Complex Concepts in Musculoskeletal Function and Alterations

what is the musculoskeletal systems

• protects vital organs

• provides body support and structure

• allows movement

• holds bones together at joints

• produces heat (through contractions)

• helps blood return to the heart

• stores important minerals (calcium, phospohorus, magnesium, fluoride in bone)

• acts as a reservoir for immature blood cells

• produces bblood cells in bone

Bone structure and tissue - shape + construction & 2 primary tissue types

• shape and construction

  • determined by its specific function and the physicial forces exerted on it

• two primary tissue types

  • cancellous (trabecular) or cortical (compact) bone tissues

4 types of bone cells

• osteoprogenitor cells: stem cells that replace needed bone cells

• osteoblasts: cells responsible for building new bone tissue

• osteocytes: mature cells that maintain bone tissue

• osteoclasts: cells that break down old bone tissue

Hormones involved with bones: Active Vitamin D (Calcitriol)

• Vitamin D incr. calcium in the blood by helping the small intestine absorb more calcium from food for the body

• Also helps calcium and phosphate get deposited into the bone matrix to which maintains bone density and strength

Hormones involved with bones: Parathyroid (PTH)

• Is released when blood calcium is low : it does this by

  • Pulling calcium out the bones

  • helping the kidneys keep calcium

  • incr. calcium absorption in the intestines

  • lowering phosphate levels (by secretion of kidneys)

Hormones involved with bones: Calcitonin

• Lowers blood calcium by:

  • Inhibiting osteoclasts, reducing bone breakdown and calcium release from bone

  • Helps the kidneys to reabsorb more calcium in the urine

  • Moves calcium into bone

What are joints

• point btwn 2 or more bones

• Primary function: permits mobility, allows fluid skeletal movement, and provides structural support

• Key components

  • Ligaments: fibrous connective tissue bands that hold bone to bone

  • Bursae: fluid filled sacs that facilitate movement and reduce friction

Joints: synarthoses (solid)

• Immovable structural connections securely joined by solid cartilage or fibrous connective tissue (e.g. skull sutures)

joints: diarthrodial (synovial)

• highly movable joints encapsulated with a fluid filled synovial cavity and protexted by smooth articular cartilage

how muscles attach?

tendons and aponeurosis

tendons and their use?

• a strong band of connective tissue that attaches muscle to bone

• when a muscle contrcats, the tendon pulls on the bone to create movement at a joint

aponeurosis and its uses?

• wide flat sheet of connective tissue

• i works similarly to a tendon but is not cord like

• connects muscle to bone or muscle to muscle

• eample: abdominal bones

isometric tone

• constant length

  • The length of the muscles remains constant but the force generate is incr.

  • Eample: pushing against an immovable wall

isotonic tone

• shortening muscle

  • characterized by shortening of the muscle with no incr. in tension within the muscle

  • Eample: fleing the forearm

Normal activities of muscle tone and contraction

• most muscle movements are a combination of both contraction

patient problems of musxle tone and contraction

• when issues occur, tone presents as

  • Flaccid

  • Spastic

  • Atonic

age related changes in musculoskeletal systeem: bones and hormones

• numerous metabolic changes, including reduction of estrogen, testosterone and growth hormone, and related decreased physicial activity, contribute to osteoporosis

age related changes in musculoskeletal systeem: cartilage

• cartilage degenerates in weight bearing areas and heals poorly

age related changes in musculoskeletal systeem: ligaments

• become weak, and this contributes to the development of osteoarthritis (degenerative joint disease)

age related changes in musculoskeletal systeem: muscles

• deacr. in muscle mass and ROM can cause functoinal impairment in older individuals

Good newurovascular assessment

• newurovascular status is important for the nurse to perform frequent neurovascular assessments of pts with musculoskeletal disorders. it is usually called CSM (circulation, sensation, movement)

  • Pain

  • pallor

  • poikilothermia

  • pulses (includes capilarry refill)

