to improve circulation.
dry. 2. Elevate affected extremity above
3. Turn the client every 2 hours to reduce heart level to reduce swelling.
pressure and promote drying. 3. Apply ice bags to each side of the
4. Do not cover the cast until it is dry cast if ordered
4. Provide health teaching and
discharged planning concerning:
a. Isometric exercises when
cleared with physician.
b. Reinforcement of instructions
given on crutch walking
c. Do not get cast wet; wrap cast
in plastic bag when bathing or
take sponge bath
d. If a cast that has already dried
and hardened does become
wet, may use blow-dryer on low
setting over wet spot; if large
area of plaster cast becomes
TRACTION
wet, call a physician.
● The application of a pulling force to a
5. Do not scratch or insert foreign bodies
part of the body.
under cast; may direct cool air from
● For bone and muscle alignment
blow-dryer under cast for itching.
● A pulling force exerted on bones to
6. Recognize and report signs of
reduce and/or immobilize fractures,
impaired circulation or of infection.
reduce muscle spasm, correct or
7. Cast cleaning
deformities.
a. Clean surface soil on plaster
cast with a slightly damp cloth;
USES OF TRACTION
mild soap may used for
1. For immobilization
synthetic cast
2. For support
b. To brighten a plaster cast, apply
3. To maintain alignment
white shoe polish sparingly
4. To correct deformity
5. To reduce pain and spasm
6. To reduce fracture

TYPES OF TRACTION
A. SKIN TRACTION
a. Used to control muscle spasms
and to immobilize an area
before surgery.
b. Accomplished by using a
weight to pull on traction tape
or on a foam boot attached to
the skin.
c. The amount of weight applied
must not exceed the tolerance
of the skin.
 d. No more than 2 to 3.5 kg (4.5 to disease processes of the hip
8 lb) of traction can be used on and knee.
an extremity. c. Elevating foot of bed slightly
e. Pelvic traction is usually 4.5 to 9 provides counteractions.
kg (10 to 20 lb), depending on d. Head of bed should remain flat
the weight of the patient e. Foot of bed usually elevated by
shock blocks to provide
counteraction

TYPES OF SKIN TRACTION

USE FOR ADULTS
1. BUCK'S EXTENSION TRACTION
a. Unilateral or bilateral
b. skin traction to the lower leg
c. The pull is exerted in one plane
when partial or temporary
immobilization is desired.
d. It is used to immobilize fractures
3. Cervical head halter
of the proximal femur before
a. Attached to weights that hand
surgical fixation
over head of bed
● ISA: Immobilization, Support,
b. Used for soft tissue damage or
Alignment
degenerative disc disease of
● DPF: Deformit Absent, Pain Reduction,
cervical spine
Fracture reduce
c. Reduce muscle spasm and
maintain alignment
d. Usually intermittent traction
e. Elevate head of bed to provide
counteraction

