Musculoskeletal Nursing

Medical and Surgical Nursing

Musculoskeletal Disorder

Prepared: Mark Fredderick Abejo RN, MAN

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MS Abejo

MEDICAL AND SURGICAL NURSING

Musculoskeletal System

Lecturer: Mark Fredderick R. Abejo RN,MAN

______________________________________________________________________________________________

DISEASES OF THE MUSCULOSKELETAL SYSTEM

I. COMMON HEALTH PROBLEMS OF THE NEONATES

AND INFANTS DEVELOPMENTAL HIP DYSPLASIA

(CONGENITAL HIP DYSPLASIA)

CLUB FOOT (TALIPES DEFORMITIES)

TORTICOLLIS (WRY NECK)

II. COMMON HEALTH PROBLEMS OF THE CHILD DISORDERS OF BONE DEVELOPMENT

A. FLAT FEET (PES PLANUS)

B. BOWLEGS (GENU VARUM)

C. BLOUNT’S DISEASE (TIBIA VARA)

D. KNOCK KNEES (GENU VALGUM)

E. TOEING-IN (PIGEON TOE)

F. LIMPS

G. OSTEOGENESIS IMPERFECTA

H. LEGG-CALVÉ-PERTHES DISEASE (COXA

PLANA)

I. OSGOOD-SCHLATTER DISEASE

J. SLIPPED CAPITAL FEMORAL EPIPHYSIS

(COXA VERA)

JUVENILE RHEUMATOID ARTHRITIS

RICKETS

III. COMMON HEALTH PROBLEMS OF THE

ADOLESCENT

SCOLIOSIS

IV. COMMON HEALTH PROBLEMS OF THE YOUNG

ADULT OSTEOGENIC SARCOMA

V. COMMON HEALTH PROBLEMS OF ADULT RHEUMATIC DISEASES

GOUT

CARPAL TUNNEL SYNDROME

DEGENERATIVE JOINT DISEASE

VI. COMMON HEALTH PROBLEMS ACROSS LIFESPAN FRACTURE

AMPUTATION

COMMON HEALTH PROBLEMS OF THE NEONATES

AND INFANTS

I. CONGENITAL HIP DYSPLASIA

Improper formation and function of the hip socket

subluxation or dislocation of the head of femur

acetabulum is either flattened or shallow

SUBLUXATION femoral head is “riding high” in

shallow acetabulum

DISLOCATION femoral head out of acetabulum

A. ETIOLOGY 1. Unknown

2. Polygenic inheritance pattern

3. Uterine position (?)

4. Children of Mediterranean ancestry

5. 6x > in girls

6. Relaxin (?)

7. Unilateral

8. Socio-cultural

9. Manner of carrying infants

B. SIGN AND SYMPTOMS Early detection is important

1. Affected leg shorter

1 knee lower: child supine, thigh flexed 90°

Ortolani’s sign

Barlow’s sign




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2. Unequal number of skin folds on posterior thigh

3. Prominence of trochanter

4. Assessment of hip abduction during health

maintenance visits (4-6 wks)

Ortolani’s sign - Pull with click sound

Barlow’s sign - Push back with click sound

C. MANAGEMENT

1. Position hip into a flexed, abducted (externally

rotated) position

a. Traction

b. Splints

c. Halters

d. Casts

e. Pins to stabilize hips

f. Multiple diapers (cloth)

bulk separates legs frog-leg, externally

rotated

g. Hip abduction splint (Frejka)

made of plastic and buckles

keep splint in place at all times except

when bathing/changing diapers

firm pressure but caution vs. forcible

abduction compromise of blood supply

good diaper care

wash area w/ clear water

A & D ointment

Vaselin

Desitin

Padding edges of brace

h. Pavlik’s Harness

adjustable chest halter that abducts legs

method of choice for long term treatment

reduces time interval for treatment to 3-4

wks

worn continually except when bathing

assess skin under straps

i. Spica cast (6-9 months)

if hip is fully dislocated or if with severe

subluxation

Bryant’s traction for 1 week

assess hourly for circulatory constriction

temperature and circulation in toes




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II. CLUB FOOT (TALIPES DEFORMITIES) 1/1000 children

boys > girls

polygenic inheritance pattern

usually unilateral vs. pseudotalipes 2° to intrauterine

position

TRUE TALIPES

(4 types):

