Musculoskeletal Disorders

1
Musculoskeletal Disorders

• Megan McClintock, MS, RN
• Fall 2011

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Skeletal Functions

• Support and framework for body
• Protection of vital organs
• Assist with movement
• Blood cell production
• Mineral and salt storage

3
Structure

• Bone
• Joints
• Cartilage
• Muscle
• Ligaments/Tendons
• Fascia
• Bursae

4
Assessment - Subjective

• Gerontologic differences
• Past health history
• Medications
• Nutrition
• Occupation

5
Assessment - Objective

• Inspection
• Palpation
• Motion
• Muscle-Strength Testing
• Measurement
• Scoliosis
• Straight-leg raising test

6
Common Abnormalities

• Table 62-6
• (pg 1577)

7
Diagnostic Studies

• Diskogram
• Myelogram
• DEXA
• Bone scan
• Arthroscopy
• Arthrocentesis
• EMG
• Duplex venous doppler
• SSEP

8
Labs

• Alkaline phosphatase
• Calcium
• Phosphorus
• RF
• ESR
• ANA
• Complement
• Uric acid
• CRP
• CK

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Contusions

• Soft tissue injury from blunt force
• Overlying skin intact, but area becomes black and
  blue from localized hemorrhage
• Usually only painful if palpated

10
Hematoma

• Blood collection that occurs from torn blood
  vessel
• Pain occurs as blood accumulates and places
  pressure on nerves
• Pain occurs without palpation
• Hematomas may burst or become infected

11
Strains

• Overstretched tendons or overused muscles
• Usually arise from twisting or wrenching
  movements
• Acute sudden, severe incapacitating pain with
  swelling
• Chronic repetitive movements pain less severe
  but longer term (tennis elbow, runners knee)

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Strains
13
Sprains

• Ligament injuries
• Grade 1 (mild) small longitudinal ligament
  fiber separation
• Grade 2 (moderate) - lt100 of ligament is torn in
  cross-sectional direction. Function impaired
• Grade 3 (severe) ligament completely torn.
  Surgery required
• Grade 4 (sprain fracture) avulsion of bone
  fragment at site of ligament attachment

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Sprains
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Interventions

• Prevent
• R est
• I ce
• C ompress
• E levate
• Analgesia as necessary
• After 24-48 hrs, warm moist heat

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Subluxation/Dislocation

• Bones are dislodged from normal positions within
  joints
• Subluxation partial dislocation
• Joint capsule and ligaments damaged
• Usually deformity at site
• S/S altered length of extremity, loss of function

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Subluxation-dislocation of knee
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Interventions

• Orthopedic emergency
• Assist with realignment
• Pain relief
• Restriction of movement
• Future activity restrictions

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Fractures

• Disruption in continuity of bone
• Usually involves damage to surrounding soft
  tissue
• S/S - pain, swelling, loss of function,
  deformity, abnormal mobility, bruising (also see
  pg 1591)
• May be classified by severity and direction of
  fracture

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Type of Fracture

• Open (compound)
• Closed (simple)
• Incomplete
• Complete
• Displaced
• Comminuted

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Direction of Fracture

• Transverse
• Oblique
• Spiral
• Greenstick

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Bone Healing
23
Fracture Reduction

• Closed reduction
• ORIF (open reduction with internal fixation)

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Traction
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Fracture Repair

• Casting

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Fracture Repair

• External fixation

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Fracture Repair

• Internal fixation

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Drugs

• Muscle relaxants
• Pain medications
• Tetanus prevention
• Antibiotics

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Nutrition

• Ample protein
• Vitamins B, C, D
• Calcium
• Phosphorus
• Magnesium
• 2000-3000 mL/day of fluids
• High-fiber diet

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Interventions

• Assessment
• Distal to the extremity
• Neurovascular
• Peripheral vascular
• Peripheral neurologic
• Prevention
• Safety equipment
• Elderly (also see pg 1584)

