Musculoskeletal System

Assessment, Diagnostic Tests, and Treatments

Prevention Strategies For Injury• Sports Training• Seat Belt use• Child Safety Seat use• Airbag use• Motorcycle education and protective

equipment• Fall prevention• Proper body mechanics• Can you think of others?

Musculoskeletal System Function

• Scaffolding/Support• Protection of vital organs• Locomotion• Production of RBC• Storage of minerals

Musculoskeletal Structures

• Skin• Muscles• Bones• Tendons• Ligaments• Cartilage

Musculoskeletal Structures - Skin

• Holds all structures together• Barrier function• Protects underlying structures• Subcutaneous tissue– Fat– Fascia

Musculoskeletal Structures -Muscle• Composed of specialized cells with ability

to contract• Voluntary (Skeletal)– Conscious control– Allows mobility

• Smooth (Bronchi, GI tract, blood vessels)– Controlled by ANS– Able to alter inner lumen diameter

• Cardiac– Contracts rhythmically on its own

Musculoskeletal Structures

• Tendons– Bands of connective tissue binding muscles to

bones• Cartilage– Connective tissue covering the epiphysis– Surface for articulation

• Ligaments– Connective tissue supporting joints– Attach bone ends to each other

Bones

• Structural form for body• Protection• Point of attachment for tendons, ligaments,

cartilage and muscles• Allows for movement• Storage of minerals• Produce red blood cells

Joints

• Points of articulation between bones• Fused/Fibrous– Sutures

• Between bones of skull

• Synovial– Fluid filled chamber which lubricates articulated

surfaces– Allow for movement

• gliding, flexion, extension, abduction, adduction, circumduction, rotation

MusculoskeletalAssessment

• Health History:• Pain• Altered Sensation (paresthia)• Limited Motion• Personal History (health problems, family

history)• Dietary Habits• Medications

Pain Assessment

Pain Assessment• PQRST Method for Pain Assessment• P = Provokes

– What causes pain?– What makes it better?– Worse?

• Q = Quality– What does it feel like?– Is it sharp?– Dull?– Stabbing?– Burning?– Crushing? ( Try to let patient describe the pain, sometimes they say what they think you would

like to hear. )• R = Radiates

– Where does the pain radiate?– Is it in one place?– Does it go anywhere else?– Did it start elsewhere and now localized to one spot?

• S = Severity– How severe is the pain on a scale of 1 - 10?

• ( This is a difficult one as the rating will differ from patient to patient. )• T = Time

– Time pain started?– How long did it last?

Physical ExamInspection:Full range of motion of all jointsSymmetryPosture (lordosis, scoliosis, kyphosis)GaitMuscles-atrophy, strength (0-5 scale, 5 being normal

strength),tenderness/soreness, guardingJoints/Bones-contractures, crepitus Head and neck:

temporomandibular joint; crepitusNeurovascular checks (5Ps on next slide)Height, WeightNutritional status

Neurovascular Checks

• PAIN• PULSE• PALLOR• PARASTHESIA (pins and needles)• PARALYSIS

Muscle Strength-ask patient to squeeze hand, push against you.

Atrophy-wasting away

Contracture-a permanent shortening (as of muscle, tendon, or scar tissue)

producing deformity or distortionFoot Drop Hip Contracture

Crepitus-grating, crackling or popping sounds and sensations experienced

under the skin and joints.

Musculoskeletal System- Diagnostic tests:Diagnostic tests:

X-ray

Arthrogram-X-ray images taken after injection of contrast material into the

joint.

Arthroscopy-Visual examination of the inside of a joint with an endoscope

and television cameras.

Bone Density Test-Low energy x-ray absorption to measure bone mass

(DEXA-dual energy x-ray absorptiometry)

Electromyography (EMG)-Process of recording the strength of muscle

contraction as a result of electrical stimulation.

Bone Marrow Biopsy/Aspirate

Musculoskeletal System – Dx Tests

Arthrocentesis- incision or puncture of joint capsule to obtain sample of synovial fluid from joint cavity or to remove excess fluid.

• Useful in dx. of joint inflammation, infection, and subtle fractures.

Musculoskeletal System - Tests

• Muscle enzymes-Muscle enzymes- used to distinguish between muscle weakness that is due to nerve innervation problems and dystrophic disease of the muscle itself.

• The level of enzymes reflects the progress of the disorder and the effectiveness of treatment.

• Example- Creatine kinase (CK),aldolase.

Musculoskeletal System – Dx Tests

• Serologic Studies:• Rheumatoid factor(RF)- Serum is tested for the presence of an

antibody found in patients with rheumatoid arthritis.• Erythrocyte sedimentation rate (ESR)-Measures the rate at

which erythrocytes settle to the bottom of a test tube. Elevated ESR is associated with inflammatory disorders like arthritis, tumors or infection.

