Musculoskeletal Disorders - Week 9

Medsurg

Functions of the Musculoskeletal System

Provides protection for vital organs, including the brain, heart and lungs

Serves as a framework to support body structures

Makes mobility possible

• muscles and tendons hold the bones together and joints allow the body to move

• movement facilitates the return of deoxygenated blood to the right side of the heart by massaging the venous vasculature

Serves as a reservoir for immature blood cells and essential minerals, including calcium, phosphorus, magnesium and fluoride

Remodeling/Formation

Old bone is removed and new bone is added to the skeleton

• physical activity, particularly weight-bearing activity, acts to stimulate bone formation and remodeling

Resorption

Removal or destruction of bone

• prolonged bedrest causes increased bone resorption from calcium loss

Aging: Bones

Gradual, progressive loss of bone mass after 30 years old, vertebral collapse

• bones are fragile and prone to fractures (esp. the vertebrae, hip and wrist)

• loss of height, postural changes, kyphosis, loss of flexibility, flexion of hips and knees, back pain, osteoporosis, fracture

Aging: Muscles

Increase in collagen and resultant fibrosis, muscles diminish in size (wasting) and tendons are less elastic

• loss of strength and flexibility, weakness, fatigue, stumbling, falls, diminished agility, decreased endurance, prolonged response time, diminished tone, broad base of support

Aging: Joints

Cartilage deterioration and thinning of intervertebral disc

• stiffness, reduced flexibility, and pain interfere with ADLs

• diminished ROM and loss of height

Aging: Ligaments

Lax ligaments, weakness

• postural joint abnormality and weakness

• joint pain on motion, resolving with rest

• crepitus

• joint swelling/enlargement

• osteoarthritis

Assessment of Poor Circulation

Pain

Pallor (cyanosis)

Poikilothermia (inability to regulate core body temperature)

Paresthesia

Paralysis

Pulselessness

Back Pain

Most common pain is in the lumbosacral and cervical vertebrae because these are the areas where the vertebral column is most flexible

• acute: < 3 months

• chronic: > 3 months

  • pain due to musculoskeletal disorders is aggravated by activity, whereas pain due to other conditions is not

  • assess gait, spinal mobility, reflexes, leg length, leg motor strength, and sensory perception

Signs of Back Pain

Pain

Radiculopathy (pinched nerve)

Sciatica

Muscle spasm and numbness/tingling

Leg weakness

Bowel/bladder incontinence or retention

Back Pain Interventions

PT

Heat/cold

Pharm:

• NSAIDs or muscle relaxants for acute pain

• Antidepressants or atypical anticonvulsants for chronic pain

Surgery

Prevention for low back pain and injury

Use good posture and safe manual handling practices, with specific attention to bending, lifting, and sitting

Assess the need for assistance with your household chores or other activities

Participate in regular exercise program (especially one that promotes back strengthening such as swimming or walking)

Avoid prolonged sitting or standing (use a footstool and ergonomic chairs and tables to lessen back strain, be sure that equipment in the workplace is ergonomically designed to prevent injury)

Keep weight within 10% of ideal body weight

Ensure adequate calcium and vitamin D intake

Stop smoking

Avoid high-heel shoes

Carpal Tunnel Syndrome

Common condition in which the median nerve in the wrist becomes compressed causing pain and numbness

• Median nerve supplies motor, sensory, and autonomic function for the first three fingers and the palmar aspect of the fourth (ring) finger

  • Since this nerve is so close to other structures, wrist flexion causes nerve impingement and extension cause increased pressure in the lower portion of the carpal tunnel

Signs of CTS

Paresthesias

Numbness

Pain worse at night

Weak pinch and clumsiness (dropping things)

Difficulty with fine motor movements

+Phalens and Tinels test

CTS Interventions

Splint/hand brace

Acupuncture

Pharm:

• NSAIDs for pain relief and inflammation

• Corticosteroid injections

Surgery

Health Promotion Activities to Prevent Carpal Tunnel

Become familiar with federal/state laws regarding workplace requirements to prevent repetitive stress injuries such as CTS

When using equipment or computer workstations that can contribute to developing CTS, assess that they are ergonomically appropriate…

• specially designed wrist rest devices

• geometrically designed computer keyboards

• chair height that allows good posture

Take regular short breaks away from activities that cause repetitive stress like working at computers

Stretch fingers and wrists frequently during work hours

Stay as relaxed as possible when using equipment that causes repetitive stress

Osteopenia

Low bone mass

Osteoporosis

A chronic metabolic disease in which bone loss causes decreased density and possible fracture from reduced bone mass, deterioration of bone matrix and diminished bone architectural strength

• both this and osteopenia occur when osteoclastic (resorption) activity is greater that osteoblastic (building) activity

• spine, hip, wrist are most often at risk, although any bone can fracture

Signs of Osteoporosis

Dowager’s hump/kyphosis

Appearing ‘shorter’

Back pain, especially with activity

Swelling

Malalignment

Constipation and abdominal distention

Reflux esophagitis

Respiratory compromise

Osteoporosis Labs/Tests

Serum calcium

Vitamin D3

Phosphorus

Urinary calcium

BMD Testing

• dual x-ray absorpitometry

  • DXA or DEXA scan

X-rays

Osteoporosis Interventions

Prevention is the best and needs to start early

Lifestyle modifications

Pharm:

• calcium and vitamin d3 supplements

• bisphosphonates: slow bone resorption by binding with crystal elements in the bone

  • fosamax, boniva, risedronate

• estrogen agonist/hormone therapy

Osteoporosis Complications

1.5 million fragility fractures each year

• women who experiences one hip fracture are 4 times greater to have a second fracture

• mortality rate for older patients with hip fractures is high, especially within the first 6 month and the debilitating effects can be devastating

• reported 1-year mortality after sustaining a hip fracture has been estimated to be 14-58%

Osteomalacia

Loss of bone related to a vitamin D deficiency causing softening of the bone resulting from inadequate deposits of calcium and phosphorus in the bone matrix (equivalent of rickets or vitamin D deficiency in children)

Signs of Osteomalacia

Muscle and bone weakness

Spinal kyphosis and bowed legs

Waddling and unsteady gait

Bone pain/tenderness

Labs/Tests for Osteomalacia

Low serum calcium and phosphorus

Low urine excretion of calcium

Use of x-rays

Interventions for Osteomalacia

For ALL at-risk patients, teach them about which high calcium and vitamin D foods to eat and the importance of adequate daily sunlight

Pharmacological:

• active vitamin D (calcitriol)

• adequate daily sunlight

• pain management

Osteoarthritis

Degenerative joint disease that is a non-inflammatory localized progressive deterioration and loss of cartilage and bone in one or more joints

• NOT systemic and NOT autoimmune

• As the cartilage and bone beneath the cartilage begin to erode, the joint space narrows and osteophytes (bone spurs) form

• Secondary joint inflammation can occur when joint involvement is severe

Signs of Osteoarthritis

Joint stiffness/pain

Pain that diminishes after rest and worsens with activity

Functional impairment

Possible tenderness

Crepitus

Heberden’s and Bouchard’s nodes

Joint effusions

Interventions for Osteoarthritis

Supportive care

Pain management

• Tylenol, NSAIDs, COX2 inhibitors, opioids

• Cortisone injections Q3 months

• Topical analgesic agents like diclofenac sodium gel, capsaicin, and methylsalicylate

PT/OT → exercise

Surgery/joint arthroplasty

Joint Arthroplasty

Surgical removal of an unhealthy joint and replacement of joint surfaces with metal or synthetic materials

Total Joint Arthroplasty

Involves the replacement of all components of an articulating joint

Indications for Joint Arthroplasty

Osteoarthritis

RA

Fractures

Failure of previous reconstructive surgeries (failed prosethesis)

What can a Joint Arthroplasty Provide?

