CIC Ragasa, RN-MD

Anatomy

& Physiology Diagnostic Exams Disorders

The bony structure provides protection for vital organs, including the brain, heart, and lungs. The bony skeleton provides a sturdy framework to support body structures. The bone matrix stores calcium, phosphorus, magnesium, and fluoride. More than 98% of the total body calcium is present in bone.

In addition, the red bone marrow located within bone cavities produces red and white blood cells in a process called hematopoiesis. Joints hold the bones together and allow the body to move. The muscles attached to the skeleton contract, moving the bones and producing heat, which helps to maintain body temperature.

Bones Ligaments Blood supply Joints Muscles Tendons and Bursae

 Excitability

Contractibility
Extensibility

Elasticity

 Four

categories: Long bones (eg, femur) Short bones (eg, metacarpals) Flat bones (eg, sternum) Irregular bones (eg, vertebrae)

I. Background of Anatomy and Physiology Human skeleton made up of 206 bones 1. Axial skeleton includes- 80 Bones of skull Ribs and sternum Vertebral column 2. Appendicular skeleton includes- 126 Bones of limbs Shoulder girdles Pelvic girdle

Osteoblasts: function in bone formation by secreting bone matrix.

The matrix, which consists of collagen and ground substances (glycoproteins and proteoglycans), provides a framework in which inorganic mineral salts are deposited.

Osteocytes: mature bone cells involved in bonemaintenance functions; they are located in lacunae (bone matrix units) Osteoclasts: located in shallow Howships lacunae (small pits in bones), are multinuclear cells involved in destroying, resorbing, and remolding bone.

Bone begins to form long before birth. Ossification is the process by which the bone matrix (collagen fibers and ground substance) is formed and hardening minerals (eg, calcium salts) are deposited on the collagen fibers. The collagen fibers give tensile strength to the bone, and the calcium provides compressional strength.

Endochondral and intramembranous. Most bones in the body are formed by endochondral ossification, in which a cartilagelike tissue (osteoid) is formed, resorbed, and replaced by bone. Intramembranous ossification occurs when bone develops within membrane, as in the bones of the face and skull.

Bone is a dynamic tissue in a constant state of turnover resorption and formation. The important regulating factors that determine the balance between bone formation and bone resorption include local stress, vitamin D, parathyroid hormone, calcitonin, and blood supply.

 Synarthroses

immovable Amphiarthroses slightly movable Diarthroses freely movable

Ball-and-socket joints, best exemplified by the hip and the shoulder, permit full freedom of movement. Hinge joints permit bending in one direction only and are best exemplified by the elbow and the knee. Saddle joints allow movement in two planes at right angles to each other. The joint at the base of the thumb is a saddle, biaxial joint.

Pivot joints are characterized by the articulation between the radius and the ulna. They permit rotation for such activities as turning a doorknob. Gliding joints allow for limited movement in all directions and are represented by the joints of the carpal bones in the wrist.

Flexion
Decreases the angle e.g. Bending of the head

Extension
Increases the angle.

Hyperextension
Continues the act of extension beyond the anatomical position e.g. Looking up toward the ceiling

Abduction Adduction
Moving away from midline
Moving towards the midline

Rotation- Pivot the bone on its axis

External Rotation
motion around the central axis away from the midline. (moving head from looking straight ahead to looking to the side) motion around the central axis towards the midline. (moving the head from looking in the side to looking straight forward)

Internal Rotation

Circumduction : Moving in a circle Inversion : Turning inward Eversion : Turning outward

Pronation
Facing downward (turning the palm downward or backward)

Supination
Turns the palm or body front

Protraction
Moves the Mandible forward

Retraction
Moves the protracted mandible back into neutral anatomical position

Plantar flexion
Pointing toes (ballerina)

Dorsiflexion
Pointing toes toward the body

Important in evaluating patients with musculoskeletal disorders. It determines bone density, texture, erosion, and changes in bone relationships. X-ray study of the cortex of the bone reveals any widening, narrowing, or signs of irregularity. Joint x-rays reveal fluid, irregularity, spur formation, narrowing, and changes in the joint structure. After being positioned for the study, the patient must remain still while the x-rays are taken.

Shows in detail a specific plane of involved bone and can reveal tumors of the soft tissue or injuries to the ligaments or tendons. It is used to identify the location and extent of fractures in areas that are difficult to evaluate (eg, acetabulum). CT studies, which may be performed with or without the use of contrast agents, last about 1 hour. The patient must remain still during the procedure

MRI is a non-invasive imaging technique that uses magnetic fields, radio waves, and computers to demonstrate abnormalities (ie, tumors or narrowing of tissue pathways through bone) of soft tissues such as muscle, tendon, cartilage,nerve, and fat. To enhance visualization of anatomic structures, contrast media may be injected intravenously.