• Serum Calcium-Measurement of calcium in the blood.

Calcium• Calcium is the most common mineral in the body and

one of the most important. The body needs it to build and fix bones and teeth, help nerves work, make muscles squeeze together, help blood clot, and help the heart to work. Almost all of the calcium in the body is stored in bone. The rest is found in the blood.

• Normally the level of calcium in the blood is carefully controlled. When blood calcium levels get low (hypocalcemia), the bones release calcium to bring it back to a good blood level. When blood calcium levels get high (hypercalcemia), the extra calcium is stored in the bones or passed out of the body in urine and stool.

Vitamin D• Vitamin D promotes calcium absorption in the

gut and maintains adequate serum calcium and phosphate concentrations to enable normal mineralization of bone. It is also needed for bone growth. Without sufficient vitamin D, bones can become thin and brittle. Vitamin D is naturally present in a few foods, added to others, and available as a dietary supplement. It is also produced endogenously when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis. Cod liver oil has been used as a vitamin D supplement for years.

Health Promotion/Illness Prevention - Osteoporosis

• Ensure adequate calcium intake.• Avoid sedentary life style.• Continue program of weight-bearing

exercises.

OsOsteoporosis

Osteoporosis

Osteoporosis—Treatment

• Bone cannot be restored to normal but therapy to prevent further loss

• Fluoride supplements to promote bone deposits• Estrogen replacement therapy• Bisphosphates (Fosamax) to inhibit osteoclast

activity and bone resorption• Calcitonin to decrease bone resorption

Drug TherapyOsteoporosis

• Parathyroid hormone• Calcium and vitamin D

Diet Therapy

• Dietary supplements of calcium and vit D• Protein• Magnesium• Vitamin K• Trace minerals• Avoid alcohol and caffeine

Fall Prevention

• Hazard-free environment• High-risk assessment • Hip protectors that prevent hip fracture in case

of a fall• Hospital care: ID of patient as a fall risk (arm

band, color coded socks), bed in low position, side rails up, call light and belongings within reach, bed alarms, placement close to nurses station, patient instruction, bedside commode, assist with ambulation, frequent monitoring.

Fall Prevention

Fall Risk/Use of Restraints• A hospital's decision to use restraints on patients is a difficult one, involving

complex issues which can pose significant risks to a hospital. A hospital may be sued for negligence for not taking adequate precautions to protect impaired, elderly, incapacitated or unstable patients. On the other hand, hospitals also have been sued for false imprisonment when patients were restrained against their wishes.

• Federal Medicare regulations and policies, as well as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), impose restrictions on how facilities may use physical or chemical restraints. Most states also have laws regarding patient restraints. Although the statutes differ slightly from state to state, such laws generally require the restraint to be:

• Authorized in writing by a physician.• Used for only a specified period of time.• Applied only by a physician or other qualified licensed nurse or personnel

under the supervision of the physician.

Restraints

• The liability risk in using restraints can be reduced significantly if the hospital has a written policy that is stated clearly and followed consistently. A written policy helps hospital personnel understand when restraints can and cannot be used.

• A patient should never be restrained solely for the convenience of the hospital staff or as punishment. Such punitive or convenience restraint use is prohibited expressly by most state laws, Medicare regulations and JCAHO standards.

Types of Restraints

• Chemical• Wrist/ankle• Lap belts• Posey vest• Mittens• Bed rails

Wrist/Ankle Restraints

Restraints

Posey Vest Lap Belt

Fractures• A fracture is a break or

disruption in the continuity of a bone.

Fracture

• Closed– Overlying skin intact

• Open– Wound extends from body surface to fracture

site– Produced either by bones or object that

caused Fx– Danger of infection– Bone end not necessarily visible

WRIST FRACTURE

Fractures—Signs and Symptoms

• Some clearly present (compound fracture) or obvious deformity

• Swelling, tenderness, altered sensation• Inability to move limb• Crepitus

– Grating sound heard if ends of bone fragments move over e/other• Pain immediately after injury

– Can be delayed if nerve damage in area• Diagnostic Tests

– X-rays

Stages of Bone Healing

• Hematoma formation within 48 to 72 hr after injury

• Hematoma to granulation tissue• Callus formation• Osteoblastic proliferation• Bone remodeling• Bone healing completed within about 6

weeks; up to 6 months in the older person

Problems Associated with Musculoskeletal Injuries

• Hemorrhage• Interruption of Blood Supply• Disability• Instability• Soft Tissue injury

Complications associated with Fractures

• Hemorrhage– Possible loss within first 2 hours• Tib/Fib - 500 ml• Femur - 500 ml• Pelvis - 2000 ml

• Interruption of Blood Supply– Compression on artery• decreased distal pulse

– Decreased venous return

Acute Compartment Syndrome

• Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area

• Pathophysiologic changes sometimes referred to as ischemia-edema cycle

COMPARTMENT SYNDROME

Emergency Care - Acute Compartment Syndrome

• Within 4 to 6 hr after the onset of acute compartment syndrome, neuromuscular damage is irreversible; the limb can become useless within 24 to 48 hr.

