13.2 Musculoskeletal Part 2 Flashcards
Soft Tissue Injuries
Affects tendons, ligaments, and muscles
Includes strains, sprains, dislocations, repetitive motion stress, tissue inflammation
Sprains/Strains
Sprain - Injury to ligament surrounding a joint often caused by twisting motion.
First degree - Little pain/swelling, minimal tearing of ligaments
Second degree - Disruption to adjacent tissue (increased pain and swelling)
Third degree - Completely torn ligament (Extremely Painful
Strain - Excess stretching of muscle (mainly effects tendons) 1st degree, 2nd degree and 3rd degree are same descriptions as sprains
MANIFESTATIONS
- Pain, swelling, decrease in function due to pain and swelling. May also be discolored/contusion.
DIAGNOSIS
- X-ray to rule out fracture then history of events and physical exam
EDUCATION
- 1st and 2nd degree heal without formal treatment.
- NSAID’s for pain with rest and elevation of extremity
- ADL’s should be continued as much as possible
- Intermittent icepack followed by intermittent heat pack
- Stretching
COMPLICATIONS
- Fractures
- Hemarthrosis (bleeding into the joint)
Repetitive Strain Injury
- Result of prolonged forceful movements causing strain to ligaments/tendons
- These movements cause small tears which overtime develop into scars
Common sites - Neck, spine, shoulder, forearm, and hand
Nursing Care
- Education and physical therapy
Carpal Tunnel Syndrome
- Compression of median nerve that overtime causes neuropathy
- Carpenters, secretaries, musicians and others are HIGH RISK
- Women are affected worse during premenstrual period (due to hormones)
MANIFESTATIONS
- Thumb weakness
- Causalgia (Burning Pain)
- Numbness
- Positive Phalen’s Test and Tinel’s Sign (tingling when preforming phalen test)
TREATMENT
- Changing activity patterns
- Cortisone injection to decrease inflammation
- Surgery to decompress median nerve
Rotator Cuff Injury
- Damage to the 4 stabilizing muscles of the shoulder (commonly results from injury/overuse)
MANIFESTATIONS
- Shoulder weakness, decreased ROM, pain
DIAGNOSIS
- X-ray or MRI
- Drop Arm Test
Treatment
- Rest, Ice, Heat, NSAID’s, Steroid injections
- SEVERE INJURIES REQUIRE SURGERY (ACROMIOPLASTY)
Meniscus Injury
- Meniscus is a crescent shaped cartilage in the knee. Usually damaged through sports
MANIFESTATIONS
- Mild swelling and pain when flexion. “Pop or Click can be heard”
DIAGNOSIS
- MRI followed by arthrogram or arthroscopy
TREATMENT
- Rest, ice, elevation, nsaids followed by exercise to strengthen muscle around the joint
- Arthroscopic Meniscectomy is surgery
EDUCATION
- Stretch before exercise to warmup muscles
Dislocation/Subluxation
Dislocation - Complete separation of joint and involves ligaments
Subluxation - Incomplete dislocation (same signs and symptoms but to a lesser degree)
COMMON IN THUMB, SHOULDER, HIP
MANIFESTATIONS
- Deformity seen, pain, loss of function, tenderness, swelling
COMPLICATIONS
- Long term injury to soft tissue, fractures, AVASCULAR NEROSIS
DIAGNOSIS
- X-ray
ASSESSMENT
- Peripheral nerve sensations, capillary refill, pulses distal to injury
DESIRED OUTCOME
- Pain relief, prevention of vascular damage, restoration of strength and joint mobility
TREATMENT
- Reduction of joint (relocation)
- Immobilize the joint
- Manage pain and swelling
ONCE A PATIENT HAS A DISLOCATION/SUBLUXATION THEY ARE AT HIGH RISK FOR REOCCURENCE
Fractures
ENVIRONMENTAL FACTORS
Open Fracture - Break in the skin (possibly with bone sticking out). Can also be penetration of something else through the skin to the bone
Closed Fracture - Skin is not broken and fracture remains internal.