It is useful in identifying acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip, or wrist. A radiopaque substance or air is injected into the joint cavity to outline soft tissue structures and the contour of the joint. The joint is put through its range of motion to distribute the contrast agent while a series of xrays is obtained. If a tear is present, the contrast agent leaks out of the joint and is evident on the x-ray image

After an arthrogram, the joint is usually rested for 12 hours, and a compression elastic bandage is applied as prescribed. In addition, the nurse provides comfort measures (mild analgesia, ice) as appropriate. The nurse should explain to the patient that it is normal to experience clicking or crackling in the joint for a day or two after the procedure, until the contrast agent or air is absorbed.

the nurse should assess for conditions that may require special consideration during the study or that may be contraindications to the study (eg, pregnancy; claustrophobia; inability to tolerate required positioning due to age, debility, or disability; metal implants). It is essential that the patient remove all jewelry, hair clips, hearing aids, and other metal before having an MRI. If contrast agents will be used for CT scan, MRI, or arthrography, the nurse should carefully assess the patient for possible allergy.

BMD is used to estimate bone mineral density This can be done through the use of x-rays or ultrasound. Dual-energy x-ray absorptiometry (DEXA) determines bone mineral density at the wrist, hip, or spine to estimate the extent of osteoporosis and to monitor a patients response to treatment for osteoporosis.

Similar to Bone scan but the test is more specific to bone disorders. Gallium isotopes is used and migrate to brain, liver and breast tissue. It is taken by the bone more slowly than technetium and given 2-3 hours before the scan.

Performed to detect metastatic and primary bone tumors, osteomyelitis, certain fractures, and aseptic necrosis. A bone-seeking radioisotope is injected intravenously. The scan is performed 2 to 3 hours after the injection. The degree of nuclide uptake is related to the metabolism of the bone. An increased uptake of isotope is seen in primary skeletal disease (osteosarcoma), metastatic bone disease, inflammatory skeletal disease (osteomyelitis), and certain types of fractures.

Before the patient undergoes a bone scan, inquire about possible allergy to the radioisotope and should assess for any condition that would contraindicate performing the procedure (eg, pregnancy). Encourage the patient to drink plenty of fluids to help distribute and eliminate the isotope. Before the scan, the nurse asks the patient to empty the bladder, because a full bladder interferes with scanning of the pelvic bones

It is a procedure that allows direct visualization of a joint to diagnose joint disorders. Treatment of tears, defects, and disease processes may be performed through the arthroscope. The procedure is carried out in the operating room under sterile conditions; injection of a local anesthetic into the joint or general anesthesia is used. A largebore needle is inserted, and the joint is distended with saline. The arthroscope is introduced, and joint structures, synovium, and articular surfaces are visualized.

The joint is wrapped with a compression dressing to control swelling. Ice may be applied to control edema and discomfort. The joint is kept extended and elevated to reduce swelling. It is important to monitor neurovascular function. The nurse administers prescribed analgesics to control discomfort.

To obtain synovial fluid for purposes of examination or to relieve pain due to effusion. Examination of synovial fluid is helpful in the diagnosis of septic arthritis and other inflammatory arthropathies and reveals the presence of hemarthrosis (bleeding into the joint cavity), which suggests trauma or a bleeding disorder. Normally, synovial fluid is clear, pale, strawcolored, and scanty in volume.

Using aseptic technique, the physician inserts a needle into the joint and aspirates fluid. Anti-inflammatory medications may be injected into the joint. A sterile dressing is applied after aspiration. There is a risk for infection after this procedure.

EMG provides information about the electrical potential of the muscles and the nerves leading to them. The test is done to evaluate muscle weakness, pain, and disability. The purpose of the procedure is to determine any abnormality of function and to differentiate muscle and nerve problems. Needle electrodes are inserted into selected muscles, and responses to electrical stimuli are recorded on an oscilloscope. Warm compresses may relieve residual discomfort after the study.

May be performed to determine the structure and composition of bone marrow, bone, muscle, or synovium to help diagnose specific diseases. The nurse monitors the biopsy site for edema, bleeding, pain, and infection. Ice is applied as prescribed to control bleeding and edema. Analgesics are administered as prescribed for comfort.

Urinalysis CBC
Hemoglobin level (which is frequently lower after bleeding associated with trauma and surgery) White blood cell count (which is elevated in acute infections, trauma, acute hemorrhage, and tissue necrosis).

Coagulation studies
to detect bleeding tendencies (because bone is very vascular tissue).

Calcium, Acid Phosphatase

Calcium

Alkaline phosphatase

NV: 8-10.3 mEq/dL or 4.5-.5 mEq/dL Decreased levels found in Osteomalacia, Osteoporosis Increased levels found in bone tumor, Pagets disease, in healing fractures NV: 30-90 iu/L Elevation found in Bone CA, Osteoporosis, Osteomalacia NV: 2.5-4.0 mg/dL Increased levels found in Bone healing fractures

Phosphorus

 An

injury from an external for to the skeleton and all tissues surrounding it.

1.

Contusion- is a bruise of the soft tissue caused by blow or blunt force, such as kick or a fall.
Signs and symptoms:
Ecchymosis, caused by localized bleeding Pain Hematoma sac of blood develops Immobility of the affected part- Bandaging

Nursing Consideration:
2.