Emergency Care (Continued)

• Fasciotomy may be performed to relieve pressure.

• Pack and dress the wound after fasciotomy.

Fasciotomy

• Fascia:• Connective tissue that

surrounds muscles, groups of muscles, blood vessels, and nerves, binding some structures together, while permitting others to slide smoothly over each other.

Fat embolism syndrome

– serious complication resulting from a fracture; Risk when fat globules are released from yellow bone marrow into bloodstream w/in 1st week after injury

– More common in fracture of pelvis or long bones, especially if not well immobilized after injury

– Can travel to lungs and cause obstruction, extensive inflammation, and respiratory distress

Fat emboli

Musculoskeletal Assessment

With few exceptions orthopedic injuries are not life threatening. Do not let drama of obvious or

grossly deformed fracture distract you from more serious problems

involving ABC’s

Fractures—Treatment• Immediate splinting and immobilization• Reduction of bones to restore normal position

– Closed reduction: exerting pressure and traction– Open reduction: requires surgery

• Pins, rods, plates, screws• Immobilization

– Cast, splints, traction• Traction

– Application of force or weight pulling on limb that is opposed by body weight

– Force maintains alignment of bones, prevents muscle spasms, and immobilizes the limb

SPLINTING INDICATIONS• Prevention of further

injury

• Decrease pain

• Decrease swelling

• Stabilize fracture or dislocation

• Relieve impaired neurological function or muscle spasms

• Reduce blood and fluid loss into tissues

Casts

Casts

• Rigid device that immobilizes the affected body part while allowing other body parts to move

• Cast materials: plaster, fiberglass, polyester-cotton

• Types of casts for various parts of the body: arm, leg, brace, body

(Continued)

Cast, Splint, Braces, and Traction Management Considerations• Arm Casts

• Leg Casts• Body or Spica Casts• Splints and Braces• External Fixator• Traction

Spica Casts

Casts

MusculoskeletalNursing Care - Casts

• Cast (Leg, arm, body)– Different materials-fiberglass,

plastic, plaster, stockinette– Neurovascular

• Check color/capillary refill• Temperature• Pulse• Movement• Sensation

• Traction– Buck’s – Russell’s – Skeletal

• Traction Nursing Care – Weighs hang free– Pin Site care– Skin and neurovascular

check

Cast Care (continued)

• Elevate Extremity• Exercises – to unaffected side; isometric exercises to

affected extremity

• Keep heel off mattress• Handle with palms of hands if cast wet• Turn every two hours till dry• Notify MD at once of wound drainage• Do not place items under cast.

Traction

• Application of a pulling force to the body to provide reduction, alignment, and rest at that site

• Types of traction: skin, skeletal, plaster, brace, circumferential

(Continued)

Traction

–Manual

Nursing Management• Positioning

• Strengthening Exercises

MusculoskeletalNursing Care

• Other External Immobilizations– Halo Vest

– External Fixation with lag screws at tibia, pelvic, ankle/foot

Halo Vest

Operative Procedures

• Open reduction with internal fixation • External fixation

Surgical Treatment

External Fixation

Surgical Treatment

• Internal Fixation (ORIF)

Managing the Patient Undergoing Orthopedic Surgery

• Joint Replacement• Total Hip Replacement• Total Knee Replacement

Acute Pain - Orthopedic Surgery

• Interventions include:– Reduction and immobilization of fracture– Assessment of pain– Drug therapy: opioid and nonopioid drugs

(Continued)

Acute Pain (Continued) Orthopedic Surgery

– Complementary and alternative therapies: ice, heat, elevation of body part, massage, baths, back rub, therapeutic touch, distraction, imagery, music therapy, relaxation techniques

Pain Management• Over-the-counter (OTC) pain relievers include:• Acetaminophen (Tylenol, Aspirin Free Excedrin)• Nonsteroidal anti-inflammatory drugs (NSAIDs;

aspirin, Motrin, and Aleve)• Topical Corticosteroids (Cortaid and Cortizone)• Both acetaminophen and NSAIDs reduce fever and relieve

pain caused by muscle aches and stiffness, but only NSAIDs can also reduce inflammation (swelling and irritation). Acetaminophen and NSAIDs also work differently. NSAIDs relieve pain by reducing the production of prostaglandins, which are hormone-like substances that causes pain. Acetaminophen works on the parts of the brain that receive the "pain messages."

