Nur105Musculoskeletal System 2006 Website

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Musculoskeletal System

NUR 105 Adult Health

Assessment of MusculoskeletalFunction


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Skeletal SystemBone types

Bone structure

Bone function

Bone growth and metabolism affectedby calcium and phosphorous, calcitonin,

vitamin D, parathyroid, growth hormone,glucocorticoids, estrogens andandrogens, thyroxine, and insulin.


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Musculoskeletal

Anatomy and PhysiologyAnatomy

Flat, Short, Long, Irregular bones

Muscles visceral, cardiac, skeletal

Joints freely & slight moveable, synovial fluid

Cartilage,Ligaments, Tendons, Fascia, Bursae

Physiology

Structure, shape, movement, protection, support,

hematopoiesis


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JointsTypes include synarthrodial, amphiarthrodial,

diarthrodial

Structure and function of the diarthrodial orsynovial joint

Subtyped by anatomic structure Ball-and-socket

Hinge

Condylar Biaxial

Pivot


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A & P of Skeletal


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Musculoskeletal

AssessmentHealth History Subjective Data -Chief Complaints pain, altered sensation, limited

motion

Family history, personal history, dietary history, socioeconomic status Medications (steroids); Current health problems - obesity

Objective Data - Physical Exam Objective Data - Diagnostic Tests

Special Assessment Techniques Ballottement Bulge Sign

Phalen

Tinels


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Physical Exam Mental Status

General inspection

Head and neck: temporomandibular joint; crepitus Height, weight, nutritional status, skin, spine

lordosis, scoliosis, posture, joint function, upper

and lower extremities

Posture, gait, ROM ex., deep tendon reflexes,bone integrity, muscle strength and tone,

neurovascular, MS injuries


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ScoliosisAbnormal spinal curvature of various

degrees or severity involving shortening

of muscles and ligaments.

Milwaukee brace, internal fixative

devices.


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Diagnostic Evaluation Imaging Procedures CT, Bone Scan, MRI

Nuclear Studies - radioisotope bone density,

Endoscopic Studiesarthrocentesis, arthroscopy

Other Studiesbiopsy, synovial fluid, Arthrogram,venogram,

Electromyography

Myelography*

Laboratory Studies


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Musculoskeletal

Assessment Diagnostic Test Laboratory

Urine Tests

24 hour creatine-

creatinine ratio

Urine Uric acid

24 hr

specimen

Urinedeoxypyridino-

line

Laboratory Blood Tests

Serum muscleenzymes

Rheumatoid Factor

LE Prep/AntinuclearAntibodies(ANA)

Erythrocyte

Sedimentation Rate Calcium,

Phosphorous,Alkaline phosphatase


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Muscluloskeletal

Assessment Diagnostic Blood Tests

CBC Hgb, Hct

Acid phosphatase Metabolic/Endocrine

EnzymesIncrease creatine

kinase, serumincrease glutamin-

oxaloacetic due to

muscle damage,

aldolase, SGOT


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Musculoskeletal - Radiographic

Standard radiography, tomography and

xeroradiography, myelography,

arthrography and CT

Other diagnostic tests: bone and muscle

biopsy


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MS Diagnostic Tests

Electromyography EMG aids in the diagnosis of neuromuscular,

lowert motor neuron, and peripheral nerve

disorders; usually with nerve conductionstudies.

Low electrical currents are passed through

flat electrodes placed along the nerve.

If needles are used, inspect needle sites for

hematoma formation.


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Arthroscopy Fiberoptic tube is inserted into a joint for

direct visualization.

Client must be able to flex the knee;exercises are prescribed for ROM.

Evaluate the neurovascular status of the

affected limb frequently.Analgesics are prescribed.

Monitor for complications.


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MS Diagnostic TestsBone Scan

Gaillum or Thallium scan

Magnetic resonance imaging

Ultrasonography


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Metabolic Bone DisordersOsteoporosis

OsteomalciaPagets Disease


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OsteoporosisA disease in which loss of bone exceeds rate

of bone formation; usually increase in older

women, white race, nulliparity. Clinical Manifestations bone pain,

decrease movement.

Treatment Calcium, Vit. D, estrogen

replacement, Calcitonin, fluoride, estrogenwith progestin, SERM with anti-estrogens,exercise.

Pathologic fracture-safety.


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Classification of Osteoporosis

Generalized osteoporosis occurs mostcommonly in postmenopausal women

and men in their 60s and 70s.

Secondary osteoporosis results froman associated medical condition such

as hyperparathyroidism, long-term

drug therapy, long-term immobility.Regional osteoporosis occurs when a

limb is immobilized.


