• Decalcification and softening of bones.
• Due to a lack of vitamin D or a problem with the body’s ability to break down and use this vitamin.
• Rickets in children.
• In adults, the condition is called osteomalacia; and in children, it’s known as rickets. Each one is a condition where prolonged and excessive vitamin D deficiency causes bones to soften, weaken, and easily fracture.

Rickets

• Disease of growing bones of children (in it epiphyseal plate not closed) in which defective mineralization occurs in both bone and cartilage of epiphyseal growth plate.

Osteomalacia

• Disorder of mature bones in adult (after epiphyseal plate closure) in which mineralization of new osteoid bone is inadequate or delayed

RISK FACTORS

• Chronic diarrhea
• GIT malabsorption
• Lack of exposure to sunlight
• Pregnancy
• Avoidance of milk
• Sedentary lifestyle
• Renal disease
• Use of strong sunscreen

CLINICAL/DIAGNOSTIC MANIFESTATION

• Fractures
• Persistent and diffuse skeletal pain
• Progressive deformities of bones
  • 1. Bowed legs
    2. Knock knees
    3. Rachitic rosary
    4. Enlarged wrists and ankles
    5. Pigeon breast
• Progressive muscle weakness
• Decreased serum levels of Calcium (44-107 IU/L)
• Looser zones on X-ray.
• Roentgenograms shows bone demineralization and multiple bone deformities. (white: more dense; otherwise: black)
• Elevated serum alkaline phosphatase.

NURSING INTERVENTIONS

1. Assess posture and gait, note ability to walk with or without aid.
2. Note ability to walk requested distances.
3. Check bony prominence for pressure sores.
4. Assess shapes of bones throughout the body.
5. Administer prescribed diet.
   • Rich in Calcium
   • Rich in Vitamin D (tuna, salmon, mackerel)
6. Discuss purpose of physical therapy.
7. Assist to a position of comfort.
8. Administer prescribed analgesics.
9. Gentle back massage.
10. Instruct regarding home safety.
11. Teach family the effects of Calcium and Vitamin D on the body and the factors affecting absorption.
12. Teach client on the signs of fracture.
13. Follow up care as needed.

Difference Between Osteoporosis & Osteomalacia

• Osteoporosis refers to the degeneration of already constructed bone, making them brittle,
• While osteomalacia is an abnormality in the building process of bone, making them soft.

• Decrease in the bone mass and density with a change in bone structure.
• May be ASYMPTOMATIC until the bones become fragile and a minor injury or movement causes a fracture.
• A disease of the bone characterized by a decrease in the bone mass and density with a change in bone structure
• METABOLIC BONE DISORDERS
• Osteoporosis is a metabolic bone disease that involves an imbalance between new bone formation and bone resorption.

Primary osteoporosis is the most common type; occurs most often in women after menopause because low levels of estrogen are associated with an increase in bone resorption.

Bone loss occurs predominantly in the vertebral bodies of the spine, the femoral neck in the hip, and the distal radius of the arm. Bone mass declines, leaving the bones brittle and weak.

PATHOPHYSIOLOGY

• Normal homeostatic bone turnover is altered rate of bone RESORPTION is greater than bone FORMATION reduction in total bone mass reduction in bone mineral density prone to FRACTURE.

Low bone mass/

impaired bone quality

Inadequate peak bone mass

Early menopausal bone loss

Decrease in bone mass/bone quality

Calcium/

vitamin D deficiency

Other

factors

Fractures

TYPES:

Primary

• • advanced age
  • post-menopausal

Secondary

• • Steroids use
    • will inhibit formation of bones
    • decrease absorption of Calcium
    • increase urine Calcium loss
  • Alcohol overuse
  • 
  • Renal failure

RISK FACTORS

• Sedentary lifestyle
• Age
• Diet: caffeine, alcohol, low Calcium and Vitamin D
• Post-menopausal
• Genetics : Caucasian and Asian
• Immobility

“FAST ACCESS”

• Family history of osteoporosis 
• Age
• Surgical menopause following hysterectomy with or without oophorectomy
• Thyrotoxicity
• Alcohol
• Corticosteroids
• Calcium deficiancy (low intake)
• Eostrogen deficiency
• Smoking
• Sedentary Lifestyle

