Week 7 Musculoskeletal System Flashcards
Bones, muscles, joints, tendons, ligaments, and cartilage serve as the body’s framework. Together, these structures form the musculoskeletal system, working together to maintain posture, protect vital organs and enable movement. Understanding the musculoskeletal system helps nurses evaluate patients' overall health through assessment of structure, movement, and mobility. These assessments inform nursing interventions and patient management and are essential in clinical practice.
Musculoskeletal
disorders are considered a major cause of chronic pain and disability and, according to Calleja, Theobald and Harvey (2020), are the second most common reason for a person to seek healthcare in Australia, making these disorders one of the highest economic burdens of disease in our country.
Components of the musculoskeletal (MSK) system includes
bones, muscles, cartilage, tendons, ligaments and joints.
Primarily, the function of the MSK system is to provide shape and support whilst facilitating motion, allowing a person to maintain and change positions in response to internal and external stimuli.
Additional functions include protection of internal organs, production of blood cells, and storage of minerals. For instance, bones facilitate mineral homeostasis, the lever function of joints enable speed and strength while muscles drive movement but also serve to maintain body temperature.
Disorders of the MSK system
can result from an injury or condition that impacts the function of any MSK structure or a person’s ability to move.
MSK disorders may be acute, chronic, or acute on chronic where a patient with an underlying chronic disorder can experience an acute exacerbation.
MSK impairment may also be acquired, congenital or traumatic.
___ of our population >50 years have a musculoskeletal disorder.
66% of our population >50 years have a musculoskeletal disorder
There are over 100 different types of musculoskeletal disorders with the most common being
arthritis, osteoporosis, spinal disorders and trauma such as fractures.
Passive motion
When someone else manually moves a person’s joint, while the person is in a relaxed state; meaning, the person does not use their muscles to manually move.
Active motion
used to assess how much a person can move their own joint, without assistance
Flexion
Bending the joint with muscle contraction so that the articulating bones on either side of the joint move closer together
Extension
Straightening a joint so that the articulating bones on either side of the joint move further apart
Adduction
Moving a part medially and towards the midline of the body
Abduction
Moving a part laterally and away from the midline of the body
Supination
Rotating the forearm laterally at the elbow so the palm of the hand turns laterally to face upwards
Pronation
Rotating the forearm medially at the elbow so the palm of the hand turns medially to face downwards
Oppostition
Moving the thumb to touch the 5th finger of the same hand
Eversion
Tilting the foot (outwards) so that the sole of the foot faces outwards away from the midline of the body
Inversion
Tilting the foot (inwards) so that the sole of the foot faces inwards towards the midline of the body
Dorsiflexion
Flexing the ankle so that the toes are lifted towards the body
Plantar flexion
Flexing the ankle so that the toes move away from the body
Antalgic Gait
Limping. Shortened stride with as little weight-bearing as possible on affected side
Ataxic Gait
Uncoordinated, straggering gait often with a sway
Soft Tissue Injuries
Soft tissue injuries (STI) are injuries to muscles, tendons, and ligaments but not bone. They can include sprains, strains, dislocations, and subluxations and are most commonly caused by trauma. The two most common STI are sprains and strains.
Sprain
Overstretching or tearing of a ligament surrounding a joint.
→ A ligament is the fibrous band that holds bones together, providing stability to the body’s joints.
Mechanism of Injury (MOI)
→ An acute injury usually caused by sudden trauma such as a fall, wrenching or twisting motion
→ inversion or eversion injury
Can become a chronic disorder with repeated overuse; when the area has not had a chance to heal between occurences, as what can occur with sports injuries.
Areas most vulnerable to sprains are knees, ankles, and wrists.
Classified by severity
Grade 1 = mild, slight stretching with some damage to the fibres of the ligament
Grade 2 = moderate, partial tearing of the ligament with abnormal laxity in the joint
Grade 3 = severe, complete tear of the ligament which results in significant joint instability.
Strain
A general term used to describe local muscle or tendon damage
→ Tendons are the fibrous bands that hold muscles to bones.
→ Occurs when a muscle, it’s facial sheath and/or it’s tendon is stretched beyond its usual capacity resulting in the muscle rupturing or the tendon tearing.
An acute disorder but can become chronic when the muscle is repeatedly stretched beyond capacity
Mechanism of injury
→ Traumatic injury resulting in sudden, forced motion causing the muscle to excessively stretch or stress.
Most common in large muscles groups, including lower back, calf, and hamstrings.
Dislocation
Usually caused by trauma
Temporary displacement of one or more bones in a joint
Opposing bone surfaces lose contact entirely
Subluxation
Partial loss of bone surface contact
Usually caused by trauma
Dislocation & Subluxation
Usually caused by trauma
More common in younger people as bones are stronger and have higher resistance to fractures but the force of the MOI disrupts the joint
Can also occur due to congenital or acquired disorders such as muscular imbalances, arthritis, or joint instability
Most common joints that are susceptible to dislocation / subluxation are shoulder, elbow, wrist, phalanges, patella
Common Clinical Manifestations Associated with Soft Tissue Injuries
Pain
→ Soft tissue injuries are quite painful. This pain is caused by the presence of inflammatory mediators, ligament / tendon cramping from changes in contour and muscle contractions.
→ Can be acute or chronic, mild, moderate or severe and worse with range of motion (ROM), weight-bearing activities, or when the injury is dependent.
→ Pain associated with soft tissue injuries is usually localised to the injury site.
→ Pain can be described as sharp, spasmodic, cramping, a deep ache, throbbing or tenderness.
→ Usually increases significantly when the injury is directly palpated
Contusions
→ Also referred to as ecchymosis, a bruise, or a haematoma
→ Occurs when the injury crushes underlying muscle fibres and connective tissue, causing localised blood vessels to rupture. The blood pools in the extravascular space (usually subcutaneous), lysing quickly, resulting in discolouration of the skin. Discolouration can range from black, blue, purple, green and yellow.
→ Discolouration will usually be evident within 24-48 hours and can take approximately 2 weeks to dissipate.
Localised swelling and inflammation
→ When MSK soft tissue is ruptured or torn, inflammatory mediators are released and fluid will accumulate locally, between the torn edges. This fluid is derived from the blood and contains inflammatory chemicals.
→ When healing begins, macrophages remove the damaged tissue, fibroblasts make new collagen and capillary buds grow new blood vessels. These processes grow inwards from the surrounding tissue.
→ Swelling is usually worse 2-4 days post injury and resolves within 1-2 weeks. Severe or chronic injuries may exhibit swelling for months when the acute inflammation transitions to chronic inflammation.
