Osteoporosis and Orthopedic Surgery - Assignment Example

Running Head: NUR2004 ORTHOPAEDIC ASSIGNMENT NUR2004 Orthopaedic assignment Insert Name Insert Course Insert Tutor’s / Professor’s Name 28th August, 2009 Introduction This paper discusses osteoporosis and orthopedic surgery. It first gives a general overview of osteoporosis and its epidemiology in Australia, then goes on to tackle the general overview of orthopedic surgery, it further proceeds to discuss the pathophysiology of fracture healing process, after that it also looks at the nursing Management after orthopedic surgery in respect to Anna’s case. This paper also looks at the Pharmacology and treatment of Osteoporosis with respect to Anna’s case conditions, the paper finally tackles the potential complications of fracture in compartment syndrome. General overview of osteoporosis and Its Epidemiology in Australia Osteoporosis is a medical condition which increases the human skeletal fragility. In the Clinical fraternity osteoporosis is normally defined with relation to the bone density (Bruce, 1999). Bone strength in a human’s life usually depends on two distinct factors which are the strength of the skeletal system which an individual achieves during adulthood and the second factor is the bone loss due to hormone deficiency (Bruce, 1999). Osteoporosis usually manifests with fracturing of the bones and trauma. Elderly women are usually at a higher risk developing osteoporosis and it usually occurs just after menopause (Avila, Colditz, et al., 1991). When a woman approaches menopause bone turnover increases. Bone loss during this time in a woman’s life usually occurs by perforation, thinning, and loss of connectivity (Simonelli, Killeen, Meehle, and Swanson, 2002). Osteoporosis in men usually ids not a common condition and if it happens there is thinning which is usually due to reduction of bone formation. The epidemiological study of Dubbo Osteoporosis, which was a study that had a very big cohort, and included old women and men who were involved in the study from the year 1989 onwards, found out that after the age of sixty year about sixty percent of women and thirty percent of men got fractures (Jones, Nguyen, Sambrook, et al., 1994). In Australia the cost of managing and rehabilitating osteoporosis fractures was estimated at about seven hundred and seventy nine million Australian dollars (Access Economics 2001, 2001). A lot of expenditure was on the rehabilitation services among the hospital treated fractures and the highest cost of expenditure on outpatient fractures was on community care of the patients. In Australia there is more likelihood of individuals with osteoporosis to develop hip fractures and almost all the hip fracture patients were hospitalized. In the Dubbo Osteoporosis study only ten percent of individuals aged between sixty and seventy nine years of age had hip fractures, in contrast to forty percent of those individuals aged above eighty years (Medical Journal of Australia, 1997). Another recent study carried out in northern Sydney reveals that death after hip fracture stood at 24% after twelve months, which is about 5 times more than that in an age-matched grouping of individuals who had not suffered from hip fracture (Angelo, Giudici, Molina, and Margaria, 2005). The north Australian study also shows that between twenty percent and twenty six percent of individuals with hip fractures were always contained in the nursing homes thought the rest of their lives (Angelo, Giudici, Molina, and Margaria, 2005). Osteoporosis fractures problem is becoming a major public health concern and has been seen to increase with the ageing of the population. Australia in the year 1994 had an estimate of fourteen thousands six hundred hip fractures. General Overview of Orthopedic Surgery Orthopedic also sometimes written as orthopaedic is a branch of surgery which is performed by medical specialists known as orthopedic surgeons or orthopedist who undergo thorough training to deal with problems or disorders which develops in the human skeletal system comprising of joints, bones and ligaments of the human body. The type of treatments which is administered by orthopedists is so enormous. It can range from amputation to traction, spinal fusion to joint replacements. Orthopedists also treat dislocations, broken bones, sprain, and strains (Schwartz, Fischer, et al., 1998). Orthopedists are usually found in trauma centers, hospitals, free standing surgical clinics, and medical centers. The surgical team usually comprises of a surgical nurse and an orthopedist and an anesthesiologist who work together in carrying out the orthopedic related function which is brought forth by a client or patient. Orthopedic treatment and surgery is an activity which can be carried out under regional, general and local anesthesia. Orthopedists are always