13.1 Musculoskeletal Part 1

Question 1

Musculoskeletal System

Answer 1

• Provides form, stability, and movement to the body

- Chief component of connective tissue such as tendons and ligaments are collagen and elastic fibers

Question 2

Formation of Bone

Answer 2

• In embryo’s the skeleton is primary made of hyaline cartilage
• During development hyaline cartilage gets replaced into bone
• Epiphyseal plates in bones allow bones to grow longer
  (This is where new cartilage is formed and old cartilage is ossified)

DEFINITION OF OSSIFY
- Cartilage is broken down and replaced with bone by osteoblasts.

Question 3

Ossification (Bone Growth)

Answer 3

• Bones are always being remodeled throughout life based on 2 factors. These include..
  1. Pull of gravity (the more stress on a bone, the more dense it gets)
  2. Blood calcium levels

Appositional Growth - Bones growing in width.

Question 4

General Facts of Bones

Answer 4

• Bone starts growing in the middle of the hyaline cartilage
• Epiphyseal plates are known as growth plates (because they help a bone grow)
• Bone growth - Hyaline cartilage continues to grow at the end of bones in-turn growing bone underneath.
• Bone remodeling - This is when bones reshape as you age. Bone tissue gets broken down by osteoclasts and built back up by osteoblasts. Some bone gets shaved off where its not needed and built up where it is needed.

Question 5

Bone Cells

Answer 5

Osteocytes - Mature bone cells
Osteoblasts - Bone building cells
Osteoclasts - Giant bone destroying cells

Question 6

Bone Fractures

Answer 6

• Break in the bone

Closed (simple) fractures - Break that does not penetrate skin
Open (compound) fractures - Broken bone penetrates the skin

Question 7

Repair of Bone Fractures

Answer 7

1st - Hematoma is formed (blood filled swelling)
2nd - The bone break is splinted by a fibrocartilage callus (framework to help bone heal)
3rd - The cartilage is replaced by a bony callus
4th - The bony callus is replaced by a permanent “patch” of bone

Question 8

In-detail Bone Cells

Answer 8

Osteoblasts - Function in bone formation
Osteocytes - Function as bone maintenance (located in lacunae)
Osteoblasts - Function in destroying, resorbing, and remodeling bone (located in Howship lacunae)

Osteogenesis - Process of bone formation
Ossification - Formation of bone matrix and deposition of minerals

• BONES ARE ALWAYS IN A CONSTANT STATE OF TURNOVER (they are formed and destroyed constantly)

BONE REGULATION FACTORS (what constitutes how much they breakdown or how much they are formed)

• Stress/Weight Bearing (The more weight you bear on your bones, the denser it gets)
• Vitamin D (The more vitamin D you have the more calcium is absorbed)
• Parathyroid hormone and calcitonin
• Blood supply
• Calcium

Question 9

Bone Healing

Answer 9

Stage 1 - Hematoma Formation (1-2 days after fracture)
Stage 2 - Fibrocartilaginous Callus Formation (Fibroblasts and Osteoblasts migrate to Fracture Site)
Stage 3 - Bony Callus Formation (Ossification Starts During 3-4 Weeks)
Stage 4 - Remodeling (Osteoclasts Remove Necrotic Bone)

Question 10

Joints (Articulations)

Answer 10

• Junction of 2 or more bones

Synarthrosis - Immovable joints (ex. between bones of the skull)
Amphiarthrosis - Allow limited movement (ex. symphysis pubis and between vertebrae of spine)

Diarthrosis - Freely moveable joints
(Ball and Socket Joint - Shoulder and Hips)
(Hinge Joints - Knees and Fingers)
(Saddle Joints - Base of Thumb)
(Pivot Joints - Neck)
(Gliding Joints - Between Carpal and Tarsal Bones)
(Condyloid Joints - Wrists and Temporomandibular Joints)

Question 11

Joint Structures

Answer 11

• Joint Capsule - The area of tough fibrous tissue surrounding a synovial joint sealing it
• Ligaments - Connects bone to bone
• Tendons - Connects bone to muscle
• Bursa Sac - Fluid filled sacs that cushion joints

Question 12

Muscles

Answer 12

• Attached to bone and other structures by TENDONS
• Fascia (encases muscle in fibrous tissue)
• Contraction of muscle is powered by ATP. They react to electrical impulses
• During strenuous muscle activity, anaerobic energy (does not require oxygen) is used. This is when glucose metabolized from glycogen provides additional needed energy.
• Using your muscles results in hypertrophy and disuse results in atrophy

Question 13

Muscle Tone (Tonus)

Answer 13

• Amount of tension generated by muscles in a contracted state.
• Muscle tone is monitored by muscle spindles (sense organs)
• Muscle tone is little when sleeping and high when anxious

Flaccid - Limp, no tension muscle tone
Spastic - Greater than normal tone
Atonic - Denervated (no nerves) muscle becomes small, flabby and atrophy

Question 14

Motor Neurons

Answer 14

Upper Motor Neurons (UMN) - Produce increased muscle tone (hypertonic) and reflexes can become hyperactive (cerebral palsy)

