MUSCULOSKELETAL

DISORDERS
Arnel A. Gervacio, RN.,MSN
 Skeletal System
includes 206 bones connected by joints.

14 % of the body’s total weight.

joints are connected by ligaments and

cushioned by cartilages.

Tendons attached muscles to the bones.

Skeletal System
⚫ Bone is a living tissue surrounded by soft
tissue with vascular connections.

⚫ Enclosed by a dense layer of fibrous tissue

called periosteum.

⚫ Composed of cells, protein matrix, and

mineral deposits.
SKELETAL
SYSTEM
Functions
⚫ Shape

⚫ Support

⚫ Protection

⚫ Allowing bodily movement

⚫ Producing blood for the body

⚫ Storing minerals such as calcium and

phosphorus.
The human skeleton is divided into two
distinct parts:
⚫ Axial Skeleton
Body’s upright structure with 80 bones.
consists of bones that form the axis of the
body and support and protect the organs of
the head, neck, and trunk.
1. The Skull
2. The Sternum
3. The Ribs
4. The Vertebral Column
BONES OF THE SKULL

1. (1) Frontal bone

2. (2) Parietal bone

3. (1) Occipital bone

4. (2) Temporal bone

BONES OF THE FACE
1. (2) orbit

2. (2) nasal

3. (2) zymogatic or cheek bone

4. (2) maxillary bone

5. (1) mandible
VERTEBRAL OR SPINAL COLUMN
1. (7) cervical bones

⚫ Atlas – 1st cervical bone

⚫ Axis – 2nd cervical bone

2. (12) thoracic

3. (5) lumbar

4. (5) sacral bones fused into one

5. (4) coccygeal bones fused into one

Ribs (12 pairs)
⚫ 7 pairs of True ribs –
attached to the
sternum by coastal
cartilages

⚫ 3 pairs of False ribs –

attach by means of
coastal cartilage of 7th
ribs

⚫ 2 pairs of Floating ribs

– 8th,9th, and 10th ribs
not attached to the
sternum
 STERNUM

1. Body of Sternum

2. Manubrium

3. Xiphoid Process
⚫ Appendicular Skeleton
is composed of bones that anchor the
appendages to the axial skeleton with
126 bones

1. The Upper Extremities

2. The Lower Extremities
3. The Shoulder Girdle
4. The Pelvic Girdle--(the sacrum and
coccyx are considered part of the
vertebral column)
 PARTS OF THE FEMUR

13
Types of Bones
Long bones
are longer than they are wide and work as
levers.
Example: Femur

Short bones
are short, cube-shaped, and found in the
wrists and ankles.
Example: Carpals
Types of Bones
Flat bones
Have broad surfaces for protection of organs
and attachment of muscles.
Example: Scapulae
Irregular bones
Are all others that do not fall into the previous
categories.
Example: Vertebral Column
TRAUMA & INJURY
Sprain
⚫ Is an injury to the ligaments around a joint.

⚫ Twisting

⚫ Around the ankle.

Clinical Manifestation
⚫ Joint pain or muscle pain

⚫ Swelling

⚫ Joint stiffness

⚫ Discoloration of the skin, especially bruising

Management
⚫ R est

⚫ I ce

⚫ C ompression

⚫ Elevation

⚫ Splinting
Management
⚫ Anti-inflammatory pain medications will reduce the
pain and combat the swelling. Several are available
over-the-counter, such as ibuprofen (Motrin IB and
Advil are common brands) and naproxen (Aleve or
Naprosyn are examples).

⚫ The doctor may elect to apply a brace or cast to reduce

motion of the ankle. Crutches are frequently provided
so you do not have to bear weight on the injured ankle.
STRAIN
⚫ Is a stretching or tearing of muscle.

⚫ Sudden and powerful contraction

⚫ Hamstring and back injuries are among the most

common strains.
Possible Causes
⚫ Running

⚫ Jumping

⚫ Throwing, lifting a heavy object

⚫ Lift in an awkward position.

⚫ A chronic strain results from prolonged, repetitive

movement of a muscle.
Clinical Manifestation
⚫ Mild
- last a few days.

⚫ Moderate
- last one to three weeks.

⚫ Severe
- The muscle is torn apart or ruptured. bleeding,
swelling and bruising around the muscle.
SYMPTOMS
∙ Swelling, bruising or redness, or open cuts as a
consequence of the injury
∙ Pain at rest

∙ Pain when the specific muscle or the joint in relation to

that muscle is used

∙ Weakness of the muscle or tendons (A sprain, in contrast,

is an injury to a joint and its ligaments.)

∙ Inability to use the muscle at all

DISLOCATION
Displacement of a bone from its normal joint position.
contact.

Causes:

1. Trauma

2. Disease

3. Congenital condition
Clinical Manifestation
1. Burning pain to joint

2. Deformity

3. Stiffness and loss of function

4. Moderate to severe edema

around joint
FRACTURE
- Is a break in the continuity of the bone.

- Is the interruption of a bone’s wholeness.

- A crack or a break in a bone is a fracture.

⚫ Causes of fracture:

1. In normal bones more stress is placed upon a bone that it is able

to absorb such as:
⚫ Direct blow or a crushing form
⚫ Twisting force
⚫ Powerful muscle contractions
⚫ Fatigue and stress

2. Bones weakened by disease or tumors are subject to pathological

fractures.
Broad Classification
A. Simple (Closed) Fracture

B. Compound (Open) Fracture

Classification as Pattern
⚫ Transverse – a fracture that is straight across the
bone
⚫ Oblique – breaks runs in slanting direction.
⚫ Spiral – breaks coils around the bone.
Classification as Appearance
⚫ Comminuted- bone splintered into fragments.

⚫ Impacted- one end of the fractured bone is forcefully driven into

the interior of the other.

⚫ Compression- vertebra collapses in itself.

⚫ Depressed fracture- broken bone being driven inward.

⚫ Longitudinal fracture- the break runs parallel with bone

⚫ Fracture dislocation- when fracture is accompanied a

bone out of joint.
Other Types of Fracture
Crush
Occurs in cancellous bone as a result of compression force.

Burst
Resulting from direct pressure leading to impaction of the disc.

Avulsion
A pulling away of a fragment of a bone by a ligament or tendon
and its attachment.

Pathologic
Result from a disease bone.

Greenstick
The bone bends without fracturing across completely.
Classification in Relation to the Joint
a. Intracapsular (within the capsule)

b. Extracapsular (outside the capsule)

c. Intra-articular (in the joint)

Classification as to Location
a. Proximal

b. Midshaft

c. Distal
Clinical Manifestation
⚫ Pain (especially at the time of injury)

⚫ Tenderness at the site

⚫ Swelling

⚫ Loss of function

⚫ Deformity

⚫ Crepitus

⚫ Dislocation

⚫ Bleeding from an open wound with protrusion of bone ends.

COMPLICATIONS
⚫ Blood loss

⚫ Injuries to organs

⚫ Growth problems
Principles of Fracture Treatment
1. Recognition

2. Reduction.

A. Closed Reduction
manual manipulation is used.
Principles of Fracture Treatment
B. Open Reduction
- done by nails, screws, pins, plates wires or rods.
Principles of Fracture Treatment
3. Retention
obtaining union of fracture fragments.
Principles of Fracture Treatment

4. Restoration of Function

A. Surgery

B. Therapy

C. Exercise
Stages of Bone Healing
⚫ Formation of Hematoma

⚫ Cellular Proliferation

⚫ Callus Formation

⚫ Bone Ossification

⚫ Remodeling
Complications of Healing
⚫ Loss of circulation

⚫ Infection

⚫ Interrupted or improper immobilization

⚫ Inadequate fixation

⚫ Necrosis due to fixation device

⚫ Metabolic disturbance
Average Period for Bone Healing
⚫ Clavicle
3 – 4 weeks

⚫ Radius
6 – 13 weeks

⚫ Metacarpals
4 weeks

⚫ Femur
12 weeks

⚫ Fibula
12 – 14 weeks
Average Period for Bone Healing
⚫ Phalanges
3 weeks

⚫ Humerus
6 weeks

⚫ Lower Third Radius

4 weeks

⚫ Tibia
8-12 weeks

⚫ Tarsals
6 – 8 weeks

⚫ Metatarsals
5 – 6 weeks
Nursing Intervention of Patients with Fracture
1. Comfort

2. Adequate oxygen of tissues

3. Rests

4. Total body mobility while keeping the injured part

at rest.

5. Protect against infection.

Slings & Bandages
Bandage
are any materials that hold the
dressing in place, hold pressure on a
wound, as a support or to secure a splint
like dressing, bandages can be bought or
improvised.

Sling
provide support & protection for an
arm. Can be improvised with a scarf,
belt, necktie etc.
TRACTION

- Is an act of pulling and drawing

which is associated with counter traction.
Purpose of Traction
1. For Support.
2. To prevent & correct deformity.
3. For immobilization.
4. To Reduce muscle spasm & pain.
5. To reduce fracture
6. To maintain good body alignment.
TYPES of TRACTION
1. Skeletal Traction

The pulling force is applied directly to the bone

using pins and wires such as KIRSHNER’S WIRE,
STEINMAN’S PIN, VINKI’S SKULL RETRACTOR,
AND CRUTCHFIELD TONGS.

Example: affection of the femur, cervical

spine or hip.
Principles of Traction
1. The patient must be in supine or dorsal
recumbent position.

2. The traction must be continuous.

3. There must be a counter traction.

4. No Friction.

5. The line of pull must be in line with the deformity.

 SKELETAL TRACTION

BALANCED SKELETAL

Hips and Femur affectation

SKELETAL TRACTION

HALO- PELVIC

For mild-moderate SCOLIOSIS

 SKELETAL TRACTION
HALO-FEMORAL

■ For moderate-severe SCOLIOSIS

 SKELETAL TRACTION

900

Subtrochanteric fracture of the Femur

 SKELETAL TRACTION
OVERHEAD Skeletal Traction

Supracondylar of Humerus
Types of Traction
2. Skin traction

Is the application of a pulling to the skin from

where it is transmitted to the muscle and then to
the bones by the use of:
Types of Skin Traction

A. ADHESIVE TYPE

Materials Used:

Wooden spreader, wadding sheet, elastic

bandage, adhesive tape

Ex. Bryan traction, Dunlop traction

 BRYANT’S SKIN TRACTION

Congenital Hip Dislocation for children 0-3 yrs. old

SKIN ADHESIVE TRACTION
BUCK`S EXTENSION

Affection of hips and femur for children

above 3 years old
 DUNLOP

Supracondylar Fracture of the Humerus

SKIN ADHESIVE TRACTION
ZERO DEGREE

■ Neck of Humerus and Shoulder joint

Types of Skin Traction
B. NON- ADHESIVE TYPE

Materials Used:
Canvass, slings, leather and strap
with buckles and laces

Example of traction :
Pelvic traction, Head Halter,
Hammock suspension.
SKIN NON -ADHESIVE TRACTION
HEAD HALTER

■ Cervical spine affectation

SKIN NON -ADHESIVE TRACTION

PELVIC GIRDLE

■ for HNP ( Herniated Nucleus Pulposus )

■ Lumbo-Sacral Spine affectation
SKIN NON -ADHESIVE TRACTION

COTREL

■ Combination of Pelvic Girdle and Head Halter

SCOLIOSIS
■
SKIN NON -ADHESIVE TRACTION
HAMMOCK SUSPENSION

■ For pelvis affection ex. Malgaine fracture

Modified Buck’s
Extension

- For hips & Femur

 SPECIAL TYPE
BOOT CAST

■ For POST-POLIOMYELITIS W/ RESIDUAL

PARALYSIS
 Skeletal Traction
❖ Skeletal traction is applied directly to the bone by use
of a metal pin or wire that is inserted through the
bone distal to the fracture, avoiding nerves, blood
vessels, muscles, tendons, and joints
❖ Skeletal traction frequently uses 7 to 12 kg to achieve
the therapeutic effect
❖ Supports the affected extremity off the bed and allows
for some patient movement without disruption of the
line of pull
1. Kirschnerts wire holder

Affectation of the radius ulna

than the Steinmann's pin
2. Steinmann's pin holder

Affectation of the humerus, femur,

tibia, fibula
1. Crutchfield tong

- Affectation of the upper dorsal cervical Spine

- Inserted at the parietal area
4. Balanced suspension traction

Affectation of the hips and or

femur
Complications of Patient with Traction
1. Pneumonia

2. Bedsore

3. Urinary & Bladder problem

4. Bowel Elimination

5. Infection

6. Deformity
Care in Client in Traction
T EMPERATURE (Extremities)
R OPES HANGING FREELY
A LIGNMENT
C IRCULATION
T YPE & LOCATION OF FRACTURE
I NCREASE THE FLUID INTAKE
O VERHEAD
N O WEIGHTS ON BED OR FLOOR
Cast
Is a temporary immobilizing device.