1. Plantar flexion: (Talipes equinus)

2. Dorsiflexion

3. Varus

4. Valgus:

Plantar flexion (Talipes Equinus) Foot lower than heel

Dorsiflexion ( Talipes Calcaneus)

heel lower than feet or anterior

foot flexed toward anterior leg

Talipes valgus

foot turns out

Talipes varus

foot turns in

A. ASSESSMENT 1. Early detection

2. Straighten all newborn feet to midline as part of

initial assessment

B. MANAGEMENT 1. Cast application in overcorrected position; extends

above knee

2. Frequent diaper changes prevent case soaked

with urine/ meconium

3. Check the coldness & capillary refill

4. Circulatory compression change cast q1-2 weeks

due to rapid growth

5. 6 weeks casting passive foot exercises

6. Denis Browne splints

7. Surgery – final option

III. TORTICOLLIS (WRY NECK) tortus – twisted; collus – neck

congenital anomaly when sternocleidomastoid muscle is

injured & bleeds during birth trauma – delivery of

shoulders

head tilted to side of involved muscle; chin rotates to

opposite side

may not be immediately evident

fibrous contraction age 1-2 mos. w/ thick mass over

muscle




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A. MANAGEMENT

1. Parent to initiate passive stretching exercises &

encourage infants to look in the direction of affected

muscle, e.g. feeding position

2. If simple exercises not effective ≈1 year of age

surgical correction followed by neck immobilizer

3. Adults Botox injections (not recommended for

children)

COMMON HEALTH PROBLEMS OF THE CHILD

DISORDERS OF BONE DEVELOPMENT

A. FLAT FEET (PES PLANUS) relaxation of the longitudinal arch of the foot;

Normal newborn foot is flatter &

proportionately wider than adult’s

longitudinal arch rarely visible until child has

been walking for months

Assess: ask child to stand on tiptoe visible

longitudinal arch

Exercises to strengthen

Tiptoe walking ≈5-10 min

Picking marbles w/ toes

Sports shoes

B. BOWLEGS (GENU VARUM)

Lateral bowing of the tibia

Malleoli are touching

Medial surface of knees is >2in (5cm) apart

Gradually corrects itself ≈2y/o

If unilateral or worsening orthopedist

C. BLOUNT’S DISEASE (TIBIA VARA) retardation of growth of the epiphyseal line on

the medial side of the proximal tibia (inside of the

knee) bowed legs

serious disturbance in bone growth

Assessment of Blount’s disease

X-ray shows medial aspect of the proximal tibia

will show a sharp beaklike appearance

Treatment of Blount’s Disease:

Osteotomy

Bracing

D. KNOCK KNEES (GENU VALGUM)

opposite of Genu Varum

medial surfaces of knees touch

medial surfaces of ankle malleoli

separated >3cm (7.5cm)

children 3-4y/o;

no treatment necessary




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E. TOEING-IN (PIGEON TOE) 2° foot, tibial, femoral or hip displacement

“awkward”

“always falling over her feet”

4 Cases of Toeing In:

1. METATARSUS ADDUCTUS

turning in of forefoot – heel has good

alignment

R/T Infants who sleep prone w/ feet

adducted

older children who watch TV kneeling,

feet turned in

>1year passive stretching exercises

May require casts or splints

Early detection & treatment before

walking N

2. INWARD TIBIAL TORSION

line drawn from anterior superior iliac

crest through center of patella intersects

4th or 5th toe (normal = 2nd toe)

No treatment required

3. INWARD FEMORAL TORSION

Normal

Internal rotation ≈ 30°

Outward rotation ≈ 90°

With Inward femoral torsion

Internal rotation ≈ 90°

No treatment required but w/

compensating tibial torsion

4. DEVELOPMENTAL HIP DYSPLASIA

F. LIMPS may reflect serious bone or muscle involvement,

e.g. CP, Osteomyelitis

History: -- Pain

measurement of leg length

Range Of Motion

growing pains (?)

biphosphonates

G. OSTEOGENESIS IMPERFECTA

connective tissue disorder: fragile bone

formation recurring pathologic fractures




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TYPE 1: Severe A.D. countless fractures related to birth trauma

X-ray ribbon like or mosaic bone pattern

blue sclera related to poor connective tissue

formation

TYPE 2: A.R. assoc deafness & dental deformities

No treatment is curative

preventive & safety measures

Growth Hormone

Calcitonin

Biphosponates

H. LEGG-CALVÉ-PERTHES DISEASE (COXA PLANA)

avascular necrosis of proximal femoral

epiphysis related to unknown cause

boys > girls

peak incidence 4-8y/o

unilateral but may be bilateral

Pain in hip joint w/ spasm & LOM

Differential Diagnosis: Synovitis

1. Stage I: Synovitis stage

2. II: Necrotic stage – 6-12 months

3. III: Fragmentation stage – 1-2 yr

4. IV: Reconstruction stage

Treatment for Legg Calve Perthes

1. NSAIDS

2. containment devices

abduction braces, casts

leather harness slings

3. reconstructive surgery osteotomy to center

femoral head

4. in acetabulum cast

I. OSGOOD-SCHLATTER DISEASE

thickening and enlargement of tibial tuberosity

resulting from microtrauma

pain/swelling over tibial tubercle

more during early adolescence

Treatment: 1. Limiting strenuous physical exercises

2. Immobilization ≈ 6 wks

3. children

J. SLIPPED CAPITAL FEMORAL EPIPHYSIS (COXA

VERA)

