Key points to remember

Perthes disease is a disease of the hip joint every case of Perthes disease is different see your GP (general practitioner) immediately if your child limps for more than 48 hours most children with Perthes disease recover completely; 75 - 80 percent recover to have normal functioning hips

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What is it?
Perthes disease is the name used for a condition which affects the ball-shaped end of the thigh bone (femoral head), where it enters into the formation of the hip joint. In this condition, the femoral head goes through a series of changes in which it softens, may become flattened and then gradually re-forms, (for more detail see What are the stages of the disease?).

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What causes it?

Perthes disease develops because the ball-shaped end of the thigh bone (femoral head) has its blood supply disturbed. It is not known why this happens.

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What are the stages of the disease?

The process of the illness can be divided into stages:

1. The blood supply to the ball-shaped end of the thigh bone (femoral head) becomes reduced. The reduced
blood supply affects the bone cells in the femoral head, causing them to die (avascular necrosis). 2. The femoral head may change from a rounded to a flattened shape as the bone is weakened. It no longer fits properly into the hip socket. It removes the dead cells and replaces them with new bone cells (re-ossification). 4. Your childs body tries to remodel the femoral head to a rounded shape.

3. Your childs body starts to repair itself by forming new blood supplies (revascularisation) to the femoral head.

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What are the symptoms?

It is important to understand that every case of Perthes disease is different; no two children will have an identical course.

Your child may have some of the following symptoms: an occasional limp early in the illness pain in the knee, thigh, groin or hip when your child puts weight on the affected side limping and pain getting worse as time goes by reduced movement of the hip joint (stiffness) the leg on the affected side becoming thinner and sometimes shorter if your child has had the condition for a long time

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What could this mean for my child?

Most children who develop Perthes disease have been very active and are often very involved in sporting activities. To manage their symptoms it is usually necessary to take them out of competitive and impacting sporting activities for a period and this can have a major psychological effect on the child. It is important to explain that Perthes disease does heal and that the reason for restricting activities is so that your child will have a better functional hip for sports in the longer term. Giving your child timeframes is very important so that they realise that they will eventually be able to return to the activities they enjoy. Sometimes it is also necessary to explain this to your child's friends, teachers and coaches.

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How long could it last?

The condition develops slowly. The symptoms - limp, pain in the hip or knee - can also develop slowly; they will often come on after sport or activity. The disease may be present for some time before anyone notices the symptoms. There may be no pain initially. The recovery phase takes a long time - rarely less than 18 months; often two years or even longer. This may seem an unbearably long period of disability, but considered in relationship to your childs total life span, it is not long. Most children with Perthes disease return to normal activities without major limitations.

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What puts my child at risk of getting it?

Perthes disease usually develops in children between the ages of about four to ten years when the stage of development of the femoral head makes it especially liable to an interruption in blood supply.

Perthes disease occurs much more commonly in boys than in girls - boys are four to five times more likely to develop it than girls. Although the cause of Perthes disease remains unknown, it has been observed to occur more commonly in smaller children.

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What about the other hip?

Approximately 85 percent of children with the disease have only one affected hip joint; in approximately 15 percent of cases both of the hip joints are affected. The opposite hip may become affected either at the same time or later. If your child complains of an ache in their good leg, tell the doctor.

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When should I seek help?

You should see your GP (general practitioner): immediately the condition is suspected, or if your child limps for more than 48 hours

Besides Perthes disease, there are other problems which may be causing your child to limp. Diagnosis at an early age is associated with a better hip recovery. Delayed treatment or diagnosis after the age of eight may affect the outlook.

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How is it diagnosed?
Your child will need to have an x-ray; Perthes disease cannot be diagnosed by a blood test. In the early stages of the disease, the x-ray may be normal. In this case, other tests may be needed such as: a bone scan, or an MRI (magnetic resonance imaging) scan

Sometimes blood tests are needed to rule out infection and other causes of hip pain.

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What treatments are required?

