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Orthopedics

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branch of medicine that deals with the prevention or correction of the disorders and diseases of the musculoskeletal system

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Orthopedics

branch of medicine that deals with the prevention or correction of the disorders and diseases of the musculoskeletal system

Musculoskeletal system

muscle, bones, joint, ligaments, tendons

locomotor

pertaining to movement or the ability to move

contractures

permanent shortening of a muscle

The prime concern of the nurse caring for a client with locomotor disorders

is the prevention of contractures.

Caring for orthopedic clients also requires

an understanding of basic principles that apply to all clients whether they are in traction, casts or recovering from surgery

The skeletal system consists of bones

attached to each other by cartilage and strong ligaments

Functions of the skeleton

provide the body with structural framework; protect internal organs such as heart, brain, lungs; allow movement by muscles attached; store calcium, phosphorus and magnesium and release these minerals when required; manufacture blood cells in red bone marrow

Classification of bones

long (humerus), short (phalanges), flat (occiput) and irregular (vertebrae)

Types of bones

cancellous (resembles a sponge with spaces found in the epipysis of long bones) and cortical (compact bone found in the shaft of long bones)

Tendons

attach muscle to bone

Voluntary muscles

muscles attached to bone can function at the will of the person

Involuntary muscles

found within body organs, regulate so the organs can perform their function, located in the intestinal tract, the pupil and in the heart and blood vessels

A joint

is a junction of two or more bones

Three types of joints

diarthrosis, synarthrosis, amphiarthhrosis

Diarthrosis joints

freely movable such as the hinge (elbow, knee), ball and socket (hip, shoulder), pivot (skull and first vertebrae), gliding (wrist), saddle (thumb)

Synarthrosis joints

are immovable such as the suture line between the temporal and occipital bones of the skull

Amphiarthrosis joints

are slightly moveable, such as the vertebrae and pelvic bones separated by fibrous cartilage

Synovial fluid

clear fluid that lubricates the joints

Bursa sacs

filled with fluid that facilitate joint movement by making it possible for muscles and tendons to move or glide over ligaments or bones

Fascia

connective tissue that covers a muscle

Tendons

strong fibrous tissue attaching muscle to bones

Ligaments

grow out of the periosteum and lash bones together more firmly

Crepitus

grating or crackling sensation or sound

Scoliosis

crooked back

Kyphosis

hump back --- increased roundness of the thoracic spinal curve

Lordosis

sway back -- exaggeration of the lumber spine curvature

Subluxation

a partial separation of an articular (joint) surface

Strain

injury to a muscle or tendon caused by overuse or overstretching

A strain

may either acute or chronic

An acute strain

may be caused when an individual performs and unaccustomed exercises vigorously

A chronic strain

may develop after repeated overuse of certain muscles

Chronic strains

require no specific treatment

In the case of a severe strain

the muscle may be completely ruptured and surgical repair may be necessary

Sprain

is an injury to ligaments surrounding a joint caused by a sudden twist, wrench or fall

Symptoms of sprains are

pain, edema, loss of motion and ecchymosis

RICE

rest, ice, compression and elevation

Dislocation

occurs when articular surfaces of a joint are no longer in contact -- "out of joint"

Tramatic dislocations

are considered orthopedic emergencies

Fracture

is a break in the continuity of a bone

Individuals considered at high risk for fractures are

predisposing bone conditions (metastic) osteoporosis, poor coordination, diminished vision, dizzy spells or general weakness

Common types of fractures are

greenstick (incomplete), simple (closed) and compound (open), impacted (telescope), spiral and comminuted

Greenstick fracture

the continuity of the bone is not completely disrupted but has splintering on one side and bending on the other---common in children

Closed (simple, complete)

skin remains intact

Compound (open)

bone and skin are broken -- bone protrudes the skin -- greater chance of infection

Impacted (telescope)

one portion of a bone fragment is forcibly driven into another

Spiral fracture

twists around the shaft of the bone, may occur from a twisting force

Comminuted

bone is splintered into many unaligned fragments

Healing time for fractures

depends on age, type of injury or underlyingdisease -- can take weeks to years

Sequence of healing

hematoma, granulation tissue formation, callus formation, callus ossification and ultimately remodeling

