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Musculoskeletal System lecture 3.ppt
- 1. Musculoskeletal System Assessment & Disorders Dr Ibraheem Bashayreh, RN, PhD
- 2. Skeletal System Bone types Bone structure Bone function Bone growth and metabolism affected by calcium and phosphorous, calcitonin, vitamin D, parathyroid, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin.
- 3. Bones Human skeleton has 206 bones Provide structure and support for soft tissue Protect vital organs
- 4. Figure 41-1 Bones of the human skeleton.
- 5. Figure 41-2 Classification of bones by shape.
- 6. Bones Compact bone ◦ Smooth and dense ◦ Forms shaft of long bones and outside layer of other bones Spongy bone ◦ Contains spaces ◦ Spongy sections contain bone marrow
- 7. Bone Marrow Red bone marrow ◦ Found in flat bones of sternum, ribs, and ileum ◦ Produces blood cells and hemoglobin Yellow bone marrow ◦ Found in shaft of long bones ◦ Contains fat and connective tissue
- 8. Joints (Articulations) Area where two or more bones meet Holds skeleton together while allowing body to move
- 9. Joints Synarthrosis ◦ Immovable (e.g., skull) Amphiarthrosis ◦ Slightly movable (e.g., vertebral joints) Diarthrosis or synovial ◦ Freely movable (e.g., shoulders, hips)
- 10. Synovial Joints Found at all limb articulations Surface covered with cartilage Joint cavity covered with tough fibrous capsule Cavity lined with synovial membrane and filled with synovial fluid
- 11. Ligaments Bands of connective tissue that connect bone to bone Either limit or enhance movement Provide joint stability Enhance joint strength
- 12. Tendons Fibrous connective tissue bands that connect bone to muscles Enable bones to move when muscles contract
- 13. Muscles Skeletal (voluntary) ◦ Allows voluntary movement Smooth (involuntary) ◦ Muscle movement controlled by internal mechanism ◦ e.g., muscles in bladder wall and GI system Cardiac (involuntary) ◦ Found in heart
- 14. Skeletal Muscle 600 skeletal muscles Made up of thick bundles of parallel fibers Each muscle fiber made up of smaller structure myofibrils Myofibrils are strands of repeating units called sarcomeres
- 15. Skeletal Muscle Skeletal muscle contracts with the release of acetylcholine The more fibers that contract, the stronger the muscle contraction
- 16. Changes in Older Adult Musculoskeletal changes can be due to: ◦ Aging process ◦ Decreased activity ◦ Lifestyle factors
- 17. Changes in Older Adult Loss of bone mass in older women Joint and disk cartilage dehydrates causing loss of flexibility contributes to degenerative joint disease (osteoarthritis); joints stiffen, lose range of motion
- 18. Changes in Older Adult Cause stooped posture, changing center of gravity Elderly at greater risk for falls Endocrine changes cause skeletal muscle atrophy Muscle tone decreases
- 19. Assessment Health history Chief complaint Onset of problem Effect on ADLs Precipitating events, e.g., trauma
- 20. Assessment Examine complaints of pain for location, duration, radiation character (sharp dull), aggravating, or alleviating factors Inquire about fever, fatigue, weight changes, rash, or swelling
- 21. Physical Examination Posture Gait Ability to walk with or without assistive devices Ability to feed, toilet, and dress self Muscle mass and symmetry
- 25. Physical Examination Inspect and palpate bone, joints for visible deformities, tenderness or pain, swelling, warmth, and ROM Assess and compare corresponding joints Palpate joints knees and shoulder for crepitus
- 26. Physical Examination Never attempt to move a joint past normal ROM or past point where patient experiences pain Bulge sign and ballottement sign used to assess for fluid in the knee joint Thomas test performed when hip flexion contracture suspected
- 27. Figure 41-4 Checking for the bulge sign.
- 28. Figure 41-5 Checking for ballottement.
