Musculoskeletal System Flashcards
Musculoskeletal System
-Main fx(s)
1-Support
2-Protection of vital organs
3-Movement
4-Blood cell production
5-Mineral storage
Musculoskeletal System
-Consists of
1-Bones
2-Ligaments
3-Fascia
4-Bursae
Bones
-What are they?
- Provide supporting framework
to body and protect underlying
organs & tissues - Participate in red & white
blood cell production - Serve as a site for storage of
inorganic minerals (Ca++,
PO4-) & contain organic
material (collagen) - Dynamic tissue (osteoblasts,
osteoclasts)
Ligaments
-What are they?
- Connect bones to bones
- More elastic than tendons
- Have poor blood supply
Fascia definition
Thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber and muscle in place
per John’s Hopkins
Bursae definition
Closed, fluid-filled sac that works as a cushion and gliding surface to reduce friction b/w tissues of the body
per John’s Hopkins
Tendons
-What are they?
- Attach muscles to bones
- Have poor blood supply
_ and _ have poor blood supply which delays healing
Ligaments and tendons have poor blood supply which delays healing
Assessment
-Inspection
- Always start w/ your initial contact w/ the patient
- Look for symmetry, general body built
Assessment
-Palpation
- If injury is the presenting problem, proceed with caution
- Palpation of soft tissue & joints allows for assessment of skin
temperature, swelling, tenderness & crepitation
Assessment
-Movement
- Observe/Evaluate ROM
Grading Muscle Strength
-5/5
Normal strength (moves against full resistance)
Grading Muscle Strength
-4/5
Moderate strength (moves against some resistance)
Grading Muscle Strength
-3/5
Eg. Person can raise hand off table w/o any resistance applied
Grading Muscle Strength
-2/5
Eg. Person able to slide hand across table but not lift it
Grading Muscle Strength
-1/5
Flicker
Grading Muscle Strength
-0/5
Paralysis
Injuries to the Musculoskeletal System
-Usually associated with abnormal stretching or twisting?
Sprains & strains
Sprain definiton
Injury to the ligaments surrounding a joint
-Ligament: connect bones to bones at joint
-Tendons: Attach muscles to bones
Sprains classified according to?
The amount of ligament fibers torn
Sprain classification
-1st degree
Tears of only few fibers
Sprain classification
-2nd degree
Partial disruption of the involved tissue w/ more swelling & tenderness
Sprain classification
-3rd degree
Complete tearing of the ligament
Strain definition
Stretching of a muscle & its fascial sheath
Strain
-Clinical manifestation(s)
Pain, edema, decreased function & bruising
Strains & sprains
-Nurs management
1-Health promotion/prevention
2-RICE
* Rest
* Ice
* Compression
* Elevation above heart level
3-Analgesia
* NSAIDS=decrease prostaglandins that contribute to inflammation & pain; increase risk for GI bleeding in older adults or if in excessive quantity
* Opioids, if severe
Injuries to the Musculoskeletal System
-Subluxation & dislocation
Subluxation:
* Partial dislocation
Dislocation:
* Needs to be attended promptly
* The longer the timeframe before reduction, the greater the possibility
of developing Avascular Necrosis
* Avascular Necrosis = bone cell death as a result of inadequate blood
supply
* The hip & shoulder are particularly at risk for this
Subluxation & dislocation
-Nurs care
- Pain management
- Support/protect the injured part
Injuries to the Musculoskeletal System
-Fractures
- Disruption or break in continuity of structure of bone
- Majority of fractures from traumatic injuries
- Some fractures secondary to disease process
- Cancer or osteoporosis
- Can be open or closed
- Complete or incomplete
- Displaced or nondisplaced
Fracture classification according to?
Location
Fracture location(s)
1-Transverse
1-Spiral
3-Greenstick
4-Comminuted
5-Oblique
6-Pathologic
7-Stress
Fractures
-Clinical manifestations
- Edema & swelling
- Localized pain & point tenderness
- Decreased function
- Muscle spasms
- Inability to bear weight or use
- Guarding against movement
- May or may not have deformity
- Ecchymosis & crepitation
Immobilize affected limb if you suspect fracture!!!!
Fractures
-Edema & swelling
- Resulting from disruption of soft tissue or bleeding into the surrounding tissue.
- If it occurs in a closed space, it can occlude circulation & damage nerves - may lead to COMPARTMENT SYNDROME
- Compartment Syndrome:
-An elevation of pressure within a closed fascial compartment
-Can be caused by hemorrhage and/or edema within a closed space or by external compression or arterial occlusion
Notify the Provider, external compression should be avoided. May require fasciotomy if symptoms not resolved within 30 min.
