1. Musculo-skeletal Disorders Semester 4
Orthopedics
Musculo-skeletal Disorders
Semester 4

2. 4 Major Areas of Orthopedic Nursing
Assessing and alleviating pain
Increasing patients mobility
Preventing complications
Providing patient teaching

3. Agenda A&P (you have already done this)
Assessment (you have already done this)
Causes of Disorders
trauma
infection
abn cellular development
degeneration
inflammation
metabolic

4. Agenda Treatment: rest traction casts internal/external fixation
assistive devices: ie crutches, walkers
surgical interventions
pharmacology

5. Pharmacology Classifications: muscle relaxants
Anti-inflammatory agents: salicylates, non-steroidal
Corticosteroids
gold treatment
uricosuric drugs
immunosuppressants

6. Physiology of Movement
3 systems
skeletal
muscular
nervous

7. Bones Constantly changing - either breaking down or renewing
Osteoblasts
Osteoclasts
Osteoblast and osteoclasts work together to achieve bone balance
negative balance vs positive balance

8. Bone: classifications
Long bones
short bones
flat bones
irregular bones

9. Bone: Function Support and protection
body movement (with CNS and muscles)
blood cell formation
inorganic salt storage - approx 70% of bone weight is calcium phosphate

10. Muscles: Types
3 types:
skeletal
smooth
cardiac

11. Assessment General observation uniformity of bones and muscles
posture, body alignment
balance and co-ordination

12. Assessing Posture

13. Congenital Deformities

14. Assessment Muscles size tone strength and endurance
hand grips, foot presses (weak, one-sides)

15. Assessment Bones and Joints palpate for prominence, contours, symmetry
ROM upper and lower noting flexibility
*never force the joint

16. Assessment * Body Balance: balance maintained - one foot, two feet
* Co-ordination:
fine motor skills - observe ADL
* Ability to transfer:
independent? Supervision? One or two person assist?

17. Assessment Musculo-skeletal + neuro-vascular
Neuro-vascular includes colour, temp, capillary refill distal to the injury
Palpation of pulses; pain; sensation & movement
May need to use dopler for pulses

18. Changes Related to Aging
Bone density decreases
Synovial joint cartilage less elastic
Muscle tissue atrophy (decreased strength)
Decreased ROM
Kyphotic posture; widened gait; shift in centre of gravity

19. Disorders: Trauma (soft tissue)
Muscle Spasm:
injury stimulates nerve endings in muscle
causes excitation of nerve endings and places muscles in spasm
S and S:
pain, palpable muscle mass (knots)
tenderness with decreased ROM and ADL

20. Muscle Spasm Sites: any muscle Treatment: physical therapy (physio)
moist heat packs
hydrotherapy
bracing, analgesics, muscle relaxants

21. Trauma: contusion

22. Trauma: Contusion
Soft-tissue injury or bruise produced by a blunt force such as a blow, kick or fall
hemorrhage into tissue
tx: elevation, moist or dry cold x’s 8-10 hrs
20 mins on - 20 mins off
after 24 hours, heat 20 on-off followed by cold, elastic bandage

23. Trauma: Strain
Injury to musculo-tendinous structures surrounding a joint
caused by over stretching or excessive force
results in hemorrhage into the tissue
1st, 2nd, 3rd degree stains
2nd and 3rd involve tearing of musculo-tendonous fibers
3rd degree may require OR

26. Trauma: Sprains
Injury to the ligamentous structures surrounding the joint
caused by a wrench or twist
hemorrhage, decreased stability of joint
surgical repair or immobilization
8 to 16 weeks in cast

27. Trauma: Meniscus injury
Meniscus: crescent shaped fibrous cartilege in the knee
stabilizes the knee
shock absorber
common in athletes
S and S: severe pain, non-functioning knee, edema at knee

28. Meniscus

29. Meniscus injury Treatment: physio to strengthen and increase stability
menisectomy-surgical repair of cartilage by arthroscopy
recovery depends on degree of tear and damage to surrounding tissue

