Disorders of Musculoskeltal System Ppt (1).pptx

1/1/2023 Mr.Adugna O.(Bsc,Msc N) 1
Musculoskeletal disorders

Objectives
• At the end of this chapter students will able
to:-
Identify components of musculoskeletal system
Describe approach to patients with MSS disorders
Describe managements of patients with fracture
Discuss joint and connective tissue disorder with their
managements
Describe different musculoskeletal care modalities

Introduction
 The musculoskeletal system is the supporting
framework and collectively the largest system in the
body.
 It is word of 2 syllables
 Muscle + Skeletal
 The term skeleton, from the Greek word skeltos
meaning “dried up,” was originally used in reference to
a dried-up mummified body

The musculoskeletal system includes:-
Bones
Joints
Muscles
Tendons
Ligaments, and
Bursae of the body.
Bursa: fluid-filled sac found in connective tissue, usually
in the area of joints

Introduction……
BONE
• Skeleton comes from a Greek word meaning dried up body.
• Bone is living tissue
• Newborn human has 350 bones
• Adult human has 206 bones
• Bones are variously classified according to shape, location and size.
– Based on that bones are divided into 4 categories:
Long bones (e.g.. femur)
Short bones (e.g. metacarpals)
Flat bones (e.g. sternum)

Introduction……

Introduction……
Functions of the bones include
 Locomotion
 Protection
 Support
 Blood production
 Mineral deposition(calcium, phosphorus, magnesium,
and fluoride).

Factors affecting Bone growth and metabolism
 Deficiency of vitamin A – retards
bone development
 Deficiency of vitamin C – results
in fragile bones
 Deficiency of vitamin D – rickets,
osteomalacia
 Excessive /insufficient growth
hormone – gigantism,
acromegaly/dwarfism
 Insufficient thyroid hormone –
delays bone growth
 Sex hormones – promote bone
formation; stimulate ossification of
epiphyseal plates
 Physical stress – stimulates bone
growth
Calcium and phosphorous
Calcitonin
Parathyroid
Gluco-corticoids
Thyroxine , and Insulin.

• Vitamin D :Is essential for the efficient absorption of calcium and
phosphorus from food in the small intestine.
• Vitamins A and C :Are needed for the production of bone matrix (a
process called calciﬁcation or ossiﬁcation.
• Growth hormone :increases mitosis and protein synthesis in growing
bones;
• Thyroxine :stimulates osteoblasts, as well as increasing energy
production from food.
• Insulin: is essential for the efficient use of glucose to provide energy.
• Estrogens and androgens: are important for the retention of calcium
in adult bones.

Divisions of the Skeleton
10
• Axial Skeleton
• Skull(22)
• Spine(26)
• Rib cage +sternum (25)
•Oscicles +hyoid =(7)
• Appendicular Skeleton
• Upper limbs
• Lower limbs
• Shoulder girdle
• Pelvic girdle
Hyoid
Cranium
Face
Clavicle
Scapula
Sternum
Ribs
Humerus
Ulna
Hip
bone
Radius
Femur
Patella
Tibia
Fibula
Tarsals
Metatarsals
Phalanges
Phalanges
Skull
Vertebral
column
Vertebral
column
Sacrum
Coccyx
Carpals
Metacarpals
(a) (b)
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Figure 41-1 Bones of the human skeleton.

ASSESMENT OF THE
MUSCULOSKELETAL SYSTEM
Stages of musculoskeletal assessment:
A-Subjective Data;
B-Objective Data;
Inspection and Palpation
ROM-limb measurement
Diagnostic Studies

History
Subjective Data
Demographic: age, gender, socioeconomic status
 PQRSTA: useful in gathering data about any
complaint/problem/symptom.
Injury, how it happened and when it happened
Occupation and activities, including sports and
other physical activities
 Risk factors musculoskeletal problems and
family history (to detect hereditary problems)

Assessment MSS …
 Current health status (such as heart disease, diabetes,
lung conditions)
 Diet history (including whether calcium and vitamin D
intake are adequate to ensure proper bone and muscle
maintenance and repair)
 Medications: For possible side effects include ant
seizure drugs(osteomalacia),corticosteroids( vascular
necrosis, decrease bone and muscle mass) and potassium
depleting diuretics( muscle cramps and weakness)

Assessment MSS …
Objective data
• Techniques of inspection and palpation are used to evaluate the patient’s :-
Posture, Gait
Bone integrity, Joint function and
Muscle strength and size
Skin and neurovascular status
• The extent of assessment depends on:-
– The patient’s physical complaints
– Health history and
– Physical clues that warrant further exploration.
• The nursing assessment is primarily a functional evaluation, focusing on the
patient’s ability to perform ADL

Palpation
Palpate joints, bursal sites, bones and surrounding
muscles.
During Palpation: Assess the patient for both
verbal and non-verbal cues of pain,
Ask the patient, ‘Does the pain radiate elsewhere
from the initial region?’

Palpation should assess for the
following:( TEC)2
T: increased temperature (use the back of the hand
above, below and on the joint and compare with the
other side)
T:tenderness
E: edema/ swelling
E: enlargement (bone tumor)
C: crepitus (osteoarthritis, listen for crepitus as well as
feeling)
C:Consistency and tone of muscle

Physical Examination
Bulge sign
 Ballottement sign
Phalen’s Test
Tinel’s Sign

The bulge sign
Method 1: Gently press just medial of the patella, then move the hand in an ascending
motion. Then press firmly on the lateral aspect of the knee. Commonly, no fluid will be
appreciated. A medial aspect that 'bulges' out after lateral pressure (positive "bulge
sign") is consistent with a moderate amount of fluid.

The Ballottement sign
Ballottement is a medical sign which indicates increased fluid in the
suprapatellar pouch over the patella at the knee joint. To test ballottement the
examiner would apply downward pressure towards the foot with one hand,
while pushing the patella backwards against the femur with one finger of the
opposite hand.

Phalen’s Test
 Ask the person to hold both hands back to back while
flexing the wrists 90 degrees. Acute flexion of the wrist
for 60 seconds produces numbness and burning in a
person with carpal tunnel syndrome
.

Tinel’s Sign
• In carpal tunnel syndrome, percussion of the
median nerve produces burning and tingling
along its distribution, which is a positive
Tinel’s sign

Assessment MSS …
 POSTURE
• The normal curvature of the spine is;
Convex through the thoracic portion and
( Concave through the cervical and lumbar portions.

Common deformities of the spine
A. Kyphosis- an increased forward curvature of the thoracic spine
– Is frequently seen in elderly patients with osteoporosis and
in some patients with neuromuscular diseases
B. Lordosis, or swayback- an exaggerated curvature
of the lumbar spine; and
– Is frequently seen during pregnancy as the woman adjusts
her posture in response to changes in her center of gravity

Assessment MSS …
C. Scoliosis- a lateral curving deviation of the spine.
– May be congenital, idiopathic or the result of damage to
the Para-spinal muscles, as in poliomyelitis.
• It is evidenced by:-
– An abnormal lateral curve in the spine
– Shoulders that are not level
– An asymmetric waistline and
– A prominent scapula, accentuated by bending forward.

Assessment MSS …
 GAIT
• Assessed by having the patient walk away from the examiner for a
short distance.
• The examiner observes the patient’s gait for smoothness and rhythm.
• Any unsteadiness or irregular movements are considered abnormal.
– E.g. If one extremity is shorter than another, a limp may
also be observed as the patient’s pelvis drops downward
on the affected side with each step.