Lower Motor Neurons (LMN) - Produce decreased tone (hypotonic) and cause muscle to dystrophy (waste away)

Question 15

Muscle Actions

Answer 15

Prime Mover - Muscle that causes a particular movement.
Synergist - Assist prime movers to move a muscle
Antagonist - Move muscles in the opposite way of the prime mover

When prime movers are moving a muscle, antagonist are relaxed to allow motion

Question 16

Gerontologic

Answer 16

Bones - Gradual bone loss begins at age 30 making them more fragile and fracture easier
Muscles - They have increased collagen (due to fibrosis), muscle atrophy (gets smaller), and tendons are less elastic
Joints - Cartilage deteriorate and intervertebral discs thin
Ligaments - Become lax and loose

Question 17

BASIC ADL’s

Answer 17

• Assessments relate to functional ability such as ADL’s (activity of daily living)

BASIC ADLS

• Personal Hygiene - Bathing, grooming, oral, nail and hair care
• Continence Management - Mental/physical ability to use the bathroom
• Dressing - Ability to dress themselves in clothes
• Feeding - Ability to eat by themselves
• Ambulating - How well they can walk independently

Question 18

Instrumental ADL’s

Answer 18

• More complex but still reflect daily needs of independence

Companionship and Moral Support - Help that is needed to maintain positive mind
Transportation/Shopping - Can people get around and get groceries without help
Preparing meals - Can they cook and shop for themselves
Management of Household - Cleaning, removing trash, laundry, folding clothes
Medication Management - Getting prescriptions filled, taking meds on time in the right dose
Communication with others - Managing phone and mail and making the home welcoming for others
Finances - Can they manage their bank and pay bills on time

Question 19

Diagnostic Tests

Answer 19

• Radiographs - X-ray that show bone, joints, dense tissue
• Computed Tomography (CT) - Creates 3D images. Fast and provides higher detail than X-ray
• Magnetic Resonance Image (MRI) - Takes a longer time than CT scans, but uses magnetic images to produce an image in greater detail than CT scans.
• Arthrography - Radioplaque contrast or air injected into a joint cavity to visualize joint structures such as ligaments, cartilage, tendons, or joint capsules
• Arthroscopy - Direct visualization of bones using an endoscope. Can be used for biopsy or treatments
• Arthrocentesis (Joint Aspiration) - Aspirate synovial fluid for examination or relieve joint effusion pain
• Bone Densitometry - Uses x-rays to evaluate bone mass and density (BMD)
• Bone Scan - Requires radioisotope via IV to detect bone tumors, osteomyelitis, fractures, aseptic necrosis, and monitor progression of degenerative bone diseases.
• Biopsy - Identifies structure and composition of bone marrow, bone muscle, and synovium
• Lab tests - Urine/Blood tests that can measure calcium, phosphorous, hormones, etc

Question 20

Diagnostic Tests (cont)

Answer 20

MRI - Patients may hear a loud knocking sound. They also need to be assessed for allergies to contrast that may be used

Arthrography - Patient may feel discomfort/tingling and hear clicking/cracking from the examined joint in the first 24-48 hours

Bone scan - Need to be assessed for allergies to radioisotopes used and increase fluids to spread the radioisotope throughout the body

Arthroscopy - After it is done, the joint must be wrapped in in compression dressing to control swelling and neuro status must be monitored

Arthrocentesis - Remove hair from procedure site, administer analgesics, apply ice intermittently for 24-48 hours after the operation

Electromyography - Electrodes may cause bleeding so patient needs to be assessed for anticoagulant usage. Also assess for skin infections

Biopsy - Monitor site for bleeding and edema. Also administer analgesics and antibiotics

Question 21

Cast

Answer 21

• External immobilization device to immobilize fractures, correct a deformity, and stabilize weak joints.

Made of plaster or fiberglass
Fiberglass is waterproof and lighter, Plaster is not waterproof

Question 22

Contoured Splints

Answer 22

• Made of plaster and used when cast immobilization is not necessary
• Used for patients where swelling may be an issue or patients who require special skin care

Question 23

Braces (Orthoses)

Answer 23

• Custom fitted and provide support to various body parts.

Question 24

Care for Patient with Brace/Splint/Cast

Answer 24

• Before applying, assess for health, emotions, and presenting signs/symptoms
• Monitor neurovascular status before and after application
• Treat lacerations/abrasions before application

NEUROVASCULAR ASSESSMENT (THE 6 P’s)

• Pain (Site, Character, and Intensity of Pain. Treated by elevating the extremity, ice packs and analgesics)
• Poikilothermia (inability to regulate body temperature)
• Pallor
• Pulselessness
• Parasthesia
• Paralysis

Question 25

COMPLICATIONS OF CASTS/SPLINTS/BRANCSE

Question 26

Compartment Syndrome

Answer 26

- Caused by increased pressure within a confined space (muscle compartment) - Ischemia and reduced blood flow from extreme pressure causes irreversible damage within hours - MAJOR INDICATOR IS PAIN OUT OF PROPORTION TO THE INJURY - If this occurs, the cast must be removed immediately and emergency fasciotomy is done