charged with the duty of adding pins, screws, wires, tongs and prosthetics to a patient’s body in order to redo the damaged bones and to ensure the proper replacement or alignment of connective tissue or bone (Schwartz, Fischer, et al., 1998). There have been radical innovations and improvements which have attained in the production and fixing of artificial joints and limbs. There has also been advancement in selection of the kind of materials which are used to do the orthopedic repairs of the affected connective tissues or bones. As further advancements and more developments are being made in the science of metallurgy and plastic manufacture, more and more changes do occur also in orthopedic surgery as well. This advancement in technology is bound to allow orthopedic surgeons to perfect there practice to a level of even duplicating the indigenous functioning of our natural skeletal system to an ability of precisely restoring the damages done to a part of the skeletal system of the human body back to their original functioning. Patients are usually asked to visit an orthopedic surgeon by normal primary care medical personnel, a trauma attendant physician, or just a medical doctor. Before the orthopedic surgery is done, the patient usually goes through thorough testing which is aimed at enabling the orthopedists to identify which forms of corrective procedures and treatments to be administered to the respective patient (Simonelli, Killeen, Meehle, and Swanson, 2002). The types of tests done before the real surgery might include; computerized tomography also known as CT scan, X rays, electro- magnetic resonance (MRI), arthroplastic diagnosis, myelograms, and blood serum tests (Canale, 2003). This tests and diagnostic procedures helps the orthopedist to correctly determine retrospective history of the type of the disorder and type of treatment previously administered to the respective patient in order for the specialist to give the right directives before the corrective surgery is initiated (Bland, and Sarr, 2001). The orthopedic patient just before being taken in for the prescribed corrective surgery by the surgeon, is made to undergo urine and blood tests then he or she is also given a an electrocardiogram or any other relevant post operation test in order to find out any complication or details that the patient manifests which might badly impact the surgery procedure or the healing process. It is also very important to make the individuals which are to be operated on to donate blood which is supposed to act as a reserve of blood which is sometimes used when a major surgery procedure is done which usually makes the patients to loose a lot of blood. Pathophysiology of Fracture Healing Process Fracture healing in the human body involves five phases. This phases include; fracturing and inflammation phase, granulation or tissue forming phase, formation of callus phase, lamellar bone deposition phase, and the bone remodeling phase (Frost, 1989). Actual fractures are those injuries caused to the local soft tissues, the periosteum and the bone marrow. The most significant, and most important stage in the healing or recovery of fractures, is usually the inflammatory phase which is always manifested by the formation of hematoma (Tscherne and Oestern, 1982). It is during this particular phase that inflammatory mechanisms and chemotaxis activities are initiated by the body in order to attract the necessary cells which are responsible for the initiation of the healing response. By the end of the seventh day after the fracture, the body will have formed granulation tissue in between the fragments of the fracture. There are several biochemical substances which are actively involved in granulation tissue formation stage, a stage which usually lasts up to two weeks. Callus formation phase is usually characterized by proliferation of cells and active cell differentiation in order to produce chondroblasts and osteoblasts in the initially formed granulation tissues. The chondroblasts and osteoblasts which are produced during the callus formation phase then actively synthesizes extra cellular matrix of woven cartilage and bone. After this activity the newly formed bone undergoes extensive mineral deposition in order to give it enough strength and support. This particular phase lasts for almost four to sixteen weeks depending on the age and other related factors which can either speed up healing or slow down the healing process. The forth phase sets in immediately after bone mineralization and involves the replacement of the woven bone which by this stage is mesh like with the lamellar bone, which is usually an elaborate organized parallel to the axis of the formed bone. The fifth and final phase is characterized by the remodeling of the bone at the exact site of the fracture which is undergoing the healing