Hematoma: contusion with a large amount of bleeding

3.

Strain: stretching injury to a muscle or muscle-tendon unit caused by mechanical overloading (overstretching or overextension of tendon)

Most common sites: lower back and cervical region of spine Manifestations: pain increasing with isometric contraction, swelling and stiffness Sign and symptoms:
Acute strain produces sudden, severe pain at the time of injury w/c then subside to local tenderness. Swelling occurs rapidly Chronic strain produces gradual onset stiffness, soreness and tenderness Ecchymosis may appear

Nursing considerations:
For acute strain: apply ice packs for the 1st 48 hours to control the swelling Then after swelling is controlled, apply warm treatment Then rest the part for 4-6 wks. For both Acute and Chronic strains, permit only minimal movement of the affected area

4.

Sprain- is an incomplete tearing of joint capsule or ligaments surrounding a joint, w/c does not disrupt ligament continuity or cause joint instability.
Cause: sudden twisting of joint beyond its normal range of motion Sign and symptoms: Pain at joint Edema around the joint Discoloration around joint Decreased joint function

 Reduce swelling- apply cold compress for the 1st 48 hrs. Then after swelling is controlled, apply warm treatment such as warm compress or heating pads Immobilized the affected part- cast or bandage

Motor vehicular accident most common cause

Acceleration moving object Deceleration stationary object Types of fracture Linear simple break Depressed injury to brain cells Basilar raccoon eyes, ecchymosis Types of hemorrhage Epidural between dura and skull Subdural between dura and arachnoid Intracerebral

Contusion severe cerebral injury in which the brain is bruised with association, longer loss of consciousness Concussion brain injury with no structural damage but with temporary loss of neurologic function with association, brief period of unconsciousness Coup site of impact is injured Contrecoup rebound reaction, opposite of the impact is injured

Decreased LOC Increased ICP CSF leak Alteration in breathing pattern Glasgow Coma Scale

Diagnostic Exams
CT scan MRI X-ray

Management:

Note: Emergency management will be discussed in Disaster Nursing and Emergency Nursing Will be dependent on the result of assessment findings Surgery = craniotomy

Motor vehicular accident most common cause Fracture compressed Clinical Findings:
Paresthesia below the injury Inability to move below the injury Loss of motor or sensory function below the injury

Level of Injury:

Sacral bladder and bowel problem Lumbar same as above Thoracic same as above but when it reaches above the diaphragm (respiratory problem) Cervical same as above plus tetraplegia or quadriplegia and if the level of injury will exceed above C4 respiration may stop - - - death

DEATH - C4 AND ABOVE TETRAPLEGIA - C1 to C8 PARAPLEGIA - T1 to L4

Absence of reflexes below the site Flaccid paralysis Immobility with soft, flabby muscles below the site Bowel and bladder distention Inability to perspire in affected area, this will lead to hyperthermia

Hyperexcitability below the site Spastic paralysis Autonomic dysreflexia (exaggerated ANS response) Hypertension, headache and flushed skin Total loss of motor and sensory Bowel and bladder distention

Central Cord Syndrome

Leg function returns Arm function will not return Peripheral cord damage

Brown-Sequards Syndrome
Paralysis in one side Loss of sensation on the other side One side of the cord is severed

Anterior Syndrome
Loss of temperature and pain sensation below the injury Paralysis below the level of injury

Posterior Syndrome
Isolated muscle weakness Tingling, pain and decreased to absent reflexes

Horners Syndrome
Facial Anhidrosis (inability to perspire) Ipsilateral ptosis of the eyelid Constricted pupil

Emergency management Symptomatic management Mechanical vent Hypothermic blanket Steroids to relieve inflammation ICP management Maintain vertebral alignment Traction (crutchfield tong) Braces (halo vest) Bowel and bladder program Surgery = laminectomy with spinal fusion

Entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema, or a soft tissue mass. The syndrome is commonly caused by repetitive hand activities but may be associated with arthritis, hypothyroidism, or pregnancy. The patient experiences pain, numbness, paresthesia, and possibly weakness along the median nerve (thumb and first two fingers). Tinels sign may be used to help identify carpal tunnel syndrome. Night pain is common.

Treatment is based on cause. Rest splints to prevent hyperextension and prolonged flexion of the wrist, avoidance of repetitive flexion of the wrist (eg, use of ergonomic changes at work to reduce wrist strain), NSAIDs, and carpal canal cortisone injections may relieve the symptoms. Specific yoga postures, relaxation, and acupuncture may provide non-traditional alternatives to relieve carpal tunnel symptoms.

A slowly progressive contracture of the palmar fascia, which causes flexion of the fourth and fifth fingers, and frequently the middle finger. This renders the fingers more or less useless. It is caused by an inherited autosomal dominant trait and occurs most frequently in men who are older than 50 years of age and who are of Scandinavian or Celtic origin. It starts as a nodule of the palmar fascia.

