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Dislocation & subluxation Dislocation- total separation; head of the bone is totally out Subluxation- occurs when the articulating surfaces lose partial contact Common sites- shoulder, hip, knee, elbow & ankle (diarthroidal joints- free moving joints) Causes: overstretching congenital defect (congenital hip displasia) presence of infxn Assessment: pain shortening of extremity change in the length of the extremity loss of normal mobility change in the axis of dislocated bone X-ray- confirms Dx * if the dislocation is not treated promptly Avascular necrosis- tissue death due to anoxia & diminished bld supply Management: 1. immobilization- splint/sling, prevent further dislocation 2. closed reduction- displaced parts are brought into normal position; pain is anticipated; Manual manipulation 3. analgesic, muscle relaxant (valium) & anesthesia4. re-application of immobilization- alignment of bones= healing 5. neurovascular status is monitored- monitor if there's a bld circulation (capillary refill,pulse, sensation, skin color) 6. after reduction.if the joint is stable, gentle, progressive, active & passive movement is begun- to return proper functioning of the joint Fracture- disruption of normal bone continuity that occurs when more stress is placed in the bone Classification: 1. closed(simple)- w/ intact skin over the fracture site; bone does not protrudes thru the skin 2. open(compound)- break in the skin is present 3. complete fracture- fracture line extends thru the entire bone fragments (all over the bone) 4. comminuted fracture- there is more than 1 fracture line & bone fragments ('na-pudpud') 5. pathologic fracture- occurs as a result of underlying disease such as osteoporosis,long term use of corticosteroid 6. Greenstick fracture- fracture in which one side of the bone is broken and the other is bent 7. oblique- fracture line in an oblique direction 8. spiral- fracture line is "S-shape" Clinical Manifestations: 1. pain- continuous & severity until the bone fragment are immobilized 2. loss of function- due to pain & injury 3. deformity- displacement, angulation or rotation; detectable when limb is compared w/ the uninjured

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extremity; may result to soft tissue swelling 4. shortening- due to contraction of the muscles that are attached distal & proximal to the site. 5. crepitus- grating sensation; caused by rubbing of the bone fragments against each other 6. swelling & discoloration- trauma & bleeding into the tissues(due to damage in the small bld vessels) Emergency management: 1. immobilize the body part before the patient is moved. 2. neurovascular status distal to the injury should be assessed- blood circulation; for adequacy peripheral tissue perfusion and nerve function 3. with an open fracture- clean dressing (to prevent osteomyelitis); no attempt to feduce fracture; splint is applied 4. In the ER- th pt is evaluated completely. clothes are removed (to assess further), first from the uninjured side of the body Medical Management: 1. Reduction- restoration of the fracture fragments to anatomic alignment & rotation (promotes union= healing) A. Closed reduction -is accomplish by bringing the bone fragments into a position, placing the ends in contract through manual manipulation, the physician will apply cast, splint and other device. -x-ray is obtained to verify that the bone fragments are correctly aligned. B. Open reduction -through a surgical approach, the fracture fragments are reduce. Internal fixation device such as metallic pins, wire, screws, plates, nails, or rods may be used to hold the bone fragments in position until solid bone healing occurs 2. Immobilization- after the fracture has been reduced, bone fragments must be immobilize or held in correct position and alignment until union occurs 3. Maintaining & restoring function: elevating the injured part- inflam & swelling applying ice- pain neurovascular status- assess blood circulation, movement, sensation; tissue perfusion pain relief- with use of analgesics isometric and muscle setting exercise- prevents muscle wasting participation in activities of daily living- promotes independent functioning & self esteem

Complication: Arterial Damage- may consist of thrombosed, lcerated, served or spastic arteries - arteries may be constricted by bandages or cast that are too tight

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Assessment: 1. variable or absent pulse 3. poor capillary return 4. cold extremity & paralysis 5. continuing bld loss- due to lacerated bld vessels Interventions: 1. Splitting or removing tight encircling cast or bandage 2. elevating or changing the position of the injured part- swelling & bleeding 3. Surgery- suturing-open skin; laceration) Complications of Fracture Compartment Syndrome: due to tight clothing - serious complication of fracture - condtion wherein there is increase pressure w/ one or more muscle compartment of the extremities causing massive comprimise to the circulation to the area (Pressure w/in compartment is greater than the normal) Causes: following an injury that causes swelling & pressure #1-4-- due to impaired circulation 2. swelling, pallor or patch cyanosis