PLASTER OF PARIS
made of gypsum sulfate

FIBER GLASS
made of polyuratane
 UPPER EXTREMITIES
SHORT ARM CIRCULAR

■ WRIST AND FINGERS AFFECTATION

 UPPER EXTREMITIES

LONG ARM CIRCULAR

■ RADIUS ULNA AFFECTATION

 UPPER EXTREMITIES
FUENSTER / MUNSTER

RADIUS-ULNA WITH CALLUS

■

FORMATION
 UPPER EXTREMITIES

HANGING CAST

■ AFFECTATION OF SHAFT OF HUMERUS

 UPPER EXTREMITIES

FUNCTIONAL

■ AFFECTATION OF SHAFT OF HUMERUS

WITH CALLUS FORMATION
 UPPER EXTREMITIES
SHOULDER SPICA

■ AFFECTATION HUMERUS AND

SHOULDER JOINT
 UPPER EXTREMITIES
AIRPLANE CAST

■ AFFECTATION OF SHAFT OF HUMERUS

WITH COMPOUND AFFECTION
 LOWER EXTREMITIES

SHORT LEG CIRCULAR

■ ANKLE AND TOES AFFECTION

LOWER EXTREMITIES
LONG LEG CIRCULAR

■ TIBIA, FIBULA AFFECTATION

 LOWER EXTREMITIES
PATELLAR TENDON WT BEARING CAST
( PTB )

■ TIBIA – FIBULA W/ CALLUS FORMATION

 LOWER EXTREMITIES

DELVIT CAST

■ AFFECTION OF D/3 TIBIA FIBULA W/

CALLUS FORMATION
 LOWER EXTREMITIES
CYLINDER CAST

■ FRACTURE OF THE PATELLA

 LOWER EXTREMITIES
BASKET CAST

PATELLA AFFECTION W/ SEVERE WOUND

■

W/C NEEDS FREQUENT WOUND

DRESSING
 LOWER EXTREMITIES
CAST BRACE

■ PROXIMAL TIBIA AND FIBULA,

DISTAL 3RD FEMUR AFFECTATION
 LOWER EXTREMITIES
SINGLE HIP SPICA CAST

■ One side of the HIP AND ONE FEMUR

 LOWER EXTREMITIES
ONE AND ONE HALF HIP SPICA

■ Both HIPS AND 1 FEMUR

■ TB OF THE HIPS
 LOWER EXTREMITIES

DOUBLE HIP SPICA CAST

■ BOTH HIPS AND FEMUR AFFECTION

 LOWER EXTREMITIES
FROG CAST

■ CONGENITAL HIP DISLOCATION

 UPPER EXTREMITIES

COLAR CAST

■ CERVICAL AFFECTATION
 TRUNK AND NECK
BODY CAST

Lower Thoracic & Upper Lumbar Spine

 TRUNK AND NECK
MINERVA CAST

FOR SCOLIOS ON UPPER DORSAL

■

CERVICAL
C TYPE
■
 LOWER EXTREMITIES

PANTALON CAST

■ FRACTURE OF THE PELVIS

 TRUNK AND NECK

RIZZER JACKET CAST

■ FOR SCOLIOSIS ON THORACO LUMBAR

■ S TYPE
Cast Care
1. Do not wet, cut or heat.

2. Allow the cast to dry naturally in circulating air.

3. If the cast becomes loose cracked & soft or is no

longer keeping the injured body immobilized.

4. Do not push any objects inside the cast.

5. Check the circulation of the finger or toes.

6. Don’t scratch under the cast with sharp objects.

7. Trim rough edges.

Posterior Mold
- fractures with compound affectation.
BRACES
1. Immobilize a joint or body segment.

2. Restrict movement in a given direction.

3. Assist movement.

4. Reduce weight bearing force.

5. Correct the shape of the body.

 BRACES

SHANTZ COLLAR

■ FOR CERVICAL SPINE AFFECTION

 BRACES
PHILADELPHIA

■ FOR CERVICAL SPINE AFFECTION

 BRACES
JEWETTE BRACE

Fracture of the Lower Thoracic & Upper Lumbar Spine

 BRACES

CHAIR BACK BRACE

■ FOR LUMBO SACRAL AFFECTION

 BRACES
TAYLOR BRACE

■ FOR UPPER THORACIC SPINE AFFECTION

 BRACES
FORESTER BRACE

■ FOR CERVICO-THORACO-LUMBAR
SPINE AFFECTION
 BRACES
MILWAUKEE BRACE
YAMAMOTO

FOR SCOLIOSIS
 BRACES
UNILATERAL / BILATERAL
SHORT / LONG LEG BRACE

■ FOR POST POLIOMYELITIS W/

RESIDUAL PARALYSIS
 BRACES

FOUR POSTER BRACE

 BRACES
BRAUN BOHLER SPLINT

TIBIAL PLATEAU
 BRACES
DENNIS BROWNE SPLINT

■ FOR CLUBFOOT DEFORMITY

 BRACES

BANJO SPLINT

■ FOR PERIPHERAL NERVE INJURY

 BRACES
OPEN HEIMMER

■ FOR RADIAL NERVE INJURY

 SPLINT
COCK-UP SPLINT SPLINT

■ TO PREVENT WRIST DROP

FIXATION
INTERNAL FIXATION
 COMPRESSION HIP SCREW FIXATOR
( CHSF )

■ FOR INTERTROCHANTERIC Fx OF FEMUR

INTRA MEDULLARY NAILING
( IM NAILING )
 X-PINNING

⚫ SUPRACONDYLAR FRACTURE OF THE HUMERUS

 TOTAL REPLACEMENT
ARTHROPLASY

■ REPLACEMENT OF FEMORAL HEAD, NECK

AND ACETABULUM
 PARTIAL HIP REPLACEMENT
ARTHROPLASY

■ REPLACEMENT OF FEMORAL HEAD, NECK

 TOTAL KNEE
ARTHROPLASTY

■ FOR Fx OF PATELLA, FEMORAL AND TIBIAL

COMPONENT; OSTEOARTHRITIS
 TENSION BOND WIRING

■ FOR Fx OF PATELLA
EXTERNAL FIXATION
 CRUTCHFIELD TONG

■ FOR CERVICAL SPINE AFFECTION

 TOWER EXTERNAL FIXATOR /
INTERDENTAL WIRING

■ Fx OF MANDIBLE
 ROGER ANDERSON EXTERNAL FIXATOR
(RAEF)

LOWER EXTREMITIES UPPER EXTREMITIES

■ FOR COMMINUTED Fx OF THE LONG BONE

 DELTA FRAME EXTERNAL FIXATOR

■ Open fracture of the tibia-fibula

 HYBRID EXTERNAL FIXATOR

■ PERIARTICULAR Fx OF ANKLE OR KNEE

JOINTS
 SPANNING EXTERNAL FIXATOR

■ Fx of the distal 3rd of femur &proximal 3rd of

 HOFFMANS EXTERNAL FIXATOR

■ FOR PELVIC AFFECTION (HIP DISLOCATION)

ILIZAROV EXTERNAL
FIXATOR
Exercise
Passive Exercise
movement of the body usually of the limbs, without
effort by the patient.
Exercise
Active Exercise
movement of the body with effort of the
patient.
Heat & Cold
Heat Application

Heat pad maybe applied to warm up the muscle

prior to doing exercising &stretching.

Cold Application

Ice pack after exercise to sooth the muscles & soft

tissues.
TENS
Transcutaneous Electric Nerve Stimulation

Sends a painless electrical current to specific

nerve. The current maybe delivered intermittently.
The mild electrical current generates heat that
serves to relieve stiffness, improve mobility & relieve
pain.

Stimulate the body’s production of endorphins

(natural pain killer).
TRANSCUTANEOUS ELECTRIC
NERVE STIMULATOR
Compartment Syndrome
The condition that results from swelling of the
muscles in the compartment of the limb which raises the
pressure within the compartment so that the blood
supply to the muscle is cut off, causing ischemia and
further swelling.
Acute Compartment Syndrome
Causes:

1. Traumatic Injury
2. Rigid Cast or dressing
3. A severely bruised muscles
4. A complication after surgery
5. Blockage of circulation such as from
pressure over a blood vessel for too long while
asleep.
6. A crush injury.
Chronic Compartment Syndrome
- Is characterized by pain & swelling caused by
exercise.

- Symptoms dissipate quickly when activity stops.

Symptoms
- The pain maybe intensely out of proportion to the
injury especially if no bone is broken.

- There maybe also be tingling or burning sensation

(paresthesias) in the muscle.

- The muscle may feel tight or full.

- If the area becomes numb or paralysis sets in, cell

death has begun & efforts to lower the pressure in the
compartment may not be successful in restoring function.
Diagnosis
- Physician measures the intramuscular pressure
before exercise, 1 min. after exercise & 5 mins. After
exercise. If pressures remain high then you have CCS.
Non Surgical Treatment

1. Avoiding activities that cause pain & swelling.

2. Applying ice & elevating the limb slightly.

3. Taking aspirin or ibuprofen to reduce

inflammation.

4. Increase in cushioning in shoes.

⚫ Do not wrap the leg because this will increase the pressure
& aggravate with conditions.
Surgical Treatment

If surgery is required to relieve the pressure, the

physician will make an incision & cut open the skin &
fascia covering the affected compartment. This
reduces the pressure in the compartment. The skin
incision is surgically repaired when swelling recedes.
Sometimes a skin graft maybe needed.
MUSCULOSKELETAL
INFECTION
Osteomyelitis

Pott’s Disease

Septic Arthritis
OSTEOMYELITIS
 is an infection of the bone. Osteomyelitis is an acute or chronic
inflammatory process of the bone and its structures secondary to
infection with pyogenic organisms.
- Male-to-female ratio is approximately 2:1.

