Musculoskeletal System

Musculoskeletal system and nervous system work together. They make up the need for
mobility w/o musculoskeletal system and w/o auto neurological system there won’t be
movement. Together they are synergistic, and work nicely to create a mobile, tall person
who can walk upright.

The supporting framework of the body consists of:

• Muscle
• Connective tissue:

Bones There are a number of

autoimmune diseases that
Cartilage
attack the connective tissue,
Ligament such as RA, scleroderma (thick
skin), a disease where the body
Tendons attacks connective tissue. It
Muscles affects blood vessels, lung
lining, every joint and
cartilage.

Purpose of Bones
1. Gives height and allows mobility.

a. We stand erect.

b. It makes us unique from any other animal. We have the ability to stand
upright and to move through the environment. We are the only mammal
to do it.

2. Used to encase/protect organs (heart, lungs, liver, spleen, pancreas, most of

stomach). All fragile organs are located under ribs, and pelvic bone is protecting
the bladder. Unprotected organs can withstand trauma without difficulty.

a. That is why when you fracture a rib that your body makes it so painful.

b. Why does your body make it painful? – so that you have to go to the ER,
you have to have an x-ray, CAT Scan, MRI to look and see if there is any
damage underneath the actual fractured rib.

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3. Blood cell formation - Marrow of long and flat bones make RBC, WBC – called
hematopoiesis(a remarkable self-regulated system).

a. Red marrow have stem cells. Based on the body’s need, they can be RBCs,
WBCs, or platelets.

b. RBCs are made b/c the kidney secretes the hormone erythropoietin to the
bone to produce more RBCs.

c. The immune system will send signal to the bone to produce WBCs.

i. When a pt feels malaise/achy, the achy feeling is the bones

producing WBC. Bone pain is achy, non-localized and hurts all
over.

ii. In case of inflammation, the bones are signaled to produce an army

of WBC.

iii. If I get an infection and my inflammatory system gets going – who

makes my WBC? My bones. The signal goes to the bone that I
need an army and the bone begins to produce WBC. How do you
feel when you have a fever? You ache – the ache is the bone
producing the WBC’s. That is why you get the malaise and the
ache. That ache is bone pain. Bone pain is not localized, you can’t
find it. You may have broken one part of the arm, but your whole
arm can hurt. It is non-localized, whole area is affected. B/c bone
produces so much blood it has a tremendous amount of blood
supply to it. Bone is not stagnate. It continually grows and
continually gets eaten up or resorbed. You Fx a femur - **every
time you break a bone you bleed** femur 1.5 L, pelvis 4 L,
humerous and ulna and radius 1 L – doesn’t mean you do, but you
have the potential. **Important thing to remember is that
whenever pt Fx a bone I think of bleeding look for shock,
hemorrhage, hypovolemic shock.
iv. The kidney is the organ sending signals to the bone to produce
which type of cell – RBC or WBC.

4. Storage of minerals – the thyroid and parathyroid control Ca (2 main minerals Ca

and MG). When the body is low in Ca, the body takes it from bone. For every
child you lose a tooth (old wives tale). In pregnancy, the baby steals Ca from the
bones and teeth. Ca intake is crucial during teens and 20s to build strong bones.

**Hematopoiesis – process that makes the cells, it doesn’t make the decision, it just
follows orders from the kidneys. The kidneys send the hormone erythropoietin to the
bones. The kidney is a very greedy organ. It wants more blood than any other organ.

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 It requires 25% of all cardiac output to keep it happy. The minute it is not happy it
sends out an alarm system. This alarm system includes the hormone erythropoietin.
If the kidney thinks it does not have adequate O2, it is going to send message to the
bone marrow to produce more RBC to produce more hemoglobin to take more O2 to
the kidney. That is what makes the bones so unique. Inside the bone you have stem
cells. Stem cells build other cells depending on what hormone is sent.

Bone stimulation
Wolf’s Law – if you don’t use it, you lose it.
• The minute you put the pt on bed rest, his bone begins to dissolve, especially in
stroke and spinal cord injured pts.
• To maintain bone integrity, we put the pt on a tilt board.
• According to wolf’s law, weight bearing is very important. The heavier you are,
the stronger the bones.
• The Tx for osteoporosis is added weight (carry around 2 dumbbells) along č good
dietary habits and consumption of Ca.

Side note on calcium:

• Ca and Ph are married to each other, but getting a divorce – When one is up, the
other is down.
• Ca gives bones its strength.
• Ca can be free floating (as in blood) or ionized (attached to proteins gamaglobulin
and albumin.
• Ca metabolism in the blood is the responsibility of the parathyroid- it decides how
much Ca is in blood. Calcitonin decides how much is in the bones.
• Vit D is needed for Ca absorption

o Osteomalacia is a Vit D deficiency, called rickets in children.

• Undigested Vit D is called ergocalcitrol – it needs to go to the kidney to become

calcitriol for Ca to be absorbed.
• Vit D is fat soluble – too much=Vit D toxicity – s/s of hypocalcaemia.

o NI -> look for S/S of Vit D toxicity -hypocalcaemia.

Types of Bones

206 bones in the body – they are highly vascular/we make blood in bone marrow

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When you break a bone, you bleed.

When we look at a Fx, we monitor for blood to prevent swelling and bleeding, RICE:
• RICE:

o Rest

o Ice

o Compress

o Elevate

▪ **This applies to all bones except the tibia, fibia and posterior
femur.

A Fx of a long bone can cause a fat emboli. The yellow marrow in long bones is
composed of fat. In Fx that fat can escape and travel in blood stream throughout the body.
Fat globules go into the capillary, and into the brain and lung causing fat emboli. The pt
has an 80% mortality rate with it.

For bone marrow biopsy:

• Flat bones are where we are going to find our best source of bone marrow.

• In babies we use the skull b/c it is rich in bone marrow and a needle can get in.
This can only be done before the skull bones are knitted together.
• We use the hip on adults. Huge needle inserted and what comes out looks like
blood. That is actually the bone marrow.

o For adults, flat bones include the sternum, but we never do a bone marrow
in the sternum b/c it is too painful. Once pain is triggered in the sternum,
the pain doesn’t go away. Doing bone marrow there would be quite
painful and pt would be in pain for a long period of time.

▪ One way to elicit a pain response is to press into muscles above

sternum, but b/c of prolonged pain, it is considered inappropriate
nursing. A better way is to press into the nail bed.
• We put needle into the bone until we hear a crack, we pull 50cc of bone marrow,
which include stem cells.
• We look to see how many RBC, WBC, and platelets are available.

Types of bones:
1. Long bone – longer than wider – 3 parts:

a. Diaphysis – shaft of long bone

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 b. Epiphysis – end of long bone

i. Includes the growth plate – during a bone Fx, the growth plate
can be impaired (a 1” difference between legs is considered a
significant disability).

ii. During growth period a Fx to bone can impair bone growth.

iii. Growth plate – is the zone of cartilage ("gristle") on the either

end of a growing bone that functions to lay down the mature
bony tissue on either side

c. Metaphysis - is the portion of a long bone between the epiphyses and

the diaphysis.

2. Short bone – fingers and toes.

3. Flat bone – skull, sternum, pelvic cavity.

4. Irregular bone – ear bones (stapes and incus), jaw, patella, vertebrae.

In trauma, when someone Fx their pelvis, they can lose 4L of blood b/c of bone
vascularity. We only have 5L of blood in our body. By comparison, Femur = 1.5L blood
loss.

Bone stimulation
Wolf’s Law – “if you don’t use it, you lose it.”
• Critical in immobility. The minute a pt is put to bed, their bones begin to dissolve.
Real damage starts to occur after a month. In quadriplegics, we have to stand pts
up (on a tilt board) so their bones do not dissolve.
• In healing Fx, we need to weight bear in the 6th – 12th week of healing – during
the remodeling phase Ca is dispersed into bone. It is crucial to weight bear so that
the bone can grow the way it was before the Fx.
• In osteoporosis, we advise the pt to lift dumb bells of 10lbs each. When the pt lifts
extra weight, the bones are stimulated to get stronger.
• Calcitonin and parathyroid control Ca release from the bone. When we run low on
Ca in the bloodstream, the parathyroid will steal it from bones.

Bone cells
Osteoblast – build up
Osteoclast – clean up
Osteocytes – bone cell that are found in the bones themselves that give it its structure and
strength and it is from the osteocyte in which osteosarcoma arises.
Bone is dynamic – not static.
It is constantly being built and broken down.

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Resorption – breaking down of bones when osteoclasts are cleaning bones. As they are
cleaning, a new influx of cells occurs.
An imbalance between osteoblasts and osteoclasts is called osteoporosis.
It is from osteocytes where osteosarcoma arises. Typically seen in children as a primary
site. In adults it is usu a secondary site.

Muscles
• Cardiac – every cell can produce electrical impulses and respond to electrical
impulse. Every cell can change its level of contraction.
• Skeletal – voluntary
• Smooth – involuntary. In surgery, we control smooth muscle by administering
anesthesia. When a pt comes back from anesthesia, there are two areas of smooth
muscle that are of primary concern: bowel sounds and gag reflex.
• Quads are given baclofen to control smooth muscle spasms (vital to relieving
bladder of urine – aka, detrusor sphincter dysinurgia).

Muscle contraction
• Isotonic – shortening of muscle. Builds muscle = hypertrophy.
• Isometric – tightening of muscle. Pt in cast needs to perform isometric exercise to
prevent atrophy (wasting away) of muscle. Atrophy à lack of muscle movement.
o Concern with polycatheters is that is that the pt’s bladder will atrophy,
particularly in elderly.
o When polycatheter is removed, the muscle has atrophied (within a week).

Joints
• Cartilage – like Teflon – a smooth, resilient layer on top of bone. It lays itself on
top of another bone. Cartilage glides against one another as in the knee, elbow,
and shoulders.
• Osteoarthritis – an interruption in cartilage. An injury sustained from repetitive
movements or an athletic event. Cartilage doesn’t grow back. When nose and ears
get frostbitten, they do not grow back.
• Bone spur – aka Osteophyte the bone that grows through a crack in cartilage. It
scratches the adjacent bone. Within 10-20 years the cartilage is lost and the two
bones rub against each other without protection.
• In RA, the antibodies attack the cartilage and destroy it.
• Synovial fluid – like extra virgin olive oil - clear and oily. Pt who has
inflammation, such as RA, will have cloudy fluid, full of protein from breakdown
of cartilage and blood cells from the antibodies (inflammation).
• Tendon – connects muscle to bone.
• Ligaments – a cord that connects bone to bone.
o Tendons and ligaments do not stretch well.
o Ligaments hold the posterior anterior knee, so the knee can only go
forward, which holds the leg in place.

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 • Bursa – little pillow-like shape filled with synovial fluid. They are found where
bone hits bone. There is a bursa on top of the greater trochanter so it is protected.
Bursitis is an inflammation of the bursa.

How Joints Move

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 • Flexion
• Hyperextension
• Abduction – push apart. In joint surgery, such as hip replacement, the pt must
keep their hip in abduction position. If they adduct their legs, the joint might pop
out. The pt might not feel it b/c it is artificial. They will feel it once it pulls on
muscle.
• Adduction – pull together.
• Dorsiflexion – toes to nose. Used to evaluate for DVT. Homen’s sign.
Prophylactic measures, we put pt on heparin or Lovenox. To test for DVT, we flex
the toes to the nose. If pt has calf pain, we suspect the pt has DVT. Dorsi flexion
with pt who has knee replacement causes pain. Instruct pt to differentiate btw calf
pain and knee pain
• Plantar flexion – downward pointing. Bibinsky is abnormal reflex, we find it in
head trauma pts. Plantar reflex is the normal reflex.
• Inversion – moving foot inward.
• Eversion – moving foot outward.
Most common replacement is the ball and socket, and hinge - in hip and knee. Sometimes
in finger joint, and rarely in wrist.
Patient history – part of the assessment – allows focusing on the problem. Writing
nursing care plan for pt is invaluable, they do 50% better than those who have none.
Assessment has 3 areas to look at: it is the cornerstone of nursing
We need to base physical assessment on pt Hx.
Pt’s description of problem. What made them seek medical help.
Family Hx – osteoporosis, fractures, RA – distant relations.
Functional assessment – degree of alteration in ADL – can they dress themselves.
Risk for falling, etc.
Surgery/Tx.
Diet – find out what pt consumed in last 24 hours. How much Ca, Vit D is the pt getting.
Assess whether they are nutritionally meeting their needs.
Exercise – American Heart Association wants everyone to exercise a minimum of 30-
minutes a day.
Weight gain/loss
Work
Medications – a couple of meds should raise red flag:
Steroids – known to cause bone loss – osteoporosis – are used to treat long term RA and
scleroderma. If on steroids longer than 6 weeks, pts are given anti-osteoporosis meds like
Fosamax. Steroids can also cause vascular necrosis – a breakdown of blood vessels.
Steroids should not be given for a long period of time.

Most common complaints:

• Pain – the 5th vital sign
• Weakness

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 • Deformity
• Limitation of movement
• Stiffness
• Joint crepitation – noises when moving, usually accompanied with pain. Limit
movement.

Pain assessment
• Intensity – use number scale.
• 1-3 pt Rx’d Tylenol
• check
• 5-6 pt rx’d
• 7-10 pt Rx’d 2 Percocet
• OPQRST Scale
o O – Onset.
o P – Prodromal - cause
o Q – Quality.
o R – Radiating.
o S – Severity.
o T – Timing.
• Any pain > 8 is a medical emergency. When in severe pain, pt can get 10mg
OxyContin and 2 Percocet. Our job is to meet pt’s pain needs.
• Pain is subjective. – Pain is what the pt says it is.
• Quality – aching, stiff, sharp, dull. Document in pt’s own words and quote them.
“An elephant sitting on my chest.” – Usu r/t MI pain.
• Onset – date it started
• Timing – pt w/ osteoarthritis will complain of pain at the end of the day. Pt with
RA does well standing up all day – they feel pain at rest. The question to ask is,
How did you sleep last night?”
• Aggravating factors – pt w/ RA experience pain in bad weather, aggravating
activities, etc.
• Associated symptoms – fever / and anything r/t it.