- 29. Diagnostic Tests Blood tests Arthrocentesis X-rays Bone density scan CT scan MRI Ultrasound Bone scan
- 30. Diagnostic Evaluation Imaging Procedures – CT, Bone Scan, MRI Nuclear Studies - radioisotope bone density, Endoscopic Studies –arthrocentesis, arthroscopy Other Studies –biopsy, synovial fluid, Arthrogram, venogram, Electromyography Myelography* Laboratory Studies
- 31. Musculoskeletal Assessment – Diagnostic Test Laboratory ◦ Urine Tests 24 hour creatine- creatinine ratio Urine Uric acid –24 hr specimen Urine deoxypyridino- line Laboratory ◦ Blood Tests Serum muscle enzymes Rheumatoid Factor LE Prep/Antinuclear Antibodies(ANA) Erythrocyte Sedimentation Rate Calcium, Phosphorous, Alkaline phosphatase
- 32. Muscoluloskeletal Assessment – Diagnostic Blood Tests ◦ CBC – Hgb, Hct ◦ Acid phosphatase ◦ Metabolic/Endocrine ◦ Enzymes Increase creatine kinase, serum increase glutamin-oxaloacetic due to muscle damage, aldolase, SGOT
- 33. Musculoskeletal - Radiographic Standard radiography, tomography and xeroradiography, myelography, arthrography and CT Other diagnostic tests: bone and muscle biopsy
- 34. Arthroscopy Fiberoptic tube is inserted into a joint for direct visualization. Client must be able to flex the knee; exercises are prescribed for ROM. Evaluate the neurovascular status of the affected limb frequently. Analgesics are prescribed. Monitor for complications.
- 36. Bone Scan Nuclear medicine procedure in which amount of radioactive isotope taken up by bones is evaluated Abnormal bone scans show hot spots due to malignancies or infection Cold spot uptakes show areas of bone that are ischemic
- 37. Arthroscopy Flexible fiberoptic endoscope used to view joint structures and tissues Used to identify: ◦ Torn tendon and ligaments ◦ Injured meniscus ◦ Inflammatory joint changes ◦ Damaged cartilage
- 38. Interventions for Clients with Musculoskeletal Trauma
- 39. Musculoskeletal Trauma Tissue is subjected to more force than it can absorb Severity depends on: ◦ Amount of force ◦ Location of impact
- 40. Musculoskeletal Trauma Mild to severe Soft tissue Fractures ◦ Affect function of muscle, tendons, and ligaments Complete amputation
- 41. Preventing Trauma Teach importance of using safety equipment ◦ Seat belts ◦ Bicycle helmets ◦ Football pads ◦ Proper footwear ◦ Protective eyewear ◦ Hard hats
- 42. Soft Tissue Trauma Contusion ◦ Bleeding into soft tissue ◦ Significant bleeding can cause a hematoma ◦ Swelling and discoloration (bruise)
- 43. Soft Tissue Trauma - Sprain Ligament injury (Excessive stretching of a ligament) Twisting motion 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
- 44. Sprains 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
- 45. Soft Tissue Trauma - Strain Microscopic tear in the muscle May cause bleeding “Pulled muscle” Inappropriate lifting or sudden acceleration-deceleration
- 46. Soft Tissue Trauma To decrease swelling and pain, and encourage rest ◦ Ice for first 48 hours ◦ Splint to support extremities and limit movement ◦ Compression dressing ◦ Elevation to increase venous return and decrease swelling ◦ NSAIDs
- 47. Soft Tissue Trauma Diagnosis ◦ X-ray to rule out fracture ◦ MRI
- 49. Fractures Break in the continuity of bone ◦ Direct blow ◦ Crushing force (compression) ◦ Sudden twisting motions (torsion) ◦ Severe muscle contraction ◦ Disease (pathologic fracture)
- 50. Fractures Classification of Fractures Closed or simple Open or compound Complete or incomplete Stable or unstable Direction of the fracture line ◦ Oblique ◦ Spiral ◦ Lengthwise plane (greenstick)
- 51. 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
- 52. Fractures – Emergency Care Immobilize before moving client Joint above and below Check pulse, color, movement, sensation before splinting Sterile dressing for open wounds
- 53. Fractures – Emergency Care Fracture reduction ◦ Closed—external manipulation ◦ Open—surgery
- 55. Acute Compartment Syndrome Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area Prevention of pressure buildup of blood or fluid accumulation Pathophysiologic changes sometimes referred to as ischemia- edema cycle
- 56. 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. (Continued)
- 57. Emergency Care (Continued) Fasciotomy may be performed to relieve pressure. Pack and dress the wound after fasciotomy.