Poorly nourished
Elderly
Obese
Impaired immune system
Chronic illness ( Diabetes, Rheumatoid Arthritis)
Receiving long term corticosteroid therapy
Hematogenous osteomyelitis
is an infection caused by bacterial seeding from the blood. Acute
hematogenous osteomyelitis is characterized by an acute infection of
the bone caused by the seeding of the bacteria within the bone from a
remote source. This condition occurs primarily in children.

Direct or contiguous inoculation osteomyelitis

is caused by direct contact of the tissue and bacteria during trauma or
surgery. Direct inoculation (contiguous-focus) osteomyelitis is an
infection in the bone secondary to the inoculation of organisms from
direct trauma, spread from a contiguous focus of infection, or sepsis
after a surgical procedure.
 Abrupt onset of high fever (fever is present in only 50% of neonates with
osteomyelitis)
Fatigue
Irritability
Malaise
Restriction of movement (pseudoparalysis of limb in neonates)
Local edema, erythema, and tenderness

Staphylococcus aureus
Enterobacter species
Streptococcus species
Haemophilus influenzae
CBC - The WBC,C-reactive protein and erythrocyte sedimentation rate are
elevated.
Radiography - evidence of acute osteomyelitis first is suggested by
overlying soft-tissue edema at 3-5 days after infection.
MRI - The MRI is effective in the early detection and surgical localization
of osteomyelitis.
Radionuclide bone scanning - A 3-phase bone scan with technetium 99m is
probably the initial imaging modality of choice.
CT scanning - CT scans can depict abnormal calcification, ossification, and
intracortical abnormalities.
Ultrasonography - may demonstrate changes as early as 1-2 days after
onset of symptoms.
Antibiotics – Clindamycin, Vancomycin, Ceftriaxone, and Ciprofloxacin
General Supportive measures
Warm wet soaks – for 20 minutes several times a day may be prescribed to
increase circulation.

Antibiotic impregnated beads may be placed in the wound for direct

application of antibiotics for 2 to 4 weeks.
. A sequstrectomy ( removal of enough involcrum to enable the surgeon to
remove the sequestrum) is performed. In many cases, sufficient bone is
removed to convert a deep cavity into a shallow saucer (saucerization).
Closed suction irrigation system may be used to remove debris.
Wound irrigation using sterile physiologic saline solution be performed for
7 to 8 days.
ANTIBIOTIC BEADS
Relieving Pain - the affected part may be immobilized with a splint to
decrease pain and muscle spasm.
Controlling the infectious process - Nurse monitors patient’s response to
antibiotic therapy and observes IV access site for evidence of phlebitis,
infection or infiltration
Continuing Care – nurse monitors the patient for response to the treatment,
signs and symptoms of superinfections and adverse reactions.

Acute hematogenous osteomyelitis can potentially be avoided by preventing

bacterial seeding of bone from a remote site. This involves the appropriate
diagnosis and treatment of primary bacterial infections.
Direct inoculation osteomyelitis can best be prevented with appropriate wound
management and consideration of prophylactic antibiotic use at the time of
injury.
Bone abscess
Bacteremia
Fracture
Loosening of the prosthetic implant
Overlying soft-tissue cellulitis
Draining soft-tissue sinus tracts

The prognosis is variable but markedly improved with timely diagnosis and
aggressive therapeutic intervention.
Osteomyelitis of index finger
metacarpal head secondary to
clenched fist injury.
POTT’S DISEASE
Pott’s Disease
Definition:

Pott's disease is a presentation of extrapulmonary

tuberculosis that affects the spine.

Tuberculosis (TB) of the spine (Pott’s disease) is the

most common site of bone infection in TB; hips and
knees are also often affected. The lower thoracic and
upper lumbar vertebrae are the areas of the spine most
often affected.
Common Predisposing Factors
- Diabetes

- Steroid use

- Chronic diesease

- Immunosuppression

- IV drug abuse

- Rheumatoid arthritis
 Clinical
The disease progresses slowly. Signs
and symptoms include:
⚫ Localised back pain
⚫ Paravertebral swelling may be
seen
⚫ Systemic signs and symptoms
of TB may be present
⚫ Neurological signs may occur,
leading to paraplegia.
Diagnostic Test
Diagnosis is based on:

⚫ blood tests - elevated ESR (Erythrocyte Sedimentation

Rate)
⚫ Tuberculine test
⚫ radiographs of the spine
⚫ bone scan
⚫ CT of the spine
⚫ bone biopsy
Microbiology
⚫ Needle biopsy of bone or synovial tissue. Numbers of tubercle bacilli
present are usually low but are pathognomonic.
⚫ Acid-fast stain and culture for Mycobacterium tuberculosis, plus fungi
and other pathogens, should be performed.

Imaging

⚫ Spinal x-ray may not show early disease as 50% of bone mass must be
lost for changes to be visible on x-ray. However, plain radiographs can
show vertebral destruction and narrowed disc space.
⚫ MRI is useful to demonstrate the extent of spinal compression and can
show changes at an earlier stage than plain radiographs. Bone elements
visible within the swelling, or abscesses, are strongly indicative of Pott’s
disease as opposed to malignancy.
⚫ CT scans and nuclear bone scans can also be used.
MANAGEMENT
I. MEDICAL MANAGEMENT

- treated with immobilization using prolonged bed rest or a body cast.

- Patients should be treated with external bracing.

- 3 antituberculous drugs.

- Surgery.

- many experts still recommend chemotherapy for 9-12 months.

(Opinions differ regarding whether the treatment of choice should be conservative
chemotherapy or a combination of chemotherapy and surgery. The treatment decision should
be individualized for each patient.)
II. Surgical Management

Surgery is required if there is spinal deformity or neurological signs

of spinal cord compression.

The most conventional approaches include anterior radical focal

debridement and posterior stabilization with instrumentation.

Duration of antituberculosis treatment:

⚫ If debridement and fusion with bone grafting are performed,

treatment can be for six months

⚫ If debridement and fusion with bone grafting are NOT performed a

minimum of 12 months’ treatment is required.
III. Nursing Management

Inpatient Care:
⚫ Once the diagnosis is established and treatment is started,
the duration of hospitalization depends on the need for
surgery and the clinical stability of the patient.

Outpatient Care:
⚫ Patients should be closely monitored to assess their
response to therapy and compliance with medication.
Directly observed therapy may be required.

⚫ The development or progression of neurologic deficits,

spinal deformity, or intractable pain should be considered
evidence of poor therapeutic response. This raises the
possibility of antimicrobial drug resistance as well as the
necessity for surgery.
IV. Pharmacologic Management

Therapy requires combination regimens with at least 3

anti-tuberculous drugs:

1. Isoniazid (Laniazid, Nydrazid) -- Highly active against

Mycobacterium tuberculosis. Has good GI absorption and
penetrates well into all body fluids and cavities.

2. Rifampin (Rifadin, Rimactane) -- For use in combination

with at least one other antituberculous drug; inhibits
DNA-dependent bacterial but not mammalian RNA
polymerase. Cross-resistance may occur.

3. Pyrazinamide -- Bactericidal against M tuberculosis in an acid

environment (macrophages). Has good absorption from the
GI tract and penetrates well into most tissues, including CSF.
4. Ethambutol (Myambutol) -- Has bacteriostatic activity against M
tuberculosis. Has good GI absorption. CSF concentrations remain
low, even in the presence of meningeal inflammation.

5. Streptomycin -- Bactericidal in an alkaline environment. Because

it is not absorbed from the GI tract, must be administered
parenterally. Exerts action mainly on extracellular tubercle bacilli.
Only about 10% of the drug penetrates cells that harbor organisms.
Enters the CSF only in the presence of meningeal inflammation.
Excretion is almost entirely renal.

(Duration of therapy should be individualized and based on the

resolution of active symptoms and the clinical stability of the
patient.)
Illustrations

Late complications of the disease are:

1. severe kyphosis
2. sinus formation,
3. paraplegia (so called Pott's paraplegia)
SEPTIC ARTHRITIS
Septic arthritis, also known as infectious arthritis
or pyogenic arthritis is a serious infection of the joints
characterized by pain, fever, chills, inflammation and
swelling in one or more joints, and loss of function in
those joints.

Septic arthritis is considered a medical emergency

because of the damage it causes to bone as well as
cartilage, and its potential for creating septic shock,
which is a potentially fatal condition.
Cause
⚫ Previous trauma to joints

⚫ Joint replacements

⚫ Coexisting arthritis

⚫ Diminished host resistance.

Risk factors
⚫ Advanced age
⚫ Diabetes mellitus
⚫ Rheumatoid arthritis
⚫ Preexisting joint disease
⚫ Joint replacement.
Sign & Symptoms
Acute Septic Arthritis usually presents with a:

⚫ Warm, painful
⚫ Swollen joint
⚫ Decreased range in motion.
⚫ Systemic chills
⚫ Fever
Diagnostic Studies
⚫ Aspiration
⚫ Examination
⚫ Culture of the synovial fluid. Radioisotope
scanning
⚫ Localization the infectious process.
Management
⚫ Prompt treatment
⚫ Broad-spectrum IV antibiotics
⚫ remove excessive fluid, exudates and debris.
⚫ The inflamed joint is supported and
immobilized
⚫ splint that increases the patients comfort.
⚫ Analgesics are given to control pain
⚫ NSAIDs are also prescribed to limit joint
damages.
 DEVELOPMENTAL
CONDITION OF THE SPINE

Scoliosis
Herniated Nucleus Pulposus
SCOLIOSIS
A Lateral or sideways curve in the
spine that is apparent when viewing
the spine from behind.
PREDISPOSING FACTORS

1.Genetic Inheritance
2. Age
3. Sex
Classification
1. Nonstructural Scoliosis
- postural scoliosis
- compensatory

2. Transient Scoliosis
- sciatic scoliosis
- hysterical scoliosis
- inflammatory scoliosis
Classification
3. Structural Scoliosis
- idiopathic (70-80 % of all cases)
- neuromuscular
- poliomyelitis
- cerebral palsy
- syringomyelia
- muscular dystrophy
- amyotonia congenita
- friedreich’s ataxia
Classification
- neurofibromatosis
- mesenchymal disorder
- marfan’s syndrome
- morquio’s syndrome
- rheumatoid arthritis
- osteogenesis imperfecta
- certain dwarves
- trauma
- fractures
- irradiation
- surgery
ETIOLOGY
1. Idiopathic
a. accounts for 80% of cases
b. possible familial incidence

2. Congenital
a. failure of vertebral fomation
b. failure of segmentation

3. Neuropathic- associated with conditions such as poliomyelitis,

cerelral palsy, paralysis, and neurofibromatosis.

4. Myopathic- results from conditions such as muscular

dystrophy and myopathies.

5. Osteophathic- results from conditions such as fractures,

bones disease, arthritis, and infection.
There are Three General
Causes of Scoliosis:

⚫ Congenital scoliosis is due to a problem with the

formation of vertebrae or fused ribs during prenatal
development.
⚫ Neuromuscular scoliosis is caused by problems such
as poor muscle control or muscular weakness or paralysis
is caused by problems such as poor muscle control or
muscular weakness or paralysis due to diseases such as
cerebral palsy is caused by problems such as poor
muscle control or muscular weakness or paralysis due to
diseases such as cerebral palsy, muscular dystrophy is
caused by problems such as poor muscle control or
muscular weakness or paralysis due to diseases such as
SIGNS AND SYMPTOMS
1. Uneven musculature on one side of the spine.

