Orthopedics - DOC

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					       Standard disclaimer:
       This is not intended to be a substitute for your own notes. These are the notes I have taken in lecture for
       my own learning. As such, the content is NOT an exact copy of the powerpoint presentation or the entirety
       of the lecture. On my distracted days, the notes may even be pretty shoddy. That said, I have tried to
       provide links to reputable websites where you can find more information. As always, refer to your textbooks
       and your instructors for the final word.
                                                                   ~ Marieke




Orthopedics
Thursday, February 01, 2007
8:32 AM

Orthopedics- the bottom line is how is FUNCTION

Kinds of bones
       Long
       Short
       Flat
       Irregular

Kinds of joints

Ortho assessment guidelines
       Provide privacy
       Appropriate attire to expose necessary structures
              Bring shorts and a t-shirt
       Problem-focused assessment
       Symmetry- comparison is a major component
       What is the influence on function

Assessment of mobility
      Range of joint motion
              Stairs
                     Need 90 degree flexion to go up and down stairs alternately
      Muscle strength
      Activity tolerance
      Gait
      Posture
      Complete head-to-toe assessment
      Physiologic changes from immobility
              Atrophy

Ortho quick assessment
       Examine while sitting
       Examine gait
       Manner of undressing
                Need help?
        Note compensatory strategies
        History
                Family, personal

Inspection
       Look for asymmetry
       Swelling
       Deformity
       Abnormal limb size
       Limb position
       Range of motion
       Presence of crepitus

Lab studies
       Renal panel
               Many meds in orthopedics can be nephrotoxic (eg NSAIDS)
               Long term will get renal panel q 6 months
       ESR estimated sedimentation rate
               Nonspecific test measure rate of red cell settling
               Elevations indicate presence of swelling
               Good indicator of improvement of osteomyelitis
       H&H
       Urine analysis
               Won't put hardware in pts with UTIs
       Joint aspirates


Xrays
        Mainstay in ortho diagnostics
        Determines bone integrity, density, texture, erosion in relation to another
        Multiple views
               AP
               LAT
               Mortise
               Oblique
               Sunset

Other diagnostic studies
       Arthrograms
              Xray study following injection of dye
              Highlights soft tissues and structures typically not visible on plain films
       Bone scan
              Radiopaque dye
              Indicates disease states and healing via increased uptake of dye due
              to metabolic activity

        CT
        MRI

Special studies (more invasive)
       Arthroscopy
              Looking with a camera
        Joint aspiration
        Nerve conduction studies

Xrays
Ortho assessment tools

Goniometer




Reflex hammer
Tape measure
Paper clip (for sharp-dull)
Cotton ball
Eyes




Osteoarthritis
Thursday, February 01, 2007
8:57 AM

AKA DJD (degenerative joint disease)
http://www.niams.nih.gov/hi/topics/arthritis/oahandout.htm

Characterized by degeneration of articular cartilage
Formation of new bone at margin of joint
Cause is unknown, but there are predisposing factors
       Trauma
       Genetics
       Congenital- some diseases
              Perthes disease
                      http://www.orthoinfo.org/fact/thr_report.cfm?Thread_ID=159&
                      topcategory=Hip
        Sepsis
        Preexisting disease

Usually affects weight-bearing, mobile joints (but can affect others)

Patho
        Noninflammatory
        Cartilage becomes pitted and yellow
        "digestive" effects of certain enzymes
        Inadequate nutrition
        Prostaglandins
        Repair of tissue is unable to keep pace

Degenerative process
      Cartilage softens and loses elasticity
      Full-thickness loss of cartilage ultimately develops
      Subchondral bone hypertrophies and forms osteophytes
      Secondary synovitis may occur

Incidence
       Most common form of disabling disease in US
       40 million americans have changes visible on xray
       Begins as early as the 20s (
       90% of all people have some changes on xray
       By age 70 80% have symptoms
       More common in caucasians

Complications/manifestations
      Pain
      Decreased ROM
      Joint contracture
      Loss of function
      Resting pain
      Loss of independence

Assessment
      History
      Physical symptoms
              Local
              Mild tenderness pain with overuse
              Crepitus (grinding, gritty sound)
              Asymmetry
              Groin pain
              Limited range of motion
              Knee "gives way"
              Varus/valgus deformity

Diagnosis
      Progressive changes on xray
      Narrowing of joint space
      Osteophytes
      Bone cysts
      Subluxation and deformity

