Week 12 - MSK Flashcards
Age-Related Considerations
Bones
- decrease in bone density and formation = osteopenia and osteoporosis = ↑ risk of fractures
Muscles
- decreased muscle cells
- replacing muscle cells with fibrous tissue = decreased strength, flabby muscle
Tendons and Ligaments
- less flexible = decreased agility and dexterity
Joint
- more rigid = pain with movement and prone to osteoarthritis
MSK Assessment
- Health history
- Injury to joints/ligamnets/bones
- Family hostory
- Medication
- Lifestyle
- Activity, diet, occupations
Physical Assessment - Inspection
- posture
- gait
- use of assistive devices
- muscle shape, size, deformity, wasting
Palpation
- tenderness, swelling, warmth
- range of motion: active or passive
- muscle strength testing
Muscle Strength Testing
0 - No muscle contraction
1- barely detectable contraction with observation or palpation
2 - can move without gravity
3- can move against gravity, but without resistance
4 - can move against gravity and SOME resistance
5 - movement against FULL resistance without fatigue
What should a nurse expect to find when performing an MSK assessment?
- Full range of motion of all joints without pain or hyper mobility
- No joint swelling, deformity or crepitation
- Normal spinal curvatures with no spinal tenderness
- No muscle atrophy or asymmetry
- Muscle strength rating of 5
Blood Work
- Calcium & phosphorus levels
- Alkaline phosphatase (ALP)
- Erythrocyte sedimentation rate (ESR)
→ measures how fast RBC’s settle
→faster settling = more inflammation - C-reactive protein (CRP)
→ protein made by the liver when there is inflammation
→ high CRP = inflammation
Diagnostic Tests
- X-rays: Fractures, bone alignment, bone density
- MRI: Soft tissue evaluation (e.g., ligaments, cartilage)
- CT scan: detailed bone structure
- Bone scans: metabolic activity in the bones
- Synovial fluid aspiration
What is Osetoporosis?
- decreased bone density and increased fragility
2 Types:
1. Post menopausal
2. Senile (>80 yrs)
Why is osteoporosis more
common in women?
- Women have lower Ca intake than men
- Women have less bone mass (due to smaller frame)
- Pregnancy and breastfeeding deplete skeletal reserve
- Longevity increases likelihood of osteoporosis and women live longer than men
- Bone reabsorption begins earlier for women and is accelerated during menopause
Risk Factors for Osteoporosis
Non-Modifiable
- age
- gender
- history
- ethnicity
Modifiable
- low calcium intake
- sedentary lifestyle
- vitamin d deficiency
- smoking
Signs & Symptoms of Osteoporosis
- asymptomatic until fracture occurs
- common fractures: vertebral, hip, wrist
Signs: loss of height, stooped posture, back pain
Diagnostic Tests
Bone Mineral Density (BMD) Test: Dual-energy X-ray absorptiometry
(DEXA) scan
Results are reported as T-scores
- A T-score of -1 or higher = normal bone density
- A T-score of -1 to -2.5 = osteopenia
- A T-score of -2.5 or lower indicates osteoporosis
- Other Tests: FRAX tool for fracture risk assessment (personal risk factors e.g. smoking, previous fractures)
Nursing Care of Clients with Osteoporosis
- health teaching abut modifiable risk factors
- reducing smoking and alcohol intake
- falls prevention: proper vision, balance training
- regular physical activity: weight bearing exercises
Pharmacological Treatment for Osteoporosis
1) Bisphosphates
→ inhibit bone reabsorption
2) Selective Estrogen Receptor Modulator
→ mimics effects of estrogen by reducing bone resorption
3) Vitamin D
→ helps absorption of Calcium
Arthritis
- inflammation of a joint
- affects women more than men
- leading cause of disability in older adults
- most common: osteoarthritis
Osteoarthritis
- degenerative joint disease
- breakdown of cartilage and bone (in synovial joints)
- decreased cartilage causes bones to rub together
- symptoms: pain, swelling, reduced motion in the joint
Modifiable risk factors
- obesity
- repetitive stress on joints
- joint injuries
Pathophysiology of OA
- Cartilage breakdown
→ loss of cartilage causes bones to rub together - Bone changes
→ extra bone growth (spurs) and bone beneath cartilage becomes hard (subchondral sclerosis) - Inflammation
- inflammation in synovial joints
Signs & Symptoms of OA
- joint pain
- stiffness
- swelling
- decreased range of motion
- crepitation (cracking/popping when joints rub together)
Assessment & Diagnosis of OA
Health History
- Family history
- History of joint injury
- Pain assessment (OLDCARTSS)
- Impact of pain/stiffness on ADLs
- Range of motion
- Swelling
Bloodwork & Diagnostic Tests
- Imaging: X-rays, MRI
- Laboratory Tests: No specific test for OA
- Rule out other types of arthritis
Nursing Care of Client with OA
- Nutrition, weight counselling
- Rest & activity balance, physical therapy
- Use of assistive devices
- Heat & cold applications
- Complementary & alternative
therapies - Supplements (e.g., glucosamine)
- Analgesics, NSAIDS,
corticosteroid injections - Joint replacement surgery
Which condition is primarily characterized by the breakdown of cartilage and the formation of osteophytes?
