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Review of Anatomy and Physiology The Musculoskeletal System The skeletal and muscular systems may be considered one system because they work together to enable the body to move. The skeleton is the framework that supports the body and to which the voluntary muscles are attached. The skeletal framework includes the joints, or articulations between bones. Contraction of a muscle pulls a bone and changes the angle of a joint. It is important to remember that movement would not be possible without the proper functioning of the nervous, cardiovascular, and respiratory systems. Voluntary muscles require nerve impulses to contract, a continuous supply of blood provided by the circulatory system, and oxygen provided by the respiratory system.

SKELETAL SYSTEM TISSUES AND THEIR FUNCTIONS The skeletal system is considered to include the bones and cartilage of the axial and appendicular skeleton, as well as the connective tissue structures (i.e., ligaments and tendons) that connect the bones and join muscles to bone. The tissues of the muscular system are skeletal (also called striated or voluntary) muscle fibrous connective tissue which forms the tendons that connect muscle to bone; and the fasciae, the strong membranes that enclose individual muscles. Smooth muscles (also called involuntary or non-striated) has the same function as skeletal muscle (i.e., contraction) but is not considered part of the skeletal system tissues as it is not involved with articulation or skeletal movement. Besides its role in movement, the skeleton has other functions. It protects organs and tissues from mechanical injury. The central cavity of some bones contains the hematopoietic connective tissue in which blood cells are formed. The bones are also a storage site for excess calcium, which may be removed from bones to maintain a normal blood calcium level. The voluntary muscles collectively contribute significantly to heat production, which maintains normal body temperature. Another important function of the muscular system is that it aids in returning blood from the legs through muscular compression on the leg veins. 2. Bone Growth and Healing The growth of bone from fetal life until a person attains final adult height depends on many factors. Proper nutrition (particularly vitamins and minerals) provides the raw material to produce bone matrix: comprised of calcium, phosphorus, and protein. Vitamin D is essential for the efficient absorption of calcium and phosphorus from food in the small intestine. Vitamins A and C do not become part of bone but are needed for the production of bone matrix (a process called calcification or ossification). Hormones directly necessary for growth include growth hormone (GH) from the anterior pituitary gland, thyroxine from the thyroid gland, and insulin from the pancreas. Growth hormone increases mitosis and protein synthesis in growing bones; thyroxine stimulates osteoblasts, as well as increasing energy production from food. Insulin is essential for the efficient use of glucose to provide energy. If a child is lacking any of these hormones, growth is much slower and the child does not reach his or her genetic potential for height. BONE HEALING Bone heals uniquely through tissue regeneration rather than through scar tissue formation. Fracture repair occurs by the same mechanism as bone formation during normal growth and maintenance, with organized mineralization of newly synthesized bone matrix followed by remodeling to mature bones. Adequate circulation to the fracture site and adequate fragment immobilization are crucial for effective bone healing. Stages of Bone Healing

Stage I: Hematoma Stage/ Inflammatory Stage Duration: 1- 3 days The immediate formation of hematoma at the site of the fracture occurs when the blood forms a clot among the fracture fragments, providing a small amount of stabilization. Stage II: Fibrocartilage Formation Duration: 3days 2 weeks Fibroblasts, osteoblasts, and chondroblasts migrate to the fracture site as a result of the acute inflammation and form Fibrocartilage. Organization of the hematoma then offers the foundation for storage II bone and tissue healing. Periosteal elevation and granulation tissue formation creates a collar around the end of each fracture fragment. Collars then advance to form a bridge across the fracture site, called the primary callus, which increases the stability for the fracture.

