MUSCULOSKELETAL

SYSTEM
MODULE I
NURSING 105: ADULT NURSING
Myrna Williamson, MSN, RN, OCN
 In the very young…
• The skeleton is
composed of mostly
cartilage and is
therefore, pliable with
a decreased
incidence of bone
fractures and
breakage in childhood
Mature Bone
• Rigid connective
tissue consisting of
cells;
– Collagen
– Calcium
– Phosphate
 SKELETON

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.
 SKELETON

• AXIAL PORTION
– Cranium
– Vertebrae
– Ribs
• APPENDICULAR
PORTION
– Limbs
– Shoulders
– Hips
 ANATOMY & PHYSIOLOGY
REVIEW
• Structure & Function
– Skeletal System
• Bone Formation, Maintenance, Healing
– Articular System
• Joints – synarthrosis, amphiarthrosis, & diarthrosis
– Skeletal Muscle System
• Contraction
• Tone
• Actions
• Exercise, Disuse, & Repair
Bone Cells

Osteogenic Cells
Osteoblasts
Osteocytes
Osteoclasts
Bone Formation & Maintenance
• Ossification
• Resorption &
Formation
– Local stress
– Vit. D
– Parathyroid hormone
– Calcitonin
– Blood supply
 TYPES OF BONES

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.
 SPONGY BONE

• Located in the ends of long bones and the

center of flat and irregular bones
• Can withstand forces applied in many
directions
 DENSE (COMPACT) BONE

• Covers spongy bone

• Cylinder around a central marrow cavity
• Can withstand force predominantly in one
direction
SPONGY BONE AND COMPACT
BONE

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.
 FUNCTIONS OF BONE
• Framework • Protects Organs
• Support • Storage
• Movement • Hematopoiesis
• Shape • Remodeling
• Maintain Position • Reformation
• Attachment of • Movable Joints
Muscles
 CHARACTERISTICS OF
JOINTS
• Allow the movement
between bones
• Formed where two
bones join
• Surfaces are covered
with cartilage
• Enclosed in a capsule
 Classification of Joints
• A-C; Synarthrotic
(immovable) &
amphiarthrotic
(slightly movable)
joints.
• D-E: Diarthrodial
(freely movable) joints
Types of Diarthrodial Joints

• Hinge
• Ball &
Socket
• Pivot
• Condyloid
• Saddle
• Gliding
 SYNOVIAL JOINT

From Applegate E: The Anatomy and Physiology Learning System, ed. 2, Philadelphia, 2000,
W.B. Saunders.
SYNOVIAL JOINT OF THE
KNEE

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.
ANTERIOR VIEW OF MAJOR
MUSCLES

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.
 POSTERIOR VIEW OF
MAJOR MUSCLES

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.
SKELETAL MUSCLE

From Herlihy, B. &

Maebius, N. (2000).
The human body in
health and illness.
Neuromuscular Junction
 CHARACTERISTICS OF
MUSCLES
• Made up of bundles of muscle fibers
• Provide the force to move bones
• Assist in maintaining posture
• Assist with heat production
 4 Steps of Muscle Contraction
• Excitation
• Coupling
• Contraction
• Relaxation
 Body Movements
• Flexion • Pronation
• Extension • Inversion
• Abduction • Eversion
• Adduction • Protraction
• Rotation • Retraction
• Circumduction
• Supination
 Age Related Changes of
Musculoskeletal System
• Bones
• Muscles
• Joints
• Ligaments
 Nursing Assessment
• Health History
– Initial Interview
– Assessment Data
• Pain
• Altered Sensations
 Nursing Assessment
• Physical Assessment
– Posture
– Gait
– Bone Integrity
– Joint Function
– Muscle Strength & Size
– Skin
– Neurovascular Status
 RISK FACTORS
• Autoimmune disorders
• Calcium deficiency
• Degenerative conditions
• Falls
• Hyperuricemia
• Infection
 RISK FACTORS (Continued)
• Medications
• Metabolic disorders
• Neoplastic disorders
• Obesity
• Postmenopausal
states
• Trauma and injury
 Diagnostic Evaluation
• Imaging Procedures
– X-ray
– Computed Tomography
(CT)
– Magnetic Resonance
Imaging (MRI)
– Arthrography
– Bone Densitometry
 Diagnostic Evaluation
• Nuclear Studies • Laboratory Studies
– Bone Scan – (CBC)
• Endoscopic Studies – Urinalysis (Calcium)
– Arthroscopy – Blood Chemistry
• Other Studies – Serum Calcium
– Arthrocentesis – Serum Phosphate
– Electromyography – Uric Acid
– Biopsy – Serum Creatinine
– LDH, SGOT, CPK
 X-RAYS