slipping of femur head in relation to neck of

femur at the epiphyseal line

Proximal femur head displaces posteriorly &

inferiorly

< preadolescence

2x African Americans

2x boys than girls

more on obese & rapidly growing

JUVENILE RHEUMATOID ARTHRITIS collagen – vascular disease; 1° involves joints also

blood vessels and connective tissue

symptoms before 16 y/o

symptoms last longer than 3 months

peak incidence: 1-3 y/o, 8-12 y/o

slightly more common in girls

acute changes rarely continue past 19

cause unknown

probably autoimmune

(+) ANA

Some w/ genetic predisposition




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A. ASSESSMENT 1. persistent fever & rash joint involvement

2. medical diagnosis

3. Nursing Assessment:

a. Effect on Individual & Family

b. Self-care

c. Ex: elevated toilet, Velcro strips

d. Complications

e. Ex: slit lamp examinations q6 months

B. MANAGEMENT 1. - Long term illness

a. Exercise

b. Heat application

c. Splinting

d. Nutrition

e. Medications

2. Exercise: Rationale – to preserve muscle and joint

function

a. Daily ROM exercises

b. Incorporate into dance routine or game

c. Family participation

d. Avoid excessive strain on joints

Running

Jumping

Prolonged walking

Kicking

Shortened school day – fatigue easily;

start midmorning

3. Heat application:

4. Rationale – reduces pain & inflammation, increases

comfort & motion

a. Warm water soaks 20-30 min

b. Paraffin soaks for finger & wrists

5. Splinting: rarely prescribed because of more

effective NSAIDS

6. Nutrition: Altered nutrition related to chronic pain

a. GIT irritation – NSAIDS

b. Plan mealtimes

7. Medications

c. Tolmetin

d. Naproxen

e. Ibuprofen

f. Celecoxib less GIT irritation

g. Rofecoxib

h. NSAIDS: reduce/control pain & inflammation

6-8 wks

Health teachings:

GIT irritation (w/

meals)

Give even if w/o pain

to exert anti-

inflammatory action

i. SAARDs (Slow Acting Anti-Rheumatic drugs)

j. DMARDs (Disease Modifying Anti-Rheumatic

drugs)

Ex. Gold salts, Penicillamine,

Hydroxychloroquinine

k. Cytotoxic Drugs: side effects

Cyclophosphamide

Chlorambucil

Methotrexate

l. Steroids

Nursing Diagnosis for Juvenile Rheumatoid Arthritis

Deficient knowledge related to care necessary to

control disease symptoms

Health Teaching for Juvenile Rheumatoid Arthritis

Active role in treatment

Need for follow-up care

Plan & schedule – balance rest & exercise

RICKETS

disorder in which mineralization of organic matrix is

defective

assoc with Vit D deficiency or resistance

growing skeleton; defective mineralization both in

bones and cartilage

vs. Osteomalacia – mineralization disorder in adults

in whom epiphyseal growth plates are closed

Bowing deformities, knocked knees

Stunting of growth of long bones

Severe muscle weakness

A. PATHOPHYSIOLOGY 1. Disorders causing alteration of Vit D nutrition or

metabolism or phosphate wasting

2. Hypovitaminosis D

3. Inadequate prod. Vit D3 in skin

4. insufficient dietary supplementation

5. inability of small intestine to absorb Vit from diet

6. resistance to effects of Vit D

drugs which interfere w/ Vit D action

7. anticonvulsants, glucocorticoids

alteration in Vit D metabolism

8. Chronic renal failure

9. Intoxication cadmium, lead, expired tetracycline

B. SIGN AND SYMPTOMS 1. Skeletal deformities – children unable to walk

2. Susceptibility to fractures

3. Weakness & hypotonia

4. Growth disturbances

5. CRANIOTABES: soft calvariae, widening of

sutures

6. RACHITIC ROSARY: prominence of

costochondral junctions




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7. HARRISON’S GROOVE: indentation of lower

ribs at site of attachment of diaphragm

8. Bowing of tibia, femur, radius, ulna

9. Flattening of pelvis

10. Enamel defects

11. Radiologic Features: Increased thickness of growth plate (physis)

due to ↓ calcification & inadequate

mineralization

C. TREATMENT 1. Vit D2 (Ergocalciferol) 800-4000 IU

2. Vit D3 (Cholecalciferol) (0.02-0.1 mg) daily for 6-

12 wks followed by 200-600 IU daily

3. Calcium supplements

COMMON HEALTH PROBLEMS OF THE ADOLESCENT

I. SCOLIOSIS lateral curvature of spine

may involve all or only a portion of SC

may be functional (2°) or structural (1° deformity)

