PLT College Inc.

Bayombong, Nueva Vizcaya

College of Nursing

Orthopedic Nursing
Ortho Lecture Series # 2 (Prepared By: Prince Rener V. Pera, RN)

Bone Maintenance and Healing

 REGULATORY FACTORS DETERMINING BOTH FORMATION & RESORPTION

1. Weight-bearing (local stress)

a. Stimulate bone formation & remodelling
b. Prolonged bed rest: bone losses calcium (resorption) & becomes
osteopenia & weak
2. Vitamin D (Calcitrol) promotes absorption of Calcium from GIT
a. ↑ amount of Ca in blood by promoting absorption of Ca from GIT
b. Facilitates mineralization of osteoid tse
c. Deficiency cause bone demineralization, deformity & fracture
3. Parathyroid Hormone regulates calcium
a. regulates calcium in blood in part by promoting mov’t of Ca from the
bone
b. ↓ Ca in blood ► ↑ PTH prompt demineralization of the bone
4. Calcitonin & Amino biphosphate (e.g. Alendronate [Fosamax]) increases
production of bone cells.
a. Alendronate [Fosamax]) increases production of bone cells
b. Calcitonin- inhibits release of calcium from the bone into the extracellular
fluid and reduces the renal tubular reabsorption of calcium

Bone Release of Kidney Reabsorption of Ca

Ca & Phosphate

Intestine Reabsorption of Ca
Via inactivated Vitamin D

 Estrogen & Androgen

 Stimulate osteoblastic activity & inhibit PTH
 Menopause/Andropause –
↓Ca ► bone loss ► osteoporosis
 Androgen-testosterone
 Promote anabolism
 ↑bone mass
 ESTROGEN-It appears that oestrogen deficiency allows greater expression
of these cytokines, all of which are associated with increased stimulation
of bone resorption which then leads to increased bone loss and a
reduction in BMD.

Bone Healing
STAGE 1. HEMATOMA FORMATION & INFLAMMATION (6-8 hours after the injury)
 When bone is damaged or injured, hematoma precedes new tissue formation in
the production of new bone substance
STAGE 2. CELLULAR PROLIFERATION:
 Granular tissue formation where BV & cartilage overlie the fracture
 Callus forms as minerals are deposited to organize new network for the new
bone
STAGE 3. PRECALLUS FORMATION: (2-6 wks)
 Callus forms the initial clinical union of the bone & provides enough stability to
prevent movement when bones are gently stressed
STAGE 4. CALLUS FORMATION:
 Consolidation & Remodelling (complete healing- 3-6months)
 Continued bone healing provides for gradual return of the injured bone to its
pre-injury shape & structural strength
FACTORS AFFECTING TIME REQUIRED FOR HEALING:

1. Age
2. Displacement
3. Site of fracture
4. Nutritional level
5. Blood supply to the area of injury

Musculoskeletal Assessment

 Health History
1. Past History
o Trauma
 Nerves
 Joints
 Bones
 Soft tissue
o Surgery on bone or joint
o Skeletal deformities
o Chronic illness
2. Family History
o Congenital abnormalities or genetic disorders
 Hip or foot deformities
 Osteogenesis imperfecta
o Scoliosis or back problems
o Arthritis
 Rheumatoid arthritis (RA)
 Osteoarthritis
 Ankylosing spondylitis
 Gout
3. Personal History
o Employment – potential for injury
o Exercise patterns
o Functional abilities
o Weight changes
o Height changes
o Nutrition
o Tobacco
o Alcohol
4. Dietary History
5. Socioeconomic Status
6. Risk Factors
o Poor physical conditioning
o Failure to warm up muscles adequately
o Intensity of competition
o Collision and contact sports participation
o Rapid growth
 o Overuse of joints
o Obesity
o Lax ligaments with postural joint deformity
o > 40 y/o
 Chief Complaints
1. Pain- The commonest orthopedic complaint. Exact Site should be determined
and it should be remembered that referred pain is always common.
PQRST Assessment
 Precipitating Factors- What triggers the pain or makes it worse?
 Quality- What the discomfort feels like? (Searing, Scalding, Sharp, Piercing,
Wrenching, Burning, Crushing, Penetrating, Pressing, Pricking)
 Radiation- Is the pain felt also on other portion of the body?
 Severity- use the Pain Scale.
 Time- When does the pain usually attack/occur?