Your child will need to see an orthopaedic doctor (bone specialist) at the hospital to monitor the condition. Many children with Perthes disease only require observation and x-ray from time to time. The type of treatment depends on the following factors: the age of your child the severity of the disease the x-ray and scan results the amount of hip pain how stiff the hip joint is

The treatments are aimed at trying to keep the ball-shaped end of the thigh bone (femoral head) as smooth and round as possible. Often a period of bed rest with no physical activity is necessary to ease severe pain and limping. Further treatments may include: traction to the affected leg braces to hold the legs apart a plaster cast for protection and support and to keep the femoral head in the hip socket - this helps the femoral head to remodel itself to fit neatly into the socket physiotherapy, including swimming - this is important to help keep the muscles strong and increase movement of the hip joint use of a wheelchair to prevent weight-bearing surgery, which may be used to protect the ball-shaped end of the thigh bone (femoral head) from becoming deformed; surgery is only recommended in a minority of cases - the orthopaedic doctor (bone specialist) can give you more information about this

Further x-rays and sometimes other tests will be needed to see if the condition is improving or getting worse.

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How can I care for my child at home / at school?

You will need to follow the instructions given to you by the doctors and nurses. It is important to keep your child as comfortable as possible. Use pillows or cushions to help your child get into the most comfortable position. The physiotherapist will be able to help you with this. Pain relief medication is often required, such as paracetamol. (You must follow the dosage instructions on the bottle. It is dangerous to give more than the recommended dose).

Your child can and should go to school as normal, but some restriction of physical activities may be necessary. Check with your doctor which activity / games / sports are allowed and tell your childs teacher. As recovery from the illness can take a number of years, involve your child in decisions about their care.

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Are there likely to be any complications?

In most cases, children recover completely from Perthes disease. Sometimes the femoral head becomes swollen beyond its normal size and if this occurs, it may become squashed out of its normal smoothly rounded shape. In these cases, the femoral head does not return to its normal shape; the new bone grows into a deformed shape which remains for the rest of your childs life. This may be a source of disability in the hip but this is rare. In general, the more severe the case, the greater the chance of your child having the following: limited hip movement different leg lengths arthritis of the affected hip joint as an adult

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1129426/?page=7 http://www.scribd.com/doc/11888420/Coxa-Plana-Pathophysiology

Legg-Calve-Perthes Disease (Coxa plana)

Author: Derek Moore MD Topic updated on 09/09/11 6:20pm

Introduction Idiopathic avascular necrosis of the proximal femoral epiphysis link with abnormal clotting factors (Protein Sand Protein C) is controversial Epidemiology 4-8 years most common age presentation

male to female ratio is 5:1 bilateral in 12% (never simultaneous)

Increased incidence with positive family history

 low birth weight abnormal birth presentation

children exposed to second hand smoke

Prognosis correlates bone age at onset onset at < 6 years has good prognosis > 6 years has a much worse prognosis lateral pillar classification

Pathophysiology
Stages of Legg-Calves-Perthes (Waldenstrm) Initial Fragmentation Infarction occurs. Radiographs may remain occult for 3 to 6 mos. Femoral head appears to fragment or disolve. Result of a revascularization process and bone resorption. Lateral pillar classification based on this stage. New bone appears. Femoral head reossifies back to normal bone density.

Reossification Healed or reossified

Presentation Symptoms painless limp knee, hip, or thigh pain Physical exam hip stiffness with loss of internal rotation and abduction

Trendelenburg gait (head collapse leads to decreased tension of abductors)

limb length discrepancy is a late finding Imaging Radiographs early findings include joint space widening (earliest) irregularity of femoral head ossification

cresent sign (represents a subchondral fracture)

Classification

Herring lateral pillar classification determined on AP xray at start of fragmentation stage, which usually occurs 6 months after the onset of symptoms

Group A Group B years

- lateral pillar maintains full height, uniformly good outcome - maintains 50 to 100% height, poor outcome in patients > 6

Group C - maintains < 50% height, poor outcomes in all patients has best interobserver agreement

Catterall classification Stages I and II - fragmentation involves < 1/2 of femoral head

