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Musculoskeletal System
Overview:
The human musculoskeletal system (also known as the human locomotor system, and
previously the activity system) is an organ system that gives humans the ability to move
using their muscular and skeletal systems. The musculoskeletal system provides form,
support, stability, and movement to the body.

Types of bones:

 Long bone
 short bone
 flat bone
 irregular bone

Sponge bone: is located in the end of

long bone and the centre of flat and
irregular bones.

Dense bone (compact): it covers

spongy bone.

Characteristics of bones:
 It support and protected structures of the bone.
 Provide attachments for muscles, tendons and ligaments.
 Bones assist in regulating calcium and phosphate concentration.

Bone growth: the length of bone growth results from ossification of the epiphyseal
cartilage at the ends of bones. bone growth stops between the age of 18 and 25 years.
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Fracture
Fracture is the break in the continuity of bone caused by any trauma, twisting or bone
decalcification and any disease that result in osteopenia.

Pathological fractures may be caused by metastatic cancer, osteoporosis, or Paget’s disease

Bone is continually going through a process of remodelling as osteoclasts release calcium

from the bone and osteoblasts build up the bone.

This process occurs at equal rates until an individual reaches their thirties. From this age on,
the activity of the osteoclasts outpace the osteoblasts, increasing an individual’s risk of
osteoporosis as he ages. In women, this process significantly increases post-menopausal.
Subsequently, women experience fractures secondary to osteoporosis a decade or so earlier
than men.

Types of fracture:

 Close or simple fracture: skin over the fractured area does not break.
 Open fracture “compound”: skin surface broken and bone is exposed to air. Risk of
infection increases known as osteomyelitis.

Keynote: If compound fracture exist splint the extremity and cover the wound with the
sterile dressing.

 Complete fracture: Whole bone broken as it is separated completely into 2 parts.

 Incomplete fracture: known as green stick fracture. in this partially broken born and
bend to other side.
 Spiral fracture: Spiral: Fracture occurs from twisting motion (common with physical
abuse)

Reported to authorities for further investigation if spiral fracture suspected in children.

 Oblique fracture: publicly broken bone. the fracture line runs at an angle across the
axis of the bone.
 Comminuted “crush” fracture: due to heavy object bone get crushed. it place the client
risk of deadly fat embolism.
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 Compression fracture: due to fall or even jump compression to the bone occur
example supine.

Keynote: when there is open fracture nurse must ensure about when tetanus vaccine
was taken by the patient last time.

Causes and Risk factors:

 Bed rest for long time because it results in bone fracture, loss of muscle tone and
atrophy.
 Osteoporosis- Women who do not use estrogen replacement therapy after menopause
lose estrogen and are unable to form strong new bone.
Clients on long-term corticosteroid therapy lose calcium from their bones due
to inhibition of gastrointestinal calcium absorption, and enhancement of bone
resorption.
 Cancer
 Substance abuse
 Trauma, twisting(abuse)

Keynote: Children tend to heal faster because periosteum is strong, thicker, and flexible
in children.

Sign and symptoms:

 Pain and swelling (bruising)

 Crepitus (grinding sound when
bone and cartilage rub together).
 Muscle spasm and loss of muscle
strength.
 Ecchymosis: Bleeding into
underlying soft tissues from
trauma

Priority findings:

Internal bleeding: hypotension, tachycardia and haematuria.

Initial care of a fracture of extremities:

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 Place the client in supine position

 Stabilize the injured area including the joints above and below the fracture, avoiding
unnecessary movement.
 Remove clothing and jewellery near injury
 Immobilised affected extremity with a cast or splint.
Closed reduction is when a pulling force (traction) is applied manually to realign the
displaced fractured bone fragments. Once the fracture is reduced, immobilization is
used to allow the bone to heal.
Open reduction is when a surgical incision is made and the bone is manually aligned
and kept in place with plates and screws. This is known as an open reduction and
internal fixation (ORIF) procedure
 Assess the neurovascular status of the extremity.
Neurovascular assessment is essential throughout immobilization. Assessments are
performed frequently following initial trauma to prevent neurovascular compromise
related to edema and/or immobilization device. Neurovascular assessment includes
the assessment of
Pain. Assess the client’s pain level, location, and frequency. Assess pain using a 0 to
10 pain rating scale and have the client describe the pain.
Sensation. Assess the client for numbness or tingling sensation of extremity. Loss of
sensation may indicate nerve damage.
Skin temperature. Check the temperature of the affected extremity. The extremity
should be warm, not cool, to touch.
Capillary refill. Press nail beds of affected extremity until blanching occurs. Blood
return should be within 3 seconds.
Pulses. Pulses should be palpable and strong. Pulses should be equal to unaffected
extremity.
Movement. Client should be able to move affected extremity in passive motion.

