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MUSCULO-SKELETAL

SYSTEM

Nurse Licensure Examination
Review
Review of Anatomy and
Physiology
 The musculo-skeletal system consists
of the muscles, tendons, bones and
cartilage together with the joints
 The primary function of which is to
produce skeletal movements
Muscles
Three types of muscles exist in the body
 1. Skeletal Muscles
 Voluntary and striated
 2. Cardiac muscles
 Involuntary and striated
 3. Smooth/Visceral muscles
 Involuntary and NON-striated
TENDONS
 Bands of fibrous connective tissue that
tie bones to muscles
LIGAMENTS
 Strong, dense and flexible bands of
fibrous tissue connecting bones to
another bone
BONES
 Variously classified according to shape,
location and size
 Functions

1. Locomotion
2. Protection
3. Support and lever
4. Blood production
5. Mineral deposition
JOINTS
 The
part of the Skeleton where two or
more bones are connected
CARTILAGES
A dense connective tissue that consists
of fibers embedded in a strong gel-like
substance
BURSAE
 Saccontaining fluid that are located
around the joints to prevent friction
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
The nurse usually evaluates
this small part of the over-all
assessment and concentrates
on the patient’s posture, body
symmetry, gait and muscle and
joint function
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
 1. HISTORY
 2. Physical Examination
 Perform a head to toe assessment
 Nurses need to inspect and palpate
 The special procedure is the
assessment of joint and muscle
movement
 Usually, a tape measure and a
protractor are the only instruments
ASSESSMENT OF THE
MUSCULO-SKELETAL SYSTEM
 Gait
 Posture
 Muscular palpation
 Joint palpation
 Range of motion
 Muscle strength
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
 1. BONE MARROW ASPIRATION
 Usually involves aspiration of the marrow to
diagnose diseases like leukemia, aplastic
anemia
 Usual site is the sternum and iliac crest
 Pre-test: Consent
 Intratest: Needle puncture may be painful
 Post-test: maintain pressure dressing and
watch out for bleeding
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
 2. Arthroscopy
 A direct visualization of the joint cavity
 Pre-test: consent, explanation of
procedure, NPO
 Intra-test: Sedative, Anesthesia, incision
will be made
 Post-test: maintain dressing,
ambulation as soon as awake, mild
soreness of joint for 2 days, joint rest
for a few days, ice application to relieve
discomfort
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
3. BONE SCAN
 Imaging study with the use of a contrast
radioactive material
 Pre-test: Painless procedure, IV radioisotope is
used, no special preparation, pregnancy is
contraindicated
 Intra-test: IV injection, Waiting period of 2 hours
before X-ray, Fluids allowed, Supine position for
scanning
 Post-test: Increase fluid intake to flush out
radioactive material
ASSESMENT OF THE
MUSCULO-SKELETAL SYSTEM
LABORATORY PROCEDURES
4. DXA- Dual-energy XRAY absorptiometry
 Assesses bone density to diagnose
osteoporosis
 Uses LOW dose radiation to measure bone
density
 Painless procedure, non-invasive, no special
preparation
 Advise to remove jewelry
Common musculoskeletal
problems

The Nursing Management
Nursing Management of common musculo-
skeletal problems
PAIN
 These can be related to joint inflammation,
traction, surgical intervention
 1. Assess patient’s perception of pain
 2. Instruct patient alternative pain
management like meditation, heat and cold
application, TENS and guided imagery
Nursing Management
PAIN
 3. Administer analgesics as prescribed
 UsuallyNSAIDS
 Meperidine can be given for severe pain

 4.
Assess the effectiveness of pain
measures
Nursing Management
IMPAIRED PHYSICAL MOBILITY
 1. Instruct patient to perform range of motion
exercises, either passive or active
 2. Provide support in ambulation with
assistive devices
 3. Turn and change position every 2 hours
 4. Encourage mobility for a short period and
provide positive reinforcements for small
accomplishments
Nursing Management
SELF-CARE DEFICITS
 1. Assess functional levels of the patient
 2. Provide support for feeding problems
 Place patient in Fowler’s position
 Provide assistive device and supervise
mealtime
 Offer finger foods that can be handled by
patient
 Keep suction equipment ready
Nursing Management
SELF-CARE DEFICITS
 3. Assist patient with difficulty bathing
and hygiene
 Assist with bath only when patient has
difficulty
 Provide ample time for patient to finish
activity
Musculoskeletal Modalities
Traction
Cast
Nursing Management
Traction
 A method of fracture immobilization by
applying equipments to align bone
fragments
 Used for immobilization, bone
alignment and relief of muscle spasm
Traction
 Skin traction

