MUSCULOSKELETAL DISORDERS

Osteoporosis
A condition characterized by low bone mass and structural deterioration of bone
tissue, leading to increased bone fragility
Major cause of fractures in elderly and post-menopausal women
8 times more common in women than men
Cannot be detected by x-ray until more than 25%-40% of calcium in the bone is lost
Cause of primary OA is unknown
Secondary OA has a precipitating event
Joint cartilage becomes yellow and opaque with rough surfaces and areas of malacia
Fragments of cartilage may come loose
Inflammation of the synovial membrane secondary to the cartilage breakdown
Clinical Manifestations
Weight bearing joints are the most affected
Joint stiffness occurs after periods of rest
Crepitation may be present
Usually affected asymmetrically
Heberdens nodes
Commonly affects hips, knees and vertebral column
Nursing Diagnoses
Pain
Sleep pattern disturbance

 Impaired physical mobility

Self-care deficit
Self-esteem disturbance
Altered nutrition: more than body requirements
FRACTURES
Disruption or break in continuity of the structure of a bone
Occurs from trauma (MVA, fall, etc.) or pathologic
Classified by types, communication with the environment and location
Can also be stable or unstable
Types of fractures
Complete fractures
Incomplete fracture
Comminuted fracture
Closed fracture
Open fracture
CLINICAL MANIFESTATIONS
Edema and swelling
Pain and tenderness
Muscle Spasm
Deformity
Ecchymosis
Loss of function

 Crepitation
COMPLICATIONS
Infection
Compartment syndrome
Fat embolism
Shock
Avascular necrosis
Delayed union and non-union
Reactions to internal fixation devices
Fat Emboli
Fat embolism: after fracture of long bones or pelvis, multiple fractures or crush
injuries, fat emboli may develop, especially in young adults men, typically 20-30
years old.
Clinical manifestations
Hypoxia
Tachypnea
Systemic emboliztion: petechiae are noted in the buccal membrane and conjunctival
sac, on the hard plate or fundus of the eye.
Over the chest and anterior axialllry folds.
Prevention
Quick immobilization of fracture
Minimal fracture manipulation
Adequate support for fractured bones during turning and positioning.

SHOCK
Delayed union and nonunion
Delayed union: occurs when healing does not advance at a normal rate for the
location and type of fracture.
Nonunion: failure of the ends of a fractured bone to unite. (please read medical
management on p. 1839)
Avascular necrosis of bone
Occurs when the bone loses its blood supply and dies.
READ
P. 1839
Reaction to internal fixation device
Reflex sympathetic dystrophy syndrome
Heterotrophic ossification
Emergency management of fractures
Immobilize the minute you believe there is a fracture.
Splint.
If an open fracture cover the wound with a clean sterile dressing to prevent
contamination of deeper tissue
Medical management
Reduction
Immobilization
Maintaining restoring function
READ p. 1840-1841

TRACTION
SKIN
Bucks
Russells
Bryants
Pelvic belt
Pelvic sling
CIRCUMFERENTIAL
SKELETAL
Overhead arm
Lateral arm
Balanced suspension
HIP FX & REPLACEMENT
Usually women > men
Approximately 75% of falls occur indoors
14% 36% death rate within one year
25% cant walk independently
60% do not gain pre-fx ambulation
Intracapsular fracture
Intracapsular fracture: occurs within the capsule
Their name is taken from the specific location (subcapital, transcervical, or basilar
neck).

 These fractures are often associated with osteoporosis and minor trauma.
Extracapsular Fracture
Occurs below the capsule and are termed intertrochanteric if they occur in a region
between the greater and lesser trochanter.
Usually occurs from sever direct trauma or a fall.
Clinical manifestations
External rotation
Muscle spasms
Shortening of the affected ext.
Severe pain
Tenderness to the region of the fracture site
Displaced femoral neck fractures cause serious disruption of the blood supply to the
femoral head, which can result in avascular necrosis.
Care
Surgery repair is the preferred method of managing Intracapsular and Extracapsular.
Treatment with traction requires 12-16 weeks of immobilization for healing to occur,
even if the blood supply to the region is intact.
Initially the affected area is placed in either a bucks or Russell until surgery.
Traction can relieve muscle spasms.
Intracapsular
are usually repaired with the replacing the head of the femur.
Slow to heal because of the disruption in the blood supply
Extracapsular
is usually pinned.

Nursing management
Patients surgery may be delayed if the patient has DM, cardiovascular issues. The
surgeon might wait till the patient is stabilized.
Analgesics or muscle relaxants (control muscle spasms)
Teach patient to use trapeze and show them the exercise prior to surgery.
Practice getting in and our of bed.
Post surgery
Vitals
I &O
Pain med
Check dressing for signs of bleeding and infection
Access the toes for neuro-vascualr assessment
Ambulaton usually begins on the first day by P/T. Either a walker or crutches are
used.

What not to do after hip surgery

Do not force hip into greater than 90 degrees of flexion
Do not force into adduction
Do not force hop into internal rotation
Do not cross legs
Do not put on shoes or stockings until 8 weeks after surgery without adaptive device
Do not sit on chairs without arms to aid rising to a standing position.
What you should do after hip surgery
Use toilet elevator on toilet seats.

