Text book of Orthopedic Nursing by RS Mehta

Text Book of
Orthopedic Nursing
[Muskelo-Skeleton System Disorders]
Prof. Dr. Ram Sharan Mehta
Available at:
www.slideshare.net/rsmehta
RS Mehta

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Text Book of
Orthopedic Nursing
[Muskelo-Skeleton System Disorders]
Prof. Dr. Ram Sharan Mehta
College of Nursing, Medical-Surgical Nursing Department
BP Koirala Institute of Health Sciences, Nepal
[For: B.Sc. Nursing, M.Sc. Nursing,
MN, BNS & CN Students of TU, PU,
KU, CTEVT & BPKIHS]

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About the Author
Prof. Dr. Ram Sharan Mehta, is currently working in the post of Professor in Medical Surgical
Nursing Department in College of Nursing, BP Koirala Institute of Health Sciences, and
involved in Nursing Profession for more than 30 years. He has vast experiences of teaching
Medical-Surgical Nursing to the Undergraduate and Post Graduate Nursing Students. He
has great experiences of teaching Basic Nursing Concepts, Leadership and Management,
Nursing Research, Nursing Education to both Under-graduate and post-graduate nursing
students. He had experiences of teaching Oncology Nursing to M. Sc. Nursing, B.Sc.
Nursing students, Post Basic BN and Certificate Nursing students. He has conducted many
research related to medical-surgical nursing contents and Presented Papers on various
scientific sessions of national as well as international conferences. He has completed his
B.N. from Nursing Campus Maharajganj with distinction and M.Sc. nursing from Punjab
University (PGIMER, Chandigarh) India. He has completed his PhD from Tribhuvan
University Kathmandu Nepal.
He has worked in Bir-hospital, Rukum hospital, Eastern Regional Hospital, Koshi Zonal
Hospital, BPKIHS and visited various nursing colleges of Nepal and India. He has presented
papers in scientific forms and participated in national as well as international conferences
at Australia, Singapore, Hong Kong, Australia, Switzerland, Belgium, France, Belgrade,
USA, South Korea, Sri-Lanka and most of the city of India. He has been awarded with
“Vice-Chancellor Gold Medal–1997, Mahendra Bidya Bhushan GA & KA, Mera devi Rana
Gold Medal– 1997” due to his outstanding performance in nursing education. He has also
written the books: Basic Nursing Concepts, Handbook of Diagnostic Procedures,
Leadership and Management, Nursing Research, Entrance Guide for nurses, Nursing
Education, Oncology Nursing. This book Orthopedic Nursing covers almost all topics of
Muskulo-Skeletion Disorder or orthopedic nursing and provides useful tips for nursing
students as well as nurses. This book will be very useful for graduate and undergraduate
students of TU, PU, KU, BPKIHS and other health professionals involved in the care of
medical-surgical nursing patients. This book covers all the course contents of B. Sc.
Nursing and BNS students of all the universities of Nepal. This books also covers all the
contents of M.Sc. Nursing/MN and the book will be also beneficial for certificate nursing
students. The constructive feedback from the students and teachers will be highly
appreciated.

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Table Contents:
1. Fractures =4
2. Trauma to Bone, Joints & Ligaments: Sprain, Strain and
Dislocations = 29
3. Traction = 40
4. Plaster Cast =44
5. Spinal Cord Injuries (SCI) = 48
6. Metabolic Bone Diseases: Osteoporosis, Osteomalasia, Paget’s
Disease = 66
7. Osteomyelitis =76
8. Arthritis: Rheumatoid, Osteoarthritis =87
9. Nerve Injuries = 100
10. Tuberculosis of Bones and Joints = 102
11. Amputation = 109
12. Ankylosing Spondylitis = 118
13. THR, TKR, Shoulder Replacement = 128
14. Auto-immune Disorders of Bone: Rheumatoid Arthritis = 154
15. Orthotics, Prosthetics, Rehabilitation, Physiotherapy, Occupational
Therapy = 165
16. Exercise and Walking Aids = 186
17. Low Back Pain = 199
18. Bone Cancer = 212
19. Hospice Care, Palliative Care and Pain Management = 215

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Orthopedic Nursing
1. Fracture
Fracture:
Fracture is the act or process of breaking or the state of being broken especially, the breaking of
hard tissue (such as bone). It is a break in the continuity of a bone that occurs when the forces from
outside the body are greater than the strength of the bone, causing the bone to break. These may
be the result of direct force, torsion or twisting, or violent contractions of highly developed
muscles.
Epidemiology: The most common fracture prior to age 75 is a wrist fracture. In those over age 75,
hip fractures become the most common broken bone. More than 40% of fractures occur at home
(22.5% inside and 19.1% outside). Approximately 6.3 million fractures occur each year in the U.S.
Fractures occur at an annual rate of 2.4 per 100 populations. Men are more likely to experience
fractures (2.8 per 100 populations) than women (2.0 per 100). After age 45, however, fracture rates
become higher among women. Among persons 65 and over, fracture rates are three times higher
among women than men. There are approximately 3.5 million visits made to emergency
departments for fractures each year.
Classification of fractures:
On the basis of aetiology:
– Traumatic fracture: A fracture sustained due to trauma is called a traumatic fracture. Normal
bone can withstand considerable force, and breaks only when subjected to excessive force.
Most fractures seen in day-to-day practice fall into this category e.g., fractures caused by a fall,
road traffic accident, fight etc.
– Pathological fracture: A fracture through a bone which has been made weak by some
underlying disease is called a pathological fracture. A trivial or no force may be required to
cause such a fracture e.g., a fracture through a bone weakened by metastasis. Although,
traumatic fractures have a predictable and generally successful outcome, pathological fractures
often go into non-union.

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– Stress Fracture: This is a special type of fracture sustained due to chronic repetitive injury
(stress) causing a break in bony trabeculae. These often present as only pain and may not be
visible on X-rays.
On the basis of displacements
– Undisplaced fracture: These fractures are easy to identify by the absence of significant
displacement. Displacement of the fracture is defined in terms of the abnormal position of the
distal fracture fragment in relation to the proximal bone.
– Displaced fracture: A fracture may be displaced in relation to the proximal bone. The
displacement can be in the form of shift, angulation or rotation.
– The factors responsible for displacement are:
 The fracturing force;
 The muscle pulls on the fracture fragments;
 The gravity.
On the basis of relationship with the external environment:
a) Closed fracture: A fracture not communicating with the external environment, i.e., the
overlying skin and other soft tissues are intact, is called a closed fracture.
Tscherne classification of closed fractures
– Grade 0: There is no or minor soft-tissue injury with a simple fracture from indirect
trauma. E.g. spiral fracture of the tibia in a skiing injury.
– Grade I: There is superficial abrasion or skin contusion, simple or medium severe fracture
types. A typical injury is the pronation-external rotation fracture dislocation of the ankle
joint. The soft-tissue damage occurs through fragment pressure at the medial malleolus.
– Grade II: There are deep contaminated abrasions and localized skin or muscle contusions
resulting from direct trauma. The imminent compartment syndrome also belongs to this
group. The injury results in transverse or complex fracture patterns. A typical example is
the segmental fracture of the tibia from a direct blow by a car fender.
– Grade III: There is extensive skin contusion, destruction of muscle or subcutaneous tissue
avulsion (closed degloving). Manifest compartment syndrome and vascular injuries are
included. The fracture types are complex.
b) Open fracture: A fracture with break in the overlying skin and soft tissues, leading to the
fracture communicating with the external environment, is called an open fracture. A fracture
may be open from within or outside, the so called internally or externally open fracture
respectively. Exposure of open fracture to the external environment makes it prone to infection.
This risk is more in externally open fracture.

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Internally open (from within): The sharp fracture end pierces the skin from within, resulting
in an open fracture.
Externally open (open from outside): The object causing the fracture lacerates the skin and
soft tissues over the bone, as it breaks the bone, resulting in an open fracture.
Gustilo-Anderson Classification for open Fracture:
– Grade I: Skin wound that communicates with the fracture measuring less than one
centimeter. Sometimes it is difficult to assess if a fracture is open, this can be determined by
injecting fluid into the fracture site, and seeing if the fluid exits from the wound.
– Grade II: Have larger soft-tissue injuries, measuring more than one centimeter.
– Grade III: Represent the most severe injuries and include three specific sub-types of injuries:
– Grade IIIA: Include high-energy fractures as evidenced by severe bone injury (segmental or
highly comminuted fractures) and/or large, often contaminated, soft-tissue wounds. Most
surgeons classify high-energy fractures as 3A even if the skin wound is not large.
– Grade IIIB: Soft-tissue damage/loss such that bone is exposed, and reconstruction may
require a soft-tissue transfer (flap) to be performed in order to cover the wound.
– Grade IIIC: specifically require vascular intervention as the fracture is associated with
vascular injury to the extremity.
On the basis of complexity of treatment:
Simple fracture: A fracture in two pieces, usually easy to treat, is called simple fracture, e.g. a
transverse fracture of humerus.
Complex fracture: A fracture in multiple pieces, usually difficult to treat, is called complex
fracture, e.g. a comminuted fracture of tibia.
On the basis of quantum of force causing fracture:
– High-velocity injury: These are fractures sustained as a result of severe trauma force, as in
traffic accidents. In these fractures, there is severe soft tissue injury (periosteal and muscle
injury). There is extensive devascularization of fracture ends. Such fractures are often unstable,
and slow to heal.
– Low-velocity injury: These fractures are sustained as a result of mild trauma force, as in a
fall. There is little associated soft tissue injury, and hence these fractures often heal predictably.
Lately, there is a change in the pattern of fractures due to shift from low-velocity to high-
velocity injuries. The latter gives rise to more complex fractures, which are difficult to treat.
On the basis of pattern:

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– Transverse fracture: In this fracture, the fracture line is perpendicular to the long axis of the
bone. Such a fracture is caused by a tapping or bending force.
– Oblique fracture: In this fracture, the fracture line is oblique. Such a fracture is caused by a
bending force which, in addition, has a component along the long axis of the bone.
– Spiral fracture: In this fracture, the fracture line runs spirally in more than one plane. Such a
fracture is caused by a primarily twisting force.
– Comminuted fracture: This is a fracture with multiple fragments. It is caused by a crushing
or compression force along the long axis of the bone.
– Segmental fracture: In this type, there are two fractures in one bone, but at different levels.
A fracture may have a combination of two or more patterns. For example, it may be a
comminuted but primarily a transverse fracture.
– Greenstick fracture: A greenstick fracture occurs when a bone bends and cracks, instead of
breaking completely into separate pieces and the structural integrity of the convex surface is
overcome. This kind of fractures are usually seen in children less than 10 years of age. The
fracture looks similar to what happens when you try to break a small, "green" branch on a tree.
– Compound fracture: A fracture in which a bone is sticking through the skin and causes injury
to the overlying skin. It is also known as an open 'fracture.
Etiology of fracture:
Trauma: A fall, a motor vehicle accident or a tackle during a football game can all result in a
fractures.
Osteoporosis: This disorder weakens bones and makes them more likely to break. This is the
common cause of pathological fractures.
Overuse: Repetitive motion can tire muscles and place more force on bone. This can result in
stress fractures. Stress fractures are more common in athletes.
Causes of pathological fractures
Localized Diseases:
Inflammatory
• Pyogenic osteomyelitis
• Tubercular osteomyelitis
Neoplastic
• Benign tumors: Giant cell tumour, Enchondroma
• Malignant tumours
Inflammatory
• Pyogenic osteomyelitis
• Tubercular osteomyelitis
Neoplastic
- Benign tumors: Giant cell tumour, Enchondroma
• Malignant tumours

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- Primary: Osteosarcoma, Ewing's tumour
- Secondary
In males: lung, prostate, kidney
In females: breast, lung, genitals
Miscellaneous
• Simple bone cyst
• Aneurysmal bone cyst
• Monostotic fibrous dysplasia
• Eosinophilic granuloma
Bone atrophy secondary to polio etc.
Generalised Diseases
Hereditary
• Osteogenesis imperfecta
• Dyschondroplasia (Ollier's disease)
• Osteopetrosis
Acquired
• Osteoporosis
• Osteomalacia
• Rickets
• Scurvy
• Disseminated malignancy in bones
- Multiple myeloma
- Diffuse metastatic carcinoma
• Miscellaneous
- Paget's disease
• Polyostotic fibrous dysplasia
Risk factors of fractures:
a. Age
The bone mineral density reduces as we age. But age can also be a risk factor independent of bone
mineral density. In other words, even older adults with normal bone mineral density are more
likely to suffer a fracture than younger people. The majority of hip fractures (90%) occur in people
aged 50 and older.
b. Gender
Women are far more likely to have a fracture than men because women’s bones generally smaller
and less dense than men’s bones. In addition, women lose more bone density than men as they age
because of the loss of estrogen at menopause. Hysterectomy, if accompanied by removal of the
ovaries, may also increase the risk for osteoporosis because of oestrogen loss This hormone is an
important component in bone formation. Women are more likely to sustain osteoporotic fracture
than men.
c. Family History

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A parental history of fracture (particularly a family history of hip fracture) is associated with an
increased risk of fracture that is independent of bone mineral density.
d. Previous Fracture
Previous Low Impact Fractures doubles the risk of having another fracture. Spine (vertebral)
fractures are strong predictors of more spine fractures to come.
e. Smoking
Smoking is a risk factor for fracture because of its impact on hormone levels. Women who smoke
generally go through menopause at an earlier age.
f. Alcohol
Drinking alcohol in excess can influence bone structure and mass. Chronic heavy drinking during
a person’s earlier years can compromise bone quality and may increase the risk of bone loss and
potential fractures even after drinking has stopped. Excessive consumption of alcohol affects
vitamin D metabolism and the risk of falling.
g. Steroids
Steroids (corticosteroids) are often prescribed to treat chronic inflammatory conditions, such as
rheumatoid arthritis, inflammatory bowel disease and chronic obstructive pulmonary disease
(COPD). Long-term corticosteroids use is a very common cause of secondary osteoporosis and is
associated with an increased risk of fracture. These unwanted side effects are dose-dependent and
are directly related to the ability of steroids to hinder the formation of bone, curtail absorption of
calcium in the gastrointestinal tract, and increase the loss of calcium through the urine. Bone loss
occurs more rapidly with steroid use.
h. Rheumatoid Arthritis
In this debilitating autoimmune disease, which strikes two to three times more women than men
the body attacks healthy cells and tissues around the joints, resulting in severe joint and bone loss.
Rheumatoid arthritis and diseases of the endocrine system can take a heavy toll on bones. Steroids,
such as Prednisone, may make life easier, but they can also trigger bone loss. Pain and poor joint
function reduce activity levels, further accelerating bone loss and fracture risk.
i. Diabetes
Typical onset of Type 1 diabetes is in childhood when bone mass is building, and some sufferers
also have celiac disease. The vision problems and nerve damage that frequently accompany
diabetes can contribute to falls and related fractures. In Type 2 diabetes, typically with onset later
in life, poor vision, nerve damage, and inactivity can lead to falls; although bone density is
typically greater than with Type 1 diabetes, bone quality may be adversely affected by metabolic
changes due to high blood sugar levels.
j. Primary or secondary hypogonadism in men
Like estrogen deficiency in women (which is observed in case of primary or secondary amenorrhea
and premature menopause), androgen deficiency in men (primary or secondary hypogonadism)

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increases the risk of fracture. At any age, acute hypogonadism, such as that resulting from
orchidectomy for prostate cancer, accelerates bone loss to a similar rate as seen in menopausal
women. The bone loss following orchidectomy is rapid for several years, then reverts to the gradual
loss that normally occurs with aging.
k. Secondary Risk Factors
Secondary risk factors are less prevalent but they can have a significant impact on bone health and
fracture incidence. These risk factors include other diseases that directly or indirectly affect bone
remodeling and conditions that affect mobility and balance, which can contribute to the increased
risk of falling and sustaining a fracture.
Disorders that affect the skeleton:
 Asthma
 Nutritional/gastrointestinal problems (e.g. Crohn’s or celiac disease)
 Rheumatoid arthritis
 Hematological disorders/malignancy
 Some inherited disorders
 Hypogonadal states (e.g. Turner syndrome/Kleinfelter syndrome, amenorrhea)
 Endocrine disorders (e.g. Cushing’s syndrome, hyperparathyroidism, diabetes)
 Immobility
Medical treatments affecting bone health:
Some medications may have side effects that directly weaken bone or increase the risk of fracture
due to fall or trauma.
 Glucocorticosteroids
 Certain immunosuppressant (calmodulin/calcineurine phosphatase inhibitors)
 Thyroid hormone treatment (L-Thyroxine)
 Certain steroid hormones (medroxyprogesterone acetate, leutenising hormone releasing
hormone agonists)
 Aromatase inhibitors
 Certain antipsychotics
 Certain anticonvulsants
 Certain antiepileptic drugs
 Lithium
 Methotrexate
 Antacids, Proton pump inhibitors
Pathophysiology:
– Stress placed on the bone, exceeds the bone ability to absorb it.

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– Injury in the bone
– Disruption in the continuity of the bone
– Disruption in the continuity of the blood vessels and muscles attached to the end of the
bone
– Soft tissue damage
– Bleeding
– Hematoma formation in the medullary canal
– Bone tissue surrounds the fracture site dies
– Inflammatory response
Clinical manifestations:
The signs and symptoms of a fracture vary according to which the bone is affected, the patients
age and general health as well as the severity of the injury. The common signs and symptoms
include the following:
 Edema and swelling: Disruption of the soft tissue or bleeding into surrounding tissues.
Unchecked edema into closed space can occlude circulation and damage nerves. (risk of
compartment syndrome).
 Pain and tenderness: Muscle spasm as a result of involuntary reflex action of muscle,
direct tissue trauma, increased pressure on sensory nerve, movement of the fracture parts.
Pain caused by swelling at the site, muscle spasm, damage to periosteum. It may be
immediate, severe and aggravated by pressure at the site of injury and attempted motion.
 Loss of normal function: Due to disruption of bone, preventing functional use the injured
parts is incapable of voluntary movement. Fracture must be managed properly to ensure
restoration of normal function.
 Deformity: Obvious deformity resulting from loss of bone continuity. Abnormal position
of bones as a result of original forces of injury and action of muscles pulling fragments into
abnormal position seen as a loss of normal bone contours. Deformity is cardinal sign of
fracture. If incorrected, it may result in problems with bony union and restoration of
function of injured part.
 Excessive motion at site: i. e motion when motion does not usually occur.
 Crepitation: Crepitus or grating sound occurs if limb is moved gently. Grating or
crunching together of bony fragments, producing palpable or audible crunching sensation.
Examination of crepitation may increase chance for nonunion and bone ends are allowed
to move excessively.
 Warmth over injured area resulting from increased blood flow to the area.

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 Ecchymosis: (may not be apparent for several days). This discoloration of skin is a result
of extravasation of blood in subcutaneous tissue. It usually appears several days after injury
and may appear distal to injury. The nurse should reassure patient that process is normal.
 Impairment or loss of sensation or paralysis distal to injury, resulting from nerve
entrapment or damage.
 Signs of shock related to severe tissue injury, blood loss, intense pain.’ When the large
bone is affected such as the pelvis or femur, the sufferer may look pale and clammy. There
may be dizziness, feeling of sickness and nausea.
 Angulation: the affected area may be bent at an unusual angle
 Bleeding: It can be usually seen in an open fracture.
Diagnosis:
X-ray: X-ray imaging produces a picture of internal tissues, bones, and organs. Most fractures are
diagnosed by using an X-ray. X-rays are usually used to confirm if a bone is broken and to find
the locations of any loose bony pieces. Other diseases of the bone can also show up on an x-ray,
such as osteoporosis, Paget’s disease, or compression fractures in the spine.
Bone densitometry: It is another type of low-dose x-ray that helps to detect osteoporosis or
thinning of the bones are present. It is also known as a bone mineral density (BMD) test. BMD
test result (usually of the hip, spine, wrist or heel bone) can be a strong predictor of a future
fracture.
Bone scan: An agent is injected that binds in the area of the fracture where bone turnover is higher
than normal.
Magnetic resonance imaging (MRI): An MRI is a procedure that produces a more detailed
image. It is usually used for smaller fractures or stress fractures. It helps to determine the extent of
associated soft tissue damage.
Computed tomography scan (CT, or CAT scan): A three-dimensional imaging procedure that
uses a combination of X-rays and computer technology to produce slices, (cross-sectional images),
horizontally and vertically, of the body.
Blood tests:
- Hemoglobin and hematocrit values: The hemoglobin level and hematocrit (H/H) level
should be monitored because of the relatively large amount of blood that can be lost into the
compartments of the upper leg. The hematocrit and hemoglobin values may be decreased.
- ESR: ESR values are important in fracture to rule out any fracture related infection and any
other related infection. ESR values is increased if any infection is present.
- Kidney function tests, Calcium levels, Vitamin D levels: Kidney dysfunction is associated
with bone loss, and patients with ESRD have an increased risk for fracture. When kidneys

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do not function properly, extra parathyroid hormone is released in the blood to
moving calcium from bones to the blood.
- Vitamin D is needed to absorb calcium and phosphate into the body, essentials for healthy
bone.
- Thyroid and other hormone levels: Excess thyroid hormones leading to accelerated bone
turnover with bone loss and increased fracture risk.
- Other blood tests to check for certain diseases, such as celiac disease, Paget’s disease, or
multiple myeloma, if any of these disorders are suspected
Bone Healing:
Healing time for fractures is affected by the age of the client and the type of injury or any
underlying disease process, and complete healing may take weeks, months, or even years. The
average healing time for an uncomplicated fracture is 6 to 8 weeks.
The repair of a bone fracture involves the following steps:
 Formation of fracture hematoma. Blood vessels crossing the fracture line are broken. As
blood leaks from the torn ends of the vessels, a mass of blood (usually clotted) forms
around the site of the fracture. This mass of blood, called a fracture hematoma, usually
forms 6 to 8 hours after the injury. Because the circulation of blood stops at the site where
the fracture hematoma forms, nearby bone cells die. Swelling and inflammation occur in
response to dead bone cells, producing additional cellular debris. Phagocytes (neutrophils
and macrophages) and osteoclasts begin to remove the dead or damaged tissue in and
around the fracture hematoma. This stage may last up to several weeks.
 Fibrocartilaginous callus formation. Fibroblasts from the periosteum invade the fracture
site and produce collagen fibers. In addition, cells from the periosteum develop into
chondroblasts and begin to produce fibrocartilage in this region. These events lead to the
development of a fibrocartilaginous callus, a mass of repair tissue consisting of collagen
fibers and cartilage that bridges the broken ends of the bone. Formation of the
fibrocartilaginous callus takes about 3 weeks.
 Bony callus formation. In areas closer to well-vascularized healthy bone tissue,
osteogenic cells develop into osteoblasts, which begin to produce spongy bone trabeculae.
The trabeculae join living and dead portions of the original bone fragments. In time, the
fibrocartilage is converted to spongy bone, and the callus is then referred to as a bony
callus. The bony callus lasts about 3 to 4 months.
 Bone remodeling. The final phase of fracture repair is bone remodeling of the callus.
Dead portions of the original fragments of broken bone are gradually resorbed by
osteoclasts. Compact bone replaces spongy bone around the periphery of the fracture.

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Sometimes, the repair process is so thorough that the fracture line is undetectable, even in
a radiograph (x-ray). However, a thickened area on the surface of the bone remains as
evidence of a healed fracture.
Although bone has a generous blood supply, healing sometimes takes months. The calcium and
phosphorus needed to strengthen and harden new bone are deposited only gradually, and bone
cells generally grow and reproduce slowly. The temporary disruption in their blood supply also
helps explain the slowness of healing of severely fractured bones.
The major factors that impede bone healing are as follows:
 Excessive motion of fracture fragments
 Poor approximation of fracture fragments
 Compromised blood supply.
 Excessive edema at fracture
 Bone necrosis
 Infection at fracture site
 Metabolic disorders or diseases
 Soft tissue injury
 Medication use(steroids)
Management of Fracture:
Management of a fracture can be considered in three phases:
• Phase I - Emergency care
• Phase II - Definitive care
• Phase III – Rehabilitation
Phase I - Emergency Care
At the site of accident: Emergency care of a fracture begins at the site of the accident. In principle,
it consists of RICE, which means:
• Rest to the part, by splinting. 'Splint them where they lie'. Almost any available object at the
site of the accident can be used for splinting. It may be a folded newspaper, a magazine, a rigid
cardboard, a stick, an umbrella, a pillow, or a wooden plank.
• Ice therapy, to reduce occurrence of swelling. This can be done by taking crushed ice in a
polythene bag and covering it with a wet cloth. Commercially available ice packs can also be
used. Any wound, if present, has to be covered with sterile clean cloth.
• Compression, to reduce swelling. A crepe bandage is applied over the injured part, making
sure that it is not too tight.

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• Elevation, to reduce swelling. The limb is elevated so that the injured part is above the level
of the heart. For lower limb, this can be done using pillows. For upper limb, a sling and pillow
can be used.
In the emergency department:
– Stabilize the patient if the patient is in shock and provide basic life support if needed before
any definitive treatment is carried out.
– A quick evaluation of the extent of injury with particular attention to head injury, chest injury
and abdominal injury.
– Any bleeding is recognized and stopped by local pressure. The fractured limb is examined to
exclude injury to nerves or vessels.
– As soon as the general condition of the patient is stabilized, the limb is splinted comfortably.
– In addition to splintage, the patient should be made comfortable by giving him intramuscular
analgesics.
Phase II - Definitive Care
The three fundamental principles of management of a fracture are:
1. Reduction;
2. Immobilization; and
3. Preservation of functions.
1. Reduction of Fractures
Reduction is the technique of ‘setting’ a displaced fracture to proper alignment. This may be done
non-operatively or operatively, so-called closed and open reduction respectively. Not all fractures
require reduction, either because there is no displacement or because the displacement is
immaterial to the final outcome.
i. Closed reduction: It is usually carried out under general anesthesia and requires experience.
It is an art of realigning a displaced bone by feeling through the soft tissues. The availability
of an image intensifier has greatly added to the skills of closed reduction. The fracture is
reduced by a three-fold maneuver:
• The distal part of the limb is pulled in the line of the bone;
• As the fragments disengage, they are repositioned (by reversing the original direction of
force if this can be deduced);
• Alignment is adjusted in each plane. This is most effective when the periosteum and
muscles on one side of the fracture remain intact; the soft-tissue strap prevents
overreduction and stabilizes the fracture after it has been reduced.

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Some fractures are difficult to reduce by manipulation because of powerful muscle pull and
these may need prolonged traction. For fractures that are unstable after reduction, can be held
in some form of splint or cast. Unstable fractures can also be reduced using closed methods
prior to stabilization with internal or external fixation.
ii. Open reduction: In this method, the fracture is surgically exposed, and the fragments are
reduced under vision. Operative reduction of the fracture under direct vision is indicated:
 When closed reduction fails, either because of difficulty in controlling the fragments or
because soft tissues are interposed between them;
 When there is a large articular fragment that needs accurate positioning;
 Need for traction (avulsion) fractures in which the fragments are held apart.
 Nonunion fractures
Other relative indications of open reduction include the following:
 Delayed union and malunion
 Multiple fractures
 Pathological fractures
 Where closed reduction is known to be ineffective e.g., fracture of the neck of the femur
 Fractures with vascular or neural injuries
2. Immobilization
Immobilization is necessary to maintain the bones in reduced position. The reasons for
immobilizing a fracture may be:
a. To prevent displacement or angulation: In general, if reduction has been necessary,
immobilization will be required.
b. To prevent movement that might interfere with the union: Persistent movement might tear
the delicate early capillaries bridging the fracture. Stricter immobilization is necessary for
some fractures (e.g., scaphoid fracture).
c. To relieve pain: This is the most important reason for the immobilization of most fractures.
As the fracture become pain free and feels stable, guarded mobilization can be started.
The immobilization or holding reduction can be done two methods:
a) Non-operative
b) Operative methods.
a) Non operative methods:
The non-operative methods include the following:
 Strapping
 Sling
 Cast splintage

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 Functional bracing
 Continuous traction
i. Strapping: The fractured part is strapped to an adjacent part of the body e.g., a phalanx
fracture, where one finger is strapped to the adjacent normal finger.
ii. Sling: A fracture of the upper extremity is immobilized in a sling. This is mostly to relieve
pain in cases where strict immobilization is not necessary e.g., triangular sling used for a
fracture of the clavicle.
iii. Cast Splintage: Plaster is still widely used as a splint, especially for distal limb fractures and
for most children’s fractures. There are two types of plaster bandages in use: prepared by
impregnating rolls of starched cotton bandages with plaster powder and the other are
readymade bandages available as a proprietary bandage. It can be applied in two forms i.e.,
slab or a cast. A plaster slab covers only a part of the circumference of a limb and is used for
the immobilisation of soft tissue injuries and for reinforcing plaster casts. A plaster cast covers
the whole of the circumference of a limb. Its thickness varies with the type of fracture and the
part of the body on which it is applied.
iv. Functional Bracing: A brace is a type of cast where the joints are not included, keeping the
fracture is in position and the joints can also be mobilized. Functional bracing is done by using
either plaster or one of the lighter thermoplastic materials commonly used for fracture
dislocations. Segments of a cast are applied only over the shafts of the bones, leaving the joints
free; the cast segments are connected by metal or plastic hinges that allow movement of the
joint in one plane. The splints are ‘functional’ in that joint movements are much less restricted
than with conventional casts. Functional bracing is used most widely for fractures of the femur
or tibia.
v. Continuous Traction: Traction is applied to the limb distal to the fracture, so as to exert a
continuous pull in the long axis of the bone, with a counterforce in the opposite direction.
Counter-traction forces are provided by the weight of the client’s body or other weight such as
elevating the foot of the bed. Traction is used to reduce a fracture, immobilize an extremity,
lessen muscle spasms, and correct or prevent a deformity.
b) Operative methods: Wherever open reduction is performed, fixation (internal or external)
should also be used. External fixation is usually indicated in situations where for some reason,
internal fixation cannot be done.
i. Internal Fixation: In this method, the fracture, once reduced, is held internally with the help
of some metallic or non-metallic device (implant), such as steel wire, screw, plate, Kirschner
wire (K-wire), intra-medullary nail etc. These implants are made of high-quality stainless
steel to which the body is inert.

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Indications:
• Fractures that cannot be reduced except by operation
• Fractures that are inherently unstable and prone to redisplace after reduction and those
fractures liable to be pulled apart by muscle action
• Pathological fractures in which bone disease may inhibit healing
• Multiple fractures where early fixation (by either internal or external fixation) reduces the
risk of general complications and late multisystem organ failure
• Fractures in patients who present nursing difficulties (e.g. Paraplegics, those with multiple
injuries and the very elderly).
Methods of internal fixation
a) Steel wire: A gauge 18 or 20 steel wire is used for internal fixation of small fractures (e.g.,
fracture of the patella, comminuted fragments of large bones etc.).
b) Kirschner wire: It is a straight stainless steel wire, 1-3 mm in diameter. It is used for the
fixation of small bones of the hands and feet.
c) Interfragmentary lag screws: Screws that are partially threaded exert a compression or ‘lag’
effect when inserted across two fragments. These can be used for fixing small fragments of
bone to the main bone (e.g., for fixation of medial malleolus). This technique is useful for
reducing single fragments onto the main shaft of a tubular bone or fitting together fragments
of a metaphyseal fracture.
d) Plates and screws: This is a device which can be fixed on the surface of a bone with the help
of screws. This form of fixation is useful for articular, metaphyseal and diaphyseal fractures.
Plates have five different functions:
 Neutralization (protection) – Plates provide protection when used to bridge a fracture and
supplement the effect of interfragmentary lag screws; the plate is applied to resist torque
and shortening.
 Compression – Plates are often used in simple metaphyseal and diaphyseal fractures to
achieve primary bone healing (no callus).
 Buttressing – Here the plate resists axial load by applying force against the axis of
deformity (e.g. in treating fractures of the proximal tibial plateau).
 Tension-band – Using a plate in this manner on the tensile surface of the bone allows
compression to be applied to the biomechanically more advantageous side of the fracture
preventing its opening.
 Bridging – The plate bridges simple or multifragmentary fractures to restore correct length,
axis and rotation with minimal stripping of soft tissues.

19
e) Intramedullary nails: It is erroneously called 'nail', but in fact is a hollow rod made of
stainless steel. A nail (or long rod) is inserted into the medullary canal to splint the fracture;
rotational forces are resisted by introducing transverse interlocking screws that transfix the
bone cortices and the nail proximal and distal to the fracture.
Complications of internal fixation
– Infection: Iatrogenic infection is now the most common cause of chronic osteomyelitis, which
can necessitate multiple revision surgeries and delay healing. The operation and quality of the
patient’s tissues, i.e. tissue handling, can influence the risk of infection.
– Non-union: If the bones have been fixed rigidly with a gap between the ends, the fracture may
fail to unite. This is more likely in the leg or the forearm if one bone is fractured and the other
remains intact. Other causes of non-union are stripping of the soft.
– Implant failure: Metal is subject to fatigue and can fail unless some bone union of the fracture
has occurred. If the device used to fix the fracture is not capable of supporting the full load
transferred through the limb on normal activity, a period of protected (or partial) weight-
bearing may be required until callus or other radiological sign of fracture healing is seen on X-
ray. Pain at the fracture site is a danger signal and must be investigated.
– Refracture: It is important not to remove metal implants too soon, or the bone may refracture.
A year is the minimum and 18–24 months safer; several weeks after removal the bone is still
weak, and care or protection is needed.
ii. External Fixation
A fracture may be held by transfixing screws that pass through the bone above and below the
fracture and are attached to an external frame.
These are of the following type:
i. Pin fixators: In these, 3–4 mm sized pins are passed through the bone. The same are held
outside the bone with the help of a variety of tubular rods and clamps
ii. Ring fixators: In these thin ‘K’ wires (1–2 mm) are passed through the bone. The same are
held outside the bone with rings.
Indications
• Fractures associated with severe soft-tissue damage (including open fractures) or those that
are contaminated, where internal fixation is risky and repeated access is needed for wound
inspection, dressing or plastic surgery
• Fractures around joints that are potentially suitable for internal fixation but the soft tissues are
too swollen to allow safe surgery – a spanning external fixator provides stability until soft-
tissue conditions improve

20
• Patients with severe multiple injuries, especially if there are bilateral femoral fractures, pelvic
fractures with severe bleeding, and those with limb and associated chest or head injuries
• Un-united fractures, which can be excised and compressed; sometimes this is combined with
bone lengthening to replace the excised segment
• Infected fractures, for which internal fixation might not be suitable.
Complications of external fixation:
 Damage to soft-tissue structures: Transfixing pins or wires may injure nerves or vessels,
or may tether ligaments and inhibit joint movement. The surgeon must be thoroughly
familiar with the cross-sectional anatomy before operating.
 Over distraction: If there is no contact between the fragments, bone union is unlikely to
occur.
 Pin-track infection: This is less likely with good operative technique. Nevertheless,
meticulous pin site care is essential to avoid infection.
3. Preservation of function:
To preserve the functions of the limb, physiotherapy all throughout the treatment, even when the
limb is immobilized, is necessary.
 Prevention of edema: Swelling is almost inevitable after a fracture and may cause skin
stretching and blisters. Persistent edema is an important cause of joint stiffness, especially in
the hand; it should be prevented if possible, and treated energetically if it is already present, by
a combination of elevation and exercise. The essence of soft-tissue care may be summed up
like this: elevate and exercise; never dangle, never force.
 Elevation: An injured limb usually needs to be elevated; after reduction of a leg fracture the
foot is raised off the bed and exercises start. If the leg is in plaster, the limb must, at first, be
dependent for only short periods; between these periods, the leg is elevated on a chair.
 Active exercise: Active movement helps to pump away edema fluid, stimulates the circulation,
prevents soft-tissue adhesion and promotes fracture healing. When splintage is removed the
joints are mobilized and muscle-building exercises are steadily increased. The unaffected joints
need exercising too.
 Assisted movement: It has long been taught that passive movement can be deleterious,
especially with injuries around the elbow, where there is a high risk of developing myositis
ossificans. Gentle assistance during active exercises may help to retain function or regain
movement after fractures involving the articular surfaces.
 Functional activity: As the patient’s mobility improves, an increasing amount of directed
activity is included in the programme. The patient may need to be taught again how to perform
everyday tasks such as walking, getting in and out of bed, bathing, dressing or handling eating

21
utensils. Experience is the best teacher and the patient is encouraged to use the injured limb as
much as possible.
Phase III - Rehabilitation of A Fractured Limb
Rehabilitation of a fractured limb begins at the time of injury, and goes on till maximum possible
functions have been regained. It consists of joint mobilization, muscle re- education exercises and
instructions regarding gait training.
 Joint mobilization: To prevent stiffness, the joint should be mobilized as soon as possible.
This is done initially by passive mobilization. Once the pain reduces, patient is encouraged to
move the joint himself with assistance or move the joint by himself. Motorized devices which
slowly move the joint through a predetermined range of motion can be used. These are called
continuous passive motion (CPM) machines. Techniques such as hot fomentation, gentle
massage and manipulation aid in joint mobilization.
 Muscle re-education exercises: This can be done even during immobilization (static
contractions) or after removal of external immobilization (dynamic contractions), as below:
a) During immobilization: Even while a fracture is immobilized, the joints which are out of
the plaster, should be moved to prevent stiffness and wasting of muscles. Such movements do
not cause any deleterious effect on the position of the fractures. The muscles working on the
joints inside the plaster can be contracted without moving the joint (static contractions). This
maintains some functions of the immobilized muscles.
b) After removal of immobilization: After a limb is immobilized for some period, it gets
stiff. As the plaster is removed, the following care is required:
• The skin is cleaned, scales removed, and some oil applied.
• The joints are moved to regain the range of motion. Hot fomentation, active and active-
assisted joint mobilizing exercises are required for this.
• The muscles wasted due to prolonged immobilization are exercised.
Functional use of the limb: Once a fracture is on way to union, at a suitable opportunity, the limb
is put to use in a guarded way. For example, in lower limb injuries, gradual weight bearing is
started – partial followed by full. One may need to support the limb in a brace, caliper, cast etc.
Walking aids such as a walker, a pair of crutches, stick etc. may be necessary.
Nursing Management:
Possible nursing diagnosis
i. Risk for trauma related to loss of skeletal integrity and movement of bone fragments.

22
ii. Acute pain related to movement of bone fragments, edema and muscle spasms.
iii. Impaired physical mobility related to restrictive therapies and unfamiliarity with the use of
mobilization devices.
iv. Risk for infection related to broken skin and environmental exposure secondary to skeletal
traction.
v. Risk for peripheral neurovascular dysfunction related to interruption of blood flow.
Interventions:
i. Preventing risk for trauma:
- Maintain bed rest or limb rest as indicated with provision of support of joints above and
below fracture sites especially while turning and moving.
- Support fracture site with pillows or folded blankets maintaining a neutral position of
affected part.
- Use sufficient personnel for turning and avoid using abduction bar for turning patient with
a Spica cast.
- Observe and evaluate splinted extremity for resolution of edema.
- Maintain position or integrity of traction. Position patient so that appropriate pull is
maintained on the long axis of the bone.
ii. Reducing pain:
- Assess and record the patient’s level of pain using pain intensity rating scale.
- Maintain immobilization of affected part by means of bed rest, cast, splint or traction.
elevate and support injured extremity.
- Provide alternative comfort measures like back care position changes etc.
- Provide emotional support and encourage the use of stress management techniques.
- Apply cold or ice packs first 24 to 72 hours and as necessary.
iii. Maintaining mobility:
- Assess the degree of immobility produced by injury or treatment and note patient’s
perception of immobility.
- Encourage participation in diversional or recreational activities and maintain a stimulating
environment.
- Teach patient and assist with active and passive range of motion exercise of affected and
unaffected extremities.
- Assist with self-care activities like bathing etc.
- Provide and assist with the use of mobility aids such as wheelchair, walker etc.
iv. Preventing infection:
- Inspect the skin for preexisting irritation or breaks in continuity.

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- Assess pin sites and skin areas for pain, burning sensation, presence of edema or erythema
foul odor or drainage.
- Instruct patient not to touch the insertion sites.
- Provide sterile pin or wound care according to protocol and do meticulous handwashing.
- Investigate abrupt onset of pain and limitation of movement with localized edema and
erythema in injured extremity.
v. Maintaining intact neurovascular status and tissue perfusion:
- Assess capillary return, skin color and warmth distal to the fracture.
- Assess the entire length of the injured extremity for swelling formation.
- Remove jewelers from affected limb.
- Maintain elevation of injured extremities unless contraindicated by the confirmed
presences of compartmental syndrome.
- Encourage patient to routinely exercise digits and joints distal to the injury and ambulate
as soon as possible.
- Institute measures to promote venous blood flow (elastic stockings, position, avoiding
pressure sites, ROM exercises)
Complications:
1. Early complications
a. Life-threatening complications
These include vascular damage such as disruption to the femoral artery or its major branches by
femoral fracture, or damage to the pelvic arteries by pelvic fracture. Patients with multiple rib
fractures may develop pneumothorax, flail chest and respiratory compromise. Hip fractures,
particularly in elderly patients, lead to loss of mobility which may result in pneumonia,
thromboembolic disease or rhabdomyolysis.
b. Local
 Vascular injury: The bone fragments spikes may cause the vessels injury. Vascular trauma
occurs relatively infrequently in association with general orthopedic trauma but may be seen
more often in injuries involving joint dislocations and areas in which vascular structures are
tethered at the fracture site.
 Visceral injury causing damage to structures such as the brain, lung or bladder. Damage to
surrounding tissue, nerves or skin.
 Hemarthrosis: Bleeding into joint spaces. Sometimes, it may be associated with lipoarthrosis
blood and fat in the joint space.
 Compartment syndrome (or Volkmann's ischemia): Compartments are sheaths of fibrous
tissue that support and partition nerves, muscles, and blood vessels, primarily in the
extremities. Compartment syndrome is described as increased pressure within the muscle

24
compartment of the arm or leg most often due to injury or fracture that cause bleeding in a
muscle. This pressure increases cause nerve damage due to decreased blood supply. The sign
and symptom of compartment syndrome can be described by 5P as pain, pallor (pale skin tone),
paresthesia (numbness feeling), pulselessness (faint pulse) and paralysis (weakness in
movement). Compartment syndrome can lead to Volkmann’s ischemia.
 Wound Infection: This may result from an open fracture in which the bone extends through
the skin, allowing contamination from the outside. They may also occur following surgical
repair of a fracture using an internal fixation device. Any infection may lead to delayed union
of the bone. Wound infections, pin-site infections, drainage tube infections, and osteomyelitis
(bone infection) are common.
 Fracture blisters: Fracture blisters form over the fracture site and alter management and
repair, often necessitating early cast removal and immobilization by bed rest with limb
elevation. They are believed to result from large strains applied to the skin during the initial
fracture deformation, and they resemble second-degree burns rather than friction blisters. They
may be clear or haemorrhagic, and they may lead to chronic ulcers and infection, with scarring
on eventual healing. Management involves delay in surgical intervention and casting. Silver
sulfadiazine seemed in one review to promote re-epithelialisation.
c. Systemic
 Fat embolism: It is usually associated with fractures of the long bones, multiple fractures, or
crushing injuries. In these types of injuries, multiple, small fat globules are released from the
bone marrow and then enter venules that are broken open from the long bone trauma. These
fat emboli scatter through the venous system and block vessels in the lung causing respiratory
distress.
An embolus usually occurs within 24 to 72 hours following a fracture but may occur up to a
week after injury. When an embolism involves a small area of the lungs, the symptoms are
pain, tachycardia, and dyspnea. Larger areas of lung involvement produce more pronounced
symptoms, including severe pain, dyspnea, cyanosis, restlessness, and shock. Petechiae may
appear over the neck, upper arms, chest, or abdomen. Treatment consists of bed rest,
respiratory support, oxygen, and IV fluids.
 Shock: Bone is highly vascular, and damage to or surgery on bone (particularly the large long
bones of the extremities) can cause bleeding. Check for bleeding and Monitor vital signs
carefully. Hypovolemic shock may result from severe hemorrhage.

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 Thromboembolism (pulmonary or venous): Deep venous thrombosis (DVT) or pulmonary
embolus can develop in patients who are immobile because of trauma or surgery.
Thromboembolic complications are the most common problems of lower extremity surgery or
trauma and the most fatal complication of musculoskeletal surgery, particularly in the older
adult. Leg exercises, early ambulation, and prophylactic anticoagulant therapy such as with
dalteparin (Fragmin), enoxaparin (Lovenox), fondaparinux (Arixtra), or rivaroxaban (Xarelto),
help prevent these problems.
 Pneumonia: Pneumonia is one of the most common complications associated with
rib fractures. Pneumonia rates vary depending on the number of fractures and age of the patient.
When patients can't breathe deeply or cough, the risk of pneumonia increases.
2. Late complications of fractures:
Late complications are those which occur after a substantial time has passed and are as a result of
defective healing process or because of the treatment itself.
a. Local
 Delayed union: Delayed union is failure of a fracture to consolidate within the expected time,
which varies with site and nature of the fracture and with patient factors such as age. Healing
processes are still continuing, but the outcome is uncertain.
Factors predisposing to delayed union
– Severe soft tissue damage.
– Inadequate blood supply.
– Infection.
– Insufficient splintage.
– Excessive traction.
– Older age.
– Severe anemia.
– Diabetes.
– Low vitamin D level.
– Hypothyroidism.
– Medications including NSAIDs and steroids.
– Complicated/compound fracture.
– Osteoporosis.
 Malunion (fracture does not heal in normal alignment): Malunion occurs when the bone
fragments join in an unsatisfactory position, usually due to insufficient reduction.

26
 Non-union (fracture does not heal): Non-union occurs when there are no signs of healing after
>3-6 months (depending upon the site of fracture). Non-union is one endpoint of delayed
union. Non-union is generally said to occur when all healing processes have ceased and union
has not occurred.
Factors disposing to non-union
– Too large a space for bony remodeling to bridge.
– Interposition of periosteum, muscle or cartilage.
– Bony site with a limited blood supply: some sites are more vulnerable to compromise of
blood supply by the fracture (e.g., scaphoid, femoral head and neck, and tibia).
Presentation of non-union
– Pain at fracture site, persisting for months or years.
– Non-use of extremity.
– Tenderness and swelling.
– Joint stiffness (prolonged >3 months).
– Movement around the fracture site (pseudarthrosis).
– Palpable gap at fracture site.
– Absence of callus (remodeled bone) or lack of progressive change in the callus suggests
delayed union.
– Closed medullary cavities suggest non-union.
– Radiologically, bone can look inactive, suggesting the area is avascular (known as atrophic
non-union) or there can be excessive bone formation on either side of the gap (known as
hypertrophic non-union).
Management of non-union
Non-surgical approaches:
– Early weight bearing and casting may be helpful for delayed union and non-union.
– Bone stimulation can sometimes be used. This delivers pulsed ultrasonic or
electromagnetic waves to stimulate new bone formation. It needs to be used for up to an
hour every day, and may take several weeks to be effective.
– Medical treatments such as teriparatide have also been used to promote fracture healing,
particularly in patients with osteoporosis.
Surgical approaches:
– Debridement to establish a healthy infection-free vascularity at the fracture site.
– Bone grafting to stimulate new callus formation. Bone may be taken from the patient or
may be cadaveric.

