Musculoskeletal

Musculo-skeletal System

Bone growth

Types of Bones ■ ■ ■

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Long bones – femur Short bones – somewhat cubedshaped as in the phalanges Flat bones – broad surface for muscular attachment or protection of organs; skull, ribs, shoulder blades, & sternum. Irregular bones – wrist, vertebrae

Functions of Bones ■

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Support & protect body tissues and organs Provides the skeletal framework of the body Provides movement through the attachment of muscles Storehouse for minerals: CA++ 99% makeup of bones & PO4 90% Production of blood cells which takes place in the bone marrow

Diarthrodial/Synovial Joints Ball & socket i.e. shoulder & hip which permits movement in any direction ■ Hinge i.e. elbow movement along one plane & allows flexion & extension ■ Condylar – functions like a hinge joint but can rotate slightly   ■

Synovial Joint Capsule ■

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Fibrous connective tissue covers the ends of bone.  Ligaments and tendons reinforce the joint capsule Bundles of rich, white fibrous tissue are supplied with nerves. Nerves are sensitive to rate and direction of motion, compression, tension, vibration and pain Blood vessels, and lymphatic vessels.

Skeletal Muscles Primary Function Provides voluntary movement ■ Maintains posture ■ Body Movement – contraction & relaxation ■

Skeletal Muscles Points of Attachment Point of origin – attachment of muscle to a more stationary bone ■ Point of insertions – attachment to a more movable bone ■

Head to Toe Assessment Health History Musculoskeletal disorders ■ Nutritional status ■ Pain History ■ ADLs, endurance, assistive devices ■ Medications – prescription and OTC ■

Assessment Skills ■

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Inspection – symmetry, body alignment, function, skin changes, swelling, deformity, contractures, gait, non-verbal indication of pain Palpation – Skin temperature, swelling, nodules, masses, crepitus Joint Structure & ROM Muscle mass & strength (atrophy, flaccidly, spasticity, paralysis)

Connective Tissue Disorders ■

Rheumatoid Arthritis

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Osteoarthritis

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Lupus Erythematous

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Gout

Rheumatoid Arthritis ■

Autoimmune connective tissue disorder characterized by inflammatory destructive changes in the joints

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Systemic disease – Inflammatory changes can affect skin, heart, lungs, eyes, blood vessels & nerves

Etiology of Rheumatoid Arthritis Autoimmune theory – Normal antibodies become autoantibodies (RH Factors) and attack the tissue. ■ Genetic Factor – 2-3 times > with family Hx ■ Virus – Epstein-Barr ■ Stressful events ■

Stages of Joint Deterioration ■

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Stage 1: Initiation - Some changes in the synovial lining – no loss of functional capacity Stage 2: Immune Response – Joint swells & thickens. Functional capacity impaired. Stage 3: Inflammatory - Progressive involvement of blood vessels. Limited ADL. Stage 4: Destructive – Granulation tissue hardens (Pannus). Leads to ankylosis. Confined to bed or wheel

Assessment Data ■

Subjective: - Stiffness especially in a.m. or after inactivity - Proximal joint pain in the fingers - Fatigue, weakness, weight loss, low grade fever

Assessment Data ■

Objective Manifestations - Swollen, reddened, warm joints - Weak hand grasp - Deformities (late stages)

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Swan Neck Ulnar Drift Boutonnière (buttonhole) Rheumatoid Nodules Vasculitis, Sjogren’s Syndrome

Diagnostic Tests ■

Blood Tests: - Rheumatoid Factor - Antinuclear Antibody Titer - Erythrocyte Sedimentation Rate - CBC; WBC

Diagnostic Tests ■

Radiographic: determines cartilage erosion, joint space narrowing, bone cysts - Arthrography- x-ray with contrast medium - Arthroscopy – endoscopic exam of joint - Arthrocentesis – needle aspiration of synovial fluid

Nursing Care Arthroscopy Postprocedure Assess neurovascular status (sx of thrombophlebitis) ■ Monitor for bleeding or leakage at site ■ Assess for pain, edema, redness ■ Ice for swelling, mild analgesic pain ■

Pain Management Prescribed Drug Therapy on timely basis ■ Rest periods ■ Warm shower, hot packs ■ Avoid sudden, jarring of joint ■ Warn clients about “quacks” (miracle cures) ■

Impaired Physical Mobility Exercise joint, but not beyond pain ■ Positioning & body alignment ■ Support joints for optimal function ■ Assistive Devices – proper fit & instruction ■

Self-care Deficit Routine that includes pacing activities ■ Encourage sleep routine ■ PT for conditioning ■ Occupational Therapy – Assistive devices ■

Drug Therapy ■

Salicylates (ASA) – Side effects/Precautions ■

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Tinnitus, GI distress, prolonged bleeding. Give with food, milk. Avoid anti-coagulants.

