Transcript File

Nursing Care of Clients
With Musculoskeletal Disorders
This Class:




Fractures: Types
Management & complications
Traction (Skin and Skeletal)
Casts (Compartment Syndrome, Infection,
Cast Syndrome)
Class Objectives:
 Describe the anatomy and physiology of the
musculoskeletal system including the significance of
health history.
 Discuss the significance of assessment and diagnosis of
musculoskeletal problems including diagnostic tests.
 Explain the pathophysiology, manifestations,
complications & collaborative care of clients with
fractures.
 Describe the preventative health teaching needs of the
client with a cast.
 Describe the various types of traction and appropriate
nursing care.
Class Objectives Cont’d:
 Compare the nursing needs of the client undergoing a
THR with those undergoing a TKR
 Discuss the etiology, pathophysiology, prevention and
management of clients with osteoporosis.
 Identfy the causes and related nursing management of
osteomalacia and Pagets’s disease.
 Discuss the pathophysiology, manifestations,
complications & collaborative care of clients with
arthritis, gout, spinal cord deformities, septic arthritis.
Readings:
– Read in your text Chapters 66, 67, 68, &
69
– Recommended readings
– Bibliography list
– Fractures
Fractures
•Read text content dealing with fractures
•Know what a closed, open,displaced
comminuted, impacted, & greestick
fractures are.
•Note the risk factors & levels of prevention
r/t #
•Review the stages of healing
•Know neuromuscular assessment
•What causes muscle spasm following #s
and what are the consequences?
 A fracture is “any disruption in the continuity
of the bone, when more stress is placed on it
than it can absorb”. (Black, Hawkes & Keene, 2001, p587).
 When # occurs, muscles are also disrupted &
pull fracture fragments out of position.
 Adjacent structures are affected – soft tissue
edema, hemorrhage, joint dislocations,
ruptured tendons, severed nerves, damaged
blood vessels
 Large muscle groups create massive spasms,
the proximal portion remains intact while the
distal portion can be displaced in response to
force and spasm.
FRACTURES
Classification of Fractures:
(See Chart 69-1)
 Open: (compound or complex) break in tissue over site of the bone
injury
 Complete: break across entire cross-section of bone & often
displaced
 Incomplete: (greenstick) though only part of the cross-section
 Closed: (simple) intact skin over site of injury
 Comminuted: produces several bone fragments
Physical Assessment may reveal:
– Deformity (hemorrhage or spasm)
– Shortening
– Swelling
– Ecchymosis
– Muscle spasm
– Pain, tenderness
– Loss of function, altered mobility & crepitus
– Neurovascular changes
– shock
Signs and Symptoms
Complications
Fat Embolism Syndrome
 Fat globules (emboli) occlude small vessels of
lungs, brain, kidneys, & other organs
 Characterized by neurologic dysfunction,
pulmonary insufficiency, and petechial rash on
chest, axilla & upper arms
 Long bone # & other major trauma ( such as
THR) are the principle risk factors
 Most frequently in young adults (20-30 years of
age)
Fat Embolism Syndrome What to
Look for:
 Manifestations of fat emboli occur within 24-72 hours but
may be up to a week after injury:
– Hypoxia PaO2 < 60 mm Hg
– Tachypnea, tachycardia, pyrexia
– Deterioration in LOC
– Confusion , agitation
– Respiratory distress response – tachypnea, dyspnea,
crackles, wheezes, precordial chest pain, copious thick
white sputum, tachycardia
– petechiae: chest, shoulders, axilla, mouth, conjunctival
sac
Fat Embolism:
Prevention:
– Immobilize fractures: early & gentle stabilization
– Gentle care
– Adequate hydration
– O2
– Aware of those at high risk
Management:
–
–
–
–
–
–
–
O2
Fluid replacement
Mechanical ventilation
Corticosteroids
Vasoactive medications
Maintain Hgb
Calm, supportive environment
Monitor Respiratory Status Every
Shift.
 Immobility increases risk for Atelectasis,
DVT and Pulmonary Emboli.
 Never ignore client's complaints.
 Follow-through and check it out.
 Fifty percent (50%) of persons with fat
emboli die.