30. Nursing Care: Crutches, Canes & Walkers
Crutches need strong upper extremities
2-3 finger spaces between crutch and axilla
Elbow flexed no more than 30 degrees when hands on handle
Usually use 3 point gait

31. Canes and Walkers
Walker used for older adults who need support and balance
Cane is used for minimal support; hemi
or quad cane offers more support
Cane is placed on unaffected side and no more than 30 degree flexion of elbow
Top of cane is parallel to greater trochanter

32. Repetitive Strain Injury (Carpal Tunnel Syndrome)
Entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, bone encroachment, edema or soft-tissue injury
repetitive strain injury
S and S:
pain, numbness, parasthesia, weakness along median nerve which inervates the thumb, 1st, 2nd fingers, common at night

33. Numbness
Median Nerve Entrapment

34. Repetitive Strain Injury (Carpel Tunnel)
Treatment:
splints to prevent hyperextension and flexion of the wrist
cortisone injections
surgery of the transverse carpal ligament
often confused with thoracic outlet syndrome

35. Trauma: Epicondylitis (tennis elbow)
Damage to the tendons of the medial or lateral radial and ulnar epicondyles
S and S: chronic pain that radiates down the dorsal surface of the arm, weakness
Tx: rest in splint, ice, NSAIDS, corticosteroid injections, gentle exercise to prevent stiffness

36. Review of the Knee

41. Anterior and Posterior Cruciate Ligaments

42. ACL/PCL Stabilize forward and backward motion of the femur and tibia
injured when foot is firmly planted, knee hyperextended and person twists torso and femur
S&S: pain, joint instability, pain with ambulation

43. ACL/PCL
Treatment: RICE, r/o fracture, joint effusion and hemarthrosis needs aspiration and wrapping with compression dressing.
Conservative: brace and physio
Surgical reconstruction or repair followed by weeks immobilization followed by brace and physio

45. Nursing Care
Potential fluid volume deficit r/t post op hematoma/hemorrahage
Knowledge deficit: pain control measures
Impaired physical mobility r/t adjustment of new walking gait
Knowledge deficit: Potential for joint weakness and the techniques for applying brace

46. Nursing Care
Potential alteration in tissue perfusion: r/t impaired circulation secondary to compression from brace,
knowledge deficit: techniques for self-neurovascular assessment

47. Care Plans

48. Trauma: Dislocations
Occurs when articular surfaces of the bones forming a joint are out of anatomical position, subluxation = partial dislocation
may be congenital, pathological or traumatic
S&S: pain changes in contour, length of extremity, loss of mobility
Tx: reduction, immobilization

49. Congenital Hip Often left hip, females, 1st born, breach birth;
First, Female, Foot, Family
Legs are a different length, uneven thigh skin folds, less mobility or flexibility in one leg

50. Developmental Dysplasia of the Hip
Skin Care
Follow these guidelines to ensure the best care for your child:
Check your child's skin every day. Press his / her skin back around all edges of the cast. Use a flashlight to give more light, and carefully look for reddened areas under the cast. Feel for blisters or sores under the edges of the cast.
Rub the skin under all edges of the cast with rubbing alcohol two to three times each day. This practice will help toughen the skin. If your child's skin becomes cracked or very dry, stop using the alcohol until the skin is clear again.
Do not use lotions or powders on your child's skin. These tend to cake and will soften rather than toughen the skin.
Do not allow your child to stick any objects (i.e., coat hangers) under the cast because it may injure the skin. ** if your child does put an object down the cast, please call the nurse immediately.
Call your child's doctor if your child has unbearable itching.
You may use a hair dryer on a cool or cold setting to blow cool air under the cast edges. Make sure the dryer air is cool. Warm and hot settings can cause burns.
Keeping Your Child Comfortable
To keep your child comfortable:
Position your child so his / her head / upper body is elevated at all times (Gravity will pull urine and stool away from the cast).
Prop him/her on pillows or elevate his/her entire head off the crib mattress.
Turn your child from front to back or side to side every two to four hours during the day, and as often as you can during the night.
If your child will not fit safely in his/her present car seat there are special loaner car seats and safety vests for transporting your child in the car. Talk to your child's nurse or doctor about how to get one for your child.
Beanbag chairs can be used to help position your child.
An outdoor lounge chair may be used as a portable bed so your child can be a part of family activities.
You can transport your child in several ways:
Smaller children may fit in a stroller or a wagon using pillows and a seatbelt.
For older children, you may rent a reclining wheelchair from a hospital or medical supply vendor listed in the phone book.
A vehicle similar to a mechanic's dolly can be made. Preschool children can wheel around on their stomachs using their arms to move themselves.
When positioning for sleeping one option is to lay them on his/her belly, place a pillow under the thigh/hip line and under the chest, this can help prevent muscle spasms in the groin area while sleeping.

