Disorders of the Musculo-skeletal Systems

Disorders of the Musculo-skeletal Systems
Compiled by Venina Navuta 30/1/17

Bone Structure & Function
Main functions Support Protection of internal organs Voluntary movement Blood cell production Mineral storage

Internal & external growth & remodeling are ongoing processes
Skeleton consists of 206 bones Joint is a place where ends of two bones are in proximity and move in relation to one another Cartilage Muscle –types Ligaments and tendons Fascia Bursae

Common Signs and Symptoms of Musculo-Skeletal Disorders
Pain Weakness Deformity Limitation of movement Stiffness Joint crepitation

Assessment of the Musculo-Skeletal Systems
Subjective data Important health information Functional health patterns Objective data - Physical examination

Effects of Aging on the Musculo-skeletal System
Mild discomfort and decreased ability to perform daily activities of living Severe chronic pain and immobility Risk of falls Bone remodeling process is altered

Other effects Decrease in bone density → osteopenia, osteoporosis
Muscle mass & strength decrease Loss of motor neurons Tendons & ligaments become less flexible, movements become more rigid

Common Diagnostic Tests
X-ray common test for any abnormality Monitor effectiveness of treatment Evaluation of hereditary, developmental, infectious, inflammatory, neoplastic, metabolic & degenerative disorders

Magnetic Resonance Imaging(MRI)
View soft tissues Assist in diagnosis of avascular necrosis, disc disease, tumors, osteomyelitis, ligament & cartilage tears. Arthroscopy

Arthrocentesis & synovial fluid analysis
Muscle enzymes: ascertain site of tissue damage Serological tests: ascertain rheumatoid factor(RF) for rheumatoid arthritis, higher with increased disease activity RF directed against IgG ↑erythrocyte sedimentation rate & C-reactive protein-non-specific indicators of active inflammation

Common Causes of Diseases
Traumatic event → fracture, dislocation & associated soft-tissue injuries → pain, disability, medical expenses & lost wages is huge →homes: falls & related injuries for adults 65years & over PREVENTION OF MS PROBLEMS IN OLDER ADULTS

Other Causes of Diseases
Infection: osteomyelitis Bone tumors: benign & malignant Muscular Dystrophy: genetically transmitted diseases→symmetrical wasting of skeletal muscle without evidence of neuro involvement Low back pain Neck pain Foot disorders Metabolic bone diseases: osteomalacia, osteoporosis Arthritis & connective tissue diseases: spondyloarthropathies, SLE, systemic sclerosis Soft tissue rheumatic syndromes: myofascial pain syndrome, fibromyalgia syndrome, chronic fatigue syndrome

SOFT-TISSUE INJURIES Usually caused by trauma Sprains Strains
Dislocations Subluxations

SPRAINS & STRAINS Sprain: injury that affects the tendons and ligaments surrounding the joint Usually associated with abnormal twisting and stretching Common areas affected: wrist and ankle

CLASSIFICATION OF A SPRAIN
According to the number of ligament fibres torn First degree sprain: few fibers involved, mild tenderness, minimal swelling Second degree: partial disruption of involved tissue, more swelling, tenderness Third degree: complete tearing of ligament, moderate to severe swelling

Strain Excessive stretching of a muscle and it’s fascial sheath
Often involves the tendon First degree: mild /slightly pulled muscle Second degree: moderately torn muscle Third degree: severely ruptured or torn muscles

Clinical Manifestations
Pain Oedema Decrease in function Contusion Sprain and Strain S/S Similiar

Diagnostic Tests X-Ray: to rule our fracture or widening of the joint structure. ‘Ottawa rules’: assessment protocol for the examination of an injured ankle or knee before an x-ray.