 Skeletal traction
Traction
 Pulling
force exerted on bones to
reduce or immobilize fractures,
reduce muscle spasm, correct or
prevent deformities
Nursing Management
Traction: General principles
 1. ALWAYS ensure that the weights hang
freely and do not touch the floor
 2. NEVER remove the weights
 3. Maintain proper body alignment
 4. Ensure that the pulleys and ropes are
properly functioning and fastened by tying
square knot
Nursing Management
Traction: General principles
 5. Observe and prevent foot drop
 Provide foot plate
 6. Observe for DVT, skin irritation and
breakdown
 7. Provide pin care for clients in skeletal
traction- use of hydrogen peroxide
Nursing Management
CAST
 Immobilizing tool made of plaster of
Paris or fiberglass
 Provides immobilization of the fracture
Nursing Management
CAST: types
2. Long arm
3. Short arm
4. Spica
Casting Materials
 Plaster of Paris
 Drying takes 1-3 days
 If dry, it is SHINY, WHITE, hard and
resistant
 Fiberglass
 Lightweight and dries in 20-30 minutes
 Water resistant
Nursing Management
CAST: General Nursing Care
 1. Allow the cast to dry (usually 24-72
hours)
 2. Handle a wet cast with the
PALMS not the fingertips
 3. Keep the casted extremity
ELEVATED using a pillow
 4. Turn the extremity for equal
drying. DO NOT USE DRYER for
plaster cast
Nursing Management
CAST: General Nursing Care
5. Petal the edges of the cast to
prevent crumbling of the edges
6. Examine the skin for
pressure areas and Regularly
check the pulses and skin
Nursing Management
CAST: General Nursing Care
7. Instruct the patient not to
place sticks or small objects
inside the cast
8. Monitor for the following: pain,
swelling, discoloration, coolness,
tingling or lack of sensation and
diminished pulses
Common Musculoskeletal
conditions

Nursing management
METABOLIC BONE
DISORDERS
Osteoporosis
 A disease of the bone characterized by
a decrease in the bone mass and
density with a change in bone structure
METABOLIC BONE
DISORDERS
Osteoporosis: Pathophysiology
 Normal homeostatic bone turnover is
altered rate of bone RESORPTION is
greater than bone FORMATION
reduction in total bone mass
reduction in bone mineral density
prone to FRACTURE
METABOLIC BONE
DISORDERS
Osteoporosis: TYPES
 1. Primary Osteoporosis- advanced
age, post-menopausal
 2. Secondary osteoporosis- Steroid
overuse, Renal failure
METABOLIC BONE
DISORDERS
RISK factors for the development of
Osteoporosis
 1. Sedentary lifestyle
 2. Age
 3. Diet- caffeine, alcohol, low Ca and Vit D
 4. Post-menopausal
 5. Genetics- caucasian and asian
 6. Immobility
METABOLIC DISORDER
ASSESSMENT FINDINGS
 1. Low stature
 2. Fracture
 Femur

