Musculoskeletal Dysfunction

8/6/2019 Musculoskeletal Dysfunction

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History` Pain` Numbness/Tingling` Joint Stiffness

` Difficulty with movement

Physical Examination` Skeletal deformity` Limited ROM` Inflammation` Edema` erythema



` Abduction is movement away from the center, as spreading the toes or fingersapart.

` Adduction is movement toward the midline of the body, as bringing the fingers and

toes together. (Adduction and abduction always refer to movements of the

appendicular skeleton).

` Angular motion is comprised of flexion, extension, adduction, and abduction. Each

is based on reference to a certain anatomical position.` Circumduction is a special type of angular motion, described as making circular

movements as moving the arm in a loop.

` Dorsiflexion / Plantar flexion refers to movements of the foot. Dorsiflexion is the

movement of the ankle while elevating the sole, as if digging in the heel . Plantar

flexion is the opposite movement, extending the ankle and elevating the heel, as

if standing on tiptoes.

` Elevation / Depression occurs when a structure moves in a superior or inferior

direction, as the mandible is depressed when the mouth is opened and elevated

when the mouth is closed.

` Extension occurs in the same plane as flexion, except that it increases the angle

between articulating elements. Extension reverses the movement of flexion.

Hyperextension is a continuation of movement past the anatomical position, which

can cause injury.



` Flexion is movement in the anterior-posterior plane that reduces theangle between the articulating elements as in bringing the headtoward the chest; that is, flexing the intervertebral joints of the neck.

` Gliding occurs when two opposing surfaces slide past each other as between articulating carpals and tarsals and between theclavicles and sternum.

` Opposition is a special movement of the thumb which enables it tograsp and hold an object.

` Pronation / Supination refers to the rotation of the distal end of theradius across the anterior surface of the ulna. This rotation moves

the wrist and hand from palm-facing-front (supination) to palm-facing-back (pronation).` Protraction entails moving a part of the body anteriorly in the

horizontal plane, as in jutting the face forward to gain distance at afinish line.

` Retraction is the reverse movement of protraction as in pulling the jaw back towards the spine.

` Rotation involves turning the body or a limb around the longitudinalaxis, as rotating the arm to screw in a lightbulb.



Electromyography

-A test for muscle activity with graphicalrecording of the muscle at rest and duringcontraction

Interventions:

1. Explain that the px muscle will asked to flex andrelax muscles during the test

2. Explain that thismay cause minor discomfort butnot painful

3. Administer analgesic as prescribed.





Arthroscopy-direct visualization of the joint (arthroscope)

Intervention:Pre-test1. Secure informed consent2. Explain the procedure3. Skin preparation

4. Use of local anesthesia5. Administer analgesic and prophylactic antibiotic as

prescribe.

Post-test1.

Apply pressure/compact dressing at site2. Monitor neurovascular status3. Limit joint use4. Administer analgesic as prescribed





Arthrocentesis-needle aspiration of synovial fluid from joint under

local anesthesia

InterventionPre-test1. Secure consent2. Explain the procedure3. Administer analgesic and prophylactic antibiotic as

prescribe.

Post-test1. Apply pressure/compact dressing at site2. Monitor neurovascular status3. Limit joint use4. Administer analgesic as prescribed





1. Pain

2. Pallor

3. Paralysis

4. Paresthesia5. Pulselessness



Bone Scan

-visual imaging of bone metabolism after

injection of IV radioisotope

Intervention

Pre-test

1. Explain the procedure

2. Determine the ability of px to lie down during the

scan.

3. Advise that radioisotope will be injected

4. Explain that the px will drink several glasses of

fluid to enhance excretion of isotope not

absorbed by bone tissue.





Myelogram-Fluoroscopic procedure using an injection of

radiopaque dye. Allows visualization of the subarachnois

space,spinal cord and vertebral bodies.

InterventionPre-test1. Explain the procedure

2. Note the px allergy to iodine, sea food andradiopaque dyes.

Post-test1.Bed rest on semi-fowlers position2. Inspect site for bleeding3. Monitor neurovascular status



X-rayKey Intervention1.Check if the female px is not pregnant to avoid fetal

damage from radiation exposure.

