3rd Semester Test 1 Ortho

What is this musculoskeletal diagnostic?

First line imaging for bone/joint abnormalities

Identifies fractures, alignment, degeneration, joints out of socket

Contraindicated in pregnancy (Usually earlier) later can be discussed

Remove metal objects due to obstructing the view of the pt anatomy

X-ray (Radiography)

What is this musculoskeletal diagnostic?

Cross sectional imaging (bone + soft tissue)

Higher detail than X-ray

Assess contrast allergies and renal function prior to diagnostic

If with contrast asses for pregnancy/lactation. Pregnancy contraindicated

Hold metformin and remove metals

CT (computed tomography)

What is this musculoskeletal diagnostic?

Best for soft tissue (ligaments, discs, infection, tendon tears

No ionizing radiation

Hold metformin 2 days prior to this diagnostic

VERY strict metal screening required

Needs to be NPO for about 8 hours or before midnight if on abdomen and pelvis

MRI (Magnetic Resonance Imaging)

What is this musculoskeletal diagnostic?

Direct visualization of joint structures (commongly used for Knee and shoulder joints)

Pre-op: needs to be NPO, consent, and hold anticoagulants

Post-op: monitor NV status and infections

Teach to watch for infection or pain/redness after diagnostic

Arthroscopy

What is this musculoskeletal diagnostic?

Measures bone mineral density

Diagnoses Osteopenia/Osteoporosis

Hold calcium 24 hours prior and cannot be done within 24 hrs of receiving other diagnostics like CT or nuclear scans

Avoid if pregnant

Baseline testing is recommended for females 40-49

Remove all metals

DEXA (Bone density)

What is this musculoskeletal diagnostic?

Detects infections, tumors, fractures

Hot spots which increases activity or uptake of radioisotope tracers

Cold spots decreases perfusion or uptake/ metabolism causing dead bone

Encourage hydration post injection//procedure. Encourage to pee

Contraindicated for pregnant women

Bone scan

What is this musculoskeletal diagnostic?

Evaluates muscle vs nerve dysfunction (peripheral muscle weakness)

Commongly ordered for carpal tunnel sydrome

Used for weakness, neuropathy

Hold anticoagulants

Check for pacemakers or any medical device prior to test

Question muscle relaxers for this test might need to hold

Electromyography (EMG)

What should you look at if serum calcium is decreased?

Check serum albumin first if low

What are we screening for when we use an RF (rheumatoid factor)?

Rheumatoid arthriitis

What would we use for an earlier detection of rheumatoid arthritis?

Anti-CCP diagnostic

What are we screening for when we use a ANA diagnostic test?

Systemic lupus

If CRP and ESR and elevated what could this indicate?

That their is inflammation and possibly and infection somewhere

What could elevated CK mean for muscle injury labs?

This could mean there is some type of muscle damage in the body

What is this lab value?

End metabolite of purine metabolism is normall yexcreted in urine

Levels are usually elevated with gout

GOUT is the main problem with this lab

Uric Acid

What is this in the musculoskeletal system?

This bone cell plays a role in building new bone

Osteoblasts

What is this in the musculoskeletal system?

This bone cell plays a role in cleaning the bones or reabsorbing

Osteoclasts

What law is this in the musculoskeletal system?

States that bone grows or remodels itself in direct response to physical forces, stress, or demand placed upon it.

Increased load= increased density.

Decreased load = decreased density (immobility, spaceflight)

Wolff’s Law

What type of exercise is this?

Tension without movement. Ex. Kegels, gluteal sets, and quad sets

Isometric

What type of exercise is this?

Movement occurs. Ex. arm through range of motion, straight leg raises

Isotonic

What is this connective structure?

Encloses individual muscle bundles and allows them to act independently and to glide over each other during contraction. Supports and separates structures.

Fascia

What is this connective structure?

are shortened, tight muscles, tendons, ligaments, or skin that can result from lack of join mobility, burns scars. Results in deformity and loss of motion/mobility

Contractures

What should a nurse do if a patient is experiencing pain during PROM or AROM?

Stop if pain or resistance occurs

What type of injury is this?

A trauma which the body oif the muscle or attachment of a tendon has been damaged by overstretching, misuse, or overexertion. Muscle/tendon injury

Strain

What type of injury is this?

A traumatic injury in which the surrounding ligament dibers have been damaged by overstretching or exertion. Ligament injry from twisting force

Sprain

What is this?