EXAM Hint - Fractures of bone predispose the client to anemia, especially if long
bones are involved. Check Hct every 3 to 4 days to monitor erythropoiesis

Types of fracture:

1. Basilar skull fracture:

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 In this CSF leakage start = draining from nose (rhinorrhoea). Clear liquid drainage
from nose.
2. Spine fracture (T6 or higher)
 In this neurogenic shock occur due to spine injury. It causes hypotension, bradycardia.
 Skin: pink and dry.
3. Mandibular fracture:
 Bleeding and drooling in the mouth. suction the mouth and oropharynx to protect the
airway.
4. Hip fracture:
 In this shortening of leg on the affected area.
 Muscle spasm around affected areas.
 Ecchymosis on thigh and hip.
 Groin and hip pain with weight bearing.
 Use bucks’ traction (for short term before surgery). Use free hanging weight.

Important points:

 Weight: Free hanging at all times.

 Traction rope tight. Not loose and not resting on bed
floor.
 Reposition: While repositioning hold weight and its ok
to lose strap.

Key point: As an RN you will never reduce or put weight, only HCP prescribed.

 Keep limb in neutral position and assess for skin breakdown.

 Neuro checks on limbs: P, M, S, C.
 Pulse Sensation
 Motor Capillary refill.
 Supine position (flat): Do not elevate head more than 25 degree.
 No semi fowlers or no high fowlers.
 For skin traction: nurse should monitor signs of skin breakdown.

Prioritise the order:

1. Bleeding
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2. Infection
3. positioning education
 Bleeding: If HB less than 7 = Report.
 Monitor pulse distal to injury
 Monitor for hypotension and tachycardia.
 Infection: WBC elevated and assess for drainage: colour, amount, and odour.
 Perform pin care with a sterile solution 3 times in a day.

Keynote: Thick and yellow drainage from pin site indicates infection and notify.

 Position: Total hip arthroplasty.

 Abducted legs: place a pillow between the legs.
 No crossing legs.
 No leaning forward (no tying shoes).
 No sitting in chairs (90-degree angle).
 Toes points upward.

After surgery of internal fixation:

 Turn the patient every 2 hours.

 Provide assistive devices for walking, such as a walker.
 Instruct the patient not to cross legs.
 Elevate head of the bed to 45 degrees.

Complications of fracture:

 Fat embolism syndrome

 Osteomyelitis
 compartment syndrome
 Pulmonary embolism
 avascular necrosis

Fat embolism

Fat embolism is originating in the bone marrow and occurs after a fracture of long bone or
pelvic fracture. in this bone release fat globules into blood stream and cause deadly blockage
in blood vessel. fat embolism can occur within the first 48 to 72 hours following the injury.
findings are similar to pulmonary embolism which include
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 Hypoxemia,
 Mental status change – confusion and restlessness.
 Dyspnea and chestpain
 Tachycardia and hypotension
 Petechiae over Neck and chest indicating lack of oxygen.

sign of resolution of fat emboli is clear mental status.

Interventions:

 Minimise movement of fracture (no blood thinner or compression devices).

 Vital signs and respiratory status are monitored closely and the client is prepared for
intubation and ventilation.
 Oxygen and IV hydration is administered to prevent hypovolemic shock.

Osteomyelitis
It is a bone infection caused by bacteria that entered through open fracture in blood.

sign and symptoms:

 Fever and pain worse with movement

 Pus from puncture site
 Tachycardia
 Leukocytosis and possible elevated sedimentation rate

Intervention:

 Notify the HCP

 Prepare to initiate aggressive, long-term IV antibiotics should be given (weeks and
months). client will go home on pig line (IV) and nurse visit home to administer
antibiotics.
 In severe cases: surgical wounds debridement should be done to drain any abscess or
necrotic dead bone tissue.
 Amputation should be done if condition is worse.