51. Trauma: Dislocations Often recognized clinically
Can occur at time of impact or during application of splint at scene
Orthopedic emergency when bone impinges on nearby vessels and nerves, compression, laceration, crushing, stretching

52. Neuro-vascular involvement
Shoulder: brachial plexus, axillary artery
Elbow: ulnar nerve, brachial artery
Wrist: median nerve
Hip: sciatic nerve
Knee: tibial/peroneal nerve, popliteal artery/vein
Ankle: tibial artery

53. Trauma: dislocation, subluxation
Assessment:
neuro/vascular status
elevate limb (caution above heart)
compression bandage
cold pack, immobilize, don’t wt bear

54. Dislocation, subluxation
Did pt. or bystander hear popping or snapping sound?
Assess below injury, pulses etc

55. Trauma: Fractures (fx)
Disruption of normal bone continuity
150 types of fractures
open (compound), closed (simple)
complete, incomplete
impacted
comminuted
displaced
complicated

56. Trauma: Fractures Fracture Direction: linear fracture oblique fracture
spiral fracture
transverse fracture

57. Trauma: Fractures Assessment: Accident data base ABC’s (c-spine)
Inspection and Palpation
edema, deformity, ecchymosis, loss of function, crepitation, muscle spasm, x-ray, CT/MRI, angiograms, pulses, capillary refill

58. Goals of Fracture Repair
Fracture reduction
Maintenance of the fragments in the correct position while healing takes place
Prevention of excessive loss of joint mobility and muscle tone
Prevention of complications
Maintenance of good general health to promote healing

59. Complications of Fx Shock, which may be fatal Hemorrhage
Acute Compartment Syndrome
Venous Thrombosis
Fat Embolism/PE
Infection
Nerve and organ damage

60. Shock Hypovolemic or traumatic shock Internal or external bleeding
Tx: replacement, relieve pain, splinting of fx, protection from further injury

61. Hemorrhage
Bones are very vascular, surgery long, may have been other surgery first
Hemorrhage may occur as a result of abnormal blood clotting i.e. DIC, or side effect of meds
Post-op assessment is critical

62. Fat Embolism
Fat in blood becomes entrapped in the lung capillaries and other small vessels that supply the brain, kidneys and other organs
Fat comes from bone marrow, stress may cause alteration of lipid stability in the blood
Fat drops lodge in capillaries and then cells accumulate and form plaque

63. Fat embolism Emboli may go to skin and petechiae
Usually hours post injury or OR
Personality changes, ABG, increased resp, chest pain,
Tx: prevention, high Fowler’s, O2, hydration; bedrest; steroids; reducing fx
10-15% mortality

64. Pulmonary Embolism
Most common cause of immediate post-op death on lower extremity OR
Fx pelvis, hip, femur
Clot comes from peripheral vein

65. Acute Compartment Syndrome
Ischemic muscle necrosis and subsequent contractures
“circulation or function of tissues within a closed space is compromised by increased pressure within that space”
Closed fascial space
Pain, pain on passive motion, parasthia, paralysis, pulselessness

66. Fasciotomy

67. Neurological Complications
Satisfactory reduction of the fx relieves stress placed on nerves
Nerve damage is usually from stress versus laceration
Review sensory assessment

68. Infection at time of Injury
Tetanus, gas gangrene
Open fx, irrigated +++, debrided, may be left open, prophylactic antibiotics
Avascular Necosis caused by infection or loss of blood supply.
Dead bone is reabsorbed and replaced by new bone, often in femoral head

69. Secondary Effects
Respiratory complications due to meds, immobility, pneumonia, pneumothorax,
Circulatory complications: DVT, Postural hypotension, venous stasis, circulatory overload with IV fluids
Gastrointestinal complications: PI, constip.

