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SYSTEM
Review of Anatomy and
Physiology
The musculo-skeletal system consists
of the muscles, tendons, bones and
cartilage together with the joints
The primary function of which is to
produce skeletal movements
Muscles
Three types of muscles exist in the
body
1. Skeletal Muscles
Voluntary and striated
2. Cardiac muscles
Involuntary and striated
3. Smooth/Visceral muscles
Involuntary and NON-striated
Visceral, plain muscles
Muscle Types:
2. Skeletal Muscle
ü accounts for at least 40% of body mass
ü aids in the formation of the smooth
contour of the body
Parts:
1.1 Epimysium
Ø Tough connective tissue covering of the
entire muscle.
Ø It binds many fascicles together.
Ø Tendon/Apponeurosis : blending of the
epimysia
1.2 Perimysium
Ø Fibrous membrane covering several
sheathed muscle fibers
Ø Fascicles – are bundles of muscle fibers
covered by perimysium.
Skeletal Muscle
Characteristics:
Ø Voluntary
Ø Multinucleated
Ø Shape:
Cylindrical
Ø Speed of
contraction:
Variable
2. Smooth Muscle
ü Found mainly in the walls of hollow
visceral organs such as the
stomach, urinary bladder and
respiratory passages.
ü propels substances along a definite
tract, or pathway, within the body.
Smooth Muscle Characteristics:
Ø Involuntary control
Ø Uninucleated
Ø Spindle-shaped
Ø (+) Striations
Ø Multinucleated
Ø Branched
4. Sarcoplasmic Reticulum
ü Surrounds individual myofibrils
ü Specialized smooth
endoplasmic reticulum.
ü Major function: storage and
release of calcium during
muscular contraction.
SARCOMERE- functional unit of the muscle; extends from one Z-
line to another Z-line
LMN control
Energy is consumed during muscle
contraction – LACTIC ACID (↓O2)
MUSCLE FATIGUE:
↑ work of muscle with inadequate O2 supply
Depletion of glycogen & energy stores
Accumulation of lactic acid
Structure and function of the
skeletal system
Skeletal system consist of Axial and
Appendicular skeleton.
Axial Skeleton- which is composed of
bones of the skull, thorax and
vertebral column which forms the axis
of the body.
Appedicular Skeleton- consist of
bones of the upper and lower
extrimities, including the hip and the
shoulder.
Two types of connective tissue found in the
skeletal system
2. Cartilage – a semi-rigid and slightly
flexible structures that plays an
essential role in prenatal and childhood
development of the skeleton and as a
surface for the articulating ends of the
skeletal joint.
3. Bones – which provide the firm
structure of the skeleton and serve as
reservoir for calcium and phosphate
Three types of cartilage
1. Locomotion
2. Protection
3. Support and lever
4. Blood production
5. Mineral deposition
Bone is made up of four major
components:
mineral (mainly calcium and phosphorus)
matrix (collagen fibers)
osteoclasts (bone-removing cells)
osteoblasts (bone-producing cells).
Osteocytes ( mature bone cells for bone
maintenance fxns)
SKELETAL SYSTEM:
BONE STRUCTURE
PERIOSTEUM:
Dense fibrous membrane covering the bone
Periosteal vessels supply bone tissue
EPIPHYSIS:
Widened area at the end of the long bone
EPIPHYSEAL PLATE (growth zone)
Cartilage area in children w/c provides for
longitudinal growth of the bone
ARTICULAR CARTILAGE:
Provides smooth surface over the ends of the
bone to facilitate joint movement
Type of bone cell
Calcium Urinary
concentration in excretion of
the extracellular Phosphate
fluid
Intestine Activation of
Reabsorption of Vit.D
Ca via activated
BONE MAINTENANCE &
HEALING:
Estrogen & Androgen
Stimulate osteoblastic activity & inhibit PTH
Menopause/Andropause –
↓Ca ► bone loss ► osteoporosis
Androgen-testosterone
Promote anabolism
↑bone mass
ESTROGEN-It appears that oestrogen
deficiency allows greater expression of these
cytokines, all of which are associated with
increased stimulation of bone resorption
which then leads to increased bone loss and
a reduction in BMD.
Androgens Androgens, like oestrogens,
can directly affect and modulate bone
cell function. Androgen receptors are
found on osteoblast cell lines and they
can cause osteoblast proliferation.
Hypogonadal men, in common with post-
menopausal women, have decreased
calcium absorption and low vitamin D
levels. The replacement of androgens
with testosterone can correct these
abnormalities, suggesting again that sex
hormones are required for the
maintenance of bone health.
