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Musculoskeletal Disorders

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Title: Musculoskeletal Disorders


1
Musculoskeletal Disorders
  • Megan McClintock, MS, RN
  • Fall 2011

2
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

9
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)

12
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

14
Sprains
15
Interventions
  • Prevent
  • R est
  • I ce
  • C ompress
  • E levate
  • Analgesia as necessary
  • After 24-48 hrs, warm moist heat

16
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

17
Subluxation-dislocation of knee
18
Interventions
  • Orthopedic emergency
  • Assist with realignment
  • Pain relief
  • Restriction of movement
  • Future activity restrictions

19
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

20
Type of Fracture
  • Open (compound)
  • Closed (simple)
  • Incomplete
  • Complete
  • Displaced
  • Comminuted

21
Direction of Fracture
  • Transverse
  • Oblique
  • Spiral
  • Greenstick

22
Bone Healing
23
Fracture Reduction
  • Closed reduction
  • ORIF (open reduction with internal fixation)

24
Traction
25
Fracture Repair
  • Casting

26
Fracture Repair
  • External fixation

27
Fracture Repair
  • Internal fixation

28
Drugs
  • Muscle relaxants
  • Pain medications
  • Tetanus prevention
  • Antibiotics

29
Nutrition
  • Ample protein
  • Vitamins B, C, D
  • Calcium
  • Phosphorus
  • Magnesium
  • 2000-3000 mL/day of fluids
  • High-fiber diet

30
Interventions
  • Assessment
  • Distal to the extremity
  • Neurovascular
  • Peripheral vascular
  • Peripheral neurologic
  • Prevention
  • Safety equipment
  • Elderly (also see pg 1584)

31
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

33
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

34
Use of Crutches
35
Fracture Complications
  • Direct
  • Infection
  • Inadequate bone union
  • Avascular necrosis
  • Indirect
  • Compartment syndrome
  • Venous thromboembolism (VTE)
  • Rhabdomyolisis
  • Fat embolism
  • Shock

36
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

37
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

38
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

39
Types of Fractures
  • Colles wrist fx
  • Silver-fork deformity
  • Move thumb, fingers, shoulder
  • Humerus
  • Cx radial nerve or brachial
  • artery injury, frozen shoulder

40
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

41
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

42
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

43
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

44
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

45
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)

46
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

47
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

48
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

49
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

50
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

51
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

52
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

54
Osteomyelitis Management
  • Long IV therapy (5 weeks 6 months)
  • Antibiotic-impregnated beads
  • Intermittent or constant irrigation
  • Wound VAC
  • Hyperbaric oxygen
  • Removal of prosthetic devices

55
Osteomyelitis Interventions
  • Absorbant dressings using sterile technique
  • Bed rest
  • No exercise or heat application
  • Observe for abx side effects

56
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

57
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)

59
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

60
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

61
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)

62
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

65
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

66
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

69
Osteoporosis
70
Treatment
  • Calcium supplementation
  • Proper nutrition
  • Exercise
  • Medications
  • Calcium supplement
  • Biphosphonates

71
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
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