Musculoskeletal Anatomy PDF

Musculoskeletal- 206 bones in the body, long bones (cortical), flat bones (cancellous), short bones Bones are constructed of cortical (more compact and provides support) bone tissue and cancellous (hematopoiesis and bone formation occurs) The function of the bone is to protect vital organs, movem...

Musculoskeletal- 206 bones in the body, long bones (cortical), flat bones (cancellous), short bones Bones are constructed of cortical (more compact and provides support) bone tissue and cancellous (hematopoiesis and bone formation occurs) The function of the bone is to protect vital organs, movement, facilitate blood return to the heart, production of blood cells, reservoir for immature blood cells and minerals (calcium, phosphorous, magnesium\...) Composed of different cells- osteoblasts-in charge of bone formation, osteocytes in charge of bone maintenance, osteoclast in charge of dissolving, reabsorbing and remodeling bone, osteogenesis- formation of bone which occurs before birth through ossification where the bone matrix is formed Bone is in a constant state of turnover, remodeling and regeneration (old bone removed and regenerated) exercise stimulates bone formation, dietary intake- calcium vitamin D, thyroid all can impact bone formation, bone mass peak reached by 20 yo Three phases of healing after a bone fracture Reactive phase-most painful, bleeding and clot formation occurs, cytokines are released, initiates fibroblast and causes angiogenesis (new blood vessel formation) Reparative phase- granulation tissue is replaced with Pro callus; fibroblast invades Pro callus and form cartilaginous callus, and bone is formed. Remodeling phase- new bine is made the same as the previous bine and necrotic bone is removed Joints- arthrosis- ball and socket (hip, shoulder, etc), hinge- bends in one direction (elbow, knee), Stattel- movement at a right angle (thumb), pivot- allows one bone to move around your central access (radial, ulnar) gliding- movement in all directions (wrist) Joint capsule- surrounds the articular bone and is lined with synovial fluid, lubricates and helps with shock absorption, ligaments bind the bines together, tendons connect muscle to the bone, bursa sac filled with synovial fluids that cushions the movements of tendons Muscles are composed of cells and fibrous tissues called fascia (fibrous tissue that incases the muscle) they are attached by tendons to bones, contractile units in the muscles, buildup of lactic acid can cause muscle fatigue Skeletal bones help with body movement, posture, and heat production, main source of energy for muscles is ATP, needs calcium to contract Muscular contraction can be isometric (length of the muscle remains constant when force is released-wall sit) or isotonic (shortening of the muscle without increased in tension --flexing forearm) Muscle tone- maintenance of muscle fibers in a contracted state, increased during anxious, decreased in sleep, flaccid- no tone, floppy, spastic- hypercontracted, greater than normal tone, hypertrophy- getting bigger, atrophy- decrease in muscle tone, fasciculation- involuntary twitching of a muscle Assessment- health Hx, symptoms, bone, muscle or joint pain, sensory disturbances, family social history, past medical Hx- medications including OTC, pain(old cart) describe the pain bone pain feels dull- deep ache can interfere with sleep, muscle pain feels more achy or sore, infection of the bone will be sharp pain, joint pain is felt with movement. Sensory disturbances (paresthesia) do they have burning, numbness, social family Hx- alcohol drug use dietary intake, occupation, activity level, family Hx od abnormalities Physical assessment- look at their posture, joints bone deformities, inflammation, spine (look for kyphosis, lordosis, scoliosis) look for symmetry right to left for comparison, neuro vascular signs- color, capillary refill, pulse, edema, assess height, gate (how they walk) joint function and ROM, movement should be smooth if not there\'s an issue, contractures- stuck in positions (shortening of surrounding joint structure),effusion- fluid in the joints looks swollen, muscle strength and size, look at skin- nodules edema, temp, color, meds that they are taking, past surgeries, injuries, pain, how long? What alleviates it? Affected limb how well can they move it, ADLs? What other health conditions do they have? Arterial insufficiency or diabetic affects the healing process, family Hx, and nutrition. Diagnostic test- Dexa scan -- bone density shows risk for fractures, Xray, Cat scan, MRI more detailed picture, orthography- pictures of the joints in movement can determine joint disease, bone scan injection