Common gait deformities
wing scapula
Varus (bow legs)
Valgus (knock-knees) Ganglion cyst

Assessment MSS …
Bone Integrity
– The bony skeleton is assessed for deformities and
alignment.
– Symmetric parts of the body are compared.
– Abnormal bony growths due to bone tumors may be
observed.
– Shortened extremities, amputations, and body parts that
are not in anatomic alignment are noted.

Assessment MSS …
Joint Function
• The Articular system is evaluated by noting;
 Range of motion,
 Deformity
 Stability and
 Nodular formation
• Range of motion: The angle of the joint is accurately
measured by goniometry,
– Actively- the joint is moved by the muscles surrounding
the joint and
– Passively- the joint is moved by the examiner
Mr.Adugna O.(Bsc,Msc N) 30

Assessment MSS …
• Limited range of motion may be the result of-
Skeletal deformity
Joint pathology or
Contracture of the surrounding muscles, tendons
and joint capsule.

Assessment MSS …
• An effusion is suspected if the joint is swollen and the
normal bony landmarks are obscured.
• The most common site for joint effusion is the knee.
• Joint deformity may be caused by
Contracture:- shortening of surrounding joint structures
Dislocation:- complete separation of joint surfaces
Sub-luxation:- partial separation of articular surfaces or
Disruption of structures surrounding the joint.

Assessment MSS …
• The tissues surrounding joints are examined for nodule
formation.
– Rheumatoid arthritis
– Gout and Osteoarthritis produce characteristic
nodules.
• The subcutaneous nodules of rheumatoid arthritis are
soft and occur within and along tendons

Assessment MSS …
• The nodules of gout are hard and lie within and
immediately adjacent to the joint capsule itself.
• They may rupture, exuding white uric acid crystals
onto the skin surface.

Assessment MSS …
Muscle Strength and Size
• Is assessed by noting the patient’s ability to change
position
• Weakness of a group of muscles might indicate
Polyneuropathy
Electrolyte disturbances (particularly potassium and
calcium),
Myasthenia gravis
Poliomyelitis, and
Muscular dystrophy.

Assessment MSS …
Neurovascular Status
Frequent neurovascular assessments, because of the risk
of tissue and nerve damage.
Major neurovascular problem caused by pressure within
a muscle compartment
In such cases microcirculation diminishes, leading to
nerve and muscle anoxia and necrosis.
Function can be permanently lost if the anoxic situation
continues for longer than 6 hours.

Diagnostic Evaluation
IMAGING PROCEDURES
X-ray Studies
Bone x-rays determine bone density, texture,
erosion, and changes in bone relationships.
Joint x-rays reveal fluid, irregularity, spur
formation, narrowing, and changes in the joint
structure.

Diagnostic Evaluation
• Computed Tomography
CT scan shows in detail
A specific plane of involved bone and
Reveal tumors of the soft tissue or injuries to the
ligaments or tendons.
It is used to identify the location and extent of fractures
in areas that are difficult to evaluate (eg. acetabulum).

Diagnostic Evaluation…
• Magnetic Resonance Imaging
– Is a noninvasive imaging technique
• Demonstrate abnormalities (i.e. tumors or narrowing of tissue
pathways through bone) of soft tissues such as muscle, tendon,
cartilage, nerve, and fat.
• Especially useful in the diagnosis of a vascular necrosis, disk
disease, tumors,; ligament tears, land cartilage tears.
• Patient is placed inside scanning chamber.
• Gadolinium may be injected IV to enhance visualization of
structures

Diagnostic Evaluation…
• Arthroscopy
– Is a procedure that allows direct visualization of a
joint
– Treatment of tears, defects, and disease processes
may be performed through the arthroscope.
– The procedure is carried out in the operating room
under sterile conditions

• ARTHROSCOPY

The Cause of Musculoskeletal Disorders
1. Work-related (ergonomic) risk factors
High task repetition.
• A job is considered highly repetitive if the cycle time is 30
seconds or less.
Forceful exertions.
• Many work tasks require high force loads on the human body.
• Muscle effort increases in response to high force requirements
Repetitive or sustained awkward postures.
• Place excessive force on joints and overload the muscles and
tendons around the effected joint.
• Joints are most efficient when they operate closest to the mid-
range motion of the joint.
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Individual-related risk factors
• Poor work practices.
Workers who use poor work practices, body mechanics
and lifting techniques are introducing unnecessary risk
factors that can contribute to MSDs.
The poor practices create unnecessary stress on their
bodies that increases fatigue and decreases their body’s
ability to properly recover.
• Poor overall health habits. Workers who smoke, drink
excessively, are obese
• Poor rest and recovery. MSDs develop when fatigue outruns
the workers recovery system, causing a musculoskeletal
imbalance.
• Poor nutrition, fitness and hydration.

Management of clients with musculoskeletal
system trauma

Musculoskeletal Trauma
 Orthopedics :deals with disorders of the
musculoskeletal system.
Trauma is the study of medical problems associated with
physical injury which is the adverse effect of a physical
force upon a person including thermal, ionizing radiation
and chemical;
Tissue is subjected to more force than it can absorb
Severity depends on:
Amount of force
Location of impact
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Mr.Adugna O.(Bsc,Msc N)
48

Soft Tissue Trauma
Contusion
Is a soft tissue injury produced by blunt force, such as a
blow, kick or fall.
 Many small blood vessels rupture and bleed into soft
tissues (ecchymosis or bruising).
Local symptoms like pain, swelling and discoloration are
controlled with intermittent application of cold.
Most contusions resolve in 1 to 2 weeks

Strain
– Is a soft tissue injury that occurs when a muscle or tendon is
excessively stretched.
– Is a “muscle pull” caused by- overuse, overstretching or
excessive stress.
– Are microscopic, incomplete muscle tears with some bleeding
into the tissue.
Causes of strains
• Falls, excessive exercise, and lifting heavy items without
using proper body mechanics.
• Back and ankle injuries are common.
• .

Strains can be mild, moderate, or
severe
A mild strain- causes minimal inﬂammation; swelling and
tenderness are present.
A moderate strain- involves partial tearing of the muscle
or tendon ﬁbers.
Pain and inability to move the affected body part result.
The most severe strain occurs when a muscle or tendon is
ruptured, with separation of muscle from muscle, tendon
from muscle, or tendon from bone.
Severe pain and disability result from this injury.

A sprain
Is an injury to the ligaments and tendons that surround a joint.
Ligament injury (excessive stretching of a ligament)
It is caused by a twisting motion or hyperextension (forcible) of a
joint.
The function of a ligament is to stabilize a joint while permitting
mobility.
A torn ligament causes a joint to become unstable.
Blood vessels rupture and edema occurs; the joint is tender, and
movement of the joint becomes painful

Overstretching or tear
◦ Grade I—mild bleeding and inflammation
◦ Grade II—severe stretching and some tearing
and inflammation and hematoma
◦ Grade III—complete tearing of ligament
◦ Grade IV—bony attachment of ligament
broken away

Treatment of sprains & strains
First-degree: rest, ice for 24 to 48 hr, compression
bandage, and elevation(Use of the acronym RICE)
Rest (prevents additional injury and promotes
healing)
Elevation (controls swelling)—is helpful
treatment interventions.
Second-degree: immobilization, partial weight bearing as
tear heals
Third-degree: immobilization for 4 to 6 weeks, possible
surgery

Management of MSS trauma…
Surgical repair or cast immobilization of the injured area
may be the last option.
Depending on the severity of injury, progressive passive
and active exercises may begin in 2 to 5 days.
Severe sprains may require 1 to 3 weeks of immobilization
before protected exercises are initiated.
Excessive exercise early in the course of treatment delays
recovery.