Complications
 Infection
Musty, unpleasant odor over cast
and/or at the ends of cast
– Drainage through cast or cast
opening
– Sudden unexplained body
temperature elevation
– “Hot Spot” felt over cast lesion
– May result in osteomyelitis
Interventions: Infection
 Wash hands
 Use aseptic technique when caring for wound and
emptying drains
 Culture drainage
 Foley catheter care
 Monitor temp
 Report excessive drainage or inflammation to
physician
Complications
Watch out for Deep Vein Thrombosis
after skeletal or muscular injury/surgery!
Muscle Spasm:
 Powerful involuntary
muscle contractions
shorten the flexor
muscles & cause
extreme pain. This
may be triggered by
hypoxia of muscle
tissue.
What Helps?







Bed cradle
Heat
Avoid heavy sedation
Avoid pressure in popiteal space
Minimize compression
Active & passive exercises as ordered
Frequent change in position
Fracture: Early Complications
Critical monitoring & assessment is imperative. Know
assessment findings that may indicate one of the following early
complications of fractures. Question waiting for a place to happen
!!!!
Shock
Nerve damage, arterial damage
Infection
Cast syndrome
Compartmental Syndrome
Volkmann’s Contracture
Fat Embolism Syndrome
Deep Vein thrombosis & Pulmonary Embolism
Long-term Complications
 Joint stiffness or post-traumatic arthritis
 Avascular necrosis
 Nonfunctional union after a fracture
 Complex regional pain syndrome
 Reaction to internal fixation device
Avascular Necrosis
Complications of Fractures:
Shock
 Bones are very vascular. In combination
with collateral damage to adjacent
structures/vessels, the patient is at risk
for hemorrhage.
 Shock fully develops if a healthy client
loses 1/3 of normal blood volume.
Blood loss:
 15-30% (up to 1500 ml) -subtle signs
 30-40% (1500-2000 ml) –obvious shock
 Over 40% (over 2000 ml)
 1 unit of packed cells raises Hgb about 1
gram. Check
with physician about
expected normal loss.
Potential Blood Loss Following
Fractures (Liters)
Humerus
1-2
Elbow
.5-1.5
Forearm
.5-1
Pelvis
1.5-4.5
Hip
1.5-2.5
Femur
1-2
Knee
1-1.5
Tibia
. 5-1.5
Ankle
.5-1.5
Spine/ribs
1-3
This is not what is expected but what is possible!
See Text
 1) Compartment Syndrome
 2) Cast Syndrome
 3) Infection
 What?
 How to recognize?
 What should be done?
Fracture Reduction
 Closed reduction: usually done under
anesthesia
– Carried out through manual traction to move
fracture fragments & restore bone alignment
 Followed by immobilization device (cast)
 Open Reduction: incision and realignment
– Usually performed with internal fixation devices
(screws, pins, plates, wires)
Closed vs. Open Reduction
Open
Reduction
Fracture Reduction Cont’d
 External Fixation: maintain position for
unstable fractures & for weakened muscles,
allow for use of contiguous joints while
affected part remains immobilized. Common
sites include face & jaw, pelvis, fingers.
 Traction: application of a pulling force to an
injured body part or extremity while a
counter-traction pulls in the opposite
direction.
External
fixation
Figure 27-3: Types of Internal
Fixation Devices
Open reduction and internal fixation
of Comminuted mandibular fracture
CASTS
•Review information learned in 2nd & 3rd year. At
this point you should know
•Types of casts
•
Why a cast may need to be Bi-valved
•
Drying & caring for a cast
•
Complications caused by casts …
•Management of Casts & Braces
•Importance of knowing weight bearing status
Windowing and Bivalving a Cast

Windows maybe cut in dried casts:
1. relieve pressure from abd. distension (body
cast)
2. To prevent “Cast Syndrome”
3. To assess radial pulse (check circulation in a
casted arm)
4. To inspect areas of discomfort or areas of
suspected tissue damage
5. To remove drains or care for wounds.
Bivalving a Cast
Window Cast
Cast Drying:
 Synthetic casts – dry approx. 20-30 mins (clients
feel the sensation of heat thus may feel hot).
 Plaster casts set rapidly but take several hrs-days to
completely dry (lg. cast).
 Promote the circulation of warm, dry air around a
damp cast to enhance moisture evaporation and
speed drying process.
 Heat occurs with early cast drying stages
 Do not cover cast while drying, can place layers of
towels underneath pillow to elevate cast to absorb
dampness.