of radiopaque dyes (tumor sometimes for fracture), arthroscopy- scope little incision to look around helpful in joint disorders, arthrocentesis- fluid from the joint aspiration to test or remove fluid after we put them on anti-inflammatory and ICE the joint, EMG- electro biography electrical potential of muscle and nerves involve needle electros if they are on blood thinner need to discontinue- nerves conduction, biopsy-puncture wound may need steri-strips, sutures and dry sterile dressing, watch site for S/S of infection and do neuro vascular checks LABS- serum calcium 8.8-10.8, serum phosphatate increases with fracture healing and bone cancer Cast- (don\'t stick anything down there)6 Ps comes back into play, injury, someone cast- want to maintain nor vascular status, looking for distal pulse, possible pressure injury- S/S- hot, itchy, pain. Make them waterproof but should not be submerged in water, should cover it when in water. Some people have a wound to begin with- bivalves a cast cut on the sides to have access to it, keeping the support but then over wrap it. Might need a tetanus shot. Maintain circulation, sensation, movement and 6 Ps, notify doctor if any signs of compromise, elevate the extremity higher than the heart, encourage movement of the fingers or toes. Cast needs time to dry- make sure its dry don\'t lean on anything that can cause a dent in the cast, pain meds (if not working that is a sign of compromise and is called COMPARTMENT SYNDROME- cast needs to be changed let doc know), application of ICE 6 ps- pain, pallor, pulselessness, parathesis, poukilothermia, paralysis Fractured HIP- S/S- increased age, female, Hx of osteoporosis, post Medi pausal women due to low estrogen, Hx of falls, patient will complain of an externally rotated shorten leg (pain can be in the hip, outer thigh, groin won\'t be able to move it) Priorities- respiratory support, circulatory check, pain control, migration, prevention of immobility and complications, ask about Hx of past conditions We can do surgery for hip fractures, Post Op- depends on the approach, use an anterior approach- less precautions, traditional approach- precautions will be required, total hip replacement- nursing care- coughing and deep breathing, compression devices to prevent DVT, turning every 2 hours, leg abductor pillow- helps prevent new hip from dislocating, circulatory and nor vascular checks for pain, getting patients up within 24 hours after surgery (faster they get up and ambulate the better they will do with less complications) Complications- dislocation, DVT, nor vascular complications- bleeding, compartment syndrome, pulmonary complications like atelectasis, urinary retention, watch out for severe pain could be compartment syndrome, inability to move the leg, or lump in the buttock that could signal dislocation, limb shortening, external rotation. Precautions- maintain a neutral position of the hip (NO external or internal rotation, want the leg positioned straight up and down) can do this by using trochanter rolls, hips need to be abducted using abductor pillows to maintain alignment to avoid rotation, isometric quad setting and gluteal metric exercises and the use of a trapeze that hangs above the bed to help them move, ambulatory aids to help, walker or cane. AVOID crossing legs, don't bend hip greater then 90 degrees (can\'t bend forward and pick something off the ground, don\'t lower into chairs, no tubs, no twisting leg in and out, keep abductor pillows in between legs, no low chairs or beds higher is ok with arm rest, non-skid socks, be careful with uneven ground or wet surfaces, raised toilets, sponge bath or tub bench, walk in shower is ok, when dressing use REACHERS should not bend over for any reason) Anterior approach- precautions are less, it involves the muscle more, usually only for 6-8 weeks until they are healed TRACTION- two types, used as a short term or temporary measure until something else can be done, usually surgery, is the application of a pulled force of the body, purpose is to reduce muscle spasms, reduce, align, and immobilize a fracture, reduce deformity, increase the space between opposing forces SKIN- Velcro boot attached to weights(4 --8lbs) lighter weights-pulled force; bucks commonly used for hip- boot attached to the weights, weight is a lot less, reduces muscle spasms until surgery can be done, different ones- cervical head holder, pelvic traction and buck which is the main one weights are not removed unless there is intermittent traction, bucks can be used for a hip or femur fracture, heal lift SKELETAL --bigger bones-femur, tibia, cervical, metal pin or wire, weight (25-40lbs) that goes in through the