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Physiology
Skeleton
Classification of bones
Compact (dense)
Cancellous (spongy)
Bone marrow
Axial section
Appendicular section
Joint articulations
Muscles
Diagnostic Tests and
Assessments
Radiologic tests
Are diagnostic studies performed using x-
rays, with or without injection of contrast
media, to detect musculoskeletal problems
and monitor effectiveness of treatment
X-ray (radiograph): most common and
widely used radiologic test for assessment
of musculoskeletal problems and
effectiveness of treatment
Diagnostic Tests and
Assessments
EMG (electromyogram or myogram):
records and evaluates the electrical
activity of muscles during contraction
Detects abnormal electrical activity in
muscle
There are two different types of EMG:
intramuscular (IM) EMG (more commonly
used) and surface EMG (SEMG)
Diagnostic Tests and
Assessments
Long, small-gauge needles are inserted through
the skin into muscle
Needles detect electrical activity of the muscle
and transmit information into electromyogram
machine; electrical activity is displayed visually
on an oscilloscope or heard audibly through an
audiotransmitter (microphone)
(SEMG): electrodes are placed above muscle to
detect electrical activity
Diagnostic Tests and
Assessments
Arthroscopy: a surgical procedure used
to examine the internal structure of a joint
using an arthroscope il-sized device with
optical fibers and lenses), which is inserted
into very small skin incisions; device is
connected to a video camera to allow for
visualization of the interior of the joint
Diagnostic Tests and
Assessments
Procedure may be used for diagnosis or
treatment of musculoskeletal disorders such
as osteoarthritis, rheumatoid arthritis,
infectious types of arthritis, and internal joint
injuries like meniscus tears, ligament strains
or tears and cartilage deterioration
Arthroscopic surgery can be done during
procedure to repair joint tissues;
arthroscopic surgery creates less tissue
trauma, less pain, and allows for a rapid
recovery
Diagnostic Tests and
Assessments
Client education: postprocedure
Encourage client to take analgesics for comfort
and limit activity as directed
Instruct client to observe site for hematoma or
bleeding
Teach client how to perform neurovascular
assessment (temperature, color, capillary refill,
movement, and sensation) on affected
extremity
Teach client about signs and symptoms of
infection to report; elevated temperature,
warmth at injection site, purulent discharge,
and redness
Diagnostic Tests and
Assessments
Arthrogram: contrast media or air
is injected into the joint cavity to
allow for visualization of joint
structures; client moves joint
through a series of movements while
a series of x-rays are taken; assess
for allergy to contrast media
Diagnostic Tests and
Assessments
Client education preprocedure: if injected
contrast dye is used, inform client that once the
dye is injected there may be a feeling of warmth,
nausea, headache, salty taste in the mouth,
itching, hives, and rash throughout the body
(symptoms are usually temporary and will be
treated if necessary
Client education postprocedure
Inform client that temporary discoloration of the
skin and urine is normal after injection of dye
Teach client to perform neurovascular assessment
on affected extremity
Diagnostic Tests and
Assessments
CT scan (computerized axial
tomography): combines x-rays with
computer technology to produce a
highly detailed, cross-sectional
image of internal organs and
structures of the body; also known as
CAT scan
Diagnostic Tests and
Assessments
Body is visualized from skin to central part
of the body being examined; recorded
image is called a “tomogram”
Client education
If ingested contrast dye is used, instruct client
to increase fluid intake to assist in elimination
of dye
Monitor for evacuation of contrast media and
possible constipation
Initial stools may be white in color, which is
normal until all contrast media is evacuated
Diagnostic Tests and
Assessments
MRI (magnetic resonance imaging):
radiologic technique (without radiation)
that uses magnetism, radio waves, and a
computer to produce cross-sectional
images of the body structures
Machine is extremely noisy and may cause or
exacerbate a claustrophobic sensation
Diagnostic Tests and
Assessments
Client education
Explain procedure to the client; a mild sedative may
be given preprocedure to help decrease any anxiety
associated with a claustrophobic feeling
Instruct client to notify healthcare providers of any
metallic body parts such as implants, pacemakers,
artificial joints, metallic bone plates, prosthetic
devices, surgical clips, bullet fragments, metallic
clips, or other al objects within the body that can
distort the MRI image or affect the magnetic field
Diagnostic Tests and
Assessments
