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Science
Medicine
Surgery
Musculoskeletal Disorders
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Terms in this set (121)
What are the different diagnosis procedures for musculoskeletal disorders ?
X-Rays
Bone Scan
CT
MRI
Electomyogram (EMG) and nerve conduction studies
Ultrasound
What is an X-Ray used for?
Shows bone density, texture and erosion seen in cancer and osteoporosis
Joint X-rays
reveal irregular fluid pockets, spur formation, and changes in structure
Spine X-rays
fractures, dislocation, osteoporosis, infection, and deviation in alignment
What do bone scans and blood studies show?
Infections, tumors, and bone marrow abnormalities
tracer (radioactive substance) can be injected into vein and the bone absorbs the substance to create an image
tracer
very small amount of radioactive substance
constantly decaying and becoming less radioactive
What is a CT scan used for?
Used for identifying obscure soft tissue leisions adjacent to the vertebral column and problems of the disks
exposes a patient to 70x more radiation than x-ray
A CT exam exposes a patient to 70x the dose of radiation than
xray exposes them to
What is an MRI used for?
Examining bones, joints, and soft tissues (cartilages, muscles, tendons)
also presence of structural abnormalities, such as tumors, inflammatory disease, congenital abnormalities, osetonecrosis, bone marrow disease, herniation or degeneration of discs
does MRI use radiation?
No radiation - just magnetic field and radio waves
What is a EMG and nerve conduction study used for? radiation?
Used to evaluate spinal nerve root disorders (radiculopathies)
no radiation
low doses of electricity
What is the use of an ultrasound?
Used for detecting tears in ligaments, muscles, tendons, and soft tissues in the back
(things an x-ray cannot detect)
neuromuscular
nerves located in the brain and spinal chord
peripheral neuropathy
nerves located outside of the brain and spinal chord
What are the different kinds of fractures of the bone?
complete
incomplete
closed (simple)
open (compound or complex)
*means broken
Complete fractures
when the bone breaks into separate pieces
Incomplete fractures
bone cracks and bends but does not break
Closed or simple fractures
when overlying skin is not broken and the bone is not exposed to air
Open/Compound/Complex Fracture
When the damage involves skin or mucous membranes and the bone is exposed
Avulsion
when a fracture to the bone happens in a location where the tendon or ligament attaches to the bone
common in children
Comminuted
broken ends of the bone are shattered into many pieces
Compression
Seen in vertebrae
when bone is compressed
happens frequently in people with osteoporosis, overweight, or very physical jobs
Depressed
Bone is crushed into a cavity
Epiphyseal
bone is broken through the tip of a long bone
Green stick
when one side of the bone is broken and the other side of the bone is bent
more common in children
Impacted
when the broken ends of a bone are jammed together by the force of injury
Oblique
fracture across the bone shaft at approximately a 45 degree angle
pathologic
fracture that occurs through a diseases bone (osteoporosis, bone cysts, bone cancer)
loss of tissue within the bone, so that the bone can no longer support the tissue and muscle surrounding it
The reason why a pathologic fracture can occur without trauma is because all of these diseases cause what we call
bone loss
or the loss of tissue within the bone, so much so that the bone can no longer support the tissue and muscle surrounding it
Spiral
helical break from a twisting injury
common in preschoolers
can be a sign of physical abuse
Stress
when the muscles become fatigued and are no longer able to absorb the shock causing severe bruising and cracks in the bone
Transverse
fracture that is straight across the bone shaft
What are the clinical manifestations of fractures?
Pain
Numbness and muscles surrounding bone become flaccid at first
muscle spasms that start shortly after
loss of function
deformity
shortening
crepitus
localized edema and ecchymosis
What is shortening and crepitus?
Shortening: compression of fractured bone causing overlap
Crepitus: crumbling sensation that is felt or heard when the extremity is gently palpated
When does localized edema and ecchymosis develop with a bone fracture?
May not develop for several hours after the injury or could develop quickly depending on the severity of the fracture
rotation
when the distal piece of the bone is rotated on its axis in a transverse fracture
angulation
normal axis of the bone has been altered, so that the distal portion of the bone points in a different direction
What are some emergency management techniques for bone fractures?
Immobilize
Assess neurovascular status
Splint
PRICE (protect, rest, ice, compress, elevate)
Apply pressure if there is bleeding
call 911
elevation: if you are able to get above heart do so
signs of shock
pale,
clammy skin,
complain of being cold-get them a blanket
anxiety
rapid HR
palpitations
N/V
dizziness, confusion
How is neurovascular status assessed?
