Musculoskeletal System

Assessment & Disorders

Dr Ibraheem Bashayreh, RN, PhD

 Skeletal System
 Bone types
 Bone structure
 Bone function
 Bone growth and metabolism affected by
calcium and phosphorous, calcitonin,
vitamin D, parathyroid, growth hormone,
glucocorticoids, estrogens and androgens,
thyroxine, and insulin.
Bones

 Human skeleton has 206 bones

 Provide structure and support for soft tissue
 Protect vital organs
Figure 41-1 Bones of the human skeleton.
Figure 41-2 Classification of bones by shape.
Bones
 Compact bone
◦ Smooth and dense
◦ Forms shaft of long bones and outside layer of
other bones
 Spongy bone
◦ Contains spaces
◦ Spongy sections contain bone marrow
Bone Marrow
 Red bone marrow
◦ Found in flat bones of sternum, ribs, and ileum
◦ Produces blood cells and hemoglobin
 Yellow bone marrow
◦ Found in shaft of long bones
◦ Contains fat and connective tissue
Joints (Articulations)
 Area where two or more bones meet
 Holds skeleton together while allowing
body to move
Joints
 Synarthrosis
◦ Immovable (e.g., skull)
 Amphiarthrosis
◦ Slightly movable (e.g., vertebral joints)
 Diarthrosis or synovial
◦ Freely movable (e.g., shoulders, hips)
Synovial Joints
 Found at all limb articulations
 Surface covered with cartilage
 Joint cavity covered with tough fibrous
capsule
 Cavity lined with synovial membrane and
filled with synovial fluid
Ligaments
 Bands of connective tissue that connect
bone to bone
 Either limit or enhance movement
 Provide joint stability
 Enhance joint strength
Tendons
 Fibrous connective tissue bands that
connect bone to muscles
 Enable bones to move when muscles
contract
Muscles
 Skeletal (voluntary)
◦ Allows voluntary movement
 Smooth (involuntary)
◦ Muscle movement controlled by internal
mechanism
◦ e.g., muscles in bladder wall and GI system
 Cardiac (involuntary)
◦ Found in heart
Skeletal Muscle
 600 skeletal muscles
 Made up of thick bundles of parallel fibers
 Each muscle fiber made up of smaller
structure myofibrils
 Myofibrils are strands of repeating units
called sarcomeres
Skeletal Muscle
 Skeletal muscle contracts with the release
of acetylcholine
 The more fibers that contract, the
stronger the muscle contraction
Changes in Older Adult
 Musculoskeletal changes can be due to:
◦ Aging process
◦ Decreased activity
◦ Lifestyle factors
Changes in Older Adult
 Loss of bone mass in older women
 Joint and disk cartilage dehydrates causing
loss of flexibility contributes to
degenerative joint disease (osteoarthritis);
joints stiffen, lose range of motion
Changes in Older Adult
 Cause stooped posture, changing center
of gravity
 Elderly at greater risk for falls
 Endocrine changes cause skeletal muscle
atrophy
 Muscle tone decreases
Assessment
 Health history
 Chief complaint
 Onset of problem
 Effect on ADLs
 Precipitating events, e.g., trauma
Assessment
 Examine complaints of pain for location,
duration, radiation character (sharp dull),
aggravating, or alleviating factors
 Inquire about fever, fatigue, weight
changes, rash, or swelling
Physical Examination
 Posture
 Gait
 Ability to walk with or without assistive
devices
 Ability to feed, toilet, and dress self
 Muscle mass and symmetry
Physical Examination
 Inspect and palpate bone, joints for visible
deformities, tenderness or pain, swelling,
warmth, and ROM
 Assess and compare corresponding joints
 Palpate joints knees and shoulder for
crepitus
Physical Examination
 Never attempt to move a joint past
normal ROM or past point where patient
experiences pain
 Bulge sign and ballottement sign used to
assess for fluid in the knee joint
 Thomas test performed when hip flexion
contracture suspected
Figure 41-4 Checking for the bulge sign.
Figure 41-5 Checking for ballottement.
Diagnostic Tests
 Blood tests
 Arthrocentesis
 X-rays
 Bone density scan
 CT scan
 MRI
 Ultrasound
 Bone scan
 Diagnostic Evaluation