Bone scan: technique used to create images of
bones on a computer screen or on a film using a
small amount of radioactive material that travels
through the bloodstream
Radioactive material is especially absorbed in
abnormal areas of a bone; degree of dye absorption is
related to the amount of blood flow to the bone
A camera scans the entire body and a recording is
made on a special film
Increased dye absorption is seen with osteomyelitis,
osteoporosis, fractures, Paget’s disease and cancer of
the bone
Diagnostic Tests and
Assessments
Arthrocentesis (joint aspiration)
and analysis: fluid is removed from
joint to reduce swelling and pain
and/or obtain fluid for examination
using a sterile needle and syringe
Post-procedure complications are
uncommon but may include localized
bruising, minor bleeding into the joint
cavity, and loss of pigment at injection
site (septic arthritis is a rare but
serious complication)
Diagnostic Tests and
Assessments
Client education
If cortisone medication was injected into the joint,
teach client to monitor for inflammation of the
injected area, atrophy or loss of pigment at the
injection site, and increased blood glucose
Instruct client to follow post-procedure activity
restrictions as directed by healthcare provider
Instruct client to monitor for post-procedure
complications and check dressing for excessive
bleeding
Laboratory Studies
Osteomyelitis
Acute or chronic infection of the
bone usually caused by the
staphylococcus aureus organism
Osteomyelitis
Assessment
Observe for symptoms of local and/or systemic
infection: elevated temperature, chills,
restlessness, severe bone pain unrelieved by
analgesics or rest and aggravated by
movement, swelling, redness, and warmth at
the infection site
Wound culture, bone scan, CT scan, and MRI
provide information for diagnosis and
assessment of the extent of infection
Osteomyelitis
Medication therapy
Indicated with or without surgical
intervention
Generally includes antibiotics and
analgesics
Reinforce information about adverse
effects of antibiotic therapy as
outlined in previous section
Osteomyelitis
Client education
Teach client about the importance of taking
antibiotic medications as prescribed (for the
full duration) and to report adverse effects
of the medication to prescriber
Review medication regimen and have client
verbalize an understanding of teaching
Reinforce the importance of rest and proper
diet to facilitate healing, and prevent
constipation and dehydration
Reinforce the importance of limb
immobilization during treatment
Osteomyelitis
Muscular dystrophy (MD)
Muscular dystrophy (MD)
Medication therapy
There is no effective
pharmacological or other treatment
Corticosteroids are often used to
increase muscle strength
Muscular dystrophy (MD)
Client education
Provide information about healthcare
team members and roles, including
those involved in homecare program
for client
Instruct family to offer client soft foods
and to cut into small pieces to prevent
aspiration and choking
Muscular dystrophy (MD)
Encourage family members to seek genetic
counseling (parents, female siblings, maternal
aunts, and female offspring)
Assist family in decision-making about
appropriate clothing and footwear because of
contractures and wheelchair-bound status
Provide family with informat6ion on community
support groups and agencies with respite services
to prevent role strain
Muscular dystrophy (MD)
Muscular dystrophy (MD)
Paget’s disease (osteitis
deformans)
Paget’s disease (osteitis deformans)
Description
Chronic skeletal bone disease with insidious
onset
Diagnosed around the fourth decade of life
Results in enlarged, deformed bones but
does not affect normal bones
Generally affects skull, long bones, spine,
and ribs
Paget’s disease (osteitis
deformans)
Etiology and pathophysiology
Cause of disease unknown; however,
viral infection has been hypothesized
as a probable etiology
Hereditary factor: may be seen in
more than one family member
Early diagnosis and treatment is
important to prevent disease
progression and deformity
Paget’s disease (osteitis
deformans)
Excessive bone resorption followed by
bone formation leads to weakened
bone, bone pain, arthritis, deformity,
and potential pathologic fractures
Normal bone marrow is replaced by
vascular, fibrous, connective tissue that
leads to formation of larger,
disorganized, and weaker bone tissue
Paget’s disease (osteitis
deformans)
Assessment
X-ray is the most definitive
diagnostic test
Initial diagnostic tests include serum
alkaline phosphatase (elevated level
is a positive indicator for the
disease)
Paget’s disease (osteitis
deformans)
Bone scan may be done after positive serum
alkaline phosphatase test (positive result will
show characteristic abnormal appearance of
bone for Paget’s disease such as curved
contours and thickened cortex)
Positive bone scan prompts x-ray for