Stage III: Callus Formation Duration: 2 6 weeks Granulation tissue matures into provisional callus (procallus) as newly formed cartilage and bone matrix disperse through the primary callus. The procallus is large and loosely woven. It is generally wider than the normal diameter of the injured bone which strategically helps it to secure the bone fragments, as it extends some distance beyond the fracture site to serve as a temporary splint, but it does not provide strength. Cartilage is then formed with cells distant from the blood supply and relatively low oxygen tensions. Fibrous bone forms as calcium deposit at the collagen network of the granulation tissue. Prober bone is essential in this stage. This stage may be the most important determinant for successful healing; if it is slowed or interrupted, the final two stages may not occur. Delayed union or non-union can then result. Stage IV: Ossification Duration: 3 weeks 6 months A permanent callus of rigid bone crosses the fracture gap between periosteum and the cortex to join the fragments. In addition, medullary callus formation occurs internally to establish continuity between the marrow cavities. Trabecular bone gradually replaces the callus along the stress line. Bone union, which can be confirmed by x-ray, is said to have occurred when there is no motion with gentle stress and no tenderness with direct pressure at the fractured site. Weight-bearing in lower extremity fractures is also pain free after the bone union. Stage V: Consolidation and Remodeling Duration: 6 months 1 year Unnecessary callus is reabsorbed and chiseled away from the healing bone. The process of bone resorption and deposition along stress lines allows bone to withstand the loads applied to it. The actual amount and timing and remodeling depends on the stresses impose on the bone by muscles, weight-bearing, and age. II. 1. Common Diagnostic Exams X-ray An x-ray examination can determine bone density, texture, changes in alignment and bone relationship, erosion, swelling, and intactness. In addition, x-ray examinations can be useful in identifying certain soft tissue damage (e.g., ligaments and tendons) because of alterations in bone position and spacing 2. Magnetic Resonance Imaging (MRI) Magnetic resonance imaging (MRI), with or without contrast media, is a commonly performed test to diagnose musculoskeletal problems, especially those involving soft tissue. MRI is more accurate than CT for diagnosing many problems of the vertebral column. If the patient has had previous spinal surgery, a contrast medium is sed. The image is produced by interaction of magnetic fields and radio waves. For very large patients or those who are claustrophobic, the open MRI offers a comfortable alternative to the traditional machine. 3. CT Scan (Computed Tomography) Tomograms are radiographs that focus on a particular slice of bone or soft tissue, such as ligaments and tendons. Computed tomography is especially helpful for diagnosing problems of the joints or vertebral column. It may be used with or without a contrast medium (similar to a dye), which is given orally or intravenously. An advantage of CT-Scan is that other structures (blood vessels) and abnormalities (hematoma) can be seen. 4. Arthroscopy Is a surgical procedure that involves inserting a small fiberoptic scope into the joint, which provide visualization of the internal structures and allow for surgical intervention at the same time. III. Fractures It refers to any disruption in the normal continuity of a bone. Clinical Manifestations

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A. Pain If the client is neurologically intact, pain always accompanies fracture; the intensity and severity of the pain differ from client to client. Pain is usually continuous, increasing in severity until the fracture is immobilized. It results from muscle spasm, overriding of fracture fragments, or damage to adjacent structures. B. Loss of Function After a fracture, the extremity cannot function properly because normal function of the muscles depends on the integrity of the bones to which they are attached. Pain contributes to the loss of function. In addition, abnormal movement (false motion) may be present. C. Deformity Displacement, angulation, or rotation of the fragments in a fracture of the arm or leg causes deformity that is detectable when the limb is compared with the injured extremity.

D. Shortening In fractures of long bones, there is actual shortening of the extremity because of the compression of the fractured bone. Sometimes muscle spasms can cause the distal and proximal site of the fracture to overlap, causing the extremity to shorten. E. Crepitus When the extremity is gently palpated, a crumbling sensation, called crepitus, can be felt. It is caused by the rubbing of the bone fragments against each other. Swelling and Discoloration Localized edema and discoloration of the skin (ecchymosis) occur after a fracture as a result of trauma and bleeding into the tissues. These signs may not develop for several hour after the injury.

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Types of fractures A. Complete Fracture line extends through the entire bone substances. The periosteum and the cortex are disrupted on both sides of the bone. B. Incomplete Fracture does not divide the bone into two portions because the break is through only part of the bone. Like for an example the Greenstick fracture C. Traumatic Stable vertebral fractures are usually caused by motor vehicle collisions, falls, diving, or athletic injuries. A stable fracture is one in which the fracture or the fragment is not likely to move or cause spinal cord injury/damage.

