MUSCULOSKELETAL DISORDER
STRUCTURE AND FUNCTION
Bones. Joints, Muscles
Synovial Joints are found at all limb articulations
Skeletal, smooth and cardiac muscle
Tendons, Ligaments, and cartilage
Tendons- are fibrous connective tissue bands that connect muscles to bones and enable the
bones to move when skeletal muscles contract
Ligaments- bands of connective tissue that connect bone to bone
Function:
Locomotion
Support
Protection
Blood production
Calcium
NEUROVASCULAR INTEGRITY
Impairment of circulation or nerve function that can lead to tissue necrosis, loss of use of extremity
Neurovascular Assessment
Color
Movement
Temperature and sensation with unaffected extremity
Edema
Capillary refill
SPLINTS
Support or immobilize area of body in specific position
Can be used to immobilize some types of fractures
Prevents contractures
SUPPORTIVE DEVICES
Corsets, back braces
Collars- neck support
External Fixation Devices
ORTHOPEDIC NURSING
Part of medical surgical nursing units
Care for patients at various developmental stages
Often have other problems: cardiovascular or renal, often have had surgery
CASTS
Use to maintain correct alignment while healing
Prevent or correct deformities
Immobilizes extremity
Short arm cast
Long arm cast
Short leg cast
Long leg cast
Body jacket- protects the thoracic area and lumbar spine. (compression fractures)
Single hip Spica
Double hip Spica- immobilizes hip and thighs (infants with congenital hip dysplasia)
Plaster
Fiberglass
CAST CARE
Plaster:
Drying time- takes 24-48 hours to dry.
Prevent indentations- causes pressure points underneath
Rough edges- petal edges using tape
Keep clean and dry
Do not stick foreign objects under cast to scratch
Report swelling, discoloration of toes or fingers, pain during motion, burning or tingling
underneath cast.
Fiberglass
Faster drying time- within minutes
Lighter and stronger material
More expensive
Do not require frequent changing
Neurovascular Assessments
Odor
Drainage
Skin Care
Position/Activity- should be positioned above the heart
Cast Removal- cut off with cast saw
NURSING CARE FOR CASTS PG. 1026
Cast Care
Support drying cast with pillows; do not cover
Use the palms of the hands to handle a drying cast
Frequently assess pulses, color, movement, and sensation of the affected extremity
Promptly report increased or severe pain; changes in pulses, color, movement and sensation
distal to the cast; or a “hot spot” or drainage on the cast
Pad or tape rough cast edges t reduce skin irritation
Use plastic wrap as needed to keep the cast clean and dry
Client and Family Teaching
The cast dries from the inside out; do not use a blow dryer to speed drying; do not cover the cast
while it is drying
A sensation of warmth during drying is normal
Keep the cast clean and dry
If a fiberglass cast gets wet, dry it with a blow dryer on cool setting
Notify your doctor immediately if you develop increased pain, coolness, color changes, increased
swelling, or loss of sensation to the injured limb
Relive itching by blowing cool air into the cast with a blow dryer on cool setting
A sling may help distribute the weight of the cast evenly around the neck; do not roll the sling
because this may impair circulation
Use crutches as taught to prevent weight bearing on the affected leg
The cast will be removed with a cast saw. You will feel the vibration, but the saw will not cut the
skin.
TRACTION
“Pulling”- uses a straightening or pulling force to return or maintain the fractured bones in normal
position.
Body acts as countertraction
Rope
Weights
Trapeze
Exercise
Types of traction
Skeletal traction- the pulling force is applies directly through pins inserted in the bone. It allows
use of more weight to maintain bone alignments. The risk of infection is greater, however, and it
may cause more discomfort
Skin traction- applies the pulling force through the client’s skin. Skin traction is noninvasive and
is relatively comfortable for the client.
Buck’s traction- The body provides a counterweight or opposing force to the traction.
The pulling force is applied to the skin of the affected leg.
Bryant’s traction- abnormal formation of hips. May have spica traction. Both legs are at
a 90 degree angle at the bend. Immobilizes the hip and the waist area.
Nurses will set up traction according to doctor’s order to type and weight.
NURSING CARE FOR TRACTION- PG 1027
Maintain the pulling force and direction
Center the client on the bed; maintain body alignment with the direction of the pull.
Ensure that nothing is lying on or obstructing the ropes
Tape knots; do not allow knots to come in contact with the pulley
Ensure that weights hang freely and do not touch the floor
For skin traction:
Frequently assess pulses, color, sensation, and movement distal to wrappings; notify the
physician or rewrap (as ordered) if necessary.
Remove weights only if intermittent traction has been ordered and to rewrap bandages
Frequently assess skin, bony prominences, and pressure points for irritation or breakdown.
