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Musculo-skeletal Disorders Semester 4

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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

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 Arthroplasty

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:

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