Blood ChemistryKey Facts1. Analyzes levels of potassium, calcium, BUN, protein,

LE cell preparation test and anti-DNA2. Monitor venipuncture site

Hematologic StudiesKey Facts1. Analyzes substances for WBC¶s, RBC¶s, Hb and HCT2. Note current drug therapy to anticipate possible

interference with test result.



Key Impact on:

Development, economic, occupation and

recreational and social.

` Decreased self-esteem

` Dependence

` Economic impact

` Restriction on body movement



Modifiable Non-modifiable

1. Occupations that requires

heavy lifting

2. Use of machinery

3. Repetitive motion

4. Vegetarian diet5. Contact sports

6. Obesity

1. Aging

2. Menopause

3. Family history



1. Impaired physical mobility

2. Ineffective tissue perfussion: Peripheral

3. Impaired skin integrity

4. Alteration in comfort: Pain



Arthrodesis ± surgical removal of cartillage from jointsurfaces to fuse a joint into a functional position.

Synovectomy ± removal of the synovial membranefrom a joint using an arthroscope to reduce pain.

Arthroplasty (total joint replacement) ± surgicalreplacement of a joint with a metal, plastic or

prosthesis.









1. Complete preoperative health teaching

2. Complete preoperative checklist

3. Administer preoperative drugs

4. Document assessment data.



1. Assess pain level

2. Administer analgesic as prescribed and evaluate

response.

3. Encourage turning, coughing, deep breathing.4. Maintain active and passive ROM for unaffected

limbs and isometric exercises.

5. Limit joint/area movement of affected limb.

6. Elevate affected extremity7. Provide wound care.



1. Infection

2. Hemmorhage

3. embolus



Fracture immobilization in which transfixing pins are

inserted through the bone above and below the

fracture site.

Pins are attached to a rigid metal frame.





Pre-Operative1. Apply the GIE2. Monitor fracture complication3. Maintain the position of the affected extremity with

sandbags and pillows.4. Maintain traction or splint.

Post-operative1. Assess pain level2. Administer analgesic as prescribed and evaluate

response.3. Provide wound care4. Maintain balanced suspension traction.



1. Infection

2. Hemorrhage

3. Chronic pain



Surgical removal of all or part of a limb with two

types: closed and open







Pre-operative

1. Complete px and family preoperative teaching

with spiritual and cultural consideration.

2. Prepare the px for the possibility of phantomlimb sensation or phantom pain.

3. Provide emotional support to allay the px and

family¶s anxiety to surgery.



Post-operative1. Assess cardiac and respiratory status2. Assess pain level and administer pain medication

(morphine, nubain) as prescribed3. Provide wound care as directed.4. Monitor vital signs, I/O, laboratory studies,

neurovascular assessment and pulse oximetry.5. Elevate the affected extremity as directed.

6. Inspect the stump for bleeding, infection and edema.7. Maintain a rigid dressing for the stump prosthesis.8. Provide trapeze.9. Encourage the px to express feelings about changes

in body image and phantom sensation and pain.



1. Infection

2. Skin breakdown

3. Depression



Surgical reduction and stabilization of a fracture

using orthopedic devices or hardware.





Pre-operative

1. Apply the GIE

2. Monitor fracture complication

3. Maintain the position of the affected extremitywith sandbags and pillows.

4. Maintain traction or splint.



Post-operative1. Assess cardiac and respiratory status2. Assess pain level and administer pain medication

(morphine, nubain) as prescribed

3. Provide wound care as directed.4. Monitor vital signs, I/O, laboratory studies,neurovascular assessment and pulse oximetry.

5. Keep px in semi-fowler¶s position: no higher than 30degrees.

6.

Use abductor pillow and trochanter rolls.7. Apply sequential compression or stockings.8. Administer anticoagulants as prescribed.9. Administer stool softeners as prescribed.



Systemic inflammatory disease that affects the

synovial lining of joints.

