Med 1 Exam 4

Musculoskeletal

low back pain

-leading cause of job related disability and a major contributor to missed days of work

-can be localized or diffused pain

• localized pain is in a specific area

• diffused pain is in a larger area and is from deep tissue

-can be radicular or referred

• radicular pain is caused by irritated nerve root

• referred pain is felt in lower back, but the source is another location

-common because of lumbar region = bears most of weight of body, is the most flexible region of the spinal column, contains nerve roots that are at risk for injury and disease, has a naturally poor mechanical structure

low back pain risk factors/ causes

Risk factors:

-lack of muscle tone

-excess body weight

-stress

-poor posture

-cigarette smoking

-pregnancy

-prior compression fracture of the spine

-spinal problems since birth

-family history of back pain

-some jobs = heavy lifting, jack-hammering, sitting for extending periods of time, health care workers (be sure to lift equipment properly and raise bed when providing care)

Causes:

-acute lumbosacral strain

-instability of the lumbosacral bony mechanism

-osteoarthritis of the lumbosacral vertebrae

-degenerative disc disease

-herniation of an intervertebral disc

acute low back pain

-4-6 weeks is usually caused by trauma or an acivity that causes undue stress = heavy lifting, overuse of back muscles during yard work, a sports injury, or a sudden jolt as in a motor vehicle crash

-symptoms often do not appear at time of injury but appear gradually (usually w/i 24 hrs)

• gradual increase in the pressure on the nerve from an intervertebral disc and/or associated edema

Symptoms:

-muscle ache

-shooting, stabbing pain

-limited movement

-inability to stand upright

Diagnostics:

-few abnormalities present

-straight leg test

-CT scan or MRI if trauma or systemic disease is present

Acute low back pain care

Health Promotion:

-proper body mechanics

-education on back safety

-physical therapy or personal trainer

-proper shoes

-maintain a healthy body weight

-sleeping posture

-smoking cessation

Implementation:

-If NOT severe = NSAIDs, muscle relaxants (cyclobenzaprine), massage, back manipulation, acupuncture, and cold and hot compress

-If SEVERE = brief course of corticosteroids or opioid analgesics

-brief period (1-2 days) of rest at home, but avoid prolonged bedrest

-continue regular activities, refrain from activities that increase the pain = lifiting, bending, twisting, and prlonged sitting

• symptoms usually improve within 2 weeks and generally resolve w/o treatment

Chronic low back pain

lasts more than 3 months or involves a repeated incapaciting episode

-is often progressive

Causes:

-degenerative conditions like arthritis or disc disease

-osteoporosis or metabolic bone disease

-weakness from scar tissue from prior injury

-chronic strain n lower back = obesity, pregnancy, stressful posture

-congenital spine problems-previous injuries or trauma to the back
-infections or tumors affecting the spine
-increased physical activity or sports after a prolonged period of inactivity

spinal stenosis

narrowing of the spinal canal which holds the spinal cords

-can be acquired or inherited

-often cause by arthritic changes s/a = RA, OA, spinal tumors, Paget’s disease, trauma, congenital or scoliosis

-Less space for spinal cord → compresses nerves, inflammation, pain, weakness, and numbness

-Can cause chronic low back pain if the lumbar spine is affected

-progressive onset

Lumbar spinal stenosis

spinal stenosis in the lower back (lower 5 vertebrae)

-pain often starts in lower back then radiatesto buttocks and legs

-worse w/ walking or prolonged standing

-numbness, tingling, weakness, and heaviness in the legs may be present

-pain often decreases when bending over or sitting is a common sign of spinal stenosis

chronic low back pain care

similar to treating acute low back pain

-pain management w/ NSAIDs, corticosteroids, opioid analgesics

-antidepressants (Cymbalta) may help pain and sleep problems

-Antiseizure med (Neurontin) may help improve walking and relieve leg symptoms

-weight reduction

-rest, TENS

-local heat or cold

-physical therapy

-exercise to keep muscles and joints mobilized

-avoid cold damp weather if it aggravates pain

-complementary therapies s/a biofeedback, acupunture, yoga

-education = good body mechanics; avoid extreme flexions of torso

-surgery may be done for severe pain that does not see improvement w/ other therapies

• intradiscal electrothermoplasty

• radiofrequency discal neruoplasty includes various non-surgical and surgical methods to alleviate pain, improve function, and enhance quality of life for individuals suffering from chronic low back pain. This may involve a combination of medication, physical therapy, and lifestyle modifications.

Intervertebral disc disease

-the deterioration, herniation, or other problem w/ the intervertebral disc

-results from loss of fluid in the intervertebral discs w/ aging

• unless accompanied by pain, DDD is a normal process

osteoarthritis

associated w/ DDD

-poorly lubricated joints rub together and the protective cartilage is damaged

-painful bone spurs can form

Intervertebral disc disease manifestations/ diagnostics

Lumbar disc disease:

-low back pain

-radicular pain that radiates to buttock and down the leg (along sciatic nerve) = indicates herniation

• herniation = spinal disc bulges outward between vertebrae

-diminished or absent reflexes

-parasthesia

-muscle weakness in legs, feet, or toes = trouble walking; falls

Cervical disc disease:

-pain radiates to arms and hands

-reflexes may be diminshed or absent

-weak handgrip

-shoulder pain or dysfunction

Diagnostics:

-history and physical exam

-Xrays

-Myleogram = evaluates nerves

-MRI

-epidural venogram (diskogram) = xray of spine after contrast is injected into disc

-electromyogram (EMG) of the extremities = determines new damage and muscle function

Cauda equina syndrome

medical emergency

-multiple lumbar nerve root compressions from herniated disc, tumor, or epidural abscess may cause:

• severe low back pain

• progressive weakness

• bowel and bladder incontinence OR retention

• saddle anesthesia (loss of or altered sensation of the perineum, buttocks, inner thighs, and back of legs)

-considered a medical emergency and surgery is needed to decompress the pressure on the nerves and prevent paralysis

Intervertebral disc disease care

Conservative Care:

-limit movement = w/ traction, brace, belt, or corset

-heat or ice

-massage

-TENS therpay

-medications

• NSAIDs

• short term corticosteroids, opioid analgesia, muscle relaxants, anti-seizure meds, and antidepressants

• corticosteroid injections = straight to site

-when pain subsides → back strenghthening exercises 2x per day

-education on proper body mechanics

Surgical Therapy:

-Intradiscal electrothermoplasty (IDET)

-Radiofrequency discal nucleoplasty

-Interspinous process decompression system (X-stop)

-Laminectomy

-Discectomy

-Percutaneous discectomy

-Artificial disc replacement

-Spinal Fusion

-Bone morphogenetic protein (BMP)

Intradiscal electrothermoplasty (IDET) (intervertebral disc disease)

minimally invasive treatment for back and sciatic pain

-needle is inserted into affected disc w/ xray

-wire is inserted through the needle and heated → destroying the nerve fibers

radiofrequency discal nucleoplasty (intervertebral disc disease)

-needle is inserted into affected disc w/ xray

-special radiofrequency probe is inserted through the needle

-probe destroys the gel in the disc

-relieves pressure

interspinous process decompression system (x-stop) (intervertebral disc disease)

titanium device fits onto a mount placed on the vertebrae in the lower back

-used to treat lumbar stenosis

-lifts vertebrae off pinched nerve

-X-stop is an example of device used

laminectomy

outpatient procedure or may need 1-3 day inpatient

-surgical excision of part of the vertebrae (lamina) to access and remove protruding disc

-goal is to relieve leg pain; may or may not relieve back pain

discectomy (intervertebral disc disease)

done to decompress the nerve root

-removes part of the damaged disc

-helps maintain the bony stability of the spine

-back pain may or may not be relieved

percutaneous discectomy

oupatient

-small tube is inserted into retroperitoneal tissue to the disc under fluoroscopy

-laser removal of damaged area

-minimally invasive

artifical disc replacement (intervertebral disc disease)

damaged disc is removed and artificial disc is inserted

spinal fusion (intervertebral disc disease)

rods and pins

-may be indicated if spine is unstable

-adjacent vertebrae are fused (ankylosis) together w/ a bone graft from the pts own fibula or iliac crest (autograft) or donated cadaver bone (allograft)

-may also include metal fixation w/ rods, plates, or screws

-less mobility

bone morphegentic protein (BMP) (intervertebral disc disease)

genetically engineered protein can be used to stimulate bone growth of the graft in a spinal fusion

-dissovalble sponge soaked w/ BMP is implanted into the spine

-the protein stimulates bone growth, beginning the process of fusion

-sponge and protein disappear, leaving new bone behind

Intervertebral disc surgical management

Vertebral disc surgery:

-maintain alignment of the spine until its healed

• for lumbar fusion, place pillows under the thighs when supine and between legs when side lying

• assist in education of repositioning = logrolling

-Monitor for CSF leakeage

• IMMEDIATELY REPORT LEAKAGE OR IF PT COMPLAINS OF HEADACHE TO SURGEON

• CSF appears clear or slighlty yellow. Also has high concentration of glucose when tested w/ dipstick

-Assess neurological status

• movement of arms and legs; sensation; Q2-4H for first 48hrs after surgery

-Assess circulation status = skin temp, cap refill, and peripheral pulses

-Assess GI status = bowel sounds, constipation, nausea, distention. Give stool softeners PRN

-Assess bladder function

• encourgae pt to get OOB to bathroom if allowed by surgeon

• possible catheter

• incontinence may indicate nerve damage and should be reported to provider

-back brace if orderd

-logrolling = rolling whole body at once

-assess incision site

-encourage activity when permitted

Pain management:

-PCA pump

-Move from IV to PO meds

-muscle relaxers

-document and reassess pain levels

osteomalacia

caused by vitamin D deficiency that causes bone to lose calcium and become soft

-same as rickets in children

-vitamin D is needed in order for calcium to be absorbed by the body

Causes:

-low sun exposure, GI malabsorption, extensive burns, chronic diarrhea, pregnancy, kidney disease and certain meds (anti-seizure meds, antacids, sedatives, and muscle relaxants)

-long term care pts do not get outside often and may not synthesize vitamin D

-darker skin tones do not synthesize vitamin D as easily as fair skin tones

-obesity = poor diet and lack of exercise

osteomalacia manifestations/ diagnostics

Manifestations:

-bone pain

-difficulty walking or rising from a chair

-muscle weakness

-weight loss

-progressive deformity of weight bearing bones (spine and extremities)

-fractures

-delayed bone healing

*at first may be asymptomatic

Diagnostics:

-decreased serum calcium, phosphorus, and vitamin D

-elevated serum alkaline phosphate level

-xrays

osteomalacia care

-correction of vitamin D deficiency

• vitamin D3 = cholecalciferol

• vitamin D2 = ergocalciferol

• calcium or phosphorus supplements

-Diet changes = add dairy, eggs, meat, oily fish, and fortified breakfast cereals

-Exposure to sunlight = 20 min/day

-Weight bearing exercises = walking

osteoporosis

chronic, progressive metabolic bone disease marked by low bone mass and deterioration of bone tissue

