1 orthopaedics

THE MUSCULAR SKELETAL SYSTEM
By C Settley

At the end of the unit,
the student will be able to:
1. Apply knowledge regarding: patho-physiology, disease process, clinical manifestations,
specific diagnostic and therapeutic interventions (diagnostic tests and examinations)
2. Distinguish between the different health problems: medical and surgical conditions of
various body systems: Congenital defects, Amputation, Osteoarthritis, Rheumatoid
arthritis, Juvenile chronic, Arthritis & Osteoporosis
3. Assess, relate and apply the scientific process of nursing, provision and facilitation of
nursing care
4. Evaluate, analyse and solve problems in familiar and unfamiliar context in the
Comprehensive Health Care system
5. Understand the relationship between social, cultural and economic factors that may
impact significantly on the health status of clients / patients and groups. (Health education)
6. Apply knowledge of emergency and trauma management principles Trauma to the
muscular skeletal system
4/23/2018 Compiled by C Settley 2

What is the muscular skeletal system?
• The musculoskeletal system provides form, support,
stability, and movement to the body.
• It is made up of the bones of the skeleton, muscles,
cartilage, tendons, ligaments, joints, and other
connective tissue that supports and binds tissues and
organs together.

The raduis and ulna

Where is cartilage found in the body?

Foot muscles

Congenital deformities of the foot
pg. 916
• Genu varum
– Genu varum is a deformity marked by
(outward) bowing at the knee, which means
that the lower leg is angled inward (medially)
in relation to the thigh's axis, giving the limb
overall the appearance of an archer's bow.
– Normal and resolves
spontaneously

pg. 916
• Genu valgum
– commonly called "knock-knee", is a condition
in which the knees angle in and touch each
other when the legs are straightened.
– Individuals with severe valgus deformities
are typically unable to touch their feet
together while simultaneously straightening
the legs.
– Corrects
Spontaneously

pg. 916
• Talipes equinovarus
– A birth defect in which the foot is twisted out of
shape or position.
– Involves bony structures of the foot.
– Adduction and supination of the forefoot, the heel,
the ankle equines and includes medial deviation of
the entire foot.
– Soft tissue tightening might also be present.
– Exact cause is unknown, but thought to be related to
genetics and intrauterine positioning.
– Treatment consists of gentle manipulation to the
desired position and application of casts or tapes.
– Treatment successful if started early.
– Surgical correction might be required.

pg. 916
• Talipes equinovarus

pg. 916
• Pes cavus
– Medical term for ‘claw foot’.
– Abnormal arch of the foot.
– Often there is clawing of the toes.
– The foot is short and the bottom of the foot reaches
the ground on the heel and metatarsal heads.
– Increased pressure and callus formation on those
areas that touches the ground.
– Exercise may be advised to try and manipulate the
foot into dorsi-flexion.
– A brace may be ordered.
– In severe cases surgery may be required.

pg. 916
• Pes cavus

pg. 916
• Pes planus
– A condition in which the entire sole of the foot touches the
floor when standing.
– May go unnoticed.
– Arch of the foot has collapsed to such a degree that the
medial border of the foot reaches the ground.
– May be congenital or acquired (associated with trauma of
muscles and ligaments, paralysis, overweight, poor
posture, poorly fitting shoes, arthritis)
– In some cases it may be painful.
– Management includes exercise to improve muscle
strength, posture and gait.
– An arch support device may be used over time.

pg. 916
• Pes planus

Trauma to the muscular skeletal system
• Fractures – pg. 919
– A complete or partial break in the
continuity of a bone.

Causes of fractures
• Trauma
– As result of direct force such as a blow or
crush as in MVA’s
– Indirect violence
– Sports and occupational injuries

Causes of fractures
• Degenerative disorders
– Such as those responsible for pathological
fractures, which occur in elderly women
as a result of osteoporosis (a condition in
which bones become weak and brittle)
associated with hormonal changes during
menopause
– Or bone metastasis

Pathophysiology of fractures
• Break in the continuity of a bone
• Which results in the periosteum being stripped
off from the bone and blood vessels supplying
the bone being severed
• The edges of the bone may damage surrounding
tissue and blood vessels resulting in bleeding
into the bone and tissues, including joint
cavities if joints are involved
• A haematoma may form increasing swelling in
the area

Types of fractures- pg. 919
(Table 47.1)
Complete and incomplete fractures refer to the way
the bone breaks. In a complete fracture, the bone
snaps into two or more parts, In an
incomplete fracture, the bone cracks but does not
break all the way through.

(Table 47.1)
Complete and Incomplete fractures
(example of the radius)

(Table 47.1)
Closed fractures or simple fractures
A closed fracture is a broken bone that does not
penetrate the skin. This is an important distinction
because when a broken bone penetrates the skin (an
open fracture) there is a need for immediate treatment,
and an operation is often required to clean the area of
the fracture.
An open fracture can be defined as a broken bone that is
in communication through the skin with the
environment.

(Table 47.1)

(Table 47.1)
Comminuted fracture
A comminuted fracture is a break or splinter of the
bone into more than two fragments.

(Table 47.1)
Compression fracture
Fractures from osteoporosis usually occur in the front
(anterior) part of the vertebral body. Osteoporosis is
a disease that weakens bone. Sometimes the bones
in the spine weaken to the point that even mild
forces can lead to a compression fracture. These
compression fractures can occur in vertebrae
anywhere in the spine, but they tend to occur most
commonly in the upper back (thoracic spine),
particularly in the lower vertebrae of that section of
the spine (e.g. T10, T11, T12).

(Table 47.1)

(Table 47.1)
Depressed fracture
A depressed skull fracture is a break in a cranial bone
(or "crushed" portion of skull) with depression of the
bone in toward the brain.

(Table 47.1)
Impacted fracture
An impacted fracture occurs when the broken ends
of the bone are jammed together by the force of the
injury or slips over the other fragment.

(Table 47.1)
Incomplete fracture/ greenstick fracture
An impacted fracture occurs when the broken ends
of the bone are jammed together by the force of the
injury or slips over the other fragment. Applies in
children

(Table 47.1)
Pathologic fracture
A pathologic fracture (also called insufficiency
fracture) is a bone fracture caused by disease that led
to weakness of the bone structure.

Assessment and common findings
• Oedema and swelling due to soft tissue
injury with bleeding into the surrounding
tissue
• Pain and tenderness
• Loss of function
• Deformity
• Discoloration
• Crepitation

Healing of fractures
1. Haematoma formation
– Bleeding around the tissues.
– Clotting may also occur.

2. Granulation tissue
– Granulation tissue is new connective
tissue and microscopic blood vessels that
form on the surfaces of a wound during
the healing process. This includes the
formation of new cells, fibroblasts and
osteoblasts.
– A new bone structure, the osteoid is
formed.

3. Callus stage
– Eventually, pain and swelling decrease
and soft callus is formed.
– This corresponds roughly to the time
when the fragments are no longer moving
freely.
– A callus is an area of thickened skin in
response to repeated friction, pressure,
or other irritation.

4. Ossification stage
- The callus gradually ossified by the
continuous action of osteoblasts. The soft
bone is replaced by mature bone during this
stage, but the fracture can still be seen on X
ray.
- Ossification (or osteogenesis) in bone
remodeling is the process of laying down new
bone material by cells called osteoblasts. It is
synonymous with bone tissue formation.

5. Consolidation stage
- Ossification continues and more mature
bone develops. The gaps between bones fills
up.
6. Remodelling stage
- Osteoclasts are active during this stage.
Removal of unnecessary material takes place.
This completes the healing process.

Therapeutic management of fractures
• Resuscitation
• Reduction of fractures
• Immobilising fractures
• Restoration of function
• Rehabilitation

Resuscitation of the patient
• Blood loss and pain from the injury
• Depending on extent of the fracture
• Signs and symptoms of shock (Cool, clammy pale skin,
rapid pulse and breathing, nausea and vomiting, enlarged pupils,
weakness, dizziness or fainting).
• To minimise shock:
– Analgesia (Pethidine 25-50 mg IM)
– Replace fluid when BP is low and the pulse is weak.
– Handle fracture with care.
– Temporary splinting may be required.

Splinting of fracture

Complications of fractures- pg. 921
• Infection
– Often occurs in open fractures.
– May become serious if it
spreads beyond the soft
tissue and infects
underlying bones
causing osteomyelitis.

• Delayed union
– May be due to poor blood supply or
inadequate immobilization.
• Malunion
– Union may occur in the wrong position.
• Non union
– When the fractures fail to unite. Soft tissue
may get interposed between bone ends. A
bone graft mat be necessary to stimulate
new bone growth.

• Fat embolism
– Acute and potentially fatal condition
– Fat embolism occurs when fat globules are released
into the bloodstream. It’s most commonly associated
with a trauma, such as a bone fracture.
– Symptoms, if present, typically occur 24 to 72 hours
after the trauma. They include shortness of breath,
confusion and a rash.
– With supportive hospital care, most people recover.
– Symptoms: fast breathing or shortness of breath, fast
heart rate, low oxygen in the body, mental confusion,
or red spots on skin

• Avascular necrosis
– The death of bone tissue due to
interruption of the blood supply; the
bone structures then collapse, resulting in
pain, loss of joint function and long-term
joint damage.

• Painful post traumatic osteoporosis
– About two months after removal of cast
– Pain, loss of function, stiff joints and
swelling
– Aim is to reduce pain and restore function
4/23/2018
Compiled by C Settley 58

• Compartment syndrome
– A painful and dangerous condition caused by
pressure build-up from internal bleeding or
swelling of tissues.
– The pressure decreases blood flow, depriving
muscles and nerves of required nourishment.
– Symptoms may include severe pain,
sensation of pins and needles and weakness
of the affected area.
– For severe cases of compartment syndrome,
emergency surgery is required.

• Gas gangrene
– Rapidly spreading gangrene affecting
injured tissue infected by a soil bacterium
and accompanied by the evolution of
foul-smelling gas.

Fracture of the hip- pg. 928
• A hip fracture can cause life-threatening
complications.
• People over the age 65 are most at risk
because bones weaken and the risk of falling
increases with age.
• A break in the upper quarter of the
thighbone, near the hip joint.

Assessment and common findings
• Symptoms include the inability to move after
a fall and severe hip or groin pain.
• Abnormality walking, bruising, swelling, or
visible deformity of lower extremity
• Diagnostic test: X ray

Nursing management after total hip
replacement- pg.928
• Monitor fluid balance and vital signs
• Administer analgesics
• Give prophylactic antibiotics to prevent
infection
• Check dressing for drainage (should not exceed
200ml per 8 hours)
• Maintain bed rest for at least 4-5 days
• Maintain leg abduction with pillows, and
commence leg exercises on the second day post
operatively

Nursing management after total hip
replacement- pg.928
• Ambulate early on the 4th day
• Do routine neurovascular assessment
• Prevent and be alert for complications of
immobility, eg. Deep vein thrombosis
• Provide education to enable the patient to
cope at home
• Provide a well balanced diet.

Patient instructions
• Box 47.1:
– Always sit with the legs slightly apart
– Avoid crossing the legs when sitting or
lying down
– Do not lie on the operated side for at
least two months
– Do not bend at the waist
– Do not bend when putting on a shoe
– Do not sit in a deep chair
4/23/2018

Amputation- pg. 928
• Amputation is the removal of a limb by
trauma, medical illness, or surgery.
• As a surgical measure, it is used to control
pain or a disease process in the affected
limb, such as malignancy or gangrene.
• Phantom pains

Amputation: Causes
• There are many reasons an amputation may be necessary.
• The most common is poor circulation because of damage or
narrowing of the arteries, called peripheral arterial disease.
• Without adequate blood flow, the body's cells cannot get oxygen and
nutrients they need from the bloodstream.
• As a result, the affected tissue begins to die and infection may set in.
• Severe injury (from a vehicle accident or serious burn, for example)
• Cancerous tumor in the bone or muscle of the limb
• Serious infection that does not get better with antibiotics or other
treatment
• Thickening of nerve tissue, called a neuroma
• Frostbite
4/23/2018

Amputation: Post operative care
• Goal is to help patient to cope with the
amputation
• complications
– Hemorrhage
– Infection
– Poor healing and skin breakdown
– Contractures (a condition of shortening and hardening of
muscles, tendons, or other tissue, often leading to deformity and
rigidity of joints)
– Psychological aspects with regard to limb
pain
4/23/2018

Amputation: Specific Post operative
nursing measures
• Observe and manage bleeding
• Wound monitoring
• Ensure that stump rests on protected bed in
extended position and in slight abduction
• Elevate the foot end to prevent oedema
• Control pain
• Refer to psychologist
• Refer to physiotherapist
4/23/2018

nursing measures
4/23/2018

Osteoarthritis – pg. 930
• Sometimes called degenerative joint disease
or degenerative arthritis, osteoarthritis (OA)
is the most common chronic condition of the
joints.
• OA can affect any joint, but it occurs most
often in knees, hips, lower back and neck,
small joints of the fingers and the bases of
the thumb and big toe.
• Chronic non-inflammatory disease

Risk factors of OA Pathophysiology- pg.
930
4/23/2018
• Congenital anatomical abnormality of the
joint
• Advancing age
• Previous joint injury or surgery
• Genetic predisposition

Causes of OA Pathophysiology- pg. 930
4/23/2018
• History of injury
• Observable deformity
• Wear and tear in the articular cartilage
• Genetic predisposition

Clinical manifestations of OA
Pathophysiology- pg. 930
4/23/2018
• Pain areas: in the joints, hands, hip, knee, lower
back, or neck
• Pain circumstances: can occur related to
weather
• Pain types: can be severe in the joints
• Joints: stiffness, crackles, swelling, or
tenderness
• Hand: bump on the finger or bony outgrowth in
fingers or toes
• Also common: joint deformity or limping

OA Pathophysiology- pg. 930
4/23/2018
• In normal joints, a firm, rubbery material called cartilage
covers the end of each bone.
• Cartilage provides a smooth, gliding surface for joint motion
and acts as a cushion between the bones.
• In OA, the cartilage breaks down, causing pain, swelling and
problems moving the joint.
• As OA worsens over time, bones may break down and develop
growths called spurs.
• Bits of bone or cartilage may chip off and float around in the
joint. In the body, an inflammatory process occurs and
cytokines (proteins) and enzymes develop that further damage
the cartilage.
• In the final stages of OA, the cartilage wears away and bone
rubs against bone leading to joint damage and more pain.

OA nursing management- pg. 931
4/23/2018
• Patient education
• Pain management
• Referrals
• Encouragement to join support group

Rheumatoid arthritis – pg. 931
• A chronic inflammatory disorder affecting
many joints, including those in the hands
and feet.

Causes of RA- pg. 931
4/23/2018
• Causes of Rheumatoid Arthritis.
• Rheumatoid arthritis is an autoimmune
disorder, meaning it is caused by an
abnormality in the immune system.

Clinical manifestations of RA- pg. 931
4/23/2018
• Pain areas: in the joints, back, or muscles
• Joints: stiffness, swelling, tenderness, or
weakness
• Whole body: fatigue, anaemia, or malaise
• Skin: lumps or redness
• Hand: bump on the finger or swelling
• Also common: flare, dry mouth, physical
deformity, or sensation of pins and needles

Comparison of rheumatoid arthritis and
osteoarthritis- pg. 931
4/23/2018

Gout- pg. 931
• A form of arthritis characterised by severe
pain, redness and tenderness in joints.

Causes of gout- pg. 931
4/23/2018
• Genetic error in purine metabolism
• Or following excessive consumption of a high
purine diet and alcohol
• More common in women and onset
between 40-60

Pathophysiology of gout- pg. 932
4/23/2018
• Pain and inflammation occur when too much
uric acid crystallises and deposits in the
joints.
• Hyperuricemia due to decreased renal
excretion
• Hyperuricemia is an excess of uric acid in the blood. Uric
acid passes through the liver, and enters your
bloodstream. Most of it is excreted (removed from your
body) in your urine, or passes through your intestines to
regulate "normal" levels.

Assessment and common findings of
gout- pg. 932
4/23/2018
• Symptoms of gout include severe pain,
redness and swelling in joints, often the big
toe. Attacks can come suddenly, often at
night.
• Diagnostic studies may reveal elevated
serum uric acid levels

Therapeutic management
of gout- pg. 932
4/23/2018
• During an acute attack, anti-inflammatory
medications can help relieve pain and shorten
the length of the attack.
• Patients with chronic gout can use behavioural
modification such as diet, exercise and
decreased intake of alcohol to help minimise
the frequency of attacks. Allopurinol may be
prescribed.
• Additionally, patients with chronic gout are
often put on medications such as colchicine,
NSAID’s (such as aspirin).

Essential health information for patients
suffering from Gout- pg. 932
4/23/2018
• Weight control
• Restriction of high purine foods such as
meats, fish, mushrooms
• Limit alcohol intake

Osteoporosis- pg. 932
• A condition in which bones become weak and
brittle.
• The body constantly absorbs and replaces bone
tissue. With osteoporosis, new bone creation
doesn't keep up with old bone removal.
• Many people have no symptoms until they have a
bone fracture.

Causes & risk factors of Osteoporosis- pg.
932
4/23/2018
• Female gender
• Caucasian or Asian race
• Thin and small body frame
• Family history of osteoporosis Personal
history of fracture as an adult
• Cigarette smoking
• Excessive alcohol consumption
• Lack of exercise
• Diet low in calcium

Causes of Osteoporosis- pg. 932
4/23/2018
• Poor nutrition, malabsorption of foods and poor general
health, especially associated with chronic inflammation or
bowel disease
• Low estrogen levels in women (which may occur in
menopause or with early surgical removal of both ovaries)
• Low testosterone levels in men (hypogonadism)
• Chemotherapy that can cause early menopause due to its toxic
effects on the ovaries
• Amenorrhea
• Chronic inflammation, due to chronic inflammatory arthritis or
diseases, such as rheumatoid arthritis or liver diseases
• Immobility, such as after a stroke, or from any condition that
interferes with walking

4/23/2018
• Hyperthyroidism, a condition wherein too
much thyroid hormone is produced by the
thyroid gland (as in Grave's disease) or is
ingested as thyroid hormone medication
• Hyperparathyroidism is a disease wherein
there is excessive parathyroid hormone
production by the parathyroid gland, a small
gland located near or within the thyroid
gland.

4/23/2018
• When vitamin D is lacking, the body cannot absorb
adequate amounts of calcium from the diet to
prevent osteoporosis. Vitamin D deficiency can
result from dietary deficiency, lack of sunlight, or
lack of intestinal absorption of the vitamin such as
occurs in celiac sprue and primary biliary cirrhosis.
• Certain medications can cause osteoporosis. These
medicines include long-term use of heparin (a blood
thinner), antiseizure medicine such as phenytoin
(Dilantin) and phenobarbital, and long-term use of
oral corticosteroids (such as prednisone).

Assessment and common findings of
Osteoporosis & management therof- pg.
932
4/23/2018
• Bone x rays
• Prevent further bone loss
• Replacement of oestrogen in post
menopausal females
• Calcium supplements
• Patient education

Reference list
• https://www.slideshare.net/LPrakash2/biomech
anics-of-fracture-healing
• https://study.com/academy/lesson/periosteum-
of-bone-definition-function.html
• https://www.epainassist.com/sports-
injuries/lower-leg-injuries/closed-tibia-or-fibula-
fracture
• http://safe-skipper.com/first-aid-afloat-deal-
fracture/
• https://www.doereport.com/generateexhibit.ph
p?ID=15292&ExhibitKeywordsRaw=&TL=&A=
• http://www.pravozatelebane.com/top-five-
arthritis-tips-myths/

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