19 Musculoskeletal System DR - Faller

19: MUSCULOSKELETAL SYSTEM NCA 1
DR. ESTHER SUNDAY C. FALLER, RMT, MD: || February 9,2023
MUSCULUSKELETAL SYSTEM 3.Osteoclasts, located in shallow Howship’s

• Musculoskeletal system includes the lacunae (small pits in bones), are multinuclear cells
bones, joints, muscles, tendons, ligaments, involved in dissolving and resorbing bone
and bursae of the body BONE FORMATION
• Functions of these components are highly • Osteogenesis (bone formation) begins long
integrated—disease in or injury to one before birth
component adversely affects the others • Ossification is the process by which the
• Diseases and injuries that involve the bone matrix is formed and hard mineral
musculoskeletal system are commonly crystals composed of calcium and
implicated in disability and death phosphorus (e.g., hydroxyapatite) are
ASSESSMENT OF MUSCULOSKELETAL bound to the collagen fibers
FUNCTION BONE MAINTENANCE
Anatomic and Physiologic Overview • Bones grow and form by a process called
• Provides protection for vital organs, modeling
including the brain, heart, and lungs • Remodeling maintains bone structure and
• Provides a sturdy framework to support function through simultaneous resorption
body structures and makes mobility and osteogenesis, and as a result,
possible complete skeletal turnover occurs every 10
• Muscles and tendons hold the bones years
together and joints allow the body to BONE HEALING
move • Most fractures heal through a combination
• Move to produce heat that helps maintain of intramembranous and endochondral
body temperature ossification processes
• Movement facilitates the return of • The process of fracture healing occurs over
deoxygenated blood to the right side of three phases, these include the following:
the heart by massaging the venous 1. Reactive phase: Cytokines are
vasculature released that initiate the fracture
• Serves as a reservoir for immature blood healing processes by causing the
cells and essential minerals, including proliferation of fibroblasts and that
calcium, phosphorus, magnesium, and cause angiogenesis to occur
fluoride 2. Reparative phase: Fibroblasts invade
Structure and Function of the Skeletal the pro-callus and produce a denser
System type of callus that is composed mostly
• Bone is composed of cells, protein matrix, of fibrocartilage
and mineral deposits 3. Remodeling phase: Remodeling the
• The cells are of three basic types: new bone into its former structural
arrangement
1.Osteoblasts • Serial x-rays are used to monitor the
function in bone progress of bone healing
formation by
secreting bone Structure and Function of the Skeletal
System
matrix
• Junction of two or more bones is called a
2.Osteocytes joint (articulation)
are mature bone • Three basic kinds of joints:
cells involved in ✓ Synarthrosis joints are
bone immovable (e.g., the skull sutures)
maintenance; ✓ Amphiarthrosis joints (e.g., the
they are located vertebral joints and the symphysis
in lacunae pubis) allow limited motion
(bone matrix units)
DIOSO,FERRERAS,FLORENCIO,JARO,JAZMINES,JUAN 1
✓ Diarthrosis joints are freely • Muscles causing movement opposite to

movable joints that of the prime mover are known as
• Several types of diarthrosis joints: antagonists
o Ball-and-socket joints (e.g., the
EXERCISE, DISUSE AND REPAIR
hip and the shoulder) permit full
freedom of movement • Muscles need to be exercised to maintain
o Hinge joints permit bending in one function and strength (hypertrophy)
direction only (e.g., the elbow and • Age and disuse cause loss of muscular
the knee) function as fibrotic tissue replaces the
o Saddle joints allow movement in contractile muscle tissue (atrophy)
two planes at right angles to each • When muscles are injured, they need rest
other (e.g., joint at the base of the and immobilization until tissue repair
thumb) occurs
o Pivot joints are characterized by
the articulation between the radius ASSESSMENT
and the ulna
Health History
o Gliding joints allow for limited
Common Symtpoms:
movement in all directions and are
represented by the joints of the PAIN
carpal bones in the wrist
✓ Most patients with diseases and traumatic
Structure and Function of the Skeletal conditions or disorders of the muscles,
Muscle System bones, and joints experience pain
✓ Bone pain is characteristically described as
SKELETAL MUSCLE CONTRACTION
a dull, deep ache that is “boring” in nature,
• Each muscle cell (also referred to as a whereas muscular pain is described as
muscle fiber) contains myofibrils, which in soreness or aching and is referred to as
turn are composed of a series of “muscle cramps”
sarcomeres, the actual contractile units of ✓ Rest relieves most musculoskeletal pain
skeletal muscle ✓ Pain is variable, and its assessment and
• Muscle cells contract in response to nursing management must be
electrical stimulation delivered by an individualized
effector nerve cell at the motor end plate ALTERED SENSATIONS
MUSCLE TONE ✓ Sensory disturbances are frequently
• Relaxed muscles demonstrate a state of associated with musculoskeletal problems
readiness to respond to contraction stimuli ✓ The patient may describe paresthesias,
• State of readiness, known as muscle tone which are burning, tingling sensations or
(tonus), is produced by the maintenance of numbness
some of the muscle fibers in a contracted ✓ May be caused by pressure on nerves or
state by circulatory impairment
MUSCLE ACTIONS Past Health, Social, and Family History

Nurse should gather pertinent data to include in the
• The body is able to perform a wide variety patient’s health history, such as:
of movements through the coordination of
muscle groups ❖ occupation (e.g., does the patient’s work
• Prime mover is the muscle that causes a require physical activity or heavy lifting?)
particular motion ❖ exercise patterns
❖ dietary intake (e.g., calcium and vitamin D)
• Muscles assisting the prime mover are
❖ concurrent health conditions (e.g.,
known as synergists
diabetes, heart disease, chronic
obstructive pulmonary disease, infection,
preexisting disability) and related o Precise measurement of range of motion

problems, such as familial or genetic can be made by a goniometer (a protractor
abnormalities designed for evaluating joint motion)
Physical Assessment MUSCLE STRENGTH AND SIZE
• Ranges from a basic assessment of
o Muscular system is assessed by noting
functional capabilities to sophisticated
muscular strength and coordination, the
physical examination maneuvers that
size of individual muscles, and the patient’s
facilitate diagnosis of specific bone,
ability to change position
muscle, and joint disorders
• Techniques of inspection and palpation are SKIN
used to evaluate the patient’s posture, gait,
bone integrity, joint function, and muscle o In addition to assessing the
strength and size musculoskeletal system, the nurse
inspects the skin for edema, temperature,
• Assessing the skin and neurovascular
and color
status is an important part of a complete
musculoskeletal assessment NEUROVASCULAR STATUS
POSTURE o In addition to assessing the
musculoskeletal system, the nurse
o Normal curvature of the spine is convex
inspects the skin for edema, temperature,
through the thoracic portion and concave
and color
through the cervical and lumbar portions
o Common deformities of the spine include DIAGNOSTIC EVALUATION
kyphosis, an increased forward curvature Imaging Studies
of the thoracic spine; lordosis, or X-RAY STUDIES
swayback, an exaggerated curvature of the
lumbar spine; and scoliosis, a lateral o Bone x-rays determine bone density,
curving deviation of the spine texture, erosion and changes in bone
relationships
GAIT
COMPUTED TOMOGRAPHY
o Gait is assessed by having the patient walk
away from the examiner for a short o Shows in detail a specific plane of involved
distance bone and can reveal tumors of the soft
o Any unsteadiness or irregular movements tissue or injuries to the ligaments or
(frequently noted in elderly patients) are tendons
considered abnormal o It is used to identify the location and extent
of fractures in areas that are difficult to
BONE INTEGRITY evaluate (e.g., acetabulum)
o The bony skeleton is assessed for MAGNETIC RESONANCE IMAGING
deformities and alignment
o Symmetric parts of the body, such as o Demonstrate abnormalities (i.e., tumors or
extremities, are compared narrowing of tissue pathways through
bone) of soft tissues such as muscle,
JOINT FUNCTION tendon, cartilage, nerve, and fat)
o Articular system is evaluated by noting ARTHROGRAPHY
range of motion, deformity, stability, and
nodular formation o Useful in identifying acute or chronic tears
o Range of motion is evaluated both actively of the joint capsule or supporting ligaments
(the joint is moved by the muscles of the knee, shoulder, ankle, hip, or wrist
surrounding the joint) and passively (the Nursing Interventions for Imaging Studies
joint is moved by the examiner) o Before the patient undergoes an imaging
study, the nurse assesses for conditions
that may require special consideration LABORATORY STUDIES