Protect pressure sites with padding and protective dressings
For skeletal traction:
Never remove weights
Frequently assess neurovascular status, skin, and pin insertion sites
Provide pin site care as ordered (or per protocol)
Report signs of infection, such as redness, drainage, and increased tenderness
Report manifestations of complications of immobility, including pressure ulcers, DVT, atelectasis
or pneumonia, paralytic ileus, and constipation.
FOR ALL ORTHOPEDIC CLIENT
Neurovascular Integrity
Skin Care
Issues of Immobility: gastrointestinal, genitourinary, respiratory
Risk for infection
Safety
Psychosocial needs
OSTEOMYELITIS
Inflammation in bone due to infection
Most common cause- repair of open fracture or open wound
Other causes:
Gunshot or deep puncture wounds
Soft tissue infection
Pressure ulcers
Impaired immune function
Venous stasis or arterial ulcers of the legs
Diabetes mellitus
Classic signs of infection present
Chronic
Painful
Diet
Increased protein and calcium
Control blood sugars
TRAUMATIC INJURIES
Contusions- bleeding into soft tissue resulting from blunt force (bruise)
Sprains- a ligament injury caused by a twisting motion that overstretches or tears the ligament
Strain(sprain)- microscopic tear in the muscle that causes bleeding into the tissue (immobilization)
Ice first 48 hours for swelling and then can use heat
Dislocation- bone out of joint- needs immobilization
Fractures- a break in the continuity of a bone
TYPES OF FRACTURES
Open (compound)- Broken bone protrudes through skin
Closed (simple)- skin over fracture remains intact
Greenstick- incomplete break occurs along the length of the bone (children)
Complete- involve the entire width of the bone
Comminuted- bone fragments into many pieces
Colles- wrist fracture (fall and catch on wrist) break in the distal radius
Impacted- broken ends of bone are forced together
Transverse- breaks straight across the width of the bone (clean break)
Oblique- a break in the bone that is diagonal
Spiral- jagged break occurs due to twisting force
Location on bone- look at what part of bone determines the treatment for the fracture
Displacement- bone breaks and does not approximate with the other piece of bone
Avulsion- tissue pulls away from the bone
Longitudinal- long piece breaks away from bone but does not go through entire width of the bone
Interarticular- a jointed area is destroyed and the bones are hitting together
Stress- common in the foot, repeated soft impact
Depressed- broken bone is pressed inward (skull)
SIGNS AND SYMPTOMS OF FRACTURES
Depends on location
Pain
Swelling
Tenderness
Deformity
Loss of function
Remember that other injuries can occur simultaneously
TREATMENT OF FRACTURES
Reduction
Closed- pull on limb to put the bone back in line
Open- surgery
HEALING PROCESS OF BONE
Formation of new bone:
Bleeding
Hematoma
Fibrin mesh- framework for new bone to grow
Inflammatory reaction
Granulation tissue- contains calcium, cartilage, and osteoblasts
Callus (what the granulation tissue is called)
Ossification- process by which new bone is formed
COMPLICATIONS OF FRACTURES
Pulmonary Embolism
Thrombophlebitis
Prolonged immobility
Fractures to lower extremities are at a higher risk
Prevention
TED hose
Sequential hose
Get the patient moving
Prophylactic Anticoagulation- Lovenox
Signs and Symptoms
Acute respiratory distress
Substernal pain
Signs of shock
Treatment
Oxygen therapy
Ventilator
Anticoagulation therapy
Fat Embolism
More common in young adults, multiple, crushing injuries, long bone injuries
Can be fatal
Prevention
Cautious movement
Minimum manipulation of bone fragments
Immediate immobilization
Signs and symptoms
Mental Disturbances
Respiratory distress
Signs of shock within 72 hours or injury
Classic appearance of Petechiae on upper chest, axillae
Blood Tinged sputum
Treatment
High concentration of O2
Control of shock, symptomatic measures to sustain life
Infection
Open fracture
Open reduction
S&S- fever, drainage, pain
Compartment Syndrome- excess pressure restricts blood vessels and nerves within a compartment
Increased pressure
Impairs circulation
Can rapidly result in permanent contracture- Volkmann’s contracture
Signs and Symptoms- 5 P’s
Pain
Pallor
Paresthesia
Paresis
Pulselessness- ominous sign
Surgical Intervention
Fasciotomy
HIP FRACTURE
Incidence is increasing b/c living longer and over age 65 has increased risk
Signs and symptoms
Pain
Affected extremity shortened, externally rotated
Post-op hip precautions
Don’t let them adduct or cross legs
Hypostatic Pneumonia
Urinary Calculi
Pressure Ulcers
Constipation
Delirium or acute confusion
BONE TUMORS
Primary or Secondary
Benign or Malignant
Osteogenic sarcoma
Affects long bones
Occurs in children 10-15 years old
If caught earlier can remove tumor and put in prosthesis
