Handout Orthopedic Nursing Chapter11,12,13

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Chapter 11 ◙Osteoporosis -low bone mass = fragile=Fx -resorption>formation -imbalance in osteoclastic and osteoblastic act. -dec. in cortical thickness -dec in no. and size o e trabeculae of cancellous bone trabecular plates abnormally perforated/ Fx trabecular connectivity is reduced t-scope- no. of standard deviation (SD) above or below the average BMD (bone mineral density) of young women. >Normal- not >1 SD below e young adult >Osteopenia- 1-2.5 below e young adult mean value >Osteoporosis- >2.5 SD below e young adult mean value >Severe Osteoporosis- more than 2.5 SD below the young adult mean value ◙Idiopathic Osteoporosis - younger men/ premenopausal women ◙Type 1 Osteoporosis -postmenopausal 51-75 -accelerated & disproportionate loss of trabecular bone - vertebral bodies and distal forearm common complication ◙Type 2 Osteoporosis -M/F over 70 -Fx in femoral neck, proximal humerus, proximal tibia & pelvis (cont. cortical and trabecular bone) ◙Etiology -unk/genetic/environment ◙Peak Bone Mass –young adulthood, maximum amount ◙Estrogen deficit/Amenorrhea - bone loss after menopause, anorexia nervosa ◙Risk Factors: >Genetic >Low estrogen >Amenorrhea >Meds= thyroid meds/corticosteroids/anticonvulsants and anticoagulant >Low Ca >Smoking & Alcoholism >Sedentary lifestyle >Vertebral Crush Fx >Hip Fx >White, thin small body build >Inflammatory arthritis, GI dse/surg. ◙Tx. Mgt. >High Vit.D Ca >Acute Pain= narcotic/analgesics/NSAIDS >Chronic Pain=NSAIDS >Weight lifting/bearing exercises >HRT Estro and Proges >Safety ◙Paget’s Disease -d/o in the bone architecture -inc. rate of bone tissue breakdown (osteoclast) and bone formation (osteoblast) ◙Pain in >Femur >Tibia

>Lower Spine >Pelvis >Cranium ◙Pagetic lesion Arthritis Pain rad. From the Spinal Stenosis spine to the lower Nerve Root impingement extremities Sx: >Enlargement of the skull >Kyphotic posture >Height loss >Bowing of the long bones >Vetigo >Tinnitus Compression of the cranial nerves >Heaing loss >Blindness Tx. Mgt: ◙Symptomatic >Pharmacologic: Analgesics Anti-inflammatory drugs >Aspirin >Plicamyin (Mithracin)-unreponsive to othe Tx. >Conservative: Heat therapy, massage bracing ◙Asymptomatic: No Tx >Surgery >Calcitonin & Etidronate –retard resorption ◙Osteomalacia - widespread decalcification and softening of bones - dec. calcified bone mass -calcium and phosphorus fails to be deposited in the bone matrix -deformities in the weight-bearing bones, distortion in bone shape and pathologic Fx. -deminiralied/ low Vit.D =Spine>Pelvis>LE =Bones-Bent/Flattened =Kyphotic and scoliotic/ Coxa-Vara of the Femoral Neck =Femoral Neck –Commonly under pressure ◙Precipitating Factors: >Low Vit.D >Meds. Phenytoin , Fluoride >Liver/Kidney Dse. >Malabsrption >Gastrectomy > Inflammatory bowel dse >Renal dse. >Chronic renal failure > Tubular Necrosis > Hypophosphatemia-low phosphate in blood ◙Tx. Mgt. >High Ca, Phosphorus, Vit. D Diet >KFT >Safety >Sun Bathing ◙Gout Purine Lasix

Cyclosporine, Hydrochorthiazide

↑Uric Acid Uric acid concentration in blood Hyperuricemia Deposition of crystalline Na Urate Particularly in the Synovial jt. ◙Primary gout-unk/genetic purine metabolism

