Musculo-skeletal System

Bone growth
 Types of Bones
■ Long bones – femur
■ Short bones – somewhat cubed-
shaped as in the phalanges
■ Flat bones – broad surface for
muscular attachment or protection
of organs; skull, ribs, shoulder
blades, & sternum.
■ Irregular bones – wrist, vertebrae
Functions of Bones
■ Support & protect body tissues and
organs
■ Provides the skeletal framework of the
body
■ Provides movement through the
attachment of muscles
■ Storehouse for minerals: CA++ 99%
makeup of bones & PO4 90%
■ Production of blood cells which takes
place in the bone marrow
Diarthrodial/Synovial
Joints

■ Ball & socket i.e. shoulder & hip

which permits movement in any
direction
■ Hinge i.e. elbow movement along
one plane & allows flexion &
extension
■ Condylar – functions like a hinge
joint but can rotate slightly
 
 Synovial Joint
Capsule
■ Fibrous connective tissue
covers the ends of
bone.  Ligaments and
tendons reinforce the
joint capsule
■ Bundles of rich, white
fibrous tissue are
supplied with nerves.
Nerves are sensitive to
rate and direction of
motion, compression,
tension, vibration and
pain
■ Blood vessels, and
lymphatic vessels.
 Skeletal Muscles
Primary Function

■ Provides voluntary movement

■ Maintains posture
■ Body Movement – contraction &
relaxation
 Skeletal Muscles
Points of Attachment

■ Point of origin – attachment of

muscle to a more stationary bone
■ Point of insertions – attachment to
a more movable bone
 Head to Toe
Assessment
Health History

■ Musculoskeletal disorders
■ Nutritional status
■ Pain History
■ ADLs, endurance, assistive devices
■ Medications – prescription and OTC
 Assessment Skills
■ Inspection – symmetry, body alignment,
function, skin changes, swelling,
deformity, contractures, gait, non-verbal
indication of pain
■ Palpation – Skin temperature, swelling,
nodules, masses, crepitus
■ Joint Structure & ROM
■ Muscle mass & strength (atrophy,
flaccidly, spasticity, paralysis)
 Connective Tissue
Disorders
■ Rheumatoid Arthritis

■ Osteoarthritis

■ Lupus Erythematous

■ Gout
 Rheumatoid Arthritis
■ Autoimmune connective tissue
disorder characterized by
inflammatory destructive changes
in the joints

■ Systemic disease – Inflammatory

changes can affect skin, heart,
lungs, eyes, blood vessels &
nerves
Etiology of Rheumatoid
Arthritis
■ Autoimmune theory – Normal
antibodies become autoantibodies
(RH Factors) and attack the tissue.
■ Genetic Factor – 2-3 times > with
family Hx
■ Virus – Epstein-Barr
■ Stressful events
 Stages of Joint
Deterioration