Types of pain
• Joint pain – bilateral or one sided. When comparing osteoarthritis vs. RA, RA is
always bilateral. In RA, every joint in their body will be affected. Osteoarthritis
can be one sided.
• Bone pain – throbbing, non-localized, aching - osteomyelitis pt has infection in
the bones and the pain is achy, malaise from blood cell count going up.
• Muscle pain – stiffness, cramping. Aching.
o Muscle spasm à $ flexibility.

Equipment
• Gloves –

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 • Goniometer – tool to measure joint movement. Every joint is assigned a
numerical movement value.
• Tape measure –

Physical assessment
During assessment, we compare joints; the good joint vs. bad joint.
• Inspection – always 1st look before touch or palpate to avoid skin breakdown.
• We need to determine if gloves are needed.
• Look and compare size of joints (good 1st, then bad to set baseline), contour
swelling and deformities of joint.
o Patient posture – you have already observed this. This patient has come
into the room, they are either in a wheelchair, walker or crutches and he is
getting into his patient gown, putting his stuff away and getting into bed,
so you then know if he can stand, walk, does he have a limp, is he
independent, does he need a supportive device?

o We are also going to be looking at body alignment and shoes. If you look
at peoples shoes, if heel is worn more on one side, then they have a gait
problem.

o Kyphosis – also known as a Dowingers hump. Dowinger hump is when

patient’s vertebral column begins to collapse, it crumbles. This is a sign of
osteoporosis. As vertebral column collapses, the person loses height. One
muscle group, usually the dominant side will pull away from the other side
of the body and the patient will develop a hump or a buildup of muscle
tissue. If you see pt with Dowinger’s hump, you can say that they have
osteoporosis or you would want to test them for osteoporosis.

o Lordosis – lumbar is in too far. Seen a lot in pregnant women.

o Scoliosis – occurs before the age of 18. It is an adolescent disease.

Occurs in the year of greatest growth, when the pt grows 2, 4, 6 inches.
One muscle group pulls, pulling out the spinal column, giving it an S
shape.
• Palpation:

o When we do the physical assessment of the joint, there is not a lot to do;
we only have inspection and palpation. We do not percuss, we do not
auscultate. We always begin physical assessment with inspection, we
always looks before we touch. We are looking at the size of one arm or
extremity compared to the other. We compare good to bad. We always do
the assessment on the good side first because that would be the norm,
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 comparing it to what the patient’s disease or ill side is. We look at the size
of the joint, the contour. We look at the skin color, swelling and
deformity. Then we touch. We do because if our patient has an open
wound or drainage or a weeping rash, we want to get our gloves on.

o We palpate for skin temperature, using dorsal side. Observe for muscle
twitching and spasm and you can feel muscle spasms – muscle is actually
hard. We will look for bony articulation. We will see that in patients with
osteoarthritis and Rheumatoid arthritis. Palpate for tenderness, pain and
crepitation.
• Once inspection is done we can palpate (touch) for:
o Skin temp. – RA is hot /osteo is cold.
o Muscle – contractures, shortening of muscle, tightness.
o We feel for bony articulations – is there anything under the skin that
shouldn’t be there.
o Tenderness, pain and crepitation.
o Scales for reflexes – 0-4 w/ 2+ optimal.
o Scales for pulses – 0-4 w/ 2+ optimal.
o Scales for muscles – muscle strength, the higher the better. 0-5 w/ 5+
optimal.

We chart as follows – 5+/0-5

Pt w/ stroke has plasticity – where arm can’t be held against gravity.
• 5 – Full ROM against gravity, full resistance
• 4 – Full ROM against gravity, some resistance
• 3 – Full ROM w/ gravity
• 2 – Full ROM w/ gravity eliminated
• 1 – Slight contraction
• 0 – No contraction

Phalen’s Test for carpal tunnel. Flex wrists for 60 seconds. Numbness, tingling, or
burning indicates carpal tunnel syndrome.

Positive Tinel's sign is used to ID Carpal Tunnel Syndrome. This test is elicited by
percussing lightly over the median nerve, located on the inner wrist until numbness,
tingling and pain are felt.

• Carpal Tunnel is when we use our fingers and wrist - muscles get larger.

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 • When I type or I sew or I do something that uses hands, that wrist movement
builds muscle and that muscle can encapsulate and cut off nerve function, so these
patients loose their nerve feeling.
• They get paresthesia or numbness and tingling of their hands.

Bulge Sign (Balloon Sign)– in osteoarthritis.

• Assess for excess fluid on the knee.

• Milk upward on medial side of knee, and then tap lateral side of the patella. It will
balloon out or bulge.
• It indicates joint swelling vs. soft tissue swelling - arthritis.

Documentation of normal findings

• Full ROM

• No joint swelling, deformity, or crepitation

• No spinal curvatures
• No muscle atrophy or asymmetry
• Muscle strength 5+/0-5

Diagnostic
X-ray - #1 test. It shows consistency of bones, swelling, blood, but doesn’t show
abscesses. CAT scan may be ordered for possible tissue damage or fracture.

Arthrography – we inject dye – the dye will show up on x-ray.

• We check for consistency and contour of bone.

• We have to find out if there is a bee-sting allergy. Depending on reaction, they

may Rx steroids and Benadryl and may give dye anyway

Bone density – measure density of bone, depth and integrity in osteoporosis.

• Typically done in (usu. lower) spine, the narrow neck of the femur bone adjoining
the hip, and the bones of the wrist and forearm.

• Using the norms for size and age, they look for bone loss.

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 • Typically this is done on menopausal women where estrogen is no longer being
produced; men don’t show osteoporosis until they are in their 70s.
• Now some MD’s are doing pre or peri menopausal (period before menopause). It
is a simple, noninvasive test.

Bone Scan – You are given dye by IV, it goes through your body and ends up in the
bladder, and then you pee it out.
• In cancer pts, the dye goes to where the cancer is and that helps identify bone
cancer.
• Dye is injected by IV and secreted through the bladder.
• Anything that glows is inflammation or cancer
• People who are suspected of cancer go for bone scans.
• Cancer of the bone is very likely a secondary site.
• Bone is vascular; cancer cells circulate through the blood and deposit themselves
in the bone.

o One of your roles as a nurse is to be able to explain each and every

diagnostic test, which means that you have to understand it. The second
role is any safety precaution. If my patient is going for an x-ray, what do
you want to ask them (female) Are you pregnant? That is really
important, because if she is pregnant, let’s not do an x-ray, or only if we
have to and if we have to, let’s cover that area that could in fact be holding
a baby.

o For tests requiring/using dye, what should you be worried about?

Allergies. The new ruling on the allergies is that it is no longer an allergy
to iodine/shellfish, it is bees. If one is allergic to bees they know to
medicate you. They will still let you have the test, they will watch you
carefully. They will give you Benadryl and steroids before you go. So that
if you have an allergic reaction, your body can’t react because you are
immuno-suppressed. Never leave a patient that you give dye to. You must
stay at least 15 – 20 minutes and make sure that they don’t have
anaphylactic shock.

o We need to get this radioactive material out of their body as quickly as

possible. If you are potentially pregnant, ask a fellow nurse if they would
you mind taking care of this patient b/c even though the radiation is in the
bladder, they are radiating?

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 o Also, we want to get the dye out of their body as quickly as possible by
offering a juice of choice or soda – whatever they like to drink that is what
we are going to give them.

Endoscopic (Arthroscopic) Surgery – the insertion of a # of needles into a joint

• We anesthetize the pt
• We insert viewing scope, trimming scope, and irrigation scope.
• In case of osteoarthritis, physician is going to go into affected cartilage and shave
off/clean bony spurs
• It will relieve pain.
• The belief was that it would delay knee replacement by 3-5 years; but studies
found that it isn’t so
• It will not delay knee replacement surgery (insurance may not cover it anymore).
• W/ viewing scope, they can video or take pictures
• W/ irrigation scope, they can irrigate (clean) the area. $ pain for a period of time
• No. 1 nursing Dx- impaired skin integrity. Infection is a main concern. We need to
watch for it carefully if pt were to develop an infection in area, it can lead to loss
of joint.

Arthrocentesis – a needle is injected and synovial fluid (should look like extra virgin
olive oil) is aspirated.
• The synovial fluid is then checked for protein, antibodies, WBC.
• Is it infected w/ RA. In this case, it will come out cloudy, milky color
• Impaired skin integrity is a concern.
• TEST RESULTS: Protein means bones breaking down and WBC count means it
is inflamed and/or infected.

Angiography –the use of a dye to check blood circulation.

• This is not commonly done in M/S, more likely seen in renal, heart, and brain.

Other Studies:
EMG – measures electrical current of nerve from one area of the body to another.
• Don’t under estimate the pain it causes.

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 • Seen more in neuro than M/S.
• Priority RN DX here is Pain.
• Many MS patients will have this done b/c it measures electrical conduction.

Urinalysis - look for calcium and protein in the urinalysis.

Myelography – the injection of dye into the spinal cord.

Blood analysis – muscle enzyme CPK – enzyme is released w/ body movement

• Every time we move around, we break down muscle
• We always have some CPK. Different CPK are called isoenzymes, which are used
to dx heart muscle damage and brain muscle damage.

Isoenzymes (part of CPK) – are used to dx heart muscle damage and brain muscle
damage.
• Ca for osteoporosis
• Vit. D – to fight osteomalacia
• Phosphorus
• Alkaline phosphate - # w/ bone growth, in fractures and bone repair
• Alkaline phosphate (enzyme) will be elevated.
• In osteomalacia, vit. D deficiency leads to no Ca the bones are weak and soft and
painful.
• The body will attempt to put Ca in bone, but there is no free Ca, in these cases we
see increased alkaline phosphate
• With a pt with a Fx, pt with bone injury, pt with osteomalacia, we’ll see elevated
alkaline phosphates because the body is attempting to build new bone.

Sedimentation rate – a tube of blood is spinned.

• The amount of time it takes to separate blood cells from plasma
• The more WBCs, particularly large ones (lymphocytes, monocytes) the longer it
takes to spin down à increased sedimentation rate .
• An increase in inflammation in RA, MS, scleroderma leads to increased
sedimentation rate.

Rheumatoid factor – not a useful test.

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 • Identifies autoimmune diseases.
• It can take 10 years to ID.
• Not a reliable test.

Antinuclear Enzymes – (HLA) Done during the pt’s flare up.

• We can actually see that pt has an inflammatory disease.
• Used to detect autoimmune diseases such as lupus, RA, scleroderma, etc.

Uric Acid– metabolic problem (genetic defect) in which people cannot remove uric acid
from their body - they don’t break it down.
• It leaves the body the way it came in, in the form of uric acid
• Sometimes uric acid can build up in joints and the patient gets gout.

Nursing DX Example
Patient Report (sample of what is expected of us in clinical)
• J.S. is a 28 yo m admitted last night after spending the night in the ER. He was in
a 1 car MVA. Sustained multiple M/S traumas to his extremity. Fx of R
humorous with dislocation that has been reduced and casted in a long arm plaster
cast. He has an opened compound Fx of L distal femur which has been reduced
and closed and is in skeletal traction at 20lbs with a suspension traction. His L
ankle sustained a commuted Fx and is in an external fixation device with a frame.
Pt is alert and oriented, remembers driving, seeing a dog in the road, attempted to
avoid hitting it and that is all he remembers. Medicated for pain 7 out of 10 at
6am with Percocet. He may get his next dose at 10am.
• V/S: 99.2, P 96 (little high), R 18, B/P 106/70 (probably a little low).
• IV in antecubital area and is getting 100 cc’s of D5W NS with drip factor of 15.
On antibiotics, Vancomycin/Gentamicin every 24 hrs.
• We do a head to toe assessment now.
• He sustained no injury to his head or scalp, was wearing seatbelt, Pupils equal and
reactive, corneal reflexes intact, no slurred speech or difficulty swallowing.
• Neck – trachea midline, no jugular vein distention, good carotids, no bruits, no
limitation to ROM.
• Chest – no redness, tenderness. Denies SOB, symmetrical expansion, resonance
percussed with good air entry, vesicular breath sounds heard in all lobes, no
adventitious sounds heard.

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• Heart – heart sounds regular, no murmurs or rubs heard.
• Abdomen – no tenderness, redness, or distention noted. Bowel sounds heard in
all 4 quadrants. Soft on palpation. Liver – dullness percussed (normal). No
bladder dullness percussed (normal).
• Genital – pt was able to void on own 1200 cc’s of clear amber urine on the 11-7
• Upper Extremities – L arm has IV, able to move without difficulty, good color,
pulse, warmth and capillary refill. R arm – long arm plaster cast. Continues to
dry. Negative to 5 P’s.
• L leg – multiple contusions to the lower leg, no open wounds, good color, pulse,
warmth, capillary refill distal to external fixation device, some redness and
swelling noted around the pin sites, brace intact (need to measure and document
pin length)
• R leg – has wound with compound Fx of femur. Sutured, some redness and
swelling noted at the site. No drainage. Wire attached to the skeletal traction as
ordered at 20 lbs. Traction setup is intact. Suspension traction and overhead
trapeze set up for pt movement.
• Orders today – bed rest. We can begin diet of clear fluids and may progress to
full liquids. OT and PT will be in to do a FIMS, V/S every 1 – 2 hours. Needs
chest x-ray, blood work, cast care, pin care
• Medication – Colace, vitamins, gentamicin, vancomycin, Lovenox (b/c of bed
rest), Vit D and Os Cal (b/c we are going to be building some bones here),
Percocet (for breakthrough pain q 4 hrs) and OxyContin (every 12 – not PRN)

!17
Musculoskeletal Trauma
Types of Fractures

Compound Fx – when bone comes out of skin

• It is the worst you can get
• The wound is dirty – even after putting it back together, there is still dirt
remaining in the wound (dirt is embedded in wound).
• Priority nsg Dx: impaired skin integrity, then risk for infection

Dislocation – usu. w/ dislocation, we pop them back in.

