Musculoskeletal Flashcards
MAIN FUNCTION OF Musculoskeletal System
Support
Protection of vital organs
Movement
Blood cell production
Mineral storage
Musculoskeletal System CONSISTS OF:
- Bones
- Ligament and Tendons (Both have poor blood supply which delays healing)
- Fascia
- Bursae (Reduce friction on bone to bonne connections)
Bones?
Provide supporting framework to body and protect underlying organs and tissues (Skull/brain)
Participate in red and white blood cell production
Serve as a site for storage of inorganic minerals (Ca++,
PO4- phosphate) and contain organic
material (collagen)
Dynamic tissue (osteoblasts, osteoclasts)
Ligaments?
Connect bones to bones
More elastic than tendons
Tendons?
Attach muscles to bones
Fascia?
Layers of connective tissue with intermeshed fibers
Bursae?
Small sacs of connective tissue lined with connective tissue containing viscous synovial fluid (Reduce friction between bones)
Check slide 4 and make flashcards.
Age-Related Changes in the Musculoskeletal System?
- Loss of bone density due to increased resorption (The rest of the tissues in the body steal Ca+ from the bones so it becomes weak) and decreased formation leading to osteopenia (loss of mineral density) and osteoporosis, kyphosis (an exaggerated, forward rounding of the upper back.)
- Loss of water from vertebral discs leads to loss of height
- Falls increase the likelihood of fractures d/t to loss of bone mass
- Increase risk for cartilage erosion-direct contact between bone ends-osteoarthritis
- Decreased muscle mass and strength-almost 30% lost by age 70-leads to decreased ability to release glycogen (energy for muscles) during stress and decreased BMR (basic metabolic rate)
Kyphosis?
Is an exaggerated, forward rounding of the upper back. In older people, kyphosis is often due to weakness in the spinal bones that causes them to compress or crack. Other types of kyphosis can appear in infants or teens due to malformation of the spine or wedging of the spinal bones over time.
ASSESSMENT: OBJECTIVE DATA?
- INSPECTION:
Always start with your initial contact with the patient
Look for symmetry, general body built - PALPATION:
If injury is the presenting problem, proceed with caution
Palpation of soft tissue and joints allows for assessment of skin temperature, swelling, tenderness and crepitation (ratteling) - MOVEMENT:
Observe/ Evaluate ROM
Grading Muscle Strength
5/5-Normal strength (moves against full resistance)
4/5-Moderate strength (moves against some resistance)
3/5-Eg. Person can raise hand off table without any resistance applied
2/5-Eg. Person able to slide hand across table but not lift it
1/5-Flicker
0/5-Paralysis
INJURIES TO THE MUSCULOSKELETAL SYSTEM: Strains and Sprains
SPRAINS AND STRAINS:
Usually associated with abnormal stretching or twisting
INJURIES TO THE MUSCULOSKELETAL SYSTEM: Strains and Sprains
Sprains classified according to the amount of ligament fibers torn:
1- First degree: tears of only few fibers
2- Second degree: partial (ONLY HALF OF THE LIGAMENT IS DAMAGED )disruption of the involved tissue with more swelling and tenderness
3- Third degree: complete tearing of the ligament
INJURIES TO THE MUSCULOSKELETAL SYSTEM: Strain
STRAIN: stretching of a muscle and its fascial sheath (THINK of when I used to play soccer)
Clinical Manifestation include:
Pain, edema, decreased function and bruising
Nursing Management: Strains and Sprains
1- Health promotion/prevention: DAAAAA
2- RICE
a) Rest
b) Ice
c) Compression
d) Elevation above heart level (the heart would have to work against gravity. more gravity = less BP in the area and therefore less inflammation)
3) Analgesia
a) NSAIDS=decrease prostaglandins that contribute to inflammation and pain; increase risk for GI bleeding in older adults or if in excessive quantity
b) Opioids if severe
INJURIES TO THE MUSCULOSKELETAL SYSTEM: Subluxation (Partial dislocation) and Dislocation (Bone completely leaves the socket: common sites shoulder and hip)
Dislocation: (not broken)
1- Needs to be attended promptly
2- The longer the timeframe before Reduction, the greater the possibility of developing Avascular Necrosis
3- Avascular Necrosis – bone cell death as a result of inadequate blood supply
4- The hip and shoulder are particularly at risk for this
NURSING CARE:
1- Pain management
2- Support/protect the injured part
INJURIES TO THE MUSCULOSKELETAL SYSTEM: Fractures
1- Disruption or break in continuity of structure of bone
2- The majority of fractures from traumatic injuries
3- Some fractures secondary to disease process
Cancer or osteoporosis
4- Can be open or closed
5- Complete or incomplete
6- Displaced or nondisplaced
Classification of fractures according to Location
- Transverse (Shaft cut in a straight line meaning in perpendicular)
- Spiral ( They happen when one of your bones is broken with a twisting motion.)