I. FUNCTIONAL SCOLIOSIS

II. STRUCTURAL SCOLIOSIS

I. FUNCTIONAL SCOLIOSIS

compensatory mechanism related to unequal leg

length, EOR constantly tilt head sideways

pelvic tilt related to unequal leg length & head

tilt spinal deviation

C shaped curve - little change in shape of

vertebrae

THERAPEUTIC MANAGEMENT of Functional

Scoliosis 1. correct the difficulty causing spinal curvature

2. unequal leg length (as is to medial malleolus)

3. shoe lift

4. correct EOR

5. maintain good posture

6. sit-ups, pushups, swimming

II. STRUCTURAL SCOLIOSIS

idiopathic permanent curvature of spine accompanied By

damage to vertebrae

primary lateral curvature

® Thoracic convexity+ Compensatory second curve

↓

S-shaped curve appearance (rotation angulation)

family history = 30% but no specific inheritance

pattern

5x more girls > boys

Peak incidence 8-15 y/o

Most marked during pre-puberty (rapid growth)

Uneven Shoulders

Curve in Spine

Uneven hips

A. ASSESSMENT 1. Bra straps adjusted to unequal length

2. Difficulty buying jeans

3. Skirts & dresses hang unevenly

4. Bend forward

5. Scoliometer: reading >7° ≈ 20°

6. PPT

7. Chest Xray

B. MANAGEMENT

1. Scoliosis (Long term)

2. <20° = no treatment; close observation until 18y/0

3. >20° = conservative non-surgical treatment, body

brace, traction

4. >40° = surgery, spinal fusion

5. Bracing > 20° - 40° skeletally immature

6. Milwaukee brace (Thoracolumbar support)

7. worn under clothing

8. worn 23H/day

9. at night Charleston Bending brace

10. Milwaukee Brace




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11. Braces 14 ½ y/o ♀

16 ½ y/o ♂

12. Halo Traction

C. NURSING MANAGEMENT 1. Health teaching how to apply braces

2. Right fit

3. Adjustment q3mos

COMMON HEALTH PROBLEMS OF THE YOUNG ADULT

I. OSTEOGENIC SARCOMA malignant tumor of long bone involving rapidly

growing bone tissue

more commonly in boys > girls

common sites

Distal femur (40-50%)

Proximal tibia (20%)

Proximal humerus (10-15%)

History of radiation

Early metastasis 2° to ↑vascularity of bones

Lungs – 25% brain, other bones

Chronic cough

Dyspnea

Chest pains

Leg pains

A. ASSESSMENT

1. usually taller children (rapid bone growth)

2. pain & swelling at tumor site

3. History of recent trauma not the cause

4. Pathologic fracture

5. Diagnostic biopsy

6. ↑ alkaline phosphatase fm rapidly growing bone cells

7. Metastatic workup

CBC, UA

CXR

Chest CT Scan

Bone scan

B. Therapeutic Management of Osteogenic Sarcoma

1. small tumor in leg – child has reached adult size

↓

Surgical removal of bone

+

Bone or metal prosthesis

If extensive total hip amputation

2. lung managements thoracotomy - lobectomy,

pneumonectomy

3. pre-op chemotherapy

methotrexate

cisplatin

doxorubicin

ifosfamide

4. present prognosis

early detection 60-65% cure rate

C. NURSING MANAGEMENT 1. Post-op: swelling disrupting neurologic & circulatory

function

2. proper position

3. monitor

Capillary refill < 5s

(-) numbness & tingling

Warm, pink

4. Post-op: Phantom Pain Syndrome

5. Nerve trunks continue to report pain

6. Need analgesics!

COMMON HEALTH PROBLEMS OF ADULT

I. RHEUMATIC DISEASES – “Arthritis” 1° affects skeletal MS, bones, cartilages, ligaments,

tendons, joints of males & females of all ages.

RHEUMATIC ARTHRITIS – Inflammatory

Arthritis 2-3x women > men

Autoimmune reaction primarily occurs in synovial tissue

A. PATHOPHYSIOLOGY 1. Phagocytosis produces enzymes within joint

2. Enzymes break down collagen

1. Edema

2. Proliferation of synovial membrane

3. Pannus formation




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Destroys cartilage, erodes bones

