Musculoskeletal System

Assessment & Disorders

Dr Ibraheem Bashayreh, RN, PhD

Skeletal System
Bone types
Bone structure
Bone function
Bone growth and metabolism affected
by calcium and phosphorous,
calcitonin, vitamin D, parathyroid,
growth hormone, glucocorticoids,
estrogens and androgens, thyroxine,
and insulin.

Bones
Human skeleton has 206 bones
Provide structure and support for soft
tissue
Protect vital organs

Figure 41-1 Bones of the human skeleton.

Figure 41-2 Classification of bones by shape.

Bones

Compact bone
Smooth and dense
Forms shaft of long bones and outside
layer of other bones

Spongy bone
Contains spaces
Spongy sections contain bone marrow

Bone Marrow

Red bone marrow

Found in flat bones of sternum, ribs, and
ileum
Produces blood cells and hemoglobin

Yellow bone marrow

Found in shaft of long bones
Contains fat and connective tissue

Joints (Articulations)
Area where two or more bones meet
Holds skeleton together while allowing
body to move

Joints

Synarthrosis
Immovable (e.g., skull)

Amphiarthrosis
Slightly movable (e.g., vertebral joints)

Diarthrosis or synovial
Freely movable (e.g., shoulders, hips)

Synovial Joints
Found at all limb articulations
Surface covered with cartilage
Joint cavity covered with tough fibrous
capsule
Cavity lined with synovial membrane
and filled with synovial fluid

Ligaments
Bands of connective tissue that
connect bone to bone
Either limit or enhance movement
Provide joint stability
Enhance joint strength

Tendons
Fibrous connective tissue bands that
connect bone to muscles
Enable bones to move when muscles
contract

Muscles

Skeletal (voluntary)
Allows voluntary movement

Smooth (involuntary)
Muscle movement controlled by internal
mechanism
e.g., muscles in bladder wall and GI
system

Cardiac (involuntary)
Found in heart

Skeletal Muscle
600 skeletal muscles
Made up of thick bundles of parallel
fibers
Each muscle fiber made up of smaller
structure myofibrils
Myofibrils are strands of repeating
units called sarcomeres

Skeletal Muscle
Skeletal muscle contracts with the
release of acetylcholine
The more fibers that contract, the
stronger the muscle contraction

Changes in Older Adult

Musculoskeletal changes can be due

to:
Aging process
Decreased activity
Lifestyle factors

Changes in Older Adult

Loss of bone mass in older women
Joint and disk cartilage dehydrates
causing loss of flexibility contributes to
degenerative joint disease
(osteoarthritis); joints stiffen, lose
range of motion

Changes in Older Adult

Cause stooped posture, changing
center of gravity
Elderly at greater risk for falls
Endocrine changes cause skeletal
muscle atrophy
Muscle tone decreases

Assessment
Health history
Chief complaint
Onset of problem
Effect on ADLs
Precipitating events, e.g., trauma

Assessment
Examine complaints of pain for
location, duration, radiation character
(sharp dull), aggravating, or alleviating
factors
Inquire about fever, fatigue, weight
changes, rash, or swelling

Physical Examination
Posture
Gait
Ability to walk with or without assistive
devices
Ability to feed, toilet, and dress self
Muscle mass and symmetry

Physical Examination
Inspect and palpate bone, joints for
visible deformities, tenderness or pain,
swelling, warmth, and ROM
Assess and compare corresponding
joints
Palpate joints knees and shoulder for
crepitus

Physical Examination
Never attempt to move a joint past
normal ROM or past point where
patient experiences pain
Bulge sign and ballottement sign used
to assess for fluid in the knee joint
Thomas test performed when hip
flexion contracture suspected

Figure 41-4 Checking for the bulge sign.

Figure 41-5 Checking for ballottement.