- Greenstick (bends and cracks, instead of breaking completely into separate pieces.)
- Oblique (Diagonal fracture)
- Pathologic (A broken bone caused by disease, often by the spread of cancer to the bone)
- stress ( tiny cracks in a bone. They’re caused by repetitive force)
Clinical Manifestations: Fractures
- Edema and swelling due to inflammation
- Localized pain and tenderness
- Decreased function
- Muscle spasms (cramp)
- Inability to bear weight or use
- Guarding against movement (can’t walk)
- May or may not have deformity
- Ecchymosis (bruising) and crepitation
**Immobilize affected limb if you suspect fracture!!!!
Clinical Manifestations: Fractures
I- (In roman numbers)————-Edema and Swelling:
1- Caused by disruption of soft tissue or bleeding into the surrounding tissue.
2- If it occurs in a closed space, it can stop circulation and damage nerves - May lead to COMPARTMENT SYNDROME
3- Compartment Syndrome:
a) An elevation of pressure within a closed fascial compartment
b) Can be caused by hemorrhage and or edema within a closed space or by external compression or arterial occlusion
c) Notify the Provider, external compression should be avoided. May require fasciotomy if symptoms not resolved within 30 min
II. Pain and tenderness
III. Deformity
IV. Ecchymosis
V. Crepitation
Nursing Assessment of Fractures:
I- Objective Data
1- Apprehension
2- Guarding (if they can move or not)
3- Point tenderness
4- Skin lacerations, color changes
5- Hematoma, edema
6- Restricted or lost function
7- Deformities; abnormal angulation
8- Shortening, rotation, or crepitation
9- Imaging findings (xray)
II- Neurovascular Assessment (assessment of neurovascular compromise, impaired blood flow to the extremities, and damage to the peripheral nerves.)
III- Peripheral vascular
1- Color and temperature-⬇temp?
2- Capillary refill-?prolonged
3- Pulses- ↓ or absent pulse
4- Edema, hematoma
IV- Peripheral neurologic
1- Sensation and motor function-Paresthesias, absent, ↓ or ↑ sensation, muscle weakness
Factors influencing healing
1- Displacement (too much space between the 2 broken parts or a small separation)and site of fracture (fx)
2- Type of fx: Open (meaning comes out of the skin) and comminuted broken at least in 2 spots) fractures take the longest
3- Blood supply to area
4- Immobilization (the sooner and longer the better)
5- Internal fixation devices
6- Infection or poor nutrition
7- Age
8- Smoking (nicotine affects wound healing)
Nursing Care: Fractures
Define and Give examples:
1- Reduction
2- Immobilization
3- Restoration of function
Fracture Reduction
1- Closed reduction
a) Correction or Setting of a fractured bone without surgery (no incision involved)
b) Ex: hip or shoulder
2- Open reduction and internal fixation aka (ORIF)
a) Surgical incision
- Internal fixation-plates, pins and screws, intramedullary nail
- Risk for infection
- Early ROM of joint to prevent adhesions (of tendons)
-Facilitates early ambulation
Fracture Reduction
External Fixation
1-Metal pins and rods
2-Applies traction (brings the 2 parts of broken bone closer)
3-Compresses fracture fragments
4-Immobilizes and holds fracture fragments in place with pins
5-Pin site care done every shift and pin sites usually wrapped with gauge
FRACTURE IMMOBILIZATION: Cast Care
1- Common after Closed Reduction
2- Frequent neurovascular assessments (to check for blood flow to that part and nerve function )
3- Apply ice for first 24 hours
4- Elevate above heart for first 48 hours
5- Exercise joints above and below the broken segment.