2. RUSSELL’S TRACTION
a. A unilateral or a bilateral
orthopedic mechanism that
combines suspension and
traction
b. To immobilize, position and
4. Pelvic traction
align the lower extremities in the
treatment of fractured femurs,
hip and knee contractures, and
 a. Pelvic girdle with extension ● Client may change position without
straps attached to ropes and disturbing the line of traction
weights
b. Used for low back pain to
reduce muscle spasm and
maintain alignment
c. Usually intermittent traction
d. Client in semi-Fowler’s position
with knee bent
e. Secure pelvic girdle around the
iliac crests
SKELETAL TRACTION
● Applied directly to the bone
● This method is used occasionally to NURSING INTERVENTIONS
treat fractures of the femur, tibia, and ● Check traction apparatus frequently
cervical spine. to ensure that:
● The traction is applied directly to the ○ Ropes are aligned and weights
bone by use of a metal pin or wire are hanging freely.
(STEINMANN PIN, KIRSCHNER WIRE) that ○ Bed is in proper position
is inserted ○ Line of traction is within the long
through the bone distal to the fracture, axis of the bone
avoiding nerves, blood vessels, ● Maintain client in proper alignment
muscles, tendons and joints ○ Align in center of bed
○ Do not rest affected limb
Halo Pelvic traction against foot of bed.
● Perform neurovascular checks to
affected extremity.
● Observe for and prevent foot drop
○ Provide footplate
○ Encourage plantarflexion and
dorsiflexion exercises
● Observe for and prevent deep venous
thrombosis
● Observe for and prevent skin irritation
and breakdown
● Provide pin care for clients in skeletal
BALANCE SKELETAL TRACTION (BST) traction
● Assist with ADL; provide overhead
● Removed after 6-8 months trapeze to facilitate moving
● Produced by a counterforce other ● Prevent complications of immobility
than the client’s weight ● Encourage active ROM exercises to
● Extremity floats or balances in the unaffected area
traction apparatus
EVALUATION Types of Orthopedic Surgery
1. Client remains free from injury a. Open Reduction Internal Fixator (ORIF)
2. Client is free from complications of i. Most popular procedure
immobility ii. The correction and alignment
a. Maintains clear, intact skin. of the fracture after surgical
b. Has regular bowel movements dissection and exposure of the
c. Is free from urinary tract fracture
infection/retention/calculi iii. The stabilization of the reduced
d. Has clear breath sounds; normal fracture by the use of metal
rate, rhythm, and depth of screws, plates, nails and pins
respiration b. Closed Reduction – External Fixators
e. Demonstrates adequate i. Used to manage open fractures
peripheral circulation with soft tissue damage.
f. Maintains joint mobility and ii. It provides stable support for
muscle tone severe comminuted (crushed or
g. Remains oriented to time, place splintered) fractures while
and person permitting active treatment of
h. Is active in decision making damaged soft tissues.
regarding own care iii. Indicated for comminuted
3. Optimum level of mobility is attained fracture of the long bones.
4. Client attains independence in
self-care activities; uses assistive External Fixator (cont.)
devices as necessary ● Fracture is reduced, aligned, and
5. Client successfully adjusts to alterations immobilized by a series of pins inserted
in body image; exhibits increased in the bone. Pin position is maintained
self-esteem through attachment to a portable
6. Pain is relieved or is more manageable frame.
● It facilitates patient comfort, early
mobility, and active exercise of
Orthopedic Surgery adjacent uninvolved joints.
● Orthopedic surgery is a surgery ● Complications related to disuse and
performed by a medical specialist, immobility are minimized
such as an orthopedist or orthopedic
surgeon, trained to deal with problems Two General Types
that develop in the bones, joints, and 1. Ilizarov Frame
ligaments of the human body. a. Used to correct bone
angulation, fractures or to
Goals lengthen bones.
● To improve function by restoring b. It consists of wires, pins and rods
motion and stability which will be attached to the
● To relieve pain and disability affected bone.
 c. For bone lengthening, it is also
for mal-union and non-union.
d. use in the fracture of the tibia

2. Orthofix Frame
a. Much simpler device than the
Ilizarov frame.
b. It is made up of two or three
pins inserted at the top and
bottom of the affected bone.
These pins are attached to an
adjustable telescopic frame.
c. Use to connect the bones in
place
d. Fixator may be in place for up
to 10 weeks.