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Interventions

• Pre-op skin prep
• Post-op neurovascular assessment
• Proper alignment positioning
• Observe for bleeding, drainage
• Prevention of constipation
• Prevention of kidney stones
• Maintenance of cardiopulmonary system

32
Traction Interventions

• Inspect skin and pin sites carefully
• Pin site care
• Correct positioning
• ROM of unaffected joints
• Maintain traction at all times

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Cast Care Interventions

• Handle a wet cast with palms only
• Support cast with pillows when wet
• Elevate at or above heart level
• Do not scratch skin with any objects
• Pad rough cast edges
• Can use cool air from hair dryer to help with
  itching
• Apply ice for first 24-36 hours
• Do not get cast wet

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Use of Crutches
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Fracture Complications

• Direct
• Infection
• Inadequate bone union
• Avascular necrosis
• Indirect
• Compartment syndrome
• Venous thromboembolism (VTE)
• Rhabdomyolisis
• Fat embolism
• Shock

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Infection

• High incidence with open fx or soft tissue injury
• Need aggressive debridement

Venous Thromboembolism (VTE)

• Esp. after hip fx, THA, total knee
• Prevent anticoagulants, SCDs, ROM to unaffected
  joints

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Compartment Syndrome

• Pressure that compromises neurovascular function
• Causes restrictive dressings, edema
• S/S Pain unrelieved by drugs and out of
  proportion 1st, late is no pulses, paralysis,
  dark brown urine
• Tx quick recognition, do
• NOT elevate, NO cold,
• fasciotomy

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Fat Embolism Syndrome

• Systemic fat globules lodge in organs and tissues
• Risk with long bone, ribs, tibia, pelvis fx
• S/S chest pain, tachypnea, dyspnea, change in
  mental status, hypoxia, petechiae on neck, chest,
  axilla, eyes, sense of impending doom
• Tx early recognition!, reposition as little as
  possible, oxygen

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Types of Fractures

• Colles wrist fx
• Silver-fork deformity
• Move thumb, fingers, shoulder
• Humerus
• Cx radial nerve or brachial
• artery injury, frozen shoulder

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Pelvic Fracture

• Can be life-threatening
• S/S bruising on the abdomen, pelvis
  instability, swelling, tenderness
• Tx Bed rest (few days to 6 weeks), may need
  traction, hip spica cast, ORIF, only turn when
  ordered by HCP

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Hip Fracture

• 30 die within 1 year of injury
• S/S external rotation, mm spasm, shortening of
  affected leg, severe pain
• Cx nonunion, avascular necrosis, dislocation,
  arthritis
• Tx surgery, may temp. use Bucks traction

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Hip Fracture Post-Op Care

• Pillows/abductor splint between knees esp. when
  turning, avoid extreme hip flexion, dont turn on
  affected side, OOB on first post-op day, in
  hospital for 3-4 days
• Posterior approach
• Table 63-11 (pg 1607)
• No extremes in flexion
• No putting on shoes, socks
• No crossing the legs or feet
• No low toilet seats
• Precautions for 6 weeks
• Anterior approach
• Limited restrictions

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Types of Fractures

• Femoral Shaft
• Can have lots of blood loss, risk of fat embolism
• Tx ORIF with traction after, hip spica cast
• Tibia
• Neurovascular assessment q 2 hrs x 48 hrs
• Stable Vertebral
• Logroll, orthotic devices, hard cervical
• collar
• Vertebroplasty
• Kyphoplasty

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Facial Fractures

• Impt to maintain patent airway, provide adequate
  ventilation
• Assume that they have a cervical injury
• Always have suction available
• For jaw fractures
• Position pt on the side with head slightly
  elevated
• Wire cutter/scissors at the bedside
• Trach tray always available
• NG tube decompression
• Oral hygiene is impt
• Protein supplements

