WEEK 15 PART 2 o Growth hormone (stimulates the liver to

MUSCULOSKELETAL NURSING produce Insulin-like growth factor-1 IGF-1)

Anatomy and Physiology o Sex hormone
→ Musculoskeletal System  Estrogen (stimulates osteoblast and
Functions: inhibits osteoclast)
o Protection  Osteoblast- bone building
o Framework  Osteoclast- destroying cell
o Mobility  Testosterone (skeletal growth –>
o Thermoregulation weight-bearing stress -> increased bone
o Venous return formation)
o Reservoir of immature blood cells and  Converted to estrogen in adipose
minerals tissue
→ Bone Formation
o Osteogenesis – production of bones.
o Ossification – hardening of bones.
→ Bone Maintenance
o Series of bone resorption and formation.
o Balance:
 Physical activity
 Diet (calcium)
 Hormones
 Calcitriol– activated vitamin D
o 2 types of vit D.
o Ergocalciferol – food CONTUSIONS | STRAINS | SPRAINS
o Cholecalciferol – human
(skin) can be stimulated CONTUSION
thru sunlight.
 Parathyroid hormone (PTH) –
release due to hypocalcemia (↓
calcium). Mechanism: PTH
pushes the calcium from the bone
to the blood to increase the
calcium.
 Calcitonin – mechanism:
calcitonin pushes the calcium
from the blood to the bone.
 Cortisol (steroid-induced
osteopenia) – the risk of → Soft tissue injury produced by blunt force causing
osteoporosis small blood vessel rupture and soft tissue bleeding.
 Thyroid hormone (increases → Hematoma develops and produces local symptoms
bone resorption) (pain, swelling, and discoloration)
 Growth hormone (stimulates the
liver to produce Insulin-like Management:
growth factor-1 IGF-1)  Intermittent application of COLD PACKS
 Sex hormone (estrogen and o 15 mins - cold compress
testosterone) o use to vasoconstriction to decrease swelling
→ Hormones o only use within 48 - 72 hours
o Calcitriol (activated Vitamin D – increases  Compression on the site
calcium absorption in GI) o Bandaging
o Parathyroid hormone (PTH)  Elevation above the level of the heart.
o Calcitonin  Resolves in 1-2 weeks
o Cortisol (steroid induced osteopenia)
o Thyroid hormone (increases bone STRAINS
resorption)
 → “Pulled MUSCLE or TENDON”
→ Caused by overuse, overstretching, or excessive
stress.
Degrees:
 1st degree
o Mild stretching of muscles and tendon,
minor edema, tenderness, mild muscle
spasm without loss of function
 2 degree
nd
o Partial tearing of muscle or tendon
o All symptoms of 1st degree and loss of
load-bearing strength
 3rd degree
o Severe muscle or tendon stretching with
rupturing and tearing of involved tissue
o All symptoms of 1st and 2nd degree, and an
evidence in X-ray of AVULSION (bone
fragment pulled-away by a tendon) or MRI
revealing 3rd degree strain
SPRAINS
→ Injury to the LIGAMENT and TENDON
surrounding joint.
→ Caused by TWISTING motion or
HYPEREXTENSION of a joint
→ Common site of sprain: knee joint affecting the
anterior cruciate ligament.
Degrees:
 1st degree
o Stretching of ligamentous fibers
 2nd degree:
o Partial tearing of ligament
 3 degree:
rd
o Complete tearing or rupture of ligament
Nursing interventions: Contusions, Sprain, and Strain
 RICE
 Rest (prevents additional injury and promotes
healing: immobilization)
 Ice (cold packs for 20-30 minutes on 1st 24-48
hours: vasoconstriction, decreases bleeding,
edema, and pain)
 Compression (elastic compression bandage:
controls bleeding, reduces edema, supports
injured tissue)
 Elevation (controls swelling)
 3rd degree:
o Surgical intervention, cast, splint, or brace
1. Assessment of neurovascular status (circulation,
motion, sensation) ever 15mins 1-2 hrs post-injury,
then every 30 minutes until stable
FRACTURES
→ COMPLETE or INCOMPLETE disruption in the
continuity of bone structure
Types:
1. COMPLETE: break across the entire cross-section
of the bone
2. INCOMPLETE: breakthrough only a part of the
cross-section of the bone
3. COMMINUTED: produces several bone fragments
4. CLOSED: does not cause a break in the skin
5. OPEN: skin or mucous membrane wound extends to
the fractured bones
a. Grade I: clean wound less than 1cm
b. Grade II: larger wound without extensive
soft tissue damage
c. Grade III: highly contaminated, extensive
soft tissue damage
6. AVULSION: fragment of bone pulled away by
tendon and its attachment
 7. COMPRESSION: bone compressed (seen in 6 P’S OF NEUROVASCULAR ASSESSMENT
vertebral fracture)
8. DEPRESSED: fragments are driven inward (skull
and facial bones)
9. EPIPHYSEAL: fracture through the epiphysis
(fracture in the head of the femur)
10. GREENSTICK: one side of the bone is broken and
the other side is bent (this is the most common
fracture in school-age)
11. IMPACTED: bone fragment driven into another
bone fragment
12. OBLIQUE: occurs at an angle across the bone
13. PATHOLOGIC: occurs through an area of diseased
bone
14. SPIRAL: a fracture that twists around the shaft of
the bone 1. Pain:
15. STRESS: results from repeated loading of bone and 2. Paralysis: mobilized – stretching.
muscle 3. Pulse: check for distal
16. TRANSVERSE: straight across the bone
4. Pallor: capillary refill.
5. Paresthesia- tingling sensation
6. Poikilothermia – temperature
 OPEN fracture:
o Cover wound with a sterile dressing.
o Never attempt to reduce the fracture.

