The Musculoskeletal System

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Chapter 32

• The Musculoskeletal System

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Overview

• Structure and functions of bones
• Structure and functions of muscles
• Age-related changes

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Musculoskeletal system

• The musculoskeletal systems consists of the
  bones, cartilage, ligaments, tendons, and
  muscles.
• There are two distinct groups of bones cells that
  are transformed into mature cells.
• These cells form Cartilage

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Major Bones of the Human Skeleton
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Skeleton and bones

• There are 206 bones that make up the Human
  Skeleton
• Bone is either compact or spongy
• Spongy bone is made up of red bone marrow.
• Bones are classified as long, short, flat or
  irregular
• Each bone has markings on it that make it unique
  See Table 32-1 Bone Markings
• The haversian system is a canal system that runs
  through the bone and contains the blood and lymph
  vessels

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General Features of Long Bones
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Functions of the Skeleton and bones

• Bones provide shape to the body
• Provides a ridged framework that supports and
  protects the internal organs of the body
• Provides attachments for the tendons and
  ligaments and contribute to the movement of the
  body
• The red bone marrow in the spongy bones forms red
  blood cells, white blood cells, and platelets.
• Store and release minerals such as calcium and
  phosphorous

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Musculoskeletal system

• Joint Articulation point between two or more
  bones of the skeleton
• Immovable EX The skull
• Slightly moveable EX Vertebrae
• And freely moveable EX Knee, elbow
• Ligaments Join the bones of a joint together
• Tendons Connective tissues that provide joint
  movement

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Musculoskeletal System

• Cartilage Connective tissue in which fibers and
  cells are embedded in a semisolid gel material.
  Serves as a cushion
• Example is the meniscus in the knee
• Bursa Fluid filled sac that provides
  cushioning at friction points in a freely
  moveable joint .
• Skeletal muscle is made up of hundreds of muscle
  fibers bundled together surrounded by connective
  tissue.

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Musculoskeletal System

• Fascia is connective tissue that surrounds and
  separates the muscles
• The muscle coverings contain blood vessels and
  and nerves
• Muscles have properties that allow it to be
  electrically excites causing it to contract,
  extend or stretch, and provide elasticity.

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Functions of the Muscles

• Contraction of the skeletal muscle produces
  synchronized contraction of many muscle fibers
• Skeletal muscles contract, thereby producing
  movement and joint stability, maintaining
  posture, and producing body heat.
• Muscles provide movement of the joints

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Aging and the musculoskeletal system

• Ossification occurs which is the replacement of
  cartilage by more boney tissue
• Bone density decreases because of resorption of
  minerals
• The loss of bone mass or osteoporosis, more
  common in women
• Bone injury or fracture takes longer to heal
• Bones in the elderly are more brittle and break
  easily
• Thinning of the intervertebral cartilage causes a
  collapse of the vertebrae creating a kyphosis
  (hump)

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Aging of musculoskeletal system

• Joint cartilage thins and erodes resulting in
  stiffness and grating of the joints
• Joint motion may decrease, causing limited
  mobility and swelling
• Los of muscle mass and less strength
• Muscle cramping especially at night increase due
  to impaired circulation

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Prevention

• Safety Measures
• Using proper body mechanics when moving or
  lifting objects. (large muscle groups)
• Using seat belts when riding in cars
• If riding bicycles or motorcycles use helmets
• Calcium and Vitamin D throughout life span

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Causes of Musculoskeletal Disorders

• Disease, trauma, malnutrition, and aging all
  contribute to musculoskeletal problems
• Trauma may cause bruising, strain, sprain, or
  fracture
• Poor nutrition may deprive the body of sufficient
  nutrients such as calcium and phosphorous to
  build strong bones
• Inadequate protein can cause muscle wasting
• Malignant tumors can invade bone either as a
  primary cancer or a metastatic disease
• Decreased Estrogen after menopause can lead to
  osteoporosis

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Prevention

• Preservation of motion and mobility are important
  to prevent long term orthopedic problems
• Weight-training and exercise throughout life to
  maintain bone mass and contribute to increase
  muscle strength, improved coordination and
  balance all decrease incidence of falls
• Nutrition for bone growth and density
• No Smoking contributes to musculoskeletal health