TREATMENT Limit movement Apply ice compresses
Compress involved extremity Elevate extremity Provide analgesia prn

Acute injury phase: 24-48hours
After acute phase Apply warm moist heat to reduce swelling for 20-30minutes only; allow for cool down time between applications Administer mild analgesic to promote comfort

Dislocation and Subluxation
Dislocation: severe injury of the ligament surrounding a joint. Complete displacement or separation of the articular surfaces of the joint Causes Congenital anomaly Pathological origin

deformity, local pain, tenderness, loss of function of injured part, swelling of soft tissues Diagnostic test: x-ray

Major Complications Open joint injuries Intra-articular fractures
Fracture dislocation Avascular necrosis Damage to adjacent neurovascular tissue neurovascular assessment is important

Subluxation partial or incomplete displacement of joint surface
s/s are similar to dislocation but with less severity; similar treatment too but require less healing time

Nursing & Collaborative Management
Traumatic dislocation are orthopedic emergencies Treatment crucial otherwise untreated dislocation can result in avascular necrosis Realignment of joint: closed or open reduction under local or general anesthesia

Immobilization of affected extremity: bracing, splinting, taping or sling to allow proper healing
Pain relief Movement restricted Regulated rehab program needed to prevent fracture instability & joint dysfunction Gentle ROM can be started if joint is stable & well supported

tears may result from an acute injury or from chronic joint stresses.
ROTATOR CUFF TEARS tears may result from an acute injury or from chronic joint stresses. involves the four major muscles that stabilise the shoulder joint (supraspinatus, teres minor and major, and subscapularis).

Causes can include degeneration of the joint with age, repetitive stress, sporting injuries (throwing, bowling, overhead motions as in tennis and squash) falls on an outstretched hand.

pain, severe pain when arm is abducted ° limited ROM and some joint dysfunction, including Shoulder muscle weakness. Sometimes night pain and sleeplessness unable to perform over-the-head activities

Medical Management nonsteroidal anti-inflammatory drugs (NSAIDs), rest with modification of activities, injection of a corticosteroid into the shoulder joint, and progressive stretching, ROM and strengthening exercises (Shelby, 2010)

arthroscopic debridement (removal of devitalized tissue)
arthroscopic or open acromioplasty with tendon repair. Postoperatively, the shoulder is immobilized for several days to 4 weeks. NB: Immobilization necessary but not for too long otherwise frozen shoulder can occur

Meniscus Injury Associated with ligament sprains
injuries leave loose cartilage in the knee joint that may slip between the femur and the tibia, preventing full extension of the leg. If this happens during walking or running, patients often describe their leg as ‘giving way’ under them. Can hear or feel a click in the knee on walking, especially when leg that is bearing weight, is extended.e.g. going upstairs.

Nursing & Collaborative Management
Conservative treatment: ambulate as tolerated, knee brace Crutches can be used Analgesic prescribed If symptoms persist MRI can be ordered before an arthroscopy is done – meniscus surgery

Bursitis Inflammation of the bursa Bursae closed sacs lined
with synovial membrane & contain small amount of synovial fluid Located at sites of friction: between tendons and bones & near joints

Causes Repeated or excessive trauma or friction Gout
Rheumatoid arthritis infection

Warmth Pain Swelling Limited ROM in affected part Common sites Hand,knee,greater trochanter of hip, shoulder and elbow

Treatment Rest Apply cold pack Immobilisation of affected part Use of NSAIDS to reduce inflammation and pain If symptoms persist: bursectomy maybe necessary If sepsis occurs: surgical incision and drainage

FRACTURES Complete- a break across the entire cross- section and is frequently displaced. Incomplete (Greenstick)-break occurs through only part of the cross-section of the bone. Closed Fracture (simple) - doesn’t break through the skin. Open fracture (compound) - extends through the skin Comminuted- splintered into fragments Depressed- fragment(s) is(are) indriven Pathologic- through an area of diseased bone

Pain & Tenderness- continuous and increases in severity after injury. Oedema & Swelling- usually over affected area, but can also occur in adjacent structures. Deformity Ecchymosis/ contusion Loss of function Crepitation Muscle spasm