- 58. 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)
- 59. Other Complications of Fractures Shock Fat embolism syndrome: serious complication resulting from a fracture; fat globules are released from yellow bone marrow into bloodstream Venous thromboembolism (Continued)
- 60. Other Complications of Fractures (Continued) Infection Ischemic necrosis Fracture blisters, delayed union, nonunion, and malunion
- 61. Musculoskeletal Complications (continued) Muscle Atrophy, loss of muscle strength range of motion, pressure ulcers, and other problems associated with immobility Embolism/Pneumonia/ARDS ◦ TREATMENT – hydration, albumin, corticosteroids Constipation/Anorexia UTI DVT
- 62. Musculoskeletal Assessment - Fracture Change in bone alignment Alteration in length of extremity Change in shape of bone Pain upon movement Decreased ROM Crepitation Ecchymotic skin (Continued)
- 63. Musculoskeletal Assessment – Fracture (Continued) Subcutaneous emphysema with bubbles under the skin Swelling at the fracture site
- 64. Special Assessment Considerations For fractures of the shoulder and upper arm, assess client in sitting or standing position. Support the affected arm to promote comfort. For distal areas of the arm, assess client in a supine position. For fracture of lower extremities and pelvis, client is in supine position.
- 65. CAST CAST
- 66. 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)
- 67. Casts (Continued) Cast care and client education Cast complications: infection, circulation impairment, peripheral nerve damage, complications of immobility
- 68. Managing Care of the Patient in a Cast Casting Materials Relieving Pain Improving Mobility Promoting Healing Neurovascular Function Potential Complications
- 69. Cast, Splint, Braces, and Traction Management Considerations Arm Casts Leg Casts Body or Spica Casts Splints and Braces External Fixator Traction
- 78. Musculoskeletal Nursing Care - Casts ◦ Neurovascular Check color/capillary refill Temperature Pulse Movement Sensation Traction Nursing Care ◦ Pin Site care ◦ Skin and neurovascular check
- 79. 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.
- 80. 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)
- 81. Traction (Continued) Traction care: ◦ Maintain correct balance between traction pull and counter traction force ◦ Care of weights ◦ Skin inspection ◦ Pin care ◦ Assessment of neurovascular status
- 84. Musculoskeletal – Fractures Treatment Primary Goal – reduce fracture- ◦ Realign and immobilize Medications ◦ Analgesics, antibiotics, tetanus toxoid Closed Reduction – Manual and Cast; External Fixation Device Traction; Splints; Braces Surgery ◦ Open reduction with internal fixation ◦ Reconstructive surgery ◦ Endoprosthetic replacement
- 86. Figure 42-5 In external fixation, pins placed through the bone above and below the fracture are attached to external fixation rods that hold the pins and bone in place.
- 88. Nursing Management Positioning Strengthening Exercises Potential Complications
- 89. Musculoskeletal Nursing Care Promote comfort Assess infection Promote mobility Teach safety Vital Signs Flotation, sheep skin Nutrition Vital Signs Monitor elimination Elevate extremity to decrease swelling/ ice pack Teach skin care, cast care, diet, complications
- 90. Operative Procedures Open reduction with internal fixation External fixation Postoperative care: similar to that for any surgery; certain complications specific to fractures and musculoskeletal surgery include fat embolism and venous thromboembolism
- 91. Managing the Patient Undergoing Orthopedic Surgery Joint Replacement Total Hip Replacement Total Knee Replacement
- 93. Risk for Infection Interventions include: ◦ Apply strict aseptic technique for dressing changes and wound irrigations. ◦ Assess for local inflammation ◦ Report purulent drainage immediately to health care provider. (Continued)
- 94. Risk for Infection (Continued) ◦ Assess for pneumonia and urinary tract infection. ◦ Administer broad-spectrum antibiotics prophylactically.