-increased bone fragility

-more common in women than men =

• women tend to have lower calcium intake

• women have less bone mass

• bone resorption occurs earlier in women and more rapidly w/ menopause

• pregnancy and breastfeeding deplete the skeletal reserve until calcium intake is adequate

• longevity increases the likelihood of osteoporosis

Risk factors:

“little old white and Asian ladies”

-65, female, low body weight

-white and Asian ethnicity

-sedentary lifestyle

-estrogen deficiency in women; low testosterone in men

-family history

-diet low in calcium and vitamin D

-excessive alcohol use (more than 2 drinks a day)

-long term use of corticosteroids, thyroid replacement, heparin, long-acting sedatives, anti-seizure drugs, aluminum containing antacids, and chemo meds

-women over 65 or at risk (smoker, low weight or prior fractures) should get a bone density test

• if test is normal and low risk does not need to be repeated for 15 years

• no sufficient evidence of benefits for testing in men

Osteoporosis patho

-osteoblasts = bone deposistion (build bone)

-osteoclasts = reabsorption of bone (consume bone)

-normally deposits and reabsorption happen at the same rate

• in osteoporosis reabsorption is happening faster than new bone deposistion

Associated diseases:

-inflammatory bowel disease (IBD = Crohn’s, UC)

-intestinal malabsorption

-kidney disease

-rheumatoid arthritis

-hyperthyroidism = thyroid plays large role w/ calcium

-alcoholism

-cirrohsis of liver

-hypogonadism

-diabetes mellitus

Osteoporosis manifestations/ diagnostics

Manifestations:

-mostly affects bones of the spine, hips, and wrists

-back pain

-spontaneous fracture (vertebrae)

-loss of weight

-humped thoracic spine (kyphosis)

*may initially be asymptomatic

Diagnostics:

-does NOT show up on xray until 25% - 40% of the calcium is lost from the bones so not best for diagnosing

-serum calcium, phosphorus, and alkaline phosphate may be elevated after a fracture

-bone mineral density measurements determine bone mass and bone loss

• QUS

• DXA = gold standard test = measures bone density in spine and hips

• be sure to remove all jewelry

-T scores

• bone mineral density results are usually reported as T scores

• +1 to -1 is normal

• -1 to -2.5 indicates osteopenia (bone loss more than normal but not as much as osteoporosis)

• -2.5 and less indicates osteoporosis

-the lower the number, the more severe osteoporosis is

osteoporosis nursing management

Assessment:

-history and physical exam

-diagnostics

Management:

-nutrition

-supplements (calcium and vitamin D)

-sun exposure

-exercise

Meds:

-Bisphosphonates = alendronate, ibandronate, risedronate, zleodronate

• take w/ full glass of water

• take 30 min before food or other drugs

• stay upright for at least 30 min after taking

-Calcitonin

• used to TREAT not prevent = decreases bone break down (action of osteoclasts) and increases calcium excretion in urine

-selective estrogen receptor modulator (SERMS) = raloxifene

• activates estrogen which decreases bone resorption and bone loss

-Recombinant parathyroid hormone = Terparatide

• stimulates osteoblasts → bone formation and increased bone density

-Monoclonal antibody agonist RANKL = Denosumab

• prevents osteoclast activation

Surgical Procedures (minamally invasive)

-Vertebroplasty

-Kyphoplasty

Vertebroplasty

bone cement is injected into the collapsed vertebra to stabalize the spine and improve the pts pain

-does not restore vertebral height or correct deformiy

Kyphoplasty

a small balloon is inserted into the collapsed vertebrae and inflated o restore vertebral body height before injection of bone cement

-preferred surgical treatment for vertebral compression fractures

Pagets Disease

chronic skeletal bone disorder = excessive bone resorption is followed by replacement of normal marrow by vascular, fibrous connective tissue

-new bone is larger, disorganized, and weaker

-common in pelvis, long bones, spine, ribs, sternum, and cranium

-etology is unknown but viral cause is suspected

-40% of pts have one family member w/ disease

-affects men twice as much as women

Pagets disease manifestations/ complications

Manifestations:

-in mild forms pts do not have symptoms

-bone pain may develop gradually and become more severe

-fatigue

-development of waddling gait

-height loss

-head (skull) enlargement

• dementia, headaches, visual deficits, hearing loss

-In spine bone enlargement can compress spinal cord or nerve roots

-pathological fractures = 1ST SIGN = not caused by fall or taruma

Complications:

-osteosarcoma, fibrosarcoma, and osetoclastoma (giant cell) tumors

Pagets disease diagnostics/ care

Diagnostics:

-xrays

-bone scan

-serum alkaline phosphate elevated

Interprofessional care:

-there is no cure = treat symptoms, supportive care

-surgery to correct deformities

braces to support bones

-Meds

• bisphsophonates to slow bone resorption

• zoledronic acid to build bone

• calcium and vitamin D

• calcitonin (if pt can not tolerate bisphosphnates) to inhibit osteoclasts

• pain management

-firm mattress for back support

-activity limits = no heavy lifting or twisting

-nutrition

-prevent falls

ostomyelitis

a severe infection of the bone, bone marrow, and surrounding soft tissue

Predisposing problems:

-pressure ulcer (stage 4)

-penetrating wound (stabbing, gunshot)

-open fracture

-orthopedic surgery (dirty hardware)

-vascular insufficiency = diabetes, atherosclerosis

-indwelling prosthetic devices = joint replacements, fixation devices

-abscessed tooth, gingival disease

-UTI

-tuberculosis

-gonorrhea

-puncture wounds

-IV drug use

-sickle cell disease

-immunocompromised host

osteomyelitis patho

micororganisms can invade the bone in 2 ways

-Indirect entry

• blunt trauma

• urinary r respiratry tract infections

• vascular insufficneicy are at risk of primary infection spreading through blood stream to bone