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Health Promotion/Illness

Prevention - OsteoporosisEnsure adequate calcium intake.

Avoid sedentary life style.

Continue program of weight-bearing

exercises.


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Osteoporosis - AssessmentPhysical assessment

Psychosocial assessment

Laboratory assessment

Radiographic assessment


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Os

O

st

e

op

o

sr

o

Osteoporosis


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Osteoporosis


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Drug Therapy

OsteoporosisHormone replacement therapyParathyroid hormone

Calcium and vitamin D

Bisphosphonates

Selective estrogen receptormodulators

CalcitoninOther agents used with varying

results


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Diet Therapy - Osteoporosis

Protein

Magnesium

Vitamin K

Trace minerals

Calcium and vitaminD

Avoid alcohol and caffeine


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F

all Prevention - OsteoporosisHazard-free environment

High-risk assessment through

programs such as Falling Star

protocol

Hip protectors that prevent hip

fracture in case of a fall


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Others - OsteoporosisExercise

Pain management

Orthotic devices


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OsteomalaciaSoftening of the bone tissue

characterized by inadequate

mineralization of osteoid

Vitamin D deficiency, lack of sunlight

exposure

Similar, but not the same asosteoporosis

Major treatment: vitamin D from

exposure to sun and certain foods


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PagetsD

isease of theB

oneMetabolic disorder of boneremodeling, or turnover; increasedresorption of loss results in bone

deposits that are weak, enlarged,and disorganized

Nonsurgical management:calcitonin, selected

bisphosphonates, mithramycin

Surgical management: tibialosteotomy or partial or total joint

replacement


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Pagets DiseaseA imbalance of increase osteoblast and

osteoclast cells; thickening and hypertrophy.

Bone pain most common symptom; bonyenlargement and deformities usually bilateral,

kyphosis, long bone.

Analgesics, meds bisphosphonates and

calcitonin, NSAID, assistance devices, and

hot/cold treatment.


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OsteomyelitisA condition caused by the invasion

by one or more pathogenic

microorganisms that stimulates the

inflammatory response in bone

tissue

Exogenous, endogenous,

hematogenous, contiguous

Drug therapy

Infection control

H erbaric ox en thera


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Osteomyelitis Infection of bone; causative agent

Staph/Strept

Typical signs and symptoms

Treatment IV antibiotic; long term for

4-6 months


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Surgical Management

OsteomyelitisSequestrectomy

Bone grafts

Bone segment transfers

Muscle flaps

Amputation


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Bone TumorsBenign Bone Tumors

Malignant Bone TumorsMetastatic Bone Disease


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B

one TumorsBenign bone tumors (noncancerous):

Chrondrogenic tumors:

osteochondroma, chondroma

Osteogenic tumors: osteoid osteoma,

osteoblastoma, giant cell tumor

Fibrogenic tumors


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InterventionsNondrug pain relief measures

Drug therapy: analgesics, NSAIDs

Surgical therapy: curettage (simple

excision of the tumor tissue), joint

replacement, or arthrodesis


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Osteosarcoma Cancer of the bone metastasis to the lung is

common. Most in long bones.

Clinical manifestations dull pain, swelling,intermittent but increases per time; night pain

common.

Treatment radiation, chemotherapy,

hormonal therapy, surgical excision withprosthetics, assistance devices, palliative

measures.


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MalignantB

one TumorsPrimary tumors, those tumors that

originate in the bone

Osteosarcoma

Ewings sarcoma

Chondrosarcoma

FibrosarcomaMetastatic bone disease


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Cancer ofBone

Acute Pain; Chronic Pain Interventions include:

Treatment aimed at reducing the size or

removing the tumor

Drug therapy; chemotherapy

Radiation therapy

Surgical managementPromotion of physical mobility with

ROM exercises


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Cancer ofBone

Anticipatory Grieving Interventions include:

Active listening

Encouraging client and family to

verbalize feelings

Making appropriate referrals

Helping client and others to cope withthe loss and grieving

Promoting the physician-client

relationship


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Disturbed Body Image

Cancer ofBone Interventions include:

Recognize and accept the clients view

of body image alteration.

Establish and maintain a trusting nurse-

client relationship.

Emphasize the clients strengths andremaining capabilities.

Establish realistic mutual goals.


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Potential forFractures

Bone Cancer InterventionsNonsurgical management: radiation

therapy and strengthening exercises.

Surgical management: replace as much ofthe defective bone as possible, avoid a

second procedure, and return client to a

functioning state with a minimum of

hospitalization and immobilization.