Compartment Syndrome
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Compartment syndrome is a progressive decrease of tissue perfusion occurring as a result of

increased pressure from edema or swelling that presses on the tissues and vessels .
Compartment syndrome occur when pressure increases within one or more compartments
leading to decrease blood flow and results in tissues ischemia and neuro vascular impairment.
it may be reversible within 4 to 6 hours after the onset of compartment syndrome, after that it
is irreversible.

Sign and symptoms:

 Early sign- severe pain unrelieved pain with morphine

 Not resolving with meds
 Extreme pain with passive movement
 Tingling “burning” and numbness for 48 to 72 hours.
 Problem in moving and extending fingers or toes.

Interventions:

 Notify the HCP immediately and assist him.

 “Fasciotomy” should be done by cut tissues to relieve pressure.
 Assess fingers and toes with neuro check “PMSC”
P: pulse - should be strong and bounded not pulseless.
M: movements - with strong grip.
S: sensation - no tingling or numbness
C: capillary refill - note over 3 seconds, not pale or cold.
 Continue to elevate the affected extremity
 loosen tight dressings or restrictive cast.

Pulmonary embolism

Pulmonary embolism is caused by the movement of blood clot or air in the pulmonary
circulation.

Sign and symptoms:

 Restlessness and confusion

 Suddenly an onset of Dyspnea and chest pain
 Cough, haemoptysis, hypoxemia or crackles sound.

Interventions:
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 Notify the hcp immediately if sign of emboli present.

 Administer oxygen and IV anticoagulant therapy.

Cast care:

Cast is a plaster, fiberglass which is used to immobilise bones and joints into correct
alignment after a fracture.

Interventions:

 Priority is to identify compartment syndrome because in first 6 hours it should be

cured.
 6 P’s of cast care:
 Pain
 Paresthesia
 Poikilothermia
 Palor
 Paralysis
 Pressure
 Identify hotspot areas – “hot area” “hot feeling” “foul order” and report to HCP.

Cast care: “CAST”

C: Clean and dry “never wet”- cover cast with plastic bag before bathing.

Plastic coverings over the cast can be used to avoid soiling from urine or feces.
Demonstrate how plastic bags can be used during baths and showers to keep cast dry

A: After cast application, position the client so that warm, dry air circulates around and under
the cast (support the casted area without pressure under or directly on the cast) for faster
drying and to prevent pressure from changing the shape of the cast. Use gloves to touch the
cast until the cast is completely dry.

Elevate cast above the level of the heart during the first 24 to 48 hr to prevent swelling.

S: Scratch an itch? - Itching under the cast can be relieved by blowing cool air from a hair
dryer under the cast.

T: take it easy- Not bearing weight on plaster cast specially for first few hours.

No finger indentation or pressure.

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 No hard surfaces under leg, it change shape of cast.

 If any drainage is seen on the cast, it should be outlined, dated, and timed, so it can be
monitored for any additional drainage.
 Clients are instructed not to place any foreign objects under the cast to avoid trauma
to the skin

Rheumatoid Arthritis
It is a chronic systemic inflammatory disease in which body attack its own joints Causing
inflammation and deformity. Rheumatoid arthritis leads to destruction of connective tissue
and synovial membrane within the joint. It also involves other organs like skin, eyes and
lungs. It occurs in any age common in early age.

 Causes- Female gender (3:1 compared to male clients)

 Age 20 to 50 years (more in young age)
 Epstein-Barr virus

Diagnostics:

 Difficult to diagnose because symptoms

mimic other disease.
 X-ray and MRI should be done
 Synovial fluid aspiration
 Arthroscopy

Blood test:

 Rheumatoid factor positive, Rheumatoid

factor antibody Diagnostic level for
rheumatoid arthritis is 1:40 to 1:60 (expected reference range 1:20 or less).
 ESR - Elevated ESR is associated with the inflammation or infection in the body.
20 to 40 mm/hr is mild inflammation.
40 to 70 mm/hr is moderate inflammation.
70 to 150 mm/hr is severe inflammation.
 CRP
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 EXAM Hint-
 Exam Hint-
A client comes to the clinic complaining of morning stiffness, weight loss, and
swelling of both hands and wrists. Rheumatoid arthritis is suspected. Which methods
of assessment might the nurse use, and which methods would the nurse not use? Use
inspection, palpation, and strength testing. Do not assess range of motion (ROM);
this activity promotes pain because ROM is limited

