Musculoskeletal Problems

Arthroscopy

visualize internal structures of a joint to veiw extent of injury (knee and shoulders)

CONTRAINDICAITON: infection, lack of mobility

Risk of infection (swelling, redness, or fever)

Nuclear scans

Bone scans

Gallium & Thallium scans

Bone scans

entire skeletal system

less common

radioisoptopes 2-3 hrs prior to scan → abNL bone formation brighter on scan

detects: hairline bone fractures, tumors, fractures & disease

Gallium & Thallium scan

more sensitive for detecting bone problems

radioisotopes: brain, liver & breast tissues

• 4-6hrs prior to scan

• scan 30-60 mins

• repeat 24, 48, 72hrs

Indications: osteomyelitis, tumors, metastatic cancer, fractures, osteoporosis

CONTRAINDICTION: pregnancy, lactation, and kidney disease

Fluids after procedures

DEXA: dual-energy x-ray absorptiometry

estimate of bone density of bone mass (hip or spine)

Indications: osteoporosis, postmenopasual state

CONTRAINDICATIONS: pregnancy & lactating

remove metal

T-score

T-score levels

healthy: 0 to -1

osteopenia: -1 to -2.5

osteoporosis: > -2.5

Electromyography (EMG)

needle placed into muscle to evaluate muscle contractions

recrods activity

presence & cause of muscle weakness

Nerve conduction study

needles placed → low electrical currents → recording of muscle response to stimulus

indications: neuromuscular disorders, motor neuron disease, peripheral nerve disorders (MS, MG, ALS, GBS, carpal tunnel)

Pre-procedure: anticoagulants, muscle relaxants, infections, avoid smoking 2hrs prior, informed consent

CONTRAINDICATIONS: anticoagulants, skin infections, muscle relaxants

Post-procedure: bruisng, ice, warm compression

x-ray

structure

CT scan

structure & soft tissue

contrast dye → allergies? & fluids

MRI

structure and soft tissue

claustrophobia?

remove metal

Ultrasonography

structure and fluid a

arthroplasty

repair of damaged joints, total replacements or partial

Indications → OA, RA, osteonecrosis

CONTRAINDICATIONS: infection, arterial impairment, DM, HTN, osteoporosis

Pre-procedure: CXR, ECG, CBC, UA, electrolytes, BUN/creatinine

total joint arthroplasty

joint replacement

total knee arthroplasty

replaces distal femoral component, tibia plate & patellar button

total hip arthroplasty

replaces acetabular cup, femoral head/stem

knee arthroplasty

neurovascular assessment (movement, sensation, color, pulse, cap refill)
CPM, knee immboliizer, or neither

limitations in flexion → prevent contracture

Pain control

PT

Antibiotics

Anticoagulants

Avoid pillows, kneeling or deep knee bends

hip arthroplasty: post op

Monitor drainage & surgical drains

Daily labs: Hgb & Hct → risk for anemia

Neurovascular status → 2 to 4 hours

Medications

• analgesics

• antibiotics

• anticoagulants

Early ambulation

• cemented → partial/full weight-bearing as tolerated

• non-cemented → partial/minimal weight-bearing (toe touch)

Assistive devices

Risk for dislocation, “pop”

Abductor pillow, DO NOT turn on operative site

AVOID: low chairs, crossed legs, hip flexion >90 degrees

PT

complications of arthroplasty

venous thromoembolisms

joint dislocation

infection

anemia

neurovascular compromise a

amputations

>2mil amputees in US

Adults w/ PVD (80%) → DM contributes

Risk factors: traumatic injury, thermal injury, malignancy

AKA → 65-100% more energy than NL

BKA → 25-45% more energy

goal of amputation

preserve length and function if possible g

guillotine

open amputation

allowing for drainage of infection

flap amputation

closed amputation

most common

Management of traumatic amputation

stop the bleeding: direct pressure tourniquets

• ask EMS what time the tourniquet was applied

elevate extremity - above heart

wrap severed extremity (sterile dry gauze → place in sealed bag → submerge in ice water)

Post op complications of amputations

hypovolemia

pain

infection

flexion contractures

• prone position → 20-30 mintues several x/day

• PT

  • ROM exercises

nursing care of amputations

assess pulse proximal to site

affected extremity in dependent position

DO NOT ELEVATE

Prepare for prosthesis - skhrinkage intervention

wrap residual limb using elastic bandages(8 figure)

residual limb shrinker sock

air splint

Attitude and perception of amuptation

stages of grief

psychosocial well being

Amputations pains

post op pain - analgesics, positioning

Phatom limb pain

Phantom limb pain

nerve pain

“deep burning, cramping, shooting, or aching”