MUSCULOSKELETAL CARE MODALITIES

CAST
→ Rigid external immobilizing device molded to the
contours of the body
→ Immobilizes and reduces fracture
→ Corrects a deformity
→ Support and stabilize weakened joint
Plaster of Paris
→ Advantages:
o Cheaper in price
o Achieves better mold
→ Disadvantages:
o Not durable
Clinical Manifestations: o Longer to dry (24-72 hrs to dry)
 Pain o Cannot be wet
 Loss of function Fiberglass
 Deformity → Advantages:
 Shortening o Lighter, durable, stronger
 Crepitus (crumbling sensation upon palpation) o Water-resistant
 Localized edema and ecchymosis o Faster to dry (minutes)
Emergency Management: → Disadvantage:
 Immobilization thru adequate splinting o More pricey
o Neurovascular status is checked before and after Plaster of Paris Fiberglass
o Do not flex!
 o Isotonic contraction – shorten muscles
that causes movement of the extremity
o Performed hourly while awake

EXTERNAL FIXATOR
Nursing Management:
General Nursing Management: Cast, Splint, Brace Post-application:
 Assess neurovascular status (6Ps) → Elevation
 Unrelieved pain: Notify the physician → Cover sharp points
o Fracture: immobilize → Assess neurovascular status every 2-4 hrs
o Edema: elevation and cold compress → Clean pin site
 Monitor for infection → Check for signs of infection
o Hot spot – hot parts inside the cast. → Isometric and active exercises
o Management: using a straw, blow inside the → Never adjust the clamps!
cast to relieve itchiness.
o Windowing - cutting portion of a cast to Roger Anderson External Fixator (RAEF)
relieve pressure.
 Assess for complications:
o Compartment Syndrome – the pressure of
muscles that decreases blood flow (painful)
o Pressure Ulcers – due to prolonged period
of casting.
o Disuse Syndrome – deterioration of
muscles due to immobilization.
Compartment Syndrome
→ Vascular insufficiency and nerve compression due to
unrelieved swelling in a limited space
TRACTION
Management:
 BIVALVING (cast cut in half longitudinally) → Application of a pulling force to a part of the body.
 Elevation above heart level Purposes:
 Pressure not relieved: FASCIOTOMY  Minimize spasms
- Hihiwaan ka sa skin to allow expansion.(painful)  Reduce, align, and immobilize fractures
- If the pressure was not relived, distal extremities  Reduce deformity
will die because of lack of blood supply.  Increase space between opposing surfaces
 Monitor neurovascular status
Pressure Ulcers
→ Tissue anoxia and ulcer due to pressure from cast or
inappropriately applied brace
→ Bony prominences: most susceptible parts
→ Pain and tightness
→ Warm area on cast or brace (erythema)
→ Skin breakdown
Management:
 BIVALVING
 WINDOWING (cutting portion of a cast)
Disuse Syndrome
→ Muscular atrophy and loss of strength due to Types:
immobilization from cast, splint, or braces → SKIN TRACTION – Tape only!
Management: → SKELETAL TRACTION*
 Prevention: o Ensure effective traction
o Tense/contract muscle (isometric o Prevent skin breakdown
contraction) o Assess nerve damage and circulatory
o Isometric contraction –only tone impairment
increases. o *Pin site care
 o Promote exercise
o Assess potential complications:
 Atelectasis and pneumonia
 DBCT
 Deep Breathing, Coughing and
Turning
 Constipation and anorexia
 Urinary stasis and infection
 Venous thromboembolism (anti embolic