Most common compression neuropathy in the upper extremity

Caused by increased pressure in the carpal tunnel; leads to sensory and motor symptoms

Risk factors: Repetitive wrist motion, diabetes, thyroid disease, pregnancy, hormonal changes, Rheuatoid arthritis

S/S: Numbness/tingling (first 3 fingers and radial side of 4th finger), pain worse at night, weak grip strength

Inflammation or edema increases tunnel pressure; results in numbness, tingling, weakness

Carpal Tunnel Syndrome

What diagnostic is this for carpal tunnel syndrome?

Taping gently over the median nerve of the wrist may reproduce tingling

Tinel’s sign (Tapping——> tingling)

What diagnostic is this for carpal tunnel syndrome?

Hold the wrist for 60 seconds in maximum flexion produces tingling and numbness over the distribution of the median nerve

Phalen’s test (flexion——> symptoms)

What would we use to get a confirmation on carpal tunnel syndrome or dicern the cause of the muscle weakness/pain?

EMG

What complications can fractures cause?

Hemorrhage into muscle joints, dislocation and rupture of tendons, disruption of blood supply, neurovascular compromise

What is the main concern for an open fracture?

Infection

What type of displacement is this?

The two ends of the broken bone are separated from another and out of their normal position. Bone ends misaligned

Displaced

What type of displacement is this?

Alignment maintained. The bone fragments are still in alignment

Non-displaced

What type of displacement is this?

Transverse, spiral, comminuted, greenstick fractures

Patterns

What is the initial management for a fracture?

Perform neurovascular assessment, Immobilize extremity (ACE wrap/splint), sterile covering, pain control

What is this fracture complication?

Fat globules released from the bone marrow, enter the systemic circulation and travel to the lungs and other tissues in the body. Fat globules then lodge in small vessels of those areas causing ischemia. Common with joint arthroplasty, long bone and pelvic fx.

Key Findings: Dyspnea, hypoxia, tachypnea (HIgh RR), tachycardia, confusion, decreased LOC, PETECHIAL RASH (distinctive but not always present)

Fat Embolism Syndrome

What fracture healing complication is this?

Slowed healing, Does not occur at a normally expected rate

Delayed union

What fracture healing complication is this?

Healing in poor alignment. Can be the result of inadequate fracture

Mal-union

What can be given to bind to the fat globules in the blood to prevent having a fat embolism?

Albumin

What is this fracture complication?

Loss of blood supply = bone death

Common after femoral head fracture

Risk factors: steroids, trauma, vascular disease, radiation therapy, RA, and Sickle cell disease

Avascular Necrosis

What is this?

Increased pressure in muscle compartment. Injury causes increasing inflammation/edema, blood flow cannot make it past the injury site, so you lose arterial blood flow past the point of injury. MEDICAL EMERGENCY

Key Findings: Pain out of proportion and with passive stretch movement (early sign), Paresthesia (Early sign), Paralysis/pulselessness (late sign), Pallor/cool to touch (early), Myoglobinuria (dark reddish/ brown urine and can lead to acute tubular necrosis)

Complications: Irreversible muscle/nerve damage, foot drop, nonfunctioning extremities, amputation

Compartment Syndrome

What kind of compartment syndrome is this?

Can result from decreased compartment size from restrictive dressings, splints, casts

External

What kind of compartment syndrome is this?

Can result from increased compartment contents related to bleeding, inflammation, edema, or IV infiltration, EX. snake bite crush injury

Internal

What is the timeline for tissue during compartment syndrome?

Ischemia begins within hours

Permanent damage possible within 4-6 hours

What are the 6 P’s?

1. Pain

2. Pallor

3. Pulse

4. Paresthesia

5. Paralysis

6. Poikilothermia

What is this related to compartment syndrome?

Opens compartments to relieve pressure

It is a secondary closure

Fasciotomy

What is this orthopedic surgery?

Replacement of the femoral head and acetabulum. Used for severe pain and loss of function

Indications: Osteoarthritis, RA, avascular necrosis, congenital deformities, femoral neck fx, pathological fx, and repeated joint dislocations, severe pain w ADL.

Total Hip Arthroplasty (THA)

Which surgical approach for a Total hip arthroplasty requires hip precaution and the one that doesnt?

Posterior lateral has a higher risk of dislocation so hip precautions for 2-3 months

Anterior lateral results in less risk of dislocation so no need for precautions

What are the hip precautions (Posterior lateral)?

Avoid flexing over 90, avoid internal rotation of toes, avoid crossing legs, use abduction pillow, use elevated seating, point toes up in neutral postion, keep affected leg slightly abducted with pillows.

What orthopedic surgery is this?