- 95. Imbalanced Nutrition: Less Than Body Requirements Interventions include: ◦ Diet high in protein, calories, and calcium, supplemental vitamins B and C ◦ Frequent small feedings and supplements of high-protein liquids ◦ Intake of foods high in iron
- 96. Upper Extremity Fractures Fractures include those of the: ◦ Clavicle ◦ Scapula ◦ Humerus ◦ Olecranon ◦ Radius and ulna ◦ Wrist and hand
- 97. Lower Extremity Fractures Fractures include those of the: ◦ Femur ◦ Patella ◦ Tibia and fibula ◦ Ankle and foot
- 99. Fractures of the Hip Intracapsular or extracapsular Treatment of choice: surgical repair, when possible, to allow the older client to get out of bed Open reduction with internal fixation Intramedullary rod, pins, a prosthesis, or a fixed sliding plate Prosthetic device
- 103. Fractures of the Pelvis Associated internal damage the chief concern in fracture management of pelvic fractures Non–weight-bearing fracture of the pelvis Weight-bearing fracture of the pelvis
- 104. Compression Fractures of the Spine Most are associated with osteoporosis rather than acute spinal injury. Multiple hairline fractures result when bone mass diminishes. (Continued)
- 105. Compression Fractures of the Spine (Continued) Nonsurgical management includes bedrest, analgesics, and physical therapy. Minimally invasive surgeries are vertebroplasty and kyphoplasty, in which bone cement is injected. (Continued)
- 106. Amputations Surgical amputation Traumatic amputation Levels of amputation Complications of amputations: hemorrhage, infection, phantom limb pain, problems associated with immobility, neuroma (a growth or tumour of nerve tissue), flexion contracture
- 107. Amputation Nursing Management ◦ relieving pain ◦ minimizing altered sensory perception ◦ promoting wound healing ◦ enhancing body image ◦ self-care
- 108. 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.
- 109. Management of Phantom Pain Phantom limb pain must be distinguished from stump pain because they are managed differently. Recognize that this pain is real and interferes with the amputee’s activities of daily living. (Continued)
- 110. Management of Phantom Pain (Continued) Some studies have shown that opioids are not as effective for phantom limb pain as they are for residual limb pain. Other drugs include intravenous infusion calcitonin, beta blockers, anticonvulsants, and antispasmodics.
- 111. Exercise After Amputation ROM to prevent flexion contractures, particularly of the hip and knee Trapeze and overhead frame Firm mattress Prone position every 3 to 4 hours Elevation of lower-leg residual limb controversial
- 114. Prostheses Devices to help shape and shrink the residual limb and help client readapt Wrapping of elastic bandages Individual fitting of the prosthesis; special care
- 115. Crush Syndrome Can occur when leg or arm injury includes multiple compartments Characterized by acute compartment syndrome, hypovolemia, hyperkalemia, rhabdomyolysis, and acute tubular necrosis Treatment: adequate intravenous fluids, low-dose dopamine, sodium bicarbonate, kayexalate, and hemodialysis
- 117. Osteoporosis A disease in which loss of bone exceeds rate of bone formation; usually increase in older women, white race, nulliparity. Clinical Manifestations – bone pain, decrease movement. Treatment – Calcium, Vit. D, estrogen replacement, Calcitonin, fluoride, estrogen with progestin, SERM (Selective Estrogen Receptor Modulator) with anti-estrogens, exercise. Pathologic fracture-safety.
- 118. Classification of Osteoporosis Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s. Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility. Regional osteoporosis occurs when a limb is immobilized.
- 119. Health Promotion/Illness Prevention - Osteoporosis Ensure adequate calcium intake. Avoid sedentary life style (a type of lifestyle with a lack of physical exercise) . Continue program of weight- bearing exercises.
- 120. Osteoporosis - Assessment Physical assessment Psychosocial assessment Laboratory assessment Radiographic assessment
- 124. Drug Therapy Osteoporosis Hormone replacement therapy Parathyroid hormone Calcium and vitamin D Bisphosphonates Selective estrogen receptor modulators Calcitonin Other agents used with varying results
- 125. Diet Therapy - Osteoporosis Protein Magnesium Vitamin K Trace minerals Calcium and vitamin D Avoid alcohol and caffeine
- 126. Fall Prevention - Osteoporosis Hazard-free environment High-risk assessment through programs such as Falling Star protocol Hip protectors that prevent hip fracture in case of a fall
- 127. Others - Osteoporosis Exercise Pain management Orthotic devices
- 128. Osteomalacia Softening of the bone tissue characterized by inadequate mineralization of osteoid Vitamin D deficiency, lack of sunlight exposure Similar, but not the same as osteoporosis Major treatment: vitamin D from exposure to sun and certain foods
- 129. Paget’s Disease of the Bone Metabolic disorder of bone remodeling, or turnover; increased resorption (the process by which osteoclasts break down bone and release the minerals, resulting in a transfer of calcium from bone fluid to the blood) of loss results in bone deposits that are weak, enlarged, and disorganized Nonsurgical management: calcitonin, selected bisphosphonates, mithramycin Surgical management: tibial osteotomy or partial or total joint replacement
- 130. Paget’s Disease An imbalance of increase osteoblast and osteoclast cells; thickening and hypertrophy. Bone pain most common symptom; bony enlargement and deformities usually bilateral, kyphosis, long bone. Analgesics, meds bisphosphonates and calcitonin, NSAID, assistance devices, and hot/cold treatment.