The patient may experience dull aching discomfort, morning numbness, cramping, and stiffness in the affected fingers. This condition starts in one hand, but eventually both hands are affected symmetrically. Initially, finger stretching exercises may prevent contractures. With contracture development, palmar and digital fasciectomies are performed to improve function. Finger exercises are begun on postoperative day 1 or 2.

An area of hyperkeratosis (overgrowth of a horny layer of epidermis) produced by internal pressure or external pressure (ill-fitting shoes). The fifth toe is most frequently involved, but any toe may be involved. Treated by soaking and scraping off the horny layer by a podiatrist, by application of a protective shield or pad, or by surgical modification of the underlying offending osseous structure. A wider shoe may be helpful.

A discretely thickened area of the skin that has been exposed to persistent pressure or friction. Faulty foot mechanics usually precede the formation of a callus. Eliminating the underlying causes A keratolytic ointment may be applied and a thin plastic cup worn over the heel if the callus is on this area. Felt padding with adhesive backing is also used to prevent and relieve pressure.

A condition in which the free edge of a nail plate penetrates the surrounding skin, either laterally or anteriorly. This painful condition is caused by improper self treatment, external pressure (tight shoes or stockings), internal pressure (deformed toes, growth under the nail), trauma, or infection. Trimming the nails properly (clipping them straight across and filing the corners consistent with the contour of the toe) can prevent this problem.

A flexion deformity of the inter-phalangeal joint,which may involve several toes. The condition is usually an acquired deformity. Tight socks or shoes may push an overlying toe back into the line of the other toes.

Refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot The shortening of the foot and increased pressure produce calluses on the metatarsal area and on the dorsum (bottom) of the foot.

A deformity in which the great toe deviates laterally Associated with this is a marked prominence of the medial aspect of the first metatarsal phalangeal joint.

Reduction of bone density and a change in bone structure, both of which increase susceptibility to fracture The normal homeostatic bone turnover is altered: the rate of bone resorption is greater than the rate of bone formation, resulting in a reduced total bone mass. The bones become progressively porous, brittle, and fragile; they fracture easily under stresses that would not break normal bone.

Inadequate nutrition Inadequate vitamin D & calcium Lifestyle choices Genetics Lack of physical Activity

Absolute decreased in the amount of bone below the level required for adequate mechanical support. Attributed to aging Primary
Common form Senile or postmenopausal

Secondary
Due to pathologic syndromes Malnutrition or malabsorption syndrome Prolonged immobilization Endocrinopathies

Loss of height Fracture of the wrist, hip and vertebrae Kyphosis Respiratory problem Pathologic fracture Low back pain

Routine x-ray : 25-40% demineralization Serum Calcium Dual energy x-ray absorptiometry (DEXA;DXA) provides information about spine & hip bone mass & bone mineral density (BMD) Quantitative ultrasound (QUS) studies of the heel are used to predict risk for fracture

Adequate, balanced diet rich in calcium & vitamin D Calcium supplements Regular weight bearing exercise to promote bone formation (20-30 minutes aerobic exercise 3days/week) Other meds : biphosphonates alendronate (Fosamax), risedronate (Actonel), calcitonin

A metabolic bone disease characterized by inadequate mineralization of bone. Primary defect is deficient activated Vit D (Calcitriol) which causes imbalance of calcium & phosphate , faulty bone calcification/mineralization of calcium. Results from failed calcium absorption, excessive calcium & vit D loss Additional risk factors : diet, CRF, prolonged anticonvulsant theraphy

Bone pain & tenderness Muscle weakness from calcium deficiency Waddling or limping gait; legs bowed in more advanced stage Pathologic fractures Softened vertebrae become compressed, shortening patients trunk & deforming thorax (kyphosis) Weakness & unsteadiness, presenting risks of falls & fractures

Radiograph, bone biopsy shows increased osteioid (demineralized bone matrix) Labs : serum calcium & phosphorus, moderately alkaline phosphatase level, urine calcium & creatinine excretion

Treatment of underlying cause Long term monitoring is undertaken to ensure stabilization or reversal Orthopedic deformities may be treated with braces or surgery (osteotomy) Physical, psychological, pharmacologic measures to reduce pain & discomfort

Disorder of localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae. There is a primary proliferation of osteoclasts, which produces bone resorption. This is followed by a compensatory increase in osteoblastic activity that replaces the bone. As bone turnover continues, a classic mosaic (disorganized) pattern of bone develops. Because the diseased bone in Pagets disease is highly vascularized and structurally weak, pathologic fractures occur.

Structural bowing of the legs causes malalignment of the hip, knee, and ankle joints, which contributes to the development of arthritis and back and joint pain. slightly greater in men than in women and increases with aging. A family history has been noted The cause of Pagets disease is not known.

Some patients do not experience symptoms but have skeletal deformity. A few patients have symptomatic deformity and pain. The condition is most frequently identified on x-ray during a routine physical examination or in the course of a workup for another problem. Sclerotic changes, skeletal deformities (eg, bowing of femur and tibia, enlargement of the skull, deformity of pelvic bones), and cortical thickening of the long bones occur. Fractures, arthritis, and hearing loss are complications of Pagets disease.