!18
Displaced Fx – we have to pull bone out and align as close as we can.
• Rule of thumb – cover Fx w/ cleanest cover you have at the time.
• Do not blot blood with tissue.
• Leave limb in position it was found in.
• Displaced Fx that needs surgery is higher risk for pt than manual set bone.
• Fx bone that heals is stronger than other bones in body, possibly larger.

Internal fixation – the use of nails, wires, screws and plates to put bones together.
• They stay in for older pts and are removed in younger pts.
• They can possibly rust or cause problems years later.

Do not cast open wounds – they can become infectious.

We as nurses must make assessments, feel for warmth, drainage.

Assessment
Trauma
• Leading cause of death in people under 40.
• Peak years 15-25 yr old males.
• Musculoskeletal trauma occurs in 85% of pts experiencing trauma.
• 80,000 people suffer permanent disability each year from trauma.

Etiology - Things that can cause M/S Trauma include:

• direct blow or trauma to bone
• crushing forces
• sudden twisting motion of ligament can shave off part of bone (fibia, tibia)
• Who can fx: extreme muscle contraction like patients with tetanus, calcium
imbalances can Fx, people having grand mal seizures in the tonic phase can
fracture.
• pathological conditions such as bone cancer, anything that weakens the bone like
osteoporosis, steroids, tumors, decalcification – bed rest, usu. occurs in hip
• Colles’ Fx – Fx to wrist (distal radius bone), caused by breaking a fall – a sign of
osteoporosis.

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Injuries

Contusion – black and blue mark or a bruise

An area where tissue is ripped w/ some bleeding into it.

Soft tissue damage w/o damage to MS system

Hematoma which rises to skin which will cause ecchymotic area which goes from black
to blue.

Healing sign – see within 7-10 days.

S/S – pain, swelling, ecchymosis, limited ROM.

Tx – RICE: Rest, Ice, Compression, Elevation

• Assess skin first
• Rest is most important – stop movement.
• Ice produces vasoconstriction.
• No need for WBC when bleeding
• Use barrier btw skin and ice
• It takes the body time to figure out what type of injury occurred. It assumes that
the whole army of inflammatory agents must go to affected area, which will cause
capillary permeability.
• Plasma will leak out into injury and cause swelling. The swelling is known as the
third space – an area of fluid that is not used by the body.
• The > edema, the longer it takes to heal. To minimize edema apply ice, or cold.
• It takes 2-3 weeks to be reabsorbed. The greater the swelling, the longer the
limitation and disability.
• Rule of thumb is 20 mins on, 20 mins off, 2 hours on, 2 hours off for a 24 hr
period.
• Importance is to RICE it as quick as possible.
• After 24 – 48 hours, that is when we begin heat, which increase blood supply,
causes vasodilatation, causes relief of muscle spasm.
• Allows army of WBCs to now go in and clean up.
• Early intervention means faster healing.

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 • Reduced swelling improves healing.

Strain – pull of muscle – excessive stretch of muscle and tendon

• Muscle is highly vascular – tearing causes bleeding, hematoma.
• S/S pain, muscle soreness, edema.
• Rx - RICE

Sprain – stretching of ligament causing joint to come out of position.

• Causes loss of stability, depending on severity, it might need casting (esp. in knee
area).
• Might cause shaving of bone
• S/S – pain, rapid swelling, joint tenderness, limited ROM
• That spraining is going to have the army of inflammatory agents come and you
will get significant edema r/t this injury.

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 • Rx – X-ray – to detect avulsion Fx, casting, surgery

!
• Avulsion above at circle

o Usually RICE

o After 48 hours, we heat to vasodilate to absorb all of the edema.

Dislocation – joint is disconnected.

• Subluxation – partial dislocation – in paralysis, we see subluxation in C-5.
Vertebral bone moves out of position and interferes w/ blood flow.

o Both considered medical emergency, not done by nurses.

o Rx – assess pt

▪ RICE

▪ Often external reduction will be done

▪ Reduction is putting back in

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 • External – no opening of body
• Open – a surgical procedure
• Closed – manually putting limbs together

6 P’s – Neurovascular Assessment

• 1. Pain - N
• 2. Pulselessness – V
• 3. Paresthesia – N
• 4. Paralysis – N
• 5. Pallor$ – V
• 6. Polar – V - cool or cold extremity distal to injury

In MS surgery, most important is neurovascular assessment to check for nerve damage. It

is possible in dislocation that a nerve was pulled or damaged.

Carpal Tunnel – when hand is used too much, wrist becomes muscular.
• Muscle compresses hand, so pt feels, numbness, tingling
• Rx - Put pt in splint

Classification of Fx
• Open vs closed – compound vs closed Fx

o Compound breaks through the skin

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!

• Complete vs incomplete – hairline Fx that doesn’t go all the way across

• Greenstick – crack – it hasn’t gone all the way through.

o Typically seen in children

o These Fx are ones in which the bones crack and bend.

o You have more of a bending motion - the bones are not totally broken or
fractured.
• Stable (non-displaced vs unstable (displaced)

o Stable – bones are still next to each other – they are approximated

o Unstable – bone is far away from each other – needs to be manually pulled
out and placed next to the other bone.
• Compression – seen in osteoporosis

o Vertebrae crumble or compress and pt gets shorter and shorter (shrinks)

• Impacted – bone moved inward

o Seen in skull fractures

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 • Spiral Fx – circular Fx – goes around bone in circles

o Considered child abuse

• Comminuted – 2-3 pieces of bone.

o When the Fx occurred, bone shattered into pieces.

Bone healing – nursing care r/t

!
• Bone injury – immediate care

!25
 o Always bleeds

• Up to 5 days

o Inflammatory agents come and bring along fibrins

o Fibrins will cause a clot

o Clot will form a callus

• 6-12 weeks

o Callus becomes stronger

o During final stage, bone begins to immerse Ca into it

o Bone remodeling occurs

o A diet rich in Ca is crucial

o Get pt out of bed and weight bear at this time

Factors influencing bone healing – positive

• Immobilization

• Timely correction of Displacement

• Application of Ice
• Adequate amounts of growth hormone, V-D and calcium
• Adequate blood supply
• Absence of infection
• Moderate activity level prior to injury
• Remember:

o 99.9% of all Fx are going to surgery

o Fx hip is a cause of death in elderly

▪ Depending on blood supply, the MD decides whether to replaced

the hip completely or plate it.

o Compound Fx are hard to keep uninfected b/c of impaired skin integrity

and foreign objects

Factors influencing bone healing – Negative

• Delay in correction of displacement
!26
 • Open fracture
• Presence of foreign body – compound Fx
• Immuno compromised – HIV, RA

• circulation
• Malnutrition
• Osteoporosis – bones wear
• Osteomalacia – absence of Vit D, soft bone disease, called rickets in children.
• Advanced age – $ bone integrity.

Clinical manifestations of Fx
• Deformity - angulation

• Swelling – bleeding, inflammatory agent will come out immediately causing

edema
• Pain – did you hear a crack?
• Numbness – neuro problem
• Crepitus
• Muscle spasm
• Ecchymosis
• Hypovolemic shock

Complications of trauma
• Soft tissue damage – always bleeding. Always look at underlying structures, if it
is ribs, etc.
• Hemorrhage
• Ruptured tendons
• Severed nerve
• Damaged blood vessels
• Body organ injuries

Closed Reduction
• Reduction of a fractured bone by manipulation without incision into the skin

!27
Traction:

1. Bucks – skin traction**

2. Skeletal -**

** - need to know

3. Russell – often used in conjunction with other traction

• It lifts leg up behind the knee àto high incidents of DVT
• Not seen much anymore

Purpose of traction
• Used in trauma
• Correct long bone and hip Fx
• Maintain anatomical alignment
• Bucks traction is used for 1 purpose only: to prevent muscle spasms
• Bucks traction – is used for a short time period, until pt goes to surgery
• $ Fx/deformities

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 • Immobilize Fx
• Stretch adhesions – not successful (cast on amputation, not an important concept)

Classification
Straight – skin traction
• Used for Buck’s
• The leg is held longitudinal – straight up
• Toes to ceiling
• It pulls it in a straight method
• It comes down and 5-8lbs weight is hung from it

Skeletal traction
• Nails, screws and wire are put through the bone
• Connect bone
• We tend to vector:
• We need to put as much as 25lb added weight vector (to put at a different angle)
• It gives the ability to double weight
• Ex) instead of 25lb, we have 12.5lb

Never allow the following to occur:

1. Do not allow pt’s foot to touch foot of bed – there is no more

traction

2. Do not allow weights to touch the floor – there is no more

• The pt must have a balanced suspension traction

• Traction must pull the pt in the opposite direction
• Pt must stay in the center of the bed
• The balanced suspension traction is going to lift the pt up (tiny bit) off bed

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 • With the trapeze, the pt can lift up and move comfortably w/o making any change
to the weight itself
• W/o trapeze, it would be very hard to move the pt in bed
• Rule: traction is NEVER interrupted
• Skeletal traction is used for spinal cord injury

o Never interrupt or you can CAUSE spinal cord injury

NI for traction

• Make sure ropes are not frayed

• Knots are tight
• No knots on pulleys
• Weights are off floor

Review:
• Bucks –straight
• Skeletal – vectored
• Balance suspension – for skeletal – to keep pt up off bed, to allow pt to move w/o
weight pulling him down

Manual traction
• Someone actually pulls on extremities to set the bone in place if it is displaced.
• Pull on extremity to pop the bone in place so it can be aligned

The following traction methods are no longer used:

• Cervical – neck piece worn
• Pelvic – very expensive

Bryants Traction is discussed in peds – NUR 242 NO NEED TO KNOW HERE!

Bucks –

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 • Used on all pts that sustain hip Fx
• All hip Fx (99.9%) are going to surgery that night or day
• Except for pt who can’t accept anesthesia (cancer pt, etc.)

o Pt stays in bed for 6 weeks

o They are a disaster pt for :

▪ hazards of immobility: DVT, UTI, disuse osteoporosis

• 2 types of hip surgery:

o Total joint replacement

o ORIF – Open Reduction Internal Fixation

• Hip Fx will heal according to the blood supply the bone receives
• If Fx occurs in a place w/ good blood supply - we could plate, wire and screw – it
will heal nicely
• If hip Fx occurs in neck or ball, - where there is no blood supply – plating can’t be
done and the joint has to be replaced
• The worst that can happen to a pt w/ ORIF is that it doesn’t heal – the joint must
get replaced – more surgery, more risk
• Hip Fx is the leading cause of death in elderly – 30% mortality rate

o With 2nd surgery the rate goes higher

o We need to get it right the 1st time

• When sustaining hip Fx, most often the hip gets displaced

o It moves away from the pelvis and it shortens

o The massive muscle in the leg shortens and the pt will be in excruciating
pain

o Bucks is used to pull the leg out, (let the bone fill in) to keep muscle
straight and minimize muscle pain (prevents muscle spasm)
• Bucks is used for a short period of time – pre-Op
• This traction can be interrupted so we can observe the leg more carefully

Other types of traction

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 • For pt that has gout in thumbs, we can hang hand off an IV pole

o In addition, we could use colchicine which treats acute gout attack

▪ Gout is a collection of uric acid in the joints

▪ It causes joint to be inflamed

▪ Severe pain – 8-10 on pain scale

• We can pull up to 8lbs on the skin

NI
• Always check distal to injury
• Can pt move toes?
• Do they feel pins and needles
• Are they cold?
• Do they have dorsalis pedis pulse?

o Check posterior to the tibia pulse

o If can’t feel dorsalis pedis, check w/ doppler

o Dorsalis pedis can be found straight down tendon of big toe

• When pt is put on bucks traction, take good baseline assessment of peripheral

vascular of the extremity

Contraindications

Ultimately, bucks traction should not be used on the following pts. But if it is used,
then NI needs to change. Instead of assessing q shift, assess 2-3 times a shift. If pt is
DM, check q2h:
• Dermatitis or other skin irritations
• Impaired circulation -
• Varicose ulcers
• Peripheral neuropathy

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 • Pressure sores

Complications
• Allergic reaction to tape – if pt allergic to latex, then they are allergic to some
adhesive tapes – if you use it, pt could go into anaphylactic shock
• Irritation of skin – be careful not to rip tape off skin

o Elderly skin more fragile

• Perineal nerve palsy – foot drop – study – worst thing to happen to pt if not
corrected in time

o Be careful assess pain, numbness and tingling – THESE SHOULD

NOT OCCUR.
• Circulation impairment
• Pressure sores can be avoided

Skeletal traction – used in long bones

• B/c the muscle is so powerful in legs and arms
• It can pull bone out of position which can cause muscle spasms
• Put much more weight b/c we need to pull in 2 directions
• Balance traction goes one way, balanced traction goes the other way
• B/c there are pins, screws and wire, the pt is running the risk of impaired skin
integrity à to risk of infection

NI – pin care:
• Sterile technique
• Prepare a solution of 50% hydrogen dioxide, 50% NS
• Clean pin w/ swap once and toss – repeat until clean
• Never double dip
• Mix solution in urine cup and date it
• Each pin gets its own sterile applicator to clean
• Initially the wound is sanguineous for 24 hours

!33
 • Sanguineous à serous
• After 2-3 days, pins are grown into wound
• Pins can shift – measure both sides of pins to make sure it hasn’t shifted inwards
• Risk for infection:

o Local inflammation: red, swollen, pain, LOF, warm

o Systemic – fever, inc. WBC

▪ If drainage in wound becomes purulent, assess, check WBC

▪ Osteomyelitis (bone infection) is the worst thing to happen to a pt

Types of skeletal traction

• Crutchfield – the one in the skull
• Long bone

NI for traction

• Assess all traction set up

o Make sure ropes are not frayed

o Knots are tight

o No knots on pulleys

o Weights are off floor

• Proper body alignment

o Pt is in center of bed

o The minute foot touches end of bed traction is no longer effective

o Make sure weight is not touching floor – traction no longer effective

• Neurovascular assessment

o Always check distal to injury

o Pulse

o Capillary refill

o Ask pt about numbness, tingling, pins and needles

!34
 • Monitor for complications
• Assist w/ ADLs – the minute a pt is put to bed, the hazards of immobility begin:

o Contractures

o Make sure all other limbs are worked out

• Diversional therapy – keep in mind many people in traction are young

o Try to meet needs of socialization

Knowledge deficit r/t traction

• Make sure pt is out of anesthesia and fully awake before education session begins
• Make sure pt is ready to look
• Turn q2h
• Instruct on proper body alignment
• ROM – QID – make sure to exercise everything that was not involved in injury

