Musculoskeletal Disorders

Megan McClintock, MS, RNFall 2011

Skeletal Functions Support and framework for body Protection of vital organs Assist with movement Blood cell production Mineral and salt storage

Structure Bone Joints Cartilage Muscle Ligaments/Tendons Fascia Bursae

Assessment - Subjective Gerontologic differences Past health history Medications Nutrition Occupation

Assessment - Objective Inspection Palpation Motion Muscle-Strength Testing Measurement Scoliosis Straight-leg raising test

Common Abnormalities Table 62-6

(pg 1577)

Diagnostic Studies Diskogram Myelogram DEXA Bone scan Arthroscopy Arthrocentesis EMG Duplex venous doppler SSEP

Labs Alkaline phosphatase Calcium Phosphorus RF ESR ANA Complement Uric acid CRP CK

Contusions Soft tissue injury from blunt force Overlying skin intact, but area

becomes black and blue from localized hemorrhage

Usually only painful if palpated

Hematoma Blood collection that occurs from

torn blood vessel Pain occurs as blood accumulates

and places pressure on nerves Pain occurs without palpation Hematomas may burst or become

infected

Strains Overstretched tendons or

overused muscles Usually arise from twisting or

wrenching movements Acute – sudden, severe

incapacitating pain with swelling Chronic – repetitive movements;

pain less severe but longer term (tennis elbow, runner’s knee)

Strains

Sprains Ligament injuries

Grade 1 (mild) – small longitudinal ligament fiber separation

Grade 2 (moderate) - <100% of ligament is torn in cross-sectional direction. Function impaired

Grade 3 (severe) – ligament completely torn. Surgery required

Grade 4 (sprain fracture) – avulsion of bone fragment at site of ligament attachment

Sprains

Interventions Prevent R – est I – ce C – ompress E – levate Analgesia as necessary After 24-48 hrs, warm moist heat

Subluxation/Dislocation Bones are dislodged from normal

positions within joints Subluxation = partial dislocation

Joint capsule and ligaments damaged

Usually deformity at site S/S: altered length of extremity,

loss of function

Subluxation-dislocation of knee

Interventions Orthopedic emergency Assist with realignment Pain relief Restriction of movement Future activity restrictions

Fractures Disruption in continuity of bone Usually involves damage to

surrounding soft tissue S/S - pain, swelling, loss of function,

deformity, abnormal mobility, bruising (also see pg 1591)

May be classified by severity and direction of fracture

Type of Fracture Open (compound) Closed (simple) Incomplete Complete Displaced Comminuted

Direction of Fracture Transverse Oblique Spiral Greenstick

Bone Healing

Fracture Reduction Closed reduction ORIF (open reduction with internal

fixation)

Traction

Fracture Repair Casting

Fracture Repair External fixation

Fracture Repair Internal fixation

Drugs Muscle relaxants Pain medications Tetanus prevention Antibiotics

Nutrition Ample protein Vitamins B, C, D Calcium Phosphorus Magnesium 2000-3000 mL/day of fluids High-fiber diet

Interventions Assessment

Distal to the extremity Neurovascular

Peripheral vascular Peripheral neurologic

Prevention Safety equipment Elderly (also see pg 1584)

Interventions Pre-op skin prep Post-op neurovascular assessment Proper alignment & positioning Observe for bleeding, drainage Prevention of constipation Prevention of kidney stones Maintenance of cardiopulmonary

system

Traction Interventions Inspect skin and pin sites carefully Pin site care Correct positioning ROM of unaffected joints Maintain traction at all times

Cast Care Interventions Handle a wet cast with palms only Support cast with pillows when wet Elevate at or above heart level Do not scratch skin with any objects Pad rough cast edges Can use cool air from hair dryer to help with

itching Apply ice for first 24-36 hours Do not get cast wet

Use of Crutches

Fracture Complications Direct

Infection Inadequate bone union Avascular necrosis

Indirect Compartment syndrome Venous thromboembolism (VTE) Rhabdomyolisis Fat embolism Shock

Infection High incidence with open fx or soft

tissue injury Need aggressive debridement

Venous Thromboembolism (VTE) Esp. after hip fx, THA, total knee Prevent – anticoagulants, SCDs,

ROM to unaffected joints

Compartment Syndrome Pressure that compromises

neurovascular function Causes – restrictive dressings, edema S/S – Pain unrelieved by drugs and out of

proportion – 1st, late is no pulses, paralysis, dark brown urine

Tx – quick recognition, do NOT elevate, NO cold, fasciotomy

Fat Embolism Syndrome Systemic fat globules lodge in organs

and tissues Risk with long bone, ribs, tibia, pelvis fx S/S – chest pain, tachypnea, dyspnea,

change in mental status, hypoxia, petechiae on neck, chest, axilla, eyes, sense of impending doom