27
– Bone graft substitutes/osteobiologics.
– Internal fixation to reduce and stabilise the fracture. (Bone grafting provides no stability.)
– Depending on the type of non-union, any combination of the above
 Joint stiffness: Joint stiffness is the feeling that the motion of a joint is limited or difficult.
Joint stiffness can be due to the presence of dense intra-articular adhesions and/or fibrotic
transformation of peri-articular structures. It can be caused by a flexion contracture, an
extension contracture or a combined contracture (affecting both flexion and extension) relative
to the contralateral side (if healthy).
 Contractures (Volkmann’s Ischaemic contracture): A Volkmann's contracture is deformity
of the hand, fingers, and wrist. Following trauma, there is a deficit in the arterio-venous
circulation in the forearm which causes a decreased blood flow and hypoxia can lead to the
damage of muscles, nerves and vascular endothelium. This results in a shortening (contracture)
of the muscles in the forearm and gives rise to claw like appearance.
 Myositis ossificans: Myositis ossificans occurs when calcifications and bony masses develop
within muscle and can occur as a complication of fractures. The condition tends to present with
pain, tenderness, focal swelling, and joint/muscle contractures. Avoid excessive
physiotherapy; rest the joint until pain subsides; NSAIDs may be helpful; and consider excision
after the lesion has stabilised (usually 6-24 months). It may be difficult to distinguish from
osteogenic sarcoma.
 Avascular necrosis: Avascular necrosis (AVN) also known as osteonecrosis, is the death of
bone tissue due to a loss of blood supply. It is also called aseptic necrosis, or ischemic bone
necrosis. In its early stages, AVN usually doesn’t have symptoms. it becomes painful and may
become constant as its progresses. If the bone and surrounding joint collapse, person may be
unable to use your joint.
 Algodystrophy (or Sudeck's atrophy): Algodystrophy, also known as Sudeck's atrophy, is a
form of reflex sympathetic dystrophy, usually found in the hand or foot. A continuous, burning
pain develops, accompanied at first by local swelling, warmth and redness, progressing to
pallor and atrophy. Movement of the afflicted limb is very restricted.
Treatment is usually multi-pronged:
• Rehabilitation: physiotherapy and occupational therapy to decrease sensitivity and
gradually increase exercise tolerance.
• Psychological therapy.

28
• Pain management: often difficult and with a disputed evidence base. Approaches used are
neuropathic pain medications (eg, amitriptyline, gabapentin, opioids), steroids, calcitonin,
intravenous bisphosphonates and regional blocks.
 Osteomyelitis: Osteomyelitis is an infection of a bone. Many different types of bacteria can
cause osteomyelitis. However, infection with a bacterium called Staph. aureus is the most
common cause. Infection with a fungus is a rare cause. After operative treatment of fracture
bacteria may spread to the bone and may cause osteomyelitis.
 Growth disturbance or deformity: Growth plate fractures affect how the bone will grow. An
improperly treated growth plate fracture could result in a fractured bone ending up more
crooked or shorter than its opposite limb. With proper treatment, most growth plate fractures
heal without complications.
b. Systemic
 Gangrene: Gangrene refers to the death of body tissue due to either a lack of blood flow or a
serious bacterial infection. Gas Gangrene is common after trauma. Gas gangrene is an invasive,
fatal anaerobic infection caused by Clostridium, especially Clostridium perfringens, that is
often secondary to open fractures, deep wounds, and other injuries. Bacteria release dangerous
toxins or poisons, along with gas that can be trapped in the tissue. The clinical symptoms of
gas gangrene include swelling and necrosis of massive muscles, accumulation of gas at the site
of infection and other general symptoms, such as fever and sudden onset of prominent pain.
 Tetanus: Tetanus, also called lockjaw, is a serious infection caused by Clostridium
tetani. Spores of tetanus bacteria are everywhere in the environment, including soil, dust, and
manure. When the spores enter a deep flesh wound, they grow into bacteria that can produce a
powerful toxin, tetanospasmin. The toxin affects the brain and nervous system and impairs the
nerves that control your muscles (motor neurons) leading to stifffnesss in the muscles.
 Septicemia: Septicemia is a serious bloodstream infection. It’s also known as blood poisoning.
Septicemia occurs when a bacterial infection elsewhere in the body, such as the lungs or skin,
enters the bloodstream. bacteria can enter the body during the injury event or surgical repair.
Septicemia can lead to serious complication of septicemia causing inflammation throughout
the body. Sepsis after hip fracture typically develops from one of the 3 potential infectious
sources: urinary tract infection (UTI), pneumonia, and surgical site infection (SSI).

29
2. Trauma to Bones, Joints and Ligaments:
Sprains, Strain and Dislocations
Anatomical and Physiological: Review
Bones: The human skeleton is made up of 206 bones. The functions of the skeleton are to provide
support, give our bodies shape, and provide protection to other systems and organs of the body, to
provide attachments for muscles, to produce movement and to produce red blood cells.
Joints: The junction of two or more bones is called a joint (articulation).
There are three basic kinds of joints: synarthrosis, amphiarthrosis, and diarthrosis joints.
– Synarthrosis joints (Fibrous joint) are immovable, as exemplified by the skull sutures.
– Amphiarthrosis joints (cartilaginous joint), such as the vertebral joints and the symphysis
pubis, allow limited motion. The bones of amphiarthrosis joints are joined by fibrous cartilage.
– Diarthrosis joints (synovial joints) are freely movable joints.
There are several types of diarthrosis joints:
 Ball-and-socket joints, best exemplified by the hip and the shoulder, permit full freedom
of movement.
 Hinge joints permit bending in one direction only and are best exemplified by the elbow
and the knee.
 Saddle joints allow movement in two planes at right angles to each other. The joint at the
base of the thumb is a saddle, biaxial joint.
 Pivot joints are characterized by the articulation between the radius and the ulna. They
permit rotation for such activities as turning a doorknob.
 Glidingjoints allow for limited movement in all directions and are represented by the joints
of the carpal bones in the wrist.
Ligaments: Ligaments are bundles of connective tissue that connect one bone to an adjacent bone.
The basic building blocks of a ligament are collagen fibers. These fibers are very strong, flexible,
and resistant to damage from pulling or compressing stresses. Collagen fibers are usually arranged
in parallel bundles, which help multiply the strength of the individual fibers. The bundles of
collagen are attached to the outer covering that surrounds all bones, the periosteum.
Function of Ligaments
– To resist external load.
– To guide joint motion.

30
– To passively control the maximum range of movement.
– To provide motor control
Trauma (Introduction): Trauma refers to a physical injury. In medicine, however, the words
trauma patient usually refers to someone who has suffered serious and life-threatening physical
injury potentially resulting in secondary complications such as shock, respiratory failure and death.
Trauma and foreign bodies in the musculoskeletal system can drastically impact the body and
cause major injury.
Trauma to Bones: Bones are rigid, but they do bend or "give" somewhat when an outside force
is applied. However, if the force is too great, the bones will break, just as a plastic ruler breaks
when it is bent too far. A bone fracture is a medical condition in which there is a partial or complete
break in the continuity of the bone. In more severe cases, the bone may be broken into several
pieces.
Trauma to Ligaments: An injury to ligament is termed as a sprain. This is to be differentiated
from the term “strain” which means stretching of a muscles or its tendinous attachment. A strain
is a “muscle pull” caused by overuse, overstretching, or excessive stress. Strains are microscopic,
incomplete muscle tears with some bleeding into the tissue. The patient experiences soreness or
sudden pain, with local tenderness on muscle use and isometric contraction.
Sprains
 A sprain is an injury to the ligaments surrounding a joint that caused by a wrenching or
twisting motion.
 The function of a ligament is to maintain stability while permitting mobility. A torn
ligament loses its stabilizing ability.
 Blood vessels rupture and edema occurs; the joint is tender, and movement of the joint
becomes painful.
 The degree of disability and pain increases during the first 2 to 3 hours after the injury
because of the associated swelling and bleeding.
 An x-ray should be obtained to rule out bone injury. Avulsion fracture (in which a bone
fragment is pulled away by a ligament or tendon) may be associated with a sprain.
Risk Factors: Factors contributing to sprains include
 Poor conditioning: Lack of conditioning can leave your muscles weak and more likely to
sustain injury.

31
 Fatigue: Tired muscles are less likely to provide good support for your joints. When you're
tired, you're also more likely to succumb to forces that could stress a joint or overextend a
muscle.
 Improper warm-up: Properly warming up before vigorous physical activity loosens your
muscles and increases joint range of motion, making the muscles less tight and less prone
to trauma and tears.
 Environmental conditions: Slippery or uneven surfaces can make you more prone to
injury.
 Poor equipment: Ill-fitting or poorly maintained footwear or other sporting equipment can
contribute to your risk of a sprain
Causes: A sprain occurs when you overextend or tear a ligament while severely stressing a joint.
Sprains often occur in the following circumstances
 Ankle — Walking or exercising on an uneven surface
 Knee — Pivoting during an athletic activity
 Wrist — Landing on an outstretched hand during a fall
 Thumb — Skiing injury or overextension when playing racquet sports, such as tennis
Classification: Sprain are classified into three degrees
– First-degree sprain: It is a tear of only a few fibres of the ligament. It is characterized by
minimal swelling, localized tenderness but little functional disability.
– Second-degree sprain: It is one where, anything from a third to almost all the fibres of a
ligament is disrupted. The patient present with pain, swelling and inability to use the limb.
Joint movements are normal. The diagnosis can be made on performing a stress test.
– Third-degree sprain: It is a complete tear of the ligament. There is swelling and pain over the
torn ligament. Contrary to expectation, often the pain in such tear is minimal. Diagnosis can
be made by performing a stress test, and by investigation such as MRI and arthroscopy.
Clinical Features
Signs and symptoms will vary, depending on the severity of the injury.
 Pain
 Swelling
 Bruising
 Limited ability to move the affected joint
 At the time of injury, you may hear or feel a "pop" in your joint

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Joints Involved
Although any joint can experience a sprain, some of the more common include:
 The ankle. It is the most common, and has been said that sprains such as serious ankle
sprains are more painful and take longer to heal than actually breaking the bones in that
area.
 The knee. One of the more talked about sprains is that to the anterior cruciate ligament
(ACL) of the knee. This is a disabling sprain common to athletes, especially in American
football, football (soccer), basketball, pole vaulting, softball, baseball and some styles of
martial arts.
 Ligaments between the spinal vertebrae
 The fingers.
 The wrist.
 The toes.
Diagnosis
 A detailed history, eliciting the exact mechanism of injury, often indicates the likely
ligaments injured.
 Clinical examination: A localized swelling tenderness and ecchymosis over a ligament
indicates injury to that ligament. Usually, a haemarthrosis is noticed in second and third
degree sprain within 2 hours.
 Stress test: This is a very useful test in diagnosing a sprain and judging its severity. The
ligament in question is put to stress by a manoueuvre.
– Ankle stress test
– Anterior Drawer Test: It is used to assess the integrity of the ATFL based on the
anterior translation of the talus under the tibia in a sagittal plane.
– Talar tilt test: It is also known as the inversion stress test and it stresses the
calcaneo-fibular ligament.
– Eversion stress test: It assesses the integrity of the deltoid ligament and is also
known as the Eversion Talar Tilt test.
Investigation
 A plain X-ray of the joint is usually normal. Sometimes, a chip of bone may be seen in the
region of the attachment of the ligament to the bone. An X-ray taken while the ligament is
being stressed (stress X-ray) may document an abnormal opening up of the joint in a third-
degree sprain.
 Other investigations required in a few cases are MRI or arthroscopy.

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Medical Management
– Emergency care: There has been significant change in the treatment of sprains. All sprains
are treated initially with rest, ice therapy, compression bandage, elevation (RICE).
– Rest prevents additional injury and promotes healing. Moist or dry cold applied intermittently
for 20 to 30 minutes during the first 24 to 48 hours after injury produces vasoconstriction,
which decreases bleeding, edema, and discomfort. Care must be taken to avoid skin and tissue
damage from excessive cold. An elastic compression bandage controls bleeding, reduces
edema, and provides support for the injured tissues. Elevation controls the swelling
– Suitable analgesics and anti-inflammatory medication are given. This is enough for first degree
sprain.
– Second and third degree sprain are immobilized in a brace or a plaster cast for a period of 1-2
weeks, mainly for pain relief.
– No longer is plaster immobilization advised for long periods.
– In fact, early mobilization and walk with support enhance healing of ligaments.
– In some third degree sprains, surgery may be required.
Nursing Management
– Elevate or immobilize the affected joint, and apply ice packs immediately
– Assist with tape, splint or cast application, as necessary
– Prepare the client with a severe sprain for surgical repair or reattachment, if indicated.
– Administer prescribed medications, which may include non-opioid analgesics.
Prevention:
 Exercise regularly to keep your joints and muscles strong
 Use protective equipment when playing sports.
 Wear shoes that fit well. When exercising, wear shoes that have a soft, even sole.
 Maintain a healthy weight. Extra weight puts more stress on your muscles and joints.
 Eat a well-balanced diet to keep muscles healthy.
 When pick up something heavy, hold it close to body, keep back straight and feet apart,
and bend

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Injury to Joints: Dislocation and Subluxation
Introduction: Joint injuries may be either a subluxation or a dislocation. A dislocation is an injury
to a joint, a place where two or more bones come together, in which the ends of your bones are
forced from their normal positions. This painful injury temporarily deforms and immobilizes your
joint. Dislocation is most common in shoulders and fingers. Other sites include elbows, knees and
hips. If suspect a dislocation, seeking prompt medical attention to return your bones to their proper
positions. When treated properly, most dislocations return to normal function after several weeks
of rest and rehabilitation. However, some joints, such as your shoulder, may have an increased risk
of repeat dislocation.
Definition
Dislocation: A dislocation of a joint is a condition in which the articular surfaces of the bones
forming the joint are no longer in anatomic contact. The bones are literally “out of joint.” OR, a
joint is dislocated when its articular surface is completely displaced, one from the other, so that all
contacts between them is lost.
Subluxation: A subluxation is a partial dislocation of the articulating surfaces. OR, a joint is
subluxated when its articular surface is only partly displaced and retained some contact between
them.
Risk Factors: Risk factors for a joint dislocation includes,
 Susceptibility to falls. Falling increases your chances of a dislocated joint if use arms to brace
for impact or if you land forcefully on a body part, such as your hip or shoulder.
 Heredity. Some people are born with ligaments that are looser and more prone to injury than
those of other people.
 Sports participation. Many dislocations occur during high-impact or contact sports, such as
gymnastics, wrestling, basketball and football.
 Motor vehicle accidents. These are the most common cause of hip dislocations, especially for
people not wearing a seat belt.
Causes:
 Trauma is the most common cause of dislocations and other musculoskeletal tissues. Trauma
includes: Direct force, as occurs in falls or motor vehicle accidents
 Repeated wear and tear, as occurs during daily activities or results from vibration or jerking
movements
 Overuse, as may occur when athletes overstrain

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 How severe a dislocation is depending partly on the type and force of the trauma that caused
it.
 Some dislocations occur while playing certain sports.
 Some disorders make dislocations more likely. An example is Ehlers-Danlos syndrome, a
rare hereditary connective tissue disorder that makes joints unusually flexible. People with this
disorder are prone to dislocations and sprains.
Clinical Features
Dislocations cause the following symptoms:
 Pain
 Swelling
 Inability to use the injured part normally
 Bruising or discoloration
 Possibly loss of feeling (numbness or abnormal sensations)
Common Dislocation of Different Joints
SPINE Cervical spine (anterior c5 over c6)
HIP Posterior, anterior
SHOULDER Anterior(commonest overall), posterior
ELBOW Posterior, posterolateral
WRIST Lunate, perilunte
KNEE Posterior
PATELLA Lateral
FOOT(Inter- tarsal ,
Tarso- metatarsal)
(chopart’s dialocation, Lisfranc’s dislocation)
Classification
Dislocation and subluxations may be classified on the basis of aetiology into congenital or
acquired.
– Congenital dislocation: It is the condition where a joint is dislocated at birth e.g.
congenital dislocation of hip (CHD).
– Acquired dislocation: It may occur at any age . It may be traumatical or pathological

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 Traumatic dislocation: Injury is far the commonest cause of dislocations and subluxations at
almost all joints. The force required to dislocate a particular joints varies from joint to joint.
The following are the different types of traumatic dislocations seen in clinical practice:
 Acute traumatic dislocation: This is an episode of dislocation where the force of injury
is the main contributing factors e.g., shoulder dislocation
 Old unreduced dislocation: A traumatic dislocation, not reduced, may present as an old
unreduced dislocation e.g., old posterior dislocation of the hip
 Recurrent dislocation: In some joints, proper healing does not occur after the first
dislocation. This results in weakness of the supporting structures of the joints so that the
joint dislocates repeatedly, often with trivial trauma. Recurrent dislocation of the shoulder
and patella are common.
 Fracture dislocation: When a dislocation is associated with a fracture of one or both of
the articulating bones, it is called fracture dislocation. A dislocation of the hip is often
associated with a fracture of the lip of the acetabulum.
 Pathological dislocation: The articulating surfaces forming a joint may be destroyed by an
infective or a neoplastic process, or the ligaments may be damaged due to some disease. This
results in dislocation or subluxation of the joint without any trauma e.g. dislocation of the hip
in septic arthritis.
Diagnosis and Investigation: Imaging tests used to diagnosis dislocations and other
musculoskeletal injuries include
X-rays: X-rays are useful for diagnosing dislocations, as well as fractures. X-rays are not useful
for detecting injuries to ligaments, tendons, or muscles because they show only bones (and the
fluid that collects around an injured joint).X-rays are usually taken from at least two angles to
show how the bones are aligned.
Magnetic resonance imaging (MRI), Computed tomography (CT)
– CT or MRI may be done to check for subtle fractures, which may accompany a dislocation.
Other tests may be done to check for other injuries that may result from a dislocation:
– Angiography (x-rays or CT scans taken after a dye is injected into arteries) to check for
damaged blood vessels
– Nerve conduction studies to check for damaged nerves

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Medical Management
 The affected joint needs to be immobilized while the patient is transported to the hospital.
 The dislocation is promptly reduced (ie, displaced parts are brought into normal position)
to preserve joint function.
 Analgesia, muscle relaxants, and possibly anesthesia are used to facilitate closed reduction.
 The joint is immobilized by bandages, splints, casts, or traction and is maintained in a stable
position. Neurovascular status is monitored.
 After reduction, if the joint is stable, gentle, progressive, active and passive movement is
begun to preserve range of motion (ROM) and restore strength.
 The joint is supported between exercise sessions.
 After your splint or sling is removed, you'll begin a gradual rehabilitation program designed
to restore your joint's range of motion and strength.
Treatment of a dislocation or subluxation depends upon its types, as discussed below:
Acute traumatic dislocation: In acute traumatic dislocation, an urgent reduction of the dislocation
is of paramount importance. Often it is possible to do so by conservation methods, although
sometimes operative reduction may be required.
a. Conservative methods: A dislocation may be reduced by closed manipulative manoeuvres.
Reduction of a dislocation joint is one of the most gratifying jobs an orthopedic surgeon is called
upon to do, as it produces instant pain relief to the patient. Prolonged traction may be required for
reducing some dislocation.
b. Operative method: Operative reduction may be required I some cases. Following are some of
the indication:
 Failure of closed reduction, often because the dislocation is detected late.
 Failure- dislocation:
 If the fracture has produced significant incongruity of the joint surfaces.
 A loose piece of bone is lying within the joint. The dislocation is difficult to maintain by closed
treatment
Old unreduced dislocation: This often needs operative reduction. In some cases, if the function
of the dislocated joint is good, nothings need to be done.
Recurrent dislocation: An individual episode is treated like a traumatic dislocation. For
prevention of reccurences, reconstructive procedures are required.

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Nursing Care for Joint Trauma
History Taking
 Circumstances of injury if known
 Pain, including location character, timing, and activities or movements that aggravate or
relieve it
 History of prior musculoskeletal injuries
 chronic illnesses
 Medications: chemo medicine, glucocorticoids
Physical Assessment
 Compare the position, color, size, and temperature of the affected joint to the corresponding
unaffected joint
 Palpate for tenderness, crepitus, temperature, and swelling
 Instruct the patient or assist to move the joint through its normal range of motion, stopping
and noting where pain is experienced
 When a joint dislocation is suspected, assess color, temperature, pulses, movement, and
sensation of the limb distal to the affected joint.
Nursing Diagnosis and Interventions
Risk for Injury
 Monitor neurovascular status by assessing the 5 “P’s”: pain, pulses, pallor, paralysis, and
paresthesia.
 Maintain immobilization as ordered after reduction.
Acute Pain
 Encourage use of an appropriate splint or joint immobilizer.
 Teach safe application of ice or heat to the affected joint as indicated.
 Instruct about using NSAIDs as ordered.
Nursing Management:
Nursing care is directed at providing comfort, evaluating the patient’s neurovascular status,
protecting the joint during healing, the nurse teaches the patient how to manage the immobilizing
devices and how to protect the joint from re injury, observation for complications administration
of ordered medications.
Complication: As with a fracture, complication following a dislocation can be immediate, early
or late. Immediate complication is an injury to the neurovascular bundle of the limb. Early
complications are: recurrence, myositis, ossificans, persistent instability, joint stiffness. Later
complications are: osteoarthritis and avascular necrosis.

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Prevention: To help prevent a dislocation
 Take precautions to avoid falls: Get your eyes checked regularly. Ask your doctor or
pharmacist if any of the drugs you take might make you dizzy. Be sure your home is well-
lighted and that you remove any potential tripping hazards from the areas where you walk.
 Play safely: Wear the suggested protective gear when you play contact sports.
 Avoid recurrence: Once you've dislocated a joint, you might be more susceptible to future
dislocations. To avoid recurrence, do strength and stability exercises as recommended by
your doctor or physical therapist to improve joint support.
 Put a pillow between the legs when sleeping.
 Never cross the legs when seated.
 Avoid bending forward when seated in a chair.
 Avoid bending forward to pick objects on the floor.
 Use a high-seated chair and a raised toilet seat.

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3. Traction
Traction refers to the practice of slowly and gently pulling on a fractured or dislocated body part.
It’s often done using ropes, pulleys, and weights. These tools help apply force to the tissues
surrounding the damaged area. The purpose of traction is to guide the body part back into place
and hold it steady. Traction may be used to:
– stabilize and realign bone fractures, such as a broken arm or leg
– help reduce the pain of a fracture before surgery
– treat bone deformities caused by certain conditions, such as scoliosis
– correct stiff and constricted muscles, joints, tendons, or skin
– stretch the neck and prevent painful muscle spasms
This is particularly useful for shaft fractures that are oblique or spiral and easily displaced by
muscle contraction. It can also be used for acetabular fractures with femoral head subluxation or
dislocation. Traction is generally used as a temporizing measure to bridge the time from fracture
to definitive treatment.
Types of traction:
i. Traction by gravity: This applies only to upper limb injuries. Thus, with a wrist sling the weight
of the arm provides continuous traction to the humerus. For comfort and stability, especially with
a transverse fracture, a U-slab of plaster may be bandaged on or, better, a removable plastic
sleeve from the axilla to just above the elbow is held on with Velcro.
ii. Skin traction: Skin traction is achieved by applying wide bands of mole- skin adhesive or
commercially available devise directly to the skin and attaching weights to them. The pull of
the weights is transmitted indirectly to the involved bone or other connective tissue.
Skin traction is generally used for short term treatment (48-72 hrs.) until skeletal traction or
surgical treatment is possible. Skin traction is frequently used to temporarily immobilize a part or
stabilize a fracture. Tape, boots or splints are applied directly to the skin to maintain alignment,
assist in reduction and help diminish muscle spasm in the injured part. The traction weight is
usually limited to 2-3 -4-5 kg.
Other types of skin Tractions are:
– Bucks extension is used for condition affecting femur, knee, or back.
– Russel’s traction used for fracture of femur or hip

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– Bryant’s traction used for fracture of the femur, fracture in small children and immobilization
of the hip joints in children and 2 years of 14 kg in weight.
– Pelvic belt or girdle used for sciatica, muscle spasm (lower back) and minor fractures of the
lower spine.
– Pelvic sling traction used for fractures to provide compression for separated pelvic girdle.
– Circumferential head halter is used for soft tissue disorders and degenerative risk of the
cervical spine.
iii. Skeletal traction
It is a traction applied directly to a bone generally in place for a longer period of time and is used
to align injured bones and joints or to treat joint contractures and congenital hip dysplasia. Skeletal
Traction requires the surgical insertion of pins (Steinmann) or wires (Kirschner) (K wire) through
the bones. It is used most frequently for fractures of the femur, tibia, and cervical spine. Weight
for skeletal traction n ranges from 2.3 kg to 20. Kg.
 Overhead arm (90-96): Commonly used for the immobilization of the fractures and
dislocation of the upper arm and shoulder.
 Later arm: Commonly used in immobilization of the upper arm and shoulder
 Balanced suspension traction: Used for injury or fracture of the femoral shaft of the femur,
acetabulum, hip, tibia or any combination of these.
 Head tongs (e.g., Gardner- Wells tongs) are fixed in the skull to apply traction that
immobilizes cervical fractures.
Complications of traction
Circulatory embarrassment: Especially in children, traction tapes and circular bandages may
constrict the circulation; for this reason, ‘gallows traction’, in which the baby’s legs are suspended
from an overhead beam, should never be used for children over 12 kg in weight.
Nerve injury: In older people, leg traction may predispose to peroneal nerve injury and cause a
drop foot; the limb should be checked repeatedly to see that it does not roll into external rotation
during traction.
Pin site infection: Pin sites must be kept clean and should be checked daily.
Ongoing Nursing Management of patient with traction:
Maintain skin integrity
 Patient’s legs, heels, elbows and buttocks may develop pressure areas due to remaining in
the same position and the bandages.
 Position a rolled up towel/pillow under the heel to relieve potential pressure.
 Encourage the patient to reposition themselves or complete pressure area care four hourly.

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 Remove the foam stirrup and bandage once per shift, to relieve potential pressure and
observe condition patients skin.
 Keep the sheets dry.
 Document the condition of skin throughout care in the progress notes and care plan
 Ensure that the pressure injury prevention score and plan is assessed and documented.
 Provide pin care per physician order.
 Patient’s diet should be high in calcium, protein, iron, and vitamins.
Traction care
 Ensure that the traction weight bag is hanging freely, the bag must not rest on the bed or
the floor
 If the rope becomes frayed replace them
 The rope must be in the pulley tracks
 Ensure the bandages are free from wrinkles
 Tilt the bed to maintain counter traction
Observations
 Check the patient’s neurovascular observations hourly and record in the medical record.
 If the bandage is too tight it can cause blood circulation to be slowed.
 Monitoring of swelling of the femur should also occur to monitor for compartment
syndrome.
 If neurovascular compromise is detected remove the bandage and reapply bandage not as
tight. If circulation does not improve notify the orthopaedic team.
 Check the extremities for color (pallor, cyanosis), numbness, edema, signs of infection,
and pain. Look for areas of skin breakdown or pressure sores on all skin surfaces.
Pain Assessment and Management
 Assessment of pain is essential to ensure that the correct analgesic is administered for the
desired effect
 Paracetamol, Diazepam and Oxycodone should all be charted and administered as
necessary.
 Pre-emptive analgesia ensures that the patient’s pain is sufficiently managed and should be
considered prior to pressure area care.
 Assess and document outcomes of pain management strategies employed
Care of Patients in Cervical Traction

43
 Verify that the head of the bed (HOB) is adjusted per physician’s order.
 Verify that suction is available at the patient’s bedside.
 When conducting Cardiopulmonary resuscitation (CPR), use jaw lift maneuver to open the
airway without hyperextending the neck. Realign patient horizontally if HOB is elevated
and put board behind patient’s neck.
 If the patient requires logrolling, the RN or licensed practitioner shall direct patient
movement from head of bed.
 Patients shall be turned every two (2) hours per physician order. The skin shall be assessed
with each turn for evidence of pressure, paying close attention to the occipital area, any
bony prominences and traction sites.
Activity
 The patient is able to sit up in bed and participate in quiet activities such as craft, board
games and watching TV. Play therapy will be beneficial for patients in traction long term.
 Non-pharmacological distraction and activity will improve patient comfort.
 The patient is able to move in bed as tolerated for hygiene to be completed.
 Patients who are in traction for a number of weeks may require a referral to the education
department/kinder.

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4. Plaster Cast
A cast holds a broken bone (fracture) in place and prevents the area around it from moving as it
heals. Casts also help prevent or decrease muscle contractions and help keep the injured area
immobile, especially after surgery, which can also help decrease pain. Several types of materials
are used to make casts.
 Plaster casts – mold very smoothly to the body’s contours. The cast initially emits heat and
takes about 15 minutes to cool and 24 to 72 hours to dry. It must be handled carefully until dry.
 Fiberglass casts – are dry in 10 to 15 minutes and can bear weight 30 minutes after application.
 Polyester-cotton knit casts – take about 7 to 10 minutes to dry and can withstand weight
bearing almost immediately.
Types of cast:
 Plaster cast: This is made from gauze and plaster strips soaked in water. These are wrapped
around the injured body part over a stockinette and cotton padding. As they dry, the strips
harden. The cast takes 24 to 48 hours to harden fully.
 Synthetic cast: This is made from fiberglass or plastic strips. These are wrapped around the
injury over a stockinette and cotton padding. Synthetic casts can be different colors. A
synthetic cast is lighter than plaster. It dries in a few minutes, but may take a few hours to
harden fully. Synthetic stockinettes and padding are also available. These can get wet for
bathing or swimming.
 Cast brace: This is made of hard plastic. Soft pads inside the brace push against (compress)
the injury. The brace is held in place with Velcro strips and can be removed. A cast brace may
be used right after the injury occurs. Or, it may be used toward the end of healing, after another
cast has been removed.
 Splint (also called a half cast). This is made from slabs of plaster or fiberglass that hold the
injury still. A bandage is wrapped around the injury to hold the plaster slabs in place. Splints
are often used when swelling is present, or you have a risk of swelling. In most cases, the splint
is eventually replaced with another type of cast.
Types of cast according to where it is applied:
a. Casts in Upper Extremity
i. Long arm Cast: Long arm cast encases the arm from the hand to about lower two-thirds
of the arm till a level below the armpit, leaving the fingers and thumbs free.
ii. Short arm cast: A short arm cast, in contrast, ends just below the elbow.

45
Both kinds of casts, depending on the injury and prescription, the cast may include thumb or
fingers. In such cases, it is called finger spica or thumb spica cast.
b. Casts in Lower Extremity
i. Short and Long Leg Casts: A cast encasing both the foot and the leg to the hip being called
a long leg cast, while a cast encasing the patient’s foot, ankle and lower leg ending below the
knee is referred to as a short leg cast.
ii. Cylinder Cast: This kind of cast is mostly used in knee injuries and afflictions. It is similar to
long leg cast but, in some cases, a cast may end just above the ankle distally.
c. Body Casts
Body casts are those casts which also include the trunk. It is very rare to use a body cast in the
adult. An EDF (elongation, derotation, flexion) cast is used for the treatment of Infantile Idiopathic
scoliosis. Scoliosis is a 3-dimensional problem that should be corrected on all 3 planes.
d. Spica Casts: Term spica is used when the cast spans the trunk of the body and one or more
limbs.
i. Shoulder Spica: The trunk is covered from the shoulder of the involved side [other side is
below the arm pit], to iliac crest and the involved limb is covered till wrist or hand.
ii. Hip Spica: A hip spica includes the trunk of the body and one or more legs. It is extended
till navel in the trunk.
 A hip spica which covers only one leg to the ankle or foot may be referred to as a single
hip spica, while one which covers both legs is called a double hip spica.
 A one-and-a-half hip spica encases one leg to the ankle or foot and the other to just above
the knee.
Application of the cast:
 A loosely knitted piece of fabric called a stockinette is placed over the fracture area.
 A layer of padding is added. Both of these layers’ act as a buffer between the skin and the cast
to reduce irritation.
 Strips are cut from the rolls of cast, moistened, applied over the fracture site and left to dry.
 Plaster and fiberglass harden into a tight, stiff encasement that prevents the fractured area from
moving and allows the broken ends of the bone to heal together.
 While applying the cast, immobilize the joints above and below the fracture, immobilize joints
in a functional position and Pad the limb adequately, especially on bony prominences.

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Complications of plaster cast
 Tight cast: The cast may be put on too tightly, or it may become tight if the limb swells.
Whenever swelling is anticipated, the cast should be applied over thick padding and the plaster
should be split before it sets, so as to provide a firm but not absolutely rigid splint.
 Pressure sores: Even a well-fitting cast may press upon the skin over a bony prominence. The
patient complains of localized pain precisely over the pressure spot. Such localized pain
demands immediate inspection through a window in the cast.
 Skin abrasion or laceration: This is really a complication of removing plasters, especially if an
electric saw is used. Complaints of nipping or pinching during plaster removal should never
be ignored; a ripped forearm is a good reason for litigation.
 Loose cast: Once the swelling has subsided, the cast may no longer hold the fracture securely.
If it is loose, the cast should be replaced.
Cast Removal
The cast must be worn until the fractured bone has knit itself together and the affected limb can
bear weight. When it’s time for the cast to be removed, a cast saw is used to cut it off. A cast saw
vibrates but does not rotate, and will not damage the tissue underneath the cast. Weight bearing
and cast removal are not necessarily related. The cast can be removed when the fracture has healed
with enough stability to hold its position with the cast off.
Nursing management of patient with cast
Assess the following before and after cast application:
• Evaluate the client’s pain, noting severity, nature, exact location, source and alleviating
and exacerbating factors.
• Access neurovascular status.
• Inspect for and document any skin lesions, discoloration, or no removable foreign material.
• Evaluate the client’s ability to learn essential procedures, such as applying slings correctly,
crutch walking, or using a walker.
Prepare the client for cast application.
• Explain the procedure and what to expect.
• Obtain informed consent if surgery is required.
• Clean the skin of the affected part thoroughly.
Assist the health care provider during application of the cast as needed.
After the cast application, provide cast care.
• Support an exposed cast, with the palms of your hands to prevent indentations.
• Ensure that the stockinet is pulled over rough edges of the cast.
• Elevate the casted extremity above the level of the heart.
• Provide covering and warmth to uncasted areas.

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• Expose the fresh plaster cast to circulating air, uncovered, until dry (24 to 72 hours). Expose
the fresh synthetic cast until it is completely set (about 20 minutes).
• Instruct the client to avoid wetting the cast. Instruct him to dry a synthetic cast with a hair
dryer on cool setting if it gets wet.
Initiate pain relief measure if indicated.
• Encourage position changes.
• Elevate the affected body part.
• Provide analgesics as appropriate.
• Promote non-pharmacologic pain relief measures, such as guided imagery, relaxation and
distraction.
Observe for signs and symptoms of cast syndrome with clients who are immobilized in large
casts, such as a body or hip Spica cast:
 Report abdominal pain and distention, nausea and vomiting, elevated blood pressure,
tachycardia, and tachypnea which are physiologic effects of cast syndrome.
 Any client who is claustrophobic is at risk for psychological cast syndrome, which includes
acute anxiety and possible irrational behavior.
 Provide nursing care for compartment syndrome, if indicated. Observe for signs and
symptoms and discuss and assist with treatments.
 Notify the health care provider immediately if signs or symptoms of other neurovascular
complications occur.
 Notify the health care provider if “hot spots” occur along the cast; they may indicate
infection under cast.
Provide client and family teaching.
 Encourage isometric exercises to strengthen muscles covered by the cast. Promote muscle-
strengthening exercises for the upper body if crutches are to be used.
 Advise the client to promptly report cast breaks and signs and symptoms of complications
(i.e. circulatory compromise, cast syndrome, and hot spots).
 Warn the client against inserting sharp objects (e.g. coat hanger to scratch itchy skin under
the cast). Instruct him to use a cool air from a dryer to help alleviate the itch.
 Teach the client appropriate cast care, depending on the type of cast.
 Encourage safety precautions (e.g. avoid walking on wet floors, watch throw rugs, be
careful with stairs).
 Teach the client skin care and muscle-strengthening exercises for the affected body part
after cast removal.
 Encourage mobility and active participation in self-care.
 Reinforce health care provider instructions on the amount of eight bearing allowed.

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5. Spinal Cord Injury (SCI)
Definition: Spinal cord injury can be defined as trauma or damage to the spinal cord, the major
column of nerve tissue that is connected to the brain and lies within the vertebral canal that results
in loss of function
Causes:
1. Traumatic
– Birth injuries, which usually affect the spinal cord in the neck area
– Falls, Motor vehicle accidents. These can be either when a person is riding as a passenger
in the car or is struck as a pedestrian.
– Sports injuries
– Diving accidents
– Trampoline accidents
– Violence. This involves penetrating injuries that pierce the cord, such as gunshots and stab
wounds.
2. Non traumatic
– Cervical spondylosis with myelopathy
– Myelitis
– Osteoporosis causing vertebral compression fractures
– Syringomyelia (central cavitation of the cord)
– Tumors, both infiltrative and compressive
– Vascular diseases, usually infarction or hemorrhage.
Classification
1. Classification according to mechanism of injury.
2. Classification according to the degree of involvement.
3. Classification according to level of injury
Mechanism of injury:
 Hyper Flexon injuries
 The most common type of SCI.
 Results in the rupture of posterior ligaments and thus causing forward dislocation of the
vertebrae.
 Nutrient blood vessels may be damaged, leading to ischemia of the spinal cord.

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 The cervical spine, usually at the C5-6 level is most commonly affected by flexion injury.
 In the thoracic-lumbar spine, this type of injury is most frequently seen at the T12-L1 level.
 Hyperextention injuries
 Results after a fall in which the chin hits an object and the head is thrown back.
 The anterior ligament is ruptured, with fracture of the posterior elements of the vertebral
body.
 Hyperextension against the ligament flavum can lead to dorsal column contusion and
posterior dislocation of the vertebrae.
 Complete transaction may occur.
 Compression injuries
 Often caused by falls or jumps in which the person lands directly on the head, sacrum or
feet.
 The force of impact fractures the vertebrae and the fragments compress the cord
 The disk and bone fragments may be propelled into the spinal cord on impact.
 The lumbar and the lower thoracic vertebrae are the most commonly injured regions after
a compression impact when the person lands on the feet.
 If the person lands on the head, the injury is to the cervical spine.
Degree of involvement
 Complete cord involvement
 It results in paralysis and flaccidity with total loss of sensory and motor function below the
level of the lesion (injury).
 A complete spinal cord injury may lead to paraplegia (paralysis of the lower body) or
quadriplegia (paralysis of all four extremities).
 Incomplete cord involvement
 This lesion result in a combination of loss of voluntary motor activity and sensation and
usually leaves some tracts intact.
 Some function is present below site of injury
 More favorable prognosis overall.
Types of incomplete cord injuries
a. Anterior cord syndrome
– Due to flexion / rotation, producing Anterior dislocation or compression fracture of a
vertebral body encroaching the ventral canal.
– May also occur as a result of injury to the anterior spinal artery, affecting cortoco-spinal
and spino-thalamic tracts functions, which supplies the anterior two third of the spinal cord.

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– Characterized by weakness, loss of pain, temperature and motor function below the level
of the lesion (due to disruption in corticospinal and spino-thalamic function)
– Light, touch, position and vibration sensation remain intact.
– Poor prognosis for injury
b. Central cord syndrome
– most commonly in those who suffer a hyperextension injury
– This commonly occurs with a fall forward, striking the chin, and having the neck extend
backward at the time of the fall.
– Elderly patients often have underlying cervical spondylosis (stress defects within the
vertebral bodies). This leads to the posterior cord being either irritated or compressed by
the posterior ligamentum flavum or can lead to anterior cord compression from underlying
spondylosis or osteolytic lesions. These two contusion type injuries to the cord can lead to
symptoms secondary to edema of the cord at the site of injury. It could also lead to bleeding
into the cord at the site of injury, which understandably has a worse prognosis.
– The upper extremity tracts are the most medial compared to the lower extremity/sacral
segments being the most lateral, so when compression occurs the central portion becomes
more effected then the external segments due to the external pressure.
c. Brown-sequard syndrome (Lateral cord syndrome) (hemitransection)
– results from a lesion in one (lateral) half of the spinal cord (for example, hemisection or
lateral injury of the cord)
– loss of pain and temperature sensation contralateral to the hemisection due to the
interruption of the crossed spinothalamic tract.
– total ipsilateral loss of position, light touch and vibration sensation at the level of the lesion.
– Ipsilateral loss of proprioception function below the level of lesion due to interruption of
ascending fibers in the posterior colums.
– Ipsilateral spastic weakness with hyperreflexia and bakinski sign caudal to the level of
lesion due to interruption of descending corticospinal tract.
d. Cauda-Equina Syndrome
– Caused by injury to the lumbosacral nerve roots below the conus medullaris.
– It results in areflexia of the bowel, bladder and lower extremities.
e. Conus medullaries
– Caused by a damage to the lumbar nerve roots and the conus medullaris in the spinal cord.
– Results in bowel and bladder areflexia and flaccid lower extremities.
– The bulbocavernosus penile erection and micturition reflexes may be preserved when
damage is limited to the upper sacral segments of the spinal cord.

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American spinal injury association impairment scale (ASIA)
The American spinal cord injury association (ASIA) provides classification of SCI according to
the degree of motor function after injury. “Neurologic level” refers to the lowest level at which
sensory and motor functions are intact.
– A (COMPLETE)= No motor or sensory function is preserved
– B (INCOMPLETE)= Sensory but not motor function is preserved below the neurologic level,
and includes the sacral segments S4-S5.
– C (INCOMPLETE)= Motor function is preserved below the neurologic level and more than
half of the key muscles below the neurologic level have a muscle grade less than 3.
– D (INCOMPLETE)= Motor function is preserved below the neurologic level and at least half
of key muscles below the neurologic level have a muscle grade of 3 or greater.
– E (NORMAL)= Motor and sensory function are preserved.
Classification according to the level of injuries
 Cervical injuries
 The most common of all spinal injuries.
 C6-C6 is most frequently affected
 Thoracic injuries
 Much less common.
 The spine here is well protected and stable
 Lumabar injuries
 Occurs next in frequency. L1-L5 are common areas.
Pathophysiology
– Injury results from primary and secondary insults
– Primary injury occurs at the time of the traumatic insult
– Secondary injury occurs over hours to days as a result of a complex inflammatory
process, vascular changes and intracellular calcium changes leading to oedema and
ischemia of the spinal cord.
– Irreversible damage occurs to nerve cells leading to permanent disability
The initial clinical manifestations depend upon the level and extent of injury to the cord. Below
the level of injury or lesion, the following functions are lost.
– Voluntary movement
– Sensation of pain, temperature, pressure and proprioception
– Bowel and bladder function
– Spinal and autonomic reflexes

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Changes in Reflexes
– Reflexes usually absent in early SCI because of spinal shock.
– BP and temperature in denervated areas fall markedly (neurogenic shock) and respond poorly
to reflex stimuli.
– After spinal shock subsides, some body functions may return by reflex (e.g control of urinary
bladder), but they lack integration with other visceral activities.
– Nervous system lesions may produce a type of defective urinary bladder function known as
neurogenic bladder.
– This form of cord bladder is called a reflex bladder.
– Such stimulation may also cause reflex ejaculation and priapism in paralyzed men.
Muscle spasm
– Intense and painful muscular spasms of the lower extremities occur following a traumatic
complete transverse spinal cord lesion.
– They range in intensity from mild muscular twitching to vigorous mass reflexogenic states.
– May be triggered by extrinsic or visceral stimuli, such as a distended bladder. Emotions or
cutaneous stimulation may initiate spastic movements.
– May be aggravated by cold weather, prolonged period of sitting, infections or emotionally
upsetting events
Autonomic Dysreflexia
This life-threatening complication occurs in patients with injuries above the T6 level. The spinal
cord injury impairs the normal equilibrium between the sympathetic and parasympathetic
autonomic nervous system. The most common cause of autonomic dysreflexia is bladder
distention.
– hypertension,
– a pounding headache,
– flushing above the level of the lesion,
– nasal stuffiness,
– diaphoresis,
– piloerection, dilated pupils with blurred vision,
– bradycardia, restlessness and nausea
Cervical injuries
– Suboccipital pain in the distribution of the greater occipital nerve (C2) and neck stiffness may
occur early.

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– Compressive lesions of the upper cervical cord (C1-C4) segments may compromise cranial
nerve functions, resulting in anamolous head position, inadequate contraction and atrophy of
the sternocleidomastoid muscle, and impaired elevation of shoulder towards ipislateral ear.
– Diaphragmatic paralysis may occur from lesions involving the C3-C5 cord segments, leading
to limited lateral expansion of the lower rib cage during inspiration.
– Lesions affecting C5 and C6 segments causes LMN signs especially involving deltoid, biceps,
brachioradialis, brachialis, pectorals, triceps. Spastic parapaesis of the lower extremities is
often present.
– Diaphragmatic functions may be compromised (C5).
– can affect all four extremities, causing paralysis and paresthesias,
– impaired respiration, and loss of bowel and bladder control.
– If the injury is at C3 or above, the injury is usually fatal because muscles used for breathing
are paralyzed.
– An injury at the C4/C5 affects breathing and may necessitate some type of ventilatory support.
Injuries to lumbosacral region:
– With L1 segment cord lesions, all muscles of the lower extremities are weak (paraparesis).
Sensory loss involves both the lower extremities up to the groins and back up to the level above
the buttocks.
– With L2 segment cord segment, spastic paraparesis, but no weakness of the abdominal nuscles.
There is normal sensation on the upper anterior aspects of the thigh.
– With L3 lesion, there is some preservation of hip flexion and leg adduction. The patellar
reflexes are hypoactive or absent. The ankle reflexes are hyperactive. Sensation is normal on
the upper anterior aspects of the thighs.
– With L4 lesion,
 Able to stand by stabilizing knees. There is patellar areflexia. Ankles reflexes are hyper
active.
 Sacral injuries affect bowel and bladder continence and may affect foot function
 Sexual dysfunction
Injuries to thoracic region
– Complete injuries at or below the thoracic spinal levels result in paraplegia.
– Functions of the hands, arms, neck, and breathing are usually not affected.
– T1 to T8: Inability to control the abdominal muscles. Accordingly, trunk stability is affected.
The lower the level of injury, the less severe the effects.
– T9 to T12: Partial loss of trunk and abdominal muscle control.

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Investigations
History taking: Perform careful history taking, focusing on symptoms related to the vertebral
column (most commonly pain) and any motor or sensory deficits. Ascertaining the mechanism of
injury is also important in identifying the potential for spinal injury
Physical examination
General examination
 Head and ear
 Spinous process and interspinous ligament palpation
 Penile erection and incontinence of bowel and bladder
 Flaccid paralysis of the extremities (quadriplegia)
Neurological assessment: Assessment of neurologic function to determine level of injury.
Sensory function is assessed according to dermatomes to identify the areas of skin with normal
sensation. Motor function is measured by testing myotomes to identify muscles with active
movement and full range of motion against gravity. Assess for reflexes.
– Biceps reflex mediated by C5 and C6 nerve roots
– Triceps reflex mediated by C6 and C7 predominantly by C7
– Knee jerk reflex meadiated by L3 and L4 mainly L4
– Ankle jerk reflex mediated by S1 nerve root
– Plantar reflex (babinski sign)
– Hoffman test
X-ray films: Locates level and type of bony injury (fracture, dislocation); determines alignment
and reduction after traction or surgery.
Spinal tap or myelography: Visualization of spinal column if pathology is unclear or if occlusion
of spinal subarachnoid space is suspected (not usually done after penetrating injuries). A
myelogram is an older test that is used to examine the spinal canal and spinal cord. The myelogram
test to determine whether there is pressure on the spinal nerves from various causes. During this
test, a special X-ray dye is placed into the spinal sac.
CT scan: Computed tomography, more commonly known as a CT or CAT scan, is a diagnostic
medical test that, like traditional x-rays, produces multiple images or pictures of the inside of the
body. Locates injury, evaluates structural alterations. Useful for rapid screening and providing
additional information if x-rays films provides insignificant result. Using CT, the bony structure
of the spine vertebrae is clearly and accurately shown, as are intervertebral disks and, to some
degree, the spinal cord soft tissues.