Treatment Reduction- open or closed Casting and/or traction

EXTERNAL FIXATION INDICATIONS - Severe open fractures
- Provides rigid fixation and reduction with the ability to manage severe soft tissue wounds. INDICATIONS - Severe open fractures - Highly comminuted closed fractures. - arthrodesis - infected joints - infected non union - fracture stabilization to protect arterial or nerve

- major alignment and length deficits - congenital contractures
- anastomosis - major alignment and length deficits - congenital contractures COMPONENTS OF EXTERNAL FIXATOR - bone anchoring devices (e.g. threaded pins, Kichner wires). - longitudinal supporting devices e.g. threaded or smooth rods.

External Fixation Manipulation & Skin/Skeletal Traction

Internal Fixation To correct long bones fractures
- Application of compression plates and screws and insertion of pins, intramedullary rods, nails or wiring.

Fracture Complications
Infection Fat embolism syndrome Compartment syndrome Venous thrombosis

Casts Used to immobilize a body part so that a fracture of a bone or dislocation can heal. Pressure from hard casting materials can produce complications such as: Pain Decreased sensation Skin breakdown Casting materials- plaster or fiberglass

Indications Provide protection and healing of fractures
Maintain therapeutic alignment- body parts Protect soft tissue injuries Provide support after orthopedic surgery Correct skeletal malformations

Nursing Management Wet cast takes 24-48 hrs to dry completely
Elevate extremity & support entire length of injured body part Look out for sharp cast areas & pressure to tissue Perform regular neurovascular assessment- Warmth, color, pulses, capillary refill, swelling. Motion checks- ask pt. to wiggle fingers or toes. Sensation checks- can pt. feel pressure, ask about pain, this may detect if cast is too tight. Check for odor and drainage

Patient & Family Teaching
Do not place any object in the cast Keep cast dry if made of POP Use blow drier to dry cast made of fiber glass Assess the injured extremity for: Coolness Changes in color Increased in pain Increased in swelling Loss of sensation

Traction Used to minimize muscle spasm
Used to reduce, align, and immobilize fractures Used to correct/prevent deformity Treatment of dislocated, degenerated, ruptured intravetebral discs and compression

Nursing Goals Maintain line of pull.
Pt. is in center of bed, with good alignment Weights hanging freely. Prevent complications

Types of Traction Skin traction (straight) - Buck’s, Bryant’s, pelvic girdle. The pull is transmitted to muscle structure, indirect traction. Skeletal traction – pins or wires inserted in bone and attached to traction, may be used to treat fractures of humerus, tibia, fibula Continuous- for fractures Intermittent- for back muscle sprains

5Ps Assessment for Orthopedic Patients
Symmetric comparison: Pain- location, severity Pulse- distal to injury, check bilaterally. Parasthesia- numbness, tingling, compare bilaterally. Sensation check Pallor- check skin color and temp. Paralysis- Assess mobility, watch for foot drop, compartment syndrome

Documentation Traction, type, weight, changes in treatment
Patient tolerance and pain Patient assessment of NV checks, skin condition, respiratory status, elimination pattern Note condition of any pin sites and any care given

NURSING CARE PLAN Formulate a nursing care plan for a patient who is on a traction – prep for clinical lab

COMMON TYPES OF FRACTURES
COLLES’ FRACTURE – Fracture distal radium – common with adults. FRACTURE OF THE HUMERUS – involves the shaft of the humerus. FRACTURE PELVIS – can be life threatening depends on the mechanism of injury. FRACTURE OF THE TIBIA – vulnerable to injury because it lacks anterior muscle covering.