BONE HEALING:
STAGE 1. HEMATOMA FORMATION &
INFLAMMATION
When bone is damaged or injured, hematoma precedes new
tissue formation in the production of new bone substance
STAGE 2. CELLULAR PROLIFERATION:
Granular tissue formation where BV & cartilage overlie the
fracture
Callus forms as minerals are deposited to organize new
network for the new bone
STAGE 3. PRECALLUS FORMATION: (2-6 wks)
Callus forms the initial clinical union of the bone & provides
enough stability to prevent movement when bones are gently
stressed
STAGE 4. CALLUS FORMATION:
Consolidation & Remodelling (complete healing- 3-6months)
Continued bone healing provides for gradual return of the
injured bone to its pre-injury shape & structural strength
Bone healing
FACTORS AFFECTING TIME
REQUIRED FOR HEALING:
1. age
2. displacement
3. site of fracture
4. nutritional level
5. blood supply to the area of injury
JOINTS
Permits bone to
change position &
facilitate body mov’t
Diarthrodial (synovial)
joint is the most
common type of joint
in the body
joints
joints
joints
Joints
joint
joints
CARTILAGE (hyaline)
ARTICULAR CARTILAGE
Rigid, connective, avascular tissue that
covers each bone ends
Damaged cartilage heals slowly (lacks
direct blood suply)
BURSAE
6 P’s of NEUROVASCULAR
DAMAGE
Swelling
Loss of function
Deformity
Crepitus
P
ai
n
a
ulseless
llo
ness
aresth
esia
araly
sis
oikilothe
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
LABORATORY PROCEDURES
1. BONE MARROW ASPIRATION
Usually involves aspiration of the
marrow to diagnose diseases like
leukemia, aplastic anemia
Usual site is the sternum and iliac crest
Pre-test: Consent
Intratest: Needle puncture may be
painful
Post-test: maintain pressure dressing
and watch out for bleeding
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
LABORATORY PROCEDURES
2. Arthroscopy
A direct visualization of the joint
cavity
Pre-test: consent, explanation of
procedure, NPO
Intra-test: Sedative, Anesthesia,
incision will be made
Post-test:
maintain dressing,
ambulation as soon as awake,
mild soreness of joint for 2 days,
joint rest for a few days & ice
application to relieve discomfort
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
2. ARTHROSCOPY -
C.I for pt who cannot flex @ 40° and with
infected knee
Uses large pneumatic tourniquet to
minimize bleeding
Apply dressing, neurovascular check,
Encourage fluid
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
LABORATORY PROCEDURES
4. DEXA- Dual-energy XRAY
Absorptiometry
Assesses bone density to diagnose
osteoporosis
Uses LOW dose radiation to measure
bone density
Painless procedure, non-invasive, no special
preparation
Advise to remove jewelry
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
5. Xray Films: Roentgenograms –
plain xray film is common APL
(Antero-posterior lateral views.
6. ARTHROGRAPHY: injection of dye
or air in the joint for x-ray study
7. MYELOGRAPHY: examines spinal
cord after introduction of contrast
medium
Myelography
ARTHROGRAPHY
Arthrography is the
radiographic examination
of a joint, after the
injection of a dye-like
contrast material and/or
air, to outline the soft
tissue and joint structures
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
8. BONE/MUSCLE BIOPSY: Iliac crest
usual puncture site; not commonly
done today
Local anesthesia, check PT & PTT
Coagulant given 2-3 days before &
after procedure
Pressure dressing after
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
9. CT SCAN: assess bone & soft
tse tumors
10. MRI: to assess soft tissue and
joints with myelography
GANDOLINIUM DTPA
(DiethyleneTriamine PentaAcetic Acid)
BLOOD STUDIES:
1. ESR (Erythrocyte Sedimentation
Rate):
non-specific test for inflammation F: 0-20
mm/hr M: 0-10 mm/hr
2. URIC ACID:Elevated in gout
Normal 2.2-7 mg/dl (F) ;4.2-8 mg/100 ml
(M)
3. ANA (Anti-nuclear Anti-body):
Measures the presence of antibodies that
destroy the nucleus of the body tissue cells
in auto-immune disorder;