Diagnosis studies

• ray - initial structual imaing

• CT scan - detailed bone and joint imaging

• Labs - Ca, Vit. D, Phosphorus, Hormones, CBC, ESR, CK, Myoglobin

• MRI

• Anthrography

• Arthroscopy

• DEXA Scan

What is bursitis

• Inflammation of bursa, a small fluid filled sac that acts as a cushion to reduce friction between bones, tendons, and muscles near joints

what is tendonitis

• is the irritation or inflammation of a tendon, the thick fibrous cords that attach muscle to bone often caused by repetitive strain or ouveruse

clinical manifestations of bursitis and tendonitis

• localized pain: pain that intensifies with movement or diect pressure on the join

• swelling and redness: visible localized swelling, warmth, and erythema around the affected region

• stiffness: reduced rangge of motion often descriibed as a “locked” or severely stiff joint

treatment and care of bursitis and tendonitis

• RICE: Rest, Ice (20 min sessions_, compressions, and elevations

• Medical therapy: NSAIDS for pain, corticosteroid inections for advamced swelling

what is carpal tunnel syndrome?

• an entrapment neuropathy where the median nerve at the wrist is compressed.

• causes include: thickened fleor tendon sheath, skeletal encroachment, edema, or a soft tissue mass

what is median nerve function?

• responsible for forearm movement and providing feeling to the fingers and hands

risk factors of carpal tunnel

• repetitive movement

• pregnancy

• obesity

• hypothyroidism

• age and trauma

signs and symptoms of carpal tunnel

• numbness/tingling

• wrist and hanf pain

• loss of control

• burning sensation

diagnostic tools for carpal tunnel

• tinels ssign

• phalen’s test

• ray

• electromyography

• ultrasound

• MRI

treatment plan of carpal tunnel

• wrist splints: worn at night for neutral positioning

• anti inflammatories

• steiroid injections

• activity changes

• alternatives

• release surgery

phalens sign

tinels sign

Always assess first: injury to the musculoskeletal system requies elevated of:

• damaged area assessment of the fracture site

• underlying structures: muscles, blood vessels, and nerves

• secondary organs: check for trauma beneath the bone

Always assess first: injury to the musculoskeletal system requies elevated of: treatment and education

• treatment: provide support until healingn is complete

• education: essential for optimal patient outcomes

common soft tissue injuries: contusion

• injurt from blunt force (blow, kick, fall) causing bleeidnf into soft tissues (ecchymosis/brusing)

common soft tissue injuries: strain

• a pulled muscle affecting a musculotendinous due to overuse or overstretching

common soft tissue injuries: sprain

• a ligamentous injury often caused by traua or a wrenching/twisting motion

managemtn and treatment of common soft tissue injuries

• history: what were you doing

• Phsycial: compare and contrast areas of edema, ecchymosis, tenderness, and abnormal motion

• diagnostics: use neurovascular assessment RAY, ultrasound, or CT/MRI later

• may require brace or physical therapy

• RICE

treatment for musculoskeletal

• some experts advocating for movement based approaches like “Police”

• protet, optimal loading, ice, compression, elevation

• some say excessice use of ice suppresses inflammatory response which is necessary for repair

• some say complete rest after injury can delay healing and that controlled mild movement might promote recovery

risk factors of fractures

• 6.3M+ incidents

• All ages young and older

• Fragility fractues

• cushings syndorme

• osteoporosis and neoplasms

• anorexia and postmenopausal status

type of fractures structural integrity

• complete: broken all the way through

• incomplete: partially broken

• example: greenstick fracture

type of fractures structural integrity: clinical classifications

• oblique: diagonal break (45-60 degrees)

• comminuted: multiple fragments

• closed: skin remains intact

• open: skin broken (infection risk)

complete fracture

incomplete fracture

closed fracture simple nondisplaced

closed simple displaced fracture

what are signs and ysmptoms of a fracture - clinical presentation

• pain, loss of function, swelling, deformity, shortening (hip), crepitus (hear it)

what are signs and ysmptoms of a fracture - systemici impact

• adjacent structures are often affected, resulting in

  • soft tissue edema and hemorrhage

  • ptoential joitn dislocations

  • ruptured tendons and severed nerves

  • damaged blood vessels

immediate care of fractures

• stabiize patient: ensure stability and rule out other vascular injuries

• immobilize secure the affected body part immediately

• good neurovascular checks (before and after)