Sign and symptoms:

 Small joints are more involved usually all joints (symmetrical)

 Early signs of RA (fatigue, joint discomfort) are vague and can be attributed to other
disorders in older adult clients
 Anorexia (weight loss)
 Morning joint stiffness.
 Severe:
 Symmetrical pain and swelling in the small joints of the hands
 Fingers: swan neck and a boutonniere deformity.
 Contractures of joints
 Joint pain at rest and relief with activity. So, help patient to conserve energy
 Synovial tissue biopsy reveals inflammation

Treatment

 Provide NSAIDS Taken with food to prevent from upset stomach.

 Methotrexate
 Side effects weak immune system, low platelet counts and fatal death.

Important point of methotrexate:

 No pregnancy no trade off baby until three months after treatment with methotrexate.
 No live vaccine and crowds.
 No hard brush and razors.
 Infection and bleeding may occur so report fever
 Avoid fresh fruits and flowers
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 Teach patient to get flu or pneumonia vaccines are OK because they are inactive.
 Thrombocytopenia
 Report bleeding: Petechiae, purpura, bleeding gums, melena and hematemesis.
 Steroids are given in rheumatoid arthritis
 Hydro chloroquine When given for treatment it can cause retinal degeneration.

Education

 Assist the client to identify and correct safety hazards in the home.
 Provide patient control analgesics to the patient and assess pain level.
 Do not elevate the knees with pillow at night
 Do not exercise painful, swollen joints.
 Do not exercise any joint to the point of pain.
 Perform exercises slowly and smoothly; avoid jerky movements.
 Ask patient to do low impact exercise example swimming. Avoid weight bearing
exercises.
 Provide heat and cold applications to affected joints alternatively.
Morning stiffness (hot shower). Hot shower is generally recommended to these
clients.
Pain in hands/fingers (heated paraffin)
Edema (cold therapy)
 Take warm showers or bath before bed. It provides relief to the patient.
 Instruct the client in energy conservation measures.
 Teach patient about the balance between rest and activity.
 And go teach the client to verbalize their feelings.
 This is the client with self-care activities and grooming.

Osteoarthritis degenerative joint disease

It is the deterioration of articular cartilage. (OA) is characterized by a degeneration of
cartilage, a wear-and-tear process. B. It usually affects one or two joints. C. It occurs
asymmetrically. D. Obesity and overuse are predisposing factors.
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Causes and risk factors:

 Older age
 Obesity
 Smoking
 Repetitive stress on joints
 Genetic changes
 It mainly occur in late age.

Sign and symptoms:

 Pain worse in the evening

 Crepitus sound crunch sound
 Pain more with activity and relief with rest
 Effect on usually larger joints and node formation:
 Heberden’s node
 Bouchard’s nodes
 Joint swelling, crepitus and limited range of motion
 Inability to perform activities of daily living

Diagnostics

 RH factor negative
 ESR and CRP normal.

Treatment:

 Provide NSAIDS to the patient

 Steroids should be given. Corticosteroids are given via intra articular injection not
orally for osteoarthritis.
 Provide glucosamine to reduce pain and tenderness. Watch for hypoglycaemia when
taken with anti-diabetic meds.
 Bisphosphonates- Alendronate it decreases bone reabsorption and decrease the risk
of fracture.
 It inhibits osteoclast activity by stopping bone reabsorption.

Key points:
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 Monitor bone density regularly

 Take an empty stomach because it causes Esophagitis.
 Instruct the client to take with full glass of water, take 30 minutes before food or other
medications, and remain upright for at least 30 minutes after taking.
 Calcium carbonate in divided doses less than 500MG. Because over 500MG at one
time not absorbed by body.
 Take magnesium and vitamin D for calcium absorption

Side effects:

 Constipation (normal and expected) Take fluids and ambulation only.