ASSESSMENT FINDINGS

• Low stature (stooping)
• Fracture (usually long bones)
• Bone pain

LABORATORY FINDINGS

1. DEXA-scan

• Provides information about bone mineral density

T-score is at least 2.5 SD below the young adult mean value

1. X-ray studies

MEDICAL MANAGEMENT

1. Diet therapy with Calcium and Vitamin D.
2. Hormone replacement therapy.
3. Moderate weight bearing exercise.
4. Management of fractures.
5. Medications.
   • 1. Calcium supplements: daily intake of calcium should be approximately 1000 mg for men and 1500 mg for postmenopausal women.
     2. Vitamin D supplements (800 to 1000 IU recommended daily for postmenopausal women and older adults) to enhance utilization of calcium; spending 20 minutes daily in the sun will provide adequate vitamin D.
6. Surgical
   1. Kyphoplasty
   • Balloon creates a cavity in vertebral body in which to inject cement
   • Restores vertebral body height in 70%
   • Reduces fracture
   • Partially corrects kyphosis
   1. Vertebroplasty
   • Fluoroscopic procedure where cement is injected into vertebral body
   • Prevents further collapse, does not restore height
   • Pain relief within 48 hours generally, effective in 75-90%

NURSING INTERVENTIONS

1. Promote understanding of osteoporosis and the treatment regimen.

• Provide adequate dietary supplement of Calcium and Vitamin D.
• Instruct to employ a regular program of moderate exercises and physical activity.
• Manage the constipating side effect of Calcium supplements.
• Take Calcium supplements with meals.
• Avoid alcohol and coffee if under Calcium Therapy.
• Instruct on intake of hormonal replacement.
• Other medications:
  1. Selective Estrogen Receptor Modulators [SERMs] (Evista)
• Drugs that block the naturally circulating estrogen in breast tissues and other estrogensensitive tissues in the body.

Alendrolate sodium

• A synthetic drug analog of pyrophosphate that acts primarily on bone to inhibit its resorption and is used to treat and prevent osteoporosis in postmenopausal women.
• Used together with vitamin D.

Calcitonin

1. Relieve pain.

• Suggest that knee flexion will cause relaxation of back muscles.
• Heat application may provide comfort.
• Encourage good posture and body mechanics.
• Instruct to avoid twisting and heavy lifting.

1. Improve bowel elimination.

• Constipation is a problem of Calcium supplements and immobility.
• Advise intake of high fiber diet and increase fluids.

1. Prevent injury.

• Instruct to use isometric exercise to strengthen the trunk muscles.
• Avoid sudden bending strenuous lifting.
• Provide a safe environment.

• Infection of the bone and the bone marrow.
• Caused by direct invasion from an open wound or a systemic infection.
• Caused by lowered body resistance and decreased blood flow to the bones
• Osteomyelitis is an infection of the bone, bone marrow, and surrounding soft tissue.
• The most common causative organism is Staphylococcus aureus.
• Inflammatory response occurs initially, with increased vascularization and edema.

ETIOLOGIES

• Escherichia coli
• Neisseria gonorrhea
• Salmonella typhi
• Staphylococcus aureus (most common)

CLINICAL & DIAGNOSTIC FINDINGS

• Fever (systemic and local)
• Pain and lack of desire to use affected limb
• Culture of drainage revealing infectious microorganism
• Elevated WBC and neutrophils (WBC: 5000-10000/mm³; Neutrophils: 50-70 %)
• Weakness, headache, nausea and vomiting
• Redness, edema and inflammation
• History of trauma

DIAGNOSTIC STUDIES

• CBC- WBC may be elevated (indicates presence of active infection).
• ESR (erythrocyte sedimentation rate) – may be elevated (indicates inflammatory process).
• Bone Scan (indicates infected bone).

• Bone lesion biopsy or culture (may reveal the causative organism).

NURSING INTERVENTIONS

1. Assess site of inflammation.
2. Assess drainage from irrigating tube.
3. Assist in positioning to comfort.
4. Maintain bed rest.
5. Assist in obtaining blood specimen for culture.
6. Administer antibiotics and pain medications.
7. Offer fluids and monitor fluid status.
8. Provide divertional activities.

