1. Management of Patients With Musculoskeletal Disorders

2. Acute low Back pain: Causes: A cut lumbosacral strain,
unstable lumbosacral ligaments and weak muscles,
osteoarithritis of the spine,
spinal stenosis, intervertebral disk problems,
and unequal leg length.
Other causes include kidney diorders, pelvic problems, retroperitoneal tumors, abdominal aneurysims, obesity and stress.
L4-L5 and L5-S1 has the greatest degenrative changes

3. Clinical manifestations:
A cute or chronic back pain lasting more than 3 months without improvement)
Fatique
Pain radiating down the leg ( radiculopathy; Sciatica)
Patient’s gait, spinal mobility, reflexes, leg length, leg motor strength and sensory perception may altered

4. Cont… Assessment and diagnostic findings:
Focused history and physical examination ( reflexes, sensory impairment, straight leg raising, muscle strength
X-ray of the spine, CT scan, MRI
Bone scan and blood study
Myelogram and dicogram
Electromyogram and nerve conduction studies
Medical management: Analgesia, rest, stress reduction and relaxation
Review the Nursing process

5. Nursing Process: The Care of the Patient with Low Back Pain—Assessment
Detailed description of the pain including severity, duration, characteristics, radiation, associated symptoms such as leg weakness, description of how the pain occurred, and how the pain has been managed by the patient
Work and recreational activities
Effect of pain and/or movement limitation on lifestyle and ADLs
Assess posture, position changes, and gait
Physical exam: spinal curvature, back and limb symmetry, movement ability, DTRs, sensation, and muscle strength
If obese, complete a nutritional assessment

6. Nursing Process: The Care of the Patient with Low Back Pain—Diagnoses
Acute pain
Impaired physical mobility
Risk for situational low self-esteem
Imbalanced nutrition

7. Nursing Process: The Care of the Patient with Low Back Pain—Planning
Major goals may include relief of pain, improved physical mobility, use of back conservation techniques and proper body mechanics, improved self-esteem, and weight reduction.

8. Interventions Pain management Exercise Body mechanics
Work modifications
Stress reduction
Health promotion; activities to promote a healthy back
Dietary plan and encouragement of weight reduction

9. Positioning to Promote Lumbar Flexion

10. Proper and Improper Standing Postures

11. Proper and Improper Lifting Techniques

12. Osteoporosis
Affects approximately 40 million people over the age of 50 in the United States.
Normal homeostatic bone turnover is altered and the rate of bone resorption is greater than the rate of bone formation, resulting in loss of total bone mass.
Bone becomes porous, brittle, and fragile, and break easily under stress
Frequently result in compression fractures of the spine, fractures of the neck or intertrochanteric region of the femur, and Colles’ fractures of the wrist
Risk factors.

13. Pathophysiology of Osteoporosis

14. Progressive Osteoporosis Bone Loss and Compression Fractures

15. Risk factors: see chart 68-7
Assessment and diagnostic findings:
Routine X-ray, and bone sonometer
Lab. Studies: Serum Ca, Serum Ph, urine calcium excretion, ESR
Medical Management:
Adequate balanced diet rich in calcium and Vit D
Regular weight bearing exercise promotes bone formation
Pharmacological therapy: Hormonal replacement therapy ( look for side effect of estrogen and progesterone replacement therapy which result in cancers… thus frequent breast examination is recommended )
Alendronate alternative to Hormonal replacement therapy: inhibiting osteoclast function and dedcreases bon loss
Calcitonin: suppress bone loss

16. Osteoporosis Manifestations : Loss of height
Progressive curvature of spine
Low back pain
Fractures of forearm, spine, hip
Development of “dowager’s hump”
Dorsal kyphosis
Cervical lordosis

17. Typical Loss of Height Associated with Osteoporosis and Aging

18. Prevention Balanced diet high calcium and vitamin D throughout life
Use of calcium supplements to ensure adequate calcium intake—take in divided doses with vitamin C
Regular weight-bearing exercises—walking
Weight training stimulates bone mineral density (BMD)

19. Pharmacologic Therapy
Biphosphonates
Alendronate: Fosamax
Risedronate: Actonel
Ibandronate: Boniva
Selective estrogen modulators (SERMs): Evista
Cacitonin
Teriparatide: Forteo
Also need adequate amounts of calcium and vitamin D

20. Management of Patients With Musculoskeletal Trauma

21. Injuries of the Musculoskeletal System
Contusion: soft tissue injury produced by blunt force
Pain, swelling, and discoloration: ecchymosis
Strain: Pulled muscle-injury to the musculcoteninous unit
Pain, edema, muscle spasm, ecchymosis, and loss of function are on a continuum graded 1st , 2nd, and 3rd degree
Sprain: injury to ligaments and supporting muscle fiber around a joint
Joint is tender and movement is painful, edema, disability and pain increases during the first 2–3 hours
Dislocation: articular surfaces of the joint are not in contact
A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility

22. RICE
Rest
Ice
Compression
Elevation

23. Common Sports-Related Injuries
Contusions, strains, sprains and dislocations
Tendonitis: inflammation of a tendon by overuse
Meniscal injuries of the knee occur with excessive rotational stress
Traumatic fractures
Stress fractures

24. Knee Ligaments, Tendons, and Menisci

25. Prevention of Sports-Related Injuries
Use of proper equipment; running shoes for runners, wrist guards for skaters, etc.
Effective training and conditioning specific for the person and the sport
Stretching prior to engaging in a sport or exercise has been recommended but may not prevent injury
Changes in activity and stresses should occur gradually
Time to “cool down”
Tune in to the body; be aware of limits and capabilities
Modify activities to minimize injury and promote healing

26. Occupational-Related Injuries
Common injuries include strains, sprains, contusions, fractures, back injuries, tendonitis, and amputations.
Prevention measures may include personnel training, proper use of equipment, availability of safety and other types of equipment (patient lifting equipment, back belts), correct use of body mechanics, and institutional policies.