70. Secondary complications
Genitourinary complications: infection, prolonged catheter use
Musculoskeletal: contactures,
Integumentary: skin breakdown, bed sores, often weight loss

71. PTSD Traumatic Family loss Loss of limb etc
Intrusive thoughts and dreams, exaggerated startle reaction, anxiety, social withdrawal

72. Specific complications
Hip:
Sciatic nerve damage
avascular necorsis

76. Fractured Left Hip Note external rotation

77. Fractures Pelvis: bleeding bladder rupture, pancreas, spleen trauma
bowel trauma (75% mortality)

78. Specific complications
Distal Femur and Knee:
popliteal artery/nerve damage
bleeding
Fibula:
injury to peroneal nerve

79. Bone Healing Continuous process that begins at injury
hemorrhage into the fracture site
within 24 hours a hematoma is formed and fills the fracture site
coagulated blood results in loose fribrin mesh that seals off the fracture site and serves as a framework for ingrowth of fibroblasts and capillary buds

80. Bone healing
During first hours inflammation results in edema, vascular congestion and infiltration of leukocytes
48 hours post injury macrophages begin phagocytosis
fibroblasts and chondroblasts begin to form a soft tissue callus

81. Bone healing
After the first few days, newly formed cartilage and bone matrix are evident
end of first week well-developed new bone and cartilage dispersed throughout soft-tissue callus
provisional callus reaches maximal size in 2-3 weeks, strengthening and remolding continues

82. Managing a Cast

83. Managing a Cast Casts immobilize reduced fractures correct a deformity
apply uniform pressure to underlying soft tissue
support and stabilize weakened joints
permit mobilization of pt, while restricting movement of a body part

84. Managing Cast Types: short arm or leg, long arm or leg
Walking cast, body cast, shoulder spica, hip spica

85. Assessment and Complications: Casts
Circulation
Movement
Sensation

86. Cast Care Impaired blood flow d/t pressure from cast
Nerve damage from nerve over bony prominence
Infection, tissue necrosis from skin breakdown
Compartment syndrome; delayed, mal- and non-union
Complications
Many potential complications are related not only to wearing a cast but also to the healing of the underlying fracture.
Immediate complications
Compartment syndrome
Compartment syndrome is a very serious complication that can happen because of a tight cast or a rigid cast that restricts severe swelling.
Compartment syndrome happens when pressure builds within a closed space that cannot be released. This elevated pressure can cause damage to the structures inside that closed space or compartment—in this case, the muscles, nerves, blood vessels, and other tissues under the cast.
This syndrome can cause permanent and irreversible damage if it is not discovered and corrected in time.
Signs of compartment syndrome
Severe pain
Numbness or tingling
Cold, pale, or blue-colored skin
Difficulty moving the joint or fingers and toes below the affected area.  
If any of these symptoms occur, call the doctor right away. The cast may need to be loosened or replaced.  
A pressure sore or cast sore can develop on the skin under the cast from excessive pressure by a cast that is too tight or poorly fitted.
Delayed complications
Healing problems
Malunion: The fracture may heal incorrectly and leave a deformity in the bone at the site of the break. (Union is the term used to describe the healing of a fracture.)
Nonunion: The edges of the broken bone may not come together and heal properly.
Delayed union: The fracture may take longer to heal than is usual or expected for a particular type of fracture.  
Children are at risk for a growth disturbance if their fracture goes through a growth plate. The bone may not grow evenly, causing a deformity, or it may not grow any further, causing one limb to be shorter than the other.
Arthritis may eventually result from fractures that involve a joint. This happens because joint surfaces are covered by cartilage, which does not heal as easily or as well as bone. Cartilage may also be permanently damaged at the time of the original injury.

