Chapter 68: Musculoskeletal Diagnostic Procedures

Chapter 68: Musculoskeletal Diagnostic Procedures

Imaging studies are the primary diagnostic tools for musculoskeletal disorders.

Muscle weakness indicates the need for further evaluation.

Common imaging modalities include:

• Radiography (x-ray)

• Computed tomography (CT)

• Magnetic resonance imaging (MRI)

• Ultrasound (US)

• Nuclear scans

• Dual-energy x-ray absorptiometry (DEXA)

• Electromyography (EMG) and nerve conduction studies

Informed consent is required for invasive procedures.

Arthroscopy

Visualization of internal joint structures using an endoscope.

Commonly used for knee and shoulder evaluation.

Performed in the operating room under local or general anesthesia.

Incision number and placement depend on joint and extent of repair.

Contraindications:

• Joint infection

• Severe joint immobility

Indications

• Evaluation of joint injury

• Assessment of ligament or meniscal damage

• Repair of torn ligaments or meniscus

• Synovial biopsy

Arthroscopy Findings

Joint swelling, pain, crepitus

Joint instability

Arthroscopy Care

Pre-Procedure Nursing Actions

• Verify informed consent.

• Educate about possible preoperative joint exercises (straight-leg raises, quadriceps isometrics).

Post-Procedure Nursing Actions

• Provide postoperative care based on sedation used.

• Usually outpatient procedure.

• Assess neurovascular status and dressing every hour per protocol.

• Administer mild analgesics as prescribed.

Post-Procedure Client Education

• Apply ice for first 24 hours to reduce edema.

• Elevate extremity for 12 to 24 hours.

• Maintain activity restrictions.

• Monitor color, temperature, pain, and sensation of extremity.

• Report increased swelling, pain, redness, warmth, purulent drainage, or fever.

Arthroscopy Complications

Infection

Client education: Report swelling, redness, or fever immediately.

A nurse is completing preoperative teaching for a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include?

Select all that apply.

a

“Avoid damage or moisture to the cast on your arm.”

b

“Inspect your incision daily for indications of infection.”

c

“Apply ice packs to the area for the first 24 hours.”

d

“Keep your arm in a dependent position.”

e

“Perform isometric exercises.”

b

“Inspect your incision daily for indications of infection.”

c

“Apply ice packs to the area for the first 24 hours.”

e

“Perform isometric exercises.”

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The nurse should identify that a cast is not typically required following arthroscopy.

The client should elevate the affected extremity for 12 to 24 hours to reduce swelling.

A nurse is planning care for a client who is postoperative following an arthroscopy of the knee. Which of the following nursing actions are appropriate?

Select all that apply.

a

Assess color and temperature of the extremity.

b

Apply warm compresses to incision sites.

c

Place pillows under the extremity.

d

Administer analgesic medication.

e

Assess pulse and sensation in the foot.

a

Assess color and temperature of the extremity.

c

Place pillows under the extremity.

d

Administer analgesic medication.

e

Assess pulse and sensation in the foot.

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The nurse should plan to apply cold compresses on the incisional site for the first 24 hours to help decrease swelling and pain.

The nurse should identify that elevating the leg will help decrease swelling and pain in the affected extremity.

Nuclear Scans

Bone Scan

• Evaluates the entire skeletal system.

• Radiopharmaceutical injected IV 2 to 3 hours before scanning.

• Areas of increased bone activity appear brighter.

• Detects:

  • Hairline fractures

  • Tumors

  • Osteomyelitis

  • Osteoporosis

  • Vertebral compression fractures

• Use is decreasing due to MRI availability.

Gallium and Thallium Scans

• More sensitive than bone scans for bone pathology.

• Radioisotope migrates to tissues such as brain, liver, and breast.

• Scan duration 30 to 60 minutes.

• May require sedation to remain still.

• Repeat scans at 24, 48, and 72 hours.

Indications

• Degenerative bone disease and progression

• Osteomyelitis

• Stress or vertebral compression fractures

• Osteoporosis

• Primary or metastatic bone cancer

• Bone pain of unknown origin

• Aseptic necrosis

Nuclear Scans Findings

Bone pain

Nuclear Scans Care

Pre-Procedure Nursing Actions

• Explain procedure.

• Assess for contraindications:

  • Pregnancy

  • Lactation

  • Kidney disease

  • Allergy to radioisotope

Pre-Procedure Client Education

• Remain still during scan.

• Empty bladder before procedure to improve pelvic bone visualization.

Post-Procedure Client Education

• No radioactive precautions needed after procedure.

• Increase fluids to promote excretion of radioisotope in urine and feces.

A nurse is teaching a client who is going to have a bone scan. Which of the following statements should the nurse include?

a

“You will receive an injection of a radioactive isotope when the scanning procedure begins.”

b

“You will be inside a tube-like structure during the procedure.”

c

“You will need to take radioactive precautions with your urine for 24 hours after the procedure.”

d

“You will have to urinate just before the procedure.”

d

“You will have to urinate just before the procedure.”

An empty bladder promotes visualization of the pelvic bones. The client should be informed that the radioactive isotope is injected intravenously (IV) 2 to 3 hours before the scanning. Inform the client that the procedure does not use a tube-like structure as for an MRI. The client should be told that radioactive precautions for their urine are not necessary following the procedure.

Dual-Energy X-Ray Absorptiometry (DEXA)

Measures bone mineral density, usually hip or spine.

Uses two low-dose x-ray beams.

