Assessment of Musculoskeletal function

Anatomic and physiologic overview

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The musculoskeletal system includes the bones, joints, muscles, tendons, ligaments, and bursae of the body. The bony structure provides protection for vital organs, including the brain, heart, and lungs. The bony skeleton provides a sturdy framework to support body structures. The bone matrix stores calcium, phosphorus, magnesium and fluoride. The red bone marrow located within bone cavities produces red and white blood cells in a process called hematopoiesis. Joints hold the bones together and allow the body to move. The muscles attached to the skeleton contract, moving the bones and producing heat, which helps to maintain body temperature.

Structure and function of the skeletal system

k There are 206 bones in the human body, divided into four categories:  Long bones (femur)  Short bones (metacarpals)  Flat bones (sternum)  Irregular bones (vertebrae) k Bones are constructed of cancellous (trabecular) or cortical (compact) bone tissue. k Diaphysis shaft of long bones k Epiphysis ends of long bones k Epiphyseal plate separates the epiphyses from the diaphysis and is the center for longitudinal growth in children. k Cartilage tough, elastic, avascular tissue. k Long bones are designed for weight bearing and movement. k Short bones cancellous bone covered by a layer of compact bone. k Flat bones important sites for hematopoiesis. k Bone is composed of cells, protein matrix, and mineral deposits. The cells are of three basic types:  Osteoblasts function in bone formation by secreting bone matrix.  Osteocytes mature bone cells.  Osteoclasts multinuclear cells involved in destroying, resorbing and remolding bone. k Osteon microscopic functioning unit of mature cortical bone. k Lamellae mineralized bone matrix. k Periosteum dense, fibrous membrane covering the bone. k Endosteum thin, vascular membrane that covers the marrow cavity of long bones and the spaces in cancellous bone. k Bone marrow vascular tissue located in the medullary cavity of long bones and in flat bones. Responsible for producing red
and white blood cells.

Bone formation (osteogenesis) k k Ossification process by which the bone matrix is formed and hardening materials are deposited on the collagen fibers. Two basic process of ossification:  Endochondral a cartilage-like tissue (osteoid) is formed, resorbed, and replaced by bone.  Intramembranous occurs when bone develops within membrane, as in the bones of the face and skull.

Bone maintenance k The important regulating factors that determine the balance between bone formation and bone resorption include:  Local stress (weight bearing) acts to stimulate bone formation and remodeling. Weight-bearing bones are thick and strong.  Vitamin D (calcitriol) functions to increase the amount of calcium in the blood by promoting absorption of calcium from the gastrointestinal tract.  Parathyroid hormone responds to low calcium levels in the blood. 1

 Calcitonin secreted in response to elevated blood calcium levels, increases the deposit of calcium in bone.  Blood supply with diminished blood supply bone density decreases. y Bone healing k Fracture healing occurs in four areas including:  Bone marrow  Bone cortex  Periosteum  External soft tissue Six stages of fracture healing: 1. Hematoma and inflammation - There is a bleeding into the injured tissue and formation of a fracture hematoma. - The hematoma is the source of signaling molecules. The injured area is invaded by macrophages (large white blood cells), which debride the area. - Inflammation, swelling, and pain are present. 2. Angiogenesis and cartilage formation 3. Cartilage calcification - Chondrocytes in the cartilage callus form matrix vesicles, which regulate calcification of the cartilage. - Enzymes within these matrix vesicle prepare the cartilage for calcium release and deposit. 4. Cartilage removal 5. Bone formation - Minerals continue to be deposited until the bone is firmly reunited. - With major adult long bone fractures, ossification takes 3 to 4 months. 6. Remodeling - The final stage of fracture repair. - Remodeling is the new bone into its former structural arrangement. - Cancellous bone heals and remodels more rapidly than does compact cortical bone.

Structure and function of the articular system

k Joint (articulation) the junction of two or more bones. Three basic kinds of joints:  Synarthrosis immovable joints  Amphiarthrosis limited motion of joints  Diarthrosis freely movable joints
 Types of diarthrosis joints:  Ball and socket joints permit full freedom of movement  Hinge joints permit bending in one direction only  Saddle joints allow movement in two planes at right angles to each other  Pivot joints permit rotation for such activities as turning a doorknob  Gliding joints allow for limited movement in all directions joint capsule tough, fibrous sheath that surrounds the articulating bones. Synovium secretes the lubricating and shock absorbing synovial fluid into the joint capsule. Ligaments fibrous connective tissue bands that bind the articulating bones together. Bursa a sac filled with synovial fluid that cushions the movement of tendons, ligaments, and bones at a point of friction.

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Structure and function of the skeletal muscle system k k k Tendons cords of fibrous connective tissue that attach muscles to bones, connective tissue, other muscles, soft tissue or skin. Fasciculi parallel groups of muscle cells Fascia fibrous tissue encasing fasciculi

Skeletal muscle contraction k k k Each muscle cell (also referred to as a muscle fiber) contains myofibrils. Sarcomeres contain thick and thin actin filaments. Muscle fibers contract in response to electrical stimulation delivered by an effector nerve cell at the motor end plate. When stimulated, the muscle cell depolarize and generates an action potential manner similar to that described for nerve cells. These 2

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actions potentials propagate along the muscle cell membrane and lead to the release of calcium ions that are stored in specialized organelles called Sarcoplasmic reticulum. Calcium is rapidly removed from the sacromeres by active reaccumulation in the sarcoplasmic reticulum. When calcium concentration in the sacromere decreases, the myosin and actin filaments cease to interact, and the sarcomere returns to oits original resting length (relaxation). Actin and myosin do not interact in the absence of calcium. The primary source of energy for the muscle cells is adenosine triphosphate (ATP), which is generated through the cellular oxidative metabolism. At mow levels of activity (eg, sedentary activity), the skeletal muscle synthesizes ATP from the oxidation of glucose to water and carbon dioxide. During strenuous activity, when sufficient oxygen may not be available, glucose is metabolized primarily to lactic acid. During isometric contraction, almost all of the energy is released in the form of heat; during isotonic contraction, some of the energy is expended in mechanical work. In some situations, such as shivering because of cold, the need to generate heat is the primary stimulus for muscle contraction.

Types of muscle contractions k k Isometric contraction the length of the muscles remain constant but the force generated by the muscles are increased. Isotonic contraction shortening of the muscle with no increase in tension within the muscle.

Ex. During walking, isotonic contraction results in shortening of the leg and isometric contraction causes the stiff leg to push against the floor.    Myoglobulin is a hemoglobin-like protein pigment present in striated muscle cells that transports oxygen. Muscles containing large quantities og myoglobulin (red muscles) have been observed to contract slowly and powerfully (eg, respiratory and postural muscles) Muscles containing little myoglobulin (white muscles) contract quickly (eg, extraocular eye muscles).

Muscle tone k k k k Tone (tonus) state of readiness Flaccid muscle that is limp and without tone Spastic - muscle with greater-than-normal tone Atonic soft and flabby muscles

Muscle actions k k Synergists muscles assisting the prime mover Antagonists muscles causing movement opposite to that of the prime mover.