 Imaging Procedures – CT, Bone Scan, MRI

 Nuclear Studies - radioisotope bone density,
 Endoscopic Studies –arthrocentesis, arthroscopy
 Other Studies –biopsy, synovial fluid, Arthrogram,
venogram,
 Electromyography
 Myelography*

 Laboratory Studies
 Musculoskeletal
Assessment – Diagnostic Test

 Laboratory  Laboratory
◦ Urine Tests ◦ Blood Tests
 24 hour creatine-  Serum muscle enzymes
creatinine ratio  Rheumatoid Factor
 Urine Uric acid –24 hr  LE Prep/Antinuclear
specimen Antibodies(ANA)
 Urine deoxypyridino-  Erythrocyte
line Sedimentation Rate
 Calcium, Phosphorous,
Alkaline phosphatase
 Muscoluloskeletal
Assessment – Diagnostic

 Blood Tests
◦ CBC – Hgb, Hct
◦ Acid phosphatase
◦ Metabolic/Endocrine
◦ Enzymes
Increase creatine kinase,
serum increase glutamin-
oxaloacetic due to
muscle damage, aldolase,
SGOT
 Musculoskeletal - Radiographic
 Standard radiography, tomography and
xeroradiography, myelography,
arthrography and CT
 Other diagnostic tests: bone and muscle
biopsy
 Arthroscopy
 Fiberoptic tube is inserted into a joint for
direct visualization.
 Client must be able to flex the knee;
exercises are prescribed for ROM.
 Evaluate the neurovascular status of the
affected limb frequently.
 Analgesics are prescribed.
 Monitor for complications.
Bone Scan
 Nuclear medicine procedure in which
amount of radioactive isotope taken up by
bones is evaluated
 Abnormal bone scans show hot spots due
to malignancies or infection
 Cold spot uptakes show areas of bone
that are ischemic
Arthroscopy
 Flexible fiberoptic endoscope used to
view joint structures and tissues
 Used to identify:
◦ Torn tendon and ligaments
◦ Injured meniscus
◦ Inflammatory joint changes
◦ Damaged cartilage
Interventions for Clients with
Musculoskeletal Trauma
Musculoskeletal Trauma
 Tissue is subjected to more force than it
can absorb
 Severity depends on:
◦ Amount of force
◦ Location of impact
Musculoskeletal Trauma
 Mild to severe
 Soft tissue
 Fractures
◦ Affect function of muscle, tendons, and
ligaments
 Complete amputation
Preventing Trauma
 Teach importance of using safety
equipment
◦ Seat belts
◦ Bicycle helmets
◦ Football pads
◦ Proper footwear
◦ Protective eyewear
◦ Hard hats
Soft Tissue Trauma
 Contusion
◦ Bleeding into soft tissue
◦ Significant bleeding can cause a hematoma
◦ Swelling and discoloration (bruise)
Soft Tissue Trauma - Sprain
 Ligament injury (Excessive stretching of
a ligament)
 Twisting motion
 Overstretching or tear
◦ Grade I—mild bleeding and inflammation
◦ Grade II—severe stretching and some tearing
and inflammation and hematoma
◦ Grade III—complete tearing of ligament
◦ Grade IV—bony attachment of ligament broken
away
 Sprains
 Treatment of sprains:
◦ first-degree: rest, ice for 24 to 48 hr,
compression bandage, and elevation
◦ second-degree: immobilization, partial
weight bearing as tear heals
◦ third-degree: immobilization for 4 to 6
weeks, possible surgery
Soft Tissue Trauma - Strain
 Microscopic tear in the muscle
 May cause bleeding
 “Pulled muscle”
 Inappropriate lifting or sudden
acceleration-deceleration
Soft Tissue Trauma
 To decrease swelling and pain, and
encourage rest
◦ Ice for first 48 hours
◦ Splint to support extremities and limit
movement
◦ Compression dressing
◦ Elevation to increase venous return and
decrease swelling
◦ NSAIDs
Soft Tissue Trauma
 Diagnosis
◦ X-ray to rule out fracture
◦ MRI
Fractures
 Break in the continuity of bone
◦ Direct blow
◦ Crushing force (compression)
◦ Sudden twisting motions (torsion)
◦ Severe muscle contraction
◦ Disease (pathologic fracture)
Fractures
Classification of Fractures
 Closed or simple
 Open or compound
 Complete or incomplete
 Stable or unstable
 Direction of the fracture line
◦ Oblique
◦ Spiral
◦ Lengthwise plane (greenstick)
 Stages of Bone Healing
 Hematoma formation within 48 to 72 hr
after injury
 Hematoma to granulation tissue
 Callus formation
 Osteoblastic proliferation
 Bone remodeling
 Bone healing completed within about 6
weeks; up to 6 months in the older
person
Fractures – Emergency Care
 Immobilize before moving client
 Joint above and below
 Check pulse, color, movement, sensation
before splinting
 Sterile dressing for open wounds
Fractures – Emergency Care
 Fracture reduction
◦ Closed—external manipulation
◦ Open—surgery
 Acute Compartment Syndrome
 Serious condition in which increased
pressure within one or more
compartments causes massive
compromise of circulation to the
area
 Prevention of pressure buildup of
blood or fluid accumulation
 Pathophysiologic changes
sometimes referred to as ischemia-
edema cycle
 Emergency Care - Acute
Compartment Syndrome
 Within 4 to 6 hr after the onset of
acute compartment syndrome,
neuromuscular damage is
irreversible; the limb can become
useless within 24 to 48 hr.
 Monitor compartment pressures.
(Continued)
 Emergency Care (Continued)
 Fasciotomy may be performed to
relieve pressure.
 Pack and dress the wound after
fasciotomy.
Possible Results of Acute Compartment
Syndrome

