Final Flashcards by Daphmy Francois

– tightening of muscle. Pt in cast needs to perform isometric exercise to prevent atrophy (wasting away) of muscle. Atrophy à lack of muscle movement.

Isometric

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– an interruption in cartilage. An injury sustained from repetitive movements or an athletic event. Cartilage doesn’t grow back. When nose and ears get frostbitten, they do not grow back.

Osteoarthritis

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– toes to nose. Used to evaluate for DVT. Homen’s sign. Prophylactic measures, we put pt on heparin or Lovenox. To test for DVT, we flex the toes to the nose. If pt has calf pain, we suspect the pt has DVT. Dorsi flexion with pt who has knee replacement causes pain. Instruct pt to differentiate btw calf pain and knee pain

Dorsiflexion

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– downward pointing. Bibinsky is abnormal reflex, we find it in head trauma pts.

Plantar flexion

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– bilateral or one sided. When comparing osteoarthritis vs. RA, RA is always bilateral. In RA, every joint in their body will be affected. Osteoarthritis can be one sided.

Joint pain

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– also known as a Dowingers hump. Dowinger hump is when patient’s vertebral column begins to collapse, it crumbles. This is a sign of osteoporosis. As vertebral column collapses, the person loses height. One muscle group, usually the dominant side will pull away from the other side of the body and the patient will develop a hump or a buildup of muscle tissue. If you see pt with Dowinger’s hump, you can say that they have osteoporosis or you would want to test them for osteoporosis.

Kyphosis

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– occurs before the age of 18. It is an adolescent disease. Occurs in the year of greatest growth, when the pt grows 2, 4, 6 inches. One muscle group pulls, pulling out the spinal column, giving it an S shape.

Scoliosis

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for carpal tunnel. Flex wrists for 60 seconds. Numbness, tingling, or burning indicates carpal tunnel syndrome.

Phalen’s Test

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sign is used to ID Carpal Tunnel Syndrome. This test is elicited by percussing lightly over the median nerve, located on the inner wrist until numbness, tingling and pain are felt.

Positive Tinel’s

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– in osteoarthritis.
• Assess for excess fluid on the knee.
• Milk upward on medial side of knee, and then tap lateral side of the patella. It will balloon out or bulge.
• It indicates joint swelling vs. soft tissue swelling - arthritis.

Bulge Sign (Balloon Sign

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– a tube of blood is spinned.
• The amount of time it takes to separate blood cells from plasma
• The more WBCs, particularly large ones (lymphocytes, monocytes) the longer it takes to spin down à increased sedimentation rate .
• An increase in inflammation in RA, MS, scleroderma leads to increased sedimentation rate.

Sedimentation rate

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– (HLA) Done during the pt’s flare up.
• We can actually see that pt has an inflammatory disease.
• Used to detect autoimmune diseases such as lupus, RA, scleroderma, etc.

Antinuclear Enzymes

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caused by breaking a fall – a sign of osteoporosis.

Colles fx

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– shortening of muscle. Builds muscle = hypertrophy.

Isotonic

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– pull of muscle – excessive stretch of muscle and tendon
• Muscle is highly vascular – tearing causes bleeding, hematoma.
• S/S pain, muscle soreness, edema.
• Rx - RICE

Strain

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– stretching of ligament causing joint to come out of position.
• Causes loss of stability, depending on severity, it might need casting (esp. in knee area).
• Might cause shaving of bone
• S/S – pain, rapid swelling, joint tenderness, limited ROM

Sprain

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Immobilization
Timely correction of Displacement
Application of Ice
Adequate amounts of growth hormone, V-D and calcium
Adequate blood supply
Absence of infection
Moderate activity level prior to injury

Factors influencing bone healing – positive

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• Delay in correction of displacement
• Open fracture
• Presence of foreign body – compound Fx
• Immuno compromised – HIV, RA
 circulation
• Malnutrition
• Osteoporosis – bones wear
• Osteomalacia – absence of Vit D, soft bone disease, called rickets in children.
• Advanced age – $ bone integrity.

