1

Alterations in the Musculoskeletal SystemSystem

NURS 142ADN Program Carole Chassereau

Musculoskeletal SystemNormal structure– Tissues

• CartilageLigaments/tendons

Function– Support

P t ti• Ligaments/tendons• Fascia• Bursae

– Bones– Muscles– Joints

– Protection– Movement– Mineral storage– Hematopoiesis

Bone Structure& Development

Continuous process of bone remodeling

Osteoblasts = builders = depositionf b

Growth zone for longitudinal growth in children

Epiphyseal plate

of new bone

Osteoclasts = removal of old bone = resorption

2

JointsDIARTHHROTIC

Ligaments attach bone to bone – joint stability

Tendons attach muscle to bone – joint movement

Normal Diarthrodial Joint (Freely movable)

bone joint movement

Fibrous tissue – low blood supply

Cartilage - avascular

Factors Influencing Musculoskeletal Health

Age– Infant – Child

Adolescent– Adolescent– Senior

Environment– Job– Sun exposure– Activity

3

Risk Factors for Alterations in Musculoskeletal Health

History– Injuries– Family history

Medical conditions– Medical conditions• Metabolic alterations• Gastrectomy• Renal tubular

necrosis• Hypoparathyroidism

– SurgeryGender

Risk Factors for Alterations in Musculoskeletal Health

History– Injuries– Family history

Medical conditions

AgeMedications– Musculoskeletal drugs

– Medical conditions• Metabolic alterations• Gastrectomy• Renal tubular

necrosis• Hypoparathyroidism

– SurgeryGender

– Antiseizure meds– Phenothiazines– Corticosteroids– K-depleting diuretics

DietObesityPosture

Assessment

History & interview– Chief complaint

M t b h i– Movement behaviors– Functional assessment– Self-care behaviors– Questions

4

AssessmentGeneral– Posture– Gait– Muscle strength– Assistive devices

Vital signsInspection & palpationNeurovascular assessment - CSM

Diagnostic TestsBlood chemistry– Calcium– Alkaline phosphatase– Creatine kinase (CK)– ESR– RF– ANA

Diagnostics - Visualizations

X-rayCTMRI

ArthrogramArthroscopyArthrocentesisMRI

Bone scanBiopsy

ArthrocentesisElectromyogram (EMG)Bone Mass Measurements

5

The Etiology of Injuries

Be alert and be aware of the environment.environment.The causes of musculoskeletal injuries are variable.

Health Alterations –Soft Tissue Injuries

Strains/sprains– Cause– Healing time– RICE

Dislocation/subluxation– Inspection

Slipped Capital Femoral Epiphysis

Soft Tissue Injuries

Rotator cuff tearsLigament injuriesMeniscus injuriesRepetitive motion injuries

6

Herniated Nucleus pulposusCommon cause of acute & chronic low back pain.

Degenerative disk disease leads to intervetebral narrowing & decreased efficiency of the “shock absorbing” affects of the disks

Risk factors for low back pain – undue strain, osteoarthritis, obesity, smoking, stress, prolonged periods of sitting

Osteomyelitis

Direct or indirect invasion of microorganisms (Staph A)

Bacteria lodge & grow –i i h iincrease pressure – ischemia and vascular compromise –sequestration = infected island of bone.

Chronic if persists for more than 4 weeks

Osteoporosis“Silent disease”Resorption > deposition (formation)– Porous & brittle bones

Risk factors– Postmenopausal women– Thin,small frame– Family history– Long-term steroid use– Inactivity– Caucasian/ Asian-American

7

Osteoporosis

Signs & symptoms– Bone mineral density

(BMD) decreased –DEXA study

Management goal –prevent or stop process– Adequate calcium intake

& Vit i D– Pathological fractures– Loss of height– Kyphosis

& Vitamin D– Exercise program – Medications

• HRT• SERM• Biphosphonates• Calcitonin

GoutMetabolic disorder– Genetic/familial tendency– 90% middle-aged men

Risk factorsDiabetes

Signs & symptoms– Swollen, tender, painful

joints, “great toe” –reddened to dusky

– Deposit of Na urate – Diabetes– Obesity– HTN

Hyperuricemia– purine synthesis

and/or– renal excretion

crystals in joint fluid = tophi

Treatment– Fluids & low-purine diet– Colchicine– Probenecid– Allopurinal– Acetominophen

ArthritisType Osteoarthritis

(OA) (DJD)Rheumatoid Arthritis (RA)

Juvenile RA

Process Degeneration of joint cartilageRough surfacesM l i

InflammationGranulation tissue

Fib

Inflammation of joints

M h MalaciaCartilage

fragmentationBone spurs

Fibrous connective tissueAnkylosisImmobilizationExtraarticular manifestations

May have extraarticular manifestations

8

ArthritisType Osteoarthritis

(OA) (DJD)Rheumatoid Arthritis (RA)

Juvenile RA

Response LocalNoninflammatory

SystemicInflammatory

Local /systemicInflammatory

Incidence 1/3 of adultsAge 60 60 80%

>women 75% >girlsAge 60 – 60-80%>men>Native-Americans

Young adult –Child-bearing age

Age 2-5 or 9-12 & adolescence

Jointsaffected

Small &/or large Small &/or large

PauciarticularSystemicPolyarticular

ArthritisType Osteoarthritis Rheumatoid

Arthritis (RA)Juvenile RA

Pattern AsymmetricalChronic

SymmetricalChronic

VariableAcuteRarely chronic

A t i Etiology Age, FracturesInfectionCongenital deformity

Autoimmune responseGeneticViral

UnknownAutoimmune response

Course Usually self-limiting

Remissions & ExacerbationMild to progressive

Resolution

ArthritisType Osteoarthritis Rheumatoid

Arthritis (RA)Juvenile RA

Mobility Stiffness after rest and inactivityImpaired mobility due to pain and swelling