Therapy
      Drugs
              NSAIDS
                      Careful! Can cause problems with GI and renal
                      Ibuprofen, relafen, naproxen sodium
                      Cox 2 inhibitors
                              Celebrex- new research indicates they are at equal risk
                              for GI bleed
                              Black label warning regarding increased risk of MI
              Corticosteroid injections
                      Methylprednisolone and local anesthetic
                      Directly into joint
                      Anti-inflammatory benefits may last 1-8 weeks
                      Limited usage r/t risk for avascular necrosis
              Narcotics
              Toradol
                      Can only be used in limited circumstances due to high risk of GI
                      bleed and renal problems
      Viscoelastic therapy
              Synvisc- injection of hyaluronan into diarthroidal joint space (which is
              the majority of synovial fluid)
              Naturally degraded and replaced by the body
              Found in surface of articular cartilage
              Considered a medical device, not a medication
              Useful in certain patients (usually must have a preserved joint space)
              http://www.synvisc.com/aboutsynvisc/ussyn_work.asp
      Multidisciplinary measures
              PT

      ROM exercises
            Full extent to which a joint can move in any direction
            Purpose is to maintain tone and joint mobility
                    As often as possible

      Surgical treatment
             Osteotomy
             Arthroscopy
             Arthroplasty
             Cartilage implantation
                     Genzyme


Rheumatoid arthritis is an INFLAMMATORY disease. Osteoarthritis is a degenerative
process. Usually presents bilaterally.




Valgus/varus
Hip fracture
Thursday, February 01, 2007
10:02 AM

Risk factors for hip fracture
       Age
       Decreased estrogen without HRT
       Smoking
       Lack of weight bearing exercises




Total joint arthroplasty
Thursday, February 01, 2007
10:03 AM

Most common indication is osteoarthritis
Debilitating joint pain
Resting pain
Loss of function
Significant loss of joint space on xray
Also performed for

Age considerations
      Hip and knee prostheses have life of about 20 years (max)
      Total joint replacement for patients age 40-50 must be carefully considered
      since revision is likely

Preoperative prep is necessary
      Multidisciplinary education coordinated by nursing
              What to expect
              Exercises
              Home modifications
              Discharge planning
      Xrays (affected joints and chest if indicated), EKG, H&H, urine and screen,
      T&C
      Autologous blood donation
              Self-donation
              One unit is typical
              Risk of donation induced anemia
              45 day window preoperatively
      Stop anticoagulants and meds that inhibit platelet aggregation 7 days preop
      Preoperative (night before) hibiclens scrub of surgical site

Total joint risks
        Acute and/or chronic infection
        Major bone loss
        DVT
        Nerve damage
        Poor outcomes (not doing the required exercises is a big cause)
        Dislocation
        Prosthetic wear and loosening

Perioperative phase
       Regional anesthesia is preferred
              Fewer risks
              Patient hears it all (Versed GOOD)
       Prosthesis is often determined by surgeon and facility

Postoperative care
      Pain management is
              Essential to ensuring participation in the rehab plan
              Epidural, PCA, other parenteral agents, oral agents
              Careful use in older populations r/t metabolism of narcotics
              Other interventions: ice, elevation, positioning
      Neurovascular assessment
              Palpation, color, temp, cap refill
              Neuromotor function
              Dorsi (peroneal nerve) and plantar flexion (tibial nerve)
      Hemodynamics
              H&H- it will drift down
              Electrolytes (metabolic or renal panel) not routine
              Urine output is monitored closely
                      Rarely a foley. Usually straight cath, bladder scan
                       Insufficient output vs insuff production
              Vitals
                       Febrile response to surgical wound and respiratory depression

       Critical potential postop problems for SP

       Monitor blood loss
              Davol drainage
              VS q15, q30

Postop PT (physical therapy)
       Ankle pumps
       Quad sets
       Heel slides
       SLR (knees primarily)

Activity
        Dangle surgical night
        Assistive devices to maintain precautions
                Reacher, elevated toilet site, dressing stick, shoe horn, etc
        Progressive ambulation
        Stairs prior to discharge
        Can they get in/out of the vehicle they're going home in?
        Much of this is universal to ortho. Nurses need to assess each individual's
        need for equipment. Documentation about need for these items will mean
        more likely reimbursement

Prevention of complications
      DVT prophylaxis
              Lovenox q 7 days
              Warfarin
              TEDs
              SCD, flowtrons, plexipulse
      Antibiotic coverage x24-48 hours
      UTI
              Early foley removal or straight cath/bladder scan
      CDB
      Bowel regimen


Hip precautions
       No crossing midline
       No bending more than 90 degrees
       No internal rotation
       Knees lower than hips
       Sit with legs and toes out