skin into the bone holding it in place, weight is going to be heavier-hold in place with the application of the pulling force, used for more severe injuries, must do pin care, assess sites for S/S of infection or skin breakdown, we would use chlorhexidine to clean then apply bacitracin, neuro vascular assessment, assess the 6 Ps, External fixator keeps the pins in place, skin sealants lollipops helps with friction to prevent skin breakdown, balanced suspension skeletal traction could be used for femur fracture, can move vertically as the result in line of pull is maintained, overhead trapeze, never remove weights Nursing care- proper application and maintenance of traction, monitor for complications of skin breakdown, nerve pressure and circulatory impairment, promptly report any alterations in sensation and circulation, assessing 6Ps, active foot exercises and leg exercises every hour to the unaffected leg and a compression device, be on anti-coagulants to prevent blood clots, inspect the skin 3 times a day, assess sensation movement color pulses cap refill and temp of toes, DVT, infection may need a 2 nurse to help turn or lift to assess properly, high fiber diet to prevent constipation, encourage fluids and voiding every 3-4hours to prevent GI issues REDUCE/ REDUCTION MEANS BACK IN ALIGNMENT- helps to immobilize the fracture, helps to reduce deformities, used short term until surgery Principles- traction must be continuous to reduce any mobilized fractures, can\'t be interrupted especially skeletal- weights can\'t be hanging freely or hanging on the floor, ties and pully system need to be in the groves and not be frayed and need to be assessed, foot plate must not touch the foot of the bed, counter traction is going to be the patient\'s own body weight ASSESSMENT- compartment syndrome, pin site should be assessed every 8 hours for infection, maintain the alignment of the poles should be along the long access of the bone, maintain traction equipment rope rest in the grove of the pulley and moves easily, counter traction (weight of the patient\'s body against the weight) continuous traction unless ordered as intermittent, body alignment and avoid friction of the skin (trapeze is important so they can shift their body weight to avoid pressure injuries) lollipops used on the boney prominences to avoid pressure injuries Not as severe injuries- contusion- soft tissue injury- pain bruising, discoloration, swelling, strain- pulled muscle injury form over use, pain edema muscle spasm ecchymosis loss of muscle functions, sprain- injury to ligaments and tendons around a joint- joint is tender and movement is painful, bleeding, edema, dislocations- articular surfaces of the joint are not in contact, traumatic dislocation is an emergency due to possible avascular necrosis ( area is not getting the blood supply that it should, leads to tissue death/damage or bone collapse) Contusion sprain/strain- use PRICE P-protect (from further injury, use immobilizer), R-rest, I-ice, C-compression (compressing by wrapping it), E-elevation If it dislocated, it\'s going to have to be reduced (out back in alignment) Pain management- may use opioids, longer term should switch to NSAIDS, don't want the pain to be out of control because we are going to get out of bed, might use a PCA pump, oral opioid, IV opioids, epidural or spinal meds depending on what the patient has had done, should take pain meds regularly TOTAL HIP- ball and socket, use a femoral stem that sticks into a femur and attach socket (ball) Hip fracture- highly happens in older adults especially older women that have osteoporosis, leg may appear adducted- close together(close to the midline), shorten and externally rotated, decrease mobility, pain in the hip, groin, medial side if the knee or the outer thigh, limited ROM Intracapsular- fracture of the neck of the femur, they could damage the vascular system that supply\'s blood to the head and neck of the femur, may become ischemic, avascular necrosis could happen Extracapsular-fracture of the trochanter region, heal more readily but have more tissue damage With a hip fracture the mortality rate is 12-30% within one year, comorbidities have a lot to do with it Prevention- regular bone density test, fall precautions, weight baring, exercise helps keep calcium in the bone Treatment and management- Xray, bucks traction skin traction to keep in alignment, but will have surgery in 12-24 hours, surgical options, may be open or closed reduction, may be internal fixator, or partial hip or total hip replacement. Goal is to obtain satisfactory fixation and immobilize the patient quickly to avoid secondary complications. Nursing assessment- conditions