Pain usually responds to administration of NSAIDs. Gait problems from bowing of the legs are managed with walking aids, shoe lifts, and physical therapy. Weight is controlled to reduce stress on weakened bones and mal-aligned joints. Asymptomatic patients may be managed with diets adequate in calcium and vitamin D and periodic monitoring.

Extension of soft tissue infection (eg, infected pressure or vascular ulcer, incisional infection) Direct bone contamination from bone surgery, open fracture, or traumatic injury (eg, gunshot wound) Hematogenous (bloodborne) spread from other sites of infection (eg, infected tonsils, boils, infected teeth, upper respiratory infections).
Osteomyelitis resulting from hematogenous spread typically occurs in a bone area of trauma or lowered resistance, possibly from subclinical (nonapparent) trauma.

Staphylococcus Aureus causes 70-80% of infections Others : Proteus, Pseudomonas, E. Coli Risk factors : poorly nourished, elderly, obese, immunocompromised

Sudden onset, occuring with manifestation of sepsis (chills, fever, tachycardia, general malaise) Painful extremity, swollen, warm & tender Constant pulsating pain that intensifies with movement In chronic osteomyelitis , continually draining sinus or recurrent periods of pain, inflammation & swelling

Early x-ray films shows soft tissue swelling Bone scans & MRI Blood studies & culture ( sedimentation rate & leukocytes) Chronic osteomyelitis : x-ray shows large, irregular cavities, a raised periosteum or dense bone formation

Initial goal is to control & arrest the infective process :

Affected area is immobilized; warm soaks for 20 mins/day Blood & wound cultures Antibiotics (usually for 3 months) Surgical debridement of bone with irrigation

Usually caused by TB infection of the lungs Aspiration and biopsy to diagnose is necessary

seeding of the bones through hematogenous route (insidious and extend into the spine and joints)

destructions are widespread, localized especially into the spine (GIBBUS FORMATION)

KYPHOSIS & SCOLIOSIS

 Early

Late

boggy swelling decrease joint motion muscle guarding afternoon fever contractures bone deformity and destruction

sign:

sign:

Abscess Paraplegia MANAGEMENT

SAME WITH PTB PLUS ORTHO INTERVENTION

Systemic Chronic Inflammatory Non suppurative synovitis Affecting joints and other organs

 Connective

tissue disease = cartilage, skin, heart, blood vessels, muscles and lungs Inflammation from immunologic process
Manifestations:

Morning stiffness and pain on the affected joints (bilateral)

Joint pain Heat Swelling Redness Limitation of function

Auto immune disease Human and cell mediated immune responses RF rheumatoid factor IgG, IgM

damage to synovial lining and articular cartilage

IgG and RF are traced in the synovial membrane inflammation will follow

PANNUS (granulation/healing of tissue)

ADHESIONS take place leading to CONTRACTURES

Pain and joint swelling Boutonniere = fixed flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint Swan neck = opposite of boutonniere Foot/wrist drop Carpal tunnel syndrome = compression of median nerve (painful wrist and hand) Rheumatoid nodules Acute pericarditis Valvular insufficiency

ESR = elevated RF = elevated ANA = elevated (specific) X-ray = (+) changes

Rest and splinting Walking and swimming Hydrotherapy in heated pools Joint movement (full range of motion, keep it mobile, reduce stiffness)

Heat application:
Chronic pain Warm bath, whirlpool, warm shower, paraffin deep/wax Reduce pain, swelling and stiffness

Cold application:
Acute pain Ice massage and ice compress

ASA drug of choice Gold compound (IM/po) effective after 3-4 months gold Na thiomalate deep IM 1x a week 3-6 months Riduarid po 3-6 months low dose side effects: can be severe (aplastic anemia) Immunosuppressive agent (methotrexate) Steroids

Synovectomy Arthrodesis = joint fusion Total joint replacement

Monosodium Urate Crystal Disorder in purine metabolism Increased uric acid (normal 7 mg/100ml) Heterogenous disorder Primary = unknown 90% Secondary = from other diseases 10%

 Pain

at night with low grade fever Single joint is affected (big toe) Cant tolerate the weight of bed linen = severe pain (use bed cradle)

Disorder in uric acid metabolism

HYPERURICEMIA

precipitation of monosodium urates into the joints progressive accumulation of urates

DESTRUCTIVE ARTHRITIS

Tophi

hallmark of gout MSU are deposited in and around the joints as well as other tissues Uric acid = elevated

Diagnostic test:

Bed rest Avoid ASA Increase fluid intake (prevent renal calculi) 2-3 L/day Wear comfortable shoes Weight reduction Diet (avoid purine rich food = organ meat, tinned fish) Decrease alcohol intake

Allopurinol (Zyloprim) Probenecid (Benamid) Steroids Colchicines

prevent uric acid formation, can be taken as prophylaxis

prevents tubular reabsorption of uric acid

drug of choice reduce pain, not a uricosuric drug IV for acute attack po hourly until pain subsides

