Nursing Management: Musculoskeletal Problems

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Nursing Management Musculoskeletal Problems

• George Ann Daniels, MS, RN

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Musculoskeletal Injuries

• Contusion
• Damage to soft tissue , sub-q structures, and
  muscle
• Strains
• Tear to the musculotendinous unit
• Sprains
• Trauma to joint, ligament may be completely torn
  or stretched
• Dislocation
• Displacement of the normal position

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• Meniscal tear
• Knee is caught between femoral condles and
  plateau of tibia- tear the meniscus
• Rotator Cuff injuries
• Tear in the rotator cuff muscles of the shoulders
• Bursitis
• Inflammation of the bursa in the joint
• Tennis elbow, housemaids knees

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Carpal Tunnel Syndrome

• Compression of the medial nerve under the carpal
  ligament in the wrist
• Causes trauma/edema, tumors, ganglion, excessive
  use wrists

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Assessment of Carpal Tunnel

• Weakness, pain, tingling, numbness night and day
• Paresthesia thumb, forefingers, and middle finger
• Phalens sign
• EMG

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Surgical Repair
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Management

• Wrist splints
• Special keyboard pads
• Avoid aggravating action
• Occupational change

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Fractures

• Crack or break in the continuity of a bone
• Assessment
• Pain, point tenderness, muscle spasms, numbness,
  Tingling, paralysis
• Change in shape
• Loss of function
• Edema
• Ecchymosis
• Crepitus
• Severe muscle rigidity

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Types of fractures
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Healing times

• Neonatal period
• 2-4 weeks
• Early childhood
• 4 weeks
• Later childhood
• 6-8 weeks
• Adolescence
• 8-12 weeks

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Fracture Treatment

• Splint Immediately
• Traction
• Realignment
• Skin or skeletal
• Closed Reduction
• Open Reduction
• ORIF- Open reduction internal fixation
• External Fixation
• Page1776

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Types of Casts
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Cast Material

• Fiberglass
• Light weight, water proof
• Dries within one hour
• Stronger

• Plaster Paris
• Dries 24-48 hours
• Turn Q2H with palms
• Do not turn with adbuctor bar
• Do not cover cast with plastic coated pillow
• Inspect for crumbling and cracking

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Cast Care

• Table 59-9
• Cast Removal
• Cast cutter

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Complication of Cast Therapy

• Impaired circulation
• Pressure areas
• Skin lesions
• Drainage
• Nerve damage
• Tissue necrosis

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Compartment Syndrome

• Pressure within a limited anatomic space
• Forearm and lower leg
• Depresses circulation
• Decreases viability and function of tissue within
  the space
• Tissue damage can occur within 30 minutes
• gt 4 hours irreversible damage

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Assessment

• Assessment
• 5 Ps
• Pain- severe or increased unrelieved
• Pallor
• Paresthesia
• Numbness, tingling, decrease in sensation
• Paralysis
• Decrease or loss of movement and strength
• Pulselessness
• Loss of distal pulse
• Compartment pressure monitor

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Nursing Management

• Relieve pressure
• Prevention
• Inspect dress/cast frequently
• Elevate dressing /cast
• Ice pack
• Petal edges of cast
• Loosen dressing
• Monitor intracompartment pressure
• gt 30 mm HG
• Fasciotomy

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Fat Embolism

• Fat globules are released from the marrow of long
  bone fractures or multiple trauma into the blood
  stream
• Cause platelets to clump
• Forms fat emboli
• Obstruction of pulmonary/vascular beds

• Effected organs
• Lungs
• Vessels
• Brain
• Heart
• Kidneys
• Tissue/organs
• Circulatory insufficiency, tissue infarcts and
  sudden death

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Assessment

• Assessment
• 12-72 hours post injury
• HA, drowsiness, irritability, memory loss,
  confusion, rapid pulse, apprehension, and fever
• Pulmonary
• Tachypnea, dyspnea, use of accessory muscles,
  wheezing, inspiratiory stridor
• Skin manifestations
• Petechiae-neck, upper chest, shoulder, axillary
  and buccal membranes

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• Diagnosis
• Symptoms and history
• ABGs
• Decrease Pa02 lt 60 mm Hg
• PaC02 gt 50 mm Hg
• Acidosis
• Elevated lipase and ESR

• Nursing Management
• Improve oxygenation and prevent deterioration
• 02 high concentrations
• Adequate hydration
• Titrated to prevent pulmonary congestion
• Dextran
• Steroids
• Decrease lung inflammation/cerebral edema
• Heparin
• Prevent future formation of emboli

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Hip Fractures

• Types
• Intracapsular
• Subcapital-(A)
• Transcervical-(B)
• Basilnar neck
• Extracapsular
• Intertronchanteric (C)
• Between greater and lesser trochanter
• Subtrochanteric
• Below trochanter

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Assessment

• External rotation
• Shortening of the affected extremity
• Pain and tenderness at fracture site
• Discoloration of surrounding tissue
• Inability to move injured leg while lying supine