Loss of articular surfaces & joint motion

3. Muscle degenerative Δs

4. Tendon & ligament elasticity & contractile

power lost

B. SIGNS AND SYMPTOMS 1. joint pain, swelling, warmth, erythema, lack of

function

2. joint fluid

3. small joints in hands, wrists, hips, elbows, ankles,

cervical spines, temporo-mandibular joint

4. acute

5. bilateral and symmetric

6. joint stiffness in AM > 30min

Extra - Articular Manifestations of Rheumatoid

Arthritis

1. fever, wt loss, fatigue, anemia, LN enlargement,

Raynaud’s phenomenon, Arterities, Scleritis,

Sjogren’s pericarditis, splenomegaly

2. Rheumatoid nodules – with Rheumatoid Factors

3. ≈50% of Patients

4. Usually non-tender & movable in subcutaneous

tissues

5. Over bony prominences

6. May disappear spontaneously

C. Assessment & diagnostic of Rheumatoid Arthritis

1. Hx & PE

Bilateral & symmetric stiffness

Tenderness & swelling

Temperature Δs in joints

Extraarticular Δs

2. Rheumatoid Factor (+) 80%

3. ESR ↑

4. RBC C4 & C4 complement ↓

5. C Reactive proteins maybe (+)

6. ANA

7. Arthrocentesis: cloudy, milky, or dark yellow

8. X-ray: bone erosions, narrowed joint spaces

II. GOUT

heterogenous group of conditions related to genetic

defect of purine metabolism hyperuricemia

oversecretion of uric acid

renal defect ↓excretion of UA

combination

males > females

↑ incidence w/ ↑ age & Body Mass Index

PRIMARY HYPERURICEMIA >7 mg/dl (0.4 fmol/L)

usually faulty uric acid metabolism

severe dieting or starvation

food high in purines

heredity

SECONDARY HYPERURICEMIA

↑ cell turnover

Leukemia

Multiple myeloma

Anemia

Psoriasis

Uric acid under excretion

SE of drugs (thiazide & furosemides)

Low dose salicylates

A. PATHOPHYSIOLOGY 1. Hyperuricemia monosodium urate crystal

deposition

2. Sudden ↑ or ↓ of serum acid levels

3. Inflammatory response

4. Tophi formation

5. great toe, hands, ear

6. Renal urate lithiasis

7. Chronic renal disease

8. IgG coating urate crystals – immunologic




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B. SIGNS AND SYMPTOMS 1. Acute Gouty Arthritis

recurrent attacks of sever articular & peri-

articular inflammation

2. Tophi

Crystalline deposits

3. Gouty Nephropathy

4. Uric Acid Calculi

5. Tophi in hand and ears

Stages of Gout

a. Asymptomatic Hyperuricemia

b. Acute Gouty Arthritis

c. Intercritical Gout

d. Chronic Tophaceous Gout

6. Metatarsophalangeal joint of big toe

7. 75% of patients

8. attack may be triggered by

Trauma

Alcohol

Dieting

Medications

Surgical stress

Illness

9. Abrupt onset awakening patient at night

10. Subdues within 3-10 days even w/o treatment

11. Symptom free period (intercritical stage)

12. Tophi also found in aortic walls, heart valves, etc

13. Definite Diagnosis

Polarized microscopy of synovial fluid

Uric acid crystals

(+)

PMN Leukocytes

C. MANAGEMENT 1. Colchicine, NSAIDs treatment of acute attack

2. Then management of Hyperuricemia after

inflammatory process has subsided

3. Colchicine

4. lowers deposition of uric acid & interferes w/

leukocytes & kinnin formation, thus reducing

inflammation

5. Does not alter serum or urine levels of uric acid,

used in acute and chronic mgt.

6. administer until pain relief or diarrhea

7. prolonged use ↓Vit B12 absorption, GI upset

8. Probenecid:Uricosuric agent

Inhibits renal reabsorption of urates

↑ urinary excretion of UA

Prevents tophi formation

S.E. nausea, rash, constipation

9. Allopurinol: Xanthine oxidase inhibitor

Interrupts breakdown of purines before uric

acid is formed

Inhibits xanthine oxidase

S.E. BM depression, vomiting, abdominal pain

10. Corticosteroids: Anti-inflammatory

III. CARPAL TUNNEL SYNDROME entrapment neuropathy; median nerve at the wrist is

compressed by

thickened flexor tendon sheath

skeletal encroachment

edema

soft tissue mass

repetitive hand activities

also assoc w/ pregnancy, arthritis, hypothyroid

characterized by pain & numbness, paresthesias,

weakness along median nerve (thumb & 1st 2 fingers)

(+) Tinel’s sign

(+) Night pain

Treatment for Carpal Tunnel Syndrome

rest splints

avoidance of repetitive flexion

NSAIDs

Cortisone injections

Laser release

IV. DEGENERATIVE JOINT DISEASE (Osteoarthritis) functional impact on quality of life

primary (idiopathic) no prior event/disease

secondary: r/t previous joint disease or inflammatory

disease

increasing age

often begins 34d decade

peaks between 5th and 6th decade

by age 75- 85 % either xray or clinical evidence

But is 15-25% with significant symptoms

ability of articular cartilage to resist microtrauma

A. RISK FACTORS 1. increased age – wear and tear

2. obesity

3. previous joint damage

4. repetitive use (occupational or recreational)