definitive diagnosis
Mild form of disease may be undetected
because there may be no symptoms
Paget’s disease (osteitis
deformans)
Symptoms include bone pain (most common
complaint) and other symptoms depending on
which bones are affected with the disease
for example, if the skull is affected, headache
and hearing loss may be reported as well as
increasing head size
Hip pain may be present if the pelvis or femur
is involved
Bowing of the lower extremities producing a
waddling gait and curvature of the spine may be
seen in advanced stages of the disease
Paget’s disease (osteitis
deformans)
Planning and implementation
Prognosis is good especially if treatment
is started before major deformity occurs
Provide analgesics and muscle relaxants
for comfort
Administer medications as directed to
control progression of disease (see
medication section)
Paget’s disease (osteitis
deformans)
Encourage client to take medication as directed by
healthcare provider since deformity and loss of bone
strength will continue without prescribed medications
If skull is affected, assists with diet modification,
dentures, and eating utensils since teeth may
become weak from the disease
Hearing aid may be recommended if hearing loss
results from the disease
Refer client and family to support group
Paget’s disease (osteitis
deformans)
Medication therapy
The goal of treatment is to control progression
of the disease
The following medications are approved by the
Federal Drug Administration (FDA):
biophosphonates, etidronate disodium
(Didronel), pamidronate disodium (Aredia),
alandronate sodium (Fosamax), tiludronate
disodium (Skelid), residronate sodium
(Actonel), and calcitonin (Miacalcin)
Paget’s disease (osteitis
deformans)
Client education
Ensure that client has a good understanding of
plan for pain management
Encourage client to take analgesics as
prescribed to enhance comfort
Teach client about the importance of a balanced
diet, high in calcium (1,00 mg to 1,mg/day) and
vitamin D (at least 400 units/day); vitamin D
can be obtained from exposure to sunlight
Instruct client to inform healthcare provider of
any history of Kidney stones or disease before
taking calcium
Paget’s disease (osteitis
deformans)
Encourage client to participate in an exercise
program to maintain skeletal muscle health, ideal
body weight, and joint mobility
Instruct client to sleep on a firm mattress if back
discomfort is present; if back brace is needed,
instruct client on the prevention of skin breakdown
under brace (undershirt) and safety measures (no
driving with brace)
Encourage client to modify environment at home to
prevent falls that may lead to subsequent fractures
Encourage client to participate in community support
group
Paget’s disease (osteitis
deformans)
Musculoskeletal trauma
Fractures
Description
A fracture is a break in the continuity of the
bone
Fractures may be classified as:
Closed (simple fracture): the bone breaks
but the skin remains intact
Open (compound fracture): broken ends
of the bone penetrate the skin
Musculoskeletal trauma
Fractures may also be classified as:
Avulsion: a fracture resulting from
the tearing of the supporting tendons
and ligaments
Comminuted: the broken bone
fragments into more then two pieces
Compressed: the bone is crushed
Impacted: ends of the broken are
driven into each other
Musculoskeletal trauma
Hip fracture
Description: the hip can be fractured at
different sites, namely, the head, neck,
and trochanteric areas;
Pathophysiology: incidence of hip
fracture increases with age; 90 percent
of hip fractures are caused by falls
Musculoskeletal trauma
Assessment
a hip fracture is a medical emergency
hip fractures are generally sustained from
falls; monitor level of consciousness and
assess for other injuries
perform neurovascular assessment on
affected extremity
extremity of affected hip will be shorter than
unaffected extremity
fractured hip will generally externally rotate
Musculoskeletal trauma
Planning and implementation
Prepare client for surgical intervention (verify
allergies, informed consent, etc.)
Instruct client that an abductor pillow or splint
may be necessary to prevent disarticulation of
the femur
Inform client that sandbags may be used
along the external border of the affected limb
to prevent external rotation
Inform client that pain medication will be
available for comfort postoperatively
(generally patient controlled analgesia [PCA] is
used)
Musculoskeletal trauma
Teach client about the pain rating scale to be
used postoperatively and encourage client to
report any discomfort
Teach client deep-breathing and coughing
exercises preoperatively
Use aseptic technique for dressing changes and
wound drainage
Provide information on therapies and equipment
to expect postoperatively (indwelling urinay
catheter, PCA, IV therapy, possible traction, etc.)