Ewing’s Sarcoma
Older school age children and adolescents
Occurs in the marrow of the long bones
Avoid weight bearing while treated to prevent pathological fractures
Susceptible to radiation and chemo
Metastasis from other primary tumor sites
Prostate, lung, breast, thyroid, and kidney cancers most likely to metastasize
AMPUTATION
May be done due to:
Malignant bone tumor
Diabetic gangrene
Other conditions that threaten patient’s life
Has significant physical and psychosocial effects
Post-op care
Monitor for shock
Monitor drainage
Prevent contractures
Monitor for signs/symptoms of infection
Help through the grieving process
Preparing for Prosthesis
Prevent contractures
Shape stump
Temporary prosthesis
Permanent Prosthesis within 3 months
Physical therapy
Watch for skin breakdown
Phantom limb sensation
Pain in amputated limb
Most intense 1st 6 months
May use TENS on unaffected limb to break the cycles
Very real sensation
PREVENTION OF CONTRACTURES AFTER AMPUTATION
Encourage joint extension
With above knee amputation, place in prone position several times a day; do not elevate stump on pillows
after the first 24 hours
For below knee amputation, elevate foot of bed, keeping knee extended
Position upper extremities using the same principles
Provide active or passive ROM exercises every 2 to 4 hours for all joints
Use trapeze on bed frame to encourage frequent position changes
Teach importance of moving and ROM exercises
For a thigh or above knee amputation, avoid sitting for long periods
Teach postural exercises to compensate for los of weight on affected side
ARTHRITIS
Inflammatory joint disease
All types characterized by inflammatory damage to synovial membrane or articular cartilage
RHEUMATOID ARTHRITIS
Most serious form
Autoimmune disease
Chronic inflammation of connective tissue- especially joints
Causes pain, joint deformity, loss of function
Most common between 20-50 years
Commonly effects the fingers, feet, wrists, elbows, ankles and knees
May also hit the shoulders, hips, and cervical spine
Because it is autoimmune, may affect the tissues in the heart, lungs, kidneys and skin
Signs and symptoms
Weight loss
Anorexia
Muscle aches
Malaise
Fever
Swollen, painful joints- stiff in the morning
Rheumatoid factor elevated
Erythrocyte sedimentation rate elevated
Joint damage visible on X-ray
Care and Treatment
Maintaining function
Relieving pain
Prevention deformities
Rest
Good body alignment
NSAIDs
Steroids
Many need joint replacement
OSTEOARTHRITIS- DEGENERATIVE JOINT DISEASE
Non-inflammatory but will progress to inflammation
Risk factors
Joint stress
Obesity
Increases with age
Congenital abnormalities
Trauma
Population affected
50% of population will have some degree of arthritis by 16
By age 65. 70% have some degree of arthritis
Joints most often affected
Wrists
hands
Neck
Back
Hips
Knees
Ankles
Feet
Proteoglycans- decreases in quantity and quality as we age (component of cartilage)
Cartilage more susceptible to breakdown
Lose cartilage, develop cysts or osteophytes (spurs, joint mice) this leads to inflammation
Treatment
Lose weight
Exercise
Analgesics
Hydrocortisone injections
Moist heat
Surgery
Post-op care for total joint replacement
TEDs or SCDs
Exercise
Wound drainage
Position to avoid dislocation
ABDUCTED
Knee replacement- CPM
Complications
Phlebitis
Urinary Retention
Infection
Compromised circulation and/or sensation
GOUTY ARTHRITIS
Metabolic disease- results from accumulation of uric acid in the blood
Occurs after puberty in males and after menopause in females- mostly males
Usually affects great toe, but can be anywhere
Primary symptoms are pain and swelling. Usually occurs at night
Diagnosis by checking the uric acid level in the blood
Drug therapies
Colchicines- PO or IV
Indocin- strong anti-inflammatory
Zyloprim (allopurinol)- decreases production of uric acid
Probenecid- increases excretion of uric acid
Foods to avoid- high in Purine
Liver
Brains
Kidneys
Sweetbreads
Sardines
Scallops
Mackerel
Anchovies
Broth/consommé
Mince meat
BURSITIS
Inflammation of the bursae (small sacs in the shoulder, elbow, knee, hip and foot) that contain lubrication
May be the result of injury, strain, or prolonged use of the joint
Treatment: immobilization in sling for shoulder, analgesics, hydrocortisone injections, surgery if calcium
deposits are causing the inflammation
CLUB FOOT
Common congenital deformity
Occurs in approx. 1 of 1000 of live births
Caused by improper positioning in the uterus
Talipes equinovarus- foot turned with toes pointed inward
Splint/cast or surgery if not corrected by the 3 years old (clipping Achilles tendon)
Keep eye for neurovascular compromise and change splints as they grow rapidly
Also due to genetic factors and mothers who use ecstasy and smoke
50% of club feet are bilateral
