Download Chapter 40 Musculoskeletal System

Chapter 40
Musculoskeletal System
Orthopedics: Is the branch of medicine that deals with the prevention or correction of
disorders/diseases of the MS system.
Anatomy and physiology: Know: Function of MS system
Other structures are; Bursa, fascia, tendons and ligaments
Assessment of MS system:
A.
Major manifestation = PAIN! Important: When assessing a patient assess their
functional abilities.
B. Inspect and palpate to evaluate bone integrity, posture, joint function, muscle
strength, and gait.
Medical History: Includes the following:
A. Past medical or surgical disorders - Symptoms that relate to the onset, duration,
location of pain.
B. Differences in height of shoulders or iliac crest.
C. Exam vertebral column, should be straight with the spine convex thru the
thoracic portion.
D. 3 Common spinal curvatures are –
1. Scoliosis- lateral curving deviation of the spine. Common in school age child
and adolescent. “crooked back”
2. Kyphosis- increased roundness of thoracic spine. Common in elderly with
osteoporosis. “hump back”
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3. Lordosis- Exaggeration of the lumbar spine curvature. Common in pregnant
women. “sway back”
E. Assess articular system: ROM, stability of joints, nodular formation and pulses.
F. ROM- assesses patients ability to change position, muscle strength, and coordination.
When assessing ROM don’t exceed by causing PAIN.
G. Joints are examined for excessive fluid (knee is common site). Edema and high temp
are signs of acute inflammation. A snap or cracking sound is indicative of ligament
slipping over a bony prominence.
H. Deformities may be due to several factors including:
1. Contractures 2. Dislocations 3. Subluxation-(incomplete or partial dislocation)
4. Nodular formations are produced by MS diseases: i.e. Gout, R.A, and
osteoarthritis
I. Pulses are assessed for arterial disorders.
Common Diagnostic Tests:
(ANA) Antinuclear antibodies
C- Reactive protein
(RF) Rheumatoid Factor
(CBC) Complete Blood count 1. WBC 2. Hgb
(ERS) Erythrocyte Sed. Rate
Serum Calcium
Uric Acid TEST:
1. Serum
2. Urine
Arthrogram
CT Scan
EMG
MRI
XRay
Arthrocentesis
Arthroscopy
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Musculoskeletal Trauma:
Strain, sprain, dislocations, fractures, and compartment syndrome
1. Strain- Injury to the muscle or tendon due to overuse or over stretching
Acute- when an individual Performs unaccustomed exercises vigorously
Rx-Rest and immobilize, if rupture surgical repair
Chronic- develops after repeated overuse of certain muscles
Rx. None
For both: cold applied 20-30 mins on then 1 hour off for 24 hours
Next (Heat)
2. Sprain-An injury to a ligament surrounding a joint. Cause: twisting, wrenching or fall!
S/S: pain, edema, loss of motion, ecchymosis
Diagnostic: X-ray
Rx: RICE- Rest, Ice, Compression, Elevation
Cast application after edema decreases
3. Dislocation-When articular surfaces of a joint are not in contact. Bones are “out of joint”
Cause: Traumatic injury, congenital (present at birth), disease
producing/pathological
S/S:
Joint pain localized, loss of function of joint, change in length of extremity
and contour of joint.
Diagnosti:
X-ray and physical exam
4. Fracture- Break in continuity of a bone. Occurs when outside forces are greater than the
strength of the bone.
Cause: Injury/accident, direct force or twisting disease producing/pathological
High Risk Individuals: Metastasis to bone, Osteoporosis, Poor coordination and
vision, dizzy spells, general weakness
Common Fx A. Compound- (OPEN Fx.) bone and skin is broken. High risk for infection
B. Simple-(CLOSED)
bone and skin is intact
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1. Greenstick- when continuity of bone is not completely disrupted but has
splintering on one side and bending on the other.
Common in children
2. Impacted-/telescoped; one portion of bone fragment is forcibly driven into
another.
3. Spiral- fracture twists around the shaft of a bone. Common in child abuse.
4. Comminuted- bone is splintered into many unaligned fragments.
5. Transverse- break runs directly across the bone.
6. Oblique-break runs along a slant the length of the bone.
Manifestations of fractures:
Healing time is affected by:
1. Age
2. Type of injury
3. Underlying disease
Healing involves: Formation of hematoma > granulation tissue form > callus formation >
callus ossification > remodeling of bone.
(complications may delay this process)
Complications of a fracture:
1. Infection: (May lead to delayed union; This can occur after ORIF
2. Fat Embolus: Occurs when bone fragments travel in the bloodstream toward the
heart and lungs
3. Compartment syndrome
1. Compartment syndrome: A form of neurovascular impairment that can lead to
permanent injury caused by constriction of blood vessels and verves.