• DESCRIPTION
• IMPLEMENTATION
 ARTHROCENTESIS
• DESCRIPTION
• IMPLEMENTATION
 ARTHROGRAM

• DESCRIPTION
• IMPLEMENTATION

Arthrogram of the Knee

 ARTHROSCOPY

• DESCRIPTION
• IMPLEMENTATION
 BONE SCAN

• DESCRIPTION
• IMPLEMENTATION
 BONE OR MUSCLE BIOPSY

• DESCRIPTION
• IMPLEMENTATION

Muscle Biopsy Showing

Polymyositis
ELECTROMYOGRAPHY
(EMG)

From Mourad LA (1991) Orthopedic disorders. St. Louis: Mosby.

 MYELOGRAM

From Herlihy B, Maebius NK: The human body in health and illness, Philadelphia, 2000,
W.B. Saunders.
 MUSCULOSKELETAL INJURIES
• Skeletal Trauma
• Injuries to Support
Structures
 Fractures
• Described according
to location and type
 Types of Fractures
• Complete or
Incomplete
• Open (formerly
referred to as
compound)
• Closed (formerly
referred to as simple)
 Complete Fractures
• Linear
• Oblique
• Transverse
• Spiral
 Complete Fractures
• Comminuted
• Impacted
• Pathologic
• Avulsion
 Complete Fractures
• Compression
• Displaced
• Extracapsular
• Intracapsular
 Incomplete Fractures
• Greenstick
• Torus
• Bowing fracture
• Transchondral fracture
• Stress Fractures
TYPES OF FRACTURES

From Ignativicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia:

W.B. Saunders.
Types of Fractures
 Pathophysiology of a Fracture
• Tissue Disrupted
• Bleeding Occurs
• Hematoma Forms
• Bone Tissue
 Healing of a Fracture
• Inflammatory
response
• Vascular tissue
• Bone-forming cells
• Callus formation
• Osteoblasts
• Remodeling
 Speed of Healing
• Hematoma formation – within hours
• Procallus – within days
• Callus formation – within weeks
• Replacement and remodeling – up
to 4 years
Fractures – Clinical Manifestations
• Impaired function
• Deformity (unnatural
alignment)
• Swelling
• Muscle spasm
• Tenderness
• Pain
• Impaired sensation
 FRACTURE OF AN
EXTREMITY
• ASSESSMENT
• INITIAL CARE
 INTERVENTIONS FOR A
FRACTURE
• Reduction
• Fixation
• Traction
• Casts
 Fractures - Treatment
• Reduction
– Closed manipulation
– Traction (skin or skeletal)
– Open reduction and internal fixation (ORIF),
(insertion of prosthesis, screw, plate, nail or
wire).
 CLOSED REDUCTION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia:
W.B. Saunders.
 INTERNAL FIXATION

From Browner BB et al (1992) Skeletal trauma. Philadelphia: W.B. Saunders.

Types of Internal Fixation for a Hip
Fracture
 EXTERNAL FIXATION

From Ignatavicius, D., Workman, M. (2002). Medical-surgical nursing, ed 3, Philadelphia: W.B.

