mobility part 1

Question 1

Age realted differences in musculoskeletal system

Answer 1

• Effects of aging vary from mild discomfort and ↓’d ability → severe chronic pain/immobility
• decreased bone density = vertebral compression
• Loss of fluid from vertebral disks, narrowing of vertebral spaces
• Cartilage destruction and bone overgrowth at joint margins
• Muscle ↓, fibrous replacement; ↓ ligament elasticity and glycogen storage for quick energy

Question 2

Exemplars of Mobility Disorders (Part I)

Answer 2

• Soft tissue injuries: sprains/strains, joint dislocations, carpal tunnel syndrome, rotator cuff injury, meniscus injury, ACL injury, bursitis
• Fractures
• Amputation
• Acute and chronic low back pain
• Intervertebral disc disease

Question 3

Sprains and Strains

Answer 3

• Often sports/work related
• Sprain - injury to ligament around joint, wrenching or twisting (often ankle or wrist)
• Strain: muscle/tendon stretching or tearing
• Repetitive strain injuries common
• Pain, edema, bruising, decreased function
• Complications: avulsion fracture, subluxation or dislocation

Question 4

joint dialocation

Answer 4

• Often sports/work related
• Sprain - injury to ligament around joint, wrenching or twisting (often ankle or wrist)
• Strain: muscle/tendon stretching or tearing
• Repetitive strain injuries common
• Pain, edema, bruising, function
• Complications: avulsion fracture, subluxation or dislocation

Question 5

Carapal tunnel syndrome

Answer 5

• Compression neuropathy
• Median nerve in carpal tunnel in wrist
• Trauma/edema from inflammation of tendon
• Usually work related (wrist movement)
• Weakness, numbness, burning pain
• Stop aggravating movement, inflammation, surgery

Question 6

Rotator cuff injury

Answer 6

• Tear/rupture of 4 rotator cuff muscles that surround the shoulder joint
• Caused by overhead movement (swimming, baseball, tennis) or fall (outstretched hand)
• Shoulder pain, weakness, ROM
• Rest, ice and heat, NSAIDs, corticosteroid injection, arthroscopic repair

Question 7

Meniscus and ACl injury

Answer 7

Meniscus injury:
- fibrocartilage in knee and other joints is torn or sheared with injury (sports)
- diagnosed by MRI and arthroscopy; surgery for tears

Anterior cruciate ligament injury:
- common sports-related injury of the knee (skiing, hockey, football)
- can be repaired arthroscopically, recovery is faster, pain is less than for open repair

Question 8

bursitis

Answer 8

• Inflamed bursa (sacs at friction joints lined with synovial membrane/fluid) due to trauma, friction, gout, rheumatoid arthritis, infection
• Warmth, pain, swelling, decreased range of motion (ROM)
• Often hand, knee, hip, shoulder, elbow
• Need to identify cause (repetitive, jogging, prolonged sitting with legs crossed) and avoid and rest

Question 9

Fractures

Answer 9

• Disruption or break in continuity of the structure of bone
• Majority of fractures from traumatic injuries
• Some fractures secondary to disease process (cancer or osteoporosis)
• Fractures can be classified: open or closed, complete or incomplete, based on direction of fracture line, displaced or nondisplaced, according to location

Question 10

fractures clinical manifestations

Answer 10

Immediate localized pain, decreased function
Inability to bear weight on or use affected part
* Patient guards and protects extremity
* Fracture may not be accompanied by obvious bone deformity
* Immobilize extremity if fracture is suspected
* (unnecessary movement increases soft tissue damage, may convert closed fracture to open)

Question 11

fractures healing

Answer 11

• Called union (when healing doesn’t happen properly we refer to delayed union, malunion or non-union)
• Factors affecting healing: age, location, blood supply, infection, implants (for instance hip replacement prostheses), immobilization (need to keep bone pieces together and stable in order for the body to heal the fracture)

