Musculoskeletal Problems
NUR 302 Unit IV
Neurovascular Assessment
5 Ps
Pain
Pulses
Pallor
Paresthesia
Paralysis or decr motor strength
Sprains & Strains
Sprain: injury to ligaments around joint
Strain: stretching of a muscle & sheath
S/S: pain, edema, decr function,
bruising
Health promotion: warm up exercises
Care: rest, elevate, ice, compression,
analgesics, after 24-48hrs heat, PT
Dislocation & Subluxation
Dislocation: complete separation of
articular surfaces of joint
Subluxation: partial displacement
Realign & reduce joint ASAP- prevent
avascular necrosis
Relieve pain, support & protect joint,
prevent contractures
Carpal Tunnel Syndrome
Compression of median nerve under the
transverse carpal ligament in wrist
S/S: weakness esp thumb, pain &
numbness, clumsiness, + Phalen’s sign,
+ Tinel’s sign
Educate about risks, wrist splint, stop
aggravating action, hydrocortisone,
surgery, eval of neurovascular status
Repetitive Strain Injury
Cumulative trauma to tendons,
ligaments, muscles-> tiny tears,
inflammation, scarring
S/S: pain, weakness, numbness,
impaired function
Education, approp job design, avoid
precipitating activity, PT, careful use of
analgesia
Rotator Cuff Injury
Complex of 4 muscles that stabilize &
rotate humerus, tear gradual,
degenerative or from trauma
Pain, can’t abduct arm or shoulder
MRI, arthrogram
Rest, ice & heat, NSAID, corticosteroid
injections, PT
Surgery, shoulder immobilizer, PT
Meniscus Injury
Meniscus- fibrous cartilage in knee,
injured by rotational stress when knee is
flexed & foot fixed.
Tenderness, pain at abduction &
adduction of leg at knee, knee unstable
Arthroscopy, arthrogram, MRI
Ice, immobilize, crutches, PT, surgery
Bursitis
Inflammation of bursae from trauma,
friction, gout, rh.arthritis, infection
Warmth, swelling, pain, decr ROM
Rest, ice, immobilize, NSAIDs
Aspiration of bursae fluid, cortisone
injections, bursectomy
Muscle Spasms
Pain, palpable muscle mass,
tenderness, decr ROM, limited ADL
H&P – R/O CNS problems
PT – heat or ice, exercise, massage,
hydrotherapy, ultrasound, bracing
Meds – mild analgesics, NSAIDs,
skeletal muscle relaxants
Bone Cancer
Multiple Myeloma- plasma cell cancer
invades bone marrow
S/S- back pain , anemia, blding
tendencies
Dx- biopsy
Prognosis- poor
Tx- Chemo, radiation, corticosteroids
Bone Cancer
Osteogenic Sarcoma- primary tumor,
grows fast, long bones, distal femor
Children & young adults, age 10-25
S/S- gradual pain, swelling, after injury
Tx- pre-op chemo then resection of
tumor, amputation
Bone Cancer
Osteoclastoma- destructive, occurs in
ends long bones
Age 20-35
S/S- swelling pain, joint problems
Dx- biopsy, x-ray-> bone destruction &
expanded bone ends
Rx- surg curettage, bone graft, chemo
Can reoccur
Ewing’s Sarcoma
Rapid growth of medullary cavity of long
bone
Metastasis early esp lungs
S/S:pain, swelling, paplable soft tissue
mass, incr size affected part, fever,
leukocytosis
Tx: radiation, chemo, resection or
amputation
Amputation
Indications- circul impairment, tumors,
uncontrolled infection, cong disorders
Assess for potential for revasculariz.