NSAID’s (Advil, Indocin, Toradol, Naprosyn) – Side effects/Precautions ■

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GI (do not crush enteric coated); give after meals or with food Dizziness, diarrhea, headache, rash

Drug Therapy ■

Glucocorticoids (dexamethasone, hydrocortisone, prednisone) – Side Effects/Precautions – Depression, euphoria, anorexia, nausea, weight gain, bruising. Taper dosage when discontinuing.

Drug Therapy ■

Slow-acting Antimalarial drugs (plaquenil) – Side Effects/Precautions ■

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Retinal edema, GI disturbance

Toxic – Gold Salts (solganol, myochrysine) – Side Effects/Precautions ■

Dizziness, flushing, metallic taste, skin rash; assess CBC & UA prior to administration

Drug Therapy ■

Cytoxic Drugs (Methotrexate, Imuran, Cytoxan) – Side Effects/Precautions ■

Pneumocystis Carinii pneumonia, mouth sores, bone marrow suppression, hepatotoxicity

Degenerative Joint Disease (Osteoarthritis) ■

Non-inflammatory disease of the weight bearing joints (hips, knees, spine, hands)

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Incidence: > in post-menopausal women

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Risk Factors: age, obesity, overuse of joints, trauma (fractures, sports

Osteoarthritis Pathophysiology – Articular cartilage becomes yellow & opaque, joint space narrows, bone spurs (osteocytes), & cysts ■ Symptoms – Joint pain / diminishes on rest ; crepitus (grating sensation); joint enlargement, Herberden’s nodes, Bouchard’s nodules, decrease ROM, joint effusion ■

Osteoarthritis ■

Diagnostic Tests: X-rays of joints indicates narrowing of joint spaces; CT Scan & MRI of spine; Bone Scan

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Differential features of RA & DJD

Osteoarthritis ■

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Medical Management Drug therapy for pain (NSAID’s), muscle relaxants (Flexeril), injection of cortisone Rest – immobilization with splint, brace, sleep (>8 hours/night) Position of joints to maintain alignment & avoid contractures Heat – hot packs, PT diathermy Exercise – walking, water aerobics

Osteoarthritis Surgical Management ■ Hemiarthroplasty: one part of a joint is replaced, i.e. head of femur ■ Total Hip replacement: Head of femur & the acetabulum replaced ■ Total Knee replacement: both articular surfaces of the knee replaced ■ Interphalangeal joint replacement

Total Hip Replacement ■

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Preoperative Care – Skin preparation, IV antibiotics, education re: nature of prosthesis, mobility restrictions, exercises Types of Prosthesis - Cemented – > 10 year life - Uncemented – bone growth occurs into the metallic surfaces within 6-12 weeks

THR - Postoperative Pain control ■ Wound & drain assessment ■ Neurovascular Assessment ■ Activity – bed rest with abduction splint or pillow, OOB with PT (NO hip flexion > 90°) weight bearing dependent on type of prosthesis ■ Use of walker – crutches - cane ■

THR - Potential Complication ■

Thromboembolism

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Subluxation - Hip Dislocation

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Neurovascular Compromise

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Hemorrhage

THR – Hip Precautions Avoid hip flexion > 90° ■ Avoid low, soft chairs ■ Avoid excessive trunk flexion in reaching ■ Maintain hip adduction ■ No leg crossing at knee ■ Use raised toilet seat ■

Total Knee Replacement ■ ■

Preoperative Care – similar to THR Postoperative Care - Pain control - Wound & drain assessment - Neurovascular Assessment - Elevate leg on pillow for comfort - Head of bed elevated for comfort - Continuous Passive Motion Machine