Pain Management-Controlled Substances (DEA Enforced)

• Definition of Controlled Substance Schedules• The drugs and other substances that are considered

controlled substances under the CSA are divided into five schedules. A listing of the substances and their schedules is found in the DEA regulations, 21 C.F.R. Sections 1308.11 through 1308.15. A controlled substance is placed in its respective schedule based on whether it has a currently accepted medical use in treatment in the United States and its relative abuse potential and likelihood of causing dependence. Some examples of controlled substances in each schedule are outlined below.

Controlled Substances

• These medications are locked up and require them to be counted by two licensed people.

• They must never be left out and any waste the medication must be witnessed by two licensed people.

• Only physicians with DEA numbers can prescribe these.

• It is illegal to give your friend one of these drugs. IT IS CONSIDERED DRUG TRAFFICING.

• Schedule I Controlled Substances• Substances in this schedule have a high potential

for abuse, have no currently accepted medical use in treatment in the United States, and there is a lack of accepted safety for use of the drug or other substance under medical supervision.

• Some examples of substances listed in schedule I are: heroin, lysergic acid diethylamide (LSD), marijuana (cannabis).

• Schedule II Controlled Substances• Substances in this schedule have a high potential for abuse

which may lead to severe psychological or physical dependence.

• Examples of schedule II narcotics include morphine and opium. Other schedule II narcotic substances and their common name brand products include: Dilaudid, methadone, meperidine (Demerol), oxycodone (OxyContin), and fentanyl.

• Examples of schedule II stimulants include: Adderall, methamphetamine, and methylphenidate (Ritalin). Other schedule II substances include: cocaine, amobarbital, and pentobarbital.

• Schedule III Controlled Substances• Substances in this schedule have a potential for abuse

less than substances in schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence.

• Examples of schedule III narcotics include combination products containing less than 15 milligrams of hydrocodone per dosage unit (Vicodin) and products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with codeine). Example of schedule III non-narcotics is ketamine.

• Schedule IV Controlled Substances• Substances in this schedule have a low potential

for abuse relative to substances in schedule III.• An example of a schedule IV narcotic is Darvocet.• Other schedule IV substances include: Xanax,

clonazepam, diazepam (Valium), lorazepam (Ativan), midazolam (Versed), temazepam (Restoril), and triazolam (Halcion).

• Schedule V Controlled Substances• Substances in this schedule have a low potential

for abuse relative to substances listed in schedule IV and consist primarily of preparations containing limited quantities of certain narcotics. These are generally used for antitussive, antidiarrheal, and analgesic purposes.

• Examples include cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC and Phenergan with Codeine).

Impaired Physical Mobility

• Interventions include:– Use of crutches to promote mobility– Use of walkers and canes to promote mobility

Dislocations• Separation of 2 bones at a joint

– Loss of contact between articulating bone surfaces– Usually one bone out of position, other normal– Ex: humerus displaced from glenoid fossa

• Subluxation– Bone only partially displaced w/ partial loss of contact between surfaces

• Trauma (fall) usually cause• Cause considerable soft tissue damage

– Also damage to ligaments, nerves, bv as bone pulled away from joint– Inflammation and bleeding

• Severe pain, swelling, tenderness• Diagnosis confirmed by X-ray• Treatment

– Reduction to dislocated bone, immobilization, therapy to maintain joint mobility

– Healing is slow if ligaments and soft tissue extensively damaged

Amputation• Levels• Complications• Rehabilitation• Nursing Management– relieving pain–minimizing altered sensory perception–promoting wound healing–enhancing body image– self-care

Amputations

Amputations

• Surgical amputation• Traumatic amputation• Levels of amputation• Complications of amputations: hemorrhage,

infection, phantom limb pain, problems associated with immobility, neuroma, flexion contracture

Phantom Limb Pain

• Phantom limb pain is a frequent complication of amputation.

• Client complains of pain at the site of the removed body part, most often shortly after surgery.

• Pain is intense burning feeling, crushing sensation or cramping.

• Some clients feel that the removed body part is in a distorted position.

Prosthesis

Contusions, Strains, and Sprains• Contusion is a soft tissue injury• Strain is a pulled muscle from

overuse, overstretching, or excessive stress• Sprain is an injury to ligaments

surrounding a joint

Sprains

Strains

• Excessive stretching of a muscle or tendon when it is weak or unstable

• Classified according to severity: first-, second-, and third-degree strain

• Management: cold and heat applications, exercise and activity limitations, anti-inflammatory drugs, muscle relaxants, and possible surgery

Sprains

• Excessive stretching of a ligament• Treatment of sprains:– first-degree: rest, ice for 24 to 48 hr, compression

bandage, and elevation– second-degree: immobilization, partial weight

bearing as tear heals– third-degree: immobilization for 4 to 6 weeks,

possible surgery