Stages III and IV - fragmentation involves > 1/2 of femoral head

Salter-Thompson classification Class A - cresent sign involve less than 1/2 of femoral head

Class B - involves > 1/2 of femoral head

Stulberg classification gold standard for rating residual femoral head deformity and joint congruence recent studies show poor interobserver and intraobserver reliability

Differential diagnosis

Table - Differential diagnosis of Hip Pain in Children

Treatment

Main goals of treatment is to keep femoral head contained and maintain good motion good outcome correlates with spherical femoral head < 6 years of age leave alone

> 6 years of age (treatment is controversial) nonoperative

activity restriction, partial weight bearing with crutches, NSAIDS, phsyica therapy to regain motion casting or bracing to produce containment operative

femoral or pelvic osteotomy for late symptoms usually reserved for patients > 8 years large recent studies show improved outcomes with surgery for lateral pillar B and B/C not beneficial for lateral pillar A and C

Complications Residual head and neck deformity coxa magna (widening)

coxa breva (shortening) coxa valga (tilting of femoral neck) overgrowth of greater trochanter

flattening of femoral head

(A) Normal hip joint; (B) coxa vara; (C) coxa valga

(A) Normal hip joint; (B) coxa vara; (C) coxa valga

LeggCalvPerthes syndrome
From Wikipedia, the free encyclopedia

This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (August 2011)

LeggCalvPerthes syndrome
Classification and external resources

Upper extremity of right femur viewed from behind and above.

ICD-10

M91.1

ICD-9

732.1

OMIM

150600

DiseasesDB

9891

MedlinePlus

001264

eMedicine

radio/387

MeSH

D007873

LeggCalvPerthes syndrome is a degenerative disease of the hip joint, where growth/loss of bone mass leads to some degree of collapse of the hip joint and to deformity of the ball of the femur and the surface of the hip socket. The disease is characterized by idiopathic avascularosteonecrosis of the capital femoral epiphysis of the femoral head leading to an interruption of the blood supply of the head of the femur close to the hip joint. The disease is typically found in young children, and it can lead to osteoarthritis in adults. The effects of the disease can sometimes continue into adulthood. It is also known more simply as Perthes disease,[1]ischemic necrosis of the hip, coxa plana, osteochondritis and avascular necrosis of the femoral head, LeggPerthes Disease or LeggCalve-Perthes Disease (LCPD). It is named for Arthur Legg, Jacques Calv and Georg Perthes[1][2][3][4] and was first described by Karel Maydl[citation needed].
Contents
[hide]

1 Cause 2 Signs and symptoms 3 Diagnosis 4 Treatment 5 Incidence 6 Prognosis 7 LeggCalvPerthes

disease in dogs

8 References 9 External links

[edit]Cause
Legg believed cause was impairment of blood supply to the femoral epiphysis, Calve ricketts, and Perthes deduced an infection possibly causing degenerative arthritis leads to LCP disease. Presently, a number of factors have been implicated including heredity, trauma, endocrine, inflammatory, nutritional, and altered circulatory hemodynamics. [5] Risk factors are not limited to impaired and disproportionate growth, low birth weight, delayed skeletal maturity, short stature, systemic hormonal changes and low economic index [6] Although no-one has identified the cause of Perthes disease it is known that there is a reduction in blood flow to the joint. The disease is theorized to include the artery of ligmentum teres femoris being constricted or even blocked too early, not allowing for time when the medial circumflex femoral artery takes over. The medial femoral circumflex artery is the principle source of blood supply to the femoral head. LCP disease is a vascular restrictive condition of idiopathic nature. Symptoms like femoral head disfigurement, flattening and collapse occurs typically between ages four to ten, mostly male children of Caucasian descent. Children affected by LCP disease often display uneven gait, limited range of motion and they experience mild to severe pain in groin area. [7][citation needed] For example, a child may be six years old chronologically but may have grown only four years old in terms of bone maturity. The child may then engage in activities appropriate for six years old child but lacking the bone strength of an older child, these activities may lead to flattening or fracture of the hip joint. Genetics do not appear to be a determining factor, but it has been suggested that a deficiency of blood factors with anticoagulant property used to disperse blood clots may lead to blockages in the vessels supplying the joint, but these have not been proven. It has also been suggested that there is a deficiency of proteins C and S which also act as blood anticoagulants; if that were the case it is possible that their deficiency could cause clot formation in ligamentum teres femoris artery and hinder blood supply to the femoral head. However there is no evidence of this, over the years many theories have been published but none have stood up to professional research.