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Amputation

• Pain is not a primary reason
• Pre-op preparation
• Post-op
• Sterile technique for dressing changes
• Immediate prosthesis vs delayed
• Dont sit in chair gt 1 hr
• Lie on abdomen 3-4 times/day
• Residual limb bandaging
• Table 63-14 (pg 1613)

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Joint Procedures

• Synovectomy
• Removal of synovial membrane
• Osteotomy
• Remove a wedge of bone
• Debridement
• Removal of degenerative debris
• Arthroplasty
• Reconstruction or replacement of a joint

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Total Hip Arthroplasty (THA)

• See notes from hip fracture
• Cant drive or take tub bath for 4-6 weeks
• Knees must be kept apart
• Dont cross legs
• Dont twist to reach behind
• Quadriceps and hip muscle exercises
• High risk for thromboembolism
• No high-impact exercises/sports
• Usually stay in the hospital 3-5 days

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Carpal Tunnel Syndrome

• Compression of the median nerve
• Women more likely to get
• S/S thumb weakness, burning pain, numbness,
  parasthesia
• Tinels and Phalens sign http//tinyurl.com/cre5l
  f2
• Tx splints, rest, surgery

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Rotator Cuff Injury

• Muscles that stabilize the humeral head and give
  ROM
• Cause fall onto outstretched arm, repetitive
  overhead arm motion, heavy lifting
• S/S shoulder weakness, pain, decreased ROM
• Drop arm test http//tinyurl.com/d2jq5jc
• Tx RICE, corticosteroid injection, surgery

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Meniscus Injury

• Occur with ligament sprains in a rotational force
  injury
• S/S no edema (unless other injury), tenderness,
  pain, effusion in the joint, felt a pop, knee
  locks or gives way, MRI
• McMurrays test http//tinyurl.com/cev9lx9
• Tx RICE, knee brace, arthroscopy, rehab starts
  quick
• Prevention warm-up exercises

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Anterior Cruciate Ligament (ACL) Injury

• Usu. Occur from non-contact
• S/S hear a pop, pain, swelling
• Lachmans test http//tinyurl.com/ccfk9ws
• Tx RICE, crutches, knee brace, reconstructive
  surgery
• May take 6-8 months to recover
• Higher risk for future knee osteoarthritis

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Bursitis

• Inflammation of the bursa (common sites hand,
  knee, hip, shoulder, elbow)
• Cause repeated trauma, gout, RA, infxn
• S/S warmth, pain, swelling, decreased ROM
• Tx REST, may ice, may aspirate or use
  corticosteroids

53
Osteomyelitis

• Acute vs Chronic
• Staphylococcus aureus
• Pathophysiology
• Signs/Symptoms
• Fever, night sweats, bone pain worse with
  activity, swelling, redness, warmth
• Diagnostic Studies
• Bone/soft tissue biopsy, WBCs, ESR, xray doesnt
  show until 10 days

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Osteomyelitis Management

• Long IV therapy (5 weeks 6 months)
• Antibiotic-impregnated beads
• Intermittent or constant irrigation
• Wound VAC
• Hyperbaric oxygen
• Removal of prosthetic devices

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Osteomyelitis Interventions

• Absorbant dressings using sterile technique
• Bed rest
• No exercise or heat application
• Observe for abx side effects

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Bone Tumors

• Osteochondroma
• Benign, overgrowth at growth plate
• S/S painless, hard mass, shortened extremity
• Tx none if asymptomatic
• Osteosarcoma
• Aggressive, rapidly metastisizes
• More common with Pagets disease
• S/S gradual onset of pain/swelling
• Is NOT caused by a minor injury
• Be very careful when turning/handling

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Muscular Dystrophy (MD)

• Genetic disease with progressive, symmetric
  wasting of skeletal muscles but no neuro
  involvement
• Several different types
• No cure (corticosteroids may help)
• Keep the patient active as long as possible