Pain
• Do not allow pt to be in pain
• Anything >8 is a medical emergency – you MUST act

o 1-3 – Tylenol

o 4-6 – 1 Percocet

o 7-10 – 2 Percocet with OxyContin

External fixation device

• Puts extremity in correct position and puts limb in frame
• Weight isn’t used
• Popular b/c pt allowed out of bed – can be mobile
• Hazards of immobility is diminished
• In spinal cord injury:

o Immediate surgery

o Large # of steroids to prevent swelling

!35
 o Will fuse/glue spinal cord so there is no movement at all

Halo

!
• Dr. drills 4 holes in the skull and attach the halo – pt placed in a frame
• It never comes off for 6 weeks
• No hands underneath the vest w/o gloves on

o Many pts will get stage 2-3 pressure ulcers on back

• Pts are uncomfortable

• Nurse needs to know where the key to the vest is

o The vest is unlocked for emergencies, heart stops and CPR needs to be
done
• We don’t tighten, loosen or lubricate – Dr. can do that

Compound Fx – is put in external device:

• When bone tore into skin and debris entered wound

o If this limb is put into a cast it will become infected

• We need to monitor compound Fx

Comminuted Fx – is put into external device

• Best way to keep bone pieces together

Leg lengthening

!36
• Pts w/ body image disturbance have the right to have a piece of their bone cut and
set apart 1”

o New bone grows in about 12 weeks to make up that 1”

o This pt will go through 12 surgeries to lengthen all limbs in their body

• Infection is the worst complication that a joint replacement pt can have

• Every time there is an artificial device placed in the body, there is a risk that the
device will become dirty, rusty or corroded

o If that happens, the device (EFD) is removed and the infection must be
resolved in next 6 weeks to 6 months and then the device is replaced

o Today there are boxes impregnated with antibiotic solution which delivers
antibiotics to the joints

▪ It doesn’t allow any flexion, but does allow weight so a pt can

weight bear
• Dr. orders antibiotic ointment – we no longer put ointment on all the time

o Antibiotics work well for 4 hours and after that it becomes a breeding
ground for bacteria to grow

o If we do put ointment on, we must cover w/ dressing so environmental

dust/dust mites can’t get into the ointment and create an infection
• Pts can impale themselves on the pins

o When turning, pins can become a hazard

o Cover them w/ rubber or cord for a smoother environment

• Never touch frame

• Monitor pin sites and measure pins, particularly in lower limbs

o Pt can bang against frame and shift EFD further into bone

o The dirty rod can infect bone, causing osteomyelitis

• Risk for infection:

o Shift to the left – an acute infection

o Shift the right – a chronic infection (such as RA)

▪ Monitor RA pt (chronic) for a for a shift to the left

!37
 • à When neutrophils inc. 70% and up, the body recognizes
an invasion and will dump immature WBC (bands, stabs)
into the bloodstream
• Blood test will show inc. in bands or stabs
• The presence means the body has begun an assault – acute
infection

Fx immobilization
• Lower casts
• Splints
•

• Casts – various types:

!38
!

Casts – 2 kinds – fiberglass and plaster:

!39
Fiberglass
• Expensive
• Potential problems with children who get casts within 24 hrs of Fx :

o Casts can be removed in 3 weeks time – when the swelling goes down

o Kids can remove the casts even though they should remain on

o These problems don’t occur with plaster ones

• Purpose:

o Fx

o Subluxation – incomplete Fx

o Correct deformities

o Support weakened ligaments, sprain tears

▪ Some ankle sprains will end up in a cast

o Amputation – in a residual limb, a little round cast is applied to reduce

residual edema (swelling)

▪ It stays there for about 4 weeks

▪ The risk is that it might infect the suture line

Plaster of Paris casts

• Advantages:

o Cheap

o Strong

o Can’t be removed by kids

• Disadvantages:

o When it dries, there is a chemical reaction that can cause heat à

vasodilatation and then edema
• It takes 24 hrs to dry

o When wet, it is a cloudy gray

o When it’s dry, it’s a shiny white

!40
 • Can’t lift w/ finger tips until totally dry b/c cast can become indented

o Cast has to be palmed until dry

• We have to turn pt from side to side to make sure all areas of cast get dry
• NEVER get cast wet – very difficult to clean
• Today there are shower boots to cover casts – they are like a B/P cuff

Fiberglass
• Advantages:

o Dries quickly – within 20 minutes it’s solid

o Can get wet – in Summer, Dr. will bubble wrap the inside so pt can go
swimming

o Very light

o Variety of colors

• Disadvantages:

o Very expensive

o Easier to remove once the swelling subsides

▪ In children, we’ll often wait to put fiberglass cast on

NI
• Assess the skin prior to application
• Any incision, any suture, any laceration can become infected

o Diagram it out so you can look for it

• Assess cast for hot areas, drainage

o When you see drainage on cast, circle it and time it

o Continue to assess to see if it gets worse

• Protect skin w/ tubular stockinet and pad bony structures and nerve endings
• Paddle the cast (smooth rough edges) so the pt is protected from rough edges

o You also apply adhesive tape over the rough edges

!41
Complications
• Cast compartment syndrome – when injury continues to develop under cast

o The cast is squeezing on the muscle underneath and can cause damage

o Perform neurovascular assessment, the 6 Ps on distal areas of cast

o Check for capillary refill, pulse, heat

o Tissue necrosis or infection can occur

o Hemorrhage – nerve damage can occur

• When we apply cast to whole body (spica cast), the abdomen underneath the cast
can become distended

o The cast can cause vascular compromise and pt can go into shock

o Today we cut a belly button in so we can check out the area

o We also pad so there is a space in case the abdomen becomes distended

• Damage to the peroneal nerve causes foot drop. The nerve needs to be padded

Cast removal
• Some Drs. Remove cast every month and put a new fresh one on
• Emergency removal - The cast saw only cuts cast, not skin (once it touches skin, it
stops)
• To remove, you must cut both sides and then lift it off to avoid pinching or tearing
skin
• Must teach pts to do isometric exercises (tighten muscles) to help muscle stay
intact
• Active/passive ROM exercises
• For itching, allow pt to blow w/ hair dryer on cool setting
• Do not scratch skin with hanger – skin can get infected
• Teach children not to stuff items, pencils, coins, etc, into cast
• No powder – can cause skin breakdown
• Notify Dr. if: These may be signs of neurovascular nerve damage

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 o Pain

o Numbness

o Poor color

o Unable to move toes

o Stain, odor, or heat

Pain
• Give pt meds before he leaves to go home
• Monitor pt for pain r/t expansion
• When applying ice, put barrier btw plaster cast and ice

Complications
• Hypovolemic shock

o Caused by bleeding – every Fx bleeds (observe for s/s)

o Initial RICEing will slow down bleeding

▪ Pelvic bone – 4L

▪ Humerus – 1L

▪ Femur – 1.5L

o Monitor pt for hypervolemic shock à s/s

▪ $ BP and tachycardia

▪ Inc. RR

▪ Cold clammy skin

▪ Restlessness

▪ $ LOC
• Management:

o WE NEVER LEAVE THEM – stay and assess them

o Keep pt covered w/ blanket

!43
 o Splint Fx – keep the pt the way you found him b/c more injury can occur
to tissue and nerves

o Monitor VS

o Oxygen

o Monitor HbG/Hct (HbG is always a third of Hct)

▪ HbG – 11

▪ Hct-33

o Replace fluids – usu IV DSW and lactate which can convert to bicarb

o Put IV in before pt crashes

Fat emboli
• Fat embolism comes directly from Fx of long bone
• Specific to orthopedic injuries:

o In long bone Fx, yellow marrow hangs outside of bone

o As the army of inflammatory agents come, they are going to cause

permeability of capillaries

o As the army comes out of blood stream, they fat emboli go in

o The tiny fat molecules are moving upstream

o They appear as a snow storm - the snowstorm effect - in lungs on x-ray

o They are so small; they can get into brain – causing confusion

o They appear on chest and neck as petechiae

• One way to differentiate btw pulmonary embolism (PE) and fat embolism (FE) is
petechiae
• Petechiae are fat emboli that are setting themselves at the lowest end of capillaries
• Pt will feel sense of impending doom
• Wheezing from accessory muscles
• 80% mortality rate

Management

!44
 • Monitor pt carefully
• Normal respiratory rate (RR) is 12-18

o If pt’s RR goes up to 20-22, administer pulse oximeter

• Monitor for change in pattern

o Transfer pt to critical care unit where they can be intubated on 100%

oxygen à inc. survival rate
• Administer heparin/aspirin/Lovenox to prevent platelets from attacking fat emboli
– so the fat emboli can remain small
• If you monitor the respiratory system for 72 hours post Fx, it can make a
difference btw life and death (to detect fat emboli)

Compartment syndrome
• Directly r/t orthopedic injury
• Muscles in legs are covered by fascia – a fibrous, strong envelope

o There is some lubricant liquid so muscle lies smooth against fascia which
will be on top of the bone

o In trauma to muscle, the muscle may swell too much in envelope and can
cause damage
• Typically, pressure inside fascia is 8mm/Hg
• Once it reaches 20mm/Hg cells begin to die
• ALL CELLS BEGIN TO DIE AT 20mm/Hg
• During musculoskeletal trauma
• S/s UNRELENTING PAIN
• Pain is not relieved by narcotics
• Prevention: RICE
• The minute you suspect compartment syndrome RICEing isn’t permitted
• Since it lowers blood supply, it can cause further damage

o At this point we need to inc. blood circulation to muscle

o Don’t elevate for same reason as above

!45
 • If pressure is > 8mm/Hg, you know something is going on
• If its 20mm/Hg à trouble
• Prepare sterile kit w/ scalpel
• The Dr. will perform a fasciotomy – a cut into the fascia to relieve pressure
• Dress at all times
• Keep it moist w/ sterile saline
• It’ll heal through secondary healing – inside out
• Distal to injury:

o Will see inc. neuromuscular dysfunction

o Poor capillary refill

o Lower pulse

o Numbness and tingling (6Ps)

o Cut and paste Q&A

• Question: Tell whether the following statement is true or false.

o A hallmark sign of acute compartment syndrome is pain that occurs or

intensifies with passive ROM
• Answer: True.
• Rationale: A hallmark sign of compartment syndrome is pain that occurs or
intensifies with passive ROM. This pain can be caused by (1) a reduction in the
size of the muscle compartment because the enclosing muscle fascia is too tight
or a cast or dressing is constrictive or (2) an increase in compartment contents
because of edema or hemorrhage.

Deep vein thrombosis

• 70% of all joint replacement pts have the potential to get DVT
• Can prevent by giving heparin or Lovenox prophylactically
• Always add to neuromuscular assessment the HOMAN’S SIGN – dorsi flexion
• Feel calf as they are performing Homan’s sign

!46
 • Pt will let you know if they feel deep calf pain
• Teach pt to differentiate btw calf pain and sight of injury (knee replacement)
• Actual symptoms are the s/s of inflammation in addition to Homan’s sign
• Loss of circulation below DVT
• Put pt on bed rest
• Some pts will receive thrombolytic agents
• Can’t use clot busters on a pt who has undergone knee replacement surgery

o The entire surgical site would declot

o The pt would hemorrhage

• Before administering clot buster agents, make sure pt doesn’t have a Hx of

bleeding w/in the last month
• We’ll put vena cava filter in some pts (it resembles and upside down umbrella)

o Goes up femoral vein

o Pop the umbrella and the legs cut into the vessels and clots will eventually
dissolve themselves – see picture below

!
• When clots leave calf, as it goes up to the heart there is a platelet party
• There are 250,000 platelets in the blood
• They attach to the clot and pile themselves one on top of another and the clot
enlarges
• Heparin and Lovenox stun platelets so they don’t stick to each other
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 • The clot remains small and can’t cause damage as it travels to lung and heart
• Clot only occurs post trauma
• Pulmonary embolus à DVT clot gets loose à platelets have a party – clot is
significant enough to occlude a vessel
• If pts don’t get heparin/Lovenox/ASA – pt O2 is cut off from lung occlusion

o Pt will show same s/s as fat emboli except for no petechiae

• Pt will sense doom

• The > the clot, the < mortality rate

Infection Assessment
• Malaise/fever
• Pain/tenderness of bone
• Redness/swelling
• Difficulty weight bearing
• Wound drainage

Infection Management
• Immobilization
• C/S Wound
• Antibiotics: penicillin, methicillin, vancomycin
• Pain Medication
• Heat application

Joint Stiffness/Contracture
• Malunion
• Ruptured Tendons
• Severed nerves
• Avascular Necrosis

Case Study

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A 59 year old right knee replacement with severe pain.

Received OxyContin at 8p and 2 Percocets at 10p. Now at

11:30 p patient remains in severe pain.

What assessments would your make?

Assessments Findings
• Edema
• Heat
• Erythema
• Swelling of right leg
• Suture site clean.
• T-99.2; P-98; R-22 and BP 130/82.
• Any other assessments you would like to include?

Other Assessments
• Neurovascular assessment
• Homen’s

Your patient suffered a fractured femur.

Which of the following would you tell

Your nursing assistant to report

Immediately?

1. Complaints of pain

2. Patient is confused

3. Blood Pressure is 136/88

4. Patient voided using fracture bedpan

You are caring for a pt with a Fx-

ulnar, which assessment should you

report immediately ?