D. Pathologic A fracture that occurs through an area of diseased bone (e.g., osteoporosis, bone cyst, Pagets disease, bony materials, tumor) and can occur without trauma or fall. E. Close/Simple A fracture that remains contained, with no disruption of the skin integrity. Open/Compound A fracture in which damage also involves the skin or mucous membranes

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Medical Management A. Reduction A1. Casts It is a rigid external immobilizing device that is molded to the contours of the body. A cast is used specifically to immobilize a reduced fracture, to correct a deformity, to apply uniform pressure to

underlying soft tissue, or to support and stabilize weakened joints. It permits mobilization of the patient while restricting movement of a body part. A2. Open Reduction Some fractures require open reduction. Through surgical approach, the fracture fragments are anatomically aligned. Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) maybe used to hold the bone fragments in position until solid bone healing occurs. These devices maybe attached to the sides of the bone, or they may be inserted through the bony fragments or directly into the medullary cavity of the bone, internal fixation devices ensure firm approximation and fixation of the bony fragments. A3. Closed Reduction In most instances, closed reduction is accomplished by bringing the bone fragments into anatomic alignment through manipulation and manual traction. The extremity is held in the aligned position while the physician applies a cast, splint, or other device. Reduction under anesthesia with pecutaneous pinning may also be used. The immobilizing device maintains the reduction and stabilizes the extremity for bone healing. X-rays are obtained to verify that the bone fragments are correctly aligned. Traction (skeletal or skin) maybe used until the patient is physiologically stable to undergo surgical fixation. B. Traction B1. Halo Vest It is a skeletal traction for fractures or discolorations of cervical or high thoracic vertebrae. It treats fractures or discolorations of cervical or high thoracic vertebrae. The duration is continuous. In a stable injury for which surgery is not done, a halo fixation apparatus may be applied. Halo apparatus can be used to apply cervical traction by means of jacket-like arrangement. Hanging weights such as those used with tongs, can be incorporated with the halo. This apparatus can be attached to a body vest, stabilizing the injured area and allowing ambulation if the patient is neurologically intact. Another alternative is to use the halo after the patient has had traction removed. It allows the patient to be more mobile and to begin active rehabilitation. B2. Skin It uses five to seven pound weights attached to the skin to indirectly apply the necessary pulling force on the bone. If the traction is temporary, or if only a light or discontinuous force is needed, then skin traction is the preferred treatment. Because the procedure is not invasive, it is usually performed in a hospital bed. B3. Bryants Traction It is used for fractures of the femur, the fractures in small children, and stabilization of hip joints in children under 2 years old or 30 lbs. in weight. The mechanism consists of a traction frame supporting weights, which are connected by ropes that run through pulleys to traction foot plates. The traction pull elevates the lower extremities to a vertical position with the patient supine, the trunk and the lower extremities forming a right angle. B4. Bucks Extension Traction Bucks extension traction (unilateral or bilateral) is skin traction to the lower leg. The pull is exerted in one plane when partial or temporary immobilization is desired. It is used to immobilize fractures of the proximal femur before surgical fixation. To apply Bucks traction, one nurse elevates and supports the extremity under the patients heel and knee while another nurse places the foam boot under the leg, with the patients heel in the heel of the boot. Next, the nurse secures Velcro straps around the leg. C. Internal/external fixations An alternative modality for the initial management of fractures is the fixation apparatus. External fixation is a method of immobilizing bones to allow a fracture to heal. External fixation is accomplished by placing pins or screws into the bone on both sides of the fracture. The pins are then secured together outside the skin with clamp and rods. The clamps and rods are known as the external frame. Internal fixation is the stabilization of fractured bony parts by direct fixation to one another with surgical wires, screws, pins or plates. 4. Nursing Management A. Pain relief Assess type, degree and location of pain.

Patient-controlled analgesia (PCA) and epidural analgesia may be prescribed to relieve pain. Handle affected extremity gently, supporting it with hands or pillow. Position for comfort and function and assist with frequent changes in position.

B. Promote mobility Preoperative education about planned postoperative treatment regimen promotes patient adherence to an optimal rehabilitation regimen. Patients often increase their mobility once they have been reassured that movement within therapeutic limits is beneficial, that the nurse will provide assistance and that discomfort can be controlled. Assistive devices may be used for postoperative mobility. C. Maintaining skin integrity The nurse assesses the patient for early sign or manifestations of pressure ulcers. Apply elastic tape in a vertical fashion to reduce the incidence of tape blisters. Provide proper skin care, especially to the heels, back, sacrum and shoulders. Turning the patient frequently at preset intervals.