[edit]Signs

and symptoms

Common symptoms include hip, knee, or groin pain, exacerbated by hip/leg movement. The pain feels like a tooth ache, possibly severe. There is a reduced range of motion at the hip joint and a painful or antalgic gait. There may be atrophy of thigh muscles from disuse and an inequality of leg length. In some cases, some activity can cause severe irritation or inflammation of the damaged area including standing, walking, running, kneeling, or stooping repeatedly for an extended period of time.

The first signs are complaints of soreness from the child, which are often dismissed as growing pains, and limping or other guarding of the joint, particularly when tired. The pain is usually in the hip, but can also be felt in the knee ('referred pain'). In some cases, pain is felt in the unaffected hip and leg[citation needed], due to the child favoring the injured side and placing the majority of their weight on the "good" leg. It is predominantly a disease of boys (4:1 ratio). Perthes is generally diagnosed between 5 and 12 years of age, although it has been diagnosed as early 18 months. Typically the disease is only seen in one hip, but bilateral Perthes is seen in about 10% of children diagnosed. (The differential diagnosis for Bi-lateral Perthes disease is Multiple Epiphyseal Dysplasia.} [8] Onset of pain may be up to 4 hours after inactivity. Knee pain is felt in the back of the knee rather than in the front, not unlike a localizedcharley horse. This lasts for an hour or so and returns nightly on inactivity.

[edit]Diagnosis
X-Rays of the hip may suggest and/or verify the diagnosis. X-rays usually demonstrate a flattened, and later fragmented, femoral head. Abone scan or MRI may be useful in making the diagnosis in those cases where xrays are inconclusive. Neither bone scan nor MRI offer any additional useful information beyond that of x-rays in an established case. If MRI or bone scans are necessary, a positive diagnosis relies upon patchy areas of vascularity to the capital femoral epiphysis (the developing femoral head).

[edit]Treatment
The goal of treatment is to avoid severe degenerative arthritis. Orthopedic assessment is crucial. Younger children have a better prognosis than older children. Treatment has traditionally centered on removing pressure from the joint until the disease has run its course. Options include traction (to separate the femur from the pelvis and reduce wear) braces (often for several months, with an average of 18 months) to restore range of motion, physiotherapy, and surgical intervention when necessary because of permanent joint damage. To maintain activities of daily living, custom orthotics may be used. Over night traction may be used in lieu of walking devices or in combination. [9] These devices internally rotate the femoral head and abduct the leg(s) at 45 degrees. Orthoses can start as proximal as the lumbar spine (LSO), and extend the length of the limbs to the floor. Most functional bracing is achieved using a waist belt and thigh cuffs derived from the Scottish-Rite Orthosis.[10] These devices are typically prescribed by a physician and implemented by a certified orthotist. For older children, the distraction method has been found to be a successful treatment, using an external fixator which relieves the hip from carrying the body's weight. This allows room for the top of the femur to regrow. Many children need no intervention at all and are simply asked to refrain from contact sports or games which impact the hip. The Perthes Association has a "library" of equipment which can be borrowed to assist with keeping life as normal as possible, newsletters, a helpline, and events for the families to help children and parents to feel less isolated.