TKR - Potential Complications ■

DVT & pulmonary emboli

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Prosthetic Dislocation

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Infection

Lupus Erythematous ■

Definition: Autoimmune disease involving diffuse inflammatory changes in vascular connective tissue

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Pathophysiology: Antigen-antibody interactions results in deposits of immune complexes in tissues & cells that damage the organs and or blood vessels

Discoid Lupus ■

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Cutaneous manifestations – butterfly rash on face Risk Factor: Sun exposure intensifies Treatment: Cortisone creams, sun screens > 30 SPF, avoid sun at peak hours

Systemic Lupus Organs affected: Heart, lungs, kidney, brain, blood vessels, & joints ■ Systemic symptoms: Fatigue, myalgia, joint pain, low grade fever, anorexia ■ System specific symptoms: Tachycardia, chest pain, proteinuria, hip & knee necrosis, ■

Laboratory Tests of SLE ■

Skin biopsy & scrapings of skin cells

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Immune tests – RF, ANA, Sed Rate

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CBC (pancytopenia), Sed Rate, Cardiac & Liver Enzymes

Pharmacological Management Lupus ■

NSAID’S

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Corticosteroids

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Immunosuppresive Agents

Nursing Care - Lupus Pain Management ■ Encourage rest periods ■ Decrease protein in diet (kidney involvement) and sodium restriction (fluid retention) ■ Referral – Local & National Lupus Foundation ■

Potential Complications Lupus Erythematous Vasculitis ■ Cardiopulmonary – pericarditis, pleural effusion ■ CNS – psychosis, seizures, peripheral neuropathies ■ Avascular Necrosis ■

Gout ■

Definition: Systemic disease involving pain & inflammation of joints due to urate crystal deposits

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Pathophysiology: Imbalance of purine metabolism & kidney function

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Incidence: Middle aged men

Types of Gout ■

Primary: Inherited defect in purine metabolism

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Secondary: Disease i.e renal, diuretic therapy & chemotherapeutic agents

Clinical Manifestations of Gout ■

Asymptomatic phase – Elevated Uric Acid (.60-. 75 gm)

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Acute Phase – Sustained elevated Uric Acid causing extremely painful, swollen, and reddened joint

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Chronic Phase – Urate crystal deposits appear in cartilage, synovial membranes, tendons, & soft tissues (tophi formation)

Drug Therapy - Gout ■

Acute Phase – Colchicine, NSAID’S

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Chronic Phase – Allopurinol (Benemid); Colbenemid

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Avoid aspirin & diuretics

Diet Therapy - Gout Low purine (avoid organ meats, shellfish, oily fish with bones) ■ Avoid Alcohol ■ Increase fluid intake to 3,000 cc/day ■ High alkaline ash foods – citrus fruits and juices, certain dairy products ■

Other Connective Tissue Disorders ■

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Polymyalgia Rheumatica Ankylosing Spongylitis (Marie-Strümpell Disease) Sjögren’s syndrome Lyme’s Disease Fibromyalgia

Osteoporosis Types ■ Primary - Bone loss related to loss of estrogen in menopausal women and low testosterone levels in men ■

Secondary – Bone loss related to disease process (hyperthyroidism, renal failure, GI malabsorption problems)

Pathophysiology Bone Remodeling ■

Resorption – Worn out bone cells are removed by bone-resorbing cells called osteoclasts

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Formation – New bone is laid down by bone-forming cells called osteoblasts

Incidence/Risk Factors Osteoporosis ■

Age

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Race

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Gender

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Life Style

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Diet

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Heredity

Prevention of Osteoporosis ■

Exercise – weight bearing types

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Diet modifications

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Calcium intake – OTC i.e. Tums, Oscal, Calcium carbonate, Dietary supplement

Clinical Manifestations Osteoporosis ■

Height loss

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Vertebral deformities

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Restricted movement

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Back pain

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Fractures

Diagnostic Tests Osteoporosis ■

Laboratory – serum calcium, Vitamin D, phosphorus, alkaline phosphatase

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Radiological – X-ray, CT Scan, MRI - Dual energy x-ray absorptiometry

Medical Management Osteoporosis Drug Therapy Estrogen replacement – Premarin ■ Calcium supplements ■ Bone resorption inhibitor – Fosamax ■ Vitamin D ■

Nursing Management Osteoporosis High Risk for Injury – Prevention of falls and fractures - safe environment (non-skid slippers, shoes, clean spills, avoid scatter rugs, lighting, access to items for ADL, hand rails, avoiding lifting heavy objects, use of walker, cane.)