6- Use hair dryer on cool setting for itching
Patient education / CAST CARE:
1- Do not get wet but if do, dry thoroughly after getting wet.
2- Report increasing pain despite elevation, ice, and analgesia.
3- Report swelling associated with pain and discoloration OR movement.
4- Report burning, tingling, sores, or foul odors under cast.
5- Don’t insert anything into cast or remove anything
6- Use hair dryer on cool if itchy
Hip Fractures:
1- Common in older adults
2- Can see shortening and external rotation of affected extremity
3- Can be treated with ORIF- with nail or plate, pins, screws
4- Total hip replacement=replacement of both the ball and socket (head of the femur and acetabulum)
5- Hemiarthroplasty-replacement of ball (head of femur) only. Hemia= half therefore Hemiarthroplasty= partial hip replacement
Postoperative Care: Hip Surgery
A) Hip Surgery:
1- Maintain hip abduction (separate legs) with pillows
2- Teach patient not to cross legs, internally rotate legs, or bend over at the waist (tying shoes). Teach to keep knees spread apart.
3- Monitor for sudden severe pain, loss of function, a lump in the buttocks, leg shortening, and external rotation=prosthetic dislocation (meaning the complete loss of contact between the 2 artificial joint parts)
B) Do not turn patient on affected side
C) Can have a significant blood loss (because remember blood is made in the bones)→ monitor CBC
Postoperative Care for Fractures
1- Monitor vitals
2- General principles of postoperative nursing care
3- Minimize pain and discomfort.
4- Monitor for bleeding or drainage
a) Aseptic technique
b) Blood salvage and reinfusion (the collection of the pt’s blood during surgery and to put it back in the pt at the end)
5- Frequent neurovascular assessments
a) Monitor Circulation, Sensation, Movement
b) Monitor compartment syndrome
COMPARTMENT SYNDROME: THE 6 P’S
1- PAIN
2- PALLOR
3- PULSELESSNESS
4- PARESTHESIA
5- PARALYSIS
6- POIKILOTHERMIA (inability to maintain a constant core temp usually higher than the rest of the environment)
Complications of Fractures:
I . Compartment Syndrome
1- Results from increased pressure within muscle compartments (fascia)
2- Occurs in 9.1% of fractures 3- Multiple other causes
4- Forearm, lower leg primary areas=36% of cases result from tib(tibia)-fib(fibula) fxs fractures
Watch slide 30 and youtube video.
Compartment Syndrome
1) Early recognition via regular neurovascular assessments!
-Notify if pain unrelieved by drugs and out of proportion to injury
-Pain is first symptom and includes pain with passive stretching of muscles in the affected compartment (stretching foot if lower leg)
2) Later signs=deterioration in Circulation, Sensation, movement, swelling
3) Permanent neurovascular (disorders in which an area of the brain is temporarily or permanently affected by bleeding or restricted blood flow.)damage can result as early as 4 hours after onset
4) Delay more than 6 hours in dx and fasciotomy leads to permanent weakness
Compartment Syndrome: Treatment
1- Bivalve or remove cast ASAP
2- Fasciotomy (surgical decompression)
3- No ICE
4- No Elevation
5- Monitor for dark tea colored urine-muscle. Because muscle breakdown=myoglobinuria-proteins precipitate in renal tubules and cause acute kidney injury
6- Monitor creatinine for renal compromise
Complications of Fractures II III IV V VI VII VIII
- Infection if open or surgical repair
- Delayed healing, nonunion of bones, deformity
- Venous thromboembolus (especially surgery on pelvis and lower extremity , gravity)
- Hemorrhage
- Fat embolism: presence of fat globules in pulmonary circulation
- Renal Calculi- Immobility alters urinary elimination. With upright position, urine flows d/t gravity. If flat in bed, kidneys and ureters are level, cause urinary stasis,(stopping of urination) increase risk of UTI and renal calculi – calcium stones lodge into renal pelvis or ureters. Immobilized pt usually have hypercalcemia (xk remember calcului are made of CALCIUM )causing them to be at risk for renal calculi
Complications: 7. Fat Embolism IN DETAIL
Fat embolism syndrome (FES)
1) Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury
2) Caused by fat obstructing the blood vessels in the lungs
3) Contributory factor in many deaths associated with fracture
4) Most common with fracture of long bones (beacuse thier medulla is long therefore it has more fat), ribs, tibia, and pelvic bones
5) Mechanical theory
-Fat released from marrow and enters circulation where it can obstruct
6) Biochemical theory
-Hormonal changes caused by trauma stimulate the release of fatty acids to form fat emboli.