Diagnostic Tests
Blood tests
Arthrocentesis
X-rays
Bone density scan
CT scan
MRI
Ultrasound
Bone scan

Diagnostic Evaluation

CT, Bone Scan, MRI

Imaging Procedures

Nuclear Studies - radioisotope bone density,

Endoscopic Studies

arthrocentesis,

arthroscopy

biopsy, synovial fluid,

Other Studies

Arthrogram, venogram,
Electromyography
Myelography*

Laboratory Studies

Musculoskeletal
Assessment Diagnostic Test

Laboratory
Urine Tests
24 hour creatinecreatinine ratio
Urine Uric acid 24
hr specimen
Urine deoxypyridinoline

Laboratory
Blood Tests
Serum muscle
enzymes
Rheumatoid Factor
LE Prep/Antinuclear
Antibodies(ANA)
Erythrocyte
Sedimentation Rate
Calcium,
Phosphorous, Alkaline
phosphatase

Muscoluloskeletal
Assessment Diagnostic

Blood Tests

CBC Hgb, Hct

Acid phosphatase
Metabolic/Endocrine
Enzymes
Increase creatine kinase,
serum increase
glutamin-oxaloacetic
due to muscle damage,
aldolase, SGOT

Musculoskeletal - Radiographic
Standard radiography, tomography
and xeroradiography, myelography,
arthrography and CT
Other diagnostic tests: bone and
muscle biopsy

Arthroscopy
Fiberoptic tube is inserted into a joint
for direct visualization.
Client must be able to flex the knee;
exercises are prescribed for ROM.
Evaluate the neurovascular status of
the affected limb frequently.
Analgesics are prescribed.
Monitor for complications.

Bone Scan
Nuclear medicine procedure in which
amount of radioactive isotope taken
up by bones is evaluated
Abnormal bone scans show hot spots
due to malignancies or infection
Cold spot uptakes show areas of bone
that are ischemic

Arthroscopy
Flexible fiberoptic endoscope used to
view joint structures and tissues
Used to identify:

Torn tendon and ligaments

Injured meniscus
Inflammatory joint changes
Damaged cartilage

Interventions for Clients with

Musculoskeletal Trauma

Musculoskeletal Trauma
Tissue is subjected to more force than
it can absorb
Severity depends on:

Amount of force
Location of impact

Musculoskeletal Trauma
Mild to severe
Soft tissue
Fractures

Affect function of muscle, tendons, and

ligaments

Complete amputation

Preventing Trauma

Teach importance of using safety

equipment

Seat belts
Bicycle helmets
Football pads
Proper footwear
Protective eyewear
Hard hats

Soft Tissue Trauma

Contusion
Bleeding into soft tissue
Significant bleeding can cause a
hematoma
Swelling and discoloration (bruise)

Soft Tissue Trauma - Sprain

Ligament injury (Excessive stretching
of a ligament)
Twisting motion
Overstretching or tear

Grade Imild bleeding and inflammation

Grade IIsevere stretching and some
tearing and inflammation and hematoma
Grade IIIcomplete tearing of ligament
Grade IVbony attachment of ligament
broken away

Sprains

Treatment of sprains:
first-degree: rest, ice for 24 to 48 hr,
compression bandage, and elevation
second-degree: immobilization, partial
weight bearing as tear heals
third-degree: immobilization for 4 to 6
weeks, possible surgery

Soft Tissue Trauma - Strain

Microscopic tear in the muscle
May cause bleeding
Pulled muscle
Inappropriate lifting or sudden
acceleration-deceleration

Soft Tissue Trauma

To decrease swelling and pain, and

encourage rest
Ice for first 48 hours
Splint to support extremities and limit
movement
Compression dressing
Elevation to increase venous return and
decrease swelling
NSAIDs

Soft Tissue Trauma

Diagnosis
X-ray to rule out fracture
MRI

Fractures

Break in the continuity of bone

Direct blow
Crushing force (compression)
Sudden twisting motions (torsion)
Severe muscle contraction
Disease (pathologic fracture)

Fractures
Classification of Fractures
Closed or simple
Open or compound
Complete or incomplete
Stable or unstable
Direction of the fracture line