during the study or that may be • Examination of the patient’s blood and
contraindications to the study (e.g., urine can provide information about a
pregnancy; claustrophobia; inability to primary musculoskeletal problem (e.g.,
tolerate required positioning due to age, Paget’s disease of the bone), a developing
debility, or disability; metal implants) complication (e.g., infection), the baseline
o If contrast agents will be used for CT scan, for instituting therapy (e.g., anticoagulant
MRI, or arthrography, the patient is therapy), or the response to therapy
assessed for possible allergies
1. Coagulation studies are performed to detect
Diagnostics bleeding tendencies (because bone is vascular
BONE DENSITOMETRY tissue)
• Used to estimate bone mineral density 2. Serum calcium levels are altered in patients
(BMD) with osteomalacia, parathyroid dysfunction,
Paget’s disease, metastatic bone tumors, or
BONE SCAN
prolonged immobilization
• Performed to detect metastatic and primary
3. Serum phosphorus levels are inversely related
bone tumors, osteomyelitis, some
to calcium levels and are diminished in
fractures, and aseptic necrosis
osteomalacia associated with malabsorption
Nursing Interventions syndrome
• Before the patient undergoes a bone scan, 4. Acid phosphatase is elevated in Paget’s
the nurse asks about possible allergies to disease and metastatic cancer
the radioisotope and assesses for any
condition that would contraindicate 5. Alkaline phosphatase is elevated during early
performing the procedure (e.g., pregnancy) fracture healing and in diseases with increased
osteoblastic activity (e.g., metastatic bone tumors)
ARTHROSCOPY
6. Bone metabolism may be evaluated through
• Allows direct visualization of a joint to thyroid studies and determination of calcitonin,
diagnose joint disorders PTH, and vitamin D levels
Nursing Interventions 7. Serum enzyme levels of creatine kinase and
• After the arthroscopic procedure, the joint aspartate aminotransferase become elevated
is wrapped with a compression dressing to with muscle damage
control swelling
8. Serum osteocalcin (bone GLA protein)
ARTHROCENTESIS indicates the rate of bone turnover
• Carried out to obtain synovial fluid for 9. Urine calcium levels increase with bone
purposes of examination or to relieve pain destruction (e.g., parathyroid dysfunction,
due to effusion metastatic bone tumors, multiple myeloma)
ELECTROMYOGRAPHY 10. Specific urine and serum biochemical markers
can be used to provide information about bone
• Provides information about the electrical
formation
potential of the muscles and the nerves to
evaluate muscle weakness, pain, and o urinary N-telopeptide of type 1 collagen
disability (N-Tx) and deoxypyridinoline (Dpd),
both of which reflect increased osteoclast
BIOPSY
activity and increased bone resorption
• Done to determine the structure and o elevated serum levels of bone-specific
composition of bone marrow, bone, alkaline phosphatase (ALP), osteocalcin,
muscle, or synovium to help diagnose and intact N-terminal pro-peptide of type 1
specific diseases collagen (P1NP) reflect increased activity
of osteoblasts and enhanced bone ASSISTIVE DEVICES FOR WALKING

remodeling activity
a. Cane
MUSCULOSKELEAL CARE MODALITIES
● Client holds the cane on the unaffected
Common Musculoskeletal Interventions hand → cane and the affected leg are
RANGE-OF-MOTION EXERCISES (ROM) advanced together → shift the weight unto
A. Active ROM the cane
-Done by the patient; increases and b. Walker
maintains muscle tone and joint mobility
B. Passive ROM ● Instruct client to use “lift and walk”
-Done for the patient; maintains joint technique (lift the walker forward, then
mobility make few small steps toward the walker)
C. Active-assistive ROM ● Height of the walker should be hip level
-Patient moves body part as far as possible ● Client using the walker may go up and
and the health worker completes the down the stairs
exercise; stronger arm and leg perform ● When going up, use the walker at the
exercises to the weaker arm and leg back; when going down, use the walker in
D. Active-resistive ROM front
-Contraction of muscle against an c. Crutches
opposing force or weight; increases muscle
power The different crutch-walking gaits:
ISOTONIC EXERCISES 1. Four point gait
● Involves change in both muscle length ● (R) Crutch → (L) foot → (L) crutch → (R)
and tension foot
ISOMETRIC EXERCISES 2. Two point gait
● Active exercises that involves alternate ● (R) Crutch and (L) foot → (L) crutch and
muscle contraction and relaxation (R) foot
● No joint movement; length of muscle 3. Three point gait
does not change
● Maintains muscle strength and size ● Both crutches and affected leg →
Unaffected leg
A. Hamstring or quadriceps setting
− Alternate tension and relaxation of 4. Swing-to gait
thigh muscles
● Both crutches → swing the body so that
− Client pushes the back of the knee
the feet will be to the level of the crutches
against the mattress to contract thigh
muscles, then relax 5. Swing-through gait
− Strengthens the thigh muscles in
preparation for ambulation and crutch- ● Both crutches → swing the body so that
walking gait the feet will be past the level of the
B. Gluteal setting crutches
− Alternate tension and relaxation of
gluteus muscles
− Client presses the buttocks together,
then release
C. Kegel’s exercises
− Alternate tension and relaxation of
pubococcygeal muscles
− Helps regain control of voiding
among incontinent clients
The Patient in a Cast, Splint or Brace BRACES
• used to provide support, control

CASTS movement, and prevent additional injury
• custom fitted to various parts of the body
● Used specifically to immobilize a reduced
fracture, to correct a deformity, to apply • generally indicated for longer use than
uniform pressure to underlying soft tissue, splints
or to support and stabilize weakened General Nursing Management of a Patient with
joints a Cast, Splint or Brace
● Permit mobilization of the patient while
restricting movement of a body part
● Before the cast, brace, or splint is applied,
TYPES OF CAST the nurse completes an assessment of
the patient’s general health, presenting
Short-arm cast: Extends from below the elbow to
signs and symptoms, emotional status,
the palmar crease, secured around the base of
understanding of the need for the device,
the thumb. If the thumb is included, it is known as
and condition of the body part to be
a thumb spica or gauntlet cast.
immobilized
Long-arm cast: Extends from the axillary fold to ● Nurse gives the patient information about
the proximal palmar crease. The elbow usually is the underlying pathologic condition and
immobilized at a right angle. the purpose and expectations of the
prescribed treatment regimen
Short-leg cast: Extends from below the knee to ● The nurse must carefully evaluate pain
the base of the toes. The foot is flexed at a right associated with the musculoskeletal
angle in a neutral position. condition, asking the patient to indicate the
Long-leg cast: Extends from the junction of the exact site and to describe the character
upper and middle third of the thigh to the base of and intensity of the pain to help determine
the toes. The knee may be slightly flexed. its cause
● To promote healing, it is important to treat
Walking cast: A short- or long-leg cast reinforced any skin lacerations and abrasions that
for strength. may have occurred as a result of the
trauma that caused the fracture before the
Body cast: Encircles the trunk.
cast, brace, or splint is applied
Shoulder spica cast: A body jacket that ● While the cast is on, the nurse observes
encloses the trunk, shoulder, and elbow the patient for systemic signs of
infection; odors from the cast, brace, or
Hip spica cast: Encloses the trunk and a lower splint; and purulent drainage staining the
extremity. A double hip spica cast includes both cast
legs. ● The nurse monitors circulation, motion,
and sensation of the affected extremity,
SPLINTS
assessing the fingers or toes of the affected
• used for conditions that do not require rigid extremity and comparing them with those
immobilization, for those in which swelling of the opposite extremity
may be anticipated, and for those that ● It is important to perform frequent, regular
require special skin care assessments of neurovascular status
• needs to immobilize and support the body (“five P’s” that require assessment are
part in a functional position and it must be symptoms of neurovascular compromise:
well padded to prevent pressure, skin pain, pallor, pulselessness, paresthesia,
abrasion, and skin breakdown and paralysis)
• generally indicated for short-term use
Monitoring and Managing Complication ● To prevent this, the patient needs to learn
to tense or contract muscles (e.g.,
Compartment Syndrome isometric muscle contraction) without
● Occurs when there is increased tissue moving the part
pressure within a limited space that ● The nurse teaches the patient with a leg
compromises the circulation and the cast, brace, or splint to “push down” the
function of the tissue within the confined knee and teaches the patient in an arm
area cast, brace, or splint to “make a fist”
● To relieve the pressure, the cast must be ● Muscle-setting exercises (e.g., quadriceps-
bivalved (cut in half longitudinally) while setting and gluteal-setting exercises) are
maintaining alignment, and the extremity important in maintaining muscles essential
must be elevated no higher than heart level for walking
to ensure arterial perfusion o ● Isometric exercises should be performed
● A fasciotomy may be necessary to relieve hourly while the patient is awake
the pressure within the muscle Nursing Management of a Patient With an
compartment Immobilized Upper Extremity
● Patient whose arm is immobilized must
readjust to many routine tasks, the
unaffected arm must assume all the upper
extremity activities
● To control swelling, the immobilized arm is
elevated and a sling may be used when the
patient ambulates
Pressure Ulcer ● Nurse encourages the patient to remove
the arm from the sling and elevate it
● Due to pressure of a cast or an
frequently
inappropriately applied brace on soft
● Circulatory disturbances in the hand may
tissues
become apparent with signs of cyanosis,
● To inspect the pressure ulcer area, the
swelling, and an inability to move the
brace may be removed
fingers
● For a patient with a cast, the physician
● One serious effect of impaired circulation in
may bivalve or cut an opening (window) in
the arm is Volkmann’s contracture
the cast
(contracture of the fingers and wrist occurs
● If the physician elects to create a window
as the result of obstructed arterial blood
to inspect the pressure site, a portion of the
flow to the forearm and hand)
cast is cut out
● If a cast is used for immobility,
compartment syndrome is managed in part
by bivalving (cutting) the cast and releasing
the constricting cast and dressings
● A fasciotomy may be necessary to improve
vascular status
Nursing Management of a Patient with an
Immobilized Lower Extremity
● Casts may include short-leg casts,
extending to the knees, or long-leg casts,
extending to the groin o
Disuse Syndrome
● Patient’s leg must be supported on pillows
● Immobilization in a cast, brace, or splint to heart level to control swelling, and ice
can cause muscle atrophy and loss of packs should be applied as prescribed over
strength the fracture site for 1 or 2 days
● Nurse assesses circulation by observing ● Monitors the neurovascular status of the