2. A rib “hump”

3. Uneven hip & shoulder levels.

4. Asymmetric size or location breast in females.

5. Unequal distance between arms & body.

6. Clothes do not hang right.

COMPLICATIONS
1. Emotional problems or lowered self-esteem

2. Spinal cord or nerve damage.

3. Failure of the bone to joint together

4. Spine infection after surgery.

5. Low back arthritis & pain.

6. Respiratory problems.
patterns of scoliosis
Diagnostic Test

The health care provider will perform a

physical exam, which includes a forward
bending test that will help the doctor
define the curve. The degree of curve seen
on an exam may underestimate the actual
curve seen on an x-ray, so any child found
with a curve is likely to be referred for an
x-ray. The health care provider will
perform a neurologic exam to look for any
changes in strength, sensation, or
reflexes.
Forward Bend Test
The forward bend test
is a test used most
often in schools and
doctor's offices to
screen for scoliosis.
During the test, the
child bends forward
with the feet together
and knees straight
while dangling the
arms. Any imbalances
in the rib cage or other
deformities along the
back could be a sign
of scoliosis.
Tests may Include:
•Spine x-rays (taken from
the front and the side)
•Scoliometer measurements (a
device for measuring the
curvature of the spine)
•MRI (if there are any neurologic
changes noted on the exam or if
there is something unusual in the
x-ray )
SCOLIOMETER
Cobb method for measurement of scoliosis
Scoliosis Brace
TRACTION
Spinal Fusion
HARRINGTON ROD INSTRUMENTATION
NURSING INTERVENTIONS
1. Prepare the child for casting or immobilization procedure
by showing materials to be used and describing procedure
in age-appropriate terms.
2. Promote comfort with proper fit of brace or cast.
3. Provide opportunity for the child to express fears and ask
questions about deformity and brace wear.
4. Assess skin integrity under and around the brace or cast
frequently.
5. Provide good skin care to prevent breakdown around any
pressure areas.
6. Care of child undergoing surgery is similar to care of patient
with herniated disc.
NURSING DIAGNOSIS
1. Body image concerns related to the appearance of
the deformity and immobilization in an attractive
devices.
2. Pain related to the extent of the defect and or surgery
3. Impaired skin integrity related to pressure from
braces, traction or casts.
4. Potential for serious post operative complications (neurology
impaired, shock, infection, urinary retention,
paralytic ileus) related to surgery.
5. Anxiety related to hospitalization and surgery.
6. Decreased independence related to immobilization.
7. Knowledge deficit regarding scoliosis and its
management.
HERNIATED NUCLEUS
PULPOSUS
Herniated Nucleus Pulposus
⚫ Nucleus pulposus of an intervertebral disc
protruded through the surrounding fibrocartilage
or anulus fibrosus

⚫ Causes
⚫ Repetitive stress
⚫ Trauma
⚫ Falls
⚫ Work related
⚫ C5-C6, C6-C7 and L4-L5, L5-S1 (most
common levels of disc herniation
⚫ Types
⚫ Bulging (disc of anulus bulges)
⚫ Protrusion (not through the post
longitudinal ligament
⚫ Extrusion (w/ herniation through PLL)
⚫ Sequestration (detached fragment of
herniated material)
Clinical Manifestation
⚫ Cervical Disc

● Pain and stiffness in neck, top of shoulder, and in region of

scapula.

● Pain in upper extremities and head.

● Paresthesia and numbness of upper extremities.

LUMBAR DISC
• Low back pain accompanied by varying degrees of
sensory and motor impairment.
• Pain radiating from the low back into the buttock and
down the leg (sciatica).
• Postural deformity of lumbar spine.
• Positive straight-leg raising test
a. With the patient lying supine, the leg is raised with
knee extended.
b. Test is positive if pain occurs in leg below the knee or
if radicular (spinal nerve root) pain ensues.
• Weakness and asymmetric reflexes.
• Sensory loss.
Diagnostic Exam
● Myelogram – demonstrate area of pressure and
localizes herniation of disc.

● CT or MRI Scan

● Electromyography – localizes specific spinal nerve

involved.
Surgical Treatment
⚫Laminectomy
DISCECTOMY
Nursing Intervention
⚫ Cervical Disc Herniations

⚫ A)Immobilize and rest the cervical spine

● Bedrest – to reduce inflammation and edema in soft tissues

around disc, relieving pressure on nerve roots; relieves
cervical spine of supporting weight of head.
● Cervical collar – allows maximum opening of intervertebral
foramina.
● Cervical traction – accomplished by head halter traction,
increases vertebral separation and thus relieves pressure on
the nerve roots.
● Brace
B)Reducing Inflammation

• Administer prescribed anti-inflammatory

medications, to treat inflammatory response.
• Administer prescribed muscle relaxant.
• Administer prescribed analgesics medications
and sedatives, to control discomfort and
anxiety often associated with cervical disc
disease.
• Teach family to apply moist hot compresses (10
– 20 min. several times daily) to back of neck,
to increase blood flow to muscles and promote
relaxation of the patient and spastic muscles.
Lumbar Disc Herniations

• Encourage to continually take prescribed

muscle relaxant drugs.

1) Reducing Pain

• Bedrest
• Encourage to assume comfortable and proper
position.
• Ambulate when inflammatory reaction &
edema have subsided.
• Instruct family member in the use of heat
compress and massage to relax muscle spasm.
2)Self-monitoring for Neurologic
Deficit

• Diminishing or loss of neurologic

function below level of disc,
including loss of bladder/bowel
control.
• Unrelieved, acute pain.
• Muscle weakness and atrophy
3)Patient Education
• Encourage client to do exercises after
acute symptoms subside.
• Advised client to sleep on side with
knees and hips flexed.
• Avoid lifting until healing has taken
place.
• Encourage proper posture while
standing. sitting, and working.
• Carry out a weight control program.
 CONGENITAL
MALFORMATION
CLUBFOOT
COXA PLANA
OSTEOGENESIS IMPERFECTA
CONGENITAL HIP DISLOCATION
CLUBFOOT
 Club foot, which is also known as Talipes
Equinovarus is a congenital deformity of the foot,
characterized by inward and downward position
of the foot.

✔ Congenital – means a deformity at birth.

✔ Talipes – the foot and ankle
✔ Equinovarus – refers to the position of the foot,
which points downwards and inwards.
TYPES OF CLUBFOOT
Predisposing factors:
❖ Genetic (family history)
❖ Sex (likely affects males with male-female ratio of 2:1)
❖ Ethnicity (those of Polynesian descent are most at risk)
❖ Other factors that may affect pre natal growth, such as infection,
drugs, disease or other factors in the uterine or outside environment

One recent study suggests that women who smoke during

pregnancy may increase risk of having a baby with clubfoot,
especially if they have family history of said defect.
CLUBFOOT
 Signs and Symptoms:
✔ Fixed Plantar Flexion (equinus) of the ankle, characterized
by the drawn up position of the heel and inability to bring the
foot to a plantigrade (flat) standing position. This is caused by
a tight achilles tendon.

✔Adduction (varus), or turning in of the heel or hindfoot

✔Adduction (turning under), of the forefoot and midfoot
giving the foot a kidney-shaped appearance.
✔ Abnormal (slightly smaller) size of foot & calf muscles
✔ The heel cord (achilles tendon) is tight causing the heel to be
drawn up toward the leg.
Diagnostic Tests:
newborn examination (Physical exam)

X-ray of the foot to see if bones in the foot are

abnormally shaped
Ultrasound examination before birth
 Management / Treatment:
Treatment ideally starts immediately
after birth…

1. Casting – can be started on the day of birth or within several

weeks after birth. In this procedure, the orthopedist
pushes and twists the foot into an over corrected position
and then cast is applied to ensure holding of foot in same
manner. (kiting)
Management / Treatment:
Ponsetti Method

The treatment involves serial

manipulation and plaster casting
of the clubfoot. The ligaments
and tendons of the foot are gently
stretched with weekly, gently
manipulations. A plaster cast is
then applied after each weekly
sessions to retain the degree of
correction obtained and to soften
the ligaments. Thereby, the displaced bones are gradually brought into the correct
alignment. Four to five long leg (from the toes to the hip) are applied with the knee at
a right angle.
Management / Treatment:
Dennis Brown
Brace
-used when long leg cast is
removed after 3 weeks of
treatment. The bar is fit
shoulder width apart and
worn with reverse last shoes. It is
worn full time for the 1st 2 months
after the last cast is removed.
Management / Treatment:
2. Physiotherapy – started after the child becomes
more than 3 months old. The physiotherapist
tapes or manipulates the foot.

3. Surgery – recommended for children above the

age of 6 months. Needed if cast treatment fails
or the club foot is rigid.
 Management / Treatment:
Surgical
Procedures:
✔Club foot repair / Club foot
release

✔Tendon transfers

-tight tissues around the

joints are released and
results in lengthening of
tendons so the foot can
assume a more corrected
position.
Pharmacologic Management:
✔ NSAIDS – used mainly for management of
pain of low to moderate intensity.

e.g. Ibuprofen
 Nursing Intervention:

✔Elevate child’s feet with pillows. Check the toes every 1-2
hours for temperature, color, sensation, motion, and
capillary refill time.
✔Insert plastic petals over the top edges of a new cast while
it is still wet to keep urine from soaking and softening the
cast.
✔ When the Kite casting method is being used, check circulatory
status frequently. Circulation maybe impaired because of
increased pressure on tissues and blood vessels. The equinus
correction specially places considerable strain on ligaments,
blood vessels, and tendons.
 COXA PLANA
LEGG-CALVE-PERTHES DISEASE
20th century following the invention of x-ray.

Dr. Legg from Boston, Dr. Perthes from

Germany, and Dr. Calve from France described
the condition almost simultaneously

Temporary loss of blood supply to the ball

(femoral head) of the hip joint.
DEFINITION
Is when the head of the thighbone (femur) in the
hip deteriorates due to insufficient blood supply to
the area.
Occurs most frequently in boys 4 to 10 years old.
Recent research shows that this disorder may
reflect subtle disorders of blood clotting.

Etiology:
The blood flow to the femur is interrupted, and
the tip of the bone dies over a period of one to three
weeks. The disorder causes a flattening of the top of
the femur (the ball of the head of the femur).
Usually just one hip is affected, although it's
possible for both to develop the condition.
CAUSES
• Low birth weight

• Delayed bone maturity

• Short stature

• Abnormal birth presentation

•Being born to older parents

SIGNS & SYMPTOMS
⚫ knee pain
⚫ persistent thigh or groin pain
⚫ atrophy of muscles in the upper thigh
⚫ muscle spasms
⚫ legs of unequal length (asymmetry)
⚫ hip stiffness that restricts movement in the hip
⚫ difficulty with or limp during walking
⚫ limited range of motion
DIAGNOSTIC PROCEDURE
⚫ X-rays

⚫ Bone scans

⚫ Magnetic resonance imaging (MRI)

⚫ Arthrograms
Four Stages of LCPD
⚫ Femoral head becomes more dense with possible
fracture of supporting bone;

⚫ Fragmentation and reabsorption of bone;

⚫ Reossification when new bone has regrown; and

Healing, when new bone reshapes.