CONGENITAL HIP DYSPLASIA
Various degrees of deformity
May be partial or complete
More common in girls (7x)
Need to catch early for effective treatment
Limited abduction
Asymmetrical gluteal folds and will have hip clicks
Barlow’s Test- bend the legs at the knees and pull and push straight down against the hip joint and hip will
dislocate
Ortolani’s sign- rotate legs up and around and the hip will click
Tests will be used up to about 4-6 months old
If tests are positive they will order x-ray to get confirmation of the hip displacement
Treatment
Hips in constant flexion and abduction
Constant pressure enlarges and deepens acetabulum
Triple thick diaper- Pavlik Harness- up to 6 months old (85% success rate if diagnosed as a
newborn)
Bryant’s traction (amount of weight=amount of countertraction)
Cast- Spica body cast
May need surgery especially if over 18 months old
MUSCULAR DYSTROPHIES
Group of inherited muscular diseases
Affects skeletal muscles- death of muscle cells and tissues
Mainly affects the arms and the legs, but can affect the heart and respiratory muscles
Duchenne’s muscular dystrophy (DMD)
 Sex-linked recessive disorder- X chromosome- female carriers, male presentation
 Life expectancy of mid-teen’s- 30’s
 Rapid progression of muscle degeneration- affects ambulation
 Progressive weakness, frequent falls, clumsiness, contractures of ankles, hips
 Gower’s maneuver- will be sitting and then go to hands, then feet wide apart with hands still on
floor, moves buttocks upwards, and then proceeds to standing
 Affects 1-3500 males
 Signs and Symptoms
Late walker (around 18 months or later)
Difficulty running or jumping
Frequent falls
Enlarged calf muscles
Scoliosis like symptoms- abnormal curvature of spine
Assess for family history
 Lab findings:
Increased CPK (released with muscle breakdown)
Diagnostic: muscle biopsy (looks to see abnormal functioning and breakdown of cells)
Electromyography: external electrodes on muscles that send shocks to see how the
muscles contract and react)
 Progresses until wheelchair confinement
 Need to encourage them to do as much as they can for as long as they can
 Inactivity can increase progression- but need to assess for safety- prevent contractures with PT
 OT from waist up to do self care ST if degeneration of swallowing
 Death may result from cardiac failure or respiratory infection- may need pacemakers
 Medications
Anti-inflammatory
Corticosteroids
Watch for GI disturbances, increased hunger causing weight changes d/t immobility
LEGG-CALVE PERTHES DISEASE
Osteochereses- diseases of the bones and cartilage
Disease that affects the hip joints- cut off of blood supply to the head of the femur causing necrosis
Tissue death occurs- avascular necrosis
The head of the femur will begin to crumble and collapse
Boys 5-12 years old most affected
Usually presents unilaterally- painless limp (may be some pain from the muscle being pulled)
Assessment:
Pain in hip
Compare range of motion with unaffected hip
Ask if any pain in the knee, may complain of pain in the groin
Limp
Diagnosis
X-ray- flat and fragmented femur
Is self-limiting disorder that heal spontaneously
Treatment involves keeping head of femur deep in socket while it heals and avoiding weight bearing
May have cast or braces
Unknown cause but may be genetic factors. Some theories are blood clotting disorder, may have had
previous trauma to the hip and over time the hip has lost blood supply.
Prognosis- younger child has better prognosis as their bones revascularize and remodel quicker, older
child will have more complications and will more than likely have osteoarthritis in the long term.
Four Stages of LCPD healing
1. Femoral head becomes more dense with possible fracture of supporting bone
2. Fragmentation and Reabsorption of the bone
3. Reossification when new bone has regrown
4. Healing when new bone reshapes
Phase 1 takes about 2-6 months, Phase 2 takes on year or more, and Phase 3 and 4 may go on for
many years
SCOLIOSIS
S shaped curvature of the spine
More common in girls
Usually found in adolescence, 8-10 years old
Untreated leads to:
Back pain
Fatigue
Disability
Heart and lung complications
Complications with pregnancy
Cause is usually unknown
May notice uneven level in shoulders
May have uneven hips, shoulder blade may protrude more than the other, head may be displaced
Rotation of the spine
Treatment:
Aimed at correcting curvature
Milwaukee Brace- CTLSO (Cervico-thoraco-lumbo-sacral orthosis)
Harrington rod, spinal fusion- 2 weeks Stryker bed
Go home in plaster body cast on strict bed rest for about 12 weeks
Then 2 weeks in hospital to PT to learn to walk again
Home with corset 24 hours a day for a year
May need halo traction to correct head alignment
Management begins with screening