Consists of replacement of the femoral condyle and the tibial plateu with prosthetic devices

Preop Care: CBC, CMP, PT/INR, EKG, infection screen, antibiotics within 60 min before incision

Postop Care: Early ambulation, NV check, pain mangement Ice/elevate, DVT prevention

Care for this: Early ambulation is priority, NO pillow under knee, support under ankle

Total Knee Arthroplasty

How do we take care of a plaster cast?

Dry time is 24-72 hrs, Handle with palms only, no weight bearing until dry, Avoid external heat, petal rough edges

What should we teach a pt about cast care?

NEVER insert anything under the cast

Itching can be relieved by cool air/ice pack

Monitor skin around cast edges

Cleanse extremity around cast daily

Exercise when cast is dry, ROM, Isometric/tonic

What is this treatment modality?

Immobilizes and aligns fractures, decreases muscle spasms, reduces pain

Principles: Let weight hang freely, maintain line of pull, do not remove weights without order, prevent skin breakdown, watch ropes for fraying, no knots in pulleys

Traction

What type of skin traction is this?

Applied to the skin and soft tissue providing a light pull

Exerts a pull in one plane or direction and is used on the low extremity to relieve pain/muscle spasm from hip/femur fx. Usually 24-72 hrs treatment before surgery

MOST IMPORTANT is to watch for skin breakdown and keep heels off the mattress

Bucks Traction

What is this treatment modality?

Pins/ wires inserted into bone attached to the external frame. Used for complex Fx

Usually all pt are NWB

External Fixators

What is this bone disorder?

Chronic metabolic bone disease = decreased bone density

Most common bone disorder

With this serum calcium level is usually normal

Patho: Imbalance in bone remodeling, increase in osteoclasts, decrease in osteoblasts

Risk factors: Ages over 50, females decreased estrogen, family hx, sedentary lifestlye, caucasian/asian

S/S: Fragility fractures (First indication), back pain, height loss, kyphosis, vertebral compression fracture (Diagnostic red flag for this), Urine calcium is elevated during shift of calcium in blood

Osteoporosis

What is this bone disorder?

The softening of bones due to vitamin D deficiency (can’t absorb calcium)

Osteomalacia

What is the gold standard diagnostic for osteoporosis?

DXA scan

What is the management for osteoporosis?

Exercise (Teach pt to walk 30 min; increases bone strength/balance), fall prevention, smoking cessation, home safety (rubber bottomed shoes, no throw rugs, clear walkways, adequate lighting, watchful for slippery surfaces (kitchens/bathrooms).

What are some calcium rich foods?

Broccoli, kale, tofu, almonds, yogurt, milk, cheese, fish with bones

What medication is this for osteoporosis?

It is the first line medication for osteoporosis; prevents fractures

Decreases osteoclast activity = decreased bone resorption

Ex. Alendronate, Ibandronate, risendronate, zoledronic acid. “-dronate”

Monitor calcium levels due to causing low levels

Teachings: Take with empty stomach, full glass of water, remain upright for 30 min, avoid GI irritation

Bisphosphonates

What medication is this for osteoporosis?

Parathyroid hormone analog

Increase osteoblast activity

Max use of 2 years if all therapies have failed

Monitor for orthostatic hypotension, tachycardia, leg cramps, and dizziness; occurs within 4 hrs of injection

Contraindicated with hypercalcemia, bone cancer, pagets disease

Teriparatide

What medication is this for osteoporosis?

Mimics estrogen in bone; decreases bone resorption

USed in postmenopausal women

Also decreased breast cancer risk

Safety: Risk for DVT/PE, hot flashes leg cramps, avoid prologned immobility, stop 72 hours prior to prolonged bedrest, encourage ambulation

Raloxifene

What medication is this for osteoporosis?

Monoclonal antibody

Treatment for post-menopausal osteoporosis

Inhibits osteoclasts formation, function, survival

Check calcium before givng: risk for hypocalcemia, Dental exams due to risk of osteonecrosis of the jaw, watch infection risk

CANNOT take if you are pregnant, lactating, or plan to become pregnant

Denosumab (Prolia)

What medication is this for osteoporosis?

Decreases osteoclast activity

Less commonly used, pain relief in fractures

Can be used to treat osteoporosis, hypercalcemia, and Paget’s disease

Calcitonin

What is this connective tissue disorder?

Most common arthritis

A progressive, non-systemic disorder of the synovial joints. Progressive deterioration of the articular cartilage. Women are more affected than men in every age

Localized cartilage breakdown, UNILATERAL joint pain

Menifestation: Pain worse with activity, Pain improves with rest, UNILATERAL, morning stiffness less than 30 min, crepitus, decreased ROM, Joint effusion

Medications: Topical NSAIDS, Oral NSAIDs, Acetaminophen, Duloxetine, Capaicin cream

Osteoarthritis

What is this connective tissue disorder?