 Green cast (damp cast)
 Lg. cast avoid covering and to allow air to circulate
 Never use heated hairdryer to dry cast.
Nerve Damage during casts/traction:
 Traction applied to an extremity puts pressure on
the peroneal nerve where it passes around the
neck of the fibula to just below the knee.
 Pressure at this point may cause footdrop, leading
to inability to dorsiflex the foot.
 Inability to plantarflex indicates damage to the
tibial nerve.
 The calf muscle is not affected & the temp of
extremity doesn’t change.
Assess for complications following
cast :
 Compartment syndrome
 Fat emboli
 Infection
 DVT
 Cast syndrome
Complications of Fractures/Casts
Compartmental Syndrome:
Edema from a fracture causes an
increase in compartmental pressure
that decreases capillary blood
perfusion.
When the local blood supply unable
to meet tissue metabolic demands
ischemia begins = compromised
circulation.
Increase pressure in a confined
space due to tight cast, edema or
bleeding.
Complications of Fractures/Casts
 Compartmental Syndrome:
– Pulselessness: slow nail bed capillary refill
(>3sec)
– Skin pallor, blanching, cyanosis or coolness
– Increasing pain, swelling,pain on passive
motion, painful edema peripheral to cast.
– Paresthesias (tingling, pricking), heightened
sensation to touch, diminished sensitivity to
touch (hypesthesia), anesthesia (numbness)
– Motor paralysis to previous functioning
muscles
Compartmental Syndrome
Swelling out of control
Compartment Syndrome Treatment
Fasciotomy
RELEASE PRESSURE
CUT OPEN
RELIEF
Complications Cont’d
Figure 27-6: Cast Syndrome
Cast syndrome results
from the compression
of the duodenum
between the aorta and
the superior
mesenteric artery. The
external compression
is usually caused by a
tight body cast.
.
Black
2001, p. 601)
Complications Cont’d
Cast Syndrome:
 Bloating feeling
– Prolonged nausea:
repeated vomiting
– Abdominal
distension: vague
abdominal pain
– Shortness of
breath
– Untreated may
lead to death!
Cast Syndrome
An abdominal flat-plate is
ordered. If you diagnosed the
cast syndrome, you correctly
identified the clinical signs
consistent with this
syndrome. This is due to an
extrinsic compression of
the third portion of the duodenum
by the superior
mesenteric artery
Other Complications Cont’d
Infection:
Musty, unpleasant odor
over cast and/or at the
ends of cast
– Drainage through cast or
cast opening
– Sudden unexplained body
temperature elevation
– “Hot Spot” felt over cast
lesion
– May result in osteomylitis
Complications Cont’d
Volkmann’s Contracture:
A common complication of elbow fractures
 Can result in unresolved compartment
syndrome. Arterial blood flow decreases,
leading to ischemia, degeneration &
contracture of muscle
 May lead to permanently stiff, claw-like
deformity of arm & hand
Volkmann’s Contracture
Complications Cont’d
FAT EMBOLISM:
 Fat emboli occur when fat globules lodge in
the pulmonary vascular bed or peripheral
circulation. Fat embolism syndrome (FES)
is characterized by neurologic dysfunction,
pulmonary insufficiency, and petechial rash
on chest, axilla & upper arms. Long bone #
& other major trauma ( such as THR) are
the principle risk factors
Fat Embolism: Beware!!
When a bone is fractured, pressure within the
bone marrow rises & exceeds capillary
pressure; fat globules leave the marrow & enter
bloodstream, it may also be caused by the
stress induced release of catecholamine, which
causes the rapid immobilization of fatty acids.
Once fat globules are released they travel to the
brain, kidney, lung & other organs, occluding
small blood vessels - - causing ischemia.
Fat Emboli:
 Fat globules within the
pulmonary arterioles. The
globules stain reddish-orange.
The cumulative effect of these
globules is similar to a large
pulmonary embolus, but the
onset is usually 2 to 3 days
following the initiating event,
such as the trauma associated
with bone fractures.
Monitor respiratory status every shift.
Nurse Alert:
 Immobility increases risk for fat embolism,
atelectasis, and pulmonary emboli. Never
ignore client's complaints. Follow-through
and check it out.
 Fifty percent 50% of persons with fat emboli
die.
