Musculoskeletal/Orthopedic

Nursing Care Management of Clients with Musculoskeletal Disorders

Musculoskeletal System

consists of:


1. bones
2. muscles
3. joints
4. tendons
5. ligaments
6. cartilages
7. bursae

supports the body & facilitates movement

Main Function of MS

* storage site of calcium, phosphorus, magnesium, fluoride
* production of blood cells in bone marrow
* protection & support to organs: lungs, heart, brain

Other Functions of MS

can cause immobility, disability, & potentially affect quality of life

What happens if there are any injuries/diseases in the MS?

206 bones

How many bones are there in the body?

femur, humerus, radius

examples of a long bone

tarsals, carpals

examples of a short bone

skull, sternum, ribs, iliac

examples of a flat bone

patella

example of a sesamoid bone

Osteoblast

* builds the bones where the minerals are deposited
* calcification
* ossification

Calcification

calcium builds up in body tissue = tissue hardens

Ossification

process of bone formation

Osteocytes

forms new bone cells

Osteoclasts

* involved in destruction, reabsorption, remodeling
* “carpentry work”

Skeletal Muscle

* involuntary
* nerve innervation/stimulation => movement
* muscle tones

Flaccid (Muscle Tone)

muscle tone is absent

Spastic (Muscle Tone)

muscle that has greater nerve innervation

Atonic (Muscle Tone)

muscle that is not innervated; soft & flabby

Hypertrophy (Muscle Tone)

muscle that is enlarged due to repetitive exertion/movement

Atrophy (Muscle Tone)

muscle deterioration due to lack of use & movement

Smooth Muscle

found in the GIT

Cardiac Muscle

most dangerous & crucial

Joints

* allow movement between bony structures
* articulation

Synarthrosis

fixed (i.e. skull)

Amphiarthrosis

slightly movable (i.e. vertebral joints)

Diarthrosis

freely movable (i.e. hips, knees, wrists)

Tendons

* cord-like structures
* connects muscle - bone

Origin Tendon

fixed

Insertion Tendon

movable

Ligament

* fibrous tissue
* connects bone - bone
* provides stability = proper alignment

Cartilage

* connective tissue
* withstands pressure
* absorbs shock, pressure
* joint surfaces

Bursae

small sac filled w/synovial fluid to prevent friction between bony structures

Pt’s present health problem

the nurse elicits this information

involves:


1. upright body alignment (posture)
2. bone discrepancies (contour, length, alignment, symmetry)
3. bone motion (difficulty, smoothness, ROM)
4. gait (coordination, rhythm, stride, balance)
5. joint alignment (4S: symmetry, size, shape, stability)
6. joint movement (range, smoothness, pain, crepitus)
7. muscle mass (shape & firmness)
8. muscle strength (resistance & contractility)
9. muscle discrepancies (hypertrophy, atrophy, fasciculation, spasms)

what should be included in the MS assessment during physical examinations?

Crepitus

a cracking sound when moving

1. pain
2. pallor
3. paresthesia
4. pulses
5. paralysis
6. pressure

what are the 6Ps in MS assessment?

Pain

pain on palpation & movement

Pallor

pale skin or poor capillary refill

Paresthesia

pins & needles sensation (numbness & tingling)

Pulses

diminished/absent

Paralysis

movement

Radiographic Studies

detects MS structures

Bone Scan/CT Scan

provides 3D, cross-sectional image of soft tissues, bone, & spinal cord

Magnetic Resonance Imaging (MRI)

* imaging studies
* allows study of soft tissue in multiple planes of the body

Specific Studies

* Arthography
* Myelography
* Biopsy
* Arthrocentesis

Arthography

* used to look at a joint in the shoulders, knees, hips
* may be done if standard x-ray does not show the needed details of the joint
* evaluation & diagnosis of joint condition

Myelography

* invasive dx test that uses x-rays to examine spinal canal
* special dye is injected into spinal canal w/a hollow needle
* can show conditions affecting spinal cord & nerves within spinal canal

Biopsy

* procedure wherein a tissue or sample of cells is taken to be tested in a laboratory
* can help determine if there is cancer/another condition