D. Increased nutritional need Encourage patient to participate in the preoperative and postoperative treatment regimen. Diets that have high protein and vitamins are essential for wound healing. E. Casts/ Tractions/ Fixations Maintain correct balance between traction pull and counteraction force. Weights should not be freely hanging at all times. Inspect skin at least every 8 hours for signs of irritation or inflammation. Check traction equipment for proper functioning. Monitor circulation every hour for the first 24 hours after traction is applied.

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Complications A. Shock Hypovolemic shock resulting from hemorrhage is more frequently noted in trauma patients with pelvic fractures and in patients with a displaced or open femoral fracture in which the femoral artery is torn by bone fragments. Treatment should consist of preventing further hemorrhage by stabilizing the fracture. B. Compartment syndrome A serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage and problem with blood flow. C. Fat embolism Fat emboli may form after a fracture of long bones or pelvic bones. During a fracture, fat globules may diffuse from the marrow into the vascular compartment ant it may occlude the small blood vessels that supply the lungs. Brain, kidneys and other organs.

D. Cast syndrome Psychological or physiologic responses to confinement cast. With decrease physical activity, gastrointestinal motility decrease, intestinal gases accumulate, intestinal pressure increases and ileus may occur. The patient exhibit abdominal distention, abdominal discomfort, nausea and vomiting. E. Nerve injury It is caused by continued ischemia and edema. The patient experiences sensations of hypoesthesia (diminished sensation followed by complete numbness). Motor weakness may occur as a late sign of nerve ischemia. No movement indicates nerve damage. Volkmans syndrome It is an acute compartment syndrome which results from antecubital swelling or damage to the brachial artery.

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Amputations - Is the removal of a body part, most often an extremity. Todays amputations are used to treat injuries, cancers, overwhelming limb gangrene, and limb-threatening arterial disease or rest pain.

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Types of amputation A. Minor Amputation

Minor amputations are amputations where only a toe or part of the foot is removed. A ray amputation is a particular form of minor amputation where a toe and part of the corresponding metatarsal bone is removed as shown in the diagram below left. A forefoot amputation can sometimes be helpful in patients with more than one toe involved by gangrene. In this operation all of the toes and the ball of the foot is removed. After minor amputations the wound is not always closed completely with stitches. It is possible to walk virtually normally after losing toes. Even after a forefoot amputation where all the toes are removed, walking is usually straightforward. This sort of operation is performed frequently for foot infections in patients with diabetes. Major Amputations Major amputations are amputations where part of the leg is removed. These are usually below the knee or above the knee. A major amputation wound is almost always closed with stitches or staples. A major amputation will take approximately 60-90 minutes to perform. B.1 Above knee amputations In this operation the bone in the thigh (femur) is divided about 12-15 cm above the knee joint and the muscle and skin closed over the end of the bone.

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B.2 Below knee amputations This operation can be performed using 2 major techniques. The most common technique is the posterior myoplastic flap (Burgess Technique) where the skin and muscle from the calf are brought forward to cover the shin bones after they have been divided. The other main technique is the skew flap (Kingsley Robinson technique) in which the muscles of the calf are brought forward in the same way as in the posterior technique but the skin flaps are skewed in relation to the muscle. There is no proven advantage for one technique, but sometimes it is easier to perform a skew flap amputation if there has been significant skin damage above the ankle. The bone in the lower leg (tibia) is divided about 12-15 cm below the knee joint. This produces a good size stump to which prosthesis can be fitted. 2. Reasons for Amputation A. Diabetic gangrene A gangrene (a death tissue generally with loss of vascular (nutritive) supply and followed by bacterial invasion and putrefaction.), usually involving the lower extremities, that develops secondary to sensory peripheral neuropathy and peripheral vascular disease complications related to the diabetic disease process. B. Tissue Necrosis When body tissue dies, infection can set in, causing dangerous conditions such as gangrene. C. Neoplasm It is an abnormal mass of tissue as a result of neoplasia. Neoplasia is the abnormal proliferation of cells. The growth of the cells exceeds, and is uncoordinated with that of the normal tissues around it. The growth persists in the same excessive manner even after cessation of the stimuli. It usually causes a lump or tumor. Neoplasms may be benign, pre-malignant (carcinoma in situ) or malignant (cancer).

D. Infection The infection sites provide a stronghold to dangerous bacteria, which can spread to other parts of the body. E. Tissue Trauma Car accidents, severe burns and gunshot wounds are all possible causes of traumatic injury. Blood vessels and other body tissue components can be ripped or shredded beyond repair by these types of injuries, leaving no other option but amputation. In the age group of 50 and younger, traumatic injury is the leading cause of amputation.

