ORTHOPEDIC NURSING

MUSCULOSKELETAL DISORDERS

MUSCULOSKELETAL DISORDERS 2. Appendicular Skeleton - articulated bones of the

1. are injuries or disorders of the muscles, nerves, tendons, upper and lower limbs and girdles
joints, cartilage, and spinal discs. a. Shoulder Girdle
2. Work-related musculoskeletal disorders (WMSD) - Scapula 2
are conditions in which the work environment and - Clavicle 2
performance of work contribute significantly to the
condition b. Upper Extremity
- Humerus 2
ORTHOPEDIC NURSING - Radius 2
• is a nursing specialty focused on the prevention, - Ulna 2
treatment and care of musculoskeletal disorders. - Carpus 16
- Metacarpal bones 10
➢ SPECIALISTS - Phalanges 28
o RHEUMATOLOGIST
• Rest c. Pelvic Girdle
• Therapy - Coxa (Hip Bones) 2
• Medications
d. Lower Extremity
o ORTHOPEDIST - Femur 2
• Rest - Tibia 2
• Therapy - Fibula 2
• Medications - Patella 2
• SURGERY - Tarsus 2
- Metatarsals 10
o PROSTHETIST – creates and supervises the use of - Phalanges 28
prosthesis
TYPES OF BONES
ANATOMY & PHYSIOLOGY (OVERVIEW)
3. FUNCTIONS OF THE BONES
o PROVIDES SHAPE - body
o PROVIDES FRAMEWORK – to support internal organs
o PROTECTION – internal organs
o MOVEMENT – attachment for tendons ligaments
o BLOOD CELL FORMATION
o STORAGE and RELEASE – minerals
o TRANSPORT OF NUTRIENTS – to bone cells by blood • Hematopoiesis
and lymph vessels and remove wastes • Bone formation
o BONE MAINTENANCE – bone remodeling
• Provides support –
weight bearing
BONES: DIVISIONS
1. Axial Skeleton - bones that form the longitudinal axis
STRUCTURE OF A LONG BONE
of the body. Axial means relating to or situated in the
central part of the body.
a. Skull
- Cranium 8
- Face 14
b. Hyoid 1
c. Vertebral Column
- Cervical 7
- Thoracic 12
- Lumbar 5
- Sacrum 1
- Coccyx 2

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BONE MARROW Haversian system

Concentric layers of ossified bone matrix arrange around a
central Haversian canal. The matrix forms a circular pattern –

BONE MATRIX
- it is made up of
– Organic components (35%)
• Composed of cells, fibers and organic
substances (OSTEOID)
• Collagen is most abundant organic substance
Yellow bone marrow • Collagen fibers (Bone Resilience)
Functions in times of stress - transformed to red
marrow to assist in hematopoeisis. – Inorganic mineral salts (65%):
• Primarily calcium phosphate
(hydroxyapatites)
• Gives bone its hardness; strength to resists
compression
• Minerals -calcium & phosphorous (bone
strength)
• If collagen removed, bone is too brittle
Microscopic Structure of Compact Bones

Cells of Bone Tissue

Canaliculi are small

fluid filled channels
that are used for
exchange of Ca,PO4,
nutrients and wastes
products through gap
junctions

BONE HISTOLOGY BONE CELLS

4. BONE MATRIX - is the extracellular element of bone 5. OSTEOBLASTS – cells that build bones and secrete bone
tissue. matrix in which inorganic minerals, such as calcium salts
are deposited.
.

• The process of ossification and calcification

transforms the blast cells into mature bone cells
called OSTEOCYTES

• If mineral removed, bone is too bendable

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Takes place in cartilage

No elongation - Dwarfism
• Achondroplastic -
– long bones stop growing in childhood
• normal torso, short limbs
– failure of cartilage growth
• Pituitary
– lack of growth hormone
– normal proportions with short stature

• OSTEOCYTES – former osteoblasts that have been

trapped in the matrix they formed.
• are mature bone cells involved in maintaining bone
tissue.
• Controls the extracellular concentration of calcium
and phosphate
• OSTEOCLASTS – cells that are involve in the
destruction, resorption and remodelling of bone.
BONE MAINTENANCE
Regulating factors
Physical activity - Stress and weight bearing
Dietary intake – Calcium and Vit. D
Parathyroid hormone and calcitonin
Thyroid hormone and cortisol
Growth hormone
Sex hormones -Estrogen and testosterone
Blood supply

1. PHYSICAL ACTIVITY (weight bearing activity)

stimulates bone formation and remodeling.
o THICK AND STRONG BONES
o WEAK BONES (CALCIUM LOSS)

