Musculoskeletal System

An-Najah National University
Faculty of Medicine
Department of nursing & midwifery
Medical surgical Nursing 2 (7401204)
Musculoskeletal System
Medical &Nursing Management of Patients With
Musculoskeletal Trauma
Muhammad Abu Rajab, RN, MSN, CRNA

2019-2020
Fractures and Immobilization
Devices
Overview
• A fracture is a break in a bone secondary to trauma or a pathological
condition.
• Fractures caused by trauma are the most common type of bone fracture.
• Pathological fractures may be caused by metastatic cancer, osteoporosis,
or Paget’s disease.
• Bone is continually going through a process of remodeling as osteoclasts
release calcium from the bone and osteoblasts build up the bone.
• Remodeling of bone occurs at equal rates until an individual reaches their
thirties. From this age on, the activity of the osteoclasts outpace the
osteoblasts, increasing an individual’s risk of osteoporosis.
• In women, this process significantly increases following menopause.
Subsequently, women experience fractures secondary to osteoporosis a
decade or so earlier than men.

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Devices
Fracture classification
• A closed, or simple, fracture does not break through the skin
surface.
• An open, or compound, fracture disrupts the skin integrity,
causing an open wound and tissue injury with a risk of infection.
• Open fractures are graded based upon the extent of tissue injury.
1.Grade I – minimal skin damage
2.Grade II – damage includes skin and muscle contusions but
without extensive soft tissue injury
3.Grade III – damage is excessive to skin, muscles, nerves, and
blood vessels

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Devices
• A complete fracture goes through the entire bone,
dividing it into two distinct parts. An incomplete
fracture goes through part of the bone.
• A simple fracture has one fracture line, while a
comminuted fracture has multiple fracture lines
splitting the bone into multiple pieces.
• A displaced fracture has bone fragments that are not
in alignment, and a non-displaced fracture has bone
fragments that remain in alignment.
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Devices
• A fatigue (stress) fracture results when excess
strain occurs from recreational and athletic
activities.
• Compression fracture occurs from a loading force
pressing on callus bone. This condition is
commonin the older adult client who has
osteoporosis.
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Devices
• Oblique: Fracture occurs at oblique angle and across bone.
• Spiral: Fracture occurs from twisting motion (common with
physical abuse).
• Impacted: Fractured bone is wedged inside opposite
fractured fragment.
• Greenstick: Fracture occurs on one side (cortex) but does
not extend completely through the bone (most often in
children).
• Hip fractures are the most common injury in older adults
and are usually associated with falls.
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Devices

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Devices
Risk Factors (causes)
• Osteoporosis
• Falls
• Substance use disorder
• Diseases (bone cancer, Paget’s disease)
• Physical abuse
• Age, as bone becomes less dense with advancing
age
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Devices
Clinical Manifestations
• History of trauma, metabolic bone disorders, chronic conditions,
and possible use of corticosteroid therapy
• Pain and/or reduced movement manifests at the area of fracture
or the area distal to the fracture.
• Crepitus: A grating sound created by the rubbing of bone
fragments
• Deformity: Internal rotation of extremity, shortened extremity,
visible bone with open fracture
• Muscle spasms: Due to the pulling forces of the bone when not
aligned
• Edema: Swelling from trauma
• Ecchymosis: Bleeding into underlying soft tissues from trauma
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Devices
Diagnostic Procedures
• Standard radiographs, computed tomography (CT)
imaging scan used to detect fractures of the hip
and pelvis, and/or magnetic resonance imagery
(MRI)
• A bone scan using radioactive material determines
hairline fractures and complications/ delayed
healing.
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Devices
Nursing Care
• Provide emergency care at time of injury.
• Monitor the client’s vital signs and neurological status because injury to vital
organs may occur due to bone fragments (fractures of pelvis, ribs).
• Stabilize the injured area, including the joints above and below the fracture, by
using a splint and avoiding unnecessary movement.
• Maintain proper alignment of the affected extremity.
• Elevate the limb above the heart and apply ice.
• Cover open wounds with a sterile dressing.
• Keep the client warm.
• Assess pain frequently and follow pain management protocols, both
pharmacologic and nonpharmacologic.
• Initiate and continue neurovascular checks at least every hour. Immediately report
any change in status to the provider.
• Prepare the client for any immobilization procedure appropriate for the fracture.