therapy by arteriogram
Explain reason for amputation,
reassure, rehab, answer questions
Manage underlying diseases
Nursing Care
Assessment- dx tests, labs, swelling, jt
function, s/s mets
Pain- medicate, gentle handling
extremity, rest
Care of pt receiving chemo, radiation
Psychol support
Care off pt with amputation
Nursing Care
Dsg change- sterile technique, molding limb
with compression bandage
Immediate post-op fitting in OR or delayed
fitting
Prevent flexion contractures- avoid sitting in
chair with hips flexed or pillow under stump,
prone 30min, 3-4X/day
Teach transfer to chair, ROM, arm strength,
crutch walking, refer to prosthetics
Nursing Care
H Promotion- teach diabetic, PVD pts &
families foot care, assessment
Psychol support- depression, grieving,
body image disturbance
Pre-op- upper extrem strengthening,
explain post-op care, phantom pain
Post-op- hemorrhage- check VS, dsg
very thick, notify MD, tourniquet
Osteomyelitis
Enter via arterial bld supply-> stay in area of
decr circulation-> infection incr pres in bone->
ischemia-> bone death-> bone separates->
forms sequestra
Acute s/s- systemic- fever chills, nausea,
malaise & local- bone pain, swelling,
tenderness, warmth, drainage
Chronic- pus -> ischemia-> granulation tissue
turns to scar ->infection unreachable by meds
Osteomyelitis
Dx- wound, bld,sequestrum C&S, bone
biopsy, elev WBC & sed rate, no s/s on
x-rays til 10 days-wks, seen on nuclear
bone scans 24-72 hrs, CT& MRI
Rx- antibiotics- central line IV, continue
at home 4-6 wks or 3-6 months, surg
debridement, wound irrig, hyperbaric O2
Nursing Care
Teach jt replacemt pts s/s infection &
prophylactic antibiotics teeth cleaning,
procedures etc
Pain- gentle moving of extremity,
elevate, correct alignment, immobilize
Dressings- sterile, wet-dry, vac system
Teach meds, care of venous access
device, nutrition, follow up care
Acute Low Back Pain
Risk factors- lack of muscle tone, excess wt,
poor posture, smoking, job, long sitting, stress
Injury->s/s develop later due to grad increase
in muscle spasm
Rx- analgesics, NSAIDs, muscle relaxants,
corset. Severe pain- bed rest, epidural
corticosteroid & anesthetic
Health Promotion- body mechanics, exercise
Chronic Low Back Pain
Degen disc disease, injury, obesity,
posture, lack of exercise, systemic
disease
Hern disc- back pain with buttock & leg
pain, paresthesia, muscle weakness
Dx- x-rays, MRI, CT, myelogram, EMG
Tx- rest, corset, heat or ice, NSAIDs,
muscle relaxants
Chronic Back Pain
Progressive worsening or loss of
bladder/bowel control-> surgery
Percutaneous laser diskectomy
Diskectomy or microsurgical diskectomy
Laminectomy
Spinal fusion
Stable Vertebral Fractures
Disrupted ligament -> unstable
Complication fx displacement ->spinal
cord injury
Keep spine in proper alignment, assess
neurovas status, bladder & bowel
Log rolling, no trapeze, heat, traction,
no turning of torso or upright position,
orthotic device, jacket cast, halo vest
Spinal Surgery Nursing Care
Bed rest (flat) 1-2 days, logroll, position
Muscle spasm- meds, correct turning
Leakage CSF->headache, report
Neuro s/s- movement, sensation, strength q24h, compare with pre-op
Assess paralytic ileus, bladder emptying
Spinal fusion- orthosis, check donor site
Teach- avoid sit/stand long, body mechanics
Foot Problems
See table 59-22
Health Promotion- proper fitting shoes
Post-op- elevate, check neuovas status,
pins/wires may extend thru toes,
dressings, slipper, boot or cast,
crutches, don’t walk on heel
Teach hygiene, trim toe nails straight
across, see podiatrist if poor circulation
Osteoporosis
Low bone mass, structural deterioration of
bone tissue-> increased bone fragility
Elderly & post-menopausal women fx hip,
spine, wrist
Risk factors- female, incr age, family history,
Caucasian or Asian, small, oophorectomy,
sedentary, insuf Calcium
Alcoholism, rh arthritis, DM, cirrhosis, kidney
disease, intest malabsorption
