Musculoskeletal Concerns

Musculoskeletal System
Functions:
o Movement and maintains posture
o Support
o Protection
o Hematopoiesis
o Mineral homeostasis

Contusions, Strains, and Sprains

o Contusion- soft tissue injury produced by blunt force.
o Strain - “muscle pull” from overuse, overstretching, or excessive stress.
o Sprain- injury to the ligaments surrounding a joint, caused by a wrenching
or twisting motion.

Treatment : “RICE”
o Rest, Ice, Compression, Elevation

Musculoskeletal Injuries
o Fracture
o Break in the continuity of bone
o Resulting from trauma or various disease processes.

Types
Complete - fracture extends
through entire bone, producing 2 or more fragments.
1. Simple or Closed- fractured bone; does not protrude through skin
2. Compound or Open- fractured
bone extends through skin and mucous membranes
3. Comminuted fracture- multiple bone fragments
A. Complete Fracture
4. Oblique fracture- fracture line at 45-degree angle to long axis of bone
5. Spiral fracture- fracture line encircling the bone
6. Transverse fracture- fracture line perpendicular to long axisof bone

B. Incomplete Fracture
Incomplete- when only part of the bone is broken.
1. Greenstick fracture- fracture of one side of bone; other side merely
bends; usually seen only in children
2. Bowing fracture- bending of bone.
3. Stress fracture- microfracture.

Stress Fracture, Bowing Fracture, Greenstick Fracture

2. Fracture

Clinical Manifestation
o Pain and tenderness
o Soft tissue edema
o Abnormal motion
o Crepitus
o Obvious deformity
o Discoloration or ecchymosis

Diagnostic Studies
o X-ray
o Objectives of Treatment
o Optimal realignment
o Rigid immobilization
o Restoration of function

Fracture Management
Treatment Modalities for Fractures:
o Closed or Open Reduction
o Casting
o Traction
o Internal or External Fixation Devices

Internal Fixation, External Fixation

o Reduction (“setting” the bone)
 Refers to restoration of the fracture fragments into anatomic
rotation and alignment
Closed Reduction (Manipulation)
o Bone ends are realigned w/o surgical exposure of the fracture site
o Anesthesia may or may not be used
o Followed by casting to maintain proper alignment

Open Reduction
o Operative procedure utilized to achieve bone alignment
o Pins, wire, nails or rods may be used to secure bone fragments in position
o Prosthetic implants may also be used

Immobilization
Maybe accomplished by internal or external fixation

Internal Fixation Devices

o Implanted surgical devices to align and stabilize the fracture site until
healing can occur
o Used when closed reduction does not provide stable immobilization
The advantage of internal fixation is that it often allows early mobility and
faster healing.

External Fixation Devices

o Two or more rigid bars are placed horizontally above and below the
fracture site in the long bones of the extremities

Complication of Fractures
o Early complications
o Shock
o Fat embolism

Assessment
o (S) dyspnea
o (O) tachypnea, tachycardia, hypoxia, crackles, wheezes, chest pain,
cerebral disturbances

N/I
High Fowler’s position
O2 stat
Respiratory support measures, CPR in event of respiratory failure
Corticosteroids: reduce inflammatory lung reaction
Morphine

Complication of Fractures
1. Compartment syndrome
o Assessment:
o (S) deep, throbbing, unrelenting pain not controlled by narcotics
o (O) paresthesia (early), swelling, motor weakness

N/I:
Elevate injured extremity
Avoid tight bandages, splints or casts
Prepare patient for fasciotomy

2.Infection
o Assessment:
o (S) pain
o (O) ↑ temperature and pulse, edema, sudden local induration, thin, watery,
foul-smelling exudate, crepitation (maybe indicative of gas gangrene; with cast-
warm area, foul smell

N/I:
Monitor V/S, drainage
Prophylactic tetanus toxoid
Prophylactic anti-infectives as ordered if wound is contaminated at time of injury
Instruct patient not to touch open wound, pin sites or put anything inside cast

