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
Support
Movement
Shape
Maintain Position
Attachment of
Muscles
•
•
•
•
•
•
Protects Organs
Storage
Hematopoiesis
Remodeling
Reformation
Movable Joints
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
Extension
Abduction
Adduction
Rotation
Circumduction
Supination
•
•
•
•
•
Pronation
Inversion
Eversion
Protraction
Retraction
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
– Bone Scan
• Endoscopic Studies
– Arthroscopy
• Other Studies
– Arthrocentesis
– Electromyography
– Biopsy
• Laboratory Studies
–
–
–
–
–
–
–
–
(CBC)
Urinalysis (Calcium)
Blood Chemistry
Serum Calcium
Serum Phosphate
Uric Acid
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