Disturbances in Musculoskeletal Function

Musculoskeletal system
● Composed of bones, joints, muscles, tendons, ligaments, and bursae
● Major functions: support and protection and motion
● Other functions: maintain body temperature (increases metabolic rate), facilitates
circulation (improves venous return to the heart), reservoir for immature blood cells and
essential minerals
● MSK disorders and injuries directly affect the quality of life of an individual
● Has vascular and nerve supplies.

Skeletal system:
● 206 bones in a normal adult
● 300+ bones before infusion in infancy
● Axial (forms the base; where vital organs are placed–skull etc.) and appendicular
skeleton (extremities)
● Cancellous bone, cortical bone
● Long bones, flat bones, irregular bones, sesamoids (patella; acts as a pulley)
● Periosteum, endosteum
● Joints and articular cartilage

metaPhysis- growth plates

● Cancellous bone (may pores na inside sang
bone; loosely pack cells; soft), cortical bone (shaft;
more densely pack; hard)
● Periosteum (protective covering or membrane;
attaches blood supply), endosteum (inner part)
● Articular cartilage- acts as a cushion or
protection in joints.; white shiny part

Muscular system:
Contributes to motion
● Flexion and
extension
● Internal and
external rotation
● Abduction and
adduction
● Circumduction
● Inversion and
eversion

Assessment
● Gait (inspection)
○ Normal or limping gait
● Spinal curvature (posture)
○ Cervical and lumbar curvature are
normally lordotic posture– the
convexity is facing anteriorly
 ○ Thoracic and sacral curvature are normally kyphotic–the convexity of the
curvature is facing posteriorly.
● Deformities, lesions (obvious upon inspection)
● Tenderness, crepitations, masses- note location, size, consistency (palpation)
● ROM, strength (special)
● Sensation
● Tissue viability (capillary refill time in less than 2 seconds- normal)

Diagnostic modalities
● Blood studies
● Radiography
● CT Scan
● MRI
● UTZ
● EMG, NCV
● DEXA scan
● Bone scan
● Arthrocentesis
● Arthroscopy
● Biopsy

Trauma
● Traumatic injuries: tissue damage of varying severity that occur suddenly from external
forces
● May be blunt (wala pelas, doesn’t have clean cut) or penetrating (may blood)
● May or may not be life-threatening
● E.g. contusions, lacerations/ incisions, abrasions (scrapes), avulsions, fractures,
dislocations
Fracture
● A break in the continuity of the bone; cortical break with corresponding damage to
surrounding soft tissue.
○ Radio dense part- cortex
○ Radio loosen part- medullary canal
● May be open or close
● Fracture–there is a break in the cortex, due to a break in the bone–there will be bleeding
on it called fracture hematoma.
○ Open fractures warrant admission for surgical debridement and antibiotics
○ Close fracture- doesn't have a cut penetrating outside
● Fracture bleeding- oozing, fat globules (oily)
○ Dress appropriately
○ Apply a splint
○ Send to a tertiary institution (ASTP)
● Venous bleeding- not oily/ fat globules
● Regular wound bleeding- pressure could stop the bleeding
● May be complete or incomplete

Dislocation
● No break in the continuity of the cortex. ONLY Complete separation of 2 bones from their
articulation
○ May be simple( wala bale) or complex (fracture dislocation; nautod pag dislocate)
● Subluxation: partial separation
● Dislocation: Complete separation/ distraction

Clinical manifestations:
 ● May have an obvious deformity (especially for dislocation)
● Pain and tenderness (acute)
● Swelling and hematoma
● Limitation in ROM (range of motion is affected)
● If ma ipit ang nerves
○ +/- paresthesias
○ +/- pulselessness

Complications (emergency)
● Nerve or vascular damage
● Malunion- bale nga nag ayo pero wala na align sakto
● Nonunion- bale that does not heal yet no pain
● Infection
● Acute Compartment syndrome- increased intracompartmental pressure that will lead to
localized ischemia and subsequent necrosis
○ Caused by the expansion of intracompartmental contents that makes the muscle
swell inside, tissue and maybe there is an external swelling. This is due to ACS
kay mahugot ang blood supply sa sulod.
○ Recognized by: 5Ps
■ Pain- out of proportion of the injury. Unrelieved by analgesic. High
intensity of pain. Elicit pain by passive stretching of the compartment.
■ Pallor
■ Pulselessness
■ Poikilothermia- temperature of a dead body (yame)--- ang temp nya
gafollow sa temperature sang surrounding.
■ Paresthesia- Paresthesia refers to a burning or prickling sensation that is
usually felt in the hands, arms, legs, or feet, but can also occur in other
parts of the body. If may naipit na nerve
■ Paralysis- due to dead nerve supply
● Fat embolism syndrome- fat globules could escape to the circulation and might block the
pulmonary circulation (pruritus, chest pain or DOB)