process. This last stage involves the conformation of the bone to fully assume its original strength and structure by the help of cellular materials such as osteoclasts. Phase four and five usually lasts one to four years depending on several factors in the body which might influence this condition. There are several distinct factors which influence the fracture healing process in a patient. These factors might include medication use, age, comorbidities, nutrition and social factors. There are also specific factors which might also influence the rate of fracture healing such as the degree of trauma to the patient, the type of fracture, systemic disease, local disease, and infection. Patients who manifest poor prognostic factors which are related to the fracture healing are usually at a very high risk of developing complications because of the fracture. Some of the complications might include malunion which basically means healing of the fracture in unacceptable plane position, nonunion which means that the fracture does not show any possible healing chance chronic pain due to the fracture and pain due to osteomylacia (Madsen, 2008). There are three immediate causes of fracture healing disturbances which a patient might be exposed to. They include; wrong movement instability, insufficient blood supply to the fracture site, concomitant bone necrosis, and fragments mis-contact. The trauma which the patient is exposed to and the destruction of blood vessels are the main causes of bone necrosis. If vessels which drain blood to the medullar of the bone are cut from the entire circulatory system then they can be the cause of necrosis. In order to enable stable healing of the bone, there should be no excessive strain to the bone, especially during the callus formation phase. Otherwise if such happens, pseudathrosis and callus fracture might easily occur. Another complication occurs when there is lack of fragmentation contact in spongy bones, this might lead to defects in the healing process and this must make an early spongiosa transplantation to be made. The various forms of complication which arises from bone fracture healing usually arises due to combined factors which can act together to bring a major medical challenge to the healing process of the patient’s fracture. Some of the well known factors include the patient’s sex, age, lifestyle, comorbidities, and occupation (Wagner, and Frigg, 2006). In the case of Anna, there are various risk factors which might have caused the complication of her fracture healing process. The quit evident factor is that Anna is quit of age and this is a well known factor which compromises fracture healing process, the other evident factor is that Anna has a lifetime history of osteoporosis and even at the time she undergoes an X ray test the presence of osteoporosis changes are revealed. Osteoporosis is usually the thinning of the bones which makes the mass of the bone to be reduced. This is caused by erosion of bone calcium and proteins which in itself makes an individual prone to fractures which are always slow to heal and can heal poorly (Cooper, 1997). It is a condition which is common in elderly individuals especially women who have are past menopause. Nursing Management of Anna’s post-surgery In orthopedic surgery there are usually a high potential of likelihood of complications to life and to the limbs of the respective patient. Therefore the specialists who are attending to Anna should be in position to quickly identify the post surgery complications which Anna develops bearing in mind that she also has an osteoporosis problem. Understanding of post orthopedic surgery complication is vital in the early recognition, prevention and treatment of the patient. The most common of all the long bone fractures is tibial fractures which has a yearly incidence of 2 tibial fractures per every one thousands individuals (Alho, Benterud, et al 1992). The type of treatment offered to tibial fracture patients, should therefore depend on the displacement caused, the location of the fracture, the comminution of the fracture, and the condition of the soft tissue. But if the patient happens to be elderly he or she is should undergo fixation of intramedullary nail (Hooper, Keddell, and Penny, 1991) of which Anna underwent. Since Anna has developed multiple sutured wounds after the fixation of the nail the first nursing step to relieve Anna’ s pain due to the wounds is apply cyanoacrylate adhesives (Derma bond, Liqui Band, Indermil) which functions to close the surface wounds and lacerations. These adhesives are usually viscous than water and should be applied to the Anna’s skin in thin layers. One other nursing issue which should be kept under close watch is the sterile dressing changes. Clean technique of wound dressing should be emphasized in order to keep Anna free from