ARTHRITIS AND TRAUMATIC INJURIES

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ARTHRITIS AND TRAUMATIC INJURIES

• ASSESSMENT OF MUSCULOSKELETAL FUNCTION

Composed by Becky DeNeve, R.N.
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How well do you remember?

• Answer the following eight questions regarding
  the bones, joints, or muscles.

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Review Questions - Write your answers in your
notes!

• 1 Improves the gliding surfaces of
  where bones join (end to end) articulating a
  joint?
• 2 Name two types of strong, flexible
  cables that attach bone-to-bone or
  bone-to-muscle?

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More M/S Questions

• 3 What cushions a joint like a shock
  absorber?
• 4 When an ankle is sprained, it prevents
  swelling and numbs the pain.
• 5 Pain, warmth, redness, swelling, and
  possible fever.

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Bones joints...

• 6 The shoulder and hip represent which
  type of joint?
• 7 The knee represents which type of
  joint?
• 8 How many inches (in height) might be
  lost, over time, from osteoporosis symptoms
  - Downagers Hump?

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Musculoskeletal Review - The Answers

• 1. Synovial Fluid
• 2. Ligaments Tendons
• 3. Cartilage
• 4. Cold application

• 5. Signs of inflammation
• 6. Ball Socket (Diarthrosis)
• 7. Hinge
• 8. 5 - 8 of height

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Ligaments and Tendons

• GO BUCS! FOOTBALL IS HARD ON THE JOINTS AND
  SUPPORTING STRUCTURES

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Ligaments

• White, shiny flexible bands of fibrous tissue
  binding joints together and connecting the
  articular bones and cartilages to facilitate
  movement.
• Yellow elastic ligaments connect parts of the
  adjoining vertebrae.

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Ligamental Tears

• Caused by an injury to a joint by either a sudden
  twisting motion or forceful blow
• The knee is, by far, the most common joint to be
  injured, especially by sports.

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Treatment for Ligamental Tears

• Mild rest, compression, applications of heat
  and cold, elevation. Injections of an
  anti-inflammatory agent, such as Kenalog
  injectable, may be desirable.
• Moderate to severe the joint may need to be
  aspirated and supported, immobilization followed
  by physical therapy, and/or surgical repair.

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Tendons

• White glistening bands of dense fibrous
  connective tissue that attach muscle to bone.
• Tendonitis treatment rest, corticosteroid
  injections, application of ice or heat, and
  support in the form of strapping or splinting.

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Our M/S system provides

• Protection, Support, and Movement
• It deals with the prevention or correction of
  disorders involving M/S locomotor structures of
  the body.
• The ability to perform these functions is closely
  associated with the nervous and circulatory
  systems. Neurovascular assessment becomes very
  important.

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Assessment is necessary when

• Symptoms occurs from trauma of the soft tissue
  and bone
• Difficulty with gait and/or balance occurs
• Muscle weakness or loss of strength is evident

What a sack!
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Contusions

• An extensive, soft tissue injury caused by a
  direct blow or blunt force. A possible hematoma
  and usually ecchymosis (considerable bruising) is
  evident.
• Name some types of accidents that could cause
  contusions.

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Diagnostic Test Screening

• Myleograms
• Magnetic Resonance Imaging (MRI)
• Computed Axial Tomography (C.T.)
• Bone Scans

• Arthroscopy and/or Repair
• Synovial Fluid Aspiration - Arthrocentesis
• Electromylogram -(EMG)

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Myelograms

• Radiopaque dye is injected into the subarachnoid
  space of the lumbar spine.

Lets take a closer look!
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Neurovascular Assessment Using A Myelogram Study

• Dianne, age 25, has had c/os severe pain in her
  lumbar spine that intermittently radiates down
  her left leg. Parasthesia is present in the
  affected leg. Her orthopaedic physician decides
  to order an invasive myelogram study to rule/out
  sciatic nerve involvement versus a ruptured
  herniated lumbar disc.