• highly vascular bones = tibia, pelvis, and vertebrae are common site of infection

-Direct entry

• occurs at any age

• open wound present and microorganisms enter the body = open fractures, foot ulcers

• foreign body implants = pins, joint replacements

-micororganisms in the bone grow and multiply causing increased pressure b/c they have nowhere to go

-pressure leads to ISCHEMIA (poor ciruclation in the periosteum)

-infection spreads to the bone cortex and marrow cavity (cortical devascularization and NECROSIS)

-ISCHEMIA CAUSES BONE DEATH

Acute Osteomyelitis

initial infection is less than 1 month

-manifestations can be local and systemic

Local:

-constant bone pain that worsens w/ activity and is unrelieved by rest

-swelling

-tenderness

-warmth at the site

-restricted movement of affected part

Systemic:

-fever

-****night sweats****

-chills

-restlessness

-nausea

-malaise

Later:

-draining from the skin (cutaneous skin tract) or the fracture site

Chronic Osteomyelitis

infection that persists longer than 1 month or has failed to respond to antibiotic treatments

-may be continuous, persistent issue or come and go (exacerbation and remissions)

Local manifestations:

-constant bone pain

-swelling

-warmth at the site

Systemic manifestations:

-may be reduced

-granulation tissue turns to scar tissues. Antibiotics can not get through avascular scar tissue so microorganisms continue to grow there

Long term complications:

-septicemia

-septic arthritis

-pathologic fractures

-amyloidosis

Ostomyelitis diagnostics

-bone or soft tissue biopsy to determine microorganism

-blood culures

-wound cultures

-WBC, ESR, CRP

-Xrays = 10 days or more after initial symptoms (disease process already progressing)

-CT scan

-MRI

-Bone scans

ostoemyelitis care

Aggressive IV antibiotic therapy:

-if bone ischemia has NOT occurred

• CVAD, PICC, or implanted port

• IV abx therapy at home (home health nurse) for 4 weeks up to 6 months

• abx = penicillin, nafcillin, neomycin, vancomycin, cephalexin, cefazolin, cefoxition, gentamycin, and tobramycin

• abx ordered depnds on sensitivity of microorganism

-oral antibitiocs may als be given after IV abx are finished for chronic osteomyelitis

Specialized wound care:

-suction to irrigation systems

-contrst or intermittent irrigation

-cast or brace to protect

-negative pressure wound therapy

-hyperbaric O2 = stimulates new bone growth and healing

-orthopedic devices that are determined to be the cause of osteomyelitis MUST BE REMOVED

-muscle flaps or skin grafts can provide coverage over the dead space in the bone

-bone grafts can help restore blood flow, but CANNOT be done if infection is still present

Amputation:

-when all else fails

-done when damage is too extensive; can improve quality of life

-can be life saving when systemic complications are developing

-surgeon will try to preserve as much length as possible while getting all the dead and infected tissue out

Treatment for chronic osteomyelitis

-surgical removal of poorly perfused tissue and dead bone

-extended use of antibiotics = IV, oral, beads

osteomyelitis nursing management

Health promotion:

-prevent and control other infections

-monitor immunocompromised pts

-educate pts to reports symptoms early (for earlier treatment)

-educate family about their role in monitoring pts health

Acute care:

-immobilize affected limb = decreases pain & reduce risk of injury

-assess pain and muscle spams

-NSAIDs, analgesia, muscle relaxants

-non med forms of therapy = guided imagery, relaxation breathing, medication

-dressing management

-repositioning, prevent contractures

-educate pt about possible adverse or toxic reactions o long term antibiotic therapy

• hearing deficit

• impaired renal function

• neurotoxicity = limb wekaness, numbness, cognitive changes, memory loss, vision changes, headache, and behavior changes

• Cephalosporins can cause hives, severe or watery diarrhea, blood in stools, throat and mouth sores

-Fluroquinolones

-Peak and trough levls

-Overgrowth of candida albicans or clostrudium diffcile in GU or GI tracts (yeast infection, thrush, C. diff)

-emotional support

Ambulatory Care:

-IV abx are administered at home or infusion center

-educat pt and family about central line care, administering abx as scheduled, and follow up lab work

-dressing changes for open wounds

• educate family and pt on proper wound care

-physical and emotional support

foot disorders

foot is a platform that supports the weight of the body

-absorbs shock when walking

-can be affected by:

• congenital conditions

• structural weakness

• traumatic and stress injuries

• systemic conditions (DM, RA)

-some are caused by poor shoes, causing crowding and angulation of toes

Proper footwear:

-provides support, stability, protection, shock absorption, increased friction on walking surfaces and treats foot abnormalities

Hallux valgus (bunion)

painful defromity of great toe w/ lateral angulation of great toe toward second toe

-bony enlargement of medial side of first metatarsal head

-swelling of bursa and formation of callus over bony enlargement

Treatment:

-wearing shoes w/ wide forefoot or “bunion pocket” and use of bunion pads to relieve pressure on bursal sac

-surgical tretamen involves removal of bursal sac and bony enlargement and correction of lateral angulation of great toe

-may include temporary or permanent internal fixation

hallux rigidus

-painful stiffness of first MTP joint caused by osetoarthritis or local trauma

Treatment:

-intraarticular corticosteroids, passive manual stretching of first MTP joint

-shoe w/ a stiff sole decreases pain in joint during walking

-surgical treatment is joint fusion or arthroplasty w/ silicone rubber implant

hammer and claw toes

-hammer toes is defoemity of PIP joint on 2nd - 5th toe causing toe to be permanently bent, resembling a hammer