Factors influencing bone healing – Negative

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The leg is held longitudinal – straight up
Toes to ceiling
It pulls it in a straight method
It comes down and 5-8lbs weight is hung from it

Bucks skin traction

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Nails, screws and wire are put through the bone
• Connect bone
• We tend to vector:
• We need to put as much as 25lb added weight
Do not allow pt’s foot to touch foot of bed – there is no more traction
2. Do not allow weights to touch the floor – there is no more traction
Pt must stay in the center of the bed
Rule: traction is NEVER interrupted

Skeletal traction

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Make sure ropes are not frayed
Knots are tight
No knots on pulleys
Weights are off floor

NI for traction

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Dermatitis or other skin irritations
Impaired circulation -
Varicose ulcers
Peripheral neuropathy
Pressure sores

Bucks traction contraindications

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• Sterile technique
• Prepare a solution of 50% hydrogen dioxide, 50% NS
• Clean pin w/ swap once and toss – repeat until clean
• Never double dip
• Mix solution in urine cup and date it
• Each pin gets its own sterile applicator to clean
• Initially the wound is sanguineous for 24 hours
• Sanguineous à serous
• After 2-3 days, pins are grown into wound
• Pins can shift – measure both sides of pins to make sure it hasn’t shifted inwards
• Risk for infection:
o Local inflammation: red, swollen, pain, LOF, warm
o Systemic – fever, inc. WBC
▪ If drainage in wound becomes purulent, assess, check WBC
▪ Osteomyelitis (bone infection) is the worst thing to happen to a pt

Skeletal traction pin care

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o Always check distal to injury
o Pulse
o Capillary refill
o Ask pt about numbness, tingling, pins and needles

Neurovascular assessment

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– we inject dye – the dye will show up on x-ray. • We check for consistency and contour of bone. • We have to find out if there is a bee-sting allergy. Depending on reaction, they may Rx steroids and Benadryl and may give dye anyway

Arthrography

– measure density of bone, depth and integrity in osteoporosis. • Typically done in (usu. lower) spine, the narrow neck of the femur bone adjoining the hip, and the bones of the wrist and forearm. • Using the norms for size and age, they look for bone loss. • Typically this is done on menopausal women where estrogen is no longer being produced; men don’t show osteoporosis until they are in their

Bone density

– You are given dye by IV, it goes through your body and ends up in the bladder, and then you pee it out.

Bone Scan

– a needle is injected and synovial fluid (should look like extra virgin olive oil) is aspirated. • The synovial fluid is then checked for protein, antibodies, WBC. • Is it infected w/ RA. In this case, it will come out cloudy, milky color • Impaired skin integrity is a concern. • TEST RESULTS: Protein means bones breaking down and WBC count means it is inflamed and/or infected.

Arthrocentesis

–the use of a dye to check blood circulation. | • This is not commonly done in M/S, more likely seen in renal, heart, and brain.

Angiography

- # w/ bone growth, in fractures and bone repair

Alkaline phosphate

– stretching of ligament causing joint to come out of position. • Causes loss of stability, depending on severity, it might need casting (esp. in knee area). • Might cause shaving of bone • S/S – pain, rapid swelling, joint tenderness, limited ROM

Sprain

* 1. Pain - N * 2. Pulselessness – V * 3. Paresthesia – N * 4. Paralysis – N * 5. Pallor$ – V * 6. Polar – V - cool or cold extremity distal to injury

6 P’s – Neurovascular Assessment

– absence of Vit D, soft bone disease, called rickets in children.

Osteomalacia

* Soft tissue damage – always bleeding. Always look at underlying structures, if it is ribs, etc. * Hemorrhage * Ruptured tendons * Severed nerve * Damaged blood vessels * Body organ injuries

Complications of trauma

Between 5-8 lbs Asses pain Asses area at least 2-3x each shift must remove boot Reposition patient for skin integrity

Nursing implications Bucks traction

Allergic rxn Skin irritation Perineal nerve palsy circulation impairment Pressure ulcers

Complications of Bucks fractures

– when injury continues to develop under cast o The cast is squeezing on the muscle underneath and can cause damage o Perform neurovascular assessment, the 6 Ps on distal areas of cast o Check for capillary refill, pulse, heat o Tissue necrosis or infection can occur o Hemorrhage – nerve damage can occur

• Cast compartment syndrome

``` Headache Drowsiness Irritability/Confusion/ Agitation Sense of impending doom Tachycardia Tachypnea/ wheezing use of accessory muscle Petechiae on neck and chest wall ```

Fat emboli

• Typically, pressure inside fascia is 8mm/Hg • Once it reaches 20mm/Hg cells begin to die • ALL CELLS BEGIN TO DIE AT 20mm/Hg • During musculoskeletal trauma • S/s UNRELENTING PAIN • Pain is not relieved by narcotics • Prevention: RICE • The minute you suspect compartment syndrome RICEing isn’t permitted • Since it lowers blood supply, it can cause further damage o At this point we need to inc. blood circulation to muscle o Don’t elevate for same reason as above • If pressure is > 8mm/Hg, you know something is going on

Compartment Syndrome

– a cut into the fascia to relieve pressure • Dress at all times • Keep it moist w/ sterile saline • It’ll heal through secondary healing – inside out

fasciotomy

pain that occurs or intensifies with passive ROM. This pain can be caused by (1) a reduction in the size of the muscle compartment because the enclosing muscle fascia is too tight or a cast or dressing is constrictive or (2) an increase in compartment contents because of edema or hemorrhage.

Compartment syndrome

* Reactive Phase- bone injury * Reparative Phase- callus formation * Remodeling Phase- new bone into former structure

Bond healing

