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

1st line-tylenol and topical agents

NSAIDS

muscle relaxants

corticosteriod injections

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

diagnostic: elevated ESR and positive rheumatoid factor; radiographic study reveals joint deterioration, synovial tissue biopsy reveals inflammation

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 of disease- prescribed secondary to NSAIDS

general SE: injection site reaction, 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.

adverse effects of antiarthritic meds

hydroxychloroquine- retinal damage; report visual disturbances

methotrexate- hepatic fibrosis, bone marrow suppression, GI ulcers and pneumonitis

sulfasalazine- GI and dermatological reaction, bone marrow suppression and heptatitis