Musculo-skeletal Terms Ankylosis stiffness and fixation of a jointAntalgic gait staggering uncoordinated gait Contracture resistance of movement of muscle or joint as a result of fibrosis of supporting soft tissues Atrophy flabby appearance of muscle leading to decreased toneCrepitation frequent audible crackling sound that accompanies movementKyphois exaggerated thoracic curve Lordosis exaggerated lumber curvatureMuscle spascity increased muscle tone and with sustained contactionsPes plantus flatfoot Scoliosis asymmetric elevation of shoulders scapula and ilian creasts with lateral spine curvature Subluxation of joint partial dislocation of joint Torticollis neck is twisted to one sideGait steppage gait foot needs to be lifted to cleat the floor and foot drop is evident Short leg gait limpingSpastic gait short steps dragging of foot jerky and uncoordinated Subjective Data Assessment Joint pain or stiffnessBone painMuscle weaknessObjective Data Assessment Skeletal and Muscular The examination should always start with a visual inspection of the exposed area at rest. Compare one side with the other, checking for symmetry. You should look specifically for skin changes, muscle bulk, and swelling in and around the joint. Look also for deformity in terms of alignment and posture of the joint.Compare skeleton for alignment, contour symmetry, size and gross deformities Observe joints for range of movement, tenderness, pain and heat, crepitus and swellingMuscles compare sides for symmetry, size and tone and tendernessBones for tenderness or painWhat will you teach the patient about cast care?The things they shouldnt doDo not get it wet Do not remove any paddingInsert any objects inside the castWeight bear for at least 48 hoursCover the cast with plastic for prolonged periods

What you do want them to doApply ice directly over the fracture site in a plastic bag Dry cast after exposure to water use a hairdryer on a low setting, blot dry with a towelElevate extremity above the level of the heart for the first 48 hoursMove joints above and below cast What should be reported Increasing painSwelling associated with pain and discoloration of toes or fingersPain or tingling under the cast or pain associated with moving Sores or foul odor under the cast Recognizing compartment syndrome (6 Ps)Paresthesia: numbness and tinglingPain: distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through compartmentPressure: in compartmentPallor: coolness and loss of normal color of extremityParalysis: loss of functionPulselessness: diminished/absent peripheral pulsesOther complications Renal FailureUrine output must be assessed Dark reddish brown urineClinical manifestations associated with acute renal failure

NB: If compartment syndrome is suspected the extremity should not be elevated above heart level. , Do not apply cold compressFat EmbolismMost patients manifest symptoms 24 to 48 hours after injury.Fat globules transported to lungs cause a hemorrhagic interstitial pneumonitis. Patient frequently expresses a feeling of impending disaster.In a short time skin color changes from pallor to cyanosis.Sudden shortness of breath.Sharp chest pain that is worse when you cough or take a deep breath.A cough that brings up pink, foamy mucus.Patient may become comatose.Pulmonary embolism can also cause more general symptoms. For example, in addition to the anxiety, diaphoresis, feeling lightheaded or faint, with fast heart rate or palpitations. Deep vein ThrombosisPrecipitating factorsIncorrectly applied cast or tractionLocal pressure on a veinImmobilitySigns and SymptomsNormally occurs in the deep veins of the legSwelling in one or both legsPain or tenderness in one or both legs, which may occur only while standing or walkingWarmth in the skin of the affected legRed or discolored skin in the affected legVisible surface veinsLeg fatigue

Hip fracture and SurgeryNormally affects older adultsFall associated with balance issuesGetting out of the chair and bedFalls to the side more likely to result in hip fractureTargeted interventions calcium and vitamin DOestrogen replacement

PresentationDamage to adjacent tissuesSerious disruption of blood supplyDeformity, angulation and shortening of the limb.Inability to move leg Pain and swellingTreatmentStabilisation and internal fixationComplications Fat embolismNerve and Vascular damageProblems associated with bone union Open fracture associated problemsSoft tissue damage

Post Surgery Monitor vital signsIntake and OutputSupervise respiratory activitiesAdminister pain medicationObserve wound siteAlignment of limbsEarly mobilizationPrevention of other complications