Delayed complications
1.Delayed union/Non-union

Assessment:
o (S) pain
o (O) callus formation, on X-ray- poor alignment
o N/I:
o Maintain immobilization and alignment
o Maintain adequate nutrition
o Avoid trauma to affected extremity
o Increase calcium in diet
2.Avascular Necrosis/Circulatory impairment
Assessment:
o (S) tenderness, pain, especially on passive motion
o (O) limited movement
o Treatment:
o Revitalize the bone with bone grafts
o Prosthetic replacement
o Arthrodesis
Fracture Care
1.Maintain in optimal alignment
Check all bony prominences for evidence of pressure q4h and prn, depending on
amount of pressure
Monitor: circulation, sensation and motion of affected part
Assess circulation in the injured limb: warmth and color, capillary refill, peripheral
pulses

2.Assessing nerve supply to the limb

Upper extremities/lower extremities
Sensory: pinprick over fingertips/heel, dorsum of hand/foot
Motor: dorsiflexion and plantar flexion of wrist/foot
Maintain mobility in unaffected limb and unaffected joints of affected limb by
active and passive ROM exercises
Prevent foot drop by using ankle-top sneakers

Traction
o mechanism by which a steady pull is placed on a part or parts of the body
2 Types:
1.Skin traction
o Application of wide band of moleskin, adhesive, or commercially available
devices directly to the skin and attaching weights to them.

Buck’s extension
o Exerts straight pull on the affected extremity; to immobilize the leg in
patient with a fractured hip
o Has a horizontal weight
o Turn towards unaffected side
o Check for pressure sore at the heel of the foot*
Balance suspension Buck’s extension

Russel traction
o Knee is suspended in a sling attached to a rope and pulley on a Balkan
frame, creating upward pull from the knee
o Weights are attached to the foot of the bed
o Used to treat fracture of the femur
o Allows patient to move about in bed more freely and permits bending of the
knee joint
o Assess back of the knee for pressure sores

Bryant’s traction
o Both legs raised 90 angle to bed
o Used for children under 3 years and 30 lbs to treat fractures of the femur
and hip dislocation
o Buttocks must be slightly off mattress
o Knees slightly flexed
The knees should be slightly flexed, and the legs should be extended at a right
angle to the body. The body provides a traction mechanism.

Pelvic traction
Pelvic girdle with extension straps attached to ropes and weights
used for low back to reduce muscle spasm and maintain alignment

2. Skeletal Traction
o Traction applied directly to the bones using pins, wires, or tongs
(Crutchfield) that are surgically inserted, used for fractures femur, tibia, humerus,
cervical spine

Balanced suspension traction

o Produced by a counterforce other than the patient’s weight
o Extremity floats or balances in the traction apparatus
o Patient may change position without disturbing the line of traction
o Used for displaced or overriding fx of femur
o Relieves muscle spasms
o Realigns fx fragments
o Promotes callus formation
Initial weights: 30 to 40 lbs Suspension weights: 7 to 8 lbs Countertraction: 7 to 8
lbs

Pearson attachment Thomas splint

Care of the Clients in Traction
5 General Principles in Traction Care:
1. Line of pull should be in line with the deformity
2. Adequate countertraction present
3. Apply traction continuously
4. Allow the weights to hang freely
5. Avoid friction

Care of the Clients in Traction

o Turn the client as indicated

Pin site care for skeletal traction:

a. Cleanse and apply antibiotic ointment
b. Do neurovascular checks
c. Prevent complication of immobility

Nursing Intervention
a. Promote healing and prevent complications
b. diet: high protein, iron, vitamins (tissue repair), moderate carbohydrates
(prevent weight gain)
c. increase fluid intake
d. assess for complications of immobility (pneumonia, constipation, decubitus
ulcers, osteoporosis)
 e. assess casted extremity for presence of foul odor, drainage, paleness or
blueness, change in temperature, pulselessness, tingling, numbness

Fracture bedpan

Nursing Intervention
a. Prevent injury or trauma
b. avoidance of high-risk activities (sky diving, high impact sports,
rollerblading)
c. avoidance of safety hazards (throw rugs, untreated vision problems)
d. regular exercise
e. provide care related to ambulation with crutches
f. provide safety measures related to possible complications following fracture

CRUTCH WALKING
a. The distance between the axilla and the arm piece on the crutches should be
at least 3 fingerwidths below the axilla
b. The elbows should be slightly flexed, 30 degrees
c. When ambulating with the client, stand on the affected side.