5. anatomic deformity




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6. genetic susceptibility

7. congenital sublaxation-dislocation of hip

8. acetabular dysplasia

9. Legg-Calves Perthes

10. slipped capital femoral epiphysis

B. SIGNS AND SYMPTOMS 1. pain

2. stiffness

3. functional impairment

4. PAIN inflammation of synovium

5. inflammation of nerve endings in periosteum over

osteophytes

6. stretching of joint capsules or ligaments

7. trabecular microfracture

8. intraosseous hpn

9. bursitis

10. tendinitis

11. muscle spasm

12. STIFFNESS “morning” or after awakening<30

min/ decreases with movement

C. PATHOPHYSIOLOGY

D. ASSESSMENT 1. Physical Exam

2. tender and enlarged joints

3. X-Ray

4. 30-50%

progressive loss of joint cartilage “narrowing of

joints spaces”

5. spur=ostephyte formation -> cartilage attempts to

regenerate

E. MEDICAL MANAGEMENT of Osteoarthritis

1. Preventive measures to slow progress

b. weight reduction

c. prevention of injuries

d. joint rest

e. perinatal screening (congenital hip dysplasia)

f. ergonomic modification

2. Conservative Measures to Slow Progress of

Osteoarthritis

a. use of heat

b. weight reduction

c. joint rest

d. avoidance of joint overuse

e. orthostatic devices (splints, braces)

f. isometric and postural exercises

g. aerobic exercises

h. OcTherap and PhysTher

F. SURGICAL MANAGEMENT 1. use of heat

2. weight reduction

3. joint rest

4. avoidance of joint overuse

5. orthostatic devices (splints, braces)

6. isometric and postural exercises

7. aerobic exercises

8. OcTherap and PhysTher

9. Osteotomy- to alter the force distribution of the

joint

10. Arthroplasty- to replace diseased joint

compnonents

11. Viscosupplemetation-reconstitution of joint fluid

viscosity using hyaluronic acid

12. (Hyalgan, Synvise Rx)

13. Tidal Lavage of Knee – stimulate production of

synoviocytes

14. Approximately 6 months pain relief

G. NURSING MANAGEMENT

1. Pain management

2. Optimizing functional ability

3. Pt referral

4. Lifestyle changes

5. Planning daily activities

Genetic and hormonal factors

Previous joint damage

Release of cytokines

Chondrocyte response

Others

Mechanical injury

Resulting damage predisposes to more,,,

Stimulation, production and release of proteolytic enzymes, metalloproteases, collagensase




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COMMON HEALTH PROBLEMS ACROSS LIFESPAN

I. FRACTURE

FRACTURE- break in the continuity of bone and

adjacent structures

soft tissue edema

hemorrhage into muscles and joints

joint dislocation

ruptured tendons

severed nerves

damaged blood vessels

body organ damage secondary to force or fracture

fragments

Types of fractures 1. Complete break across entire cross section of bone

(displacement)

2. Open, Compound, Complex skin or muscle

extends thru fractured bone

a. Grade I clean wound <1cm

b. Grade II larger wound without extensive soft

tissue damage

c. Grade III highly contaminated

d. Compressed – bone has been compressed

(ie. Vertebral fractures)

3. Depressed- fragments driven inwards

e. (ie. Skull and facial bones)

4. Epiphyseal- fracture thru epiphysis

5. Impacted- bone fragment is driven thru another

bone fragment

6. Pathologic- occurs thru an area of diseased bone

7. Stress- results from repeated loading without bone

and muscle recovery

8. Incomplete (greenstick) break thru only part of

cross section of bone

9. Transverse-fracture straight across the bone

10. Closed (simple)- no break in skin

11. Oblique occur at an angle across the bone (less

stable than transverse)

12. Comminuted one that produces several bone

fragments

13. Spiral fracture that twists around shaft of bone

14. Open, Compound, Complex skin or muscle

extends thru fractured bone

A. CLINICAL MANIFESTATIONS

1. pain

2. loss of function, abnormal movement

3. deformity: displacement, angulation, rotation,

swelling – VISIBLE or PALPABLE

4. shortening- 2.5-5cm r/t contraction of muscles

5. crepitus – grating sensation

6. swelling and discoloration

B. MANAGEMENT OPEN FRACTURE

1. cover wound with a clean / sterile dressing

2. do not attempt to reduce fracture

3. ASSESS NEUROVASCULAR STATUS DISTAL

TO INJURY

C. MEDICAL MANAGEMENT 1. Reduction “setting the bone”

2. restore the fracture fragments to anatomical

alignment and rotation

OPEN

CLOSED

3. early Fracture reduction, gentle manipulation

4. Nursing consideration written consent / analgesia

CLOSED REDUCTION

-bring bone fragments into apposition (ends in

contact) via

a. manipulation

b. traction and counter traction (thru patients

weight and bed position)