TOTAL HIP REPLACEMENT (NOT INCLUDED)

→ Replacement of severely damaged hip with artificial
3. Iliza rov external fixator
joint.
Nursing Interventions:
→ PREVENT DISLOCATION
1. Affected leg should not cross the center of the
body
2. Hip should not bend more than 90 degrees
3. Affected leg should not turn inward
4. Maintain ABDUCTION of legs (abduction
splint/wedge pillow)
5. Knees apart at all times
6. Never cross the legs when seated
7. Avoid bending forward when seated in chair or
picking up an object
4. Delta external fixator
8. Use high-seated chair and raised toilet eat
9. Do not flex the hip
Medical Management:
REDUCTION
→ Fracture reduction: restoration of fracture fragments
to anatomic alignment and positioning
Closed Reduction
→ Bringing bone fragments into anatomic
alignment through manipulation and manual
traction
Open Reduction
→ Surgical realignment of fractured bone Nursing Management:
→ Internal Fixation devices: metallic pins, wires, → Closed fracture
screws, plates, nails, or rods) o Health teaching on control of edema and pain
IMMOBILIZATION o Exercises on the unaffected side
→ Accomplished by external or internal fixation o Proper use of assistive devices
External factors: → Open fracture
1. Bandages, casts, splints, continuous traction o Administration of IV antibiotics and tetanus
toxoid (risk of infection)
o Wound irrigation and debridement (clean!!)
o Elevation of extremity
o Neurovascular status check
o Temperature check (infection)
Watch out for complications:
→ SHOCK
→ FAT EMBOLISM SYNDROME
2. Roger-Anderson External Fixator (RAEF)
→ Fracture of long bones/pelvic bone
→ Lungs, kidneys, brain
S/sx:
 o
Hypoxia, tachypnea, tachycardia, and
pyrexia
o Petichiae on chest, free fat on urine
 COMPARTMENT SYNDROME
DEVELOPMENTAL DYSPLASIA OF THE HIP
 Spectrum of disorders related to abnormal
development of the hip occurring on the fetal life,
infancy, and childhood.
Cause:
 UNKNOWN
 RISKS:
o Female gender
o First pregnancy
o Family history
o Breech
o High birth weight
o Joint laxity
o Postnatal positioning
Three Degrees: Therapeutic Management:
1. Acetabular dysplasia  Newborn to 6 months – SPLINTING (proximal
2. Subluxation femur centered in the acetabulum in a degree of
3. Dislocation FLEXION) using abduction devices
- Ortolani sound - Clicking sound around the o PAVLIK HARNESS – for 6-12 weeks
hips.  6 months to 24 months
o SPICA Cast
o Closed Reduction
 Skin care is IMPORTANT

Diagnostic Evaluation:
 Barlow test
- gently adducting the hip while palpating for the
head falling out the back of the acetabulum and
that no posterior-directed force be applied.
 Ortolani test
o Most reliable from birth to 4 weeks of age
o At 6-10 weeks, adduction contracture
develops and Ortolani Sign disappears SCOLIOSIS
o Beyond 4 weeks – limited hip abduction  Complex spinal deformity in three planes usually
(sensitive test) involving LATERAL curvature, spinal rotation,
o Older infant/children – one leg appears causing rib asymmetry.
SHORTER  Scoliosis – lateral curvature
Barlow – adduction - refers to moving your limbs closer to the  Kyphosis – anterior curvature (kuba)
midline.  Lordosis – L shape lumbar
Ortolani – abduction- moved away from your body's midline
Short Adducted Externally Rotated
 Cause:
 Unknown
Therapeutic Management:
 Correction of the deformity
 Maintenance of the correction until normal muscle
balance is regained
 Follow up observation to avert possible recurrence
Cause:  PONSETI METHOD
 Unknown (Idiopathic Scoliosis)  Percutaneous Heelcord Tenotomy
 Dennis Browne bar
Correction of deformity:

Levoscoliosis – towards left

Dextroscoliosis – towards right
Diagnostic Evaluation:
 PHYSICAL Assessment
o Assessment technique: lean forward,
normal: even back.
Achiless tenotomy:
 Radiographic studies (best)

Therapeutic Management:
 Observation and regular clinical and radiographic
observation (mild curvature)
 Orthotic intervention (bracing)
 Surgical spinal fusion
Milwaukee Brace
Dennis Browne bar

CONGENITAL CLUBFOOT
→ A.K.A Congenital Talipes Equinovarus
→ Complex deformity of the ankle and foot that
includes forefoot adduction, cavus, hindfoot varus,
and ankle equinus