the color, temperature, and capillary refill of extremity every 2 to 4 hours and assesses
the exposed toes o each pin site for redness, drainage,
● Nerve function is assessed by observing tenderness, pain, and loosening of the pin
the patient’s ability to move the toes and by ● Alert for potential problems caused by
asking about the sensations in the foot pressure from the device on the skin,
● Nurse and physical therapist teach the nerves, or blood vessels and for the
patient how to transfer and ambulate safely development of compartment syndrome
with assistive devices (e.g., crutches, ● Encourages isometric and active exercises
walker) as tolerated
● Teaches the patient to perform pin site care
Nursing Management of Patient with a Body or
according to the prescribed protocol (clean
Hip Spica Cast
technique can be used at home) and to
● Body casts are used to immobilize the
report promptly any signs of pin site
spine
infection: redness, tenderness, increased
● Hip spica casts are used for some femoral
or purulent pin site drainage, or fever
fractures and after some hip joint surgeries,
and shoulder spica casts are used for some The Patient in Traction
humeral neck fractures
● Nursing responsibilities include preparing
and positioning the patient, assisting with TRACTION
skin care and hygiene, and monitoring for ● application of a pulling force to a part of the
cast syndrome body
● Medications for pain relief and relaxation ● used to minimize muscle spasms; to
administered before the procedure reduce, align, and immobilize fractures; to
● Nurse inspects the skin around the edges reduce deformity; and to increase space
of the cast frequently for signs of irritation between opposing surfaces
● Patients immobilized in large casts may ● effects are evaluated with x-ray studies,
develop cast syndrome that may include: and adjustments are made if necessary
1. psychological component is similar ● used primarily as a short-term intervention
to a claustrophobic reaction until other modalities, such as external or
2. physiologic cast syndrome internal fixation, are possible
responses are associated with ● reduce the risk of disuse syndrome and
immobility in a body cast minimize the length of hospitalization, often
allowing the patient to be cared for in the
The Patient with an External Fixator home setting
● External fixators are used to manage open TYPES OF TRACTION
fractures with soft tissue damage
● Provide stable support for severe SKIN TRACTION
comminuted (crushed or splintered)
fractures while permitting active treatment • Used to control muscle spasms and to
of damaged soft tissues immobilize an area before surgery
● Fracture is reduced, aligned, and • Accomplished by using a weight to pull on
immobilized by a series of pins inserted in traction tape or on a foam boot attached to
the bone the skin
● Pin position is maintained through • Amount of weight applied must not exceed
attachment to a portable frame the tolerance of the skin
● Fixator facilitates patient comfort, early • No more than 2 to 3.5 kg (4.5 to 8 lb) of
mobility, and active exercise of adjacent traction can be used on an extremity
uninvolved joints; thus, complications due • Pelvic traction is usually 4.5 to 9 kg (10 to
to disuse and immobility are minimized 20 lb), depending on the weight of the
Nursing Management patient
Types of skin traction used for adults include: ● Patient’s body weight and bed position
adjustments supply the needed
▪ Buck’s extension traction (applied to countertraction
the lower leg)
▪ cervical head halter (occasionally
used to treat neck pain)
▪ pelvic belt (sometimes used to treat
back pain)
SKELETAL TRACTION
● applied directly to the bone
● used occasionally to treat fractures of the
femur, the tibia and the cervical spine
● applied directly to the bone by use of a
metal pin or wire that is inserted through
the bone distal to the fracture, avoiding
nerves, blood vessels, muscles, tendons,
and joints.
● tongs applied to the head are fixed to the
skull to apply traction that immobilizes
cervical fractures NURSING MANAGEMENT
● frequently uses 7-12 kg (15 to 25 lb) to ● Assessing anxiety
achieve the therapeutic effect ● Assisting with self-care
● Monitoring and managing potential
● weights applied initially must overcome
complications:
the shortening spasms of the affected
● atelectasis and pneumonia
muscles ○ constipation and anorexia
● often, balanced traction, which supports ○ urinary stasis and infection
the affected extremity, allows for some ○ venous thromboembolism
patient movement, and facilitates patient
independence and nursing care while THE PATIENT UNDERGOING ORTHOPEDIC
maintaining effective traction SURGERY
● Thomas splint with a Pearson attachment
is frequently used with skeletal traction for ● Many patients with musculoskeletal
fractures of the femur dysfunction undergo surgery to correct the
PRINCIPLES OF EFFECTIVE TRACTION condition
● Whenever a traction is applied, ● conditions that may be corrected by
countertraction must be used to achieve surgery include unstabilized fracture,
traction deformity, joint disease, necrotic or
● Countertraction is the force acting in the infected tissue, and tumors
opposite direction ● the goals may include improving function
by restoring and stability and relieving
pain and disability
Terms:
Open Reduction- the correction and alignment of
the fracture after surgical dissections and
exposure of the fracture
Internal Fixation- the stabilization of the reduced
fracture by the use of metal screws, plates, wires,
nails, and pins.
Arthroplasty- the repair of joint problems through
the operating arthroscope (an instrument that
allows the surgeon to operate with a join without a ● Joints frequently replaced include the hip,
large incision) or through open joint surgery knee, and finger joints
● Less frequently, more complex joints
Hemiarthroplasty- the replacement of one of the
(shoulder, elbow, wrist, ankle) are
articular surfaces (e.g. in a hip hemiarthroplasty,
replaced
the femoral head and neck are replaced with a
● With joint replacement, excellent pain
femoral prosthesis- the acetabulum is not
relief is obtained in most patients
replaced
● Return of motion and function depends on
Joint arthroplasty- the replacement of joint preoperative soft tissue condition, soft
surfaces with metal or synthetic materials tissue reactions, and general muscle
strength
Total Joint arthroplasty- the replacement of ● Early failure of joint replacement is
both articular surfaces within a join with metal or associated with excessive activity and
synthetic materials preoperative joint and bone pathology
Meniscectomy- the excision of damaged joint TOTAL HIP REPLACEMENT
fibrocartilage ● Replacement of a severely damaged hip
with an artificial joint
Amputation- the removal of a body part
● Indications for this surgery include:
Bone graft- the placement of bone tissue ○ osteoarthritis
(autologous or homologous grafts) to promote ○ rheumatoid arthritis
healing, to stabilize, or to replace diseased bone ○ femoral neck fractures
○ failure or previous reconstructive
Tendon transfer- the insertion of tendon to
surgeries (failed prosthesis,
improve function
osteotomy)
Fasciotomy- the incision and diversion of the ○ conditions resulting from
muscle fascia to relieve muscle constriction, as in developmental dysplasia
compartment syndrome, or to reduce fascia ○ Legg-Calve-Perthes (avascular
contracture necrosis of the hip in childhood)
● Variety of total hip prostheses are
● Indications for a surgical procedure are available, most consist of a metal femoral
based on the patients age, underlying component topped by a spherical ball, of
orthopedic condition, and general physical metal, ceramic, or plastic, fitted into a
health and the impact of joint disability on plastic or metal acetabular socket
daily activities ● The patient has irreversibly damaged hip
● Surgery should be performed before joints, and the potential benefits, including
surrounding muscles become contracted improved quality of life, outweigh the
and atrophied and serious structural surgical risks
abnormalities occur
● During orthopedic surgery on a limb, a MANAGEMENT OF PATIENTS WITH
pneumatic tourniquet may be applied to MUSCULOSKELETAL TRAUMA
produce a “bloodless field”
JOINT REPLACEMENT CONTUSIONS
● Done to patients with severe joint pain and ● soft tissue injury produced by blunt force
disability such as a blow, kick or fall, causing small
● Conditions contributing to joint blood vessels to rupture and bleed into
degeneration include: OA, RA, trauma, soft tissues (ecchymosis, or bruising)
and congenital deformity ● Local symptoms (pain, swelling, and
● Some fractures may cause disruption of discoloration) are controlled with
the blood supply and subsequent intermittent application of cold packs
avascular necrosis; management with joint applied with pressure to the site and
replacement may be elected over ORIF elevation of the extremity above the heart
level
● Most contusions resolve in 1 to 2 weeks tenderness, increased edema, and