Assessment and diagnostics

● Plain radiography
● CT Scan
● MRI
● Arthroscopy

Medical/ surgical treatment

● Pain control
● Immobilization
● Close reduction - using cast or splint
● ORIF - by the use of screws
● External fixation - by using antenna “kudal” ila extremities

Nursing interventions
● Assess trauma patient ABC (airway, breathing, circulation)
● Bleeding control
● Assess pulse, motor, sensory (neurovascular status)
● Immobilize the extremity (splint- should put accordingly: encompass 1 joint above and 1
joint below– cover both joint para di maghulag ang fracture sa tunga); splint the extremity
where it lies, kung ano tsura nya pagkita mo, maintain that position in splinting, di na
pagtadlunga before e splint.
For arterial bleeding/ excessive bleeding
● Pressure pack to stop bleeding and put a bandage. Not too tight nga mapatay ang
extemity

If gagwa tul’an
1. Irrigate with normal saline (or other isotonic solution)
2. Betadine should not be put on the bone (kay mapatay ang tul’an), ONLY around the
wound.
3. Cover the wound with moist gauze( normal saline ang e basa sa gauze)
4. Cover with dry gauze
5. Put with an elastic bandage
6. Apply splint

Basic sprains
RICE
● Rest (avoid weight bearing)
● Ice (to avoid swelling and acute compartment syndrome)
● compress
● Elevate

Infection
Risk factors:
● Poor nutritional status (esp. For pt who has hypoproteinemia)
● IV drug users (using needles)
● Immunocompromise
● Infection at remote sites

Osteomyelitis
Inflammation of the bone caused by an infecting organism
● Most common: S. aereus
Infection of bone characterized by progressive inflammatory destruction (old bone: sequestrum)
and apposition of new bone (new bone: involucrum)
Duration:
● Acute: <2 weeks
● Subacute: 2 weeks- 6 weeks
● Chronic: >6 weeks

Mechanism of infection
● Exogenous: direct inoculation
● Hematogenous

Most response
Pyogeric- creating pus
Nonpyogenic

Pathophysiology
1. Hematogenous bacteria’s seeding or direct inoculation
2. Inflammatory reaction of bone
3. Local ischemic necrosis
4. Abscess formation
5. Increased medullary pressure
6. Cortical ischemia
7. Escape of pus into subperiosteal space
8. Subperiosteal abscess (cloace- gadrain sang pus in the presence of ulcerations)
 9. Sequestrum formation; chronic osteomyelitis

Clinical manifestations
● Fever
● Tachycardia
● Diaphorisis
● Body malaise
● erythema
● pain/tenderness
● Swelling
● Warmth around the affected area
● Skin ulceration (chronic)

Assessment and diagnostics

● CBC- infection parameter
● ESR- infection parameter
● CRP- infection parameter
● Plain radiograph- to detect Sequestrum
● Technetium 99 bone scan- to detect areas with high metabolic activity
● MRI- to detect surrounding soft tissue edema and surrounding Sequestrum and
involucrum
● Aspiration- to take abscess and send for culture and biopsy
● Biopsy
● Culture

Treatment
● Supportive care
● Antibiotics
● Debridement (removal of devitalized tissue), curettage (scrape), sequestrectomy
(removal of dead bone)
● Antibiotic beads (look like rosary beads)

Nursing intervention
Dependent nursing intervention- pre-meds, antibiotics PRN
Independent nursing intervention
Bed rest
Provide comfort
Wound care and good hygiene
Increase OFI to improve hydration status
High protein diet
Vitamin C

Discharge:
Encourage compliance with antibiotics
Teach wound dressing
Use of ambulation aids

Septic arthritis
Results from bacterial invasion of a joint space which can occur through:
● Hematogenous spread
● Direct inoculation from trauma or surgery
● Contiguous spread from an adjacent site of osteomyelitis or cellulitis
Considered an orthopedic emergency
The lower extremity weight-bearing joints are predominantly affected by (61% to 79%); however,
any joint can be involved, and multiple joint infections do occur