Question 27

Pressure Ulcers

Answer 27

- Caused by inappropriate application of a cast - Most often happens in lower extremities - CHIEF COMPLAINT IS PAINFUL "HOTSPOT" AND TIGHTNESS - A window will be cut in the cast to examine the area, and a dressing is then applied over exposed skin

Question 28

Disuse Syndrome

Answer 28

- Muscle atrophy and loss of strength from not using muscles while wearing a cast TREATMENT - Isometric Exercises and Muscle Exercises

Question 29

Education for Cast/Brace/Splint

Answer 29

- Educate how they may affect ADL's - Balancing Activity/Exercise/Rest - Medications - Control of swelling and pain - How to dry their cast AVOID SKIN IRRITATION - Pad rough edges of cast with tape or moleskin - Use a blow dryer to relieve itching (or casting cooler) - DO NOT stick objects into cast for itching REPORT - Persistent pain/swelling - Changes in sensation and skin color/temperature - Signs of infection and pressure

Question 30

External Fixation Devices

Answer 30

- Often used for open fractures with tissue damage (complicated or comminuted fractures) - Pins are inserted through skin to stabilize bone fragments - Extremities should be elevated to reduce edema - Monitor for complications such as loose pins and infection - THIS IS A LONG TERM PROCESS

Question 31

Traction

Answer 31

- Application of pulling force to a part of the body - Used as a short term intervention to reduce muscle spasms and align/immobilize fractures. This also helps to reduce deformities and increase space between opposing forces - Traction must be applied continuously to immobilize fractures without interruption. A counterforce must also be applied (usually body weight and bed position is enough counterforce). You must reduce anything that can affect the pulling pressure.

Question 32

Skin Traction

Answer 32

- Non-invasive use of materials like boots, straps, velcro to promote traction COMPLICATIONS - Skin breakdown, circulatory impairment, damage to nerves INTERVENTIONS - Inspect skin 3 times a day and assess tenderness, sensation, movement, pulses, color, capillary refill and temperature. - Assess DVT

Question 33

Skeletal Traction

Answer 33

- Inserting metal pins or wires (Steinmann Pinn or Kirschner's Wire) through a bone to immobilize, position and align the fracture. - Uses ropes and weights attached to the pin to provide traction. - Used when skin traction cannot be used. NURSING INTERVENTIONS - Maintain proper alignment of body - Use overbed trapeze so the patient can move - Assess pressure points every 8 hours - Exercises to maintain muscle tone should be done every hour - They should use TED hoses or SCD's to reduce chance of DVT

Question 34

Pin Care

Answer 34

- Goal is to avoid infection and OSTEOMYELITIS - Hand hygiene always - Pins located in different areas of soft tissue are at greatest risk for infection - Cover pin site with sterile non-stick dressing, then after 48 hours, no dressing or loose cover dressing is recommended NURSING INTERVENTIONS - Inspect pin site every 8 hours - After 48-72 hours, pin site care should be preformed daily/weekly - CHLORHEXIDINE IS THE MOST EFFECTIVE SOLUTION FOR CLEANING PIN SITES. IF THERE IS AN ALLERGY THEN USE STERILE SALINE

Question 35

Nursing Management for Traction

Answer 35

Common Complications - Pressure injury - Atelectasis - Pneumonia - Constipation - Anorexia - Urinary Stasis - Infection - DVT

Question 36

Joint Replacement Surgery

Answer 36

- Used to treat severe joint pain and disability or joint necrosis

Question 37

Hip Replacement Surgery Interventions

Answer 37

- MUST PREVENT DISLOCATION OF HIP by using abduction wedges or pillows to keep hips abducted. - When transferring patients, leg should be adducted but never cross midline of body - Leg should not flex more than 90 degrees - Ambulation can begin 1 day after surgery - Wound drain must be removed in 24-48 hours - Prophylactic antibiotics are given to prevent infection but patient is still in danger of infection for up to 24 months. - Normal activities can resume in 10-12 weeks but full recovery takes 6 months to a year

Question 38

Knee Replacement Surgery

Answer 38

- Initially a knee compression bandage is used - Assess neurovascular status every 2-4 hours - Monitor for DVT, infection and bleeding as well every 2-4 hours - Wound suction drain is removed in 24-48 hours Continuous Passive Movement Device (CPM) is used after surgery to promote ROM, circulation and healing.

Question 39

Interventions for Joint Replacement Surgery

Answer 39

PAIN MANAGEMENT - Begins with PCA (Patient Controlled Analgesic) and then moves onto oral meds - MEDICATE 30 MINUTES BEFORE AMBULATION/ACTIVITIES - LARGE AMOUNTS OF MILK SHOULD NOT BE GIVEN TO PATIENTS ON BED REST DUE TO BONE DEMINERALIZATION THAT INCREASES THEIR SERUM CALCIUM - Encourage patient to set realistic goals and preform self-care within their limits