 Ask patient to do weight bearing exercises and frequent ambulation

Intervention:

 Administer medications as prescribed such as acetaminophen.

 Position joint in function position and avoid flexion of knees and hips.
 Immobilize the affected joint with a splint or brace until inflammation subsides.
 Ask patient to apply heat or cold applications alternatively.
 Encourage adequate rest and well-balanced diet.
 Maintain weight within normal range to decrease stress on the joint.
 Teach patient the importance of balance between rest and work.
 Teach regular exercise program. ROM exercise several times a day
 Regular weight-bearing exercises promote bone formation
 Provide diet that is high in protein, calcium, and vitamin D; discourage use of alcohol
and caffeine
 Create a hazard-free environment.
 Keep bed in low position.
 Encourage client to wear shoes or non-skid slippers when out of bed.
 Encourage environmental safety. 1. Provide adequate lighting. 2. Keep floor
clear. 3. Discourage use of throw rugs. 4. Clean spills promptly.

Surgery
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 Total knee replacement

 Osteotomy

Post operative interventions:

 Big risk of DVT

 Elevate entire leg above heart
 Never place below under the new operative knee because this cause blood stasis.
 Early weight bearing ambulation and flexing the foot every hour.
 Prevent DVT by giving blood thinner like heparin and warfarin.

Osteoporosis
It is a metabolic disease characterized by bone demineralization, with loss of calcium and
phosphorus leading to fragile bone which cause big holes inside bone. It occurs because of
increased bone reabsorption. It may be either primary or secondary.

Primary osteoporosis

 Most often occurs in post-menopausal women, and men with low testosterone level.

Secondary osteoporosis

 It may occur with prolonged use of corticosteroids, thyroid reducing medications.

Risk factors and causes:

 Female gender. Postmenopausal

women are at highest risk.
 Older age
 Post or early menopause
 Cigarette smoking and excess
caffeine
 Family history
 Decrease in oestrogen
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 Insufficient intake of calcium

 Sedentary lifestyle
 Caucasian And Asian population
 Medications like anti-convulsant and steroids.
 Diseases like hyperparathyroidism, Cushing syndrome, diverticulitis
 Weight bearing exercises

Sign and symptoms:

 Porous bone Cause fracture

 Loss of height, often 2 to 3 inches
 Kyphosis (dowager’s hump)
 Back pain, Pelvic or hip pain
 Problems with balance
 Degeneration of lower thorax and lumbar vertebrae.

Keynote: the client with osteoporosis is at risk for pathological fractures.

Treatment:

 Provide vitamin D and calcium supplements

 Bisphosphonates- Alendronate it decreases bone reabsorption and decrease the risk
of fracture.
 It inhibits osteoclast activity by stopping bone reabsorption.

Key points:

 Monitor bone density regularly

 Take an empty stomach because it causes Esophagitis.
 Instruct the client to take with full glass of water, take 30 minutes before food or other
medications, and remain upright for at least 30 minutes after taking.
 Calcium carbonate in divided doses less than 500MG. Because over 500MG at one
time not absorbed by body.
 Take magnesium and vitamin D for calcium absorption

Side effects:

 Constipation (normal and expected) Take fluids and ambulation only.

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 Ask patient to do weight bearing exercises and frequent ambulation

Interventions:

 Assess for risk and prevent injury in the client’s personal environment
 Provide rubber mats in showers
 Ask patient that halls should be well lighted.
 Assist with ambulation if the client is unsteady
 Instruct the client in the use of correct body mechanics.
 Ask patient to stop bad habits like smoking and caffeine.
 Instruct the client to maintain an adequate fluid intake to prevent renal calculi.
 Move the client gentle even turning and repositioning.

Gout
This is a systemic disease in which uric acid build up in joints and other body tissues which
caused pain and inflammation inside joints. It causes destruction inside joints and lead to
arthritis.

It is a systemic disorder caused by hyperuricemia (increase in serum uric acid). Urate levels
can be affected by medications, diet, and overproduction in the body. This can cause uric
crystal deposits to form in the joints, and a gout attack can occur.