that require monitoring, respiratory is going to prone them more to pneumonia. Dehydration, muscle weakness, stress and immobility predisposes the patient to atelectasis, pneumonia, sepsis, venous thrombosis, pressure injuries, and reduced ability to cope with unfamiliar surroundings, medications, sleep deprivations and can be a problem because it can lead to delirium Diagnosis-acute pain, impaired physical mobility, risk for infection, risk for DVT, skin integrity, ineffective coping. Interventions- T.H- maintain the hip in a neutral position (want it straight forward) helps to prevent stress at the sight, trochanter rolls can be use with a bath blanket, abductor pillows, isometric quad and gluteal exercises to strengthen their muscles, use a trapeze for patients with upper body strength to move themselves, walker, cane, physical therapy. Promoting comfort administer analgesics as prescribed, bucks\' traction, with these patients we don't want their pain to get out of control, handle the extremity gently, support pillows, frequent position changes, alternate pain methods, watch out for DVT, hemorrhage neurovascular complications, pressure injuries Osteoporosis- Access, most common bone disease, risks are- genetic, nutrition, physical activity, medications, endocrine disorders, general health and post-menopausal, common is small framed Asian and Caucasian women, older adults need to increase amount of calcium taking due to decrease absorption, and increased excretion, can be caused by corticoid steroids known as secondary osteoporosis, women greater then 80 yo, reduced bone mass and deterioration of bone matrix, Older at risk, bone becomes porous, spine collapses, end up with Kyphosis (bent over) or start shrinking, lordosis (spine) Effected- bone turnover --bine reabsorption greater than the rate of formation, decreased strength, bones become porous or brittle leading to compression fractures (spine) Prevention- after menopause, increase calcium and vitamin b, modify lifestyle decrease caffeine, smoking, carbs, soft drinks and alcohol, regular weight baring exercise can be helpful to keep calcium in the bone and stimulate bone mineral density A-alcohol use, C-corticoid steroid use (long term use can be damaging to bones), C-calcium low, E-estrogen low, S-smoking, S-sedentary lifestyle Assessment and diagnostic findings- Dexa or dual energy Xray- bone density test recommended for women over the age of 50 post-menopausal, tells them percentages of how at risk they are for fracture, fracture risk assessment tool, labs-calcium, phosphorus, alkaline, phosphate, urine calcium, hematocrit, ESR-Detects inflammation Managment- diet rich in vitamin D, regular weight baring exercise, meds calcium vitamin d supplements, bisphosphonates on the meds list (specific instructions- take first thing in the morning, sitting up right, 2 hours before food, drink 8 oz of water with it, phrotao is an injection Fracture management- joint replacement, compression fracture spine stabilization surgery Osteomyelitis- infection of the bone results in inflammation, necrosis and formation of new bone, occurs due to an extension of soft tissue infection or direct bone contamination (contiguous) due to open fracture, traumatic injury, orthopedic surgery)), or blood born (hematogenous) from another site if infection, vascular insufficiency usually a patient with diabetes and PVD Risk factors on the slide- older adult, poor nutrition, obese, immunocompromised, diabetes, chronic illness, orthopedic surgery, on corticoid steroids, immunosuppressant agents or IV drug use. S/S- constant pulsating pain, area swollen, tender to touch, non-healing ulcer or fracture TOTAL KNEE REPLACEMENT- overnight stay, educate more because pt goes home and must take care of it, CPM- continuous passive motion machine, ICE Compartment syndrome complications- fat embolism happens with fractures of the large bones, fat globules will embolize and go into your lung (prevent at all costs not much can be done once this happens) Assist devices- Physical therapy will help set up device to appropriate height, DO NOT share device, Walkers- go with affected leg don't use to pull themselves up, Canes- opposite of affected leg, Crutches-partial could be weight baring or non-weight baring and have erect posture , all weight on the hand bars don't lean armpits on top could cause nerve damage, gates for crutches, swing through and swing too, 4 point, 3 point, 2 point, most common is the swing through. Contusion- soft tissue injury produced by blunt force into the soft tissue, pain swelling discoloration, ecchymosis Strain- pulled muscle or tendon injury due to overuse, it can have edema, muscle