Exercise, disuse, and repair k k k k Muscles need to be exercised to maintain function and strength. Hypertrophy increase in size of individual muscle fibers without an increase in the number of muscle fibers. Atrophy decrease in the size of the muscle. Bed rest and immobility cause loss of muscle mass and strength.

Body movements produced by muscle contraction k k k k k k k k k k Fexion bending at a joint (eg, elbow) Extension straightening at a joint Abduction moving away from midline Adduction moving toward midline Rotation turning around a specific axis (eg, shoulder joint) Circumduction cone-like movement Supination turning upward Pronation turning downward Inversion turning inward Eversion turning outward 3

k Protraction pushing forward k Retraction pulling backward

Peripheral nerve function Test of sensation Prick the skin centered between the great and second toe Prick the medial and lateral surface of the sole Prick the skin centered between the thumb and second finger Test of movement Ask the patient to dorsiflex the ankle and extend the toes. Ask the patient to plantarflex toes and ankle. Ask the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. Ask the patient to spread all fingers. Ask the patient to touch the thumb to the little finger. Also observe whether the patient can flex the wrist.

Nerve Peroneal nerve Tibial nerve Radial nerve

Ulnar nerve Median nerve

Prick the fat pad at the top of the small finger. Prick the top or distal surface of the index finger.

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Physical assessment: Posture k The normal curvature of the spine is convex through the thoracic portion and concave through the cervical and lumbar portions. k Common deformities of the spine include:  Kyphosis increased forward curvature of the thoracic spine  Lordosis or sway back, an exaggerated curvature of the lumbar spine  Scoliosis lateral curving deviation of the spine Gait k Gait is assessed by having the patient walk away from the examiner for a short distance. k The examiner observes the patients gait for smoothness and rhythm. k Any unsteadiness or irregular movements are considered abnormal. Bone integrity k The bony skeleton is assessed for deformities and alignment. k Symmetric parts of the body are compared. Joint function k The articular system is evaluated by noting the range of motion, deformity, stability, and nodular formation. k Range of motion is evaluated both actively and passively. k Goniometer a protractor designed for evaluating joint motion. Muscle strength and size k The muscular system is assessed by noting the patients ability to change position, muscular strength and coordination, and the size of individual muscles. Skin k The nurse inspects the skin for edema, temperature, and color. Diagnostic evaluation y Imaging procedures 4

X-ray studies  Bone x-rays determine bone density, texture, erosion, and changes in bone relationships.  Multiple x-ray are needed for full assessment of the structure being examined.  X-ray study of the cortex of the bone reveals any widening, narrowing, or signs of irregularity.  Joint x-ray reveal fluid, irregularity, spur formation, narrowing, and changes in the joint structure. Computed tomography  CT scan shows in detail a specific plane of involved bone and can reveal tumors of the soft tissue or injuries to the ligaments or tendons.  Identify the location and extent of fractures in areas that are difficult to evaluate (eg, acetabulum). CT studies, which mat be performed with or without the use of contrast agents, last about 1 hour. Magnetic resonance imaging  Jewelry, hair clips, hearing aids, credit cards with magnetic strips, and other metal-containing objects must be removed before the MRI is done; otherwise they can become dangerous projectile objects. Arthrography  Is useful in identifying acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip or wrist.  A radiopaque substance or air is injected into the joint cavity to outline soft tissue structures and the contour of the joint. Bone densitometry  Is used to estimate bone mineral density (BMD). This can be done through the use of x-rays or ultrasound.  Dual-energy x-ray absorptiometry (DEXA) determines bone mineral density at the wrist, hip or spine to estimate the extent of osteopososis and to monitor a patients response to treatment for osteoporosis.  Bone sonometry (ultrasound) measures heel bone quantity and quality and is used to estimate BMD and the risk of fracture for people with osteoporosis.  Bone density sonography is a cost-effective, readily available screening tool for disgnosing osteoporosis and predicting a persons risk for fracture.

k Nursing interventions: k Before the patient undergoes an imaging study, the nurse should assess for conditions that may require special considerations during the study or that may be contraindications to the study. k It is essential that the patient remove all jewelry, hair clips, hearing aids, and other metal before having an MRI. k If contrast agent will be used, the nurse should carefully assess the patient for possible allergy. y k Nuclear studies Bone scan  Is performed to detect metastatic and primary bone tumors, osteomyelitis, certain faractures, and aseptic necrosis. Nursing interventions: Before a bone scan, the nurse should ask about possible allergy to radioisotope. Assess for any condition that would contraindicate performing the procedure. Encourage the patient to drink plenty of fluids. Ask the patient to empty the bladder before the procedure. Endoscopic studies

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k Arthroscopy
 Is a procedure that allows direct visualization of a joint to diagnose joint disorders.  The procedure is carried out in the operating room under sterile conditions; injection of a local anesthetic into the joint or general anesthesia is used.  A large-bore needle is inserted, and the joint is distended with saline.  The arthroscope is introduced, and joint structures, synovium and articular surfaces are visualized.  After the procedure, the puncture wound is closed with adhesive strips or sutures and covered with a sterile dressing.

k Nursing interventions:
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Wrap the joint with a compression dressing to control swelling. Apply ice to control edema. Extend and elevate the joint. Explain to the patient and family the symptoms to watch for to determine occurrence of complications. Other studies Arthrocentesis  (joint aspiration) is carried out to obtain synovial fluid for purposes of examination or to relieve pain due to effusion. Electromyography  Provides information about the electrical potential of the muscles and the nerves leading to them. Biopsy  May be performed to determine the structure and composition of bone marrow, bone, muscle or synovium to help siagnose specific disease.  The nurse monitors the biopsy site for edema, bleeding and edema.  Analgesics are administered as prescribed for comfort.

Laboratory studies  Blood and urine o CBC, hemoglobin level, WBC Before surgery, coagulation studies are performed to detect bleeding tendencies.  Serum calcium level  Serum phosphorus level  Acid phosphatase is elevated in Pagets disease and metastatic cancer.  Alkaline phosphatase is elevated during early fracture healing and in disease with increased osteoblastic activity (eg, metastatic bone tumors)  Bone metabolism may be evaluated through thyroid studies and determination of calcitonin, parathyroid hormone and vitamin D levels  Serum enzymes  Aldolase is elevated in muscle disease (eg, muscular dystrophy, skeletal muscle necrosis)  Serumosteocalcin (bone GLA protein) indicates the rate of bones turnover. k

Musculoskeletal System k k k Action taken as a result of nervous system stimulation is largely the function of the musculoskeletal system. This system enables the human organism to move the glands and organs to function. It carries out the direction of the nervous and endocrine system.