LOCATION OF FRACTURES
- Location is the bone itself
- Proximal, distal, midshaft, or through the epiphyseal plate (growth plate)
STABILITY OF FRACTURE
Stable - Able to withstand pressure (transverse, spiral, greenstick fractures)
Unstable - Unable to handle pressure and affects nearby muscles/blood vessels (comminuted or oblique fractures) RISK OF INJURY IS HIGH IN UNSTABLE FRACTURES
Types of Fractures
Avulsion - Small piece of bone attached to tendon/ligament is pulled away from the bone
Comminuted - Bone breaks into pieces (3 or more fragments)
Displaced - Fractured bone ends are out of alignment
Greenstick - Incomplete fracture where bone bends and cracks (common in children under 10)
Impacted - Bone ends are crushed together from force of injury
Intra-Articular - Fracture crosses joint surface and damages cartilage
Longitudinal - Fracture occurs along the length (axis) of the bone
Oblique - Fractures occur at an angle to the axis of the bone (diagonal)
Pathologic - Caused by underlying disease (osteoporosis)
Spiral - Fracture results from twisting force (may indicate child abuse)
Stress - Small cracks in bones from repetitive stress
Torus (Buckle Fracture) - Compression of bone on one side while other side remains intact. Looks like its bulging
Transverse - Fracture is 90 degree angle to axis of bone.
Manifestations of Fractures
- Pain, swelling, spasms, deformities, ecchymosis distal to fracture, loss of function, bony crepitation from bone fragments rubbing against each other
Complications of Fractures
- Closed injury becomes opened injury due to excessive movement
- Delayed union (healing)
- No Union (no fusion of fracture) which can result in pseudo arthritis (false joint created while healing)
- Malunion (heals in proper amount of time but in wrong position)
- Angulation (Abnormal angle of healing)
- Compartment Syndrome
- Osteomyelitis
Treatment for Fractures
- Goal is to realign the bone (reduction)
- Immobilize the bone (maintain realignment)
- Restore function
Closed Reduction
- Manual realignment of bone with traction and countertraction (requires 2 people)
- Done with moderate sedation
- Complications include damage to surrounding tissue and potential refracture
Open Reduction
- ORIF (Open Reduction and Internal Fixation)
- Surgical realignment of bone
- Usually requires plates or screws to maintain alignment
- ONGOING NEUROVASCULAR CHECKS ARE IMPORTANT
- Medicare will cover 3 nights in the hospital
COMPLICATIONS
- Infection/Bleeding
- PAIN CONTROL POST-OP IS NECESSARY with opiates and muscle relaxants (to prevent spasms)
Connective Tissue Disorders
- Usually caused by inflammation to the joints
Arthritis
- Inflammation of a joint
- Affects women more than men
Osteoarthritis (OA)
- Slow, Progressive NON-INFLAMMATORY (not systemic) disorder of synovial joints.
- NOT A NORMAL PROCESS OF AGING
- Can be caused by primary, idiopathic, or secondary to joint defects, trauma, inflammation, and metabolic disorders.
RISKS
- Age, family history, hormones, obesity, joint overuse
PATHO
- Articular surface cartilage breaks down and osteophytes develop (bony formations). Collagen is decreased due to less synthesis and greater breakdown
MANIFESTATIONS
- NO SYSTEMIC MANIFESTATIONS (ALL LOCALIZED).
- Mild to severe pain of the joint during activity
- Joint stiffness (less in the morning)
- Joint crepitus (grating sensation and sound when moving the joint)
LATE MANIFESTATIONS
- Deformity, Redness/Swelling
- HEBERDEN’s AND BOUCHARD’s NODES
- SHORTENING OF EXTREMITY
DIAGNOSIS
- CT or MRI to identify joint changes
- Bone scan
- X-ray to monitor changes overtime
- ESR (to rule out rheumatic diseases) - Erythrocyte Sedimentation Rate
CARE FOR OA
- Pain management via Heat/Cold application, yoga, massage, therapeutic touch
- Rest the joint to reduce inflammation (less than a week)
- Do non-weightbearing exercises to prevent disability and maintain joint function
- Maintain independent ADL’s as much as possible
ACUTE
- Pain control, heat/cold, rest, education on low impact exercises, posture, body mechanics, assistive devices, protection of joints, and weight loss
CHRONIC
- Safety measures at home (rugs, nightlights)
- Firm mattress may help
- Long term therapies are medications with more significant side-effects
OA Medications
Pain Management - Acetaminophen and NSAID’s later on.
