Unit Three: Musculoskeletal Disorder

Anatomy and physiology of MS

The musculo-skeletal system comprises mainly
Muscles
Bones
Joints
Ligament
 Tendons
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 Anatomy of Musculoskeletal

By KIDIST REBA
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Introduction…
It performs a number of essential functions including:
• Maintenance of body shape.
• Support and protection of soft tissues such as
the brain,
heart and
lungs
• Movement.
• Storage of calcium and phosphate.
• The manufacture of RBC,WBC and platelets in bone marrow.
Bones
 is a rigid structure ideally suited for its supportive and protective function.
 Contain sites for muscle attachment, the mechanical basis for movement.
Muscles
• Muscle tissue is made up of contractile cells.
• is responsible for movement, maintenance of posture and heat production
Joints
• are the site at which two or more bones are united.
• are the functional unit of the musculoskeletal system because
they permit the mobility needed activities of daily living.
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Synovial joints are freely movable cavity filled with lubricant called synovial fluid.
 In synovial joints, a layer of resilient cartilage covers the surface of opposing bones.
The cartilage cushions the bones and gives a smooth surface to facilitate movement.
The joint is surrounded by a fibrous capsule and is supported by ligaments.
Ligament are fibrous bands running directly from one bone to another that strengthen
and help prevent movement in undesirable directions.
Skeleton muscle is attached to bone by a tendon – a strong fibrous cord.

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 Assessment methods
Common MS manifestations includes:
Pain-over joints, muscles ,bones
Stiffness
Swelling
Deformity.
Movement restriction
Local warmth-over joints 6
 Physical examination
General inspection
The clinician has to note on the following conditions

 Look for obvious deformities

 A general description of the skin, including texture,
scars and pigmentation
Overall gait (Pattern of movements of the extremities)

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1. Muscle examination
When examining the muscle, the following aspects need to be
carefully assessed;-

Muscle tenderness
The tone of the muscle
The muscle power

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 I. Tenderness
Gently palpate for evidence of tenderness, especially when any part

of a limb fails to move.

The examiner must determine whether or not there is muscle spasm

or relative weakness because of myositis or other local conditions.

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 II. Muscle tone
Refers to the degree of tension in the muscle.
 Muscle resistance to passive stretch
 Classified as normal, hypotonic and hypertonic

Muscle hypotonia: refers to a decreased tension or tone of a muscle with

minimal or no resistance.

A muscle usually becomes hypotonic when its nerve supply is disturbed.

Muscle hypertonia: state refers to an increased muscle tone.

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 III. Muscle power
 Indicates about the strength of the muscle.

 Can numerically be graded according to the degree of contractility .

With grade zero indicating complete paralysis and

Grade five indicating full power of the muscle

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 Muscle power cont’d

0= No evidence of contractility

1= slight contractility, no motion with gravity eliminated

2= Poor Complete range of motion with gravity eliminated

3= active movement against gravity
4= active movement against gravity with some resistance
5= active movement against gravity and full resistance
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 2. Joint examination
Includes:
The general movement of major joints
The manner in which the patient stands or holds the extremity.
 The general contour and length of the extremity in relation to the trunk
 A comparison of each side for any noticeable difference
During palpation, check for warmth, swelling and tenderness.

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RANGE OF MOTION
•The six motions of the shoulder
girdle are flexion, extension,
abduction,adduction, and internal
and external rotation.
Abnormal findings
 limited ROM, asymmetry, pain or
crepitus motion

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There are two forms of joint movement

 Active movement, where the patient him/her self moves the joint.

 Passive movement, where the examiner moves the joint for the test.

Note : Active movement may be reduced or absent in cases of pain

in the joint or paralysis of muscles moving the joint.

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 Standard joint positions
The skeletal muscle produces the following movements
Abduction= Drawing away from the midline of the body
Adduction= Draw towards the midline of the body
Eversion= Turning outward
Inversion= Turning inward
Extension= The act of straightening, when the part distal to a joint extends.
Flexion= The act of bending, when the part distal to a joint bends
Internal rotation= Rotation towards midline in a transverse plane.