 3. Bone pain
METABOLIC DISORDER
LABORATORY FINDINGS
 1. DEXA-scan
 Provides information about bone mineral
density
 T-score is at least 2.5 SD below the young
adult mean value
 2. X-ray studies
METABOLIC DISORDER
Medical management of Osteoporosis
 1. Diet therapy with calcium and Vitamin D
 2. Hormone replacement therapy
 3. Biphosphonates- Alendronate, risedronate
produce increased bone mass by inhibiting
the OSTEOCLAST
 4. Moderate weight bearing exercises
 5. Management of fractures
METABOLIC DISORDER
Osteoporosis Nursing Interventions
1. Promote understanding of osteoporosis and
the treatment regimen
 Provide adequate dietary supplement of
calcium and vitamin D
 Instruct to employ a regular program of
moderate exercises and physical activity
 Manage the constipating side-effect of
calcium supplements
METABOLIC DISORDER
Osteoporosis Nursing Interventions
 Take calcium supplements with meals
 Take alendronate with an EMPTY
stomach with water
 Instruct on intake of Hormonal
replacement
METABOLIC DISORDER
Osteoporosis Nursing Interventions
2. Relieve the pain
 Instruct the patient to rest on a firm
mattress
 Suggest that knee flexion will cause
relaxation of back muscles
 Heat application may provide comfort
 Encourage good posture and body
mechanics
 Instruct to avoid twisting and heavy lifting
METABOLIC DISORDER
Osteoporosis Nursing Interventions
 3. Improve bowel elimination
 Constipation is a problem of calcium
supplements and immobility
 Advise intake of HIGH fiber diet and
increased fluids
METABOLIC DISORDER
Osteoporosis Nursing Interventions
 4. Prevent injury
 Instruct to use isometric exercise to
strengthen the trunk muscles
 AVOID sudden jarring, bending and
strenuous lifting
 Provide a safe environment
Juvenile rheumatoid Arthritis
 Definition:
 AUTO-IMMUNE inflammatory joint disorder
of UNKNOWN cause
 SYSTEMIC chronic disorder of connective
tissue

 Diagnosed BEFORE age 16 years old
Juvenile rheumatoid Arthritis
 PATHOPHYSIOLOGY : unknown

 Affected by stress, climate and genetics

 Common in girls 2-5 and 9-12 y.o.
Juvenile rheumatoid Arthritis
Systemic JRA Pauci-articular Polyarticular

FEVER MILD joint pain Morning joint
and swelling stiffness and
fever
Salmon-pink IRIDOCYCLITIS Weight
rash Bearing joints
Five or more Less than 4 Five or more
joints joints joints
Anorexia, Very Good Poor prognosis
anemia, fatigue prognosis
JRA
 Symptoms may decrease as child
enters adulthood
 With periods of remissions and
exacerbations
JRA
Medical Management
 ASPIRIN and NSAIDs- mainstay
treatment
 Slow-acting anti-rheumatic drugs
 Corticosteroids
JRA
Nursing Management
2. Encourage normal performance of
daily activities
3. Assist child in ROM exercises
4. Administer medications
5. Encourage social and emotional
development
JRA
Nursing Management
During acute attack:
 SPLINT the joints
 NEUTRAL positioning
 Warm or cold packs
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS
 The most common form of degenerative
joint disorder
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS
 Chronic, NON-systemic disorder of
joints
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Pathophysiology
 Injury, genetic, Previous joint
damage, Obesity, Advanced age 
Stimulate the chondrocytes to
release chemicals chemicals will
cause cartilage degeneration,
reactive inflammation of the synovial
lining and bone stiffening
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Risk factors
 1. Increased age
 2. Obesity
 3. Repetitive use of joints with previous
joint damage
 4. Anatomical deformity
 5. genetic susceptibility
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
 1. Joint pain
 2. Joint stiffness
 3. Functional joint impairment limitation
 The joint involvement is ASYMMETRICAL
 This is not systemic, there is no FEVER, no
severe swelling
 Atrophy of unused muscles
 Usual joint are the WEIGHT bearing joints
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
1. Joint pain
 Caused by
 Inflamed synovium
 Stretching of the joint capsule

 Irritation of nerve endings
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Assessment findings
2. Stiffness
 commonly occurs in the morning after
awakening
 Lasts only for less than 30 minutes
 DECREASES with movement
 Crepitation may be elicited
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Diagnostic findings
1. X-ray
 Narrowing of joint space
 Loss of cartilage
 Osteophytes
2. Blood tests will show no evidence of
systemic inflammation and are not
useful
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Medical management
 1. Weight reduction
 2. Use of splinting devices to support joints
 3. Occupational and physical therapy
 4. Pharmacologic management
 Use of PARACETAMOL, NSAIDS

