Joint Disorders & Amputation Care

2 major joint disorders

• osteoarthritis (OA): primarily noninflammatory/degenerative

• rheumatoid arthritis (RA): inflammatory autoimmune

musculoskeletal basis

• ligaments: bone to bone

• tendons: muscle to bone

• joint types:

  • synovial: freely moveable

    • joint cavity

    • synovial membrane

    • synovial fluid: lubricates joint (smooth movement)

    • articular cartilage

    • ligaments

    • bursa: fluid-filled sacs that reduce friction (muscles/tendons glide over bone)

  • nonsynovial: immovable/slightly movable

osteoarthritis

• chronic, progressive, primarily noninflammatory degeneration of articular cartilage in synovial joints, especially weight-bearing joints

• primary/idiopathic OA: no prior joint injury/systemic dz

  • women (post-menopausal)

• secondary OA: joint trauma, repetitive occupational/sports injury, previous inflammatory dz, other joint abnormalities

  • men

OA common sites

• Hips

• Knees

• Cervical/lumbar spine

• Fingers: DIP + PIP

• Foot: MTP

OA patho

• articular cartilage degenerates → body attempts repair → new cartilage softer + less elastic → cartilage fissures/erodes → bone-on-bone contact → osteophytes/bone spurs form

• osteophytes: bone growths/bone spurs that develop at joint margins

OA risk factors

• Age

• Female sex/hormonal changes

• Obesity: greater weight places greater mechanical stress on joints (knees and hips)

• Genetics

• Joint abnormalities

• Weak supporting muscles

• Trauma

• Repetitive joint use

• Occupational stress

• Inactivity

OA sxs

• Usually asymmetrical/unilateral

• Localized rather than systemic

• Pain worsens with activity/use

• Crepitus (grinding/crunching/grating sensation or sound during joint movement d/t roughed surfaces/cartilage loss)

• Limited ROM

• Joint stiffness (<30 minutes and improves w/ movement)

  • joint that locks/gives way: more advanced OA in weight-bearing joint

• Possible instability/locking

heberden vs bouchard nodes

• Heberden nodes → DIP joints

• Bouchard nodes → PIP joints

Both are osteophyte/bony enlargements associated with OA

OA diagnosis

• H&P (main)

• X-ray

  • Joint-space narrowing

  • Osteophytes

  • Cartilage loss-related changes

• Labs mainly used to rule out inflammatory arthritis, infection, gout

• OA synovial fluid: clear/yellow, noninflammatory, WBC <2,000

OA treatment goals

goals

• Manage pain/inflammation

• Prevent disability

• Maintain/improve joint function

• Preserve independence/QOL

OA pain medications

• Acetaminophen (1000 mg Q6h; 4g/day max) → liver toxicity

• NSAIDs

  • GI irritation/bleeding (abd pain, tarry stools, hematemesis)

  • Renal toxicity

  • Cardiovascular effects

• COX-2 inhibitors: celecoxib (Celebrex)

• Opioids

• Cymbalta

• Lyrica

• Topical/counter-irritants

• Intra-articular injections:

  • hyaluronan/viscosupplementation: knee OA to improve lubrication and help reduce pain

• corticosteroid joint injections: temp reduce pain/inflammation

  • excessive → accelerate cartilage deterioration

OA nonpharmacologic treatment

• Weight reduction if appropriate

• PT

• Aerobic exercise

• ROM

• Strengthening

• Flexibility

• Balance training

• Low-impact exercise

• Assistive devices

• Heat/cold

• Tai chi

• Water exercise

low impact exercise for OA

Helps:

• Maintain ROM

• Strengthen supporting muscles

• Improve stability

• Support weight management

examples:

• Walking

• Water exercise

• Tai chi

• Cycling

OA surgery

considered for:

• Significant loss of joint function

• Severe/unrelieved pain

• Conservative treatment failure

• Reduced ability to perform self-care independently

types

• Repair

• Fusion

• Total hip replacement

• Total knee replacement Joint Disorders_UNRS314_VJS

rheumatoid arthritis

• chronic systemic autoimmune inflammatory disease causing symmetrical, erosive inflammation of synovial joints, usually with periods of remission and exacerbation

RA risk factors

• Female sex

• Genetic component

• Viral/bacterial/hormonal factors

• Smoking

• Environmental factors

• Stress

• Comorbidities

• Possible periodontal/gut bacterial associations

RA common sites

• MCP

• PIP

• Wrists

• Feet/MTP

• Knees

• Elbows

• Shoulders

(DIP joint spared)