External rotation= Rotation away from the midline in a transverse plane

Pronation= Assuming a prone position, turning inward (palm and sole)

Supination= Assuming a supine position, turning upward (palm and sole)

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Diagnostic studies
1.Arthroscopy
• used to visually examine the joint
• performed under some type of anesthesia.
• Post procedure, color, sensation, motion.
2. Biopsy
• A tissue sample is taken from muscle to determine disease state of tissue.
• done to determine the presence of infection, cancer, muscular atrophy.
3.Complete blood count (CBC)
• Is performed for all components of blood: RBC, WBC and platelets
4. Magnetic Resonance Imaging (MRI)
• It diagnoses problems within joints, soft tissue (tendons,
ligaments),spine, intervertebral discs, and spinal cord.
5. Ultrasound
• Sound waves are used to generate an image.
• done to determine the presence and location of mass, fluid.
6. Computed Tomography (CT) Scan
• Is a computer-manipulated pictures of radiologic images that are not
obstructed by overlying anatomy.
• This is done to detect fractures and bone metastasis.
Musculoskeletal disorder
Contusion- is a soft tissue injury produced by blunt force.
s/sx
-Does not affect ms tissue
-Usually resolve with in 2 wks
- Ecchymosis and bruising.
-Hematoma-collection of blood
- Pain & swelling.
Strain – injury to a muscle when it is stretched or pulled beyond its capacity
- Caused by overuse, overstretching or excessive stress.
- S/SX- sudden pain, with local tenderness, inflammation & muscle spasm.
 Cont….
Sprain-injury to the ligaments surrounding a joint.
-caused by sudden, unusual movement or stretching about a joint
-Areas most subject to sprains are: wrist, elbow, knee.
-Common with falls &other accidental injuries.
S/SX :
- ligament loss its stabilizing ability
- blood vessel rupture,
- pain during mov’t of joint
 Cont…
DX
Radiographic film- show a larger than usual joint space.
-Arthrography- asymmetry in the joint, trauma in the joint capsule.
Mgt.
-RICE(Rest, Ice, Compression & Elevation)
-After 2 days- apply heat to reduce pain & edema
• NSAIDS
If sprain is severe
-Surgical repair
- Cast to Immobilization
 Cont…
• Dislocations- separation of joint surfaces
 shoulder, hip & knee are commonly affected.
- Traumatic dislocations are orthopedic emergency.
Cause:
Congenital
present at birth(more often the hip)
spontaneous or pathologic, traumatic
S/SX:
pain, change in length of extremity
loss of normal mobility & non support joint.
 “popping”sound
• Mgt
- Immobilization
-Reduction
- Analgesia, muscle relaxants
Nsg Mgt:-
-provide comfort
- Evaluate pt’s neuro vascular status
- protect joint during healing
- pt. education.
 Cont..
Fractures- is a break in the continuity of bone.
Cause –1)Trauma (e.g blow or fall)
2) pathologic condition(e.g bone ca)
3) Strong muscle contraction(e.g seizure)
Classification
Based on- 1)type
2) location
3)communication
Classification of fracture based on type
1. Avulsion – a pulling away of a fragment of bone by a ligament or tendon & its attachment
2. Transverse- a fracture that is straight across the bone.
3. Spiral-a fracture twisting around the shaft of the bone.
4. Comminuted- a fracture in which bone has splintered into several fragments
5. Depressed – a fracture in which fragments inward e.g skull & facial bones fractured.
6. Impacted – a fracture in which a bone fragment is driven into another bone fragment
7. Green stick- a fracture in which one side of a bone is broken & other side is bent
Classification based on the Communication
1. Open fracture-is one that cause a break in the skin & underlying tissue.
• Contamination and infection can occur.
• Compound fracture- is a type of open fracture in w/c damage involves in the
skin or mucus membrane.
2. Closed fracture/simple fracture/- is one that does not cause a break in skin.
Clinical manifestation
Pain , loss of function, deformity, Shortening of the extremity, & local
swelling & discoloration, spasm.
Diagnosis
-S/SX
-X- ray findings
 Cont…
Emergency management of fractures
-immobilize body part before the patient is moved.
-prevent rotation by supporting extremity
- Adequate splinting (bandage).
- If open fracture, wound is covered with a clean (sterile ) dressing.
Medical mgt
-reduction
- Immobilization
- Regaining of normal function & strength through rehabilitation
 Cont…
- Reduction- ‘’Setting ‘’ the bone
- Refers to restoration of the fracture fragments to the anatomic
alignment & rotation.
Is of two type:
Closed Reduction- bringing the bone fragments into a position(placing
ends in contact) through manipulation and manual traction.
-external Immobilizing devices used
Open Reduction- a fracture fragments are reduced through a surgical
approach.
 Cont…
Immobilization is accomplished by
external fixation-bandage, casts, continuous tractions,
Internal fixation- Metallic pins, wires, screws , nails, or rods.
Maintaining & Restoring function.
• Promote bone & soft tissue healing.
• Elevating & applying ice  control swelling
 Complications
Early complications
• Shock- Hypovolemic shock
C/M – hypoxia, tachypnea, tachycardia &pyrexia
Other early complications.
-DVT
- Pulm-embolism
- Infection
Delayed complications
-Delayed union- healing does not occur at a normal rate for the location & type of fracture.
Non Union- result from failure of the ends of fractured bone to unite.
- A false joint (pseudarthrosis) often develops at the site of the fracture.
 Cont…..
Cast- is a rigid externally immobilizing device that is molded to
the contours of the body part.
Purpose:
- To immobilize /esp. a reduced fracture/
- To correct a deformity.
- To apply uniform pressure
- To support & stabilize weakened joints.
 Traction
• Application of a pulling force to a part of the body
Purpose:
-To minimize muscle spasms
-To immobilize fracture
- To reduce fracture
- To reduce deformity
- To increase space b/n opposing surfaces
 Lower back pain
Cause: -Acute lumbosacral strain
- Unstable lumbosacral ligaments
- weak muscles
- Osteoarthritis of the spine
- Spinal stenosis
- intra vertebral disk problems.
- Unequal leg length.
Cont….
Patho physiology

