MUSCULOSKELETAL SYSTEM

Review of Anatomy and Physiology The musculo-skeletal system

consists of the muscles, tendons, bones and cartilage together with the joints

The primary function of which is to produce skeletal movements

Muscles

Three types of muscles exist in the body

1. Skeletal Muscles Voluntary and striated

2. Cardiac muscles Involuntary and striated

3. Smooth/Visceral muscles Involuntary and NON-striated Visceral, plain muscles

Muscle Types:1. Skeletal Muscle

accounts for at least 40% of body mass aids in the formation of the smooth contour of the bodyParts:1.1 Epimysium

Tough connective tissue covering of the entire muscle. It binds many fascicles together. Tendon/Apponeurosis : blending of the epimysia

1.2 Perimysium Fibrous membrane covering several sheathed muscle

fibers Fascicles – are bundles of muscle fibers covered by

perimysium.1.3 Endomysium

This is connective tissue sheath enclosing individual muscle fiber.

Skeletal Muscle Characteristics:

Voluntary control (but can also be activated by reflexes)

(+) Striations Multinucleated Shape: Cylindrical

Speed of contraction: Variable

2. Smooth Muscle Found mainly in the walls of hollow

visceral organs such as the stomach, urinary bladder and respiratory passages.

propels substances along a definite tract, or pathway, within the body.

Smooth Muscle Characteristics: Involuntary control (-) Striations; no distinct sarcomeres Uninucleated Spindle-shaped Speed of Contraction: slow and sustained; does not develop an oxygen debt

Smooth muscle

3. Cardiac Muscle Found only in the heart (cardiac). Heart – serves as a pump, propelling

blood into the blood vessels and to all tissues of the body.

Cardiac fibers are cushioned by small amounts of soft connective tissue and arranged in spiral or figure 8-shaped bundles.

Cardiac Muscle Characteristics: Involuntary control (+) Striations Multinucleated Branched Speed of contraction: Variable

Muscle Functions:1) Production of

movements/locomotion2) Maintenance of posture3) Joint stabilization4) Generating heat5) Energy production

Similarities of all Muscle Types:a) All muscle cells are elongated (this

explains the term muscle fibers)b) Muscle contractions depends on

the types of myofilaments (thin and thick myofilaments)

c) Terminology (prefixed: myo, mys, & sarco)

Microscopic Anatomy of Skeletal Muscle

1. Sarcolemma Plasma membrane of skeletal

muscle cells.2. Myofibrils

Long ribbon like organelles, pushing the nuclei aside

Alternating dark (A) and light (I) bands along the length of the myofibrils, give the muscle cell (as a whole) a striated appearance.

Microscopic Anatomy of Skeletal Muscle3. Sarcomere

Functional unit of a muscle. These are chains of contractile

units of myofibrils.

4. Sarcoplasmic Reticulum Surrounds individual myofibrils Specialized smooth endoplasmic

reticulum. Major function: storage and

release of calcium during muscular contraction.

SARCOMERE- functional unit of the muscle; extends from one Z-line to another Z-line - mainly composed of actin & myosin myofilaments

Z-disk or Z-line = anchors the actin myofilaments

M-line= holds the myosin filaments in place

Muscle Physiology Stimulation and Contraction of a Single Skeletal

Muscle Cell Functional Properties of Muscle Fibers:

1. Irritability – ability to react and respond to stimulus

2. Contractility – ability to shorten when stimulated by adequate stimulus

The Nerve Stimulus and Action Potential1. Motor Unit - single motor neuron and all of the

corresponding muscle fibers it innervates. 2. Action Potential - the electrical signal sent out

by the body to control bodily processes such as muscular movement.

SKELETAL MUSCLE:

LMN control Energy is consumed during muscle

contraction – LACTIC ACID (↓O2) MUSCLE FATIGUE:

↑ work of muscle with inadequate O2

supply Depletion of glycogen & energy stores Accumulation of lactic acid

Structure and function of the skeletal system

Skeletal system consist of Axial and Appendicular skeleton.

Axial Skeleton- which is composed of bones of the skull, thorax and vertebral column which forms the axis of the body.

Appedicular Skeleton- consist of bones of the upper and lower extrimities, including the hip and the shoulder.

Two types of connective tissue found in the skeletal system

1. Cartilage – a semi-rigid and slightly flexible structures that plays an essential role in prenatal and childhood development of the skeleton and as a surface for the articulating ends of the skeletal joint.

2. Bones – which provide the firm structure of the skeleton and serve as reservoir for calcium and phosphate storage.

Three types of cartilage

Elastic Cartilage- Contain some elastin in each intracellualr substance. ( ears)

Hyaline Cartilage- Pearly white, found in the articulating ends of the bones.

- form the fetal skeleton . Fibro cartilage- has a characteristic that are

intermediate between dense connective tissue and hyaline cartilage. It is found in the intervertebral disks, in areas where tendons are connective to bone and in the symphysis pubis.

- 65-80% are water.

Bone- is a connective tissue in which the intracellular matrix has been impregnated with inorganic calcium salts so that it has a great tensile and compressible strength but is light enough to be move by coordinated muscle contractions.