2. GOOD DIETARY INTAKE → bone health

o Calcium 1500 mg/day- to maintain adult bone
mass
o Eat calcium rich foods
o Dairy products - cheese, yogurt, milk (drink 16 -
24 ounces of milk/day
BONE FORMATION – ENDOCHONDRAL OSSIFICATION o Nondairy sources –canned sardines, salmon,
tofu, green leafy vegetables

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3. CALCITRIOL (ACTIVE VITAMIN D) 5.GROWTH HORMONE

- functions to increase the amount of Calcium in the - stimulates the liver to produce insulin like growth
blood by promoting absorption of calcium from the factor-1
GIT. (IGF-1) → accelerates bone modeling in children and
- facilitates mineralization of osteoid tissue. adolescents.

4. MAJOR HORMONAL REGULATORS OF CALCIUM 6. SEX HORMONES:

HOMEOSTASIS Estrogen – stimulates osteoblast and inhibits osteoclast
Testosterone - ↑ skeletal growth → ↑muscle mass →
↑ weight bearing stress on bones → ↑ bone formation.

7. BLOOD SUPPLY TO THE BONE:

↓ blood supply
↓
↓ osteogenesis and bone density
↓
bone necrosis (deprived of blood)

BONE HEALING
BONE INJURY
Bone fracture → blood vessels & soft tissue tear

Fracture Repair

CORRECTION FOR HYPERCALCEMIA

ASESSMENT
Physical Assessment

Subjective Data:
Pain - fracture, osteoarthritis
History – injury, post menopausal
Social History – Occupation (low back pain), activities (
tendinitis)

OBJECTIVE DATA:
Skeletal Component - bony deformities, length discrepancies,
►↑ Thyroid hormone production(GRAVE’S DISEASE) alignment, amputations, fractures.
► ↑ Cortisol →↑Bone resorption & ↓bone formation. Joint Component – swelling
► Patient (rheumatoid problems) receiving long term Muscle Component – size, strength
synthetic cortisol or costicosteroids (prednisone Skin component – cuts and bruises
[Deltasone,Prednicot] Neurovascular Component – circulatory status
↑ risk fracture

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NERVES
6. PERONEAL NERVE in the lower leg provides sensation
over the posterolateral part of the leg and the knee joint.

Peroneal nerve damage

Symptoms RADIAL NERVE runs down the underside of the arm and
• Decreased sensation, numbness, or tingling in the top controls movement of the triceps (the muscle located at the
of the foot or the outer part of the upper or lower leg. back of the upper arm).
• Foot that drops (unable to hold the foot up)
• "Slapping" gait (walking pattern in which each step
makes a slapping noise)
• Toes drag while walking.
• Walking problems.
• Weakness of the ankles or feet.

TIBIAL NERVE - provides innervation to the muscles of the

lower leg and foot. The tibial nerve generally follows the
course of the tibial artery through the body, which supplies
blood to the same areas. INJURY:
- Fracture of Body of Humerus
- Saturday Night Palsy
- Compression of nerve in the Axilla
- Using improperly adjusted crutches
- Results in:
- ‘Wrist drop’

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of the thenar eminence, thus controlling the coarse

movements of the hand. Therefore, it is also called "labourer's
nerve".

➢ Saturday night palsy has become synonymous with

radial nerve compression in the arm resulting from
direct pressure against a firm object. It typically
follows deep sleep on the arm, often after alcohol
intoxication.

Radial nerve Injury

Locations
Holstein – Lewis Fracture
- Injury to the nerve at this level will cause the condition
of wrist drop as well as weakness of finger extension
ULNAR NERVE gives sensation to the forearm and fourth and
fifth fingers. Entrapment occurs when the nerve is compressed
or irritated.
Physical Assessment
Posture
• Kyphosis – exaggerated convex curvature of the
thoracic spine (humpback) elderly
• Lordosis – excessive concave curvature of the lumbar
spine (swayback) seen in pregnant women

Screening for Scoliosis

• Inspection of the spine for scoliosis

Anatomy of the Ulnar Nerve Gait-can be assesed by having the patient walk away
Pressure on the nerve at the elbow can cause numbess or pain • Limping - caused by painful weight bearing
in the elbow, hand, wrist, or fingers. - ask patient to pin point area of discomfort
- one extremity is shorter than the other
Ulnar Nerve, Clinical Examination
➢ Tinel’s Sign
- It is a tapping technique performed to test for
symptoms of ulnar nerve entrapment at the elbow
(cubital tunnel syndrome)