No contrast used.

Produces a score comparing bone density to population norms.

Scores are not sex specific.

Client lies on x-ray table during scan.

Indications

• Osteoporosis

• Postmenopausal state

• Baseline testing for females aged 40 to 49 years

Dual-Energy X-Ray Absorptiometry (DEXA) Findings

Loss of height

Bone pain

Fractures

A nurse is educating clients at a health fair about dual-energy x-ray absorptiometry (DEXA) scans. Which of the following information should the nurse include?

Select all that apply.

a

The test requires the use of contrast material.

b

The hip and spine are the usual areas the device scans.

c

The scan detects osteoarthritis.

d

Bone pain can indicate a need for a scan.

e

Females aged 40-49 years should have a baseline scan.

b

The hip and spine are the usual areas the device scans.

d

Bone pain can indicate a need for a scan.

e

Females aged 40-49 years should have a baseline scan.

Dual-Energy X-Ray Absorptiometry (DEXA) Care

Pre-Procedure Client Education

• Not recommended during pregnancy or lactation.

• Remain dressed but remove metal objects.

Post-Procedure Client Education

• Follow up with provider regarding supplements or medications if bone loss is present.

Electromyography (EMG) and Nerve Conduction Studies

Determine presence and cause of muscle weakness.

EMG

• Performed at bedside or EMG lab.

• Thin needles inserted into muscle.

• Electrodes record electrical activity during muscle contraction.

Nerve Conduction Study

• Surface or needle electrodes placed on skin.

• Low electrical current stimulates nerve.

• Measures muscle response.

Indications

• Neuromuscular disorders

• Motor neuron disease

• Peripheral nerve disorders (carpal tunnel syndrome)

Electromyography (EMG) and Nerve Conduction Studies Care

Pre-Procedure Nursing Actions

• Explain procedure and expectations.

• Assess anticoagulant use (bleeding risk).

• Assess for skin infection at insertion sites.

• Ask about muscle relaxant use (may need to be held).

• Verify informed consent.

• Fasting usually not required.

• Avoid smoking and stimulants for at least 2 hours before test.

• Premedication and sedation usually avoided (client must follow commands).

Client Education

• Avoid lotions or creams on day of procedure.

• Expect discomfort with needle insertion and electrical stimulation.

• May be asked to flex muscles during testing.

Post-Procedure Client Education

• Bruising may occur at insertion sites.

• Report swelling or tenderness.

• Apply ice to reduce hematoma or swelling.

• Warm compresses may relieve residual discomfort.

CT Scan, MRI, Radiography, Ultrasonography

Provide detailed images of body structures, bone density, texture, and surgical hardware.

MRI, CT, and US visualize soft tissues.

Indications

• Tendon and ligament injuries

• Chest and pelvic fractures

• Skull or vertebral fractures

• Herniated discs

CT Scan, MRI, Radiography, Ultrasonography Findings

Bone pain

Joint instability

CT Scan, MRI, Radiography, Ultrasonography Care

Nursing Actions

• CT with contrast:

  • Assess for contrast allergy.

  • Encourage adequate fluid intake after procedure.

• MRI:

  • Screen for implanted metal or pacemakers.

  • Remove all external metal objects (jewelry, hair clips).

Electromyography (EMG)

Evaluates muscle weakness.

Differentiates muscle disease from neurologic conditions.

Assesses neuromuscular function.

Pre-procedure:

• Avoid stimulants (accurate electrical activity).

• Avoid muscle relaxants (prevents false results).

Dual-Energy X-Ray Absorptiometry (DEXA)

Determines bone mineral content and bone density.

Primary test for osteoporosis.

Noninvasive, low radiation.

Pre-procedure:

• Remove all metallic objects (prevents artifact).

Gallium Scan

Detects:

• Metastatic tumors

• Infection

• Inflammation

Monitors response to treatment.

Uses radioactive tracer.

Post-procedure:

• No radioactive exposure precautions required.

Bone Scan

Identifies:

• Pathologic bone conditions

• Metastatic bone cancer

Uses injected radioactive isotope.

Areas of increased bone activity appear brighter.

Nursing action:

• Encourage increased oral fluids between injection and scan (promotes isotope excretion).

Arthroscopy

Endoscopic procedure to directly examine a joint.

Used for diagnosis and repair.

Minimally invasive.

Pre-procedure:

• NPO after midnight (aspiration prevention).

A nurse is planning care for a client who will undergo an electromyography (EMG). Which of the following actions should the nurse include?

Select all that apply.

a

Assess for bruising.

b

Administer aspirin prior to the procedure.

c

Determine whether the client takes a muscle relaxant.

d

Instruct the client to flex muscles during needle insertion.

e

Expect swelling, redness, and tenderness at the insertion sites.

a

Assess for bruising.

c

Determine whether the client takes a muscle relaxant.

d

Instruct the client to flex muscles during needle insertion.

Bruising can occur at the needle insertion sites. The nurse should assess the client’s medications to determine if they take a muscle relaxant, which can decrease the accuracy of the test results. The nurse should ask the client to flex their muscles for an easier insertion of the needle into the muscle

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The nurse should instruct the client to report swelling, redness, and tenderness at the insertion sites to the provider because this can indicate an infection

CT Scan

Evaluates:

• Pain

• Trauma

• Masses

• Possible fractures

Provides detailed cross-sectional images.

If contrast is used:

• Client may feel warmth or flushing (expected reaction).