JOINT DISLOCATIONS
It is a condition in which the articular surfaces of
the bones forming the joint are no longer in
anatomic contact.
The bones are literally “out of joint.”
A subluxation is a partial dislocation of the
articulating surfaces.

Types of Dislocation
1- Traumatic dislocations
• caused by trauma.
• A force strong disrupt the joint capsule and other supporting ligamentous
structures dislocates normal joint.
2- Pathological /Spontaneous dislocation
• occurs when a pathological condition in the joint causes abnormality in
the structural integrity of the joint.
E.g. Septic hip dislocation
3- Recurrent dislocation
– A dislocation which repeatedly occurs after trivial injuries due to weakening
of the supportive joint structures
4-Congenital dislocation
• - A type of dislocation which is present congenitally since birth.
• E.g. Congenital hip dislocation

Joint Dislocations…
• Traumatic dislocations are orthopedic emergencies
because:-
– The associated joint structures
– Blood supply and
– Nerves are displaced and may be entrapped with
extensive pressure on them.

• S/S of a traumatic dislocation are
 Acute pain
Change in positioning of the joint
Shortening of the extremity
Deformity
Decreased mobility
X-rays confirm the diagnosis and demonstrate any
associated fracture.

Medical Management
Early reduction of the dislocation
Immobilizing the joint to allow time for the
supporting structures of the joint to heal
Rehabilitation of the joint
Analgesia
Muscle relaxants and
– Possibly anesthesia are used to facilitate closed
reduction.

• The joint is immobilized and is maintained in a stable
position.
• Neurovascular status is monitored.
• After reduction, if the joint is stable, gentle,
progressive, active and passive movement is begun
• This helps to preserve range of motion and restore
strength.
• The joint is supported between exercise sessions

Nursing management
• Frequent assessment and evaluation of the injury
Complete neurovascular assessment with proper
documentation and communication with the physician.
• Education for patient and supporting family(proper
exercises and activities as well as danger signs and
symptoms )

Fractures
Is a complete or incomplete disruption in the continuity of
bone structure and is defined according to its type and
extent.
Fractures occur when the bone is subjected to stress
greater than it can absorb.
Fractures may be caused by direct blows, crushing forces,
sudden twisting motions, and extreme muscle
contractions

Fractures …
Structures adjacent to fractures are also affected,
resulting in
Soft tissue edema
Hemorrhage into the muscles and joints
Joint dislocations
Ruptured tendons
Severed nerves and
Damaged blood vessels.
Even can damage body organs

Fractures…
TYPES OF FRACTURE
Complete fracture:- a break across the entire cross-section
of the bone and is frequently displaced (removed from its
normal position).
 Incomplete fracture:- (e g, greenstick fracture) involves a
break through only part of the cross-section of the bone.
 Comminuted fracture:- is one that produces several bone
fragments.

Fractures…
• Closed fracture (simple fracture) is one that does
not cause a break in the skin.
• Open fracture (compound, or complex, fracture)
is one in which the skin or mucous membrane
wound extends to the fractured bone.
• Greenstick:- a fracture in which one side of a bone
is broken and the other side is bent

• Depressed: a fracture in which fragments are driven
inward (seen frequently in fractures of skull and
facial bones)
• Oblique:- a fracture occurring at an angle across the
bone (less stable than a transverse fracture)

Fractures…
• Types of Fractures
• A complete:- involves a break across
the entire cross-section of the bone
• Is frequently displaced (removed from
normal position).
• Incomplete:-the break occurs through
only part of the cross-section of the
bone.
E.g, greenstick fracture),

Depressed fx.

Fractures…
• Clinical Manifestations
• The clinical manifestations of a fracture are
Pain
Loss of function
Deformity
Shortening of the extremity,
Crepitus and
Local swelling and discoloration.

Fractures…
• The Dx is based on
The patient’s symptoms
The physical signs and
The x-ray findings
• Usually, the patient reports having sustained an injury
to the area

Bone Healing
phases
a) Hematoma,
b) Cellular proliferation,
c) Callus formation
d) Remodeling
o Generally takes longer than soft tissue healing

Factors affecting fracture healing
• Local factors:
 Degree of soft tissue injury
 Pattern and site of fracture
 Presence of Infection
 Adequacy of reduction
 Adequacy of immobilization
• Systemic factors:
• Debilitating diseases and immunosuppressive drugs impair healing.

Fractures…
• EMERGENCY MANAGEMENT OF FRACTURE
a) Immobilize any suspected fracture
b) Support the extremity above and below when
moving the affected part from a vehicle
c) Suggested temporary splints- hard board, stick,
rolled sheets
d) Apply sling if forearm fracture is suspected or the
suspected fractured arm maybe bandaged to the
chest

Fractures…
• Emergency Management of Fractures …
e)Open fracture is managed by covering a
clean/sterile gauze to prevent contamination
f) DO NOT attempt to reduce the fracture

Medical Management of Fractures
The principles of fracture treatment include:-
Reduction:-Restoration of the fracture fragments to anatomic
alignment and positioning.
Closed reduction:- bringing the bone fragments into
anatomic alignment through manipulation and manual
traction.
The extremity is held in the aligned position with cast,
splint, or other device.

Medical Management of Fractures….
Open reduction:-the fracture fragments are
anatomically aligned through surgery, internal
fixation devices (metallic pins, wires, screws, plates,
nails, or rods.

Medical Management of Fractures…
1. Immobilization
2. Reduction (Restoration Of Function)
3. Antibiotics
4. Muscle Relaxants(methocarbamol) And
5. Pain Medications

Immobilization
The Purpose Of Immobilization Is To:
Prevent re displacement of a reduced fracture
Decrease movement at the site of fracture and prevent further soft
tissue injury
 Relieve pain
Methods Of Immobilization
1- Plaster Of Paris (POP) Cast
2- Traction
A) Using Gravity
B) Skin Traction
C) Skeletal Traction
3- External Fixation
4- Internal Fixation

General Nursing Management
• FOR CLOSED FRACTURE
 Assist in reduction and immobilization
 Administer pain medication and muscle relaxants
 Teach patient to care for the cast
 Teach patient about potential complication of fracture and
to
 Report infection, poor alignment and continuous pain

General Nursing Management…
• FOR OPEN FRACTURE
1. Prevent wound and bone infection
– Administer prescribed antibiotics
– Administer tetanus prophylaxis
– Assist in serial wound debridement
2. Elevate the extremity to prevent edema formation
3. Administer care of traction and cast

FRACTURE COMPLICATIONS
• Early
Shock
Fat embolism
Compartment
syndrome
Infection
DVT
• Late(delayed)
Delayed Union, Mal-
union, and Nonunion.
Avascular necrosis
Delayed reaction to
fixation devices
Complex regional
syndrome

Bone healing abnormalities
1- Delayed Union
Failure of a fracture to heal in the expected time
period.
2- Non union
- Total failure of the fracture to heal with formation of
a false joint between the fractured ends (pseudoarthrosis)
3- Malunion
- Healing occurs with deformity
4- Avascular necrosis
- Necrosis of part of the fractured bone occurs due to
disruption of its vascular supply. E.g. Femoral head.