■ Stage 1: Initiation - Some changes in

the synovial lining – no loss of functional
capacity
■ Stage 2: Immune Response – Joint
swells & thickens. Functional capacity
impaired.
■ Stage 3: Inflammatory - Progressive
involvement of blood vessels. Limited
ADL.
■ Stage 4: Destructive – Granulation
tissue hardens (Pannus). Leads to
ankylosis. Confined to bed or wheel
 Assessment Data
■ Subjective:
- Stiffness especially in a.m. or after
inactivity
- Proximal joint pain in the fingers
- Fatigue, weakness, weight loss,
low grade fever
 Assessment Data
■ Objective Manifestations
- Swollen, reddened, warm joints
- Weak hand grasp
- Deformities (late stages)
■ Swan Neck
■ Ulnar Drift
■ Boutonnière (buttonhole)
■ Rheumatoid Nodules
■ Vasculitis, Sjogren’s Syndrome
 Diagnostic Tests
■ Blood Tests:
- Rheumatoid Factor
- Antinuclear Antibody Titer
- Erythrocyte Sedimentation Rate
- CBC; WBC
 Diagnostic Tests
■ Radiographic: determines cartilage
erosion, joint space narrowing, bone
cysts
- Arthrography- x-ray with contrast
medium
- Arthroscopy – endoscopic exam of
joint
- Arthrocentesis – needle aspiration of
synovial fluid
 Nursing Care
Arthroscopy Post-
procedure
■ Assess neurovascular status (sx of
thrombophlebitis)
■ Monitor for bleeding or leakage at
site
■ Assess for pain, edema, redness
■ Ice for swelling, mild analgesic
pain
 Pain Management
■ Prescribed Drug Therapy on timely
basis
■ Rest periods
■ Warm shower, hot packs
■ Avoid sudden, jarring of joint
■ Warn clients about “quacks”
(miracle cures)
Impaired Physical Mobility
■ Exercise joint, but not beyond pain
■ Positioning & body alignment
■ Support joints for optimal function
■ Assistive Devices – proper fit &
instruction
 Self-care Deficit
■ Routine that includes pacing
activities
■ Encourage sleep routine
■ PT for conditioning
■ Occupational Therapy – Assistive
devices
 Drug Therapy
■ Salicylates (ASA)
– Side effects/Precautions
■ Tinnitus, GI distress, prolonged bleeding. Give
with food, milk. Avoid anti-coagulants.
■ NSAID’s (Advil, Indocin, Toradol,
Naprosyn)
– Side effects/Precautions
■ GI (do not crush enteric coated); give after meals
or with food
■ Dizziness, diarrhea, headache, rash
 Drug Therapy
■ Glucocorticoids (dexamethasone,
hydrocortisone, prednisone)
– Side Effects/Precautions
– Depression, euphoria, anorexia,
nausea,
weight gain, bruising. Taper dosage
when discontinuing.
 Drug Therapy
■ Slow-acting Antimalarial drugs
(plaquenil)
– Side Effects/Precautions
■ Retinal edema, GI disturbance
■ Toxic – Gold Salts (solganol,
myochrysine)
– Side Effects/Precautions
■ Dizziness, flushing, metallic taste, skin rash;
assess CBC & UA prior to administration
 Drug Therapy
■ Cytoxic Drugs (Methotrexate,
Imuran, Cytoxan)
– Side Effects/Precautions
■ Pneumocystis Carinii pneumonia, mouth
sores, bone marrow suppression,
hepatotoxicity
Degenerative Joint Disease
(Osteoarthritis)
■ Non-inflammatory disease of the
weight bearing joints (hips, knees,
spine, hands)

■ Incidence: > in post-menopausal

women

■ Risk Factors: age, obesity, overuse

of joints, trauma (fractures, sports
 Osteoarthritis
■ Pathophysiology – Articular cartilage
becomes yellow & opaque, joint space
narrows, bone spurs (osteocytes), &
cysts
■ Symptoms – Joint pain / diminishes on
rest ; crepitus (grating sensation); joint
enlargement, Herberden’s nodes,
Bouchard’s nodules, decrease ROM,
joint effusion
 Osteoarthritis
■ Diagnostic Tests: X-rays of joints
indicates narrowing of joint spaces;
CT Scan & MRI of spine; Bone Scan

■ Differential features of RA & DJD

 Osteoarthritis
Medical Management
■ Drug therapy for pain (NSAID’s), muscle
relaxants (Flexeril), injection of
cortisone
■ Rest – immobilization with splint, brace,
sleep (>8 hours/night)
■ Position of joints to maintain alignment
& avoid contractures
■ Heat – hot packs, PT diathermy
■ Exercise – walking, water aerobics
 Osteoarthritis
Surgical Management
■ Hemiarthroplasty: one part of a
joint is replaced, i.e. head of femur
■ Total Hip replacement: Head of
femur & the acetabulum replaced
■ Total Knee replacement: both
articular surfaces of the knee
replaced
■ Interphalangeal joint replacement
Total Hip Replacement
■ Preoperative Care – Skin preparation, IV
antibiotics, education re: nature of
prosthesis, mobility restrictions,
exercises
■ Types of Prosthesis
- Cemented – > 10 year life
- Uncemented – bone growth occurs into
the metallic surfaces within 6-12 weeks
 THR - Postoperative
■ Pain control
■ Wound & drain assessment
■ Neurovascular Assessment
■ Activity – bed rest with abduction
splint or pillow, OOB with PT (NO
hip flexion > 90°) weight bearing
dependent on type of prosthesis
■ Use of walker – crutches - cane
 THR - Potential
Complication
■ Thromboembolism

■ Subluxation - Hip Dislocation

■ Neurovascular Compromise

■ Hemorrhage
 THR – Hip Precautions
■ Avoid hip flexion > 90°
■ Avoid low, soft chairs
■ Avoid excessive trunk flexion in
reaching
■ Maintain hip adduction
■ No leg crossing at knee
■ Use raised toilet seat
Total Knee Replacement
■ Preoperative Care – similar to THR
■ Postoperative Care
- Pain control
- Wound & drain assessment
- Neurovascular Assessment
- Elevate leg on pillow for comfort
- Head of bed elevated for comfort
- Continuous Passive Motion Machine
 TKR - Potential
Complications
■ DVT & pulmonary emboli