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MRI: MRI a test that uses powerful magnets, radio waves, and a computer to make detailed pictures
inside of body. Overall status of cord i.e. cord lesion, edema, compression etc.
Management
Management requires multidisciplinary approach because of multiple-system involvement and the
psychological aspects of catastrophic injuries.
1. Pre-hospital management/Emergency management
2. Hospital management
 Medical management
 Conservative (general)
 Conservative (medical)
 Surgical management
 Surgical decompression
 Surgical stabilization
 Fixation of vertebra
 Fixation of spine
 Artificial disc implantation
Emergency management/immediately after trauma (less than 1 hour)
The immediate management at the scene of injury is critical, because improper handling of the
patient can cause further damage and loss of neurologic function. Immediate (initial) care must
include rapid assessment, immobilization, extrication, stabilization or control of life threatening
injuries and transport to the nearest medical facility.
– At the site of injury, patient must be immobilized on a spinal board, with head and neck
maintain in neutral position to prevent incomplete injury being complete.
– Attention should be given to maintain patient’s head so as to prevent flexion, rotation or
extension. This is done by placing both hands on patient’s both side of the face at ear level.
– The patient should be slided carefully onto a board for transfer to the hospital and log
rolling method should be used.
– Any twisting movements should be avoided. After determining the extent of injury the
patient may be placed on a rotating bed or in a cervical collar.
– If rotating bed not available, the patient should be placed in a cervical collar and on a firm
mattress.

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Medical management (Acute Phase. 1 to 24 hours)/ immediate (conservative general). The goals
of medical management are to prevent secondary injury to observe for symptoms of progressive
neurologic deficts and prevent complications. Resuscitation according to ATLS guidelines:
Follow ATLS principles: (Primary Survey)
– A irway; protect Spine
– B reathing
– C irculation
– D isability, Dx and Rx shock
– E xpose patient
Then shift treatment to secondary survey: mechanism of injury and neurological examination.
1. Maintenance of pulmonary and cardiovascular stability
 Intubation and mechanical ventilation if needed.
 Vasopressors to maintain adequate perfusion to sustain mean arterial BP> 90mm of Hg
 Medical stabilization before spinal stabilization and decompression.
2. Spinal cord immobilization (use of skeletal tongs)
 Crutchfield and vinke tongs require predrilled holes in the skull under local anesthesia;
Wells and heifitz tongs do not.
 Weight is added to traction gradually to reduce the vertebral fracture; weight maintained
at the level to ensure verbal alignment. lateral soine filme are taken after the addition of
weight to asses’ spinal alignment.
3. Rigid kinetic turning bed can be used to immobilizes patient with thoracic and lumbar
injuries
4. Methylprednisolone sodium succinate may be administered within 8 hours of injury:
 Bolus 30mg/kg administered over 15minutes; maintenance infusion of 5.4 mg/kg/hr
infused for 24 hr
 Additional benefit may be achieved by administering the maintenance dose for 48 hours
5. Maintenance of neurogenic bladder
 Foleys cauterization
6. Pressure ulcer prevention
 Pressure reduction mattress or kinetic turning frame
7. Prevention of DVT and its sequelae for sustained SCI due to high risk of thromboembolic
complications.
 Adjusted heparin dose or LMWH for anticoagulant prophylaxis within 72 hours of SCI,
except in those with active bleeding, evidence of head injury or coagulopathy.

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Conservative medical management:
– Epidural stimulation implant
– Epidural steroid injection
– Intradiscal thermoplasty
– Nucleoplasty
– Facet injections, / medical branch blockadge
– Radio frequency rhizotomy or Denervation
 Epidural stimulation implant: The surgically implanted devices sits over spinal cord
protecting coating and is connected to the nerve system where it is able to stimulate loco motor
like activity. This treatment can be offered to the patients with both complete and incomplete
injuries.
 Epidural steroid injection: An epidural steroid injection is a common procedure to
treat spinal nerve irritation that is most often caused by tissues next to the nerve pressing
against it. The beginning of the nerve (nerve root) may be irritated by a bulging intervertebral
disc, disc contents ("ruptured disc”) or bone spur, directly touching the spinal nerve.
 Intradiscal thermoplasty (IDET): a relatively new, minimally invasive treatment for spinal
disc-related chronic low back pain.
 Nucleoplasty: Intervertebral discs are cushion-like structures that are located between the
bones that make up the spine. Under certain conditions, the discs can bulge and cause back
pain. Percutaneous disc nucleoplasty is a minimally invasive procedure used to reduce the
pressure inside a disc to relieve pain. A live X-ray image (fluoroscope) to guide a thin tube-
like cannula to the bulging disc is used. Next, a narrow radiofrequency device is inserted
through the cannula. The device transmits radio waves that dissolve small areas of the nucleus
pulposus. In turn, this creates space for the nucleus’ contents to spread into, reducing pressure
in the disc and decreasing the disc bulge. When the procedure is complete, the cannula and
radiofrequency devices are removed. Because a tiny incision is required for this procedure,
there are no stitches and the insertion point is simply covered with a small bandage.
 Facet joint injection: Facet joints are small joints at each segment of the spine that provide
stabilityand help guide motion. A cervical, thoracic orlumbar facet joint injection involves injecting
a small amount oflocal anesthetic (numbingagent) and/or steroidmedication,which can anesthetize
the facet joints and block the pain.
 Radio frequency rhizotomy / Denervation: Radiofrequency (RF) rhizotomy or neurotomy is a
therapeutic procedure designed to decrease and/or eliminate nerve pain symptoms that have
not responded to more conservative pain treatments. The procedure involves destroying the
nerves causing the pain with highly localized heat generated with radiofrequency. By
destroying these nerves, pain signals are prevented from being transmitted from the spine to
the brain.

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Chronic phase (beyond 1 week)
 Segmental instrumentation systems are used in conjunction with a body jacket and are used
for patients with thoracolumbar injuries.
 Stiff orthosis is utilized for external stabilization of cervical fractures. Devices include the
halo brace, Minerva collar, extended Philadelphia collar, and fabricated orthosis. Devices
is selected based on the types of fracture and extent or instability. Average length of time
in halo brace is 12 weeks followed by Philadelphia collar for 4 weeks.
 Compression boots, anticoagulants for the minimization of risk of thrombophlebitis
– Minimum of 8 weeks from time of injury for those with incomplete or complete motor
injury with no additional risk factors.
– For 12 weeks with complete motor injury with additional risk factors.
Surgical management
Depending on the circumstances, when surgery is required. Surgery may be considered if the spinal
cord is compressed and when the spine requires stabilization. The surgeon decides the procedure
that will provide the greatest benefit for the patient. Surgery is recommended in any of these
following conditions:
– Compression of the cord is evident
– The injury results in fragmented or unstable vertebral body.
– The injury involves a wound that penetrates the cord.
– Bony fragments are in the spinal cord.
– Patient’s neurologic status is deteriorating
Common surgical procedures are:
 Surgical decompression: it is a surgical procedure to relieve pain pressure and pain caused by
the impingment. A small portion of bone presents over the nerve root called lamina, or disc
material from under the nerve root is removed to give the nerve more space.
 Laminotomy/ foraminotomy: the procedure involves partial removal of lamina.
 Laminectomy: A laminectomy is the total removal of the lamina.
 Disectomy: removing the part of disc that is compressing nerve.
 Surgical Stabilization: Stabilization is also called immobilization. Spinal stabilization
involves the installation of hardware and bone grafts to fuse segments of the spine
 Spinal fusion: Spinal fusion is a surgical procedure used to correct problems with the
small bones in the spine (vertebrae). It is essentially a "welding" process. The basic idea
is to fuse together two or more vertebrae so that they heal into a single, solid bone. This
is done to eliminate painful motion or to restore stability to the spine.

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 Fixation of Vertebra: Spinal fixation devices provide stability and restore anatomic
alignment. Spinal fixation device stabilizes an area of the posterior spine while allowing for a
significant range of motion and limiting the compression of the affected vertebrae.
 Artificial disc implantation: Cervical disc replacement is a surgical procedure that involves
removing a damaged or degenerated cervical disc and replacing it with an artificial disc device.
Cervical discs are the cushions or shock absorbers between the bones (vertebra) of the neck
(cervical spine)
Rehabilitation
Acute: This period begins with admission to hospital and stabilization of the patient’s neurological
state and is a 6-12 wk bed period. The aim of rehabilitation in this period is to prevent
complications that may occur long term.
 Passive exercises should be done intensively to resolve contractures, muscle atrophy and
pain during the acute period of hospitalization in patients with complete injury.
 Positioning of the joints is important in order to protect the articulary structure and maintain
the optimal muscle tonus.
 Sand bags and pillows can be useful in positioning. If the pillows and sandbags are not able
to provide positioning, it can be achieved with plaster splints or more rigid orthotics. Ankle
foot orthosis, knee-ankle foot orthosis or static ankle foot orthosis, etc. are mainly used for
this purpose
 Muscles are flaccid during the spinal shock period. Exercises can be done more easily with
flaccid muscles
 Early mobilization plays an important role in prevention of pulmonary function decline
and in the development of muscle strength. Breathing exercises should be carried out and
taught and its importance should be explained to complete or incomplete paraplegic and
tetraplegic patients during the acute phase in order to protect lung capacity
Chronic rehabilitation: The most important expectations in the chronic phase or phase to return
home are ensuring the maximum independence related to the level of the patient’s injury,
integration of the patient to society and teaching the importance of the family’s role.
 One of the important features of this period is restoring the patient’s psychological and
emotional state again because of the high incidence of depression in patients (the incidence
is about 1/3 in the first six months)
 Occupational therapy is an important part of the rehabilitation process. In developed
countries, occupational therapy is carried out by the occupational therapist in the

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rehabilitation team. Occupational therapists assess the patient’s limitations and plan the
occupational activities. Occupational therapy is planned and implemented depending on
the social and cultural characteristics of individuals, level of education, personality traits,
interests, values, attitudes and behaviors before and after the injury. Pictures, music, crafts,
ceramic work and a variety of activities (for example, sports) and entertainment are
implemented and planned to focus on the purpose in the occupational treatment
Complications
Early
 Atelectasis: cervical injury or fracture above the level of C4 presents special problems because
of total loss of respiratory muscle function. Injury below level of C4 results in diaphragmatic
breathing if the phrenic nerve is functioning. Later spinal cord edema, hemorrhage can affect
the function of phrenic nerve and cause respiratory insufficiency. If the injury is more severe,
paralysis of abdominal muscle and intercostals muscle will allow secretions remain in the lungs
causing atelectasis. Bronchial hygiene, chest physiotherapy is important to minimize the risk.
 Spinal shock: immediate temporary loss of total power, sensation, and reflexes below the level
of injury. In addition to the discrete damage at trauma site, the entire cord below the level of
lesion fails to function, resulting in spinal shock, characterized by hypotension, bradycardia,
warm dry extremities. Patient suffering from spinal shock has loss of reflexes in the beginning,
but it is followed by gradual recovery of the reflexes. Spinal shock is a combination of
autonomic and motor dysreflexia. The care provided during this phase are:
 Immobilization of the injured part with spinal board or cervical collar.
 Airway is maintained
 Intravenous catheter is inserted to inject medications to control tachycardia,
bradycardia and hypotension
 Intravenous fluid is initiated if patient is suffering with low blood pressure.
 Nasal oxygen is provided to maintain normal blood oxygenation.
 Methylprednisolone is given as bolus 30mg/kg body weight, followed by infusion
5.4mg/kg/hr for 24 hr.
 Venous Thrombo embolism(VTE): VTE includes deep vein thrombosis (DVT), when a
blood clot forms in a deep vein, usually in the leg due to lack of immobilization.
 Bradycardia
 Hypotension
 Psychological dysfunction such as denial and depression.
 The muscles show loss of sensation, paralysis, absent reflexes and are flaccid.

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 The bowel and bladder initiation reflexes are affected resulting in bowel distention and
paralytic ileus.
Late complications
 Autonomic dysreflexia
This potentially serious complication occurs after lesions above T6 and mainly in those of the
cervical cord above the sympathetic flow. The commonest provoking causes are distension or
irritation of bladder, often due to detrusor-sphincter dysynergia, infection or calculi. These
stimuli cause reflex vasoconstriction below the level of lesion, leading to arterial hypertension.
And without prompt treatment, there is a risk for intracranial haemorrhage. So in patients
known to be disposed to autonomic dysreflexua, treatment with antihypertensive (nifedipine)
should br given prior to the delivery of stimulus. Once the acute attack has been dealt with,
provoking stimuli should be eradicated.
 Pressure ulcers
Shock in early stages of injury, vasomotor paralysis, repeated minor trauma, and above all
local ischaemia caused by pressure are aggravating factors for pressure sore. So the patients
should be cared:
• On a Ripple bed or any type of bed which reduces or regularly transfers pressure.
• Care should be taken that the bed clothes are warm, dry and free from rucks.
• Hot water bottles or electric blanket is not placed in contact with the skin.
• The patient should be bathed daily, thoroughly cleaned with soap and water and
carefully dried.
• Posture should be changed in every 2hours.
• The lower limbs should be kept extended and the calves should be rest upon small
pillows with the heels projecting beyond them.
 Joint Contractures
Immobility alters the pattern of collagens in ligaments, tendons and joint capsules and allows
the loss of sarcomeres from muscles fixed in shortened position. It is therefore important to
put limb movements through a fullrange of movement several times a day and to discourage
postures in which muscle spend excessive periods in a shortened position. Postures should be
selected that inhibits spasticity and stretch the muscle that are likely to develop contractures.
For e.g. when lying supine, feet should always be supported by a roll or pillow to discourage
shortening of paralysed calf muscle. The sitting position should be meticulously controlled
with a suitable back rest, pelvic support to prevent tilting of the pelvis, pommel and foot rest
at the correct angle and height.

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 Respiratory tract infection
Impaired respiratory effort, decreased cough, mechanical ventilation, and immobility all
predispose the cervical cord–injured patient to pneumonia. Catheterization, whether
indwelling or intermittent, places patients at risk for urinary tract infection.
 Urinary tract infection/ Renal calculi formation
Interruption in sacral reflux arc usually causes retention of urine, owing to the unopposed
action of the sympathetic. Urinary tract infections are an ongoing concern to spinal cord–
injured patients. Both urinary reflux and untreated urinary tract infections can cause permanent
damage to the kidneys. When the bladder is normally atonic, the choice of bladder evacuation
is, intermittent urethral catheterization with a 12FG or 14FG catheter every 6 hours, restricting
fluid intake to 1500ml/24 hr. And suprapubic catheterization using a 10 or 15FG catheter which
avoids the risk associated with urethral catheterization and allows a high fluid intake if
necessary. Electrical stimulation of sacral nerve roots to achieve continence and voiding, using
implanted implanted electrodes activated via a transcutaneous radio-frequency link.
 Hypertrophic ossification:
Heterotopic Ossification (HO) is the abnormal growth of bone in the non-skeletal tissues
including muscle, tendons, or other soft tissue. When HO develops, new bone grows at 3 times
the normal rate resulting in jagged, painful joints. HO may develop within days following the
spinal cord injury or several months later. HO usually occurs 3-12 weeks after spinal cord
injury yet has been known to also develop years later.
 Deep vein thrombosis: Lack of movement in the legs inhibits normal blood circulation.
Compression stockings, sequential compression devices, and subcutaneous heparin may be
used separately or together to reduce the risk of deep vein thrombosis.
 Depression: Depression is not a natural process experienced after SCI but is a complication
that needs to be treated. Suicide is the most common cause of death after SCI among patients
under the age of 55. Frequency of posttraumatic stress disorder is 17% and usually occurs in
the first 5 years. Consultation with a psychiatrist is needed if there is psychotic behavior and
depression. Occupational therapy and finding the patient’s role in society are most important
factors in restoring the psychological state. Social and psychological problems in the absence
of daily activities have been reported. Suicide attempts have been reported due to a lack of
daily activity, depression, alcohol dependence and emotional distress. Occupational therapy
allows SCI patients to be more social, to use their own functions for creative jobs and to deal
with psychological problems like depression.

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Nursing management
Assessment
 Assessing respiratory patter and ensuring adequate airway (risk for respiratory compromise if
C3 through C5 is injured as it inervates the phrenic nerve which controls diaphragm)
 The patient is monitored closely for any changes in motor or sensory function and for
symptoms of progressive neurologic damage.
 Careful neurologic examination is carried out
 Assess vital signs with a focus to respiratory function.
 Motor ability is tested by asking the patient to spread the fingers, squeeze the examiner’s hand
and move the toes or turn the feet.
 Sensation is evaluated by gently pinching the skin or touching it lightly with an object.
Nursing diagnosis
– Ineffective breathing pattern related to weakness or paralysis of abdominal and intercostals
muscles and inability to clear secretions.
– Ineffective airway clearance related to weakness of intercostal muscles.
– Impaired physical mobility related to motor and sensory impairments.
– Risk for impaired skin integrity related to immobility and sensory loss.
– Impaired urinary elimination related to inability to void spontaneously.
– Acute pain and discomfort related to treatment and prolonged immobility.
– Self-care deficit related to paralysis.
– Risk for autonomic dysreflexia related to stimuli below the level of injury
– Constipation related to immobility and nerve damage.
Interventions for effective breathing
 Give special attention to patient’s vitals sign
 Do cautiously suction to clear pharyngeal secretions.
 Specific breathing exercises are supervised by the nurse to increase the strength and
endurance of the inspiratory muscle.
 Proper humidification and hydration are important to prevent secretions from becoming
thick and difficult to remove even with coughing.
Intervention for improving mobility
 Proper body alignment is maintained all the time.
 Patient is assisted to reposition Frequently and is assisted out of bed as soon as spinal
column is stabilized.
 Various types of splints are used to prevent foot drop.

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 Regular ROM exercises to preserve joint motion and stimulate circulation.
 Log rolling method
Maintaining skin integrity
 Change the position of patient at least 2 hourly.
 Careful skin inspection is done in every turn of patients
 The skin above pressure points is aasessed for redness or breaks.
 Skin are to be kept clean washing with mild soap, rinsing well, and blotting dry.
 Pressure is kept lubricated with moisturing lotion.
Maintaining urinary elimination:
Immediately after SCI, the urinary bladder becomes atonic and cannot contract by reflex activity
resulting in urinary retention.
 Immediate catherization is carried out to avoid over distenstion
 Family members should be provided with an instruct for cather care
 Patient party is asked to notice fluid intake, voiding pattern, amount of residual urine after
catherization.
 Teach to record fluid intake, voiding pattern, amount of residual urine after catheterization,
characteristic of urine.
Self-care maintaining
 Encourage the patient and significant others to participate in hands-on care as much as
possible.
 If the patient will not be able to perform self-care, assist him or her to learn to direct care.
 Physical and occupational therapists can help the patient adapt to a wheelchair or other
mobility aids. Most patients spend some time in a rehabilitation facility to learn to function
independently. Some patients may require long term care
Risk for autonomic dysreflexia related to stimuli below the level of injury
 If any sign of autonomic dysreflexia, immediately take the patient’s blood pressure and
continue to monitor it every 5 minutes.
 Remember that patients with spinal cord injury are typically hypotensive, so a finding of
even mild, Place the patient in a Fowler’s position to utilize the effect of orthostasis to
control blood pressure hypertension may represent a dramatic increase from their baseline
blood pressure

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 Evaluate the indwelling catheter for patency. If it is not patent or a catheter is not in place,
obtain an order to insert one immediately.
 Monitor blood pressure during catheterization
 Make confirmation for bowel distention
 If bowel and bladder distention are absent, rule out associated cause
 If hypertension is still present, notify the physician
Managing constipation
 Diet rich in fiber to be administered
 Ambulate the patient depending upon his/her condition
 Stool softener to be given to relief constipation.

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6. Metabolic Bone Diseases
Metabolic bone disease is an umbrella term referring to abnormalities of bones caused by a broad
spectrum of disorders. Most commonly these disorders are caused by abnormalities of minerals
such as calcium, phosphorus, magnesium or vitamin D leading to dramatic clinical disorders that
are commonly reversible once the underlying defect has been treated. The most common MBD is
osteoporosis. Examples of metabolic bone diseases include osteoporosis, rickets, osteomalacia,
osteogenesis imperfecta, marble bone disease (osteopetrosis), Paget disease of bone, and fibrous
dysplasia.
Metabolic Bone Disorders are:
– Osteoporosis
– Osteomalacia
– Rickets
– Paget’s Disease
Osteoporosis
Introduction
– Most prevalent bone disease in the world
– Osteoporosis (“porous bones”, from Greek: osteon meaning “bone” and porous meaning
“pore”) is a disease of bones that leads to an increased risk of fracture. In most cases, bones
weaken when low levels of calcium, phosphorus and other minerals in the bones and results as
low bone density.
– Although it's often thought of as a women's disease, osteoporosis also affects many men.
Osteoporosis: Metabolic skeletal disease characterized by low bone density and micro
architectural deterioration of bone tissue which results in increased bone fragility and susceptibility
to fracture.
Pathophysiology
– is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone
architectural strength

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– rate of bone resorption that is maintained by osteoclasts is greater than the rate of bone
formation
– bones become progressively porous, brittle, and fragile;
– Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased.
– Estrogen, which inhibits bone breakdown, decreases with aging.
Risk Factors
– Genetics (whites and Asians, female, small frame)
– Age (postmenopausal, advanced age, decreased calcitonin)
– Nutrition (low calcium and vitamin D, small calories)
– Physical exercise (sedentary, low weight and BMI)
– Lifestyle choices (caffeine, alcohol and smoking)
– Medications (corticosteroids, anti-seizure meds, heparin)
Signs and symptoms: Osteoporosis has been called “silent disease” because bone mass is lost
over many years with no signs or symptoms.
Clinical manifestation:
 Back pain.
 Fracture of bone; break easily even sneeze or minor fall
 Compression fracture of spine
 Kyphosis, shortened stature
 Change in height (loss of height)
 Bone loss in mandible: loss of teeth or poorly fitted teeth changes in appearance
 Hunch back appearance (dowager’s hump)
Normal bone has the appearance of a honeycomb matrix (left). Under a microscope, osteoporotic
bone (right) looks more porous.
Diagnosing Osteoporosis:
1.History Taking and Physical Examination
2. Blood and urine test:(e.g., serum calcium, serum phosphate, serum alkaline phosphatase,
urine calcium excretion, hematocrit, erythrocyte sedimentation rate [ESR])
3. x-ray studies: determine bone density.
4. radiographic: bone mass (osteopenia).
5.ultrasonography: determine bone density.
6.Dual-energy x-ray absorptiometry: The best screening test is dual energy X-ray
absorptiometry (DEXA) – measures the density of bones in the spine, hip and wrist and it's
used to accurately follow changes in these bones over time

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Management
The goals of osteoporosis treatment are to:
– Control pain from the disease
– Slow down or stop bone loss
– Prevent bone fractures with medicines that strengthen bones
– Minimize the risk of falls that might cause fracture.
A. Medical management:
1. Bisphosphonates:
Mechanism: inhibits bone resorption by attaching to bony surfaces undergoing active
resorption and inhibiting action of osteoclasts, leads to increases in bone density and reduced
fracture risk. Following are the primary drugs used to both prevent and treat osteoporosis in
post-menopausal women: Alendronate, Risedronate, Ibandronate
2. Calcitonin:
3. Hormone replacement therapy: to increase serum estrogen levels, which in turn decrease
the rate of bone resorption.
4. Parathyroid hormone
5. Other agents used with varying results
Drug Therapy
Osteoporosis
– Hormone replacement therapy
– Parathyroid hormone
– Calcium and vitamin D
– Bisphosphonates
– Selective estrogen receptor modulators
– Calcitonin
– Other agents used with varying results
Diet Therapy
– Protein
– Magnesium
– Vitamin K
– Trace minerals
– Avoid alcohol and caffeine

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Others -
– Exercise
– Pain management
– Orthotic devices
Nursing Management:
Assessment:
– Profile: Age and gender
– Risk factor
– Secondary causes
– Symptoms related
– Past medical history
– Family history
– Social history
Physical Exam:
General:
- decreasing height greater > 1.5inches
- dorsal kyphosis
- exaggerated cervical lordoisis
- low body weight.
Assessed for:
- localized pain
- muscle spasm
- neurologic deficit (risk of spinal cord compression)
- loss of strength
- range of motion in the affected area
Fractures most commonly occur in the vertebral bodies, wrist, humerus, hip. rib and pelvis (in
that order).
Nursing Diagnosis:
– Acute pain
– Impaired physical mobility
– Self-care deficit (Dressing or grooming)
– Imbalanced nutrition: Less than body requirements
– Risk for impaired skin integrity
– Risk for injury

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– Risk for constipation RT immobility
– Deficient knowledge about the osteoporosic process and treatment regimen
Goals:
– relieving pain
– improve self-care.
– improve nutritional status.
– improve physical mobility.
– prevent injury. (no new fracture)
– improving bowel elimination.
– promoting understanding of osteoporosis and the treatment regimen.
Intervention
– consumes adequate dietary calcium and vitamin D.
– encourage to increase level of exercise.
– modify lifestyle choices: avoid smoking, alcohol, carbonated beverages.
– maintain optimal body wt.
– creates safe home environment.
– adheres to prescribe screening and monitoring prcedures.
– take prescribed medication as instruction.
Osteomalasia
Introduction:
– Osteomalacia is the softening of the bones caused by defective bone mineralization
secondary to inadequate levels of available phosphate and calcium, or because of overactive
reasorption of calcium from the bone which can be caused by hyperparathyroidism (which
causes hypercalcemia).
– Osteomalacia in children is known as rickets, and because of this, use of the term
"osteomalacia". Osteomalacia is not same as osteoporosis that can also lead to bone
fractures. Osteomalacia results from a defect in bone building process, while osteoporosis
develops due to a weakening of previously constructed bone.
Causes:
– Osteomalacia is a generalized bone condition in which there is inadequate mineralization of
the bone. Many of the effects of the disease overlap with the more common osteoporosis, but

71
the two diseases are significantly different.
– There are two main causes of osteomalacia:
 Insufficient calcium absorption from the intestine because of lack of dietary calcium or a
deficiency of, or resistance to, the action of vitamin D; and
 Phosphate deficiency caused by increased renal losses.
Other causes:
– Vitamin D deficiency
– Certain surgeries
– Celiac disease
– Kidney or liver disorders
– Drugs: phenytoin, Phenobarbitone
Risk Factors:
– Dietary calcium and vitamin D deficiency
– Limited sunlight exposure
– Chronic kidney disease
– Inherited disorders of vitamin D and bone metabolism
– Hypo phosphatasia
– Anticonvulsant therapy.
Signs and Symptoms
– Diffuse joint and bone pain (especially of spine, pelvis, and legs)
– Muscle weakness
– Difficulty walking, often with waddling gait
– Hypocalcemia (positive Chovestek sign)
– Compressed vertebrae and diminished stature
– Pelvic flattening
– Weak, soft bones
– Easy fracturing
– Bending of bones
– Knock knee
– Bowel legs
– Pigeon breast
– Delayed closing of fontanels
– Softening skull

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– Bulging forehead
– Poorly developed muscles (pot belly)
– Difficulty climbing and walking stairs
Diagnostic Investigation
History
Physical examination
Laboratory test:
 blood: Low serum calcium and phosphate
 Urine: calcium and creatinine level
 Elevated parathyroid hormone (due to low calcium)
 Plasma level of vitamin D decreases especially in elderly
 X-ray: diminished bone density
 Bone biopsy
 Other test: hepatic, renal function test
 Small bowel biopsy
Treatment
Medical management
– Massive oral dose of vitamin D: Nutritional osteomalacia responds well to administration of
10,000 IU weekly of vitamin D for four to six weeks.
– Osteomalacia due to malabsorption may require treatment by injection or daily oral dosing
of significant amounts of vitamin D.
– Calcitriol supplement for CKD.
Exercise: Exercise helps to strengthen the bones, especially weight-bearing exercise (anything
that involves walking or running). However, avoid intensive exercise while any fractures or
cracks in the bones are healing.
Sunlight: Where possible, going outside and exposing arms and face to sunlight is the best way
to get vitamin D. 15 minutes a day is generally enough. Don’t allow your skin to go red and
take care not to burn, particularly in strong sunshine and if you have fair or sensitive skin.
Diet and nutrition: A diet that includes vitamin D and calcium can help, but this won’t prevent
the condition by itself. Nevertheless, a diet that provides vitamin D is especially important
if you don’t get enough exposure to sunlight.
Nursing Diagnosis
– Impaired physical mobility related to bone decalcification and bone deformities and possible

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fracture.
– High risk for injuries related to weak bones due to demineralization
– Acute pain due to skeletal deformities and muscular stretching or strain
– Disturb body image related to trauma
– Risk for powerlessness related to deformed bones through body
Paget’s Disease of Bone (Osteitis Deformans)
Paget ’s disease of the Bone
An imbalance of increase osteoblast and osteoclast cells; thickening and hypertrophy. Bone pain
most common symptom; bony enlargement and deformities usually bilateral, kyphosis, long bone.
Analgesics, meds bisphosphonates and calcitonin, NSAID, assistance devices, and hot/cold
treatment. It’s a chronic disease of the skeleton. Normal growth of bone is changed: Bone breaks
down more quickly and Bone can grow larger than before. Paget’s disease is a chronic condition
of bone characterized by disorder of the normal bone remodeling process.
Etiology
 The exact cause is Unknown
 Most probably, a slow or dormant virus with a long latent period causes the disease e.g.
mumps
 Positive family history( about 30%)
 Ageing: above 40 yrs
 Other likely factors are: autoimmune dysfunctions, Vitamin D deficiency in childhood, Viral
infection: numps, respiratory infection etc.
Symptoms:
 Pain in or over a bone
 The affected area may feel extra warm
 The shape of the bone may change
 the bone in the legs may bend or bow out
 the bone in the skull may get bigger
 Bone breaks more easily
 In late stages hipjoint may damage
 Hearing problems may occur because the bone expands and heart problems may also
occur
Diagnostic Investigation
 History

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 Physical examination
 Blood: Elevated serum phosphates level, normal calcium
 RBC shows anemia
 X-ray: demineralization, increased density
 Bone biopsy: shows early piagetic bone
 Bone biopsy: may help in differential diagnosis
Management
1. General management
– Pain management: NSAIDS
– Weight control
– Fracture: reduction, immobilization
2. Pharmacological therapy
– Bisphosphonates
– Calcitonin
– Cytotoxic, antibiotics (pilomycin)
3. Surgical management: osteotomy, joint replacement
4. Supportive management: hearing aid if loss hearing
5. Physical activity
6. Diet: Adequate calcium and vitamin D
Nursing Management:
Nursing intervention
– Pain management
– Promote rest by using from bed rest
– Use brace to support
– Heat application, massage promotes comfort
– Administer prescribed medicines
– Promote activity and rest
– Prevent injury
– Nutritional management
– Increase fluid intake
Prognosis
– Disease activity and symptoms can generally be
– Controlled with current medications
– A small percentage of patients may develop a
– Cancer of the bone called osteosarcoma.
– Some patients will need joint replacement
– Surgery

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Possible complication
– Bone fractures
– Deafness
– Deformities
– Heart failure
– Paraplegia
– Spinal stenosis

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7. Osteomyelitis
Introduction: Osteomyelitis is a severe an infection of bone and bone marrow and surrounding.
It is inflammation and destruction of bone caused by pyogenic organism (bacteria, mycobacteria,
or fungi).
Classifications of osteomyelitis:
Based on the time of disease onset (i.e. occurrence of infection or injury)
a. Acute: Acute osteomyelitis develops within two weeks after disease onset. The acute form
may result from an infection in other tissues (hematogenic osteomyelitis) or from an open
fracture with bacterial contamination.
i. Acute hematogenous osteomyelitis occurs predominantly in children (boys more often
than girls), with the metaphysis of long bones the most common location. The most common
bone involved in acute hematogenous osteomyelitis in children is the femur.
ii. Post-traumatic osteomyelitis (secondary osteomyelitis) results from pathogenic
organisms that proliferate in traumatized tissue. Traumatized tissue also results in
compromised blood supply, leading to tissue and bone necrosis, which promotes infection.
Moreover, the fixation devices that are required in the management of fractures serve as
additional foci for bacterial colonization.
b. Subacute: Subacute osteomyelitis occurs within one to several months. Subacute
osteomyelitis is a chronic low-grade infection of bone characterized by a lack of systemic
manifestations. The onset is insidious. The most common manifestation of a subacute
osteomyelitis in a child is a geographic lytic metaphyseal lesion (Brodie's abscess).
c. Chronic: Chronic osteomyelitis occurs after a few months. Acute osteomyelitis that is
inappropriately treated can become chronic osteomyelitis with irreversible changes in the bone.
The chronic form may result from inadequate initial antimicrobial therapy or lack of response
to treatment (relapse occurs when the patient’s resistance is lowered). The formation of
sequestrum marks the beginning of chronic osteomyelitis. Externally, a draining sinus is the
hallmark of chronic osteomyelitis.
There are three types of chronic osteomyelitis:
a) Chronic osteomyelitis secondary to acute osteomyelitis.
b) Garre’s osteomyelitis: It is sclerosing, non-suppurative chronic osteomyelitis. It may
begin with acute local pain, pyrexia and swelling. There is tenderness on deep palpation.
Shafts of the femur or tibia are the most commonly affected. It may be due to dental caries

77
c) Brodie’s abscess: It involves a subacute or chronic infection of the bone with development
of a localized abscess, usually within the metaphysis of long bones. The tibia is the most
common bone involved and staphylococcus aureus is the most common organism
identified.
The subacute and chronic forms of osteomyelitis usually occur in adults. Generally, these bone
infections are secondary to an open wound, most often an open injury to bone and surrounding
soft tissue.
According to Waldvogel classification system, osteomyelitis is classified according the
transmission:
1. Hematogenous osteomyelitis: Hematogenous osteomyelitis is an infection caused by
bacterial seeding from the blood, involves a single species of microorganism (typically a
bacterium), occurs primarily in children, and is most common in the rapidly growing and
highly vascular metaphysis of growing bones.
2. Contiguous osteomyelitis: Contiguous osteomyelitis occurs when the microorganisms are
introduced into bone by trauma, nosocomial contamination following surgical procedure and
extension from adjacent soft tissue infection. Predisposing factors include open fractures,
internal fixation devices, prosthetic devices and chronic soft tissue infection. Multiple
organisms are usually isolated from the bone although Staphylococcus
aureus and Staphylococcus epidermidis are the most prevalent pathogens.
3. Chronic Osteomyelitis: Acute osteomyelitis that is inappropriately treated can become
chronic osteomyelitis. Chronic osteomyelitis resulting from acute osteomyelitis is often caused
by S. aureus; however, chronic osteomyelitis occurring after a fracture can be poly-microbial.
Cierny-Mader Staging System, based on the status of the disease process:
a. Anatomic type:
Stage 1: Medullary osteomyelitis (osteomyelitis is confined to the medullary cavity of the
bone., hematogenous osteomyelitis and infections of IM nails).
Stage 2: Superficial osteomyelitis (confined to the bone surface and most often originates from
a direct inoculation or a contiguous focus infection)
Stage 3: Localized osteomyelitis (full thickness of the cortex but without the loss of axial
stability, osteomyelitis usually involves both cortical and medullary bone)
Stage 4: Diffuse osteomyelitis (circumference of the cortex and loss of axial stability).
b. Physiologic class
A host: healthy, patients without systemic or local compromising factors

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B host: are affected by one or more compromising factors
Bs: systemic compromise
Bl: local compromise
Bls: local and systemic compromise
C host: treatment worse than the disease, patients so severely compromised that the radical
treatment necessary would have an unacceptable risk-benefit ratio
Factors affecting immune surveillance, metabolism and local vascularity
 Systemic factors (Bs): malnutrition, renal or hepatic failure, diabetes mellitus, chronic
hypoxia, immune disease, extremes of age, immunosuppression or immune deficiency
 Local factors (Bl): chronic lymphedema, venous stasis, major vessel compromise, arteritis,
extensive scarring, radiation fibrosis, small-vessel disease, neuropathy, tobacco abuse
Etiology
The specific microorganism(s) isolated from patients with bacterial osteomyelitis is often
associated with the age of the patient or the clinical scenario.
Infants (< 1 year)
 Group B streptococci
 Staphylococcus aureus
 Escherichia coli
Children (1 to 16 years)
 S. aureus
 Streptococcus pyogenes
 Haemophilus influenzae
Adults (> 16 years)
 Staphylococcus epidermidis
 S. aureus
 Pseudomonas aeruginosa
 Serratia marcescens
 E. coli
Route of transmission:
 Contiguous spread from infected tissue or an infected prosthetic joint
 Blood borne organisms (hematogenous osteomyelitis)
 Open wounds (from contaminated open fractures or bone surgery)
Risk factors:

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Factors that can makes bones more vulnerable to osteomyelitis includes:
– Recent injury or orthopedic surgery: A severe bone fracture or a deep puncture wound gives
bacteria a route to enter the bone or nearby tissue. A deep puncture wound, such as an animal
bite or a nail piercing through a shoe, can also provide a pathway for infection. Surgery to
repair broken bones or replace worn joints also can accidentally open a path for germs to enter
a bone. Implanted orthopedic hardware is a risk factor for infection.
– Circulation disorders: When blood vessels are damaged or blocked, our body has trouble
distributing the infection-fighting cells needed to keep a small infection from growing larger.
What begins as a small cut can progress to a deep ulcer that may expose deep tissue and bone
to infection.
– Diseases that impair blood circulation includes Poorly controlled diabetes, Peripheral artery
disease, often related to smoking, Sickle cell disease.
– Problems requiring intravenous lines or catheters: A number of conditions that require the
use of medical tubing to connect the outside world with the internal organs such as urinary
catheters, Central venous line, dialysis etc. This tubing can also serve as a way for germs to
get into the body, increasing risk of an infection in general, which can lead to osteomyelitis.
– Conditions that impair the immune system: If the immune system is affected by a medical
condition or medication, it increases the risk of osteomyelitis. It may include cancer treatment.
Poorly controlled diabetes, corticosteroids intake.
– Illicit drugs: People who inject illegal drugs are more likely to develop osteomyelitis because
of use of nonsterile needles and are less likely to sterilize their skin before injections.
Pathophysiology:
Healthy bone tissue is extremely resistant to infection
– Bacterial inoculation in combination with trauma, necrosis or ischemia of tissue and/ or
the presence of foreign material.
– Bacteria may reach the bone via the bloodstream, by direct inoculum caused by, trauma
or surgery, or by direct spread from an adjacent soft tissue infection.
– Subsequently adhere to components of the bone matrix in order to start the infection.
– Bacteria clump together and are covered in a layer of fibrinogen, thus protected from host
defense mechanisms and antibiotics. There is also evidence for a local host defense defect
in the pathogenesis of foreign body infection.
– Infection of the bone, Osteomyelitis, tends to occlude local blood vessels
– Induce local bone destruction (osteolysis) and aids the spread and persistence of
infection.
– Intense inflammatory response and edema, thrombosis of endosteal and periosteal vessels

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– Devitalization of bone and bone infarcts with subsequent abscess and sequestrum
formation.
– Infection expand and abscesses that may drain spontaneously through the skin.
– Formation of involucrum around the sequestrum.
– Draining sinus can get sealed off. They remain latent for some time and during the flare-
ups they burst out again. (chronic osteomyelitis)
– The sclerosis can make bone brittle, thereby increasing the risk of pathological fracture.
 Acute osteomyelitis:
In children:
– Pain or tenderness over the affected bone
– Fever, chills, and redness at the site of the infected area
– Difficulty or inability to use the affected limb or to bear weight
– Difficulty to walk due to severe pain (limp)
In adult:
– Fever, chills, irritability, swelling or redness over the infected bone
– Drainage of pus,
– Stiffness
– nausea
– Erythema
– In people with diabetes, peripheral neuropathy, or peripheral vascular disease, there
may be no pain or fever.
 Chronic osteomyelitis
– Fever
– Intermittent Pain and tenderness
– Redness
– Draining sinuses.
 Vertebral osteomyelitis
Early:
 Localized back pain and tenderness
 Paravertebral muscle spasm that is unresponsive to conservative treatment.
Lately:
 Compression of the spinal cord or nerve roots
 Radicular pain
 Extremity weakness or numbness
Diagnosis:
1. History:
 Acute onset of signs and symptoms (eg. localized pain, edema, erythema, ever)

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 Recurrent drainage of an infected sinus with associated pain, edema, and low-grade fever.
 Risk factors (eg. older age, diabetes, long-term corticosteroid therapy)
 History of previous injury, infection, or orthopedic surgery.
 Avoiding pressure and movement of the area.
 Generalized weakness due to the systemic reaction to the infection.
2. Physical examination:
 Inflamed, markedly edematous, warm area that is tender.
 Purulent drainage
 Elevated temperature.
 In chronic osteomyelitis, the temperature elevation may be minimal, occurring in the afternoon
or evening.
3. Laboratory Test Findings:
 Differential Count- Leukocytosis
 ESR and CRP- Elevations in the ESR and C-reactive protein level. It may be elevated in the
inflammatory conditions like RA, or normal in infection caused by indolent pathogens.
 Blood cultures- positive in up to one half of children with acute osteomyelitis.
 Pus culture: Positive
4. X-rays: Radiographic evidence of bone destruction by osteomyelitis may not appear until
approximately two weeks after the onset of infection. The radiographs may reveal osteolysis,
periosteal reaction and sequestrum (segments of necrotic bone separated from living bone by
granulation tissue).
5. Radio isoptopic Bone Scanning: A radioisotope bone scan with technetium-99m can be done.
The bone scan shows abnormalities earlier than plain x-rays but does not distinguish between
infection, fractures, and tumors. In many instances, a bone scan will be positive despite the
absence of bone or joint abnormality. Indium-111 labelled leucocyte scan is most specific for
diagnosis of bone infection.
6. Magnetic resonance imaging (MRI): It is useful when a patient is suspected of having
osteomyelitis, discitis or septic arthritis involving the axial skeleton and pelvis. MRI also
provides greater spatial resolution in delineating the anatomic extension of infection.
7. Ultrasonography: helpful in the evaluation of suspected osteomyelitis, an abscess and surface
abnormalities of bone.
8. Sinogram: In this test, a sterile thin catheter is introduced into the sinus as far as it can go.
Then, a radio-opaque dye is injected, and X-rays taken. The radio-opaque dye travels to the
root of the infection, and thus helps localize it better. It is indicated in situations where one
cannot tell on X-rays where the pus may be coming from.

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9. Computed Tomographic (CT) scanning: CT scan can reveal small areas of osteolysis in
cortical bone, small foci of gas and minute foreign bodies.
10. Histopathologic and microbiologic examination of bone: Gold standard for diagnosing
osteomyelitis.
11. Biopsy: It helps to determine the etiology of osteomyelitis. The accuracy of biopsy is often
limited by lack of uniform specimen collection and previous antibiotic use. Bone biopsy with
a needle or surgical excision and aspiration or debridement of abscesses provides tissue for
culture and antibiotic sensitivity testing.
Differential diagnosis
Any acute inflammatory disease at the end of a bone, in a child, should be taken as acute
osteomyelitis unless proved otherwise.
a) Acute septic arthritis:
• Tenderness and swelling localised to the joint rather than the metaphysis.
• Movement at the joint is painful and restricted.
• In case of doubt, joint fluid may be aspirated under strict aseptic conditions, and the
fluid examined for inflammatory cells.
b) Acute rheumatic arthritis: The features are similar to acute septic arthritis. The fleeting
character of joint pains, elevated ASLO titre and CRP values may help in diagnosis.
c) Scurvy: There is formation of sub-periosteal haematomas in scurvy. These may mimic acute
osteomyelitis radiologically, but the relative absence of pain, tenderness and fever points to the
diagnosis of scurvy. There may be other features of malnutrition.
d) Acute poliomyelitis: In the acute phase of poliomyelitis, there is fever and the muscles are
tender, but there is no tenderness on the bones. Parents often tend to relate an episode of injury
to onset of symptoms in any musculo-skeletal pain. This may give a wrong lead, and a novice
may make a diagnosis of a fracture or soft tissue injury. Often such a patient is immobilized in
plaster cast, only to know later that the infection was the cause. Any history of trauma,
particularly in children must be thoroughly questioned.
e) Tubercular osteomyelitis: The discharge is often thin and watery. A tubercular sinus may
show its characteristic features like undermined margins and bluish surrounding skin.
Tubercular osteomyelitis is often multifocal.
f) Soft tissue infection: Absence of thickening of underlying bone, and absence of sinus fixed to
the bone, may point towards the infection not coming from the bone. Absence of any
radiological changes in the bone would help conform the diagnosis.
g) Ewing’s sarcoma: A child with Ewing’s sarcoma sometimes presents with a rather sudden
onset pain and swelling, mostly in the diaphysis. Radiological appearance often resembles that
of osteomyelitis. A biopsy will settle the diagnosis.