Saunders. Courtesy of Smith and Nephew, Inc., Orthopedics Division, Memphis, TN.
 TYPES OF HIP FRACTURES
• Intracapsular
• Extracapsular
 HIP REPLACEMENTS

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St.
Louis: Mosby. Courtesy of Zimmer, Inc., Warsaw, IN.
TOTAL HIP REPLACEMENT

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.
 HIP FRACTURE
• POSTOPERATIVE
CARE
• CLIENT EDUCATION
TOTAL KNEE REPLACEMENT
• DESCRIPTION
• POSTOPERATIVE
CARE
 KNEE PROSTHESIS

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.
CONTINUOUS PASSIVE MOTION
CASTS
 Cast Care
• Educate
• Apply Ice
• Instruct
• Prevent
• Attend
 TRACTION
• DESCRIPTION
• IMPLEMENTATION
 SKELETAL TRACTION

• DESCRIPTION
• IMPLEMENTATION
 SKIN TRACTION
• DESCRIPTION
– Traction applied by the
use of elastic
bandages or adhesive

Side Arm
CERVICAL SKIN TRACTION

From James, S. Ashwill, R., & Droske, S. (2002). Nursing care of children, ed 2,
Philadelphia: W.B. Saunders.
HEAD HALTER TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
BUCK’S SKIN TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
PELVIC SKIN TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
BALANCED SUSPENSION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical

nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.
DUNLOP’S SKIN TRACTION

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
 COMPLICATIONS OF
FRACTURES
• Fat embolism
• Compartment syndrome
• Infection and osteomyelitis
• Avascular necrosis
• Pulmonary emboli
• Venous thrombosis
• Delayed union & nonunion
 FAT EMBOLISM
• DESCRIPTION
• ASSESSMENT
• IMPLEMENTATION
COMPARTMENT SYNDROME
 INFECTION AND
OSTEOMYELITIS
• DESCRIPTION
• ASSESSMENT
• IMPLEMENTATION
 AVASCULAR NECROSIS
• DESCRIPTION

• ASSESSMENT

• IMPLEMENTATION
 PULMONARY EMBOLISM
• DESCRIPTION
– Caused by immobility precipitated by a
fracture
 Venous Thrombosis
• Description
• Assessment
• Implementation
 Delayed Union & Nonunion
• Description
• Assessment
• Implementation
 Other Skeletal Trauma
• Dislocation
• Subluxation
• Injuries to Support Structures
– Tendon tear
– Ligament tear
– Strain
– Sprain
– Avulsion
– Tendonitis
– Bursitis
Soft Tissue Injury of Hip
CARPAL TUNNEL SYNDROME
Associated with
occupations that
require
continuous wrist
movement.
 Sports-Related Injuries
• Rotator Cuff Tears
• Epicondylitis (Tennis Elbow)
• Lateral & Medial Collateral Ligament Injury
• Anterior & Posterior Cruciate Ligament
Injury
• Meniscal Injuries
• Rupture of Achilles Tendon
CRUTCH WALKING
 CRUTCH GAITS

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
SINGLE- AND QUAD-FOOT
CANES

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.
WALKERS
 HERNIATION:
INTERVERTEBRAL DISC
CERVICAL DISC

CERVICAL COLLAR
 LUMBAR DISC

• DESCRIPTION
• IMPLEMENTATION
 LOW BACK CARE

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.
 TYPES OF DISC SURGERY
• CHEMOLYSIS
• DISCECTOMY
• DISCECTOMY WITH
FUSION
• LAMINOTOMY
• LAMINECTOMY
 DISC SURGERY
• PREOPERATIVE
• POSTOPERATIVE: CERVICAL DISC
• POSTOPERATIVE: LUMBAR DISC
 AMPUTATION OF A LOWER
EXTREMITY
• DESCRIPTION
– The surgical removal
of a lower limb or part
of the limb
 AMPUTATION FLAPS

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.
 AMPUTATION OF A LOWER
EXTREMITY
• POSTOPERATIVE
– Monitor vital signs
– Monitor for infection and hemorrhage
– Mark bleeding and drainage on the dressing if
it occurs
– Keep a tourniquet at the bedside
– Monitor for pulmonary emboli
 STUMP WRAPPING