(+) in about 94% of clients w/ SLE
Sjoren’s syndrome
RA
BLOOD STUDIES:
1. CALCIUM : ↓ in osteomalacia,
hypoparathyroidism; ↑bone tumors, acute
osteoporosis,bone fracture(healing phase)
Normal: 4.5 – 5.8 mEq/L or 9-10.5 mg/dL
2. PHOSPHORUS:↓ in osteomalacia, ↑
healing fractures, CRF, bone tumor
Normal: 3 - 4.5 mEq/L
MUSCLE ENZYME TESTS:
1. CREATININE PHOPHOKINASE
(CK3 or CK-MM)
F: 30-135 U/L; M:55-170 U/L – highest
concentration in traumatic injuries,
progressive muscular dystrophy
2. ALKALINE PHOSPHATASE (ALP-2)
– Increased in Cancer, Paget’s Dse &
Osteomalacia. Normal: 20-90 IU/L
COMMON
MUSCULOSKELET
AL PROBLEMS
The Nursing Management
Nursing Management of common musculo-
skeletal problems
1. PAIN
These can be related to joint
inflammation, traction, surgical
intervention
1. Assess patient’s perception of pain
2. Instruct patient alternative pain
management like meditation, heat
and cold application, guided imagery
Nursing Management
PAIN
3. Administer analgesics as prescribed
Usually NSAIDS
Meperidine (demerol)can be given
for severe pain
4. Assess the effectiveness of pain
measures
Nursing Management
SELF-CARE DEFICITS
3. Assist patient with difficulty bathing
and hygiene
Assist with bath only when patient has
difficulty
Provide ample time for patient to finish
activity
FRACTURES
Fracture
TYPES OF FRACTURE
5. Comminuted fracture
A fracture that involves production of several
bone fragments
6. Greenstick Fracture
One side is broken the other side is beat
7. Depressed
fragment is driven inward (skull,facial
bones)
TYPES OF FRACTURE
8. Transversed
Break straight across the bone
9. Spiral
Forms oblique angle to the bone
shaft
Fracture: ASSESSMENT
CLINICAL MANIFESTATIONS:
2. Pain: immediate, sever
3. Loss of function
4. Deformity; abnormal positioning of extremity
5. Shortening
6. Crepitation: palpable or audible
7. Edema
7. Paresthesia- burning or
tingling sensation
8. Numbness
9. Motor weakness
10. Pulselessness, impaired
capillary refill time and
cyanotic skin
Fracture
ASSESSMENT FINDINGS
1. Pain
Continuous and increases in
severity
Muscles spasm accompanies the
fracture is a reaction of the body to
immobilize the fractured bone
Fracture
ASSESSMENT FINDINGS
2. Loss of function
Abnormal movement and
pain can result to this
manifestation
Fracture
ASSESSMENT FINDINGS
3. Deformity
Displacement, angulations or
rotation of the fragments
Fracture
ASSESSMENT FINDINGS
4. Crepitus
A grating sensation produced
when the bone fragments rub
each other
Fracture
DIAGNOSTIC TEST
X-ray
Fracture
EMERGENCY MANAGEMENT:
OPEN FRACTURE
1. Open fracture is managed by covering a
clean/sterile gauze to prevent
contamination
2. DO NOT attempt to reduce the facture
Fracture
Early
1. Shock (Hypovolemic Shock)
2. Fat embolism - 1st 48 hrs
3. Infection
4. Impaired Circulation (cast/edema)
5. Compartment syndrome
6. Venous Stasis & thrombus formation
FRACTURE COMPLICATIONS
Late
1. Delayed union / Nonunion
2. Angulation (bone heals at a distorted angle)
3. Delayed reaction to fixation devices
4. Complex regional syndrome
FRACTURE COMPLICATIONS:
Fat Embolism
Occurs usually in fractures of the long bones
Fat globules may move into the blood stream
because the marrow pressure is greater than
capillary pressure
Fat globules occlude the small blood vessels
of the lungs, brain kidneys and other organs
FRACTURE COMPLICATIONS:
Fat Embolism
Onset is rapid, within 24-72 hours
ASSESSMENT FINDINGS
A. 1. Sudden dyspnea and respiratory
distress & hypoxia
2. tachycardia
3. Chest pain
4. Crackles, wheezes and cough
5. Petechial rashes over the chest, axilla and
hard palate
Fat embolism
Assessment finding
B. Neurological finding
1. Cerebral emboli- frequently present
after early stages. 86 % after the
respiratory distress.
- The more common presentation is
with an acute confusional statebut
focal neurological signs, including
hemiplegia, aphasia,apraxia, visual
field disturbances, and anisocoria,
have beendescribed.