Spinal Column rigid units(ventebrae)

Flexible units(intervertebral )disks
- Disuse weakens supporting structure back pain
- Disk degradation is a common cause of back pain
C/M
-acute or chronic back pain.
-fatigue
- Para vertebral muscle spasm
- Loss of normal lumbar curve
- Spinal deformity
Cont…
Dx
• Hx and P/E
- Back examination
- Neurologic testing.
- X- ray of the spine
- CT scan
- MRI
 Cont…
Mgt
- Most back pain is self- limited & resolves with in 4 week
analgesics, rest, stress reduction& relaxation.
- Relief pain & discomfort-(acetaminophen, ibuprofen)
- Activity modification
- Patient education
- Other physical modalities have no proven efficacy in
treating acute low back pain (e,g traction, massage).
- Exercises which stress the back are avoided.
Cont…
Nsg intervention:
- reduce stress
- limit bed rest, keep knees flexed to decrease strain on back.
- relaxation, cold/hot application.
- side lying / curled position
- using proper body mechanics
Standing – avoid prolonged standing &walker
Sitting – avoid sitting for prolonged periods.
Lying- avoid sleeping in a prone position
Lifting – lift with large leg muscles, not the back muscles.
Pharmacologically- NSAIDs, analgesics , muscle relaxants.
Amputation
• An amputation is the surgical removal of part of the body.
Etiology
• The primary indication for surgical amputation is ischemia from
peripheral vascular disease in the elderly, arteriosclerosis or diabetes
mellitus and fulminating gas gangrene
Methods to perform amputation are two:
• Open method – is used for clients who have or are likely to develop
an infection.
• Closed method - skin flaps are pulled over the bone end and are
sutured in places as part of the amputation procedure.
Potential Complication of amputation
• Infection that occur in the wound or bone
• Phatom limb pain – pain often the removal of the part
• Formation of neuroma – tumor consisting of nerve cells
• Fixation contractures of the hip or knee
• Post operative hemorrhage
• Skin break down
Nursing implementation
• The nurse administers medication, as ordered
• Antidepressants are used to improve mood and coping ability
• Early intensive rehabilitation
• Edema is controlled by compression
• Range of motion exercises.
• Gait training
• Monitoring and managing potential complication.
Cont….
Osteomyelitis – is an inflammation/ infection of the bone
Cause
-S. aurous 70-80% of bone infections
-protease
-pseudomonas spp.
E.coli
 Cont….
Pathophysiology
Infection  inflammation , ↑ed vascularity,& edema 
thrombosis of b/d vessels ischemia with bone
necrosis infection extends in to modularly cavity&
under periosteum spread into adjacent soft tissues &
joints.
Complications
• Bone abscess contain dead bone tissue &joints
Cont….
C/M