Medications

• calcitonin

• BB

• antiepileptics (gabapentin)

• antispasmodics (baclofen)

• antidepressants

• desensitization techniques

  • alternative health - TENS, accupuncture

Closed fracture

does ot break through the skin surface o

open fracture

disrupts skin integrity → open wound & tissue injury

risk of infection

3 grades

Grade I open fracture

minimal skin damage

Grade II open fracture

skin and muscle contusion w/o extensive soft tissue injury

Grade III open fracture

extensive damage to skin, muscke, nerves & bvs

complete fracture

goes through the entire bone

incomplete fracture

part of the bone

simple fracture

one fracture line

comminuted fracture

multiple fracture lines splitting the bone into multiple pieces

displaced fracture

bone fragments not aligned

non-displaced fracture

bone fragments remain aligned

fatigue (stress) fracture

excess strain from rec and athletic activties

Pathological (spontaenous) fracture

due to weak bone from disease process

osteoporosis

bone cancer

compression fracture

loading force pressing ons pongy bone

elders with osteoporosis

comminuted

fragmented bone

oblique

angled and acrosss bone

spiral

twisting motion

impacted

wedged inside opposite fractured fragment

greenstick

one side, does not extent all the way aross

most common in children

health promotion and disease prevetion - Fx

intake of calcium, vit D and sunlight

screen for osteoporosis and htyroid disease

weight-bearing exercises

bisphosphonate → slow bone resorption and tx osteoporosis

fall/injury prevention

risk factors of fractures

osteoporosis

falls

MVA

SUD

metastatic cancer, bone cancer

contact sports

physical abuse

lactose intolerance/malnutrition

age

Clincial Manifestations of Fx

deformity

pain

crepitus

muscle spasms

edema

eccymosis

loss of function

unable to bear weight

Dx of Fx

x-ray

CT

MRI

Bone scan

CBC - infection/bleeding

ESR - inflammation

Nursing care of Fx

immobilize - casts, splints, internal or external fixators

realignment - traction, surgery

neurovascular assessment (pain, sensation, temp, cap refill, pulses, mobility)

nutrition → increase protein, calcium

medications: pain, muscle relaxants, stool softners, abx

tetanus vax for open fractures or wounds

closed fx immobilzation

manual traction

must be done soon after fracture

under sedation or anesthesia

splints, casts, or braces to maintain alignment open

open fx immbilizer

surgical

nails, pins, rods to align and stabilize bone

risk - infection, DVT

benefit - early mobilizations

casts

temporary

plaster - 24 to 72 hrs to dry

hold w/ palm, avoid direct pressure while drying

neurovascular checks Q1 first 24hr

elevate and ice 24h-48 hrs

Traction

skin - Bucks traction

skeletal - pin

weight may vary depending on alignment

weights hang freely through pulley

don’t let weights rest on floor

pin care

halo

external fixator

indication → comminuted fractures w/ soft tissue injury

elevate extremity

neurovascular assessment

DVT prevention

pin care

report loose pins

s/sx of infection

compartment syndrome

pressure within one or more of the muscle compartments compromises circulation → ischemia-edema

external factors: tight, cast, post surgical repair

internal factors: edema or bleeding

most common in lower leg and forearm

Assess 6 P’s

emergent fasciotomy

risk for rhabdomyolysis

Rhabdomyolysis

skeletal muscle injury

Dx: UA, Ck total, myoglobin

Manifestations: dyspnea, HA, tachycardia, CP, confusion

Complication: ATN, hyperkalemia, metabolic acidosis

TX: IVF, sodium bicarbonate

Complications of Rhab

Fat embolism → fat globutes from bone marrow enter circulation

• Late manifestation → petechiae

• Tx: bedrest, O2, steroid, fluids, analgesic

DVT w/ risk for PE

osteomyelitis

infection in the bone

manifestations: localized pain but worse w/ movement, erythema, edema, fever

Dx: CBC, ESR, bone scan, cultures

Abx 4-6wks - IV and oral

surgical tx

antibiotic beads

hyperbaric O2

possible amputation

carpal tunnel syndrome

median nerve in wrist

numbness, tingling - palmer side of thumb, index, middle and half ring finger

pain worse at night, mat radiate

Phalen’s maneuver & Tinel sign

NSAIDS

splint or brace

surgery if severely pinched

strain

excessive stretching, pulling muscle or tendon

tx. cold or heat, exercise, anti-inflammatory, muscle relaxants

sprain

excessive stretching of ligament, twisting motions

tx. RICE

xray to r/o fracture