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Before Diannes examination the nurse should

• Explain the test in terminology she will
  understand (laymans).
• Check for any past history of allergies to
  iodine. Ask her if she can eat shellfish like
  shrimp or crab.
• Check medical history hay fever, asthma, or
  eczema (skin) conditions. NEXT

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The physician should be notified when

• there is a yes answer to the medical history
  questioning. A
  desensitization procedure using anti-histamines
  and steroids can be started a day or two before
  hand.

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The patient needs to be informed of the risks
before

• undergoing the procedure or signing the consent
  form. IT IS THE PHYSICIANS ROLE TO
  INFORM THE PATIENT, NOT THE NURSE!
• Damage or paralysis to the spinal cord is a
  possible risk.

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The nurse needs to ask what type of dye was used

• Water-soluble Position the patient in a
  semi-fowlers for a eight hour period.
• There is no need to
  diuresis the pt. and remove the dye afterwards.

• Oil-based Lay the patient flat on their
  backs for twelve hours. The dye must be
  removed to avoid meningeal irritation. And, it
  often causes severe headaches.

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After the myelogram

• Encourage fluids, if tolerated, to help the body
  quickly absorb the dye in the spinal column.
  Remember, this is a foreign material to the
  bodys immune system.
• Watch for headache, stiff neck, difficulty
  voiding, and leg weakness.

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Diannes Diagnosis

• Herniation of L4 and L5, 50 stenosis with
  involved sciatic nerve compression down the left
  leg.
• Laser micro-discectomy was performed.

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Nuclear Bone Scans

• Nuclides (atomic materials) injected by I.V.
  route that are useful in detecting metastatic and
  inflammatory bone diseases.

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Case Study Damage to the knee joints

• Henry Finch, age 27, played high school and
  college football. He sustained previous trauma
  to both knees. Today, his pain is so unbearable
  that he seeks out an orthopaedic specialist who
  diagnoses bilateral degenerative joint disease
  with suspected anterior cruciate ligament and
  medial meniscus damage.

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These test might be ordered to confirm the need
for surgery

• MRI
• Knee Arthroscopy
• Synovial Fluid Aspiration (arthrocentesis)

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Precautions afterwards

• Arthroscopy - Limit activity for several days,
  may use crutches or walker to keep weight-bearing
  limited.
• Arthrocentesis - Elevate, maintain joint rest for
  12 hours. Apply ice 24-48 hrs. Watch for signs
  of infection. Pressure dressings originally
  placed for both.
• Synovial fluid - straw-colored or clear. It
  should not be cloudy.

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ARTHRITIS, AGING, JOINT TRAUMA

• 1. Rheumatoid
• 2. Ankylosing Spondylitis
• 3. Degenerative Joint - (Osteoarthritis)
• 4. Gouty Arthritis

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Rheumatoid (R.A.)

• May become severely crippling
• Usually strikes between the ages of 30 and 55,
  esp. women
• Attacks the synovial membranes of the freely
  moving joints - (Diarthrodial)

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Process of Destruction

• The synovial membranes become masses of
  inflammatory cells - etiology unknown. Some say
  there is a genetic link.
• This then progresses to granulations, scarring,
  and adhesions. The end result can be complete
  immobility of one or more joints.

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Other Characteristics

• Auto-immune reaction causing a chronic
  inflammatory response
• Leads to gross deformity and loss of function
• I.E. Swan-neck deformities of the fingers
• Periods of remission and exacerbation
• Pain, stiffness, and edema of affected joints

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Early symptoms of the disease

• Fatigue
• Soreness
• Stiffness
• Achy feeling
• Low-grade fever
• Hands feet usually involved first

Even favorite hobbies become difficult to
achieve.
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Progressed symptoms of R.A.

• Loss of appetite with weight loss
• Increased fever
• Anemia
• Inflammation of the eyes, lungs, muscle, or skin
  nodules
• Swelling of weight-bearing joints

A Crippling Disease
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Laboratory Tests for R.A.