Modern treatment focuses on removing pressure from the joint to increase blood flow, in concert with physiotherapy. Pressure is minimized on the hip through use of crutches or a cane, and the avoidance of running-based sports. Swimming is highly recommended, as it allows exercise of the hip muscles with full range of motion while reducing the stress to a minimum. Cycling is another good option as it also keeps stress to a minimum. Physiotherapy generally involves a series of daily exercises, with weekly meetings with a physiotherapist to monitor progress. These exercises focus on improving and maintaining a full range of motion of the femur within the hip socket. Performing these exercises during the healing process is essential to ensure that the femur and hip socket have a perfectly smooth interface. This will minimize the long term effects of the disease. Use of zoledronic acid has also been investigated.[11] Perthes disease is self limiting, but if the head of femur is left deformed there can be a long-term problem. Treatment is aimed at minimizing damage while the disease runs its course, not at 'curing' the disease. It is recommended not to use steroids or alcohol as these reduce oxygen in the blood which is needed in the joint. As sufferers age, problems in the knee and back can arise secondary to abnormal posture and stride adopted to protect the affected joint. The condition is also linked to arthritis of the hip, though this appears not to be an inevitable consequence. Hip replacements are relatively common as the already damaged hip suffers routine wear; this varies by individual, but generally is required any time after age 50.

[edit]Incidence
Perthes is rare, occurring in approximately 5.5 of 100,000 children per year (and therefore a lifetime risk of developing the disease is about 1 per 1200 individuals). Male to female ratio of occurrence is 5:1. Most cases of Perthes disease have presented themselves by age 14 years old. [12] Caucasians are affected more frequently than other races.[citation needed] Children of sufferers of the disease themselves have a very slightly increased risk; 1 in 100 male children of adults with LeggCalvPerthes syndrome also exhibit the syndrome. It is most commonly seen in persons aged 312 years, with a median of 6 years of age.[citation needed] In the US, 1 in 1200 children younger than 15 years will have this condition, while the occurrence in the UK is a slightly more common. Maternal cigarette smoking adds confounding factors beyond biological and environmental. Maternal tobacco smoking appears to be another significant risk which carries a risk five times higher than those not exposed to smoking. Second hand and side stream smoke appear less significant than maternal ingestion during pregnancy. [13]

[edit]Prognosis
Children younger than 6 have the best prognosis since they have time for the dead bone to revascularize and remodel, with a good chance that the femoral head will recover and remain spherical after resolution of the disease. [14] Children who have been diagnosed with Perthes' Disease after the age of 10 are at a very high risk of developing osteoarthritis and Coxa Magna. When an LCP disease diagnosis occurs after age eight, a better

outcome results with surgery rather than non-operative treatments. [15] Shape of femoral head at the time when Legg-Calve Perthes Disease heals is the most important determinant of risk for degenerative arthritis; hence, the shape of femoral head and congruence of hip are most useful outcome measures.[16]

[edit]LeggCalvPerthes

disease in dogs

Osteonecrosis of the femoral head of young, small breed dogs (LCP disease) was first described in veterinary literature by Tutt in 1935 [17]: he described the disease, as did Waldenstromin 1(1909) in humans,[18] Toy and small breeds, particularly Toy Poodles, Yorkshire Terriers, Pugs, Jack Russell Terriers, and Dachshunds can be affected. LCP disease is an osteonecrosis of the femoral head in small breed dogs, usually those weighing less than 12 kg. There seems to be no sex predilection in the dog as contrasted to humans, in whom an 80% male incidence of the disease is evident. As in children, however, the condition is usually unilateral, with only about 10% to 15% incidence of bilateral disease. The age of onset varies between 4 months and 12 months, with a peak incidence at about 7 months. [19] The pathology of avascular necrosis followed by revascularization and bony remodeling of the femoral head in the dog certainly suggests a vascular etiology even though the cause of the condition is not completely understood. [20] Hip pain is usually seen by the age of 6 to 8 months.
[21]

The disease is bilateral in 12 to 16 percent of cases.[22] X-rays are necessary to make the diagnosis and

show increased opacity and focal lysis in the head of the femur, and later in the disease, collapse and fracture of the neck of the femur. The recommended treatment is surgical removal of the head of the femur, but conservative treatment (rest, exercise restriction, and pain medication) may be effective in a limited number of cases (less than 25 percent, according to some studies).[22] The prognosis is excellent with surgery.