OA
Which condition is often referred to as a ‘silent disease’ because it progresses without symptoms until a fracture occurs?
OP
Which condition’s risk factors include low calcium intake, vitamin D deficiency, and a sedentary lifestyle
OP
Which condition is commonly managed with weight-bearing exercises
and medications like bisphosphonates?
OP
Which condition often involves joint pain, stiffness, and decreased range of motion, particularly in the knees, hips, and hands?
OA
Rheumatoid Arthritis (RA)
- systemic autoimmune disease
- causes inflammation of the synovial joints
- most common chronic inflammatory joint disease
- marked by periods of remission and exacerbation
Risk Factors for RA
Non-modifiable: genetics
Modifiable: smoking
Signs & Symptoms of RA
Symptoms
- pain
- stiffness (esp in morning)
- less ability to perform ADL’s
- small joints of hands and feet are affected
- inflammation causes muscle atrophy, tendon destruction, and joint deformity
Signs
- heat
- symmetrical swelling
- contractures
- loss of grip strength
- Ulnar Deviation
→ fingers bend toward pinky - Swan-neck deformity
→middle joints bend backward
→ end joint bend forward - Boutonnière Deformity:
→ middle joints bend forward
Assessments & Diagnosis of RA
Health history
- Pain, stiffness (OLD CARTSS)
- Family history
- Physical exam (ROM, inflammation)
- Nodules, deformities
Pharmacological Management for RA
1) Disease-Modifying Antirheumatic Drugs (DMARDs)
- Immunosuppressants- reduce inflammation & joint damage
- Take several weeks to work
- Side effects: risk of infection, bone marrow suppression,
hepatotoxicity
2) Biological Response Modifiers (BMRs)
- supress immune system to decrease inflammation & joint damage
- Used if DMARDs not effective
- Side effects: bone marrow suppression, hepatotoxicity,
cardiopulmonary & renal dysfunction, DIC
3) Corticosteroids
- Supress immune system, decrease inflammatory response
- Side effects: hyperglycemia, risk for infection, dyslipidemia
4) NSAIDS
- Treat pain, inflammation
- Side effects: GI bleeding, renal damage
Fractures
- disruption or break in the continuity of bone
2 Types:
1. Close - simple
2. Open - compound
- complete: break across entire bone
- incomplete - bone does not break completely through
- displaced: 2 ends of bone separate each other and are out of alignment
- Non-displaced - periosteum intact across fracture, bone still in alignment
Signs & Symptoms of a Fracture
- pain
- swelling, bruising
- deformity
- muscle spams - irritation of tissue as a protective response to injury
- loss of function
-crepitus
Fracture Reduction
Closed Reduction
- fixing a bone without surgery
- doctor manually moves the bone back into place by pulling it
- the bone is kept still with a cast
Open Reduction
- surgical correction of bone alignment
- involves screws, wires, pins, rods, nails
Fracture reduction: pulling force to injured body part to help it heal
→ used for muscle spasms and keeping body parts still
Skin Traction
→ short term
→ uses tape, splints
Skeletal Traction
→ long term
→ uses pins or wires inside bones
→ high risk of infection
Fracture Immobilization
Casts
- Temporary immobilization device used following
a closed reduction
- Incorporates the joints above and below a fracture
External fixation
- Metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals
Internal fixation
- Pins, plates, screws attached during realignment
Nursing Care of a Client with a Fracture
NEUROVACULAR ASSESSMENT
- Colour, movement, sensation (pain, numbness, tingling), temperature, blanching (capillary refill), edema, pulse
- Always compare the unaffected limb to the affected limb
- Report any deviation from expected IMMEDIATELY