NB: Use an abductor pillow in between limbs, sandbags and pillow to prevent external rotation Avoid extreme hip flexion, avoid turning patient on the affected sideIf a hip prosthesis has ben insertion dislocation can occur therefore you should teach patient to avoid extremes in flexion. The patient should not sit for prolonged periods in the chair, should not cross feet and legs when sitting, bend over to put on shoes and socks, avoid low seats such as toilet seats for at least six weeksPotential for neurovascular impairmentAssess ColourTemperatureCapillary refillDistal (pedal)pulsesSensationMotor functionPain Limb amputation Limb AmputationUndertaken for Trauma, Thermal injuries, Infection, Circulatory complicationsGoal of amputation is to preserve extremity, length and function whilst removing all infected, pathogenic and ischemic tissue.Postoperatively - Vital signs, Sterile dressing techniques and bandaging the limb, making sure prosthesis fits properly and does not rub, Physical therapy and crutch walking Potential complications - Flexion contractures, Bleeding, InfectionFlexion contractures hip flexion - avoid sitting in the chair for more than an hour, or having pillows under the surgical extremity, lying on their abdomen for 30 minutes three to four time a day also helps to prevent this ROM exercises should be started asap after surgery once pain level and medical condition allow. Balance of the altered body and proprioception needs to be considered. If a lower limb is involved - Crutch walking will be taught as soon as the person is mobile and well enough.Osteomyelitis Chronic osteomyelitis is either aContinuous, persistent problem, or aProcess of exacerbations and remissions Granulation tissue turns to scar tissue.Very difficult to treatSystemicFever, night sweats, chills, restlessness, nauseaLocalConstant bone pain that worsens with activitySwelling, tenderness, warmth at infection siteRestricted movement of affected partLater signs: drainage from sinus tractsNursing Care General: restlessness, high spiking temperature, night sweatsIntegumentary: diaphoresis, erythema, warmth, edema at infected boneMusculoskeletal: restricted movement, wound drainage, spontaneous fracturesPatient is frequently on bed rest in early stages of acute infection.Patient teaching Good body alignment and frequent position changes Prevention of flexion contracture is a common sequela of osteomyelitis. Prevention of contracture which may then progress to deformity.Instruct patient to avoid activities that circulation and swelling and serve as stimuli to spread infectionInstruct the patient to avoid any activities such as exercise or heat application that increase circulation and swelling and serve as stimuli to the spread of infection. Uninvolved joints and muscles should continue to be exercised.Teach the patient the potential adverse and toxic reactions associated with prolonged and high-dose antibiotic therapy.Importance of continuing antibiotics after symptoms have subsided should be stressed.Frequent dressing changes for open woundsMay require supplies and instruction in techniqueIf the osteomyelitis becomes chronic, patients need physical and psychologic support for a prolonged period.Treatment Long term antibiotics normally IV for several weeks Variety of antibiotics may be prescribed.Penicillin, nafcillin (Nafcil) renal impairment Neomycin, vancomycin caution side effects cardiac arrest vascular collapse, nephrotoxicityCephalexin (Keflex) renal impairment GI Cefazolin (Ancef) renal impairment Gentamycin caution side effects ototoxicity and nephrotoxicityTeaching - Care of PICC line Do not allow any sharp objects near the line.Do not clean the skin near the line with any acetone containing cleanser.Keep the insertion site clean and dressing dry.Caution against swimming Do not allow pets or young children to play with the PICC line.Changing dressings Seek professional help immediately if any discharge, redness, swelling or pain around the catheter insertion site is noticedOsteoporosis - Risk Factors Female genderIncreasing ageLow body weightWhite or Asian ethnicityFamily historyEarly menopauseExcess alcohol intakeCigarette smokingSedentary lifestyleInsufficient calcium intakeLong-term use of corticosteroids, thyroid replacement, antiseizure drugsLow testosterone levels in menDiseases associated with Osteoporosis Intestinal malabsorptionKidney diseaseRheumatoid arthritisHyperthyroidismChronic alcoholismCirrhosis of the liverHypogonadismDiabetes mellitusClinical Manifestations Often termed the silent disease because there are no symptomsSudden strain FracturesBack painLoss of heightSpinal deformities Wedging and fractures of vertebraeOsteopenia is more than normal bone loss but not yet at the level of osteoporosis.Nutrition - food sources of calcium Good sources of calciumMilk YogurtTurnip greensSpinachCottage cheeseIce creamSardinesExercise should be encouraged to build up and maintain bone mass.Types of exerciseWeight bearingWalkingStair climbingDancingDrug TherapyCalciumVitamin DCalcitonin Bisphosphonates inhibit osteoclast-mediated bone resorption (e.g., etidronate [Didronel], alendronate [Fosamax]).Selective estrogen receptor modulators - Raloxifene (Evista), Teriparatide (Forteo)Lower Back PainAcute back pain - Treatment Analgesics (e.g. NSAIDs)Muscle relaxants (e.g. Flexeril)Massage & back manipulationAlternating use of heat & cold compressesOpioid analgesics for severe painBrief period of rest (1-2 days) but avoid prolonged bed restRefrain from anything that aggravates the painTeaching Advice DOPrevent lower back from straining forward by placing a foot on a step or stool during prolonged standingSleep in a side-lying position with knees & hips bentSleep on back with a lift under knees & legs or on back with 10-inch-high pillow under knees to flex hips & kneesExercise 15 minutes in the morning & evening regularlyCarry light items close to bodyMaintain appropriate body weightUse local heat & cold applicationUse a lumbar roll or pillow for sitting DO NOTSLean forward without bending kneesLift anything above level of elbowsStand in one position for prolonged timeSleep on abdomen or on back or side with legs out straightExercise without consulting health care provider if having severe painChronic Back Pain Formal back pain programRest & local heat application when cold, damp weather aggravates back pain Mild analgesics to pain & stiffnessWeight reductionSufficient rest periodsLocal heat & cold applicationExercise & activity throughout dayAntidepressants Pain relief & sleep problemsEpidural corticosteroid injectionsNursing management Post -Operative Back surgery

Maintain proper alignment of spine Pillows under thighs of each leg when supine & between legs when side-lying Fears of any movement that increases pain Sufficient staff should be available to move patient Opioids for 24 to 48 hours w/ patient-controlled analgesia (PCA) pumps Once fluids are being taken, switch to oral drugs & possible muscle relaxant (e.g. Valium) Check for cerebrospinal fluid (CSF) leakage Severe headaches Monitor peripheral neurologic signs of extremities Extremity circulation should be assessed by temperature, capillary refill, & pulses Repeat assessments q2-4 hours during first 48 hours post surgery Paresthesias may not be relived immediately relieved after surgery Note new muscle weakness or paresthesias & report to surgeon Paralytic Ileus Altered bladder emptying Use commode or ambulate to bathroom when allowed Ensure patient privacy Intermittent catheterization or indwelling catheter may be necessary Patient usually ambulates as early in postoperative period Before discharge home will be assessed on the stairs and will need to pass urine normally

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