Farahnaz Danandeh, BSN, MSN/Ed., RN

Musculoskeletal system

Grossmont Vocational Nursing Spring 2016

Objectives:

● Describe functions of the skeletal system.● Discuss common musculoskeletal disorders using the nursing process in

the pediatric, adult and elderly patient.● Identify elements of the nursing assessment of the musculoskeletal

system, including therapeutic communication and psychological factors.● Describe the differences between rheumatoid arthritis and degenerative

joint disease.● List common diagnostic and laboratory test used in the evaluation of

musculoskeletal disorders.● Identify types of fractures and hip fractures.● Describe the common signs and symptoms and treatment modalities of

fractures.● Describe types of reduction procedures.● Describe crutch gait and list elements of patient education related to using

crutches.● Discuss the nursing care for the patient with an amputation with special

emphasis on rehabilitation.● Identify nutritional considerations for patients with musculoskeletal

disorders.

Anatomy and Physiology

•Bones–There are 206 bones in the human body–Classification: short bones, long bones, flat bones,–and irregular bones–Two types of bony tissue (compact and spongy bones)

–Composition of bones (Your bones contain a matrix, osteoblasts, osteoclasts, osteocytes, and collagen fibers. Bones are hard structures because of the calcium that builds up in the matrix,

but they retain a slight amount of elasticity due to the fibers). –Types of bone cells (Osteoblasts, Osteoclasts, Osteocytes )

Bone marrow red marrow that is responsible for producing red blood cells, white blood cells and platelets. yellow marrow consisting mainly of fat cells

There are a number of blood vessels and capillaries traversing through the marrow making it a very vascular organ.

The musculoskeletal system's primary functions include supporting the body, allowing motion, and protecting vital organs.

The musculoskeletal system is made up of the body's bones (the skeleton), muscles, cartilage, tendons, ligaments, joints, and other connective tissue that supports and binds tissues and organs together.

The skeleton serves as the main storage system for calcium and phosphorus.

The skeleton also contains critical components of the hematopoietic (blood production) system and fat storage. These functions occur in red marrow and yellow marrow, respectively.To allow motion, different bones are connected by articulating joints. Cartilage prevents the bone ends from rubbing directly on to each other while the muscles contract, or undergo shortening, to move the bones associated with the joint.

Functions of the skeleton: Support, Protection, Movement, Hematopoiesis ( RBC,WBC,PLT), Storage(ca, p)

Functions of Muscles: Voluntary Movement (posture,gait, upright position,balance), Involuntary Muscle action (maintain Heart beat to pump blood, provides arterial blood flow, promotes lymphatic and venous return to heart, dilates and contracts blood vessels to control blood flow, maintain respiration, performs digestion processes, participates in reflexes, enable all other involuntary actions of body), protection Reflex action in stress situation, support internal organs and produces heat, assists in regulating body temp., shape of the body.

Question•Is the following statement true or false?

•There are two types of bones in the body.

Answer•False

•Rationale: Bones are classified as short bones, long bones, flat bones, and irregular bones. There are two types of bony tissue in the body.

Anatomy and Physiology—(cont.)

•Muscles: skeletal, smooth, and cardiac•Joints–The junction between two or more bones –Free-moving or diarthrodial joints•Tendons–Cordlike structures that attach muscles to the periosteum of the bone–Attachments of the muscle•Origin and insertion

Question

•Is the following statement true or false?

•Tendons attach bone-to-bone.

Answer

•False

•Rationale: Tendons are cordlike structures that attach muscles to the periosteum of the bone. Tendons connect muscles to their corresponding bone.

Anatomy and Physiology—(cont.)

•Ligaments: fibrous tissue connecting two adjacent, freely movable bones•Cartilage–Firm, dense type of connective tissue–Types: hyaline or articular, costal, semilunar, fibrous, and elastic•Bursae–Small sac filled with synovial fluid–Reduces friction between areas

Question•Is the following statement true or false?

•Ligaments attach bone-to-bone.