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Carpal Tunnel Syndrome

Common condition; the median

nerve in the wrist becomes

compressed, causing pain andnumbness

Common repetitive strain injury via

occupational or sports motionsNonsurgical management: drug

therapy and immobilization

Possible surgical management


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Hand Disorders

Dupuytren's contractureslowly

progressive contracture of the

palmar fascia resulting in flexion ofthe fourth or fifth digit of the hand

Gangliona round, cystlike lesion,

often overlying a wrist joint ortendon


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Disorders of the Foot

Hallux valgus

Hammertoe

Mortons neuroma

Tarsal tunnel syndrome

Plantar fasciitis

Other problems of the foot


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Scoliosis

Changes in muscles and ligaments

on the concave side of the spinal

column

Congenital, neuromuscular, or

idiopathic in type

Assessment: complete history, painassessment, observation of posture

Interventions: exercise, weight

reduction, bracing, casting, surgery


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Osteogenesis Imperfecta

Rare genetic disorder in which the

bones are fragile and fracture easily,

resulting in bone deformity

Clinical manifestations: poor skeletal

development

Treatment: palliative; clients lifespan is often shortened

Steroids, calcium, vitamin C, and

possibly sodium fluoride


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Progressive MuscularDystrophies

At least nine types of muscular

dystrophies identified; categorized

as slowly or rapidly progressive

Diagnosis often difficult

Management

Supportive, making client as

comfortable as possiblePrednisone, immunosuppressive

agents, anabolic steroids


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Chapter 55Interventions for Clients

with MusculoskeletalTrauma


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Classification ofFractures

A fracture is a break or disruption inthe continuity of a bone.

Types of fractures include:Complete

Incomplete

Open or compound

Closed or simple

Pathologic (spontaneous)

Fatigue or stress

Compression


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Stages ofBone Healing

Hematoma formation within 48 to 72

hr after injury

Hematoma to granulation tissue

Callus formation

Osteoblastic proliferation

Bone remodeling

Bone healing completed within about

6 weeks; up to 6 months in the older

erson


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Acute Compartment

SyndromeSerious condition in which increased

pressure within one or more

compartments causes massivecompromise of circulation to the area

Prevention of pressure buildup of

blood or fluid accumulationPathophysiologic changes

sometimes referred to as ischemia-

edema cycle


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Emergency Care - Acute

Compartment SyndromeWithin 4 to 6 hr after the onset of

acute compartment syndrome,

neuromuscular damage isirreversible; the limb can become

useless within 24 to 48 hr.

Monitor compartment pressures.(Continued)


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Emergency Care (Continued)

Fasciotomy may be performed to

relieve pressure.

Pack and dress the wound afterfasciotomy.


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Possible Results of Acute

Compartment Syndrome Infection

Motor weakness

Volkmanns contractures

Myoglobinuric renal failure, known

as rhabdomyolysis


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Other Complications of

FracturesShock

Fat embolism syndrome: serious

complication resulting from afracture; fat globules are released

from yellow bone marrow into

bloodstreamVenous thromboembolism

(Continued)


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Other Complications of

Fractures (Continued) Infection

Ischemic necrosis

Fracture blisters, delayed union,

nonunion, and malunion


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Musculoskeletal

Complications (continued) Muscle Atrophy, loss of muscle strength

range of motion, pressure ulcers, and other

problems associated with immobility Embolism/Pneumonia/ARDS

TREATMENT hydration, albumin, corticosteroids

Constipation/Anorexia

UTI

DVT


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Fractures (contd)

avascularnecrosis

reaction tointernalfixationdevices

complexregional pain

heterotrophicossification


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Musculoskeletal

Assessment - FractureChange in bone alignment

Alteration in length of extremity

Change in shape of bone

Pain upon movement

Decreased ROM

Crepitation

Ecchymotic skin(Continued)


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Musculoskeletal

AssessmentFrac

ture(Continued)

Subcutaneous emphysema with

bubbles under the skin

Swelling at the fracture site


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Special Assessment

Considerations For fractures of the shoulder and

upper arm, assess client in sitting or

standing position.Support the affected arm to promote

comfort.

For distal areas of the arm, assessclient in a supine position.

For fracture of lower extremities and

pelvis, client is in supine position.