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Immobilizing Interventions: Casts,
Splints, and Traction
Overview
• Immobilization secures the injured extremity in order to:
1.Prevent further injury.
2.Promote healing/circulation.
3.Reduce pain.
4.Correct a deformity.
• Types of Immobilization Devices
1.Casts
2.Splints/immobilizers
3.Traction
4.External fixation
5.Internal fixation
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Overview
• Closed reduction is when a pulling
force (traction) is applied manually
to realign the displaced fractured
bone fragments. Once the fracture is
reduced, immobilization is used to
allow the bone to heal.
• Open reduction is when a surgical
incision is made and the bone is
manually aligned and kept in place
with plates and screws. This is
known as an open reduction and
internal fixation (ORIF) procedure.
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Nursing Care
Assessments are performed every hour for the first 24 hr and every 1 to 4 hr thereafter
following initial trauma to monitor neurovascular compromise related to edema and/or
the immobilization device. Neurovascular assessment includes the assessment of:
• Pain – Assess the client’s pain level, location, and frequency. Assess pain using a 0 to
10 pain rating scale and have the client describe the pain. Immobilization, ice, and
elevation of the extremity with the use of analgesics should relieve most of the pain.
• Sensation – Assess the client for numbness or tingling sensation of extremity. Loss of
sensation may indicate nerve damage.
• Skin temperature –Cool skin may indicate decreased arterial perfusion.
• Capillary refill –Prolonged refill indicates decreased arterial perfusion. Nail beds that
are cyanotic may indicate venous congestion.
• Pulses – Pulses should be palpable and strong. Pulses should be equal to unaffected
extremity.
• Edema can make it difficult to palpate pulses so Doppler ultrasonography may be
required.
• Movement – Client should be able to move affected extremity in passive motion.
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Casts
• Casts are more effective than splints or
immobilizers because they cannot be
removed by the client.
• Types of Casts:
1.Short and long arm and leg casts
2.Walking cast (a rubber walking pad on the
sole of the cast assists the client in
ambulating when weight bearing is
allowed)
3.Spica casts (a portion of the trunk and one
or two extremities; typically used on
children with congenital hip dysplasia)
4.Body casts (encircle the trunk of the body)

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Traction
• Traction uses a pulling force to promote
and maintain alignment of the injured
area.
• Goals of traction include:
1.Prevent soft tissue injury.
2.Realign of bone fragments.
3.Decrease muscle spasms and pain.
4.Correct or prevent further
deformities.
• Traction prescriptions should include
the type of traction, amount of weight,
and whether traction can be removed
for nursing care.
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Traction
Nursing Actions
• Assess neurovascular status of the affected body part every hour for
24 hr and every 4 hr after that.
• Maintain body alignment and realign if the client seems
uncomfortable or reports pain.
• Avoid lifting or removing weights.
• Ensure that weights hang freely and are not resting on the floor.
• If the weights are accidentally displaced, replace the weights. If the
problem is not corrected, notify the provider.
• Ensure that pulley ropes are free of knots, fraying, loosening, and
improper positioning at least every 8 to 12 hr.
• Routinely monitor skin integrity and document.
• Use heat/massage, as prescribed, to treat muscle spasms.