Tx – early recognition!, reposition as little as possible, oxygen

Types of Fractures Colles’ – wrist fx

Silver-fork deformity Move thumb, fingers, shoulder

Humerus Cx – radial nerve or brachial

artery injury, frozen shoulder

Pelvic Fracture Can be life-threatening S/S – bruising on the abdomen,

pelvis instability, swelling, tenderness

Tx – Bed rest (few days to 6 weeks), may need traction, hip spica cast, ORIF, only turn when ordered by HCP

Hip Fracture 30% die within 1 year of injury S/S – external rotation, mm spasm,

shortening of affected leg, severe pain Cx – nonunion, avascular necrosis,

dislocation, arthritis Tx – surgery, may temp. use Buck’s

traction

Hip Fracture Post-Op Care Pillows/abductor splint between knees esp. when turning,

avoid extreme hip flexion, don’t turn on affected side, OOB on first post-op day, in hospital for 3-4 days

Posterior approach Table 63-11 (pg 1607) No extremes in flexion No putting on shoes, socks No crossing the legs or feet No low toilet seats Precautions for 6 weeks

Anterior approach Limited restrictions

Types of Fractures Femoral Shaft

Can have lots of blood loss, risk of fat embolism

Tx – ORIF with traction after, hip spica cast Tibia

Neurovascular assessment q 2 hrs x 48 hrs Stable Vertebral

Logroll, orthotic devices, hard cervicalcollar

Vertebroplasty Kyphoplasty

Facial Fractures Impt to maintain patent airway, provide

adequate ventilation Assume that they have a cervical injury Always have suction available For jaw fractures:

Position pt on the side with head slightly elevated Wire cutter/scissors at the bedside Trach tray always available NG tube decompression Oral hygiene is impt Protein supplements

Amputation Pain is not a primary reason Pre-op preparation Post-op

Sterile technique for dressing changes Immediate prosthesis vs delayed Don’t sit in chair > 1 hr Lie on abdomen 3-4 times/day Residual limb bandaging Table 63-14 (pg 1613)

Joint Procedures Synovectomy

Removal of synovial membrane Osteotomy

Remove a wedge of bone Debridement

Removal of degenerative debris Arthroplasty

Reconstruction or replacement of a joint

Total Hip Arthroplasty (THA) See notes from hip fracture Can’t drive or take tub bath for 4-6 weeks Knees must be kept apart Don’t cross legs Don’t twist to reach behind Quadriceps and hip muscle exercises High risk for thromboembolism No high-impact exercises/sports Usually stay in the hospital 3-5 days

Carpal Tunnel Syndrome Compression of the median nerve Women more likely to get S/S – thumb weakness, burning pain,

numbness, parasthesia Tinel’s and Phalen’s sign

http://tinyurl.com/cre5lf2 Tx – splints, rest, surgery

Rotator Cuff Injury Muscles that stabilize the humeral head

and give ROM Cause – fall onto outstretched arm,

repetitive overhead arm motion, heavy lifting

S/S – shoulder weakness, pain, decreased ROM

Drop arm test http://tinyurl.com/d2jq5jc Tx – RICE, corticosteroid injection, surgery

Meniscus Injury Occur with ligament sprains in a rotational

force injury S/S – no edema (unless other injury),

tenderness, pain, effusion in the joint, felt a “pop”, knee locks or gives way, MRI

McMurray’s test http://tinyurl.com/cev9lx9 Tx – RICE, knee brace, arthroscopy, rehab

starts quick Prevention – warm-up exercises

Anterior Cruciate Ligament (ACL) Injury Usu. Occur from non-contact S/S – hear a “pop”, pain, swelling Lachman’s test

http://tinyurl.com/ccfk9ws Tx – RICE, crutches, knee brace,

reconstructive surgery May take 6-8 months to recover Higher risk for future knee osteoarthritis

Bursitis Inflammation of the bursa (common

sites – hand, knee, hip, shoulder, elbow)

Cause – repeated trauma, gout, RA, infxn

S/S – warmth, pain, swelling, decreased ROM

Tx – REST, may ice, may aspirate or use corticosteroids

Osteomyelitis Acute vs Chronic

Staphylococcus aureus Pathophysiology

Signs/Symptoms Fever, night sweats, bone pain worse with

activity, swelling, redness, warmth Diagnostic Studies

Bone/soft tissue biopsy, WBCs, ESR, xray doesn’t show until 10 days+

Osteomyelitis Management Long IV therapy (5 weeks – 6 months) Antibiotic-impregnated beads Intermittent or constant irrigation Wound VAC Hyperbaric oxygen Removal of prosthetic devices

