musculoskeletal

1. MUSCULOSKELETAL
SYSTEM
MODULE I
NURSING 105: ADULT NURSING
Myrna Williamson, MSN, RN,
OCN

2. In the very young…
• The skeleton is
composed of mostly
cartilage and is
therefore, pliable with
a decreased
incidence of bone
fractures and
breakage in childhood

3. Mature Bone
• Rigid connective
tissue consisting of
cells;
– Collagen
– Calcium
– Phosphate

4. SKELETON
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.

5. SKELETON
• AXIAL PORTION
– Cranium
– Vertebrae
– Ribs
• APPENDICULAR
PORTION
– Limbs
– Shoulders
– Hips

6. ANATOMY & PHYSIOLOGY
REVIEW
• Structure & Function
– Skeletal System
• Bone Formation, Maintenance, Healing
– Articular System
• Joints – synarthrosis, amphiarthrosis, & diarthrosis
– Skeletal Muscle System
• Contraction
• Tone
• Actions
• Exercise, Disuse, & Repair

7. Bone Cells
Osteogenic Cells
Osteoblasts
Osteocytes
Osteoclasts

8. Bone Formation & Maintenance
• Ossification
• Resorption &
Formation
– Local stress
– Vit. D
– Parathyroid hormone
– Calcitonin
– Blood supply

9. TYPES OF BONES
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.

10. SPONGY BONE
• Located in the ends of long bones and the
center of flat and irregular bones
• Can withstand forces applied in many
directions

11. DENSE (COMPACT) BONE
• Covers spongy bone
• Cylinder around a central marrow cavity
• Can withstand force predominantly in one
direction

12. SPONGY BONE AND COMPACT
BONE
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.

13. FUNCTIONS OF BONE
• Framework
• Support
• Movement
• Shape
• Maintain Position
• Attachment of
Muscles
• Protects Organs
• Storage
• Hematopoiesis
• Remodeling
• Reformation
• Movable Joints

14. CHARACTERISTICS OF
JOINTS
• Allow the movement
between bones
• Formed where two
bones join
• Surfaces are covered
with cartilage
• Enclosed in a capsule

15. Classification of Joints
• A-C; Synarthrotic
(immovable) &
amphiarthrotic
(slightly movable)
joints.
• D-E: Diarthrodial
(freely movable) joints

16. Types of Diarthrodial Joints
• Hinge
• Ball &
Socket
• Pivot
• Condyloid
• Saddle
• Gliding

17. SYNOVIAL JOINT
From Applegate E: The Anatomy and Physiology Learning System, ed. 2, Philadelphia, 2000,
W.B. Saunders.

18. SYNOVIAL JOINT OF THE
KNEE
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.

19. ANTERIOR VIEW OF MAJOR
MUSCLES
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.

20. POSTERIOR VIEW OF
MAJOR MUSCLES
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia:
W.B. Saunders.

21. SKELETAL MUSCLE
From Herlihy, B. &
Maebius, N. (2000).
The human body in
health and illness.

22. Neuromuscular Junction

23. CHARACTERISTICS OF
MUSCLES
• Made up of bundles of muscle fibers
• Provide the force to move bones
• Assist in maintaining posture
• Assist with heat production

24. 4 Steps of Muscle Contraction
• Excitation
• Coupling
• Contraction
• Relaxation

25. Body Movements
• Flexion
• Extension
• Abduction
• Adduction
• Rotation
• Circumduction
• Supination
• Pronation
• Inversion
• Eversion
• Protraction
• Retraction

26. Age Related Changes of
Musculoskeletal System
• Bones
• Muscles
• Joints
• Ligaments

27. Nursing Assessment
• Health History
–Initial Interview
–Assessment Data
• Pain
• Altered Sensations

28. Nursing Assessment
• Physical Assessment
– Posture
– Gait
– Bone Integrity
– Joint Function
– Muscle Strength & Size
– Skin
– Neurovascular Status

29. RISK FACTORS
• Autoimmune disorders
• Calcium deficiency
• Degenerative conditions
• Falls
• Hyperuricemia
• Infection

30. RISK FACTORS (Continued)
• Medications
• Metabolic disorders
• Neoplastic disorders
• Obesity
• Postmenopausal
states
• Trauma and injury

31. Diagnostic Evaluation
• Imaging Procedures
– X-ray
– Computed Tomography
(CT)
– Magnetic Resonance
Imaging (MRI)
– Arthrography
– Bone Densitometry

32. Diagnostic Evaluation
• Nuclear Studies
– Bone Scan
• Endoscopic Studies
– Arthroscopy
• Other Studies
– Arthrocentesis
– Electromyography
– Biopsy
• Laboratory Studies
– (CBC)
– Urinalysis (Calcium)
– Blood Chemistry
– Serum Calcium
– Serum Phosphate
– Uric Acid
– Serum Creatinine
– LDH, SGOT, CPK

33. X-RAYS
• DESCRIPTION
• IMPLEMENTATION

34. ARTHROCENTESIS
• DESCRIPTION
• IMPLEMENTATION

35. ARTHROGRAM
• DESCRIPTION
• IMPLEMENTATION
Arthrogram of the Knee

36. ARTHROSCOPY
• DESCRIPTION
• IMPLEMENTATION

37. BONE SCAN
• DESCRIPTION
• IMPLEMENTATION

38. BONE OR MUSCLE BIOPSY
• DESCRIPTION
• IMPLEMENTATION
Muscle Biopsy Showing
Polymyositis

39. ELECTROMYOGRAPHY
(EMG)
From Mourad LA (1991) Orthopedic disorders. St. Louis: Mosby.

40. MYELOGRAM
From Herlihy B, Maebius NK: The human body in health and illness, Philadelphia, 2000,
W.B. Saunders.

41. MUSCULOSKELETAL INJURIES
• Skeletal Trauma
• Injuries to Support
Structures

42. Fractures
• Described according
to location and type

43. Types of Fractures
• Complete or
Incomplete
• Open (formerly
referred to as
compound)
• Closed (formerly
referred to as simple)

44. Complete Fractures
• Linear
• Oblique
• Transverse
• Spiral

45. Complete Fractures
• Comminuted
• Impacted
• Pathologic
• Avulsion

46. Complete Fractures
• Compression
• Displaced
• Extracapsular
• Intracapsular

47. Incomplete Fractures
• Greenstick
• Torus
• Bowing fracture
• Transchondral fracture
• Stress Fractures

48. TYPES OF FRACTURES
From Ignativicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia:
W.B. Saunders.

49. Types of Fractures

50. Pathophysiology of a Fracture
• Tissue Disrupted
• Bleeding Occurs
• Hematoma Forms
• Bone Tissue

51. Healing of a Fracture
• Inflammatory
response
• Vascular tissue
• Bone-forming cells
• Callus formation
• Osteoblasts
• Remodeling

52. Speed of Healing
• Hematoma formation – within hours
• Procallus – within days
• Callus formation – within weeks
• Replacement and remodeling – up
to 4 years

53. Fractures – Clinical Manifestations
• Impaired function
• Deformity (unnatural
alignment)
• Swelling
• Muscle spasm
• Tenderness
• Pain
• Impaired sensation

54. FRACTURE OF AN
EXTREMITY
• ASSESSMENT
• INITIAL CARE

55. INTERVENTIONS FOR A
FRACTURE
• Reduction
• Fixation
• Traction
• Casts

56. Fractures - Treatment
• Reduction
– Closed manipulation
– Traction (skin or skeletal)
– Open reduction and internal fixation (ORIF),
(insertion of prosthesis, screw, plate, nail or
wire).

57. CLOSED REDUCTION
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia:
W.B. Saunders.

58. INTERNAL FIXATION
From Browner BB et al (1992) Skeletal trauma. Philadelphia: W.B. Saunders.

59. Types of Internal Fixation for a Hip
Fracture

60. EXTERNAL FIXATION
From Ignatavicius, D., Workman, M. (2002). Medical-surgical nursing, ed 3, Philadelphia: W.B.
Saunders. Courtesy of Smith and Nephew, Inc., Orthopedics Division, Memphis, TN.

61. TYPES OF HIP FRACTURES
• Intracapsular
• Extracapsular

62. HIP REPLACEMENTS
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St.
Louis: Mosby. Courtesy of Zimmer, Inc., Warsaw, IN.

63. TOTAL HIP REPLACEMENT
From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

64. HIP FRACTURE
• POSTOPERATIVE
CARE
• CLIENT EDUCATION

65. TOTAL KNEE REPLACEMENT
• DESCRIPTION
• POSTOPERATIVE
CARE

66. KNEE PROSTHESIS
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.

67. CONTINUOUS PASSIVE MOTION

68. CASTS

69. Cast Care
• Educate
• Apply Ice
• Instruct
• Prevent
• Attend

70. TRACTION
• DESCRIPTION
• IMPLEMENTATION

71. SKELETAL TRACTION
• DESCRIPTION
• IMPLEMENTATION

72. SKIN TRACTION
• DESCRIPTION
– Traction applied by the
use of elastic
bandages or adhesive
Side Arm

73. CERVICAL SKIN TRACTION
From James, S. Ashwill, R., & Droske, S. (2002). Nursing care of children, ed 2,
Philadelphia: W.B. Saunders.

74. HEAD HALTER TRACTION
From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical
nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

75. BUCK’S SKIN TRACTION
From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical
nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

76. PELVIC SKIN TRACTION
From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical
nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

77. BALANCED SUSPENSION
From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensen’s medical-surgical
nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

78. DUNLOP’S SKIN TRACTION
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

79. COMPLICATIONS OF
FRACTURES
• Fat embolism
• Compartment syndrome
• Infection and osteomyelitis
• Avascular necrosis
• Pulmonary emboli
• Venous thrombosis
• Delayed union & nonunion

80. FAT EMBOLISM
• DESCRIPTION
• ASSESSMENT
• IMPLEMENTATION

81. COMPARTMENT SYNDROME

82. INFECTION AND
OSTEOMYELITIS
• DESCRIPTION
• ASSESSMENT
• IMPLEMENTATION

83. AVASCULAR NECROSIS
• DESCRIPTION
• ASSESSMENT
• IMPLEMENTATION

84. PULMONARY EMBOLISM
• DESCRIPTION
– Caused by immobility precipitated by a
fracture

85. Venous Thrombosis
• Description
• Assessment
• Implementation

86. Delayed Union & Nonunion
• Description
• Assessment
• Implementation

87. Other Skeletal Trauma
• Dislocation
• Subluxation
• Injuries to Support Structures
– Tendon tear
– Ligament tear
– Strain
– Sprain
– Avulsion
– Tendonitis
– Bursitis

88. Soft Tissue Injury of Hip

89. CARPAL TUNNEL SYNDROME
Associated with
occupations that
require
continuous wrist
movement.

90. Sports-Related Injuries
• Rotator Cuff Tears
• Epicondylitis (Tennis Elbow)
• Lateral & Medial Collateral Ligament Injury
• Anterior & Posterior Cruciate Ligament
Injury
• Meniscal Injuries
• Rupture of Achilles Tendon

91. CRUTCH WALKING

92. CRUTCH GAITS
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

93. SINGLE- AND QUAD-FOOT
CANES
From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

94. WALKERS

95. HERNIATION:
INTERVERTEBRAL DISC

96. CERVICAL DISC
CERVICAL COLLAR

97. LUMBAR DISC
• DESCRIPTION
• IMPLEMENTATION

98. LOW BACK CARE
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.

99. TYPES OF DISC SURGERY
• CHEMOLYSIS
• DISCECTOMY
• DISCECTOMY WITH
FUSION
• LAMINOTOMY
• LAMINECTOMY

100. DISC SURGERY
• PREOPERATIVE
• POSTOPERATIVE: CERVICAL DISC
• POSTOPERATIVE: LUMBAR DISC

101. AMPUTATION OF A LOWER
EXTREMITY
• DESCRIPTION
– The surgical removal
of a lower limb or part
of the limb

102. AMPUTATION FLAPS
From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

103. AMPUTATION OF A LOWER
EXTREMITY
• POSTOPERATIVE
– Monitor vital signs
– Monitor for infection and hemorrhage
– Mark bleeding and drainage on the dressing if
it occurs
– Keep a tourniquet at the bedside
– Monitor for pulmonary emboli

104. STUMP WRAPPING
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.

105. BELOW-THE-KNEE AMPUTATION
• POSTOPERATIVE
– Prevent edema
– Do not allow the stump to hang over the edge
of the bed
– Do not allow the client to sit for long periods of
time to prevent contractures

106. ABOVE-THE-KNEE
AMPUTATION
• POSTOPERATIVE
– Prevent internal or external rotation of the
limb
– Place a sandbag or rolled towel along the
outside of the thigh to prevent rotation

107. DISORDERS OF BONE
• Metabolic Bones Diseases
• Infectious Bone Disease
• Bone Tumors

108. Infectious Bone Disease:
Osteomyelitis
• Difficult to treat
• Physical disability
• Bacteria
– Exogenous
– Endogenous

109. OSTEOMYELITIS
• DESCRIPTION
• ASSESSMENT
• IMPLEMENTATION

110. Bone Tumors
• Incidence
• Signs & Symptoms
• Diagnosis

111. DISORDERS OF JOINTS
• Noninflammatory joint
disease
• Inflammatory joint
disease

112. INFLAMMATORY JOINT DISEASE
• Rheumatoid arthritis
• Ankylosing
Spondylitis
• Gouty arthritis

113. RHEUMATOID ARTHRITIS
(RA)
• DESCRIPTION
• ASSESSMENT

114. RHEUMATOID ARTHRITIS
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.
MUSCLE ATROPHY
BOUTONNIERE DEFORMITY
SWAN NECK DEFORMITY

115. RHEUMATOID NODULE
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.

116. RHEUMATOID ARTHRITIS
(RA)
• NONSTEROIDAL
ANTIINFLAMMATORY
DRUGS (NSAIDs)
• CORTICOSTEROIDS
• ANTINEOPLASTIC
MEDICATIONS
• GOLD SALTS

117. RHEUMATOID ARTHRITIS
(RA)
• PHYSICAL MOBILITY
• SELF-CARE

118. RHEUMATOID ARTHRITIS
(RA)
• FATIGUE
• BODY IMAGE
DISTURBANCE

119. RHEUMATOID ARTHRITIS (RA)
SURGICAL INTERVENTIONS
• SYNOVECTOMY
• ARTHRODESIS
• JOINT REPLACEMENT
(ARTHROPLASTY)

120. Ankylosing Spondylitis
• Chronic Inflammatory Disease
• Systemic autoimmune disease
• Differs from RA
• Signs & Symptoms
• Treatment

121. GOUTY JOINT
• Description
• Phases
• Assessment
• Implementation

122. GOUT
From Clinical Slide Collection of the Rheumatic Diseases, © 1991,1995,1997.
Used with permission of the American College of Rheumatology.

123. Noninflammatory Joint Disease
• Degenerative joint
disease
(osteoarthritis) is the
most common

124. OSTEOARTHRITIS
• DESCRIPTION
– Also known as
degenerative joint
disease (DJD)
JOINT CHANGES IN OSTEOARTHRITIS

125. OSTEOARTHRITIS
From Kamal A, Brockelhurst J: Color atlas of geriatric medicine, ed. 2, St. Louis, 1991, Mosby.
SEVERE OSTEOARTHRITIS
HEBERDEN’S NODES
BOUCHARD’S NODES

126. OSTEOARTHRITIS
• PHYSICAL MOBILITY

127. OSTEOARTHRITIS
SURGICAL INTERVENTIONS
• OSTEOTOMY
• TOTAL JOINT
REPLACEMENT
(TJR)

128. RHEUMATOID ARTHRITIS
AND OSTEOARTHRITIS
CLIENT EDUCATION
• Assist
• Instruct
• Review

129. Metabolic Bone Diseases
• Osteoporosis
• Osteomalacia
• Paget’s Disease

130. OSTEOPOROSIS
DOWAGER’S HUMP

131. OSTEOPOROTIC CHANGES
From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.

132. SEVERE OSTEOPOROSIS
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000,
W.B. Saunders.

133. MILWAUKEE BRACE
From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

134. OSTEOMALACIA
• Metabolic disease
• Bone volume unchanged
• Osteomalacia – adults
• Rickets - children

135. Paget’s Disease
• Osteitis Deformans
• Increased metabolic activity
• Usually no TX
• Affects men and women equally

136. Nursing Diagnoses
• Knowledge Deficit
• Impaired Physical Mobility
• Self-care Deficit
• Risk for Infection
• Impaired Skin Integrity
• Imbalanced Nutrition
• Acute/Chronic Pain

137. THE END OF MUSCULOSKELETAL