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Occurrence: it can occur with any orthopedic injury that results in bleeding into the
tissues. If untreated within 4-6 hours it can lead to permanent damage.
S/S: Pain not relieved by analgesics, diminished cap refill, weak or
unequal pulses, paresthesia (numb or tingle), paralysis
Rx: Relieve pressure (i.e. cast),
Fasciotomy; incision into fascia to relieve pressure on nerves and blood
vessels.
2. Fat Embolism: Occurs when there is a chance of fat entering the circulatory
system
(during surgery or trauma occurs 1-3 days after surgery)
S/S: SOB, agitation, delirium or coma, petechial rash, anemia with dec. platelets
RX: supportive:
Bedrest , O2
Med/Surg Management of Fractures:
Goal- Realign or reduce fracture, maintain alignment, regain function
Method depends on: site, severity, and type of fracture, age and condition of fracture
Repair or Reduction: 2 methods
1. Open reduction (ORIF)- at higher risk for infection
2. Closed reduction (cast application)
Closed reduction or external manipulation: doesn’t require surgical intervention
Following reduction a cast is applied. This requires traction, angulation, and rotation.
Cast: made of plastic or fiberglass (light weight)
Purpose: immobilize, support, protect the effected part, prevent deformity/correct
deformity.
Types: 1. Long and short arm 2. Long and short leg
3. Spica cast- used for hip, shoulder, and thumb dislocations
4. Hip Spica Cast: Used to ummobolize hip joint/or thigh
5. Body cast- used to immobilize the spine following a spinal fusion , spinal
injury, or degenerative disorder.
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Manifestations of cast:
1.Should be dry, odorless, shiny in appearance, resonant when percussed and have
temp similar to room air.
2.Moisture from drainage is indicated by: musty odor, dullness on percussion cool
temp.
3. windowing a cast means - cast cutting for visualization and relief of pressure
4. When cast is removed- joint should be supported, yellow exudate should not be
rubbed or forced off
4. Handle wet casts with palms of hands, NOT fingers
5. Patient will feel warmth during cast application (subsides in 10-5 mins. )
DON’T get cast wet
Traction: Forces pulling in opposite direction
Types: Skeletal- requires insertion of pin, screw, wires, etc. Traction is applied directly
to bone by inserting pin or wire.
Skin- used to temporarily immobilize a part or stabilize a fracture.
Nursing care of patients in traction: 1. Know extent of injury and purpose of traction,
maintenance of injured part, body alignment, alignment of traction apparatus, ROM.
Types of skin traction:
1.
2.
3.
4.
Bucks- conditions that affect hip, femur, knee
Russels- fractures of femur, hip, knee
Bryants- fractures of femur, fx. Seen in small child
Pelvic- used for sciatica, muscle spasms- minor fractures or lower
spine
Cervical Traction: used for injury to cervical or thoracic vertebrae or spinal cord
injuries.
Halo Ring- tongs or pins are placed against the outer table of the skull with
traction.
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Rehab of fracture: periodic x-rays and physical exams, physical therapy, proper use of
assistive devices(crutches, walkers, canes)
Purpose of devices: Crutches- limited/ no weight bearing
Canes- balance/support
Walkers- weight bearing
Surgical Correction of Fracture:
Open reduction-(ORIF) with wire, pin, nail. Disadvantage- possibility of introducing
infection
Pharmacological: Analgesics for pain, muscle relaxants (Flexeril),
stool softeners (Colace)
Diet: High fiber, high protein, high calcium, phosphorous and increase fluids.
Activity: Exercises to maintain muscle strength and minimize C-V probs. Joints should
be exercised (active/passive), Isometric exercises.
Inflammatory Disorders1.
2.
3.
4.
Rheumatoid Arthritis- inflammation of joint
Bursitis- inflammation of bursa
Polymyositis- inflammation involves striated muscle
Osteomyelitis
Bursitis- major joints usually seen in shoulder, knee, hip and elbow.
Cause: Repetitive movements and trauma
Diagnostic: X-ray
Rx: anti inflammatory drugs( NSAIDS) or cortisone injections
Polymyositis- Eitiology unknown, may be autoimmune disorder
Affects skeletal muscle, heart, GI tract and lungs
S/S: muscle weakness with activity, muscles of swallowing may be involved,
Arthralgia ( pain in joint) and Raynauds phenomenon
Rx: Prednisone (high doses)
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Diet: Frequent small meals, antacids(reflux)
Activity: At first PT, then eventually complete bed rest
Osteomyelitis- inflammation of the bone
Cause: Pathogen enters bone, spread from another part of body to bone, staph- most
common- pseudomonas and ecoli.
S/S: sudden pain and tenderness of affected bone, warmth, redness, edema, and pain
with movement.