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Diagnostic Tests and Procedures

• Diagnostic Tests evaluate for Autoimmune
  disorders
• Blood counts
• Blood Culture
• Erythrocyte sedimentation rate (ESR)
• Serum protein electrophoresis
• See charts 32-2 pgs 740-741

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Diagnostic Blood Tests

• Needed for bone formation
• Needed for bone formation
• Useful in determining if primary or metastatic
  cancer present
• Used to test for skeletal muscle trauma or disease

• Calcium
• Phosphorous
• AlP (Alkaline phosphotase)
• CPK

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Diagnostic lab tests

• Used to detect gout
• To detect antibodies, indicating rheumatoid
  arthritis, lupus or scleroderma
• Useful to diagnosis rheumatoid arthritis, lupus,
  and other connective tissue disorders

• Uric Acid
• Rheumatoid Factor
• ANA (Anti nuclear Antibody)

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Diagnostic Tests and Procedures (cont.)

• Imaging and use of contrasts to diagnose
  musculoskeletal disorders
• MRI
• CAT scan
• X-rays of joints or bones
• Goniometry and range of motion

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Diagnostic tests

• DEXA Scan
• Bone Scan
• Gallium/Thallium Scan
• Arthrogram

• Measures bone density
• To detect bone injury/tumor
• To detect bone problems especially tumor
• Provides pictures of the joint cavity and soft
  tissue structures

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Diagnostic Studies

• Arthroscopy
• Arthrocentesis

• To inspect the interior aspect of a joint,
  usually knee with a fiberoptic scope to diagnoses
  problems with the meniscus, or arthritis
• To extract synovial fluid for analysis or to
  reduce swelling

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Diagnostic procedures

• Arthrocentesis

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Measurement of Joint Motion with a Goniometer

• The measurement of a joint. Each joint is
  evaluated in terms of degrees it can be moved
  from the 0 degrees position

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Nursing Care post Procedure

• Nursing Care post arthroscopy/ Arthrocentesis
• Observe for signs of bleeding or swelling ice
  packs may be used post procedure
• Assess for swelling, circulation, sensation,
  pulses, and color of extremity.
• Apply ice packs post procedure
• Wrap with elastic bandage if ordered
• Instruct patient not to overuse joint until pain
  and selling decrease
• Analgesics as ordered.

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Diagnostic procedures

• Bone marrow biopsy

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Diagnostic Studies

• Biopsy
• EMG

• Done to detect tumor cells. Muscle biopsy may be
  done to diagnose several muscles disorders
• To determine abnormal nerve transmission to the
  muscle and abnormal muscle function.

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Assessment (Data Collection)

• Family history may be significant for
  musculoskeletal problems osteoporosis, rheumatoid
  arthritis
• Assess pain. What makes it worse precipitating
  factors
• Pain in wrists, knees, hips or feet?
• Note problems of movement and changes in facial
  expression related to activities of daily living
• Family members and patients ability to perform
  the activities of daily living

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Data collection assessment

• History Taking/Nursing Assessment
• When reviewing the patient history the nurse
  needs to keep in mind the significance of
  disorders that affect other systems but
  secondarily affect bones and muscles.
• Example psoriasis is sometimes the first sign
  of psoriatic arthritis.
• Nutritional deficiencies can affect the
  nutritional composition of bone and muscle
• Example Osteoporosis (Risk for falls/fracture.

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Assessment data collection

• Has the patient experienced any sensory changes?
  Sensation in feet, hands or elsewhere?
• Any trouble sleeping because of muscle or joint
  pain?
• Any restriction in movement?
• Does the patient have any joint deformity?
  Example Bunion, Hammertoe, Swan neck deformity
• Any previous injury to the bone?
• Have any problems with ADLs

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Physical Assessment of the Musculoskeletal System

• Posture, gait, and balance
• Mobility, range of motion, and strength
• Spine
• Appearance of joints
• Skeletal muscle appearance in arms and legs
• Ability to perform activities of daily living
• Elder considerations