TREATMENT

1. Intensive intravenous (IV) antibiotics; oral antibiotic therapy for 6 to 8 weeks.
2. Immobilization of affected area.
3. Surgical debridement may be necessary.
4. Hyperbaric oxygen therapy to stimulate circulation and healing.

TEACHINGS

1. Teach self-care.
2. Wound care.
3. Self-administration of antibiotics analgesics.
4. Use of ambulatory aids.
5. Complete continuity of care.

– Inflammation of the bursa.

ETIOLOGIES

• Excessive trauma
• Excessive friction
• Rheumatoid arthritis

MANIFESTATIONS

• Point tenderness
• Limited ROM
• Calcified bursa
• History of repeated trauma

NURSING INTERVENTIONS

1. Assess bursal area and surrounding tissues for ROM limitations.
2. Apply moist compress to the area.
   • • warm: decrease swelling
     • cold: prevent swelling
3. Support inflamed tissues.
4. Arm support/sling if shoulder bursa is affected.
5. Administer prescribed medications.
6. Arrange follow up visits.
7. Refer to physical therapist for exercise regimen.

Definition of Arthritis

The word “arthritis” is derived from two Greek words: arthron, meaning a joint, and – itis, meaning inflammation. Inflammation typically involves redness, heat, swelling and tenderness. So, arthritis means an inflammation joint.

Types of Arthritis

Arthritis is not a single disease with a single cause. There are dozens of different types of arthritis, each with its own cause. These are five types of arthritis which often occurs:

GOUT/GOUTY ARTHRITIS

• Gout is an arthritic condition resulting from a defect in the metabolism of uric acid (hyperuricemia).
• Uric acid is the end product of purine metabolism.
• Hyperuricemia may also occur in individuals receiving chemotherapy (secondary gout).
• Deposition of urate crystals in the joint spaces.
• Build up is caused by lack of enzymes to complete purine metabolism. – Common in males.

Also Known As

• Disease Of Kings
• ‘Disease of kings’ on the rise as more people get gout because of increase in obesity. Soaring numbers of patients are being admitted to hospital with gout triggered by obesity and heavy drinking. The painful illness is known as the disease of kings as it afflicted a number of monarchs including Henry VIII.

Incidence

• Primary gout has 85% incidence of all cases, of which 95% are men

ETIOLOGIES

• Buildup of uric acid crystals due to incomplete metabolism of purine.
• Increased production of uric acid secondary to increased cell destruction.

Pathophysiology

• In the body, uric acid is made by enzymatic breakdown of tissue and dietary purines. Huperuricemia develops because of underexcretion or overproduction of uric acid. In addition to accumulation in the blood, uric acid is concentrated in the synovial fluid, myocardium, kidneys, and ears. When uric acid levels reach a certain level, they crystallize, and the crystals (trophy) are deposited in connective tissue. Because the crystals are deposited in connective tissue, gout is classified as a form of arthritis.

CLINICAL MANIFESTATION

• Appearance of tophi.
• Arthritic joint deformities.
• Pain on the large toe on other joints.

DIAGNOSTIC FINDING

• Elevated serum uric acid.
• Joint tenderness.
• Red hot swollen joint.
• Joint fluid analysis shows characteristic of urate crystals.

NURSING INTERVENTIONS

1. Assess severity and duration of pain.
2. Place on bed rest; keep covers off the inflamed joint.
3. Ice bag on inflamed joints.
4. Avoid ASA (Aspirin) because it will increase uric acid.
5. Administer prescribed medications.
6. Example:
   1. Uricosuricagents :↑ urinal excretion of uric acids.

• Probenecid
• Sulfinpyrazone
  1. Allopurinol: inhibit/prevent uric acid formation.

1. Monitor side effects of medications.
2. Teach client and family to control gout through diet therapy.
3. Increase fluid intake (prevent formation of renal stones).

PURINE CONTAINING FOOD

• Osteoarthritis is a progressive, non-inflammatory disease that causes a progressive degeneration of synovial joints.
• Primarily associated with aging; may also be caused by musculoskeletal injury or conditions that cause repetitive damage to joints.
• The cartilage at the ends of the long bones and in the intervertebral joints of the spine deteriorates and leaves the ends of the bones or vertebrae rubbing together; this produces a painful, swollen joint or spine.
• Most common form of degenerative joint disorder.
• Chronic, NON-systemic disorder of joints.