 Use of Glucosamine and chondroitin

 Topical analgesics

 Intra-articular steroids to decrease inflam
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Nursing
Interventions
 1. Provide relief of PAIN
 Administer prescribed analgesics
 Application of heat modalities. ICE
PACKS may be used in the early acute
stage!!!
 Plan daily activities when pain is less
severe
 Pain meds before exercising
DEGENERATIVE JOINT
DISEASE
OSTEOARTHRITIS: Nursing
Interventions
 2. Advise patient to reduce weight
 Aerobic exercise
 Walking

 3. Administer prescribed medications
 NSAIDS
Rheumatoid arthritis
A type of chronic systemic inflammatory
arthritis and connective tissue disorder
affecting more women (ages 35-45)
than men
Rheumatoid arthritis
FACTORS:
Genetic
Auto-immune connective tissue disorders
Fatigue, emotional stress, cold, infection
Rheumatoid arthritis
Pathophysiology
 Immune reaction in the synovium 
attracts neutrophils  releases
enzymes  breakdown of collagen 
irritates the synovial liningcausing
synovial inflammation edema and
pannus formation and joint erosions
and swelling
Rheumatoid arthritis
ASSESSMENT FINDINGS
 1. PAIN
 2. Joint swelling and stiffness-
SYMMETRICAL, Bilateral
 3. Warmth, erythema and lack of
function
 4. Fever, weight loss, anemia, fatigue
 5. Palpation of join reveals spongy tissue
 6. Hesitancy in joint movement
Rheumatoid arthritis
ASSESSMENT FINDINGS
 Joint involvement is SYMMETRICAL
and BILATERAL
 Characteristically beginning in the
hands, wrist and feet
 Joint STIFFNESS occurs early morning,
lasts MORE than 30 minutes, not
relieved by movement, diminishes as
the day progresses
Rheumatoid arthritis
ASSESSMENT FINDINGS
 Joints are swollen and warm
 Painful when moved
 Deformities are common in the hands
and feet causing misalignment
 Rheumatoid nodules may be found
in the subcutaneous tissues
Rheumatoid arthritis
Diagnostic test
 1. X-ray
 Shows bony erosion
 2. Blood studies reveal (+)
rheumatoid factor, elevated ESR and
CRP and ANTI-nuclear antibody
 3. Arthrocentesis shows synovial fluid
that is cloudy, milky or dark yellow
containing numerous WBC and
inflammatory proteins
Rheumatoid arthritis
MEDICAL MANAGEMENT
 1. Therapeutic dose of NSAIDS and
Aspirin to reduce inflammation
 2. Chemotherapy with methotrexate,
antimalarials, gold therapy and steroid
 3. For advanced cases- arthroplasty,
synovectomy
 4. Nutritional therapy
Rheumatoid arthritis
MEDICAL MANAGEMENT
GOLD THERAPY:
 IM or Oral preparation
 Takes several months (3-6) before
effects can be seen
 Can damage the kidney and causes
bone marrow depression
Rheumatoid arthritis
Nursing MANAGEMENT
1. Relieve pain and discomfort
 USE splints to immobilize the affected
extremity during acute stage of the
disease and inflammation to REDUCE
DEFORMITY
 Administer prescribed medications
 Suggest application of COLD packs during
the acute phase of pain, then HEAT
application as the inflammation subsides
Rheumatoid arthritis
Nursing MANAGEMENT
2. Decrease patient fatigue
Schedule activity when pain is
less severe
Provide adequate periods of rests
3. Promote restorative sleep
Rheumatoid arthritis
Nursing Management
4. Increase patient mobility
 Advise proper posture and body
mechanics
 Support joint in functional position
 Advise ACTIVE ROME
Rheumatoid arthritis
Nursing Management
5. Provide Diet therapy
 Patients experience anorexia,
nausea and weight loss
 Regular diet with caloric
restrictions because steroids
may increase appetite
 Supplements of vitamins, iron
and PROTEIN
Rheumatoid arthritis
6. Increase Mobility and prevent
deformity:
 Lie FLAT on a firm mattress
 Lie PRONE several times to
prevent HIP FLEXION contracture
 Use one pillow under the head
because of risk of dorsal kyphosis
 NO Pillow under the joints because
this promotes flexion contractures
Hot versus Cold
HOT Cold