■ Prosthetic Dislocation

■ Infection
 Lupus Erythematous
■ Definition: Autoimmune disease
involving diffuse inflammatory changes
in vascular connective tissue

■ Pathophysiology: Antigen-antibody
interactions results in deposits of
immune complexes in tissues & cells
that damage the organs and or blood
vessels
 Discoid Lupus
■ Cutaneous
manifestations –
butterfly rash on face
■ Risk Factor: Sun
exposure intensifies
■ Treatment: Cortisone
creams, sun screens
> 30 SPF, avoid sun
at peak hours
 Systemic Lupus
■ Organs affected: Heart, lungs,
kidney, brain, blood vessels, &
joints
■ Systemic symptoms: Fatigue,
myalgia, joint pain, low grade
fever, anorexia
■ System specific symptoms:
Tachycardia, chest pain,
proteinuria, hip & knee necrosis,
Laboratory Tests of SLE
■ Skin biopsy & scrapings of skin
cells

■ Immune tests – RF, ANA, Sed Rate

■ CBC (pancytopenia), Sed Rate,

Cardiac & Liver Enzymes
 Pharmacological
Management
Lupus
■ NSAID’S

■ Corticosteroids

■ Immunosuppresive Agents
 Nursing Care - Lupus
■ Pain Management
■ Encourage rest periods
■ Decrease protein in diet (kidney
involvement) and sodium
restriction (fluid retention)
■ Referral – Local & National Lupus
Foundation
Potential Complications
Lupus Erythematous
■ Vasculitis
■ Cardiopulmonary – pericarditis,
pleural effusion
■ CNS – psychosis, seizures,
peripheral neuropathies
■ Avascular Necrosis
 Gout
■ Definition: Systemic
disease involving pain &
inflammation of joints due
to urate crystal deposits

■ Pathophysiology:
Imbalance of purine
metabolism & kidney
function

■ Incidence: Middle aged

men
 Types of Gout
■ Primary: Inherited defect in purine
metabolism

■ Secondary: Disease i.e renal,

diuretic therapy &
chemotherapeutic agents
Clinical Manifestations of
Gout
■ Asymptomatic phase –
Elevated Uric Acid (.60-.
75 gm)

■ Acute Phase – Sustained

elevated Uric Acid
causing extremely
painful, swollen, and
reddened joint

■ Chronic Phase – Urate

crystal deposits appear
in cartilage, synovial
membranes, tendons, &
soft tissues (tophi
formation)
 Drug Therapy - Gout
■ Acute Phase – Colchicine, NSAID’S

■ Chronic Phase – Allopurinol

(Benemid);
Colbenemid

■ Avoid aspirin & diuretics

 Diet Therapy - Gout
■ Low purine (avoid organ meats,
shellfish, oily fish with bones)
■ Avoid Alcohol
■ Increase fluid intake to 3,000 cc/day
■ High alkaline ash foods – citrus fruits
and juices, certain dairy products
Other Connective Tissue
Disorders
■ Polymyalgia
Rheumatica
■ Ankylosing
Spongylitis
(Marie-Strümpell
Disease)
■ Sjögren’s
syndrome
■ Lyme’s Disease
■ Fibromyalgia
 Osteoporosis
Types
■ Primary - Bone loss related to loss
of estrogen in menopausal women
and low testosterone levels in men

■ Secondary – Bone loss related to

disease process (hyperthyroidism,
renal failure, GI malabsorption
problems)
 Pathophysiology
Bone Remodeling
■ Resorption – Worn out bone cells
are removed by bone-resorbing
cells called osteoclasts

■ Formation – New bone is laid down

by bone-forming cells called
osteoblasts
 Incidence/Risk Factors
Osteoporosis
■ Age

■ Race

■ Gender

■ Life Style

■ Diet

■ Heredity
Prevention of Osteoporosis
■ Exercise – weight bearing types

■ Diet modifications

■ Calcium intake – OTC i.e. Tums,

Oscal, Calcium carbonate, Dietary
supplement
Clinical Manifestations
Osteoporosis
■ Height loss

■ Vertebral deformities

■ Restricted movement

■ Back pain

■ Fractures
 Diagnostic Tests
Osteoporosis
■ Laboratory – serum calcium,
Vitamin D, phosphorus, alkaline
phosphatase