-the onset is usually sudden In blood borne infection

- Septicemia(chills, high fever,
rapid pulse, general malaise).

-Infected area- painful, swollen &extremely tender

-Constant, pulsating pain In direct contamination of infection
 No symptoms of septicemia
 The area is swollen, warm,
painful, tender to touch
Prevention
-Prophylactic antibiotics- is important.
- Remove urinary catheters & drains as soon as possible
- Aseptic post operative wound care
- Prompt mgt of soft tissue infection.
- Elective orthopedic surgery
 Ms –disorder….
Mgt
-IV antibiotic therapy(penicillin/cephalosporin)
Surgical Mgt
-surgical debridement-removal of dead tissue.
-Sequestrectomy- removal of dead bone
Nsg interventions
-Relieving pain
-Immobilization, Elevation, Analgesics
-Controlling the infection process.
Rheumatoid arthritis
• is a chronic inflammatory disease characterized by uncontrolled
proliferation( production) of synovial tissue
• Genetic and environmental factors play a role in pathogenesis.
• It is characterized by persistent joint synovial tissue inflammation.
• Over time, bone erosion, destruction of cartilage, and complete loss
of joint integrity can occur.
• Eventually, multiple organ systems may be affected.
- The auto immune reaction primarily occurs in the synovial tissue
Phatophysiology
Phagocytosis produce enzyme within joint  the enzyme break down
collagen, causing edema, proliferation of the synovial membrane &
ultimately pannus formation the pannus destroy the cartilage&
erode the bone  loss of articular surface &join motion.
Risk factors
Sex (females are mostly affected)
family history
older age
silicate exposure and
smoking
C/m
- Classic signs of joint pain, swelling, warmth, erythema & lack of
function, joint stiffness.
A systemic diseases of rheumatoid arthritis includes.
 fever, wt. loss, fatigue, anemia, lymph node enlargement
 Raynaud’s phenoment-cold and stress induced vasospasm causing
episodes of digital blanching or Cyanosis)
Nodules (non tender& moveable)in Sc tissue.
DX
-Rheumatoid nodules
-Joint inflammation detected on palpation.
-Certain lab findings
- ↑ESR, ↓RBC
- Arthrocentesis- cloudy, milky or dark yellow
- Numerous inflammatory components
Mgt
• NSADS
• high dose methotexate, azathiprine
N.B: Methotrexate is currently the gold standard in the treatment of RA.
Surgical Mgt
Indication: For persistent, erosive RA(reconstructive surgery &
corticosteroid are often use).
-When pain cannot relieved by conservative measures.
Tenorrhaphy-suturing a tendon
Arthrodesis- Surgical fusion of the joint.
Arthroplasty- surgical repair & replacement of the joint.
Septic (infectious) Arthritis
Routes –spread of infection (hematopenous spread)
-Directly through trauma to joints, joint replacement, coexisting
arthritis & diminished host resistance, DM, advanced age.
Cause: - S.aureus
-Streptococci
- Gram negative Organisms
C/m
-Warm, painful swollen joint with increased role
- chills, fever, & leukocytosis.
DX. Aspiration, examination, &culture of synovial fluid.
Mgt : -Broad spectrum antibiotics
-joint aspiration to remove excessive joint fluid, exudates& debris.
-Analgesics: codeine, NSAIDS
-Immobilization of inflamed joint in a functional position by a splint.
 Gout
Is inflammatory reaction to urate crystals in joints.
Is a hetrogenous group of conditions related to a genetic defect of purine
metabolism resulting in hyperuricemia.
patho physiology
Hyperuricemiaincreased risk of monosodium urate crystal
depositinflammatory response within joint  attack of gout begins.
• With repeated attacks tophi (accumulations of sodium urate crystals)
are deposited in peripheral areas of the body(great toe, hands,& ear)
• Renal urate lithiasis (kidney stones) may develop