FRACTURE COMPLICATIONS…
Fat embolism:- Occurs usually in fractures of the
long bones.
• Fat globules may move into the blood stream because
the marrow pressure is greater than capillary pressure
• Fat globules occlude the small blood vessels of the
lungs, brain kidneys and other organs

Compartment Syndrome
• Compartment is an area of the body encased by bone or fascia that contains
muscles, nerves, and blood vessels.
• Is a dangerously increased pressure within the enclosed fascia compartments of
extremities, especially forearm and leg.
• The high compartmental pressure causes Ischemia and necrosis of soft tissues in
the compartment.
• It may be aggravated by application of tight bandages or circular POP casts on a
freshly injured limb.
• Severe pain, especially with passive flexion of fingers is the earliest indicator.
• Acute compartment syndrome involves a sudden and severe decrease in blood
flow to the tissues distal to an area of injury that results in ischemic necrosis if
prompt, decisive intervention does not occur.

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.
Monitor compartment pressures.
Fasciotomy may be performed to relieve
pressure.
Pack and dress the wound after
fasciotomy.

Possible Results of Acute Compartment
Syndrome
• Infection
• Motor weakness
• Volkmann’s contractures: (a deformity
of the hand, fingers, and wrist caused
by a lack of blood flow (ischemia) to
the muscles of the forearm)

JOINT AND CONNECTIVE TISSUE
DISORDER

Osteoarthritis
OA is primarily a disease of cartilage
Also known as degenerative joint disease or
osteoarthrosis (wear‐and‐tear arthritis).
Is the most common and most frequently disabling of
the joint disorders
The primary enzymes responsible for the degradation of
cartilage are the matrix metalloproteinase's (MMPs)
They are secreted by both synovial cells and
chondrocytes and are categorized into three general
categories: a) collagenases; b) stromelysins; and, c)

• What factor(s) is responsible for
inducing metalloprotease synthesis?

OA----
The most commonly involved joints are those near the
ends of the fingers,
Distal interphalangeal (DIP)
Proximal interphalangeal (PIP)
Carpometacarpal joint of the thumb
Weight-bearing joints (hips, knees)
Metatarsophalangeal (MTP) joint of the foot
Cervical and lumbar vertebrae
neck
Joints on one side of the body are often more affected
than those on the other.
 Usually the symptoms come on over years.

Osteoarthritis
Most Involved Joints

Classification
 Idiopathic (primary) Cause – unknown
 Secondary
Trauma / Mechanical stress
Overused joints from work or sports related activities
Inflammation
Joint instability
Neurologic disorders
Skeletal deformities
Side Effects of Medications
Weakened immune system
Chronic illness such as diabetes, cancer or liver disease
Infections such as Lyme disease

Osteoarthritis……
• Increasing age directly relates to the degenerative
process in the joint. Why?
• Because the ability of the articular cartilage to resist
microfracture with repetitive low loads diminishes
with age.
• OA often begins in the third decade of life and peaks
between the fifth and sixth decades.

Patho-physiology of osteoarthritis
• OA may be the end result of many factors that, when
combined, predispose the patient to the disease
• OA affects the articular cartilage, subchondral bone
(the bony plate that supports the articular cartilage),
and synovium.
• A combination of cartilage degradation, bone
stiffening, and reactive inflammation of the synovium
occurs.

• Risk factors for OA include:-
 Increased age
 Obesity
 Previous joint damage
 Repetitive use (occupational or recreational)
 Anatomic deformity
 Genetic susceptibility

Clinical Manifestations……
Pain
Functional impairment
swollen joints,
joint stiffness,
joint creaking, and
loss of range of motion.

Diagnosis
 Diagnosis is made with reasonable certainty based on
history and clinical examination
 X-rays may confirm the diagnosis.
 The typical changes seen on X-ray include:
Joint space narrowing,
 Subchondral sclerosis (increased bone formation
around the joint),
Subchondral cyst formation, and
Osteophytes.

Medical Management
There is no curative therapy currently available for OA.
Conservative treatment measures include
Patient education
The use of heat
Weight reduction
Joint rest and avoidance of joint overuse
Orthotic devices (e.g. splints, braces) to support
inflamed joints, isometric and postural exercises, and
aerobic exercise.

Pharmacologic Therapy
Pharmacologic management of OA is directed toward
symptom management and pain control.
The most typically used drugs are nonsteroidal anti-
inflammatory drugs (NSAIDs).
Nonselective cyclooxygenase (COX-1 and COX-2)
inhibitors(Acetylsalicylic acid (aspirin) Diclofenac sodium
(Voltaren)
Newer NSAIDs called COX-2 inhibitors are effective for
short-term treatment of the pain of OA(i.e Celecoxib
(Celebrex).

Physical Therapy
There is no treatment to stop the erosion of
cartilage in the joints, but there are ways to
improve joint function.
Physical therapy is used to increase flexibility
and strengthen the muscles around the affected
joints.
 The therapist may also apply hot or cold
therapies such as compresses to relieve pain.

Supportive Devices
• Supportive devices, such as finger splints or knee
braces, can reduce stress on the joints and ease pain.
• If walking is difficult, canes, crutches, or walkers may
be helpful.
• People with osteoarthritis of the spine may benefit
from switching to a firmer mattress and wearing a back
brace or neck collar.

According to DACA
• First line
Paracetamol, 500-1000 mg P.O. PRN (4-6 times
daily) is the treatment of choice when only pain
relief is needed
• Alternatives
Ibuprofen, 600-1,200 mg/day P.O. in divided
doses as needed

Surgical Management
 Used in moderate to severe OA
 The procedures most commonly used are:-
Osteotomy (to alter the distribution of weight within
the joint)
Arthroplasty(diseased joint components are
replaced).
Nursing management
Pain management

Preventing Osteoarthritis
• The most important thing you can do to ward off
osteoarthritis is keep your weight in check.
Hamstring Stretch
Warm up with a five-minute walk. Then, stretch. Lie down.
Loop a bed sheet around your right foot.
 Use sheet to help pull and stretch leg up.
 Hold for 20 seconds. Repeat twice, then switch legs.
Stretching is one of three important types of exercises for
knee OA. Range of motion or stretching exercises keep you
limber. Strengthening exercises build muscle strength to
stabilize weak joints. Aerobic exercises, like walking, help
lung and heart fitness.

Hamstring stretch

Straight Leg Raise
 To try this leg strengthening move, lie on the floor.
 Prop your back up on your elbows.
 Bend your left knee, keeping foot on floor.
 Keep the right leg straight, toes pointed up. Tighten
thigh muscles of your right leg.
 Slowly and smoothly use your thigh muscles -- not
your back -- to raise your leg.
 Pause, for five seconds. With thigh still tight, slowly
lower leg to ground. Relax. Repeat 10 times. Rest. Do
another 10; then switch legs.

Straight Leg Raise exercise

Pillow Squeeze
This move helps strengthen the inside of your
legs to help support your knee. Lie on your
back, both knees bent.
 Place a pillow between knees.
Squeeze knees together, squishing pillow
between them. Hold for five seconds.
 Relax. Repeat 10 times. Rest, then do another
set of 10.

Rheumatoid Arthritis
Chronic multisystemic inflammatory disease of unknown
cause
Characterized by persistent inflammatory synovitis, usually
involving peripheral joints in a symmetrical distribution.
Pathophysiology
Autoimmune reaction primarily occurs in the synovial tissue.
Phagocytosis produces enzymes within the joint.
The enzymes break down collagen, causing edema,
proliferation of the synovial membrane, and ultimately
pannus formation.