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Nursing Management Osteoporosis ■

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Impaired Physical Mobility Increase mobility to level of independence in ADL Interventions Physical therapy program (strengthening & weight bearing exercises) Occupational Therapy (Adaptive Devices)

Nursing Management Osteoporosis ■

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Pain Management - reduce & alleviate pain Interventions Drug Therapy - opioid, non-opioid analgesics, muscle relaxants, anti-inflammatory agents Use of heat Orthotic devices – braces, splints

Other Metabolic & Degenerative Bone Disorders ■

Osteomalacia

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Paget’s Disease

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Herniated Nucleus Pulposus - Laminectomy - Spinal Fusions

Fracture Patterns ■ ■ ■ ■ ■ ■

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Oblique – Line of fx angled Transverse – Across the bone Longitudinal – Length of bone Spiral – Twisting or rotation of bone Comminuted – broken in > 2 places Impacted – Fragments driven into each other Displaced or Avulsed – torn away by a ligament or tendon

Fractures

Classification by Anatomical Location ■ ■ ■ ■ ■ ■ ■ ■

Humerus Tibia, Fibula Pelvis Hip Skull Mandible Ribs Vertebrae

Fractures Definition: Interruption in normal bone continuity, which is accompanied by soft tissue injury ■ Classification: - Simple or closed - Open or compound ■

Stages of Bone Healing 1. 2. 3. 4. 5. 6.

Hematoma Granulation Callus Formation Osteoblastic Proliferation Bone Remodeling Complete Healing

Bone Healing Problems ■

Delayed Union - > 6 months to a year

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Nonunion - < ½ of bone fragments joined together

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Malunion – Bone healed in state of deformity

Assessment of Fractures ■

Subjective Data – History, complaints of pain, loss of sensation, movement

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Objective Data – Warmth, edema, ecchymosis, neurovascular impairment, splinting, anxiety, fear

Emergency Care Inspect area ■ Control bleeding ■ Immobilize/splint ■ Prevent shock ■ Transport safely to ER ■

INTERVENTIONS ■R

Rest/immobilize ■ I - Ice ■ C - Compression ■ E - Elevation ■ S - Support

Nursing Diagnoses Acute Pain ■ Risk for Neurovascular Dysfunction ■ Risk for Infection ■ Altered Mobility ■ Activity Intolerance ■

Complications of Fractures Shock ■ Neurovascular Compromise ■ DVT & Pulmonary Emboli ■ Aseptic Necrosis ■ Acute Compartment Syndrome ■ Fat Embolism Syndrome ■ Osteomyelitis ■

Shock ■

Etiology: Hemorrhage into damaged tissues, especially thorax, pelvis, & extremities

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Treatment: Control bleeding and restore blood volume

Neurovascular Compromise ■

Etiology: Damage to nerves from fragments of bone, pressure from casts, splints, & traction

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Assessment: 6 P’s – Pain, Pulselessness, Paresthesia, Pallor, Paralysis, Poikilothermia

INSPECTION/PALPATION FIVE P’S ■ PAIN ■ PULSE ■ PALLOR ■ PARASTHESI

A ■ PARALYSIS

Fat Embolism Syndrome ■

Etiology: Release of particles of fat into the blood stream from the yellow marrow at site of injury

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Risk Factors: Fx. of long bones, multiple fx., high serum glucose or cholesterol level

DVT & Pulmonary Emboli ■

Etiology: Immobility, trauma, surgery

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Risk Factors: Incidence in fractures of the lower extremities; smoking, obesity, heart disease

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Treatment:

Avascular Necrosis ■

Etiology: Loss of blood supply to bone

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Risk Factors: Hip fractures or any fracture where this bone displacement

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Treatment: Surgical joint replacement

Compartment Syndrome Etiology: Massive compromise in circulation from external (tight, bulky dressings, casts) & internal (blood & fluid) ■ Treatment: Immediately loosen any tight dressings & MD can bivalve cast ■ Surgery – Decompression fasciotomy for edema and bleeding ■

Surgical Management

Fasciotomy to relieve pressure. The fascia is divided along the length of the compartment to release pressure within.