Pathophysiology
1. Systemic bacteremia/ direct inoculation
2. Spreads throughout the synovium and synovia fluid
3. Hyperemia and infiltration with polymorphonuclear leukocytes that rapidly increase over
the next several days
4. Activation of enzymes from the acute inflammatory response, production of toxins and
enzymes by bacteria, and stimulation of T. lymphocytes
5. Collagen is exposed to collagenases and the mechanical properties of the articular
cartilage are altered
6. Destruction of articular cartilage (4-6 days after infection)
7. Complete destruction occurs at– 4 weeks

Risk factors:
● Rheumatoid arthritis
● Osteoarthritis
● Prosthetic joint
● Low socioeconomic status
● Intravenous drug abuse
● Alcoholism
● Diabetes
● Previous intraarticuular corticosteriod injection
● Cutaneous ulcers

Clinical manifestations
● Joint pain and swelling
● Area is warm to touch
● Fever
● Refusal to use involved extremity

Assessment and diagnostics

● CBC- inflammatory parameters
● ESR- inflammatory parameters
● CRP- inflammatory parameters
● Joint fluid studies-
● Imaging
● Kochers criteria- to assess for the presence of Septic arthritis
■ 1 point each, the higher the score, the higher the probability that the
patient is having a septic arthritis
○ Fever > 38.5C
○ WBC > 12,000
○ ESR >40mm/s
○ Refusal to bear weight

Treatment
● Antibiotic therapy
● Pain management
● Arthrocentesis
● Arthrotomy and debridement
● Temporary immobilization (knee-knee immobilizer; ankle-splint)

Nursing interventions
 ● Provide comfort
● Pain control
● Supportive therapy
● Encourage compliance with immobilization (needs time to heal)
● Drain attach to post-op- monitor drain output (amount, characteristics)

Necrotizing fasciitis
● Flesh-eating bacteria
● A life-threatening infection that spreads along the soft tissue planes
● Risk factors: immune suppression, bacterial introduction
● Has a mortality rate of 32%- correlates with time to surgical interventions

Inflammatory reaction in the soft tissue creates thrombosis in the capillaries

Thrombosis leads to local ischemia to necrosis of the soft tissues

Clinical manifestations
● Localized abscess or cellulitis with rapid progression
● Toxic looking patient
● Fever, chills
● Tachycardia
● Severe pain
● Skin bullae
● Discoloration
● Swelling
● Subcutaneous emphysema (crepitus)

Assessment and diagnostics

The higher the score, the higher the chance that the patient is having necrotizing fasciitis
● CBC- part of the diagnostic criteria called LRINEC SCORE
● CRP- part of the diagnostic criteria called LRINEC SCORE
● S.Na- part of the diagnostic criteria called LRINEC SCORE
● S.Crea- part of the diagnostic criteria called LRINEC SCORE
● Blood glucose- part of the diagnostic criteria called LRINEC SCORE
● Biopsy, gram stain, and culture- get a specimen or blood for biopsy, gram, and culture

Treatment
● Antibiotic therapy
● Emergency radical debridement

Nursing interventions
● Look out for the development of septic shock; monitor VS ( hypotension, tachypneic,
tachycardic, hyperthermic)
● Ensure patent IV line
Post-op
● Monitor still for septic shock (VS and MIO)
● Check dressing
● Ensure pt comfort
● Diet; high protein, vit c
● wound hygiene
● CBG monitoring

Inflammatory and metabolic disorders

Gout
Most common form of inflammatory arthritis
3-4 M is more than :F
Incidence increases with age, BMI, alcohol consumption, HTN, and diuretic
Patients with gout have an increased risk for CV diseases

Oxidize by xanthin oxidace

1. Purine
2. Hypoxanthine
3. Xanthin
4. Uric acid
Uricase (enzyme not present in human) metabolize uric
acid into its inactive form allantoin

Clinical manifestations
● Acute gouty arthritis
● Tophi
● Gouty nephropathy
● Uric acid urinary calculi

Assessment and diagnostics

● Pain, swelling, redness, and warmth, without the presence of infection
○ The manifestations usually awaken the patient at night
○ Self-limiting even without medication; madula after 7-19 days pero gabalik balik.
○ Preceded by a night of binge drinking or binge eating of red meats or organ
meats
● Synovial fluid polarized light microscopy
● Uric acid levels (may be falsely low during gouty attacks)
○ Clinical check-up should be a week after the flare-up to have accurate result
● 24h urinary uric acid
● S.Crea- check kidney function