Answer•True

•Rationale: Ligaments attach bone-to-bone. The connection is of two adjacent, freely movable bones.

Diagnostic Studies

● Electromyogram (EMG)

a neurodiagnostic, graphic record of the electrical activity of muscle both at rest and during contraction; used to diagnose

neuromusculoskeletal disorders (e.g., muscular dystrophy); usually performed by a neurologist

● Magnetic resonance imaging (MRI)

a nonionizing (no x-ray) imaging technique using magnetic fields and radiofrequency waves to visualize anatomic structures; useful in

orthopedic studies to detect joint, tendon, and vertebral disk disorders. Radio waves and magnetic field used to view soft tissue. Inform patient

that procedure is painless. Ensure patient has no metal on clothing. Tell pt that machine is loud, provide ear plugs or music if requested. Tell pt

to remain still. Administer ANTIANXIETY(Ativan or Xanax). Can do an open MRI for obese pt or pt with large chest and abdominal girth or

severe claustrophobia.

● Nuclear medicine imaging or radionuclide organ imaging

an ionizing imaging technique using radioactive isotopes

● Bone scan

a nuclear scan (radionuclide image) of bone tissue to detect a tumor, malignancy, etc.

● Radiography

an imaging modality using x-rays (ionizing radiation); commonly used in orthopedics to visualize the extremities, ribs, back, shoulders, and joints

● Arthroscopy is a procedure for diagnosing and treating joint problems.

● Computed tomography (CT) or computed axial tomography (CAT)

a specialized x-ray procedure producing a series of cross-sectional images that are processed by a computer into a two-dimensional or

three-dimensional image.Inform patient that procedure is painless and to REMAIN STILL during procedure. If contrast medium is being

used, verify that pt doesn't have shellfish allergy.

● Sonography

ultrasound imaging; a nonionizing technique that is useful in orthopedics to visualize muscles, ligaments, displacements, and dislocations or

to guide a therapeutic intervention, such as that performed during arthroscopy.

● Rheumatoid Factor (RF)Assess presence of autoantibodies in serum. CAN INDICATE RHEUMATOID ARTHRITIS; seen in other connective tissues diseases.

● Erythrocyte sedimentation rate (ESR)

Measures rapidity with which red blood cells settle from unclotted blood in 1 hr. CAN INDICATE INFLAMMATION.

● Arthrogram

a radiograph of a joint taken after the injection of a contrast medium

● Antinuclear antibody (ANA)

assess presence of antibodies capable of destroying the nucleus of the body's tissue cells. INDICATES LUPUS (positive in 95% of lupus)

● Uric acid

end product of purine metabolism normally excreted in urine. INDICATES GOUT.

● C-reactive protein (CRP)

diagnoses inflammatory diseases, infections, and active widespread malignancy. Present in large amounts in serum 18-24 hours after onset

of tissue damage.

● Arthrocentesis

Done to obtain synovial fluid from a joint for diagnosis (such as infections) or to remove excess fluid. A needle is inserted through

the joint capsule and fluid is aspirated.No special preparation is needed. Apply compression dressing and assess for bleeding and

leakage of fluid following the procedure.

● Dual X-ray Absorptiometry (DXA)

DXA scans are done to to estimate the density of a client’s bone mass- usually in the hip or spine- and the presence/extent of osteoporosis.

Assessment/ Musculoskeletal examination

•History–Chronic disorder: medical, drug, allergy; familial; –occupational–Recent injury: occurrence of trauma–Open injury•Date of last tetanus immunization–Completion of list of symptoms–Determining the effect of activity on symptoms occupational diseases

Musculoskeletal examination , Cont.

Heat Soft tissue swellingSkin Synovial thickening Color change  Periarticular swelling  Consistency Nodules  Sweating or coldness Effusion  Eruptions Ulcerations Wasting (atrophy, dystrophy, spasm, contracture) Tenderness to palpation and pain on motion CrepitationDeformity Abnormal angulation Subluxation

Stability Abnormalities of trunk and spineLimitation of motion Scoliosis  Flexion (mostly easily documented by measuring lengthening) Kyphosis (thoracic level)   Lateral flexion Lordosis (lumbar level)   Rotation

Ambulation Gait Ability to ambulate with or without aids 

Assessment—(cont.)