MUSCLES k carry out movements of the body. 3 Types: 1. SMOOTH k This type of muscle is also called visceral, plain and involuntary muscles. k This muscle is present as sheets in the walls of the blood vessels, the gastrointestinal tract, urinary bladder, ducts of the reproductive system, ureters, respiratory passages, lymphatic vessels, capsule of the spleen, around hair follicles, within connective tissue of the skin and within the eyeball. k It is not under voluntary control. CARDIAC MUSCLE k This type of muscle is also called striated involuntary or heart muscle. k It beats spontaneously and in rhythm. SKELETAL MUSCLE k This type of muscle is striated voluntary and attached to bones. 6

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It is composed of parallel bundles of fibers which are the units of histological organization. Skeletal muscles are attached to the skeleton and permit movements. The are excitable and capable of contraction or extension. Arrangement of the skeleton is usually in antagonistic pairs so that one muscle is extended while the other contracts. After a force that has been applied to a muscle is released, the muscle will return to its normal length because of the characteristics of elasticity. The muscles are attached to the bones at points of insertion by strong fibrous tendons. Each muscle also has a point of origin, which is usually more fixed than the point of insertion. Muscle contraction is initiated by a nerve impulse that reaches the muscle fiber at the myoneural junction. The nerves are located in the middle of the fiber so that the impulse spread out toward both ends, allowing for more coincident contraction of all sacromeres. Energy for contraction is supplied by the breakdown of ATP. Oxygen and glucose are also needed for this reaction.

Skeletal muscles are divided according to the following: 1. According to location a. Intercostal muscle between ribs b. Femoris muscle in the femur c. Brachii muscle in the arm According to direction of fibers a. Rectus straight b. Transverse across c. Oblique oblique, diagonal According to the type of action performed a. Abductor muscle which move limb (or other part) away from the midline of body. b. Flexor muscle which bend a limb at a joint c. Levator muscle which lift a part eg, eyelid d. Extensor muscle which straighten a limb at a joint e. Adductor muscle which move a limb (or other part) towards the midline. According to the shape or size a. Deltoid from greek letter delta b. Trapezius four-sided c. Maximus largest d. Longus longest e. Minimus smallest f. Brevis short g. Fusiform spindle shaped h. Rhomboid quadrilateral According to the number of the heads or origin a. Biceps muscle with 2 heads b. Triceps muscle with 3 heads c. Quadriceps muscle with 4 heads

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A skeletal muscle has 3 parts namely: 1. Origin, the end which is the more fixed point of attachment 2. Insertion, the end which is freely movable. 3. Body or Belly, the portion between the origin and insertion. Attachment of skeletal muscle may either be tendons or fasciae. 1. Tendons attach muscle to bone. Broad sheats of tendons are termed aponeurosis. 2. Fasciae (singular fascia) are tough fibrous connective tissues which separate muscles from one another and hold them in position. Muscles are also named according to movement 1. Prime mover or agonist muscle which execute actual movement e.g., the biceps in flexion of elbow 2. Antagonist muscle that acts against the prime mover, e.g., the triceps in flexion 3. Synergist muscle that enables prime mover e.g., perform the action efficiently and smoothly. 7

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Fixator muscle which studies the bone giving origin to the prime mover so that the insertion will move.

SKELETON k k k k k

The bone consist of cells, fibers and ground substances. It is calcified, making it hard substance suited for supportive and protective functions. Bone tissue is nourished by the haversian system. i.e., a network of minute canals traversed with blood vessels. Bone tissue is constantly crerated and reabsorbed. These 2 processes: i.e., bone creation (deposition) by osteoblasts and bone reabsorption, determine skeletal bone size and strength. I. SKELETAL FUNCTION 1. Provides attachment of muscles, tendons and ligaments 2. Protects delicate4 organs of the body (e.g., brain, heart, lungs and other soft tissue) 3. Stores minerals salts, e.g., calcium, phosphorous and release them whenever necessary. 4. Encloses bone marrow which is responsible for production of blood corpuscles. 5. Assists with movement by providing leverage and attachment for muscles. II. BONE HISTOLOGY  Histologically, bones consist of 2 types 1. Compact bone i.e., strong and dense with closely spaced lamellae (concentric layers of mineral depositions). 2. Cancellous i.e., spongy appearance with more widely spaced lamellae.  Between layers of lamellae are small cavities called lacunae. Suspended in tisuue fluid within each lacuna is an osteocyte (mature bone forming cells). Tiny canals (canaliculi) connects the lacunae and hence the osteocytes.  Red bone marrow has a hematopoietic function (manufactures red and white blood cells) and is located in cancellous bone spaces.  Yellow marrow occurs in the shaft of long bones and extends into the haversian systems. Yellow marrow is connective tissue composed of fat cells. Blood supply to bone comes: (a) via arterioles through the haversian canals, (b) via vessels in the periosteum that center bone through the minute Volkmann;s Canals, (c) via blood vessels in the marrow and bone ends.  Bone is supplied with a network of sensory nerves. III. BONE CLASSIFICATION ACCORDING TO SHAPE Long bones consist of epiphysis, articular cartilage, diaphysis, periosteum and medullary cavity. This type is found in the extremities and as levers. Example: humerus, radius, fibula      2. EPIPHYSIS End of long bones and is composed of cancellous bone. ARTICULAR CARTILAGE Covers long bone ends and provides smooth surfaces for joint movement. DIAPHYSIS Main shaft of a long bone and is composed of compact bone. It provides structural support. METAPHYSIS Flared port of a long bone between the epiphysis and diaphysis. MEDULLARY CAVITY (MARROW) Is in the center of the diaphysis. 1.

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Short bones consist of cancellous bone covered by a thin layer of compact tissue. These type of bones are cube-shaped and provide strength. Example: carapls, tarsals, palanches Flat bones consist of cancellous bone encased in two flat plates of compact bone. These bones protect delicate organs. Example skull, scapula, ribs, sternum Irregular bones are bones of no definite shape. The thinner part consist of two plates of compact bone with cancellous bone between them while the bulky part consist of cancellous bone surrounded by a layer of compact bone. Example: skull and vertebrae Sesamoid bones are rounded, bones which develop in the capsules of joints or in tendons. The function of this bone is to eliminate friction and increase leverage of muscle. Example: patella, knee cap

IV. DIVISION OF HUMAN SKELETON - There are a total of 206 bones in the human body. The skeleton has been divided into axial and appendicular skeleton. A. AXIAL SKELETON 8

The axial skeleton comprises the bones of the vertebral column, thorax and skull. It has a total of 80 bones: 29 bones of the skull (8 cranial, 14 bones of the face, 6 bones of the middle ears and 1 hyoid bone): 26 bones of the thorax (sternum and ribs)