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Splints
• Splints and immobilizers provide support, control movement, and
prevent additional injury.
• Splints are removable and allow for monitoring of skin swelling
or integrity.
• Splints can be used to support fractured/injured areas until
casting occurs and swelling is decreased. Casting is then done or
used for post-paralysis injuries to avoid joint contracture.
• Immobilizers are prefabricated and typically fasten with Velcro
straps.
• Ensure the client is aware of application protocol regarding full-
time or part-time use.
• Instruct the client to observe for skin breakdown at pressure
points.
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Complications of Immobilizing Interventions: Casts,
1- Compartment syndrome
• Compartment syndrome usually affects extremities and occurs when
pressure within one or more of the muscle compartments (an area covered
with an elastic tissue called fascia) of the extremity compromises
circulation, resulting in an ischemia-edema cycle.
• Capillaries dilate in an attempt to pull oxygen into the tissue. Increased
capillary permeability from the release of histamine leads to edema from
plasma proteins leaking into the interstitial fluid space.
• Increased edema causes pressure on the nerve endings, resulting in pain.
Blood flow is further reduced and ischemia persists, resulting in
compromised neurovascular status.
• Pressure can result from external sources, such as a tight cast or a
constrictive bulky dressing.

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1- Compartment syndrome/ Clinical Manifestations
• Compartment syndrome (ACS) is assessed by using the five P’s
(pain, paralysis, paresthesia, pallor, and pulselessness).
• Increased pain unrelieved with elevation or by pain medication.
• Intense pain when passively moved.
• Paresthesia or numbness, burning, and tingling are early signs.
• Paralysis, motor weakness, or inability to move the extremity
indicate major nerve damage and are late signs.
• Color of tissue is pale (pallor), and nail beds are cyanotic.
• Pulselessness is a late sign of compartment syndrome.
• Palpated muscles are hard and swollen from edema.
• If untreated, tissue necrosis can result. Neuromuscular damage
occurs within 4 to 6 hr. Muhammad Abu Rajab, RN, MSN, CRNA
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1- Compartment syndrome/ Surgical treatment is a fasciotomy.
• A surgical incision is made through the subcutaneous tissue and
fascia of the affected compartment to relieve the pressure and restore
circulation.
• After the fasciotomy, the open wounds require sterile packings and
dressings until secondary closure occurs. Skin grafts may be
necessary.
Nursing Actions
1. Notifying the provider when compartment syndrome is suspected.
2. The provider will cut the cast on one side (univalve) or both sides
(bivalve).
3. Loosening the constrictive dressing or cutting the bandage or tape.

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1- Fat embolism
• Adults between age 70 and 80 are at the greatest risk of developing a
fat embolism. Hip and pelvis fractures are most common.
• Fat embolism can occur after the injury, usually within 48 hr
following long bone fractures or with total joint arthroplasty.
• Fat globules from the bone marrow are released into the vasculature
and travel to the small blood vessels, including those in the lungs,
resulting in acute respiratory insufficiency and organ perfusion.
• Careful diagnosis should differentiate between fat embolism and
pulmonary embolism.

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2- Fat embolism/ Clinical manifestations

• Dyspnea, chest pain, decreased oxygen saturation
• Decreased mental acuity related to low arterial oxygen level (earliest
sign)
• Respiratory distress
• Tachycardia
• Tachypnea
• Fever
• Cutaneous petechiae

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2- Fat embolism/ Nursing Actions

• Maintain the client on bed rest.
• Prevention includes immobilization of fractures of the long bones
and minimal manipulation during turning if immobilization
procedure has not yet been performed.
• Treatment includes oxygen for respiratory compromise,
corticosteroids for cerebral edema, vasopressors, and fluid
replacement for shock, as well as pain and antianxiety medications
as needed.