HIP FRACTURES High incidence in elderly due to risk for falls, osteoporosis. Intracapsular- fx. Neck of femur, may damage blood supply, aseptic necrosis. Extracapsular- base of neck and lesser tronchanter of femur- heals more easily. ORIF- open reduction with internal fixation

Symptoms of Fractures Deformity Swelling Bruising Muscle spasms
Tenderness Pain Impaired sensation Loss of normal function Abnormal mobility Crepitus Shock Abnormal Xrays

Nursing Diagnoses Risk for injury: subluxation or dislocation
Pain related to surgical incision Risk for infection: impaired skin integrity Impaired physical mobility Risk for Peripheral Neurovascular Dysfunction

Amputation More advancement in the surgical amputation techniques, prosthetic design and rehabilitation programs

Nursing Management Assessment – most important part to assess is the vascular and neurological status. Nursing Diagnosis - disturbed body image related to amputation and impaired mobility - impaired skin integrity Objectives Nursing Intervention Evaluation

Care Of The Patient Undergoing An Amputation
Pre-op monitor N/V status both extremities Observe for ulceration, edema, necrosis. Baseline VS and lab data, doppler studies, angiography, ECG, chest x-ray. Time for verbalization fears, anxieties. Teach re; overhead trapeze, incentive spirometer.

Types of Joint Surgery Synovectomy – removal of synovial fluids
Osteotomy – removing or adding a wedge or slice of bone to change alignment and shift weighting bearing, thereby correcting deformity and relieving pain. Debridement – removal of degenerative debris such as loose bodies, osteophytes, joint debris and degenerated menisci.

ARTHROPLASTY Reconstruction or replacement of a joint Hip arthroplasty
- relief of pain - improve function Knee Arthroplasty - unremitting pain and stability as a result of severe destructive deterioration of the knee joint.

Finger Joint Arthroplasty
- device used to help restore function in fingers. Elbow and Shoulder Arthroplasty COMPLICATIONS - infection - deep venous thrombosis

Discharge Teaching Assess home environment for safety reason
Social support must also be assessed Rehabilitation services – elderly Educate the patient and relatives on how to look after the patient at home. Teach the patient/relative on when and how often to take medications.

Bloopers On the second day, the knee was better, and on the third day, it had completely disappeared. While in the emergency department, she was examined, X-rated, and sent home The patient will need disposition, and therefore, we will get Dr. Blank to dispose of him. Patient seen in the floor. I saw your patient today, who is still under our car for physical therapy. She slipped on the ice and apparently her legs went in separate directions in early December

Arthritis Degenerative Joint Disease Arthritis= joint inflammation.
Arthralgia= joint pain Different types of arthritis: Osteoarthritis Rheumatoid arthritis Gouty arthritis

Osteoarthritis Most common form of arthritis, non-inflammatory, non-systemic disease One or many joints undergo degenerative and progressive changes, mainly wt. bearing joints. Stiffness, tenderness, crepitus and enlargement develop. Deformity, incomplete dislocation and synovial effusion may eventually occur. Treatment: rest, heat, ice, anti inflammatory drugs, decrease wt. if indicated, injectable corticosteroids, surgery.

Osteoarthritis- Risk Factors
Age Decreased muscle strength Obesity Possible genetic risk Early in disease process, OA is difficult to dx from RA History of Trauma to joint

Joint pain and stiffness that resolves with rest or inactivity Pain with joint palpation Crepitus in one or more joints Enlarged joints Heberden’s nodes enlarged at distal Interphalangeal (IP)joints Bouchard’s nodes located at proximal IP joints

Diagnostic Tests ESR, Xrays, CT scans. Assess for Pain
Degree of functional limitation Levels of pain/fatigue after activity Range of motion Proper function/joint alignment Home barriers

Treatment Pharmacotherapy- panadol, NSAIDS, ASA
Intra-articular injections of corticosteroids Glucosamine- acts as a lubricant and shock absorbing fluid in joint, helps rebuild cartilage Balance rest with activity Use bracing or splints Apply thermal therapies Arthroplasty