Assessment: traumatic injury•Vital signs; swelling; external bleeding, bruising; open wounds, debris, protrusion of bone or tissue•Peripheral circulation, sensation•malalignment of the injured limb•Injury beyond the original area•Pain: type and location

Cont.Is the problem a local one or are many areas involved? Is the problem symmetrical?Is the functional abnormality due to:A defect in the forces acting on the joint?A defect in the fulcrum (joint) itself?Are there systemic manifestations (e.g., rash, fever)?

Neuromuscular assessment

Neurovascular assessment ( CSM)

6 P’s: Pulselessness, Paresthesia, Pallor, Puffiness, Pain, Poikilothermia or cool exts.

Assessment of Upper ExtremitiesAssessment of SpineAssessment of Lower Extremities

Nursing Management

•Diagnostic Tests–Diagnostic examination protocols–Send specimens to the laboratory–Ensure safe recovery after

procedure, Chronic Disorder

–General medical history–Current symptoms–Compile drug, allergy histories

Nursing Management—(cont.)● Invasive Joint Examination–Inspect: swelling, bleeding, or drainage–Change or reinforce dressings

Traumatic Injury–Information regarding injury–Monitor: vital signs, neurovascular status–Provide comfort and support

Nursing Process of the Adult, Elderly and Pediatric patient:Assessment: subjective data; pain objective data; gait, posture, appearance, deformities, ROM, history:social and illness, locomotor exam: limbs and muscles, bones and joints.

Nursing Diagnosis and planning

Teaching

Nutritional needs: high protein, high fiber, fluid and electrolytes, I&O

pharmacology: Nonsteroidal anti-inflammatory drugs(NSAIDs), gold salts, corticosteroids, immunosuppressive, antimalarials, antibiotics, muscle relaxants, anti gout

special gerontologic considerationsDecline in muscle mass and strength associated with aging.

increased risk of disability, falls, unstable gait

Risk of osteoporosis and osteopenia ( decreased bone mineral density

caused by osteoporosis)

Limited ROM, joint instability, risk of osteoarthritis.

Nursing measures:Prevent osteoporosis by adequate daily intake of calcium and vitamin D, physical exercise, smoking cessation, Advice routine bone-mineral density screening, Pain medication to enhance functionality. Implement strategies to prevent falls, Encourage physical activity through health education and goal setting to maintain function.

Special considerations in Peds:The main difference between adult and children is that children's bones are growing; adults' bones have stopped growing. This bone growth happens in two ways - by growing lengthwise and widthwise. The bone grows lengthwise in an area at the ends of the bones called the epiphyseal plate or growth plate, in the region known as the metaphysis. The widthwise growth occurs on the surface of the bone. Growing bone has inherent areas of weakness due to the growth process. In fact, children's tendons and ligaments are relatively stronger than the growth plate; therefore, with severe trauma the growth plate will give way before the ligament. On the other hand, children's bones and muscles are more elastic and heal faster compared to adults.

Traumatic injuries

Sprains , Contusions and strains are common injuries that share similar signs and symptoms, but involve different parts of your body.

Sprains (injury to ligament) Strains (Streched) Contusions ( soft tissue damage)

Pain Pain

Swelling SwellingMuscle spasms Muscle spasmsLimited ability to move the affected muscle Limited ability to move the affected muscle

You need to see the doctor if:

● Can't walk more than four steps without significant pain● Can't move the affected joint● Have numbness in any part of the injured area

Sprains causes● Ankle — Walking or exercising on an uneven surface● Knee — Pivoting during an athletic activity● Wrist — Landing on an outstretched hand during a fall● Thumb — Skiing injury or overextension when playing racquet sports, such as tennis

Strains causes● Slipping on ice● Running, jumping or throwing● Lifting a heavy object or lifting in an awkward position

Diagnostic test:

X-rays can help rule out a fracture or other bone injury as the source of the problem.