c. splint or cast

d. x-rays

e. traction (skin or skeletal) for fracture

reduction/ for fracture immobilization

PRINCIPLES OF TRACTION

1. traction must be continuous to be effective

2. skeletal muscle traction is never interrupted

3. do not remove weights unless intermittent is

prescribed

4. eliminate any factor that reduces effective pull or

alter resultant line of pull

good body alignment in center of bed

ropes unobstructed

weights should hang free




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knot in rope or footplate must not touch pulley

or foot of bed

5. VECTOR OF FORCE

6. RESULTANT LINE OF PULL

7. Types of Traction 1. Straight or running traction

2. balanced suspension traction

3. skeletal

4. skin: traction tape/foam boot

5. manual

6. SKELETAL TRACTION

7. BUCK’S EXTENSION TRACTION

OPEN REDUCTION (ORIF) Open

reduction internal

fixation

D. NURSING MANAGEMENT 1. encourage patient to return to usual activity as

rapidly as possible

2. teach patient to control selling and pan

3. teach exercises, use assistive devices

4. environmental modification

5. self-care, medications, potential complications

6. open fracture

a. prevent infection (monitor)

b. delayed closure (5-7 days)

c. bone grafting (4-8 weeks to bridge defects)

FRACTURE HEALING AND COMPLICATIONS

Factors that Enhance Fracture Healing 1. immobilization of fracture fragments

2. maximum bone fragment contact

3. sufficient blood supply

4. nutrition

5. exercise: weight bearing for long bones

6. Hormones: GH, Thyroid, Calcitonin, Vit. D.

anabolic Steroids

7. electric potential across fracture

1. Factors that Inhibit Fracture Healing 1. extensive local trauma

2. bone loss

3. inadequate mobilization

4. space between fragments

5. infection

6. local malignancy

7. Metabolic bone disease (ie. Paget’s disease)

8. irradiated bone (radiation necrosis)

9. avascular necrosis

10. intra-articular fracture (synovial fluid contains

fibrolysis, which lyse initial clot and retard clot

formation)

11. age

12. steroids

13. flat bones heal rapidly (pelvis, scapula)

14. fx at ends of ling bones heal rapidly than

midshaft fracture – more vascular and

cancellous

15. weight bearing stimulates healing of stabilized

fractures

EARLY COMPLICATIONS SHOCK

FAT METABOLISM

SYSTEMIC EMBOLIZATION

SHOCK

hypovolemia, traumatic shock leads to blood

loss and ECF – extracellular fluid

-restore blood volume and circulation

-pain relief

-splint

-protect from other injuries

FAT METABOLISM

-usually young adults (20-30%) and elderly

adults with fracture proximal femur

fat globules blood

As marrow pressure > capillary pressure

secondary to increase catecholamines

mobilization of fatty acids

Occlude small blood vessel lungs, brain,

kidney, etc.

usuall approx. 24-48 degrees ~ week after

injury

Hypoxia, tachypnea, pyrexia

Dyspnea, crackles, wheezes

Chest pain, thick white sputum, tachycardia

r/t increase pulmonary pressure

ABG PaO2 < 60 mmHg

Respiratory alkalosis ~ respiratory acidosis

Chest XRay: Snowstorm infiltrates ~>

pulmonary edema. AARDS, CHF

CNS: r/t fat emboli in brain and hypoxis

SYSTEMIC EMBOLIZATION

pale

thrombocytopenia- petechiae

hyperpyrexia (39.5C)

fat emboli kidney failure

PREVENTION 1. immediate immobilization

2. minimal fracture manipulation

3. adequate support

4. fluid and electrolyte

5. prompt invitation of respiratory support- high oxygen

MANAGEMENT 1. respiratory support controlled volume ventilation

PEEP (positive expiratory e pressure)

2. prevents respiratory and metabolic acidosis

3. steroids- inflammatory lung reaction and cerebral

edema

4. vasoactive meds

5. accurate fluid Input and Output

6. morphine

7. nursing reassurance




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EARLY COMPLICATIONS:

Compartment Syndrome

Tissue Perfusion < tissue viability

Signs and Symptoms unrelenting pain resistant to opioids r/t

reduction in size of muscle compartment

because enclosing muscle fascia is too tight or

constricting cast or dressing

increase in muscle compartment because of edema

or hemorrhage

Esp. forearm, leg muscle

decrease microcirculation nerve, muscle

anoxia necrosis

Loss of function > 6 hours

Assessment and Diagnostic findings 1. paresthesis – early sign

2. motor weakness: late sign of nerve ischemia

3. paralysis – nerve damage

Assessment of peripheral circulation 1. color- cyanotic- venous congestion,

2. pale, cold

3. prolonged capillary refill

4. decrease arterial perfusion

5. pulselessness if with arterial occlusion, not

compartment syndrome

6. Doppler ultrasound

7. Pain

8. Hypoesthesia

9. Anesthesia

10. Nerve tissue pressure = 8 mmg Hg or less

Compromised = 30 mmHg

MEDICAL MANAGEMENT of Compartment Syndrome

1. elevate above level of heart

2. release restrictive dressings

3. if unsuccessful fasciotomy 1 hour

4. splint and elevate

5. Passive range of motion Q 4-6Hours

6. Deep vein thrombosis

7. Thromboembolism

8. Pulmonary Embolism

9. DIC

BONE GRAFT osteogenesis-bone formation occurs after

transplantation of bone containing osteoblasts

osteoconduction-provision by graft of structural

matrix for ingrowth of blood vessels and osteoblasts

osteoinduction-stimulation of host stem cells to

differentiate into osteoblasts b several growth factor

including bone morphogenic proteins

autograft- tissue harvested from the donor to the

donor

Allograft: tissue harvested from donor other than the

person who will receive the tissue

Healing= 6-12 months

Problems:

1. Wound or graft infection

2. Graft fracture

3. Non-union

4. Partial acceptance

5. Graft rejection

6. Transmission of disease (rare)

Electrical Bone Stimulation

Modifies tissue environment making it

electronegative enhances mineral

deposition and bone formation

Non-invasive inductive coupling

Pulsing electromagnetic field delivered to

fracture approximately 10 hours each day

with electromagnetic coiled over non-union

site 3-6 months

NURSING MANAGEMENT 1. Provide emotional support and encouragement

2. encourage compliance

3. pain management

4. monitor for signs and symptoms of infection

5. health teaching-reinforcement

6. Immobilization

REACTION TO INTERNAL FIXATION DEVICES 1. usually not removed unless with symptoms

2. pain and decreased function

3. mechanical failure: inadequate insertion and stabilize

4. material failure

5. corrosion

6. allergic reaction

7. osteoporotic remodeling adjacent to fixation device

r/t disuse osteoporosis

COMPLEX REGIONAL PAIN SYNDROME (CRPS) reflex sympathetic dystrophy (RSD)

upper extremity

> women

painful sympathetic nervous system problem

CLINICAL MANIFESTATIONS of Complex

Regional Pain Syndrome

1. severe burning pain

2. local edema

3. hyperesthesia

4. stiffness

5. discoloration




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vasomotor changes

trophic changes

Management of Complex Regional Pain Syndrome

1. -elevation

2. -immobility device with greatest ROM

3. -pain control

4. -NSAIDS

5. -Steroids

6. -anti-depressants

7. -avoid BP and venipuncture

AMPUTATION removal of body parts (extremity)

peripheral vascular disease *

folminating gas gangrene

trauma-crushing, frostbite, electrical

malignant tumor

chronic osteomyelitis

LEVEL OF AMPUTATION 1. circulation

2. functional usefulness (prosthesis)

COMPLICATIONS OF AMPUTATION 1. hemorrhage

2. infection

3. skin break down

4. phantom limb: r/t severing of peripheral nerves

5. joint contracture: r/t positioning and protective

flexion withdrawal pattern associated with pain and

muscle imbalance

MEDICAL MANAGEMENT of Amputation

1. Objective

healing of amputation wound

Non-tender stump

health skin for prosthesis

2. 1. gentle handling of stamp

3. 2. control of edema by rigid or soft compression

dressings

4. 3. use of aseptic technique in wound care

5. CLOSED RIGID CAST DRESSINGS: uniform

compression for support soft tissues, control pain

and prevent joint contractures

6. SOFT DRESSINGS- if there is significant wound

drainage require frequent inspection

NURSING DIAGNOSIS of AMPUTATION

acute pain r/t amputation

Risk for disturbed sensory perception: phantom limb

pain r/t amputation

impaired skin integrity r/t surgical amputation

disturbed body image r/t amputation of body part

self-care deficit r/t loss of extremity

impaired physical mobility r/t loss of extremity

NURSING INTERVENTION after Amputation

1. PAIN RELIEF opioid analgesics

non pharmaceutical

evac of hematoma / fluid

counteract muscle spasm

may be expression of grief

2. Minimizing altered sensory perceptions phantom limb approx. 2-3 months post-op

acknowledge feelings

keep patient active

early intensive rehab and stump

desensitization with kneading massage

distraction activities

3. TENS (transcutaneous electrical stimulation)

4. Ultrasound

5. local anesthetics

6. identify patient’s strength and resource to facilitate

rehab

7. help patient resolve grieving

8. promote independent self-care

9. help patient achieve physical mobility

Musculoskeletal Nursing

Health & Medicine

Transcript of Musculoskeletal Nursing