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3- Deep-vein thrombosis (DVT)

• Deep-vein thrombosis is the most common complication following
trauma, surgery, or disability related to immobility.
• Nursing Actions
1. Encourage early ambulation.
2. Apply antiembolism stockings, sequential compression device
(SCD).
3. Administer anticoagulants as prescribed.
4. Encourage intake of fluids to prevent hemoconcentration.
5. Instruct the client to rotate feet at the ankles and perform other
lower extremity exercises as permitted by the particular
immobilization device.
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4- Osteomyelitis
• Osteomyelitis is an infection of the bone that begins as an
inflammation within the bone secondary to penetration by infectious
organisms (virus, bacteria, or fungi) following trauma or surgery.
• Clinical Manifestations
1. Bone pain that is constant, pulsating, localized, and worse with
movement
2. Erythema and edema at the site of the infection
3. Fever
4. Leukocytosis and possible elevated sedimentation rate
5. Many of these manifestations will disappear if the infection
becomes chronic.
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4- Avascular necrosis
• Avascular necrosis results from the circulatory compromise that
occurs after a fracture. Blood flow is disrupted to the fracture site
and the resulting ischemia leads to tissue (bone) necrosis.
• Commonly found in hip fractures or in fractures with displacement
of a bone.
• Clients receiving long-term corticosteroid therapy are at greater risk
for developing avascular necrosis.
• Replacement of damaged bone with a bone graft or prosthetic
replacement may be necessary.

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4- Failure of fracture to heal

• A fracture that has not healed within 6 months of injury is
considered to be experiencing “delayed union.”
• Malunion: Fracture heals incorrectly
• Nonunion: Fracture that never heals
• Electrical bone stimulation and bone grafting can be used to treat
nonunion.
• May occur more frequently in older adult clients due to impaired
healing process.
• Malunion or nonunion may cause immobilizing deformity of the
bone involved.

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Carpal tunnel syndrome
• Carpal tunnel syndrome is the most common nerve entrapment
syndrome.
• It results from compression of the median nerve at the wrist, within
the carpal tunnel (formed by the carpal bones and the transverse
carpal ligament).
• The median nerve, along with blood vessels and flexor tendons,
passes through this tunnel to the fingers and thumb.
• Carpal tunnel syndrome usually occurs in women between ages 30
and 60 and poses a serious occupational health problem.
• Assembly- line workers, packers, and people who repeatedly use
poorly designed tools are most likely to develop this disorder.
• Any strenuous use of the hands aggravates this condition.

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Causes
• Unknown
• Repetitive wrist motions involving excessive flexion or extension
• Dislocation
• Acute sprain.
Pathophysiology
• The median nerve controls motions in the forearm, wrist, and hand
and supplies sensation to the index, middle, and ring fingers.
Compression of the median nerve results in sensory and motor
changes in the median distribution of the hand.

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Signs and symptoms

• Weakness
• Pain
• Burning
• Numbness
• Tingling in one or both hands.
• Paresthesia affects the thumb, forefinger, middle finger, and onehalf
of the fourth finger.

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Diagnostic tests
Diagnosis of carpal tunnel syndrome is based on these characteristic
tests and findings:
• Tinel’s sign: Tingling occurs over the median nerve on light
percussion.
• Phalen’s maneuver: Carpal tunnel syndrome symptoms occur when
the patient holds his forearms vertically and allows both hands to
drop into complete flexion at the wrists for 1 minute.
• Compression test: Blood pressure cuff inflated above systolic
pressure on the forearm for 1 to 2 minutes provokes pain and
paresthesia along the distribution of the median nerve.
• Electromyography: A median nerve motor conduction delay of more
than 5 milliseconds suggests carpal tunnel syndrome.
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Treatment
• Conservative treatment includes resting the hands by splinting
• the wrists in neutral extension for 1 to 2 weeks.
• If a definite link has been established between the patient’s
occupation and carpal tunnel syndrome, he may have to seek other
work.
• Effective treatment may also require correction of an underlying
disorder.
• Surgical decompression of the nerve by sectioning the entire
transverse carpal tunnel ligament.

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Osteoarthritis
Overview
• Osteoarthritis is the most common form of arthritis.
• Symptoms usually begin in middle age and may progress
with age.
• Disability depends on the site and severity of
involvement and can range from minor limitation of the
fingers to severe disability in people with hip or knee
involvement.
• The rate of progression varies, and joints may remain
stable for years in an early stage of deterioration.