Treatment:

medication, conservative treatment (RICES), surgery

REST, ICE, COMPRESSION, ELEVATION, STABILIZATION

Prevention

By Mayo Clinic Staff

Regular stretching and strengthening exercises for your sport, fitness or work activity, as part of an overall physical conditioning program, can help to minimize your risk of sprains and strains. Try to be in shape to play your sport; don't play your sport to get in shape. If you have a physically demanding occupation, regular conditioning can help prevent injuries.

You can protect your joints in the long term by working to strengthen and condition the muscles around the joint that has been injured. The best brace you can give yourself is your own "muscle brace." Ask your doctor about appropriate conditioning and stability exercises. Also, use footwear that offers support and protection.

Dislocations:A dislocation is an injury to a joint —

a place where two or more of your bones

come together — in which the ends of your

bones are forced from their

normal positions. This painful injury

temporarily deforms and

immobilizes your joint.Subluxation is the result of an incomplete separation of the bones that come together at the joints. Dislocation is more common to be found on arms and legs while the partial dislocation or subluxation is more common on the shoulders, fingers and kneecaps.

● Visibly deformed or out of place● Swollen or discolored● Intensely painful● Immovable,

also experience tingling or numbness near or below the injury — such as in your foot for a dislocated knee or in your hand for a dislocated elbow.Causes:Sports, Fall, MVADiagnostic tests:Xrays, MRITreatments and drugs:

Treatment of the dislocation depends on the site and severity of your injury and may include:● Reduction. During this process, your doctor may try some gentle maneuvers to help your bones back into position.

Depending on the amount of pain and swelling, you may need a local anesthetic or even a general anesthetic before manipulation of your bones.

● Immobilization. After your bones are back in their right positions, your doctor may immobilize your joint with a splint or sling for several weeks. How long you wear the splint or sling depends on the joint involved and the extent of damage to nerves, blood vessels and supporting tissues.(conservative tx.)

● Surgery. You may need surgery if your doctor can't move your dislocated bones back into their correct positions or if the nearby blood vessels, nerves or ligaments have been damaged. Surgery may also be necessary if you have had recurring dislocations, especially of your shoulder.

● Rehabilitation. After your splint or sling is removed, you'll begin a gradual rehabilitation program designed to restore your joint's range of motion and strength.

Fractures

A fracture, also known as a broken bone, is a condition

that alters the contour in the bone. There are many types of fractures.

Fractures often occur when there is a high force or impact put on a bone.Symptoms:

● Pain● Swelling● Bruising● Discolored skin around the affected area● Angulation - the affected area may be bent at an unusual angle● The patient is unable to put weight on the injured area● The patient cannot move the affected area● The affected bone or joint may have a grating sensation● If it is an open fracture there may be bleeding

When a large bone is affected, such as the pelvis or femur..The sufferer may look pale and clammy There may be dizziness (feeling faint)...as well as a feeling of sickness and nausea.

Causes:Fractures occur when there is a force applied to a bone that is stronger than

the bone itself. Fractures can occur from falls, trauma, and a direct blow to a bone.

Repetitive forces caused by running can cause a fracture as well. Often these running fractures are termed stress fractures; these are small cracks in the bone. Osteoporosis may also cause a fracture within the older population.

Treatment

A bone fracture is most commonly treated by the use of a cast and/or splint. A cast or splint will immobilize the bone in order to promote bone alignment and prevent use of the bone. In some cases when the bone is small (toes or fingers) no cast is needed and the fracture is immobilized by wrapping. Medication may also be prescribed to ease the pain of the fracture.Traction may also be necessary to treat a fracture. Traction uses a system of pulleys and weights to stretch the muscles and tendons around the broken bone. If a fracture is bad enough, surgery may be required. Hip fractures almost always require surgery since non-operative treatments require prolonged immobilization and often result in poor functional outcome. Internal and external rods and/or pins (ORIF) may be used to hold the bone in place in order for bone alignment.

