Management of Clients with Musculoskeletal Disorders

I. General
A. Functions of the musculoskeletal system
1. Support- of vital organs (heart, lungs, brain, etc.)
2. Locomotion- mobility, strong muscles
3. Protection
4. Mineral storage- calcium, phosphorus, magnesium, fluoride
5. Hematopoiesis- rbc produced in flat bones (sternum, ileum, ribs)
6. Heat production- with muscle contraction, maintaining body heat
B. Consists of
1. Bones
2. Joints
3. Muscles
4. Tendons- connect muscle to bone
5. Ligaments- connect bone to bone
6. Bursa- padlike sac in connective tissue of joint
* intact nerves are required to send impulse to muscle to move bone

II. Pain
A. Subjective state which a variety of unpleasant sensations with wide range of facors
may be experienced
B. 5th vital sign
C. Types of pain
1. Bone pain- dull, deep ache; boring in nature
2. Muscular pain- soreness, aching; muscle cramps
3. Fracture pain
a. sharp, piercing
b. immobilization decreases the pain
4. Bone infection
a. pain level steadily increases
b. difficult to manage- drugs don’t help
c. look for temp, swelling, redness
d. often increased pain after discharge- instructions include if when get
home and use the pain meds given with no relief, call dr because may be
infection
5. Joint sprain/strain
a. causes limited mobility
b. pain that increases with activity- if off of, is ok
6. Nerve root pressure- pain radiates
D. Assessment
1. Body alignment
2. Check pressure from appliances or hardware
3. Location of pain
4. Anything onsets discomfort
5. Other locations of pain
 6. Describe pain
7. Identify if consistent or relief maintained by anything
E. Managing pain
1. Relaxation techniques
2. Behavioral therapy
3. Diaphragmatic breathing
4. Diversion
5. Guided imagery
6. Rest
7. Medications
8. Heat and ice

III. Immobility
A. Causes physiological problems affecting majority of body systems
B. Complications related to immobility
1. Respiratory- pneumonia
a. tcdb
1. Turn q2- prevent stasis
2. Nurses responsibility to see if appropriate pt treatments being
done
2. Cardiovascular- venous pooling
a. venous stasis due to no muscle contractions
b. dvt treat with lovenox or fragmen
c. use ted & scd
d. assess plexi pulses
e. monitor side effects
1. Blood in urine
2. Bleeding anywhere outside the norm
3. Orthostatic htn
4. At risk for emboli
f. keep hydrated
3. Musculoskeletal- hypercalcium
a. will become stiff with decreased flexiblity
1. Aging
2. Prevent contractures
3. Prevent muscle atrophy
4. Prevent osteoporosis
b. perform rom if able and ordered
4. Integumentary
a. breakdown risk
b. turn q2 hours
c. massage bony prominences
5. Genitourinary
a. not able to empty bladder completely
b. may have a foley and be at risk for infection
6. Gastrointestinal
 a. constipation
b. decrease in gi motility
c. nausea
7. Metabolic
a. electrolytes
b. calcium will be increased if immobilized due to breakdown of calcium
in the bones and spillage into the blood serum
c. calcimar if too hypercalcemic

IV. Neurovascular Compromise

A. Altered sensations or sensory disturbances frequent associations with musculoskeletal
problems
B. Often experience paresthesia, numbness
C. Loss of function can result from impaired nerves, circulatory structures
D. Causes
1. Soft tissue swelling or direct trauma
2. Swelling
a. leads to pressure on nerves or circulating structures
b. can lead to impairment of tissue perfusion
1. Sluggish capillary refill
2. Cool skin
3. Discoloration
c. causes altered or diminished sensory & motor function
E. Assessment
1. Wash Hands and Identify patient
2. Abnormal sensations or numbness
3. Experiencing Pain- when did it begin and is it getting worse
4. Color of part distal to affected area equal and is rapid capillary refill
5. Ability to move part
a. if forearm broken have them move hands and fingers (flexion and
extension)
b. motor compartment
6. Blanching / Capillary refill
7. Temperature
8. Edema
a. presence- symptoms decrease by elevating affected area)
b. can lead to impairment of tissue perfusion
c. swelling occurs confined space – cast, muscle fascia, tissue sheath of
extremity leads to swelling until out of room leading to compartment
syndrome
1. if swelling occurs the MD should be notified and get the cast
removed or whatever type bandage loosened or removed.
d. assess for volkmans contracture- compromise of forearm or calf, lose
mobility
9. Presence of pulse and character
a. pulse distal to injury
 b. if you are unable to palpate pulse do rest of assessment and document
“unable to assess”
10. Constrictive device or clothing- can cause nerve vascular compression
 Musculoskeletal Traumatic Injuries

I. Contusions
A. Ecchymosis or bruising
B. Soft tissue injuries due to blunt force
C. Small vessels rupture with bleeding into tissue
D. Cause hematoma
E. Pain, swelling, discoloration
F. Control with intermittant application of cold, 15 min X many times

