Musculoskeletal Lecture Notes Review

Skeletal Muscle Structure

• Tendons anchor muscles to bones.

Radiographic Studies

• Used to examine muscles and bones.

Myelogram/Myelographic Exams

• Radiopaque dye injected into the subarachnoid space.
• Detects structural disorders: herniated discs, tumors, infections.

Assessment for Radiopaque Dye

• Allergies to iodine or seafood.
• Exam may involve entire spine or lumbar area.

Post-Myelogram

• Oil-based dye: Removed through spinal needle to prevent meningeal irritation.
• Water-soluble dye: Most often used; body absorbs and excretes it in urine.
• Encourage fluid intake to promote excretion.
• Inform patient about tilting table during test.

Patient Positioning After Water-Soluble Dye

• Lie quietly in semi-Fowler's position for ~8 hours to keep dye in lower spine.
• Encourage fluid consumption.

Patient Positioning After Oil-Based Dye

• Rest in flat position for up to 12 hours.

Post-Procedure Instructions

• Report headache, stiff neck, leg weakness, or difficulty voiding.
• Rare complications: seizures, numbness, paralysis, severe headache.

Procedure Explanation

• Needle inserted below spinal cord at L4-L5 space.

Body Movement

• Abduction: Moving away from midline.
• Adduction: Adding towards midline.
• Rotation.
• Supination: Palm faces upward and forward. Memory trick: "super" landlords holding hands up for rent.
• Pronation: Palm faces downward and back. Memory trick: pro basketball player dribbling.

Nuclear Scanning

• Performed in nuclear medicine department.
• Images recorded on radiographic film using low-dose radioactive isotopes.

Nursing Interventions

• Consent form required due to radioactive isotope.
• Inform patient isotopes will not affect family/visitors.
• Follow nuclear medicine department's instructions for specific scans.

MRIs (Magnetic Resonance Imaging)

• Preferred method for detailed pictures inside the body.

Contraindications

• Metal jewelry, metal fasteners, glasses, hair clips.
• Metal prostheses (heart valves, orthopedic screws).
• Pacemakers (magnetic effect).
  • Some newer pacemakers use different metals.
• Patients required to lie still for 30-60 minutes.

Claustrophobia

• Assess for claustrophobia due to tunnel environment.
• Sedation may be necessary for claustrophobic, demented, or anxious patients.
• Coordinate sedation timing with MRI schedule for effectiveness.

CT Scans (Computed Tomography)

• Uses narrow X-ray beam for 3D images.
• Iodine contrast dye may be used; assess for allergies.

Preparation

• Consent form.
• Baseline vital signs.
• Void before test.
• Remove metal articles.
• NPO for 3-4 hours before test.
• Working IV.

Patient Education

• Warmth or burning sensation in upper torso during infusion; may extend downwards.

Post-Test Care

• Observe for allergic reactions.
• Encourage fluids unless contraindicated.
• Resume diet unless changed by doctor.

Bone Scan

• Diagnoses conditions like osteomyelitis.
• IV administration of radionuclide 2-3 hours before the scan.
• Drink water to aid renal clearance of radioisotope.
• Scanning camera reveals radioisotope uptake.
• Concentrated uptake areas may indicate tumors or abnormalities.
• Test takes 30-60 minutes; patient must lie still.

Renal Clearance Monitoring

• Monitor BUN and creatinine levels.

Medication Interference

• Certain medications can interfere with the test.

Aspiration

• Needle used to obtain body fluid under local anesthesia.
• Biopsy of tissue often taken during aspiration.
• Consent required.
• Patient remains immobile during procedure.
• Maintain sterile technique to prevent infection.
• Apply sterile dressing to puncture site until bleeding stops.
• Collect and label specimens; send to lab immediately.
• Observe patient afterwards.

Arthrocentesis

• Puncture of a joint to withdraw synovial fluid.
• Diagnoses trauma, systemic lupus, gout, osteoarthritis, rheumatoid arthritis.
• Medication can be instilled during procedure.

Synovial Fluid Appearance

• Normal: Straw-colored, clear, or slightly cloudy.
• Trauma: Cloudy, milky, sanguineous, yellow, green, or gray.

Post-Procedure Care

• Proper joint support (e.g., pillow under knee).
• Rest joint for 12 hours.
• Apply ice for 24-48 hours (intermittently).
• Anti-infectives or corticosteroids may be prescribed (steroid injection often given).

Endoscopic Exams

• Consent form required.
• Preoperative checklist: Remove jewelry, dentures.
• NPO for 6-12 hours before.
• Baseline vital signs.
• Maintain safety with preoperative medications.

EGD (Esophagogastroduodenoscopy)

• Must spell out completely on consent form: Esophagogastroduodenoscopy.
• Cannot abbreviate on consent form.

Arthroscopy

• Endoscopic examination for direct visualization of joints.
• Determines presence of disease, drains fluid, removes damaged tissue/foreign bodies.
• Commonly performed on knee (synovium, meniscus); can also be done on hip/shoulder.
• Insertion of large-bore needle into suprapatellar pouch and saline instillation into the joint.

Anesthesia

• Local or general anesthetic given.

Post-Exam Instructions

• Limit activities for several days.
• If done on the knee, patient must be able to bend knee 45 degrees and be free of infection.

Electrographic Procedures

Electromyogram (EMG)

• Insertion of needle electrodes into skeletal muscles to assess electrical activity.
• Electrical activity heard, seen on oscilloscope, and recorded on paper.
• Observes nerves for neuropathy and muscles for myopathy.
• Used for diagnostic purposes (chronic lower back pain, ulnar nerve dysfunction).
• Uncomfortable test with a mild shock sensation.