!49
1. Complaints of pain and pressure

2. Cast is dry and intact

3. Skin is pink and warm to touch

4. Patient can move all fingers and thumb

Amputation

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Amputation
• Ischemic ulcers are critical and can become gangrenous in:

o Diabetics

o Chronic renal failure

o Peripheral vascular disease (PVD)

• Removal of an extremity
• Can be:

o Traumatic injury – accident

o Therapeutic – typically some gangrene present

• Gangrene is death of tissue

o It happens in an anaerobic environment

• If gangrenous limb isn’t removed, pt can be dead w/in 2 weeks

o It poisons the body

• Disarticulation – removal through a joint – amputation is removal in a joint

o Rarely seen anymore

• Traumatic amputation – sometimes you can reattach if bones and muscles can be
realigned

o The peripheral nerves will grow back (they are the only group of nerves
that can regrow)

o They will get some movement and feeling back into the extremity

• Who gets amputated?

o Pt w/ severe PVD who develops ulcer and gangrenous toes

o Traumatic injury

o Malignant tumor

o Gangrenous infection

o Congenital deformities

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 ▪ For a period of time pregnant mothers took med for nausea
(Thalidomide) which caused poor limb development

▪ For body image reasons, they may choose to amputate limbs

o Chronic pain

• Most amputations occur either above the knee or below the knee
• Drs. keep as much healthy tissue as possible

o The more joint that remains, the easier it is for the pt to remain mobile

▪ Above the knee amputations are tougher on the pt than below the
knee

Types of amputation

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 • Closed vs open
• Closed:

o Planned amputation

o Goes into healthy tissue

o Leaves a large enough flap of tissue to flip up and saw around

o Removal of bone w/ the suturing of skin w/ a muscle flap

• Open – guillotine:

o Clear, clean break w/o flap of tissue

o Soft tissue and bone are severed at the same level

o For pt w/ osteomyelitis, they’ll often perform guillotine amputation

▪ Cut right into limb, remove affected tissue and attempt to keep the
area from getting infected

▪ Once Drs. are sure the infection has not spread, they will take skin
from another area on the body (usu. Hip or buttocks) and put on
amputation site to close off.
• Similar to fasciotomy, we will have a wet sterile NS dressing
• High risk of infection r/t impaired skin integrity

Clinical manifestations
• The following are seen prior to amputation:
• Pallor
• Infection
• Loss of sensation
• Inadequate circulation
• For amputation to heal, we must go into healthy tissue
• Go as far needed into healthy tissue for the body to heal
• In order to determine how far to cut, we perform:

o Arteriography – look at vessels and the circulation to area

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 o Thermography – through heat, it gives picture where blood supply is

o Plethysmography - a test used to measure changes in blood flow or air

volume in different parts of the body. It may be done to check for blood
clots in the arms and legs, or to measure how much air you can hold in
your lungs.
• We measure B/P to both limbs w/ a Doppler
• JACHO – nurse and pt must write on the limb that is intended for amputation,
“this leg is to be removed, “ to avoid amputation to wrong limb
• Educate pt
• Inform them about phantom limb sensation
• Phantom pain is what the pt continues to feel once the extremity is removed
• Pt who has had chronic pain to extremity and the limb is amputated, the nerve
causing the pain is still imprinted into the brain
• The pain is a memory pattern
• Tx phantom pain pts w/ narcotics even though the limb isn’t there anymore – the
pain is what the pt says it is
• We will toughen the stump in order for it to fit a prosthesis
• This will cause nerve sensation to diminish
• TREAT THE PAIN AS THOUGH IT IS REAL
• Assess emotional reaction
• Assess baseline to both extremities

• Question:

o Who is more likely to have difficulties w/ amputation, a child or an elderly

pt?
• Answer:

o An elderly pt – an elderly pt is likelier to grieve the loss of their limb

Prevent complications

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 • The biggest complication is BLEEDING for the first 24 hours
• We have 100,000 capillaries
• We will try to seal w/ heat all major arteries and veins, but it is impossible to zap
every single capillary
• Monitor pt carefully for bleeding
• Control residual limb edema

o Remove q shift the stump wrap

o Observe suture line

o Put stump wrap back on

• For the first 24 hours only, we will permit stump to be elevated on pillow
• After that, use of pillow is contraindicated in a pt w/ a residual limb to prevent
flexion deformities
• For the first 24 hours look for bleeding/hemorrhage under the limb

o You might not see it on dressing

o It might be bleeding under stump

• $ phantom pain
• This is done for prosthetic fitting

Complications
• Hemorrhage
• Infection
• Delayed healing
• Flexion deformity

o B/c we removed 10 pounds of limb, center of gravity has shifted

o Pt is not even

o There is nothing holding the muscle

o To prevent flexion deformity, 3-4 times a day, for 10-15 minutes, pt will
lay prone

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 o If pt cannot lay prone, we will put sandbags on legs to cause it to go
straight so it shouldn’t pop up

Dressing
• Today we use shrinker sock, similar to TEDS, they are very tight
• Compression dressing is removed only for bathing and when not wearing
prosthesis
• Teach pt to look daily at residual limb w/ mirror
• Putting stump into prosthesis often causes skin breakdown
• Pt usu. Puts on a sock which usu. fits into residual limb

o The sock needs to be removed daily and cleaned to prevent skin

breakdown

o Prosthesis should be put on 1st thing in the morning

Stump care
• Q shift remove shrinker sock and look at wound
• First 10 days there will be sutures and staples

o Look and describe how well it is healing

• Wash daily
• Avoid lotions – skin needs to be tough to fit a prosthesis
• Never put on powder
• Toughen residual limb by pushing it into a pillow
• As soon as it has gotten used to a pillow, push stump into a mattress
• The tougher it is, the better it is going to do when fitted into prosthesis
• Nice, soft delicate skin will break easily
• We do permit pillow under stump when sitting, but no longer than an hour
• Change stump sock often and wash them
• To avoid swelling to stump, put prosthesis on the minute pt wakes up first thing in
the morning

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Care of prosthetic limb
• Teach pt care of prosthetic limb
• Keep clean
• Lubricate articulated feet at regular intervals?
• Avoid the use of talcum powder, it can get into joint of prosthesis

Decrease phantom pain

• Warn pt about phantom pain
• If pt isn’t told, they might think something is wrong w/ them
• Treat pain w/ narcotics
• Provide music, imagery, biofeedback and hypnosis
• The toughening of stump will diminish nerve response
• Change position
• Splint and support area
• Elevate for the first 24 hours only

Body image disturbance

• Most pts grieve the loss of an extremity
• Some pts are upset about body image
• Encourage pts to talk about it
• Some pts don’t want to look at residual limb
• Encourage pts to look at, feel and care for residual stump
• Never say I know how you feel, b/c you don’t
• Have another amputee visit pt

Risk for injury

• Pt needs PT to help them reset center of balance
• Center of balance is in core of abdomen
• The minute a part of the body is removed, the core changes

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 • Give pt supportive devices and exercises to strengthen healthy leg and balance
both sides to $ risk for injury
• Help pt w/ dysfunctional grieving

Dysfunctional grieving r/t loss of body part

• Allow pt to discuss feeling of loss of limb
• Seek assistance from other amputees
• Encourage communication

Question

Tell whether the following statement is true or false. Following an amputation, the
residual limb should not be placed on a pillow.

Answer

True.

Rationale: The residual limb should not be placed on a pillow because a flexion
contracture of the hip may result.

Supportive devices – chapter 11

• Canes
• Walkers
• Crutches

Rules
• Elbow should be at 20-30 degree flexion for all supportive devices
• Cane should be held on the strong side

o Must be at 20-30 degree flexion

o Must have rubber stoppers at the bottom

o There are tripod canes and quadpod canes

o The more unbalanced, the more legs the cane will have

Crutch walking

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 • Elbow at 20-30 degree flexion
• 2” (2 finger breadths) btw top of crutch and axilla
• axilla nerve is very close to skin, very fragile and sensitive area
• When leaning on crutch, pt can create paralysis to the axilla nerve
• teach pt not to lean on crutch
• teach pt proper walking mechanics

Gaits

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!

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!
• Most common gait is a 3-point gait

o 3-points on the ground at all times

o The 4th point is the injured limb that can’t weight bear

o Move crutches 1st followed by good leg

o Crutches should be held slightly in front of pt about 8-10 inches away

from feet to prevent leaning on crutches
• 4-point gait

o 4-points on the ground at all times

o Used when pt is weak, lack of balance and needs to move slowly

o Each point will move at a time, left leg, right crutch, R leg, L crutch

o One at a time, alternating crutch, leg, crutch, leg

• 2-point gait

o Most like walking, crutch, leg, crutch, leg

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 o For pts who need slight balance

Swing through – it is illegal, not encouraged

o Used only when crossing street

o When swinging through, pt puts extreme pressure on axilla

Going up and down stairs

• “good go to heaven, “ – going up, the good leg goes 1st,
• “the bad go to hell,” – going down, the bad leg goes 1st

Osteoarthritis
• The most common joint disease
• Degenerative joint disease - DJD
• Crack in joint, bone grows through and scratches opposite bone until there is no
cartilage and bone leans on bone
• S/S HARD AND COLD JOINT
• Affects btw 20-40million Americans
• Begins in the 3rd decade, peaks btw 5th and 6th decade
• We see them at 50-60
• By 75, nearly 85% show DJD
• Used to be considered normal aging, it isn’t really
• It is a negative impact of aging
• Women going through menopause are more likely to develop DLD b/c of a lack
of estrogen

Etiology
• Idiopathic – cause is unknown, might be

o Genetic

o Congenital

• The older you are, the worse it gets

• The heavier you are, the more pressure you put on joint

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 • Neurological disorders

History and clinical manifestation

• Pain is severe upon movement
• It begins to affect tendons and ligaments
• Pt begins to have difficulty w/ mobility
• Asymmetrical pain
• Joint stiffness upon waking (similar to RA)
• Everything is stiff
• Hot shower will reduce stiffness
• $ ROM

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!

Photograph of a left hand showing Heberden's and Bouchard's nodes at the usual
dorsomedial and dorsolateral. Bouchard’affects the middle (proximal) joints and
Heberden's affects the distal phalanges.
• w/ osteo to hand we will see Heberden and Bouchard’s nodes, it’s idiopathic
o on fingers we get nodules known as finger arthritis

o seen in people who use their hands for livelihood, such as coastal workers

• Joint enlargement/flexion contractures

• When pt moves, we hear crepitation

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Diagnostic
• Bone scan
• CT/MRI will clearly ID joint breakdown
• X-ray – the gold std to detect DJD

Medical management
• Prevention

o Weight loss – the less you weigh, the less pressure on joints

o Exercise – to strengthen muscle

• Medical management

o NSAIDs – best drug is ASA (wonder drug)

o If pts can’t take ASA b/c of GI upset, pt will take ibuprofen

o Steroids – injected inside joint

▪ Rule is you get it once, the pain comes back – and worse - in 6
mos., and on and on

o Topical analgesic – aspercreme rub

o Hyaluronic acid- new med – is supposed to stimulate growth of cartilage

(it helps for 6 mos. Then pt is back to where he was)

Nursing intervention: education

• Pt might use supportive devices, cane, splint, esp. for their knees
• Pt should complete their tasks early
• Osteoarthritis DJD pain is > at the end of day b/c pt is using the joint
• Modify environment
• Avoid repetitive movement
• Hot shower might relieve pain
• Pts do well w/ heat – they are not inflamed – they are in pain

Alternative
• Glucosamine – believed to inc. synthesis of new cartilage – very expensive

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 • Massage and yoga are very helpful
• Tai chi in elderly found to be very helpful for joint stability

Surgical intervention
• Arthroscopy – the gold std

o You stick a needle and clean it up, take a picture of it

o Shave off bone spurs

o Not long term – pain comes back

• Osteotomy – to alter the distribution of weight within the joint

o Putting joint together

o Shaving it, cleaning it, redirecting it

• Vicosupplementation and tidal irrigation both wash out joints, one is more
lubricant, the other is more saline

o Hasn’t been helpful

• Arthroplasty – done after arthroscopy

o Arthroplasty known as joint replacement – new hip or knee

Rheumatoid arthritis
• Shows itself early as joint deterioration
• It is not a joint disease, it is an autoimmune disease
• Pt’s own body is destroying itself – in this case. It is the connective tissue
• In addition to joints, it’s going to attack all the connective tissue pouches that
organs are found in

o In lungs we get pleurisy

o In heart à pericarditis

o It’s going to breakdown vessels, veins, particularly in legs and arms

• It flares up or exacerbates
• Goal of Tx is to keep pt in remission
• Damage is done during exacerbation not remission

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 • The disease affects the whole body

o See the image below

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 • Pts have more than joint deterioration,

o Sjögren’s syndrome, drying of saliva and tear ducts

o Myocarditis

o Tendonitis

o Peripheral edema

o Raynaud’s – hands turn white and red

o Carpal tunnel syndrome –

o Lymphedema -

o Chronic state of inflammation

o Anorexia

o Terrible sleep patterns

o Low-grade fever

Incidents
• 1% of population
• 3X more likely in women
• Shows itself after birth of 1st child, not during pregnancy, but during labor
• Characterized by exacerbation and remission
• White, thin, female, blonde, blue-eyed and short

Etiology
• It runs in families
• Gene is turned on somehow:

o Can be viral infection

o Sometime during 18-19th year

• It is connected to Epstein-barr virus – scientists are looking to see if E-B turns on

RA gene

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 • RA attacks the body itself, we have flare-ups

Stages

Stage 1
• During 1st attack – s/s resemble flu
• The joints hurt for a day or two
• The body goes into remission for 1-3 yrs
• no destructive changes
• the body begins to break down joints

Stage 2
• Joints are hot, red and painful – they are inflamed
• Sed rate elevation b/c WBC fight off inflammation
• Joint pain is typically bilateral
• at this point slight bone and cartilage destruction

Stage 3
• cartilage and bone destruction
• bony ankylosis (bone on bone)

Typically it takes 10 yrs to dx from the time it starts to the time we absolutely know pt
has RA

Patient Hx
• Morning stiffness
• Swelling in 3 or more joints – persisting for 6 weeks
• Bilateral presentation
• Joints are hot, red swollen and painful
• Swan neck deformity – there is no longer synovial fluid in joints

