Musculoskeletal Alterations

Bone-forming cells

Osteoblasts

Cells that breakdown bone tissue

Osteoclasts

Mature bone cells

Osteocytes

Bone remodeling =

• Removal of old bone by osteoclasts

• Deposit of new bone by osteoblasts

Attach muscles to bones

Tendons

Attach bones to bones (fibrous connective tissue). Have poor blood supply → slow repair after injury

Ligaments

Gerontological effects of aging on MS system

• Functional problemsv (ADLs e.g. walking/get out of bed)

• Decreased bone density

  • Increased r/o osteopenia and osteoporosis

• Decreased muscle mass and strength

• Decreased flexibility

• Increased r/o OA

• Decreased height (kyphosis)

• Risk for falls

  • Changes in proprioception awareness of self in relation to environment)

Why do older adults have higher risk for falls?

Changes/decreases in proprioception awareness of self in relation to environment)

Diagnostic test used to check for osteoporosis (measures bone density)

Dual energy X-ray absorptiometry (DEXA)

Preventive teaching for people at high risk for falls

• Those with gait instability, vision impairment

• Age0appropriate exercise to help maintain muscle strength and balance

• Adequate calcium and vitamin D for bone health

• Assess living environemnt for safety risks

Soft tissue injuries

• Sprains

• Strains

• Dislocations

• Subluxation

Nursing managemnet for sprains and strains

• RICE (rest, ice, compression, elevation)

• Analgesia (NSAIDs or tylenol)

RICE (management of sprains and strains)

R – Rest: stop activity and limit movement

I – Ice (cryotherapy) on area: 24-48 hrs; 20-30 min at a time

C – Compression: elastic bandage; apply distal to proximal

E – Elevation: above the heart

Why take NSAIDs with food?

To prevent GI irritation and bleeding

Injuries from prolonged force or repetitive movements and awkward posture

Repetitive strain injury (RSI & cumulative trauma disorder)

Those who are at risk for RSI

Those who perform repetitive motions without sufficient muscle rest

• E.g. dancers, butchers, athletes, and keyboard operator (gamers), sewing, hair cutters

• Caused by compression of the median nerve

• Associated with activities that require continuous wrist movement

• Compression often caused by trauma, edema, cancer, rheumatoid arthritis, or soft tissue masses, hormones

Carpal tunnel syndrome (CTS)

Which populations have increased incidence of CTS?

Diabetes, PVD, RA, and women

CTS manifestations

• Impaired sensation, pain, numbness, or weakness; clumsiness

• Tinel’s sign or Phalen’s sign

• Late stages:

  • Atrophy, recurrent pain, and dysfunction of hand

Function of rotator cuff

• Four muscles in the shoulder that stabilize humeral head: assist ROM and rotation

• Tear may occur with aging, repetitive stress, or injury

Manifestations of rotator cuff injury

• Shoudler weakness, pain, and decreased ROM (can’t raise arm up)

• Positive drop arm test

Diagnosis of rotator cuff injury

MRI is best

Conservative and surgical tx of rotator cuff injuries

• Conservative: Rest, ice, heat, NSAIDs, corticosteroid injections, US, and PT

• Surgical (if does not improve): Arthroscopy or acromioplasty, immobilization 6 weeks, passive exercises followed by PT

Conservative tx of rotator cuff injuries

Rest, ice, and heat, NSAIDs, corticosteroid injections, US, and PT

Surgical tx of rotator cuff injuries

Arthroscopy or acromioplasty; affected area is immobilized for 6 weeks, and followed by passive exercises, then followed by PT

Associated with ligament sprains in sports

• Rotational stress when knee in flexion and foot planted

• Blow to knee causes shearing of meniscus resulting in tear

• Also, degenerative tears in older adults and people who squat or kneel at work

Meniscus injury

Diagnosis for ACLs

• Positive Lachman’s test

• MRI

Inflammation of the bursae from repeated or excessive trauma, friction, gout, RA, or infection

• Hands, elbows, shoulders, knees, and hips

Bursitis

S&S of bursitis

Warmth, pain, swelling, limited ROM

Tx of bursitis

• Identify and correct cause; rest with immobilization; ice and NSAIDs

• Surgery: bursectomy

Risks of skeletal traction

• Delayed union, nonunion, or infection at pin sites

• Complications of immobility (pneumonia, skin breakdown, DVT, loss of bone density)

Healing process of fractures

1) Fracture hematoma

2) Granulation tissue formation

3) Callus formation

4) Ossification

5) Consolidation

6) Remodeling

FGCOCR (healing process of fracturos: union)