Arthrocentesis

* joint aspiration
* performed to diagnose & may treat some MS conditions
* involves injecting medications (i.e. corticosteroid) to relieve pain

Electromyography (EMG)

* assess health of muscles & nerve cells that control them (motor neurons)
* may reveal nerve dysfunction, muscle dysfunction, problems w/nerve-muscle signal transmission

Relevant Laboratory Studies

* alkaline phosphate
* creatinine phosphokinase (CPK)
* serum calcium
* lactic dehydrogenase (LDH)
* rheumatoid factor (RH factor)

Alkaline Phosphate

* 44-147 IU/L
* screen/help diagnose diseases of liver/bones

Creatinine Phosphate (CPK)

* 10-120 mcg/L
* if muscle tissue is damaged, CPK leaks into the blood
* CPK indicate stress/injury to heart
* specific for muscular dystrophy (MD)
* elevated levels indicate muscle disease

Serum Calcium

* 8.5 - 10.2 mg/dL
* measure amount of calcium in the blood
* screens/monitors bone diseases/calcium regulation disorders

Lactic Dehydrogenase (LDH)

* 105 - 333 IU/L
* help identify location & severity of tissue damage in the body

Rheumatoid Factor

*

Bursitis (ID)

* inflammation/irritation of bursa sac
* bursa becomes irritated by overuse/excess pressure
* pain from bursitis may be sudden/builds up overtime
* common around major joints: shoulder, elbow, hip, knee

1. older age
2. jobs/hobbies that involve repetitive task (sports, manual labor, music)
3. arthritis, diabetes, gout, thyroid disease

what are the 3 main risk factors for Bursitis?

1. repetitive motion (i.e. pitcher throwing a baseball over & over)
2. spending time in positions that put pressure on specific parts of the body (kneeling may cause flare-ups)
3. sudden injury/infection (occasionally)

what are the causes of Bursitis?

1. carpentry
2. gardening/raking
3. poor posture/poorly positioned joint/bone (due to different leg lengths, bone spurs, or arthritis in a joint)
4. scrubbing
5. shoveling
6. sports (tennis, golf, baseball)

what are activities that can lead to Bursitis?

Median Nerve

* provides sensation (ability to feel) to the thumb, index finger, long finger, & part of the ring finger
* supplies impulse to muscle - thumb

Carpal Tunnel Syndrome (ID)

* median nerve compression
* pressure on the median nerve (which runs through the arm & goes through a passage in the wrist = carpal tunnel)
* can occur in 1 or both hands
* swelling inside the wrist causes compression in carpal tunnel syndrome = numbness, weakness, tingling on side of the hand

1. hand may “fall asleep” & drop objects
2. numbness
3. tingling
4. pain in the thumb & 1st 3 fingers of the hand
5. pain & burning that travels up the arm
6. wrist pain at night that interferes w/sleep
7. weakness in the muscles of the hand

what are the symptoms of carpal tunnel syndrome?

1. avoid positions that extends the wrist
2. wrist splints that hold the hand in a neutral position (especially at night)
3. mild pain medications & medications to reduce inflammation
4. treatment of any underlying conditions (arthritis or diabetes)
5. steroid injections into carpal tunnel to reduce inflammation

what are non-surgical options to treat carpal tunnel syndrome?

Osteomalacia (MBD)

* softening of the bones caused by severe Vitamin D deficiency
* can lead to bowing during growth (especially in weight-bearing bones of the legs)
* may lead to fractures in older adults

Vitamin D

* helps absorb calcium in the stomach
* help maintain calcium & phosphate levels to help bones form properly

1. lack of vitamin D


1. problem with diet
2. lack of sun exposure
3. issue w/intestines
2. body cannot process calcium in the bones

what are the causes of osteomalacia?

1. bone fractures are easy to induce
2. muscle weakness
3. hard time walking/develop a waddling gait
4. bone pain (especially in the hips)
5. dull, aching pain (may spread from hips to lower back, pelvis, legs, ribs)

what are the symptoms of osteomalacia?

1. low levels of vitamin D, calcium, phosphorus
2. alkaline phosphatase isoenzymes
3. levels of parathyroid hormone
4. Looser’s transformation zones

what are the dx tests for osteomalacia?