spasm, ecchymosis or loss of function Dislocation-when articular surfaces of the joint are not in contact (common in the shoulder and the hip) Traumatic dislocation is an emergency due to possible development due to avascular necrosis Avascular necrosis- no blood supply to the tissue or bone, bone can weaken and collapse Hematoma- bleeding into the tissue that can compromise circulation-do a neuro vascular assessment Treatment and management for injuries PRICE Protect from further injury, rest allows healing, ice intermittent applications for 20- 30 mins in the first 48hours causing vasoconstriction to reduce edema, discomfort, bleeding, swelling, compression strain or sprain to help provide support reduce edema and swelling, elevation to help with swelling ,Immobilization- slings, reduction to put back in anatomical alignment, after could do gentle ROM with support Sports injuries could be a rotator cuff tear, tear in the tendon that connects one of the rotator muscles to the humeral head, treat with rest, NSAIDs, cortisone injections, physical therapy Lateral and medial collateral ligament is another common injury this is of the knee, treat with PRICE, aspiration of the joint, passive ROM, physical therapy Cruciate ligament the anterior ACL and posterior PCL, helps to stabilize the knee, injury you will hear a POP noise, significant swelling on two hours, put in a brace, physical therapy and reconstructive surgery Stress fracture result from repeated loading of bone and muscle Meniscus- shock absorber, in between ACL and PCL, physical therapy if that doesn't work, they will do a repair Prevention of sports injuries use proper equipment, proper running shoes, wrist guards, effective training and conditioning, specific to the person and the sport, stretching prior to engaging in a sport or exercise but may not prevent injury, changes in activity in stresses should occur gradually, give yourself time to cool down, ne attune to the body be aware of capabilities and limits. Fractures Complete or incomplete disruption of bone structure, it occurs when bones are exposed to stress greater than it can absorb Complete- break across the entire cross section of the bone, that\'s when the bone is displaced Incomplete- part of the bone that is fractured Comminuted- means that its bone fragments Closed- means no break in the skin or mucous membranes Open --was a break in skin or mucous membranes, does have different grades the higher the grade the more extensive tissue damage (broke through the skin will involve a wound dressing and need to be covered to prevent an infection) Inarticular- it extends into the joint, can lead to arthritis S/S- pain, continuous and increasing pain until it is immobilized, pian from muscle spasm that can begin within 20 mins, loss of function, deformity, shortening of the extremity due to muscle spasms compression, crepitus you can hear it or palpate it, its bone fragments, localized edema and ecchymosis Management- use immobilizers joint distal and proximal to the suspected fracture sight is supported and immobilized, splints (ridged, control movement and prevent additional injury) is stable and used for sprains tendon injuries and other soft tissues injuries, and braces (helps with movement), a lot of this is done in outpatient, check neurovascular status, check the 6Ps Cast- ridged, external, immobilizing device that is molded to the contour of the body, used to apply uniform pressure and material could be fiberglass or plaster, or the patient could have surgery as part of the management, used to reduce fracture, correct deformity and it applies uniform pressure to SOFT tissue. Materials used would be non-plaster, they are lightweight and water resistant, could swim or shower with them, still should be covered, dries on 2-3 hours once its applied, sometimes they soak them, and it doesn't fully dry and then there could be a fungal infection, itchier. Plaster-takes about 24-72 hours to dry completely, doesn't have its full strength until it dries, less costly, better mold, (blow dryer on the cold setting to dry them if they get wet) if they get cast wet and they feel like there is a hotspot we would want to investigate Pressure areas in the cast- unrelieved pain that has to be reported to the doctor to AVOID paralysis and necrosis, never want to ignore complaints of pain that could indicate poor tissue perfusion or pressure ulcer formation, complaints could be burning pain, want to check the cast when it\'s a plastered cast it shouldn't be leaned on that is what causes dents and those dents can cause an pressure injury Nursing interventions- maintain skin integrity, may have a skin wound may have to