Question 12

steps of a healing fracture

Answer 12

Fractures – Healing

A. Bleeding at broken ends of the bone with subsequent hematoma formation.

B. Organization of hematoma into fibrous network (osteoid).

C. Invasion of osteoblasts, lengthening of collagen strands, and deposition of calcium.

D. Callus formation: new bone is built up as osteoclasts destroy dead bone.

E. Remodeling is accomplished as excess callus is reabsorbed and trabecular bone is laid down

Question 13

fracture a closed reduction intervention

Answer 13

• Nonsurgical, manual realignment of bone fragments to previous anatomical position
• Local or general anaesthesia
• Traction and counter-traction manually applied to bone fragments to restore position, length, and alignment
• Traction, casting, splints, or orthoses (braces) to immobilize to maintain alignment until healing occurs

Question 14

fraction traction intervention

Answer 14

• Application of a pulling force to an injured or diseased part of body or extremity, while counter-traction pulls in opposite direction
• Prevent or ↓ muscle spasm
• Immobilize joint or part of body
• ↓ a fracture or dislocation
• Treat a pathological joint condition
• To expand a joint space - during arthroscopic procedures or before major joint reconstruction

Question 15

fracture immobilization - casts

Answer 15

Temporary circumferential immobilization
Able to perform most activities of daily living
Cast materials are natural, synthetic acrylic, fibreglass-free, latex-free polymer, or hybrid
Application incorporates joints above and below fracture
Restricts tendinoligamentous movement - assists with joint stabilization while fracture heals

Question 16

casts do

Answer 16

Do’s
- Once thoroughly dry, edges may need to be petalled to avoid skin irritation
- Dry cast after exposure to water
- Elevate extremity above level of heart for first 48 hours
- Move joints above and below cast regularly

Question 17

casts donts

Answer 17

Don’ts
- Get plaster cast wet
- Fresh plaster should never be covered with a blanket, no direct pressure, no fingertips
- Remove any padding
- Insert any objects inside cast
- Bear weight on new cast for 48 hours (not all casts are weight bearing)
- Cover cast with plastic for prolonged periods

Question 18

fracture immoblization - slings

Answer 18

Placement should not put undue pressure on posterior neck
Encourage patient to move fingers and non-immobilized joints of the upper extremity

Question 19

Fracture Immobilization – Body Brace

Answer 19

Immobilization/support for stable spine injuries of thoracic or lumbar spine
Assess patient for cast syndrome (brace is applied too tightly) - abdominal pain, abdominal pressure, nausea, and vomiting
Observation of respiratory status
Bowel and bladder function
Areas of pressure over bony prominences

Question 20

Fractures – Open Reduction intevention

Answer 20

Correction of bone alignment through surgical incision
Includes internal fixation (ORIF) with use of wires, screws, pins, plates, intramedullary rods, or nails
Facilitates early ambulation, promotes fracture healing with gradually increasing increments of stress
Possibility of infection, complications associated with anaesthesia, effects of pre-existing medical conditions

Question 21

fracture external fixation intervention

Answer 21

• Pins into bone and then attached to rods and frame to reduce/stabilize fracture or to apply traction
• Used for simple fractures, fractures with ++ soft tissue damage, correction of congenital bony defects, nonunion or malunion issues, limb lengthening
• Can be used in severely complex fractures
• Used when closing the wound is not possible (or not prudent due to risk of infection)

Question 22

amputation

Answer 22

• Causes – circulatory impairment, traumatic or thermal injuries, malignancies, infection, congenital disorders
• Try to preserve as much limb as possible
• Closed (to create weight bearing residual limb) or open stump (in cases of infection/drainage)
• Complications maybe due to comorbidities
• Phantom limb pain (90% will have)
• Prosthesis can be fitted right away or later
• Physio/OT for ambulation and ADLs

Question 23

low back pain

Answer 23

• Common, has probably affected 70% to 85% of adults at least once during their lifetime
• Second only to headache as the most common pain complaint
• Low back pain common because lumbar region:
• • bears most of the weight of body
• • is the most flexible region of the spinal column
• • contains nerve roots that are vulnerable to injury or disease
• • has an inherently poor biomechanical structure