Rheumatoid Arthritis……
Pannus destroys cartilage and erodes the bone.
The consequence is loss of articular surfaces and joint
motion.
Muscle fibers undergo degenerative changes.
Tendon and ligament elasticity and contractile power
are lost.

Rheumatoid arthritis (RA)----
 Rheumatoid arthritis (RA) is a crippling disease that
predominantly affects individuals in the prime of their
lives.
 In early disease, pain and stiffness
 The underlying lesion is a destructive inflammatory
tissue composed of two components, infiltrating T cells
and macrophages and resident synovial membrane
cells, both of which play a part in the tissue damage

Rheumatoid Arthritis
Anatomic 4 Stages
 Stage 1 – Early
No destructive changes on x-ray; possible
osteoporosis
 Stage II – Moderate
X-ray osteoporosis; no joint deformities; possible
presence of extraarticuloar soft tissue lesions
 Stage III – Severe
X-ray evidence of cartilage and bone destruction in
addition to osteoporosis; joint deformity—
subluxation, ulnar deviation, hyperextension, bony
ankylosis; muscle atrophy, soft tissue lesions
 Stage IV – Terminal
Fibrous or bony ankylosis; criteria of Stage III

Rheumatoid Arthritis…..
Etiology
• The cause of RA remains unknown.
1. Genetic factors : genetic susceptibility to altered
immune response may play a role
2. Infectious agent: may play a role in triggering an
autoimmune reaction.
Infectious agents such as rubella, Mycoplasma, CMV
and EBV virus may play a role in the pathogenesis

Clinical Manifestations
Joint pain
Swelling
Warmth
Erythema
Lack of function
Deformities of the hands and feet
Rheumatoid nodules in more advanced RA

RA is a systemic disease with multiple extra-articular
features.
 fever, weight loss, fatigue, anemia,
 lymph node enlargement
 Raynaud’s phenomenon
 Arteritis,neuropathy
 scleritis,
 pericarditis,
 splenomegaly,
 Sjögren’s syndrome (dry eyes and dry mucous membranes

Assessment and Diagnostic Findings
Rheumatoid nodules,
Joint inflammation detected on palpation,
Laboratory findings
Rheumatoid factor
ESR is significantly elevated in RA.
RBC cell countand C4 complement component are
decreased
Arthrocentesis
X-rays show bony erosions and narrowed joint spaces

RA diagnostic criteria's
Morning stiffness Duration ˃1hr lasting ˃6wks
Arthritis of at least 3
areas
Soft tissue swelling or exudation ˃6wks
Arthritis of hand joint Wrist, metacarpopharyngeal joints lasting
˃6wks
Symmetrical arthritis At least 1 area lasting ˃6wks
Rheumatoid nodules As observed by physician
Serum rheumatoid
factor
As assessed by a method positive in less than
5% of control subjects
Radiographic changes As seen on anterioposterior films of wrist &
hands
Presence of 4 of the above criteria = diagnosis of RA

Medical Management
First line NSAIDs ( Non steroidal anti-inflammatory
drugs)
• Aspirin, Ibuprofen, diclofenac, indometacin may be used
Dose:
• Aspirine 900 mg PO TID, Ibuprofen 400 mg PO BID or
Diclofenac 50 mg PO BID or TID
Second line : low dose oral Corticosteroids
Third line: Disease modifying antirheumatic drugs- or
slow acting antirheumatic drugs (DMARD
• Methotrexate is the most frequently DMARD used, given
in an intermittent low dose: 7.5-30 mg once weekly .

• Fourth line: Anti cytokine agents: this are biological
agents that bind and neutralize TNF. Used when
symptoms not respond to DMARDs.
• Fifth line:immunosuppressive therapy : These include
drugs such as Azathioprine, cyclsosporine, and
cyclophosphamide
Surgical therapy
• Early: synovectomy
• Late: artheroplasy or total joint replacement.

• According to DACA
Drug Treatment:
• First line
Aspirin, 600-1200mg P.O. TID,
• Alternatives
Ibuprofen, 400-800 mg P.O. TID
OR
Indomethacin, 25-50 mg P.O. TID
OR

• Indomethacin, 100 mg rectal at night, as part of the total daily dose
of NSAID, may be needed in some patients for severe nocturnal
pain.
Cimetidine, 200 mg P.O. twice BID may be considered for those at
risk for gastrointestinal side effects.

For non-responders
A. Disease-modifying Anti-rheumatic Drugs (DMARD):
Chloroquine phosphate, 150-300 mg P.O. as base QD
Alternatives
• Methotrexate, 7.5 mg P.O. weekly,
N.B. Patients on methotrexate should be placed on
supplementary folic acid, P.O. 5 mg QD
OR
Azathioprine, 50-100 mg P.O QD.

B. Oral Corticosteroids
• Prednisone, 30-40 mg/day P.O. for 1-2 weeks with
rapid tappering to minimize side effects. Use for
longer duration at doses of 5- 7.5mg/day.
OR
C. Intra-articular Corticosteroids
• Methylprednisolone acetate, 20-80 mg intra-
articular depending on the joint.

• NURSING MANAGEMENT
Patient education
Monitoring and Managing Potential Complications
Nutritional therapy

A spinal disc herniation
 Is a medical condition affecting the spine due to trauma,
lifting injuries, or idiopathic, in which a tear in the outer,
fibrous ring of an intervertebral disc allows the soft,
central portion (nucleus pulposus) to bulge out beyond the
damaged outer rings.
 The tear in the disc ring may result in the release of
inflammatory chemical mediators which may directly cause
severe pain, even in the absence of nerve root compression
 Disc herniation are normally a further development of a
previously existing disc "protrusion", a condition in which
the outermost layers of the annulus fibrosus are still
intact, but can bulge when the disc is under pressure. In
about 95% of all disc herniation cases, the L4-L5 or L5-S1
disc levels are involved.

Vertebral Disc
Gel like Tissue between each vertebra fibro
cartilaginous serve as the spine's shock
absorbing system
It protect the vertebrae, brain, and other
structures
The discs allow some vertebral motion extension
and flexion.

 The disc is made up of 3 structures the
(1) Nucleus pulposus, gelatinous center
(2) Annulus Fibrosus. Its job is to contain the
nucleus
(3) Vertebral end plates that attach the disc to the
vertebrae
 Herniated disc can occur when there is enough pressure
from the vertebrae above and below
 This can force some or all of the nucleus pulposus
through a weakened or torn part of the annulus
fibrosus.

Types of herniation
Posterolateral disc herniation
 Protrusion is usually posterolateral into vertebral canal,
compress the roots of a spinal nerve.
 Protruded disc usually compresses next lower nerve as that
nerve crosses level of disc in its path to its foramen.
Central (posterior) herniation:
Less frequently, a protruded disc above second lumbar
vertebra may compress spinal cord itself or may result in
cauda equina syndrome
 In the lower lumbar segments, central herniation may result
in S1 radiculopathy.
lateral disc herniation
 May compress the nerve root above the level of the herniation
 L4 nerve root is most often involved & patient typically have intense radicular pain.

Classifications Of Herniations
Disc Degeneration
 Chemical changes associated with aging causes discs
to weaken, but without a herniation.
Loss of fluid in nucleus pulposus
Prolapse
 The form or position of the disc changes with some
slight impingement into the spinal canal. Also called a
bulge or protrusion
 Nucleus forced into outermost layer of annulus
fibrosus- not a complete rupture

Classifications----
Extrusion
 The gel-like nucleus pulposus breaks through
the tire like wall (annulus fibrosus) but remains
within the disc.
 A small hole in annulus fibrosus and fluid moves
into epidural space
Sequestration
 The nucleus pulposus breaks through the
annulus fibrosus and lies outside the disc in the
spinal canal
 Disc fragments start to form outside of the
disc area.