abnormal joint motion)
STRAIN
NURSING MANAGEMENT
● “Pulled muscle or tendon”
● Injury caused by overuse, overstretching, ● The acronym RICE—rest, ice,
or excessive stress compression, elevation—is helpful for
● Graded along a continuum based on post
injury symptoms and loss of function and
reflect the degree of injury
● Three types of strain are recognized:
○ first-degree strain is mild
stretching of the muscle or tendon
(minor edema, tenderness, and
mild muscle spasm, without
noticeable loss of function)
○ second-degree strain involves
partial tearing of the muscle or
tendon (loss of load-bearing
strength with accompanying remembering treatment interventions
edema, tenderness, muscle ○ Rest prevents additional injury and
spasm, and ecchymosis) promotes healing
○ third-degree strain is severe ○ intermittent application of moist or
muscle or tendon stretching with dry cold packs for 20 to 30 minutes
rupturing and tearing of the during the first 24 to 48 hours after
involved tissue (significant pain, injury produces vasoconstriction,
muscle spasm, ecchymosis, which decreases bleeding, edema,
edema, and loss of function) and discomfort
○ An elastic compression bandage
SPRAIN controls bleeding, reduces edema,
● Injury to the ligaments and tendons that and provides support for the
surround a joint injured tissues
● Caused by a twisting motion or ○ Elevation controls the swelling
hyperextension (forcible) of a joint ● If the sprain or strain is third degree,
● Sprains are graded in a manner similar to surgical repair or immobilization by a
the grading system used for strains: splint, brace, or cast may be necessary so
○ first-degree sprain is caused by that the joint will not lose its stability
stretching the ligamentous fibers, JOINT DISLOCATIONS
resulting in minimum damage (mild
edema, local tenderness, and pain ● Articular surfaces of the distal and
that is elicited when the joint is proximal bones that form the joint are no
moved) longer in anatomic alignment
○ second-degree sprain involves ● Subluxation is a partial dislocation, in
partial tearing of the ligament complete dislocation, the bones are
(increased edema, tenderness, literally “out of joint”
pain with motion, joint instability, ● Traumatic dislocations are orthopedic
and partial loss of normal joint emergencies
function) ● Signs and symptoms of a traumatic
○ third-degree sprain occurs when dislocation include acute pain, change in
a ligament is completely torn or positioning of the joint, shortening of the
ruptured and may also cause an extremity, deformity, and decreased
avulsion of the bone (severe pain, mobility
EPICONDYLITIS
● Chronic, painful condition that is caused
by excessive, repetitive extension, flexion,
pronation, and supination motions of the
forearm
● Lateral epicondylitis (ie, tennis elbow) is
frequently identified in someone who
repeatedly extends the wrist or frequently
pronates and supinates the forearm
● Medial epicondylitis (ie, golfer’s or
pitcher’s elbow) is consistent with
repetitive wrist flexion
MEDICAL MANAGEMENT
● Application of ice and administration of
● Dislocation is promptly reduced and NSAIDs usually relieve the pain
displaced parts are placed back in proper ● In some instances, the arm is immobilized
anatomic position to preserve joint in a molded splint or cast
function ● Local injection of a corticosteroid is
● Analgesia, muscle relaxants, and possibly reserved for patients with severe pain who
anesthesia are used to facilitate closed do not respond to NSAIDs and
reduction immobilization
NURSING MANAGEMENT LATERAL/MEDIAL COLLATERAL LIGAMENT

INJURY
● Frequent assessment and evaluation of
the injury including complete ● Injury to these ligaments occur when the
neurovascular assessment with proper foot is firmly planted and the knee is
documentation and communication with struck
the physician ● Acute onset of pain, point tenderness,
joint instability, and inability to walk
INJURIES TO TENDONS, LIGAMENTS AND without assistance
MENSCI ● Early management is RICEA
● Conservative management includes
ROTATOR CUFF TEARS limited weight bearing and use of a
protective brace
● Tear in a tendon that connects one of the ● If needed surgical reconstruction may be
rotator muscles to the humeral head performed immediately or it may be
● Patients complain of pain, limited ROM, delayed
and some joint dysfunction, including ● The nurse instructs the patient about
muscle weakness proper use of ambulatory devices, the
● Arthrography and MRI or ultrasound are healing process, and activity limitation to
used to determine soft tissue pathology promote healing.
and the extent of the rotator cuff tear
● Initial conservative management includes CRUCIATE LIGAMENT INJURY
use of non- steroidal anti-inflammatory
drugs (NSAIDs), rest with modification of ● Injury occurs when the foot is firmly
activities, injection of a corticosteroid into planted and the leg sustains direct force,
the shoulder joint, and progressive forward or backward
stretching, ROM, and lengthening ● A torn cruciate ligament produces pain,
exercises joint instability, and pain with weight
● Some rotator cuff tears require bearing
arthroscopic debridement (removal of ● Management includes RICE and
devitalized tissue) or arthroscopic or open stabilization of the joint until it is evaluated
acromioplasty with tendon repair for a fracture
● Early treatment involves application of a b) Incomplete fracture involves a break

brace and physical therapy through only part of the cross-section of the
● Surgical ACL or PCL reconstruction may bone
be scheduled after near-normal joint ROM c) Comminuted fracture is one that produces
is achieved and includes tendon repair several bone fragments
with grafting d) Closed fracture (simple fracture) is one that
does not cause a break in the skin
MENISCAL INJURIES
e) Open fracture (compound, or complex,
● These injuries leave loose cartilage in the fracture) is one in which the skin or mucous
knee joint that may slip between the femur membrane wound extends to the fractured
and the tibia, preventing full extension of bone and graded according to the following
the leg criteria:
● Patient may hear or feel a click in the knee ✓ Grade I is a clean wound less than 1 cm
when walking, especially when extending long
the leg that is bearing weight ✓ Grade II is a larger wound without
● When a meniscus is torn, the synovial extensive soft tissue damage
membrane secretes additional synovial ✓ Grade III is highly contaminated, has
fluid due to the irritation and the knee extensive soft tissue damage, and is
becomes very edematous the most severe.
● Conservative treatment includes • Fractures may also be described according
immobilization of the knee, use of to the anatomic placement of fragments
crutches, anti-inflammatory agents, • Clinical signs and symptoms of a fracture
analgesics, and modification of activities include acute pain, loss of function,
to avoid those that cause the symptoms deformity, shortening of the extremity,
● Damaged cartilage is surgically removed crepitus, and localized edema and
(meniscectomy) arthroscopically ecchymosis
RUPTURE OF ACHILLES TENDON

● Occurs during activities when there is a
sudden contraction of the calf muscle with
the foot fixed firmly to the floor or ground
● Sharp pain and cannot plantar flex the
foot
● Immediate surgical repair is usually
recommended to obtain satisfactory
results
FRACTURES
● Complete or incomplete disruption in the
continuity of bone structure and is defined
according to its type and extent
● Occur when the bone is subjected to
stress greater than it can absorb
● Caused by direct blows, crushing forces,
sudden twisting motions, and extreme
muscle contractions
TYPES OF FRACTURES
a) Complete fracture involves a break across
the entire cross-section of the bone and is
frequently displaced
EMERGENCY MANAGEMENT time frame for the location and type