RISK FACTORS

• Increased age
• Obesity
• Repetitive use of joints with previous joint damage
• Anatomical deformity
• Genetic susceptibility

ASSESSMENT FINDINGS

Joint pain

• caused by:

1. commonly occurs inflamed cartilage and synovium
2. stretching of the joint capsule
3. irritating of nerve endings

Stiffness

1. commonly occurs in the morning after awakening
2. last only for less than 30 minutes
3. decreases with movement, but worsens after increased weight bearing activity d. crepitation may be elicited

DIAGNOSTIC FINDINGS

• X-ray
• narrowing joint space
• loss of cartilage
• osteophytes (spurs)

MANAGEMENT

1. Weight reduction
2. Occupational and physical therapy
3. Pharmacologic management
   • Use of NSAIDS
   • Topical analgesics
   • Intra-articular steroids to decrease inflammation

NURSING INTERVENTIONS

1. Provide relief of pain.
   • Administer prescribed analgesics.
   • Application of heat modalities. ICE packs maybe used in the early acute stage.
   • Plan daily activities when pain is less severe.
   • Pain medications before exercising.
2. Advise patient to reduce weight.
   • Aerobic exercises
   • Walking
3. Administer medications.
   • NSAIDS
     • Mefenamic Acid
     • Ibuprofen
     • Naproxen
     • Endometacin
4. Position the client to prevent flexion deformity.
   • Use of foot board, splints and pillows.

Rheumatoid arthritis is a chronic, systemic autoimmune disease that affects all areas of the body; inflammatory responses occur in all connective tissue. Early symptoms include inflammation of the synovial joints.

• Joint involvement progresses in stages; if disease is diagnosed early, permanent joint deterioration may be prevented.

1. The synovium becomes thickened and inflamed, and fluid accumulates in the joint space; this causes a pannus to form.
2. The pannus tissue erodes the cartilage and destroys the joint.

• In medicine, pannus is any abnormal tissue that: Contains blood vessels.
• Type of chronic systemic inflammatory arthritis and connective tissue disorder affecting more women (ages 35-45) than men—3:1.

FACTORS

• Genetic
• Autoimmune connective tissue disorders
• Fatigue, emotional stress, cold, infection

ASSESSMENT FINDINGS

• Joint involvement is symmetrical and bilateral.
• Characteristically beginning in the hands, wrist and feet.
• Joint stiffness occurs early morning, lasts more than 30 minutes, not relieved by movement, and diminishes as the day progresses.
• Joints are swollen and warm.
• Painful when moved.
• Deformities are common in the hands and feet causing misalignment.
• Rheumatoid nodules may be found in the subcutaneous tissues.

DIAGNOSTIC TESTS

1. X-ray shows a marked deformity.
2. Blood studies reveal (+) elevated ESR and CRP. ***also ANA and RF
3. Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow containing numerous WBC and inflammatory proteins.

MEDICAL MANAGEMENT

1. Therapeutic dose of NSAIDS and Aspirin to reduce inflammation.
2. Chemotherapy with methotrexate and gold therapy.

• IM or oral preparation
• Takes several months (3-6) before effects can be seen.
• May cause bone marrow depression.

NURSING MANAGEMENT

1. Relieve pain and discomfort.

• Use splints to immobilize the affected extremity during acute stage of the disease and inflammation to reduce deformity.
• Suggest application of COLD PACKS during the acute phase of pain, and then HEAT application as the inflammation subsides.

1. Decrease patient’s fatigue.

• Scheduled activity when pain is less severe.
• Provide adequate periods of rests.

1. Promote restorative sleep.
2. Increase patient mobility.

• Advise proper posture and body mechanics.
• Support joint in functional position.
• Advise active ROM.

1. Provide diet therapy.

• Patients experience anorexia, nausea and weight loss
• Gluten free diet
  • Oats, wheat, cucumber
• Supplements of vitamins, iron and protein

Heberden’s nodes are hard or bony swellings that can develop in the distal interphalangeal joints (DIP) (the joints closest to the end of the fingers and toes). They are a sign of osteoarthritis and are caused by formation of osteophytes (calcific spurs) of the articular (joint) cartilage in response to repeated trauma at the joint.