Phase I takes about 6-2 months, Phase 2 takes

one year or more, and Phase 3 and 4 may go on for
many years.
Initial Phase
Reabsorption Phase
Reossification Phase/Healed
Surgical Treatment
⚫ Tenotomy

A "Tenotomy" is a surgery that is performed to release an

atrophied muscle that has shortened due to limping. Once
released, a cast is applied allowing the muscle to regrow to
a more natural length. Cast time is about six to eight weeks.

⚫ Osteotomy

There are different types of "osteotomies" (cutting the bone

to reposition it) and, depending on the need they are
performed at different stages of the disease. At times with
the softening of the ball, there is the possibility of the ball
slipping out of the socket. To protect it, a femoral varus
osteotomy, with or without rotation partially redirects the
ball into the socket.
 Nursing Intervention:
⚫ Bed rest

⚫ Care for the child requiring traction and spine cast

⚫ Provide diversional activities

⚫ Provide range of motion exercises

OSTEOGENESIS
IMPERFECTA
DEFINITION
⚫ Osteogenesis Imperfecta (OI) is a genetic disorder
characterized by bones that breaks easily without a
specific cause.

SYNONYMS:
>-Brittle-bone disease, Fragile bone dse., Broken bone
ETIOLOGY
⚫ The specific cause of Osteogenesis Imperfecta is unknown,
but some cases are of congenital origin and the hereditary
factor is demonstrable in many, with the disease usually
transmitted as an autosomal-dominant trait.

INCIDENCE
>Osteogenesis Imperfecta is relatively rare, with the
congenital type occurring in approximately 1 of every
40,000 births. It is somewhat more frequent in females
than in males.
SIGNS & Symptoms

Type I:

•most common & mildest

•bones fracture easily
•can usually be traced through the family
•near normal stature or slightly shorter
•blue sclera (the normally white area of the eye ball)
•dental problems
•hearing loss beginning in the early 20s and 30s
•most fractures occur before puberty; occasionally
women will have fractures after menopause
•triangular face
•tendency toward spinal curvatures
Type II:

⚫ Most severe
⚫ newborns severely affected; frequently fatal
⚫ usually resulting from a new gene mutation
⚫ very small stature with extremely small chest and
under developed lungs
Type III:

⚫ tend to be isolated family incidents

⚫ very small in stature - some only 3 feet tall
⚫ fractures at birth very common
⚫ x-ray may reveal healing of in utero fractures
⚫ severe early hearing loss
⚫ loose joints and poor muscle development in arms and
legs
⚫ barrel-shaped rib cage
⚫ Triangular face
Type IV:

⚫ can frequently be traced through the family

⚫ bones fracture easily - most before puberty
⚫ normal or near normal colored sclera
⚫ problems with teeth - more than Type I
⚫ spinal curvatures
Diagnostic Procedure
⚫ Physical examination
⚫ Family’s medical history
⚫ Blood & urine test
⚫ Collagen synthesis analysis
⚫ Prenatal DNA
- Ultrasound
- Amniocentesis
- Chorionic Villus Sampling (10-13 weeks of
pregnancy)
⚫ Bone mineral density analysis
Treatment for Osteogenesis Imperfecta

Specific treatment for osteogenesis imperfecta will

be determined by your physician based on:

⚫ your age, overall health, and medical history

⚫ extent of the disease
⚫ your tolerance for specific medications,
procedures, or therapies
⚫ expectations for the course of the disease
⚫ your opinion or preference
 Treatments for preventing or correcting
symptoms may include:

⚫ care of fractures
⚫ surgery
⚫ rodding - a procedure to insert a metal bar the length
of a long bone to stabilize it and prevent deformity
⚫ dental procedures
⚫ physical therapy
⚫ assistive devices, such as wheelchairs, braces, and
other custom-made equipment
NSG. MANAGEMENT
⚫ Support limbs. Do not pull on arms or legs to prevent fractures.
⚫ Position with care
⚫ Check the pts. Circulatory and motor sensory abilities
⚫ Provide emergency car e of fractures
⚫ Encourage diet high in protein and vitamins to promote healing.
⚫ Encourage fluids to prevent constipation , renal calculi and UTI’s.
⚫ Provide care for client with traction, cast or open reduction.
⚫ Provide psychological support and diversional activities.
⚫ Encourage mobility when possible.
⚫ Teach preventive measures
⚫ Refer the parents and child for genetic counseling to assis t the
recurrence risk.
⚫ Promote preventive dental care and repair of dental caries.
⚫ Monitor hearing needs.
⚫ Teach pt. to avoid activities which have a negative impact on bone
density such as smoking , drinking and taking steroids.
⚫ Aggressively treat all URI .
CONGENITAL HIP
DISLOCATION
Definition
Congenital hip dysplasia is an abnormal formation
of the hip joint in which the ball at the top of the
thighbone (femoral head) is not stable in the
socket (acetabulum). Also, the ligaments of the
hip joint may be loose and stretched. The degree of
instability or looseness varies. A baby born with
DDH may have the ball of his or her hip loosely in
the socket, the looseness may worsen as the child
grows and becomes more active, or the ball may be
completely dislocated at birth.
CLASSIFICATION
1. Acetabular Dysplasia – deficient development of the
acetabulum & femoral head.

2. Subluxation - partial displacement of a joint with

some contract remaining between the articular
surface.

3. Dislocation - complete displacement of a joint with

no contract between the articular surface.
❖ Unknown

❖ Genetic factors may play a role.

❖ Female sex

❖ Oligohydramnios
> Can result in fetal compression and diminished
movement.
❖ Being the first born child.

❖ Occurs 1 out of 1,000 births.

❖ Large for Gestational Age (LGA)

❖ Positive family history (first-degree relatives)
❖ Breech presentation

Help!!
❖ A “hip click” during routine post – natal checkup.
❖ Reduced movement in the affected side.
❖ The leg may appear shorter on the side of the
dislocated hip.
❖ The leg positions may be different (asymmetric).
❖ The folds in the skin of the thigh or buttocks may
appear uneven.
❖ After 3 months of age, the affected leg may turn
outward or be shorter than the other leg.
❖ Space between the legs may look wider than normal.
❖ Ortolani test
> Done by spreading the thighs.

A) Initial downward pressure further

dislocates the hip, which then,
(B) Relocates as the thigh is adducted.
❖ Barlow test
> Done by bringing the knees together.

(A) The leg is pulled forward and then

(B) Adducted in an attempt to dislocate the femur.
❖ Trendelenburg’s sign.

Done by having the child rest his weight on the side

of the dislocation and lift his other knee. His pelvis
drops on the normal side because of weak
abductor muscles in the affected hip.
Alli’s or Galeazzi’s Sign
❖ Medical Management :
> In the first 4 to 6 months of life, the device used
is often a Pavlik harness.
> Traction, bracing and casting if the hip continues
to be partially or completely dislocated.
FROG CAST TRACTION TRACTION

SPICA CAST BRACING BRACING

❖ Surgical Management :

> Close reduction

> Open reduction

> Osteotomy
❖ Nursing Management :

> When transferring the child immediately after

casting, use your palms to avoid making dents in
the cast.
> Position the child either on a Bradford frame
elevated on blocks, with a bedpan under the frame,
or on pillows to support the child’s legs. keep the
cast dry, and change the diapers often.
> Wash and dry the skin under the cast edges
every 2 to 4 hours, and rub it with alcohol. Do not
use oils or powders; they can macerate skin.
> Turn the child every 2 hours during the day and
every 4 hours at night. Check color, sensation, and
motion of the infant’s legs and feet.
> Shine a flashlight under the cast every four
hours to check for objects and crambs.
> If the child complains of itching, she may benefit
from diphenhydramine.
> Provide adequate nutrition, and maintain adequate
fluid intake to avoid renal calculi and constipation,
both complications of inactivity.
> If the child is very restless, apply a jacket
restraint to keep her from falling out of bed or
off the frame.
> Provide adequate stimuli to promote growth and
development.
INFLAMMATORY
Rheumatoid Arthritis
Osteoarthritis
Gouty Arthritis
Buerger’s Disease
Raynaulds Disease
RHEUMATOID ARTHRITIS
Definition:

This refers to an autoimmune

inflammatory diseases of joints and
various organ systems. In this
disorder, synovial inflammation
produces antigens and inflammatory
by-products leading to destruction on
joint cartilage, edema, and production
of granulation tissue (pannus).
The Pannus forms adhesions on joint
surfaces and supporting structures such
as ligaments and tendons, causing
contractures and ruptures that degrade
joint structure and mobility. Bilateral
symmetric arthritis affects any diarthrodial
joint but most often involves the hands,
wrists, knees, and feet.
The Cause
is
Unknow
n
It maybe a result from a combination
of the following factors:

• Environment

• Demographic

• Infectious

• Genetic
Predisposing Factors include:
•Fatigue

•Cold

•Emotional stress

•Infection
Signs & Symptoms
⚫ Pain and swelling in the joints
⚫ Generalized aching or stiffness of the joints and
muscles
⚫ Loss of motion
⚫ Fatigue
⚫ Low-grade fever
⚫ Deformity of joints overtime
⚫ Malaise
⚫ Small lumps (rheumatoid nodules)
Diagnostic Test
⚫ CBC
⚫ Rheumatoid factor
⚫ ESR
⚫ Sinovial fluid analysis
⚫ X-rays
⚫ MRI
⚫ Bone scan
⚫ Synovial biopsy
Therapeutic Intervention
⚫ Application of heat and cold to relieve pain
and inflammation

⚫ Use of splints to prevent contractures

⚫ Use of transcutaneous electrical nerve

stimulation (TENS) unit to treat chronic pain

⚫ Iontophoresis (delivery of medication

through the skin using direct electrical
current) to relieve pain.
Nursing Intervention
⚫ Monitor length of stiffness on arising.

⚫ Monitor pain control measures.

⚫ Monitor for signs and symptoms indicating

adverse reaction to medications, such as rash,
visual symptoms, GI distress.

⚫ Monitor functional ability.

Medical Intervention
⚫ Aspirin – mainstay of treatment, has both analgesic and
anti-inflammatory effects.

⚫ Nonsteroidal anti-inflammatory drugs (NSAIDs):

⚫ Indomethacin (Indocin)
⚫ Phenylbutazone (Butazolidin)
⚫ Ibuprofen (Motrin)
⚫ Fenoprofen (Nalfon)
⚫ Naproxen (Naprosyn)
⚫ Sulindac (Clinoril)
 Medical Intervention
Gold compunds (chrysotherapy)
•Injectable form: sodium thiomalate (Myochrysine).
Aurothioglucose (Solganal); given IM once a
week; takes 3-6 months – to become effective.
Oral form: auranofin (Ridaura); smaller doses
are effective; diarhhea is a common side effect.
Corticosteroids (intra-articular injections)
Surgical Intervention
Osteotomy
Surgical removal of a wedge from the
joint.
Synovectomy
Removal of synovia.
Arthroplasty
Replacement of joints with prostheses
OSTEOARTHRITIS
OSTEOARTHRITIS:
• the most common of all joint diseases.

• A type of arthritis that is cause by the breakdown and

eventual loss of the cartilage of one or more joints.