■ Radiological – X-ray, CT Scan, MRI

- Dual energy x-ray absorptiometry
 Medical Management
Osteoporosis
Drug Therapy

■ Estrogen replacement – Premarin

■ Calcium supplements
■ Bone resorption inhibitor –
Fosamax
■ Vitamin D
 Nursing Management
Osteoporosis
■High Risk for Injury – Prevention of
falls and fractures
- safe environment
(non-skid slippers, shoes, clean spills,
avoid scatter rugs, lighting, access to
items for ADL, hand rails, avoiding
lifting heavy objects, use of walker,
cane.)
 Nursing Management
Osteoporosis
■ Impaired Physical Mobility
Increase mobility to level of
independence in ADL
Interventions
4. Physical therapy program
(strengthening & weight bearing
exercises)
5. Occupational Therapy (Adaptive
Devices)
 Nursing Management
Osteoporosis
■ Pain Management - reduce &
alleviate pain
Interventions
3. Drug Therapy - opioid, non-opioid
analgesics, muscle relaxants,
anti-inflammatory agents
4. Use of heat
5. Orthotic devices – braces, splints
 Other Metabolic &
Degenerative Bone
Disorders
■ Osteomalacia

■ Paget’s Disease

■ Herniated Nucleus Pulposus

- Laminectomy
- Spinal Fusions
 Fracture Patterns
■ Oblique – Line of fx angled
■ Transverse – Across the bone
■ Longitudinal – Length of bone
■ Spiral – Twisting or rotation of bone
■ Comminuted – broken in > 2 places
■ Impacted – Fragments driven into each
other
■ Displaced or Avulsed – torn away by a
ligament or tendon
Fractures
 Classification by
Anatomical Location
■ Humerus
■ Tibia, Fibula
■ Pelvis
■ Hip
■ Skull
■ Mandible
■ Ribs
■ Vertebrae
 Fractures
■ Definition: Interruption in normal
bone continuity, which is
accompanied by soft tissue injury
■ Classification:

- Simple or closed
- Open or compound
Stages of Bone Healing
1. Hematoma
2. Granulation
3. Callus Formation
4. Osteoblastic Proliferation
5. Bone Remodeling
6. Complete Healing
Bone Healing Problems
■ Delayed Union - > 6 months to a
year

■ Nonunion - < ½ of bone fragments

joined together

■ Malunion – Bone healed in state of

deformity
Assessment of Fractures
■ Subjective Data – History,
complaints of pain, loss of
sensation, movement

■ Objective Data – Warmth, edema,

ecchymosis, neurovascular
impairment, splinting, anxiety, fear
 Emergency Care
■ Inspect area
■ Control bleeding
■ Immobilize/splint
■ Prevent shock
■ Transport safely to ER
INTERVENTIONS
■R -
Rest/immobilize
■ I - Ice
■ C - Compression
■ E - Elevation
■ S - Support
 Nursing Diagnoses
■ Acute Pain
■ Risk for Neurovascular Dysfunction
■ Risk for Infection
■ Altered Mobility
■ Activity Intolerance
Complications of Fractures
■ Shock
■ Neurovascular Compromise
■ DVT & Pulmonary Emboli
■ Aseptic Necrosis
■ Acute Compartment Syndrome
■ Fat Embolism Syndrome
■ Osteomyelitis
 Shock
■ Etiology: Hemorrhage into
damaged tissues, especially
thorax, pelvis, & extremities

■ Treatment: Control bleeding and

restore blood volume
 Neurovascular
Compromise
■ Etiology: Damage to nerves from
fragments of bone, pressure from
casts, splints, & traction

■ Assessment: 6 P’s – Pain,

Pulselessness, Paresthesia, Pallor,
Paralysis, Poikilothermia
INSPECTION/PALPATION
FIVE P’S
■ PAIN
■ PULSE
■ PALLOR
■ PARASTHESI
A
■ PARALYSIS
Fat Embolism Syndrome
■ Etiology: Release of particles of fat
into the blood stream from the
yellow marrow at site of injury

■ Risk Factors: Fx. of long bones,

multiple fx., high serum glucose or
cholesterol level
 DVT & Pulmonary Emboli
■ Etiology: Immobility,
trauma, surgery

■ Risk Factors:
Incidence in fractures
of the lower
extremities; smoking,
obesity, heart disease

■ Treatment:
 Avascular Necrosis
■ Etiology: Loss of blood supply to
bone

■ Risk Factors: Hip fractures or any

fracture where this bone
displacement

■ Treatment: Surgical joint

replacement
Compartment Syndrome
■ Etiology: Massive compromise in
circulation from external (tight,
bulky dressings, casts) & internal
(blood & fluid)
■ Treatment: Immediately loosen
any tight dressings & MD can
bivalve cast
■ Surgery – Decompression
fasciotomy for edema and bleeding
Surgical Management