of fracture
• Important to immobilize the body part ✓ Nonunion results from failure of the
before the patient is moved, adequate ends of a fractured bone to unite
splinting is essential ✓ Malunion results from failure of the
• Neurovascular status distal to the injury ends of a fractured bone to unite in
should be assessed both before and after normal alignment
splinting to determine the adequacy of ✓ Avascular necrosis of bone
peripheral tissue perfusion and nerve ✓ Reaction to internal fixation devices
function ✓ Complex regional pain syndrome
• With an open fracture, the wound is ✓ Heterotopic ossification (Myositis
covered with a sterile dressing to prevent ossificans)
contamination of deeper tissues
FRACTURE OF SPECIFIC SITES
MEDICAL MANAGEMENT
CLAVICLE
• Reduction
a. Closed reduction • Common injury that results from a fall or a
b. Open reduction direct blow to the shoulder
• Immobilization • Treatment goal is to align the shoulder in
• Maintaining and restoring function its normal position by means of closed
reduction and immobilization
NURSING MANAGEMENT • Most of these fractures occur in the middle
• Patients With Closed Fractures third of the clavicle
✓ The nurse instructs the patient • Fracture of the distal third of the clavicle,
regarding the proper methods to without displacement and ligament
control edema and pain disruption, is treated with a sling and
✓ The patient is also taught how to use restricted motion of the arm
assistive devices safely • When a fracture in the distal third is
✓ Patient teaching includes self-care, accompanied by a disruption of the
medication information, monitoring coracoclavicular ligament, it may be
for potential complications, and the treated by open reduction with internal
need for continuing health care fixation
supervision HUMERAL NECK
• Patients With Open Fractures
✓ Objectives of management are to • Fractures of the proximal humerus may
prevent infection of the wound, soft occur through the neck of the humerus
tissue, and bone and to promote • Impacted fractures of the surgical neck of
healing of bone and soft tissue the humerus are seen most frequently in
older women after a fall on an outstretched
FRACTURE HEALING AND COMPLICATIONS arm
• Early Complications • Affected arm hanging limp at the side or
✓ Hypovolemic hock supported by the uninjured hand
✓ Fat Embolism Syndrome • Many impacted fractures of the surgical
✓ Compartment Syndrome neck of the humerus are not displaced and
✓ Venous thrombo-emboli, including do not require reduction, the arm is
DVT and PE supported and immobilized by a sling and
✓ Disseminated intravascular swathe that secure the supported arm to
coagulation (DIC) the trunk
• Delayed Complications • When a humeral neck fracture is displaced,
✓ Delayed union occurs when healing treatment consists of closed reduction,
does not occur within the expected ORIF, or a total shoulder replacement
HUMERAL SHAFT RADIAL and ULNAR SHAFTS
• Fractures of the shaft of the humerus are • Fractures of the shaft of the bones of the
most frequently caused by: forearm occur more frequently in children
1. direct trauma that results in a than in adults
transverse, oblique, or comminuted • If the fragments are not displaced, the
fracture fracture is treated by closed reduction with
2. an indirect twisting force that results a long-arm cast applied from the upper arm
in a spiral fracture to the proximal palmar crease
• Well-padded splints are used to initially • Displaced fractures are managed by ORIF,
immobilize the upper arm and to support using a compression plate with screws,
the arm in 90 degrees of flexion at the intramedullary nails, or rods
elbow and a sling or collar and cuff support
the forearm WRIST
• External fixators are used to treat open • Fractures of the distal radius (Colles
fractures of the humeral shaft fracture) are common and results due to fall
• ORIF of a fracture of the humerus is on an open, dorsiflexed hand
necessary with nerve palsy, blood vessel • Frequently seen in elderly women with
damage, comminuted fracture, or osteoporotic bones and weak soft tissues
displaced fracture • Deformed wrist, pain, swelling, weakness,
ELBOW limited finger ROM, and complaints of
“tingling”
• Fractures of the distal humerus result from • Treatment usually consists of closed
motor vehicle crashes, falls on the elbow reduction and immobilization with a short-
(in the extended or flexed position), or a arm cast
direct blow • Fractures with extensive comminution,
• May result in injury to the median, radial, or ORIF, arthroscopic percutaneous pinning,
ulnar nerves or external fixation
• Most serious complication of a
supracondylar fracture of the humerus is HAND
Volkmann’s contracture (an acute • Objective of treatment is always to regain
compartment syndrome), which results maximum function of the hand
from antecubital swelling or damage to the • Nondisplaced fracture of the phalanx
brachial artery (finger bone), the finger is splinted for 3 to
• If the fracture is not displaced, the arm is 4 weeks to relieve pain and to protect the
immobilized in a cast or posterior splint with finger from further trauma
the elbow at 45 to 90 degrees of flexion and • Displaced fractures and open fractures
placed in a sling may require ORIF, using wires or pins
• A displaced fracture is treated with ORIF • Swelling is controlled by elevation of the
hand
RADIAL HEAD PELVIS
• Radial head fractures are common and are • Falls, motor vehicle crashes, and crush
usually produced by a fall on an injuries can cause pelvic fractures
outstretched hand with the elbow extended • Signs and symptoms of pelvic fracture
• Immobilization for nondisplaced fractures include:
is accomplished with a splint ✓ ecchymosis
• If the fracture is displaced, surgery is ✓ tenderness over the symphysis
typically indicated, with excision of the pubis, anterior iliac spines, iliac
radial head when necessary crest, sacrum, or coccyx
✓ local edema
✓ numbness or tingling of the pubis, HIP

genitals, and proximal thighs
✓ inability to bear weight without • Elderly people (particularly women) who
discomfort have low bone density from osteoporosis
• Computed tomography (CT) of the pelvis and who tend to fall frequently have a high
incidence of hip fracture
helps determine the extent of injury by
demonstrating sacroiliac joint disruption, • Two major types of hip fracture:
soft tissue trauma, pelvic hematoma, and 1. Intracapsular fractures are
fractures fractures of the neck of the femur
• Stable Pelvic Fractures 2. Extracapsular fractures are
fractures of the trochanteric region
✓ Include fracture of a single pubic or
(between the base of the neck and
ischial ramus, fracture of ipsilateral
the lesser trochanter of the femur)
pubic and ischial rami, fracture of
and of the subtrochanteric region
the pelvic wing of the ilium
(Duverney fracture), and fracture of • Leg is shortened, adducted, and externally
the sacrum or coccyx rotated
✓ Treated with a few days of bed rest • Patient reports pain in the hip and groin or
and symptom management until in the medial side of the knee
discomfort is controlled • Buck’s extension traction, a type of
• Unstable Pelvic Fractures temporary skin traction, may be applied to
✓ Result in rotational instability, reduce muscle spasm, to immobilize the
vertical instability, or a combination extremity, and to relieve pain, although its
of both efficacy has not been demonstrated in
✓ Immediate treatment includes clinical trials
stabilizing the pelvic bones and • Goal of surgical treatment of hip fractures
compressing bleeding vessels with is to obtain a satisfactory fixation so that the
a pelvic girdle, an external binding patient can be mobilized quickly and avoid
and stabilizing device secondary medical complications
✓ When the patient is Surgical treatment consists of:
hemodynamically stable, treatment
generally involves external fixation 1. open or closed reduction of the fracture and
or ORIF internal fixation
• Acetabulum
2. replacement of the femoral head with a
✓ Drivers and passengers sitting in
prosthesis (hemiarthroplasty)
the right front seat in motor vehicle
crashes may forcibly propel their 3. closed reduction with percutaneous
knees into the dashboard, injuring stabilization for an intracapsular fracture
the knee-thigh-hip complex
✓ The acetabulum is particularly Nursing Management
vulnerable to fracture with injuries 1. Repositioning the patient - most
✓ Treatment depends on the pattern comfortable and safest way to turn the
of fracture patient is to turn to the uninjured side
✓ Stable, nondisplaced fractures may
be managed with traction and 2. Promoting exercise - encouraged to
protective weight bearing so that exercise as much as possible by means of
the affected foot is only placed on the overbed trapeze
the floor for balance 3. Monitoring and managing potential
✓ Displaced and unstable acetabular complications - homeostasis after injury
fractures are treated with open and after surgery is accomplished through
reduction, joint debridement, and careful monitoring and collaborative
internal fixation or arthroplasty management
4. Health Promotion - osteoporosis screening TIBIA AND FIBULA

of patients who have experienced hip
fracture is important for prevention of future • Most common fractures below the knee are
fractures tibia and fibula fractures
• Occur in association with each other and
KNEE tend to result from a direct blow, falls with
the foot in a flexed position, or a violent
• Fracture to the most distal portion of the
twisting motion
femur, the patella (kneecap), and fracture
• Presents with pain, deformity, obvious
to the most proximal portion of the tibia,
hematoma, and considerable edema
may be defined as fractures of the knee
• Cannot dorsiflex the great toe and has
• Caused by motor vehicle crashes, direct
diminished sensation in the first web space
blows to the knee from contact sports or
• Treated with closed reduction and initial
intentionally inflicted trauma, or falls
immobilization in a long-leg walking cast or
• Presents with acute pain to the affected
a patellar tendon–bearing cast
knee with noted edema and cannot
• Comminuted fractures may be treated with
ambulate or bear weight on the affected
skeletal traction, internal fixation with
extremity
intramedullary nails or plates and screws,
• An MRI or CT scan can define the details
or external fixation
of the injury of bone, cartilage, tendons,
• Open fractures are treated with external
and ligaments
fixation
• Patients with significant joint effusions may
• Distal fractures with extensive soft tissue
benefit from arthrocentesis to provide relief
damage heal slowly and may require bone
of intra-articular pressure
grafting
• Anti-inflammatory and analgesic effects of
NSAIDs such as ibuprofen (Motrin, Advil) RIB
may be prescribed
• Nondisplaced fractures may be effectively • Uncomplicated fractures of the lower ribs
treated with 6 weeks of immobilization and occur frequently in adults and usually result
gradual increases in weight bearing, while in no impairment of function
displaced fractures typically require ORIF • Fractures cause pain with respiratory
surgical procedures effort, the patient tends to decrease
respiratory excursions and refrains from
FEMORAL SHAFT coughing
• To help the patient cough and take deep
• Considerable force is required to break
breaths, the nurse may splint the chest with
the shaft of a femur in adults
his or her hands
• Occur in young adults who have been
• The pain associated with rib fracture
involved in a motor vehicle crash or
diminishes significantly in 3 or 4 days, and
who have fallen from a high place
the fracture heals within 6 weeks
• Presents with an edematous,
deformed, painful thigh and cannot THORACOLUMBAR SPINE
move the hip or the knee
• Dislocation of the hip and knee may • The T12 to L2 area of the spine is most
accompany these fractures vulnerable to fracture
• Skeletal traction or splinting is used to • Fractures generally result from indirect
immobilize fracture fragments until the trauma caused by excessive loading,
patient is physiologically stable and sudden muscle contraction, or excessive
ready for ORIF procedures motion beyond physiologic limits
• A common complication after fracture • Osteoporosis contributes to vertebral body
of the femoral shaft is restriction of collapse (compression fracture)
knee motion • Presents with acute tenderness, swelling,
paravertebral muscle spasm, and change
in the normal curves or in the gap between