- Risk- compromised circulation, nerve damage
- Vital signs
- Frequent neurovascular assessments
- Pain management
- Proper positioning & alignment- follow surgeon’s orders
- Observation for bleeding/drainage
- High-fluid intake to prevent constipation & renal calculi
- Early mobilization, unless contraindicated (with PT/OT)
Complications of Fractures: Infection
- damage to soft tissue can impede bodys ability to fight infection
- necrotic tissue is an ideal environment for pathogens
Complications of Fractures: Compartment Syndrome
- compression of blood vessels, nerves, and tendons which reduces blood flow and tissue viability
- affects legs mostly
- compromised blood flow leads to ischemia, muscle and nerve destruction, and fibrotic tissue
6 P’s of Compartment Syndrome
1) Pain distal to the injury that is not relieved by opiod analgesics
2) Increasing pressre in the compartment
3) Parasthesisa (numbness and tingling)
4) Pallor, coolness, loss of normal color of the extremeity
5) Paralysis or loss of function
6) Pulselessness - absent peripheral pulses
Compartment Syndrome is Associated with:
- Trauma, fractures (especially long bones), extensive soft tissue damage, crush injuries
- fractures of the distal humerus & proximal tibia
- Can occur after knee or leg surgery or prolonged pressure on a muscle compartment
Nursing Management of Compartment Syndrome
- Early identification- Neurovascular assessments!
- Pain assessment (unrelieved pain & pain on passive stretch)
- Check urine for signs of rhabdomyolysis from muscle breakdown (dark urine)
Management
- Elevate above heart
- Avoid cool compress (vasoconstricts)
- Loosen or remove restrictive bandages & split casts if needed
- Surgery, if needed: Fasciotomy
- Severe cases: Amputation
Complications of Fractures: Venous Thromboembolism
- fractures cause immobility which slow blood flow and cause clots
- clot forms in deep veins of legs
- S&S: cramps, swelling, redness, warmth
Prevention
- leg exercises
- compression stockings
- anticoagulation meds
Risk: clot migrates and causes pulmonary embolism
Complications of Fractures: Fat Embolism
- after a bone break, fat from bone marrow can enter bloodstream
- fat travels to organs
Manifestations
Lungs (most common): Chest pain, tachypnea, cyanosis, dyspnea, tachycardia, and decreased PaO2
Brain: confusion, seizures, change in mental status
Skin: Petechiae (red spots) on the neck, chest, armpits, buccal membrane, & eyes
Diagnosis & Treatment of Fat Embolism
- No specific test
- May find fat cells in blood, sputum, urine
- Treamtent: prevention early ambulation
- Suportive: o2 intubatuon
Hip Fractures
- break in top part of thigh (femur)
Intracapsular: breaks inside hip joint (neck or head of femur)
Extra capsular: breakes outside hip joint
Risk factors
- age
- gender
- falls
- osteoporosis
Signs & Symptoms of a Hip Fracture
- Pain
- Inability to move
- Deformity (affected leg may appear shorter & externally rotated)
- Swelling
- Bruising
Diagnosis & Treatment of a Hip Fracture
Diagnosis
- X-rays: primary way to identify a
fracture
- MRI or CT Scan: Used if the X-ray is inconclusive or to assess soft tissue damage
Treatment
- Pain control
- Immobilization (initially)
- Maintain proper hip alignment!
Surgical Intervention
- Open Reduction and Internal
Fixation (ORIF)
- Hemiarthroplasty (replace head of femur)
- Total Hip Replacement (replace entire hip joint)
Nursing Care of a Client with a Hip Fracture
- Pain management
- Prevent complicatoin of immbolity
- Safe modiliztaoin - consult PT
- Infection prevention - monitor for pain, fever wbc
- Client and fainmly teaching re: activity use of walker/cane
- Health promtion diet, exersize to promtoe bone health