BONES

Variously classified according to shape, location and size

Functions1. Locomotion2. Protection3. Support and lever4. Blood production5. Mineral deposition

Bone is made up of four major components: mineral (mainly calcium and

phosphorus) matrix (collagen fibers) osteoclasts (bone-removing cells) osteoblasts (bone-producing cells).

Osteocytes ( mature bone cells for bone maintenance fxns)

SKELETAL SYSTEM: BONE STRUCTURE

PERIOSTEUM: Dense fibrous membrane covering the bone Periosteal vessels supply bone tissue

EPIPHYSIS: Widened area at the end of the long bone

EPIPHYSEAL PLATE (growth zone) Cartilage area in children w/c provides for

longitudinal growth of the bone ARTICULAR CARTILAGE:

Provides smooth surface over the ends of the bone to facilitate joint movement

Type of bone cell

Osteogenic cells- Undifferentiated cells that differentiate into osteoblasts. They are found in the periosteum, endosteum, and epiphyseal growth plate of growing bones.

Osteoblasts- Bone building cells that synthesize and secrete the organic matrix of bone. It also participate in the calcification of the organic matrix.

Osteocytes- Mature bone cells that function in the maintenance of bone matrix. Osteocytes also play an active role in releasing calcium in the blood .

Ostroclasts- Bone cells responsible for the resorption of bone matrix and the release of calcium and phosphate from bone.

SKELETAL SYSTEM: BONE STRUCTURE

RED BONE MARROW: Hemopoietic tissue located in the central

bone cavities. Adults: ribs, sternum, vertebrae, portions

of hips & pelvic bones Long Bones filled with fatty, yellow

marrow FUNCTIONS:

Formation of RBC, WBC & platelets Destruction of old RBC (phagocytosis)

BONE FORMATION (Osteogenesis) OSSIFICATION

Process by which matrix (collagen fiber & ground substance) is formed & hardening minerals are deposited on collagen fibers (give tensile strength)

ENDOCHONDRAL Osteoid (cartilage-like tissue) is formed,

reabsorbed, & replaced by bone

INTRAMEMBRANOUS Bone develops within membrane (e.g. face,

skull)

BONE MAINTENANCE & HEALING: REGULATORY FACTORS DETERMINING

BOTH FORMATION & RESORPTION: 1. Weight-bearing (local stress) 2. Vitamin D (Calcitrol) promotes

absorption of calcium from GIT 3. Parathyroid Hormone regulates

calcium 4. Calcitonin & Amino biphosphate

(e.g. Alendronate [Fosamax]) increases production of bone cells

BONE MAINTENANCE & HEALING: 1. Weight-bearing (local stress)

Stimulate bone formation & remodelling Prolonged bed rest: bone losses calcium

(resorption) & becomes osteopenia & weak

2. Biologically Active Vitamin D (Calcitrol)

↑ amount of Ca in blood by promoting absorption of Ca from GIT

Facilitates mineralization of osteoid tse Deficiency cause bone demineralization,

deformity & fracture

BONE MAINTENANCE & HEALING: 3. Parathyroid Hormone

(parathormone) regulates calcium in blood in part by

promoting mov’t of Ca from the bone ↓ Ca in blood ► ↑ PTH prompt

demineralization of the bone 4. Calcitonin & Amino biphosphate

(e.g. Alendronate [Fosamax]) increases production of bone cells

Calcitonin- inhibits release of calcium from the bone into the extracellular fluid and reduces the renal tubular reabsorption of calcium

Parathyroid hormone

Parathyroid gland

Bone – release of Ca and phosphate

Calcium concentration in the extracellular fluid

Kidney reabsorption of Calcium

Urinary excretion of Phosphate

Activation of Vit.D

Intestine Reabsorption of Ca via activated vit. D

BONE MAINTENANCE & HEALING: Estrogen & Androgen

Stimulate osteoblastic activity & inhibit PTH Menopause/Andropause –

↓Ca ► bone loss ► osteoporosis

Androgen-testosterone Promote anabolism ↑bone mass ESTROGEN-It appears that oestrogen deficiency

allows greater expression of these cytokines, all of which are associated with increased stimulation of bone resorption which then leads to increased bone loss and a reduction in BMD.

Androgens Androgens, like oestrogens, can directly affect and modulate bone cell function. Androgen receptors are found on osteoblast cell lines and they can cause osteoblast proliferation. Hypogonadal men, in common with post-menopausal women, have decreased calcium absorption and low vitamin D levels. The replacement of androgens with testosterone can correct these abnormalities, suggesting again that sex hormones are required for the maintenance of bone health.