Basic Pathophysiological process of RA1. Inflammation of synovium

2. Pannus formation

3. Pannus replacement by fibrotic tissue and

calcifies.4. Destruction of cartillage, bone and ligaments.







Etiology:

1. Idiophatic

2. Autoimmune disease

Top 4 signs and symptoms:

1. Painful, swollen joint

2. Symmetrical joint swelling

3. Morning stiffness (stiffness from rest to

movement)

4. Crepitus



Diagnostics:

1. Rheumatoid factor: (+)

2. Latex fixation test: (+) rheumatoid factor

3. ANA test

4. Synovial fluid analysis

5. Increased ESR

Management:

1. Anti-rheumatic drugs as prescribed

2. NSAIDs

3. Glucocorticoids

4. Heat andcold therapy

5. Joint replacement



Intervention:1. Assess neuromuscular status2. Assess pain level for tolerance

3. Administer prescribed medication4. Keep joint extended; provide passive ROM5. Provide heat and cold therapy

Complications:

1. Deppression2. Peripheral neuropathy3. Keratoconjunctivitis

Surgical Intervention:1. Synovectomy2. Joint replacement



-Degeneration of articular cartillage.

-Affects weight bearing joints

-Degenerated cartillage enters synovium which

fibroses and limits joint movement.-Primarily affects the knee, spine and hip joints.











Etiology

1. Aging

2. Obesity3. Joint trauma

4. Congenital abnormalities

Tops 3 signs and symptoms1. Enlarged; edematous joints

2. Joint stiffness

3. Heberden¶s and Bouchard¶s nodes





Diagnostics

1. X-ray: joint deformities or bone spur

2. Hematology: increased ESR

Management

1. NSAIDs

2. Heat and cold therapy3. Exercise as tolerated

4. Analgesic: aspirin

5. Weight reduction



Intervention:

1. Assess neuromuscular status

2. Assess pain level for tolerance

3. Administer prescribed medication

4. Provide heat and cold therapy

Complications:

1. Contractures

2. Injury

Surgical Management

1. Synovectomy

2. Arthrodesis

3. Joint replacement



` Inflammatory joint disease caused by deposits of uricacid crystals

Etiology:1. Genetics2. Decreased uric acid excretion3. Chronic renal failure

Signs and symptoms:

1. Joint pain2. Redness and swelling3. Tophi or great toe, ankle and outer ear









Pathophysiology

Purine metabolism (uric acid)

Abnormal purine metabolism

Decreased excretion of urates

Increased blood levels of urates

Precipitation of urates in areas with slow bloodcirculation

Accumulation in synovium cavity

Damage to adjacent tissues



Signs and symptoms:

1. Joint pain

2. Redness and swelling in joint3. Tophi formation

Diagnostics:

1. hematology: increased ESR2. Blood chemistry: increased uric acid

3. Synovial fluid analysis: (+) crystals



I t ti



Intervention:

1. Patient health education: diet

2. Uricosuric agents: probenicid

3. Xanthine-oxidase inhibitor: allopurinol4. Analgesic

5. Increase fluid intake for excretion

Surgical Intervention:1. Joint replacement

2. Arthoplasty

3. Evacuation of uric crystals

Complication:

Renal calculi





` Bacterial infection of the bone and soft tissue` Infection that causes bone destruction` Bone fragments necroses` New bone cells form; causing nonunion

Etiology` Staphylococcus aureus` Hemolytic streptococcus

Risk Factors` Infection near bone` Open wound





Signs and symptoms

` Bone pain

`

Localized edema` Increased pain with movement

Diagnostics:

1. Blood culture: (+) bone organism2. Hematology: increased WBC, ESR

3. Bone scan: (+)

4. Bone biopsy: (+)

M t



Management:

1. Specific antibiotic

2. Analgesic

3. Wound care

4. IV therapy

5. Cast or splint

Intervention:

1. Monitor v/s and I/O

2. Provide wound care

3. Maintain cast

4. Assess level of pain

5. Administer drugs as prescribed



Comp[lication:

1. Bone necrosis

2. Amputation3. Chronic osteomyelitis

4. Pathologic fractures

5. Sepsis

Surgical Intervention:

1. I and D of bone abcess

2. Bone graft

3. Bone segment transfer



`

Metabolic bone dysfunction; reduced bone massand density and porosity

` Illness and medications increases the risk of skeletal fractures

Etiology

1. Calcium deficiency

2. Bone marrow disorders

3. Vitamin D deficiency

4. Cushing¶s syndrome

5. hyperthyrodism



Risk Factors

1. Age

2. Post menopausal3. Immobility

4. Corticosteroid use

Signs and symptoms1. Dowager¶s hump

2. Thoracic and lumbar pain

3. Decrease in height

4. Joint pain

5. Pathologic fracture



Diagnostics:



Diagnostics:1. X-ray: porous bone2. DEX A scan: decreased bone mineral density

3. Bones scan: decreased bone mineral density

Treatment1. Calcium supplementation2. Exercise program with weight bearing

Intervention1. Assess musculoskeletal status2. Assist with planning exercises3. Prevent fall4. Administer medication as prescribed

Complication ± pathologic fracture



` Chronic compression neuropathy of the median

nerve at the wristmedian nerve supplies motor

innervention (function) of the wrist and fingers.

Etiology

1. Streneous and repetitive use of the hand

2. Fractures of the wrist

3. Tenosynovitis4. Obesity

Si d t



Signs and symptoms

1. Nocturnal pain and paresthesia

2.B

urning and tingling of the hand3. Weakness

4. Tinel¶s sign: (+)

5. Phalen¶s test: (+)

Diagnostic:

` Motor nerve velocity (MNV) studies: (+) delayed

conduction of the nerve at the wrist









Intervention:

1. Health teaching: avoid wrist flexion

2. Carpal tunnel release3. Hand splint

4. NSAID

5. Instruct the patient to avoid manual activity that

includes dorsiflexion and volar flexion of thewrist.

Complication

1. Chronic hand pain

2. Loss of thumb abduction

3. Trophic changes of the hand and fingers



` Rupture of the intervertebral disk

` Lumbo sacral (L4,L5)

` Cervical (C5,C6,C7)

Etiology

1. Back and neck strain

2. Degeneration of the disk

3. Weakness of ligaments

4. Heavy lifting

5. trauma













` Primarily caused by nerve root compression due

to herniation.







Sensory Impairmentr/t Spinal Cord Injury

Signs and symptoms:



Signs and symptoms:

1. Pain in the back radiating across the buttock and

down to the leg

2. Weakness, numbness and tingling of the foot

and leg.

3. Cervical affection: neck pain that radiates down

the arm and hand.

Diagnostics:

1. CT scan: disk displacement

2. MRI: disk protrusion3. X-ray: narrowing of disk space

Interventions:



Interventions:1. Assess neuromuscular status2. Maintain traction: braces and cervical collar

3. Assess level of pain4. Administer pain medication as prescribed5. Reposition patient every 2 hours using log rolling

technique.

Complications:1. Thrombophlebitis2. Chronic pain3. Muscle arthropy4. Progressive paralysis

Surgical Interventions:1. Laminectomy2. Spinal fusion3. Microdisktectomy



` Break in the continuity of the bone

` Occurs when the stress in the bone is greater than

the bone can withstand.

` Results in muscle spasm, edema,

hemmorhage,compressed nerve and ecchymosis.

Etiology:

1. Trauma2. Force on a bone

Risk Factors:



1. Aging: demineralization of the bone

2. Osteoporosis: decreased bone density

3. Contact sports4. Increased stress in the bone.

5. History of fracture.

Signs and symptoms:1. Pain aggravated by motion

2. Loss of motor function

3. Deformity

4. Edema

5. Ecchymosis

Diagnosis- X-ray: (+) deformity

Management:



Management:

1. Abductor pillow (fractured hip)

2.