Nodules Heberden’s Rheumatoid NonePainfulInterphalangeal joints

Non-tenderSubcutaneous

Goals Control pain & fatigue Joint protectionMaintain ROM EducationPromote mobility Support measures

9

Curvature of the Spine

Normal Kyphosis Lordosis MildScoliosis

Normal SevereScoliosis

Fractures by Communication

10

Fracture Classification by Location

Fracture Management

First assess neurovascular status distal to the injury

Immobilization– Skeletal or skin

tractionj yReduction(alignment)– Open - surgical– Closed – manipulation

or traction

– External fixator– Cast– Splint– Brace

Healing Process of Fractures

Hematoma formation

Fibrous networkFibrous network

Osteoblasts – collagen –calcium deposition

Callus formation

Ossification –consolidation- remodeling

11

Immobilization With TractionSkin – Bryant’s, Buck’s, Russell– No more than 5-10# weight– Concern – skin breakdown– Bryant’s – child < 35 # & <3years

Immobilization With TractionSkin –Buck’s, Bryant’s, Russell– No more than 5-10# weight– Concern – skin breakdown– Bryant’s – child < 35 # & <3years

Skeletal

Countertraction

Proximalfragment

– Weight – 5 – 45#– Pins – Skin care

General– Ropes & pulleys in straight alignment– Extremity in straight alignment– Knots not touching pulleys– Weights hang freely Traction

Distalfragment

Fracture

Immobilization with Casts

Drying – Use palm of hands– Heat production

Assess – CSM– Skin at cast edges

Teach– Elevation– Ice @ fracture site for 24 hrs.– Keep cast dry– No foreign objects– Exercise joints above & below the cast– Elevate extremity

12

Hip Fracture – Internal FixationORIF

Femoral head endoprosthesis– Intracapsular fractures

Compression screw with side plate– Extracapsular fractures

Fracture ComplicationsUnion– Delayed– Non-union– Malunion

Compartment syndrome

OsteomyelitisVenous thrombosisFat embolism– Long bones & pelvis– Bone marrow or

– Compression - edema• Fascia• Circumferential device

– Consequences – CSM– Action

Avascular necrosis

catecholamine action– S & S

• 48 hours post fracture • Respiratory/Cardiac

signs• Petechiae – neck,

anterior chest wall, conjuctiva

Muscular DystrophyGenetic - malesMuscle fiber degeneration and muscle wastingProgressive weakness & muscle deformitySigns & symptoms– Generalized muscle weakness– Gower’s maneuver– Deficiency of dystrophin

Management– Supportive– ROM– PT

13

Medical Management

MedicationsNutritionImmobilizationRestExercise– Active/passive– Isometric– Isotonic

Medical Management

MedicationsNutritionImmobilization

Cold– Vasoconstriction edema– Nerve transmission pain

RestExercise– Active/passive– Isometric– Isotonic

– Conduction velocity muscle spasmHeat– Edema– Comfort

Medical Management

Closed Reduction

Assistive devicesAssistive devices

Special beds &

frames

14

Surgical Management

OsteotomyArthrodesisORIFORIFTotal hip, knee replacements– Special restrictions– Special goals

Surgical Management

OsteotomyArthrodesisORIF

Amputations– Assessment

S t ORIFTotal hip, knee replacements– Special restrictions– Special goals

– Support measures– Psychosocial

implications

Fluid & Electrolytes

Fluid intakeElectrolyte effectsElectrolyte effects–⇓ K+

–⇓Ca+

Acid-base imbalances

15

Pharmacological TherapyAnalgesics– Acetaminophen (Tylenol)– Propoxyphene hydrochloride

(Darvon)Salicylates– Aspirin (acetylated)– Arthropan (nonacetylated)

NSAIDs– Ibuprofen (Advil, Nuprin,

Motrin)– Indomethacin (Indocin)– Diclofenac (Cataflam,

Voltaren)

NSAIDs– Cox-2 inhibitors

• Celebrex

Muscle relaxantsCalcium supplements

Pharmacological Therapy

EstrogenAntibioticsCorticosteroidsCorticosteroidsDisease-modifying antirheumatic drugs (DMARDs)– Immunosuppressives/Cytotoxics

• Methotrexate• Immuran• Cyclosporin• Arava

Nutrition

ProteinVitamins

FluidsFiber

Calcium Weight control

16

Nursing Diagnosis

Altered nutrition: < or > than body requirementsAlteration in comfortRisk for infection Impaired physical mobilityAltered health maintenanceSocial isolationBody image disturbanceRisk for injury

Outcomes

Adequate nutritionVital signs WNLCSM WNLCSM WNLMobility/ ROMDecreased painNormal elimination patternUnderstanding of disease process

Nursing Interventions & Discharge Planning

AssessSupportTeach

Community resourcesTeach & evaluate activitiesTeach

– Diet– Medications– Assistive devices– Safety– Pain management

Referral

activitiesCoordinate home careS & S to reportMedication usage

17

Legal & Ethical Issues

Pain control managementUse of cadaver bones, ligamentsAutonomyAutonomyConfidentialityBeneficience