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Surgical Interventions
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Avascular Necrosis

• Necrosis of bone/intra-articular structures
• Lack of circulation
• Misalignment, Fracture thrombus, constriction
  from device
• Ischemic bone becomes necrotic
• collapse

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Post-Op Interventions

• VS
• I O
• Respiratory
• TCDB, IS
• Infection Assessment
• Thrombus/emboli Precautions

• Pain control
• Assess incision
• Assess circulation
• Abductor pillow or splint ( Hip)
• Controls rotation
• Mobility
• Use opposite leg to pivot

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Home Teaching Hip FractureTable 59-11
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Osteomyelitis

• Infection of the bone
• Necrosis of bone/marrow tissue
• Weakens the bone
• Risk for fractures
• Staph
• Direct contamination
• Open fracture with open wound
• Surgery
• Transmitted by the blood
• Travels to the bone

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Acute Osteomyelitis

• Initial infection or infection of less then 1
  month in duration
• Common in children
• Assessment
• General
• Night sweats
• Chills
• nausea
• Irritable
• Restlessness
• Elevated temperature
• Rapid pulse
• Dehydration

• Local assessment
• Tenderness
• Warmth
• Diffuse swelling over the bone
• Bone pain
• Unrelieved by rest
• Worse with activity
• Holds part in semi-flexion
• Surrounding muscle tense with resistance to
  passive movements
• Muscle spasms

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• Management
• Halt infection
• Prevent spread
• Possible debridement of necrotic tissue
• Antibiotics
• Big guns
• Pain management
• nutrition

• Complications
• Septicemia
• Meningitis
• Tenosynovitis
• Thrombophlebitis

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Chronic Osteomyelitis

• Gradual progression
• Infection for more than 4 weeks or failure to
  respond to antibiotics
• Pus accumulationischemia bonetissue forms scar
  tissueavascular scar impenetrable to antibiotics
• Pain
• Worse at night
• Red, swollen, warm, tender
• Deformed bone
• Dusky skin
• Atrophied muscles

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Medical Management

• Surgical removal of involved tissue
• Continueous closed suction wound drainage
• Combination antibiotic therapy
• Window casts
• Supports weakened bone
• Assessment of the wound
• Splint
• Comfort/support
• Myocutaneous flaps
• Bone grafting

• Complications
• Muscle contractures
• Septic arthritis
• Osteoarthritis
• Decreased rate of bone growth
• Non-union of fractures

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Nursing Management

• Pain management
• Analgesics
• Non-steroidal anti-inflammatory drugs
• Schedule activities around medication
• Elevate and support
• Teach
• Avoid exercise
• Increased circulation may spread disease
• Avoid heat
• Maintain proper alignment/positioning
• Cast care

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Amputation

• Removal of an extremity or part of an extremity
• Reasons
• Circulatory disorders
• PVD
• DM
• ASHD
• Traumatic injury
• Malignant tumors
• Uncontrolled infection

• Gangrene
• Severe thermal or crushing injuries
• Congenital deformities
• Auto-amputation
• Spontaneous separation

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Types of Amputation

• Closed
• Flaps of muscle or tissue
• Disarticulation
• Through the joint
• Open
• Guillotine amputation
• Soft tissue and bone are severed at the same
  level
• Infection present

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Phantom Limb Sensation

• Patient feels the amputated part is still present
• Pain, tingling, numbness, itching, and
  temperature changes
• Several months to years

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Phantom Pain

• Aching, knifelike, jabbing, throbbing, tearing,
  burning pain in amputated part
• Relief
• Exercise residual limb
• Divisional activities

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Post- Op Nursing Care

• Assess for hemorrhage and infection
• Assess types of dressings
• Application of prosthesis immediately
• Cast/rigid dressing
• Elastic wrap dressing
• Pain Control
• Elevate limb for the 1st 24 hours

• Prevent external rotation and abduction
  contractures
• ROM
• Prevent edema
• Avoid dangling stump over bed
• Teach follow-up care
• Table 59-15

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Malignant BoneTumors

• Rapid growth with metastasizes
• Blood and lymph
• Destroys surrounding tissue
• Primary tumors
• Arise from Musculoskeletal tissue
• Osteosarcomas, Ewings sarcomas, chondrosarcomas,
  fibrosarcomas, and malilgnant fibrous
  histicytomas
• Secondary metastatic tumors
• Cancer spreads to the bone from another
  malignancy

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Osteoporosis

• Metabolic bone disorder
• Thinning, less dense or porous bone mass
• Localized low-back or mid-thoracic pain from
  vertebral
• Collapse
• Dowagers hump
• Pathogenic fractures

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• Diagnostic test
• X-ray
• Bone density
• Management
• Avoid lifting objects
• Straining
• House safety
• Back brace
• Calcium Vit D
• 1000mg
• 1500 mg post menopause
• 400 IU Vit D
• Exercise
• Medication
• Decreases rate of bone loss
• Fosamax