• Erythrocyte Sedimentation Rate
• Rheumatoid Factor
• Latex Agglutination Test for IgM anti- IgG
  antibodies

• Red Cell Count to detect presence of anemia
• Synovial fluid aspiration

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Goals of Medical Management for Many Arthritic
Conditions

• Relieving pain and inflammation
• Preventing joint damage and deformity
• Promoting ADLs by restoring or main- taining
  function
• Improving patient education

Extreme!
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Arthritic Interventions That Help

• Plenty of rest and daily exercise
• Proper support - firm mattress, bed cradle,
  splints, traction
• Local Arthritis Foundation

• Counseling and support groups to help manage
  stress and depression
• Heat Therapy
• Physical and/or occupational therapy modalities

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Other Important Tips

• PREVENT external rotation of the extremities
• AVOID lengthy hip/knee flexion while sitting
• TAKE hot bathes or showers first thing in the
  morning
• USE self-help devices
• Avoid the use of unproven remedies

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Treatments for arthritis must show that they work
and are safe

• Meets one or more of the following goals
• Reduces pain
• Reduces inflammation
• Keeps joints moving safely

• Avoids stress damage to joints
• Keeps you independent as possible
• People might be desperate enough to try anything!

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Ads often make false or exaggerated claims that
they

• Cure arthritis
• Be natural with no side-effects
• Work for all types of arthritis
• Require NO EFFORT on your part!
• Work for everyone are inexpensive
• Keep you from needing drugs or surgery
• Suspect health fraud when you see these claims
  for a remedy!

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A closer look at heat application

• Uses To increase blood circulation to a
  specific area. To relax and soothe sore, achy
  muscles.
• Types Hot packs, heat lamps, heating pads, and
  paraffin wax hand dips.
• Relocating Move to a dry, warm climate such as
  Arizona or New Mexico.

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More inflammatory disorders Ankylosing
Spondylitis

• Definition Chronic, progressive disorder of
  the sacro-iliac and hip joints, the synovial
  joints of the spine, and adjacent soft tissues.
• Complaints of low backache, sciatica pain and
  stiffness.
• Seen more often in young men.

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Degenerative Joint Disease - (Osteoarthritis)

• Often a consequence of aging after 40 but more
  likely seen at age 65 or older (Accelerated by
  being overweight)
• May lead to a severe and chronic disability later
  in life
• Non-systemic usually non-inflammatory

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DJDs Aging and Trauma Pathophysiology

• Smooth cartilage surfaces soften leaving a
  pitted, frayed, rough surface.
• Loss of elasticity occurs making it easier to be
  damaged by stress trauma.

I keep taking the hits!
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Then...

• Large sections of cartilage may wear down
  completely leaving ends of bones unprotected.
• Without normal gliding surfaces, joints become
  painful to move.
• Bones may actually thicken forming bony growth
  spurs where ligaments and the joint capsule
  attaches to the bone.

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And finally...

• Fluid-filled sacs may appear.
• Hard nodules, especially on the fingers and
  elbows.
• Bits of bone or cartilage can float loosely in
  the joint spaces causing inflammation.

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Causes of DJD

• Trauma, i.e. falls, MVAs
• Infections
• Previous fractures
• Obesity

• Added stress to weight-bearing or damaged joints
• Rheumatoid arthritis
• Occupational
• Poor posture

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Surgical Procedures for Arthritis

• Synovectomy - excision of the synovial membrane
• Arthrodesis - surgical fusion of a joint into a
  functional position
• Arthroscopy repair
• Arthroplasty
• Total Joint Replacement

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Drug Classifications Used for Arthritis

• Salicylates - better known as aspirin
• NSAIAs non-steroidal anti-inflammatory agents
• Non-narcotic analgesics

• Anti-inflammatory - better known as steroids
• Gold Salts
• Anti-malarials
• Anti-Gout

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NSAIAS - Inhibits the action of prostaglandin
activity

• Some of the many names in this class -
• Indocin
• (Ibuprofen) Motrin, Advil, Aleve
• Naprosyn E.C.

• Dolobid
• Feldene
• Day-Pro

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Symptoms of N.S.A.I.AS...

