MUSCULOSKELETAL DISORDERS

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MUSCULOSKELETAL DISORDERS

• NURS 124

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BONES CHANGE AS YOU AGE

• Throughout life, your body loses bone
• New bone grows to replace lost bone
• The rate of new bone growth changes as you age
• Peak bone mass between ages 25 and 35
• How do you maximize bone mass?
• As you grow older bone loss bone growth
• Bones become weak and brittle

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Calcium

• Metabolic Homeostasis and Structural Integrity
• Important for
• -Bone growth and thickening
• -Clotting of body fluids
• -Muscle irritability
• -Maintain mucous coverings
• -Intercellular activity

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OSTEOPOROSIS

• Disease in which your bones become thin and weak.
• Occurs mostly in women after menopause.
  Estrogen is lost.
• Leads to weakened and broken bones.
• Bones at the greatest risk for breaking-
• 98 of calcium found in bones
• Hip fractures results in disability, dependency,
  and death.

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RISK FACTORS

• Female
• Family history of osteoporosis
• Diet low in calcium
• Inactive lifestyle
• Smoking- may be due to inc. estrogen breakdown
• Certain medications- steroids, heparin, anti-HTN

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ASSESSMENT

• Determine risk factors
• Diet history
• Previous falls
• Environment/ routines
• Classic dowagers hump- Kyphosis of the spine
• c/o back pain with lifting, stooping, bending
• Vertebrae tender on palpation
• Psychosocial

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DIAGNOSIS

• Labs
• X-rays-
• CT- view spine. Provides early dx. of
  osteoporosis
• MRI-
• Bone Density test-

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Common nursing diagnoses

• Pain r/t deformity, edema, fractures
• Impaired mobility
• Knowledge deficit
• High risk for injury
• Body image disturbance
• Anxiety
• Activity Intolerance

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PREVENTION

• NUTRITION
• Calcium 1500 mg/ day
• Milk (low fat)
• Yogurt (low fat)
• Foods with added calcium like orange juice,
  cereal, or bread
• AVOID foods with a lot of salt. Large amounts
  lost calcium
• NEVER diet to the point that you lose enough
  body weight/ fat to cause irregularity of your
  menstrual periods.

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EXERCISE

• Plays a critical part in maintaining bone mass no
  matter what your age.
• Type and amount of activity plays a part
• Weight bearing and resistance exercises are very
  good for your bones
• Should exercise 30 minutes/ day
• Walking Hiking Weight Training
• Running Tennis Yoga
• Dancing Bicycling
• NEVER exercise to the point that you lose enough
  body weight/ fat to cause irregularity of your
  menstrual periods.

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LIFESTYLE

• NO SMOKING
• LIMIT ALCOHOL/ CAFFEINE USE

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MEDICATIONS

• Calcium
• Vitamin D supplements
• Estrogen-
• Sodium fluoride-
• Calcitonin-

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FRACTURES

• Definition- break in the continuity of a bone.
  There is complete or partial interruption of
  osseous tissue.
• Causes-
• Usually the result of a blow, fall, or accident,
  ie. Trauma
• May occur during normal activities or minimal
  injury in diseased/ altered bones- pathologic
  fracture

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Classifications

• Break
• Complete- broken completely through the bone
• Greenstick- bone bends, breaks on one side,
  incomplete break ,common in children
• Wound
• Closed or simple- no open wound, skin intact
• Open, compound- bone ends come through the skin
• Line of fracture
• Oblique- breaks in a slanting direction

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Line of fracture cont.

• Spiral- fx. spirals, coils, encircles bone
• Comminuted- three of more fragments
• Impacted- bone is broken and wedged together
• Depressed- bone is driven inward, usually in the
  skull

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Signs and Symptoms of Fractures

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Diagnostics

• X- ray of extremity or body part
• CT scan
• MRI- internal metal?
• Bone Scan

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Stages of Bone Healing

• Inflammation-
• -Bleeding occurs into the injured tissue, creates
  a fx. hematoma
• -Blood supply to and within the bone usually
  decreases, causing bone necrosis
• -Macrophages (large WBC) invade and debride the
  injured area
• -Inflammation
• -Usually lasts several days and resolves after
  the pain and swelling subside

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Stages cont.

• Cellular Proliferation
• -Occurs within 5 days
• -Hematoma organizes and fibrin strands form
  creating a network for revascularization
• -Invasion of fibroblasts and osteoblasts and
  granulation stage of healing is begun
• -Fibrin becomes firm and blood vessels develop
  from capillary buds, brings nourishment to build
  collagen
• -A collar of growth is detectable
• -Calcium deposits begin
• -Need minimal motion for the callus structure to
  begin

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Stages Cont.

• CallusFormation
• -Beginning of a non-boney union
• -Callus new vascular tissue
• -Cartilage collar forms as each bone fragment
  grows toward the other side until fracture gap is
  bridged
• -Fracture fragments are joined by
• -Takes 3-4 weeks for the fracture fragments to be
  united by cartilage or fibrous tissue
• -Clinically- fragments are no longer easily moved

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Stages Cont.