Osteoporosis
Long term meds- corticosteroids,
antiseizure, Al antacids, heparin, INH,
tetracycline, thyroid replacemt meds
Genetic marker- VDR gene
S/S: “silent”, bump or fall->fx, vertebrae
collapse->back pain, ht loss, kyphosis
Dx: shows on x-ray only after 25-40%
loss, BMD, DEXA, Ca, phos, alk phos
Nursing Care
Prevention- Ca Intake: premenopausal
& postmen women taking ERP1000 mg,
1500mg postmenopausal women
Vit D needed for Ca absorption
Exercise builds & maintains bone mass
Keep pts with osteoporosis ambulatory,
prevent potential pathological fx
Drug Therapy
Calcitonin- Calcimar-inhibits
osteoclastic bone resorption
Biphosphates- Fosamax- inhibits
osteoclast mediated bone resorption,
incr bone mineral density & bone mass
Evista- mimics estrogen on bone,
doesn’t effect uterus or breast tissue
Paget’s Disease
Excessive bone resorption, replacement
bone marrow by vascular, fibrous tissue
that makes bone larger
S/S- skeletal pain, waddling gait, elev
alk phos shorter, large head, wt bearing
bones curved, complication- patholog fx
Tx- Calcitonin, Fosamax, radiation,
brace, analgesics, muscle relaxants
Fractures
Types: avulsion, comminuted,
displaced, greenstick, impacted,
interarticular, longitudinal, oblique,
pathologic, spiral, stress, transverse
Communicating or noncommunicating –
open or closed
Location
Stable or unstable
Clinical Manifestations
Determined by history of injury
Pain & tenderness, muscle spasm
Edema, swelling, deformity, ecchymosis
Loss of function, crepitation
Immobilize in position found
Children – epiphyseal plate
Process of Union of Fx
Fracture hematoma
Granulation tissue
Callus formation
Ossification
Consolidation
Remodeling
Age, displacement, site, blood supply
Factors that affect bone healing
 Age
Severity of the trauma
Type of bone Injured
Inadequate immobilization
Infection
Nutrition
Fracture Reduction
Manipulation or closed reduction –
nonsurgical, manual reduction
Open reduction – surgical, often internal
fixation (ORIF) with wires, screws, rods
Complication open reduction- infection
Advantage – early ambulation
Traction – skin or skeletal
Traction
Skin - Buck’s, Russell's, Bryant’s, Pelvic
belt
Short term (48-72hrs) til surgery, skel tx
Circumferential – head halter
Skeletal - Overhead arm, lateral arm,
balanced suspension traction
See table 59-6
Traction Care
 Maintain weight (freely hanging)
 Inspect Skin
 Pin Site Care
Neurovascular Assessment
External Fixator Device
Metal pins inserted into bone & attached
to external rod, stabilizes fx, holds
pieces in place
Assess loose pins
s/s infection- exudate, redness,
tenderness, pain
Pin care
Cast Materials
Traditional- Plaster of Paris
* Stockinette, Padding, Plaster Rolls
* Feels hot when first applied
* 24-72 hours to dry
* Petal the cast
Synthetic- Fiberglass; Polyester cotton knit
Cast Materials
Traditional- Plaster of Paris
* Stockinette, Padding, Plaster Rolls
* Feels hot when first applied
* 24-72 hours to dry
* Petal the cast
Synthetic- Fiberglass; Polyester cotton knit
Casts
Long arm cast: support & elevate, use
sling-> decr edema, encourage finger
movement
If proximal humerus fx, traction by
hanging, aids healing
Body jacket cast: assess bowel sounds,
“cast syndrome”, resp status, bladder,
pres over iliac crest, position q2-3 hrs
Casts
Hip spica cast- femoral fx, children, when
drying place in prone position, slightly turn,
don’t use support bar to turn, skin care to cast
edges, same care as jacket cast
Long leg cast, short leg cast, Jones dressing
– elev above heart 24 hrs, initially no wt
bearing, later heel or shoe cast, check for
pressure areas
Drug Therapy
Pain due to muscle spasms
Soma, Flexaril, Robaxin
S/E: drowsiness, headache, weakness,
GI upset, potential abuse
Other belief - Relieve pain, spasm will
disappear
Nutritional Therapy
Need protein & vit C for healing
Immobility & callus formation increases
Calcium needs