 Infection
 Motor weakness
 Volkmann’s contractures: (a deformity of
the hand, fingers, and wrist caused by a lack of blood flow
(ischemia) to the muscles of the forearm)
 Other Complications of Fractures

 Shock
 Fat embolism syndrome: serious
complication resulting from a fracture;
fat globules are released from yellow
bone marrow into bloodstream
 Venous thromboembolism
(Continued)
Other Complications of Fractures
(Continued)

 Infection
 Ischemic necrosis
 Fracture blisters, delayed union,
nonunion, and malunion
 Musculoskeletal
Complications (continued)

 Muscle Atrophy, loss of muscle strength range of

motion, pressure ulcers, and other problems
associated with immobility
 Embolism/Pneumonia/ARDS
◦ TREATMENT – hydration, albumin, corticosteroids
 Constipation/Anorexia
 UTI
 DVT
Musculoskeletal Assessment - Fracture

 Change in bone alignment

 Alteration in length of extremity
 Change in shape of bone
 Pain upon movement
 Decreased ROM
 Crepitation
 Ecchymotic skin
(Continued)
Musculoskeletal Assessment – Fracture
(Continued)

 Subcutaneous emphysema with

bubbles under the skin
 Swelling at the fracture site
Special Assessment Considerations

 For fractures of the shoulder and upper

arm, assess client in sitting or standing
position.
 Support the affected arm to promote
comfort.
 For distal areas of the arm, assess client
in a supine position.
 For fracture of lower extremities and
pelvis, client is in supine position.
CAST
CAST
 Casts

 Rigid device that immobilizes the

affected body part while allowing other
body parts to move
 Cast materials: plaster, fiberglass,
polyester-cotton
 Types of casts for various parts of the
body: arm, leg, brace, body
(Continued)
 Casts (Continued)
 Cast care and client education
 Cast complications: infection, circulation
impairment, peripheral nerve damage,
complications of immobility
 Managing Care of the Patient in a Cast

 Casting Materials
 Relieving Pain
 Improving Mobility
 Promoting Healing
 Neurovascular Function
 Potential Complications
Cast, Splint, Braces, and Traction
Management Considerations
 Arm Casts
 Leg Casts
 Body or Spica Casts
 Splints and Braces
 External Fixator
 Traction
POLYESTER/FIBERGLASS
UPPER EXTREMITY CAST
LOWER EXTREMITY CAST
 Musculoskeletal
Nursing Care - Casts

◦ Neurovascular
 Check  Traction Nursing Care
color/capillary refill
◦ Pin Site care
 Temperature
◦ Skin and neurovascular
 Pulse check
 Movement
 Sensation
 Cast Care (continued)
 Elevate Extremity
 Exercises – to unaffected side; isometric exercises to
affected extremity
 Keep heel off mattress
 Handle with palms of hands if cast wet
 Turn every two hours till dry
 Notify MD at once of wound drainage
 Do not place items under cast.
 Traction
 Application of a pulling force to the
body to provide reduction,
alignment, and rest at that site
 Types of traction: skin, skeletal,
plaster, brace, circumferential