Auto-Immune Disease Inflammatory and immune response are normally helpful BUT these responses can fail to recognize self cells and attack normal body tissues. Called an auto-immune response Can severly damage cells, tissues and organs e.g. RA, SLE, Progressive systemic sclerosis, connective tissue disorders and other organ specific disorders

Rheumatoid Arthritis Chronic, systemic, progressive inflammatory disease of the synovial tissue, bilateral, involving numerous joints. Synovitis-warm, red, swollen joints resulting from accumulation of fluid and inflammatory cells. Classified as autoimmune process Exacerbations and remissions Can cause severe deformities that restrict function

RA- Risk Factors Female gender Age 20-50 years Genetic predisposition
Epstein Barr virus Stress

Rheumatoid Arthritis Rheumatoid Factor antibody- High titers correlate with severe disease, 80% pts. Antinuclear Antibody (ANA) Titer- positive titer is associated with RA.

Cont’d C- reactive protein- 90% pts.
ESR: Elevated, moderate to severe elevation Arthrocentesis- synovial fluid aspirated by needle

Joints- bilateral and symmetric stiffness, tenderness, swelling and temp. changes in joint. Pain at rest and with movement Pulses- check peripheral pulses, use doppler if necessary, check capillary refill.

Cont’d Edema- observe, report and record amt. and location of edema.
ROM, muscle strength, mobility, atrophy Anorexia, weight loss Fever- generally low grade

Treatment Rest, during day- decrease wt. bearing stress.
ROM- maintain joint function, exercise –water. Medication- analgesic and anti-inflammatory (NSAIDS), topical meds. Immunosuppressive drugs- Imuran, Cytoxan, methotrexate. Monitor for toxic effects

Biological response modifiers (BRM):Inhibit action of tumor necrosis factor (Humira, Enbrel, Remicade) Ultrasound, diathermy, hot and cold applications Surgical- Synovectomy, Arthroplasty, Total hip replacement.

Nursing Interventions
Assist with/encourage physical activity Provide a safe environment Utilize progressive muscle relaxation Refer to support groups Emotional support

Complications Sjogrens’s syndrome Joint deformity Vasculitis
Cervical subluxation

Gout Maybe classified as primary or secondary
Caused by ↑ in uric acid production or under excretion of uric acid by the kidneys Deposits of sodium urate crystals in articular, periarticular and subcutaneous tissues

May occur in one or more joints, usually fewer than 4 joints Joints are dusky/cyanotic, extremely tender Inflammation of big toe(podagra) most common initial problem Other sites: midtarsal of foot, ankle, knee & wrist

Diagnostic Tests History & physical examination Family history of gout
Presence of sodium urate crystals in synovial fluid Elevated serum uric acid levels Elevated 24-h urine for uric acid

Treatment Meds- colchicine, NSAIDS, Indocin (indomethacin), glucocorticoid drugs, Allopurinol, Probenecid-reduce uric acid levels Febuxostat Corticosteroids(prednisone); intrarticular corticosteroids Adrenocorticotrophic hormone(ACTH)

Joint immobilisation Local application of heat or cold Joint aspiration & intraarticular corticosteroids Diet- excludes purine rich foods, such as organ meats, anchovies, sardines, lentils, sweetbreads, red wine Avoid ASA and diuretics- may precipitate attacks

Systemic Lupus Erythematosus
SLE- Chronic Inflammatory disease affecting many systems. Women between 18-40, black>white, child bearing years Autoimmune process- antibodies react with DNA, immune complexes form- damage organs and blood vessels. Includes: vasculitis; renal involvement; lesions of skin and nervous system. Initial manifestation- arthritis, butterfly rash, weakness, fatigue, wt. loss Symptoms and tx. depend on systems involved.

Systemic Lupus Erythematosus
Pathologic changes-Autoimmune process Vasculitis in arterioles and small arteries Granulomatous growths on heart valves- non bacterial endocarditis. Fibrosis of the spleen, lymph node adenopathy Thickening of the basement membrane of glomerular capillaries. .