Fat Emboli Syndrome: Clinical Manifestations
1- Early recognition crucial
2- Symptoms 12-24 hrs after injury
3- Fat globules travel to lungs cause a hemorrhagic interstitial pneumonitis.
4- Petechiae small red patches on skin) – neck, chest wall, axilla, buccal membrane, conjunctiva
5- Clinical course of fat embolus may be rapid and acute
6- Pt frequently expresses a feeling of impending death and restlessness
7- Agitation, Restlessness, Delirium, Convulsions – change in LOC, wheezing, blood tinged sputum, copious production of white sputum, fever especially 12-24 hrs after injury when fat emboli most likely to occur
8- In a short time skin color changes from pallor(palidez) to cyanosis (bluish skin)
9- Patient may become comatose
FES: Collaborative Care
A)
1- Treatment is aimed at prevention
Careful immobilization of a long bone fracture is probably the most important factor in prevention IMMEDIATELY DONE
2- Cough and deep breathing
B) Management is symptom-related and supportive
1- Oxygen for respiratory distress (intubation (tube through trachea) may be required for severe respiratory distress)
2- Corticosteroids (controversial) and Heparin (both Blood thinners)
FES: Collaborative Care
- Assistive devices for ambulation that can help reduce or eliminate weight bearing on affected limbs
CANE: relieve 40% of weight bearing
Use to support affected area
WALKER and CRUTCHES: Allow complete non-weight bearing ambulation
Joint Replacement Surgery
1- Most common are (THR total hip replacement ) also known as THA, total hip arthoplasty
2- TKA total knee arthoplasty-can replace part or all of knee joint
3- Major complications are infection and VTE (venous thromboembolism)=antibiotics and anticoagulants given postop.
These and other surgeries raise your risk for DVT because you often stay in bed for long periods of time while you recover. When you stop moving, blood flows more slowly in your deep veins, which can lead to a clot.
Osteomyelitis
1) Severe infection of the bone, bone marrow, and surrounding soft tissue
2) Most common microorganism is Staphylococcus aureus but can be caused by a variety of organisms (MRSA, Pseudomonas, and Enterobacteriaceae
3) Indirect entry (hematogenous)
results from a secondary infection such as gums teeth urinary tract
a) Young boys (Because they don’t have a strong immune system)
b) Blunt trauma
c) Vascular insufficiency disorders (coz blood doesn’t bring enough immune cells to the site)
d) IVDU meaning injection of drugs intravenously
e)GI & respiratory infections
4) Direct entry
a) Via open wound/open fractures, orthopedic surgeries
b)Foreign object-joint prosthesis
Clinical Manifestations Osteomyelitis
1- Acute: Infection which lasts less than a month
2- Local manifestations
a) Pain unrelieved by rest; worsens with activity
b) Swelling, tenderness, warmth
c) Restricted movement
3- Systemic manifestations
a) Fever
b) Night sweats
c) Chills
d) Restlessness
e) Nausea
f) Malaise
g) Drainage (late)
4- Chronic:
5- Infection lasting longer >1 month or has failed to respond to initial course of antibiotic therapy
6- Continuous and persistent or process of exacerbations and remissions
Chronic Osteomyelitis of Femur
1- Systemic signs diminished
2- Local signs of infection more common
a) Pain, swelling, warmth
3- Granulation tissue turns to scar tissue → avascular → ideal site for microorganisms to grow → away from antibiotic penetration by blood
Collaborative Care for Osteomyelitis (nurses and doctors and other medical staff)