1
2
3
4

Cellular and Biochemical Changes of the
Intervertebral Disc
 Decrease proteoglycan content.
 Loss of negative charged proteoglycan side chain.
 Water loss within the nucleus pulposus.
 Decrease hydrostatic property.
 Loss of disc height.
 Uneven stress distribution on the annulus.

CAUSES
Repetitive mechanical activities – Frequent bending,
twisting, lifting, and other similar activities without breaks
and proper stretching can leave the discs damaged.
Living a sedentary lifestyle – Individuals who rarely if
ever engage in physical activity are more prone to herniated
discs because the muscles that support the back and neck
weaken, which increases strain on the spine.
Traumatic injury to lumbar discs commonly occurs
when lifting while bent at the waist, rather than lifting with
the legs while the back is straight.

Causes---
Obesity – Spinal degeneration can be quickened as a
result of the burden of supporting excess body fat.
Practicing poor posture – Improper spinal alignment
while sitting, standing, or lying down strains the back
and neck.
Tobacco abuse – The chemicals commonly found in
cigarettes can interfere with the disc’s ability to absorb
nutrients, which results in the weakening of the disc.
Mutation- in genes coding for proteins involved in the
regulation of the extracellular matrix, such as MMP2 and
THBS2, has been demonstrated to contribute to lumbar
disc herniation.

Clinical manifestations of disc
herniation
 sensory changes such as numbness, tingling, muscular
weakness, paralysis, Paresthesia, and affection of
reflexes.
 If the disc protrudes to one side, it may irritate the dural
covering of the adjacent nerve root causing pain in the
buttock, posterior thigh and calf (sciatica).
 Unlike a pulsating pain or pain that comes and goes,
which can be caused by muscle spasm, pain from a
herniated disc is usually continuous or at least is
continuous in a specific position of the body.

If the herniated disc is:
Not pressing on a nerve, you may have an ache in the
low back or no symptoms at all.
Pressing on a nerve, you may have pain, numbness, or
weakness in the area of your body to which the
nerve travels.
With herniation in the lower (lumbar) back, sciatica
may develop. sciatica is pain that travels through
the buttock and down a leg to the ankle or foot
because of pressure on the sciatic nerve. Low back
pain may accompany the leg pain
Clinical manifestations---

 Leg pain caused by a herniated disc
 Usually occurs in only one leg.
 May start suddenly or gradually.
 May be constant or may come and go
(intermittent).
• May get worse ("shooting pain") when sneezing,
coughing, or straining to pass stools.
• May be aggravated by sitting, prolonged
standing, and bending or twisting movements.
• May be relieved by walking, lying down, and other
positions that relax the spine and decrease
pressure on the damaged disc.

Diagnostic studies
X-Ray : lumbo-sacral spine;
Narrowed disc spaces.
 Loss of lumber lordosis.
Compensatory scoliosis.
CT scan lumber spine;
 It can show the shape and size of the spinal canal,
its contents, and the structures around it, including
soft tissues.
Bulging out disc.
MRI lumber spine;
Intervertebral disc protrusion.
Compression of nerve root.
Myelogram;
 pressure on the spinal cord or nerves, such as herniated
discs, tumors, or bone spurs.

Management of disc herniation
The medical management traditionally involves:
 Bed rest and analgesics and anti-inflammatory
drugs.
 Muscle relaxants help in some. Transcutaneous
electrical nerve stimulation (TENS) helps in
about 20% of patients.
Physical therapy such as (exercise, relaxation,
massage, and hot compressors).
Medications
• NSAID, such as aspirin, naproxen, ibuprofen, etc
• used to reduce inflammatory and relieve pain.

 Analgesic, such as Acetaminophen can relieve pain but don’t have
the anti-inflammatory effect of NSAIDs.
 Muscle relaxant such as methocarbamol may be prescribed to
control muscle spasm
 Steroid may be prescribed to reduce swelling and inflammation of
the nerves. Taken orally in tapering dosage over a-five day period
Surgical management:
 Indications for surgery include failure of acceptable pain control
by nonoperative measures, progressive neurological deficit. The
traditional approach to lumbar discectomy (laminectomy) usually
under general anesthesia
 Chemonucleolysis
 Is the term used to denote chemical destruction of nucleus pulposus

GOUT
 Ancient disease : “the king of diseases and the disease of
kings”
 First identified by the Egyptians
 5thcentury BC: Hippocrates referred to gout as “unwalkable
disease” and noted links between gout & lifestyle, demographics &
other variables
 Heterogeneous group of conditions related to a genetic
defect of purine metabolism that results in hyperuricemia.
 Gout is a form of inflammatory arthritis that develops in
some people who have high levels of uric acid in the blood.

The acid can form Needlelike crystals in a
joint and cause sudden, severe episodes of
pain, tenderness, redness, warmth and
swelling.
Oversecretion of uric acid or a renal defect
resulting in decreased excretion of uric acid,
or a combination of both, occurs.
Hyperuricemia (serum concentration greater
than 7 mg/dL.

Pathophysiology
Uric acid is a waste product resulting from the
breakdown of proteins (purines) in the body.
 Urate crystals, formed because of excessive uric acid
(hyperuricemia) build up and are deposited in joints
and other connective tissues, causing severe
inflammation.
When an “attack” of gout occurs, the patient has severe
pain and inflammation in one or more small joints,
usually the great toe.

GOUT…….
Primary gout:- is the most common and is caused by an
inherited problem with purine metabolism.
Uric acid production is greater than the kidneys’ ability to excrete
Secondary gout:- patients also experience hyperuricemia, but
the increase is the result of another health problem, such as
renal insufficiency, or medications, such as diuretic therapy and
certain chemotherapeutic agents.

Stages Of Gout
Asymptomatic hyperuricemia
 Is the period prior to the first gout attack.
There are no symptoms, but blood uric acid levels are high and
crystals are forming in the joint.
Acute gout, or a gout attack
Happens when uric acid levels spike or jostles the crystals that have
formed in a joint, triggering the attack. The resulting inflammation and
pain usually strike at night
Interval gout
Is the time between attacks.
Low level inflammation may be damaging joints.
This is the time to begin managing gout – via lifestyle changes and
medication
Chronic gout
Develops in people with gout whose uric acid levels remain high over
a number of years.
 Attacks become more frequent and the pain may not go away as it
used to. Joint damage may occur, which can lead to a loss of mobility.

Gout Risk Factors
Genes
Other health conditions: High cholesterol, high blood
pressure, diabetes and heart disease may raise your risk.
Medications: Diuretic medications or “water pills”
Gender and age
Diet: Eating red meat and shellfish increases your risk.
Alcohol
Obesity
Bypass surgery

GOUT…….
Etiologic classification of Hyperuricemia
Overproduction: account for 10 % of patients.
• synthesize greater than normal amount of uric acid.
• The urinary excretion of urate is >1000mg/day (they have
normal urinary excretion of uric acid).
• The defect causing uric acid overproduction may be
a) Primary: purine pathway enzyme defect
b) Secondary : increased cell turn over or cellular
destruction associated with alcohol use, hematologic
malignancies , chronic Hemolysis , or cancer chemotherapy

GOUT…….
Under secretion of Uric acid:
Account for 90 % of patients.
Decreased renal excretion of uric acid is the
underlying reason for hyperuricemia (urinary
excretion of uric acid is < 700mg/dl )
a) Drugs: Diuretics , alcohol , Aspirin interfere with
tubular handling of urate
b) Renal diseases ; chronic renal failure , lead
nephropathy , inherited disorders

GOUT…….
Clinical Manifestations
Acute gouty arthritis (recurrent attacks of severe
articular and periarticular inflammation)
Tophi (crystalline deposits accumulating in articular
tissue, osseous tissue, soft tissue, and cartilage)
Gouty nephropathy (renal impairment), and
Uric acid urinary calculi.
• Four stages of gout can be identified: Asymptomatic
hyperuricemia, acute gouty arthritis, intercritical gout,
and chronic tophaceous gout.