II. Strains
A. Over use of muscles, stretching, stress
B. Complaints of soreness, sudden pain
C. Tendons are affected (connects muscle to bone)

III. Sprains
A. Associated with stretched, torn or completely ruptured ligaments
B. More serious because it surrounds a joint
C. Avulsion fracture- pulls away part of bone

IV. Joint Dislocations

A. Subluxation means out of joint
B. When the articular surface of the bones forming the joint are no longer an anatomical
contact
C. Congenital, trauma, diseased joint
D. Management
1. Need plenty of rest
2. Neuro checks
3. Control pain
4. Compression bandage
5. Elevate

V. Fractures
A. Disruption in continuity (breaking) of bone as a result of trauma or venous
disease
B. Process that weakens bone structure
C. Defined according to extent o and location
D. Weight greater can support
E. Immobilization helps with pain the most
F. Causes
1. Direct blow
2. Crushing force
3. Extreme muscle contracture
4. Sudden twisting motion
G. Force applied to bone results in vasculature and neurological destruction.
H. Blood vessels and nerves are torn and tendons are ruptured. WILL BLEED
I. Bones broken with disruption of normal movement of bone
J. Soft tissue swelling
K. Hemorrhage of bone into muscles and joints
L. May have dislocations, strains, sprains and injury to body organs are protected
M. Defining fractures look at the type and extent (Degree and Integrity)
1. Degree
a. complete
1. Break across entire cross section of bone
2. Often displaced: not in normal alignment anymore and must be
complete fracture for this to happen
b. incomplete
1. Break through only part of cross section
2. Example: Green stick in children
2. Integrity
a. closed /simple- break in bone with no break in skin
b. open / compound
1. Air exposure, skin or mucus membrane wound extend to fractured
bones
2. Deep enough for bone to gat air – Exposed to environment
3. Increased R/F Infection - Osteomyletis
a. antibiotics to prevent infection
N. Types
1. Greenstick- one side bone broken, other side just bent
2. Transverse- break straight across bone, complete fracture
3. Oblique- at an angle across the bone
4. Spiral- bone has been twisted, associated with abuse
5. Comminuted
a. bone splatters or shatters 3 or more fragments
b. spinal cord injuries
c. external fixation (fixator)- device used to treat an extremity
6. Depressed- depression of skull inward, facial
7. Compression
a. usually back or neck
b. compression into spinal cord
c. C5-C7
d. lower lumbar region
8. Pathological
a. disease process that weakens bone to where minor movements of any
kind can fracture bone
b. tumors, osteoporosis
9. Avulsion- ligaments torn at attachments that rip bone with it
10. Epiphyseal
a. seen in children
b. goes into growth plate
c. may affect child’s growth
 11. Impacted hip fracture- head/neck ball with femur into head/neck are
O. Clinical Manifestations
1. Pain
a. increase in severity unless fracture immobilized
b. muscle spasms can cause pain, hurts worse than fracture, total
disruption of bone so muscle not aligned so spasms occur
2. Loss of function- can’t use like before
3. False motion- bone not rigid & straight so moves unnaturally
4. Deformity
a. compare opposite extremity
b. extremity rotates out
5. Shortening
a. seen in long bone (femur) or hip fracture
b. the muscle wrapping around the femur can cause the bone not to
align thus causing shortening
c. causes misalignment
6. Crepitation- rubbing bone fragments
7. Swelling & discoloration
a. bruising
b. bleeding & edema
c. common with fractures
P. Emergency management
1. Reduction- getting things back to normal position, realign bones
a. closed reduction- no surgery, manipulation by md, ends of bones
brought together by manual traction
b. traction- a means of reduciton by helping realign an extremity
c. ORIF- open reduction & internal fixation, is a surgical procedure
d. open or closed manipulation
2 Immobilize- maintain reduction in place until healing occurs
a. external- any kind of support or bandage
b. internal- inside screws, plates, rods, etc
c. physiologically splinting
d. traction
3. Rehabilitation- promote & regain normal function & strengthen affected part
a. maintain reduction & immobilization
b. elevate extremities to decrease swelling
c. frequent neuro checks
d. control pt anxiety & pain to help pt with participation
e. assist with adl’s to increase independence
f. promote circulation- ankle pump
g. try to medicate prior to pt
h. isometric exercises- tensing muscles without moving extremity
Q. Healing
1. stages
a. stage 1 - Inflammation and Swelling or Hematoma Formation
1. each end of bone
 2. last 2-3 days
3. put on ice, give NSAIDS for inflammation
4. bleeding – leads to hematoma formation (weak fibrous
network) – macrophages arrive for healing
b. stage 2 - Cellular Proliferation
1. hematoma organizes within 5 days – begin to create
network
2. have osteoblast and fibroblast cells
3. purpose is to produce collagen for collagen matrix
(Callus)
c. stage 3 - Callus Formation