SLE Renal- Lupus nephritis Pleural effusion or PN
Raynaud’s phenomenon- about 15% cases Neuro- psychosis, paresis, migraines, and seizures

Diagnosis ANA- hallmark test, + in 98% pts. Medications- NSAIDS
Antimalarial meds- hydroxychloroquine (Plaquenil) Immunosuppressive agents- pt teaching corticosteroids, methotrexate, cyclophosphamide Antidepressants

Systemic Lupus- Education
Encourage to avoid undue emotional/ physical stress and to get enough rest Alternate exercise; planned rest periods. Teach how to recognize the symptoms of a flare Teach how to prevent and recognize infection Avoid sunlight, use sunscreen Eat a well balanced diet,vitamins and iron. Establish short term goals Teach re: meds. Meds avoid- Pronestyl, Hydralazine.

Joint Replacement Indications
Rheumatoid arthritis Trauma Congenital deformity Avascular necrosis

Total Hip Replacement Indications for surgery: Arthritis
Femoral neck fractures Congenital hip disease Failed prosthesis

Pre-op management Assess medication history.
Assess Respiratory, neurovascular, nutritional and integumentary status. Presence of other diseases- COPD, CAD, Hx. Of DVT or pulmonary embolism. Discuss surgical procedure, informed consent. Prepare for autologous blood donation.

Pre-op teaching Presence of drains and hemovac postoperatively.
Pain management (epidural/PCA). Coughing and deep breathing. Use of incentive spirometer ROM exercises to unaffected extremities. Post-op restrictions: Need to avoid bending beyond 90 degrees Importance of leg abduction post-op.

Post-op Management Assess neurovascular status of involved extremity.
Incision site, wound drains, hemovac. Note excessive bleeding or drainage Respiratory status- elderly population. Position of affected joint and extremity Mental alertness Assess Hgb and Hct Pain management

Osteomyelitis Infection of the bone Endogenous:
Extension of soft tissue infection- infected pressure ulcers or incision. Blood borne (spread from other body sites) Dx- increased leukocytes, elevated ESR, blood cultures, x-rays, Bone scan, MRI

Cont’d At risk- poorly nourished, elderly, obese, impaired immune systems, corticosteroid therapy, chronic illnesses. Prevention- proper tx. of infections, aseptic post op wound care Exogenous: Organism enters from outside the body. eg. Open fracture

Osteomyelitis Signs and symptoms-
High fever, chills, increased HR, general malaise, swelling, tenderness, heat and erythema, painful movement. Draining ulcers, bone pain Diagnostic Tests- increased WBCs, elevated ESR, positive blood cultures, X-rays, bone scan, MRI. X-ray- blackened area Warm soaks helpful

Treatment Long term IV antibiotics Hickman or other CVAD catheter
Strict sterile technique for treatment Hyperbaric oxygen treatment Surgery- bone exposed and necrotic tissue removed, debridement, bone grafts, amputation

‘The study concluded that mobile phones and gadgets that promoted the predominant usage of thumb or only one finger while texting or using the controls were associated with a higher prevalence of MSDs. Treatment using a sequenced rehabilitation protocol was found to be effective’. Ann Occup Environ Med. 2014; 26: 22. Published online 2014 Aug 6. doi: /s PMCID: PMC Musculoskeletal Disorders of the Upper Extremities Due to Extensive Usage of Hand Held Devices Deepak Sharan, 1 Mathankumar Mohandoss,2 Rameshkumar Ranganathan,2 and Jeena Jose2

End of Presentation

Reference Brown, D., & Edwards, H (2012). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems (3rd ed.).Sydney. Elservier Dempsey, Maureen Farrell and J. S meltzer & Bare's Textbook of Medical Surgical Nursing, 3rd Edition. Lippincott Williams & Wilkins, 10/2013. VitalBook file

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