infections. Because Anna has just been through surgery the first thing to be done is to avoid great pressure to her left affected leg by supporting it. This is because the first thing that happens after surgery is usually inflammation which usually lasts three to four days and during this moment the patient’s skin is usually held together by clots of blood and new vessels which are reaching out to close wound. Excess pressure and infections are the two most dangers to the initial healing stages. After day four of Anna’s post surgery care, the nurses should be keen of evisceration and dehisceration which are usually an emergency during this time (Mangram, A., et al., 1999). If a patient experiences dehiscence he or she usually has an opening on the surgical part and this should be a warning to the specialist that may be something might have been given way and in such an incident the nurse should keep the wound sterile and report this to the surgeon. This alarm period usually lasts from four to twenty one days (Mangram, A., et al., 1999). During this time pink granulation tissue usually fills the place and the place remains inflamed. Because this wound is always susceptible to bleeding at any time the nurse should teach Anna how to avoid more stress or damage to the wound for example by not lifting or stretching her left leg. Since today’s medical practices have shortened the hospitalization time Anna might be allowed to go home even before the healing process ids through so Anna needs to be educated of what she should expect and what she needs to do in order to care for herself (Canale, 2003). Another thing that should be observed is that, because Anna is an osteoporosis patient she needs to be given extra care and continue receiving osteoporosis treatment in order to a void complication which might result due to osteoporosis. Because Anna has to be discharged from hospital before she is fully recovered, she needs to be educated on the does and the don’ts and all the necessary information which will help her to hasten her recovery and to enable her not to develop complications. Anna should be told that since she is going home before full recovery she should keep watch of her wound which is forming granulation tissues and making her wound to be inflamed and that because her wound would be prone to further bleeding she should avoid any activity which might cause more damage and stress to her wounds for example by not lifting her left leg, by having more bed rests, and by putting the leg horizontally straight while sitting. Anna should be told that it will take some time before the wounds are finally filled with collagen and make them smaller, stronger, and less likely to bleed. Anna should also be educated to understand that the amount of bleeding which she might be going through will gradually lessen and that the colour of the wound will with time become less and less pink in colour and it will start becoming yellow as days go by. Anna should also be told that in case she blood suddenly increases to ooze out, or when her wounds develops signs of infections and complications then she should make a point of immediately calling her physician. After Anna undergoing the orthopedic surgery just like other limb fracture patients, she should undergo a rehabilitation process which usually at times takes a very long period of time. The process of rehabilitation is always a mental and physical taxing activity. After surgery the orthopedic surgeons should not terminate their relationship with Anna. Anna should always make a point of being in close association with her physiotherapists who will take her through the rehabilitation process; all this is meant to ensure that Anna is well monitored in order to enable her to attain back the normal functioning of the initially affected left leg. Anna should also be told that if her healing progresses on well then her left leg might be quit shorter than her right leg and that she will be feeling some mild pains in the affected area at some times during her stay which can only cause an alarm for further visits to the physician if the pain drastically becomes strong. Pharmacology of Anna’s Conditions Osteoporosis is managed by treatment which is categorized into two distinct classes of medication. Osteoporosis treatment is usually aimed at preventing fractures in patients with osteoporosis and preventing further fractures in patients who are already have their bones fractured. They act by bone remodeling imbalance correction or by stimulating bone formation (Avila, Colditz, et al., 1991). This kind of treatment should always be given to women who are above seventy years like Anna. Some of the therapeutic drugs classes available for treatment of osteoporosis include; use of selective estrogen receptor modulators such as fluoride and raloxifine. The other class of