Increase fluids to 2000 – 3000 cc
Hi fiber diet, fruits & veg prevent
constipation
Jacket cast – don’t over eat
Health Promotion
Prevention precautions- work sports,
home, driving
Seat belts, helmets etc, stretching
before exercise
Elderly- look at environment, exercise,
vit D & calcium
Nursing Care Fractures
Initial assessment, quick history, to ER
Guarding, deformity, laceration, loss of
function, rotation, edema, crepitus
ecchymosis, compare to uninjured side
Focus on area distal to injury – pulse ?,
decreased cap refill, cool vs bluish &
warm, decreased or absent sensation,
paresthesia
Emergency Management
Priority: ABC, life threatening injuries,
control bleeding
Splint above & below fx site
Neurovascular status, elevate, ice
Don’t manipulate protruding bones,
tetanus
VS, LOC, O2 sat, pulses, pain
Pre-op Care
Routine pre-op teaching
Explain type of immobilization & activity
limits, time
Pain meds
Skin prep
Post-op Care
VS, neurovascular checks
Proper alignment & positioning
Pain meds
Observe for bleeding, report increase
Patency of wound drain
Care of cast or traction, pin care
Prevent constipation & renal calculi
Ambulatory & Home Care
Cast care- do not get wet, remove padding,
put things in cast or if synthetic cast – check
with MD before wet, dry after
Report: incr pain, swelling, burning under
cast, sores or odor, discolored fingers/toes
Elevate, move joints
Follow up with MD
Ambulatory & Home
Short term rehab
PT: strengthening, assistive devices,
ambulation progression
Crutch walking: two-point gait, four-point gait,
swing-to gait, swing-through gait
Involved limb advanced at same time or
immed following the device
Hold cane in hand opposite of involved
extremity
Complications of Fractures
Infection- open fx, surgery, irrigation,
debridement, left open vs closed, drains
Compartment Syndrome- compression, upper
& lower extrem by fascial sheath or bone->
stop venous & arterial bld flow-> ischemia->
cell damage. Tx- fasciotomy
S/S Unrelieved pain distal to injury, numb,
tingling, decr-> loss function, cool , no or poor
pulse. Check myoglobin in urine & output
Complications of fractures
Venous thrombosis esp with hip fx, due
to stasis, immobility
Prevent- SCD ,TEDS, ROM, anticoag
Fat Embolism- fx long bones, pelvis, jt
replacement, sp fusion, crush injuries
S/S- chest pain, tachypnea, cyanosis,
tachycardia, dyspnea, decr o2 sat
Little repositioning til immobilize fx
Types of Fractures
Colles’ fracture –distal radius
Fx of humerus- hanging arm cast,
shoulder immobilizer, swathe, elev
HOB, axilla skin care
Fx pelvis- check neurovasc status lower
extremities, GI & GU function, turn only
when ordered, carefully, back care
Types of Fractures
Femoral shaft fx- complications also
soft tissue damage, bld loss
Rx- skel traction 8-12 wks or internal
fixation, restricted wt bearing til union
Tibial fx- long leg cast, assess neurovas
q2h for 48 hrs, need strengthening of
quadriceps & upper arms, non wt
bearing 6-12 wks, then walking heel
Hip Fracture
S/S- external rotation, muscle spasm,
shortened extremity, pain
Buck’s or Russell’s tx til surgery of pin
or femoral head replacement
Complications- avascular necrosis,
dislocation, nonunion, degen arthritis
Pre-op- manage pain, care of tx,
position, teaching- trapeze, pre-op
Hip Fracture
Post-op- VS, dsg & hemovac, neurovas
stasus, pain, abductor pillow
Pinning- OOB by PT, crutches or walker
Prosthesis- hip precautions- no 90 degree
flexion, elev tiolet seat, shower chair, chair
with arms & elev leg, keep straight when
sitting, pillow bet legs when lying on side,
turning, do not cross legs
Maxillofacial Fractures
Establish & maintain patent airway
Remove foreign material, blood, prn
suction, packing to control hemorrhage
Treat as if cervical spine injury &
suspect injury to eye esp global rupture
Soft tissue injury-> swelling-> hard to
assess, dx CT scan
Alteration in body image