5 Ps: pain, pulse (distal), pallor, paresthesia, paralysis
Perform assessment every hour for 24 hours, prior to surgery and post-op
assess for bruising and decreased skin integrity for pressure ulcers
What is PRICE?
Protect
Rest: stop what they are doing and reduce movement
Ice
Compress: using ace wrap after applying ice to reduce swelling
Elevate: above heart
What are the processes to manage fractured bones?
Reduction: open or closed
Fixation: Internal or External
ex: ORIF
What is reduction?
Describes how bone was anatomically aligned and put back to original form
pieces of the bone must be put in close proximity to each other to heal
fraction reduction is essentially to ensure
bone heals properly and to avoid permanent functional loss or deformity
Open Reduction
Surgeon makes an incision to re-align the bone
Closed Reduction
Bringing the bone fragments to anatomical alignment through manipulation or manual traction
extremity is held in aligned position while a cast, splint, or other device is applied
What is fixation?
Immobilizing the fractured bone
Internal fixation
Bone is held together with hardware such as metal pins, plates, rods, and screws
External fixation
Use of hardware and other materials on the outside of the body to fixate the bones
ORIF
open reduction internal fixation
What does emergency management of compound open fractures involve?
Preventing tetanus through antibiotics and cleaning/debridment of wound
Prevent osteomyelitis or soft tissue injury
If closure is delayed by edema and wound drainage, more debridment may be needed
What are general complications of fracture?
Age, nutrition, presence of other diseases, alignment achievement, infection, surgery requirement, osteoporosis, steroids
What are other complications?
VTE
Blood loss (common in pelvis or femur fracture)
Delayed union, nonunion, malunion
What is the risk of VTE with fracture?
Venous thromboembolism includes a DVT or PE
happens due to bed rest and reduced muscle contractions leading to blood clots
What is delayed union, non union, and malunion?
Delayed union: occurs when healing does not occur within expected time frame for location and type of fracture
Nonunion: failure of the ends of a fractured bone to unite (common in fingers and hands)
Malunion: healing of bone in malaligned position
What are some reactions to internal fixation devices?
Complex regional pain syndrome: abnormal sympathetic nervous system response
Avascular necrosis
Heterotrophic ossification: extra bone tissue formed outside of the bone growing into muscles and soft tissues
Osteomyelitis
Fat embolism
Compartment syndrome
What is osteomyelitis?
Inflammation of the bone or bone marrow due to an infection (usually MRSA or S. aureus)
Hematogenous: infection from bacteria in the blood
Contingous Focus: from something that has touched the area of the bone (surgical instrument)
Vascular insufficiency related: common in diabetes and PVF
What are the signs and symptoms of osteomyelitis? diagnosed by? treated by?
Diagnosed vis MRI and Bone Scan
localized swelling, redness, unusual pain, fever, chills, rapid pulse
treated with 8 week IV antibiotics and managed at home VNA
What are the signs of fat embolism?
First sign is pulmonary symptoms: dyspnea, tachypnea, hypoxemia, tachycardia, substernal chest pain, low grade fever, crackles and fluid build up in the lungs
onset of delirium: changes in LOC, restlessness, agitation
Development of petechial rash in the conjunctiva or oral membranes
fat embolism? what to do...
no specific treatment, meaning there is no cure
so all we can do is support the patient
What is compartment syndrome?
When increased pressure in the muscle compartments
(groupings of muscles, nerves, blood vessels) causes decreased blood flow to the area
caused by too tight cast, circumferential burns, closed fracture
What are the signs of compartment syndrome?
Pain
Paresthesia
Paralysis
Pulseness
Tight and Shiny Skin
congestion of digits with prolonged capillary refill time
tense and swollen shiny skin, sometimes with obvious bruising of the skin
Bruising
What intervention should be made if compartment syndrome is suspected?
Place affected limb at level of the heart
elevation is contraindicated because it decreases arterial flow to the injured area
What devices are used to monitor for compartment syndrome?
Wick catheter technique: accurate and continuously monitors pressure
Slit catheter: monitors pressure over a larger area
Stryker ICP: takes direct measure of the compartment pressure
What is the most extreme intervention for compartment syndrome?
Fasciotomy
surgical decompression by cutting into the facia to relieve pressure
wound is left open to allow the muscle tissue to expand
ensure coverage with moist sterile dressing
manage care by ensuring affected arm or leg is splinted
What are external fixation devices used for?
Management of open fractures with soft tissue damage
limb lengthening
support for complicated or comminuted fractures
What does pin care involve with an external fixation device?