Generalized S/S: fever, chills, high temp, increased pulse, increased leukocytes(WBC)
Medical Rx: Bedrest, Antibiotics(IV), Observe for bone abcess-drainage
Surgical Rx: Sequestrectomy- removal of dead bone tissue- strict aseptic
technique during dressing change.
Pharm: High doses of antibiotics(IV), Analgesics, wound irrigations with
antiseptics/antibiotics.
Degenerative Disorders: Osteoporosis and
DJD(Osteoarthritis)
Osteoporosis: Bone becomes porous increases susceptible to fractures.
Diagnostic: (BMD) Bone mineral density
DXA-
DPA-
SXA-
U.S-
Risk Factors: thin females, age, family history, postmenopausal women not getting ERT,
amenorrhea, eating disorders, decreased calcium intake, inactivity, smoking, excessive alcohol,
corticosteroids, anticonvulsant meds, low testosterone levels
Pharm: For Women- Estrogen(Premarin-Post menopausal), Fosamax, Meacalcin taken
with calcium and Vitamin D supplements. Evista
Actinol
For men- Testosterone
Diet: Adequate Vitamin D and calcium,
low consumption of alcohol, caffeine, excess protein and cigarettes
Activity: Good body mechanics and posture, walk outdoors.
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Degenerative Joint Disease: DJD Osteoarthritis. Not an inflammatory disease, is considered 1
type of arthritis, caused by wearing and tearing of joint, nonsystemic, most common type of
arthritis, etiology is unknown,
predisposing factors includes:
1. Obesity
2. Injury to joint
3. Poor posture
4. Occupation.
Joints most frequently affected are weight bearing(knees-hands-cervical and lumbar),
onset begins during middle age.
S/S:Early morning stiffness and pain with physical activity, joint enlargement
called “Herberdens Nodes”
Diagnostic: X-Ray
Cat Scan/MRI
Medical: Analgesics, Local heat, rest joints(affected), weight reduction, orthotic
devices to relieve strain on affected joint, PT.
Surgical Rx: Total Knee/ Hip replacement, Osteotomy, to correct mal alignment
Pharm: ASA or NSAIDS Steroids-intraarticular injections into joint, Muscle
relaxants(Flexeral)
Total Joint Arthroplasty: (Replacement) Most common: Knee, Hip, Shoulder,Fingers
Total Hip Replacement: Who? Usually elderly
older than 60 years.
Post Op: 1. Position of choice “abduction” with abd. Pillow.
1.
2.
3.
4.
Client may lie on unaffected side
Turn with abd. Pillow between legs
Avoid acute flelxion of hip
Fracture bedpan until ambulation to bathroom
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5.
6.
7.
8.
9.
Raised toilet seat
Specific turning, movement and position MD will order.
Neurovascular checks CMS(circular, movement, sensation)
Monitor signs for blood loss
JP drain in place
Goal: Total Hip 1. Ambulate independently
2. OOB first pos top day (STRAIGHT BACKED CHAIR)
3. Gait training
4. When abduction pillow removed, soft pillow between legs
Total Knee Replacement: Post Op:
1. Client uses CPM machine
It helps increase circulation to operative site and promotes
flexibility to knee joint
2. Knee is immobilized with firm compression dressing
3. Transfer OOB to W/C with immobilizer on
4. No weight bearing until MD orders
5. SCD (sequential compression device) to reduce development
of thrombophlebitis
6. Rehab starts second day post op – When OOB in chair knee is
elevated and ambulate with assistive device weight bearing
limits is 1-2 days after surgery
Musculoskeletal Disorders: Amputations, Temporomandibular joint Disease
disorder(TMD), Carpal tunnel
Amputations: Surgical removal of a part
Cause: 1. Injury > lacerations of arteries or verves
2. Diseases (malignant tumors, infections, peripheral vascular disorders)
3. Extensive osteomyelitis
4. Congenital disorders
5. Severe trauma to save patients life
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Medical Rx: Requires major physical/psychological adjustments
Surgical: Before surgery – evaluate:
1. Necessity of amputation
2. Type of amputation
3. Level of amputation (determined by vascular supply never higher
than necessary
4. Potential for rehab
5. Type of prosthesis and rehab program
Types of Surgery: 1. Closed Amputation- use skin flap to cover bone
2. Open Amputation- straight cut allows for drainage
Pharm: Narcotic Analgesics and Antibiotic therapy- if infection
Diet: Balanced diet with adequate vitamins and protein
Activity: 1. Post op positioning determined by MD
2. Stump placed in extended position or increased on pillow
3. Prone position-to prevent contractures of hip)
4. Bed exercises 1-2 post op
5. Ambulation begins in PT and progresses according to whether the
client is fitted for prosthesis
Temporomandibular Joint Disease: Is a collection of conditions affecting the
temporomandibular joint and/or muscles of mastication
Manifestations: Affects Male or Female, 90% Females
Cause: Trauma, stress, teeth clenching or grinding, joint diseases such as
R.A/osteoarthritis
S/S: 1. Limited jaw movement
2. clicking Crepitis when jaw moves
3. Popping when chewing/talking
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4. Radiating pain in face, neck, shoulders
Diagnostic Tests: X-Ray
CT Scan
MRI
Medical Management:
1.