BONE HEALING: STAGE 1. HEMATOMA FORMATION &

INFLAMMATION When bone is damaged or injured, hematoma precedes new

tissue formation in the production of new bone substance STAGE 2. CELLULAR PROLIFERATION:

Granular tissue formation where BV & cartilage overlie the fracture

Callus forms as minerals are deposited to organize new network for the new bone

STAGE 3. PRECALLUS FORMATION: (2-6 wks) Callus forms the initial clinical union of the bone & provides

enough stability to prevent movement when bones are gently stressed

STAGE 4. CALLUS FORMATION: Consolidation & Remodelling (complete healing- 3-6months) Continued bone healing provides for gradual return of the

injured bone to its pre-injury shape & structural strength

Bone healing

FACTORS AFFECTING TIME REQUIRED FOR HEALING: 1. age 2. displacement 3. site of fracture 4. nutritional level 5. blood supply to the area of injury

JOINTS

Permits bone to change position & facilitate body mov’t

Diarthrodial (synovial) joint is the most common type of joint in the body

joints

joints

joints

Joints

joint

joints

CARTILAGE (hyaline)

A dense connective tissue that consists of fibers embedded in a strong gel-like substance that cover the end of the bone

CARTILAGE

ARTICULAR CARTILAGE Rigid, connective, avascular tissue that

covers each bone ends Damaged cartilage heals slowly (lacks

direct blood suply)

BURSAE

Sac containing fluid that are located around the joints to prevent friction

A fibrous capsule of connective tissue joins the 2 bones together

1. SYNOVIUM (synovial membrane) Lines the capsule

2. SYNOVIAL FLUID Secreted by the synovium & decreases

friction by lubricating the joints

TENDONS (aponeurosis)

Bands of fibrous connective tissue that tie bones to muscles

LIGAMENTS

Strong, dense and flexible bands of fibrous tissue connecting bones to another bone

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM The nurse usually

evaluates this small part of the over-all assessment and concentrates on the patient’s posture, body symmetry, gait and muscle and joint function

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM 1. HISTORY

Injury, surgery, disability, inflammatory / metabolic conditions

Familial predisposition Level of normal activity (occupation,

exercise, recreation) 2. Physical Examination

Inspection for gross deformities, asymmetry, swelling, edema

Nutritional status: weight, body frame

ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM

Gait (Antalgic); Genu Valgum (Knock-Knee), Genu Varum (Bow-Legged)

Posture (Kyphosis/Lordosis/Scoliosis) Muscular palpation Joint palpation (Crepitus-grating

sound) Range of motion Muscle strength

Assessment Findings

6 P’s of NEUROVASCULAR DAMAGE

Swelling Loss of function Deformity Crepitus

P allorulselessness

aresthesia

aralysis

ain

oikilothermia

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES 1. BONE MARROW ASPIRATION

Usually involves aspiration of the marrow to diagnose diseases like leukemia, aplastic anemia

Usual site is the sternum and iliac crest Pre-test: Consent Intratest: Needle puncture may be

painful Post-test: maintain pressure dressing

and watch out for bleeding

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES 2. Arthroscopy

A direct visualization of the joint cavity

Pre-test: consent, explanation of procedure, NPO

Intra-test: Sedative, Anesthesia, incision will be made

Post-test: maintain dressing, ambulation as soon as awake, mild soreness of joint for 2 days, joint rest for a few days & ice

application to relieve discomfort

2. ARTHROSCOPY - C.I for pt who cannot flex @ 40° and with

infected knee Uses large pneumatic tourniquet to

minimize bleeding Apply dressing, neurovascular check,

observe for complications swelling,hyperthermia, thrombophlebitis,infxn

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM

KNEE ARTHROSCOPY

ARTHROSCOPY

KNEE ARTHROSCOPY

SHOULDER ARTHROSCOPY

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES3. BONE SCAN Imaging study with the use of a contrast

radioactive material Pre-test: Painless procedure, IV

radioisotope is used, no special preparation, pregnancy is contraindicated

Intra-test: IV injection, Waiting period of 2 hours before X-ray, Fluids allowed, Supine position for scanning

Post-test: Increase fluid intake to flush out radioactive material

BONE SCAN– Radioisotope injected IV (technetium, Gallium, Thalium)

Adm. Isotope 1-2 days before scanning

No radioactive threats Procedure lasts 30-60 min No special care after procedure Excreted in Urine & feces Encourage fluid

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEMLABORATORY PROCEDURES

4. DEXA- Dual-energy XRAY Absorptiometry

Assesses bone density to diagnose osteoporosis

Uses LOW dose radiation to measure bone density

Painless procedure, non-invasive, no special preparation

Advise to remove jewelry

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM 5. Xray Films: Roentgenograms –

plain xray film is common APL (Antero-posterior lateral views.

6. ARTHROGRAPHY: injection of dye or air in the joint for x-ray study

7. MYELOGRAPHY: examines spinal cord after introduction of contrast medium

Myelography

ARTHROGRAPHY

Arthrography is the radiographic examination of a joint, after the injection of a dye-like contrast material and/or air, to outline the soft tissue and joint structures on the images.