Question 24

Low back pain – Risk Factors

Answer 24

• Lack of muscle tone, decreased activity/exercise
• Excess body weight
• Poor posture
• Prolonged sitting
• Jobs requiring repetitive heavy lifting, vibration (such as a jackhammer operator)
• Stress
• Smoking
• Most often due to musculoskeletal problems

Question 25

Acute Back Pain

Answer 25

* Lasts 6 weeks or less * Usually associated with some type of activity that causes undue stress (often hyperflexion) on the tissues of the lower back * One diagnostic test is straight-leg raise, positive for disk herniation when radicular pain (pain that radiates into a lower extremity) occurs * Symptoms often do not appear at time of injury but develop later – gradual increase in muscle spasm, increase in pressure on a nerve by an intervertebral disk * Treated on an outpatient basis if not severe and debilitating – analgesics, muscle relaxants, massage, back manipulation, hot/cold compresses Brief period of rest at home may be necessary Most persons do better with continuation of their regular activities Prolonged bed rest should be avoided Should avoid activities that aggravate pain: bending, lifting, twisting, prolonged sitting Most cases improve in 2 weeks

Question 26

acute back pain nursing education dos

Answer 26

* Act as a role model, nurse should use proper body mechanics at all times * Assess patient’s use of body mechanics, offer advice when activities could produce back strain * Place a foot on a step or stool during prolonged standing * Use a lumbar roll or pillow for sitting * Maintain appropriate body weight, exercise regularly * Avoid sleeping in a prone position

Question 27

acute back pian nursing education donts

Answer 27

* Lean forward without bending knees * Lift anything above level of elbows * Stand in one position for prolonged time * Sleep on abdomen or on back or side with legs out straight * Exercise without consulting health care provider if having severe pain

Question 28

Chronic Low Back Pain

Answer 28

Lasts longer than 3 months or is a repeated incapacitating episode Same causes as for acute; osteoarthritis (OA) of lumbar spine can be cause > 50, OA of thoracic or lumbar spine < 50 Discomfort is ↑ following periods of inactivity, particularly on awakening or after long periods of sitting

Question 29

Chronic Low Back Pain - Management

Answer 29

Formal back pain program Rest and local heat application when cold, damp weather aggravates back pain Mild analgesics to decrease pain and stiffness Weight reduction Sufficient rest periods Exercise and activity throughout day Antidepressants Surgery if pain is severe, do not respond to conservative care, and/or have neurological deficits

Question 30

Chronic Low Back Pain - Spinal Stenosis

Answer 30

* Common cause of chronic or recurrent low back pain * May be congenital, more often acquired through degenerative or traumatic changes to spine * Narrowing of vertebral canal or nerve root canals caused by encroachment of bone on space * Compression of nerve roots can result with subsequent disk herniation * Pain often starts in low back and radiates to buttock and leg, worsens with walking, particularly standing without walking

Question 31

Intervertebral Disc Disease

Answer 31

* Natural disk degeneration or repeated stress * Degenerative disc disease or herniated disc * Nucleus pulposus rupture: L4-5, L5-S1, * C5-6-7 * Compression of nerve roots and cord may occur * Manifestations: low back pain radiating down buttock/below knee along sciatic nerve

Question 32

Intervertebral Disc Disease - Diagnostics

Answer 32

* Straight leg raise test * Decreased reflexes * Parathesias (pins and needles sensation) or muscle weakness in legs/feet/toes * Bowel or bladder incontinence from nerve compression * X-ray, myelogram * MRI, CT

Question 33

Intervertebral Disc Disease - Management

Answer 33

* Limit mobility (brace), local heat/ice, ultrasound, massage, transcutaneous nerve stimulation, strengthening exercises * NSAIDS, muscle relaxants, short-term narcotics * Surgery if has radiculopathy and/or incontinence * Laminectomy, discectomy, percutaneous laser discectomy, replacement, spinal fusion