Pain relief

Return of joint motion

Improved functional status and quality of life

• these all depend on the patient’s preoperative soft tissue condition and general muscle strength

Postoperative Care for an Older Adult with a Total Hip Arthroplasty

Abduction pillow/splint to prevent adduction after surgery if the patient is very restless or confused

Keep patients heels off the bed to prevent pressure ulcers

Do not rely on fevers as a sign of infection, decreased mental status is a better indicator in the elderly

Move the patient slowly as to prevent orthostatic hypotension

Encourage cough and deep breathing and use of the incentive spirometer

As soon as permitted, get them up!!

Anticipate pain relief needs

Expect a temporary change in mental status immediately after surgery as a result of anesthetic and unfamiliar sensory stimuli (reorient them frequently)

Postoperative care for the Adult with a Total Knee Arthroplasty

Apply CPM machine as soon as it is ordered

Manage the patient’s pain to provide comfort, increase participation in activity and improve joint mobility

Maintain the knee in a neutral position and not rotated internally or externally

Teach the patients that they are able to partially weight bear unless their prosthesis is not cemented

Complications of Total Joint Arthroplasty

Dislocation

VTE

Infection

Anemia

Neurovascular compromise

Osteomyelitis

Infection of the bone caused by bacteria, viruses, or fungi that can be severe and difficult to treat

Osteomyelitis: Vascular Insufficiency

Seen most commonly with diabetes and PVD

Most commonly affects the feet

Osteomyelitis: Hematogenous

Organisms are carried by the bloodstream from other areas of infection in the body

Osteomyelitis: Contiguous

Bone infection results from contamination from surgery, open fracture or traumatic injury

Signs of Acute Osteomyelitis

Fever (>38.3)

Swelling, erythema, increase heat and tenderness at the affected area

Constant localized bone pain

Pulsating that interferes with movement

Signs of Chronic Osteomyelitis

Foot ulcers

Sinus tract infection

Localized pain

Drainage from the affected area

Labs/Tests for Osteomyelitis

Leukocytosis

Elevated ESR

Blood/wound cultures

Radionuclide scans and MRI

Osteomyelitis Interventions

Prevention

General supportive measures (hydration, diet high in vitamins and protein)

Improve physical mobility with avoidance of stress on that bone

Pharm:

• ABX

• Pain management

Wound care

Surgery/debridement

Contusion

Soft tissue injury produced by blunt force (blow, kick, fall) causing small blood vessels to rupture and bleed into soft tissues (ecchymosis or bruising)

• a hematoma will form from bleeding at the site of impact leaving that black and blue appearance

Signs and Management of Contusions

Pain, swelling, possible discoloration

PRICE: protection, rest, ice, compression, elevation

Strain

Excessive stretching of a muscle or tendon when it is weak or unstable (sometimes called muscle pulls)

First Degree Strain

Mild inflammation, little bleeding, swelling, ecchymosis, and tenderness present

Second Degree Strain

Tearing of the muscle or tendon fibers without complete disruption

• muscle function may be impaired

Third Degree Strain

Ruptured muscle or tendon with separation of muscle from muscle, tendon from muscle or tendon from bone

• severe pain and disability result from severe strains and surgery may be needed

Strain Management

Cold/heat

Exercise

Activity limitations

NSAIDs and/or muscle relaxants

Sprain

Excessive stretching of a ligament caused by a twisting motion or hyperextension of a joint

First Degree Sprain Management

PRICE Therapy

Second Degree Sprain Therapy

Immobilization (elastic bandage and an air stirrup ankle brace or splint, and partial weight bearing while the tear heals)

Third Degree Sprain Therapy

Immobilization for 4-6 weeks and arthroscopic surgery many be done

Joint Dislocation

Occurs when the ends of two or more bones are moved away from each other and no longer in anatomic alignment