- Celebrex - COX 2 inhibitor has less risk of bleeding and GI issues
- Capsaicin - Cream that interrupts pain signals
Doxycycline - Helps to preserve knee cartilage
Corticosteroids - Used conservatively for joint inflammation
Rheumatoid Arthritis
- CHRONIC SYSTEMIC AUTOIMMUNE DISEASE with inflammation of connective tissue in synovial joints
- Has exacerbations and remissions
- Most common between 30-50 y/o
PATHO
- Autoimmune disorder (genetic) and tissue hypersensitivity
- Your WBC (neutrophils, lymphocytes, etc) destroy your own cartilage and cartilage becomes fibrous and calcified
MANIFESTATIONS
- Early on patients will have fatigue, anorexia, weight loss, and general stiffness
- This builds onto pain, stiffness, limitations on movement, inflammation (heat, swelling, tender)
- Later signs include fibrosis of joints, atrophy of muscle, and tendon destruction
COMMON LATE SIGNS
- Ulnar Drift (Fingers bend abnormally towards pinky)
- Swan neck deformity
- Boutonniere deformity of thumb
- Hallux Vagus (Bunion)
COMPLICATIONS
- Advanced joint destruction and hand deformities
- NODULE FORMATION AFFECTING EYES, GI, VOCAL CORDS AND VERTEBRA
- Cardiopulmonary (PLEURAL EFFUSION, PERICARDITIS, CARDIOPULMONARY)
DIAGNOSIS
- ELEVATED ESR (Erythrocyte Sedimentation Rate) and C-REACTIVE PROTEIN indicate systemic inflammation.
- Aspiration of synovial fluid which show straw colored fluid with fibrin necks
RA Medications
- DMARD’s (Disease Modifying Antirheumatic Drugs) - Methotrexate/Antimetabolite
- Corticosteroids (Controls pain and inflammation)
- NSAID’s/Aspirin (Celecoxib is preferred due to less GI effects)
Methotrexate (Rheumatrex)
DMARDs
- Methotrexate is the faster acting DMARDs (begins working in 3-6 weeks) (First line of defense)
- Administered orally or injection
CONTRAINDICATIONS
- Immunosuppression
- Preexisting blood dyscrasias (general issues with blood)
- Impaired bone marrow function
- Category X Drug (DO NOT USE IN PREGNANCY)
ADVERSE EFFECTS
- Stomatitis, Gingivitis, Alopecia, Suppression of Bone Marrow Function, GI Ulcers, Hepatic Fibrosis, Pneumonitis, Photosensitivity
DO NOT USE WITH OTHER DRUGS THAT CAUSE NEPHRO/HEPATO TOXICITY OR BONE MARROW SUPPRESSION
ADMINISTER VITAMIN B (FOLIC ACID) EVERYDAY TO REDUCE POTENTIAL ADVERSE EFFECTS
EDUCATION
- IM, protect yourself from the sun (photosensitivity), ROM exercises
Psoriatic Arthritis
- Inflammation associated with psoriasis (skin cells buildup and form scales and dry, itchy patches)
- Unknown cause but is genetic or bacterial/viral infections, or Trauma
- HUMAN LEUKOCYTE ANTIGEN (HLA) IS A RISK FACTOR
PATHO
- Autoimmune disease that effects ligaments, tendons, fascia and joints. Can develop without psoriasis.
MANIFESTATIONS
- Silver/Gray spots on scalp, elbows, knees, lower back, nails
- ONYCHOLYSIS - Detachment of nail from nail bed
- Tender joints when stressed
- Swelling of fingers and toes
- TENOSYNOVITIS - Sheaths around certain tendons/ligaments become swollen and inflamed
- DACTYLITIS - Diffuse swelling of entire finger (digit)
DIAGNOSIS
- X-ray, MRI
- Joint fluid test
- Rheumatoid Factor WILL BE NEGATIVE
MEDICAL TREATMENT
- Steroid injections to reduce inflammation or joint replacement
NURSING INTERVENTIONS
- Pain relief, protecting joints with splints
Septic Arthritis
- Joint cavity gets invaded with bacteria (Staph)
- Usually seen in hip/joint replacement
MANIFESTATIONS
- Pain, Erythema, Swelling
DIAGNOSIS
- Joint Aspiration
TREATMENT
- Antibiotics (2-8 weeks)
- Aspiration of drainage of fluid in the joint
NURSING MANAGEMENT
- Medication, Pain Control, ROM, Rest