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Medical management:
i. General supportive measures: hydration, diet high in vitamins and protein, correction of
anemia, quitting smoking
ii. Immobilization: Helps to decrease discomfort and to prevent pathologic fracture of the
weakened bone.
iii. Pharmacological management (Antibiotic Therapy): The initial goal of therapy is to
control and halt the infective process. As soon as the culture specimens are obtained, IV
antibiotic therapy begins, based on the assumption that infection results from a
staphylococcal organism that is sensitive to a penicillin or cephalosporin. The aim is to
control the infection before the blood supply to the area diminishes as a result of
thrombosis. Around-the-clock dosing is necessary to maintain a high therapeutic blood
level of the antibiotic. IV antibiotic therapy continues for 3 to 6 weeks. After the infection
appears to be controlled, the antibiotic may be administered orally for up to 3 months. The
common antibiotics used are ceftazidime, Ampiicillin/sulbactam, Vancomycin and
Methicillin.
iv. Analgesics and antipyretics:
Non-steroidal anti-inflammatory drugs (NSAIDs) are best for treating mild or moderate
pain. Most of these medications are available over the counter, and include
Acetaminophen, Aspirin, Ibuprofen, Naproxen. Opioids are much stronger medications
that treat moderate to severe pain so should not be taken without prescription.
Surgical Management: Depending on the severity of the infection, osteomyelitis surgery may
include one or more of the following procedures,
 Drain the infected area (saucerization): The cavity is converted into a ‘saucer’ by removing
its wall. This allows free drainage of the infected material. This allows free drainage of the
infected material.
 Sequestrectomy (Removal of diseased bone and tissue): In a procedure called debridement,
the surgeon removes as much of the diseased bone as possible and takes a small margin of
healthy bone to ensure that all the infected areas have been removed. Surrounding tissue that
shows signs of infection also may be removed.
 Restoration of blood flow to the bone: The empty space left by the debridement procedure
is filled with a piece of bone or other tissue, such as skin or muscle, from another part of your
body. Sometimes temporary fillers are placed in the pocket until patient is healthy enough to
undergo a bone graft or tissue graft. The graft helps the body to repair damaged blood vessels
and form new bone.
 After surgery, the wound is closed over a continuous suction irrigation system. This system
has an inlet tube going to the medullary cavity, and an outlet tube bringing the irrigation fluid

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out. A slow suction is applied to the outlet tube. The irrigation fluid consists of suitable
antibiotics and a detergent. The medullary canal is irrigated in this way for 4 to 7 days.
 Removal of foreign objects: In some cases, foreign objects, such as surgical plates or screws
placed during a previous surgery, may have to be removed.
 Amputation the limb: As a last resort, amputation of the affected limb is performed to stop
the infection from spreading further.
Complications:
 General complications: In the early stage, the child may develop septicaemia and pyaemia.
 Local complications:
 Bone death (osteonecrosis): An infection in your bone can impede blood circulation within
the bone, leading to bone death. Areas where bone has died need to be surgically removed for
antibiotics to be effective.
 Septic arthritis: Sometimes, infection within bones can spread into a nearby joint.
 Impaired growth: Normal growth in bones or joints in children may be affected if
osteomyelitis occurs in the softer areas, called growth plates, at either end of the long bones of
the arms and legs. There may be:
 Shortening, when the growth plate is damaged.
 Lengthening because of increased vascularity of the growth plate due to the nearby
osteomyelitis.
 Deformities may appear if a part of the growth plate is damaged and the remaining
keeps growing.
 Skin cancer: If your osteomyelitis has resulted in an open sore that is draining pus, the
surrounding skin is at higher risk of developing squamous cell cancer.
 Pathological fracture: This occurs through a bone which has been weakened by the disease
or by the window made during surgery. It can be avoided by adequately splinting the limb.
 Amyloidosis: It is a rare disease that occurs when a substance called amyloid builds up in the
organs. Amyloid is an abnormal protein that is produced in bone marrow and can be deposited
in any tissue or organ.
Nursing Management:
Assessment:
History:
– Acute onset of signs and symptoms (e.g. localized pain, edema, erythema, ever)
– Recurrent drainage of an infected sinus with associated pain, edema, and low-grade fever.

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– Risk factors (e.g. older age, diabetes, long-term corticosteroid therapy)
– History of previous injury, infection, or orthopedic surgery.
– Avoiding pressure and movement of the area.
– Generalized weakness due to the systemic reaction to the infection.
Physical examination:
– Inflamed, markedly edematous, warm area that is tender.
– Purulent drainage
– Elevated temperature.
– In chronic osteomyelitis, the temperature elevation may be minimal, occurring in the
afternoon or evening.
Review of lab reports: Blood Test reports and Pus culture as well as Blood Culture reports.
Nursing Diagnosis
Based on the nursing assessment data, nursing diagnosis for the patient with osteomyelitis includes
the following:
– Acute pain related to inflammation and edema
– Impaired physical mobility related to pain, use of immobilization devices, and weight-
bearing limitations
– Increased body temperature related to infection.
– Risk for impaired skin integrity related to infection.
– Risk for extension of infection: bone abscess formation
– Deficient knowledge related to the treatment regimen
Nursing interventions:
Relieving Acute Pain
– Assess wound appearance and new sites of pain and monitor for an infection or other
complications.
– Provide diet high in vitamin C and protein as Vitamin C heals tissues and protein builds
new tissues.
– Administer pain medications as ordered.
– A sudden movement or fall may fracture the weakened bone so protect client from jerky
movements and falls.
Impaired Physical Mobility
– Encourage to perform light exercises of the non-affected.
– Perform range of motion exercise gently.
– Explain about the importance of range of motion exercise.

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– Discourage to move the affected part to prevent pathological fracture.
Risk for Impaired Skin
– Handle the affected extremity gently, protect it from injury, keep it in good body alignment
and level with the body.
– Irrigate wound as ordered. It helps flush bacteria and debris from the wound. Use aseptic
technique when irrigating the affected area and when changing the dressing.
– Assess skin and bony prominences for reddened areas.
– Encourage adequate fluid intake to meet the body’s need for fluids, keep tissues moist, and
flush bacteria from the body.
Maintaining body temperature:
– Assess the general condition of patient.
– Monitor vital signs.
– Remove extra blankets and clothes of patient.
– Encourage to wear loose fitting cloth.
– Maintain cross ventilation.
– Provide cold sponging.
– Switch on the fan as necessary.
– Administer antipyretics drugs as prescribed.
– Administer antibiotics as prescribed.
– Encourage for adequate fluid intake.
Controlling the infection:
– Monitor the patient’s response to antibiotic therapy.
– Observe the IV access site for evidence of infection.
– Change dressing using aseptic technique.
Improving knowledge:
– Assess the knowledge level of patient.
– Explain about what osteomyelitis is, its causes, sign and symptoms, diagnostic procedure
and treatment.
– Explain about the importance of immobilization.
– Advice for range of motion exercise.

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8. Arthritis
Definition: It is derived from Greek word “Arthron” meaning “Joint” and Latin word “It is”
meaning “Inflammation”. Hence, arthritis is the inflammation of the joints. Arthritis is not a single
disease. It is a term that covers over 100 medical conditions. Osteoarthritis (OA) is the most
common form of arthritis and generally affects elderly patients.
Causes:
1. Genetics: Mechanism not understood.
2. Age: Cartilage becomes more brittle with age and has less of a capacity to repair itself. As
people grow older, they are more likely to develop arthritis.
3. Weight: Excess body weight can lead to arthritis.
4. Previous injury: Joint damage can cause irregularities in the normal smooth joint surface.
Previous major injuries can be part of the cause of arthritis.
5. Occupational hazards: Workers in some specific occupations like assembly line workers
and heavy construction are at more risk of developing arthritis.
6. Some high-level sports: Sports participation can lead to joint injury and subsequent
arthritis.
7. Illness or infection: People, who exercise a joint infection (septic joint), multiple episodes
of gout, or other medical conditions, can develop arthritis of the joint.
Types of Arthritis:
There are over 100 types of arthritis. Some common types are:
1. Osteoarthritis: Cartilage loses its elasticity. The cartilage which acts as a shock absorber,
will gradually wear away in some areas. As the cartilage becomes damaged tendons and
ligaments become stretched, causing pain. Eventually the bones may rub against each other
causing severe pain.
2. Rheumatoid arthritis: This is an inflammatory form of arthritis. The synovial membrane
(synovium) is attacked, resulting in swelling and pain. If left untreated, the arthritis can
lead to deformity. Rheumatoid arthritis is significantly more common in women than men
and generally strikes when the patient is aged between 40 and 60. However, children and
much older people may also be affected.
3. Infectious arthritis (septic arthritis): An infection in the synovial fluid and tissues of a
joint. It is usually caused by bacteria, but could also be caused by fungi or viruses. Bacteria,
fungi or viruses may spread through the bloodstream from infected tissue nearby, and infect

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a joint. Most susceptible people are those who already have some form of arthritis and
develop an infection that travels in the bloodstream.
4. Juvenile Rheumatoid Arthritis (JRA): This type of arthritis affects person aged 16 years
or less. JRA can be various forms of arthritis; it basically means that a child has it. There
are three main types:
 Pauciarticular JRA, the most common and mildest. The child experiences pain in up
to 4 joints.
 Polyarticular JRA affects more joints and is more severe. As time goes by it tends to
get worse.
 Systemic JRA is the least common. Pain is experienced in many joints. It can spread
to organs. This can be the most serious JRA.
5. Gouty Arthritis: It is a kind of arthritis that can cause an attack of sudden burning pain,
stiffness, and swelling in a joint, usually a big toe. These attacks can happen over and over
unless gout is treated. Gout is caused by too much uric acid in the blood. Over time, they
can harm the joints, tendons, and other tissues. Gout is most common in men.
Signs and Symptoms
The signs and symptoms depend upon the type of arthritis:
Osteoarthritis:
 The symptom develops slowly and gets worse as the time goes by.
 Joint pain, either during or after use, or after a period of inactivity.
 Tenderness over the joint.
 Stiff joint, especially in the morning.
 Loss of flexibility of the joint
 Grating sensation while using the joint
 Hard lumps, or bone spur
 May appear around the joint.
 Most commonly affected joints are: hips, hands, knees and spine.
Rheumatoid Arthritis
 Symmetrical swelling, inflammation and stiffness of the joints.
 The fingers, arms, legs and wrists are most commonly affected.
 Symptoms are usually worse in the morning and the joint stiffness can last for 30 minutes
at this time.
 Tenderness over the joint
 Red and puffy hands

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 Rheumatoid nodules in the arms
 Weight loss and fatigue
Infectious Arthritis
 Fever, joint inflammation and swelling
 Tenderness and/or sharp pain
 Usually linked with a prior injury or another illness
 Most commonly affected areas are knee, shoulder, elbow, wrist and finger.
 In the majority of cases, just one joint is involved.
Juvenile Rheumatoid Arthritis
 Intermittent fever which tend to peak in the evening and then suddenly disappear.
 Decreased appetite and weight loss
 Blotchy rashes on arms and legs
 Anemia
 Limping gait
 Sore on wrist, finger or knee
 Swollen and enlarged joint
 Stiff neck, hips or some other joint
Gouty Arthritis
 Nighttime attack of swelling
 Tenderness, redness, and sharp pain in big toe.
 Gout attacks in foot, ankle, or knees, or other joints which can last a few days or many
weeks before the pain goes away.
Overall symptoms of arthritis
 Joint pain
 Joint swelling
 Reduced ability to move the joint
 Redness of the skin around the joint
 Stiffness, especially around the morning
 Warmth around the joint
Diagnosis:

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 Medical History and Clinical Symptoms: List of current medications, medication
allergies, past and present medical history
 Physical Examination: Joint stiffness, redness/warmth, Nodules, pattern of affected
joints, Limited range of motion, fever, fatigue
Laboratory Tests:
 Rheumatoid Factor: Antibody or immunoglobulin which is present in about 70 to 80
percent of adults who have rheumatoid arthritis.
 Erythrocyte Sedimentation Rate: Indicates presence of nonspecific inflammation
 C-Reactive Protein (CRP): Raised plasma levels indicating inflammation
 Anti-cyclic Citrullinated Peptide Antibody Test (anti-CCP): Moderate to high levels
confirm the diagnosis of Rheumatoid Arthritis. The test is more specific than Rheumatoid
Factor.
 Antinuclear Antibodies (ANA): They are autoantibodies. Moderate to high levels re
suggestive of autoimmune disease. Positive tests are seen in 50% of rheumatoid arthritis
patients.
 Complete Blood Count: Suggests active infection
 HLA tissue typing: Human Leukocyte Antigens are proteins on the surface of cells.
Specific HLA proteins are genetic markers for some of the rheumatic diseases.
 Uric acid: High levels of uric acid in the blood can cause crystal formation which can
deposit in the tissues and joints causing painful gout attacks. Uric acid is the final product
of purine metabolism.
 Medical Imaging: X-Rays
 MRI
Medications for Arthritis
 NSAIDs: Ibuprofen, Naproxen, Diclofenac
 Glucocorticoids: Prednisolone
 Minocycline: Can be used as an antibiotic therapy for rheumatoid arthritis but it’s use is
controversial.
 Sulfasalzine: Commonly used for many types of inflammatory arthritis.
 Methotrexate: works by blocking the metabolism of rapidly dividing cells and commonly
used for treating more serious types of inflammatory arthritis.
 Azathioprine: Used for severe forms of inflammatory arthritis.
 Leflunomide: Used to treat rheumatoid arthritis and psoriatic arthritis. It also blocks cell
metabolism.

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 Cyclosporine: Immunosuppressant used by transplant patients so that their bodies do not
reject their transplanted organs.
Nursing Management:
Assessment: Obtain history of pain and its characteristics, including specific joints involved.
Evaluate ROM and strength. Assess effect on ADLs and emotional status.
Nursing Interventions
Relieving Pain
 Advice patient to take prescribed NSAIDs or OTC analgesics as directed to relieve
inflammation and pain. May alternate with opioid analgesic, if prescribed.
 Provide rest for involved joints. Excessive use aggravates the symptoms and accelerates
degeneration.
 Use splints, braces, cervical collars, traction, lumbosacral corsets as necessary.
 Have prescribed rest periods in recumbent position.
 Advise patient to avoid activities that precipitate pain.
 Apply heat as prescribed. It relieves muscle spasm and stiffness; avoid prolonged
application of heat may cause increased swelling and flare symptoms.
 Provide crutches, braces, or cane when indicated to reduce weight-bearing stress on hips
and knees.
 Encourage weight loss to decrease stress on weight-bearing joints.
 Encourage use of stress management techniques such as progressive relaxation,
biofeedback, visualization, guided imagery, self-hypnosis, and controlled breathing.
Provide Therapeutic Touch.
Increasing Physical Mobility
 Assess and continuously monitor degree of joint inflammation and pain. Encourage activity
as much as possible without causing pain.
 Maintain bed rest or chair rest when indicated. Schedule activities providing frequent rest
periods and uninterrupted nighttime sleep.
 Teach ROM exercises to maintain joint mobility and muscle tone for joint support.
 Teach isometric exercises and graded exercises to improve muscle strength around the
involved joint.
 Advise putting joints through ROM after periods of inactivity (e.g., automobile ride).
 Discuss and provide safety needs such as raised chairs and toilet seat, use of handrails in
tub, shower and toilet, proper use of mobility aids and wheelchair safety.
 Position with pillows, sandbags, trochanter roll. Provide joint support with splints, braces.

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Promoting Self-Care
 Suggest performing important activities in morning, after stiffness has been abated and
before fatigue and pain become a problem.
 Urge the patient to perform activities of daily living (ADLs), such as practicing good
hygiene, dressing and feeding himself.
 Advise on modifications, such as wearing looser clothing without buttons, placing bench
in tub or shower for bathing, sitting at table or counter in kitchen to prepare meals.
 Allow patient sufficient time to complete tasks to fullest extent of ability.
 Help with obtaining assistive devices, such as padded handles for utensils and grooming
aids, to promote independence.
 Refer to OT for additional assistance.
 Consult with rehabilitation specialists (occupational therapist).
Patient Education and Health Maintenance
 Suggest swimming or water aerobics as a form of non-stressful exercise to preserve
mobility.
 Encourage adequate diet and sleep to enhance general health.
 Advise patient to discuss the use of complementary therapies, such as glucosamine and
chondroitin sulfate, with his health care provider.
Evaluation: Expected Outcomes
 Reports reduction in pain while ambulatory
 Performs ROM exercises
 Dresses, bathes self, and grooms with assistive devices

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Rheumatoid Arthritis
Rheumatoid arthritis (RA) is an autoimmune disease of unknown origin. It is classified as
a diffuse connective tissue disease and is chronic in nature. It is characterized by diffuse
inflammation and degeneration in the connective tissues.
Statistics and Incidences: Rheumatoid arthritis is common worldwide. Rheumatoid arthritis
affects 1% of the population worldwide. The ratio of female to male with RA is between 2:1 and
4:1.
Causes:
Diffuse connective tissue diseases have unknown causes, but they are also thought to be the result
of immunologic abnormalities.
 Genetics. Researchers have shown that people with a specific gene marker called
the HLA shared epitope have a fivefold greater chance of developing rheumatoid arthritis
than do people without the marker.
 Infectious agents. Infectious agents such as bacteria and viruses may trigger the
development of the disease in a person whose genes make them more likely to get it.
 Female hormones. 70% of people with RA are women, and this occur because of the
fluctuations of the female hormones.
 Environmental factors. Environmental factors such as exposure to cigarette smoke, air
pollution, and insecticides.
 Occupational exposures. Substances such as silica and mineral oil may harm the worker
and result in contact dermatitis.
Pathophysiology
The pathophysiology of rheumatoid arthritis is brief and concise.
 Autoimmune reaction: In RA, the autoimmune reaction primarily occurs in
the synovial tissue.
 Phagocytosis: Phagocytosis produces enzymes within the joint.
 Collagen breakdown: The enzymes break down collagen, causing edema,
proliferation of the synovial membrane, and ultimately pannus formation.
 Damage: Pannus destroys cartilage and erodes the bone.
 Consequences: The consequences are loss of articular surfaces and joint motion.
 Degenerative changes: Muscle fibers undergo degenerative changes, and tendon and
ligament elasticity and contractile power are lost.

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Clinical Manifestations:
Clinical manifestations of RA vary, usually reflecting the stage and severity of the disease.
 Joint pain. One of the classic signs, joints that are painful are not easily moved.
 Swelling. Limitation in function occurs as a result of swollen joints.
 Warmth. There is warmth in the affected joint and upon palpation, the joints are spongy
or boggy.
 Erythema. Redness of the affected area is a sign of inflammation.
 Lack of function. Because of the pain, mobilizing the affected area has limitations.
 Deformities. Deformities of the hands and feet may be caused by misalignment
resulting in swelling.
 Rheumatoid nodules. Rheumatoid nodules may be noted in patients with more
advanced RA, and they are non-tender and movable in the subcutaneous tissue.
Complications:
Medications used for treating rheumatoid arthritis may cause serious and adverse side effects.
 Bone marrow suppression. Improper use of immune-suppressants could lead to bone
marrow suppression.
 Anemia. Immunosuppressive agents such
as methotrexate and cyclophosphamide are highly toxic and can produce anemia.
 Gastrointestinal disturbances. Some NSAIDs are likely to cause gastric irritation
and ulceration.
Assessment and Diagnostic Findings
Several factors contribute to the diagnosis of RA.
 Antinuclear antibody (ANA) titer: Screening test for rheumatic disorders, elevated in
25%–30% of RA patients. Follow-up tests are needed for the specific rheumatic
disorders, e.g., anti-RNP is used for differential diagnosis of systemic rheumatic
disease.
 Rheumatoid factor (RF): Positive in more than 80% of cases (Rose-Waaler test).
 Latex fixation: Positive in 75% of typical cases.
 Agglutination reactions: Positive in more than 50% of typical cases.
 Serum complement: C3 and C4 increased in acute onset (inflammatory response).
Immune disorder/exhaustion results in depressed total complement levels.
 Erythrocyte sedimentation rate (ESR): Usually greatly increased (80–100 mm/hr).
May return to normal as symptoms improve.
 CBC: Usually reveals moderate anemia. WBC is elevated when inflammatory
processes are present.

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 Immunoglobulin (Ig) (IgM and IgG): Elevation strongly suggests autoimmune
process as cause for RA.
 X-rays of involved joints: Reveals soft-tissue swelling, erosion of joints, and
osteoporosis of adjacent bone (early changes) progressing to bone-cyst formation,
narrowing of joint space, and subluxation. Concurrent osteoarthritic changes may be
noted.
 Radionuclide scans: Identify inflamed synovium.
 Direct arthroscopy: Visualization of area reveals bone irregularities/degeneration of
joint.
 Synovial/fluid aspirate: May reveal volume greater than normal; opaque, cloudy,
yellow appearance (inflammatory response, bleeding, degenerative waste products);
elevated levels of WBCs and leukocytes; decreased viscosity and complement (C3 and
C4).
 Synovial membrane biopsy: Reveals inflammatory changes and development of
pannus (inflamed synovial granulation tissue).
Medical Management
Medical management is aligned with each phase of rheumatoid arthritis.
 Rest and exercise. There should be a balance of rest and exercise planned for a patient
with RA.
 Referral to community agencies such as the Arthritis Foundation could help the patient
gain more support.
 Biologic response modifiers. An alternative treatment approach for RA, biologic
response modifiers, has emerged, wherein a group of agents that consist of molecules
produced by cells of the immune system participate in the inflammatory reactions.
 Therapy. A formal program with occupational and physical therapy is prescribed to
educate the patient about the principles of joint protection, pacing activities, work
simplification, range of motion, and muscle-strengthening exercises.
 Nutrition. Food selection should include the daily requirements from the basic food
groups, with emphasis on foods high in vitamins, protein, and iron for tissue building
and repair.
Pharmacologic Therapy
The drugs used in each phase of rheumatoid arthritis include:
Early Rheumatoid Arthritis
 NSAIDs. COX-2 medications block the enzyme involved in inflammation while
leaving intact the enzyme involved in protecting the stomach lining.

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 Methotrexate. Methotrexate is currently the standard treatment of RA because of its
success in preventing both joint destruction and long-term disability.
 Analgesics. Additional analgesia may be prescribed for periods of extreme pain.
Moderate, Erosive Rheumatoid Arthritis
 Cyclosporine. Neoral, an immunosuppressant is added to enhance the disease
modifying effect of methotrexate.
Persistent, Erosive Rheumatoid Arthritis
 Corticosteroids. Systemic corticosteroids are used when the patient has unremitting
inflammation and pain or needs a “bridging” medication while waiting for slower
DMARDs to begin taking effect.
Advanced, Unremitting Rheumatoid Arthritis
 Immunosuppressants. Immunosuppressive agents are prescribed because of their
ability to affect the production of antibodies at the cellular level.
 Antidepressants. For most patients with RA, depression and sleep deprivation may
require the short-term use of low-dose antidepressants such as amitriptyline,
paroxetine, or sertraline, to reestablish an adequate sleep pattern and to manage
chronic pain.
Surgical Management
For persistent, erosive RA, reconstructive surgery is often used.
 Reconstructive surgery. Reconstructive surgery is indicated when pain cannot be
relieved by conservative measures and the threat of loss of independence is eminent.
 Synovectomy. Synovectomy is the excision of the synovial membrane.
 Tenorrhaphy. Tenorrhaphy is the suturing of a tendon.
 Arthrodesis. Arthrodesis is the surgical fusion of the joint.
 Arthroplasty. Arthroplasty is the surgical repair and replacement of the joint.
Discharge and Home Care Guidelines
Patient teaching is an essential aspect of discharge and home care.
 Disorder education. The patient and family must be able to explain the nature of the
disease and principles of disease management.
 Medications. The patient or caregiver must be able to describe the medication regimen
(name of medications, dosage, schedule pf administration, precautions, potential side
effects, and desired effects.
 Pain management. The patient must be able to describe and demonstrate use of pain
management techniques.
 Independence. The patient must be able to demonstrate ability to perform self-care
activities independently or with assistive devices.

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Osteoarthritis
Osteoarthritis is a degenerative joint disease or sometimes called osteoarthrosis even though
inflammation may be present. It is the most common among the joint disorders and also the most
disabling. OA is both over-diagnosed and trivialized; it is frequently over treated or undertreated.
The functional impact of OA on the quality of life, especially elderly patients, is often ignored.
Classification: Osteoarthritis is classified into two classifications, yet the distinction between the
two of them is always unclear.
 Primary or idiopathic OA has no prior event or disease related to it.
 Secondary OA results from previous joint injury or inflammatory disease.
Pathophysiology
Osteoarthritis may be thought of as the result of many factors that, when combined, predispose the
patient to the disease.
 Mechanical injury. OA starts from an injury of the articular cartilage, subchondral
bone, and synovium.
 Chondrocyte response. Factors that initiate chondrocyte response include previous
joint damage, genetic and hormonal factors, and others.
 Cytokines. After the chondrocyte response, the release of cytokines occurs.
 Stimulation of enzymes. Proteolytic enzymes, metalloproteases, and collagenase are
stimulated, produced, and, released.
 Damage. The resulting damage predisposes to damage further as the chondrocyte is
triggered to respond again.
Causes
Understanding of osteoarthritis has been greatly expanded beyond what was previously thought of
as simply “wear and tear” related to aging and the causes include:
 Increased age. Most elderly people experience osteoarthritis because the ability of the
articular cartilage to resist microfracture with repetitive loads diminishes with age.
 Obesity. Obese people easily wear out their weight-bearing joints because of their
increased weight.
 Previous joint damage. Having previous joint damage predisposes the patient to
secondary OA.
 Repetitive use. Repetitive use due to occupational or recreational factors also causes
OA.

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Clinical Manifestations
Osteoarthritis has primary signs and symptoms, and that includes:
 Pain. Inflamed synovium causes the pain, stretching of the joint capsule or ligaments,
irritation of the nerve endings in periosteum over osteophytes, trabecular microfracture,
intraosseous, hypertension, bursitis, tendinitis, and muscle spasm.
 Stiffness. Stiffness, which is mostly experienced in the morning or upon awakening, usually
lasts less than 30 minutes and decreases with movement.
 Functional impairment. Functional impairment results from pain on movement and limited
motion caused by structural changes in the joints.
Prevention
Although no treatment halts the degenerative process, certain preventive measures can slow the
progress if undertaken early enough.
 Weight reduction. To avoid too much weight upon the joints, reduction of weight is
recommended.
 Prevention of injuries. As one of the risk factors for osteoarthritis is previous joint
damage, it is best to avoid any injury that might befall the weight-bearing joints.
 Perinatal screening for congenital hip disease. Congenital and developmental disorders
of the hip are well known for predisposing a person to OA of the hip.
Assessment and Diagnostic Findings
Diagnosis of osteoarthritis is complicated only because of 30% of patients with changes seen on
x-ray report symptoms.
 Physical assessment. Physical assessment of the musculoskeletal system reveals
the tender and swollen joints.
 X-ray. OA is characterized by a progressive loss of joint cartilage, which appears on x-
ray as a narrowing of the joint space.
Medical Management
Medical management involves conservative measures, physical modalities, and alternative
therapies.
 Use of heat. To reduce the pain, heat application can be performed over the joints.
 Weight reduction. Weight reduction is strongly recommended for obese patients to
avoid further damage to the cartilage.
 Joint rest. The patient should avoid joint overuse and rest the joints regularly.
 Orthotic devices. Devices such as splints and braces can be used to support inflamed
joints.

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 Pharmacologic therapy. Initial analgesic therapy is acetaminophen, while some are
responsive to NSAIDs, COX-2 enzyme blockers, opioids, and intra-articular
corticosteroids.
Surgical Management
In moderate to severe OA, when pain is severe or because of loss of function, surgical intervention
may be used.
 Osteotomy. Osteotomy is performed to alter the distribution of weight within the joint.
 Arthroplasty. Diseased joint components are replaced in arthroplasty.

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9. Nerve Injury
Nerves are the body’s “telephone wiring” system that carries messages between the brain and the
rest of the body. Some nerves carry messages from the brain to muscles to make the body move.
Other nerves carry messages about pain, pressure, or temperature from the body to the brain. Many
small fibers are bundled inside each nerve to carry the messages. There is an outer layer that
insulates and protects the nerves. Sometimes, nerves can be damaged. Damage to the peripheral
nerves is called peripheral neuropathy. It's important to get medical care for a peripheral nerve
injury as soon as possible. Early diagnosis and treatment may prevent complications and
permanent damage.
Causes
Peripheral nerves can be damaged in several ways:
 Injury from an accident, a fall or sports can stretch, compress, crush or cut nerves.
 Medical conditions, such as diabetes, Guillain-Barre syndrome and carpal tunnel syndrome.
 Autoimmune diseases including lupus, rheumatoid arthritis and Sjogren's syndrome.
 Other causes include narrowing of the arteries, hormonal imbalances and tumors.
Signs and Symptoms
With a peripheral nerve injury, patients may experience symptoms that range from mild to
seriously limiting daily activities. The symptoms often depend on which nerve fibers are affected:
 Motor nerves. These nerves regulate all the muscles under your conscious control, such as
walking, talking, and holding objects. Damage to these nerves is typically associated with
muscle weakness, painful cramps and uncontrollable muscle twitching.
 Sensory nerves. Because these nerves relay information about touch, temperature and pain,
you may experience a variety of symptoms. These include numbness or tingling in your
hands or feet. You may have trouble sensing pain or changes in temperature, walking,
keeping your balance with your eyes closed or fastening buttons.
 Autonomic nerves. This group of nerves regulates activities that are not controlled
consciously, such as breathing, heart and thyroid function, and digesting food. Symptoms
may include excessive sweating, changes in blood pressure, the inability to tolerate heat and
gastrointestinal symptoms.
Diagnosis
Diagnosis is based on medical history, history of accidents or previous surgeries, and symptoms
experiencing. physical and neurological examination. Neurological examination shows signs of a
nerve injury, recommend diagnostic tests, which may include:

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 Electromyography (EMG). In an EMG, a thin-needle electrode inserted into your muscle
records your muscle's electrical activity at rest and in motion. Reduced muscle activity can
indicate nerve injury.
 Nerve conduction study. Electrodes placed at two different points in your body measure
how well electrical signals pass through the nerves.
 Magnetic resonance imaging (MRI). MRI uses a magnetic field and radio waves to produce
detailed images of the area affected by nerve damage.
Treatment
 If a nerve is injured but not cut, injury is more likely to heal. Injuries in which the nerve has
been completely severed are very difficult to treat and recovery may not be possible.
 If your nerve is healing properly, may not need surgery. Nerves recover slowly and maximal
recovery may take many months or several years.
 Depending on the type and severity of your nerve injury, you may need medications such as
aspirin or ibuprofen (Advil, Motrin IB, others) to relieve your pain. Medications used to treat
depression, seizures or insomnia may be used to relieve nerve pain. In some cases, may need
corticosteroid injections for pain relief.
 Physical therapy to prevent stiffness and restore function.
Surgery
Peripheral nerve graft Open
Nerve transfer Open: remove the damaged section and reconnect healthy nerve ends (nerve
repair) or implant a piece of nerve from another part of the body (nerve graft).
Restoring function
A number of treatments can help restore function to the affected muscles.
 Braces or splints. These devices keep the affected limb, fingers, hand or foot in the proper
position to improve muscle function.
 Electrical stimulator. Stimulators can activate muscle served by an injured nerve while the
nerve regrows. However, this treatment may not be effective for everyone. Your doctor will
discuss electrical stimulation with you if it's an option.
 Physical therapy. Therapy involves specific movements or exercises to keep your affected
muscles and joints active. Physical therapy can prevent stiffness and help restore function
and feeling.
 Exercise. Exercise can help improve your muscle strength, maintain your range of motion
and reduce muscle cramps.

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10. Tuberculosis of Bones and Joints
Introduction:
 Tuberculosis (T.B.) is still a common infection in developing countries.
 After lung and lymph nodes, bone and joint is the next common site of tuberculosis in the
body.
 It constitutes about 1-4 percent of the total number of cases of tuberculosis.
 The spine is the commonest site of bone and joint tuberculosis, constituting about 50 per-
cent of the total number of cases. The next in order of frequency are the hip, the knee and
the elbow.
Aetio-Pathogenesis:
 The common causative organism is Mycobacterium tuberculosis.
 Bone and joint tuberculosis is always secondary to some primary focus in the lungs, lymph
nodes etc.
 The mode of spread from the primary focus may be either haematogenous or by direct
extension from a neighbouring focus.
Pathology:
Tubercular infection of the bone and synovial tissue produces two types of responses: proliferative,
exudative or both;
a. Proliferative response: This is the commoner of the two responses. It is characterised by
chronic granulomatous inflammation with a lot of fibrosis.
b. Exudative response: In some cases, particularly in immuno-deficient individuals, elderly
people and people suffering from leukaemia etc., there is extensive caseation necrosis
without much cellular reaction. This results in extensive pus formation.
Natural history:
 The inflammation results in local trabecular necrosis and caseation.
 Demineralization of the bone occurs because of intense local hyperaemia.
 In the absence of adequate body resistance or chemotherapy, the cortices of the bone get
eroded, and the infected granulation tissue and pus find their way to the subperiosteal and
soft-tissue planes. Here they present as cold abscesses, and may burst out to form sinuses.
Healing: It occurs by fibrosis, which results in significant limitation or near complete loss of joint
movement (fibrous ankylosis).

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 If considerable destruction of the articular cartilage has occurred, the joint space is
completely lost, and is traversed by bony trabeculae between the bones forming the joint
(bony ankylosis).
 Fibrous ankylosis is a common outcome of healed tuberculosis of the joints except in the
spine where bony ankylosis follows more often.
Clinical Features:
 Patients of all ages and both sexes are affected frequently.
 The onset is gradual in most cases.
 Usual presenting complaints are pain, swelling, deformity and inability to use the part.
 Sometimes, the presentation is atypical. Tuberculosis should be included in the differential
diagnosis of any slow onset disease of the musculo-skeletal system, particularly in
countries where tuberculosis is still prevalent.
Investigations:
 Radiological examination: X-ray examination of t h e affected part, antero-posterior and
lateral views.
 Other investigations:
 Blood examination: Lymphocytic leukocytosis, high ESR.
 Montoux test: useful in children.
 Serum ELISA tests for detecting anti-mycobacterium antibodies.
 Synovial fluid aspiration
 Aspiration of cold abscess and examination of pus for AFB.
 Histopathological examination of the granulation tissue obtained from biopsy or
curettage of a lesion.
Treatment:
1. Control of Infection
a. Anti-tubercular drugs: It is usual practice to start the treatment with 4 drugs: Rifampicin,
INH, Pyrazinamide, Ethambutol for 3 months. In selected cases with multifocal
tuberculosis, 5 drugs: RF, INH, PZ, ETH and Streptomycin, may be required for the
initial period.
b. Rest: The affected part should be rested during the period of pain. In the upper extremities
this can be done with a plaster-slab; in the lower extremities traction can be applied. In
most cases of spinal tuberculosis bed rest for a short period is sufficient; in others,
support with a brace may be necessary.

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c. Building up the patient's resistance: The patient should be given a high protein diet and
exposed to fresh air and sunlight to build up his general resistance.
2. Care of The Affected Part:
a. Proper positioning of the joint: The joints should be kept in proper position so that
contractures do not develop.
b. Mobilization: As the disease comes under control and the pain reduces, joint
mobilization is begun. This prevents contractures and helps regain movement.
c. Exercises: As the joint regains movement, muscle strength-building exercises are
taught.
d. Weight-bearing: It is started gradually as the osteoporosis secondary to the disease is
reversed.
Operative intervention:
 Treatment of cold abscess: A small stationary abscess may be left alone; it will regress
with the healing of the disease. A bigger cold abscess may need aspiration or evacuation.
 Curettage of the lesion: If the lesion is in the vicinity of a joint, the infection is likely to
spread to the joint. An early curettage of the lesion may prevent this complication.
 Joint debridement: Surgical removal of infected and necrotic material from the joint
 Operative intervention…
 Synovectomy: In cases of synovial tuberculosis, a synovectomy may be required to
promote early recovery.
 Salvage operations: Procedures performed for markedly destroyed joints in order to
salvage whatever useful functions are possible e.g., Girdlestone arthroplasty of the hip.
 Decompression: In cases with paraplegia secondary to spinal T.B., surgical
decompression may be necessary.
Tuberculosis of the Spine (Pott's disease)
 Commonest site of bone and joint tuberculosis; the dorso-lumbar region being the one
affected most frequently.
 T.B. of the spine is always secondary. The bacteria reach the spine via the haematogenous
route, from the lungs or lymph nodes.
 Common signs and symtoms are back pain, stiffness, paraplegia, deformity, and
constitutional symptoms like fever and weight loss.

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Pott's Paraplegia (T.B. spine with neurological involvement)
 The incidence of neurological deficit has been reported to be 20 per cent. It occurs most
commonly in tuberculosis of the dorsal spine because the spinal canal is narrowest in this
part, and even a small compromise can lead to a neurological deficit.
 This consists of pressure on the neural tissues within the canal by the products from the
diseased vertebrae.
 Tubercular paraplegia is usually spastic to start with. Clonus (ankle or patellar) is the most
prominent early sign, followed by muscle weakness and paraplegia.
Conservative treatment:
 Anti-tubercular chemotherapy
 Rest by a sling traction for the cervical spine, and bed rest for the dorsolumbar spine.
 Care of paralysed limbs with repeated neurological examination to detect any deterioration
or improvement in the neurological status.
 If the paraplegia improves, the conservative treatment is continued. The patient is allowed
to sit in the bed with the help of braces as soon as the spine has gained sufficient strength.
Bracing is continued for a period of about 6 to 12 months.
Operative procedures for Pott's paraplegia
 Costo-transversectomy: Removal of a section of rib (about 2 inches), and transverse
process.
 Antero-lateral decompression (ALD): This is the most commonly performed operation.
In this operation, the spine is opened from its lateral side and access is made to the front
and side of decompression. The cord is laid free of any granulation tissue, caseous material,
bony spur or sequestrum pressing on it.
 Operative procedures for Pott's paraplegia…
 Radical debridement and arthrodesis (Hongkong operation): Radical debridement is
performed by exposing the spine from front using transthoracic or transperitoneal
approaches. All the dead and diseased vertebrae are excised and replaced by rib grafts.
 Laminectomy: It is indicated in cases of spinal tumour syndrome, and those where
paraplegia has resulted from posterior spinal disease.
Tuberculosis of the Hip
 After the spine, the hip is affected, most commonly.
 Usually it occurs in children and adolescents, but patients at any age can be affected.

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 The usual initial lesion is in the bone adjacent to the joint i.e., either the acetabulum or the
head of the femur (osseous tuberculosis).
 Presenting complaints: The disease is insidious in onset and runs a chronic course. The
child may be apathetic and pale with loss of appetite before definite symptoms pertaining
to the hip appear.
 One of the first symptoms is stiffness of the hip, and it produces a limp.
 The child may complain of 'night cries', the so-called 'starting pain', caused by the rubbing
of the two diseased surfaces when the movement occurs as a result of the muscle relaxtion
during sleep.
 Later, there may be cold abscesses around the hip or these may burst, resulting in
discharging sinuses.
 Diagnosis is made by X-Ray and Biopsy.
 Conservative management includes rest of the affected hip and immobilization using below
knee skin traction.
Operative Treatment
 Joint debridement
 Girdlestone arthroplasty: The hip joint is exposed using the posterior approach. The head
and neck of the femur are excised The dead necrotic tissues and granulation tissues are
excised. Post-operatively, bilateral skeletal tractionis given for 4 weeks, followed by
mobilisation of the hip.
 Arthrodesis: In selected cases, where a stiff hip in a functional position is more suitable
considering the day-to-day activity of the patient, it is produced surgically by knocking the
joint out.
 Corrective osteotomy: Cases where bony ankylosis of the hip has occurred in an
unacceptable position from the functional view point, a subtrochanteric corrective
osteotomy of the femur may be required.
 Total hip replacement: Useful in some patients with quiescent tuberculosis but costly so
an excision arthroplasty is a preferred option.
Tuberculosis of the Knee
 Common site of tuberculosis.
 Being a superficial joint, early diagnosis is usually possible.
 The patient, usually in the age group of 10-25 years, presents with complaints of pain and
swelling in the knee.
 It is gradual in onset without any preceding history of trauma.

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 Subsequently, the pain increases and the knee takes an attitude of flexion. The child starts
limping. There is severe stiffness of the knee.
 The general management is the same as other joint tuberculosis.
Operative treatment
 Synovectomy: Required in cases of purely synovial tuberculosis.
 Joint debridement: This may be required in cases where the articular cartilage is
essentially preserved. The pus is drained, the synovium excised, and all the cavities
curetted.
 Arthrodesis: In advanced stages of the disease with triple subluxation and complete
cartilage destruction the knee is arthrodesed in functional position, i.e., about 5-10 degrees
of flexion and neutral rotation.
Tuberculosis of Other Joints
 Other joints uncommonly affected by tuberculosis are the elbow, shoulder and ankle joints.
 The clinical features are similar to tuberculosis of other joints.
 Diagnosis is generally possible by X-ray examination. Occasionally a biopsy may be
required.
 Shoulder joint tuberculosis, at times, may not produce any pus etc, and hence is called
'caries sicca' and should always be considered in differential diagnosis of much commoner
shoulder problem 'frozen shoulder'.
Nursing Management
 Acute pain related to pus collection, muscle spasm and edema
 Impaired physical Mobility May be related to Neuromuscular skeletal impairment,
pain/discomfort, restrictive therapies (limb immobilization)
 Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care,
and discharge needs related to Information misinterpretation/unfamiliarity with information
resources
Managing pain
 Document location and intensity of pain (0–10 scale).
 Investigate changes in pain characteristics; e.g., numbness, tingling.
 Provide/promote general comfort measures (and diversional activities.
 Encourage use of stress management techniques (e.g., deep-breathing exercises,
visualization, and guided imagery) and therapeutic touch.

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 Medicate before care activities. Let client know it is important to request medication before
pain becomes severe.
 Identify diversional activities appropriate for client age, physical abilities, and personal
preferences.
 Investigate any reports of unusual/sudden pain or deep, progressive, and poorly localized
pain unrelieved by analgesics.
Maintaining joint mobility
 Assess degree of immobility produced by injury/treatment and note client’s perception of
immobility.
 Maintain stimulating environment; e.g., radio, TV, newspapers, personal
possessions/pictures, clock, calendar, visits from family/friends.
 Instruct client in/assist with active/passive ROM exercises of affected and unaffected
extremities.
 Encourage use of isometric exercises starting with the unaffected limb.
 Instruct in/encourage use of trapeze.
 Assist with/encourage self-care activities (e.g., bathing, shaving).
 Provide/assist with mobility by means of wheelchair, walker, crutches, canes as soon as
possible. Instruct in safe use of mobility aids.
Patient education
 Review pathology, prognosis, and future expectations.
 Discuss dietary needs.
 Discuss individual drug regimen as appropriate.
 Reinforce methods of mobility and ambulation as instructed by physical therapist when
indicated.
 Identify available community services; e.g., rehabilitation team, home nursing/homemaker
services.
 Discuss importance of clinical and therapy follow-up appointments.
 Review proper pin/wound care.

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11. Amputation
Introduction: Amputation is the removal of a body extremity by trauma, prolonged
constriction, or surgery. As a surgical measure, it is used to control pain or a disease process
in the affected limb, such as malignancy or gangrene. Amputation is used to relieve symptoms,
improve function, and save or improve the patient’s quality of life.
Epidemiology: Each year over 150,000 individuals are admitted to hospitals to undergo
amputations secondary to peripheral vascular disease or diabetes. As of 2005, an estimated 1.6
million people with amputation live in the United States, of whom approximately 65%
underwent lower limb amputation.
Indication:
The six d’s for amputation are as follows:
 A dead limb, e.g. vascular gangrene.
 A dying limb, e.g. , frost bite, etc.
 A destroyed limb, e.g. crush injury.
 A denervated limb ,e.g. hereditary sensory neuropathy,
 A dangerous limb, e.g. malignant bone tumor, gas gangrene,
 A deformed limb: Congenital limb deficiency.
Causes
 Circulatory disorders: Diabetic foot infection or gangrene (the most common reason
for non-traumatic amputation), Sepsis with peripheral necrosis
 Neoplasm: Cancerous bone or soft tissue tumors (e.g. osteosarcoma, osteochondroma,
fibro sarcoma, epithelioid sarcoma, synovial sarcoma, sacrococcygeal teratoma,
liposarcoma), Melanoma
 Trauma: where it is not possible to save the part: for example, a fingertip that is
cut off by a meat grinder).
 Deformities: Deformities of digits and/or limbs, Extra digits and/or limbs
 Infection: Bone infection (osteomyelitis)
 Legal punishment: Amputation is used as a legal punishment in a number of countries,
among them Iran, Yemen, Saudi Arabia, Sudan, and Islamic regions of Nigeria
Types of amputation:
In lower limbs:
 General Amputations

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 A ray amputation
 Below knee amputation
 Above knee amputation
 Disarticulation of hip, knee, etc.
– A ray amputation: A ray amputation is a particular form of minor amputation where toe
(phalange) and part of the corresponding metatarsal bone is removed.
– Gille’s Amputation: It is a transmetatarsal amputation done in the foot. It preserves the
function of weight bearing. Toes off phase of stance is lost. Needs special shoes with toe inset
filled for a good cosmetic and to overcome the deficit of push off.
– Chopart amputation: Amputation of the foot by a midtarsal disarticulation. In fact, Chopart’s
amputation can result in foot drop because of lack of muscle and tendon attachments.
– Lisfranc amputation: Amputation of the foot between the metatarsal and tarsal. The
Lisfranc’s and Chopart’s amputations result in considerable gait problems during walking.
Weight bearing function is preserved. Special shoes with anterior fill, is used for cosmetic.
– Syme’s ((modified ankle disarticulation) amputation: Disarticulation of the foot with
removal of both malleolus, 0.6 cms proximal to joint line. It is an excellent amputation through
the ankle, is performed most frequently for extensive foot trauma and produces a painless,
durable extremity end which retains the function of weight bearing because of intact heel pad.
It results in a bulbous stump. A special prosthetic shoe is necessary after Syme’s amputation.
Weight bearing function is preserved. But, all the stages of stance phase of gait are affected.
– Pirogoff’s Amputation: Amputation of the foot at the ankle, part of the calcaneus being left
in the stump. In this modification, the calcaneum is resected partly and turned 90° upwards
towards the tibia. This increases the length of the stump.
– Kruckenberg’s Amputation: This amputation was described by Kruckenberg and Putti. The
amputation involves conversion of the amputated stump of the forearm into radial and ulnar
pincers (bifid forceps). These two pincers open and close in pronation and supination
movements of the forearm. The length of the pincers can be varied from 7–12 cm. Longer the
pincer length, the strength of the grip decreases. The amputation is unsightly, but highly
efficacious functionally with retained sensation. Can be fitted with a cosmetic hand prosthesis.
mostly performed on patients in developing countries who lack the means to obtain expensive
prosthesis.
In upper extremities
 Forearm amputation(transradial)
 Upperarm amputation
 amputation of digits

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 metacarpal amputation
 wrist disarticulation
 elbow disarticulation
 above-elbow amputation (transhumeral) amputation
 shoulder disarticulation.
 Krukenberg amputation
Others
 Amputation of the ears, nose (rhinotomy), tongue (glossectomy),eyes
(enucleation),amputation of the teeth.
 Amputation of the breasts (mastectomy).
 Amputation of the testicles (castration).
 Amputation of the penis (penectomy).
 Amputation of the foreskin (circumcision).
 Amputation of the clitoris (clitoridectomy).
Self-amputation
In some rare cases when a person has become trapped in a deserted place, with no means of
communication or hope of rescue, the victim has amputated his or her own limb. The most
notable case of this is Aron Ralston, a hiker who amputated his own right forearm after it was
pinned by a boulder in a hiking accident and he was unable to free himself for over five days.
Stump
 The distal portion of an amputated extremity.
 The part of a limb that remains after amputation also called residual limb.
Recommended Ideal Length of the Stump
 In below-knee amputations, 10.0–12.5 cm from the Tibial tuberosity.
 In above-knee amputations, 22.5–25.0 cm from the greater trochanter
 In above and below elbow amputations, 20.0 cm from the Acromion process and the
Olecrenon process respectively.
 These stump lengths recommended, are not constant.
 The length varies depending on the length of the limb. Basically, it gives a rough idea
as to how much length of the stump is desirable for fitting a prosthesis.
An ideal stump of amputation
It should fulfill the following criteria:

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 Long enough to fit a prosthesis
 Good sensation
 Good blood supply
 Good soft tissue cover
 No bad scarring
 No infection
 Conical shape
 Proximal joint should be normal
Signs and Symptoms: Prior to Amputation
– Pain: reduced perfusion often relieved by lowering the limb
– Absence of pulse: popliteal, Dorsalis pedalis
– Skin changes: hairless, flaky, ulcerated, shiny Blue/black discoloration
– Necrosis of toes/foot
– Anaerobic infection: Gas gangrene
Complication
– Haemorrhage,
– Haematoma
– Infection.
– Pain
– Gas gangrene can occur in a mid-thigh stump from faecal contamination.
– Wound dehiscence and gangrene of the flaps are caused by ischaemia,
– Risk of deep vein thrombosis and pulmonary embolism in the early postoperative period.
– Phantom limb sensation and
– Phantom pain
Complication of stump
Early complication
– Secondary hemorrhage
– Breakdown of the skin flaps (may be due to ischemia or excessive suture tension)
– Gas gangrene
– Skin
– eczema
– purulent lumps
– Fissuring & ulceration
– Infected epidermoid cyst

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– Squamous cell carcinoma
– Muscle If excessive muscle left, it will produce unstable, loose cushion
– Artery poor vascularity gives cold blue color stump liable to ulcerate
– Nerve Painful neuromas attached to the scar
Rehabilitation
– Because the amputation is the result of an injury, the patient needs psychological support
in accepting the sudden change in body image and in dealing with the stresses of
hospitalization, and modification of lifestyle. The nurses’ attitude should be one of firm
reassurance.
– Patients who undergo amputation need support as they grieve the loss, and they need time
to work through their feelings about their permanent loss and change in body image.
– The nurse should create an accepting and supportive atmosphere in which the patient and
family are encouraged to express and share their feelings and work through the grief
process. This process of rehabilitation should begin before surgery.
– The multidisciplinary rehabilitation team (patient, nurse, physician, social worker,
psychologist, prosthetist, vocational rehabilitation worker) helps the patient achieve the
highest possible level of function and participation in life activities.
– Prosthetic clinics and amputee support groups facilitate this rehabilitation process.
– Vocational counseling and job retraining may be necessary to help patients return to work.
– Teach the client to use the trapeze and side rails for independent movement in bed,
Maintain or promote strength in upper arms to facilitate rehabilitation.
– The nurse should teach the patient how to use walker, crutch walking techniques.
– If the health care team communicates a positive attitude, the patient adjusts to the
amputation more readily and actively participates in the rehabilitative plan, learning how
to modify activities and how to use assistive devices for ADLs and mobility.
– Early assessment of the home is part of the program; it allows time for minor alterations,
such as the addition of stair rails, movement of furniture to give support near doors and
provision of clearance in confined passages.
– Continued support and supervision by the home care nurse are essential. Family counseling
is also must.
– Physical therapy and occupational therapy may continue in the home or on an outpatient
basis.
Phantom limb sensation
– Phantom sensation is feelings that the amputated part is still present. Although these
sensations are often referred to as phantom pain, not all of the sensation are painful.