``` Oxygen •Coughing, Deep Breathing •Heparin/Aspirin •Bedrest •Fluids •Prevention ```

Fat embolism management

``` Deep, Throbbing, Unrelenting Pain •Pain not relieved by narcotics •Swelling •Numbness and Tingling •Paresis/Paralysis •Loss of distal pulse, cyanotic nailbeds ```

Compartment syndrome management

* Can prevent by giving heparin or Lovenox prophylactically * Always add to neuromuscular assessment the HOMAN’S SIGN – dorsi flexion * Feel calf as they are performing Homan’s sign * Pt will let you know if they feel deep calf pain * Teach pt to differentiate btw calf pain and sight of injury (knee replacement) * Actual symptoms are the s/s of inflammation in addition to Homan’s sign * Loss of circulation below DVT * Put pt on bed rest

DVT

``` Redness* •Heat* •Swelling* •Tenderness/Pain cramping •Loss of Function •Homans’ sign •Doppler / Venogram ```

DVT

``` Prevention – can lead to PE •Heparin/Lovenox •Bedrest •Anti embolic stockings •Venodynes (CPM machine) •Vena Cava Filter •Thrombectomy ```

DVT treatment

``` dyspnea, tachypnea •chest pain •anxiety, diaphoresis •tachycardia Clot travels to lung and obstructs branch of Pulmonary Artery ```

PE ASSESSMENT

``` Peripheral Vascular Disease (PVD) •Traumatic injuries •Malignant tumors •Infection, Gangrene •Complications associated with DM ```

Amputation indications

``` Pallor •Infection •Loss of sensation •Inadequate circulation •gangrene ```

Clinical manifestations for amputations

o Planned amputation o Goes into healthy tissue o Leaves a large enough flap of tissue to flip up and saw around o Removal of bone w/ the suturing of skin w/ a muscle flap

Closed amputation

o Clear, clean break w/o flap of tissue o Soft tissue and bone are severed at the same level o For pt w/ osteomyelitis, they’ll often perform guillotine amputation ▪ Cut right into limb, remove affected tissue and attempt to keep the area from getting infected ▪ Once Drs. are sure the infection has not spread, they will take skin from another area on the body (usu. Hip or buttocks) and put on amputation site to close off.

Open – guillotine:

``` •Control residual limb edema •Residual Limb Care –bandage fosters shaping •Decrease Phantom Pain •Prosthetic Fitting •Pain management •Early PT for balance exercises ```

Prevent complications of amputation

``` •Elevate on pillow for first 24 hours ONLY •Compression dressing ◦remove for bathing ◦when not wearing prosthesis ◦Clean everyday •Closed rigid dressing fosters shaping and molding ```

Controlling Residual Limb Edema

``` Hemorrhage •Infection •Delayed healing •Flexion Deformity •Skin irritation from prosthesis •Phantom limb sensation/pain •Early PT- balance ```

Complications of amputations

``` •Keep compressed •Wash daily •Inspect with each wrap •Avoid topical antiseptics or lotions •Toughen residual limb/massage •Change shrinker socks daily •Avoid use of talcum powder for prosthetic limb ```

Residual Limb Care

No pillow elevation after 24h •Avoid sitting more than 1 h in chair •Lay prone 15 - 30 minutes TID or QID

Flexion deformity prevention

• Today we use shrinker sock, similar to TEDS, they are very tight • Compression dressing is removed only for bathing and when not wearing prosthesis • Teach pt to look daily at residual limb w/ mirror • Putting stump into prosthesis often causes skin breakdown • Pt usu. Puts on a sock which usu. fits into residual limb o The sock needs to be removed daily and cleaned to prevent skin breakdown o Prosthesis should be put on 1st thing in the morning

Dressing for limbs

Cane opposite affected leg

CANE

Walker with affected leg

Walker

Degenerative Joint Disease (DJD) •Characterized by: •progressive loss of joint cartilage •loss of articular cartilage in synovial fluid