Osteomyelitis Interventions Absorbant dressings using sterile

technique Bed rest No exercise or heat application Observe for abx side effects

Bone Tumors Osteochondroma

Benign, overgrowth at growth plate S/S – painless, hard mass, shortened extremity Tx – none if asymptomatic

Osteosarcoma Aggressive, rapidly metastisizes More common with Paget’s disease S/S – gradual onset of pain/swelling Is NOT caused by a minor injury Be very careful when turning/handling

Muscular Dystrophy (MD) Genetic disease with progressive, symmetric

wasting of skeletal muscles but no neuro involvement

Several different types No cure (corticosteroids may help) Keep the patient active as long as possible

Low Back Pain Very common Causes – strain, instability, osteoarthritis, DDD,

disk herniation Acute vs chronic Straight leg test http://tinyurl.com/btbnoq4 Tx – analgesics, muscle relaxants, massage,

heat and cold Avoid prolonged bed rest Stop smoking See Table 64-6 (pg 1627)

Intervertebral Disk Disease Progressive degeneration – normal process of

aging – that can lead to herniated disks Most common sites of slipped disks – L4-5, L5-S1,

C5-6, C6-7 S/S – low back pain, radicular pain to buttock and

below the knee, for cervical disk have radicular pain to arms/hands

Straight leg test is usu. positive Xray, myelogram, MRI, CT Conservative tx first, may need laminectomy,

diskectomy, or spinal fusion

Spinal Surgery Must maintain proper alignment until healing has occurred Pillows under thighs when supine, between legs when

side-lying IV opioids for 24-48 hrs, muscle relaxers Watch for CSF leak Movement and sensation should be unchanged after

surgery – check q 2-4 for 48 hours Clarify if they need brace or corset Check donor site – usu. more painful Avoid sitting or standing for prolonged times No twisting movements of the spine Firm mattress or bed board

Neck Pain Very common Usu. occur from hyperflexion and

hyperextension S/S – stiffness, neck pain, pain radiating to

arm/hand Tx – conservative, head support, heat and ice,

massage, rest, PT, US, NSAIDs See Table 64-10 (pg 1632)

Foot Disorders Usu. caused by improperly fitted shoes Send to a podiatrist If surgery, usu. have a bulky dressing

Elevate foot Crutches, cane, walker (may have throbbing

sensation when starting to walk) Daily foot care Trim toenails straight across

Osteomalacia (Rickets) Loss of minerals in bones

Bones soft rather than brittle Caused by

Inadequate calcium intake Inadequate Vit. D intake or

resistance to actions of Vit. D Increased renal loss of phosphate

Osteomalacia Bones most affected

Spine, pelvis, lower extremities S/S

Localized bone pain Difficulty getting up from chair, walking Bone deformities (bowed legs) Fractures

Tx Vit D supplements Diet Exposure to sunlight Weight bearing exercise

Osteoporosis Resorption rate > formation rate

Net loss of both bone protein matrix and mineral components

Bone composition normal just not enough of it Bone is brittle, fragile, easily broken

Osteoporosis bone mass

Osteoporosis Risk Factors

Heredity, sex, race, early menopause, poor nutrition, sedentary lifestyle, thinness, smoking, ETOH ingestion

Endocrine causes Cushing’s syndrome, diabetes,

hyperthyroidism, hyperparathyroidism Drug-related causes

Glucocorticosteriods, anticonvulsants, some antacids, diuretics, thyroid medications

OsteoporosisSigns & symptoms

Back pain or spontaneous fractures (1st symptom)

Loss of height Deformity (Dowager’s hump) Pathological fracture

As many as 30% of white women will have a pathological fracture d/t osteoporosis

Osteoporosis

Treatment Calcium supplementation Proper nutrition Exercise Medications

Calcium supplement Biphosphonates

Paget’s Disease Systemic disease involving

multiple body systems Excessive bone resorption followed

by excessive and abnormal bone replacement long bones, pelvis, cranium, & spine

Cause – may be viral

Paget’s DiseaseSigns & Symptoms

Pain with weight-bearing, cranial enlargement, kyphosis, bowed legs, reduction in height, sore bones, pathological fractures

Headaches, tinnitus, hearing loss, nerve palsies, cardiovascular & respiratory failure

Alkaline phosphatase levels increased