Bouchard’s nodes are hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are seen in osteoarthritis, where they are caused by formation of calcific spurs of the articular (joint) cartilage.

Crepitus (also termed crepitation) is a medical term to describe the grating, crackling or popping sounds and sensations experienced under the skin and joints or a crackling sensation due to the presence of air in the subcutaneous tissue.

1. A fracture is a break in the continuity of the bone.

2. Common fracture sites:

• Clavicle
• Humerus – In subpracondylar fractures, which occur when child falls backward on hands with elbows straight, there is a high incidence of neurovascular complications due to the anatomic relationship of the brachial artery and nerves to the fracture site.
• Radius and ulna
• Femur (often associated with child abuse)
• Epiphyseal plates (potential for growth deformity)

3. Types of Fracture

• Closed or simple fracture – The bone is broken, but the skin is not lacerated.
• Open or compound fracture – The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound.
• Transverse fracture – The fracture is at right angles to the long axis of the bone.
• Greenstick fracture – Fracture on one side of the bone, causing a bend on the other side of the bone.
• Comminuted fracture – A fracture that results in three or more bone fragments.
• Oblique Fracture – The fracture is diagonal to a bone’s long axis.
• Spiral Fracture – At least one part of the bone has been twisted.

4. Complications of fracture include:

• problems associated with immobility (muscle atrophy, joint contracture, pressure sores)
• growth problems ( in children)
• infection
• shock
• venous stasis and thromboembolism
• pulmonary emboli and fat emboli
• and bone union problems

B. Etiology

1. Fracture in children usually are the result of trauma from motor vehicle accidents, falls or child abuse.
2. Because of the resilience of the soft tissue of children, fracture occur more often than soft tissue injuries.

C. Pathopysiology

1. Fractures occur when the resistance of bone against the stress  being exerted yields to the stress force.
2. Fractures most commonly seen in children:

• Bend Fracture – is characterized by the bone bending to the breaking point and not straightening without intervention.
• Buckle fracture – results from compression failure of the bone, with the bone telescoping on itself.
• Greenstick fracture – is an incomplete fracture.

D. Assessment Findings

1. Clinical Manifestations

• The five “Ps” – pain, pulse, pallor, paresthesia, and paralysis are seen with all types of fractures.
• Other characteristic findings include deformity, swelling, bruising, muscle spasms, tenderness, pain, impaired sensation, loss of function, abnormality, crepitus, shock or refusal to walk (in small children).
• Laboratory and diagnostic findings
• Radiographic examination reveals initial injury and subsequent healing progress. A comparison film of an opposite, unaffected extremity is often used to look for subtle changes in the affected extremity.
• Blood studies reveal bleeding (decreased hemoglobin and hematocrit) and muscle damage (elevated aspartate transaminase (AST) and lactic dehygrogenase (LHD).

Fracture Healing

Reparative process of self-healing (union) occurs in the following stages:

• Fracture hematoma (d/t bleeding, edema)
• Granulation tissue → osteoid (3 – 14 days post injury)
• Callus formation (minerals deposited in osteoid)
• Ossification (3 wks – 6 mos)
• Consolidation (distance between fragments decreases → closes).
• Remodeling (union completed; remodels to original shape, strength)

COMPLICATIONS OF FRACTURES

1. Shock
   • With severe injuries or femur fracture
     • Neurogenic
     • Hypovolemic
       • Due to loss of blood volume
       • Nursing Action: Replace BV, Relieve Pain, Adequate splinting/mobilization
2. Fat Embolism Syndrome
   • Occurs within 24-72 hours and can also occur up to 1 week after injury
     • Seen more severe injuries
     • Mostly men 20-30 y/o
     • FIRST Symptom: Change in Mental status (mild agitation – Confusion – Delirium – Coma)
     • Tachycardia, SOB, Dyspnea, tachypnea, petechia on shoulder and conjunctiva
     • First give increased concentration of O₂
     • Steroids
3. Compartment Syndrome
   • Swelling peaks at 24-48 hours after fracture
   • Signs and Symptoms
     • Deep Throbbing pain that doesn’t respond to morphine
     • Muscle is hard
     • Diminished capillary refill
     • Cyanotic nail beds
     • Paralysis
     • Parasthsia
     • Edema – Can’t get a pulse
4. Other Complications
   • Thromboembolism
   • Infection
   • DIC – Disseminated Intravascular Coagulation
5. Delayed Complications
   • Delayed Union
     • Healing not at rate expected possible due to Steroids, diabetic, age
   • Non Union
     • Bone didn’t unite the way is should
   • Avascular Necrosis
     • Complete blood loss to bone or neck of femur
   • Reaction to Internal Fixation Devices
     • Left in permanently – a rare occurrence
     • Treatment is by removal of hardware
   • Osteomyelitis
     • Infection of bone occur with our without surgery