WHAT TO LOOK FOR:
 Manifestations of fat emboli occur within
a few hours to weeks after injury:
– deterioration in LOC
– confusion , agitation
– SOB
– petechiae: Chest, axilla, mouth, conjunctival sac
– atelectasis may result
– signs of shock- tachycardia, tachypnea
– Hypoxia Po2 < 60 mm Hg
Fat Embolism:
Fat globulins released from long bone
pelvis or multiple fractures
Prevention:
– Immobilize
fractures: early &
gentle stabilization
– Gentle care
– Adequate
hydration
– O2
Management:
 O2
 Fluid replacement
 Mechanical ventilation
 Corticosteroids
 Maintain Hgb
 Corticosteroids
Complications Cont’d
Neuro-vascular problems
Early detection may mean no or slight
disability in the future. Assess carefully &
knowingly!
Who is at Risk for Neurovascular Problems?
Those with/who:
 External fixators
 Interstitial edema/bleeding
 Excessive exercise
 Trauma to joint/limb
 Casts, Splints, Constrictive Dressings
 Medical Procedures (heart cath)
 Traction
 Spinal Surgery/injury
 Tissue compression
KNOW the SIX Ps: Cast
Assessment






Pain
Pallor
Paresthesia
Pulselessness
Paralysis
Polar
Compartment
Syndrome??
Infection??
Cast Syndrome??
Assess
 Monitor neurovascular status of distal aspects of involved
extremities in comparison with corresponding body part
after the initial post op period & every 2 hours for the
following 24 hours and every 4 to 12 hours thereafter
(according to agency policy).
Nurse Alert: Irreversible tissue death occurs in 4 to 12 hours.
 Inspect color and temperature.
 Monitor for edema caused by tissue trauma or venous
stasis.
 Assess capillary refill by pressing on toe or fingernail,
releasing, and noting "pinking" on nail within 3 seconds
Complications Cont’d
Watch out for Deep Vein
Thrombosis after skeletal
or muscular
injury/surgery!
Hemorrhage: Know what it
means!
 Stage I up to 15% (up to 750 ml)
 Stage II 15-30% (up to 1500 ml) -subtle signs
 Stage III 30-40% (1500-2000 ml) –obvious
shock
 Stage IV over 40% (over 2000 ml)
Complications Cont’d
Blood Loss in Fractures
• Bones are very vascular. In combination with collateral damage
to adjacent structures/vessels, the patient is at risk for
hemorrhage.
• Shock fully develops if a healthy client looses 1/3 of normal
blood volume.
• 7 - 8% of body wt is blood. An adult has about 5.5 L of blood.
• 10% volume loss = tachycardia
• 30% loss affects B.P
• 1 unit of packed cells raises Hgb about 1 gram. Check with
physician about expected normal loss.
Potential Blood Loss Following
Fractures (Liters)





Humerus
1-2
Elbow .5-1.5
Forearm .5-1
Pelvis 1.5-4.5
Hip
1.5-2.5





Femur 1-2
Knee
1-1.5
Tibia
.5-1.5
Ankle .5-1.5
Spine/
ribs 1-3
This is not what is
Check with surgeon to
expected but what is determine extent of
possible!
expected blood loss
Watch for Blood loss post op
For Example
 In the client with a total hip replacement
(THR) the total amount of drainage is
usually less than 50 ml every 8 hours, it may
be a bit more if the client received a plasma
expander such as dextran.
 Drains are usually removed within 48-72
hours post surgery.
Muscle Spasms Interventions:
Powerful involuntary muscle contractions
shorten the flexor muscles & cause extreme
pain. This may be triggered by hypoxia of
muscle tissue.
•What helps?
•Bed cradle
•Heat
•Avoid heavy sedation
•Avoid pressure in popliteal space
•Minimize compression
•Active & passive exercises as ordered
•Frequent change in position
Interventions: Infection
 Wash Hands.
 Use aseptic technique when caring for
wound and emptying drains.
 Culture drainage.
 Foley catheter care
 Monitor temp.
 Report excessive drainage or inflammation
to physician.
Intervention: DVT/PE/FES
 Client wears elastic stockings.
 Teach leg exercises.
 Observe for changes in mental status, chest
pain and SOB.
 Observe for swelling, redness and pain in
legs (DO NOT MESSAGE).
 Fat embolism is the most lethal complication
of THR.
Interventions: Bleeding
 Vitals q4h.
 Assess for bleeding.
 Report excessively low BP.