The lower Ext. has 4 compartment: 1. Anterior 2. lateral 3. superficial 4. deep posterior Upper Ext. has 3 compartment: 1. Superficial flexor 2. Deep flexor 3. Extensor * Every compartment is composed of a muscle, nerves & blood vessel *coated & wrapped by a fascia (will not stretch/expand) Compartment Syndrome can also develop if external pressure is applied, such as from a cast or tight dressings.

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Clinical manifestations: 1. Sensory deficits- paresthesia, pain, hypothesia (early signs of nerve involvement, motion impairment.. Motor weakness- late sign of nerve congestion) 2. impairment of peripheral circulation- color, temp, capillary refill, swelling & pulses * cyanotic- suggests venous congestion * Pale dusky & cold fingers or toes & prolonged capillary refill suggests arterial congestion 3. palpation of muscle- swollen hard 4. measuring the normal tissue perfussion is increased. the Normal pressure is 8mmHg, prolonged pressure of more than 30mmHg can result in compromised microcirculation Medical Management: 1. notify the physician immediately 2. elevation of the extremity to the heart lvl 3. release of the constrictive devices 4. fasciotomy- surgical decompression w/ excision of fascia -release tension/pressure; improves circulation Fat embolism -uncommon but potentially life-threatening complication of long bone & pelvis fracture -fat embolism syndrome occurs 24-48h after surgery Signs & sypmtoms: 1. altered mental status 2. tachypnea 3. tachycardia 4. hypoxemia 5. delayed union & nonunion 6. avascular necrosis of bone 7. complex regional pain syndrome 8. hypertrophic ossification Soft tissue injury - trauma to subcutaneous tissue, muscle, ligaments & or bld vessels -severe contussions, lacerations, degloving injuring, avulsion, ecchymosis w/ swelling #1-4- due to oxygenation

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Treatment: 1. Pain meds 2. RICE 3. Surgery- bacause of laceration Crushing Injury -compressive force applied to muscles -may result from falls, MVA and blunt trauma -multiple fracture & internal bleeding may result. Bleeding the usual cause of death. Assessment: 1. hypovolemic shock- results from extravasation of blood & plasma into injured tissue after compression has been released 2. paralysis of the body part 3. erythema & blistering of skin- due to injury of muscles/subcutaneous tissues 4. swelling- result to compartment syndrome 5. renal dysfunction- could lead to acute renal failure Management: 1. Maintaining the ABG- cause of bleeding; impaired oxygenation 2. observed for acute renal insufficiency 3. major soft tissue injury are splinted- to control bleeding & pain 4. if an extremity is involved- it elevated-- to swelling 5. fasciotomy- surgical incision to the lvl of fascia 6. medication for pain 7. wound debridement & fracture repair Traumatic Amputation -surgical removal of all or part of an extremity Causes: 1. Peripheral vascular dse.- Buergers dse. 2. Metabolic D.O- DM 3. Trauma 4. Malignant Tumors 5. Congenital deformities 6. Cancer 7. severe limb gangrene- irreversible

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2 types of Amputation: 1. close or flap- sutured over the end of the stump; surgeon covers stump w/ a flap of the skin 2. open or guillotine- does not close the stump immediately but leaves it open allowing the wounds to drain freely - antibiotics is used -if infxn is healed, the client will undergo operation for stump closure -distal lvl required for any extremity amputation Level of Amputation: 1. Above the knee- performed between the lower third to the midline of the thigh 2. Below knee- usually done in middle third of leg 3. Syme amputation-locate for the ankle (below ankle) 4. Mid foot amputation 5. Toe amputation *Elbow- Point of reference (upper ext) Assessment: 1. Evaluate dressings for signs of infxn or hemorrhage- purulent discharge;foul smell; check operative site 2. Observe for signs of developing necrosis or neuroma(abnormal tissue) in incision site- impaired circulation 3. Evaluate for phantom limb pain- 'mabatyagan ang amputated ext.' 4. Observe for signs of contracture- spastic flexion due to abnormal positioning 5. Psychological reaction to amputation: feeling of loss, greiving loss of independence lowered self-esteem depression Management: 1. Routine Post-op care 2. prevent hip/knee contracture 3. avoid sitting w/ hips flexed for long period in chair 4. assume prone position several times a day- promotes circulation; hip is extended 5. avoid elevation of stump area after 12-24h- swelling, bleeding from operative site 6. observe stump dressing for hemorrhage 7. pain meds