Lateral curvature of the spine C or S shaped Age of onset the younger the child the greater the chances for deformity Deformity increases in growth periods Not noticed until adolescence Girls are commonly affected than boys Size of curve 2045 degrees are treated non surgically. > 45 degrees with resp. problems may necessitate

Harrington rod Bone graft from iliac crest are inserted to achieve fusion Rods are inserted along the vertebrae and attached by Harrington hooks and wires to achieve tension along the spine Casting is required post op to protect spinal fusion and stability

Luque Procedure
Placement of wireloops under the lamina at each vertebaral level Steel rods aligned along the curvature of the spine are fixated to the spine by the wires

Fatigue, dyspnea and backache Assess for respiratory problems Observe for deviation of hips, rib cage, shoulders, iliac crest Assess for mild pain and discomfort

Expose back and check for deviation Client bent forward at waist Check level of scapulae Check difference in shoulder height Elbow level Height of iliac crest Flank region (infolding and flattening) ROM of spine

Instruct on use of braces Remove only to bathe or as ordered Skin care where brace touches Stress importance of the brace Deal with altered body image Provide periop care Non surgical correction

Exercise Plastic braces (orthoses)

Milwaukee or boston brace When curve is 20-24 degrees Worn 16-23 hours

Halo traction Casting Surgical correction

When curve is > 40 degrees

 Is

a break in the continuity of and is defined according to type and extent.

Complete Fracture

Involves a break across the entire cross-section of the bone and is frequently displaced (removed from the normal position) The break occurs through only part of the crosssection of the bone
Does not produce a break in the skin

Incomplete Fracture

Closed Fracture (Simple Fracture)

Open Fracture (Compound/ Complex Fracture)

Is one in which the skin or mucous membrane would extend to the fractured bone.

Grade 1 A clean wound less than 1 cm

Grade 2 A larger wound without extensive soft tissue damage Grade 3 Highly contaminated and has extensive soft tissue damage, is most severe

Greenstick Fracture
In which one side of the bone is broken and the other side is bent

Transverse Fracture
Fracture that is across the bone

Oblique Fracture
Fracture occurring at the angle across the bone (less stable than transverse)

Spiral Fracture
Fracture twisting around the shaft of the bone

Comminuted Fracture

Fracture in which bone is splintered into several fragments Fracture in which the fragments are driven inward (seen in fracture of the skull and facial bones)

Depressed Fracture

Compression Fracture Pathologic Fracture

fracture in which bones has been compressed (seen in Vertebral fractures)

Fracture that occurs through an area of diseased bone (Bone cyst, tumor)

Avulsion
Pulling away of a fragment of bone by a ligament or tendon and its classification in relation to the joint attachment

Epiphyseal Fracture
Fracture in which a bone fragment is driven into another bone fragment

I.

In normal bones, fractures occur when more stress is placed upon a bone that is able to absorb such as:
1.

Direct force or a Crashing force

in which the bone absorbs more stress that it can endure from impact with a solid object E.g. when a person hit with a baseball bat.

2.

Twisting force (Torsion)

A severe twisting of a broken bone at the site different where the force was actually applied E.g. Skiing accident

3.

Powerful muscle contraction

Highly developed muscles contract so violently that muscles tear from bone, sometimes pulling a small piece of bone with it. E.g. Grand mal seizure

4.

II.

Fatigue and Stress

Bone break after a repeated stress. E.g. Soldier breaks foot during prolonged marching

Pathologic Decay
Bones weakened by disease or tumors and subject to pathologic fractures E.g. Bone CA

Pain (especially at the time of injury) Tenderness at the site of injury Swelling Loss of function Deformity Crepitus (grating sensation either heard or felt as bone ends rub together) Discoloration Bleeding from an open wound with protrusion of bone ends.

1.

Principles of Fracture Management Reduction or Realignment of bone fracture Maintenance of reduction until healing is sufficient to prevent displacement Preservation and restoration of function of muscles, joints and tendons

2.

Reduction is accomplished by:

Closed manipulation in which a cast or sling is used Traction used to effect fracture reduction and immobilization used when manipulation is inappropriate Open reduction done thru surgical approach, the fracture fragments are reduced, internal devices are used like pins, wires, screws, plates, nails or rods are used to hold the bones until healing occurs.

3.

4.

Immobilization the most important element in obtaining the union of fracture fragments.
Closed reduction- accomplished by application of plaster cast Open reduction

Restoration of function
Aim of treatment is an ongoing process actually begins with the maintenance of function of the unaffected joint and extremities. Healing of the fractured part will be faster if normal circulation of the body is maintained.

 When there is fracture, there is bleeding, extravasation of blood and the formation of fracture hematoma The area exhibits edema, inflammation and pain, the injured areas is invaded by macrophages (large white blood cells) w/c debride the area.

 Fibrin strands from within the clot creating a network for revascularization and invasion by fibroblast and osteoblast produce substance called osteoids forming a bridge across the fractured site.

 Tissue growth continues and the cartilage callus from each bone fragment grows toward the other until the fracture gap is bridged.