Advantages of External Fixator

1. The method provides rigid fixation of
the bones in cases in which other
forms of immobilization, for one reason
or another, are inappropriate. This is
most common in severe, open types II
 and III fractures in which cast or
traction methods would not permit
access for management of the soft
tissue wounds.
2. Uncomminuted transverse
can be optimally compressed, length
can be maintained in comminuted
fractures by pins in the major proximal
and distal fragments (neutralization
mode).
3. It allows direct surveillance of the limb
and wound status, including wound
healing, neurovascular status, viability
of skin flaps, and tense
compartments
4. Associated treatment, for example,
dressing changes, skin grafting, bone
grafting, and irrigation, is possible
without disturbing the
alignment or fixation.
5. Immediate motion of the proximal and
distal joints is allowed. This aids in
reduction of edema and nutrition of
articular surfaces and hinder joint
stiffening, and muscle atrophy.
6. The extremity is elevated
pressure on the posterior soft tissues.
The pins and frames can
suspended by ropes from overhead
frames on the bed, aiding edema
resolution and relieving pressure on the
posterior soft tissue part.
7. Early patient mobilization is allowed.
With rigid fixation the limb can be
moved and positioned without fear of
loss of fracture position.
8. Insertion can be performed with the
patient under local anesthesia,
although this is not optimal.
9. Rigid fixation can be used in infected,
acute fractures or non union's. Rigid
fixation of the bone fragments in
infected fractures or in infected
established non union's is a critical
factor in controlling and obliterating
the infection
fractures
Disadvantages of External Fixator
1. Meticulous pin insertion technique and
skin and pin tract care are required to
prevent pin tract infection.
2. The pin and fixator frame can be
muscle mechanically difficult to assemble by
the uninitiated surgeon.
3. The equipment is expensive.
4. The frame can be awkward, and the
patient may reject it for aesthetic
fracture reasons.
5. Fracture through pin tracts may occur
6. It is difficult to do delicate surgery such
as skin flaps once the exfix apparatus is
in place. Rather do this type of surgery
before the frame is applied
7. Re-fracture after exfix removal may
without occur unless the limb is adequately
protected (e.g. by walking cast
be application), until the underlying bone
can again become accustomed to
stress.
8. The noncompliant patient may disturb
the appliance adjustments.
9. The head injured patient may injure
himself by thrashing his pin studded
limb against other parts.
10. Joint stiffness may occur if the fracture
requires that the fixator immobilize the
adjacent joint. e.g. an exfix placed
over the ankle for a pilon fracture as
there was insufficient space for pins in
the distal tibial fragment
Complications 5. Be alert for potential problems caused
1. Pin tract infection – most common by pressure from the device on the
complication, occurring in 30% of skin, nerves or blood vessels and for
patients the development of compartment
2. Neurovascular impalement – syndrome
3. Muscle or tendon Impalement – Pins 6. Provide proper pin care
inserted through tendons or muscle 7. If signs of infection are present or if the
bellies restrain the muscle from its pins or clamps seem loose, notify the
normal excursion and can lead to physician
tendon rupture, or muscle fibrosis. 8. Encourage isometric and active
4. Delayed union – due to prolonged use exercises within the limits of tissue
of the rigid fixator. damage
5. Compartment syndrome – external 9. When the swelling subsides, help the
fixator is basically a closed method patient to become mobile within the
and there is a higher rate of prescribed weight-bearing limits.
compartment syndrome. Adherence to weight-bearing
6. Refracture – it is possible after fixator instructions minimizes the chance of
removal unless the limb is adequately loosening of the pins when stress is
protected by crutches, supplemental applied to the bone- pin interface
casts, or supports
7. Limitation of future alternatives – Open Health Teaching
reduction become difficult or 1. Teach the patient or significant other
impossible if pin tracts become to perform proper pin site care.
infected. Do not use an exfix for an 2. Advice to report occurrence of pin site
extended period ,if you anticipate infection: redness, tenderness,
open reduction will later be required. increased or purulent pin site
drainage, or fever.
Nursing Considerations 3. Teach patient and significant other to
Before Application monitor neurovascular status and
1. Prepare the patient psychologically for report any changes promptly.
application of external fixation. 4. Teach patient or family member to
check the integrity of the fixator frame
After Application daily and to report loose pins or
1. Elevate the affected extremity to clamps
reduce swelling
2. Cover sharp points on the fixator or Arthroplasty : The repair of joint problems
pins to prevent device-induced injuries through the operating arthroscope or
3. Monitor neurovascular status of the through open joint surgery (OPERATION OF
extremity every 2 to 4 hours. JOINTS)
4. Assess each pin site for redness,
drainage, tenderness, pain, and Herniarthroplasty: The replacement of one of
loosening of the pin the articular surfaces
Joint Arthroplasty or Replacement: The Other Considerations
replacement of joint surfaces with metal or ● Surgical candidates undergo standard
synthetic materials blood and urine tests before surgery
and, for major procedures, may be
Total Joint Arthroplasty or Replacement: The given an electrocardiogram or other
replacement of both articular surfaces within diagnostic tests prior to the operation.
a joint with metal or synthetic materials ● Individuals may choose to donate
some of their own blood to be held in
Meniscectomy: The excision of damaged reserve for their use in major surgery
joint fibrocartilage. such as knee replacement, during
which heavy bleeding is common.
Amputation: The removal of a body part
Nursing Interventions
Bone Graft: The placement of bone tissue to 1. Relieving Pain and Discomfort
promote healing, to stabilize, or to replace a. Can be physical,
diseased bone. (NEED OF NEW CELLS) pharmacologic (analgesics as
prescribed), or psychological
Tendon Transfer: The movement of tendon strategies such as distraction
insertion to improve function (movement of 2. Maintain adequate neurovascular
tendon to improve function and circulation) function
a. Assess neurovascular status:
Fasciotomy: The incision and diversion of the color, temperature, capillary
muscle fascia to relieve muscle constriction, refill, pulses, edema, pain,
as in compartment syndrome, or to reduce sensation, and motion
fascia contracture 3. Promote Health
a. Assess nutritional status and
Nursing Considerations hydration
Pre-operative Phase b. Coughing and deep breathing
● Prior to any surgery, candidates exercises
undergo extensive testing to c. Provide skin care
determine appropriate corrective 4. Improve mobility
procedures. a. Practice use of assistive devices
Tests May Include (ex: crutches) preoperatively to
● X-rays promote earlier independent
● Computed tomography (CT) scans mobility.
● Magnetic resonance imaging (MRI) 5. Help the patient to maintain
● Myelograms self-esteem
● Diagnostic arthroplasty a. Promote a trusting relationship
● Blood tests. within the patient
b. Allow patient to express feelings
of anxieties
 c. Clarify any misconceptions Potential Complications
Post-Operative Phase 1. Hypovolemic Shock
1. Relieving Pain and Discomfort a. Monitor signs of hypovolemic
a. Use of analgesics shock: increased pulse rate,
b. Application of cold compress decreased BP, urine output less
c. Suction wound if necessary (to than 30ml per hour,
decrease fluid accumulation) restlessness,thirst, decreased
d. Report incidence of hgb and hct
uncontrollable pain 2. Atelectasis and Pneumonia
2. Maintain adequate neurovascular a. Monitor breath sounds
function b. Monitor signs of resp. distress:
a. Monitor neurovascular status increased RR, productive
b. Patient is reminded to perform cough, diminished or
muscle setting, ankle, and adventitious breath sounds,
calf-pumping exercises hourly fever
while awake to enhance 3. Urinary Retention
circulation a. Monitor urinary output
3. Promote and Maintain Health b. Encourage to void every 3 to 4
a. Provide a well-balanced diet hours
with adequate protein and c. Voiding in side-lying position
vitamins (for wound healing) may be helpful to male patients
b. Proper turning, washing, and d. If patient is unable to void,
drying the skin and minimizing intermittent catheterizations
pressure over the bony may be prescribed until the
prominences are necessary to patient is able to void
avoid skin breakdown independently
4. Improve mobility 4. Infection
a. Instruct patient to comply in the a. Prophylactic systemic
exercise program prescribed by antibiotics as prescribed
the physician or the therapist b. Assess patient’s response to
b. Make sure that the patient uses antibiotics
the walking device prescribed c. Regular wound dressing with
safely aseptic technique as observed
5. Help the patient to maintain 5. Venous Stasis and Deep Vein
self-esteem Thrombosis
a. Continue preoperative plan of a. Encourage use of ankle and
care calf-pumping exercises, elastic
b. Support the patient which can compression stockings and
help in acceptance of altered encourage early mobilization
body image b. Adjusted-dose heparin, or
6. Monitor and manage potential low-molecular-weight heparin
complications may be prescribed
Pagets disease Musculoskeletal Cancer
- Breakdown by osteoclasts followed by ● Is caused by a problem with the cells
excessive bone resorption and bone that make bone.
growth ● Bone tumors occur most commonly in
- Chronic disease children and adolescents and are less
- Aged bone resorption common in older adults.
- Cause ● Cancer involving the bone in older
- Unknown adults is most commonly the result of
- More common in males metastatic spread from another tumor.
- 40 years old ● Pain is EXCRUCIATING, Crucial