Oblique
Spiral
Lengthwise plane (greenstick)

Stages of Bone Healing

Hematoma formation within 48 to 72 hr

after injury
Hematoma to granulation tissue
Callus formation
Osteoblastic proliferation
Bone remodeling
Bone healing completed within about 6
weeks; up to 6 months in the older
person

Fractures Emergency Care

Immobilize before moving client
Joint above and below
Check pulse, color, movement,
sensation before splinting
Sterile dressing for open wounds

Fractures Emergency Care

Fracture reduction
Closedexternal manipulation
Opensurgery

Acute Compartment Syndrome

Serious condition in which
increased pressure within one or
more compartments causes
massive compromise of circulation
to the area
Prevention of pressure buildup of
blood or fluid accumulation
Pathophysiologic changes
sometimes referred to as ischemiaedema cycle

Emergency Care - Acute

Compartment Syndrome
Within 4 to 6 hr after the onset of
acute compartment syndrome,
neuromuscular damage is
irreversible; the limb can become
useless within 24 to 48 hr.
Monitor compartment pressures.

(Continued)

Emergency Care (Continued)

Fasciotomy may be performed to
relieve pressure.
Pack and dress the wound after
fasciotomy.

Possible Results of Acute Compartment

Syndrome
Infection
Motor weakness
Volkmanns contractures: (a deformity of

the hand, fingers, and wrist caused by a lack of blood

flow (ischemia) to the muscles of the forearm)

Other Complications of Fractures

Shock
Fat embolism syndrome: serious
complication resulting from a
fracture; fat globules are released
from yellow bone marrow into
bloodstream
Venous thromboembolism
(Continued)

Other Complications of Fractures

(Continued)

Infection
Ischemic necrosis
Fracture blisters, delayed union,
nonunion, and malunion

Musculoskeletal
Complications (continued)
Muscle Atrophy, loss of muscle strength
range of motion, pressure ulcers, and other
problems associated with immobility
Embolism/Pneumonia/ARDS

TREATMENT hydration, albumin,

corticosteroids

Constipation/Anorexia
UTI
DVT

Musculoskeletal Assessment - Fracture

Change in bone alignment
Alteration in length of extremity
Change in shape of bone
Pain upon movement
Decreased ROM
Crepitation
Ecchymotic skin

(Continued)

Musculoskeletal Assessment Fracture

(Continued)

Subcutaneous emphysema with

bubbles under the skin
Swelling at the fracture site

Special Assessment Considerations

For fractures of the shoulder and upper
arm, assess client in sitting or standing
position.
Support the affected arm to promote
comfort.
For distal areas of the arm, assess
client in a supine position.
For fracture of lower extremities and
pelvis, client is in supine position.

CAST
CAST

Casts
Rigid device that immobilizes the
affected body part while allowing other
body parts to move
Cast materials: plaster, fiberglass,
polyester-cotton
Types of casts for various parts of the
body: arm, leg, brace, body

(Continued)

Casts (Continued)
Cast care and client education
Cast complications: infection,
circulation impairment, peripheral
nerve damage, complications of
immobility

Managing Care of the Patient in a Cast

Casting Materials
Relieving Pain
Improving Mobility
Promoting Healing
Neurovascular Function
Potential Complications

Cast, Splint, Braces, and Traction

Management Considerations
Arm

Casts
Leg Casts
Body or Spica Casts
Splints and Braces
External Fixator
Traction

POLYESTER/FIBERGLASS

UPPER EXTREMITY CAST

LOWER EXTREMITY CAST

Musculoskeletal
Nursing Care - Casts
Neurovascular
Check
color/capillary refill
Temperature
Pulse
Movement
Sensation

Traction Nursing Care

Pin Site care
Skin and
neurovascular check

Cast Care (continued)

Elevate Extremity
Exercises to unaffected side; isometric

exercises to affected extremity

Keep heel off mattress

Handle with palms of hands if cast wet
Turn every two hours till dry
Notify MD at once of wound drainage
Do not place items under cast.