(Continued)
 Traction (Continued)
 Traction care:
◦ Maintain correct balance between
traction pull and counter traction force
◦ Care of weights
◦ Skin inspection
◦ Pin care
◦ Assessment of neurovascular status
 Musculoskeletal – Fractures
Treatment

 Primary Goal – reduce fracture-

◦ Realign and immobilize
 Medications
◦ Analgesics, antibiotics, tetanus toxoid
 Closed Reduction – Manual and Cast; External
Fixation Device
 Traction; Splints; Braces
 Surgery
◦ Open reduction with internal fixation
◦ Reconstructive surgery
◦ Endoprosthetic replacement
Figure 42-5 In external fixation, pins placed through the bone above and below the fracture are attached to external
fixation rods that hold the pins and bone in place.
Nursing Management
 Positioning

 Strengthening Exercises

 Potential Complications
 Musculoskeletal
Nursing Care

 Promote comfort  Elevate extremity to

 Assess infection decrease swelling/ ice
 Promote mobility pack
 Teach safety  Teach skin care, cast
 Vital Signs care, diet,
 Flotation, sheep skin complications
 Nutrition
 Vital Signs
 Monitor elimination
 Operative Procedures

 Open reduction with internal

fixation
 External fixation
 Postoperative care: similar to that
for any surgery; certain
complications specific to fractures
and musculoskeletal surgery include
fat embolism and venous
thromboembolism
Managing the Patient Undergoing
Orthopedic Surgery

 JointReplacement
 Total Hip Replacement
 Total Knee Replacement
 Risk for Infection
 Interventions include:
◦ Apply strict aseptic technique for
dressing changes and wound irrigations.
◦ Assess for local inflammation
◦ Report purulent drainage immediately
to health care provider.
(Continued)
 Risk for Infection (Continued)
◦ Assess for pneumonia and urinary tract
infection.
◦ Administer broad-spectrum antibiotics
prophylactically.
Imbalanced Nutrition: Less Than Body
Requirements

 Interventions include:
◦ Diet high in protein, calories, and
calcium, supplemental vitamins B and C
◦ Frequent small feedings and
supplements of high-protein liquids
◦ Intake of foods high in iron
 Upper Extremity Fractures

 Fractures include those of the:

◦ Clavicle
◦ Scapula
◦ Humerus
◦ Olecranon
◦ Radius and ulna
◦ Wrist and hand
 Lower Extremity Fractures

 Fractures include those of the:

◦ Femur
◦ Patella
◦ Tibia and fibula
◦ Ankle and foot
 Fractures of the Hip
 Intracapsular or extracapsular
 Treatment of choice: surgical repair,
when possible, to allow the older
client to get out of bed
 Open reduction with internal
fixation
 Intramedullary rod, pins, a
prosthesis, or a fixed sliding plate
 Prosthetic device
 Fractures of the Pelvis
 Associated internal damage the
chief concern in fracture
management of pelvic fractures
 Non–weight-bearing fracture of the
pelvis
 Weight-bearing fracture of the
pelvis
Compression Fractures of the Spine
 Most are associated with
osteoporosis rather than acute
spinal injury.
 Multiple hairline fractures result
when bone mass diminishes.
(Continued)
Compression Fractures of the Spine
(Continued)

 Nonsurgical management includes

bedrest, analgesics, and physical
therapy.
 Minimally invasive surgeries are
vertebroplasty and kyphoplasty, in
which bone cement is injected.
(Continued)
 Amputations

 Surgical amputation
 Traumatic amputation
 Levels of amputation
 Complications of amputations:
hemorrhage, infection, phantom
limb pain, problems associated with
immobility, neuroma (a growth or tumour of
nerve tissue), flexion contracture
 Amputation

Nursing Management
◦ relieving pain
◦ minimizing altered sensory perception
◦ promoting wound healing
◦ enhancing body image
◦ self-care
 Phantom Limb Pain

 Phantom limb pain is a frequent

complication of amputation.
 Client complains of pain at the site
of the removed body part, most
often shortly after surgery.
 Pain is intense burning feeling,
crushing sensation or cramping.
 Some clients feel that the removed
body part is in a distorted position.
Management of Phantom Pain

 Phantom limb pain must be

distinguished from stump pain
because they are managed
differently.
 Recognize that this pain is real and
interferes with the amputee’s
activities of daily living.