2 ◙Secondary gout-aquired impaired renal fxn, malignant dse, myeloproliferative d/o and hemolytic anemia. ◙Clinical Manifestation p254-255

Chapter 12

◙Osteoarthritis (misnomer) ◙Degenerative Joint Disease (a.k.a) -progressive -noninflammatory d/o of mobile jts. esp. weightbearing -loss of articular cartilage ◙Primary= aging & Genetic (autosomal recessive) ◙Secondary= any condition >Trauma Sprain Strain Dislocation Fractures Avascular necrosis Osteonecrosis > Mechanical Stress Athletics Hazardous jobs >Inflammation in joint structures Autodigestion of joint by enzymes >Joint instability > Neurologic d/o Charcot neuropathy >Congenital /acquired skeletal deformity Varus leg Dislocated hip Joint laxity Legg-Calve-pertheses disease >Hematologic/Endocrine d/o Hemophilia Hyperthyroidism Hypocalcemia >Meds. Collagen-digesting enzymes Colchicines Indomethacin Steroids ◙Clinical manifestations Objective: popping, cracking, grinding Limited ROM (DIOJ) Unstable, enlarged (spurs,boggy synovium joints) Joint deformity *loss of articular cartilage *collapse of subchondral bone *Heberden’s nodes Subjective: Pain Stiffness(inactivity weather changes) ◙Tx. Mgt >NSAIDS >Steroids >Splint-not for long term use >Heat-suana warm compress >Obese-lose some weght >Sugery: DAAOT ◙Rheumatoid Arthritis ◙Unknown etiology (may be) >Infections >Autoimmunity >Genetics >Others >Autoimmune >Probable familial predisposition >Great Crippling disease >Inflammation of Diarthrodial joint

◙Order of affectations 1. hand joints 2. wrist joints 3. metacarpophalangeal joint 4. knee joint 5. hip joint 6. elbow joint ◙Clinical Manifestation p.261 ◙Swan-Neck deformity >Extension of the Proximal Interphalangeal joint. >Flexion of the Distal Interphalangeal joint ◙Boutonniere deformity > Extension of the Distal Interphalangeal joint > Flexion of the Proximal Interphalangeal joint ◙Hallux Valgus > Lateral deviation of the metatarsophalangeal joint ◙Ulnar Drift > Most common >deviation of the metacarpophalangeal joint to the ulnar side

Chapter 13 Osteomyelitis- infection of the bone ◙Acute Osteomyelitis –initial, <1month ◙Chronic Osteomyelitis – antibiotic therapy failed, >4 weeks ◙DIRECT ENTRY contamination from B-one surgery O-pen Fx A-gunshot wound T-raumatic injury BACTERIA Arterial supply Camp Site (bone) Circulation Slows (growing) Ichemia Bone dies ◙INDIRECT INOCULATION (hematogenous) - from a blood borne disease like: B-oils U-pper Respiratory Tract Infections T-onsillitis T-eeht infection S .aurues most common infecting agent >trauma >weak immune system ◙Tx Mgt. >Cx & Sensitivity- id. the agent to know the appropriate antibiotic >Antibiotic tx- best choice for acute stage as long as there is no ischemia >Saucerization-surgical decompression - to relieve pressure in the bone - to prevent ischemia >Grafting- for extensive damage >.Surgical debridement >Hemovac/ Jackson-Pratt-removal of devitalized tissue >Antibiotic beads Implantation - 6-8 weeks >Amputation- massive infection ◙Septic Arthritis -joint ( +bone) cavity invasion -most rapidly destructive form ◙Agents