Inflammatory Disorders

Rheumatoid Arthritis (RA)

• Chronic systemic inflammatory autoimmune disorder leading to severe joint deformity.
• More common in women; has a genetic link.
• Smoking increases risk; additional risk factors include bacterial/viral diseases.
• Systemic disorder affecting any organ.
• Characterized by chronic inflammation of the synovial membrane (synovitis).

Pathophysiology

• Body's immune system attacks its own proteins.
• Periods of remission and exacerbation (flare-ups due to stressful events).
• During flares, the body is being damaged, which can eventually lead to death.

Assessment

• Joint pain, tenderness, stiffness (≥6 weeks).
• Morning stiffness (≥30 minutes).
• Small joints affected (wrists, hands, feet).
• Bilateral involvement.
• Fatigue, low-grade fever.
• Flares last days to months.
• Commonly affected organs: eyes, oral cavity, skin, lungs.
• Edema, tenderness, nodules on fingers.

Diagnostic Tests

• No specific test; includes rheumatoid factor (positive during active flare), uric acid, CBC, ESR (indicates inflammation).
• Four frequent symptoms: morning stiffness, joint pain, muscle weakness, fatigue.
• Other tests: anti-CCP, ANA titer, CRP, ESR.

Medical Management

• Aggressive treatment early in disease course.
• Pain relief and reduced clinical symptoms.
• Medications: disease-modifying and anti-inflammatory drugs (DMARDs).
  • Methotrexate suppresses immune system; educate about avoiding crowds, handwashing, and sick people.
• Mobility and physical therapy.
• Weight management.
• NSAIDs (fish oil, vitamin C, E, antioxidants).

Interventions and Teaching

• Fatigue management (restful sleep during exacerbation).
• Exercise to prevent joint freezing and muscle weakening.
• Warm packs, heating lamps, paraffin wax treatments.
• Protect joints, energy conservation, balance rest and activity.
• Medication compliance and side effects.

Medications (detailed)

• Meloxicam: Anti-inflammatory; Avoid taking other NSAIDs.
• Hydroxychloroquine: Antimalarial with anti-inflammatory effects.
  • Requires eye exam before starting and every 6 months. Eye damage can occur.
• Methotrexate: Antineoplastic; suppresses immune system.
  • Avoid pregnancy and vaccinations without provider consent.

Ankylosing Spondylitis (AS)

• Rheumatic disorder affecting spine, sacroiliac, and hip joints (psoriatic arthritis group).
• Affects fingers, toes, causes back pain/stiffness, changes to nails, psoriatic lesions.
• Cause unknown; genetic link (HLA-B27 marker), environmental triggers, family history, frequent GI infections.
• Occurs more commonly in men.

Clinical Manifestations

• Inflammation of the spine causes fusion.
• Affects neck, jaw, shoulders, knees, hips.
• Ligaments harden (ossification).
• Cardiovascular issues: cardiomegaly, pericarditis.
• Kyphosis (hunchback).
• Respiratory concerns due to spine involvement.
• Vision loss and blindness can occur.

Assessment

• Low back pain, sciatica pain, weight loss, abdominal distension, fatigue.

Diagnostic Tests

• Lab values: CBC (anemia: low hemoglobin/hematocrit).
• Elevated ESR and CRP (inflammation).
• Elevated serum alkaline phosphatase.
• Positive HLA-B27 marker.
• X-ray shows fusion.

Medical Management

• Pain and inflammation management with analgesics, NSAIDs, corticosteroids, TNF inhibitors (infliximab, etanercept).
• Regular low-impact exercise recommended to prevent bone demineralization, promote flexibility, and improve posture. Swimming, walking.
• Surgery may be necessary to replace fused joints.

Nursing Interventions

• Maintain spine alignment with a firm mattress, bed board, back brace.
• Lie on abdomen for 15-30 minutes, 4 times a day to extend the spine.
• Turn and reposition every 2 hours to prevent bedsores.
• Postural and breathing exercises.
• Heat reduces pain and stiffness; cold helps with inflammation and swelling.

Osteoarthritis (OA) / Degenerative Joint Disease (DJD)

• Most common form of arthritis from regular wear and tear.
• Nonsystemic, noninflammatory disorder.
• Begins with cartilage degeneration causing damage to bones.
• Obesity is a major factor.
• Consequence of aging; major cause of severe chronic disability.
• Primary (cause unknown) and secondary (trauma, infections, rheumatoid arthritis, stress on bones).

Manifestations

• Joints of hands, knees, hips, cervical and lumbar vertebrae most commonly affected.
• Stiffness, usually in the morning.
• Grating or cracking sound when moving joints.

Assessment

• Joint edema, tenderness.
• Bouchard's nodes on fingers.

Diagnostic tests

• No specific test; includes MRI, arthroscopy, synovial fluid analysis.

Medical Management

• Exercise balanced with rest periods; physical therapy.
• Gait enhancers (walkers, canes).
• NSAIDs, corticosteroids (injection of corticosteroids following aspiration of synovial fluid).
• Hypertension screening required (NSAIDs increase blood pressure).
• Indomethacin decreases the effect of enalapril.
• Ibuprofen and, lisinopril together can trigger a hypertensive response.
• Tramadol hydrochloride (pain medication; now classified as a narcotic).

Nonpharmacological Management

• Heat therapy, relaxation techniques, massage therapy, cupping.

Nursing Interventions

• Maintain ADLs as much as possible (promote independence).
• Adapt to disease: weight loss, diet, exercise, gait enhancers.
• Ensure patient safety.