SKULL BONES - The skull includes the cranial and facial bones joined together by the mandible (lower jaw). There is a total of 29 skull bones. 1.) Cranial bones a. Frontal bone- forms the forehead, roof of the nasal cavity and the orbits b. Parietal bone forms the sides and roof of the cranium and are joined at the sagittal suture in the midline c. Occipital bone forms the back and base of the cranium and joints the parietal bone anteriorly at the lambdoid through which the spinal cord joints the medulla oblongata of the brain. d. Temporal bone helps to form the sides and base of the cranium. e. Spheroid bone forms the anterior portion of the base of the cranium. f. Ethmoid bone principal supporting structure of the nasal cavity and contributes to the formation of the orbits. Structure between Cranial bones Sutures the articulation between the cranial bones. a. coronal suture between the frontal and parietal bones b. lambdoid suture between parietal bones and occipital bones c. squamous suture between part of the temporal and parietal d. sagittal suture units parietal bones. Fontanels are soft boneless areas in the skull which are later closed up by the formation of cranial bones, occurring at birth. There are usually 6 fontanels, namely: a. Anterior or bregmatic fontanel the largest and diamond shape located at junctions of the coronal, sagittal and frontal sutures which closes at the middle of the second year of life at 18th months stage. b. Posterior fontanel triangular in shape, located at the union of sagittal and lambdoid sutures. Closes one month after birth. c. Anterol lateral and posterolateral on each side of the skull; normally closed a month or two after birth. 2.) Skull bones - the facial bones consist of 1 mandible 1 vomer, 2 maxillary, 2 xygomatic. 2 nasal, 2 lacrimal, 2 inferior nasal conchae and 2 palatine. a. Mandile the strongest and the longest bone of the face. It is the bone of the lower jaw. b. Maxilla the upper jaw is formed by the fusion of two maxillae which articulate with the frontal bone. c. Nasal bone paired nasal bones join to form the bridge of the nose. d. Palatine bone two bones forming the posterior of the roof of the mouth or hard palate. e. Zygomatic bone the two bones forming the prominence of the cheek called malar bones and rest upon the maxillae articulating with their zygomatic processes. f. Lacrimal bone the paired bone make up part of the orbit at the inner angle of the eye. g. Nasal Conchae or Inferior Turbinae bones lies immediately below each nostril on the lateral side. h. Vomer constitutes the lower posterior portion of the nasal septum. 3.) Bones of the middle ear - A chain of three small bones extends acroos the middle ear. These are the smallest bones of the body known as the ear ossicles. a. Hammer or malleus b. Anvil or Incus c. Stirrup or stapes 4.) Hyoid bone VERTEBRAL COLUMN - The vertebral column or backbone extends the full length of the back. The vertebrae are grouped based on their location cervical, 12 thoracic, 5 lumbar and 1 coccyx. 1. Cervical vertebrae smallest vertebrae, having oblong bodies which are broader from side to side. 2. Thoracic Vertebrae their bodies are no longer and more rounded than those of the cervical region. 3. Lumbar Vertebrae largest and strongest of all vertebrae. 4. Sacrum lies below the 5th lumbar vertebrae and is triangular in shape. 5. Coccyx is formed by the fusion of four rudimentary coccygeal vertebrae or segments and is attached to the tip of the s acrum. 9

THORAX The thorax encloses and protects the lungs and other structures of the chest cavity. It provides support for the bones of the shoulder girdle and upper extremities. Red blood corpuscles are formed in the red bone marrow of the ribs and sternum. 1.) Sternum lies in the midline of the thorax in front. 2.) Ribs are long slender and curved bones attached to the thoracic vertebrae. a. True ribs first 7 pairs are attached to the sternum b. False ribs the 8th, 9th, and 10th pairs and are attached to the 7th ribs by the costal cartilage. c. Free or floating ribs last 2 pairs and are attached in front. - The spaces between the ribs are called intercostals spaces and are filled with muscle. B. APPENDICULAR SKELETON - The appendicular skeleton is composed of bones of the upper and lower extremities including the shoulder and pelvic girdles. 1. Bones of the Upper Extremity a. Shoulder girdle this is made of clavicle and scapula on each side of the body. It serves to attach the bones of the upper extremities to the axial division of the skeleton and provides places for muscle attachments. 1.) Clavicle known as the collar bone located at the root of the neck and anterior to the first rib. 2.) Scapula a large flat triangular bone located on the dorsal portion of the thorax covering the area from the 2nd rib to the 7th rib. It serves as the origin for some muscles that move the arm. b. Humerus long bone of the upper arm c. Radium lies on the lateral thumb side of the forearm d. Ulna lies on the medial side of the forearm e. Carpals there are 8 in each extremity f. Metacarpals the palm of the hand consist of 5 metacarpal bones, each with a base, shaft and head. 2. Bones of the Lower Extremity a. Pelvic Girdle supports the trunk and provides attachment for the legs. It is made up of hip bone or os coxae on each side of the body. This is the broadest bone of the body. y Ilium uppermost and largest portion of the pelvic bone y Ischium lowest and strongest portion of the pelvic bone y Pubic lies superior and slightly anterior to the ischium. Between the pubis and the ischium is an obturator foramen. b. Femur form the bone of the thigh. It is the heartiest, largest and strongest bone in the body. It transmits the entire weight of the trunk from the hip to the tibia. c. Patella or knee cap largest seasamoid bone in the body and is embedded in the tendon of the quadriceps femoris. It is movable and serves to increase leverage of muscles that straighten the knee. d. Bones of the leg y Tibia medial and larger bone of the leg also known as skin bone y Fibula a long, slender bone on the lateral side of the leg. e. Bones of the foot y Tarsal bone 7 in each foot are arranged in the hindfoot and forefoot. y Metatarsals bases of the inner three five metatarsals articular with the 3 cuneiform bones and those of the outer teo warticulates with the cuboid. y Phalanges there are 14 in each foot, 2 of which are in the great toes and 3 in each of the other toes.

DIAGNOSTIC ASSESSMENT

1. Radiologic Studies a. Roentgenograms (X-ray films) to establish presence of musculo-skeletal problems, follow its progress and evaluate treatment effectiveness. y Plain X-ray film is common usually from antero-posterior (AP) and/or lateral view. b. Arthrography injection of a dye or air in the joint for x-ray study c. Myelography examines the spinal cord after introduction of the contrast medium. d. CT Scan useful is assessing some bone and soft tissue tumors and some spinal fractures. 2. Blood Studies 10

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ESR non-specific test for inflammation Uric Acid usually elevated in gout Antinuclear antibody assess presence of antibodies capable of destroying cell nuclei. positive in about 94% of clients with SLE Anti DNA detects serum antibodies that react with DNA most specific test for SLE Test of Mineral Metabolism Calcium decreased levels found in osteomalacia, hypoparathyroidism. increased levels found in bone tumors, acute osteoporosis, hyperparathyroidism. y Phosphorus increased levels found in healing fractures, chronic renal disease. f. Muscle Enzyme tests y Creatine Phosphorus highest concentration found in skeletal muscle. - increased levels found in traumatic injuries, progressive muscular dystrophy y Adolase useful in monitoring muscular dystrophy and dermatomyositis Arthroscopy direct visualization of a joint usong an arthroscope after injection of local anesthesia. Arthrocentesis method of aspirating synovial fluid, blood or pus via a needle inserted into the joint cavity. EMG Electromyelography non-invasive test that graphically records the electrical activity of the muscle at rest and during contraction. Bone scanning radio isotope that are taken up by bones are injected intravenous (usually Na pertechnetae 99 MTc). Musculoskeletal care modalities

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y Cast

Managing care of the patient in a cast

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Is a rigid external immobilizing device that is molded to the contours of the body. Its purposes are to immobilize a body part in a specific position and apply uniform pressure on encased soft tissue. A cast is used specifically to:  Immobilized a reduced fracture  Correct a deformity  Apply uniform pressure to underlying soft tissue  Support and stabilize weakened joints. Generally, casts permit mobilization of the patient while restricting movements of a body part.