Knee precautions
      Knee is neutral with little or no flexion
      Hip is abducted (foam wedge or pillows)
      Hip precautions (no flex,
      Never turn without pillow between knees
      Out of bed surgical as soon as is tolerated
             Bedside commode
       CPM
       Head of bed at or below 60 degrees

Discharge planning
       Begins with admission
       Assess supports
       Stairs into and inside home
       Inpatient rehab? SNF placement?
       PT continues outpatient with knees (not so much with hips)
       Long-term follow-up (2 weeks, 3 months, 6 months, and annually)

Total joint risks


Monitor for wound infection
       VS q4h




Low back pain
Thursday, February 01, 2007
11:07 AM

Spine is designed to provide max flex with max protection of cord
Disuse weakens supporting structures
Obesity, posture, structural problems and overstretching may contribute to low back
pain
Disks change with age
       Increased density
       Increased irregularity in shape
HNP
       Herniated nucleus propulsus


Manifestations
       Acute-

       Chronic (longer than 3 months)

       Radiating (radiculopathy)

       Sciatica (nerve root involvement)

       Gait, spinal mobility, reflexes, leg length, motor strength and sensory
       perception all may be altered

Management
      Most resolves with conservative management in about 4 weeks
             Bedrest and pills will NOT likely work. Must MOVE. Atrophy can occur
             really early (much faster than one would think)
       Focus on pain relief, activity modification and patient education
       First line is Tylenol or Advil, sometimes muscle relaxants or opioids

       Traction, massage, diathermy, ultrasound, cutaneous laser treatment,
       biofeedback, and TENS have no consistent benefit. What works is what works
       for the PATIENT.

Assessment
      Pain location, quality, quantity, duration, radiation
      Previous successful pain management strategies
      Observe posture, compensatory strategies, position changes, gait, leaning,
      walking flat-footed on one side

Diagnosis
      Acute pain
      Impaired physical mobility
      Deficient knowledge (body mechanics)
      Risk for situational low self esteem
      Imbalanced nutrition r/t obesity

Relieving pain
       Frequent position changes
       Reducing muscular and psych tension
       Breathing exercises
       Diversion
       Guided imagery
       Assess responses and any pain meds taken

Improving mobility
      As it improves, make position changes slowly
      Avoid twisting and jarring
      Avoid sitting, standing, walking for extended periods (>30 minutes)
      Severe pain, head elevated 30 degrees, knees slightly flexed with pillow or
      sidelying with pillow between knees
      Initiate exercise regimen when tolerable
      Active physical rehab has been shown more effective than conservative
      treatment

Prevention
      Good mechanics
             Lifting technique- when lifting a patient, look in the eyes of the person
             helping you. Keep back straight.
      Changing posture takes upwards of 6 months
      Major key is continuing exercise and weight control

Disk degeneration
       Begins in 2nd decade of life
              Drying of disk
              Narrowing of intervertebral space
              Osteophytes
              Thickening of ligamentum flavum
       Normal result of aging
Disk herniation
       Rupture of nucleus propulsus
              "slipped" or "ruptured", HNP
              50% of patients with no precipitating injury or event
              Varied dermatomal distribution with paresthesia and motor weakness
              possible
              Muscle spasm is usually the cause of the most severe pain (a
              compensatory mechanism)

Spinal stenosis
       A distinct clinical syndrome
       Thickening of ligamentum flavum
       Bony osteophytes
       Degen of bony facets
       Limits space for exiting nerve root (pain, paresthesia, weakness)
       Pain usually relieved with forward flexing, sitting or lying
       Important to distinguish between vascular claudication and neurogenic
       claudication



Degenerative lumbar disease
Thursday, February 01, 2007
11:25 AM

Pain and functional


Treatment
      Rest
      Major anterior/posterior surgical interventions
      (which is better depends on a lot of factors)
      Risk for "malingering" or chronic complainer (bell-ringer)
      Conservative treatment might not be the best approach

Surgical (HNP)
       Results can be good to excellent 90-95% of cases
       Laminotomy or discectomy
       Disc replacement is new

Postoperative activity
      Early mobilization is encouraged
      Postop bracing might be needed
              Preop bracing helpful
              Alcohol for skin care
              Support system
      Patients need to know that they will be expected to walk after surg

Assessment
      Neuro assessment distal to surgical site
      Dermatomes
      Strength
              Dorsi/plantar
              Grip

Postop complications
       Dural tear intraop
       Nerve injury
       Wound infection
       PE
       Electrolyte disturbances
       Delayed union or hardware failure with fusions

Discharge
       Restricted from bending, twisting, lifting for 2-4 weeks
       Sitting (no more than 15-20 minutes
       Gradually resume pre-problem activity
       Be wary of the person likely to overdo