Fasciotomy to relieve pressure. The

fascia is divided along the length of the
compartment to release pressure within.
 Osteomyelitis
■ Acute – infection in another part of
the body invades bone tissue or
occurs from penetrating trauma

■ Chronic – Infection persists

especially in a patient with
compromised circulation
Medical Management of
Fractures
■ Closed reduction & immobilization –
Manual traction to align the bone

■ External Fixation – Percutaneous

placement of pins implanted into bone

- Kronner 4-Barr Compression Frame

- Hex-Fix External device for tibial
fractures
- Halo Traction – Cervical spinal
fractures
 Nursing Care – External
Fixation
■ Teach patient patient to grasp
frame when moving, rather than
limb
■ Frequent observation &
neurovascular assessments
■ Pin Care – Note symptoms of
infection
■ Assess for loosening or shifting of
devices
External Fixator
External Fixation
External Fixator
 Casts
■ Purpose: Immobilze, correct
deformity, allow early mobility, &
provide support & protection

■ Types: Plaster of Paris & Fiberglass

 Plaster Cast Care
■ Instruct that cast will feel warm
■ Handle cast with palms of hands
■ Turn client q 1-2 hours for drying
■ Elevate on pillow higher than heart
■ Pedal rough edges with moleskin
■ Inspect q 4-8 hours – drainage,
cracking, odor, alignment & fit
 Cast Complications
■ Circulatory impairment
■ Peripheral nerve damage
■ Impaired skin integrity
■ Pneumonia, DVT, Constipation
■ Compartment Syndrome
■ Cast Syndrome – Body cast
■ Fracture blisters
 Traction
■ Definition: Pulling force that is
applied to part of an extremity
while a counter traction pulls in the
opposite direction

■ Purpose: Reduce Fracture,

immobilize, decrease pain &
muscle spasm, correct deformities,
stretch tight muscles
 Types of Traction
■ Continuous or Running – Buck’s, Russell

■ Circumferential – Pelvic

■ Cervical

■ Suspension or Balanced – Thomas Ring

■ Skeletal – Steinmann pins, Kirschner

wires, Crutchfield tongs
Bucks Traction
Bryants Traction
Skeletal Traction
 Nursing Assessment
■ Equipment – weights, pulley’s, ropes, Balkan
frame

■ Mobility

■ Skin integrity

■ Neurovascular

■ Gastrointestinal

■ Urinary
 Fractured Hip
■ Incidence: Prevalent women > 65;
200,000 annually; by age 80 1 in 5

■ Risk Factors: Falls, osteoporosis,

age related changes in balance
 Anatomy of Hip
■ Head of femur

■ Acetabulum

■ Femoral neck

■ Greater trochanter

■ Lesser or sub-trochanter
Types of Hip Fractures
■ Femoral Neck – displaced,
impacted, comminuted

■ Intertrochanteric (Intracapsular,
Extracapsular)

■ Subtrochanteric
 Signs & Symptoms of Hip
Fractures

■ Pain – hip or thigh

■ Adduction, external rotation

■ Shortening of leg

■ Inability to move or bear weight

 Surgical Intervention
■ Total Hip Arthroplasty –
- Cemented allows full weight
bearing
- Uncemented – full weight bearing
not permitted for 6-8 weeks

■ ORIF – Intramedullay rods, plates,

compression screws; allows early
ambulation
Internal Fixation: Plates and
Pins
Post-operative Care - ORIF
■ Bedrest 1st day; OOB with walker
■ HOB > 35 - 40°
■ Avoid hip flexion > 90°
■ Trochanter roll for hip alignment
■ Pillow splint when turning (per MD)
■ Isometric exercises
■ Pain control – narcotic analgesics
 Complications ORIF
■ DVT, PE

■ Hemorrhage

■ Infection

■ Subluxation or dislocation
Carpal Tunnel Syndrome
■ Definition: compression of the
medial nerve in the wrist

■ Etiology: Repetitive motions, wear

& tear, fracture of wrist

■ Symptoms: Pain, paresthesia,

difficulty in grasping
Carpal tunnel syndrome - atrophy
and weakness of the hand
 Diagnostic Tests CTS
■ Phalen’s – wrist flexed back to
back results in paresthesia >60
seconds
■ Tinel’s – Tapping over the median
nerve pain, tingling, numbness or
inflating a BP cuff will result in
same sx.
■ X-ray
■ EMG
 Interventions CTS
■ Non-invasive – wrist support,
immobilization with splint, frequent
breaks, cushion grippers on pencils
& pens, rest, ice, heat, anti-
inflammatory agents

■ Invasive – Cortisone Injections,

Surgery