MSS Disorders N.pptx

NURSING MANAGEMENT OF PATIENTS WITH
MUSCULOSKELETAL DISORDERs
NURSING MANAGEMENT OF MSS
DISORDES
1

Outline
Objective
Anatomic and Physiologic Overview MSS
Assessment of MSS
Diagnostic evaluation of MSS
Common musculoskeletal disorders
Musculoskeletal infection: osteomyelitis
Management of MSSD
Medical
Surgical
Nursing NURSING MANAGEMENT OF MSS
DISORDES
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Objectives
At the end of session students will be able to :
1.Define MSS
2. Differentiate components of MSS
3.Explain functions of MSS
4.Describe types MSS Disorders
5.Prepare nursing care plan for client with MSSD
DISORDES
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Brainstorming
• How you define MSS?
• What are components of MSS?
DISORDES
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REVIEW OF ANATOMY AND PHYSIOLOGY OF MSS
• It is the second largest system in the body.
• The skeletal and muscular systems considered
one system because they work together to
enable the body to move.
DISORDES
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REVIEW OF ANATOMY AND PHYSIOLOGY OF MSS….
Musculoskeletal system consists of :-
Bone :206 bone in adult
Muscle: more than 600 muscles
Joints:
Supportive connective tissue
 Cartilage:
 Tendons: attaches the end of a muscle to the bone
 Ligaments: attaches bones together
DISORDES
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Classification of skeletal system
I. The axial skeleton
Form the axis of the body
Support and protect the organs of the head, neck,
and trunk.
II. Appendicular portions
Bones of the upper
 Lower extremities and
 Bony girdles that anchor the appendages to the
axial skeleton NURSING MANAGEMENT OF MSS
DISORDES
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Classification of skeletal system
It divided into:
I. Axial
II. Appendicular portions
DISORDES
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Classification of skeletal system…
DISORDES
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Divisions of the Skeletal System
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I. The axial skeleton
 Form the axis of the body
 Support and protect the organs of the head, neck, and
trunk.
1. Skull:22bones
 Cranial(8)
 Facial bones(14)
2. Auditory ossicles: 6 ear bones
3. Hyoid bone =1boneNURSING MANAGEMENT OF MSS
DISORDES
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4. Vertebral column= 26 Bones
Cervical vertebra (7)
Thoracic vertebra (12)
Lumbar vertebra (5)
Sacrum (1)
Coccyx (1)
5. Rib Cage—25 Bones
Rib= 12 pairs of ribs =24
Sternum (1)
DISORDES
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II. The Appendicular skeleton
Bones of the upper
 Lower extremities and
 Bony girdles that anchor the appendages to the axial
skeleton
DISORDES
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1. Pectoral girdle/shoulder Girdle
– Paired scapulae (“shoulder blades)
– Paired clavicles (“collarbones”)
2. Upper extremities =60 Bones
Each upper extremity contains
 Humerus
 Ulna and Radius,
 Carpal bones,
 Metacarpal bones, and
 Phalanges (“finger bones”) of the hand.
DISORDES
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3.Pelvic girdle –hipbones =3 Bones
sacrum (1)
Ilium, Pubis, Ischium
4. Lower extremities= 60 Bones
Each lower extremity contains
Femur (“thighbone”) ,
Tibia (“shinbone”) and fibula within the leg,
Foot bones
 Tarsal bones,
Metatarsal bones
Phalanges (“toe bones”)
Patella – kneecap NURSING MANAGEMENT OF MSS
DISORDES
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Functions of Skeletal System
• The musculoskeletal system includes the bones, joints,
muscles, tendons, ligaments, and bursae of the body.
• The functions of these components are highly
integrated; therefore, disease or injury to one
component adversely affects the others.
DISORDES
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Functions of Skeletal System…
1. Support body position
2. Promote mobility
3. Protects underlined soft organs (vital)
4. Place for mineral storage
 About 99% of the body’s calcium.
 85% of the body’s phosphorous.
5. Produce selected blood components (platelets and RBC
and WBC)
DISORDES
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Bones
At birth, the skeleton consists of about 270 bones.
Adult’s human skeletons is composed of 206 bones
DISORDES
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Type of Bones
Four principal categories:
1. Long bones
 Most of the bones of the upper and lower
extremities
2. Short bones
 Wrist and ankle
3. Flat bones
4. Irregular bones
 (e.g., the cranial bones, ribs, and bones of
the shoulder girdle). 19
DISORDES

Types of Bones:
1. Long Bones
 Much longer than they are wide.
 All bones of the limbs except for the
patella (kneecap), bones of the wrist
and ankle.
 Consists of a shaft (diaphysis)
Expanded ends. (epiphysis)
Femur 
DISORDES
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2. Short Bones
 Roughly cube shaped.
 Bones of the wrist and
the ankle.
Carpal Bones
DISORDES
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Flat Bones
Thin, flattened, and usually a bit
curved.
Scapulae, sternum, (shoulder
blades), ribs and most bones of
the skull.
Irregular Bones
Have weird shapes that fit none of
the 3 previous classes.
Vertebrae, hip bones, 2 skull
bones ( sphenoid and the
ethmoid bones).
Sternum
Sphenoid
Bone
DISORDES
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Bone composition
Bones are composed of:
 Fibrous connective tissue.
 Vascular tissue.
 Lymphatic tissue.
 Adipose tissue.
 Nervous tissue.
 Cartilage
DISORDES
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Bone structure
 All bones consist of a dense, solid
outer layer known as compact bone
and an inner layer of spongy bone – a
honeycomb of flat, needle-like
projections called trabeculae.
 Bone is an extremely dynamic
tissue!!!!
DISORDES
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DISORDES
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Bone cells
The cells of the bone are of three types
1. Osteoblasts: - Bone-building cells.
Synthesize and secrete collagen fibers and other organic
components of bone matrix.
Initiate the process of calcification.
2. Osteocytes: - Mature bone cells.
Osteoblasts that have become trapped by the secretion
of matrix.
Responsible for maintaining the bone tissue
DISORDES
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Bone cells …
Osteoclasts
 Cells that digest bone matrix – this process is called
bone resorption and is part of normal bone growth,
development, maintenance, and repair.
 Concentrated in the endosteum.
 It also pumps out hydrogen ions to create an acid
environment that eats away at the matrix.
DISORDES
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Muscle
28
DISORDES

Types of Muscle Tissue
Skeletal muscle
• >650 muscles
• Located throughout the body connected to bones and
joints
• Striated in appearance
• Under voluntary nervous control.
Smooth or visceral muscle
• Located in the walls of organs
• No striations
• Under involuntary or unconscious nervous control.
Cardiac muscle
o Located only in the heart
o Striated in appearance
o Under involuntary or unconscious nervous control.
DISORDES
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30
Functions of Muscle Tissue
 Provide shape to the body
 Producing body movements
 Stabilizing body positions
 Producing heat
DISORDES

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DISORDES

Joints
 Formed where two bones meet each other
 Also called an articulation
 Three types based on movement allowed between the 2
bones:
 Synovial
 Cartilaginous
 Fibrous
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Synovial Joints
 Freely moving joints
 Most common type of joint
 Example is ball-and-socket joint
 Bones held together by ligaments
 Strong bands of connective tissue
 Some contain a bursa
 Sac-like structure lined with synovial membrane
DISORDES
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Synovial Joints…
 Enclosed in an elastic joint
capsule
 Contains synovial fluid
 Lubricant secreted by synovial
membrane
 Ends of bones are covered
with articular cartilage
DISORDES
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Cartilaginous Joints
 Allow slight movement
 Hold bones firmly in place by solid piece of cartilage
 Example
 Pubic sympysis
DISORDES
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DISORDES
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Type of Joint Extent of
Movement
Example
Synovial Freely movable.
Bones do not
Touch each other
Knee, shoulder
Cartilaginous Slightly
movable
Vertebral bodies of the
spine
Fibrous Immovable Skull sutures
37
DISORDES

Nursing Assessment of the Musculoskeletal System
History
The patient’s history should include the following:
If there was an injury, how it happened and when it happened
• Occupation
 Sports
• Physical activities
• Risk factors for musculoskeletal problems
Family history of musculoskeletal problems (to detect
hereditary problems) NURSING MANAGEMENT OF MSS
DISORDES
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TECHNIQUES OF EXAMINATION
– Inspection
– Palpation
– ROM
• Direct your attention to function as well as structure
– Keeping in mind normal activities of daily living.
Generally, Musculoskeletal assessment includes
1. Assessment of Joint
2. Assessment Muscle
3. Assessment Bones
39
DISORDES

Assessment of Joint
Joints are assessed for :
A. Range of motion
B. Any sign of inflammation
C. Crepitation
D. Deformities
E. Condition of surrounding tissue
F. Symmetry of involvement
40
DISORDES

A. Range of motion
• Determined by its anatomic shape of each joint
• Greatest in synovial
 Limitations in ROM
Decreased range of motion in arthritis
Inflammation of tissues around a joint
Fibrosis in or around a joint & Bony fixation
 Joint Instability -unusual increase in mobility
knee trauma 41
1. Assessment of Joint Cont’d
DISORDES

B. Any sign of inflammation
Swelling -synovitis
Warmth-
- Arthritis, tendinitis, bursitis, osteomyelitis
Tenderness
- trauma ,infection
Redness of the overlying skin
42
Assessment of Joint Cont’d
DISORDES

C. Crepitation
We can detect
Inflamed joints
Osteoarthritis
Inflamed tendon sheaths
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DISORDES

D. Deformities
• Mal alignment of bones
– Fractures
 contractures
44
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E .Condition of surrounding tissue
• Noting skin changes, subcutaneous nodules,
and muscle atrophy
Subcutaneous nodules in rheumatoid arthritis
Effusions in trauma
45
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F. Symmetry of involvement
• Note that whether a symmetric change in joints on both
sides of the body, or only in one or two joints.
• Acute involvement of only one joint suggests
 Trauma
Septic arthritis
Gout
• Typically involvement of several joints, symmetrically
distributed. 46
DISORDES

Assessment of Muscle
Assess muscles
A. Bulk
B. Tone
C. Strength/power
Check each component in the arms, legs, and trunk.
47
DISORDES

A. Muscle Bulk.
• Compare the size and shapes of muscles.
• Do the muscles look flat or concave, suggesting
atrophy?
– If so, is the process unilateral or bilateral?
– Is it proximal or distal?
• When looking for atrophy, pay particular attention to the
hands, shoulders, and thighs 48
2. Assessment of Muscle Cont’d
DISORDES

Muscular atrophy
Diabetic neuropathy
Motor neuron diseases
Disuse of the muscles
Rheumatoid arthritis
Protein-calorie malnutrition
49
2. Assessment of Muscle Bulk Cont’d
DISORDES

• The thenar and hypothenar eminences should be full
and convex
• Atrophy of hand muscles occur with normal aging.
50
Atrophy
Hypothenar Eminence
Flattening of the thenar
eminence due to mild
atrophy
DISORDES

Hypertrophy
• Refers to an increase in bulk with proportionate
strength.
• While increased bulk with diminished strength is called
pseudohypertrophy
51
DISORDES

B. Muscle Tone
• It is the state of muscle tension at rest.
Normal muscle tone : the right amount of “tension”
inside the muscle at rest, that inherently enable the
muscle to contract on command.
• Purpose of muscle tone
– to keep your muscles primed and ready for action
52
DISORDES

Example : You are sitting in your chair, arms
resting on your lap (your arm muscles are
“at rest”).
You decide to have a sip of your coffee,
which is on the table next to you.
With your normal muscle tone, you reach
out with your arm, your hand makes
connection with your cup of coffee, and
you bring it back to your mouth.
No spills, no fuss! 53
Assessment of Muscle Tone Cont’d
DISORDES

Muscle tone can be assessed best by feeling the muscle’s
resistance to passive stretch.
Technique
• Persuade the patient to relax
• Take one hand with yours
• supporting the pt.'s elbow
54
2. Assessment of Muscle Tone Cont’d
DISORDES

• Flex and extend the patient’s fingers, wrist, and elbow,
and put the shoulder through a moderate range of
motion.
• On each side, note muscle tone—the resistance offered
to your movements.
55
DISORDES

Muscle tone
 Normal
 Decreased
 Some decrease
 Complete loss
 Increased
 Spasticity
 Rigidity
56
DISORDES

C. Muscle strength
Nb.
Normal individuals vary widely in their strength;
Age,
Sex,
Muscular training.
 Person’s dominant side
57
DISORDES

Technique
• Asking the patient to move actively against your
resistance or to resist your movement.
• If the muscles are too weak to overcome resistance, test
them against gravity alone.
• If still weak test them both resistance & gravity free.
58
2. Asses’t of Muscle Strength Cont’d
DISORDES

Examples
• Put forearm rests in a pronated position
• Dorsiflexion at the wrist can be tested against gravity
alone
• Free of gravity
o Forearm is midway between pronation and
supination, test extension at the wrist.
• Finally, if the patient fails to move the body part, watch
or feel for weak muscular contraction.
59
DISORDES

60
Muscle strength is graded on a 0 to 5 scale:
0—No muscular contraction detected/no contraction; paralysis
1—A barely detectable or trace of contraction/contraction felt,
but no limb movement
2—Active movement of the body part with gravity eliminated
3—Active movement against gravity/passive ROM/Full ROM
against gravity
4—Active movement against gravity and some resistance/Full
ROM against some resistance
5—Active movement against full resistance without evident
fatigue/Full ROM against full resistance
• This is normal muscle strength.
DISORDES

Causes for muscle weakness (paresis) or paralysis (plegia):
Peripheral or central nerve damage
Musculoskeletal problem
Problem of neurotransmission
61
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3. Assessment of Bone
 Inspect any deformity, malalignments of bones as in
fractures, contractures.
 Observe the patient from the side for any abnormality in
the cervical, thoracic or lumbar curvature .
 Observe the patient from behind for any abnormality in
lateral curvature.
62
DISORDES

3. Assessment of Bone Cont’d
• To detect spinal deformity easily ask the patient to
twist his shoulder side to side, to bend to each side
and to bend backward.
• Palpate bone for tenderness
– Bone pain is often the only symptom of osseous
disease.
63
DISORDES

64
Common Musculo-Skeletal System Trauma
Strain
Sprain
Joint dislocation
Fracture
NURSING MANAGEMENT OF MSS DISORDES

STRAIN
Definition: - is microscopic incomplete muscle tear with
some bleeding into the tissue.
A strain is a soft tissue injury that occurs when a muscle or
tendon is excessively stretched.
Cause:
Overstretching
Overuse or excessive exertion of local tenderness
Falls
Lifting heavy items without using proper body
mechanics.
65
DISORDES

Sign & symptoms
The pt. experiences soreness or sudden pain with local
tenderness upon muscle use.
• Diagnosis: - radiography to rule out possible fracture
66
DISORDES

Classification
A mild strain causes minimal inflammation; swelling and
tenderness.
A moderate strain involves partial tearing of the muscle
or tendon fibers.
• Pain and inability to move the affected body part.
• The most severe strain occurs when a muscle or tendon
is ruptured, with separation of muscle from muscle,
tendon from muscle, or tendon from bone.
67
DISORDES

Management
• RICE is an acronym for rest, ice, compression, and
elevation.
• Immediately after a strain, ice should be applied to
decrease pain, swelling, and inflammation.
• Applying an elastic bandage (compression) and
elevating the affected area provide support and
minimize swelling.
• Once inflammation subsides, heat application (15 to 30
minutes four times a day) brings increased blood flow to
the injured area for healing.
68
DISORDES

Management…
• Limit activity & immobilize until the soft tissue heals.
• Anti-inflammatory drugs may be needed!
• Exercise may begin as early as 2 to 5 days after the
injury, but it may take 1 to 3 weeks of immobility before
exercise can begin.
• For more severe strains, surgery to repair the tear or
rupture may be needed.
69
DISORDES

Sprains
• A sprain is excessive stretching of one or more
ligaments that usually results from twisting movements
during a sports activity, exercise, or fall.
It is an injury to the ligamentous structures surrounding a
joint.
• Like strains, sprains also vary in severity.
Causes: Over stretching of local muscles and ligaments by
twisting action 70

Sign & symptoms
 Loss of function
 Ruptured blood vessels
 Significant edema
 Tenderness
 Pain
71
DISORDES

Classification
• A mild sprain involves tearing of just a few ligament
fibers and causes tenderness.
• In a moderate sprain, more fibers are torn but the
stability of the joint is not affected.
• A severe sprain causes instability of the joint and
usually requires surgical intervention for tissue repair or
grafting.
• Pain and inflammation prevent mobility.
72
DISORDES

Management
• For mild sprains, RICE is used for several days until
swelling and pain diminish.
• Anti-inflammatory drugs can be used to decrease
inflammation and control pain.
• Moderate & severe sprains need immobilization with a
brace or cast until healing occurs.
73
DISORDES

Joint Dislocation
Definition
it is the condition in which the articular surfaces of the bones
forming the joint are no longer in anatomical contact.
Dislocations are a common injury in which the ends of the
bones are forced from their normal position.
They are usually caused by trauma as in falls or contact
sports or a disease such as rheumatoid arthritis.
74

Types & causes: -
Congenital
 Present at birth
 May occur due to some mal development
Pathologic (spontaneous)
o Due to disease of the articular or the peri articular
structure
75
DISORDES

Types & causes: -
Traumatic
 Due to injury in which the joint is disrupted by force
 Traumatic dislocations are emergencies
 If traumatic dislocation is not treated promptly, vascular
necrosis & nerve damage may occur
76
DISORDES

Signs & symptoms of traumatic dislocation
Pain
Change in contour of the joint
Change in the length of the extremities
Loss of normal mobility
Change in the axis of dislocated joint
77
DISORDES

Diagnosis and Management of dislocation
Diagnosis – Hx, x- ray
Management
 Immobilization of the affected joint
 Reduction under anaesthesia
 Several days to week after reduction, gentle active
movement 3-4 times per day is begun to preserve range
of motion.
78
DISORDES

Diagnosis and Management of dislocation…
 Immediate medical treatment is required to preserve
function.
 Splint the extremity as it is found, apply ice, and seek
help.
 Do not move the extremity as blood vessels, muscles,
and nerves could be damaged.
79
DISORDES

Nursing mgt
Nursing diagnosis
 Pain
 Impaired (decreased) mobility
 Knowledge deficit on risk factors
Goal
Relief of pain
Increased mobility
Awareness of risk factors
80
DISORDES

Nursing intervention
Cold application immediately about the first 24-48hrs
minimizes bleeding & swelling as well as pain.
After initial period intermittent heat application will
promote circulation & healing.(15-30 min four times
daily is desirable) immediate elevation & immobilization
An elastic pressure bandage is used to achieve good
support, immobilization & minimizes swelling.
81
DISORDES

Nursing intervention…
 Careful pt. & family teaching about risk factors,
application of the bandage.
 Provision of comfort protection of the joint from further
injury
 Pt. Teaching how to immobilize
 Evaluate neuromuscular status
82

Nursing care…
Most soft tissue injuries are managed by RICE
R= Rest
 I = Ice rifling cold compress immediately for the 1st 24
hrs. 20-30 min intermittently
C= Compression bandage to minimizes swelling & to
support the area
E = Elevation
83
DISORDES

Quiz
1. List at least 3 functions of MSS(1.5 mark)
2. Write components of MSS Assessment(1.5 mark)
3. List common MSS trauma(2 marks)
DISORDES
84

Fractures
Definition : is a break in a bone and can occur at any age
and in any bone.
 Fracture is a break in the continuity of bone and it is
defined according to type and extent
• It occurs when the bone is subjected to stress greater
than it can absorb
85
DISORDES

Cause
1. Direct blow
2. Crushing force
3. Sudden twisting motion
4. Extreme muscle contraction
86
DISORDES

Risk factors
 Old age
 Osteoporosis
 Infection
 Tumor
87
DISORDES

Main types of fractures
• Complete: A complete fracture is exactly what the name
implies, in that the bone breaks into two or more pieces.
• Incomplete: An incomplete fracture occurs when the
bone is cracked but does not completely break into
pieces.
• Compound: In a compound fracture, the bone breaks
through the skin and is exposed.
• This is also known as an open fracture.
88
DISORDES

Main types of fractures…
Simple: When the bone breaks but does not compromise
the skin.
There are many different types of simple fractures, and
they are all determined by the actual break of the bone (
greenstick fractures, oblique fractures, etc.).
89

Specific types of fracture
Green stick:- one side of the
bone is broken and other side is
bent.
Transverse:- straight across the
bone
90
DISORDES

Specific types of fracture…
Oblique:- occurring at an angle
across the bone
Comminuted:- in which bone
has splintered in to several
fragments
91
DISORDES

Specific types of fracture…
Depressed:- in which fragments are driven in ward (seen
frequently skull/facial fractures)
It is a type of fracture usually resulting from blunt force
trauma, such as getting struck with a hammer, rock or
getting kicked in the head.
Comminuted fractures in which broken bones displace
inward 92
DISORDES

Images of Depressed
DISORDES
93

Clinical manifestations
 Pain
 loss of function
 Deformity
 shortening of the
extremity
 Crepitus
 local swelling and
dislocation
 Soft tissue oedema
 Warmth over injured area
 Loss of sensation or paralysis
distal to injury resulting from
nerve damage
 Ecchymosis of the skin
surrounding the injured site
94
DISORDES

Diagnosticstudies---
 History of pt.
 X-ray examinations
 Determines location and extent of fractures/trauma
 CT scans
 Magnetic resonance imaging (MRI).
 Visualizes fractures, bleeding, and soft-tissue damage
95
DISORDES

Complete blood count (CBC): -
Hematocrit (Hct) (signifying hemorrhage at the fracture
site or at distant organs in multiple trauma)
Increased WBC.
96

 Urine creatinine (Cr) clearance:-
Muscle trauma increases load of Cr for renal clearance.
 Coagulation profile: -
Alterations may occur because of blood loss, multiple
transfusions, or liver injury.
97
DISORDES

Emergency management:-
 Immobilization of the affected part immediately
 If an injured pt 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
 The injured area is immobilized by applying temporary,
well padded splints.
98
DISORDES

Emergency management...
 The circulation distal to the injury should be assessed to
determine adequacy of peripheral tissue perfusion
 In an open fracture, the wound is covered with a clean
(sterile) dressing to prevent contamination
 No attempt is made to reduce the fracture in emergency
room (department) the pt is evaluated completely
99
DISORDES

Principles of managing fracture
The principles of fracture mgt includes:
- Reduction – restore fracture fragments to their
normal anatomic position
- Immobilization – maintain reduction until
healing occurs
- Rehabilitation – promote regaining of normal
flexion and strength of the affected part
100
DISORDES

Principles of managing fracture…
2.Methods of reduction
A. Closed reduction:- is accomplished by bringing the
bone fragments into opposition by manipulation and
manual traction
• X- ray is obtained to determine that the bone
fragments are correctly aligned
101
DISORDES

Methods of reduction...
DISORDES
102
External fixation

B. Open reduction:- through a surgical approach the
fracture fragments are reduced
 Internal fixation devices in the form of metallic pins,
wires, screws, plates, nails may be used to hold the bone
fragments in position until solid bone healing occurs.
103
DISORDES

2. Traction: Used to effect fracture reduction and
immobilization
Purpose
 Reduce fracture
 Maintain correct alignment of bone fragments during
healing
 Immobilize a limb while soft tissue healing takes place
 Correct deformities
 Stretch adhesions
 Overcome muscle spasm 104
DISORDES

DISORDES
105
Figure - Balanced suspension skeletal traction .The patient can move vertically as
long as the resultant line of pull is maintained.

3. Immobilization- maintains reduction until healing occurs.
External fixation devices (cast, splint, brace, cast brace)
-Internal fixation with mental plates, screws and nails
106
DISORDES

4. Cast: A cast is a rigid external immobilizing device that
is moulded to the contours of the body part
Purpose
• To immobilize a reduced fracture
• To provide support and stability for weakened joints
• To correct deformity
• Generally it can permit mobilization of the pt. while
restricting movement of fracture part
107
DISORDES

Figure 17.33: Short arm thumb spica cast
Figure 17.34: Long arm cast
Figure 17.35: Short leg patella tendon bearing
cast
2/5/2023 Prepared by Dereje Addisu 108

Figure 17.36: Cylinder cast Figure 17.37: Hip
spica cast Figure 17.38: Minerva jacket
2/5/2023 Prepared by Dereje Addisu 109

Cast materials
Plaster of paris (POP)
– It is saturate with powder, anhydrous calcium sulphate
(gypsum)
When wet, a crystallization reaction occurs and heat is
given off.
110
DISORDES

Nursing Care of the individual with a cast
The nurse may be required to prepare the
equipment for application of a cast, to assist in the
individual’s care
The area should be clean and dry
If there is skin abrasions, it should be disinfected and
dressed before cast application
DISORDES
111

Nursing Care of the individual with a cast…
 Ensure that the body part immobilized in the desired
position
 The edge needs to be smooth and padded to prevent skin
abrasion
 Internal fixation devices- must be strong and flexible.
E.g. of the materials are titanium alloy stainless steel
 They provide adequate strength and fatigue resistance to
allow healing of the fracture.
DISORDES
112

3. Rehabilitation
 Maintain reduction and immobilization as prescribed
 Elevating the part to minimize swelling
 Monitor neurovascular status
 Control anxiety and pain with reassurance, position
change & analgesics
 Encourage in participation in daily living activities
 Encourage isometric and muscle setting exercise to
improve circulation & minimize disuse atrophy
DISORDES
113

Factors enhancing & inhibiting fracture healing
Enhancing
- Immobilization
- Maximum bone fragment
contact
- Sufficient blood supply
- Proper nutrition
• Growth hormone, vi-t D
Inhibiting
- Extensive trauma
- Bone loss
- Inadequate immobilization
- Infection
- Vascular necrosis
114
DISORDES

Early complications
Local:
• Vascular injury causing hemorrhage, internal or external
• Visceral injury causing damage to structures such as
brain, lung or bladder
• Damage to surrounding tissue, nerves or skin
• Compartment syndrome (or Volkmann's ischemia)
• Wound infection, more common for open fractures
• Exacerbation of underlying diseases such as diabetes
115
DISORDES

Complications ….
Systemic:
• Fat embolism
• Shock
• Thromboembolism (pulmonary or venous)
116
DISORDES

Late Complications
Local:
• Delayed Union
• Non-union
• Malunion
• Joint stiffness
• Contractures
• Avascular necrosis
• Osteomyelitis
117
DISORDES

DISORDES
118
MSSS Infection

Osteomyelitis
• Osteomyelitis is an infection of the bone that results in
inflammation, necrosis, and formation of new bone
(Davis, 2005).
• Osteomyelitis is an infection of bone that can be either
acute or chronic.
• A bone infection lasting less than 4 weeks is considered
acute; one that lasts more than 4 weeks is chronic.
DISORDES
119

CLASSIFICATION
Based on cause
• Haematogenous Osteomyelitis: i.e., due to blood borne
spread of infection)
• Contiguous-focus Osteomyelitis: from contamination
from bone surgery, open fracture, or traumatic injury
(eg, gunshot wound)
• Osteomyelitis with vascular insufficiency: peripheral
vascular disease, most commonly affecting the feet (DM,
PVD) NURSING MANAGEMENT OF MSS DISORDES
120

CLASSIFICATIONS …
Based on Duration
Acute: a bone infection lasting less than 4 weeks
Chronic: a bone infection lasting lasts more than 4 weeks
It commonly affects children, boys more than girls
DISORDES
121

Risk Factors
Poorly nourished
Elderly
Obese
Impaired immune systems
Chronic illnesses (eg, diabetes, rheumatoid
Arthritis),
 Those receiving long-term corticosteroid therapy
Immunosuppressive agents.
Postoperative surgical wound infections occur
within 30 days after surgery.
NURSING MANAGEMENT OF MSS DISORDES 122

Pathophysiology
• Bacterial invasion of bone and surrounding soft tissues.
• Inflammation followed by ischemia
• Bone tissue then becomes necrotic (dies)
• Retards healing and causes more infection
• Bone abscess.

Pathophysiology...
• The resulting abscess cavity contains sequestrum
• Therefore, the cavity cannot collapse and heal, as it does
in soft tissue abscesses.
• New bone growth (Involucrum) forms and surrounds
the sequestrum.
• Chronically infected sequestrum remains and produces
recurring abscesses throughout the patient’s life.
• Chronic Osteomyelitis.
DISORDES
124

DISORDES
125

What Causes Osteomyelitis?
• In most cases, a bacteria called Staphylococcus
aureus, a type of staph bacteria, causes Osteomyelitis.
• Certain chronic conditions like diabetes may increase
your risk for Osteomyelitis.
DISORDES
126

Age Most common organisms
New born (younger than
4 months)
S. Aaureus, Enterobacter species,
and group A and B Streptococcus
species
Children (aged 4mo - 4
yrs
S. Aureus group A Streptococcus
species, Haemophilus influenza,
and Enterobacter species
Children, adolescents
(aged 4 y to adult)
S. Aureus (80%), group A
Streptococcus species, H.
Influenzae, and Enterobacter
species
Adult S. Aureus and occasionally
Enterobacter or Streptococcus
species
2/5/2023 127
What Causes Osteomyelitis....?

Clinical Manifestations
Systematic-fever, nigh sweats, chills, restlessness, nausea
Local symptoms
Constant bone pain that worsens with activity.
Swelling, tenderness, warmth at infection site
Restricted movement of affected part
Later signs: drainage from sinus tracts

Clinical Manifestations …
The patient with acute Osteomyelitis has
• Fever
• Local signs of inflammation(tenderness, redness, heat,
pain, and swelling).
• Pain (particularly over the area of infection), may be the
only apparent complaint.
• Ulceration
• Drainage

Diagnostic Tests
 CBC
Elevated leukocyte count, and ESR
 Biopsy
 Cultures &sensitivity test
 MRIs: Early definitive diagnosis.
 X-ray: Inflammation and edema(early), Irregular
cavities; dense bone formations(late)
 CT scans can show areas of infection.

Management
 IV antibiotic up to 2-3 weeks then oral up to 3 months
 Neonates:- E.g. Cloxacillin + Gentamycine
 Children under 5 years: E.g. Cloxacillin +
Chloramphenicol
 Patients above 5 years:- E.g. Cloxacillin
DISORDES
131

Management…
Surgery: Surgery to drain abscess is recommended
if fever and pain fail to subside after 48 hours of IV
antibiotic treatment or if there is evidence of pus
collection.
Analgesics and splinting: Analgesics and POP casts
splinting of the limb in functional position.
 skin traction: Also reduces pain in the acute phase.

Chronic Osteomyelitis
• It is bone infection lasting longer than a month
 follows a delay/inappropriate treatment of acute
stage.
It follows direct infection of bone in compound
fracture and occurs failed to respond initial course of
antibiotic therapy

Systemic signs may be diminished.
Local signs of infection more common
Constant bone pain
Swelling, tenderness, warmth at infection site
Wound discharges & dead bone (sequester) lies in an
abscess cavity.

Diagnosis
Lab studies
CBC:
leucocytosis.
ESR
Culture, test sensitivity.
Imaging studies
 X-Ray
 CT-Scan
 MRI
Bone biopsy
DISORDES
135

Diagnosis criteria
Requires 2 of the 4 following:-
 Localized classic physical findings of bony
tenderness, with overlying soft-tissue erythema
or edema.
 Purulent material on aspiration of affected bone.
 Positive findings of bone tissue or blood culture.
 Positive radiological imaging study.
DISORDES
136

Chronic Osteomyelitis of the Femur
137

Management
Start with IV antibiotics for 1-2 weeks then oral for 3-6
weeks.
Take cultures to detect the organism and its sensitivity
pattern.
Start empirical treatment before the results came back,
then modify it according to the results.
Surgery
DISORDES
138

Therapeutic Interventions
• Long-term antibiotic therapy
• Infection in bone tissue is difficult to resolve and may
require weeks to months of medication.
• Antibiotic therapy alone may not resolve the
infection.
• May require surgery to remove necrotic bone tissue or
replace it with healthy bone tissue.
• Amputations may be needed for patients who have
massive infections that have not responded to one or
more of the conventional treatments.
DISORDES
139

Nursing Management
• Patients often administer their intravenous antibiotics at
home rather than have a costly stay in a hospital.
• Teach the patient and caregiver about antibiotics.
• Ensure that sterile technique is used for dressing
changes.
• The home health nurse may teach the patient and family
how to perform dressing changes, the importance of
hand washing prior to dressing changes, and how to
avoid the spread NURSING MANAGEMENT OF MSS DISORDES 140

Nursing Diagnoses
Based on the nursing assessment data, nursing diagnoses
for the patient with Osteomyelitis may include the
following:
• Acute pain related to inflammation and edema
• Impaired physical mobility related to pain, use of
immobilization devices, and weight- bearing limitations
• Deficient knowledge related to the treatment regimen
• Risk for extension of infection: bone abscess formation
DISORDES
141

Nursing Interventions
 Relieving pain
 Improving physical mobility
 Controlling the infectious process
 Promoting home and community-based care
– Teaching patients self-care

METABOLIC BONE DISORDERS
Osteoporosis
Osteomalacia
Paget’s Disease

Osteoporosis
• Osteoporosis is a common metabolic disorder in which
the bone loses its density, resulting in fragile bones and
possibly fractures.
• The wrist, hip, and vertebral column are most commonly
involved.
• Osteoporosis generally does not become clinically
apparent until a fracture occurs.
DISORDES
144

Pathophysiology
• Bone is living tissue that is resorbing breaking down) old
tissue (osteoclast cells) and constantly building new
tissue (osteoblast cells).
• Bone density (mass) peaks between 30 and 35 years of
age.
• After these peak years, the rate of bone breakdown
exceeds the rate of bone building as we age.

Pathophysiology....
• Bone mass, deterioration of bone matrix, and
diminished bone architectural strength.
• Alteration of normal homeostatic bone turnover
• The rate of bone resorption that is maintained by
osteoclasts is greater than the rate of bone formation
that is maintained by osteoblast.
• Reduced total bone mass.
• The bones become progressively porous, brittle, and
fragile
• The bone may fracture easily under stresses that would
not break normal bone.

Pathophysiology....
Figure Showing Progressive
osteoporotic bone loss and
compression fractures.
DISORDES
147

Risk factors osteoporosis
 Caucasian or Asian heritage,
 Postmenopausal
 Female (less oestrogen available to protect bone)
 Sedentary lifestyle
 Decreased calcium intake
 Lack of vitamin D
 Excessive alcohol consumption
 Cigarette smoking
 Excessive caffeine intake
 Small boned, petite body build
148

149

Assessment and Diagnosis
• Osteoporosis may be undetectable on routine x-rays
until there has been 25% to 40% demineralization,
resulting in radiolucency of the bones.
• When the vertebrae collapse, the thoracic vertebrae
become wedge shaped and the lumbar vertebrae
become biconcave
DISORDES
150

Signs and Symptoms
 Most women do not realize they have osteoporosis until
they fracture a bone.
 Classic “dowager’s hump,” or kyphosis of the spine, is
usually present at middle age.
 The patient’s height decreases and back pain may be
present.
 Change in body image and may have curtailed social
activities.
 Some patients have difficulty finding clothes that fit
151

152

Diagnostic Tests
CT scans
Ultrasound can also be used to screen bone mass.
• Dual-energy x-ray absorptiometry (DXA) is used as a
screening tool to measure bone mineral content.
Serum analysis
Calcium
vitamin D
phosphorus may be increased.

DISORDES
154

Management
The cornerstone of Rx for osteoporosis is medication and
avoidance of modifiable risk factors
Medication.
 Calcium, vitamin D, and bisphosphonates, such as
Alendronate (fosamax) and risedronate (actonel).
 Selective estrogen receptor modulator (SERM)
 Testosterone (the male hormone that helps build bone),
 Calcitonin (nasal spray, injection),
 Sodium fluoride.

Management....
Diet: Increasing calcium and fluids are the main dietary
considerations for women.
 Calcium intake should be 1000 mg/day for those age 25
to 65 and 1500 mg for those over age 65.
 Teach patients foods having calcium, like dairy products
and dark green, leafy vegetables.
 Avoid using excessive caffeine .
Exercise
Fall prevention NURSING MANAGEMENT OF MSS DISORDES 156

Nursing Diagnoses
• Acute pain related to fracture and muscle spasm
• Deficient knowledge about the osteoporotic process and
treatment regimen
• Risk for constipation related to immobility or
development of ileus (intestinal obstruction)
• Risk for injury: additional fractures related to
osteoporosis

Nursing Interventions
• Relieving Pain
• Promoting Understanding of Osteoporosis and
the Treatment Regimen
• Improving Bowel Elimination
• Preventing Injury
DISORDES
158

Osteomalacia
• Osteomalacia is a metabolic bone disease characterized
by inadequate mineralization of bone.
• As a result of faulty mineralization, there is softening
and weakening of the skeleton, causing pain, tenderness
to touch, bowing of the bones, and pathologic fractures.

Osteomalacia...
• As a result of calcium deficiency, muscle weakness, and
unsteadiness, there is an increased risk for falls and
fractures, particularly pathologic fractures of the distal
radius and the proximal femur
DISORDES
160

Pathophysiology
• The primary defect in osteomalacia is a deficiency of
activated vitamin D (calcitriol), which promotes calcium
absorption from the gastrointestinal tract and facilitates
mineralization of bone.
• The supply of calcium and phosphate in the extracellular
fluid is low.
• Without adequate vitamin D, calcium and phosphate are
not moved to calcification sites in bones.
161

Causes/ Risk Factors
Vitamin D deficiency
Certain surgeries (Gastrectomy, Bypass)
Celiac disease(Autoimmune disorder, the lining of
your small intestine )
Drugs used to treat seizure
Severe renal insufficiency
Hyperparathyroidism
Malnutrition
NURSING
MANAGEMENT
OF
MSS
DISORDES
162

Assessment
• Clients may experience bone pain and weakness.
• Client may complain of tenderness if the bones are
palpated.
• Bone deformities, such as kyphosis and bowing of the
legs)
• Clients exhibit a waddling type of gait, putting them at
risk for falls and fractures.

Diagnosis
X-ray shows generalized demineralization
Laboratory studies show:
– low serum calcium and phosphorus
– Moderately elevated alkaline phosphatase.
Urine analysis
• Excretion of calcium
• Creatinine is low.
Bone biopsy shows
– Increased amount of osteoid
– A demineralized cartilaginous bone matrix
164

Medical and Surgical Treatment
This includes supplements of:
 Calcium
 Phosphorus
 Vitamin D
Adequate nutrition
Exposure to sunlight
Progressive exercise and ambulation.
braces or surgery for correction.
165

Paget’s Disease
• Paget’s disease, also called osteitis deformans, is
a metabolic bone disease in which increased bone
loss results in large, disorganized bone deposits
throughout the body.
• It is primarily a disease of the older adult.
DISORDES
166

Paget’s Disease...
• Paget’s disease (osteitis deformans) is a disorder of
localized rapid bone turnover, most commonly affecting:
–Skull
–Femur
–Tibia
–Pelvic bones
–Vertebrae.
167

Paget’s Disease...
• It is caused by the excessive breakdown and formation of
bone, followed by disorganized bone remodelling.
• This causes affected bone to weaken, resulting in pain,
miss hapen bones, fractures and arthritis in the joints
near the affected bones.
168

Pathophysiology
 A prolific increase in osteoclasts causes massive bone deformity
and destruction.
 Osteoblast then react to form new bone.
 Osteoblastic activity exceeds the osteoclastic activity, the inactive
phase occurs.
 The newly formed bone becomes sclerotic with increased
vascularity.
 Structural bowing of the bones causes malalignment of the hip,
knee, and ankle joints, which contributes to the development of
arthritis and back and joint pain

Causes and symptoms
• The exact cause of this disease is not known, but it tends
to run in families.
DISORDES
170

Signs and Symptoms
• Most patients with Paget’s disease have no obvious
symptoms, particularly when the disorder is confined to
one bone.
• Pain is a major symptom.
• For patients with more severe disease, signs and
symptoms are varied and potentially fatal.
DISORDES
171

 Paget’s disease is insidious; most patients never
experience symptoms.
 Some patients do not experience symptoms but have
skeletal deformity; a few patients have symptomatic
deformity and pain.

• Sclerotic changes, skeletal deformities (eg, bowing of the
femur and tibia, enlargement of the skull, deformity of
pelvic bones), and thickening of the long bones occur.
• A small triangular appearance face.
• The femurs and tibiae tend to bow, producing a waddling
gait
173

• The spine is bent forward and is rigid; the chin rests on
the chest.
• The thorax is compressed and immobile on respiration.
• The trunk is flexed on the legs to maintain balance and
the arms are bent outward and forward and appear long
in relation to the shortened trunk
• The temperature of the skin overlying the affected bone
increases because of increased bone vascularity
174

Assessment and diagnosis
• Elevated serum alkaline phosphatase concentration and urinary
hydroxyproline excretion reflect increased osteoblastic activity.
• Higher values suggest more active disease.
• Patients with Paget’s disease have normal blood calcium levels.
• X-rays confirm the diagnosis of Paget’s disease.
• Local areas of demineralization and bone overgrowth produce
characteristic mosaic patterns and irregularities.
• Bone scans demonstrate the extent of the disease.
• Bone biopsy may aid in the differential diagnosis

Diagnostic Tests
Generally we can diagnose Paget’s disease by:
X-ray findings
Serum calcium, phosphorus level
Urine test
176

Management
Anti pain
Calcitonin
Walking aids
Shoe lifts
Physical therapy
Weight reduction
Diets
177

Bone Tumor
• Neoplasms of the musculoskeletal system are of
various types, including osteogenic, chondrogenic,
fibrogenic, muscle (rhabdomyogenic), and marrow
(reticulum) cell tumors as well as nerve, vascular,
and fatty cell tumors.
• They may be primary tumors or metastatic tumors
from primary cancers elsewhere in the body (eg,
breast, lung, prostate, kidney).
178

Types of bone tumor
Benign Bone Tumors (Primary)
Malignant Bone Tumors (Secondary)

Primary bone Tumors
• Benign tumors of the bone and soft tissue are more
common than malignant primary bone tumors.
• Benign bone tumors generally are slow growing, well
circumscribed, and encapsulated; present few
symptoms; and are not a cause of death.

Primary bone Tumors...
Benign primary Neoplasms of the musculoskeletal system
include:
– Osteochondroma
– Enchondroma
– Bone cyst (eg, aneurysmal bone cyst)
– Osteoid osteoma
– Rhabdomyoma
– Fibroma.
181

• Osteochondroma is the most common benign bone
tumor.
• It usually occurs as a large projection of bone at the end
of long bones (at the knee or shoulder).
• It develops during growth and then becomes a static
bony mass.
182

• Enchondroma is a common tumor of the hyaline
cartilage that develops in the hand, femur, tibia, or
humerus.
• Usually, the only symptom is a mild ache.
• Pathologic fractures may occur.
• Bone cysts are expanding lesions within the bone.
• Aneurysmal (widening) bone cysts are seen in young
adults, who present with a painful, palpable mass of the
long bones, vertebrae, or flat bone.
183

Primary Tumors...
Osteoid osteoma is a painful tumor that occurs in children
and young adults.
• The neoplastic tissue is surrounded by reactive bone
formation that can be identified by x-ray.
Giant cell tumors (osteoclastomas) are benign for long
periods but may invade local tissue and cause
destruction.
• They occur in young adults and are soft and
hemorrhagic. NURSING MANAGEMENT OF MSS DISORDES 184

Management
• The goal of primary bone tumor treatment is to destroy
or remove the tumor.
• Surgery
• Radiation therapy
• Chemotherapy
DISORDES
185

Malignant Bone Tumors
• Malignant musculoskeletal tumors are relatively rare
and arise from connective and supportive tissue cells
(sarcomas) or bone marrow elements (multiple
myeloma).
• Malignant primary musculoskeletal tumors include
osteosarcoma, chondrosarcoma, Ewing’s sarcoma, and
fibrosarcoma.
• Soft tissue sarcomas include liposarcoma, fibrosarcoma
of soft tissue, and rhabdomyosarcoma.
DISORDES
186

Malignant Bone Tumors...
Osteosarcoma (ie, osteogenic sarcoma) is the most
common and most often fatal primary malignant bone
tumor.
Appears most frequently in: Children, adolescents and
young adults.
• Prognosis depends on whether the tumor has
metastasized to the lungs at the time the patient seeks
health care.
DISORDES
187

Metastatic Bone Disease
• Metastatic bone disease is more common
• Tumors arising from tissues elsewhere in the body may
invade the bone and produce localized bone destruction
or bone overgrowth.
• The most common primary sites of tumors that
metastasize to bone are:
Kidney
Prostate
Lung
Breast, ovary &Thyroid.

Pathophysiology
• A tumor in the bone causes the normal bone tissue to
react by osteolytic response (bone destruction) or
osteoblastic response (bone formation).
• Primary tumors cause bone destruction, which weakens
the bone, resulting in bone fractures.
• Adjacent normal bone responds to the tumor by altering
its normal pattern of remodelling.

Pathophysiology...
• The bone’s surface changes and the contours enlarge in
the tumor area.
• Malignant bone tumors invade and destroy adjacent
bone tissue.
• Malignant bone tumors invade and weaken the structure
of the bone until it can no longer withstand the stress of
ordinary use; pathologic fracture commonly results.

• They may be symptom-free
• Pain that ranges from mild and occasional to constant
and severe
• Varying degrees of disability, and, at times, obvious bone
growth.
• Weight loss, malaise, and fever may be present.
• The tumor may be diagnosed only after pathologic
fracture has occurred.
• Spinal Cord Compression
• Neurologic deficits (eg, progressive pain, weakness, gait
abnormality, paresthesia, paraplegia, urinary retention,
loss of bowel or bladder control

Diagnosis
History
Physical examination
X-ray
CT scans
MRI
Biopsy
 Blood and urine test.

Management
The treatment of metastatic bone cancer is palliative.
Pain management
Symptom management
Hypercalcemia results from breakdown of bone
Emotional and spiritual support
End of life care

Nursing management
Monitoring and Managing Potential Complications
Delayed Wound Healing
Osteomyelitis and Wound Infections
Inadequate Nutrition
Hypercalcemia
Promoting Home and Community-Based Care
 Teaching Patients Self-Care

DISORDES
195
Connective tissue disorders of MSS
– Degenerative joint disease/ osteoarthritis
– Rheumatoid arthritis
– Septic arthritis
– Gout arthritis

Degenerative joint disease (DJD)
Degenerative joint disease (DJD), also referred to as
osteoarthritis (OA), is the most common form of
arthritis.
It also is known as the ‘‘wear and tear’’ disease and
typically affects the weight-bearing joints.
Although osteoarthritis can damage any joint in your body,
the disorder most commonly affects joints in your hands,
knees, hips and spine.
196
DISORDES

Degenerative joint disease (DJD)...
• It is characterized by a slow and steady progression of
destructive changes in weight-bearing joints and those
that are repeatedly used for work
DISORDES
197

Causes and types
- Osteoarthritis can be primary or secondary
- OA is results from a series of cellular, biochemical, and
biomechanical factors that affecting cartilage,
subchondral bone and soft tissues of joint
• Primary /idiopathic/ OA:-
- The cause? Unknown but
- Genetic factors and aging is the most common
predisposing factors
- It is not inflammatory joint disease
198

Secondary OA
Caused by any conditions that damages cartilage subjects the
joints to chronic stress, causes joint instability such as:
- Previous joint infection
- Inflammation
- Trauma
- Surgery
- Certain occupation or activities
- Endocrine disorder (hyperparathyroidism)
- Skeletal deformity & Hemophilia
199
DISORDES

• Pain – worse with weight breaking and improve with
rest
- Swelling and joint enlargement due to inflammatory
exudates, blood, fragments of osteophaytes entering
synovial cavity
- Decreased range of motion
- Muscular atrophy due to disuse, joint instability
- Crepitus
• Joint stiffness
• Tenderness.
• Loss of flexibility
200
DISORDES

Pathophysiology
• 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.

Pathophysiology...
• In an attempt to repair the damaged surface, new bone
develops in the form of bone spurs, bone cysts, which
are extended margins of the joints.
• The joint becomes deformed, and the client experiences
pain and limited joint movement.
• The resulting deformity may partially dislocate the joint.
• Structures around the affected joint (such as the joint,
capsule, synovial membrane, and ligaments)
demonstrate degenerative changes.
DISORDES
202

Assessment Findings
Early symptoms
• brief joint stiffness
• pain after a period of inactivity.
• The pain usually increases with heavy use and is relieved
by rest.
• Later, even rest may not adequately relieve the pain.
203

Assessment Findings...
• The joint undergoes enlargement and increased
limitation of movement.
• When DJD afflict the hands, the fingers frequently
develop painless bony nodules on the dorsolateral
surface of the interphalangeal joints:
• Heberden’s nodes formed

Assessment Findings...
• Bouchard’s nodes (bony enlargement of the proximal
interphalangeal joints).
• Crepitus may be heard and felt when the joint is moved.
• The ROM of the affected joint becomes progressively
limited, and stiffness and pain increase.
• Radiographic films demonstrate disruption of the joint
cartilage and bony changes.
• Some clients may have a slightly elevated ESR.
205

Diagnosis
- Client history
- Physical examination
• X-ray
• Magnetic resonance imaging (MRI)
• CT Scans
207
DISORDES

Medical and Surgical Management
Non pharmacological mgt
 Rest &Heat application
 Weight loss
 Splints
 Braces
 Canes, or crutches may reduce discomfort, relieve pain,
and prevent further destruction of the affected joints
 Exercise

Medical and Surgical Management...
Pharmacological mgt
- Acetaminophen
- Systemic NSAID
- Corticosteroid
- Intra articular steroid
injection
Surgical management
- Arthrodesis or joint
fusion
• Joint replacement
DISORDES
209

Rheumatoid arthritis
210
DISORDES

Rheumatoid arthritis is a chronic systemic
inflammatory disease affecting primarily the
diarthrodial joint and surrounding soft tissue
Rheumatoid arthritis (RA) is an autoimmune
disease that causes chronic inflammation of
the joints.
Because it can affect multiple other organs of
the body, rheumatoid arthritis is referred to as
a systemic illness and is sometimes called
rheumatoid disease. 211
DISORDES

212
DISORDES

Etiology
•
 Unknown
Predisposing includes
 Autoimmune reaction (response)
 Genetic predisposition (HLAS)
 Prolonged exposure to antigen
213
DISORDES

The key pathologic features RA
Proliferation of synovial membrane
Erosion of articular cartilage and
Erosion of subchondral bone
- These process results in destruction of intra articular
and periarticular structures and joint deformity
214
DISORDES

- Macrophages and monocytes produce cytokines affects
the inflammatory process
- WBCS release chemicals (like superoxid radicals and
H2O2) that destroy bacteria and normal cells.
Prostaglandins, leukotrienes, digestive enzymes (like
collagenase) are released that breaks collagen
(periarticular structure of connective tissue) and attract
more WBCs
215
DISORDES

- As the inflammation continue results in thickening of
synovium and the junctures fibrin developed in to
granulation tissue (pannus)
- The pannus obstruct the nutrition supply of the
subchondral bone and results in necrosis and adhesions
of joint surface
- Environmental stimulus (antigen: an infectious
microorganisms)
216
DISORDES

- Antigen-antibody response (production of normal
immunoglobulin against the antigen)
- Transformation of IgG and Igm in to rheumatoid factors
- Formation of immune complex in the blood and synovial
fluid
217
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218
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Clinical Features
- Early symptoms include:
- Fatigue
- Weight loss
- Fever
- Malaise
- Morning stiffness of joints
- Pain at rest and with movement
- Edematous, Erythematous “baggy” joint
219
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Clinical Features…
Late symptoms include
- Color changes of digitalis (bluish, rubor, pallor)
- Muscle weakness, atrophy
- Joint deformity
- Decreased joint mobility
- Contractures
- Subluxation or complete dislocation
- Increasing pain
- Formation of rheumatoid nodules are aggregate of
inflammatory cues 220
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Diagnosis
- Clinical Features
- Blood test (RF)
- Lab finding ESR in creased, RBCs decreased
- X-ray study
- MRI
- Ultrasonography
• Biopsy
221
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Diagnostic Criteria
1. Morning stiffness > 1 hours and at least 6 ks duration
2. Soft tissue swelling of 3 or more joints for at least 6 weeks (wks)
3. Swelling of wrist, metacarpophalangeal or proximal
interphalangeal (P/P) joints at least 6wks
4. Symmetric soft tissue swelling
5. Rheumatoid nodules
6. Positive serum rheumatoid factors
7. Radiographic changes (bone erosion or decalcification) in hand or
wrist joint
• N.B four fo these criteria are necessary to diagnosis RH.
222
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Management
Pharmacological Tratement
- NSAIDS like aspirin – inhibiting prostaglandin synthesis,
analgesics, antipyretic
- Corticosteroids like prednisone (oral), hydrocortisone
(intra articular)
- Disease – modifying antirheumatic drugs (DMARD) like-
chloquine phosphate 150-300mg po, or methotrexate
7.5 mg p.o weekly or
- Azathioprine 50-coonry/day P.O 223
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Non drug mgt /nursing management
- Health education about balance of rest and exercise
- Monitor drug side effects
- Give the prescribed drugs
- Encourage physiotherapy and occupational therapy
- Teach the pt about application of heat and cold
- Surgical mgt like: Arthroplasty, synovectomy, tendon
transplants.
224
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Septic arthritis
Septic arthritis, also known as infectious arthritis or joint
infection, is the purulent invasion of a joint by an infectious
agent which produces arthritis.
Septic arthritis is infection of one or more joints by
microorganisms.
Septic arthritis can be caused by bacteria, viruses, and
fungi.
225
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• Septic arthritis is also known as infectious arthritis, and
is usually caused by bacteria, or fungus.
• The condition is an inflammation of a joint that's caused
by infection.
• Typically, septic arthritis affects one large joint in the
body, such as the knee or hip. Less frequently, septic
arthritis can affect multiple joints.
226
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Bacterial arthritis is the result of invasion of the synovial
membrane by microorganism.
Joint can become infected by spread of infection from one
part of the body (Hematogenous spread) or directly by
trauma or surgical instrumentation.
Previous trauma to joints coexisting arthritis, and
diminished host resistance contribute to the development
of an infected joint
227
DISORDES

Cause
Bacteria
Viruses
Fungi
Bacteria
Neisseria gonorrhea,
Mengococeal
Streptococci
Staphylococcus aurous
Distraction of hyaline cartilage w/h heels poorly 228
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Clinical Manifestation
The patient with acute sepsis arthritis usually present
with:
Warm &painful swollen joint
Decreased range of motion
Systemic chills
Fever and leukocytes are present assessment for a
primary locus for infection (e.g. a carbuncle) is
performed.
Elder patients and persons taking corticosteroids or
immune suppressive drugs may not exhibit typical
clinical diagnestive of infection
229
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Symptoms of septic arthritis usually come on rapidly with:
• Intense pain,
• joint swelling, and fever.
Septic arthritis symptoms may include:
Chills
Fatigue and generalized weakness
Fever
Inability to move the limb with the infected joint
Severe pain in the affected joint, especially with movement
Swelling (increased fluid within the joint)
Warmth (the joint is red and warm to touch because of
increased blood flow) 230
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Diagnosis
Diagnostic studies include aspiration, examination, and
culture of synovial fluid.
CT and MRI may dislocate damage to the joint lining Radio
isotopes scanning may be useful in localizing the process
231
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Management
Prompt treatment is essentially antibiotic, such as Nafcillin,
Cefoperazone
Gentamicin, should be started promptly by intravenous
infusion,
penicillin G is used for Gonococcal septic arthritis.
The Parentral antibiotic are continued until symptoms
Disappears.
The synovial fluid is monitored for sterility and decrease in
white blood cells.
232
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In addition to prescribing antibiotics.
The physician may aspirate the joint with a needle to
remove excessive joint fluid exudates and debris.
This promotes comfort as well as decreases joint
destruction due to the action of the photolytic enzyme in
the purulent fluid
233
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Nursing Intervention
The patient nutrition and fluid are monitored to promote
heeling progressive range of motion exercise are
prescribed, which the infection subsides.
In generally nursing care is
- Promote rest
- Administering prescribed drug
- Encourage self-care
234
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Gout
Gout is a clinical syndrome resulting from the deposition
of urate crystals in the synovial fluid, joints or ortiacular
cartilage
- Results from prologld hyperaricemia (elevated serum
uric acid) caused by problems in the synthesiz of
purines or by poor renal excretion of uric acid
• Primary affects adult men.
• Postmenopausal women
235
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Causes
- It can be primary or secondary gout
- The primary gouty arthritis is caused by s starvation,
excessive intake of food that is high in Purine (shellfish,
organ meat)
- Secondary gout is caused by:
- Over production of uric acid by
- Polycythemia vera
- Cancer
236
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Causes…
 Cytotoxic drugs
 Hemorytic anemia
 Leukemia
 Multiple myelama
 under excretion uric acid by:Chronic renal insufficiency
,Lactic acidosis
 Ketoacidosis, Certain drugs that results in under
excretion of uric acid like diuretics like thiazides,
frusomide 237
DISORDES

Predisposing factors/Rio factors:
Family history
Mall gender
Obesity
Excessive alcohol in take
Hyperlipidemia
Hypertension
Diuretic uses
238
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Pathophysiology: -
239
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 With repeated attack, accumulation of sodium urate
crystal(tophi) are deposited in peripheral areas of the
body like great toe, hands & the ear.
 Renal urate lithiasis (kidney stone) with chronic renal
disease secondary to urate deposition may develop.
240
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Clinical Manifestation
Acute gouty arthritis (recurrent attack of severe
articular & periarticular inflammation)
Tophi (crystalline deposits accumulating in articular
tissue, soft tissue & cartilage)
Gouty nephropathy (renal impairment)
241
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Stages of gout can be identified
1. Asymptomatic hyperuricemia
2. Acute gouty arthritis
3. Inter critical gout
4. Chronic tophaceous gout
242
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 For those who are hyper uricemic & going to develop
gout, acute arthritis is the most common early clinical
manifestation.
 The abrupt onset often occurs at night, awakening the pt.
with severe pain, tenderness, swelling & warmth of the
affected joint.
 Early attacks tend to subside spontaneously over 3-10
days even without treatment.
243
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 The attack is followed by a symptom free period (the
inter critical stage).
 Until the next attack, which may not come for months to
years?
• Tophi are generally first noted an average of 10 years
after the onset of gout.
244
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Diagnostic procedures
-Arthrocenthesis: - finding of urate in the synovial fluid
-History & careful physical examination
-Serum level of uric acid
245
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Management; pharmacological
 Colchicines; oral or Parentral -> reduce inflammation
 NSAIDS such as indomethasine is used to relief acute
attack of gout
 Uricosuric agents; like probenecid used to correct
hyperuricemia by increasing urinary excretion of uric
acid.
 Allopurinol; is the medication of choice & used to
decrease uric acid formation but due to its toxicity effect
the use is limited.
246
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Nursing mgt
 Support the pt. in any limitation of ADL.
 Teach about the disease process and avoidance of food
groups rich in purine
 Describe the course of Rx, side effects of drugs and about
signs and symptoms that should be reported
 Follow up, emotional support is very important.
247
DISORDES

- Neoplasm of the musculoskeletal system are of a variety
of types
- They may be  primary tremors  Metastatic tumours:
- from primary cancer of other parts of the body.
- A bone tumor is an abnormal growth of cells within a
bone. A bone tumor may be cancerous (malignant) or
noncancerous (benign).
248
DISORDES

Malignant bore tumours
 Primary malignant musculoskeletal tumours are
relatively rare and arise from connective tissue and
supportive tissue cells or bone marrow elements.
 Malignant primary musculoskeletal tumours include
osteosarcoma, chondrosarcoma, and fibrosarcoma
249
DISORDES

• Bone tumors can be cancerous - or non-cancerous, called
benign.
• Primary bone cancer begins in the bones but may then
spread to other parts of the body.
• Metastatic bone cancer spreads to the bones from
another part of the body
250
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References
1. (n.d.). Retrieved February 05, 2013, from
http://meded.ucsd.edu/clinicalmed/pe_muscskelexam.p
df
2. (n.d.). Retrieved January 30, 2013, from Introduction to the
Musculoskeletal System : www. Ccsf
fog.ccsf.edu/jlansang/.../N41B-
IntroductiontoMusculoskeletalSys.ppt
3. Biomechanics of The Spine. (n.d.). Retrieved February 03,
2013, from
www.hper.txstate.edu/hper/faculty/pankey/5309/Spine..
./Spine.ppt
4. Bates. In Bates’ Guide to Physical Examinationand History
Taking 8th Edition (8th ed.). Philadelphia: Lippinicott
Company.
251
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References
5. Biomechanics of The Spine. (n.d.). Retrieved February 03,
2013
6. Boksmart. (n.d.). Retrieved February 01, 2013, from
http://www.sarugby.co.za/boksmart/pdf
7. Fentie Ambaw, B.T. (2003). In Health Assessments in Nursing
for Professional Nurses, Lecture Note Serious Jimma
University. (pp. 223-232). Carter Center(EPHI) and Fderal
Democratic Republic of Ethiopia MOE & MOH.
8. Graaff,V. D. (2001). In V. D. Graaff, Human Anatomy (6th ed.).
The McGraw−Hill Companies.
9. Musculoskeletal Examination: General Principles. (n.d.).
Retrieved February 05, 2013, from Learning Ace:
www.meded.ucsd.edu/clinicalmed/pe_muscskelexam.pdf
252
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