Alkaline phosphatase isoenzymes

high levels indicate osteomalacia

Level of Parathyroid Hormone

high levels indicate insufficient vitamin D & other related problems

Looser’s Transformation Zones

fractures can begin in these zones even with small injuries

Osteoporosis (MBD)

* body looses too much bone, makes too little bone or both = bones become weaker & may break down from a fall or minor bumps
* causes loss of bone density = increased risk for fractures
* “porous bones”
* increases size of spaces = lose bone strength & density
* more common in older adult women
* most common affected areas: ribs, hip, bones in wrists & spine

1. receding gums
2. weakened grip strength
3. weak & brittle nails
4. fracture from a fall or even a strong sneeze/cough
5. back/neck pain
6. loss of height

what are the symptoms of osteoporosis?

1. Age
2. Menopause
3. Gender (Female)
4. Ethnicity (Caucasian/Asian)
5. Family History of Osteoporosis
6. Poor Nutrition
7. Physical Inactivity
8. Smoking
9. Low Body Weight
10. Small-Boned Frame

what are the risk factors of osteoporosis?

Age

* biggest risk factor in osteoporosis
* 30s = body starts breaking down bone faster than its ability to replace it
* leads to bones with less density & more fragile (prone to breaking)

Menopause

* occurs in women aged around 45-55
* due to change in hormone levels, it can cause a woman’s body to lose bone even more quickly

Bone Density Test

* dx test for osteoporosis
* bone densitometry/dual energy x-ray absorptiometry (DEXA)
* measure density of bones in the wrist, hips, spine
* painless & takes 10-30 mins.

1. Bisophosphonates
2. Lifestyle Changes

treatment for osteoporosis

Bisophosphonates

* prevents loss of bone mass
* orally/injected
* includes:
* Aldendronate = Fosamax
* Ibandronate = Boniva
* Risedronate = Actonel
* Zoledronic Acid = Reclast

Lifestyle Changes

* increased intake of calcium & Vitamin D
* appropriate exercises

Osteoarthritis (DJD)

* wear & tear of weight-bearing joints (hip, knee, ankle)

1. increasing age
2. obesity
3. heredity
4. decreased bone density

what are the risk factors of osteoarthritis?

weight bearing joints: hips, knees, and spine

what joints are involved in osteoarthritis?

1. Herberden’s Node (distal interphalangeal joint)
2. Bouchard’s Node (proximal interphalangeal joint)

what are the bone affectations in osteoarthritis?

1. Radiographic X-Rays
2. Arthroscopy

what are the dx tests for osteoarthritis?

Rheumatoid Arthritis (DJD)

* autoimmune, systemic, inflammatory disorder of connective tissues/joint
* chronic w/remissions & exacerbations

Acute

RH nodules develop or are evident in bony prominences.

onset of RH symptoms

Bilateral & Symmetric

joint involvement of rheumatoid arthritis

1. Swan Neck Deformity
2. Boutonniere Deformity
3. Ulnar Deviation

what are the bone affectations in rheumatoid arthritis?

1. (+) C-reactive Protein (CRP)
2. (+) Rheumatoid Factor (RF)

what are the dx of rheumatoid arthritis?

Gouty Arthritis

* painful, metabolic inflammatory reaction in the joints
* decreased renal excretion of uric acid
* abnormal purine metabolism

Acute

* Tends to be inherited.
* Affects men more than women.
* Presence of hyperuricemia.

onset of symptoms of gouty arthritis

feet (great toe), hands, elbows, ankles, knees

what are the joints involved in gouty arthritis?

Gout Tophi (uric acid accumulation in the joint)

bone affectation of gouty arthritis

1. High Uric Acid Blood Test
2. 24-hour Urine Collection

dx tests involved in gouty arthritis

Inflammatory Symptoms

1. pain
2. swelling
3. redness
4. warmth

Systemic Symptoms

1. fever
2. malaise
3. anorexia
4. weight loss

Specific Symptoms

1. stiffness
2. movement limitation

Non-Pharmacologic Management for Degenerative Joint Diseases

1. local rest affected area
2. support devices: splints, braces, canes, crutches
3. exercises/physical therapy measures