y Types of Cast 1.) TRUNK y Collar cast affectations of the cervical spine y Minerva Cast affectations of the upper dorsal and cervical spine y Trauma y POtts disease y Scoliosis y Rizzers Jacket Cast scoliosis y Plaster Shell surgeries involving the spine y Body cast affectations of the lower dorso lumbar spine y Shoulder apica affectations on shoulder joint, upper portion of the humerus y Observations of Pateints with Cast involving the trunk 1. Signs or respiratory distress 2. Signs of cast syndrome y Prolonged nausea and vomiting y Repeated vomiting y Abdominal distention y Vague abdominal pain y Absence of bowel sound 3. Pressure on the chin, jaw, ear, face, axilla, clavicular area, anterior-superior iliac crest, groin, buttocks 4. Urinary and bowel disturbance 11

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Signs of Plaster Sore Itchiness and burning sensation Severe pain Rise of temperature Disturbed sleep Restlessness Offensive odor Discharge on case

2.) UNDER EXTREMITY CIRCULAR CAST a. Short Arm circular cast affections of the wrist and fingers b. Long Arm Circular Cast affections on the forearm c. Hanging Cast fracture of radius ulnar with callus 3.) LOWER EXTREMITY CIRCULAR CAST a. Short leg circular cast (boot cast) affections of ankle and toes b. Walking Cast affections of the ankle with callus formation c. PTB Patellar Tendon Bearing Cast fracture of the tibia fibula with callus d. Long Leg Circular Cast fracture of tibia fibula e. Quadrilateral Cast fracture of the shaft femur with good callus formation f. Cylinder Cast fracture of patella y OBSERVATIONS ON PATIENTS CASTED EXTREMITY 1. Signs of impaired circulation on toes and fingers a. color- cyanosis of the skin b. temperature coldness of the skin c. movement loss of function d. sensation numbness e. pulsation pulselessness in extremity f. severe pain g. marked swelling 2. Nerve damage due to pressure in a nerve as it passes over body prominence. a. increasing pain, persistent and localized b. numbness c. feeling of deep pressure d. paresthesias e. motor weakness or paralysis 3. Infection, tissue necrosis due to skin breakdown a. unpleasant odor over the cast or at edges of cast b. drainage through cast c. sudden unexplained fever d. hot spot on cast over lesion 4. Pressure on axilla, elbow, wrist, metacarpals, iliac crest, groin, knee, ankle and metatarsals. y GUIDELINES FOR BIVALVING A CAST k When cutting a cast in half (bivalving), the physician or nurse practitioner proceeds as follows: 1. With a cast cutter, a longitudinal cut is made to divide the cast in half. 2. The underpadding is cut with scissors. 3. The cast is spread apart with a cast spreaders to relieve pressure and to inspect and treat the skin without interrupting the reduction and alignment of the bone. 4. After the pressure is relieved, the anterior and posterior parts of the cast are secured together with an elastic compression bandage to maintain immobilization. 5. to control swelling and promote circulation, the extremity is elevated (but no higher than heart level, to minimize the affect of gravity on perfusion of the tissue).

4.) SPICA TYPE y Single spica affections of the hip and femur 12

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1 & hip spica Double hip spica Frog Cast congenital hip dislocation Panatalon Case fracture of the pelvis Observations on patients in spica type 1. Signs of respiratory distress 2. Signs of cast syndrome 3. Signs of impaired circulation on toes 4. signs of urinary bowel disturbance 5. signs of infection tissue necrosis 6. pressure around edge of cast below nipple axillary, iliac crest, buttocks, sacral, groin, knee and metatarsals. Casting materials Non plaster k Referred to as fiberglass casts, these water-activated polyurethane materials have the versatility of plaster but are lighter in weight, stronger, water resistant, and durable. k They are used for non displaced fractures with minimal swelling and for long term wear. Plaster k The traditional cast is made of plaster. Rolls of plaster bandage are wet in cool water and applied smoothly to the body. k A crystallizing reaction occurs, and heat is given off. SPLINT OR POSTERIOR MOLD

I. UPPER EXTREMITY a. Short arm posterior mold affections of the wrist and infection, open wounds b. Long arm, posterior mold infections of the forearm, open wounds c. Sugar tong affections of the shoulder, upper portion of humerus with infections, open wounds. d. Abduction Splint fracture of the neck of humerus e. Cock-up-splint fracture of the neck of humerus f. Banjo splint brachial nerve paralysis g. Dennis Browne splint congenital clubfoot II. LOWER EXTREMITY a. Short leg posterior mold affections of the ankle and toes with infections, open wounds. b. Long leg posterior mold affections of the knees, tibia fibula with infections, open wounds c. Night splint post polio with residual paralysis of lower extremity d. Spica Mold affections of the hip, femur-like septic hip, osteomyelitis NOTE: Observations same as in a circular type of cast for upper and lower extremity. y BRACES Types: a. Milwaukee brace scoliosis b. Taylor body brace Potts disease on thoracic vertebrae c. Jawet brace compression fracture of vertebral body d. Shantz collar cervical spine affection e. SOMI sterno occipito madibular immobilizer cervical spine affection f. Forester cervico thoraco-lumbar affections g. Chair back dorso-lumbar affections

TRACTION k is an act pulling and drawing which is associated with counter traction. y PURPOSE/INDICATIONS  For immobilization  To prevent and correct deformity  To maintain good alignment 13

  y

To give support to reduce pain and muscle spasm To reduce fracture

PRINCIPLES OF TRACTION 1. Keep body alignment at normal position the client in dorsal recumbent 2. For every traction, there is always a counter traction y use shock blocks y use half ring Thomas splint 3. For traction to be effective, it must be applied continuously 4. The line of pull must be in line with deformity 5. Friction should be eliminated y Weights should be hanging freely y Rope of sash cord runs freely along the pulley y Knots should be away from the pulley y Weights should not be resting on the floor y Observe the rope and bag weights for signs of wear and tear. TYPES OF TRACTION according to manner of application 1. Manual Traction traction applied to the body by the hand of operator 2. Skin Traction traction applied at the surface of the skin and soft tissue and indirectly to the bone using adhesive elastic bandage and spreader Examples: Bryant Traction, Russell Traction 3. Skeletal Traction traction applied directly to the bone using pin, wires, tongs Example: Halo pelvic traction, Crutchfiels tong traction 4. Filled or adjustable traction traction applied to the body using devices like canvass, laces, buckles, leathers used according to the side of the patient. Examples: Anklet Traction Pelvic Strap Traction Head Halter Traction

NURSING DIAGNOSIS FOR CLIENTS IN TRACTION 1. Potential for immobility related to therapy - provide for active motion of the unaffected joints - deep breathing coughing exercise 2. Potential for neurovascular compromise related to traction 3. Potential for skin breakdown related to pressure on soft tissues. 4. Potential for complication like y Infection at the pin/wire site inspect insertion sites carefully every shift, cleanse sites with saline, peroxide or betadine, use antibiotic ointments and dry sterile dressing if ordered. y Pneumonia, atelectasis y Contractures y Constipation y Bedstore 5. Potential for boredorm 6. Social isolation 7. Partial self-care deficit