1. fracture gap is bridged
2. hematoma and cellular proliferation grow together for
callus (hardening bone)
3. takes 3-4 weeks but begins around the 6th day
4. united by cartilage and fibrous tissues
5. degree stability with fragments locked together and cant
easily move
6. callus gradually reabsorbed
d stage 4 - Remodeling
1. previous anatomical condition
2. further hardening may take years to complete
3. monitor with X-Ray
2. factors affecting
a. location & severity of fracture
1. Arm- 3 months
2. Leg- 6 months
b. blood supply to body part- edema impedes healing
c. age
1. Osteoblasts build
2. Osteoclasts break down- increased in elderly
d. presence of infection
e. general condition
1. Diseases
2. Nutritional status
f. medications
1. Corticosteriods inhibit repair rate by increasing Ca in the
blood
2. Anti-inflammatory agent lengthens the 1st stage of
healing
g. flat bones heal quickly- sternum, pelvis, scapula
h. end of long bones heal more quickly than midshaft due to
spongy tissues & vascular supply
i. complication of fracture
R. Complications
1. Hypovolemic shock
 a. with severe injuries or femur fracture
b. due to loss of blood volume
c. replace bv, relieve pain, adequate splinting/mobilization
2. Fat Embolism Syndrome
a. potentially serious & life threatening complication of long bone trauma
(femur), blunt trauma, intramedullary manipulations (rods) placement
b. theories
1. Fat globules may move into blood
because marrow pressure is greater than capillary pressure
2. Catecholomines elevated by stress reaction which
mobilizes fatty acids and promotes development of fat globules
into blood stream
* either theory will combine with platelets that will from emboli that will block small vessels that
can supply blood to brain, lung, kidneys, and other major organs
c. occurs within 24-72 hours and up to 1 week after injury
d. mostly men 20-30 y/o
e. clinical manifestations
1. FIRST Symptom: Change in Mental status (mild
agitation – Confusion – Delirium – Coma)
2. Tachycardia, SOB, Dyspnea, tachypnea, petechia on
shoulder and conjunctiva
* call dr at frist sign of R distress
f. treatment
1. First give increased concentration of O2
2. Steroids
g. management of
1. Early stabilization of fracture
2. Minimal fracture manipulation
3. Support bones during turning & positioning
4. Monitor high-risk pt’s
5. Note personality changes
6. Support R system- ABG’s, O2
7. Correct homeostatic disturbance
3. Compartment syndrome
a. caused by swelling in a confined space- may be a compromise,
but through a good assessment and elevating extremities when we have to
b. swelling peaks at 24-48 hrs after fracture
c. can lead to loss of extremity
d. occurs with increase tissue pressure within closed anatomical
space that compromises circulation
e. usually seen in leg muscles or forearm
f. can be caused by a blood clot
g. signs & symptoms
1. Unrelieved pain
a. may elevate & medicate for pain
but they still have pain
 b. throbbing unrelenting pain
possible due to buildup of metabolic waste
2. Excessive swelling with harder consistency
3. Poor capillary refill- cyanotic nail beds
4. Inability to move fingers or toes
5. Positive tinel’s sign- tingling sensation in distal limbs
brought on by tapping over injured nerve of extremity
6. Elevated tissue pressure
7. Can still feel pulses- major arteries not occluded,
muscles more affected
8. Paralysis
9. Parasthesia
h. treatment
1. Bi valve- if there is a cast, the dr would cut alongside
and remove the top; bottom might be left for support
2. Fasciotomy- surgical excision of fibrous membrane that
covers and separates muscles; wound is left open & covered with
a moist saline dressing
3. Minimize/prevent edema
a. elevate extremities
b. ice packs
c. fasciotomy- to relieve pressure
4. Thromboembolism
5. Infection
6. Disseminated Intravascular Coagulation (DIC)
7. Delayed complications
a. delayed union- healing not at rate expected possible due to steroids,
diabetes, & age
b. non union- bone didn’tunite they wat it should
c. avascular necrosis- complete blood loss to bone or neck of
femur
d. reaction to internal fixation devices
1. Left in permanently- a rare occurrence
2. Treatment is by removal of hardware
e. osteomyelitis- infection of bone occurs with or without surgery

VI. RICE
R- Rest: prevents additional injury & promotes healing

I- Ice: produces vasoconstriction which decreases bleeding, edema, & discomfort

Moist or dry cold intermittently for 15-20 minutes during first 24-48 hours
C- Compression: controls bleeding & reduces edema
provides physical support
E- Elevation- controls swelling
* after acute inflammatory stage, heat may be applied intermittently; relieves muscle spasms;
promotes vasodilation, absorption, & repair
VII. Prevention of Injuries
A. Proper way to lift – good body mechanics
B. Bend at knees – not back
C. Carry loads close to body and not away
D. Should not twist when reaching for something
E. Don’t bend down or reach up high unnecessarily
F. Watch where you walk
G. Stretch