(Continued)
 Management of Phantom Pain
(Continued)

 Some studies have shown that

opioids are not as effective for
phantom limb pain as they are for
residual limb pain.
 Other drugs include intravenous
infusion calcitonin, beta blockers,
anticonvulsants, and antispasmodics.
 Exercise After Amputation

 ROM to prevent flexion

contractures, particularly of the hip
and knee
 Trapeze and overhead frame
 Firm mattress
 Prone position every 3 to 4 hours
 Elevation of lower-leg residual limb
controversial
 Prostheses
 Devices to help shape and shrink the
residual limb and help client readapt
 Wrapping of elastic bandages
 Individual fitting of the prosthesis;
special care
 Crush Syndrome
 Can occur when leg or arm injury
includes multiple compartments
 Characterized by acute compartment
syndrome, hypovolemia, hyperkalemia,
rhabdomyolysis, and acute tubular
necrosis
 Treatment: adequate intravenous fluids,
low-dose dopamine, sodium
bicarbonate, kayexalate, and
hemodialysis
 Metabolic Bone Disorders

 Osteoporosis
 Osteomalcia
 Paget’s Disease
 Osteoporosis

 A disease in which loss of bone exceeds rate of

bone formation; usually increase in older
women, white race, nulliparity.
 Clinical Manifestations – bone pain, decrease
movement.
 Treatment – Calcium, Vit. D, estrogen
replacement, Calcitonin, fluoride, estrogen with
progestin, SERM (Selective Estrogen Receptor
Modulator) with anti-estrogens, exercise.
 Pathologic fracture-safety.
 Classification of Osteoporosis

 Generalized osteoporosis occurs most

commonly in postmenopausal women
and men in their 60s and 70s.
 Secondary osteoporosis results from an
associated medical condition such as
hyperparathyroidism, long-term drug
therapy, long-term immobility.
 Regional osteoporosis occurs when a
limb is immobilized.
Health Promotion/Illness Prevention -
Osteoporosis

 Ensure adequate calcium intake.

 Avoid sedentary life style (a type of
lifestyle with a lack of physical
exercise) .
 Continue program of weight-bearing
exercises.
 Osteoporosis - Assessment
 Physical assessment
 Psychosocial assessment
 Laboratory assessment
 Radiographic assessment
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 Drug Therapy
Osteoporosis

 Hormone replacement therapy

 Parathyroid hormone
 Calcium and vitamin D
 Bisphosphonates
 Selective estrogen receptor
modulators
 Calcitonin
 Other agents used with varying
results
Diet Therapy - Osteoporosis

 Protein
 Magnesium
 Vitamin K
 Trace minerals
 Calcium and vitamin D
 Avoid alcohol and caffeine
Fall Prevention - Osteoporosis

 Hazard-free environment
 High-risk assessment through
programs such as Falling Star
protocol
 Hip protectors that prevent hip
fracture in case of a fall
 Others - Osteoporosis

 Exercise
 Pain management
 Orthotic devices
 Osteomalacia

 Softening of the bone tissue

characterized by inadequate
mineralization of osteoid
 Vitamin D deficiency, lack of sunlight
exposure
 Similar, but not the same as
osteoporosis
 Major treatment: vitamin D from
exposure to sun and certain foods
 Paget’s Disease of the Bone

 Metabolic disorder of bone remodeling, or

turnover; increased resorption (the process by
which osteoclasts break down bone and release the
minerals, resulting in a transfer of calcium from bone fluid
to the blood)
of loss results in bone deposits
that are weak, enlarged, and disorganized
 Nonsurgical management: calcitonin,
selected bisphosphonates, mithramycin
 Surgical management: tibial osteotomy or
partial or total joint replacement
 Paget’s Disease
 An imbalance of increase osteoblast and
osteoclast cells; thickening and
hypertrophy.
 Bone pain most common symptom; bony
enlargement and deformities usually
bilateral, kyphosis, long bone.
 Analgesics, meds bisphosphonates and
calcitonin, NSAID, assistance devices, and
hot/cold treatment.
 Osteomyelitis