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Osteoarthritis
Causes
• Unknown
• Normal part of aging
• Metabolic
• Genetic
• Chemical
• Mechanical factors.

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Osteoarthritis
signs and symptoms

The severity of these signs and symptoms increases with
poor posture, obesity, and occupational stress:
• Joint pain (the most common symptom) that occurs
particularly after exercise or weight bearing and is
usually relieved by rest
• Stiffness in the morning and after exercise that’s usually
relieved by rest
• Achiness during changes in weather
• Grating of the joint during motion
• Limited movement.
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Osteoarthritis

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Osteoarthritis
Treatment
• Most measures are palliative.
• Medications for relief of pain and joint inflammation include
aspirin (or other nonopioid analgesics), indomethacin, ketorolac,
ibuprofen.
• In some cases, intraarticular injections of corticosteroids. Such
injections may delay the development of nodes in the hands.
• Patients who have severe osteoarthritis with disability or
uncontrollable pain may undergo one or more of these surgical
procedures: Arthroplasty, arthrodesisthem, osteoplasty,
osteotomystress.

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Osteomyelitis
Overview
• A pyogenic bone infection, osteomyelitis may be chronic or acute.
• The infection causes tissue necrosis, breakdown of bone structure,
and decalcification. Although it commonly remains localized,
osteomyelitis can spread through the bone to the marrow, cortex,
and periosteum.
• In acute osteomyelitis, bacteria or fungi are either carried through
the blood from another infectious site or enter the bone through the
skin after surgery or trauma.
• With prompt treatment, the prognosis is good.

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Osteomyelitis
Causes
• Traumatic injury
• Acute infection originating elsewhere in the body
• Organisms, such as Staphylococcus aureus (most common),
Streptococcus pyogenes, Pneumococcus, Pseudomonas aeruginosa,
Escherichia coli, and Proteus vulgaris
• Fungi or viruses.

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Osteomyelitis
signs and symptoms
• Sudden pain in the affected bone
• Tenderness, heat, and swelling over the affected area
• Restricted movement.

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Osteomyelitis
Treatment
• Administration of large doses of I.V. antibiotics after blood cultures
are taken (usually a penicillinase-resistant penicillin, such as
nafcillin or oxacillin)
• Early surgical drainage to relieve pressure
• Immobilization of the affected bone by plaster cast, traction, or bed
rest
• Supportive treatment, such as analgesics and I.V. fluids.

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Osteoporosis
Overview
• In osteoporosis, bones lose calcium and phosphate salts and
become abnormally vulnerable to fracture.
• Osteoporosis may be primary or secondary to an underlying
disease.
• Primary osteoporosis most commonly develops in postmenopaus al
women, although men may also develop osteoporosis. It’s called
postmenopausal osteoporosis if it occurs in women ages 50 to 75
and senile osteoporosis if it occurs between ages 70 and 85.
• Risk factors include inadequate intake or absorption of calcium,
estrogen deficiency, and sedentary lifestyle.
• Osteoporosis primarily affects the weight-bearing vertebrae, ribs,
femurs, and wrist bones. Vertebral and wrist fractures are common.
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Osteoporosis
Causes
• The cause of primary osteoporosis remains unknown.
• Secondary osteoporosis may result from:
1. Prolonged therapy with steroids, aluminum-containing antacids,
heparin, anticonvulsants, or thyroid preparations
2. Total immobility or disuse of a bone (as with hemiplegia).
• Osteoporosis is also linked to alcohol abuse, malnutrition,
malabsorption, hyperthyroidism.

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Osteoporosis
signs and symptoms
• Pain in the lower back that radiates around the trunk
• Deformity
• Kyphosis (humpback)
• Loss of height
• A markedly aged appearance.

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Osteoporosis
Causes
• X-rays show typical degeneration in the lower thoracic and lumbar
vertebrae.
• CT scan accurately assesses spinal bone loss.
• Bone scans show injured or diseased areas.
• Serum calcium, phosphorus, and alkaline phosphatase levels are
within normal limits, but parathyroid hormone levels may be
elevated.