• Emergency: Maintain airway, assess distal pulses

E. Nursing Management

1. Provide emergency management when situation warrants, for a new fracture.

• Assess the five “Ps”.
• Determine the mechanism of injury.
• Immobilize the part. Move injured parts as little as possible.
• Cover any open wounds with a sterile, or clean dressing.
• Reassess the five “Ps”.
• Apply traction if circulatory compromise is present.
• Elevate the injured limb, if possible.
• Apply cold to the injured area.
• Call emergency medical services.

1. Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral pulses, positive blanch sign, edema not relieved by elevation, pain or cramping).
2. Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, or numbness and tingling).
3. Administer analgesic medications.
4. Explain fracture management to the child and family. Depending on the type of break and its location, repair (by realignment or reduction) may be made by closed or open reduction followed by immobilization with a splint, traction or a cast.
5. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care.
6. Prevent Complications

• Prevent circulatory impairment by assessing pulses, color and temperature, and by reporting changes immediately.
• Prevent nerve compression syndromes by testing sensation and motor function, including subjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the health care provider.
• Prevent compartment syndrome by assessing for muscle weakness and pain out of proportion to injury. Early detection is critical to prevent tissue damage.
• Causes of compartment syndrome include tight dressings or casts, hemorrhage, trauma, burns and surgery.
• Treatment entails pressure relief, which sometimes require performing a fasciotomy.

1. Prevent infection, including osteomyelitits, bys using infection control measures.
2. Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the child as much as possible.
3. Prevent pulmonary emboli by carefully monitoring adolescents and children with multiple fractures. Emboli generally occur within the first 24 hours.

• The word “gangrene” comes from the Greek “ganggraina” denoting “an eating sore that ends in mortification”.
• The death of body tissue due to the loss of blood supply to that tissue, sometimes permitting bacteria to invade it and accelerate its decay.
• Gangrene is a complication of necrosis “cell death” characterized by the decay of body tissues, which become black and appearing “rotten”.
• It is caused by infection or ischemia, such as a thrombosis.

GANGRENE… WHAT IS IT???

• It is usually the result of critically insufficient blood supply.
• Often associated with diabetes and long-term smoking.
• Condition is most common in the lower extremities.
• Basically Your Blood Supply Gets Cut Off And Your Tissue Decides To Die

TYPES OF GANGRENE

1. DRY GANGRENE
2. WET GANGRENE
3. GAS GANGRENE

DRY GANGRENE

• The early signs are a dull ache and sensation of coldness in the affected are.
• If caught early, the process can sometimes be reversed by vascular surgery.
• If necrosis sets in, the affected tissue must be removed and treated like a case of wet gangrene.

WET GANGRENE

• Wet gangrene occurs in naturally moist tissue and organs such as the mouth, bowel, lungs, cervix, and vulva.
• Bedsores occurring on body parts such as the sacrum, buttocks and heels (not in “moist” areas) are also categorized as wet gangrene infections.
• In wet gangrene, the tissue is infected by microorganisms, which cause tissue to swell and emit a fawol order.
• Wet gangrene usually develops rapidly due to blockage of venous and/or arterial blood flow.
• The affected part is saturated with stagnant blood which promotes the rapid growth of bacteria.
• The toxic products formed by bacteria are absorbed causing systemic manifestation of bacteria and finally death.
• The affected part is soft, putrid, rotten and dark.
• The darkness in wet gangrene occurs due to the same mechanism as in dry gangrene.