Usually use chlorhexidine or alcohol swabs
avoid cross contamination between pins
treat each pin as an individual wound
What is the comfort of external fixation devices?
Discomfort is usually minimal and early mobility can be anticipated
external fixation devices, you do what to reduce edema?
elevate to reduce edema
monitor for signs and symptoms of complications
don't adjust clamps
What are braces used for?
Used to provide support, control movement and prevent additional injury
custom fitted to the individual body
- TLSO: Thoracic-Lumbar- Sacral Orthoses
AFO
ankle-foot orthosis
TLSO
thoracic lumbar-sacral orthoses
What are the priority interventions for patients with a brace, splint or cast?
Relieving pain
Treating skin wounds and maintaining skin integrity
Treat skin wounds before brace, splint or cast is applied
Observe for S/S of pressure or infection
Encourage movement of digits every hour
Notify physician of signs of compromise
What are the interventions for pain relief?
Elevation above the heart to reduce edema
Intermittent application of ice or cold
Positioning changes
Administration of analgesics
What is a "cast window"?
Allows for skin care and major wounds to heal as the cast is healing the bones
can be dangerous if left open
cut piece of cast and place over dressing
secure with elastic bandages
What does a patient need to be educated on with a cast before application?
Explain condition, need for cast, purpose and goals of cast
Expectations during this casting process
What does cast care involve?
keeping the cast dry, don't cover with plastic
Positioning: elevation of the extremity and use of slings
Keeping hygiene: not inserting anything into the cast
Observing restriction of activity and use of assistive devices
How can mobility be maintained with a cast?
Suggest PT or OT evaluation
determine what exercises are appropriate for the patient
Quad sets, Glut sets, etc.
What can a nurse do to prevent irritation by "rough edges of a cast?
Can be pataled by placing tape over the edge of the case
What s/s should the patient with a cast be instructed to report?
Persistant pain or swelling
Changes in sensation or feeling
Bone movement
Skin color or temperature changes
Signs of infection
Signs of pressure areas
What are additional problems and complications with braces, splints, and casts?
pressure ulcers
Disuse syndrome
"Cast syndrome"
Nerve damage
How can a pressure ulcer develop with a cast?
Uses materials of plaster and nonplaster (fiberglass)
if applied incorrectly causes pressure necrosis or anoxia that can lead to pressure ulcers
What needs to be assessed in looking for a pressure ulcer?
Assess for drainage, erythema, warmth, discoloration, odor
If development is suspected, notify physician
What is disuse syndrome?
Deterioration of body systems as a result of prescribed or unavoidable musculoskeletal inactivity
can occur with casts/splints or immobility in general
causes muscle atrophy
How can disuse syndrome be prevented?
Isometric exercise of tensing or contracting muscles without moving underlying bones
ex: quad sets, by pushing anterior thigh against bed and holding for 5-10 secs for 10 x per hour
What brace is disuse syndrome common in?
Occurs for ankle foot orthorosis (AFOs) causing foot drop
when the individual looses the ability to flex the foot due to nerve damage
foot remains in passive extension position
patient is at a risk for falls and needs to walk by lifting their thighs
What is a hip or spica caset?
Casts that encase the body or portions of one or two extremities
used for immobilization of spine
remain in place for 4-6 weeks
causes claustrophobia or anxiety
What are the physiological effects of cast syndrome related to spica cast used?
Decreased GI motility causing ileus
- assess bowel sounds
- treat with NG tube (npo or Ivf)
- can also cause superior mesenteric artery syndrome causing pressure build up leading to gangrenous bowel
What are the psychological effects of caste syndrome?
Claustophobia and anxiety causing autonomic responses
increase in respiratory rate, diaphoresis, tachycardia
What are distraction methods for the psychological effects of cast syndrome?
Playing music
watching Netflix
Anti-anxiety meds to decrease or prevent a reaction
what causes foot drop?
peroneal nerve damage
happens from positioning in surgery improperly applied traction
What are the consequences of nerve damage related to cast use?
Causes decompression of the nerve, which happens from incorrect positioning and applying traction
- may result in need for surgery
What is traction?
the application of pulling force to a part of the body
needs to be applied in two directions (two vectors of force)
What is the purpose of traction?
Reduce muscle spasms
Reduce, align and immbolize fraction
Reduce deformity
Increase space between opposing forces: used as a short term intervention until all other modalities are possible
traction is used as a short term intervention until?
all other modalities are possible
What are the principles of effective traction? (counter...must be....skeletal traction...weight is not....any factor that reduces...ropes should be...knots...)