Crutch stance: tripod (triangle) position (6-10 inches in front and to the side).
a. Instruct the client never to rest the axilla on the axillary bars.
b. Instruct the client to look up and outward when ambulating.
c. Instruct the client to stop ambulation if numbness or tingling in the hands
or arms occurs

Crutch gaits:
o Four-point gait

Sequence:
a. Advance left crutch 4-6 inches
b. Advance right foot
c. Advance right crutch
d. Advance left foot
Advantages : most stable crutch gait
Requirements : Partial weight bearing on both legs

Three-point gait
Sequence:
a. Advance both crutches forward with the affected leg and shift weight to
crutches.
b. Advance unaffected leg and shift weight onto it.
Advantages: allows the affected leg to be partially or completely free of weight
bearing
Requirements: full weight bearing on one leg, balance and upper-body strength.

Two-point gait
Sequence:
a. Advance left crutch and right foot
b. Advance right crutch and left foot
Advantages: Faster version of the four-point, normal walking pattern.
Requirements: Partial weight bearing on both legs
 Swing-through gait
Sequence:
a. Move both crutches forward.
b. Move both legs farther ahead than crutches.

Amputation of a Lower Extremity:

a. Removal of a body part, usually an extremity
b. phantom limb pain.10% of patients experience uncomfortable sensations
c. Risk Factors
d. Atherosclerosis obliterans
e. Uncontrolled DM
f. Malignancy
g. Extensive and intractable infection
h. Severe trauma

1. Below the knee amputation

Nursing Intervention
Preoperative:
Offer support/encouragement
Discuss:
a. Rehabilitation program & use of prosthesis
b. Upper extremity exercise such as push ups in bed
c. Crutch walking
d. Amputation dressing/cast
e. Phantom limb sensation as a normal occurrence
Observe stump dressing for signs of hemorrhage and mark outside of dressing so
rate of bleeding can be assessed (tourniquet at bedside)

Post-operative Care:
a.Prevent edema
 Raise extremity with pillow support for first 24 h
a. Prevent hip/knee contractures
 Avoid letting patient sit in chair with hips flexed for long periods of
time
 Have patient assume prone position several times a day and position
hip on extension
 Avoid elevation of stump after 24 hrs
 For BKA: hip & knee exercises
 For AKA: hip exercises
b. Pain medication as ordered (phantom limb pain)
c. Ensure that stump bandages fit tightly and are applied properly to enhance
prosthesis fitting

Inflammatory Disorders of the Musculoskeletal System:

Rheumatoid arthritis
a. chronic systemic inflammatory disease
b. destruction of connective tissue and synovial membrane within the joints
c. weakens and leads to dislocation of the joint and permanent deformity
Risk Factors
a.exposure to infectious agents
b.fatigue
 c.stress

Rheumatoid Arthritis
Signs and Symptoms:
a.Morning stiffness
b. Fatigue
c. Weight loss
d. Joints are warm, tender, and swollen
e. Swan neck deformity-late

Diagnostic Studies
a. X-ray
b. Elevated WBC, platelet count, ESR*, and positive RF
Treatment
a. No cure for RA
c. Swan neck deformity

Pharmacotherapy
a.Aspirin- mainstay of treatment, has both analgesic and anti-inflammatory
effects
b.Nonsteroidal anti-inflammatory drugs (NSAIDs):
 Indomethacin (Indocin)
 Phenylbutazone (Butazoldin)
 Ibuprofen (Motrin)
 Fenoprofen (Nalfon)
 Naproxen (Naprosyn)
 Sulindac (Clinoril)
c.Immunosuppressives : Methotrexate
 Gold Standard for RA treatment
 Teratogenic

Other treatment:
 Gold compounds
 Injectable form: sodium thiomalate, aurothioglucose; given IM
once a week; takes 3-6 months to become effective
 Oral form: auranofin- smaller doses are effective; diarrhea is
a common side effect
 Corticosteroids
 Intra-articular injections
Treatment
 Surgical Procedures: synovectomy, arthrotomy, arthrodesis,
arthroplasty
 Nursing Management
 Advised bed rest during acute pain
 Passive ROM exercise of joints
 Splint painful joints
 Heat & Cold application
 Advised warm bath in the morning
 Protect from infection
 Advised well-balanced diet
  Arthrotomy Arthrodesis Arthroplasty

Osteoarthritis (Degenerative Joint Disease):

a. Progressive degeneration of the joints as a result of wear and
tear
b. affects weight-bearing joints and joints that receive the
greatest stress, such as the knees, toes, and lower spine .