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 o It is bone on bone

o AKA Ulnar deviation

o See picture below

!
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 • Fever
• Raynaud’s – hands turn white and red
• Sjögren’s disease – $ in saliva and teardrops
• Felty syndrome:

o Inflammation of the eye

o Splenomegaly

o Lymphadenopathy

• Pleural disease/fibrosis/pneumonitis
• The whole body is affected
• In exacerbation, the whole body aches – it feels like a long-term flu
• Typically we see pts during exacerbations and bilateral joint replacement
• We will give pts a tune-up of steroids – in RA every joint is involved

Diagnostic
• Rheumatoid factor – not very reliable, takes too long to show up
• CBC
• Elevated ESR à inflammation
• Elevated C-active protein
• Positive antinuclear antibody (AMA)
• Arthrocentesis – will show up as cloudy fluid full of WBC, and protein from
breaking down of bones
• CT/X-ray

Early Tx
• Best Tx for pt is swimming
• ROM
• OT/PT

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 • During RA exacerbation, pt is hot and swollen
• DO NOT TX WITH HEAT – WE TREAT PT WITH COLD – ICE THEM
• During remission, we Tx pt w/ paraffin = hot, warm, wax, b/c it radiates inwards,
it makes the joint feel more comfortable

Drug Therapy
• NSAID
• During exacerbation, we Tx pts for 3 days w/ Solu Medrol IV steroids
• For the following 6 weeks we Tx pt w/ $ amounts of prednisone orally
• After that pts are off meds
• New meds which are making a dramatic change are:

o Enbrel, Remicade – it prevents the damage done by inflammation

▪ It keeps pts in remission longer

• Gold compounds – it doesn’t work

o Injected into body

Moderate erosive RA
• OT/PT
• Immunosuppressive therapy – doesn’t work

Persistent erosive RA
• Surgery - MD might go in and clean out the bone/joint
• Corticosteroids - these meds have a lot of side effects

o We do not want to keep pts on these drugs for a long time

o Try and get pt off med as quickly as possible

o Pt has to be WEANED off med, not abruptly

o If not, pt can go into adrenal failure

o Corticosteroids can cause the following:

▪ Cushing’s disease

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 ▪ avascular necrosis

▪ osteoporosis

▪ immunocompromised body can’t fight super infections

Total hip replacement – very invasive procedure

Arthroplasty - surgical removal and replacement of a damaged joint w/ an artificial joint

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 • Pt w/ osteoporosis don’t do well w/ procedure since procedure itself might fx
bone
• Significant amt of bone is cut
• Tremendous amt of blood is lost during surgical procedure since bone is highly
vascular
• Pt will often require blood transfusion post op
• Advise pt to pack 2-3 units of their own packed cells prior to surgery
• We hope that most of blood is suctioned in OR, but some of it is lost in tissue
• Pt comes out of surgery highly ecchymotic at surgical sight
• w/ hip replacement we don’t see much ecchymosis since the muscle hides it, but
w/ knee replacement we see behind knees
• leg is swollen twice as much as other leg
• 24 hours post op – we will drain up to 500cc blood it is the blood that was lost in
surgical incision
• after that, we see only 25-30cc bleeding

Hemiarthroplasty –
• Hip fx – the MD looks at this AFTER buck’s traction
• if it’s a poor healing situation, MD will perform hemi, ½ joint replacement
• It is the replacement of one of the articular surfaces
• Replacement hip can weigh up to 5 lb

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 • !

Surgical methods

Cemented
• We use crazy glue (methyl methacrylate) bone cement – sterile
• Good for 10-15 years
• After 10-15 yrs, it begins to crack and disintegrate
• Pt is mobile very fast

Ingrown prosthesis
• Coated prostheses of porous surface which allows the bone to grow into artificial
joint pieces
• The porous surface of prosthesis creates a dimpling effect
• The bone grows into dimples to hold joints in place
• Estimated to last 40 years
• Pt is immobile for 6 weeks
• Healing time is 6-12 weeks (as long as a fx)

Internal fixation – A-cemented joint; B-ingrown

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!
General notes to remember:
• An elderly pt will generally be cemented since an elderly pt can’t be bed bound
for more than 24-48 hours – skin breakdown concerns
• Younger pts will get ingrown
• The worst thing that can happen to pt is dislocation of hip ball

o It happens b/c pt has suture line from mid thigh to hip w/ multiple staples

o Pt has a cut in one of the major muscles to keep hip in place – now the
muscle is weak and inflamed which makes it easier for the hip to pop out
of artificial joint
• S/s of dislocated hip

o One leg is shorter that the other b/c of muscle shortening

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 o Pain not relieved by narcotics

o Pt can’t walk/move leg

Indications

Severe arthritis: –
• Osteoarthritis
• RA – usu. 4 replacements at a time

o The question to ask is how many joints have you had done

o RA pts need all joints replaced

Femoral neck fx

Avascular necrosis – bone death b/c blood loss

• Can be caused by steroids – bone dies

Non-union
• Non-healing fx w/ poor bld supply, neck and ball have poor bld supply

Congenital hip
• Pt w/ down’s syndrome
• In addition to genetic defect, physically and mentally they also have hip dysplasia
(genetic, causes various forms of arthritis) and heart problems
• We tend to do bilateral hip replacements

Post op complications:
• Dislocation of hip prosthesis

o Metal pops out of metal cup

o In 1st dislocation, we will reattach hip prosthesis

o In 2nd, pt will get a totally new replacement, since the previous prosthesis
has most likely stretched

NI – educate pt
• Make sure prosthesis does not pop out
• Remember dos and don’ts in library packet

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!78
!

!79
 • Make sure pt understands and is educated in procedure
• Make sure pt knows which sexual positions are not permitted w/ hip replacement

Complications
• Limb length is different
• Injury to nerve

o Particularly in the sciatica area

o Pt might experience parathesia/numbness – this happens when nerves

sometimes don’t match up

o Generally, peripheral nerves will grow back if put in close proximity

• Excessive wound drainage – pt could be at risk for hemorrhage

• Infection of surgical incision or a new joint – anytime there is an artificial piece in
the body, bacteria like to attack

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 • When hip is infected, joint is removed

o Space is left empty for 12 weeks – pt has no joint for 12 weeks

▪ A box – spacer – the same size as joint, is installed

▪ It is impregnated w/ antibiotic solution and placed in the joint area

for 12 weeks
• Osteomyelitis is the #1 concern

Signs of dislocation
• Rule of thumb – any slight complaint of a groin pain is an indication of the
beginning of dislocation.

o The pt is put to bed immediately

• Prior to being mobile, we must take x-ray to make sure hip is in anatomical
alignment
• Inability to move
• Malalignment
• Abnormal rotation
• Inc. discomfort – expect screaming pain – it is that severe

Prevent dislocation
• Pt must be at abduction all the time
• Pt must have triangular pillow w/ Velcro or 1-2 pillows between legs
• Even in wheel chair, we need a pillow between the legs
• We must have hip apart, not together
• Legs should not hit each other
• No internal/external rotation of hip
• Toes to ceiling

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 • Pt may not bend/reach
• Pt should not put on socks
• Pt cannot reach for things, not even blanket
• Never flex more than 90 degrees
• HOB not more than 60 degrees – can cause hip flexion
• No crossing legs
• No bending at waist
• All chairs must be high chairs w/ arms
• Pt must not get into chair w/o arms
• Pt can’t sit in couch when flexion of hip is such that it can cause flexion and
dislocation
• Toilet seat must be raised
• Must not get into car at curb

o Feet must be at same height as vehicle

• This takes about 12 weeks

o This allows for the muscle that was sutured to be completely healed again
and develop scar tissue to hold the joint in place

Pain r/t surgical interventions

• Pt will get 10 mg OxyContin plus 2 Percocet

o It allows pt to do PT/OT

• Must give med prior to therapy so they can participate in pt/ot

• It is written nursing order that we can ice them:
• Knee replacement pt tends to want ice every X days

o Maintain barrier btw ice and skin

• Encourage deep breathing – aids in relaxation

Impaired physical mobility r/t pain and swelling

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• Exercise all joints
• Use ambulatory aid
• Help pt get in and out of bed

o Do not get pt out of bed on their good side

• When getting out on good side, the injured leg is adducting

o This can be done ONLY if the injured leg is held/supported at all times

• When getting out of bed on operative side, leg is always moving in abducting
motion
• If pt moves slowly, there is less risk of injury

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Osteomyelitis

Osteomyelitis
• The worst infection a pt can experience
• Bone is highly vascular, but where the long bones flare out, there is little or no
blood

o This includes:

▪ Distal femur

▪ Proximal, fibula and tibia

• If an organism (such as in microscopic surgery) gets into this area of the bone, it
can enter the bone itself, à eating away at tissue
• The body will cover the infection with good fresh bone

o This is called involcrum - encapsulation of a sequestrum

• The body does not recognize this as an infection but as a fx

• The body will heal it as a fx and build fresh bone over the infection

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 • Osteoblasts will build bone over the infection
• The infection is now protected inside bone
• Pt will have vague non-localized symptoms
• It can take up to 10 days to see abscess in bone
• This infection can be:

o Acute

o Sub-acute

o Chronic - characterized by exacerbation and remission

o Pt w/ chronic infection can suffer w/ it for years

• How do we get antibiotics to the site?

o Bacteria invades an avascular area

o Pt goes on high-dose powerful IV meds for 6-12 weeks which in itself is

very dangerous

▪ Vancomycin –

▪ Gentamycin -
• Many times chronic infection results in amputation

Risk factors
• Malnourished
• Children and elderly
• Obese
• DM
• RA
• Orthopedic surgery
• Trauma – due to dirt/glass being embedded into tissue
• When faced w/ a pt w/ ORIF, we as nurses should note that this pt is at risk to
develop osteomyelitis
• Hip surgery pt is at risk

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 • The min. a pt runs a fever, it must raise a red flag pt might have bone infection

Etiology
• Virus, bacteria, fungi, foreign object
• Most common:

o Staph aureus – 70% - takes many lives

o Staph pyrogen – lives on body and skin and is less devastating

• Common areas are distal femur, proximal tibia and fibula, fingers and toes

Causes
• Human bite – worst bite to get – it is dirtiest bite
• Blood – boils, infected teeth
• Extension of soft tissue infection

o Pressure ulcers, septicemia – the result of osteomyelitis

• Direct bone contamination

• Foreign body – nail from ORIF

Critical thinking:
• The minute we know there is an abscess in the bone, we must stop it b/c we have
to put bone in by graft to grow new bone
• The larger the hole, the more difficult it will be to stabilize the bone
• Pt will go into surgery:

o Open up abscess and clean it out

o Pt comes back from surgery with antibiotic drip

o What goes in must come out – we will see the pieces of mucus, tissue,
bacteria coming out through drain
• Typically they will graft bone, usually from hip and grow in place of abscess

Hx
• Trauma – bone injury
• Illness – pneumonia, sinusitis, skin infection

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 • Infected tooth
• Recent illness – UTI

Clinical manifestation
• Local

o Aching, throbbing bone pain – non localized

o Muscle spasm

o Edematous, redness, heat, LOF

o Thin, scarred, shiny

LOF Red

Swollen Heat

Pain
o !
• Systemic

o Malaise

o Leukocytosis

o Lymph node involvement

Diagnostic

• CBC
• ESR – Elevated Sed Rate
• X-ray – takes 10 days to see
• CT/MRI – good tool to detect right away

!87
 o Expensive

o Complications b/c allergy, implants etc.

• Bone biopsy
• Ultra sound:

o Will help ID cavity inside bone

o The cavity is the abscess eating the bone

o At this point, the MD will do surgical debridement

▪ He will go in and scoop out bacteria and abscess

▪ He will insert new bone in cavity w/ the hope that it will grow
bone

o A biopsy will be done when it is needed to ID organism

▪ A piece of bone will be taken out and cultured

Medical management
• #1 prevention – look at the risk to pt:

o The following pt can develop osteomyelitis b/c of the surgical procedure

they had:

▪ Hip replacement

▪ Knee replacement

▪ ORIF

▪ EFD
• IV antibiotics:

o Vancomycin:

▪ The drug of choice

▪ Dangerous b/c there is no treatment for VRE – vancomycin

resistant enterococci

▪ If VRE gets into the wound or lungs, the pt is dead

!88
 ▪ VRE is an organism that once responded to vancomycin, but no
longer does b/c the drug was overused

▪ To give vancomycin, every hospital has their own infection policy

and they determine who gets it – everyone gets it
• Needle aspiration for c/s
• Surgical debridement – sequestrectomy, antibiotic irrigation

o Sequestrum - A fragment of dead bone separated from healthy bone as a

result of injury or disease
• Hyperbolic chamber:

o 100% O2

o Room or chamber – looks like a space capsule

o Pt sits in room for X amt time

o Shown to have tremendous results

• Bone graft/amputation – the worst to have:

o Used w/ pt who has had osteomyelitis for a long time

o Not making headway or too much bone is infected

• NI
• Assessment
• Immobilization
• Pain treatment
• Bedrest/prevent hazards immobilization
• Dressing change
• Prevention of flexion contraction/footdrop
• Diet
• Antibiotic Side effects
• Complications

• Septicemia
• Meningitis
• Thrombophlebitis
!89
 • Prevention of flexion contraction – foot drop:

o We are concerned pt will develop foot drop

o Caused by pt being unable to move foot b/c of pain

• Diet

o High protein

o High Vit C

o Zinc

o High Ca – for bone build-up in cavity

o Mg

• Aminoglycosides – has some devastating side effects:

o Ototoxicity

o Nephrotoxicity – renal failure

Osteoporosis
• Age related
• We see it 2 times in life – at menopause and age 75 for men and women

o Metabolic

o Systemic

o Skeletal disease characterized by:

▪ Low bone mass

▪ Micro architectural deterioration

▪ Bone fragility – inc. risk for fx

• We now know that pt who fx hips:

o The belief was that the pt fell and fx their hip

o Now believed that fx hip caused pt to fall

• Peak bone mass (PBM)– what we need to attain

• We all need to take Ca and vit D

!90
 • We need to build bone mass so when we get to 60s, 70s and 80s, we have enough
bone to get us through even as we lose bone
• PBM is the max bone density a person can attain
• Influenced by genetics
• Reached between 18-25 (28 today)

