Chapter 62: Nursing Assessment: Musculoskeletal System

STRUCTURES AND FUNCTIONS

• The main functions of bone are support, protection of internal organs, voluntary movement,
blood cell production, and mineral storage.

• Cylinder-shaped structural units (haversian systems) fit closely together in compact bone,
creating a dense bone structure.

• Types of bone cells include osteoblasts, osteocytes, and osteoclasts.

o Osteoblasts synthesize organic bone matrix (collagen) and are the basic bone-
forming cells.
o Osteocytes are the mature bone cells.
o Osteoclasts participate in bone remodeling by assisting in the breakdown of bone
tissue.
o Bone remodeling is removal of old bone by osteoclasts (resorption) and the
deposition of new bone by osteoblasts (ossification).

• Each long bone consists of the epiphysis, diaphysis, and metaphysis.

o Epiphysis, the widened area found at end of a long bone, is composed of cancellous
bone. Epiphysis is the location of muscle attachment.
o Diaphysis is the main shaft of the bone. It provides structural support and is
composed of compact bone. Marrow is in the center.
o Metaphysis is the flared area of cancellous bone between the epiphysis and the
diaphysis.

• A joint (articulation) is where ends of two bones are in proximity and move in relation to
each other. Joints are classified according to degree of movement they allow.

• Cartilage is a rigid connective tissue in synovial joints that serves as support for soft tissue
and provides articular surface for joint movement. Types of cartilage tissue include hyaline,
elastic, and fibrous.

• Types of muscle tissue are cardiac (striated, involuntary), smooth (nonstriated, involuntary),
and skeletal (striated, voluntary) muscle.

• A nerve fiber and the skeletal muscle fibers it stimulates are called a motor endplate. The
junction between axon of nerve cell and adjacent muscle cell is called the myoneural or
neuromuscular junction.

• Ligaments and tendons are composed of dense, fibrous connective tissue. Tendons attach
muscles to bones, and ligaments connect bones to bones.

• Fascia is defined as layers of connective tissue with intermeshed fibers that can withstand
limited stretching.

• Bursae are small sacs of connective tissue lined with synovial membrane and contain
synovial fluid.
Assessment
• Many functional problems experienced by the aging adult relate to changes of the
musculoskeletal system.
o Increased bone resorption and decreased bone formation cause a loss of bone
density, contributing to development of osteoporosis.
o Tendons and ligaments become less flexible, movement becomes rigid.

• Common symptoms of musculoskeletal impairment include pain, weakness, and deformity,

limitation of movement, stiffness, and joint crepitation.

• Health history questions should focus on past medical problems, surgeries, and symptoms of
arthritic and connective tissue diseases.

• Maintenance of normal body weight, nutrition, avoidance of excessive stress on muscles and
joints, and the use of proper body mechanics when lifting objects are noted.

• Inspection is performed starting at head and neck and proceeding to upper extremities, lower
extremities, and trunk. The opposite body part is used for comparison when an abnormality
is suspected.

• Palpation of both muscles and joints allows for evaluation of skin temperature, local
tenderness, swelling, and crepitation.

• Carefully evaluate both passive and active range of motion; measurements should be
similar for both maneuvers.
o Active range of motion means patient takes his or her own joints through all
movements without assistance.
o Passive range of motion occurs when someone else moves patient’s joints without
his or her participation.

• If patient able to move independently, assess posture and gait by watching patient walk,
stand, and sit.

• When length discrepancies or subjective problems are noted, obtain limb length and
circumferential muscle mass measurements.

• Scoliosis is a lateral S-shaped curvature of thoracic and lumbar spine. Unequal shoulder and
scapula height is usually noted when patient is observed from back.

Diagnostic Studies
• X-rays provide information about bone deformity, joint congruity, bone density, and
calcification in soft tissue.
o Fracture diagnosis and management are indications for x-ray; also useful in
evaluation of hereditary, developmental, infectious, inflammatory, neoplastic,
metabolic, and degenerative disorders.