[edit]References

Coxa PlanaI . D e f i n i t i o n Legg-Calve-Perthes disease is when the head of the thighbone (femur) inthe hip deteriorates due to insufficient blood supply to the area. I I . A K A ( a l s o k n o w n a s ) Legg-Calve-Perthes disease; Perthes disease I I I . I n c i d e n c e s United StatesOne in 1200 children younger than 15 years is affected by LCPD. RaceCaucasians are affected more frequently than persons of other races. SexMales are affected 4-5 times more often than females. AgeLCPD most commonly is seen in persons aged 3-12 years, with amedian age of 7 years. IV.Risk/ Predisposing Factors

Legg-Calve-Perthes disease occurs most frequently in boys 4 to 10 yearsold. Recent research shows that this disorder may reflect subtle disordersof blood clotting. R i s k g r o u p a l s o i n c l u d e s t h o s e w h o h a v e a b n o r m a l i t i e s i n g e n e t i c s , hormonal changes, trauma, infection and metabolic abnormalities. M a n i f e s t a t i o n s Knee pain (may be the only symptom, initially) Persistent thigh or groin pain Atrophy (wasting) of muscles in the upper thigh Slight shortening of the leg, or legs of unequal length Hip stiffness restricting movement in the hip Difficulty walking, walking with a limp (which is often painless) Limited range of motion Decreased range of motion (ROM), particularly with internal rotation andabduction Painful gait Muscle spasm Leg length inequality due to collapse Thigh atrophy: Thigh circumference on the involved side will be smaller than on the unaffected side secondary to disuse. Short stature: Children with LCPD often have delayed bone age. VI.Type/Stage/Classifications of the Disease Stage I (avascularity)T h e b l o o d s u p p l y t o t h e u p p e r f e m o r a l e p i p h y s i s i s h a l t e d spontaneously and bone growth is halted (lasts a few weeks) Stage II (revascularization)New blood vessels arise to supply the necrotic area, and boner e s o r p t i o n a n d d e p o s i t i o n t a k e p l a c e ( l a s t s e v e r a l m o n t h s t o 1 y e a r ) Ho wever the new bone lacks strength and pathologic fractures may occur;the weakened epiphysis may be progressively deformed Stage III (reossification)The head of the femur gradually reforms as dead bone is replacedw i t h n e w b o n e , w h i c h g r a d u a l l y s p r e a d s t o h e a l t h e l e s i o n ( l a s t s 2 t o years)

 Stage IV (postrecovery)The femoral head becomes permanently distorted, with resultant joint misalignment

1.Instruct child and parents to maintain activities that promote range of motion, such as swimming and bicycling, but to avoid contact sportsand high impact-running.2.Limitation of activities, bed rest with or without skin traction3 . P r o v i d e e q u i p m e n t t o a s s i s t w i t h m o b i l i t y ( e . g w h e e l c h a i r , w a l k e r ) i f needed4.Teach parents and siblings to assist only as needed.5.Allow child to care for self and participate as able.6 . R e i n f o r c e t o c h i l d t h a t h e o r s h e i s o n l y t e m p o r a r i l y r e s t r i t e d . S t r e s s positive aspects of activity.7 . E n c o u r a g e f o l l o w u p . 8.Salicylates or anti-inflammatory agents are given to relieve synovitis,muscle spasm, and pain in the joint and help restore motion. Surgical1 . I n o m i n a t e o s t e o t o m y ; v a r u s o s t e o t o m y ; o s t e o t o m y o f t h e p r o x i m a l f emur, acetabulum (Salter innominate), or a combination of these maybe required X . N u r s i n g D i a g n o s i s Top 5 Priorities includes:1 . A c u t e P a i n 2.Bathing or Self-Care Deficit3 . I m p a i r e d P h y s i c a l M o b i l i t y 4 . D i s t u r b e d B o d y I m a g e 5.Ineffective Therapeutic Regimen Management XI.Nursing Responsibilities Preoperative Management1.Assess nutritional status; hydration, protein and caloric intake. Maximize healingand reduce risk of complications by providing I.V. fluids, vitamins and nutritionalsupplements as indicated.2 . D e t e r m i n e i f t h e p a t i e n t h a s h a d p r e v i o u s c o r t i c o s t e r o i d t h e r a p y c o u l d contribute to current orthopedic condition (aseptic necrosis of the femoral head;