Pathophysiology
• Imbalance btw osteoclasts and osteoblasts
• Bone loss occurs when resorption exceeds formation
• When we initiate tx for osteoporosis, we could never rebuild bone that was lost –
only prevent further loss by inc. Ca
• Osteoporosis is mostly seen in 3 areas:

o Hips

o Spine – crumbling fx – compression fx

▪ Bone crumbles and person loses height

o Wrists – Colles’ fx

Stages
• Menopausal women lose 2-5% bone/yr in the 1st 10 yrs
• Intervene early
• Can’t get bone back, but prevent further loss w/ meds, exercise and tx
• Have pt get bone density scan as soon as pt is menopausal/peri

o This way we know if pt is at risk

o This way we know how much density a pt has and can check against how
much pt lost during the first 1-2 yrs

▪ This will help w/ tx regimen

• 25 million suffer from osteoporosis
• 8 million women – 2 million men
• 1 out of 2 women will get fx

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 • 1 out of 8 men will get fx

Risk factors – unmodifiable

• Genetic factors
• Age
• Race
• Endocrine
• Other diseases

o Esp. thyroid disease/cancer

▪ Pt on Synthroid will get osteoporosis (just a matter of when)

Risk factors – modifiable

• Hormonal status – being on estrogen carries risk for cancer and heart disease
• Ca and Vit D deficiency

o Start taking today

o Teach pt to read labels

o 30% = 300mg

o We need 1200mg per day

▪ Can process 600mg at one time

• Cigarettes, caffeine, alcohol all leach Ca from bone
• Low body weight
• Sedentary life style à couch potatoes
• Must exercise – for osteoporosis it must be weight bearing
• Swimming doesn’t work since you weigh less
• Wolf’s law – if you don’t use it, you lose it
• By overusing, we make stronger bones

o Ca migrates to bones

Medication risk factor

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 • Steroids are a cause of osteoporosis

o Pt should not be on steroids > 6 weeks

o Long-term use linked to RA, Lupus, scleroderma

▪ These pts are treated w/ Fosamax

• Coumadin, heparin
• Chemotherapy
• Dilantin
• Lupron/Zoladex – chemo used for prostate cancer

o These are female hormones given to men w/ prostate cancer to prevent

further tumor growth
• Immunosuppressants:

o Cyclosporin

o Methotrexate

o Thyro methcyntroite

• Thyroid meds

Assessment
• Hx of recent fx
• Colles’ fx indicator of osteoporosis

Clinical manifestation
• Dowager’s hump:

o Pt loses height

o One side of muscle gets stronger and pt develops hump

o Dowager’s hump is osteoporosis

• Abdomen protrudes
• Pt gets lordosis

Diagnostic tests

!93
 • Bone mineral density – the gold std
• Bone scan – quicker, less useful

Prevention
• Follow a balanced diet high in Ca and Vit D throughout life
• Use Ca supplements such as Tums à the problem w/ Tums is that it must be
taken w/ Vit D in order for the Ca to get absorbed by the body
• Walking – the best exercise

o With osteoporosis can cause fx

o Start high impact exercise young and keep it up

o Interval training excellent

o Weight training builds muscle

▪ Inc. weight encourages bone to absorb more Ca

!94
Typical loss of height associated w/ osteoporosis and aging

Drug therapy
• Fosamax – most common one used

o Can cause esophageal irritation

o Must be taken on empty stomach w/ water

o No food for 30 minutes

o No Ca for 2 hours

o Give it at 6 am

o Must sit upright

▪ Put head of bed up so pt does not get esophageal irritation

o Avascular necrosis to jawbone

▪ Idiopathic, may be r/t cancer

▪ If pt had cancer they would be at higher risk

• Selective estrogen receptor modulator
• Evista – cousin to estrogen

o Works selectively

o Works on bones

o Remarkable drug – it works on heart as well

▪ Dec. heart episodes by 25%

o Same family as birth control

o Can cause blood clots – can be dangerous

o Educate pt to s/s of DVT

• Nutrition – know diet high in Ca – milk, dairy, green vegetables, antacids

• Calcium:

!95
 o Age 19-50 – 1000mg/day

o Age 51 à older – 1200mg /day

▪ Problem w/ older adults is that they can’t afford many of the foods
high in Ca
• Vit D – recent study shows it to improve outlook on life

o Age 2-50 – 200u/day

o Age 51-70 – 400u/day

o 70 à older – 600u/day

Hip fx
• Seen very often in hospital
• 30% mortality rate w/ 1st fx
• 60% mortality rate 2nd fx
• We typically see it in elderly b/c muscle becomes atrophied

o Poor eyesight

o Lack of balance

o Chronic disease – neuropathy

o Immobile

o Pt has osteoporosis

• Occult fx:

o A crack in bone that doesn’t go all the way through

o Over next 24-hours crack will cont. to develop

o Pt will get non-displaced fx

o Pt can still walk

o Pt will get groin pain

o Suddenly pt gets displaced joint

o Leg shortens, pt is incapacitated and in pain

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 • Note that in case pt fell, but continues to walk, you write up the incident in
your report. Pt may have sustained an occult fx
• Check fx for intracapsular(ball and neck) vs extracapsular

• !

o Typically, head and neck of trochanter have poor blood supply

▪ When it fxs it is very difficult to repair

▪ We usu replace intracapsular fx

o Extracapsular has great bld supply

▪ Fx here will be placed in ORIF

Stages

!97
 • Occult – crack
• Impacted non displaced – still together
• Displaced – no longer bone to bone

Extracapsular – has good bld supply and will heal

• Pt will get Open Reduction Internal Fixation device
• If during surgery, Md assess good bld supply, he will apply ORIF

o Usu in:

▪ Trochanteric

▪ Subtrochanteric

Colles’ fx

!
• Fx of distal radius and ulnar
• Result of breaking a fall – usu a sign of osteoporosis
• Clinical manifestation – aka dinner fork deformity
• Pt will go into short arm cast
• Unless they need an internal fixation which will accompany external fixation

ORIF
• Use of pins, wires, screws and plates to hold bone together
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 • Can be temporary or permanent
• In the elderly, hip fx is permanent
• By law, Mds cannot name internal fixation after themselves
• This has cut way down on the dramatic and different types of ORIF

Indications
• Reduction and alignment of fractures
• Allows direct visualization of injury
• Fill in defect or maintain fragments
• Early ambulation & healing
• For the elderly it is wonderful:
o Even if they can’t weight bear, they can sit up

o This is much preferred over a pt lying in bed in traction

Assessment
• 2 items of concern:

o Dislocation:

▪ Possible for body to reject device

▪ Possible that if osteoporosis is an underlying disease, screws may

not take hold and pull out

o Infection – osteomyelitis

Dislocation
• Pt loses their function
• Protrusion:

o When we palpate the area we may find a screw hanging out in the wrong
place which in itself can cause pain
• Limited ROM
• No sign of inflammation
• It will be sudden
• Pt will be in pain

Infection

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 • 5 signs of local inflammation
• 2 signs of systemic inflammation – inc. WBC and fever
• Grave concern is osteomyelitis
• Both dislocation and infection will lead to further surgical intervention

Emergency removal
• Possible for pt to reject it
• Breaks/bends/loosens
• Pain – dec. function
• Faulty or damaged device
• Corrosion
• Disuse osteoporosis – pt can lose bone b/c of ORIF
• Recall

END OF UNIT 1 MATERIAL

Independent Study

Carpal Tunnel Syndrome

NURSING CARE OF THE PATIENT WITH CARPAL TUNNEL SYNDROME
Definition- an entrapment neuropathy that occurs when the median nerve at the wrist is
compressed by a thickened flexor tendon sheath, skeletal encroachment, edema or soft
tissue mass.
· Most common nerve entrapment syndrome
· Compression of the median nerve at the wrist
· Causes sensory motor changes in the hand
· Affects the thumb, index finger, middle finger and radial side of the ring finger
Incidence
· Occurs most frequently in the summer months
· Middle-aged or postmenopausal women
· Between 30 and 60 years of age

!100
Etiology
• Due to pressure from trauma or edema caused by inflammation
• Associated with arthritis, hypothyroidism or pregnancy
• Aggravated by repetitive or strenuous wrist and hand motions like knitting,
computer typing, driving, and sewing.
Assessment:
• History: patient complains of pain, paresthesia, numbness, and weakness along
median nerve. Patient may complain of night pain.
• Clinical Manifestations: Positive Tinel's sign. This test is elicited by percussing
lightly over the median nerve, located on the inner wrist until numbness, tingling
and pain are felt.
• Diagnostic Procedures: Electromyography
Medical Management
· Rest and immobilization of affected wrist and hand with splints
· Avoidance of repetitive flexion of wrist
· NSAIDs and carpal canal cortisone injections
· Decompression of nerve with traditional or endoscopic laser surgical release of
transverse carpal ligament
· Nontraditional: Yoga, postures, relaxations and acupuncture
Nursing Diagnosis
Pain related to swelling and inflammation
Impaired Physical Mobility related to joint pain and swelling

!101
!

OSTEOMALACIA
Definition / Incidence - a metabolic bone disease characterized by inadequate
mineralization of bone. Known as adult rickets. It is seen in cultures whose diets tend to
be deficient in calcium & VD. Women in China, Japan, and northern India have the
highest incidence. It is almost non-existent in the US but may be seen in elderly, &
vegetarian diets
Pathophysiology ? Vitamin D maintains adequate serum levels of calcium and phosphate
for normal mineralization of the bone. 2 Step process: Step 1 ? Vit D is transported to the
kidney and converted to calcitriol. Step 2 ? Calcidiol is transported to kidney where it is
transformed into an active form of cacitriol. Calcitriol promotes calcium absorption from
the GI. Osteromalacia arises from undermineralization of bone matrix and failure of
calcium and phophorus deposits in new bone. (Adult Rickets)
Etiology / Predisposing Factors ?

!102
 • Vitamin D Deficiency: lack of dietary vitamin D; Lack of sunshine;
• Phosphate Depletion: Inadequate intake; impaired absorption; Systemic acidosis:
ureterosigmoidostomy
• Bone Mineralization Inhibitors: hypophosphatasia; Sodium fluoride; CRF
• Malabsorption syndrome ? celiac disease, biliary tract obstruction, pancreatitis
and small bowel resection. Steatorrhea causes increase in fat loss along with Vit D
• Prolonged anticonvulsant therapy
Patient History ? dietary, medical history, pain history, muscle weakness (seen with CA+
+ deficiency)
Clinical Manifestations
· Bone pain and tenderness to touch
· Muscle weakness which increases risk of falls and pathologic fractures
· Waddling or limping gait may cause unsteadiness and falls
· Legs become bowed in advanced stages of disease due to body weight
· Shortening of patient's trunk due to softened vertebrae
· Deformity of thorax (Kyphosis) due to softened vertebrae
· May have deformities of pelvis necessitating cesarean section
Diagnostic testing:
· X-rays show generalized bone demineralization
Looser's Zones - zigzagging bands of decalcification with callus
formation on each side of the bone
· normal to low Calcium/phos - increased alkaline phosphatase; high parathyroid
hormone
· Bone Biopsy shows increased amount of osteoid
Medical Management
1. Treat disorder.
2. Pharmacology:
• Vitamin D is to raise Ca levels; caution when eating fortified food and sunshine;
• Monitor for S/S of excessive accumulation of Vit D seen with hypercalcemia
(deep bone pain, flank pain, renal calculi, anorexia, N/V, thirst, constipation,
muscle hypertonicity, bradycardia, lethargy and psychosis.) Improvement should
be seen within 7 ? 10 days and may last up to 30 days when d/c
3. Diet (fortified milk, cerals, eggs), Sunshine, Exercise
II. NURSING PROCESS

!103
Pain R/T structural changes in bones.
Patient denies discomfort or pain.
1. Administer prescribed analgesics
2. Teach relaxation strategies.
3. Assist with ambulation
Knowledge deficit: nature of the disorder, its treatment; prevention.
Patient states accurate information about the disorder.
1. Inform patient about the disease.
2. Review diet plan
3. Demonstrates prescribed exercises
Altered Nutrition: Less than Body Requirements
Pt will describe appropriate dietary changes.
1. Review dietary sources of Calcium, Phosphorus and Vit D
2. Teach patient about foods fortified with V-D
Risk for Injury
Impaired Physical Mobility

!104
"Differential Features of Osteoporosis, Osteomalacia and Pagets
Disease"

Differential
Osteoporosis Osteomalacia Paget's Disease
Features

 
 


 Resorption greater Inadequate Excessive osteoclastic activity
Pathophysiology than bone mineralization of and formation of poor quality
formation bone bone

 
 
 

Calcium level Normal Low or Normal Normal or elevated

 
 
 

Phosphate level Normal Low or Normal Normal



 
 

Parathyroid
Normal High or Normal Normal
hormone



 
 

Alkaline
Normal Elevated Increased
phosphatase

 
 
 

Hydroxyproline Not applicable Not applicable Increased





 
 Punched-out appearance of bone,
Decreased Bone
Radiographic Osteopenia, increased in bone thickness,
density

Findings fractures linear fractures, mosaic pattern of
Losers zones
bone matrix

Deep Vein Thrombosis

Deep Vein Thrombosis

Joint replacement surgery, especially in the lower extremities, is becoming more
common. Orthopaedic surgeons performed a total of 309,000 hip arthroplasties and
340,000 knee arthroplasties in 1999. The vast majority of these surgeries are very
successful, and patients go on to live fuller, more active lives without pain. But no
operation is without risks. One of the major risks facing patients who undergo
orthopaedic surgery in the lower extremities is a complication called deep vein
thrombosis, a form of venous thromboembolic disease.

What is it?