Analgesics3. Skin traction: Buck¶s, Bryant¶s and Russel

traction

4. Skeletal traction

5. Casting6. Closed reduction

7. ORIF

8. External fixation

Intervention:



Intervention:

1. Assess neuromuscular status

2. Keep legs abducted (hip fracture)

3. Monitor and record v/s, I and O.

4. Provide skin, pin and cast care.

5. Provide a trapeze.

6. Encourage turning, coughing, deep breathingand passive ROM



1. Check ropes, pulleys, freedom of movement This helps to ensure that traction is functioning properly

2. Check traction set up, pin site and suspensions. This helps to ensure that traction is functioning properly

3.

Check weights and avoid unnecessary movement This ensures that proper amount of weight is suspended andprevent additional pain upon movement

4. Check all skin surfaces for signs of tolerance or pressure areas

This helps uncover signs of pressure that will lead topressure sores.



Complication:

1. DVT

2. Fat embolism

3. Pulmonary embolism4. Pneumonia

5. Compartment syndrome

6. Osteomyelitis



` Chronic inflammatory autoimmune disorder thataffects the connective tissue

` Deposits of antigen/antibody complexes affect theconnective tissue cells

`

Normally, the immune system helps protect the bodyfrom harmful substances. But in patients with anautoimmune disease, the immune system cannot tellthe difference between harmful substances andhealthy ones. The result is an overactive immune

response that attacks otherwise healthy cells andtissue. This leads to long-term (chronic) inflammation.

Etiology ± Idiopathic



Signs and symptoms:

Almost all people with SLE have joint pain and swelling. Somedevelop arthritis. Frequently affected joints are the fingers, hands,wrists, and knees.

` Other common symptoms include:` Chest pain when taking a deep breath` Fatigue` Fever with no other cause` General discomfort, uneasiness, or ill feeling (malaise)` Hair loss` Mouth sores

` Sensitivity to sunlight` Skin rash -- a "butterfly" rash over the cheeks and bridge of the

nose affects about half of people with SLE. The rash gets worsein sunlight. The rash may also be widespread.

` Swollen lymph nodes

Other symptoms depend on what part of the body is affected:B i d t



` Brain and nervous system: Headaches Mild cognitive impairment

Numbness, tingling, or pain in the arms or legs Personality change Psychosis Risk of stroke Seizures Vision problems

` Digestive tract: abdominal pain, nausea, and vomiting` Heart: abnormal heart rhythms (arrhythmias)` Kidney: blood in the urine` Lung: coughing up blood and difficulty breathing` Skin: patchy skin color, fingers that change color when cold

(Raynaud's phenomenon)





Diagnostics:



Diagnostics:

1. LE cell preparation test: (+)

2.

ANA test: (+)3. Rheumatoid factor: (+)

4. Urine chemistry: proteinuria, hematuria

5. Antibody tests, including: Antinuclear antibody (ANA) panel

Anti-double strand (ds) DNA

Antiphospholipid antibodies

Anti-Smith antibodies

6. CBC to show low white blood cells, hemoglobin,

or platelets7. Chest x-ray showing pleuritis or pericarditis

8. Kidney biopsy



Intervention:

1. Assess musculoskeletal and renal status

2. Provide adequate rest period

3.

Prevent infection4. Minimize environmental stress

5. Avoid exposing patient to sunlight

6. Patient should wear protective clothing,

sunglasses, and sunscreen when in the sun.

TreatmentN t id l ti i fl t di ti (NSAID )



` Nonsteroidal anti-inflammatory medications (NSAIDs)are used to treat arthritis and pleurisy.

` Corticosteroid creams are used to treat skin rashes.` An antimalaria drug (hydroxychloroquine) and low-

dose corticosteroids are sometimes used for skin andarthritis symptoms.

` Immunosuppressant` Plasmapharesis

Complication:1. Pleural effusion2. Renal failure

3. Coronary atherosclerosis, pericarditis, myocarditis,endocarditis4. Systemic infection5. deppression



Thank you very much for listening and activeparticipation!

Prepared and discussed by:

MELVIN NIZEL M. ALARCA

Documents

Musculoskeletal Dysfunction