Muscle/Skeletal Rehabilitation Lesson #2

Objectives Identify the principles of rehabilitation after a fracture Describe arthroplasty and teaching for the patient in rehabilitation after a joint replacement Describe the role of the rehab nurse in fracture and arthroplasty rehabilitation Describe amputation rehabilitation State the interventions by the rehab nurse that can help the patient with arthritis to improve functional abilities

Few Statistics Over 10 million people in USA have osteoporosis 1.5 million fractures are credited to osteoporosis 350, 000 hip fractures included More than 70% of knee/hip replacements from osteoarthritis

Prohibits Surgery Bone infection Severe osteoporosis Uncontrolled medical problem

Desired Post-Fracture Rehab Outcomes Normal position healing Full ROM to joints around fracture Normal strength returns Prevent complications

General Rule A fracture will require immobilization of the joint both above and below the fracture site during the healing process

Types of Fractures Muscle/Skeletal Rehab Nursing

#1 Stable fracture

Stable Fractures Require very little treatment Rehab course begins as soon as initial symptoms of fracture subside. Perform progressive ROM exercises 3-4 days post fracture Progressive strengthening of fracture 3rd of 4th week post fracture Example: Radial Head Fracture Non displaced ulna fracture

#2 Moderately stable fracture Requires some form of immobilization yet allows movement of the joints nearest fracture

#2 Moderately Stable Fracture

#3 Unstable Fracture

#4 Grossly Unstable Fracture Can’t be immobilized Requires surgical intervention Requires plaster or fiberglass cast May require a cast or air brace Examples: Hip Fractures Femur Fractures

#4 Grossly Unstable Fracture

Unstable Fracture Advantages and Disadvantages Early mobilization Early return to general mobility Sometimes early protected weight bearing Decreased risk with spinal anesthesia Newer smaller incisions Increased risks w/general anesthesia (elderly) Increased risk of infection Risk of interference w/the natural physiology of healing process..(screws may loosen, unresolved pain) Advantages

#5 Comminuted Fracture External Fixator

External Fixators Used for complicated, very commuted and grossly unstable fractures Usually have a lot of soft tissue damage and edema

Basic Principles of Rehab post fracture #1 All Joints not requiring immobilization should be mobilized #2 Gait Training/weight bearing as soon as possible #3 Mobilization of the fracture area as soon as stability has been achieved #4 Use of Local Help Techniques for pain and muscle spasms #5 Muscle Strengthening as soon as fracture stabilized #6 Perform ROM Exercises #7 Strengthening Exercises

Systemic Complications of Fractures Atelectasis and Pneumonia Infection GU stasis Deep Vein Thrombosis Fat Emboli Pulmonary Emboli Systemic problems of Immobility ARDS

Local Complications of Specific Fractures Non-Union Mal-Union Infection-Osteomyelitis Stiffness

Surgeries Arthroplasty Defined Two Goals Candidates for surgery Our focus: Hip Knee

Hip Abductor Wedge

Complications of Hip Dislocation Causes S&S of dislocation Five “P’s” neurovascular check Nursing responsibility Anterior Posterior

Knee Replacement Purpose When? Critical pathway Other replacements

Role of Rehab Nurse in Fractures and Arthroplasty Routine cast care Monitor the extremity regularly Provide/teach skin care/pin site care Position properly Supervise and monitor client’s weight bearing Perform ROM as PT directed Provide and encourage ADL training Monitor for systemic and local complications Monitor and perform pain management

Amputations

Amputation Rehabilitation Children do well for injuries requiring rehab Indications for an amputation is when the limb is no longer of any use Severe trauma Thermal injuries Infections Tumors Pain Severe circulatory problems) Goal with amputations

Level of Amputation Severity of soft tissue damage Assessment Vascularity of the tissue Best level of function

Types of Amputations

Stump Healing Care and inspection S&S of infection W/C support Expected outcomes

Stump Shrinking Purpose Dressings

Preventing Contractures Principles #1 Prevent hip flexion and external rotation of stump #2 Promote prone position #3 Encourage crutch walking ASAP #4 Avoid prolong sitting in W/C, bed, chair #5 Patient performs resistance strengthening exercises on other limb

Amputee Mobility Training

Problem/Complications of Amputees Skin problems Atrophy Phantom Limb Sensation Phantom Pain Interventions Desensitizing techniques Alternative methods to help phantom pain Edema Bony overgrowths

Rehab Nurse Role in Care of Amputation Appropriate care to enable the patient to wear a prosthetic Ensure appropriate care of stump healing/shrinking Prevention of contractures

Arthritis Rheumatoid Arthritis Osteoarthritis

Arthritis Rheumatoid Osteoarthritis Chronic/ ?autoimmune Systemic and symmetrical Periods of exacerbation/remission Onset: insidious S&S Treatment: Drugs, rest, Protect, change environment Degenerative Unknown cause Localized and asymmetrical Can’t function with ADLs RT pain S&S Treatment: Wt loss Drugs, rest, ROM, heat, Environment changes

Arthritis Problems

Arthritis Rehabilitation Nurses Role Minimize morning stiffness Manage environment Provide /maintain stress free environment Encourage/support: proper positioning comfort measures

Summary So what did I learn? Name one thing How you will incorporate it into your nursing practice

References http://www.sportmedstore.com/products/images/POST-OP_WOUND_CARE_FRACTURE.jpg http://www.mdguidelines.com/images/Illustrations/fr_fem_n.jpg http://nemsi.uchc.edu/images/image_wristfract1.jpg http://media.summitmedicalgroup.com/media/db/relayhealth-images/radihead.jpg http://www.drfoot.co.uk/pictures/CollesFracture.gif http://www.hmc.org.qa/mejem/sept2003/images/Figure%202%20pg%2044.jpg http://www.ossur.co.uk/library/10461&proc=6/Soft%20Humeral%20Fracture%20Brace.jpg http://www.orthosupersite.com/images/content/ot/201012/ot1210podeszwaF1.gif http://www.irishvetjournal.org/content/figures/2046-0481-62-10-663-3.gif http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/10202.jpg http://teamofmonkeys.com/html/images/a%20Ilizarov%20External%20Fixation%20at%20Bat%20Yam%20Migdal%20Zahav%20Israel%202006%20yfrimer.jpg http://www.the-hospitalist.org/SpringboardWebApp/userfiles/hosp/image/TH_2012_09_pp09_02.jpg http://www.doctortipster.com/4163-deep-venous-thrombosis-treatment-and-prophylaxis.html/lovenox http://hanyhefny.com/images/malunion.jpg