• A fiberoptic tube called an arthroscope is used to directly examine interior of joint cavity in
 an arthroscopy.
o Torn tissue can be repaired through arthroscopic surgery, eliminating the need for a
larger incision and greatly decreasing the recovery time.

• Arthrocentesis or joint aspiration is usually performed for a synovial fluid analysis. The
fluid is examined grossly for volume, color, clarity, viscosity, and mucin clot formation.

****Chapter 63: Nursing Management: Musculoskeletal Trauma and Orthopedic

Surgery

• The most common cause of musculoskeletal injuries is a traumatic event resulting in

fracture, dislocation, and associated soft tissue injuries.

• Nurses have an important role in public education about the basic principles of safety and
accident prevention.

SOFT-TISSUE INJURIES
• A sprain is an injury to tendinoligamentous structures surrounding a joint, usually caused
by wrenching or twisting motion.

• A strain is an excessive stretching of a muscle and its fascial sheath. It often involves the
tendon.

• Symptoms of sprains and strains are similar and include pain, edema, decrease in function,
and contusion.

• Mild sprains and strains are usually self-limiting, with full function returning within 3 to 6
weeks.

• Severe strains may require surgical suturing of muscle and surrounding fascia.

• RICE (rest, ice, compression, elevation) can decrease inflammation and pain for most of
these injuries.

• Stretching and warm-up prior to exercising and before vigorous activity significantly
reduces sprains and strains.

DISLOCATION
• Dislocation is a severe injury of the ligamentous structures that surround a joint.

• The most obvious sign is deformity, also local pain, tenderness, loss of function of
injured part, and swelling of soft tissues in joint region.

• Requires prompt attention with the dislocated joint first realigned in its original
anatomic position.

• Extremity then is immobilized by bracing, taping, or using a sling to allow torn

ligaments and tissue time to heal.
SUBLUXATION
• Subluxation is a partial or incomplete displacement of the joint surface.

• Manifestations are similar to a dislocation but are less severe. Treatment is similar to a
dislocation, but subluxation may require less healing time.

• Nursing care of subluxation or dislocation is directed toward pain relief and support and
protection of injured joint.

REPETITIVE STRAIN INJURY

• Repetitive strain injury (RSI) is a cumulative traumatic disorder resulting from prolonged,
forceful, or awkward movements.

• RSI can be prevented through education and ergonomics.

• Treatment includes identifying the precipitating activity, modification of activity, pain

management with heat/cold application, drugs, rest, physical therapy for strengthening and
conditioning, and lifestyle changes.

CARPAL TUNNEL SYNDROME

• Carpal tunnel syndrome (CTS) is caused by compression of the median nerve, which
enters the hand through the narrow confines of the carpal tunnel.

• CTS is often caused by pressure from trauma or edema caused by inflammation of tendon
(tenosynovitis), rheumatoid arthritis, or soft tissue masses.

• Signs are weakness (especially in thumb), burning pain, and numbness.

• Holding the wrists for 60 seconds produces tingling and numbness over the distribution of
the median nerve, a positive Phalen’s test.

• Prevention involves educating employees and employers to identify risk factors.

• Early symptoms usually relieved by stopping the aggravating movement and by placing
hand and wrist at rest by immobilizing them in a hand splint. Injection of a corticosteroid
drug directly into carpal tunnel may provide some relief.

• If CTS continues, median nerve may need to be surgically decompressed. Rehabilitation can
last up to 7 weeks.

ROTATOR CUFF INJURY

• Rotator cuff injury may occur gradually from aging, repetitive stress, or injury to the
shoulder while falling.

• Manifestations include shoulder weakness and pain and decreased range of motion.

• Conservative treatment involves rest, ice and heat, NSAIDs, corticosteroid injections into
joint, and physical therapy.

• Surgery may be done with complete tear or no improvement with conservative therapy.
MENISCUS INJURIES
• Meniscus injuries are associated with ligament sprains that commonly occur in athletes.

• Pain is elicited by flexion, internal rotation, and then knee extension.

• Surgery may be indicated for a torn meniscus.