- 131. Osteomyelitis A condition caused by the invasion by one or more pathogenic microorganisms that stimulates the inflammatory response in bone tissue Exogenous, endogenous, hematogenous, contiguous
- 132. Osteomyelitis Infection of bone; causative agent – Staph/Strept Typical signs and symptoms : Acute osteomyelitis include: Fever that may be abrupt Irritability or lethargy in young children Pain in the area of the infection Swelling, warmth and redness over the area of the infection Chronic osteomyelitis include: Warmth, swelling and redness over the area of the infection Pain or tenderness in the affected area Chronic fatigue Drainage from an open wound near the area of the infection Fever, sometimes Treatment – IV antibiotic; long term for 4-6 months
- 133. Surgical Management Osteomyelitis Sequestrectomy (Surgical removal of a sequestrum), a detached piece of necrotic bone that often migrates to a wound, abscess, etc. Bone grafts Bone segment transfers Muscle flaps Amputation
- 134. Bone Tumors Benign Bone Tumors Malignant Bone Tumors Metastatic Bone Disease
- 135. Bone Tumors Benign bone tumors (noncancerous): ◦ Chrondrogenic tumors: osteochondroma, chondroma ◦ Osteogenic tumors: osteoid osteoma, osteoblastoma, giant cell tumor ◦ Fibrogenic tumors
- 136. Interventions Nondrug pain relief measures Drug therapy: analgesics, NSAIDs Surgical therapy: curettage (simple excision of the tumor tissue), joint replacement, or arthrodesis
- 137. Malignant Bone Tumors Primary tumors, those tumors that originate in the bone ◦ Osteosarcoma ◦ Ewing’s sarcoma ◦ Chondrosarcoma ◦ Fibrosarcoma ◦ Metastatic bone disease
- 138. Osteosarcoma Cancer of the bone – metastasis to the lung is common. Most in long bones. Clinical manifestations – dull pain, swelling, intermittent but increases per time; night pain common. Treatment – radiation, chemotherapy, hormonal therapy, surgical excision with prosthetics, assistance devices, palliative measures.
- 139. Treatment Cancer of Bone Interventions include: ◦ Treatment aimed at reducing the size or removing the tumor ◦ Drug therapy; chemotherapy ◦ Radiation therapy ◦ Surgical management ◦ Promotion of physical mobility with ROM exercises
- 140. Cancer of Bone Anticipatory Grieving Interventions include: ◦ Active listening ◦ Encouraging client and family to verbalize feelings ◦ Making appropriate referrals ◦ Helping client and others to cope with the loss and grieving ◦ Promoting the physician-client relationship
- 141. Cancer of Bone Disturbed Body Image Interventions include: ◦ Recognize and accept the client’s view of body image alteration. ◦ Establish and maintain a trusting nurse-client relationship. ◦ Emphasize the client’s strengths and remaining capabilities. ◦ Establish realistic mutual goals.
- 142. Potential for Fractures Bone Cancer Interventions ◦ Nonsurgical management: radiation therapy and strengthening exercises. ◦ Surgical management: replace as much of the defective bone as possible, avoid a second procedure, and return client to a functioning state with a minimum of hospitalization and immobilization.
- 143. Carpal Tunnel Syndrome Common condition; the median nerve in the wrist becomes compressed, causing pain and numbness Common repetitive strain injury via occupational or sports motions Nonsurgical management: drug therapy and immobilization Possible surgical management
- 144. Scoliosis Abnormal spinal curvature of various degrees or severity involving shortening of muscles and ligaments. Milwaukee brace (a back brace used in the treatment of spinal curvatures) , internal fixative devices.
- 145. Scoliosis Changes in muscles and ligaments on the concave side of the spinal column Congenital, neuromuscular, or idiopathic in type Assessment: complete history, pain assessment, observation of posture Interventions: exercise, weight reduction, bracing, casting, surgery