An internal callus also develops and invades the remaining blood clot
It takes 3-4 weeks for fracture fragments be united by cartilage or fibrous tissue.

Final laying down of bone, is the stage in which the fracture ends knit together

 Consist of removal of any remaining devitalized tissue and reorganization of the new bone on its former structural arrangement.

Clavicle- 3-4 wks. Radius, Ulna- 6-13 wks. Metacarpals- 4 wks. Femur- 12 wks. Fibula 12-14 wks.

Phalanges- 3 wks. Humerus- 6 wks Lower third radius- 4 wks Tibia 8-12 wks. Tarsals 6-8 wks.

Extensive local trauma Bone loss Inadequate immobilization Space/tissue in between bone fragments Infection Local malignancy Metabolic bone disease Age (elderly person heals more slowly Loss of bone substance (lack of Vit. D)

Early possible Complications: Nerve damage

It may be caused by the sharp edges of the bone fragments or by injury that cause fracture

Fat embolism
Occurs 24 to 48 hrs. after injury Causes disruption to the fragile veins and fat cells in the bone marrow of the fractured site. Fat globules enter circulation, aided by the increased interstitial pressure at the hematoma on the fractured site.

 Compartment syndrome: excess pressure in limited space, constricting structures within and reducing circulation to muscles and nerves; normal pressure is 10 20 mm Hg Deep vein thrombosis (DVT): blood clot forms in lining of large vein; can lead to pulmonary embolism Infection: any complication decreasing blood supply increases risk; may result from contamination at time of injury or during surgery Delayed union: prolonged healing of bones beyond usual time period Nonunion

Bartons fracture Cottons fracture

Dorsal rim fracture of the radius Trimalleolar ankle fracture of the dorsal tibia (medial, lateral and posterior articular margin or posterior malleolus of the tibia) Fracture of the radius and ulna that may or may not involve the wrist joint, caused by extending the outstretched hand Double fracture of the pelvic ring, causing instability of the pelvis

Colles fracture

Malgaignes fracture

Galeazzis fracture
Fracture of the distal third of the radius with associated radioulnar dislocation

Monteggias fracture
Fracture of the shaft of the ulna with displacement of the fragments

Bennetts fracture
Fracture of the base of the thumb; acute with associated subluxation or dislocation of the metacarpal joint of the thumb

Potts fracture
Fracture of the fibul, including the malleolus of the ankle

The head of the femur is outside the confines of the acetabulum at birth Degrees of Disclocation:
Subluxation or Predislocation
Is an incomplete dislocation. Congenital Hip Dysplasia used in reference to the dislocatable hip of the newborn An actual complete dislocation

Congenital dislocation

Incidence: F:M 8:1 Incidence increases 10X with breech delivery >60% of dislocated hip spontaneously stabilized Increased incidence is evident among siblings of affected children Left hip is affected more often than right hip Increased incidence occurs in Canadian Eskimos and certain American Indian groups that swaddle children in cradle boards during first few months of life

Infancy Possibly NO symptoms evident because infant may have minimal displacement of femur Asymmetry of skin folds in inner side of thigh Shortened leg Limitation of abduction (+) Galeazzis sign (flexing both hips at 90 degrees result in one knee being below the level of the other)

(+) Barlow maneuver

hand is placed over knee. Leg is adducted past midline and outward. Positive sign is a sensation of abnormal movement

(+) Ortolani maneuver

fingers are placed over greater trochanter as thigh is abducted and lifted toward the acetabulum. A click is heard in infants less than 3 mos. Of age, and a jerk is felt in children more than this age

Palpable femoral head in buttocks Elevated trochanter

Abnormal Duck-waddle gait (waddling) caused by bilateral dislocation of the hip (+) Trendelenburg sign
patient stand bearing weight on the affected hip, the pelvis is tilted downward on the normal side

Lean to side of the body that bears weight Increased Lumbar lordosis during standing Standing position- knee flexed in unaffected and on toes of the affected side Adolescence- increasingly painful Adulthood- degenerative arthritis

AP pelvic X-ray
to assess extent of femoral displacement or dislocation

1. Frejka pillow, Pavlik Harness

a. b. c. d.
2.

To maintain hip flexion: Maintain harness (continuously for 2-3 mos.) Performing skin care (lubricant and sponge bath Turning q 2h Changing diapers frequently to prevent skin breakdown

Abduction brace maintain hips in abducted and fixed position

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If conservative treatment is unsuccessful or if condition is diagnosed after 3 months of age, the child is treated with traction (4-6 mos.) followed by open or closed reduction and then spica cast Monitor child response to traction (2-3 wks) Monitor child response to spics cast

If Open reduction is performed 1. Prepare child and parent for surgery Provide information about presurgical routine Reinforce information given about surgery and open reduction 2. Monitor childs response postoperatively Monitor v/s q 2h until stable, then q 4h Monitor for signs of drainage on cast Perform circulation checks hourly during the immediate postoperative period the q 4h 3. Provide pain relief measures as necessary Provide tactile comfort and holding Administer analgesic

A congenital or acquired condition of limited neck motion in w/c the child hold the head to one side with the chin pointing to the opposite side An abnormal condition in which the head is inclined to one side as a result of the contraction of the muscles of the neck. Taken the Latin word torti- twisted, collies meaning neck

Incidence: at Birth 1:5 ratio within the 1st month of birth Predisposing factor: Breech deliveries Causes:

The neck strap muscles is injured either before birth during or after birth The child develops a fixed, fusiform swelling on one sterno-mastoid muscle. The SCM tumor subsides but the subsequent fibrosis causes a tilt and rotation of the neck to the opposite side. When the condition is well established, the face is asymmetrical with the eyes in the different level.