-claw toe is simialar deformiity w/ dorsiflexion of proximal phalanx on MTP joint combine w/ felxion of both PIP and DIP joints

Treatment:

-passive mannual stretching of PIP joint, use of metatarsal arch support

-surgical correction consists of resection of base of middle phalanx and head of proximal phalanx, bringing raw bone ends together

-kirshner wire maintains straight position

morton’s neuroma

neuroma in a web space between 3rd and 4th metatarsal heads, causing sharpp, sudden attacks of pain

Treatment:

-surgical excision

Pes cavus (high arch)

elevation of longitudinal foot arch resulting from contracture of plantar fascia or bony deformity of arch

Treatment:

-surgical correction needed if condiion interferes w/ ambulation

pes planus (flat foot)

loss of metatasral arch causing pain in foot or leg

Treatment:

-use of resilient longitudinal arch supports

-surgical treatment consists pf triple arthrodesis or fusion of subtalar joint

heel pain

heel pain w/ weight bearing.

-common cause are plantart brsitis, plantar fascitis, bone spur

Treatment:

-corticosteroids injected directly into inflamed bursa

-spong rubber heel cup

-surgical excision of bursa or spur

-stretching exercises, ice, shoe heel cup, shock-wave therapy, NSAIDs, corticosteroids for planater facitis

calcanues stress fracture

heel pain after moderate walking

-common causes are overtraining, running on hard surfaces, osteoporosis

Treatment:

-rest, ice, shoe heel pad, NSAIDs

-see HCP to assess for osteoporosis

corn

localized thickening of the skin caused by continual pressure over bony prominence, especially metatarsal head, often causing localized pain

-usually found on top (dorsal) or side of foot

-Treatment:

-same w/ callus

soft corn

painful lesion caused by bony prominence of a toe pressing against adjacent toe

-usual location is web space between toes

-softness caused by secretions keeping web space relatively moist

Treatment:

-pain relived by placing cotton or spacers btwn toes to separarte them

-surgical treatment is excision of projecting bone spur

callus

localized thkening of skin

-cover wide area and usually found on weight bearing part of foot

Treatment:

-softened w/ warm water or preparartions containing slaicylic acid and trimmed w/ razor blade or scalpel

-pressure on bony prominences caused by shoes is relieved

plantar wart

painful papillomatous growth cause by virus that may occur on any part of skin on sole of foot

-warts tend to cluster on pressure points

Treatment:

-remidies containing salicylic acid (compound W)

-excision w/ electrocoagulation

-surgical removal

-laser treatments

-may disappear w/o treatments

Foot disorder care

Health promotion:

-proper fitting shoes

-prolonged high heel wear can lead to corns, hemmer toes, and morton’s neuroma

Acute care:

-referral to podiatrist

-conservative therapies = NSAIDs, ice, PT, footwear alterations, stretching, warm soaks, orthotics, US, corticosteroid injections

Surgery:

-post-op immobilization (cast, shoe)

-elevate the foot

-assess neurovascular status (cap refill in toes)

-activity as ordered = may need crutches, walker, cane, walking boot

-pain management

Ambulatory Care:

-instruct pt to perform daily foot care and wear clean socks

-toenails are trimmed to prevent ingrown toenails, reduce risk of infection

-educate pts especially pts w/ diabetes or circulatory issues

soft tissue injury

can include strains, sprains, dislocations, and subluxations

-usually result from a traumatic event

-sports related injuries are one of the most common reasons for ED and urgent care visits

injuries may include ACL tears, impingement syndrome, ligament injuries, meniscus injuries, rotator cuff tears, shin splints, and tendonitis

strains and sprains

are both common injuries that occur from vigourous activity, abnormal stretching, or twisting

-tend to occur around joints and the spinal musculature

-low back sprain is common

sprain

injury to the ligaments surrounding a joint

-most common in wrist, ankle, and knee joints

-calssified by degree

• 1st degree (mild) = involves tears in only a few fibers, with mild tenderness and minimal swelling

• 2nd degree (moderate) = results in partial disruption of the involved tissue w/ more swelling and tenderness

• 3rd degree (severe) = complete tear of the ligament w/ moderate to severe swelling (Ex: ACL tear)

  • can lead to avulsion fracture = the ligament pulls loos a fragment of the bone it was attached to

strains

exsessive stretching of a msucle and its fascial sheath, often involving the tendon

-usually occur in large muscle groups s/a lower back, calf, and hamstrings

-classified by degree of severity

• 1st degree = mild or slightly pulled muscle

• 2nd degree = moderate or moderately torn muscle

• 3rd degree = severely torn or ruptured muscle. A defect in the muscle may be apparent if palpated through skin

strains and sprains manifestations/ diagnostics

Manifestations:

-pain and inflammation

-edema

-decreased function of extremity

-ecchymosis

-mild strains and sprains are self-limiting and pt. can return to normal activity in 3-6 weeks

Diagnostics:

-xrays may be done to rule out fractures

-joint may become unstable and result in dislocations, subluxations, and hemarthrosis (bleeding into the joint)

-severe injuries may need surgical repair

sprains and strains care

Health promotion:

-warming up before ctivity by strecthing

-exercises to improve sterngth, balance, and endurance

• improves muscle strength and bone density

• better balance reduces risk of falls

Acute care:

-stop the activity and LIMIT MOTION!! (rest)

-ice the injured area (20 min at a time)

-compress the area, possibly w/ elastic wrap (start distal and work way up)

-elevate the area

-analgesics as needed

Ambulatory Care:

-most strains and sprains are treated as outpatients

-RICE = rest, ice, compression, elevate

-mild analgesics

-elastic wrap

-prevent further injuries

-PT if needed

subluxation

partial or incomplete displacement of the joint surface

dislocation

complete displacement or separation of the articular surfaces of the joint, resulting in the severe injury of the ligaments surrounding the joints

subluxation/ dislocation manifestations/ complications

are similar for both but dislocations more severe

-pain or tenderness

-loss of function of the extremity

-soft tissue swelling near the joint

-deformed appearance (ex: on a hip dislocation one leg will look shorter than the other)

Major complications:

-open joint injuries

-fractures

-avascular necrosis

-damage to nerves and blood vessels

-xrays may be needed to determine severity

-joint aspiration may be done to assess for hemarthrosis or fat cells

subluxation/ dislocation care

-both are considered orthopedic emergency (risk of avascular necrosis or compartment syndrome)

-goal is to realign dislocated portion

-after realignment

• immobilize

• pain management

• restrict motion

• increase activity gradually

repetitive strain injury (RSI)

aka cumulative trauma disorder

-injuries resulting from prolonged force or repetitive movements and awkward postures

-repeated movemens strain tendons/ ligaments, and muscles causing tiny tears to become inflamed

-exact cause is unknown. No specific test available to diagnose

Persons at risk:

-musicians

-athletes

-dancers

-butchers

-grocery clerks

-vibratory tool workers

-those who frequently use a computer mouse and keyboard

Symptoms:

-pain

-weakness

-numbeness

-impaired motor function

repetitive strain injury (RSI) prevention/ treatment

Prevention:

-education and ergonomics

• hip and knees at 90 degrees

• feet flat on the floor

• wrists straight to type

• hourly stretch breaks

Treatment:

-identify the activity

-modify equipment or activity

-pain management

-rest

-PT

-lifestyle change (job change)

carpal tunnel syndrome

caused by compression of the median nerve which enters the hand through the narrow carpal tunnel

-carpal tunnel is formed by ligaments and bones

-most common compression neuropathy in upper extremity

-associated w/ continuous wrist movements (computer users)

-often caused by pressure from trauma or edema, neoplasm, RA, or soft tissue masses s/a ganglia, hormones, and diabetes

-more common in women due to fact they have smaller carpal tunnel

Manifestations:

-weakness, pain, numbness, or impaired sensations in the median nerve, clumsiness in fine motor movements

-pt may awake at night from numbness and tingling

-shaking the hands may relieve symptoms

Tinel’s sign

tap over median nerve as it passes through the carpal tunnel into the wrist

-a positive response is a sensation of tingling in the distribution of the median nerve over the hand

Phalen’s test

allowing wrist to free fall into maximum flexion and maintain for more than 60seconds

-positive response is if there is a sensation of tingling in the distributions of the median nerve

Carpal tunnel syndrome prevention/ treatment

Prevention:

-adaptive devices s/a splints (holds the wrist in extension to relieve pressure)

-work station modification s/a keyboards, pads

-frequent breaks

Treatment:

-change in occupation

-PT

-carpal tunnel release surgery if symptoms persist for more than 6 months

• open release or endoscopic release

• ligament is cut to make the tunnel bigger

Rotator cuff injury

rotator cuff is composed of 4 musles in the sshoulder that stabilize the humoral head in the gloid fossa while assisting w/ ROM of the shoulder joint and rotation of the humerus

Causes:

-tear could be gradual, degenerative process due to aging or repetitive stress (especially over head arm motions = tennis, swimming, basketball)

-injury to the shoulder, falling on outstrectched arm

-heavy lifting

Manifestations:

-shoulder weakness

-pain

-decreased ROM

-severe pain when arm is abducted 60-120 degrees (painful arc)

-positive drop arm test

-Xray won’t be able to see tears so MRI is needed

drop arm test

• arm is abducted 90 degrees and pt is asked to slowly lower arm to side

• if arm falls suddenly rotator cuff injury is suspected

rotator cuff injury treatment

Conservative treatment:

-ice

-rest

-heat

-NSAIDs, analgesia

-corticosteroid injections in joint

-PT

Aggressive treatment:

-when conservative treatment does not help or tear is extensive or complete

-surgery (usually done outpatient)

• arthroscopy

• acromioplasty = part of the acromion process on scapula is removed. This relieves the compression of the rotator cuff during movement

Post-op care:

-sling, swathe, shoulder immobilizer may be needed to limit movement

-shoulder should not be immobilized for too long → could cause frozen shoulder (arthrofibrosis)

-PT

-pendulum exercises post-op day 1

-weight and lifting restrictions

-pain management

-recovery may take up to 6 months

meniscus injury

meniscus is crescent shaped piece of fibrocartilage. most commonly mentioned is in knee but also exists in acromiclavicular, sternoclavicular, and temporomandibular joints

-closely associated w/ ligament sprains

-common in athletes = football, basketball, soccer, and hockey

-damage from rotational stress of the knee joint while in flexion and foot is planted

-meniscus gets sheared btwn the femoral condyles and the tibia plateau = resulting in a torn meniscus (gets caught in between bones then tears)

Meniscus injury manifestations/ diagnostics

Manifestations:

-edema is not typiaclyy seen b/c area is avascular so not a lot of fluid to leak and build up

-acute tear

• localized tenderness, pain, pt may state the knee feels unsteady or unstable, may report pops, clicks, or knee gives way

-quadricep muscle may atrophy

-traumatic arthritis may occur w/ repeated meniscus injury and chronic inflammation

Diagnostics:

-McMurray’s test (+)

