Unit 6: Ch 48 (Porth's 5th Ed) - Disorders of Musculoskeletal Function: Trauma, Infection, Neoplasms Flashcards
- While being tackled, a 20-year-old football player puts out his hand to break his fall to
the ground. Because the intense pain in his wrist did not subside by the end of the game,
he was brought to an emergency department where diagnostic imaging indicated an
incomplete tear of the ligament surrounding his wrist joint. At the time of admission, his
wrist was swollen with a severely restricted range of motion. What will his care team
most likely tell the player about his diagnosis and treatment?
A) “This strain will likely resolve itself with sufficient rest.”
B) “You’ve suffered a severe sprain, and you might need a cast.”
C) “Your wrist contusion will have to be observed for bleeding under the skin
surface.”
D) “It looks like a mild to moderate sprain, and you’ll need to keep it immobilized for
a few weeks.”
Ans: D
Feedback:
Damage to the ligament structures is associated with sprains, and an incomplete tear
would be indicative of a mild to moderate (grade 1 or 2) sprain. A strain is associated
most commonly with overuse, and severe sprain would involve total disruption of the
ligament.
- A 41-year-old woman has been diagnosed as having a loose body of cartilage in her left
knee. What data would most likely lead clinicians to this conclusion?
A) A visible hematoma is present on the anterior portion of the knee.
B) The woman experiences intermittent, painful locking of her joint.
C) Computed tomography indicates a complete tear of her knee ligament.
D) An x-ray shows that her femoral head and tibia are no longer articulated.
Ans: B
Feedback:
The symptoms of loose bodies are painful catching and locking of the joint. The loose
body repeatedly gets caught in the crevice of a joint, pinching the underlying healthy
cartilage. A tear of her ligament, a hematoma, or a lack of articulation is not as closely
associated with the presence of loose bodies in a joint
- A 22-year-old woman has sustained a lateral blow to her right knee during a game, and
subsequent imaging has confirmed a severe meniscus injury. Which of the following
consequences should the woman expect over the course of recovery? Select all that
apply.
A) Decreased lubrication in the knee joint
B) Decreased stability of the knee
C) Reduced shock absorption capacity
D) Presence of infectious microorganisms in the synovial capsule
E) Rapid restoration of the cartilage cells in the meniscus
Ans: A, B, C
Feedback:
Meniscal injuries have consequences for the lubricating and shock absorption capacities
of the meniscus and would involve decreased range of motion. An infectious process is
unlikely due to the internal nature of meniscal injuries, and healing is typically very
slow.
- The nurse knows that which of the following patients listed below is at high risk for
developing a hip fracture?
A) A 77-year-old male who runs marathons and maintains a BMI of 25.
B) An 82-year-old female with macular degeneration and uses a walker to go to the
bathroom.
C) A 64-year-old male with uncontrolled diabetes and chronic kidney disease on
dialysis.
D) A 73-year-old nursing home patient with long-term continence issues but able to
walk the hallways for exercise.
Ans: B
Feedback:
Hip fracture is a major public health problem in the Western world. The incidence of hip
fractures increases with age. The incidence is also higher in white women compared
with nonwhite women. Risk factors for hip fracture include low BMI, tall body
structure, use of benzodiazepines, lack of exercise, previous injury to lower body
extremity, vision problems, and confusion.
- A public health nurse is conducting a health promotion teaching session at a seniors’
drop-in center. Which of the following teaching points about hip fractures in older
adults is most justified?
A) “Current treatment options for hip fractures in older adults mean that surgery is no
longer a common necessity.”
B) “Because of their generally higher body mass, men are particularly susceptible to
breaking a hip in a fall.”
C) “Most hip fractures are actually a break at the very top of the thigh bone.”
D) “Because bone density is largely determined by your genes, there’s little you can
do to prevent hip fractures other than avoiding falls.”
Ans: C
Feedback:
Fractures to the femoral head are the most common etiology of hip fractures in the older
adult. Surgery is commonly required, and incidence is higher in women than in men.
There are numerous risk factors for hip fracture beyond genetic factors, many of which
are modifiable.
- Which of the following recent admissions to an emergency department is most likely to
be diagnosed with a greenstick fracture?
A) A 20-year-old football player who had an opposing player fall laterally on his leg
B) An 8-year-old boy who fell out of a tree and on to his arm
C) An 81-year-old woman with a history of osteoporosis who stumbled and fell on
her hip
D) A 32-year-old woman who fell awkwardly on her arm while skiing
Ans: B
Feedback:
A greenstick fracture is seen almost exclusively in children under age 10.