Use to RELIEVE joint Use to control
stiffness, pain and inflammation and pain
muscle spasm
After acute attack ACUTE ATTACK
Gouty arthritis
A systemic disease caused by
deposition of uric acid crystals in the
joint and body tissues
 CAUSES:
 1. Primary gout- disorder of Purine
metabolism
 2. Secondary gout- excessive uric
acid in the blood like leukemia
Gouty arthritis
 ASSESSMENT FINDINGS
 1. Severe pain in the involved joints,
initially the big toe
 2. Swelling and inflammation of the joint
 3. TOPHI- yellowish-whitish,
irregular deposits in the skin that
break open and reveal a gritty
appearance
 4. PODAGRA
Gouty arthritis
ASSESSMENT FINDINGS
 5. Fever, malaise
 6. Body weakness and headache
 7. Renal stones
Gouty arthritis
DIAGNOSTIC TEST
 Elevated levels of uric acid in the blood
 Uric acid stones in the kidney
Gouty arthritis
 Medical management
 1. Allupurinol- take it WITH FOOD
 Rash signifies allergic reaction
 2. Colchicine
 For acute attack
Gouty arthritis
Nursing Intervention
1. Provide a diet with LOW purine
 Avoid Organ meats, aged and processed foods
 STRICT dietary restriction is NOT necessary