• Ossification
• -Occurs within 2-3 weeks of fracture
• -The developed callus begins to ossify through
  endochondral ossification
• -Minerals continue to be deposited until bone is
  firmly reunited
• -With major adult long bones it takes 3-4 months

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Stages Cont.

• Remodeling
• -Removal of remaining devitalized tissue
• -Reorganization of new bone into its former
  structural arrangement
• -May take months or years
• -Adequate immobilization is essential until
  evidence of callus formation

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Treatment of fractures

• Immediate management
• -Splint
• -Preserve body alignment
• -Elevate part
• -Apply cold pack
• -Observe body part
• -Observe for shock- ABCs, save life then limbs
• -Apply pressure to site- Never apply a tourniquet.

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Treatment cont.

• Secondary treatment Goals-
• -Reduce fracture
• -Maintain alignment
• -Restore function

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Simple fractures

• Closed Reduction-
• Open Reduction
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• -

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Casts

• Two types of material used
• Plaster of Paris- rolls of crinidine impregnated
  with calcium sulfate
• -Dropped in water and applied over stockinette
  and cast padding
• -Gives off heat as it dries (d/t chemical
  reaction) (takes 24 hrs.)
• -Heavy and must be kept dry
• -Inexpensive

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Casts cont.

• Synthetic cast
• -Water activated- polyurethane material
• -Dries in 7-15 minutes
• -Light weight
• -Very durable, can be wet without crumbling
• -Expensive
• -Stronger than plaster of paris
• -Available in colors
• Cast Care

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Traction

• Two main types-
• -
• -
• Countertraction- pull in opposite directions.
• Important points
• -Weights-
• -Skin and pin care-
• -ROM-

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Complications of Fractures

• Compartment Syndrome- a condition in which
  increased pressure in a limited space compromises
  the circulation and function of the tissues
  within that space.
• Compartment consists of bone, blood vessels,
  nerves, muscles, and soft tissue with a fascial
  envelope.

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C.S.

• Two conditions for CS to develop
• Space limiting envelope- can be created
  externally- ie. Too tight dressing, splint, cast
• Increased pressure- blood, tissue, fluid leaking
  into tissues (ischemia damages the capillary
  endothelium and allows leakage)
• Skeletal traction pulls leg-decreases size of
  compartment

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C.S. cont.

• Most common sites-
• -4 compartments in lower leg- deep posterior,
  superficial posterior, lateral and anterior
• -2 dorsal and one on top in forearm
• End Result-

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C.S. cont.

• Muscle and nerve tissues are more sensitive to
  hypoxia than skin and subq tissues.
• Average time between trauma and symptoms is 2
  hours.
• 4-6 hrs. ischemia develops and results in
  irreversible tissue changes.
• Maybe enough to cause permanent functional loss
• Can have a contracture within 12 hrs. of ischemia

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Signs and Symptoms of C.S.

• Pain- out of proportion to expected injury
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Neurovasc. Assessment

• Ulnar
• Radial
• Medial 9median)
• Deep peroneal
• Posterior tibial
• Check NV status q 2-4 hrs

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Diagnosis and Monitoring

• Intracompartmental Pressure Monitor
• Myoglobinuria- myoglobin in urine, indicative of
  muscle cell death
• -Myoglobin- muscle protein responsible for
  transport of O2 to muscle cells. Myoglobulin is
  toxic to kidney tubules and contributes to renal
  failure

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C.S. Treatment

• Goal is to decrease tissue pressure, restore
  blood flow, and minimize functional loss
• Independent nursing actions-
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• -

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C.S. Treatment

• MD Order- remove or loosen external compression
  splint or bivalve cast
• Surgical treatment- Fasciotomy
• -All compartments in affected area are surgically
  opened.
• -Wounds packed with saline dressings and fx
  immobilized
• -Nsg. Assessment- NV checks, observe for
  infection, maintain joint mobility
• -Surgery later for closure and skin grafts

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Complications cont.

• Fat embolism
• -Serious complication resulting from a fracture,
  in which fat globules are released from the
  yellow bone marrow into the bloodstream
• -Bones most likely to occur-
• -At risk pts.-
• -Usually occurs within 48 hrs after fracture

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Fat Embolism cont.

