Musculoskeletal Problems

Mona GarrettNURS 210

Fractures of the Hip

IncidenceS/S:External rotationExtremity shorteningPainBruisingDiagnosis: Xrays

Treatment of Hip Fractures

Preoperative managementBuck’s traction with 5-7 lbs of weightTurn to unaffected sideTrapezeNeurovascular checksSurgeryOpen Reduction Internal Fixation (ORIF)Total Hip Arthroplasty (THR)

ORIF of the HipMost common surgical procedure for repairing hip fracturesUsed for inter and subtrochanter fracturesFracture realigned and secured with hardwarePostoperative careMaintain good limb alignmentEarly mobility; PT; adequate pain controlRehabilitation

Total Hip Arthroplasty (THR)

Used for femoral head fracturesIf only femoral head or acetabulum replaced, called partial / hemi-arthroplastyPostoperative careAbduction pillowHemovac or other drain for 2 daysUrinary catheter for 2 daysHip precautionsPain management

Complications of Hip Fractures

DVT - SCD’s, TED’s, anticoagulants, early mobilityAtelectasis/pneumoniaSkin breakdownUTI or unable to voidConstipationConfusion

Interventions for Clients with Connective Tissue Disease

OsteoarthritisRheumatoid Arthritis

LupusGout

Other

Osteoarthritis

Most common form of arthritisProgressive deterioration of joint cartilageAlso called Degenerative Joint Disease (DJD)Affects weight bearing joints (hips, knees, spine, hands)Risk factors: Aging, obesity, repetitive joint overuse

Osteoarthritis

S/S: Joint pain usually aggravated by use, loss of function, decreased ROM, crepitus (grating), enlarged joints are hard and cool to touch Diagnostic TestsLab values usually normalXrays; CT or MRI for vertebralSynovial fluid analysis to R/O rheumatoid

Treatment of Osteoarthritis

AcetaminophenNSAIDSCOX 2 Inhibitors (Celebrex and Bextra)Intra-articular corticosteroidsWeight lossExercise after heat applicationSurgery: Arthroscopy, osteotomy, arthrodesis, joint replacement (total joint arthroplasty)

Total Joint ReplacementGoal: Restores mobility and relieves painHip, knee, shoulder, elbow, fingers, toesCemented versus non-cementedComplicationsInfectionLooseningDislocationContraindications: Infection or advanced osteoporosisNursing Implications

Total Knee ReplacementReplacement with 3 parts: femoral component, tibial plate, patellar buttonBilateral TKRs possiblePostoperative care:Drain and pressure dressingHot/ice machine or ice packsPain managementBlood transfusionsContinuous Passive Motion (CPM) machineRehabilitation

Rheumatoid Arthritis

Chronic, systemic inflammatory disease that affects synovial jointsSpontaneous remissions & exacerbationsS/S: Systemic signs of inflammationJoint swelling with stiffness, warmth, tendernessAffects wrists, elbows, knees, ankles, PIP and MCP joints usually bilaterally

Diagnosis of Rheumatoid Arthritis

Positive rheumatoid factorElevated ESRSynovial fluid analysis(arthrocentesis)Xrays

Medications for RA

ASA and NSAIDS (Celebrex, Bextra)DMARDS (Disease modifying drugs) Plaquenil, Azulfidine, MinocyclineCytotoxic drugs (Methotrexate)Biological Response ModifiersEnbrel, Remicade, Humira, KineretLong term steroidsGold salts

Rheumatoid ArthritisTreatment: Moist heat or iceJoint rest with progressive exerciseCortisone injectionsDiet with omega 3 fatty acids & antioxidantsAssistive devices Management of fatigue and stressAlternative therapiesPlasmapheresisSurgery: Arthroplasty, arthrodesis

Systemic Lupus Erythematosus

Chronic inflammatory autoimmune disorder affecting the connective tissuesAntibody-antigen reactionCharacterized by recurrent seasonal remissions and exacerbationsS/S: Similar to RA in beginningRed butterfly rash; wolf bite “lupus”Photosensitivity; alopecia

Systemic Lupus Erythematosus

Diagnosis: Positive rheumatoid factorAntinuclear antibody; elevated ESR

Treatment: Goal is to control symptomsASA and NSAIDS for arthritis symptomsTopical medications and sunscreenCorticosteroids for systemic symptomsDialysis or kidney transplant for ESRDPlasmapheresis

Client Teaching for SLE

Protect the skinMonitor body temperaturePsychological support for unpredictability of lifeBalance life and stressPregnancy issuesRefer to Lupus Foundation of America

Gout (Gouty Arthritis)

Results from decreased renal excretion of uric acid or genetic defect in purine metabolism that causes overproduction of uric acidRed, swollen, and acutely painful jointsIntermittent attacks earlyChronic gout results in tophi (urate deposits) on outer ear, arms and fingers near joints; and kidney stones

GoutDiagnosis: Synovial fluid analysisElevated serum uric acid, WBC’s and ESRTreatment: Bedrest; immobilization of painful jointsApplication of cold; analgesicsNSAIDS especially Indocin; corticosteroidsColchicine for acuteAllopurinol or Benemid for chronicLots of fluid to prevent renal calculiAvoid diuretics and ASA; excess alcohol and fad “starvation” diets

Other Connective Tissue Diseases

Progressive Systemic Sclerosis (Scleroderma) - hardening of the skinLyme Disease - has an identified causeIf not diagnosed and treated early, chronic complications and arthritis occurFibromyalgiaTrunk, extremity, and facial painAssociated with Chronic Fatigue Syndrome