3 N. gonorrhea S. aureus S.hemolyticus D. pneumoniae

TB sinus Spread to other parts Complete destruction of bones and joints

Septic Arthritis cont’d Pus- Forming organism Synovial membrane Joint space Closed-space infection ◙Risk factors: >Leukemia >DM >Joint trauma /disease >Corticosteroids, ISD intake >Chronic illness ◙Manifestations: Fever Pain Swelling of joint/s ◙Tx Mgt. Goal: >elimination of the pathogen >removal of joint debris >prevention of deformities >Antimicrobial Tx >Hemovac/ Jackson-Pratt –to drain purulent Synovial effusion >Early immobilization >Needle Aspiration >Arthroscopy >Surgical operation ◙TB of bones and joints ◙TB of the spine- most common and dangerous form found in both adults and children ◙Lesion in the lower thorax, upper lumbar-usual cases ◙Upper thoracic lesion- seen in most children ◙Risk Factors: >D-irty environment >U-ntreated primary (P)TB >D-M >E-SRD >P-oor nourishment >T-rauma ◙Pattern of Invasion: starts centrally, spread outward M. tuberculosis (attacks) Synovial membrane Pdxn of excessive secretion, proliferation and thickening TB granulation tissue (covers) Hyaline cartilage and subchondral bone Pdxn of caseous necrotic material and TB exudates Build up of pressure within the bone/joint Rupture (releasing) Cold Abscess containing necrotic debris and pyogenic pus Bursting in the skin

◙S/Sx Sketetal TB *Early >Night pain dystrophy >Muscle spasms grade fever >Joint swelling >localized redness, warmth *monoarticular involvement reactivated

*Late >Muscle >Low >Night sweats >Anorexia >Cough if PTB >growth def.

◙Tx. Mgt. >Pharmacologic: RIPES+C >Conservative: Bed rest, Traction >Surgical: *Focal Fusion- Bone and joint Stability (-) pain *Arthrodesis- joint fusion (-) pain *Joint Replacement- not now but later Spinal TB (Pott’s dse) ◙S/Sx *Early >Same > with peripheral involvement >discomfort >Dec. in Spinal ROM *Late >Kyphosis >Paraplegia-due to cord compression ◙Tx. Mgt >Pharmacologic: RIPES+C >Conservative: Bed rest >Surgical: *spinal Fusion – prev. vertebral collapse and neurology sequelae in major cases with Neurologic abnormality, spinal instability and large abcess formation

Chapter 12 Osteoarthritis (misnomer) Degenerative Joint Disease (a.k.a) -progressive -noninflammatory d/o of mobile jts. esp. weightbearing -loss of articular cartilage Primary= aging & Genetic (autosomal recessive) Secondary= any condition >Trauma Sprain Strain Dislocation Fractures Avascular necrosis Osteonecrosis > Mechanical Stress Athletics Hazardous jobs >Inflammation in joint structures Autodigestion of joint by enzymes >Joint instability > Neurologic d/o Charcot neuropathy >Congenital /acquired skeletal deformity Varus leg Dislocated hip

4 Joint laxity Legg-Calve-pertheses disease >Hematologic/Endocrine d/o Hemophilia Hyperthyroidism Hypocalcemia >Meds. Collagen-digesting enzymes Colchicines Indomethacin Steroids Clinical manifestations Objective: popping, cracking, grinding Limited ROM (DIOJ) Unstable, enlarged (spurs,boggy synovium joints) Joint deformity *loss of articular cartilage *collapse of subchondral bone *Heberden’s nodes Subjective: Pain Stiffness(inactivity weather changes) Tx. Mgt NSAIDS Steroids Splint-not for long term use Heat-suana warm compress Obese-lose some weght Sugery: >DAAOT Rheumatoid Arthritis Unknown etiology (may be) Infections Autoimmunity Genetics Others Autoimmune Probable familial predisposition Great Crippling disease Inflammation of Diarthrodial joint Order of affectations 1. hand joints 2. wrist joints 3. metacarpophalangeal joint 4. knee joint 5. hip joint 6. elbow joint Clinical Manifestation p.261 Swan-Neck deformity >Extension of the Proximal Interphalangeal joint. >Flexion of the Distal Interphalangeal joint Boutonniere deformity > Extension of the Distal Interphalangeal joint > Flexion of the Proximal Interphalangeal joint Hallux Valgus > Lateral deviation of the metatarsophalangeal joint Ulnar Drift > Most common >deviation of the metacarpophalangeal joint to the ulnar side