• S S
• -Confusion
• -Increased respirations, pulse, temperature
• -Dyspnea
• -Decreased level of consciousness
• -Petechiae (50-60 of pts)
• -Mild thrombocytopenia

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Fat embolism treatment

• Bedrest
• Gentle handling
• Oxygen
• Hydration (IV fluids)
• Possible steroid therapy- ?pulmonary edema

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Avascular Necrosis (AVN)

• Definition-
• AVN is most frequently a complication of hip
  fractures or any fracture in which there is
  displacement of bone
• Treatment-

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Delayed Union, Nonunion, Malunion

• Delayed union-
• Nonunion-
• Malunion
• Most common in tibial fractures
• Elderly are prone to delayed or nonunion due to
  health conditions

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Arthritis
Handout
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Nursing Care of the Patient with Musculoskeletal
Disorders

• Rheumatoid Arthritis
• Assess
• Pain
• Decreased mobility
• Self care deficits
• Body image disturbances

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Intervention

• Rheumatoid Arthritis
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• OA
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• -

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Intervention

• OA cont.
• PT/OT
• ROM
• Orthotic devices
• Pain medications
• No pillows under knees unless ordered/ prone
  position
• Environmental barriers
• Independence ADLs
• Home health needs

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Evaluation

• Maintain mobility
• Uses orthotic devices
• Demonstrates motivation
• Identify strategies to maintain balance

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Other Nursing Diagnosis

• Self-care deficits
• Identify deficits
• Consult healthcare team when patient has reached
  max. level of functioning
• Body Image disturbances
• Identify patients strength/ control over symptoms
  
• and treat
• Communication/feelings and fears
• Encourage past coping skills as well as identify
  new ones.

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HIP Replacement

• Due to
• Most common sites
• Materials used
• Arthroplasty/ internal fixation
• 85 of patient experience pain relief

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Pre-op

• Optimal health
• Evaluate cardio, pulmonary, renal and hepatic
  function
• Age, obesity, swelling, DVT and varicosities
• Prophylactic anticoagulation
• Neurovascular assessment of extremity
• Include pulses femoral, popliteal and pedal
  pulses on BOTH extremities
• CSMF is part of the neuro check

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Post- op

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Nursing ImplicationsHip Replacements

• AVOID DISLOCATION OF HIP!
• The operative site may appear shorter and
  externally rotated
• ABDUCTION with pillows
• ABDUCTION IS MAINTAINED AT HOME
• Limit HOB at 30 degrees
• Knee is kept lower than the hip when moving OOB
  to chair
• Encourage activity. TCDB, incentive spirometer,
  isometrics
• Pain control
• Avoid rotation (internal or external)

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Hip Replacement

• NEVER cross legs
• Keep off operative side until surgeon has cleared
  pt
• Activity restrictions 3-6 months
• Post-op wounds
• Drains/ Drainage
• Edema is common

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Knee Replacement

• Considered for arthritis and/ or
  trauma/congenital deformities
• Knee immobilizer
• Neuro checks
• Drainage
• CPM hospital and home
• OOB night of surgery, ambulation 1-2 days after
  surgery

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Interventions

• Pain relief
• Check tissue perfusion and CSMF
• Maintain diet, fluids and movement
• PT mobility
• Verify limitations in activity
• Prevent hypovolemia, pneumonia, urinary
  retention, infection, and DVT

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DVTs

• Develops in pts that are
• Most common complication of lower extremity
  surgery or trauma
• Most frequently fatal complication of MS surgery-

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DVT

• Signs/ Symptoms- Same as fat embolism except no
  petechiae
• Treatment-
• Preventive measures
• Bed rest
• Oxygen
• Possible mechanical ventilation
• Heparin therapy
• Thrombolytics
• Poss. Surgery ligation of vena cava

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Infection

• Serious post op complication
• Due to
• Range from superficial skin infections to deep
  wound abscesses
• High risk pts.-?
• Avoid foley catheters, drains
• Prophylactic antibiotics
• S S

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Systemic Lupus Erythematosus

• A chronic remitting, inflammatory, autoimmune
  disease of connective tissues
• May affect skin, joints, pleural, and pericardial
  membranes, kidneys, and hematological and central
  nervous system
• Involves an abnormal reaction of the body to its
  own connective tissue
• Referred as a collagen disease (protein
  synthesized by fibroblasts, whose function to
  support and protect tissues and cells.
• Cause is unknown

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SLE cont.

• Affects more females, adolescent to adult
• S S- involvement of multiple body systems
• Most familiar is skin butterfly rash across the
  bridge of nose and cheeks
• Also common- Fever, fatigue, weight loss
• MS system- arthralgias, arthritis
• Pericarditis
• Lung and pleural involvement
• Lymphadenopathy
• Depression and psychosis

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SLE Diagnosis

• Classic symptoms of fever, fatigue and weight
  loss
• Assess for pericarditis, arthritis, and pleurisy
• No single definitive lab test
• Other tests used to rule out other problems

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SLE Treatment

• Goals-
• 1. prevent progressive loss of organ function, 2.
  minimize disabilities
• 3. prevent complications
• NSAIDS
• Corticosteroids
• Antimalarials- for cutaneous, MS, and mild
  systemic problems
• Immunosuppressive agents
• Avoid sunlight
• Remissions and exacerbations

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Amputations

• Usually either due to trauma or PVD
• Pre-op-
• Labs, diagnostics similar to other surgeries
• Pre-op visit by prosthetist for residual limb
  fitting
• Psychological adjustment!!!!

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Post op

• Psychological
• Pain- phantom limb pain
• Keep extremity in extended position- no pillows!
• NV checks
• Stump wrapping important to residual limb fitting
• Stump care-
• Monitor for complications-