Other Pain Assessments:

 Location- Where is your discomfort?
 Pattern- Duration (How long have you had it?) Constancy (Do you have
pain free periods?)
 Alleviating Factors- What measures have you found helpful in lessening or
relieving pain?
 Associated Symptoms- Do you have any other symptoms (nausea,
dizziness, blurred vision, SOB) before, during and after your pain?
 Effects on ADL’s- How does the pain affects your daily life (eating,
working, recreational activities, bathing etc.)
 Coping Resources- What do you usually do to help you deal with pain?
 Affective Response- How does the pain make you feel?
Anxious?Depressed? Tired? etc.

COLDERR Assessment
 Character- Describe the sensation? (Aching, sharp, burning)
 Onset- When it started? How it has changed?
 Location- Where it hurts?
 Duration- Is it constant or intermittent in nature?
 Exacerbation- Factors that make it worse?
 Relief- Factors that make it better? (Medications, Massage etc)
 Radiation- Pattern of shooting, spreading, location of pain away from its
origin.

2. Impaired Physical Mobility

 Instruct patient to perform range of motion exercises, either passive or
active
 Provide support in ambulation with assistive devices
 Turn and change position every 2 hours
 Encourage mobility for a short period and provide positive reinforcements
for small accomplishments

3. Limited Range of Motion

 a) Active ROME
b) Passive ROME
c) Active Assistive ROME

 Medications (e.g. Steroids); Current health Problems (e.g. obesity)

 Physical Examination
1. Inspection
 Gait and Posture
Gait- Gait should be smooth and coordinated with arms swinging freely at
the sides, opposite to leg movements. The head and face should orient in
the direction of the movement.
Types of Gait:
a) Ataxic Gait
b) Double Step
c) Irregular and Non-Directive
d) Waddling
e) Equine
f) Festinating
g) Helicopod
h) Hemiphlegic
i) Shuffling
j) Scissors
k) Spastic
 l) Steppage
Posture- It should be erect posture while standing, with the shoulders and hips
aligned over the knees and ankles. Sitting posture is with straight back and
slight rounding of the shoulders.
Observe also for localized or generalized muscle wasting.
Surface abnormalities (Discoloration, scars, ulceration, bruising, rashes etc.)
Abnormalities of the contour of an extremity (swelling, deformity, hollows etc.)
2. Palpation (Tenderness, Temperature, Movement)
Causes of Movement Restrictions:
a) Mechanical Block (Loose body, torn meniscus)
b) Soft Tissue Contractive
c) Effusion
d) Paralysis & Paresis
e) Spasm and Spasticity
 General Survey
Vital Signs and the Integument
Appearance and Mental Status
1. Observe the body built height & weight In relation to patient’s age, health
& lifestyle.
2. Observe client’s hygiene, grooming, and body odor.
3. Observe for signs of distress in posture and facial expression
4. Assess the client’s attitude, affect, mood, and appropriateness of
responses.
5. Listen for quantity, quality, organization, and coherence of speech.
6. Document the findings.
 Head and Neck: Temporomandibular Joint; Crepitus
 Nutritional Status
 Spine – lordosis, scoliosis, posture, joint function, upper and lower extremities
 Deep Tendon Reflexes, bone integrity, muscle strength and tone,
neurovascular, MS injuries
 Glasgow Coma Scale (Verbal, Motor & Eye Opening)
 Muscle Strength

5 Normal 100% Complete ROM against full resistance

4 Good 75% Complete ROM against moderate resistance
3 Fair 50% Complete ROM without resistance
2 Poor 25% Complete ROM only if joint fully supported
1 Trace 10% Muscle contraction visible but insufficient to
move joint
0 None 0% No visible or palpable muscle contraction

Special Assessment Techniques

 Ballottement
 Bulge Sign

Test for Tinel’s Sign

 Strike the median nerve
  Tingling or prickling sensation radiating from wrist to the hand especially to
the thumb, index and middle fingers
 Positive sign is associated with carpal tunnel syndrome