!105
Deep vein thrombosis (DVT) refers to the formation of a thrombus (blood clot) within a
deep vein, commonly in the thigh or calf. This can have two serious consequences:
1. If the thrombus partially or completely blocks the flow of blood through the vein,
blood begins to pool and build-up below the site. Chronic swelling and pain may develop.
The valves in the blood vessels may be damaged, leading to venous hypertension. A
person's ability to live a full, active life may be impaired.
2. If the thrombus breaks free and travels through the veins, it can reach the lungs, where
it is called a pulmonary embolism (PE). A pulmonary embolism is a potentially fatal
condition that can kill within hours.
Both DVT and PE may be asymptomatic and difficult to detect. Thus, physicians focus
on preventing their development by using mechanical or drug therapies. Without this
preventive treatment, as many as 80 percent of orthopaedic surgical patients would
develop DVT, and 10 percent to 20 percent would develop PE. Even with these
preventative therapies, DVT and subsequent PE remain the most common cause for
emergency readmission and death following joint replacement.
Contributing Factors
Although venous thromboembolic disease can develop after any major surgery, people
who have orthopaedic surgery on the lower extremities are especially vulnerable. Three
factors contribute to formation of clots in veins:
1. Stasis, or stagnant blood flow through veins. This increases the contact time between
blood and vein wall irregularities. It also prevents naturally occurring anticoagulants from
mixing in the blood. Prolonged bed rest or immobility promotes stasis.
2. Coagulation, which is encouraged by the presence of tissue debris, collagen or fats in
the veins. Orthopaedic surgery often releases these materials into the blood system.
During hip replacement surgery, reaming and preparing the bone to receive the prosthesis
can also release chemical substances (antigens) that stimulate clot formation into the
blood stream.
3. Damage to the vein walls, which can occur during surgery as the physician retracts,
twists, folds or manipulates veins. This can also break intercellular bridges and release
substances that promote blood clotting.
Other factors that may contribute to the formation of thrombi in the veins include: age,
previous history of DVT or PE, metastatic malignancy, vein disease (such as varicose
veins), smoking, estrogen usage or current pregnancy, obesity and genetic factors.
After hip surgery, thrombi often form in the veins of the thigh; these clots are more likely
to lead to PE. After knee surgery, most thrombi occur in the calf; although less likely to
lead to PE, these clots are more difficult to detect. Fewer than one third of patients with
DVT present with the classic signs of calf discomfort, edema, distended veins, or foot
pain.
Prevention

!106
Prevention is a three-pronged approach designed to address the issues of stasis and
coagulation. Usually, several therapies are used in combination. For example, a patient
may be fitted with graded compression elastic stockings and an external compression
device upon admittance to the hospital; movement and rehabilitation begin the first day
after surgery and continue for several months; anticoagulant therapy may begin the night
before surgery and continue after the patient is discharged.
1. Early movement/rehabilitation: With hospital stays averaging just four to seven days
after an arthroplasty on the lower extremity, early movement is imperative as well as
beneficial. Physical therapy, including joint range of motion, gait training and isotonic/
isometric exercises, usually begins on the first day after the operation. Pain relievers
administered intravenously also facilitate early mobilization.
2. Mechanical prophylaxes: Mechanical preventatives are usually used in combination
with other therapies. They include:
• Lower extremity exercises such as simple leg lifts, elevating the foot of the bed, and
active and passive ankle motion to increase blood flow through the femoral vein.
• Graded compression elastic stockings, which are more effective in preventing
thrombi formation in the calf than in the thigh.
• Continuous passive motion, which is a logical treatment, but has not been proven
effective in preventing the development of DVT.
• External pneumatic compression devices that apply pulsing pressures similar to those
that occur during normal walking. They can help reduce the overall rate of DVT
occurrence when used with other therapies, but they are difficult to apply and patient
compliance is often a problem.
• In rare cases, a filter device may be inserted in the vein.
3. Pharmacologic prophylaxis: The use of anticoagulant pharmacologic agents includes
an inherent risk of increased bleeding, which must be measured against their
effectiveness in preventing clot formation. The most common anticoagulants are aspirin,
warfarin and heparin.
• Aspirin is easy to administer, is low cost, has few bleeding complications, and
doesn't need to be monitored. However, it has not been proven more effective than
other agents and may not be advisable for all patients. Studies have shown that
aspirin has a greater protective effect for men than for women.
• Warfarin is the most commonly used agent for hip and knee replacement patients.
Warfarin interferes with vitamin K metabolism in the liver to prevent formation of
certain clotting factors. Because warfarin takes at least 36 hours to start working, and
four to five days to reach its maximum effectiveness, it is usually started the day
before surgery. Low doses are used because higher doses can cause episodes of
bleeding, but the dose response is difficult to predict and warfarin must be
administered through an outpatient clinic. Warfarin can cause fetal damage.

!107
• Heparin is a naturally occurring substance that inhibits the clotting cascade. It can
come in high (standard unfractionated heparin) or low (fractionated heparin)
molecular weights. Recent emphasis has been on low molecular weight heparins
(LMWH) because they are more predictable and effective, with fewer bleeding
complications than standard unfractionated heparin. LMWH is effective after both
hip and knee joint replacement surgeries, but there is a higher incidence of bleeding
when it is used after knee replacement surgery. The most commonly used and
researched LMWH are enoxaparin, ardeparin, dalteparin and fraxiparine. Heparin
works much faster than warfarin, so it is often administered initially and followed by
warfarin therapy, or administered as a single agent.

Diagnosis
Diagnosing DVT is difficult, and current diagnostic techniques have both advantages and
disadvantages. The most commonly used diagnostic tests include venography, duplex or
Doppler ultrasonography, magnetic resonance imaging (MRI), and cuff-impedence
plethysmography.
Venography uses a radiographic material injected into a vein on the top of the foot. The
material mixes with blood and flows toward the heart. An X-ray of the leg and pelvis will
then show the calf and thigh veins and reveal any blockages.
Although venography is very accurate and can detect blockages in both the thigh and the
calf, it is also costly and cannot be repeated often. In addition, the injected material may
actually contribute to the creation of thrombi.
Duplex ultrasonography can also be very accurate in identifying clogged veins. Projected
sound waves bounce off structures in the leg and create images that reveal abnormalities.
The addition of color Doppler imaging improves accuracy. This test is noninvasive and
painless, requires no radiation, can be repeated regularly and can reveal other causes for
symptoms. It also costs substantially less than venography. However, it is technically
demanding and requires a skilled, experienced operator to obtain the most accurate
results. Ultrasonography is less sensitive in detecting thrombi in the calf and it has
limited ability to directly image the deep veins of the pelvis.
Magnetic resonance imaging is particularly effective in diagnosing DVT in the pelvis,
and as effective as venography in diagnosing DVT in the thigh. This technique is being
increasingly used because it is noninvasive and allows simultaneous visualization of both
legs. However, an MRI is expensive, not always readily available, and cannot be used if
the patient has certain implants, such as a pacemaker. In addition, the patient can
experience claustrophobia.
Cuff-impedance plethysmography uses blood pressure checks at different places in the
leg to identify possible blockages. Although once used extensively, this procedure is no
longer recommended as a diagnostic tool because of its high false-positive rate.

!108
Postoperative Treatment
The risk of developing DVT extends for at least three months after joint replacement
surgery. The risk is greatest two to five days after surgery; a second peak development
period occurs about 10 days after surgery, after most patients have been discharged from
the hospital. Recently, the Food and Drug Administration approved the use of the LWMH
dalteparin sodium in a once-daily, 14-day dosing regimen to prevent DVT after hip
surgery. A common postoperative regimen is five days of heparin followed by three
months of warfarin therapy. However, the length of time that therapy should continue
after surgery varies depending on the agent used and individual patient considerations.
Orthopaedic surgeons are continuing to research techniques, such as the use of regional
anesthesia and intraoperative heparin, to reduce the risk of DVT formation. Studies have
shown that using regional rather than general anesthesia can reduce the overall rate of
DVT formation by up to 50 percent.
Research to identify those patients particularly at risk for DVT formation after surgery is
also ongoing. Some risk factors such as weight and history have been identified. Based
on these risk factors, some physicians use regular surveillance of patients, while others
recommend using venography to identify those patients at risk for developing DVT. In
general, orthopaedic surgeons would rather avoid extended outpatient prophylaxis for all
patients, preferring to focus on those most at risk.
Treatment is the same for both asymptomatic and symptomatic venous thrombo-
embolisms. If the clot is located in the femoropoliteal vein of the thigh, treatment consists
of bed rest and five days of heparin therapy followed by three months of warfarin. A clot
in the calf veins does not normally require heparin treatment; outpatient warfarin
treatment for six to 12 weeks is sufficient. These treatment regimens are designed to
prevent the occurrence of a fatal pulmonary embolism and reduce the morbidity
associated with DVT.

!109
How to Assess Pedal Pulses

!
With your index, middle, and ring fingers, locate the Dorsalis pedis artery by palpating
the dorsal aspect of the foot.

Gently press against the artery so that you feel a pulse.
Assess the strength.
Document the strength of the Dorsalis pedis pulse in terms of "0" for not palpable, "1+"
for weak and thready, "2+" for normal, "3+" for full and bounding.
With your index, middle, and ring fingers, locate the Posterior tibial artery by palpating
the inside of the ankle, immediately behind the tibial ankle bone.
Gently press against the artery so that you feel a pulse.
Assess the strength.
Document the strength of the Posterior tibial pulse in terms of "0" for not palpable, "1+"
for weak and thready, "2+" for normal, "3+" for full and bounding.
Tips:

!110
Do not use your thumb to palpate a pulse -- it has its own strong pulse.

Do not exert too much pressure over the artery -- you may obstruct the blood flow.

If you are unable to palpate a pulse, use a Doppler device.

Supportive & Assistive Devices

SUPPORTIVE AND ASSISTIVE DEVICES
Patients with musculoskeletal disorders can use a variety of assistive and supportive
devices. These devices are used to help a person adapt to almost any physical limitation.
Ambulatory Devices:
• · canes
• · walkers
• · crutches
Purpose of Assistive Devices:
1. Assist to release pressure on joint
2. Provide or help maintain balance
3. Promote a sense of security
General Measurement Criteria
1. Patient should be in a standing position.
2. Patient is standing on a flat surface.
3. Patient is wearing the same shoes that will be worn for daily activity.
CANES
• Used for balance
• Promote sense of security
• Cannot be used unless patient has weight bearing on both lower extremities.
• Tip of cane should have a thick nonskid rubber surface
Nursing Intervention: Patient teaching
1. Canes require weight bearing status on both legs
2. Tip of cane must have non-skid rubber tip
3. Measure so 20 to 30 degree flexion of elbow
4. Measure so cane approximately level with greater trochanter
5. Cane held in hand ON THE STRONG SIDE (opposite weaker side)
WALKERS

!111
 • Has four points on the ground surrounding the patient, providing a wide base and
giving maximum security. Some walkers have wheels.
• Used primarily by the elderly or by postoperative patients when they begin
ambulating.
• They are difficult to maneuver in small tight places.
• Provides support and balance.
Nursing Intervention:
1. Measure so that top of walker is level with the proximal thumb joints
2. Allow 20 to 30 degree flexion of elbow
3. Do not pull on walker when rising from a sitting position
4. Sides of walker should be 6 inches from the side of the foot.
Gait Pattern
• Walkers has slow gait.
• Patient places walker in front and then steps forward.
• Patient must not use walker to rise from a sitting position!
• Patient must first rise, using the arms of a chair.
• Once in a standing position, hands can be placed on walker for balance and
support
CRUTCHES
• Used when no weight-bearing is permitted on one lower extremity or when
weight-bearing is allowed on one or both lower extremities.
• Patient must have upper body strength and arm control.
• Patient's weight is supported on the wrists, hands, and shoulders, not on the
axillae.
• Can lead to nerve paralysis!
Measuring for Crutches
1. Crutch tips in place
2. Wear sturdy, well-fitting walking shoes
3. Measuring while standing is preferable
4. If measure in bed, measure from axilla to foot and add 2 inches
5. Padded Hand Piece placed to allow 20-30 degree elbow flexion
6. Weight of body is carried on hands, not axilla with two inches between padded
crutch top and axilla paralysisof brachial plexus may result.

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 7. Body is in good alignment, with head held high, shoulders back, and stomach and
buttocks in.
Gaits:
Two Point Gait: right leg - left crutch then, left leg - right crutch
• Patient needs good coordination and strength
• Resembles normal walking.
• Used for partial but equal weight bearing on both legs
Three Point Gait: full weight on one leg; none or partial weight on other leg. So
that weak leg and two crutches move together.
• Faster than four-point gait
• Three Points on floor at same time
Four Point Gait: alternating right crutch, left leg, left crutch, right leg
• Must be weight-bearing on both legs. Used for someone with poorer balance
• Four Points on floor at same time
Swing Through Gait - patient can bear weight on either or both legs
• Fastest of all gaits.
• Permissible for hurrying across street
NURSING DIAGNOSIS/EXPECTED OUTCOME
1. Risk for injury related to improper fit or misuse of the device.
Patient demonstrates safe use of the prescribed device.
NURSING INTERVENTIONS
Teaching Safe Crutch Walking -
Standing Up and Sitting Down

a. Place affected leg forward to prevent weight bearing or flexion

b. Place both crutches in hand on side of affected extremity
c. Grasping hand pieces, push down on hand piece when sitting/standing
Tripod Standing Position
a. Crutches 8-10 inches ahead of feet and 6 inches out to the side of patient's
toes
b. Lean Forward from the Ankles, not from the waist, hips, or the neck
Going Up and Down Stairs.
a. Going up, the strong leg goes up first and the weaker leg goes up last along
with the crutches

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 b. Going down, the strong leg goes down last
Asess Environment for Safety - Avoid wet floors, highly polished floors and loose
rugs
NURSING DIAGNOSIS/EXPECTED OUTCOME
Impaired home maintenance related to use of device, proper manipulation of device in
the home, and usage of device to perform ADL's.
Patient demonstrates proper use of device
NURSING INTERVENTIONS
1. Explain the purpose for the usage of the device prescribed to patient.
2. Teach patient correct usage of device and patient demonstrates its use.
3. Assess proper fitting and measurement of device.
4. Refer patient to physical or occupational therapy.
5. Determine the patient's ability to maneuver the device in a simulated home setting
and plan instruction to assist patient to cope with problems) prior

to discharge.
6. Encourage patient to do ROM and strength exercises to build upper body strength.
7. Teach patient proper maintenance of the device.

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