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– The patient may describe unusual sensations, such as numbness, warmth, cold, itching as
well as a feeling that the extremity is present, crushed, cramped, or twisted in an abnormal
position
– Phantom sensation is caused by intact peripheral nerves proximal to the amputation site
that carried messages between the brain and the now amputated part.
– Amputees may experience phantom limb pain soon after surgery or 2 to 3 months after
amputation. It occurs more frequently in above-knee amputations. Phantom sensations
diminish over time. It gradually decreases over the next 2 years.
Phantom pain
– Pain is usually burning, cramping, squeezing, or shooting in nature.
– May occur in large number of clients.
– It is thought to be caused by combination of physiologic and psychological components.
– Phantom pain occurs most often in clients who had pain in the limb before the amputation.
– Distraction techniques and activity are helpful.
Investigation
– The diagnostic assessments include the usual preoperative blood studies and radiographs
to determine the level of amputation that is most likely to heal.
– Arteriography may be done to determine the level of blood flow in the extremity.
– Doppler studies are used to measure blood flow viscosity.
– Transcutaneous oxygen level may also be measured.
Nursing management
Pre-operative assessment:
– Before surgery, the nurse must evaluate: the neurovascular and functional status of the
extremity through history and physical assessment.
– If the patient has experienced a traumatic amputation, the nurse assesses the function and
Condition of the residual limb. The circulatory status and function of the unaffected
extremity.
– Hemodynamic evaluation is performed through testing: angiography, arterial blood flow
– Cultural and sensitivity test of draining wounds: to assist in control of infection
preoperatively
– Evaluation of any concurrent health problems (e.g.: dehydration, anemia)
– The patient’s nutritional status and creates a plan for nutritional care, if indicated. For
wound healing, a balanced diet with adequate protein and vitamins is essential.

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– Patient’s physical condition: Any concurrent health problems (eg, dehydration, anemia,
cardiac insufficiency, chronic respiratory problems, diabetes mellitus) need to be
identified.
– The age of the patient, the ability to become ambulatory, the willingness of the client to
participate in rehabilitation program also should be assessed.
– Assess for the use of corticosteroids, anticoagulants, vasoconstrictors, or vasodilators
which may influence management and wound healing.
– The client’s attitude towards amputation: The nurse assesses the patient’s psychological
status. Determination of the patient’s emotional reaction to amputation is essential for
nursing care.
– Support the client and family through their pain, suffering and decision making for
amputation.
– Monitor for glucose level if diabetes.
Nursing diagnosis
1. Acute pain related to amputation.
Goals: patient will be relief of pain, absence of altered sensory perception.
– Keep patient in comfort position
– Measure stump size in every shift.
– Administer analgesic as prescribed and patients need.
– Keep stump in elevation
2. Impaired physical mobility related to disease condition, loss of limb.
– Assess degree of pain, listening to client’s description.
– Determine degree of cognitive impairment and ability to follow direction.
– Assess nutritional status and energy level.
– support affected body part using pillow,foot support/shoes ,air mattress.
– administer medication prior to activity as nedded for pain relife.
– Provide regular skin care to include pressur area management.
3. Risk of infection related to traumatized tissue, Invasive procedures, environmental.
Exposure
Goal - Achieve timely wound healing; be free of purulent drainage or erythema; and be afebrile.

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 During emergency treatment, monitor vital signs, clean the wound and give tetanus
prophylaxis, and antibiotics as ordered.
 After a complete amputation, wrap the amputated part in wet dressing soaked in normal
saline solution.
 Flush the wound with sterile saline solution, apply a sterile pressure dressing.
 Maintain aseptic technique when changing
dressings and caring for wound.
 Expose stump to air; wash with mild soap and water after
dressings are discontinued.
4. Risk for Ineffective Tissue Perfusion: At risk for decreased in the oxygen resulting in the
failure to nourish the tissues at the capillary level.
Goal - Patient will maintain adequate tissue perfusion as evidenced by palpable peripheral pulses,
warm/dry skin, and timely wound healing.
• Monitor vital signs. Palpate peripheral pulses, noting strength and equality.
• Perform periodic neurovascular assessments (sensation, movement, pulse, skin color, and
temperature).
• Inspect dressings and drainage device, noting amount and characteristics of drainage.
• Apply direct pressure to bleeding site if hemorrhage occurs. Contact physician
immediately.
• Investigate reports of persistent or unusual pain in operative site.
• Encourage and assist with early ambulation.
• Monitor laboratory studies: Hb and Hct
Post-operative management
 The extremity must be in full extension and may be elevated (if possible).
 Complications are to be monitored.
 Rehabilitation is initiated through physiotherapy and prosthetic fitting if indicated.
 Therapy is provided for diabetes mellitus, heart disease, infection, chronic obstructive
pulmonary disease, and age-related deterioration., which are factors for poor healing
 If wound breakdown, infection, delay in healing of residual limb occur, therapy is provided
to prevent delay in rehabilitation.
 Acceptance of body image change is promoted.

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Care of stump
Instruct patient to:
 Inspect stump daily for Redness, blistering or abrasions.
 Use a mirror to examine all sides and aspects of stump.
 Continue prescribed exercises to prevent weakness
 Keep the stump clean, dry, and free from infection at all times.
 Inspect and wash the stump with mild soap and warm water every night, then dry thoroughly
and apply powder.
 Wear stump socks.
 Change the stump sock daily, and the inside of the socket may be cleaned with mild soap.
 remove prosthesis before going to sleep if fitted with a prosthesis
 Not to use the prosthesis until the skin has healed.
Prosthesis care
– Remove sweat and dirt from the prosthesis socket daily by wiping the inside of the socket with
damp soapy cloth and dry thoroughly.
– Never attempt to adjust or mechanically alter the prosthesis. If problems develop, consult the
prosthesist.
– Schedule a yearly appointment with the prosthesist.

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12. Ankylosing Spondylitis
Introduction: Ankylosing spondylitis (AS) is a chronic inﬂammatory disease primarily affecting
the spine and sacroiliac joints. It is the most common of a group of diseases known as
spondyloarthritides, which are rheumatic diseases with common clinical symptoms. It is a form of
arthritis that affects the cartilaginous joints in the spine and surrounding tissues. Its name comes
from the Greek words ankylos, meaning stiffening of a joint, and spondylo, meaning vertebra.
Spondylitis causes inflammation (redness, heat, swelling, and pain) in the spine or vertebrae.
Ankylosing spondylitis often involves an inflamed sacroiliac (SI) joint, where the spine joins the
pelvis.
Incidence: The incidence of AS may be underestimated due to unreported cases. The average
annual age-adjusted rate of AS has been reported to be 6.6 per 100,000 populations, with men
affected three times as frequently as women. Although the usual age of onset has been established
as between 15-35 years, the age group with the highest incidence rate is the 25-34-year-old group.
The overall incidence rate is estimated to be 129 per 100,000 populations. Thus the overall
incidence rate for the entire population has been estimated to fall between 1 and 2 per 1000
population.
Risk Factors: Risk factors associated with AS include gender with a 3:1 to 4:1 predominance of
males over females (the reasons for this are unknown), the young adult years of adolescences
through adulthood (15-35years old), and a genetic predisposition. A strong tendency toward
familial aggregation has been seen and a sex-linked hormone may be important. The presence of
HLA-B27 may also be a risk factor. Scientists recently discovered two more genes (IL23R and
ERAP1) that, along with HLA-B27, carry a genetic risk for ankylosing spondylitis.
Etiology: The cause of ankylosing spondylitis is unknown. It’s likely that genes (passed from
parents to children) and the environment both play a role. The environmental factors such as stress
might also inﬂuence the development of the disease. The main gene associated with the risk for
ankylosing spondylitis is called HLA-B27. Less than 1 of 20 people with HLA-B27 gets
ankylosing spondylitis. The variation in prevalence is thought to occur because of the presence of
the human leucocyte antigen (HLA)-B27 gene within different populations. HLA-B27 is a protein
on the surface of white blood cells.

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Pathophysiology:
There are no single agents that have been associated with the causation of ankylosing spondylitis.
There seems to be a complex interaction between raised serum levels of IgA (Immunoglobulin A)
and acute phase reactants of inflammation, the body’s immune system and the HLA-B27 gene.
Both genetic and environmental factors appear to be involved in the pathogenesis of ankylosing
spondylitis. There is probably an interaction between the class I MHC molecule HLA-B27 and the
T cell immune response. The HLAB27 presents an antigen to the CD8+ T cells and this in turn
activates the immune system to attack the ﬁbrocartilage or cartilage. Bacterial infections are
suggested to be triggering events in some cases and thus the environment may also play a part.
Tumor necrosis factor (TNF)-α and interleukin 1 (IL-1) are thought to play a role in the
inflammatory reactions observed with the disease. Increased T-cell and macrophage
concentrations as well as enhanced expression of pro-inflammatory cytokines, including TNF-α,
are characteristic findings.
The inflammatory reactions are responsible for distinguishing characteristics of the disease. This
includes the enthesis, which is the site of major histologic changes. This begins with a destructive
enthesopathy followed by a healing process with new bone formation, linking deeper bone to the
ligament and ultimately resulting in bony ankylosis. This causes fusion or joining up of the joint
bones and stiffness and immobility. This is the hallmark symptom in the spine in ankylosing
spondylitis.
There are a variety of clinical manifestations of ankylosing spondylitis, and these include:
– Pain: The initial symptom is typically a dull pain that is insidious in onset. The pain is
generally felt deep in the buttock and/or in the lower lumbar regions and is accompanied by
morning stiffness in the same area that lasts for a few hours, improves with activity, and returns
with inactivity. The pain becomes persistent and bilateral within a few months and is usually
worse at night. About 5% of patients presenting with chronic inﬂammatory back pain have AS
or another SpA subset
– Early morning stiffness: can take from a few minutes to many hours to ease, and it can take
up to two or more hours for a person to get going in the morning. Sitting down for any length
of time can cause the spine to stiffen up again.
– For some patients, bone tenderness may be the primary complaint or may accompany back
pain or stiffness. Arthritis in the hips and shoulders occurs in some patients, often early in the
course of the disease. Asymmetric arthritis of other joints, predominantly of the lower limbs,

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can be present at any stage of the disease. Neck pain and stiffness is characteristic of advanced
disease.
– Enthesitis: is pain and swelling where ligaments and tendons attach to bone. A common site
is the heel and pain on walking can be significant, particularly in the morning when the heel
has been rested overnight.
– Fatigue: constant exhaustion not relieved by sleep.
– Feverishness or night sweats: are commonly reported symptoms in people with ankylosing
spondylitis. However, these symptoms are also associated with other inflammatory and
autoimmune disorders and there is a lack of evidence about the cause of feverishness or night
sweats.
– Shortness of breath: as the disease progresses it can cause fusion of the thoracic vertebrae
and also the attached ribs, limiting expansion of the chest. If the spine becomes fully ankylosed
it can lead to a stoop, which will also limit chest expansion.
– Flares: individuals can go through periods where ankylosing spondylitis is dormant and then
flares up.
Physical findings: A principal physical finding is loss of spinal mobility, with restrictions of
flexion, extension of the lumbar spine, and expansion of the chest. The limitation of motion is
disproportionate to the degree of ankylosis because of secondary muscle spasms. Pain in the SIJs
may be elicited with direct pressure or movement, but its presence is not a reliable indicator of
sacroiliitis. There may be detectable inflammation of peripheral joints.
– Clinical signs of the disease can range from mild stiffness to a totally fused spine, with any
combination of severe bilateral hip involvement, peripheral arthritis, or extra-articular
manifestations. A patient’s posture undergoes characteristic changes if a severe case goes
untreated. The lumbar lordosis is destroyed, the buttocks atrophy, the thoracic kyphosis is
exaggerated, and the neck may stoop forward.
– There are several extra-articular manifestations of AS, the most common condition being acute
anterior uveitis. Patients may present with unilateral pain, photophobia, and increased
lachrymation. Up to 60% of patients with AS have asymptomatic IBD. In some cases, frank
IBD will develop. Aortic insufficiency, with possible congestive heart failure, is seen
infrequently in patients with AS.
– Neurological changes such as bowel and bladder incontinence, paresthesia and numbness may
also occur. Several other systemic manifestations of AS can be seen, such as uveitis, pulmonary
fibrosis, inflammatory bowel disease and aortic insufficiency. Uveitis occurs in up to 25% of
all clients with AS, especially in HLA-B27 positive clients with peripheral joint disease.
Intestinal inflammation is frequent in clients with spondylarthropathy and one fourth of clients
have early features of Crohn’s disease. Aortic insufficiency, accompanied by a typical diastolic

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murmur, occurs in 5% of those with AS, and this problem frequently leads to the need for an
aortic valve replacement.
Complications:
In severe cases of ankylosing spondylitis, new bone forms as part of the body's attempt to heal.
This new bone gradually bridges the gap between vertebrae and eventually fuses sections of
vertebrae together. Those parts of spine become stiff and inflexible. Fusion can also stiffen rib
cage, restricting lung capacity and respiratory function.
Other complications may include:
– Eye inflammation (uveitis): One of the most common complications of ankylosing
spondylitis, uveitis can cause rapid-onset eye pain, sensitivity to light and blurred vision.
– Compression fractures: Some people experience a thinning of their bones during the early
stages of ankylosing spondylitis. Weakened vertebrae may crumble, increasing the severity of
stooped posture. The most common site for fracture is cervical spine. Vertebral fractures
sometimes can damage the spinal cord and the nerves that pass through the spine.
– Heart problems: Ankylosing spondylitis can cause problems with aorta, the largest artery in
body. The inflamed aorta can enlarge to the point that it distorts the shape of the aortic valve
in the heart, which impairs its function.
– Amyloidosis: A deposition of a protein like material in a number of visceral organs is a very
rare complication of AS.
Diagnosis
Positive physical examination findings include the presence of sacroilitis, spinal muscle spasms,
and decreased hip motility. Decreased chest expansion is seen later in the disease. Early changes
in AS include a squaring off of anterior lumbar vertebral surfaces. A better understanding of
ankylosing spondylitis and developments in diagnostic techniques has led to changes in the
diagnostic criteria for the disease.
Imaging tests: X-rays aids in diagnosis by checking changes in joints and bones, though the
visible signs of ankylosing spondylitis may not be evident early in the disease. Magnetic resonance
imaging (MRI) uses radio waves and a strong magnetic field to provide more-detailed images of
bones and soft tissues. MRI scans can reveal evidence of ankylosing spondylitis earlier in the
disease process, but are much more expensive.
Lab tests: There are no specific lab tests to identify ankylosing spondylitis. Certain blood tests
can check for markers of inflammation (such as ESR, C-reactive protein), but inflammation can
be caused by many different health problems. Initially, ankylosing spondylitis was thought to be a
variation of rheumatoid arthritis; however, it was not until the advent of diagnostic tests such as

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that for the HLA-B27 gene that ankylosing spondylitis was recognised as being different from
rheumatoid arthritis
Treatment
There's no cure for ankylosing spondylitis (AS), but treatment is available to help relieve the
symptoms. Treatment can also help delay or prevent the process of the spine joining up (fusing)
and stiffening. The treatment goals for AS are to maintain mobility, decrease inflammation, and
control pain. As with other chronic conditions treatment is more successful when clients are
engaged in and assume responsibility for health promotion and other self-care activities.
In most cases treatment involves a combination of:
 Reduce pain and inflammation
 Maintain skeletal mobility
 Preventing deformity
Reduce pain and inflammation:
The first type of painkiller usually prescribed is NSAIDs. As well as helping ease pain, NSAIDs
can help relieve swelling (inflammation) in joints. Examples of NSAIDs include:
 Ibuprofen, indomethacin
 naproxen
 diclofenac
 etoricoxib
Paracetamol: If NSAIDs are unsuitable, an alternative painkiller, such as paracetamol, may be
recommended. However, paracetamol may not be suitable for people with liver problems or those
dependent on alcohol.
Anti-TNF medication: If the symptoms can't be controlled using painkillers or exercising and
stretching, anti-tumour necrosis factor (TNF) medication may be recommended. TNF is a chemical
produced by cells when tissue is inflamed. Anti-TNF medications are given by injection and work
by preventing the effects of TNF, as well as reducing the inflammation in joints caused by
ankylosing spondylitis. These are relatively new treatments for AS and their long-term effects are
unknown. Examples of anti-TNF medication include:
 adalimumab
 etanercept
 golimumab
 certilizumab
Corticosteroids: Corticosteroids have a powerful anti-inflammatory effect and can be taken as
tablets or injections by people with AS. If a particular joint is inflamed, corticosteroids can be
injected directly into the joint. Corticosteroids may also calm down painful swollen joints when

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taken as tablets.It's usually considered wise to have a corticosteroid injection up to three times in
one year, with at least three months between injections in the same joint. This is because
corticosteroids injections can cause a number of side effects, such as:
– infection in response to the injection
– the skin around the injection may change color (depigmentation)
– the surrounding tissue may waste away
– a tendon near the joint may burst (rupture)
Disease-modifying anti-rheumatic drugs (DMARDs): Disease-modifying anti-rheumatic drugs
(DMARDs) are an alternative type of medication often used to treat other types of arthritis.
DMARDs may be prescribed for AS, although they're only beneficial in treating pain and
inflammation in joints in areas of the body other than the spine. Sulfasalazine is the
main DMARD sometimes used to treat inflammation of joints other than the spine.
Maintaining mobility:
Instructing the client to perform appropriate exercises and engage in ADL is critical if the client is
to maintain mobility with minimal spinal curvature.
Physiotherapy and exercise: Physiotherapy is a key part of treating AS. A physiotherapist can
advise about the most effective exercises and draw up an exercise programme that suits the
particular individuals with AS. Being active can improve posture and range of spinal movement,
along with preventing spine becoming stiff and painful. Good posture must be encouraged through
exercises that promote stretching and extension of spine.
Types of physiotherapy recommended for AS includes:
An exercise programme: Individual are given Range of motion exercises to do by themselves.
Regular exercise program must be started as part of the treatment immediately after the patient is
diagnosed. The exercises done under supervision are more effective than home exercises. The
intensity of exercises must be adapted according to the activity and stage of the disease for each
patient.
– Patients must be trained on physical therapy explaining which posture is appropriate,
how they should walk and sleep, and which exercises are suitable.
– Specific exercises, such as spine extension, joint range of motion, and deep breathing
exercises, must be applied a minimum of twice a day.
– Patients must be instructed for the right postures while walking, sitting, and laying
down.

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– They should be advised to walk tall and keep the spine in an upright position as much
as possible. They should avoid some unintentional postures, such as spinal curvature
or leaning forward while working.
– Lying down in the face down position for 15–30 min a few times a day may prevent
kyphosis and flexion contracture in the hip.
– A cane or a walker may be used for people with severe kyphosis or lower extremity
arthritis.
– Sports supporting axial mobility (swimming, badminton, volleyball, running, skiing,
etc.) should be preferred over other sportive activities carrying high bone-fracture risk
(cycling, horse riding, boxing, football).
 Massage: Muscles and other soft tissues are manipulated to relieve pain and improve
movement; the bones of the spine should never be manipulated as this can cause injury in
people with AS.
 Hydrotherapy: exercise in water, usually a warm, shallow swimming pool or a special
hydrotherapy bath; the buoyancy of the water helps make movement easier by supporting
joints and the warmth can relax muscles. Swimming is an excellent general conditioner as
well as an activity that promotes spinal extension without increased pain.
Preventing Deformity
• Patient should adopt the habit of sleeping flat upon his back on a firm mattress, with a small
pillow to prevent increasing flexion deformity of the spine.
• Instruction on maintenance of erect posture during sitting, standing and walking is a must
and in case of limited mobility assisting devices such as cane or walkers can be used.
• Spinal braces may be used to prevent continued deformity of the spine and ribs.
• Foot pain is a common and can be further aggravated with disease progression so instruct
on using of soft footwear & heel cushion/ cup in footwear helps reduce the pain.
Surgery: Most people with AS won't need surgery. However, joint replacement surgery may be
recommended to improve pain and movement in the affected joint if the joint has become severely
damaged. For example, if the hip joints are affected, a hip replacement may be carried out. In rare
cases corrective surgery may be needed if the spine becomes badly bent.
Prognosis: The prime predictor of more severe dysfunction is the presence of peripheral joint
involvement, particularly in the hips, however total hip replacement may improve their function.
Patient with spinal rigidity but normal hip function has minimal disability.

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Nursing Management
Assessment
History and complete physical assessment
 Assess for pain, stiffness, ADL, sleep, morning stiffness, fatigue, weight loss and low grade
fever.
 Neurologic changes: decreased motor activity, paresthesias, numbness, and bowel/bladder
incontinence.
 Eyes, respiratory status and heart.
Nursing Diagnoses
1. Pain related to inflammation and stiffness in joints.
2. Ineffective breathing pattern related to reduced chest expansion secondary to vertebral
spine involvement.
3. Impaired physical mobility related to hip joint inflammation and pain.
4. Fatigue related to pain and fever
5. Self-care deficit related to reduced mobility.
6. Body image disturbances related to changes in body appearance due to loss of spinal
mobility.
7. Knowledge deficit related to prognosis of disease condition and therapy.
8. Risk for injury related to improper gait and balance.
Expected patient outcomes:
1. Patient is more accepting of change in body appearance.
2. Patient can demonstrate postural and breathing exercises to minimize interference with
breathing capacities.
3. Patient is able to perform activities of daily living with less fatigue and discomfort.
4. Patient states the pain is lessened.
5. Patient knows the course of disease, prescribed therapy and plas for follow-up care.
Nursing Interventions
1. Reducing pain and inflammation
 Apply heat packs at the affected area.
 Give anti-inflammatory analgesics as prescribed. Indomethacin is the most commonly used
NSAIDS. Ask to take rest periods alternating activity or provide adequate rest. Encourage
diversional activities.

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2. Promote Effective Breathing Another important area for nursing intervention, especially as
the disease progress, is the maintenance of effective breathing patterns and adequate
oxygenation. Ongoing assessment of chest wall expansion, instructions in deep breathing
exercises, and the avoidance of smoking and respiratory depressants can help the client to
maintain optimal breathing.
3. Promote mobility: To provide mobility, teach the clients to take NSAIDS at regular intervals
throughout the day with food, milk or antacid. Encourage the client to maintain a fluid intake
of 2500 ml or more per day. Suggest that the client perform exercise in the shower because
warm, moist heat prompts mobility. Stress the importance of following the prescribed physical
therapy and exercise program to maintain mobility. Teach the client that proper positioning
and posture are important. When sleeping a bed board may be used to provide firmness, and
the person should sleep in supine position using either no pillow or only one small pillow.
Other important self-care activities include losing weight if applicable, avoiding smoking, and
using muscle strengthening exercises. Suggest occupational counseling if pain and deformity
are severe enough to cause work related problems. Assist with range of motion exercises 3
times in a day.
4. Reducing Fatigue
Good pain control can significantly reduce fatigue. Patients should be encouraged to take
analgesia and prescribed medication effectively. Advice on stress management may also be
given due to the impact of stress on fatigue. Regular short breaks e.g. 3-5 minutes every 30-45
minutes sitting and relaxing joints or microbreaks e.g. 30 seconds every 5-10 minutes
stretching and relaxing those joints and muscles being most used can be very useful and can
improve duration of physical activity.
Patients can balance activities by alternating heavy, medium and light activities during the day
and throughout the week.
5. Promoting self-care and daily activities of living
6. Providing psychological support
Encourage patient to express feelings about changes in body image, if able to do so.
Compliment patient on each improvement in mobility.
7. Provide Education
The nurse plays a key role in educating the client about health promotion activities, exercise
and the management of pain. The client may be so concerned about appearance that he or she
avoids social interaction.

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8. Prevent Deformity/Joint Protection
Lessen forces on the joints, both internal (i.e. muscular compression e.g. strong grip) and external
(i.e. forces applied to joints during activities such as carrying) forces should be considered.
Promote safe physical environment and individual safety.
Advice patient to maintain following principle:
– Use assistive devices (such as cane/walker) and a reduction in weight of objects to change
working methods and consequently reduce the force and effort necessary for the
completion of tasks.
– Use the joints in their most stable positions.
– Avoid positions of deformity and forces in the direction of the deformity.
– Avoid maintaining the same position for long periods of time.
– For completion of tasks, ensure use of the strongest and largest joint available.
– Do not grip very strongly.
– Employ appropriate body posture.
– Utilise correct moving and handling techniques.
– Maintain muscle strength and ROM.

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13. Total Hip Replacement (THR), Total Knee
Replacement (TKR) & Shoulders Replacement
Total Hip Replacement (THR):
Introduction of Total Hip Replacement: Hip replacement is also known as arthroplasty. Hip
replacement is a surgical procedure in which the painful hip with any diseased condition or pain
is replaced with an artificial joint often made from metal or plastic components. It is most common
orthopedic surgery. THA is an effective option if the patient’s pain does not respond to
conservative treatment and has caused a decline in their health, quality of life, or ability to perform
activities of daily living.
History: The earliest recorded attempts at hip replacement (Gluck T, 1891) which were carried
out in Germany used ivory to replace the femoral head. The first to use a metal-on-metal prosthesis
on a regular basis was English surgeon George McKee in 1953; he began by using the modified
Thompson stem (a cemented hemiarthroplasty used for neck of femur fracture treatment) with a
new one-piece cobalt-chrome socket as the new acetabulum. The orthopedic surgeon Sir John
Charnley, who worked at the Manchester Royal Infirmary, is considered the father of the modern
THA.
Epidemiology of Total Hip Replacement: According to the Agency for Healthcare Research and
Quality, more than 450,000 total hip replacements are performed each year in the United States.
Total joint replacement done at department of Orthopedics of BPKIHS, Dharan Nepal from 2010
to 2014 showed that 65 patients with problems of either knee/Hip joints were treated by total joint
replacement.
Indications:
 Osteoarthritis- This is an age-related "wear and tear" type of arthritis. It usually occurs in
people 50 years of age and older and often in individuals with a family history of arthritis.
The cartilage cushioning the bones of the hip wears away. The bones then rub against each
other, causing hip pain and stiffness. Osteoarthritis may also be caused or accelerated by
subtle irregularities in how the hip developed in childhood.
 Rheumatoid arthritis- This is an autoimmune disease in which the synovial membrane
becomes inflamed and thickened. This chronic inflammation can damage the cartilage,

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leading to pain and stiffness. Rheumatoid arthritis is the most common type of a group of
disorders termed "inflammatory arthritis."
 Post-traumatic arthritis- This can follow a serious hip injury or fracture. The cartilage
may become damaged and lead to hip pain and stiffness over time.
 Avascular necrosis- An injury to the hip, such as a dislocation or fracture, may limit the
blood supply to the femoral head. This is called avascular necrosis (also commonly referred
to as "osteonecrosis"). The lack of blood may cause the surface of the bone to collapse, and
arthritis will result. Some diseases can also cause avascular necrosis.
 Childhood hip disease- Some infants and children have hip problems. Even though the
problems are successfully treated during childhood, they may still cause arthritis later on
in life. This happens because the hip may not grow normally, and the joint surfaces are
affected.
 Failure of previous reconstructive surgery
 Pathologic fractures from metastatic cancer
Contraindications:
1. Acute/chronic local or systemic infection
2. Severe diseases of muscles, nerves or blood vessels that could endanger limbs.
3. Periarticular bone stock deficiency, making it difficult or impossible for implantation poor
muscle or ligament tissues conditions
4. Joint disease which may require alternative reconstruction (osteotomy)
5. Patients under 60 years of age
6. Any disease that might result from the operation and affect the function and success of
implants.
7. Allergy to implants, particularly to metals (e.g.: cobalt, chromium, nickel, etc.)
8. Renal dysfunction. Although the relationship between serum cobalt and chromium level is
not yet well determined, the influence of increased serum level of cobalt and chromium on
patients’ health should still be considered. In the case of renal dysfunction, metal
accessories like Metasul is not advised or should be used only under close monitoring
(cobalt and chromium serum level, serum creatinine, BUN, echocardiography) so as to
avoid the increase of the cobalt and chromium contents in serum. It should only be used
after careful evaluation and where the operation benefits are greater than risks.
9. Local bone tumor or bone cyst
10. Pregnancy
Diagnostic Procedures

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The diagnosis of patients requiring total hip replacement surgery is mostly symptom-based. Pain,
loss of range of motion and functional impairments are mostly considered. It includes:
 Observation
 Subjective interview:
 Complaints of pain, deformity, stiffness and/or limp
 Previous history linked to hip pain (congenital or childhood problems, previous
trauma)
 Physical examination:
 Standing
 Trendelenberg test
 Gait
 Supine (including leg length)
 Objective observation (posture, deformities, muscle atrophy)
 Range of motion
 Special investigations include X-ray, blood test (CBC), CT- Scan and MRI
Types of Hip Replacement Surgeries:
1. Total hip replacement: In this type both of the opposed articulating surface is removed
and replaced by prosthetic compounds i.e. replacement of the femoral head and the
acetabular articular surface.
2. Hemiarthroplasty (Half hip replacement): In this type only one of the articulating
surfaces is removed and replaced by prosthesis of similar type i.e. replacement of only the
femoral head.
Surgical Approaches:
THA procedure involves various surgical approaches. The approaches are posterior (Moore),
lateral (Hardinge or Liverpool), antero-lateral (Watson-Jones), anterior (Smith-Petersen) and
greater trochanter osteotomy. The most commonly used approaches for THA include posterior
approach (PA), direct lateral approach (DLA), and direct anterior approach (DAA). These
approaches determine the amount of soft tissue damage and are used to determine the major
precautions following total hip replacement surgery. This method provides good visualization of
the femur and acetabulum and also spares the abductor muscle group. Anterior approach surgery
is less invasive and damaging for muscles, capsules, ligaments and nerves.
Implants
An implant is a medical device manufactured to replace a missing biological structure, support a
damaged biological structure, or enhance an existing biological structure. Medical implants are

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man-made devices, in contrast to a transplant, which is a transplanted biomedical tissue. The
prosthetic implant used in hip replacement consists of different part. They are- the acetabular cup,
the femoral component and the articular interface. The implants options exist for different patients
and indications. So, correct selection of the prosthesis is important.
Types of fixation:
Cemented fixation in this cement stem use acrylic bone cement to form a mantle between the
stem and the bone. This prosthesis is used for older clients or for those with compromised bone
strength resulting from conditions such as osteoporosis. Use of polymethyl methacrylate (PMMA)
bone cement allows immediate intraoperative fixation of femoral and acetabular components.
Implant does not need to fit cavity exactly
Uncemented fixation, Uncemented stem use friction, shape and surface coating to stimulate bone
to remodel and bond the implant. In younger, active or heavier clients, prostheses with porous
surfaces are used to allow fixation without cement. In this method, fixation is more secure,
dynamic and biological
Materials used in implants:
 Metal-on-Polyethylene: The ball is made of metal and the socket is made of plastic
(polyethylene) or has a plastic lining.
 Ceramic-on-Polyethylene: The ball is made of ceramic and the socket is made of plastic
(polyethylene) or has a plastic lining.
 Ceramic-on-Ceramic: The ball is made of ceramic and the socket has a ceramic lining.
 Ceramic-on-Metal: The ball is made of ceramic and the socket has a metal lining
Possible Side Effects
Risks derived from having an artificial joint include suffering an allergic reaction and
experiencing loosened, worn, torn, corroded, partially or totally dislocated, aged, broken artificial
joint, and the need for modification or reoperation.
 The function of the implanted artificial joint may be affected by factors including:
breakage, loosening, over-wearing, excessive force, damage, inappropriate installation and
treatment.
 The implants may loosen because the strength transmission is changed, the cement base is
worn, torn and damaged, and/or because body tissues react to the implants.

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 Early or late infection, Dislocation, subluxation, limited movement, and unexpected
lengthening or shortening of the affected leg could occur if the implants are not properly
installed.
 Fractures may occur when too much stress is put on one side or when the bone quality
weakens.
 Wound hematomas or delayed wound healing.
 Cardiovascular diseases, including thromboembolism, pulmonary embolism and heart
failure.
 Limited movements.
 Blood circulation deficiencies, including damaged vessels (iliac artery, obturator artery,
and femoral artery), thromboembolism pulmonary embolism, and myocardial infection.
 Temporary or perpetual diseases of femoral nerves, sciatic nerve, peroneal nerve, and
obturator nerve.
 Aggravation due to operation trauma, leg length discrepancy, weakening femur or muscle.
 Corrosion and wear of implanted materials, and tissue reaction and allergy caused by
cement particles.
Nursing Management
Pre-operative management:
– Infections are ruled out or treated prior to surgery.
– Discontinuation of anticoagulants or other regular medications as indicated preoperatively.
– Anti- embolism stockings are applied.
– Antimicrobial skin preparation per order.
– Antibiotics are administered as prescribed.
– Cardiovascular, respiratory, renal and hepatic functions are assessed by ECG and
laboratory test.
– Skin preparation
Pre-operative teaching is provided on the following:
– Post-operative regimen (e.g. extended exercise program) that will be carried out after
surgery is explained; atrophied muscles must be re-educated and strengthened
– Isometric exercises of quadriceps and gluteal muscles are taught.
– Bed-to-wheel chair transfer without going beyond the hip flexion limits (usually 60-90º) is
taught.
– Non-weight and partial weight bearing ambulation with ambulatory aid (walker, crutches)
is taught to facilitate post-operative ambulation.

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– Abduction splint, knee immobilizer, or continuous passive motion is demonstrated if
equipment will be used post-operatively.
– Anti-embolism stockings are applied to minimize development of thrombophlebitis.
– Skin preparation includes antimicrobial solution to reduce the skin microorganisms, a
potential source of infection.
– Antibiotics are administered, as prescribed, to ensure therapeutic blood level during and
immediately after surgery.
– Cardiovascular, respiratory, renal and hepatic functions are assessed and measures are
taken to maximize general health conditions.
– Review discharge and rehabilitation options post-surgery
Post-operative management
1. Use of appropriate position: To prevent dislocation of prosthesis and facilitate healing.
Numerous modifications are required in positioning the patient post-operatively.
 After Hip Arthroplasty
– Patient is usually positioned supine in bed.
– The affected extremity is held in slight abduction by either abduction splint or pillow or
Buck’s extension traction to prevent dislocation of the prosthesis.
– Avoid adduction of the hip for 2-3 months.
– Observe the signs of hip dislocation and they are- shortened extremity, increasing
discomfort and inability to move.
– Two nurse turn patient on un-operated side while supported operated hip securely in an
abducted position; the entire length of leg is supported by pillows. Use of pillows to keep
the leg abducted; place pillow at back for comfort. Use of overhead trapeze to assist with
position change.
– The bed is not usually elevated more than 45-60º; placing the patient in an upright sitting
position, put a strain on the hip joint and may cause dislocation.
– A fracture bed pan is used. Instruct patient to flex the un-operated hip and knee & pull up
on the trapeze to lift buttocks onto pan. Instruct patient not to bear down on operated hip
in flexion when getting off the pan.
2. Deterring complications
 Provide aggressive care and continuous assessment.
 Prevent thromboembolism by continuous use of elastic hose and SCD while patient
is in bed. Discontinue SCD when patient is ambulatory.
3. Promoting early ambulation
 Within 1 day after surgery, short period of standing may be ordered.
 Monitor orthostatic hypotension.

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 Weight bearing may be limited with in growth prosthesis to prevent disruption of
bone growth.
 Transfer to the chair or ambulation with aids, such as walkers, are encouraged as tolerated
and based on patient’s condition and type of surgery.
Health Education
1. Encourage patient to continue to wear elastic stockings after discharge until full activities
are resumed.
2. Ensure that patient avoid excessive hip adduction, flexion and rotation for 6 weeks after
hip arthroplasty.
 Avoid sitting low chair or toilet seat to avoid flexing hip > 90º.
 Keep knees apart: - do not cross leg.
 Limit sitting to 30 minutes at a time – to minimize hip flexion and the risk of
prosthetic dislocation and to prevent hip stiffness & flexion contractures.
 Avoid internal rotation of the hip.
 Follow weight-bearing restrictions from surgeon.
3. Encourage quadriceps setting and range of motion exercise as directed.
 Have a daily program of stretching, exercise and rest throughout life time
 Do not participate in any activity placing undue or sudden stress on joint. (jogging,
jumping, lifting, excessive bending)
 Use a cane when taking fairly long steps.
4. Suggest self-help and energy-saving devices.
5. Advise patient to sleep with 2 pillows between the legs to prevent turning over in sleep.
6. Tell patient to lie prone when able twice daily for 30 minutes to promote full extension of
hip.
7. Monitor for late complications: deep infection, increased pain or decreased function,
implant wear, dislocation, avascular necrosis.
8. Teach patient use of supportive equipment (crutches, canes) as prescribed.
9. Avoid MRI studies because of implanted metal components.
10. Advice patient that metal components in hip may set off metal detectors (airports, some
buildings). They should carry a medical identification card.
Exercise Guide for Hip Replacement:
 Regular exercises to restore normal hip motion and strength and a gradual return to
everyday activities are important for full recovery.
 Orthopaedic surgeon and physical therapist may recommend an exercise for 20 to 30
minutes, 2 or 3 times a day during early recovery.

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The following exercises are advised:
1. Ankle Pumps
 Slowly push foot up and down.
 Do this exercise several times as often as every 5 or 10 minutes.
 This exercise can begin immediately after surgery and continue until fully recovered
2. Ankle rotation
 Move ankle inward toward other foot and then outward away from other foot.
 Repeat 5 times in each direction, 3 or 4 times a day.
3. Bed-Supported Knee Bends
 Slide heel toward buttocks, bending knee and keeping heel on the bed. Do not let knee roll
inward.
 Repeat 10 times, 3 or 4 times a day
4. Buttock Contractions
 Tighten buttock muscles and hold to a count of 5.
 Repeat 10 times 3 or 4 times a day
5. Abduction Exercise
 Slide leg out to the side as far as one can and then back.
6. Quadriceps Set
 Tighten thigh muscle. Try to straighten knee. Hold for 5 to 10 seconds.
 Repeat this exercise 10 times during a 10-minute period.
 Continue until thigh feels fatigued
7. Straight Leg Raises
 Tighten thigh muscle with knee fully straightened on the bed.
 As thigh muscle tightens, lift leg several inches off the bed.
 Hold for 5 to 10 seconds. Slowly lower.
 Repeat until thigh feels fatigued
8. Standing Knee Raises
 Lift operated leg toward chest.
 Do not lift knee higher than waist.
 Hold for 2 or 3 counts and put leg down.
9. Standing Hip Abduction
 Be sure hip, knee and foot are pointing straight forward.
 Keep body straight. With knee straight, lift leg out to the side.
 Slowly lower leg so foot is back on the floor.

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10. Standing Hip Extensions
 Lift operated leg backward slowly.
 Try to keep back straight. Hold for 2 or 3 counts. Return foot to the floor.
11. Walking and Early Activity.
12. Walking with Walker, Full Weight-bearing.
13. Walking with Cane or Crutch.
14. Stair Climbing and Descending
Complications
a. Intraoperative complications
 Nerve injury: sciatic, femoral and obturator
 Vascular injury: femoral vein and artery
 Femoral fracture
 Fragments of cement left in joint
b. Postoperative complications
 Deep vein thrombosis (most common and most serious complication): Blood clots in the
leg veins or pelvis are one of the most common complications of hip replacement surgery.
These clots can be life-threatening if they break free and travel to your lungs. So,
prevention program which may include blood thinning medications, support hose,
inflatable leg coverings, ankle pump exercises, and early mobilization.
 Pulmonary embolism
 Infection: this can be reduced by using antibiotics at the time of surgery and by using
‘clean air’ ventilation in theatre. However, infection still occurs in around 10% of cases.
Deeper infection is serious and requires removal and re-implantation of the joint. Other
prevention protocols that include are preoperative weight loss, smoking cessation,
methicillin-resistant Staphylococcus aureus (MRSA) screening, skin preparation/washing,
and routine antibiotics (during the first 24 hours only) can all help to minimize the risk of
infection.
 Dislocation or subluxation: Dislocation of the artificial hip joint can occur if the ball
becomes dislodged from the socket. Dislocation occurs in less than 2 percent of cases. In
most cases, an orthopedic surgeon can move the joint back into place while the patient is
sedated. To minimize the risk of dislocation, some people may be given specific
precautions related to the motion of the hip. The need for precautions depends upon how
surgery is performed and should be discussed with surgeon.

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 Leg length inequality: before, during, and after hip replacement surgery, a surgeon
carefully measures the length of legs in an attempt to make them equal length. However,
in rare cases, the procedure results in one leg being slightly longer than the other. Some
people with a significant difference in leg length find that wearing a lift in one shoe is
helpful.
 Implant loosening: Over years, the hip prosthesis may wear out or loosen. This is most
often due to everyday activity. It can also result from a biologic thinning of the bone called
osteolysis. If loosening is painful, a second surgery called a revision may be necessary.
Prognosis
 Hip replacement surgery results are often excellent. Most or all of pain and stiffness should go
away.
 Some people may have problems with infection, loosening, or even dislocation of the new hip
joint.
 Over time the artificial hip joint will loosen. This can happen after as long as 15 - 20 years.
One may need a second replacement.
 Younger, more active people may wear out parts of their new hip. It may need to be replaced
before the artificial hip loosens.

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Total Knee Replacement (TKR)
Introduction to Total Knee Replacement: A total knee replacement is a surgical procedure
whereby the diseased knee joint is replaced with artificial material. During a total knee
replacement, the end of the femur bone is removed and replaced with a metal shell. The end of the
lower leg bone (tibia) is also removed and replaced with a channeled plastic piece with a metal
stem. Depending on the condition of the kneecap portion of the knee joint, a plastic "button" may
also be added under the kneecap surface. The artificial components of a total knee replacement are
referred to as the prosthesis.
History: Knee replacement surgery was first performed in 1968. Since then, improvements in
surgical materials and techniques have greatly increased its effectiveness. Total knee replacements
are one of the most successful procedures in all of medicine. And it is second most common
arthroplasty after hip arthroplasty.
Epidemiology of Total Knee Replacement
According to the Agency for Healthcare Research and Quality, more than 790,000 knee
replacements are performed each year in the United States.
Indications
Total knee replacement may be recommended when other treatment options (e.g., weight loss, pain
relievers) no longer reduce knee pain and disability effectively.
Symptoms of knee damage that may require knee replacement surgery include the following:
 Knee pain that hinders walking, climbing stairs, or getting in and out of a chair
 Knee pain that interferes with sleep or does not subside with res
 Inability to cope with side effects of pain relief medication
 Knee swelling that does not respond to treatment and that limits bending or straightening the
knee
 Significant bowing in or out of the knee
 Osteoarthritis (the most common reason for knee joint replacement)
 Meniscal or cruciate ligament injuries
 Infection
 Instability
 Fracture into the joint
 Cartilage destruction

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 Avascular necrosis
Contraindications
a. Absolute contraindications:
 Knee sepsis
 Extensor mechanism dysfunction
 Severe vascular disease
 Recurvatum deformity secondary to muscular weakness
 Presence of a well-functioning knee arthrodesis
b. Relative contraindications
 Skin conditions within the field of surgery (e.g., psoriasis)
 Past history of osteomyelitis around the knee
 Neuropathic joint
 Obesity
Diagnostic Procedures
The diagnosis of patients requiring total knee replacement surgery is mostly symptom-based. Pain,
loss of range of motion and functional impairments are mostly considered. It includes:
a) History:
 Pain characteristics: The patient's description of knee pain is helpful in focusing the
differential diagnosis. It is important to clarify the characteristics of the pain, including its
onset (rapid or insidious), location (anterior, medial, lateral, or posterior knee), duration,
severity, and quality (e.g., dull, sharp, achy). Aggravating and alleviating factors also need
to be identified. If knee pain is caused by an acute injury, the physician needs to know
whether the patient was able to continue activity or bear weight after the injury or was forced
to cease activities immediately.
 Mechanical symptoms: The patient should be asked about mechanical symptoms, such as
locking, popping, or giving way of the knee. A history of locking episodes suggests a
meniscal tear. A sensation of popping at the time of injury suggests ligamentous injury,
probably complete rupture of a ligament (third-degree tear). Episodes of giving way are
consistent with some degree of knee instability and may indicate patellar subluxation or
ligamentous rupture.
 Effusion: The timing and amount of joint effusion are important clues to the diagnosis. Rapi
onset (within two hours) of a large, tense effusion suggests rupture of the anterior cruciate
ligament or fracture of the tibial plateau with resultant hemarthrosis, whereas slower onset
(24 to 36 hours) of a mild to moderate effusion is consistent with meniscal injury or
ligamentous sprain. Recurrent knee effusion after activity is consistent with meniscal injury.