87. Traction
Three types, manual, skin and skeletal

88. Purposes of Traction Reduce a fx and realign bone fragments
Maintain skeletal length and alignment
Reduce and treat dislocations
Immobilize to prevent further soft-tissue damage
Prevent the development of contractures
Relieve muscle spasm

89. Purposes of Traction
Lessen deformities
Rest a diseased joint

90. Skin Traction

91. Balanced Skeletal Traction

92. Traction Care
Keep patient clean, comfortable and free of pressure sores
Assess (q2-3h or more frequently prn)
wts from traction are hanging freely
pts body weight is counteracting pull of wts
that traction boot is not slipping off of pt
all bony prominences, skin, circulation
pt posture in bed, position of joints for alignment
slings, ropes, sheets are not cutting into skin and creating sores
pin sites for infection

93. Osteomyelitis
Inflammation and infection of bone tissue and bone marrow
Retards healing by destroying newly forming bone, disrupts blood supply
Usually caused by hemolytic staphlococcus aureus bacteria, e-coli, pseudomonas
Risk: immune suppressed, long term CS, IDDM and NIDDM

94. Disorders of the Musculoskeletal System
Due to Degeneration

95. Muscular Dystrophy Neuromuscular disease
Genetically determined, progressive disease of specific muscle groups
Progressive weakness of the voluntary muscles
Many types
Usually male, female carry the gene

96. Types of MD Duchenne’s (pseudohypertrophic) Becker’s
onset rapid, usually by age 5, cardiac involvement, mental retardation, death by adult
Becker’s
age 5-15, rare cardiac, usually normal lifespan

97. Muscular Dystrophy Facio-scapulo-humeral: Limb-girdle
age 10-30, inability to raise arms above head, eyes remain partially open during sleep
Limb-girdle
age 10-30, weakness in proximal muscles of the upper and lower extremities, gradual atrophy and weakness then loss of function

98. Signs and Symptoms Generally: muscle fiber atrophy
Necrosis of muscle tissue
Fibrosis
Increase serum creatine phosphotinase (CPK)
Replacement of muscle tissue with connective tissue
Weakness, some immobility

99. Treatment
Physio to prevent muscle tightness, contractures, disuse atropy
Night splints for contractures in ankles, hips and knees
Braces for muscle weakness to increase mobility
Orthotic jacket for spinal support

100. Nursing implementations
Physical and psychological support including ROM
Reinforce PT and OT
Encourage independence
Teach use of equipment

101. Disorders of the Musculoskeletal System
Osteoporosis

102. Osteoporosis
Causes skeleton weakness and fractures during routine activites
between age 20 and 40 bones reach maximum density
after that resorption > than formation
after bone peak, loss is about 1% / year
lifetime losses may reach %

103. Osteoporsis In osteoporosis, osteoblasts do not replace resorbed bone
usually first sign is a fx, kyphosis and loss of height, bone density test

104. Interventions Estrogen dietary supplements exercise
pharmacologic therapy
alternative therapies

105. Community care
Assessment
monitoring
prevention

106. Prognosis Not curable can prevent bone loss
early detection results in preventing further loss and life-threatening fx
prevent pain and immobility

107. Orthopedics - Amputations

108. Amputation Removal of a body part
Often necessary as a result of progressive PVD (diabetes), gas gangrene, trauma (injury, frostbite, electrical burn), congenital deformities, chronic osteomylitis, or malignant tumor
Relieves symptoms, improves function, save or improve quality of life

109. Amputation
Performed at the most distal point that will heal successfully
Determined by circulation in the part and functional usefullness
Objective is to conserve as much length as possible, try and preserve knee and elbow
May use staged amputation