RA patho

RF antibodies develop against immunoglobulin
↓
Antigen-antibody immune complexes form
↓
Complexes deposit in synovium
↓
Joint becomes swollen/inflamed
↓
Synovium hypertrophies
↓
PANNUS forms (thick, proliferative, invasive inflamed synovial tissue that destroys cartilage and eventually bone)
↓
Pannus erodes cartilage + tendons + ligaments + bone

RA sxs

• Morning stiffness that improves with activity (≥60 minutes to several hours)

• Symmetric swelling

• Warmth

• Tenderness

• Pain

• Small joints first

• Reduced ROM

systemic RA sxs

• Fatigue

• Malaise

• Muscle aches

• Anorexia

• Weight loss

• Low-grade fever

• Anemia

• Possible lymphadenopathy

RA deformities

• Swan-neck deformity: PIP hyperextends, DIP flexes, MCP may flex

• Boutonniere deformity: PIP flexes, DIP hyperextends

• ulnar deviation: fingers drift toward ulnar side due to joint capsule stretching and muscle imbalance

• rheumatoid nodules: firm, usually nontender subcutaneous nodules, often near extensor surfaces such as the elbow

• hallux valgus: lateral deviation of the great toe with bunion formation; can occur with chronic RA

RA diagnosis

• Rheumatoid factor (positive ~80%)

  • not only specific to RA

• Anti-CCP (most specific)

• ESR/CRP → active inflammation

• ANA

• Synovial fluid: inflammatory and cloudy with elevated WBC; >20,000-25,000/µL

• X-ray/imaging

RA treatment goals

• Decrease pain/swelling

• Prevent structural joint damage

• Preserve joint function

• Slow progression

• Reduce systemic disease activity

RA medications (NSAIDs + glucocorticoids)

• NSAIDs: pain, inflammation, swelling (does not stop progression/prevent joint destruction)

• Glucocorticoids: rapid tx pain, swelling, stiffness, acute inflammatory activity (bridge for slower DMARDs)

  • SE: infection, hyperglycemia, osteoporosis/fractures, weight gain, thin skin, GI problems, mood changes

RA medications (DMARDs + biologics)

• DMARDs: slow disease progression and prevent permanent joint destruction (early RA)

  • first-line: methotrexate (MTX)

    • SE: bone marrow suppression, hepatotoxicity (monitor CBC/LFTs)

  • Hydroxychloroquine/Plaquenil: report vision changes/eye exams

  • Leflunomide/Arava: liver injury, diarrhea, teratogenicity (no pregnancy)

  • Sulfasalazine

  • Methotrexate

• Biologic agents

  • Etanercept — Enbrel

  • Infliximab — Remicade: TB testing/chest imaging before therapy

  • Adalimumab — Humira

  • Rituximab — Rituxan

  • Abatacept — Orencia

• IMMUNOSUPPRESION → INFECTION RISK

  • TB testing, hepatitis testing, avoid infection exposure/crowds, no live vaccines, monitor fever/nfection

RA nursing management

• Pain control

• Maintain ROM

• Preserve mobility

• Prevent deformity

• Rest during flares

• Exercise when inflammation controlled

• Coping/body image

• Sleep

• Medication education

• Infection precautions

• Nutrition/spiritual support

RA exercises

• ROM

• Strengthening

• Low-intensity aerobic activity

• Water exercise

• PT/OT

During severe acute inflammation→ limit exercise intensity/repetitions

OA vs RA

	OA	RA
Main problem	Cartilage degeneration	Autoimmune inflammation
Pattern	Often asymmetrical	Symmetrical
Inflammation	Minimal/noninflammatory	Inflammatory
Pain	Worse with activity/later day	Morning stiffness
Systemic symptoms	No	Yes
Common finger joints	DIP + PIP	PIP + MCP; DIP spared

postop joint replacement priorities

• Neurovascular status Q4h

  • Pain, Pulse, Pressure, Paresthesia, Pallor, Paralysis

• DVT/PE prevention: early ambulation, anticoag (Lovenox)

• Infection

• Pain

• Mobility

• Dislocation prevention

• Skin integrity

• Education

hip replacement precautions

AVOID:

• Hip flexion >90°

• Adduction (use abduction wedge/pillow)