Signs:

• pain, decreased mobility, deformity, and deviation in length and rotation of the extremity

Management:

• immobilization

• closed reduction of the joint

• pain management

Subluxed Joint Dislocation

When the joint is only partially dislocated

Fracture

Break or disruption in the continuity of a bone that often affects mobility and sensory perception

Complete Fracture

The break is through the bone in such a way that the bone is divided into two distinct sections

Incomplete Fracture

The fracture is through only part of the bone

Open (Compound) Fracture

The skin surface over the broken bone is disrupted so there is an external wound

Closed (Simple) Fracture

Does not extend through the skin and therefore has no visible wound

Pathologic (Spontaneous)

Occurs after minimal trauma to a bone that has been weakened by disease

Fatigue (Stress)

Results from excessive strain and stress on the bone

Compression

Produced by a loading force applied to the long axis of cancellous bone

Facts of Fractures

When the bone is broken, adjacent structures also affected, which may result in soft tissue edema, hemorrhage into the muscle and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that cause the fracture or by fracture fragments.

Signs of Fractures

Moderate to severe pain

Muscle spasm, paresthesias

Loss of function

Ecchymosis, edema

Deformity, shortening of the extremity

SubQ emphysema, crepitus

Emergency Care of an Extremity Fracture

Assess ABCs, perform a quick head to toe

Immobilize by splinting, including joints above and below the injury

Remove clothing to inspect the affected area

Remove jewelry on the affected extremity in case of swelling

Apply direct pressure if there is bleeding

Keep the patient warm and in a supine position

Assess neurovascular status (check 6ps)

Cover any open wounds with a sterile dressing

Fractures Interventions

Reduce and immobilize

• Traction:

  • the application of a pulling force to part of the body to provide reduction, alignment, and rest

  • the goals of traction include decreasing muscle spasms and pain, realignment of bone fractures, and correcting or preventing deformities

• Splints or casts

Assess neurovascular and neuromuscular system frequently

PRICE therapy

Pain management

• non-opioid and opioid analgesics with anti-inflammatory drugs and muscle relaxants

Surgery

Immobilization devices potential complications

Compartment syndrome

Pressure ulcer/injuries

Infection

Disuse syndrome

Immobility

Anxiety

Complications from Fractures

Acute compartment syndrome

Crush syndrome

Hypovolemic shock

Fat embolism syndrome

VTE

Infection

Chronic compilations like ischemic necrosis or delayed union

Acute Compartment Syndrome

Increased pressure within one or more compartments encased by bone or fascia, reducing circulation to the area

Management:

• Fasciotomy

Signs of Acute Compartment Syndrome

Sensory perception deficits or paresthesia (usually 1st sign)

Pallor, pulses weaken

Affected area is palpably tense

Pain with movement

Then cyanosis, numbness, paresis, paralysis and necrosis

Crush Syndrome

Systemic manifestation of muscle cell damage resulting from pressure or crushing

• caused by a traumatic rhabdomyolysis due to muscle reperfusion injury when compressive forces on the tissues are released

  • this can cause local tissue injury, organ dysfunction, and metabolic abnormalities, including acidosis, hyperkalemia and hypocalcemia

• Prevention of renal failure is important

  • alkaline diuresis and mannitol therapy is recommended (hemodialysis is also recommended for acute renal failure)

Hypovolemic Shock

From a loss of blood

• the bone is very vascular and bleeding is at risk

• in addition, trauma can cut nearby arteries and cause hemorrhage

Management:

• stabilize the fracture to prevent further bleeding

• restore blood volume and circulation

• provide prover immobilization and protect from further injury

• pain relief

Fat Embolism Syndrome

Fat globules are released from the yellow bone marrow into the bloodstream causing clots

Signs:

• hypoxemia, dyspnea with tachypnea