Fractures nurs assessment
-Objective data
- Apprehension
- Guarding
- Point tenderness
- Skin lacerations, color changes
- Hematoma, edema
- Restricted or lost function
- Deformities; abnormal angulation
- Shortening, rotation, or crepitation
- Imaging findings
Fractures nurs assessment
-Neurovascular assessment
- Peripheral vascular
-Color & temperature
-Capillary refill
-Pulses- decreased or absent
-Edema, hematoma - Peripheral neurologic
-Sensation & motor function-Paresthesias, absent, decreased or increased sensation, muscle weakness
Fractures
-Factors influencing healing?
- Displacement & site of fracture (fx)
- Type of fx: Open & comminuted fractures take longest
- Blood supply to area
- Immobilization
- Internal fixation devices
- Infection or poor nutrition
- Age
- Smoking
Fractures
-Nurs care
1-Reduction
2-Immobilization
3-Resoration of function
Fracture Reduction
-Closed reduction
- Correction or setting of a fractured bone w/o surgery
- Ex: hip or shoulder
Fracture Reduction
-Open reduction aka ORIF
- Surgical incision
-Internal fixation-plates, pins & screws, intramedullary nail
-Risk for infection
-Early ROM of joint to prevent adhesions
-Facilitates early ambulation
Fracture Reduction
-External fixation aka Ex fix
- Metal pins & rods
- Applies traction
- Compresses fracture fragments
- Immobilizes & holds fracture fragments in place w/ pins
- Pin site care done every shift & pin sites usually wrapped w/ gauge
Fracture Immobilization
-Cast care
- Common after Closed Reduction
- Frequent neurovascular assessments
- Apply ice for first 24 hours
- Elevate above heart for first 48 hours
- Exercise joints above & below
- Use hair dryer on cool setting for itching
Fracture Immobilization
-Cast care pt edu
- Do not get wet but if do, dry thoroughly after getting wet
- Report increasing pain despite elevation, ice & analgesia
- Report swelling associated w/ pain & discoloration OR movement
- Report burning, tingling, sores, or foul odors under cast
- Don’t insert anything into cast or remove anything
- Use hair dryer on cool if itchy
Fractures
-Hip
- Common in older adults
- Can see shortening & external rotation of affected extremity
- Can be treated w/ ORIF - w/ nail or plate, pins, screws
- Total hip replacement = replacement of both the ball & socket (head of the femur & acetabulum)
- Hemiarthroplasty-replacement of ball (head of femur) only
Hip surgery
-Postop care
- Maintain hip abduction w/ pillows
- Teach patient not to cross legs, internally rotate legs, or bend over at the waist (tying shoes). Teach to keep knees spread apart.
- Monitor for sudden severe pain, loss of function, a lump in the buttocks, leg shortening & external rotation=prosthetic dislocation
- Do not turn patient on affected side
- Can have a significant blood loss → monitor CBC
Fractures
-Postop care
- Monitor vitals
- General principles of postoperative nursing care
- Minimize pain & discomfort
- Monitor for bleeding or drainage
-Aseptic technique
-Blood salvage & reinfusion - Frequent neurovascular assessments
-Monitor circulation, sensation, movement
-Monitor compartment syndrome
Fractures
-Complications
- Compartment Syndrome
- Infection, if open or surgical repair
- Delayed healing, nonunion of bones, deformity
- Venous thromboembolus (ex: surgery on pelvis & lower extremity)
- Hemorrhage
- Fat embolism
- Renal Calculi
Compartment Syndrome
-The 6 P’s
- Pain
- Pallor
- Pulselessness
- Paresthesia
- Paralysis
- Poikilothermia (inability to maintain a constant core temperature independent of ambient temperature)
Complications of fractures
-Compartment Syndrome
- Results from increased pressure within muscle compartments (fascia)
- Occurs in 9.1% of fxs
- Multiple other causes
- Forearm, lower leg primary areas=36% of cases result from tib-fib fxs
- Early recognition via regular neurovascular assessments!
-Notify if pain unrelieved by drugs & out of proportion to injury
-Pain is first symptom & includes pain w/ passive stretching of
muscles in the affected compartment (stretching foot if lower leg) - Later signs=deterioration in circulation, sensation & movement, swelling
- Permanent neurovascular damage can result as early as 4 hours after onset
- Delay more than 6 hours in dx & fasciotomy leads to permanent weakness
Compartment Syndrome tx
- Bivalve or remove cast ASAP
- Fasciotomy (surgical decompression)
- No ICE
- No Elevation
- Monitor for dark tea colored urine-muscle breakdown=myoglobinuria-proteins precipitate in renal tubules & cause acute kidney injury
- Monitor creatinine for renal compromise
Complications of fractures
-Renal Calculi
- Immobility alters urinary elimination. W/ upright position, urine flows d/t gravity. If flat in bed, kidneys & ureters are level, cause urinary stasis, increase risk of UTI & renal calculi – calcium stones lodge into renal pelvis or ureters.
- Immobilized pt usually have hypercalcemia causing them to be at risk for renal calculi.