Risk Factors
a. aging (>50 yr)
b.rheumatoid arthritis
c. arteriosclerosis
d. obesity
e. trauma
f. family history
g. Signs and Symptoms
h. Dull, aching pain,* tender joints
i. fatigability, malaise
j. crepitus
k. cold intolerance*
l. joint enlargement
m. presence of Heberden’s nodes or Bouchard’s nodes
n. weight loss
Medications
Aspirin
a.inhibits cyclooxygenase enzyme, diminishes the formation of
prostaglandins
b. anti-inflammatory, analgesic, antipyretic action
c. inhibit platelet aggregation in cardiac disorders
Adverse effects
d. Epigastric distress, nausea, and vomiting
e. In toxic doses, can cause respiratory depression
f. Hypersensitivity
g. Reye’s syndrome
Ibuprofen
a.use for chronic treatment of rheumatoid and osteoarthritis
b.less GI effects than aspirin
Adverse effects
 dyspepsia to bleeding
 e.headache, tinnitus and dizziness

Indomethacin
a.inhibits cyclooxygenase enzyme
b.more potent than aspirin as an anti-inflammatory agent
Adverse effects:
 nausea, vomiting, anorexia, diarrhea
 headache, dizziness, vertigo, light-headedness, and mental confusion
 Hypersensitivity reaction

Nursing Intervention
a. Promote comfort: reduce pain, spasms, inflammation, swelling
  Heat to reduce muscle spasm
 Cold to reduce swelling and pain
a. Prevent contractures: exercise, bed rest on firm mattress, splints to
maintain proper alignment
b. Weight reduction
c. Isometric and postural exercises
d. Nursing Diagnosis
e. Pain related to friction of bones in joints
f. Risk for injury related to fatigue
g. Impaired physical mobility related to stiff, limited movement

Gouty Arthritis
a. Metabolic disorder that develops as a result of prolonged hyperuricemia
b. Caused by problems in synthesizing purines or by poor renal excretion
of uric acid.
c. Acute onset, typically nocturnal and usually monarticular, often
involving the first metatarsophalangeal joint

Risk Factors
a. Men
b. Age (>50 years)
c. Genetic/familial tendency
Signs and Symptoms
a. extreme pain
b. swelling
c. erythema of the involved joints
d. fever
e. Tophi
Laboratory Findings
a. elevated serum uric acid (>7.0 mg/dl)*
b. urinary uric acid
c. elevated ESR and WBC
d. crystals of sodium urate aspirated from a tophus confirms the diagnosis*
Treatment
Allopurinol
a. - a purine analog
b. - reduces the production of uric acid by competitively inhibiting uric acid
biosynthesis which are catalyzed by xanthine oxidase.
c. Effective in the treatment of primary hyperuricemia of gout and
hyperuricemia secondary to other conditions (malignancies).
Adverse effects : hypersensitivity reactions, nausea and diarrhea
Colchicine
a.Effective for acute attacks
b.Anti-inflammatory activity alleviating pain within 12 hours
Adverse effects : nausea, vomiting, abdominal pain, diarrhea, agranulocytosis,
aplastic anemia, alopecia
Probenecid/Sulfinpyrazone
a.uricosuric agents
b.increases the renal excretion of uric acid
c.Sulfinpyrazone used as a preventive agent.
Adverse effects: nausea, rash & constipation
Nursing Implementation
a. Maintain a fluid intake of at least 2000 to 3000 ml a day to avoid kidney
stone.
b. Avoid foods high in purine such as wine, alcohol, organ meats, sardines,
salmon, anchovies, shellfish and gravy.
c. Take medication with food.
d. Have a yearly eye examination because visual changes can occur from
prolonged use of allopurinol
e. Caution client not to take aspirin with these medication because it may
trigger a gout attack and may cause an elevated uric acid levels.
f. Encourage rest and immobilize the inflamed joints during acute attacks
g. Avoid excessive alcohol intake
h. Notify physician if rash, sore throat, fever or bleeding develops.