Osteomyelitis ■

Acute – infection in another part of the body invades bone tissue or occurs from penetrating trauma

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Chronic – Infection persists especially in a patient with compromised circulation

Medical Management of Fractures ■

Closed reduction & immobilization – Manual traction to align the bone

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External Fixation – Percutaneous placement of pins implanted into bone - Kronner 4-Barr Compression Frame - Hex-Fix External device for tibial fractures - Halo Traction – Cervical spinal fractures

Nursing Care – External Fixation Teach patient patient to grasp frame when moving, rather than limb ■ Frequent observation & neurovascular assessments ■ Pin Care – Note symptoms of infection ■ Assess for loosening or shifting of devices ■

External Fixator

External Fixation

External Fixator

Casts ■

Purpose: Immobilze, correct deformity, allow early mobility, & provide support & protection

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Types: Plaster of Paris & Fiberglass

Plaster Cast Care Instruct that cast will feel warm ■ Handle cast with palms of hands ■ Turn client q 1-2 hours for drying ■ Elevate on pillow higher than heart ■ Pedal rough edges with moleskin ■ Inspect q 4-8 hours – drainage, cracking, odor, alignment & fit ■

Cast Complications Circulatory impairment ■ Peripheral nerve damage ■ Impaired skin integrity ■ Pneumonia, DVT, Constipation ■ Compartment Syndrome ■ Cast Syndrome – Body cast ■ Fracture blisters ■

Traction ■

Definition: Pulling force that is applied to part of an extremity while a counter traction pulls in the opposite direction

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Purpose: Reduce Fracture, immobilize, decrease pain & muscle spasm, correct deformities, stretch tight muscles

Types of Traction ■

Continuous or Running – Buck’s, Russell

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Circumferential – Pelvic

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Cervical

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Suspension or Balanced – Thomas Ring

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Skeletal – Steinmann pins, Kirschner wires, Crutchfield tongs

Bucks Traction

Bryants Traction

Skeletal Traction

Nursing Assessment ■

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Equipment – weights, pulley’s, ropes, Balkan frame Mobility Skin integrity

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Neurovascular

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Gastrointestinal

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Urinary

Fractured Hip ■

Incidence: Prevalent women > 65; 200,000 annually; by age 80 1 in 5

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Risk Factors: Falls, osteoporosis, age related changes in balance

Anatomy of Hip ■

Head of femur

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Acetabulum

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Femoral neck

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Greater trochanter

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Lesser or sub-trochanter

Types of Hip Fractures ■

Femoral Neck – displaced, impacted, comminuted

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Intertrochanteric (Intracapsular, Extracapsular)

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Subtrochanteric

Signs & Symptoms of Hip Fractures ■

Pain – hip or thigh

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Adduction, external rotation

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Shortening of leg

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Inability to move or bear weight

Surgical Intervention ■

Total Hip Arthroplasty – - Cemented allows full weight bearing - Uncemented – full weight bearing not permitted for 6-8 weeks

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ORIF – Intramedullay rods, plates, compression screws; allows early ambulation

Internal Fixation: Plates and Pins

Post-operative Care - ORIF Bedrest 1st day; OOB with walker ■ HOB > 35 - 40° ■ Avoid hip flexion > 90° ■ Trochanter roll for hip alignment ■ Pillow splint when turning (per MD) ■ Isometric exercises ■ Pain control – narcotic analgesics ■

Complications ORIF ■

DVT, PE

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Hemorrhage

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Infection

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Subluxation or dislocation

Carpal Tunnel Syndrome ■

Definition: compression of the medial nerve in the wrist

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Etiology: Repetitive motions, wear & tear, fracture of wrist

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Symptoms: Pain, paresthesia, difficulty in grasping

Carpal tunnel syndrome - atrophy and weakness of the hand

Diagnostic Tests CTS Phalen’s – wrist flexed back to back results in paresthesia >60 seconds ■ Tinel’s – Tapping over the median nerve pain, tingling, numbness or inflating a BP cuff will result in same sx. ■ X-ray ■ EMG ■

Interventions CTS ■

Non-invasive – wrist support, immobilization with splint, frequent breaks, cushion grippers on pencils & pens, rest, ice, heat, antiinflammatory agents

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Invasive – Cortisone Injections, Surgery