Impaired range of motion (ROM)
→ Reduction in the normal range of motion of a joint, i.e. how far the joint can bend, rotate, or twist and the direction in which the joint performs these actions.
→ Can be caused by pain, swelling of the tissue surrounding the joint or muscle stiffness.
Impaired weight bearing with loss of strength and function
Fractures
A fracture is a traumatic injury interrupting bone continuity and usually occurs when the stress placed on a bone exceeds the bone’s ability to absorb it. Most fractures are caused by trauma, some will result from disease processes. The latter are referred to as pathological fractures.
You will see fractures abbreviated to a hash (#) on medical records.
Fractures can be described and classified in relation to:
Type
Open or closed → in relation to the external environment
Location of the bone involved → proximal, distal, mid-, inter-
Degree of stability → stable, unstable, displaced, non-displaced
Fracture TYPES
Closed simple, uncomplicated fractures
Open compound, complicated fractures
Incomplete fractures
Complete fractures
Comminuted fractures
Greenstick fractures
Spiral (torsion) fractures
Transverse fractures
Oblique fractures
Closed simple, uncomplicated fractures
→do not cause a break in the skin.
Open compound, complicated fractures
→ involve trauma to surrounding tissue and break in the skin
Incomplete fractures
→ are partial cross-sectional breaks with incomplete bone disruption.
Complete fractures
→ are complete cross-sectional breaks severing the periosteum.
Comminuted fractures
→ produce several breaks of the bone, producing splinters and fragments.
Greenstick fractures
→ break one side of a bone and bend the other.
Spiral (torsion) fractures
→ involve a fracture twisting around the shaft of the bone.
Transverse fractures
→ occur straight across the bone.
Oblique fractures
→ occur at an angle across the bone (less than a transverse)
Fracture Risk Factors
From crushing force or direct blow
Sudden twisting motion → risk increases with osteoporosis
Extreme muscle contractions
Pathological fractures → a weakness in bone tissue → which may be caused by disease processes such as neoplasm or a malignant growth, liver disease
Advancing age
History of age-related fractures in a first-degree relative
Excessive alcohol consumption
Weight extremes
Medications → steroid therapy, chemotherapy, proton pump inhibitors
Smoking
Being a female → increased risk of osteoporosis, different bone structures, decreased bone density with advancing age
Stages of normal fracture healing include:
Inflammation
Cellular proliferation
Callus formation
Callus ossification
Mature one remodelling
Clinical Manifestations
The clinical manifestations associated with a fracture will occur immediately at the time of the injury.
Pain → increased pressure on nerves with involuntary reflex action of surrounding muscles → will be localised to site of fracture → when assessing a fracture, the site of maximum pain coincides with the location of the fracture
Oedema → penetration of bone through soft tissue bleeding into tissues
Tenderness
Guarding → an individual will guard, or self-splint their injured body part to protect from further injury, movement, and pain
Abnormal movement and crepitus → grating or crunching of bony fragments
Loss of function
Inability to weight bear or use the affected part → either grasping an object or tolerating body weight with steps
Ecchymoses → extravasation of blood into subcutaneous tissue
Deformity → common with displaced / unstable fractures → not obvious with stable, non-displaced fractures
Paraesthesias and other sensory abnormalities
Muscle spasms → irritation of surrounding tissues and protective response → can further displace fractures
Diagnosis
Radiographs and other imaging studies can be used to identify the site and type of fracture, plus any complications inluding soft tissue concomitant injuries.
Tools have been developed to guide radiography decisions. For example:
Ottawa Ankle Rules
Ottawa Knee Rules
Imaging Options:
X-ray → standard diagnosing tool for bone structure and continuity assessment
CT scan → computed tomography → if a fracture is suspected but not obvious on an x-ray then a CT scan may be ordered to rule out or confirm a fracture
MRI → magnetic resonance imaging → shows hydrogen density of tissues to construct images of soft tissue and bone
Ottawa Ankle Rules
Whilst diagnosing a fractured ankle is outside of your scope of practice, you can apply the Ottawa Ankle Rules to guide ankle injury radiography and subsequent nursing care considerations. This is especially relevant for rural and remote nursing care where a senior nurse with accreditation can initiate simple x-rays. If working in an acute setting, Ottawa ankle rules can be used to initiate earlier intervention after discussion with the treating doctor.
Ottawa Knee Rules
As per the Ottawa Ankle Rules, the Ottawa Knee Rules can be applied to determine if your patient requires medical imaging. Remember, you cannot order imaging, but you can utilise the Ottawa Knee Rules to initiate care through discussion with the treating team.
Medical Management
Fracture
The principles of fracture treatment include anatomical realignment of bone fragments through reduction, immobilisation to maintain realignment and regaining of normal function and strength through rehabilitation.
Reduction
Immobilisation
Function
→ Maintained and restored by controlling swelling with elevation of the injured extremity and applying ice as prescribed.
Symptom management
→ Restlessness, anxiety, and discomfort are controlled using a variety of approaches → reassurance, position changes, analgesics, and anti-inflammatories
Rehabilitation
→ Isometric and muscle-setting exercises are done to minimise disuse atrophy and to promote circulation.
→ With internal fixation, the surgeon determines the amount of movement and weight-bearing stress the extremity can withstand and prescribed the level of activity.
Reduction
A displaced fracture can be reduced using a non-surgical, closed method of manipulation and manual traction with counter-traction. This method is distressing and very painful so the patient will require a form of anaesthesia → procedural sedation, Bier block, local anaesthetic, general anaesthesia.
Some fractures will require an open method of reduction which involves surgical placement of internal fixation devices like pins, wires, screws, plates and nails. This is abbreviated to an ORIF (open reduction and internal fixation).
Both methods of reduction are designed to restore the fracture fragments to anatomic alignment and rotation. The specific method depends on the nature of the fracture.
Traction is the application of a pulling force to an injured extremity to realign a fractured bone or dislocation. Some fractures are managed with skin traction, others require skeletal traction with the surgical insertion of internal nailing with an external splinting frame.
Immobilisation
After the fracture has been reduced, immobilisation holds the bone in correct position and alignment until union occurs. Immobilisation is accomplished by external or internal fixation → casting, pins, plates
Casting → a temporary immobilisation device → can be a back slab or circumferential casting → casting often needs to incorporate joints above and below the fracture with the extremity aligned in a neutral position → materials include Plaster of Paris (POP), synthetic material or fibreglass → each have their own pros and cons which are important to note when educating your patient
Nursing Management of Acute Musculoskeletal Injuries
Nursing care of acute MSK injuries varies depending on location, severity, type, concomitent injuries and patient lifestyle/demographics. The aim is to reduce symptoms such as pain, muscle spasms, muscle atrophy, contracture, footdrop, and loss of function. Assessments of the musculoskeletal system commence with a comprehensive patient history to obtain subjective data and is followed by a focused physical assessment to collect objective data.