58
Low Back Pain

• Very common
• Causes strain, instability, osteoarthritis,
  DDD, disk herniation
• Acute vs chronic
• Straight leg test http//tinyurl.com/btbnoq4
• Tx analgesics, muscle relaxants, massage, heat
  and cold
• Avoid prolonged bed rest
• Stop smoking
• See Table 64-6 (pg 1627)

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Intervertebral Disk Disease

• Progressive degeneration normal process of
  aging that can lead to herniated disks
• Most common sites of slipped disks L4-5, L5-S1,
  C5-6, C6-7
• S/S low back pain, radicular pain to buttock
  and below the knee, for cervical disk have
  radicular pain to arms/hands
• Straight leg test is usu. positive
• Xray, myelogram, MRI, CT
• Conservative tx first, may need laminectomy,
  diskectomy, or spinal fusion

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Spinal Surgery

• Must maintain proper alignment until healing has
  occurred
• Pillows under thighs when supine, between legs
  when side-lying
• IV opioids for 24-48 hrs, muscle relaxers
• Watch for CSF leak
• Movement and sensation should be unchanged after
  surgery check q 2-4 for 48 hours
• Clarify if they need brace or corset
• Check donor site usu. more painful
• Avoid sitting or standing for prolonged times
• No twisting movements of the spine
• Firm mattress or bed board

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Neck Pain

• Very common
• Usu. occur from hyperflexion and hyperextension
• S/S stiffness, neck pain, pain radiating to
  arm/hand
• Tx conservative, head support, heat and ice,
  massage, rest, PT, US, NSAIDs
• See Table 64-10 (pg 1632)

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Foot Disorders

• Usu. caused by improperly fitted shoes
• Send to a podiatrist
• If surgery, usu. have a bulky dressing
• Elevate foot
• Crutches, cane, walker (may have throbbing
  sensation when starting to walk)
• Daily foot care
• Trim toenails straight across

63
Osteomalacia (Rickets)

• Loss of minerals in bones
• Bones soft rather than brittle
• Caused by
• Inadequate calcium intake
• Inadequate Vit. D intake or resistance to actions
  of Vit. D
• Increased renal loss of phosphate

64
Osteomalacia

• Bones most affected
• Spine, pelvis, lower extremities
• S/S
• Localized bone pain
• Difficulty getting up from chair, walking
• Bone deformities (bowed legs)
• Fractures
• Tx
• Vit D supplements
• Diet
• Exposure to sunlight
• Weight bearing exercise

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Osteoporosis

• Resorption rate gt formation rate
• Net loss of both bone protein matrix and mineral
  components
• Bone composition normal just not enough of it
• Bone is brittle, fragile, easily broken

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Osteoporosis bone mass
67
Osteoporosis

• Risk Factors
• Heredity, sex, race, early menopause, poor
  nutrition, sedentary lifestyle, thinness,
  smoking, ETOH ingestion
• Endocrine causes
• Cushings syndrome, diabetes, hyperthyroidism,
  hyperparathyroidism
• Drug-related causes
• Glucocorticosteriods, anticonvulsants, some
  antacids, diuretics, thyroid medications

68
Osteoporosis

• Signs symptoms
• Back pain or spontaneous fractures (1st symptom)
• Loss of height
• Deformity (Dowagers hump)
• Pathological fracture
• As many as 30 of white women will have a
  pathological fracture d/t osteoporosis

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Osteoporosis
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Treatment

• Calcium supplementation
• Proper nutrition
• Exercise
• Medications
• Calcium supplement
• Biphosphonates

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Pagets Disease

• Systemic disease involving multiple body systems
• Excessive bone resorption followed by excessive
  and abnormal bone replacement ? long bones,
  pelvis, cranium, spine
• Cause may be viral

72
Pagets Disease

• Signs Symptoms
• Pain with weight-bearing, cranial enlargement,
  kyphosis, bowed legs, reduction in height, sore
  bones, pathological fractures
• Headaches, tinnitus, hearing loss, nerve palsies,
  cardiovascular respiratory failure
• Alkaline phosphatase levels increased