 A condition caused by the invasion by

one or more pathogenic
microorganisms that stimulates the
inflammatory response in bone tissue
 Exogenous, endogenous,
hematogenous, contiguous
 Osteomyelitis
 Infection of bone; causative agent – Staph/Strept
 Typical signs and symptoms : Acute osteomyelitis include:
 Fever that may be abrupt
 Irritability or lethargy in young children
 Pain in the area of the infection
 Swelling, warmth and redness over the area of the
infection
 Chronic osteomyelitis include:
 Warmth, swelling and redness over the area of the
infection
 Pain or tenderness in the affected area
 Chronic fatigue
 Drainage from an open wound near the area of the
infection
 Fever, sometimes
 Treatment – IV antibiotic; long term for 4-6 months
 Surgical Management
Osteomyelitis

 Sequestrectomy (Surgical removal of a

sequestrum), a detached piece of necrotic bone that
often migrates to a wound, abscess, etc.
 Bone grafts
 Bone segment transfers
 Muscle flaps
 Amputation
 Bone Tumors

 Benign Bone Tumors

 Malignant Bone Tumors
 Metastatic Bone Disease
 Bone Tumors
 Benign bone tumors
(noncancerous):
◦ Chrondrogenic tumors:
osteochondroma, chondroma
◦ Osteogenic tumors: osteoid osteoma,
osteoblastoma, giant cell tumor
◦ Fibrogenic tumors
 Interventions
 Nondrug pain relief measures
 Drug therapy: analgesics, NSAIDs
 Surgical therapy: curettage (simple
excision of the tumor tissue), joint
replacement, or arthrodesis
 Malignant Bone Tumors
 Primary tumors, those tumors that
originate in the bone
◦ Osteosarcoma
◦ Ewing’s sarcoma
◦ Chondrosarcoma
◦ Fibrosarcoma
◦ Metastatic bone disease
 Osteosarcoma
 Cancer of the bone – metastasis to the
lung is common. Most in long bones.
 Clinical manifestations – dull pain,
swelling, intermittent but increases per
time; night pain common.
 Treatment – radiation, chemotherapy,
hormonal therapy, surgical excision with
prosthetics, assistance devices, palliative
measures.
 Treatment Cancer of Bone
 Interventions include:
◦ Treatment aimed at reducing the size or
removing the tumor
◦ Drug therapy; chemotherapy
◦ Radiation therapy
◦ Surgical management
◦ Promotion of physical mobility with ROM
exercises
 Cancer of Bone
Anticipatory Grieving

 Interventions include:
◦ Active listening
◦ Encouraging client and family to
verbalize feelings
◦ Making appropriate referrals
◦ Helping client and others to cope with
the loss and grieving
◦ Promoting the physician-client
relationship
 Cancer of Bone
Disturbed Body Image

 Interventions include:
◦ Recognize and accept the client’s view
of body image alteration.
◦ Establish and maintain a trusting nurse-
client relationship.
◦ Emphasize the client’s strengths and
remaining capabilities.
◦ Establish realistic mutual goals.
 Potential for Fractures
Bone Cancer

 Interventions
◦ Nonsurgical management: radiation therapy
and strengthening exercises.
◦ Surgical management: replace as much of
the defective bone as possible, avoid a
second procedure, and return client to a
functioning state with a minimum of
hospitalization and immobilization.
 Carpal Tunnel Syndrome

 Common condition; the median

nerve in the wrist becomes
compressed, causing pain and
numbness
 Common repetitive strain injury via
occupational or sports motions
 Nonsurgical management: drug
therapy and immobilization
 Possible surgical management
 Scoliosis

 Abnormal spinal curvature of various

degrees or severity involving
shortening of muscles and ligaments.
 Milwaukee brace (a back brace used in the
treatment of spinal curvatures) , internal
fixative devices.
 Scoliosis
 Changes in muscles and ligaments on
the concave side of the spinal column
 Congenital, neuromuscular, or
idiopathic in type
 Assessment: complete history, pain
assessment, observation of posture
 Interventions: exercise, weight
reduction, bracing, casting, surgery