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.
BELOW-THE-KNEE AMPUTATION
• POSTOPERATIVE
– Prevent edema
– Do not allow the stump to hang over the edge
of the bed
– Do not allow the client to sit for long periods of
time to prevent contractures
 ABOVE-THE-KNEE
AMPUTATION
• POSTOPERATIVE
– Prevent internal or external rotation of the
limb
– Place a sandbag or rolled towel along the
outside of the thigh to prevent rotation
 DISORDERS OF BONE
• Metabolic Bones Diseases
• Infectious Bone Disease
• Bone Tumors
 Infectious Bone Disease:
Osteomyelitis
• Difficult to treat
• Physical disability
• Bacteria
– Exogenous
– Endogenous
 OSTEOMYELITIS
• DESCRIPTION
• ASSESSMENT
• IMPLEMENTATION
 Bone Tumors
• Incidence
• Signs & Symptoms
• Diagnosis
 DISORDERS OF JOINTS
• Noninflammatory joint
disease
• Inflammatory joint
disease
INFLAMMATORY JOINT DISEASE
• Rheumatoid arthritis
• Ankylosing
Spondylitis
• Gouty arthritis
 RHEUMATOID ARTHRITIS
(RA)
• DESCRIPTION
• ASSESSMENT
 RHEUMATOID ARTHRITIS

BOUTONNIERE DEFORMITY

MUSCLE ATROPHY
SWAN NECK DEFORMITY
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.
 RHEUMATOID NODULE

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.
 RHEUMATOID ARTHRITIS
(RA)
• NONSTEROIDAL
ANTIINFLAMMATORY
DRUGS (NSAIDs)
• CORTICOSTEROIDS
• ANTINEOPLASTIC
MEDICATIONS
• GOLD SALTS
 RHEUMATOID ARTHRITIS
(RA)
• PHYSICAL MOBILITY
• SELF-CARE
 RHEUMATOID ARTHRITIS
(RA)
• FATIGUE
• BODY IMAGE
DISTURBANCE
 RHEUMATOID ARTHRITIS (RA)
SURGICAL INTERVENTIONS

• SYNOVECTOMY
• ARTHRODESIS
• JOINT REPLACEMENT
(ARTHROPLASTY)
 Ankylosing Spondylitis
• Chronic Inflammatory Disease
• Systemic autoimmune disease
• Differs from RA
• Signs & Symptoms
• Treatment
 GOUTY JOINT
• Description
• Phases
• Assessment
• Implementation
 GOUT

From Clinical Slide Collection of the Rheumatic Diseases, © 1991,1995,1997.

Used with permission of the American College of Rheumatology.
 Noninflammatory Joint Disease
• Degenerative joint
disease
(osteoarthritis) is the
most common
 OSTEOARTHRITIS
• DESCRIPTION
– Also known as
degenerative joint
disease (DJD)

JOINT CHANGES IN OSTEOARTHRITIS

 OSTEOARTHRITIS

HEBERDEN’S NODES

SEVERE OSTEOARTHRITIS

From Kamal A, Brockelhurst J: Color atlas of geriatric medicine, ed. 2, St. Louis, 1991, Mosby.

BOUCHARD’S NODES
 OSTEOARTHRITIS
• PHYSICAL MOBILITY
 OSTEOARTHRITIS
SURGICAL INTERVENTIONS
• OSTEOTOMY
• TOTAL JOINT
REPLACEMENT
(TJR)
 RHEUMATOID ARTHRITIS
AND OSTEOARTHRITIS
CLIENT EDUCATION
• Assist
• Instruct
• Review
 Metabolic Bone Diseases
• Osteoporosis
• Osteomalacia
• Paget’s Disease
OSTEOPOROSIS

DOWAGER’S HUMP
OSTEOPOROTIC CHANGES

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.
SEVERE OSTEOPOROSIS

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.
 MILWAUKEE BRACE

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.
 OSTEOMALACIA
• Metabolic disease
• Bone volume unchanged
• Osteomalacia – adults
• Rickets - children
 Paget’s Disease
• Osteitis Deformans
• Increased metabolic activity
• Usually no TX
• Affects men and women equally
 Nursing Diagnoses
• Knowledge Deficit
• Impaired Physical Mobility
• Self-care Deficit
• Risk for Infection
• Impaired Skin Integrity
• Imbalanced Nutrition
• Acute/Chronic Pain
THE END OF MUSCULOSKELETAL