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 Mechanism of injury
 Medical history: A history of knee injury or surgery is important. The patient should be
asked about previous attempts to treat knee pain, including the use of medications, supporting
devices, and physical therapy. The physician also should ask if the patient has a history of
gout, pseudo gout, rheumatoid arthritis, or other degenerative joint disease.
b) Physical examination- the physical examination should include careful inspection of the knee,
gait, palpation for point tenderness, assessment of joint effusion, range-of-motion testing, and
evaluation of ligaments for injury or laxity, and assessment of the menisci.
 Lachman's test- most sensitive test for ACL ruptures. Flex the knee to 30 degrees. Place
one hand on the distal femur and one hand on the proximal tibia. Firmly pull the tibia
anteriorly, whilst stabilizing the femur with the contra lateral hand. Lack of a clear end
point indicates a positive Lachman’s test.
 Varus stress test- A varus stress test is performed by stabilizing the femur and
palpating the lateral joint line. The other hand provides a varus stress to the ankle. The
test is performed at 0° and 20-30°, so the knee joint is in the closed packed position.
The physiotherapist stabilizes the knee with one hand, while the other hand adducts
the ankle. If the knee joint adducts greater than normal (compared to the unaffected
leg), the test is positive. This test is used to assess lateral collateral ligament injury.
 Valgus stress test- The patient's leg should be relaxed for this test. The examiner should
passively bend the affected leg to about 30 degrees of flexion. While palpating the medial
joint line, the examiner should apply a valgus force to the patient's knee. A positive test
occurs when pain or excessive gapping occurs (some gapping is normal at 30 degrees).
This test is used to assess medial collateral ligament.
c) Laboratory studies- a complete blood count with differential and an erythrocyte
sedimentation rate (ESR), arthrocentesis, rheumatoid factor
d) Radiology – X-ray, MRI and CT- Scan
Types of Knee Replacement Surgery
There are broadly four types of knee replacement surgery. They are;
1. Total knee replacement
2. Unicompartmental (partial) knee replacement
3. Kneecap replacement (patellofemoral arthroplasty)
4. Complex or revision knee replacement

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1. Total knee replacement: in this type of replacement the articular surfaces of the femoral
condyles, tibial plateau and patella are removed and replaced by artificial components.
2. Unicompartmental (partial) knee replacement: This involves replacement of the medial
or lateral tibiofemoral compartment. It is usually used for osteoarthritis (OA). It is not
suitable for patients with rheumatoid arthritis (RA).
3. Kneecap replacement (patellofemoral arthroplasty): A kneecap replacement involves
replacing just the under-surface of the kneecap and its groove (the trochlea) if these are the
only parts affected by arthritis. The operation is only suitable for about 1 in 40 people with
osteoarthritis. However, the outcome of kneecap replacement can be good if the arthritis
doesn’t progress and it’s a less major operation offering speedier recovery times.
4. Complex or revision knee replacement: A complex knee replacement may be needed if
a second or third joint replacement in the same knee or arthritis is very severe. Some people
may need a more complex type of knee replacement. The usual reasons for this are: major
bone loss due to arthritis or fracture, major deformity of the knee and weakness of the main
knee ligaments.
Surgical Approaches
There are various approaches of total knee replacement. The most common approaches are:
 Anteromedial approaches- divided into two approaches and are anteromedial para patellar
and subvastus anteromedial.
 Anterolateral approach
 Posterolateral approach
 Posteromedial approach
 Medial approaches to knee and supporting structures
 Transverse approaches to menisci
 Lateral approaches to the knee and supporting structures
 Extensile approaches to the knee: it is further divided into two and are Mc cannel extensile
approach and Fernandez extensile anterior approach
 Posterior approach
Implants
During knee replacement surgery, an orthopedic surgeon will resurface damaged knee with
artificial components, called implants. There are many different types of implants. The brand and
design used by doctor or hospital depends on many factors, including:
 Patient needs, based on knee problem and knee anatomy, as well as age, weight, activity
level, and general health

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 doctor's experience and familiarity with the device
 The cost and performance record of the implant.
Implant Components
Implants are made of metal alloys, ceramic material, or strong plastic parts. Up to three bone
surfaces may be replaced in a total knee replacement:
 The lower end of the femur- the metal femoral component curves around the end of the
femur (thighbone). It is grooved so the kneecap can move up and down smoothly against
the bone as the knee bends and straightens.
 The top surface of the tibia- the tibial component is typically a flat metal platform with a
cushion of strong, durable plastic, called polyethylene. Some designs do not have the metal
portion and attach the polyethylene directly to the bone. For additional stability, the metal
portion of the component may have a stem that inserts into the center of the tibia bone.
 The back surface of the patella- the patellar component is a dome-shaped piece of
polyethylene that duplicates the shape of the patella (kneecap). In some cases, the patella
does not need to be resurfaced.
Note: Components are designed so that metal always borders with plastic, which provides for
smoother movement and results in less wear of the implant.
Implant Designs
Several manufacturers make knee implants and there are more than 150 designs on the market
today. They are mentioned below;
a) Posterior-Stabilized Designs: One of the most commonly used types of implant in total
knee replacement is a posterior-stabilized component. In this design, the cruciate ligaments
are removed and parts of the implant substitute for the posterior cruciate ligament (PCL).
The tibial component has a raised surface with an internal post that fits into a special bar
(called a cam) in the femoral component. These components work together to do what the
PCL does: prevent the thighbone from sliding forward too far on the shinbone when you
bend your knee.
b) Cruciate-Retaining Designs: As the name implies, the posterior cruciate ligament is kept
with this implant design (the anterior cruciate ligament is removed). Cruciate-retaining
implants do not have the center post and cam design. This implant may be appropriate for a
patient whose posterior cruciate ligament is healthy enough to continue stabilizing the knee
joint.
c) Bicruciate-Retaining Designs: In most total knee replacement procedures, the anterior
cruciate ligament is removed to allow for precise placement of the implant. In bicruciate-
retaining designs, both the anterior and posterior cruciate ligaments are kept. The rationale

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for this type of design is that by saving both ligaments, the knee will function and feel more
like a non-replaced knee.
Implant Materials
The metal parts of the implant are made of titanium or cobalt-chromium based alloys. The
plastic parts are made of ultra-high molecular weight polyethylene. Some implants are made
of ceramics or ceramic/metal mixtures. Whether metal or ceramic, implants weigh between
15 and 20 ounces, depending on the size selected.
Implant Fixation
There are different types of fixation used to connect knee implants to the bone.
 Cemented fixation- implants are most commonly held in place with fast-curing bone cement
(polymethylmethacrylate).
 Cementless fixation- implants can also be "press-fit" onto bone. This type of fixation relies
on new bone growing into the surface of the implant. Cementless implants are made of a
material that attracts new bone growth. Most are textured or coated so that the new bone
actually grows into the surface of the implant.
 Hybrid fixation- in hybrid fixation for total knee replacement, the femoral component is
inserted without cement, and the tibial and patellar components are inserted with cement.
Nursing Management
Assessment
 Hydration status (skin and mucous membrane, vital signs, urine output and lab values).
 Current medication history.
 Infections are ruled out or treated prior to surgery.
 Discontinuation of anticoagulants or other regular medications as indicated
preoperatively.
 Previous operations
Diagnosis
1. Acute pain related to orthopedic problem, swelling or inflammation.
2. Impaired physical mobility related to pain, swelling and possible presence of an
immobilization devices.
3. Risk for ineffective regimen management related to insufficient knowledge or lack of
available support and resources.

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4. Risk for situational low self-esteem, disturbed body image or functional impairments
related to impact of musculoskeletal disorder.
Post- operative management:
 Pain related to total knee replacement.
 Assess patient for pain using a standard pain intensity scale.
 Ask patient to describe discomfort.
 Use pain modifying techniques like change position, modify environment, music therapy,
etc.
 Provide analgesic as ordered.
 Impaired physical mobility related to positioning, weight bearing and activity restriction
after surgery.
 Maintain proper position of the knee joint (limited flexion)
 Instruct and assist in position changes and transfer.
 Promote early ambulation as per surgeon and allowed to weight bear as tolerated.
 Encourage knee exercise- straightening/ bending.
 Offer encouragement and support exercise regimen.
 Instruct and supervise safe use of ambulatory aids.
 Hemorrhage related to surgery
 Monitor vital signs, observing for shock.
 Note character and amount of drainage.
 Notify surgeon if patient develops shocks or excessive bleeding and prepared for
administration of fluids, blood component therapy and medications.
 Monitor hemoglobin and hematocrit values.
 Neurovascular dysfunction related to surgery.
 Assess affected extremity for colour and temperature.
 Assess toes for capillary refill response.
 Assess extremity for edema and swelling.
 Report patients complain of leg tightness.
 Assess for deep, throbbing pain.
 Assess for change in sensation and numbness.
 Assess ability to move foot and toes.
 Assess pedal pulses in both feet.
 Notify surgeon if altered neurovascular status is noted.
 Deep vein thrombosis
 Use elastic compression stockings or sequential compression devices as prescribed.

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 Remove stocking for 20 minutes twice a day and provide skin care.
 Assess popliteal, dorsalis pedis pulses.
 Assess skin temperature.
 Assess for Homans sign every 8 hourly.
 Avoid pressure on popliteal blood vessels from equipments or pillows.
 Change position and increase activity as prescribed.
 Supervise ankle exercise hourly.
 Encourage fluids.
 Infection
 Monitor vital signs.
 Use aseptic techniques for dressing change and emptying of portable drainage.
 Assess wound appearance and character of drainage.
 Assess complain of pain.
 Administer prophylactic antibiotics if prescribed and observe for side effects.
 Risk for ineffective health maintenance related to TKR.
 Assess home environment for discharge planning.
 Encourage patient to express concerns about care at home; explore together possible
solution of the problem.
 Assess availability of physical assistance for health care activities.
 Teach caregiver home health care regimen.
 Instruct patient on post hospital care:
 Activity limitations
 Exercises instruction
 Safe use of ambulatory aids
 Wound care
 Measures to promote healing
 Medications
 Potential problems
 Continuing health care supervision and management.
Health Education
– Provide various methods to reduce pain like periodic rest, distractions and relaxation
techniques and medication therapy.
– Instruct the patient to keep incision clean and dry.
– Instruct the patient to recognize signs of wound infection like pain, swelling, drainage,
fever, etc.
– Explain that sutures or staples will be removed 10-15 days after surgery.

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– Teach patient about safe use of assistive devices, weight bearing limits, changing position
frequently, etc.
– Provide information that swelling of leg may remain for up to 4-6 months.
– Instruct patient to return to household work and other day to day activities in 6-8 weeks.
– Tell patient to avoid squatting.
– Teach patient to avoid sitting cross legged.
– Tell patient try to avoid alcohol and smoking.
– Teach patient to carry a medical certificate for metal detectors places.
– Provide information about the complication about the surgery so that they can report in
time.
– Discuss with patient the need to continue regular health care and screening.
Exercise Guide for Knee Replacement
– Frequent deep breathing.
– Pull toes towards and away.
– Circle feet in both directions.
– Push knee down, tighten thigh muscles count to 10 and relax. Do it 10 times per hour.
– Place a rolled towel under knee. Lift heel to straighten knee. Count to 10 and do 10 times
per hour.
– Lie flat on back and lift operated leg straight of bed and count 10.
– Sit at the edge of bed/ chair. Bend the operated knee and straighten slowly. Repeat 10 times
per hour.
Complication
Intraoperative complications
 Misplacement of implants leading to instability or stiffness or pain
 Nerve or vessel injury
 Fracture
 Patellar tendon avulsion
 Mal-alignment
 Fat embolism
Postoperative complications
 Infection
 Deep vein thrombosis/pulmonary embolism
 Pain/stiffness
 Instability/ Dislocation
 Component loosening
Prognosis: For most people, knee replacement provides pain relief, improved mobility and a better
quality of life. And most knee replacements can be expected to last more than 15 years.

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Shoulders Replacement
Introduction to Total Shoulder Replacement: Shoulder arthroplasty is a procedure used to
replace the diseased or damaged ball and socket joint of the shoulder with a prosthesis made of
polyethylene and metal components. The treatment options are either replacement of just the head
of the humerus bone (ball), or replacement of both the ball and the socket (glenoid). The procedure
is performed to relieve pain and improve mobility.
History: First recorded shoulder arthroplasty was done by French Surgeon Pean in 1893 with Tb
arthritis. Charles Neer is credited with the advancement of modern total shoulder arthroplasty
(TSA), developing more modern prostheses for surgical procedures beginning in the 1950’s.
Shoulder replacement surgery was first performed in the United States in the 1950s to treat severe
shoulder fractures.
Epidemiology of Total Shoulder Replacement: According to the Agency for Healthcare
Research and Quality, about 53,000 people in the U.S. have shoulder replacement surgery each
year.
Indications: Shoulder replacement surgery is usually recommended for people who have severe
pain in their shoulder and have found little or no relief from more conservative treatments. Some
conditions that may require a shoulder replacement include:
 Osteoarthritis
 Rheumatoid arthritis
 Rotator cuff tear arthropathy
 Avascular necrosis (Osteonecrosis)
 Post-traumatic arthritis
 Severe fractures
 Failed previous shoulder replacement surgery
Contraindications
 Active or recent shoulder joint infection
 Paralysis with complete loss of rotator cuff and deltoid function
 A neuropathic arthropathy
 Irreparable rotator cuff tear

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Orthopedic Evaluation
Physicians may refer to an orthopedic surgeon for a thorough evaluation to determine benefit from
the surgery. An evaluation with an orthopedic surgeon consists of several components:
 A medical history- orthopedic surgeon will gather information about general health and
ask about the extent of shoulder pain and ability to function.
 A physical examination- this will assess shoulder motion, stability, and strength.
 X-rays- these images help to determine the extent of damage in shoulder. They can show
loss of the normal joint space between bones, flattening or irregularity in the shape of the
bone, bone spurs, and loose pieces of cartilage or bone that may be floating inside the joint.
 Other tests- occasionally blood tests, a magnetic resonance imaging (MRI) scan, nerve
conduction test or a bone scan may be needed to determine the condition of the bone and
soft tissues of shoulder.
Orthopedic surgeon will review the results of evaluation and discuss whether shoulder joint
replacement is the best method to relieve pain and improve function.
Types of Shoulder Replacement Surgery
There are 3 main categories of shoulder reconstruction surgery: Hemiarthroplasty, total shoulder
arthroplasty (TSA), and reverse total shoulder arthroplasty (rTSA)
1. Hemiarthroplasty
 Hemiarthroplasty involves the humeral articular surface being replaced with a stemmed
humeral component coupled with a prosthetic humeral head component.
 Indications include: arthritic conditions involving both the humeral head and osteonecrosis
without glenoid involvement, however the most common indication for this procedure are
severe fractures of the proximal humerus.
 This procedure has proven effective at managing arthritic conditions of the shoulder and is
favorable for young, athletic patients with worries of loosening prosthetic components.
2. Total Shoulder Arthroplasty
 Total shoulder arthroplasty, or TSA, is a procedure used to replace the diseased or damaged
ball and socket joint of the shoulder with a prosthesis made of polyethylene and metal
components.
 Both the head of the humerus and the glenoid are replaced.
 Indications for TSA include: osteoarthritis, inflammatory arthritis, osteonecrosis involving
the glenoid, and posttraumatic degenerative joint disease.
 A plastic "cup" is fitted into the glenoid, and a metal "ball" is attached to the top of the
humerus.

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3. Reverse total shoulder replacement
 A reverse total shoulder arthroplasty, or rTSA, refers to a similar procedure in which the
prosthetic ball and socket that make up the joint are reversed to treat certain complex
shoulder problems.
 In a reverse total shoulder replacement, the position of the ball and socket is changed so
that the ball is on the socket side of the joint and the socket is on the ball side.
 Reverse total shoulder replacement may be recommended in the case of completely torn
rotator cuff that cannot be repaired, previous shoulder replacement that was unsuccessful
and failure of other treatment.
Surgical Approaches: Shoulder arthroplasty is most commonly performed via a deltopectoral
(DP) or anterosuperior (AS) approach.
Implants: An implant is a medical device manufactured to replace a missing biological structure,
support a damaged biological structure, or enhance an existing biological structure.
Implant Components
There are basically 3 components used in total shoulder replacement. They are:
 The humeral component
 The glenoid component
 The stem
Implant Fixation
There are different types of fixation used to connect shoulder implants to the bone.
 Cemented fixation: implants are most commonly held in place with fast-curing bone cement
(polymethylmethacrylate).
 Cementless fixation: implants can also be "press-fit" onto bone. This type of fixation relies
on new bone growing into the surface of the implant. Cementless implants are made of a
material that attracts new bone growth. Most are textured or coated so that the new bone
actually grows into the surface of the implant.
Complication
 Instability
 Infection
 Stiffness
 Per prosthetic fracture
 Axillary nerve injury
 Loosening of prosthesis

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Nursing Management
Assessment
 Hydration status (skin and mucous membrane, vital signs, urine output and lab values).
 Current medication history.
 Infections are ruled out or treated prior to surgery.
 Discontinuation of anticoagulants or other regular medications as indicated
preoperatively.
 Previous operations
Diagnosis
 Acute pain related to orthopedic problem, swelling or inflammation.
 Impaired physical mobility related to pain, swelling and possible presence of an
immobilization devices.
 Risk for ineffective regimen management related to insufficient knowledge or lack of
available support and resources.
 Risk for situational low self-esteem, disturbed body image or functional impairments
related to impact of musculoskeletal disorder.
Post- operative management:
 Pain related to total shoulder replacement.
 Assess patient for pain using a standard pain intensity scale.
 Ask patient to describe discomfort.
 Use pain modifying techniques like change position, modify environment, music therapy,
etc.
 Use ice to control pain and swelling.
 Use a sling to immobilize an injured joint.
 Provide analgesic as ordered.
 Impaired physical mobility related to positioning, weight bearing and activity restriction
after surgery.
 Maintain proper position of the shoulder joint.
 Instruct and assist in position changes and transfer.
 Promote early ambulation as per surgeon and allowed to weight bear as tolerated.
 Encourage knee exercise- straightening/ bending.
 Offer encouragement and support exercise regimen.

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 Hemorrhage related to surgery
 Monitor vital signs, observing for shock.
 Note character and amount of drainage.
 Notify surgeon if patient develops shocks or excessive bleeding and prepared for
administration of fluids, blood component therapy and medications.
 Monitor hemoglobin and hematocrit values.
 Neurovascular dysfunction related to surgery.
 Assess affected extremity for colour and temperature.
 Assess for capillary refill response.
 Assess extremity for edema and swelling.
 Assess for deep, throbbing pain.
 Assess for change in sensation and numbness.
 Assess ability to move hand and fingers.
 Assess brachial pulse.
 Notify surgeon if altered neurovascular status is noted hourly.
 Encourage fluids.
 Infection
 Monitor vital signs.
 Use aseptic techniques for dressing change and emptying of portable drainage.
 Assess wound appearance and character of drainage.
 Assess complain of pain.
 Administer prophylactic antibiotics if prescribed and observe for side effects.
 Risk for ineffective health maintenance related to TSR.
 Assess home environment for discharge planning.
 Encourage patient to express concerns about care at home; explore together possible
solution of the problem.
 Assess availability of physical assistance for health care activities.
 Teach caregiver home health care regimen.
 Instruct patient on post hospital care:
 Activity limitations
 Exercises instruction
 Wound care
 Measures to promote healing
 Medications
 Potential problems
 Continuing health care supervision and management.

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Health Education
 Provide various methods to reduce pain like periodic rest, distractions and relaxation
techniques and medication therapy.
 Instruct the patient to keep incision clean and dry.
 Instruct the patient to recognize signs of wound infection like pain, swelling, drainage, fever,
etc.
 Staples are removed after a week of surgery.
 Don't lift anything heavier than a glass of water for the first 2 to 4 weeks after surgery.
 Exercises 2 to 3 times a day for a month or more as prescribed by doctor.
 Do ask for assistance.
 Don't participate in contact sports or do any repetitive heavy lifting after shoulder replacement.
 Do avoid placing arm in any extreme position, such as straight out to the side or behind body
for the first 6 weeks after surgery.
 Teach patient to carry a medical certificate for metal detectors places.
 Provide information about the complication about the surgery so that they can report in time.
 Discuss with patient the need to continue regular health care and screening
Exercise Guide for Knee Replacement
 Exercise to maintain mobility of adjacent joints through
 wrist flexion and extension
 wrist stretch
 forearm pronation and supination
 wrist flexion
 grip strengthening
 forearm supination and pronation with small weight like hammer
 resisted elbow flexion and extension
 Exercise to restore shoulder mobility, minimize muscle inhibition, guarding and atrophy
through
 isometric shoulder extension
 isometric shoulder flexion
 isometric shoulder abduction
 isometric shoulder adduction
 Exercise for moderate protection
 horizontal shoulder abduction
 shoulder extension
 shoulder flexion

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 scapular active range of motion
 Exercise from return to functional activity phase
 resisted shoulder extension
 resisted shoulder adduction
 scaption
 push up with a plus
Prognosis
Total shoulder replacement is a very successful operation and the 10-year survival rate is up to 90
percent. Many patients end up with extremely functional shoulders and are able to return to the
activities of daily living and low impact sports without pain.

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14. Autoimmune Disease of Bone
Introduction: An autoimmune disease is a condition in which our immune system mistakenly
attacks our body. The immune system normally guards against germs like bacteria and viruses.
When it senses these foreign invaders, it sends out an army of fighter cells to attack them.
Normally, the immune system can tell the difference between foreign cells and our own cells. In
an autoimmune disease, the immune system mistakes part of our body, like our joints or skin, as
foreign. It releases proteins called autoantibodies that attack healthy cells. Some autoimmune
diseases target only one organ. Type 1 diabetes damages the pancreas. Other diseases, like
systemic lupus erythematosus (SLE), affect the whole body.
There are different types of autoimmune disease of bone. They are:
 Rheumatoid Arthritis
 Ankylosing Spondylitis
 Psoriatic arthritis
 Autoimmune Mysolitis
 Eosinophilic fasciitis
 Mixed Connective tissue disorder
 Sjogen Syndrome
 Systemic sclerosis
Ankylosing Spondylitis: Ankylosing spondylitis is an inflammatory disease that, over time, can
cause some of the small bones in the spine (vertebrae) to fuse. This fusing makes the spine less
flexible and can result in a hunched-forward posture. If ribs are affected, it can be difficult to
breathe deeply. Ankylosing spondylitis affects men more often than women. Signs and symptoms
typically begin in early adulthood. Inflammation also can occur in other parts of the body most
commonly, the eyes. There is no cure for ankylosing spondylitis, but treatments can lessen the
symptoms and possibly slow progression of the disease.
Psoriatic Arthritis: Psoriatic arthritis is a type of inflammatory arthritis that occurs in some
patients with psoriasis. This particular arthritis can affect any joint in the body, and symptoms vary
from person to person. Research has shown that persistent inflammation from psoriatic arthritis can
lead to joint damage.
Autoimmune Mysolitis: Autoimmune myositis is a group of autoimmune rheumatic
disorders that cause inflammation and weakness in the muscles (polymyositis) or in the skin and

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muscles (dermatomyositis). Muscle damage may cause muscle pain and muscle weakness may
cause difficulty lifting the arms above the shoulders, climbing stairs, or arising from a sitting
position.
Eosinophilic fasciitis: Eosinophilic fasciitis (EF) is a syndrome in which tissue under the skin and
over the muscle, called fascia, becomes swollen, inflamed and thick. The skin on the arms, legs,
neck, abdomen or feet can swell quickly. The condition is very rare.
Mixed connective tissue disease (MCTD): Mixed connective tissue disease (MCTD) is a rare
autoimmune disorder that is characterized by features commonly seen in three different connective
tissue disorders: systemic lupus erythematosus, scleroderma, and polymyositis. Some affected
people may also have symptoms of rheumatoid arthritis.
Sjogren’s Syndrome : Sjogren’s syndrome is a long-term autoimmune disease that affects the
body's moisture-producing glands. Primary symptoms are a dry mouth and dry eyes. Other
symptoms can include dry skin, vaginal dryness, a chronic cough, numbness in the arms and
legs, feeling tired, muscle and joint pains, and thyroid problems.[4]
Those affected are at an
increased risk (5%) of lymphoma
Systemic Sclerosis: Systemic Sclerosis, is an autoimmune rheumatic disease characterized by
excessive production and accumulation of collagen, called fibrosis, in the skin and internal organs
and by injuries to small arteries. There are two major subgroups of systemic sclerosis based on the
extent of skin involvement: limited and diffuse. The limited form affects areas below, but not
above, the elbows and knees with or without involvement of the face. The diffuse form affects also
the skin above the elbows and knees and can spread also to the torso. Visceral organs, including
the kidneys, heart, lungs, and gastrointestinal tract can also be affected by the fibrotic process.
Prognosis is determined by the form of the disease and the extent of visceral involvement. Patients
with limited systemic sclerosis have a 10-year survival rate of 75%; less than 10%
develop pulmonary arterial hypertension after 10 to 20 years. Patients with diffuse cutaneous
systemic sclerosis have a 10-year survival rate of 55%. Death is most often caused by lung, heart,
and kidney involvement. There is also a slight increase in the risk of cancer

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Rheumatoid Arthritis:
Introduction to Rheumatoid Arthritis: Rheumatoid arthritis (RA) is a potentially destructive
and disabling disease. It is a chronic, systemic inflammatory disease that affects the small joints
of the hands and wrists and the surrounding muscles, tendons, ligaments, and blood vessels; it may
progress to other joints and body tissues, including the heart, lungs, kidneys, and skin.
Epidemiology:
RA is an autoimmune disease of unknown origin that affects 1% of the population worldwide, two
to three times greater incidence in women of age between 30 and 50 and becomes more evident
during the winter. This is most marked in those with severe disease, with a reduction in expected
lifespan by 8–15 years. About 1% of the world's population is afflicted by rheumatoid arthritis,
Affecting approximately 1.3 million people in the United States, according to current census data.
RA affects about 0.92% of adult population in India.
Etiology and Risk Factors:
The main cause of RA is unknown, other predisposing factors are:
– Infection: Studies continues to prove the possibility of specific infections, pathogens, such as
Epstein Bar Virus and mycobacterium which may trigger the process.
– Autoimmunity: It is likely that an autogenic stimulus such as a virus leads to the formation of
an abnormal immunoglobulin (IgG). RA is characterized by the presence of antibodies against
the abnormal IgG. The antibodies to this altered IgG termed as rheumatoid factors and they
combine with IgG to form immune complexes that deposits to the joints, blood vessels and
pleura.
– Genetic Factors: A genetic predisposition has been also identified related to certain human
leukocytes antigen (HLA). HLA_DRB1 is the single strongest known genetic factor for RA.
– Gender: Rheumatoid arthritis is three times more common in women than in men. This may
be due to the effects of oestrogen (a female hormone). Research has suggested that oestrogen
may be involved in the development and progression of the condition.
– Hereditary: There is an increased incidence in those with a family history of Rheumatoid
Arthritis.
– Cigarette Smoking is strongest known environmental risk factor for RA. Strongly associated
with ACPA and Ra factor positively. risk factors.
– Other factors: Age, Metabolic and biochemical abnormalities; nutrition and environmental
factors and occupational and psychosocial factors.

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Pathophysiology
The inflammatory process primarily affects the lining of the synovium, in contrast to osteoarthritis
which primarily involves the cartilage. The inflamed synovium leads to erosions of the cartilage
and bone and if the inflammatory process is unchecked leads to joint deformity.
The disease progresses through 4 stages which include:
– First stage (Initiation phase): The unknown etiologic factor initiates joints inflammation i.e.
synovitis with swelling of the synovial living membrane and production of excess synovial
fluid.
– Second Stage (Immune Phase): Inflammatory granular tissue (Pannus) is formed at the
junction of the synovium and cartilage. This extends over the surface of the articular cartilage
and eventually invades the joint capsule and subchondral bone i.e. destroys cartilage and erodes
the bone.
– Third Stage (Inflammatory Phase): Tough (hard) fibrous connective tissue replaces pannus
occluding the joint space, fibrous ankylosis results in decreased joint motion mal-alignment
and deformity.
– Forth Stage (Destructive Phase): As fibrous tissue calcified bony ankylosis may result in
total joint immobilization.
Clinical features
RA typically develops insidiously.
1. Non Specific Manifestations:
- Fatigue, anorexia, weight loss, fever, malaise, morning stiffness
- Pain at rest and with movement, night pain in joint.
- Edematous, Boggy joint
2. Specific Manifestations in particular involvement
- The joints of the hands are often the very first joints affected by Rheumatoid Arthritis.
These joints are swollen red and tender when squeezed. Swelling is due to synovitis.
- Pain, stiffness, limitations of motion and sign of inflammation (heat, swelling and
tenderness).
- Joint Symptoms are generally; bilaterally symmetrical and frequently affect small joint
of hands (proximal interphalangeal) and feet including wrists, elbows, shoulders,
knees, hips, ankles and jaw)
- Joint stiffness as arising in the morning and after period of inactivity. This morning
stiffness may last for 30 minutes to several hours or more depending on disease activity.
3. Later Symptoms of Rheumatoid Arthritis
- Pallor, anaemia, colour changes of digits (bluish, rubber, pallor)

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- Muscle weakness, atrophy, contracture usually flexion.
- Joint deformity, paresthesis, decrease joint mobility and increasing pain.
- Subluxation and dislocation.
Following deformity may can occurred due to rheumatoid arthritis, e.g.
 “Z” deformity of the thumb is due to rupture of the extensor tendon.
 “Swan neck “deformity arises from hyperextension of the proximal interphalangeal
joint, while the distal interphalangeal joint is flexed.
 “Button hole” rheumatoid nodule.
 “Wasted shoulder”
Systemic Manifestations:
RA is a systemic disease with multiple extra- articular manifestations. It may also affect other body
systems and rheumatoid nodules take form in the heart, lungs, spleen.
The systemic manifestations of RA are as follows:
– Cardiovascular: Pericarditis, vascular lesions, myocarditis, Raynaud’s phenomena
– Pulmonary: Pleural effusions (exudative, increased monocytes and neutrophils) Pleurisy,
Rheumatoid nodules in lungs, pneumoconiosis, pulmonary fibrosis, Pulmonary neuropathy.
– Neurological: Compression neuropathy, Peripheral neuropathy.
– Hematological: Anemia, leucopenia, eosinophilia, thrombocytopenia
– Renal: Rheumatoid nodules in Kidneys
– Dermatological: Scleritis, sicca syndrome (Kerato conjunctivitis)
– Others: Fever, malaise and weakness, weight loss
– Heart and Peripheral vessels: pericarditis, pericardial effusion, Raynaud’s Syndrome
Diagnostic Procedures:
1. History and Physical Examinations
– Morning stiffness: 1 hour for at least 6 weeks’ duration.
– Symmetrical joint swelling
– Swelling of wrist metacarpophalangeal and proximal intraphalangeal joint.
– Rheumatoid nodules and positive serum RA factor test.
2. Laboratory test:
– An elevated erythrocyte sedimentation rate (ESR)
– Positive C-reactive protein test during acute phase
– Positive antinuclear antibody test
– Mild leukocytosis and Anemia (Hypochromic)
– Positive RA factors (> 80%) and antinuclear antibody (ANA)
– Narrowing of joint space and erosion of articular surface
– Increasing turbidity and decreasing viscosity of the synovial fluid

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Rheumatoid Factor (RF) is a specific antibody in the blood. A negative RF doesn’t rule out RA.
The arthritis is then called seronegative, most common during the first year of illness and
converting to seropositive status over time.
3. Imaging Test
 MRI: Primarily in patients with abnormalities of the cervical spine, Early recognition of
erosions
 X-ray:
 Early changes are limited to the soft tissues with fusiform swelling and joint effusion
 Cartilage destruction produces narrowing of the joint
 Erosion of bone occurs characteristically in the metaphyseal region underlying
collateral ligament attachments
 Subchondral cysts
 Bone scanning: Findings may help to distinguish inflammatory from non-inflammatory
changes in patients with minimal swelling
 Densitometry: Findings are useful for helping diagnose changes in bone mineral density
indicative of osteoporosis
Diagnostic Criteria
The 2010 American College of Rheumatology/European League Against Rheumatism
Classification Criteria for Rheumatoid Arthritis
Score
Target population (Who should be tested?): Patients who
1. have at least 1 joint with definite clinical synovitis (swelling)*
2. with the synovitis not better explained by another disease†
Classification criteria for RA (score-based algorithm: add score of categories A–D; a score of
6/10 is needed for classification of a patient as having definite RA)
A. Joint involvement
1 large joint
2-10 large joints
1-3 small joints (with or without involvement of large joints)
4-10 small joints (with or without involvement of large joints)
>10 joints (at least 1 small joint)
0
1
2
3
5
B. Serology (at least 1 test result is needed for classification)
Negative RF and negative ACPA
Low-positive RF or low-positive ACPA
High-positive RF or high-positive ACPA
0
2
3
C. Acute-phase reactants (at least 1 test result is needed for classification)
Normal CRP and normal ESR
Abnormal CRP or abnormal ESR
0
1
D. Duration of symptoms
<6 weeks
≥6 weeks
0
1

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Differential Diagnosis
 Systemic Lupus Erythematous
 Osteoarthritis
 Psoriatic arthropathy
Management
– No any treatment cures Rheumatoid Arthritis.
– The Principles of treatment are:
 Remission of Symptoms
 Preservation of joint functions and prevention of deformities
 Repair of joint damage
Medical Management
Establish early diagnosis and start on Medicines.
Medical treatment consists of anti-rheumatic drugs. These consist of:
 Non-steroid anti-inflammatory Drugs (NSAIDs)
 Disease Modifying Anti-Rheumatic Drugs (DMARDs)
 Steroids
NSAID: It is a common medication for arthritis which helps to reduce joint pain and stiffness of
RA. E.g.: Salicylate, Diclophenac, Ibuprofen, Endomethacin
Corticosteroids: It is an anti-inflammatory steroid and it is very effective at combating
inflammation. It suppresses disease activity. Prednisolone-oral and Hydrocortisone – intra articular
DMARDs (Disease-modifying AntiRheumatic Drugs)
DMARDs are used as soon as RA is diagnosed to retard disease progression. Treatment options
include:
– Conventional synthetic DMARDs (csDMARDs)
– Targeted synthetic DMARDs (tsDMARDs)
– Biologic DMARDs (bDMARDs)
a. Conventional synthetic DMARDs: They may be used as monotherapy or in combination to
achieve treatment target. In general, csDMARDs may take up to eight weeks to exert their
effects hence the need for bridging therapy with corticosteroids. The four mainly used
csDMARDs are:
 Methotrexate (Trexall) (Gold standard)
 Hydroxychloroquine (Plaquenil)
 Leflunomide (Arava) blocks t cell proliferation
 Sulfasalazine (Azulfidine)

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I. Methotrexate (Oral/ Intramuscular injection): Methotrexate should be used as the first-
line Disease Modifying Anti-Rheumatic Drug in all patients with rheumatoid arthritis unless
contraindicated. Methotrexate is currently the gold standard in the treatment of RA because
of its success in improving disease parameters (i.e., pain, tender and swollen joints). It is
contraindicated in pregnancy (teratogenic). Methotrexate is one of the most effective and
commonly used medications in the treatment of Rheumatoid Arthritis
II. Sulfasalazine is used in patients with mild to moderate disease and for many is the drug of
choice especially in younger patients and women who are planning a family.
III. Biologic Disease Modifying Anti-Rheumatic Drugs (bDMARDs) and targeted synthethic
DMARDs (tsDMARDs) should be considered when the treatment target is not achieved
with conventional synthetic DMARDs. • All patients should be screened for tuberculosis,
hepatitis B and C, and human immunodeficiency virus prior to treatment with bDMARDs or
tsDMARDs.
Special Considerations while giving medicines:
– Start high dose and increase as required controlling the disease and then maintenance dose.
– All patients on HCQ should have a baseline eye examination and ophthalmological review
while they are on treatment.
– If no improvement by 3 month or target not achieved by 6 months.
– Change to or add another DMARD or Add a biologic agent if available
– All the drugs have serious side effects.
– Monitor disease activity every 1-3 month in active disease
– Monitor LFT/ RFT every 3-4 months.
Side effects:
– Bone marrow suppression. - Improper use of immunosuppressant's could lead to bone
marrow suppression.
– Anaemia- Immunosuppressive agents such as methotrexate and cyclophosphamide are highly
toxic and can produce anaemia.
– Gastrointestinal disturbances. Some NSAIDs are likely to cause gastric irritation and
ulceration.
Surgical procedure:
If the conservative management is ineffective, surgery is indicated for correction of deformity,
relieve pain or restoration of pain or restoration of function. The objective of surgery are restoration
or maintenance of body part; prevention of deformity and correction of deformity.

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Commonly performed surgical procedures are:
 Arthroscopy is endoscoping examination of joints, indicated for diagnosis, synovectomy
and chondroplasty.
 Orthotomy: Opening of joint indicating for exploration of joint – drainage joint and
removal of damaged tissue.
 Orthoplasty: Reconstructions of joint, indicated to restore motion, relieve pain, and
correct deformity and vascular necrosis.
- Interposition: replacement of part of joint with prosthesis or with soft tissue.
- Hemiarthroplasty: Replacement of one articulating surface.
- Replacement: Total joint replacement of both articulating surfaces with prosthesis.
 Synovectomy: Removal of part or all of the synovial membrane indicated when delay the
progresses of RA.
 Osteotomy: Cutting a bone to change its alignment indicating to correct deformity.
 Tendon transplants: Moving tendon from its anatomical position for substitute one tendon
for another that is not working or realigns tendon function.
Conservative Management:
Patient Education Care
 Disease Information
 Rest and Exercise
 Lifestyle Modification
- Knee and foot support
- Walking
- Crutches and sticks may be required to mobilize the patient and protect the skin
Allied Health Care
 Physiotherapy
 Occupational Therapy
Rest and Exercise
A balance of physical activity and rest periods are important in managing rheumatoid arthritis.
Exercise more when the symptoms are minimal, rest more when the symptoms are worse. Exercise
helps maintain joint flexibility and motion. There are therapeutic exercises, such as physical
therapy that is prescribed, that can help with strength, flexibility, and range of motion of specific
joints or body parts affected by RA.
Prognosis:
– Increased mortality in severe cases (5 years’ survival for severe cases)

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– Forty percent of patient will be registered disabled within 3 years. Among them 80%
moderately to severely disabled within 20 years 0r 20% required a large joint replacement.
– Poor prognosis for higher baseline disability – disease duration more than 3 months; female
gender and positive RA factors.
Nursing Management
Assessment
– History should be taken in all areas as, past, present, and personal about the disease e.g. on set,
duration and, chief complains .as well as Genetic history.
– Complete physical examination should be done to assess the patient's health status level e.g.
inspection of all joints for inflammation, warmness, and redness time of severe pain.
– Deformity, limitation of normal movements
– Coping abilities should be assessment should be done because it is chronic disease related to
deformity.
Nursing Diagnosis
– Acute and chronic pain related to inflammation and tissue damage
– Fatigue related to increased disease activity, pain, inadequate sleep, inadequate nutrition and
emotional stress
– Impaired physical mobility related to decreased range of motion, muscle weakness, pain on
movement
– Self-care deficits related too contractures, fatigue or loss of motion.
– Disturbed body image related to physical and psychological changes
– Ineffective coping related to actual or perceived limitation
– Complications secondary to effects of medications.
Nursing Interventions:
 Provide verity of comfort measures such as, application of cold, administered it can be relieve
pain and swelling during acute pain. Anti-inflammatory and analgesic drugs as prescribed by
doctor.
 Provide instruction about fatigue e.g. explain relationship of disease activity.
 Diet therapy: No specific diet but balance diet is necessary to prevent fatigue and increase energy.
If overweight, weight reduction diet is recommended combined with exercise.
 Rest: Two forms of rest
- Absolute rest: no activity during acute pain

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- Exercise to preserve joint mobility, maintain muscle tone and strengthen selected muscle
groups.
- Physical therapy for exercise prescription, to relieve stiffness, maintains joint movements.
- Apply moist heat (15-30 minutes) to reduce muscle spasm post rest stiffness,
 Planning for appropriate activity rest schedule.
 Assess for occupational or physical therapy consultation.
 Encourage in independence in mobility.
 Assess pain; note the location and intensity (scale 0-10). Write down the factors that accelerate
and signs of pain non-verbal.
 Assist in determining the need for pain management and program effectiveness.
 Instruct the patient to a warm bath or shower at the time awake. Monitor the water temperature,
water bath, and so forth.
 Heat enhances muscle relaxation, and mobility, reduce pain and stiffness in the morning release.
Sensitivity to heat, can be removed and dermal wound can be healed.
 Encourage the use of stress management techniques, such as progressive relaxation, therapeutic
touch, biofeed back
 Collaboration: Provide drugs according to doctor's instructions as anti-inflammatory and mild
analgesic effect in reducing stiffness and increasing mobility.
 Provide Client teaching:
- To enable the patient to maintain as much independence as possible.
- About medication: Medications used for treating RA may cause serious complications like bone
marrow suppression, anemia, GI disturbances and rashes. In such condition the medicines should
be readjusted.
- To ensure the patient’s safety at home.
Evaluations:
– Goal was completely met
– Indicates no pain Looks relaxed, to sleep / rest
– Participate in activities based on ability
– Maintaining a function of position with no presence / restrictions contractures.
– Maintain or increase the power and functionality of and / or compensation of the body.
– Demonstrate techniques / behaviors that allow doing activities.

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15. Orthotics, Prosthesis, Physiotherapy,
Rehabilitation, and Occupational Therapy
Orthotics:
Introduction: Orthotics is the unit of rehabilitation which deals with improving function of the
body by the application of a device which aids the body part. The device so manufactured is called
an orthosis. Orthosis is an appliance used to support part of a body or perform certain function. An
orthotist is the primary medical clinician responsible for the prescription, manufacture and
management of orthosis.
Uses
 To immobilize a joint or body parts. (painful joint)
 To prevent deformity (polio limb).
 To correct a deformity.
 To assist the movement.
 To relieve weight bearing (in an un-united fracture)
 To provide support (fractured spine).
 Assist rehabilitation.
 Increase independence.
Nomenclature of orthosis:
Until recently, the terms braces, callipers, splints, and corsets, used to name and describe orthoses
were not uniform. Now, a logical, easy to use system of standard terminology has been developed.
This system uses the first letter of the name of each joint which the orthosis crosses in correct
sequence, with the letter O (for orthoses) attached at the end.
– AFO= Ankle foot orthosis (previously called below knee calliper)
– KAFO=Knee –Ankle-foot orthosis (previously called above- knee calliper)
– HKAFO= Hip-Knee-Ankle-foot orthosis (previously called above-knee calliper with
pelvic band)
– KO= Knee orthosis (previously called knee brace)
– CO=Cervical Orthosis (previously called cervical collar)
– WHO= Wrist Hand orthosis (previously called cock up orthosis)
– CTLSO= Cervico- Thoraco- Lumbo-Sacral orthosis (previously called body brace)

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– FO= Foot orthosis (previously called surgical orthosis)
Classification
Static orthosis
• Do not allow motion.
• They serve as a rigid support in fractures, inflammatory conditions of tendons and soft
tissue, and nerve injuries.
Dynamic orthosis
• Do permit motion on which its own effectiveness depends.
• Are used primarily to assist movement of weak muscles.
Classification
1. Upper limb orthosis
2. Trunk orthosis
3. Lower limb orthosis
Upper limb orthosis
 Upper-limb (or upper extremity) orthoses are mechanical or electromechanical devices
applied externally to the arm or segments thereof in order to restore or improve function,
or structural characteristics of the arm segments encumbered by the device Upper limb
orthoses improve function and also fix structural characteristics of the nervous and the
musculoskeletal systems. Some of the orthosis are
 Clavicular orthosis: it is made of durable foam fabric covered with a material. This
orthosis supports and functions according to the principle of the figure-of-eight bandage.
It is used for posttraumatic or postoperative immobilization of the shoulder and upper arm.
 shoulder orthoses: Shoulder Orthosis is designed to rehabilitate shoulder impairments.
Developed from extensive research, its unique design pulls the shoulders back, supports
the shoulder blades and stabilises the shoulder joints, providing greater comfort, improved
posture and range of movement.
 Elbow and Arm orthoses
 Functional arm orthoses
 Forearm-wrist orthoses
 Forearm-wrist-thumb orthoses
 Forearm-wrist-hand orthoses

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Lower limb orthosis: A lower-limb orthosis is an external device applied to a lower-body segment
to improve function by controlling motion, providing support through stabilizing gait, reducing
pain through transferring load to another area, correcting flexible deformities, and preventing
progression of fixed deformities. Some of the lower foot orthosis are
Foot orthosis: Foot orthoses (commonly called "orthotics") are devices inserted into shoes to
provide support for the foot by redistributing ground reaction forces acting on the foot joints while
standing, walking or running. A foot orthosis would be prescribed to you if you have had recent
injuries, or fractures or partial amputation. It also helps with post-operative management and to
prevent, correct or accommodate foot deformities.
Ankle foot orthosis: An ankle-foot orthosis (AFO) is an orthosis or brace that encumbers
the ankle and foot. AFOs are externally applied and intended to control position and motion of the
ankle, compensate for weakness, or correct deformities. AFOs can be used to support weak limbs,
or to position a limb with contracted muscles into a more normal position. They are also used to
immobilize the ankle and lower leg in the presence of arthritis or fracture, and to correct foot drop;
an AFO is also known as a foot-drop brace
Knee-ankle-foot orthosis (KAFOs):
A knee orthosis (KO) or knee brace is a brace that extends above and below the knee joint and is
generally worn to support or align the knee. In the case of diseases causing neurological or
muscular impairment of muscles surrounding the knee, a KO can prevent flexion or extension
instability of the knee. In the case of conditions affecting the ligaments or cartilage of the knee, a
KO can provide stabilization to the knee by replacing the function of these injured or damaged
parts. Conditions that might benefit from the use of a KAFO include paralysis, joint laxity or
arthritis, fracture, and others.
Trunk/spinal orthosis:
1. Scoliosis Orthoses Braces: Externally applied devices used in the treatment of scoliosis
2. Milwaukee Brace: An externally applied Cervico-Thoraco-Lumbo-Sacral Orthosis
(CTLSO) brace used in treatment of adolescent scoliosis that is especially effective to
correct kyphosis
3. Boston Brace: An externally applied Thoraco-Lumbro-Sacral Orthosis (TLSO) brace used
in treatment for curves in the middle and lower back
4. Charleston Brace: An externally applied nighttime bending brace that is intended to wear
lying down to apply pressure to hold the spine in an overcorrected position

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5. Spinal Orthoses Braces: Externally applied devices used in the treatment of spinal
fractures or following spinal surgery
6. Halo Brace: An externally applied device used to immobilize the cervical thoracic spine
following injury or surgery.
7. Jewitt Brace: An externally applied device to facilitate healing of fracture within the T10-
L3 vertebrae
8. Body Jacket: An externally applied device used to stabilize more involved fractures of the
spine
Care of orthosis
 Don the orthosis first and then the shoe.
 Slip the orthosis in the shoe first and then slide the foot into the orthosis using like a shoe
horn.
 Clean cotton stocking should be worn under the AFO. This will more comfortable and
reduce perspiration.
 Keep the stockings wrinkle free, however, do not pull the stockings tightly over shoes.
 The AFO should be worn with shoes all the time. The plastic is too slippery to be worn
without shoe.
 Wear the laced shoe that are the same heel height. Avoid spikes heels, slippers, sandals or
loafers.
 To clean your orthosis, wipe with a damp cloth and completely dry with a towel, or allow
orthosis device to dry at room temperature.
 Examine your skin under the orthosis every day. Redness of skin under pressure areas of
orthosis may develop. The redness should disappear 20 to 30 minutes after orthosis is
removed.
 If the blisters or open sores occurs in the pressure areas, stop wearing the orthosis and
contact your orthotic for adjustment.
 Follow up should be made to ensure if orthosis is working well.
Wearing schedule of orthosis
 Day 1-3: begin wearing orthosis in non-weight bearing situation for 15-30 minutes several
times a day, i.e., watching television, eating.
 Day 4-7: continue step 1, add 15 to 30 minutes of function such as walking around the house.
 Days 8-14: gradually work into orthosis by increasing the wearing time daily.
 Only increase the wearing time if you are able to wear it comfortably.