Intervention: Pain Management
 Encourage client to report hip pain
immediately.
 Promote adequate rest through out the day.
 Administer oral analgesics PRN.
Traction
•What is used traction for?
•What is the difference between Skeletal & Skin traction?
•What would the nurse assess for that is particular to each
type?
•Differentiate between the following types of traction & give an
example of each:
•Continuous & Intermittent
•Running & Suspension
•Skeletal/ Skin/ Cervical
•Russell’s & Buck’s
Traction serves several
purposes:
 It aligns the ends of a fracture by pulling
the limb into a straight position.
 It ends muscle spasm.
 It relieves pain.
 It takes the pressure off the bone ends by
relaxing the muscle.
Skin Traction:
http://www.youtube.com/watch?v=2ZEWz_Ps7vo
 Apply traction to underlying bones and
other structures (muscles).
Used :
 1. with commercially prepared foam
slings
 2. by encircling a body part with a halter,
corset or sling.
 Counteraction is provided by a persons
wt. when the bed is tilted away from the
pull.
Buck’s SKIN TRACTION
Skin traction uses 5 to 7 pound weights attached to
the skin to indirectly apply the necessary pulling
force on the bone. If traction is temporary, or if only
a light or discontinuous force is needed, then skin
traction is the preferred treatment. Because the
procedure is not invasive, it is usually performed in
a hospital bed.
Skeletal Traction:
 Is accomplished by surgically inserting metal
wires or pins thru distal bones to the # site
or by anchoring metal tongs in the skull.
 A traction bow is attached to wire or pin and
traction force is applied .
 Used to reduce unstable fractures of long
bones
Skeletal traction is performed when more pulling
force is needed, or when the part of the body
needing traction is positioned so that skin traction is
impossible. Skeletal traction uses weights of 25-40
pounds. It requires the placement of tongs, pins, or
screws into the bone so that the weight is applied
directly to the bone. This is an invasive procedure
that is done in an operating room under general,
regional, or local anesthesia.
Thomas Splint Picture
http://www.scribd.com/doc/12356898/Balance
-Skeletal-Traction
 Skin Traction
 Advantage:
 Relative ease of use
and ability to maintain
comfort
Disadvantage:
 Wt required to
maintain Normal
body alignment or
fracture alignment
can not exceed 6 lbs
per extremity.
– Skeletal Traction
– Advantage:
– Increases mobility
without threatening
joint continuity.
Easier to change
linen, backcare
Disadvantage:
Need to use multiple
wts makes client
slide in bed more.
Bucks
 The main risks associated with skin traction are
that the traction will be applied incorrectly, or
that the skin will become irritated.
 More risks associated with skeletal traction.
– Bone inflammation.
– Infection can occur at the pin sites.
 Both types of traction have complications
associated with long periods of immobility:
–
–
–
–
–
–
bed sores
reduced respiratory function
urinary & and circulatory problems
occasionally, fractures fail to heal
emotional toll of prolonged bedrest
Kidney/gallstones
More about traction
 Positioning the extremity so that the angle of
pull brings the ends of the fracture together is
essential. Weights must hang freely
 Elaborate methods of weights, counterweights,
and pulleys have been developed to provide
the appropriate force, while keeping the bones
aligned and preventing muscle spasm.
 The patient's age, weight, and medical
condition are all taken into account when
deciding on the type and degree of traction.
Check the four P's of traction
maintenance:
 Pounds: Inspect traction setup. Is the
correct weight in place?
 Pull: Is the direction of pull aligned with the
long axis of affected bone?
 Pulleys: Is the rope gliding smoothly over
pulley?
 Pressure: Are clamps and connections
tight?
Assess, Assess, Assess
 Assess client's knowledge of the reason for
traction, including nonverbal behavior and
responses.
 Assess integrity and condition of skin over bony
prominences and under devices in use.
 Assess client's overall health condition, including
degree of mobility, ability to perform ADLs, and
current medical conditions.
 Assess client's level of pain and need for
analgesics before procedure begins.
 Assess for respiratory dysfunction
USUAL PIN SITE CARE
 With gloves remove gauze dressings from around
pins
 Inspect sites for drainage or inflammation.
 Prepare supplies and apply new gloves.
 Clean each pin site with NaCl by placing sterile
applicator close to the pin and cleaning away from
the insertion site. Dispose of applicator.
 Continue process for each pin site.