GOUT…….
Medical Management
Acute Gout
First line
Indomethacin, 50 mg P.O. 4-6 hourly for 24-48 hours; thereafter
25-50 mg TID for symptomatic relief for the duration of the
attack.
Alternatives
Colchicine, 0.5-1 mg P.O. initially, followed by 0.5 mg every 30
minutes to 1 hour for a total dose of 6 mg or until relief has
been obtained, or until severe nausea/vomiting/diarrhea
occur.

GOUT…….
Or
Prednisolone, 30-40 mg/day P.O. may be needed in some
cases
Chronic Gout
First line
Allopurinol, 100 mg P.O. QD, increasing weekly by 100 mg
to 400 mg QD, the mean dose is 300 mg/day
Alternative
Probenecid 500 mg P.O. BID.

Nursing management
The nurse should encourage the patient to restrict
consumption of foods high in purines, especially
organ meats, and to limit alcohol intake.
Maintenance of normal body weight should be
encouraged.
In an acute episode of gouty arthritis, pain
management with prescribed, avoidance of trauma,
stress, and alcohol.

Musculoskeletal Infections
OSTEOMYELITIS
 Osteomyelitis (osteo- bone, myelo- marrow, and –itis -
inflammation)
 It is an infection of the of the bone or bone marrow which leads to
a subsequent inflammatory process.
• The bone becomes infected by one of three modes:
– Extension of soft tissue infection
– Direct bone contamination from
• Bone surgery,
• Open fracture, or
• Traumatic injury
– Hematogenous (blood borne) spread from other sites of
infection

Musculoskeletal Infections…
• High risk patients are:-
– Poorly nourished
– Elderly or Obese.
– Patients with impaired immune systems
– Those with chronic illness and
– Those receiving long term corticosteroid therapy.

Staphylococcus aureus causes 70% to 80% of bone
infections.
Other pathogenic organisms include Proteus and
Pseudomonas species and Escherichia coli.
The incidence of penicillin-resistant, nosocomial,
gram-negative, and anaerobic infections is increasing

Acute Osteomyelitis
Hematogenous Osteomyelitis:
Bacterial seeding from the blood.
Seen primarily in Children.
The most common site is the Metaphysis at the
growing end of Long Bones in Children, and The
Vertebrae and pelvic in Adults.

Direct Inoculation Osteomyelitis
Direct contact of the tissue and bacteria as a
result of an Open Fracture or Trauma.
Tend to involve multiple organisms

Pathology
 Inflammation.
• Earliest Change
• Increase interaosseous pressure leads to Pain.
 Suppuration.
• Pus @ Medulla =Volkmann canals=>Surface => Subperiosteal Abscess=> spread
along the shaft=> re-enter the bone or burst into the soft tissue
May extend to Epiphysis and Metaphysis in Neonates and Children. May extend to
Interverteberal Discs in Adults.
 Necrosis.
• Begin to see signs with in one week.
 New-bone formation.
• Bone thickens to form an involucrum enclosing the infected tissue.
• Perforation may occur converted acute into chronic osteomyelitis.
 Resolution.

• Clinical manifestation
– When the infection is blood borne, the onset is
usually sudden, (e.g. chills, high fever, rapid pulse,
general malaise).
– The infected area becomes painful, swollen and
extremely tender.

• The patient may describe a constant, pulsating pain
that intensifies with movement
• The area is swollen, warm, painful, and tender to
touch.
• Continuously draining sinus or
• Recurrent periods of pain, inflammation, swelling,
and drainage in chronic Osteomyletis.

Treatment
Principles of treatment:
1. Analgesia an general supportive measures.
2. Rest of the affected part
3. Antibiotic treatment.
4. Surgical eradication of pus and necrotic
tissue(debridement).

Antibiotic treatment:
 Start with IV antibiotics for 1-2 weeks then oral for 3-6 weeks.
 Older children and adults (staph infection): fluloxacillin and fusidic
acid.MRSA: Vancomycin
 Children younger than 4 year-old or those with gram negative
organisms: 3rd generation cephalosporins.
 Sickle cell anemia and osteomyelitis: fluoroquinolone antibiotic (not
in children). A 3rd cephalosporin (eg, ceftriaxone) is an alternative
choice.
 Nail puncture occurs through an athletic shoe (S aureus and
Pseudomonas aeruginosa): ceftazidime or cefepime. Ciprofloxacin is
an alternative treatment.
 Trauma (S aureus, coliform bacilli, and Pseudomonas aeruginosa):
nafcillin and ciprofloxacin. Alternatives include vancomycin and a
3rd cephalosporin with antipseudomonal activity.

• SEPTIC (INFECTIOUS) ARTHRITIS
• Joints can become infected through hematogenous
spread or directly through trauma or surgical
instrumentation.
– Previous trauma to joints
– Joint replacement
– Coexisting arthritis and
– Diminished host resistance contribute to the
development of an infected joint.

• S. aureus causes most adult joint infections, followed
by streptococci and gram-negative organisms.
• Prompt recognition and treatment of an infected joint
are important
o because accumulating pus results in chondrolysis
(destruction of hyaline cartilage).

• Clinical Manifestations
Warmth
Painful
swollen joint with decreased range of motion.
• Systemic chills, fever and Leukocytosis are present.

• Elderly patients and patients taking corticosteroids or
immunosuppressive medications may not exhibit
typical clinical manifestations of infection.
• Therefore, they require ongoing assessment to detect
infection as early as possible in the infectious process

• Rx:- Broad-spectrum IV antibiotics are started
promptly and then changed to organism-specific
antibiotics after culture results are available.
• The IV antibiotics are continued until symptoms
disappear.
• The synovial fluid is monitored for sterility and
decrease in WBCs.

• In addition aspirate the joint with a needle
• This promotes comfort and decreases joint
destruction.
• Occasionally, arthrotomy or arthroscopy is used to
drain the joint and remove dead tissue.
• Progressive range-of-motion exercises are prescribed
after the infection subsides

According to DACA
• Cloxacillin, IV, 2 g every 6 hr QID for 4-6 weeks

Musculo skeletal care modalities
• The management of musculoskeletal injuries and
disorders frequently includes:-
use of casts, braces, splints, traction, surgery, or a
combination of these.
Patient education is essential for optimal outcomes.
The nurse prepares the patient for immobilization
• Nursing care is planned
to maximize the effectiveness of these treatment
modalities and
to prevent potential complications associated with
each of the interventions.

Managing Care of the Patient in a Cast
• A cast is a rigid external immobilizing device
• It is molded to the contours of the body.
• The purposes of a cast are-
o To immobilize a body part in a specific position
and

Managing Care of the Pt in a Cast …
• A cast is used specifically;
To immobilize a reduced fracture
To correct a deformity
To apply uniform pressure to underlying soft tissue
or
To support and stabilize weakened joints.
• Casts permit mobilization of the patient while restricting
movement of a body part.