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8. active ROM of all joints, crutch, walking, arm/shoulder exercise- prevents contracture 9. provide stump care Inspect skin for signs of irritation wash w/ warm water, bacteriostatic soap, rinse & dry daily & thoroughly avoid lotions, alcohol, powder (irritating substances) Metabolic conditions Osteoporosis -a reduction of bone density & change in bone structure, both of which inrease susceptibility to fracture - rate of bone resorption is greater than bone formation resulting in a reduced bone mass. - loss of bone mass is a universal phonomenon associated w. aging - aging-related loss begins soon after the peak bone mass is achieved *Calcitonin- *Estrogen- *PTH- promote movement of Ca from the bones Vit D- necessary for Ca absorption & normal bone mineralization Risk Factors: Unmodifiable: 1. Genetics- Caucasian, Asain; Female; Fam Hx 2. Age- Post menopausal; advanced age; testosterone; calcitonin Modifiable: 1. Nutrition- Ca & Vit D intake; PO4; inadequate calories 2. Physical Exercise- sedentary lifestyle; lack of wt bearing exercise 3. Lifesyle- caffeine; alcohol; smoking;lack of exposure to sun 4. Medications- Cortcosteroid, anti seizure, heparin, TH (affects Ca absorption & metabolism) 5. Co-morbidity- anorexia N.( intake of food);hyperthyroidism ( PTH), malabsorption syndrome; renal failure(loss of Vit D leads to Ca absorption) Types of Osteoporosis: 1. Primary -refer to the occurence of the condition among oldest person in whom no secondary predisposing condition exist. this include both Post-menopausal osteoporosis & osteoporosis of aging 2. Secondary -results from an underlying condtion such as hyperparathyroidism or iatrogenic causes such as long term corticosteroid use.

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Assessment: 1. back pain-@ lower back that radiate around the trunk 2. fracture- vulnerable sites are the distal radius, proxismal femur & thoracic & lumbar vertebrae 3. Dowager's hump (kyphosis) Diagnostic studies: 1. DEXA (dual energy xray absorptiometry)- provides info about bone mass density (BMD) @ spine & hip 2. QUS (quantitative ultrasound studies)- study of the heel;help dx osteoporosis 3. Laboratory studies- Ca, PO4, urine Ca excretion, urinary hydroxyprolineexcretion(determines if there is osteoblast activity.supports dx of osteoporosis) 4. Routine Xray- 25-40% deminiralization of bone Medical Management: 1. Balanced diet rich in Ca & Vit D 2. Ca supplements- Caltrate, Citrocal 3. Regular wt bearing exercise 4. Firm Mattress should be used to provide back support & to relieve pain- prevents structural deformities; pain 5. Pt may be required to wear light brace to relieve back pain & provide support when in the upright position- prevent fx 6. Activity such as lifting & twisting should be discouraged- prevent fx 7. Good body mechanics is essential 8. Analgesics & muscle relaxants may be administered to relieve pain 9. Assistive device to prevent fall & subsequent fx - prevent injury & fx Pharmacologic Management: 1. selective estrogen receptors modulators- roloxifene 2. alendronate (fosamax)- produces bone mass; osteoplastic activity 3. biphosphonates-reduce spine & hip fx 4. risedronate(actonel)- prevention & tx of glucocorticoid induced ostoporosis 5. calcitonin (micalcin)- suppressbone loss thru direct action on osteoclast & reduce bone turnover. Effective in BMD

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