• wound care

• debridement or cover: if open cover to prevent infection

medical protocoles for fractures

• pain management

• may ice or elevate, depend on the MD

• If it is open:

  • cover

  • antibiotics

  • look at other stuff (trauma)

treatment options of fractures

• closed reduction: setting a bone without surgery; requires a cast or splint

• ORIF: open reduction with internal fiation using hardware

• traction: may be required with ORIF or closed reduction

• open fractures lead to infections

fracture management: closed reduction

• set (reduce) a broken bone without surgery

• nurse role: assist rhe HCP during the procedure

• patient needs: sedation is required during the process

• Post-procedure: cast application and neurovascular “good checks”

• additional needs: may require temporary traction

fracture management: open reduction (ORIF)

• internal fiation via surgical intervention

• utilizes hardware: plates and screws to secure bone

major goals of fracture management

• treatment knowledge

  • understand annd follow the treatment regimen

• pain relief

  • monitor continuously; address persistent pain

• physical mobility

  • improve ROM and use SCDs effectively

• self care mastery

  • achieve maimum possible level of self care

• tissue healing

  • heal trauma lacerations and abrasions

• neurovascular function

  • maintain adequate system function

• complication prevention

  • ensure complete absence of slinical complications

compartment syndrome

• pain out of proportion to injury

  • most common: lower leg and forearm

  • 6 Ps: pain, pressure, paresthesia, pallor, paralysis, pulselessness (late)

  • risk can lead to tissue necrosis

  • t: prompt recognition, remove cast, or fasciotomy

fat embolism syndrome

• mechanism: fat globules released from bone marrow

• high risk: long bone fractures (24-48hr post injury)

• S/S: AMS, petecial rash, hypotension

• Respiratory distress: tachyppnea, tachycardia, crackles

• T: IV hydration, support respiratory status (O2/intubation)

other complications of fractures

• Healing issues

  • delayed union, malunion, and nonunion

• Vascular risks

  • Venous thromboemboli (DVT/PE)

• Coagulation disorders

  • Disseminated INtravascular Coagulation

• Device sensitivity

  • Reaction to internal/eternal devices

Pelvic fractures and intability: stable fractures

• do not break the pelvc ring: just need rest and pain medication

Pelvic fractures and intability: unstable fractures

• may result in rotational instability

Pelvic fractures and intability: severe cases

life threatening complications and systemic problems

pelvic fractures clinical manifestations

• phsyical signs (Ecchymosis and local edema)

• localized tendernedd

  • symphysis pubis, iliac spines, sacrum, or coccy)

• sensory changes

  • Numbness, tingling of pubis, genitals, anf thighs

• Mobility impact

  • inability to bear weight, pain with movement

diagnostic and treatment of pelvic fracture

• Good neuro assessment

  • No pulse of lower etremities means blood pool closing up flow from arteries and veins

  • because of the fracture may not be able to void

  • look at urine

  • think of what organs and other vascular that is around pelvic for potential complications, it is a very vascular area

  • stabilize pelvic w pelvic binder

  • prevent or minimize compications such as bleeding and shock

  • once pt. is stable then think about fiing the pelvic

  • use of FAST (focused abdominal ST - ultrasound over pelvic cavity)

  • CT/CTA scan

  • retrograde cystourethrogram

importance of hip fracture ? in elederly

• risk of falls

• disease processes

• meds

• area rugs, loose carpeting, inadequate lighting, pets

S/S of hip fracture

• acute pain (groin pain. hip or knee)

• loss of function

• leg is shortened, abducted and rotated

• swelling, discoloration

• crepitu

management of hip fracture

• good history and physical (good neurovascular checks)

• RAY

• may need CT

• MRI

• initiral or urgent

  • immobilize (may need traction)

