Week 14 osteoporosis, musculoskeletal trauma and ortho surgery

Osteoporosis

Chronic metabolic disease from bone demineralization causing fragile bones and increased risk of fracture

Osteomalacia

Soft bone from vitamin D deficiency; at risk for fractures

Osteopenia

Low bone density, not yet severe enough to be osteoporosis

Pathophysiology of Osteoporosis

Bone resorption increases as formation slows; Primary- psotmenopasual; dec. testosterone

secondary- prolonged steroid/antithyroid/antacids/antiseizure meds

Risk factors for Osteoporosis

Female, postmenopausal, age >65, white/Asian, smoking, alcohol, low Ca/Vit D, corticosteroids.

Manifestations of Osteoporosis

possibly asymptomatic

Back pain after lifting, bending, stooping

increased pain w palpatation

vertebral fracture

height loss

kyphosis.

Diagnosis of Osteoporosis

DXA scan; T-score ≤ -2.5 diagnostic.

Lifestyle recommendations to decrease risk of Osteoporosis

1200 mg calcium/day, Vit D3 800-1000 IU/day, weight-bearing exercise, limit alcohol & coffee, stop smoking.

Calcium supplementation

MOA: increase body's available Ca+

SE: hypercalcemia (GI upset, renal dysfunc, lethargy, dysrhythmias)

admin: NO MORE than 600 mg/dose

carbonate with meals; citrate if on PPI.

Vitamin D3

Essential for Ca+ absorption in intestines.

SE: toxicity

Bisphosphonates (-nate)

Inhibit osteoclast mediated bone resorption;

DO NOT GIVE: existing hypercalcemia or hyperparathyriod

SE: esophagitis, muscle pain, eye issues

ADMIN: take with water NOT food immediately in morning, sit upright 30 min.

Recombinant DNA Parathyroid Hormone: Teriparatide

Stimulates osteoblasts

used for high fracture risk.

DO NOT USE: bone metastases, hx of skeletal cancer, inc. risk of bone cancer

SE: nausea, headache, back pain, leg cramps

ADMIN: pen expires 28 days after 1st injection, store pen COLD

Pathophysiology of Osteoarthritis

progressive deterioration of articular cartilage

Manifestations of Osteoarthritis

joint Pain worsens with use, relieved by rest; crepitus; stiffness; nodes in hands.

Management of Osteoarthritis

meds

heat/cold, weight loss, bracing, PT, balanced activity/rest.

medications for osteoarthritis

Rheumatoid Arthritis

Autoimmune inflammatory disease causing synovial joint and connective tissue destruction.

Manifestations of Rheumatoid Arthritis

Local: Morning stiffness >30 min, symmetrical joint pain/swelling, deformities

systemic: fatigue, fever, weakness, anorexia

Medications for Rheumatoid Arthritis

NSAIDs- pain/inflammation SE: stomach upset, heart burn, headaches, GI bleeds

glucocorticoids-anti-inflammatory & immunosuppresion SE weight gain, mood changes, GI upset, inc BP/BG

DMARDs (methotrexate, hydroxychloroquine, sulfasalazine) slow degenerative effects SE: infection, immunosuppression, anemia, hepatotoxicity, ecchymosis *frequent neutrophil/WBC/platelet labs

Management of Rheumatoid Arthritis

preserve function, joint protective devices, ROM, exercise program, heat/cold therapy, paraffin bath

Preoperative care for Joint Replacement

Infection screen

medication adjustments

assistive device/precaution teaching

Postoperative care for Hip Replacement

ABduction pillow

no internal rotation

no flexion >90°

raised toilet seat.

Postoperative care for Knee Replacement

Immobilizer, early PT, ROM goal 90°, pain management

strain vs sprain

Strain = muscle/tendon stretching

sprain = ligament injury

S/S- similar for both= pain, edema, decreased function, bruising

RICE & tylenol/NSAIDS

colles' fracture

result of fall onto an outstretched hand

s/s of fractures

pain and tenderness

edema

ecchymosis

pallor

obvious deformity

decreased ROM of joint or distal to joint

classification of fractures

position of bone ends:

displaced = bone ends separated, non-displaced= bone end still together

completeness of break: incomplete= bone cracks/bends but doesn't completely break

complete= break completely through bone

direction of break:

oblique, transverse, spiral

communication w external environment:

closed= under skin

open= bone outside skin

traumatic

pathologic= underlying weakness of bone structure

Salter-Harris Fracture

injury or fracture through growth plate

most common type of fracture in children

if not treated properly can interfere w growth

Healing stages of fractures

Hematoma → fibrocartilaginous callus formation → bony callus → bone remodeling.

fracture management

acute: neurovascular assessments

splint fracture site

remove sources of contamination

pain relief and reduce swelling

Reduction methods

realignment of bone fragments

Closed = realignment without surgery

open= surgery

Fixation

immobilization to maintain realignment of fracture site

traction

internal (devices like plates, screws, or rods surgically placed inside the body to hold the bone together)

external (External fixation uses pins and a rigid frame outside the body to stabilize a bone)

cast

Cast care

Neurovascular checks; elevate; ice first 24 hrs; prevent DVT (ROM, heparin)

no objects inside cast.

Traction

Skin- usually intermittent, no more than 10 lbs

skeletal- traction applied continuously, heavier weights can be used alignment; pain management; prevent complications.

Neurovascular Assessment

5 P's: Pain, Pulse, Pallor, Paresthesia, Paralysis.

Complications of Fractures

Infection, VTE, fat embolism (resp distress + petechiae),

compartment syndrome

s/s- early= severe pain unrelieved by meds

late=pallor, pulselessness, paralysis

treatment: fasciotomy to relieve pressure

Pelvic and Hip Fractures

Risk for hemorrhage;

extracapsular= ORIF

intracapsular= arthroplasty often required.

post op care from pelvis/hip fracture

monitor vs

watch for s/s of hemorrhage

anticoagulants

manage pain

encourage coughing/deep breathing

perform nv assessment of distal extremity

Amputation Care

Causes: Diabetes, PAD, trauma;

postop: rigid dressing, prevent contractures (prone lying), phantom limb pain management.