apply a dressing that's when they will bivalve the cast, treat the wound apply the cast in place and then over wrap it. S/S- pressure or infection, may need a tetanus booster, maintain neuro vascular status assessing CIRCULATION, SENSATION, AND MOEVEMENT AND 6 PS, notify the doctor of any signs of compromise, elevate the extremity NO HIGHER THEN THE HEART, encourage movement of the fingers and toes every hours, always compare to the other extremities, should have minimal edema, discomfort, skin should look pink in color, have rapid capillary refill and sensation, elevate to reduce edema, apply ice, position changes and administration of analgesics, Unrelieved pain may indicate COMPARTMENT SYNDROME, require a change pf a cast notify the doctor, want to teach the patients S/S that can occur- if they notice increased swelling, can't move their fingers and toes, pain, itchy Surgery- fracture reduction putting it back in anatomical alignment, can be closed- manipulation and manual traction is applied and then the cast is applied or open fracture they go into surgery they could use an internal fixator device, pins and wires can be uses to hold it in place, it is reduces and stabilized with external fixator for 5-7 days, IV antibiotics a wound that needs to be cleansed at risk or osteomyelitis and tetanus - can be done under anesthesia with pinning traction may be used until its stable enough to undergo surgical fixation Nursing prevention -- assess every 1-3 hours, check the skin, check symmetry, bruising, apply ice, neuro vascular status of the effected limb, provide pain relief Complications- factors that can impair is inadequate immobilization, inadequate blood supply and infection, Early-shock, fat embolism, compartment syndrome, DVT, PE Delayed- complex regional pain syndrome-inappropriate response to tissue injury after injury it could happen after surgery, stroke or MI patient would have extreme pain, swelling, limited ROM, change in skin tone, can start in one limb and go throughout the body/ heterogenic ossification- due to injury there is bone that is in the soft tissue, can happen after joint replacement surgery, they will have pain , fever, soft tissue swelling and poor mobility of the limb/ and sepsis External fixator- used to manage open fractures with soft tissue damage provides support for complicated or comminuted fractures, (LOOK OUT FOR INFECTION AT THE PIN SIGHTS redness drainage pain or tenderness foul odor, assess every 8 hours ) surgical insertion of pins into the bone held by an external metal apparatus that will hold the fracture in alignment. Neuro vascular checks are important, 6Ps, pin care is important, clean pin sight with chlorhexidine solution than apply bacitracin every 8 hours, should be assessing 8 hours for S/S, could use traction which uses a pulling force to maintain and promote alignment and is done for a short period of time, temporary means until surgery can happen, with traction it\'s important that proper position, cannot turn side to side can shift slightly with help, skin integrity is important, inspecting the skin using skin sealants (lollipops) to protect the skin, especially over boney prominences to prevent skin break down, special mattress, assess for nerve damage, have them plantar or dorsiflex, checking circulation is important Patient teaching- should be pin care, chlorhexidine solutions to clean pin sights and apply bacitracin, pain care, S/S of infections and when to notify the provider, once the soft tissue has healed the fixator will be removed AS A NURSE WE NEVER ADJUST THE PINS WE JUST CLEAN AND MONITOR THEM Internal fixators-6Ps, assess for signs and symptoms of infection, Nursing management- assessing the skin, elevating the extremity, checking symmetry, apply ICE, pain relief Acute complications- compartment syndrome- blood flow is compromised, body has 46 compartments, 36 are in the extremities, limb threatening, emergency, suspected we NEED to contact health care provider, compartment is an area of the body incased by fascia that contains the muscles, nerves, and blood vessels, elevated pressure within the compartment there is a decrease in blood flow distal to the tissue injury that can result in ISCHEMIC NECROSIS prompt intervention does not occur( have to address right away),this can occur due to a cast or a dressing being too tight, can occur if there is increases volume in the compartment (if the patient has increased swelling, bleeding within that compartment, if a patient is in traction and they have the Velcro boot that is too tight) Pressure ulcers or injuries- cast can create a hotspot, have odor or drainage these are signs of pressure injury Cast syndrome