Osteoarthritis

``` asymmetrical unilateral pain •joint stiffness/ache (most common in am upon rising, lasts 30 min S/S HARD AND COLD JOINT •pain worsens with joint use •decreased ROM •Herberden and Bouchard’s nodes •joint enlargement/flexion contractures •crepitation ```

Osteoarthritis

* During 1st attack – s/s resemble flu * The joints hurt for a day or two * The body goes into remission for 1-3 yrs * no destructive changes * the body begins to break down joints

Stage 1 RA

* Joints are hot, red and painful – they are inflamed * Sed rate elevation b/c WBC fight off inflammation * Joint pain is typically bilateral * at this point slight bone and cartilage destruction

Stage 2 RA

* cartilage and bone destruction | * bony ankylosis (bone on bone)

Stage 3 RA

• Morning stiffness • Swelling in 3 or more joints – persisting for 6 weeks • Bilateral presentation • Joints are hot, red swollen and painful • Swan neck deformity – there is no longer synovial fluid in joints o It is bone on bone o AKA Ulnar deviation • Fever • Raynaud’s – hands turn white and red • Sjögren’s disease – $ in saliva and teardrops • Felty syndrome: o Inflammation of the eye o Splenomegaly o Lymphadenopathy • Pleural disease/fibrosis/pneumonitis

* CBC * Elevated ESR à inflammation * Elevated C-active protein * Positive antinuclear antibody (AMA) * Arthrocentesis – will show up as cloudy fluid full of WBC, and protein from breaking down of bones * CT/X-ray

Diagnostic RA

* Best Tx for pt is swimming * ROM * OT/PT * During RA exacerbation, pt is hot and swollen * DO NOT TX WITH HEAT – WE TREAT PT WITH COLD – ICE THEM * During remission, we Tx pt w/ paraffin = hot, warm, wax, b/c it radiates inwards, it makes the joint feel more comfortable

Treatment for RA

▪ Cushing’s disease ▪ avascular necrosis ▪ osteoporosis ▪ immunocompromised body can’t fight super infections

Corticosteroids

o One leg is shorter that the other b/c of muscle shortening o Pain not relieved by narcotics o Pt can’t walk/move leg

S/s of dislocated hip

Avascular necrosis – bone death b/c blood loss • Can be caused by steroids – bone dies Non-union • Non-healing fx w/ poor bld supply, neck and ball have poor bld supply Congenital hip • Pt w/ down’s syndrome • In addition to genetic defect, physically and mentally they also have hip dysplasia (genetic, causes various forms of arthritis) and heart problems • We tend to do bilateral hip replacements

Femoral neck fx

* Abduction with pillows * Never flex more than 90 degrees * HOB not more than 60 degrees * No adduction, no internal/external rotation * No crossing legs * No bending at waist * Sit in high chairs-no more than 70 degrees * Do not bend or lean forward * Knees always lower than hips

Prevent Dislocation

* Pt must be at abduction all the time * Pt must have triangular pillow w/ Velcro or 1-2 pillows between legs * Even in wheel chair, we need a pillow between the legs * We must have hip apart, not together * Legs should not hit each other * No internal/external rotation of hip * Toes to ceiling * Pt may not bend/reach * Pt should not put on socks * Pt cannot reach for things, not even blanket * Never flex more than 90 degrees * HOB not more than 60 degrees – can cause hip flexion * No crossing legs * No bending at waist * All chairs must be high chairs w/ arms * Pt must not get into chair w/o arms * Pt can’t sit in couch when flexion of hip is such that it can cause flexion and dislocation * Toilet seat must be raised

Hip dislocation prevention

The body will cover the infection with good fresh bone

involcrum

Abscessed dead bone

sequestrum

: right leg - left crutch then, left leg - right crutch

Two Point Gait

: full weight on one leg; none or partial weight on other leg. So that weak leg and two crutches move together.

Three Point Gait

the strong leg goes up first and the weaker leg goes up last along with the crutches

Going up stairs

metabolic bone disease characterized by inadequate mineralization of bone. Known as adult rickets. It is seen in cultures whose diets tend to be deficient in calcium & VD. Women in China, Japan, and northern India have the highest incidence. It is almost non-existent in the US but may be seen in elderly, & vegetarian diets

Osteomalacia

Vitamin D Deficiency: lack of dietary vitamin D; Lack of sunshine; Phosphate Depletion: Inadequate intake; impaired absorption; Systemic acidosis: ureterosigmoidostomy Bone Mineralization Inhibitors: hypophosphatasia; Sodium fluoride; CRF Malabsorption syndrome ? celiac disease, biliary tract obstruction, pancreatitis and small bowel resection. Steatorrhea causes increase in fat loss along with Vit D Prolonged anticonvulsant therapy

Osteomalacia Predisposing Factors

· Bone pain and tenderness to touch · Muscle weakness which increases risk of falls and pathologic fractures · Waddling or limping gait may cause unsteadiness and falls · Legs become bowed in advanced stages of disease due to body weight · Shortening of patient's trunk due to softened vertebrae · Deformity of thorax (Kyphosis) due to softened vertebrae · May have deformities of pelvis necessitating cesarean section

Osteomalacia Clinical Manifestations

· X-rays show generalized bone demineralization Looser's Zones - zigzagging bands of decalcification with callus formation on each side of the bone · normal to low Calcium/phos - increased alkaline phosphatase; high parathyroid hormone · Bone Biopsy shows increased amount of osteoid

Osteomalacia Diagnostic testing

rapid bone turnover affecting the skull, femur, tibia, pelvic bones and vertebrae. Seen after the age of 50; men more than women Then it is followed by a compensatory increase in osteoblastic activity that replaces the bone in a classic mosaic pattern. Because the diseased bone is highly vascularized ant structurally weak, pathologic fractures occur. Bowing of the legs cause misalignment of hip knees, ankle joints leading to arthritis.

Paget's disease

Early stages – symptoms are few and vague Later stages – fractures and deformities occur Bowing of the femurs and tibia producing a waddling gait Enlargement of skull may lead to impaired hearing Pain (increasing with weight bearing); tenderness and warmth over bones

Paget's disease