• Derived from Greek word “osteo” means bone; “arthro”

means joint and “itis” means inflammation.
Osteoarthritis is characterized by bony spur formation at the edges of
the joint surfaces, thickenning of the capsule and the synovial
membrane and thinning of articular cartilage.
weight-bearing joints, such as hips and knees.
Types of Osteoarthritis
1) Primary Osteoarthritis

Osteoarthritis with no known cause but mostly

related to aging.

2. Secondary Osteoarthritis

Osteoarthritis with known cause such as obesity,

trauma or surgery, congenital abnormalities (hip
dysplacia), gout and diabetes.
Predisposing Factors
1. Aging.
2. Anatomic abnormality; mal-alignment.
3. Joint injury/Trauma/Surgery
-Stresses at the joints from certain jobs and
playing sports.
4. Obesity.
5. Systemic diseases.
6. Genetic factors.
7. Other form of arthritis (like gout, rheumatoid
arthritis)
SIGNs AND SYMPTOMS
1. Pain and swelling.
2. Stiffness.
3. Enlargement of joint.
-Heberden’s nodes
- nodular bony enlargement (spurs) that form on
the distal joints of some or all of the fingers.
-Bouchard’s nodes
- nodular bony enlargements that form on the
proximal joints of some or all of the fingers.
4. Crepitus
- audible grating sound produced by bony
irregularities with joints.
5. Discomfort in the joint before or during a change in
the weather.
DIAGNOSTIC STUDIES

X-Ray MRI

ARTHROSCOPY
Arthrocentesis
 MEDICAL MANAGEMENT

1. Symptomatic relief
-osteoarthritis is irreversible; goal of treatment is to reduce
joint pain and inflammation while improving and
maintaining joint function.

2. Injection of hyaluronic acid into the joint

-temporarily restore the thickness of the joint fluid.
 SURGICAL MANAGEMENT

1. Excision Arthroplasty
- excising the joint margins, e.g. in the metatarsals.
2. Osteotomy
- realignment of bone surfaces.
3. Fusion/Arthrodesis
- fusing the joint.
4. Arthroscopic joint debridement
- removal of loose bodies and smoothing articular surfaces.
5. Total joint arthroplasty
- surgical replacement of destroyed joint.
 PHARMACOLOGY
1. NSAID
-aspirin, ibuprofen, naproxen.
2. Topical
-creams and lotion containing capsaicin, ex.: methyl salicylate
(bengay).
3. Analgesic like paracetamol or acetaminophen.
4. Dietary Supplements
- Glucosamine-provides the building blocks for the body to
make and repair cartilage
-Chondroitin- contribute to cartilage elasticity
NURSING MANAGEMENT
1. Assess joints for pain and ROM
2. Relieve strain and prevent further trauma to joints:
-use cane or walker when indicated
-correct posture and body mechanics
-avoid weight bearing and continuous standing
-promote relief of pain
3. Avoid activities that precipitate pain
4. Provide rest for involved joints
5. Maintain proper weight
6. Use heat as prescribed
GOUTY ARTHRITIS
GOUT (METABOLIC ARTHRITIS)

⚫ Is a disease due to an inborn

uric acid metabolism. In this
condition, sodium urate crystals
are eposited on the adicular
cartilage of joints and in
particular tissue like tendons.
⚫ Also known: Gout, the disease
of kings, the king of disease
⚫ Normally, the human blood
stream only causes small
amount of uric acid. However, if
the blood has an elevated
concentration of uric acid, uric
acid crystals are deposited in
the cartilage and tissue
surrounding the joints.
SYMPTOMS
⚫ Joint pain
⚫ Joint swelling of the affected joint
⚫ Stiffness of the joint
⚫ Fever may be present
⚫ Skin lump which may drain chalky
material.
Gouty Arthritis usually strikes a single joint such as……

⚫ BIG TOE ⚫ FOOT

Gouty Arthritis usually strikes a single joint such as……

⚫ ANKLE ⚫ KNEES
Gouty Arthritis usually strikes a single joint such
as……
⚫ WRISTS ⚫ FINGERS

⚫ ELBOWS
MOST AFFECTED…..

⚫ Men are more likely to develop than

women.

⚫ It is rare in children and young adults.

Four Stages
ASYMPTOMATIC HYPERURICEMIA

⚫ Stage which is
usually doesn’t
require treatment,
a person has
elevated blood uric
levels but no other
symptoms.
ACUTE GOUTY ARTHRITIS

⚫ In this stage,
hyperuricemia has
caused deposits of
uric acid crystals in
joint spaces leading
to Gouty attacks.
INTERVAL / INTERCRITICAL

⚫ In this stage, the

periods between
acute Gouty
attacks, a person
has no
symptoms.
CHRONIC TOPHACEOUS GOUT

⚫ In this stage, the

disease has caused
permanent
damage, treatment
never progress to
this advanced
stage.
DIAGNOSTIC TEST
⚫ Synovial (joint) analysis- ⚫ OTHERS
detects uric acid crystals Uric Acid test – urine
⚫ Elevated Uric Acid level-
blood test Synovial biopsy
⚫ Joint X-ray- which show
damage consistent with
Blood differential
Gouty Arthritis.
Medical Management
Medications

● Colchicine (0.6 mg), Oral administration of 2 tablets

initially, then 1 tablet per hour until nausea, vomiting
or diarrhea develops or joint symptoms subside. Limit
is (6.0 – 8.0 mg)

●Colchicine 1.0 to 3.0 mg in saline Intravenously over

a period of 10 minutes.

●Phenybutazone (Butazolidin)

● Indomethacin (Indocin)

Absolute joint rest

SURGERY
⚫For extreme cases of Gout,
surgery may be necessary to
remove large tophil and
correct joint deformity.
Surgical Management

The removal of detached osteophytes

and advance tophi can reduce the
articular destruction taking place.
Anthroplasty or Anthrodesis should be
considered if there is a severe pain
associated with the movement of the
joint in a digit.
.Triple Anthrodesis is the last resort
Nursing and Pharmacologic Management
Patient teaching

✔Instruct the patient about the nature of the disease

✔Instruct for proper use of medication
✔Encourage the patient to lose weight
✔Encourage the patient to take sufficient fluids to assure daily
output of 2-3 liters

Promoting comfort

✔Provide absolute rest until the pain of acute attack subsides.

✔Avoid touching the joint or moving the affected extremity until
acute pain subsides
■Heat and Cold Application
DIET-food to avoid
⚫ Foods high in PURINE
Sweet breads, kidneys, liver, brains or other offal
meats
Sardines
Anchovies or dilis
Scallops, prawns and crabs
Alcohol
Moderate intake of purine-rich vegetables in not
associated with increased Gout.
VITAMINS AND SUPPLEMENTS
⚫ The following is based on information from a
Naturopathic Physician….
Quercetin- inhibits Uric Acid production
Bromelain- anti-inflammatory
Vitamin E
Flaxseed Oil
Avoid high doses of Vit.C and Niacin (B3)- may
increase uric acid
BUERGER’S DISEASE
DEFINITION
It is an obliterative disease of arteries and veins
characterized by acute and chronic inflammation in
the blood vessels of the lower and upper extremities

that result in thrombus formation and occlusion of

the vessels.
DEFINITION

⚫ It begins in the small arteries and progresses to the

larger vessels.

⚫ The mechanisms underlying Buerger's disease are still

largely unknown.

⚫ It is suspected that immunological reactions play a

role.
PREDISPOSING FACTORS
⚫ SMOKING:
The cause of the disease is unknown but heavily linked
to tobacco use.

⚫ RACE:
Buerger disease is relatively less common in people of
northern European descent. Natives of India, Korea, and
Japan, and Israel have the highest incidence of the
disease.
PREDISPOSING FACTORS
⚫ SEX:
Though Buerger’s Disease is more common in males
(male-to-female ratio, 3:1),

incidence is believed to be increasing among women,

and this trend is postulated to be due to the increased
prevalence of smoking among women.

⚫ AGE:
Most patients with Buerger disease are aged 20-40 years.
SIGNS AND SYMPTOMS
Signs and symptoms of Buerger’s Disease often
include:

⚫ PAIN/CLAUDICATION
Pain induced by insufficient blood flow during exercise
in the feet and/or hands.

This pain typically begins in the extremities but may

radiate to other (more central) parts of the body.
SIGNS AND SYMPTOMS
⚫ NUMBNESS

⚫ RAYNAUD’S PHENOMENA
a condition in which the distal extremities — fingers, toes,
hands, feet — turn white upon exposure to cold.

⚫ ISCHEMIC ULCERATIONS

⚫ GANGRENE
Even as ulcers and gangrene develop in the digits, organs such
as the lung, kidneys, brain, and gastrointestinal (GI) tract
remain unaffected. The reasons for this are unknown.
DIAGNOSTIC TESTS
⚫ A concrete diagnosis of thromboangiitis obliterans
is often difficult as it relies heavily on exclusion of
conditions. The commonly followed diagnostic criteria
are below although the criteria tend to differ slightly
from author to author. Olin (2000) proposes the
following criteria:
DIAGNOSTIC TESTS
⚫ Age younger than 45 years.

⚫ Current (or recent) history of tobacco use.

⚫ Presence of distal extremity ischemia (indicated

by claudication, pain at rest, ischemic ulcers or
gangrene) documented by noninvasive vascular
testing such as ultrasound.
DIAGNOSTIC TESTS
⚫ Exclusion of autoimmune diseases,
hypercoagulable states, and diabetes mellitus by
laboratory tests.

⚫ Exclusion of a proximal source of emboli by

echocardiography and arteriography.

⚫ Consistent arteriographic findings in the

clinically involved and noninvolved limbs.
Complete Blood Count
Urinalysis
Erythrocyte
Sedimentation Rate
(ESR)
IMAGING TESTS
⚫ Angiography/Arteriography

⚫ Digital Subtraction

⚫ Doppler Ultrasound

⚫ Exercise Testing
Angiography/Arteriography
An angiogram demonstrating lack of blood flow to vessels of the
hand. This decreased blood flow (“ischemia”) led to ulcers of the
fingers and severe pain.
An abnormal result from an
angiogram of the hand.
Angiograph
Doppler Ultrasound
Doppler Ultrasound
MANAGEMENT
⚫ Except for absolute tobacco avoidance, no
forms of therapy are definitive.

⚫ The only way to prevent the progression of the

disease is to abstain from all tobacco products.
MEDICAL
Since there is no cure for Buerger's disease, the goal of
treatment is to control symptoms. Some measures include:

⚫ Immediate and absolute cessation of tobacco use is

necessary to slow any further progression of the disease.

⚫ Early and aggressive treatment of extremity injuries to

protect against infections.
MEDICAL
⚫ Adequate hydration and scrupulous attention to cleanliness.

⚫ Gentle massaging and warming of patient to increase

circulation.

⚫ Avoidance of conditions that reduce circulation to the

extremities (such as cold temperatures and the use of
vasoconstrictors and tight or restrictive clothing).

⚫ Avoidance of sitting or standing in one position for long

periods of time.

⚫ Avoidance of walking Barefoot.

SURGICAL
⚫ AUTOLOGOUS VEIN BYPASS

To improve distal arterial flow in patients with Buerger

disease, and consider autologous vein bypass of coexistent
large-vessel atherosclerotic stenoses in patients with severe
ischemia who have an acceptable distal target vessel.