Osteomyelitis
a. Infection of the bone
b. Staphylococcus aureus is the most common pathogen.
c. Other organisms include Proteus, Pseudomonas and E. Coli

Risk Factors
a. poorly nourished, elderly or obese
b. impaired immune systems
c. chronic illnesses
d. long term corticosteroid therapy
Clinical Manifestation
a. area appears warm, swollen and extremely painful
b. systemic manifestations (fever, chills, tachycardia)
Diagnostic Studies
a. X-ray
b. Bone Scan
c. Blood and wound culture
Nursing Management
a. Promote comfort
b. Immobilized affected bone by maintaining splinting.
c. Elevate affected leg
d. Administer analgesics as needed.
e. Control infectious process
f. Apply warm, wet soaks 20 min. several times a day.
g. Administer antibiotics as prescribed.
h. Use aseptic technique when dressing the wound.
i. Encourage participation in ADL within the physical limitations of the
patient.

Osteoporosis
a. reduction of total bone mass
b. change in bone structure, which increases susceptibility to fracture
c. bone becomes porous, brittle, and fragile
Risk Factors
a. Menopause
b. aging
c. long term corticosteroid therapy
 d. high caffeine intake
e. smoking
f. high alcohol intake
g. sedentary lifestyle or immobility
h. insufficient calcium intake or absorption
i. hereditary predisposition
j. coexisting medical conditions (hyperparathyroidism, hyperthyroidism)
Clinical Findings
a. loss of height
b. fractures of the wrist, vertebral column and hip
c. lower back pain
d. kyphosis
e. Respiratory impairment
Diagnostic Findings
a. X-rays
b. Dual-energy x-ray absorptiometry (DEXA)
c. Serum calcium
d. Serum phosphatase
e. Urine calcium excretion
Medical Management
a. Pharmacologic Therapy
b. Hormone replacement therapy
c. Alendronate (Fosamax)
d. Calcitonin- ↓ plasma levels of Ca, ↑ deposition of Ca in the bone
Nursing Management
a. Prevention
b. Adequate dietary or supplemental calcium
c. Regular weight bearing exercise
d. Modification of lifestyle
e. Calcium with vitamin D supplements
f. Administer HRT, as prescribed
g. Relieving pain
h. Improving bowel elimination
i. Preventing injury
j. Nursing Activities
k. Encourage use of assistive devices when gait is unstable
l. Protect from injury (side rails, walker)
m. Encourage active/passive ROM
n. Promote pain relief
o. Encourage good posture and body mechanics

Bone Tumors
Osteosarcoma
a. Most common primary bone tumor
b. Occurs between 10-25 years of age, with Paget's disease and exposure to
radiation
c. Exhibits a moth-eaten pattern of bone destruction.
d. Most common sites: metaphysis of long bones especially the distal femur,
proximal tibia and proximal humerus
Clinical Manifestation
 a. local signs – pain ( dull, aching and intermittent in nature), swelling,
limitation of motion
b. palpable mass near the end of a long bone
c. systemic symptoms: malaise, anorexia, and weight loss
Diagnostic Findings
a. Biopsy- confirms the diagnosis
b. X-ray
c. MRI
d. Bone Scan
e. Increase alkaline phosphatase
Medical Management
a. Radiation
b. Chemotherapy
c. Surgical management
 amputation
 limb salvage procedures
d. Prognosis: poor prognosis (rapid growth rate)
Nursing Management
a. Promote understanding of the disease process and treatment regimen
b. Promote pain relief
c. Prevent pathologic fracture
d. Assess for potential complications (infection, complications of immobility).
e. Encourage exercise as soon as possible (1st or 2nd post-op day)

Total Hip Replacement

a. a plastic surgery that involves removal of the head of the femur followed by
placement of a prosthetic implant
Nursing Management
a. Teach client how to use crutches
b. Teach client mechanics of transferring.
c. Discuss importance of turning and positioning post-op.
d. Place affected leg in an abducted position and straight alignment following
surgery
e. Prevent hip flexion of more than 90 degrees.
f. Apply support stockings
g. Advise client to avoid external/internal rotation of affected extremity for 6
months to 1 year after surgery
h. Instruct client to avoid excessive bending, heavy lifting, jogging, jumping
i. Encourage intake of foods rich in Vitamin C, protein, and iron.
j. Administer prescribed medications.