1- Surgical removal infected bone
2- Extended use of antibiotics-4-6 week minimum
3- Antibiotic-impregnated polymethyl methacrylate bead chains=antibiotic spacers inserted into infected bone
4- Intermittent or constant antibiotic irrigation of bone
5- Casts or braces
6- Negative-pressure wound therapy=wound vac
7- Hyperbaric oxygen therapy (Application of large amounts of O2 to help tissue grow fast)
8- Removal of prosthetic devices (hardware)
8- Muscle flaps, skin grafting, bone grafts
9- Amputation
AMPUTATION
A) Pre Op Teaching/ Education:
1- Phantom pain
2- Pain management
3- Need for grieve/psychological support
4- Need for rehab and prosthesis
B) PostOp management/Education:
1- Maintain an aseptic technique during wound care
2- Use of rigid or compression dressings to minimize edema
3- Monitor for signs and symptoms of infection
4- Prevention of flexion contractures (a bent (flexed) joint that cannot be straightened actively or passively)
OSTEOPOROSIS
Who are at Risk:
1- one in 2 Americans over 50 years old will be at risk for fractures r/t osteoporosis
2- 44 million Americans (55% over age 50) will either have or is at risk of Osteoporosis
3- 80% of those with osteoporosis are female (National Osteoporosis Foundation 2010)
Prevention:
1- Encourage those at risk to be screened
2- Assess diet for calcium and vit D intake
3- Those with lactose intolerance should seek alternative source of calcium
4- Weight bearing exercise (walking, dancing, low-impact aerobics, elliptical training machines, stair climbing and gardening. )
5- Maintain optimal urinary function
6- Minimize alcohol intake and quite smoking
7- Home safety assessment for fall risk
Treatment:
1- Calcium supplement w/Vit D (take on empty stomach or with orange juice)
2- Bisphosphates, Alendronate, RANKL inhibitor (monoclonal antibody)
Check case study on slide 46
grade 0/5 Paralysis
no muscle contraction seen or identified with palpation.
grade 1 Flicker (make small, quick movements)
Muscle contraction is seen or identified with palpation but it is insufficient to produce joint motion even with elimination of gravity.
Grade 2 Person table to cross hands across table but not lift it./
The muscle can move the joint through a full range of motion only if the part is properly positioned so that the force of gravity is eliminated.
Grade 3 Person can raise hand off the table without any resistance applied
The muscle can move the joint it crosses through a full range of motion against gravity but without any resistance
grade 4 Moderate strength (Moves against some resistance)
The muscle can move the joint it crosses through a full range of motion against gravity but with some resistance
5/5 Normal strength (moves against full resistance)
The muscle can move the joint it crosses through a full range of motion against gravity and against full resistance applied by the examiner.
5/5 Normal (moves against full resistance )
Print Lippincott Neurovascular Assessment Pocket Card
Slide 4 flashcards
Can compression or arterial occlusion cause compartment syndrome?
Hell ya
When do Fat Emboli Syndrome symptoms appear?
Symptoms 12-24 hrs after injury
Osteomyelitis definition
Severe infection of the bone, bone marrow, and surrounding soft tissue
Most common microorganism that cause Osteomyelitis?
Staphylococcus aureus but can be caused by a variety of organisms (MRSA, Pseudomonas, and Enterobacteriaceae
Treatment of osteoporosis ?