spinous processes
• Most frequent types of single injuries are:
• Immobilization is essential until initial
1. sprains, strains, and tears (40.8%)
assessments
2. cuts, lacerations, and punctures
• If spinal cord injury with neurologic deficit
(9.6%)
occurs, it usually requires immediate
3. bruises and contusions (8.7%)
surgery (laminectomy with spinal fusion) to
4. fractures, (7.8%)
decompress the spinal cord
5. soreness and pain (5.3%)
• Analgesics are prescribed for pain relief
6. multiple injuries (4.1%)
• Spinal brace or plastic thoracolumbar
7. back pain (2.9%)
orthosis may be applied for support during
progressive ambulation and resumption of AMPUTATION
activities
• Removal of a body part, often an extremity
SPORTS-RELATED INJURIES • Amputation of a lower extremity occurs
more frequently than a upper extremity
Management
• Used to relieve symptoms, to improve
• Patients who have experienced sports- function, and, most important, to save or
related injuries are often highly motivated improve the patient’s quality of life
to return to their previous level of activity
Levels of Amputation
• Compliance with restriction of activities and
gradual resumption of activities need to be • Performed at the most distal point that
reinforced will heal successfully
• Time required to recover from a sports- • Site of amputation is determined by two
related injury can be as short as a few days factors: circulation in the part and
or considerably longer than 6 weeks, functional usefulness
depending on the severity of the injury • Objective of surgery is to conserve as
• Increasing activities gradually to acclimate much extremity length as needed to
the muscles, tendons, and joints to the preserve function and possibly to
sport motions will assist in recovery and achieve a good prosthetic fit.
rehabilitation
Prevention
• Sports-related injuries can often be

prevented by using proper equipment and
by effectively training and conditioning the
body
• Specific training needs to be tailored to the
person and the sport
• Stretching prior to engaging in sports or
exercise had long been recommended;
however, studies suggest that stretching
may not prevent injury
Complications:
OCCUPATION-RELATED INJURIES
• Hemorrhage
• Injuries or illnesses of the muscles, nerves,
• Infection
tendons, joints, cartilage, and bones that
• Skin breakdown
occur because of exposure to work-related
risks • Phantom limb pain
• Joint contracture
Medical Management • Health care organizations should institute

“no lift” policies for individual nursing
• Objective of treatment is to achieve
personnel
healing of the amputation wound, the
• Health care organizations should devise
result being a nontender residual limb
methods to assess their patient care
with healthy skin for prosthetic use
ergonomic risks and develop algorithms for
Rehabilitation patient handling and movement that
include patient transfer and movement
• Multidisciplinary rehabilitation team activities
(patient, nurse, physician, social
worker, physical therapist,
occupational therapist, psychologist, MANAGEMENT OF PATIENT WITH
prosthetist, vocational rehabilitation MUSCULOSKELETAL DISORDERS
worker) helps the patient achieve the
LOW BACK PAIN
highest possible level of function and
participation in life activities Pathophysiology
• Prosthetic clinics and amputee support
• Disk degeneration is a common cause of
groups facilitate this rehabilitation
back pain
process
• L4–L5 and L5–S1, are subject to
• Psychological issues may be
mechanical stress and degenerative
influenced by the type of support the
changes
patient receives from the rehabilitation
team and by how quickly ADLs and use • Disk protrusion (herniated nucleus
of the prosthesis are learned pulposus) or facet joint changes can cause
pressure on nerve roots as they leave the
• Knowing the full options and
spinal canal → resulting in pain
capabilities available with the various
prosthetic devices can give the patient Clinical Manifestations
a sense of control over the resulting
disability • Pain radiating down the leg (radiculopathy
or sciatica)
PREVENTION OF INJURIES IN NURSING • Gait, spinal mobility, reflexes, leg length,
PERSONNEL leg motor strength, and sensory
• Nursing is consistently ranked among the perception may be affected
top ten occupations that are most involved • PE may disclose paravertebral muscle
in occupation-related injuries and lost work spasm with a loss of the normal lumbar
days curve and possible spinal deformity
• Types of injuries that are most common Assessment and Diagnostic Findings
include back, neck, shoulder, wrist, and
knee injuries • Focused history and PE, including general
• Most of these injuries have occurred during observation of the patient, back
patient handling and movement activities examination, and neurologic testing
• If the initial examination does not suggest a
American Nurses Association (ANA) “Handle serious condition, no additional testing is
with Care” campaign performed during the first 4 weeks of
• American Nurses Association (ANA) symptoms
“Handle with Care” campaign Medical Management
• Hospitals, long-term care facilities, and
other health care organizations should • Pain is self-limited (4 weeks) with analgesic
purchase patient handling equipment and agents, rest, and relaxation
train nursing personnel in their appropriate • Nonpharmacologic interventions:
use application of superficial heat and spinal
manipulation
• Patients need to alter their activity patterns IMPINGEMENT SYNDROME

to avoid aggravating the pain
• General term that describes all lesions that
• If no improvement within a month,
involve the rotator cuff of the shoulder
additional assessments for physiologic
• Occurs from repetitive overhead
abnormalities are performed
movement of the arm or from acute trauma
Nursing Assessment 1. Stage I is characterized by edema
and hemorrhage of the rotator cuff
• During the interview, the patient’s posture, tendons or subacromial bursa
position changes, and gait is observed (pain, shoulder tenderness, limited
• On PE, the spinal curve, any leg length movement, muscle spasm, and
discrepancy, and pelvic crest and shoulder eventual atrophy)
symmetry is assessed 2. Stage II is due to partial rotator cuff
• Nurse evaluates nerve involvement by tear
assessing deep tendon reflexes, 3. Stage III is due to complete rotator
sensations, and muscle strength cuff tear
Nursing Management • Treatment with corticosteroids generally
results in speedier symptomatic
• Include relief of pain, improved physical improvement than that with NSAIDs
mobility, use of back-conserving
techniques of body mechanics, improved
self-esteem, and weight reduction CARPAL TUNNEL SYNDROME
• Entrapment neuropathy that occurs when

COMMON UPPER EXTREMITY PROBLEMS the median nerve at the wrist is
compressed by a thickened flexor tendon
BURSITIS AND TENDINITIS sheath, skeletal encroachment, edema, or
a soft tissue mass
• Inflammatory conditions that commonly
• Commonly caused by repetitive hand and
occur in the shoulder
wrist movements, but it may also be
• Traditional conservative treatment includes
associated with arthritis, diabetes, tumors,
rest of the extremity, intermittent ice and
or trauma
heat to the joint, and NSAIDs to control the
• Patient experiences pain, numbness,
inflammation and pain
paresthesia, and possibly weakness along
• Newer therapies that include
the median nerve (thumb, index, and
extracorporeal shock wave therapy, pulsed
middle fingers)
magnetic field therapy, laser phototherapy,
• Tinel’s sign may be used to help identify
and radiofrequency coblation therapy
carpal tunnel syndrome Intra-articular
• Arthroscopic synovectomy may be
injections of corticosteroids is very effective
considered if shoulder pain and weakness
at relieving symptoms
persist
• Application of wrist splints to prevent
LOOSE BODIES hyperextension and prolonged flexion of
the wrist are also effective interventions
• Result of articular cartilage wear and bone • Traditional open nerve release or
erosion endoscopic laser surgery are the two most
• Removed by arthroscopic surgery common surgical management options for
treatment of carpal tunnel syndrome
GANGLION Nursing Management of the Patient

