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