110. Amputation sites

111. Complications Hemorrhage Infection Skin breakdown Phantom limb pain
As well as other we have discussed related to immobility

112. Post op objective In addition to everything else
a non-tender residual limb with healthy skin for prosthesis use

113. Nursing Diagnosis Pain related to amputation
Sensory/perceptual alteration: phantom pain r/t amputation
Impaired skin integrity r/t surgical procedure
Body image disturbance r/t amputation
Coping, ineffective amputation
Grieving r/t amputation

114. Nursing Diagnosis
Self care deficit: bathing, feeding, toileting, grooming
Impaired physical mobility r/t amputation

115. Nursing Intervetions
Pain: identify hematoma, muscle spasm as possible cause
Phantom pain and sensation: occurs more frequently in AKA, Nurse offers support, distractions,
Wound healing: usual wound care, compression or limb shaping dressing, plaster slab, physio,

116. Nursing Interventions
Body image: accepting and supportive atmosphere, social worker, physio, family,
Independent self care: OT, time, encourage independence, assistive devices
Increase physical mobility: Trapeze, arm strengthening, avoid hip and knee contractures, limb should not be up on a pillow, roll from side to side and prone

117. Interventions Amputation changes center of gravity
some may not have prosthesis and will use wheelchair, special chair so it won’t tip
Post op complication: hemorrage, infection, skin breakdown
Home Care:

118. Orthopedics
Back injury

119. Acute Low Back Pain Etiology: acute lumbosacral strain
unstable lumbosacral ligaments
weak muscles
osteoarthritis of the spine
spinal stenosis
intervertebral disk problems
unequal leg length

120. Low Back Pain Disk degeneration is a common cause of back pain
Lower lumbar disks L4-5 and L5-S1
complains of acute or chronic pain
radiating pain
assessment may show changes in reflexes, gait, mobility, paravertebral muscle spasm, loss of lumbar curve.

121. ALB pain Usually self limiting - one month
rest, analgesics, stress reduction, heat or cold therapy, muscle relaxants
limit sitting to mins, slow movement and twisting, begin muscle strengthening
should be preventable!

122. Nrsg Dx
Pain r/t
impaired physical mobility r/t pain, muscle spasm, decreased flexibility
knowledge deficit r/t back-conserving body mechanics
self-concept deficit
altered nutrition: greater than

123. Total Knee/Hip ArthroplastyPN

124. Case Study, Total Knee Arthroplasty
Patient:
75 yr old male
Hx: osteoarthritis (pain, stiffness and difficulty moving lt knee)
Meds at home: ASA,
Activity: walks 1 mile/day, rides bike
Other: nil

125. What is the difference between OA and RA?

126. Pre op
Blood Work (CBC, Electrolytes, ECG, UA, Bld screen, clotting/bleeding times)
Xrays: Knee, chest?
Pre and post-op teaching
Discharge Planning

128. Pre Op health Teaching Clinical Pathway
Deep breathing/coughing; incentive spirometer
Type of anesthetic, post op pain management
Practice the post op exercises (foot and ankle; static quads; static gluts)
What to bring to the hospital
The morning of surgery…(NPO,meds, where to check in)
Dental work

129. Day of Surgery NPO (morning meds with a sip of water) IV started
Leg prep’ed
Surgery
PACU
Return to the unit

131. Back on the Unit Vital signs Pain Assessment of Knee (dressing) IV
Chest
Food
Bath
Family
Nausea/vomiting
Voiding

132. Days 1-3

136. Home Care Bathing Anti Em stockings Incision care Dressing Toileting
Avoid jarring or twisting of Knee/hip
Bathing
Anti Em stockings
Incision care
Dressing
Toileting
Getting on and off a chair
Stairs
Sexual activity
Driving a car
Who will visit? Physio, lab,

137. Things to avoid with a total hip
NO hip bending (flexing) beyond 70 degrees (90)
NO crossing legs
NO rolling kneecap in
Limit car rides x 6 weeks
When sitting, including toilet:
When sleeping:
When walking/stairs: