MUSCULOSKELETAL DISORDERS PRESENTATION .

MUSCULOSKELETAL DISORDERS
PART-II

MUSCULOSKELETAL DISORDERS
• Musculoskeletal disorders (MSDs) are injuries or pain that affect the
musculoskeletal system, which includes:
1. The muscles
2. Ligaments
3. Joints
4. Nerves
5. Tendons
6. structures that support the back, neck, and limbs.
• MSDs can range from short-term conditions, like sprains, fractures, and strains, to
long-term conditions, like osteoarthritis and chronic back pain.
• It can be acute and chronic.

TENDONITIS
 It is defined as is the inflammation of a tendon
or a condition in which the tissue connecting
muscle to bone become inflamed.
 Its happen when a person overuse or injures a
tendon.
 It is normally linked to an acute injury with
inflammation.
 It often affects the elbow, wrist, finger, thigh,
and other parts of the body.

Etiology
 Ageing.
 trauma.
 Certain disease like diabetes or rheumatoid arthritis.
 Certain antibiotics like quinolones.
 Most people develop tendonitis because their jobs and hobbies involve
repetitive motions, which put stress on the tendon.

RISK FACTORS
 Age: Tendons become less flexible with age and more susceptible to injury.
 Profession: A person whose job involves repetitive movements, awkward
positions, frequently reaching overhead, vibration, and forceful exertion has a
higher risk.
 Sports: Sports that involve repetitive movements can lead to tendinitis, for
example, running, tennis, swimming, basketball, bowling, and baseball.

 Some health conditions: People with diabetes and rheumatoid arthritis are more
likely to develop tendinitis.
 Aggravating Factors: A diet that fosters the accumulation of uric acid includes
large quantities of caffeine, meat. animal fat. dairy products, eggs, citrus fruits,
tomatoes.

Most common type of tendonitis
 1.Medial epicondylitis (Golfer's Elbow)It is tendinopathy of the medial
common flexor tendon of the elbow due to overload or overuse.
Common Tendons:
 PT (posterior tibial)
 FCR (flexor carpi radialis)
 FCU (flexor carpi ulna)
 PL (palmaris longus)
 GOLFER'S ELBOW

2. Lateral Epicondylitis (Tennis Elbow): It is tendinopathy of the lateral common
extensor's tendon of the elbow due to overload or overuse.
Common Tendons:
 ECRL
 ECRB
 ED EI
 ECU

 3. Achilles Tendonitis:
 An injury of the Achilles tendon, which connects the calf muscle to the heel
bone.
 It's common in runners and middle-aged people. (Sports persons)
 Heel pain and tenderness are key symptoms.

 4. Patellar Tendonitis (Jumper's Knee): An injury to the tissue connecting the
kneecap to the shin bone (patellar tendon).
 The patellar tendon helps the muscles extend the knee.
 This injury is most common in athletes who frequently jump, such as when
playing basketball and volleyball.
 Knee pain, swelling and stiffness are common symptoms.

5.Bicipital Tendonitis (Biceps Tendonitis):It is an inflammatory
process of the long head of Biceps Tendon.
Causes for Bicipital tendonitis, Impingement in sub acromial
space.
Bicipital Tendonitis diagnosed by SPEED TEST:
Patient position, standing.
Therapist position, standing front of patient First, put shoulder
of patient 90 degree flexion; extension of elbow & supination of
forearm.
Now, therapist apply resistance downward direction.
If pain in bicipital grove indicate bicipital tendonitis.
Same way done in pronated forearm.

 6.Supraspinatus Tendonitis:
The tendon around the top of the shoulder joint becomes inflamed, causing pain when the
arm is moved, especially upwards; (Abduction).
 It is assessed by EMPTY CAN TEST & DROP ARM TEST.

 EMPTY CAN TEST:
 Patient position is standing.
 Therapist standing front of patient.
 Patient's both arm abducted to near 90 & than fully internal rotation, both thumb
point downward.
 Resistance applied downward direction; reproduction of pain indicate test is
positive

 DROPARM TEST:
 Patient position is standing.
 Place Patient affected shoulder 90 of abduction, ask the patient to slowly lowers
the arm.
 If, test is positive patient is unable to do slowly.
 Dropping of arm test is positive indicate supraspinatus tear.

Clinical features:
 Pain (dull & ache, especially when moving the affected limb or joints)
 Tenderness
 Reduced
 ROM
 Mild swelling

DIAGNOSIS:
 Patient's History & Symptoms.
 Physical Examination(to move the tendon, a creaky sound may be heard.)
 Special Test (depending upon involvement of tendon special test use)
 Ultrasound & MRI imaging

 Physiotherapy- Aims To relieve pain & Inflammation.
 Medication: NSAID, Ibuprofen/Corticosteroid injection.
RICE Protocol
 R: Rest
 I: Ice
 C: Compression
 E: Elevation

 If tendinitis persist and there are calcium deposits around the tendon,
extracorporeal shock wave therapy (ESWT) may help.
 A shock wave is passed through the skin, breaking up the calcium deposits.
 The deposits may also be removed surgically.

Surgical management:
Surgical management for tendonitis depends on the location and
severity of the injury, and may include:
•Tendon repair: A surgeon will reattach a torn or ruptured tendon
using sutures, anchors, or other surgical techniques.
•Debridement: A surgeon will remove damaged tissue to promote
healing.
•Bone spur removal: A surgeon will remove bone spurs that may be
putting pressure on the tendon.
•Calcium buildup removal: A surgeon will remove areas of calcium
buildup.
•Tendon grafting: A surgeon will take a tendon from another part of
the body and graft it to the damaged tendon

 Osteoarthritis (OA) is the most common form of arthritis and the most common
joint disease.
 It is also known as degenerative joint disease or osteoarthritis Lumbar spine.
 Most of the people who have OA are older than age 45, and women are more
commonly affected than men.
 Osteoarthritis most often occurs at the ends of the finger, thumbs, neck, lower
back, knees, and hips.

 Osteoarthritis (OS) is a slowly progressive non-
inflammatory disorder of the diarthrodial (synovial)
joints.
 Osteoarthritis is a type of arthritis caused by
inflammation, breakdown and eventual loss of
cartilage in the joints. It is a degeneration of joint
cartilage and underlying bone. It causes pain,
stiffness, especially in the hip, knee, and thumb
joints.

Osteoarthritis in finger joints

ETIOLOGY:
 Older age
 Sex
 Obesity
 Strenuous and repetitive exercise
 Inflammatory and septic arthritis
 Over use or injury to the joints
 Increased parathyroid hormone
 A Metabolic diseases: Paget's disease, diabetes, gout, other hormonal diseases
 Repeated intraarticular haemorrhage e.g. Haemophilia

CLASSIFICATION OF OSTEOARTHRITIS
1.Primary Osteoarthritis
2. Secondary Osteoarthritis

1. PRIMARY OSTEOARTHRITIS
More common than secondary OA
Cause – Unknown
Common in elders where there is no previous pathology
It is mainly due to wear & tea changes occurring in old ages mainly in weight
bearing joints

2. SECONDARY OSTEOARTHRITIS
Due to predisposing cause such as –
Injury to the joint.
Previous infection.
Strain/ sprain/fracture/ dislocation.
Inflammation.
Deformity.
Obesity.
Hyperthyroidism.

CLINICAL MANIFESTATION
 Joint pain
 Paresthesias (numbness, tingling)
 Muscle weakness
 Joint swelling/ synovitis
 Joint tenderness, soreness, stiffness
 Loss of joint flexibility
 Grafting sensation and crepitus
 Bony swelling and deformity

DIAGNOSIS
 Physical Examination
 X-Ray
 CT Scan and MRI
 Blood test
 Erythrocyte Sedimentation Test (ESR)
 Joint Aspiration for joint fluid (synovial Analysis).

MANAGEMENT (MEDICAL)
Analgesic/Antipyretic - Acetaminophen
(Paracetamol): 650mg q4-6 hr prn
NSAIDS - Ibuprofen (Advil, Motrin): 400-800 mg
tid-qid
Narcotic or central acting agents - Tramadol: 50-
150mg/day
Cox Inhibitors - celecoxib/amlodipine: 200mg/day
as a single dose or 100mg bid

SURGICAL MANAGEMENT
 Arthroscopy.
 Joint Replacement.
 Osteotomy.
 Joint Fusion.

NURSING MANAGEMENT
 Assess and document the type, location, severity, frequency, and duration of the
patient's joint pain and stiffness.
 Identify the patient's pain management practices, and ask about success of each
treatment.
 Assess tenderness, swelling, limitation of movement and crepitation of affected joints.
 Compare an involved joint with the opposite joint if it is not affected

NURSING DIAGNOSIS
 Acute and chronic pain related to physical activity and lack of knowledge of pain self
management techniques.
 Impaired physical mobility related to weakness, stiffness or pain with ambulation.
 Overweight or weight related to intake in excess of energy output.
 Depression related to chronic pain, change in physical appearance and impaired social
and work roles.
 Imbalance nutrition less than body requirement related to unwillingness to eat,
anorexia, secondary to pain and verbalization.

HEALTH EDUCATION
 Diet:
1. Take green leafy vegetables, calcium rich foods.
2. Avoid smoking/ alcohol.
3. Restrict fat intake.

 Medications:
1. Seven rights should be checked before administration.
2. Do not take insulin before checking blood sugar.
Rest: Adequate rest is needed during this time.
Lifestyle modifications: losing weight, exercise, swimming, cycling can help.
Follow up care: doctor's order must be followed properly. Clinical follow-up
and check-ups should be done on proper time.

COMPLICATIONS
 Rapid, complete breakdown of cartilage resulting in loose tissue material in
the joint (chondrolysis).
 Bone death (osteonecrosis).
 Stress fractures (hairline crack in the bone that develops gradually in
response to repeated injury or stress).
 Bleeding inside the joint.
 Infection in the joint.
 Deterioration or rupture of the tendons and ligaments around the joint,
leading to loss of stability.
 Pinched nerve (in osteoarthritis of the spine).

RHEUMATOID ARTHRITIS
• Rheumatoid arthritis (RA) is an autoimmune disease of unknown origin.
• It is classified as a diffuse connective tissue disease and is chronic in nature.
• It is characterized by diffuse inflammation and degeneration in the connective
tissues

RISK FACTORS
Genetics: Certain genes, such as the human leukocyte antigen (HLA) class II gene,
can increase the risk of RA
Age :The risk of RA increases with age, and is highest in adults 50 to 59
Sex : Women are two to three times more likely to have RA than men
Smoking
Air pollution: Exposure to air pollution, such as from heavy traffic, industry, and
forest fires, may increase the risk of RA
Other risk factors:
•Early life exposures, such as exposure to smoke from parents
•Periodontitis
•Stress
•Lack of exercise
•Trauma
•Drinking alcohol

CAUSES
• Genetics. Researchers have shown that people with a specific gene marker
called the HLA shared epitope have a fivefold greater chance of developing
rheumatoid arthritis than do people without the marker.
• Infectious agents. Infectious agents such as bacteria and viruses may
trigger the development of the disease in a person whose genes make them
more likely to get it.
• Female hormones. 70% of people with RA are women, and this occur
because of the fluctuations of the female hormones.

• Environmental factors. Environmental factors such as exposure to cigarette
smoke, air pollution, and insecticides.
• Occupational exposures. Substances such as silica and mineral oil may
harm the worker and result in contact dermatitis.

CLINICAL MANIFESTATIONS
 Clinical manifestations of RA vary, usually reflecting the stage and severity of the
disease.
• Joint pain. One of the classic signs, joints that are painful are not easily moved.
• Swelling. Limitation in function occurs as a result of swollen joints.
• Warmth. There is warmth in the affected joint and upon palpations, the joints are
spongy or boggy.
• Erythema. Redness of the affected area is a sign of inflammation.
• Lack of function. Because of the pain, mobilizing the affected area has
limitations.
• Deformities. Deformities of the hands and feet may be caused by misalignment
resulting in swelling.
• Rheumatoid nodules. Rheumatoid nodules may be noted in patients with more
advanced RA, and they are nontender and movable in the subcutaneous tissue.

COMPLICATIONS
• Bone marrow suppression.
• Improper use of immunosuppressants could lead to bone marrow suppression.
• Anemia.
• Immunosuppressive agents such as methotrexate and cyclophosphamide are
highly toxic and can produce anemia.
• Gastrointestinal disturbances. Some NSAIDs are likely to cause gastric
irritation and ulceration.

Assessment and Diagnostic Findings
• Antinuclear antibody (ANA) titer: Screening test for rheumatic disorders,
elevated in 25%–30% of RA patients. Follow-up tests are needed for the specific
rheumatic disorders, e.g., anti-RNP is used for differential diagnosis of systemic
rheumatic disease.
• Rheumatoid factor (RF): Positive in more than 80% of cases (Rose-Waaler test).
• Latex fixation: Positive in 75% of typical cases.
• Agglutination reactions: Positive in more than 50% of typical cases.
• Serum complement: C3 and C4 increased in acute onset (inflammatory response).
Immune disorder/exhaustion results in depressed total complement levels.

• Erythrocyte sedimentation rate (ESR): Usually greatly increased (80–100
mm/hr). May return to normal as symptoms improve.
• CBC: Usually reveals moderate anaemia. WBC is elevated when inflammatory
processes are present.
• Immunoglobulin (Ig) (IgM and IgG): Elevation strongly suggests autoimmune
process as cause for RA.
• X-rays of involved joints: Reveals soft-tissue swelling, erosion of joints,
and osteoporosis of adjacent bone (early changes) progressing to bone-cyst
formation, narrowing of joint space, and subluxation. Concurrent osteoarthritic
changes may be noted.
• Radionuclide scans: Identify inflamed synovium.
• Direct arthroscopy: Visualization of area reveals bone irregularities/degeneration
of joint.
• Synovial/fluid aspirate: May reveal volume greater than normal; opaque, cloudy,
yellow appearance (inflammatory response, bleeding, degenerative waste
products); elevated levels of WBCs and leukocytes; decreased viscosity and
complement (C3 and C4).

MEDICAL MANAGEMENT
• Rest and exercise. There should be a balance of rest and exercise planned for
a patient with RA.
• Referral to community agencies such as the Arthritis Foundation could help
the patient gain more support.
• Biologic response modifiers. An alternative treatment approach for RA,
biologic response modifiers, has emerged, wherein a group of agents that
consist of molecules produced by cells of the immune system participate in
the inflammatory reactions.
• Therapy. A formal program with occupational and physical therapy is
prescribed to educate the patient about the principles of joint protection,
pacing activities, work simplification, range of motion, and muscle-
strengthening exercises.
• Nutrition. Food selection should include the daily requirements from the
basic food groups, with emphasis on foods high in vitamins, protein, and iron
for tissue building and repair.

Pharmacologic Therapy
 Early Rheumatoid Arthritis
• NSAIDs. COX-2 medications block the enzyme involved in inflammation
while leaving intact the enzyme involved in protecting the stomach lining.
• Methotrexate. Methotrexate is currently the standard treatment of RA
because of its success in preventing both joint destruction and long-term
disability.
• Analgesics. Additional analgesia may be prescribed for periods of extreme
pain.

 Moderate, Erosive Rheumatoid Arthritis
• Cyclosporine.
• Neoral, an immunosuppressant is added to enhance the disease modifying
effect of methotrexate.
 Persistent, Erosive Rheumatoid Arthritis
• Corticosteroids. Systemic corticosteroids are used when the patient has
unremitting inflammation and pain or needs a “bridging” medication while
waiting for slower DMARDs to begin taking effect.

 Advanced, Unremitting Rheumatoid Arthritis
• Immunosuppressants. Immunosuppressive agents are prescribed because
of their ability to affect the production of antibodies at the cellular level.
• Antidepressants. For most patients with RA, depression and sleep
deprivation may require the short-term use of low-dose antidepressants such
as amitriptyline, paroxetine, or sertraline, to reestablish an
adequate sleep pattern and to manage chronic pain.

SURGICAL MANAGEMENT
• Reconstructive surgery. Reconstructive surgery is indicated when pain
cannot be relieved by conservative measures and the threat of loss of
independence is eminent.
• Synovectomy. Synovectomy is the excision of the synovial membrane.
• Tenorrhaphy. Tenorrhaphy is the suturing of a tendon.
• Arthrodesis. Arthrodesis is the surgical fusion of the joint.
• Arthroplasty. Arthroplasty is the surgical repair and replacement of the joint.

NURSING MANAGEMENT
 Nursing Assessment
• History and physical exam: The history and physical examination address
manifestations such as bilateral and symmetric stiffness, tenderness,
swelling, and temperature changes in the joints.
• Extra-articular changes: The patient is also assessed for extra-articular
changes and these include weight loss, sensory changes, lymph node
enlargement, and fatigue.

NURSING DIAGNOSIS
• Acute and chronic pain related to inflammation and increased disease
activity, tissue damage, fatigue, or lowered tolerance level.
• Fatigue related to increased disease activity, pain, inadequate sleep/rest,
deconditioning, inadequate nutrition, and emotional stress/depression
• Impaired physical mobility related to decreased range of motion,
muscle weakness, pain on movement, limited endurance, lack or improper use
of ambulatory devices.
• Self-care deficit related to contractures, fatigue, or loss of motion.
• Disturbed body image related to physical and psychological changes and
dependency imposed by chronic illness.

NURSING CARE PLAN AND GOALS
• Improvement in comfort level.
• Incorporation of pain management techniques into daily life.
• Incorporation of strategies necessary to modify fatigue as part of the daily
activities.
• Attain and maintain optimal functional mobility.
• Adapt to physical and psychological changes imposed by the rheumatic
disease.

NURSING INTERVENTIONS
 Relieving Pain and Discomfort
• Provide a variety of comfort measures (e.g., application of heat or
cold; massage, position changes, rest; foam mattress, supportive pillow,
splints; relaxation techniques, diversional activities).
• Administer anti-inflammatory, analgesic, and slow-acting antirheumatic
medications as prescribed.
 Reducing Fatigue
• Provide instruction about fatigue: Describe relationship of disease activity
to fatigue; describe comfort measures while providing them; develop and
encourage a sleep routine (warm bath and relaxation techniques that
promote sleep); explain importance of rest for relieving systematic, articular,
• and emotional stress.

 Increasing Mobility
 Facilitating Self Care
• Assist patient to identify self-care deficits and factors that interfere
with ability to perform self-care activities.
• Develop a plan based on the patient’s perceptions and priorities on
how to establish and achieve goals to meet self-care needs,
incorporating joint protection, energy conservation, and work
simplification concepts: Provide appropriate assistive devices.

 Improving Body Image and Coping Skills
• Help patient identify elements of control over disease symptoms and
treatment.
• Encourage patient’s verbalization of feelings, perceptions, and fears.
• Identify areas of life affected by disease. Answer questions and dispel
possible myths

EVALUATION
 Expected outcomes include:
• Improved comfort level.
• Incorporated pain management techniques into daily life.
• Incorporated strategies necessary to modify fatigue as part of the daily
activities.
• Attained and maintained optimal functional mobility.
• Adapted to physical and psychological changes imposed by the rheumatic
disease.

 "A fracture is a disruption or break in the continuity of the structure
of bone.“
 A fracture is a partial or complete break in the bone. There are many
different types of fractures. Bone fractures are often caused by falls,
injury, or because of a direct hit or kick to the body.

CAUSES
 Trauma - RTA, falls, blunt injuries etc.
 Pathologic fracture - Secondary to some diseases like
 Osteoporosis
 Osteomalacia
 Cancer
 Other bone infections
 Long use of corticosteroids
 old age
 occupation- steel industries, car racer etc

CLASSIFICATIONS
 Open and closed fracture.
 Complete and incomplete facture.
 Classification according to types.

 COMPLETE FRACTURE
1. Simple fracture- The wound is non communicating between skin and bone.
2. Open (compound) fracture- The wound is communicating between skin and
bone.
3. Complicated fracture-Along with the fracture, there is associated injury to
internal structure.
4. Comminuted fractures- A fracture with more than two fragments

 1. Linear fracture-Fracture line is linear to the long axis of the bone.
 2. Transverse fracture-Fracture line is perpendicular to the long axis
of the bone.
 3. Oblique fractures-Fracture line is oblique at 45 to the long axis of
the bone.
 4. Spiral fracture -Fracture line encircles the shaft of the bone like a
spiral.
 5. Impacted fracture-Fractures fragments are pushed into each other
i.e.one overrides the other fragment.

 1. Pathological fractures-Fracture of appoint in the bone weakened
by a disease.
 2. Avulsion fracture-Fracture of the bone at the site of attachment of
tendons or ligaments due to strong pulling force.
 3. EXTRACAPSULAR a fracture outside the joint capsule and
INTRACAPSULAR a fracture within the joint capsule.

 INCOMPLETE FRACTURE
1. Greenstick fractures - Break on one cortex of the bone with
splintering of bone surface.
2. Torus fracture -Buckling of cortex.
3. Bowing fractures- A fracture with bending of bone.

 1. Stress fractures-These are small or micro-fractures resulting from
repeated stress during playing or exercise as jogging or running.
 2.Transchondrial fracture-Separation of articular cartilage from
main shaft of the bone.
 3. Depressed fracture- Broken parts of the bone are driven inwards.
An example is skull fracture.

PATHOPHYSIOLOGY
Due to any etiology(crushing movement)
Fracture occurs, muscle that were attached to bone are disrupted and cause
spasm
Proximal portion of bone remains in place, the distal portion can become
displaced in response to both causative force & spasm in the associated muscles
In addition, the periosteum and blood vessels in the cortex and marrow are
disrupted

Soft tissue damage occurs, leads to bleeding and formation of hematoma
between the fracture fragment and beneath the periosteum
Bone tissue surroundings the fracture site dies, creating an intense
inflammatory response
release chemical mediators (histamines, prostaglandins)
Resulting in vasodilation, edema, pain, loss of function, leukocytes and
infiltration of WBC

CLINICAL MANIFESTATIONS
 1. Pain and tenderness at the site of a fracture- pain is serve,
excruciating and increased on movement. pain is caused by swelling at
the site putting pressure on the sensory nerves, muscle spasms and
damage to the periosteum
 2. Swelling and oedema of the surrounding tissue- There is swelling
and oedema due to disruption of soft tissues or bleeding into the
surrounding tissue producing the risk of acute compartment syndrome.
 3. Increased temperature or warmth-Due to fracture, there is increased
blood flow to the part involved.

 4. Loss of function-Due to disruption of the bone, there is loss of
function of the part involved.
 5. Deformity due to alteration in the shape and length-In a fracture,
there is abnormally in the shape and position of bone because the
muscles pull or displace the fragments into an abnormal position

 6. Crepitus (grating sensation)- A crepitus or grating sensation at the
site is produced by grating or crunching together of the broken
fragments. The crepitus is palpable as crushing or abnormal
sensation.
 7. Involvement of surrounding tissue-Ecchymosis of skin
surrounding the injured area, impairment or loss of sensation or
paralysis distal to injury due to entrapment of nerve and infection
occur as associated features of the fractures.
 8. Blood loss or shock-Hypovolemic (due to blood loss) or
neurogenic shock due to pain can occur.

DIAGNOSIS
 History and physical examination
 X – Ray
 CT Scan
 MRI

FRACTURE HEALING
 Fracture hematoma: when a fracture occurs, bleeding creates a
hematoma, which surrounds the ends of the fragments. (within 72
hours)
 Granulation tissue: active phagocytosis absorbs the products of
local necrosis. The hematoma converts to granulation tissue.
Granulation tissue produces the basis for new bone substance called
osteoid (days 3 to 14)
 Callus formation: As minerals and new bone matrix are deposited in
the osteoid, an unorganized network of bone is formed. It usually
appears by the end of the second week after injury. Evidence of
callus formation can be verified by x-ray.

 Ossification: Ossification of the callus occurs from 3weeks to 6 months
after the fracture and continues until the fracture has healed. During this
stage of clinical union, the patient may be allowed limited mobility or
the cast may be removed.
 Consolidation: As callus continues to develop, the distance between bone
fragments diminishes and eventually closes. This stage is called
consolidation, and ossification continues. It can be equated with
radiologic union.
 Remodeling: Excess bone tissue is reabsorbed in the final stage of bone
healing, and union is completed. Gradual return of the injured bone to its
pre injury structural strength and shape occurs. Radiologic union occurs
when there is x-ray evidence of complete bony union. This phase can
occur up to a year following injury

MANAGEMENT
 Goals
 ➤ Anatomic realignment of bone
 ➤ Immobilization to maintain realignment
 ➤ Restoration of normal to near normal function of the injured part

TREATMENT OF FRACTURE PHASE
 I: Emergency care Phase
 II: Definitive care Phase
 III: Rehabilitation

PHASE I
Emergency care:
Begins at the site of the accident.
It consists of 'splint them where they lie'.