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Risk for Peripheral

NeurovascularDysfunction Interventions include:

Emergency care: assess for respiratory

distress, bleeding and head injuryNonsurgical management: closed

reduction and immobilization with a

bandage, splint, cast, or traction


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CastsRigid device that immobilizes the

affected body part while allowing other

body parts to move

Cast materials: plaster, fiberglass,

polyester-cotton

Types of casts for various parts of the

body: arm, leg, brace, body(Continued)


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Casts (Continued)

Cast care and client education

Cast complications: infection,

circulation impairment, peripheralnerve damage, complications of

immobility


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Managing Care of the Patient in a

CastCasting Materials

Relieving PainImproving Mobility

Promoting Healing

Neurovascular Function

Potential Complications


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Cast, Splint, Braces, and Traction

Management Considerations

Arm Casts

Leg CastsBody or Spica Casts

Splints and Braces

External Fixator

Traction


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Musculoskeletal

Nursing Care - Casts Cast (Leg, arm, body)

Different materials-

fiberglass, plastic,

plaster, stockinette Neurovascular

Check color/capillary

refill

Temperature

Pulse Movement

Sensation

Traction

Bucks

Russells

Skeletal

Traction Nursing Care

Weighs hang free

Pin Site care

Skin and neurovascularcheck


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Traction

Application of a pulling force to the

body to provide reduction,

alignment, and rest at that site Types of traction: skin, skeletal,

plaster, brace, circumferential

(Continued)


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Traction (Continued)

Traction care:

Maintain correct balance between

traction pull and countertraction forceCare of weights

Skin inspection

Pin careAssessment of neurovascular status


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Musculoskeletal Fractures

Treatment Primary Goal reduce fracture-

Realign and immobilize

MedicationsAnalgesics, antibiotics, tetanus toxoid

Closed Reduction Manual and Cast;External Fixation Device

Traction; Splints; Braces Surgery

Open reduction with internal fixation

Reconstructive surgery

Endoprosthetic replacement


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Nursing ManagementPositioning

Strengthening Exercises

Potential Complications


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Musculoskeletal

Nursing CareOther External Immobilizations

Halo Vest

External Fixation with lag screws at tibia,

pelvic, ankle/foot


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Musculoskeletal

Nursing Care -2 Promote comfort

Assess infection

Promote mobility

Teach safety

Vital Signs

Flotation, sheep skin

Nutrition Vital Signs

Monitor elimination

Elevate extremity to

decrease swelling/

ice pack Teach skin care,

cast care, diet,

complications


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Operative Procedures


External fixation

Postoperative care: similar to that for

any surgery; certain complications

specific to fractures and

musculoskeletal surgery include fatembolism and venous

thromboembolism


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Procedures for Nonunion

Electrical bone stimulation

Bone grafting

Bone banking


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Managing the Patient UndergoingOrthopedic Surgery

Joint Replacement

Total Hip Replacement

Total Knee Replacement


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Acute Pain - Orthopedic Surgery

Interventions include:

Reduction and immobilization of fracture

Assessment of pain

Drug therapy: opioid and nonopioid drugs(Continued)


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Acute Pain (Continued)

Orthopedic SurgeryComplementary and alternative

therapies: ice, heat, elevation of body

part, massage, baths, back rub,therapeutic touch, distraction, imagery,

music therapy, relaxation techniques


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Risk for Infection


Apply strict aseptic technique for

dressing changes and woundirrigations.

Assess for local inflammation

Report purulent drainage immediately to

health care provider.

(Continued)


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Risk for Infection (Continued)

Assess for pneumonia and urinary tract

infection.

Administer broad-spectrum antibioticsprophylactically.


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Impaired Physical Mobility


Use of crutches to promote mobility

Use of walkers and canes to promotemobility


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Imbalanced Nutrition: Less

Than Body Requirements Interventions include:

Diet high in protein, calories, and

calcium, supplemental vitamins B and C Frequent small feedings and

supplements of high-protein liquids

Intake of foods high in iron


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Upper Extremity Fractures

Fractures include those of the:

Clavicle

ScapulaHumerus

Olecranon

Radius and ulnaWrist and hand


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Lower Extremity Fractures

Fractures include those of the:

Femur

Patella Tibia and fibula

Ankle and foot


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Fractures of the Hip

Intracapsular or extracapsular

Treatment of choice: surgical repair,

when possible, to allow the olderclient to get out of bed


Intramedullary rod, pins, aprosthesis, or a fixed sliding plate

Prosthetic device


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Fractures of the Pelvis

Associated internal damage the chief

concern in fracture management of

pelvic fracturesNonweight-bearing fracture of the

pelvis

Weight-bearing fracture of the pelvis

C i F t f


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Compression Fractures of

the SpineMost are associated with

osteoporosis rather than acute spinal

injury.Multiple hairline fractures result

when bone mass diminishes.(Continued)