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Care of low and high profile scoliosis orthosis
While being fitted with your Scoliosis Orthosis, your orthotist will instruct you on how to wear
and use your orthosis effectively.
Some points to remember:
– Proper orthosis application may require two people, the wearer and helper. This keeps the brace
from being twisted when it is put on.
– Wear the orthosis over a cotton undershirt (preferably with no side seams). Loose fit clothing
can be worn over the brace. It may be necessary to wear larger size trousers with an elastic or
drawstring waist over your new orthosis. Tops with turtlenecks or cowl necks may fit more
comfortably
– It is important to prevent skin breakdown and to toughen the skin in contact with orthosi.
Protection of skin can be done by:
 Bathing daily (bath or shower)
 Toughening the skin by apply rubbing alcohol to all skin areas that the orthosis covers
(especially where the orthosis presses against the skin).
 Do not use creams, lotions or powder under the orthosis as they soften the skin
– Consult your orthotist if you experience skin breakdown (sore, red and/or raw skin). Do not reapply
the orthosis until the skin heals.
– Clean the orthosis with soap and water. Allow the orthosis to air dry (usually 25 minutes) at room
temperature. Do Not leave the orthosis in the sun or near a radiator as it may lose its shape
– For the first 5-7 days, wear the orthosis for a total of six (6) hours each day. The orthosis should be
removed every two (2) hours and rubbing alcohol applied to the skin. If there are any red/sore areas,
leave the orthosis off for one half hour and then re-apply.
– For the next 2-3 days, wear the orthosis for a total of ten (10) hours each day. The orthosis should be
removed every 2-4 hours and rubbing alcohol applied to the skin. If there are any red/sore areas, leave
the brace off for one half hour and then re-apply.
– During the following 2-3 days, wear the orthosis for a total of 20 hours a day. Apply the orthosis in the
morning and remove it every four (4) hours to check your skin. Remove the orthosis in the evening for
4-5 hours and re-apply at bedtime. Wear the orthosis during the night. Remember to use rubbing alcohol
on your skin every time the orthosis is removed.
– During the final stage, the orthosis is to be worn 23 hours a day. The orthosis is usually removed only
for cleaning of the brace, doing special exercises, and for skin care. Rubbing alcohol should be applied
three (3) times per day.
– A follow-up appointment will be scheduled two weeks after you have been fit with your Scoliosis
orthosis.
– Every six months your orthotist should check the fit and condition of your orthosis. If there are problems schedule
an appointment sooner.

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Prosthetic
– Meaning "add to" OR "to put”, “place”.
– Prosthetics: The science that deals with functional and/or cosmetic restoration for all or part of
a missing limb. (prostheses = artificial limb).
– Prosthesis is a mechanical device that replaces a member of a body. The device is made up of
several types of materials such as: wood, plastic, steel, titanium, carbon fiber or silicon to
provide functional or cosmetic prostheses.
– Prosthetic amputee rehabilitation is primarily coordinated by a prosthetist and an inter-
disciplinary team of health care professionals including psychiatrists, surgeons, physical
therapists, and occupational therapists
Classification:
 Exoprosthesis : Prosthesis which can be put on and taken off the body
 Endoprosthesis : An artificial device to replace a missing bodily part that is placed inside
the body. Endoprosthetic reconstruction is a highly successful and durable method for the
restoration of skeletal integrity and joint function. Use of a cemented stem provides
immediate fixation, which allows for early mobilization and rehabilitation. Extensive
experience in joint replacement has led to the development of materials suited for longterm
prosthetic survival; at the same time, advances in the use of local rotational flaps have
improved joint stability and simultaneously reduced the risk of infection
Parts of prosthesis
• Socket: Provides weight bearing and receptive areas for stump.
• Suspension: Holds prosthesis to the stump.
• Joints: Joints are replaced by artificial mechanical joints.
• Base: It provides contact with floor.
Types of prostheses:
1. Upper extremity prostheses
 Transhumeral prosthesis: it is an artificial limb that replaces an arm missing above the elbow.
Transhumeral amputees experience some of the same problems as transfemoral amputees, due
to the similar complexities associated with the movement of the elbow. This makes mimicking
the correct motion with an artificial limb very difficult.
 Finger prosthetics: silicon finger or partial finger amputation fabricated to match the color
and shape of adjacent finger and adapted to fit the residual part of amputed finger.

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 Partial hand prostheses: composed of silicon glove with openings for remaining fingers.
It is attached to the residual part of the hand through narrow shape of the wrist section of
glove.
 Total hand prostheses: complete without any openings for fingers, used for the
amputations of all fingers (trans- carpal or trans- metacarpals). It is attached via suction to
the residual part of hand.
 Mechanical hook: operated and designed for partial function replacement for a missing
hand, the prostheses may be patient actuated. The hand is commonly operated by cables
attached to a harness strapped around the shoulder.
 Myo electric prostheses/ Bionic hands: myo electric prostheses fitted on the residual limb
of the patient are electrically powered prostheses controlled by the myo – electrical
impulses generated by a user’s muscle contraction.
2. Lower extremity prostheses:
 Trans tibial prostheses: The transtibial amputation (also known as a below the knee or
BK) is the most common level of lower limb amputation. Due to the preservation of the
knee joint, many amputees are able to return to or exceed the level of activity prior to their
surgery! P&O Care prosthetists have extensive experience with transtibial prostheses,
including bilateral, or both side involvement
 A transfemoral prosthesis is an artificial limb that replaces a leg missing above the knee.
Transfemoral amputees can have a very difficult time regaining normal movement. In
general, a transfemoral amputee must use approximately 80% more energy to walk than a
person with two whole legs. This is due to the complexities in movement associated with
the knee. In newer and more improved designs, after employing hydraulics, carbon fiber,
mechanical linkages, motors, computer microprocessors, and innovative combinations of
these technologies to give more control to the user.
 Hip disarticulation prostheses
Care of prosthesis:
 Do not allow your prostheses to become submerged in water unless it has been designed
for that purpose.
 Do not attempt to repair or adjust your own prosthesis. Contact the prosthetics service
 Do not put oil, grease or any other chemical as it may cause damage to certain parts.
 Do not lean prosthesis against a radiator, as this may distort it.
 When you are walking with your prosthesis for the first few days at home, you must check
the skin over the whole of your stump regularly.
 If any blisters or sore areas of skin form, do not put your prosthesis on again until you have
seen your physiotherapist.

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Rehabilitation:
Rehabilitation is treatments that can help patient recover from a serious injury, illness, or surgery.
After these events, individual may need time to regain the strength, re-learn skills, or find new
ways of doing the things that were able to do before.
Rehabilitation is a highly person-centered health strategy that may be delivered either through
specialized rehabilitation programme (commonly for people with complex needs), or integrated
into other health programme and services, for example, primary health care, mental health, vision
and hearing programme.
Rehabilitation is a set of interventions needed when a person is experiencing or is likely to
experience limitations in everyday functioning due to ageing or a health condition, including
chronic diseases or disorders, injuries or traumas. Musculoskeletal rehabilitation is a form of
orthopedic rehab that can help an individual with the strength, fitness, and ability to move.
Classifications of Rehabilitations:
Inpatient and outpatient rehabilitation treatments
Inpatient rehabilitation refers to treatment or therapy received in a hospital or clinic prior to being
discharged. Patients who go through an amputation, suffer a brain injury or stroke, experience an
orthopedic or spinal cord injury or receive a transplant may require inpatient therapy to recover to
a point where they can safely go home.
Outpatient rehabilitation therapy refers to treatment received when not admitted to a hospital or
clinic. Outpatient rehabilitation centers tend to offer therapy for a wide range of conditions
including cancer, neurological disorders, neck and back pain, speech problems, psychological
disorders, pre- and post-natal issues and more.
According to the treatment types
Physical Therapy – This type of rehabilitation therapy works to improve movement dysfunction.
Therapists work with patients to restore movement, strength, stability and/or functional ability and
reduce pain via targeted exercise and a range of other treatment methods.
Occupational Therapy – This form of therapy focuses on restoring an individual's ability to
perform necessary daily activities. This may mean working to improve fine motor skills, restore
balance, or assist patients in learning how to increase their functional ability via use of adaptive
equipment, among other potential treatment options.
Speech Therapy – This type of rehabilitation therapy is used to address difficulties with speech,
communication and/or swallowing.

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Respiratory Therapy – Used to aid patients who have breathing disorders or difficulties, this
form of rehabilitation therapy works to help them decrease respiratory distress, maintain open
airways and, when necessary, learn how to use inhalers and supplemental oxygen properly.
Cognitive Rehabilitation – Also commonly called cognitive-behavior rehabilitation, this type of
therapy works with patients to improve memory, thinking and reasoning skills.
Vocational Rehabilitation – This form of therapy is geared towards preparing individuals to
return to work after an injury, illness, or medical event.
Other Types:
Medical Rehabilitation: Help a person better in all his daily physical and mental activities.
Related to increasing the potential capabilities and correction of deformities, restoration of
functions.
Social Rehabilitation: Implies social life; restoration of family, social interactions or relationship.
Psychological Rehabilitation: Includes psychological restoration of personal dignity and
confidence of the disabled.
Vocational Rehabilitation: help those patient who find it difficult to get employment.
Process of rehabilitation
1. Identify problems and needs
2. Relate problems to modifiable and limiting factors
3. Define target problems and target mediators, select appropriate measures
4. Plan, implement, and coordinate interventions
5. Assess effects
Benefits of rehabilitations
Physical Benefits of Rehabilitation
 Lessens pain so that one can become more active and enjoy life without suffering from
discomfort.
 Helps restore to the level of pre-illness or accident function and mobility.
 Strengthens the muscles so that there are less at risk of falls or accidents.
 Improves the coordination for better mobility and easier movement.
 Improves flexibility – physical therapy for injury can help achieve a full range of motion in the
joints and muscles.
 Reduces swelling in the affected joints and muscles.
 Helps improve balance.

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 Improves endurance – gain strength and the ability to complete physical rehabilitation
exercises and progress with treatment program.
 Decreases the frequency and intensity of muscle spasms.
 Promotes healing of lesions and soft tissue injuries.
 Prevents deformities and limb problems.
 Corrects gait and posture problems.
Psychological Benefits of Rehabilitation
 Enhances self-confidence and ability to deal psychologically with illness or injury.
 Provides with greater independence – returns to pre-injury state of mental wellbeing.
Lifestyle Benefits of Rehabilitation
 Allows to get back to work more quickly (financial concerns)
 Helps to return to sport or exercise. It also improves general health when one can exercise or
play sport to their original capacities.
Risk of rehabilitations:
 It might not recover all of the functions
 The rehabilitation might make patient sore, or can cause pain
 Straining too much during the exercises can cause injuries to the body parts.
Physiotherapy
Physiotherapy, sometimes called physical therapy, is a science-based health care profession which
assists people to restore, maintain and maximize their strength, function, movement, and overall
well-being. Physiotherapy includes rehabilitation, as well as prevention of injury, and promotion
of health and fitness. Physiotherapists often work in teams with other health professionals to help
meet an individual's health care needs.
Types of physiotherapy Sub-Specialties:
Geriatric physiotherapy: Geriatric physiotherapy focuses on the unique movement needs of older
adults which is more efficient and safer, and is less likely to lead to injuries. The goal of geriatric
physiotherapy treatments is to help restore mobility affected by old age, reduce pain, work around
physical limitations and improve physical fitness and overall health.
Pediatric physiotherapy: Pediatric physiotherapy focuses on the physical needs of infants,
toddlers, children and adolescents with a variety of developmental, neuromuscular, skeletal or
other physical disorders. It is particularly designed to help in growth, overcome problems, and

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build their muscular and skeletal strength, often teaching them movement types and ranges of
movement which they may never have experienced before. Physiotherapists use various
therapeutic exercises in children, which can aid in strengthening the affected parts; thereby
improving the precise and overall movement of those parts.
Cardiorespiratory physiotherapy: It specializes in the prevention, rehabilitation and
compensation of people suffering from diseases or injuries affecting the heart, chest and lung
including heart attacks, or pulmonary fibrosis. Treatments include deep breathing and circulation
exercises, correct breathing techniques, strategies to help manage coughs and shortness of breath,
positioning for optimal lung expansion.
Neurological Physiotherapy: Neurological conditions lead to extreme muscle weakness, loss of
balance and coordination, muscle spasm, tremors, loss of function, and decreased sensation. It also
helps to treat neurological balance issues that can arise due to conditions such as vertigo.
Neurological Physiotherapy Treatments focus on improving motor control, balance and
coordination.
Orthopedic physiotherapy: This branch of physiotherapy is concerned with the treatment of
injuries or disorders of the skeletal system and associated muscles, joints and ligaments.
Orthopedic Physiotherapy also includes pre and post-operative rehabilitation of hip, shoulder and
knee. The treatment goal is to provide pain relief, increase joint range, improve strength and
flexibility and restore the patient to full function.
In general, treatment involves a mix of balance and stretching exercises, cryotherapy, massage, ice
and heat therapy, or spine manipulation techniques.
Sports Physiotherapy: Sports Physio is the specialized branch of physiotherapy which deals with
injuries and issues related to sportspeople.
Types of Treatment Modalities Used in Physiotherapy
In general, treatment involves a mix of balance and stretching exercises, cryotherapy, massage, ice
and heat therapy, or spine manipulation techniques.
1. Hands-On Physiotherapy Techniques (Manual Therapy):
Manual therapy techniques are skilled hand movements and skilled passive movements of joints
and soft tissue and are intended to improve tissue extensibility; increase range of motion; induce
relaxation; mobilize or manipulate soft tissue and joints; modulate pain; and reduce soft tissue
swelling, inflammation, or restriction.
a. Joint Mobilization (gentle joint gliding techniques): Joint mobilization is a type of straight-
lined, passive movement of a skeletal joint that addresses arthrokinematics joint motion
(joint gliding) rather than osteokinematic joint motion. Joint mobilization is a slower

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movement of a joint in a specific direction. It is usually aimed at a 'target' synovial joint with
the aim of achieving a therapeutic effect.
b. Joint Manipulation: Joint manipulation involves a quick, but small thrust to a joint to provide
immediate pain relief and improved mobility.
c. Physiotherapy Instrument Mobilization (PIM): Physiotherapy Instrument Mobilization
(PIM) involves mobilizing spinal and peripheral joints via a mechanical spring-loaded
instrument. The PIM is a hand held, spring loaded instrument which delivers a small impulse
to a specific joint in the spine, producing just enough force to correct positional faults of the
vertebrae gently and safely and can often bring immediate improvement in movement
dysfunction and pain. Physiotherapy Instrument Mobilization is a safe measurable and
extremely effective joint mobilization technique provided by specially trained
physiotherapists.
d. Muscle Energy Techniques (METs): Muscle Energy Technique (MET) uses the gentle
muscle contractions of the patient to relax and lengthen muscles and normalize joint motion.
It is “a direct manipulative procedure that uses a voluntary contraction of the patient’s muscles
against a distinctly controlled counter-force from a precise position and in a specific direction”.
It is considered an active technique, as opposed to a passive technique where only the massage
therapist does the work. MET is based on the principle of reciprocal inhibition, a theory that
explains that muscles on one side of a joint will always relax to accommodate the contraction
of muscles on the other side of that joint when indirect pressure is applied.
e. Massage: Massage is an age-old technique uses both stretching and pressure in a rhythmic
fashion and manipulation of the body's soft tissues. The purpose of massage is generally for
the treatment of body stress or pain. Massage provides a healing treatment that can be gentle
or strong, deep or shallow, when muscles and tendons become damaged, impaired, knotted,
tense or immobile.
2. Physiotherapy Taping:
This technique ease pain and facilitate normal movement by promoting the body’s natural healing
process. A tape is used, which lifts the skin away from the connective tissue, hence increases the
space and allows the lymphatic fluid to move more effectively.
 Rigid Strapping Tape: Rigid Strapping Tape (often referred to as ‘sports tape’ or ‘athletic tape’)
is arguably one of the most rigid tapes commonly used by health professionals. The tape provides
extra support to the joints when under high stress particularly during intensive sporting activities.
 Elastic Strapping Tape: Elastic Strapping Tape is often used when less support is required such
as for compression bandaging over muscle and joint areas and to help keep wound dressings in
place during intensive sporting activities.
 Kinesiology Taping: Kinesiology taping (or Kinesio taping) is the application of a thin, stretchy,
cotton-based therapeutic tape that can benefit a wide variety of injuries and inflammatory
conditions. It is almost identical to human skin in both thickness and elasticity, which allows it to
be worn without binding, constricting or restriction of movement.

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3. Acupuncture and Dry Needling
a. Acupuncture: Acupuncture is the Chinese art of medicine which states that an illness is
due to an imbalance in the body’s energy known as Qi. Qi runs throughout the body by
way of channels and meridians that run both superficially & deep. Traditionally it is
thought that acupuncture promotes the free flow of the body’s Qi (energy) to bring the
body into its natural balance.
b. Dry Needling: Dry needling or intramuscular stimulation (IMS) is a technique that was
developed by Dr Chan Gunn. Dry needling works by changing the way body feels pain and
by helping the body heal trigger points. The treatment involves needling of a muscle’s
trigger points without injecting any substance. Dry needling is a beneficial method to relax
overactive muscles.
4. Physiotherapy Exercises
a. Muscle Stretching: Stretching is a form of physical exercise in which a specific muscle or
tendon (or muscle group) is deliberately flexed or stretched in order to improve the muscle's
felt elasticity and achieve comfortable muscle tone. The result is a feeling of increased
muscle control, flexibility, and range of motion.
 Static Stretching: A static stretch should be held for 20 to 30 seconds at a point where
one can feel the stretch but do not experience any discomfort. Do not bounce when holding
the stretch.
 Dynamic Stretching: Dynamic Stretching (DS) involves the performance of a controlled
movement through the available ROM. DS involves progressively increasing the ROM
through successive movements till the end of the range is reached ie the stretch is repetitive
and progressive. DS is good to use in advanced sports related rehabilitation and active
sports persons.
 Ballistic Stretching: Ballistic stretching includes rapid, alternating movements or
‘bouncing’ at end-range of motion; however, because of increased risk for injury, ballistic
stretching is no longer recommended.
 Proprioceptive Neuromuscular Facilitation (PNF) Stretching: Proprioceptive
Neuromuscular Facilitation or PNF stretching involves a component of stretch – muscle
contraction – and further stretch. This process is usually repeated several times and uses a
trick on the muscle spindle reflex to help elongate muscles.
The types of PNF stretch techniques
 Contract Relax (CR) Contraction of the muscle through its spiral-diagonal PNF
pattern, followed by stretch.
 Hold Relax (HR) Contraction of the muscle through the rotational component of the
PNF pattern, followed by stretch.

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 Contract-Relax Agonist Contract (CRAC) Contraction of the muscle through its
spiral-diagonal PNF pattern, followed by contraction of opposite muscle to stretch
target muscle.
b. Core Exercises: Core stability retraining is a vital component of optimizing the core
strength program while reducing the chance of injury and improved performance. Core
muscle provide a solid platform that dynamic muscles enact upon.
c. Strengthening Exercises:
 Stability muscle exercises: low intensity – long duration type exercises.
 Dynamic strengthening exercises: higher intensity (weight, speed, power) and shorter
duration but this can vary.
 Eccentric strengthening exercises are important for both speed and weight-bearing
control.
d. Neurodynamics: Neurodynamics is the mobilization of the nervous system as an approach
to physical treatment of pain. Neurodynamics involves conservative decompression of
nerves, various neural mobilizing techniques and patient education techniques. This
mobilization activates a range of mechanical and physiological responses in nervous
tissues. eg neural sliding, pressurization, elongation, tension and changes in intraneural
microcirculation, axonal transport and nervous impulse movements.
e. Balance Exercises: Balance exercises improve body awareness, which decreases the
likelihood of injury. Improving balance increases coordination and strength, allowing to
move freely and steadily. Enhancing stability, mobility, and flexibility makes it easier to
perform the daily tasks.
f. Proprioception Exercises: Proprioception is the sense of knowing where the body part is
in space. Proprioceptive and balance exercises teach the body to control the position of a
deficient or an injured joint. A common example of a proprioceptive or balance exercise is
the use of a balance or wobble board after an ankle sprain.
g. Real-Time Ultrasound Physiotherapy: Real time ultrasound physiotherapy utilizes an
ultrasound machine to assist with the assessment and treatment of certain conditions. It
provides real time imaging by transmitting sound waves through the body. These sound
waves are then reflected by tissues in the body to create images on the screen. The benefit
of real time ultrasound physiotherapy is that it allows to see how muscles contract whilst
performing certain exercises.
h. Swiss Ball Exercises: Swiss balls are large, heavy-duty inflatable balls with a diameter of
45 to 75 cm (18 to 30 inches). A primary benefit of exercising with an exercise ball as
opposed to exercising directly on a hard flat surface is that the body responds to the
instability of the ball to remain balanced, engaging many more muscles.
5. Hydrotherapy:

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Hydrotherapy exercises utilize the buoyancy of the water (floating properties). The body weight is
reduced by up to 90% in the water, making exercising very effective in improving mobility and
strength. Specialized exercises are performed inside water with a temperature range of 33-36
degree Celsius under the guidance of a physiotherapist. It involves various stretching, aerobics,
and strengthening exercises.
6. Electrotherapy:
Electrotherapy uses electrical signals to interfere with the transmission of neural pain signals into
the brain. It effectively slows down or distracts the message from the nerve to the brain.
Electrotherapy can also involve the use of electric current to speed tissue healing where tissue
damage has also occurred.
a. Ultrasound Therapy: An electrical machine which produces ultrasonic waves which are
transmitted into the affected area using conducting gel. Ultrasound is applied using the head
of an ultrasound probe placed in direct contact with skin via a transmission coupling gel.
Therapeutic ultrasound uses the frequency range of 0.5 – 3 MHz. This in turn causes a micro-
massage effect which promotes circulation, reduces pain and increases regenerative powers of
tissues and helps muscle relaxation. It is very helpful in the treatment of soft tissue injuries.
This technique helps in lowering down the inflammation by inducing a deep heat to a localized
area to cure muscle spasms, promote healing at the cellular level, increase metabolism, and
improve blood flow to the damaged tissue. Phonophoresis is a technique which utilizes
ultrasonic waves for effective absorption of the drugs which are topically applied. This
technique has been found to be effective in relieving pain as it allows maximal absorption of
drugs such as anti-inflammatory and analgesics.
b. Interferential Therapy: This is an electrical current delivered to the injured part via 2 or 4
electrodes. It sends two interfering currents into the body part which feels to the patient like
pins and needles. It can be used to relieve pain. reduce swelling and optimise the healing
process. This type of stimulation is characterized by the crossing of two electrical medium,
independent frequencies that work together to effectively stimulate large impulse fibers. These
frequencies interfere with the transmission of pain messages at the spinal cord level. Because
of the frequency, the Interferential wave meets low impedance when crossing the skin to enter
the underlying tissue. This deep tissue penetration can be adjusted to stimulate parasympathetic
nerve fibres for increased blood flow. Interferential Stimulation differs from TENS because it
allows a deeper penetration of the tissue with more comfort (compliance) and increased
circulation.
c. Transcutaneous electrical nerve stimulation (TENS) therapy – It is a technique wherein a
small battery-driven device is used to send low-grade current through the electrodes placed on
the skin surface. A TENS device temporarily relieves the pain of the affected area. This type
of stimulation is characterized by biphasic current and selectable parameters such as pulse rate

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and pulse width. TENS stimulates sensory nerves to block pain signals, stimulate endorphin
production to help normalize sympathetic function. TENS is generally used to treat medical
conditions .
d. Electrical Muscular Stimulation (EMS): An electrical machine with variable currents which
is applied using electrodes to strengthen very weak muscles. Neuromuscular electrical
stimulation (NMES)uses high intensities that cause excitation of peripheral nerves to produce
a muscle contraction. The impulses are generated by a device and delivered through electrodes
(pads that adhere to the skin) over the middle of the muscles that require stimulating. The
impulses from EMS mimic the action potential (stimulus required to make the muscle contract)
coming from the central nervous system. This causes the muscles to contract. Portable version
is now available. Fine needles are inserted into specific body points, which reduce pain for a
short span of time.
e. Magnetic Field therapy: Magnetotherapy is a form of physical therapy that uses a
pulsing magnetic field to generate electromagnetic energy. Electromagnets of different types
and sizes are available, and can be self-applied under the guidance of a trained professional.
This can help in limiting the pain.
7. Local modalities:
a. Hot applications: Superficial heat therapy is commonly used in physiotherapy practice in the
non-acute injury phase. Heat therapy works by relieving pain, reducing muscle spasm and
improving circulation to the injured area. A dilation of the blood vessels in the muscle increases
the flow of nutrients and oxygen to said muscle, in turn speeding up the healing process.
Physiotherapists use hot packs, infrared heat, diathermy, and ultrasonic waves.
b. Cold Therapy: Application of ice, cold packs, nitrogen spray, and techniques such as
cryotherapy can relieve the patients from acute conditions. This limits the amount of fluid that
is able to pool around the injury, which helps minimize swelling and bruising.
Cold therapy also helps to numb the nerve endings which decreases messages sent to the brain
by the pain receptors. Cold therapy should be used for short periods of time, several times a
day. Periods of 10 to 15 minutes are usually around where a person want to be. Anything over
20 minutes open the possibility of nerve, tissue or skin damage.
8. Range of Motion (ROM) exercises:
Range of motion exercises are used to improve joint mobility and to decrease muscle stiffness.
Various types of ROM exercises:
a. Passive range of motion: It is the movement applied to a joint solely by another person or
persons or a passive motion machine. When passive range of motion is applied, the joint of an
individual receiving exercise is completely relaxed while the outside force moves the body
part, such as a leg or arm, throughout the available range. Injury, surgery, or immobilization
of a joint may affect the normal joint range of motion.

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b. Active range of motion: Active range of motion is movement of a joint provided entirely by
the individual performing the exercise. In this case, there is no outside force aiding in the
movement.
c. Active assisted range of motion: Active assist range of motion is described as a joint receiving
partial assistance from an outside force. This range of motion may result from the majority of
motion applied by an exerciser or by the person or persons assisting the individual. It also may
be a half-and-half effort on the joint from each source.
Benefits of physiotherapy
i. Reduce or eliminate pain: Therapeutic exercises and manual therapy techniques such as
joint and soft tissue mobilization or treatments such as ultrasound, taping or electrical
stimulation can help relieve pain and restore muscle and joint function to reduce pain. Such
therapies can also prevent pain from returning.
ii. Avoid surgery: If physical therapy helps eliminate pain or heal from an injury, surgery may
not be needed. And even if surgery is required, may benefit from pre-surgery physical therapy.
Also, by avoiding surgery, health care costs are reduced.
iii. Improve mobility: Stretching and strengthening exercises help restore the ability to move.
Physical therapists can properly fit individuals with a cane, crutches or any other assistive
device, or assess for orthotic prescription. By customizing an individual care plan, whatever
activity that is important to an individual’s life can be practiced and adapted to ensure
maximal performance and safety.
iv. Recover from a stroke: It’s common to lose some degree of function and movement after
stroke. Physical therapy helps strengthen weakened parts of the body and improve gait and
balance. Physical therapists can also improve stroke patients’ ability to transfer and move
around in bed so that they can be more independent around the home, and reduce their burden
of care for toileting, bathing, dressing and other activities of daily living.
v. Recover from or prevent a sports injury: Physical therapists understand how different
sports can increase the risk for specific types of injuries (such as stress fractures for distance
runners). They can design appropriate recovery or prevention exercise programs to ensure a
safe return to sport.
vi. Improve balance and prevent falls: physical therapy also screens for risk of fall. If
individual is at high risk for falls, therapists will provide exercises that safely and carefully
challenge the balance as a way to mimic real-life situations. Therapists also help with
exercises to improve coordination and assistive devices to help with safer walking. When the
balance problem is caused by a problem in one’s vestibular system, Physical therapists can
perform specific maneuvers that can quickly restore proper vestibular functioning, and reduce
and eliminate symptoms of dizziness or vertigo.
vii. Manage diabetes and vascular conditions: As part of an overall diabetes management plan,
exercise can help effectively control blood sugar. Additionally, people with diabetes may

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have problems with sensation in their feet and legs. Physical therapists can help provide and
educate these patients on proper foot care to prevent further problems down the road.
viii. Manage age-related issues: As individuals age, they may develop arthritis or osteoporosis
or need a joint replacement. Physical therapists are experts in helping patients recover from
joint replacement, and manage arthritic or osteoporotic conditions conservatively.
ix. Manage heart and lung disease: While patients may complete cardiac rehabilitation after a
heart attack or procedure, also may receive physical therapy if daily functioning is affected.
For pulmonary problems, physical therapy can improve quality of life through strengthening,
conditioning and breathing exercises, and help patient’s clear fluid in the lungs.
x. Manage Women’s Health and other conditions: Women have specific health concerns,
such as with pregnancy and post-partum care. Physical therapists can offer specialized
management of issues related to women’s health. Additionally, PT can provide specialized
treatment for: Bowel incontinence, breast cancer, constipation, fibromyalgia, lymphedema,
male pelvic health, pelvic pain, and urinary incontinence.
Occupational therapy:
Occupational therapy (OT) is the use of assessment and intervention to develop, recover, or
maintain the meaningful activities, or occupations, of individuals, groups, or
communities. Occupational therapy is a kind of treatment that helps people be independent in all
parts of their life.
Occupation includes all the activities or tasks that a person performs each day. For example, getting
dressed, playing a sport, taking a class, cooking a meal, getting together with friends, and working
at a job are considered occupations. It endeavors to provide a progressive programme of mental,
physical, and social activity according to the needs and capabilities of each patient. By
achievement confidence is restored and recovery and rehabilitation hastened.
Occupational therapy is used for people recovering from injuries or illness, as well as children and
adults with disabilities, and older people who are having age-related concerns.
Occupational therapy practitioners have a holistic perspective, in which the focus is on adapting
the environment and/or task to fit the person, and the person is an integral part of the therapy team.
It is an evidence-based practice deeply rooted in science.
Participation in occupations serves many purposes, from taking care of oneself and interacting
with others to earning a living, developing skills, and contributing to society.
Common occupational therapy interventions include helping children with disabilities to
participate fully in school and social situations, injury rehabilitation, and providing supports for
older adults experiencing physical and cognitive changes.

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Types of occupational therapy
Diversional or prophylactic occupational therapy aims at diverting attention from a physical or
nervous disability and directing interest towards some prescribed activity.
Remedial therapy has these attributes also, but in addition is directed towards the restoration of
a special function.
Specialties of Occupational Therapies
Because occupational therapy is used for people of all ages and circumstances, there are a large
number of specialties, some of which are listed below.
Acute medicine: Dealing with the provision of care for people with acute medical problems,
Occupational Therapists (OTs) play a vital role in today’s acute medical units and they work with
patients who experience difficulties in completing activities of daily living due to a wide range of
health problems such as heart or lung conditions.
Adult therapy: This branch of Occupational Therapy services focuses upon the care of adults and
covers a wide range of sub-specialities. They teach self-care skills including homemaking,
cooking, eating, dressing and grooming among other activities. Occupational therapy also aids in
emotional and social adjustment following injury or illness
Drug and alcohol: This category of OT deals with the treatment of people suffering from
substance abuse addiction via a myriad of techniques, including the development of specialist
strategies that can help with getting individuals focused upon making significant lifestyle changes.
Elderly: OTs specialising in providing care to elderly people help individuals to adapt to changes
in their life and improve their wellbeing through an on-going series of specialist techniques.
Geriatric occupational therapy is usually focused on the most basic Activities of Daily Living. As
people age, they may lose their ability to do everyday tasks that most of us take for granted.
Chewing and swallowing, bathing, toileting, getting in and out of bed, and controlling our bladder
and bowels may slowly become more and more difficult. OT can help older people stay
independent in their own home for longer. It can help them deal with Alzheimer's or dementia,
arthritis, or any of the other challenges older adults commonly face.
Mental health: Occupational therapy for mental health is a growing field. People with mental
disorders such as anxiety/panic attacks, depression, bipolar disorder, schizophrenia, and other
mental illnesses are sometimes referred to OT or take OT classes in a hospital setting. In their case,
OT can help them learn better self-care and prevent relapse of symptoms.
Oncology: This OT category has a significant role to play in the field of helping individuals to
overcome new challenges which may be faced when receiving cancer treatment.

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Orthopaedics: When recovering from orthopaedic surgery, many people benefit from the advice
and special care that comes from consulting with a specialist orthopaedic OT.
Paediatrics: Paediatric OT specialists play an important role when it comes to helping children to
develop essential life skills.
Rehab: This specialism relates to OTs to work with people who are recovering from the effects
of injury or illness: By employing a series of home and/or work-based strategies, the goal of this
type of treatment is to help an individual to take steps towards becoming fully rehabilitated.
Stroke: OTs dealing with this specialism work with people who have suffered a stroke; by
providing support and helpful advice, these OTs help individuals to make steps towards
rehabilitation.
Autism: Occupational therapy for autism is a specialty where therapists may work with children,
adolescents, and adults to help them overcome social and communication difficulties as well as
participate in their ADL. Sessions may take place in a school or daycare if the client is a child. For
adults with severe autism, the sessions may take place in an adult day care.
School Systems Specialty: In the OT field, a school systems specialist is just what it sounds like.
It's someone who works in schools, whether that's a preschool, elementary school, middle school,
or high school. They also help students who are making the transition to another school or from a
school to the workplace.
Environmental Modification: Occupational therapists who specialize in environmental
modification look at home, school, and/or workplace to determine if any modifications are needed
to support in living, studying, or working there.
Physical Rehabilitation: Occupational therapists who specialize in physical rehabilitation usually
work with clients who have been injured or are disabled. People who have been seriously injured
usually need occupational therapy for some time before they can resume their normal activities.
Driving and Community Mobility: For many people, driving is such a crucial skill that it's hard
to survive without it in some locations. A driving and community mobility occupational therapist
may teach disabled clients how to drive and/or use adaptive equipment.
Occupational Therapy Interventions
Within occupational therapy (OT), there are five primary intervention types:
1. Occupations and activities: In occupational therapy, occupations and activities
interventions refer to specific activities that can be done every day or have therapeutic
purposes. For example, someone recovering from a stroke needs assistance in how to take a
shower while using adaptive equipment.
2. Preparatory methods and tasks: Rather than going straight into a physical activity like
washing dishes, recommend a client use therapy putty to ensure adequate hand strength and

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flexibility. It helps to think of preparatory methods and tasks as ways to warm-up properly for
an activity or therapy and support progress they want to make on their goals.
3. Education and training: Education and training may involve not only clients, but also family
members, caregivers, and teachers. These interventions may include helping parents
understand how their child is using an adaptive tool, such as a weighted blanket, to feel
comfortable and secure. Understanding how to wash and dry the weighted blanket (which often
has special care instructions) as well as when to offer the child the blanket will increase the
effective use and function of the blanket. The OTA might provide this information in both one-
on-one or group settings.
4. Advocacy: Clients often need someone to support them in their goals. Advocacy on the part
of OTAs could range from personal encouragement to changes involving legislative or civic
action. OTAs may also assist clients with methods and behaviors to advocate for their own
needs.
5. Group intervention: Occupational therapy treatment sometimes involves participating
in group interventions. Identify appropriate, beneficial opportunities in the community or
elsewhere that will help keep the progress of clients moving forward.
General Responsibilities of the Rehabilitation Staff Nurse
 Possesses the specialized knowledge and clinical skills necessary to provide care for people
with physical disability and chronic illness
 Coordinates educational activities and uses appropriate resources to develop and implement an
individualized teaching and discharge plan with clients and their families
 Performs hands-on nursing care by utilizing the nursing process to achieve quality outcomes
for clients
 Provides direction and supervision of ancillary nursing personnel, demonstrates professional
judgment, uses problem solving techniques and time-management principles, and delegates
appropriately
 Coordinates nursing care activities in collaboration with other members of the interdisciplinary
rehabilitation team to facilitate achievement of overall goals
 Coordinates a holistic approach to meeting patient's medical, vocational, educational, and
environmental needs
 Demonstrates effective oral and written communication skills to develop a rapport with clients,
their families, and health team members and to ensure the fulfilment of requirements for legal
documentation and reimbursement
 Acts as a resource and a role model for nursing staff and students and participates in activities
such as nursing committees and professional organizations that promote the improvement of
nursing care and the advancement of professional rehabilitation nursing
 Encourages others to obtain advance degrees, participate on committees, and/or join
professional organizations
 Facilitates community education regarding acceptance of people with disabilities
 Actively engages in legislative Initiatives affecting the practice of rehabilitation nursing or the
people in their care
 Applies nursing research to clinical practice and participates in nursing research studies

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16. Exercise and Walking Aids
Exercise:
Definition: Exercise is a physical activity that is planned, structured, and repetitive for the purpose
of conditioning the body. Physical exercise is any bodily activity that enhances or
maintains physical fitness and overall health and wellness.
Purpose:
– Maintain normal joint movement
– Increase muscle flexibility and strength
– Maintain weight to reduce pressure on joints
– Keep bone and cartilage tissue strong and healthy
– Improve endurance and cardiovascular fitness
– Improve coordination
– Improve self-esteem and self-confidence
– Decrease the risk of developing certain diseases like diabetes and hypertension
Types of exercises
– Aerobic exercise
– Strengthening
– Flexibility
Aerobic exercise: This is any activity that uses oxygen, raises heart rate and makes one slightly
breathless. Not only does it keep the heart, lungs and muscles healthy, it also improves the fitness
levels. Examples:
– Walking
– Cycling
– Swimming exercises
– Running
– Team sports
Aim to do aerobic exercise at a moderate intensity for 150 minutes (two and a half hours) a week
in bouts of 10 minutes or more.
Strength (resistance) exercise:
– Strength training involves moving the muscles against some kind of resistance.
– One can use rubber bands, free weights (such as dumb-bells), weight-lifting machines or

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simply one’s own body weight.
– Strength training is advised to be done two or three times a week, working on all the major
muscle groups in the body.
– One has to first identify the right level at which s/he can do a set of eight to 12 repetitions
of an exercise, rather than going for heavy lifts.
Flexibility exercise
– Exercise that stretch all the major muscles in the upper and lower body
– Yoga, Pilates and tai-chi include many exercises that focus on suppleness and flexibility.
– This includes gently easing and stretching the body into different positions, and then
holding these while concentrating on breathing.
– These exercises not only help to increase flexibility and strength of the muscles, but also
help to relax, and improve the circulation, balance and posture.
Isotonic vs. Isometric contraction:
Exercises with movement involve isotonic muscle contractions and exercises without movement
involve isometric muscular contractions.
Isotonic Contractions:
– An isotonic contraction is any contraction is which a muscle shortens to overcome resistance,
causing joint movement
– An isotonic contraction involves two phases. The concentric phase occurs when muscle is
shortened in an upward movement. The eccentric phase occurs when the muscle is
lengthened in a downward movement.
Examples: Most gym exercises are isotonic exercises. Simple exercises such as push-ups, squats,
lunges and sit-ups are all isotonic. Any weight machine that involves movement is also isotonic,
such as lat pull-downs, chest presses and leg extensions.
Isometric Contractions:
– An isometric contraction occurs when the muscles push against a fixed resistance and no joint
or body movement occurs.
– Even though there is no movement, the muscles are still working and contracting. Isometric
contractions can significantly increase blood pressure.
Examples:
– Isometric exercises can be done in two different ways: By trying to move something that is too
heavy for one to move or by holding static exercise poses.
– Rather than counting repetitions, isometric exercises involve holding the position for a given
amount of time, such as 30 seconds.

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Range of motion exercise:
– Range-of-motion is the phrase used to describe how much a joint can move. Normal range-
of-motion varies from joint to joint.
– All exercises should be done on both sides of the body if possible.
Purpose of ROM exercises:
– To assist client in recovering or increasing a full range of motion in bending joints
– Help to decrease pain, strengthen the muscles surrounding the joint, and enable to work out
or do daily tasks with minimal discomfort.
Exercise Tips
– Dress comfortably. The clothes should not limit the movements.
– Move slowly through all the movements.
– Do not hold the breath while doing any of these exercises. Breathe deeply. Count out loud
during the exercises to keep the breaths evenly paced and remind one to breathe.
– Do the exercises lying in bed or sitting up straight in a chair. One can also try to do them
while standing or sitting at the edge of the bed but make sure another adult is around. This
will help to make sure of safety and reduce risk of falling.
– Stop any exercise that causes pain or discomfort and tell the physical therapist. Continue to
do the other exercises.
Types of ROM exercises:
– Active ROM exercises
– Active-assisted ROM exercises
– Passive ROM exercises
General instructions:
– Ideally, these exercises should be done once per day.
– Do each exercise 10 times or move to the point of resistance and hold for 30 seconds.
– Begin exercises slowly, doing each exercise a few times only and gradually build up to
more.
– Try to achieve full range of motion by moving until you feel a slight stretch, but don't force
a movement.
– Move only to the point of resistance. Do not force the movement.
– Keep limbs supported throughout motion.
– Move slowly, watching the patient's face for response to ROM.

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Passive ROM:
– Passive range of motion exercises help keep a person's joints flexible, even if he cannot
move by himself.
– Range of motion is how far the person's joints can be moved in different directions. The
exercises help to move all the person's joints through their full range of motion.
Neck exercise:
– Head turns
– Head tilts
– Chin-to-chest
– Neck Rotation
– Neck Flexion
Upper Extremity Passive ROM Exercises:
Shoulder and elbow exercises:
– Shoulder Flexion and Extension
– Shoulder Internal and External Rotation
– Horizontal Shoulder Abduction
– Elbow Flexion and Extension
– Wrist Flexion and Extension
Palm up, palm down and Wrist rotation
Finger exercises
– Finger bends
– Finger spreads
– Finger-to-thumb touches
– Finger rotations
– Thumb Flexion and Extension
Lower Extremity Passive ROM Exercises
Hip and knee exercises
– Hip and Knee Flexion
– Hip Rotation
– Hip Abduction
Ankle and foot exercises
– Ankle bends
– Ankle movement, side to side

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– Toe spreads
– Ankle rotation
– Toe bends
Heel-cord stretching
Lumbar rotation
Strengthening Exercises
Gastrocnemius and Soleus Muscles: Stretch and Strengthen
– Step 1: start with both legs on a step with your legs bent go all the way up on to your tip toes
and then all the way down into a minor stretch, go slowly and repeat 25 x with your knees
straight then 25 times with your knees bent
– Step 2: same but one leg only on ten step. So standing with one leg on the step and a straight
knee, go up and down 10x then bend your knee and go up and down 10 more times. Switch
legs ad repeat.
– once you are strong build up to 25x per leg. 25x with straight knees, 25x with bent knees.
Therefore, you will be doing 100 calf raises, to strengthen both gastrocnemius and soleus.
every second day.
Quadriceps Strengthening Exercises
– The following quadriceps strengthening exercises are designed to improve strength of the
quadriceps muscle. The quadriceps comprises of four muscle bellies (Vastus Medialis, Vastus
Intermedius, Vastus Lateralis, Rectus Femori).
– Static Inner Quadriceps Contraction: Tighten the muscle at the front of your thigh
(quadriceps) by pushing your knee down into a towel. Put your fingers on your inner
quadriceps (VMO) to feel the muscle tighten during contraction. Hold for 5 seconds and
repeat 10 times as hard as possible pain free.
– Quadriceps over Fulcrum: Begin this exercise lying on your back with a rolled towel or
foam roll under your knee and your knee relaxed. Slowly straighten your knee as far as
possible tightening the front of your thigh (quadriceps). Hold for 5 seconds then slowly lower
back down. Repeat 10 times as hard as possible pain free.
Hamstring Stretch: Assisted range of motion exercise
– It refers to a therapist or doctor manually helping a patient move a particular body part along
a joint.
– The patient exerts a small amount of effort during this movement.

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– This type of therapeutic exercise is beneficial for the treatment of many joint injuries, and is
best completed under the supervision of a medical professional or physical therapist.
Examples:
– Neck exercise
– Shoulder Flexion
– Knee exercise
Active Range-of-Motion Exercises
– If the patient performs the exercise himself, rather than having an assistant do it, it is called
active range-of-motion exercise.
– In cases of rehabilitation, the exercises may start as passive, but become active as the patient
develops increased muscle tone and begins to move the joints himself.
– Exercise the joints in sequence, beginning with the neck, and moving down the body. Each
joint should be exercised at least three times, and five times if possible. When the patient
starts to get tired, stop the exercises.
Exercises for spine
Lumbar extension exercise
– Prone extension (positioned)
– Prone extension on elbows
– Prone press-ups
– Standing extension
– Sideglide in standing
– Bridging
Lumbar flexion exercise
– Posterior pelvic tilt
– Single knee to chest stretch
– Double knee to chest stretch
– Lumbar flexion with rotation
Seated lumbar flexion
– Partial sit-up
– Partial diagonal sit-up

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Assistive devices:
Definition: Any device that is designed, made, or adapted to assist a person perform a particular
task. Examples:
– Parallel bar
– Walker (zimmer frame)
– Rollator
– Axillary crutch
– Elbow crutch
– Stick
– Wheel chairs
Walking with assistive devices (Crutches, Canes, and Walkers)
General Guidelines
– Remove anything else that may cause you to fall.
– In the bathroom, use nonslip bath mats, grab bars, a raised toilet seat
– Simplify household to keep the items you need handy and everything else out of the way.
– Walk at a safe, comfortable pace.
– Be careful when walking on uneven or wet surfaces.
– Maintain good posture when walking.
– Wear shoes that fit well, support your feet, and are comfortable.
– Check balance before you go on
Crutch Basics
Moving around with crutches:
– Place the crutches under the arms. Squeeze them to the sides of the body.
– Let the hands carry body weight, not the armpits.
– Look forward when walking, not down at the feet.
– Use a chair with armrests to make sitting and standing easier.
– The top should be 1 to 1 1/2 inches below your armpit while standing up straight.
– The handgrips of the crutches should be even with the top of your hip line.
– Elbows should be slightly bent when holding the handles.
– Keep the tips of the crutches about 3 inches away from feet
– Move the crutches 6 to 12 inches ahead.
– Do not hang or lean on the crutches. Support all the weight on the hands, not under arms
– Rest the crutches upside down when you are not using them so that they do not fall down.

