Musculoskeletal nursing

Mulugeta Emiru
(MSc in Adult Health Nursing)
Mizan-Tepi University,Ethiopia
2017

MUSCULOSKELETAL SYSTEM
Consists of the bones, muscles, ligaments, tendons,
and cartilage together with the joints.
Human skeleton has 206 bones
Bone growth and metabolism is affected by vit D,
calcium and phosphorous, calcitonin, growth
hormone, estrogens, testosterone, parathyroid, and
glucocorticoids.

Figure 41-1 Bones of the human skeleton.
Axial Skeleton
Appendicular Skeleton

Figure 41-2 Classification of bones by shape.

Functions
1. Supports soft tissue and provides attachment for
skeletal muscles
2. Assists in mov’t, along with skeletal muscles
3. Protects internal organs
4. Stores and releases minerals
5. stores fats
6. produces blood cells

Bone Cells
 The three types of bone cells are
Osteoblasts –bone forming cells by secreting bone matrix.
Osteocytes –bone maintaining cells, matured osteoblasts.
Osteoclasts –bone resorbing cells
 Bones that are in use, and are therefore subjected to stress,
increase their osteoblastic activity to increase ossiﬁcation.
 Bones that are inactive undergo increased osteoclast activity
and bone resorption.

Tendons
 connect bone to muscles, and aids movement when muscles
contract.
Ligaments
 connect bone to bone
 Provide joint stability and strength
Joints (Articulations)
 Area where two or more bones meet
 Holds skeleton together while allowing body to move

Types of joints
 Fibrous - Immovable
 Cartilaginous - Slightly movable
 Synovial - Freely mobile
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.

Bursa
A small sac filled with synovial fluid.
Inflammation of these sacs is called bursitis

Nursing Assessment
Health History
Assessment Data
Pain,
Tenderness,
Tightness, and
Altered sensations

 Posture
 Gait
 Bone Integrity
 Joint Function
 Muscle Strength & Size
 Skin
 Neurovascular Status
Physical Assessment

 Inspect and palpate bone and joints for visible deformities,
tenderness or pain, swelling, warmth, and ROM
 Assess and compare corresponding joints
 Palpate each joint for any crepitus
 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.

1. Arthrocentesis: A needle is inserted through the joint
capsule and fluid is aspirated.
Diagnostic: done to obtain synovial fluid
Therapeutic: to remove excess fluid.
2. Arthroscopy: is the internal inspection of a joint using an
instrument called an arthroscope. Arthroscope is a thin
fiber-optic viewing instrument that is inserted into the joint
through a small incision in the knee.
Diagnostic Tests

Nsg mgt. After the procedure,
 Leg is elevated without flexing the knee.
 A cold pack is placed over the bulky dressing covering the site
where the arthroscope was inserted.
 Administer analgesic as necessary.
3. Dual energy x-ray absorptiometry (DEXA)- bone density
examinations are done to evaluate bone mineral density
(BMD) and to evaluate degree of osteoporosis.

4. SKELETAL X-RAY, CT and MRI: help to identify traumatic
disorders, such as fractures and dislocations, and other bone
disorders, such as malignant bone lesions, joint deformities,
calcification, degenerative changes, osteoporosis, and joint
disease.
5. Bone Scan
 Uses the intravenous injection of a radionuclide to detect the
uptake of the radioactive substance by the bone.
 The radionuclide is taken up in areas of increased
metabolism, which occur in osteosarcoma, metastatic bone
disease, and osteomyelitis (bone infection).

 CBC- to detect infection, inflammation, or anemia.
 Alkaline phosphatase (ALP)- to identify bone diseases.
Increased in bone cancer, Paget’s disease, healing fractures,
rheumatoid arthritis, osteomalacia.
 Calcium (Ca): Decreased with lack of Ca++ and vit D intake,
and malabsorption from the GIT which leads to softening of
the bones (osteomalacia) and resulting pain and weakness.
 Increased in bone cancer and multiple fractures.
BLOOD TESTS

 RHEUMATOID FACTOR (RF) To diagnose rheumatoid
arthritis (RA) (positive for RA)
 URIC ACID To diagnose and monitor the treatment of gout.
 Panic level considered > 12 mg/dl.