• Prolongs bleeding times
• Frequent gastric irritation
• Peripheral edema
• Systemic Rash
• Adverse reactions peptic ulcer, anemia, bone
  marrow suppression, renal impairment.

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New classification (CELEBREX)

• COX 2 Inhibitor Inhibits prostaglandin
  synthesis of cyclooxygenase-2. Suppose to be
  less irritating to the stomach lining by shunting
  the fluid and reducing HCL. It will increase
  fluid retention elsewhere. Dispensed 100 or 200
  mg. caps. Patients allergic to SULFA
  shouldnt take this medication.
• Vioxx 25 mg. is similar and the newest of this
  classification.

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How effective is Tylenol on inflammatory joint
symptoms?
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Gouty Arthritis

• A metabolic disease resulting from an
  accumulation of uric acid in the blood. Far more
  prevalent in men.
• It takes approx.15 to 20 years for sufficient
  urates to accumulate causing S/S.

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Characterized by Tophi

• Stones containing sodium urate deposits in large
  quantities. Typically, the big toes are
  involved.
• Excruciating pain and swelling no matter which
  joint is affected.

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Restricted from diet foods high in purines

• Organ Meats brain, kidney, liver, and heart.
• Anchovies, yeast, herring, mackerel, and scallops.

Youre not incising my brain!
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Anti-Gout Medications

• Colchicine - decreases urate crystal deposits
• Butazolidin and Indocin - anti-inflammatory
• Allopurinol (Zyloprim) - decreases the production
  of uric acid
• Probenecid (Benemid) - increases the excretion
  of uric acid

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Trauma in the ER
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Sprains

• A wrenching or twisting motion to a joint. Signs
  of edema, limited R.O.M., and bruising present.
• Wrists and ankles are the most common areas to be
  affected.

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Dislocations

• Trauma causing temporary displacement of a bone
  end from its original position of alignment
  within a joint (hip or shoulder).
• Immediate pain, deformity, and loss of function
  is evident. Manual manipula- tion is necessary
  by trained personnel.

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Rotator Cuff Tears

• Damage to the shoulder muscle group by repetitive
  lifting, pitching, or quarterbacking. Definitely
  a sports related injury most of the time.
• An elderly person could sustain this injury by
  falling direct and hard on the either shoulder.

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Intervertebral Herniated Disc

• Rupture of the fibrocartilage that surrounds the
  vertebrae that it cushions.
• One of the most common causes is from compression
  or arthritic changes in the spinal column caused
  by previous trauma.

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Whiplash (neck)

• Injury that involves hyperextension and/or
  compression fracture to the cervical vertebrae.
  Most often caused by a MVA (motor
  vehicle accident).

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Strains

• Microscopic muscle tears as a result of
  overstretching muscles and tendons. The
  lumbar-sacral area is often involved.
• Most often caused by not warming up
  (stretching a muscle group) before an activity or
  exercising.

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Pathological or spontaneous fractures

• Fractures that occur without related trauma
  caused by weakened bone.
• Metastatic tumors, osteoporosis, long-term
  steroid use are the main reasons.

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Medications for Trauma Patients

• Relief for Muscles, Joints, Tendons, and Ligaments

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Motorcycles are sometimes DONOR cycles!
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Skeletal Muscle Relaxants

• Used for trauma to the M/S system, post-surgery,
  or spasticity related to spinal cord injury.
• Assess the patient for pain R.O.M.
  limitations stiffness

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Recognize these manufacturers for this
classification

• Darvon, Flexaril, Norflex, Parafon Forte,
  Robaxin, Skelaxin, Soma, Valium, and Vistaril in
  this classification.
• Very sedating, avoid CNS depressants such as
  alcohol, hyponotics, and anti- anxiety
  medications. Supervise ambulations and
  transfers. May cause dizziness, weakness, and
  hypotension.

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Other classifications used

• Previously mentioned N.S.A.I.A.s,
  anti-inflammatory steroids, non-narcotic or
  narcotic analgesics.
• Toradol injectible works directly on peripheral
  pain sites. Great post-op for leg or arm
  (extremity) discomfort.