Undergoing Surgery of the Hand or Wrist
• Collection of gelatinous material near
the tendon sheaths and joints, appears • Surgery of the hand or wrist, unless
as a round, firm, cystic swelling, usually related to major trauma, is generally an
on the dorsum of the wrist ambulatory procedure
• Locally tender and may cause an • Before surgery, the nurse assesses the
aching pain patient’s level and type of discomfort
• Treatment may include aspiration, and limitations in function
corticosteroid injection, or surgical • Neurovascular assessment of the
excision exposed fingers every hour for the first
24 hours following surgery is essential
for monitoring function of the nerves
and perfusion of the hand
• Intermittent use of ice packs to the
surgical area during the first 24 to 48
hours may be prescribed to control
edema
• Pain and discomfort can be controlled
by oral analgesic agents
• Nurse teaches the patient to monitor
DUPUYTREN’S DISEASE temperature and signs and symptoms
that suggest an infection
• Results in a slowly progressive
• After the patient has undergone hand
contracture of the palmar fascia, called
surgery, the nurse teaches the patient
Dupuytren’s contracture, which causes
how to monitor neurovascular status
flexion of the fourth and fifth fingers,
and the signs of complications that
and frequently the middle finger
need to be reported to the surgeon
• Associated with arthritis, diabetes,
gout, cigarette smoking, and COMMON FOOT PROBLEMS
alcoholism
• Starts as a nodule of the palmar fascia, PLANTAR FASCIITIS
in one hand, but eventually both hands
are affected • Inflammation of the foot-supporting fascia
• Finger-stretching exercises or intra- • Presents as an acute onset of heel pain
nodular injections of corticosteroids experienced with the first steps in the
might prevent contractures morning
• Palmar and digital fasciectomies are • Management includes:
performed to improve function ✓ stretching exercises
✓ wearing shoes with support and
cushioning to relieve pain
✓ orthotic devices (eg, heel cups,
arch supports, night splints)
✓ corticosteroid injections
• A toenail may need to be excised by the

podiatrist if there is severe infection
CORN
HAMMER TOE
• Area of hyperkeratosis (overgrowth of a
horny layer of epidermis) produced by • Flexion deformity of the interphalangeal
internal pressure (the underlying bone is joint, which may involve several toes
prominent because of a congenital or • Toes usually are pulled upward, forcing the
acquired abnormality, commonly arthritis) metatarsal joints (ball of the foot)
or external pressure (ill-fitting shoes) downward
• Fifth toe is most frequently involved, but • Treatment consists of conservative
any toe may be involved measures:
• Treated by a podiatrist by soaking and ✓ wearing open-toed sandals or
scraping off the horny layer, by application shoes that conform to the shape of
of a protective shield or pad, or by surgical the foot, carrying out manipulative
modification of the underlying offending exercises
osseous structure ✓ protecting the protruding joints with
• Treatment consists of drying the affected pads
spaces and separating the affected toes • Surgery (osteotomy) may be used to
with lamb’s wool or gauze correct a resulting deformity
CALLUS
• Discretely thickened area of the skin that

has been exposed to persistent pressure or
friction
• Faulty foot mechanics usually precede the
formation of a callus
• Keratolytic ointment may be applied and a
thin plastic cup worn over the heel if the HALLUX VALGUS (BUNION)
callus is on this area
• Felt padding with an adhesive backing is • Deformity in which the great toe deviates
also used to prevent and relieve pressure laterally
• Orthotic devices can be made to remove • Marked prominence of the medial aspect of
the pressure from bony protuberances, or the first metatarsophalangeal joint
the protuberance may be excised • Factors contributing to bunion formation
include heredity, ill-fitting shoes, and
INGROWN TOENAIL (ONCHOCRYPTOSIS) gradual lengthening and widening of the
• Condition in which the free edge of a nail foot associated with aging
plate penetrates the surrounding skin, • Corticosteroid injections control acute
either laterally or anteriorly inflammation
• Caused by improper self-treatment, • Surgical removal of the bunion (exostosis)
external pressure (tight shoes or and osteotomies to realign the toe may be
stockings), internal pressure (deformed required to improve function, appearance,
toes, growth under the nail), trauma, or and symptoms
infection
• Trimming the nails properly (clipping them
straight across and filing the corners
consistent with the contour of the toe) can
prevent this problem
• Active treatment consists of washing the
foot twice a day, followed by the application
of a local antibiotic ointment
PES CAVUS (CLAWFOOT) • Signs and symptoms include a burning

sensation, fatigue, clumsy gait, edema,
• Refers to a foot with an abnormally high
and pain
arch and a fixed equinus deformity of the
• Exercises to strengthen the muscles and to
forefoot
improve posture and walking habits are
• Charcot-Marie-Tooth disease (a
helpful
peripheral neuromuscular disease
associated with a familial degenerative
disorder), diabetes mellitus, and tertiary
Nursing Management of the Patient
syphilis are common causes
Undergoing Foot Surgery
• Exercises are prescribed to manipulate the
forefoot into dorsiflexion and relax the toes • Generally, foot surgery is performed on an
• Orthotic devices alleviate pain and can outpatient basis
protect the foot • Before surgery, the nurse assesses the
• In severe cases, arthrodesis (fusion) is patient’s ambulatory ability and balance
performed and the neurovascular status of the foot
• After surgery, neurovascular assessment
of the exposed toes every 1 to 2 hours for
the first 24 hours is essential to monitor the
function of the nerves and the perfusion of
the tissues
MORTON’S NUEROMA (PLANTAR DIGITAL METABOLIC BONE DISORDERS

NEUROMA, NEUROFIBROMA)
• Swelling of the third (lateral) branch of the OSTEOPOROSIS

median plantar nerve • Most prevalent bone disease in the world
• Third digital nerve, which is located in the • Consequence of osteoporosis is bone
third intermetatarsal (web) space, is most fracture
commonly involved • Primary osteoporosis occurs in women
• Throbbing, burning pain in the foot that is after menopause (usually between the
usually relieved when the patient rests ages of 45 and 55 years) and in men later
• Conservative treatment consists of in life, but it is not merely a consequence of
inserting innersoles and metatarsal pads aging
designed to spread the metatarsal heads • Secondary osteoporosis is the result of
and balance the foot posture medications or other conditions and
• Local injections of a corticosteroid and a diseases that affect bone metabolism
local anesthetic agent may provide relief, if
these fail, surgical excision of the neuroma Pathophysiology
is necessary Characterized by reduced bone mass,
deterioration of bone matrix, and diminished bone
FLATFOOT (PES PLANUS) architectural strength
• Common disorder in which the longitudinal Assessment and Diagnostic Findings

arch of the foot is diminished • Undetectable on routine x-rays until there
• May be caused by congenital abnormalities has been 25% to 40% demineralization,
or associated with bone or ligament injury, resulting in radiolucency of the bones
muscle and posture imbalances, excessive • Diagnosed by dual-energy x-ray
weight, muscle fatigue, poorly fitting shoes, absorptiometry (DXA), which provides
or arthritis information about BMD at the spine and hip
Medical Management
Pharmacologic Therapy PAGET’S DISEASE
• First-line medications include calcium and • Disorder of localized rapid bone turnover,
vitamin D supplements and most commonly affecting the skull, femur,
bisphosphonates tibia, pelvic bones, and vertebrae
• Medications that might be prescribed after • Cause of Paget’s disease is not known
these medications are tried include
calcitonin, selective estrogen receptor
modulators, and anabolic agents. Pathophysiology
Fracture Management • Primary proliferation of osteoclasts, which
• Managed surgically by joint replacement or induce bone resorption followed by a
compensatory increase in osteoblastic
by closed reduction or ORIF
activity that replaces the bone classic
• Osteoporotic compression fractures are
mosaic (disorganized) pattern of bone
managed conservatively
develops
• Percutaneous vertebroplasty or
kyphoplasty can provide rapid relief of Clinical Manifestations
acute pain and improve quality of life
• Paget’s disease is insidious; most patients
never experience symptoms
• Some patients do not experience
OSTEOMALACIA
symptoms but have skeletal deformity; a
• Metabolic bone disease characterized by few patients have symptomatic deformity
inadequate mineralization of bone resulting and pain
to softening and weakening of the skeleton,
Assessment and Diagnostic Findings
causing pain, tenderness to touch, bowing
of the bones, and pathologic fractures • Elevated serum alkaline phosphatase and
• Skeletal deformities (spinal kyphosis and urinary hydroxyproline excretion
bowed legs) give patients an unusual • X-rays confirm the diagnosis of Paget’s
appearance and a waddling or limping gait disease
Pathophysiology
Medical Management
• Deficiency of activated vitamin D (calcitriol)
• Failed calcium absorption or from • Pain usually responds to NSAIDs
excessive loss of calcium from the body • Gait problems from bowing of the legs are
managed with walking aids, shoe lifts, and
physical therapy
• On x-ray studies, generalized • Pharmacologic therapy
demineralization of bone is evident ✓ Patients with moderate to severe
• Studies of the vertebrae may show a disease may benefit from specific
compression fracture with indistinct anti-osteoclastic therapy
vertebral endplates ✓ Calcitonin, a polypeptide hormone,
retards bone resorption
Medical Management ✓ Bisphosphonates produce rapid
• Physical, psychological, and reduction in bone turnover and
pharmaceutical measures are used to relief of pain
reduce the patient’s discomfort and pain ✓ Plicamycin, a cytotoxic antibiotic,
• Long-term monitoring to ensure may be used to control the disease
stabilization or reversal of osteomalacia
MUSCULOSKELETAL INFECTIONS scan, and magnetic resonance imaging