Nursing Management of Acute Musculoskeletal Injuries
Considerations
Linked body systems
How other body systems influence the musculoskeletal system
Assessment tools can be used to assist with assessing the MSK system, e.g., falls risk assessment, pressure injury risk, pain assessment
There is a systemic approach to a musculoskeletal assessment which involves:
Inspection → look → asymmetry of joints, swelling, deformity, erythema, lesions, rashes, open wounds, ecchymosis, cyanosis
Palpation → feel → soft tissue swelling, bony nodules, tenderness, crepitus, joint warmth, pain, fracture → temper your palpation according to the degree of pain being experienced → severe pain = only light palpation required
Movement → active then passive movement of the limb / joint → always perform painful movements last → consider gait, ability to weight-bear, movement of arms, transferring
Strength → asymmetrical, loss, normal
Measurements → swelling, oedema
Neurovascular compromise can occur with a MSK injury, including swelling, and oedema, and with interventions such as bandaging, casting, anaesthesia, poor positioning, or dressings → all can result in nerve or vascular impairment distal to the injury → can then lead to permanent damage, loss of function, infection, avascular necrosis or amputation
Neurovascular status can be determined by assessing the 6 Ps during your neurovascular assessment
Pain → should be localised to site of injury → increased, diffuse pain is an indication of compartment syndrome
Pallor → is the skin colour paler than usual, is there cyanosis → pale skin distal to the injury may indicate compartment syndrome. Cyanosis distal to an injury may indicate poor venous return
Pulse (pulselessness) → compare affected and unaffected side for rate and quality → an absent pulse may indicate vascular dysfunction and insufficiency
Paraesthesia → often described as ‘pins & needles’ and may include numbness or tingling → documented as altered sensation → usually first sign of neurovascular compromise from nerve damage or inadequate circulation typically associated with compartment syndrome
Polar (poikilothermia) → is the skin cooler to touch when compared to the unaffected side or baseline → indication of impaired circulation → often associated with compartment syndrome
Paralysis → can the affected area be moved or is it without movement / weaker than usual → partial or complete loss of sensation or function is a late stage of neurovascular damage
Acute Interventions
When an acute injury occurs, nurses can implement immediate interventions with the aim of reducing pain and swelling, minimising movement, ensuring the safety of the individual and limiting further injury.
Some options include:
R.I.C.E → rest, ice, compression, elevation
Immobilisation
Compression
Ice (cryotherapy)
Heat
Elevation
Pharmacological options
Acute Interventions
R.I.C.E
→ rest, ice, compression, elevation
→ a traditional intervention designed to reduce swelling, reduce pain, prevent further injury
Acute Interventions
Immobilisation
→ splinting with bandaging, slings, casting material, prefabricated splint boards, braces
→ remember to include the immediate proximal and distal joints
Acute Interventions
Compression
→ elastic bandages can be applied over and around the injury
→ reduces inflammation and oedema by encouraging fluid return which in turn decreases pain → start distally to the injury and progress proximally ensuring that the bandage is firm but not tight which could compromise circulation and increase pain and/or numbness
Acute Interventions
Ice (cryotherapy)
→ acute injuries should have ice applied immediately for intermittent periods of 20-30 minutes
→ never heat
→ produces localised hypothermia
→ physiological changes in the soft tissue including vasoconstriction (reduces inflammation, oedema, and bruising), reduction of nerve pain transmission and impulses (reduces pain) and reduction of muscle spasms
Acute Interventions
Heat
→ 48 hours after the injury
→ the acute phase has passed
→ you can apply heat for intermittent periods of 20-30 minutes
Acute Interventions
Elevation
→ elevate an injured part above the level of the heart
→ reduces oedema by mobilising excess fluid away from the injury
→ examples include a broad arm sling, using pillows to elevate an injured ankle
Acute Interventions
Pharmacological options
→ combined paracetamol and ibuprofen (NSAID) is often more efficacious than opioids in reducing pain and inflammation associated with MSK injuries
→ both can be nurse initiated (check organisation policy first)
Fracture Specific Nursing Care Considerations
An important component of nursing care for a person experiencing a fracture is comprehensive assessment and management. Bone malalignment, and compartment syndrome can place pressure on nerves and blood vessels causing temporary or permanent damage to the distal part of the limb.
Initial primary assessment → DRSABCDE → treat life-threatening injuries first → control external bleeding with pressure bandaging and elevation
Prevent infection
→ Cover any breaks in the skin with clean or sterile dressing.
Provide care during client transfer.
→ Immobilise a fractured extremity with splint in the position of the deformity before moving the client; avoid strengthening the injured body part if a joint is involved. Immobilising a fracture is an important intervention that decreases the risk of further damage to the bones and surrounding soft tissues along with reducing risk of complication.
→ Support the affected body part above and below fracture site when moving the client.
Provide client and family teaching.
→ Explain prescribed activity restrictions and necessary lifestyle modification because of impaired mobility.
→ Educate correct use of assistive devices, such as crutches
Administer prescribed medications, which may include opioid or nonopioid analgesics and prophylactic antibiotics for an open fracture.
Prevent and manage potential complications.
→ Observe for symptoms of life-threatening fat embolus, which may include personality change, restlessness, dyspnoea, crackles, white sputum, and petechiae over the chest and buccal membranes. Assist with respiratory support, which must be instituted early.
→ Observe for symptoms of compartment syndrome, which include deep, unrelenting pain; hard oedematous muscle; and decreased tissue perfusion with impaired neurovascular assessment findings.
→ Monitor closely for signs and symptoms of other complications.
Patient education regarding different factors that affect fracture healing
→ Cast Care
→ Factors that enhance fracture healing
→ Factors that inhibit fracture healing
Patient education regarding different factors that affect fracture healing
Cast Care
→ It takes 48 hours for Plaster of Paris to set → do not weight-bear during this time
→ Do not get wet → skin will break down under cast
→ Do not put foreign bodies under cast to stratch skin → skin can open
→ Do not remove inner padding
→ Adhere to medical advice
→ Observe for altered sensation, changes to skin colour, increased pain within first 48 hours → seek medical review if occurs
→ Any concerns → seek medical advice
Factors that enhance fracture healing
→ Immobilization of fracture fragments
→ Maximum bone fragment contact
→ Sufficient blood supply
→ Proper nutrition
→ Exercise: weight bearing for long bones
→ Hormones: growth hormone, thyroid, calcitonin, vitamin D, anabolic steroids
Factors that inhibit fracture healing
→ Extensive local trauma
→ Bone loss
→ Inadequate immobilization
→ Space or tissue between bone fragments
→ Infection
→ Local malignancy
→ Metabolic bone disease (Paget’s disease)
→ Irradiated bone (radiation necrosis)
→ Avascular necrosis
→ Intra-articular fracture (synovial fluid contains fibrolysins, which lyse the initial clot and retard clot formation)
→ Age (elderly persons heal more slowly)
→ Corticosteroids (inhibit the repair rate)
Complications
Soft tissue injuries are often associated with concurrent injuries, such as a fractures, due to the stress applied to the bone, bruising, and nerve impairment.