• Proper stretching may make the patient less prone to meniscal injury when a fall or twisting
occurs.

BURSITIS
• Bursitis results from repeated or excessive trauma or friction, rheumatoid arthritis, or
infection.

• Manifestations are warmth, pain, swelling, and limited ROM in the affected part.

• Rest is often the only treatment needed for bursitis.

FRACTURE
• Fracture is a disruption or break in the continuity of the bone structure.

• Traumatic injuries account for the majority of fractures.

• Fractures are often described according to 1) type, 2) communication or

noncommunication with the external environment, and 3) anatomic location.

• Signs include immediate localized pain, decreased function, and inability to bear
weight or use affected part. Obvious bone deformity may not be present.

• Fractures require nursing assessments of the peripheral vasculature (color,

temperature, capillary refill, peripheral pulses, and edema) and neurologic systems
(sensation, motor function, and pain).

• Treatment goals are anatomic realignment of bone fragments, immobilization to

maintain realignment, and restoration of function.

• Lower extremity injuries are often immobilized by casts, dressings, or

splints/immobilizers.

• The majority of fractures heal without complications, which include bone infection,
avascular necrosis, compartment syndrome, venous thrombosis, fat embolism, and shock.

• Nursing care involves comfort measures for pain, maintenance of nutrition, and
prevention of complications associated with immobility.

• A Colles’ fracture is a fracture of the distal radius. Usually managed by closed

manipulation, by immobilization by splint or a cast, or, if displaced, by internal or external
fixation.

• Fractures involving the shaft of the humerus are a common injury among young and
middle-aged adults. If surgery is done, skin or skeletal traction may be used for reduction
 and immobilization.

• Pelvic fractures range from benign to life threatening depending on mechanism of

injury and associated vascular insult.
o Physical examination demonstrates local swelling, tenderness, deformity, unusual
pelvic movement, and ecchymosis on abdomen.
o Treatment depends on the injury severity and ranges from limited intervention to
pelvic sling traction, hip spica casts, external fixation, and open reduction.

HIP FRACTURES
• Hip fractures are common in older adults.

• Manifestations are external rotation, muscle spasm, shortening of affected extremity,

and severe pain in region of fracture.

• Surgical repair is preferred for managing intracapsular and extracapsular fractures.

• After surgery—in addition to teaching on how to prevent prosthesis dislocation—the

nurse should place a large pillow between patient’s legs when turning, avoid extreme hip
flexion, and avoid turning the patient on affected side until approved by surgeon.

• The nurse assists both the patient and family in adjusting to restrictions and
dependence imposed by hip fracture.

AMPUTATION
• Older persons have the highest incidence of amputation due to effects of peripheral vascular
disease, atherosclerosis, and diabetes.

• Indications for amputation include circulatory impairment resulting from a peripheral

vascular disorder, traumatic and thermal injuries, malignant tumors, and infection of the
extremity.

• Goal of surgery is to preserve extremity length and function while removing all infected,
pathologic, or ischemic tissue.

• Goals for the nurse are that the patient will have pain relief from the underlying health
problem, satisfactory pain control, maximum rehabilitation potential, and ability to cope
with the body image changes.

JOINT REPLACEMENT SURGERY

• Joint replacement surgery is the most common orthopedic operation performed on older
adults.

• Surgery is aimed at relieving pain, improving joint motion, correcting deformity and
malalignment, and removing intraarticular causes of erosion.

• Types of joint surgeries include synovectomy, osteotomy, debridement, and arthroplasty.

• Arthrodesis is the surgical joint fusion which may be done if articular surfaces are too
damaged or infected to allow joint replacement or for reconstructive surgery failures.
• Postoperatively, neurovascular assessment is performed to assess nerve function and
circulatory status. Anticoagulation therapy, analgesia, and antibiotics are administered.

• Ambulation is encouraged as early as possible to prevent immobility complications.

• Patient discharge teaching includes instructions on reporting complications, including

infection and dislocation of the prosthesis (e.g., pain, loss of function, shortening or
malalignment of an extremity).