• Excessive internal rotation

• Crossing legs

• Twisting

home devices:

• Elevated toilet seat

• Reacher/grabber

• Long-handled shoehorn

• Sock aid

signs of dislocation:

• Pain

• Loss of function

• Limb shortening

• Malalignment

knee replacement device for early knee ROM:

• continuous passive motion (CPM) machine

main indications for amputations

• Peripheral arterial disease

• Diabetes

• Nonhealing ischemic wounds

• Gangrene

• Severe trauma/crush (MVA, workplace injury, sports, military)

• Burns/frostbite

• Cancer

• Severe/recurrent infection/sepsis

• Severe loss of function

PAD/amputation risk factors

• Smoking

• Diabetes: neuropathy, foot ulceration, poor healing, PAD, repeat amputation risk (foot ulcer)

• Obesity

• Hypertension

• Hyperlipidemia

• Increasing age

• Family history of PAD/CAD/stroke

6 P’s of limb ischemia/neurovascular compromise

• Paresthesia: tingling/numbeness/loss of normal sensation

• Pain: sudden increasing distal pain or pain not relieved by medication

• Pressure

• Pallor: arterial insufficiency

• Paralysis: serious neurovascular injury/ischemia

• Pulselessness: severe arterial compromise → report urgently

intermittent claudication

• leg: pain, numbness, aching, heaviness

• occurs w/ exercise/activity (impaired arterial blood flow)

compartment syndrome

• dangerous pressure buildup in a closed muscle compartment → ↓ blood flow → tissue/nerve ischemia → permanent injury

• sxs: tightness, severe pain, tingling/burning, neurovascular changes

• causes: fracture, crush injury, severe muscle bruise, excessive exercise/overstretching, tight cast/bandage

geriatric amputation considerations

• Cognitive changes

• Lower cardiopulmonary reserve

• Reduced coordination

• Visual/hearing impairment

• Weakness/deconditioning

• Gait/balance problems

• Limited ROM/arthritis

• Reduced independence

• Multiple comorbidities

• Social determinants

• 4 M’s: what matters, medications, mobility, mentation

pediatric amputation considerations

• Often related to congenital limb differences

• Parents also experience grief

• Rehab must educate both child + parents

• Repeated prosthetic evaluation/refitting is needed with growth

psychological response to amputation

• Grief: not just limb

  • also body part, function, independence, roles/routines, body image, future expectations

• Anger

• Crying

• Denial

• Withdrawal

• Anxiety

• Depression

• Body-image changes

• Fear of intimacy

• Reduced self-esteem/isolation

• FAMILY NEEDS SUPPORT TOO

interdisciplinary rehab team

• Patient/family

• Nursing

• Rehab physician

• Psychologist/psychiatrist

• PT

• OT

• Social worker

• Case manager

• Dietitian

• Prosthetist

• Chaplain

• goal: restore and maintain optimal function and quality of life

residual limb care

• Promote wound healing

  • wound care: mild soap/water, soft dressing, avoid adhesive directly on fragile skin, inspect skin regularly

• Prevent infection

• Manage edema

• Shape limb for prosthesis

• Prevent contractures/deformity

• Maintain alignment

• Preserve ROM/strength

• Prepare for prosthetic use

residual-limb edema management

• Soft dressing

• Ace wrap

• Residual-limb shrinker/sock

• Semi-rigid/rigid dressing when indicated

• goal: promote healing, shape limb, prepare for prosthetic fitting, improve comfort

limb wrapping

• figure-8 wrapping

• Control edema

• Shape limb

• Promote healing

• Prepare for prosthesis

positioning/contracture prevention

• prevent: malalignment, contracture/deformity, loss of ROM

• contractures make transfers, ambulation, prosthetic fitting/use more difficult

prosthesis preparation

• Wound healing

• Edema reduction

• Residual limb shaping

• Adequate ROM/strength

• Skin integrity

• Functional training

• prosthetist: helps evaluate, fit, and adjust the patient’s prosthetic limb

pain after amputation

• residual limb pain: originating from remaining tissue/surgical site

• phantom limb pain: perceived in limb that is no longer physically present

  • phantom sensation: feeling that missing limb is still there

amputation care plan priorities

• Knowledge deficit

• Self-care needs

• Impaired mobility

• Residual pain

• Body image/change in routine

• Psychosocial stress

• Spiritual distress

• Social determinants affecting outcomes