Common musculoskeletal problems: y Acute lower back pain k Acute low back pain refers to patients who have a problem with their back that occurred within hours to 1 month. k Is the recent onset of back pain in the lumbar region. k Pain in this area can derive from any of the region's structures, including the spinal bones, the discs between the vertebrae, the ligaments around the spine, the spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the lumbar area. y Back pain is classified into three categories based on the duration of symptoms: 14

k k k

Acute back pain is arbitrarily defined as pain that has been present for six weeks or less. Subacute back pain has a six- to 12-week duration. Chronic back pain lasts longer than 12 weeks. Clinical manifestations: Clinical clues: No nerve root compromise, localized pain over lumbosacral area Back-related lower extremity symptoms and spasm in radicular pattern, positive straight leg raising test History of trauma, osteoporosis, localized pain over spine Affects young athletes (gymnastics, football, weight lifting); pain with spine extension; oblique radiographs show defect of pars interarticularis Unexplained weight loss, fever, abnormal serum protein electrophoresis pattern, history of malignant disease Fever, increased erythrocyte sedimentation rate, positive for antinuclear antibodies, scleroderma, rheumatoid arthritis Fever, parenteral drug abuse, history of tuberculosis or positive tuberculin test Inability to find position of comfort, back pain not relieved by rest, pulsatile mass in abdomen Urinary retention, bladder or bowel incontinence, saddle anesthesia, severe and progressive weakness of lower extremities Insidious, associated with hypercalcemia, renal stones, constipation ostly men in their early 20s, positive for HLA-B27 antigen, positive family history, increased erythrocyte sedimentation rate

Condition:

Nonspecific back pain (mechanical back pain, facet joint pain, osteoarthritis, muscle sprains, spasms) Sciatica (herniated disc)

Spine fracture (compression fracture) Spondylolysis

Malignant disease (multiple myeloma), metastatic disease Connective tissue disease (systemic lupus erythematosus) Infection (disc space, spinal tuberculosis) Abdominal aortic aneurysm

Cauda equina syndrome (spinal stenosis)

Hyperparathyroidism Ankylosing spondylitis (morning stiffness)

AUTO-IMMUNE DISORDERS: y RHEUMATOID ARTHRITIS k It is a connective tissue disease characterized by chronic inflammatory changes in the synovial membrane and other structure. k Is a chronic systemic disease although most prominent as a non suppurative inflammation in the diarthroidal joints, may also be manifested by lesion of the vasculature, lungs, nervous system, and other major organs of the body. Etiology k Exact cause is unknown k Hereditary k Infection k Stress k Metabolic disorder 15

k k

Auto-immune Allergic phenomenon

Pathology k 4 stages of rheumatoid arthritis:

STAGE 1 SINOVITIS STAGE - inflammation of the synovial membrane - tissue thickens with edema and congestion of the synovial membrane STAGE 2 PANNUS STAGE - Thickened synovial tissue grows inward along the surface of the articular cartilage - Pannus appears to be reddish, rough and adheres tightly to the underlying cartilage and damages it. STAGE 3 FIBROUS ANKYLOSIS STAGE - Granulation of tissue becomes invaded with tough fibrous tissue and converted into scar tissue which inhibits joint movement. - Cause subluxation and distortion of affected joints STAGE 4 BONY ANKYLOSIS - there is form bony union as bone tissue calcifies and changes into osseous tissues. y PATHOPHYSIOLOGY k k k y The disease process with in the joints (intraarticular) begins as an inflammation of the synovium wuth edema vascular congestion, fibrin exudates and cellular infiltrate. Particularly damaging to joint tissue is the enzyme collagenase because it breaks down collagen, the main structural protein of connective tissue. RA may also affect other body system and rheumatoid nodules may form in the heart, lung and spleen.

Signs and Symptoms 1. 2. 3. 4. 5. 6. 7. 8. k k k k Subcutaneous nodules appear over tendon sheaths particularly over pressure areas like the elbow Painful, swollen joints especially proximal interphargeal joints of fingers, wrist knees, feet and ankle. Elevated body temperature Morning stiffness Paresthesias of hands and feet Splenomegaly Enlarged lymph nodes Signs of anemia CLASSIC RA = Seven or more criteria observed DEFINITE RA = 5 criteria with joint signs or symptoms continues for at least 6 weeks PROBABLE RA = 3 criteria with joint signs or symptoms continuous for at least 6 weeks POSSIBLE RA = 2 criteria with joint signs or symptoms continuous for at least 6 weeks.

Laboratory Diagnosis k k k k k k Elevated ESR Leukocytes Anemia Latex fixation test presence of rheumatoid factor Narrowing of the joint spaces and crosion of articular surfaces on X-ray examination Inflammatory changes in synovial tissue obtained by biopsy

Nursing Interventions 16

1. Provide rest keep joints as straight as possible. Prevent flexion deformities firm mattress, no pillows under his knees use footboard and trochanter roll to prevent external rotation. 2. Relieve pain by analgesics and NSAID, provide heat therapy as ordered - warm compresses. - heat paraffin to 125 to 129 F (52-54 C) 3. Diet should be well balanced 4. Anemia should be treated 5. Maitain mobility exercises are done slowly, increased gradually and not carried past the point of being painful.  Passive exercises  Isometric Exercises client exerts force without changing the length of the muscle setting exercises, ( alternating tightening and relaxing the muscle), gluteal muscles setting by contracting and relaxing the buttocks, quadriceps setting pressing the popliteal space against the mattress.  Resistive Exercises those actively done by the client with manual or mechanical resistance. To develop muscle strength. y 1. 2. 3. 4. Treatment Analgesic aspirin Non-steroidal anti-inflammatory drugs (NSAID) Indocin Indomethacin Gold compounds myochrysine sodium thiomalate Antimalaria drugs Chloroquine Hydroxychloroquine Corticosteroids Antacids Paraffin dips of affected extremity for relief of joint pain by providing uniform heat. Surgery when medical therapy fails to reduce inflammation y Synovectomy to remove access synovial fluid and tissue in order to prevent recurrence of inflammation. y Arthrotomy opening in the joints to remove damaged tissue or calcium deposits. y Arthrodesis fusion of the joint to give stability, correct deformity and relieve pain. y Arthroplasty plastic reconstruction of a joint to permit mobility and weight bearing and alleviate pain.

5. 6. 7. 8.

SYSTEMIC LUPUS ERYTHEMATOSUS SLE k k Chronic connective tissue disease involving multiple organ system. Is a chronic inflammatory disease of autoimmune origin that affects primarily the skin, joints and kidneys, although it may affect virtually every organ of the body.

Clinical features 1. 2. 3. 4. etiology not clearly understood but believed to be auto-immune, hereditary and viral cause, drug-induced most frequently found in young woman with signs and symptoms referable to joints and skin remissions and exacerbation very difficult to validate diagnosis

3 major areas are currently being researched as possible causes of SLE: 1. Genetic Factors family members of persons with SLE have an increased chance of developing the disease. 2. Environmental Factors ultraviolet light is known to cause exacerbations. 3. Alteration in the Immune Response cause immune complexes containing antibodies to be deposited in tissue, causing tissue damage. Necrosis of the glomerular capillaries, inflammation of cerebral and ocular blood vessels, necrosis of lymph nodes, vasculitis of the GI tract and pleura, and degeneration of the basal layer of the skin. y Signs and Symptoms: 1. Subjective: y Malaise y Photosensitivity y Joint pain 2. Objective y Fever y Butterfly erythema on the face y Positive LE prep. 17

Diagnostic Tests k Clinically documented multiorgan damage k Positive fluorescent anti nuclear antibody test (ANA) k Increase ESR k Elevated serum rheumatoid factor k Increased WBC k Decreased RBC and hemoglobin k Renal function test is elevated k Positive LE cell test Treatment k Corticosteroids and analgesics to reduce pain and inflammation k Supportive therapy as major organs become affected (heart, kidneys, CNS, GI) Nursing Care 1. 2. 3. Administer medications and observe for side effects . Help the clients and family code with severity of the disease as well as its poor prognosis. Improve and maintain nutritional status.