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M/S Bone Fractures
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At the time of injury

• Presence of pain, considerable swelling,
  tenderness, muscle spasm, and loss of function.
• Deformity of an extremity may also be observed.

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Fractures are classified four ways first, by
TYPE

• A. Simple - (closed)
• B. Compound - (open) with considerable soft
  tissue damage and a noticeable break in the
  skin integrity.

I broke my right arm sliding into third base!
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II. Appearance

• Comminuted (shattered into many fragments)
• Transverse (completely across)
• Oblique (diagonal)

• Greenstick (hairline) often seen in childrens
  fractures
• Impacted (driven into another long bone)
• Spiral (twisted)

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III. Location

• Proximal
• Midshaft
• Distal

I kind of like the beach for my location
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IV. Displacement

• Sideways
• Override
• Angulate
• Rotate

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How does a fracture heal?

• D. Calcium, cartilage, collagen, and
  osteoblasts form into callus.
• E. Remodeling - Excess callus is reabsorbed
  leaving trabecular bone along lines of
  stress

• A. Hematoma forms from soft tissue bleeding
• B. Fibroblasts soon become a fibrin mesh work
  and a scab forms
• C. WBCs wall off - localizing site of
  inflammation aided by the osteoblasts

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Solid Callus Formation (Weight-bearing)

• Small child 2 to 3 weeks
• Adult 6 to 8 weeks
• Elderly 3 to 4 months

Cities arent built in a day and neither are
bones!
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Symptoms of Bone Fractures

• Crepitus (grating sounds)
• Deformity
• Ecchymosis (bruising)
• Edema
• Impaired Sensation (parasthesia)

• Loss of Normal Function
• Muscle Spasm
• Shock
• Shortening of extremity
• Tenderness/Pain

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Emergency Medical System (EMS) Response

• A TEAM EFFORT FOR A TRAUMATIC ROADSIDE EVENT!

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The Train wreck victim!

• What criteria needs to be present in the
  assessment and data collection to label this
  patient as a train wreck?
• It doesnt mean that theyve been necessarily hit
  by a steam engine train!

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• A long and drawn out rehabilitation is ahead of
  them.
• Sustained multiple injuries lacerations,
  fractures, and contusions to BOTH SIDES of the
  body.

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Truth is better than fiction any day!

• GRANDMA got run over by a golf cart!

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BEFORE SURGERY

• Granny was discovered lying next to the golf cart
  and has an apparent fracture of the right hip.
  And, a shoulder dislocation to the left
  extremity. She doesnt know what really HIT her!

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Preoperatively, the fractures appearance
demonstrates

• Considerable edema and painful muscle spasm
• To be found noticeably shortened and externally
  rotated outward.
• Skin traction will be applied to realign the
  leg and reduce the painful spasms.

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If there were decreased arterial flow to the
affected right extremity, what would the nurse be
observing?

• A. Coolness and pallor
• B. Purplish discoloration
• C. Swelling of the ankle
• D. Throbbing pedal tibial pulses

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Grannys pain

• What should the nurses FIRST action be when she
  has complaints of incisional pain?
• A. Administer PRN. Vistaril.
• B. Assess circulation, motion and
  sensitivity.
• C. Call the surgeon at once.
• D. Change the bed mattress.

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Postoperative ORIF complications to be introduced
in the next unit.

• 1. Pulmonary or fat embolism
• 2. Compartment Syndrome
• 3. Gas gangrene
• 4. Tetanus

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Measures to prevent thrombophlebitis

• Prophylactic anti-coagulation therapy
• ROM exercises
• Early ambulation
• Use of sequential pressure stockings or elastic
  ted hose.

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Fat embolism

• More common following a multiple crushing-type
  fracture.
• Examples include pelvic fractures not
  stabilized on the scene of the accident or a
  motorcycle accident.
• Fat droplets are released from the original
  trauma site into the blood stream.

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This completes the program