Test for Phelan’s Sign

 Wrist flexed and dorsum of hands pressed together
 Hold for 1 minute
 Sensations of numbness and paresthesia in palmar aspects of hand,
especially the first 3 fingers
 Positive sign is associated with carpal tunnel syndrome

Diagnostic Tests

1. Electromyography aids in the diagnosis of neuromuscular, motor neuron, and

peripheral nerve disorders; usually with nerve conduction studies.
 Low electrical currents are passed through flat electrodes placed along
the nerve.
 If needles are used, inspect needle sites for hematoma formation.
2. Arthroscopy- A direct visualization of the joint cavity where a fiberoptic tube
is inserted into a joint for direct visualization.
Pre-test: consent, explanation of procedure, NPO
Intra-test: Sedative, Anesthesia, incision will be made
Post-test:
 maintain dressing,
 ambulation as soon as awake,
 mild soreness of joint for 2 days,
 joint rest for a few days & ice application to relieve discomfort
 Client must be able to flex the knee; exercises are prescribed for
ROM.
 Evaluate the neurovascular status of the affected limb frequently.
 Analgesics are prescribed.
 Monitor for complications
3. Bone Scan -Imaging study with the use of a contrast radioactive material
(technetium, Gallium, Thalium)
Pre-test: Painless procedure, IV radioisotope is used, no special preparation,
pregnancy is contraindicated
Intra-test: IV injection, Waiting period of 2 hours before X-ray, Fluids allowed,
supine position for scanning
Post-test: Increase fluid intake to flush out radioactive material
Remember:
 Adm. Isotope 1-2 days before scanning
 No radioactive threats
 Procedure lasts 30-60 min
 No special care after procedure
 Excreted in Urine & feces
 Encourage fluid
4. DEXA- Dual-energy XRAY Absorptiometry
 Assesses bone density to diagnose osteoporosis
  Uses LOW dose radiation to measure bone density
 Painless procedure, non-invasive, no special preparation
 Advise to remove jewelry
5. X-Ray Films: Roentgenograms – plain x-ray film is common APL (Antero-
posterior lateral views.
6. ARTHROGRAPHY: injection of dye or air in the joint for x-ray study
7. MYELOGRAPHY: examines spinal cord after introduction of contrast medium
8. BONE/MUSCLE BIOPSY: Iliac crest usual puncture site; not commonly done
today
 Local anesthesia, check PT & PTT
 Coagulant given 2-3 days before & after procedure
 Pressure dressing after
9. CT SCAN: assess bone & soft tse tumors
10. MRI: to assess soft tissue and joints with myelography
GANDOLINIUM DTPA (DiethyleneTriamine PentaAcetic Acid)

Blood Studies:

1. ESR (Erythrocyte Sedimentation Rate):

 non-specific test for inflammation F: 0-20 mm/hr M: 0-10 mm/hr
2. URIC ACID: Elevated in gout
 Normal 2.2-7 mg/dl (F) ;4.2-8 mg/100 ml (M)
3. ANA (Anti-nuclear Anti-body):
 Measures the presence of antibodies that destroy the nucleus of the body
tissue cells in auto-immune disorder;
 (+) in about 94% of clients w/ SLE
 Sjoren’s syndrome
4. RHEUMATOID FACTOR (Latex Fixation):
 Determine presence of auto antibodies (RF) found in clients with
connective tissue dse
 (+) RF is suggestive of RA
 The higher the antibody titer the greater the degree of inflammation

Muscle Enzyme Tests

1. CREATININE PHOPHOKINASE (CK3 or CK-MM)

 F: 30-135 U/L; M:55-170 U/L – highest concentration in traumatic injuries,
progressive muscular dystrophy
2. ALKALINE PHOSPHATASE (ALP-2) – Increased in Cancer, Paget’s Dse &
Osteomalacia.
Normal: 20-90 IU/L

“Treat Everyone with LOVE, even those who are RUDE to you…
Not because they are not NICE, but because you are NICE.”
princerenerpera