F – Fracture hematoma

G – Granulation tissue formation

C – Callus formation

O – Ossification

C – Consolidation

R – Remodeling

Factors influencing fracture healing

• Displacement and site of fracture

• Blood supply

• Other local tissue injury

• Immobilization (slows healing)

• Internal fixation devices (infection)

• Infection

• Poor nutrition (patient needs protein + hydration)

• Age

• Smoking

Clinical manifestations of fractures

• Edema and swelling

• Pain and tenderness

• Muscle spasm

• Deformity

• Contusion

• Loss of function

• Crepitation

• Guarding

Overall goals for fracture care

• Anatomic realignment (reduction)

• Immoblization to maintain alignment

• Restoration of normal or near normal function

Diagnostic assessment of fractures

• H&P

• X-ray

• CT scan + MRI

Management for open fractures

• Surgical debridement and irrigation

• Tetanus and diptheria immunization (ask patient for immunization hx)

• Prophlactic abx therapy (open fractures have high infection risk)

• Short-term (48-72 hrs)

• Tape, boots, or splints, applied directly to the skin to reduce muscle spasms

  • For example, Buck’s traction for femor fracture

• Traction weighs 5-10 lbs

• Skin assessment and prevention of breakdwon imperative

Skin traction

• Align injured bones and joints or treat joint contractures and congenital hip dysplasia (bone alignment in fractures)

• Long-term pull to maintain alignment

• Pin or wire inserted into bone (weighs 5-45 lbs)

• Risk for delayed union, nonunion, or infection at pin sites, complications of immobility (pneumonia, skin breakdown, DVT, loss of bone density)

Skeletal traction

What is used for fracture immobilization

• Casts

• Sling

• Temporary after closed reduction

• Allows patient to perform ADLs while maintaining immobilizations

• Incorporates joints above and below fracture for stabilization during healing

  • Two most common materials: plaster of Paris; Fiberglass

Casts (fracture immobilization)

• Used to support and elevate arm

• C/I with proximal humerus fracture

• Ensure axillary area is well-[added

• No undue pressure on neck

• Encourage movement of fingers and non-immobilized joints

Sling (fracture immobilization)

Nursing implications for slings

• Used to support and elevate arm

• C/I with proximal humerus fracture

• Ensure axillary area is well-[added

• No undue pressure on neck

• Encourage movement of fingers and non-immobilized joints

Fracture assessment

• Obtain a brief history of:

  • Traumatic episode

  • Mechanism of injury

  • Patient position when found

• Transport to ED ASAP

  • Thorough assessment and start of tx

• Neurovascular assessment

Neurovascular assessment for fractures

• Musculoskeletal injuries can alter the neurovascular status of an extremity

  • Espeically important distal to the injury (e.g. foot injury = watch out for toes)

• Assess and document before and after treatment

• Compare bilaterally

• Palpate pulses

• Assess for tingling, paresthesia, numbness

Preoperative care for fractures

• Patient teaching

  • Immobilize injured area

  • Educate about assistive devices

  • Expected activity limitations

  • Assure that needs will be met

  • Pain meds

Postoperative care for fractures

• Monitor VS and S&S of infection

• General principles of post-op care (early ambulation, cough, deep breathing, incentive spirometer, monitor for DVT, skin assessment)

• Frequent neurovascular assessment (pulse + ask if feeling numb, paresthesia, tingling)

  • Cast can be too tight or light; cause impingement; swelling can cause obstruction of nerve or blood vessels

  • Monitor cast if too tight or if swelling is causing tightness

• Be attentive to limitations with turning, positioning, or extremity support

• Minimzie pain and discomfort

• Monitor for bleeding or discharge

  • Aseptic technique

  • Blood salvage and autotransfusion (give patient’s blood back to themselveS)

Postoperative neurovascular assessment (fractures)

Assess Pulse + ask if feeling numb, paresthesia, tingling, pain

• Cast can be too tight or light; cause impingement; swelling can cause obstruction of nerve or blood vessels

• Monitor cast if too tight or if swelling is causing tightness; ask patient if cast is uncomfortable

Nutrition therapy for musculoskeletal recovery

Optimal soft tissue and bone healing

• Increase protein (1g/kg of body weight)

• Increase vitamins (B, C, D)

• Increase calcium, phosphorus, and magnesium

• Increase fluid (2000-3000 mL/day)

• Increase fiber

  • Body jacket and hip spica cast patients: eat six small meals a day

    • They don’t have much room in abd area

Complications of fractures

• Majority health w/o complications

• Medical emergencies needing immediate attention required with

  • Open fractures w/ severe blood loss

  • Fractures that damage vital organs

• Death is usually result of:

  • Damage to underlying organs and vascular structures

  • Complications of frature or immobility

• Infection

• Compartment syndrome

• DVT

• Fat embolism

• Rhabdomyolysis

Common complications of fractures

• Infection

• Compartment syndrome

• Venous thromboembolism (DVT)

• Fat embolism

• Rhabdomyolysis

ICVFR (common complications of fractures)

I – Infection

C – Compartment syndrome

V – Venous thromboembolism (DVT)

F – Fat embolism

R – Rhabdomyolysis

A complication of fractures that is a medical emergency: swelling and increased pressure within a limited space (muscle compartment); compromises neurovascular function of tissues within that space (e.g. patient has cast on arm, then hand becomes tingling/swelling)

• Causes excruciating pain not relieved by pain meds

• Associated with fractures with extensive tissue damage and crush injury

• Most common site = distal humerus and proximal tibia

• May occur after knee or leg surgery or with prolonged pressure (limb trapped under the body)

Compartment syndrome

Most common site affected by compartment syndrome

Distal humerus and proximal tibia

May occur after knee or leg surgery or with prolonged pressure (limb trapped under the body)

Compartment syndrome

Clinical manifestations of compartment syndrome

• Pain: out of proportion to injury and refractory to opioids; passive stretch (swelling stretches skin and fascia and makes them taut)

• Pressure

• Paresthesia (numbness/tingling)

• Pallor

• Paralysis or loss of function

• Pulselessness

Six P’s of compartment syndrome

• Pain: out of proportion to injury and refractory to opioids; passive stretch (swelling stretches skin and fascia and makes them taut)

• Pressure

• Paresthesia (numbness/tingling)

• Pallor

• Paralysis or loss of function

• Pulselessness

Early signs of compartment syndrome

• Notify HCP if pain unrelieved by drugs and out of proportion to injury

• Paresthesia is also an early sign

• Relieving the source of pressure may prevent progression (e.g. loosen cast)

Late signs of compartment syndrome

• Pulselessness

• Paralysis

• May require amputation

What NOT to do if compartment syndrome is suspected?

• Do not elevate extremity above the heart

• Do not apply cold compresses or ice

Why not elevate extremity above the heart nor apply cold compres or ice if suspecting compartment syndrome?

Causes vasoconstriction and reduced circulation to an already comprimised extremity (or it may even lead to compartment)

Treatment of compartment syndrome

• Relieve pressure

• Surgical decompression (fasciotomy) to release pressure

• Amputation (if severe or pulseless)

A complication of fracture; veins of lower extremities and pelvis are highly susceptible to thrombus formation due to venous stasis from muscle inactivity; increased risk with hip fracture, THR, or TKR

Venous thromboembolisms

Interventions to prevent venous thromboembolism (complication of fractures)

• Prophylactic anticoagulant drugs for 10 to 14 days

• Antiembolism stockings

• Intermittent pneumatic compression-devices

• Exercises

What veins are at increased risk for forming venous thromboembolisms?

Veins of lower extremities and pelvis are highly susceptible to thrombus formation due to venous stasis from muscle inactivity; increased risk with hip fracture, THR, or TKR

What fractures/procedures causes increased r/o venous thromboembolism

Hip fracture, THR, TKR

A complication of fractures. Systemic fat globules from fracture/broken bone that are distributed into tissues and organs (especially lungs and brain)

• Contributory factor in mortality

Fat embolism

What fractures can most commonly cause fat embolisms to develop

Fracture of long bones, ribs, tibia, and pelvis

When does fat embolism occur?

• Most common with fracture of long bones, ribs, tibia, and pelvis

• May also occur after joint replacement, burns, pancreatitis, liposuction, crush injuries, and bone marrow transplants

Pelvic fracture =

Increased r/o fat embolism

Hip fracture, THR, and/or TKR =

Increased r/o venous thromboembolism

Complication of fractures; syndrome caused by breakdown of damaged skeletal muscle

• Releases myoglobin into circulation resulting in obstruction of renal tubules, causing ATN and kidney failure

Rhabdomyolysis

Monitoring for rhabdomyolysis

• Assess urine output

  • Dark-reddish brown urine (cola-colored)

• Assess for symptoms of AKI

Most common cause for amputation

PVD, especially related to diabetes

Causes of amputation

• PVD, especially related to diabetes

• Thermal injuries

• Tumors, osteomyelitis

• Congenital limb disorders

Complications of joint surgery

• Infection

  • Common organisms: gram-positive streptococci and staphylococci

  • Loosens prosthesis and causes pain

  • Prophylaxis: self-contained OR suites, laminar airflow, and abx

• VTE

  • Anticoagulants

  • Intermittent pneumatic compression

  • Early ambulation

Preoperative care for joint surgeries

• The patients needs to be free from:

  • Infection

  • Skin breakdwon

  • Acute joint inflammation

• Explain post-op care:

  • Early mobility, hydration, VTE, prophylaxis

  • Assure availability of analgesia

  • PT visit with practice of exercises and use of assistive devices

Post-op management (joint surgeries + all of musculoskeletal)

• Regular neurovascular assessments (important for all musculoskeletal)

  • Prevent impingement/compartment syndrome

• Administer: anticoagulants and abx prophylactically

  • Teach the patient about continuing meds at home

  • Monitoring coagulation/WBC studies

• Pain management: analgesia

  • May consider epidural, intrathecal, femoral nerve block, PCA, oral opioids, or NSAIDs

• Exercise and mobility (early ambulations); follow protocols

  • Reduce risk of complications of decreased mobility

Severe infection of bone, bone marrow, and surrounding soft tissue

• Can be caused by a variety of organisms; but most common is staphylococcus aureus

• Indirect entry (hematogenous) = 20%

• Direct entry (contiguous e.g. bone surgery) = 80%

Osteomyelitis

Pathophysiology of osteomyelitis

• Microorganisms enter the blood and grow

  • Increasing pressure in bone leads to ischemia and vascular comprimise of the periosteum

• Infection spreads through bone, cortex, and marrow cavity, causing obstruction of blood flow, necrosis, and sequestrum (piece of dead, devascularized bone that has separated from healthy bone)

Clinical manifestations of acute osteomyelitis

• Systemic manifestations

  • Fever

  • Night sweats

  • Chills

  • Restlessness

  • Nausea

  • Malaise

  • Drainage (late)

Clinical manifestations of chronic osteomyelitis

• Systemic manifestations are lessened

• Local signs of infection are more common

  • Pain, swelling, warmth

• Granulation tissue turns to avascular scar tissue which is an ideal site for microorganism growth because it cannot be penetrated by abx

Conditions takes a long time to heal, and very difficult for abx to reach the bone

Osteomyelitis

Interprofessional care for acute osteomyelitis

• Most start IV abx therapy, then switch to oral agents

• IV for 4-6 weeks; some need 3-6 months

• CVAD requires follow-up from skilled nursing facility or home care

• Cultures or bone biopsy before abx

• Surgical debridement and drainage of abscess or ulcer

Interprofessional care for chronic osteomyelitis

• Surgical removal of poorly perfused tissue, dead bone

• Extended use of abx

  • Oral therapy with a fluoroquinolone for 6-8 weeks

  • Oral therapy for 4-8 weeks after acute IV therapy is done

Health promotion for osteomyelitis

• Control other current infections

• Persons at risk:

  • Immunocomprimised

  • Have diabetes, orthopedic prosthetic devices, or vascular insufficiency (PVD)

• Patient/caregiver education: S&S of osteomyelitis)

• Encouarge to call HCP if:

  • Bone pain, fever, swelling, restricted limb movement

What people are at risk for developing osteomyelitis?

• Immunocomprimised

• Have diabetes, orthopedic prosthetic devices, or vascular insufficiency (PVD)

Encourage to call HCP if osteomyelitis patient experiences these symtpoms:

Bone pain, fever, swelling, restricted limb movement

Group of genetic diseases characterized by symmetric wasting of skeletal muscles w/o neurological involvement

• Gradual loss of strength with increasing disability and deformity

• Most common is Duchenne

Muscular dystrophy (MD)

MD treatment

• No cure

• Corticosteroids → slow progression for up to 2 years; improve survivial

  • Deflazacort

• Disease-modifying drug:

• Eteplirsen (Exondys 51)

Treatment goals for MD

• Preserve mobility and independece through exercise, PT, and use of assistive devices

• Orthotic jacket to prevent spinal deformity or injury

What to monitor for MD?

• Cardiomyopathy and HF

• CPAP, tracheostomy, and mechanical ventilation

Function of intervertebral discs

• Separate vertebrae and help absorb shock

• Intervertebral disc disease involves deterioration, herniation, or other problem with intervertebral discs (can involve cervical, thoracic, and lumbar spine)

• Loss of fluid leads to loss of elasticity, flexibility, and shock-absorbing capabilities in intervertebral discs

• Disc becomes thinner as nucleus pulposus dries out, and load is shifted to annulus fibrosus

• Results in progressive destruction as nucleus pulposus seeps out (herniated or slipped disc)

Degenerative disc disease (DDD)