Avulsion injury
Suspected dislocations / subluxations
Nerve damage
Chronic loss of function and weakness secondary to decreased strength and reduced range of motion
Arthritis
Avulsion injury
A fracture that occurs as a complication of a soft tissue injury → when a bony fragment attached to a ligament or tendon gets pulled away from main part of the bone → often treated as a severe sprain
Suspected dislocations / subluxations Complications
→ should have radiological investigations prior to reduction of the joint
→ reducing a dislocation without an x-ray ruling out a fracture could result in further fracture complications
Delayed complications may occur after initial treatment or in response to treatment.
Non-union
Compartment syndrome
Fat Emboli
Arterial damage during treatment
Infection and possibly sepsis
Hemorrhage, possibly leading to shock
Non-union
Some open fractures may have difficulty healing because of damage to the blood supply around the bone at the time of injury. If the bone does not heal, further surgery, including bone grafting to the fracture site and repeat internal fixation, may be necessary.
Compartment syndrome
Acute compartment syndrome occurs when there is increased pressure with nerve and vessel compression within a closed osteofascial compartment, resulting in impaired local circulation → time critical
→ immediate treatment required to prevent ischemia, necrosis and loss of limb
→ escalate to nurse in charge / medical team
→ do not raise limb above heart level, avoid ice, administer analgesics, reassure patient
6 cardinal signs of compartment syndrome
Pain that is not relieved by narcotic analgesics
Pulselessness or diminshed peripheral pulses
Pallor and cool to touch
Paraesthesia
Paralysis, weakness, loss of function
Pressure → skin tightness, firm / tight to touch, shiny skin
Fat Emboli
This is a life-threatening syndrome caused by fat golubles being released into the circulation most commonly following orthopedic trauma causing systemic embolisation. The most common systemic manifestations are: respiratory distress, altered LOC and peticchial rash
→ most commonly develops within 24 to 72 hours after fracture.
What Are Chronic Musculoskeletal Disorders?
These disorders can include back pain, inflammatory joint disorders like rheumatoid arthritis, osteoporosis, gout and osteoarthritis.
Some chronic MSK disorders can have acute exacerbations secondary to infection such as septic arthritis, osteomyelitis or even gout.
As MSK disorders are typically characterised by loss of function, chronic pain, mobility impairment and loss of dexterity, chronic MSK disorders are a major contributor to disability, loss of income, poor mental health and wellbeing and illness.
Non-inflammatory: Osteoarthritis
Osteoarthritis (OA) is the most common form of arthritis in Australia. OA is a slowly progressive non-inflammatory disorder which essentially wears out a joint. It affects the synovial joints, or weight-bearing joints, and involves the formation of new joint tissue in response to cartilage destruction. OA is characterised by localised loss and damage of articular cartilage, new bone formation of joint margins, subchondral bone changes, synovitis and thickening of the joint capsule.
→ Mostly occurs >40 years, but can occur earlier from repeated joint stress
Cartilage destruction can begin in later adolescent years
→ Leading cause of pain and disability in older adults → onset due to bone on bone contact from a deteriorated joint and complete loss of articular cartilage
→ Not considered normal process of ageing
→ Affects women more than men
→ Most often caused by a known event or condition that directly damages cartilage or tissue resulting in joint instability
→ Inflammation is not a characteristic of OA, but secondary inflammation can occur when phagocytic cells attempt to repair the joint damage → early disease pain and stiffness
Joints Most Commonly Affected by Osteoarthritis
Peripheral joints → hands, wrists, fingers (distal interphalangeal [DIP] & proximal interphalangeal [PIP] joints), knees, feet, toes
Central joints → shoulders, hips, lower cervical spine, lumbosacral spine
Osteoarthritis
Risk factors
Reduction oestrogen → menopause
Obesity → hip and knee OA
Mechanical stress → sporting injuries → quick stops and pivoting → netball, football, and soccer.
Occupations which require frequent kneeling and stooping → carpeting, plumbing, mechanics
Trauma → fractures
Inflammation
Medications → corticosteroids, colchicine, indomethacin
Osteoarthritis
Causes
→ interaction of all factors that result in destruction of cartilage → body can’t keep up with repairing the destruction → fissures and erosion on a normally smooth surface, osteophytes, joint surface incongruity → uneven distribution of stress → reduction of mobility and increasing pain
Genetic links
Metabolic factors
Local factors
Osteoarthritis Clinical Manifestations
Onset of clinical manifestations is gradual with most people affected not experiencing symptoms until >50 years of age → symptoms will be specific to the joint involved
Symptoms more commonly unilateral
Systemic clinical manifestations do not occur
Pain → aching, sometimes difficult to localise, aggravated by weight-bearing → relieved by resting the joint
Referred pain to buttocks, sciatic, groin, medial thigh, or knee
Joint stiffness → early morning stiffness is very common usually resolved within 30 minutes
Decreased ROM → difficulty sitting and moving from sitting to standing
Bone spurs (osteophytes)
Heberden’s nodes
Muscle atrophy
Overactivity will lead to joint effusion
Joint deformity → bowlegs, one leg shorter than the other
Joint crepitus
Night pain not relieved by rest is very common later in disease progression → occasionally associated with altered sensation → leads to sleep deprivation
Antalgic gait
Osteoarthritis Diagnosis
x-rays → used for confirming disease and for staging
CT scan
MRI
Bone scan
Osteoarthritis Treatment
Conservative → rest, ROM exercises, mobility aides, simple analgesics (paracetamol) and anti-inflammatories (NSAIDs), weight loss
Surgery → used to improve joint ROM, correct deformities and reduce pain → joint replacement, arthroscopies
Osteoarthritis Interprofessional Care
OA has no cure. Therefore, nursing referrals for interprofessional support can be very effective in ensuring person-centered care. The focus is on symptom management, preventing disability, and maintaining and improving joint function.