treatment is the use of hormone replacement therapy, under this therapy there is the use of such hormones as estrogen and use of non hormonal drugs such as calcitonin and biphosphonates (alendronate), calcitonin, selective estrogen-receptor modulators (raloxifene), and fluoride. The other three classes of osteoporosis drugs which Anna might use are; the human parathyroid hormone, use of growth hormone known as somatotropin, and finally the use of combination therapy which involves the use of two different antiresorptive agents from different classes. The following table shows the information regarding treatment of osteoporosis by showing the generic names for each class of drug, the usual route of administration, the potential side effects of administration, and the rationale for use the drug use.   Class and Drug Brand Name Usual Route of Admn. Side Effects Rationale for use Bisphosphonates Class     Abdominal or musculoskeletal pain, irritation of the esophagus, nausea, and heartburn Enhances bone resorption Alendronate Fosamax® Oral (tablet) , , , , Alendronate     Fosamax Plus D™ (with 2,800 IU or 5,600 IU of Vitamin D3)  Oral (tablet) , , , , Alendronate Fosamax® Oral (liquid solution) , , , , Ibandronate  Boniva® Oral (tablet) , , , , Ibandronate   Boniva® Intravenous  (IV) , , , , Risedronate    Actonel® Oral (tablet) , , , , Risedronate  Actonel® with Calcium Oral (tablet) , , , , Zoledronic Acid   Reclast® Intravenous (IV) , , , , Calcitonin Class       1) Used where estrogen is contraindicated. 2) It inhibits the activity of specialized bone cells called osteoclasts. Calcitonin Fortical® Nasal spray Running nose, nasal crust, dryness, redness, irritation, sinusitis, nose bleeds, and headache. , , Calcitonin Miacalcin® Nasal spray Running nose, nasal crust, dryness, redness, irritation, sinusitis, nose bleeds, and headache. , , Calcitonin Miacalcin® Injection Headache , , Estrogen* Class       Breast cancer, endometrial cancer, vaginal bleeding, formation of blood clots, elevated blood pressure, and throbo-embolism 1) Decreasing fracture rates in women immediately after menopause. 2). Reduces bone turnover and thus conserves bone mass Estrogen    Multiple Brands Oral (tablet) , , , , Estrogen    Multiple Brands Transdermal (skin) patch , , , , Estrogen also called Selective Estrogen Receptor Modulators (SERMs) Class     1) Hot flushes and leg cramps. 2) Vein thrombosis 1) Acts as weak estrogen in some systems and as an estrogen antagonist in others. 2) Protection against four important hormone-dependent diseases: osteoporosis, coronary artery disease, endometrial cancer, and breast cancer. Raloxifene   Evista® Oral (tablet) , , , , Parathyroid Hormone Class       Transient muscle cramps, and increase in blood concentration of calcium 1) Stimulates bone turnover and causes an increase in bone formation. 2) Use is limited to two years. Teriparatide   Forteo® Injection , , , , Potential Complication of Fracture in Compartment Syndrome Compartment syndrome can either be chronic or acute which is caused by the raising of tissue pressure within the fascial space; this pressure is abnormally high and leads to lowering of blood flowing into the extremity (Pollak, and Ficke, 2008). It usually occurs after an injury to the arms and causes bleeding at the injured place. If this condition is not treated immediately then it can cause muscle damage, nerve damages, and even loss of the affected limb. Acute compartment syndrome is usually treated as an emergency which urgently needs fasciotomy if the pressure is too high. Fasciotomy is the incision of the skin to open up the place in order to relieve the pressure. Chronic compartment syndrome on the other hand may be managed by decreasing physiotherapy and then return to the regular exercises slowly. Steroid free anti-inflammatory medication may be used. If the above does not work then fasciotomy is done (Bong, Polatsch, Jazrawi, Roki, 2005). Conclusion With the drastic global increase of osteoporosis and its related complications there is need for an elaborate system for its monitoring and surveillance in order to improve its control and management. An effective framework should be made which is supposed to enable intensive osteoporosis epidemiology in Australia and also enable individuals to have maximum benefits from various health care interventions. References Access Economics 2001. (2001). Costing of osteoporosis burden in Australia. Canberra. Alho, A., Benterud, J., Hogevold, H., Ekeland, A., and Stromsoe, K. (1992). “intramedullary nailing in the management and rehabilitation of tibial shaft fractures.” Clinical Orthopedic. 277: 243–250. Angelo, F., Giudici, M., Molina, M, and Margaria, G. (2005). Mortality rate after hip hemiarthroplasty: analysis of risk factors in 299 consecutives cases. 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