METABOLIC CONDITIONS y GOUTY ARTHRITIS k k k k k Inflammation of the joints secondary to abnormal metabolism of uric acid. Usually affects the big toe Is ametabolic disorder that develops as a result of prolonged hyperuricemia (elevated serum uric acid ) caused by problems in synthesizing purines or by poor renal excretion of uric acid. Incidence highest in males, a familial tendency has been demonstrated. May have deposition of uric acid crystal (tophi) in tissue or renal urate lithiasis (kidney stone) may result from precipitation of uric acid in the presence of a low urinary pH.

Etiology k Genetic defect in purine metabolism overproduction of uric acid k Decreased uric acid excretion CRF k Diet high in purine Diagnostic Test k Elevated ESR, WBC k Increase serum uric acid levels k Synovial fluid reveal urate crystals Signs and Symptoms k Redness, swelling joints k Joint pain k Limited movement k Tophi urate crystals deposited in great toe, ankle, or increase wherein there is dimished blood flow. Management k Administration of anti-inflammatory and (ANTI GOUT) agents to decrease synthesis of uric acid - Purinase - Llanol - Synol - Syloprim - Allopurinol k Salicytes 18

k k k k k k k y

NSAID alkaline-ash diet to increase the pH of urine to discourage precipitation of uric acid and enhance the action of drugs (URICOSURIC AGENT) increase excretion of uric acid Benemid - Probenecid Colsalide - Colchicine elimination of foods high in purines weight loss is encouraged if indicated Diet low purine diet, alkaline ash diet avoid shellfish, sardines, liver, kidneys, internal organs

Nursing Care: 1. Assess joint pain, motion and appearance 2. Administer anti- inflammatory agents such as Butazolicin, oxypheabutazone (Tandearil), or endomethacin (Indocin) with antacids or milk to prevent peptic ulcers. Observe therapeutic response. 3. Careful align joints so they are slightly flexed during acute stage, encourage regular exercise, which is important for long term management. 4. Use a bed cradle during the acute phase to keep pressue of sheets off joints. 5. Increase fluid intake to 2000 to 3000 ml / day to prevent formation of calculi 6. Instruct client to avoid high-purine foods suchs as organ meats, anchovies, sardines and shellfish diet. OSTEOARTHRITIS k k k Degenerative joint disease also known as osteoarthritis is an extremely common disease that is probably as old as civilization. Women are more severely affected by the disease, although the incidence rates are the same for males and females Primary joint disease is the most common type of noninflammatory joint disease. Primary degenerative joint disease is distributed throughout the central and peripheral joints of the body, usually affecting the joints of the hand, wrist, neck, lumbar spine, hips, knees and ankle. The etiology is unknown, but age is an important factor in the development of the disease. The quantity and quality of proteoglycans decrease with the aging process and predispose the cartilage to breakdown and degenerate.

k k

Clinical Manifestations 1. Pain worse with weight bearing, improves with rest. 2. Swelling and joint enlargement: a. Heberdens Nodes bony protuberances occurring on the dorsal surface of the distal interphalangeal joints of the finger. b. Bouchards Nodes bony protuberance occurring on the proximal interphalangeal joints of the finger c. Coxachrosis (Degenerative Joint Disease of the hip) pain in the hip on weight bearing, with pain progressing to include groin and medial knee pain. 3. Muscular Atrophy from disuse, joint instability and deformity 4. Decreased Range of Motion depends on amount of destroyed cartilage 5. Join stiffness worse in the morning and after a period of rest or disuse. CHARACTERISTIC PATHOLOGIC CHANGES AFFECTING THE ARTICULAR CARTILAGE 1. Erosion of articular cartilage 2. Thickening of underneath the cartilage 3. Medications to reduce symptoms such as analgesics, anti-inflammatory agents, and steroids. 4. Exercise of affected extremities. 5. Surgical intervention a. Synovectomy removal of the enlarged synovial membrane before bone and cartilage destruction occurs. b. Arthrodeseis fusion of a joint performed when the joint surfaces are severely damaged, this leaves the client with no range of motion of the affected joint. c. Reconstructive Surgery replacement of a badly damaged joint with a prosthetic device.

OSTEOPOROSIS k k A clinical condition in which there is a decrease in total amount of bone to the point that factures occur with minor trauma. Calcium in the bone is depleted and the bone matrix fails to produce replacement bone. The result is a weakening of the structure. 19

Causes k Exact cause is not known k Nutritional deficiency Vitamin C, calcium deficiency k Endocrine disease hyperthyroidism, hyperparathyroidism, cushings syndrome, women past menopause k Prolonged immobility due to lack of normal stresses and strains. Signs and Symptoms k Low back pain or musculo-skeletal aching k Pathological fracture k Increase in urinary calcium especially at night as calcium withdrawal increase. Management k Exercise with frequent rest periods k Avoidance of severe fatigue k Spinal support corset or light brace in upright position k Analgesic k Muscle relaxants k Adequate intake of protein, Vitamin D and Calcium k Estrogen therapy to post menopausal women.

OSTEOMALACIA k k Decalcification, softening of bones Defined as a defect in mineralization of adult bone, generally resulting from abnormalities in Vitamin D metabolism.

Cause k Poor intake of Vitamin D k Decrease exposure to sunlight k Intestinal malabsorption k Anticonvulsant therapy and hepatic and renal disease Signs and Symptoms k Widespread softening of bones especially on spine, pelvis and lower extremities k Bones are deformed, maybe bent or flattened as the bone soften k Pain k Tenderness k x-ray changes reveal pseudofractures or cyst formation Management k Adequate nutrition k Sunshine exposure k Vitamin D supplements

INFECTIOUS CONDITIONS y y BACTERIAL ARTHRITIS Etiology k invasion of the synovial membrane by microorganism, most often Gonocossi, meningococci, coliforms, salmonellae and Haemophilus Influenzae. Epidemiology k susceptible to patient who had recent joint surgery and trauma, intraarticular injections and rheumatoid arthritis. Pathophysiology 20

k k k

synovial tissue respond to bacterial invasion by becoming inflamed. The joint cavity may become involved, and pus will be present in the synovial membrane and synovial fluid. patient complain of pain, swelling, and tenderness of the joint joint aspiration is helpful in making the diagnosisi if the presence of organism can be demonstrated in the synovial fluid. White blood cell will be high, and glucose content of fluid may be reduced.

Medical Management 1. Appropriate antibiotic therapy. 2. Rest or immobilization of the joint. 3. Surgical drainage if infection does not respond to antibiotic therapy 4. Resumption of active range of motion when infection subsides and motion can be tolerated. Nursing Management 1. Promoting rest of the affected joint. 2. Administering antibiotics and pain medication as prescribed. 3. Encouraging the patient to participate within restriction of prescribed rest for joint. 4. Patient teaching: a. Encouraging active joint motion when motion is permitted. b. Instructing in proper administration of antibiotics if theraphy is to be continued after discharge. c. Assuring that patient is aware of plans for follow up with physician.