-MRI

-possible atrhoscopy

meiscus injury care

-prevention = teach pts to warm up and stretch before activity

-acute injuries should be examines w/i 24 hrs

-ice

-imobilization/ knee brace

-crutches/ weight bearing as tolerated (WBAT)

-pain management

-PT/ rehab

-surgical repair or excision meniscectomy

• done by arthroscopy

Anterior cruciate ligament injury (ACL)

most common knee ligament injury

Causes:

-pivoting/ twisting

-landing from a jump

-sudden slow down while running

-hearing a sudden pop

Manifestations:

-painful

-acute swelling in the knee

-may have a partial or complete tear of the ligament

-avulsion = ligament tears a piece of bone off bone it was attached to

ACL injury Diagnositics/ care

Diagnostics:

-lachman test (+)

-MRI = can also look at coexisting conditions s/a fractures, meniscus injury and other ligament damage

Care:

-prevention

-conservative treatment = rest, ice, NSAIDs, elevation, ambulation, WBAT, crutches, aspiration, knee brace, immobilizer, physical therapy

Aggressive treatment:

-reconstructive surgery (for severe injury)

-the ton ACL is removed and replaced w/ autologous or allograft tissue

Post-op care:

-ROM is encouraged soon after surgery

-brace or immobilizer

-PT or rehab

-may take 6-8 months

Bursitis

inflammation of the bursa sacs in joints

Causes:

-repeated, excessive trauma or friction

-gout

-rheumatoid arthritis

-infection

Manifestations:

-warm

-pain

-swelling

-limited ROM

-common sites = hands, elbows, knees, greater trochanter of hip

Treatment:

-try to determine cause and correct it

-ice and heat intermittently

-rest, NSAIDs, possible immobilization

-aspiration of bursal fluid

-corticosteroid injection in joint

-possible surgical excision (bursectomy)

-if septic = incision and drain of bursae

Fractures

a disruption or break in the continuity of bone

-caused by traumatic injury or secondary to a disease process (pathologic)

-can be open or closed

• open = skin is broken and bone exposed causing soft tissue injury

• closed = skin is intact over the site

-can be complete or incomplete

• complete = break goes completely through bone

• incomplete = fracture occurs partly across bone shaft, but bone is still intact

-can be displaced or nondisplaced

• displaced = 2 ends of broken bone are out of their normal positions (usually comminuted or oblique)

• nondisplaced = bone fragments stay in alignment (usually transverse, spiral, or greenstick)

types of fractures

-Transverse: the line of the fracture extends across the bone shaft at a right angle to the longitudinal axis (bone in half)

-Spiral fracture: the line of the fracture extends in a spiral direction along the bone shaft

-Greenstick fracture: an incomplete fracture w/ 1 side splintered and the other side bent (common in children)

-Comminuted fracture: an fracture w/ more than 2 fragments and the smaller fragments appear to be floating (common in crush injuries)

-Oblique fracture: the line of the fracture extends across and down the bone

-Pathologic fracture: a spontaneous fracture at the site of diseased bone

-Stress fracture: occurs in bone that is subject to repeated stress, s/a from jogging or running

Fracture healing

-Fracture hematoma

• when a bone fractures, blood clots at the injury site, forming a hematoma (clot)

• this clot turns semisolid within first 3 days

-Granulation tissue

• phagocytes clear dead tissue, turning the clot into granulation tissue

• new blood vessesl, firboblasts, and osteoblasts start forming the foundatio for new bone (osetoid)

• this happens btwn days 3 and 14

-Callus formation

• minerals like calcium and phosphorus begin bulding and unorganized bone network around the fracture

• the callus (cartilage, ostoeblasts, clacium, phosphrus) usually appears w/i 2 weeks and xrays can show it starting to solidify

-Ossification

• the callus hardens (ossifies) btwn 3 weeks and 6 months

• movement at the fracture site reduces, but the fracture is still visible on xray

• limited mobility or cast removal may be allowed

-Consolidation

• the bone fragments move closer as callus grows

• complete healing (shown on xray) can take up to 1 year

-Remodeling

• excess bone is absorbed, and the bone regains its original shape and strength

• physical activity and weight-bearing exercises can help this process

fracture healing complications

Factors that affect healing time:

-extent of damage

-blood supply to the area

-immobilization or movement

-hardware (screws, pins, fixators)

-number of fragments

-infection (osteomyelitis)

-nutrition

-age

-smoking

-systemic diseases

Complications:

-delayed union = heals slower than expected

-nonunion = does not heal, no callus (cartilage, osteoblasts, calcium) seen on xray/ does not form

-malunion = healing time as expected but NOT in correct position

-angulation = heals in abnormal position in relation to midline (form of malunion)

-pseudoarthrosis = false joint formed at site (form of nonunion)

-refracture = new fracture occurs at old fracture site (this area is weak)

-myositis ossificans = deposits of calcium in muscle tissue at the site of significant blunt muscle trauma or repeated muscle injury

fracture manifestations

Manifestations:

-edema and swelling

-pain and tenderness

-muscle spasm

-deformity

-contusion

-loss of function

-crepitation (crunchy or grating feeling)

-unable to bear weight

-guarding or protecting extremity

Fracture care

-Realignment, Immobilize, Restore function

-Diagnostics

• H&P

• Xray, CT, MRI

-Fracture Reduction (putting back into place)

• Closed, open (surgery), traction

-Fracture Immobilization

• Cast, splint, traction, fixation (hardware)

Fracture realignment (reduction)

Closed reduction:

-nonsurgical

-manual realignment of the bone fragments

-usually done w/ local or general anesthesia

-traction, casting, splinting, or braces may be used after reduction to maintain alignment and immobilize injured part until healing occurs

Open reduction:

-surgical

-correction of bone alignment through a surgical incision

-usually includes internal fixation of the fracture (pins, screws, wires, plates, rods, or nails)

-Risk of infection and anesthetic complications

-Allows for earlier ambulation, decreasing risk of PNA, and VTE

Traction

application of a pulling force to adjust to an injured or diseased body part or extremity

Used to:

-prevent or reduce pain and muscle spasm

-immobilize a joint or body part, prevents soft tissue damage

-reduce fracture or dislocation

-treat a pathologic joint condition

-promote active and passive exercise

-expand joint spaces before and during surgery

-must be maintained continuously = keep weights off the floor and moving freely through the pulleys

skin traction (buck’s traction)

short term (48-72 hrs) until skeletal traction is possible

-tape, boots, splints

-diminishes muscle spasms in injured extremity

-buck’s traction is used pre-op for hip fracture

-wietghts are usually limited to 5-10lbs but pelvis or cervical traction may require more

• weight should remain freely hanging

• do not remove weight to reposition client

-regular skin assessment is a priority b/c pressure points and skin breakdown may develop

skeletal traction

longer than skin traction

-maintains alignment

-surgeon places a pin or wire into bone, weights hang from the pins or wires

-weights are usually btwn 5-45lbs (too much weight can affect healing)

-risk for infection at pin insertion sites

-adverse effects of prolonged immobility

Fixation

Internal fixation:

-pins, plates, rods, screws

-placed during surgery to realign and maintain position of the fragments

• put into bone then incision closed = not seen externally

-evaluated by xray

-assess dressing or incision site

External fixation:

-inserted pins and external rods to stabilize the fracture as it heels

-for complicated fractures w/ excessive soft tissue damage, correction of bony defects, nonunion or malunion and limb lengthening

-often used in attempt to salvage extremity that may otherwise need amputation

-long process

-assess for pin loosening and infection

• infection may require removing the device

• chlorexidine often used for cleaning

-no bath but showering may be okay

Fracture immobilization devices (other)

-Casts:

• applied after closed reduction

• often allows pt to perform many normal ADLs while providing stability

• keep dry, do NOT stick anything inside to scratch (instead use dryer on cool setting)

-Body Jackets:

• for stable spine injuries (thoracic or lumbar)

• goes around chest and abdomen

-Halo brace:

• top (halo) portion drilled into skull for stability

-Neck brace

Fracture care/ complications

Care:

-frequent nerovascular checks = 6Ps

• Pain, pallor, paralysis, pulse, pressure, parasthesis

-assess skin pressure points for breakdown

-monitor pin insertion sits for signs of infection

-check weights and pulleys

-manage pain

-assist w/ ADLs

Complications:

-Infection

• common w/ open fracture & soft tissue injuries

• expensive to treat

• delayed or ineffective treatment can lead to osteomyelitis = bone infection which can lead to amputation

• may need surgical debridement = wound is cleaned and dead and diseased tissue is removed

-Compartment Syndrome

-VTE

-Fat embolism syndrome

Compartment syndrome (fracture complication)

-swelling causes increased pressure w/i limited space

-fascia surrounding muscle has limited ability to stretch, increased swelling increases pressure

-pressure compromises nerves, blood flow, and perfusion

-usually occurs in the leg but can occur in arm, shoulder, buttock, and abdomen

-very painful

Compartment syndrome causes

-Causes:

• decreased compartment size from restrictive dressing (casts, splints, traction)

• increased compartment contents related to bleeding, inflammation, edema, or IV filtration

• prolonged pressure from heavy object or laying on extremity too long

-Common w/ trauma fractures, extensive soft tissue damage, crush injuries, knee and leg surgeries

-Pressure and edema cause circulation obstruction

• when veins are compressed blood can not return to the heart (edema)

• when arteries are compressed, blood can not perfuse distal tissue (ischemia, tissue death)

Compartment syndrome care

Neurovascular checks - 6Ps

-Pain = out of proportion to injury, hard to manage (grown man about to cry type of pain)

-Pressure in extremity area

-Parasthesia = numbness, tingling

-Pallor = pale, cool

-Paralysis = loss of function; LATE SIGN

-Pulselessness = diminished or absent; LATE SIGN

-do not wait for late signs to occur

Care:

-DO NOT ELEVATE: lowers venous pressure and slows arterial perfusion

-DO NOT APPLY ICE: constricts vessels that are already compressed

-NOTIFY PROVIDER IMMEDIATELY!!!!!

-Surgical Intervention (fasciotomy)

• incision cut to relieve pressure

• limb saving procedure

Venous thromboembolism (VTE) (fracture complication)

immobility causes venostasis (muscles are inactive. When active, they assist in blood return to heart)

-venostasis leads to blood clot formation

-when the VTE start to travel through the blood stream, it is an embolus (DVT)

-embolism can land in other areas = heart, lungs, brain

Prevention:

-anticoagulants

-sequential compression devices

-TED hose

-ambulation OOB (out of bed)

Fat embolism syndrome (fracture complication)

systemic fat globules from fractured bone are distributed into tissues, lungs, and other organs after a traumatic skeletal injury

-most common fractures of long bones, ribs, and pelvis. Can also happen w/ total joint replacements, spinal fusions, liposuction, crush injuries, and bone marrow transplants

-common factor in mortality associated w/ fractures

Manifestations:

-early recognition is key

-usually occurs 24-48hrs after injury but severe FES can occur w/i hrs

-signs and symptoms depend where the fat embolism lands (usually lungs)

• chest pain

• tachypnea

• cyanosis

• dyspnea

• tachycardia

• hypoxemia

• petechiae on neck, anterior chest wall, and head (can help discern from other problems)