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Examples of joint Deformities
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Joint Deformities

• HAMMERTOE

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Joint Deformites

• Rheumatoid Arthritis Swan Neck Deformity

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Lifting and Turning the Patient

• All movements need to be
• gentle and firm movements
• Sufficient help and adequately trained personnel
• If the patient can help without damaging the
  diseased joint or limb, he should be
• to do so
• If the patient is not able to help, explain the
  procedure to him and instruct him to relax
  completely during the procedure

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Interventions to Prevent Disability

• Within a few days, the structures of immobilized
  muscles and joints begin to undergo changes
• The forming of contractures, loss of muscle tone,
  and the fixation of joints can be prevented in
  most cases by consistent nursing intervention
• The major components of this intervention
• Gradual mobilization
• Exercise program
• Proper positioning
• Patient and family teaching
• Initiate and maintain measures to prevent
  complications

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Preventing contractures

• The major components of this intervention
• Gradual mobilization
• Exercise program
• Proper positioning
• Instruction of the patient and family

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Interventions to Prevent Disability (cont.)

• Preventing contractures When muscles are not
  regularly stretched and contracted they attempt
  to adapted them selves and become shorter
• Adaptive shortening Can begin in 3 7 days
  after immobilization of a body part.
• Most common footdrop, knee and hip flexion
  contractures, wrist drop, and contractures of
  the fingers and arms
• Loss of muscle tone
• ROM exercises important in preventing this and
  must begin as soon as possible .

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Interventions to Prevent Disability (cont.)

• Prevent ankylosis Result of injury the tissues
  of the joint are replaced by a bony overgrowth
  that completely obliterates the joint Proper
  positioning and movement of the joint can help
  prevent this
• Gradual mobilization
• Nursing responsibility Recognize patients who
  are at risk for falls while they are learning to
  regain their mobility
• Set goals for progressive mobilization. Must take
  into account the pathological condition or cause
  for immobilization

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Nursing Care/planning

• Caring for immobile patients requires careful
  planning.
• Making beds for the bed confined orthopedic
  patient is best done by two people.
• Bathing and grooming are more time consuming when
  a patient has an immobilized limb, or a
  immobilizing device
• Planning for toileting at regular Intervals for
  the patient who cant get out of bed by self.
• Repositioning the patient is important q 2 hours
  and for comfort.

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Preventing Contractures

• ROM exercises 3-4 times a day
• Physical/Occupational Therapy needs to be
  involved as soon as possible for evaluation and
  treat.
• Patients experiencing intense pain need to be
  assess and proper analgesics and anti
  inflammatory drugs administered before their
  exercises. 30-60 minutes before
• CPM Post joint surgery. This machine provides
  passive motion of the joint

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Interventions to Prevent Disability (cont.)
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Intervention to Prevent Diablity

• CPM machine passive exercise

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Interventions to Prevent Disability (cont.)

• Exercise and ROM exercises
• Isometric exercises
• Administration of analgesic and anti-inflammatory
  drugs
• Continuous passive motion
• Positioning and special beds
• Foot drop (Footboard may be appropriate) for
  flaccid paralysis
• Foot Cradle may be appropriate for patients with
  specific paralysis (Relieves the pressure of bed
  sheets and blankets)

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Prevention Devices

• Foot Board and Bed Cradle

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Interventions to Prevent Disability (cont.)

• Speciality Beds Use Often use for patient in
  cervical traction Beds turn the patient 300 times
  a day. Allows access to all areas of te body.
• Use of slings and splints
• Teaching ambulation with assistive devices
• Crutch safety see page 730-731
• Special maneuvers on crutches
• Psychosocial care

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FluidAir Bed
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PSYCHOSOCIAL cARE

• Psychosocial Care
• Many orthopedic conditions require prolonged
  periods of confinement to bed, immobilization,
  and restricted physical activity
• This can lead to frustration and depression due
  to the dependence on others for care.

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Wrist Splint
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Sling Support device
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Evaluation

• Determine effectiveness of interventions
• Be alert to nuances of body language
• Observe patients ability to accomplish ADLs
• Check x-rays and laboratory tests
• Collaborate among all health professionals