Compression Fract res of


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Compression Fractures of

the Spine (Continued)Nonsurgical management includes

bedrest, analgesics, and physical

therapy.Minimally invasive surgeries are

vertebroplasty and kyphoplasty, in

which bone cement is injected.(Continued)


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AmputationLevelsComplications

Rehabilitation

Nursing Managementrelieving pain

minimizing altered sensory

perceptionpromoting wound healing

enhancing body image

self-care


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Amputations

Surgical amputation

Traumatic amputation

Levels of amputation

Complications of amputations:

hemorrhage, infection, phantom limb

pain, problems associated withimmobility, neuroma, flexion

contracture


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Phantom Limb PainPhantom limb pain is a frequent

complication of amputation.

Client complains of pain at the site

of the removed body part, mostoften shortly after surgery.

Pain is intense burning feeling,

crushing sensation or cramping.Some clients feel that the removed

body part is in a distorted position.


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Management of Phantom Pain

Phantom limb pain must be

distinguished from stump pain

because they are managed

differently.Recognize that this pain is real

and interferes with the amputees

activities of daily living.

(Continued)

Management of Phantom


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Management of Phantom

Pain (Continued)Some studies have shown that

opioids are not as effective for

phantom limb pain as they are forresidual limb pain.

Other drugs include intravenous

infusion calcitonin, beta blockers,anticonvulsants, and

antispasmodics.


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Exercise After Amputation

ROM to prevent flexion contractures,

particularly of the hip and knee

Trapeze and overhead frame Firm mattress

Prone position every 3 to 4 hours

Elevation of lower-leg residual limbcontroversial


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Prostheses

Devices to help shape and shrink the

residual limb and help client readapt

Wrapping of elastic bandages Individual fitting of the prosthesis;

special care


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Crush SyndromeCan occur when leg or arm injury

includes multiple compartments

Characterized by acute compartment

syndrome, hypovolemia,hyperkalemia, rhabdomyolysis, and

acute tubular necrosis

Treatment: adequate intravenousfluids, low-dose dopamine, sodium

bicarbonate, kayexalate, and

hemodialysis

Complex Regional Pain


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Complex Regional Pain

SyndromeA poorly understood complex

disorder that includes debilitating

pain, atrophy, autonomicdysfunction, and motor impairment

Collaborative management: pain

relief, maintaining ROM, endoscopicthoracic sympathectomy, and

psychotherapy.


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Sports-Related InjuriesRotator Cuff TearsEpicondylitis (Tennis Elbow)

Lateral and Medial CollateralLigament Injury

Anterior and Posterior

Cruciate Ligament InjuryMeniscal Injuries

Rupture of the Achilles

Tendon

C t i St i d


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Contusions, Strains, and

SprainsContusion is a soft tissue injury

Strain is a pulled muscle fromoveruse, overstretching, or

excessive stress

Sprain is an injury to ligamentssurrounding a joint

RICE


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StrainsExcessive stretching of a muscle or

tendon when it is weak or unstable

Classified according to severity:

first-, second-, and third-degreestrain

Management: cold and heat

applications, exercise and activitylimitations, anti-inflammatory drugs,

muscle relaxants, and possible

surgery


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Sprains

Excessive stretching of a ligament

Treatment of sprains:

first-degree: rest, ice for 24 to 48 hr,compression bandage, and elevation

second-degree: immobilization, partial

weight bearing as tear heals

third-degree: immobilization for 4 to 6

weeks, possible surgery


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Rotator Cuff Injuries

Shoulder pain; cannot initiate or

maintain abduction of the arm at the

shoulderDrop arm test

Conservative treatment: nonsteroidal

anti-inflammatory drugs, physicaltherapy, sling support, ice or heat

applications during healing

Surgical repair for a complete tear


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Musculoskeletal Disorders


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Musculoskeletal Disorders

SummaryMany diseases are systemic,

progressive inflammatory disorders.

No cure; treat symptom.Promote optimum mobility- therapy,

rest, hot/cold treatments, steroids,NSAID, immunosuppressants,

assistance device, Calcitonin.Diet lo purine diet, Calcium, Vit. D.

Musculoskeletal


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Musculoskeletal

Summary - 2 Prevention- infections, stress, no rest.

Surgical intervention removal of in case of

cancer, internal fixative device for Scolosis, orhip or knee replacement with prothesis for

degenerative joint disease, rheumatoid

arthritis.

Key prevent complications, patient teachingand achieve optimum level of mobility.

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