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM 8. BONE/MUSCLE BIOPSY: Iliac

crest usual puncture site; not commonly done today

Local anesthesia, check PT & PTT Coagulant given 2-3 days before &

after procedure Pressure dressing after

ASSESMENT OF THE MUSCULO-SKELETAL SYSTEM 9. CT SCAN: assess bone & soft

tse tumors 10. MRI: to assess soft tissue

and joints with myelography GANDOLINIUM DTPA

(DiethyleneTriamine PentaAcetic Acid)

BLOOD STUDIES:1. ESR (Erythrocyte Sedimentation

Rate): non-specific test for inflammation F: 0-20

mm/hr M: 0-10 mm/hr

2. URIC ACID: Elevated in gout Normal 2.2-7 mg/dl (F) ;4.2-8 mg/100 ml

(M)

3. ANA (Anti-nuclear Anti-body): Measures the presence of antibodies that

destroy the nucleus of the body tissue cells in auto-immune disorder;

(+) in about 94% of clients w/ SLE Sjoren’s syndrome RA

BLOOD STUDIES:

RHEUMATOID FACTOR (Latex Fixation): Determine presence of auto antibodies (RF)

found in clients with connective tissue dse (+) RF is suggestive of RA The higher the antibody titer the greater the

degree of inflammation

MINERAL METABOLISM:

1. CALCIUM : ↓ in osteomalacia, hypoparathyroidism; ↑bone tumors, acute osteoporosis,bone fracture(healing phase) Normal: 4.5 – 5.8 mEq/L or 9-10.5

mg/dL 2. PHOSPHORUS: ↓ in

osteomalacia, ↑ healing fractures, CRF, bone tumor Normal: 3 - 4.5 mEq/L

MUSCLE ENZYME TESTS:

1. CREATININE PHOPHOKINASE (CK3 or CK-MM) F: 30-135 U/L; M:55-170 U/L – highest

concentration in traumatic injuries, progressive muscular dystrophy

2. ALKALINE PHOSPHATASE (ALP-2) – Increased in Cancer, Paget’s Dse & Osteomalacia. Normal: 20-90 IU/L

COMMON MUSCULOSKELETAL

PROBLEMS

The Nursing Management

Nursing Management of common musculo-skeletal problems

1. PAIN These can be related to joint

inflammation, traction, surgical intervention

1. Assess patient’s perception of pain

2. Instruct patient alternative pain management like meditation, heat and cold application, guided imagery

Nursing Management

PAIN 3. Administer analgesics as

prescribed Usually NSAIDS Meperidine (demerol)can be

given for severe pain 4. Assess the effectiveness of pain

measures

Nursing Management

2. IMPAIRED PHYSICAL MOBILITY 1. Instruct patient to perform range of

motion exercises, either passive or active

2. Provide support in ambulation with assistive devices

3. Turn and change position every 2 hours

4. Encourage mobility for a short period and provide positive reinforcements for small accomplishments

Nursing Management

3. SELF-CARE DEFICITS 1. Assess functional levels of the

patient 2. Provide support for feeding problems

Place patient in Fowler’s position Provide assistive device and supervise

mealtime Offer finger foods that can be handled by

patient Keep suction equipment ready

Nursing Management

SELF-CARE DEFICITS 3. Assist patient with difficulty

bathing and hygiene Assist with bath only when patient has

difficulty Provide ample time for patient to finish

activity

FRACTURES

Fracture

A break in the continuity of the bone and is defined according to its type and extent

Fracture

Severe mechanical Stress to bone bone fracture Direct Blows Crushing forces Sudden twisting motion Extreme muscle contraction

fractures

Fracture

TYPES OF FRACTURE 1. Closed fracture (SIMPLE)

The fracture that does not cause a break in the skin

2. Open fracture (COMPOUND or COMPLEX) The fracture that involves a break in the

skin3. Complete Fracture-involves entire cross

section of the bones4. Incomplete Fracture – involves only a

portion of the cross section of the bone

Fracture

TYPES OF FRACTURE 5. Comminuted fracture

A fracture that involves production of several bone fragments

6. Greenstick Fracture One side is broken the other side is beat

7. Depressed fragment is driven inward (skull,facial bones)

TYPES OF FRACTURE

8. Transversed Break straight across the bone

9. Spiral Forms oblique angle to the bone shaft

Fracture: ASSESSMENT

CLINICAL MANIFESTATIONS:1. Pain: immediate, sever2. Loss of function3. Deformity; abnormal positioning of

extremity4. Shortening5. Crepitation: palpable or audible6. Edema

7. Paresthesia- burning or tingling sensation

8. Numbness 9. Motor weakness 10. Pulselessness, impaired capillary refill time and cyanotic skin

Fracture

ASSESSMENT FINDINGS1. Pain Continuous and increases in

severity Muscles spasm accompanies

the fracture is a reaction of the body to immobilize the fractured bone

Fracture

ASSESSMENT FINDINGS2. Loss of function Abnormal movement and pain can result to this manifestation

Fracture

ASSESSMENT FINDINGS3. Deformity

Displacement, angulations or rotation of the fragments

Fracture

ASSESSMENT FINDINGS4. Crepitus A grating sensation

produced when the bone fragments rub each other

Fracture

DIAGNOSTIC TEST

X-ray

Fracture

EMERGENCY MANAGEMENT OF FRACTURE 1. Immobilize any suspected

fracture Support the extremity above and below

when moving the affected part from a vehicle

Suggested temporary splints- hard board, stick, rolled sheets

Apply sling if forearm fracture is suspected or the suspected fractured arm maybe bandaged to the chest

Fracture

EMERGENCY MANAGEMENT:OPEN FRACTURE 1. Open fracture is managed by

covering a clean/sterile gauze to prevent contamination

2. DO NOT attempt to reduce the facture

Fracture

General Nursing MANAGEMENT For CLOSED FRACTURE 1. Assist in reduction and

immobilization 2. Administer pain medication and

muscle relaxants 3. Teach patient to care for the cast 4. Teach patient about potential

complication of fracture and to report infection, poor alignment and continuous pain.