- The parents of an active 9-year-old are leaving the emergency department (ED)
following cast placement for their son’s lower extremity as a result of a fall in soccer.
The nurse should emphasize that assessment of the cast is important and that they
should bring their son back to the ED if they note which of the following signs and
symptoms? Select all that apply.
A) Cold, pale toes on the side with the cast.
B) Patient complaining of tingling and numbness in the casted leg.
C) Swelling in the lower leg has remained the same since they left the ED 12 hours
ago.
D) Pulses are palpable below the level of the cast.
E) Bruising noted in the lower foot and toes
Ans: A, B
Feedback:
If the circulation becomes inadequate (on a casted extremity), the parts that are exposed
at the distal end of the cast (i.e., the toes with a leg cast and the fingers with an arm cast)
usually become cold and cyanotic or pale. An increase in pain may occur initially,
followed by paresthesia (tingling or abnormal sensation) or anesthesia as the sensory
neurons that supply the area are affected. There is a decrease in amplitude of the pulse
in areas where the arteries can be palpated. Bruising in the lower foot and toes would be
considered normal following this type of fracture. Blood tends to pull in the lower
tissues.
- A nurse is providing care for a client who has had a cast applied to her fractured arm 6 hours prior. The client is now complaining of severe pain that she describes as “even
worse than when I broke my arm.” What would be the nurse’s best course of action?
A) Administration of analgesics and teaching the client about the normal course of
pain after a fracture
B) Teaching the client simple range of motion exercises to promote circulation and
perfusion
C) Taking the client’s temperature due to the possibility of infection
D) Assessment of motor and sensory function with the goal of identifying
compartment syndrome
Ans: D
Feedback:
Severe pain in the site of a fracture that is out of proportion to the original injury is a
hallmark of compartment syndrome. Assessment of sensory and motor function would
be an appropriate first action. Analgesia alone and exercises would be insufficient to
diagnose or address compartment syndrome, and infection would be an unlikely
etiology of sudden pain after cast application.
- Following a motorcycle accident that resulted in bilateral femoral fractures, a
42-year-old male has been receiving skeletal traction for the past 8 days. His care
providers would recognize that which of the following risks is paramount?
A) Risk of thromboemboli
B) Risk of compartment syndrome
C) Risk of permanent muscle atrophy
D) Risk of decreased bone density and increased future fracture risk
Ans: A
Feedback:
For individuals with lower limb injuries, there is a high risk of venous thromboemboli.
Compartment syndrome normally manifests within 64 hours of injury, and muscle
atrophy is not likely to be permanent. His injury and recovery are not likely to result in
long-standing decreased bone density.
- A patient has been admitted with a fractured pelvis that occurred in an auto accident just
a few hours ago. The nurse notices a slight change in behavior. Which of the following
clinical manifestations would lead the nurse to suspect that the patient has fat emboli
that has migrated? Select all that apply.
A) Complaints of substernal chest pain
B) Complaints of pain in the lower abdomen and back
C) Pulse rate 120 with temperature of 99.7°F
D) Profuse diaphoresis with pallor noted
E) Urine output of 30 mL/hour
Ans: A, C, D
Feedback:
Initial symptoms of FES are a subtle change in behavior and signs of disorientation
resulting from emboli in the cerebral circulation combined with respiratory depression.
There may be complaints of substernal chest pain and dyspnea accompanied by
tachycardia and low-grade fever. Diaphoresis, pallor, and cyanosis become evident as
respiratory function deteriorates. It would be expected that the patient have lower
abdominal and back pain since they have a pelvic fracture. The normal urine output is a
minimum of 30 mL/hour.
- Following prosthetic joint replacement of the knee, the patient continues to complain of
pain and discomfort above what would be expected. There is poor incisional healing.
The clinic nurse is concerned when she sees that the incision is still draining after 3
weeks post-op. The nurse suspects a prosthetic joint infection. The nurse should
anticipate the physician will prescribe
A) complete bed rest with immobilization of the knee.
B) high doses of nonsteroidal anti-inflammatory drugs.
C) antimicrobial treatment depending on the microbe.
D) wound irrigations with hydrogen peroxide twice daily.
Ans: C
Feedback:
Treatment includes the use of antibiotics and selective use of surgical interventions.