Monitor preoperative use of skin traction to
immobilize the limb until surgery is ordered
Musculoskeletal trauma
Client education
Reinforce deep-breathing and coughing
exercises postoperatively
Preoperatively teach client about
postoperative precautions to prevent hip
dislocation (no hip flexion greater than 90
degrees, internal rotation of affected hip, or
adduction of affected hip); these include such
activities as avoiding low chairs, using raised
toilet seat, no excessive bending
Reinforce teaching about postoperative
course
Sprains and strains
Musculoskeletal trauma
Sprains and strains
Description
A sprain is a stretch and/or tear of
a ligament
A strain is a twist, pull, and/or
tear that may involve both
muscles and tendons
Musculoskeletal trauma
Etiology
Direct or indirect trauma (caused by fall, blow to the body,
muscle exhaustion)
Overuse or prolonged repetitive motion of tendons
Inadequate rest periods during intensive training
Ankles, knees, and wrist are most vulnerable
Frequently seen in athletes and individuals with poor
physical conditioning or who are overweight
Musculoskeletal trauma
Assessment
Sprains are classified based on the
degrees of ligament injury
Pain is aggravated continuous use and
influenced by the degree of injury
Assess for changes in neurovascular status
(pulse, temperature, capillary refill, and
movement) of affected extremity
Decreased mobility in affected extremity
Musculoskeletal trauma
Medication theraphy:
anti-inflammatory agents, (such as
colchicines, NSAIDs or
corticosteroids),
antihyperuricemic (such as allop-
urinol [Zyloprim]) and uricosurics
(such as prebenecid [Probalan])
Gout
Client education
Reinforced teaching covered in planning
implementation sections above
Teach client about, side/adverse effects of
medication
Teach client that medications should be
taken with meals to avoid gastric irritation
Instruct client to avoid use of alcoholic
beverages when taking medication
Instruct client to drink at least 2.5 to 3 liters
of fluid/day when taking medication
Degenerative Joint Disease
(DJD) or Osteoarthritis (OA)
Osteoarthritis (OA)
Slowly progressive disorder of articulating
joints especially weight-bearing joints
Commonly affects hand and weight-bearing
joints (knees, hips, feet, and back)
Breakdown of articular cartilage occurs
Injury is usually limited to joint and
surrounding tissue
Disease ranges from very mild to very severe
Osteoarthritis (OA)
Osteoarthritis (OA)
Etiology and pathophysiology
Cartilage degeneration causes bones to rub
against each other, causing pain and decreasing
function of the joint
Risk factors
Age (most significant): primarily affects
middle-age to older adults
Obesity (generally causes arthritis of the
knees)
Repetitive joint injuries caused by sports,
accidents, or work-related injuries
Osteoarthritis (OA)
Assessment
Disease is diagnosed with physical exam
and a history of symptoms
X-ray confirms the disease
Joint pain is present with movement and
weight-bearing and is relieved by rest
There is limited range of motion with
progressive loss of function
Osteoarthritis (OA)
Medication therapy
Acetaminophen is generally used to control
mild pain without inflammation
Therapy also includes anti-inflammatory
agents such as NSAIDs and corticosteroids
If NSAIDs are ineffective in controlling
inflammation and pain, glucocorticosteroids
may be injected directly into the joint
Osteoarthritis (OA)
Client education
Teach client about the nature of and treatment of disease
Teach client principles of good body mechanics
Instruct client about the correct use of assistive devices
and encourage use as needed
Assist client in planning daily activities and tasks that
allow for schedule rest periods
Teach client to avoid activities that put excessive stress
on joints and caused pain
Low Back Pain
Low Back Pain
Low Back Pain
Pain may be a result of acute or repeated stress on
the lower back over a period of years
Pain occurs because of degeneration and/or acute
injury to the tissue of the lower back
Caused by sprain or strain of ligaments and
muscles
Pain may be felt at the site of the injury or referred
Overall health of muscles of the lower back
determines the degree of risk for injury as well as
the speed of recovery
Low Back Pain
Medication therapy
Medication therapy includes but is not
limited to analgesics, NSAIDs, and
muscle relaxants
Epidural corticosteroid injections may
be used if conservative treatment is
ineffective
Low Back Pain
Client education
Teach client about expected therapeutic
effects, side/adverse effects, and
contraindications with medication use
Teach client about the pain rating scale
Teach client the importance of adhering to
activity restrictions such as bed rest as
indicated
Teach client the importance of adhering to
gradual to activity restrictions such as
adherence with exercise plan
Low Back Pain