Traction
Application of a pulling force to the
body to provide reduction,
alignment, and rest at that site
Types of traction: skin, skeletal,
plaster, brace, circumferential

(Continued)

Traction (Continued)

Traction care:
Maintain correct balance between
traction pull and counter traction force
Care of weights
Skin inspection
Pin care
Assessment of neurovascular status

Musculoskeletal Fractures
Treatment

Primary Goal reduce fracture Realign and immobilize

Medications
Analgesics, antibiotics, tetanus toxoid

Closed Reduction Manual and Cast;

External Fixation Device
Traction; Splints; Braces
Surgery

Open reduction with internal fixation

Reconstructive surgery
Endoprosthetic replacement

Figure 42-5 In external fixation, pins placed through the bone above and below the fracture are attached to external
fixation rods that hold the pins and bone in place.

Nursing Management

Positioning

Strengthening Exercises

Potential Complications

Musculoskeletal
Nursing Care
Promote comfort
Assess infection
Promote mobility
Teach safety
Vital Signs
Flotation, sheep skin
Nutrition
Vital Signs
Monitor elimination

Elevate extremity
to decrease
swelling/ ice pack
Teach skin care,
cast care, diet,
complications

Operative Procedures
Open reduction with internal
fixation
External fixation
Postoperative care: similar to that
for any surgery; certain
complications specific to fractures
and musculoskeletal surgery
include fat embolism and venous
thromboembolism

Managing the Patient Undergoing

Orthopedic Surgery

Joint

Replacement
Total Hip Replacement
Total Knee Replacement

Risk for Infection

Interventions include:
Apply strict aseptic technique for
dressing changes and wound
irrigations.
Assess for local inflammation
Report purulent drainage immediately
to health care provider.
(Continued)

Risk for Infection (Continued)

Assess for pneumonia and urinary
tract infection.
Administer broad-spectrum antibiotics
prophylactically.

Imbalanced Nutrition: Less Than Body

Requirements

Interventions include:
Diet high in protein, calories, and
calcium, supplemental vitamins B and
C
Frequent small feedings and
supplements of high-protein liquids
Intake of foods high in iron

Upper Extremity Fractures

Fractures include those of the:

Clavicle
Scapula
Humerus
Olecranon
Radius and ulna
Wrist and hand

Lower Extremity Fractures

Fractures include those of the:

Femur
Patella
Tibia and fibula
Ankle and foot

Fractures of the Hip

Intracapsular or extracapsular
Treatment of choice: surgical
repair, when possible, to allow the
older client to get out of bed
Open reduction with internal
fixation
Intramedullary rod, pins, a
prosthesis, or a fixed sliding plate
Prosthetic device

Fractures of the Pelvis

Associated internal damage the
chief concern in fracture
management of pelvic fractures
Nonweight-bearing fracture of the
pelvis
Weight-bearing fracture of the
pelvis

Compression Fractures of the Spine

Most are associated with
osteoporosis rather than acute
spinal injury.
Multiple hairline fractures result
when bone mass diminishes.

(Continued)

Compression Fractures of the Spine

(Continued)

Nonsurgical management includes

bedrest, analgesics, and physical
therapy.
Minimally invasive surgeries are
vertebroplasty and kyphoplasty, in
which bone cement is injected.

(Continued)

Amputations
Surgical amputation
Traumatic amputation
Levels of amputation
Complications of amputations:
hemorrhage, infection, phantom
limb pain, problems associated
with immobility, neuroma (a growth or
tumour of nerve tissue), flexion contracture

Amputation

Nursing Management

relieving pain
minimizing altered sensory
perception
promoting wound healing
enhancing body image
self-care

Phantom Limb Pain

Phantom limb pain is a frequent
complication of amputation.
Client complains of pain at the site
of the removed body part, most
often shortly after surgery.
Pain is intense burning feeling,
crushing sensation or cramping.
Some clients feel that the removed
body part is in a distorted position.