causes
cause of hyperurecemia
10 hyperurecemia is caused by
Heredity
Starvation
 excessive ingestion of purines.
20 hyperurecemia is caused by
abnormal purine metabolism,
increased rate of protein synthesis
Cancer
altered renal tubular function.
 C/m
Gout Syndrome:
-Acute gout arthritis –recurrent attack of severe articular inflammation
- It is a painful inflammation of big toe and foot caused by defects in uric acid
metabolism resulting in deposit of acid and salt in the blood and joint
-Gouty nephropathy(renal impairment).
-Spondylitis – inflammation of a spinal joint , characterized by painful and
stiffness
DX
-Clinical signs & hyperurecemia (usually)
-Urate crystals in synovial fluid.
-Radiographic examination- urate deposits.
-Elevated uric acid levels in serum & urine
Mgt
- Two main treatment approaches
1. Using uricosuric drugs that promote renal excretion of urates by inhibiting
reabsorption of uric acid in the renal tubules.
2. Decreasing ingestion of purine.
Drug treatment
-colchicine-reduce inflammation.
-probenecid- Uricosuric agent
-Allopurinol- Xanthine Oxidase inhibitor
-NSAIDS- Ibuprofen & indomethacin
Surgical Interv: To remove large tophi of advanced gout.
 General Guidelines for Gout prevention
• Avoid purine-rich foods
• Rapid / sudden fasting is not recommended as this can raise uric acid levels .
• Avoid heavy, rich meals with high fat and protein content.
• Alcohol should be avoided, particularly wine since it interferes with uric acid
excretion.
• high fluid intake
Osteoarthritis(OA)
The most common &frequently disabling of the joint disorders.
Also known as degenerative joint disease or osteoarthritis
Classification
• Primary(idiopathic)
-No previous event or disease r/t to OA
• Secondary
-Result from previous joint injury or inflammatory disease.
-By age 75yrs. 85% of the population has either x-ray or clinical
evidence of OA.
• Risk factors
- Increased age
- Obesity
- Previous joint damage
- Anatomic deformity
- Genetic Susceptibility
C/m
- Primary c/m- pain, stiffness, & functional impairment
Dx
- x-rays report
- S/sx
- P/E – Tender& enlarged joints.
- Blood is not useful for dx of OA.
Medical Mgt
-Conservative treatment
-Wt. reduction
-Joint rest, avoidance of joint overuse
-Support inflamed joint.
Pharmacologic Therapy
-symptomatic mgt & pain control
Surgical management
Indication: when pain is severe/loss of function.
*Osteotomy –surgical sectioning of bone
–alter force distribution in the joint
*Arthroplasty- affected joint components are replaced with artificial products.
Nsg Mgt
-Pain mgt
-Optimizing functional ability
Bone Tumors
1.Benign Bone Tumors
- Most common than malignant primary bone tumors.
- Slow growing & well circumscribed, few Sx & not cause death.
- E.g Osteochondroma- most common.
2.Malignant Bone tumors
-primary malignant tumors are relatively rare & arise from connective
&supportive tissue(sarcoma) or bone marrow (multiple myeloma).
-e.g Osteosarcoma-most common& most often fatal primary malignant
bone tumor.
C/M: pain, swelling , limited motion & wt. loss.
Metastatic bone Disease
-it is known as secondary bone tumor disease and more common than
any primary bone tumor.
The most primary sites for bone metastasize are: kidney, prostate lung,
breast, ovary & thyroid.
C/M
- Metastatic bone tumor: pain, disability, obvious bone growth, wt.
loss, malaise & fever , spinal cord compression.
Diagnosis
-P/E
-Diagnostic Studies
Mgt
-primary Bone tumors
Goal- to destroy or remove the tumor.
*surgical excision
*Radiation therapy
*Chemotherapy
-Metastatic Bone Disease
• Palliative
Goal- to relieve the pt’s pain & discomfort while promoting QOL.
*Rx of pain, hypercalcemia, blood transfusions.