General Nursing MANAGEMENT For OPEN FRACTURE 1. Prevent wound and bone infection Administer prescribed antibiotics Administer tetanus prophylaxis Assist in serial wound debridement 2. Elevate the extremity to prevent

edema formation 3. Administer care of traction and cast

FRACTURE COMPLICATIONS

Early1. Shock (Hypovolemic Shock)2. Fat embolism - 1st 48 hrs3. Infection 4. Impaired Circulation (cast/edema)5. Compartment syndrome6. Venous Stasis & thrombus formation

FRACTURE COMPLICATIONS

Late 1. Delayed union / Nonunion 2. Angulation (bone heals at a distorted

angle) 3. Delayed reaction to fixation devices 4. Complex regional syndrome

FRACTURE COMPLICATIONS: Fat Embolism Occurs usually in fractures of the long

bones Fat globules may move into the blood

stream because the marrow pressure is greater than capillary pressure

Fat globules occlude the small blood vessels of the lungs, brain kidneys and other organs

FRACTURE COMPLICATIONS: Fat Embolism Onset is rapid, within 24-72 hours

ASSESSMENT FINDINGSA. 1. Sudden dyspnea and

respiratory distress & hypoxia 2. tachycardia 3. Chest pain 4. Crackles, wheezes and cough 5. Petechial rashes over the chest,

axilla and hard palate

Fat embolism

classic triad: hypoxemia; neurologic abnormalities; and a petechial rash.

H- Hypoxemia N- N eurologic a-bnormalities P- Petechial rash

Fat embolism

Assessment finding B. Neurological finding 1. Cerebral emboli- frequently present

after early stages. 86 % after the respiratory distress.

- The more common presentation is with an acute confusional statebut focal neurological signs, including hemiplegia, aphasia,apraxia, visual field disturbances, and anisocoria, have beendescribed.

Fat embolism

The characteristic petechial rash may be the last componentof the triad to develop. It occurs in up to 60% of cases andis due to embolization of small dermal capillaries leading toextravasation of erythrocytes. This produces a petechial rashin the conjunctiva, oral mucous membrane, and skin folds ofthe upper body, especially the neck and axilla.[6] It does notappear to be associated with any abnormalities in platelet function.The rash appears within the first 36 h and is self-limiting,disappearing completely within 7 days.

Nursing ManagementMany studies shows that early

immobilization and fixation decrease the incidence of pulmonary complication.

- Adequate fluid resuscitation, transfusion and TPN could decrease the incidence of FES ( Fat embolism syndrome )

1. Support the respiratory function Respiratory failure is the most common cause of

death Administer O2 in high concentration Prepare for possible intubation and ventilator

support

2. Administer drugs

Corticosteroids Dopamine Morphine

3. Institute preventive measures Immediate immobilization of fracture Minimal fracture manipulation Adequate support for fractured bone during

turning and positioning Maintain adequate hydration and

electrolyte balance

Early complication: Compartment syndrome

A complication that develops when tissue perfusion in the muscles is less than required for tissue viability

COMPARTMENT SYNDROME

Muscles, nerves, vessels are restricted to confined space (myofascial compartment) within an extremity

ETIOLOGY: Decreased Compartment size from cast,

splints, tight bandage, tight surgical closure

Increase in compartment contents d/t edema or hemorrhage

Early complication: Compartment syndrome

ASSESSMENT FINDINGS 1. Pain- Deep, throbbing and

UNRELIEVED pain by opioids d/t reduction in the size of the muscle

compartment by tight cast d/t increased mass in the compartment by

edema, swelling or hemorrhage

Muscle ischemia (compression) Arterial compression may not occur;

pulses may be (+) – (early) Blisters Can result in permanent damage in a

short time (6-8 hrs) PARESTHESIA- first sign PULSELESSNESS - late sign

Medical and Nursing management:

1. Assess frequently the neurovascular status of the casted extremity

2. Elevate the extremity above the level of the heart

3. Assist in cast removal and FASCIOTOMY

Surgical Treatment If surgery is required to relieve the

pressure, the physician will make an incision and cut open the skin and fascia covering the affected compartment. This reduces the pressure in the compartment. The skin incision is surgically repaired when swelling recedes. Sometimes a skin graft may be needed.

4 R’S IN MGMT OF FRACTURE

1. RECOGNITION of presence of fracture

2. REDUCTION: Closed Reduction (manipulation) Open Reduction (ORIF – surgery) Traction

4 R’S IN MGMT OF FRACTURE

3. RETENTION Cast Traction Braces / splints Bandage

4. REHABILITATION – restoration to normal fxn Walker Crutches Cane

CANES

Should be used on the side opposite the affected leg

Cane + Affected leg move together

CANES

Canes

Handle should be always level of clients greater trochanter .

Clients elbow should be flex at a 15- 30 degrees angle

Instruct the client to hold the cane 4-6 inches on the side of the client.