Fat embolism
Corticosteroids
Dopamine
Morphine
3. Institute preventive measures
Immediate immobilization of fracture
Minimal fracture manipulation
Adequate support for fractured bone during turning
and positioning
Maintain adequate hydration and electrolyte
balance
Early complication:
Compartment syndrome
A complication that develops when
tissue perfusion in the muscles is less
than required for tissue viability
COMPARTMENT SYNDROME
ASSESSMENT FINDINGS
1. Pain- Deep, throbbing and
UNRELIEVED pain by opioids
d/t reduction in the size of the muscle
compartment by tight cast
d/t increased mass in the compartment by
edema, swelling or hemorrhage
Muscle ischemia (compression)
Arterial compression may not occur;
pulses may be (+) – (early)
Blisters
Can result in permanent damage in a
short time (6-8 hrs)
PARESTHESIA- first sign
PULSELESSNESS - late sign
Medical and Nursing
management:
1. RECOGNITION of presence of
fracture
2. REDUCTION:
Closed Reduction (manipulation)
Open Reduction (ORIF – surgery)
Traction
4 R’S IN MGMT OF FRACTURE
3. RETENTION
Cast
Traction
Braces / splints
Bandage
4. REHABILITATION – restoration to
normal fxn
Walker
Crutches
Cane
CANES
C
ANE Should be used
on the side
opposite the
affected leg
Cane + Affected
leg move
together
Canes
Sequence:
1-Left crutch,
2-right foot,
3-right crutch,
4-left foot. Then repeat.
Advantages:
Provides excellent stabilty as there are always three points in
contact with the ground
Disadvantages:
Slow walking speed
Indication:
Inability to bear weight on one leg. (fractures, pain,
amputations)
Pattern Sequence:
1-move both crutches and
2- the weaker lower limb forward. Then bear all
your weight down through the crutches
3- move the stronger or unaffected lower limb
forward. Repeat.
Advantages:
Eliminates all weight bearing on the affected leg.
Disadvantages:
Indication:
Weakness in both legs or poor coordination.
Pattern Sequence:
1-Left crutch and right foot together,
then the 2-right crutch and left foot
together. Repeat.
Advantages:
Faster than the four point date.
Disadvantages:
Can be difficult to learn the pattern.
Indications:
Patients with weakness of both lower extremities.
Pattern Sequence:
Advance both crutches forward then, while
bearing all weight down through both
crutches, swing both legs forward at the
same time to (not past) the crutches.
Advantage:
Easy to learn.
Disadvantage:
Requires good upper extremity strength.
Indications:
Inability to fully bear weight on both legs. (fractures,
pain, amputations)
Pattern Sequence:
Advance both crutches forward then, while
bearing all weight down through both crutches,
swing both legs forward at the same time past
the crutches.
Advantage:
Fastest gait pattern of all six.
Disadvantage:
Energy consuming and requires good upper extremity
TRAUMATIC CONDITIONS:
S/Sx:
a. hemorrhage (ecchymosis) ruptured
BV
b. pain & swelling
CONTUSION
Mgmt:
Nursing management:
1. Immobilize affected part
2. Apply cold packs initially, then heat
packs
3. Limit joint activity
4. Administer NSAIDs and muscle
relaxants
Sprains
Nursing management
1. Immobilize extremity and advise rest
2. Apply cold packs initially then heat packs
3. Compression bandage may be applied to
relieve edema
4. Assist in cast application
5. Administer NSAIDS
Re
st
I c
e
C ion
ompress
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on
Musculoskeletal Modalities
Traction
Cast
Nursing Management
Traction
A method of fracture immobilization
by applying equipments to align bone
fragments
Used for immobilization, bone
alignment and relief of muscle spasm
Traction
Skin
tracti
on
Non-adhesive traction
Bryants traction Cervical traction
Balance suspension traction
Position clients: low fowlers position
Maintain 20 degree angle at the thigh
to bed
Protect the skin from break down
Provide pin care if pin is used with the
skeletal traction
INDICATIONS/PURPOSES:
For immobilization
Prevent & correct deformity
Maintain good alignment
Give support to reduce pain & muscle
spasm
To reduce fracture
Indications for Traction
reduction, immobilisation & alignment
of fractures
relieve muscle spasm & pain
prevent further soft tissue damage
to promote rest
ne
RUSSEL’S TRACTION
Russell’s traction
CAST
Immobilizing tool made of plaster of
Paris or fiberglass
Provides immobilization of the
fracture
PURPOSES:
IMMOBILIZATION
PREVENTION/CORRECTION OF
DEFORMITY
SUPPORT
OBTAINING A HOLD OF A LIMB TO
SERVE AS MODEL FOR MAKING
ARTIFICIAL LIMB
Nursing Management
CAST: types
1. TRUNK
Minerva Cast, Rizzers Jacket-
Scoliosis,
2. UPPER EXTREMITY
3. LOWER EXTREMITY
4. Spica
CASTS
CASTS
SCOLIOSIS BRACE
Casting
Materials
Plaster of Paris
Drying takes 1-
3 days
If dry, it is
SHINY, WHITE,
hard and
resonant.