27. Joint Dislocation articular surfaces of the joint are not in contact
A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility
Most common
Shoulder
Acromioclavicular joints
Subluxation
Partial dislocation

28. Types of Fractures Complete Incomplete Closed or simple
Open or compound/complex
Grade I
Grade II
Grade III

29. Cont… Grade I: clean wound less than 1 cm
Grade II: larger wound without extensive soft tissue damage
Grade III: is highly contaminated, has extensive soft tissue damage, and is the most severe

30. Types of Fractures

31. Types of Fractures

32. Types of Fractures

33. Manifestations of Fracture
Pain
Loss of function
Deformity
Shortening of the extremity
Crepitus
Local swelling and discoloration
Diagnosis by symptoms and x-ray
Patient usually reports an injury to the area

34. Emergency Management Immobilize the body part
Splinting: joints distal and proximal to the suspected fracture site must be supported and immobilized
Assess neurovascular status before and after splinting
Open fracture: cover with sterile dressing to prevent contamination
Do not attempt to reduce the fracture

35. Medical Management Reduction
Closed
Open
Immobilization: internal or external fixation
Open fractures require treatment to prevent infection
Tetanus prophylaxis, antibiotics, and cleaning and debridement of wound
Closure of the primary wound may be delayed to permit edema, wound drainage, further assessment, and debridement if needed

36. Techniques of Internal Fixation

37. Three Phases of Fracture Healing
Inflammatory phase
Reparative phase: collagen formation and calcium deposition
Remodeling phase:
1. Excess callus is removed
2. New bone is laid down
3. Fracture site calcifies
4. Bone is reunited

38. Three Phases of Fracture Healing
Inflammatory phase
Reparative phase: collagen formation and calcium deposition
Remodeling phase:
1. Excess callus is removed
2. New bone is laid down
3. Fracture site calcifies
4. Bone is reunited

39. Three Phases of Fracture Healing
Inflammatory phase
Reparative phase: collagen formation and calcium deposition
Remodeling phase:
1. Excess callus is removed
2. New bone is laid down
3. Fracture site calcifies
4. Bone is reunited

40. Complications of Fractures
Factors that affect fracture healing
Shock
Fat embolism
Compartment syndrome
Delayed union and nonunion
Avascular necrosis
Reaction to internal fixation devices
Complex regional pain syndrome (CRPS)
Heterotrophic ossification

41. Fracture Complications
Early complications:
Shock: Hypovolemic or traumatic shock
result from bleeding or from loss of extracellular fluid
Treatment:
1. Restoring blood volume and circulation
2. Releiving patient pain
3. Provide adequate splinting.

42. Compartment Syndrome
develop when tissue perfusion in the muscles less than that required for tissue viability.
Physiology
Entrapment of the blood vessels limits tissue perfusion
Results in edema within the compartment
Edema causes further pressure
Early Manifestations
Deep Pain which is not controlled by opioids
Normal or decreased peripheral pulse
Later Manifestations
Cyanosis
Paresthesias, paresis
Severe pain

43. Cross-Sections of Anatomic Compartments

44. Treatment Interventions to alleviate pressure Removal of the cast
Fasciotomy

45. Wick Catheter Used to Monitor Compartment Pressure

46. Bone Healing Stimulator
Refer to fig. 69-6

47. 3. Fat Embolism Syndrome Pathophysiology
Bone fracture results in a rise of pressure in the bone marrow
Fat globules enter the bloodstream
Combine with platelets
Travel throughout the body
Occluding small blood vessels
Causes tissue ischemia

48. Fat Embolism Syndrome Manifestations Confusion
Changes in level of consciousness
Pulmonary edema
Impaired surfactant production
Atelectasis
ARDS

49. Fat Embolism Syndrome Prevention
Early stabilization of long bone fracture.
Treatment:
Intubation and mechanical ventilation
Fluid balance
Corticosteroids
Vasoactive medication to support the cardiovascular system and prevent hypotension.

50. 4. Deep Vein Thrombosis Manifestations Swelling Leg pain Tenderness
Cramping
Some are asymptomatic
Diagnosis
Doppler ultrasound

51. Deep Vein Thrombosis Treatment Bed rest Thrombolytic agents Heparin
Vena cava filter
Thrombectomy
Prevention is the best treatment
Early immobilization of fractures
Early mobilization of the client

52. 5. DIC 6. Infection Delayed complications:
Cont…..
5. DIC
6. Infection
Delayed complications:
Delayed Union: Delay healing, which result from infection and distraction of bone fragment, poor nutrition
Nonunion: failure of the ends of the fractured bone to unite, pt complain of discomfort and abnormal movement at the fracture site. Managed by internal fixation or grafting
Result from infection, interposition of tissue between the bone ends, inadequate immobilization, excessive space, and impaired blood supply