 Closed fracture
 Before splinting remove any ring or bangles worn by the patient.
 Almost any available object( for e.g.: folded news paper, magazine,
rigid cardboard, stick, umbrella, pillow etc.) can be used for
splinting at the site of the accident.

 OPEN FRACTURE
 The bleeding from the wound is stopped by applying firm pressure
using a clean piece of cloth.
 Circular bandage can apply proximal to the wound in order to stop
bleeding.
 If the wound is very dirty, it is washed with clean tap water and
covered with a clean cloth.
 The fracture is splinted

 IN THE EMERGENCY DEPARTMENT
 Basic life support.
 Bleeding is recognized and stopped by local pressure.
 Wooden plank, Cramer-wire splint, Thomas' splint, inflatable splint
are some of the splints used in emergency department.
 After emergency care is provided, suitable radiological and other
investigations are carried out.

 FOR OPEN FRACTURE
 Wound care
 Prophylactic antibiotics: Cephalexin is a good broad-spectrum
antibiotic for this purpose.
 In serious compound fractures, a combination of third generation
cephalosporins and an amino- glycoside is preferred. Tetanus
prophylaxis.
 Analgesics to be given parentally to make the patient comfortable.

PHASE-II
 Definitive care: The aim of treatment is rehabilitation of the limb to
pre-injury status.
 Anatomic realignment of bone fragments(reduction).
 Immobilization to maintain realignment.
 Restoration of normal or near normal function of the injured part

METHODS OF TREATMENT
 Not all fractures need all three of these treatment.
 Treatment by functional use of the limb: Some fractures (e.g.: fractured
ribs, scapula) need no reduction or immobilization. These fractures unite
despite functional use of the body part. Analgesics are needed for the
initial few days.
 Treatment by immobilization: Fractures without significant displacement
or fractures where the displacement is of no concern are treated this way.
 Treatment by reduction followed by immobilization: It is required for most
displaced fractures. These otherwise result in deformity, shortening etc.

 Open reduction and internal fixation:
 Some fractures, such as intraarticular fractures, are best treated by
open reduction and internal fixation.

Fracture reduction:
Reduction of a fracture can be carried out by following methods:
Closed reduction
 Open reduction.
 Continuous traction.

FRACTURE REDUCTION:
Closed reduction it is the non surgical reduction. under local or general
anesthesia.
Open reduction:
Surgical
ORIF
OREF

IMMOBILIZATION:
Casts
Splints
Tractions.

ORIF:
 To stabilize a long bone fracture, a plate and screws outside the bone or a
rod inside the bone may be used.

DRUG THERAPY
 Muscle relaxants.
 Analgesics.
 Prophylactic antibiotics
 Tetanus immunization.
 Surgical debridement and irrigation

NUTRITIONAL
 High protein.
 Vitamins minerals.
 High fluid intake.
 Small and frequent diet.
 Avoid constipation.

STAGES OF BONE HEALING
 Fracture hematoma - 72 hours of injury.
 Granulation tissue - 3 to 14 days.
 Callus formation - end of 2nd week.
 Ossification - 3 weeks to 6 months, clinical union, cast can be
removed. Consolidation - radiological union.
 Remodeling - up to one year

NURSING DIAGNOSIS
 1.Increased risk of hypovolemia and shock related to trauma and bleeding.
 2.Increased risk of bone inflammation related to open fracture.
 3.Increased risk of fat embolism related to fracture of the long bones.
 4.Increased risk of severe fluid, electrolyte, and metabolic imbalances
related to injury or inflammation.
 5.Pain and immobility, related to diagnosis of fracture.
 6.Increased risk of respiratory, cardiovascular, bowel, and skin
complications related to a long period of immobility.
 7.Anxiety related to the symptoms of disease and fear of the unknown.

MUSCULOSKELETAL DISORDERS PRESENTATION .

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