Chapter 13 Osteomyelitis- infection of the bone

◙Acute Osteomyelitis –initial, <1month ◙Chronic Osteomyelitis – antibiotic therapy failed, >4 weeks ◙DIRECT ENTRY contamination from B-one surgery O-pen Fx A-gunshot wound T-raumatic injury BACTERIA Arterial supply Camp Site (bone) Circulation Slows (growing) Ichemia Bone dies ◙INDIRECT INOCULATION (hematogenous) - from a blood borne disease like: B-oils U-pper Respiratory Tract Infections T-onsillitis T-eeht infection S .aurues most common infecting agent >trauma >weak immune system

◙Tx Mgt. >Cx & Sensitivity- id. the agent to know the appropriate antibiotic >Antibiotic tx- best choice for acute stage as long as there is no ischemia >Saucerization-surgical decompression - to relieve pressure in the bone - to prevent ischemia >Grafting- for extensive damage >.Surgical debridement >Hemovac/ Jackson-Pratt-removal of devitalized tissue >Antibiotic beads Implantation - 6-8 weeks >Amputation- massive infection ◙Septic Arthritis -joint ( +bone) cavity invasion -most rapidly destructive form ◙Agents N. gonorrhea S. aureus S.hemolyticus D. pneumoniae Pus- Forming organism Synovial membrane Joint space Closed-space infection ◙Risk factors: >Leukemia >DM >Joint trauma /disease >Corticosteroids, ISD intake >Chronic illness ◙Manifestations: Fever Pain Swelling of joint/s ◙Tx Mgt. Goal: >elimination of the pathogen

5 >removal of joint debris >prevention of deformities >Antimicrobial Tx >Hemovac/ Jackson-Pratt –to drain purulent Synovial effusion >Early immobilization >Needle Aspiration >Arthroscopy >Surgical operation

>Conservative: Bed rest, Traction >Surgical: *Focal Fusion- Bone and joint Stability (-) pain *Arthrodesis- joint fusion (-) pain *Joint Replacement- not now but later Spinal TB (Pott’s dse) ◙S/Sx *Early

◙TB of bones and joints ◙TB of the spine- most common and dangerous form found in both adults and children ◙Lesion in the lower thorax, upper lumbar-usual cases ◙Upper thoracic lesion- seen in most children ◙Risk Factors: >D-irty environment >U-ntreated primary (P)TB >D-M >E-SRD >P-oor nourishment >T-rauma ◙Pattern of Invasion: starts centrally, spread outward M. tuberculosis (attacks) Synovial membrane Pdxn of excessive secretion, proliferation and thickening TB granulation tissue (covers) Hyaline cartilage and subchondral bone Pdxn of caseous necrotic material and TB exudates Build up of pressure within the bone/joint Rupture (releasing) Cold Abscess containing necrotic debris and pyogenic pus Bursting in the skin TB sinus Spread to other parts Complete destruction of bones and joints ◙S/Sx Sketetal TB *Early >Night pain dystrophy >Muscle spasms grade fever >Joint swelling >localized redness, warmth *monoarticular involvement reactivated

*Late >Muscle >Low >Night sweats >Anorexia >Cough if PTB >growth def.

◙Tx. Mgt. >Pharmacologic: RIPES+C

>Same > with peripheral involvement >discomfort >Dec. in Spinal ROM *Late >Kyphosis >Paraplegia-due to cord compression ◙Tx. Mgt >Pharmacologic: RIPES+C >Conservative: Bed rest >Surgical: *spinal Fusion – prev. vertebral collapse and neurology sequelae in major cases with Neurologic abnormality, spinal instability and large abcess formation