WALKERS

LIFT the walker & place it approx. 2 ft. in front

Gain balance before moving walker forward again

Balance provides stability & equal wt. bearing

PROSTHESIS

UP WITH THE GOODDOWN WITH THE BAD

4-Point Crutch Gait

Indication:Weakness in both legs or poor coordination

Sequence:1-Left crutch, 2-right foot, 3-right crutch, 4-left foot. Then repeat.

Advantages:Provides excellent stabilty as there are always three points in contact with the ground

Disadvantages:Slow walking speed

3-Point Crutch Gait

Indication:Inability to bear weight on one leg. (fractures, pain, amputations)

Pattern Sequence:1-move both crutches and 2- the weaker lower limb forward. Then bear all your weight down through the crutches3- move the stronger or unaffected lower limb forward. Repeat.

Advantages:Eliminates all weight bearing on the affected leg.

Disadvantages:Good balance is required.

2-Point Crutch Gait

Indication:Weakness in both legs or poor coordination.

Pattern Sequence:1-Left crutch and right foot together, then the 2-right crutch and left foot together. Repeat.

Advantages:Faster than the four point date.

Disadvantages:Can be difficult to learn the pattern.

SWING-TO Gait

Indications:Patients with weakness of both lower extremities.

Pattern Sequence:Advance both crutches forward then, while bearing all weight down through both crutches, swing both legs forward at the same time to (not past) the crutches.

Advantage:Easy to learn.

Disadvantage:Requires good upper extremity strength.

SWING THROUGH GAIT

Indications:Inability to fully bear weight on both legs. (fractures, pain, amputations)

Pattern Sequence:Advance both crutches forward then, while bearing all weight down through both crutches, swing both legs forward at the same time past the crutches.

Advantage:Fastest gait pattern of all six.

Disadvantage:Energy consuming and requires good upper extremity strength.

TRAUMATIC CONDITIONS:

1. CONTUSION – soft tissue injury produce by blunt force, blow, kick or fall

S/Sx: a. hemorrhage (ecchymosis) ruptured

BV b. pain & swelling

CONTUSION

Mgmt:

1. elevate affected part 2. cold compress to diminish

edema (1st 24H) 3. apply pressure bandage to

reduce swelling 4. apply heat to affected area after

6 hrs to promote absorption.

Strains

Excessive stretching of a muscle or tendon

Nursing management:1. Immobilize affected part2. Apply cold packs initially, then

heat packs3. Limit joint activity4. Administer NSAIDs and muscle

relaxants

Sprains

Excessive stretching of the LIGAMENTS

Nursing management1. Immobilize extremity and advise rest2. Apply cold packs initially then heat packs3. Compression bandage may be applied to

relieve edema4. Assist in cast application5. Administer NSAIDS

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Musculoskeletal ModalitiesTractionCast

Nursing Management

Traction A method of fracture immobilization

by applying equipments to align bone fragments

Used for immobilization, bone alignment and relief of muscle spasm

Traction

Skin traction – applied at the surface of skin & soft tissue & indirectly to the bone using adhesive elastic bandage & spreader. max. 7lbs (e.g. Bryant, Russel Traction)

Skeletal traction – applied directly to the bone using wire, pins, tongs. max. 40 lbs. (e.g. Halo pelvic, Crutchfield tong traction)

Traction

Non-adhesive traction

Skin traction

Bryants traction Cervical traction

Position clients: low fowlers positionMaintain 20 degree angle at the thigh to bed Protect the skin from break downProvide pin care if pin is used with the skeletal traction Clean the pin site with sterile normal saline and hydrogen peroxide or povidone iodine

Balance suspension traction

INDICATIONS/PURPOSES:

For immobilization Prevent & correct deformity Maintain good alignment Give support to reduce pain &

muscle spasm To reduce fracture

Indications for Traction reduction, immobilisation &

alignment of fractures relieve muscle spasm & pain prevent further soft tissue damage to promote rest

ne

RUSSEL’S TRACTION

Russell’s traction

Commonly used to stabilized the fracture femur before the surgery. - Similar to bucks traction but provide double pull with

the use of knee sling- traction pull’s the knee and the foot.

BALANCED SUSPENSION

BUCK’S EXTENSION TRACTION

- Is used to alleviate muscle spasm and immobilized a lower limb by maintaining a straight pull on the limb with the use of weights.

- boot appliance is applied to attach to the traction.- Not more than 8-10 lbs - Elevate the foot of the bed to provide traction.

90-90 TRACTION

Dunlop’s traction

Description: Horizontal traction used to align fractures of the humerus. Vertical traction: used to maintain forearm for proper alignment

Halo vest traction Cervical traction

Nursing Management

Traction: General principles1. ALWAYS ensure that the weights

hang freely and do not touch the floor

2. NEVER remove the weights3. Maintain proper body alignment (dorsal

recumbent)4. Ensure that the pulleys and ropes are

properly functioning and fastened by tying square knot

Nursing Management

Traction: General principles5. Observe and prevent foot drop

Provide foot plate

6. Observe for DVT, skin irritation and breakdown

7. Provide pin care for clients in skeletal traction

EXTERNAL FIXATOR DEVICE

External frame with a lot of pins.Provide more freedom compare to traction.

Internal fixator

Provide immediate bone strength but risk for infection.