⚫ OMENTAL TRANSFER

⚫ SYMPATHECTOMY

⚫ SPINAL CORD STIMULATOR IMPLANTATION

SURGICAL
⚫ AMPUTATION

Indications for amputation:

Severe Rest Pain

Sepsis Secondary to Gangrene
Worsening Gangrene
PHARMACOLOGIC
⚫ Analgesics

⚫ Antibiotics

⚫ Anticoagulation Drugs

Strategies of anticoagulation (thinning of the blood with

aspirin or other agents to prevent clots) have not proven
effective.
PHARMACOLOGIC
⚫ Anti-inflammatory Drugs
Despite the clear presence of inflammation in this disorder,
anti-inflammatory agents such as steroids have not been
shown to be beneficial.
⚫ Prostaglandin Analogs
Intravenous ILOPROST use is probably of greatest value in
slowing progressive tissue loss and reducing the need for
amputation in patients with Buerger’s Disease during the
period when they first discontinue cigarette smoking.

⚫ Vasodilators

⚫ Vitamins
Illustration of the Disease
Illustration of the Disease
Raynaud's
Disease
DEFINITION
Raynaud's disease or phenomenon (pronounce ray-noze)
is a condition that makes it harder for blood to reach certain
areas of the body.
This happens because blood vessels under the skin tighten.
When blood does not reach parts of the body, these areas may
turn blue and feel cold. Most often Raynaud's phenomenon
affects the fingers and toes. It can alse affect the ears and nose.

Raynaud's disease or phenomenon is a condition resulting

from poor circulation in the extremeties ( i.e. fingers and
toes). In a person with Raynaud's when his or her skin is
exposed to cold or the person becomes emotionally upset , the
blood vessels under the skin tighten and the blood flow slow.
This is called "vasospasm."
Hands and feet have fewer large blood vessels and, therefore
when a vasospasm occurs, it is harder for the blood to keep
flowing and these areas may turn blue because less oxygen is
reaching the skin. The skin will also feel cold because less
blood is reaching the skin to keep it warm. While attack of
vasospasm may last from minutes to hours, only rarely do they
cause severe tissue damage.
Etiology
Doctors don't completely understand the cause of Raynaud's
attacks, but blood vessels in the hands and feet appear to overreact
to cold temperatures or stress.
⚫ When your body is exposed to cold temperatures, your
extremities lose heat. Your body slows down blood
supply to your fingers and toes to preserve your body's
core temperature. Your body specifically reduces blood
flow by narrowing the small arteries under the skin of
your extremities.

⚫ In people with Raynaud's, this normal response is

exaggerated. Stress causes a similar reaction to cold in
the body, and likewise the body's response may be
exaggerated.
Etiology (cont.)
⚫ With Raynaud's, arteries to your fingers and toes go into what's
called vasospasm. This constricts the vessels, dramatically but
temporarily limiting blood supply. Over time, these same small
arteries may also thicken slightly, further limiting blood flow. The
result is that affected skin turns a pale and dusky color due to the
lack of blood flow to the area. Once the spasms subside and blood
returns to the area, the tissue may turn red before returning to a
normal color.

⚫ Cold temperatures are most likely to provoke an attack.

Exposure to cold can be as simple as putting your hands under a
faucet of running cold water, taking something out of the freezer or
exposure to cold air. For some people, exposure to cold
temperatures isn't necessary. Emotional stress alone can cause an
episode of Raynaud's
Causes of secondary Raynaud's (cont.)
⚫ Diseases of the arteries.
⚫ atheroscleros is, which is the gradual buildup of plaques in
blood vessels that feed the heart (coronary arteries),
⚫ Buerger's disease, a disorder in which the blood vessels of
the hands and feet become inflamed.
⚫ Primary pulmonary hypertension, a type of high blood
pressure that affects only the arteries of the lungs, is
frequently associated with Raynaud's.
⚫ Carpal tunnel syndrome. The carpal tunnel is a narrow
passageway in your wrist that protects a major nerve to your
hand. Carpal tunnel syndrome is a condition in which pressure is
put on this nerve, producing numbness and pain in the affected
hand.
Causes of secondary Raynaud's (cont.)
REPETITIVE TRAUMA
⚫ that damages nerves serving blood vessels in the hands and feet.
In fact, nerve damage is thought to play a role in many cases of
Raynaud's. Some people who type or play the piano vigorously
or for long periods of time may be susceptible to Raynaud's.
Workers who operate vibrating tools can develop a type of
Raynaud's phenomenon called vibration-induced white finger.

⚫ Injuries. Prior injuries to the hands or feet, such as wrist

fracture, surgery or frostbite, can lead to Raynaud's
phenomenon.
Causes of secondary Raynaud's (cont.)
CHEMICALS
⚫ Smoking. Smoking constricts blood vessels and is a potential cause of
Raynaud's.
⚫ Chemical exposure. Some workers in the plastics industry who are exposed
to vinyl chloride develop an illness similar to scleroderma. Raynaud's can be a
part of that illness.

MEDICATIONS
⚫ Certain medications. Some drugs — including beta blockers, which are used
to treat high blood pressure; migraine headache medications that contain
ergotamine; medications containing estrogen; certain chemotherapy agents;
and drugs that cause blood vessels to narrow, such as some over-the-counter
cold medications

OTHER CAUSES Raynaud's has also been linked to an underactive

thyroid gland (hypothyroidism) and, rarely, to certain cancers.
 Risk Factors
⚫ About 3 out of 4 cases of primary Raynaud's occur in
WOMEN between the ages of 15 and 40 years, although
the reason is unknown.
⚫ People in COLDER CLIMATES are also more likely to
develop Raynaud's than people in warmer areas.
⚫ Risk factors for secondary Raynaud's
include associated DISEASES, such as
scleroderma and lupus, and smoking.
⚫ People in certain occupations,
such as WORKERS WHO OPERATE
TOOLS THAT VIBRATE, also may
be more vulnerable to secondary Raynaud's
Signs & Symptoms
⚫ People with Raynaud's (primary or secondary) have attacks in response to
cold or emotional stress. The attacks can affect the fingers and toes, and
rarely the nose, ears, nipples, or lips. The affected body parts will usually
have two or more of the following changes:
⚫ Look pale due to lack of blood flow
⚫ Look bluish due to a lack of oxygen
⚫ Feel numb, cold, or painful
⚫ Redden and throb or tingle as blood returns to the affected area

⚫ Attacks usually last about 15 minutes. They can last less than a minute or as
long as several hours. Attacks can occur daily or weekly.
⚫ Sometimes attacks affect only one or two fingers or toes. Different areas
may be affected at different times. Attacks can cause sores or tissue death
(gangrene) in people with severe secondary Raynaud's. However, severe
Raynaud's is very uncommon.
Diagnostic Tests
⚫ Cold Simulation Test - This test can trigger an attack that
is typical of the disorder. Temperature sensors are taped to
the fingers of the hand. The hand is then briefly exposed to
the cold, usually by dunking it in ice water. If the patient
likely has Raynaud's, it will take more than the normal time
for the finger temperature to return to what it was at the start
of the test.
⚫ Tests For Inflammatory Disorders that damage blood
vessels or nerves. Having these conditions along with
Raynaud's symptoms makes it more likely that a patient has
secondary Raynaud's disease.
⚫ Nailfold Capillaroscopy (Kap-i-lar-os-ko-pe). For this
test, the doctor puts a drop of oil on the skin at the base of
the fingernail and then looks at it under a microscope. If the
doctor sees abnormal looking blood vessels, this suggests an
inflammatory disorder such as scleroderma.
Diagnostic Test (cont..)

⚫ Antinuclear antibodies (ANA) test. A positive test for

the presence of these antibodies — produced by your
immune system — indicates a stimulated immune system
and is common in people who have connective tissue
diseases or other autoimmune disorders.

⚫ Erythrocyte sedimentation rate (ESR). This blood test

determines the rate at which red blood cells settle to the
bottom of a tube in the space of an hour. A faster than
normal rate may signal an underlying inflammatory or
autoimmune disease. Autoimmune diseases are commonly
associated with Raynaud's.
Complications
⚫ If Raynaud's is severe — WHICH IS RARE — blood
circulation to your fingers or toes could permanently
diminish, causing deformities of your fingers or toes.

⚫ If an artery to an affected area becomes blocked

completely, sores (skin ulcers) or dead tissue (gangrene)
may develop. Ulcers and gangrene can be difficult to treat.

⚫ See your doctor right away if you have a history of severe

Raynaud's and develop an ulcer or infection in one of your
affected fingers or toes.
Treatment
Self-care and preventive treatment usually are effective
in alleviating mild symptoms of Raynaud's.

The goals of treatment are to reduce the number and severity of

attacks and to prevent tissue damage. Doctors also want to treat
any underlying disease or condition

Medications
To widen (dilate) blood vessels and
promote circulation, your doctor may
prescribe:
Medical Management
Calcium channel blockers. These drugs relax and open up small blood vessels in
your hands and feet. They decrease the frequency and severity of attacks in about two-thirds
of people with Raynaud's. These drugs can also help heal skin ulcers on your fingers or toes.
Examples include nifedipine (Adalat, Procardia), amlodipine (Norvasc), diltiazem
(Cardizem, Dilacor), felodipine (Plendil), nisoldipine (Sular) and isradipine (DynaCirc Cr).

Alpha blockers. Some people find relief with drugs called alpha blockers, which
counteract the actions of norepinephrine, a
hormone that constricts blood vessels. Examples
include prazosin (Minipress) and doxazosin (Cardura).

Vasodilators. Some doctors prescribe a

vasodilator — a drug that relaxes blood vessels —
such as nitroglycerin cream. You apply the cream to your
fingers to help heal skin ulcers.
Surgical Management
Nerve surgery. Nerves called sympathetic nerves in your hands and
feet control the opening and narrowing of blood vessels in your skin.
Sometimes it's necessary in cases of severe Raynaud's to cut these nerves to
interrupt their exaggerated response as seen in Raynaud's. Through small
incisions in the affected hands or feet, a doctor strips away these tiny nerves
around the blood vessels. The surgery, called sympathectomy, may reduce
the frequency and duration of attacks, but it's not always successful.

Chemical injection. Doctors can inject chemicals to block

sympathetic nerves in affected hands or feet. You may need to have the
procedure repeated if symptoms return or persist.

Amputation. Sometimes, doctors need to

amputate a finger or toe affected by Raynaud's
in which the blood supply has been completely
blocked and the tissue has developed gangrene. But this is rare.
Prevention
Dress warmly outdoors.
Wear a hat, scarf, socks and boots, and mittens or gloves under mittens
A hat because you lose a great deal of body heat through your head.
Wear a coat with fairly snug cuffs to go around your mittens or gloves, Wear
earmuffs and a face mask
Run your car heater for a few minutes before driving in cold weather.

Take precautions indoors.

Wear socks.
When taking food out of the refrigerator or freezer, wear gloves,
Air conditioning can trigger attacks, turning down the air
conditioning may help prevent attacks.
You also may find it helpful to use insulated drinking glasses.

Consider moving to a location with a milder climate.

Moving to a warmer climate may help people with severe Raynaud's.

However,
Self-care / Patient’s Teaching
⚫ Don't smoke. Nicotine in cigarettes causes skin temperature to drop by
constricting blood vessels, which may lead to an attack. Inhaling
secondhand smoke also can aggravate Raynaud's.

