Musculoskeletal Nursing Care & Orthopedic Conditions

Osteoarthritis vs. Rheumatoid Arthritis

• Osteoarthritis (OA)
  • Also called “degenerative joint disease.”
  • Primarily a wear-and-tear process affecting cartilage.
  • Management focuses on localized joint protection and symptom control.
• Rheumatoid Arthritis (RA)
  • Auto-immune etiology; systemic inflammatory response.
  • All general principles of immunity/auto-immunity apply (e.g., immunosuppression, infection monitoring).
  • Nursing care differs from OA because of systemic involvement (fever, fatigue, multi-joint pain, need for disease-modifying drugs).

Lower-Extremity Amputation & Prosthesis

• Post-surgical swelling must resolve before prosthesis fitting.
• “Stump shrinker”
  • Tight, elastic stocking applied immediately post-op.
  • Functions like compression/anti-embolism stockings to reduce edema.
• Prosthesis care
  • Must be completely dry before application.
  • Routine: stump shrinker → clean sock with a metal screw at distal end → prosthetic socket.
  • Comfort fit critical to prevent skin breakdown.

Pain & Comfort Concepts in Orthopedics

• Ice vs. Heat
  • Ice for the first 24–48\text{ hr} after acute injury/surgery → slows bleeding/edema.
  • Heat may be introduced after 48\text{ hr} based on patient preference to promote circulation & relaxation.
• Orthopedic surgeries (e.g., hip, knee, ORIF) carry significant blood loss; most patients placed on iron supplementation post-op.

Total Knee Replacement & Continuous Passive Motion (CPM) Machine

• Purpose: maintain joint mobility immediately after surgery.
• Key components
  • Soft cotton/sheepskin pads under thigh, calf, and foot.
  • Straps secure foot to prevent plantar-flexion (foot-drop).
• Parameter adjustment (per MD/PT order)
  • Flexion degrees: start ≈ 30^{\circ}, advance to 45^{\circ}, goal up to 60^{\circ} as tolerated.
  • Speed can be increased gradually.
• Nursing interventions
  • Pre-medicate for pain before initiating CPM or PT sessions.
  • Monitor for discomfort; reduce degree/speed if intolerable.
  • Ice wrap often applied concurrently over knee.

Patient & Family Teaching (Global Themes)

• Medications: indications, dosing schedules, side-effects.
• Infection prevention & wound care.
• Exercise/physical-therapy protocols; safe weight-bearing.
• Use of assistive devices (cane, walker, crutches): demonstrate 1-, 2-, and 3-point gait.
• Reinforce with teach-back: client verbalizes or demonstrates understanding.

Hip Fracture

• Classic clinical picture
  • Affected leg appears shortened.
  • Foot/leg externally rotated.
  • Severe pain; possible intra-capsular bleeding.
• Goal: prompt surgical repair (often same day) to limit pain & hemorrhage.
• Pre-op traction: Buck’s (skin) traction
  • Velcro boot or calf sleeve connected to pulley & free-hanging weights (≈ 5–10\text{ lb}) to align & stabilize.
  • Weight must hang freely—not rest on bed/floor.
  • Monitor skin integrity under boot and neuro-vascular status of foot.

Soft-Tissue Injuries

• Strain: excessive stretching/tearing of a tendon.
• Sprain: excessive stretching/tearing of a ligament.
• Dislocation: bone displaced from normal anatomic position; requires closed reduction or surgery.
• Bursitis: inflammation of bursal sac; rest & ice essential, often co-exists with arthritis.
• Rotator-cuff injury: overuse of shoulder tendons (e.g., baseball pitchers); may need surgical repair.
• Standard care mnemonic R-I-C-E
  • Rest → protect & immobilize.
  • Ice → decrease pain & swelling.
  • Compression → elastic bandage, stump shrinker, TED hose, SCDs to limit edema & DVT risk.
  • Elevation → reduce swelling when appropriate (contraindicated in unstable fractures).

Lifting & Staff Safety

• Use mechanical devices (“safe-back” equipment, ceiling lifts) to prevent caregiver musculoskeletal injuries.

Carpal Tunnel Syndrome (CTS)

• Pathophysiology
  • Swelling within carpal tunnel compresses median nerve → neuropathic pain.
  • More common in women; strong familial (congenital) predisposition.
  • Aggravated by repetitive wrist/hand motion (typing, chopping, assembly-line work).
• Clinical features
  • Hand, finger, arm pain described as burning, lightning, electric.
  • Weak grip; impaired fine motor skills.
  • Positive Phalen’s test: flex wrist → pain within seconds.
  • May develop tremors; EMG used to assess nerve damage.
• Conservative management
  • Rest & wrist splint (slight extension) worn for prolonged periods.
  • Ice for inflammation; NSAIDs often ineffective.
  • Neuropathic agents: Gabapentin (Neurontin).
  • Oral or injected steroids to shrink local swelling.
• Surgical release
  • 10-minute out-patient procedure; usually one hand at a time.
  • Post-op: ace wrap/cast x 4–7 days; encourage finger motion to assess color, motion, sensation (CMS).
  • Early intervention prevents permanent numbness; delayed surgery may leave lasting sensory loss.

Quick Glossary

• CPM = Continuous Passive Motion machine.
• ORIF = Open Reduction Internal Fixation (hip fracture surgery).
• Buck’s Traction = skin traction with weights/pulleys for hip alignment.
• RICE = Rest, Ice, Compression, Elevation.
• TED hose/SCDs = elastic & pneumatic devices preventing DVT.

Numerical / Statistical References & Examples

• Ice optimal for 24–48\text{ hr} post-injury.
• CPM flexion settings: 30^{\circ} \rightarrow 45^{\circ} \rightarrow 60^{\circ} as tolerated.
• Typical Buck’s traction weight: 5–10\text{ lb}.