ORTHOPEDIC DISORDERS

 TOPICS:

A. FRACTURES:

1. OSTEOPOROSIS

2. TRAUMA

TRACTION

CASTS

SURGERY: O.R.I.F.

B. OSTEOMYELITIS

AMPUTATION

C. ARTHRITIS

JOINT REPLACEMENT SURGERY

D. HERNIATED NUCLEUS PULPOSUS

 A. FRACTURES: TWO COMMON ETIOLOGIES ARE OSTEOPOROSIS AND TRAUMA

1. OSTEOPOROSIS--age related metabolic bone disease wherein bone demineralization leads to porous bone with subsequent fractures. The wrist, hip and vertebral column are most affected.

a. INCIDENCE & RISK FACTORS

b. ETIOLOGY--Primary and Secondary

c. DIAGNOSIS--Labs: calcium, phosphorus, vit. D, Alkaline phosphatase,

CT, MRI and densitometer studies

d. MEDICAL MANAGEMENT--DRUGS: Calcium, Vit.D., HRT, Fosamax, Calcitonin. Also, exercise program, diet therapy, safe environment, orthosis or ambulatory aids as needed.

e. HIP FRACTURES:

(1) PATHOPHYSIOLOGY--A&P and Avascular Necrosis

(2) MANIFESTATIONS--helpless eversion, shortening of the extremity, considerable pain, muscle spasm when attempting to move

(3) TYPES OF HIP FRACTURES

(a) Intracapsular

(b) Extracapsular

(4) SURGICAL MANAGEMENT--OPEN REDUCTION, INTERNAL FIXATION (O.R.I.F.) OR TOTAL HIP REPLACEMENT (THR)

TOTAL HIP REPLACEMENT OR LOW FRICTION ARTHROPLASTY:

PRE-OP: Bucks's Traction to immobilize leg temporarily and to reduce muscle spasm

2. TRAUMA CAUSING FRACTURES (Review strains and sprains on your own):

a. EMERGENCY CARE--immobilize and splint before moving, ice packs, control bleeding if accompanied by open wound, treat for shock and other injuries

b. ASSESSMENT--5 P'S (SEE SYLLABUS)

c. COMPLICATIONS:

d. MANAGEMENT:

(1) Reduction and Immobilization until healing occurs

Principle of reduction and immobilization--the fractured ends of the bone must be accurately approximated and remain in this position until healing occurs because movement and irritation at the fracture site impairs callus formation

Types of Reduction: Closed and open

(2) Methods:

(a) TRACTION (tx):

NURSING CARE:

COMPLICATIONS OF TRACTION:

(b) CASTS: Plaster, fiberglass or other materials

Before applying:

After applying:

Drying period

Maintenance care:

"CMS" or NEUROVASCULAR CHECKS

"Cast syndrome" with body casts

Crutch walking

Care after removal:

(c) EXTERNAL FIXATION DEVICE(HOFFMAN DEVICE)--a device that is used to stabilize fractures(severe, open fx's) that are difficult or impossible to immobilize any other way (such as casts or traction)

(d) O.R.I.F.(Open Reduction Internal Fixation):

B. OSTEOMYELITIS--BONE INFECTION--CAN BE ACUTE OR CHRONIC

1. ETIOLOGIES--PVD, DM, Complication of fracture or bone surgery

2. MANIFESTATIONS--p. 1429 TEXT

3. MANAGEMENT:

(a) Antibiotic Therapy after cultures; 4-6wks. for acute and >3mos. for chronic

(b) Wound irrigations

(c) HBO--Hyperbaric Oxygen Therapy daily x wks.

(d) Surgical: Incision & Drainage; Debridement; Removal of dead bone that has been chronically infected(Sequestrectomy); Bone Grafts;

AMPUTATION if bone and tissue destruction too great or circulation too inadequate for proper healing

(e) Isolation Precautions

(f) Pain Management

4. AMPUTATION:

(a) PVD is number one cause; diabetes with foot ulcers, trauma, tumors, are other indications

(b) Preoperative Care:

(1) Any chronic diseases must be controlled

(2) Nutritious diet high in protein, vits and minerals

(3) Evaluate vascular status of patient and consider vascular surgery first if the limb can be saved (like a femoral- popliteal bypass)

(4) Principle to salvage as much viable tissue as possible so surgeon identifies a "line of demarcation" between devitalized tissue and living tissue and bases level of amputation on this

(c) Types of Surgery

(1) Closed or Flap Method

(2) Open or Guillotine

(d) Postoperative Care

C. ARTHRITIS--RA, DJD(OSTEOARTHRITIS OR "OA"), AND GOUT--HANDOUT

FOR COMPARISON

1. INTERVENTIONS FOR THE KNEE JOINT:

(a) Common surgery due to RA or OA is a Total Knee Replacement or Total Knee Arthroplasty(TKR or TKA) wherein both components--tibial and femoral-- are replaced

(b) Procedure--removal of the synovial membrane, distal femoral and proximal tibial joint surfaces; the femoral joint surface is replaced with a metal implant and the tibial joint surface is replaced with a polyethylene implant

(c) Postoperative:

(3) Pain is controlled with a PCA pump or sometimes a TENS unit, continuous ice is applied and all measures for preventing thrombi are provided--LOVENOX--use of PAS stockings, etc. P.T. works with progressive ambulation and gait training

(4) Complications: infection or loosening of components; if prosthesis has to be removed and cannot be replaced ( a revision arthroplasty), then an arthrodesis may be done

(d) Other common knee procedures:

D. HERNIATED NUCLEUS PULPOSUS--"HNP" OR "SLIPPED DISK"-- "BACK PAIN"

a. CERVICAL AND LUMBAR REGION are most common sites--assess level of pain and signs and symptoms of nerve root compression causing neuralgia and dysfunction of nerve transmission

b. CONSERVATIVE MANAGEMENT--MEDICAL:

(1) Rest and Positioning--"Williams position"; use firm mattress

(2) Exercises; teach proper body mechanics; avoid prone position

(3) Medications

(4) Heat/Ice

(5) Bracing

(6) Weight reduction

(7) TENS unit

(8) Traction to relieve muscle spasm

c. SURGICAL MANAGEMENT:

(1) Microdiskectomy--small incision, in hospital two days; may use with laser

(2) Laminectomy--more extensive--long incision because surgeon has to remove portions or the lamina to get to the protruding portion of the disk and remove it

(a) Bedrest with logrolling side to side to keep spine straight; keep bed flat and when patient gets up, keep his/her back straight

(b) Check dressing frequently for CSF leakage; check incision for bulging; measure Hemovac drainage--should be minimal

(c) Assess neurovascular status, bowel and bladder function

(d) Check with surgeon as to whether coughing will be encouraged post-op

(e) Reassure patient that pain is from trauma of surgery, not continued nerve root compression

(3) Spinal Fusion--done when more than two disks are removed and/or instability of spine will result

(a) Anterior or Posterior approach to spine

(b) Bone grafts from iliac crest or bone bank

(c) Bone grafts laid in along bony defect created surgically, and supported by metal apparatus such as Harrington rods, C-D rods or "cages"; these remain in as long as no complications result from them

(d) Portion of spine that is fused is not flexible--"rigid"

(e) Stay in bed longer than laminectomy and have a brace fitted to get out of bed--must wear for several weeks to months

(f) Discharge Teaching--"Back Instructions"

 Great site for Orthopedic Information-- a whole text online!

Wheeless' Textbook of Orthopedics:

http://www.medmedia.com/Welcome.html

or

Proceed to Topic 3: Respiratory Disorders