Recurring unilateral stiffness of the neck muscles Momentary twitching or contraction that pulls the head to the affected side Severe neuralgic pain throughout head and neck

Firm, nontender, palpable enlargement of the sternocleidomastoid muscles at birth visible for several weeks after. Possible flattening of the infants head and face on affected side that gradually worsens Chin turned away from the side of the shortened muscle and head tilted to shortened side Possible elevation of shoulder on affected side restricting neck movement

X-ray of the cervical spine may reveal an associated disorder (such as TB, scar tissue formation or arthritis) in acquired torticollis CT scan neck radiograph MRI

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Prevent local infection by cleansing the defect gently with sterile saline positions or other antiseptic solution Prevent skin breakdown by placing sheepskin or foam pad under the infant Handle infant gently and do not apply pressure to the defect Measure head circumference daily and watch for signs of Hydrocephalus. Minimize contractures by range of motion.

Daily use of heat massage and carefully regulated stretching of the affected muscle.

E.g. several times a day, have one person hold the childs arm and shoulder firmly while another person draws the childs head and head into as far as over corrected position without causing severe pain, then massage the stretched muscles for a few minutes.

Encourage the infant to look in the in the direction in the affected side
E.g hand the child object always from the affected side to make the child look away

SURGERY- if simple exercise are not effective and the condition still exist at a year

Congenital anomaly characterized by the webbing of two or more fingers or toes. The web may be formed on the skin alone or skin, subcutaneous tissues and fusion of bone. Treatment:
Surgical separation of digits and grafting of denuded areas w/ free full thickness skin grafting Immobilize the digits spread apart in a plaster cast or splint Best time for Surgery: 2-3 yrs.

Over development of one or more fingers or toes. Presumably resulted from an abnormal growth capacity in the embryonic tissue forming in this part. Treatment: Amputation or Plastic operation to reduce the size

Supernumerary digits are common and frequently inherited anomalies. It can be very small appendages to a well developed digit on fingers and toes. Treatment: Amputation or Reconstructive Surgery

Congenital foot deformity TALIPES VARUS

INVERSION EVERSION

TALIPES VALGUS

TALIPES EQUINUS
PLANTAR FLEXION DORSIFLEXION

TALIPES CALCANEUS TALIPES EQUINOVARUS = MOST COMMON

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Congenital clubfoot
Most common form of clubfoot and also referred asIdiopathic clubfoot, condition arises spontaneously from an unknown cause. Usually Genetics

2.

Teratologic clubfoot
Occurs as a part of an underlying neuromuscular disorder, such as Spina bifida. It is often severe and nearly always requires early radical surgery to achieve correction

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Syndrome Complex Clubfoot

Occurs when the child is born with one of the number of the genetic disorder such as Downs Syndrome.

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Positional Clubfoot
When a normal foot is held in a deformed position in utero and is molded incorrectly (not consider a true clubfoot)

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Physical therapy, taping and splinting, Plaster casting Manipulation and serial casting (6 MOS., 510 application
Physical therapist or doctor slowly manipulate or stretch out the tigthened muscles and hold the foot in an improved position with a plaster cast

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Splinting- Denis Browne splint Strapping or Taping- strapping allows positioning of the foot by adhesive taping

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Soft Tissue releases the tight tissue around the joints and result in lengthening of tendons. Bony procedures such as osteotomies that divide or remove bone to correct deformities, or arthrodeses w/c surgically stabilize joints to enable the bones to grow solidly together Tendon transfer to place the tendons or ligaments in an improved position.

Most common malignant bone tumor in children Originates from bone forming cells Common in males Occurs between 4-25 years of age Usual location is in the metaphysis of long bones lower extremities

 Location

of tumor (long bones, pelvis, jaw and phalanges)

CT scan Biopsy Bone scan Assess for pain at site, swelling, limitation of movement Evaluate metastasis (lungs, kidneys and thyroid)

Local swelling Weight loss Anemia Elevated serum alkaline phosphatase Fever Microscopic evaluation of biopsy reveals neoplastic cells

Amputation of limb or resection of tumor Chemotherapy Radiation

Therapy is aimed to save the limb whenever possible, resection of tumor followed by chemo and radiation therapy. Special care for radiation and chemotherapy Discuss fears, concerns and treatment procedures to the patient and family High CHON, high calorie meals Administer special nursing care following surgery