A chronic progressive, systemic, autoimmune disease; The immune system attacks the tissue surrounding the joints, causing damage

There is no known cure or prevention

BILATERAL joint pain; affects the small joints first

Risk factors: Infection (trigger), Stress/smoking (trigger), obesity, women, genetics, older age 40-60

2 deformities: Ulnar drift, Swan neck deformity (Late signs)

Manifestation: Joint pain, over 30-60 min stiffness, joint swelling, symmetrical pattern, dry eyes and mouth, systemic symptoms like the cold

Waxes and wanes of pain

Diagnostics: Anti-CCP, RF, Elevated ESR/CRP

Rheumatoid Arthritis

What is the hallmark sign for Rheumatoid Arthritis?

Pannus (Synovial lining hypertrophies into a mass)

What is this connective tissue disorder?

A metabolic disorder in which purine metabolism is altered and allows the build up of uric acid

Risk factors: Male, alc use, chronic kidney disease, obesity, hereditary, aspirin, diuretics, high purine diet

2 types: Primary and Secondary

S/S: Acute: Red, warm, swollen joints, low grade fever, can last 1 to 2 weeks

Chronic: Tophi

Diagnostic: Serum Uric acid and Arthrocentesis

Gout

What type of Gout is this?

Hereditary error of purine metabolism leads to overproduction or retention of uric acid

An inborn error

Primary Gout

What type of gout is this?

Occurs when a separate factor either increases production of uric acid or decreases excretion of uric acid

Increased uptake of purine rich foods is a cause of this: Organ meats, shellfish, fructose drinks

Medication can also do the same: Thiazide diuretics

Secondary Gout

What is the gold standard and most definitive diagnostic test for gout?

Arthrocentesis

What is the priority action during an acute gout attack?

Reducing pain and inflammation

What is this medication for gout?

Reduces migration of leukocytes to the synovial fluids

Used in acute attack

Needs to be taken with food

May be used in low doses to prevent recurrent attack; usually has dramatic effect with pain relief

Does not lower uric acid levels in the blood or increase uric excretion from the kidneys

Colchicine

What is this medication for gout?

Decreases the production of uric acid by inhibiting the action of the enzyme that converts purines to uric acid and promotes uric acid excretion

SE: skin rashes, hypersensitivity reactions

Interactions: Prolongs the action of anticoagulants, Thiazide diuretics may reduce action

Take with meals and full glass of water

Febuxostat can be used if this is not tolerated

Allopurinol

What is this medication for gout?

Promotes kidney excretion of uric acid

Contraindicated if patient has chronic kidney disease and uric acid nephrolithiasis

Contraindicated to use with clients that have renal impairements or stones; increases risk of uric acid stones

SE: Renal calculi, allergic dermatitis, N/V, anemia, fever, flushing, headache

Probenecid

What are the purine foods that need to be restricted?

Mussels, seafood, goose, venison, meat soups, anchovies, liver, sardines, herring, kidneys, sweet breads, wine/beer, fructose sweetened beverages

What is the most common cause for amputation and what is the target for it?

Diabetes Mellitus is the most common. Nurses should always target towards prevention

What is our priority action when there is emergency care for an amputation?

Prioritize life over the limb. Control the hemorrhage

What is the treatment for emergency care for amputation?

Control Hemorrhage first, Treat for shock, Wrap limb, bag it, place in ice water, lastly transport with pt.

What classification for an amputation is this?

The wound is left open to allow for drainage

Major indication is infection

The wound is closed by secondary closure

Have a better chance of success replantation when associated with trauma

Open (Guillotine)

What classification for an amputation is this?

The stump is covered by a flap of soft tissue and skin

Preformed to create a weight-barring stump

Closed (Flap)

What classification for an amputation is this?

An amputation performed through a joint

Disarticulation

What amputation diagnostic is this?

Uses contrast and imaging, to visualize blood flow through the arteries or veins

Angiograms

What amputation diagnostic is this?

MEasure the difference between ankle and brachial systolic pressure

Ankle-brachial indiex (ABI)

What amputation diagnostic is this?

Mesure oxygen pressure in an extremity to indicate blood flow in the extremity

Transcutaneous oxygen pressure (TcPO2)

What is the postoperative care for an amputation?

Monitor bleeding, watch infection, ELEVATE 24-48 hrs only, Avoid prolonged dangling (Prolonged increases risk of contractures)

What is this rehab technique for amputations?