 Using a sterile applicator, apply a small amount of
topical antibiotic ointment as ordered
 Provide pin site care according to hospital policy/
Dr. orders.
 Cover with a sterile 2 X 2 split gauze dressing or
leave site open to air (OTA) as prescribed
More care for traction client
 Assess level of discomfort and provide
nonpharmacological and pharmacological
relief as indicated.
 Encourage active and passive exercises
and use of unaffected extremities for ADLs.
 Encourage us of trapeze bar for
repositioning in bed.
 Provide a fracture pan for elimination prn
 Evaluate effectiveness of care & need for
intervention
Care of the Client in Traction
•When caring for a client in continuous, balanced,
skeletal traction with a Thomas Splint what should
the nurse know? Wow, what a question!
•Consider skin, infection, personal care,
ROM/exercises
•Care of ropes, pulleys
•What to do when transporting client/bed elsewhere
Nerve damage during traction
•Traction applied to an extremity puts pressure on the
peroneal nerve where it passes around the neck of the
fibula to just below the knee.
•Pressure at this point may cause footdrop, leading to
inability to dorsiflex the foot.
•Inability to plantarflex indicates damage to the tibial
nerve.
•The calf muscle is not affected & the temp of
extremity doesn’t change.
Specific Fractures







Hip Fractures
Condylar fractures
Pelvic fractures
Patellar fractures
Tibial & fibular fractures
Foot fractures
Upper extremities
 Please review Pages 607-619 for care of specific fractures
Sports Injuries
Common Overuse injuries:
– Lower Extremities:
 Stress fractures (common in tarsal bones)
 Plantar fasciitis (damage of long ligament that
attaches to the sole of the heal bone)
 Shin splints (medial tibial area)
 Patellar tendinitis (jumper’s knee)
– Upper Extremities
 Tennis elbow
 Tendinitis (hand & wrist)
– Strains & sprains
Sports Injuries Cont’d
 Rotator cuff tears
– Shoulder muscle injury
 Anterior cruciate ligament injuries
– Tear of ACL
 Meniscal injuries
Arthroscopy
 Same day surgery.
 Mostly preformed on knee and shoulder by use of
a fibroptic arthoscope
 Candidates for surgery are people who can flex
their joint greater than fourty degrees and the joint
is infection free.
 Used for obtaining a Biopsy, assessing cartilage,
removing loose bodies & trimming cartilage.
 Infection is the major complication to arthroscopy.
Complications of Arthroscopy:






Infection
Blood in joint (hemarthrosis
Swelling
Synovial rupture
Joint injury
Thrombophlebitis.
By the time a person presents with complaints
of numbness, paresthesias, pain, or motor
deficit, nerve damage has progressed to the
stage of larger fiber sensory and/or motor loss.
The median nerve shares confined space with
nine flexor tendons as it travels through the
carpal tunnel. Any condition which reduces that
space is likely to cause CTS due to
compression of the vulnerable median nerve.
 Any solution which relieves
pressure on the nerve and
promotes circulation in the
microvascular neural blood
supply is likely to "cure" CTS
and relieve its attendant
symptoms of pain, etc.
DUPUYTREN'S CONTRACTURE
 A painless thickening of the
connective tissue in the palmar
hand that can lead to difficulty
extending the digits. Causes
include hand trauma and genetic
predisposition.
 Painless nodule on the palm,
 Cord-like bands across the palm &
thickening of the lines of the palm,
and curling (contracture) of the 4th
and 5th digits.
Surgery is performed in some cases
unresponsive to conservative measures
such as (splinting, warm soaks,
exercises).
Neurovascular Assessment:
Questions to Consider:
1. Discuss why neurovascular assessment is so
important. Your answer should include consideration of
the three components of neurovascular assessment:
Circulation, Motor Function, & Sensation, as well as
discussion of the 6Ps of neurovascular assessment.
2.Who is most at risk for problems of the peripheral
nervous system/blood flow?
Explanation
A loss of the bone’s blood supply causes
avascular necrosis (AN) - the bone dies &
bone structure collapses . Femoral neck
fractures which damage local blood
vessels, increase the risk of avascular
necrosis. Long term high dose steroids
also increase risk. Symptoms of AN
include pain & reduced ROM in affected
joint. Heparin, Lasix &NSAIDs aren’t
associated with AN.