Traction: General principles8. For every traction, there is

always a counter traction – use shock blocks; use half ring Thomas splint

9. The line of pull must be in line with deformity

10. Friction should be eliminated

Nursing Management

CAST Immobilizing tool made of plaster of

Paris or fiberglass Provides immobilization of the

fracture

PURPOSES:

IMMOBILIZATION PREVENTION/CORRECTION OF

DEFORMITY SUPPORT OBTAINING A HOLD OF A LIMB TO

SERVE AS MODEL FOR MAKING ARTIFICIAL LIMB

Nursing Management

CAST: types1. TRUNK

Minerva Cast, Rizzers Jacket-Scoliosis,

2. UPPER EXTREMITY3. LOWER EXTREMITY4. Spica

CASTS

MINERVA CAST SCOLIOSIS BRACE

BODY BRACES

SCOLIOSIS BRACE

Casting Materials

Plaster of Paris• Drying takes 1-

3 days• If dry, it is

SHINY, WHITE, hard and resonant.

Fiberglass• Lightweight

and dries in 20-30 minutes

• Water resistant

CHARACTERISTICS OF GOOD CAST: White, shiny Odorless Light in wt Not too tight Not too loose Resonant on

percussion

Nursing Management

CAST: General Nursing Care 1. Allow the cast to dry (usually

24-72 hours) 2. Handle a wet cast with the

PALMS not the fingertips 3. Keep the casted extremity

ELEVATED using a pillow 4. Turn the extremity for equal

drying. Use low cool drier.

CAST: General Nursing Care 5. Petal (cutting the edges) the edges of the cast to prevent crumbling of the edges

6. Examine the skin for pressure areas and Regularly check the pulses and skin

CAST: General Nursing Care 7. Instruct the patient not

to place sticks or small objects inside the cast

8. Monitor for the following: pain, swelling, discoloration, coolness, tingling or lack of sensation and diminished pulses

CAST: General Nursing Care9. Observe for signs of plaster sore:

itchiness/burning sensation, sever pain, rise of temp, disturbed sleep, restlessness, offensive odor, discharges(windowing-exposing a tight area to relieve edema/pain, petalling)

10. Observe for signs of cast syndrome: prolonged N/V, repeated vomiting, abd.distention, vague abd.pain, (-)bowel sound

PLASTER CAST SAW

Specific Fractures:

COLLE’S FRACTURE Distal radius

PELVIC FRACTURE: Freq in elderly Can cause intra abd injury and urinary

tract injury Turn pt only on specific orders

HIP FRACTURE Common in elderly women Clinical manifestation:

External rotation & adduction of affected extremity

Shortening of the length of the affected extremiety

Severe pain & tenderness Treatment:

Initially- Buck’s traction Surgery

AFTER SURGERY Neurovascular check Position: PREVENT FLEXION

ADDUCTION & INTERNAL ROTATION Do not adduct past neutral position Maintain in abducted position with A-

frame pillow or pillows between legs Avoid flexion of hip of more than 90

degrees Prevent internal or external rotation by

using sandbags, pillows, trochanter rolls at the thigh

After surgery

Extreme external rotation accompanied by severe Pain ---displaced hip prosthesis

Amputation

Etiology and pathophysiology 1. Refers to the removal of a body

part as a result of trauma or surgical intervention 2. Necessitated by: a. Malignant tumor b. Trauma c. Acute arterial insufficiency

Amputation Therapeutic interventions 1. Below-the-knee amputation (BKA)

common in peripheral vascular disease; facilitates successful

adaptation to prosthesis because of retained knee function 2. Above-the-knee amputation (AKA)

necessitated by trauma or extensive disease 3. Upper extremity amputation usually

necessitated by severe trauma, malignant tumors, or

congenital malformation

Amputation

Assessment 1. Neurovascular status of involved extremity 2. History to determine a. Causative factors b. Health problems that can compromise

recovery 3. Client's understanding of the extent of the

surgery 4. Client's coping skills 5. Client's support system

Amputation

Assessment 1. Neurovascular status of involved extremity 2. History to determine a. Causative factors b. Health problems that can compromise

recovery 3. Client's understanding of the extent of the

surgery 4. Client's coping skills 5. Client's support system

Amputation Planning/Implementation 1. Provide care preoperatively a. Initiation of exercises to strengthen muscles

of extremities in preparation for crutch walking b. Coughing and deep-breathing exercises c. Emotional support for anticipated alteration

in body image 2. Monitor vital signs and stump dressing for

signs of hemorrhage 3. Elevate stump for 12 to 24 hours to

decrease edema; remove pillow after this time to promote functional

alignment and prevent contractures

Amputation 4. Provide stump care a. Maintain elastic bandage to shrink and

shape stump in preparation for prosthesis b. When wound is healed, wash stump daily,

avoiding the use of oils, which may cause maceration

c. Apply pressure to end of stump with progressively firmer surfaces to toughen stump

d. Encourage client to move the stump e. Place the client with a lower extremity

amputation in a prone position twice daily to stretch the flexor muscles and prevent hip flexion contractures