Manifestations Types of Bone Cancer

- Bone pain
- Bone deformity
- Pathologic fractures Osteosarcoma
- Nerve compression

Diagnostic test
- Elevates serum Ca
- Anemia
- Increased alkaline phosphatase
- Increased hydroxyproline (protein
Collagen; stabilize protein in the body)
(urine test)

Collab management
- analgesic/ anti inflammatory agents
(ASA/ nsaids ● most common primary malignant

- Calcitonin: retired bone reabsorption bone cancer

- Cytotoxic antibiotic: to reduce ● Long bones

● most commonly affects males
between 10 and 25 years old, but can
less commonly affect older adults
● occurs in the long bones of the arms
and legs at areas of rapid growth
around the knees and shoulders of
children
 aggressive or relatively slow- growing.
Cell mutation from the area

Ewing's sarcoma ● most common in people over 40 years

old
● slightly more common in males and
can potentially spread to the lungs
and lymph nodes
● most commonly affects the bones of
the pelvis and hips
● The five-year survival for the aggressive
form is about 30%, but the survival rate
for slow-growing tumors is 90%.

Malignant fibrous histiocytoma

● most aggressive bone tumor (MFH)
● Affects younger people between 4-15
years of age
● Childhood tumor
● most commonly occurs in the middle
of the long bones of the arms and legs
● three-year survival rate is about 65%,
but this rate is much lower if there has
been spread to the lungs or other
tissues of the body.