Decreases hypersensitivity of the residual limb

Reduce stump pain and phantom pain; trains brain to interpret sensory input normally

Works by gradually exposing the residual limb to different sensory stimuli (touch, pressure, texture, temeprature), which helps the nervous system adapt and respond less intensly over time

Desensitization

What is the contracture prevention for amputations?

For Knee flexion contracture: No pillows under the knee after 24-48 hours

For Hip flexion contracture: Lie prone for 30-60 min several times daily: If cannot lie prone, lie flat

For abduction contracture: Adduction exercises, lift stump, cross over midline and back

Keep stump in neutral position

ROM exercises

Avoid sitting in chair more than one hour with hips flexed

What is the most common contracture in amputations?

Hip flexion contractures

What type of DMARDs is this?

Often combined with other DMARDs

NO live vaccines; give non-live vaccines

Monitor- CBC, liver enzymes, kidney function, s/s of infection

Should not be initiated or stopped in the presence of active bacterial infection, but can be initiated after infections resolve

Administered oral

Ex. Methotrexate, hydroxychlororquine, Leflunomide

Non-biologic DMARDs

What non-biologic DMARD med is this?

Preferred for early treatment RA

Monitor CBC, liver and kidney function

Contraindicated with pregnancy and lactation

Increased risk of infection with this med due to bone marrow suppression

Are prescribed folic acid supplement dialy to prevent oral ulcers

Methotrexate

What non-biologic DMARD med is this?

Can be given during pregnancy depending on risk vs benefits

S/E: May cause ocular toxicity and ototoxicity

Must have baseline and regular exams

Monitor liver and kidney function and CBC for bone marrow suppression (Doesn’t cause as bad as methotrexate)

Hydroxychloroquine

What non-biologic DMARD med is this?

If stopped taking, need to do a drug elimination procedure prior to conceiving

Men trying to father a child should not take

Will need a negative pregnancy test prior to starting

Monitor renal and liver function and CBC

Leflunomide

What type of DMARDs is this?

Usually not combined with other biologics

NO live vaccines (can cause severe bone marrow suppression), but DO use regular vaccines

Patient should must have baseline screenings: Hepatitis screenings, TB screening, CXR

Monitor for infections: CBC, electrolytes, renal and hepatic function

Can combine with nonbiologics

IV and SQ

EX. Etanercept, Infliximab, Adalimumab, Golimumab, Abatacept, Tocilizumab, Sarilumab, Rituximab, Certolizumab. “-mab”

Biologic DMARDs

Which TNF blocking agents can exacerbate heart failure?

Etanercept/Infliximab

What type of medication is this for OA or RA?

Prevents or suppresses many of the components of the inflammatory process; can be given temporarily for flare. Not long term, and cannot abruptly stop

S/E: GI upset, dry skin, fluid retention, increased sodium, decreased potassium, Osteoporosis, hyperglycemia, avascular necrosis

Corticosteroids

What is this connective tissue disease?

A disorder in which the atypical immune response results in chronic inflammation and destruction of healthy tissue; chronic multisystem autoimmune disease

Risk factors: Female sex, Genetic predisposition, UV exposure, Infections/stress, Certain medications

Manifestation: Malar rash, Photosensitivity, Polyarthralgia, Proteinuria, Fatigue/Fever, Skin lesions, BUTTERFLY rash, oral/nasopharyngeal ulcers, alopecia, Swan neck fingers, subluxation with hyperlaxity of joints, Scarring/permanent damage of renal system.

Diagnostic: ANA, Anti-dsDNA (Correlates with nephritis), low C3/C4, urinalysis for nephritis

Systemic Lupus Eryhtematosus

What is the education for Systemic Lupus Eryhtematosus?

Limit sunlight and UV exposure, Mild soaps, lotion daily, pat skin dry, do not rub, Steroid creams for rash, avoid crowds, pace activities, avoid stress, stop smoking

What is the first line therapy for SLE (Lupus)?

Hydroxychloroquine

What is this connective tissue disease?

Chronic pain syndrome which manifests as widespread musculoskeletal pain, stiffness, and tenderness that affects both sides of the body: Central sensitization syndrome

Abnormal pain processing, altered neurotransmitter activity, amplified pain perception

Diagnosis: Generalized pain, Moderate to severe symptoms burden (Fatigue, Unrefreshing sleep, cognitive difficulties (Fibro Frog), Symptoms present for at least 3 months

Interventions: Aerobic exercises(Most effective therapy), sleep improvement, cognitive behavioral therapy, reduce foods that worsen symptoms.

Fibromyalgia