5. Teach client about phantom limb sensation

Rheumatoid Arthritis

Etiology and pathophysiology 1. Chronic disease characterized by

inflammatory changes in the body's connective tissue, particularly areas

that have a cavity and easily moving surfaces 2. Cause unknown, although theories include

autoimmunity, heredity, and psychophysiologic factors 3. Exacerbations are linked to physical and

emotional stress

Rheumatoid arthritis

Clinical findings 1. Subjective a. Fatigue b. Malaise c. Joint pain d. Stiffness after periods of inactivity,

particularly in the morning e. Paresthesia f. Anorexia

Rheumatoid arthritis

Objective a. Anemia b. Weight loss c. Joint inflammation and deformity d. Subcutaneous nodules e. Elevated sedimentation rate f. Low-grade fever g. Presence of rheumatoid factors in serum

identified by latex fixation test h. Positive C-reactive protein and antinuclear

antibody (ANA) tests

Rheumatoid arthritis

Therapeutic interventions 1. Corticosteroids, antiinflammatories, analgesics, immunosuppressive drugs; aspirin is drug of

choice followed by the addition of nonsteroidal antiinflammatory drugs and then gold or penicillamine, an oral chelating agent; corticosteroids are reserved for acute inflammation, if possible

2. Physiotherapy to minimize deformities 3. Surgical intervention to remove severely

damaged joints (e.g., hip replacement)

Rheumatoid arthritis

4. Application of heat or cold; paraffin dips of affected extremity for

relief of joint pain by providing uniform heat

5. Plasmapheresis may be used when the disease is advanced

Rheumatoid arthritis

Assessment 1. History of onset and progression of

symptoms, noting degree to which pain interferes with normal

activities 2. Family history of rheumatoid

arthritis 3. General physical health 4. Coping skills

Rheumatoid arthritis

Planning/Implementation 1. Administer analgesics and other medications as

ordered 2. Teach the client to take medications as ordered

and observe foraspirin toxicity (tinnitus, bleeding) and other adverse effects of medications

3. Apply heat and cold as ordered; heat paraffin to 125o to 129o F (52o to 54o C)

4. Promote rest and position to ease joint pains 5. Provide for range-of-motion exercises up to the

point of pain, recognizing that some discomfort is always present

Rheumatoid arthritis

6. Emphasize the need to remain active, but incorporate rest

periods to avoid fatigue 7. Encourage the client to verbalize feelings 8. Help set realistic goals, focusing on

strengths 9. Encourage use of supportive devices to help

client conserve energy and maintain independence 10. Provide care for the client following joint

replacement

Rheumatoid arthritis

11. Encourage diet rich in nutrient-dense foods such as fruits, vegetables, whole grains, and legumes to improve and maintain nutritional status and compensate for nutrient interactions of corticosteroid and other treatment medications

D. Evaluation/Outcomes 1. Experiences a reduction in pain 2. Completes activities of daily living using

supportive devices as needed 3. Accepts life-style consistent with abilities 4. Maintains or improves range of motion of

involved joints

Osteoarthritis (Degenerative Joint Disease) Etiology and pathophysiology 1. Etiology relates to wear and tear of

joints; predisposing factors include obesity, aging, and joint trauma 2. A degeneration and atrophy of the

cartilages and calcification of the ligaments 3. Primarily affects weight-bearing

joints, spine, and hands

Osteoarthritis (Degenerative Joint Disease) Clinical findings 1. Subjective a. Pain after exercise b. Stiffness of joints 2. Objective a. Heberden's and Bouchard's nodes

symmetrically occurring on fingers (bony hypertrophy) b. Decreased range of motion c. Crepitus when joint is moved

Osteoarthritis (Degenerative Joint Disease) Therapeutic interventions 1. Weight reduction in instances of

obesity 2. Local heat to affected joints 3. Medications to reduce symptoms,

such as analgesics, antiinflammatory agents, and steroids

4. Exercise of affected extremities

Osteoarthritis (Degenerative Joint Disease) 5. Surgical intervention a. Synovectomy: removal of the enlarged

synovial membrane before bone and cartilage destruction occurs b. Arthrodesis: fusion of a joint performed when

the joint surfaces are severely damaged; this leaves the

client with no range of motion of the affected joint c. Reconstructive surgery: replacement of a badly

damaged joint with a prosthetic device

Assessment 1. History for risk factors such as

obesity, trauma, athletic involvement, and occupation 2. Joints, noting evidence of

deformities, inflammation, and muscle

atrophy 3. Extent of range of motion of

involved joints

Planning/Implementation 1. Assist client in activities that require using affected

joints; allow for rest periods 2. Maintain functional alignment of joints 3. Attempt to relieve the client's discomfort and edema

by the use of medications or the application of heat as ordered

4. Allow client ample time to verbalize feelings regarding limited motion and changes in life-style

5. Support client through weight loss program if indicated

6. Encourage client to follow physical therapist's instruction regarding regular exercise program and use of supportive

7. Provide care for the client requiring joint replacement (see Nursing Care of Clients with Fractures of the Hips)

8. Refer client and family to the Arthritis Foundation

D. Evaluation/Outcomes 1. Reports a reduction in pain 2. Completes activities of daily living using

supportive devices as needed 3. Develops life-style consistent with limitations 4. Follows daily program of prescribed exercise 5. Complies with weight-loss program