  • splinting

  • ice and elevation

  • pain management

  • orthopedic consult

  • if trauma, surgery in 24-48 hrs

pre nursing care of hip fracture

• informed consent

• blood transfusion

• cardiac clearance

• PT/OT/Rehab

• Education: abduction pillow, no fleing hips, no crossing elgs

post nusing care hip fracture

• good neurovascular assessment

• pain management

• wound check and care (drains)

• documentation

• complications

• Day 1: OOB, DVT precaution, PT at bedside

• Discharge: rehab? diet? education

• Always follow facilitys protocol

Hip replacement rules

• use adductor pillow

• no more than 90 degree fleion of the hip

• do not cross legs

• watch for dislocation signs

• acute paain

• popping sensation

knee replacement rules

• use a knee immobilize

• elevate the leg

complications of joint surgery

• imeediate complications post-op

  • hypotension

  • bleeding

  • hypovolemima

  • infeciton

    • infection

    • dislocation or subluation

what is traction

• application of pulling force to a part of the body

  • Purposes:

    • Reduce muscle spasms

    • Reduce, align, and immobilize fractures

    • Reduce deformity

    • 2 types of sekeletal and skin (bucks traction)

skeletal traction

• use of pins, tongs, screws and wires that are surgically secured to the bone (need to do pin care)

• frequently the pts body weight and positioning in bed supply the counterforce

• traction is never interrupted

• weights are not removed

• ropes must be unobstructed and weights must hang freely

skin traction (bucks)

• use of a boot or harness with a weight

• good positioning, maintain alignment, use trapeze, prevent complications

• complications:

  • nerce damage, infection, vascular injury, prolonged immobilization, skin breakdown

cast assessments

• assessment prior to placement (neurovascular)

• management of wounds first

s/s to report of cast

• persistent pain or swelling

• changes insensation, movement, skin color or temperature

• signs of infection or pressure areas

• abnormalities distal to cast

complications of a cast

• compartment syndrome (need to remove cast and or fasciotomy)

• disuse

• pressure ulcers (may need a window)

pt education for cast

• keep clean and cry

• postioning: elevation of etremity, use of slings (Weight across shoulder, not neck)

• should be able to insert a finger btwn cast and skin

• elevate limb higher than heart for first 24-48 hrs

• do not scratch or stick anything under cast

• no pwder or deoderant under cast

• petal/cusion rough edges-cau use tape

• report mustiness or unpleasant odor, painful “hot” spot under the cast - can be infection

amputations

• surigcal removal of a limb or part of a limb

• etiologies may be due to disease processes "(such as progressive peripheral vascular disease, infection or malignant tumor) or traumatic injury

• elective amputation is usually due to disorders that lead to ischemia or cell death

• amputations is used to relieve, improve functiom, or improve QOL

elective amputations

• surgical procedure (try everything first, diagnostic/t)

• monitor pt, s/s of bleeding (1st 24 hr)

• manage pain (phantom pain)

• alternative pain relief

• good neurovascular checks

• have them use a trapeze

• stump care

• they are a surgical patient

long term goals of amputation

• interprofessional team approach

• commicate a positive attitude to facilitate acceptance and participation in rehabilittion

  • prostheses fitting anf use

  • PT

  • vocational or occupational training

  • encourage active participation in care

  • focus on safety and mobility

  • psychological and emotional spport

complications of amputations

• hemorrhage (traumatic)

• infection

• contractures

• phantom limb pain

pharmacotherapy for musculoskeletal pain: NSAIDS

• ibuprofen, naproxen, celecoxib

  • stops prostaglandin production at site of injurt to systemically lower bothlocalized swlling and acute physical pain

  • commonly used as a first line treatment ofor acute inflammation and arthritis flare ups

pharmacotherapy for musculoskeletal pain: corticosteroids

• prednisone, methylprednisolone

  • fast, powerful, anti-inflam. hormones that act globally to suppress overwhelming immune responses and reduce severe joint swelling

  • typically reserved for short-term management of acute, severe inflam, episodes

pharmacotherapy for musculoskeletal pain: analgesics

• acetaminophen

  • acts primarily on CNS to block pain signaling and regulate body temp. offering effective relief without targeting localized inflam.

  • suitable for mild to moderate pain managment when anti-inflam. action is not required