Download Health Alterations

Musculoskeletal Disorders
Megan McClintock, MS, RN
Fall 2011
Skeletal Functions
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Support and framework for body
Protection of vital organs
Assist with movement
Blood cell production
Mineral and salt storage
Structure
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Bone
Joints
Cartilage
Muscle
Ligaments/Tendons
Fascia
Bursae
Assessment - Subjective
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Gerontologic differences
Past health history
Medications
Nutrition
Occupation
Assessment - Objective
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Inspection
Palpation
Motion
Muscle-Strength Testing
Measurement
Scoliosis
Straight-leg raising test
Common Abnormalities
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Table 62-6
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(pg 1577)
Diagnostic Studies
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Diskogram
Myelogram
DEXA
Bone scan
Arthroscopy
Arthrocentesis
EMG
Duplex venous doppler
SSEP
Labs
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Alkaline phosphatase
Calcium
Phosphorus
RF
ESR
ANA
Complement
Uric acid
CRP
CK
Contusions
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Soft tissue injury from blunt force
Overlying skin intact, but area
becomes black and blue from
localized hemorrhage
Usually only painful if palpated
Hematoma
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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
Strains
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Overstretched tendons or overused
muscles
Usually arise from twisting or
wrenching movements
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Acute – sudden, severe incapacitating
pain with swelling
Chronic – repetitive movements; pain
less severe but longer term (tennis
elbow, runner’s knee)
Strains
Sprains
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Ligament injuries
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Grade 1 (mild) – small longitudinal ligament
fiber separation
Grade 2 (moderate) - <100% 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
Sprains
Interventions
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Prevent
R – est
I – ce
C – ompress
E – levate
Analgesia as necessary
After 24-48 hrs, warm moist heat
Subluxation/Dislocation
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Bones are dislodged from normal
positions within joints
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Subluxation = partial dislocation
Joint capsule and ligaments damaged
Usually deformity at site
S/S: altered length of extremity,
loss of function
Subluxation-dislocation of
knee
Interventions
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Orthopedic emergency
Assist with realignment
Pain relief
Restriction of movement
Future activity restrictions
Fractures
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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
Type of Fracture
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Open (compound)
Closed (simple)
Incomplete
Complete
Displaced
Comminuted
Direction of Fracture
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Transverse
Oblique
Spiral
Greenstick
Bone Healing
Fracture Reduction
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Closed reduction
ORIF (open reduction with internal
fixation)
Traction
Fracture Repair
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Casting
Fracture Repair
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External fixation
Fracture Repair
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Internal fixation
Drugs
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Muscle relaxants
Pain medications
Tetanus prevention
Antibiotics
Nutrition
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Ample protein
Vitamins B, C, D
Calcium
Phosphorus
Magnesium
2000-3000 mL/day of fluids
High-fiber diet
Interventions
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Assessment
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Distal to the extremity
Neurovascular
Peripheral vascular
 Peripheral neurologic
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Prevention
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Safety equipment
Elderly (also see pg 1584)
Interventions
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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
Traction Interventions
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Inspect skin and pin sites carefully
Pin site care
Correct positioning
ROM of unaffected joints
Maintain traction at all times
Cast Care Interventions
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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
Use of Crutches
Fracture Complications
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Direct
 Infection
 Inadequate bone union
 Avascular necrosis
Indirect
 Compartment syndrome
 Venous thromboembolism (VTE)
 Rhabdomyolisis
 Fat embolism
 Shock
Infection
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High incidence with open fx or soft
tissue injury
Need aggressive debridement
Venous Thromboembolism (VTE)
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Esp. after hip fx, THA, total knee
Prevent – anticoagulants, SCDs, ROM
to unaffected joints
Compartment Syndrome
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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
Fat Embolism Syndrome
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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
Types of Fractures
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Colles’ – wrist fx
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Silver-fork deformity
Move thumb, fingers, shoulder
Humerus
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Cx – radial nerve or brachial
artery injury, frozen shoulder
Pelvic Fracture
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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
Hip Fracture
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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 Buck’s
traction
Hip Fracture Post-Op Care
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Pillows/abductor splint between knees esp. when turning,
avoid extreme hip flexion, don’t turn on affected side, OOB
on first post-op day, in hospital for 3-4 days
Posterior approach
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Table 63-11 (pg 1607)
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No extremes in flexion
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No putting on shoes, socks
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No crossing the legs or feet
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No low toilet seats
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Precautions for 6 weeks
Anterior approach
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Limited restrictions
Types of Fractures
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Femoral Shaft
 Can have lots of blood loss, risk of fat
embolism
 Tx – ORIF with traction after, hip spica cast
Tibia
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Neurovascular assessment q 2 hrs x 48 hrs
Stable Vertebral
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Logroll, orthotic devices, hard cervical
collar
Vertebroplasty
Kyphoplasty
Facial Fractures