 Place chair inside shower or tub and remain seated while you wash.
Use pillow between legs for 8 weeks when lying on the good side or when supine.
Keep hip in neutral , straight position when sitting, walking or lying.
Notify surgeon of severe pain, deformity or loss of function.
Inform dentist of presence of prosthesis before dental work so that antibiotics can
be given.
NURSING DIAGNOSES
Impaired physical mobility related to surgical procedure
Pain related to edema from surgery site
High risk for infection related to surgical procedure
Impaired skin integrity related to immobility and to surgical procedure
CRITICAL THINKING
You have a 68 yo female patient that presents to your floor from the ER with a Right
Hip Fx. She has a foley in place. Ordered is Bucks traction with 5 lbs. weight. She is
scheduled to have surgery tomorrow.
Your pt. comes back after surgery. What will you do to care for her over the next
few days?
AMPUTATIONS
In upper extremities, usually from trauma
In lower extremities, usually from vascular problems, except in younger patients
In patients with DM, wound care and eye exams should be a priority due to potential
complications of this disease
Goal is to preserve extremity length and function while removing all infected, etc.
tissue
TYPES

 Symes
Below the knee (BKA)
Above the knee (AKA)
Hip disarticulation
Guillotine (open)
Rays
Above the elbow (AEA)
Nursing Management
Inspect the amputation for signs of irritation, especially redness and abrasion.
Discontinue use of the prosthesis if an irritation develops.
Wash residual limb thoroughly each night with warm water and bacteriostatic soap.
Dry gently
Do not use any substance such as lotions, alcohol, powders, or oil unless prescribed
by doc.
Change residual limb sock daily
Post op
Use pain med
Perform ROM to all joints daily.
Do not elevate residual limb on pillows
Lay prone with hp extension for 30 minutes three to hour times a day.
Phantom pain
Warn the patient that they might feel this.
That they might feel that the limb is still there.

 itching, tingling, aching.

Coldness, shooting, burning or crushing pain.
This pain is real
NURSING DIAGNOSES
Body image disturbance related to loss of body part
Impaired skin integrity related to surgical procedure
Pain related to phantom limb sensation
Impaired physical mobility related to loss of body part
POST-OP CARE
Hemorrhage
Phantom pain or sensation
Sterile dressing changes
KEEP TOURNIQUET AT BEDSIDE
Watch for flexion contractures
Immediate prosthetic vs. delayed prosthetic fitting
Grieving process
Encourage behaviors other members of health care team have taught
Orthopedic Surgery
Pre-op care
Focus on hydration
Current med history
Possible infection

Diagnosis
Pain related to fracture, orthopedic problems, swelling, or inflammation
Risk for peripheral neurovascualr dysfunction related to swelling, constricting
devices, impaired venous return
Risk for ineffective management of therapeutic regimen related to insufficient
knowledge or available support and resources.
Nursing Interventions
Relieving pain
Maintaining adequate neuro-vascular function
Promoting Health
Improved mobility
Helping the patient maintain self-esteem.
Assessment of post op
All systems
Please read p.1801-1802
Complications
Hypovelmic shock
Atelectasis pneumonia
Urinary retention
Infection
Venous stasis
Interventions
Relieve pain

 Maintain adequate neurovascular

Maintain Health
improve physical mobility
Maintain self-esteem
Monitor complications
Diagnosis
Pain related to the surgical procedure, swelling, and immobilization.
Risk for peripheral neurovascular dysfunction related to swelling, constrictive
devices, or impaired circulation.
Osteomyelitis
An infection of bone by direct or indirect invasion by an organism
Most commonly affected is the vertebrae in an adult
Direct entry is contamination from open fracture or surgery
Indirect is a blood-borne infection from a distant site
Most common infecting organism is Staphylococcus aureus
Are seeing occurrence of MRSA now
Acute osteomyelitis refers to the initial infection or an infection of less than 1
month in duration
Chronic osteomyelitis refers to a bone infection that persists for longer than 4 weeks
or an infection that has failed to respond to initial tx
Clinical Manifestations
Fever
Night sweats
Chills

 Restlessness
Nausea
Malaise
Severe bone pain
Swelling
Tenderness
Warmth at site
Restricted movement
Drainage from sinus tracts to the skin and fracture site
Chronic Pus accumulation and scar tissue formation
Diagnostics
Wound culture determines the causative organism
A bone or tissue biopsy is the definitive way to determine the causative agent
Elevated WBC, Leukocytes and Sed. Rate
On x-ray, will take at least 10 days to show if not weeks
Can also do a CT or MRI or gallium scan
Collaborative Care
Vigorous antibiotic therapy
Surgical debridement and decompression
Immobilization of affected part
Surgical removal of dead bone
Constant irrigation

 Long hospital stay due to need for IV antibiotics

Diagnoses
Pain
Hyperthermia
Impaired physical mobility
Ineffective management of therapuetic regimen
High risk for infection
Knowledge deficit
Self-care deficit
Body image disturbance
Impaired skin integrity
Osteoarthritis
Also known as degenerative joint disease (DJD)
Is a slowly progressive disorder of articulating joints and is characterized by
degeneration of articular cartilage
Damage is confined to the joints and surrounding tissues
Cause of primary OA is unknown
Secondary OA has a precipitating event
Joint cartilage becomes yellow and opaque with rough surfaces and areas of malacia
Fragments of cartilage may come loose
Inflammation of the synovial membrane secondary to the cartilage breakdown
Clinical Manifestations
Weight bearing joints are the most affected

 Joint stiffness occurs after periods of rest

Crepitation may be present
Usually affected asymmetrically
Heberdens nodes
Commonly affects hips, knees and vertebral column
Nursing Diagnoses
Pain
Sleep pattern disturbance
Impaired physical mobility
Self-care deficit
Self-esteem disturbance
Altered nutrition: more than body requirements