is a psychological/ physiologic condition --patient has anxiety, increase respiration, diaphoresis (sweating), dilated pupils, increase heart rate, hypertension, can happen with a spica cast- is the whole trunk of the body Management- pain meds, anti-anxiety meds Fat embolisms- more common in men under 40 yo and patients that have multiple fractures, it occurs 12-72 hours after the injury, is very common with a femur (largest bone) fracture, fat globules leave the marrow and enter the vascular compartment and the stress response releases fatty acids as well, the fat globules occlude the small blood vessels that supply the lungs, brain, kidneys and other organs. It usually goes to the lungs and causes respiratory complications, HYPOXIA, decreased PA02 80-100, tachypnea, crackles and wheezes, chest pain, cough, thick white sputum, tachycardia, fever, pulmonary edema, atelectasis, pale, later sign 2-3 days after they will have THROMBOCYTOPNE which leads to petechiae of the upper body. Can lead to neuro disfunction, mental status changes, restlessness, headache, agitation, seizures, delirium and coma. Risk factors- would be long bone femur-hip replacement surgery or major trauma, management- prevent by position changes and early surgical fixation. If they do have fat embolisms it could lead to intubation, steroids, vasopressors, mortality rate is high. Complications could be shock, hypovolemic shock with hemorrhage from trauma if they have a pelvic fracture or torn artery, delayed healing is due to infection, avascular necrosis is due to bone losing blood supply can happen with dislocation. Fracture locations Clavicle- due to a fall or direct blow to the shoulder, assume a protective position by slumping the shoulders and immobilize the effected arm. Use a clavicular strap to keep it in alignment and immobilize the fracture, use exercises to exercise the arm, elbow, wrist and fingers, they do not elevate the arm (do not want the arm elevated above the shoulders or approximately 6 ft) Humoral, neck, shaft fracture- use slings and braces to support the arm and it is usually at a 90 degree of flexion, encourage them to do pendulum exercises once they are healed for prevention of future injury, unaffected arm is used to help the effected arm humeral fracture- use an immobilizer 90 degree of flexion pelvic fracture- can be caused by falls a motor vehicle accident, crush injury, high mortality rate due to complications of shock, fat emboli, hemorrhage, pulmonary problems and infection, also might be injuries to the bladder, the rectum, intestines, pelvic vessels and the nerves. Need to do a neuro vascular assessment to determine extended injuries, fracture may be stable or unstable. with the pelvis the sacrum, ileum, pubis, and ischium form the pelvic bone S/S- P.F- ecchymosis, tenderness, numbness and tingling of the pubis and genitalia and thighs, they are unable to bare weight, hemorrhage due to torn artery, bone fragments, handle the patient very gently Stable-one part is affected Unstable- broken in more than one spot Joint replacement- Used to treat severe joint pain and disability for repair and management of joint fractures or joint necrosis, frequently replace including the hip and the knee, patients with osteoarthritis or rheumatoid arthritis, congenital deformities, trauma, femoral neck fracture will need joint replacement Post op- mobility and ambulation will begin within a day after surgery using a walker or crutches, weight baring as prescribed by the provider, usually a drain post op, assess for fluid, drains should have decreasing amounts of drainage after 48 hours should decrease to 25-30 mls, once the drain shows very little drainage that\'s when it will be taken out by the doctor, if you notice greater than 250mls of drainage in the first 8 hours call the doctor, bright red drainage it is an indicator of bleeding, part of prevention is checking the incision line for signs of infection Total hip arthroplasty (replacement) - They would get it due to arthritis, hip fracture, failed reconstruction surgery, leg has hurts disease that happens in childhood its avascular necrosis Nursing interventions- looking out for complications, dislocation, infection, excessive wound drainage, venous thromboembolism, DVT, pressure ulcer, heterotopic ossification- formation of bone in the prosthetic space, avascular necrosis, want to make sure they are in a correct position and monitor for wound drainage, could use a trapeze, should be supine with the HOB slightly elevated, less than 60 degrees, and effected leg should be in neutral position, use abductor pillow, should NOT be turned on the OPERATIVE SIDE, legs need to remain abducted