Antimicrobial agents are usually used prophylactically in persons undergoing bone
surgery. For persons with osteomyelitis, early antimicrobial treatment, before there is
extensive destruction of bone, produces the best results. Bed rest is not encouraged. The
patient may be given NSAIDs for pain, but usually he or she will require a more potent
pain killer. Wound irrigations are usually performed in OR rather than at bedside for
infected prosthetic joints.
- A 56-year-old male is obese and has poorly controlled type 2 diabetes mellitus. The
home care nurse who changes the dressing on his chronic foot ulcer three times weekly
has noted that the client’s bone is now visible in the wound bed. The client has a fever
and has not complained of any notable increase in pain to his foot. Which of the
following statements best captures what is likely occurring?
A) The client is possibly experiencing direct penetration osteomyelitis in which
microorganisms have entered through his foot wound.
B) Infectious microorganisms in his blood supply have proliferated in the distal
portions of his skeletal system.
C) Vascular insufficiency has contributed to infection in both soft tissue and now his
bone.
D) His immunocompromised status associated with diabetes has allowed skin flora to
penetrate his foot bone via the surface wound.
Ans: C
Feedback:
Diabetes is strongly associated with vascular insufficiency; this process is more likely
than infection from the bloodstream, and his situation is not indicative of direct
penetration osteomyelitis. Decreased immune status is not directly responsible for his
problem.
- Which of the following individuals is likely to have the highest risk of developing
tuberculosis osteomyelitis?
A) A 55-year-old female who is in renal failure secondary to poorly controlled type 1
diabetes
B) A 79-year-old man who is immunocompromised following a bone marrow
transplant
C) A 30-year-old man who has undergone open reduction and internal fixation of his
fractured tibia
D) A 68-year-old woman who had a laminectomy 4 days prior for treatment of her
chronic back pa
Ans: B
Feedback:
Older age and immunocompromised status are noted risk factors for the development of
tuberculosis osteomyelitis. Postsurgical status and diabetes are not noted to be strongly
associated with the pathology.
- A patient asks the nurse why his hip fracture (head of the femur) bone has died
(osteonecrosis). The nurse responds based on which of the following pathophysiological
principles?
A) All fractured bones interrupt blood supply and thereby results in death of the bone
no matter where it is located.
B) Most of the time when the head of the femur breaks, the entire neck region is
disconnected to the rest of the bone so the blood vessels are severed.
C) Since the head of the femur has only limited collateral circulation, interruption in
the blood flow from the fracture causes necrosis and irreversible damage.
D) When the femur head breaks, it dislocates and crushes the surrounding area
causing the blood vessels to be occluded.
Ans: C
Feedback:
Bone has a rich blood supply that varies from site to site. The flow in the medullary
portion of bone originates in nutrient vessels from an interconnecting plexus that
supplies the marrow, trabecular bone, and endosteal half of the cortex. Some bony sites,
such as the head of the femur, have only limited collateral circulation, so that
interruption of the flow, such as with a hip fracture, can cause necrosis of a substantial
portion of medullary and cortical bone and irreversible damage. Not all fractures
interrupt blood supply to the bone. It is not common for the entire head of the femur to
break off leaving the area with no blood supply.
- A 51-year-old male with a history of hypertension has received a kidney transplant. The
client’s physician is explaining some of the consequences of the procedure, including the
fact that he will need to be on long-term steroid therapy. Which of the following
teaching points should the physician emphasize?
A) “One of the risks that these steroids bring is the possibility that part of a bone
might die.”
B) “Steroids will help your body to not reject your new kidney, but they bring a risk
of bone infection.”
C) “You’re going to have to avoid contact sports because the steroids will make your
bones very susceptible to breakage.”
D) “If you notice sudden limb pain after taking your steroid pills, it could be an
increase in pressure in the compartment around your muscles.”
Ans: A
Feedback:
Osteonecrosis is strongly associated with steroid therapy. Osteomyelitis, decreased bone
density, and compartment syndrome are not associated with steroid therapy.
- A 35-year-old woman who has been in recovery from alcoholism for 2 years presents at
her primary care physician’s office with chronic hip pain. She reports that as part of her
commitment to her recovery, she began exercising regularly about a year earlier. After a
month or two, her hip began to hurt when she ran on the treadmill. She stretches, has
had a physical trainer check her form to ensure that it is correct, and rests adequately
between each workout. Six months ago, the pain began waking her at night, and now it
is constant. She is not aware of any injury to her hip and has no other outward
symptoms. Which of the following is most likely to be the cause of her pain?