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Nursing Management A. Relieve pain Pain may be caused by inflammation, infection, pressure on a bony prominence or hematoma. Surgical pain can be effectively controlled with opioid analgesics that may be accompanied with evacuation of a hematoma or accumulated fluid. Changing the patients position or placing a light sandbag on the residual limb to counteract the muscle spasm may improve the patients level of comfort. Evaluation of the patients pain and responses to interventions is an important component of pain management. B. Minimizing altered sensory perceptions When a patient describes phantom pains or secretions, the nurse acknowledges these feelings as real and encourages the patient to verbalize when in pain so that effective treatment may be given. Keep the patient active to decrease occurrence of phantom limb pain. Early intensive rehabilitation and residual desensitization with kneading massage bring relief.

Distraction techniques and activity are help. Local anesthetic may provide relief for some patients Beta-blockers may relieve dull, burning discomfort Antiseizure medications control stabbing and cramping pain Tricyclic antidepressants may not only alleviate phantom pain, they may also be prescribed to improve mood and coping ability

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Promote wound healing The residual limb must be handled gently. Whenever dressing is changed, aseptic technique is required to prevent wound infection and possible osteomyelitis. Residual limb shaping is important for prosthesis fitting The nurse instructs the patient and family to apply elastic wraps on the residual limb. Using ace wraps on the residual limb is discouraged because they may apply inconsistent pressure on the residual limb, causing problem with shaping it to fit a prosthetic. Patient is instructed how to care for the residual limb after the incision.

D. Resolve grieving The patients behavior and expressed feelings reveal how the patient is coping with the loss and working through the grieving process. The nurse creates an accepting and supportive atmosphere in which the patient and family are encouraged to express and share their feelings and work through the grief process. Support from family and friends promote the patients acceptance of the loss. The nurse helps the patient deal with immediate needs and become oriented to realistic rehabilitation goals and future independent functioning. Mental health and support group referrals may be appropriate. E. Promote independent self-care The patient is encouraged to be an active participant in self-care. Patient needs time to accomplish these tasks and must not be rushed. Practicing an activity with consistent, supportive supervision in a relaxed environment enables the patient to learn self-care skills. The patient and the nurse need to maintain positive attitudes and to minimize fatigue and frustration during the learning process. Independence in dressing, toileting, and bathing depends on balance, transfer abilities and physiologic tolerance of the activities. The nurse works with the physical therapist and occupational therapist to teach and supervise the patient in self-care abilities. Assistance is provided only when needed The nurse encourages the patient to learn to do these tasks, using assistive feeding and dressing aids when needed. The nurse, therapists and prosthetist works with the patient to achieve maximum independence. Helping achieve physical mobility Proper positioning prevents the development of hip or knee joint contracture in the patient with a lower extremity amputation. Abduction, external rotation and flexion of the lower extremity are avoided. The residual limb may be placed in an extended position or elevated for a brief period after surgery. The nurse encourages the patient to turn from side to side and to assume a prone position. The patient is encouraged not to sit for long periods of time to prevent flexion contracture. The legs should remain close together to prevent an abduction deformity. The nurse encourages the patient to use assistive devices to more readily perform self-care activities and identify what home modifications should be made. Postoperative ROM exercises should are started early because contracture deformities may develop rapidly

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Complications A. Phantom limb pain These sensations are normal and are felt immediately after surgery and their frequency gradually decrease over the next 2 years. Phantom pain is a form of central pain. The client reports actual pain. It is thought to be a combination of physiologic and psychological components. Phantom pain often occurs most often in clients who had pain in the limb before the amputation. B. Infections Open wounds and soft tissue have high incidence of infection. A wound from amputation usually results from the impact of severe external forces. Devitalized and contaminated tissue is an ideal medium for many common pathogens. C. Fat emboli

Fat embolism syndrome (FES) is a major cause of delayed recovery and mortality after an amputation. The mechanical theory of FES origin describes the release of fat globules from the bone marrow into the venous circulation after the amputation, particularly amputation of the long bones. A biochemical or metabolic theory suggests that trauma leads to the release of fatty acids and neutral fats. Platelet aggregation and fat formation then occur. Open Forum/ Evaluation