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To sit down:
– Back up to a chair, bed, or toilet until the seat touches the back of legs.
– Move weak leg forward, and balance on strong leg.
– Hold both crutches in then hand on the same side as the weak leg.
– Using the free hand, grab the armrest, the seat of the chair, or the bed or toilet.
– Slowly sit down. Lean the crutches upside down in a handy location.
To stand up:
– Move to the front of the seat and move the weak leg forward.
– Hold both crutches in the hand on the same side as the weak leg.
– Use the free hand to help you push up from seat to stand up.
– Balance on the strong leg while placing a crutch in each hand.
Stairs:
– Avoid stairs until one are ready to use them. At first, be sure to practice them with help from
someone to support.
– Use 1 crutch and the stair rail if present (only if the railing is stable and there is someone to
carry the other crutch). Use 2 crutches if there is no stair rail.
– It does not matter which side the stair rail is on.
– If both crutches can be held in 1 hand safely, one can use both crutches on 1 side and the
railing on the other.
Up stairs:
– Walk close to the first stair and hold onto the stair rail.
– Hold onto the rail with 1 hand and the crutch with the other hand.
– Push down on the stair rail and the crutch and step up with the "good" leg.
– If not allowed to place weight on the "bad" leg, hop up with the "good" leg.
– Bring the "bad" leg and the crutches up beside the "good" leg.
– Remember, the "good" leg goes up first and the crutches move with the "bad" leg.
Down stairs:
– Walk to the edge of the stairs in the same way.
– Place the "bad" leg and the crutches down on the step below; support weight by leaning on
the crutches and the stair rail.
– Bring the "good" leg down.
– Remember the "bad" leg goes down first and the crutches move with the "bad" leg.
Canes: Proper Positioning
The top of the cane should reach to the crease in your wrist when you stand up straight. The elbow
should bend a bit when you hold the cane. Hold the cane in the hand opposite the side that needs
support.

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Walking: When walking, the cane and injured leg swing and strike the ground at the same time.
To start, position the cane about one small stride ahead and step off on the injured leg. Finish the
step with the normal leg.
Stairs: To climb stairs, grasp the handrail (if possible) and step up on good leg first, with cane in
the hand opposite the injured leg. Then step up on the injured leg. To come down stairs, put the
cane on the step first, then injured leg, and finally the good leg, which carries body weight.
Walkers
Helps with balance and walking
– Allows one keep all or some of the weight off of lower body as one takes steps
Walking
– First, put walker about one step ahead, making sure the legs of the walker are level to the
ground.
– With both hands, grip the top of the walker for support and walk into it, stepping off on
injured leg.
– Touch the heel of this foot to the ground first, then flatten the foot and finally lift the toes
off the ground as you complete the step with your good leg.
– Don't step all the way to the front bar of the walker. Take small steps when turning.
Sitting: To sit, back up until legs touch the chair. Reach back to feel the seat before sitting. To get
up from a chair, push oneself up and grasp the walker's grips. Make sure the rubber tips on your
walker's legs stay in good shape.
Stairs: Never try to climb stairs or use an escalator with your walker.
Gait: It is the manner or style of walking. There are six different way to use crutches to assist
with ambulation, or walking.
 Four-Point Crutch Gait
Indication: Weakness in both legs or poor coordination.
 Pattern Sequence: Crutch opposite to affected leg, affected leg, contralateral crutch, sound
leg. Then repeat.
Advantages: Provides excellent stability as there are always three points in contact with the
ground
Disadvantages: Slow walking speed

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 Three-point crutch gait
Indication: Inability to bear weight on one leg. (fractures, pain, amputations)
 Pattern Sequence:
First move both crutches and the weaker lower limb forward. Then bear all your weight
down through the crutches, and move the stronger or unaffected lower limb forward. Repeat.
Advantages: Eliminates all weight bearing on the affected leg.
Disadvantages: Good balance is required.
 Two-point crutch gait
Indication: Weakness in both legs or poor coordination.
 Pattern Sequence:
Affected leg and opposite crutch at the same level then opposite crutch and sound leg.
Repeat.
Advantages: Faster than the four-point gait
Disadvantages: Can be difficult to learn the pattern.
Swing To:
– Start in a balanced standing (tripod) position.
– Squeeze the pads against the sides of your chest.
– The tips should be wide enough apart for you to move easily between them.
– Support your weight on your hands.
– Press down on the handgrips.
– Lift your unaffected foot and swing your body up to the crutches.
– Land on your unaffected foot, between your crutches.
– Keep the unaffected knee slightly bent.
– Reach forward and out with the crutches to begin the next step.
Indications: Patients with weakness of both lower extremities.
Pattern Sequence: Advance both crutches forward then, while bearing all weight down through
both crutches, swing both legs forward at the same time to (not past) the crutches.
Advantage: Easy to learn.
Disadvantage: Requires good upper extremity strength.

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Swing Through
– Start in a balanced standing (tripod) position.
– Squeeze the pads against the sides of your chest.
– The tips should be wide enough apart for you to move easily between them.
– Support your weight on your hands.
– Press down on the handgrips.
– Lift your unaffected foot and swing your body through the crutches.
– Land on your unaffected foot, about 12 inches in front of the crutches.
– Keep the unaffected knee slightly bent.
Indications: Inability to fully bear weight on both legs. (fractures, pain, amputations)
Pattern Sequence: Advance both crutches forward then, while bearing all weight down through
both crutches, swing both legs forward at the same time past the crutches.
Advantage: Fastest gait pattern of all six.
Disadvantage: Energy consuming and requires good upper extremity strength.
Non-Weight-Bearing
Using Crutches
– A healthy leg can bear body weight.
– The “swing to” gait is easy to learn and takes less arm strength and balance.
– The “swing through” gait takes more practice, but it moves one farther with each step and
is less tiring in the long run. Start with “swing to,” and progress to “swing through” when
instructed
Using walker
– For this method, do not let your injured or weak leg touch the floor when standing or
walking. When using the walker, hold your injured or weak leg up off the floor.
– Move your walker out in front of you. Be sure all 4 legs of your walker are flat on the floor.
– While pushing down on your walker with your arms, hop on your good foot to the center of
your walker.
Partial weight bearing
Using crutches
– Put the crutches forward about 1 step's length.
– Put the "bad" leg forward, level with the crutch tips.
– Take most of the weight by pushing down on the handgrips, squeezing the top of the
crutches between the chest and arm.

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– Take a step with the "good" leg.
– Make steps of equal length.
Step to
– Lift your unaffected foot and step to the crutches.
– Land on your unaffected foot, between your crutches.
– Keep the knee slightly bent.
Step through
– Lift the unaffected foot.
– Step forward through the crutches.
– Land on the unaffected foot, with the heel slightly in front of the toe of the other foot.
– Keep the knee slightly bent.
Using a Walker
– For this method, you will be told how much weight you can put on the injured or weak leg.
– Move your walker out in front of you about an arm’s length. Be sure all 4 legs of the
walker are flat on the floor.
– Step your injured or weak leg into the walker, only putting the allowed weight on that leg.
– While pushing down on your walker with your arms to keep some weight off of your leg,
step your good leg forward into the center of the walker.
Weight Bearing as Tolerated
For this method, put as much weight on the injured or weak leg as you are able to without much
pain. The walker helps give you some support and balance.
– Two-point gait
– Four-point gait
Moving a patient from bed to a wheelchair
– Explain the steps to the patient.
– Place the wheelchair on the same side as the patient's good leg.
– Park the wheelchair next to the bed, close to you.
– Put the brakes on and move the footrests out of the way.

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Getting a Patient Ready to Transfer
– Before transferring into the wheelchair, the patient must be sitting.
– To get the patient into a seated position, roll the patient onto the same side as the
wheelchair.
– Allow the patient to sit for a few moments, in case the patient feels dizzy when first sitting
up.
– Put one of your arms under the patient's shoulders and one behind the knees. Bend your
knees.
– Swing the patient's feet off the edge of the bed and use the momentum to help the patient
into a sitting position.
– Move the patient to the edge of the bed and lower the bed so the patient's feet are touching
the ground.
Moving a person from wheelchair to bed:
Steps for transferring from Wheelchair to Bed:
– Have the bed at the lowest level.
– Park the wheelchair with the person’s strongest side next to the bed.
– Lock the wheelchair brakes and remove feet from foot rests.
– Swing or remove foot rests from wheelchair.
– Explain the sequence of lifting and pivoting into the wheelchair (example: on the count of
3, I am going to help you stand up and turn to your strong side; eg right side as in above
example; and sit in the wheelchair).
– Using the bear hug technique, ask the person to place his/her arms on your shoulders as you
place your arms around his/her trunk.
– Bracket their feet with your feet to prevent slipping.
– Using your leg muscles, stand up and bring the person upward in a slow steady rising
motion.
– Seat the person on the bed
– Assist in bring the person’s legs up onto the bed.
– Position for comfort.

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17. Low Back Pain (LBP)
Introduction: Lower back pain is characterized by pain in the lumbosacral area associated with
severe spasm of the paraspinal muscles. Low back pain is pain, muscle tension, or stiffness
localized below the costal margin and above the inferior gluteal folds. Low back pain is a common
problem because the lumbar region:
 Bears most of the weight of the body
 Is the most flexible region of the spinal column
 Contains nerve roots that are vulnerable to injury or disease
 Has an inherently poor biomechanical structure
Epidemiology: Lower back pain impacts an estimated 540 million people across the globe. About
40% of people have LBP at some point in their lives, with estimates as high as 80% among people
in the developed world. Low back pain is more common among people aged between 40 and 80
years, with the overall number of individuals affected expected to increase as the population ages.
The prevalence of back pain was respectively 64.8%, 19.8%, 69.5%, 40.6% and 36.2% in
Bangladesh, India, Nepal, Pakistan and Sri Lanka. (Bishwajit, Tang, Yaya, & Feng, 2017)
Risk Factors
• Age: Posture and gait changes as person ages. low back pain typically begins at 30th
decade of life.
Back pain is uncommon in children, but if present, it is often due to some organic disease. In
adolescents, postural and traumatic back pain are common. In adults, ankylosing spondylitis and
disc prolapse are common. In elderly persons, degenerative arthritis, osteoporosis and metastatic
bone disease are usually the cause.
• Sex: Women typically have a smaller Sacroiliac (SI) joint surface area compared to men, resulting in a
higher concentration of stresses across the joint. The sacrum is also wider, more uneven, less curved,
and tilted more backward in women, which may cause problems in the SI joint. Moreover, pregnancy,
taking care of child, double work-paid, degeneration of bone after menopause, poor health condition
(vit D deficiency) also accounts for LBP.
• Poor posture: slouching in chair, sticking your bottom out (hyperlordosis/Donald duck posture),
standing with a flat back, leaning on one leg, hunched back and text neck, poking your chin,
rounded shoulder, cradling your phone.
• Nicotine use: nicotine kills the cells that grows bone
• Stress: stress causes straining on neck and mid-back.
• Excess body weight: the excess weight pulls the pelvis forward and strains the lower back.
• Prolonged period of sitting/ Sedentary lifestyles

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• Occupational factors: Jobs that require repetitive heavy lifting (lead to muscle sprain); vibration
(fatigue of spinal stabilizing muscle)
Causes of Low Back Pain: The specific etiology of most back pains is not clear. Postural and
traumatic back pains are among the commonest. Common causes are:
1. Mechanical (80%):
a. Congenital
 Spina bifida
 Lumbar scoliosis
 Spondylolysis (may be traumatic: stress fracture in the vertebral arch)
 Spondylolisthesis (may be traumatic: the displacement of one spinal vertebra compared to
another)
 Transitional vertebra
 Facet tropism
b. Degenerative
 Osteoarthritis: type of joint disease that results from breakdown of joint cartilage and
underlying bone.
c. Metabolic
 Osteoporosis: medical condition in which the bones become brittle and fragile from loss of
tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D.
 Osteomalacia: Osteomalacia is a disease characterized by the softening of the bones caused
by impaired bone metabolism primarily due to inadequate levels
of available phosphate, calcium, and vitamin D, or because of resorption of calcium. The
impairment of bone metabolism causes inadequate bone mineralization
d. Traumatic
 Vertebral fractures
 Prolapsed disc
 Sacroiliac joint pathology, injury to psoas muscle
2. Neurogenic (15%)
 Herniated disc
 Spinal stenosis
 Foraminal stenosis
 Disc anular tear and neuritis
3. Non- mechanical (1-2%)
a. Inflammatory
 Tuberculosis
 Ankylosing spondylitis
 Sacroiliitis
b.Neoplastic

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 Benign
 osteoid osteoma: benign bone tumor that arises from osteoblasts and some components of
osteoclasts. The tumor can be in any bone in the body but are most common in long bones
 Eosinophilic granuloma: a rare, benign tumor like disorder characterized by clonal
proliferation of antigen-presenting mononuclear cells of dendritic origin known as
Langerhans cells
 Malignant
 Primary: multiple myeloma (Multiple myeloma is a cancer that forms in a type of white blood
cell called a plasma cell. Multiple myeloma causes cancer cells to accumulate in the bone
marrow, where they crowd out healthy blood cells. Rather than produce helpful antibodies, the
cancer cells produce abnormal proteins that can cause complications); lymphoma (a group
of blood malignancies that develop from lymphocytes)
 secondary from other sites
4. Pain referred from viscera (1-2%)
 Genitourinary diseases: UTI, renal calculi
 Gynecological diseases: endometriosis, uterine fibroid
5. Vascular disease: Vascular causes of low back pain are often due to arterial occlusive disease
which causes ischemia, discomfort, pain, and other symptoms depending on the location of the
pathology (arterial obstruction)
6. Miscellaneous causes (2-4%)
 Functional back pain: Functional back pain is a term that is often used to describe back
pain without a clearly identifiable surgical cause and may account for up to half of
all cases and many of the cases of surgical failure.
 Postural back pain
 Somatization disorder
Pathophysiology of LBP

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Types of Low Back Pain:
Acute and subacute low back pain:
 Acute low back pain lasts less than 6 weeks and subacute 6-12 weeks.
 It is usually associated with some type of activity that causes undue stress on the tissues of the
lower back.
Chronic low back pain:
 Chronic low back pain lasts more than more than 12 weeks
 The causes of chronic low back pain include degenerative disc disease, lack of physical
exercise, prior injury, obesity, structural and postural abnormalities and systemic disease.
 Mechanical pain is aggravated with movement and relieved by rest. Pain is described as dull,
aching and similar to toothache.
 Patients may complain of symptoms on standing up from supine or seated positions, and pain
on turning over in bed.
 An acute flare-up of pain often occurs on a background of chronic back pain and an increase
in frequency may interfere with activities of daily living (ADLs)
 It is usually not possible to clinically distinguish the source of pain between the disc, facet
joints, muscles, ligaments and the sacroiliac joints. However, pain on flexion may be related
to discogenic pain and facetogenic pain may be aggravated by hyperextension.
 Patients with pain radiating down to the buttocks and posterior thigh may have neurogenic pain
 Poor walking distance is a typical feature
 Stenotic symptoms are typically relieved by flexion (‘shopping-cart sign’ in spinal stenosis)
 Muscle spasm, local tenderness, stiffness and restriction of back movements
 Radiculopathy: when a herniated disc pushes on a nerve a variety of symptoms can occur eg:
sciatica. Pain, aching, numbness and/or tingling can occur in the leg on the side of disc
herniation. Symptoms can worsen with the straightening the leg, coughing, sneezing. Leg pain
is greater than back pain, bulge or arthritis.
 Claudication: It occurs when the whole lumbar canal is significantly narrowed due to disc
herniation. Aching, paresthesia (pins and needles, tingling), numbness or weakness in both
legs. Symptoms are worse while walking and improve with bending forward.Leg symptoms
are classically worse than back pain.
 Cauda equina syndrome: severly compressed nerves from a large acute disc herniation. Pain
radiates down the leg, numbness around the anus, and loss of bowel or bladder control.
 Vascular-induced back pain:
 throbbing pain

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 diminished or absent pulses;
 Patient may present with trophic changes (such as changes in skin color, texture,
or temperature)
 Activity (usually walking) brings on symptoms (within 1-5 minutes)
 Pain is present in all spinal positions
Diagnostic Evaluation: In evaluating patient with low back pain should remember:
 Determine that the pain is intrinsic to the back and not referred (Referred pain is pain
perceived at a location other than the site of the painful stimulus/ origin. It is the result of
a network of interconnecting sensory nerves, that supplies many different tissues.) from
problem elsewhere.
 Rule out progressive and life-threatening disease
 Determine whether nerve root compromise is present or not
1. History Taking
Personal data:
 Age
 Sex
 Past history
 Medical and surgical history: trauma, back pain, malignancy, disc prolapse surgery,
obstetric disease, genitourinary diseases
 Medication: corticosteroids, immunosuppresants
 Family history: cancers, back pain, spondylarthropathies
 Social history: current stresses, occupation (activity level, job tasks), perception of the pain,
impact of life
 Personal habits: nicotine use
Present complaint
 Onset and how it starts: acute or chronic
 Nature: mechanical vs non-mechanical; reffered vs radicular; vascular vs spinal
 Character: sharp, dull, throbbing
 Location and radiation: buttocks, below the knee
 Duration: acute, subacute, chronic
 Associated symptoms
 Aggravating factors: sitting, walking, flexion or extension of spine
 Relieving factors: pharmacologic, non-pharmacologic

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2. Physical Examination
 General appearance: Posture; sitting, standing or leaning on something; walking;
comfortable or not
 Vital signs: Fever
 Back examination:
 Look: From side: spine curvature, from behind: swelling, erythema
 Feel:
 The spinous processes of each vertebra: tenderness due to fracture, dislocation, infection
 Any step-offs: In spondylolisthesis which may compress the spinal cord
 Muscle spasm or tenderness: degenerative or inflammatory process, prolong contraction
from abnormal posture or anxiety
 Sacroiliac joint: sacroilitis
 Move: Flexion, extension, rotation, lateral bending
 Special tests:
 modified-schober’s test: positive in ankylosing spondylitis
 straight leg raising test: positive indicates lumbar nerve root compromise
 crossed straight leg raising test
 Examination of limbs for lumbar nerve root compromise
 Motor power
 Deep tendon reflexes
 Sensation
 Screening examination includes squat and rise, heel walking, walking on toes
 Special Tests
 Modified Schober’s Test
 Patient is standing with leg apart(30cm), examiner marks both posterior superior iliac
spine (PSIS) and then draws a horizontal line at the centre of both marks
 A second line is marked 5 cm below the first line.
 A third line is marked 10 cm above the first line. Total distance between top to bottom
mark is 15.
 Patient is then instructed to flex forward as if attempting to touch his/her toes,
examiner re-measures distance between the top and bottom line and difference in
distance between two readings is noted.
 Differences of less than 5cm is a positive test and may indicate ankylosing spondylitis

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Abdominal Aortic Aneurysm(AAA): type of visceral disease that may cause low back pain is
an abdominal aortic aneurysm (AAA), which is an abnormal dilation in a weakened or
diseased arterial wall.
3. Investigations
a) Radiological imaging
 X-ray:
 AP and lateral view of lumbosacrel spine and AP of pelvis should be done in all cases
which provides baseline.
 It is used if the pain is associated with red flag signs.
 There is no use getting X-rays done in acute back pain less than 3 weeks duration, as it
does not affect the treatment. On the contrary, X-ray examination is a must for back pain
lasting more than 3 weeks.
 These are useful in diagnosing metabolic, inflammatory, neoplastic conditions, trauma,
fractures, dislocation, curvatures, degenerative changes
 MRI:
 Provide more detailed image of soft tissue(disc and nerve roots).
 If red flags are present, MRI should be undertaken even if X-ray is normal.
 MRI is prefferable to CT scanning when neurological signs and symptoms are present.
 Use to identify infections, spinal tumours, spinal stenosis, disc bulge,cauda equina.
 CT: Most of boney spinal pathology like trauma, infections, tumors,osteomylitis and cases
where MRI is contraindicated (eg: pacemaker)
 Discography: It uses imaging guidance to direct an injection of contrast material into the
center of one or more spinal discs to help identify the source of back pain.
 Facetography: it is also contrast radiography to diagnose small facet joints.
b) Radionuclide bone scan:
 A radionuclide bone scan is a nuclear imaging technique that uses a very small amount of
radioactive material, which is injected into the patient's bloodstream to be detected by a
scanner. This test shows blood flow to the bone and cell activity within the bone
 Useful when radiographs of the spine are normal but clinical findings are suspected.
 More sensitive than radiography in detecting metastasis, inflammatory codition, paget’s
disease, trauma, tumours
c) Electromyography: the recording of the electrical activity of muscle tissue and functioning of
nerves in the limbs, or its representation as a visual display or audible signal, using electrodes
attached to the skin or inserted into the muscle. If nerve root compression is a possibility,
electromyography (EMG) may be appropriate.

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d) Blood investigations
 Carried out especially for non- mechanical cause like malignancies, metabolic disorders,
infections and red flag signs.
 Full Blood Count(FBC), ESR/CRP,
Management
Symptomatic treatment that aims to
 Relieve pain
 Improve quality of life
 Treat underlying cause
Conservative Management
 Rest: 70% of acute back pains recover with rest in acute phase. Absolute bed rest on a hard
bed is advised. Bed rest for more than 2-3weeks is of no use rather a gradual mobilization
using aids like brace is preferred (reduce chance of chronic pain).
 Drugs:
Analgesics Acetaminophen: PO 352-650 mg every 4-6 hours
Max. 4g per day
NSAIDs Ibuprofen: Adult: PO 200-400mg q4-6hour; max
3.2g/day
Non benzodiazipine muscle
relaxants
Cyclobenzaprine: Ext.rel. PO15 mg orally once a
day
Tricyclic antidepressants for
chronic LBP
Amitriptyline : 25-50 mg PO qHS
anticonvulsant tends to be
used in radiculopathy
Gabapentin: 600 mg orally once daily
 Physiotherapy: it’s important to consult a physical therapist prior to starting a new
exercise program
 Heat therapy (hot packs, short wave diathermy, ultrasonic wave etc.).
 Spinal manipulation: Spinal manipulation is the application of a force (a quick, shallow
thrust) to spinal joints that moves the target joint or nearby joints slightly beyond their
normal range of movement. It is often accompanied by an audible "pop" believed to be
dissolved gas released from joint fluids by a quick drop in pressure. This gas suddenly joins
into small bubbles, making a popping sound however it is not always necessary to hear.
 Exercices: It includes stretching lower back muscles, abdominal muscles, hips, and legs. The
patient should never bounce during stretching, and all stretches should be slow and gradual.
Exercises such as:

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 In long term, weight control and strengthening vertebral, abdominal and limbs may prevent
recurrences.
 Traction: It is given to a patient with back pain with a lot of muscle spasm. Also sometimes
help in ‘forcing’ the patient to rest in the bed.
 Spinal support: Use of corset as a temporary measure in treating acute back pain however
a simple corset may provide symptomatic relief in some patients but in general they have
no proven benefit and are costly.
 Activity modification: One of the most important aspects of treatment is modification of
daily activities (bending, lifting, climbing, etc.) and specific activities relating to work.
 Psychological support: Chronic back pain can be psychologically as well as physically
debilitating. Counselling and support are often welcomed by the patient. Perhaps the most
successful treatment is the reassurance that the surgeon can provide for the vast majority
of patients, to the effect that the patient has no serious spinal disease.
 Complementary and alternative medicine: acupuncture, massage therapy
Surgical Management
Surgeries include: Person who do not respond to conservative therapy
1. Lumbar discectomy:
 Removal of disc material when there is disc bulge or herniation.
 Immediate/urgent surgery: Discitis, cauda equina syndrome, severe muscle weakness
innervated by compressed nerves are immediate indications
 Elective surgery: if no urgent indications for surgery are present, surgery is considered for
radicular pain that has failed conservative treatment for approximately 6 weeks.
 Discectomy invoves:
 Open discectomy
 Microscope assisted discectomy
 Less invasive tube assisted discectomy/ endoscopy assisted discectomy
2. Fusion surgery: it takes more time to do and longer to recover than a disectomy because
screws and rods are placed to stabilize the spine while the bone grafts fuse and hence fusion of
lumbar vertebrae. Fusion is done for
 Sign of instability
 If removing the bone and disc for conditions such as radiculopathy, claudication is
large enough such that spine is likely to become unstable
 Spine is stable but there is larger amount of low back pain that has failed extensive
conservative therapy for several months.

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 Pain in this case is largely in the low back versus legs.
 Fusion involves either anterior body fusion or posterior body fusion
3. Use of disc implants
 Firstly, the overall success rates for spinal fusion range from 48% to 89%.
 Second, a spinal fusion at one or more levels causes stiffness and decreased motion of
the spine.
 Third, spinal fusion at one or more levels increases stress to the rest of the spine. This
transferred stress may cause new problems to develop at the other levels, which may
lead to additional back surgery. Clearly, an alternative treatment option is needed.
 Types of disc implants:
 Composite: This device is made of a polyethylene spacer and two separate
metal endplates
 Hydraulic: gel-like core covered with a tightly woven polyethylene "jacket"
 Elastic: made of a rubber core bonded to two titanium endplates
 Mechanical: Several pivot or ball type artificial discs have been developed for
the lumbar spine
4. Lumbar Laminectomy: removal of lamina for nerve decompression
Rehabilitation
 Diet and healthy personal habits
 Exercises for strength and flexibility
 Weight control management
 Behavioral relaxation techniques
 Appropriate use of body mechanics
Complications
 Chronic pain
 Spinal instability, infection, sensory and motor deficits
 Cauda equina syndrome.
 Malingering and other psychosocial reactions
 Depression

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Nursing Diagnosis and Nursing Interventions:
1. Acute or Chronic Pain related to injury, muscle spasm
 Assessment of pain to include location, characteristics, onset/duration, frequency, quality,
intensity or severity of pain and precipitating factors
 Promote adequate rest/sleep to facilitate pain relief and to reduce paravertebral muscle
spasm
 Teach the use of non-pharmacologic techniques (e.g., relaxation, distraction, hot/cold
application, and massage)
 Keep pillow between flexed knees while in side-lying position to minimize strain on back
muscles.
 Administer or teach self-administration of pain medications and muscle relaxants, as
prescribed.
2. Imbalanced nutrition: more than body requirements related to obesity
 Weight reduction through diet modification may prevent recurrence of back pain. Weight
reduction is based on a sound nutritional plan that includes a change in eating habits to
maintain desirable weight.
 Monitoring weight reduction, noting achievement, and providing encouragement and
positive reinforcement facilitate adherence
3. Impaired Physical Mobility related to pain as evidenced by limited range of motion,
movement restrictions, muscle spasms.
 Determine limitations of joint movement and effect on function
 Encourage active ROM exercises of all uninvolved muscle groups
 Suggest gradual increase of activities and alternating activities with rest in semi-Fowler's
position
 Avoid prolonged periods of sitting, standing, or lying down
 Encourage patient to discuss problems that may be contributing to backache.
 Encourage patient to do prescribed back exercises. Exercise keeps postural muscles strong,
helps recondition the back and abdominal musculature, and serves as an outlet for
emotional tension.
4. Altered elimination pattern related to neurological impairment
 Assess the bowel and bladder pattern of the patient.
 Monitor for urinary incontinence, difficulty in defecation.
 Advise patient catheterization is necessary to prevent urinary incontinence.
 Use protective pads and pants to prevent bowel leaks.
 Encourage patient to drink plenty of fluids.
 Check for presence of waste regularly and clear the bowels with gloved hands.
 Provide suppositories or enemas that helps empty the bowels.
5. Anxiety related to situational crisis, recurrent disorder with continuing pain

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 Assess level of anxiety of patient. Determine how patient had dealt with problem in the
past, and how he/she is coping with current situation.
 Provide accurate information and honest answers.
 Provide hope within parameters of individual situation; do not give false reassurance.
 Provide opportunity for expression of concerns, possible permanent nerve damage
paralysis, changes in employment/finances.
6. Knowledge deficit related to the lack of information about the condition, prognosis
 Assess the level of understanding of the patient.
 Maintain good interpersonal relationship with patient.
 Provide informal health teaching about disease condition (cause, sign and symptoms,
management and prevention).
 Provide detail information about his/her daily progress.
 Provide information about self-care and preventive measures.
Instruct patient to avoid recurrences as follows:
 Standing, sitting, lying, and lifting properly are necessary for a healthy back.
 Alternate periods of activity with periods of rest.
– Avoid prolonged sitting (intradiskal pressure in lumbar spine is higher during
sitting), standing and driving.
– Change positions and rest at frequent intervals.
– Sit in a straight-back chair with the knees slightly higher than the hips.
– Avoid knee and hip extension. When driving a car, have the seat pushed forward as
necessary for comfort. Place a
– Avoid fatigue, which contributes to spasm of back muscles.
 Use good body mechanics when lifting or moving.
 Daily exercise is important in the prevention of back problems
7. Ineffective coping related to effects of chronic pain
 Assess for the influence of cultural beliefs, norms, and values on the patient’s perceptions
of effective coping.
 Observe for causes of ineffective coping such as poor self-concept, lack of problem-solving
skills, lack of support or recent change in life situation
 Assist patient set realistic goals and identify personal skills and knowledge
 Discuss with patient about his or her previous stressors and the coping mechanisms used.
 Assist client in use of diversion, recreation, relaxation techniques
8. Risk for situational low self-esteem related to impaired mobility, chronic pain, and
altered role performance
 Assisting both the patient and support people to recognize continued dependency helps the
patient identify and cope with the underlying reason for the dependency.
 As recovery from acute low back pain and immobility progresses, the patient may resume
former role-related responsibilities.

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 If the patient experiences secondary gains associated with low back disability (eg, worker’s
compensation, easier lifestyle or workload, increased emotional support), a “low back
neurosis” may develop. The patient may need help in coping with specific stressors and in
learning how to control stressful situations.
 Psychotherapy or counseling may be needed to assist the person in resuming a full,
productive life.
 Back clinics use multidisciplinary approaches to help the patient with pain and with
resumption of role-related responsibilities
Prognosis
 Most acute episodes settle down with bed rest in 4-6 weeks
 90% of cases don’t require surgery.
 5% of people experience chronic severe, incapacitating lower back pain
 After successful laminectomy 80-85% of patients do extremely well and are able to return
to their job in 6 weeks
Prevention of Low Back Pain
 Maintain healthy weight
 Avoid nicotine products
 Obtain regular physical activity
 Use proper body mechanics to avoid low back strain (e.g. when lifting heavy objects, bend
at the knees, not at the waist and stand up slowly while holding object close to your body)
 Do not sleep in a prone position. Sleep on side with knees flexed and a pillow between the
knees
 Use medium firm mattresses for chronic pain
Advancements in Treatment
a. Tissue engineering should help in addressing the issue of disc prosthesis for low back pain:
bioprinted IVD
b. Stem cell therapies in the intra-vertebral disc space brings new hope for delaying the time
before surgery is required may bring new hope for the treatment of low back pain. It includes:
 Neural stem/Progenitor cells
 Mesenchymal cells
 Reprogramming fibroblasts

212
18. Bone Cancer
Bone cancer can be primary bone cancer or secondary bone cancer. Primary bone cancer starts in
the bone; the cancer initially forms in the cells of the bone, while secondary cancer starts elsewhere
in the body and spreads to the bone. Examples of primary bone cancer include steosarcoma, Ewing
sarcoma, malignant fibrous histiocytoma, and chondrosarcoma.
Primary bone cancer (tumor): these can be divided into benign tumors - which can have a
neoplastic (abnormal tissue growth), developmental, traumatic, infectious, or inflammatory cause
cancers. Examples of benign bone tumors include: osteoma, osteoid osteoma, osteochondroma,
osteoblastoma, enchondroma, giant cell tumor of bone, aneurysmal bone cyst, and fibrous
dysplasia of bone. Examples of malignant primary bone tumors include: osteosarcoma,
chondrosarcoma, Ewing's sarcoma, malignant fibrous histiocytoma, fibrosarcoma, and other
sarcomas. Multiple myeloma is a blood cancer which may include one or more bone tumors.
Teratomas and germ cell tumors are frequently located in the tailbone. Osteosarcoma is the most
common type of bone cancer. It usually develops in children and young adults.
Symptoms of bone cancer
 Typically, bone cancer pain is deep, nagging and has a permanent character.
 There may also be swelling in the affected area.
 Often the bone will weaken, resulting in a significantly higher risk of fracture.
 The patient may find he/she loses weight unintentionally.
 A mass (lump) may be felt in the affected area.
 Although much less common, the patient may also experience fever, chills and/or night
sweats.
Causes of bone cancer
The following groups of people may be at a higher risk of developing bone cancer (risk factors):
 Being a child or very young adult - most cases of bone cancer occur in children or young
adults aged up to 20.
 Patients who have received radiation therapy (radiotherapy).
 People with a history of Paget's disease.
 People with a close relative (parent or sibling) who has/had bone cancer.

213
 Individuals with hereditary renoblastoma - a type of eye cancer that most commonly affects
very young children.
 People with Li-Fraumeni syndrome - a rare genetic condition.
 Babies born with an umbilical hernia.
Diagnosis of bone cancer
The following diagnostic tests may be ordered:
 Bone scan: a liquid which contains radioactive material is injected into a vein. This
material collects in the bone, especially in abnormal areas, and is detected by a scanner.
The image is recorded on a special film.
 Computerized tomography (CT): CT scans are commonly used to see whether the bone
cancer has spread and where it has spread to.
 Magnetic resonance imaging (MRI): the device uses a magnetic field and radio waves to
create detailed images of the bone.
 Positron emission tomography (PET): a PET scan uses radiation, or nuclear medicine
imaging, to produce 3-dimensional, color images of the functional processes within the
human body.
 X-rays: this type of scan can detect damage the cancer may have caused to the bone.
 Bone biopsy - a sample of bone tissue is extracted and examined for cancer cells.
Staging the bone cancer
Bone cancer has different stages which describe its level of advancement.
 Stage I - the cancer has not spread out of the bone. The cancer is not an aggressive one.
 Stage II - same as Stage I, but it is an aggressive cancer.
 Stage III. Tumors exist in multiple places of the same bone (at least two).
 Stage IV. The cancer has spread to other parts of the body.
Treatments for bone cancer:
The type of treatment for bone cancer depends on several factors, including what type of bone
cancer it is, where it is located, how aggressive it is, and whether it is localized or has spread.
There are three approaches to bone cancer:
 Surgery
 Chemotherapy
 Radiotherapy (radiation therapy)

214
Surgery: The aim of surgery is to remove the tumor, all of it if possible, and some of the bone
tissue that surrounds it. If some of the cancer is left behind after surgically removing the tumor it
may continue to grow and eventually spread.
Radiation therapy: Radiotherapy can be used for different reasons:
 Total Cure - to cure the patient by completely destroying the tumor.
 To alleviate symptoms - radiotherapy is often used to relieve pain in more advanced
cancers.
 Neo-adjuvant radiotherapy (before surgery) - if a tumor is large, radiotherapy can shrink
it, making it easier and less harmful to then surgically remove it.
 Adjuvant radiotherapy - given after surgery. The aim is to eliminate the cancer cells that
remained behind.
 Combination therapy (radiotherapy combined with another type of therapy) - in some
cases, chemoradiation - radiotherapy combined with chemotherapy - is more effective.
Chemotherapy: In general, chemotherapy has 5 possible goals:
 Total remission - to cure the patient completely. In some cases, chemotherapy alone can
get rid of the cancer completely.
 Combination therapy - chemotherapy can help other therapies, such as radiotherapy or
surgery have more effective results.
 Delay/Prevent recurrence - chemotherapy, when used to prevent the return of a cancer,
is most often used after a tumor is removed surgically.
 Slow down cancer progression - used mainly when the cancer is in its advanced stages
and a cure is unlikely. Chemotherapy can slow down the advancement of the cancer.
 To relieve symptoms - also more frequently used for patients with advanced cancer.
Phantom limb pain: Also known as phantom limb syndrome - the patient feels sensations, often
of pain, in a limb that has been amputated; the limb is no longer there. The brain still receives
messages from the nerves that originally carried impulses from the missing arm or leg.

215
19. Hospice Care, Palliative Care and
Pain Management
Hospice and Palliative Nursing
Hospice care: Hospice care is a philosophy of care that focuses on patient’s comfort and quality
of life rather than curing the patient’s disease. Hospice care is usually meant for patients who are
not expected to live longer than six months. So it focuses on quality of life rather than length of
life.
Palliative care: Palliative care is an approach of care that improves the quality of life of patients
and their family facing the problems associated with life threatening illness through prevention
and relief of suffering by means of early identification, impeccable assessment and treatment of
pain, other problems, psychosocial and spiritual. (WHO, 2002)
Hospice care
The term hospice care is derived from the Latin word hospitium, which referred to a place of
shelter or rest and implied what we now refer to as ‘hospitality’. More traditionally, hospice care
places the patient and family at the center of an interdisciplinary model of caring for individuals
in the final stages of an illness.
It means care for the whole person aiming to meet all needs: physical, emotional, social and
spiritual. Hospice is a coordinated program of interdisciplinary services provided by professional
caregivers and trained volunteer to patients with serious, progressive illnesses that are not
responsive to cure.
Hospice care does not seek to hasten death, nor does it encourage the prolongation of life through
artificial means. Hospice care hinges on the competent patients full or open awareness of dying. It
embraces realism about death and helps patients and families understand the dying process so that
they can live each moment as fully as possible.
Primary goals of hospice care
 To provide comfort.

216
 To relieve physical, emotional, and spiritual suffering, promote the dignity of terminally
ill persons.
 Hospice care neither prolongs nor hastens the dying process.
Hospice Services
Hospice services usually include:
 Basic medical care with a focus on pain and symptom control.
 Access to a member of hospice team 24 hours a day, 7 days a week.
 Medical supplies and equipment as needed.
 Counseling and social support to help patients and family with psychological, emotional,
and spiritual issues.
 Guidance with the difficult, but normal, issues of life completion and closure.
 A break (respite care) for caregivers, family, and others who regularly care for patients.
 Volunteer support, such as preparing meals and running errands.
 Counseling and support for loved ones after patient die.
Hospice Team
In addition to a doctor and nurses, hospice teams usually include:
 Social workers
 Medicine specialists
 Spiritual advisers
 Nursing assistants
 Trained volunteers
Some hospice teams also include:
 Pharmacists
 Respiratory therapists
 Psychologists
 Psychiatrists
 Music therapists
 Physical therapists
 Occupational therapists

217
Hospice Care:
 Pain and symptom control: The goal of pain and symptom control is to help patient be
comfortable while allowing patient to stay in control of and enjoy the life. This means that
discomfort, pain, and side effects are managed to make sure that patients are as free of pain
and symptoms as possible
 Home care and inpatient care: Although most hospice care is centered in the home, there
might be times when patients need to be admitted to a hospital, extended-care facility, or an
inpatient hospice center. Home hospice team can arrange for inpatient care and will stay
involved in patients care and with their family. Patients can go back to in-home care when they
and their family are ready.
 Spiritual care: Since people differ in their spiritual needs and religious beliefs, spiritual care
is set up to meet specific needs. It might include helping the patients look at what death means
to them, helping to say good-bye, or helping with a certain religious ceremony or ritual.
 Family meetings: Regularly scheduled family meetings, often led by the hospice nurse or
social worker, keep family members informed about patient condition and what to expect.
Family meetings also give everyone a chance to share feelings, talk about what’s happening
and what’s needed, and learn about death and the process of dying. Family members can get
great support and stress relief through these meetings. Daily updates may also be given
informally as the nurse or nursing assistant talks with patient and caregivers during routine
visits.
 Coordination of care: The interdisciplinary team coordinates and supervises all care 7 days a
week, 24 hours a day. This team is responsible for making sure that all involved services share
information. This may include the inpatient facility, the home care agency, the doctor, and
other community professionals, such as pharmacists, clergy, and funeral directors. Patients and
caregivers are encouraged to contact hospice team if patients are having a problem, any time
of the day or night. There’s always someone on call to help with whatever may arise. Hospice
care assures that patients are not alone and help can be reached at any time.
 Respite care: For patients being cared for at home, hospice service may offer respite care to
allow friends and family some time away from caregiving. Respite care can be given in up to

218
5 day periods of time, during which patients are cared for either in the hospice facility or in
beds that are set aside in nursing homes or hospitals. Families can plan a mini-vacation, go to
special events, or simply get much-needed rest at home while patients are cared for in an
inpatient setting.
 Bereavement care: Bereavement is the time of mourning after a loss. The hospice care team
works with surviving loved ones to help them through the grieving process. A trained
volunteer, clergy member, or professional counselor provides support to survivors through
visits, phone calls, and/or other contact, as well as through support groups. The hospice team
can refer family members and caregiving friends to other medical or professional care if
needed. Bereavement services are often provided for about a year after the patient’s death
Concept of Palliative Care:
 Palliative care is a concept that has been defined with some degree of ambiguity.
 The word palliative is derived from the Latin word ‘pallium’ meaning a clock or cover
refers to the alleviation of symptoms.
 The Oxford English dictionary defines palliative as ‘to relieve without curing’.
 The term palliative care may be used generally to refer to any care that alleviates symptoms.
 Palliative care focuses on the person as a whole and offers a wide range of support services
to the ill person.
 It also offers bereavement support and can help the family.
 This was simplified succinctly by the National Institute for Clinical Excellence (NICE),
United Kingdom in 2004 as follows: ‘palliative care is the active holistic care of patients
with advanced progressive illness’.
 Palliative care begins with the initial identification of an incurable illness and concludes as
the illness ends in death and bereavement.
 Its fundamental precept is that the goals of care are patient directed and quality oriented.
 Palliative care follows a design that neither hasten nor prolong death but allows individual
to live with their illness as long as possible prior to ‘dying from it’.
 Worldwide, over 20 million people are estimated to require palliative care at the end of life
every year.
 The majority (69%) are adults over 60 years old and only 6% are children.
 The highest proportion (78%) of adults in need of palliative care at the end of life live in
low and middle-income countries, but the highest rates are found in the higher-income
groups.
 Those dying from non-communicable diseases represent around 90% of the burden of end
of life palliative care.

219
Goals of palliative care
 To maximize the quality of life of patients.
 To provide relief from pain and other physical symptoms.
 To provide psychosocial and spiritual care.
 To provide support to the family during the patients’ illness and bereavement.
Basic Principles of Palliative Care
 Patient and family as a unit of care.
 Attention to whole person.
 Interdisciplinary team approach.
 Education and support of patient and family.
 Extends across illnesses and settings.
 Bereavement support.
 Palliative care can help people suffering from:
 Cancer
 HIV
 Progressive neurological illnesses
 Sever kidney or heart failure
 End stage lung disease
 Other life limiting illness.
Models of care
 There is no one right or wrong model for the provision of palliative care.
 The best model is determined by local needs and resources.
 IAHPC (International association for hospice and palliative care) believes that each
developing country should be encouraged and enabled to develop its own model of
palliative care.
 There are different models of palliative care. They are:
 Hospital palliative care
 Independent hospice care unit
 Community palliative care services/ home care services
 Day hospice/day care hospice services

220
Teamwork in palliative care
• Successful palliative care requires attention to all aspects of patient suffering: physical,
psychological, social and economical, cultural, spiritual and so on which requires
involvement of all multidisciplinary team.
• Multidisciplinary team is the term that is used in palliative care.
• Effective teamwork depends on good communication, effective leadership and
coordination.
• Team members are as follows:
 Medical staff
 Nursing staff
 Social worker
 Physiotherapist
 Occupational therapist
 Counselor/
 psychologist
 Spiritual therapist
 Volunteer
Components of palliative care
Palliative care has been described as incorporating three essential components:
Symptom control
In palliative care often people have to deal with a variety of symptoms which can be distressing
for the patient. Common symptoms controlled in palliative care are:
– Pain management
– Nausea/vomiting
– Loss of appetite
– Weakness/confusion
– Breathing difficulty
– Bowel and bladder problems
Support to the patient
 Social, psychological, emotional and spiritual support to the patient.
 Palliative care focuses on the person as a whole and offers a wide range of support services
to the ill person.

221
 It also offers bereavement support and can help the family work through emotions and grief
regarding the illness and death of a loved one.
Support for the family
• Offers bereavement support and can help the family work through emotions and grief
regarding the illness and death of a loved one.
• Instruction on how to care for the patient.
• Home support services that provide assistance with household tasks such as meal
preparation, shopping and transportation.
• Relief for the care giver, sometimes a volunteer stays with the person so the family
caregiver can go out.
Palliative Care in Nepal
 No well-organized palliative care systems.
 Palliative care has to be done by primary physicians/ surgeons.
 Subject of least priority.
Challenges
 Poverty
 Existence of other areas of priorities in health care
 Lack of knowledge amongst medical professionals in the area of palliative care
 Unrealistic fears regarding opioids
 Late diagnosis
Hospice and Palliative Centers in Nepal
 In 2000, Hospice Nepal was started. It is situated in Lagankhel, Lalitpur.
 Shechen Clinic and Hospice: Boudha, Kathmandu, 2000
 Nepalese Network for Cancer Treatment and research: Scheer memorial Hospital, Banepa,
2002
 Bhaktapur Cancer Hospital, which opened in 1998, has provided palliative care services in
close cooperation with NNCTR and INCTR since 2002. In 2006, it started a twinning
project with Nanaimo Hospice, in Canada.

222
 Bharatpur, B.P. Koirala Memorial Cancer Hospital opened a hospice and palliative care
unit in 2004
 Thankot Hospice Centre: 100% charity hospice in Nepal, established in 2007
Pain management
Pain is an unpleasant sensory or emotional experience associated with actual or potential tissue
damage or described in terms of such damage. The aim of pain management is to allow patients to
be pain free or for their pain to be sufficiently controlled that it does not interfere with their ability
to function or delay from their quality of life
Commonly used pain scales
 Numerical rating scale 0 – 10, 0 signifying no pain, 1-3-mild pain, 4-6 moderate pain, 7-10
severe pain
 Simple descriptive pain intensity scale
 Visual analog scale
Pain management
WHO analgesic ladder stepwise approach established in 1986
 Mild pain- non opoid (paracetamol and or NSAID. Cyclooxygenase (COX) selective NSAID
drugs have not, overall been shown to be superior and they are more expensive than other
NSAID +/- adjuvant
 Moderate pain- weak opoid +/- NSAID +/-adjuvant
 Severe pain- strong opoid +/- NSAID +/-adjuvant
Adjuvants
 Steroids like dexamethasone 8-16 mg / day. Give before mid afternoon
 Antidepressents amitriptyline 10- 75 mg/day
 Anticonvulsants (carbamazemine 100-400 mg/day)
 Bisphosphonates for bone pain (zoledronic acid 4 mg/ monthly)

223
Five essential concepts of analgesics (WHO)
 by the mouth
 By the clock
 By the ladder
 For the individual
 Attention to the details, to consider all aspects of suffering/ all causes of pain
Morphine in chronic cancer pain
Oral morphine
 Tablet
 Quick release 10mg
 Control release -10 mg. 30mg
 Syrup morphine- 120mg/ 60 ml
 Injection Morphine-Injection- 15 mg/ 1ml, 10 mg/ 1 ml
 Usually given subcutaneous route for sever cancer pain in palliative setting
Prescribing guidelines of morphine
 Start with low dose 2.5-5 mg 4 hourly
 Titrate according to pain relief and toxicity
 When two or more breakthrough doses are needed in 24 hours, increases the dosage by 30-
50% every 2-3 days
 Double dose can be given at bed time that patient do not need to wake up in middle of the night
to take the medicine
 For break through pain is treated with extra dose of morphine but do not omit the next regular
dose
 Always prescribe a stimulant laxative prophylactically
Special procedures in palliative care
 Manual removal of impacted stool
 Subcutaneous opioid administration- preferable site upper outer aspect of arm
 Management of fungating wound- wound dressing, odor control, bleeding control, pain control
 Abdominal paracentesis

224
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