(MRI) help with early definitive diagnosis
OSTEOMYELITIS
• Wound and blood culture studies are
• Infection of the bone that results in performed, although they are only positive
inflammation, necrosis, and formation of in 50% of cases
new bone
Medical Management
• Classified as:
✓ Hematogenous osteomyelitis (ie, • Initial goal of therapy is to control and halt
due to bloodborne spread of the infective process
infection) • Antibiotic therapy depends on the results of
✓ Contiguous-focus osteomyelitis, blood and wound cultures
from contamination from bone • General supportive measures (eg,
surgery, open fracture, or traumatic hydration, diet high in vitamins and protein,
injury (eg, gunshot wound) correction of anemia) should be instituted
• Postoperative surgical wound infections
occur within 30 days after surgery and are Pharmacologic Therapy
classified as: • As soon as the culture specimens are
✓ incisional (superficial, located obtained, IV antibiotic therapy begins,
above the deep fascia layer) based on the assumption that infection
✓ deep (involving tissue beneath the results from a staphylococcal organism
deep fascia) that is sensitive to a penicillin or
Pathophysiology cephalosporin
• Aim is to control the infection before the
• >50% of bone infections are caused by blood supply to the area diminishes as a
Staphylococcus aureus result of thrombosis
• Other pathogens include streptococci and
enterococci, followed by gram-negative Surgical Management
bacteria that include Pseudomonas • If the infection is chronic and does not
species respond to antibiotic therapy, surgical
Clinical Manifestations debridement is indicated
• Antibiotic-impregnated beads may be
• When the bloodborne, the onset is usually placed in the wound for direct application of
sudden, occurring often with the clinical antibiotics for 2 to 4 weeks
and laboratory manifestations of sepsis
(eg, chills, high fever, rapid pulse, general
malaise) SEPTIC (INFECTIOUS) ARTHRITIS
• When osteomyelitis occurs from spread of
adjacent infection or from direct • Joints can become infected through spread
contamination, there are no symptoms of of infection from other parts of the body
sepsis (hematogenous spread) or directly through
• Chronic osteomyelitis: nonhealing ulcer trauma or surgical instrumentation
that overlies the infected bone with a • Previous trauma to joints, joint
connecting sinus that will intermittently and replacement, coexisting arthritis, and
spontaneously drain pus diminished host resistance contributes to
the development of an infected joint
Assessment and Diagnostic Findings • S. aureus causes at least 50% of all joint
• In acute osteomyelitis, early x-ray findings infections, and 80% of cases of septic
demonstrate soft tissue edema arthritis in patients with rheumatoid arthritis
• Radioisotope bone scans, particularly the and diabetes
isotope-labeled white blood cell (WBC)
• Knee joint that is most commonly infected • Osteochondroma is the most common
(50% of cases), followed by the hip and the benign bone tumor
shoulder • Enchondroma is a common tumor of the
hyaline cartilage that develops in the hand,
Clinical Manifestations
femur, tibia, or humerus
• Presents with a warm, painful, swollen joint • Only symptom is a mild ache and
with decreased range of motion pathologic fractures may occur
• Systemic chills, fever, and leukocytosis are • Osteoid osteoma is a painful tumor that
present occurs in children and young adults
• Giant cell tumors (osteoclastomas) are
Assessment and Diagnostic Findings benign for long periods but may invade
• Diagnostic studies include aspiration, local tissue and cause destruction
examination, and culture of the synovial
fluid
• CT and MRI may reveal damage to the joint MALIGNANT BONE TUMORS
lining
• Relatively rare and arise from connective
• Radioisotope scanning may be useful in
and supportive tissue cells (sarcomas) or
localizing the infectious process
bone marrow elements Include
Medical Management osteosarcoma, chondrosarcoma, Ewing’s
sarcoma, and fibrosarcoma
• Broad-spectrum IV antibiotics are started • Soft tissue sarcomas include liposarcoma,
promptly and then changed to organism- fibrosarcoma of soft tissue, and
specific antibiotics after culture results are rhabdomyosarcoma
available • Bone tumor metastasis to the lungs is
• Inflamed joint is supported and immobilized common
in a functional position by a splint that • Osteosarcoma is the most common and
increases the patient’s comfort most often fatal primary malignant bone
• Analgesic agents, such as codeine, may be tumor
prescribed to relieve pain • Clinical manifestations typically include
Nursing Management localized bone pain that may be
accompanied by a tender, palpable soft
• Nurse describes the septic arthritis tissue mass
physiologic process to the patient and • Primary lesion may involve any bone, but
teaches the patient how to relieve pain the most common sites are the distal
using pharmacologic and femur, the proximal tibia, and the proximal
nonpharmacologic interventions humerus
• Malignant tumors of the hyaline cartilage
are called chondrosarcomas - second most
BONE TUMORS common primary malignant bone tumor
METASTATIC BONE DISEASE
BENIGN BONE TUMORS
• Secondary bone tumor is more common
• More common than malignant primary than primary bone tumors
bone tumors • Tumors arising from tissues elsewhere in
• Slow growing, well circumscribed, and the body may invade the bone and produce
encapsulated; present few symptoms; and localized bone destruction (lytic lesions) or
are not a cause of death bone overgrowth (blastic lesions)
• Include osteochondroma, enchondroma, • Most common primary sites of tumors that
bone cyst, osteoid osteoma, metastasize to bone are the kidney,
rhabdomyoma, and fibroma prostate, lung, breast, ovary, and thyroid
• Metastatic tumors most frequently attack Nursing Management

the skull, spine, pelvis, femur, and humerus
• Monitoring and Managing Potential
and often involve more than one bone
Complications
(polyostotic)
• Delayed wound Healing
Pathophysiology • Inadequate nutrition
• Hypercalcemia is a dangerous
A tumor in the bone causes the normal bone tissue
complication of bone cancer
to react by osteolytic response (bone destruction)
or osteoblastic response (bone formation) Promoting home and community-based Care
• Teaching patients self-care

Clinical Manifestations • Continuing care
May be symptom-free or have pain that ranges

from mild and occasional to constant and severe,
varying degrees of disability, and, at times, obvious
bone growth

Differential diagnosis is based on the history,
physical examination, and diagnostic studies,
including CT, bone scans, myelography,
arteriography, MRI, biopsy, and biochemical
assays of the blood and urine
Medical Management
Primary Bone Tumors
• Goal of primary bone tumor treatment is to

destroy or remove the tumor
• May be accomplished by surgical excision
(ranging from local excision to amputation
and disarticulation), radiation therapy if the
tumor is radiosensitive, and chemotherapy
(preoperative, intraoperative
[neoadjuvant], postoperative, and
adjunctive for possible micrometastases)
Secondary Bone Tumors
• Treatment of metastatic bone cancer is

palliative
• Therapeutic goal is to relieve the patient’s
pain and discomfort while promoting quality
of life

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19: MUSCULOSKELETAL SYSTEM NCA 1

DR. ESTHER SUNDAY C. FALLER, RMT, MD: || February 9,2023

MUSCULUSKELETAL SYSTEM 3.Osteoclasts, located in shallow Howship’s

✓ Diarthrosis joints are freely • Muscles causing movement opposite to

MUSCLE ACTIONS Past Health, Social, and Family History

preexisting disability) and related o Precise measurement of range of motion

that may require special consideration LABORATORY STUDIES

of osteoblasts and enhanced bone ASSISTIVE DEVICES FOR WALKING

ISOTONIC EXERCISES 1. Four point gait

ISOMETRIC EXERCISES 2. Two point gait

The Patient in a Cast, Splint or Brace BRACES

• used to provide support, control

● Nurse assesses circulation by observing ● Monitors the neurovascular status of the

● Most contusions resolve in 1 to 2 weeks tenderness, increased edema, and

NURSING MANAGEMENT LATERAL/MEDIAL COLLATERAL LIGAMENT

● Early treatment involves application of a b) Incomplete fracture involves a break

RUPTURE OF ACHILLES TENDON

EMERGENCY MANAGEMENT time frame for the location and type

HUMERAL SHAFT RADIAL and ULNAR SHAFTS

✓ numbness or tingling of the pubis, HIP

4. Health Promotion - osteoporosis screening TIBIA AND FIBULA

in the normal curves or in the gap between

• Sports-related injuries can often be

Medical Management • Health care organizations should institute

• Patients need to alter their activity patterns IMPINGEMENT SYNDROME

• Entrapment neuropathy that occurs when

GANGLION Nursing Management of the Patient

• A toenail may need to be excised by the

• Discretely thickened area of the skin that

PES CAVUS (CLAWFOOT) • Signs and symptoms include a burning

MORTON’S NUEROMA (PLANTAR DIGITAL METABOLIC BONE DISORDERS

• Swelling of the third (lateral) branch of the OSTEOPOROSIS

• Common disorder in which the longitudinal Assessment and Diagnostic Findings

MUSCULOSKELETAL INFECTIONS scan, and magnetic resonance imaging

• Metastatic tumors most frequently attack Nursing Management

• Teaching patients self-care

May be symptom-free or have pain that ranges

Assessment and Diagnostic Findings

Primary Bone Tumors

• Goal of primary bone tumor treatment is to

Secondary Bone Tumors

• Treatment of metastatic bone cancer is

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