GAS GANGRENE

• Gas gangrene is a bacterial infection that produces gas within tissues.
• It is a deadly form of gangrene usually caused by bacteria.
• Infection spreads rapidly as the gases produced by bacteria expand and effect healthy tissue.
• Gas gangrene is caused by environmental bacteria.
• These Bacteria are mostly found in soil.
• These environmental bacteria enter the muscle through a wound and cause necrotic tissue and powerful toxins.
• These toxins destroy nearby tissue, generating gas at the same time.
• Gas gangrene can cause necrosis, gas production, and sepsis.
• Progression to toxemia and shock is often very rapid.
• Because of its ability to quickly spread to surrounding tissues, gas gangrene should be treated as a medical emergency.

SPECIFIC GANGRENES

• Noma is a gangrene of the face.
• Necrotizing fasciitis affects the deeper layers of the skin.
• Fournier gangrene usually affects the male genitals.

NOMA

• Is a gangrenous disease leading to tissue destruction of the face, especially the mouth and cheek.
• Risk factors include severe protein mal nutrition and unsanitary conditions.

NECROTIZING FASCIITIS

• Commonly known as flesh-eating disease or flesh-eating bacteria.
• Rare infection of the deeper layers of skin and easily spread within the subcutaneous tissue

FOURNIER GANGRENE

• A type of necrotizing infection usually affecting the male genitals.
• In the majority of cases it is a mixed infection caused by both aerobic and anaerobic bacteria

Prevention

• Cleaning the wound
• Avoid the contaminated material
• Improve circulation in patients with poor circulation
• Antitoxin

Treatment

• Removal of the Tissue.
• In case of moist gangrene we can make scarification of Tissue. with knife or puncture the gangrenous Tissue.
• to permit the escape of toxic liquid and allowing the introduction of antiseptic inside the lesion
• Application of counter-irritant at the periphery of the affected part
• This will cause increasing of hyperemia and phagocytosis near the affected Tissue.
• Which accelerate the separation of the moist or dry gangrene from the health Tissue.
• The best treatment of gangrene is amputation of the part from the body
• High doses of antibiotic : Penicillin
• The dead tissue is removed or limbs are amputated
• No vaccine
• 10 megaunits of benzyl penicillin daily for 5 days as four 6 hourly doses Or Tetracycline 0.5 g intravenously or 1 g orally every 6 hours.
• Clostridia not sensitive to metronidazole, some other anaerobic bacteria are, so give it.

A Sprain is a torn ligament. The area around the affected joint becomes Swollen, and painful. Sprains occur most in the ankles, wrist, fingers and knees.

Sign and Symptoms of Sprain

• Pain in the joint
• Redness and swelling
• Restricted or no movement due to pain
• Discoloration (Contusion)

STRAIN

A Strain is an overstretching or tear of muscle

Sign and Symptoms of Strain

• Pain in the joint
• Redness and swelling
• Restricted or no movement due to pain

Management of Sprain & Strain [ R.I.C.E]

• Rest

• • Steady and Support the Injured part in an comfortable position
• Ice
  • Place Ice pack over a cloth on the injured part for about 10-20 minutes to reduce swelling and ease pain
  • Do not place Ice directly on the Skin
• Compression
  • Use a Crepe Bandage to apply pressure over the Injured part
• Elevation
  • Raise and support the Injured area to reduce swelling
  • Seek further medical assistance if necessary

DISLOCATION

• Is a complete loss of congruity between the articulating surfaces of a joint. The bones taking part in the articulation are displaced relative to one another.

Subluxation

• In a subluxation the articulating surfaces of a joint are no longer congruous, but loss of contact is incomplete.
• The term is often used to describe the early stages in a condition which may proceed to complete dislocation.

Types of dislocations

• According to the severity: If incomplete it is called subluxation and if complete it is called dislocation.
• According to Anatomy: Anterior, posterior, superior, inferior, central or combination likes anteroinferior etc.
• According to co-existing conditions: If it is associated with fracture it is called fracture dislocation.

Treatment of dislocations

• As it obvious the mainstay of treating dislocation remains reduction of the dislocation and maintaining the same by either strapping, plaster casts, splints etc. until the surrounding soft tissues like capsules and ligaments have healed.
• Reduction must be checked radio logically immediately after reduction and from time to time as needed.
• A very important point is to achieve a congruous reduction.