Inflammatory arthritis (IA) is
a group of disorders that result in varying degrees of joint pain, swelling, warmth and tenderness with morning stiffness lasting >1 hour and mobility dysfunction. Most IA are systemic with inflammatory clinical manifestations occurring in multiple areas of the body including the skin, lungs, kidneys, heart, and eyes. What makes IA different to non-inflammatory forms of arthritis are the associated inflammatory symptoms → pain, erythema, warmth, swelling and loss of function. All forms of IA can result in infectious processes. If left untreated, IA will result in joint damage and deformities.
Rheumatoid arthritis (RA)
A chronic disease of the MSK system with an autoimmune aetiology characterised by inflammation of connective tissue in the synovial joints. The inflammation eventually spreads to articular cartilage and surrounding soft tissues including ligaments and tendons. Localised vasculature can also be affected when swelling results in the compression of veins. This, in turn, results in poor circulation, metabolic acidosis, localised tissue hypoxia and potential tissue necrosis.
Rheumatoid arthritis RA is characterised by periods of remission and exacerbation and is often associated with extra-articular symptoms.
Considered a systemic autoimmune disease → immune system mistakenly attacks joints → chronic pain and inflammation → also affects surrounding joint soft tissue
Exact cause is unknown → thought to be a combination of environmental and genetic factors.
More common in women → 70% prevalence with 55% >55 years
Onset usually between 35 - 50 years but can occur at any age, including young children
Can affect any joint → more common in hands and feet
Commonly affects internal organs including the heart, lungs, kidneys, skin and nervous system → pericarditis, valvular deformities, splenomegaly, acute glaucoma, diffuse pleuritis, pulmonary fibrosis, thrombosis, myocardial infarcts from tissue necrosis
Seasonal variations → clinical manifestations worse in colder climates and during winter
If left untreated → joint erosion and permanent damage
Chronic inflammation can result in granulated tissues, haemorrhages, and coagulation changes.
Joints Involved in Rheumatoid arthritis
Multiple joints will be affected by rheumatoid arthritis → bilateral, or symmetrical presentation → due to being an autoimmune disease
Peripheral joints → hands, wrists, elbows, feet, ankles → the first joints involved will be metacarpophalangeal [MCP] joint, PIP joint of the 3rd phalanges and wrists
Central joints → shoulders, hips, spine
Rheumatoid arthritis
Risk Factors
Modifiable factors → smoking, obesity, air pollution exposure
First Nations peoples → prevalence doubles
Female → prevalence triples → hormonal involvement → symptoms decrease during pregnancy but increase during postpartum period
Advancing age → rates increase after the age of 30 years
Genetics → increases risk by 50%
Vitamin D deficiency
Rheumatoid arthritis Clinical Manifestations
Insidious onset
Begins with general systemic symptoms → fever, malaise, rash, fatigue, lymphadenopathy, enlarged spleen, Raynaud’s phenomenon, anorexia, weight loss
Localised symptoms gradually occur over a period of months
→ Chronic joint pain, tenderness, and stiffness → occurs initially from pressure within the joints
→ Joint stiffness on waking → lasting for >1 hour → caused by synovitis
→ Heat and swelling to joints → symmetrical → caused by increased inflammatory exudate
→ Skin over joints appear cyanosed and ruddy with thin and shiny skin
→ Loss of joint function with decreased ROM and loss of strength
→ Joint deformity → ulnar deviation, boutonniere, swan-neck deformities of the fingers, hallux valgus, flexion contractures of knees and hips
→ Muscular atrophy
Joint instability
→ Rheumatoid nodules → on skin, in the heart, spleen and lungs
Rheumatoid arthritis Diagnosis
The key to managing rheumatoid arthritis is early diagnosis and early interventions. If an individual has had symptoms for >6 weeks, the following diagnostic criteria will be used with an individual requiring at least 4 of the following, to be diagnosed:
Early morning stiffness >1 hour
Arthritis >3 joints
Arthritis of the hand
Symmetrical symptoms
Rheumatoid nodules
Serum rheumatoid factor
X-ray changes
Rheumatoid arthritis Investigations include:
Serology testing → CRP, rheumatoid factor, circulating immune complexes, routine FBC and UEC
X-ray
Rheumatoid arthritis Treatment
As with osteoarthritis, treatment approach can be conservative or surgical.
Education on symptoms and disease management
Resting for several hours per day with flare ups
Hot / cold pack application
Gout
A syndrome of impaired uric acid metabolism and hyperuricaemia. Excess urate forms needle-like crystals that are deposited in connective, articular and subcutaneous tissue and synovial fluid, resulting in sudden and severe joint pain, inflammation and erythema of the joints.