Hematoma formation

begins with the formation of a clot that serves as a fibrin network

Complications of a fracture

infection, fat embolism syndrome, compartment syndrome

Infections may result

from an open fracture allowing contamination

Fat embolism syndrome

usually associated with fractures of the long bones, multiple fractures or crushing injuries

An embolus

usually occurs within 24-72 hours after injury

Treatment for embolus

consist of bed rest, repiratory support, oxygen and IV fluids

Symptoms of an embolus are

(small area) pain, tachycardia and dispnea. (large area) severe pain, dyspnea, cyanosis, restlessness and shock

Rhabdomyolysis

curshing injuries most commonly cause--myoglobin, creatine kinase (CK) and other inflammatory mediators escape from the injured muscle tissue into the circulation

Circulating myoglobin (rhabdomyolysis)

filtered by the kidneys can precipitate, causing renal tubular obstruction...also respiratory distress and fluid/electrolyte imbalance

Treatment for rhabdomyolysis

includes IV fluids to maintain circulating blood volume and renal perfusion so the myoglobin is flushed from the kidneys

Compartment syndrome

form of neurovascular impairment that may lead to permanent injury of an affected limb caused by progressive constriction of blood vessels and nerves

Compartment syndrome can occur

with any orthopedic injury as a result of bleeding into the tissue, tissue edema or prolonged external pressure (cast or tight dressing)

Untreated compartment syndrome

4-6 hours can lead to irreversible damage to nerves and muscles.....24-48 hours permenant loss of normal limb function

Neurovascular assessment for compartment syndrome

pain not relieved by narcotic analgesics, greater pain with passive motion than active, diminished cap refill, weak/unequal pulses, parasthesia, and paralysis

Treatment for compartment syndrome consist

of relieving pressure by removing the cast or dressing or by performing a fasciotomy

Parasthesia

numbness or tingling

Fasciotomy, surgical

an incision into the fascia to relieve pressure on the nerves and blood vessels

Treatment of fractures

requires immediate attention

Most important objective for treatment of fractures

realign the fracture, maintain the alignment and regain the function of the injured part

Closed reduction

repair of a fracture accomplished without surgical intervention

External manipulation requires three maneuvers

traction and countertraction, angulation and rotation

Major purposes of casts are

immobilization, support and protection of the affected part, prevention of deformities that may be the result of conditions such as arthritis and the correction of deformities such as scoliosis

Dry cast

should be odorless, shiny in appearance, resonant when percussed and temp similar to room air

Moisture in a cast

from any underlying drainage will give the cast a musty smell, dullness on percussion, lusterless color and cool temp

Long and short arm cast

allow the fingeers to be visible

Long and short leg cast

allow the toes to be visible

Spica cast

used for hip, shoulder and thumb dislocations or injuries

Body cast

used to immobilize the spine following surgical spinal fusions, unstable spinal injuries or degenerative disorders

Windowing

cut in a cast to allow visualization of a body area or to relieve pressure

Traction

principle is to have two forces pulling in opposite directions

Traction is used

to reduce a fracture, immobilize an extremity, lessen muscle spasms or correct or prevent a deformity

Types of tractions

skeletal, skin and manual

Skeletal traction

requires the surgical insertion of pins (Steinman) or wires (Kirschner) through the bones. used for fractures of femur, tibia and cervical spine

Skin traction

non-surgical method of providing necessary pull for shorter periods, Buck's traction..frequently used to temporarily immobilize a part or stabilize a fracture

Skin traction disadvantage

does not adequately control rotation and cannot be maintained for the length of time necessary for adult healing

Open reduction

surgical procedure that enable the surgeon to reduce (repair) the fracture under direct visualization...use of pins, screws, nails, plates, wire, rods

Open reduction disadvantage

possibility of introducing infection into the bone

Meds for fractures

analgesics, Flexeril (muscle relaxant), Colace (stool softener)

Isometric

maintaining constant resistive force --exercises help maintain muscle strength of immobilized muscles

Immobility complications include

constipation, skin breakdown, urinary calculi and respiratory complications

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