 Regardless of the type of diagnostic test, the nurse is
responsible for:
o explaining the procedure and any special preparation
needed,
o assessing for medication use that may affect the outcome
of the tests,
o supporting the patient during the examination as
necessary,
o documenting the procedures as appropriate,
o ensuring the consent form is signed (if required) and
o Monitoring the results of the tests.

The management of musculoskeletal injuries and disorders
frequently includes the use of
Casts
Braces
Splints
 Traction,
 Surgery, or a combination
of these.
Cast
 Is a rigid external immobilizing device that is molded to the
contours of the body.
 It permit mobilization of the patient while restricting movement of a
body part.

 Uses
To immobilize a body part in a specific position
To immobilize a reduced fracture
To apply uniform pressure on encased soft tissue
To correct a deformity
To support and stabilize weakened joints
 Generally, the joints proximal and distal to the area to be
immobilized are included in the cast.

Types of Casts
 Short arm cast: Extends from below the elbow to the palmar
crease and is secured around the base of the thumb.
 Long arm cast: Extends from the upper level of the axillary
fold to the proximal palmar crease. The elbow is usually
immobilized at a right angle.
 Short leg cast: Extends from below the knee to the base of
the toes.
 Long leg cast: Extends from the junction of the upper and
middle third of the thigh to the base of the toes.

Others
 Body cast, Shoulder Spica cast, Hip spica cast

 Nursing Management
- Carry cast with palms of the hands when WET
- Elevate with pillow support
- Should be exposed to circulating air to dry
- Keep clean and dry
- Maintain skin integrity, observe for signs of inflammation
- Neurovascular assessment meticulously and regularly
- Move patient every 2 hours to relieve pressure
- In turning, use of trapeze or railings can be helpful

Potential complications of cast and their mg’t
Compartment Syndrome
 Occurs when there is increased tissue pressure within a limited space
that compromises the circulation and the function of the tissue within the
confined area.
 The patient complains of deep, throbbing, unrelenting pain, which
continues to increase despite the administration of opioids and seems
out of proportion to the injury.
 The lower leg is most frequently involved, but forearm is also at risk.
 Pain is the hallmark sign that occurs or intensifies with passive ROM.

 Pain can be caused by :
1. a reduction in the size of the muscle compartment because
the enclosing muscle fascia is too tight or a cast or dressing
is constrictive.
2. an increase in compartment contents because of edema or
hemorrhage from the fracture site.
Within 4 to 6 hr. after the onset of acute compartment
syndrome, neuromuscular damage is irreversible; the limb
can become useless.

Injury to the peroneal nerve as a result of pressure is a
cause of foot drop (the inability to maintain the foot in a
normally flexed position). Consequently, the patient drags
the foot when ambulating.

Management: To relieve the pressure, the cast must be bivalved while
maintaining alignment, and the extremity must be elevated no higher
than heart level.
 If pressure is not relieved and circulation is not restored, fasciotomy
may be necessary.
 The nurse records neurovascular responses and promptly reports
changes to the physician.

Pressure Ulcers
 Pressure of the cast on soft tissues may cause tissue anoxia and
ulcers.
 pain and tightness
 Warm area on the cast
 Drainage stain the cast and emit
an odor
Symptoms

Management: To inspect the pressure area, the physician may bivalve
the cast or cut an opening (window) in the cast.
• If the physician elects to create a window to inspect the pressure
site, a portion of the cast is cut out.
• The portion of the cast is replaced and held in place by an elastic
compression dressing or tape.
• This prevents the underlying tissue from swelling through the
window and creating pressure areas around its margins.

Disuse Syndrome
 Immobilization in a cast or splint can cause muscle atrophy and loss
of strength
 While in a cast, the patient needs to learn to tense or contract
muscles (e.g., isometric muscle contraction) without moving the part.
 This helps to reduce muscle atrophy and maintain muscle strength.
 After removal of a cast, the formerly immobilized body part is
weak from disuse, is stiff, and may appear atrophied.

 Support is needed when the cast is removed.
 The skin needs to be washed gently and lubricated with an
emollient lotion.
 The nurse and physical therapist teach the patient to resume
activities gradually within the prescribed therapeutic regimen.
 Exercises prescribed to help the patient regain joint motion are
explained and demonstrated.

Traction
 Traction is the application of a pulling force to part of the body.
Traction is used:
o to minimize muscle spasms;
o to reduce, align, and immobilize fractures;
o to reduce deformity; and
o to increase space between opposing surfaces.
 For traction to achieve its purpose, it requires counter traction, a
force opposite to the mechanical pull usually is supplied by the
client’s own weight.

Types of traction
 Straight or running traction: applies the pulling force in a straight
line with the body part resting on the bed.
 Balanced suspension traction: supports the affected extremity off
the bed and allows for some patient movement without disruption
of the line of pull. Lines of pull are known as the vectors of force.

 Skin traction: Is an indirect traction which is applied on the
skin.
Used to control muscle spasms and to immobilize an
area before surgery.
is not used for long period of time
 Amount of weight applied must not exceed 2 to 3.5
kg for extremities.
Nursing Interventions
 Monitor and manage potential complications
Skin Breakdown
Nerve Damage
Circulatory Impairment

Skeletal Traction
 Applied directly to the bone by use of a metal pin or wire that is inserted
through the bone distal to the fracture.
 Used occasionally to treat fractures of the femur, the tibia, and the
cervical spine.
 Used for long period of time and used to apply high weight.
 Skeletal traction frequently uses 7 to 12 kg to achieve the therapeutic
effect (usually 10% the patient’s body weight).
 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.
 Manual traction: traction temporarily applied with the hands.

 Maintaining effective traction
 Preventing skin breakdown
 Monitoring neurovascular status
 Providing pin site care
 Promoting exercise
 Monitor and manage immobility-related complications
pressure ulcers, atelectasis, pneumonia, constipation, loss
of appetite, urinary stasis, urinary tract infections, and
venous thromboembolism formation.

Management of patients
with
Musculoskeletal Trauma

1. Contusions, Strains, and Sprains
 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).
 A hematoma develops when the bleeding is sufficient to
cause an appreciable collection of blood.
 Local symptoms includes pain, swelling, and discoloration
 Most contusions resolve in 1 to 2 weeks.
Contusions

Strains
 Is a “muscle pull” caused by overuse, overstretching, or
excessive stress.
 Strains are microscopic, incomplete muscle tears with some
bleeding into the tissue.
 The patient experiences soreness or sudden pain, with local
tenderness on muscle use.

Sprains
 Is an injury to the ligaments surrounding a joint that is caused
by a wrenching or twisting motion.
 The function of a ligament is to maintain stability while
permitting mobility. A torn ligament loses its stabilizing ability.
 Blood vessels rupture and edema occurs; the joint is tender,
and movement of the joint becomes painful.

 The degree of disability and pain increases during the
first 2 to 3 hours after the injury because of the
associated swelling and bleeding.
 An x-ray should be obtained to rule out bone injury.
 Avulsion fracture (in which a bone fragmented is pulled
away by a ligament or tendon) may be associated with a
sprain.

Management
 Treatment of contusions, strains, and sprains includes RICE
 Rest prevents additional injury and promote healing.
 Ice applied intermittently for 20 to 30 minutes during the first
24 to 48 hours after injury produces vasoconstriction, which
decreases bleeding, edema, and discomfort.
 Care must be taken to avoid skin and tissue damage from
excessive cold.
 After 24 to 48 hours of injury heat may be applied
intermittently (for 15 to 30 minutes, QID) to relieve muscle
spasm, promote vasodilation, absorption, and repair.

 An elastic compression bandage controls bleeding,
reduces edema, and provides support for the injured
tissues.
 Elevation controls the swelling.
 If the sprain is severe (torn muscle fibers and disrupted
ligaments), surgical repair or cast immobilization may be
necessary so that the joint will not lose its stability.
 The neurovascular status (circulation, motion, sensation)
of the injured extremity is monitored frequently.

2. Joint Dislocations
 A dislocation of a joint 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.
 Dislocations may be congenital, spontaneous or
pathologic or traumatic.

 Traumatic dislocations are orthopedic emergencies
because the associated joint structures, blood supply, and
nerves are distorted and severely stressed.
 If the dislocation is not treated promptly, avascular
necrosis (AVN) (tissue death due to anoxia and
diminished blood supply) and nerve palsy may occur.

 Signs and symptoms of dislocation are:
o acute pain,
o change in positioning of the joint,
o Shortening of the extremity,
o loss of normal mobility, and
o deformity
 X-rays confirm the diagnosis and demonstrate any
associated fracture.

Medical Management
 The affected joint needs to be immobilized while the patient
is transported to the hospital.
 Analgesia, muscle relaxants, and possibly anesthesia are
used to facilitate closed reduction.
 The dislocation is promptly reduced (i.e. displaced parts are
brought into normal position) to preserve joint function.
 The joint is immobilized by bandages, splints, casts, or
traction 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 to preserve range of
motion (ROM) and restore strength.
 The joint is supported between exercise sessions.
Nursing Management
 Providing comfort,
 Evaluating the patient’s neurovascular status, and
 Teaching the patient how to manage the immobilizing
devices and how to protect the joint from reinjury.

3. Fractures
Is a break in the continuity of bone when it is
subjected to stress greater than it can absorb.
causes
• A metabolic bone disease /pathological such as osteoporosis
• An endocrine disorder E.g. Hyperparathyroidism
• Direct force/ trauma or crushing force
• Sudden twisting motion
• Powerful muscle contraction pulls against the bone
• Bone tumors, which weaken the bone structure

 When the bone is broken, adjacent structures are also
affected,
 Resulting in soft tissue edema, hemorrhage into the
muscles and joints, joint dislocations, ruptured
tendons, severed nerves, and damaged blood vessels.

Types of Fractures
 Based on cross-section of the bone involved:
1. Complete fracture: involves a break across the entire
cross-section of the bone and is frequently displaced
(removed from normal position).
2. Incomplete fracture (eg, greenstick fracture): the break
occurs through only part of the cross-section of the bone.
3. Comminuted fracture: is one that produces several bone
fragments.

 Based on involvement of the skin:
1. Closed (simple fracture): does not cause a break in the skin.
2. Open (compound, or complex, fracture): the skin or mucous
membrane wound extends to the fractured bone.
Open fractures are graded according to the following criteria:
A. Grade I: is a clean wound less than 1 cm long.
B. Grade II: is a larger wound without extensive soft tissue
damage.
C. Grade III: is highly contaminated, has extensive soft tissue
damage, and is the most severe.

Clinical Manifestations
 Pain
 loss of function
 Deformity
 shortening of the extremity
 crepitus (a grating sensation palpation)
 swelling and discoloration.
 False movement
 Note: all of these clinical manifestations may not present in
every fracture.

Emergency Management of Fractures
 Immediately after injury, whenever a fracture is suspected,
immobilize the body part before the patient is moved.
 Splints are applied for immobilization.
 If an injured patient must be removed from a vehicle before
splints can be applied, the extremity is supported above and
below the fracture site to prevent rotation as well as angular
motion.
 With an open fracture, the wound is covered with a clean
(sterile) dressing to prevent contamination of deeper tissues.
 Do not attempt to reduce the fracture, even if one of the
bone fragments is protruding through the wound.

Medical and surgical Management
1. REDUCTION
 Reduction refers to restoration of the fracture fragments to
anatomic alignment and rotation.
1. Closed Reduction: closed reduction is accomplished by
bringing the bone fragments into apposition (ie, placing the
ends in contact) through manipulation and manual traction.
2. Open Reduction: Through a surgical approach, the
fragments are reduced. Internal fixation devices (metallic
pins, wires, screws, plates, nails, or rods) may be used to
hold the bone fragments in position.

2. IMMOBILIZATION
After the fracture has been reduced, the bone fragments
must be immobilized, or held in correct position and
alignment, until union occurs.
Immobilization may be accomplished by external or
internal fixation.

3. MAINTAINING AND RESTORING FUNCTION
 Swelling is controlled by elevating the injured extremity and
applying ice as prescribed.
 Neurovascular status (circulation, movement, sensation) is
monitored, and the orthopedic surgeon is notified immediately
if signs of neurovascular compromise are identified.
 Isometric and muscle-setting exercises are encouraged to
minimize disuse atrophy and to promote circulation.

Nursing Management
 Instruct the patient regarding the proper methods to control
edema and pain
 Teach exercises to maintain the health of unaffected muscles
and how to use assistive devices such as crutches, walkers.
 Teach about selfcare, medication information, and
monitoring for potential complications.
 In an open fracture, there is a risk for osteomyelitis, tetanus,
and gas gangrene. Intravenous antibiotics are administered
immediately upon the patient’s arrival in the hospital along
with tetanus toxoid if needed.

Complications of Fracture
 Complications of fractures fall into two categories
 Early complications include:
Shock,
Fat embolism,
Compartment syndrome,
Deep vein thrombosis,
Thromboembolism (pulmonary embolism),
Disseminated intravascular coagulopathy (DIC), and
Infection.

Delayed complications include:
Delayed union and nonunion,
Avascular necrosis of bone,
Reaction to internal fixation devices,
Complex regional pain syndrome (formerly
called reflex sympathetic dystrophy).

Stages of Bone Healing
 Hematoma formation within 48 to 72 hr. after injury
 Hematoma to granulation tissue
 Callus formation and Osteoblastic proliferation
 Bone remodeling
 Bone healing completed within about 6 weeks; up
to 6 months in the older person

Amputation
 Amputation- is the removal of a body part, usually an extremity.
Indications
 progressive peripheral vascular disease. E.g.DM
 fulminating gas gangrene
 Trauma / accident- (crushing injuries, burns, frostbite, explosions,
ballistic injuries)
 Congenital deformity
 malignant tumor
 Chronic uncontrollable infections - chronic osteomyelitis , osteoarthritis
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 Types of amputation
open (guillotine)
closed (flap amputation)
open amputation
 It is a type of amputation performed during emergency
condition like gas gangrene or sever trauma.
 The skin and the bones are at equal level.
 The main purpose is to save the remaining part and
extremity & reserve an emergency situation.
pic

Closed amputation
 It is a planned type .
 The skin and the bone are not at equal level.
 Skin closure is done surgically.
 Antibiotics is administered to prevent re infection
levels of amputation
Amputation is performed at the most distal point that will heal
successfully. If it is done at a joint it is called disarticulation.
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pic

 The site of amputation is determined by two factors
1. Circulation in the part
2. Functional usefulness (muscle balance to meet the
requirement of the prosthesis)

Complications
 Hemorrhage
 Infection
 Skin breakdown - irritation due to prosthesis
 Stump edema- edema of amputated limb
 Phantom limb pain –it is false sensation, pain that seems
to come from an amputated limb as a result of severing
of the peripheral nerves
 Joint contracture – caused by positioning & protective
flexion withdrawal pattern associated with pain.
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Medical Management
 The objectives of treatment:
• to achieve healing of the amputation wound
• to get a non tender residual limb (stump) with healthy
skin for prosthesis use
 Healing is enhanced by:
• gentle handling of the residual limb,
• control of residual limb edema through rigid or soft
compression dressings
• the use of aseptic technique in wound care to avoid
infection.
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 A closed rigid cast dressing is frequently used:
-to provide uniform compression
-to support soft tissues
-to control pain
-to prevent joint contractures
 Immediately after surgery, a sterilized residual limb sock is
applied to the residual limb.
 Felt pads are placed over pressure-sensitive areas.
 The residual limb is wrapped with elastic POP bandages while
ﬁrm, even pressure is maintained.
 Care is taken not to constrict circulation.
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 A removable rigid dressing may be placed over a soft
dressing:
-to control edema
-to prevent joint ﬂexion contracture
-to protect the residual limb from unintentional
trauma during transfer activities.
 This rigid dressing is removed several days after surgery
for wound inspection and is then replaced to control
edema.
 The dressing facilitates residual limb shaping.
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 A soft dressing with or without compression may be used
if there is:
-signiﬁcant wound drainage
-desire of frequent inspection of the limb
 An immobilizing splint may be incorporated in the
dressing.
 Stump (wound) hematomas are controlled with wound
drainage devices to minimize infection.
 Rehabilitation- help the pt to achieve the highest
possible level of function & participation in ADLs.
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Nursing Management
relieving pain
minimizing altered sensory perception
promoting wound healing
enhancing body image
self-care

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.

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.
 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.

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

Metabolic Disorders
 Is a metabolic bone disorder characterized by loss of bone
mass, and an increased risk of fractures.
Pathophysiology
• The reduced bone mass is caused by an imbalance of bone
resorption and bone formation.
• The total bone mass and density is reduced, resulting in
bones that become progressively porous, brittle, and fragile.
1. Osteoporosis “porous bones”

 Although osteoporosis may result from an endocrine disorder
or malignancy, it is most often associated with aging.
 With aging level of calcitonin and estrogen decreases but
levels of parathyroid hormone increases.
 Estrogen deficiency, which occurs at menopause, is
considered the leading factor in osteoporosis among aging
women.
 Osteoporosis can be primary or secondary.

 Primary osteoporosis occurs in women after menopause and
in men due to failure to develop optimal peak bone mass
during childhood, adolescence, and young adulthood.
 Secondary osteoporosis is the result of medications and
diseases that affect bone metabolism.
Prolonged use of medications that increase calcium
excretion, such as aluminum-containing antacids and
anticonvulsants, increase the risk of developing
osteoporosis.
Corticosteroids

Assessment Findings
 loss of height
 progressive curvature of the spine(dorsal kyphosis and cervical
lordosis) / “dowager’s hump”.
 low back pain, and fractures of the forearm, spine, or hip.
 Radiographic examinations; X-ray and DEXA show bone loss,
deformities and pathologic fractures in long bones.

Medical Management
Oral calcium preparations with vit D
Bisphosphonates- alendronate
Calcitonin
Hormone replacement therapy (HRT)
A diet rich in calcium and vitamin D
Bone pain or tenderness may respond to mild
analgesics such as aspirin.
Moderate weight bearing exercises
1st line

• Provide adequate dietary supplement of calcium and vit D
• Teach patients who are able to participate in weight-
bearing exercises to perform exercises at least three times
a week for a sustained period of 30 to 40 minutes.
• Manage constipating side-effect of calcium supplements
• Relieve the pain
• Prevent injury

2. OSTEOMALACIA
 Often referred to as adult rickets, is characterized by
inadequate or delayed mineralization of bone matrix,
resulting in softening of bones.
 Marked deformities of weight bearing bone and pathologic
fractures occur.
 The two main causes of osteomalacia are
• Insufficient calcium absorption in the intestine due to a
lack of calcium intake or vitamin D deficiency,
• Increased losses of phosphorus through the urine

 Bone volume unchanged, but the replaced bone consists of
soft osteoid instead of rigid bone.
Manifestations
 Weakness, bone pain, and tenderness
 kyphosis and bowing of the legs
 Waddling type of gait, putting them at risk for falls and
fractures

Diagnostic Findings
 x-ray- generalized demineralization
 low serum calcium and phosphorus
 elevated alkaline phosphatase
 Bone biopsy demonstrates an increased amount of osteoid
Medical Management
 supplements of calcium, phosphorus, with vitamin D;
adequate nutrition; exposure to sunlight; and progressive
exercise and ambulation.

3. Paget’s Disease
 An imbalance of increased osteoblast and osteoclast cells;
thickening and hypertrophy.
 Results in bone deposits that are weak, enlarged, and
disorganized
 Bone pain most common symptom; bony enlargement and
deformities of long bone usually bilateral, kyphosis,.

Rx- Analgesics, bisphosphonates and
calcitonin, assistive devices, and
hot/cold treatment.

Musculoskeletal Infections
1. OSTEOMYELITIS
 Is an infection of the bone.
 Staph. aureus is the most common infecting organism.
 Classified as:
Hematogenous osteomyelitis
Contiguous-focus osteomyelitis, from contamination from
bone surgery, open fracture, or traumatic injury (eg,
gunshot wound)
Osteomyelitis with vascular insufficiency eg. DM and
peripheral vascular disease

 After entry, bacteria lodge and multiply in the bone, resulting
in the inflammatory and immune system response.
 If the infection reaches the outer margin of the bone, it raises
the periosteum of the bone, spreading along the surface.
 Lifting of the periosteum from the cortex disrupts the blood
vessels that enter the bone, compromising the vascular
supply and leading to ischemia and eventual necrosis of the
bone.
 New bone cells are deposited on the periosteum while the
underlying bone becomes necrotic.

 The pocket of necrotic bone (sequestrum) may remain
sequestered for years or eventually drain by forming a sinus
tract through to the skin; which leads to chronic osteomyelitis.
 complications of osteomyelitis include:
o Septicemia
o Thrombophlebitis
o muscle contractures
o pathologic fractures and
o nonunion of fractures

Assessment Findings
 Acute infection: high fever, chills, rapid pulse, tenderness or
pain over the affected area, redness, and swelling.
 Chronic infection:
persistent draining sinus.
elevated leukocyte count, an elevated ESR, +ve blood culture
Radiographic findings: irregular bone decalcification, bone
necrosis, elevation of the periosteum, and new bone formation.
Bone scans and MRI are useful in definitive diagnoses.
PIC

Medical and Surgical Management
 Immobilization to decrease pain and prevent fracture.
 Apply warm saline soaks to increase circulation
 Intravenous (IV) antibiotic therapy is administered for 3 to 6
weeks. Oral antibiotics then follow for as long as 3 months.
 Surgical debridement of the necrotic tissue and sequestrum
to remove the infected areas.

Nursing management
 Protecting the skin from breakdown,
 administering the prescribed antibiotics and pain
medications,
 informing the client about the expected therapeutic effects
and possible side effects.
 Clients with chronic osteomyelitis require extensive
emotional support, related to the long-term nature of this
illness.

2. SEPTIC (INFECTIOUS) ARTHRITIS
 Joints can be infected through hematogenous spread or
directly through trauma or surgical instrumentation.
 Infection of the joint leads to synovitis, joint effusion and
abscesses formation; can lead to destruction of the affected
joint.
 A single joint, often the knee, is usually affected.
Manifestations
 Abrupt onset, warm, painful, swollen joint with decreased ROM.
 chills, fever, and leukocytosis

Risk factors
advanced age, impaired immunity, diabetes,
rheumatoid arthritis, and preexisting joint disease or
joint replacement.
Assessment and Diagnostic Findings
Diagnostic studies include aspiration, examination, and
culture of the synovial fluid.
Computed tomography (CT) and MRI

Medical Management
 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 resolve.
 The synovial fluid is aspirated and analyzed periodically
for sterility and decrease in WBCs.
 Arthrotomy or arthroscopy is used to drain the joint and
remove dead tissue.

Nursing Care
 Monitor the patient’s response to therapy, including
systemic manifestations such as fever.
 Position the affected joint appropriately, using pillows to
elevate it as needed.
 Immobilize the joint using splints or traction .
 Warm compresses may be ordered for comfort.
 Active ROM exercises preserve joint mobility and should
be initiated as soon as the physician allows.

Joint and connective tissue diseases
1. OSTEOARTHRITIS (OA)
 Degenerative Joint Disease (DJD)
 the most common form of arthritis.
 degeneration and wearing away of the articular cartilage 
exposing bone
 Typically affects the weight-bearing joints and those that are
repeatedly used for work.
 Unlike RA, DJD has no remissions and no systemic
symptoms, such as malaise and fever.

 Risk factors include increasing age, previous joint injury,
obesity, congenital and developmental disorders, hereditary
factors, and decreased bone density.
 Classified as:
o Primary, when the etiology is unknown, or
o Secondary, when OA has an underlying cause such as
injury or a congenital disorder

 The degenerative process begins when the cartilage that
covers the bone ends becomes thin, rough, and ragged.
 The cartilage no longer springs back into shape after normal
use.
 As the cartilage wears away, the joint space decreases, so
that the bone surfaces are closer and rub together.
 In an attempt to repair the damaged surface, new bone
develops in the form of bone spurs, bone cysts, or
osteophytes, which are extended margins of the joints.
 The joint becomes deformed, and the client experiences
pain and limited joint movement.

 Often affects only one large weight-bearing joint, such as hip,
spine, or knee
 Joint pain occurs often after exercise or weight bearing
 Pain often relieved by rest
 morning stiffness, aches during weather changes
 Functional impairment results from pain on movement and
limited motion caused by structural changes in the joints.
 X-ray films demonstrate disruption of the joint cartilage and
bony changes.

Medical and Surgical Management
 Non-pharmacological
 local rest of the affected joints, heat applied to the painful part,
weight loss
 Splints, braces, canes, or crutches may reduce discomfort,
relieve pain, and prevent further destruction of the affected
joints.
 Large doses of acetaminophen
 Aspirin and NSAIDs
 Corticosteroids may be injected into inflamed joints

2. Rheumatoid arthritis
 Systemic autoimmune inflammatory disorder of connective
tissue / joints characterized by chronicity, remissions, and
exacerbations.
 Female-to-male ratio is 2-4:1
 Its cause is unknown
 Particularly affect small joints of the hands and feet,
 can also affect large joints
 Chronic inflammation begins in the synovial membrane

 Approximately 70% to 80% of people with RA have a
substance called rheumatoid factor (RF), an antibody that
reacts with a fragment of immunoglobulin G (IgG).
 This self-produced (autologous) antibody forms immune
complexes (IgG/RF).
 PMN leukocytes, monocytes, and lymphocytes are attracted
to the area and cause phagocytosis of the immune
complexes.
 lysosomal enzymes are released and enzymes break down
collagen, causing edema, proliferation of the synovial
membrane, and ultimately pannus formation.

 Pannus destroys cartilage and erodes the bone.
 loss of articular surfaces and joint motion.
Signs and Symptoms
 onset of symptoms is acute.
 Joint involvement usually is bilateral and symmetric.
 Localized symptoms include joint pain, swelling, and
warmth; erythema, stiffness in the morning;
 Spongy tissue on joint palpation, and fluid on joints.
 Swelling and pain comes and goes

 Deformities of the hands and feet are common in RA
 Non-tender and movable nodules may be noted in 25% of
patients with more advanced RA.
 Swan neck deformity—Hyperextension of the proximal
interphalangeal joint with fixed flexion of the distal
interphalangeal joint.
 Ulnar deviation—Fingers deviating laterally toward the
ulna.

Diagnostic Findings
 Radiographic films
 Arthrocentesis- synovial fluid usually appears cloudy, milky,
or dark yellow, and contains many inflammatory cells
 Arthroscopy- to visualize the extent of joint damage
 Positive RF

Medical management
 Drug therapy is not curative but helps relieve pain
 NSAIDs, Steroids, Immunosuppressant- methotrexate
 surgery to repair or replace joints or remove tissues
interfering with movement
 Local applications of heat and cold
 gait training

3. GOUT
 A genetic defect of purine metabolism resulting in
hyperuricemia, usually affects the feet (especially the
great toe), hands, elbows, ankles, and knees.
 Over secretion of uric acid or a renal defect resulting in
decreased excretion of uric acid, or a combination of both,
occurs.
 It occurs more commonly in males than females

 Attacks of gout appear to be related to sudden increases or
decreases of serum uric acid levels.
 When the urate crystals precipitate within a joint, an
inflammatory response occurs and an attack of gout begins.
 Collections of urate crystals, called tophi, are found in the
cartilage of the outer ear (pinna), the great toe.
 As these deposits accumulate, they destroy the joint,
producing a chronically swollen, deformed appearance.
 The uric acid also may precipitate in urine, causing renal
stones.

 sudden onset of acute pain and tenderness in one joint.
 skin turns red and the joint swells, warm and hypersensitive
to touch
 The attack may last for 1 or 2 weeks
 Repeated episodes in the same joint may deform the joint
Diagnostic Findings
 Hyperuricemia
 arthrocentesis - urate crystals

 The aim of treatment is to decrease sodium urate in the
ECF so that deposits do not form.
 NSAIDs, such as ibuprofen and indomethacin
 Acute attacks of gout also may be treated with colchicine
 Other drugs used include probenced and allopurinol.
Nursing Management
 patients should be encouraged to decrease foods high in
purines, especially organ meats, and to limit alcohol intake.
 increase their fluid intake
Medical Management

4. Ankylosing Spondylitis
 Ankylosing spondylitis affects the cartilaginous joints of the
spine and surrounding tissues.
 Occasionally, the large synovial joints, may be involved.
 Characteristics include spondylosis and fusion of the vertebrae
 Usually begins in early adulthood and mainly affects men than
women.
 Back pain is the characteristic feature.

 As the disease progresses, ankylosis (stiffness) of the entire
spine may occur, leading to respiratory compromise and
complications.
Medical Management
 Focuses on treating pain and maintaining mobility by
suppressing inflammation.
 Good body positioning and posture are essential, so that if
ankylosis (fixation) does occur, the patient is in the most
functional position.
 Maintaining ROM with a regular exercise and muscle-
strengthening program is especially important.

Pharmacologic therapy
 NSAIDS such as naproxen or indomethacin are usually
prescribed for relieving inflammation and pain.
Surgical management
 Surgical management may include total hip replacement.
Nursing management of spondylitis
 The nurse administers prescribed drugs
 Encourages the client to perform ADLs as much as
possible.
 Teaches the client to perform mild exercises that reduce
stiffness and pain.

Musculoskeletal nursing

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