Uric acid is the end product of purine metabolism → renally excreted
All primary processes can lead to elevated plasma urate levels → hyperuricaemia → insoluble crystals form → deposited in joints → exact process of deposition is unknown → initial deposits most commonly affects joints of the great toe (metatarsophalangeal joint) → 50% → inflammation of the great toe is called podagra
Decreasing temperature → decreased solubility of urate → peripheral regions of the body have lower temperatures
Uric acid crystal deposits progressively worsen over years and are deposited systemically
Crystals buildup in subcutaneous tissue → tophi, or white nodules develop → most common site is the helix
Crystals can also be deposited in the kidneys → urate kidney stones → renal failure
Can be treated with some Rheumatologists claiming gout can be cured
Considered a complex form of recurring arthritis → most common type of inflammatory arthritis → slowly progressive disability
Gout
Gout is precipitated by primary processes which can occur singularly or in combination:
Increased uric acid production
Underexcretion of uric acid → impaired renal function = impaired excretion → primary gout → most common cause → 90% of cases
Exposure to a trigger → trauma, systemic illness, medications, high alcohol consumption, diet high in purine (shellfish, lentils, asparagus, spinach, beef, chicken) → metabolised to uric acid
Gout Risk Factors
More common in affluent countries with the rate of occurrence in Australia as 10% of all types of arthritis
→ New Zealand has the highest rate of gout in the world
Modifiable factors
→ Obesity
→ HTN
→ High alcohol consumption → increased keto acids
→ Hyperlipidaemia
→ Prolonged fasting → increased keto acids
Male > 50 years of age → peak onset 40-60 years
Medications
→ Diuretics
→ Chemotherapy agents
→ Aspirin
Cancers
Gout Joints Involved
Initial attack → usually one joint affected → metatarsophalangeal joint (MTP)
Peripheral joints → hands, wrists, elbows (olecranon), feet, ankles, heal, mid-tarsal
Central joints → spine
Gout Clinical Manifestations
Onset typically at night
→ Mild attack → symptoms last 1-2 days
→ Severe attack → symptoms can last weeks
Severe, excruciating pain
Swelling to joints
Hot, erythematous joints
Lymphangitis
Systemic signs of inflammation → fever, malaise, leucocytosis, nausea
Progressive joint stiffness
Persistent aching
Gout Complications
Septic arthritis
Carpal tunnel syndrome
Kidney stones → renal failure
Gout Diagnosis
80% of cases → diagnosis can be made on clinical history and assessment
Blood test → serum uric acid levels → not used in isolation due to the number of other disorders that can result in hyperuricaemia
24 hour urine collection → test urine uric acid levels
Joint aspiration → performed under sterile precautions → synovial fluid aspirate tested for crystal deposits → used to rule out septic arthritis → also acts to decompress pressure in a swollen affected join
Gout Treatment
Medications → primary therapy
→ Inflammation and pain experienced during acute attack are treated as soon as possible → NSAIDs (indomethacin), colchicine, allopurinol
→ Once resolved, aim is to prevent further attacks and decrease risk of complications → corticosteroid injection, probenecid
Infection needs to be ruled out
Reversing modifiable causes
Ice
Rest
Low-purine diet
Weight reduction
High water intake to increase urinary output
Gout is characterised by the following 4 stages:
Asymptomatic gout
Acute gouty arthritis
Intercritical gout
Chronic tophaceous gout
Asymptomatic gout
= also known as asymptomatic hyperuricaemia
→ serum urate levels abnormally high with an absence of arthritic symptoms
→ a person can have hyperuricaemia all their life and never progress to symptomatic gout
→ diagnosed with a blood test
→ no treatment recommended
Acute gouty arthritis
= characterised by acute ‘attacks’ with hyperuricaemia
→ can be triggered by trauma, surgery, medications, systemic infection or high alcohol and purine food intake
→ attacks usually occur at night and are sudden and excruciating
→ can affect one or more joints
→ peaks within 12-24 hours after initial onset of symptoms
→ can begin to resolve without treatment
→ full resolution can take 7-14 days with return to being asymptomatic
→ 75% of people will experience a 2nd or 3rd attack with 12 months
Intercritical gout
= asymptomatic period between attacks
→ remission
→ buildup of urate crystals still occurring while a person feels well
→ potential for joint damage remains
Chronic tophaceous gout
= chronic gout
→ multiple joint involvement associated with visible crystal deposits in the subcutaneous tissue
→ tophi
→ common locations include olecranon, helix, vertebrae, and tendons
→ occurs many years after initial onset of acute attack
Gout Nursing Management
Education → symptom awareness, rest, when to apply ice, elevation, importance of following medical advice, taking medication as directed and prompt review with onset of symptoms
→ Comprehensive program
→ Balance of rest and activity
→ Joint protection
→ Heat and cold applications
→ Exercise
→ Patient and caregiver teaching
→ Ambulatory and home care
→ Modify tasks for less stress on joints
→ Energy conservation
Support
Bed rest with foot cradle if lower limb affected
Joint immobilisation → decrease possible ROM → avoid using / palpating affected joint
Cryotherapy
Nursing referrals → dietician, pharmacist, exercise physiologist, occupational therapist
Osteomyelitis
A severe infection of the bone, bone marrow and surrounding tissue
Occurs when a pathogen, such as a bacterium or a fungi infect the bone
→ Haematogenous spread → indirect entry → from the bloodstream usually affects long bones in paediatrics and vertebrae in adults → common infections include ear infections, skin sores, urinary tract infections, respiratory infections
→ Contagious spread → from nearby tissue → common in trauma, surgery, diabetic foot ulcers, or foreign body
→ Direct Inoculation → direct entry through, for example, a compound fracture or surgical procedure, penetrating wound, ulcers
Infection → inflammation → formation of pus → increased pressure in bone → compromised circulation → ischaemia → bone destruction → necrosis of the bone tissue
May lead to chronic infection if not treated properly
Septic Arthritis
Infection of a joint
Usually caused by a bacterium → can also be caused by fungi or viruses
Considered a medical emergency → requires prompt diagnosis and treatment to prevent joint destruction and serious complications
Occurs when a pathogen enters the joint space → inflammation, destruction of cartilage and bone → suseptible to the same types of spread as per osteomyelitis
Osteomyelitis & Septic arthritis
Risk Factors
Co-morbidities → diabetes, peripheral vascular disease, rheumatoid arthritis
Immunosuppression → immunosuppressive therapy
Recent trauma
Surgery → joint replacement surgery, prosthetic joints
Osteomyelitis & Septic arthritis
Causes
Bacteria → Staphylococcus aureus, Escherichia coli, Pseudomonas, Salmonella
Fungal → less common but can occur in immunocompromised patients
Trauma or surgery → open fractures or surgical procedures can introduce pathogens
Clinical Manifestations
Acute Osteomyelitis → initial infection or an infection of <1 month
Rapid onset of local and systemic symptoms
Severe and constant bone pain → unrelieved by rest → worsens with activity
Swelling, tenderness, erythema, hot to touch over site of infection
Restricted ROM and decreased strength
Systemic symptoms → fever, malaise, lethargy, night sweats, chills, restlessness, nausea
Clinical Manifestations
Chronic Osteomyelitis → bone infection that persists > 1 month or an infection that has not responded to treatment
Continuous or chronic problem → characterised by periods of remissions and exacerbations → symptoms usually not as severe as an acute episode
Chronic, constant bone pain
Drainage / pus from abscess or sinus tracts
Swelling, tenderness, erythema, hot to touch over site of infection
Restricted ROM and decreased strength
Systemic symptoms → fever, malaise, lethargy, night sweats, chills, restlessness, nausea
Granulated tissue → scar tissue → site for ongoing microorganisms growth
Clinical Manifestations
Septic Arthritis
Rapid onset of symptoms
Severe joint pain, swelling, erythema, warmth to joint
Restricted ROM, decreased strength, decrease weight bearing
Systemic symptoms → fever, malaise, lethargy, night sweats, chills, restlessness, nausea
Osteomyelitis & Septic arthritis
Diagnosis
Prompt diagnosis and treatment are required to prevent serious complications and to restore function:
Clinical assessment
Imaging → x-ray, CT scan, MRI → to visualise the infection
Blood test → inflammatory markers, UEC, FBC, blood cultures
MCS of fluid aspirated from either the bone tissue or joint
Osteomyelitis & Septic arthritis
Treatment
Hospitalisation
Antimicrobials → dependent on type of pathogen→ antibiotics if bacteria is the causative agent → usually intravenously administered then transitioned to oral route of administration
Surgery → to wash out an infected joint, drain abscesses, remove infected tissue, remove necrotic bone, stabilise affected area
Supportive care → symptom management and physiotherapy to restore function
Osteomyelitis & Septic arthritis
Complications
Chronic pain
Bone abscess or sinus tract
Bone necrosis → osteonecrosis
Inflammation and/or infection of soft tissue → cellulitis
Leg length discrepancies
Pathological fractures
Amputation
Sepsis
Multisystem failure
Death
Osteomyelitis & Septic arthritis
Nursing Management
Hospital nursing care
Subjective assessment → targeted health history questions
Objective assessment → primary survey, secondary assessment
→ Monitoring vital signs, neurovascular assessment, fluid balance, pain assessment
→ Observing and assessing for deterioration
Limb elevation and immobilisation
DVT prevention
Wound care if necessary
Education
Supportive care
Medication administration → analgesia, NSAIDs, antibiotics
Coordination of care → collaborate with interprofessional team, nursing referrals
Health promotion
Discharge planning
Osteoporosis is
a chronic, progressive metabolic bone disease characterised by decreased bone mass and density, leading to fragile bones that are prone to fractures. It is often referred to as a “silent disease” because it progresses without symptoms until a fracture occurs.