MEDIAN NERVE is the main nerve of the front of the forearm

and is the only nerve that passes through the carpal tunnel It
supplies the muscles of the front of the forearm and muscles

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Identifying Gait Abnormalities

• Checking for larger amounts of fluids in the knee

• Ballottement positive –if patella elevates
• due to large amount of fluid

• Balance – able to sit, stand, and walk with a good

center of balance
• Mobility – supportive device used like cane, walkers
• Range of Motion
• Strength
• Handgrip
• Bilaterally equal
- straight leg raising
- push and pull in arms
• Spine – tenderness of the vertebrae on palpation
• Joint appearance - Any redness, deformity or loss of
motion DIAGNOSTIC EXAMS
• Skeletal muscle appearance – atrophy/shrinking of 1. X-RAYS
arms or legs - X-rays are a form of ionizing radiation that can
• Ability to perform ADL – independent or need penetrate the body to form an image on film
assistance to dress, bath, toilet, eat
• Phalen’s test – wrist are held in acute flexion for 60 Traumatic Disorders and Bone Diseases
seconds.
Numbness and burning in the fingers – • Jewelries removed
Carpal tunnel syndrome • Analgesics given as ordered
• Position properly
• Shield testes, ovaries or pregnant women

2. COMPUTED TOMOGRAPHY SCAN (CT-SCAN)

COMMON AMONG
⮚ SECRETARY
⮚ MEDICAL TRANSCRIPTIONIST
⮚ PIANIST
• Checking for small amount of fluids in the knee
• Bulge sign- observe medial side of patella for bulging,
an indication of fluid displacement
o Cross sectional images provided
o Scanning may or may not require injection of a dye.
Tumors/Injuries Detected
• Consent – use of dye
• Allergies assessed ( iodine, contrast dye, shelfish)
• Claustrophobia assessed
• Lie still and flat
• Mechanical noises
• Painless
3. MAGNETIC RESONANCE IMAGING
o Magnetic fields and radiowaves are used.

Preprocedure
Remove all metal objects from the client.

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Examples: 5. BONE DENSITOMETRY

Jewelry Keys (pockets). o Measures bone mineral density of the entire body
Eyeglasses Clothes with metal zippers or just the hip and spine.
Watches buckles and buttons
Pins Credit, bank and parking cards • Jewelries removed
Hearing aids (erase the magnetic codes)) • Painless
Dental appliance IV poles, and oxygen tanks. • Minimal radiation exposure
Hair clips Pens

CONTRAINDICATED: magnetic field could cause these to

malfunction.
• Permanent pacemaker
• Artificial heart valves
• Implanted insulin pump
• Internal metal devices(e.g. aneurysm clips, hip
prosthesis)
• Dental implants
• Intraocular metallic fragments

CENTRAL DUAL ENERGY X-RAY ABSORPTIOMETRY (DXA OR

• Foil backed skin patches nitroglycerine (Transderm-Nitro) DEXA)
removed
• Claustrophobia assessed
• Blindfold during the procedure.
• Lie still

4. ARTHROGRAPHY
• Tears of the joint capsule identified
• Infection
• Injection - air/radiopaque substance into joint cavity
to outline soft tissue structures
• NPO 8 hours before procedure
• Inform consent obtained
• Allergies -checked

• Joint is put through its range of motion to distribute

the contrast agent while a series of x-rays is obtained.
• TEAR present – the dye leaks out of the joint & is
evident on x-ray

• Post procedure:
1. Compression elastic bandage, joint rest for 12
hours.
2. Comfort measures given- analgesia, ice
therapy
3. Explain – normal to experience
clicking/crackling in the joint for 1-2 days, PERIPHERAL DXA
until the agent or air is absorbed o Measures BMD of the forearm, finger or heel.
o Small device
o Bone density reading within a few minutes.

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7. ARTHROSCOPY
Direct visualization of a joint to diagnose joint
disorders.
Remove articular debris and small, loose bodies
Repair a torn meniscus and a biopsy may be
performed.

6. BONE SCAN
- imaging test shows areas of increased or decreased
bone turnover (metabolism)
• Informed consent - obtain
Asess – allergies/ pregnancy • NPO 8 hours before the test
DX. – bone tumor, fracture, infection, metabolic disorders • Sedation / local anesthesia
• Informed consent • Shave area around the joint
• Empty bladder • When fully awake – can walk but will experience
• Hold fluids 4 hrs preprocedure mild soreness and a slight grinding sensation in his
• No jewelries knee for 1-2 days.