2.
3.
4.
5.
6.
7.
Moist heat
Promote muscle relax
Cold therapy
Analgesic/NSAIDS
Dental retain/bite plate
Soft diet
Discourage chewing gum
Carpal Tunnel Syndrome: Compression of the median nerve in the wrist, caused by
inflammation, edema of flexor tendon
S/S: Pain, parasthesia, weakness of thumb, index, middle and part of ring fingers
High incidence: People with occupations that require repetitive hand
movements, arthritis and fractures
Diagnostic: Physical exam of subjective symptoms
Medical Management: Rest for hands and splints to immobilize
Surgical Rx:
1.
2.
3.
4.
Surgery to relieve the pressure on the median nerve
Post op hand is elevated
Splint up to 2 weeks
Restrict lifting
Pharm: Anti inflammatory to decrease edema and decrease inflam.
NSaids provide pain relief
Cortisone injections
Gout: Metabolic disease of ineffective purine metabolism- crystals of uric acid accumulate in
joint spaces. Effects Middle age males, post menopausal women. Can be primary or
Secondary(from another disease /drugs)
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Familial tendency, and excessive use of alcohol can interfere with uric acid excretion
Manifestations:
1.
2.
3.
4.
Attack is abrupt
Joint swollen, red and tender
Great toe (more frequent)
If untreated can cause increase frequency of attacks
S/S: Tophi deposits- nodules that contain uric acid
Diagnostic: Fluid aspiration to isolate urate crystals
Medical Rx:
1. Instruct to avoid foods high in purine: liver, sardines, anchovies,
gravies, asparagus
2. Increase oral intake to 3000 ml per day
3. NSAIDS (Indocin and Naprosyn)
4. Colchine (when NSAIDS are not effective) used for acute attacks
5. Allopurinol- decreases production of uric acid in body
6. Benemed
- increases excretion of uric acid by kidney
Lyme Disease: Cause: Deer ticks
Manifestations:
1.
2.
3.
4.
5.
Occurs from spring to fall
People with high incidence should wear protective clothing
Manifests with red rash known as “erythema migrans” .
H/A, neck stiffness, fever, pain.
If untreated S/S: fatigue and neurological abnormalities(facial palsy,
meningitis, encephalitis)
Diagnostic: ELISA
( test of antibody)
Rx: Apply DEET to exposed body parts and Antibiotics (Vibramycin, Ceftin,
Amoxil)
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Rheumatoid Arthritis: Chronic systemic autoimmune disease. Persons immune system attacks
the cells inside the joint.
Cause:
1. Unknown – genetic predisposition
2. Something triggers disease- bacteria, hormonal factor, or stress
3. Immune complex forms within the joint > inflammation, swelling and
increased synovial fluid. As condition worsens surrounding cartilage,
tendons and ligaments become involved > thickening of synovial
tissue > calcification of joint, joint pain, limited mobility, and
deformity
Manifestations:
1. Joints of hands and wrists are initially effected
2. Shoulder, elbow, hip, knee, ankle and cervical spine later become
infected
3. Periods of remission and exacerbation occur
4. Stress can trigger attack
5. Pattern of joint involvement all symmetrical
6. Weight loss
7. Loss of appetite
8. Fatigue
Medical Management:
1. Reduce inflam.
2. Relieve pain
3. Promote general health
Medications, Rest, Hot and Cold applications, Stress management
Surgical Management: Hip, Knee and finger joint replacements
Pharm:
1. Salicylates- ASA > GI Upset best for pain relief, does not stop
progression
2. NSAIDS –Motrin, Naprsyn, Clinirol, Celebrex, Indocin
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3. DMARDS- Disease modifying anti rheumatic drugs (Prednisone- gold
salts- Azulfidine
4. In severe cases: Imuran, Plaquel Sulfate, Depen, Methotrexate
5. Enbrel (Stops progression of disease)
Diet: Nutritious, well balanced diet, food high in iron when RBCs are low.
Activity:
1.
2.
3.
4.
Physical therapy
ROM exercises
Assistive devices- cane, handrails
Frequent rest periods
Diagnostic:
1. X-Rays
2. No specific test
3. RBCs Low (Anemia) WBCs High ESR High ANA High Platelets High
C-Reactive Proteins Elevated
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