⚫ Exercise. Your doctor may encourage you to exercise regularly, particularly if

you have primary Raynaud's. Exercise can increase circulation, among other
health benefits.

⚫ Control stress. Because stress may trigger an attack, learning to recognize

and avoid stressful situations may help control the number of attacks.

⚫ Take care of your hands and feet. If you have Raynaud's, guard your hands
and feet from injury. Don't walk barefoot. Take care of your nails to avoid
injuring sensitive toes and fingertips. In addition, avoid wearing tight
wristbands, rings or footwear that compresses blood vessels in your hands or
feet.

⚫ Avoid workplace triggers. Avoiding tools that vibrate the hand may reduce
the frequency of attacks.
TO AVOID RAYNAUD’S…

Use your hands to clap …

MALIGNANCY
OSTEOSARCOMA
DEFINITION
⚫ Osteogenic sarcoma is a primary
malignant tumour of the skeleton
characterised by the direct formation of
immature bone or osteoid tissue by the
tumour cells. More rarely Osteogenic
sarcoma may arise in the soft tissue.
Osteosarcoma
⚫ Other term: Osteogenic Sarcoma

⚫ It is a bone tumor and can occur in any bone

⚫ It is the most common and the most often fatal
primary malignant bone tumor in youth
(adolescents)

⚫ A deadly form of musculoskeletal cancer that most

commonly causes patients to die from pulmonary
metastatic disease.
Osteosarcoma
⚫ A tumor in the bone causes the normal bone tissue
to react by osteolytic response (bone destruction) or
osteoblastic response (bone formation)

⚫ Can cause bone destruction, which weakens the

bone, resulting in bone fracture.

⚫ Adjacent normal bone responds to the tumor by

altering its normal pattern of remodeling, the
bone’s surface changes, and the contours enlarge in
the tumor area.
Osteosarcoma
Most common sites of Osteosarcoma

⚫ Femur
⚫ Tibia
⚫ Humerus
⚫ Skull
⚫ Jaw
⚫ Pelvis
Etiology
⚫ The exact cause of osteosarcoma is unknown.
However, a number of risk factors are apparent, as
follows:

⚫ Male between the ages of 10 – 25 years

⚫ Hereditary
⚫ Exposure to radiation
Etiology
⚫ Genetic predisposition: Bone dysplasias,
including Paget disease, fibrous dysplasia,
enchondromatosis, and hereditary multiple
exostoses and retinoblastoma (germ-line form)

⚫ Rapid bone growth: Rapid bone growth appears

to predispose persons to osteosarcoma, and
osteosarcoma's typical location in the metaphyseal
area adjacent to the growth plate (physis) of long
bones.
Signs & Symptoms
⚫ pain, particularly pain with activity

⚫ swelling

⚫ weight loss

⚫ fever

⚫ night sweats

⚫ decreased range of motion

Clinical appearance of teenager presenting with osteosarcoma of the proximal
humerus. Note impressive swelling throughout deltoid region as well as disuse
atrophy of pectoral musculature.
Complications
⚫ Pathologic fractures

⚫ Lung metastasis

⚫ Limb removal
Chest radiograph of patient with osteosarcoma who died from pulmonary
metastatic disease. Note pneumothorax as well as radiodense (bone-forming)
metastatic lesions.
Diagnosis
⚫ CT scan; bone scans

⚫ MRI

⚫ Biopsy

⚫ Laboratory findings: hyperphosphotemia

⚫ Chest x-ray – performed to determine the presence of

lung metastasis.
MRI appearance (T1-weighted image) of osteosarcoma of the proximal
humerus. Note dramatic tumor extension into adjacent soft tissue regions.
Diagnosis
Staging: Used for planning treatment.

⚫ Low-grade tumor, intracompartmental - I-A

⚫ Low-grade tumor, extracompartmental - I-B
⚫ High-grade tumor, intracompartmental - II-A
⚫ High-grade tumor, extracompartmental - II-B
⚫ Any tumor with evidence of metastasis - III
Treatment
Medical management:

⚫ Radiation therapy and/ or chemotherapy

Surgical therapy:

1. Surgical excision (ranging from local excision to

amputation and disarticulation)
2. Limb-sparing (salvage) procedures- used to
remove the tumor and adjacent tissue
Treatment
3. Total joint prosthesis, total joint
arthroplasty – to replace the resected tissue

4. Rotationplasty- distal portion of the leg then is

rotated 180 degrees and reattached to the thigh
at the proximal edge of the resection.
⚫ Other osteosynthesis variations also are possible.
The rotation allows the ankle to become a
functional knee joint, so the length of the leg
should be adjusted to match the contralateral
knee.
Nursing interventions
⚫ During nursing care, the affected extremities must be
supported and handled gently, external supports (splint)
may be used for additional protection.

⚫ Teach the patient how to used assistive devices safely and

how to strengthen unaffected extremities.

⚫ Monitor full cycles of chemotherapy

⚫ Admission is required for IV antibiotics and monitoring

for fever and neutropenia

⚫ Assist in passive ROM because some are restricted to

perform other activities.
METABOLIC CONDITIONS

OSTEOPOROSIS

OSTEOMALACIA
OSTEOPOROSIS
Osteoporosis
is a disease of bone in which:

1. bone mineral density (BMD) is reduced,

2. bone microarchitecture is disrupted, and

3. the amount and variety of non-collagenous

proteins in bone is changed
Osteoporosis
⚫ Osteoporosis is a condition that causes thinning and
weakening of normal bone; a decrease of the
density of bone mass.

⚫ When this occurs, a patient with osteoporosis will

have weaker bones and have a higher risk of bone
fracture.
Osteoporosis
Osteoporosis
⚫ The underlying mechanism in all cases of
osteoporosis is an imbalance between bone
resorption and bone formation.

⚫ Either bone resorption is excessive, or bone

formation is diminished.
Osteoporosis
Two main categories of osteoporosis:

⚫ Type I osteoporosis occurs only in post-menopausal

women, and is due to estrogen deficiency.

⚫ Type II osteoporosis occurs in both men and women

(about two times more frequently in women), and is
due to aging, and calcium deficiency over many years.
Clinical Picture
⚫ Osteoporotic fractures - those that occur under
slight amount of stresses that would not normally
lead to fractures in nonosteoporotic people.
Common sites are: the wrist, the hip and the spine

⚫ Collapse of a vertebra ("compression fracture")

can cause : acute onset of back pain, a hunched
forward or bent stature; loss of height; limited
mobility and possibly disability and bedrest.
Osteoporosis
Risk factors

Nonmodifiable:

⚫ history of fracture

⚫ female sex - rate of bone loss in women is greater

than men

⚫ advanced age - bone mass peaks in both men and

women between the ages of 25 and 35, thereafter
diminishing

⚫ European or Asian ancestry

Risk factors

Potentially modifiable:

⚫ tobacco smoking

⚫ intake of soft drinks

⚫ low body weight <58 kg (127 lb),

⚫ Estrogen deficiency,

⚫ early menopause (<45 years) or bilateral oophorectomy

Risk factors
Potentially modifiable:

⚫ premature ovarian failure

⚫ prolonged premenstrual amenorrhea (>1 year),

⚫ low calcium and vitamin D intake,

⚫ alcoholism

⚫ recurrent falls,

⚫ inadequate physical activity

Etiology

⚫ Estrogen deficiency

⚫ Testosterone deficiency

Estrogen and testosterone increase osteoblast

activity, causing bone growth.

The loss of estrogen following menopause

causes a phase of rapid bone loss. Similarly,
testosterone levels in men diminish with
advancing age and are related to male
osteoporosis.
Etiology

⚫ Glucocorticoid or thyroxine excess

Cause osteoclast activity to increase, causing bone
resorption.

⚫ Calcium and/or vitamin D deficiency

Calcium and vitamin D are nutrients required for
normal bone growth.
Diagnosis

⚫ Dual energy X-ray absorptiometry (DXA,

formerly DEXA)
- gold standard for diagnosis of osteoporosis.

⚫ Diagnosis is made when the bone mineral

density is equal to or greater than 2.5 standard
deviations below that of a young adult reference
population. This is translated as a T-score.
⚫ T-score -1.0 or greater is "normal“
⚫ T-score between -1.0 and -2.5 is "low bone mass"
(or "osteopenia")
⚫ -2.5 or below as osteoporosis.
Treatment
⚫ Exercise
maintains and increases bone mass

⚫ Calcium supplementation - at least 1200 to 1500 mg

every day = 5 glasses of milk each day
Treatment
⚫ Medications

Bisphosphanates (Fosamax)
regulate calcium and prevent bone breakdown

Calcitonin (Miacalcin)
slow bone loss, and also decrease pain associated with
osteoporosis fractures
Treatment

Raloxifene
Similar effects with estrogen; increases bone mass

Hormonal replacement therapy (HRT) increase bone

mass after menopause
Nursing Interventions

⚫ Encourage diet high in calcium and high in fiber

⚫ Encourage vitamin D supplementation.

⚫ Advice to avoid smoking and to reduce use of caffeine

(e.g. coffee, soda) and alcohol. – it decrease calcium
absorption
Nursing Interventions
⚫ For relief of back pain:
⚫ > Advice to rest in bed in a supine or side-lying
position.
⚫ > Mattress should be firm and non-sagging.
⚫ > Intermittent local heat and back rubs promote
muscle relaxation.
⚫ Encourage good posture and good body
mechanics.
⚫ Encourage daily weight-bearing exercises.
Osteomalacia
Osteomalacia
⚫ is a metabolic bone disease characterized by
inadequate mineralization of bone

⚫ results from the deficiencies of vitamin D in

adults, characterized by deficient calcification
of bone and softening of bone to osteoid failing
to ossify

⚫ Softening and weakening of the skeleton

 Pelvis
Normal Osteomalacia
Signs and Symptoms
⚫ muscular weakness and softening of the skeleton,
resulting from decalcification

⚫ skeletal pains and swelling and numerous fracture

⚫ brittleness of bone

⚫ waddling or limping gait

Diagnostic Tests
⚫ X-ray: generalized demineralization of bone

⚫ Laboratory studies: low serum calcium and

phosphorus levels, and moderately elevated
alkaline phosphatase concentration

⚫ Urine: low excretion of calcium and creatinine

⚫ Bone biopsy: increased amount of osteoid.

Medical Management

⚫ Administration of adequate amount of vitamin D,

calcium salts and phosphates

⚫ Splintage – braces to correct deformities

⚫ Surgery – osteotomy to correct deformity.

Nursing Management
⚫ Advise client to have adequate exposure to sunlight
(for ultraviolet radiation to transform cholesterol
substance (7-dehydrocholesterol) present in the skin
into vitamin D.)

⚫ Encourage client to have adequate protein and

increased calcium and vitamin D in their diet.
Nursing Management
⚫ Stress the importance of monitoring
serum calcium levels

⚫ Assist patient in changing positions,

and handles the patient gently, and use
pillows to support the body.
Osteomalacia
 QUOTE FOR THE DAY
“ People don’t seem to see the avenue of care that is
being given by the NURSE. They always say ‘the
DOCTOR was good! He cured and treated the patient”
But as we all know , through the attributes given.
“Behind a good DOCTOR stands a GREAT NURSE”..
The real epitome of care…
QUESTIONS???
THANK YOU FOR YOUR KIND
ATTENTION!!!