Complications of fractures
-Fat Embolism Syndrome aka FES
- Presence of systemic fat globules from fracture that are distributed into tissues & organs after a traumatic skeletal injury
- Caused by fat obstructing the blood vessels
- Contributory factor in many deaths associated w/ fracture
- Most common w/ fracture of long bones, ribs, tibia & pelvic bones
Fat Embolism Syndrome
-Mechanical theory
Fat released from marrow & enters circulation where it can obstruct
Fat Embolism Syndrome
-Biochemical theory
Hormonal changes caused by trauma stimulate release of fatty acids to form fat emboli
Fat Embolism Syndrome
-Clinical manifestations
- Early recognition crucial
- Symptoms 12-24 hrs after injury
- Fat globules travel to lungs cause a hemorrhagic interstitial pneumonitis
- Petechiae – neck, chest wall, axilla, buccal membrane, conjunctiva
- Clinical course of fat embolus may be rapid & acute
- Pt frequently expresses a feeling of impending death & restlessness
- 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
- In a short time skin color changes from pallor to cyanosis
- Pt may become comatose
Fat Embolism Syndrome
-Collaborative care (tx)
- Tx is aimed at prevention
- Careful immobilization of a long bone fracture is probably the most important factor in prevention - IMMEDIATELY DONE
- Cough & deep breathing
Fat Embolism Syndrome
-Collaborative care (management)
- Management is symptom-related & supportive
- Oxygen for respiratory distress (intubation may be required for severe respiratory distress)
- Corticosteroids (controversial) & Heparin
Fat Embolism Syndrome
-Collaborative care (assisted devices)
- 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 & CRUTCHES: Allow complete non-weight bearing ambulation
Joint Replacement Surgery
- Most common are THR also known as THA
- TKA-can replace part or all of knee joint
- Major complications are infection and VTE=antibiotics & anticoagulants given postop
Osteomyelitis?
- Severe infection of bone, bone marrow & surrounding soft tissue
- Most common microorganism is Staphylococcus aureus but can be caused by variety of organisms (MRSA, Pseudomonas & Enterobacteriaceae)
- Indirect entry (hematogenous)
-Young boys
-Blunt trauma
-Vascular insufficiency disorders
-IVDU
-GI & respiratory infections - Direct entry
-Via open wound/open fractures, orthopedic surgeries
-Foreign object-joint prosthesis
Osteomyelitis
-Clinical manifestations (acute)
- Acute
-Infection of <1 month in duration
Osteomyelitis
-Clinical manifestations (local)
- Local manifestations
-Pain unrelieved by rest; worsens w/ activity
-Swelling, tenderness, warmth
-Restricted movement
Osteomyelitis
-Clinical manifestations (systemic)
- Systemic manifestations
-Fever
-Night sweats
-Chills
-Restlessness
-Nausea
-Malaise
-Drainage (late)
Osteomyelitis
-Clinical manifestations (chronic)
- Chronic:
-Infection lasting longer >1 month or has failed to respond to initial course of antibiotic therapy
-Continuous & persistent, or process of exacerbations & remissions
Chronic osteomyelitis of femur
- Systemic signs diminished
- Local signs of infection more common
- Pain, swelling, warmth
- Granulation tissue turns to scar tissue → avascular → ideal site for microorganisms to grow → away from antibiotic penetration
Osteomyelitis
-Collaborative care
- Surgical removal infected bone
- Extended use of antibiotics-4-6 week minimum
- Antibiotic-impregnated polymethyl methacrylate bead chains=antibiotic spacers inserted into infected bone
- Intermittent or constant antibiotic irrigation of bone
- Casts or braces
- Negative-pressure wound therapy=wound vac
- Hyperbaric oxygen therapy
- Removal of prosthetic devices (hardware)
- Muscle flaps, skin grafting, bone grafts
- Amputation
Amputation
-Preop teaching/edu
- Phantom pain
- Pain management
- Need for grieve/psychological support
- Need for rehab & prosthesis
Amputation
-Postop management/edu
- Maintain aseptic technique during wound care
- Use of rigid or compression dressings to minimize edema
- Monitor for s/s of infection
- Prevention of flexion contractures
Osteoporosis
-Who are at risk?
- 1 in 2 Americans over 50 years old will be at risk for fractures r/t osteoporosis
- 44 million Americans (55% over age 50) will either have or is at risk of Osteoporosis
- 80% of those w/ osteoporosis are female (National Osteoporosis Foundation 2010)
Osteoporosis
-Prevention
- Encourage those at risk to be screened
- Assess diet for calcium & vit D intake
- Those w/ lactose intolerance should seek alternative source of calcium
- Weight bearing exercise
- Maintain optimal urinary function
- Minimize alcohol intake & quit smoking
- Home safety assessment for fall risk
Osteoporosis tx
- Calcium supplement w/ Vit D (take on empty stomach or with orange juice)
- Bisphosphates, Alendronate, RANKL inhibitor (monoclonal antibody)