Treatment
● Colchicine- manage pain
● NSAIDs- manage pain
● Xanthine oxidase inhibitors- e.g. allopurinol, febuxostat
● Uricosuric agent- urinates uric acid e.g. probenecid
● Corticosteroids- to modulate the inflammatory reaction
● Lifestyle changes- low purine diet, low fat diet, avoid binge drinking and smoking,
exercise
Nursing intervention
● Patient Education
○ Low purine diet
○ Decrease red meat
○ Decrease organ meat
○ Decrease processed meat, legumes
○ Decrease fat in the diet
○ Avoid binge drinking
○ Avoid smoking
○ Educate regarding disease process for compliance
● The more frequent attack, the closer intervals

Osteoporosis
● Most prevalent bone disease in the world
● BMD T-score <-2.5Standard Deviation
○ Osteopenia- low but does not reach -2.5
○ “penia”- kulang
● May occur as primary or secondary osteoporosis
● Hereditary
● Prolonged steroid use
● Thyroid medication prolonged

Mas laban ang ginabreak (osteoclast) nga bone kaysa sa gina build up nga bone (osteoblast).

Clinical manifestations
● Asymptomatic in the early stages
● Back pain- collapse of vertebral body seen in elderly
● Loss of height- collapse of vertebral body seen in elderly
● Fragility fractures- e.g. hip fracture esp. for elderly, wrist fracture or colles fracture,
vertebral body compression deformities.
Assessment and diagnostics
● DEXA scan
● Conventional radiographs

Treatment
● Vit D and Ca supplementation
● Bisphosphonates- can be oral or parenteral.
○ Ex. risedronate
○ orally; has a side effect of esophageal ulcerations
■ remain upright after taking the med atleast 30min-1hr
■ take med with full glass of water
■ take before breakfast/ on empty stomach
■ given once a week
■ take med on the same day each week; pwede palagsan if mamiss ang
dose
■ Ensure safety/ full precautions
■ Increase calcium in diet
■ Exposure to sunlight to convert steroid in the body to vit D
■ Teach weight-bearing exercises (walking, light jogging, etc); this activity
apply stress to the bone and stress stimulate bone formation more than
bone resorption
■ Proper positioning
○ Post-op PHA
■ Pillow between both legs for dislocation precaution
● Avoid hip flexion of more than or beyond 90 degrees
● Avoid hip internal rotation and hip adduction
 ■ Teach to use ambulation aids
■ Wound care
● RANKL inhibitors- ginaguba ang ngipun ngipun sang osteoclast, thus preventing
resorption. Ex. denosumab (prolia)
● Selective estrogen receptor modulators- raloxifene
● PTH analogues- teriparatide
Parathyroid hormone acts to resolve calcium to the bone to increase serum levels of calcium
however, there were studies that showed pathologic continuous exposure to PTH such as in
hyperparathyroidism amuna nga gahabog habog kay ginasuyop nya lng ang calcium nga
ginahatag sa bloodstream
Normal parathyroid function and just take PTH analogues, intermittent lng daw ang exposure ta
sa PTH hormone, this would create a paratoxical effect than the PTH. It will stimulate more
absorption of calcium by the bone than resorption.

Osteoarthritis
● A non-inflammatory degenerative disorder of the joints
● Most common degenerative joint disease
○ May be primary or secondary
○ Elderly
● Due to a history of fractures or septic arthritis
● Often begins in the third decade of life and peaks between the 5th and 6th decades
Pathophysiology

Articular cartilage facilitate gliding

Synovial fluid aids in lubrication in joints and cushion

Osteoarthritis
Articular cartilage degenerate along with the formation of the subchondral cyst and bone spurs
(osteophytes)

Clinical manifestations
● Pain aggravated by movement and relieved by rest
● Stiffness
● Functional impairment
 ● May cause bony enlargements in the PIP- proximal interphalangeal joint and the DIP-
distal interphalangeal joint (Bouchard’s and Heberden’s nodes)

Assessment and diagnostics

Plain radiographs

In normal joint- there is joint space

Osteoarthritis- with increasing grade, the joint space becomes narrower

Treatment
Goal: decrease pain and stiffness; improve mobility if possible
● Orthotics/ ambulation aids
● Weight reduction
● TENS
● NSAIDs as needed
● Arthroplasty- removal and change of joint only in severe case of osteoarthritis

Nursing interventions
● Patient education
● Non-weight-bearing exercise (swimming)
● Proper use of orthotics
● Rest as needed
● Take NSAIDs as needed, not as maintenance to avoid peptic ulcer disease
● Seek consultation to a joint specialist or arthroplasty surgeon for evaluation for joint
replacement