1- Calcium supplement w/Vit D (take on empty stomach or with orange juice)
2- Bisphosphates, Alendronate, RANKL inhibitor (monoclonal antibody)
Surgical removal infected bone
Collaborative Care for Osteomyelitis
Extended use of antibiotics-4-6 week minimum
Collaborative Care for Osteomyelitis
Antibiotic-impregnated polymethyl methacrylate bead chains=antibiotic spacers inserted into infected bone
Collaborative Care for Osteomyelitis
Intermittent or constant antibiotic irrigation of bone
Collaborative Care for Osteomyelitis
Casts or braces
Collaborative Care for Osteomyelitis
Negative-pressure wound therapy=wound vac
Collaborative Care for Osteomyelitis
Hyperbaric oxygen therapy (Application of large amounts of O2 to help tissue heal fast)
Collaborative Care for Osteomyelitis
Removal of prosthetic devices (hardware)
Collaborative Care for Osteomyelitis
Muscle flaps, skin grafting, bone grafts
Collaborative Care for Osteomyelitis
Amputation
Collaborative Care for Osteomyelitis
Edema and swelling due to inflammation
Clinical Manifestations: Fractures
Localized pain and tenderness
Clinical Manifestations: Fractures
Decreased function
Clinical Manifestations: Fractures
Muscle spasms (cramp)
Clinical Manifestations: Fractures
Inability to bear weight or use
Clinical Manifestations: Fractures
Guarding against movement (can’t walk)
Clinical Manifestations: Fractures
May or may not have deformity
Clinical Manifestations: Fractures
Ecchymosis (bruising) and crepitation (a crackling or rattling sound.)
**Immobilize affected limb if you suspect fracture!!!!
Clinical Manifestations: Fractures
The longer the timeframe before Reduction, the greater the possibility of developing Avascular Necrosis
Dislocation: (not broken)
Avascular Necrosis – bone cell death as a result of inadequate blood supply
Dislocation: (not broken)
The hip and shoulder are particularly at risk for this
Dislocation: (not broken)
Comminuted
Bone broken at least in 2 spots
SPRAIN la peninsula
injury to the LIGAMENTS surrounding a joint
Caused by disruption of soft tissue or bleeding into the surrounding tissue.
Edema and Swelling in fractures
If it occurs in a closed space, it can stop circulation and damage nerves - May lead to COMPARTMENT SYNDROME
Edema in fractures
An elevation of pressure within a closed fascial compartment
Compartment Syndrome
Can be caused by hemorrhage and or edema within a closed space or by external compression or arterial occlusion
Compartment Syndrome
Notify the Provider, external compression should be avoided. May require fasciotomy if symptoms not resolved within 30 min
Compartment Syndrome
Cartilage arosion causing direct contact between bone ends?
osteoarthritis
The majority of fractures are from traumatic injuries
yes
Fractures can be Displaced or nondisplaced
oui
Common after Closed Reduction
cast
Exercise joints above and below the broken segment.
Broken bone with a cast
Frequent neurovascular assessments (to check for blood flow to that part and nerve function )
When you have a cast
Apply ice for first 24 hours
and Elevate above heart for first 48 hours
Cast
Loss of bone density due to increased resorption (The rest of the tissues in the body steal Ca+ from the bones so it becomes weak)
Age-Related Changes in the Musculoskeletal System
Decreased formation leading to osteopenia (loss of mineral density) and osteoporosis, kyphosis (an exaggerated, forward rounding of the upper back.)
Age-Related Changes in the Musculoskeletal System
Increase risk for cartilage erosion-direct contact between bone ends-osteoarthritis
Age-Related Changes in the Musculoskeletal System
Transverse
(Shaft cut in a straight line meaning in perpendicular)
Spiral
( They happen when one of your bones is broken with a twisting motion.)
Greenstick
(The bone bends and cracks a little bit, instead of breaking completely into 2 separate pieces.)
Oblique
(Diagonal fracture)
Pathologic
(A broken bone caused by disease, often by the spread of cancer to the bone)
Stress fracture
( tiny cracks in a bone. They’re caused by repetitive force)
(assessment of neurovascular compromise, impaired blood flow to the extremities, and damage to the peripheral nerves.)
Neurovascular Assessment
Color and temperature-⬇temp?
Found during Peripheral vascular assessment for fractures
Capillary refill-?prolonged
Found during Peripheral vascular assessment for fractures
Pulses- ↓ or absent pulse
Found during Peripheral vascular assessment for fractures
Edema, hematoma
Found during Peripheral vascular assessment for fractures
Sensation and motor function-Paresthesias, absent, ↓ or ↑ sensation, muscle weakness
Found during Peripheral neurologic assessment for fractures