osteoporosis), as well as affect his or her response to anesthesia and the stressof surgery. The patient may need corticotrophin postoperatively.3 . D e t e r m i n e i f t h e p a t i e n t h a s a n i n f e c t i o n ( c o l d , d e n t a l , s k i n , U T I ) ; i t c o u l d contribute to development of osteomyelitis after surgery. Administer preoperativeantibiotics as ordered.4 . P r e p a r e p a t i e n t f o r p o s t o p e r a t i v e r o u t i n e s , w / c i n c l u d e c o u g h i n g a n d d e e p breathing, frequent v/s and wound checks and repositioning.5 . H a v e the patient practice voiding on bed pan or urinal in r e c u m b e n t p o s i t i o n before surgery. This helps reduce the need for post operative catheterization.6.Acquaint the patient with traction apparatus and the need for splint or cast, asindicated by the type of surgery.Post operative Management1.Monitor for hemorrhage and shock, which may result from significant bleedingand poor hemostasis of muscles that occur with orthopedic surgery.a . E v a l u a t e t h e b l o o d p r e s s u r e a n d p u l s e r a t e s f r e q u e n t l y r e p o r t r i s i n g pulse rate or slowly decreasing blood pressure.b.Watch for increased oozing of wounds.c.Measure suction drainage if used. Anticipate up to 7 to 17 oz (200 500mL) drainage in the first 2 hours, decreasing to less than 1 oz (30 mL) per 8 hours within 48 hours, depending on surgical procedure.d.Report increased wound drainage or steady increase in pain of operativearea.2.Administer I.V fluids or blood products as ordered.3.Monitor neurovascular status.a.Watch circulation distal to the part where cast, bandage, or splint has beenapplied; check pulses, color, warmth, and capillary refill.b.Prevent constriction leading to interference with blood or nerve supply;check for swelling.c.Note movement, and ask about sensation of distal extremities.

4.Elevate affected extremity and apply ice packs as directed to reduce swelling andbleeding into tissues.5 . M o n i t o r p a i n l e v e l a n d r e s p o n s e t o a n a l g e s i a ; a d m i n i s t e r p a t i e n t c o n t r o l l e d analgesia or other method of pain relief as directed; notify health care provider if not effective or if the patient cannot tolerate adverse effects.6.Immobilize the affected area and limit activity to protect the operative site andstabilize musculoskeletal structures.7 . G i v e a n a l g e s i c s t h a t m a y c a u s e r e s p i r a t o r y d e p r e s s i o n c a u t i o u s l y. Monitor r e s p i r a t i o n d e p t h a n d r a t e f r e q u e n t l y . O p i o i d a n a l g e s i c e f f e c t s m a y b e cumulative.8.Change position and encourage use of incentive spirometer and coughing anddeepbreathing exercises every 2 hours to mobilize secretions and preventatelectasis. Auscultate lungs frequently.9 . M o n i t o r v / s f o r f e v e r , t a c h y c a r d i a , o r i n c r e a s e d r e s p i r a t o r y r a t e , w h i c h m a y indicate infection.10.Maintain aseptic technique for dressing changes and wound care.11.Encourage the patient to move joints that are not fixed by traction or appliancet h r o u g h t h e i r r a n g e o f m o t i o n a s f u l l y a s p o s s i b l e . S u g g e s t m u s c l e - s e t t i n g exercises (quadriceps setting) if active motion is contraindicated.12.Apply antiembolism stockings, sequential compression, or give prop hylacticanticoagulants, if prescribed, to prevent thromboembolism.13.Encourage early resumption of activity.14.Monitor for anemia, especially after fracture of long bones.15.Avoid giving calcium supplements patients on bed rest, and encourage other fluids to prevent other fluids to

prevent urinary calculi

http://www.scribd.com/doc/17647415/Coxa-Plana