Osteoporosis → porous bone or fragile bone disease
Osteoporosis occurs when the creation of new bone doesn’t keep up with the removal of old bone → imbalance → decreased bone density → impaired structural integrity of the bone → porous, brittle bones that cannot withstand normal mechanical stress
The process in osteoporosis involves:
Bone remodelling → normally, bone is continuously broken down (resorption) and rebuilt (formation).
In osteoporosis, resorption outpaces formation.
Hormonal influence → decreased levels of oestrogen in women and testosterone in men → bone loss.
Other hormones like parathyroid hormone and calcitonin also influence bone remodelling
Primary Osteoporosis
→ often related to aging and decreased sex hormones.
Secondary Osteoporosis
→ results from co-morbidities or medications such as glucocorticoids or anticonvulsants
Osteoporosis Risk Factors
→ Non-Modifiable
Advancing age → > 60 years → 9% of people > 50 years have osteoporosis
More common in women → 75% prevalence → women have lower calcium intake, less bone mass, pregnancy, and breast feeding deplete skeletal reserves of calcium, bone resorption begins earlier with menopause
Family history
Ethnicity → higher in Caucasians and Asians
Small statue, thin build
Early menopause
Late menarche
Nulliparity (no children)
Cushing’s syndrome
Hypoparathyroidism
Rheumatoid arthritis
Renal insufficiency
→ Modifiable
Low calcium and vitamin D intake
Excessive sodium intake
Sedentary lifestyle
Smoking
Excessive alcohol comsumption
Low body weight
Obesity
Malabsorption
Anorexia
Osteoporosis
Clinical Manifestations
Clinical manifestations depend on the bones that are involved. Onset is insidious and awareness usually occurs once the disease is at an advance state, and this usually coincides with the first fracture resulting from low-height. By this stage, bone deterioration is unable to be reversed:
Bone pain → especially in the back
Bone deformity
Fractures → commonly occur in the hip, spine, ribs, long bones, and wrist. Neck of femur (NOF) fractures are also very common and occur most commonly with very elderly woman
Loss of height → due to vertebral compression fractures
Kyphosis → hunched posture from spinal fractures
Osteoporosis
Complications
Pathological fractures → risk of fractures increases 42% once over the age of 50 years → occurs because spongy bone becomes too thin and compact bone becomes too porous
Fat emboli → from fractures
Pulmonary embolism → from fractures
Pneumonia
Haemorrhage
Hypovolaemic shock
Osteoporosis
Diagnosis
Health prevention
→ Bone screening from age 60 years for women and 75 years for men
Bone Mineral Density (BMD) Test → the gold standard for diagnosing osteoporosis → a DEXA scan measures bone density at the hip and spine → measured in grams of mineral per volume
→ Osteoporosis is defined as BMD ≤-2.5
→ Osteopenia → bone loss > normal → T score -1 to - 2.5
Bone biopsy
Pathology testing → calcium, vitamin D, thyroid function test (LFT)
X-rays cannot detect osteoporosis until >40% calcium in the bone is lost
Osteoporosis
Treatment
Medications:
Bisphosphonates → inhibit bone resorption.
Calcitonin → helps regulate calcium levels and bone metabolism.
Parathyroid Hormone Analogues → stimulate bone formation.
Calcium and Vitamin D Supplements → essential for bone health.
*Lifestyle Modifications
Osteoporosis
Nursing Considerations
Patient Education → educate patients about the importance of medication adherence, diet, exercise, medical reviews and falls prevention
Monitoring → regularly assess pain levels, mobility, psychosocial wellbeing, nutrition
Support → provide emotional support and resources for patients coping with chronic illness.
Understanding osteoporosis is crucial as it involves comprehensive care, from prevention and early detection to treatment and patient education. Effective management can significantly improve patient outcomes and quality of life.
Joint replacement surgery, also known as arthroplasty, involves
replacing a damaged joint with a prosthesis. The most common joints replaced are the hip and knee, but other joints like the shoulder, elbow, and ankle can also be replaced. Arthroplasty is the most common orthopaedic surgical procedure performed on older adults.
Aimed at relieving pain, improving joint motion, correcting deformity and malalignment, and removing intraarticular causes of erosion
Nursing Care Considerations: Pre-operative Phase
Joint replacement surgery
Patient Education → educate the patient about the procedure, expected outcomes, and postoperative care and expectations. This includes discussing PACU, ward care, pain management, mobility expectations, and potential complications.
Assessment → conduct a thorough preoperative assessment, including medical history, current medications, and any allergies. Evaluate the patient’s physical and psychological readiness for surgery.
Discharge planning → starts on admission. Consider nursing referrals and your patient’s needs once discharged.
Home Care Instructions → ensure the patient and their caregivers understand how to care for the surgical site, manage pain, and perform prescribed exercises at home.
Follow-Up Care → schedule follow-up appointments with the surgeon and physical therapist. Provide information on when to seek medical attention for any concerning symptoms
Nursing care Considerations: Post-operative Care
Pain Management → administer prescribed pain medications and monitor their effectiveness. Some patients may return to the ward with a PCA running. Use non-pharmacological methods like ice packs and positioning to help manage pain.
Wound Care → monitor the surgical site for signs of haemorrhaging. After 48 hours, monitor for infection, such as redness, swelling, or discharge. Keep the wound clean and dry and follow the surgeon’s instructions for dressing changes. The patient may also return to the ward with a surgical drain insitu. Follow medical advice on expected date for removal and document output on the FBC.