Causes and risk factors:

 Genetic overproduction of uric acid

 High purine food meat, alcohol, and seafood.
 Meats chicken, steak, and liver
 Alcohol vine, beer, and liquor
 Seafood crabs, Lobster, shrimp,
and pulses.
 No cashew
 Overweight
 Stress
 Dehydration
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Diagnostics:

 Serum uric acid level increases

Treatment:

 Allopurinol to prevent gout does not take for acute gout attacks
 Colchicine For acute gout attacks does not provide pain relief
 These drugs are not used to reduce pain but reduce uric acid level and inflammation.
 NSAIDS Used for pain relief.
Allopurinol:
 Stop taking if mild rash occur and report HCP Because it caused deadly Steven
Johnson syndrome.
 Increase fluids and take with full glass of water
 Avoid in clients with kidney and liver disease
 Monitor lab liver, renal function
 Evaluation of effectiveness by checking normal uric acid level. It may take several
months to work.

Interventions:

 Avoid high protein food

 Increase fluid intake OF2000ML per day to prevent stone formation
 Encourage patient to lose weight
 Increase urine pH by eating alkaline ash foods.
 Provide by dressed during acute attacks
 Provide heat or cold applications alternatively to affected joint.

Amputation
Amputation is cut off body parts by surgical procedure that turns into gangrenes tissues. It is
very common in diabetic patient, crushing injury, burns, below knee amputation (results in
better circulation and healing).
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Post op interventions:

 Monitor for signs of complications.

 Mark bleeding and drainage on the dressing if it occurs.
 To prevent hip flexion contractures, do not elevate the
residual limb on a pillow after 48 hours postoperatively
 After 24 to 48 hours postoperatively, position the client
prone to stretch the muscles and prevent hip flexion
contractures.
 Keep limb in dependent position.
 Wrap figure 8 pattern to prevent restrict blood flow
during paracentesis.
 Phantom limb pain – Be aware that phantom pain is
real; it will eventually disappear, and it responds to pain
medication.
 Put patient in front of mirror.
 Maintain surgical application of dressing, elastic compression wrap to reduce swelling
and minimise pain and mold the residual limb in preparation for prosthesis.
 Encourage independence in self-care, allowing sufficient time for client to complete
care and to have input into care.
 Encourage verbalization regarding loss of the body part and assist the client to
identify coping mechanism to deal with loss.

Interventions for below-knee amputation:

 Prevent edema. Assess for redness and irritation.

 Do not allow the residual limb to hang over the edge of the bed.
 Discourage long periods of sitting to lessen complications of knee flexion.
 Wash limb everyday with soap and water. Expose to air.
 Place the client in prone position 30 minutes x 3 times/ day.
 Push stump into the bed.
 Limb socks and wraps: clean and dry.

Interventions for above knee amputation:

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 Prevent internal or external rotation of limb.

 Place a sandbag, rolled towel along the outer side of the thigh to prevent external
rotation.
 Place the client improve position throughout the day.

Keynote: Put tourniquet if haemorrhage occur and call HCP.

In case of emergency or traumatic amputation:

 Call 911
 Stay with the victim, check amputation site and apply direct pressure (remove applied
pressure dressing to prevent dislodging of a formed clot).
 Elevate the extremity above heart level.
 If fingers were amputated, place them in ice water but not directly. put a sealed plastic
bag over the hand.

Scoliosis
Scoliosis is an abnormal curvature of the spine (backbone). There is a natural, forward-and-
backward curve to the spine. With scoliosis, the spine rotates and develops a side-to-side
curve. It often noted during growth spurt just before a child attains puberty.

“S” shaped spine – “lateral curvature”

Causes and risk factors:

 Exact course is unclear

 Intervertebral disc deformity
 Neuromuscular disorder (cerebral
palsy and muscular dystrophy)
 Marfen syndrome (genetic disorder
that affects connective tissues).

Note: Teach patient to avoid participating

in contact sports.
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Sign and symptoms:

 Hard to move because of stiffness

 Mild to severe pain
 Deformity of the chest cavity
 First noticed during periods of rapid growth specially in adolescent females age 10-
12.
Screening is done for school going girls and boys (13-14).

Diagnostics:

 Physical examination (Cobb’s angle measure).

 X ray

Treatment:

 limited physical exercise but range of motion maintained.

 Assist patient for social interaction (visit friends), to prevent isolation.
 Fixing braces: Boston brace - Wear cotton shirt under the brace at all times.