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Osteosarcoma

• Most common
• Rapid growth and metastases
• Highest in adolescent males
• Elderly with Pagets disease

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• Assessment
• Debilitating pain unrelieved by analgesics
• Awaken from sleep
• Enlargment of affected area
• Restriction of movement
• Children
• Limb
• Curtails physical activity
• Unable to hold heavy objects

• Diagnosis
• Xray
• Soft tissue looks like a sunburst
• Biopsy
• Treatment
• Surgical excision
• Wide section from 7-10 cm beyond involved area
• Amputation
• Radiation and chemotherapy

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Ewings Sarcoma

• Rare, highly malignant
• Originates in the marrow
• Early metatasizes
• Long bones, flat bones, and ribs
• Pulmonary involvement
• Age
• lt 30 years
• Diagnosis
• X-ray

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• Assessment
• Pain, malaise, lethargy, and weight loss
• Treatment
• Systemic chemotherapy
• Two or more drugs
• Radiation after chemotherapy

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Developmental Dysplasia of the Hip (DDH)

• Hip abnormality
• 10 per 1000 births
• Usually left hip
• Caucasian girls
• Cultural considerations
• Tightly wrapped blankets
• Carrying infants on the hips
• Straddle position

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Acetabular dysplasia, subluxation, dislocation
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Assessment data of DDH

• Infant
• Shortening of limb on affected side
• Restricted abduction of hip on affected side
• Unequal gluteal folds
• Positive Ortolani-Barlow test

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• Older infant/child
• Affected leg shorter
• Telescoping or piston mobility of joint
• Trendelenburg sign
• Prominent greater trochanter
• Lordosis
• Waddling gate

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Therapeutic management

• NB-6months
• Pavlik harness
• Continuous for 3-6 months
• Skin traction
• Adduction contracture
• Hip spica cast
• 3-6 months then to a brace

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• 6-18 months
• After standing or walking
• Gradual traction
• Cast immobilization
• Abduction splint

• Older child
• Open reduction surgery

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Nursing management

• Compliance with corrective devices by parents
• Not removed for bathing
• Sponge bath
• No powder/lotions
• Prevent skin irritation
• Cast care
• Diaper area

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Congenital Clubfoot

• Talipes Equinovarus
• Feet are pointed inward and down
• Serial casting
• Immediately post birth
• Change cast via growth and manipulation of foot

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Legg-Calve-Perthes

• LCP
• Self limiting disorder
• Aseptic necrosis of the femoral head
• Age
• 3-12 yrs
• Most common 4-8 years
• Cause unknown
• Delayed skeletal maturation

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Stages of LCP

• Stage I
• Avascular stage
• Aseptic necrosis of the femoral capitol epiphysis
  with degenerative changes producing flattening of
  the femoral head
• Stage II
• Fragmentation/
• revascularization stage
• Old bone absorption and revascularization

• Stage III
• Reparative stage
• New bone formation
• Stage IV
• Regeneration stage
• Gradual reformation of the femoral head

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• Nursing Management
• Reduce inflammation and restore motion
• Rest, avoid weight bearing on lower extremities,
  traction, abduction braces, leg casts, leather
  harness slings
• Objective is to keep head of femur in contact
  with acetabulum, serves as a mold for the femoral
  head
• Possible surgery

• Assessment
• Insidious onset
• Intermitten limping on affected side
• Pain
• Soreness, aching,
• Pain in hip, anterior thigh
• Stiffness in the morning, end of day, or after
  rest
• Limited ROM, weakness, muscle wasting
• Shortening of limb
• External hip rotation

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Scoliosis

• Lateral curvature lf the spine
• Seen during growth spurts of adolescents

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• Assessment
• One shoulder higher than the other
• Scapula prominences
• Rib prominences
• Chest asymmetry
• Uneven waist line
• Hems hang unevenly
• Screened during school at 5th grade
• scoliometer

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Treatment

• Curve lt 15-20 degrees
• Monitor every 3-6 months
• Postural exercises
• Curve gt 24 degrees
• Treatment by orthopedic surgeon
• Curve lt 40 degrees
• Boston Brace
• Milwaukee Brace

• Electrical stimulation
• Mild to moderate curvatures
• Causes muscle to contract at regular and frequent
  intervals
• Helps straighten spine
• Surgical treatment
• rods, and screws with fusion

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Post Operative Care

• Log roll when changing position
• Vital signs
• Wound assessment
• Circulation assessment
• Assess for paralytic ileus
• May have N/G until bowel function returns
• Monitor foley
• Strict I O
• Pain management

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Milwaukee Brace

• Brace is worn 23 hours/day
• Brace off for show, bathe, and swim
• Wear T-shirt under brace
• Exercise
• Keep brace on
• Pelvic tilt and lateral strengthening
• Muscle aches in the beginning
• Stay active
• Dont hid away from friends