What are the possible complications of a bone fracture?

● Compartment syndrome: raised pressure within a closed part of the body (compartment) that cuts off blood supply to muscles and nerves, often caused by bleeding and hematoma around the fracture site.

● Hemarthrosis: bleeding into a joint space causing the joint to swell● Shock● Blood clot in a blood vessel : blockage of a blood vessel which can break off and move through the body, fat

embolism, PE● Complications from casting such as pressure ulcers, and joint stiffness● Delayed bone healing● Damage to surrounding tissue, nerves, skin, blood vessels, or nearby organs● Avascular Necrosis● Wound infection

How long does it take for a bone fracture to heal?

It depends. Each person’s healing process is different. It depends on the location of the fracture, the severity of the break, age, and nutritional status. For example, a fractured leg is going to take a lot longer to heal than a fractured finger. Generally, younger individuals heal faster than older individuals. Proper nutrition also plays a role. The average healing process takes anywhere from 6 to 8 weeks.stage 1: right after fxstage 2: after 1 weekstage 3: in 6-12 weeksstage 4: about 12 months

Vertebrae have 3 main parts. The body (purple) is a weight-bearing surface and an attachment for the disc. The vertebral arch (teal) forms the spinal canal through which the spinal cord runs. The processes (beige) arise from the vertebral arch to form the facet joints and processes for muscle and ligament attachments.

Symptoms of vertebral fracture can include pain or

the development of neural deficits such as the following:● Weakness● Numbness● Tingling● Neurogenic shock – In this situation, hypotension is associated

with relative bradycardia as a result of autonomic hyporeflexia● Spinal shock - The temporary loss of spinal reflex activity that occurs below a total or near-total spinal cord injury;

initially results in hyporeflexia and flaccid paralysis; with time, the descending inhibitory influence is removed and hyperreflexive arches—even spasticity—may occur

TreatmentMinor fractures or those with column stability are treated without surgery.The 4 basic types of stabilization procedures are as follows:

● Posterior lumbar interspinous fusion - Least-invasive method; involves the use of screws to achieve stability and promote fusion

● Posterior rods - Effective in stabilizing multiple fractures or unstable fractures

● Z-plate anterior thoracolumbar plating system - Has been used for the treatment of burst fractures

● Cage

The most common types of repetitive motion injuries are tendonitis and bursitis.

A tendon is a white fibrous tissue that connects muscle to bone and allows for movement at all joints throughout the human body.Tendinitis is an inflammation of the tendon.

A bursa is a small pouch or sac that is found over an area where friction may develop and serves to cushion or lubricate the area between tendon and bone.Bursitis is inflammation of a bursa sac. Different types of bursitis include traumatic, infectious, and gouty.

Carpal tunnel syndrome: due to repetitive wrist motions and the symptoms are Pain, numbness, tingling, burning sensations, wasting of muscles at base of thumb, dry palm.Repeated use of the same motion may cause tissues to swell and become fatigued. Both work and recreational activities can cause repetitive motion syndrome. When the tissues swell and put pressure on the nerves, you may experience:

● Tenderness● Tingling● Numbness● Weakness● Pain with use

Treatment for repetitive motion syndrome may include:● Avoiding activities that cause symptoms.● Stretching and strengthening exercises.● Applying moist heat or cold packs alternately.● Resting the area and using splints.● Using anti-inflammatory medicines.● Avoiding alcohol, tobacco, and caffeine.

Repetitive Motion Injuries

Elbow Bursitis

Other traumatic injuries

● Rotator cuff tear chronic overuse of shoulder joint. s/s pain and limited mobility. tx NSAIDs, rest, immobilization, steroid injections, progressive exercises and stretching, surgery● Ligament and Meniscal injuries

s/s pain, instability, ambulatory difficulty. tx NSAIDs, ice, immobilization, limited weight bearing, progressive activity, surgery● Ruptured Achilles tendon

s/s loud pop, severe pain, inability to plantar flex. tx surgical repair then cast or brace and physical therapy