• The joints proximal and distal to the area to be immobilized
are included in the cast.
• But With some fractures, cast construction and molding
may allow movement of a joint while immobilizing a
fracture
• Various types of casts include the following:

• Short arm cast: Extends from below the elbow to the
palmar crease, secured around the base of the thumb.
• If the thumb is included, it is known as a thumb spica or
gauntlet cast.
• Long arm cast: Extends from the upper level of the
axillary fold to the proximal palmar crease.
• The elbow usually is immobilized at a right angle.

Upper extremity cast

• Short leg cast: Extends from below the knee to the base
of the toes.
• The foot is flexed at a right angle in a neutral position.
• Long leg cast: Extends from the junction of the upper
and middle third of the thigh to the base of the toes.
• The knee may be slightly flexed.
• Walking cast: A short or long leg cast reinforced for
strength.

LOWER EXTREMITY CAST

• Body cast: Encircles the trunk
• Shoulder spica cast: A body jacket that encloses the trunk
and the shoulder and elbow.
• Hip spica cast: Encloses the trunk and a lower extremity.
• A double hip spica cast includes both legs.

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

NURSING PROCESS THE PATIENT IN A
CAST
• Assessment
• Before the cast is applied assess the patient’s
– General health Presenting signs and symptoms
– Emotional status
– Condition of the body part to be immobilized
– Physical assessment of the part to be immobilized
– Neurovascular status of the body part
– Degree and location of swelling, bruising, and skin
abrasions.

NURSING DIAGNOSES
• Based on the assessment data, major nursing
diagnoses for the patient with a cast may include-
Deficient knowledge
Acute pain
Impaired physical mobility
Self-care deficit
Impaired skin integrity
Risk for peripheral neurovascular dysfunction

NURSING DIAGNOSES
• POTENTIAL COMPLICATIONS
• Based on the assessment data, potential complications
that may develop include the following:
Compartment syndrome
Pressure ulcer
Disuse syndrome

Planning and Goals
• The major goals for the patient with a cast
include
– Knowledge of the treatment regimen
– Relief of pain
– Improved physical mobility
– Achievement of maximum level of self-care
– Healing of lacerations and abrasions,
– Maintenance of adequate neurovascular function and
– Absence of complications

Nursing Interventions
Explaining the treatment regimen
The purpose and expectations of the prescribed
treatment regimen.
Describing the anticipated sights, sounds, and
sensations
What to expect during application and
The body part will be immobilized after casting

Nursing Interventions …
Relieving pain
Most pain can be relieved by
Elevating the involved part
Applying cold as prescribed and
Administering usual dosages of analgesics

IMPROVING MOBILITY
Every joint that is not immobilized should be
exercised and
Moved through its range of motion to maintain
function.
If the patient has a leg cast, encourage toe
exercises.
If the patient has an arm cast encourage finger
exercises.

Promoting healing of skin abrasions
Thoroughly clean the skin and treats it as
prescribed
Use sterile dressings to cover the injured skin.
– Observe the patient for
Systemic signs of infection
Odors from the cast and
Purulent drainage staining the cast

Maintaining adequate neurovascular function
Monitors circulation, motion and sensation of the
affected extremity
Early recognition of diminished circulation and
nerve function is essential to prevent loss of
function

Evaluation
a) Understands the therapeutic regimen
b) Reports less pain
c) Demonstrates increased mobility
d) Exhibits healing of abrasions and lacerations
e) Maintains adequate neurovascular function of affected
extremity
f) Exhibits absence of complications
g) Participates in self-care activities

Managing the Patient in Traction
Traction is the application of a pulling force to a part of
the body.
 It is used to minimize muscle spasms
 To reduce, align and immobilize fractures
 To reduce deformity and increase space b/n opposing
surfaces.
 Traction must be applied in the correct direction and
magnitude to obtain its therapeutic effects.

…
• Skin traction is used to control muscle spasms and
to immobilize an area before surgery.
• Skin traction is accomplished by using a weight to
pull on traction tape or on a foam boot attached to
the skin.
• The amount of weight applied must not exceed the
tolerance of the skin.
• No more than 2 to 3.5 kg (4.5 to 8 lb) of traction
can be used on an extremity.
• Pelvic traction is usually 4.5 to 9 kg (10 to 20 lb),
depending on the weight of the patient.

…
• Skeletal traction is applied directly to the
bone.
• This method of traction is used occasionally to
treat fractures of the femur, the tibia, and the
cervical spine.
• The traction is applied directly to the bone by
use of a metal pin or wire (eg, Steinmann pin,
Kirschner wire) that is inserted through the
bone distal to the fracture, avoiding nerves,
blood vessels, muscles, tendons, and joints.

…
• Skeletal traction frequently uses 7 to 12 kg (15 to 25 lb)
to achieve the therapeutic effect.
• The weights applied initially must overcome the
shortening spasms of the affected muscles.
• As the muscles relax, the traction weight is reduced to
prevent fracture dislocation and to promote healing.
• Often, skeletal traction is balanced traction, which
supports the affected extremity, allows for some patient
movement, and facilitates patient independence and
nursing care while maintaining effective traction.

Managing the Patient in Traction…
• At times, traction needs to be applied in more than one
direction to achieve the desired line of pull.
• When this is done, one of the lines of pull counteracts the
other
• These lines of pull are known as the vectors of force.
• The actual resultant pulling force is somewhere between the
two lines of pull.
• The effects of traction are evaluated with x-ray studies.

• PRINCIPLES OF EFFECTIVE TRACTION
• Always ensure that the weights hang freely and do not
touch the floor
• Never remove the weights
• Maintain proper body alignment
• Ensure that the pulleys and ropes are properly functioning
and fastened by tying square knot

• Observe and prevent foot drop
– Provide foot plate
• Observe for DVT, skin irritation and breakdown
• Provide pin care for clients in skeletal traction- use of
hydrogen peroxide

• Promote skin integrity
– Use special mattress if possible
– Provide frequent skin care
– Assess pin entrance and cleanse the pin with
hydrogen peroxide solution
– Turn and reposition within the limits of traction
– Use the trapeze

External fixators
• Are used to manage open fractures with soft tissue
damage.
• They provide stable support for severe comminuted
(crushed or splintered) fractures while permitting active
treatment of damaged soft tissues.
• Complicated fractures of the humerus, forearm, femur,
tibia, and pelvis are managed with external skeletal
fixators.
• The fracture is reduced, aligned, and immobilized by a
series of pins inserted in the bone.

NURSING MANAGEMENT
• Prepare the patient psychologically for application of
the external fixator.
• Reassurance that the discomfort associated with the
device is minimal and
• Early mobility is anticipated promotes acceptance of
the device

……
After the external fixator is applied, the extremity is
elevated to reduce swelling.
If there are sharp points on the fixator or pins, they are
covered with caps to prevent device-induced injuries.
The nurse monitors the neurovascular status of the
extremity every 2 to 4 hours and assesses each pin site for
redness, drainage, tenderness, pain, and loosening of the
pin.
Some serous drainage from the pin sites is to be expected.
•

……..
• The nurse must be alert for potential problems caused
by pressure from the device on the skin, nerves, or
blood vessels and for the development of compartment
syndrome .
• The nurse carries out pin care as prescribed to prevent
pin tract infection.
• This typically includes cleaning each pin site separately
one or two times a day with cotton-tipped applicators
soaked in chlorhexidine solution.

The end

Disorders of Musculoskeltal System Ppt (1).pptx

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