OSTEOMYELITIS k k k k k Bone infection from pyrogenic microorganism i.e., Staphylococcus Aureus 90% of cases Streptococcus Salmonella although the development of osteomyelitis is often precipitated by a traumatic event or is a complication of trauma. It is included with the degenerative disorders because of its chronic and debilitating aspect.

2 Types a. b. Exogenous Osteomyelitis caused by pathogen from outside the body, such as from an open fracture or surgical procedure. Hemategenous Osteomyelitis caused by blood-borne pathogen originating from infectious site within the body. Examples include sinus, ear, dental, respiratory and genitourinary infectious.

Pathophysiology In hematogenous Osteomyelitis, the organism reach the bone through the circulatory and lymphatic system. The bacteria lodge in the small vessels of the bone, triggering an inflammatory response. The femur, tibia, humerus and radius are commonly affectede. Bone inflammation is marked by edema, increased vasculature and leukocyte activity. The infectious process weakens the cortex, thereby increasing the risk of pathologic fracture. Brodies Abcesses are characteristic of chronic osteomyelitis. In cases of exogenous esteomyelitis, the infections begin in the soft tissue and eventually forming abscess. Chronic Osteomyelitis is difficult to treat. Recurrent infections, areas of dead bone (sequestrum), and scar tissues are contributing factors to its resistance to treatment. Patient may report fever, malaise, anorexia and headache. The affected body part maybe erythematous, tender and edematous. There maybe an opening in the skin, draining purulent material.

Signs and Symptoms y Pain y Heat, redness, swelling, tenderness y Limited movement y Rise in temperature, chills y General body malaise and weakness y Marked leukocytosis y Elevated ESR 21

y Possibly, positive blood cultures y Management y Analgesic y Anti-inflammatory y Antibiotic especially Penicillin y Wound Irrigation y Incision and drainage y Debridement y Complete removal of dead bone and soft tissue y Control of infection y Elimination of dead space (after removal of necrotic bone) y Sequestrectomy surgical removal of the dead infected bone and cartilage Nursing Care y Use surgical aseptic technique when changing dressings y Maintain functional body augment and promote comfort. y Allow the client ample time to express feelings about long term hospitalization. y Utilize room deorizer is a foul odor is apparent y Encourage nutrient dense diet to compensate for antibiotic impact on nutritional status.

TB of the Spine POTTS Disease bone infection caused by invasion in the body by Kocks bacillus

Signs and Symptoms y Muscle spasm y Stiffness y Tendency to reach things on the floor by bending the knees rather than the back. Effects usually the lower dorsal spine and upper lumbar spine. y Gibbus formation angulation or pronounce antero-posterior curve of the spine as in hunchback due to collapse of the vertebrae y Paralysis occasionally y Afternoon fever Complications abscess formation 1. Cervical region pharynx respiratory problems. 2. Dorsal region mediastinum and may rupture into the lungs. 3. Lumbar spine lumbar muscles or gluteal region or may follow the course of ilopsoas muscles and point in the groin (psoas abscess) - most common. Management 1. Anti TB drugs - Rifampicin - PZA - INH Immobilization Taylor body brace Fresh air, sunshine and proper diet

2. 3.

DYSPLASIA OF THE HIP  Condition in which the head of the femur is improperly seated in the acetabulum, or hip socket, of the pelvis  Congenital or develop after birth  Neonate: - due to laxity of ligament around the hip, allowing the femoral head to be displaced from the acetabulum upon manipulation. 22

 Implementation: splinting of the hips with Pavlik harness to maintain flesion and abduction and external rotation (neonatal period)  Assessment: - infacnts has asymmetry of the gluteal and thigh skin folds when the child is placed prone and the legs are extended against the examining table.  Limited range of motion in the affected hip.  Asymmetric abduction of the affected hip when the child is placed supine with the knees and hips flexed.  Apparent short femur on the affected side. CONGENITAL HIP DYSPASIA       Traction and surgery to release muscles and tendons Maintain abduction and external rotation ( application of double diapers when changing the infant ). Following surgery, positioning and immobilization in a spica cast until healing is achieved. Walking child has minimal to pronounced variation in gait with lurching toward the affected side. Positive Trendelenburg sign Positive Barlow or Ortolanis maneuver.

DEVELOPMENTAL ANOMALIES OF THE EXTREMITIES A. B. C. D. polydactyl extra digits Syndactyly partial or complete fusion of two or more digits Amelia absence of a limb Treatment if possible, early correction and preparation for use of a prosthesis.

MUSCULO-SKELETAL CONDITIONS

y Traumatic Conditions 1. Contusion an injury to soft tissue produced by blunt force, blow, kick or fall. y Signs and Symptoms y Hemorrhage into the injured part (ecchymosis) from rupture of small blood vessels y Pain, swelling y Treatment y Elevate the affected part y Cold compress to diminish edema formation y Pressure bandage to reduce swelling y Apply heat to affected area after 6 hours to promote absorption 2. Strain injury to muscle or tendons. Treatment same as contusion 3. Sprain injury to ligamentous structures surrounding a joint, caused by wrenching or twisting 4. Dislocation a condition in which the articular surfaces of the bones forming the joints are no longer in anatomic contact with one another.

y Clinical Manifestations y Change in contour of the joint y Change in length of extremity y Loss of normal movement y Change in axis of dislocated bones. 5.Fracture a break in the continuity of a bone 23

y General Classification a. Complete Fracture fracture involving the entire cross-section of the bones b. Incomplete Fracture a fracture involving only a portion of the cross section of the bone. c. Open Fracture (compound) break in the bone, skin and theres communication between the fracture site and the external air. d. Closed Fracture (simple) break in the bone, skin and theres communication between the fracture site and the external air. y Specific types of fracture a. Greenstick Fracture fracture in which one side of a bone is broken, the other side is being beat. b. Comminuted a fracture in which bone has splintered into fragments. c. Depressed a fracture in which a fragment is driven inward (fracture of skull, facial bones) d. Transverse a break straight across the bone e. Spiral with the fracture lines partially encircling the bone f. Spiral with the line of fracture at an oblique angle to the bone shaft. y Signs and Symptoms 1. Signs of local trauma (injury to soft tissue) y pain y tenderness y swelling y bruising y muscle spasm y redness 2. Due to damage to blood vessels y bleeding 3. Crepitus sound grafting sound produced as bones rub against each other 4. Shortening of extremity 5. Presence of deformity 6. Limited function/loss of function 7. Numbness if with injury to the nerves y Complication of Fracture 1. Immediate - shock - fat embolism - injury to skin, muscle, blood vessels and nerves 2. Early - infection gas gangrene, tetanus, osteomyelitis 3. Late - non-union - delayed union - mal-union - avascular necrosis of the bone y MANAGEMENT OF FRACTURE (4 Rs) 1. RECOGNITION of presence of fracture 2. REDUCTION a. Closed Reduction done by manipulation b. Open Reduction c. Traction 3. RETENTION a. Cast b. Traction c. Braces and splints d. Bandage 4. REHABILITATION restoration to normal function

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