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Impt to maintain patent airway, provide adequate
ventilation
Assume that they have a cervical injury
Always have suction available
For jaw fractures:
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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
Amputation
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Pain is not a primary reason
Pre-op preparation
Post-op
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Sterile technique for dressing changes
Immediate prosthesis vs delayed
Don’t sit in chair > 1 hr
Lie on abdomen 3-4 times/day
Residual limb bandaging
Table 63-14 (pg 1613)
Joint Procedures
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Synovectomy
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Osteotomy
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Remove a wedge of bone
Debridement
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Removal of synovial membrane
Removal of degenerative debris
Arthroplasty
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Reconstruction or replacement of a
joint
Total Hip Arthroplasty (THA)
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See notes from hip fracture
Can’t drive or take tub bath for 4-6 weeks
Knees must be kept apart
Don’t cross legs
Don’t 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
Carpal Tunnel Syndrome
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Compression of the median nerve
Women more likely to get
S/S – thumb weakness, burning pain,
numbness, parasthesia
Tinel’s and Phalen’s sign
http://tinyurl.com/cre5lf2
Tx – splints, rest, surgery
Rotator Cuff Injury
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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
Meniscus Injury
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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
McMurray’s test
http://tinyurl.com/cev9lx9
Tx – RICE, knee brace, arthroscopy, rehab
starts quick
Prevention – warm-up exercises
Anterior Cruciate Ligament
(ACL) Injury
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Usu. Occur from non-contact
S/S – hear a “pop”, pain, swelling
Lachman’s 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
Bursitis
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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
Osteomyelitis
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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
doesn’t show until 10 days+
Osteomyelitis Management
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Long IV therapy (5 weeks – 6 months)
Antibiotic-impregnated beads
Intermittent or constant irrigation
Wound VAC
Hyperbaric oxygen
Removal of prosthetic devices
Osteomyelitis Interventions
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Absorbant dressings using sterile
technique
Bed rest
No exercise or heat application
Observe for abx side effects
Bone Tumors
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Osteochondroma
 Benign, overgrowth at growth plate
 S/S – painless, hard mass, shortened
extremity
 Tx – none if asymptomatic
Osteosarcoma
 Aggressive, rapidly metastisizes
 More common with Paget’s disease
 S/S – gradual onset of pain/swelling
 Is NOT caused by a minor injury
 Be very careful when turning/handling
Muscular Dystrophy (MD)
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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
Low Back Pain
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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)
Intervertebral Disk Disease
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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
Spinal Surgery
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Must maintain proper alignment until healing has occurred
Pillows under thighs when supine, between legs when sidelying
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
Neck Pain
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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)
Foot Disorders
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Usu. caused by improperly fitted shoes
Send to a podiatrist
If surgery, usu. have a bulky dressing
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Elevate foot
Crutches, cane, walker (may have throbbing sensation
when starting to walk)
Daily foot care
Trim toenails straight across
Osteomalacia (Rickets)
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Loss of minerals in bones
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Bones soft rather than brittle
Caused by
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Inadequate calcium intake
Inadequate Vit. D intake or resistance
to actions of Vit. D
Increased renal loss of phosphate
Osteomalacia
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Bones most affected
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Spine, pelvis, lower extremities
S/S
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Localized bone pain
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Difficulty getting up from chair, walking
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Bone deformities (bowed legs)
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Fractures
Tx
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Vit D supplements
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Diet
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Exposure to sunlight
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Weight bearing exercise
Osteoporosis
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Resorption rate > formation rate
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Net loss of both bone protein matrix
and mineral components
Bone composition normal just not
enough of it
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Bone is brittle, fragile, easily broken
Osteoporosis bone mass
Osteoporosis
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Risk Factors
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Endocrine causes
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Heredity, sex, race, early menopause, poor
nutrition, sedentary lifestyle, thinness,
smoking, ETOH ingestion
Cushing’s syndrome, diabetes,
hyperthyroidism, hyperparathyroidism
Drug-related causes
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Glucocorticosteriods, anticonvulsants, some
antacids, diuretics, thyroid medications
Osteoporosis
Signs & symptoms
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Back pain or spontaneous fractures (1st
symptom)
Loss of height
Deformity (Dowager’s hump)
Pathological fracture
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As many as 30% of white women will have a
pathological fracture d/t osteoporosis
Osteoporosis
Treatment
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Calcium supplementation
Proper nutrition
Exercise
Medications
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Calcium supplement
Biphosphonates
Paget’s Disease
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Systemic disease involving multiple
body systems
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Excessive bone resorption followed by
excessive and abnormal bone
replacement  long bones, pelvis,
cranium, & spine
Cause – may be viral
Paget’s Disease
Signs & Symptoms
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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