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Osteoporosis
Treatment
• A physical therapy program emphasizing gentle exercise and
activity.
• Estrogen to decrease the rate of bone resorption and calcium and
vitamin D to support normal bone metabolism (However, drug
therapy merely arrests osteoporosis; it doesn’t cure it.)
• A back brace to support weakened vertebrae.
• Surgery to correct pathologic fractures of the femur by open
reduction and internal fixation.

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Osteoporosis
Treatment
• Adequate intake of dietary calcium and regular weight-bearing
exercise may reduce a person’s chances of developing senile
osteoporosis.
• Although hormone therapy may offer some preventive benefit, it
also has risks and adverse effects.
• Secondary osteoporosis can be prevented through effective
treatment of the underlying disease and by judicious use of steroid
therapy, early mobilization after surgery or trauma, decreased
alcohol consumption, careful observation for signs of
malabsorption, and prompt treatment of hyperthyroidism.

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GANGLION
Overview
• A ganglion, a collection of gelatinous material near
the tendon sheaths and joints, appears as a round,
firm, cystic swelling, usually on the dorsum of the
wrist.
• It most frequently occurs in women younger than 50
years.
• The ganglion is locally tender and may cause an
aching pain.
• When a tendon sheath is involved, weakness of the
finger occurs.
• Treatment may include aspiration, corticosteroid
injection, or surgical excision.
• After treatment, a compression dressing and
immobilization splint are used.
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Paget’s disease
Overview
• Paget’s disease is a slowly progressive metabolic bone disease.
• It usually localizes in one or several areas of the skeleton (most
commonly the lower torso), although occasionally, widely
distributed skeletal deformity occurs.
• Paget’s disease can be fatal, particularly if associated with heart
failure (widespread disease creates a continuous need for high
cardiac output), bone sarcoma, or giant cell tumors.

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Paget’s disease
Causes
• The cause remains unknown, but one theory holds that early viral
infection (possibly with mumps virus) causes a dormant skeletal
infection that erupts many years later as Paget’s disease.
• The disease also tends to run in families.

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Paget’s disease
Pathophysiology
• In the initial phase of Paget’s disease (osteoclastic phase),
excessive bone resorption occurs.
• The second phase (osteoblastic phase) involves excessive abnormal
bone formation.
• Affected bones enlarge and soften, and the new bone structure is
chaotic, fragile, and weak.

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Paget’s disease
Signs & Symptoms
• Severe, persistent pain that intensifies with weight bearing and may
impair movement.
• Cranial enlargement occurs over frontal and occipital areas (hat
size may increase).
• Headaches also occur with skull involvement.
• Bony infringement on cranial nerves may impair hearing and
visual acuity.

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Paget’s disease
Diagnostic tests
• X-rays may show increased bone expansion and
• A bone scan (more sensitive than an X-ray) clearly shows early
pagetic lesions.
• A bone biopsy reveals the characteristic mosaic pattern.
• Blood tests reveal anemia and elevated serum alkaline phosphatase
levels.

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Paget’s disease
Treatment
• Drug therapy is the primary intervention. It includes the hormone
calcitonin, given subcutaneously or I.M.; etidronate (Didronel),
taken by mouth; and plicamycin (Mithracin), a cytotoxic
• Antibiotic.

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Musculoskeletal System

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An-Najah National University

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

2- Fat embolism/ Clinical manifestations

Muhammad Abu Rajab, RN, MSN, CRNA

2- Fat embolism/ Nursing Actions

Muhammad Abu Rajab, RN, MSN, CRNA

3- Deep-vein thrombosis (DVT)

Muhammad Abu Rajab, RN, MSN, CRNA

4- Failure of fracture to heal

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Signs and symptoms

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

signs and symptoms

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

Muhammad Abu Rajab, RN, MSN, CRNA

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