➢ RADIOTRACER Post-op
- The radiotracer, injected into a vein, emits gamma 1. Assess neurovascular status of the affected extremity.
radiation as it decays. A gamma camera scans the 2. Joint - wrapped with compression bandage (2-4 days)
radiation area and creates an image 3. Extend and elevate extremity for 2 days to control
o Scanning Procedure: swelling.
1-2 hours after injection 4. Ice therapy to minimize swelling - CRYOCUFF →
o After Injection: 5. Analgesics given
Drink Plenty fluids 6. Walk without weight bearing after sensation returns,
o Scan: limit activity for 1 – 4 days
2-3 hours after injection 7. Crutches ( 5 -7 days) for walking
8. Notify physician ( more than 3 days)
- fever
- increased knee pain occur
- edema

8. ARTHROCENTESIS
Joint aspiration - synovial fluid, blood (trauma) or pus for
examination or to relieve pain.
Performed
❖ Diagnostically
↑ isotope uptake = osteosarcoma, osteomyelitis, and – To diagnose septic arthritis
fractures that do not heal. – To reveal hemarthrosis (bleeding into the
joint cavity) which suggest trauma
POSTPROCEDURE: ❖ Therapeutically - for pain relief, drainage of septic
• LAXATIVE effusion, or injection of medications
• INJECTION SITE MONITORED

NO Breast feeding for at least 4 weeks

after test to prevent radionuclide exposure to infant.
Flush toilet 3x after voiding - small amount of radioactive
material does not stay in the toilet bowl.
INFORMED CONSENT

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Laboratory Studies
• Performed under local anesthesia.
• Normally, synovial fluid is clear, pale, straw colored, Uric Acid Normal value:
and scanty in volume. Women: 2.6 – 6.8 mg/dl
Men: 3.5 – 8.0 mg/dl
POST OP. • Elevated levels are found in gout
• Cold pack, pressure dressing Nursing interventions
• Elevate joint : 8-24 hours • NPO 12 hours before the test
• Rest joint: 2-3 days

9. ELECTROMYOGRAPHY Nursing Diagnosis and Planning

- Evaluates muscle weakness, pain and disability. • ALTERED PHYSICAL MOBILITY – due to immobilization,
- Provides information about the electrical potential of loss of limb, stiffness, pain, weakness or inability to bear
the muscles and the nerves leading to them. weight.
• LIMITED ACTIVITY – intolerance due to stiffness, pain,
➢ Kinds of EMG limited mobility, fatigue.
Surface EMG (wireless) • PAIN due to injury, surgery or joint disorder.
▪ Monitors – general picture of muscle • POTENTIAL FOR INFECTION- due to trauma or surgical
activation incision
Intramuscular • ALTERED TISSUE PERFUSION due to swelling and
▪ Monitors – activity of only few muscle fibers pressure.
• ALTERED SELF CARE ABILITY due to immobilization
• Informed consent • ALTERED BODY IMAGE due to change in appearance
BEFORE THE TEST and/or loss of mobility or function.
• no smoking • DECREASED ABILITY FOR HOME MAINTENANCE due to
• no fluids with caffeine immobility or limited self care ability.
• no meds (stimulants,sedatives) • POTENTIAL FOR DISUSE SYNDROME due to immobility or
trauma

10. BIOPSY (BONE OR MUSCLE) IMPLEMENTATION

POSITIONING – patients with musculoskeletal problems MUST
change their body position frequently and get up in chair.- to
prevent pressure ulcers, circulatory stasis, and respiratory and
urinary complications.

EXERCISE – ROM exercises both passive and active are planned

and carried out as soon as feasible after decreased mobility
occurs (disease, injury, surgery).

To maintain connective tissue within the joint and ensure that

every joint retains its function and mobility
ROM exercises – should be done 3 or 4 times/day
BONE/MUSCLE SAMPLES EXAMINED FOR CANCER OR OTHER Patient receives the first dose of pain medication in the AM
ABNORMAL CELLS 30-60 min BEFORE beginning exercise.
• NEEDLE BIOPSY
• OPEN BIOPSY Isometric exercise – may be contraindicated with
hypertension, increased intracranial pressure or congestive
• Nursing Interventions heart failure – significant increase in BP and heart rate.
1. Informed consent – obtain
2. Monitor site for bleeding, swelling, hematoma, GRADUAL MOBILIZATION – progressive mobilization involves
severe pain and infection. assessing the patient’s ability to move her limbs, turn herself
3. Elevate site – 24 hours postop in bed, transfer herself from bed to chair and back again, stand,
4. Ice therapy walk – to measure signs of independent movement
5. Analgesics – postop.

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