Metallic implant
Complications
a. Infection
b. Hemorrhage
c. Thrombophlebitis
d. Pulmonary embolism
e. Prosthesis dislocation
f. Prosthesis loosening

Dysplasia of the Hip

 a. condition in which the head of the femur is improperly seated in the
acetabulum, or hip socket, of the pelvis.
b. Congenital or develop after birth
Assessment
a. Neonates: laxity of the ligaments around the hip, allowing the femoral head
to be displaced from the acetabulum upon manipulation.
b. Implementation:
c. Splinting of the hips with Pavlik harness to maintain flexion and abduction
and external rotation (neonatal period)

Pavlik harness
Assessment
Infants
a. Asymmetry of the gluteal and thigh skin folds when the child is placed
prone and the legs are extended against the examining table.
b. Limited range of motion in the affected hip.
c. Asymmetric abduction of the affected hip when the child is placed supine
with the knees and hips flexed.
d. apparent short femur on the affected side

Congenital Hip Dysplasia

a. Implementation
b. Traction and/or surgery to release muscles and tendons
c. Following surgery, positioning and immobilization in a spica cast until
healing is achieved.
Assessment
a. The walking child
b. minimal to pronounced variation in gait with lurching toward the affected
side; positive Trendelenburg sign
c. Positive Barlow or Ortolani’s maneuver
d.Ortolani’s maneuver Barlow maneuver

Scoliosis
a. Lateral curvature of the spine
b. Surgical and nonsurgical interventions are employed
c. The type of treatment depends on the degree of curvature, the age of the
child, and the amount of growth that is anticipated.
Assessment
a. visible curve fails to straighten when the child bends forward and hangs
arms down toward feet.
b. asymmetry of hip height
c. pelvic obliquity
d. inequalities of shoulder height
e. scapular prominence
f. rib prominence and rib humps
g. severe cases, cardiopulmonary and digestive function may be affected
because of compression or displacement of internal organs.
Nursing Intervention
a. Monitor progression of the curvature
b. Prepare the child and parents for the use of a brace if prescribed
c. Worn from 23 hours a day
 d. Inspect the skin for signs of redness or breakdown
e. Keep the skin clean and dry, avoiding lotions and powders
f. Advise the child to wear soft nonirritating clothing under the brace
g. Scoliosis screening: 8 years old*
Nursing Implementation
a. Prepare the child and parents for surgery if prescribed.
b. Postoperative
c. maintain proper alignment; avoid twisting movements
d. logroll the child when turning, to maintain alignment
e. instruct in activity restrictions
f. instruct the child to roll from a side-lying position to a sitting position, and
assist with ambulation
Laminectomy
a. Surgical incision of part of posterior arch of vertebrae and removal of
protruded disc
b. Nursing Intervention
c. Preoperative
i. Teach patient log rolling and use of bedpan
d. Postoperative
e. Position as ordered
f. Lower spinal surgery- flat
g. Cervical spine surgery: slight elevation of head of bed
h. Proper body alignment- cervical spinal surgery: avoid flexion of neck and
apply cervical collar
Laminectomy: Postoperative Care
o Avoid:
 Acute hip flexion (bending, stooping, crossing the legs
 Prolonged sitting/standing
 Running, jogging, horseback riding
o Back- strengthening exercises
 Prone position
 Walk in seawater
o Lie in side- lying with hip flexion
Patient teaching and Discharge Planning
 Wound care
 Good posture and proper body mechanics
 Activity level as ordered
 Recognition and reporting of complications such as wound infection,
sensory or motor deficits