``` • Local o Aching, throbbing bone pain – non localized o Muscle spasm o Edematous, redness, heat, LOF o Thin, scarred, shiny Red Heat Pain Swollen LOF • Systemic o Malaise o Leukocytosis o Lymph node involvement ```

Clinical manifestation osteomyelitis

``` Age related • We see it 2 times in life – at menopause and age 75 for men and women o Metabolic o Systemic o Skeletal disease characterized by: ▪ Low bone mass ▪ Micro architectural deterioration ▪ Bone fragility – inc. risk for fx ```

Osteoporosis

``` o High protein o High Vit C o Zinc o High Ca – for bone build-up in cavity o Mg ```

Osteoporosis diet

* Imbalance btw osteoclasts and osteoblasts | * Bone loss occurs when resorption exceeds formation

Osteoporosis

``` • Genetic factors • Age • Race • Endocrine • Other diseases o Esp. thyroid disease/cancer ```

Osteoporosis Risk factors – unmodifiable

• Hormonal status – being on estrogen carries risk for cancer and heart disease • Ca and Vit D deficiency o Start taking today o Teach pt to read labels o 30% = 300mg o We need 1200mg per day ▪ Can process 600mg at one time • Cigarettes, caffeine, alcohol all leach Ca from bone • Low body weight • Sedentary life style à couch potatoes • Must exercise – for osteoporosis it must be weight bearing • Swimming doesn’t work since you weigh less • Wolf’s law – if you don’t use it, you lose it • By overusing, we make stronger bones o Ca migrates to bones

Osteoporosis Risk factors – modifiable

milk, dairy, green vegetables, antacids o Age 19-50 – 1000mg/day o Age 51 à older – 1200mg /day

Calcium

o Age 2-50 – 200u/day o Age 51-70 – 400u/day o 70 à older – 600u/day

Vit D

o A crack in bone that doesn’t go all the way through o Over next 24-hours crack will cont. to develop o Pt will get non-displaced fx o Pt can still walk o Pt will get groin pain o Suddenly pt gets displaced joint o Leg shortens, pt is incapacitated and in pain

Occult fx:

– has good bld supply and will heal • Pt will get Open Reduction Internal Fixation device • If during surgery, Md assess good bld supply, he will apply ORIF o Usu in: ▪ Trochanteric ▪ Subtrochanteric

Extracapsular hip fx

shortened, adducted, and externally rotated.

Femoral neck fx

wrapping the joint in a compression dressing, extending and elevating the joint, and applying ice or cold packs.

arthroscopy interventions

Affects 5th cranial nerve and is characterized by paroxysms of pain in the area inner step by the three branches of the nerve. The unilateral nature of the pain

Trigeminal neuralgia

Facial paralysis | Disorder of the 7th cranial nerve characterized by unilateral paralysis of facial muscles

Bell's palsy