2. Encourage an increased fluid intake (2-
3L/day) to prevent stone formation
3. Instruct the patient to avoid alcohol
4. Provide alkaline ash diet to increase urinary
pH
5. Provide bed rest during early attack of gout
Gouty arthritis
Nursing Intervention
6. Position the affected extremity in mild
flexion
7. Administer anti-gout medication and
analgesics
Fracture
A break in the continuity of the bone
and is defined according to its type and
extent
Fracture
 Severe mechanical Stress to bone 
bone fracture
 Direct Blows
 Crushing forces
 Sudden twisting motion
 Extreme muscle contraction
Fracture
TYPES OF FRACTURE
 1. Complete fracture
 Involves a break across the entire cross-
section
 2. Incomplete fracture
 The break occurs through only a part of the
cross-section
Fracture
TYPES OF FRACTURE
 1. Closed fracture
 The fracture that does not cause a break in
the skin
 2. Open fracture
 The fracture that involves a break in the
skin
Fracture
TYPES OF FRACTURE
 1. Comminuted fracture
A fracture that involves production of
several bone fragments
 2. Simple fracture
A fracture that involves break of bone into
two parts or one
Fracture
ASSESSMENT FINDINGS
 1. Pain or tenderness over the involved area
 2. Loss of function
 3. Deformity
 4. Shortening
 5. Crepitus
 6. Swelling and discoloration
Fracture
ASSESSMENT FINDINGS
1. Pain
 Continuous and increases in severity
 Muscles spasm accompanies the
fracture is a reaction of the body to
immobilize the fractured bone
Fracture
ASSESSMENT FINDINGS
2. Loss of function
 Abnormal movement and pain can
result to this manifestation
Fracture
ASSESSMENT FINDINGS
3. Deformity
 Displacement, angulations or rotation of
the fragments Causes deformity
Fracture
ASSESSMENT FINDINGS
4. Crepitus
 A grating sensation produced when the
bone fragments rub each other
Fracture
 DIAGNOSTIC TEST
 X-ray
Fracture
EMERGENCY MANAGEMENT OF FRACTURE
 1. Immobilize any suspected fracture
 2. Support the extremity above and below
when moving the affected part from a vehicle
 3. Suggested temporary splints- hard board,
stick, rolled sheets
 4. Apply sling if forearm fracture is suspected
or the suspected fractured arm maybe
bandaged to the chest
Fracture
EMERGENCY MANAGEMENT OF
FRACTURE
 5. Open fracture is managed by
covering a clean/sterile gauze to
prevent contamination
 6. DO NOT attempt to reduce the
facture
Fracture
MEDICAL MANAGEMENT
 1. Reduction of fracture either open or
closed, Immobilization and Restoration
of function
 2. Antibiotics, Muscle relaxants and
Pain medications
Fracture
General Nursing MANAGEMENT
 For CLOSED FRACTURE
 1. Assist in reduction and immobilization
 2. Administer pain medication and muscle
relaxants
 3. teach patient to care for the cast
 4. Teach patient about potential complication
of fracture and to report infection, poor
alignment and continuous pain
Fracture
General Nursing MANAGEMENT
 For OPEN FRACTURE
 1. Prevent wound and bone infection
 Administer prescribed antibiotics
 Administer tetanus prophylaxis
 Assist in serial wound debridement
 2. Elevate the extremity to prevent edema
formation
 3. Administer care of traction and cast
Fracture
 FRACTURE COMPLICATIONS
 Early
 1. Shock
 2. Fat embolism
 3. Compartment syndrome
 4. Infection
 5. DVT
Fracture
 FRACTURE COMPLICATIONS
 Late
 1. Delayed union
 2. Avascular necrosis
 3. Delayed reaction to fixation devices
 4. Complex regional syndrome
Fracture
 FRACTURE COMPLICATIONS: Fat
Embolism
 Occurs usually in fractures of the long
bones
 Fat globules may move into the blood
stream because the marrow pressure is
greater than capillary pressure
 Fat globules occlude the small blood
vessels of the lungs, brain kidneys and
other organs
Fracture
 FRACTURE COMPLICATIONS: Fat
Embolism
 Onset is rapid, within 24-72 hours
 ASSESSMENT FINDINGS
 1. Sudden dyspnea and respiratory
distress
 2. tachycardia
 3. Chest pain
 4. Crackles, wheezes and cough
 5. Petechial rashes over the chest, axilla
and hard palate
Fracture
 FRACTURE COMPLICATIONS: Fat
Embolism
 Nursing Management
 1. Support the respiratory function
 Respiratory failure is the most common
cause of death
 Administer O2 in high concentration
 Prepare for possible intubation and
ventilator support
Fracture
 FRACTURE COMPLICATIONS: Fat
Embolism
 Nursing Management
 2. Administer drugs
 Corticosteroids
 Dopamine
 Morphine
Fracture
 FRACTURE COMPLICATIONS: Fat Embolism
 Nursing Management
 3. Institute preventive measures
 Immediate immobilization of fracture
 Minimal fracture manipulation
 Adequate support for fractured bone during
turning and positioning
 Maintain adequate hydration and electrolyte
balance
Fracture
 Early complication: Compartment
syndrome
 A complication that develops when
tissue perfusion in the muscles is less
than required for tissue viability
Fracture
 Early complication: Compartment syndrome
 ASSESSMENT FINDINGS
 1. Pain- Deep, throbbing and UNRELIEVED
pain by opiods
 Pain is due to reduction in the size of the
muscle compartment by tight cast
 Pain is due to increased mass in the
compartment by edema, swelling or
hemorrhage
Fracture
 Early complication: Compartment syndrome
 ASSESSMENT FINDINGS
 2. Paresthesia- burning or tingling sensation
 3. Numbness
 4. Motor weakness
 5. Pulselessness, impaired capillary refill
time and cyanotic skin
Fracture
 Early complication: Compartment
syndrome
 Medical and Nursing management
 1. Assess frequently the neurovascular
status of the casted extremity
 2. Elevate the extremity above the
level of the heart
 3. Assist in cast removal and
FASCIOTOMY
Strains

 Excessive stretching of a muscle or
tendon
 Nursing management
 1. Immobilize affected part
 2. Apply cold packs initially, then heat
packs
 3. Limit joint activity
 4. Administer NSAIDs and muscle
relaxants
Sprains
 Excessive stretching of the LIGAMENTS
 Nursing management
 1. Immobilize extremity and advise rest
 2. Apply cold packs initially then heat packs
 3. Compression bandage may be applied to
relieve edema
 4. Assist in cast application
 5. Administer NSAIDS