Fiberglass
Lightweight and
dries in 20-30
minutes
Water resistant
CHARACTERISTICS OF GOOD
CAST:
White, shiny
Odorless
Light in wt
Not too tight
Not too loose
Resonant on
percussion
Nursing Management
COLLE’S FRACTURE
Distal radius
PELVIC FRACTURE:
Freq in elderly
Can cause intra abd injury and urinary
tract injury
Turn pt only on specific orders
HIP FRACTURE
Common in elderly women
Clinical manifestation:
External rotation & adduction of affected
extremity
Shortening of the length of the affected
extremiety
Severe pain & tenderness
Treatment:
Initially- Buck’s traction
Surgery
AFTER SURGERY
Neurovascular check
Position: PREVENT FLEXION
ADDUCTION & INTERNAL ROTATION
Do not adduct past neutral position
Maintain in abducted position with A-
frame pillow or pillows between legs
Avoid flexion of hip of more than 90
degrees
Prevent internal or external rotation by
using sandbags, pillows, trochanter rolls
After surgery
Assessment
1. Neurovascular status of involved
extremity
2. History to determine
a. Causative factors
b. Health problems that can compromise
recovery
3. Client's understanding of the extent of
the surgery
4. Client's coping skills
5. Client's support system
Amputation
Assessment
1. Neurovascular status of involved
extremity
2. History to determine
a. Causative factors
b. Health problems that can compromise
recovery
3. Client's understanding of the extent of
the surgery
4. Client's coping skills
5. Client's support system
Amputation
Planning/Implementation
1. Provide care preoperatively
a. Initiation of exercises to strengthen muscles
of extremities in
preparation for crutch walking
b. Coughing and deep-breathing exercises
c. Emotional support for anticipated alteration
in body image
2. Monitor vital signs and stump dressing for
signs of hemorrhage
3. Elevate stump for 12 to 24 hours to decrease
edema; remove
pillow after this time to promote functional
alignment and prevent
Amputation
4. Provide stump care
a. Maintain elastic bandage to shrink and shape
stump in
preparation for prosthesis
b. When wound is healed, wash stump daily,
avoiding the use of oils, which may cause
maceration
c. Apply pressure to end of stump with
progressively firmer surfaces to toughen stump
d. Encourage client to move the stump
e. Place the client with a lower extremity
amputation in a prone position twice daily to
stretch the flexor muscles and prevent hip
Rheumatoid Arthritis
Clinical findings
1. Subjective
a. Fatigue
b. Malaise
c. Joint pain
d. Stiffness after periods of inactivity,
particularly in the morning
e. Paresthesia
f. Anorexia
Rheumatoid arthritis
Objective
a. Anemia
b. Weight loss
c. Joint inflammation and deformity
d. Subcutaneous nodules
e. Elevated sedimentation rate
f. Low-grade fever
g. Presence of rheumatoid factors in serum
identified by latex fixation test
h. Positive C-reactive protein and antinuclear
antibody (ANA) tests
Rheumatoid arthritis
Therapeutic interventions
1. Corticosteroids, antiinflammatories,
analgesics,
immunosuppressive drugs; aspirin is drug
of choice followed by the addition of
nonsteroidal antiinflammatory drugs and
then gold or penicillamine, an oral chelating
agent; corticosteroids are reserved for
acute inflammation, if possible
2. Physiotherapy to minimize deformities
3. Surgical intervention to remove severely
damaged joints (e.g.,
hip replacement)
Rheumatoid arthritis
Assessment
1. History of onset and progression of
symptoms, noting degree to
which pain interferes with normal
activities
2. Family history of rheumatoid
arthritis
3. General physical health
4. Coping skills
Rheumatoid arthritis
Planning/Implementation
1. Administer analgesics and other
medications as ordered
2. Teach the client to take medications as
ordered and observe foraspirin toxicity
(tinnitus, bleeding) and other adverse
effects of medications
3. Apply heat and cold as ordered; heat
paraffin to 125o to 129o F (52o to 54o C)
4. Promote rest and position to ease joint
pains
5. Provide for range-of-motion exercises up
to the point of pain,
recognizing that some discomfort is always
Rheumatoid arthritis