Counterforce in patient's body weight and positioning in bed
must be continuous to reduce and immobilize fractures
Skeletal traction should never be interrupted
Skin traction is used intermittently
Weight not removed unless intermittent traction prescribed
Any factor that reduces pull needs to be eliminated
Ropes should be unobstructed and weight hang freely
Knots on footplate should not touch foot of bed
What are the types of traction?
Skin traction
Skeletal traction
=
Halo traction
What is skin traction?
Applying force over a large area of skin or soft tissue to transmit traction to the bone
Bucks extension, Pelvic traction, Cervical traction
What is buck's traction, pelvic traction, cervical traction?
Buck's traction: used short term to stabilize fractured leg until other means can be implemented, weight is hanging free
Pelvic traction: for lower back pain
Cervical traction: for neck arthritis and neck pain
What is skeletal traction? (Force is...used for..for what type of term..involves...)
Force is applied directly to the bone through metal pins being inserted into the bone
used for continuous traction to immobilize bone
for longer term use and involves passing a pin or wire through the bone with local anesthesia
involves ropes or weights attached to the end of the pin
What is halo traction?
Skeletal traction used for cervical spine injuries
involves 4 pins drilled into the skull with 2 in the front and 2 in the back
What is arthoplasty?
Repair of joint problems through the operating arthoscope or through open joint surgery
Arthroscope: instrument that allows the surgeon to operate within a joint without a large incision
Hemiarthroplasty
replacement of one articular surface of a joint
ex: hip replacement hemiarthroplasty involves replacing femoral head and neck only
Joint arthroplasty or replacement
Replacement of joint surfaces with metal or synthetic materials
Total joint arthroplasty or replacement
Replacement of both articular surgaces within a joint with metal or synthetic materials
Meniscectomy
excision of damaged joint fibrocartilage
Bone graft
placement of bone tissue (autologous or homologous grafts)
to promote healing, stabilize, or replace diseased bone
Tendon transfer
insertion of tendon to improve function
Fasciotomy
incision and diversion of the muscle fascia to relieve muscle constriction
as in compartment syndrome or to reduce fascia contracture
What is the purpose of joint arthroplasty?
For severe joint pain and disability, repair and management of joint or joint necrosis
hip and knee replacements most common
removal of joint and replacement with metal or synthetic materials (1 time replacement)
What diseases cause deterioration of joints?
Osteoarthritis,
Rheumatoid arthritis,
trauma and congenital abnormalities
What are the needs of patients with hip or knee replacement surgery?
Mobility and ambulation
Drain use postoperatively: assess for bleeding and fluid accumulation
Prevention of infection
Prevention of DVT
Patient education and rehabilitation
What does mobility and ambulation for patients with hip or knee replacement surgery involve?
Usually begin ambulation within 1 day after surgery using crutches or walker
Weight bearing as prescribed by the physcian
What kind of care do patients receive after a knee or hip replacement surgery?
Can be an outpatient procedure or involve rehabilitation facilities depending on the patient
What are the components of the post op assessment for a patient with knee or hip replacement surgery?
Pain
Vital signs
LOC
neurovascular status and tissue perfusion
mobility and understanding of mobility restrictions
bowel sounds and elimination
urinary output
wound drainage
What are S/S of complications following a hip or knee replacement surgery?
Bleeding
Hypovolemic shock
Atelectasis
Pneumonia
Urinary retention
Infection
VTE (on anticoagulants)
Constipation
Remove foley as soon as possible
Hemovac drain up to 500 cc for first 24 hours and should be discontinued by day 3
What are pharmacological methods of pain relief for hip and knee replacements?
Important to medicate before planned activity and ambulation
PCAs
recurring pain meds for vs PRNs
What are alternate methods of pain relief?
Repositioning, distraction, guided imagery
also use of ice, elevation and immobilization
What is important in preventing dislocation with hip prosthesis patients post op?
Risk for dislocation is highest in the first 8-12 weeks
Instruct the patient to not flex hip more than 90 degrees, avoid internal rotation, provide protective positioning, hip precautions, no leg crossing, and may be instructed to not turn on post-op side
What medical equipment can help with hip prosthesis post-op?
Devices to help put on shoes and socks, raised toilet seat, pressure relieving mattress, abduction pillow
What are ongoing patient care interventions for orthopedic surgery?
Muscle setting
Ensuring adequate nutrition and hydration (avoid large amounts of milk)
Skin care and frequent turning and repositioning
PT and rehab programs
Setting realistic goals and performing self care within limits of therapeutic regimen
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