Exam Hint- Orthopaedic wounds have a tendency to ooze more than other
wounds. A suction drainage device usually accompanies the client to the
postoperative floor. Check drainage often.
Assess suture line for erythema and edema.
Assess suction drainage apparatus for proper functioning.
Assess for signs of infection.

Fractured Hip
Fracture in the upper part of the femur, the upper bone of the thigh that extends from hip to
knee.

Hip fractures are the most common injury in older adults and are usually associated with
falls.
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Types of hip fracture:

 Intracapsular (Femoral head is broken within the joint capsule).

femoral head and neck receive decreased blood supply so healing is very slow. skin traction
is applied preoperatively to reduce the fracture and decrease muscle spasm.

Surgery: Total Hip Replacement (THR), ORIF with femoral head replacement.

 Extracapsular (Fracture is outside the joint capsule).

fracture can occur at the greater trochanter or can be an

intertrochanteric fracture. skin traction is applied
preoperatively to relieve muscle spasm and reduce pain.

Surgery: ORIF with nail plate, screws, pins, or wires.

Post op interventions:

 Separate room because of infection chances.

 Monitor for signs of delirium i.e. not oriented to time,
place and person. (this is because of anesthetic meds,
old age or previous psychiatric problem). So, patient
forgot about surgery.
 Maintain leg and help in proper alignment to prevent internal or external rotation and
avoid extreme hip flexion (not 90-degree angle) because it place patient at risk of
dislocation
 Position: abduction (pillow place between legs), not crossed legs, feet pointing
upwards.
 Use elevated toilet seat and chairs with high seats for those who have had hip or knee
replacements (prevents dislocation)
 Follow the HCP prescriptions regarding turning and repositioning (turn on unaffected
site but only with physician’s order).

EXAM Hint - After hip replacement, instruct the client not to lift the leg upward from a
lying position or to elevate the knee when sitting. This upward motion can pop the
prosthesis out of the socket
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 Elevated the head of bed 30 to 45 degree for meals only. Not sit on toilet seat, offer
bed pan.
 Wait for doctor’s order for ambulation.
ask client to use walker after order.
(Weight bearing is often restricted after
ORIF and may not be restricted after
THR.
 Monitor for wound infection or
haemorrhage.
 Monitor and record drainage amount, which decrease consistently.
 Neurovascular assessment should be done frequently
 anti embolism stockings aur sequential compression stocking as prescribed to reduce
the risk of DVT.

Total knee Replacement

It is the implantation of a device 2 substitute for the femoral condyles and tibial joint
surfaces.

Post operative interventions:

 Monitor for evidence of incisional infection (fever,

increased redness, swelling, purulent drainage)
 The client requires extensive physical therapy to
regain mobility. The client can be discharged
home or to an acute rehabilitation facility. If
discharged home, outpatient or in-home therapy
must be provided. Home care should be available
for 4 to 6 weeks.
 Avoid leg dangling
 Ambulation done on very next day. Administer analgesics before continuous
passive movement to decrease pain.
 Weight bearing with an assistive device is prescribed as tolerated.
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 Administer antibiotics within a specified time frame.

Crutch and Cane Training

1. Safe crutch use:
 Weight should be on hands and arms.
 Not Armpits- injury to the brachial plexus nerves. always assess hands and arms
strength before crutch training. There should be two to three finger widths between
the axilla and the top of the crutch
 Do not use someone's else crutches.
2. Technique Gait:
 Step 1: both crutches forward with injured leg.
 Step 2: move unaffected leg forward.

3 types of gaits:

 2-point gait
 3-point gait
 4-point gait: most advanced gait and most closely resembles normal walking. it is
used in the case of one leg weakness.
3. Stairs:
 Up with the good leg = upstairs
 Down with the bad leg = downstairs

Steps:

 Place body weight on crutches.

 Advance the unaffected leg (good) onto the stairs.
 Shift weight from crutches to unaffected leg.
 Bring the crutches and the affected leg up to the
stairs.
 Steps for going down:
 Crutches and affected leg (bad) down followed by the unaffected leg.
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Correct cane use:

 Stronger side hold the cane.

 Move cane first and weaker leg second.
 The top of the cane should be at the level of the greater trochanter.