Mobility and Rehabilitation → encourage early mobilization to prevent complications like deep vein thrombosis (DVT), prevent dislocation of the new prosthesis and promote recovery.
Ensure correct positioning of the limb as per post-operative instructions. This can include:
Total hip replacement → position the patient in a semi-fowler position whilst using a Charnley pillow with legs abducted for hip immobility.
Total knee replacement → avoid the use of a pillow under the knee and use a Richard splint for joint immobility.
Assist the patient with physical therapy exercises and ensure they understand the importance of adhering to their rehabilitation plan.
Monitoring for Complications → watch for signs of complications such as DVT, pulmonary embolism (PE), volume deficit, or prosthesis dislocation. Assess vital signs as per postoperative care guidelines and regularly perform neurovascular assessments of the affected limb.
Patient Education → provide instructions on postoperative care, including activity restrictions, wound care, and signs of potential complications. Educate the patient on the importance of follow-up appointments and adherence to their rehabilitation program.
Post-operative Complications
Cardiovascular
Hypotension
Hypertension
Arrhythmias
Venous thromboembolism (VTE)
Syncope
Fluid and Electrolyte
Fluid overload
Fluid deficit
Electrolyte imbalances
Acid-base imbalances
Respiratory
Airway obstruction
Hypoxaemia
Atelectasis
Aspiration
Bronchospasm
Hypoventilation
Orthopaedic Specific
Bleeding at wound site
Joint dislocation (hip)
Fixed flexion deformity (knee)
SSI – surgical site infection
DVT
Nursing Management Pre and Post Hip Replacement
Early surgical intervention is the preferred method of managing hip fractures as this allows early mobilisation and decreases the risk of complications.
Traction may be used in the early management of these fractures to help relieve muscle spasms and immobilisation of the affected extremity assists in reduction of pain.
Nursing care focuses on pre and post operative care, minimising pain, managing discomfort and preventing deterioration through early recognition.
Here are some resources that you can review to help develop your understanding:
Hip fracture Clinical Care Standard from the Australian Commission on Safety and Quality in Health Care
Orthogeriatric Hip Fracture Care by the NSW Agency for Clinical Innovation
Nursing Management Pre and Post Hip Replacement
Pain Management
Assessment → regularly assess pain levels, vital signs, neurovascular status, fluid balance
Medication → administer prescribed analgesics as charted and monitor for adverse effects
Non-Pharmacological Methods → splinting, encourage the use of ice packs, positioning, and relaxation techniques.
Nursing Management Pre and Post Hip Replacement
Mobility and Physical Therapy
Early Mobilisation → encourage patients to start moving as soon as possible post-operatively to prevent complications like deep vein thrombosis (DVT) → refer to physiotherapist for guidance
Mobility Devices → educate patients how to use walkers, crutches, or canes safely → refer to physiotherapist for guidance
Nursing Management Pre and Post Hip Replacement
Post-operative Wound Care
Assessment → monitor the surgical site for signs of infection (will not show within first 48 hours), such as erythema, swelling, or discharge.
Dressing changes → perform dressing changes as per protocol using an ANTT approach
Patient education educate patient on how to care for their wound at home and how to recognise signs and symptoms of a wound infection
Nursing Management Pre and Post Hip Replacement
Prevention of Complications
DVT prevention → administer anticoagulants as prescribed and encourage leg exercises as guides by physio
Respiratory care → encourage deep breathing exercises and the use of incentive spirometry to prevent pneumonia
Pressure injury prevention reposition patients regularly and use pressure-relieving devices
Nursing Management Pre and Post Hip Replacement
Nutrition and Hydration
Balanced diet → encourage a diet rich in protein, vitamins, and minerals to promote healing
Hydration → ensure adequate fluid intake to prevent dehydration and constipation
Nursing Management Pre and Post Hip Replacement
Patient Education and Discharge Planning
Activity restrictions → educate patients on activity restrictions and safe movements to avoid dislocation
Home environment → discuss modifications to the home environment to ensure safety, such as removing tripping hazards and installing grab bars → refer to occupational therpaist
Follow-up → ensure your patient knows when follow-up reviews are scheduled, provide information on when to seek medical advice
Nursing Management Pre and Post Hip Replacement
Emotional Support
Psychosocial assessment → assess the patient’s emotional state and provide support as needed
Encouragement → offer encouragement and reassurance to boost the patient’s confidence in their recovery process
Damage to the external intercostal muscles would interfere with what important process?
Standing upright
Gait
Respirations
Digestion
Respirations
Which of the following would be the most appropriate for long term treatment of rheumatoid arthritis?
Methotrexate
Ibuprofen
Paracetamol
Codeine
Methotrexate
If someone hit you in your rectus abdominis muscle, how would your body position change?
You would lean to the right
You would double over
You would bend backwards
you would twist to the left
You would double over
Which of the following would be the most appropriate treatment for the early stages of both osteoarthritis and gout?
Methotrexate
Ibuprofen
Dexamethasone
Certolizumab
Ibuprofen
Which muscle would be the prime mover for dorsiflexion at the ankle?
Gastrocnemius
Tibialis posterior
Soleus
Tibialis anterior
Tibialis anterior
In fracture repair, which of the following does NOT occur during soft callus formation?
Fibroblasts form collagen strands which links bone ends
Chondrocytes form a cartilage matrix between fracture ends
Angiogenesis continues to supply the wound site with nutrients
Osteoblasts form a spongy bone network in the site of the fracture
Osteoblasts form a spongy bone network in the site of the fracture
Which of the following best describes the role of Vitamin D in the regulation of calcium balance in the body?
It is a precursor for parathyroid hormone which stimulates osteoclast activity
It is a precursor for calcitriol which stimulates intestinal absorption of calcium
It increases calcium deposition in bone by stimulating osteocyte contract
It is a precursor for calcitonin and stimulates osteoblast activity
It is a precursor for calcitriol which stimulates intestinal absorption of calcium
What is the primary goal of nursing care for a patient with a fracture?
Prevent infection
Increase physical activity
Restore function
Reduce dietary calcium
Restore function
What is the recommended position for a patient with a hip fracture to prevent complications?
High-fowler position
Supine with legs extended
Prone position
Semi-fowler with legs abducted
Semi-fowler with legs abducted
Which of the following is a key nursing assessment for a patient with osteoporosis?
Monitoring blood glucose levels
Checking skin turgor and skin integrity
Evaluating neurological status
Assessing for signs of bone pain and fractures
Assessing for signs of bone pain and fractures