A) Hematogenous osteomyelitis
B) Osteomyelitis with vascular insufficiency
C) Tuberculosis of the bone
D) Osteonecrosis
Ans: D
Feedback:
The symptoms associated with osteonecrosis are varied and depend on the extent of
infarction. Typically, subchondral infarcts cause chronic pain that is initially associated
with activity, but that gradually becomes more progressive until it is experienced at rest.
Osteonecrosis is a common complicating disorder of Legg-Calvé-Perthes disease,
slipped capital epiphysis, sickle cell disease, steroid therapy, alcohol abuse, and hip
trauma, fracture, or surgery. In adults, hematogenous osteomyelitis is seen most
commonly in debilitated patients; in those with a history of chronic skin infections,
chronic urinary tract infections, and intravenous drug use; and in those who are
immunologically suppressed. Osteomyelitis with vascular insufficiency is characterized
by local cellulitis with inflammation and necrosis. Local symptoms of tuberculosis of
the bone include pain, immobility, and muscle atrophy; joint swelling, mild fever, and
leukocytosis also may occur.
- When trying to explain to a patient diagnosed with a benign bone tumor, the nurse
should emphasize the fact that benign tumors primarily
A) grow rapidly and can spread to the surrounding tissue.
B) cause growth of other tumors as they spread their cancer cells into the
bloodstream.
C) tend to grow very slowly without destroying the supporting tissue.
D) occur as a result of tumors in other areas of the body metastasizing into the bone.
Ans: C
Feedback:
Benign tumors, such as osteochondromas, tend to grow rather slowly and usually do not
destroy the supporting or surrounding tissue or spread to other parts of the body
(metastasize). Malignant tumors tend to grow rapidly, destroy supporting or surrounding
tissue, or spread to other parts of the body through the bloodstream or lymphatics.
- A 13-year-old girl and her father come in to the local health clinic hoping to see an
orthopedic doctor about the girl’s stiff and warm knee. The father reports that she hurt it
sliding into base during a softball game, and the daughter concurs, but with further
discussion, it becomes clear that the slide made an existing pain worse. Her knee had
been stiff, warm, and shiny and had been keeping her awake at night for a week or so
before the game. Which of the following might be the cause of the girl’s symptoms?
A) Osteosarcoma
B) Osteoma
C) Chondroma
D) Osteochondroma
Ans: A
Feedback:
Osteosarcoma is the most common bone tumor in children and the third most common
cancer in children and adolescents; they most commonly arise in the vicinity of knee.
The primary clinical feature of osteosarcoma is deep localized pain with nighttime
awakening and swelling in the affected bone. Because the pain is often of sudden onset,
patients and their families often associate the symptoms with recent trauma. The skin
overlying the tumor may be warm, shiny, and stretched, with prominent superficial
veins. The range of motion of the adjacent joint may be restricted. The four most
common types of benign bone tumors are osteoma, chondroma, osteochondroma, and
giant cell tumor; pain is a feature common to almost all malignant tumors but may or
may not occur with benign tumors; pain that persists at night and is not relieved by rest
suggests malignancy
- A 17-year-old male has been diagnosed with osteosarcoma of the upper tibia following
several months of leg pain. Which of the following statements by the client
demonstrates that he has an accurate understanding of his diagnosis?
A) “I guess it’s good that at least my tumor’s a benign type.”
B) “I’m really nervous about having to get surgery and chemo.”
C) “I’m gaining hope from the fact that it’s really rare for someone to die from this.”
D) “It still feels surreal that I’m going to have to get my leg amputated.”
Ans: B
Feedback:
Osteosarcomas are malignant bone tumors that are treatable by surgery and
chemotherapy. Survival is in the range of 55% to 70%, so death is not uncommon.
Amputation is sometimes necessary but is certainly not an inevitability.
- A 56-year-old female with a diagnosis of breast cancer has developed bone metastases,
which her oncologist would like to treat with radiation therapy. What is her physician’s
most likely primary goal in the treatment plan of the metastases?
A) Thorough elimination of neoplastic cells in the bone structure
B) Preservation of normal weight bearing and range of motion
C) Ensuring vascular supply to the bone is not affected
D) Prevention of pathologic fractures
Ans: D
Feedback:
While care providers would certainly try to maintain blood supply and mobility, the
primary goal in the treatment of bone metastases is to prevent pathologic fractures.
Complete elimination of neoplastic cells is not commonly attainable with radiation
treatment.