Chondrosarcoma
● Affects the soft tissues including
muscle, ligaments, tendons, and fat
● most common soft-tissue malignancy
in later adult life, usually occurring in
people 50-60 years of age
● most commonly affects the extremities
and is about twice as common in
males as females.
● MFH also has a wide range of severity.
● The overall five-year survival rate is
about 35%- 60%.
● second most common bone tumor
● Affects mostly muscles, ligaments,
and accounts for about 25% of all
tendons, Fats
malignant bone tumors
● These tumors arise from the cartilage
cells and can either be very
Fibrosarcoma Chordoma

● much more rare than the other bone

tumors.
● It is most common in people 35-55
years of age.
● it most commonly affects the soft
tissues of the leg behind the knee. It is
slightly more common in males than
females.
● Affects soft tissues
● Common in male patients ● is a very rare tumor with an average
survival of about six years after
diagnosis.
● It occurs in adults over 30 years of age
and is about twice as common in
males as females.
● It most commonly affects either the
lower or upper end of the spinal
column
● Dangerous type of bone cancer,
affects SPINAL COLUMN

Signs and Symptoms

● Pain in the affected bone
● Swelling in the area of pain site
● Lump or mass that is felt
● Tenderness of the affected site
 ● The overlying skin is warm to touch tumors is important for
● Dilated superficial veins planning the type of
● Decrease in movement of the surgery that is best for
affected limb each patient. MRI scans
● Increase pain with activity/lifting are also very helpful in
● Weight loss looking at the brain and
spinal cord
Diagnostic Procedure 4. Chest X-Ray
A. Imaging Studies a. This test can spot
1. Bone X-Ray cancers if they are large
a. Doctors will usually enough (one-half inchor
recognize (or at least larger) that have spread
suspect) bone cancer on from the original site in
regular x-rays of the the bone. (A CT scan of
bone the chest is more
2. Computed Tomography sensitive; it can spot very
a. A CT scan of the small tumors.)
affected bone can show 5. Radionuclide Bone Scan
if the tumor has grown a. During a bone scan, a
into nearby muscle, fat, radioactive tracer is
etc. The scan will also injected into a vein. The
help the surgeon pick tumor absorbs these
the best area to biopsy. radioactive materials,
A chest CT scan is very which are detected by a
important in determining special type of camera.
if bone cancer has A computer reconstructs
metastasized (spread) to images showing all the
the lungs bones of the body.
3. Magnetic Resonance Imaging b. Bone cancer will usually
a. MRI gives more details of appear as a darker spot
the soft tissues, the bone in the scan indicating
tumor, and the bone more concentrated
marrow cavity than a CT radioactivity. The bone
scan. It is thought to be scan can also detect
better for evaluating spread of the
bone cancer. osteosarcoma to the
Sometimes, the MRI can lungs and/or to other
help find small tumors bones
several inches away from 6. Positron Emission Tomography
the main tumor (called a. With PET, the patient will
"skip metastases"). receive an infusion of
Finding these small glucose (a form of sugar)
 that contains a ● Prepare client for invasive tests to
radioactive atom. A confirm location and size
special camera can ● Follow guidelines for care before and
detect the radioactivity. after surgery, chemotherapy, and
b. Cancer cells in the body radiation treatments
absorb high amounts of ● Encourage increased fluid intake,
the radioactive sugar, unless contraindicated
c. because of their high ● Provide analgesics as needed for pain
rate of metabolism. PET ● Encourage client to express feelings
may be useful for looking about potentially life- threatening
at spread of cancer illness and ask questions
Blood Tests ● Explain all nursing and medical
● High levels of certain chemicals in the interventions, including benefits and
blood can suggest that bone cancer is possible adverse effects
more advanced than it appears. The ● Instruct client in methods to prevent
most important of these are called infection
alkaline phosphatase and LDH. They ● Teach relaxation techniques and other
are released into the blood by cancer coping mechanisms
cells. Higher levels indicate a worse
outlook for cure

Biopsy
● A biopsy procedure takes a sample of
tumor tissue to examine under the
microscope and use for certain other
laboratory tests

Medical Management
● chemotherapy (using drugs to kill
cancer cells)
● surgery (to take out the tumor in an
operation)
● radiotherapy (using high-dose x-rays to
kill cancer cells) Can target an area or
general
● Adjunct therapy (Multiple or
combined therapies)

Nursing Considerations
● Explain risk factors from exposure to
known carcinogens