Management of Phantom Pain

Phantom limb pain must be

distinguished from stump pain
because they are managed
differently.
Recognize that this pain is real and
interferes with the amputees
activities of daily living.

(Continued)

Management of Phantom Pain

(Continued)

Some studies have shown that

opioids are not as effective for
phantom limb pain as they are for
residual limb pain.
Other drugs include intravenous
infusion calcitonin, beta blockers,
anticonvulsants, and
antispasmodics.

Exercise After Amputation

ROM to prevent flexion
contractures, particularly of the hip
and knee
Trapeze and overhead frame
Firm mattress
Prone position every 3 to 4 hours
Elevation of lower-leg residual limb
controversial

Prostheses
Devices to help shape and shrink
the residual limb and help client
readapt
Wrapping of elastic bandages
Individual fitting of the prosthesis;
special care

Crush Syndrome

Can occur when leg or arm injury

includes multiple compartments
Characterized by acute compartment
syndrome, hypovolemia, hyperkalemia,
rhabdomyolysis, and acute tubular
necrosis
Treatment: adequate intravenous fluids,
low-dose dopamine, sodium
bicarbonate, kayexalate, and
hemodialysis

Metabolic Bone Disorders

Osteoporosis

Osteomalcia
Pagets

Disease

Osteoporosis
A disease in which loss of bone exceeds
rate of bone formation; usually increase in
older women, white race, nulliparity.
Clinical Manifestations bone pain,
decrease movement.
Treatment Calcium, Vit. D, estrogen
replacement, Calcitonin, fluoride, estrogen
with progestin, SERM (Selective Estrogen
Receptor Modulator) with anti-estrogens,
exercise.
Pathologic fracture-safety.

Classification of Osteoporosis

Generalized osteoporosis occurs most

commonly in postmenopausal women
and men in their 60s and 70s.
Secondary osteoporosis results from
an associated medical condition such
as hyperparathyroidism, long-term
drug therapy, long-term immobility.
Regional osteoporosis occurs when a
limb is immobilized.

Health Promotion/Illness Prevention Osteoporosis

Ensure adequate calcium intake.
Avoid sedentary life style (a type of
lifestyle with a lack of physical
exercise) .
Continue program of weightbearing exercises.

Osteoporosis - Assessment
Physical assessment
Psychosocial assessment
Laboratory assessment
Radiographic assessment

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Drug Therapy
Osteoporosis

Hormone replacement therapy

Parathyroid hormone
Calcium and vitamin D
Bisphosphonates
Selective estrogen receptor
modulators
Calcitonin
Other agents used with varying
results

Diet Therapy - Osteoporosis

Protein
Magnesium
Vitamin K
Trace minerals
Calcium and vitamin D
Avoid alcohol and caffeine

Fall Prevention - Osteoporosis

Hazard-free environment
High-risk assessment through
programs such as Falling Star
protocol
Hip protectors that prevent hip
fracture in case of a fall

Others - Osteoporosis
Exercise
Pain management
Orthotic devices

Osteomalacia
Softening of the bone tissue
characterized by inadequate
mineralization of osteoid
Vitamin D deficiency, lack of
sunlight exposure
Similar, but not the same as
osteoporosis
Major treatment: vitamin D from
exposure to sun and certain foods

Pagets Disease of the Bone

Metabolic disorder of bone remodeling,

or turnover; increased resorption (the
process by which osteoclasts break down bone and
release the minerals, resulting in a transfer of calcium
from bone fluid to the blood)

of loss results in
bone deposits that are weak, enlarged,
and disorganized
Nonsurgical management: calcitonin,
selected bisphosphonates, mithramycin
Surgical management: tibial osteotomy
or partial or total joint replacement

Pagets Disease
An imbalance of increase osteoblast and
osteoclast cells; thickening and
hypertrophy.
Bone pain most common symptom;
bony enlargement and deformities
usually bilateral, kyphosis, long bone.
Analgesics, meds bisphosphonates and
calcitonin, NSAID, assistance devices,
and hot/cold treatment.

Osteomyelitis
A condition caused by the invasion
by one or more pathogenic
microorganisms that stimulates the
inflammatory response in bone
tissue
Exogenous, endogenous,
hematogenous, contiguous

Osteomyelitis

Infection of bone; causative agent Staph/Strept

Typical signs and symptoms : Acute osteomyelitis
include:
Fever that may be abrupt
Irritability or lethargy in young children
Pain in the area of the infection
Swelling, warmth and redness over the area of the
infection
Chronic osteomyelitis include:
Warmth, swelling and redness over the area of the
infection
Pain or tenderness in the affected area
Chronic fatigue
Drainage from an open wound near the area of the
infection
Fever, sometimes
Treatment IV antibiotic; long term for 4-6 months

Surgical Management
Osteomyelitis

Sequestrectomy (Surgical removal of a

sequestrum), a detached piece of necrotic bone
that often migrates to a wound, abscess, etc.

Bone grafts
Bone segment transfers
Muscle flaps
Amputation

Bone Tumors
Benign

Bone Tumors
Malignant Bone Tumors
Metastatic Bone Disease

Bone Tumors

Benign bone tumors

(noncancerous):

Chrondrogenic tumors:
osteochondroma, chondroma
Osteogenic tumors: osteoid osteoma,
osteoblastoma, giant cell tumor
Fibrogenic tumors

Interventions
Nondrug pain relief measures
Drug therapy: analgesics, NSAIDs
Surgical therapy: curettage (simple
excision of the tumor tissue), joint
replacement, or arthrodesis

Malignant Bone Tumors

Primary tumors, those tumors that

originate in the bone

Osteosarcoma
Ewings sarcoma
Chondrosarcoma
Fibrosarcoma
Metastatic bone disease

Osteosarcoma
Cancer of the bone metastasis to the
lung is common. Most in long bones.
Clinical manifestations dull pain,
swelling, intermittent but increases per
time; night pain common.
Treatment radiation, chemotherapy,
hormonal therapy, surgical excision with
prosthetics, assistance devices,
palliative measures.

Treatment Cancer of Bone

Interventions include:
Treatment aimed at reducing the size or
removing the tumor
Drug therapy; chemotherapy
Radiation therapy
Surgical management
Promotion of physical mobility with ROM
exercises

Cancer of Bone
Anticipatory Grieving

Interventions include:
Active listening
Encouraging client and family to
verbalize feelings
Making appropriate referrals
Helping client and others to cope with
the loss and grieving
Promoting the physician-client
relationship

Cancer of Bone
Disturbed Body Image

Interventions include:
Recognize and accept the clients view
of body image alteration.
Establish and maintain a trusting
nurse-client relationship.
Emphasize the clients strengths and
remaining capabilities.
Establish realistic mutual goals.

Potential for Fractures

Bone Cancer

Interventions
Nonsurgical management: radiation
therapy and strengthening exercises.
Surgical management: replace as much of
the defective bone as possible, avoid a
second procedure, and return client to a
functioning state with a minimum of
hospitalization and immobilization.

Carpal Tunnel Syndrome

Common condition; the median
nerve in the wrist becomes
compressed, causing pain and
numbness
Common repetitive strain injury via
occupational or sports motions
Nonsurgical management: drug
therapy and immobilization
Possible surgical management

Scoliosis
Abnormal spinal curvature of various
degrees or severity involving
shortening of muscles and
ligaments.
Milwaukee brace (a back brace used in the
treatment of spinal curvatures) , internal
fixative devices.

Scoliosis
Changes in muscles and ligaments
on the concave side of the spinal
column
Congenital, neuromuscular, or
idiopathic in type
Assessment: complete history, pain
assessment, observation of posture
Interventions: exercise, weight
reduction, bracing, casting, surgery